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AN OFFICIAL JOURNAL OF PESHAWAR MEDICAL COLLEGE
CHIEF ADVISER CHIEF EDITOR Prof. Najib ul Haq Prof. M.Yasin Khan Durrani
OPHTHALMIC SECTION INTERNATIONAL BOARD Prof. Arthur S.M. Lim (Singapore), Prof. Robert N. Weinrub (USA) Prof. Khalid Tabbara (S. Arabia), Dr. Syed Sikandar Hasnain (USA) Prof. Emeritus Diljeet Singh (India), Dr. Sakkaf Ahmed Aftab (UK) Dr. Madiha Durrani (UAE)
ASSOCIATE EDITORS Prof. Syed Imtiaz Ali, Prof. Hafeez ur Rehman, Prof. Jahangir Akhtar Prof. Shahid Wahab
ASSISTANT EDITORS Prof. Nadeem Qureshi, Prof. Naqaish Sadiq, Prof. B.A. Naeem, Prof. Imran Azam Butt Dr. Ghulam Sabir, Dr. Inam ul Haq Khan, Dr. Liaqat Ali Shaikh, Dr. Munira Shakir Dr. Syeda Aisha Bukhari, Prof. Niamatullah Kundi, Dr. Mahfooz Hussain Dr. Zeeshan Kamil, Dr. Shakir Zafar
GENERAL SECTION ASSISTANT EDITORS Prof. Zahoor Ullah, Prof. Zafar Iqbal, Dr. Faiz-ur-Rehman Dr. Misbah Durrani
MANAGING EDITOR Dr. Jahanzeb Durrani
Registered vide No. 3405/2/(63) under Press and Publication Ordinance ‘98 Govt. of Pakistan Published quarterly by Ophthalmic Newsnet from 267-A, St: 53, F-10/4, Islamabad - Pakistan Phones:051-2222922 ext.1255, 051-4414091 Mob: 0333-5158885, Fax:051-2299113 E-mail: [email protected] Ophthalmology Update Vol. 10. No.Printed 2, April-June at 2012 PanGraphics (Pvt) Ltd., Islamabad. i Contents
Contents n EDITORIAL
n Over indulgence in T.V. & Computers can produce Visual and other Health Problems Prof. M. Yasin Khan Durrani ------113
OPHTHALMIC SECTION n ORIGINAL ARTICLES
n A Computer-based Anaglyphic System for the Treatment of Amblyopia Dr. Ali Rastegarpour------115
n Change in Refractive Status, after Removal of sutures, in conventional Extra-Capsular Cataract Extraction with IOL Implantation Shafqat ullah Khan Marwat et al ------119
n Trabeculectomy with Mitomycin-C in Patients of Primary Open Angle Glaucoma Saber Mohammad et al ------124
n Concussional Injuries of the Eye Sofia Iqbal et al ------128
n Complications of Intravitreal Injections of Bevacizumab Mushtaq Ahmed et al------133
n An audit of Neonatal Services in Khyber Pakhtunkhwa Province (KPK), Pakistan to identify Implications for screening ‘Retinopathy of Prematurity’ Sadia Sethi et al ------136
n A Review of Microbial Keratitis Sofia Iqbal et al ------143
n Frequency of Ocular Injuries at Tertiary Care Hospital A. Khalil Lakho et al ------148
n Phacoemulsification under Topical Anaesthesia with Intracameral Lignocaine Mushtaq Ahmed et al------152
n Angiographic Features of Central Serous Chorio-retinopathy in Pakistani Population Muhammad Nawaz et al ------156
n Can we use Non-Ophthalmic Drug in Ophthalmology ? (Non-ophthalmic drug potential for ophthalmology) Prof. Marianne L. Shahsuvrayan et al ------161
n Intravitreal Triamcinolone (IVTA) vs Laser Photocoagulation as a Primary Treatment for Diabetic Macular Oedema(DME) — A Comparative Study Embong Zunaina et al ------166
ii Ophthalmology Update Vol. 10. No. 2, April-June 2012 Contents
n Topical Nsaid’s and Flouoromethalone in the Treatment of Epidemic Keratoconjunctivitis (A Comparative Study) Inam ul Haq Khan et al ------172
n Expanding the Role of Trabeculectomy with 5-FU Hashim Imran et al ------177
n Door to Door Trachoma Survey in North Waziristan Agency, Tehsil Mir Ali Sanaullah Khan et al ------181
n Subtenon vs Peribulbar Anaestheia for Manual Small Incision Cataract Surgery Zakir Hussain et al ------186
n Frequency and Types of Comitant Esotropia Among Patients Attending Eye OPD Nuzhat Rahil et al ------189 n CASE REPORT
n Glioblastoma Multiforme (GBM) as a cause of Foster Kennedy Syndrome (An interesting Case) Inamul Haq Khan et al ------192
GENERAL SECTION
n Short Term Results of Closing Wedge High Tibial Osteotomy for Medial Compartmental Osteoarthritis of the Knee M. Imran Khan et al ------195
n Comparison of Normal and Abnormal Umbilical Artery Waveforms with Early Neonatal Outcome in Asymmetrical Intra-Uterine Growth Retardation (IUGR) Misbah Durrani et al ------199
n Weight loss, Exercise, or Both improve Physical function in Obese Older Adults Dennis T. Villareal et al ------203
CURRENT RESEARCH
n Probing the Floor of the Optic Nerve head in Glaucoma Madiha Durrani ------208
Ophthalmology Update Vol. 10. No. 2, April-June 2012 iii Instructions to the authors
Instructions to the Authors
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iv Ophthalmology Update Vol. 10. No. 2, April-June 2012 Editorial Over indulgence in T.V. & Computers can produce Visual and other Health Problems
With the change of life style, children are crazy in on computers, the eye ball is thought to grow longer spending more time in indoor-activities and less in out- and longer so that less effort is needed to see near door sports like activities. It has firmly been established objects clearly , but an elongated eye will no longer that the computer games are most likened mode of focuses distant objects thus inducing myopia, which entertainment for children as well as the elderly. These explains the prominence of myopic eye. On the computers (especially the laptops) have captured our contrary, the children who take more interest in lives and made us dependent on them. Research shows physical activities or games are less susceptible to that computers badly affect the brain as well as the shortsightedness as it tend to involve more focusing body. Parents have noticed that their children are on distant objects rather near objects, thus protecting playing computer games for a longer period and they the eyes from abnormal growth. The best example is often complain of watery eyes, frequent headaches, that the youngsters playing Tennis are less likely to back aches, emotional instability and lack of suffer from Myopia. It is also postulated that apart from concentration in their studies myopia they get glaucoma like symptoms with field Doctors have observed increasing incidence of changes in the long run. In view of the changing life worldwide Myopia (shortsightedness) with physical style, as observed by Prof. Ian Morgan from the and emotional changes leading to moral turpitude in Australian National University in Canberra that the some cases. Reaching home after schooling the children myopia is rising at a fastest rate in Far-eastern spend most of their time in front of TV or playing SIMS- countries but the western world is equally worried most popular series of computer games. Globally about it. speaking, there is an alarming rise of Myopia to the Recently, a team of scientists lead by Prof. Loren extent of an epidemic form especially in countries with Cordain of Colorado State University has found that a advanced Information Technology. For example, in diet rich in sugar and refined starch including white Singapore and Israel, 30 years ago, the incidence of bread and cereals can cause shortsightedness. They myopia in teen agers was just 30-35% which has now argue that the foods may affect the development of eyes jumped to 80% especially in school children where the by stimulating the production of high level of insulin state has laid more emphasis on reading religious books. and reduction of protein-3, which is thought to be According to an unofficial study in Pakistan, most of responsible for growth of eye ball and lens. The the children involved in memorizing the books suffer evidence was well observed in North American from myopia. There could be other reasons like under Canadian Eskimos, where incidence of myopia is hardly nutrition, over-indulgence in TV and computers apart 1-2%, the reason scientists believe that they eat fish, from increasing burden of studies right from the tender tuberous plants and coconut rather than bread and age which is the most vulnerable age to suffer myopia cereals. However this needs further study. i.e., 8-12years. No doubt, genetics is also an important It has also been clearly demonstrated that factor in producing myopia. According to a study in playing video games like Medal of Honor, Pacific USA, the incidence of myopia in non-myopic parents Assault-MOH and SIMS series induce functional is 6%, in a single myopic parents it is 18% and in parents plasticity and spatial resolution which improve the (both myopic) it is 33%. irreversible Amblyopia in adults as experienced by The question arises, how myopia develops? What Prof. Roger W. Li, Ph.D. research optometrist from happens anatomically? According to a school of University of California. Let us see when a child should thought, the explanation appears relevant, that during start using a computer? Is it at the age of 3 years? The the developing age, children spend more time focusing fact cannot be ignored that the computer application on close objects such as studying books and focusing improves children’s performance in reading, writing
Ophthalmology Update Vol. 10. No. 2, April-June 2012 113 Editorial: Ocular Surface Damage by Medication – Current Opinion
and basic mathematics, but involvement at an early age 1. Prevalence of amblyopia and strabismus in white and African may expose to the risks of: American children aged 6 through 71 months the Baltimore Pediatric Eye Disease Study. Ophthalmology116: 2128–2134 Physical hazards like visual strain and obesity ii) e2121–2122. Emotional and social hazards like isolation, weak 2. Levi D. M, Polat U (1996) Neural plasticity in adults with relationship with teachers and lack of self-discipline amblyopia. Proc NatlAcadSci U S A 93: 6830–6834. iii) Intellectual hazards like lack of creativity to some 3. Polat U, Ma-Naim T, Belkin M, Sagi D (2004) Improving vision in adult amblyopia by perceptual learning. extent, non-realistic imaginations, poor language skills, ProcNatlAcadSci U S A 101: 6692–6697. too little patience for hard work and lack of seeking 4. Li R. W, Young K. G, Hoenig P, Levi D. M (2005) Perceptual knowledge iii) and finally moral hazards leading learning improves visual perception in juvenile amblyopia. moral degradation. Invest Ophthalmol Vis Sci 46: 3161–3168. Zhou Y, Huang C, Xu P, Tao L, Qiu Z, et al. (2006) There are many useful and positive observations, 5. Perceptual learning improves contrast sensitivity and visual as computer games are not only a modern craze but acuity in adults with anisometropic amblyopia. Vision Res also an effective tool to enhance the intelligence quotient 46: 739–750. (IQ) of the children from 30-35%. Even the seniors who Prof. Dr. M. Yasin Khan Durrani suffer from CVA stroke may lose the skill of processing Editor in Chief data in their field of vision. There is a dramatic impact on the skill of perception and this has lead the scientists to believe the possibilities how computer games may help to rehabilitate the stroke patients and also help How things have changed? the elderly to keep them sufficiently alert as safe drivers. Similarly, computers can ease the tasks faster than humans can do. It can resolve harder problems easily and remember lot of facts, while computer games enhance the capacity of human brains and visual attention skill. Regular players of computer games show dramatic perception, 20-50% better at taking in everything that happens around them. In Summary, there are some useful guidelines for parents and teachers to use computers with their children as an opportunity to talk, listen and share experiences to make computer time multi-sensory with real life objectives. According to Prof. Karl Zadnick of Ohio State University, College of Optometry in Columbia, we must get the parents, cutting the time of their children spending on computer games or watching T.V. to the extent of less than an hour a day and encouraging them to spend more time in out-door activities. In bygone days, people preferred healthy foods with energy drinks like taking grams, yams, dates and fresh fruits and not the junk foods with cokes and candies, refrigerated and micro-wave processed diet. They led a real healthy life style. In this context, the parents must ensure that the children take balanced/ wholesome diet with energy drinks and have at least 8 hours continuous uninterrupted sleep increasing their perceptive ability with freshness to take more interest in their lessons in the school. A computer junkie advises while working/playing at computers one must take short breaks, walk about to relax the body. Finally, listen to your body when it tells you ‘enough is enough’. The ancient rule seems unchanged, if you want to be smart, work hard. REFERENCES: Courtesy: Dr. Arshad Mehmood, Prof. Daljit Singh & Dr Yost Lynn
114 Ophthalmology Update Vol. 10. No. 2, April-June 2012 Outcomes & Complications of Frontalis Brow Suspension with Silicone Tube in Congenital Ptosis
Original Article
A Computer-based Anaglyphic System for the Treatment of Amblyopia*
Dr. Ali Dr. Ali Rastegarpour Rastegarpour
ABSTRACT Purpose: Virtual Reality (VR)-based treatment has been introduced as a potential option for amblyopia management, presumably without involving the problems of occlusion andpenalization, including variable and unsatisfactory outcomes, long duration of treatment, poorcompliance, psychological impact, and complications. However, VR-based treatment is costly and not accessible for most children. This paper introduces a method that encompasses the advantages of VR- based treatment at a lower cost. Methods: The presented system consists of a pair of glasses with two color filters and software for use on a personal computer. The software is designed such that some active graphic components can only be seen by the amblyopic eye and are filtered out for the other eye. Some components would be seen by both to encourage fusion. The result is that the patient must useboth eyes, and specifically the amblyopic eye, to play the games. Results: A prototype of the system, the ABG InSight, was found capable of successfully filteringout elements of a certain color and therefore, could prove to be a viable alternative to VR-based treatment for amblyopia. Conclusion: The anaglyphic system maintains most of the advantages of VR-based systems,but is less costly and highly accessible. It fulfills the means that VR-based systems are designed to achieve, and warrants further investigation. Keywords: amblyopia, computer-based, open source, virtual reality, color filters, 3-D
INTRODUCTION of the dominant eye is a recently developed alternative As the development of virtual reality (VR)-based withbreportedly better compliance and lower costs,9 treatment systems such as the Interactive Binocular and of equal efficacy.6,7,9 However,batropine as a Treatment (I-BiT™) system presented by Eastgateet al1 medication has its side effects, ranging from and the Viston-VR™ system presented by Qiu et al2 thebcommon and benign experience of light have demonstrated, the advent ofVR technology has sensitivity,7,10,11 to alarge variety of less common but been introduced as a promising solution for the more serious symptoms.4 Although rare,7,12 there have management of amblyopia. Preliminary findings imply also been reports of reverse amblyopia,13,14 a that VR-based treatment could be effective3 and does complication in which the unaffected penalized eye not involve many of the numerous problems confronted becomes amblyopic due to inhibition.VR-based in the conventional approach of occlusion or treatment overcomes many of these problems. VR- penalization. Conventional occlusion therapy, by based treatment is interactive and adjustable for ageand patching the dominant eye to encourage stimulation of therefore it is enjoyable for the patients and resultsin the amblyopic eye, is traditionally the mainstay excellent patient compliance.1 It does not entail the treatment for amblyopia.4 Although effective,5–7 this stigmatization of patching or side effects of atropine, simple intervention produces variable and and has no risk of reverse amblyopia, since the healthy unsatisfactory outcomes, long durations of treatment, eye is not occluded or rendered inactive and is not high costs, negative psychological and emotional deprived of stimuli.VR-based treatment is said to be impacts, poor compliance, which may even render the successful in preliminary reports.3 In addition, while treatment completelyineffective.8 Atropine penalization occlusion and penalization canpotentially disrupt fusion, VR-based therapy encouragesfusion and is ––––––––––––––––––––––––––––––––––––––––––––––––––––––– *The study was conducted at Ophthalmic Research Center, Shahid expected to enhance binocular vision. On the other Beheshti University of Medical Sciences, Tehran, Iran hand, VR-based treatment requires expensive elaborate ––––––––––––––––––––––––––––––––––––––––––––––––––––––– equipment. It would be costly to implement on alarge Correspondence: Dr. Ali Rastegarpour Ophthalmic Research Center, scale, and it would not be accessible or convenient for Shahid Beheshti University of Medical Sciences, 23 Paidarfard St, Boostan 9, Pasdaran Ave, Tehran 16666, Iran Tel +98 21 2277 0957 most children. Fax +98 21 2259 0607 Email [email protected] The current paper attempts to introduce a method ––––––––––––––––––––––––––––––––––––––––––––––––––––––– that could encompass the advantages of VR-based Acknowledgement: The management of Ophthalmology Update treatment, at a much lower cost. The introduced system thanks Dr. Ali Rastegarpour for permitting to publish the whole article…..Editor can produce an effect similar to the underlying concept –––––––––––––––––––––––––––––––––––––––––––––––––––––––
Ophthalmology Update Vol. 10. No. 2, April-June 2012 115 A Computer-based Anaglyphic System for the Treatment of Amblyopia
of VR-based treatment, using simple technology and system. The system consists of a software package and obviating the need for complex equipment. The a pair of glasses made of two color filters. The software software of this system could be installed on a personal is designed to be engaging and interactive, but in a computer at home, and conveniently operated along manner that at least some of the main active moving with a pair of special glasses. components can only be seen by the amblyopic eye and MATERIAL AND METHODS are filtered out for the other eye.This is achieved by The essence of VR-based treatment consists of simply arranging these elements (and the feeding the two eyes two different but related images. corresponding backgrounds they cover) to appear in Instead of having the two images differ slightly in the same colors that the filters allow entry for. Some perspective, as would be intended for three- components, especially the non mobile or background dimensional (3-D) viewing, the two images would elements, would be seen by both eyes to encourage overlap and create a single image, however some fusion. The result is, thepatient must use both eyes, and elements would be missing for each eye. In particular, specifically the amblyopiceye, to play the games (Figure there would necessarily be main active elements that 1). The glasses consisted of two blue (Wratten #47) and would be presented to the amblyopic eye but not to the orange (Wratten #21) generic photographic filters. The non-amblyopic eye. Thus, the amblyopic eye would filters Figure 1A diagram of the anaglyphic system for need to play an active role in binocular vision in order amblyopia treatment. The display(A) consists of to see thecomplete image, whether it be a video or a elements that, based on color, may be visible by one or game.VR, however, is not the only method that can be both eyes.The filter for the unaffected eye (B) filters out used to feed two different images to the two eyes. Long main moving elements (D), while thefilter of the before the very concept of feeding a different image to amblyopic eye (C) allows for the eye to see the main each eye was adopted for the treatment of amblyopia, elements and mayor may not filter out less significant it had been usedto create 3-D images and movies. An features (E). An anaglyphic system for amblyopia were older technique for creating 3-D experiences was the mounted on a frame that adequately covered the fieldof anaglyphic method. In this method, two images created vision.Software of the prototype model consisted of from a slightly differing point ofview were presented simple modified open source Flash (Adobe, San Jose, in two distinct colors. The viewer would wear a pair of CA) games.The games used included the open source 3-D glasses consisting of two color filters, each to filter Flash games ofPing, Xtreme Climber, Snake, and one of the images. Pacman.The backgrounds of all games were changed Therefore, each eye would only see one of the to white,and main elements were changed to the filtered images.This is the exact mechanism used in the current colors. The colors for two different hexadecimal codes
Figure 1
116 Ophthalmology Update Vol. 10. No. 2, April-June 2012 A Computer-based Anaglyphic System for the Treatment of Amblyopia
were successfully filtered out by each lens. Codes restricted. Althoug hanaglyphs can reproduce color #99FFFF and #CCFFFF were filtered by the blue lens images and to a point, color distinction and clarity, the and #FFFF33 and #FFFF99 were filtered by the orange scope of options is limited.For example, the main lens. This enabled us to create images with three shades moving elements, as well as other components which (two shades of color and white), which could be filtered are selected for filtering, along with the corresponding out for one eye. backgrounds they cover, must be invariably RESULTS monochrome. For this reason, the background and A laboratory prototype of the proposed system, mainelements can only consist of white and various the ABG InSight (v1.2 β), was designed. The system shades of the filtered color. In most cases, between the was used onnine monitors, with different darkest shade of the filtered color and white, only one manufacturers and models, and complete filtering was distinctively visible shade will be practical for use. This confirmed by twelve people withouta history of any limits the colors for use in themain elements and ophthalmologic or neurological problems.A simple backgrounds to three colors; white and the two shades calibration module could be added to the software later of the filtered color. Aside from this issue the use of to guarantee consistency in filtering elements, or for various points of view, perspectives, and move- the time being the monitors could be adjusted by any mentsremain unrestricted. person without color vision deficits, to ensure correct A minor advantage for some VR-based systems filtering. The glasses consisted of two generic would be that they can be made to adjust for angles of photographic filters,which were for the purpose of this strabismus, which means they can be used for untreated study, blue and orange,but other color pairs, such as strabismic amblyopes and adjusted as such to provide the traditional 3-D red-cyanor amber-pure dark blue binocular vision and fusion without requiring (used in ColorCode 3-D)15 would presumably be satisfactory alignment. Since the anaglyphic system equally functional. The prototype system was capable uses a single display, its use is limited to amblyopic of successfully filteringout elements of a certain color patients for whom the underlying condition, usually and therefore, was found to bea potential alternative strabismus or anisometropia, has been resolved, atleast to VR for amblyopia management. to some extent, by corrective glasses or other means. A DISCUSSION minor advantage of the anaglyphic system is that the As mentioned, the computer-based anaglyphic fusion promoted for seeing the images in this system, system provides most of the advantages of the VR- is similar to the fusion required in the actual world, based treatment, in addition to reduced cost and high becauseboth eyes are watching the same interface. VR- availability. based systemsmay not represent the actual angles, The open source initiative allows for the distances, or proportions seen in the natural modification, and in most cases, distribution, of a surroundings. This is why prolongedwork with VR variety of software packages, free of charge and systems has been associated with vomiting, sweating, licensing. This creates the opportunity for researchers headaches, and drowsiness.16 The anaglyphic system to gain access to libraries of software, and from the has much potential to becomea large-scale open source many available programs, select and use those that may research project. Various opensource applications could suit their purpose. In this case, applying a few be modified by volunteers to enrichthe library of simplechanges in the code of a game, such as changing software used in the project, and researchers the color of the elements, could make it completely throughout the world could use standard filters to compatible with the proposed system. For this means, create the glasses, and download the software free of many of the available games can be used, taking into charge. consideration only the appropriateness of the game for A major concern is the actual effectiveness of the target age group, and complexity of the graphic theVR-based systems. Although the anaglyphic system interface. The license of some open source games does couldpotentially serve as an alternative to VR-based not allow them to be modified for commercial use. This systems by accomplishing the same objectives, the should be taken into consideration, the license evidence supportingVR-based systems as a therapeutic respected, and no financial gain received fromsuch intervention is limited,and the only available studies games. including clinical data in this regard are two case series One of the limitations for such a system would be reporting the short-term outcomesin six and twelve the main limitation of all anaglyphic systems: the patients, respectively.3,17 Computer-based active vision limited useof color. Games that include color as a main therapy has received much attention for amblyopia and theme orinclude color-based elements, as well as games one of the recent publications by Hess et al,18 and media with complex graphics, would be slightly demonstrating success for active vision therapy in three
Ophthalmology Update Vol. 10. No. 2, April-June 2012 117 A Computer-based Anaglyphic System for the Treatment of Amblyopia
amblyopic patients. However, there is still not much treatment (I-BiT) system, inthe treatment of strabismic and evidence in the literature to support most modalities. anisometropic amblyopia. Eye (Lond).2006;20 (3):375–378. 4. Webber AL. Amblyopia treatment: an evidence-based Nonetheless, introducing the anaglyphic system approachto maximising treatment outcome. ClinExpOptom. provides an excellent opportunity to investigate the role 2007;90(4):250–257.5. Teed RG, Bui CM, Morrison DG, Estes of computer-based therapy in the management of RL, Donahue SP. Amblyopia therapy in children identified amblyopia, by enabling researchers worldwide to by photoscreening. Ophthalmology. 2010;117(1):159–162. 6. Repka MX, Kraker RT, Beck RW, et al. Pediatric Eye evaluate its effectiveness without the need for expensive DiseaseInvestigator Group. A randomized trial of atropine or exclusive equipment, and therefore allowing vs patching fortreatment of moderate amblyopia: follow-up interested researchers to continue from where the at age 10 years. ArchOphthalmol. 2008;126(8):1039–1044. previous studies were left. 7. Scheiman MM, Hertle RW, Kraker RT, et al. Pediatric Eye DiseaseInvestigator Group. Patching vs atropine to treat CONCLUSION amblyopia in childrenaged 7 to 12 years: a randomized trial. The current lack of clinical data for the amblyopic Arch Ophthalmol. 2008;126(12):1634–1642. system is a major drawback of this introductory paper. 8. Awan M, Proudlock FA, Grosvenor D, Choudhuri I, However, it has not been claimed that the anaglyphic Sarvanananthan N,Gottlob I. An audit of the outcome of amblyopia treatment: a retrospectiveanalysis of 322 children. method is an effectivetreatment for amblyopia, but Br J Ophthalmol. 2010;94 (8):1007–1011. rather that the system could logically be a suitable 9. Li T, Shotton K. Conventional occlusion versus alternative to the VR systems. The cost of anaglyphic pharmacologicpenalization for amblyopia. Cochrane Database systems is much lower, therefore they may be a more Syst Rev. 2009;4:CD006460. 10. Pediatric Eye Disease Investigator Group. Pharmacological viable option for research and may be ultimately, plus opticalpenalization treatment for amblyopia: results of treatment. The evidence for VR-based systems could a randomized trial. ArchOphthalmol. 2009;127(1):22–30. beintriguing enough for researchers to test an 11. Repka MX, Kraker RT, Beck RW, et al. Pediatric Eye anaglyphic system that functions similarly, with better DiseaseInvestigator Group. Treatment of severe amblyopia with weekendatropine: results from 2 randomized clinical availability and lower costs. Future clinical trials trials. J AAPOS. 2009;13(3):258–263. performed on VR-based treatmentsystems can 12. North RV, Kelly ME. Atropine occlusion in the treatment of document the effectiveness of the underlying concept, strabismicamblyopia and its effect upon the non-amblyopic on which the current system was designed. Inaddition, eye. OphthalmicPhysiol Opt. 1991;11(2):113–117.An anaglyphic system for amblyopia clinical trials and case series performed with the 13. Kubota N, Usui C. The development of occlusionamblyopia anaglyphic system itself will determine its true followingatropine therapy for strabismic amblyopia.Nippon effectiveness and implications. In conclusion, the GankaGakkaiZasshi. 1993;97(6):763–768. Japanese. anaglyphic system maintains most advantages of the 14. Simons K, Stein L, Sener EC, Vitale S, Guyton DL. Full-time atropine, intermittent atropine, and optical penalization and VR-based systems, but is less costlyand more accessible. binocular outcomin treatment of strabismic The system logically fulfills what theVR-based system amblyopia.Ophthalmology. 1997; 104 (12):2143–2155. was designed to achieve and therefore, warrants further 15. Sorensen SEB, Hansen PS, Sorensen NL, inventors.Method investigation. forrecording and viewing stereoscopic images in color using multichromefilters.United States Patent 6687003. May 31, REFERENCES 2001. 1. Eastgate RM, Griffiths GD, Waddingham PE, et al. Modified 16. Oman CM. Sensory conflict in motion sickness: an observer virtualreality technology for treatment of amblyopia. Eye theoryapproach. In: Ellis SR, editor. Pictorial Communication (Lond). 2006;20 (3):370–374. in Virtual andReal Environments. London, UK: Taylor and 2. Qiu F, Wang L, Liu Y, Yu L. Interactive binocular amblyopia Francis; 1993:362–376. treatmentsystem with full-field vision based on virtual 17. Cleary M, Moody AD, Buchanan A, Stewart H, Dutton GN. reality. The 1st InternationalConference on Bioinformatics Assessmentof a computer-based treatment for older and Biomedical Engineering 2007(ICBBE 2007) July 6–8, 2007; amblyopes: the Glasgow PilotStudy. Eye (Lond). 2009;23 Wuhan, China: Institute of Electricaland Electronics (1):124–131. Engineers (IEEE); 2007:1257–1260. 18. Hess RF, Mansouri B, Thompson B. A binocular approach to 3. Waddingham PE, Butler TK, Cobb SV, et al. Preliminary treatingamblyopia: antisuppression therapy. Optom Vis Sci. results fromthe use of the novel Interactive binocular 2010;87(9):697–704.
118 Ophthalmology Update Vol. 10. No. 2, April-June 2012 Original Article Change in Refractive Status, after Removal of sutures, in conventional Extra-Capsular Cataract Extraction with IOL Implantation Dr. Shafqat Shafqat ullah Khan Marwat, FCPS1, Saber Mohammad, FCPS2 Ihsan Ullah, FCPS3 Mohammad Alam FCPS4 , Zaman shah, FCPS5 Prof. Naimat Ullah Khan Kundi6
ABSTRACT Objective: To study the change in refractive status, after removal of sutures, in eyes having undergone conventional extra-capsular cataract extraction with intra-ocular lens implantation. Material & Methods: This study was conducted in Ophthalmology Department Khyber Teaching Hospital, Peshawar from 15th January 2005 to 15th July 2005. This prospective comparative study was performed on 100 eyes of 100 patients who presented for their cataracts surgeries. In all patients, amount of astigmatism based on the keratometry readings, un-aided visual acuity and best-corrected visual acuity were recorded preoperatively and 2-months postoperatively before and after the removal of sutures. Results: Out of hundred patients, 46 were males and 54 were females. Mean age of the patients was 58.5 years. Laterality of the operated eye was 50% for the right and 50% for the left eye. Amount of astigmatism calculated two- months postoperatively, before removal of sutures was 0.25 to < 1D in 14 eyes, 1 to 2 D in 35 eyes, and > 2 D in 51 eyes. Just after removal of sutures, the amount of astigmatism was 0.25 to < 1D in 20 eyes, 1 to 2 D in 55 eyes, and > 2 D in 25 eyes. Type of astigmatism pre-operatively was with-the-rule in 12 eyes, against-the-rule in 43 eyes and oblique in 45 eyes. Two-months post-operatively before removal of sutures, it was with-the-rule in 24 eyes, against-the-rule in 23 eyes, and oblique in 53 eyes. Just after removal of sutures, there was with-the rule astigmatism in 17 eyes, against-the-rule in 29 eyes, and oblique astigmatism in 54 eyes. Applying T-test to the amount of astigmatism before and after stitch removal, P-value comes out to be 0.000 < 0.05, showing significant difference between astigmatism before and after sutures removal. Conclusion: There was a significant change in the refractive status in respect of the amount of astigmatism, after removal of sutures in eyes having undergone conventional extra-capsular cataract extraction with intra-ocular lens implantation.
INTRODUCTION decades, extra-capsular cataract extraction (ECCE) with Cataract and refractive errors are among the com- the implantation of intra-ocular lens (IOL) has become monest cause of visual morbidity all over the world. 1 the standardized surgical treatment for defective vision, 5 Cataract is generally defined as an opacification of the caused by the opacification of human crystalline lens. Crystalline lens of the eye. It accounts for nearly half of all the causes of blindness and is particularly common The principal cause of post-operative astigmatism in developing countries. 2 was surgically induced corneal distortion. Several factors have been identified, mainly involving the In the present state of knowledge, there is no incision size, wound healing, suture material and its proven means of preventing cataract or halting its removal all contribute to surgically induced progression to blindness. The condition is however astigmatism, thus affecting the post operative refractive amenable to surgical treatment, which together with status. 6, 7, 8 the optical correction of the ensuing refractive deficit, Conventional extracapsular cataract extraction 3, 4 results in the restoration of vision. For the last few with implantation of intraocular lens is still the most ––––––––––––––––––––––––––––––––––––––––––––––––––––––– frequently performed surgical option in our part of the 1Senior Registrar Eye A Ward Khyber Teaching Hospital Peshawar 2Registrar 3 Eye Specialist Timargara Hospital Dir 4Senior Registrar world. Due to lack of facilities, expenses of surgery and Eye WardDepartment of ophthalmology Lady Reading Hospital long learning curve, phacoemulsification and small Peshawar5Senior Registrar 6Professor and Head of Ophthalmology, incision cataract surgeries are the emerging forms. In Khyber Teaching Hospital, Peshawar. conventional extracapsular cataract surgeries, ––––––––––––––––––––––––––––––––––––––––––––––––––––––– Correspondence: Flat No,14, New Doctors Colony, Khyber Teaching astigmatism induced by sutures is the main cause of Hospital, Peshawar Tel: 03345701112 defective vision postoperatively. Site of incision, Email: [email protected] distances between the sutures all play important role ––––––––––––––––––––––––––––––––––––––––––––––––––––––– in inducing astigmatism and hence causing defective Received: Oct’2011 Accepted: Jan’2012 –––––––––––––––––––––––––––––––––––––––––––––––––––––––
Ophthalmology Update Vol. 10. No. 2, April-June 2012 119 Change in Refractive Status, after Removal of sutures, in conventional Extra-Capsular Cataract Extraction with IOL Implantation
vision postoperatively. Our plan was to study the effects or perception of light. Pre-operatively 40 patients had of suture removal two months postoperatively on best corrected visual acuity between counting fingers refractive status of the eye and thus on overall visual to < 6/60, while postoperatively after stitch removal 3 outcome. patients had best corrected visual acuity between MATERIAL AND METHODS: counting fingers to < 6/60. Pre-operatively 16 patients This study was conducted in Ophthalmology had best corrected visual acuity between 6/60 to 6/18, Department Khyber teaching Hospital, Peshawar from while postoperatively after stitch removal 13 patients 15th January 2005 to 15th July 2005. This prospective had the best corrected visual acuity between 6/60 to comparative study was performed on 100 eyes of 100 6/18. Pre-operatively 9 patients had the best correct patients who presented for their cataracts surgeries. In visual acuity > 6/18, while postoperative after stitch all patients, Keratometry readings, amount of removal 84 patients had the best corrected visual acuity astigmatism based on the keratometry readings, un- of > 6/18. aided visual acuity and best-corrected visual acuity Before removal of sutures 5 patients had best were recorded preoperatively and subsequently 2- corrected visual acuity of counting finger to less than months after sutures removal. 6/60 while after stitch removal 3 patients had best Follow Up: Follow up period was two months. corrected visual acuity of counting fingers to less than RESULTS: 6/60. Out of 100 patients, 46 were males and 54 were Before stitch removal 17 patients had best correct females (Figure-I). Out of operated cases, in half (50 visual acuity of 6/60 to 6/18, while after stitch removal eyes) of the patients was right eye and half (50 eyes) of 13 patients had best corrected visual acuity of 6/60 to left eye was operated (Figure-II). Mean age of all the 6/18. Before stitch removal 78 patients had best patients was 58.55 years with a range from 40 years to corrected visual acuity of more than 6/18, while after 85 years. 23 patients were between 40 and 50 years, 48 removal of sutures 84 patients had best corrected visual patients were between 51 to 60 years, 18 patients were acuity of more than 6/18. between 61 to 70 years, 9 patients between 71 to 80 years Post-operatively, after 2 months, before sutures and 2 patients were more than 80 years of age (Figure- removal the un-aided visual acuity was HM/ PL in no III). All the patients were admitted one day before patient, CF to < 6/60 in 9 patients, 6/60 to 6/18 in 26 surgery and discharge on first post op day in order to patients, and better than 6/18 in 65 patients. Similarly, facilitate the study. post-operative best-corrected visual acuity before Regarding systemic co-morbidity, 3 patients were sutures removal was HM/ PL in no patients, CF to 6/ suffering from hypertension, 7 were diabetics, 3 were 60 in 5 patients, 6/60 to 6/18 in 17 patients and better diabetic as well as hypertensive and one was a known than 6/18 in 78 patients. case of ischemic heart disease (Figure-IV). All the Post-operatively, after sutures removal, the un- patients having any ocular co-morbidity were already aided visual acuity was HM/ PL in no patients, CF to excluded from the study. Pre-operatively, 37 patients 6/60 in 6 patients, 6/60 to 6/18 in 22 patients and better had un-aided visual acuity of hand movement or than 6/18 in 72 patients. Similarly post-operatively, perception of light while postoperatively after stitch after removal of sutures, the best-corrected visual acuity removal no patient had unaided visual acuity of hand was HM/ PL in no patients, CF to 6/60 in 3 patients, movement or perception of light. 6/60 to 6/18 in 13 patients and better than 6/18 in 84 Pre-operatively 48 patients had visual acuity patients. Comparisons of unaided and best corrected between counting fingers to less than 6/60 while visual acuity are given in (Figers No, V&VI). postoperatively after stitch removal 6 patients had Pre-operatively the amount of astigmatism was visual acuity between counting fingers to less than 6/ 0.25 to less than 1 D in 39 eyes, 1 D to 2 D in 51 eyes, 60. Pre-operatively 12 patients had visual acuity and more than 2 diopters in 10 eyes. between 6/60 and 6/18 while postoperatively after Two-months postoperatively, before removal of stitch removal 22 patients had visual acuity between sutures, the amount of astigmatism was 0.25 to < 1D in 6/60 and 6/18. Pre-operatively 3 patients had visual 14 eyes, 1 to 2 D in 35 eyes, and > 2 D in 51 eyes. Post- acuity better than 6/18 while postoperatively after operatively, just after removal of sutures, the amount stitch removal 72 patients had visual acuity better than of astigmatism was 0.25 to < 1D in 20 eyes, 1 to 2 D in 6/18. 55 eyes, and > 2 D in 25 eyes. (Table No, I) Pre-operatively the best corrected visual acuity Pre-operatively, there was with-the-rule was hand movement / perception of light in 35 patients, astigmatism in 12 eyes, against-the-rule astigmatism in while postoperatively after stitch removal no patient 43 eyes and oblique astigmatism in 45 eyes. Two- had the best corrected visual acuity of hand movement months post-operatively before removal of sutures,
120 Ophthalmology Update Vol. 10. No. 2, April-June 2012 Change in Refractive Status, after Removal of sutures, in conventional Extra-Capsular Cataract Extraction with IOL Implantation
there was with-the-rule astigmatism in 24 eyes, against- astigmatism in 54 eyes. (Table No, II). Comparison of the-rule astigmatism in 23 eyes, and oblique astigmatism are given in (Table No, III). astigmatism in 53 eyes. Just after removal of sutures, Applying T-test in SPSS to the amount of there was with-the rule astigmatism in 17 eyes, against- astigmatism before and after stitch removal, the mean the-rule astigmatism in 29 eyes, and oblique value was ± 2.36 before stitch removal and ± 1.64 just after stitch removal (P < 0.001), showing significant Figure I: Gender distribution difference between astigmatism before and after sutures 54 removal. (Table No. IV) 54
52 Figure IV: Systemic Co-morbidity 50 7 48 46 7 46 6 Percentage 5 44 4 3 3 42 3 Males Females 2 Percentage 1 1 Gender 0 Hypertension IHD Figure II: Literality of Operated Eyes Systemic co-morbidity 50 50 IHD = Ischemic heart disease 50
40 Figure V: Comparison of unaided visual acuities
30 80 70 20 60 50 Percentage 40 10 30 20 0 10 Right Left 0 HM/PL CF - < 6/60 6/60 - 6/18 > 6/18
Laterality of the operated eyes Pre-operative UAVA Pre-ROS UAVA Post-ROS UAVA
HM/PL: Hand Movement / Perception of light CF: Counting fingers Figure III: Age-wise distribution of the patients
50 48 Figure VI: Comparison of best corrected visual acuity 45
40 90 35 80 70 30 60 25 23 50 18 40 20 30 15 9 20 Percentoftotal 10 10 2 0 5 HM/PL CF- <6/60 6/60 -6/18 > 6/18 0 40-50 yrs 51-60 yrs 61-70 yrs 71-80 yrs > 80 yrs Pre-operative BCVA Pre-ROS BCVA Post-ROS BCVA
HM/PL: Hand Movement / Perception of light Age of the patients CF: Counting fingers
Ophthalmology Update Vol. 10. No. 2, April-June 2012 121 Change in Refractive Status, after Removal of sutures, in conventional Extra-Capsular Cataract Extraction with IOL Implantation
DISCUSSION: Astigmatism was more than 2 diopters in about half of In this prospective study, change in refractive the patients (51%) before removal of stitches. This status within thirty minutes after removal of sutures; percentage came down to 25% just after removal of assessed as change in corneal curvature measured by stitches. Previously conducted other studies also keratometry readings were analyzed in 100 patients suggest that keratometry done just after sutures who underwent conventional extra-capsular cataract removal is significantly different from that before extraction with intra-ocular lens implantation. removal of sutures. Potamitis and his colleagues studied 34 patients with high post-operative astigmatism following extra- Table-I: Amount of Astigmatism 9 capsular cataract surgery. They suggested that greatest change occurred within the first five minutes of sutures 0.25 - < 1D 1D - 2D > 2D removal. The rate of decay then declined so that 15 to Pre-operative 39 % 51 % 10 %
Before ROS 14 % 35 % 51 % Table-III: Comparison of astigmatism before and after After ROS 20 % 55 % 25 % Suture removal ROS = Removal of sutures n= Total number of patients Amount of Before Suture After Suture Table-II: Type of Astigmatism Astigmatism Removal Removal in diopters n=100 n=100 With the rule Against the rule Oblique 0.00 – 1.0 20 31 Astigmatism Astigmatism Astigmatism Pre-operative 12 % 43 % 45 % 1.1 – 2.0 28 46
Before ROS 24 % 23 % 53 % 2.1 – 3.0 28 15 After ROS 17 % 29 % 54 % 3.1 – 4.0 16 05 ROS = Removal of sutures > 4.0 8 03
Table-IV: T-Test
Paired Samples Statistics
Std. Std. Error Mean N Deviation Mean
Astigmatism Before 2.3680 100 1.3969 .1397 Stitch Removal Pair 1 Astigmatism After 1.6420 100 .9608 9.608E-02 Stitch Removal
Paired Samples Correlations
N Correlation Sig. Astigmatism Before Stitch 100 .302 .002 Pair 1 Removal & Astigmatism After After Stitch Removal
Paired Samples Test
Paired Differences 95% Confidence Interval Mean Std. Std. Error of the Difference t df Sig. Deviation Mean (2-tailed) Lower Upper Astigmatism Before Stitch Pair 1 Removal & Astigmatism After .7260 1.4363 .1436 .4410 1.0110 5.054 99 .000 StitchRemoval
122 Ophthalmology Update Vol. 10. No. 2, April-June 2012 Change in Refractive Status, after Removal of sutures, in conventional Extra-Capsular Cataract Extraction with IOL Implantation
30 minutes after removal of sutures the change was sutures removal and at 6 months post-operatively. again significant, but after 30 minutes the astigmatism Although the time of removal did not affect the change decay was insignificant. Although not stable, but it may in cylinderical power, the subsequent refraction was be reasonable to offer a temporary spectacles correction more stable when the sutures were removed at 12 about 30 minutes after sutures removal, in cases where weeks. early visual recovery is essential, such as in monocular CONCLUSION: patients. There was a significant change in the refractive In our study, all the incisions were given at the status in respect of the amount of astigmatism, after limbus as superior approach roughly from 10 to 2 O’ removal of sutures in eyes undergone conventional clock position. According to one other study, conducted extra-capsular cataract extraction with intra-ocular lens by Wong and his colleagues, the type of post-operative implantation. astigmatism depends upon the site of corneal section.10 REFERENCES They proved that the superior corneal incision causes 1. Jahangir S, Kadri WM. Extra-capsular cataract extraction with intra-ocular lens implantation in Pakistan. Pak J Ophthalmol significantly less astigmatism than the temporal 1999; 4:80-2. incisions and that the temporal incision induces a 2. Churchill JA, Hillman JS. Post-operative astigmatism control moderate degree of with-the rule astigmatism. by selective suture removal. Eye. 1996; 10:103-6. In this study, we applied four limbal sutures with 3. Spencer MF. Extra-capsular cataract and lens implant surgery in developing countries: keeping it simple. Ophthalmic Surg 10/0 ethilon in all the cases. All the sutures were 1990; 21:447-52. removed in all cases after a period of two months. 4. Muralikrishnan R, Venkatesh R, Manohar B, Venkatesh P. A Previously in a study by Krishnamachary and Basti comparison of the effectiveness and cost-effectiveness of three from LV Prasad Eye Institute Hyderabad India, the different methods of cataract extraction in relation to the magnitude of post-operative astigmatism. AsiaPacific J efficiency of selective sutures removal and all sutures Ophthalmol 2003; 15:5-12. removal in controlling corneal astigmatism after 5. Kumar A. Small incision extracapsular cataract extraction cataract surgery was compared.7311 The pattern of decay (Dissertation). Karachi: College of Physicians and Surgeons of astigmatism after sutures removal was studied using Pakistan 1999:44-5. 6. Afzal M, Hamid K. Comparison of Pre and Postoperative computerized video-keratography. They concluded Astigmatism: Review of 120 cases of Phacoemulsification. that all sutures removal technique was more predictable Pakistan J Ophthalmol 1999; 15:69-71. and less cumbersome than the selective sutures removal 7. Butt NH, Naeemullah, Riaz MA. Cataract backlog in Pakistan method. and possible control measures. Pakistan J Ophthalmol 1999; 15:149-51. In our study, 24 % of the eyes had with-the-rule 8. Anwar MS. Changes in surgically induced Astigmatism over or against-the-rule astigmatism preoperatively, which a period of time after Extracapsular Cataract Extraction. changed post-operatively from a horizontal to an Pakistan J Ophthalmol 1999; 15:102-4. oblique axis. Previously a study conducted by Luntz 9. Potamitis T, Fouladi M, Eperjese F, McDonnel PJ. Astigmatism decay immediately following suture removal. and Livingston showed that in forty percent of the eyes Eye 1997; 11: 84-6. the axis of the cylinder changed from a horizontal to 10. Wong HC, Davis G, Della N. Corneal astigmatism induced an oblique axis but did not change from a with- to by superior versus temporal corneal incisions for against- the-rule axis.12 In our study we removed the extracapsular cataract extraction. Aust N Z J Ophthalmol. 1994; 22:237-41. sutures two months post-operatively. Previously a 11. Krishnamachary M, Basti S. Computerized topography of study conducted by Stanford and his colleagues from selective versus all-suture release to manage high Department of Ophthalmology, King’s College Hospital astigmatism after cataract surgery. J Cataract Refract Surg. London showed that after uncomplicated extra- 1997; 23:1380-3. 12. Stanford MR, Fenech T, Hunter PA. Timing of removal of capsular cataract extraction with a corneal section and sutures in control of post-operative astigmatism. Eye 1993; 7 10/0 Nylon sutures; patients with more than 3 diopters (Pt 1): 143-7. of cylinders were allocated to have their sutures 13. Mafra CH, Dave AS, Pilai CT, Klyce SD, Wilson SE. removed at 6, 9, or 12 weeks post-operatively.13 Visual Prospective study of corneal topographic changes produced by extracapsular cataract surgery. Cornea 1996; 15: 196-203. and optical outcome were assessed after one week after
Ophthalmology Update Vol. 10. No. 2, April-June 2012 123 Original Article Trabeculectomy with Mitomycin-C in Patients of Primary Open Angle Glaucoma
Dr. Saber 1 2 3 Mohammad Saber Mohammad FCPS , Sadia Sethi FCPS , Sanaullah Khan FCPS Muhammad Naeem Khan FCPS4, Samina Karim FCPS5 Zaman Shah FCPS6
ABSTRACT Objectives: To study the results of intra ocular pressure control following primary Trabeculectomy with Mitomycin-c in patients of Primary Open Angle Glaucoma. Material and Methods: This study was conducted on patients presenting to the Department of clinical ophthalmology, Khyber Institute of Ophthalmic Medical Sciences, HMC, Peshawar from 7th October 2005 to 8th October 2006. Results: The results of primary Trabeculectomy with MMC were studied in term of lowering of IOP in POAG. The mean age of the patients was 54 years with standard deviations of 12.90.There were 12 male and 18 female in our study. The success rate of surgery in term of intraocular pressure control of 20 mmHg or less without medication in primary Trabeculectomy with MM-C was 94%. Follow Up: The follow up period were 3 months. Conclusion: Trabeculectomy with intraoperative use of Mitomycin-C gives better control of IOP.
INTRODUCTION of this agent results in better control of postoperative Primary open angle glaucoma (POAG) is the most intra ocular pressure with less antiglaucoma prevalent type of glaucoma, affecting approximately medication.5 Mitomycin-c is a naturally occurring 1% of the general population over the age of 40 years.3 antibiotic-antineoplastic compound that is derived from Glaucoma is considered as the second leading cause of Streptomyces ceaspitosus. It acts as a alkylating agent blindness after cataract1 and fourth commonest cause after enzyme activation resulting in DNA cross linking of blindness in Pakistan.2 and is a strong antifibrotic agent.7 The concentration in Trabeculectomy is the standard surgical current usage is typically 0.2mg/ml with duration of procedure of choice if the medical therapy fails. It application for 3 minutes.8 5-fluorouracil (5-FU) inhibit lowers the intraocular pressure by creating a fistula, fibroblast proliferation and has proven useful in which allows aqueous outflow from the anterior reducing scarring after filtration surgery.6 Mitomycin- chamber to the sub- tenon space.3 It is successful c is more effective than 5-fluorouracil in improving the between 86% and 90% of the cases of primary open success rate of IOP control with trabeculectomy.9 angle glaucoma.4 Trabeculectomy is not free of postoperative Antiproliferative agents such as Mitomycin-c complications but if managed properly, visual acuity (MMC) and 5-fluorourcil (5-FU) have markedly in majority of cases is shown to be good.10The improved the success rate of glaucoma filtering surgery complication of trabeculectomy with antimetabolite are and are widely used to treat glaucomatous eye with a avascular cystic bleb, persistant wound leakage, poor surgical prognosis.5 shallow anterior chamber, possibility of hypotony, The success rate of Mitomycin-c is 85%.6 The use endophthalmitis, superficial punctate keratopathy, ––––––––––––––––––––––––––––––––––––––––––––––––––––––– corneal epithelial defect, choroidal detachment and 1Registrar Eye A ward, Department of Ophthalmology, Khyber maculopathy.11 2 Teaching Hospital, Peshawar. Associate Professor Eye A Ward, MATERIAL AND METHODS Khyber Teaching Hospital, Peshawar, 3Assistant Professor, Khalifa Gul Nawaz Hospital, Bannu, 4Senior Registrar Department of This study was conducted at the KIOMS, HMC, Ophthalmology Hayatabad Medical Complex, Peshawar, 5-6Medical Peshawar, on 30 patients who underwent augmented Officer, Department of Ophthalmology, Hayatabad Medical Complex, glaucoma filtration surgery for POAG from 07th Peshawar. October, 2005 to 6th October, 2006. Only patients having ––––––––––––––––––––––––––––––––––––––––––––––––––––––– Correspondence: Dr. Saber Mohammad, Flat No, 13 New. Doctor primary open angle glaucoma were included in the Colony Khyber Teaching Hospital, Peshawar study. Patients who had history of previous surgery Email> [email protected] Tel No. 0346-9155303 like cataract extraction and Trabeculectomy were not ––––––––––––––––––––––––––––––––––––––––––––––––––––––– included in this study. Received: October’2011 Accepted Feb’2012 ––––––––––––––––––––––––––––––––––––––––––––––––––––––– A total of 30 patients, 12 were male and 18 were
124 Ophthalmology Update Vol. 10. No. 2, April-June 2012 Trabeculectomy with Mitomycin-C in Patients of Primary Open Angle Glaucoma
female were selected for the study. All the patients had figure No: 4. Patients using post op antiglaucoma symptoms of POAG with elevated IOP, enlargement medication are given in Figure No.5. The visual acuity of the optic nerve head and visual field defects. The returned to the normal within one month after surgery. mean age was 54 Years, most of the patients being above The higher incidence of complications was due to higher 40 years of age. incidence of flat anterior chamber. The flat anterior Gonioscopy were performed in every case with chamber was treated by double padding to which the Goldmann three mirrors and IOP were measured by response was seen in 24 to 48 hours. There were 2 cases Goldmann tonometer. Visual field examination was in which the pressure remained above 20mmHg mark. done preoperatively for every case. They were given the option of using antiglaucoma Operative Procedure: A fornics based conjunctival medication initially up to the follow up period but later flap was made by cutting conjunctiva along with on they refused the option of repeat surgery. Tenon’s capsule about 2.0mm from the limbus with the help of scissors. The conjunctiva and Tenon’s capsule Table 1: Age of the patients were separated from the episcleral tissue through blunt dissection about 8-10mm from the limbus. Bleeding Number of patients 30 points were cauterized with wet field bipolar cautery Mean 53.48 upto this point.Mitomycin-C was applied on the scleral Median 53 bed in a dose of 0.2mg/ml for 2 minutes. The sponge was removed and the area was thoroughly rinsed with Mode 30 balanced salt solution. A limbal based scleral flap about Std.Deviation 12.90 3×4 mm two-thirds of scleral thickness was dissected Range 25-85 upto the clear cornea. Paracentesis was performed through superotemporal clear corneal incision. Anterior chamber was entered and a block of scleral tissues about Fig: 1. Gender 1×2mm was excised and peripheral iridectomy was performed. A scleral flap was secured by applying two GENDER
20 stitches of 8/0 vicryl at the two corners of the flap. 19 Conjunctival flap was sutured by the same 8/0 vicryl 18 by applying continuous stitches, making sure that the 16 wound was water tight. Anterior chamber and bleb was 14
12 formed with balance salt solution through Paracentasis 11 port. 10 Data Collection Procedure: The procedure done 8 under local anesthesia. Thirty patients underwent 6 standard trabeculectomy with Mitomycin-C as 4 Mitomycin-C applied on the scleral bed and under 2
0 surface of the conjunctiva before making an opening Male Female into anterior chamber. The contact time of Mitomycin- Gender C was 2 minutes and the dose was 0.2 mg / ml.4All surgeries done by single consultant. The procedure was Fig: 2. Pre op IOP (mmHg) defined as successful if the intraocular pressure was below 20mmHg without any antiglaucoma medication PRE OP IOP (mmHg) in our study and follow up period were 3 months. 16.5
RESULTS 16 The results of trabeculectomy with Mitomycin-C 16 were studied in term of lowering of IOP in POAG. In 15.5 30 patients, 11 were male and 19 were female shown in 15 Figure No, 1.Mean age of the patients were 54 years with standard.deviaton of ±12.90 given in Table No,1. 14.5
The preoperative IOP was given in figure No: 2. The 14 14 success rate of surgery in intraocular pressure control of 20 mmHg or less without medication in primary 13.5 trabeculectomy with MM-C was 94% which is given in 13 figure No: 3. The incidence of complications is given in IOP 20 or < 20 With Medication IOP 20 or < 20 Without Medication
Ophthalmology Update Vol. 10. No. 2, April-June 2012 125 Trabeculectomy with Mitomycin-C in Patients of Primary Open Angle Glaucoma
Fig: 3. Post- op IOP (mmhg) population over the age of 40 years.3 In this study, we selected uncomplicated cases of POST OP IOP mmHg IOP 20 or < 20 With Medication IOP 20 or < 20 Without Medication 30 primary open angle glaucoma with achievement of 28 target pressure of 20 or less without medication in 25 93.3%.The numbers of patients included in this study were 30 with primary open angle glaucoma, which is 20 consistent with other studies carried out abroad. O’Brart
15 et al conducted a study which included 50 eyes of 45 and 48 patients’ respectively12, 13 and they included 10 patients suffering from open angle glaucoma and they compared trabeculectomy with MMC and 5 viscocanalostomy respectively. Beatty et al conducted 2
0 a study comprising of 69 high risk patients whose IOP 20 or < 20 With Medication IOP 20 or < 20 Without Medication glaucoma were not controlled medically.14 Work done by Hye included 9 patients with POAG including young Fig: 4. Post Operative Complications patients ranging in age from 24 years to 50 years.15
POST OP COMPLICATIONS Adeqbehinqbe conducted a study, which consisted of 16 12 53 primary open angle glaucoma patients. Study done by Babar TF included 81 patients of POAG and all these 10 10 10 above studies consistent with our study. 9 In our study, 16 (53.3%) patients were using 8 glaucoma medications respectively, while 14 (46.7%) Shallow A/C Hyphema Flat Bleb patients were not using medicines. This observation in 6 Cataract 5 Failed Trab our study is in sharp contrast to the study carried out Nil 4 4 by Casson et al and Hye in which all patients were using glaucoma medications.17, 15 Our study is also 2 inconsistent with that one conducted by Dandona et 1 1 al, in which only 2 patients out of 27 with POAG were 0 18 Shallow A/C Hyphema Flat Bleb Cataract Failed Trab Nil using glaucoma medications. Our study is consistent with Edmunds et al in which 50% patients were on Fig: 5. Post op drugs glaucoma treatment.19 While Adeqbehinqbe noted success of glaucoma drugs in lowering IOP in 13% POST OP DRUGS patients.16 In this study, 16 patients each had a 30 28 preoperative IOP of 20 mm Hg or less with glaucoma
25 medications and 14 patients had preoperative IOP of 20 mm Hg Or less without glaucoma medications. 20 In study carried out by Dandona et al, 66.7%
15 patients had an IOP less than 22 mm Hg and 33.3% had an IOP of more than 22 mm Hg.18 Edmund et al 10 showed that POAG patients had a mean IOP of 29.5 mm Hg at diagnosis and 26.5 mm Hg at the time of 5 19 2 listing for surgery. Mean preoperative IOP recorded 15 0 by Hye was 26.43 mmHg. Mean preoperative IOP Yes No POST OP DRUGS recorded by Adeqbehinqbe et al was 35.5 mm Hg ? 6.2 mmHg.16In our study, operative complications included DISCUSSION shallow A/C in 30% patients, hyphema in 13.33%, Glaucoma is a progressive optic neuropathy with cataract in 16.66%, flat bleb in 3.33% and failed trab in characteristic changes in the optic nerve head and 3.33%. There were no complications in 33.33% patients. corresponding loss of visual field. It is considered as Hye noted conjunctival wound gap, shallow A/C, the second leading cause of blindness after cataract choroidal detachment, cataract formation, hypotony worldwide1 and fourth commonest cause of blindness maculopathy, hyphema in 6.66% of cases. Casson et al in Pakistan.2 Amongst the glaucomas, primary open noted that 10% patients required another surgery in the angle glaucoma (POAG) is the most prevalent type of first year, hypotony maculopathy in 5% and cataract in glaucoma, affecting approximately 1% of the general 35%.17 There was blebitis / endophthalmitis at 4 years
126 Ophthalmology Update Vol. 10. No. 2, April-June 2012 Trabeculectomy with Mitomycin-C in Patients of Primary Open Angle Glaucoma
in 4% and hypotony maculopathy in 4% in study done 2003; 192-269. by Betty et al.14 O’Brat et al noted hypotony in 52% cases 4. Beatty S, Potamitis T, Kheterpal S.Trabeculectomy 13 augmented with Mitomycin-C application under the scleral at one week and 8% needed another trabeculectomy. flap. Br J ophthalmol 1999; 82:397-403. Hyphema was the main complication in 15.3% 5. Mochizuki K, Jikihara S, Ando Y. Incidence of delayed onset patients.16 infection after trabeculectomy with adjunctive Mitomycin-c Post operative IOP in our case series was 20 or 5-flurouracil treatment. Br J ophthalmol 1997; 81:877-83. 6. Talya H, Kupin MD, Mark S. Adjunctive Mitomycin-C in mmHg or less in 93.3% patients without medication and primary trabeculectomy in phakic eyes. Am J of ophthalmol 20mm Hg or less in 6.66% patients with medication. 1995; 119:30-9. Postoperative IOP in Betty series was 16.63mm Hg. Hye 7. American Academy of Ophthalmology. Basic and clinical noted an average postoperative reduction in IOP of Science Course. Section 10, Glaucoma. American Academy of Ophthalmology; 2001-2002; 147-74. 14.04 mm Hg. His mean postoperative IOP was 13.3mm 8. Sirivardina D, Edmunds B. National Survey of antimetabolite 15 Hg. O’Brat et al noted a mean IOP was 7.3mm Hg at use in glaucoma surgery in the United Kingdom. Br J 1st post operative day, 8.3mm Hg at one week.12 In Ophthalmol 2004; 88:873-6. another study they noted a mean IOP of 7mm Hg and 9. Munden PM, Alward WLM. Combined Phacoemulsification, 13 posterior chamber intraocular lens implantation and 7.88mmHg at one week. Mean post operative IOP trabeculectomy with Mitomycin-C. Am J Ophthalmol 1995; recorded by Adeqbehinqbe et al was 10.6mm Hg ? 2.3 119:20-9. mmHg.16 Mean preoperative IOP at 3 months was 10. Babar TF.An audit of 81 cases of Trabeculectomy in primary 14.6mmHg ? 4.2 mm Hg.16 All these studies were open angle glaucoma in NWFP. Pak J Ophthalmol 2001:17:27- 31. consistent with our study. In our study, 6.66% operated 11. Paul M, Munden, MD. Combined phacoemulsification, patients required glaucoma medications. Betty et al posterior chamber intraocular lens implantation and reported that 11.1% patients required topical trabeculectomy with Mitomycin-c. Am J of Ophthalmol 1995; antiglaucoma medications postoperatively.14 None of 119(10):20-9. 12. O’Brart DPS, Rowlands E, Islam N, Noury AMS. A the patients operated by Adeqbehinqe et al required randomized, prospective study comparing trabeculectomy 16 postoperative medication. Karger and Basel reported augmented with antimetabolites with a viscocanalostomy in their study that the target pressure was achieved in technique for the management of open angle glaucoma 73% with MM-C and 68% with out MM-C20. It showed uncontrolled by medical therapy. Br J Ophthalmol 2002; 86:748-54. that our results were satisfactory. S. Beatty et al reported 13. O’Brart DPS, Shiew M, Edmunds B. A randomized, in their study that the success rate of achieving target prospective study comparing trabeculectomy with IOP was 83.3% in MM-C group.14 Babar TF reported in viscocanalostomy with adjunctive antimetabolites for the their study that the target pressure of 21mmHg was management of open angle glaucoma uncontrolled by 10 medical therapy. Br J Ophthalmol 2004; 88:1012-7. achieved in 91.3 %. This study is also consistent with 14. S. Beatty, Potamitis T, Kheter pal S, O’Neill ECO. our study. Mandal et al reported a success rate of 94.7% Trabeculectomy augmented with Mitomycin C application with trabeculectomy supplemented with antimetabo- under the scleral flap. Br J Ophthalmol 1998; 82:397-403. lites in older children.21 So in comparison with other 15. Hye A. Primary trabeculectomy with topical Mitomycin –C in primary glaucoma. Pak J Ophthalmol 2000; 16:124–30. studies our results for augmented trabeculectomies 16. Adeqbehinqbe, Majemqbasan T. A review of regarding intraocular pressure control in POAG were trabeculectomieas at a Nigerian teaching hospital. Ghana satisfactory. Med J 2007; 41:176-80. CONCLUSION: 17. Casson R, Rahman R, Salmon JF. Long term results and complications of trabeculectomy augmented with low dose Trabeculectomy with intraoperative use of Mitomycin C in patients at risk for filtration failure. Br J Mitomycin-C gives better control of IOP because Ophthalmol 2001; 85:686-8. Mitomycin C (MMC) is an antimetabolite used during 18. Dandona L, Dandona R, Srinivas M, Mandal P, John RK, the initial stages of a trabeculectomy to prevent McCarty CA, et al. Open angle glaucoma in an urban population in Southern India. Ophthalmology 2000; excessive postoperative scarring and thus reduce the 107:1702-9. risk of failure. 19. Edmunds B, Thompson JR, Salmon JF, Wormald RP, REFERENCES Edmunds B. The National Survey of trabeculectomy. 1. 1. Khan MD, Qureshi MB, Khan MA. Facts about the status of Sample and methods. Eye 1999; 13:524-30. blindness in Pakistan.Pak J ophthalmology 1999; 15:15-9. 20. Karger, Basel et al. Outcome of trabeculectomy with MMC 2. Babar TF, Saeed N, Masud Z, Khan MD. Two years audit of versus without MMC. Ophthalmologica 2003; 217:24-30. Glaucoma admitted patients in Hayatabad Medical 21. Mandal AK, Waltan DS, John T, et al. Mitomycin C- Complex, Peshawar. Pak J ophthalmol 2003; 19:32-9. augmented trabeculectomy in refractory congenital 3. Kanski JJ, Menon J.Glaucoma.in: Clinical Ophthalmology: glaucoma. Ophthalmology 1997; 104:996-100. A systemic approach.5th ed. London: Butterworth Heinemann
Ophthalmology Update Vol. 10. No. 2, April-June 2012 127 Original Article
Concussional Injuries of the Eye
Dr. Sofia Sofia Iqbal MRCOphth (Lond), FRCS1, Mushtaq Ahmad FCPS,2 Naz Jehangir3 Prof. Zafar ul Islam FCPS4
ABSTRACT Purpose: The aim of the study was to determine the incidence of concussional eye injuries presenting to Hayatabad Medical Complex, Peshawar, its common causes, and the extent of damage it does to the eye. Material and Methods: This prospective study was conducted from 1st January 2009 to 31st December 2010 in the department of ophthalmology Hayatabad Medical Complex Peshawar. Six hundred and thirty five patients presented with ocular trauma. Among them 90 patients had concussional injuries and they were thoroughly analyzed. Results: A total of 635 patients presented during the 24 months period with ocular injuries. Among them 90 (14.17%) had concussional injuries. Males female ratio was 8:1. Children under 15 years of age were most commonly involved especially during play and sports activities as the most incriminating factor. Conclusion: Concussional injuries form a significant part of ocular trauma and can lead to permanent visual disability. Preventive measures and education at school level is of utmost importance in preventing such injuries. Media should be used to create public awareness and education.
INTRODUCTION lack of awareness, poverty and paucity for eye care and Injury to the eye is one of the most common cause traveling long distances to obtain appropriate of ophthalmic morbidity and monocular blindness in treatment9. the whole world 1. Ocular trauma has always been and Mechanical injuries to the eye are mainly of two will be a challenge to the Ophthalmologists. In this types10, concussions and contusions caused by blunt violent and sophisticated age of communication, objects and perforating injuries with or without retained increased industrialization, heightened interest in foreign bodies caused by sharp objects. The blunt sports activity and urban guerrillas, both the number trauma can be divided into three types in terms of and severity of these injuries are increasing.2,3, 4. Eye severity10.Concussions are due to moderate blunt injuries have a significant impact not only in terms of trauma to the eye, and causes changes that are barely suffering and medical costs but also in terms of lost visible to the eye, and are reversible, Contusions are productivity.5 Eye is vulnerable to any type of trauma produced by severe blunt trauma presenting with tissue in spite of the fact that it is protected anatomically by damage without disruption of surface layers of the eye. being placed in a cavity with its overhang bony In laceration the tissue integrity is completely lost and projections, and physiologically by blink reflex and there is disruption of the surface layers of the eye. In copious lacrimation.6 Eyes are injured in 10% of all body this study we have studied the blunt injuries causing injuries which is a disproportionately high percentage, concussion and contusion and have excluded blunt keeping in mind that the front surface of the eye injuries with disruption of the eye ball. constitutes about 0.27% of the body surface7.The MATERIAL AND METHODS: incidence of blindness resulting from trauma has a A total of 635 patients who sustained injuries to worldwide variation8.In developing countries the the eye were admitted to the eye unit of Hayatabad problem of eye trauma is much more severe because of Medical Complex, Peshawar during a period of 24 ––––––––––––––––––––––––––––––––––––––––––––––––––––––– months from 1st January 2009 to 31st December 2010. 1Associate Professor Ophthalmology, Department, Hayatabad Out of these 90 patients (14.17%) had concussional Medical Complex Peshawar. injuries to the eye. At the time of admission detail 2Registrar Ophthalmology Department, Hayatabad Medical Complex, Peshawar. 3Medical Officer history of the patient including date, time and location 4.Professor of Ophthalmology, Kabir Medical College, Gandhara of accident, whether the injury occurred at work, during Medical University, Peshawar play or some other activity. A detail description of the ––––––––––––––––––––––––––––––––––––––––––––––––––––––– object, distance traveled to the eye and direction was Correspondence: Dr. Sofia Iqbal, House no 86, street no 6, sector G-2, Phase 2, Hayatabad,Peshawar noted. A special check into pre-existing diseases of the E.Mail>sofiaiqbal71@ yahoo.com 03339254264 eye was also made. ––––––––––––––––––––––––––––––––––––––––––––––––––––––– The examination of the injured eye included visual Received: Oct’2011 Accepted: Jan’2012 acuity measurement using Snellen’s chart, intraocular –––––––––––––––––––––––––––––––––––––––––––––––––––––––
128 Ophthalmology Update Vol. 10. No. 2, April-June 2012 Concussional Injuries of the Eye
pressure measurement using Goldmann tononmeter, age and gender traumatic hyphema was highest among Slit lamp biomicroscopy, Direct and Indirect children and young adults, and males were at greater ophthalmoscopy, examination under anesthesia (when risk than females (Table 4) A quantitative grading needed), x-rays of the orbit, CT Scan orbit and system for the amount of blood in the anterior chamber ophthalmic ultrasound. A quantitative grading system was devised as reported by Kennedy and Brubaker. for the amount of blood in the anterior chamber was (Table 5).Highest number of patients (42.86%) devised as reported by Kennedy and Brubaker11. presented with grade 5 hyphema. grade 1 and grade 3 Patients were keenly observed during their stay in the hyphema each was seen in 7 (11.11%) patients. grade 2 hospital including daily visual acuity measurement, in 19 (30.16%) cases. grade 4 hyphema was observed in intraocular pressure measurement and slit lamp 3 (4.76%) cases. biomicroscopy. Corneal staining occurred in 4 (6.35%) patients. The treatment regimen included bed rest, All had grade 5 hyphema with raised intraocular analgesia and sedation as required, patching of the pressure. Gonioscopy was routinely performed on involved eye, local antibiotics, local steroids, follow up examination. 65 patients came for follow up cycloplegics and intraocular pressure lowering drugs and gonioscopy was performed on 58 patients. 12 eyes as and when required. Traumatic cataract was removed (31.60%) showed recession of angle. All the cases were by lens matter aspiration and phacoemulsification. associated with hyphema. 62 (68.88%) eyes had iris or Secondary hyphemas aspirated when the eyes were pupillary abnormalities. Traumatic mydriasis was the endangered by raised intraocular pressure and corneal most common presentation and was seen in 54 (60%) staining. 65 patients came for follow up examination patients. Traumatic iritis in 2(2.22%) cases and posterior and a complete examination including gonioscopy was synechiae in 3 (3.33%) patients. Spastic miosis was performed. observed in 3 (3.33%) cases. RESULTS: Out of the 90 patients 17(18.89%) developed A total of 90 cases of Concussional eye injury were traumatic cataract. Ten eyes had total opacification, five studied, representing 14.17% of all ocular injuries (total eyes had rosette located in the posterior cortex and two 635) in 24 months duration. Males were affected more eyes had posterior sub-capsular cataract. 17(18.89%) than females, and male to female ratio was 8:1.Children eyes had subluxation of the lens, while dislocation was were most frequently affected (Table 1). The incidence not observed in any case in our study. A total of in age group 0-15 was 58.88%. However the ratio of 34(37.78%) cases developed vitreous haemorrhage. In children, affected in ocular trauma as a whole, was 19 eyes the vitreous haemorrhage was associated with comparatively less, and this was because of higher total hyphema. Retinal and macular damage occurred incidence of perforating and penetrating injuries in in 35 (38.89%) eyes. 24(26.66%) had commotio retinae. adults which is not included in this study. The right Out of these 13 had mild retinal edema with no other eye was affected slightly more often (54.44%) than the changes in the retina. The remaining eleven eyes had left eye. One eye of each patient was affected. other changes including macular edema (3 eyes), retinal The most common cause of injury to the eye was or macular hemorrhages (3 eyes), retinal tear (2 eyes) sports and play (Table 2).There were 55 patients and pre-retinal haemorrhages (3 eyes). Among the rest (61.11%) in this group. Out of 55 patients, 51 were under of eleven patients (12.22%) the following changes were 15 years of age. The second major group fell into the observed. 5 patients had extensive chorio-retinal tears category of fight and assault (14.45%). Injuries during with massive vitreal hemorrhages (chorioretinitis occupational activities and road traffic accidents sclopeteria), four patients had retinal detachment, one accounted for 10% and 5.58% of total injuries patient had retinal dialysis, which was infero-temporal respectively. Domestic and firearm injuries fell into the and was associated with shallow Retinal detachment. last group, each accounting for 3.33% of all the One patient presented with optic nerve avulsion. concussional injuries to the eye. 43 (47.77%) eyes showed damage to the cornea Table 1: Age and gender distribution (Table 3). Corneal edema was seen in 35 (38.88%) patients. Folds in the Descemet’ membrane in 21 Age Male Female Total Percentage (%) (23.33%) patients. All were associated with corneal edema. Corneal abrasions were present in 11(12.22%) 0-15 46 7 53 58.89 cases. In one case there was corneal edema with tears 16-30 25 1 26 28.89 in the Descemet’ membrane. > 30 9 2 11 12.22 Hyphema which occurred in 63 (70%) patients, was the commonest mode of presentation. Regarding total 80 10 90 100.00
Ophthalmology Update Vol. 10. No. 2, April-June 2012 129 Concussional Injuries of the Eye
Table 2: Etiology of injury with regards to age and gender
Causes 0-15 years 16-30years Over 30 years Total %age Male Female Male Female Male Female Sports 438211-5561.11
Catapult 12 4____
Stone 13 1____
Stick 5111__
Airgun 41__1_
Toypistol 31____
Golidanda 3_____
Mudball 2_____
Cricket ball 1_1___
Fight/assault 1_8_4_1314.45
Occupational __6_3_910.00
Road traffic accidents 1_2_2_55.56
Domestic - _21__33.33
Fire arm injury __3___33.33
Bullet __1____
Gunshot __1____
Bomb blast __1____
Miscellaneous __1_1_22.22
Total 90 100.0
Table 3: Concussion effects on the cornea Table: 5. Extent of Hyphema at presentation
No of patients %age Extent of hyphema No of patients %age
Corneal edema 35 38.88 Grade 1 Microscopic 7 11.11 Descemet’folds 21 23.33 Grade 2 Microscopic to 1/3 19 30.16
Corneal abrasion 11 12.22 Grade 3 1/3 to 1/2 7 11.11
Corneal staining 4 4.44 Grade 4 1/2 to > total 3 4.76 Tears in descemt’membrane 1 1.11 Grade 5 Total 27 42.88
Overall 63 100.00
Table 4: Hyphema: Age and gender distribution DISCUSSION: Ocular trauma is the most frequent cause of Age (years) Male Female Total %age monocular blindness1. It occurs most frequently in the 0-15 33 6 39 61.91 active years of life and is associated with economic 16-30 18 _ 18 28.57 losses, pain and psychological upsets which may be severe and persistent. A total of 90 cases of concussional More than 30 4 2 6 9.52 eye injuries were studied representing 14.17% of all Total 55 8 63 100.00 ocular injuries (total 635) in 24 months duration. The
130 Ophthalmology Update Vol. 10. No. 2, April-June 2012 Concussional Injuries of the Eye
incidence of concussional eye injuries was much higher The incidence of angle recession matches closely with in a study reported from Nigeria (37.4%)12, while the that found by Kennedy and Brubaker11 who found incidence was only 1.56% in a study conducted in 28.6% incidence of angle recession in a series of 248 USA13.The reason for this decrease incidence is due to eyes. seat belt legislation and other preventive measures in 62 eyes 68.88 had iris or pupillary abnormalities. the developed countries. Traumatic mydriasis was observed in 54(60%) patients. Children were most frequently affected. The This figure is very similar to a study from Ireland19and incidence in age group 0-15 years was 58.88%. This is higher than a study conducted in Nigeria12. Out of higher incidence is mainly because of children being the 90 patients, 17 eyes (18.89%) developed traumatic engaged in aggressive games and lack of awareness and cataract. The incidence of traumatic cataract in the blunt supervision of parents in low and middle class families. trauma to the eye may range from 2.7% to 37% 12,14 &23. Similar situation has been observed in a study from Seventeen eyes (18.89 %) had subluxation of lens. This India14. The right eye was affected slightly more often correlates well with a study from Belfast19, while in (54.44%) than the left eye. Similar right eye another study there was not a single case of preponderance was reported in a study from USA15. subluxation24. Male to female ratio was 8:1, such statistics have been CONCLUSION reported by other studies12&16.This may be due to the Concussional injuries form a significant part of fact that young boys are more actively involved in ocular trauma. Children are at high risk and sports is sports. the most common incriminating factor. Preventive In our study the most common cause of injury to measures must form the corner stone of management the eye was sports and play (55 patients, 61.11%). This regardless of the cause. Prevention of ocular trauma correlates with a studies from India and Australia.17&18 pose a great challenge and justifies our priority The second major group fell into the category of attention. fight and assault (14.45%). The reason for this incidence REFERENCES may be due to the aggressive nature of a particular tribal 1. Wong T, Klein B, Klein R. The Prevalence and 5-year incidence of Ocular trauma –The Beaver Dam Eye Study. culture and the cross border terrorism .This figure Ophthalmology.2000; 107: 2196-2202. coincides with a study from USA, where 14.3% of eye 2. Chen G, Sinclair SA, Smith GA, Ranbom L, Xiang H: injuries were inflicted during fight and assault13. Hospitalized ocular injuries among persons with low Injuries during occupational activities and road socioeconomic status: a medical enrollees-based study.Ophthalmic Epidemiol 2006, 13:199-207 traffic accidents accounted for 10% and 5.56% of total 3. Kuhn F, Maisiak R, Mann L, Mester V, Morris R, Witherspoon injuries respectively. These figures are relatively less CD:The ocular trauma score (OTS). Ophthalmol Clin N Am than what might be, keeping in mind that this study 2002, 15:163-165. includes only non-perforating injuries while most of the 4. Kuhn F, Maisiak R, Mann L, Mester V, Morris R, Witherspoon CD: The Birmingham Eye Trauma Terminology system injuries occurring during road traffic accidents are (BETT)J Fr Ophthalmol 2004, 27:206-210 associated with perforation. In developing countries 5. Bhogal G, Tomlins PJ, Murray PI: Penetrating ocular injuries like Pakistan, the industrial accidents are mostly due in the Home. J Public Health (Oxf) 2007, 29:72-74. to poor working conditions with minimal safety 6. Mela EK, Dvorak GJ, Mantzouranis GA, Giakoumis AP, Blatsios G, Andrikopoulos GK, Gartaganis SP:Ocular trauma measures. Long working hours and little leisure time in a Greek population: review of 899 cases resulting in also increase accidents due to fatigue. Domestic and hospitalization.Ophthalmic Epidemiol 2005, 12:185-190. firearm injuries fell in the last group, each accounting 7. Tomazzoli L, Renzi G, Mansoldo C: Eye injuries in childhood: for 3.33% of the concussional eye injuries. a retrospective 8. investigationof 88 cases from 1988 to 2000.Eur J Ophthalmol Hyphema which occurred in 63 patients (70%) 2003, 13:710-713. was the commonest mode of presentation. This was 8. Bianco M, Vaiano AS, Colella F, Coccimiglio F, Moscetti M, similar to studies from Nigeria and Ireland12&19. Palmieri V, Focosi F, Zeppilli P, Vinger PF: Ocular Traumatic hyphema was most commonly observed in complications of boxing Br J Sports Med 2005, 39: 70-74. 9. Mieler W: Overview of ocular trauma. In Principles and children and young adults and males were at a greater Practice of Ophthalmolgy. 2nd edition. Edited by Albert D, risk. Similar findings were noted in a number of other Jakobiec F, Philedelphia, WB Saunders Co; 2001:5179. studies12&20. 27 patients (42.86%) presented with total 10. Smith ARE, O’Hagan SB, Gole GA: Epidemiology of open- hyphema. Similar higher ratios were observed by and closed-globe trauma presenting to Cairns Base Hospital, 21&22 Queensland. Clin Experiment Ophthalmol 2006, 34:252. studies by Pizzarello and Witteman . This higher 11. Kennedy RH, Brubaker RF: Traumatic hyphema in a defined incidence can be explained by the fact that most of the population Am J Ophthalmol 1988; 106; 123-30. patients having lesser degree of hyphema do not seek 12. Onyekonwu GC, Chuka-Okosat CM. Pattern and visual medical advice. Gonioscopy was performed in 58 outcome of eye injuries in children at Abakaliki, Nigeria.West patients. Twelve eyes (31.60%) showed angle recession. Afr J Med. 2008 Jul; (3):152-4.
Ophthalmology Update Vol. 10. No. 2, April-June 2012 131 Concussional Injuries of the Eye
13. May DR, Kuhn FP, Morris RE, Witherspoon CD, Danis RP, 18. Mc Carty CA, Fu CL, Taylor HR. Epidemiology of ocular Mathews GP, Mann L. The epidemiology of serious eye trauma in Australia. Ophthalmology. 1999 Sep; 106(9):1847- injuries from the United States Eye Injury Registry. Graefes 52. Arch Clin Exp Ophthalmol. 2000 Feb; 238(2):153-7. 19. Saeed A, Khan I, Duanne O, Stack J, Beatly S.Ocular injury 14. Nirmalan PK, Katz J, Tielsch JM, Robin AL, Thulasiraj RD, requiring hospitalization in the south east of Ireland: 2001- Krishnadas R, Ramakrishan R; Arvind. Ocular trauma in 2007. Injury.2010 Jan; 41(1):86-91. a rural south Indian population: Comprehensive eye survey. 20. Khan MD, Kundi N, Mohammed Z, Nazeer AF: Eye injuries Ophthalmology.2004 Sep;111(9):1778-81. in North West Frontier province of Pakistan. Pak J 15. Baker RS, Wilson MR, Flowers CW, Lee DA, Wheeler NC, Ophthalmol, 1988;4:5-9. Demograhic factors in a population based survey of 21. Pizzarello LD. Ophthalmic Epidemiol. 1998 Sep;5(3):115-6. hospitalized work-related, ocular injury.Am.J Ophthol 22. Witteman GJ, Brubaker SJ, Johnson M, Marks RG: The 1996;122:2139. incidence of rebleeding in traumatic hyphema. Am J 16. Karlson TA, Klein BEK. The incidence of acute hospital- Ophthalmol 1985: 17; 525-9. treated eye injuries. Arch Ophthalmol 1986;106:785-9. 23. Canvan YM, Archer DB. Anterior segment consequences of 17. Krishnaiah S, Nirmalan PK, Shamanna BR, Srinivas M, Rao blunt ocular injury. Br J Ophthalmol 1982;17:457-60. GN, Thomas R. Ocular trauma in a rural population of 24. Spoor TC, Hamer M, Belloso H, Traumatic hyphema: failure southern India: the Andhra Pradesh eye disease study. of steroids to alter its course, a double blind prospective Ophthalmology.2006 Jul; 113(7):1159-64. study. Arch Ophthalmol 1980; 98:116-9.
15th Annual Congress of Ophthalmology OSP. Federal Brach, Islamabad to be held at Bhurban (Murree) 4-6 May 2012 Theme: INNOVATION IN OPHTHALMOLOGY Please contact: Col. Amer Yaqub Chairman, Scientific Committee Cell: 0342 5174777 E. Mail: [email protected]
132 Ophthalmology Update Vol. 10. No. 2, April-June 2012 Original Article
Complications of Intravitreal Injections of Bevacizumab Dr. Mushtaq Mushtaq Ahmad FCPS1, Sofia Iqbal MRCOphth FRCS2, Nazullah FCPS3 Muhammad Naeem4
ABSTRACT Objective: To evaluate the short term complications after intravitreal injection of Bevacizumab(Avastin). Materials and Methods: The clinical interventional case-series study included 100 intravitreal injections of about 1.25mg bevacizumab, performed in the period from August 2010 to August 2011 by three surgeons at their private clinics for patients who were diagnosed to have macular oedema or retinal neovascular disease . Patients were followed for 3 months after injectin. Results: One patient got endophthamitis (1/100 or 1%) with hypopyon but resolved after one intravitreal injection of vancomycine and ceftazidime, Painless vitreous haze was observed in one eye (1/100 or 1%) from the bevacizumab injection , Chemosis in 4 cases (4/100 or 4%) and one eye (1/100 or 1%) showed rapidly progressive lenticular changes. The total rate of these complicatios was 7/100 (7.00%). Conclusion: Injection-related complications such as infectious endophthalmitis, Painless vitreous haze, Chemosis and traumatic cataract may occur after intravitreal injections of bevacizumab the beneficial effectiveness of the drug overwhelms these adverse effects. These injection-related risks compare favourably with the therapeutic benefit by the intravitreal therapy. Keyword:Bevacizumab,intravitreal injection,Vitreous
INTRODUCTION 3. Proliferative diabetic retinopathy Bevacizumab (Avastin Genetech Inc, South San 4. Iris neovascularization with proliferative diabetic Francisco, California, USA) is a humanized vascular retinopathy endothelial growth factor (VEGF) antibody used for 5. CNV caused by pathological myopia and metastatic colorectal carcinoma.1 Recent reports have idiopathic CNV10 described the application of Bevacizumab to treat ocular Regarding the safety use of intravitrel injection neovascular disorder including proliferative diabetic of bevacizumab many studies have been done and still retinopathy.2-5 More recently intravitreal injection of other are under progress to determine the effectiveness Bevacizumab (IVB) before PRP has been reported to be versus complications of this drug. Ocular adverse effective also in preventing PRP induced visual effects like chemosis, corneal abrasion, inflammation dysfunction and foveal thickening6,7 and promoting ,cataract formation, retinal pigment epithelial tear and greater reduction in the area of active leaking of (new endophthalmitis after intravitreal injections of vessels) NV in Proliferative Diabetic Retinopathy (PDR) bevacizumab11 have been reported but the frequency patients.8,9 rate of these adverse effects is so low that the benefits Nowadays intravitreal Bevacizumab is used to overwhelms them. treat following disorders: MATERIALS AND METHODS: 1. CNV caused by age related macular degeneration The clinical interventional case-series study 2. Retinal vein occlusion included 100 intravitreal injections of about 1.25mg bevacizumab, performed in the period from August ––––––––––––––––––––––––––––––––––––––––––––––––––––––– 2010 to August 2011 by three surgeons at their private 1.Registrar Ophthalmology Department Hayatabad Medical Complex,Peshawar.2. Associate Professor Ophthalmology, clinics for patients who were diagnosed to have macular Department, Hayatabad Medical Complex, Peshawar.3 Assistant oedema or retinal neovascular disease. Patients were Professor Ophthalmology, Bannu Medical College, Bannu, 4 Medical followed for 3 months after injectin. Officer Ophthalmology, Hayatabad Medical Complex, Peshawar Before disinfecting with povidone iodine, topical ––––––––––––––––––––––––––––––––––––––––––––––––––––––– Correspondence: Dr Mushtaq Ahmad, House 31B, street no 2, propracaine 0.5% was applied to anesthesize the eye. sector N4, Phase 4, Hayatabad, Peshawar About 3.5mm from the lumbus in the supero-temporal E.Mail> [email protected] Cell: 03339119605 site of the eye injection 1.25mg bevacizumab was ––––––––––––––––––––––––––––––––––––––––––––––––––––––– injected intravitreally via 29g needle. Pressure was Received: Oct’2011 Accepted: Jan’2012 ––––––––––––––––––––––––––––––––––––––––––––––––––––––– applied at injection site with tying forceps to avoid
Ophthalmology Update Vol. 10. No. 2, April-June 2012 133 Complications of Intravitreal Injections of Bevacizumab
reflux for 30 seconds. Antiboitic drops (vigamox) of bevacizumab have markedly increased in frequency prescribed 4 hourly for one week. Patients having as therapy of diabetic macular oedema, exudative age- macular oedema and retinal neovascularization due to related macular degeneration and other intraocular several causes were included in this study. Only those neovascular or oedematous diseases.12 patients were excluded from the study who did not Ischemic diseases of eye like central retinal vein gave consent for the injection and who rejected to occlusion and diabetic or hypertensive retinopathy comply for the follow up visits. Patients were followed causes microangiopathies at tissue level. The resultant at 1st post operative day four weeks and then after three hypoxia leads to release of vascular endothelial growth months. The examination at each follow up was done factor(VEGF) . VEGF has dual actions, one it causes to measure visual acuity, intraocular pressure, detailed neovessels formation other it increases vascular anterior segment and fundus examination. permeability which leads to retinal RESULTS edema.Bevacizumab is a monoclonal antibody that was A total of 100 eyes of 78 patients with various first used in the treatment of colorectal cancer . The intraocular edematous and neovascular diseases mode of action of this drug is to inhibit the increased (Table 1) given single dose of intravitreal activity of VEGF. This in turn will reverse the bevacizumab were evaluated. phenomena of neovascularization and oedema formation. Other uses of intravitreal Bevacizumab are Table 1. Patients treated with Bevacizumab retinopathy of prematurity (ROP), psuedophakic Indication for Inj. No. of Pt. macular edema,central serious chorioretinopathy (CSCR) and radiation retinopathy Despite the beneficial Wet AMD 15 effects, one should remember that intravitreal injections CRVO 20 of Bevacizumab carries the risk of traumatic cataract, 13 Diabetic macular oedema 29 endophthalmitis and retinal detachment. Our study sample of 100 eyes for the intravitreal Proliferative diabetic ret. 33 injection of bevacizumab yielded adverse events in NVG 3 seven eyes. This was comparable with other studies where there were multiple complications. It was One patient got endophthamitis (1/100 or 1%) therefore presumed that the complications were not with hypopyon but resolved after one intravitreal associated with chemical composition of Bevacizumab injection of vancomycine and ceftazidime. Out of 100 but with the route of injection. The use of intravitreal eyes 4 cases developed conjunctival chemosis (4%), one bevacizumab is still limited in our area of study because case developed traumatic cataract (1%)and one of the cost effectiveness and availability. It is therefore developed vitreous haze (1%). chemosis was of early expected that with the passage of time the beneficial onset and subsided soon, cataract was of iatrogenic effects of this drug will make it freely available and trauma origin and treated successfully with price reduction to patient’s range so that a large sample Phacoemulsifiaction. The painless vitreous clouding of study will be available to determine the injection subsided after intensified topical antibiotic therapy related risks versus therapeutic benefits. (Table 2). CONCLUSION: Injection-related complications such as infectious Table 2. Post intravitraeal injection endophthalmitis, Painless vitreous haze, chemosis and traumatic cataract may occur after intravitreal injections Name of Complication No. of Pts. of bevacizumab, the beneficial effectiveness of the drug Endophthalmitis 1 (1%) overwhelms these adverse effects. These injection- Chemosis 4(4%) related risks compare favourably with the therapeutic benefit by the intravitreal therapy. Corneal abrasion 0 REFRENCES: Cataract 1 (1%) 1. Quillen DA, Gardner TW, Blankenship GW. Clinical Trials in Ophthalmology: A Summary and Practice Guide. In: Uveitis 0 Kertes C, ed. diabetic retinopathy study. 1998:1-14. 2. Kramer I, Lipp HP. Bevacizumab, a humanized Raised IOP 0 antiangiogenic monoclonal antibody for the treatment of Vitreous haze 1 (1%) colorectal cancer.J Clin Pharm Ther 2007; 32: 1-14. 3. Avery RL, Pearlman J, Pieramici DJ, Rabena MD,Castellarin AA, Nasir MA et al. Intravitreal Bevacizumab (Avastin) in DISCUSSION the treatment of proliferative diabetic retinopathy. Since 2000 to 2005, the intravitreal applications Ophthalmology 2006; 113: 1695.e1-1695.e15.
134 Ophthalmology Update Vol. 10. No. 2, April-June 2012 Complications of Intravitreal Injections of Bevacizumab
4. Chen E, Park CH. Use of intravitreal Bevacizumab as a severe proliferative diabetic retinopathy. Retina preoperative adjunct for tractional retinal detachment repair 2008;28:1319e24. in severe proliferative diabetic retinopathy. Retina 2006; 26: 10. Gomi F, Nishida K, Oshima Y, Sakaguchi H, Sawa M, 699-700. Tsujikawa M & Tano Y. Intravitreal bevacizumab for 5. Mason III JO, Nixon PA, White MF. Intravitreal injection of idiopathic choroidal neovascularization after previous Bevacizumab (Avastin) as adjunctive treatment of injection with posterior subtenon triamcinolone. Am J proliferative diabetic retinopathy.Am J Oph-thalmol 2006; Ophthalmol;143: 507–510. 142: 685-688. 11. Wu L, Martinez-Castellanos MA, Quiroz-Mercado H, 6. Luke M, Januschowski K, Warga M, Beutel J, Leitritz M, Arevalo JF, Berrocal MH, Farah ME. Twelve-month safety Gelisken F et al. Intravitreal Bevacizumab (Avastin) therapy of intravitreal injections of bevacizumab (Avastin(R)): results for persistent diffuse diabetic macular edema. Retina 2006; of the Pan-American Collaborative Retina Study Group 26: 999-1005. (PACORES). Graefes Arch Clin Exp Ophthalmol 2008; 246: 7. Cho WB, Moon JW, Kim HC, et al. Panretinal 81–87. photocoagulation combined with intravitreal bevacizumab 12. Rosenfeld PJ, Moshfeghi AA, Puliafito CA. Optical coherence in high-risk proliferative diabetic retinopathy. Retina tomography findings after an intravitreal injection of 2009;29:516e22. bevacizumab (avastin) for neovascular age-related macular 8. Tonello M, Costa RA, Almeida FP, et al. Panretinal degeneration. Ophthalmic Surg Lasers Imaging 2005; 36: 331– photocoagulation versus PRP plus intravitreal bevacizumab 335. for high-risk proliferative diabetic retinopathy (IBeHi study). 13. Meyer CH, Mennnel S, Schmidt JC & Kroll P. Acute retinal Acta Ophthalmol 2008;86:385e9. epithelial tear followingintravitreal bevacizumab (Avastin) 9. Mason JO 3rd, Yunker JJ, Vail R, et al. Intravitreal injection for occult choroidal neovascularisation secondary bevacizumab (Avastin) prevention of panretinal to age related macular degeneration. Br J Ophthalmol photocoagulation-induced complications in patients with 2006;90: 1207–1208.
Ophthalmology Update Vol. 10. No. 2, April-June 2012 135 Original Article
An audit of Neonatal Services in Khyber Pakhtunkhwa Province (KPK), Pakistan
Dr. Sadia to identify Implications for screening Sethi ‘Retinopathy of Prematurity’
Sadia Sethi,1 Haroon Awan,2 Niaz Ullah Khan3
ABSTRACT: Aims and Objectives: To identify nurseries / neonatology units where underweight / premature babies were born and subsequently treated in Khyber Pakhtunkhwa. To determine the extent of neonatal services available / developed in different hospitals all over the province. To suggest policy guidelines for screening of low birthweight and premature babies. Study Period: 2005 - 2006 Methodology A standard questionnaire was designed by International Center for Eye Health London and all neonatal units of Khyber Pakhtunkhwa were visited. Information was obtained from files of all neonatal units covering a two year period (2005 and 2006) except two hospitals Naseer Teaching Hospital and Health Care Center where information was obtained from hospital record and data was manually complied. Results: In year 2007, there were 74 neonatal units in Pakistan (30 neonatal units in Sindh, 27 in Punjab, 15 in KPK and 2 in Baluchistan). There were 28,738 babies admitted over a two year period preceding the study in neonatal units in different hospitals in KPK excluding CMH Peshawar and CMH Nowshera. There 1411 were very low birth weight babies, 6182 Low birth weight babies(LBW) , 4623 premature babies(PB) in different neonatal units in KPK. There were two neonatal units where neonatologists were available. These included Khyber Teaching Hospital and Kuwait Teaching Hospital, Peshawar. Full time anesthetists were not available in any neonatal units in KPK. 62 incubators were present in 13 neonatal units in KPK. Discussion: In this study a total of 28738 babies were admitted in 13 neonatal units of KPK in year 2005-2006. Low birth weight babies accounted for 21.19%of total admissions. In our study there were 4623 (16.60% ) premature babies, 3258 survived (survival 70.47%). Khyber Teaching Hospital had maximum number of premature babies (1931) that were admitted during the study period. Lady Reading Hospital had second highest number of babies, where 1806 babies were admitted. The survival percentage of Mardan Medical Complex was best among neonatal units in the province where out of 341 premature babies, 323 survived survival ( 94.72%). Conclusion: In our study 664 (2.3%) babies had weight <1500gm, while in 639 (2.2%), the babies had gestational age <31 weeks requiring ROP screening. Ventilation was not available anywhere Khyber Pakktunkhwa except at CMH Peshawar. There were 99 medical personnel and 53 nursing personnel involved in Khyber Pakhtunkhwa in providing services to neonates. No regular screening for Retinopathy of Prematurity was done anywhere in Khyber Pakhtunkhwa. Key words: Prematurity, low birth weight, retinopathy of prematurity, neonatal units.
INTRODUCTION for managing different neonatal problems. A large Neonatology is a branch of Pediatrics which is majority of newborn babies do not develop any serious rapidly emerging as a sub specialty and in near future problem or difficulties and require only minimal care, it is expected to expand further as a result of neonatal which can be provided by the mother if properly screening programs and the availability of resources supervised by a health worker. High-risk mothers are likely to give birth to preterm or low birth weight babies ––––––––––––––––––––––––––––––––––––––––––––––––––––––– 1 1Associate Professor Ophthalmology, Khyber Teaching Hospital, who suffer a large number of problems . Majority of Peshawar Representative,2Regional Representative, Sightsavers the causes of neonatal morbidity in Pakistan are International (Previously at the time of study) 3Country preventable2. Some of the newborns in developing Representative, Sightsavers International countries have impaired growth right during their ––––––––––––––––––––––––––––––––––––––––––––––––––––––– Corresponding address: Dr. Sadia Sethi, House: 33, St: 4, intrauterine life, reflecting the nutritional status of the Defence Colony, Khyber Road, Peshawar. mother3. Almost half of the infant deaths in Pakistan Cell: 0092 308 8269668. E.Mail: [email protected] occur within first 28 days of life4. Pre-maturity accounts ––––––––––––––––––––––––––––––––––––––––––––––––––––––– for majority of high risk newborns as they face a large Acknowledgement: We are grateful to Prof. Clare Gilbert of the 5 International Centre for Eye Health, UK for providing the template number of problems . Recent advances in neonatal care for data collection. have improved survival rates for premature infants6 ––––––––––––––––––––––––––––––––––––––––––––––––––––––– and this has been accompanied by an increase in Received: Oct’ 2011 Accepted: Jan’ 2012 incidence of Retinopathy of Prematurity7-9. –––––––––––––––––––––––––––––––––––––––––––––––––––––––
136 Ophthalmology Update Vol. 10. No. 2, April-June 2012 Neonatal Services in KPK Province, Pakistan to identify Implications for screening ‘Retinopathy of Prematurity’
Neonatal audit is carried out in Pakistan from time only neonatal unit where ventilation of children is done to time in order to create awareness regarding pre-term in KPK is Combined Military Hospital Peshawar. babies and other neonatal problems which they face Photographs of the peripheral hospitals were not and their management in an effective way. For better feasible. neonatal care and prevention of the preventable causes RESULTS of neonatal morbidity and mortality, there is a need to In year 2007 there were 30 neonatal units in Sindh, be continuously reporting the audit of neonatal 27 in Punjab, 15 in KPK and 2 in Baluchistan. There admissions to neonatal units all over the country. The were 28738 babies admitted in year 2005-2006 in purpose behind such types of audits in neonatal units different neonatal units in Khyber Pakhtunkhwa should be for the identification of various deficiencies excluding CMH Peshawar and CMH Nowshera. There in the management of these neonates and also to assist were 4 private hospitals where neonatal services were the health workers specially those at the community provided to babies while 11 government hospitals had level for better understanding and effective neonatal units; 5 were university hospitals (Fig. 1). 4656 management of various neonatal problems in Pakistan. (16.2%) neonates in 2005-2006 were treated in private AIMS AND OBJECTIVES hospitals while 24082 (83.7%) were treated in 1. To identify nurseries / neonatology units where government hospitals. Table:1 shows the hospitals in underweight / premature babies were born and KPK and number of neonatal admissions. There were subsequently treated in KPK. 13390 (46.59%) admissions in year 2005 and 15348 2. To determine the extent of neonatal services (53.41%) of admissions in year 2006. (Table 1) available / developed in different hospitals all Facility of Endotracheal intubation was available over KPK. only in CMH Peshawar. Ventilation and surgery was 3. To determine type of training / qualification of unavailable to babies anywhere in KPK, while no staff. ventilation was given in 14 hospitals visited in KPK. 4. To formulate a policy for screening of low birth Table:2 shows that 1411 babies of very low birth weight and premature babies. were admitted during the study period. They had mean METHODOLOGY survival rate of 48.48%. Table: 3 shows that 6182 low A consultation workshop was organized at the birth weight babies were admitted in the study period College of Ophthalmology and Allied Sciences, with a mean survival rate of 62.97%. Table: 4 shows (previously Punjab Institute of Preventive that 4623 babies were born premature out of which 3258 Ophthalmology-PIPO) on 12th October 2006, to develop babies survived with a mean survival rate of 70.47%. a joint course of action by the ophthalmologists, Table: 5 shows that 664 (2.3%) babies were less than pediatricians and neonatologists for the early detection 1500gms who needed ROP screening. Table: 6 shows and control of retinopathy of prematurity in children that 639 (2.2%) babies were born premature (<31 weeks) and to collect data regarding prevalence of prematurity and needed ROP screening. / low birth weight babies born at all hospitals across There were only two neonatal units where the country as well as concentration of oxygen given to neonatologists were available. These included the them was recommended. A questionnaire was designed Khyber Teaching Hospital and Kuwait Teaching by International Center for Eye Health London and Hospital Peshawar. There were 31 pediatricians, 19 information about the neonatal units all over Pakistan resident, and 47 medical officers in different neonatal was obtained with the help of the Pakistan Pediatric units in KPK. A total of 97 medical personnel were Association KPK. Four Focal Persons were identified, involved in providing neonatal services. There were one for each Province. They provided us with the list of hospitals in all the four provinces of Pakistan. We Figure 1: Types of Hospitals in Khyber Pukhtoonkhwa where selected KPK as a sample and conducted a situation Neonatal Units were present analysis of KPK. All the hospitals of KPK where neonatal units exist were visited in year 2007 and available data was retrieved in all hospitals through files of year 2005 and 2006 with the help of a pediatrician in Health Care Center and Naseer Teaching Hospital, though it was difficult to obtain the files in these two hospitals. Constraints. Due to reasons of official clearance, we were unable to obtain any data from the Combined Military Hospitals in Peshawar and Nowshera. The
Ophthalmology Update Vol. 10. No. 2, April-June 2012 137 Neonatal Services in KPK Province, Pakistan to identify Implications for screening ‘Retinopathy of Prematurity’
Table 1. Admissions of children in nursery in different hospitals in Khyber Pukhtunkhwa, Province in year 2005-2006.
S.No. Neonatal Unit Number of total neonatal Number of total neonatal Total of year admissions of two years in admission of two years in 2005 and nursery - year 2005 nursery - year 2006 2006 1. Rehman Medical Institute Peshawar 222 281 503 2. Saidu Teaching Hospital Swat 1850 2286 4136
3. Naseer Teaching Hospital Peshawar 000 13 13
4. Lady Reading Hospital Peshawar 2759 2822 5581 5. Kuwait Teaching Hospital Peshawar 275 206 481
6. Khyber Teaching Hospital Peshawar 1694 2206 3900
7. Health Care Center Peshawar 1737 1922 3659 8. Hayatabad Medical Complex Peshawar 899 906 1805
9. Fauji Foundation Hospital Peshawar 000 245 245
10. DHQ D.I. Khan 1600 1832 3432 11. DHQ Mardan 425 456 881
12. CMH Peshawar Refused to provide statistics Refused to provide statistics
13. CMH Kohat 421 845 1266 14. Ayub Teaching Hospital Abbottabad 1508 1328 2836
15. CMH Nowshera Refused to provide Statistics Refused to provide Statistics
Total 13390 15348 28738 Percentage of total admissions in nursery of two years 46.59% 53.41%
Table 2. Very low birth weight in different hospitals in KPK Pakistan in year 2005-2006.
Hospitals Very low birth weight Status at birth Survival %age
Rehman Medical Institute, Peshawar 12 9 75% Saidu Teaching Hospital, Swat 115 Unknown Unknown
Naseer Teaching Hospital, Peshawar Unknown Unknown Unknown
Lady Reading Hospital, Peshawar 526 155 29.46% Kuwait Teaching Hospital, Peshawar 2 2 100%
Khyber Teaching Hospital, Peshawar 496 335 67.5%
Health Care Center, Peshawar Unknown Unknown Unknown Hayatabad Medical Complex, Peshawar 104 76 73.0%
Fauji Foundation Hospital, Peshawar 25 17 68%
District Hospital Dera Ismail Khan 20 11 55% District Hospital Mardan 20 18 90%
CMH Peshawar Unknown Unknown Unknown
CMH Nowshera Unknown Unknown Unknown CMH Kohat 51 43 84.3%
Ayub Teaching Hospital, Abbottabad 40 18 45%
Total 1411 684 48.47%
138 Ophthalmology Update Vol. 10. No. 2, April-June 2012 Neonatal Services in KPK Province, Pakistan to identify Implications for screening ‘Retinopathy of Prematurity’
Table 3. Low birth weight in different hospitals in KPK Pakistan in year 2005-2006.
Hospitals Low birth weight Status at birthAlive Survival %age Rehman Medical Institute, Peshawar 48 38 79.1%
Saidu Teaching Hospital, Swat 570 Unknown Unknown
Naseer Teaching Hospital, Peshawar Unknown Unknown Unknown Lady Reading Hospital, Peshawar 1963 897 45.6%
Kuwait Teaching Hospital, Peshawar 60 57 95
Khyber Teaching Hospital, Peshawar 2124 1747 82.25% Health Care Center, Peshawar Unknown Unknown Unknown
Hayatabad Medical Complex, Peshawar 461 357 77.4%
Fauji Foundation Hospital, Peshawar 135 109 80% District Hospital Dera Ismail Khan 133 105 78.9%
District Hospital Mardan 161 140 86.9%
CMH Peshawar Unknown Unknown Unknown CMH Nowshera Unknown Unknown Unknown
CMH Kohat 268 229 85.4%
Ayub Teaching Hospital, Abbottabad 259 214 82.6% Total 6182 3893 62.97%
Table 4. Premature births in different hospitals in KPK Pakistan in year 2005-2006.
Hospitals Gestational age Premature Birth Status at birth Alive Survival %age Rehman Medical Institute, Peshawar 38 35 92.11%
Saidu Teaching Hospital, Swat Unknown Unknown
Naseer Teaching Hospital, Peshawar Unknown Unknown Unknown Lady Reading Hospital, Peshawar 1806 834 46.25%
Kuwait Teaching Hospital, Peshawar 52 47 90.38%
Khyber Teaching Hospital, Peshawar 1931 1663 86.12% Health Care Center, Peshawar Unknown Unknown Unknown
Hayatabad Medical Complex, Peshawar 371 319 85.98%
Fauji Foundation Hospital, Peshawar 55 24 43.63% District Hospital Dera Ismail Khan Unknown Unknown Unknown
District Hospital Mardan 341 323 94.72%
CMH Peshawar Unknown Unknown Unknown CMH Nowshera Unknown Unknown Unknown
CMH Kohat 18 11 61.11%
Ayub Teaching Hospital, Abbottabad 11 2 18.18% Total 4623 3258 70.47%
Ophthalmology Update Vol. 10. No. 2, April-June 2012 139 Neonatal Services in KPK Province, Pakistan to identify Implications for screening ‘Retinopathy of Prematurity’
Table 5. Babies who needed ROP screening by birth weight less than 1500 grams
Year 1 Year 2 Cumulative both years Babies Number Percentage Number 664
< 1500g 360 2.6% 304 2.3%
Table 6. Premature babies who needed ROP screening
Year 1 Year 2 Cumulative both years Babies Number Percentage Number 639
> 31 weeks 322 2.4% 317 2.2% two trained neonatal nurses in Khyber Teaching 341 premature babies, 323 survived (94.72%). In Hospital, one in Hayatabad Medical Complex and other Rehman Medical Institute, reputed to be one of the in CMH Peshawar. A total of 53 nurses were working better private hospitals in KPK, the survival of in different neonatal units in KPK. There was no full premature babies was (92.11%). In Ayub Teaching time anesthetist specifically for any neonatal unit in in Hospital, only 11 premature babies were admitted and KPK. In 5 units, full time anesthetists were available in out of which 2 survived having a survival of (18.18%). the hospital and were readily available to the neonatal In our series, 664 (2.3%) babies had a birth weight < unit. 8 neonatal units had difficulty in accessing the 1500gm, while 639 (2.2%) babies had a gestational age anesthetist. Sixty two incubators were present in 13 < 31 weeks requiring ROP screening. In a retrospective neonatal units of KPK. Out of these, 37 were study done in Karachi in 2003 on premature infants intermediate dependency and 25 were high admitted in tertiary hospital in Karachi, 32.4% dependency. In 2 hospitals, 95-100% of babies were developed ROP18. estimated to be on oxygen that was continuously Retinopathy of prematurity is a condition which monitored, while in 4 hospitals it was 75-94%, in one is preventable and treatable in middle income countries hospital 50-74%, and in other hospital 25-49%, and in and in urban centres in developing countries19. ROP 6 hospitals 0-24%. develops in 16% of all premature births, the figure rising Screening for retinopathy of prematurity was not to over 65% of infants weighing less than 1250 gms at done in any hospital in KPK. birth20. Some studies suggest that as more and more DISCUSSION smaller and younger babies are surviving, its incidence In this study a total of 28,738 babies were admitted is increasing21. However, others say that better in 13 neonatal units of KPK over a two-year study understanding of screening and management of these period (2005-2006). 6122 low birth weight babies were babies has resulted in a decrease in its incidence20. Risk admitted in neonatal units in KPK. They accounted for factors22 include prematurity (particularly less than 32 21.199% of the total admissions in neonatal units in weeks of gestational age), low birth weight (< 1500gms KPK. In South Asia, the incidence of LBW is 36%, 30% and particularly if < 1250gms), oxygen therapy in Bangladesh and India, and 19% in Pakistan10. In (hypoxaemia and hypercarbia also increase the risk), Pakistan, the LBW rate varies from 5% to 23% in and co-morbidity. The goal of an effective screening different parts of the country11-16. The overall incidence programme must be to identify the relatively few of LBW in a study at Peshawar (10%)17 was half that of preterm infants who require treatment for ROP from recent studies (19%–23%) in Lahore and Karachi12-14 and among the much larger number of at risk infants while overall national average10. minimizing the number of stressful examinations In our study, there were 4623 (16. 08%) premature required for these sick infants. babies, of which 3258 survived (survival 70.47%). In There is no agreed policy on the screening of Khyber Teaching Hospital had maximum number of babies larger than 1250g23. The American screening premature babies (1931) that were admitted during the guidelines for ROP suggest that babies d” 1500 g birth study period. Lady Reading Hospital had the second weight or d” 32 weeks gestational age must be screened, incidence, where 1806 babies were admitted. The while those infants > 1500 g or > 32 weeks be screened survival percentage of Mardan Medical Complex was at the discretion of the attending neonatologist24. best among neonatal units in province, where out of However, developing countries may require
140 Ophthalmology Update Vol. 10. No. 2, April-June 2012 Neonatal Services in KPK Province, Pakistan to identify Implications for screening ‘Retinopathy of Prematurity’
modification of these screening guidelines25-27. 3. There should be trained neonatal nurses, ROP was a major cause of blindness in children neonatologists and fulltime anesthetists available in Europe and North America during the late 1940s and for neonatal units. 1950s with unmonitored supplemental oxygen being 4. More incubators should be available in neonatal the major risk factor28-29. This was called the first units. epidemic and during this blindness occurred in larger 5. Proper documentation of all admissions, survivals more mature babies from retrolental fibroplasias (this and discharges, and deaths should be done. terminology being used earlier for the same). At that 6. A counselor should be available, who could guide time, the mean birth weight (BW) of affected babies in the parents for proper follow up and vaccination the United Kingdom was 1370g (range 936-1843g) and of babies. in the United States of America was 1354g (range 770- 7. A formal screening protocol for ROP for babies < 3421g)29-30. By the mid 1950s, abundant clinical and than 1750gms and gestational age < 35 weeks experimental data had accumulated and it was should be adopted. concluded that retrolental fibroplasias was due to 8. Proper feeding and waiting area for parents of overuse of oxygen. Since then, careful curtailment of babies should be available in neonatal units. oxygen has resulted in a lower incidence31. At present, REFERENCES in developed countries the majority of babies getting 1. Parthasarathy A. Text book of Paediatrics, 2nd Edition severe ROP weigh less than 1000g at birth. This has 2002;42-73. 32 2. Bhutta ZA. Priorities in newborn care and development of been termed the “second epidemic” . India and other clinical neonatology in Pakistan: where to now? J Coll developing countries are now facing what is termed Physician Surg Pak 1997;7:231-4. the “third epidemic” which is a mixture of the first two 3. Yinger NV, Ransom EI. 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Pediatrics 1990; 684 very low birth weight babies survived with a 6: 405-12. survival rate was 48.48%. 3893 low birth weight babies 9. Schlij-Delfos NE, Cats BP. Retinopathy of prematurity / the survived with a survival rate was 62.65%. 3258 continuing threat to vision in preterm infants. Acta Ophthalmol Scand 1997; 75: 72-5. premature babies survived with a survival rate was 10. UNDP Infants with low birth weight accessed December 17, 70.47%. In our study, 664 (2.3%) babies had weight 2006. <1500gm. while in 639 (2.2%), the babies had gestational 11. Northrop-Clewes CA, Ahmad N, Paracha P, David IT. Impact age < 31 weeks requiring ROP screening. Ventilation of health services provision on mothers and infants in a rural village in North West Frontier province, Pakistan. Public was unavailable anywhere in KPK except CMH Health Nutr. 1998;1:51–59. doi: 10.1079/PHN19980008. Peshawar. There were 99 medical personnel and 53 12. Najmi RS. 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All babies on oxygen should be properly of stay in hospital for very low birthweight infants by monitored. involving mothers in a stepdown unit: an experience from
Ophthalmology Update Vol. 10. No. 2, April-June 2012 141 Neonatal Services in KPK Province, Pakistan to identify Implications for screening ‘Retinopathy of Prematurity’
Karachi (Pakistan) BMJ. 2004; 13; 329:1151–5. doi: 10.1136/ Pediatrics 2005;115:e518-25. bmj.329.7475.1151. 26. Jalali S, Matalia J, Hussain A, Anand R. Modification of 17. Badshah S, Mason L, McKelvie K, Payne R, Lisboa JGP. Risk screening criteria for retinopathy of prematurity in India and factors for low birthweight in the public-hospitals at other middle-income countries. Am J Ophthalmol Peshawar, KHYBER PAKHTUNKHWA-Pakistan. BMC 2006;141:966-8. Public Health 2008; 8-197. 27. Trinavarat A, Atchaneeyasakul L, Udompunturak S. 18. Taqui AM, Sayed R, Chaudary TA. Retinopathy of Application of American and British criteria for screening of prematurity: frequency and risk factors in a tertiary care the retinopathy of prematurity in Thailand. Jpn J Ophthalmol hospital in Karachi, Pakistan. JPMA 2008; 58:186-190. 2004;48:50-3. 19. Gilbert C. New issues in childhood blindness. JCEH, 14 28. Sorsby A. The incidence and causes of blindness in England (40):53-56;2001. and Wales 1948-1962, Reports on Public Health and Medical 20. Retinopathy of prematurity – UK guideline, Royal College subjects NO. 114. London: HMSO, 1966. of Ophthalmologists (December 2007). 29. King M. Retroplental fibroplasia. Arch Ophthalmol 21. Bashour M; eMedicine: Retinopathy of Prematuirty (2006). 1950;43:694-711. 22. Willshaw H, Scotcher S, Beatty S: A Handbook of Paediatric 30. Gillbert C, Fielder A, Gordillo L, Quinn G, Semiglia R, Ophthalmology, 2000. Visintin P et al. Characteristics of infants with severe 23. Quinn GE. What do you do about screening in ‘big’ babies? retinopathy of prematurity in countries with low, moderate, Br J Ophthalmol 2002;86:1072-3. and high levels of development: implications for screening 24. Section on Ophthalmology American Academy of Pediatrics; programs, Pediatrics 2005;115:518-525. American Academy of Ophthalmology; American 31. Patz A, The role of oxygen in retro lentil fibroplasia. Tr Am Association for Pediatric Ophthalmology and Strabismus. Opth Soc 1968;66:940-985. Screening examination of premature infants for retinopathy 32. Gilbert C, Rahi J, Eckstein M, O’Sullivan J, Foster A. of prematurity. Pediatrics 2006;117:572-6. Retinopathy of prematurity in middle income countries. 25. Gilbert C, Fielder A, Gordillo L, Quinn G, Semiglia R, Visintin Lancet 1997;350:12-14. P, et al . Characteristics of infants with severe retinopathy of 33. Shah PK, Narendran V, Kalpana N and Gilbert C. Severe prematurity in countries with low, moderate, and high levels retinopathy of prematurity in Big babies in India: history of development: implications for screening programs. repeating itself. Indian J of Pedia 2009; 76: 801-804.
142 Ophthalmology Update Vol. 10. No. 2, April-June 2012 Original Article
A Review of Microbial Keratitis
Dr. Sofia Sofia Iqbal MRCOphth (Lond) FRCS1, Mushtaq Ahmad FCPS2 Prof. Zafar ul Islam FCPS3
ABSTRACT Background: This study was conducted at Khyber Institute of Ophthalmic Medical Sciences, Hayatabad Medical Complex, Peshawar from 1st January 2009 to 31st December 2009. The objectives were to identify common etiological organisms in microbial keratitis, to identify predisposing risk factors, discuss best treatment protocol, and to recommend preventive measures. Method: It was a prospective study of 112 patients suffering from Microbial Keratitis who presented over a period of one year. A detailed history and clinical features of the patients were noted down on a predesigned proforma. Culture and sensitivity was done, and patients were followed for a period of three weeks. Results: The Risk Factors identified were : Trauma in 41.96% and pre-existing ocular, lid and adnexal disease in 57.14%. There were 54.46% culture positive cases. The organisms isolated were: Staphlococcus aureus in 36.06%; Staphlococcus epidermidis in 26.22%; Streptococcus Pyogenes in 19.67%; Aspergillus in 13.11%; Candida in 03.27% and Fusorium in 01.63%. Most of the organisms showed higher sensitivity to Quinolones than the other drugs. 53.57% patients had a final Visual Acuity of 6/18-6/60 or better and 14.28% patients ended up with a Visual Acuity of 3/60 or worse. Conclusions: This study indicate that Quinolones appears to be the therapy of choice for Bacterial Keratitis and Itraconazol seems to be the therapy of choice for Fungal Keratitis in our set up. Approximately one third cases had chronic Dacryocystitis, 66.96% had received some kind of treatment at the time of presentation. Early detection, early referral, proper management of pre-existing ocular and adnexal diseases and effective treatment will bring a significant change in the final outcome of corneal ulcers in KPK, Pakistan. Key Words: Microbial Keratitis, Culture and Sensitivity, Corneal Scrapping.
INTRODUCTION bacterial, fungal or amoebic infection occurs in eyes Ocular infections are one of the leading causes of with pre-existing pathology, where the micro- blindness in the world in general and in developing environment has been disturbed by trauma, eyelid countries in particular. Certain features of microbial dysfunction, abuse of contact lens or the administration keratitis are more prevalent in some countries than of topical medications, which influence the commensal others. This may be related to nutritional factors, organisms or defense mechanism2. According to the economic factors, environmental factors, illiteracy, poor most recent data available, 27-35 million people of the hygiene, concurrence of other infections such as world are blind.3 25-50% of this blindness, (vision in trachoma or herpes, trauma, temperature, humidity and the better eye d” 3/60), is due to corneal diseases.4 other seasonal variations and general health1. Corneal infection is a leading cause of ocular morbidity Environmental influences dictate the pattern of external and blindness in the under developed world.5 The eye diseases. In dry hot deserts, where flies abound and condition may be more serious than is apparent, personal hygiene is poor, blinding trachoma is because blindness refers to the definition adopted by prevalent, while in rain forests ridden with parasite the W.H.O., that is a person is considered blind if his laden black fly, people face the challenge of visual acuity in the better eye is 3/60 or a visual field Onchocerciasis. The general environment in the cities of ten degrees or worse. If one adds the uniocular blinds, of the developed western world is less hostile. In such the above figures will immediately increase by two conditions, suppurative keratitis resulting from folds. In Pakistan , no clear-cut statistics are available ––––––––––––––––––––––––––––––––––––––––––––––––––––––– about the corneal blindness but in a study from 1Associate Professor Ophthalmology, Department, Hayatabad Nawabshah, corneal ulcer patients constituted about Medical Complex,Peshawar. 2RegistrarOphthalmology 14.5% of all cases admitted in the department of 3 Department, Hayatabad Medical Complex, Peshawar. Professor Ophthalmology6. In another study from Larkana, the of Ophthalmology, Kabir Medical College, Gandhara Medical University, Peshawar incidence of corneal involvement was assessed to be ––––––––––––––––––––––––––––––––––––––––––––––––––––––– 15%7 The developed world has a low incidence of Correspondence: Dr. Sofia Iqbal, House no 86, street no 6, sector Corneal diseases. Comparison of the important causes G-2, Phase 2, Hayatabad,Peshawar of Blindness in USA, UK, Canada and Sweden does E.Mail>sofiaiqbal71@ yahoo.com 03339254264 ––––––––––––––––––––––––––––––––––––––––––––––––––––––– not put corneal diseases as a cause for blindness in the Received: Oct’2011 Accepted: Jan’2012 first five commonest causes.8 In these countries the ––––––––––––––––––––––––––––––––––––––––––––––––––––––– commonest causes of blindness include conditions like
Ophthalmology Update Vol. 10. No. 2, April-June 2012 143 A Review of Microbial Keratitis
diabetic retinopathy, cataract, age related macular period of 72 hours before discarded for no growth. degeneration, myopia and glaucoma. Microbial Sabouraud’s agar plates were incubated at 25ºC. They keratitis is more severe in the underdeveloped world, were examined daily for any growth and were probably due to delayed attendance 9 discarded if no growth took place in 3 weeks time. The objectives of this study are: Thioglycolate broth was heated for 5 minutes in a • To identify common etiological organisms in boiling water bath before incubation at 37ºC. It was kept microbial keratitis in KPK Pakistan. for 7 days before they were discarded for no growth. • To identify predisposing risk factors. The organism’s sensitivity to the antibiotics was • To identify and recommend best treatment determined with the disc diffusion method of Kirby- protocols. Bauer.11 • To identify and recommend preventive After comparing the size of inhibition zones with measures. the standard, the antibiotic sensitivity was recorded as. MATERIALS AND METHODS • Very sensitive ( + + + ) A total of 112 patients admitted to the eye unit of • Moderately sensitive (+ + ) Hayatabad Medical Complex from 1st January 2009 to • Mildly sensitive ( + ) 31st December 2009 were recruited in this prospective • Resistant ( - ) study. Patients with clinically diagnosed viral corneal Every patient was put on the following treatment ulcers were excluded from the study. A detailed history after corneal scraping and before the laboratory results. and a complete ocular examination was done according Frequent use of ciprofloxacin/ofloxacin eye drops. This to a predesigned proforma. After a detailed can be used as a mono-therapy (12) but we often added examination on a slit lamp, corneal scraping was a second antibiotic (tobramycin ) to the regimen to obtained and was sent for culture and sensitivity (C/ ensure adequate antibiotic coverage. S). Most of the time, it was performed under a Topcon • Atropine eye drops twice a day. slit lamp or under a Topcon Operating Microscope. • Syrup / Tablets Brufen (400mg) according to The cornea was anaesthetized using a topical anesthetic the weight and age of the patient twice a day. (Proparacain Hydrochloride) while children were given • Tablets Diamox (250mg & 500mg ) were used general anesthesia. Most of the time, a disposable in cases of raised Intraocular Pressure. syringe needle, bent at its tips, was used as described • Itraconazole (Sporanox) Tablets as antifungal by Smith et al 10. Scalpel blade was used in some cases agents in patients with suspected Fungal corneal ulcers for getting the corneal scraping . Scrape was taken from as twice a day regimen. the edges of the ulcer all around and from the base of The initial therapy was changed only when the the ulcer. sensitivity report showed another medicine to be more Four types of growth media were used routinely appropriate. The patients were examined on a slit lamp for inoculating the material taken from the cornea. A twice a day, paying due attention to the site, size and blood Agar plate was inoculated first followed by depth of the ulcer. Anterior chamber reaction was Chocolate agar plate, Sabouraud’s agar plate and recorded, and any vascularization of the ulcer was Thioglycolate broth. Sabouraud’s agar plate was noted. Patients were discharged only when the ulcer cycloheximide free and in some cases, gentamicin showed signs of healing. All the patients were followed 100umg/ml was added to it to suppress bacterial for 3 weeks. If the ulcer was large initially and there growth. Four slides were prepared for Microscopic was a fear of perforation, a surgical modality, most of examination. Half of the slides were stained with the time, a conjunctival flap was chosen. In cases of Gram’s method; other slides were treated with 20% predisposing factors amenable to surgery like trichiasis, Potassium Hydroxide (KOH). In few cases, the slides entropion, chronic dacrocystitis, lagophthalmos, were treated with KOH were further treated with treated with appropriate surgical interventions. A final Lactophenol Blue to facilitate the identification of fungal record of the eye was made after a follow up of 3 weeks. elements. In few cases Zeil-Neilson stain was also This included, visual acuity, corneal condition, and performed. All the slides were examined by the same condition of the eye as a whole. microbiologist. Blood Agars were incubated at 37ºC. Table 1: Culture Reports Usually Bacterial growth occurred within 24 hours . However, if no growth occurred, the specimen was kept S. No Cases Male Female Total % age for another 3 weeks at 37ºC for the growth of any slow 1 Total 40 21 61 54.46 growing bacteria or fungi. If still no growth the culture Positive Cases (65.57%) (34.42%) specimen was discarded as culture negative. Chocolate 2 Total 11 30 51 45.53 agar plates were incubated at 37ºC for a minimum Negative Cases (21.56%) (58.82%)
144 Ophthalmology Update Vol. 10. No. 2, April-June 2012 A Review of Microbial Keratitis
Table: 2. Etiology of micro-organisms
S.No Organism Male % Female % Total %
1 Staph.Aureus 17 42.50 05 23.80 22 36.06 2 Staph. Epidermidis 10 25.00 06 28.57 16 26.22
3 Strep. Pyogens 04 10.00 08 38.09 12 19.67
4 Aspergillus 08 20.00 0.00 0.00 08 13.11 5 Candida 01 02.50 01 04.76 02 03.27
6 Fusarium 0.00 0.00 01 04.76 01 01.63
Table 3: Culture and sensitivity results (bacterial) the patients were on antibiotic treatment while 10( 13.34% ) patients were using topical steroids. Total S.No Drugs Staph Staph Strep Aureus Epidermidis Pyogenes number of patients with a history of trauma were 47 1 Ofloxacin + + + + + + + + + (41.96%), out of which agricultural trauma was responsible in 59.57% cases. Patients with ocular and 2 Norfloxacin + + + + + + lid diseases at the time of presentation were 64 (57.14%). 3 Tobramycin + + + + + + + Chronic dacryocystitis was present in 37.50 % cases , 4 Chloramphenicol + + + + while 23.88% had an old herpetic scar , who presented with secondary corneal infection or a flare up of old 5 Gentamycin + + _ herpetic infection. The complaints of the majority 6 Ciprofloxacin ++ + + + + + + + (93.74%) of the patients were redness, dimness of vision and photophobia. In 93 (83.03%) patients the ulcer was central, while in 19(16.96%) it was marginal in location. Table 4: Culture and sensitivity results (fungi) In 50 (44.64%) patients hypopyon was present. The culture and sensitivity reports of 61 (54.46%) patients S.No Drugs Aspergillus Candida Fusarium were positive while in 51 (45.53%) patients it was 01 Fluconazole + + + + reported as Negative. Staphlococcus aureus was the 02 Ketoconazole + + + + + most common bacterial isolate accounting for 22 (36.06%) cases, while Aspergillus was the most common 03 Itraconazole + + + + + + fungus isolated which accounted for 72.72% of mycotic ulcers. The presenting visual acuity in 94.63% patients Table 5: Final visual outcome was less than 6/60, only 5.35% patients had a presenting Visual Acuity of better than 6/60.The final visual acuity Visual Ist 2nd 3rd Final Acuity week week week of 53.57% patients was better than 6/60, while 46.41% ended up with a visual acuity less than 6/60. 6/12-6/18 03(02.67%) 03(02.67%) 04(03.57%) 04(03.57%) DISCUSSION 6/18-6/60 38(33.92%) 46(41.07%) 54(48.21%) 56(50.00%) This prospective study at KIOMS looked at the 6/60-3/60 41(36.60%) 37(33.03%) 34(30.35%) 36(32.14%) profile of corneal ulcers which consisted of predisposing factors, causative agents, age, sex, and the final visual 3/60-HM 20(17.78%) 16(14.28%) 12(10.71%) 09(08.03%) outcome. In this study corneal ulcer patients comprised HM-PL 10(08.92%) 10(08.92%) 08(07.14%) 07(5.35%) 3.689% of the total admissions during the year 2000. NPL 1(0.89%) 1(0.89%) 1(0.89%) 1(0.89%) This is comparable to the figure reported by Dr Nasir 13 who conducted a similar study in 1989. However, it is lower than the prevalence reported by Haider7 from RESULTS Larkana & Khan and Baig6 from Nawbshah (14.5%). It Corneal ulcer patients comprised 3.689% of the also corresponds well to a study by Omerod5 from South total admissions. Africa (5%). The figure obtained by us might be lower (112/3028). Male patients were 74 (66.07%) and as viral corneal ulcer diagnosed on clinical grounds female patients were 38 (33.92%). Most of the patients were excluded from the study. (56.24%) were between the ages 31 and 50 years. Total Corneal ulcers in our study were found to be more number of patients receiving treatment before common in males (66.07%) than in females (33.92%), presentation were 75(66.96%). Fifty two ( 69.34% )of which correspond well with similar studies.5,13,14,15,16 The
Ophthalmology Update Vol. 10. No. 2, April-June 2012 145 A Review of Microbial Keratitis
reason for male preponderance may be due to more and accounted for 72.72% of the Mycotic ulcers. exposure of the male patients to ocular trauma. More Fusarium was responsible for 9.09% of the Mycotic than half of the patients (66.96%) were already on ulcers in this study. Similar figures are reported from medications at the time of presentation, out of which India 1&24 and Nepal 9. Candida accounted for 18.18% 13.34% were on steroid eye drops. These patients of the mycotic ulcers but this figure is much lower than probably got their medications from quacks, hakims, that reported by Nasir (13) and other studies.1,18&24. or from drug stores without a prescription (self- Fungal infections are considered to occur in medication). Microbial keratitis is rare in the absence immune-compromised hosts. Any injury with vegetable of predisposing factors. 41.96% of the patients gave a matter, an occupation like Farming and previous history of ocular trauma, this is in accordance with the treatment with broad spectrum antibiotics and steroids similar studies from Bangladesh and India.17&18. It is are strong predisposing factors 25. All these factors were however higher than that reported by Coster et al from frequently seen to be involved in patients in this study. London19 and Coster and Badenoch20 from Australia. The cultures of all the patients were tested with the In this study, agricultural trauma was responsible in antibiotic prescriptions currently available at the 59.57% cases, whereas contact lens trauma accounted medicine stores. This was done mainly to come to a for 2.12% cases only. This figure is much less than that common conclusion about the sensitivity of the most reported by Fredric Schaffer et al21 which is 36%. common accessible medicine available at the drug Pakistan is a low-income country which depends stores. mostly on Agriculture for employment, This accounts The results of this study showed that all the for the higher frequency of agricultural trauma and Bacteria (87%) were very sensitive to ofloxacin and lower frequency of contact lens trauma. 57.17% of the ciprofloxacin whereas sensitivity to tobramycin was patients were having an ocular surface and lid disease 80% and chloramphenicol and gentamycin 46.5% only. at the time of presentation. This is higher than that Tobramycin was found to be more effective than observed by Bennett et al 45.6%22 and Nasir 32.4%13, gentamycin and even more effective than but it is much lower than that reported by Ormerod chloramphenicol. This was probably the result of from South Africa5. In the latter study they considered resistance developed to these antibiotics due to their topical steroids and trauma among the local wide spread and indiscriminate use. The trend showing predisposing factors while we have considered them resistance was also reported by other Authors.10,13,&28. separately. 7.50% of the patients had chronic It was observed that on presentation, 94.63% of dacryocystitis, which is very high as compared to that the patients had a Visual Acuity worse than 6/60 while reported by Nasir13. Most of the patients with chronic 5.35% of the patients had a visual acuity of better than dacryocystitis had come from the hilly areas like 6/60 on the Snellen’s chart. With effective management, Chitral, where trachoma had been very common until 53.57% patients had a final visual acuity of better than recently. Whether there is a correlation between 6/60 and 46.41% ended up with a visual acuity of worse trachomatous scarring and chronic dacryocystitis in than 6/60 which is much lower than that observed by these hilly areas need to be investigated further. 83.03% Nasir (73%) . This is probably due to the fact that we of the ulcers located centrally, whereas 16.96% were now have access to much effective drugs than 10 years marginally located. This corresponds well with other ago. However the big change in the outcome may also studies5,13&22. 54.46% cases in our study had a positive be because of the improved primary eye care culture which is in accordance with studies reported introduced at the Basic Health Units (BHU) levels by Nasir and Bennett 13&22. Ormerod5 in his two series throughout the province and to the creation of reported a positive culture in 75% and 82% of the cases. functional eye units at the district levels. The education Staph. aureus was the most common bacterial of the patients has also improved so overall the patients isolate and accounted for 36.06% of the pathogens present earlier, treatment is started sooner and patients isolated. Staph. aureus, which was previously are referred in time to the tertiary eye care centres. At considered to be an opportunistic organism, is now the end of the third week 74.10% of the eyes were becoming the most common cause of corneal already healed. 58.92% of the patients in this study infection.15. It may be due the fact that it is not ended up with a dense corneal scar, most of such uncommonly found in the conjunctival bacterial flora23 patients can be rehabilitated if proper Keratoplasty and can easily cause infection if the local situation services were available at our tertiary care centres. becomes less favorable. Another important factor may CONCLUSION be the Antibiotic resistance of many strains of Corneal ulcer is one of the common causes of Staphylococci. ocular morbidity and corneal blindness in KPK, Aspergillus was the most common fungus isolated Pakistan. Public health education, prevention of
146 Ophthalmology Update Vol. 10. No. 2, April-June 2012 A Review of Microbial Keratitis
agricultural trauma, improved primary eye care in Southern California, A multivariate analysis. services and ban on the over counter sale of ocular Ophthalmolgy 1987; 94: 1322-33. 15. Asbell P, Stenson S. Ulcerative Keratitis: Survey of 30 years medications, can have a positive effect on the Laboratory Experience. Arch Ophthalmol 1982; 100:77-80. prevalence and incidence of corneal ulcers. Availability 16. Reddy PR. Topical Antibiotics in the treatment of Corneal of effective keratoplasty services will be a major step ulcers. Ind J Ophthalmol 1988; 36: 95-7. forward in the visual rehabilitation of corneal blindness. 17. Williams G, Billson F, Howlader SA, Islam N, McClellan K. Microbiological Diagnosis of suppurative keratitis in REFERENCES: Bangladesh Br J Ophthalmol 1987; 71:315-21. 1. Nema HV. Keratomycosis in India .In: Shimizu K.ed. 18. Reddy PS, Satyendran OM, Satapathy M, Kumar HV, Reddy Ophthalmology, Amsterdam: Excrepta Medica, 1979; 1716- R. Mycotic Keratitis. Ind J Ophthalmol 1972; 20: 101-8. 20. 19. Anderson B, Chick EW. Treatment of Fungal Corneal ulcers 2. Coster DJ. Inflammatory Diseases of the Outer Eye. Trans with Amphotericin B and mechanical Debridement. South Ophthalmol Soc UK 1979; 99: 463-80. Med J 1993;56:270-4. 3. Minassian DC. Epidemiological methods in prevention of 20. Coster DJ, Badenoch PR. Microbial and Pharmacological blindness. Eye 1988; 2:53-512. factors affecting the outcome of Suppurative Keratitis. Br J 4. Mohan M, Agarwal LR, Malik SRK, Gupta AK, eds. Ophthalmol 1987;71:96-101. Ophthalmology. Proceedings of X Congress of APAO 1985. 21. Schaefer F, Bruttin O Zografos L, Guex-Crosier Y. Bacterial New Delhi. Tata McGraw Hill Publication Co 1987: 75-7 Keratitis: A prospective clinical and microbiological study. 5. Ormerod LD. Causation and Management of Microbial Br J Ophthalmol 2001;85:842-7 Keratitis in subtropical Africa. Ophthalmology. 1987; 94: 22. Bennett HGB, Hay J, Kirkness CM, Seal DV, Devonshire 1662-8. P.Antimicrobial Management of Presumed Microbial 6. Khan SA, Baig MSA. Review of 152 cases of corneal ulcer in Keratitis. Guidelines for the treatment of Central/Peripheral Nawabshah. In: All Pakistan Ophthalmological Conference Corneal ulcers. Br J Ophthalmol 1998;82: 137-45. Quetta:1986. 23. Locatcher-Khorazo D, Guierrez E. The bacterial flora of the 7. Haider A. Experience with Osmotic agents in Corneal ulcers healthy eye. In: Microbiology of the Eye. St Louis: CV Mosby with raised tension. In: Yaqin M, ed. Transactions 8th Afro Co, 1972: 13-23. Asian Congress of Ophthalmology, Lahore: 1984 65-71 24. Sandhu DK, Randhawa IS, Singh D. The co relation between 8. Ghafour IM, Allan D, Foulds WS. Common causes of environmental and ocular fungi. Ind J Ophthalmol 1981; 29: blindness and visual handicap in the west of Scotland. Br J 177-82. Ophthalmol 1983; 67:209-13. 25. Chin GN, Hyndiuk RA, Kwasny GP, Schultz RO, 9. Upadhay MP, Rai NC, Brandt F, Shresta RB. Corneal ulcers Keratomycosis in Wisconsin. Am J Ophthalmol 1975; 79:121- in Nepal.Graefes Arch Clin Exp Ophthalmol 1982; 219:55-9. 5. 10. Smith SG, Herman WK, Linstorm RL, Doughman DJ, A 26. Hyndiuk RA, Eiferman RA, Caldwell DR, Rosenwasser GO, method of collecting culture material from Corneal ulcers. Santos CI, Katz HR,et al. Comparison of Ciprofloxacin Am J Ophthalmol 1984; 97:105-6. Ophthalmic solution0.3% to fortified Tobramycin-Cefazolin 11. Baur AW, Kirby WMM, Sheris JC, Turk M. Antibiotic in treating Bacterial Corneal ulcers. Ophthalmology 1996; sensitivity testing by a Standardized single Disk method. Am 103: 1854-1863 J Clin Pathol 1966;45:493-496. 27. O’ Brien TP, Sawusch MR, Dick JD. Topical Ciprofloxacin 12. Gangopadhyay N, Daniell M, Weih L, Taylor HR. treatment of Pseudomonas keratitis. Arch Ophthalmol 1988; Flouroquinolone and fortified antibiotics for treating 144-6. Bacterial Corneal ulcers. Br J Ophthalmol 2000; 84:378-84. 28. Abott RL, Abrams MA. Bacterial Corneal ulcers. Clinical 13. Saeed N. Microbial Keratitis. A Study Review, Peshawar, Ophthalmolgy vol IV chapter 18, Philadelphia: Harper and NWFP: PGMI LRH, 1989. Row Publishers, 1988. 14. Ormerod LD, Hertzmark E, Gomez DS, Stabiner RG, Schanzlin DJ, Smith RE, Epidemiology of Microbial Keratitis
Ophthalmology Update Vol. 10. No. 2, April-June 2012 147 Original Article
Frequency of Ocular Injuries at Tertiary Care Hospital
1 2 3 Dr. Lakho A. Khalil Lakho MSc , A. Haleem Mirani FCPS , N, M. Sial
ABSTRACT: Objective: To estimatethe incidenceof the eye injuries reporting at the hospital eye services to facilitate the planners and providers of eye care to make necessary strategies applicable for the prevention and management of ocular injuries. Study Design: Retrospective study of descriptive type. Place and Duration of the Study: Conducted at Al-Ibrahim Eye Hospital, Isra postgraduate institute of Ophthalmology, Karachi from January 2006 to December 2006. Patients and Methods: This is a retrospective study on indoor and outdoor patients with ocular injuries presented at Al- Ibrahim Eye Hospital during January to December 2006. All the patients attending OPD with the history of ocular trauma were included in the study. A team was engaged in examiningthe patient files of ocular injury patients from various departments of the hospital and filling the printed questionnaire. Results:Total of 82837 patients attendedOPD in the year 2006; out of them, 1457 (1.75%)were with Ocular trauma. There was clear preponderance of male, 87.64% over female 12.35%. Adults with 16-25 years age proved to be more prone to injuries with 24.50%.Next in frequency were children of the age group 0-15 years (21.2%) .Age group 50 years and above were only 14.28%. 73.10% of the injuries happened at home,followed by workplace injuries (office/shop),8.44%; 3.91% sustained injuries at farms; 4.39% were on the playground;2.33% patients were involved inRTA; I.44% at industrial units; at School 0.55%; due to war/terrorism 0.27%; 0.07% by physical abuse. Place of trauma in 5.49% was not available. Conclusion: Males are more involved specially in working age 16-25 years; commonest place of injury in this study was home. Key Words: Eye injuries, age & gender distribution, causes, work places, health services, Pakistan.
INTRODUCTION greater exposure to hazards, decreased ability to avoid Ocular trauma is a major cause of preventable or detect hazards, and/or a lower likelihood of monocular blindness and visual impairment in the functional recovery following eye injury3. Hence further world1. During last decade epidemiological studies evaluation and research are required on this have contributed significantly to a better understanding area.Although one of the major causes of visual of disease patterns of cataract, trachoma, morbidity, it has remained a neglected disorder and xerophthalmia, and diabetic retinopathy resulting in has not received any importance from public health prevention and control of blindness due to these point of view. diseases.Eye injuries have been considered a clinical Globally in 2001, 1.6 million people were blind issue and are mostly addressed within the context of from ocular injuries, 2.3 million had bilateral low vision, clinical eye care delivery systems including emergency and 19 million were unilaterally blind or had low case management2. However, like any other eye vision4. In developing countries most ofthe disorder, eye injuries do not occur as random events: complications occurdue to delayed presentation at the there is evidence that some population groups are at hospital as well as lack of vitreo-retinal or corneal increased risk of sustaining eye injuries because of transplantation facilities.No national data are available on the incidence or prevalence of ocular injury. ––––––––––––––––––––––––––––––––––––––––––––––––––––––– However few hospital based studies from the North of 1Community Ophthalmologist/Medical Director Makkah Eye Complex, Khartoum, Sudan. Pakistan show a high number of ocular injuries coming 2&3Ophthalmologists, Al-Ibrahim Eye Hospital, Isra Postgraduate to those hospitals5.6Non-trachomatous corneal opacity Institute of Ophthalmology, Gadap Town, Karachi. is the second most important cause of blindness in ––––––––––––––––––––––––––––––––––––––––––––––––––––––– Pakistan and has shown an increase within the last Correspondence: Dr.Mirani A. Haleem FCPS2, Al-Ibrahim Eye 7 Hospital, Isra Postgraduate Institute of Ophthalmology, Gadap Town, fifteen years . It especially affects the south of Pakistan. Karachi. Tele: 0092214560718, Cell No: 00249922453410, E-mail: Most of this is caused by Trauma. [email protected] To determine the pattern of ocular trauma in local ––––––––––––––––––––––––––––––––––––––––––––––––––––––– circumstances, and places of the injury is one of the Acknowledgement: Thanks to Mr. H.Tariq Ali Shaikh, IT consultant, for computing the statistical work. objectives of this study carried out at Al-Ibrahim Eye ––––––––––––––––––––––––––––––––––––––––––––––––––––––– Hospital, Isra Postgraduate Institute of ophthalmology, Received: Oct’2011 Accepted: Jan’2012 Karachi from January to December 2006; that took a ––––––––––––––––––––––––––––––––––––––––––––––––––––––– deeper look at the local pattern of ocular trauma,
148 Ophthalmology Update Vol. 10. No. 2, April-June 2012 Frequency of Ocular Injuries at Tertiary Care Hospital
itsdistribution, causes and complications. This hospital 26(1.8%) and heat exposure to 5 eyes (0.34%), with is situated in Gadap Town, an important geographical variable depth of injury. Penetration with perforation and agricultural area of Karachi which is one of the was observed in 194(13.32%) patients, while mega cities of the worldandis situated in south-eastern 283(19.42%) patient had perforation only, 29(2.0%) region of Pakistan. patient had penetration only and 904 (62.04%) had METHODS superficial injuries (Table 3). No visual impairment (VA This is a retrospective study on indoor and 6/6 -6/18) was seen in 921(60.91%), visual impairment outdoor patients with ocular injury presented at Al- (VA <6/18-6/60) in 139(9.19%) patient, severe visual Ibrahim Eye Hospital duringJanuaryandDecember, impairment (VA< 6/60-3/60) in 41(2.71%) and blind 2006. All the patients attending general eye OPD, (VA< 3/60) were in 271(17.92%). The visual acuity of pediatric eye clinic, retina and cataract clinics with the 140(9.25%) was not recorded due to poor cooperation history of ocular trauma were included in the study.The of patient. Table 5 corneal damage was the most questionnaire was designed at community common of visual impairment observed in 203(45.01%), ophthalmology department and was piloted over ten followed by posterior segment 145(32.15%) and lens patients selected at random from the said period. damage in 103(22.83%) patients. Table: 7 Necessary changes were made by removing irrelative DISCUSSION variables / fields and adding required columns.Most This study shows that 1.75% (1475) of the patients of the variables were coded in order to facilitate attending this tertiary eye care hospital presented with statistical analysis. The team involved in designing and conducting the study consisted of a clinical Table 1: Age and Gender Distribution ophthalmologist, an ophthalmic paramedic and a data entry operator oriented with statistical methods. They Age Group Male Female Total Percent were engaged in collecting files of ocular injury patients Up to 15 years 237 72 309 21.20% from various departments of the hospital and filled all 16 to 25 years 342 15 357 24.50% required data on the printed questionnaire. The data was double-checked, verified against actual case sheets 26 to 35 years 264 18 282 19.35% and forwarded for data entry.For the purpose of this 36 to 50 years 238 43 281 19.29% study, asoftware application was specifically designed Over 50 years 179 29 208 14.28% using Microsoft visual basic 6.0 and Microsoft office access 2007. Various statistics were extracted using the Age data N/A 17 3 20 1.37% structured query language (SQL). Total 1277 180 1457 100% RESULTS: (87.64%) (12.35%) A Total of 82837 patients attended OPD in year Table 2: Ocular trauma 2006 at Al-Ibrahim Eye Hospital, Karachi, out of them 1457(1.75%) were with ocular trauma, while 1512 eyes Eye No: Cases Percent were affected; thus 55 (3.77%) patient had bilateral trauma (Table 2). The majority of victims were male.Out Both 55 3.77% of 1457 patients 1277(87.64%) were male, and 180 Right 672 46.12% (12.35%) were female, an approximately 1:7 ratio. The Left 680 46.67% preponderant age group was 16-25 years accompanying for 357 (24.50%) patients of whom 342 were males, NA 50 3.43% followed by children <15 years 309(21.2%). Age Total 1457 100% distribution with gender is given in Table 1. More than half of the injuries happened at work place Table 3 (54.91%),followed by home (31.9%), playground 4.39%, farms 3.91%, RTA 2.33%, industry 1.44 %, Type of Injury No % school 0.55%, war/terrorism 0.27% and 0.07% by Sharp 482 33.08 physical abuse. Information about place of injury in Blunt 897 61.56 5.49% wasnot available (Table 4). Mechanical trauma was the commonest cause of eye injury, accounting for Chemical 26 1.78 1328 (91.15%), followed by Agricultural trauma, which Heat 5 0.34 was in 82 eyes (5.63%) (Table 6). Most of the patients, Data not available 47 3.23 that is 897 (61,56%), were hit by blunt objects, followed by sharp objects in 482(33.08%), chemical burns in Total 1457 100
Ophthalmology Update Vol. 10. No. 2, April-June 2012 149 Frequency of Ocular Injuries at Tertiary Care Hospital
Table 4: Frequency of place of injury to use protective devices at work. This fact is supported by the high incidence of trauma in working age groups Place of Injury Frequency Percentage (16 – 35 years) as demonstrated in this study. Similar Work place 801 54.91% correlations have been demonstrated inother studies as well.34 The most common affected group in this study Home 465 31.90% is young adults in 16-25 and 26-35 age-groups.5-6 Physical abuse 1 0.07% Bilateral involvement of the eyes was in 3.1% cases in Playground 64 4.39% this study, similar to Karaman et al & Khan etal 7,8. Usually bilateral eye injuries occur as a result of bomb RTA 34 2.33% blasts, anti-personal mines and motor vehicle School 8 0.55% accidents.Pakistan being a country under terrorist BBI 4 0.27% attacks now for more than a couple of decades and Southern Pakistan being one of the most affected areas N/A 80 5.49% suffers more causalities as a result of various disputes. Total 1457 99.99% Work place, including agricultural trauma, has been recognized as the most common location for ocular Table 5: Visual Acuity in injured eye injury in this study.Agriculture is the most common occupation in rural Pakistan where the farmers still use VA Group Frequency Percentage very old techniques of cultivation without any protective measures. In other places, ignorance, 6/6-6/18 921 60.91% negligence and lack of protective measures (industries) <6/18-6/60 139 9.19% are the common causes of ocular trauma..Home is the <6/60-3/60 41 2.71% second most common location of ocular injury similar to the studies from India917. Both the young and the old <3/60 271 17.92% are the most vulnerable for ocular trauma at home.More NA 140 9.25% than 80% of ocular trauma was reported to have Total 1512 100% occurred at workplace and home.This study showed a high frequency of blunt trauma which was consistent Table 6: Pattern of trauma withsome studies while others report more injuries with sharp objects1011 Type of Trauma Cases Percentage Agricultural trauma was the most common cause Agricultural 782 53.67 of ocular injuriesreported in this study similar to India and Malawi12’13 and also rural Nepal14. Sport and leisure Mechanical 628 43.10 activities became the main source of serious eye injuries Thermal 9 0.62 in the 1980s with sports associated eye injuries Chemical 24 1.65 becoming responsible for most cases of hospitalized eye trauma15.In our study trauma at playground were 4.39% Radiational 4 0.27 (64); compared with study conducted in UK16 were NA 10 0.69 2.3%, and in Malaysia17 was 4.7%.The road traffic Total 1457 100.00 accident took over as the most common cause of serious injury in the 1960s and 1970s, with car occupants suffering penetratinginjuries due to glass18windscreen. ocular trauma, significant enough for seeking Accidents are preventable to a large extent and they treatment. Although it seemed to be a small proportion commonly occur as a result of ignorance, haste, of the total OPD, yet it was a large number and the negligence, carelessness and lack of knowledge. This trauma cases that came through ER were not included, studyshows patients were involved in RTA 2.33% (34) which might further increase the incidenceof ocular ;and is compared with a study in Balochistan13 where it injuries was 5.7% of injuries; in Malaysia10 it was 21.4%. This study showed a high number of CONCLUSION maleinvolvement in ocular trauma similar to many Young adults at workplace and home are the most hospital and population based studies.12The greater affected subjects. Agriculture trauma is the most tendency for men to sustain eye injury is multifactorial common cause of eye injuries. Amongst other causes, such as work-related, sports related, aggressive mechanical trauma with flying iron particles is an behavior, assault, alcohol, drug abuse and reluctance important cause of injury in young adults.
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Recommendations 8. Schein OD, Hibberd PL, Shingleton BJ, et al. The spectrum and burden of ocular injury.Ophthalmology.1988;95(3):300-5 l Public awareness raising and health education for 9. Katz J, Tielsch JM. Lifetime prevalence of ocular injuries from using eye safety measures, through electronic me- the Baltimore Eye Survey.ArchOphthalmol. 1993; 111(11):1564- dia, leaflets in community and teaching in Schools. 10. Qureshi MB. Ocular injury Pattern in Turbat, Baluchistan, l Provision of better eye care services at the primary and Pakistan.Community Eye Health Journal.1997; 10(24):57- level and an emphasis on the training of 8. 11. PS Mallika1, AK Tan, T Asok, et al. Pattern of Ocular Trauma paramedical staff in the recognition and treatment in Kuching, Malaysia. Malaysian Family Physician 2008; Vol of minor injuries and referral of major ones. 3, No. 3: 140-5 l Education ofthe mother - the first health provider 12. Wong TY, Tielsch JM. A population-based study on the in the home. incidence of severe ocular trauma in Singapore.Am J Ophthalmol.1999;128(3):345-51 l Creatingawareness regarding eye injuries at the 13. Shukla IM, Verma RN. A clinical study of ocular group level, for example, amongst groups sharing injuries.Indian J Ophthalmol.1979;27(1):33-6 a common occupation or activity such as welders, 14. Khan MD, Mohammad S, Islam ZU, KhattakMN.An 11 years football players, cyclists and industrial workers. review of ocular trauma in the North-West Frontier Province of Pakistan.Pakistan Journal of Ophthalmology.1991;7:15-8 At group level one might channel messages 15. Karaman K, Gveroviæ-Antunica A, Rogošiæ V, through community health workers, teachers, etal.Epidemiology of adult eye injuries in Split Dalmatian sports coaches, volunteers and journalists, who country.Croat Med J. 2004;45(3):304-9 themselves will need to be educated. 16. Desai P, MacEwen CJ, Baines P, Minaissian DC. Epidemiology and implications of ocular trauma admitted l Advocacyamongst leaders and policy makers to to hospital in Scotland. J Epidemiol Community Health.1996; introduce and enforce policies which will help 50(4):436-41 prevent blindness from injuries, for example, 17. Schrader WF. Open globe injuries: epidemiological study of legislation for health and safety at work, the twoeye clinics in Germany, 1981-1999. Croat Med J.2004;45(3):268-7 wearing of car seat belts, the banning of explosive 18. S Vats MD, GVS Murthy MD, M Chandra MS et al. fire crackers, etc. Epidemiological study of Ocular Trauma in an urban slum REFERENCES: population in Delhi Indian: Indian Journal of 1. Schin OD, Hibberd P, Shinglten BJ, Kunzweiler T, Frambach Ophthalmology, Vol 56; No 4; 313-316 DA, Seddon JM, et al. The spectrum and burden of Ocular 19. Ilsar M, Chirambo M, Belkin M Ocular injuries in Malawi. Injury. Ophthalmology1988; 95: 300-5. Br J Ophthalmol 1982, 66:145-8 2. http://www.v2020eresource.org/newsitenews. 20. Nirmalan PK, Katz J, Tielsch JM, Robin AL, et al; Ocular aspx?tpath=news42007. trauma in a rural south Indian population: the Aravind 3. Negrel AD. Magnitude of Eye Injuries Worldwide. Comprehensive Eye Survey. Ophthalmology Community Eye Health Journal 1997; 10(24):49-53. 2004,111(9):1778-81 4. John P. Whitcher, M. Srinivasan, Madan P. Upadhyay. 21. Khatry SK, Lewis AE, Schein OD, Thapa MD, Pradhan EK, Corneal blindness: a global perspective. Bull World Health Katz J. The epidemiology of ocular traumain rural Nepal.Br Organ vol.79 no.3 Genebra 2001. J Ophthalmol. 2004 Apr;88(4):456-60. 5. Mohammad Daud Khan, Zia-ul-Islam, Khalid Nawaz, 22. Jones NP. One year of severe eye injuries in sport. Eye 1988; Zafar-ul-Islam and M. Aman Khan; penetrating eye injuries 2 (Pt 5): 484-7 by disposable syringes PJO, Vol.6, No.4, October 1990 23. C J Macewen,Eye injuries: a prospective survey of 5671 cases. 6. Mohammad Daud Khan, Niamatullah Khan Kundi, Zia Br J Ophthalmol1989 73: 888-894.). Mohammad and Dr. Anisa F. Nazeer. A 6 1/2 years survey 24. PS Mallika1, AK Tan, T Asok, et al. Pattern of Ocular Trauma of intraocular and interorbital foreign bodies in North West in Kuching, Malaysia. Malaysian Family Physician 2008; Vol Frontier Province, Pakistan, B.J.O., 1987, 71, 716-719. 3, No. 3: 140-5 7. Brendan Dineen, Rupert Bourne, ZahidJadoon, 25. Canavan YM, O’Flaherty MJ, Archer DB, Elwood JH. A 10- ShaheenPravin Shah, Causes ofBlindness and Visual year survey of eye injuries in Northern Ireland, 1967-76.Br J Impairment Pakistan. The Pakistan National Blindness and Ophthalmol1980; 64(8): 618-25 Low Vision Survey 10.1136/bjo.2006.108035 jan 2007
Ophthalmology Update Vol. 10. No. 2, April-June 2012 151 Original Article
Phacoemulsification under Topical Anaesthesia with Intracameral Lignocaine Dr. Mushtaq Mushtaq Ahmad FCPS1, Sofia Iqbal MRCOphth FRCS2, Nazullah FCPS3 Muhammad Naeem4
ABSTRACT: Objectives: To evaluate the patients’ and surgeons’ experience in phacoemulsification using topical anesthesia with intracameral lignocaine in terms of pain, surgical complications, and the outcome. Materials and Methods: Forty eight patients of senile cataract were operated by phacoemulcification under topical anesthesia with intracameral lignocaine in the department of ophthalmology Hayatabad Medical Complex from January 2011 to July 2011. One superior 3.2mm incision and two horizontal side ports with 15 degree were made.The patients and the single operating surgeon were given a questionnaire to evaluate their experience in terms of pain, surgical experience, and complications. Results: There were 48 patients enrolled in the study. The mean pain score was 0.7 (SD ± 0.97, range 0-5, median 0.0, and mode 0.0). Fifty-one patients (53%) had pain score of zero, that is, no pain. Ninety-one patients (~95%) had a score of less than 3, that is, mild pain to none. All the surgeries were complication-free except one and the surgeon’s experience was favourable in terms of patient’s cooperation, anterior chamber stability, difficulty, and complications. The ocular movements were not affected, and hence, the eye patch could be removed immediately following the surgery. Conclusions: Phacoemulsification under topical anesthesia with the use of 2% lignocaine jelly and 0.5% intracameral lignocaine makes cataract management better in every respect. The anesthesia achieved is adequate for patient comfort and safe cataract surgery Keywords: Anesthesia, intracameral lignocaine, pain evaluation, manual small incision cataract surgery, topical
INTRODUCTION: and John sheets were more popular in small incision Cataract is the commonest age related disease in ultrasonic surgery.7 Howard Gimbel introduced most countries world wide.1,2 There are approximately capsulorhexis first time.8 Small incision closing sutures 45 million blind people in the world. At least 80% of introduced by John Shepherd and later by Howard these people live in developing countries and more than Fine.9 Kelman performed phacoemulsification into half are blind as a result of cataract. These areas are anterior chamber and D. Calvard, Kratz T performed under privileged in terms of medical services. phacoemulsification into the papillary plane.10 Ophthalmology is even scarcely available speciality in Endocapsular phacoemulcification was introduced by such areas of the world3. Cataract extractions is one of Shephard.11 the most cost-effective of all surgical interventions in Several studies have demonstrated that topical terms of quality of life restored. The only treatment anesthesia provides satisfactory analgesia, comparable option for cataract is the surgical removal of the opaque with regional blocks (retrobulbar, peribulbar and lens and the implantation of an artificial lens.4 The state- subtenon anesthesia).12 On the other hand, even if of-the-art technique is phacoemulsification with the current best practice is used, the retro and peribulbar insertion of a foldable intraocular lens (IOL) through a techniques (using a sharp needle in the orbit) can cause self-sealing incision.5 Kelman introduced his serious and life-threatening complications in a limited phacoemulsifier in 1967 but many intracapsular number of cases (0.066%).13 Sub-Tenon’s anaesthesia by surgeons were not convinced.6 After that Robert Sinskey cannula can counteract this complication, but it increases the risk of mild complications of anaesthesia.14 ––––––––––––––––––––––––––––––––––––––––––––––––––––––– Moreover, these techniques can cause post-operative 1.Registrar Ophthalmology Department Hayatabad Medical 15 Complex,Peshawar.2. Associate Professor Ophthalmology akinaesia which is undesirable in one-day surgery. Department, Hayatabad Medical Complex, Peshawar.3 Assistant We here describe a topical anesthesia approach for Professor Ophthalmology, Bannu Medical College, Bannu, 4 Medical performing phacoemulsification. We have performed Officer Ophthalmology, Hayatabad Medical Complex, Peshawar a pain evaluation survey on patients who underwent ––––––––––––––––––––––––––––––––––––––––––––––––––––––– Correspondence: Dr Mushtaq Ahmad, House 31B, street no 2, this procedure. So for no study available in our setup sector N4, Phase 4, Hayatabad, Peshawar of phacoemulsification under topical anesthesia with E.Mail> [email protected] Cell: 03339119605 intracameral 0.5% lignocaine. ––––––––––––––––––––––––––––––––––––––––––––––––––––––– MATERIAL AND METHODS: Received: Sept’2011 Accepted: March’2012 ––––––––––––––––––––––––––––––––––––––––––––––––––––––– This prospective interventional case series
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containing forty eight patients of senile cataract were Patient’s cooperation, difficulty due to ocular operated by phacoemulcification under topical movements, and anterior chamber stability were anesthesia with intracameral lignocaine in the graded on a scale of 1-3, thus giving a cumulative range department of ophthalmology Hayatabad edical of 3-9 points. The questionnaire was designed to Complex from January 2011 to July 2011. provide results in a manner that the lower values The patients with significant cataract causing represent favorable experience. The fourth parameter impairment of visual functions not correctable by was complications or adverse events, which were glasses or with unacceptable glare, polyopia, or reduced mentioned as and when they happened. quality of vision attributable to cataract and willing for RESULTS: cataract surgery were included in the study. Only There were 48 patients enrolled in the study contraindication was inability to understand verbal according to the inclusion and exclusion criteria. commands. Sensitivity to lignocaine was also an Twenty three (47.9%) patients were male. Patients’ age absolute contraindication to topical anesthesia. Forty ranged from 38 to 78 years (mean age 64.2 years). eight patients were included in the study after Twenty-one were the right eye and 27 left eye. Type of performing tests and investigations for cataract surgery cataract according to the morphology was nuclear in under local anesthesia. At the start of the surgery, the 36 patients (37.5%), nuclear and subcapsular in 42 patients were instructed to hold the hand of the patients (43.7%), and subcapsular the rest. Nuclear paramedical staff and to squeeze the hand whenever density ranged from grade I-V and correlated with age. they felt pain, which was recorded together with the The pain experience during the surgical procedure was surgical step during which they felt pain. recorded as the patient’s response by squeezing the Lignocaine 2% drops were instilled in the hand of the operation theater assistant during the conjunctival sac 5 minutes before the surgery. The lids surgery. The patients felt pain when the viscoelastic was and periocular area were painted with povidone iodine being injected before capsulorrhexis (3 patients), during 5% solution twice and the patient draped. Once fully the stretching of the wound while delivering the draped, the surgery was started. No superior rectus nucleus (4 patients), and during the irrigation aspiration suture was taken. One superior 3.2mm incision and two procedure (4patients). horizontal side ports with 15 degree were made The The visual analog scale or the Wong scale was entry into the anterior chamber was followed by used to evaluate the mean pain score. The mean pain intracameral injection of diluted 2% lignocaine score was 0.70 ±0.97SD, range 0-5). Only five patients (xylocaine) solution, either commercially available (~5%) out of the whole series experienced pain who preservative-free or regular 2% lignocaine injection. In rated more than three on the visual analog scale of 10. our pain evaluation survey, we gave intracameral The pain scores more than three has been accepted to lignocaine to all the patients. Then, 2% hydroxy propyl represent moderate pain. Thus, rest of the patients can methyl cellulose was injected into the anterior chamber be assumed to have mild pain. There were 91 patients and capsulorrhexis was done. Hydrodissection was (~95%) who had a mean pain score of two or less. Fifty- performed to separate the cortex from the capsule. one patients (53%) had pain score of zero that is no pain Divide and concur technique used to emulsify the Figure 1. nucleus. Cortex aspirated with simcoe cannula, then the chamber filled with 2% hydroxy propyl methyl Fig 1: Frequency distribution of visual analog scale response of cellulose foldable intraocular lens implanted in the bag. patients undergoing cataract surgery under topical anesthesia The gel was washed out and wound hydration done. At the end of the surgery, a subconjunctival injection of dexamethasone and gentamycin was given (0.25 ml each). The eye was patched for about 2-3 hours, and then, the dressing was removed, eye was examined, and topical medications were started. Before opening the dressing, a pain survey questionnaire having visual analog scale for pain evaluation or Wong scale for simplified version of pain evaluation was given to the patients depending on their ability to comprehend. The surgeon also evaluated his experience in terms of surgical ease or difficulty, complications with regards to the topical anesthesia at the end of the surgeries. The surgeon’s evaluation was based on four parameters.
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The surgeon’s evaluation of the technique in terms to be an effective and possibly, a superior substitute to of surgical ease and complications was favorable. On a lignocaine drops. There has been no unwanted effect cumulative scale ranging from 3 to 9 (lower value of the gel preparation of the drug on extracapsular indicating favorable result), the average score was 3.4 cataract surgery and phacoemulsification; both have (SD ±0.85). Table 1 for frequency distribution of been successfully performed using the 2% lignocaine individual parameters taken into account. jelly. In this study, the mean pain score of 0.70 (SD Table 1: Frequency distribution of surgeon’s score ±0.97, range 0-5) is comparable to the studies done on for surgical experience during phacoemulcification topical anesthesia use for phacoemulsification. The under topical anesthesia (n = 48) mean pain score of 0.84 (SD ±1.30, range 0-7) against Surgeon’s Patient Unwanted Anterior peribulbar anesthesia 0.73 (SD ±1.5, range 0-5) was seen Score cooperation ocular chamber in a study done by Philipp, using 2% lignocaine drops. movements stability Similar results have been observed with the use of 1 848092lignocaine 2% jelly for providing topical anesthesia for 21013 0phacoemulsification for cataract removal in various other studies. The mean pain score in the present study 3 2 3 4was similar to the mentioned studies for the topical group, except that none of the patients in our studies Only one patient had a small zonular dehiscence, needed subtenon lignocaine supplementation as was which did not relate to the anesthesia technique, but it required by some patients in all the mentioned studies. was because of small capsulorrhexis during the Topical anesthesia is used to anesthetize insertion of the IOL. conjunctiva and sclera for several procedures like scleral DISCUSSION: indentation, forced duction test, subconjunctival The described use of topical anesthesia is injections, pterygium surgery, and cryoapplication for presently limited to clear corneal phacoemulsification retinal cryopexy. Thus, topical anesthesia is effective technique. The advantages are numerous, for the and safe for manipulating conjunctiva and sclera as patients as well as for the surgeon. Topical anesthesia well. This fact has been utilized and demonstrated well saves the patients from the risks of globe perforations, in our study, where the pain experience of the patients optic nerve injury, possibility of life-threatening has been comparable to that during phaco- respiratory arrest, 16 and above all, the pain and fear emulsification performed under topical anesthesia as perceived because of the peribulbar or retrobulbar reported in other studies. A pain evaluation study injections. Topical anesthesia has additional benefits comparing the delivery of prechopped nucleus through like not interfering with visual function, immediate a clear corneal incision and phacoemulsification visual recovery, absence of pain due to injection, through clear corneal incision using topical anesthesia unlimited ocular motility, and absence of an increase has shown that the perioperative pain is significantly in orbital volume.Various studies regarding the pain higher in the prechop method. The pain experienced perception and patients’ acceptability for anesthetic by the patients during cataract surgery under topical technique have been done and they concluded that the anesthesia is during the steps when there is stretching patients’ satisfaction for anesthesia is comparable for of the eye ball. Similar opinion has been expressed by topical versus other techniques. Besides the patients’ Philipp et al. , regarding the cause of pain in topical subjective appreciation of pain during surgery, which anaesthesia. may be limited by their tolerance and expression, there Surgeon’s evaluation of the technique has been are studies which have investigated the various favorable as demonstrated by the fact that patients’ physiological and biochemical parameter changes cooperation was good in majority of cases (87.5%). In during the surgery under topical anesthesia. Fichman most of the patients, there were no unwanted eye has investigated the blood pressure, pulse rate, and movements (83%). With topical anesthesia, there is no respiration rate of patients during surgery under topical rise in intraocular pressure as compared with anesthesia and has found no major changes in these peribulbar anesthesia. This is because the placement of parameters.There is no significant change in the plasma 5 ml of anesthetic cocktail in the orbit increases the cortisol levels during surgery under topical anesthesia, intraocular pressure. Thus, even without the use of indicating that the procedure is well tolerated and does ocular pressure, the anterior chamber stability is good not pose stress to the patient.Thus, with all the in topical anesthesia. Thus, combining advantages of topical anesthesia, it may be the preferred phacoemulsification with topical anesthesia with technique. Lignocaine gel has been previously shown intracameral 0.5% lignocaine makes cataract
154 Ophthalmology Update Vol. 10. No. 2, April-June 2012 Phacoemulsification under Topical Anaesthesia with Intracameral Lignocaine
management better in every respect. 8. Gimbel HV. Capsulotomy method eases intra-bag-posterior CONCLUSION: chamber IOL Ocul Surg News. 1985; 20. 9. Fine IH. Infinity suture in Koch pc. Davisan JA (eds), Text Phacoemulsification under topical anesthesia with book of advanced phacoemulsification techniques 1st ed. the use of 2% lignocaine jelly and 0.5% intracameral Tholofare N J Slack. 1991; 383. lignocaine makes cataract management better in every 10. Calvard Dm, Kratz RP. Endothelial cell loss following respect. The anesthesia achieved is adequate for patient phacoemulsification in the papillary plane. J Am Intraocular implant Soc T. 1981; 334. comfort and safe cataract surgery. 11. Shephard J. In Situ fracture phacoemulsification method, REFRENCES: phaco, PI. 1989. 1. Klein BE,Klein R, Moss SE. Changes in visual acuity 12. Haider SA, Khaqan HA. Topical versus periocular anesthesia associated with cataract surgery. The Beaver Dam Eye Study for cataract surgery what is best? Pak J Ophthalmol. 2005, Ophthalmology. 1996; 103: 1727-31. 21: 1-5. 2. Weale RA. The age variation of senile cataract in various 13. El-Hindy N, Johnston RL, Jaycock P, et al.; and the UK EPR parts of the world. Br J Ophthalmol. 1982; 66: 31-4. user group, The Cataract National Dataset Electronic Multi- 3. Evans JR, Henning A, Pradhan D, et al. Randomized control centre Audit of 55 567 operations: anaesthetic techniques and trial of anterior chamber intraocular lenses in Nepal: Long complications, Eye, 2009;23(1):50–55. term follow up .Bull World Health Organ. 2000; 78: 372-8. 14. Eke T, Thompson JR, Serious complications of local 4. Marseille E. Cost-effectiveness of cataract surgery in a public anaesthesia for cataract surgery: a 1 year national survey in health eye care program in Nepal. World Health Organ Bull the United Kingdom, Br J Ophthalmol, 2007;91: 470–75. OMS 1996;74:319-24 15. Kumar MC, Dodds C, Ophthalmic reginal block, Ann Acad 5. Porter R. Global initiative: The economic case. Commun Eye Med Singapore, 2006;35:158–68. Health 1998;27:44-5. 16. Eke, Tom, Thompson, John R. Serious complications of local 6. Emery JM, Little TH. Phacoemulsification and Aspiration of anaesthesia for cataract surgery: A 1 year national survey in Cataract, 1st ed; St. Louis C V Mosby. 1979. the United Kingdom. Br J Ophthalmol 2007;91:470-5. 7. Sinkey RM, Cain W Jr. The posterior capsule and phcoemulsification Am. Intraocular Implant Soc. 1978; 4: 26
Ophthalmology Update Vol. 10. No. 2, April-June 2012 155 Original Article
Angiographic Features of Central Serous Chorio-retinopathy Dr. Nawaz in Pakistani Population
Muhammad Nawaz1, Muhammad Ahmad2, Prof. Muhammad Sultan3, Faisal Saleem4
ABSTRACT Purpose: To investigate the angiographic features of central serous chorioretinopathy in terms of number of leaking points, patterns of leaking points during the angiogram, quadrant-wise location of leaking points in the macula, distance of leaking points from the centre of fovea, area of detached retina, and the presence or absence of leaking points in the fellow eye. Study design: This was a hospital based, prospective, cross-sectional observational study done at Department of Ophthalmology, Allied Hospital Punjab Medical College Faisalabad during July 2007 to June 2011. Methods: Both eyes of 86 patients of Central Serous Chorioretinopathy fulfilling the inclusion criteria were studied. After detailed ocular examination fundus fluorescein angiography was done. All the required information of the patients and the results of angiography were entered in a proforma. The data was analysed by SPSS and t-test. Results: Out of the total 86 patients of Central Serous Chorioretinopathy 78(91%) were male and 8(9%) were female. The mean age of the patients was 35±3 years. Visual acuity was reduced to less than 6/12 in 77 (79%) eyes. On angiography unilateral CSCR was found in 75(87%) patients and 11(13%) patients had bilateral disease. Only one leaking point was observed in 73 (75.5%) eyes and more than one leaking points were visible in 24 (24.5%)) eyes. In total 134 leaking points were observed in 97 eyes of 86 patients. Out of these, 126 (94%) points followed the ink-blot pattern and 8(6%) leaking points followed the smoke-stack pattern. Location wise, 80(60%) leaking points were located in the superonasal(SN) quadrant and 32(23%) in superotemporal (ST) quadrant of the macula. Furthermore, 121 (90%) of the leaking points were located within 3.0 mm from the centre of fovea. Unilateral cases have a mean detachment area of 24.78±15.75mm2 as compared to bilateral cases with a mean detachment area of 9.95±6.69mm2(P=0.012). Conclusions; Pakistani population has the same demographic and angiographic features of Central Serous Chorioretinopathy as in other parts of the world. It affects the young males more commonly and causes significantly reduced vision. It can be classified as, a more aggressive Type-I disease involving usually one eye with less number of leaking points but larger area of serous detachment and a less aggressive Type-II, involving both eyes with multiple leaking sites but causing smaller detachments Key words: Central Serous Chorioretinopathy, Fundus Fluorescein Angiography, Stress, Inkblot, Smokestack.
INTRODUCTION patients and author speculated that increased Central Serous Chorio-retinopathy (CSCR) was sympathetic nervous system activity may induce described by Albrecht Von Graefe, 150 years ago in CSCR.6 Choroidal ischemia has been considered as a 1866.1 Since then different etiological and patho- possible pathophysiologic factor for CSCR.7 physiological mechanisms have been proposed but still Clinically CSCR is characterized by an idiopathic the exact aetiology of CSCR is not clear.2 serous detachment of the central neurosensory retina, A high proportion of the patients with CSCR were secondary to retinal pigment epithelium (RPE) leaking found to be young males, and especially those working points as observed on Fundus fluorescein angiography under stressful conditions and experiencing acute (FFA). Usually it resolves spontaneously within few psychological trauma.3,4 It may be associated with months.8 But a few patients may require focal Type-A personality behavior.5 In one study, the use of photocoagulation, photodynamic treatment or Anti- psychopharmacological drugs like anxiolytic and anti- VEGF injections given intra-vitreally.9,10,11 The common depressive medications were found in 13% of the presentation of CSCR is a unilateral complaint of ––––––––––––––––––––––––––––––––––––––––––––––––––––––– blurred vision, a relative central scotoma, metamor- 1Assistant Professor, 4Postgraduate Trainee, 3Professor and Head phopsia and colour desaturation.12 of Department, Department of Ophthalmology Allied Hospital, Punjab Medical College Faisalabad. Different investigative procedures have been used 2 Assistant Professor, Islam Medical College, Sialkot. to confirm the diagnosis and monitor the treatment ––––––––––––––––––––––––––––––––––––––––––––––––––––––– efficacy of CSCR, including Fundus fluorescein Correspondence: Dr. Muhammad Nawaz 27/A-1- Satellite Town, angiography (FFA), Indocyanine green (ICG) Sargodha. Pakistan. E-mail: >[email protected]. Phone: 048 3215253 angiography, and Optical Coherence Tomography 13,14 ––––––––––––––––––––––––––––––––––––––––––––––––––––––– (OCT). Received: Oct’2011 Accepted Jan’2012 FFA of acute CSCR shows focal hyperfluorescent –––––––––––––––––––––––––––––––––––––––––––––––––––––––
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leaking point(s) at the level of retinal pigment All the findings were entered on a proforma and the epithelium (RPE). These leaking points may be single, results were analysed using Statistical package for social multiple or there may be a rarely generalized RPE sciences (SPSS) for windows (version 16, Inc. Chicago) dysfunction.15, 16. and t-test was applied for calculating the means and P- The objective of this prospective study was to values of various outcomes. investigate about the numbers of leaking points, the RESULTS: leaking pattern of these points during the FFA, Out of 86 patients presenting with the diagnosis quadrant wise location of these leaking points in the of CSCR in at least one eye, 78 (91%) were male and 8 macular area, their distance from the centre of fovea, (9%) were female with a male to female ratio of 10:1. area of serous retinal detachment in millimetre square All patients were Pakistani nationals without any other (mm2) and the presence or absence of RPE leaking racial or ethnic mixture. points in the fellow eyes of Pakistani patients diagnosed The age of the patients ranged from 25 to 60 years for CSCR. with a mean of 35±3.0 years. All 86 patients were MATERIALS AND METHODS: divided into four different age groups. Age of 13(15%) This was a hospital based, prospective, cross- patients was between 25 to 30 years, 51(59%) from 31- sectional observational study done at the Department 40 years, 19 (22%) patients from 41-50 years and only of Ophthalmology, Allied Hospital, Punjab Medical three (4%) patients aged between 51-60 years (Figure College Faisalabad during July 2007 to June 2011. 1). According to the inclusion criteria, 86 patients Visual acuity was 6/12 in 20 (21%) eyes, between presenting with the diagnosis of CSCR in at least one 6/18 to 6/36 in 48 (49%) eyes and between 6/60 to eye were enrolled for the study. Patients with history counting fingers in 29 (30%) eyes (Table I). of previous attacks of CSCR, and the patients with a Angiographically, CSCR was found in one eye of 75 history of any ocular surgery were excluded from the (87%) patients and both eyes of 11 (13%) patients. So a study. Similarly diabetic and hypertensive patients and total of 97 eyes of 86 patients were found to be affected the patients with any other ocular disease were also with CSCR. Left eye was more commonly affected as excluded from the study. After a detailed history and compared to right eye (48 vs. 27) while 11 patients had ophthalmic examination of these patients, Fundus bilateral disease. fluorescein angiography of both eyes of these patients Only one leaking point was observed in 73 (75.5%) was done using Topcon TRC DX-50 Retinal Camera. eyes, two leaking points were visible in 17 (17.5%) eyes, The coloured fundus photographs and angiograms of three leaking points in three (3%) eyes, four leaking these patients were stored and analysed using points in two (2%) eyes and five leaking points in two Imagenet ® Topcon software. (2%) eyes (Table II). In total 134 leaking points were CSCR was confirmed angiographically by the observed in 97 eyes of 86 patients. Out of these, 126 presence of hyperfluorescent leaking point(s) taking the (94%) points followed the ink-blot pattern of fluorescein pattern of either inkblot, smokestack or a generalized leakage, while the smoke-stack pattern was seen in only RPE dysfunction. An “ink-blot” pattern was assigned 8 (6%) leaking points. when a small focal hyperfluorescent leaking point Quadrant wise location of these 134 leaking points increased in size and intensity during the course of in the macular region was noted and it was found that angiogram. A “smokestack pattern” was labelled when 80 (60 %) points were located in the superonasal the hyperfluorescent leakage ascended vertically with quadrant of the macula, 32(23%) leaking points were linear configuration and then spreading laterally like a found in the superotemporal quadrant, 17 (13%) points plume of smoke during the course of angiogram. were located in inferonasal quadrant, and only five (4%) Number of leaking points was noted for each leaking points were found in inferotemporal quadrant angiogram. The location of each of these leaking points (Table III). The distance of the 134 leaking points from was recorded regarding superonasal, (S.N) inferonasal, the centre of fovea was also measured in millimetres. (I.N) superotemporal, (S.T) and inferotemporal (I.T) Thirty two (24%) leaking points were within 1.0 mm quadrants of the macular region. The macula was for the centre of fovea and 55 (41%) points were located defined as the retinal area within the temporal vascular between 1.1mm-2.0mm, while 34 (25%) points were arcades. The distance of the centre of leaking points located between 2.1mm-3.0 mm from the centre of from the centre of fovea was calculated using the fovea. Only 13 (10%) leaking points were located at a Imagenet ® Topcon software. The area of serous retinal distance of more than 3.0 mm from the centre of fovea. detachment was also measured by marking the So overwhelming majority (90%) of leaking points were boundary of the detachment and then calculating the located within 3mm from the centre of fovea (Table IV). area within the boundary using the same programme. In the study we also calculated the area of serous
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retinal detachment by marking the outline of the dome Table V: Area of serous detachment in CSCR of retinal detachment using the Imagenet software and 2 it was found that usually a large area of the central Area in mm No. of eyes %age retina is detached in this pathology. In 28 (29%) eyes < 10.0 28 29 2 the detachment area was between 1.0-10 mm and in 30 11-20 30 31 (31%) eyes detached retina was in the range of 10-20 mm2 while 15 (15.5%) eyes had 21-30 mm2 area of retinal 21-30 15 15.5 detachment. In 13 (13.5%) eyes the detached retinal 31-40 13 13.5 2 area was found to be of the size of 31-40 mm and 11 > 40 11 11 (11%) eyes had more than 41 mm2 area of serous detachment (Table V). Total 97 100
Table I: Visual Acuity of CSCR patients on presentation DISCUSSION: Visual Acuity No. of eyes (%) Clinical entity of central serous chorioretinopathy 1 < 6/12 20 (21) was described by Albrecht Von Graefe in 1866 but it was Maumene, 100 years later, who utilized Fundus 6/18-6/36 48 (49) Fluorescein Angiography to demonstrate that the 6/60 -CF 29 (30) subretinal fluid in CSCR was derived from the Total 97 (100) disturbance of outer blood retinal barrier i.e. retinal pigment epithelium13. Since then different studies have Table II: Number of leaking points in CSCR patients been done to find out the demographic and angiographic features of CSCR. In our study, 78 (91%) No. of leaks No. of eyes (%) Total no. of leaks patients out of 86 patients were male and 8 (9%) patients 1 73 (75.5) 73 were female with a male: female ratio of 10:1. This gender distribution of CSCR in Pakistani patients is the 2 17 (17.5) 34 same as reported in most of the studies15, 16, 17 with the 3 3 (03) 9 findings that CSCR is 6-10 times more common in males 4 2 (02) 8 than in females. Mean age of our patients was 35 ± 3.0 years, with a range from 25 years to 60 years. However 5 2 (02) 10 81% of our patients were between 31 years to 50 years. Total 97 (100) 134 This corresponds to the mean age of 41years found in a study in Asian population.18 Our study shows that Table III: Quadrant-wise location of leaking points in the macula the incidence of CSCR increases during the 4th and 5th decade of life (Figure 1). Quadrant No. of leaks %age Visual acuity was significantly reduced in most S.N 80 60 of the patients at the time of presentation. A total of 21% patients had visual acuity of 6/12, 49% had visual S.T 32 23 acuity of 6/18-6/36 and 30% had visual acuity of 6/60 I.N 17 13 to counting fingers only. So a total of 79% patients had I.T 5 4 visual acuity of less than 6/12 at presentation (Table I). S.N= Superonasal, S.T=Superotemporal, I.N=Inferonasl, I.T= Inferotemporal Figure-1 Incidence of CSR in relation to age groups Table IV: Distance of the leaking points from the centre of fovea
Distance from fovea No. of leaks %age < 1.0 mm 32 24
1.1-2.0 mm 55 41
2.1-3.0 mm 34 25 > 3.1 mm 13 10
Total 134 100
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This finding corresponds with the results of other leaking points were found within two disc diameter. 15 studies.19 Central serous chorioretinopathy (CSCR) results The “inkblot” pattern of leaking was observed in in exudative detachment of the central retina causing a overwhelming majority 126 (94%) of leaking points as dome shaped elevation of the detached retina. We compared to “smokestack” pattern which was observed measured the area of this retinal elevation and the mean in only 8(6%) leaking points. This finding is comparable area of detachment was 22.6±15.60 mm. This to the finding by Mutlak et al.15 But it is in contradiction measurement of the detached retinal area caused by to the finding of Kansky which states that smokestack CSCR is done for the first time and has not been pattern of leakage is more common than the inkblot reported in any earlier study. The large area of retinal pattern.20 detachment corresponds with the profound loss of Our study shows that 75% of the eyes affected by central vision observed in patients of CSCR. CSCR have one leaking point and 25% eyes have two Furthermore t-test analysis revealed that in unilateral or more than two leaking points on angiography. cases of CSCR the mean area of detached retina was Similarly 87% of the patients have unilateral disease 24.78±15.75 mm2 and in cases of bilateral disease the while 13 % of the patients have bilateral involvement. mean area of detached retina was 9.95±6.69 mm2 These findings support the concept that although CSCR (P=0.012). These findings suggest that the first type of presents as unilateral disease but in quite a significant CSCR, which is more common, causes less number of number of patients CSCR is caused by systemic RPE leakages but is more aggressive in nature resulting disorders resulting in bilateral disease and causing in relatively larger area of detached retina and a large multiple leaking points of RPE. central scotoma. The second type of CSCR, less common T-test analysis of the group statistics revealed that in frequency, seems to be less aggressive in nature average number of leaking points per eye in unilateral causing multiple RPE defects usually in both eyes of cases was 1.48 points, while the average number of the patient. However further extensive studies are leaking points per eye in bilateral cases was 2.21 required to confirm these findings. (P=0.030 & t-value=2.21). These findings suggest that CONCLUSION: possibly there are two different types of CSCR. First 1. Pakistani population has the same demographic type of CSCR causing a localised dysfunction of RPE, and angiographic features of Central serous involving usually one eye of the patient and a second chorioretinopathy as in other parts of the world. type of CSCR causing widespread RPE dysfunction 2. Central serous chorioretinopathy affects the resulting in multiple leaking points in both eyes of the young males causing significant loss of productive patient. work hours adding burden to the economies Location of the leaking points was noted by already under stress. dividing the macular area into four different quadrants 3. Central Serous Chorioretinopathy can be by drawing a vertical and a horizontal line passing classified as Type-I, more aggressive but localized through the fovea. A total of 80 (60%) leaking points disease and Type II, less aggressive but were located in the superonasal(SN) quadrant of the widespread disease of the Retinal Pigment macula involving the RPE beneath the maculopapillar Epithelium. bundle, whereas 32 (23%) leaks were found in the REFERENCES; superotemporal (ST) quadrant (Table III). Out of the 1. Graefe A Von. Uber zentrale rezidivierende Retinitis. V Graefes Arch Ophthal 1866; 12:211 rest, 17(13%) leaks were in inferonasal(IN) quadrant 2. Marmor MF. On the cause of serous detachments and acute and 5(4%) leaks were found in inferotemporal(IT) serous chorioretinopathy. Br J Ophthalmol 1997; 81: 812-13 quadrant. These results show that 83% of the leaking 3. Harrington DO. Psychosomatic interrelationship in points were located above the horizontal raphe of ophthalmology. Am J Ophthalmol 1948; 31: 1241-51 4. Zeligs MA. Central angiospastic retinopathy. A temporal retina. These findings are almost in the same psychosomatic study of its occurrence in military personnel. range as observed by Mutlak & Dutton in their study Psychosom Med 1947; 9: 110-17 and other studies done in the west. 15,16 5. Yanuzzi LA. Type-A behaviour and central serous Regarding the distance of the leaking points from chorioretinopathy. Retina 1987, 7: 111-30 6. Tittl MK, Spaide RF, Wong D, et al. Systemic findings the centre of fovea, it was observed that 121 (90%) of associated with central serous chorioretinopathy. Am J the leaking points were within 3.0 mm (2 disc diameter) Ophthalmol 1999;128:63-8 from the centre of fovea. Only 13(10%) leaks were 7. Kitaya N, Nagaoka T, Hikichi T, Sugawara R, Fukui K, Ishiko located more than 3.0mm away from the centre of fovea S, et al. Featuers of abnormal choroidal circulation in central serous chorioretinopathy. Br J Ophthalmol 2003; 87:709-12 (Table IV). The mean distance of all the leaking points 8. Otsuka S, Ohba N, Nakao K. A long-term follow-up study from the centre of fovea was 1.8 ±1.1mm. These finding of severe variant of central serous chorioretinopathy. Retina confirm the results of other studies where 82 % of the 2002; 22:25-32.
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9. Costa RA, Scapucin L,Moraes NS, et al Indocyanine green- Ophthalmol. 1995; 120:65-74. mediated photothrombosis as a new technique of treatment 15. Mutlak JA, Dutton GN. Fluorescein angiographic features for persistent central serous chorioretinopathy. Curr Eye Res of acute central serous retinopathy. A retrospective study. 2002; 25:287-97. Acta Ophthalmol. 1989; 67:467-69. 10. Yannuzzi LA, Slakter JS, Gross NE, et al. Indocyanine green 16. Spitznas M, Huke J. Numbers, shape and topography of angiography guided photodynamic therapy for treatment of leaking points in acute type I central serous retinopathy. chronic central serous chorioretinopathy: a pilot study. Retina Graefe’s Arch Clin Exp Ophthalmol. 1987; 225:437-40. 2003; 23:288-98. 17. Afzal Q, Shafqat AS, Yasir M, Zubairullah K. Factors 11. Hyun KS, Ji HB, Eung SK, Jae RH, Woo HN, Ha KK. Associated with Central Serous Chorioretinopathy in our Intravitreal Bevacizumab to treat acute central serous setup. Ophthalmology Update. 2011; 9:7-10 chorioretinopathy: short-term effect. Ophthalmologica.2009; 18. Alicia CSW, Adrian HC Koh, Angiographic Charactistics of 223:343-347 Acute Central Chorioretinopathy in an Asian Population. 12. Bennett G. Central Serous retinopathy. Br J Ophthalmol Ann Acad Med Singapore 2006; 35:77-79. 1955; 39: 605-18 19. Sahu DK, Namperumalsamy P, Hilton GF, De Susa N. 13. Maumene AE. Fluorescein angiography in the diagnosis and Bullous variant of idiopathic central serous treatment of lesions of the ocular funds. Trans Ophthalmol chorioretinopathy. Br J Ophthalmol 2000;84:485-92 Soc UK 1968; 88: 529-56. 20. Kansky JJ. Acquired macular disorders and related 14. Hee MR, Puliafito CA, Wong C, et al. Optical Coherence conditions. In: Kansky JJ. editor. Clinical Ophthalmology: a Tomography of central serous chorioretinopathy. Am J systematic approach. 6th ed. London: Elsevier 2007; 648
160 Ophthalmology Update Vol. 10. No. 2, April-June 2012 Original Article
Can we use Non-Ophthalmic Drug in Ophthalmology ? (Non-ophthalmic drug potential for ophthalmology) Prof. Marianne Prof. Marianne L. Shahsuvrayan, MD, Ph.D, D.Sc (Medicine), Professor of Ophthalmology Yerevan State Medical University, Republic of Armenia
ABSTRACT: Back Ground: Progress in ophthalmology is accompanying with non-ophthalmic drug use. Calcium channel blockers, which alter the intracellular calcium concentration by modifying calcium flux across cell membranes and affect various intracellular signaling processes, have been long and widely used to treat essential hypertension and certain types of cardiac diseases such as angina pectoris. Among five subtypes of calcium channels, only specific agents for L-type calcium channels have been used as therapeutics. There are potentially multiple biological bases for the protective effect of calcium channel blockers on eye structures. Objective: The objective of this review is to evaluate the evidence and discuss the rationale behind the recent suggestions that calcium channel blockers may be useful in the prevention and the treatment of different eye diseases. Key words: calcium channel blockers, glaucoma, retinal degeneration, ocular inflammation, neuroprotective effect, antioxidative action.
INTRODUCTION: calcium channel inhibition4,5. Neuroprotective effect of Calcium channel blockers, which alter the calcium channel blockers against retinal ganglion cell intracellular calcium concentration by modifying damage under hypoxia was shown by Yamada et al. 6, calcium flux across cell membranes and affect various and also by Garcia-Campos et al.7. Apoptosis, intracellular signaling processes, have been long and genetically programmed mechanism of cell death in widely used to treat essential hypertension and certain which the cell activates a specific set of instructions that types of cardiac diseases such as angina pectoris. lead to the deconstruction of the cell from within, is Among five subtypes of calcium channels, only specific now understood as a final common pathway for retinitis agents for L-type calcium channels have been used as pigmentosa. Retinitis pigmentosa is an inherited retinal therapeutics. Calcium antagonists induce degeneration characterized by nyctalopia, ring scotoma, vasodilatation at smooth muscle cells and are neuro- and bone-spicule pigmentation of the retina. Apoptosis protective through the intracellular decrease of K +. can thus be considered as a therapeutic target for Calcium channel blockers generally dilate isolated retinitis pigmentosa 8,9. ocular vessels and increase ocular blood flow in The general consensus is that intracellular experimental animals, healthy humans, patients with concentrations of calcium ion are increased in apoptosis open-angle glaucoma 1-3 and in patients who have 10-15 These findings suggest that calcium channel vascular diseases in which considerable vascular tone blockers may potentially inhibit ganglion cells and is present. As well contrast sensitivity in patients with photoreceptor apoptosis in glaucoma and retinitis normal tension glaucoma was found ameliorated by pigmentosa respectively 3,16 ––––––––––––––––––––––––––––––––––––––––––––––––––––––– There are potentially multiple biological bases for Correspondence: Prof. Dr. Marianne Shahsuvrayan, MD, Ph.D, D.Sc the protective effect of calcium channel blockers on eye (Medicine), Professor of Ophthalmology, 8th Hospital, Yerevan State structures, as was shown above. The objective of this Medical University, Republic of Armenia review is to evaluate the evidence and discuss the E-mail: [email protected] Postal Address: 7 Ap., 1 Entr., 26 Sayat-Nova Avenue, rationale behind the recent suggestions that calcium Yerevan 0001, Republic of Armenia channel blockers may be useful in the prevention and ––––––––––––––––––––––––––––––––––––––––––––––––––––––– the treatment of different eye diseases. Prof. Dr. Marianne L. Shahsuvrayan, is a general Ophthalmologist NON-OPHTHALMIC DRUGS and Professor of Ophthalmology at 8th Hospital, Yerevan State Medical University in the Republic of Armenia. She has done 1. Diltiazem 17 considerable research work on Retinal Vein Occlusion particularly Frasson et al., first reported the effects of D-cis- the use of non-ophthalmic drugs (calcium channel blockers) in diltiazem, a benzothiazepin calcium channel antagonist Ophthalmology. On the basis of her original work she has earned which blocks both cyclic-nucleotid-gated cation Ph.D. and Doctorate in Ophthalmic Sciences (D.Sc). She is quite adept in many languages like English, Armenian and Russian. channels (CNGC) and voltage-gated calcium channels ………Editor (VGCC) on photoreceptor protection in rd1 mice, –––––––––––––––––––––––––––––––––––––––––––––––––––––––
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several investigators have reported positive and that nimodipine is capable of preventing neurological negative effects of calcium channel blockers on animal deficits secondary to aneurysmal subarachnoid models of retinitis pigmentosa 13, 18-24. The intracellular haemorrhage. The results of the VENUS (very early concentration of calcium ions is subsequently elevated, Nimodipine use in stroke) study do not support the leading to photoreceptor apoptosis17. Sanges et al.13 concept that early nimodipine exerts a beneficial effect demonstrated that systemic administration of D-cis- in stroke patients 31 . On the other hand oral nimodipine diltiazem reduced intracellular concentrations of showed an enhanced acute reperfusion if applied calcium, down regulating calpains and photoreceptor within 12 hours of onset of acute stroke 6,31,32. Yamada apoptosis in rd1 mice. Direct inhibitory effects of D- et al.,6 in experimental in vitro model revealed that cis-diltiazem on L-type VGCC have been reported by nimodipine have a direct neuroprotective effect against Hart et al.21, and D-cis-diltiazem effectively blocks retinal ganglion cells damage related to hypoxia. photoreceptor light damage in mouse models by Michelson et al.,33 have evaluated the impact of inhibiting photoreceptor apoptosis 24. In contrast, L-cis nimodipine on retinal blood flow in double-blind, two- isomer inhibits L-type VGCC similarly to D-cis isomer25. way, crossover study of healthy subjects and found that The difference in action between D-cis and L-cis- orally administered at a dosage of 30 mg three times a diltiazem on photoreceptor apoptosis suggests that day nimodipine significantly increases retinal perfusion CNGC might also be important for photoreceptor in healthy subjects. Based on experimental findings neuroprotection17. Despite these studies, however, Shahsuvaryan34 investigated the efficacy of nimodipine Takano et al.23 and Pawlyk et al.26 found no rescue effects in the prospective comparative clinical interventional of D-cis-diltiazem on retinal degeneration in rd1 mice, study of patients with non-arteritic anterior and and Bush et al.18 also reported that D-cis-diltiazem was posterior optic neuropathy. The author stated that ineffective for photoreceptor rescue in rhodopsim P23H increase in visual acuity was higher in the posterior transgenic rats. The effects of diltiazem on animal ischemic neuropathy subgroup than in the anterior models of retinal degeneration remain controversial. ischemic subgroup. Visual field testing during the Pasantes-Morales et al.27 in human study reported follow-up also revealed positive transformation of that a combination of D-cis-diltiazem, taurin, and visual field defects size and location, which correlated vitamin E has beneficial effects on the visual field to visual acuity changes. These encouraging findings progression, although the study did not clarify whether need to be confirmed by double-blind study. diltiazem alone demonstrated beneficial effects. Otori Nimodipine has also been shown to significantly et al.28 evaluated the effect of diltiazem on inhibition of inhibit the growth of new vessels in experimental rat glutamate-induced apoptotic retinal ganglion cells model of retinopathy of prematurity35. Vascular death and concluded that application of diltiazem do endothelial growth factor (VEGF) can induce cell not appear to reduce apoptosis. Investigating the proliferation by activating the calcium channel in cell pharmacokinetics of diltiazem after subconjunctival membrane through the influx of calcium increased. and topical administration in rabbits and effect on Another animal study36 also have found a beneficial wound healing after the creation of conjunctival flaps, inhibitory effect of nimodipine on proliferative Oruc et al.29 have found that topical and subconjunctival retinopathy by blocking the influx of calcium and diltiazem successfully penetrated the aqueous humor, expression of VEGF. but did not appear to affect wound healing. The impact of nimodipine on ocular circulation Based on antioxidative action of calcium channel in normal tension glaucoma have been evaluated in blockers, which have recently been shown, another many clinical studies. Piltz et al.,37 have described a therapeutic target is ocular inflammation. Animal study performance-corrected improvement in visual field of intra-peritoneal injections of either nilvadipine, deviation and contrast sensitivity in patients with diltiazem, or vehicle have not found a beneficial normal tension glaucoma (NTG) and in control subjects inhibitory effect of diltiazem on the pathogenesis of in a prospective, placebo-controlled double-masked ocular inflammation through the suppression of study after oral administration of nimodipine (30 mg inflammation-related molecules30. twice a day). Other authors 38 also stated that a single 2. Nimodipine dose of 30mg nimodipine normalizes the significantly Nimodipine is an isopropyl calcium channel reduced retinal blood flow in NTG patients with clinical blocker which readily crosses the blood-brain barrier signs of vaso-spasmic hyperactivity. Luksch et al.,1 have due to its high lipid solubility. Its primary action is to examined the impact of 60 mg nimodipine in NTG reduce the number of open calcium channels in cell patients 2 hours after oral administration. Results membranes, thus restricting influx of calcium ions into disclosed that nimodipine increased the blood flow of cells. Several clinical trials have unequivocally shown the optic nerve head by 18% and improved color-
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contrast sensitivity. Thus, nimodipine is potentially nilvadipine on ocular circulation in normal tension useful calcium channel blocker for eye disorders glaucoma has been evaluated in different clinical treatment due to its high lipid solubility and ability to studies. cross the blood-brain barrier. Yamamoto et al.,42, Tomita et al.,43, Niwa et al.,44 3. Nilvadipine have found that nilvadipine reduces vascular resistance Recent experimental evidences suggest that in distal retrobulbar arteries and significantly increases Nilvadipine appear to have beneficial effects on velocity in the central retinal artery in patients with different ocular structures. Ogata et al.,39 have normal tension glaucoma. Tomita et al.43 also stated that evaluated the effects of nilvadipine on retinal blood reduced orbital vascular resistance after a 4-week flow and concluded that this agent may directly and treatment with 2 mg oral nilvadipine consequently selectively increase retinal tissue blood flow, while increases the optic disc blood flow. Koseki et al.2 having only minimal effect on systemic circulation conducted a randomized, placebo-controlled, double- including arterial blood pressure. Another experimental masked, single-center 3-year study of nilvadipine on study conducted by Uemura and Mizota40 have also visual field and ocular circulation in glaucoma with advocated the use of nilvadipine for the treatment of low-normal pressure. No topical ocular hypotensive glaucoma or other retinal diseases that have some drugs were prescribed. relation to apoptosis, based on claims that nilvadipine The authors concluded that nilvadipine (2 mg has high permeability to retina and neuroprotective twice daily) slightly slowed the visual field progression effect to retinal cells. Otori et al.,28 in the experimental and maintained the optic disc rim, and the posterior study of different calcium channel blockers protective choroidal circulation increased over 3 years in patients effect against glutamate neurotoxicity in purified retinal with open-angle glaucoma with low normal intraocular ganglion cells has found that nilvadipine significantly pressure. The results of this study add to the growing reduce glutamate-induced apoptosis. body of evidence that nilvadipine may be useful for Systemic administration of nilvadipine has been neuroprotection in glaucoma. Thus, nilvadipine is shown to be effective for protecting photoreceptors in potentially useful calcium channel blocker for eye rats experienced by the Royal College Surgeons20, on disorders treatment due to its hydrophobic nature with rd1 mice23, and heterozygous rd2 (rds) mice24 In high permeability to the central nervous system, addition to direct effects of calcium channel blockers including the retina and the highest antioxidant potency on intracellular concentrations of calcium ion in among calcium channel blockers. photoreceptor cells, other indirect effects are expected 4. Other Calcium Channel Blockers such as increased expression of fibroblast growth factor The experimental study conducted by Oku et al., (FGF)2 23 and ciliary neurotrophic factor (CNTF) in the 45 evaluated the effect of topical Iganidipine, a new retina24 ,and increased choroidal blood flow 2. Dihydropyridine derivative calcium channel blocker on In the latest animal study of intraperitoneal the impaired visual evoked potential after endothelin- injections of nilvadipine Ishida et al,30 have found a 1 injection into the vitreous body of rabbits and have beneficial inhibitory effect of this drug on the advocated iganidipine eyedrops for the treatment of pathogenesis of ocular inflammation through the ischemic retinal and optic nerve disorders for the suppression of inflammation-related molecules. Several maintenance of visual function. clinical trials have shown the effectiveness of The latest experimental study46 evaluated a nilvadipine in retinitis pigmentosa and glaucoma. neuroprotective effect of another new calcium channel Ohguro41 reported the photoreceptor rescue effects of blocker lomerizine. The authors stated that lomerizine nilvadipine in a small patient group. Nakazawa et al.,16 alleviates secondary degeneration of retinal ganglion expanded his nilvadipine study for RP patients to cells induced by an optic nerve crush injury in the rat, confirm the results. Although both treated and control presumably by improving the impaired axoplasmic groups are still small, authors results have shown flow. Tamaki et al.,47 also investigated the effects of significant retardation of the mean deviation (MD) lomerizine on the ocular tissue circulation in rabbits slope as calculated by the central visual field (Humphry and on the circulation in the optic nerve head and Visual Field Analyzer, 10-2 Program) after a mean of choroid in healthy volunteers and have found that 48 months of observation. As these pilot studies are lomerizine increases blood velocity, and probably blood small-sized and cannot completely exclude possible flow, in the optic nerve head and retina in rabbits, and biases, a large-scale, randomized, multicenter human it also increases blood velocity in the optic nerve head trial of calcium channel blockers is required in order to in healthy humans, without significantly altering blood evaluate their efficacy as therapeutic agents for retinitis pressure or heart rate. pigmentosa. The potential beneficial impact of
Ophthalmology Update Vol. 10. No. 2, April-June 2012 163 Can we use Non-Ophthalmic Drug in Ophthalmology ?
CONCLUSION 14. Paquet-Durand F, Johnson L, Ekstrom P (2007). Calpain activity In conclusion, there are potentially multiple in retinal degeneration. Journal of Neuroscience Research. 85(4):693-702. biological bases for the therapeutic effect of calcium 15. Read DS, McCall MA, and Gregg RG (2002).Absence of voltage- channel blockers in eye diseases. Taken into account dependent calcium channels delays photoreceptor degeneration in that not all calcium channel blockers are equally rd mice. Experimental Eye Research. 75(4):415-420. effective, the challenge for future laboratory research 16. Nakazawa M, Ohguro H, Takeuchi K, Miyagawa Y, Ito T, Metoki T (2011). Effect of nilvadipine on central visual field in retinitis will be to determine the best type and dosage of calcium pigmentosa: a 30-month clinical trial. Ophthalmologica. channel blockers and also to determine which processes 225(2):120-126. are modulated by these drugs in vivo and therefore are 17. Frasson M, Sahel JA, Fabre M, Simonutti M, Dreyfus H, Picaud S primarily responsible for the apparent beneficial effects (1999). Retinitis pigmentosa: rod photoreceptor rescue by a calcium-channel blocker in the rd mouse. Nature observed in the previous studies. 18. Bush RA, Kononen L, Machida S, Sieving PA (2000). The effect Clearly, further observational studies cannot of calcium channel blocker diltiazem on photoreceptor degeneration adequately address many unanswered questions. It is in the rhodopsin Pro23His rat. Investigative Ophthalmology and time to conduct a randomized controlled trial to provide Visual Science. 41(9):2697-2701. 19. Pearce-Kelling SE, Aleman TS, Nickle A (2001). Calcium channel direct evidence of the effectiveness of specific type blocker D-cis-diltiazem does not slow retinal degeneration in the nonophthalmic drug - calcium channel blocker in PDE6B mutant rcd1 canine model of pigmentosa. Molecular Vision. different eye diseases. 7:42-47. REFERENCES 20. Yamazaki H, Ohguro H, Maeda T, Maruyama I, Takano Y, Metoki 1. Luksch A, Rainer G, Koyuncu D, Ehrlich P, Maca T, Gschwandtner T, Nakazawa M, Sawada H, Dezawa M (2002). Preservation of ME, Vass C, Schmetterer L (2005). Effect of nimodipine on ocular retinal morphology and functions in Royal College Surgeons rat blood flow and color contrast sensitivity in patients with normal by nilvadipine, a Ca2+ Antagonist Investigative Ophthalmology tension glaucoma. Br.J.Ophthalmol. 89:21-25. and Visual Science. 43(4):919-926.. 2. Koseki N, Araie M, Tomidokoro A (2008). A placebo-controlled 3- 21. Hart J, Wilkinson MF, Kelly MEM, Barnes S (2003). Inhibitory year study of a calcium blocker on visual field and ocular circulation action of diltiazem on voltage-gated calcium channels in cone in glaucoma with low-normal pressure. Ophthalmology. photoreceptors. Experimental Eye Research. 76(5):597-604. 115(11):2049-2057. 22. Sato M, Ohguro H, Ohguro I, Mamiya K, Takano Y, Yamazaki H, 3. 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Otori Y, Kusaka S, Kawasaki A, Morimura H, Miki A, Tano Y rod photoreceptor apoptotic cell death in chemical-induced and (2003). Protective effect of nilvadipine against glutamate inherited retinal degenerations. Annals of the New York Academy neurotoxicity in purified retinal ganglion cells. Brain Res. of Science. 893:282-285. 31;961(2):213-219. 12. Delyfer MN, Leveillard T, Mohand-Said S, Hicks D, Picaud S, 29. Oruç S, Orhan D, Orhan M, Irkeç M, Baºçi N, Barun S, Bozkurt A Sahel A (2004). Inherited retinal degenerations: therapeutic (2000). The pharmacokinetics and effects of diltiazem in rabbits. prospects. Biology of the Cell. 96(4):261-269. Eur J Ophthalmol. 10(1):46-50. 13. Sanges D, Comitato A, Tammaro R, Marigo V (2006). Apoptosis 30. Ishida S, Koto T, Nagai N, Oike Y (2010). Calcium channel blocker in retinal degeneration involves cross-talk between apoptosis- nilvadipine, but not diltiazem, inhibits ocular inflammation in inducing factor (AIF) and caspase-12 and is blocked by calpain endotoxin-induced uveitis. Jpn J Ophthalmol. 54(6):594-601. inhibitors. Proceedings of the National Academy of Sciences of 31. orn J.de Haan RJ,Vermeulen M.(2001). Very Early Nimodipine Use the United States of America. 103(46):17366-17371. in Stroke (VENUS): a randomized, double-blind, placebo-controled
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trial.Stroke.32:461-465. Ophthalmol. 18(1):87-93. 32. Infeld B, Davis SM, Donnan GA. (1999). Nimodipine and 41. Ohguro H (2008). New drug therapy for retinal degeneration . perfusion changes after stroke. Stroke.30:1417-1423. Nippon Ganka Gakkai zasshi. 112(1):7-21. 33. Michelson G, Wärntges S, Leidig S, Lötsch J, Geisslinger G (2006). 42. Yamamoto T, Niwa Y, Kawakami H, Kitazawa Y (1998). The effect Nimodipine plasma concentration and retinal blood flow in healthy of nilvadipine, a calcium-channel blocker, on the hemodynamics subjects. Invest Ophthalmol Vis Sci. 47(8):3479-86. of retrobulbar vessels in normal-tension glaucoma. J Glaucoma. 34. Shahsuvaryan ML (2008). Neuroprotective therapy in ischemic 7(5):301-305. optic neuropathy. 7th International Symposium on Ocular 43. Tomita G, Niwa Y, Shinohara H, Hayashi N, Yamamoto T, Kitazawa Pharmacology and Therapeutics. Budapest, Hungary, A60. Y (1999). Changes in optic nerve head blood flow and retrobular 35. Juarez CP, Muino JC, Guglielmone H, Sambuelli R, Echenique hemodynamics following calcium-channel blocker treatment of JR, Hernandez M, Luna JD (2000). Experimental retinopathy of normal-tension glaucoma. Int Ophthalmol. 23(1):3-10. prematurity: angiostatic inhibition by nimodipine, ginkgo-biloba, 44. Niwa Y, Yamamoto T, Harris A, Kagemann L, Kawakami H, and dipyridamole, and response to different growth factors.Eur J Kitazawa Y (2000). Relationship between the effect of carbon Ophthalmol.10(1):51-59. dioxide inhalation or nilvadipine on orbital blood flow in normal- 36. KongY, Han LR, Peng YS, Deng DY (2004). Experimental study tension glaucoma. J Glaucoma. 9(3):262-267. of nimodipine and vascular endothelial growth factor in 45. Oku H, Sugiyama T, Kojima S, Watanabe T, Ikeda T (2000). proliferative retinopathy. Zhonghua Yan Ke Za Zhi. 40(5):226-330. Improving effects of topical administration of iganidipine, a new 37. Piltz JR, Bose S, Lanchoney D (1998). The effect of nimodipine, a calcium channel blocker, on the impaired visual evoked potential centrally active calcium antagonist, on visual function and mascular after endothelin-1 injection into the vitreous body of rabbits. Curr blood flow in patients with normal-tension glaucoma and control Eye Res. 20(2):101-108. subjects. J Glaucoma. 7(5):336-342. 46. Karim Z, Sawada A, Kawakami H, Yamamoto T, Taniguchi T 38. Michalk F, Michelson G, Harazny J, Werner U, Daniel WG, Werner (2006). A new calcium channel antagonist, lomerizine, alleviates D (2004). Single-dose nimodipine normalizes impaired retinal secondary retinal ganglion cell death after optic nerve injury in the circulation in normal tension glaucoma. J Glaucoma. 13:158-162. rat. Curr Eye Res. 31(3):273-283. 39. Ogata Y, Kaneko T, Kayama N, Ueno S (2000). Effects of 47. Tamaki Y, Araie M, Fukaya Y, Nagahara M, Imamura A, Honda M, nilvadipine on retinal microcirculation and systemic circulation. Obata R, Tomita K (2003). Effects of lomerizine, a calcium channel Nippon Ganka Gakkai Zasshi. 104(10):699-705. Japanese. antagonist, on retinal and optic nerve head circulation in rabbits 40. Uemura A, Mizota A (2008). Retinal concentration and protective and humans. Invest Ophthalmol Vis Sci. 44(11):4864-4871. effect against retinal ischemia of nilvadipine in rats. Eur J
Ophthalmology Update Vol. 10. No. 2, April-June 2012 165 Original Article
Intravitreal Triamcinolone (IVTA) vs Laser Photocoagulation Dr. E. Zunaina as a Primary Treatment for Diabetic Macular Oedema(DME)* (A Comparative Study)
Mustapha Norlaili1, Shaharuddin Bakiah2, Embong Zunaina3
ABSTRACT: Background: Diabetic macular oedema is the leading causes of blindness. Laser photocoagulation reduces the risk of visual loss. However recurrences are common and despite laser treatment, patients with diabetic macular oedema experienced progressive loss of vision. Stabilization of the blood retinal barrier introduces a rationale for intravitreal triamcinolone treatment in diabetic macular oedema. This study is intended to compare the best corrected visual acuity (BCVA) and the macular oedema index (MEI) at 3 month of primary treatment for diabetic macular oedema between intravitreal triamcinolone acetonide (IVTA) and laser photocoagulation. Methods: This comparative pilot study consists of 40 diabetic patients with diabetic macular oedema. The patients were randomized into two groups using envelope technique sampling procedure. Treatment for diabetic macular oedema was based on the printed envelope technique selected for every patient. Twenty patients were assigned for IVTA group (one injection of IVTA) and another 20 patients for LASER group (one laser session). Main outcome measures were mean BCVA and mean MEI at three months post treatment. The MEI was quantified using Heidelberg Retinal Tomography II. Results: The mean difference for BCVA at baseline [IVTA: 0.935 (0.223), LASER: 0.795 (0.315)] and at three months post treatment [IVTA: 0.405 (0.224), LASER: 0.525 (0.289)] between IVTA and LASER group was not statistically significant (p = 0.113 and p = 0.151 respectively). The mean difference for MEI at baseline [IVTA: 2.539 (0.914), LASER: 2.139 (0.577)] and at three months post treatment [IVTA: 1.753 (0.614), LASER: 1.711 (0.472)] between IVTA and LASER group was also not statistically significant (p = 0.106 and p = 0.811 respectively). Conclusions: IVTA demonstrates good outcome comparable to laser photocoagulation as a primary treatment for diabetic macular oedema at three months post treatment.
INTRODUCTION lens. The retinal thickness can be measured or Background: quantified by Optical Coherent Tomography (OCT), Diabetic macular oedema (DME) is the leading Confocal laser scanning using Heidelberg Retina causes of blindness in an increasing number of patients Tomography II (HRT II) or Retinal Thickness Analyzer. with diabetes. Reduction of visual acuity in DME results Scanning laser tomography (SLT) in HRT II is a from accumulation of fluid produced from a rupture non-invasive technique which permits the objective, of the blood-retinal barrier into the inner nuclear layer topographic measurement of the fundus. SLT employs of the retina. The thickened macula can be visualized confocal optics to attain a high resolution not only on slit lamp examination using 90 Dioptre or 78 Dioptre perpendicular to x and y axis but also along z axis (the optical axis). The distribution of reflected light intensity ––––––––––––––––––––––––––––––––––––––––––––––––––––––– *The study was approved by the Research and Ethical Committee, along the optical axis for a given pixel is described as School of Medical Sciences, Universiti Sains, Malaysia the z-profile or confocal intensity profile. An oedema ––––––––––––––––––––––––––––––––––––––––––––––––––––––– index can be derived for each pixel, which is sensitive 1,2, Ophthalmologists, Advanced Medical and Dental Institute, to oedematous changes of the retina. A resultant map Universiti Sains Malaysia, 13200 Kepala Batas, Pulau Pinang, Malaysia 3Senior Ophthalmologist & Medical Lecturer in the of these oedema indices gives a measure of the location Department of Ophthalmology, School of Medical Sciences, and extent of retinal oedema. It should be noted that Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, the macular oedema index (MEI) is not a measure of Malaysia. retinal thickness but reflects the changes of retinal ––––––––––––––––––––––––––––––––––––––––––––––––––––––– Correspondence: DrZunaina Embong, Medical Lecturer & Senior thickness based on the retinal refractive index in the Ophthalmologist, Department of Ophthalmology, Universiti Sains areas of oedema. The oedema index methodology has Malaysia. E.Mail>[email protected] been validated in diabetic retinopathy but not in other ––––––––––––––––––––––––––––––––––––––––––––––––––––––– disease states. Change of the oedema index has been Acknowledgement: The management of Ophthalmology Update thanks Dr. Embong Zunaina for permitting to reprint the original shown to correlate with change of visual function, article with reference to her E-Mail dated: 31st Jan’2012 including logarithm of the minimum angle of resolution –––––––––––––––––––––––––––––––––––––––––––––––––––––––
166 Ophthalmology Update Vol. 10. No. 2, April-June 2012 Intravitreal Triamcinolone (IVTA) vs Laser Photocoagulation as a Primary Treatment for Diabetic Macular Oedema(DME)
(log MAR) visual acuity, conventional automated static intravitreal injection or laser photocoagulation perimetry and short-wavelength automated perimetry, procedure, DME with proliferative diabetic retinopathy in patients undergoing grid laser treatment for clinically still undergoing pan retinal photocoagulation, history significant macular oedema.1 of ocular surgery (eg. cataract operation) or Yag Laser photocoagulation reduces the risk of visual procedure with the risk of further aggravating the loss in 60% of patients. However recurrences are macular oedema, intra-ocular pressure > 25 mmHg or common and despite laser treatment, 26% of patients any established glaucoma patient, ocular or systemic with DME experienced progressive loss of vision.2 infection, known steroid allergy or responder, history Furthermore, 40% of treated eyes that had retinal of systemic steroid within 4 months prior to oedema involving the centre of the macula at baseline randomization and HbA1c more than 10% were still had oedema involving the centre at 12 months, as excluded from the study. did 25% of treated eyes at 36 months.3 The frequency Sampling Procedure: Envelope technique of an unsatisfactory outcome following laser sampling procedure was conducted. A stack of opaque photocoagulation in some eyes with DME has envelope was prepared with 20 envelopes containing prompted interest in other treatment modalities. a piece of paper with the word ‘IVTA’ and the Intravitreal triamcinolone acetonide (IVTA) has remaining 20 envelopes stated ‘LASER’. The envelope been shown experimentally to reduce the breakdown was drawn for each patient by a co-investigator. This of blood retinal barrier.4 It down regulates the was performed once the patient had agreed to be production of vascular endothelial growth factor; a included in the study. known vascular permeability factor hence reduced the Study Procedure: All patients underwent a vascular permeability. Stabilization of the blood retinal complete ocular and systemic assessment once they barrier introduces a rationale for IVTA treatment in consented for the study. The assessment was performed DME. by the primary investigator before they were IVTA has proved to be effective in the treatment randomized into the two groups. of DME from previous study. It constitutes a newer, 1. Pre-treatment Parameters Measurements less destructive treatment modality in the management 1.1 Visual Acuity: Visual acuity of both eyes was of DME. Two previous studies of primary IVTA in tested with the standard retro illuminated Snellen chart. DME5,6 have shown improvement on visual acuity as BCVA for each eye was recorded in logarithm of the well as central macular thickness. Massinet. al. minimum angle of resolution (log MAR) notations10 and compared the use of IVTA as an adjunctive therapy in used as a baseline. DME eyes which failed laser treatment where it All patients underwent subjective refraction by effectively reduced the macular thickening.7 Jonas et. one optometrist. This is important as any astigmatism al. in 2003 reported in their prospective, interventional, of -1 Dioptre and more need to be corrected with clinical case series study, the visual acuity had astigmatism lens before proceeding with the HRT II for significantly improved with IVTA.8 measurement of MEI. This study is designed to compare the best 1.2. Fundus Examination: Fundus examination was corrected visual acuity (BCVA) and the macular done using 78 Dioptre lens on slit lamp bio microscopy oedema index (MEI) at 3 months of primary treatment and binocular indirect ophthalmoscopy. DME was for DME between IVTA and laser photocoagulation. classified as mild, moderate and severe based on the Confocal laser scanning machine, HRT II is used to International Clinical Diabetic Macular Oedema quantify the MEI pre and post treatment. To our Disease Severity Scale.11 knowledge, HRT II has never been used as an 1.3 Macular Oedema Index: MEI analysis has been evaluation tool in comparative study to assess macular incorporated within the HRT II as the macular oedema oedema in DME before and after treatment mapping (MEM). The baseline MEM was taken using MATERIAL & METHOD: the HRT II. Patients were properly positioned in front A comparative pilot study was conducted from of the HRT II system with their full correction of June 2007 to February 2008, at Hospital UniversitiSains astigmatism if any. The focus was then adjusted to get Malaysia, Kelantan, Malaysia. It was calculated based a clear image of the macula formed on the monitor. on improvement of visual acuity in IVTA, 81%8 and Three sets of three consecutive images were captured 25% in laser photocoagulation group.9 A total 40 each time. To ensure image quality and proper patients (20 per arm) was required for this study. handling, all guidelines recommended by the Diabetic patients with newly diagnosed clinically manufacturer were followed. as DME, and age more than 18 years old were included The best image was chosen based on the quality in this study. Patients with media opacity impairing and smallest standard deviation. One good quality scan
Ophthalmology Update Vol. 10. No. 2, April-June 2012 167 Intravitreal Triamcinolone (IVTA) vs Laser Photocoagulation as a Primary Treatment for Diabetic Macular Oedema(DME)
of each eye was utilised in all analyses. A 0.5 mm vitreous using a 27-gauge needle trans-conjunctivally. diameter circle was drawn using the circle draw facility Using a single, purposeful continuous maneuver, the 4 of the HRT II. The area was chosen based on the most mg triamcinolone acetonide was injected into the eye. oedematous area and the same area was marked for The needle was removed simultaneously with the the follow up photograph at three months. application of cotton tipped applicator over its entry Measurement of MEI was performed by a blinded site to prevent regurgitation of the injected material. trained medical technician. After the baseline Indirect ophthalmoscopy was performed to check for measurement of MEI, all the patients were randomized central retinal artery pulsation. The procedure was done using the envelope technique. The type of treatment by Investigator B (ophthalmologist). Topical chloram- selected would be performed the next day. phenicol four times daily would be continued for one TREATMENT PROCEDURE week. Only one injection of IVTA was given to each 2.1 Laser Photocoagulation: patient in IVTA group. Patient was follow-up at 3 Patients were properly positioned on a stable chair months post IVTA and no other treatment was given with the chin rested on the slit lamp that was mounted during that period. with a laser wavelength, Carl Zeiss Visulas 532S laser 3. Post-treatment Parameters Measurements: system. Patients were given grid or focal laser Patient was follow-up at 3 months post procedure. The depending on the type of the macular oedema. Topical similar step of visual acuity and MEI assessment as pre- anaesthetic, 5% proparacaine hydrochloride was treatment measurement was done. The outcome instilled in the eye which needed to be lasered. The laser measures were mean BCVA and mean MEI. settings were 50 micron spot size, duration of 0.1 Statistical Analysis: All the statistical method seconds and appropriate power started from 50 mW analysis was done with Statistical Package for Social and stepped up till it burned the retina with light gray Sciences (SPSS Inc) software, version 12.0. Normality burn. The number of laser burn given was based on was tested using Eye-balling (histogram pattern). the severity of diabetic macular oedema (range: 20 - Independent T-test, paired T-test and Chi square test 200 laser burns and 500 ìm away from the centre of the were used to analyze the results where appropriate. fovea). Only one session of laser (either focal or grid The p value of < 0.05 is considered as statistically laser) was given to each patient in LASER group. The significant. procedure was done by Investigator A (ophthalmo- Ways to minimize study error: The following logist). Patient was follow-up at 3 months post laser steps were taken to reduce errors while conducting the and no other treatment was given during that period. study:- 2.2 Intravitreal Triamcinolone Acetonide: (i) Patients were selected strictly based on the Intravitreal injection of triamcinolone was carried inclusion and exclusion criteria. out under sterile conditions in the operation room. (ii) Randomization of patients. Patient was admitted on a day care basis. Topical (iii) IVTA and laser photocoagulation were performed chloramphenicol four times a day was prescribed one by experienced ophthalmologist who was masked day prior to procedure. The procedure was done under to patient’s identity. A standardized technique local anaesthesia using topical 5% Proparacaine was used for both procedures. hydrochloride. The selected eye was properly cleaned (iv) The measurement of MEI was performed by one and draped. An eye speculum was then applied; flush identified and trained medical technician. irrigation with 5 mls 5% Povidone iodine was (v) The primary investigator was masked to patient’s performed on the eye for one minute. identity and procedures when analyzing the MEI Triamcinolone acetonide in a single-use vial results (pre and post intervention) of all patients. (40mg/ml, 1 ml vial), was drawn into a 1-cc tuberculin RESULTS: syringe after cleansing the top of the bottle with an Demographic Data: A total of 40 patients were alcohol wipe. A separate 27 gauge needle was placed enrolled into this study. Twenty patients were assigned onto the syringe, which was then inverted to remove for IVTA group and another 20 patients for LASER air bubbles. The excess triamcinolone was discarded group. Mean age, duration of Diabetes Mellitus (DM), till 0.1 ml (4 mg) remained in the syringe. and status of HbA1c of patients in IVTA and LASER The site of injection was then identified, at 3.5 mm group is shown in Table 1. There were 8 males (40%) in pseudophakic and 4 mm in Phakic eye to ensure and 12 females (60%) in the IVTA group while 11 males against passage of the needle through the vitreous base. (55%) and 9 females (45%) in the LASER group. The It was given at the infero-temporal region to avoid drug severity of DME for both groups is shown in Table 2. deposition in front of the visual axis. Triamcinolone Comparison of BCVA and MEI: The comparison acetonide of 4 mg in 0.1 mls was injected into the of mean BCVA and MEI in both groups at baseline and
168 Ophthalmology Update Vol. 10. No. 2, April-June 2012 Intravitreal Triamcinolone (IVTA) vs Laser Photocoagulation as a Primary Treatment for Diabetic Macular Oedema(DME)
Table 1. Characteristic of patients in IVTA and LASER group at baseline
Variables IVTA (n = 20) LASER (n = 20) (95% CI of mean difference) *p value Mean SD Mean SD Age (year) 58.65 7.26 56.85 6.40 (-2.58, 6.18) 0.411 Duration of DM (year) 8.40 3.98 8.35 4.98 (-2.83, 2.93) 0.972
HbA1c (mmols) 8.92 0.81 9.01 0.95 (-0.65, 0.48) 0.762 DM: Diabetes Mellitus, *Independent T-test, p < 0.05 significant
at three months post treatment is shown in Table 3. The baseline and at three months post treatment between mean difference for BCVA and MEI within the group IVTA and LASER was not statistically significant (p = at baseline and at three months post treatment was 0.113 and p = 0.151 respectively). Similarly, the mean statistically significant (p < 0.01). The comparison of difference for MEI at baseline and at three months post mean BCVA and MEI between IVTA and LASER treatment between IVTA and LASER group was also groups at baseline and three months post treatment is not statistically significant (p = 0.106 and p = 0.811 shown in Table 4. The mean difference for BCVA at respectively). DISCUSSION Table 2. Distributions of cases according to severity of DME We conducted this comparative pilot study to assess whether there was a significant difference Severity of DME IVTA (n = 20) LASER (n = 20) *p value between IVTA and laser photocoagulation with a single n%n% treatment as primary treatment of DME at three months Mild 6 30 9 45 0.265 by evaluating the BCVA and MEI. We used HRT II to evaluate the DME. We did not perform OCT to quantify Moderate 8 40 9 45 the DME. MEM of HRT II showed very good agreement Severe 6 30 2 10 with fundus biomicroscopy in diabetic maculopathy.1 DME: Diabetic macular oedema, *Chi square test, p < 0.05 In this study, the duration of DM in both groups significant were comparable (p = 0.972). Mean diabetic controlled
Table 3. Comparison of best corrected visual acuity and macular oedema index within the group at baseline and at three months post treatment
At baseline At 3 months post treatment (95% CI of mean difference) *p value Mean SD Mean SD Best Corrected Visual Acuity
IVTA 0.935 0.223 0.405 0.224 (0.430, 0.629) p < 0.01
LASER 0.795 0.315 0.525 0.289 (0.162, 0.377) p < 0.01 Macular Oedema Index
IVTA 2.539 0.914 1.753 0.614 (0.549, 1.022 p < 0.01
LASER 2.139 0.577 1.711 0.472 (0.252, 0.604) p < 0.01 *Paired t-test, p < 0.05 significant
Table 4. Comparison of best corrected visual acuity and macular oedema index between IVTA and LASER groups at baseline and at three months post treatment
IVTA (n = 20) LASER (n = 20) (95% CI of mean difference) *p value Mean SD Mean SD Best Corrected Visual Acuity
At baseline 0.935 0.223 0.795 0.315 (-0.349, 0.315) 0.113
At 3 months post treatment 0.405 0.224 0.525 0.289 (-2.857, 0.457) 0.151 Macular Oedema Index
At baseline 2.539 0.914 2.139 0.577 (-0.089, 0.889) 0.106
At 3 months post treatment 1.753 0.614 1.711 0.472 (-0.315, 0.400) 0.811 *Independent T test, p < 0.05 significant
Ophthalmology Update Vol. 10. No. 2, April-June 2012 169 Intravitreal Triamcinolone (IVTA) vs Laser Photocoagulation as a Primary Treatment for Diabetic Macular Oedema(DME)
would give a better and reliable result. Another as being shown by the HbA1c results were almost the same in each group, 8.92 (0.81) in IVTA and 9.01 (0.95) limitation of this study was a short duration of follow up. A longer period of follow up, at least over 12 months in LASER group. The HbA1c results showed moderate controlled of DM among our study samples. Our would give more value especially to arrive a treatment patients had poor control of DM compared to study by recommendation and able to assess the side effect of Triamcinolone. The analysis of macular oedema may Batioglu and colleagues where the HbA1c was 4% to 6%.12 be improved by using alternative instrument like OCT In our study, we treat the patient either IVTA or to support the HRT II findings. laser for DME and review the mean BCVA and MEI at CONCLUSION: three months post procedure. Three months follow-up Both IVTA and laser photocoagulation showed was chosen because only a single treatment was given. good comparable outcomes in term of BCVA and MEI The requirement of re-treatment if needed will be given at three months post treatment as primary treatment after three months. The mean BCVA in IVTA group at for DME. three months was 0.405 (0.224) and 0.525 (0.289) in REFERENCES: 1. Kisilevsky M, Hudson C, Flanagan JG, Nrusimhadevara RK, LASER group. The mean difference at three months was Guan K, Wong T, Mandelcorn M, Lam WC, Devenyi RG: not statistically significant (p = 0.151) which meant that Agreement of the Heidelberg Retina Tomograph II macula neither IVTA nor laser were superior to each other as a edema module with fundus biomicroscopy in diabetic primary treatment of DME at 3 months of treatment. maculopathy. Arch Ophthalmol 2006, 124(3):337–342. 2. Sutter FK, Simpson JM, Gillies MC: Intravitreal triamcinolone Our result showed a comparable outcome with study for diabetic macular edema that persists after laser treatment: 13 done by Lam et al. three-month efficacy and safety results of a prospective, The significant improvement of BCVA in the IVTA randomized, double-masked, placebo-controlled clinical group (p < 0.01) in our study was similar to the studies trial. Ophthalmology 2004, 111(11):2044–2049. 1,14 3. Ip MS: Intravitreal injection of triamcinolone: an emerging reported by few published data. Our result also treatment for diabetic macular edema. Diabetes Care 2004, showed significant improvement of BCVA post laser 27(7):1794–1797. therapy at three months (p < 0.01). However a study 4. Wilson CA, Berkowitz BA, Sato Y, Ando N, Handa JT, de done by Lee et al15 showed no significant improvement Juan E Jr: Treatment with intravitreal steroid reduces blood- retinal barrier breakdown due to retinal photocoagulation. of BCVA at three months after laser treatment. Arch Ophthalmol 1992, 110(8):1155–1159. The mean MEI at three months in IVTA group 5. Ozkiris A, Evereklioglu C, Erkili K, Tamelik N, Mirza E: was 1.753 (0.614) and 1.711 (0.472) in the LASER group. Intravitreal triamcinolone acetonide injection as primary The mean difference of both groups was not statistically treatment for diabetic macular edema. Eur J Ophthalmol 2004, significant (p = 0.811). Both modalities demonstrated 14(6):543–549. 6. Karacorlu M, Ozdemir H, Karacorlu S, Alacali N, Mudun B, comparable outcome of reduction of MEI at three Burumcek E: Intravitreal triamcinolone as a primary therapy months. There was no published data on study using in diabetic macular oedema. Eye 2005, 19(4):382–386. HRT II as an objective evaluation for DME post IVTA 7. Massin P, Audren F, Haouchine B, Erginay A, Bergmann JF, or laser treatments. Hence we could only compare our Benosman R, Caulin C, Gaudric A: Intravitreal triamcinolone acetonide for diabetic diffuse macular edema: preliminary study with study using OCT measurement. Lam et al results of a prospective controlled trial. Ophthalmology 2004, again reported comparable outcome of central macular 111(2):218–245. thickness of IVTA and laser treatment at three months 8. Jonas JB, Kreissig I, Sofker A, Degenring RF: Intravitreal which was similar to our result.13 injection of triamcinolone for diffuse diabetic macular edema. Arch Ophthalmol 2003, 121(1):57–61. The significant improvement of mean MEI at three 9. Yanyali A, Nohutcu AF, Horozoglu F, Celik E: Modified grid months in the IVTA group in our study (p < 0.01) was laser photocoagulation versus pars planavitrectomy with comparable to previous studies using OCT internal limiting membrane removal in diabetic macular evaluation.1,5,14,16–18 We also found that the mean MEI in edema. Am J Ophthalmol 2005, 139(5):795–801. 10. Dehghan MH, Ahmadieh H, Ramezani A, Entezari M, the LASER group also showed significant improvement Anisian A: A randomized, placebo-controlled clinical trial at three months (p < 0.01). However, Lee et al[15] of intravitreal triamcinolone for refractory diabetic macular reported that there was no significant improvement of edema. IntOphthalmol 2008, 28(1):7–17. central macular thickness at 3 months after laser 11. Wilkinson CP, Ferris FL III, Klein RE, Lee PP, Agardh CD, Davis M, Dills D, Kampik A, Pararajasegaram R, Verdaguer treatment. They found that for DME patients, the JT, Global Diabetic Retinopathy Project Group: Proposed combination treatment (laser and IVTA) had a better international clinical diabetic retinopathy and diabetic therapeutic effect than the laser alone for improving macular edema disease severity scales. Ophthalmology 2003, BCVA and central macular thickness at the early follow- 110(9):1677–1682. 12. Batioglu F, Ozmert E, Parmak N, Celik S: Two-year results 15 up time periods. of intravitreal triamcinolone acetonide injection for the Limitation of this present study is our number of treatment of diabetic macular edema. IntOphthalmol 2007, patients was relatively small and a bigger sample size 27(5):299–306.
170 Ophthalmology Update Vol. 10. No. 2, April-June 2012 Intravitreal Triamcinolone (IVTA) vs Laser Photocoagulation as a Primary Treatment for Diabetic Macular Oedema(DME)
13. Lam DSC, Chan CKM, Tang EWH, Li KKW, Fan DSP, Chan macular detachment after intravitreal triamcinolone WM: Intravitreal triamcinolone for diabetic macular oedema acetonide in patients with diabetic macular edema. Am J in Chinese patients: six-month prospective longitudinal pilot Ophthalmol 2005, 140(2):251.e1-251.e6. study. Clin Experiment Ophthalmol 2004, 32(6):569–572. 17. Gibran SK, Cullinane A, Jungkim S, Cleary PE: Intravitreal 14. Larson J, Zhu M, Sutter F, Gillies MC: Relation between triamcinolone for diffuse diabetic macular oedema. Eye 2006, reduction of foveal thickness and visual acuity in diabetic 20(6):720–724. macular edema treated with intravitreal triamcinolone. Am 18. Lam DSC, Chan CKM, Mohamed S, Lai TYY, Lee VYM, Liu J Ophthalmol 2005, 139(5):802–806. DTL, Li KKW, Li PSH, Shanmugam MP: Intravitreal 15. Lee HY, Lee SY, Park JS: Comparison of photocoagulation triamcinolone plus sequential grid laser versus triamcinolone with combined intravitreal triamcinolone for diabetic or laser alone for treating diabetic macular edema: six-month macular edema. Korean J Ophthalmol 2009, 23(3):153–158. outcomes. Ophthalmology 2007, 114(12):2162–2167. 16. Ozdemir H, Karacorlu M, Karacorlu SA: Regression of serous
Ophthalmology Update Vol. 10. No. 2, April-June 2012 171 Original Article Topical Nsaid’s and Flouoromethalone in the Treatment of Epidemic Keratoconjunctivitis*
(A Comparative Study) Dr Anwar Dr Ashok Dr. Inam Co-author Co-author Inam ul Haq Khan FCPS1, Anwar Ali FCPS2, Ashok Kumar Pinjani FCPS3
ABSTRACT Purpose: The purpose of this study is to compare the role of NSAIDS and Fluoromethalone in the treatment of epidemic keratoconjunctivitis. Patient and Methods: 30 patients of bilateral punctuate epithelial keratitis were diagnosed as cases of adenoviral keratitis on the basis of their clinical picture. 18 males, 12 females, aged from 12 to 40 years, were selected for study. First group. In right eye NSAIDS eye drops were used. Second group. In left eye Fluorometholone eye drops were used. In the first group, 18 eyes (60 %) have completed resolution of conjunctivitis and anterior stromal infiltrates after 3 weeks of treatment. Complaints of stinging sensation were present in all the patients. In spite of unpleasant stinging sensations these patients were encouraged to continue using the eye drops. After three weeks of treatment the patients with minimal improvement were switched on to topical Fluorometholone. Out of these 12 patients, 7 recovered completely in one weeks time, 3 took another week to recover and in 2 patients topical steroids had to be used in tapering dosage for 4 months. In 1 patient after the cessation of therapy there was recurrence of sub epithelial opacities and topical Fluorometholone had to be started again, in TID dosage for 2 weeks, followed by BD dosage for another 2 weeks. In the second group, 24 eyes (80%) recover completely within 10 days without sub epithelial opacities or stromal infiltrates. They were told to continue eye drops for another week and then to stop. 28 patients (84%) recover completely in three weeks time. 2 patients had to use topical steroids for about 4 months. In 1 patient after the cessation of therapy there was recurrence of sub epithelial opacities and topical Fluorometholone had to be started again, in TID dosage for 2 weeks, followed by BD dosage for another 2 weeks. Fluoromethalone eye drops proved to be significantly better than the NSAID eye drops with no rise in IOP. In addition stinging sensations of NSAIDS eye drops heralds their use as the First choice in the management of the disease. Results: NSAIDS group • Conjunctivitis recovered completely in one week time. 18 eyes (60 %) have complete resolution of anterior stromal infiltrates on their third visit. Complaints of stinging sensation were present in all the patients, in spite of this the patients were encouraged to continue using the eye drops. • After three weeks of treatment 12 patients had either no or minimal improvement and these patients were switched on to topical Fluorometholone. Out of these 12 patients, 7 recovered completely in one weeks time (total 25 patients 83.3%), 3 took another week to recover and in 2 patients topical steroids had to be used in tapering dosage for 4 months. In 1 patient after the cessation of therapy there was recurrence of sub epithelial opacities and topical Fluorometholone had to be started again, in TID dosage for 2 weeks, followed by BD dosage for another 2 weeks Fluoromethalone group • Conjunctivitis recovered completely on second visit. 24 patients (80%) recover completely within 9-12 days without sub epithelial opacities or stromal infiltrates. • 28 patients (93.3%) recover completely in three weeks time. • 2 patients had to use topical steroids for about 4 months. In 1 patient after the cessation of therapy there was recurrence of sub epithelial opacities and topical Fluorometholone had to be started again, in TID dosage for 2 weeks, followed by BD dosage for another 2 weeks. This patient had to use topical medications once a day for six months for complete resolution of corneal stromal infiltrates. Conclusion: We conclude from our study that the use of Fluorometholone in the management of epidemic viral Keratoconjunctivitis alleviate the patient’s symptoms (redness, discomfort, swelling, tearing, photophobia, blurring of
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– *The Study was conducted at Saudi Armed Forces Hospital, Sharourah, Saudi Arabia, between July’2008 and August 2009 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– 1Classified Ophthalmologist & Assistant Professor, A.K.Medical College, & His Highness Shaiekh Khalifa Bin Zayed An-Nahyan Hospital, AJK / CMH Muzaffarabad 2,3Assistant Professors (Ophthalmology), PIMS, Islamabad. –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Correspondence: Lt. Col. Dr. Inam ul Haq Khan, Classified Ophthalmologist & Assistant Professor, His Highness Shaiekh Khalifa Bin Zayed An-Nahyan Hospital, AJK / CMH Muzaffarabad. E-mail> [email protected]. Mobile: 00923009771066. Received Nov’2011 Accepted March’2012 –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Received Nov’2011 Accepted March’2012 ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
172 Ophthalmology Update Vol. 10. No. 2, April-June 2012 Topical Nsaid’s and Flouoromethalone in the Treatment of Epidemic Keratoconjunctivitis
vision and pain as well). It decreases the course of the disease, as without treatment the course is prolonged and may accompany complications. It also decreases the occurrence of sub- epithelial opacities and helps in the complete resolution of residual opacities. Key Words: Fluorometholone, NSAIDS. EKC. Punctate epithelial keratitis.
INTRODUCTION in tapering dosage for 4 months. In 1 patient after the In Saudi Arabia due to the peculiar conditions, cessation of therapy there was recurrence of sub added by the world’s largest gathering of human beings epithelial opacities and topical Fluorometholone had during Hajj adenoviral infections are common. It to be started again, in TID dosage for 2 weeks, followed involves upper respiratory tract, and large number of by BD dosage for another 2 weeks. GIT infections are attributed to this virus. It is seen that In the second group, 24 eyes (80%) recover after every Hajj there is an endemic of upper respiratory completely within 10 days without sub epithelial tract infections and conjunctivitis. Different viruses are opacities or stromal infiltrates. They were told to the culprit among them is multiple strains of continue eye drops for another week and then to stop. adenovirus. This virus keeps on changing its genetic 28 patients (84%) recover completely in three weeks code. It is said that upto50 different strains of this virus time. 2 patients had to use topical steroids for about 4 have been identified till now. Due to its behavioral months. In 1 patient after the cessation of therapy there diversity it is difficult to develop a much needed was recurrence of sub epithelial opacities and topical vaccine. Fluorometholone had to be started again, in TID dosage The treatment options available to us are based for 2 weeks, followed by BD dosage for another 2 weeks. on the symptomatic and physical findings. If the disease Fluorometholone eye drops proved to be involves the cornea we think of more aggressive means significantly better than the NSAID eye drops with no of treatment. If it is limited to the conjunctiva; our aim rise in IOP. In addition stinging sensations of NSAIDS is to prevent the involvement of cornea and prevention eye drops heralds their use as the First choice in the of spread of infection as well as secondary infections. management of the disease. MATERIAL AND METHODS: Aim of the Study: Different treatment options are Epidemic Viral Keratoconjunctivitis (EKC) is a available for the treatment of adenoviral keratitis. Aim type of adenovirus ocular infection. EKC is highly of this study was to see the efficacy of fluorometholone contagious and has tendency to occur in epidemics. At compared to NSAIDS in the treatment of adenoviral least 19 serotypes of adenovirus have been implicated keratitis. in causing eye infection. The aim of this study was to Selection Criteria: Patients with bilateral sub compare the role of NSAIDS and Fluorometholone in epithelial opacities diagnosed as cases of adenoviral the treatment of epidemic keratoconjunctivitis. 30 keratitis were selected (Thygeson superficial punctuate patients of red eye were diagnosed as cases of keratitis need to be differentiated from epidemic adenoviral keratoconjunctivitis on the basis of their keratoconjunctivitis. In former, conjunctivitis is absent clinical picture. 18 males, 12 females, aged from 9 to while in the later it is present). A thorough history was 40 years. taken. Clinical examination was performed. Diagnosis First group. In right eye NSAIDS eye drops were used. of adenoviral keratitis was on the basis of clinical Second group. In left eye Fluorometholone eye drops findings. Those cases with bilateral findings were were used. recruited. Performa of history, clinical examination and The study was held between July 2008 and treatment plan was prepared for each patient. In the August 2009 in SAFH Sharourah KSA. Patients were end, data was compiled and results were prepared. followed up for 6 months. Aim of this study was to see the efficacy of In the first group, 18 eyes (60 %) have complete Fluorometholone compared to NSAIDS in the treatment resolution of conjunctivitis and anterior stromal of adenoviral keratitis. Since the facilities for the infiltrates after 3 weeks of treatment. Complaints of identification of the virus strains are not available, the stinging sensation were present in all the patients. In study was based on the symptomatic and clinical spite of unpleasant stinging sensations these patients improvements. were encouraged to continue using the eye drops. After 30 patients were selected for the study. They were three weeks of treatment the patients with minimal briefed about the purpose of the study and their improvement were switched on to topical cooperation in this regard was requested. Those who Fluorometholone. Out of these 12 patients 7 recovered were willing to cooperate and agreed to follow the completely in one weeks time, 3 took another week to instructions were recruited. Results of medication were recover and in 2 patients topical steroids had to be used monitored meticulously. Diagrams of corneal changes
Ophthalmology Update Vol. 10. No. 2, April-June 2012 173 Topical Nsaid’s and Flouoromethalone in the Treatment of Epidemic Keratoconjunctivitis
were drawn. Number, size and depth of the stromal monitored by air puff tonometer. exudates were noted down. Patients were requested to TREATMENT visit after three days of initiation of therapy and then In right eye NSAIDS eye drops and in the left eye after one week. If there is improvement they were Fluorometholone eye drops were started simultane- requested to visit after two weeks, otherwise after one ously. The dose was one drop five times a day. Patients week. Further visits were requested depending upon were called after three days for the first visit and then the response from the treatment. In one eye NSAID after one week. Further visit was requested after two eye drops and in the other Fluorometholone eye drops weeks in cases which were showing good response, in were used. Symptomatic as well as clinical other cases patients were called after one week. improvements were monitored. Changes in the cornea were noted down. After second Performa of History: Name, age, sex, occupation, visit, in patients showing improvement the dose was numbers of individuals in the family, history of eye reduced to one drop three times a day for another one complaints in other family members, history of recent week. Treatment was continued in the patients showing upper respiratory tract/ gastrointestinal infections and improvement. In those patients in whom there was history of Umra or Hajj in the recent past or of contact complete resolution of corneal changes, the treatment with such an individual. The complaints of the patient was stopped and the patient was requested to come along with duration were noted down. Redness, pain, again after one week. Intra ocular pressure was noted discharge, foreign body sensations, generalizedvisual by air puff tonometer. complaints, history of conjunctivitis in the past and use RESULTS of eye drops. Systemic complaints, specifically upper NSAIDS group: respiratory tract infections and GI infections were also • Conjunctivitis recovered completely in one week asked. time. 18 eyes (60 %) have complete resolution of Performa of Clinical Examination: VA on anterior stromal infiltrates on their third visit. Snellen’s projector was documented on Ist visit and Complaints of stinging sensation were present in subsequently. Examination of lids for lid edema noted, all the patients, in spite of this the patients were involvement of the conjunctiva documented, type of encouraged to continue using the eye drops. response (follicular or papillary), pre-auricular • After three weeks of treatment 12 patients had lymphadenopathy, subconjunctival hemorrhages and either no or minimal improvement and these pseudo- membranes were noted down1 . Location and patients were switched on to topical size of subconjunctival hemorrhages were also noted Fluorometholone. Out of these 12 patients, 7 and drawn. Corneal changes are documented recovered completely in one weeks time (total 25 meticulously. Epithelial edema, sub epithelial deposits patients 83.3%), 3 took another week to recover were noted down, counted and drawn carefully on the and in 2 patients topical steroids had to be used paper. Staining with Fluorescein and Rose Bengal done. in tapering dosage for 4 months. In 1 patient after Anterior chamber reaction was noted down. IOP the cessation of therapy there was recurrence of
Table 1. Recovery Table
Number of Eyes Complete recovery Recovery with subepithelial infiltrates No % No % No % First group 30 100 18 60 12 40
Second group 30 100 24 80 6 20
Table 2. Duration Table
Number of Eyes Recovery Recovery Recovery Recovery after 1 week after 2 weeks after 3 weeks after 4 weeks No % No % No % No % No %
First group 30 100 10 33.3 14 46.6 18 60 Fluoromethalone added in Ist gp 30 100 Second group 30 100 18 60 24 80 28 84 30 100
174 Ophthalmology Update Vol. 10. No. 2, April-June 2012 Topical Nsaid’s and Flouoromethalone in the Treatment of Epidemic Keratoconjunctivitis
sub epithelial opacities and topical pools. Adenovirus can be recovered from the eye Fluorometholone had to be started again, in TID and throat for as long as 14 days after onset of dosage for 2 weeks, followed by BD dosage for clinical symptoms9. Many epidemics have been another 2 weeks initiated in ophthalmology outpatient clinics by Fluorometholone group: direct contact with contaminated diagnostic • Conjunctivitis recovered completely on second instruments10. visit. 24 patients (80%) recover completely within The following explains the infectious transmission 9-12 days without sub epithelial opacities or in hospitals and clinics: (1) the virus (adenovirus type stromal infiltrates. 19) remains viable for 5 weeks, (2) the virus is resistant • 28 patients (93.3%) recover completely in three against standard disinfectants such as 70% isopropyl weeks time. alcohol and ammonia, and (3) the virus sheds from the • 2 patients had to use topical steroids for about 4 eye 3 days before and 14 days after symptom onset11. months. In 1 patient after the cessation of therapy Epidemics of Keratoconjunctivitis are often traced to there was recurrence of sub epithelial opacities an eye care facility. Disease is commonly spread by and topical Fluorometholone had to be started ophthalmologists ‘contaminated fingers or again, in TID dosage for 2 weeks, followed by BD contaminated instruments and eye drops12. Virus can dosage for another 2 weeks. This patient had to be spread by finger to eye contact; it can also be spread use topical medications once a day for six months to contaminated instruments such as applanation for complete resolution of corneal stromal tonometers13. infiltrates. EKC in East Asia and other parts of the world is DISCUSSION endemic and does not appear to be transmitted through Human adenovirus type 37 (HAdV-37) is a major medical intervention. Viruses were isolated from more cause of epidemic Keratoconjunctivitis and has recently than 50% of cases of viral conjunctivitis; adenovirus been the largest causative agent of Keratoconjunctivitis constituted 94% of the EKC is a self-limiting disease14 . in Japan2. Adenovirus types 8 and 19 are responsible It tends to resolve spontaneously within 1-3 weeks for epidemic Keratoconjunctivitis and they are highly without significant complications. In 20-50% of cases, contagious for up to 2 weeks3. The incubation period is corneal opacities can persist for a few weeks to months 2-14 days and the person may remain infectious for 10- (rarely up to 2 y). This phenomenon can decrease visual 14 days after symptoms develop4. It is characterized acuity significantly and cause glare symptoms .In rare by conjunctivitis: acute onset of watering redness, cases; conjunctival scarring and symblepharon can foreign body sensation and discomfort. Both eyes are occur secondary to membranous conjunctivitis15. affected in 60% of cases5. The patients recover spontaneously within 2-3 Keratitis occurs in 80 % of cases and divided into weeks with subepithelial opacities in 80 % of cases 3 stages: which persists for months or years even with the use of • Stage 1: occurs within 7-10 days of the onset of topical steroid16. It is necessary to pay attention to the symptoms. It is characterized by a diffuse health education of population as well as to improve punctate epithelial Keratitis which may resolve hygienic habits17. or may go to stage 2. CONCLUSION • Stage 2: is characterized by focal white We conclude from our study that the use of subepithelial infiltrates which develop beneath the Fluorometholone in the management of epidemic viral epithelial lesions. They are thought to represent Keratoconjunctivitis alleviate the patient’s symptoms immune response to adenovirus and may be (redness, discomfort, swelling, tearing, photophobia, associated with mild transient anterior uveitis. blurring of vision and pain as well). It decreases the • Stage 3: is characterized by anterior stromal course of the disease, as without treatment the course infiltrates which may persist for months and even is prolonged and may accompany complications. It also years6. decreases the occurrence of sub epithelial opacities and • No gender predilection exists. The infection is helps in the complete resolution of residual opacities. more common in adults, but all age groups can REFERENCES be affected7. EKC epidemics tend to occur in 1. Boerner CF, Lee FK, and Wickliffe CL. Electron microscopy closed institutions (e.g., schools, hospitals, camps, for the diagnosis of ocular viral infections. Ophthalmology 8 1981 Dec; 88(12): 1377-81. nursing homes, workplaces) . Direct contact with 2. Satoshi Takeuchi, Adenovirus Strains of Subgenus D eye secretions is the major mode of transmission. Associated with Nosocomial Infection as New Etiological Other possible methods of transmission are Agents of Epidemic Keratoconjunctivitis in Japan Journal of through air droplets and possibly swimming Clinical Microbiology, October 1999, p. 3392-3394, Vol. 37.
Ophthalmology Update Vol. 10. No. 2, April-June 2012 175 Topical Nsaid’s and Flouoromethalone in the Treatment of Epidemic Keratoconjunctivitis
3. Jackson WB: Differentiating conjunctivitis of diverse origins. 11. Buehler JW, Finton RJ and Goodman RA. Epidemic Surv. Ophthalmol 1993 Jul-Aug; 38 Suppl: 91-104. keratoconjunctivitis: report of an outbreak in an 4. Tasman W and Jaeger EA: Epidemic Keratoconjunctivitis. ophthalmology practice and recommendations for Duane’s Clinical Ophthalmology (Text book) 8th ed. 2001; prevention. Infect Control 1984;5:390-4. 4(7): 5-8. 12. Azar MJ; and Dhaliwal DK, and Bower KS .Possible 5. Barnard DL, Hart JCD, Marmion VJ, and Clarke SKR. Consequences of Shaking Hands with Your Patients with Outbreak in Bristol of conjunctivitis caused by adenovirus Epidemic Keratoconjuctivitis. Pa Am J Ophthalmol 121:711- type 8, and its epidemiology and control. Br Med J 1973;2:165- 712, 1996. 9. 13. Weiss AH, Brinser JH, and Nazar-Stewart V. Acute 6. Jack J. Kanski . Adenoviral Epidemic keratoconjunctivitis. conjunctivitis in childhood. J Pediatr. 1993;122(1):10-14. Clinical Ophthalmology. (Text book) 6th ed. 2007; 226-7 &283. 14. D’Angelo LJ, Hierholzer JC, Holman RC , and Smith JD. 7. Tasman W and Jaeger EA: Epidemic Keratoconjunctivitis. Epidemic keratoconjunctivitis caused by adenovirus type 8: Duane’s Clinical Ophthalmology (Text book) 8th ed. 2001; epidemiologic and laboratory aspects of a large outbreak. 4(7): 5-8. Am J Epidemiol 1981;113:44-9.) 8. D’Angelo LJ, Hierholzer JC, Holman RC , and Smith JD. 15. Tasman W and Jaeger EA: Epidemic Keratoconjunctivitis. Epidemic keratoconjunctivitis caused by adenovirus type 8: Duane’s Clinical Ophthalmology (Text book) 8th ed. 2001; epidemiologic and laboratory aspects of a large outbreak. 4(7): 5-8. Am J Epidemiol 1981;113:44-9.) 16. Barnard DL, Hart JCD, Marmion VJ, and Clarke SKR. 9. Nagington J, Stehall GM, and Whipp P. Tonometer Outbreak in Bristol of conjunctivitis caused by adenovirus disinfection and viruses. Br J Ophthalmol 1983;67:674-6. type 8, and its epidemiology and control. Br Med J 1973;2:165- 10. Tasman W and Jaeger EA: Epidemic Keratoconjunctivitis. 9. Duane’s Clinical Ophthalmology (Text book) 8th ed. 2001; 17. Nagington J , Stehall GM, and Whipp P. Tonometer 4(7): 5-8. disinfection and viruses. Br J Ophthalmol 1983;67:674-6.
176 Ophthalmology Update Vol. 10. No. 2, April-June 2012 Original Article
Expanding the Role of Trabeculectomy with 5-FU Dr. Hashim
Hashim Imran FCPS1, Muhammad Umar Farooq FCPS, FRCS2
INTRODUCTION the reviewed procedure a primary trabeculectomy in The antimetabolites Mitomycin and 5-flourouracil these eyes. As mentioned earlier majority 34 eyes (77%) have been used intra-operatively to augment the of these eyes had no history of any prior eye disease success of trabeculectomy in primary glaucomas for except glaucoma (Table 2-A). Out of the total 44 eyes about two decades. The experience over time has 22(50%) had primary open angle glaucoma (POAG), suggested that the 5-fluorouracil(5-FU) may be less 9(20%) had chronic narrow angle glaucoma and 3(7%) potent than Mitomycin-C in lowering the IOP had pseudo-exfoliative glaucoma. Three eyes had a postoperatively but is quiet safer as regards the long history of previous ailments out of these two eyes (5%) term post-op complications are concerned. The had angle recession glaucoma from previous blunt confidence in this wonderful tool has encouraged us to trauma and one eye (2%) had a history of idiopathic use it not only in the primary glaucoma patients in a uveitis leading on to glaucoma( Table 2-B). Seven eyes conventional way but also a few carefully selected other (15%) did have a history of intraocular surgery like types of glaucoma cases with a view to the possibility phacoemulsification in 4 eyes(9%), penetrating of expanding its role in these situations. keratoplasty in 2(5%) and repaired penetrating corneal This retrospective study was made to check the trauma in 1 eye (2%). In this group (Table 2-C) the IOP lowering effect of trabeculectomy with 5- conjunctiva at the planned drainage site appeared to Fluorouracil (5-FU) in various types of our adult be healthy and there was no obvious sign of glaucoma patients. The records of the patients who subconjunctival scarring. It would also be appropriate underwent primary trabeculectomy with 5-FU in the to mention here that eyes having Argon laser last one year were reviewed. The indication for surgery trabeculoplasty and YAG laser iridotomy in the past in the majority of the patients was uncontrolled intraocular pressure (IOP) in spite of maximal tolerable Table 1: Patient characteristics medical treatment. The other important indications for Total number of patients 39 surgery included in-affordability of the cost of medications, inability to follow the physician’s Total number of eyes 44 instructions properly, unavailability of medications in Age 16 to 85 years (mean 56 years) the far flung areas of the country and the allergy to the Sex Male 27 Female 12 drugs.Majority of the patients did not have any previous history of intraocular surgery but others did Table 2: Types of Glaucoma have a prior history of intraocular surgery other than the glaucoma drainage procedure. 2-A: Primary Glaucoma MATERIALS AND METHOD A total number of 44 eyes in 39 patients were POAG 22 50% operated (Table 1). All these eyes had no previous Ch. NAG 9 20% glaucoma drainage procedure done on them making PXE 3 7%
––––––––––––––––––––––––––––––––––––––––––––––––––––––– 2-B: Secondary Glaucoma 1Assistant Professor, Sargodha Medical College, University of Sargodha, Sargodha. 2Consultant Glaucoma Department, Al-Shifa Angle recession Glau. 2 5% Trust Eye Hospital, Rawalpindi, UveiticGlau. 1 2% ––––––––––––––––––––––––––––––––––––––––––––––––––––––– Correspondence: Dr. Muhammad Umar Farooq, House No. 105, 2-C:- Secondary Glaucoma- Post surgical Street 5, Phase 1, Bahria Town, Rawalpindi. Cell: 0321 6032085, Phone : 048 3723830 PKP 2 5% E.Mail>[email protected] Phaco 4 9% ––––––––––––––––––––––––––––––––––––––––––––––––––––––– Received: Nov’2012 Accepted: March’2012 Corneal repair 1 2% –––––––––––––––––––––––––––––––––––––––––––––––––––––––
Ophthalmology Update Vol. 10. No. 2, April-June 2012 177 Expanding the Role of Trabeculectomy with 5-FU
were not excluded from the study. were usually sufficient to secure it back to its bed Surgical procedure satisfactorily. A/C was deepened with injection of BSS IOP was controlled preoperatively with topical through the temporal paracentesis. End point was a medications as well as oral Diamox and if the IOP steady ooze of aqueous humour with a stable anterior exceeded 25mmHg IV Mannitol (1gm/kg body weight) chamber. When it was achieved the conjunctiva was was given half an hour before surgery in the operation sutured at the limbus with 10/0 nylon sutures. room to bring the IOP down to a safer level. Generally Subconjunctival injection of 20mg gentamycin and 2mg patients less than 30 years of age were operated under of dexamethsone was given in the inferior fornix. The general anaesthesia and above that age were operated eye was patched for 24 hours after instillation of 1% under local anaesthesia. Local infiltration anaesthesia cyclopentolate and betnesol-N eye ointment. The was given as peribulbar block with or without facial patient was instructed to stop systemic antiglaucoma block. It consisted of a mixture of 2%Xylocaine and 0.5% medications as well as the topical medications in the of Bupevicaine in equal amounts. 5% Povidone solution operated eye. was used to clean the lids and area around the orbit. DISCUSSION Sterile drapes were placed with opsite film over the Full thickness trabeculectomy is still the most lids to isolate the lashes. Wire lid speculum was placed commonly performed surgical procedure to lower the to open the eye. A 6/0 vicryl traction suture with a IOP in patients with otherwise uncontrolled glaucoma spatulated needle was passed through the superior and is considered the gold standard1. The procedure cornea to expose the surgical field. Fornix based was described originally by Sugar in 19612,3 but conjunctival/tenon flap at the limbus with a cord length innumerable variation of the technique has since been of about 8mm without a radial relaxing incision was suggested with the success rate of the primary usually sufficient to expose the episclera. The flap was procedure with antimetabolites being around 84.0% at undermined with blunt conjunctival spring scissors. one year follow-up4. The most common cause of failure Gentle bipolar wet field cautery was used over the of this drainage procedure is considered to be the intended scleral flap area. Tenon capsule was not postoperative subconjunctival fibrosis at the drainage usually excised until excessively thick. 3x4 mm site and to prevent this complication various substances rectangular half thickness scleral incision was given were used. These substances known as metabolites not superiorly to demarcate the extant of the scleral flap. only enhanced the success of this surgery but were This flap was raised in a horizontal plane with the help helpful in achieving lower intraocular pressures of a crescent knife till it reaches 1mm into the clear postoperatively5. The two most commonly used anti- cornea. 3 to 4 cellulose sponges impregnated with 50 fibrosis substances are Mitomycin C and 5 fluorouracil mg/ml 5-flurouracil (5-FU) were placed over and (5-FU). around the scleral flap and under the conjunctiva/tenon Mitomycin C is an alkylating agent which flap. Care was taken that the edge of the conjunctival damages the DNA of replicating as well as non- flap does not touch the sponges at all times. The sponges replicating cells. Clinically Mitomycin C is much more were removed after 5 minutes and this area was washed potent as compared to 5-FU6. The 5-FU is an with at least 30 ml of balanced salt solution. antimetabolite which acts on the DNA synthesis “S” A paracentasis was made in the temporal cornea phase of only the replicating cells. It selectively affects with a fine sharp blade while taking care that the A/C the replicating fibroblasts only and does not damage does not collapse. 2x2 mm full thickness sclerectomy/ DNA of the stable cells in the area of its application. In trabeculectomy was done with the help of sharp blade present day world terminology it means that it causes and Vanna’s scissors. Peripheral iridectomy was done less collateral damage to the adjacent tissues. and the scleral flap was reposited to take its place. Two Comparing it with mitomycin C it leads to fewer 10/0 nylon sutures placed at the corners of scleral flap incidences of late complications related with
Table :3 Intra-ocular pressures-IOP
Post-op Post-op Post-op Post-op Post-op drop in Pre-op (mmHg) (mmHg) (mmHg) (mmHg) (mmHg) IOP(mmHg) One day One week 3 weeks End of follow-up End of follow-up 16 to55 03 to 56 06 to 35 05 to 34 Mean(28.2) Mean (11.3) Mean (12.2) Mean (13.7) Mean (15.2)* Mean(13.0) *32 eyes (73 %) had IOP of less than 21 mmHg without antiglaucoma medications and 12 eyes (27%) required medications to bring their IOP to to this level.
178 Ophthalmology Update Vol. 10. No. 2, April-June 2012 Expanding the Role of Trabeculectomy with 5-FU
trabeculectomy like thin walled blebs, late wound them 27 were male and 12 female and their ages ranged leakage, blebitis and endophthalmitis. from 16 to 85 with a mean age of 56. The diagnosis of The use of 5-FU was started in 1989 followed by Primary open angle glaucoma was made in 22 the Mitomycin C in 1991 as an adjunct to eyes(50%), Pseudo-exfoliative glaucoma in 3 eyes(7%), trabeculectomy7,8. 5-FU was used initially in the form Chronic angle closure glaucoma in 9 eyes(20%).The of multiple subconjunctival injections postoperatively. secondary glaucomas included angle recession In most instances it required the patient to be admitted glaucoma in 2 eyes(5%), Uveitic glaucoma in 1 eye(2%), in the hospital for a prolonged period of time adding glaucoma following penetrating keratoplasty (PKP) in to the cost of the surgery. Among other complications 2 eyes (5%), glaucoma following an un-eventful there was almost universal occurrence of corneal phacoemulsification was seen in 3 eyes(7%) where as epithelial defects in these patients postoperatively. The secondary glaucoma following a phacoemulsification intra-operative use of 5-FU was reported in 19929,10 complicated by the posterior capsular rupture(PCR) which was found to have much less immediate post- requiring anterior vitrectomy and PC IOL implant was operative problems and was convenient for the patient seen in 1 eye (2%) and 1 eye(2%) had glaucoma as well as the physician.This was found to be as much following a penetrating paracentral corneal injury effective as given subconjunctivaly. In some studies was which was repaired in the past . even considered to be as safe and effective as The intraocular pressures at presentation in these MitomycinC11. eyes ranged from 16 mmHg to 55 mmHg with a mean The 5-FU has generally been used to augment pre-operative IOP of 28.2 mmHg (Table 3). It will be trabeculectomies in previously un-operated eyes but worthwhile to mention here that the cup disc ratio its usefulness was also demonstrated by the (CDR) at presentation in these patients ranged from 0.3 Fluorouracil filtering surgery study in the to 1.0 with a mean of 0.78 indicating that our patients pseudophakic patients as well7. tend to present for treatment at a fairly advanced stage We have been using anti-metabolites intra- of the disease. The IOPs recorded 24 hours after operatively for a long time now in our hospital and are trabeculectomy (with 5-FU) in these eyes ranged from confident about the efficacy as well as the relative safety 03 mmHg to 56 mmHg with a mean IOP of 11.3mmhg. of the use of 5-FU in our patients. We have used 5-FU At one week the IOPs ranged from 06 to 35 mmHg with with trabeculectomy not only in the primary glaucomas a mean of 12.2 mmHg. The mean drop of IOP recorded in the conventional sense but have tried to explore the in one week after the surgery from the IOP at possibility of expanding its use in few other situations. presentation was 16 mmHg (60%). At three weeks the We have tried to check the efficacy of the procedure in intraocular pressures ranged from 05 to 34 mmHg with lowering the IOP as well as its safety in the post- a mean of 13.7 mmHg. The follow-up period for these operative period in all these patients. patients ranged from one month to 12 months (mean RESULTS of 6.9 months). At the end of one year 32 eyes (73 %) The operated patients were examined on the slit had IOP of less than 21 mmHg without anti-glaucoma lamp next morning. Particular attention was given to medication and 12 eyes (27%) required medication to the trabeculectomy site for the appearance of drainage bring their IOP to less than 21 mmHg. The mean IOP bleb and any leakage. Anterior chamber was noted for achieved in these eyes at the end of the study was its depth, hyphema and the extent of inflammatory 15.2mmHg with a mean drop of 13 mmHg (46%). reaction. Intra-ocular pressure was measured with the We all are aware that the post trabeculectomy help of Goldmann tonometer. The patients with period is a turbulent one and many complications/ satisfactory post-op condition were discharged from the variations are noted in the post-operative course until hospital with a combination of topical steroids, the drainage bleb matures. In our patients we saw antibiotics and cycloplegic eye drops. The frequency leakage from the conjunctival wound without of post-op use of drops was determined by the shallowing of anterior chamber in 9 eyes (20%) and inflammatory activity noted in the eye as well as the leakage with shallowing of anterior chamber in 6 eyes age of the patients. The younger patients generally (14 %), 5 of these 6 eyes settled with conservative received more frequent post-op steroid drops as they management and only one required reformation of AC. are considered prone to excessive inflammatory Varying degrees of hyphema was observed response to surgery leading on to scarring. The patients postoperatively in 7 eyes (16%) which was absorbed in were seen in the OPD after one week, three weeks and due course of time in all these eyes and none required then every month till the IOP was stabilized. surgical evacuation. Flattish blebs with deep anterior Trabeculectomy with 5-FU (as described in M & chamber and higher than expected IOP in the initial M) was done in 44 eyes of 39 adult patients. Among post-op period were noted in 11 eyes(25%) which
Ophthalmology Update Vol. 10. No. 2, April-June 2012 179 Expanding the Role of Trabeculectomy with 5-FU
responded to massage and suture lysis favorably in 8 encountered after phaco-emulcification especially if the eyes (18%) and the remaining 3 eyes (7%) in this group surgery was not complicated by the posterior capsular eventually required antiglaucoma medications to rupture. achieve their target pressures. Tenon cysts formed in 3 In a study where the maximum follow-up period eyes (7%) and required needling with sub-conjuntival is one year we did not expect to find many late injection of 5-FU to achieve a functioning bleb. complications of glaucoma surgery. We will continue Choroidal detachment was seen in only one eye which to monitor these patients in future regarding the pattern had a history of complicated phacoemulsification with of IOP control and the development of late PC rupture and anterior vitrectomy. This choroidal complications attributed to the use of antimetabolites detachment was treated with medications and settled during trabeculectomy. without surgical intervention. During the follow-up one REFERENCES eye developed blebitis which settled with intensive 1. Fontana H, Nouri-Mahdavi K, Caprioli J, Trabeculectomy with mitomycin C in pseudophakic patients with open angle topical broad spectrum antibiotic treatment. This eye glaucoma: Outcomes and risk factors for failure. Am J incidentally had PKP done previously. Ophthalmol. 2006; 141(4):652-9 CONCLUSION 2. Sugar HS. Experimental trabeculectomy in glaucoma.Am J Despite being a potent antimetabolite 5-FU has Ophthalmol.1961; 51: 623–7.) 3. Cairns JE. Trabeculectomy.Preliminary report of a new method.Am J generally been used to augment the success of Ophthalmol.1968; 66:673–8. trabeculectomy in eyes having primary types of 4. Edmunds B, Thompson JR, Salmon JF, Wormald RP. The glaucoma but in our patients some eyes did have national survey of trabeculectomy. II. Variations in operative secondary glaucomas and even others had intraocular technique and outcome. Eye 2001; 15: 441-448 5. Ingrid U. Scott, MD, MPH; David S. Greenfield, MD; Joyce surgeries performed on them in the past. The key was Schiffman, MS; Marcelo T. Nicolela, MD; Juan C. Rueda, MD; that despite the history of prior surgey in this group James C. Tsai, MD; Paul F. Palmberg, MD, PhD Outcomes their trbeculectomy sites did not show any obvious sign of Primary Trabeculectomy with the Use of Adjunctive of disturbance or scarring. Mitomycin Arch Ophthalmol. 1998; 116:286-291. 6. Ando H, Ido T, Kawai Y, et al. Inhibition of corneal epithelial The mean intraocular pressure drop achieved in wound healing. Ophthalmology. 1992; 99:1809–14 this group of patients having various types of 7. The Fluorouracil Filtering Surgery Study Group. Fluorouracil glaucomas was significant (13 mmHg) at the end of Filtering Surgery Study one-year follow-up. Am J mean follow-up period of 6.9 months. Post-operative Ophthalmol. 1989; 108:625–35 8. Kitazawa Y, Kawase K, Matsushita H, et al. Trabeculectomy period was more eventful and a tendency towards with mitomycin. A comparative study with fluorouracil.Arch having postoperative complications was noted in the Ophthalmol. 1991; 109:1693–8 eyes having previous history of intraocular surgeries 9. Dietze PJ, Feldman RM, Gross RL.Intra-operative application but still these patients could achieve acceptable of 5-fluorouracil during trabeculectomy.Ophthalmic Surg. 1992; 23:662–5. lowering of IOP at least during this follow-up period. 10. ShelatBinita, Rao B Sridhar, Vijaya L, Revathi B, Garg Dinesh, At the end of this review we tend to think that 5-FU Results of intraoperative 5-fluorouracil in patients can not only be used safely in the primary glaucomas undergoing trabeculectomy - pilot trial, Indian journal of but in some carefully selected eyes having secondary ophthalmology1996,Volume : 44,Issue:: 91-94 11. K.Singh, Trabeculectomy with intraoperative mitomycin C glaucomas as well. We were encouraged by the results versus 5 fluorouracil prospective randomised clinical trial, of our use of 5-FU in conditions like angle recession Ophthalmology, volume 107, issue 12, pages 2305-2309. glaucoma and open angle type of glaucoma
180 Ophthalmology Update Vol. 10. No. 2, April-June 2012 Original Article
Door to Door Trachoma Survey in North Waziristan Agency, Tehsil Mir Ali Dr. Sanaullah Sanaullah Khan FCPS1, Saber Mohammad, FCPS2, Mushtaq Ahmad, FCPS3 Awalia Jan FCPS4, Zakir Hussain FCPS5, Khan Nawaz6
ABSTRACT OBJECTIVES: To determine the age and gender wise distribution of trachoma and its complications in the target population of North Waziristan agency MATERIAL AND METHODS Study Design: It was a cross sectional population based study. Duration of Study: The study was conducted from 1st June 2011 to 2nd September 2011. Two villages (IPI & Haider Khel) were selected by non-random sampling from Tehsil Mir Ali of North Waziristan Agency. Sample Size: Sample size was 1929 in one village and 3166 in 2nd village. Results: The prevalence of trachoma in village Ipi was 22%. 35% of the patients were between 0—9 years of age and 15% of patients were age group of 30 and above. The prevalence of trachoma in village Haider Khel was 26.64 %, 42.8% in age 0-9years and 16.7% in 30years and above. The gender wise distribution of trachoma in village Ipi was 18% in male and 27% in females. The gender wise distribution of trachoma in village Haider khel was 22.8% in male and 32.4% in female. Key words: Non random sampling. Trachoma,TF (Trachomatis Follicle). TI (Trachomatis Inflammation). TS (Trachomatis Scaring). TT (Trachomatis Trichiasis) CO (corneal opacity). Ophthalmologist, Hygiene and Environmental factors. CONCLUSION: The prevalence of trachoma is because of multiple factors like 1. The villagers keep buffalos, cows, goats and sheep’s inside or adjacent to their living places. 2. Animals dung harbors the larvae of houseflies which are the main vector in transmission of trachoma. 3. Improper solid waste disposal and drainage systems in these areas are ideal places for increased breeding of flies. 4. Lack of Public Health Education.
INTRODUCTION for trachoma. Disease transmission occurs primarily Trachoma is exclusively a disease of poor families between children and women. Most of the children are and communities living in developing countries. infected by the age of one to two years. The peak rate Although it is avoidable, continues to blind and as it of active trachoma varies from 2—7 years. Repeated remains a neglected public health issue. Trachoma is episodes of infection within the family leads to chronic Greek word used for rough and swelling. Globally it is follicular conjunctivitis, which in turn leads to tarsal a leading infectious cause of preventable blindness. conjunctival scaring. The scaring distorts the upper Trachoma is chronic kerato conjunctivitis, caused by tarsal plates and leads to entropion and trichiasis which Chlamydia trachomatis an obligate intracellular in turn results in corneal abrasions, corneal scaring, bacterium. Only serotype A, B, Ba and C are responsible opacification and ultimately blindness. ––––––––––––––––––––––––––––––––––––––––––––––––––––––– Trachoma is an ancient disease; it is present in 1 Note: Since there was no laboratory facility available in North Chinese from the 27th century BC . In Egypt the features Waziristan Agency, hence the survey was conducted on purely of trachoma were described in Ebers’ papyrus, a clinical basis. collection of writings by ancient Egyptian physician ––––––––––––––––––––––––––––––––––––––––––––––––––––––– 1.Assistant Professor,Bannu Medical College & Khalifa Gul Nawaz found by Ebers in 1889. In Egypt the device used for Hospital, Bannu2Registrar Eye A ward, Khyber Teaching Hospital, epilation of trichiasis (inward turning of eye lashes) was Peshawar3Medical Officer, Department of Ophthalmology, present in the Egyptian tomb in 19th century BC2. Hayatabad Medical Complex, Peshawa 4Assistant Professor Kohat .5 Hipocrates has written prescription for trachoma Medical College Kohat. Medical Officer, Department of 2, 3 Ophthalmology, Hayatabad Medical Complex, Peshawar, 6Principal, treatment and its complicatios. Bannu Medical College, Bannu. Global loss of productivity related to impaired ––––––––––––––––––––––––––––––––––––––––––––––––––––––– vision and blindness from trachoma is thought to be as Correspondence: Dr, Sanaullah Khan FCPS,MPH Assistant $ US 5.3 billion annually. Professor Khalifa Gul Nawaz Hospital, Bannu, Mob.no.0333- 9107871Email: [email protected] Transmission occurs from eye to eye via hands, ––––––––––––––––––––––––––––––––––––––––––––––––––––––– clothing and other fomites. Flies have been identified Received: Jan’2012 Accepted: March’2012 as major vector for the infection’s spread6, 7, 8, 9 .The
Ophthalmology Update Vol. 10. No. 2, April-June 2012 181 Door to Door Trachoma Survey in North Waziristan Agency, Tehsil Mir Ali
presences of open latrines favor the vector population.4,5 figure no, 4. The prevalence was 42.8% in age range 0 Factors associated with trachoma are age, socio- to 9 years & 16.7% in 30 years & above shown in table economic background and rural regions in which the no, D. Age and gender wise distribution of trachoma extent to the water supply is limited, the distance from signs in village Haider Khel shown in tables no, E & F. the water source, the amount of water used for washing purposes and overcrowding.10, 11 RESULTS OF VILLAGE IPI DATA COLLECTION PROCEDURE Total Population: 2900 A meeting was held with the elders of the two Sample 1929 villages. They were informed about the survey. They were requested to extend their full cooperation and to RESULTS OF VILLAGE HAIDER KHEL give support regarding the human resources. The Total Population of Village: 4018 survey team comprising of ophthalmologist, ophthal- Sample: 3166 mic technicians, and the village volunteers conducted a door to door survey of every family in the village. DISCUSSION Each member of the family was screened for Trachoma is considered as a public health trachoma or its complications. In the younger age group problem in many developing countries, where as it has both the upper eyelids were everted and examined for disappeared in the western world. North Waziristan trachoma follicles and trachomatis inflammation with Tehsil Mir Ali showed the high prevalence of trachoma the help of the loupe. in IPI and Haider Khel villages with rates of 22% and The older age groups were examined for 26.46% respectively. Trachoma is considered therefore trachomatis scarring, trichiasis and corneal opacity. The family members absent were examined latter and every Figure 1: Tocal Cases examined in Village IPI possible effort was made that no one could be missed. Questions regarding the water supply, sanitary conditions and disposal of wastes was also asked and entered in the Performa. Many people with active infection who were very poor given medicines free of cost. ETHICAL CONSIDERATION Permission was sought from the village (Malik) and Executive District Officer (Health). A meeting was arranged with community leaders of the village and they were informed about the nature of the survey. Before examining an informed consent was taken. LIMITATIONS OF THE STUDY The Financial resources were zero and the time limit was too short for the Conduction of the study. Talebanization and army operation was another major Figure 2: Gender wise Prevalence of Trachoma (%) in Village IPI obstacle for free movement and team work. RESULTS The number of cases examined in village IPI were 1929 in which 1049 were male and 880 were female shown in figure no, 1.The prevalence of trachoma in village IPI was 22% in which 18% were male and 27% female shown in figure no, 2.The prevalence of trachoma is 35% in age group 0-9 years and 15% in age group 30 and above shown in table no, A. Age and gender wise distribution of trachoma signs in village IPI shown in tables no, B & C. The numbers of cases examined in village Haider Khel were 3166 in which 1705 were male and 1461 were female shown in figure no, 3.The prevalence of trachoma in village Haider Khel was 26.46% in which 22.80 % were male and 32.40 % were female shown in
182 Ophthalmology Update Vol. 10. No. 2, April-June 2012 Door to Door Trachoma Survey in North Waziristan Agency, Tehsil Mir Ali
Figure 3 Figure 4
as a public health problem in Tehsil Mir Ali. The total population of village IPI and Haider Khel were 2900 rationale for the study that although water is plenty in and 4018 respectively. The missing people were either these two villages but people are not using it for abroad or living in various parts of the country for cleanliness. various purposes that is education, employment and CONCLUSION: business etc. The result of both villages show that the The prevalence of trachoma is because of multiple prevalence of trachoma was more in females compared factors like to males. The study also shows that in both the villages 1. The villagers keep buffalos, cows, goats and TF and TI were more common in younger age group sheep’s inside or adjacent to their living places. (0—9 years) while ST, TT, and CO were more common 2. Animals dung harbors the larvae of houseflies in old age group (30 years above). which are the main vector in transmission of The present study showed high results with what trachoma. was found in Shabwah district/ Yemen (17% of active 3. Improper solid waste disposal and drainage trachoma by TRA) 12. However, these results are lower systems in these areas are ideal places for increase compared to many TRA performed in endemic breeding of flies. countries. A TRA performed in the southern Zambia Recommendations: showed 55.5% of children with active trachoma; and 2 After having completed the study and knowing years after the implementation of SAFE strategy, the about some of the contributory factors involved in the overall percentage of trachoma was reduced to 10.6%13. transmission of trachoma in the villages of IPI and The Ethiopian study mentioned 51.1% of children Haider Khel, we have few recommendations to put having active trachoma14. Another rapid assessment of forward. trachoma done in Yemen showed a higher rate among 1) Health education should be given to the public rural children (73.2%) compared to urban children using different media to create a general (23.1%) 12. awareness regarding trachoma. In the study it was found that out of 51 patients 2) The community should be involved in the of TT, 10 patients had developed corneal opacities. Only trachoma control because without involving them 4 patients with trichiasis had surgery. If surgery is not the task is impossible. It is only the community performed on these TT patients, there is a risk of who can keep their environment clean. developing CO leading to visual loss and blindness. It 3) The cases of red eye should not be taken lightly was also found in our study that there is a correlation and proper eye examination should be done by a between active trachoma and unclean face. Unclean trained person. faces being observed in more than 40% children in both 4) All the people with trachoma visiting the hospital the villages. This highlights the importance of focusing should be advised to take the drugs regularly and on health education. In our study, no correlation was not to share their towels with others. found between active trachoma and the absence of 5) The cowsheds in the villages should be latrines or water supply, as already mentioned in the constructed a little distance away from the house
Ophthalmology Update Vol. 10. No. 2, April-June 2012 183 Door to Door Trachoma Survey in North Waziristan Agency, Tehsil Mir Ali
Table (A) Age Wise Prevalence of Trachoma signs in Village IPI
Age in Year Total TF TI TS TT CO
0-9 681 117(26%) 61(9%) 2(0.3%) - -
30 & above 1248 61(4.9%) 26(2.1%) 75(6%) 21(1.7%) 3(0.26%)
Table (B) Gender Wise Prevalence of Trachoma signs in Village IPI
Age 0-9 Years Gender Total TF TI TS TT Co
Male 381 93(24.4%) 28(7.3%) - - -
Female 300 84(28%) 33(11%) 2(0.7%) - -
Table (C): Gender Wise Prevalence of Trachoma signs in Village IPI
Age 30 years and above Gender Total TF TI TS TT Co
Male 668 31(4.6%) 6(0.9%) 23(3.3%) 6(0.9%)
Table D: Age Wise Prevalence of Trachoma signs in Village Haider Khel
Age in Yrs Total # TF TI TS TT CO
0-9 1180 354(30%) 141(12%) 10(0.84%) - - 30 and above 1986 91(4.6%) 46(2.3%) 161(8.1%) 30(1.5%) 5(0.25%)
Table E. Gender Wise Prevalence of Trachoma signs in Village Haider Khel
Age 0-9 years
Gender Total Number TF TI TS TT Co
Male 578 179(31%) 58(10%) 6(1.00) - - Female 602 222(37.8%) 72(12%) 4(0.66%) - -
Table F. Gender Wise Prevalence of Trachoma signs in Village Haider Khel
Age 30 years and above
Gender Total TF TI TS TT Co
Male 668 31(4.6%) 6(0.9%) 23(3.3%) 6(0.9%) 1(0.14%) Female 580 30(5.1%) 20(3.4%) 52(8.9%) 15(2.5%) 2(0.34%)
and the cow dung should be disposed daily. in the trachoma endemic areas, so that a better 6) The poor people who cannot afford to construct attention is paid to this blinding disease. latrine should be given financial assistance by the REFERENCES: government from zakat funds or by any other Non 1. Al- Rafia KMJ. Trachoma throughout history. Int ophthaimol 1988: 12:9-14. Government Organization. 2. MacCallan AF.The epidemiology of trachoma.Br j 7) Trachoma control programme should be initiated ophthalmol 1931:15- 370-411
184 Ophthalmology Update Vol. 10. No. 2, April-June 2012 Door to Door Trachoma Survey in North Waziristan Agency, Tehsil Mir Ali
3. Mettir CC. in: Metler FA(ed) History of medicine. 10. S.P Mariotti, D Pascoilini, J Rose-Nussbaumer. Trachoma; Philadelphia, PA: The Blackiston Co: 1947.pp.1005-1023 Global magnitude of a preventable cause of blindness. B J O 4. Tielsh jM West KP, katz j et al. The epidemiology of trachoma 2009;93; 563-568 doi; 10.1136/bjo.2008. 148494. in Southem Malawi. Amj Trop Med Hyg 1988; 30:393-399 11. Y Jie, L Xu K Ma et al. Prevalence of trachoma in the adult 5. Taylor HR, West SK, Mnbaga BB et al. Hygiene factors and Chinese population, the Beijing Eye study. Eye 2008 22, 790- increased risk of trachoma in central Tanzania. Arch 791; doi; 10.1038/sj.eye.6702857; published online 11 may ophthalmol 1989; 107: 1821- 1825 2007. 6. Jones BR. Changing concepts of trachoma and its control. 12. Alkhatib T, Rapid assessment of trachoma and governorates Trans ophthalmol soc UK 1980; 100:25-25 and Socotra island in yeman, faculty of medicine and health 7. Wilson RP ophthalmia Aegyptiaca. Amj ophthalmol 1932; sciences, university of Sana, A, LA revue de sente de la 15: 397-406 mediterranee, volume 12, number 5,2006. 8. Dawson CR, Dagh four T, Messadi M, Howshiwara I, 13. Actle W et al. Tachoma controle in southern Zimbia, in Schachter j- severe endemic trachoma in Tunisia.Brj international scheme, project employee the SAFE strategy, ophthalmol 1976; 60: 245-252. Ophthmic epidemiology, volume 13, number 4, august 2006, 9. Gupta CK, Gupta UK, Flies and mothers as modes of 227-236 (10). transmission of trachoma and associated bacterial 14. Gordon J, et all. The epidemiology of eye disease, 2nd edition, conjunctivitis. J All India ophthalmol society 1970; 18:17-22 2003, isbn 0340808929HB0, P 171-176.
Ophthalmology Update Vol. 10. No. 2, April-June 2012 185 Original Article
Subtenon vs Peribulbar Anaestheia for Manual Small Incision Cataract Surgery* Dr. Zakir Zakir Hussain1, Samina Karim2, Muhammad Naeem Khan3 Mohammad Sabir4
ABSTRACT Objectives: To compare the safety and efficacy of subtenon anaesthesia with peribulbar anaesthesia in manual small incision cataract surgery Place and duration of study: The study was carried out at Department of Clinical Ophthalmology, Khyber Institute of Ophthalmic Medical Sciences (KIOMS), Postgraduate Medical Institute (PGMI), Hayatabad Medical Complex (HMC), Peshawar from 1st March 2011 to 30th July 2011. Patients and Methods: 93 patients were randomised to subtenon and peribulbar groups with preset criteria after informed consent. All surgeries were performed by single surgeon. Pain during administration of anaesthesia, during surgery and 4 hours after surgery was graded on a visual analogue pain scale and compared for both the techniques. Positive pressure during surgery were also compared. Patients were followed up for 6 weeks postoperatively. Results: There were 27 (52.94%) male and 24 (47.05%) were female in the peribulbar group and there were 24 (57.14%) male and 18 (42.85%) female in the subtenon group. Average age in the two groups was 64 and 58 years respectively.35.29% patients of peribulbar group and 76.19% patients of subtenon group experienced no pain during administration of anaesthesia. There was no significant difference in pain during and 4 h after surgery. The absolute akinesia was present in 66.66% of the patients in the peribulbar group as compared to none in the subtenon group. Conclusions: Sub-Tenon’sanaesthesia is an effective and safe technique for manual small incision cataract surgery. Comparing this technique with peribulbar anaesthesia, there was no significant difference in terms of pain perception during surgery. Key words: Manual small incision cataract surgery; peribulbar anaesthesia; sub-tenonanaesthesi
INTRODUCTION anaesthetic drop in the conjunctiva is instilled which Regional anaesthesia is commonly used for takes away the pain of the needle prick. This technique cataract surgery.1Peribulbar anaesthesia for cataract has been used for conventional extracapsular cataract surgery was the popular technique in the last decade, 2 extraction (ECCE) with posterior chamber intraocular but it is not completely free from complications.3,4 lens implantation (PCIOL) and phacoemulsification.11,12 Retrobulbar anaesthesia, which was previously used, Manual small incision cataract surgery (MSICS) has was associated with a number of potentially sight- become popular in developing countries like Pakistan threatening complications.5 Other anaesthesia as it results in better uncorrected vision as compared procedures have been developed to reduce the risk of to ECCE, 13 and at an affordable cost.10 We designed this complications. 6-9 Advances in cataract surgery study to compare the two methods of anaesthesia in including the use of a smaller, self-sealing incision have MSICS with respect to pain, akinesia, intraocular reduced the duration of surgery10resulting in the use pressure control and complications, using a randomised of shorter acting anaesthetic agents with less invasive control clinical trial. methods of administration. In sub-tenon anaesthesia8,9,11 MATERIAL AND METHODS trans-conjunctival infiltration of local anaesthetic agent All the patients admitted for cataract surgery, directly to the subtenons space occurs. Before this local were asked to participate in the trial. The first 100, who agreed to informed consent, were randomised to either ––––––––––––––––––––––––––––––––––––––––––––––––––––––– subtenon or peribulbar technique. The study was conducted at the Department of Ophthalmology, The exclusion criteria were Khyber Institute of Ophthalmic Medical Sciences, Hayatabad 1. Sensitivity to xylocain Medical Complex, Peshawar. ––––––––––––––––––––––––––––––––––––––––––––––––––––––– 2. History of convulsion or epilepsy 1,2Medical Officers, 3Senior Registrar, 4Registrar, Khyber Teaching 3. Patients who had previous intraocular surgery, Hospital, Peshawar injury or any inflammation ––––––––––––––––––––––––––––––––––––––––––––––––––––––– 4. Inability to understand the visual analogue Correspondence: Dr Zakir Hussain, No. 86, St. No. 9, Sector: J-1, Phase II, Hayatabad, Peshawar. pain scale Ph: 091-5811020 (Res) Email: [email protected] The patients were asked to grade the pain they ––––––––––––––––––––––––––––––––––––––––––––––––––––––– felt on a linear scale of 0-4 (No pain = grade 0, mild Received: Jan’2012 Accepted: March’2012 pain= grade 1, moderate pain =grade 2, severe pain = –––––––––––––––––––––––––––––––––––––––––––––––––––––––
186 Ophthalmology Update Vol. 10. No. 2, April-June 2012 Subtenon vs Peribulbar Anaestheia for Manual Small Incision Cataract Surgery
grade 3 and maximum pain imaginable = grade 4). Table: I Pain during anaesthesia Patients were asked to grade separately for pain during administration of anaesthesia, pain during surgery and Peribulbar Subtenon pain 4 hours after surgery. The last was taken when Grade 0 18 (35.29%) 32 (76.19%) the patient was shifted to the wards. After each surgery Grade 1 26 (50.98%) 8 (19.04%) the surgeon was asked to score for akinesia and to grade for positive pressure during surgery, chemosis, Grade 2 3 (5.88%) 1 (2.38%) subconjunctival haemorrhage and overall ‘discomfort’. Grade 3 3 (5.88%) 1 (2.38%) ‘Akinesia’ was scored on a scale designed to measure Grade 4 1 (1.96%) 0 ( 0%) ocular movements in each quadrant (no movement = score 0, mild = 1, moderate = 2, severe = 3 in each Total 51 (100%) 42 (100%) quadrant, minimum score possible = 0, maximum score possible = 3 x 4 = 12). Intraoperative complications Table :2 Pain during surgey were noted. All patients underwent MSICS; any change Peribulbar Subtenon in technique, if needed, was noted. RESULTS: Grade 0 44 (86.27%) 37 (88.19%) In this study, we evaluated 93 eyes of 93 patients Grade 1 3 (5.88%) 4 (9.52%) who presented with cataract and were admitted in our Grade 2 2 (3.92%) 1 (2.38%) unit from 1st March 2011 to 30th July 2011. There were 27 (52.94%) male and 24 (47.05%) were female in the Grade 3 2 (3.92%) 0 (0%) peribulbar group and there were 24 (57.14%) male and Grade 4 0 (0%) 0 ( 0%) 18 (42.85%) female in the subtenon group. Average age Total 51 (100%) 42(100%) in the two groups was 64 and 58 years respectively. Pain during anaesthesia is shown in Table I. Table II Table: III Ocular movements during surgery shows the various grades of pain during surgery. All patients of the peribulbar group reported no pain 4 Akinesia (score) Peribulbar Subtenon hours after surgery compared to 2 patients in the subtenon group. The various scores of ocular 0 34 (66.66%) 0(0%) movements after anaesthesia are shown in Table III. 2 6 (11.76%) 0(0%) DISCUSSION: 4 8 (15.68%) 5(11.90%) For cataract surgery,nowadays,various methods of local anaesthesia are in use. These includes 6 2 (3.92%) 3(7.14%) retrobulbar, peribulbar, subtenon’s, subconjuctival and 8 1 (1.96%) 16(38.09%) topical. Both retrobulbar and peribulbaranaesthesia 12 0 (0%) 2(4.76%) involve blindly placing a sharp needle into the orbit to deliver the anaesthetic agent. The technique of Total 51 (100%) 42(100%) peribulbar anaesthesia has been preferred to retrobulbar anaesthesia as it is associated with a smaller some may find discomforting. The surgery was started risk of globe perforation, retrobulbar haemorrhage, immediately after administration of anaesthesia in optic nerve damage, and injection of the anaesthetic subtenon group. As lesser amount of the anaesthetic solution into the subarachnoid space. However, the agent was used for subtenon, the chances of adverse peribulbar method itself is not absolutely safe. Some effects are also minimized. In a large hospital or in a serious complications has been reported community eye care setting, the cost would also be less. frequently.3,5,6,14,15 Subconjuctival anaesthesia is an There was no difference in positive pressure rise during effective and safer alternative; however, this technique surgery and postoperative pain between both the provides no akinesia.16 Topical anaesthesia has gained techniques of anaesthesia. An audit of subtenon and wide popularity particularly with the advent of peribulbar anesthesia for cataract surgery in UK phacoemulsification.17 However, it does not provide demonstrated sub-Tenon’s methods to be more akinesia. Lack of akinesia can pose significant difficulty effective than the peribulbar technique, with particularly when dealing with un-cooperative patients. significantly fewer patients experiencing unacceptable Subtenon anaesthesia was more comfortable for levels of pain.11 It was significantly less uncomfortable the patient at the time of anaesthetic administration. on administration than the peribulbar methods and They also had good analgesia intraoperatively, but the reduced the interval between administration of surgeon had to operate with incomplete akinesia, which anaesthesia and surgery. On the range of 1-10, pain on
Ophthalmology Update Vol. 10. No. 2, April-June 2012 187 Subtenon vs Peribulbar Anaestheia for Manual Small Incision Cataract Surgery
administration of anaesthetic had a mean of 2.4 for the REFERENCES: peribulbar group and 1.4 for the subtenon group. This 1. Hamilton RC. Complication of ophthalmic regional anaesthesia. OphthalmolClin North Am 1998;11:99-114 correlated with results of our study. The subtenon 2. Davis DB, Mandel MR. Efficacy and complication rate of technique appeared to be the safest method of 16,224 causative peribulbar blocks. A postoperative multi introducing anaesthetic fluid into the retrobulbar space Centre study. J Cataract Refract surg 1994;20:327-37. without the potential complication of a sharp needle 3. Mount AM, Seward HC. Sceral perforations during 14 peribulbar anesthesia. Eye 1993;7:766-7. injection. But a single case of globe perforation was 4. Hay A, Flynn H, Hoffman J. Needle penetration of the globe reported15 in a patient who had underwent detachment during retrobulbar and peribulbar injections. Ophthalmolo surgery and had thinned sclera. It is likely that 1991;98:1017-24 subtenon anaesthesia offers a significantly reduced risk 5. Murdoch IE. Peribulbar versus retro bulbar anesthesia. Eye 1990;4:445-9. of complication such as scleral perforation, retro bulbar 6. Stevens JD. A new local anesthetics techniques for cataract haemorrhage, optic nerve injury and injection of extraction by one quadrant sub-Tenon’s infiltration. Br J anaesthetic solution into the subarachnoid space, as no Ophthalmol 1992;76:670-4 sharp instrument is passed into the orbit. It should, 7. de la Marnieere E, Maye R, Albertim, Batissc JL, Baltenneck. Comparison between GreenbachsParabulbarAnaesthesia and however, be used with caution in patients with Ripart’ssubtenonanaesthesia in the anterior. segment compromised and thin sclera. A randomised study in surgery. J FrOphthalmol 2002;25:161-5. Denmark comparing retrobulbar, subtenon and topical 8. Stevens JD. A new local anaesthesia technique for cataract anaesthesia for phacoemulcification found retrobulbar extraction by on quadrant sub-Tenon’s infiltration. Br J Ophthalmol 1992;76:670. techniques had less discomfort/pain during surgery 9. Hansen EA, Mein CE, Mazzoli R. Ocular anesthesia for but patient preferred subtenon or topical anaesthesia, cataract surgery: a direct sub-Tenons’s approach. Ophthalmic as it did not involve the needle prick during Surg 1990; 21 :696-9 anaesthesia.12 10. Gogate PM, Deshpande M, Wormald RP. Is manual small incision cataract surgery affordable to developing countries? Subtenon anaesthesia has also been used for optic A cost comparison with extra capsular cataract extraction. nerve sheath fenestration.16 Subtenon anaesthesia has Br J Ophthalmol 2003;87:843-6. been found to be more comfortable for the patient, 11. Briggs MC, Back SA, Esakowitz L. Subtenons versus reliable, long lasting and with deeper anaesthesia as peribulbar anesthesia for cataract . Eye 1997; 11 :611-43. 12. Davis DB, Mandel MR. Nileson PJ Alerod CW. Evaluation compared to topical anaesthesia for of local anesthesia technique for small incision cataract phacoemulcification patients. It was also more surgery.J Cataract Refract Surg 1998;24:1136-44. comfortable for the surgeon with better pupillary 13. Gogate PM, Deshpande M, Wormald RP, Deshpande RD, dilatation17. A randomised trial in the UK18 found the Kulkarni SK. Extra capsular cataract surgery compared with manual small incision cataract surgery in community eye difference between the pain score in the subtenon and care setting in western India: a randomized control trial. Br topical groups to be highly statistically significant, with J Ophthalmol 2003;87:667-72. subtenon being more pain free, for phacoemulcification 14. Loinder S, Walka SB, Atth HR. Ultrasonic localization of patients. Limitations of the study include subjective anesthetic fluid in subtenon, peribulbar and retro bulbar techniques.J Cataract Refract Surg 1949;25:56. nature of the visual analog pain scales. But past studies 15. Freiman BJ. Friedberg MA. Globe Perforation associated with and postoperative visual acuity results indicate that it sub tenon’s anesthesia. Am J Ophthalmol 2001;131 : 520-1. would not be significant. 16. Rizzuto PR, Spoor TC, Ramock JM, McHenry JG. Subtenon’s CONCLUSION: local anesthesia for optic nerve sheath fenestration. Am J Ophthalmol 1996;121:326-7. Sub-tenon’sanaesthesia is an effective and safe 17. Vielpeau I, Billotte L, Kreidie J, Lecoq P. Comparative study technique for manual small incision cataract surgery. of topical anesthesia and subtenon anesthesia for cataract Comparing this technique with peribulbar anaesthesia surgery. J FrOphthalmol 1999;22:48-51. there was no significant difference in terms of pain 18. Manner TB, Burton RL. Randomized trial of topical versus subtenon local anesthesia for small incision cataract surgery. perception during surgery. Eye1997;10:367-20.
188 Ophthalmology Update Vol. 10. No. 2, April-June 2012 Original Article
Frequency and Types of Comitant Esotropia Among Patients Attending Eye OPD Dr. Nuzhat Nuzhat Rahil1, Kanwal Ahad2, Rahil Malik3, Muhammad Sardar4
ABSTRACT Objectives: To estimate the frequency and types of comitant esotropia among all age groups attending eye OPD. Methods: This was a hospital based descriptive cross sectional study on 123 patients who visited eye department Lady Reading Hospital, Peshawar during three months’ period in 2011. Results: Total of 4884 (100%) patients with eye problems visited the eye OPD in three months. Among these patients of all age groups 123(2.15%) patients had comitant esotropia. Of the total patients with esotropia 57 (46.34%) were males and 66 (53.65%) were females .Age wise the patients were grouped in to 3; In group 1, 0 to 10 years age there were 90 patients. In group 2, 10 to 20 years age there were 27 patients. In group 3, above 20 years age there were 6 patients. Among patients with Comitant esotropia , 78 (63.41%) had accommodative esotropia and 18 (14.63%) had infantile esotropia .Refractive errors were observed in 90 patients while 11 patients needed squint surgery. Conclusion: It was concluded that the most common type of comitant convergent squint was accommodative esotropia followed by infantile esotropia. More than half of patients with comitant convergent squint (esotropia) were under the age of 10 years which showed that Comitant Convergent squint is more common in children than adults so its early detection and management with simple glasses in children can reduce the risk of amblyopia and constant esotropia. Key Words: Comitant esotropia, Accommodative esotropia, infantile esotropia.
INTRODUCTION comitant strabismus .Accommodative esotropia is the Convergent squint is the most common form of most common type of comitant convergent squint strabismus constituting 1/2 to 2/3 of all misaligned accounting for 36.4%.3in total, 10% with paretic, 8% with eyes.1 Strabismus is a common disorder that affects 3% decompensated heterophoria and 6% convergence to 5% of children, with 126 400 new cases occurring insufficiency.8 All accommodative esodeviations are year in the United States.2 acquired with an onset generally between 6 months and The prevalence of comitant convergent squint seven years averaging nearly two and half years of age. varies in different parts of the world. In United States It is attributed totally or partly to uncorrected refractive of America, prevalence of esotropia constituted 75% of error (hypermetropia) or an abnormal accommodative total3,4. In Ibadan esotropia constituted 80% of total convergence/ accommodation (AC/A) relationship. cases.5 Similarly in Ireland (UK), it was found that Infantile esotropia is the second most common type of esotropia was five times more common than exotropia.6 Comitant Convergent squint, occurs in early infancy, In northern Nigeria, esotropia was found in 62.5% usually at 3 months to 6 months of age, and is rarely cases.7 present at birth. When the infantile esotropia is constant In Pakistan, children under the age of 15 years and unilateral, it will likely develop amblyopia9,10. account for 45% of the total population.8 The overall MATERIAL AND METHODS estimated prevalence of strabismus in Pakistan is 5.4%.8 This was a hospital based descriptive cross Out of this 2.5% strabismus patients are under the age sectional study on hundred and twenty three patients of the 5 years while 2.9% patients are over the age of 5 attending eye department Lady Reading Hospital years.8 The national prevalence of squint of 5.4% Peshawar during three months in 2011. After suggests that there are 7.02 million patients with permission of an Ethical Committee of Postgraduate strabismus in a population of 130 million.8 Medical Institution, Peshawar and written informed Binocular anomalies constituted 74% with consent from the patients and the parents were taken. ––––––––––––––––––––––––––––––––––––––––––––––––––––––– To estimate the frequency and types of comitant 1Junior registrar, 2Orthoptist, 3Senior Registrar, 4Medical Officer, convergent squint among all age groups patients Lady Reading Hospital, Peshawar. attending eye OPD at Lady Reading Hospital Peshawar ––––––––––––––––––––––––––––––––––––––––––––––––––––––– Correspondence: Dr. Rahil Aumer Malik, FCPS, Eye Specialist, were included in the study. House: 47, Army Housing Scheme, Askari-IV, Warsak Road, Patients with mental disorder, patients with other Peshawar Cantt. Cell : 0321 903 6959 associated systemic illness and old patients were E-mail: [email protected] excluded from the study. All age group are selected ––––––––––––––––––––––––––––––––––––––––––––––––––––––– Received: Dec’2011 Accepted March 2012 and then are divided into 3 groups. Group 1 included ––––––––––––––––––––––––––––––––––––––––––––––––––––––– patients between age 0 and 10 years, group 2
Ophthalmology Update Vol. 10. No. 2, April-June 2012 189 Frequency and Types of Comitant Esotropia Among Patients Attending Eye OPD
included10-20 years and group 3 included 20 years and frequency of comitant convergent squint of our study above. All the patients were examined and assessed which is 2.5% is almost similar to the Prevalence of with the help of refractionist and orthoptist. Type of squint in Pakistan which is 2.75% in study done by Khan esotropia, gender distribution, type of refractive error et al 8. and amount of amblyopia were assessed. Nominal data More than half of the patients with comitant of all the patients was recorded on a data collection convergent squint in our study were under 10 years performa. After completion of data collection, the data (73.17%). The incidence of childhood esotropia from was analyzed using SPSS version 10. population-based study done by Greenberg et al is RESULTS comparable with prevalence rates reported among Total of 4884 (100%) patients with eye problems Western populations. According to that study visited the eye OPD in three months. Among these Esotropia is most common during the first decade of patients of all age groups 123(2.15%) patients had life, with the accommodative and acquired comitant esotropia. Of the total patients with esotropia Nonaccomodative forms occurring most frequently. 66 (53.65%) were females and 57 (46.34%) were males The congenital, sensory, and paralytic forms of .Age wise the patients were grouped in to 3; In group childhood esotropia were less common in this 1, 0 to 10 years age there were 90 (73.17 %) patients. In population12 group 2, 10 to 20 years age there were 27(21.95 %) This is the period to develop amblyopia. patients. In group 3, above 20 years age there were 6 Amblyopia causes more vision loss in individuals under (4.87%) patients. the age of 10 years than do all other ocular diseases Among patients with comitant convergent squint combined. So early detection is important for (esotropia), 78 (63.41%) had Accommodative esotropia, restoration of normal ocular alignment and 18 (14.63%) had infantile esotropia, 9(7.31%) had establishment of binocular single vision will reduces Residual esotropia, 9 (7.31%) had Acquired Non- the risk of amblyopia and constant squint. Accommodative esotropia and the remaining 9(7.31%) In this study of 123 patients with comitant had constant esotropia with amblyopia. Refractive error convergent squint 78 (63.41%) had accommodative was observed in 90 patients while 11 patients needed esotropia .According to a study done by Kothari et al 13 squint surgery. accommodative component can play a significant DISCUSSION causative role in esotropia and needs to be ruled out in Out of total 4884 ophthalmic patients , 123(2.51%) every esotropia. In our study 14.63% of patient had were patients with comitant convergent esotropia .In infantile esotropia and,3(7.31%) had residual esotropia, this study 53.65% of patients were female which is 3(7.31%) had non accommodative esotropia; the different from the study done by Kac et al11 in which remaining 3(7.31%) patients had constant esotropia esotropia was the most prevalent misalignment in his with amblyopia. According to a study done by Mohney sample group (44.52%). There were more males in this who provides population-based data on the most group (p=0.001) with a predominance of the age group prevalent forms of childhood strabismus. 0-2 years (p=0.009).E. In other studies of squint there Accommodative esotropia, intermittent exotropia, and were not much difference in the gender affected 2 The acquired non-accomodative esotropia were the predominant forms of strabismus in this Western Distribution of Patients age-wise population 14.according to another study, accommodative esotropia is the most common pediatric Age Group No of Patient Percentage strabismus and must be differentiated from other 0-10 age group 90 73.17% pediatric esotropia.15 Although its average age of onset 10-20 age group 27 21.95% is 2.5 years, it can begin during the first year of life and 20 years and above 06 4.87% is seen rarely in older children and teenagers. Refractive error was the main culprit for the esotropia in our study Distribution of patients according to types of squint and 2/3 of the patients had some type of refractive error which is similar to the other international studies16. Types No. of Patients Peercentage CONCLUSION: Accomodative 78 63.41 It is concluded that the most common type of Comitant Convergent squint is Accommodative Infantile 18 14.63 esotropia followed by infantile esotropia .More than Residual 9 7.31 half of patients with Comitant Convergent squint Non-accomodative 9 7.31 (esotropia) were under the age of 10 years which shows Constant 9 7.31 that Comitant Convergent squint is more common in
190 Ophthalmology Update Vol. 10. No. 2, April-June 2012 Frequency and Types of Comitant Esotropia Among Patients Attending Eye OPD
children than adults so its early detection in children 8. Khan A. Child and adult health (Eds) National health survey can reduces the risk of amblyopia and constant of Pakistan.Islamabad: Pakistan Medical Research Council. 1996; 19-22 esotropia. The most leading cause of 2/3 patients with 9. Tollefson M, Mohney BG, Diehl NN, Burke JP. Incidence and comitant convergent squint was refractive error types of childhood hypertropia: a population-based study. (hypermetropia) which shows that management with 10. Birch EE, Fawcett SL, Morale SE, et al. Risk factors for simple corrective glasses can exclude more than half of accommodative esotropia among hypermetropic children. Invest Ophthalmol Vis Sci 2005;46:526-9. esodeviations. 11. Kac MJ, Freitas Júnior MB, Kac SI, Andrade EP Frequency of REFRENCES ocular deviations at the strabismus sector of the Hospital do 1. Pai A and Mitchell P. Prevalence of amblyopia and Servidor Público Estadual de São Paulo. J AAPOS. 2005 strabismus. Volume: 116, Issue: 2: American Academy of Dec;9(6):522-6. Ophthalmology 2010: 365-66. 12. Greenberg AE, Mohney BG, Diehl NN, Burke JP.Incidence 2. Mohney BG. Common forms of childhood esotropia. and types of childhood esotropia: a population-based study. Ophthalmology 2001;108:805 Optometry. 2008 Aug;79(8):422-31. 3. Greenberg A, Mohney BG, Diehl NN, Burke JP. Incidence 13. Kothari M. Indian J Ophthalmol. 2008 Mar-Apr;56(2):168– and types of childhood esotropia: a population-based 169.Department of Pediatric Ophthalmology . Am J study. . Ophthalmology.2007;114(1):170–174 Ophthalmol. 2007 Sep;144(3):465-7. 4. Friedman Z, Neumann E,Hyams S W,Pelag B.opthalmic 14. Mohney BG.Common forms of childhood strabismus in an screening of 38,000 children, age 1-2 years in child welfare incidence cohort. Ophthalmology. 2007 Jan;114(1):170-4. clinics .J.Peadiatr Opthalmol strabismus 1980:17:261-267 15. Rutstein RP . Update on accommodative esotropia. Arq Bras 5. Baiyeroju AM,Owoeye JFA.Strabismus in children in Ibadan Oftalmol. 2007 Nov-Dec;70(6):939-42. Nig J. Opthalmology 1998;6:31-33 16. Birch EE, Fawcett SL, Morale SE, Weakley DR Jr, Wheaton 6. Donelly U M , Stewart N M Hollinger M. Prevalence and DH. Risk factors for accommodative esotropia among outcome of children visual disorders.opthalmic hypermetropic children. Invest Ophthalmol Vis Sci Epidimeology 2005:12:243-250 2005;46:526-9. 7. Morgan R E .Pattern of eye diseases in children seen at Jos university teaching hospital . Br J Ophthalmol 2007;91:1337– 4.
Ophthalmology Update Vol. 10. No. 2, April-June 2012 191 Case report Glioblastoma Multiforme (GBM) as a cause of Foster Kennedy Syndrome (An interesting Case)
Inamul Haq Khan FCPS1, Misbah Durrani, FCPS2, Hafeez uddin FCPS3 Dr. Inam Dr. Misbah ABSTRACT Introduction Foster Kennedy syndrome (FKS) is a rare condition. It is characterized by the presence of ipsilateral optic atrophy, contra lateral papilloedema and ipsilateral anosmia. It was ûrst described in 1911. Glioblastoma multiforme (GBM) is a constellation of tumors. Some of them if diagnosed early can save the patient from morbidity and mortality. This patient reported with symptoms of epilepsy at the age of 53, headaches and visual symptoms. Lack of education & financial constraints are the main reasons for the dreadful outcomes of many treatable diseases. This case is one of the many examples of this painful situation. Keywords :Foster Kennedy syndrome; Papilloedema; Optic atrophy.
CASE REPORT Figure 1 A 53-year-old, gentleman reported with loss of vision left eye in 03 months and deterioration of vision right eye 3 weeks. He had headaches from the last three months which are now severe and exacerbated by coughing and postural changes. There is history of partial and generalized seizures off and on in the last 06 months. The seizures commenced suddenly without an aura, progressing to involuntary jerking of the right arm and leg. There was history of tongue biting and incontinence. He is being treated for epilepsy. Loss of a. Right disc swelling b. Left pale looking disc vision in left started 03 months back. Initially he noticed Figure 2 that there was generalized haziness when he closed his right eye, followed by complete loss of vision. From the last 03 weeks he is having similar symptoms in his left eye and he is afraid that he may lose vision in this eye as well. On examination, right sided vision was 6/24 with generalized haziness; color vision was 12/15 on Ischiara color plates. Fundoscopy revealed disc swelling with no venous pulsations (figure 1a). Left sided vision was perception of light, RAPD (relative affrent pupillary a. Right Optic atrophy b. Left Optic atrophy defect) and optic atrophy (figure 1b). He had left sided anosmia as well. He was advised MR imaging of the brain with ––––––––––––––––––––––––––––––––––––––––––––––––––––– contrast. Unfortunately the patient vanished, went to 1Classified Ophthalmologist & Assistant Professor, A.K.Medical “quacks” He reported again after 02 months with loss College & His Highness Shaiekh Khalifa Bin Zayed An-Nahyan of vision in right eye as well, loss of some memory and Hospital, AJK, CMH Muzaffarabad. 2Radiologist & Assistant Professor, A.K. Medical College & His Highness Shaiekh Khalifa personality changes. On Examination visual acuity Bin Zayed An-Nahyan Hospital, AJK, CMH Muzaffarabad, right eye was perception of light, disc was now pale 3Histopathologist, CMH Muzaffarabad looking (fig 2a). visual acuity left eye was no light ––––––––––––––––––––––––––––––––––––––––––––––––––––– perception and optic atrophy (fig 2b). MRI brain with Correspondence: Lt. Col. Dr. Inamul Haq Khan1, Classified Ophthalmologist & Assistant Professor, His Highness Shaiekh contrast was done, which showed a rim enhanced, Khalifa Bin Zayed An-Nahyan Hospital, AJK, CMH Muzaffarabad. predominantly multicystic mass lesion with enhancing E-mail>[email protected]. Mobile: 00923009771066. solid component noted in leftfrontoparietalregion . The ––––––––––––––––––––––––––––––––––––––––––––––––––––– mass lesion also show a haemorrhagic component Received Nov’2011 Accepted March’2012 ––––––––––––––––––––––––––––––––––––––––––––––––––––– showing high signal on T1W and low signal on T2W
192 Ophthalmology Update Vol. 10. No. 2, April-June 2012 Gliblastoma Multiforme (GBM) as a cause of Foster Kennedy Syndrome
Image 1. T1W Image 2. T2W Image 3. T2W SAG Image 4. T1W C + sequences. There is extensive surrounding vasogenic in optic neuroglioma en-tering the cranium. In this edema extending along genu of corpus callosum to condition the ipsila-teral optic atrophy occurs well in contralateral side, subfalcine herniation as well as ad-vance of any evidence of the oedema. On the other effacement of ipsilateral frontal, temporal and body of hand a meningioma may exhibit the oedema on the lateral ventricle. MR findings of this patient suggested contrala-teral side before the atrophic changes on the diagnosis of Glioblastomamultiforme. He was ipsilateral side8. In 1909 Paton re-ported a case of advised CT guided biopsy and Neuro surgical unilateral papillo-edema with contralateral blindness consultation. without optic disc involvement. How-ever, two years Biopsy of the lesion was done which showed later frontal lobe tumor was detected during autopsy. “Clusters of neoplastic cells. These cells have pleomorphic In five cases of frontal lobe tumor and one of frontal hyperchromatic nuclei with high N/C (nuclear/cytoplasm) lobe abscess Foster Kennedy thought the optic atrophy ratio &fibrillary cytoplasmic extensions focally. There is no to be due to a toxic factor and papill-oedema to be due evidence of tuberculosis in the material examined. Findings to raised intracranial tension. Mehra et al consider it to are suggestive of ‘ Anaplastic astrocytoma ( WHO grade occur in about 2% of all cerebral tumors. Depending III)’ “The relatives of the patients refused further on the site and size of the tumor, various changes in intervention. the two eyes will be found9. In the early phase the DISCUSSION atrophy may be missed. Early pallor, good vision and FKS is an uncommon condition and even due to corresponding field defect on the ipsilateral side with advancement in imaging techniques, computed normal disc on the contralateral side is to be expected. tomography and MR imaging, the condition is still Gradual develop-ment of papilloedema on the contrala- rarely seen1. The syndrome was rst described in 1911 teral side with increase in optic atro-phy on the by the Robert Foster Kennedy, a British neurologist, ipsilateral side follows. Ultimately, the second eye who spent the majority of his working life in America develops post-papilloedemic atrophy. (1884-1952). He presented a series of six patients with Various causes have been assigned to this con- the triad of ipsilateral optic atrophy, contralateral dition. Tumors are the most common factor. Amongst papilloedema and ipsilateral anosmia2. It is rarely the non-neoplastic condi-tions, optochiasma caused by a frontal lobe tumor but is common with larachnoiditis, sclerosis of the internal carotid artery, tumors arising from the olfactory groove3. Histology syphilitic basal meningitis and Paget’s disease of the invariably shows a meningioma4. skull, craniostenosis, tubercular meningitis, and frontal The etiological mechanism of this syndrome is lobe ab-scess have been reported. unclear. Foster Kennedy originally hypothesized that The tumors are mostly gliomas in connection with ipsilateral optic atrophy resulted from direct pressure frontal lobe & olfactory groove, chiasmal, sphenoidal on the optic nerve, and the contra lateral papilloedema ridge meningioma are also seen. It is worth mentioning from long-standing elevated intra-cranial pressure5. An that not all such cases de-velop the Foster-Kennedy analysis of 36 reported cases showed that in 22% the syndrome. In Bynke’s (1958) series only 17 out of 1400 above applied, in 33% there was bilateral optic nerve cases of gliomas, this syndrome was seen and only in 1 compression, in 5% there was long-standing, increased out of 180 patients of frontal lobe tumor, FKS was intracranial pressure and in 40% the mechanism was present. Similarly in Huber’s (1961) series 2 out of 25 unclear6. cases of sphenoid wing tumor and 3 out of 16 cases of The order of precedence of papil-loedema and meningioma of the olfactory groove, had this atrophy is uncertain and depends on the site and size syndrome.This case report supports the original of the tumour7. A typical example of such influence is hypothesis of Foster Kennedy, as there was direct
Ophthalmology Update Vol. 10. No. 2, April-June 2012 193 Gliblastoma Multiforme (GBM) as a cause of Foster Kennedy Syndrome
compression of the left optic nerve and clinical features of radiotherapy. Some advocate radiotherapy at an of raised intracranial pressure. early stage of the disease, while others follow a non- aggressive management, with irradiation only at the Pseudo-Foster Kennedy syndrome is defined as time of progression11. one-sided optic atrophy with papilloedema in the other 10 REFERENCES eye but with the absence of a mass. FKS should be 1. Frenkel RE, Spoor TC. Visual loss and intoxication. differentiated from Pseudo-Foster Kennedy syndrome in SurvOphthalmol 1986; 30(6): 391–6. which there is disc swelling on one side and optic atro- 2. Miller DW, Hahn JF. General methods of clinical phy on the other. It is due to anterior Ischemic optic examination. In: Neurological Surgery, vol. 1, 2nd edn, Youmans JR, ed. Philadelphia, PA: WB Saunders, 1997: 13. neuropathy(AION). Recurrences of AION in the same 3. Frank WN. Central nervous system & the eye. eye are rare. However AION develop in the fellow eye Ophthalmology principles & concepts, 7th ed. Mosby, 1992: in 25% of cases. Usually months to years after the ini- 506. tial involvement. When this occurs a Pseudo-Foster 4. Yildizhan A. A case of Foster Kennedy syndrome without frontal lobe or anterior cranial fossa involvement. Neurosurg Kennedy syndrome develops. Rev 1992; 15(2): 139–42. MANAGEMENT AND PROGNOSIS 5. Kennedy F; Retrobulbar neuritis as an exact diagnostic sign of certain tumors and abscesses in the frontal lobe. American Both depend on the underlying tumor. There is Journal of the Medical Sciences, Thorofare, N.J., 1911, 142: no single treatment for the syndrome. However, there 355-368 are medications that are given to manage the signs and 6. Coppetto JR, Monteiro ML, Collias J, Upho D, Bear L. Foster symptoms as well as the four major diseases that make Kennedy syndrome caused by solitary intra-cranial plasmacytoma. SurgNeurol 1983; 19(3): 267–72. up the syndrome. In cases where surgical resection is 7. Jarus GD, Feldon SE. clinical & computed tomoraphic not possible, surgical intervention in the form of findings in the Foster Kennedy syndrome. AM J Ophthalmol resection or needle biopsy is the mainstay of treatment. 1982; 93(3):317-22. Radiotherapy represents one of the standard adjuvant 8. Neville RG, Greenblatt SH, Collartis CR. Foster Kennedy syndrome and an optociliary vein in a patient with a falx treatment modalities in cases of low-grade meningioma. J ClinNeuroophthalmol 1984; 4(2): 97–101. oligodendrogliomata. Chemotherapy is reserved for 9. Watnick RL, Trobe JD. Bilateral optic nerve compression as those with recurrence following radiotherapy. The a mechanism for the Foster Kennedy syndrome. median survival periods range from 8 to 10 years in Ophthalmology 1989; 96(12): 1793–8. 10. Beck RW, Smith GH. Anterior ischemic optic Neuropathy. cases of low-grade oligodendrogliomata. Large series Neuro-ophthalmology: A problem oriented approach. have reported no plateau in survival, so radiotherapy Little,Brown& company, Boston, 1998:48-50 has been proposed to optimize surgery and to delay 11. Yeh SA, Lee TC, Chen HJet al. Treatment outcomes and recurrences. However, there has been no randomized prognostic factors of patients with supratentorial low-grade oligodendroglioma. Int J RadiatOncolBiolPhys 2002; 54(5): trial assessing the optimal timing and the benecial role 1405–9.
194 Ophthalmology Update Vol. 10. No. 2, April-June 2012 General Section Original Article
Short Term Results of Closing Wedge High Tibial Osteotomy for Medial Compartmental Osteoarthritis of the Knee* Dr. Imran M. Imran Khan FCPS1, M. Salman2, M. Ayaz Khan FCPS3 Prof. Zafar Durrani FRCS4
ABSTRACT Objective: The objective of this study was to see the short term results of lateral closing wedge high tibial osteotomy in terms of patient satisfaction and pain relief for medial compartmental osteoarthritis. Material and Methods: Forty patients underwent lateral closing wedge high tibial osteotomy for medial compartmental osteoarthritis between February 2008 to February 2011. Patients with active life style, age < 60 years and osteoarthritis limited only to medial compartment were included in the study. Patients with lateral compartment and patello-femoral involvement, inflammatory arthritis, range of knee motion less than 90 degrees and flexion contracture more than 15 degrees were not included in the study. The patients were evaluated at six weeks, six months and one year. Outcome was categorized as good, fair and poor at the end of one year as shown in table 2. Results: Forty patients, 15 females (37.5%) and 35 males (62.5%) were included in the study. Complications occurred in the form of superficial infection in one patient and deep infection in two patients. Range of motion of the knee joint improved in the 80% of the patients at the end of one year. Results of the study were found good in thirty patients (75%), fair in seven patients (17.5%) and poor in three patients (7.5%). The outcome of the study was based on patient satisfaction, pain relief, union of the osteotomy site and joint stability (table 2). Conclusion: High tibial osteotomy is a better, simpler and cost effective procedure in medial compartmental osteoarthritis of the knee joint in early stages. It prolongs life of the damaged knee, relieve pain and disability and delay the need for future total knee replacement. Keywords: Medial compartmental osteoarthritis of the knee, high tibial osteotomy.
INTRODUCTION: quadriceps strengthening exercises and low impact Arthritic disease of the knee is a disabling activity4, 5. condition, negatively affecting life style in active aging Most commonly, varus deformity develops when population. It ranges from involvement of a single the disease progresses to its end stage. High tibial compartment to end-stage tricompartmental disease. osteotomy, unicompartmental arthroplasty and total Involvement of the medial compartment with a genu knee arthroplasty are various surgical options to treat varum deformity is a common occurrence in this this condition5, 6. Other surgical options described in disease1,2,3. The symptoms of the knee osteoarthritis are the literature are synovectomy, arthroscopic joint disabling pain, deformity and restriction of debridement and wash, arthrodesis, patellectomy, movements. During early stages the disease is treated petalloplasty and menisectomy8. conservatively by encouraging weight loss, Tibial osteotomies were introduced in 1950s7. physiotherapy, avoid squatting, life style modifications, These osteotomies have shown variable results as 22 ––––––––––––––––––––––––––––––––––––––––––––––––––––– shown in (table-1) . Lateral closing wedge osteotomy *The study was conducted at the Orthopaedic Unit of Khyber is more famous osteotomy as compared to medial Teaching Hospital Peshawar. opening wedge osteotomy for medial compartmental ––––––––––––––––––––––––––––––––––––––––––––––––––––– disease. It shifts the weight bearing axis from medial 1,2 3 4 Medical Officers, Associate Professor, Prof & Head of the 8 Orthopaedic and Trauma Unit, Khyber Teaching Hospital, Peshawar. to lateral compartment . Venous decongestion is ––––––––––––––––––––––––––––––––––––––––––––––––––––– another factor for pain relief apart from axial Correspondence: Dr Muhammad Ayaz Khan, Associate Professor realignment10. The damaged articular weight bearing Orthpeadic Surgery, Khyber Medical College & Khyber Teaching regions of the medial compartment heals with Hospital, Peshawar. Room No. A3-4, Ist floor, Khyber Medical Centre, Dabgari Gardens, Peshawar. Phone : 0912217255 fibrocartilage after axial realignment as obvious from 10, 11, 12 Cell : 03005933101 E-mail > [email protected] biopsy and second look arthroscopy . ––––––––––––––––––––––––––––––––––––––––––––––––––––– It has been proved that the results of these Received: Jan’2012 Accepted: March’2012 osteotomies deteriorate with the passage of time14 but –––––––––––––––––––––––––––––––––––––––––––––––––––––
Ophthalmology Update Vol. 10. No. 2, April-June 2012 195 Short Term Results of Closing Wedge High Tibial Osteotomy
good short and medium term results of lateral closing The patient was kept touch down weight bearing for wedge high tibial osteotomy14, 15 advocates its use in four weeks, partial weight bearing for next six to eight young enthusiastic patients who wants to keep active weeks and full weight bearing at 12 weeks. The range life style. of motion exercises were encouraged after the removal The objective of this study was to see the short of pop at 6 weeks. The quadriceps strengthening term results of lateral closing wedge high tibial exercises were encouraged during the whole post- osteotomy, in terms of patient satisfaction and pain operative period. relief, for medial compartmental OA. Results of the study were evaluated at six weeks, MATERIAL AND METHODS: six months and one year and were categorized into The study was conducted in Orthopaedics unit good, fair and poor as shown in table 26. of Khyber Teaching Hospital, Peshawar and Khyber RESULTS: Medical Center, Dabgari Gardens, Peshawar from Preoperatively, all patients had loss of normal February 2008 to February 2011. We included 40 knee valgus. The tibio-femoral angle ranged from 2 patients in our study, out of which 15 (37.5%) were valgus to 8 varus. Joint space narrow was more on females and 25 (62.5%) were males. All the patients medial then on the lateral side. The range of motion of were admitted through out-patient department. the knee were restricted in 32 (80%) of the patients. 20 Routine investigations were performed. This problem patients (50%) had restriction of flexion, eight patients occurs in older age group, the patient’s fitness for (20%) had restriction of extension and four patients general anesthesia was routinely taken into account. (10%) had restriction of both flexion and extension. Scanograms were taken to calculate the tibio-femoral There was no non-union in our study which, we angle and to measure the mechanical axis deviation. think, was because of good healing potential of Inclusion criteria were; metaphyseal area. All the osteotomies united in 6-9 1. Medial compartmental osteoarthritis. weeks tibio-femoral angle improved in all the cases. 2. Age < 60 years. The correction persisted till the end of one year. All the 3. Active life style. patients showed dramatic relief of pain which persisted Exclusion criteria were; till the end of one year. Range of motion improved in 1. Involvement of the lateral compartment and 80% of the patients. There was full range of motion of patella-femoral joint. the knee in 20 patients (50%) at the end of one year. 2. Inflammatory arthritis. The range of motion deteriorated in three patients. One 3. Range of motion < 90 . patient had superficial infection of the wound site at 4. Flexion contracture > 15 . three weeks while two patients had deep infection 5. History of previous lateral menisectomy. leading to knee stiffness. The functional outcome, 6. Lower limbs ischemia. according to table 2, at the end of one year of study 7. Knee subluxation. was good in 30 patients (75%), fair in seven patients All the osteotomies were performed by the same (17.5%) and poor in three patients (7.5%). Complications surgeon. The lateral closing wedge osteotomy was (poor results) observed were in the form of superficial performed with the aim to shift the weight bearing axis infection in one patient which was treated with oral to lateral compartment from medial compartment and antibiotics. Deep infection in two patients which was to exaggerate the tibio-femoral angle to 10 from a treated with staple removal, debrima, wash and normal tibio-femoral angle of 5-7 . The main steps of injectable antibiotics. Both the patients had poor range procedure were supine positioning of the patient and of knee motion and poor patient satisfaction. tourniquet application. Proper scrubbling and draping. DISCUSSION: Posterolateral hockey stick incision, identification and Osteoarthritis is a common disease of articular protection of common peroneal nerve, resection of cartilage in adults above 60 years of age. Distal and anteromedial part of fibular head to gain better access proximal inter-phalangeal joints of the hand are the to osteotomy site, proper siting of the osteotomy most common joints involved followed by knee joint17, (superior transverse cut was at the level of proximal 18. Involvement of the knee joint ranges from mild tibio-femoral joint and parallel to joint surface) proper reduction of the joint space to complete obliteration and sizing of the wedge (calculated from = 0.03 x width of osteophyte formation by then the patient is usually tibia x correction required), closure and fixation of the severely disabled. Pain, swelling and deformity of the osteotomy with staples, assessment of valgus/varus knee joint are the usual complaints and the cause of stability, deflation of the tourniquet, securing functional deficit. Treatment of this disease ranges from hemostasis and wound closure. The lower limb was conservative in mild disease to surgical in advanced kept immobilized in long leg cylinder cast for 6 weeks. involvement.
196 Ophthalmology Update Vol. 10. No. 2, April-June 2012 Short Term Results of Closing Wedge High Tibial Osteotomy
Table 1: Survivorship of HTO in the literature review
Authors Year Survivorship Naudie et al. 1999 75% at 5 years, 51% at 10 years & 30% at 20 years.
Sprenger and Doerzbacher 2003 65– 74% at 10 years
Koshino et al. 2004 97.3% at 7 years & 86.9% at 15 years. Tang and Henderson 2005 89.5% at 5 years, 74.7% at 10 years.
Papachristou et al. 2006 80% at 10 years & over 52.8% at 17 years.
Flecher et al. 2006 85% at 20 years. Gstöttner et al. 2008 94% at 5 years, 79.9% at 10 years.
Akizuki et al. 2008 97.6% at 10 years and 90.4% at 15 years
Table 2: Evaluation of results
Good Fair Poor Complete relief of pain Partial relief of pain No relief of pain
Normal union of osteotomy Normal union of osteotomy Delayed Union
Movements either improved or Movements decreased e” 20° of pre-op level Movements decreased e” 20° retained at pre-op level Joint stable Joint stable Joint unstable
Patient fully satisfied Patient partially satisfied Not satisfied
Involvement of the medial compartment with Henderson and Papachriston et al22. varus deformity is the most common presentation in CONCLUSION: advanced cases. Flexion contracture, limitation of range High tibial osteotomy is a better, simpler and cost of motion, knee instability, loss of medial effective procedure in medial compartmental compartmental subchondral bone and subluxation of osteoarthritis of the knee joint in early stages. It prolongs the knee joint are sequel to medial compartmental life of the damaged knee, relieve pain and disability osteoarthritis. and delay the need for future total knee replacement. Uni-condylar or total knee arthroplasty is the REFERENCES: treatment of choice for medial compartmental 1. Brouwer GM, van Tol AW, Bergink AP, et al. Association between valgus and varus alignment and the development osteoarthritis in the west. Patients in our part of the and progression of radiographic osteoarthritis of the knee. world are subjected to squatting for toilet and other Arthritis Rheum. 2007; 56(4):1204-1211. purposes. Moreover, knee arthroplasty is a difficult 2. Gandhi R, Ayeni O, Davey J, Mahomed N. High tibial undertaking due to socioeconomic reasons. Patients in osteotomy compared with unicompartmental arthroplasty for the treatment of medial compartment osteoarthritis: a this part of the world are subjected to manual labour. meta-analysis. Curr Orthop Prac. 2009;20(2):164-169. Due to these reasons high tibial osteotomy is an 3. Koshino T, Yoshida T, Ara Y, Saito I, Saito T. Fifteen to acceptable way of managing this disease as the patients twenty-eight years’ follow-up results of high tibial valgus do not have to change the work profile. High tibial osteotomy for osteoarthritic knee. Knee. 2004;11(6):439-444. 4. Richmond J, Hunter D, Irrgang J, et al. Treatment of osteotomy shift the weight bearing axis from involved osteoarthritis of the knee (nonarthroplasty). J Am Acad medial compartment to the less affected lateral Orthop Surg. 2009;17(9): 591-600. compartment leading to relief of symptoms and patient 5. Brinkman J-M, Lobenhoffer P, Agneskirchner JD, Staubli AE, satisfaction. Sacrifice of the proximal tibiofibular joint Wymenga AB, van Heerwaarden RJ. Osteotomies around the knee: patient selection, stability of fixation and bone healing and deterioration of results with the passage of time in high tibial osteotomies. J Bone Joint Surg Br. has made these osteotomies unpopular18. 2008;90(12):1548-1557. The outcome of our study was good in 30 patients 6. Devgan A, Marya KM, Kundu ZS, Sangwan SS, Siwach RC. (75%), fair in 7 patients (17.5%) and poor in 3 patients Medial Opening Wedge High Tibial Osteotomy for Osteoarthritis of Knee; Long term results in 50 knees. Med J (7.5%) at one year which is comparable to studies Malaysia 2003; 58:62-68. conducted by Ivarsson20, Naudie et al21, Tang and 7. Jackson JP, Waught W, Green JP. High tibial osteotomy for
Ophthalmology Update Vol. 10. No. 2, April-June 2012 197 Short Term Results of Closing Wedge High Tibial Osteotomy
osteoarthritis of the knee. J Bone Joint Surg 1969; 5IB: 88-94. osteotomy in patients who are fifty years old or less: a long- 8. Bauer GCH, Insall J, Koshino T. Tibial osteotomy in term follow-up study. J Bone Joint Surg Am. 1988;70(7):977- gonarthrosis. J Bone Joint Surg 1969; 51A: 1545-62. 982. 9. Helal B. The pain in primary osteoarthritis of knee. Its causes 16. Lawrence RC, Hochberg MC, Kelsey JL et al. Estimates of and treatment by osteotomy. Postgrad Med J 1965; 41: 172- the prevalence of selected arthritic and musculoskeletal 81. diseases in the United States. J Rheumatol 1989; 16: 427-41. 10. Bergenudd H, Johnell O, Redlund-Johnell I, Lohmander LS. 17. Oliveria SA, Felson DT, Reed JI et al. Incidence of The articular cartilage after osteotomy for medial symptomatic hand, hip and knee osteoarthritis among gonarthrosis: biopsies after 2 years in 19 cases. Acta Orthop patients in a health maintenance organization. Arthritis Scand. 1992;63(4):413-416. Rheum 1995; 38: 1134-41. 11. Kanamiya T, Naito M, Hara M, Yoshimura I. The influences 18. Sangwan SS, Siwach RC, Singh Z, Duhan S. of biomechanical factors on cartilage regeneration after high Unicompartmental osteoarthritis of the knee: an innovative tibial osteotomy for knees with medial compartment osteotomy. Int Orthop 2000; 24: 148-50. osteoarthritis: clinical and arthroscopic observations. 29. Ivarsson I, Myrnerts R, Gillquist J (1990) High tibial Arthroscopy. 2002;18(7):725-729. osteotomy for medial osteoarthritis of the knee. A 5 to 7 and 12. Odenbring S, Egund N, Lindstrand A, Lohmander LS, Wille´ 11 year followup. J Bone Joint Surg Br 72:238–244 n H. Cartilage regeneration after proximal tibial osteotomy 20. Naudie D, Bourne RB, Rorabeck CH, Bourne TJ (1999) The for medial gonarthrosis: an arthroscopic, roentgenographic, Install Award. Survivorship of the high tibial valgus and histologic study. Clin Orthop Relat Res. 1992;277:210- osteotomy. A 10- to 22-year followup study. Clin Orthop 216. Relat Res 367:18–27 13. Tang WC, Henderson IJP. High tibial osteotomy: long term 21. Papachristou G, Plessas S, Sourlas J, Levidiotis C, survival analysis and patients’ perspective. Knee. Chronopoulos E, Papachristou C (2006) Deterioration of long- 2005;12(6):410-413. term results following high tibial osteotomy in patients under 14. Hernigou P, Medevielle D, Debeyre J, Goutallier D. Proximal 60 years of age. Int Orthop 30:403–408. tibial osteotomy for osteoarthritis with varus deformity: a 22. Amendola A, Bonasia DE. Result of high tibial osteotomy: ten to thirteenyear follow-up study. J Bone Joint Surg Am. Review of the literature. International Orthopaedics (SICOT) 1987;69(3):332-354. 2010; 34; 155-160. 15. Holden DL, James SL, Larson RL, Slocum DB. Proximal tibial
198 Ophthalmology Update Vol. 10. No. 2, April-June 2012 Original Article Comparison of Normal and Abnormal Umbilical Artery Waveforms with Early Neonatal Outcome in Asymmetrical Dr. Misbah Intra-Uterine Growth Retardation (IUGR)
Misbah Durrani,1 Hina Hanif Mughal,2 Tayyaba Afzal3
ABSTRACT Background: Fetuses with intrauterine growth retardation(IUGR) are delivered if they have evidence of distress, as manifested by abnormalities in the fetal heart rate and umbilical-artery blood flow. We studied whether umbilical-artery Doppler waveform correlates with early neonatal outcomes. Study design: Descriptive (case series) study. Setting: The study was conducted at the Department of Medical Imaging, Rawalpindi Medical College & Allied Hospitals, Rawalpindi. Duration of study: The study was conducted from November 2009 to March 2010. Sample size: A total of 105 fetuses with Doppler diagnosis of IUGR were included in the study. Methods: - We measured hemoglobin and lactate concentrations, oxygen content, pH, blood gas levels, and base deficit in umbilical-vein blood and correlated these measurements with the heart rate and umbilical-artery wave forms recorded by Doppler velocimetry in 56 fetuses with growth retardation. Twenty-one fetuses had normal heart rates and normal results of velocimetry, 24 had normal heart rates and abnormal results of velocimetry (indicative of decreased diastolic flow), and 11 had abnormal heart rates and abnormal results of velocimetry. Results: - The study included 105 patients with diagnosed asymmetric fetal growth restriction on ultrasound criteria. The mean maternal age was 25.30±2.78 years. 62 (59%) patients had an abnormal doppler flow in umblical artery. The mean birth weight in the abnormal Doppler flow group was 2.20 ±0.565 kg vs 2.84 ± 0.43 kg in the normal Doppler flow group; p = 0.000. The mean apgar score at 05 minute was significantly lower in the abnormal Doppler flow group; 7.366 ± 2.13 vs 9.23 ± 0.648; p = 0.000. Conclusions: - Assessment of fetal umbilical artery Doppler waveform can help us predict the neonatal outcome. Fetuses with abnormal waveform have a poorer outcome as compared to those with normal waveform.
INTRODUCTION an important role in fetal surveillance. In IUGR fetuses IUGR is a “sonographic estimated fetal weight with absent or reversed blood flow velocity in the below the 10th percentile gestational age.”1 Incidence umbilical artery, there is increased risk of cesarean of IUGR is 3% if the 3rd or 5% if the 5th centile is chosen2. section, respiratory distress, chronic lung disease, acute In the etiology of the IUGR, fetal factors such as renal function, necrotizing enterocolitis or death4. There infection, chromosomal and structural anomalies, is ample evidence that Doppler indices from the fetal placental factors and maternal factors like toxin or drug circulation can reliably predict adverse perinatal exposure, illicit drugs use and medical conditions such outcomes in an obstetric patient population with a high as anemia and hypertension are responsible. IUGR is prevalence of complications such as fetal growth associated with the increased risk of perinatal mortality, restriction5. IUGR is a clinical situation at highest risk morbidity and impaired neurological development of intrauterine hypoxia or acidosis. IUGR fetuses with outcomes. IUGR fetuses have increased risk of abnormal PI of umbilical artery had 15% incidence of intrauterine death and asphyxia at birth. Correct acidosis and IUGR fetuses with normal PI of umbilical detection of the compromised IUGR fetus to allow artery had 34% incidence of acidosis6. timely intervention is a main objective of antenatal care3. Assessment of fetal growth and well-being is one In management of IUGR Doppler ultrasound play of the major purposes of antenatal care. Small for gestational age fetus is either constitutionally small or ––––––––––––––––––––––––––––––––––––––––––––––––––––– has failed to meet its growth potential and thus becomes 1 Assistant Professor Diagnostic Radiology HHSKBZ / AK CMH 7 Muzaffarabad.2.Medical Officer, DHQ hospital Rawalpindi.3 Classified growth restricted . Fetal growth restriction has high risk 8 Radiologist HHSKBZ / AK CMH Muzaffarabad. (AJ&K) of perinatal mortality and morbidity . ––––––––––––––––––––––––––––––––––––––––––––––––––––– The purpose of this study was to know that Correspondence:: Dr Misbah Durrani, Assistant Professor umbilical artery Doppler can accurately predict acid- Diagnostic Radiology HHSKBZ / AK CMH Muzaffarabad. E-mail: [email protected]. base status at the time of birth to improve fetal ––––––––––––––––––––––––––––––––––––––––––––––––––––– surveillance. Received: Oct’2011 Accepted: Jan’2012 MATERIALS AND METHODS ––––––––––––––––––––––––––––––––––––––––––––––––––––– Sampling technique: Consecutive sampling.
Ophthalmology Update Vol. 10. No. 2, April-June 2012 199 Comparison of Normal and Abnormal Umbilical Artery Waveforms
SAMPLE SELECTION: (live or stillbirth), birth weight (normal, LBW, VLBW), Inclusion Criteria: Singleton pregnancy, Fundal abnormal Doppler flow (absent or reversed) and height 3cm less than gestational age, longitudinal lie, APGAR score (<7, >7) at 5min. Gestational age > 28 weeks, Chi-square test was used to compare birth weight Exclusion criteria: Twin pregnancy, congenitally and APGAR score at 5min in normal and abnormal abnormal fetuses, premature rupture of membranes, umbilical artery wave forms. Independent sample t-test Diabetes with pregnancy, Eclampsia, Placental will be used to compare APGAR score value in both abruption. groups. P value less than 0.05 was considered Data collection: significant. Before conducting this study, approval from RESULTS Hospital Ethical Committee was taken. Informed The study included 105 patients with diagnosed written consent was taken from patients included in asymmetric fetal growth restriction on ultrasound study. Patients were selected coming to Medical criteria. The maternal age ranged from 18 to 30 years Imaging Department of RMC & Allied Hospitals with a mean age of 25.30±2.78 years. Doppler flow recruited into the study after 28 weeks of gestation waveform in umbilical artery 62 (59%) patients had an (fulfilling inclusion criteria). All these patients abnormal Doppler flow in umblical artery whereas 43 underwent obstetric ultrasonography and if there is (41%) patients had a normal Doppler flow in umblical suspicion of asymmetrical IUGR i.e. discrepancy artery. between dates and fetal parameters (elevated ratio of Birth weight: The mean birth weight in the abnormal head circumference to abdominal circumference, Doppler flow group was confirmed by a senior consultant) then they will 2.20±0.565 kg and the mean birth weight in the undergo Doppler of umbilical artery. The outcome normal Doppler flow group was 2.84 ± variables noted at delivery (by a 3rd or 4th year obstetric 0.43 kg, the difference in weight was statistically resident) were the state of baby (still birth/ alive), birth significant between the two groups; weight (measured on standard neonatal weighing scale) p = 0.000. Only 13 (21%) babies had normal weight and Apgar score at five minutes after delivery. All the in the abnormal Doppler flow group as compared to findings were noted on performa. 37 (86%) in the normal Doppler flow group. 42 (67.7%) Data Analysis: babies were low birth weight (1500-2500 gm) in the Results were analyzed by using SPSS (V.10). Mean abnormal Doppler flow group as compared to 6 (14%) and standard deviation will be used for numerical in the normal Doppler flow group. 7 (11.3%) babies variables i.e. age. Frequency and percentages were presented for categorical variables i.e. neonatal outcome
Figure 2 Figure 1 Stacked Bar graph of Apgar score at 5 min; abnormal vs normal Morbidity and mortality in 1560 small-for-gestational age fetuses Doppler flow in umbilical artery groups
200 Ophthalmology Update Vol. 10. No. 2, April-June 2012 Comparison of Normal and Abnormal Umbilical Artery Waveforms
Figure 3 Comparison of birth weight; abnormal vs normal Doppler flow in umbilical artery groups were very low birth weight (<1500 gm) in the abnor- Figure 4 mal Doppler flow group as compared to none in the Duplex pulsed Doppler sonogram depicting umbilical arterial circulation normal Doppler flow group. This difference was sta- tistically significant; p = 0.00. Apgar score at 05 minutes. The mean apgar The umbilical artery waveform provides information score at 05 minute in the abnormal Doppler about placental resistance, which, in turn, reflects the flow group was 7.366 ± 2.13 and the mean apgar degree of fetal compromise. Lastly, recent investigation score at 05 minute in the normal suggests that decreased velocity during arterial Doppler flow group was 9.23 ± 0.648, the contraction noted in the inferior vena cava and ductus difference in 05 minute apgar score was venosus correlates well with the presence or absence statistically significant between the two groups; of metabolic acidemia, the best correlate of neurological p = 0.000. outcome. A combination of the above Doppler In the abnormal Doppler flow group 40 (64.5%) parameters can be used today to separate the deprived babies had an apgar score of > 7 at 05 minute as opposed from the ‘normal’, but biometrically compromised, to 43 (100%) in the normal Doppler flow group. In the fetus to detect early hypoxia in IUGR, and to precisely abnormal Doppler flow group 22 (35.5%) babies had time delivery to avoid neurological sequlae in the an apgar score of 0-6 at 05 minute as opposed to none acidotic fetus12. in the normal Doppler flow group. This difference was Doppler velocimetry of the umbilical artery (UA) statistically significant; p= 0.00. provides a noninvasive measure of the feto-placental DISCUSSION hemodynamic state. UA Doppler indices indirectly Fetal growth restriction is a syndrome reflect impedance of downstream circulation. characterized by failure of the fetus to reach its normal Abnormality of the Doppler index has been correlated growth potential; fetuses with fetal growth restriction to feto-placental vascular mal-development. There is a therefore represent a subset of those designated as small significant association between abnormal Doppler for gestational age (SGA). Fetal growth restriction is indices and fetal hypoxia, fetal acidosis, and adverse the second leading cause of perinatal death9 and is perinatal outcome. Most randomized trials of UA associated with significant morbidity, including Doppler ultrasound in high risk pregnancies show increased rates of meconium aspiration, hypoglycemia, improved outcome when this technique is used in respiratory distress syndrome, intrapartum asphyxia, pregnancies complicated by growth restriction. Clinical developmental delay, and stillbirth. Unfortunately, management should integrate the Doppler approach fetuses with fetal growth restriction are often difficult with existing modalities of antepartum fetal monitoring. to differentiate from fetuses that are merely small owing The most important diagnostic characteristic of the UA to constitutional or genetic causes. Doppler waveform is the state of the end diastolic Doppler sonography is a non-invasive method of velocity: absent end-diastolic velocity (AEDV) is an evaluating utero-placental circulation110 Changes in the ominous finding and reversed end-diastolic velocity velocimetric values seen on serial Doppler examinations (REDV) should be interpreted as a preterminal finding. may be helpful in documenting improvement in flow In pregnancies complicated by fetal growth restriction with therapy or in determining the need for delivery11. or preeclampsia at e” 32 weeks of gestation, prompt Doppler provides the clinician with the best way delivery is recommend rather than expectant to evaluate the condition of the growth restricted fetus. management in the setting of AEDV or REDV13.
Ophthalmology Update Vol. 10. No. 2, April-June 2012 201 Comparison of Normal and Abnormal Umbilical Artery Waveforms
Doppler has revolutionized the field of obstetrics CONCLUSION since its introduction in late 1950‘s. Useful information Growth restricted fetuses with abnormal umbilical is obtained during second half of pregnancy and artery Doppler waveform have a poor neonatal pregnancies with high resistance can be determined. outcome in terms of significantly lower birth weight The cut off values of Doppler indices for defining and lower apgar scores at 5 minutes. abnormal Doppler waveform are controversial. 100 REFERENCES patients were studied in Combined Military Hospital, 1. Kalanithi LEG, Illuzzi JL, Nossor VB, Frisback Y, RazeqSA, 14 Coel JA, et al. Intrauterine growth restriction and placental Rawalpindi in 2003 . Doppler examination was localization. J Ultrasound Med 2007; 26:1481-9. performed and the range of normal indices determined 2. Baker PN. Obstetrics by ten teachers. 18h ed. London.Hodder from all the four vessels. For umbilical artery mean PI Arnold 2006. 156-78. was 1.48 (range = 0.92-1.91), RI was 0.78 (range = 0.64- 3. LBN, RKV, GPT. Doppler prediction of adverse perinatal outcome in PIH and IUGR. Ind JRadipl Imag 2006;16:1:109- 0.84) S/D ratio was 4.68 (range = 3.84-5.6). We used a 16. RI of >0.6 as the cut off level for abnormal Doppler 4. Nicholl RM, Deenmamode JM, Gamsu HR. Intrauterine waveform. Using a lower cut off value may have had growth restriction, visceral blood flow velocityand exocrine an impact on the outcome in our data. pancreatic function. BMC research notes 2008,1:115. 5. Malhotra N, hanana C, Kumar S, Roy K, Sharma JB. Local data on the subject is sparse. Similar results Comparison of perinatal oucome of growth-restrictes fetuses have also been documented from few local studies. At with normal and abnormal umbilical artery waveforms. MCH center, PIMS, Islamabad 15 a study was carried Indian J Med Si. 2006;60:311-7. out to assess the role of umbilical artery Doppler 6. Marconi AM, Paolini CL, Zerbe G, Battaglia FC. Lactacidemiain intrauterine GrowthRestricted (IUGR) examination in the management of high-risk Prreganancies: Relationship to clinical Severity, Oxygenation pregnancies. 54 women with singleton pregnancies at and Placental Weight. Pediatr Res 2006,59:570-4. high risk of IUGR delivered in 2004. Normal Doppler 7. Breeze ACG, Lees CC. Pediction and perinatal outcomes of group showed 31% emergency C sections performed fetal growth restriction. Sem Fet Neonat 2007;12:383-97. 8. Smith GCS, Lees CC. Disorders of fetal growth and compared to 38% in abnormal Doppler group, 26.3% assessment of fetal well being. In: Edmonds DK (edi). 7th patients in normal Doppler group and 33% in abnormal ed.London: Blackwell 2007;159-65. Doppler group delivered vaginally. At 5 min of birth 9. Wolfe HM, Gross TL. Increased risk to the growth retarded Apgar scores of 5-10 were seen in all the babies fetus. In: Gross TM, Sokol RJ, editors. Intrauterine growth retardation. Chicago: Year Book Medical Publishers; 1989. p belonging to mothers of normal Doppler group and in 111. the other group 95% babies showed the same score. 10. Goldkrand JW, Morre DH, Lenz SU, Clements SP, Turner NICU admissions were 15% in the normal Doppler AD, Bryant JL. Volumetric flow in the umbilical artery: group and in the other group they were 22%. Our study normative data. J Matern Fetal Med 2000;9: 224–8. 11. Acharya G, Wilsgaard T, Berntsen GK, Maltau JM, Kiserud in fact showed a much higher NICU admission rate of T. Reference ranges for serial measurements of blood velocity 80% in the abnormal Doppler group, however rate of and pulsatility index at the intra-abdominal portion, and fetal NICU admission rate of normal Doppler group was and placental ends of the umbilical artery. Ultrasound Obstet similar (18%) in our study when compared to this local Gynecol 2005;26: 162–9. 12. Kotini1 A, Avgidou K, Koutlaki N, Sigalas A, Anninos P, study. Anastasiadis P. Correlation between biomagnetic and To evaluate the role of Colour Doppler Ultrasound Doppler findings of umbilical artery in fetal growth in the management of small for gestational age fetus or restriction. Prenat Diagn 2003; 23: 325–30. IUGR pregnancies, a study was performed in Allied 13. Galan HL, Ferrazzi E, John C. Hobbins. Intrauterine growth 16 restriction (IUGR): biometric and Doppler assessment. Prenat Hospital, Faisalabad in 2006. 45 growth restricted Diagn 2002; 22: 331–7. fetuses were evaluated; 33.3% with normal end- 14. Saeed M, Qureshi IA, Tarin A, Ghani N, Hyder RR, Rashid I. diastolic flow were delivered at 37 weeks; 44.47% with Doppler indices in fetoplacental and uteroplacental absent or reversed end-diastolic flow were delivered circulation at 22 weeks of gestation. Pak Armed Forces Med J 2006;56:7-11. at 34-35 weeks. We did not document the gestational 15. Afghan S, Masood S, Mahzar B. The role of Doppler age at the time of delivery and hence no data is available Ultrasound in the management of high-risk Pregnancies: A for comparison. Perinatal mortality was 8.8% mostly PIMS experience. Ann Pak Inst Med Sci 2005;1:215-9. due to extreme prematurity. There was one fetal death 16. Rizvi SMR, Yasmeen N, Iqbal N. Small for gestational age fetus; role of colour Doppler ultrasound in the management. but no perinatal mortality in our group. Professional Med J 2006;13:705-9.
202 Ophthalmology Update Vol. 10. No. 2, April-June 2012 Original Article
Weight loss, Exercise, or Both improves Physical function in Obese Older Adults*
Dennis T. Villareal, M.D., Suresh Chode, M.D., NehuParimi, M.D., Dr. David R. Sinacore, P.T., Ph.D., Dr. Tiffany Hilton, P.T., Ph.D., Reina Armamento-Villareal, M.D., Dr. Nicola Napoli, M.D., Ph.D., Dr. Clifford Qualls, Ph.D., &Krupa Shah, M.D., M.P.H. Edited by. Dr. Inamul Haq Khan, FCPS, FICO(UK)
ABSTRACT: Background: Obesity exacerbates the age-related decline in physical function and causes frailty in older adults; however, the appropriate treatment for obese older adults is controversial. Period of Study:April’2005 to August’2009 Place of Study: Washington University School of Medicine,Washington Material &Methods:In this 1-year, randomized, controlled trial, we evaluated the independent and combined effects of weight loss and exercise in 107 adults who were 65 years of age or older and obese. Participants were randomly assigned to a control group, a weight-management (diet) group, an exercise group, or a weight-management-plus-exercise (diet– exercise) group. The primary outcome was the change in score on the modified Physical Performance Test. Secondary outcomes included other measures of frailty, body composition, bone mineral density, specific physical functions, and quality of life. Results: A total of 93 participants (87%) completed the study. In the intention-to-treat analysis, the score on the Physical Performance Test, in which higher scores indicate better physical status, increased more in the diet–exercise group than in the diet group or the exercise group (increases from baseline of 21% vs. 12% and 15%, respectively); the scores in all three of those groups increased more than the scores in the control group (in which the score increased by 1%). Moreover, the peak oxygen consumption improved more in the diet–exercise group than in the diet group or the exercise group (increases of 17% vs. 10% and 8%, respectively; the score on the Functional Status Questionnaire, in which higher scores indicate better physical function, increased more in the diet–exercise group than in the diet group (increase of 10% vs. 4%) Body weight decreased by 10% in the diet group and by 9% in the diet–exercise group, but did not decrease in the exercise group or the control group. Lean body mass and bone mineral density at the hip decreased less in the diet–exercise group than in the diet group (reductions of 3% and 1%, respectively, in the diet–exercise group vs. reductions of 5% and 3%, respectively, in the diet group. Strength, balance, and gait improved consistently in the diet–exercise group. Conclusions: These findings suggest that a combination of weight loss and exercise provides greater improvement in physical function than either intervention alone.
INTRODUCTION approximately 20% of adults around 65 years of age Obesity in older adults is becoming a serious or older are obese, and the prevalence will continue to public health problem in the world.1-4 as the number of rise as more and more become senior citizens.37 In older obese older adults is increasing markedly.5.,6 Currently, adults, obesity exacerbates the age-related decline in physical function, which causes frailty, impairs quality ––––––––––––––––––––––––––––––––––––––––––––––––––––– of life.8-12Given the increasing prevalence of obesity, the *The study was approved and monitored by the Institutional Review Board & Monitoring Board and carried out in most common phenotype of frailty in the future may Washington University School of Medicine.,Intensive Research be an obese, disabled, older adult.4.,13 Unit of the Institute of Clinical &Translational Sciences. Although obesity is an important cause of ––––––––––––––––––––––––––––––––––––––––––––––––––– disability in older adults,14,15 there is little evidence from Correspondence: Dr. Dennis T. Villareal, M.DIntensive Research Unit of the Institute of Clinical and Translational Sciences;New clinical trials regarding the benefits and risks of weight- Mexico VA Health Care System, Geriatrics (111K), 1501 San loss interventions to guide the care of population.6.17 In Pedro., Dr., Albuquerque, NM 87108, fact, the clinical approach to obesity is controversial, E.Mail. >[email protected] given the reduction in relative health risks associated –––––––––––––––––––––––––––––––––––––––––––––––––––– 2 Acknowledgement: Ophthalmology Update acknowledges with with increasing body-mass index (BMI) in this group. It thanks Dr. Dennis T. Villareal, M.D., permitting us to take the excerpts has been suggested that it may be difficult to achieve from his original article. successful weight loss because of life long diet and –––––––––––––––––––––––––––––––––––––––––––––––––––––
Ophthalmology Update Vol. 10. No. 2, April-June 2012 203 Weight loss, Exercise, or Both improves Physical function in Obese Older Adults
activity habits.18 Moreover, there is major concern that flight of stairs, and performing a progressive Romberg weight loss could worsen frailty by accelerating the test) plus two additional tasks (climbing up and down usual age-related loss of muscle that leads to four flights of stairs and performing a 360-degree turn). sarcopenia.4 In a preliminary, short-term study.19We The score for each task ranges from 0 to 4; a perfect report the results of a randomized, controlled trial that score is 36.20-23 A low score on the Physical Performance was designed to determine the independent and Test is associated with a high BMI,8,24 and the score 19 combined effects of sustained weight loss and regular increases in response to weight-loss therapy. VO2peak exercise on physical function, body composition, and was assessed during graded treadmill walking, as quality of life. We hypothesized that weight loss and described previously.8 Information regarding the ability exercise would each improve physical function and that to perform activities of daily living was obtained with the combination of the two would result in the greatest the use of the Functional Status Questionnaire (on improvement in physical function and amelioration of which scores range from 0 to 36, with higher scores physical frailty. indicating better functional status).25 We also assessed MATERIAL &METHODS specific physical functions such as strength, balance, We conducted the study from April 2005 through and gait and determined one-repetition maximums (the August 2009 at the Washington University School of maximal weight a person can lift at one time). We Medicine. The study was approved by the institutional assessed static balance by measuring the time the review board and was monitored by an independent participant could stand on a single leg8 and dynamic data and safety monitoring board. Volunteers were balance by measuring the time needed to complete an recruited after written consent. Potential participants obstacle course.20 Fast gait speed was determined by a underwent a comprehensive medical screening measurement of the time needed to walk 25 ft. procedure. Volunteers were eligible for inclusion in the ii) Body Composition and Bone Mineral Density: study if they were 65 years of age or older and obese, if Fat mass, lean body mass, and bone mineral density of they had a sedentary lifestyle, if their body weight had the whole body and at the lumbar spine and total hip been stable during the previous year and if their were measured with the use of dual-energy x-ray medications had been stable for 6 months before absorptiometry.19,26 Thigh muscle and fat volumes were enrollment. All participants had to have mild-to- measured with the use of MRI..27 moderate frailty, on the basis of meeting at least two of iii) Health-Related Quality of Life,The Medical the following operational criteria8,19,20: a score on the Outcomes: 36-items Short-Form Health Survey (SF-36) modified Physical Performance Test (in which the total was used to evaluate quality of life.28 The subscales we score ranges from 0 to 36, with higher scores indicating used were those for the physical component summary better physical status) of 18 to 32; a peak oxygen and the mental component summary.29 Scores on these consumption (VO2peak) of 11 to 18 ml per kilogram of two subscales range from 0 to 100, with higher scores body weight per minute; or difficulty in performing two indicating better health status. instrumental activities of daily living or one basic FOLLOW-UP ASSESSMENTS activity of daily living. Persons who had severe All baseline assessments were repeated at 6 cardiopulmonary disease; musculoskeletal or months and 12 months, with the exception of the MRI, neuromuscular impairments or a history of cancer, as which was repeated only at 12 months. Participants well as persons who were receiving drugs that affect assigned to the control group did not receive advice to bone health and metabolism or who were current change their diet or activity habits and were prohibited smokers, were excluded. from participating in any weight-loss or exercise The primary outcome was the change from program. They were provided general information baseline in the score on the modified Physical about a healthy diet during monthly visits with the staff. Performance Test. Secondary outcomes included other Participants assigned to the diet group were measures of frailty, body composition, bone mineral prescribed a balanced diet that provided an energy density, specific physical functions, and quality of life. deficit of 500 to 750 kcal per day from their daily energy BASELINE ASSESSMENTS: requirement.2 The diet contained approximately 1 g of i) Physical Function: Frailty was assessed with high-quality protein per kilogram of body weight per the use of the modified Physical Performance Test, the day.2 Participants met weekly as a group with a dietitian measurement of VO2peak, and the Functional Status for adjustments of their caloric intake and for behavioral Questionnaire. The modified Physical Performance Test therapy. They were instructed to set weekly behavioral includes seven standardized tasks (walking 50 ft, goals and attend weekly weigh-in sessions. Food diaries putting on and removing a coat, picking up a penny, were reviewed, and new goals were set on the basis of standing up from a chair, lifting a book, climbing one diary reports. The goal was to achieve a weight loss of
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approximately 10% of their baseline body weight at 6 diet–exercise group (a weight loss of 8.6±3.8 kg, months and to maintain that weight loss for an representing a 9% decrease), but not in the exercise additional 6 months. group (a weight loss of 1.8±2.7 kg, representing a 1% Participants in the exercise group were given decrease) or the control group (a weight loss of 0.9±1.5 information regarding a diet that would maintain their kg, representing <1% decrease) Lean body mass current weight and participated in three group exercise- decreased less in the diet–exercise group than in the training sessions per week. Each session was diet group (a decrease of 1.8±1.7 kg, representing a 3% approximately 90 minutes in duration and consisted of change from baseline, vs. a decrease of 3.2±2.0 kg, aerobic exercises, resistance training, and exercises to representing a 5% change). The lean body mass improve flexibility and balance. The exercise sessions increased by 1.3±1.6 kg in the exercise group (a 2% were led by a physical therapist. The aerobic exercises increase from baseline). Fat mass decreased by 6.3±2.8 included walking on a treadmill, stationary cycling, and kg in the diet–exercise group (a 16% change from stair climbing. The participants exercised so that their baseline), by 7.1±3.9 kg in the diet group (a 17% change), heart rate was approximately 65% of their peak heart and by 1.8±1.9 kg in the exercise group (a 5% change). rate and gradually increased the intensity of exercise Similar changes were observed with respect to thigh so that their heart rate was between 70 and 85% of their muscle and fat. peak heart rate. The progressive resistance training Bone mineral density at the total hip decreased included nine upper-extremity and lower-extremity by 0.011±0.026 g per square centimeter (a decrease of exercises with the use of weight-lifting machines. 1.1% from baseline) in the diet–exercise group, as Participants performed 1 or 2 sets at a resistance of compared with 0.027±0.021 g per square centimeter (a approximately 65% of their one-repetition maximum, decrease of 2.6%) in the diet group, whereas it with 8 to 12 repetitions of each exercise; they gradually increased, by 0.013±0.014 g per square centimeter (a increased the intensity to 2 to 3 sets at a resistance of 1.5% increase), in the exercise group. approximately 80% of their one-repetition maximum, The total one-repetition maximum (i.e., the sum with 6 to 8 repetitions of each exercise. Participants in of the maximal weights lifted in the biceps curl, bench the diet–exercise group participated in both the weight- press, seated row, knee extension, knee flexion, and leg management and exercise programs described above. press exercises) increased in the diet–exercise group (an All participants were given supplements to ensure an increase of 164±124 lb [75±56 kg], representing a 35% intake of approximately 1500 mg of calcium per day change from baseline) and in the exercise group (an and approximately 1000 IU of vitamin D per day.2 increase of 174±166 lb [79±75 kg], representing a 34% We estimated that with 26 to 28 participants in change), whereas it was maintained in the diet group each group, the study would have more than 80% (an increase of 1±85 lb [0.5±39 kg], representing a 3% power to detect a clinically important difference among change). The time needed to complete the obstacle the groups in the change in the score on the Physical course was reduced by 1.7±2.2 seconds in the diet– Performance Test, assuming a mean between-group exercise group (a reduction of 12%), by 1.1±1.1 seconds difference in the score of 1.7 points, with a pooled in the diet group (a reduction of 10%), and by 1.5±1.4 standard deviation of 2.1 (on the basis of preliminary seconds in the exercise group (a reduction of 13%). The data), at an alpha level of 5%. duration of time the participant could stand on a single RESULTS leg increased by similar amounts in those groups. Gait- A total of 107 volunteers underwent random- speed increased in the diet–exercise group (an increase ization; 93(87%) completed the study (Screening, of 16.9±42.3 seconds, representing a 23% change from randomization, and follow-up). Fourteen participants baseline) and in the exercise group (an increase of discontinued the intervention and were included in the 8.2±15.5 seconds, representing a 14% change).The intention-to-treat analyses.The median attendance at physical-component summary score of the SF-36 (which diet-therapy sessions was 83%, and 82%, among those was used to measure quality of life) increased by 8.6±9.3 in the diet–exercise group. The median attendance at points in the diet–exercise group (a 15% increase from exercise sessions was 88%, among participants in the baseline), by 8.4±10.1 points in the diet group (a 14% exercise group and 83% (interquartile range, 80 to 88) increase), and by 5.7±8.0 points in the exercise group among those in the diet–exercise group.One participant (a 10% increase) fell during testing of physical function, and the fall DISCUSSION resulted in an ankle fracture. In this 1-year, randomized, controlled trial There was a substantial decrease in body weight involving obese older adults, weight loss plus exercise in the diet group (a weight loss of 9.7±5.4 kg, improved physical function and ameliorated frailty representing a 10% decrease from baseline) and in the more than either weight loss or exercise alone, although
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each of those was beneficial.Currently, evidence-based A limitation of our study is that it was not data to guide the treatment of obese older adults are powered to determine potential differences in the limited.16,17The few clinical trials that have been outcomes between sexes.Because we selected conducted typically addressed cardiovascular risk volunteers who were able to participate in a lifestyle factors rather than physical function.16However, frailty program, the results may not necessarily apply to the is an important problem in the elderly because it leads general obese, older adult population. Nonetheless, to loss of independence and increased morbidity and they provide evidence that successful weight loss is mortality.30,31Our study suggests that weight loss alone achievable in this population. Further studies are or exercise alone can reverse frailty but that the needed to determine whether weight loss can be combination of weight loss and exercise is more maintained beyond 1 year and prevent effective than either individual intervention. Therefore, institutionalization of obese older adults. Our sample weight loss and exercise may be an important therapy size was small, and most of the participants were for frail, obese older adults. Moreover, one study has women, white, well educated, and older with mild-to- shown that weight loss and exercise reduce knee pain moderate frailty thus limiting broader inferences of our and improve physical function in overweight and obese results. Our study did not address the usefulness or older adults with osteoarthritis of the knee.34 safety of these interventions for markedly obese older Physical frailty in obese older adults is associated persons with severe frailty. with low muscle mass relative to body weight (relative CONCLUSION: sarcopenia) despite a greater absolute amount of muscle our findings suggest that weight loss alone or mass.4,8 In the current study, relative sarcopenia was exercise alone improves physical function and reduced in all the intervention groups — owing to the ameliorates frailty in obese older adults; however, a larger reduction in fat mass relative to lean body mass combination of weight loss and regular exercise may in the diet and diet–exercise groups and owing to the provide greater improvement in physical function and decrease in fat mass and increase in lean body mass in amelioration of frailty than either intervention alone. the exercise group. These positive changes in body Therefore, weight loss combined with regular exercise composition could underlie the improvement in may be beneficial in helping obese older adults maintain physical function in the participants.4,8 However, their functional independence. because the greatest improvement occurred in the diet– REFERENCES: exercise group, adding an exercise program to a diet 1. vanBaak MA, Visscher TL. Public health success in recent regimen, which results in the preservation of lean body decades may be in danger if lifestyles of the elderly are neglected. Am J ClinNutr 2006;84:1257-1258 mass in addition to the reduction in fat mass induced 2. Villareal DT, Apovian CM, Kushner RF, Klein S. Obesity in by a diet, may be the best approach. Accordingly, the older adults: technical review and position statement of the diet–exercise group had not only the greatest increase American Society for Nutrition and NAASO, The Obesity in scores on the Physical Performance Test but also Society. Am J ClinNutr 2005;82:923-934 3. Arterburn DE, Crane PK, Sullivan SD. The coming epidemic the most consistent improvements in strength, balance, of obesity in elderly Americans. J Am GeriatrSoc and gait. 2004;52:1907-1912 A potential adverse effect of our interventions was 4. Roubenoff R. Sarcopenic obesity: the confluence of two the reduction in lean body mass and bone mineral epidemics. Obes Res 2004;12:887-888 5. Mokdad AH, Ford ES, Bowman BA, et al. Prevalence of density at the hip in the diet groups. However, the obesity, diabetes, and obesity-related health risk factors, 2001. addition of exercise to diet attenuated the losses of lean JAMA 2003;289:76-79 tissue and further augmented physical function. 6. Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence Although the clinical importance of the modest loss of and trends in obesity among US adults, 1999-2008. JAMA 2010;303:235-241 bone mineral density is unclear, strategies to prevent 7. Li F, Fisher KJ, Harmer P. Prevalence of overweight and this loss in participants involved in future studies might obesity in older U.S. adults: estimates from the 2003 include prescribing higher doses of calcium and vitamin Behavioral Risk Factor Surveillance System survey. J Am D than those used in this study. An additional health GeriatrSoc 2005;53:737-739 8. Villareal DT, Banks M, Siener C, Sinacore DR, Klein S. concern is raised by findings from observational studies Physical frailty and body composition in obese elderly men that suggest that weight loss may be associated with and women. Obes Res 2004;12:913-920 an increased risk of death.2 However, these studies did 9. Blaum CS, Xue QL, Michelon E, Semba RD, Fried LP. 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Ophthalmology Update Vol. 10. No. 2, April-June 2012 207 Current Research
Probing the Floor of the Optic Nerve head in Glaucoma
Dr. Douglas R. Anderson, MD -Miami, Florida Edited by: Dr. Madiha Durrani FRCS, U.A.E.
Spectral domain optical coherence tomography of a nonvascular cavity within the choroid. The authors (SD-OCT) applied to the eye is rapidly expanding its thus illustrated new, but perhaps very infrequent, scope of usefulness. The authors have described the use features that accompany glaucomatous disease. of “Enhanced Depth Imaging” (EDT) to explore the Thus, EDI has not only enabled study of optic disc, and in particular the lamina cribrosa, in the thechoroid (and possibly sclera), but is beginning to context of glaucoma. The lamina cribrosa is of special open new windows to the depths of the optic nerve interest because the excavation of the optic nerve head, head. Already details are emerging about the collapse so characteristic of glaucoma in contrast to other optic and thinning of the lamina cribrosa,posterior migration atrophies, is related to the collapse and posterior of its insertion into the sclera. These events seem to bowing of the lamina cribrosa with widening of the occur in the early stages of glaucomatous cupping. scleral opening. Although histological verification that structures are The EDI method has been used to evaluate the correctly identified would be valuable. choroid in glaucoma, with the finding that the choroid In addition, while EDI is a major step forward. becomes thinner with age, but is seemingly not affected the image of deeper structures is still imperfect. The by glaucoma.In a previous study with standard SD- ultimate hope is that we not only come to understand OCT, the anterior portion of the lamina cribrosa was the pathogenic process, but can use the information in visible only in the cup, but not under the rim of making clinical evaluation and decisions. neuroretinal tissue. In 42% of the eyes the posterior Based on evidence, observation and clinical boundary of the lamina cribrosa could not be identified, judgment, Dr. S.S. Hasnain, a Pakistani scientist who is even in the region of the cup, so thickness could be practicing Ophthalmology for the last 40 years in measured in only 58% of the eyes and for the most part California, has challenged the old paradigm of ’Cupped only at the center disc’ in glaucoma by a new hypothesis, ‘Optic disc may Park et al of the Catholic University of Korea, be sinking’. Dr. Hasnain has made a relentless effort to made measurements at 3 locations along the vertical establish this new paradigm, indicating that why are midline of the disc (in the cup), to avoid shadows the arcuate axons selectively destroyed first in the initial caused by blood vessels and other overlying tissue. stages of Glaucoma? He strongly thinks that this is the They reported that among 137 eyes with glaucoma, the only core issue in resolving the pathogenesis of front surface of the lamina cribrosa could be seen in glaucoma. He considers that the loss of neurons in all, even with the standard mode. The posterior surface Lateral Geniculate body and loss of ganglion cells in was adequately seen in only 66% with the standard the retina simultaneously supports his hypothesis of mode, but in 93% with EDI. They also found a greater ‘sinking disc’ resulting in the axons being axotomized repeatability when measuring the lamina cribrosa and not atrophied as in glaucoma. He considers that thickness with EDI than in the standard mode . With axotomy of axons result in excavation of disc, a feature regard to glaucoma, they found that the lamina cribrosa of chronic glaucoma. was thickest in healthy eyes, less thick in eyes with high- REFERENCES pressure glaucoma, and thinner yet in eyes with I. Park H-YL, Jeon SH, Park CK. Enhanced depth imaging detects laminacribrosa thickness differences in normal normal-tension glaucoma, particularly in those in which tension glaucoma and primary open angle glaucoma. disc hemorrhages were seen. Ophthalmology 2llI2;11 9: lO-20. In 76% of the eyes, pores of the lamina cribrosa 2. Park Sc. De Moraes CGV, Teng C, et a1. Enhanced depth could be seen in regions of the disc, mainly centrally or imaging optical coherence tomography of deep optic nerve Olliplex structures in glaucoma. Ophthalmology 2012; 119:j. temporally. They made note of other structures as well. 3. SpaideRF, Koizumi H, Pozzoni Me. Enhanced depth imaging The central retinal vessels could be seen in all eyes, and spectral-domain optical coherence tomography. Am I in 86% at least one short posterior ciliary artery was Ophthalmol. 2008; 146496 —500. seen. In a minority, other details were observed, 4. Chang S, FlueraruC, Mao Y. Sherif S. Anenuation compensation. including the anterior termination of the subarachnoid space, a patch of absent lamina cribrosa, and an instance
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