Newsltr April 2012 - prime.edu.pk · Ophthalmology Update Vol. 10. No. 2, April-June 2012 iii Contents Topical Nsaid’s and Flouoromethalone in the Treatment of Epidemic Keratoconjunctivitis

Ophthalmology Update Vol. 10. No. 2, April-June 2012 i

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Vol. 10. No. 2 April-June 2012

Update

ii Ophthalmology Update Vol. 10. No. 2, April-June 2012

Contentsn EDITORIAL

n Over indulgence in T.V. & Computers can produce Visual and other Health ProblemsProf. M. Yasin Khan Durrani ---------------------------------------------------------------------------------------------------- 113

OPHTHALMIC SECTION

n ORIGINAL ARTICLES

n A Computer-based Anaglyphic System for the Treatment of AmblyopiaDr. Ali Rastegarpour ---------------------------------------------------------------------------------------------------------------- 115

n Change in Refractive Status, after Removal of sutures, in conventional Extra-CapsularCataract Extraction with IOL ImplantationShafqat ullah Khan Marwat et al ------------------------------------------------------------------------------------------------- 119

n Trabeculectomy with Mitomycin-C in Patients of Primary Open Angle GlaucomaSaber Mohammad et al ------------------------------------------------------------------------------------------------------------- 124

n Concussional Injuries of the EyeSofia Iqbal et al ---------------------------------------------------------------------------------------------------------------------- 128

n Complications of Intravitreal Injections of BevacizumabMushtaq Ahmed et al --------------------------------------------------------------------------------------------------------------- 133

n An audit of Neonatal Services in Khyber Pakhtunkhwa Province (KPK), Pakistanto identify Implications for screening ‘Retinopathy of Prematurity’Sadia Sethi et al --------------------------------------------------------------------------------------------------------------------- 136

n A Review of Microbial KeratitisSofia Iqbal et al ---------------------------------------------------------------------------------------------------------------------- 143

n Frequency of Ocular Injuries at Tertiary Care HospitalA. Khalil Lakho et al --------------------------------------------------------------------------------------------------------------- 148

n Phacoemulsification under Topical Anaesthesia with Intracameral LignocaineMushtaq Ahmed et al --------------------------------------------------------------------------------------------------------------- 152

n Angiographic Features of Central Serous Chorio-retinopathy in Pakistani PopulationMuhammad 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 forDiabetic Macular Oedema(DME) — A Comparative StudyEmbong Zunaina et al ------------------------------------------------------------------------------------------------------------- 166

Contents

Ophthalmology Update Vol. 10. No. 2, April-June 2012 iii

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-FUHashim Imran et al ----------------------------------------------------------------------------------------------------------------- 177

n Door to Door Trachoma Survey in North Waziristan Agency, Tehsil Mir AliSanaullah Khan et al --------------------------------------------------------------------------------------------------------------- 181

n Subtenon vs Peribulbar Anaestheia for Manual Small Incision Cataract SurgeryZakir Hussain et al ----------------------------------------------------------------------------------------------------------------- 186

n Frequency and Types of Comitant Esotropia Among Patients Attending Eye OPDNuzhat 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 CompartmentalOsteoarthritis of the KneeM. Imran Khan et al ---------------------------------------------------------------------------------------------------------------- 195

n Comparison of Normal and Abnormal Umbilical Artery Waveforms with Early NeonatalOutcome in Asymmetrical Intra-Uterine Growth Retardation (IUGR)Misbah Durrani et al --------------------------------------------------------------------------------------------------------------- 199

n Weight loss, Exercise, or Both improve Physical function in Obese Older AdultsDennis T. Villareal et al ----------------------------------------------------------------------------------------------------------- 203

CURRENT RESEARCH

n Probing the Floor of the Optic Nerve head in GlaucomaMadiha Durrani -------------------------------------------------------------------------------------------------------------------- 208

iv Ophthalmology Update Vol. 10. No. 2, April-June 2012

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Ophthalmology Update Vol. 10. No. 2, April-June 2012 113

With the change of life style, children are crazy inspending more time in indoor-activities and less in out-door sports like activities. It has firmly been establishedthat the computer games are most likened mode ofentertainment for children as well as the elderly. Thesecomputers (especially the laptops) have captured ourlives and made us dependent on them. Research showsthat computers badly affect the brain as well as thebody. Parents have noticed that their children areplaying computer games for a longer period and theyoften complain of watery eyes, frequent headaches,back aches, emotional instability and lack ofconcentration in their studies

Doctors have observed increasing incidence ofworldwide Myopia (shortsightedness) with physicaland emotional changes leading to moral turpitude insome cases. Reaching home after schooling the childrenspend most of their time in front of TV or playing SIMS-most popular series of computer games. Globallyspeaking, there is an alarming rise of Myopia to theextent of an epidemic form especially in countries withadvanced Information Technology. For example, inSingapore and Israel, 30 years ago, the incidence ofmyopia in teen agers was just 30-35% which has nowjumped to 80% especially in school children where thestate has laid more emphasis on reading religious books.According to an unofficial study in Pakistan, most ofthe children involved in memorizing the books sufferfrom myopia. There could be other reasons like undernutrition, over-indulgence in TV and computers apartfrom increasing burden of studies right from the tenderage which is the most vulnerable age to suffer myopiai.e., 8-12years. No doubt, genetics is also an importantfactor in producing myopia. According to a study inUSA, the incidence of myopia in non-myopic parentsis 6%, in a single myopic parents it is 18% and in parents(both myopic) it is 33%.

The question arises, how myopia develops? Whathappens anatomically? According to a school ofthought, the explanation appears relevant, that duringthe developing age, children spend more time focusingon close objects such as studying books and focusing

on computers, the eye ball is thought to grow longerand longer so that less effort is needed to see nearobjects clearly , but an elongated eye will no longerfocuses distant objects thus inducing myopia, whichexplains the prominence of myopic eye. On thecontrary, the children who take more interest inphysical activities or games are less susceptible toshortsightedness as it tend to involve more focusingon distant objects rather near objects, thus protectingthe eyes from abnormal growth. The best example isthat the youngsters playing Tennis are less likely tosuffer from Myopia. It is also postulated that apart frommyopia they get glaucoma like symptoms with fieldchanges in the long run. In view of the changing lifestyle, as observed by Prof. Ian Morgan from theAustralian National University in Canberra that themyopia is rising at a fastest rate in Far-easterncountries but the western world is equally worriedabout it.

Recently, a team of scientists lead by Prof. LorenCordain of Colorado State University has found that adiet rich in sugar and refined starch including whitebread and cereals can cause shortsightedness. Theyargue that the foods may affect the development of eyesby stimulating the production of high level of insulinand reduction of protein-3, which is thought to beresponsible for growth of eye ball and lens. Theevidence was well observed in North AmericanCanadian Eskimos, where incidence of myopia is hardly1-2%, the reason scientists believe that they eat fish,tuberous plants and coconut rather than bread andcereals. However this needs further study.

It has also been clearly demonstrated thatplaying video games like Medal of Honor, PacificAssault-MOH and SIMS series induce functionalplasticity and spatial resolution which improve theirreversible Amblyopia in adults as experienced byProf. Roger W. Li, Ph.D. research optometrist fromUniversity of California. Let us see when a child shouldstart using a computer? Is it at the age of 3 years? Thefact cannot be ignored that the computer applicationimproves children’s performance in reading, writing

Over indulgence in T.V. & Computerscan produce Visual and other Health Problems

Editorial

114 Ophthalmology Update Vol. 10. No. 2, April-June 2012

and basic mathematics, but involvement at an early agemay expose to the risks of:

Physical hazards like visual strain and obesity ii)Emotional and social hazards like isolation, weakrelationship with teachers and lack of self-disciplineiii) Intellectual hazards like lack of creativity to someextent, non-realistic imaginations, poor language skills,too little patience for hard work and lack of seekingknowledge iii) and finally moral hazards leadingmoral degradation.

There are many useful and positive observations,as computer games are not only a modern craze butalso an effective tool to enhance the intelligence quotient(IQ) of the children from 30-35%. Even the seniors whosuffer from CVA stroke may lose the skill of processingdata in their field of vision. There is a dramatic impacton the skill of perception and this has lead the scientiststo believe the possibilities how computer games mayhelp to rehabilitate the stroke patients and also helpthe elderly to keep them sufficiently alert as safedrivers. Similarly, computers can ease the tasks fasterthan humans can do. It can resolve harder problemseasily and remember lot of facts, while computer gamesenhance the capacity of human brains and visualattention skill. Regular players of computer games showdramatic perception, 20-50% better at taking ineverything that happens around them.

In Summary, there are some useful guidelines forparents and teachers to use computers with theirchildren as an opportunity to talk, listen and shareexperiences to make computer time multi-sensory withreal life objectives. According to Prof. Karl Zadnick ofOhio State University, College of Optometry inColumbia, we must get the parents, cutting the time oftheir children spending on computer games or watchingT.V. to the extent of less than an hour a day andencouraging them to spend more time in out-dooractivities.

In bygone days, people preferred healthy foodswith energy drinks like taking grams, yams, dates andfresh fruits and not the junk foods with cokes andcandies, refrigerated and micro-wave processed diet.They led a real healthy life style. In this context, theparents must ensure that the children take balanced/wholesome diet with energy drinks and have at least 8hours continuous uninterrupted sleep increasing theirperceptive ability with freshness to take more interestin their lessons in the school. A computer junkie adviseswhile working/playing at computers one must takeshort 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:

1. Prevalence of amblyopia and strabismus in white and AfricanAmerican children aged 6 through 71 months the BaltimorePediatric Eye Disease Study. Ophthalmology116: 2128–2134e2121–2122.

2. Levi D. M, Polat U (1996) Neural plasticity in adults withamblyopia. Proc NatlAcadSci U S A 93: 6830–6834.

3. Polat U, Ma-Naim T, Belkin M, Sagi D (2004) Improvingvision in adult amblyopia by perceptual learning.ProcNatlAcadSci U S A 101: 6692–6697.

4. Li R. W, Young K. G, Hoenig P, Levi D. M (2005) Perceptuallearning improves visual perception in juvenile amblyopia.Invest Ophthalmol Vis Sci 46: 3161–3168. Zhou Y, Huang C,Xu P, Tao L, Qiu Z, et al. (2006)

5. Perceptual learning improves contrast sensitivity and visualacuity in adults with anisometropic amblyopia. Vision Res46: 739–750.

Prof. Dr. M. Yasin Khan DurraniEditor in Chief

Editorial: Ocular Surface Damage by Medication – Current Opinion

How things have changed?

Courtesy: Dr. Arshad Mehmood, Prof. Daljit Singh & Dr Yost Lynn


–––––––––––––––––––––––––––––––––––––––––––––––––––––––*The study was conducted at Ophthalmic Research Center, ShahidBeheshti University of Medical Sciences, Tehran, Iran–––––––––––––––––––––––––––––––––––––––––––––––––––––––Correspondence: Dr. Ali Rastegarpour Ophthalmic Research Center,Shahid Beheshti University of Medical Sciences, 23 Paidarfard St,Boostan 9, Pasdaran Ave, Tehran 16666, Iran Tel +98 21 2277 0957Fax +98 21 2259 0607 Email [email protected]–––––––––––––––––––––––––––––––––––––––––––––––––––––––Acknowledgement: The management of Ophthalmology Updatethanks Dr. Ali Rastegarpour for permitting to publish the wholearticle…..Editor–––––––––––––––––––––––––––––––––––––––––––––––––––––––

INTRODUCTIONAs the development of virtual reality (VR)-based

treatment systems such as the Interactive BinocularTreatment (I-BiT™) system presented by Eastgateet al1

and the Viston-VR™ system presented by Qiu et al2

have demonstrated, the advent ofVR technology hasbeen introduced as a promising solution for themanagement of amblyopia. Preliminary findings implythat VR-based treatment could be effective3 and doesnot involve many of the numerous problems confrontedin the conventional approach of occlusion orpenalization. Conventional occlusion therapy, bypatching the dominant eye to encourage stimulation ofthe amblyopic eye, is traditionally the mainstaytreatment for amblyopia.4 Although effective,5–7 thissimple intervention produces variable andunsatisfactory outcomes, long durations of treatment,high costs, negative psychological and emotionalimpacts, poor compliance, which may even render thetreatment completelyineffective.8 Atropine penalization

of the dominant eye is a recently developed alternativewithbreportedly better compliance and lower costs,9

and of equal efficacy.6,7,9 However,batropine as amedication has its side effects, ranging fromthebcommon and benign experience of lightsensitivity,7,10,11 to alarge variety of less common butmore serious symptoms.4 Although rare,7,12 there havealso been reports of reverse amblyopia,13,14 acomplication in which the unaffected penalized eyebecomes amblyopic due to inhibition.VR-basedtreatment overcomes many of these problems. VR-based treatment is interactive and adjustable for ageandtherefore it is enjoyable for the patients and resultsinexcellent patient compliance.1 It does not entail thestigmatization of patching or side effects of atropine,and has no risk of reverse amblyopia, since the healthyeye is not occluded or rendered inactive and is notdeprived of stimuli.VR-based treatment is said to besuccessful in preliminary reports.3 In addition, whileocclusion and penalization canpotentially disruptfusion, VR-based therapy encouragesfusion and isexpected to enhance binocular vision. On the otherhand, VR-based treatment requires expensive elaborateequipment. It would be costly to implement on alargescale, and it would not be accessible or convenient formost children.

The current paper attempts to introduce a methodthat could encompass the advantages of VR-basedtreatment, at a much lower cost. The introduced systemcan produce an effect similar to the underlying concept

Outcomes & Complications of Frontalis Brow Suspension with Silicone Tube in Congenital Ptosis

A Computer-based Anaglyphic Systemfor the Treatment of Amblyopia*

Dr. Ali Rastegarpour

ABSTRACTPurpose: 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 iscostly 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 personalcomputer. The software is designed such that some active graphic components can only be seen by the amblyopic eyeand are filtered out for the other eye. Some components would be seen by both to encourage fusion. The result is that thepatient 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 certaincolor 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 andhighly 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

Dr. AliRastegarpour

Original Article


of VR-based treatment, using simple technology andobviating the need for complex equipment. Thesoftware of this system could be installed on a personalcomputer at home, and conveniently operated alongwith a pair of special glasses.MATERIAL AND METHODS

The essence of VR-based treatment consists offeeding the two eyes two different but related images.Instead of having the two images differ slightly inperspective, as would be intended for three-dimensional (3-D) viewing, the two images wouldoverlap and create a single image, however someelements would be missing for each eye. In particular,there would necessarily be main active elements thatwould be presented to the amblyopic eye but not to thenon-amblyopic eye. Thus, the amblyopic eye wouldneed to play an active role in binocular vision in orderto see thecomplete image, whether it be a video or agame.VR, however, is not the only method that can beused to feed two different images to the two eyes. Longbefore the very concept of feeding a different image toeach eye was adopted for the treatment of amblyopia,it had been usedto create 3-D images and movies. Anolder technique for creating 3-D experiences was theanaglyphic method. In this method, two images createdfrom a slightly differing point ofview were presentedin two distinct colors. The viewer would wear a pair of3-D glasses consisting of two color filters, each to filterone of the images.

Therefore, each eye would only see one of theimages.This is the exact mechanism used in the current

system. The system consists of a software package anda pair of glasses made of two color filters. The softwareis designed to be engaging and interactive, but in amanner that at least some of the main active movingcomponents can only be seen by the amblyopic eye andare filtered out for the other eye.This is achieved bysimply arranging these elements (and thecorresponding backgrounds they cover) to appear inthe same colors that the filters allow entry for. Somecomponents, especially the non mobile or backgroundelements, would be seen by both eyes to encouragefusion. The result is, thepatient must use both eyes, andspecifically the amblyopiceye, to play the games (Figure1). The glasses consisted of two blue (Wratten #47) andorange (Wratten #21) generic photographic filters. Thefilters Figure 1A diagram of the anaglyphic system foramblyopia treatment. The display(A) consists ofelements that, based on color, may be visible by one orboth eyes.The filter for the unaffected eye (B) filters outmain moving elements (D), while thefilter of theamblyopic eye (C) allows for the eye to see the mainelements and mayor may not filter out less significantfeatures (E). An anaglyphic system for amblyopia weremounted on a frame that adequately covered the fieldofvision.Software of the prototype model consisted ofsimple modified open source Flash (Adobe, San Jose,CA) games.The games used included the open sourceFlash games ofPing, Xtreme Climber, Snake, andPacman.The backgrounds of all games were changedto white,and main elements were changed to the filteredcolors. The colors for two different hexadecimal codes

A Computer-based Anaglyphic System for the Treatment of Amblyopia

Figure 1


were successfully filtered out by each lens. Codes#99FFFF and #CCFFFF were filtered by the blue lensand #FFFF33 and #FFFF99 were filtered by the orangelens. This enabled us to create images with three shades(two shades of color and white), which could be filteredout for one eye.RESULTS

A laboratory prototype of the proposed system,the ABG InSight (v1.2 β), was designed. The systemwas used onnine monitors, with differentmanufacturers and models, and complete filtering wasconfirmed by twelve people withouta history of anyophthalmologic or neurological problems.A simplecalibration module could be added to the software laterto guarantee consistency in filtering elements, or forthe time being the monitors could be adjusted by anyperson without color vision deficits, to ensure correctfiltering. The glasses consisted of two genericphotographic filters,which were for the purpose of thisstudy, blue and orange,but other color pairs, such asthe traditional 3-D red-cyanor amber-pure dark blue(used in ColorCode 3-D)15 would presumably beequally functional. The prototype system was capableof successfully filteringout elements of a certain colorand therefore, was found to bea potential alternativeto VR for amblyopia management.DISCUSSION

As mentioned, the computer-based anaglyphicsystem provides most of the advantages of the VR-based treatment, in addition to reduced cost and highavailability.

The open source initiative allows for themodification, and in most cases, distribution, of avariety of software packages, free of charge andlicensing. This creates the opportunity for researchersto gain access to libraries of software, and from themany available programs, select and use those that maysuit their purpose. In this case, applying a fewsimplechanges in the code of a game, such as changingthe color of the elements, could make it completelycompatible with the proposed system. For this means,many of the available games can be used, taking intoconsideration only the appropriateness of the game forthe target age group, and complexity of the graphicinterface. The license of some open source games doesnot allow them to be modified for commercial use. Thisshould be taken into consideration, the licenserespected, and no financial gain received fromsuchgames.

One of the limitations for such a system would bethe main limitation of all anaglyphic systems: thelimited useof color. Games that include color as a maintheme orinclude color-based elements, as well as gamesand media with complex graphics, would be slightly

restricted. Althoug hanaglyphs can reproduce colorimages and to a point, color distinction and clarity, thescope of options is limited.For example, the mainmoving elements, as well as other components whichare selected for filtering, along with the correspondingbackgrounds they cover, must be invariablymonochrome. For this reason, the background andmainelements can only consist of white and variousshades of the filtered color. In most cases, between thedarkest shade of the filtered color and white, only onedistinctively visible shade will be practical for use. Thislimits the colors for use in themain elements andbackgrounds to three colors; white and the two shadesof the filtered color. Aside from this issue the use ofvarious points of view, perspectives, and move-mentsremain unrestricted.

A minor advantage for some VR-based systemswould be that they can be made to adjust for angles ofstrabismus, which means they can be used for untreatedstrabismic amblyopes and adjusted as such to providebinocular vision and fusion without requiringsatisfactory alignment. Since the anaglyphic systemuses a single display, its use is limited to amblyopicpatients for whom the underlying condition, usuallystrabismus or anisometropia, has been resolved, atleastto some extent, by corrective glasses or other means. Aminor advantage of the anaglyphic system is that thefusion promoted for seeing the images in this system,is similar to the fusion required in the actual world,becauseboth eyes are watching the same interface. VR-based systemsmay not represent the actual angles,distances, or proportions seen in the naturalsurroundings. This is why prolongedwork with VRsystems has been associated with vomiting, sweating,headaches, and drowsiness.16 The anaglyphic systemhas much potential to becomea large-scale open sourceresearch project. Various opensource applications couldbe modified by volunteers to enrichthe library ofsoftware used in the project, and researchersthroughout the world could use standard filters tocreate the glasses, and download the software free ofcharge.

A major concern is the actual effectiveness oftheVR-based systems. Although the anaglyphic systemcouldpotentially serve as an alternative to VR-basedsystems by accomplishing the same objectives, theevidence supportingVR-based systems as a therapeuticintervention is limited,and the only available studiesincluding clinical data in this regard are two case seriesreporting the short-term outcomesin six and twelvepatients, respectively.3,17 Computer-based active visiontherapy has received much attention for amblyopia andone of the recent publications by Hess et al,18

demonstrating success for active vision therapy in three



amblyopic patients. However, there is still not muchevidence in the literature to support most modalities.Nonetheless, introducing the anaglyphic systemprovides an excellent opportunity to investigate the roleof computer-based therapy in the management ofamblyopia, by enabling researchers worldwide toevaluate its effectiveness without the need for expensiveor exclusive equipment, and therefore allowinginterested researchers to continue from where theprevious studies were left.CONCLUSION

The current lack of clinical data for the amblyopicsystem is a major drawback of this introductory paper.However, it has not been claimed that the anaglyphicmethod is an effectivetreatment for amblyopia, butrather that the system could logically be a suitablealternative to the VR systems. The cost of anaglyphicsystems is much lower, therefore they may be a moreviable option for research and may be ultimately,treatment. The evidence for VR-based systems couldbeintriguing enough for researchers to test ananaglyphic system that functions similarly, with betteravailability and lower costs. Future clinical trialsperformed on VR-based treatmentsystems candocument the effectiveness of the underlying concept,on which the current system was designed. Inaddition,clinical trials and case series performed with theanaglyphic system itself will determine its trueeffectiveness and implications. In conclusion, theanaglyphic system maintains most advantages of theVR-based systems, but is less costlyand more accessible.The system logically fulfills what theVR-based systemwas designed to achieve and therefore, warrants furtherinvestigation.REFERENCES1. Eastgate RM, Griffiths GD, Waddingham PE, et al. Modified

virtualreality technology for treatment of amblyopia. Eye(Lond). 2006;20 (3):370–374.

2. Qiu F, Wang L, Liu Y, Yu L. Interactive binocular amblyopiatreatmentsystem with full-field vision based on virtualreality. The 1st InternationalConference on Bioinformaticsand Biomedical Engineering 2007(ICBBE 2007) July 6–8, 2007;Wuhan, China: Institute of Electricaland ElectronicsEngineers (IEEE); 2007:1257–1260.

3. Waddingham PE, Butler TK, Cobb SV, et al. Preliminaryresults fromthe use of the novel Interactive binocular


treatment (I-BiT) system, inthe treatment of strabismic andanisometropic amblyopia. Eye (Lond).2006;20 (3):375–378.

4. Webber AL. Amblyopia treatment: an evidence-basedapproachto maximising treatment outcome. ClinExpOptom.2007;90(4):250–257.5. Teed RG, Bui CM, Morrison DG, EstesRL, Donahue SP. Amblyopia therapy in children identifiedby photoscreening. Ophthalmology. 2010;117(1):159–162.

6. Repka MX, Kraker RT, Beck RW, et al. Pediatric EyeDiseaseInvestigator Group. A randomized trial of atropinevs patching fortreatment of moderate amblyopia: follow-upat age 10 years. ArchOphthalmol. 2008;126(8):1039–1044.

7. Scheiman MM, Hertle RW, Kraker RT, et al. Pediatric EyeDiseaseInvestigator Group. Patching vs atropine to treatamblyopia in childrenaged 7 to 12 years: a randomized trial.Arch Ophthalmol. 2008;126(12):1634–1642.

8. Awan M, Proudlock FA, Grosvenor D, Choudhuri I,Sarvanananthan N,Gottlob I. An audit of the outcome ofamblyopia treatment: a retrospectiveanalysis of 322 children.Br J Ophthalmol. 2010;94 (8):1007–1011.

9. Li T, Shotton K. Conventional occlusion versuspharmacologicpenalization for amblyopia. Cochrane DatabaseSyst Rev. 2009;4:CD006460.

10. Pediatric Eye Disease Investigator Group. Pharmacologicalplus opticalpenalization treatment for amblyopia: results ofa randomized trial. ArchOphthalmol. 2009;127(1):22–30.

11. Repka MX, Kraker RT, Beck RW, et al. Pediatric EyeDiseaseInvestigator Group. Treatment of severe amblyopiawith weekendatropine: results from 2 randomized clinicaltrials. J AAPOS. 2009;13(3):258–263.

12. North RV, Kelly ME. Atropine occlusion in the treatment ofstrabismicamblyopia and its effect upon the non-amblyopiceye. OphthalmicPhysiol Opt . 1991;11(2):113–117.Ananaglyphic system for amblyopia

13. Kubota N, Usui C. The development of occlusionamblyopiafollowingatropine therapy for strabismic amblyopia.NipponGankaGakkaiZasshi. 1993;97(6):763–768. Japanese.

14. Simons K, Stein L, Sener EC, Vitale S, Guyton DL. Full-timeatropine, intermittent atropine, and optical penalization andbinocular outcomin treatment of strabismicamblyopia.Ophthalmology. 1997; 104 (12):2143–2155.

15. Sorensen SEB, Hansen PS, Sorensen NL, inventors.Methodforrecording and viewing stereoscopic images in color usingmultichromefilters.United States Patent 6687003. May 31,2001.

16. Oman CM. Sensory conflict in motion sickness: an observertheoryapproach. In: Ellis SR, editor. Pictorial Communicationin Virtual andReal Environments. London, UK: Taylor andFrancis; 1993:362–376.

17. Cleary M, Moody AD, Buchanan A, Stewart H, Dutton GN.Assessmentof a computer-based treatment for olderamblyopes: the Glasgow PilotStudy. Eye (Lond). 2009;23(1):124–131.

18. Hess RF, Mansouri B, Thompson B. A binocular approach totreatingamblyopia: antisuppression therapy. Optom Vis Sci.2010;87(9):697–704.


–––––––––––––––––––––––––––––––––––––––––––––––––––––––1Senior Registrar Eye A Ward Khyber Teaching Hospital Peshawar2Registrar 3 Eye Specialist Timargara Hospital Dir 4Senior RegistrarEye WardDepartment of ophthalmology Lady Reading HospitalPeshawar5Senior Registrar 6Professor and Head of Ophthalmology,Khyber Teaching Hospital, Peshawar.–––––––––––––––––––––––––––––––––––––––––––––––––––––––Correspondence: Flat No,14, New Doctors Colony, Khyber TeachingHospital, Peshawar Tel: 03345701112Email: [email protected]–––––––––––––––––––––––––––––––––––––––––––––––––––––––Received: Oct’2011 Accepted: Jan’2012–––––––––––––––––––––––––––––––––––––––––––––––––––––––

INTRODUCTION

Cataract and refractive errors are among the com-monest cause of visual morbidity all over the world. 1

Cataract is generally defined as an opacification of theCrystalline lens of the eye. It accounts for nearly half ofall the causes of blindness and is particularly commonin developing countries. 2

In the present state of knowledge, there is noproven means of preventing cataract or halting itsprogression to blindness. The condition is howeveramenable to surgical treatment, which together withthe optical correction of the ensuing refractive deficit,results in the restoration of vision.3, 4 For the last few

decades, extra-capsular cataract extraction (ECCE) withthe implantation of intra-ocular lens (IOL) has becomethe standardized surgical treatment for defective vision,caused by the opacification of human crystalline lens. 5

The principal cause of post-operative astigmatismwas surgically induced corneal distortion. Severalfactors have been identified, mainly involving theincision size, wound healing, suture material and itsremoval all contribute to surgically inducedastigmatism, thus affecting the post operative refractivestatus. 6, 7, 8

Conventional extracapsular cataract extractionwith implantation of intraocular lens is still the mostfrequently performed surgical option in our part of theworld. Due to lack of facilities, expenses of surgery andlong learning curve, phacoemulsification and smallincision cataract surgeries are the emerging forms. Inconventional extracapsular cataract surgeries,astigmatism induced by sutures is the main cause ofdefective vision postoperatively. Site of incision,distances between the sutures all play important rolein inducing astigmatism and hence causing defective

Change in Refractive Status, after Removal of sutures,in conventional Extra-Capsular Cataract Extraction

with IOL Implantation

Shafqat ullah Khan Marwat, FCPS1, Saber Mohammad, FCPS2

Ihsan Ullah, FCPS3 Mohammad Alam FCPS4 , Zaman shah, FCPS5

Prof. Naimat Ullah Khan Kundi6

ABSTRACTObjective: To study the change in refractive status, after removal of sutures, in eyes having undergone conventionalextra-capsular cataract extraction with intra-ocular lens implantation.Material & Methods: This study was conducted in Ophthalmology Department Khyber Teaching Hospital, Peshawarfrom 15th January 2005 to 15th July 2005. This prospective comparative study was performed on 100 eyes of 100 patientswho 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 beforeand 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 in25 eyes. Type of astigmatism pre-operatively was with-the-rule in 12 eyes, against-the-rule in 43 eyes and oblique in 45eyes. 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 in29 eyes, and oblique astigmatism in 54 eyes. Applying T-test to the amount of astigmatism before and after stitchremoval, P-value comes out to be 0.000 < 0.05, showing significant difference between astigmatism before and aftersutures removal.Conclusion: There was a significant change in the refractive status in respect of the amount of astigmatism, afterremoval of sutures in eyes having undergone conventional extra-capsular cataract extraction with intra-ocular lensimplantation.

Dr. Shafqat

Original Article


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 effectsof suture removal two months postoperatively onrefractive status of the eye and thus on overall visualoutcome.MATERIAL AND METHODS:

This study was conducted in OphthalmologyDepartment Khyber teaching Hospital, Peshawar from15th January 2005 to 15th July 2005. This prospectivecomparative study was performed on 100 eyes of 100patients who presented for their cataracts surgeries. Inall patients, Keratometry readings, amount ofastigmatism based on the keratometry readings, un-aided visual acuity and best-corrected visual acuitywere recorded preoperatively and subsequently 2-months after sutures removal.

Follow Up: Follow up period was two months.RESULTS:

Out of 100 patients, 46 were males and 54 werefemales (Figure-I). Out of operated cases, in half (50eyes) of the patients was right eye and half (50 eyes) ofleft eye was operated (Figure-II). Mean age of all thepatients was 58.55 years with a range from 40 years to85 years. 23 patients were between 40 and 50 years, 48patients were between 51 to 60 years, 18 patients werebetween 61 to 70 years, 9 patients between 71 to 80 yearsand 2 patients were more than 80 years of age (Figure-III). All the patients were admitted one day beforesurgery and discharge on first post op day in order tofacilitate the study.

Regarding systemic co-morbidity, 3 patients weresuffering from hypertension, 7 were diabetics, 3 werediabetic as well as hypertensive and one was a knowncase of ischemic heart disease (Figure-IV). All thepatients having any ocular co-morbidity were alreadyexcluded from the study. Pre-operatively, 37 patientshad un-aided visual acuity of hand movement orperception of light while postoperatively after stitchremoval no patient had unaided visual acuity of handmovement or perception of light.

Pre-operatively 48 patients had visual acuitybetween counting fingers to less than 6/60 whilepostoperatively after stitch removal 6 patients hadvisual acuity between counting fingers to less than 6/60. Pre-operatively 12 patients had visual acuitybetween 6/60 and 6/18 while postoperatively afterstitch removal 22 patients had visual acuity between6/60 and 6/18. Pre-operatively 3 patients had visualacuity better than 6/18 while postoperatively afterstitch removal 72 patients had visual acuity better than6/18.

Pre-operatively the best corrected visual acuitywas hand movement / perception of light in 35 patients,while postoperatively after stitch removal no patienthad the best corrected visual acuity of hand movement

or perception of light. Pre-operatively 40 patients hadbest corrected visual acuity between counting fingersto < 6/60, while postoperatively after stitch removal 3patients had best corrected visual acuity betweencounting fingers to < 6/60. Pre-operatively 16 patientshad best corrected visual acuity between 6/60 to 6/18,while postoperatively after stitch removal 13 patientshad the best corrected visual acuity between 6/60 to6/18. Pre-operatively 9 patients had the best correctvisual acuity > 6/18, while postoperative after stitchremoval 84 patients had the best corrected visual acuityof > 6/18.

Before removal of sutures 5 patients had bestcorrected visual acuity of counting finger to less than6/60 while after stitch removal 3 patients had bestcorrected visual acuity of counting fingers to less than6/60.

Before stitch removal 17 patients had best correctvisual acuity of 6/60 to 6/18, while after stitch removal13 patients had best corrected visual acuity of 6/60 to6/18. Before stitch removal 78 patients had bestcorrected visual acuity of more than 6/18, while afterremoval of sutures 84 patients had best corrected visualacuity of more than 6/18.

Post-operatively, after 2 months, before suturesremoval the un-aided visual acuity was HM/ PL in nopatient, CF to < 6/60 in 9 patients, 6/60 to 6/18 in 26patients, and better than 6/18 in 65 patients. Similarly,post-operative best-corrected visual acuity beforesutures removal was HM/ PL in no patients, CF to 6/60 in 5 patients, 6/60 to 6/18 in 17 patients and betterthan 6/18 in 78 patients.

Post-operatively, after sutures removal, the un-aided visual acuity was HM/ PL in no patients, CF to6/60 in 6 patients, 6/60 to 6/18 in 22 patients and betterthan 6/18 in 72 patients. Similarly post-operatively,after removal of sutures, the best-corrected visual acuitywas HM/ PL in no patients, CF to 6/60 in 3 patients,6/60 to 6/18 in 13 patients and better than 6/18 in 84patients. Comparisons of unaided and best correctedvisual acuity are given in (Figers No, V&VI).

Pre-operatively the amount of astigmatism was0.25 to less than 1 D in 39 eyes, 1 D to 2 D in 51 eyes,and more than 2 diopters in 10 eyes.

Two-months postoperatively, before removal ofsutures, the amount of astigmatism was 0.25 to < 1D in14 eyes, 1 to 2 D in 35 eyes, and > 2 D in 51 eyes. Post-operatively, just after removal of sutures, the amountof astigmatism was 0.25 to < 1D in 20 eyes, 1 to 2 D in55 eyes, and > 2 D in 25 eyes. (Table No, I)

Pre-operatively, there was with-the-ruleastigmatism in 12 eyes, against-the-rule astigmatism in43 eyes and oblique astigmatism in 45 eyes. Two-months post-operatively before removal of sutures,



there was with-the-rule astigmatism in 24 eyes, against-the-rule astigmatism in 23 eyes, and obliqueastigmatism in 53 eyes. Just after removal of sutures,there was with-the rule astigmatism in 17 eyes, against-the-rule astigmatism in 29 eyes, and oblique

46

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Figure I: Gender distribution

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Pre-operative UAVA Pre-ROS UAVA Post-ROS UAVA

HM/PL: Hand Movement / Perception of lightCF: Counting fingers

Figure V: Comparison of unaided visual acuities

0

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Pre-operative BCVA Pre-ROS BCVA Post-ROS BCVA

Figure VI: Comparison of best corrected visual acuity

HM/PL: Hand Movement / Perception of lightCF: Counting fingers

Figure III: Age-wise distribution of the patients

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Figure II: Literality of Operated Eyes

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Systemic co-morbidity

Figure IV: Systemic Co-morbidity

IHD = Ischemic heart disease

astigmatism in 54 eyes. (Table No, II). Comparison ofastigmatism are given in (Table No, III).

Applying T-test in SPSS to the amount ofastigmatism before and after stitch removal, the meanvalue was ± 2.36 before stitch removal and ± 1.64 justafter stitch removal (P < 0.001), showing significantdifference between astigmatism before and after suturesremoval. (Table No. IV)


DISCUSSION:In this prospective study, change in refractive

status within thirty minutes after removal of sutures;assessed as change in corneal curvature measured bykeratometry readings were analyzed in 100 patientswho underwent conventional extra-capsular cataractextraction with intra-ocular lens implantation.

Astigmatism was more than 2 diopters in about half ofthe patients (51%) before removal of stitches. Thispercentage came down to 25% just after removal ofstitches. Previously conducted other studies alsosuggest that keratometry done just after suturesremoval is significantly different from that beforeremoval of sutures.

Potamitis and his colleagues studied 34 patientswith high post-operative astigmatism following extra-capsular cataract surgery.9 They suggested that greatestchange occurred within the first five minutes of suturesremoval. The rate of decay then declined so that 15 to

Table-I: Amount of Astigmatism

0.25 - < 1D 1D - 2D > 2D

Pre-operative 39 % 51 % 10 %

Before ROS 14 % 35 % 51 %

After ROS 20 % 55 % 25 %

ROS = Removal of sutures

Table-II: Type of Astigmatism

With the rule Against the rule ObliqueAstigmatism Astigmatism Astigmatism

Pre-operative 12 % 43 % 45 %

Before ROS 24 % 23 % 53 %

After ROS 17 % 29 % 54 %

ROS = Removal of sutures

Table-III: Comparison of astigmatism before and afterSuture removal

n= Total number of patientsAmount of Before Suture After Suture

Astigmatism Removal Removalin diopters n=100 n=100

0.00 – 1.0 20 31

1.1 – 2.0 28 46

2.1 – 3.0 28 15

3.1 – 4.0 16 05

> 4.0 8 03


Table-IV: T-Test

Paired Samples Test

Paired Differences

95% Confidence Intervalof the Difference

Pair 1Astigmatism Before StitchRemoval & Astigmatism AfterStitchRemoval

Mean Std.Deviation

Std. ErrorMean

t df Sig.(2-tailed)Lower Upper

.7260 1.4363 .1436 .4410 1.0110 5.054 99 .000

Paired Samples Statistics

Std. Std. ErrorMean N Deviation Mean

Astigmatism Before 2.3680 100 1.3969 .1397Stitch Removal

Pair 1Astigmatism After 1.6420 100 .9608 9.608E-02Stitch Removal

Paired Samples Correlations

N Correlation Sig.Astigmatism Before Stitch 100 .302 .002

Pair 1 Removal & Astigmatism After After Stitch Removal


30 minutes after removal of sutures the change wasagain significant, but after 30 minutes the astigmatismdecay was insignificant. Although not stable, but it maybe reasonable to offer a temporary spectacles correctionabout 30 minutes after sutures removal, in cases whereearly visual recovery is essential, such as in monocularpatients.

In our study, all the incisions were given at thelimbus as superior approach roughly from 10 to 2 O’clock position. According to one other study, conductedby Wong and his colleagues, the type of post-operativeastigmatism depends upon the site of corneal section.10

They proved that the superior corneal incision causessignificantly less astigmatism than the temporalincisions and that the temporal incision induces amoderate degree of with-the rule astigmatism.

In this study, we applied four limbal sutures with10/0 ethilon in all the cases. All the sutures wereremoved in all cases after a period of two months.Previously in a study by Krishnamachary and Bastifrom LV Prasad Eye Institute Hyderabad India, theefficiency of selective sutures removal and all suturesremoval in controlling corneal astigmatism aftercataract surgery was compared.7311 The pattern of decayof astigmatism after sutures removal was studied usingcomputerized video-keratography. They concludedthat all sutures removal technique was more predictableand less cumbersome than the selective sutures removalmethod.

In our study, 24 % of the eyes had with-the-ruleor against-the-rule astigmatism preoperatively, whichchanged post-operatively from a horizontal to anoblique axis. Previously a study conducted by Luntzand Livingston showed that in forty percent of the eyesthe axis of the cylinder changed from a horizontal toan oblique axis but did not change from a with- toagainst- the-rule axis.12 In our study we removed thesutures two months post-operatively. Previously astudy conducted by Stanford and his colleagues fromDepartment of Ophthalmology, King’s College HospitalLondon showed that after uncomplicated extra-capsular cataract extraction with a corneal section and10/0 Nylon sutures; patients with more than 3 dioptersof cylinders were allocated to have their suturesremoved at 6, 9, or 12 weeks post-operatively.13 Visualand optical outcome were assessed after one week after

sutures removal and at 6 months post-operatively.Although the time of removal did not affect the changein cylinderical power, the subsequent refraction wasmore stable when the sutures were removed at 12weeks. CONCLUSION:

There was a significant change in the refractivestatus in respect of the amount of astigmatism, afterremoval of sutures in eyes undergone conventionalextra-capsular cataract extraction with intra-ocular lensimplantation.REFERENCES1. Jahangir S, Kadri WM. Extra-capsular cataract extraction with

intra-ocular lens implantation in Pakistan. Pak J Ophthalmol1999; 4:80-2.

2. Churchill JA, Hillman JS. Post-operative astigmatism controlby selective suture removal. Eye. 1996; 10:103-6.

3. Spencer MF. Extra-capsular cataract and lens implant surgeryin developing countries: keeping it simple. Ophthalmic Surg1990; 21:447-52.

4. Muralikrishnan R, Venkatesh R, Manohar B, Venkatesh P. Acomparison of the effectiveness and cost-effectiveness of threedifferent methods of cataract extraction in relation to themagnitude of post-operative astigmatism. AsiaPacific JOphthalmol 2003; 15:5-12.

5. Kumar A. Small incision extracapsular cataract extraction(Dissertation). Karachi: College of Physicians and SurgeonsPakistan 1999:44-5.

6. Afzal M, Hamid K. Comparison of Pre and PostoperativeAstigmatism: Review of 120 cases of Phacoemulsification.Pakistan J Ophthalmol 1999; 15:69-71.

7. Butt NH, Naeemullah, Riaz MA. Cataract backlog in Pakistanand possible control measures. Pakistan J Ophthalmol 1999;15:149-51.

8. Anwar MS. Changes in surgically induced Astigmatism overa period of time after Extracapsular Cataract Extraction.Pakistan J Ophthalmol 1999; 15:102-4.

9. Potamitis T, Fouladi M, Eperjese F, McDonnel PJ.Astigmatism decay immediately following suture removal.Eye 1997; 11: 84-6.

10. Wong HC, Davis G, Della N. Corneal astigmatism inducedby superior versus temporal corneal incisions forextracapsular cataract extraction. Aust N Z J Ophthalmol.1994; 22:237-41.

11. Krishnamachary M, Basti S. Computerized topography ofselective versus all-suture release to manage highastigmatism after cataract surgery. J Cataract Refract Surg.1997; 23:1380-3.

12. Stanford MR, Fenech T, Hunter PA. Timing of removal ofsutures in control of post-operative astigmatism. Eye 1993; 7(Pt 1): 143-7.

13. Mafra CH, Dave AS, Pilai CT, Klyce SD, Wilson SE.Prospective study of corneal topographic changes producedby extracapsular cataract surgery. Cornea 1996; 15: 196-203.



–––––––––––––––––––––––––––––––––––––––––––––––––––––––1Registrar Eye A ward, Department of Ophthalmology, KhyberTeaching Hospital, Peshawar. 2Associate Professor Eye A Ward,Khyber Teaching Hospital, Peshawar, 3Assistant Professor, KhalifaGul Nawaz Hospital, Bannu, 4Senior Registrar Department ofOphthalmology Hayatabad Medical Complex, Peshawar, 5-6MedicalOfficer, Department of Ophthalmology, Hayatabad Medical Complex,Peshawar.–––––––––––––––––––––––––––––––––––––––––––––––––––––––Correspondence: Dr. Saber Mohammad, Flat No, 13 New. DoctorColony Khyber Teaching Hospital, PeshawarEmail> [email protected] Tel No. 0346-9155303–––––––––––––––––––––––––––––––––––––––––––––––––––––––Received: October’2011 Accepted Feb’2012–––––––––––––––––––––––––––––––––––––––––––––––––––––––

Trabeculectomy with Mitomycin-C in Patients ofPrimary Open Angle Glaucoma

Saber Mohammad FCPS1, Sadia Sethi FCPS2, Sanaullah Khan FCPS3

Muhammad Naeem Khan FCPS4, Samina Karim FCPS5

Zaman Shah FCPS6

ABSTRACTObjectives: To study the results of intra ocular pressure control following primary Trabeculectomy with Mitomycin-c inpatients 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 meanage of the patients was 54 years with standard deviations of 12.90.There were 12 male and 18 female in our study. Thesuccess rate of surgery in term of intraocular pressure control of 20 mmHg or less without medication in primaryTrabeculectomy 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.

Original Article

Dr. SaberMohammad

INTRODUCTIONPrimary open angle glaucoma (POAG) is the most

prevalent type of glaucoma, affecting approximately1% of the general population over the age of 40 years.3

Glaucoma is considered as the second leading cause ofblindness after cataract1 and fourth commonest causeof blindness in Pakistan.2

Trabeculectomy is the standard surgicalprocedure of choice if the medical therapy fails. Itlowers the intraocular pressure by creating a fistula,which allows aqueous outflow from the anteriorchamber to the subtenon space.3 It is successfulbetween 86% and 90% of the cases of primary openangle glaucoma.4

Antiproliferative agents such as Mitomycin-c(MMC) and 5-fluorourcil (5-FU) have markedlyimproved the success rate of glaucoma filtering surgeryand are widely used to treat glaucomatous eye with apoor surgical prognosis.5

The success rate of Mitomycin-c is 85%.6 The use

of this agent results in better control of postoperativeintra ocular pressure with less antiglaucomamedication.5 Mitomycin-c is a naturally occurringantibiotic-antineoplastic compound that is derived fromStreptomyces ceaspitosus. It acts as a alkylating agentafter enzyme activation resulting in DNA cross linkingand is a strong antifibrotic agent.7 The concentration incurrent usage is typically 0.2mg/ml with duration ofapplication for 3 minutes.8 5-fluorouracil (5-FU) inhibitfibroblast proliferation and has proven useful inreducing scarring after filtration surgery.6 Mitomycin-c is more effective than 5-fluorouracil in improving thesuccess rate of IOP control with trabeculectomy.9

Trabeculectomy is not free of postoperativecomplications but if managed properly, visual acuityin majority of cases is shown to be good.10Thecomplication of trabeculectomy with antimetabolite areavascular cystic bleb, persistant wound leakage,shallow anterior chamber, possibility of hypotony,endophthalmitis, superficial punctate keratopathy,corneal epithelial defect, choroidal detachment andmaculopathy.11

MATERIAL AND METHODSThis study was conducted at the KIOMS, HMC,

Peshawar, on 30 patients who underwent augmentedglaucoma filtration surgery for POAG from 07th

October, 2005 to 6th October, 2006. Only patients havingprimary open angle glaucoma were included in thestudy. Patients who had history of previous surgerylike cataract extraction and Trabeculectomy were notincluded in this study.

A total of 30 patients, 12 were male and 18 were


female were selected for the study. All the patients hadsymptoms of POAG with elevated IOP, enlargementof the optic nerve head and visual field defects. Themean age was 54 Years, most of the patients being above40 years of age.

Gonioscopy were performed in every case withGoldmann three mirrors and IOP were measured byGoldmann tonometer. Visual field examination wasdone preoperatively for every case.

Operative Procedure: A fornics based conjunctivalflap was made by cutting conjunctiva along withTenon’s capsule about 2.0mm from the limbus with thehelp of scissors. The conjunctiva and Tenon’s capsulewere separated from the episcleral tissue through bluntdissection about 8-10mm from the limbus. Bleedingpoints were cauterized with wet field bipolar cauteryupto this point.Mitomycin-C was applied on the scleralbed in a dose of 0.2mg/ml for 2 minutes. The spongewas removed and the area was thoroughly rinsed withbalanced salt solution. A limbal based scleral flap about3×4 mm two-thirds of scleral thickness was dissectedupto the clear cornea. Paracentesis was performedthrough superotemporal clear corneal incision. Anteriorchamber was entered and a block of scleral tissues about1×2mm was excised and peripheral iridectomy wasperformed. A scleral flap was secured by applying twostitches of 8/0 vicryl at the two corners of the flap.Conjunctival flap was sutured by the same 8/0 vicrylby applying continuous stitches, making sure that thewound was water tight. Anterior chamber and bleb wasformed with balance salt solution through Paracentasisport.

Data Collection Procedure: The procedure doneunder local anesthesia. Thirty patients underwentstandard trabeculectomy with Mitomycin-C asMitomycin-C applied on the scleral bed and undersurface of the conjunctiva before making an openinginto anterior chamber. The contact time of Mitomycin-C was 2 minutes and the dose was 0.2 mg / ml.4Allsurgeries done by single consultant. The procedure wasdefined as successful if the intraocular pressure wasbelow 20mmHg without any antiglaucoma medicationin our study and follow up period were 3 months.RESULTS

The results of trabeculectomy with Mitomycin-Cwere studied in term of lowering of IOP in POAG. In30 patients, 11 were male and 19 were female shown inFigure No, 1.Mean age of the patients were 54 yearswith standard.deviaton of ±12.90 given in Table No,1.The preoperative IOP was given in figure No: 2. Thesuccess rate of surgery in intraocular pressure controlof 20 mmHg or less without medication in primarytrabeculectomy with MM-C was 94% which is given infigure No: 3. The incidence of complications is given in

figure No: 4. Patients using post op antiglaucomamedication are given in Figure No.5. The visual acuityreturned to the normal within one month after surgery.The higher incidence of complications was due to higherincidence of flat anterior chamber. The flat anteriorchamber was treated by double padding to which theresponse was seen in 24 to 48 hours. There were 2 casesin which the pressure remained above 20mmHg mark.They were given the option of using antiglaucomamedication initially up to the follow up period but lateron they refused the option of repeat surgery.

Table 1: Age of the patients

Number of patients 30

Mean 53.48

Median 53

Mode 30

Std.Deviation 12.90

Range 25-85

GENDER

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Fig: 2. Pre op IOP (mmHg)

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Trabeculectomy with Mitomycin-C in Patients of Primary Open Angle Glaucoma


POST OP IOP mmHg

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Fig: 3. Post- op IOP (mmhg)

Fig: 4. Post Operative Complications

POST OP COMPLICATIONS

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Fig: 5. Post op drugs

DISCUSSIONGlaucoma is a progressive optic neuropathy with

characteristic changes in the optic nerve head andcorresponding loss of visual field. It is considered asthe second leading cause of blindness after cataractworldwide1 and fourth commonest cause of blindnessin Pakistan.2 Amongst the glaucomas, primary openangle glaucoma (POAG) is the most prevalent type ofglaucoma, affecting approximately 1% of the general

population over the age of 40 years.3

In this study, we selected uncomplicated cases ofprimary open angle glaucoma with achievement oftarget pressure of 20 or less without medication in93.3%.The numbers of patients included in this studywere 30 with primary open angle glaucoma, which isconsistent with other studies carried out abroad. O’Brartet al conducted a study which included 50 eyes of 45and 48 patients’ respectively12, 13 and they includedpatients suffering from open angle glaucoma and theycompared trabeculectomy with MMC andviscocanalostomy respectively. Beatty et al conducteda study comprising of 69 high risk patients whoseglaucoma were not controlled medically.14 Work doneby Hye included 9 patients with POAG including youngpatients ranging in age from 24 years to 50 years.15

Adeqbehinqbe conducted a study, which consisted of53 primary open angle glaucoma patients.16 Study doneby Babar TF included 81 patients of POAG and all theseabove studies consistent with our study.10

In our study, 16 (53.3%) patients were usingglaucoma medications respectively, while 14 (46.7%)patients were not using medicines. This observation inour study is in sharp contrast to the study carried outby Casson et al and Hye in which all patients were usingglaucoma medications.17, 15 Our study is alsoinconsistent with that one conducted by Dandona etal, in which only 2 patients out of 27 with POAG wereusing glaucoma medications.18 Our study is consistentwith Edmunds et al in which 50% patients were onglaucoma treatment.19 While Adeqbehinqbe notedsuccess of glaucoma drugs in lowering IOP in 13%patients.16 In this study, 16 patients each had apreoperative IOP of 20 mm Hg or less with glaucomamedications and 14 patients had preoperative IOP of20 mm Hg Or less without glaucoma medications.

In study carried out by Dandona et al, 66.7%patients had an IOP less than 22 mm Hg and 33.3%had an IOP of more than 22 mm Hg.18 Edmund et alshowed that POAG patients had a mean IOP of 29.5mm Hg at diagnosis and 26.5 mm Hg at the time oflisting for surgery.19 Mean preoperative IOP recordedby Hye was 26.43 mmHg.15 Mean preoperative IOPrecorded by Adeqbehinqbe et al was 35.5 mm Hg ? 6.2mmHg.16In our study, operative complications includedshallow A/C in 30% patients, hyphema in 13.33%,cataract in 16.66%, flat bleb in 3.33% and failed trab in3.33%. There were no complications in 33.33% patients.Hye noted conjunctival wound gap, shallow A/C,choroidal detachment, cataract formation, hypotonymaculopathy, hyphema in 6.66% of cases. Casson et alnoted that 10% patients required another surgery in thefirst year, hypotony maculopathy in 5% and cataract in35%.17 There was blebitis / endophthalmitis at 4 years



in 4% and hypotony maculopathy in 4% in study doneby Betty et al.14 O’Brat et al noted hypotony in 52% casesat one week and 8% needed another trabeculectomy.13

Hyphema was the main complication in 15.3%patients.16

Post operative IOP in our case series was 20mmHg or less in 93.3% patients without medication and20mm Hg or less in 6.66% patients with medication.Postoperative IOP in Betty series was 16.63mm Hg. Hyenoted an average postoperative reduction in IOP of14.04 mm Hg. His mean postoperative IOP was 13.3mmHg.15 O’Brat et al noted a mean IOP was 7.3mm Hg at1st post operative day, 8.3mm Hg at one week.12 Inanother study they noted a mean IOP of 7mm Hg and7.88mmHg at one week.13 Mean post operative IOPrecorded by Adeqbehinqbe et al was 10.6mm Hg ? 2.3mmHg.16 Mean preoperative IOP at 3 months was14.6mmHg ? 4.2 mm Hg.16 All these studies wereconsistent with our study. In our study, 6.66% operatedpatients required glaucoma medications. Betty et alreported that 11.1% patients required topicalantiglaucoma medications postoperatively.14 None ofthe patients operated by Adeqbehinqe et al requiredpostoperative medication.16 Karger and Basel reportedin their study that the target pressure was achieved in73% with MM-C and 68% with out MM-C20. It showedthat our results were satisfactory. S. Beatty et al reportedin their study that the success rate of achieving targetIOP was 83.3% in MM-C group.14 Babar TF reported intheir study that the target pressure of 21mmHg wasachieved in 91.3 %. 10 This study is also consistent withour study. Mandal et al reported a success rate of 94.7%with trabeculectomy supplemented with antimetabo-lites in older children.21 So in comparison with otherstudies our results for augmented trabeculectomiesregarding intraocular pressure control in POAG weresatisfactory.CONCLUSION:

Trabeculectomy with intraoperative use ofMitomycin-C gives better control of IOP becauseMitomycin C (MMC) is an antimetabolite used duringthe initial stages of a trabeculectomy to preventexcessive postoperative scarring and thus reduce therisk of failure.REFERENCES1. Khan MD, Qureshi MB, Khan MA. Facts about the status of

blindness in Pakistan.Pak J ophthalmology 1999; 15:15-9.2. Babar TF, Saeed N, Masud Z, Khan MD. Two years audit of

Glaucoma admitted patients in Hayatabad MedicalComplex, Peshawar. Pak J ophthalmol 2003; 19:32-9.

3. Kanski JJ, Menon J.Glaucoma.in: Clinical Ophthalmology:A systemic approach.5th ed. London: Butterworth Heinemann

2003; 192-269.4. Beatty S, Potamitis T, Kheterpal S.Trabeculectomy

augmented with Mitomycin-C application under the scleralflap. Br J ophthalmol 1999; 82:397-403.

5. Mochizuki K, Jikihara S, Ando Y. Incidence of delayed onsetinfection after trabeculectomy with adjunctive Mitomycin-cor 5-flurouracil treatment. Br J ophthalmol 1997; 81:877-83.

6. Talya H, Kupin MD, Mark S. Adjunctive Mitomycin-C inprimary trabeculectomy in phakic eyes. Am J of ophthalmol1995; 119:30-9.

7. American Academy of Ophthalmology. Basic and clinicalScience Course. Section 10, Glaucoma. American Academyof Ophthalmology; 2001-2002; 147-74.

8. Sirivardina D, Edmunds B. National Survey of antimetaboliteuse in glaucoma surgery in the United Kingdom. Br JOphthalmol 2004; 88:873-6.

9. Munden PM, Alward WLM. Combined Phacoemulsification,posterior chamber intraocular lens implantation andtrabeculectomy with Mitomycin-C. Am J Ophthalmol 1995;119:20-9.

10. Babar TF.An audit of 81 cases of Trabeculectomy in primaryopen angle glaucoma in NWFP. Pak J Ophthalmol 2001:17:27-31.

11. Paul M, Munden, MD. Combined phacoemulsification,posterior chamber intraocular lens implantation andtrabeculectomy with Mitomycin-c. Am J of Ophthalmol 1995;119(10):20-9.

12. O’Brart DPS, Rowlands E, Islam N, Noury AMS. Arandomized, prospective study comparing trabeculectomyaugmented with antimetabolites with a viscocanalostomytechnique for the management of open angle glaucomauncontrolled by medical therapy. Br J Ophthalmol 2002;86:748-54.

13. O’Brart DPS, Shiew M, Edmunds B. A randomized,prospective study comparing trabeculectomy withviscocanalostomy with adjunctive antimetabolites for themanagement of open angle glaucoma uncontrolled bymedical therapy. Br J Ophthalmol 2004; 88:1012-7.

14. S. Beatty, Potamitis T, Kheter pal S, O’Neill ECO.Trabeculectomy augmented with Mitomycin C applicationunder the scleral flap. Br J Ophthalmol 1998; 82:397-403.

15. Hye A. Primary trabeculectomy with topical Mitomycin –Cin primary glaucoma. Pak J Ophthalmol 2000; 16:124–30.

16. Adeqbehinqbe, Majemqbasan T. A review oftrabeculectomieas at a Nigerian teaching hospital. GhanaMed J 2007; 41:176-80.

17. Casson R, Rahman R, Salmon JF. Long term results andcomplications of trabeculectomy augmented with low doseMitomycin C in patients at risk for filtration failure. Br JOphthalmol 2001; 85:686-8.

18. Dandona L, Dandona R, Srinivas M, Mandal P, John RK,McCarty CA, et al. Open angle glaucoma in an urbanpopulation in Southern India. Ophthalmology 2000;107:1702-9.

19. Edmunds B, Thompson JR, Salmon JF, Wormald RP,Edmunds B. The National Survey of trabeculectomy. 1.Sample and methods. Eye 1999; 13:524-30.

20. Karger, Basel et al. Outcome of trabeculectomy with MMCversus without MMC. Ophthalmologica 2003; 217:24-30.

21. Mandal AK, Waltan DS, John T, et al. Mitomycin C-augmented trabeculectomy in refractory congenitalglaucoma. Ophthalmology 1997; 104:996-100.



–––––––––––––––––––––––––––––––––––––––––––––––––––––––1Associate Professor Ophthalmology, Department, HayatabadMedical Complex Peshawar. 2Registrar Ophthalmology Department, Hayatabad MedicalComplex, Peshawar. 3Medical Officer4.Professor of Ophthalmology, Kabir Medical College, GandharaMedical University, Peshawar–––––––––––––––––––––––––––––––––––––––––––––––––––––––Correspondence: Dr. Sofia Iqbal, House no 86, street no 6, sectorG-2, Phase 2, Hayatabad,Peshawar E.Mail>sofiaiqbal71@ yahoo.com 03339254264–––––––––––––––––––––––––––––––––––––––––––––––––––––––Received: Oct’2011 Accepted: Jan’2012–––––––––––––––––––––––––––––––––––––––––––––––––––––––

Concussional Injuries of the Eye

Sofia Iqbal MRCOphth (Lond), FRCS1, Mushtaq Ahmad FCPS,2 Naz Jehangir3

Prof. Zafar ul Islam FCPS4

ABSTRACTPurpose: The aim of the study was to determine the incidence of concussional eye injuries presenting to HayatabadMedical 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 thedepartment of ophthalmology Hayatabad Medical Complex Peshawar. Six hundred and thirty five patients presented withocular 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%) hadconcussional injuries. Males female ratio was 8:1. Children under 15 years of age were most commonly involved especiallyduring 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 beused to create public awareness and education.

Dr. Sofia

Original Article

INTRODUCTIONInjury to the eye is one of the most common cause

of ophthalmic morbidity and monocular blindness inthe whole world 1. Ocular trauma has always been andwill be a challenge to the Ophthalmologists. In thisviolent and sophisticated age of communication,increased industrialization, heightened interest insports activity and urban guerrillas, both the numberand severity of these injuries are increasing.2,3, 4. Eyeinjuries have a significant impact not only in terms ofsuffering and medical costs but also in terms of lostproductivity.5 Eye is vulnerable to any type of traumain spite of the fact that it is protected anatomically bybeing placed in a cavity with its overhang bonyprojections, and physiologically by blink reflex andcopious lacrimation.6 Eyes are injured in 10% of all bodyinjuries which is a disproportionately high percentage,keeping in mind that the front surface of the eyeconstitutes about 0.27% of the body surface7.Theincidence of blindness resulting from trauma has aworldwide variation8.In developing countries theproblem of eye trauma is much more severe because of

lack of awareness, poverty and paucity for eye care andtraveling long distances to obtain appropriatetreatment9.

Mechanical injuries to the eye are mainly of twotypes10, concussions and contusions caused by bluntobjects and perforating injuries with or without retainedforeign bodies caused by sharp objects. The blunttrauma can be divided into three types in terms ofseverity10.Concussions are due to moderate blunttrauma to the eye, and causes changes that are barelyvisible to the eye, and are reversible, Contusions areproduced by severe blunt trauma presenting with tissuedamage without disruption of surface layers of the eye.In laceration the tissue integrity is completely lost andthere is disruption of the surface layers of the eye. Inthis study we have studied the blunt injuries causingconcussion and contusion and have excluded bluntinjuries with disruption of the eye ball.MATERIAL AND METHODS:

A total of 635 patients who sustained injuries tothe eye were admitted to the eye unit of HayatabadMedical Complex, Peshawar during a period of 24months from 1st January 2009 to 31st December 2010.Out of these 90 patients (14.17%) had concussionalinjuries to the eye. At the time of admission detailhistory of the patient including date, time and locationof accident, whether the injury occurred at work, duringplay or some other activity. A detail description of theobject, distance traveled to the eye and direction wasnoted. A special check into pre-existing diseases of theeye was also made.

The examination of the injured eye included visualacuity measurement using Snellen’s chart, intraocular


pressure measurement using Goldmann tononmeter,Slit lamp biomicroscopy, Direct and Indirectophthalmoscopy, examination under anesthesia (whenneeded), x-rays of the orbit, CT Scan orbit andophthalmic ultrasound. A quantitative grading systemfor the amount of blood in the anterior chamber wasdevised as reported by Kennedy and Brubaker11.

Patients were keenly observed during their stay in thehospital including daily visual acuity measurement,intraocular pressure measurement and slit lampbiomicroscopy.

The treatment regimen included bed rest,analgesia and sedation as required, patching of theinvolved eye, local antibiotics, local steroids,cycloplegics and intraocular pressure lowering drugsas and when required. Traumatic cataract was removedby lens matter aspiration and phacoemulsification.Secondary hyphemas aspirated when the eyes wereendangered by raised intraocular pressure and cornealstaining. 65 patients came for follow up examinationand a complete examination including gonioscopy wasperformed.RESULTS:

A total of 90 cases of Concussional eye injury werestudied, representing 14.17% of all ocular injuries (total635) in 24 months duration. Males were affected morethan females, and male to female ratio was 8:1.Childrenwere most frequently affected (Table 1). The incidencein age group 0-15 was 58.88%. However the ratio ofchildren, affected in ocular trauma as a whole, wascomparatively less, and this was because of higherincidence of perforating and penetrating injuries inadults which is not included in this study. The righteye was affected slightly more often (54.44%) than theleft eye. One eye of each patient was affected.

The most common cause of injury to the eye wassports and play (Table 2).There were 55 patients(61.11%) in this group. Out of 55 patients, 51 were under15 years of age. The second major group fell into thecategory of fight and assault (14.45%). Injuries duringoccupational activities and road traffic accidentsaccounted for 10% and 5.58% of total injuriesrespectively. Domestic and firearm injuries fell into thelast group, each accounting for 3.33% of all theconcussional injuries to the eye.

43 (47.77%) eyes showed damage to the cornea(Table 3). Corneal edema was seen in 35 (38.88%)patients. Folds in the Descemet’ membrane in 21(23.33%) patients. All were associated with cornealedema. Corneal abrasions were present in 11(12.22%)cases. In one case there was corneal edema with tearsin the Descemet’ membrane.

Hyphema which occurred in 63 (70%) patients,was the commonest mode of presentation. Regarding

age and gender traumatic hyphema was highest amongchildren and young adults, and males were at greaterrisk than females (Table 4) A quantitative gradingsystem for the amount of blood in the anterior chamberwas devised as reported by Kennedy and Brubaker.(Table 5).Highest number of patients (42.86%)presented with grade 5 hyphema. grade 1 and grade 3hyphema each was seen in 7 (11.11%) patients. grade 2in 19 (30.16%) cases. grade 4 hyphema was observed in3 (4.76%) cases.

Corneal staining occurred in 4 (6.35%) patients.All had grade 5 hyphema with raised intraocularpressure. Gonioscopy was routinely performed onfollow up examination. 65 patients came for follow upand gonioscopy was performed on 58 patients. 12 eyes(31.60%) showed recession of angle. All the cases wereassociated with hyphema. 62 (68.88%) eyes had iris orpupillary abnormalities. Traumatic mydriasis was themost common presentation and was seen in 54 (60%)patients. Traumatic iritis in 2(2.22%) cases and posteriorsynechiae in 3 (3.33%) patients. Spastic miosis wasobserved in 3 (3.33%) cases.

Out of the 90 patients 17(18.89%) developedtraumatic cataract. Ten eyes had total opacification, fiveeyes had rosette located in the posterior cortex and twoeyes had posterior sub-capsular cataract. 17(18.89%)eyes had subluxation of the lens, while dislocation wasnot observed in any case in our study. A total of34(37.78%) cases developed vitreous haemorrhage. In19 eyes the vitreous haemorrhage was associated withtotal hyphema. Retinal and macular damage occurredin 35 (38.89%) eyes. 24(26.66%) had commotio retinae.Out of these 13 had mild retinal edema with no otherchanges in the retina. The remaining eleven eyes hadother changes including macular edema (3 eyes), retinalor macular hemorrhages (3 eyes), retinal tear (2 eyes)and pre-retinal haemorrhages (3 eyes). Among the restof eleven patients (12.22%) the following changes wereobserved. 5 patients had extensive chorio-retinal tearswith massive vitreal hemorrhages (chorioretinitissclopeteria), four patients had retinal detachment, onepatient had retinal dialysis, which was infero-temporaland was associated with shallow Retinal detachment.One patient presented with optic nerve avulsion.

Table 1: Age and gender distribution

Age Male Female Total Percentage (%)

0-15 46 7 53 58.89

16-30 25 1 26 28.89

> 30 9 2 11 12.22

total 80 10 90 100.00



Table 3: Concussion effects on the cornea

No of patients %age

Corneal edema 35 38.88

Descemet’folds 21 23.33

Corneal abrasion 11 12.22

Corneal staining 4 4.44

Tears in descemt’membrane 1 1.11

Table 2: Etiology of injury with regards to age and gender

Causes 0-15 years 16-30years Over 30 years Total %ageMale Female Male Female Male Female

Sports 43 8 2 1 1 - 55 61.11

Catapult 12 4 _ _ _ _

Stone 13 1 _ _ _ _

Stick 5 1 1 1 _ _

Airgun 4 1 _ _ 1 _

Toypistol 3 1 _ _ _ _

Golidanda 3 _ _ _ _ _

Mudball 2 _ _ _ _ _

Cricket ball 1 _ 1 _ _ _

Fight/assault 1 _ 8 _ 4 _ 13 14.45

Occupational _ _ 6 _ 3 _ 9 10.00

Road traffic accidents 1 _ 2 _ 2 _ 5 5.56

Domestic - _ 2 1 _ _ 3 3.33

Fire arm injury _ _ 3 _ _ _ 3 3.33

Bullet _ _ 1 _ _ _ _

Gunshot _ _ 1 _ _ _ _

Bomb blast _ _ 1 _ _ _ _

Miscellaneous _ _ 1 _ 1 _ 2 2.22

Total 90 100.0

Table 4: Hyphema: Age and gender distribution

Age (years) Male Female Total %age

0-15 33 6 39 61.91

16-30 18 _ 18 28.57

More than 30 4 2 6 9.52

Total 55 8 63 100.00

Table: 5. Extent of Hyphema at presentation

Extent of hyphema No of patients %age

Grade 1 Microscopic 7 11.11

Grade 2 Microscopic to 1/3 19 30.16

Grade 3 1/3 to 1/2 7 11.11

Grade 4 1/2 to > total 3 4.76

Grade 5 Total 27 42.88

Overall 63 100.00

DISCUSSION:Ocular trauma is the most frequent cause of

monocular blindness1. It occurs most frequently in theactive years of life and is associated with economiclosses, pain and psychological upsets which may besevere and persistent. A total of 90 cases of concussionaleye injuries were studied representing 14.17% of allocular injuries (total 635) in 24 months duration. The



incidence of concussional eye injuries was much higherin a study reported from Nigeria (37.4%)12, while theincidence was only 1.56% in a study conducted inUSA13.The reason for this decrease incidence is due toseat belt legislation and other preventive measures inthe developed countries.

Children were most frequently affected. Theincidence in age group 0-15 years was 58.88%. Thishigher incidence is mainly because of children beingengaged in aggressive games and lack of awareness andsupervision of parents in low and middle class families.Similar situation has been observed in a study fromIndia14. The right eye was affected slightly more often(54.44%) than the left eye. Similar right eyepreponderance was reported in a study from USA15.Male to female ratio was 8:1, such statistics have beenreported by other studies12&16.This may be due to thefact that young boys are more actively involved insports.

In our study the most common cause of injury tothe eye was sports and play (55 patients, 61.11%). Thiscorrelates with a studies from India and Australia.17&18

The second major group fell into the category offight and assault (14.45%). The reason for this incidencemay be due to the aggressive nature of a particular tribalculture and the cross border terrorism .This figurecoincides with a study from USA, where 14.3% of eyeinjuries were inflicted during fight and assault13.

Injuries during occupational activities and roadtraffic accidents accounted for 10% and 5.56% of totalinjuries respectively. These figures are relatively lessthan what might be, keeping in mind that this studyincludes only non-perforating injuries while most of theinjuries occurring during road traffic accidents areassociated with perforation. In developing countrieslike Pakistan, the industrial accidents are mostly dueto poor working conditions with minimal safetymeasures. Long working hours and little leisure timealso increase accidents due to fatigue. Domestic andfirearm injuries fell in the last group, each accountingfor 3.33% of the concussional eye injuries.

Hyphema which occurred in 63 patients (70%)was the commonest mode of presentation. This wassimilar to studies from Nigeria and Ireland12&19.Traumatic hyphema was most commonly observed inchildren and young adults and males were at a greaterrisk. Similar findings were noted in a number of otherstudies12&20. 27 patients (42.86%) presented with totalhyphema. Similar higher ratios were observed bystudies by Pizzarello and Witteman 21&22. This higherincidence can be explained by the fact that most of thepatients having lesser degree of hyphema do not seekmedical advice. Gonioscopy was performed in 58patients. Twelve eyes (31.60%) showed angle recession.

The incidence of angle recession matches closely withthat found by Kennedy and Brubaker11 who found28.6% incidence of angle recession in a series of 248eyes.

62 eyes 68.88 had iris or pupillary abnormalities.Traumatic mydriasis was observed in 54(60%) patients.This figure is very similar to a study from Ireland19andis higher than a study conducted in Nigeria12. Out ofthe 90 patients, 17 eyes (18.89%) developed traumaticcataract. The incidence of traumatic cataract in the blunttrauma to the eye may range from 2.7% to 37% 12,14 &23.Seventeen eyes (18.89 %) had subluxation of lens. Thiscorrelates well with a study from Belfast19, while inanother study there was not a single case ofsubluxation24.CONCLUSION

Concussional injuries form a significant part ofocular trauma. Children are at high risk and sports isthe most common incriminating factor. Preventivemeasures must form the corner stone of managementregardless of the cause. Prevention of ocular traumapose a great challenge and justifies our priorityattention.REFERENCES1. Wong T, Klein B, Klein R. The Prevalence and 5-year

incidence of Ocular trauma –The Beaver Dam Eye Study.Ophthalmology.2000; 107: 2196-2202.

2. Chen G, Sinclair SA, Smith GA, Ranbom L, Xiang H:Hospitalized ocular injuries among persons with lowsocioeconomic status: a medical enrollees-basedstudy.Ophthalmic Epidemiol 2006, 13:199-207

3. Kuhn F, Maisiak R, Mann L, Mester V, Morris R, WitherspoonCD:The ocular trauma score (OTS). Ophthalmol Clin N Am2002, 15:163-165.

4. Kuhn F, Maisiak R, Mann L, Mester V, Morris R, WitherspoonCD: The Birmingham Eye Trauma Terminology system(BETT)J Fr Ophthalmol 2004, 27:206-210

5. Bhogal G, Tomlins PJ, Murray PI: Penetrating ocular injuriesin the Home. J Public Health (Oxf) 2007, 29:72-74.

6. Mela EK, Dvorak GJ, Mantzouranis GA, Giakoumis AP,Blatsios G, Andrikopoulos GK, Gartaganis SP:Ocular traumain a Greek population: review of 899 cases resulting inhospitalization.Ophthalmic Epidemiol 2005, 12:185-190.

7. Tomazzoli L, Renzi G, Mansoldo C: Eye injuries in childhood:a retrospective

8. investigationof 88 cases from 1988 to 2000.Eur J Ophthalmol2003, 13:710-713.

8. Bianco M, Vaiano AS, Colella F, Coccimiglio F, Moscetti M,Palmieri V, Focosi F, Zeppilli P, Vinger PF: Ocularcomplications of boxing Br J Sports Med 2005, 39: 70-74.

9. Mieler W: Overview of ocular trauma. In Principles andPractice of Ophthalmolgy. 2nd edition. Edited by Albert D,Jakobiec F, Philedelphia, WB Saunders Co; 2001:5179.

10. Smith ARE, O’Hagan SB, Gole GA: Epidemiology of open-and closed-globe trauma presenting to Cairns Base Hospital,Queensland. Clin Experiment Ophthalmol 2006, 34:252.

11. Kennedy RH, Brubaker RF: Traumatic hyphema in a definedpopulation Am J Ophthalmol 1988; 106; 123-30.

12. Onyekonwu GC, Chuka-Okosat CM. Pattern and visualoutcome of eye injuries in children at Abakaliki, Nigeria.WestAfr J Med. 2008 Jul; (3):152-4.



13. May DR, Kuhn FP, Morris RE, Witherspoon CD, Danis RP,Mathews GP, Mann L. The epidemiology of serious eyeinjuries from the United States Eye Injury Registry. GraefesArch Clin Exp Ophthalmol. 2000 Feb; 238(2):153-7.

14. Nirmalan PK, Katz J, Tielsch JM, Robin AL, Thulasiraj RD,Krishnadas R, Ramakrishan R; Arvind. Ocular trauma ina rural south Indian population: Comprehensive eye survey.Ophthalmology.2004 Sep;111(9):1778-81.

15. Baker RS, Wilson MR, Flowers CW, Lee DA, Wheeler NC,Demograhic factors in a population based survey ofhospitalized work-related, ocular injury.Am.J Ophthol1996;122:2139.

16. Karlson TA, Klein BEK. The incidence of acute hospital-treated eye injuries. Arch Ophthalmol 1986;106:785-9.

17. Krishnaiah S, Nirmalan PK, Shamanna BR, Srinivas M, RaoGN, Thomas R. Ocular trauma in a rural population ofsouthern India: the Andhra Pradesh eye disease study.Ophthalmology.2006 Jul; 113(7):1159-64.

18. Mc Carty CA, Fu CL, Taylor HR. Epidemiology of oculartrauma in Australia. Ophthalmology. 1999 Sep; 106(9):1847-52.

19. Saeed A, Khan I, Duanne O, Stack J, Beatly S.Ocular injuryrequiring hospitalization in the south east of Ireland: 2001-2007. Injury.2010 Jan; 41(1):86-91.

20. Khan MD, Kundi N, Mohammed Z, Nazeer AF: Eye injuriesin North West Frontier province of Pakistan. Pak JOphthalmol, 1988;4:5-9.

21. Pizzarello LD. Ophthalmic Epidemiol. 1998 Sep;5(3):115-6.22. Witteman GJ, Brubaker SJ, Johnson M, Marks RG: The

incidence of rebleeding in traumatic hyphema. Am JOphthalmol 1985: 17; 525-9.

23. Canvan YM, Archer DB. Anterior segment consequences ofblunt ocular injury. Br J Ophthalmol 1982;17:457-60.

24. Spoor TC, Hamer M, Belloso H, Traumatic hyphema: failureof steroids to alter its course, a double blind prospectivestudy. Arch Ophthalmol 1980; 98:116-9.


15th Annual Congress ofOphthalmology

OSP. Federal Brach, Islamabadto be held at Bhurban (Murree)

4-6 May 2012

Theme:

INNOVATION IN OPHTHALMOLOGY

Please contact:Col. Amer Yaqub

Chairman, Scientific CommitteeCell: 0342 5174777 E. Mail: [email protected]


–––––––––––––––––––––––––––––––––––––––––––––––––––––––1.Registrar Ophthalmology Department Hayatabad MedicalComplex,Peshawar.2. Associate Professor Ophthalmology,Department, Hayatabad Medical Complex, Peshawar.3 AssistantProfessor Ophthalmology, Bannu Medical College, Bannu, 4 MedicalOfficer Ophthalmology, Hayatabad Medical Complex, Peshawar–––––––––––––––––––––––––––––––––––––––––––––––––––––––Correspondence: Dr Mushtaq Ahmad, House 31B, street no 2,sector N4, Phase 4, Hayatabad, PeshawarE.Mail> [email protected] Cell: 03339119605–––––––––––––––––––––––––––––––––––––––––––––––––––––––Received: Oct’2011 Accepted: Jan’2012–––––––––––––––––––––––––––––––––––––––––––––––––––––––

INTRODUCTIONBevacizumab (Avastin Genetech Inc, South San

Francisco, California, USA) is a humanized vascularendothelial growth factor (VEGF) antibody used formetastatic colorectal carcinoma.1 Recent reports havedescribed the application of Bevacizumab to treat ocularneovascular disorder including proliferative diabeticretinopathy.2-5 More recently intravitreal injection ofBevacizumab (IVB) before PRP has been reported to beeffective also in preventing PRP induced visualdysfunction and foveal thickening6,7 and promotinggreater reduction in the area of active leaking of (newvessels) NV in Proliferative Diabetic Retinopathy (PDR)patients.8,9

Nowadays intravitreal Bevacizumab is used totreat following disorders:1. CNV caused by age related macular degeneration2. Retinal vein occlusion

3. Proliferative diabetic retinopathy4. Iris neovascularization with proliferative diabetic

retinopathy5. CNV caused by pathological myopia and

idiopathic CNV10

Regarding the safety use of intravitrel injectionof bevacizumab many studies have been done and stillother are under progress to determine the effectivenessversus complications of this drug. Ocular adverseeffects like chemosis, corneal abrasion, inflammation,cataract formation, retinal pigment epithelial tear andendophthalmitis after intravitreal injections ofbevacizumab11 have been reported but the frequencyrate of these adverse effects is so low that the benefitsoverwhelms them.MATERIALS AND METHODS:

The clinical interventional case-series studyincluded 100 intravitreal injections of about 1.25mgbevacizumab, performed in the period from August2010 to August 2011 by three surgeons at their privateclinics for patients who were diagnosed to have macularoedema or retinal neovascular disease. Patients werefollowed for 3 months after injectin.

Before disinfecting with povidone iodine, topicalpropracaine 0.5% was applied to anesthesize the eye.About 3.5mm from the lumbus in the supero-temporalsite of the eye injection 1.25mg bevacizumab wasinjected intravitreally via 29g needle. Pressure wasapplied at injection site with tying forceps to avoid

Complications of Intravitreal Injectionsof Bevacizumab

Mushtaq Ahmad FCPS1, Sofia Iqbal MRCOphth FRCS2, Nazullah FCPS3

Muhammad Naeem4

ABSTRACTObjective: To evaluate the short term complications after intravitreal injection ofBevacizumab(Avastin).Materials and Methods: The clinical interventional case-series study included 100intravitreal injections of about 1.25mg bevacizumab, performed in the period fromAugust 2010 to August 2011 by three surgeons at their private clinics for patients who were diagnosed to have macularoedema 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 ofvancomycine and ceftazidime, Painless vitreous haze was observed in one eye (1/100 or 1%) from the bevacizumabinjection , 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 andtraumatic cataract may occur after intravitreal injections of bevacizumab the beneficial effectiveness of the drug overwhelmsthese adverse effects. These injection-related risks compare favourably with the therapeutic benefit by the intravitrealtherapy.Keyword:Bevacizumab,intravitreal injection,Vitreous

Original Article

Dr. Mushtaq


reflux for 30 seconds. Antiboitic drops (vigamox)prescribed 4 hourly for one week. Patients havingmacular oedema and retinal neovascularization due toseveral causes were included in this study. Only thosepatients were excluded from the study who did notgave consent for the injection and who rejected tocomply for the follow up visits. Patients were followedat 1st post operative day four weeks and then after threemonths. The examination at each follow up was doneto measure visual acuity, intraocular pressure, detailedanterior segment and fundus examination.RESULTS

A total of 100 eyes of 78 patients with variousintraocular edematous and neovascular diseases(Table 1) given single dose of intravitrealbevacizumab were evaluated.

Table 1. Patients treated with Bevacizumab

Indication for Inj. No. of Pt.

Wet AMD 15

CRVO 20

Diabetic macular oedema 29

Proliferative diabetic ret. 33

NVG 3

One patient got endophthamitis (1/100 or 1%)with hypopyon but resolved after one intravitrealinjection of vancomycine and ceftazidime. Out of 100eyes 4 cases developed conjunctival chemosis (4%), onecase developed traumatic cataract (1%)and onedeveloped vitreous haze (1%). chemosis was of earlyonset and subsided soon, cataract was of iatrogenictrauma origin and treated successfully withPhacoemulsifiaction. The painless vitreous cloudingsubsided after intensified topical antibiotic therapy(Table 2).

Table 2. Post intravitraeal injection

Name of Complication No. of Pts.

Endophthalmitis 1 (1%)

Chemosis 4(4%)

Corneal abrasion 0

Cataract 1 (1%)

Uveitis 0

Raised IOP 0

Vitreous haze 1 (1%)

DISCUSSIONSince 2000 to 2005, the intravitreal applications

of bevacizumab have markedly increased in frequencyas therapy of diabetic macular oedema, exudative age-related macular degeneration and other intraocularneovascular or oedematous diseases.12

Ischemic diseases of eye like central retinal veinocclusion and diabetic or hypertensive retinopathycauses microangiopathies at tissue level. The resultanthypoxia leads to release of vascular endothelial growthfactor(VEGF) . VEGF has dual actions, one it causesneovessels formation other it increases vascularpermeability which leads to retinaledema.Bevacizumab is a monoclonal antibody that wasfirst used in the treatment of colorectal cancer . Themode of action of this drug is to inhibit the increasedactivity of VEGF. This in turn will reverse thephenomena of neovascularization and oedemaformation. Other uses of intravitreal Bevacizumab areretinopathy of prematurity (ROP), psuedophakicmacular edema,central serious chorioretinopathy(CSCR) and radiation retinopathy Despite the beneficialeffects, one should remember that intravitreal injectionsof Bevacizumab carries the risk of traumatic cataract,endophthalmitis and retinal detachment.13

Our study sample of 100 eyes for the intravitrealinjection of bevacizumab yielded adverse events inseven eyes. This was comparable with other studieswhere there were multiple complications. It wastherefore presumed that the complications were notassociated with chemical composition of Bevacizumabbut with the route of injection. The use of intravitrealbevacizumab is still limited in our area of study becauseof the cost effectiveness and availability. It is thereforeexpected that with the passage of time the beneficialeffects of this drug will make it freely available andprice reduction to patient’s range so that a large sampleof study will be available to determine the injectionrelated risks versus therapeutic benefits.CONCLUSION:

Injection-related complications such as infectiousendophthalmitis, Painless vitreous haze, chemosis andtraumatic cataract may occur after intravitreal injectionsof bevacizumab, the beneficial effectiveness of the drugoverwhelms these adverse effects. These injection-related risks compare favourably with the therapeuticbenefit by the intravitreal therapy.REFRENCES:1. Quillen DA, Gardner TW, Blankenship GW. Clinical Trials

in Ophthalmology: A Summary and Practice Guide. In:Kertes C, ed. diabetic retinopathy study. 1998:1-14.

2. Kramer I, Lipp HP. Bevacizumab, a humanizedantiangiogenic monoclonal antibody for the treatment ofcolorectal cancer.J Clin Pharm Ther 2007; 32: 1-14.

3. Avery RL, Pearlman J, Pieramici DJ, Rabena MD,CastellarinAA, Nasir MA et al. Intravitreal Bevacizumab (Avastin) inthe treatment of proliferative diabetic retinopathy.Ophthalmology 2006; 113: 1695.e1-1695.e15.

Complications of Intravitreal Injections of Bevacizumab


4. Chen E, Park CH. Use of intravitreal Bevacizumab as apreoperative adjunct for tractional retinal detachment repairin severe proliferative diabetic retinopathy. Retina 2006; 26:699-700.

5. Mason III JO, Nixon PA, White MF. Intravitreal injection ofBevacizumab (Avastin) as adjunctive treatment ofproliferative diabetic retinopathy.Am J Oph-thalmol 2006;142: 685-688.

6. Luke M, Januschowski K, Warga M, Beutel J, Leitritz M,Gelisken F et al. Intravitreal Bevacizumab (Avastin) therapyfor persistent diffuse diabetic macular edema. Retina 2006;26: 999-1005.

7. Cho WB, Moon JW, Kim HC, et al. Panretinalphotocoagulation combined with intravitreal bevacizumabin high-risk proliferative diabetic retinopathy. Retina2009;29:516e22.

8. Tonello M, Costa RA, Almeida FP, et al. Panretinalphotocoagulation versus PRP plus intravitreal bevacizumabfor high-risk proliferative diabetic retinopathy (IBeHi study).Acta Ophthalmol 2008;86:385e9.

9. Mason JO 3rd, Yunker JJ, Vail R, et al. Intravitrealbevacizumab (Avastin) prevention of panretinalphotocoagulation-induced complications in patients with

severe proliferative diabetic retinopathy. Retina2008;28:1319e24.

10. Gomi F, Nishida K, Oshima Y, Sakaguchi H, Sawa M,Tsujikawa M & Tano Y. Intravitreal bevacizumab foridiopathic choroidal neovascularization after previousinjection with posterior subtenon triamcinolone. Am JOphthalmol;143: 507–510.

11. Wu L, Martinez-Castellanos MA, Quiroz-Mercado H,Arevalo JF, Berrocal MH, Farah ME. Twelve-month safetyof intravitreal injections of bevacizumab (Avastin(R)): resultsof the Pan-American Collaborative Retina Study Group(PACORES). Graefes Arch Clin Exp Ophthalmol 2008; 246:81–87.

12. Rosenfeld PJ, Moshfeghi AA, Puliafito CA. Optical coherencetomography findings after an intravitreal injection ofbevacizumab (avastin) for neovascular age-related maculardegeneration. Ophthalmic Surg Lasers Imaging 2005; 36: 331–335.

13. Meyer CH, Mennnel S, Schmidt JC & Kroll P. Acute retinalepithelial tear followingintravitreal bevacizumab (Avastin)injection for occult choroidal neovascularisation secondaryto age related macular degeneration. Br J Ophthalmol2006;90: 1207–1208.

Complications of Intravitreal Injections of Bevacizumab


–––––––––––––––––––––––––––––––––––––––––––––––––––––––1Associate Professor Ophthalmology, Khyber Teaching Hospital,Peshawar Representative,2Regional Representative, SightsaversInternational (Previously at the time of study) 3CountryRepresentative, Sightsavers International–––––––––––––––––––––––––––––––––––––––––––––––––––––––Corresponding address: Dr. Sadia Sethi, House: 33, St: 4,Defence Colony, Khyber Road, Peshawar.Cell: 0092 308 8269668. E.Mail: [email protected]–––––––––––––––––––––––––––––––––––––––––––––––––––––––Acknowledgement: We are grateful to Prof. Clare Gilbert of theInternational Centre for Eye Health, UK for providing the templatefor data collection.–––––––––––––––––––––––––––––––––––––––––––––––––––––––Received: Oct’ 2011 Accepted: Jan’ 2012–––––––––––––––––––––––––––––––––––––––––––––––––––––––

INTRODUCTIONNeonatology is a branch of Pediatrics which is

rapidly emerging as a sub specialty and in near futureit is expected to expand further as a result of neonatalscreening programs and the availability of resources

for managing different neonatal problems. A largemajority of newborn babies do not develop any seriousproblem or difficulties and require only minimal care,which can be provided by the mother if properlysupervised by a health worker. High-risk mothers arelikely to give birth to preterm or low birth weight babieswho suffer a large number of problems1. Majority ofthe causes of neonatal morbidity in Pakistan arepreventable2. Some of the newborns in developingcountries have impaired growth right during theirintrauterine life, reflecting the nutritional status of themother3. Almost half of the infant deaths in Pakistanoccur within first 28 days of life4. Pre-maturity accountsfor majority of high risk newborns as they face a largenumber of problems5. Recent advances in neonatal carehave improved survival rates for premature infants6

and this has been accompanied by an increase inincidence of Retinopathy of Prematurity7-9.

An audit of Neonatal Services inKhyber Pakhtunkhwa Province (KPK), Pakistan

to identify Implications for screening‘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 andsubsequently treated in Khyber Pakhtunkhwa. To determine the extent of neonatal services available / developed indifferent hospitals all over the province. To suggest policy guidelines for screening of low birthweight and prematurebabies.Study Period: 2005 - 2006Methodology A standard questionnaire was designed by International Center for Eye Health London and all neonatalunits of Khyber Pakhtunkhwa were visited. Information was obtained from files of all neonatal units covering a two yearperiod (2005 and 2006) except two hospitals Naseer Teaching Hospital and Health Care Center where information wasobtained 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 and2 in Baluchistan). There were 28,738 babies admitted over a two year period preceding the study in neonatal units indifferent 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 twoneonatal units where neonatologists were available. These included Khyber Teaching Hospital and Kuwait TeachingHospital, Peshawar. Full time anesthetists were not available in any neonatal units in KPK. 62 incubators were present in13 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 birthweight babies accounted for 21.19%of total admissions. In our study there were 4623 (16.60% ) premature babies, 3258survived (survival 70.47%). Khyber Teaching Hospital had maximum number of premature babies (1931) that were admittedduring 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 341premature 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 toneonates. No regular screening for Retinopathy of Prematurity was done anywhere in Khyber Pakhtunkhwa.Key words: Prematurity, low birth weight, retinopathy of prematurity, neonatal units.

Original Article

Dr. SadiaSethi


Neonatal audit is carried out in Pakistan from timeto time in order to create awareness regarding pre-termbabies and other neonatal problems which they faceand their management in an effective way. For betterneonatal care and prevention of the preventable causesof neonatal morbidity and mortality, there is a need tobe continuously reporting the audit of neonataladmissions to neonatal units all over the country. Thepurpose behind such types of audits in neonatal unitsshould be for the identification of various deficienciesin the management of these neonates and also to assistthe health workers specially those at the communitylevel for better understanding and effectivemanagement of various neonatal problems in Pakistan.AIMS AND OBJECTIVES1. To identify nurseries / neonatology units where

underweight / premature babies were born andsubsequently treated in KPK.

2. To determine the extent of neonatal servicesavailable / developed in different hospitals allover KPK.

3. To determine type of training / qualification ofstaff.

4. To formulate a policy for screening of low birthand premature babies.METHODOLOGY A consultation workshop was organized at the

College of Ophthalmology and Allied Sciences,(previously Punjab Institute of PreventiveOphthalmology-PIPO) on 12th October 2006, to developa joint course of action by the ophthalmologists,pediatricians and neonatologists for the early detectionand control of retinopathy of prematurity in childrenand to collect data regarding prevalence of prematurity/ low birth weight babies born at all hospitals acrossthe country as well as concentration of oxygen given tothem was recommended. A questionnaire was designedby International Center for Eye Health London andinformation about the neonatal units all over Pakistanwas obtained with the help of the Pakistan PediatricAssociation KPK. Four Focal Persons were identified,one for each Province. They provided us with the listof hospitals in all the four provinces of Pakistan. Weselected KPK as a sample and conducted a situationanalysis of KPK.

All the hospitals of KPK where neonatal units existwere visited in year 2007 and available data wasretrieved in all hospitals through files of year 2005 and2006 with the help of a pediatrician in Health CareCenter and Naseer Teaching Hospital, though it wasdifficult to obtain the files in these two hospitals.

Constraints. Due to reasons of official clearance,we were unable to obtain any data from the CombinedMilitary Hospitals in Peshawar and Nowshera. The

only neonatal unit where ventilation of children is donein KPK is Combined Military Hospital Peshawar.Photographs of the peripheral hospitals were notfeasible.RESULTS

In year 2007 there were 30 neonatal units in Sindh,27 in Punjab, 15 in KPK and 2 in Baluchistan. Therewere 28738 babies admitted in year 2005-2006 indifferent neonatal units in Khyber Pakhtunkhwaexcluding CMH Peshawar and CMH Nowshera. Therewere 4 private hospitals where neonatal services wereprovided to babies while 11 government hospitals hadneonatal units; 5 were university hospitals (Fig. 1). 4656(16.2%) neonates in 2005-2006 were treated in privatehospitals while 24082 (83.7%) were treated ingovernment hospitals. Table:1 shows the hospitals inKPK and number of neonatal admissions. There were13390 (46.59%) admissions in year 2005 and 15348(53.41%) of admissions in year 2006. (Table 1)

Facility of Endotracheal intubation was availableonly in CMH Peshawar. Ventilation and surgery wasunavailable to babies anywhere in KPK, while noventilation was given in 14 hospitals visited in KPK.Table:2 shows that 1411 babies of very low birth weightwere admitted during the study period. They had meansurvival rate of 48.48%. Table: 3 shows that 6182 lowbirth weight babies were admitted in the study periodwith a mean survival rate of 62.97%. Table: 4 showsthat 4623 babies were born premature out of which 3258babies survived with a mean survival rate of 70.47%.Table: 5 shows that 664 (2.3%) babies were less than1500gms who needed ROP screening. Table: 6 showsthat 639 (2.2%) babies were born premature (<31 weeks)and needed ROP screening.

There were only two neonatal units whereneonatologists were available. These included theKhyber Teaching Hospital and Kuwait TeachingHospital Peshawar. There were 31 pediatricians, 19resident, and 47 medical officers in different neonatalunits in KPK. A total of 97 medical personnel wereinvolved in providing neonatal services. There were

Figure 1: Types of Hospitals in Khyber Pukhtoonkhwa whereNeonatal Units were present

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 yearadmissions of two years in admission of two years in 2005 andnursery - 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%



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



Kuwait Teaching Hospital, Peshawar 60 57 95




Fauji Foundation Hospital, Peshawar 135 109 80%

District Hospital Dera Ismail Khan 133 105 78.9%

District Hospital Mardan 161 140 86.9%



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



Kuwait Teaching Hospital, Peshawar 52 47 90.38%




Fauji Foundation Hospital, Peshawar 55 24 43.63%

District Hospital Dera Ismail Khan Unknown Unknown Unknown

District Hospital Mardan 341 323 94.72%



CMH Kohat 18 11 61.11%

Ayub Teaching Hospital, Abbottabad 11 2 18.18%

Total 4623 3258 70.47%



two trained neonatal nurses in Khyber TeachingHospital, one in Hayatabad Medical Complex and otherin CMH Peshawar. A total of 53 nurses were workingin different neonatal units in KPK. There was no fulltime anesthetist specifically for any neonatal unit in inKPK. In 5 units, full time anesthetists were available inthe hospital and were readily available to the neonatalunit. 8 neonatal units had difficulty in accessing theanesthetist. Sixty two incubators were present in 13neonatal units of KPK. Out of these, 37 wereintermediate dependency and 25 were highdependency. In 2 hospitals, 95-100% of babies wereestimated to be on oxygen that was continuouslymonitored, while in 4 hospitals it was 75-94%, in onehospital 50-74%, and in other hospital 25-49%, and in6 hospitals 0-24%.

Screening for retinopathy of prematurity was notdone in any hospital in KPK.DISCUSSION

In this study a total of 28,738 babies were admittedin 13 neonatal units of KPK over a two-year studyperiod (2005-2006). 6122 low birth weight babies wereadmitted in neonatal units in KPK. They accounted for21.199% of the total admissions in neonatal units inKPK. In South Asia, the incidence of LBW is 36%, 30%in Bangladesh and India, and 19% in Pakistan10. InPakistan, the LBW rate varies from 5% to 23% indifferent parts of the country11-16. The overall incidenceof LBW in a study at Peshawar (10%)17 was half that ofrecent studies (19%–23%) in Lahore and Karachi12-14 andoverall national average10.

In our study, there were 4623 (16. 08%) prematurebabies, of which 3258 survived (survival 70.47%). InKhyber Teaching Hospital had maximum number ofpremature babies (1931) that were admitted during thestudy period. Lady Reading Hospital had the secondincidence, where 1806 babies were admitted. Thesurvival percentage of Mardan Medical Complex wasbest among neonatal units in province, where out of

341 premature babies, 323 survived (94.72%). InRehman Medical Institute, reputed to be one of thebetter private hospitals in KPK, the survival ofpremature babies was (92.11%). In Ayub TeachingHospital, only 11 premature babies were admitted andout of which 2 survived having a survival of (18.18%).In our series, 664 (2.3%) babies had a birth weight <1500gm, while 639 (2.2%) babies had a gestational age< 31 weeks requiring ROP screening. In a retrospectivestudy done in Karachi in 2003 on premature infantsadmitted in tertiary hospital in Karachi, 32.4%developed ROP18.

Retinopathy of prematurity is a condition whichis preventable and treatable in middle income countriesand in urban centres in developing countries19. ROPdevelops in 16% of all premature births, the figure risingto over 65% of infants weighing less than 1250 gms atbirth20. Some studies suggest that as more and moresmaller and younger babies are surviving, its incidenceis increasing21. However, others say that betterunderstanding of screening and management of thesebabies has resulted in a decrease in its incidence20. Riskfactors22 include prematurity (particularly less than 32weeks of gestational age), low birth weight (< 1500gmsand particularly if < 1250gms), oxygen therapy(hypoxaemia and hypercarbia also increase the risk),and co-morbidity. The goal of an effective screeningprogramme must be to identify the relatively fewpreterm infants who require treatment for ROP fromamong the much larger number of at risk infants whileminimizing the number of stressful examinationsrequired for these sick infants.

There is no agreed policy on the screening ofbabies larger than 1250g23. The American screeningguidelines for ROP suggest that babies d” 1500 g birthweight or d” 32 weeks gestational age must be screened,while those infants > 1500 g or > 32 weeks be screenedat the discretion of the attending neonatologist24.However, developing countries may require

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%



modification of these screening guidelines25-27.ROP was a major cause of blindness in children

in Europe and North America during the late 1940s and1950s with unmonitored supplemental oxygen beingthe major risk factor28-29. This was called the firstepidemic and during this blindness occurred in largermore mature babies from retrolental fibroplasias (thisterminology being used earlier for the same). At thattime, the mean birth weight (BW) of affected babies inthe United Kingdom was 1370g (range 936-1843g) andin the United States of America was 1354g (range 770-3421g)29-30. By the mid 1950s, abundant clinical andexperimental data had accumulated and it wasconcluded that retrolental fibroplasias was due tooveruse of oxygen. Since then, careful curtailment ofoxygen has resulted in a lower incidence31. At present,in developed countries the majority of babies gettingsevere ROP weigh less than 1000g at birth. This hasbeen termed the “second epidemic”32. India and otherdeveloping countries are now facing what is termedthe “third epidemic” which is a mixture of the first twoepidemics. This “third epidemic” is characterized bysevere ROP in both relatively mature as well asimmature babies reflecting varying levels of neonatalcare.

Even larger and mature babies are developingsevere ROP in South India than in industrializedcountries. The characteristics of babies affected aresimilar to those seen during the first epidemic of ROPwhich occurred during the 1950s in Europe and NorthAmerica. Guidelines on oxygenation and screeningpolicies should be jointly developed by pediatriciansand ophthalmologists to end this epidemic of avoidableblindness 33.CONCLUSIONS:

684 very low birth weight babies survived with asurvival rate was 48.48%. 3893 low birth weight babiessurvived with a survival rate was 62.65%. 3258premature babies survived with a survival rate was70.47%. In our study, 664 (2.3%) babies had weight<1500gm. while in 639 (2.2%), the babies had gestationalage < 31 weeks requiring ROP screening. Ventilationwas unavailable anywhere in KPK except CMHPeshawar. There were 99 medical personnel and 53nursing personnel involved in KPK in providingservices to neonates. No screening for Retinopathy ofPrematurity was done anywhere in KPK.Recommendations1. All neonatal units should improve their neonatal

care facilities if we want more babies to survive.All units should have facilities for endotrachealintubations.

2. All babies on oxygen should be properlymonitored.

3. There should be trained neonatal nurses,neonatologists and fulltime anesthetists availablefor neonatal units.

4. More incubators should be available in neonatalunits.

5. Proper documentation of all admissions, survivalsand discharges, and deaths should be done.

6. A counselor should be available, who could guidethe parents for proper follow up and vaccinationof babies.

7. A formal screening protocol for ROP for babies <than 1750gms and gestational age < 35 weeksshould be adopted.

8. Proper feeding and waiting area for parents ofbabies should be available in neonatal units.

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Pediatrics 2005;115:e518-25.26. Jalali S, Matalia J, Hussain A, Anand R. Modification of

screening criteria for retinopathy of prematurity in India andother middle-income countries. Am J Ophthalmol2006;141:966-8.

27. Trinavarat A, Atchaneeyasakul L, Udompunturak S.Application of American and British criteria for screening ofthe retinopathy of prematurity in Thailand. Jpn J Ophthalmol2004;48:50-3.

28. Sorsby A. The incidence and causes of blindness in Englandand Wales 1948-1962, Reports on Public Health and Medicalsubjects NO. 114. London: HMSO, 1966.

29. King M. Retroplental fibroplasia. Arch Ophthalmol1950;43:694-711.

30. Gillbert C, Fielder A, Gordillo L, Quinn G, Semiglia R,Visintin P et al. Characteristics of infants with severeretinopathy of prematurity in countries with low, moderate,and high levels of development: implications for screeningprograms, Pediatrics 2005;115:518-525.

31. Patz A, The role of oxygen in retro lentil fibroplasia. Tr AmOpth Soc 1968;66:940-985.

32. Gilbert C, Rahi J, Eckstein M, O’Sullivan J, Foster A.Retinopathy of prematurity in middle income countries.Lancet 1997;350:12-14.

33. Shah PK, Narendran V, Kalpana N and Gilbert C. Severeretinopathy of prematurity in Big babies in India: historyrepeating itself. Indian J of Pedia 2009; 76: 801-804.



–––––––––––––––––––––––––––––––––––––––––––––––––––––––1Associate Professor Ophthalmology, Department, HayatabadMedical Complex,Peshawar. 2RegistrarOphthalmologyDepartment, Hayatabad Medical Complex, Peshawar. 3Professorof Ophthalmology, Kabir Medical College, Gandhara MedicalUniversity, Peshawar–––––––––––––––––––––––––––––––––––––––––––––––––––––––Correspondence: Dr. Sofia Iqbal, House no 86, street no 6, sectorG-2, Phase 2, Hayatabad,PeshawarE.Mail>sofiaiqbal71@ yahoo.com 03339254264–––––––––––––––––––––––––––––––––––––––––––––––––––––––Received: Oct’2011 Accepted: Jan’2012–––––––––––––––––––––––––––––––––––––––––––––––––––––––

A Review of Microbial Keratitis

Sofia Iqbal MRCOphth (Lond) FRCS1, Mushtaq Ahmad FCPS2

Prof. Zafar ul Islam FCPS3

ABSTRACTBackground: 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 organismsin microbial keratitis, to identify predisposing risk factors, discuss best treatment protocol, and to recommend preventivemeasures.Method: It was a prospective study of 112 patients suffering from Microbial Keratitis who presented over a period of oneyear. A detailed history and clinical features of the patients were noted down on a predesigned proforma. Culture andsensitivity 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%; Staphlococcusepidermidis in 26.22%; Streptococcus Pyogenes in 19.67%; Aspergillus in 13.11%; Candida in 03.27% and Fusorium in01.63%. Most of the organisms showed higher sensitivity to Quinolones than the other drugs. 53.57% patients had a finalVisual 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 Itraconazolseems to be the therapy of choice for Fungal Keratitis in our set up. Approximately one third cases had chronicDacryocystitis, 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 inthe final outcome of corneal ulcers in KPK, Pakistan.Key Words: Microbial Keratitis, Culture and Sensitivity, Corneal Scrapping.

Dr. Sofia

Original Article

INTRODUCTIONOcular infections are one of the leading causes of

blindness in the world in general and in developingcountries in particular. Certain features of microbialkeratitis are more prevalent in some countries thanothers. This may be related to nutritional factors,economic factors, environmental factors, illiteracy, poorhygiene, concurrence of other infections such astrachoma or herpes, trauma, temperature, humidity andother seasonal variations and general health1.

Environmental influences dictate the pattern of externaleye diseases. In dry hot deserts, where flies abound andpersonal hygiene is poor, blinding trachoma isprevalent, while in rain forests ridden with parasiteladen black fly, people face the challenge ofOnchocerciasis. The general environment in the citiesof the developed western world is less hostile. In suchconditions, suppurative keratitis resulting from

bacterial, fungal or amoebic infection occurs in eyeswith pre-existing pathology, where the micro-environment has been disturbed by trauma, eyeliddysfunction, abuse of contact lens or the administrationof topical medications, which influence the commensalorganisms or defense mechanism2. According to themost recent data available, 27-35 million people of theworld are blind.3 25-50% of this blindness, (vision inthe better eye d” 3/60), is due to corneal diseases.4

Corneal infection is a leading cause of ocular morbidityand blindness in the under developed world.5 Thecondition may be more serious than is apparent,because blindness refers to the definition adopted bythe W.H.O., that is a person is considered blind if hisvisual acuity in the better eye is 3/60 or a visual fieldof ten degrees or worse. If one adds the uniocular blinds,the above figures will immediately increase by twofolds. In Pakistan , no clear-cut statistics are availableabout the corneal blindness but in a study fromNawabshah, corneal ulcer patients constituted about14.5% of all cases admitted in the department ofOphthalmology6. In another study from Larkana, theincidence of corneal involvement was assessed to be15%7 The developed world has a low incidence ofCorneal diseases. Comparison of the important causesof Blindness in USA, UK, Canada and Sweden doesnot put corneal diseases as a cause for blindness in thefirst five commonest causes.8 In these countries thecommonest causes of blindness include conditions like


diabetic retinopathy, cataract, age related maculardegeneration, myopia and glaucoma. Microbialkeratitis is more severe in the underdeveloped world,probably due to delayed attendance 9

The objectives of this study are:• To identify common etiological organisms in

microbial keratitis in KPK Pakistan.• To identify predisposing risk factors.• To identify and recommend best treatment

protocols.• To identify and recommend preventive

measures.MATERIALS AND METHODS

A total of 112 patients admitted to the eye unit ofHayatabad Medical Complex from 1st January 2009 to31st December 2009 were recruited in this prospectivestudy. Patients with clinically diagnosed viral cornealulcers were excluded from the study. A detailed historyand a complete ocular examination was done accordingto a predesigned proforma. After a detailedexamination on a slit lamp, corneal scraping wasobtained and was sent for culture and sensitivity (C/S). Most of the time, it was performed under a Topconslit lamp or under a Topcon Operating Microscope.The cornea was anaesthetized using a topical anesthetic(Proparacain Hydrochloride) while children were givengeneral anesthesia. Most of the time, a disposablesyringe needle, bent at its tips, was used as describedby Smith et al 10. Scalpel blade was used in some casesfor getting the corneal scraping . Scrape was taken fromthe edges of the ulcer all around and from the base ofthe ulcer.

Four types of growth media were used routinelyfor inoculating the material taken from the cornea. Ablood Agar plate was inoculated first followed byChocolate agar plate, Sabouraud’s agar plate andThioglycolate broth. Sabouraud’s agar plate wascycloheximide free and in some cases, gentamicin100umg/ml was added to it to suppress bacterialgrowth. Four slides were prepared for Microscopicexamination. Half of the slides were stained withGram’s method; other slides were treated with 20%Potassium Hydroxide (KOH). In few cases, the slidestreated with KOH were further treated withLactophenol Blue to facilitate the identification of fungalelements. In few cases Zeil-Neilson stain was alsoperformed. All the slides were examined by the samemicrobiologist. Blood Agars were incubated at 37ºC.Usually Bacterial growth occurred within 24 hours .However, if no growth occurred, the specimen was keptfor another 3 weeks at 37ºC for the growth of any slowgrowing bacteria or fungi. If still no growth the culturespecimen was discarded as culture negative. Chocolateagar plates were incubated at 37ºC for a minimum

period of 72 hours before discarded for no growth.Sabouraud’s agar plates were incubated at 25ºC. Theywere examined daily for any growth and werediscarded if no growth took place in 3 weeks time.Thioglycolate broth was heated for 5 minutes in aboiling water bath before incubation at 37ºC. It was keptfor 7 days before they were discarded for no growth.The organism’s sensitivity to the antibiotics wasdetermined with the disc diffusion method of Kirby-Bauer.11

After comparing the size of inhibition zones withthe standard, the antibiotic sensitivity was recorded as.

• Very sensitive ( + + + )• Moderately sensitive (+ + )• Mildly sensitive ( + )• Resistant ( - )Every patient was put on the following treatment

after corneal scraping and before the laboratory results.Frequent use of ciprofloxacin/ofloxacin eye drops. Thiscan be used as a mono-therapy (12) but we often addeda second antibiotic (tobramycin ) to the regimen toensure adequate antibiotic coverage.

• Atropine eye drops twice a day.• Syrup / Tablets Brufen (400mg) according to

the weight and age of the patient twice a day.• Tablets Diamox (250mg & 500mg ) were used

in cases of raised Intraocular Pressure.• Itraconazole (Sporanox) Tablets as antifungal

agents in patients with suspected Fungal corneal ulcersas twice a day regimen.

The initial therapy was changed only when thesensitivity report showed another medicine to be moreappropriate. The patients were examined on a slit lamptwice a day, paying due attention to the site, size anddepth of the ulcer. Anterior chamber reaction wasrecorded, and any vascularization of the ulcer wasnoted. Patients were discharged only when the ulcershowed signs of healing. All the patients were followedfor 3 weeks. If the ulcer was large initially and therewas a fear of perforation, a surgical modality, most ofthe time, a conjunctival flap was chosen. In cases ofpredisposing factors amenable to surgery like trichiasis,entropion, chronic dacrocystitis, lagophthalmos, weretreated with appropriate surgical interventions. A finalrecord of the eye was made after a follow up of 3 weeks.This included, visual acuity, corneal condition, andcondition of the eye as a whole.

Table 1: Culture Reports

S. No Cases Male Female Total % age1 Total 40 21 61 54.46

Positive Cases (65.57%) (34.42%)2 Total 11 30 51 45.53

Negative Cases (21.56%) (58.82%)



RESULTSCorneal ulcer patients comprised 3.689% of the

total admissions.(112/3028). Male patients were 74 (66.07%) and

female patients were 38 (33.92%). Most of the patients(56.24%) were between the ages 31 and 50 years. Totalnumber of patients receiving treatment beforepresentation were 75(66.96%). Fifty two ( 69.34% )of

Table 5: Final visual outcome

Visual Ist 2nd 3rd FinalAcuity week week week

6/12-6/18 03(02.67%) 03(02.67%) 04(03.57%) 04(03.57%)

6/18-6/60 38(33.92%) 46(41.07%) 54(48.21%) 56(50.00%)

6/60-3/60 41(36.60%) 37(33.03%) 34(30.35%) 36(32.14%)

3/60-HM 20(17.78%) 16(14.28%) 12(10.71%) 09(08.03%)

HM-PL 10(08.92%) 10(08.92%) 08(07.14%) 07(5.35%)

NPL 1(0.89%) 1(0.89%) 1(0.89%) 1(0.89%)

Table 3: Culture and sensitivity results (bacterial)

S.No Drugs Staph Staph StrepAureus Epidermidis Pyogenes

1 Ofloxacin + + + + + + + + +

2 Norfloxacin + + + + + +

3 Tobramycin + + + + + + +

4 Chloramphenicol + + + +

5 Gentamycin + + _

6 Ciprofloxacin ++ + + + + + + +

Table 4: Culture and sensitivity results (fungi)

S.No Drugs Aspergillus Candida Fusarium

01 Fluconazole + + + +

02 Ketoconazole + + + + +

03 Itraconazole + + + + + +

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

the patients were on antibiotic treatment while 10(13.34% ) patients were using topical steroids. Totalnumber of patients with a history of trauma were 47(41.96%), out of which agricultural trauma wasresponsible in 59.57% cases. Patients with ocular andlid diseases at the time of presentation were 64 (57.14%).Chronic dacryocystitis was present in 37.50 % cases ,while 23.88% had an old herpetic scar , who presentedwith secondary corneal infection or a flare up of oldherpetic infection. The complaints of the majority(93.74%) of the patients were redness, dimness of visionand photophobia. In 93 (83.03%) patients the ulcer wascentral, while in 19(16.96%) it was marginal in location.In 50 (44.64%) patients hypopyon was present. Theculture and sensitivity reports of 61 (54.46%) patientswere positive while in 51 (45.53%) patients it wasreported as Negative. Staphlococcus aureus was themost common bacterial isolate accounting for 22(36.06%) cases, while Aspergillus was the most commonfungus isolated which accounted for 72.72% of mycoticulcers. The presenting visual acuity in 94.63% patientswas less than 6/60, only 5.35% patients had a presentingVisual Acuity of better than 6/60.The final visual acuityof 53.57% patients was better than 6/60, while 46.41%ended up with a visual acuity less than 6/60.DISCUSSION

This prospective study at KIOMS looked at theprofile of corneal ulcers which consisted of predisposingfactors, causative agents, age, sex, and the final visualoutcome. In this study corneal ulcer patients comprised3.689% of the total admissions during the year 2000.This is comparable to the figure reported by Dr Nasir 13

who conducted a similar study in 1989. However, it islower than the prevalence reported by Haider7 fromLarkana & Khan and Baig6 from Nawbshah (14.5%). Italso corresponds well to a study by Omerod5 from SouthAfrica (5%). The figure obtained by us might be loweras viral corneal ulcer diagnosed on clinical groundswere excluded from the study.

Corneal ulcers in our study were found to be morecommon in males (66.07%) than in females (33.92%),which correspond well with similar studies.5,13,14,15,16 The



reason for male preponderance may be due to moreexposure of the male patients to ocular trauma. Morethan half of the patients (66.96%) were already onmedications at the time of presentation, out of which13.34% were on steroid eye drops. These patientsprobably got their medications from quacks, hakims,or from drug stores without a prescription (self-medication). Microbial keratitis is rare in the absenceof predisposing factors. 41.96% of the patients gave ahistory of ocular trauma, this is in accordance with thesimilar studies from Bangladesh and India.17&18. It ishowever higher than that reported by Coster et al fromLondon19 and Coster and Badenoch20 from Australia.In this study, agricultural trauma was responsible in59.57% cases, whereas contact lens trauma accountedfor 2.12% cases only. This figure is much less than thatreported by Fredric Schaffer et al21 which is 36%.

Pakistan is a low-income country which dependsmostly on Agriculture for employment, This accountsfor the higher frequency of agricultural trauma andlower frequency of contact lens trauma. 57.17% of thepatients were having an ocular surface and lid diseaseat the time of presentation. This is higher than thatobserved by Bennett et al 45.6%22 and Nasir 32.4%13,but it is much lower than that reported by Ormerodfrom South Africa5. In the latter study they consideredtopical steroids and trauma among the localpredisposing factors while we have considered themseparately. 7.50% of the patients had chronicdacryocystitis, which is very high as compared to thatreported by Nasir13. Most of the patients with chronicdacryocystitis had come from the hilly areas likeChitral, where trachoma had been very common untilrecently. Whether there is a correlation betweentrachomatous scarring and chronic dacryocystitis inthese hilly areas need to be investigated further. 83.03%of the ulcers located centrally, whereas 16.96% weremarginally located. This corresponds well with otherstudies5,13&22. 54.46% cases in our study had a positiveculture which is in accordance with studies reportedby Nasir and Bennett 13&22. Ormerod5 in his two seriesreported a positive culture in 75% and 82% of the cases.

Staph. aureus was the most common bacterialisolate and accounted for 36.06% of the pathogensisolated. Staph. aureus, which was previouslyconsidered to be an opportunistic organism, is nowbecoming the most common cause of cornealinfection.15. It may be due the fact that it is notuncommonly found in the conjunctival bacterial flora23

and can easily cause infection if the local situationbecomes less favorable. Another important factor maybe the Antibiotic resistance of many strains ofStaphylococci.

Aspergillus was the most common fungus isolated

and accounted for 72.72% of the Mycotic ulcers.Fusarium was responsible for 9.09% of the Mycoticulcers in this study. Similar figures are reported fromIndia 1&24 and Nepal 9. Candida accounted for 18.18%of the mycotic ulcers but this figure is much lower thanthat reported by Nasir (13) and other studies.1,18&24.

Fungal infections are considered to occur inimmune-compromised hosts. Any injury with vegetablematter, an occupation like Farming and previoustreatment with broad spectrum antibiotics and steroidsare strong predisposing factors 25. All these factors werefrequently seen to be involved in patients in this study.The cultures of all the patients were tested with theantibiotic prescriptions currently available at themedicine stores. This was done mainly to come to acommon conclusion about the sensitivity of the mostcommon accessible medicine available at the drugstores.

The results of this study showed that all theBacteria (87%) were very sensitive to ofloxacin andciprofloxacin whereas sensitivity to tobramycin was80% and chloramphenicol and gentamycin 46.5% only.Tobramycin was found to be more effective thangentamycin and even more effective thanchloramphenicol. This was probably the result ofresistance developed to these antibiotics due to theirwide spread and indiscriminate use. The trend showingresistance was also reported by other Authors.10,13,&28.

It was observed that on presentation, 94.63% ofthe patients had a Visual Acuity worse than 6/60 while5.35% of the patients had a visual acuity of better than6/60 on the Snellen’s chart. With effective management,53.57% patients had a final visual acuity of better than6/60 and 46.41% ended up with a visual acuity of worsethan 6/60 which is much lower than that observed byNasir (73%) . This is probably due to the fact that wenow have access to much effective drugs than 10 yearsago. However the big change in the outcome may alsobe because of the improved primary eye careintroduced at the Basic Health Units (BHU) levelsthroughout the province and to the creation offunctional eye units at the district levels. The educationof the patients has also improved so overall the patientspresent earlier, treatment is started sooner and patientsare referred in time to the tertiary eye care centres. Atthe end of the third week 74.10% of the eyes werealready healed. 58.92% of the patients in this studyended up with a dense corneal scar, most of suchpatients can be rehabilitated if proper Keratoplastyservices were available at our tertiary care centres.CONCLUSION

Corneal ulcer is one of the common causes ofocular morbidity and corneal blindness in KPK,Pakistan. Public health education, prevention of



agricultural trauma, improved primary eye careservices and ban on the over counter sale of ocularmedications, can have a positive effect on theprevalence and incidence of corneal ulcers. Availabilityof effective keratoplasty services will be a major stepforward in the visual rehabilitation of corneal blindness.REFERENCES:1. Nema HV. Keratomycosis in India .In: Shimizu K.ed.

Ophthalmology, Amsterdam: Excrepta Medica, 1979; 1716-20.

2. Coster DJ. Inflammatory Diseases of the Outer Eye. TransOphthalmol Soc UK 1979; 99: 463-80.

3. Minassian DC. Epidemiological methods in prevention ofblindness. Eye 1988; 2:53-512.

4. Mohan M, Agarwal LR, Malik SRK, Gupta AK, eds.Ophthalmology. Proceedings of X Congress of APAO 1985.New Delhi. Tata McGraw Hill Publication Co 1987: 75-7

5. Ormerod LD. Causation and Management of MicrobialKeratitis in subtropical Africa. Ophthalmology. 1987; 94:1662-8.

6. Khan SA, Baig MSA. Review of 152 cases of corneal ulcer inNawabshah. In: All Pakistan Ophthalmological ConferenceQuetta:1986.

7. Haider A. Experience with Osmotic agents in Corneal ulcerswith raised tension. In: Yaqin M, ed. Transactions 8th AfroAsian Congress of Ophthalmology, Lahore: 1984 65-71

8. Ghafour IM, Allan D, Foulds WS. Common causes ofblindness and visual handicap in the west of Scotland. Br JOphthalmol 1983; 67:209-13.

9. Upadhay MP, Rai NC, Brandt F, Shresta RB. Corneal ulcersin Nepal.Graefes Arch Clin Exp Ophthalmol 1982; 219:55-9.

10. Smith SG, Herman WK, Linstorm RL, Doughman DJ, Amethod of collecting culture material from Corneal ulcers.Am J Ophthalmol 1984; 97:105-6.

11. Baur AW, Kirby WMM, Sheris JC, Turk M. Antibioticsensitivity testing by a Standardized single Disk method. AmJ Clin Pathol 1966;45:493-496.

12. Gangopadhyay N, Daniell M, Weih L, Taylor HR.Flouroquinolone and fortified antibiotics for treatingBacterial Corneal ulcers. Br J Ophthalmol 2000; 84:378-84.

13. Saeed N. Microbial Keratitis. A Study Review, Peshawar,NWFP: PGMI LRH, 1989.

14. Ormerod LD, Hertzmark E, Gomez DS, Stabiner RG,Schanzlin DJ, Smith RE, Epidemiology of Microbial Keratitis

in Southern California, A multivariate analysis.Ophthalmolgy 1987; 94: 1322-33.

15. Asbell P, Stenson S. Ulcerative Keratitis: Survey of 30 yearsLaboratory Experience. Arch Ophthalmol 1982; 100:77-80.

16. Reddy PR. Topical Antibiotics in the treatment of Cornealulcers. Ind J Ophthalmol 1988; 36: 95-7.

17. Williams G, Billson F, Howlader SA, Islam N, McClellan K.Microbiological Diagnosis of suppurative keratitis inBangladesh Br J Ophthalmol 1987; 71:315-21.

18. Reddy PS, Satyendran OM, Satapathy M, Kumar HV, ReddyR. Mycotic Keratitis. Ind J Ophthalmol 1972; 20: 101-8.

19. Anderson B, Chick EW. Treatment of Fungal Corneal ulcerswith Amphotericin B and mechanical Debridement. SouthMed J 1993;56:270-4.

20. Coster DJ, Badenoch PR. Microbial and Pharmacologicalfactors affecting the outcome of Suppurative Keratitis. Br JOphthalmol 1987;71:96-101.

21. Schaefer F, Bruttin O Zografos L, Guex-Crosier Y. BacterialKeratitis: A prospective clinical and microbiological study.Br J Ophthalmol 2001;85:842-7

22. Bennett HGB, Hay J, Kirkness CM, Seal DV, DevonshireP.Antimicrobial Management of Presumed MicrobialKeratitis. Guidelines for the treatment of Central/PeripheralCorneal ulcers. Br J Ophthalmol 1998;82: 137-45.

23. Locatcher-Khorazo D, Guierrez E. The bacterial flora of thehealthy eye. In: Microbiology of the Eye. St Louis: CV MosbyCo, 1972: 13-23.

24. Sandhu DK, Randhawa IS, Singh D. The co relation betweenenvironmental and ocular fungi. Ind J Ophthalmol 1981; 29:177-82.

25. Chin GN, Hyndiuk RA, Kwasny GP, Schultz RO,Keratomycosis in Wisconsin. Am J Ophthalmol 1975; 79:121-5.

26. Hyndiuk RA, Eiferman RA, Caldwell DR, Rosenwasser GO,Santos CI, Katz HR,et al. Comparison of CiprofloxacinOphthalmic solution0.3% to fortified Tobramycin-Cefazolinin treating Bacterial Corneal ulcers. Ophthalmology 1996;103: 1854-1863

27. O’ Brien TP, Sawusch MR, Dick JD. Topical Ciprofloxacintreatment of Pseudomonas keratitis. Arch Ophthalmol 1988;144-6.

28. Abott RL, Abrams MA. Bacterial Corneal ulcers. ClinicalOphthalmolgy vol IV chapter 18, Philadelphia: Harper andRow Publishers, 1988.



–––––––––––––––––––––––––––––––––––––––––––––––––––––––1Community Ophthalmologist/Medical Director Makkah EyeComplex, Khartoum, Sudan.2&3Ophthalmologists, Al-Ibrahim Eye Hospital, Isra PostgraduateInstitute of Ophthalmology, Gadap Town, Karachi.–––––––––––––––––––––––––––––––––––––––––––––––––––––––Correspondence: Dr.Mirani A. Haleem FCPS2, Al-Ibrahim EyeHospital, Isra Postgraduate Institute of Ophthalmology, Gadap Town,Karachi. Tele: 0092214560718, Cell No: 00249922453410, E-mail:[email protected]–––––––––––––––––––––––––––––––––––––––––––––––––––––––Acknowledgement: Thanks to Mr. H.Tariq Ali Shaikh,IT consultant, for computing the statistical work.–––––––––––––––––––––––––––––––––––––––––––––––––––––––Received: Oct’2011 Accepted: Jan’2012–––––––––––––––––––––––––––––––––––––––––––––––––––––––

INTRODUCTIONOcular trauma is a major cause of preventable

monocular blindness and visual impairment in theworld1. During last decade epidemiological studieshave contributed significantly to a better understandingof disease patterns of cataract, trachoma,xerophthalmia, and diabetic retinopathy resulting inprevention and control of blindness due to thesediseases.Eye injuries have been considered a clinicalissue and are mostly addressed within the context ofclinical eye care delivery systems including emergencycase management2. However, like any other eyedisorder, eye injuries do not occur as random events:there is evidence that some population groups are atincreased risk of sustaining eye injuries because of

greater exposure to hazards, decreased ability to avoidor detect hazards, and/or a lower likelihood offunctional recovery following eye injury3. Hence furtherevaluation and research are required on thisarea.Although one of the major causes of visualmorbidity, it has remained a neglected disorder andhas not received any importance from public healthpoint of view.

Globally in 2001, 1.6 million people were blindfrom ocular injuries, 2.3 million had bilateral low vision,and 19 million were unilaterally blind or had lowvision4. In developing countries most ofthecomplications occurdue to delayed presentation at thehospital as well as lack of vitreo-retinal or cornealtransplantation facilities.No national data are availableon the incidence or prevalence of ocular injury.However few hospital based studies from the North ofPakistan show a high number of ocular injuries comingto those hospitals5.6Non-trachomatous corneal opacityis the second most important cause of blindness inPakistan and has shown an increase within the lastfifteen years7. It especially affects the south of Pakistan.Most of this is caused by Trauma.

To determine the pattern of ocular trauma in localcircumstances, and places of the injury is one of theobjectives of this study carried out at Al-Ibrahim EyeHospital, Isra Postgraduate Institute of ophthalmology,Karachi from January to December 2006; that took adeeper look at the local pattern of ocular trauma,

Original Article

Frequency of Ocular Injuries at Tertiary Care Hospital

A. Khalil Lakho MSc1, A. Haleem Mirani FCPS2, N, M. Sial3

ABSTRACT:Objective: To estimatethe incidenceof the eye injuries reporting at the hospital eye services to facilitate the planners andproviders 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 traumawere included in the study. A team was engaged in examiningthe patient files of ocular injury patients from variousdepartments 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 moreprone to injuries with 24.50%.Next in frequency were children of the age group 0-15 years (21.2%) .Age group 50 yearsand 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 industrialunits; at School 0.55%; due to war/terrorism 0.27%; 0.07% by physical abuse. Place of trauma in 5.49% was notavailable.Conclusion: Males are more involved specially in working age 16-25 years; commonest place of injury in this study washome.Key Words: Eye injuries, age & gender distribution, causes, work places, health services, Pakistan.

Dr. Lakho


itsdistribution, causes and complications. This hospitalis situated in Gadap Town, an important geographicaland agricultural area of Karachi which is one of themega cities of the worldandis situated in south-easternregion of Pakistan.METHODS

This is a retrospective study on indoor andoutdoor patients with ocular injury presented at Al-Ibrahim Eye Hospital duringJanuaryandDecember,2006. All the patients attending general eye OPD,pediatric eye clinic, retina and cataract clinics with thehistory of ocular trauma were included in the study.Thequestionnaire was designed at communityophthalmology department and was piloted over tenpatients selected at random from the said period.Necessary changes were made by removing irrelativevariables / fields and adding required columns.Mostof the variables were coded in order to facilitatestatistical analysis. The team involved in designing andconducting the study consisted of a clinicalophthalmologist, an ophthalmic paramedic and a dataentry operator oriented with statistical methods. Theywere engaged in collecting files of ocular injury patientsfrom various departments of the hospital and filled allrequired data on the printed questionnaire. The datawas double-checked, verified against actual case sheetsand forwarded for data entry.For the purpose of thisstudy, asoftware application was specifically designedusing Microsoft visual basic 6.0 and Microsoft officeaccess 2007. Various statistics were extracted using thestructured query language (SQL).RESULTS:

A Total of 82837 patients attended OPD in year2006 at Al-Ibrahim Eye Hospital, Karachi, out of them1457(1.75%) were with ocular trauma, while 1512 eyeswere affected; thus 55 (3.77%) patient had bilateraltrauma (Table 2). The majority of victims were male.Outof 1457 patients 1277(87.64%) were male, and 180(12.35%) were female, an approximately 1:7 ratio. Thepreponderant age group was 16-25 years accompanyingfor 357 (24.50%) patients of whom 342 were males,followed by children <15 years 309(21.2%). Agedistribution with gender is given in Table 1. More thanhalf of the injuries happened at work place(54.91%),followed by home (31.9%), playground4.39%, farms 3.91%, RTA 2.33%, industry 1.44 %,school 0.55%, war/terrorism 0.27% and 0.07% byphysical abuse. Information about place of injury in5.49% wasnot available (Table 4). Mechanical traumawas the commonest cause of eye injury, accounting for1328 (91.15%), followed by Agricultural trauma, whichwas in 82 eyes (5.63%) (Table 6). Most of the patients,that is 897 (61,56%), were hit by blunt objects, followedby sharp objects in 482(33.08%), chemical burns in

26(1.8%) and heat exposure to 5 eyes (0.34%), withvariable depth of injury. Penetration with perforationwas observed in 194(13.32%) patients, while283(19.42%) patient had perforation only, 29(2.0%)patient had penetration only and 904 (62.04%) hadsuperficial injuries (Table 3). No visual impairment (VA6/6 -6/18) was seen in 921(60.91%), visual impairment(VA <6/18-6/60) in 139(9.19%) patient, severe visualimpairment (VA< 6/60-3/60) in 41(2.71%) and blind(VA< 3/60) were in 271(17.92%). The visual acuity of140(9.25%) was not recorded due to poor cooperationof patient. Table 5 corneal damage was the mostcommon of visual impairment observed in 203(45.01%),followed by posterior segment 145(32.15%) and lensdamage in 103(22.83%) patients. Table: 7DISCUSSION

This study shows that 1.75% (1475) of the patientsattending this tertiary eye care hospital presented with

Table 1: Age and Gender Distribution

Age Group Male Female Total Percent

Up to 15 years 237 72 309 21.20%

16 to 25 years 342 15 357 24.50%

26 to 35 years 264 18 282 19.35%

36 to 50 years 238 43 281 19.29%

Over 50 years 179 29 208 14.28%

Age data N/A 17 3 20 1.37%

Total 1277 180 1457 100%(87.64%) (12.35%)

Table 2: Ocular trauma

Eye No: Cases Percent

Both 55 3.77%

Right 672 46.12%

Left 680 46.67%

NA 50 3.43%

Total 1457 100%

Table 3

Type of Injury No %

Sharp 482 33.08

Blunt 897 61.56

Chemical 26 1.78

Heat 5 0.34

Data not available 47 3.23

Total 1457 100



ocular trauma, significant enough for seekingtreatment. Although it seemed to be a small proportionof the total OPD, yet it was a large number and thetrauma cases that came through ER were not included,which might further increase the incidenceof ocularinjuries

This study showed a high number ofmaleinvolvement in ocular trauma similar to manyhospital and population based studies.12The greatertendency for men to sustain eye injury is multifactorialsuch as work-related, sports related, aggressivebehavior, assault, alcohol, drug abuse and reluctance

to use protective devices at work. This fact is supportedby the high incidence of trauma in working age groups(16 – 35 years) as demonstrated in this study. Similarcorrelations have been demonstrated inother studiesas well.34 The most common affected group in this studyis young adults in 16-25 and 26-35 age-groups.5-6

Bilateral involvement of the eyes was in 3.1% cases inthis study, similar to Karaman et al & Khan etal 7,8.Usually bilateral eye injuries occur as a result of bombblasts, anti-personal mines and motor vehicleaccidents.Pakistan being a country under terroristattacks now for more than a couple of decades andSouthern Pakistan being one of the most affected areassuffers more causalities as a result of various disputes.

Work place, including agricultural trauma, hasbeen recognized as the most common location for ocularinjury in this study.Agriculture is the most commonoccupation in rural Pakistan where the farmers still usevery old techniques of cultivation without anyprotective measures. In other places, ignorance,negligence and lack of protective measures (industries)are the common causes of ocular trauma..Home is thesecond most common location of ocular injury similarto the studies from India917. Both the young and the oldare the most vulnerable for ocular trauma at home.Morethan 80% of ocular trauma was reported to haveoccurred at workplace and home.This study showed ahigh frequency of blunt trauma which was consistentwithsome studies while others report more injuries withsharp objects1011

Agricultural trauma was the most common causeof ocular injuriesreported in this study similar to Indiaand Malawi12’13 and also rural Nepal14. Sport and leisureactivities became the main source of serious eye injuriesin the 1980s with sports associated eye injuriesbecoming responsible for most cases of hospitalized eyetrauma15.In our study trauma at playground were 4.39%(64); compared with study conducted in UK16 were2.3%, and in Malaysia17 was 4.7%.The road trafficaccident took over as the most common cause of seriousinjury in the 1960s and 1970s, with car occupantssuffering penetratinginjuries due to glass18windscreen.Accidents are preventable to a large extent and theycommonly occur as a result of ignorance, haste,negligence, carelessness and lack of knowledge. Thisstudyshows patients were involved in RTA 2.33% (34);and is compared with a study in Balochistan13 where itwas 5.7% of injuries; in Malaysia10 it was 21.4%.CONCLUSION

Young adults at workplace and home are the mostaffected subjects. Agriculture trauma is the mostcommon cause of eye injuries. Amongst other causes,mechanical trauma with flying iron particles is animportant cause of injury in young adults.

Table 4: Frequency of place of injury

Place of Injury Frequency Percentage

Work place 801 54.91%

Home 465 31.90%

Physical abuse 1 0.07%

Playground 64 4.39%

RTA 34 2.33%

School 8 0.55%

BBI 4 0.27%

N/A 80 5.49%

Total 1457 99.99%

Table 5: Visual Acuity in injured eye

VA Group Frequency Percentage

6/6-6/18 921 60.91%

<6/18-6/60 139 9.19%

<6/60-3/60 41 2.71%

<3/60 271 17.92%

NA 140 9.25%

Total 1512 100%

Table 6: Pattern of trauma

Type of Trauma Cases Percentage

Agricultural 782 53.67

Mechanical 628 43.10

Thermal 9 0.62

Chemical 24 1.65

Radiational 4 0.27

NA 10 0.69

Total 1457 100.00



Recommendationsl Public awareness raising and health education for

using eye safety measures, through electronic me-dia, leaflets in community and teaching in Schools.

l Provision of better eye care services at the primarylevel and an emphasis on the training ofparamedical staff in the recognition and treatmentof minor injuries and referral of major ones.

l Education ofthe mother - the first health providerin the home.

l Creatingawareness regarding eye injuries at thegroup level, for example, amongst groups sharinga common occupation or activity such as welders,football players, cyclists and industrial workers.At group level one might channel messagesthrough community health workers, teachers,sports coaches, volunteers and journalists, whothemselves will need to be educated.

l Advocacyamongst leaders and policy makers tointroduce and enforce policies which will helpprevent blindness from injuries, for example,legislation for health and safety at work, thewearing of car seat belts, the banning of explosivefire crackers, etc.

REFERENCES:1. Schin OD, Hibberd P, Shinglten BJ, Kunzweiler T, Frambach

DA, Seddon JM, et al. The spectrum and burden of OcularInjury. Ophthalmology1988; 95: 300-5.

2. h t t p : / / w w w . v 2 0 2 0 e r e s o u r c e . o r g / n e w s i t e n e w s .aspx?tpath=news42007.

3. Negrel AD. Magnitude of Eye Injuries Worldwide.Community Eye Health Journal 1997; 10(24):49-53.

4. John P. Whitcher, M. Srinivasan, Madan P. Upadhyay.Corneal blindness: a global perspective. Bull World HealthOrgan vol.79 no.3 Genebra 2001.

5. Mohammad Daud Khan, Zia-ul-Islam, Khalid Nawaz,Zafar-ul-Islam and M. Aman Khan; penetrating eye injuriesby disposable syringes PJO, Vol.6, No.4, October 1990

6. Mohammad Daud Khan, Niamatullah Khan Kundi, ZiaMohammad and Dr. Anisa F. Nazeer. A 6 1/2 years surveyof intraocular and interorbital foreign bodies in North WestFrontier Province, Pakistan, B.J.O., 1987, 71, 716-719.

7. Brendan Dineen, Rupert Bourne, ZahidJadoon,ShaheenPravin Shah, Causes ofBlindness and VisualImpairment Pakistan. The Pakistan National Blindness andLow Vision Survey 10.1136/bjo.2006.108035 jan 2007

8. Schein OD, Hibberd PL, Shingleton BJ, et al. The spectrumand burden of ocular injury.Ophthalmology.1988;95(3):300-5

9. Katz J, Tielsch JM. Lifetime prevalence of ocular injuries fromthe Baltimore Eye Survey.ArchOphthalmol. 1993; 111(11):1564-

10. Qureshi MB. Ocular injury Pattern in Turbat, Baluchistan,and Pakistan.Community Eye Health Journal.1997; 10(24):57-8.

11. PS Mallika1, AK Tan, T Asok, et al. Pattern of Ocular Traumain Kuching, Malaysia. Malaysian Family Physician 2008; Vol3, No. 3: 140-5

12. Wong TY, Tielsch JM. A population-based study on theincidence of severe ocular trauma in Singapore.Am JOphthalmol.1999;128(3):345-51

13. Shukla IM, Verma RN. A clinical study of ocularinjuries.Indian J Ophthalmol.1979;27(1):33-6

14. Khan MD, Mohammad S, Islam ZU, KhattakMN.An 11 yearsreview of ocular trauma in the North-West Frontier Provinceof Pakistan.Pakistan Journal of Ophthalmology.1991;7:15-8

15. Karaman K, Gveroviæ-Antunica A, Rogošiæ V,etal.Epidemiology of adult eye injuries in Split Dalmatiancountry.Croat Med J. 2004;45(3):304-9

16. Desai P, MacEwen CJ, Baines P, Minaissian DC.Epidemiology and implications of ocular trauma admittedto hospital in Scotland. J Epidemiol Community Health.1996;50(4):436-41

17. Schrader WF. Open globe injuries: epidemiological study oftwoeye clinics in Germany, 1981-1999. Croat MedJ.2004;45(3):268-7

18. S Vats MD, GVS Murthy MD, M Chandra MS et al.Epidemiological study of Ocular Trauma in an urban slumpopulation in Delhi Indian: Indian Journal ofOphthalmology, Vol 56; No 4; 313-316

19. Ilsar M, Chirambo M, Belkin M Ocular injuries in Malawi.Br J Ophthalmol 1982, 66:145-8

20. Nirmalan PK, Katz J, Tielsch JM, Robin AL, et al; Oculartrauma in a rural south Indian population: the AravindComprehensive Eye Survey. Ophthalmology2004,111(9):1778-81

21. Khatry SK, Lewis AE, Schein OD, Thapa MD, Pradhan EK,Katz J. The epidemiology of ocular traumain rural Nepal.BrJ Ophthalmol. 2004 Apr;88(4):456-60.

22. Jones NP. One year of severe eye injuries in sport. Eye 1988;2 (Pt 5): 484-7

23. C J Macewen,Eye injuries: a prospective survey of 5671 cases.Br J Ophthalmol1989 73: 888-894.).

24. PS Mallika1, AK Tan, T Asok, et al. Pattern of Ocular Traumain Kuching, Malaysia. Malaysian Family Physician 2008; Vol3, No. 3: 140-5

25. Canavan YM, O’Flaherty MJ, Archer DB, Elwood JH. A 10-year survey of eye injuries in Northern Ireland, 1967-76.Br JOphthalmol1980; 64(8): 618-25



–––––––––––––––––––––––––––––––––––––––––––––––––––––––1.Registrar Ophthalmology Department Hayatabad MedicalComplex,Peshawar.2. Associate Professor OphthalmologyDepartment, Hayatabad Medical Complex, Peshawar.3 AssistantProfessor Ophthalmology, Bannu Medical College, Bannu, 4 MedicalOfficer Ophthalmology, Hayatabad Medical Complex, Peshawar–––––––––––––––––––––––––––––––––––––––––––––––––––––––Correspondence: Dr Mushtaq Ahmad, House 31B, street no 2,sector N4, Phase 4, Hayatabad, PeshawarE.Mail> [email protected] Cell: 03339119605–––––––––––––––––––––––––––––––––––––––––––––––––––––––Received: Sept’2011 Accepted: March’2012–––––––––––––––––––––––––––––––––––––––––––––––––––––––

Phacoemulsification under Topical Anaesthesiawith Intracameral Lignocaine

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 withintracameral lignocaine in terms of pain, surgical complications, and the outcome.Materials and Methods: Forty eight patients of senile cataract were operated by phacoemulcification under topicalanesthesia with intracameral lignocaine in the department of ophthalmology Hayatabad Medical Complex from January2011 to July 2011. One superior 3.2mm incision and two horizontal side ports with 15 degree were made.The patients andthe 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 scoreof less than 3, that is, mild pain to none. All the surgeries were complication-free except one and the surgeon’s experiencewas favourable in terms of patient’s cooperation, anterior chamber stability, difficulty, and complications. The ocularmovements 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% intracamerallignocaine makes cataract management better in every respect. The anesthesia achieved is adequate for patient comfortand safe cataract surgeryKeywords: Anesthesia, intracameral lignocaine, pain evaluation, manual small incision cataract surgery, topical

Original Article

Dr. Mushtaq

INTRODUCTION:Cataract is the commonest age related disease in

most countries world wide.1,2 There are approximately45 million blind people in the world. At least 80% ofthese people live in developing countries and more thanhalf are blind as a result of cataract. These areas areunder privileged in terms of medical services.Ophthalmology is even scarcely available speciality insuch areas of the world3. Cataract extractions is one ofthe most cost-effective of all surgical interventions interms of quality of life restored. The only treatmentoption for cataract is the surgical removal of the opaquelens and the implantation of an artificial lens.4 The state-of-the-art technique is phacoemulsification with theinsertion of a foldable intraocular lens (IOL) through aself-sealing incision.5 Kelman introduced hisphacoemulsifier in 1967 but many intracapsularsurgeons were not convinced.6 After that Robert Sinskey

and John sheets were more popular in small incisionultrasonic surgery.7 Howard Gimbel introducedcapsulorhexis first time.8 Small incision closing suturesintroduced by John Shepherd and later by HowardFine.9 Kelman performed phacoemulsification intoanterior chamber and D. Calvard, Kratz T performedphacoemulsification into the papillary plane.10

Endocapsular phacoemulcification was introduced byShephard.11

Several studies have demonstrated that topicalanesthesia provides satisfactory analgesia, comparablewith regional blocks (retrobulbar, peribulbar andsubtenon anesthesia).12 On the other hand, even ifcurrent best practice is used, the retro and peribulbartechniques (using a sharp needle in the orbit) can causeserious and life-threatening complications in a limitednumber of cases (0.066%).13 Sub-Tenon’s anaesthesia bycannula can counteract this complication, but itincreases the risk of mild complications of anaesthesia.14

Moreover, these techniques can cause post-operativeakinaesia which is undesirable in one-day surgery. 15

We here describe a topical anesthesia approach forperforming phacoemulsification. We have performeda pain evaluation survey on patients who underwentthis procedure. So for no study available in our setupof phacoemulsification under topical anesthesia withintracameral 0.5% lignocaine.MATERIAL AND METHODS:

This prospective interventional case series


containing forty eight patients of senile cataract wereoperated by phacoemulcification under topicalanesthesia with intracameral lignocaine in thedepartment of ophthalmology Hayatabad edicalComplex from January 2011 to July 2011.

The patients with significant cataract causingimpairment of visual functions not correctable byglasses or with unacceptable glare, polyopia, or reducedquality of vision attributable to cataract and willing forcataract surgery were included in the study. Onlycontraindication was inability to understand verbalcommands. Sensitivity to lignocaine was also anabsolute contraindication to topical anesthesia. Fortyeight patients were included in the study afterperforming tests and investigations for cataract surgeryunder local anesthesia. At the start of the surgery, thepatients were instructed to hold the hand of theparamedical staff and to squeeze the hand wheneverthey felt pain, which was recorded together with thesurgical step during which they felt pain.

Lignocaine 2% drops were instilled in theconjunctival sac 5 minutes before the surgery. The lidsand periocular area were painted with povidone iodine5% solution twice and the patient draped. Once fullydraped, the surgery was started. No superior rectussuture was taken. One superior 3.2mm incision and twohorizontal side ports with 15 degree were made Theentry into the anterior chamber was followed byintracameral injection of diluted 2% lignocaine(xylocaine) solution, either commercially availablepreservative-free or regular 2% lignocaine injection. Inour pain evaluation survey, we gave intracamerallignocaine to all the patients. Then, 2% hydroxy propylmethyl cellulose was injected into the anterior chamberand capsulorrhexis was done. Hydrodissection wasperformed to separate the cortex from the capsule.Divide and concur technique used to emulsify thenucleus. Cortex aspirated with simcoe cannula, thenthe chamber filled with 2% hydroxy propyl methylcellulose foldable intraocular lens implanted in the bag.The gel was washed out and wound hydration done.At the end of the surgery, a subconjunctival injectionof dexamethasone and gentamycin was given (0.25 mleach). The eye was patched for about 2-3 hours, andthen, the dressing was removed, eye was examined,and topical medications were started. Before openingthe dressing, a pain survey questionnaire having visualanalog scale for pain evaluation or Wong scale forsimplified version of pain evaluation was given to thepatients depending on their ability to comprehend. Thesurgeon also evaluated his experience in terms ofsurgical ease or difficulty, complications with regardsto the topical anesthesia at the end of the surgeries. Thesurgeon’s evaluation was based on four parameters.

Patient’s cooperation, difficulty due to ocularmovements, and anterior chamber stability weregraded on a scale of 1-3, thus giving a cumulative rangeof 3-9 points. The questionnaire was designed toprovide results in a manner that the lower valuesrepresent favorable experience. The fourth parameterwas complications or adverse events, which werementioned as and when they happened.RESULTS:

There were 48 patients enrolled in the studyaccording to the inclusion and exclusion criteria.Twenty three (47.9%) patients were male. Patients’ ageranged from 38 to 78 years (mean age 64.2 years).Twenty-one were the right eye and 27 left eye. Type ofcataract according to the morphology was nuclear in36 patients (37.5%), nuclear and subcapsular in 42patients (43.7%), and subcapsular the rest. Nucleardensity ranged from grade I-V and correlated with age.The pain experience during the surgical procedure wasrecorded as the patient’s response by squeezing thehand of the operation theater assistant during thesurgery. The patients felt pain when the viscoelastic wasbeing injected before capsulorrhexis (3 patients), duringthe stretching of the wound while delivering thenucleus (4 patients), and during the irrigation aspirationprocedure (4patients).

The visual analog scale or the Wong scale wasused to evaluate the mean pain score. The mean painscore was 0.70 ±0.97SD, range 0-5). Only five patients(~5%) out of the whole series experienced pain whorated more than three on the visual analog scale of 10.The pain scores more than three has been accepted torepresent moderate pain. Thus, rest of the patients canbe assumed to have mild pain. There were 91 patients(~95%) who had a mean pain score of two or less. Fifty-one patients (53%) had pain score of zero that is no painFigure 1.

Fig 1: Frequency distribution of visual analog scale response ofpatients undergoing cataract surgery under topical anesthesia

Phacoemulsification under Topical Anaesthesia with Intracameral Lignocaine


The surgeon’s evaluation of the technique in termsof surgical ease and complications was favorable. On acumulative scale ranging from 3 to 9 (lower valueindicating favorable result), the average score was 3.4(SD ±0.85). Table 1 for frequency distribution ofindividual parameters taken into account.

Table 1: Frequency distribution of surgeon’s scorefor surgical experience during phacoemulcification

under topical anesthesia (n = 48)

Surgeon’s Patient Unwanted AnteriorScore cooperation ocular chamber

movements stability

1 84 80 92

2 10 13 0

3 2 3 4

Only one patient had a small zonular dehiscence,which did not relate to the anesthesia technique, but itwas because of small capsulorrhexis during theinsertion of the IOL.DISCUSSION:

The described use of topical anesthesia ispresently limited to clear corneal phacoemulsificationtechnique. The advantages are numerous, for thepatients as well as for the surgeon. Topical anesthesiasaves the patients from the risks of globe perforations,optic nerve injury, possibility of life-threateningrespiratory arrest, 16 and above all, the pain and fearperceived because of the peribulbar or retrobulbarinjections. Topical anesthesia has additional benefitslike not interfering with visual function, immediatevisual recovery, absence of pain due to injection,unlimited ocular motility, and absence of an increasein orbital volume.Various studies regarding the painperception and patients’ acceptability for anesthetictechnique have been done and they concluded that thepatients’ satisfaction for anesthesia is comparable fortopical versus other techniques. Besides the patients’subjective appreciation of pain during surgery, whichmay be limited by their tolerance and expression, thereare studies which have investigated the variousphysiological and biochemical parameter changesduring the surgery under topical anesthesia. Fichmanhas investigated the blood pressure, pulse rate, andrespiration rate of patients during surgery under topicalanesthesia and has found no major changes in theseparameters.There is no significant change in the plasmacortisol levels during surgery under topical anesthesia,indicating that the procedure is well tolerated and doesnot pose stress to the patient.Thus, with all theadvantages of topical anesthesia, it may be the preferredtechnique. Lignocaine gel has been previously shown

to be an effective and possibly, a superior substitute tolignocaine drops. There has been no unwanted effectof the gel preparation of the drug on extracapsularcataract surgery and phacoemulsification; both havebeen successfully performed using the 2% lignocainejelly.

In this study, the mean pain score of 0.70 (SD±0.97, range 0-5) is comparable to the studies done ontopical anesthesia use for phacoemulsification. Themean pain score of 0.84 (SD ±1.30, range 0-7) againstperibulbar anesthesia 0.73 (SD ±1.5, range 0-5) was seenin a study done by Philipp, using 2% lignocaine drops.Similar results have been observed with the use oflignocaine 2% jelly for providing topical anesthesia forphacoemulsification for cataract removal in variousother studies. The mean pain score in the present studywas similar to the mentioned studies for the topicalgroup, except that none of the patients in our studiesneeded subtenon lignocaine supplementation as wasrequired by some patients in all the mentioned studies.

Topical anesthesia is used to anesthetizeconjunctiva and sclera for several procedures like scleralindentation, forced duction test, subconjunctivalinjections, pterygium surgery, and cryoapplication forretinal cryopexy. Thus, topical anesthesia is effectiveand safe for manipulating conjunctiva and sclera aswell. This fact has been utilized and demonstrated wellin our study, where the pain experience of the patientshas been comparable to that during phaco-emulsification performed under topical anesthesia asreported in other studies. A pain evaluation studycomparing the delivery of prechopped nucleus througha clear corneal incision and phacoemulsificationthrough clear corneal incision using topical anesthesiahas shown that the perioperative pain is significantlyhigher in the prechop method. The pain experiencedby the patients during cataract surgery under topicalanesthesia is during the steps when there is stretchingof the eye ball. Similar opinion has been expressed byPhilipp et al. , regarding the cause of pain in topicalanaesthesia.

Surgeon’s evaluation of the technique has beenfavorable as demonstrated by the fact that patients’cooperation was good in majority of cases (87.5%). Inmost of the patients, there were no unwanted eyemovements (83%). With topical anesthesia, there is norise in intraocular pressure as compared withperibulbar anesthesia. This is because the placement of5 ml of anesthetic cocktail in the orbit increases theintraocular pressure. Thus, even without the use ofocular pressure, the anterior chamber stability is goodin topical anesthesia. Thus, combiningphacoemulsification with topical anesthesia withintracameral 0.5% lignocaine makes cataract



management better in every respect.CONCLUSION:

Phacoemulsification under topical anesthesia withthe use of 2% lignocaine jelly and 0.5% intracamerallignocaine makes cataract management better in everyrespect. The anesthesia achieved is adequate for patientcomfort and safe cataract surgery.REFRENCES:1. Klein BE,Klein R, Moss SE. Changes in visual acuity

associated with cataract surgery. The Beaver Dam Eye StudyOphthalmology. 1996; 103: 1727-31.

2. Weale RA. The age variation of senile cataract in variousparts of the world. Br J Ophthalmol. 1982; 66: 31-4.

3. Evans JR, Henning A, Pradhan D, et al. Randomized controltrial of anterior chamber intraocular lenses in Nepal: Longterm follow up .Bull World Health Organ. 2000; 78: 372-8.

4. Marseille E. Cost-effectiveness of cataract surgery in a publichealth eye care program in Nepal. World Health Organ BullOMS 1996;74:319-24

5. Porter R. Global initiative: The economic case. Commun EyeHealth 1998;27:44-5.

6. Emery JM, Little TH. Phacoemulsification and Aspiration ofCataract, 1st ed; St. Louis C V Mosby. 1979.

7. Sinkey RM, Cain W Jr. The posterior capsule andphcoemulsification Am. Intraocular Implant Soc. 1978; 4: 26

8. Gimbel HV. Capsulotomy method eases intra-bag-posteriorchamber IOL Ocul Surg News. 1985; 20.

9. Fine IH. Infinity suture in Koch pc. Davisan JA (eds), Textbook of advanced phacoemulsification techniques 1st ed.Tholofare N J Slack. 1991; 383.

10. Calvard Dm, Kratz RP. Endothelial cell loss followingphacoemulsification in the papillary plane. J Am Intraocularimplant Soc T. 1981; 334.

11. Shephard J. In Situ fracture phacoemulsification method,phaco, PI. 1989.

12. Haider SA, Khaqan HA. Topical versus periocular anesthesiafor cataract surgery what is best? Pak J Ophthalmol. 2005,21: 1-5.

13. El-Hindy N, Johnston RL, Jaycock P, et al.; and the UK EPRuser group, The Cataract National Dataset Electronic Multi-centre Audit of 55 567 operations: anaesthetic techniques andcomplications, Eye, 2009;23(1):50–55.

14. Eke T, Thompson JR, Serious complications of localanaesthesia for cataract surgery: a 1 year national survey inthe United Kingdom, Br J Ophthalmol, 2007;91: 470–75.

15. Kumar MC, Dodds C, Ophthalmic reginal block, Ann AcadMed Singapore, 2006;35:158–68.

16. Eke, Tom, Thompson, John R. Serious complications of localanaesthesia for cataract surgery: A 1 year national survey inthe United Kingdom. Br J Ophthalmol 2007;91:470-5.



–––––––––––––––––––––––––––––––––––––––––––––––––––––––1Assistant Professor, 4Postgraduate Trainee, 3Professor and Headof Department, Department of Ophthalmology Allied Hospital, PunjabMedical College Faisalabad.2 Assistant Professor, Islam Medical College, Sialkot.–––––––––––––––––––––––––––––––––––––––––––––––––––––––Correspondence: Dr. Muhammad Nawaz 27/A-1- Satellite Town,Sargodha. Pakistan.E-mail: >[email protected]. Phone: 048 3215253–––––––––––––––––––––––––––––––––––––––––––––––––––––––Received: Oct’2011 Accepted Jan’2012–––––––––––––––––––––––––––––––––––––––––––––––––––––––

INTRODUCTIONCentral Serous Chorio-retinopathy (CSCR) was

described by Albrecht Von Graefe, 150 years ago in1866.1 Since then different etiological and patho-physiological mechanisms have been proposed but stillthe exact aetiology of CSCR is not clear.2

A high proportion of the patients with CSCR werefound to be young males, and especially those workingunder stressful conditions and experiencing acutepsychological trauma.3,4 It may be associated withType-A personality behavior.5 In one study, the use ofpsychopharmacological drugs like anxiolytic and anti-depressive medications were found in 13% of the

patients and author speculated that increasedsympathetic nervous system activity may induceCSCR.6 Choroidal ischemia has been considered as apossible pathophysiologic factor for CSCR.7

Clinically CSCR is characterized by an idiopathicserous detachment of the central neurosensory retina,secondary to retinal pigment epithelium (RPE) leakingpoints as observed on Fundus fluorescein angiography(FFA). Usually it resolves spontaneously within fewmonths.8 But a few patients may require focalphotocoagulation, photodynamic treatment or Anti-VEGF injections given intra-vitreally.9,10,11 The commonpresentation of CSCR is a unilateral complaint ofblurred vision, a relative central scotoma, metamor-phopsia and colour desaturation.12

Different investigative procedures have been usedto confirm the diagnosis and monitor the treatmentefficacy of CSCR, including Fundus fluoresceinangiography (FFA), Indocyanine green (ICG)angiography, and Optical Coherence Tomography(OCT). 13,14

FFA of acute CSCR shows focal hyperfluorescent

Angiographic Features ofCentral Serous Chorio-retinopathy

in Pakistani Population

Muhammad Nawaz1, Muhammad Ahmad2, Prof. Muhammad Sultan3, Faisal Saleem4

ABSTRACTPurpose: To investigate the angiographic features of central serous chorioretinopathy in terms of number of leakingpoints, patterns of leaking points during the angiogram, quadrant-wise location of leaking points in the macula, distanceof leaking points from the centre of fovea, area of detached retina, and the presence or absence of leaking points in thefellow eye.Study design: This was a hospital based, prospective, cross-sectional observational study done at Department ofOphthalmology, 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. Afterdetailed ocular examination fundus fluorescein angiography was done. All the required information of the patients and theresults 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. Onangiography unilateral CSCR was found in 75(87%) patients and 11(13%) patients had bilateral disease. Only one leakingpoint was observed in 73 (75.5%) eyes and more than one leaking points were visible in 24 (24.5%)) eyes. In total 134leaking points were observed in 97 eyes of 86 patients. Out of these, 126 (94%) points followed the ink-blot pattern and8(6%) leaking points followed the smoke-stack pattern. Location wise, 80(60%) leaking points were located in thesuperonasal(SN) quadrant and 32(23%) in superotemporal (ST) quadrant of the macula. Furthermore, 121 (90%) of theleaking points were located within 3.0 mm from the centre of fovea. Unilateral cases have a mean detachment area of24.78±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 SerousChorioretinopathy as in other parts of the world. It affects the young males more commonly and causes significantlyreduced vision. It can be classified as, a more aggressive Type-I disease involving usually one eye with less number ofleaking points but larger area of serous detachment and a less aggressive Type-II, involving both eyes with multipleleaking sites but causing smaller detachmentsKey words: Central Serous Chorioretinopathy, Fundus Fluorescein Angiography, Stress, Inkblot, Smokestack.

Original Article

Dr. Nawaz


leaking point(s) at the level of retinal pigmentepithelium (RPE). These leaking points may be single,multiple or there may be a rarely generalized RPEdysfunction.15, 16.

The objective of this prospective study was toinvestigate about the numbers of leaking points, theleaking pattern of these points during the FFA,quadrant wise location of these leaking points in themacular area, their distance from the centre of fovea,area of serous retinal detachment in millimetre square(mm2) and the presence or absence of RPE leakingpoints in the fellow eyes of Pakistani patients diagnosedfor CSCR.MATERIALS AND METHODS:

This was a hospital based, prospective, cross-sectional observational study done at the Departmentof Ophthalmology, Allied Hospital, Punjab MedicalCollege Faisalabad during July 2007 to June 2011.According to the inclusion criteria, 86 patientspresenting with the diagnosis of CSCR in at least oneeye were enrolled for the study. Patients with historyof previous attacks of CSCR, and the patients with ahistory of any ocular surgery were excluded from thestudy. Similarly diabetic and hypertensive patients andthe patients with any other ocular disease were alsoexcluded from the study. After a detailed history andophthalmic examination of these patients, Fundusfluorescein angiography of both eyes of these patientswas done using Topcon TRC DX-50 Retinal Camera.The coloured fundus photographs and angiograms ofthese patients were stored and analysed usingImagenet ® Topcon software.

CSCR was confirmed angiographically by thepresence of hyperfluorescent leaking point(s) taking thepattern of either inkblot, smokestack or a generalizedRPE dysfunction. An “ink-blot” pattern was assignedwhen a small focal hyperfluorescent leaking pointincreased in size and intensity during the course ofangiogram. A “smokestack pattern” was labelled whenthe hyperfluorescent leakage ascended vertically withlinear configuration and then spreading laterally like aplume of smoke during the course of angiogram.Number of leaking points was noted for eachangiogram. The location of each of these leaking pointswas recorded regarding superonasal, (S.N) inferonasal,(I.N) superotemporal, (S.T) and inferotemporal (I.T)quadrants of the macular region. The macula wasdefined as the retinal area within the temporal vasculararcades. The distance of the centre of leaking pointsfrom the centre of fovea was calculated using theImagenet ® Topcon software. The area of serous retinaldetachment was also measured by marking theboundary of the detachment and then calculating thearea within the boundary using the same programme.

All the findings were entered on a proforma and theresults were analysed using Statistical package for socialsciences (SPSS) for windows (version 16, Inc. Chicago)and t-test was applied for calculating the means and P-values of various outcomes.RESULTS:

Out of 86 patients presenting with the diagnosisof CSCR in at least one eye, 78 (91%) were male and 8(9%) were female with a male to female ratio of 10:1.All patients were Pakistani nationals without any otherracial or ethnic mixture.

The age of the patients ranged from 25 to 60 yearswith a mean of 35±3.0 years. All 86 patients weredivided into four different age groups. Age of 13(15%)patients was between 25 to 30 years, 51(59%) from 31-40 years, 19 (22%) patients from 41-50 years and onlythree (4%) patients aged between 51-60 years (Figure1).

Visual acuity was 6/12 in 20 (21%) eyes, between6/18 to 6/36 in 48 (49%) eyes and between 6/60 tocounting fingers in 29 (30%) eyes (Table I).Angiographically, CSCR was found in one eye of 75(87%) patients and both eyes of 11 (13%) patients. So atotal of 97 eyes of 86 patients were found to be affectedwith CSCR. Left eye was more commonly affected ascompared to right eye (48 vs. 27) while 11 patients hadbilateral disease.

Only one leaking point was observed in 73 (75.5%)eyes, two leaking points were visible in 17 (17.5%) eyes,three leaking points in three (3%) eyes, four leakingpoints in two (2%) eyes and five leaking points in two(2%) eyes (Table II). In total 134 leaking points wereobserved in 97 eyes of 86 patients. Out of these, 126(94%) points followed the ink-blot pattern of fluoresceinleakage, while the smoke-stack pattern was seen in only8 (6%) leaking points.

Quadrant wise location of these 134 leaking pointsin the macular region was noted and it was found that80 (60 %) points were located in the superonasalquadrant of the macula, 32(23%) leaking points werefound in the superotemporal quadrant, 17 (13%) pointswere located in inferonasal quadrant, and only five (4%)leaking points were found in inferotemporal quadrant(Table III). The distance of the 134 leaking points fromthe centre of fovea was also measured in millimetres.Thirty two (24%) leaking points were within 1.0 mmfor the centre of fovea and 55 (41%) points were locatedbetween 1.1mm-2.0mm, while 34 (25%) points werelocated between 2.1mm-3.0 mm from the centre offovea. Only 13 (10%) leaking points were located at adistance of more than 3.0 mm from the centre of fovea.So overwhelming majority (90%) of leaking points werelocated within 3mm from the centre of fovea (Table IV).

In the study we also calculated the area of serous

Angiographic Features of Central Serous Chorio-retinopath in Pakistani Population


retinal detachment by marking the outline of the domeof retinal detachment using the Imagenet software andit was found that usually a large area of the centralretina is detached in this pathology. In 28 (29%) eyesthe detachment area was between 1.0-10 mm2 and in 30(31%) eyes detached retina was in the range of 10-20mm2 while 15 (15.5%) eyes had 21-30 mm2 area of retinaldetachment. In 13 (13.5%) eyes the detached retinalarea was found to be of the size of 31-40 mm2 and 11(11%) eyes had more than 41 mm2 area of serousdetachment (Table V).

DISCUSSION:Clinical entity of central serous chorioretinopathy

was described by Albrecht Von Graefe in 18661 but itwas Maumene, 100 years later, who utilized FundusFluorescein Angiography to demonstrate that thesubretinal fluid in CSCR was derived from thedisturbance of outer blood retinal barrier i.e. retinalpigment epithelium13. Since then different studies havebeen done to find out the demographic andangiographic features of CSCR. In our study, 78 (91%)patients out of 86 patients were male and 8 (9%) patientswere female with a male: female ratio of 10:1. Thisgender distribution of CSCR in Pakistani patients is thesame as reported in most of the studies15, 16, 17 with thefindings that CSCR is 6-10 times more common in malesthan in females. Mean age of our patients was 35 ± 3.0years, with a range from 25 years to 60 years. However81% of our patients were between 31 years to 50 years.This corresponds to the mean age of 41years found ina study in Asian population.18 Our study shows thatthe incidence of CSCR increases during the 4th and 5th

decade of life (Figure 1).Visual acuity was significantly reduced in most

of the patients at the time of presentation. A total of21% patients had visual acuity of 6/12, 49% had visualacuity of 6/18-6/36 and 30% had visual acuity of 6/60to counting fingers only. So a total of 79% patients hadvisual acuity of less than 6/12 at presentation (Table I).

Table I: Visual Acuity of CSCR patients on presentation

Visual Acuity No. of eyes (%)

< 6/12 20 (21)

6/18-6/36 48 (49)

6/60 -CF 29 (30)

Total 97 (100)

Table II: Number of leaking points in CSCR patients

No. of leaks No. of eyes (%) Total no. of leaks

1 73 (75.5) 73

2 17 (17.5) 34

3 3 (03) 9

4 2 (02) 8

5 2 (02) 10

Total 97 (100) 134

Table III: Quadrant-wise location of leaking points in the macula

Quadrant No. of leaks %age

S.N 80 60

S.T 32 23

I.N 17 13

I.T 5 4S.N= Superonasal, S.T=Superotemporal, I.N=Inferonasl, I.T=Inferotemporal

Table IV: Distance of the leaking points fromthe 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

Table V: Area of serous detachment in CSCR

Area in mm2 No. of eyes %age

< 10.0 28 29

11-20 30 31

21-30 15 15.5

31-40 13 13.5

> 40 11 11

Total 97 100


Figure-1Incidence of CSR in relation to age groups


This finding corresponds with the results of otherstudies.19

The “inkblot” pattern of leaking was observed inoverwhelming majority 126 (94%) of leaking points ascompared to “smokestack” pattern which was observedin only 8(6%) leaking points. This finding is comparableto the finding by Mutlak et al.15 But it is in contradictionto the finding of Kansky which states that smokestackpattern of leakage is more common than the inkblotpattern.20

Our study shows that 75% of the eyes affected byCSCR have one leaking point and 25% eyes have twoor more than two leaking points on angiography.Similarly 87% of the patients have unilateral diseasewhile 13 % of the patients have bilateral involvement.These findings support the concept that although CSCRpresents as unilateral disease but in quite a significantnumber of patients CSCR is caused by systemicdisorders resulting in bilateral disease and causingmultiple leaking points of RPE.

T-test analysis of the group statistics revealed thataverage number of leaking points per eye in unilateralcases was 1.48 points, while the average number ofleaking points per eye in bilateral cases was 2.21(P=0.030 & t-value=2.21). These findings suggest thatpossibly there are two different types of CSCR. Firsttype of CSCR causing a localised dysfunction of RPE,involving usually one eye of the patient and a secondtype of CSCR causing widespread RPE dysfunctionresulting in multiple leaking points in both eyes of thepatient.

Location of the leaking points was noted bydividing the macular area into four different quadrantsby drawing a vertical and a horizontal line passingthrough the fovea. A total of 80 (60%) leaking pointswere located in the superonasal(SN) quadrant of themacula involving the RPE beneath the maculopapillarbundle, whereas 32 (23%) leaks were found in thesuperotemporal (ST) quadrant (Table III). Out of therest, 17(13%) leaks were in inferonasal(IN) quadrantand 5(4%) leaks were found in inferotemporal(IT)quadrant. These results show that 83% of the leakingpoints were located above the horizontal raphe oftemporal retina. These findings are almost in the samerange as observed by Mutlak & Dutton in their studyand other studies done in the west. 15,16

Regarding the distance of the leaking points fromthe centre of fovea, it was observed that 121 (90%) ofthe leaking points were within 3.0 mm (2 disc diameter)from the centre of fovea. Only 13(10%) leaks werelocated more than 3.0mm away from the centre of fovea(Table IV). The mean distance of all the leaking pointsfrom the centre of fovea was 1.8 ±1.1mm. These findingconfirm the results of other studies where 82 % of the

leaking points were found within two disc diameter. 15

Central serous chorioretinopathy (CSCR) resultsin exudative detachment of the central retina causing adome shaped elevation of the detached retina. Wemeasured the area of this retinal elevation and the meanarea of detachment was 22.6±15.60 mm. Thismeasurement of the detached retinal area caused byCSCR is done for the first time and has not beenreported in any earlier study. The large area of retinaldetachment corresponds with the profound loss ofcentral vision observed in patients of CSCR.Furthermore t-test analysis revealed that in unilateralcases of CSCR the mean area of detached retina was24.78±15.75 mm2 and in cases of bilateral disease themean area of detached retina was 9.95±6.69 mm2

(P=0.012). These findings suggest that the first type ofCSCR, which is more common, causes less number ofRPE leakages but is more aggressive in nature resultingin relatively larger area of detached retina and a largecentral scotoma. The second type of CSCR, less commonin frequency, seems to be less aggressive in naturecausing multiple RPE defects usually in both eyes ofthe patient. However further extensive studies arerequired to confirm these findings.CONCLUSION:1. Pakistani population has the same demographic

and angiographic features of Central serouschorioretinopathy as in other parts of the world.

2. Central serous chorioretinopathy affects theyoung males causing significant loss of productivework hours adding burden to the economiesalready under stress.

3. Central Serous Chorioretinopathy can beclassified as Type-I, more aggressive but localizeddisease and Type II, less aggressive butwidespread disease of the Retinal PigmentEpithelium.

REFERENCES;1. Graefe A Von. Uber zentrale rezidivierende Retinitis. V

Graefes Arch Ophthal 1866; 12:2112. Marmor MF. On the cause of serous detachments and acute

serous chorioretinopathy. Br J Ophthalmol 1997; 81: 812-133. Harrington DO. Psychosomatic interrelationship in

ophthalmology. Am J Ophthalmol 1948; 31: 1241-514. Zeligs MA. Central angiospastic retinopathy. A

psychosomatic study of its occurrence in military personnel.Psychosom Med 1947; 9: 110-17

5. Yanuzzi LA. Type-A behaviour and central serouschorioretinopathy. Retina 1987, 7: 111-30

6. Tittl MK, Spaide RF, Wong D, et al. Systemic findingsassociated with central serous chorioretinopathy. Am JOphthalmol 1999;128:63-8

7. Kitaya N, Nagaoka T, Hikichi T, Sugawara R, Fukui K, IshikoS, et al. Featuers of abnormal choroidal circulation in centralserous chorioretinopathy. Br J Ophthalmol 2003; 87:709-12

8. Otsuka S, Ohba N, Nakao K. A long-term follow-up studyof severe variant of central serous chorioretinopathy. Retina2002; 22:25-32.



9. Costa RA, Scapucin L,Moraes NS, et al Indocyanine green-mediated photothrombosis as a new technique of treatmentfor persistent central serous chorioretinopathy. Curr Eye Res2002; 25:287-97.

10. Yannuzzi LA, Slakter JS, Gross NE, et al. Indocyanine greenangiography guided photodynamic therapy for treatment ofchronic central serous chorioretinopathy: a pilot study. Retina2003; 23:288-98.

11. Hyun KS, Ji HB, Eung SK, Jae RH, Woo HN, Ha KK.Intravitreal Bevacizumab to treat acute central serouschorioretinopathy: short-term effect. Ophthalmologica.2009;223:343-347

12. Bennett G. Central Serous retinopathy. Br J Ophthalmol1955; 39: 605-18

13. Maumene AE. Fluorescein angiography in the diagnosis andtreatment of lesions of the ocular funds. Trans OphthalmolSoc UK 1968; 88: 529-56.

14. Hee MR, Puliafito CA, Wong C, et al. Optical CoherenceTomography of central serous chorioretinopathy. Am J

Ophthalmol. 1995; 120:65-74.15. Mutlak JA, Dutton GN. Fluorescein angiographic features

of acute central serous retinopathy. A retrospective study.Acta Ophthalmol. 1989; 67:467-69.

16. Spitznas M, Huke J. Numbers, shape and topography ofleaking points in acute type I central serous retinopathy.Graefe’s Arch Clin Exp Ophthalmol. 1987; 225:437-40.

17. Afzal Q, Shafqat AS, Yasir M, Zubairullah K. FactorsAssociated with Central Serous Chorioretinopathy in oursetup. Ophthalmology Update. 2011; 9:7-10

18. Alicia CSW, Adrian HC Koh, Angiographic Charactistics ofAcute Central Chorioretinopathy in an Asian Population.Ann Acad Med Singapore 2006; 35:77-79.

19. Sahu DK, Namperumalsamy P, Hilton GF, De Susa N.Bullous variant of idiopathic central serouschorioretinopathy. Br J Ophthalmol 2000;84:485-92

20. Kansky JJ. Acquired macular disorders and relatedconditions. In: Kansky JJ. editor. Clinical Ophthalmology: asystematic approach. 6th ed. London: Elsevier 2007; 648



–––––––––––––––––––––––––––––––––––––––––––––––––––––––Correspondence: Prof. Dr. Marianne Shahsuvrayan, MD, Ph.D, D.Sc(Medicine), Professor of Ophthalmology, 8th Hospital, Yerevan StateMedical University, Republic of ArmeniaE-mail: [email protected] Address: 7 Ap., 1 Entr., 26 Sayat-Nova Avenue,Yerevan 0001, Republic of Armenia–––––––––––––––––––––––––––––––––––––––––––––––––––––––Prof. Dr. Marianne L. Shahsuvrayan, is a general Ophthalmologistand Professor of Ophthalmology at 8th Hospital, Yerevan StateMedical University in the Republic of Armenia. She has doneconsiderable research work on Retinal Vein Occlusion particularlythe use of non-ophthalmic drugs (calcium channel blockers) inOphthalmology. On the basis of her original work she has earnedPh.D. and Doctorate in Ophthalmic Sciences (D.Sc). She is quiteadept in many languages like English, Armenian and Russian.

………Editor–––––––––––––––––––––––––––––––––––––––––––––––––––––––

Can we use Non-Ophthalmic Drug in Ophthalmology ?(Non-ophthalmic drug potential for ophthalmology)

Prof. Marianne L. Shahsuvrayan, MD, Ph.D, D.Sc (Medicine), Professor of OphthalmologyYerevan 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 variousintracellular signaling processes, have been long and widely used to treat essential hypertension and certain types ofcardiac diseases such as angina pectoris. Among five subtypes of calcium channels, only specific agents for L-typecalcium channels have been used as therapeutics. There are potentially multiple biological bases for the protective effectof calcium channel blockers on eye structures.Objective: The objective of this review is to evaluate the evidence and discuss the rationale behind the recent suggestionsthat 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.

Original Article

Prof. Marianne

INTRODUCTION:Calcium channel blockers, which alter the

intracellular calcium concentration by modifyingcalcium flux across cell membranes and affect variousintracellular signaling processes, have been long andwidely used to treat essential hypertension and certaintypes of cardiac diseases such as angina pectoris.Among five subtypes of calcium channels, only specificagents for L-type calcium channels have been used astherapeutics. Calcium antagonists inducevasodilatation at smooth muscle cells and are neuro-protective through the intracellular decrease of K +.

Calcium channel blockers generally dilate isolatedocular vessels and increase ocular blood flow inexperimental animals, healthy humans, patients withopen-angle glaucoma 1-3 and in patients who havevascular diseases in which considerable vascular toneis present. As well contrast sensitivity in patients withnormal tension glaucoma was found ameliorated by

calcium channel inhibition4,5. Neuroprotective effect ofcalcium channel blockers against retinal ganglion celldamage under hypoxia was shown by Yamada et al. 6,

and also by Garcia-Campos et al.7. Apoptosis,genetically programmed mechanism of cell death inwhich the cell activates a specific set of instructions thatlead to the deconstruction of the cell from within, isnow understood as a final common pathway for retinitispigmentosa. Retinitis pigmentosa is an inherited retinaldegeneration characterized by nyctalopia, ring scotoma,and bone-spicule pigmentation of the retina. Apoptosiscan thus be considered as a therapeutic target forretinitis pigmentosa 8,9.

The general consensus is that intracellularconcentrations of calcium ion are increased in apoptosis10-15 These findings suggest that calcium channelblockers may potentially inhibit ganglion cells andphotoreceptor apoptosis in glaucoma and retinitispigmentosa respectively 3,16

There are potentially multiple biological bases forthe protective effect of calcium channel blockers on eyestructures, as was shown above. The objective of thisreview is to evaluate the evidence and discuss therationale behind the recent suggestions that calciumchannel blockers may be useful in the prevention andthe treatment of different eye diseases.NON-OPHTHALMIC DRUGS1. Diltiazem

Frasson et al.,17 first reported the effects of D-cis-diltiazem, a benzothiazepin calcium channel antagonistwhich blocks both cyclic-nucleotid-gated cationchannels (CNGC) and voltage-gated calcium channels(VGCC) on photoreceptor protection in rd1 mice,


several investigators have reported positive andnegative effects of calcium channel blockers on animalmodels of retinitis pigmentosa 13, 18-24. The intracellularconcentration of calcium ions is subsequently elevated,leading to photoreceptor apoptosis17. Sanges et al.13

demonstrated that systemic administration of D-cis-diltiazem reduced intracellular concentrations ofcalcium, down regulating calpains and photoreceptorapoptosis in rd1 mice. Direct inhibitory effects of D-cis-diltiazem on L-type VGCC have been reported byHart et al.21, and D-cis-diltiazem effectively blocksphotoreceptor light damage in mouse models byinhibiting photoreceptor apoptosis 24. In contrast, L-cisisomer inhibits L-type VGCC similarly to D-cis isomer25.

The difference in action between D-cis and L-cis-diltiazem on photoreceptor apoptosis suggests thatCNGC might also be important for photoreceptorneuroprotection17. Despite these studies, however,Takano et al.23 and Pawlyk et al.26 found no rescue effectsof D-cis-diltiazem on retinal degeneration in rd1 mice,and Bush et al.18 also reported that D-cis-diltiazem wasineffective for photoreceptor rescue in rhodopsim P23Htransgenic rats. The effects of diltiazem on animalmodels of retinal degeneration remain controversial.

Pasantes-Morales et al.27 in human study reportedthat a combination of D-cis-diltiazem, taurin, andvitamin E has beneficial effects on the visual fieldprogression, although the study did not clarify whetherdiltiazem alone demonstrated beneficial effects. Otoriet al.28 evaluated the effect of diltiazem on inhibition ofglutamate-induced apoptotic retinal ganglion cellsdeath and concluded that application of diltiazem donot appear to reduce apoptosis. Investigating thepharmacokinetics of diltiazem after subconjunctivaland topical administration in rabbits and effect onwound healing after the creation of conjunctival flaps,Oruc et al.29 have found that topical and subconjunctivaldiltiazem successfully penetrated the aqueous humor,but did not appear to affect wound healing.

Based on antioxidative action of calcium channelblockers, which have recently been shown, anothertherapeutic target is ocular inflammation. Animal studyof intra-peritoneal injections of either nilvadipine,diltiazem, or vehicle have not found a beneficialinhibitory effect of diltiazem on the pathogenesis ofocular inflammation through the suppression ofinflammation-related molecules30.2. Nimodipine

Nimodipine is an isopropyl calcium channelblocker which readily crosses the blood-brain barrierdue to its high lipid solubility. Its primary action is toreduce the number of open calcium channels in cellmembranes, thus restricting influx of calcium ions intocells. Several clinical trials have unequivocally shown

that nimodipine is capable of preventing neurologicaldeficits secondary to aneurysmal subarachnoidhaemorrhage. The results of the VENUS (very earlyNimodipine use in stroke) study do not support theconcept that early nimodipine exerts a beneficial effectin stroke patients 31 . On the other hand oral nimodipineshowed an enhanced acute reperfusion if appliedwithin 12 hours of onset of acute stroke 6,31,32. Yamadaet al.,6 in experimental in vitro model revealed thatnimodipine have a direct neuroprotective effect againstretinal ganglion cells damage related to hypoxia.

Michelson et al.,33 have evaluated the impact ofnimodipine on retinal blood flow in double-blind, two-way, crossover study of healthy subjects and found thatorally administered at a dosage of 30 mg three times aday nimodipine significantly increases retinal perfusionin healthy subjects. Based on experimental findingsShahsuvaryan34 investigated the efficacy of nimodipinein the prospective comparative clinical interventionalstudy of patients with non-arteritic anterior andposterior optic neuropathy. The author stated thatincrease in visual acuity was higher in the posteriorischemic neuropathy subgroup than in the anteriorischemic subgroup. Visual field testing during thefollow-up also revealed positive transformation ofvisual field defects size and location, which correlatedto visual acuity changes. These encouraging findingsneed to be confirmed by double-blind study.

Nimodipine has also been shown to significantlyinhibit the growth of new vessels in experimental ratmodel of retinopathy of prematurity35. Vascularendothelial growth factor (VEGF) can induce cellproliferation by activating the calcium channel in cellmembrane through the influx of calcium increased.Another animal study36 also have found a beneficialinhibitory effect of nimodipine on proliferativeretinopathy by blocking the influx of calcium andexpression of VEGF.

The impact of nimodipine on ocular circulationin normal tension glaucoma have been evaluated inmany clinical studies. Piltz et al.,37 have described aperformance-corrected improvement in visual fielddeviation and contrast sensitivity in patients withnormal tension glaucoma (NTG) and in control subjectsin a prospective, placebo-controlled double-maskedstudy after oral administration of nimodipine (30 mgtwice a day). Other authors 38 also stated that a singledose of 30mg nimodipine normalizes the significantlyreduced retinal blood flow in NTG patients with clinicalsigns of vaso-spasmic hyperactivity. Luksch et al.,1 haveexamined the impact of 60 mg nimodipine in NTGpatients 2 hours after oral administration. Resultsdisclosed that nimodipine increased the blood flow ofthe optic nerve head by 18% and improved color-

Can we use Non-Ophthalmic Drug in Ophthalmology ?


contrast sensitivity. Thus, nimodipine is potentiallyuseful calcium channel blocker for eye disorderstreatment due to its high lipid solubility and ability tocross the blood-brain barrier.3. Nilvadipine

Recent experimental evidences suggest thatNilvadipine appear to have beneficial effects ondifferent ocular structures. Ogata et al.,39 haveevaluated the effects of nilvadipine on retinal bloodflow and concluded that this agent may directly andselectively increase retinal tissue blood flow, whilehaving only minimal effect on systemic circulationincluding arterial blood pressure. Another experimentalstudy conducted by Uemura and Mizota40 have alsoadvocated the use of nilvadipine for the treatment ofglaucoma or other retinal diseases that have somerelation to apoptosis, based on claims that nilvadipinehas high permeability to retina and neuroprotectiveeffect to retinal cells. Otori et al.,28 in the experimentalstudy of different calcium channel blockers protectiveeffect against glutamate neurotoxicity in purified retinalganglion cells has found that nilvadipine significantlyreduce glutamate-induced apoptosis.

Systemic administration of nilvadipine has beenshown to be effective for protecting photoreceptors inrats experienced by the Royal College Surgeons20, onrd1 mice23, and heterozygous rd2 (rds) mice24 Inaddition to direct effects of calcium channel blockerson intracellular concentrations of calcium ion inphotoreceptor cells, other indirect effects are expectedsuch as increased expression of fibroblast growth factor(FGF)2 23 and ciliary neurotrophic factor (CNTF) in theretina24 ,and increased choroidal blood flow 2.

In the latest animal study of intraperitonealinjections of nilvadipine Ishida et al,30 have found abeneficial inhibitory effect of this drug on thepathogenesis of ocular inflammation through thesuppression of inflammation-related molecules. Severalclinical trials have shown the effectiveness ofnilvadipine in retinitis pigmentosa and glaucoma.Ohguro41 reported the photoreceptor rescue effects ofnilvadipine in a small patient group. Nakazawa et al.,16

expanded his nilvadipine study for RP patients toconfirm the results. Although both treated and controlgroups are still small, authors results have shownsignificant retardation of the mean deviation (MD)slope as calculated by the central visual field (HumphryVisual Field Analyzer, 10-2 Program) after a mean of48 months of observation. As these pilot studies aresmall-sized and cannot completely exclude possiblebiases, a large-scale, randomized, multicenter humantrial of calcium channel blockers is required in order toevaluate their efficacy as therapeutic agents for retinitispigmentosa. The potential beneficial impact of

nilvadipine on ocular circulation in normal tensionglaucoma has been evaluated in different clinicalstudies.

Yamamoto et al.,42, Tomita et al.,43, Niwa et al.,44

have found that nilvadipine reduces vascular resistancein distal retrobulbar arteries and significantly increasesvelocity in the central retinal artery in patients withnormal tension glaucoma. Tomita et al.43 also stated thatreduced orbital vascular resistance after a 4-weektreatment with 2 mg oral nilvadipine consequentlyincreases the optic disc blood flow. Koseki et al.2

conducted a randomized, placebo-controlled, double-masked, single-center 3-year study of nilvadipine onvisual field and ocular circulation in glaucoma withlow-normal pressure. No topical ocular hypotensivedrugs were prescribed.

The authors concluded that nilvadipine (2 mgtwice daily) slightly slowed the visual field progressionand maintained the optic disc rim, and the posteriorchoroidal circulation increased over 3 years in patientswith open-angle glaucoma with low normal intraocularpressure. The results of this study add to the growingbody of evidence that nilvadipine may be useful forneuroprotection in glaucoma. Thus, nilvadipine ispotentially useful calcium channel blocker for eyedisorders treatment due to its hydrophobic nature withhigh permeability to the central nervous system,including the retina and the highest antioxidant potencyamong calcium channel blockers.4. Other Calcium Channel Blockers

The experimental study conducted by Oku et al.,45 evaluated the effect of topical Iganidipine, a newDihydropyridine derivative calcium channel blocker onthe impaired visual evoked potential after endothelin-1 injection into the vitreous body of rabbits and haveadvocated iganidipine eyedrops for the treatment ofischemic retinal and optic nerve disorders for themaintenance of visual function.

The latest experimental study46 evaluated aneuroprotective effect of another new calcium channelblocker lomerizine. The authors stated that lomerizinealleviates secondary degeneration of retinal ganglioncells induced by an optic nerve crush injury in the rat,presumably by improving the impaired axoplasmicflow. Tamaki et al.,47 also investigated the effects oflomerizine on the ocular tissue circulation in rabbitsand on the circulation in the optic nerve head andchoroid in healthy volunteers and have found thatlomerizine increases blood velocity, and probably bloodflow, in the optic nerve head and retina in rabbits, andit also increases blood velocity in the optic nerve headin healthy humans, without significantly altering bloodpressure or heart rate.



CONCLUSIONIn conclusion, there are potentially multiple

biological bases for the therapeutic effect of calciumchannel blockers in eye diseases. Taken into accountthat not all calcium channel blockers are equallyeffective, the challenge for future laboratory researchwill be to determine the best type and dosage of calciumchannel blockers and also to determine which processesare modulated by these drugs in vivo and therefore areprimarily responsible for the apparent beneficial effectsobserved in the previous studies.

Clearly, further observational studies cannotadequately address many unanswered questions. It istime to conduct a randomized controlled trial to providedirect evidence of the effectiveness of specific typenonophthalmic drug - calcium channel blocker indifferent eye diseases.REFERENCES1. Luksch A, Rainer G, Koyuncu D, Ehrlich P, Maca T, Gschwandtner

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21. Hart J, Wilkinson MF, Kelly MEM, Barnes S (2003). Inhibitoryaction of diltiazem on voltage-gated calcium channels in conephotoreceptors. Experimental Eye Research. 76(5):597-604.

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23. Takano Y, Ohguro H, Dezawa M, Ishikawa H, Yamazaki H, OhguroI, Mamiya K, Metoki T, Ishikawa F, Nakazawa M (2004). Study ofdrug effects of calcium channel blockers on retinal degenerationof rd mouse. Biochemical and Biophysical researchCommunications. 313(4):1015-1022.

24. Takeuchi K, Nakazawa M, Mizukoshi S (2008). Systemicadministration of nilvadipine delays photoreceptor degenerationof heterozygous retinal degeneration slow (rds) mouse.Experimental Eye Research. 86(1):60-69.

25. Cia D, Bordais A, Varela C, Forster V, Sahel JA, Rendon A, PicaudS (2005).Voltage-gated channels and calcium homeostasis inmammalian rod photoreceptors. Journal of Neurophysiology.93(3):1468-1475.

26. Pawlyk BS, Li T, Scimeca MS, Sandberg MA, Berson EL (2002).Absence of photoreceptor rescue with KD-cis-diltiazem in the rdmouse. Investigative Ophthalmology and Visual Science.43(6):1912-1915.

27. Pasantes-Morales H, Quiroz H and Quesada O (2002). Treatmentwith taurine, diltiazem, and vitamin E retards the progressive visualfield reduction in retinitis pigmentosa: a 3-year follow-up study.Metabolic Brain Disease. 17(3):183-197.

28. Otori Y, Kusaka S, Kawasaki A, Morimura H, Miki A, Tano Y(2003). Protective effect of nilvadipine against glutamateneurotoxicity in purified retinal ganglion cells. Brain Res.31;961(2):213-219.

29. Oruç S, Orhan D, Orhan M, Irkeç M, Baºçi N, Barun S, Bozkurt A(2000). The pharmacokinetics and effects of diltiazem in rabbits.Eur J Ophthalmol. 10(1):46-50.

30. Ishida S, Koto T, Nagai N, Oike Y (2010). Calcium channel blockernilvadipine, but not diltiazem, inhibits ocular inflammation inendotoxin-induced uveitis. Jpn J Ophthalmol. 54(6):594-601.

31. orn J.de Haan RJ,Vermeulen M.(2001). Very Early Nimodipine Usein Stroke (VENUS): a randomized, double-blind, placebo-controled



trial.Stroke.32:461-465.32. Infeld B, Davis SM, Donnan GA. (1999). Nimodipine and

perfusion changes after stroke. Stroke.30:1417-1423.33. Michelson G, Wärntges S, Leidig S, Lötsch J, Geisslinger G (2006).

Nimodipine plasma concentration and retinal blood flow in healthysubjects. Invest Ophthalmol Vis Sci. 47(8):3479-86.

34. Shahsuvaryan ML (2008). Neuroprotective therapy in ischemicoptic neuropathy. 7th International Symposium on OcularPharmacology and Therapeutics. Budapest, Hungary, A60.

35. Juarez CP, Muino JC, Guglielmone H, Sambuelli R, EcheniqueJR, Hernandez M, Luna JD (2000). Experimental retinopathy ofprematurity: angiostatic inhibition by nimodipine, ginkgo-biloba,and dipyridamole, and response to different growth factors.Eur JOphthalmol.10(1):51-59.

36. KongY, Han LR, Peng YS, Deng DY (2004). Experimental studyof nimodipine and vascular endothelial growth factor inproliferative retinopathy. Zhonghua Yan Ke Za Zhi. 40(5):226-330.

37. Piltz JR, Bose S, Lanchoney D (1998). The effect of nimodipine, acentrally active calcium antagonist, on visual function and mascularblood flow in patients with normal-tension glaucoma and controlsubjects. J Glaucoma. 7(5):336-342.

38. Michalk F, Michelson G, Harazny J, Werner U, Daniel WG, WernerD (2004). Single-dose nimodipine normalizes impaired retinalcirculation in normal tension glaucoma. J Glaucoma. 13:158-162.

39. Ogata Y, Kaneko T, Kayama N, Ueno S (2000). Effects ofnilvadipine on retinal microcirculation and systemic circulation.Nippon Ganka Gakkai Zasshi. 104(10):699-705. Japanese.

40. Uemura A, Mizota A (2008). Retinal concentration and protectiveeffect against retinal ischemia of nilvadipine in rats. Eur J

Ophthalmol. 18(1):87-93.41. Ohguro H (2008). New drug therapy for retinal degeneration .

Nippon Ganka Gakkai zasshi. 112(1):7-21.42. Yamamoto T, Niwa Y, Kawakami H, Kitazawa Y (1998). The effect

of nilvadipine, a calcium-channel blocker, on the hemodynamicsof retrobulbar vessels in normal-tension glaucoma. J Glaucoma.7(5):301-305.

43. Tomita G, Niwa Y, Shinohara H, Hayashi N, Yamamoto T, KitazawaY (1999). Changes in optic nerve head blood flow and retrobularhemodynamics following calcium-channel blocker treatment ofnormal-tension glaucoma. Int Ophthalmol. 23(1):3-10.

44. Niwa Y, Yamamoto T, Harris A, Kagemann L, Kawakami H,Kitazawa Y (2000). Relationship between the effect of carbondioxide inhalation or nilvadipine on orbital blood flow in normal-tension glaucoma. J Glaucoma. 9(3):262-267.

45. Oku H, Sugiyama T, Kojima S, Watanabe T, Ikeda T (2000).Improving effects of topical administration of iganidipine, a newcalcium channel blocker, on the impaired visual evoked potentialafter endothelin-1 injection into the vitreous body of rabbits. CurrEye Res. 20(2):101-108.

46. Karim Z, Sawada A, Kawakami H, Yamamoto T, Taniguchi T(2006). A new calcium channel antagonist, lomerizine, alleviatessecondary retinal ganglion cell death after optic nerve injury in therat. Curr Eye Res. 31(3):273-283.

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–––––––––––––––––––––––––––––––––––––––––––––––––––––––*The study was approved by the Research and Ethical Committee,School of Medical Sciences, Universiti Sains, Malaysia–––––––––––––––––––––––––––––––––––––––––––––––––––––––1,2,Ophthalmologists, Advanced Medical and Dental Institute,Universiti Sains Malaysia, 13200 Kepala Batas, Pulau Pinang,Malaysia 3Senior Ophthalmologist & Medical Lecturer in theDepartment of Ophthalmology, School of Medical Sciences,Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan,Malaysia.–––––––––––––––––––––––––––––––––––––––––––––––––––––––Correspondence: DrZunaina Embong, Medical Lecturer & SeniorOphthalmologist, Department of Ophthalmology, Universiti SainsMalaysia. E.Mail>[email protected]–––––––––––––––––––––––––––––––––––––––––––––––––––––––Acknowledgement: The management of Ophthalmology Updatethanks Dr. Embong Zunaina for permitting to reprint the originalarticle with reference to her E-Mail dated: 31st Jan’2012–––––––––––––––––––––––––––––––––––––––––––––––––––––––

Intravitreal Triamcinolone (IVTA)vs Laser Photocoagulation

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 ofvisual loss. However recurrences are common and despite laser treatment, patients with diabetic macular oedemaexperienced progressive loss of vision. Stabilization of the blood retinal barrier introduces a rationale for intravitrealtriamcinolone 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 betweenintravitreal triamcinolone acetonide (IVTA) and laser photocoagulation.Methods: This comparative pilot study consists of 40 diabetic patients with diabetic macular oedema. The patients wererandomized into two groups using envelope technique sampling procedure. Treatment for diabetic macular oedema wasbased on the printed envelope technique selected for every patient. Twenty patients were assigned for IVTA group (oneinjection of IVTA) and another 20 patients for LASER group (one laser session). Main outcome measures were meanBCVA 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 monthspost 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 LASERgroup 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 diabeticmacular oedema at three months post treatment.

Original Article

INTRODUCTIONBackground:

Diabetic macular oedema (DME) is the leadingcauses of blindness in an increasing number of patientswith diabetes. Reduction of visual acuity in DME resultsfrom accumulation of fluid produced from a ruptureof the blood-retinal barrier into the inner nuclear layerof the retina. The thickened macula can be visualizedon slit lamp examination using 90 Dioptre or 78 Dioptre

lens. The retinal thickness can be measured orquantified by Optical Coherent Tomography (OCT),Confocal laser scanning using Heidelberg RetinaTomography II (HRT II) or Retinal Thickness Analyzer.

Scanning laser tomography (SLT) in HRT II is anon-invasive technique which permits the objective,topographic measurement of the fundus. SLT employsconfocal optics to attain a high resolution not onlyperpendicular to x and y axis but also along z axis (theoptical axis). The distribution of reflected light intensityalong the optical axis for a given pixel is described asthe z-profile or confocal intensity profile. An oedemaindex can be derived for each pixel, which is sensitiveto oedematous changes of the retina. A resultant mapof these oedema indices gives a measure of the locationand extent of retinal oedema. It should be noted thatthe macular oedema index (MEI) is not a measure ofretinal thickness but reflects the changes of retinalthickness based on the retinal refractive index in theareas of oedema. The oedema index methodology hasbeen validated in diabetic retinopathy but not in otherdisease states. Change of the oedema index has beenshown to correlate with change of visual function,including logarithm of the minimum angle of resolution

Dr. E. Zunaina


(log MAR) visual acuity, conventional automated staticperimetry and short-wavelength automated perimetry,in patients undergoing grid laser treatment for clinicallysignificant macular oedema.1

Laser photocoagulation reduces the risk of visualloss in 60% of patients. However recurrences arecommon and despite laser treatment, 26% of patientswith DME experienced progressive loss of vision.2

Furthermore, 40% of treated eyes that had retinaloedema involving the centre of the macula at baselinestill had oedema involving the centre at 12 months, asdid 25% of treated eyes at 36 months.3 The frequencyof an unsatisfactory outcome following laserphotocoagulation in some eyes with DME hasprompted interest in other treatment modalities.

Intravitreal triamcinolone acetonide (IVTA) hasbeen shown experimentally to reduce the breakdownof blood retinal barrier.4 It down regulates theproduction of vascular endothelial growth factor; aknown vascular permeability factor hence reduced thevascular permeability. Stabilization of the blood retinalbarrier introduces a rationale for IVTA treatment inDME.

IVTA has proved to be effective in the treatmentof DME from previous study. It constitutes a newer,less destructive treatment modality in the managementof DME. Two previous studies of primary IVTA inDME5,6 have shown improvement on visual acuity aswell as central macular thickness. Massinet. al.compared the use of IVTA as an adjunctive therapy inDME eyes which failed laser treatment where iteffectively reduced the macular thickening.7 Jonas et.al. in 2003 reported in their prospective, interventional,clinical case series study, the visual acuity hadsignificantly improved with IVTA.8

This study is designed to compare the bestcorrected visual acuity (BCVA) and the macularoedema index (MEI) at 3 months of primary treatmentfor DME between IVTA and laser photocoagulation.Confocal laser scanning machine, HRT II is used toquantify the MEI pre and post treatment. To ourknowledge, HRT II has never been used as anevaluation tool in comparative study to assess macularoedema in DME before and after treatmentMATERIAL & METHOD:

A comparative pilot study was conducted fromJune 2007 to February 2008, at Hospital UniversitiSainsMalaysia, Kelantan, Malaysia. It was calculated basedon improvement of visual acuity in IVTA, 81%8 and25% in laser photocoagulation group.9 A total 40patients (20 per arm) was required for this study.

Diabetic patients with newly diagnosed clinicallyas DME, and age more than 18 years old were includedin this study. Patients with media opacity impairing

intravitreal injection or laser photocoagulationprocedure, DME with proliferative diabetic retinopathystill undergoing pan retinal photocoagulation, historyof ocular surgery (eg. cataract operation) or Yagprocedure with the risk of further aggravating themacular oedema, intra-ocular pressure > 25 mmHg orany established glaucoma patient, ocular or systemicinfection, known steroid allergy or responder, historyof systemic steroid within 4 months prior torandomization and HbA1c more than 10% wereexcluded from the study.

Sampling Procedure: Envelope techniquesampling procedure was conducted. A stack of opaqueenvelope was prepared with 20 envelopes containinga piece of paper with the word ‘IVTA’ and theremaining 20 envelopes stated ‘LASER’. The envelopewas drawn for each patient by a co-investigator. Thiswas performed once the patient had agreed to beincluded in the study.

Study Procedure: All patients underwent acomplete ocular and systemic assessment once theyconsented for the study. The assessment was performedby the primary investigator before they wererandomized into the two groups.1. Pre-treatment Parameters Measurements1.1 Visual Acuity: Visual acuity of both eyes wastested with the standard retro illuminated Snellen chart.BCVA for each eye was recorded in logarithm of theminimum angle of resolution (log MAR) notations10 andused as a baseline.

All patients underwent subjective refraction byone optometrist. This is important as any astigmatismof -1 Dioptre and more need to be corrected withastigmatism lens before proceeding with the HRT II formeasurement of MEI.1.2. Fundus Examination: Fundus examination wasdone using 78 Dioptre lens on slit lamp bio microscopyand binocular indirect ophthalmoscopy. DME wasclassified as mild, moderate and severe based on theInternational Clinical Diabetic Macular OedemaDisease Severity Scale.11

1.3 Macular Oedema Index: MEI analysis has beenincorporated within the HRT II as the macular oedemamapping (MEM). The baseline MEM was taken usingthe HRT II. Patients were properly positioned in frontof the HRT II system with their full correction ofastigmatism if any. The focus was then adjusted to geta clear image of the macula formed on the monitor.Three sets of three consecutive images were capturedeach time. To ensure image quality and properhandling, all guidelines recommended by themanufacturer were followed.

The best image was chosen based on the qualityand smallest standard deviation. One good quality scan

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 mmdiameter circle was drawn using the circle draw facilityof the HRT II. The area was chosen based on the mostoedematous area and the same area was marked forthe follow up photograph at three months.Measurement of MEI was performed by a blindedtrained medical technician. After the baselinemeasurement of MEI, all the patients were randomizedusing the envelope technique. The type of treatmentselected would be performed the next day.TREATMENT PROCEDURE2.1 Laser Photocoagulation:

Patients were properly positioned on a stable chairwith the chin rested on the slit lamp that was mountedwith a laser wavelength, Carl Zeiss Visulas 532S lasersystem. Patients were given grid or focal laserdepending on the type of the macular oedema. Topicalanaesthetic, 5% proparacaine hydrochloride wasinstilled in the eye which needed to be lasered. The lasersettings were 50 micron spot size, duration of 0.1seconds and appropriate power started from 50 mWand stepped up till it burned the retina with light grayburn. The number of laser burn given was based onthe severity of diabetic macular oedema (range: 20 -200 laser burns and 500 ìm away from the centre of thefovea). Only one session of laser (either focal or gridlaser) was given to each patient in LASER group. Theprocedure was done by Investigator A (ophthalmo-logist). Patient was follow-up at 3 months post laserand no other treatment was given during that period.2.2 Intravitreal Triamcinolone Acetonide:

Intravitreal injection of triamcinolone was carriedout under sterile conditions in the operation room.Patient was admitted on a day care basis. Topicalchloramphenicol four times a day was prescribed oneday prior to procedure. The procedure was done underlocal anaesthesia using topical 5% Proparacainehydrochloride. The selected eye was properly cleanedand draped. An eye speculum was then applied; flushirrigation with 5 mls 5% Povidone iodine wasperformed on the eye for one minute.

Triamcinolone acetonide in a single-use vial(40mg/ml, 1 ml vial), was drawn into a 1-cc tuberculinsyringe after cleansing the top of the bottle with analcohol wipe. A separate 27 gauge needle was placedonto the syringe, which was then inverted to removeair bubbles. The excess triamcinolone was discardedtill 0.1 ml (4 mg) remained in the syringe.

The site of injection was then identified, at 3.5 mmin pseudophakic and 4 mm in Phakic eye to ensureagainst passage of the needle through the vitreous base.It was given at the infero-temporal region to avoid drugdeposition in front of the visual axis. Triamcinoloneacetonide of 4 mg in 0.1 mls was injected into the

vitreous using a 27-gauge needle trans-conjunctivally.Using a single, purposeful continuous maneuver, the 4mg triamcinolone acetonide was injected into the eye.The needle was removed simultaneously with theapplication of cotton tipped applicator over its entrysite to prevent regurgitation of the injected material.Indirect ophthalmoscopy was performed to check forcentral retinal artery pulsation. The procedure was doneby Investigator B (ophthalmologist). Topical chloram-phenicol four times daily would be continued for oneweek. Only one injection of IVTA was given to eachpatient in IVTA group. Patient was follow-up at 3months post IVTA and no other treatment was givenduring that period.3. Post-treatment Parameters Measurements:Patient was follow-up at 3 months post procedure. Thesimilar step of visual acuity and MEI assessment as pre-treatment measurement was done. The outcomemeasures were mean BCVA and mean MEI.

Statistical Analysis: All the statistical methodanalysis was done with Statistical Package for SocialSciences (SPSS Inc) software, version 12.0. Normalitywas tested using Eye-balling (histogram pattern).Independent T-test, paired T-test and Chi square testwere used to analyze the results where appropriate.The p value of < 0.05 is considered as statisticallysignificant.

Ways to minimize study error: The followingsteps were taken to reduce errors while conducting thestudy:-(i) Patients were selected strictly based on the

inclusion and exclusion criteria.(ii) Randomization of patients.(iii) IVTA and laser photocoagulation were performed

by experienced ophthalmologist who was maskedto patient’s identity. A standardized techniquewas used for both procedures.

(iv) The measurement of MEI was performed by oneidentified and trained medical technician.

(v) The primary investigator was masked to patient’sidentity and procedures when analyzing the MEIresults (pre and post intervention) of all patients.

RESULTS:Demographic Data: A total of 40 patients were

enrolled into this study. Twenty patients were assignedfor IVTA group and another 20 patients for LASERgroup. Mean age, duration of Diabetes Mellitus (DM),and status of HbA1c of patients in IVTA and LASERgroup is shown in Table 1. There were 8 males (40%)and 12 females (60%) in the IVTA group while 11 males(55%) and 9 females (45%) in the LASER group. Theseverity of DME for both groups is shown in Table 2.

Comparison of BCVA and MEI: The comparisonof mean BCVA and MEI in both groups at baseline and



at three months post treatment is shown in Table 3. Themean difference for BCVA and MEI within the groupat baseline and at three months post treatment wasstatistically significant (p < 0.01). The comparison ofmean BCVA and MEI between IVTA and LASERgroups at baseline and three months post treatment isshown in Table 4. The mean difference for BCVA at

Table 2. Distributions of cases according to severity of DME

Severity of DME IVTA (n = 20) LASER (n = 20) *p value

n % n %

Mild 6 30 9 45 0.265

Moderate 8 40 9 45

Severe 6 30 2 10DME: Diabetic macular oedema, *Chi square test, p < 0.05significant

Table 3. Comparison of best corrected visual acuity and macular oedema index within the groupat baseline and at three months post treatment

At baseline At 3 months post treatment (95% CI of mean difference) *p valueMean 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 groupsat baseline and at three months post treatment

IVTA (n = 20) LASER (n = 20) (95% CI of mean difference) *p valueMean 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

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 valueMean 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) 0.762DM: Diabetes Mellitus, *Independent T-test, p < 0.05 significant

baseline and at three months post treatment betweenIVTA and LASER was not statistically significant (p =0.113 and p = 0.151 respectively). Similarly, the meandifference for MEI at baseline and at three months posttreatment between IVTA and LASER group was alsonot statistically significant (p = 0.106 and p = 0.811respectively).DISCUSSION

We conducted this comparative pilot study toassess whether there was a significant differencebetween IVTA and laser photocoagulation with a singletreatment as primary treatment of DME at three monthsby evaluating the BCVA and MEI. We used HRT II toevaluate the DME. We did not perform OCT to quantifythe DME. MEM of HRT II showed very good agreementwith fundus biomicroscopy in diabetic maculopathy.1

In this study, the duration of DM in both groupswere comparable (p = 0.972). Mean diabetic controlled



as being shown by the HbA1c results were almost thesame in each group, 8.92 (0.81) in IVTA and 9.01 (0.95)in LASER group. The HbA1c results showed moderatecontrolled of DM among our study samples. Ourpatients had poor control of DM compared to study byBatioglu and colleagues where the HbA1c was 4% to6%.12

In our study, we treat the patient either IVTA orlaser for DME and review the mean BCVA and MEI atthree months post procedure. Three months follow-upwas chosen because only a single treatment was given.The requirement of re-treatment if needed will be givenafter three months. The mean BCVA in IVTA group atthree months was 0.405 (0.224) and 0.525 (0.289) inLASER group. The mean difference at three months wasnot statistically significant (p = 0.151) which meant thatneither IVTA nor laser were superior to each other as aprimary treatment of DME at 3 months of treatment.Our result showed a comparable outcome with studydone by Lam et al.13

The significant improvement of BCVA in the IVTAgroup (p < 0.01) in our study was similar to the studiesreported by few published data.1,14 Our result alsoshowed significant improvement of BCVA post lasertherapy at three months (p < 0.01). However a studydone by Lee et al15 showed no significant improvementof BCVA at three months after laser treatment.

The mean MEI at three months in IVTA groupwas 1.753 (0.614) and 1.711 (0.472) in the LASER group.The mean difference of both groups was not statisticallysignificant (p = 0.811). Both modalities demonstratedcomparable outcome of reduction of MEI at threemonths. There was no published data on study usingHRT II as an objective evaluation for DME post IVTAor laser treatments. Hence we could only compare ourstudy with study using OCT measurement. Lam et alagain reported comparable outcome of central macularthickness of IVTA and laser treatment at three monthswhich was similar to our result.13

The significant improvement of mean MEI at threemonths in the IVTA group in our study (p < 0.01) wascomparable to previous studies using OCTevaluation.1,5,14,16–18 We also found that the mean MEI inthe LASER group also showed significant improvementat three months (p < 0.01). However, Lee et al[15]

reported that there was no significant improvement ofcentral macular thickness at 3 months after lasertreatment. They found that for DME patients, thecombination treatment (laser and IVTA) had a bettertherapeutic effect than the laser alone for improvingBCVA and central macular thickness at the early follow-up time periods.15

Limitation of this present study is our number ofpatients was relatively small and a bigger sample size

would give a better and reliable result. Anotherlimitation of this study was a short duration of followup. A longer period of follow up, at least over 12 monthswould give more value especially to arrive a treatmentrecommendation and able to assess the side effect ofTriamcinolone. The analysis of macular oedema maybe improved by using alternative instrument like OCTto support the HRT II findings.CONCLUSION:

Both IVTA and laser photocoagulation showedgood comparable outcomes in term of BCVA and MEIat three months post treatment as primary treatmentfor DME.REFERENCES:1. Kisilevsky M, Hudson C, Flanagan JG, Nrusimhadevara RK,

Guan K, Wong T, Mandelcorn M, Lam WC, Devenyi RG:Agreement of the Heidelberg Retina Tomograph II maculaedema module with fundus biomicroscopy in diabeticmaculopathy. Arch Ophthalmol 2006, 124(3):337–342.

2. Sutter FK, Simpson JM, Gillies MC: Intravitreal triamcinolonefor diabetic macular edema that persists after laser treatment:three-month efficacy and safety results of a prospective,randomized, double-masked, placebo-controlled clinicaltrial. Ophthalmology 2004, 111(11):2044–2049.

3. Ip MS: Intravitreal injection of triamcinolone: an emergingtreatment for diabetic macular edema. Diabetes Care 2004,27(7):1794–1797.

4. Wilson CA, Berkowitz BA, Sato Y, Ando N, Handa JT, deJuan E Jr: Treatment with intravitreal steroid reduces blood-retinal barrier breakdown due to retinal photocoagulation.Arch Ophthalmol 1992, 110(8):1155–1159.

5. Ozkiris A, Evereklioglu C, Erkili K, Tamelik N, Mirza E:Intravitreal triamcinolone acetonide injection as primarytreatment for diabetic macular edema. Eur J Ophthalmol 2004,14(6):543–549.

6. Karacorlu M, Ozdemir H, Karacorlu S, Alacali N, Mudun B,Burumcek E: Intravitreal triamcinolone as a primary therapyin diabetic macular oedema. Eye 2005, 19(4):382–386.

7. Massin P, Audren F, Haouchine B, Erginay A, Bergmann JF,Benosman R, Caulin C, Gaudric A: Intravitreal triamcinoloneacetonide for diabetic diffuse macular edema: preliminaryresults of a prospective controlled trial. Ophthalmology 2004,111(2):218–245.

8. Jonas JB, Kreissig I, Sofker A, Degenring RF: Intravitrealinjection of triamcinolone for diffuse diabetic macular edema.Arch Ophthalmol 2003, 121(1):57–61.

9. Yanyali A, Nohutcu AF, Horozoglu F, Celik E: Modified gridlaser photocoagulation versus pars planavitrectomy withinternal limiting membrane removal in diabetic macularedema. Am J Ophthalmol 2005, 139(5):795–801.

10. Dehghan MH, Ahmadieh H, Ramezani A, Entezari M,Anisian A: A randomized, placebo-controlled clinical trialof intravitreal triamcinolone for refractory diabetic macularedema. IntOphthalmol 2008, 28(1):7–17.

11. Wilkinson CP, Ferris FL III, Klein RE, Lee PP, Agardh CD,Davis M, Dills D, Kampik A, Pararajasegaram R, VerdaguerJT, Global Diabetic Retinopathy Project Group: Proposedinternational clinical diabetic retinopathy and diabeticmacular edema disease severity scales. Ophthalmology 2003,110(9):1677–1682.

12. Batioglu F, Ozmert E, Parmak N, Celik S: Two-year resultsof intravitreal triamcinolone acetonide injection for thetreatment of diabetic macular edema. IntOphthalmol 2007,27(5):299–306.



13. Lam DSC, Chan CKM, Tang EWH, Li KKW, Fan DSP, ChanWM: Intravitreal triamcinolone for diabetic macular oedemain Chinese patients: six-month prospective longitudinal pilotstudy. Clin Experiment Ophthalmol 2004, 32(6):569–572.

14. Larson J, Zhu M, Sutter F, Gillies MC: Relation betweenreduction of foveal thickness and visual acuity in diabeticmacular edema treated with intravitreal triamcinolone. AmJ Ophthalmol 2005, 139(5):802–806.

15. Lee HY, Lee SY, Park JS: Comparison of photocoagulationwith combined intravitreal triamcinolone for diabeticmacular edema. Korean J Ophthalmol 2009, 23(3):153–158.

16. Ozdemir H, Karacorlu M, Karacorlu SA: Regression of serous

macular detachment after intravitreal triamcinoloneacetonide in patients with diabetic macular edema. Am JOphthalmol 2005, 140(2):251.e1-251.e6.

17. Gibran SK, Cullinane A, Jungkim S, Cleary PE: Intravitrealtriamcinolone for diffuse diabetic macular oedema. Eye 2006,20(6):720–724.

18. Lam DSC, Chan CKM, Mohamed S, Lai TYY, Lee VYM, LiuDTL, Li KKW, Li PSH, Shanmugam MP: Intravitrealtriamcinolone plus sequential grid laser versus triamcinoloneor laser alone for treating diabetic macular edema: six-monthoutcomes. Ophthalmology 2007, 114(12):2162–2167.



––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––*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 ZayedAn-Nahyan Hospital, AJK / CMH Muzaffarabad. E-mail> [email protected]. Mobile: 00923009771066.Received Nov’2011 Accepted March’2012––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––Received Nov’2011 Accepted March’2012––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

Topical Nsaid’s and Flouoromethalonein the Treatment of

Epidemic Keratoconjunctivitis*(A Comparative Study)

Inam ul Haq Khan FCPS1, Anwar Ali FCPS2, Ashok Kumar Pinjani FCPS3

ABSTRACTPurpose: The purpose of this study is to compare the role of NSAIDS and Fluoromethalone in the treatment of epidemickeratoconjunctivitis.Patient and Methods: 30 patients of bilateral punctuate epithelial keratitis were diagnosed as cases of adenoviralkeratitis 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 weeksof treatment. Complaints of stinging sensation were present in all the patients. In spite of unpleasant stinging sensationsthese patients were encouraged to continue using the eye drops. After three weeks of treatment the patients with minimalimprovement were switched on to topical Fluorometholone. Out of these 12 patients, 7 recovered completely in oneweeks time, 3 took another week to recover and in 2 patients topical steroids had to be used in tapering dosage for 4months. In 1 patient after the cessation of therapy there was recurrence of sub epithelial opacities and topicalFluorometholone 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 threeweeks time. 2 patients had to use topical steroids for about 4 months. In 1 patient after the cessation of therapy therewas recurrence of sub epithelial opacities and topical Fluorometholone had to be started again, in TID dosage for 2weeks, followed by BD dosage for another 2 weeks. Fluoromethalone eye drops proved to be significantly better than theNSAID eye drops with no rise in IOP. In addition stinging sensations of NSAIDS eye drops heralds their use as the Firstchoice 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 thepatients 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 onto topical Fluorometholone. Out of these 12 patients, 7 recovered completely in one weeks time (total 25 patients83.3%), 3 took another week to recover and in 2 patients topical steroids had to be used in tapering dosage for 4months. In 1 patient after the cessation of therapy there was recurrence of sub epithelial opacities and topicalFluorometholone 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 forcomplete resolution of corneal stromal infiltrates.

Conclusion: We conclude from our study that the use of Fluorometholone in the management of epidemic viralKeratoconjunctivitis alleviate the patient’s symptoms (redness, discomfort, swelling, tearing, photophobia, blurring of

Original Article

Dr. InamDr AnwarCo-author

Dr AshokCo-author


vision and pain as well). It decreases the course of the disease, as without treatment the course is prolonged and mayaccompany complications. It also decreases the occurrence of subepithelial opacities and helps in the complete resolutionof residual opacities.Key Words: Fluorometholone, NSAIDS. EKC. Punctate epithelial keratitis.

INTRODUCTIONIn Saudi Arabia due to the peculiar conditions,

added by the world’s largest gathering of human beingsduring Hajj adenoviral infections are common. Itinvolves upper respiratory tract, and large number ofGIT infections are attributed to this virus. It is seen thatafter every Hajj there is an endemic of upper respiratorytract infections and conjunctivitis. Different viruses arethe culprit among them is multiple strains ofadenovirus. This virus keeps on changing its geneticcode. It is said that upto50 different strains of this virushave been identified till now. Due to its behavioraldiversity it is difficult to develop a much neededvaccine.

The treatment options available to us are basedon the symptomatic and physical findings. If the diseaseinvolves the cornea we think of more aggressive meansof treatment. If it is limited to the conjunctiva; our aimis to prevent the involvement of cornea and preventionof spread of infection as well as secondary infections.MATERIAL AND METHODS:

Epidemic Viral Keratoconjunctivitis (EKC) is atype of adenovirus ocular infection. EKC is highlycontagious and has tendency to occur in epidemics. Atleast 19 serotypes of adenovirus have been implicatedin causing eye infection. The aim of this study was tocompare the role of NSAIDS and Fluorometholone inthe treatment of epidemic keratoconjunctivitis. 30patients of red eye were diagnosed as cases ofadenoviral keratoconjunctivitis on the basis of theirclinical picture. 18 males, 12 females, aged from 9 to40 years.First group. In right eye NSAIDS eye drops were used.Second group. In left eye Fluorometholone eye dropswere used.

The study was held between July 2008 andAugust 2009 in SAFH Sharourah KSA. Patients werefollowed up for 6 months.

In the first group, 18 eyes (60 %) have completeresolution of conjunctivitis and anterior stromalinfiltrates after 3 weeks of treatment. Complaints ofstinging sensation were present in all the patients. Inspite of unpleasant stinging sensations these patientswere encouraged to continue using the eye drops. Afterthree weeks of treatment the patients with minimalimprovement were switched on to topicalFluorometholone. Out of these 12 patients 7 recoveredcompletely in one weeks time, 3 took another week torecover and in 2 patients topical steroids had to be used

in tapering dosage for 4 months. In 1 patient after thecessation of therapy there was recurrence of subepithelial opacities and topical Fluorometholone hadto be started again, in TID dosage for 2 weeks, followedby BD dosage for another 2 weeks.

In the second group, 24 eyes (80%) recovercompletely within 10 days without sub epithelialopacities or stromal infiltrates. They were told tocontinue eye drops for another week and then to stop.28 patients (84%) recover completely in three weekstime. 2 patients had to use topical steroids for about 4months. In 1 patient after the cessation of therapy therewas recurrence of sub epithelial opacities and topicalFluorometholone had to be started again, in TID dosagefor 2 weeks, followed by BD dosage for another 2 weeks.

Fluorometholone eye drops proved to besignificantly better than the NSAID eye drops with norise in IOP. In addition stinging sensations of NSAIDSeye drops heralds their use as the First choice in themanagement of the disease.

Aim of the Study: Different treatment options areavailable for the treatment of adenoviral keratitis. Aimof this study was to see the efficacy of fluorometholonecompared to NSAIDS in the treatment of adenoviralkeratitis.

Selection Criteria: Patients with bilateral subepithelial opacities diagnosed as cases of adenoviralkeratitis were selected (Thygeson superficial punctuatekeratitis need to be differentiated from epidemickeratoconjunctivitis. In former, conjunctivitis is absentwhile in the later it is present). A thorough history wastaken. Clinical examination was performed. Diagnosisof adenoviral keratitis was on the basis of clinicalfindings. Those cases with bilateral findings wererecruited. Performa of history, clinical examination andtreatment plan was prepared for each patient. In theend, data was compiled and results were prepared.

Aim of this study was to see the efficacy ofFluorometholone compared to NSAIDS in the treatmentof adenoviral keratitis. Since the facilities for theidentification of the virus strains are not available, thestudy was based on the symptomatic and clinicalimprovements.

30 patients were selected for the study. They werebriefed about the purpose of the study and theircooperation in this regard was requested. Those whowere willing to cooperate and agreed to follow theinstructions were recruited. Results of medication weremonitored meticulously. Diagrams of corneal changes

Topical Nsaid’s and Flouoromethalone in the Treatment of Epidemic Keratoconjunctivitis


were drawn. Number, size and depth of the stromalexudates were noted down. Patients were requested tovisit after three days of initiation of therapy and thenafter one week. If there is improvement they wererequested to visit after two weeks, otherwise after oneweek. Further visits were requested depending uponthe response from the treatment. In one eye NSAIDeye drops and in the other Fluorometholone eye dropswere used. Symptomatic as well as clinicalimprovements were monitored.

Performa of History: Name, age, sex, occupation,numbers of individuals in the family, history of eyecomplaints in other family members, history of recentupper respiratory tract/ gastrointestinal infections andhistory of Umra or Hajj in the recent past or of contactwith such an individual. The complaints of the patientalong with duration were noted down. Redness, pain,discharge, foreign body sensations, generalizedvisualcomplaints, history of conjunctivitis in the past and useof eye drops. Systemic complaints, specifically upperrespiratory tract infections and GI infections were alsoasked.

Performa of Clinical Examination: VA onSnellen’s projector was documented on Ist visit andsubsequently. Examination of lids for lid edema noted,involvement of the conjunctiva documented, type ofresponse (follicular or papillary), pre-auricularlymphadenopathy, subconjunctival hemorrhages andpseudo- membranes were noted down1 . Location andsize of subconjunctival hemorrhages were also notedand drawn. Corneal changes are documentedmeticulously. Epithelial edema, sub epithelial depositswere noted down, counted and drawn carefully on thepaper. Staining with Fluorescein and Rose Bengal done.Anterior chamber reaction was noted down. IOP

monitored by air puff tonometer.TREATMENT

In right eye NSAIDS eye drops and in the left eyeFluorometholone eye drops were started simultane-ously. The dose was one drop five times a day. Patientswere called after three days for the first visit and thenafter one week. Further visit was requested after twoweeks in cases which were showing good response, inother cases patients were called after one week.Changes in the cornea were noted down. After secondvisit, in patients showing improvement the dose wasreduced to one drop three times a day for another oneweek. Treatment was continued in the patients showingimprovement. In those patients in whom there wascomplete resolution of corneal changes, the treatmentwas stopped and the patient was requested to comeagain after one week. Intra ocular pressure was notedby air puff tonometer.RESULTSNSAIDS group:• Conjunctivitis recovered completely in one week

time. 18 eyes (60 %) have complete resolution ofanterior stromal infiltrates on their third visit.Complaints of stinging sensation were present inall the patients, in spite of this the patients wereencouraged to continue using the eye drops.

• After three weeks of treatment 12 patients hadeither no or minimal improvement and thesepatients were switched on to topicalFluorometholone. Out of these 12 patients, 7recovered completely in one weeks time (total 25patients 83.3%), 3 took another week to recoverand in 2 patients topical steroids had to be usedin tapering dosage for 4 months. In 1 patient afterthe cessation of therapy there was recurrence of

Table 1. Recovery Table

Number of Eyes Complete recovery Recovery with subepithelial infiltratesNo % 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 Recoveryafter 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



sub epithelial opacities and topicalFluorometholone had to be started again, in TIDdosage for 2 weeks, followed by BD dosage foranother 2 weeks

Fluorometholone group:• Conjunctivitis recovered completely on second

visit. 24 patients (80%) recover completely within9-12 days without sub epithelial opacities orstromal infiltrates.

• 28 patients (93.3%) recover completely in threeweeks time.

• 2 patients had to use topical steroids for about 4months. In 1 patient after the cessation of therapythere was recurrence of sub epithelial opacitiesand topical Fluorometholone had to be startedagain, in TID dosage for 2 weeks, followed by BDdosage for another 2 weeks. This patient had touse topical medications once a day for six monthsfor complete resolution of corneal stromalinfiltrates.

DISCUSSIONHuman adenovirus type 37 (HAdV-37) is a major

cause of epidemic Keratoconjunctivitis and has recentlybeen the largest causative agent of Keratoconjunctivitisin Japan2. Adenovirus types 8 and 19 are responsiblefor epidemic Keratoconjunctivitis and they are highlycontagious for up to 2 weeks3. The incubation period is2-14 days and the person may remain infectious for 10-14 days after symptoms develop4. It is characterizedby conjunctivitis: acute onset of watering redness,foreign body sensation and discomfort. Both eyes areaffected in 60% of cases5.

Keratitis occurs in 80 % of cases and divided into3 stages:• Stage 1: occurs within 7-10 days of the onset of

symptoms. It is characterized by a diffusepunctate epithelial Keratitis which may resolveor may go to stage 2.

• Stage 2: is characterized by focal whitesubepithelial infiltrates which develop beneath theepithelial lesions. They are thought to representimmune response to adenovirus and may beassociated with mild transient anterior uveitis.

• Stage 3: is characterized by anterior stromalinfiltrates which may persist for months and evenyears6.

• No gender predilection exists. The infection ismore common in adults, but all age groups canbe affected7. EKC epidemics tend to occur inclosed institutions (e.g., schools, hospitals, camps,nursing homes, workplaces)8. Direct contact witheye secretions is the major mode of transmission.Other possible methods of transmission arethrough air droplets and possibly swimming

pools. Adenovirus can be recovered from the eyeand throat for as long as 14 days after onset ofclinical symptoms9. Many epidemics have beeninitiated in ophthalmology outpatient clinics bydirect contact with contaminated diagnosticinstruments10.The following explains the infectious transmission

in hospitals and clinics: (1) the virus (adenovirus type19) remains viable for 5 weeks, (2) the virus is resistantagainst standard disinfectants such as 70% isopropylalcohol and ammonia, and (3) the virus sheds from theeye 3 days before and 14 days after symptom onset11.Epidemics of Keratoconjunctivitis are often traced toan eye care facility. Disease is commonly spread byophthalmologists ‘contaminated fingers orcontaminated instruments and eye drops12. Virus canbe spread by finger to eye contact; it can also be spreadto contaminated instruments such as applanationtonometers13.

EKC in East Asia and other parts of the world isendemic and does not appear to be transmitted throughmedical intervention. Viruses were isolated from morethan 50% of cases of viral conjunctivitis; adenovirusconstituted 94% of the EKC is a self-limiting disease14 .It tends to resolve spontaneously within 1-3 weekswithout significant complications. In 20-50% of cases,corneal opacities can persist for a few weeks to months(rarely up to 2 y). This phenomenon can decrease visualacuity significantly and cause glare symptoms .In rarecases; conjunctival scarring and symblepharon canoccur secondary to membranous conjunctivitis15.

The patients recover spontaneously within 2-3weeks with subepithelial opacities in 80 % of caseswhich persists for months or years even with the use oftopical steroid16. It is necessary to pay attention to thehealth education of population as well as to improvehygienic habits17.CONCLUSION

We conclude from our study that the use ofFluorometholone in the management of epidemic viralKeratoconjunctivitis alleviate the patient’s symptoms(redness, discomfort, swelling, tearing, photophobia,blurring of vision and pain as well). It decreases thecourse of the disease, as without treatment the courseis prolonged and may accompany complications. It alsodecreases the occurrence of sub epithelial opacities andhelps in the complete resolution of residual opacities.REFERENCES1. Boerner CF, Lee FK, and Wickliffe CL. Electron microscopy

for the diagnosis of ocular viral infections. Ophthalmology1981 Dec; 88(12): 1377-81.

2. Satoshi Takeuchi, Adenovirus Strains of Subgenus DAssociated with Nosocomial Infection as New EtiologicalAgents of Epidemic Keratoconjunctivitis in Japan Journal ofClinical Microbiology, October 1999, p. 3392-3394, Vol. 37.



3. Jackson WB: Differentiating conjunctivitis of diverse origins.Surv. Ophthalmol 1993 Jul-Aug; 38 Suppl: 91-104.

4. Tasman W and Jaeger EA: Epidemic Keratoconjunctivitis.Duane’s Clinical Ophthalmology (Text book) 8th ed. 2001;4(7): 5-8.

5. Barnard DL, Hart JCD, Marmion VJ, and Clarke SKR.Outbreak in Bristol of conjunctivitis caused by adenovirustype 8, and its epidemiology and control. Br Med J 1973;2:165-9.

6. Jack J. Kanski . Adenoviral Epidemic keratoconjunctivitis.Clinical Ophthalmology. (Text book) 6th ed. 2007; 226-7 &283.


8. D’Angelo LJ, Hierholzer JC, Holman RC , and Smith JD.Epidemic keratoconjunctivitis caused by adenovirus type 8:epidemiologic and laboratory aspects of a large outbreak.Am J Epidemiol 1981;113:44-9.)

9. Nagington J, Stehall GM, and Whipp P. Tonometerdisinfection and viruses. Br J Ophthalmol 1983;67:674-6.


11. Buehler JW, Finton RJ and Goodman RA. Epidemickeratoconjunctivitis: report of an outbreak in anophthalmology practice and recommendations forprevention. Infect Control 1984;5:390-4.

12. Azar MJ; and Dhaliwal DK, and Bower KS .PossibleConsequences of Shaking Hands with Your Patients withEpidemic Keratoconjuctivitis. Pa Am J Ophthalmol 121:711-712, 1996.

13. Weiss AH, Brinser JH, and Nazar-Stewart V. Acuteconjunctivitis in childhood. J Pediatr. 1993;122(1):10-14.

14. D’Angelo LJ, Hierholzer JC, Holman RC , and Smith JD.Epidemic keratoconjunctivitis caused by adenovirus type 8:epidemiologic and laboratory aspects of a large outbreak.Am J Epidemiol 1981;113:44-9.)


16. Barnard DL, Hart JCD, Marmion VJ, and Clarke SKR.Outbreak in Bristol of conjunctivitis caused by adenovirustype 8, and its epidemiology and control. Br Med J 1973;2:165-9.

17. Nagington J , Stehall GM, and Whipp P. Tonometerdisinfection and viruses. Br J Ophthalmol 1983;67:674-6.



–––––––––––––––––––––––––––––––––––––––––––––––––––––––1Assistant Professor, Sargodha Medical College, University ofSargodha, Sargodha. 2Consultant Glaucoma Department, Al-ShifaTrust Eye Hospital, Rawalpindi,–––––––––––––––––––––––––––––––––––––––––––––––––––––––Correspondence: Dr. Muhammad Umar Farooq, House No. 105,Street 5, Phase 1, Bahria Town, Rawalpindi.Cell: 0321 6032085, Phone : 048 3723830E.Mail>[email protected]–––––––––––––––––––––––––––––––––––––––––––––––––––––––Received: Nov’2012 Accepted: March’2012–––––––––––––––––––––––––––––––––––––––––––––––––––––––

Expanding the Role of Trabeculectomy with 5-FU

Hashim Imran FCPS1, Muhammad Umar Farooq FCPS, FRCS2

Original Article

INTRODUCTIONThe antimetabolites Mitomycin and 5-flourouracil

have been used intra-operatively to augment thesuccess of trabeculectomy in primary glaucomas forabout two decades. The experience over time hassuggested that the 5-fluorouracil(5-FU) may be lesspotent than Mitomycin-C in lowering the IOPpostoperatively but is quiet safer as regards the longterm post-op complications are concerned. Theconfidence in this wonderful tool has encouraged us touse it not only in the primary glaucoma patients in aconventional way but also a few carefully selected othertypes of glaucoma cases with a view to the possibilityof expanding its role in these situations.

This retrospective study was made to check theIOP lowering effect of trabeculectomy with 5-Fluorouracil (5-FU) in various types of our adultglaucoma patients. The records of the patients whounderwent primary trabeculectomy with 5-FU in thelast one year were reviewed. The indication for surgeryin the majority of the patients was uncontrolledintraocular pressure (IOP) in spite of maximal tolerablemedical treatment. The other important indications forsurgery included in-affordability of the cost ofmedications, inability to follow the physician’sinstructions properly, unavailability of medications inthe far flung areas of the country and the allergy to thedrugs.Majority of the patients did not have anyprevious history of intraocular surgery but others didhave a prior history of intraocular surgery other thanthe glaucoma drainage procedure.MATERIALS AND METHOD

A total number of 44 eyes in 39 patients wereoperated (Table 1). All these eyes had no previousglaucoma drainage procedure done on them making

the reviewed procedure a primary trabeculectomy inthese eyes. As mentioned earlier majority 34 eyes (77%)of these eyes had no history of any prior eye diseaseexcept glaucoma (Table 2-A). Out of the total 44 eyes22(50%) had primary open angle glaucoma (POAG),9(20%) had chronic narrow angle glaucoma and 3(7%)had pseudo-exfoliative glaucoma. Three eyes had ahistory of previous ailments out of these two eyes (5%)had angle recession glaucoma from previous blunttrauma and one eye (2%) had a history of idiopathicuveitis leading on to glaucoma( Table 2-B). Seven eyes(15%) did have a history of intraocular surgery likephacoemulsification in 4 eyes(9%), penetratingkeratoplasty in 2(5%) and repaired penetrating cornealtrauma in 1 eye (2%). In this group (Table 2-C) theconjunctiva at the planned drainage site appeared tobe healthy and there was no obvious sign ofsubconjunctival scarring. It would also be appropriateto mention here that eyes having Argon lasertrabeculoplasty and YAG laser iridotomy in the past

Table 1: Patient characteristics

Total number of patients 39

Total number of eyes 44

Age 16 to 85 years (mean 56 years)

Sex Male 27 Female 12

Table 2: Types of Glaucoma

2-A: Primary Glaucoma

POAG 22 50%

Ch. NAG 9 20%

PXE 3 7%

2-B: Secondary Glaucoma

Angle recession Glau. 2 5%

UveiticGlau. 1 2%

2-C:- Secondary Glaucoma- Post surgical

PKP 2 5%

Phaco 4 9%

Corneal repair 1 2%

Dr. Hashim


were not excluded from the study.Surgical procedure

IOP was controlled preoperatively with topicalmedications as well as oral Diamox and if the IOPexceeded 25mmHg IV Mannitol (1gm/kg body weight)was given half an hour before surgery in the operationroom to bring the IOP down to a safer level. Generallypatients less than 30 years of age were operated undergeneral anaesthesia and above that age were operatedunder local anaesthesia. Local infiltration anaesthesiawas given as peribulbar block with or without facialblock. It consisted of a mixture of 2%Xylocaine and 0.5%of Bupevicaine in equal amounts. 5% Povidone solutionwas used to clean the lids and area around the orbit.Sterile drapes were placed with opsite film over thelids to isolate the lashes. Wire lid speculum was placedto open the eye. A 6/0 vicryl traction suture with aspatulated needle was passed through the superiorcornea to expose the surgical field. Fornix basedconjunctival/tenon flap at the limbus with a cord lengthof about 8mm without a radial relaxing incision wasusually sufficient to expose the episclera. The flap wasundermined with blunt conjunctival spring scissors.Gentle bipolar wet field cautery was used over theintended scleral flap area. Tenon capsule was notusually excised until excessively thick. 3x4 mmrectangular half thickness scleral incision was givensuperiorly to demarcate the extant of the scleral flap.This flap was raised in a horizontal plane with the helpof a crescent knife till it reaches 1mm into the clearcornea. 3 to 4 cellulose sponges impregnated with 50mg/ml 5-flurouracil (5-FU) were placed over andaround the scleral flap and under the conjunctiva/tenonflap. Care was taken that the edge of the conjunctivalflap does not touch the sponges at all times. The spongeswere removed after 5 minutes and this area was washedwith at least 30 ml of balanced salt solution.

A paracentasis was made in the temporal corneawith a fine sharp blade while taking care that the A/Cdoes not collapse. 2x2 mm full thickness sclerectomy/trabeculectomy was done with the help of sharp bladeand Vanna’s scissors. Peripheral iridectomy was doneand the scleral flap was reposited to take its place. Two10/0 nylon sutures placed at the corners of scleral flap

were usually sufficient to secure it back to its bedsatisfactorily. A/C was deepened with injection of BSSthrough the temporal paracentesis. End point was asteady ooze of aqueous humour with a stable anteriorchamber. When it was achieved the conjunctiva wassutured at the limbus with 10/0 nylon sutures.Subconjunctival injection of 20mg gentamycin and 2mgof dexamethsone was given in the inferior fornix. Theeye was patched for 24 hours after instillation of 1%cyclopentolate and betnesol-N eye ointment. Thepatient was instructed to stop systemic antiglaucomamedications as well as the topical medications in theoperated eye.DISCUSSION

Full thickness trabeculectomy is still the mostcommonly performed surgical procedure to lower theIOP in patients with otherwise uncontrolled glaucomaand is considered the gold standard1. The procedurewas described originally by Sugar in 19612,3 butinnumerable variation of the technique has since beensuggested with the success rate of the primaryprocedure with antimetabolites being around 84.0% atone year follow-up4. The most common cause of failureof this drainage procedure is considered to be thepostoperative subconjunctival fibrosis at the drainagesite and to prevent this complication various substanceswere used. These substances known as metabolites notonly enhanced the success of this surgery but werehelpful in achieving lower intraocular pressurespostoperatively5. The two most commonly used anti-fibrosis substances are Mitomycin C and 5 fluorouracil(5-FU).

Mitomycin C is an alkylating agent whichdamages the DNA of replicating as well as non-replicating cells. Clinically Mitomycin C is much morepotent as compared to 5-FU6. The 5-FU is anantimetabolite which acts on the DNA synthesis “S”phase of only the replicating cells. It selectively affectsthe replicating fibroblasts only and does not damageDNA of the stable cells in the area of its application. Inpresent day world terminology it means that it causesless collateral damage to the adjacent tissues.Comparing it with mitomycin C it leads to fewerincidences of late complications related with

Table :3 Intra-ocular pressures-IOP

Post-op Post-op Post-op Post-op Post-op drop inPre-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 34Mean(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 theirIOP to to this level.



trabeculectomy like thin walled blebs, late woundleakage, blebitis and endophthalmitis.

The use of 5-FU was started in 1989 followed bythe Mitomycin C in 1991 as an adjunct totrabeculectomy7,8. 5-FU was used initially in the formof multiple subconjunctival injections postoperatively.In most instances it required the patient to be admittedin the hospital for a prolonged period of time addingto the cost of the surgery. Among other complicationsthere was almost universal occurrence of cornealepithelial defects in these patients postoperatively. Theintra-operative use of 5-FU was reported in 19929,10

which was found to have much less immediate post-operative problems and was convenient for the patientas well as the physician.This was found to be as mucheffective as given subconjunctivaly. In some studies waseven considered to be as safe and effective asMitomycinC11.

The 5-FU has generally been used to augmenttrabeculectomies in previously un-operated eyes butits usefulness was also demonstrated by theFluorouracil filtering surgery study in thepseudophakic patients as well7.

We have been using anti-metabolites intra-operatively for a long time now in our hospital and areconfident about the efficacy as well as the relative safetyof the use of 5-FU in our patients. We have used 5-FUwith trabeculectomy not only in the primary glaucomasin the conventional sense but have tried to explore thepossibility of expanding its use in few other situations.We have tried to check the efficacy of the procedure inlowering the IOP as well as its safety in the post-operative period in all these patients.RESULTS

The operated patients were examined on the slitlamp next morning. Particular attention was given tothe trabeculectomy site for the appearance of drainagebleb and any leakage. Anterior chamber was noted forits depth, hyphema and the extent of inflammatoryreaction. Intra-ocular pressure was measured with thehelp of Goldmann tonometer. The patients withsatisfactory post-op condition were discharged from thehospital with a combination of topical steroids,antibiotics and cycloplegic eye drops. The frequencyof post-op use of drops was determined by theinflammatory activity noted in the eye as well as theage of the patients. The younger patients generallyreceived more frequent post-op steroid drops as theyare considered prone to excessive inflammatoryresponse to surgery leading on to scarring. The patientswere seen in the OPD after one week, three weeks andthen every month till the IOP was stabilized.

Trabeculectomy with 5-FU (as described in M &M) was done in 44 eyes of 39 adult patients. Among

them 27 were male and 12 female and their ages rangedfrom 16 to 85 with a mean age of 56. The diagnosis ofPrimary open angle glaucoma was made in 22eyes(50%), Pseudo-exfoliative glaucoma in 3 eyes(7%),Chronic angle closure glaucoma in 9 eyes(20%).Thesecondary glaucomas included angle recessionglaucoma in 2 eyes(5%), Uveitic glaucoma in 1 eye(2%),glaucoma following penetrating keratoplasty (PKP) in2 eyes (5%), glaucoma following an un-eventfulphacoemulsification was seen in 3 eyes(7%) where assecondary glaucoma following a phacoemulsificationcomplicated by the posterior capsular rupture(PCR)requiring anterior vitrectomy and PC IOL implant wasseen in 1 eye (2%) and 1 eye(2%) had glaucomafollowing a penetrating paracentral corneal injurywhich was repaired in the past .

The intraocular pressures at presentation in theseeyes ranged from 16 mmHg to 55 mmHg with a meanpre-operative IOP of 28.2 mmHg (Table 3). It will beworthwhile to mention here that the cup disc ratio(CDR) at presentation in these patients ranged from 0.3to 1.0 with a mean of 0.78 indicating that our patientstend to present for treatment at a fairly advanced stageof the disease. The IOPs recorded 24 hours aftertrabeculectomy (with 5-FU) in these eyes ranged from03 mmHg to 56 mmHg with a mean IOP of 11.3mmhg.At one week the IOPs ranged from 06 to 35 mmHg witha mean of 12.2 mmHg. The mean drop of IOP recordedin one week after the surgery from the IOP atpresentation was 16 mmHg (60%). At three weeks theintraocular pressures ranged from 05 to 34 mmHg witha mean of 13.7 mmHg. The follow-up period for thesepatients ranged from one month to 12 months (meanof 6.9 months). At the end of one year 32 eyes (73 %)had IOP of less than 21 mmHg without anti-glaucomamedication and 12 eyes (27%) required medication tobring their IOP to less than 21 mmHg. The mean IOPachieved in these eyes at the end of the study was15.2mmHg with a mean drop of 13 mmHg (46%).

We all are aware that the post trabeculectomyperiod is a turbulent one and many complications/variations are noted in the post-operative course untilthe drainage bleb matures. In our patients we sawleakage from the conjunctival wound withoutshallowing of anterior chamber in 9 eyes (20%) andleakage with shallowing of anterior chamber in 6 eyes(14 %), 5 of these 6 eyes settled with conservativemanagement and only one required reformation of AC.Varying degrees of hyphema was observedpostoperatively in 7 eyes (16%) which was absorbed indue course of time in all these eyes and none requiredsurgical evacuation. Flattish blebs with deep anteriorchamber and higher than expected IOP in the initialpost-op period were noted in 11 eyes(25%) which



responded to massage and suture lysis favorably in 8eyes (18%) and the remaining 3 eyes (7%) in this groupeventually required antiglaucoma medications toachieve their target pressures. Tenon cysts formed in 3eyes (7%) and required needling with sub-conjuntivalinjection of 5-FU to achieve a functioning bleb.Choroidal detachment was seen in only one eye whichhad a history of complicated phacoemulsification withPC rupture and anterior vitrectomy. This choroidaldetachment was treated with medications and settledwithout surgical intervention. During the follow-up oneeye developed blebitis which settled with intensivetopical broad spectrum antibiotic treatment. This eyeincidentally had PKP done previously.CONCLUSION

Despite being a potent antimetabolite 5-FU hasgenerally been used to augment the success oftrabeculectomy in eyes having primary types ofglaucoma but in our patients some eyes did havesecondary glaucomas and even others had intraocularsurgeries performed on them in the past. The key wasthat despite the history of prior surgey in this grouptheir trbeculectomy sites did not show any obvious signof disturbance or scarring.

The mean intraocular pressure drop achieved inthis group of patients having various types ofglaucomas was significant (13 mmHg) at the end ofmean follow-up period of 6.9 months. Post-operativeperiod was more eventful and a tendency towardshaving postoperative complications was noted in theeyes having previous history of intraocular surgeriesbut still these patients could achieve acceptablelowering of IOP at least during this follow-up period.At the end of this review we tend to think that 5-FUcan not only be used safely in the primary glaucomasbut in some carefully selected eyes having secondaryglaucomas as well. We were encouraged by the resultsof our use of 5-FU in conditions like angle recessionglaucoma and open angle type of glaucoma

encountered after phaco-emulcification especially if thesurgery was not complicated by the posterior capsularrupture.

In a study where the maximum follow-up periodis one year we did not expect to find many latecomplications of glaucoma surgery. We will continueto monitor these patients in future regarding the patternof IOP control and the development of latecomplications attributed to the use of antimetabolitesduring trabeculectomy.REFERENCES1. Fontana H, Nouri-Mahdavi K, Caprioli J, Trabeculectomy

with mitomycin C in pseudophakic patients with open angleglaucoma: Outcomes and risk factors for failure. Am JOphthalmol. 2006; 141(4):652-9

2. Sugar HS. Experimental trabeculectomy in glaucoma.Am JOphthalmol.1961; 51: 623–7.) 3. Cairns JE.Trabeculectomy.Preliminary report of a new method.Am JOphthalmol.1968; 66:673–8.

4. Edmunds B, Thompson JR, Salmon JF, Wormald RP. Thenational survey of trabeculectomy. II. Variations in operativetechnique and outcome. Eye 2001; 15: 441-448

5. Ingrid U. Scott, MD, MPH; David S. Greenfield, MD; JoyceSchiffman, MS; Marcelo T. Nicolela, MD; Juan C. Rueda, MD;James C. Tsai, MD; Paul F. Palmberg, MD, PhD Outcomesof Primary Trabeculectomy with the Use of AdjunctiveMitomycin Arch Ophthalmol. 1998; 116:286-291.

6. Ando H, Ido T, Kawai Y, et al. Inhibition of corneal epithelialwound healing. Ophthalmology. 1992; 99:1809–14

7. The Fluorouracil Filtering Surgery Study Group. FluorouracilFiltering Surgery Study one-year follow-up. Am JOphthalmol. 1989; 108:625–35

8. Kitazawa Y, Kawase K, Matsushita H, et al. Trabeculectomywith mitomycin. A comparative study with fluorouracil.ArchOphthalmol. 1991; 109:1693–8

9. Dietze PJ, Feldman RM, Gross RL.Intra-operative applicationof 5-fluorouracil during trabeculectomy.Ophthalmic Surg.1992; 23:662–5.

10. ShelatBinita, Rao B Sridhar, Vijaya L, Revathi B, Garg Dinesh,Results of intraoperative 5-fluorouracil in patientsundergoing trabeculectomy - pilot trial, Indian journal ofophthalmology1996,Volume : 44,Issue:: 91-94

11. K.Singh, Trabeculectomy with intraoperative mitomycin Cversus 5 fluorouracil prospective randomised clinical trial,Ophthalmology, volume 107, issue 12, pages 2305-2309.



–––––––––––––––––––––––––––––––––––––––––––––––––––––––Note: Since there was no laboratory facility available in NorthWaziristan Agency, hence the survey was conducted on purelyclinical basis.–––––––––––––––––––––––––––––––––––––––––––––––––––––––1.Assistant Professor,Bannu Medical College & Khalifa Gul NawazHospital, Bannu2Registrar Eye A ward, Khyber Teaching Hospital,Peshawar3Medical Officer, Department of Ophthalmology,Hayatabad Medical Complex, Peshawa 4Assistant Professor KohatMedical College Kohat. .5Medical Officer, Department ofOphthalmology, Hayatabad Medical Complex, Peshawar, 6Principal,Bannu Medical College, Bannu.–––––––––––––––––––––––––––––––––––––––––––––––––––––––Correspondence: Dr, Sanaullah Khan FCPS,MPH AssistantProfessor Khalifa Gul Nawaz Hospital, Bannu, Mob.no.0333-9107871Email: [email protected]–––––––––––––––––––––––––––––––––––––––––––––––––––––––Received: Jan’2012 Accepted: March’2012

INTRODUCTIONTrachoma is exclusively a disease of poor families

and communities living in developing countries.Although it is avoidable, continues to blind and as itremains a neglected public health issue. Trachoma isGreek word used for rough and swelling. Globally it isa leading infectious cause of preventable blindness.Trachoma is chronic kerato conjunctivitis, caused byChlamydia trachomatis an obligate intracellularbacterium. Only serotype A, B, Ba and C are responsible

for trachoma. Disease transmission occurs primarilybetween children and women. Most of the children areinfected by the age of one to two years. The peak rateof active trachoma varies from 2—7 years. Repeatedepisodes of infection within the family leads to chronicfollicular conjunctivitis, which in turn leads to tarsalconjunctival scaring. The scaring distorts the uppertarsal plates and leads to entropion and trichiasis whichin turn results in corneal abrasions, corneal scaring,opacification and ultimately blindness.

Trachoma is an ancient disease; it is present inChinese from the 27th century BC1. In Egypt the featuresof trachoma were described in Ebers’ papyrus, acollection of writings by ancient Egyptian physicianfound by Ebers in 1889. In Egypt the device used forepilation of trichiasis (inward turning of eye lashes) waspresent in the Egyptian tomb in 19th century BC2.Hipocrates has written prescription for trachomatreatment and its complicatios.2, 3

Global loss of productivity related to impairedvision and blindness from trachoma is thought to be as$ US 5.3 billion annually.

Transmission occurs from eye to eye via hands,clothing and other fomites. Flies have been identifiedas major vector for the infection’s spread6, 7, 8, 9 .The

Door to Door Trachoma Surveyin North Waziristan Agency, Tehsil Mir Ali

Sanaullah Khan FCPS1, Saber Mohammad, FCPS2, Mushtaq Ahmad, FCPS3

Awalia Jan FCPS4, Zakir Hussain FCPS5, Khan Nawaz6

ABSTRACTOBJECTIVES: To determine the age and gender wise distribution of trachoma and its complications in the target populationof North Waziristan agencyMATERIAL AND METHODSStudy 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 and15% 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 maleand 27% in females. The gender wise distribution of trachoma in village Haider khel was 22.8% in male and 32.4% infemale.Key words: Non random sampling. Trachoma,TF (Trachomatis Follicle). TI (Trachomatis Inflammation). TS(Trachomatis Scaring). TT (Trachomatis Trichiasis) CO (corneal opacity). Ophthalmologist, Hygiene andEnvironmental factors.CONCLUSION:The prevalence of trachoma is because of multiple factors like1. 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.

Original Article

Dr. Sanaullah


presences of open latrines favor the vector population.4,5

Factors associated with trachoma are age, socio-economic background and rural regions in which theextent to the water supply is limited, the distance fromthe water source, the amount of water used for washingpurposes and overcrowding.10, 11

DATA COLLECTION PROCEDUREA meeting was held with the elders of the two

villages. They were informed about the survey. Theywere requested to extend their full cooperation and togive support regarding the human resources. Thesurvey team comprising of ophthalmologist, ophthal-mic technicians, and the village volunteers conducteda door to door survey of every family in the village.

Each member of the family was screened fortrachoma or its complications. In the younger age groupboth the upper eyelids were everted and examined fortrachoma follicles and trachomatis inflammation withthe help of the loupe.

The older age groups were examined fortrachomatis scarring, trichiasis and corneal opacity. Thefamily members absent were examined latter and everypossible effort was made that no one could be missed.Questions regarding the water supply, sanitaryconditions and disposal of wastes was also asked andentered in the Performa. Many people with activeinfection who were very poor given medicines free ofcost.ETHICAL CONSIDERATION

Permission was sought from the village (Malik)and Executive District Officer (Health). A meeting wasarranged with community leaders of the village andthey 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 timelimit was too short for the Conduction of the study.Talebanization and army operation was another majorobstacle for free movement and team work.RESULTS

The number of cases examined in village IPI were1929 in which 1049 were male and 880 were femaleshown in figure no, 1.The prevalence of trachoma invillage IPI was 22% in which 18% were male and 27%female shown in figure no, 2.The prevalence oftrachoma is 35% in age group 0-9 years and 15% in agegroup 30 and above shown in table no, A. Age andgender wise distribution of trachoma signs in villageIPI shown in tables no, B & C.

The numbers of cases examined in village HaiderKhel were 3166 in which 1705 were male and 1461 werefemale shown in figure no, 3.The prevalence oftrachoma in village Haider Khel was 26.46% in which22.80 % were male and 32.40 % were female shown in

figure no, 4. The prevalence was 42.8% in age range 0to 9 years & 16.7% in 30 years & above shown in tableno, D. Age and gender wise distribution of trachomasigns in village Haider Khel shown in tables no, E & F.

RESULTS OF VILLAGE IPITotal Population: 2900Sample 1929

RESULTS OF VILLAGE HAIDER KHELTotal Population of Village: 4018Sample: 3166

DISCUSSIONTrachoma is considered as a public health

problem in many developing countries, where as it hasdisappeared in the western world. North WaziristanTehsil Mir Ali showed the high prevalence of trachomain IPI and Haider Khel villages with rates of 22% and26.46% respectively. Trachoma is considered therefore

Figure 2: Gender wise Prevalence of Trachoma (%) in Village IPI

Figure 1: Tocal Cases examined in Village IPI

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 totalpopulation of village IPI and Haider Khel were 2900and 4018 respectively. The missing people were eitherabroad or living in various parts of the country forvarious purposes that is education, employment andbusiness etc. The result of both villages show that theprevalence of trachoma was more in females comparedto males. The study also shows that in both the villagesTF and TI were more common in younger age group(0—9 years) while ST, TT, and CO were more commonin old age group (30 years above).

The present study showed high results with whatwas found in Shabwah district/ Yemen (17% of activetrachoma by TRA) 12. However, these results are lowercompared to many TRA performed in endemiccountries. A TRA performed in the southern Zambiashowed 55.5% of children with active trachoma; and 2years after the implementation of SAFE strategy, theoverall percentage of trachoma was reduced to 10.6%13.The Ethiopian study mentioned 51.1% of childrenhaving active trachoma14. Another rapid assessment oftrachoma done in Yemen showed a higher rate amongrural children (73.2%) compared to urban children(23.1%) 12.

In the study it was found that out of 51 patientsof TT, 10 patients had developed corneal opacities. Only4 patients with trichiasis had surgery. If surgery is notperformed on these TT patients, there is a risk ofdeveloping CO leading to visual loss and blindness. Itwas also found in our study that there is a correlationbetween active trachoma and unclean face. Uncleanfaces being observed in more than 40% children in boththe villages. This highlights the importance of focusingon health education. In our study, no correlation wasfound between active trachoma and the absence oflatrines or water supply, as already mentioned in the

rationale for the study that although water is plenty inthese two villages but people are not using it forcleanliness.CONCLUSION:

The prevalence of trachoma is because of multiplefactors like1. 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 oftrachoma.

3. Improper solid waste disposal and drainagesystems in these areas are ideal places for increasebreeding of flies.

Recommendations:After having completed the study and knowing

about some of the contributory factors involved in thetransmission of trachoma in the villages of IPI andHaider Khel, we have few recommendations to putforward.1) Health education should be given to the public

using different media to create a generalawareness regarding trachoma.

2) The community should be involved in thetrachoma control because without involving themthe task is impossible. It is only the communitywho can keep their environment clean.

3) The cases of red eye should not be taken lightlyand proper eye examination should be done by atrained person.

4) All the people with trachoma visiting the hospitalshould be advised to take the drugs regularly andnot to share their towels with others.

5) The cowsheds in the villages should beconstructed a little distance away from the house



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


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


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.6) The poor people who cannot afford to construct

latrine should be given financial assistance by thegovernment from zakat funds or by any other NonGovernment Organization.

7) Trachoma control programme should be initiated

in the trachoma endemic areas, so that a betterattention is paid to this blinding disease.

REFERENCES:1. Al- Rafia KMJ. Trachoma throughout history. Int ophthaimol

1988: 12:9-14.2. MacCallan AF.The epidemiology of trachoma.Br j

ophthalmol 1931:15- 370-411



3. Mettir CC. in: Metler FA(ed) History of medicine.Philadelphia, PA: The Blackiston Co: 1947.pp.1005-1023

4. Tielsh jM West KP, katz j et al. The epidemiology of trachomain Southem Malawi. Amj Trop Med Hyg 1988; 30:393-399

5. Taylor HR, West SK, Mnbaga BB et al. Hygiene factors andincreased risk of trachoma in central Tanzania. Archophthalmol 1989; 107: 1821- 1825

6. Jones BR. Changing concepts of trachoma and its control.Trans ophthalmol soc UK 1980; 100:25-25

7. Wilson RP ophthalmia Aegyptiaca. Amj ophthalmol 1932;15: 397-406

8. Dawson CR, Dagh four T, Messadi M, Howshiwara I,Schachter j- severe endemic trachoma in Tunisia.Brjophthalmol 1976; 60: 245-252.

9. Gupta CK, Gupta UK, Flies and mothers as modes oftransmission of trachoma and associated bacterialconjunctivitis. J All India ophthalmol society 1970; 18:17-22

10. S.P Mariotti, D Pascoilini, J Rose-Nussbaumer. Trachoma;Global magnitude of a preventable cause of blindness. B J O2009;93; 563-568 doi; 10.1136/bjo.2008. 148494.

11. Y Jie, L Xu K Ma et al. Prevalence of trachoma in the adultChinese population, the Beijing Eye study. Eye 2008 22, 790-791; doi; 10.1038/sj.eye.6702857; published online 11 may2007.

12. Alkhatib T, Rapid assessment of trachoma and governoratesand Socotra island in yeman, faculty of medicine and healthsciences, university of Sana, A, LA revue de sente de lamediterranee, volume 12, number 5,2006.

13. Actle W et al. Tachoma controle in southern Zimbia, ininternational scheme, project employee the SAFE strategy,Ophthmic epidemiology, volume 13, number 4, august 2006,227-236 (10).

14. Gordon J, et all. The epidemiology of eye disease, 2nd edition,2003, isbn 0340808929HB0, P 171-176.



–––––––––––––––––––––––––––––––––––––––––––––––––––––––The study was conducted at the Department of Ophthalmology,Khyber Institute of Ophthalmic Medical Sciences, HayatabadMedical Complex, Peshawar.–––––––––––––––––––––––––––––––––––––––––––––––––––––––1,2Medical Officers, 3Senior Registrar, 4Registrar, Khyber TeachingHospital, Peshawar–––––––––––––––––––––––––––––––––––––––––––––––––––––––Correspondence: Dr Zakir Hussain, No. 86, St. No. 9, Sector: J-1,Phase II, Hayatabad, Peshawar.Ph: 091-5811020 (Res) Email: [email protected]–––––––––––––––––––––––––––––––––––––––––––––––––––––––Received: Jan’2012 Accepted: March’2012–––––––––––––––––––––––––––––––––––––––––––––––––––––––

INTRODUCTIONRegional anaesthesia is commonly used for

cataract surgery.1Peribulbar anaesthesia for cataractsurgery was the popular technique in the last decade, 2

but it is not completely free from complications.3,4

Retrobulbar anaesthesia, which was previously used,was associated with a number of potentially sight-threatening complications.5 Other anaesthesiaprocedures have been developed to reduce the risk ofcomplications. 6-9 Advances in cataract surgeryincluding the use of a smaller, self-sealing incision havereduced the duration of surgery10resulting in the useof shorter acting anaesthetic agents with less invasivemethods of administration. In sub-tenon anaesthesia8,9,11

trans-conjunctival infiltration of local anaesthetic agentdirectly to the subtenons space occurs. Before this local

anaesthetic drop in the conjunctiva is instilled whichtakes away the pain of the needle prick. This techniquehas been used for conventional extracapsular cataractextraction (ECCE) with posterior chamber intraocularlens implantation (PCIOL) and phacoemulsification.11,12

Manual small incision cataract surgery (MSICS) hasbecome popular in developing countries like Pakistanas it results in better uncorrected vision as comparedto ECCE, 13 and at an affordable cost.10 We designed thisstudy to compare the two methods of anaesthesia inMSICS with respect to pain, akinesia, intraocularpressure control and complications, using a randomisedcontrol clinical trial.MATERIAL AND METHODS

All the patients admitted for cataract surgery,were asked to participate in the trial. The first 100, whoagreed to informed consent, were randomised to eithersubtenon or peribulbar technique.

The exclusion criteria were1. Sensitivity to xylocain2. History of convulsion or epilepsy3. Patients who had previous intraocular surgery,

injury or any inflammation4. Inability to understand the visual analogue

pain scaleThe patients were asked to grade the pain they

felt on a linear scale of 0-4 (No pain = grade 0, mildpain= grade 1, moderate pain =grade 2, severe pain =

Subtenon vs Peribulbar Anaestheiafor Manual Small Incision Cataract Surgery*

Zakir Hussain1, Samina Karim2, Muhammad Naeem Khan3 Mohammad Sabir4

ABSTRACTObjectives: To compare the safety and efficacy of subtenon anaesthesia with peribulbar anaesthesia in manual smallincision cataract surgeryPlace and duration of study: The study was carried out at Department of Clinical Ophthalmology, Khyber Institute ofOphthalmic 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 informedconsent. All surgeries were performed by single surgeon. Pain during administration of anaesthesia, during surgery and4 hours after surgery was graded on a visual analogue pain scale and compared for both the techniques. Positivepressure 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 yearsrespectively.35.29% patients of peribulbar group and 76.19% patients of subtenon group experienced no pain duringadministration of anaesthesia. There was no significant difference in pain during and 4 h after surgery. The absoluteakinesia 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 perceptionduring surgery.Key words: Manual small incision cataract surgery; peribulbar anaesthesia; sub-tenonanaesthesi

Original Article

Dr. Zakir


grade 3 and maximum pain imaginable = grade 4).Patients were asked to grade separately for pain duringadministration of anaesthesia, pain during surgery andpain 4 hours after surgery. The last was taken whenthe patient was shifted to the wards. After each surgerythe surgeon was asked to score for akinesia and to gradefor positive pressure during surgery, chemosis,subconjunctival haemorrhage and overall ‘discomfort’.‘Akinesia’ was scored on a scale designed to measureocular movements in each quadrant (no movement =score 0, mild = 1, moderate = 2, severe = 3 in eachquadrant, minimum score possible = 0, maximum scorepossible = 3 x 4 = 12). Intraoperative complicationswere noted. All patients underwent MSICS; any changein technique, if needed, was noted.RESULTS:

In this study, we evaluated 93 eyes of 93 patientswho presented with cataract and were admitted in ourunit from 1st March 2011 to 30th July 2011. There were27 (52.94%) male and 24 (47.05%) were female in theperibulbar group and there were 24 (57.14%) male and18 (42.85%) female in the subtenon group. Average agein the two groups was 64 and 58 years respectively.Pain during anaesthesia is shown in Table I. Table IIshows the various grades of pain during surgery. Allpatients of the peribulbar group reported no pain 4hours after surgery compared to 2 patients in thesubtenon group. The various scores of ocularmovements after anaesthesia are shown in Table III.DISCUSSION:

For cataract surgery,nowadays,various methodsof local anaesthesia are in use. These includesretrobulbar, peribulbar, subtenon’s, subconjuctival andtopical. Both retrobulbar and peribulbaranaesthesiainvolve blindly placing a sharp needle into the orbit todeliver the anaesthetic agent. The technique ofperibulbar anaesthesia has been preferred toretrobulbar anaesthesia as it is associated with a smallerrisk of globe perforation, retrobulbar haemorrhage,optic nerve damage, and injection of the anaestheticsolution into the subarachnoid space. However, theperibulbar method itself is not absolutely safe. Someserious complications has been reportedfrequently.3,5,6,14,15 Subconjuctival anaesthesia is aneffective and safer alternative; however, this techniqueprovides no akinesia.16 Topical anaesthesia has gainedwide popularity particularly with the advent ofphacoemulsification.17 However, it does not provideakinesia. Lack of akinesia can pose significant difficultyparticularly when dealing with un-cooperative patients.

Subtenon anaesthesia was more comfortable forthe patient at the time of anaesthetic administration.They also had good analgesia intraoperatively, but thesurgeon had to operate with incomplete akinesia, which

some may find discomforting. The surgery was startedimmediately after administration of anaesthesia insubtenon group. As lesser amount of the anaestheticagent was used for subtenon, the chances of adverseeffects are also minimized. In a large hospital or in acommunity eye care setting, the cost would also be less.There was no difference in positive pressure rise duringsurgery and postoperative pain between both thetechniques of anaesthesia. An audit of subtenon andperibulbar anesthesia for cataract surgery in UKdemonstrated sub-Tenon’s methods to be moreeffective than the peribulbar technique, withsignificantly fewer patients experiencing unacceptablelevels of pain.11 It was significantly less uncomfortableon administration than the peribulbar methods andreduced the interval between administration ofanaesthesia and surgery. On the range of 1-10, pain on

Table: I Pain during anaesthesia

Peribulbar Subtenon

Grade 0 18 (35.29%) 32 (76.19%)

Grade 1 26 (50.98%) 8 (19.04%)

Grade 2 3 (5.88%) 1 (2.38%)

Grade 3 3 (5.88%) 1 (2.38%)

Grade 4 1 (1.96%) 0 ( 0%)

Total 51 (100%) 42 (100%)

Table :2 Pain during surgey

Peribulbar Subtenon

Grade 0 44 (86.27%) 37 (88.19%)

Grade 1 3 (5.88%) 4 (9.52%)

Grade 2 2 (3.92%) 1 (2.38%)

Grade 3 2 (3.92%) 0 (0%)

Grade 4 0 (0%) 0 ( 0%)

Total 51 (100%) 42(100%)

Table: III Ocular movements during surgery

Akinesia (score) Peribulbar Subtenon

0 34 (66.66%) 0(0%)

2 6 (11.76%) 0(0%)

4 8 (15.68%) 5(11.90%)

6 2 (3.92%) 3(7.14%)

8 1 (1.96%) 16(38.09%)

12 0 (0%) 2(4.76%)

Total 51 (100%) 42(100%)

Subtenon vs Peribulbar Anaestheia for Manual Small Incision Cataract Surgery


administration of anaesthetic had a mean of 2.4 for theperibulbar group and 1.4 for the subtenon group. Thiscorrelated with results of our study. The subtenontechnique appeared to be the safest method ofintroducing anaesthetic fluid into the retrobulbar spacewithout the potential complication of a sharp needleinjection.14 But a single case of globe perforation wasreported15 in a patient who had underwent detachmentsurgery and had thinned sclera. It is likely thatsubtenon anaesthesia offers a significantly reduced riskof complication such as scleral perforation, retro bulbarhaemorrhage, optic nerve injury and injection ofanaesthetic solution into the subarachnoid space, as nosharp instrument is passed into the orbit. It should,however, be used with caution in patients withcompromised and thin sclera. A randomised study inDenmark comparing retrobulbar, subtenon and topicalanaesthesia for phacoemulcification found retrobulbartechniques had less discomfort/pain during surgerybut patient preferred subtenon or topical anaesthesia,as it did not involve the needle prick duringanaesthesia.12

Subtenon anaesthesia has also been used for opticnerve sheath fenestration.16 Subtenon anaesthesia hasbeen found to be more comfortable for the patient,reliable, long lasting and with deeper anaesthesia ascompared to topical anaesthesia forphacoemulcification patients. It was also morecomfortable for the surgeon with better pupillarydilatation17. A randomised trial in the UK18 found thedifference between the pain score in the subtenon andtopical groups to be highly statistically significant, withsubtenon being more pain free, for phacoemulcificationpatients. Limitations of the study include subjectivenature of the visual analog pain scales. But past studiesand postoperative visual acuity results indicate that itwould not be significant.CONCLUSION:

Sub-tenon’sanaesthesia is an effective and safetechnique for manual small incision cataract surgery.Comparing this technique with peribulbar anaesthesiathere was no significant difference in terms of painperception during surgery.

REFERENCES:1. Hamilton RC. Complication of ophthalmic regional

anaesthesia. OphthalmolClin North Am 1998;11:99-1142. Davis DB, Mandel MR. Efficacy and complication rate of

16,224 causative peribulbar blocks. A postoperative multiCentre study. J Cataract Refract surg 1994;20:327-37.

3. Mount AM, Seward HC. Sceral perforations duringperibulbar anesthesia. Eye 1993;7:766-7.

4. Hay A, Flynn H, Hoffman J. Needle penetration of the globeduring retrobulbar and peribulbar injections. Ophthalmolo1991;98:1017-24

5. Murdoch IE. Peribulbar versus retro bulbar anesthesia. Eye1990;4:445-9.

6. Stevens JD. A new local anesthetics techniques for cataractextraction by one quadrant sub-Tenon’s infiltration. Br JOphthalmol 1992;76:670-4

7. de la Marnieere E, Maye R, Albertim, Batissc JL, Baltenneck.Comparison between GreenbachsParabulbarAnaesthesia andRipart’ssubtenonanaesthesia in the anterior. segmentsurgery. J FrOphthalmol 2002;25:161-5.

8. Stevens JD. A new local anaesthesia technique for cataractextraction by on quadrant sub-Tenon’s infiltration. Br JOphthalmol 1992;76:670.

9. Hansen EA, Mein CE, Mazzoli R. Ocular anesthesia forcataract surgery: a direct sub-Tenons’s approach. OphthalmicSurg 1990; 21 :696-9

10. Gogate PM, Deshpande M, Wormald RP. Is manual smallincision cataract surgery affordable to developing countries?A cost comparison with extra capsular cataract extraction.Br J Ophthalmol 2003;87:843-6.

11. Briggs MC, Back SA, Esakowitz L. Subtenons versusperibulbar anesthesia for cataract . Eye 1997; 11 :611-43.

12. Davis DB, Mandel MR. Nileson PJ Alerod CW. Evaluationof local anesthesia technique for small incision cataractsurgery.J Cataract Refract Surg 1998;24:1136-44.

13. Gogate PM, Deshpande M, Wormald RP, Deshpande RD,Kulkarni SK. Extra capsular cataract surgery compared withmanual small incision cataract surgery in community eyecare setting in western India: a randomized control trial. BrJ Ophthalmol 2003;87:667-72.

14. Loinder S, Walka SB, Atth HR. Ultrasonic localization ofanesthetic fluid in subtenon, peribulbar and retro bulbartechniques.J Cataract Refract Surg 1949;25:56.

15. Freiman BJ. Friedberg MA. Globe Perforation associated withsub tenon’s anesthesia. Am J Ophthalmol 2001;131 : 520-1.

16. Rizzuto PR, Spoor TC, Ramock JM, McHenry JG. Subtenon’slocal anesthesia for optic nerve sheath fenestration. Am JOphthalmol 1996;121:326-7.

17. Vielpeau I, Billotte L, Kreidie J, Lecoq P. Comparative studyof topical anesthesia and subtenon anesthesia for cataractsurgery. J FrOphthalmol 1999;22:48-51.

18. Manner TB, Burton RL. Randomized trial of topical versussubtenon local anesthesia for small incision cataract surgery.Eye1997;10:367-20.

Subtenon vs Peribulbar Anaestheia for Manual Small Incision Cataract Surgery


–––––––––––––––––––––––––––––––––––––––––––––––––––––––1Junior registrar, 2Orthoptist, 3Senior Registrar, 4Medical Officer,Lady Reading Hospital, Peshawar.–––––––––––––––––––––––––––––––––––––––––––––––––––––––Correspondence: Dr. Rahil Aumer Malik, FCPS, Eye Specialist,House: 47, Army Housing Scheme, Askari-IV, Warsak Road,Peshawar Cantt. Cell : 0321 903 6959E-mail: [email protected]–––––––––––––––––––––––––––––––––––––––––––––––––––––––Received: Dec’2011 Accepted March 2012–––––––––––––––––––––––––––––––––––––––––––––––––––––––

Frequency and Types of Comitant EsotropiaAmong Patients Attending Eye OPD

Nuzhat Rahil1, Kanwal Ahad2, Rahil Malik3, Muhammad Sardar4

ABSTRACTObjectives: 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 LadyReading 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 ofall age groups 123(2.15%) patients had comitant esotropia. Of the total patients with esotropia 57 (46.34%) were malesand 66 (53.65%) were females .Age wise the patients were grouped in to 3; In group 1, 0 to 10 years age there were 90patients. 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 infantileesotropia .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 esotropiafollowed by infantile esotropia. More than half of patients with comitant convergent squint (esotropia) were under the ageof 10 years which showed that Comitant Convergent squint is more common in children than adults so its early detectionand management with simple glasses in children can reduce the risk of amblyopia and constant esotropia.Key Words: Comitant esotropia, Accommodative esotropia, infantile esotropia.

Original Article

Dr. Nuzhat

INTRODUCTIONConvergent squint is the most common form of

strabismus constituting 1/2 to 2/3 of all misalignedeyes.1 Strabismus is a common disorder that affects 3%to 5% of children, with 126 400 new cases occurringyear in the United States.2

The prevalence of comitant convergent squintvaries in different parts of the world. In United Statesof America, prevalence of esotropia constituted 75% oftotal3,4. In Ibadan esotropia constituted 80% of totalcases.5 Similarly in Ireland (UK), it was found thatesotropia was five times more common than exotropia.6

In northern Nigeria, esotropia was found in 62.5%cases.7

In Pakistan, children under the age of 15 yearsaccount for 45% of the total population.8 The overallestimated prevalence of strabismus in Pakistan is 5.4%.8

Out of this 2.5% strabismus patients are under the ageof the 5 years while 2.9% patients are over the age of 5years.8 The national prevalence of squint of 5.4%suggests that there are 7.02 million patients withstrabismus in a population of 130 million.8

Binocular anomalies constituted 74% with

comitant strabismus .Accommodative esotropia is themost common type of comitant convergent squintaccounting for 36.4%.3in total, 10% with paretic, 8% withdecompensated heterophoria and 6% convergenceinsufficiency.8 All accommodative esodeviations areacquired with an onset generally between 6 months andseven years averaging nearly two and half years of age.It is attributed totally or partly to uncorrected refractiveerror (hypermetropia) or an abnormal accommodativeconvergence/ accommodation (AC/A) relationship.Infantile esotropia is the second most common type ofComitant Convergent squint, occurs in early infancy,usually at 3 months to 6 months of age, and is rarelypresent at birth. When the infantile esotropia is constantand unilateral, it will likely develop amblyopia9,10.MATERIAL AND METHODS

This was a hospital based descriptive crosssectional study on hundred and twenty three patientsattending eye department Lady Reading HospitalPeshawar during three months in 2011. Afterpermission of an Ethical Committee of PostgraduateMedical Institution, Peshawar and written informedconsent from the patients and the parents were taken.To estimate the frequency and types of comitantconvergent squint among all age groups patientsattending eye OPD at Lady Reading Hospital Peshawarwere included in the study.

Patients with mental disorder, patients with otherassociated systemic illness and old patients wereexcluded from the study. All age group are selectedand then are divided into 3 groups. Group 1 includedpatients between age 0 and 10 years, group 2


included10-20 years and group 3 included 20 years andabove. All the patients were examined and assessedwith the help of refractionist and orthoptist. Type ofesotropia, gender distribution, type of refractive errorand amount of amblyopia were assessed. Nominal dataof all the patients was recorded on a data collectionperforma. After completion of data collection, the datawas analyzed using SPSS version 10.RESULTS

Total of 4884 (100%) patients with eye problemsvisited the eye OPD in three months. Among thesepatients of all age groups 123(2.15%) patients hadcomitant esotropia. Of the total patients with esotropia66 (53.65%) were females and 57 (46.34%) were males.Age wise the patients were grouped in to 3; In group1, 0 to 10 years age there were 90 (73.17 %) patients. Ingroup 2, 10 to 20 years age there were 27(21.95 %)patients. In group 3, above 20 years age there were 6(4.87%) patients.

Among patients with comitant convergent squint(esotropia), 78 (63.41%) had Accommodative esotropia,18 (14.63%) had infantile esotropia, 9(7.31%) hadResidual esotropia, 9 (7.31%) had Acquired Non-Accommodative esotropia and the remaining 9(7.31%)had constant esotropia with amblyopia. Refractive errorwas observed in 90 patients while 11 patients neededsquint surgery.DISCUSSION

Out of total 4884 ophthalmic patients , 123(2.51%)were patients with comitant convergent esotropia .Inthis study 53.65% of patients were female which isdifferent from the study done by Kac et al11 in whichesotropia was the most prevalent misalignment in hissample group (44.52%). There were more males in thisgroup (p=0.001) with a predominance of the age group0-2 years (p=0.009).E. In other studies of squint therewere not much difference in the gender affected 2 The

frequency of comitant convergent squint of our studywhich is 2.5% is almost similar to the Prevalence ofsquint in Pakistan which is 2.75% in study done by Khanet al 8.

More than half of the patients with comitantconvergent squint in our study were under 10 years(73.17%). The incidence of childhood esotropia frompopulation-based study done by Greenberg et al iscomparable with prevalence rates reported amongWestern populations. According to that studyEsotropia is most common during the first decade oflife, with the accommodative and acquiredNonaccomodative forms occurring most frequently.The congenital, sensory, and paralytic forms ofchildhood esotropia were less common in thispopulation12

This is the period to develop amblyopia.Amblyopia causes more vision loss in individuals underthe age of 10 years than do all other ocular diseasescombined. So early detection is important forrestoration of normal ocular alignment andestablishment of binocular single vision will reducesthe risk of amblyopia and constant squint.

In this study of 123 patients with comitantconvergent squint 78 (63.41%) had accommodativeesotropia .According to a study done by Kothari et al 13

accommodative component can play a significantcausative role in esotropia and needs to be ruled out inevery esotropia. In our study 14.63% of patient hadinfantile esotropia and,3(7.31%) had residual esotropia,3(7.31%) had non accommodative esotropia; theremaining 3(7.31%) patients had constant esotropiawith amblyopia. According to a study done by Mohneywho provides population-based data on the mostprevalent forms of childhood strabismus.Accommodative esotropia, intermittent exotropia, andacquired non-accomodative esotropia were thepredominant forms of strabismus in this Westernpopulation 14.according to another study,accommodative esotropia is the most common pediatricstrabismus and must be differentiated from otherpediatric esotropia.15 Although its average age of onsetis 2.5 years, it can begin during the first year of life andis seen rarely in older children and teenagers. Refractiveerror was the main culprit for the esotropia in our studyand 2/3 of the patients had some type of refractive errorwhich is similar to the other international studies16.CONCLUSION:

It is concluded that the most common type ofComitant Convergent squint is Accommodativeesotropia followed by infantile esotropia .More thanhalf of patients with Comitant Convergent squint(esotropia) were under the age of 10 years which showsthat Comitant Convergent squint is more common in

Distribution of Patients age-wise

Age Group No of Patient Percentage

0-10 age group 90 73.17%

10-20 age group 27 21.95%

20 years and above 06 4.87%

Distribution of patients according to types of squint

Types No. of Patients Peercentage

Accomodative 78 63.41

Infantile 18 14.63

Residual 9 7.31

Non-accomodative 9 7.31

Constant 9 7.31

Frequency and Types of Comitant Esotropia Among Patients Attending Eye OPD


children than adults so its early detection in childrencan reduces the risk of amblyopia and constantesotropia. The most leading cause of 2/3 patients withcomitant convergent squint was refractive error(hypermetropia) which shows that management withsimple corrective glasses can exclude more than half ofesodeviations.REFRENCES1. Pai A and Mitchell P. Prevalence of amblyopia and

strabismus. Volume: 116, Issue: 2: American Academy ofOphthalmology 2010: 365-66.

2. Mohney BG. Common forms of childhood esotropia.Ophthalmology 2001;108:805

3. Greenberg A, Mohney BG, Diehl NN, Burke JP. Incidenceand types of childhood esotropia: a population-basedstudy. . Ophthalmology.2007;114(1):170–174

4. Friedman Z, Neumann E,Hyams S W,Pelag B.opthalmicscreening of 38,000 children, age 1-2 years in child welfareclinics .J.Peadiatr Opthalmol strabismus 1980:17:261-267

5. Baiyeroju AM,Owoeye JFA.Strabismus in children in IbadanNig J. Opthalmology 1998;6:31-33

6. Donelly U M , Stewart N M Hollinger M. Prevalence andoutcome of children visual disorders.opthalmicEpidimeology 2005:12:243-250

7. Morgan R E .Pattern of eye diseases in children seen at Josuniversity teaching hospital . Br J Ophthalmol 2007;91:1337–4.

8. Khan A. Child and adult health (Eds) National health surveyof Pakistan.Islamabad: Pakistan Medical Research Council.1996; 19-22

9. Tollefson M, Mohney BG, Diehl NN, Burke JP. Incidence andtypes of childhood hypertropia: a population-based study.

10. Birch EE, Fawcett SL, Morale SE, et al. Risk factors foraccommodative esotropia among hypermetropic children.Invest Ophthalmol Vis Sci 2005;46:526-9.

11. Kac MJ, Freitas Júnior MB, Kac SI, Andrade EP Frequency ofocular deviations at the strabismus sector of the Hospital doServidor Público Estadual de São Paulo. J AAPOS. 2005Dec;9(6):522-6.

12. Greenberg AE, Mohney BG, Diehl NN, Burke JP.Incidenceand types of childhood esotropia: a population-based study.Optometry. 2008 Aug;79(8):422-31.

13. Kothari M. Indian J Ophthalmol. 2008 Mar-Apr;56(2):168–169.Department of Pediatric Ophthalmology . Am JOphthalmol. 2007 Sep;144(3):465-7.

14. Mohney BG.Common forms of childhood strabismus in anincidence cohort. Ophthalmology. 2007 Jan;114(1):170-4.

15. Rutstein RP . Update on accommodative esotropia. Arq BrasOftalmol. 2007 Nov-Dec;70(6):939-42.

16. Birch EE, Fawcett SL, Morale SE, Weakley DR Jr, WheatonDH. Risk factors for accommodative esotropia amonghypermetropic children. Invest Ophthalmol Vis Sci2005;46:526-9.

Frequency and Types of Comitant Esotropia Among Patients Attending Eye OPD


–––––––––––––––––––––––––––––––––––––––––––––––––––––1Classified Ophthalmologist & Assistant Professor, A.K.MedicalCollege & His Highness Shaiekh Khalifa Bin Zayed An-NahyanHospital, AJK, CMH Muzaffarabad. 2Radiologist & AssistantProfessor, A.K. Medical College & His Highness Shaiekh KhalifaBin Zayed An-Nahyan Hospital, AJK, CMH Muzaffarabad,3Histopathologist, CMH Muzaffarabad–––––––––––––––––––––––––––––––––––––––––––––––––––––Correspondence: Lt. Col. Dr. Inamul Haq Khan1, ClassifiedOphthalmologist & Assistant Professor, His Highness ShaiekhKhalifa Bin Zayed An-Nahyan Hospital, AJK, CMH Muzaffarabad.E-mail>[email protected]. Mobile: 00923009771066.

–––––––––––––––––––––––––––––––––––––––––––––––––––––Received Nov’2011 Accepted March’2012–––––––––––––––––––––––––––––––––––––––––––––––––––––

Glioblastoma Multiforme (GBM)as a cause of Foster Kennedy Syndrome

(An interesting Case)

Inamul Haq Khan FCPS1, Misbah Durrani, FCPS2, Hafeez uddin FCPS3

ABSTRACTIntroductionFoster Kennedy syndrome (FKS) is a rare condition. It is characterized by the presence of ipsilateral optic atrophy, contralateral papilloedema and ipsilateral anosmia. It was ûrst described in 1911. Glioblastoma multiforme (GBM) is a constellationof tumors. Some of them if diagnosed early can save the patient from morbidity and mortality. This patient reported withsymptoms of epilepsy at the age of 53, headaches and visual symptoms. Lack of education & financial constraints arethe main reasons for the dreadful outcomes of many treatable diseases. This case is one of the many examples of thispainful situation.Keywords :Foster Kennedy syndrome; Papilloedema; Optic atrophy.

Case report

Dr. Inam Dr. Misbah

CASE REPORTA 53-year-old, gentleman reported with loss of

vision left eye in 03 months and deterioration of visionright eye 3 weeks. He had headaches from the last threemonths which are now severe and exacerbated bycoughing and postural changes. There is history ofpartial and generalized seizures off and on in the last06 months. The seizures commenced suddenly withoutan aura, progressing to involuntary jerking of the rightarm and leg. There was history of tongue biting andincontinence. He is being treated for epilepsy. Loss ofvision in left started 03 months back. Initially he noticedthat there was generalized haziness when he closed hisright eye, followed by complete loss of vision. Fromthe last 03 weeks he is having similar symptoms in hisleft eye and he is afraid that he may lose vision in thiseye as well.

On examination, right sided vision was 6/24 withgeneralized haziness; color vision was 12/15 on Ischiaracolor plates. Fundoscopy revealed disc swelling withno venous pulsations (figure 1a). Left sided vision wasperception of light, RAPD (relative affrent pupillarydefect) and optic atrophy (figure 1b). He had left sidedanosmia as well.

a. Right disc swelling

Figure 1

b. Left pale looking disc

a. Right Optic atrophy

Figure 2

b. Left Optic atrophy

He was advised MR imaging of the brain withcontrast. Unfortunately the patient vanished, went to“quacks” He reported again after 02 months with lossof vision in right eye as well, loss of some memory andpersonality changes. On Examination visual acuityright eye was perception of light, disc was now palelooking (fig 2a). visual acuity left eye was no lightperception and optic atrophy (fig 2b). MRI brain withcontrast was done, which showed a rim enhanced,predominantly multicystic mass lesion with enhancingsolid component noted in leftfrontoparietalregion . Themass lesion also show a haemorrhagic componentshowing high signal on T1W and low signal on T2W


sequences. There is extensive surrounding vasogenicedema extending along genu of corpus callosum tocontralateral side, subfalcine herniation as well aseffacement of ipsilateral frontal, temporal and body oflateral ventricle. MR findings of this patient suggestedthe diagnosis of Glioblastomamultiforme. He wasadvised CT guided biopsy and Neuro surgicalconsultation.

Biopsy of the lesion was done which showed“Clusters of neoplastic cells. These cells have pleomorphichyperchromatic nuclei with high N/C (nuclear/cytoplasm)ratio &fibrillary cytoplasmic extensions focally. There is noevidence of tuberculosis in the material examined. Findingsare suggestive of ‘ Anaplastic astrocytoma ( WHO gradeIII)’ “The relatives of the patients refused furtherintervention.DISCUSSION

FKS is an uncommon condition and even due toadvancement in imaging techniques, computedtomography and MR imaging, the condition is stillrarely seen1. The syndrome was rst described in 1911by the Robert Foster Kennedy, a British neurologist,who spent the majority of his working life in America(1884-1952). He presented a series of six patients withthe triad of ipsilateral optic atrophy, contralateralpapilloedema and ipsilateral anosmia2. It is rarelycaused by a frontal lobe tumor but is common withtumors arising from the olfactory groove3. Histologyinvariably shows a meningioma4.

The etiological mechanism of this syndrome isunclear. Foster Kennedy originally hypothesized thatipsilateral optic atrophy resulted from direct pressureon the optic nerve, and the contra lateral papilloedemafrom long-standing elevated intra-cranial pressure5. Ananalysis of 36 reported cases showed that in 22% theabove applied, in 33% there was bilateral optic nervecompression, in 5% there was long-standing, increasedintracranial pressure and in 40% the mechanism wasunclear6.

The order of precedence of papil-loedema andatrophy is uncertain and depends on the site and sizeof the tumour7. A typical example of such influence is

in optic neuroglioma en-tering the cranium. In thiscondition the ipsila-teral optic atrophy occurs well inad-vance of any evidence of the oedema. On the otherhand a meningioma may exhibit the oedema on thecontrala-teral side before the atrophic changes onipsilateral side8. In 1909 Paton re-ported a case ofunilateral papillo-edema with contralateral blindnesswithout optic disc involvement. How-ever, two yearslater frontal lobe tumor was detected during autopsy.In five cases of frontal lobe tumor and one of frontallobe abscess Foster Kennedy thought the optic atrophyto be due to a toxic factor and papill-oedema to be dueto raised intracranial tension. Mehra et al consider it tooccur in about 2% of all cerebral tumors. Dependingon the site and size of the tumor, various changes inthe two eyes will be found9. In the early phase theatrophy may be missed. Early pallor, good vision andcorresponding field defect on the ipsilateral side withnormal disc on the contralateral side is to be expected.Gradual develop-ment of papilloedema on the contrala-teral side with increase in optic atro-phy on theipsilateral side follows. Ultimately, the second eyedevelops post-papilloedemic atrophy.

Various causes have been assigned to this con-dition. Tumors are the most common factor. Amongstthe non-neoplastic condi-tions, optochiasmalarachnoiditis, sclerosis of the internal carotid artery,syphilitic basal meningitis and Paget’s disease of theskull, craniostenosis, tubercular meningitis, and frontallobe ab-scess have been reported.

The tumors are mostly gliomas in connection withfrontal lobe & olfactory groove, chiasmal, sphenoidalridge meningioma are also seen. It is worth mentioningthat not all such cases de-velop the Foster-Kennedysyndrome. In Bynke’s (1958) series only 17 out of 1400cases of gliomas, this syndrome was seen and only in 1out of 180 patients of frontal lobe tumor, FKS waspresent. Similarly in Huber’s (1961) series 2 out of 25cases of sphenoid wing tumor and 3 out of 16 cases ofmeningioma of the olfactory groove, had thissyndrome.This case report supports the originalhypothesis of Foster Kennedy, as there was direct

Image 1. T1W Image 2. T2W Image 3. T2W SAG Image 4. T1W C +

Gliblastoma Multiforme (GBM) as a cause of Foster Kennedy Syndrome


compression of the left optic nerve and clinical featuresof raised intracranial pressure.

Pseudo-Foster Kennedy syndrome is defined asone-sided optic atrophy with papilloedema in the othereye but with the absence of a mass.10 FKS should bedifferentiated from Pseudo-Foster Kennedy syndrome inwhich there is disc swelling on one side and optic atro-phy on the other. It is due to anterior Ischemic opticneuropathy(AION). Recurrences of AION in the sameeye are rare. However AION develop in the fellow eyein 25% of cases. Usually months to years after the ini-tial involvement. When this occurs a Pseudo-FosterKennedy syndrome develops.

MANAGEMENT AND PROGNOSISBoth depend on the underlying tumor. There is

no single treatment for the syndrome. However, thereare medications that are given to manage the signs andsymptoms as well as the four major diseases that makeup the syndrome. In cases where surgical resection isnot possible, surgical intervention in the form ofresection or needle biopsy is the mainstay of treatment.Radiotherapy represents one of the standard adjuvanttreatment modalities in cases of low-gradeoligodendrogliomata. Chemotherapy is reserved forthose with recurrence following radiotherapy. Themedian survival periods range from 8 to 10 years incases of low-grade oligodendrogliomata. Large serieshave reported no plateau in survival, so radiotherapyhas been proposed to optimize surgery and to delayrecurrences. However, there has been no randomizedtrial assessing the optimal timing and the benecial role

of radiotherapy. Some advocate radiotherapy at anearly stage of the disease, while others follow a non-aggressive management, with irradiation only at thetime of progression11.REFERENCES1. Frenkel RE, Spoor TC. Visual loss and intoxication.

SurvOphthalmol 1986; 30(6): 391–6.2. Miller DW, Hahn JF. General methods of clinical

examination. In: Neurological Surgery, vol. 1, 2nd edn,Youmans JR, ed. Philadelphia, PA: WB Saunders, 1997: 13.

3. Frank WN. Central nervous system & the eye.Ophthalmology principles & concepts, 7th ed. Mosby, 1992:506.

4. Yildizhan A. A case of Foster Kennedy syndrome withoutfrontal lobe or anterior cranial fossa involvement. NeurosurgRev 1992; 15(2): 139–42.

5. Kennedy F; Retrobulbar neuritis as an exact diagnostic signof certain tumors and abscesses in the frontal lobe. AmericanJournal of the Medical Sciences, Thorofare, N.J., 1911, 142:355-368

6. Coppetto JR, Monteiro ML, Collias J, Upho D, Bear L. FosterKennedy syndrome caused by solitary intra-cranialplasmacytoma. SurgNeurol 1983; 19(3): 267–72.

7. Jarus GD, Feldon SE. clinical & computed tomoraphicfindings in the Foster Kennedy syndrome. AM J Ophthalmol1982; 93(3):317-22.

8. Neville RG, Greenblatt SH, Collartis CR. Foster Kennedysyndrome and an optociliary vein in a patient with a falxmeningioma. J ClinNeuroophthalmol 1984; 4(2): 97–101.

9. Watnick RL, Trobe JD. Bilateral optic nerve compression asa mechanism for the Foster Kennedy syndrome.Ophthalmology 1989; 96(12): 1793–8.

10. Beck RW, Smith GH. Anterior ischemic optic Neuropathy.Neuro-ophthalmology: A problem oriented approach.Little,Brown& company, Boston, 1998:48-50

11. Yeh SA, Lee TC, Chen HJet al. Treatment outcomes andprognostic factors of patients with supratentorial low-gradeoligodendroglioma. Int J RadiatOncolBiolPhys 2002; 54(5):1405–9.

Gliblastoma Multiforme (GBM) as a cause of Foster Kennedy Syndrome


–––––––––––––––––––––––––––––––––––––––––––––––––––––*The study was conducted at the Orthopaedic Unit of KhyberTeaching Hospital Peshawar. –––––––––––––––––––––––––––––––––––––––––––––––––––––1,2Medical Officers, 3Associate Professor, 4Prof & Head of theOrthopaedic and Trauma Unit, Khyber Teaching Hospital, Peshawar. –––––––––––––––––––––––––––––––––––––––––––––––––––––Correspondence: Dr Muhammad Ayaz Khan, Associate ProfessorOrthpeadic Surgery, Khyber Medical College & Khyber TeachingHospital, Peshawar. Room No. A3-4, Ist floor, Khyber MedicalCentre, Dabgari Gardens, Peshawar. Phone : 0912217255Cell : 03005933101 E-mail > [email protected]–––––––––––––––––––––––––––––––––––––––––––––––––––––Received: Jan’2012 Accepted: March’2012 –––––––––––––––––––––––––––––––––––––––––––––––––––––

INTRODUCTION:Arthritic disease of the knee is a disabling

condition, negatively affecting life style in active agingpopulation. It ranges from involvement of a singlecompartment to end-stage tricompartmental disease.Involvement of the medial compartment with a genuvarum deformity is a common occurrence in thisdisease1,2,3. The symptoms of the knee osteoarthritis aredisabling pain, deformity and restriction ofmovements. During early stages the disease is treatedconservatively by encouraging weight loss,physiotherapy, avoid squatting, life style modifications,

quadriceps strengthening exercises and low impactactivity4, 5.

Most commonly, varus deformity develops whenthe disease progresses to its end stage. High tibialosteotomy, unicompartmental arthroplasty and totalknee arthroplasty are various surgical options to treatthis condition5, 6. Other surgical options described inthe literature are synovectomy, arthroscopic jointdebridement and wash, arthrodesis, patellectomy,petalloplasty and menisectomy8.

Tibial osteotomies were introduced in 1950s7.These osteotomies have shown variable results asshown in (table-1)22. Lateral closing wedge osteotomyis more famous osteotomy as compared to medialopening wedge osteotomy for medial compartmentaldisease. It shifts the weight bearing axis from medialto lateral compartment8. Venous decongestion isanother factor for pain relief apart from axialrealignment10. The damaged articular weight bearingregions of the medial compartment heals withfibrocartilage after axial realignment as obvious frombiopsy and second look arthroscopy10, 11, 12 .

It has been proved that the results of theseosteotomies deteriorate with the passage of time14 but

Original ArticleGeneral Section

Short Term Results of ClosingWedge High Tibial Osteotomy

for Medial CompartmentalOsteoarthritis of the Knee*

M. Imran Khan FCPS1, M. Salman2, M. Ayaz Khan FCPS3

Prof. Zafar Durrani FRCS4

ABSTRACTObjective: The objective of this study was to see the short term results of lateral closing wedge high tibial osteotomy interms of patient satisfaction and pain relief for medial compartmental osteoarthritis.Material and Methods: Forty patients underwent lateral closing wedge high tibial osteotomy for medial compartmentalosteoarthritis between February 2008 to February 2011. Patients with active life style, age < 60 years and osteoarthritislimited only to medial compartment were included in the study. Patients with lateral compartment and patello-femoralinvolvement, inflammatory arthritis, range of knee motion less than 90 degrees and flexion contracture more than 15degrees were not included in the study. The patients were evaluated at six weeks, six months and one year. Outcome wascategorized 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 inthe form of superficial infection in one patient and deep infection in two patients. Range of motion of the knee jointimproved 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 osteoarthritisof the knee joint in early stages. It prolongs life of the damaged knee, relieve pain and disability and delay the need forfuture total knee replacement.Keywords: Medial compartmental osteoarthritis of the knee, high tibial osteotomy.

Dr. Imran


good short and medium term results of lateral closingwedge high tibial osteotomy14, 15 advocates its use inyoung enthusiastic patients who wants to keep activelife style.

The objective of this study was to see the shortterm results of lateral closing wedge high tibialosteotomy, in terms of patient satisfaction and painrelief, for medial compartmental OA.MATERIAL AND METHODS:

The study was conducted in Orthopaedics unitof Khyber Teaching Hospital, Peshawar and KhyberMedical Center, Dabgari Gardens, Peshawar fromFebruary 2008 to February 2011. We included 40patients in our study, out of which 15 (37.5%) werefemales and 25 (62.5%) were males. All the patientswere admitted through out-patient department.Routine investigations were performed. This problemoccurs in older age group, the patient’s fitness forgeneral anesthesia was routinely taken into account.Scanograms were taken to calculate the tibio-femoralangle and to measure the mechanical axis deviation.Inclusion criteria were;1. Medial compartmental osteoarthritis.2. Age < 60 years.3. Active life style.Exclusion criteria were;1. Involvement of the lateral compartment andpatella-femoral joint.2. Inflammatory arthritis.3. Range of motion < 90�.4. Flexion contracture > 15�.5. History of previous lateral menisectomy.6. Lower limbs ischemia.7. Knee subluxation.

All the osteotomies were performed by the samesurgeon. The lateral closing wedge osteotomy wasperformed with the aim to shift the weight bearing axisto lateral compartment from medial compartment andto exaggerate the tibio-femoral angle to 10� from anormal tibio-femoral angle of 5-7�. The main steps ofprocedure were supine positioning of the patient andtourniquet application. Proper scrubbling and draping.Posterolateral hockey stick incision, identification andprotection of common peroneal nerve, resection ofanteromedial part of fibular head to gain better accessto osteotomy site, proper siting of the osteotomy(superior transverse cut was at the level of proximaltibio-femoral joint and parallel to joint surface) propersizing of the wedge (calculated from = 0.03 x width oftibia x correction required), closure and fixation of theosteotomy with staples, assessment of valgus/varusstability, deflation of the tourniquet, securinghemostasis and wound closure. The lower limb waskept immobilized in long leg cylinder cast for 6 weeks.

The patient was kept touch down weight bearing forfour weeks, partial weight bearing for next six to eightweeks and full weight bearing at 12 weeks. The rangeof motion exercises were encouraged after the removalof pop at 6 weeks. The quadriceps strengtheningexercises were encouraged during the whole post-operative period.

Results of the study were evaluated at six weeks,six months and one year and were categorized intogood, fair and poor as shown in table 26.RESULTS:

Preoperatively, all patients had loss of normalknee valgus. The tibio-femoral angle ranged from 2�valgus to 8� varus. Joint space narrow was more onmedial then on the lateral side. The range of motion ofthe knee were restricted in 32 (80%) of the patients. 20patients (50%) had restriction of flexion, eight patients(20%) had restriction of extension and four patients(10%) had restriction of both flexion and extension.

There was no non-union in our study which, wethink, was because of good healing potential ofmetaphyseal area. All the osteotomies united in 6-9weeks tibio-femoral angle improved in all the cases.The correction persisted till the end of one year. All thepatients showed dramatic relief of pain which persistedtill the end of one year. Range of motion improved in80% of the patients. There was full range of motion ofthe knee in 20 patients (50%) at the end of one year.The range of motion deteriorated in three patients. Onepatient had superficial infection of the wound site atthree weeks while two patients had deep infectionleading to knee stiffness. The functional outcome,according to table 2, at the end of one year of studywas good in 30 patients (75%), fair in seven patients(17.5%) and poor in three patients (7.5%). Complications(poor results) observed were in the form of superficialinfection in one patient which was treated with oralantibiotics. Deep infection in two patients which wastreated with staple removal, debrima, wash andinjectable antibiotics. Both the patients had poor rangeof knee motion and poor patient satisfaction.DISCUSSION:

Osteoarthritis is a common disease of articularcartilage in adults above 60 years of age. Distal andproximal inter-phalangeal joints of the hand are themost common joints involved followed by knee joint17,

18. Involvement of the knee joint ranges from mildreduction of the joint space to complete obliteration andosteophyte formation by then the patient is usuallyseverely disabled. Pain, swelling and deformity of theknee joint are the usual complaints and the cause offunctional deficit. Treatment of this disease ranges fromconservative in mild disease to surgical in advancedinvolvement.

Short Term Results of Closing Wedge High Tibial Osteotomy



Involvement of the medial compartment withvarus deformity is the most common presentation inadvanced cases. Flexion contracture, limitation of rangeof motion, knee instability, loss of medialcompartmental subchondral bone and subluxation ofthe knee joint are sequel to medial compartmentalosteoarthritis.

Uni-condylar or total knee arthroplasty is thetreatment of choice for medial compartmentalosteoarthritis in the west. Patients in our part of theworld are subjected to squatting for toilet and otherpurposes. Moreover, knee arthroplasty is a difficultundertaking due to socioeconomic reasons. Patients inthis part of the world are subjected to manual labour.Due to these reasons high tibial osteotomy is anacceptable way of managing this disease as the patientsdo not have to change the work profile. High tibialosteotomy shift the weight bearing axis from involvedmedial compartment to the less affected lateralcompartment leading to relief of symptoms and patientsatisfaction. Sacrifice of the proximal tibiofibular jointand deterioration of results with the passage of timehas made these osteotomies unpopular18.

The outcome of our study was good in 30 patients(75%), fair in 7 patients (17.5%) and poor in 3 patients(7.5%) at one year which is comparable to studiesconducted by Ivarsson20, Naudie et al21, Tang and

Henderson and Papachriston et al22.CONCLUSION:

High tibial osteotomy is a better, simpler and costeffective procedure in medial compartmentalosteoarthritis of the knee joint in early stages. It prolongslife of the damaged knee, relieve pain and disabilityand delay the need for future total knee replacement.REFERENCES:1. Brouwer GM, van Tol AW, Bergink AP, et al. Association

between valgus and varus alignment and the developmentand progression of radiographic osteoarthritis of the knee.Arthritis Rheum. 2007; 56(4):1204-1211.

2. Gandhi R, Ayeni O, Davey J, Mahomed N. High tibialosteotomy compared with unicompartmental arthroplastyfor the treatment of medial compartment osteoarthritis: ameta-analysis. Curr Orthop Prac. 2009;20(2):164-169.

3. Koshino T, Yoshida T, Ara Y, Saito I, Saito T. Fifteen totwenty-eight years’ follow-up results of high tibial valgusosteotomy for osteoarthritic knee. Knee. 2004;11(6):439-444.

4. Richmond J, Hunter D, Irrgang J, et al. Treatment ofosteoarthritis of the knee (nonarthroplasty). J Am AcadOrthop Surg. 2009;17(9): 591-600.

5. Brinkman J-M, Lobenhoffer P, Agneskirchner JD, Staubli AE,Wymenga AB, van Heerwaarden RJ. Osteotomies around theknee: patient selection, stability of fixation and bone healingin high tibial osteotomies. J Bone Joint Surg Br.2008;90(12):1548-1557.

6. Devgan A, Marya KM, Kundu ZS, Sangwan SS, Siwach RC.Medial Opening Wedge High Tibial Osteotomy forOsteoarthritis of Knee; Long term results in 50 knees. Med JMalaysia 2003; 58:62-68.

7. Jackson JP, Waught W, Green JP. High tibial osteotomy for

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



osteoarthritis of the knee. J Bone Joint Surg 1969; 5IB: 88-94.8. Bauer GCH, Insall J, Koshino T. Tibial osteotomy in

gonarthrosis. J Bone Joint Surg 1969; 51A: 1545-62.9. Helal B. The pain in primary osteoarthritis of knee. Its causes

and treatment by osteotomy. Postgrad Med J 1965; 41: 172-81.

10. Bergenudd H, Johnell O, Redlund-Johnell I, Lohmander LS.The articular cartilage after osteotomy for medialgonarthrosis: biopsies after 2 years in 19 cases. Acta OrthopScand. 1992;63(4):413-416.

11. Kanamiya T, Naito M, Hara M, Yoshimura I. The influencesof biomechanical factors on cartilage regeneration after hightibial osteotomy for knees with medial compartmentosteoarthritis: clinical and arthroscopic observations.Arthroscopy. 2002;18(7):725-729.

12. Odenbring S, Egund N, Lindstrand A, Lohmander LS, Wille´n H. Cartilage regeneration after proximal tibial osteotomyfor medial gonarthrosis: an arthroscopic, roentgenographic,and histologic study. Clin Orthop Relat Res. 1992;277:210-216.

13. Tang WC, Henderson IJP. High tibial osteotomy: long termsurvival analysis and patients’ perspective. Knee.2005;12(6):410-413.

14. Hernigou P, Medevielle D, Debeyre J, Goutallier D. Proximaltibial osteotomy for osteoarthritis with varus deformity: aten to thirteenyear follow-up study. J Bone Joint Surg Am.1987;69(3):332-354.

15. Holden DL, James SL, Larson RL, Slocum DB. Proximal tibial

osteotomy in patients who are fifty years old or less: a long-term follow-up study. J Bone Joint Surg Am. 1988;70(7):977-982.

16. Lawrence RC, Hochberg MC, Kelsey JL et al. Estimates ofthe prevalence of selected arthritic and musculoskeletaldiseases in the United States. J Rheumatol 1989; 16: 427-41.

17. Oliveria SA, Felson DT, Reed JI et al. Incidence ofsymptomatic hand, hip and knee osteoarthritis amongpatients in a health maintenance organization. ArthritisRheum 1995; 38: 1134-41.

18. Sangwan SS, Siwach RC, Singh Z, Duhan S.Unicompartmental osteoarthritis of the knee: an innovativeosteotomy. Int Orthop 2000; 24: 148-50.

29. Ivarsson I, Myrnerts R, Gillquist J (1990) High tibialosteotomy for medial osteoarthritis of the knee. A 5 to 7 and11 year followup. J Bone Joint Surg Br 72:238–244

20. Naudie D, Bourne RB, Rorabeck CH, Bourne TJ (1999) TheInstall Award. Survivorship of the high tibial valgusosteotomy. A 10- to 22-year followup study. Clin OrthopRelat Res 367:18–27

21. Papachristou G, Plessas S, Sourlas J, Levidiotis C,Chronopoulos E, Papachristou C (2006) Deterioration of long-term results following high tibial osteotomy in patients under60 years of age. Int Orthop 30:403–408.

22. Amendola A, Bonasia DE. Result of high tibial osteotomy:Review of the literature. International Orthopaedics (SICOT)2010; 34; 155-160.


–––––––––––––––––––––––––––––––––––––––––––––––––––––1Assistant Professor Diagnostic Radiology HHSKBZ / AK CMHMuzaffarabad.2.Medical Officer, DHQ hospital Rawalpindi.3 ClassifiedRadiologist HHSKBZ / AK CMH Muzaffarabad. (AJ&K)–––––––––––––––––––––––––––––––––––––––––––––––––––––Correspondence:: Dr Misbah Durrani, Assistant ProfessorDiagnostic Radiology HHSKBZ / AK CMH Muzaffarabad.E-mail: [email protected].–––––––––––––––––––––––––––––––––––––––––––––––––––––Received: Oct’2011 Accepted: Jan’2012–––––––––––––––––––––––––––––––––––––––––––––––––––––

INTRODUCTIONIUGR is a “sonographic estimated fetal weight

below the 10th percentile gestational age.”1 Incidenceof IUGR is 3% if the 3rd or 5% if the 5th centile is chosen2.In the etiology of the IUGR, fetal factors such asinfection, chromosomal and structural anomalies,placental factors and maternal factors like toxin or drugexposure, illicit drugs use and medical conditions suchas anemia and hypertension are responsible. IUGR isassociated with the increased risk of perinatal mortality,morbidity and impaired neurological developmentoutcomes. IUGR fetuses have increased risk ofintrauterine death and asphyxia at birth. Correctdetection of the compromised IUGR fetus to allowtimely intervention is a main objective of antenatal care3.

In management of IUGR Doppler ultrasound play

an important role in fetal surveillance. In IUGR fetuseswith absent or reversed blood flow velocity in theumbilical artery, there is increased risk of cesareansection, respiratory distress, chronic lung disease, acuterenal function, necrotizing enterocolitis or death4. Thereis ample evidence that Doppler indices from the fetalcirculation can reliably predict adverse perinataloutcomes in an obstetric patient population with a highprevalence of complications such as fetal growthrestriction5. IUGR is a clinical situation at highest riskof intrauterine hypoxia or acidosis. IUGR fetuses withabnormal PI of umbilical artery had 15% incidence ofacidosis and IUGR fetuses with normal PI of umbilicalartery had 34% incidence of acidosis6.

Assessment of fetal growth and well-being is oneof the major purposes of antenatal care. Small forgestational age fetus is either constitutionally small orhas failed to meet its growth potential and thus becomesgrowth restricted7. Fetal growth restriction has high riskof perinatal mortality and morbidity8.

The purpose of this study was to know thatumbilical artery Doppler can accurately predict acid-base status at the time of birth to improve fetalsurveillance.MATERIALS AND METHODS

Sampling technique: Consecutive sampling.

Comparison of Normal and AbnormalUmbilical Artery Waveforms with

Early Neonatal Outcome in AsymmetricalIntra-Uterine Growth Retardation (IUGR)

Misbah Durrani,1 Hina Hanif Mughal,2 Tayyaba Afzal3

ABSTRACTBackground: Fetuses with intrauterine growth retardation(IUGR) are delivered if they have evidence of distress, asmanifested by abnormalities in the fetal heart rate and umbilical-artery blood flow. We studied whether umbilical-arteryDoppler 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 deficitin umbilical-vein blood and correlated these measurements with the heart rate and umbilical-artery wave forms recordedby Doppler velocimetry in 56 fetuses with growth retardation. Twenty-one fetuses had normal heart rates and normalresults of velocimetry, 24 had normal heart rates and abnormal results of velocimetry (indicative of decreased diastolicflow), 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. Themean maternal age was 25.30±2.78 years. 62 (59%) patients had an abnormal doppler flow in umblical artery. The meanbirth 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 ± 2.13vs 9.23 ± 0.648; p = 0.000.Conclusions: - Assessment of fetal umbilical artery Doppler waveform can help us predict the neonatal outcome. Fetuseswith abnormal waveform have a poorer outcome as compared to those with normal waveform.

Dr. Misbah

Original Article


SAMPLE SELECTION:Inclusion Criteria: Singleton pregnancy, Fundal

height 3cm less than gestational age, longitudinal lie,Gestational age > 28 weeks,

Exclusion criteria: Twin pregnancy, congenitallyabnormal fetuses, premature rupture of membranes,Diabetes with pregnancy, Eclampsia, Placentalabruption.Data collection:

Before conducting this study, approval fromHospital Ethical Committee was taken. Informedwritten consent was taken from patients included instudy. Patients were selected coming to MedicalImaging Department of RMC & Allied Hospitalsrecruited into the study after 28 weeks of gestation(fulfilling inclusion criteria). All these patientsunderwent obstetric ultrasonography and if there issuspicion of asymmetrical IUGR i.e. discrepancybetween dates and fetal parameters (elevated ratio ofhead circumference to abdominal circumference,confirmed by a senior consultant) then they willundergo Doppler of umbilical artery. The outcomevariables noted at delivery (by a 3rd or 4th year obstetricresident) were the state of baby (still birth/ alive), birthweight (measured on standard neonatal weighing scale)and Apgar score at five minutes after delivery. All thefindings were noted on performa.Data Analysis:

Results were analyzed by using SPSS (V.10). Meanand standard deviation will be used for numericalvariables i.e. age. Frequency and percentages werepresented for categorical variables i.e. neonatal outcome

(live or stillbirth), birth weight (normal, LBW, VLBW),abnormal Doppler flow (absent or reversed) andAPGAR score (<7, >7) at 5min.

Chi-square test was used to compare birth weightand APGAR score at 5min in normal and abnormalumbilical artery wave forms. Independent sample t-testwill be used to compare APGAR score value in bothgroups. P value less than 0.05 was consideredsignificant.RESULTS

The study included 105 patients with diagnosedasymmetric fetal growth restriction on ultrasoundcriteria. The maternal age ranged from 18 to 30 yearswith a mean age of 25.30±2.78 years. Doppler flowwaveform in umbilical artery 62 (59%) patients had anabnormal Doppler flow in umblical artery whereas 43(41%) patients had a normal Doppler flow in umblicalartery.Birth weight: The mean birth weight in the abnormalDoppler flow group was

2.20±0.565 kg and the mean birth weight in thenormal Doppler flow group was 2.84 ±

0.43 kg, the difference in weight was statisticallysignificant between the two groups;

p = 0.000. Only 13 (21%) babies had normal weightin the abnormal Doppler flow group as compared to37 (86%) in the normal Doppler flow group. 42 (67.7%)babies were low birth weight (1500-2500 gm) in theabnormal Doppler flow group as compared to 6 (14%)in the normal Doppler flow group. 7 (11.3%) babies

Figure 1 Morbidity and mortality in 1560 small-for-gestational age fetuses

Figure 2Stacked Bar graph of Apgar score at 5 min; abnormal vs normal

Doppler flow in umbilical artery groups

Comparison of Normal and Abnormal Umbilical Artery Waveforms


were very low birth weight (<1500 gm) in the abnor-mal Doppler flow group as compared to none in thenormal Doppler flow group. This difference was sta-tistically significant; p = 0.00.

Apgar score at 05 minutes. The mean apgarscore at 05 minute in the abnormal Doppler

flow group was 7.366 ± 2.13 and the mean apgarscore at 05 minute in the normal

Doppler flow group was 9.23 ± 0.648, thedifference in 05 minute apgar score was

statistically significant between the two groups;p = 0.000.

In the abnormal Doppler flow group 40 (64.5%)babies had an apgar score of > 7 at 05 minute as opposedto 43 (100%) in the normal Doppler flow group. In theabnormal Doppler flow group 22 (35.5%) babies hadan apgar score of 0-6 at 05 minute as opposed to nonein the normal Doppler flow group. This difference wasstatistically significant; p= 0.00.DISCUSSION

Fetal growth restriction is a syndromecharacterized by failure of the fetus to reach its normalgrowth potential; fetuses with fetal growth restrictiontherefore represent a subset of those designated as smallfor gestational age (SGA). Fetal growth restriction isthe second leading cause of perinatal death9 and isassociated with significant morbidity, includingincreased rates of meconium aspiration, hypoglycemia,respiratory distress syndrome, intrapartum asphyxia,developmental delay, and stillbirth. Unfortunately,fetuses with fetal growth restriction are often difficultto differentiate from fetuses that are merely small owingto constitutional or genetic causes.

Doppler sonography is a non-invasive method ofevaluating utero-placental circulation110 Changes in thevelocimetric values seen on serial Doppler examinationsmay be helpful in documenting improvement in flowwith therapy or in determining the need for delivery11.

Doppler provides the clinician with the best wayto evaluate the condition of the growth restricted fetus.

Figure 3Comparison of birth weight; abnormal vs normal Doppler flow

in umbilical artery groups

Figure 4Duplex pulsed Doppler sonogram depicting

umbilical arterial circulation

The umbilical artery waveform provides informationabout placental resistance, which, in turn, reflects thedegree of fetal compromise. Lastly, recent investigationsuggests that decreased velocity during arterialcontraction noted in the inferior vena cava and ductusvenosus correlates well with the presence or absenceof metabolic acidemia, the best correlate of neurologicaloutcome. A combination of the above Dopplerparameters can be used today to separate the deprivedfrom the ‘normal’, but biometrically compromised,fetus to detect early hypoxia in IUGR, and to preciselytime delivery to avoid neurological sequlae in theacidotic fetus12.

Doppler velocimetry of the umbilical artery (UA)provides a noninvasive measure of the feto-placentalhemodynamic state. UA Doppler indices indirectlyreflect impedance of downstream circulation.Abnormality of the Doppler index has been correlatedto feto-placental vascular mal-development. There is asignificant association between abnormal Dopplerindices and fetal hypoxia, fetal acidosis, and adverseperinatal outcome. Most randomized trials of UADoppler ultrasound in high risk pregnancies showimproved outcome when this technique is used inpregnancies complicated by growth restriction. Clinicalmanagement should integrate the Doppler approachwith existing modalities of antepartum fetal monitoring.The most important diagnostic characteristic of the UADoppler waveform is the state of the end diastolicvelocity: absent end-diastolic velocity (AEDV) is anominous finding and reversed end-diastolic velocity(REDV) should be interpreted as a preterminal finding.In pregnancies complicated by fetal growth restrictionor preeclampsia at e” 32 weeks of gestation, promptdelivery is recommend rather than expectantmanagement in the setting of AEDV or REDV13.



Doppler has revolutionized the field of obstetricssince its introduction in late 1950‘s. Useful informationis obtained during second half of pregnancy andpregnancies with high resistance can be determined.The cut off values of Doppler indices for definingabnormal Doppler waveform are controversial. 100patients were studied in Combined Military Hospital,Rawalpindi in 200314. Doppler examination wasperformed and the range of normal indices determinedfrom all the four vessels. For umbilical artery mean PIwas 1.48 (range = 0.92-1.91), RI was 0.78 (range = 0.64-0.84) S/D ratio was 4.68 (range = 3.84-5.6). We used aRI of >0.6 as the cut off level for abnormal Dopplerwaveform. Using a lower cut off value may have hadan impact on the outcome in our data.

Local data on the subject is sparse. Similar resultshave also been documented from few local studies. AtMCH center, PIMS, Islamabad 15 a study was carriedout to assess the role of umbilical artery Dopplerexamination in the management of high-riskpregnancies. 54 women with singleton pregnancies athigh risk of IUGR delivered in 2004. Normal Dopplergroup showed 31% emergency C sections performedcompared to 38% in abnormal Doppler group, 26.3%patients in normal Doppler group and 33% in abnormalDoppler group delivered vaginally. At 5 min of birthApgar scores of 5-10 were seen in all the babiesbelonging to mothers of normal Doppler group and inthe other group 95% babies showed the same score.NICU admissions were 15% in the normal Dopplergroup and in the other group they were 22%. Our studyin fact showed a much higher NICU admission rate of80% in the abnormal Doppler group, however rate ofNICU admission rate of normal Doppler group wassimilar (18%) in our study when compared to this localstudy.

To evaluate the role of Colour Doppler Ultrasoundin the management of small for gestational age fetus orIUGR pregnancies, a study was performed in AlliedHospital, Faisalabad16 in 2006. 45 growth restrictedfetuses were evaluated; 33.3% with normal end-diastolic flow were delivered at 37 weeks; 44.47% withabsent or reversed end-diastolic flow were deliveredat 34-35 weeks. We did not document the gestationalage at the time of delivery and hence no data is availablefor comparison. Perinatal mortality was 8.8% mostlydue to extreme prematurity. There was one fetal deathbut no perinatal mortality in our group.

CONCLUSIONGrowth restricted fetuses with abnormal umbilical

artery Doppler waveform have a poor neonataloutcome in terms of significantly lower birth weightand lower apgar scores at 5 minutes.REFERENCES1. Kalanithi LEG, Illuzzi JL, Nossor VB, Frisback Y, RazeqSA,

Coel JA, et al. Intrauterine growth restriction and placentallocalization. J Ultrasound Med 2007; 26:1481-9.

2. Baker PN. Obstetrics by ten teachers. 18h ed. London.HodderArnold 2006. 156-78.

3. LBN, RKV, GPT. Doppler prediction of adverse perinataloutcome in PIH and IUGR. Ind JRadipl Imag 2006;16:1:109-16.

4. Nicholl RM, Deenmamode JM, Gamsu HR. Intrauterinegrowth restriction, visceral blood flow velocityand exocrinepancreatic function. BMC research notes 2008,1:115.

5. Malhotra N, hanana C, Kumar S, Roy K, Sharma JB.Comparison of perinatal oucome of growth-restrictes fetuseswith normal and abnormal umbilical artery waveforms.Indian J Med Si. 2006;60:311-7.

6. Marconi AM, Paolini CL, Zerbe G, Battaglia FC.Lactacidemiain intrauterine GrowthRestricted (IUGR)Prreganancies: Relationship to clinical Severity, Oxygenationand Placental Weight. Pediatr Res 2006,59:570-4.

7. Breeze ACG, Lees CC. Pediction and perinatal outcomes offetal growth restriction. Sem Fet Neonat 2007;12:383-97.

8. Smith GCS, Lees CC. Disorders of fetal growth andassessment of fetal well being. In: Edmonds DK (edi). 7th

ed.London: Blackwell 2007;159-65.9. Wolfe HM, Gross TL. Increased risk to the growth retarded

fetus. In: Gross TM, Sokol RJ, editors. Intrauterine growthretardation. Chicago: Year Book Medical Publishers; 1989. p111.

10. Goldkrand JW, Morre DH, Lenz SU, Clements SP, TurnerAD, Bryant JL. Volumetric flow in the umbilical artery:normative data. J Matern Fetal Med 2000;9: 224–8.

11. Acharya G, Wilsgaard T, Berntsen GK, Maltau JM, KiserudT. Reference ranges for serial measurements of blood velocityand pulsatility index at the intra-abdominal portion, and fetaland placental ends of the umbilical artery. Ultrasound ObstetGynecol 2005;26: 162–9.

12. Kotini1 A, Avgidou K, Koutlaki N, Sigalas A, Anninos P,Anastasiadis P. Correlation between biomagnetic andDoppler findings of umbilical artery in fetal growthrestriction. Prenat Diagn 2003; 23: 325–30.

13. Galan HL, Ferrazzi E, John C. Hobbins. Intrauterine growthrestriction (IUGR): biometric and Doppler assessment. PrenatDiagn 2002; 22: 331–7.

14. Saeed M, Qureshi IA, Tarin A, Ghani N, Hyder RR, Rashid I.Doppler indices in fetoplacental and uteroplacentalcirculation at 22 weeks of gestation. Pak Armed Forces MedJ 2006;56:7-11.

15. Afghan S, Masood S, Mahzar B. The role of DopplerUltrasound in the management of high-risk Pregnancies: APIMS experience. Ann Pak Inst Med Sci 2005;1:215-9.

16. Rizvi SMR, Yasmeen N, Iqbal N. Small for gestational agefetus; role of colour Doppler ultrasound in the management.Professional Med J 2006;13:705-9.



Weight loss, Exercise, or Both improvesPhysical 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’2009Place of Study: Washington University School of Medicine,WashingtonMaterial &Methods:In this 1-year, randomized, controlled trial, we evaluated the independent and combined effects ofweight loss and exercise in 107 adults who were 65 years of age or older and obese. Participants were randomly assignedto 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. Secondaryoutcomes included other measures of frailty, body composition, bone mineral density, specific physical functions, andquality of life.Results: A total of 93 participants (87%) completed the study. In the intention-to-treat analysis, the score on the PhysicalPerformance Test, in which higher scores indicate better physical status, increased more in the diet–exercise group thanin the diet group or the exercise group (increases from baseline of 21% vs. 12% and 15%, respectively); the scores in allthree 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 higherscores indicate better physical function, increased more in the diet–exercise group than in the diet group (increase of10% vs. 4%) Body weight decreased by 10% in the diet group and by 9% in the diet–exercise group, but did not decreasein the exercise group or the control group. Lean body mass and bone mineral density at the hip decreased less in thediet–exercise group than in the diet group (reductions of 3% and 1%, respectively, in the diet–exercise group vs. reductionsof 5% and 3%, respectively, in the diet group. Strength, balance, and gait improved consistently in the diet–exercisegroup.Conclusions: These findings suggest that a combination of weight loss and exercise provides greater improvement inphysical function than either intervention alone.

–––––––––––––––––––––––––––––––––––––––––––––––––––––*The study was approved and monitored by the InstitutionalReview Board & Monitoring Board and carried out inWashington University School of Medicine.,Intensive ResearchUnit of the Institute of Clinical &Translational Sciences. –––––––––––––––––––––––––––––––––––––––––––––––––––Correspondence: Dr. Dennis T. Villareal, M.DIntensive ResearchUnit of the Institute of Clinical and Translational Sciences;NewMexico VA Health Care System, Geriatrics (111K), 1501 SanPedro., Dr., Albuquerque, NM 87108,E.Mail. >[email protected] ––––––––––––––––––––––––––––––––––––––––––––––––––––Acknowledgement: Ophthalmology Update acknowledges withthanks Dr. Dennis T. Villareal, M.D., permitting us to take the excerptsfrom his original article.–––––––––––––––––––––––––––––––––––––––––––––––––––––

Original Article

INTRODUCTIONObesity in older adults is becoming a serious

public health problem in the world.1-4 as the number ofobese older adults is increasing markedly.5.,6 Currently,

approximately 20% of adults around 65 years of ageor older are obese, and the prevalence will continue torise as more and more become senior citizens.37 In olderadults, obesity exacerbates the age-related decline inphysical function, which causes frailty, impairs qualityof life.8-12Given the increasing prevalence of obesity, themost common phenotype of frailty in the future maybe an obese, disabled, older adult.4.,13

Although obesity is an important cause ofdisability in older adults,14,15 there is little evidence fromclinical trials regarding the benefits and risks of weight-loss interventions to guide the care of population.6.17 Infact, the clinical approach to obesity is controversial,given the reduction in relative health risks associatedwith increasing body-mass index (BMI) in this group.2Ithas been suggested that it may be difficult to achievesuccessful weight loss because of life long diet and


activity habits.18 Moreover, there is major concern thatweight loss could worsen frailty by accelerating theusual age-related loss of muscle that leads tosarcopenia.4 In a preliminary, short-term study.19Wereport the results of a randomized, controlled trial thatwas designed to determine the independent andcombined effects of sustained weight loss and regularexercise on physical function, body composition, andquality of life. We hypothesized that weight loss andexercise would each improve physical function and thatthe combination of the two would result in the greatestimprovement in physical function and amelioration ofphysical frailty.MATERIAL &METHODS

We conducted the study from April 2005 throughAugust 2009 at the Washington University School ofMedicine. The study was approved by the institutionalreview board and was monitored by an independentdata and safety monitoring board. Volunteers wererecruited after written consent. Potential participantsunderwent a comprehensive medical screeningprocedure. Volunteers were eligible for inclusion in thestudy if they were 65 years of age or older and obese, ifthey had a sedentary lifestyle, if their body weight hadbeen stable during the previous year and if theirmedications had been stable for 6 months beforeenrollment. All participants had to have mild-to-moderate frailty, on the basis of meeting at least two ofthe following operational criteria8,19,20: a score on themodified Physical Performance Test (in which the totalscore ranges from 0 to 36, with higher scores indicatingbetter physical status) of 18 to 32; a peak oxygenconsumption (VO2peak) of 11 to 18 ml per kilogram ofbody weight per minute; or difficulty in performing twoinstrumental activities of daily living or one basicactivity of daily living. Persons who had severecardiopulmonary disease; musculoskeletal orneuromuscular impairments or a history of cancer, aswell as persons who were receiving drugs that affectbone health and metabolism or who were currentsmokers, were excluded.

The primary outcome was the change frombaseline in the score on the modified PhysicalPerformance Test. Secondary outcomes included othermeasures of frailty, body composition, bone mineraldensity, specific physical functions, and quality of life.BASELINE ASSESSMENTS:i) Physical Function: Frailty was assessed withthe use of the modified Physical Performance Test, themeasurement of VO2peak, and the Functional StatusQuestionnaire. The modified Physical Performance Testincludes seven standardized tasks (walking 50 ft,putting on and removing a coat, picking up a penny,standing up from a chair, lifting a book, climbing one

flight of stairs, and performing a progressive Rombergtest) plus two additional tasks (climbing up and downfour flights of stairs and performing a 360-degree turn).The score for each task ranges from 0 to 4; a perfectscore is 36.20-23 A low score on the Physical PerformanceTest is associated with a high BMI,8,24 and the scoreincreases in response to weight-loss therapy.19 VO2peakwas assessed during graded treadmill walking, asdescribed previously.8 Information regarding the abilityto perform activities of daily living was obtained withthe use of the Functional Status Questionnaire (onwhich scores range from 0 to 36, with higher scoresindicating better functional status).25 We also assessedspecific physical functions such as strength, balance,and gait and determined one-repetition maximums (themaximal weight a person can lift at one time). Weassessed static balance by measuring the time theparticipant could stand on a single leg8 and dynamicbalance by measuring the time needed to complete anobstacle course.20 Fast gait speed was determined by ameasurement of the time needed to walk 25 ft.ii) Body Composition and Bone Mineral Density:Fat mass, lean body mass, and bone mineral density ofthe whole body and at the lumbar spine and total hipwere measured with the use of dual-energy x-rayabsorptiometry.19,26 Thigh muscle and fat volumes weremeasured with the use of MRI..27

iii) Health-Related Quality of Life,The MedicalOutcomes: 36-items Short-Form Health Survey (SF-36)was used to evaluate quality of life.28 The subscales weused were those for the physical component summaryand the mental component summary.29 Scores on thesetwo subscales range from 0 to 100, with higher scoresindicating better health status.FOLLOW-UP ASSESSMENTS

All baseline assessments were repeated at 6months and 12 months, with the exception of the MRI,which was repeated only at 12 months. Participantsassigned to the control group did not receive advice tochange their diet or activity habits and were prohibitedfrom participating in any weight-loss or exerciseprogram. They were provided general informationabout a healthy diet during monthly visits with the staff.

Participants assigned to the diet group wereprescribed a balanced diet that provided an energydeficit of 500 to 750 kcal per day from their daily energyrequirement.2 The diet contained approximately 1 g ofhigh-quality protein per kilogram of body weight perday.2 Participants met weekly as a group with a dietitianfor adjustments of their caloric intake and for behavioraltherapy. They were instructed to set weekly behavioralgoals and attend weekly weigh-in sessions. Food diarieswere reviewed, and new goals were set on the basis ofdiary reports. The goal was to achieve a weight loss of

Weight loss, Exercise, or Both improves Physical function in Obese Older Adults


approximately 10% of their baseline body weight at 6months and to maintain that weight loss for anadditional 6 months.

Participants in the exercise group were giveninformation regarding a diet that would maintain theircurrent weight and participated in three group exercise-training sessions per week. Each session wasapproximately 90 minutes in duration and consisted ofaerobic exercises, resistance training, and exercises toimprove flexibility and balance. The exercise sessionswere led by a physical therapist. The aerobic exercisesincluded walking on a treadmill, stationary cycling, andstair climbing. The participants exercised so that theirheart rate was approximately 65% of their peak heartrate and gradually increased the intensity of exerciseso that their heart rate was between 70 and 85% of theirpeak heart rate. The progressive resistance trainingincluded nine upper-extremity and lower-extremityexercises with the use of weight-lifting machines.Participants performed 1 or 2 sets at a resistance ofapproximately 65% of their one-repetition maximum,with 8 to 12 repetitions of each exercise; they graduallyincreased the intensity to 2 to 3 sets at a resistance ofapproximately 80% of their one-repetition maximum,with 6 to 8 repetitions of each exercise. Participants inthe diet–exercise group participated in both the weight-management and exercise programs described above.All participants were given supplements to ensure anintake of approximately 1500 mg of calcium per dayand approximately 1000 IU of vitamin D per day.2

We estimated that with 26 to 28 participants ineach group, the study would have more than 80%power to detect a clinically important difference amongthe groups in the change in the score on the PhysicalPerformance Test, assuming a mean between-groupdifference in the score of 1.7 points, with a pooledstandard deviation of 2.1 (on the basis of preliminarydata), at an alpha level of 5%.RESULTS

A total of 107 volunteers underwent random-ization; 93(87%) completed the study (Screening,randomization, and follow-up). Fourteen participantsdiscontinued the intervention and were included in theintention-to-treat analyses.The median attendance atdiet-therapy sessions was 83%, and 82%, among thosein the diet–exercise group. The median attendance atexercise sessions was 88%, among participants in theexercise group and 83% (interquartile range, 80 to 88)among those in the diet–exercise group.One participantfell during testing of physical function, and the fallresulted in an ankle fracture.

There was a substantial decrease in body weightin the diet group (a weight loss of 9.7±5.4 kg,representing a 10% decrease from baseline) and in the

diet–exercise group (a weight loss of 8.6±3.8 kg,representing a 9% decrease), but not in the exercisegroup (a weight loss of 1.8±2.7 kg, representing a 1%decrease) or the control group (a weight loss of 0.9±1.5kg, representing <1% decrease) Lean body massdecreased less in the diet–exercise group than in thediet group (a decrease of 1.8±1.7 kg, representing a 3%change from baseline, vs. a decrease of 3.2±2.0 kg,representing a 5% change). The lean body massincreased by 1.3±1.6 kg in the exercise group (a 2%increase from baseline). Fat mass decreased by 6.3±2.8kg in the diet–exercise group (a 16% change frombaseline), by 7.1±3.9 kg in the diet group (a 17% change),and by 1.8±1.9 kg in the exercise group (a 5% change).Similar changes were observed with respect to thighmuscle and fat.

Bone mineral density at the total hip decreasedby 0.011±0.026 g per square centimeter (a decrease of1.1% from baseline) in the diet–exercise group, ascompared with 0.027±0.021 g per square centimeter (adecrease of 2.6%) in the diet group, whereas itincreased, by 0.013±0.014 g per square centimeter (a1.5% increase), in the exercise group.

The total one-repetition maximum (i.e., the sumof the maximal weights lifted in the biceps curl, benchpress, seated row, knee extension, knee flexion, and legpress exercises) increased in the diet–exercise group (anincrease of 164±124 lb [75±56 kg], representing a 35%change from baseline) and in the exercise group (anincrease of 174±166 lb [79±75 kg], representing a 34%change), whereas it was maintained in the diet group(an increase of 1±85 lb [0.5±39 kg], representing a 3%change). The time needed to complete the obstaclecourse was reduced by 1.7±2.2 seconds in the diet–exercise group (a reduction of 12%), by 1.1±1.1 secondsin the diet group (a reduction of 10%), and by 1.5±1.4seconds in the exercise group (a reduction of 13%). Theduration of time the participant could stand on a singleleg increased by similar amounts in those groups. Gait-speed increased in the diet–exercise group (an increaseof 16.9±42.3 seconds, representing a 23% change frombaseline) and in the exercise group (an increase of8.2±15.5 seconds, representing a 14% change).Thephysical-component summary score of the SF-36 (whichwas used to measure quality of life) increased by 8.6±9.3points in the diet–exercise group (a 15% increase frombaseline), by 8.4±10.1 points in the diet group (a 14%increase), and by 5.7±8.0 points in the exercise group(a 10% increase)DISCUSSION

In this 1-year, randomized, controlled trialinvolving obese older adults, weight loss plus exerciseimproved physical function and ameliorated frailtymore than either weight loss or exercise alone, although



each of those was beneficial.Currently, evidence-baseddata to guide the treatment of obese older adults arelimited.16,17The few clinical trials that have beenconducted typically addressed cardiovascular riskfactors rather than physical function.16However, frailtyis an important problem in the elderly because it leadsto loss of independence and increased morbidity andmortality.30,31Our study suggests that weight loss aloneor exercise alone can reverse frailty but that thecombination of weight loss and exercise is moreeffective than either individual intervention. Therefore,weight loss and exercise may be an important therapyfor frail, obese older adults. Moreover, one study hasshown that weight loss and exercise reduce knee painand improve physical function in overweight and obeseolder adults with osteoarthritis of the knee.34

Physical frailty in obese older adults is associatedwith low muscle mass relative to body weight (relativesarcopenia) despite a greater absolute amount of musclemass.4,8 In the current study, relative sarcopenia wasreduced in all the intervention groups — owing to thelarger reduction in fat mass relative to lean body massin the diet and diet–exercise groups and owing to thedecrease in fat mass and increase in lean body mass inthe exercise group. These positive changes in bodycomposition could underlie the improvement inphysical function in the participants.4,8 However,because the greatest improvement occurred in the diet–exercise group, adding an exercise program to a dietregimen, which results in the preservation of lean bodymass in addition to the reduction in fat mass inducedby a diet, may be the best approach. Accordingly, thediet–exercise group had not only the greatest increasein scores on the Physical Performance Test but alsothe most consistent improvements in strength, balance,and gait.

A potential adverse effect of our interventions wasthe reduction in lean body mass and bone mineraldensity at the hip in the diet groups. However, theaddition of exercise to diet attenuated the losses of leantissue and further augmented physical function.Although the clinical importance of the modest loss ofbone mineral density is unclear, strategies to preventthis loss in participants involved in future studies mightinclude prescribing higher doses of calcium and vitaminD than those used in this study. An additional healthconcern is raised by findings from observational studiesthat suggest that weight loss may be associated withan increased risk of death.2 However, these studies didnot rigorously distinguish intentional from non-intentional weight loss. Follow-up data from arandomized, controlled trial involving overweight andobese older adults suggest that intentional weight lossmay reduce the risk of death.40

A limitation of our study is that it was notpowered to determine potential differences in theoutcomes between sexes.Because we selectedvolunteers who were able to participate in a lifestyleprogram, the results may not necessarily apply to thegeneral obese, older adult population. Nonetheless,they provide evidence that successful weight loss isachievable in this population. Further studies areneeded to determine whether weight loss can bemaintained beyond 1 year and preventinstitutionalization of obese older adults. Our samplesize was small, and most of the participants werewomen, white, well educated, and older with mild-to-moderate frailty thus limiting broader inferences of ourresults. Our study did not address the usefulness orsafety of these interventions for markedly obese olderpersons with severe frailty.CONCLUSION:

our findings suggest that weight loss alone orexercise alone improves physical function andameliorates frailty in obese older adults; however, acombination of weight loss and regular exercise mayprovide greater improvement in physical function andamelioration of frailty than either intervention alone.Therefore, weight loss combined with regular exercisemay be beneficial in helping obese older adults maintaintheir functional independence.REFERENCES:1. vanBaak MA, Visscher TL. Public health success in recent

decades may be in danger if lifestyles of the elderly areneglected. Am J ClinNutr 2006;84:1257-1258

2. Villareal DT, Apovian CM, Kushner RF, Klein S. Obesity inolder adults: technical review and position statement of theAmerican Society for Nutrition and NAASO, The ObesitySociety. Am J ClinNutr 2005;82:923-934

3. Arterburn DE, Crane PK, Sullivan SD. The coming epidemicof obesity in elderly Americans. J Am GeriatrSoc2004;52:1907-1912

4. Roubenoff R. Sarcopenic obesity: the confluence of twoepidemics. Obes Res 2004;12:887-888

5. Mokdad AH, Ford ES, Bowman BA, et al. Prevalence ofobesity, diabetes, and obesity-related health risk factors, 2001.JAMA 2003;289:76-79

6. Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalenceand trends in obesity among US adults, 1999-2008. JAMA2010;303:235-241

7. Li F, Fisher KJ, Harmer P. Prevalence of overweight andobesity in older U.S. adults: estimates from the 2003Behavioral Risk Factor Surveillance System survey. J AmGeriatrSoc 2005;53:737-739

8. Villareal DT, Banks M, Siener C, Sinacore DR, Klein S.Physical frailty and body composition in obese elderly menand women. Obes Res 2004;12:913-920

9. Blaum CS, Xue QL, Michelon E, Semba RD, Fried LP. Theassociation between obesity and the frailty syndrome in olderwomen: the Women’s Health and Aging Studies. J AmGeriatrSoc 2005;53:927-934

10. 1Zizza CA, Herring A, Stevens J, Popkin BM. Obesity affectsnursing-care facility admission among whites but not blacks.Obes Res 2002;10:816-823



11. Lapane KL, Resnik L. Obesity in nursing homes: an escalatingproblem. J Am GeriatrSoc 2005;53:1386-1391

12. Elkins JS, Whitmer RA, Sidney S, Sorel M, Yaffe K, JohnstonSC. Midlife obesity and long-term risk of nursing homeadmission. Obesity (Silver Spring) 2006;14:1472-1478

13. Alley DE, Ferrucci L, Barbagallo M, Studenski SA, HarrisTB. A research agenda: the changing relationship betweenbody weight and health in aging. J Gerontol A BiolSci MedSci 2008;63:1257-1259

14. Rejeski WJ, Marsh AP, Chmelo E, Rejeski JJ. Obesity,intentional weight loss and physical disability in older adults.Obes Rev 2010;11:671-685

15. Jensen GL, Hsiao PY. Obesity in older adults: relationship tofunctional limitation. CurrOpinClinNutrMetab Care2010;13:46-51

16. Witham MD, Avenell A. Interventions to achieve long-termweight loss in obese older people: a systematic review andmeta-analysis. Age Ageing 2010;39:176-184

17. Bales CW, Buhr G. Is obesity bad for older persons? Asystematic review of the pros and cons of weight reductionin later life. J Am Med DirAssoc 2008;9:302-312

18. Elia M. Obesity in the elderly. Obes Res 2001;9:Suppl 4:244S-248S

19. Villareal DT, Banks M, Sinacore DR, Siener C, Klein S. Effectof weight loss and exercise on frailty in obese older adults.Arch Intern Med 2006;166:860-866

20. Brown M, Sinacore DR, Binder EF, Kohrt WM. Physicaland performance measures for the identification of mild tomoderate frailty. J Gerontol A BiolSci Med Sci2000;55:M350-M355

21. Host H, Sinacore D, Brown M, Holloszy J. Reliability of themodified physical performance test in older adults. PhysTher1996;76:Suppl:S23-S24

22. Brown M, Sinacore DR, Ehsani AA, Binder EF, Holloszy JO,Kohrt WM. Low-intensity exercise as a modifier of physicalfrailty in older adults. Arch Phys Med Rehabil 2000;81:960-965

23. Binder EF, Schechtman KB, Ehsani AA, et al. Effects ofexercise training on frailty in community-dwelling olderadults: results of a randomized, controlled trial. J AmGeriatrSoc 2002;50:1921-1928

24. Apovian CM, Frey CM, Rogers JZ, McDermott EA, Jensen

GL. Body mass index and physical function in obese olderwomen. J Am GeriatrSoc 1996;44:1487-1488

25. JetteAM, Cleary PD. Functional disability assessment.PhysTher 1987;67:1854-1859

26. Villareal DT, Fontana L, Weiss EP, et al. Bone mineral densityresponse to caloric restriction-induced weight loss orexercise-induced weight loss: a randomized controlled trial.Arch Intern Med 2006;166:2502-2510[Erratum, Arch InternMed 2007;167:452.]

27. Weiss EP, Racette SB, Villareal DT, et al. Lower extremitymuscle size and strength and aerobic capacity decrease withcaloric restriction but not with exercise-induced weight loss.J ApplPhysiol 2007;102:634-640

28. Lyons RA, Perry HM, Littlepage BN. Evidence for the validityof the Short-form 36 Questionnaire (SF-36) in an elderlypopulation. Age Ageing 1994;23:182-184

29. Kalantar-Zadeh K, Kopple JD, Block G, Humphreys MH.Association among SF36 quality of life measures andnutrition, hospitalization, and mortality in hemodialysis. JAm SocNephrol 2001;12:2797-2806

30. Hamerman D. Toward an understanding of frailty. AnnIntern Med 1999;130:945-950

31. Ahmed N, Mandel R, Fain MJ. Frailty: an emerging geriatricsyndrome. Am J Med 2007;120:748-753

32. Bouchard DR, Soucy L, Senechal M, Dionne IJ, Brochu M.Impact of resistance training with or without caloricrestriction on physical capacity in obese older women.Menopause 2009;16:66-72

33. Miller GD, Nicklas BJ, Davis C, Loeser RF, Lenchik L, MessierSP. Intensive weight loss program improves physicalfunction in older obese adults with knee osteoarthritis.Obesity (Silver Spring) 2006;14:1219-1230

34. Messier SP, Loeser RF, Miller GD, et al. Exercise and dietaryweight loss in overweight and obese older adults with kneeosteoarthritis: the Arthritis, Diet, and Activity PromotionTrial. Arthritis Rheum 2004;50:1501-1510

35. Klein S, Wadden T, Sugerman HJ. AGA technical review onobesity. Gastroenterology 2002;123:882-932[Erratum,Gastroenterology 2002;123:1752.]

36. Reuben DB, Siu AL, Kimpau S. The predictive validity ofself-report and performance-based measures of function andhealth. J Gerontol 1992;47:M106-M110



Probing the Floor of the Optic Nerve head in Glaucoma

Dr. Douglas R. Anderson, MD -Miami, FloridaEdited by: Dr. Madiha Durrani FRCS, U.A.E.

Current Research

Spectral domain optical coherence tomography(SD-OCT) applied to the eye is rapidly expanding itsscope of usefulness. The authors have described the useof “Enhanced Depth Imaging” (EDT) to explore theoptic disc, and in particular the lamina cribrosa, in thecontext of glaucoma. The lamina cribrosa is of specialinterest because the excavation of the optic nerve head,so characteristic of glaucoma in contrast to other opticatrophies, is related to the collapse and posteriorbowing of the lamina cribrosa with widening of thescleral opening.

The EDI method has been used to evaluate thechoroid in glaucoma, with the finding that the choroidbecomes thinner with age, but is seemingly not affectedby glaucoma.In a previous study with standard SD-OCT, the anterior portion of the lamina cribrosa wasvisible only in the cup, but not under the rim ofneuroretinal tissue. In 42% of the eyes the posteriorboundary of the lamina cribrosa could not be identified,even in the region of the cup, so thickness could bemeasured in only 58% of the eyes and for the most partonly at the center

Park et al of the Catholic University of Korea,made measurements at 3 locations along the verticalmidline of the disc (in the cup), to avoid shadowscaused by blood vessels and other overlying tissue.They reported that among 137 eyes with glaucoma, thefront surface of the lamina cribrosa could be seen inall, even with the standard mode. The posterior surfacewas adequately seen in only 66% with the standardmode, but in 93% with EDI. They also found a greaterrepeatability when measuring the lamina cribrosathickness with EDI than in the standard mode . Withregard to glaucoma, they found that the lamina cribrosawas thickest in healthy eyes, less thick in eyes with high-pressure glaucoma, and thinner yet in eyes withnormal-tension glaucoma, particularly in those in whichdisc hemorrhages were seen.

In 76% of the eyes, pores of the lamina cribrosacould be seen in regions of the disc, mainly centrally ortemporally. They made note of other structures as well.The central retinal vessels could be seen in all eyes, andin 86% at least one short posterior ciliary artery wasseen. In a minority, other details were observed,including the anterior termination of the subarachnoidspace, a patch of absent lamina cribrosa, and an instance

of a nonvascular cavity within the choroid. The authorsthus illustrated new, but perhaps very infrequent,features that accompany glaucomatous disease.

Thus, EDI has not only enabled study ofthechoroid (and possibly sclera), but is beginning toopen new windows to the depths of the optic nervehead. Already details are emerging about the collapseand thinning of the lamina cribrosa,posterior migrationof its insertion into the sclera. These events seem tooccur in the early stages of glaucomatous cupping.Although histological verification that structures arecorrectly identified would be valuable.

In addition, while EDI is a major step forward.the image of deeper structures is still imperfect. Theultimate hope is that we not only come to understandthe pathogenic process, but can use the information inmaking clinical evaluation and decisions.

Based on evidence, observation and clinicaljudgment, Dr. S.S. Hasnain, a Pakistani scientist who ispracticing Ophthalmology for the last 40 years inCalifornia, has challenged the old paradigm of ’Cuppeddisc’ in glaucoma by a new hypothesis, ‘Optic disc maybe sinking’. Dr. Hasnain has made a relentless effort toestablish this new paradigm, indicating that why arethe arcuate axons selectively destroyed first in the initialstages of Glaucoma? He strongly thinks that this is theonly core issue in resolving the pathogenesis ofglaucoma. He considers that the loss of neurons inLateral Geniculate body and loss of ganglion cells inthe retina simultaneously supports his hypothesis of‘sinking disc’ resulting in the axons being axotomizedand not atrophied as in glaucoma. He considers thataxotomy of axons result in excavation of disc, a featureof chronic glaucoma.REFERENCESI. Park H-YL, Jeon SH, Park CK. Enhanced depth imaging

detects laminacribrosa thickness differences in normaltension glaucoma and primary open angle glaucoma.Ophthalmology 2llI2;11 9: lO-20.

2. Park Sc. De Moraes CGV, Teng C, et a1. Enhanced depthimaging optical coherence tomography of deep optic nerveOlliplex structures in glaucoma. Ophthalmology 2012; 119:j.

3. SpaideRF, Koizumi H, Pozzoni Me. Enhanced depth imagingspectral-domain optical coherence tomography. Am IOphthalmol. 2008; 146496 —500.

4. Chang S, FlueraruC, Mao Y. Sherif S. Anenuationcompensation.

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Newsltr April 2012 - prime.edu.pk · Ophthalmology Update Vol. 10. No. 2, April-June 2012 iii Contents Topical Nsaid’s and Flouoromethalone in the Treatment of Epidemic Keratoconjunctivitis