Compliance to medical treatment in patients of chronic simple glaucoma: study of factors causing non-compliance

Objective: To determine how many patients with glaucoma do not comply with medical therapy and study the factors which make them distinguishable from complying patients

Study Design: Cross sectional comparative study

Place and duration: At Glaucoma clinic, Al-Shifa Trust Eye Hospital, Rawalpindi over a period of 6 months from 1[st] May 2006 to 30[th] Nov 2006

Methodology: A pre-tested structured questionnaire was used. The data collected was of patient's age, years of glaucoma diagnosis, number of medicines advised their educational level, socioeconomic conditions and distance they travel to the hospital. Patients were asked of difficulty in self administration of medicines and whether or not the medicine finished before the visit and is it available near their home? Non compliance was regarded as the missing of prescribed medicines for 1 day or more as reported by the patient. The patients were grouped as compliers [group 1] and non-compliers [group 2], and all the variables were analyzed to find any significant intergroup differences by using SPSS version 16

Results: Of 100 patients, 65% were males and 35% were female patients of glaucoma. Among them, the compliers were 61 [group 1] and non compliers were 39 [group 2]. Statistically significant difference in compliance behavior was found in relation to number of medicines prescribed [p=0.039], problems with self administration of drops [p=0.05], eye drops finished before follow up visit [p=0.001], and non-availability of medicines at pharmacy near home [p=0.034]

Conclusion: Several interrelated factors may contribute to noncompliance. Poor compliance may be due to less educated patients, problems with managing multiple eye drops and the complex regimens. Problems with self administration of medicines and poor socioeconomic status may be the reason behind discontinuation of medicines. All these factors must be looked into in a glaucoma patient non compliant to medical treatment

Keratometry, axial length and intra-ocular lens power variations observed during biometry

Objective: To document the variations in keratometry, axial length of eye and intra-ocular lens [IOL] power observed during biometry of cataract patients and to find any significant gender difference

Study Design: A retrospective review of the biometry records

Place and Duration: Saeed Eye and Medical Complex, Rawalpindi from 1st Nov 2010 to 31st Dec 2014

Methodology: Patients of senile cataract were included from the biometry records. Keratometry readings of vertical and horizontal corneal meridian [K1 and K2] were measured with automated keratometre and axial length was measured with contact A-scan. Power of IOL was calculated by using SRK-T formula in patients with axial lengths between 22 and 26, Hoffer Q for axial lengths <22mm and Haigis for axial lengths >26 mm with A-constant of 118. The data was analyzed with SPSS version 16

Results: 908 patient records were analyzed. The mean +/- SD keratometry readings [K1 and K2] were 43.46 +/- 1.68 D and 44.41 +/- 1.98 D respectively. The mean +/- SD axial length was 23.45 +/- 1.20mm. SRK-T was used in 818 [90.1%] cases, Hoffer Q in 68 [7.5%] and Haigis in 22 [2.4%] of cases. The mean +/- SD intra-ocular lens power was 20.22 +/- 3.06D. Gender based comparison showed that the mean +/- SD K1 in males [42.95 +/- 1.54D] was less than 43.88 +/- 1.67D for females [p=0.0001]. The mean +/- SD K2 for males [43.9 +/- 1.66D] was also less in females [44.78 +/- 1.70D] [p=0.0001]. The mean +/- SD axial length of eyes in males was 23.81 +/- 1.23mm significantly more than 23.16 +/- 1.08mm in females [p=0.0001]. The mean +/- SD IOL power was 19.68 +/- 3.19D in males and 20.67 +/- 2.86D in females [p=0.0001]

Conclusion: The mean keratometry readings [K1 and K2] were 43.46 +/- 1.68 D and 44.41 +/- 1.98 D respectively. The mean axial length was 23.45 +/- 1.20mm and mean intra-ocular lens power was 20.22 +/- 3.06D. Gender based analysis showed that females have more keratometric readings but shorter axial lengths than males and required more power of IOL to be implanted after cataract surgery

Most common clinical features of age related macular degeneration in Pakistan

To document the most common clinical symptoms and signs in patients diagnosed with ARM and ARDM. Observational study. The study was conducted at Retina clinic, Al-Shifa Trust Eye Hospital, Rawalpindi. Patients with age related macular degeneration were randomly selected over a period of 6 months. A pre-tested structured questionnaire was filled by a consultant in retina clinic. Patients were asked about the presenting symptoms already enlisted in the questionnaire. The pupil was dilated till adequate retinal examination was possible and the clinical signs observed and documented. 209 eyes of 106 patients were examined. 18 were having age related maculopathy, 80 had atrophic type of ARMD and 111 were having exudative ARMD. The patients were having gradual blurring of central vision [91%], reading difficulty [28%] and metamorphopsia [9.6%] as the most common presenting symptoms. Macular drusen were the most common feature of maculopathy. Also, macular drusen were the most common clinical feature of eyes with Dry ARMD. Eyes with wet ARMD were having choroidal neo-vascular membrane [CNV] in 86% of cases and pigment epithelial detachment [PED] in rest of the 14%. There is need for making an organized screening protocol of macular degeneration for our population at risk. Every patient complaining of gradual blurring of vision and metamorphopsia should be examined for signs of ARMD. Macular drusen, hypo and hyper-pigmentation of RPE, CNV with exudation and hemorrhage or fibro-glial scar and PED must be identified on retinal examination for proper diagnosis and management of the ARMD

Tissue transglutaminase autoantibodies as predictors of celiac disease and its relationship to histopathological findings of intestinal biopsy

Celiac disease [CD] is a common autoimmune disorder, induced by the intake of gluten proteins present in wheat, barley and rye. Previously, it was considered to be a rare childhood disorder, but is actually considered a frequent condition, present at any age, which may have multiple complications. Active CD is characterized by intestinal and/or extra-intestinal symptoms, villous atrophy and crypt hyperplasia, and strongly positive IgA anti-endomysial antibody [EMA] and tissue transglutaminase [tTG] auto-antibodies. The duodenal biopsy is considered to be the "gold standard" for diagnosis. The use of screening tests for celiac disease has increased the number of patients referred for evaluation. We proposed that the subgroup of patients with very high tissue transglutaminase antibody [t-TGIgA] titers is positive for celiac disease and a small-bowel biopsy is not necessary to make the diagnosis. A gluten-free diet should be attempted and, if the patient's symptoms do not improve, then a biopsy should be performed to confirm the diagnosis. It is a retrospective study, reviewed 51 patients who underwent both t-TGIgA testing and a small-bowel biopsy was performed. We examined the impact of using t-TGIgA values of >100U and <20U as cutoff values and suggested performing biopsies for patients with t-TGIgA values of 20 to 100U, as is current practice. Twenty-nine of 51 patients demonstrated positive biopsy results. Twenty-four of 51 patients had t-TGIgA levels of >100U, with 23 of 24 exhibiting positive biopsy results. Only 3 of 8 patients with t-TGIgA values of 20 to 100U exhibited positive biopsy results. Three patients with t-TGIgA levels of <20U had positive biopsies; 2 were IgA negative and 1 had a duodenal ulcer. With the cutoff values of >100U and <20U with known IgA status, the sensitivity was 0.958 [23 of 24 cases] and the specificity was 0.941 [16 of 17 cases]. When the cutoff values were changed to >100 and <20U and IgA levels were verified, the sensitivity and specificity were very high. Patients with midrange t-TGIgA values [20-100U] or values of <20U with negative IgA status should continue to undergo biopsies for diagnosis of celiac disease

Refractive error study in strabismic children: results from Al-Shifa Trust, Rawalpindi, Pakistan

To assess the prevalence of refractive error and visual impairment in children with strabismus. Study design:-Hospital based prospective study. July 1995 to June 1998. A total of 1120 strabismic children between the ages of 02-l 5 years were examined to identify those having refractive error. visual acuity measurement, cycloplegic retinoscopy, ocular motility evaluation and examination of the external eye, anterior segment, media and fundus were performed in all the strabismic children. Out of 1120 strabismic children, 622 [55.54%] had esotropia, 370 [3104%] had exotropia and 128 [11.42%] had vertical strabismus.148 [13.21%] were emmetropic, 972 [86.79%] strabismic children had refractive errors. Esotropia was the most common strabismus followed by exotropia and vertical strabismus. Severe visual impairment was found in 27.30% of the strabismic children. The most common refractive error was hypermetropia followed by astigmatism and myopia. About half of all the strabismic children had amblyopia

Role of intraoperative 360 retinal endophotocoagulation in the management of giant retinal tears

To determine the effectiveness of intraoperative 360 degree retinal photocoagulation in the management of giant retinal tears [GRTs]. Departments of Vitreoretina, Al Shifa Trust Eye Hospital, Rawalpindi. From 2000 to 2004. Sixteen eyes of 16 consecutive patients with GRTs were operated at Al Shifa trust eye hospital. Eyes included in this study underwent pars plana vitrectomy, perfluorocarbon liquid injection, 360 degree retinal photocoagulation and silicone oil exchange. Retinopexy was applied to the edges of the tear through endolaser photocoagulation and extended over 360 degree to the peripheral attached retina. No scieral bijckle was placed in any of these cases. The extent of the GRT was 180 degree or greater in four eyes and 90 degree to 180 degree in twelve eyes. The lower edge of the GRT was located in the inferior quadrant in fourteen eyes. PVR was grade A in five eyes, grade B in eight eyes and grade C in three eyes. In 12 [75%] of the 16 eyes, the retina was successfully reattached after surgery and 360 degree laser photocoagulation. The silicone oil was removed after a mean period of twelve weeks. Two of the four eyes were successfully reoperated by performing relaxing retinotomies. At the end of the follow up, the retinal was reattached in 14 [87.5%] of the 16 eyes. The mean follow up period was 14 months [range 5-23 months]. The success rate of management of GRTs with pars plana vitrectomy, internal temponade and 360 photocoagulation of the retina without scleral buckle is high

Steroid induced glaucoma: a case report

Purpose: To highlight the importance of intra-ocular pressure monitoring to reduce incidence of visual loss in children being treated with topical steroids

Study design: Case report

Participant: An 11 year old boy with gradually decreasing vision using topical steroids

Discussion: Of all the various routes of steroid administration, topical steroid therapy most commonly causes elevation of IOP by decreasing the outflow facility of aqueous. Topical steroids can cause an IOP rise correlated with the duration and frequency of drug administration. The height and duration of the pressure rise depends upon factors like drug potency, penetration, dosage, length of administration as well as individual susceptibility and age. Children younger than 10 years of age show marked elevation of IOP when treated with topical preparations. Despite their popularity as anti-allergic and anti-inflammatory agents, corticosteroids can have tragic consequences and should be used only with judicious monitoring in young children. This case report highlights the problem of glaucoma in a child following unsupervised use of the steroids