Serum IgE levels: an effective diagnostic tool for evaluation and monitoring of orbital fungal granuloma

To determine the changes in IgE levels in diagnosis and postoperative monitoring of orbital fungal granuloma. Descriptive analytical study. Al-Shifa Trust Eye Hospital, Rawalpindi, Pakistan, from July 2012 to June 2013. Cases with clinically high index of suspicion for orbital fungal granuloma and 50 healthy volunteers were inducted as control subjects. Patients with recurrent cases of orbital fungal granuloma, previous orbital surgery, and those with very low clinical suspicion of fungal granuloma were excluded. Total serum IgE level [IU/ml], eosinophil counts and skin prick test were performed in all subjects. Independent t-test was used for comparison of healthy volunteers and patients with biopsy proven orbital fungal granuloma. Repeated measures ANOVA was used for comparing the preoperative and postoperative total serum IgE level of patients with biopsy proven fungal granuloma. The mean total serum IgE level for the healthy volunteers was 208.82 +/- 41.43 IU/ml. The mean pre-operative IgE value of histologically confirmed cases of fungal granuloma was 1613.72 +/- 282.83 IU/ml. The total serum IgE level gradually declined after surgery and anti-fungal treatment. The mean serum IgE level 3, 6 and 9 months postoperatively were 1039.48 +/- 308.40, 568.77 +/- 162.01 and 224.92 +/- 51.55 IU/ml respectively. These tests showed that the drop in IgE level in cases of fungal granuloma with treatment was statistically significant [p < 0.001]. Total serum IgE level can be used as a reliable diagnostic and postoperative monitoring tool in orbital fungal granuloma

Barriers to low vision services and challenges faced by the providers

There were two objectives of the study. First to identify the barriers as perceived by patients and providers to access the low vision services and second was to identify the challenges faced by the main providers. Structured questionnaire based interviews of patients and providers. To find out the barriers to access of low vision services. The interviews based on structured questionnaire were conducted for two patient groups. The first group consisted of 97 visually impaired individuals attending the department of low vision services at Al- Shifa Trust Eye Hospital Rawalpindi while the second group included 56 visually impaired individuals attending the four rehabilitation centers/schools for the blind in Rawalpindi/Islamabad. To identify the barriers as perceived by the main providers of low vision services and challenges faced by them the interviews based on structured questionnaire were conducted for 19 low vision service providers. From patients point of view, major barrier to low vision services identified was inability to visit hospital /rehabilitation center alone, 29.8% in hospital group and 33.9% in rehabilitation centers group while the lack of social and family support, cost of travelling, long distance, affordability, hesitation in using devices and lack of satisfaction were other important barriers identified. From providers point of view, major barrier to uptake of services was the need for repeated follow-ups. Optometrists were the main provider of low vision services contributing to 47.4% of the providers. The major challenge faced by the providers was motivation of patients to use low vision devices. The major barrier to low vision services according to the patients is inability to visit the hospital alone, while according to providers, it is the need for repeated follow up which proves major barrier towards uptake of services. Motivation is the major challenge faced by providers, majority of which are optometrists

Prevalence of ocular Leishmaniasis in district Chakwal

Cutaneous Leishmaniasis is endemic in Pakistan. The current study was undertaken in District Chakwal to measure the prevalence of ocular lesions in cutaneous leishmaniasis. A 60 years male presented to the Oculoplastic Clinic at Al- Shifa Trust Eye Hospital Rawalpindi, Pakistan, with an isolated chronic non-healing ulcerative lesion of left upper eye lid. Clinically suspected to be squamous cell carcinoma, it underwent total excision followed by Cutler-Beard reconstruction. The histopathology was cutaneous leishmaniasis. A team was dispatched to the health center, Choa Saiden Shah of the area to which the patient belonged [120 km southeast of Islamabad]. The area was found to be endemic for leishmaniasis. A total of 925 patients with known cutaneous leishmaniasis were registered for treatment at the health center and examined for ocular involvement. The prevalence of ocular lesions was found to be about 1%. Most of the lesions involved the skin of the upper eyelid. All the non-ocular patients were undergoing treatment with intralesional injection of Glucantime, while patients with exclusive ocular involvement were treated with intramuscular injections. Ocular involvement in Leishmaniasis is relatively rare, but it should be kept in mind in the differential diagnosis of ulcerative lesions of the eyelid especially in an endemic area

Pakistan earthquake 2005: the role of subspecialty hospitals in national disasters - the scope and limitations: modeling the Eye Hospital response

Purpose: To study the role of subspecialty hospitals in national disasters, its scope and limitations in context of an eye hospital response during Pakistan October 2005 earth quake

Study Design: A retrospective observational study

Subject and Method: The study was carried out at Al Shifa Trust Eye Hospital Rawalpindi [ASTEH] and comprises of the scope and limitations faced by ASTEH, a subspecialty eye hospital, when it offered its services to the victims of October 2005 earthquake. A special trauma management team from UK with over two dozen specialists joined the hospital voluntarily. A total of 156 patients admitted to the hospital were managed surgically and medically, the limitations and scope analyzed and the patients interviewed at the time of presentation regarding the age, district, mechanism of injury, time elapsed under debris, delay in reporting to the health care facility, type of injury and type of surgery undergone

Results: The limitations faced by the hospital included overwhelmed resources [ASTEH being a charity hospital], budget reallocation, emergency planning, collecting additional donations, funds and grants, providing medical and surgical care to a different class of patients, and provision of accommodation, food, water and electricity to the patients and their attendants. With the help of donations from Pakistan Red Crescent Society and Islamic Help Charity of UK as well as personal donations Al Shifa Trust Eye Hospital effectively managed all the patients. Psychological and emotional support was also provided. 59% of the affected were females. The most common injury was bony fractures in 64% of cases and the most common mechanism of injury was roof collapse. Among ocular injuries again fractures caused by roof collapse were more prevalent

Conclusion: Disaster management is everyone's responsibility. Being a specialized hospital should not bar any health facility to contribute to the national disaster management in hours of need. Al-Shifa Trust Eye Hospital effectively proved that with proper management and networking, a subspecialty hospital can play vital part in national emergencies. The pattern of ocular injuries observed was a unique opportunity for ophthalmic research workers and health policy makers

Choroidal melanoma in a young patient - a case report and mini review of literature

Background: Choroidal melanoma is the most common primary intraocular malignant neoplasm in adults[1]. However, there are various benign and malignant lesions that mimic ophthalmoscopic features of choroidal melanoma[2]. Moreover, atypical presentation and unusual age distribution of choroidal melanoma in some cases make the diagnostic elucidation even more difficult and in such cases, supplementary tests especially ultrasonographic methods gain prime importance

Case Description: The authors report a case of primary choroidal melanoma in a 27 years old young male patient who presented to department of Orbit and Oculoplastic at Al-Shifa Trust Eye Hospital, Rawalpindi, Pakistan in 2013 being the first case to be reported at this age at Al-Shifa Trust Eye Hospital, Rawalpindi, Pakistan in more than fifteen years. Keeping in view the uncommon age distribution, supplementary tests and the clinical follow-up was essential for the correct diagnosis of the lesion

Conclusion: The present case report draws attention to the fact that age can be a misleading factor and choroidal melanomas should not be over looked in young individuals

Sling materials for management of congenital ptosis - a major review

Blepharoptosis affects individuals of all ages, races and genders. It has a significant impact on a patient's functional and psychological status and may cause poor visual development in childhood. Since the Italian anatomist and surgeon Antonio Scarpa's publication of Practical Observations on the Principle and Disease of the Eye in 1806, ptosis surgery has undergone many revolutions as the knowledge of anatomy and physiology progressed and as types of materials expanded. It is essential that a multidisciplinary approach, encompassing pediatric ophthalmology, oculplastics surgeon, and orthoptic department work closely to optimize patient management. Correction of congenital ptosis is one of the most difficult challenges ophthalmologists face. Ptosis surgical correction techniques depend on the degree of ptosis and the levator muscle action. Multiple surgical procedures are available including frontalis sling, levator advancement, Whitnall sling, frontalis muscle flap, and Mullerectomy. In cases with severe levator muscle dysfunction, the choice of surgery is a sling procedure. Materials which have been used for this purpose are widely variable and divided into non synthetic and synthetic. Non synthetic include fascia lata [both autogenous and allogenic], palmaris longus tendon and temporalis fascia, while synthetic include mersilene mesh, silicone rods and sutures [prolene, nylon, silk and Gortex]

Prevalence of secondary complications and visual outcome in penetrating ocular injuries

To assess the prevalence of secondary complications and their effect on visual outcome in penetrating ocular injuries. A retrospective review. This study was carried out at Al Shifa Trust Eye Hospital Rawalpindi and consisted of a retrospective analysis of the data of patients presenting with penetrating ocular injuries from 1[st] January 2009 to 30[th] June 2011. At the time of presentation and after final treatment all patients underwent a complete ocular examination. In all cases primary globe repair was performed in the first stage. The percentage of secondary complications and related visual deficiency was calculated taking into consideration degree of penetration and the visual acuity at time of presentation. A proforma was prepared for documentation. A total of 93 eyes, with a male to female ratio of 3:1 and mean age of 20.5 years were enrolled. Overall incidence of post op complications was 55.91% [Cataract 42.3%, Phthisis 34.61%, retinal detachment 26.92%, vitreous haemorrhage 21.15%, endophthalmitis 11.5%, secondary glaucoma and APD 3.84%]. Best corrected final VA of up to or better than 6/12 was found in only 19.35% of patients. At the end of three months, the cases with normal vision were 16.3%, visual impairment 19.6%, severe visual impairment 04.1% and monocular blindness 60.8%. Penetrating ocular trauma in Pakistan has a high rate of secondary complications which carries a poor visual prognosis and leads to monocular blindness in signified number of cases

Systemic clinical manifestations associated with simple congenital ptosis

To highlight the possible systemic co-existing manifestations in congenital ptosis Department of Orbit and Oculoplastics, Al-Shifa Trust Eye Hospital Rawalpindi. Retrospective case series. Medical record of 300 patients who were operated by the author during a seven year period [2001-2007] was analysed to look for patients who presented with systemic associations. 2% of patients had some associated systemic anomaly. Out of 300 patients, six patients were identified. The anomalies included dextrocardia, skeletal anomalies like absence of phalanx, fusion of ribs, shortening of limbs, as well as cleft palate and atrophy of thigh muscles. The systemic anomalies noted were mostly skeletal in origin and had low prevalence. However thorough systemic examination in a patient with congenital ptosis is mandatory to rule out more serious systemic associations

Adenocystic carcinoma of eyelid: a case report and review of literature

Adenoid cystic carcinoma [ACC] is a rare slow growing epithelial malignancy. ACC is an intractable neoplasm due to its ability to invade perineural spaces. In eye, ACC most commonly arises in the lacrimal gland. Very rarely, ACC originates from accessory lacrimal gland tissue. In the rare instance of taking origin from eyelid, it can arise from eyelid skin, glands of Moll, palpebral lobe of lacrimal gland, accessory lacrimal glands in conjunctiva, or from ectopic lacrimal gland tissue. Here, we present a patient with an ACC of the outer part of upper eyelid, clinically presenting like sebaceous gland carcinoma. Its origin most likely was palpebral lobe of lacrimal gland. Palpebral lobe tumors should be strongly considered in the differential diagnosis of upper outer eyelid masses

Prevalence study of Age Related Macular Degeneration in a target population of Rawalpindi Division

To estimate the prevalence of age related macular degeneration [AMD] in a target population of Rawalpindi Division. A community based prevalence study was carried out at village Kanooha in Rawalpindi Division. Persons aged 55 years or above residing in the target population zone in Rawalpindi Division were examined for AMD by an ophthalmologist. Total number of persons examined was 1152. There were 520 males and 632 females. 816 persons met the inclusion criteria, out of which 55 [6.74%] patients had signs of AMD. Late AMD was seen in 7 [0.86%] and early AMD in 47 [5.88%]. The prevalence [6.74%] of AMD observed in our study is less than that reported in white races

Screening for diabetic retinopathy: a comparative study between hospital and community based screening and between paying and non-paying patients

Prevalence of diabetes and diabetic retinopathy varies in the population considering the background and financial status. A total of 79, 194 people more than 40 years, were screened for diabetes both in the community and eye hospital setting. Initial screening was carried out by urine dipstick followed by random blood sugar examination. A value >/= 140 mg/dl of blood sugar was considered positive for diabetes. All the diabetics were then examined for any evidence of diabetic retinopathy through indirect ophthalmoscopy in a dilated pupil by a midlevel ophthalmologist. Health education campaign at public, patient and professional level was also conducted. The results of screening were analyzed for three distinct groups; rural population, hospital based free patients and hospital based paying patients. The prevalence of diabetes was found to be 9.12%, 10.34% and 18.57% in rural community, poor hospital and affluent hospital groups respectively. The prevalence of diabetic retinopathy in the total screened population in these three subgroups was 1.92%, 2.52% and 4.42% respectively, while this prevalence in the diabetic population was 21.05%, 24.39% and 23.80% respectively. The cost per person screened was $2.6-3.4, while the cost per diabetic identified was $26-28 and the cost per patient of diabetic retinopathy identified was $108-135. The prevalence of diabetic retinopathy was two times more in the affluent hospital patients as compared to poor hospital patients or rural population. For each known diabetic, there were four previously undiscovered diabetics in the rural population, and two previously undiscovered diabetics in hospital based population

Mortality from Diamox

To report life threatening acute confusional state as an adverse reaction of oral Acetazolamide in an eye care setup. Case Series Two elderly females [60 and 65 years] and one male [68 years] admitted for cataract surgery and prescribed with prophylactic Diamox presenting with identical symptoms. All presented with symptoms of acute confusion, altered awareness and irritability during admission in the ward. Two of these jumped out of ward windows and lost their lives. The third patient was overpowered and managed later thus preventing the fatal outcome. Acute confusion or delirium is a rare complication of Diamox. Never reported in ophthalmic literature and very infrequently reported in non-ophthalmic literature, these case reports display the need of nursing vigilance and awareness by ophthalmologists during the use of Diamox. Since these episodes, the practice of using pre-operative Diamox in cataract surgery patients has been abandoned at Al-Shifa Trust Eye Hospital

Screening for diabetic retinopathy: a hospital based study of paying and non-paying patients

A descriptive study was carried out to determine that results of screening for diabetes and diabetic retinopathy amongst the paying and free hospital patients. Tertiary eye care hospital. A total of 25, 510 people over 40 years were screened for diabetes in an eye hospital setting. Initial screening was carried out by urine dipstick followed by random blood sugar examination. A value [x] 140 mg/dl of blood sugar was considered positive for diabetes. All the diabetics were then examined for any evidence of diabetic retinopathy through indirect ophthalmoscopy in a dilated pupil by a midlevel ophthalmologist. Health education campaign at public, patient and professional level was also conducted. Prevalence of diabetes and diabetic retinopathy amongst paying and non-paying hospital patients. The results of screening were analyzed for two distinct groups: hospital based free patients [poor urban population] and hospital based paying patients [affluent urban population]. The prevalence of diabetes was found to be 10.34% and 18.57% in poor urban and affluent urban groups respectively. The prevalence of diabetic retinopathy in the total screened population in these two subgroups was 2.52% and 4.42% respectively, while this prevalence in the diabetic population was 24.39% and 23.80% respectively. It was observed that the prevalence of diabetic retinopathy was two times more in the affluent urban population as compared to poor urban population. For each known diabetic, there were three previously undiscovered diabetics in urban/hospital based population

Prevalence of amblyopia in school population

Purpose of study: To measure prevalence of avoidable visual impairment in school children

Design and Setting: Retrospective analysis of school screening carried out in Rawalpindi District

Main outcome measures: Proportion of children with amblyopia

Results: 518,648 children were screened over a period of 4 years in Rawalpindi District. Trained teachers carried out the primary screening while our clinical medical officers carried out further examination of screened children. 35% of children had some sort of ocular symptoms. 6% of children had significant visual problems to warrant further management. Amblyopia was found in 0.43% of children

Conclusion: School screening with assistance from teachers is a cost-effective measure for prevention of visual impairment in children