Iridogoniodysgenesis: a challenging case

Iridogoniodysgenesis is a rare autosomal dominant disorder affecting anterior segment of the eye. Fifty percent cases of iridogoniodysgenesis have glaucoma, which is particularly difficult to manage. We report here a case of 40 years old man with this rare disorder, presenting to our glaucoma department. It was characterised by iris hypoplasia and juvenile glaucoma. To stop fluctuation in his intraocular pressure [IOP] and to save his vision from glaucomatous damage, our team had to do three different surgical procedures, i.e. trabeculectomy with F5U, diode laser cycloablation and aqueous shunt procedure, over a period of 10 months. This case report discusses management of glaucoma in this particular patient and challenges faced during the treatment. Regular follow-up and timely intervention can save such patients from complete blindness. To authors' knowledge, this is the first reported case of iridogoniodysgenesis in Pakistan

Visual fields defects as a possible cause of trauma or falls in the patients blaming trauma for their visual loss

To investigate the possibility of visual field defects as a cause of trauma or falls in glaucoma patients who blamed trauma for their visual loss. Study Design: A hospital based cross sectional observational study Place and Duration of study: Al-Shifa Trust Eye Hospital Rawalpindi from January 2006 to December 2010. After taking a detailed history of the patients [who correlated their visual problems secondary to trauma / falls], a thorough ocular examination was conducted followed by visual field analysis and ocular coherence tomography of both eyes. All clinical findings and diagnosis were noted on a proforma and data analysis was done using statistical software SPSS 17.0. Out of 384 patients enrolled in the study, the most common type of ocular trauma was blunt close type observed in 229 [59.6%] patients while 81 [21.1%] patients had non ocular trauma. Glaucoma was diagnosed in 324 [84.37%] traumatized and 143 [37.23%] non traumatized fellow eyes while 53 [13.8%] non traumatized eyes were labeled as glaucoma suspects. Glaucoma hemifield test was found outside normal limits in 101[26.3%] non traumatized eyes. Detection of advanced glaucoma in traumatized eyes and visual field defects in a significant number of fellow eyes suggests the possibility of existing visual field defects as a likely cause of injuries or falls in glaucoma patients. This emphasizes the need for developing prevention programs and enhancement of quality of life in glaucoma patients as ignorance of visual field defects can lead to injuries / falls

Frequencies of various ocular pathologies detected on B-scan ultrasonography in patients of ocular trauma

To determine the frequencies of various ocular pathologies detected on B-scan ultrasonography in patients of ocular trauma. A descriptive cross-sectional study. The study was conducted in 162 patients of ocular trauma from 14th September 2011 to 14th march 2012 presenting to the outpatient department of Al-Shifa Trust Eye Hospital in collaboration with the B-scan department of the hospital. All the information was recorded on proformas and data analysis was done using SPSS 13.0. There were 134 [82.7%] males and 28 [17.3%] females. The study showed that age group 1-20 yrs is most commonly affected by ocular trauma. Males are 5 times more commonly affected by ocular trauma than females. Vegetative material [29%], metallic objects [27.2%] and stone material [17.9%] were most common causes of ocular trauma. While plastic objects [8.6%], blast injuries [4.9%], glass [4.9%], hand and finger trauma [3.7%] and animal horn trauma [3.7%] were less common causes. The study showed vitreous hemorrhage to be most common B-scan finding in ocular trauma [31.5%] while 19.8% patients had no abnormality detected on B scan. Retinal detachment was present in 17.9% patients, intraocular foreign body [IOFB] in 9.9% and endophthalmitis in 7.4%. In patients of ocular trauma, most common B-scan finding is vitreous hemorrhage, retinal detachment and intraocular foreign body. Although significant number of trauma patients have normal B-scans as well. In ocular trauma patients B-scan can be an excellent tool to examine posterior segment when anterior segment pathology precludes clinical examination. This study provides a local data base of the burden of posterior segment pathology in ocular trauma patients that requires urgent management by Vitreoretinal specialist for better visual outcome

Hypermetropia as a presentation of diffuse choroidal haemangioma in Sturge-Weber syndrome

A 16 years old male patient of Sturge-Weber syndrome was referred to glaucoma clinic for the management of unilateral glaucoma. There was also an ipsilateral hypermetropic shift. On detailed investigations, a diffuse choroidal haemangioma was diagnosed which induced this hypermetropic shift. Anisometropia in Sturge-Weber syndrome can give us clue regarding some underlying pathology, so unilateral myopia or hypermetropia should be thoroughly evaluated in such patients

Awareness of diabetic retinopathy among the known diabetic patients at a tertiary care eye hospital

To assess the awareness of diabetic retinopathy [DR] among the known diabetics at Al-Shifa Trust Eye Hospital [ASTEH] Rawalpindi. A cross sectional observational study. Study was conducted on 200 known diabetics from 1[st] April 2007 to 30[th] September 2007. Level of knowledge about DR was assessed on the basis of a face-to-face interview and graded according to the number of correct responses. All the information was recorded on proformas and data analysis was done using SPSS 13.0. There were 85 [42.5%] male and 115 [57.5%] female participants with a mean age of 56.0 [ +/- 9.740] years while mean duration of diabetes was 8.468 [ +/- 6.034] years. Knowledge of 72 [36%] patients was found satisfactory. Gender [p=0.000], socioeconomic status [p=0.000], education [p=0.001] and source of information [p=0.000] were significantly associated with awareness. Ophthalmologists were the major source of information for the patients. Awareness about DR is low in our diabetic patients. More emphasis should be given to health education of diabetics along with treatment

Validity of frequency doubling technology to diagnose glaucoma

To determine the validity of frequency doubling technology [FDT] in identifying glaucoma subjects using Humphrey perimetry as gold standard. Cross-sectional validation study. The study was conducted at the Glaucoma clinic of Al-Shifa Trust Eye Hospital Rawalpindi from 16[th] Nov 2009 to 15[th] May 2010 on 84 eyes suspected to have glaucoma. After an informed consent, detailed history and complete ocular examination, patients were briefed about the two diagnostic tests. Each patient performed both perimetry tests, i.e. Standard Automated Perimetry [Humphrey 30-2] and FDT. At the end of each test, perimetry systems calculated mean deviation for the eye examined. Sensitivity and specificity of the procedures was calculated using formulae. Mean test duration for FDT perimetry was 4.44 min and for Humphrey perimetry duration was 9.10 min. The sensitivity and specificity calculated for FDT perimetry were 85.4% and 90.7% respectively. Area under the receiver operating curve for FDT perimetry was 0.880 [95%CI=0.799-0.961]. FDT perimetry has ability to discriminate between glaucomatous and healthy eyes, in less duration and can be effectively used as a screening tool to diagnose glaucoma

Ocular digital massage for the management of post-trabeculectomy underfiltering blebs

To evaluate the efficacy and safety of ocular digital massage [ODM] in the management of underfiltering blebs after trabeculectomy. Quasi experimental study. Glaucoma Clinic of Al-Shifa Trust Eye Hospital, Rawalpindi, from January 2007 to November 2008. ODM was performed 3-4 times daily in 20 eyes having intraocular pressure [IOP] above the target level after trabeculectomy. Equal number of eyes with satisfactory IOP after trabeculectomy were taken as controls. Both groups were evaluated at 1 week, 3 weeks, 6 weeks, 3 months, 6 months and 9 months. Mean IOP, frequency of complications and required number of IOP lowering medicines in both groups were compared using 't' test. Massage group had a significantly higher mean IOP than the control group before the initiation of massage [p < 0.001]. After initiating ODM, there were no significant differences in the mean IOP of two groups at 1 week [p = 0.421], 3 weeks [p = 0.073], 6 weeks [p = 0.575], 3 months [p = 0.071], 6 months [p = 0.085] and 9 months [p = 0.369]. The difference in terms of required number of IOP lowering medicines [p = 0.075] and complication rates [p = 0.411] was also not significant. ODM is an effective method for controlling IOP after trabeculectomy, and thus contributes to long-term surgical success with an acceptable risk / benefit ratio

Hemodynamic differences in Primary Open Angle and Primary Closed Angle Glaucoma: a cross sectional retrospective study

To determine whether or not there is an association of hemodynamic factors with Primary Closed Angle Glaucoma as well the comparison of these factors in Primary Closed Angle Glaucoma [PCAG] and primary open angle glaucoma [POAG]. A cross sectional retrospective study by medical record review was perused. 170 POAG and 170 PCAG were identified from the record of patients presenting to Christian Eye Hospital, Taxila and different hemodynamic parameters were evaluated. Descriptive statistical analysis as well as logistic regression was performed to analyze the data. High Systolic Perfusion Pressure [SPP], Diastolic Perfusion Pressure [DPP], and Mean Perfusion Pressure [MPP] were more strongly associated with PCAG [p-value 0.0001]and Odd Ratios [OR] 3.65[CI 2.30, 5.78], 7.04[CI 4.22, 11.73] and 6.64[CI 3.31, 14.07] respectively. In patients with no systemic diseases, DPP and Mean Arterial Pressure [MAP] was significantly associated with PCAG [p-value 0.0001] whereas SPP [p-value 0.03] was associated with POAG. We suggest that patients with PCAG have high values of systolic, diastolic and mean perfusion pressure and it can be attributed to disturbance at different levels of visual processing, whereas POAG are associated with low systolic perfusion pressure and high intraocular pressure

Risk factors for early posterior capsule opacification after cataract surgery

To determine risk factors for early posterior capsule opacification [PCO] following cataract surgery. Case-Control study. Patients developing PCO within and after 12 months of cataract extraction were selected as cases [early PCO] and controls [late PCO] respectively. PCO [central/ peripheral] was diagnosed by clinical examination with slit lamp biomicroscope under pupillary dilation. Operation notes were also reviewed from the hospital record. Risk factors including age of patient, surgical procedure, intraocular lens material, anterior capsulotomy/ capsulorhexis, duration since operated and experience of surgeon were observed. The study population was 146 patients, 73 in each group. There were 84 male and 62 female patients with mean age 59.33years + 15.76 SD. The study revealed significant risk of early PCO in patients who underwent standard ECCE versus Phacoemulsification [p value 0.000], PMMA vs. Acrylic IOLs [p 0.000], and can-opener capsulotomy vs. Continuous curvilinear capsulorhexis [p 0.001]. Experience of surgeon was not related with early onset PCO[p 0.184]. Early PCO has multifactor etiology; related to surgical technique and IOL implant. Meticulous surgical technique, performed under more physiological conditions, with minimum compromise of blood aqueous barrier, thorough removal of lens matter, implantation of an acrylic IOL into capsular bag are various factors that may retard the onset of PCO. These factors are interdependent and cannot slow down the process of PCO formation independently

Does gender have an effect in the prevalence of types of glaucoma in Pakistani population?

To assess the prevalence of various types of glaucoma, blindness and severity of disease with respect to gender differences. A hospital based retrospective study. Study included 3021 patients presenting to glaucoma clinic. Type and severity of glaucoma in the patients was analyzed to determine the gender inequality. Data was analyzed with the statistical software SPSS. It was found that overall the ratio of males affected with glaucoma was higher then females [2.3: 1]. Males had a more prevalent POAG whereas females were suffering more from PCAG glaucoma. Although the overall prevalence was higher in males but the blindness rate in all types of glaucoma was greater in females. Due to severity in POAG surgery of greater number of females was performed. PEXG and NTG were more pronounced in males. Females have more prevalent PCAG while males have POAG. Overall the blindness rate in different types of glaucoma was high in females therefore the results of present study indicated that gender does have an effect in the prevalence and blindness due to different types of glaucoma

Comparison of diode laser trans-scleral cyclo-photo-coagulation with cyclocryopexy in refractory glaucoma

To compare the efficacy and safety of diode laser trans-scleral cyclophotocoagulation [TDC] and cyclocryopexy in refractory glaucoma in term of intraocular pressure control, pain relief and complications. Retrospective Case Series. Medical records of 49 patients who underwent trans-scleral diode laser cycloablation [24 patients] and cyclocryopexy [25 patients] at the Al-Shifa Trust Eye Hospital during a 12 month period were analyzed. In diode laser TDC group mean pretreatment IOP was 50 mmHg with anti-glaucoma medication [SD 9.48, range 26-60] and 61 mmHg [SD 10.75, range 40-76] without medication. Mean postoperative IOP was 14 mmHg with medication and 20 mmHg without medication [SD12.73, range 2-50]. 70% eyes had IO P< 21 mmHg at 3 months. None of patients had deterioration of vision. Pain was absent in 96% at 6 weeks after single TDC session. In cyclocryopexy group mean pretreatment IOP was 49 mmHg with medication [Range 26-60, SD10.48] and 56 mmHg [Range 40-76, SD11.70] without medication. Mean postoperative IOP was 22 mmHg without treatment [range 2-75, SD 17.78]. 59% of patients had IOP < 2 ImmHg at 3 months. At 3 months, only 50% patients had significant pain reduction. 38% patients did not have any relief in pain. Postoperative complications were more frequent with cyclocryopexy and lasted longer than TDC. Neovascular glaucoma was the most common variety of refractory glaucoma in both groups. Our study confirms that in refractory glaucoma, TDC is more effective in decreasing intraocular pressure as compared to cyclocryotherapy. TDC also has a lower rate of complications and is relatively safer than cyclocryopexy

Profile of primary open angle glaucoma at a tertiary care Eye Hospital

To report the frequency, demographic pattern and clinical profile of primary open angle glaucoma [POAG] at Al-Shifa Trust Eye Hospital, Rawalpindi. A hospital based cross sectional observational study. All the patients aged 40 years and above reporting for the first time at glaucoma clinic of Al-Shifa Trust Eye Hospital, Rawalpindi from 1[st] July 2006 to 31[st] December 2007. Initial screening of all the patients was done at general outpatient department of hospital. All confirmed or suspected cases of glaucoma were referred to glaucoma clinic. After taking history, a detailed ocular examination of all patients including Snellen visual acuity, slit lamp biomicroscopy, applanation tonometry, gonioscopy and a stereoscopic assessment of cup disc ratio [CDR] was performed. In selected subjects, Heidelberg retinal tomography and automated visual field assessment was advised. Individual treatment plan for each eye was made keeping in view the stage of disease, compliance and affordability of the patient. Statistical analysis of the data was done with statistical software SPSS version 13.0. Out of the total 1068 patients aged 40 years and above, primary open angle glaucoma was diagnosed in 403 [37.73% of total] patients. Among these 403 patients, 250 [62.0%] were male and 153 [38.0%] were female. Male to female ratio was 1.63:1. Age of the patients ranged from 40-103 years with a mean age of 60.64years [ +/- 12.824 Std. Devj. Bilateral POAG was found in 334 patients [82.87%]. 33 [8%] patients were blind at the time of presentation while 134 [33.25%] patients had a cup disc ratio of 0.8 or more in both eyes. 603 [82.82%] eyes were treated medically, while trabeculectomy was the most common surgical procedure performed in 102 [14.01%] eyes. Majority of the patients belonged to Rawalpindi/Islamabad [43%] and Azad Kashmir [9.3%]. POAG is the most frequent type of glaucoma in our population with male predominance. Unfortunately the disease is more advanced at the time of presentation due to lack of public awareness. Despite availability of modern investigations, finding a patient of glaucoma while there is still some useful visual potential to save is still a big challenge for ophthalmologists in Pakistan

audit of patients presenting to glaucoma clinic

To report the demographic pattern and frequencies of various types of glaucomas and their treatment strategies. At glaucoma clinic of Al-Shifa Trust Eye Hospital, Rawalpindi, from 1st July 2006 to 30th June 2007. All the patients above 16 years of age reporting for the first time at glaucoma clinic were included. After recording the demographic profile and taking history, a detailed ocular examination including Snellen visual acuity, slit lamp examination, applanation tonometry, gonioscopy and a stereoscopic assessment of the vertical cup disc ratio [CDR] were performed. In selected subjects, visual field examination was advised. Keeping in view the compliance, affordability of the patient and stage of the disease a treatment plan was made. All the data was recorded on a special proforma then assessed using statistical software SPSS version 12.0. A total number of 800 new patients were examined in the glaucoma clinic during the study period. Among them 487 [60.9%] were males. The male to female ratio was 1.55:1. The age of the patients ranged from 16 years -103 years with a mean age of 57.7 years [ +/- 17.47 SD]. Primary open angle glaucoma [POAG] was the most frequent type of glaucoma [33.50%] followed by the primary angle closure glaucoma [PACG - 22.12%]. POAG was more common in males [34.90% of males] while PACG was more common in females [28.43% of females]. Regarding the management 912 eyes were treated medically, while 273 eyes required some sort of surgical intervention. POAG was the most frequent type of glaucoma at our clinic. The risk of developing glaucoma increases with the advancing age so people aged 40 years and above should be encouraged to visit hospitals for glaucoma screening at least once a year so that the burden of permanent visual morbidity caused by glaucoma could be decreased

Aqueous misdirection syndrome as a complication of neodymium:YAG posterior capsulotomy

To highlight aqueous misdirection syndrome as a rare complication of Nd:YAG posterior capsulotomy performed for posterior capsule opacification [PCO]. Case report. A 50 year old psuedophakic female who had Nd:YAG posterior capsulotomy six days before for posterior capsule opacification developed rise in intraocular pressure associated with flat anterior chamber. After brief history and a detailed ocular examination full-thickness iridotomy was performed with Nd:YAG laser. Patent iridotomy did not reduce the intraocular pressure. A-scan ultrasonography was performed which showed aqueous pockets in vitreous, leading to diagnosis of aqueous misdirection syndrome. Medical therapy comprising atropine, 0.5% timolol, mannitol, and acetazolamide was given. Anterior vitrectomy to disrupt un-interrupted anterior vitreous face was carried out to reduce vitreous volume and to reform anterior chamber. Medical and surgical therapy normalized intraocular pressure and resolved symptoms of aqueous misdirection syndrome. Aqueous misdirection syndrome can be a rare and serious complication of Nd:YAG posterior capsulotomy where early recognition is crucial. The role of echographic examination is also emphasized which must be performed as soon as possible

Prevalence and causes of amblyopia in children in a hospital-setting

Purpose of Study: To find out the prevalence and etiology of amblyopia in children

Study design: Case series

Methodology: Children up to 12 years of age coming to department of ophthalmology, Children hospital, Pakistan Institute of Medical Sciences, Islamabad were screened for amblyopia. All strabismic, hypermetropic and anisometropic cases were enrolled in study before starting the amblyopia therapy. Occlusion therapy for management of amblyopia was conducted from July 1992-June 1993. The results of amblyopia therapy will be published in another study

Results: Out of a total of 2,794 patients, 136 cases of amblyopia were identified giving a prevalence of 4.9%. Causes of amblyopia were strabismus in 25%, combined strabismus and anisometropia in 14.0%, ametropia in 4.4%, form deprivation in 38.2% and anisometropia in 18.4%

Conclusion: The prevalence of amblyopia was found to be relatively higher in this age group, which underlines the importance of early screening regimen in children