Intravascular and Extravascular Migratory, Metastatic Melanoma of the Great Saphenous Vein

Melanoma blood vessel metastases are very uncommon. Wereport this very rare case of metastatic melanoma along thewall of great saphenous vein (GSV), showing intra and extravascular metastasis. By far only a single case of intravascularmetastatic melanoma (IVMM) of GSV and thirty six cases ofextravascular migratory metastatic melanoma (EVMM) ofGSV have been reported. In our case melanoma cells wereseen both inside and outside of the wall of GSV, and in thedermis. A 60 years old male presented with multiple swellingsupper left thigh since one and a half year. Patient wasoperated. All swellings, along with, part of saphenous vein tillthe knee, and small part of skin were excised under GA.Microscopically, hematoxylin and eosin sections given fromvarious sites showed features of malignant melanoma. Tumorcells were seen in the dermis, and the lumen, as well asoutside the wall of saphenous vein, but not in the epidermis.Only very few melanocytic granules were seen in a singlearea of a section. On Immunohistochemistry –, MarkersHMB45, S100 and Vimentin are strong immunoreactive. CKPAN was focal immunoreactive.In our case the melanoma spread along the wall of the GSV.This pericytic angiotropism of melanoma cells, also showingsigns of intravasation, which suggests that melanomacells may migrate along the external surface of vessels, amechanism termed ‘EVMM and also by invading the bloodvessels ‘IVMM’.

Histopathological Patterns of the Testicular Biopsies and its Role in the Evaluation of Infertility Among Azoospermic Male Patients: A Hospital Based Study From Northern India

To identify and categorize various pathological patterns seen in testicular biopsies of azoospermic males along with their Johnson’s score and to evaluate the importance of the histological examination of testicular biopsies for further clinical planning. Methods: The study was conducted in the Department of Pathology of Mahatma Gandhi Medical College and Hospital, Jaipur, India. Slides prepared from testicular biopsies either unilateral or bilateral (received between January 2003 to December 2012), of 135 patients who had azoospermia on routine semen analysis were retrospectively retrieved and reviewed. Various histopathological patterns were evaluated and categorized and were graded according to the Johnson’s scoring. If more than one histological pattern was noted in the same testicular biopsy it was called as ‘Mixed pattern’ whereas if the right and left testes showed different histological pattern it was called as ‘Discordant pattern’. Results: A total of 152 testicular biopsies were collected from 135 patients (118 patients with unilateral and 17 patients with bilateral testicular biopsies). All the patients had azoospermia on routine semen analysis. The age of the patients ranged from 20 to 51 years. The most common histological pattern observed was Normal spermatogenesis (35.56%) followed by Sertoli cell only syndrome (23.70%) and Germ cell maturation arrest (20%). Hypospermatogenesis and Seminiferous tubule hyalinization was seen only in 2.96% and 2.22% of the cases respectively. Conclusion: This study has shed some light on the possible underlying etiologies of primary male infertility and emphasizes the need for bilateral testicular biopsies and on meticulous pathological examination of all seminiferous tubules in order to identify mixed and discordant patterns. The data extrapolated from our study can serve as a template for better management of primary male infertility and will optimize the advanced therapeutic modalities for the infertile couples.

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

Evaluation The Discomfort Level For Students Polytechnic Kuching Sarawak Sitting On Chairs

This study was conducted to evaluate the discomfort level of students from the Polytechnic Kuching Sarawak while they were sitting on chairs. Polytechnic Kuching students (n=500) completed a set of questionnaires utilizing a survey form which showed the body chart discomfort using Borg’s CR-10 Scale. The students was asked to identify body areas experiencing discomfort and to rate this discomfort using score rating groups (0 to 5) where score 0-1.99 = No discomfort (1), score 2.00-3.99 = Discomfort (2) and score 4.00-5.00 = Very uncomfortable (3). The evaluation of seating discomfort levels showed acceptable levels for the students and possible outstanding problems. Students were asked to rank over an order 10 statements about comfort and choose three responses which gave the most consistent equal interval scale. The results showed that the main response of discomfort indicated the students felt cramped, stiff, numb, sore and tender muscle, unbearable pain, barely comfortable and uncomfortable. This project was identified to evaluate the comfort level for classrooms chairs of polytechnic students. Overall, there was a significant discomfort level for the students whilst sitting on chairs and a possible solution put forward is to design a new type of classroom chair made of natural fibre reinforced composite.

Comparison of pre-operative central corneal thickness in pediatric cataract cases versus normal

To compare the pre-operative central corneal thickness [CCT] in paediatric cataract patients with reference to normal control group. A case control study. Paediatric Ophthalmology Clinic of Al-Shifa Trust Eye Hospital [ASTEH], Rawalpindi, from November 2009 to May 2010. The study included 116 subjects with equal number of cases and controls. Demographic profile of all the subjects was noted followed by history and detailed ophthalmic examination. CCT was measured using an ultrasonic pachymeter [model Pac Scan 300]. The mean of three measurements from the central cornea were recorded in microns. Results were analyzed using SPSS version 17.0. Mean CCT values of the cases was 566.83 +/- 37.646 microns while the control group had a mean CCT of 535.81 +/- 24.466 microns. Difference between the CCT values of the two groups was highly significant [p < 0.001]. Eyes with congenital cataracts have greater CCT values as compared to normal paediatric population. This factor must be kept in mind while interpreting intra-ocular pressure in such patients

[ survey on the effect of ultrasonic method on dewatering of bio sludge in wastewater treatment plant]

Background: Disintegration and dewatering of produced sludge during wastewater treatment is one of the main challenges in wastewater treatment process. The aim of this study is to investigate the efficiency of ultrasonic method on dewatering of bio sludge in wastewater treatment plant under different conditions and select the best conditions.

Materials and Methods: In the present study, sludge disintegration and sludge dewatering after undergoing different conditions of frequency [35 and 130 KHz] and detention time [3, 5, 10 and 30 min] were investigated and finally the changes of SCOD, CST and SRF were determined.

Results: The results illustrated that the maximum ability of dewatering was obtained at a detention time of 5 min and frequency of 35 KHz for ultrasonic. Under this conditions SCOD%, CST and SRF were achieved to 4.3%, 151 S and 2.1×1013 m/kg respectively.

Conclusion: According to the results, ultrasonic method significantly increases the sludge disintegration and improves the sludge dewatering.

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

Correlation between contrast sensitivity and visual fields in patients with primary open angle glaucoma

To investigate effect of glaucoma on contrast sensitivity and to assess the relationship between contrast sensitivity and visual field loss in patients of primary open angle glaucoma. Cross-sectional case series. 24 patients from glaucoma department at the Al-Shifa Trust Eye Hospital Rawalpindi were evaluated. Subjects with diagnosis of glaucoma having visual acuity 6/12 or better were recruited. Visual acuity was measured using the standard Snellen Acuity chart at 6m. Contrast sensitivity was measured using the Pelli- Robson Chart .Visual fields of the patients were analyzed using the 30-2 full threshold program on the Humphrey Visual Field Analyzer. A total of 46 eyes were studied of 24 patients. Out of which male patients were 67% and females were 37%. The Pelli- Robson contrast sensitivity score correlated more strongly with the MD of the visual fields[r=-0.615, P<0.001]. For the PSD of the visual fields, the correlation was r=-0.453, P=0.003. Reduced contrast sensitivity is significantly correlated with visual field loss in patients with primary open angle glaucoma. The study data supports the conclusion that the disease process affects contrast sensitivity

Clinical indications of enucleation surgery

Purpose: To determine the clinical indications of enucleation surgery at Al-Shifa Trust Eye Hospital Rawalpindi

Participants and Methodology: An observational case series was carried out for the study being conducted at Al-Shifa Trust Eye Hospital, Rawalpindi in which 60 new cases undergoing enucleation during 6 months were included by non probability convenience sampling

Results: There were 31[51.7%] male and 29 [48.3%] female patients with a mean age of 23.51[SD 19.546] years. Malignant tumours [41.66% eyes] were the most common indication of enucleation followed by phthisis bulbi [23.33% eyes] and trauma [16.7% eyes]. Retinoblastoma [RB] was found to be the most common malignant tumour diagnosed in 20% eyes. Students comprised 28.33% of the cases followed by farmers / laborers [23.33%] and housewives [13.33%]. In terms of socioeconomic status 37 [61.66%] patients belonged to lower class

Conclusion: Advanced ocular malignancies, phthisis bulbi and traumatically shattered eye globes are the major indications for enucleation in our country. Protective measures from trauma, early detection of tumours and creating awareness at various levels can decrease the incidence of enucleation

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

Role of intravitreal bevacizumab [avastin] in the treatment of clinically significant macular edema

To determine efficacy of single intravitreal injection of bevacizumab [Avastin] for treatment of clinically significant macular edema [CSME]. A quasi experimental month study was carried out at the retina clinic of Al Shifa Trust Eye Hospital, Rawalpindi from 1[st] January 2010 to 31[st] December 2010. A total 107 patients with CSME were included in this study. All patients were evaluated for visual acuity, anterior and posterior segment while central macular thickness was documented through optical coherence tomography. A single injection of bevacizumab was administered in all the patients. Outcome measures [improvement in BCVA and decrease in central retinal thickness] were evaluated at 2 weeks, 1 month and 2 months. All except one patient completed 2 months of follow-up. At baseline mean BCVA +/- SD was 0.967591 +/- 0.3705 log MAR of Snellen letters, which significantly improved to 0.808525 +/- 0.3260 at 2 weeks, 0.65581 +/- 0.36078 at 1 month, and 0.6319 +/- 0.3900 at 2 months [for each, p-value < 0.05]. The mean central retinal thickness +/- SD was 502.60 +/- 81.622microm at baseline and significantly decreased to 307.69 +/- 82.306 microm at 2 weeks, 235.75 +/- 63.162 microm at 1 month, and 237.58 +/- 64.230 microm at 2 months [for each, p-value < 0.05]. Primary single intravitreal bevacizumab injection in a concentration of 1.25mg / 0.05ml in patients with CSME resulted in significant improvement in BCVA and central macular thickness as early as 2 weeks after injection, and this beneficial effect persisted for up to 2 months

Retinal thickness evaluation in healthy eyes from north-west Punjab through optical coherence tomography

To determine the mean retinal thickness in healthy eyes from north-west Punjab through commercially available optical coherence tomography [OCT] mapping software, version 3.0, from the Stratus OCT [OCT3]. Descriptive study. Al-Shifa Trust Eye Hospital, Rawalpindi, from August 2008 to February 2009. One hundred and two eyes of 75 healthy north-west Punjabis, fulfilling inclusion criteria were enrolled from OPD of Al-Shifa Trust Eye Hospital. After informed consent, demographic detail was taken. Best-corrected Snellen visual acuity was recorded. OCT was performed by using Stratus Carl Zeiss OCT through dilated pupil by an experienced operator. The retinal thickness was divided into 9 sections and displayed as three concentric circles including a central circle at fovea [1 mm], an inner ring [3 mm] and an outer ring [6 mm], each ring being divided into four quadrants. OCT parameters of macular thickness were analysed with baseline variables including age, gender and best corrected visual acuity. The mean central foveal thickness [at foveola] was 166.30 +/- 24.95 micro m while the mean foveal thickness [in central 1000 microns] was 194.89 +/- 21.33 micro m. There was no correlation between macular thickness and either age [r=0.109, p=0.275] or gender [Eta=0.128] or best corrected visual acuity [Eta=0.234]. Reference values were determined for mean retinal thickness in healthy eyes from north-west Punjab through OCT. These measurements were upto 54-micro m higher and upto 29 micro m lower than some previously reported healthy retinal thickness values. Therefore, normative database should be determined for the population under study based on regional and ethnic differences

Knowledge of depression among community members and health care providers in two selected areas of district Rawalpindi

To determine the level of knowledge about depression in two selected areas of district Rawalpindi. Cross-sectional survey report. Union council Rehmatabad and mohalla Sultanpura, Rawalpindi, from June to December 2007. Strata of community were interviewed regarding the knowledge about depression using an indigenously developed questionnaire. To determine any association between difference of level of knowledge and different strata of community Chi-square [X][2] tests was applied at 5% level of significance and p-value less than 0.05 was considered significant. Most of the respondents [63%] thought that diabetes was the major health problem in our country. Most of participants thought that drug abuse and addiction [74.3%], adolescent emotional and behavioral problems [66.8%] followed by alcohol abuse [50.3%] and personality disorders [49.2%] were the common mental illnesses. Chi-square [X][2] statistics showed a highly significant association between difference of level of knowledge and the two strata of community i.e. health care providers and community members [p < 0.001]. People in the selected areas of district Rawalpindi had a poor knowledge about depression

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

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

visual outcomes and complications of intraocular lens implantation in children aged 1 year or less

To present the visual outcomes and complications of intraocular lens [IOL] implantation in children aged 1 year or less. A total of 30 consecutive eyes of 19 children undergoing cataract removal combined with IOL implantation at less than I year of age were evaluated. SRK-T formula was used to calculate the IOL power and emmetropic power was under corrected by 20%. After aspiration of the lens matter and posterior capsule polishing, acrylic hydrophilic foldable or PMMA rigid IOL was implanted by a paediatric Ophthalmologist. Visual acuity, refractive status and postoperative complications were recorded throughout the 12 months of follow up. Data was analyzed using SPSS version 13.0, Out of 19 children, 8 [42.1%] had unilateral cataract [8 eyes], and 11 [57.9%] had bilateral cataracts [22 eyes]. Mean age at the time of surgery was 8.7 [ +/- 2.5] months. Foldable IOL implantation in capsular bag was achieved in 17 [56.7%] eyes while sulcus fixation of IOL was done in 13 [43.3%] eyes. Mean post-operative refraction was +5.97 [ +/- 2.60] DS. Postoperative fibrinous reaction was seen in 4 [13.3%] eyes, visually significant PC0 requiring surgical posterior capsulotomy developed in 2 [6.66%] eyes while 24 eyes [80%] retained a clear visual axis during the follow up period. Lens matter aspiration combined with IOL implantation in children less than 1year of age resulted in better visual outcomes with acceptable risk to benefit ratio. 101, power calculations and refractive outcomes were predicted satisfactorily using SRK-T formula with 20% under correction

Mono therapy versus double therapy versus triple therapy in the treatment of diabetic macular edema

To compare the efficacy of macular laser photocoagulation [MPC] alone or MPC with intravitreal Bevacizumab or MPC with both intravitreal bevacizumab and intravitreal triamcinolone as primary treatment of Diabetic macular edema [DME]. A randomized clinical trial. Fifty eyes of 30 patients with clinically significant DME and no previous treatment were enrolled. The eyes were randomly assigned to one of three treatments groups. In Group-1, 20 eyes underwent focal or modified grid laser, In group-2, 15 eyes received 1.25 mg / 0.05ml of intravitreal bevacizumab [IVB] followed by MPC while in group-3, 15 eyes received 1.25 mg / 0.05ml of IVB and 2 mg / 0.05ml of intravitreal triamcinolone [IVT] followed by MPC. At 12 weeks after treatment, average improvement of visual acuity in group-1 was 1.0 line, in group-2 was 1.5 lines and in group-3 was 2.0 lines. Average central macular thickness reduction was significantly more [p=0.001] in group-3 [354 +/- 110 [micro]m] than in group- 1 [1 67 +/- 57 [micro]m] and group- 2 [278 +/- 76 [micro]m]. Up to 12 weeks triple therapy group showed better visual outcome than the other two groups where as the average reduction in central macular thickness was also more in triple therapy group. Further clinical trials with longer follow-up are required to evaluate the long-term visual outcomes and complication profiles after this treatment

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