Anisometropia and ptosis in patients with monocular elevation deficiency

Objective: To determine the effect of ptosis on the refractive error in eyes having monocular elevation deficiency. Study Design: Case series. Place and Duration of Study: Al-Shifa Trust Eye Hospital, Rawalpindi, from January 2011 to January 2014

Methodology: Visual acuity, refraction, orthoptic assessment and ptosis evaluation of all patients having monocular elevation deficiency [MED] were recorded. Shapiro-Wilk test was used for tests of normality. Median and interquartile range [IQR] was calculated for the data. Non-parametric variables were compared, using the Wilcoxon signed ranks test. P-values of <0.05 were considered significant

Results: A total of 41 MED patients were assessed during the study period. Best corrected visual acuity [BCVA] and refractive error was compared between the eyes having MED and the unaffected eyes of the same patient. The refractive status of patients having ptosis with MED were also compared with those having MED without ptosis. Astigmatic correction and vision had significant difference between both the eyes of the patients. Vision was significantly different between the two eyes of patients in both the groups having either presence or absence of ptosis [p=0.04 and p < 0.001, respectively]

Conclusion: Significant difference in vision and anisoastigmatism was noted between the two eyes of patients with MED in this study. The presence or absence of ptosis affected the vision but did not have a significant effect on the spherical equivalent [SE] and astigmatic correction between both the eyes

Tumor regression patterns in retinoblastoma

Objective: To observe the types of tumor regression after treatment, and identify the common pattern of regression in our patients

Study Design: Descriptive study

Place and Duration of Study: Department of Pediatric Ophthalmology and Strabismus, Al-Shifa Trust Eye Hospital, Rawalpindi, Pakistan, from October 2011 to October 2014

Methodology: Children with unilateral and bilateral retinoblastoma were included in the study. Patients were referred to Pakistan Institute of Medical Sciences, Islamabad, for chemotherapy. After every cycle of chemotherapy, dilated fundus examination under anesthesia was performed to record response of the treatment. Regression patterns were recorded on RetCam II

Results: Seventy-four tumors were included in the study. Out of 74 tumors, 3 were ICRB group A tumors, 43 were ICRB group B tumors, 14 tumors belonged to ICRB group C, and remaining 14 were ICRB group D tumors. Type IV regression was seen in 39.1% [n=29] tumors, type II in 29.7% [n=22], type III in 25.6% [n=19], and type I in 5.4% [n=4]. All group A tumors [100%] showed type IV regression. Seventeen [39.5%] group B tumors showed type IV regression. In group C, 5 tumors [35.7%] showed type II regression and 5 tumors [35.7%] showed type IV regression. In group D, 6 tumors [42.9%] regressed to type II non-calcified remnants

Conclusion: The response and success of the focal and systemic treatment, as judged by the appearance of different patterns of tumor regression, varies with the ICRB grouping of the tumor

Ophthalmic manifestations of Linear Nevus Sebaceous/Organoid Nevus Syndrome

Linear Nevus Sebaceous Syndrome [LNSS] is a rare sporadic oculoneurocutaneous disorder, also classified as Organoid Nevus Syndrome. It consists of a triad of midline facial linear nevus sebaceous, central nervous system and ocular abnormalities. To the best of authors' knowledge ophthalmic features of LNSS have never been reported in Pakistani population. We report two cases of LNSS, associated with multiple cutaneous nevus sebaceous lesions, complex ocular choristomas and rare bilateral presentation in one patient. Ocular choristomas included limbal dermoids, dermolipomas at superior fornices and chroidal choristoma. Ocular surface was successfully reconstructed by excision of limbal dermoids, partial keratectomy and amniotic membrane transplant

Ocular features, clinical profile and results of surgical intervention in a series of patients with Port Wine Stain and neurofibromatosis

To describe the ocular features, clinical profile and results of surgical intervention in a series of patients with facial port-wine stain [PWS] and neurofibromatosis [NF] in the pediatric age group. All consecutive patients having PWS and NF presenting between January 2011 and April 2012 were included. Their systemic and ocular features were recorded. Imaging study of brain and orbits was carried out where required. Appropriate surgical interventions were carried out as indicated. These included trabeculectomy, cycloablation, excision of episcleral haemangioma and vitreo-retinal surgery. Patients were followed up for complications and control of intra ocular pressure [IOP]. A total of 9 eyes of 8 patients were included. At presentation IOP in the involved eye ranged from 6 to 42 mmHg [mean 25.00 +/- 12.23]. Glaucoma was present in 6 eyes. Episcleral haemangioma was noticed in one patient, retinal detachment [RD] was seen in 2 patients. Diffuse choroidal thickening on B scan was noted in 5 eyes of patients with PWS. After applying the appropriate management option, IOP on last follow up ranged from 6 to 24mmHg [mean 13.44 +/- 5.43] in the involved eye the last follow up ranged from 6 to 24mmHg [mean 13.44 +/- 5.43] in the involved eye. The difference between IOP of the involved eyes at initial presentation and that recorded at the last follow-up was significant [p=0.005]. Patients with SWS and NF present with varied clinico-ocular profiles and therapeutic interventions are individualized according to the ocular involvement. Post operative complications after treatment of glaucoma in such patients can largely be prevented with special measures taken per-operatively

Factors associated with breast arterial calcification on mammography

To determine the frequency of breast arterial calcifications [BAC] as seen on mammographic examination and to determine the association between BAC and hypertension, age, parity and weight of the person. Cross-sectional analytic study. Department of Diagnostic Radiology, Military Hospital, Rawalpindi, from January 2006 to January 2007. Two hundred patients undergoing mammography were studied to evaluate the association of BAC with raised blood pressure, age and parity. Previous history of lactation and the patients' weight were also recorded. Proportions of classes were compared using chi-square test. 13.5% of the subjects [n = 200] were positive for BAC on mammograms. Mean age of the BAC positive subjects was higher than their counterparts found negative for BAC. Women bearing 5 - 6 children showed the highest frequency of BAC. Seventy seven [10.38%] of the BAC positive cases had previous history of lactation, whereas 15.44% [n = 123] had not breast fed their children and showed BAC. No significant association of presence of BAC was noted with the weight of the subjects. The frequency of presence of BAC on mammography was associated with systemic hypertension and higher age. It also increased with the reproductive parameters of a woman

Clinical course of retinoblastoma

To determine the clinical manifestations and results of current treatment for patients with retinoblastoma [Rb] in a tertiary care eye hospital in the north west of Pakistan. Case series. Al-Shifa Trust Eye Hospital, Rawalpindi, Pakistan, from January 2006 and December 2009. The data of 139 patients diagnosed as having retinoblastoma was collected. Gender, age at diagnosis, laterally, presenting sign, classification of tumour, treatment modality and outcome were noted. The mean age of presentation in this patients ranged from 6 to 50 months [mean: 24.05 +/- 10.74 months] The most common presenting sign was leucocoria in 78 eyes [44.1%]. One hundred and one [72.7%] patients had unilateral retinoblastoma. Using the International Classification of Retinoblastoma [ICRB], 135 [76.3%]eyes were placed in group-E. one hundred and twenty four [77.5%] eyes were enucleated or exenterated while globe preservation was achieved by chemoreduction and/or focal therapy in the rest of the treated eyes [n = 36, 22.5%]. Twenty three [16.5%] cases were lost to follow-up before one year. Ninety two [66.2%] patients survived, being free of tumour, at least one year after the completion of treatment. Most children with Rb showed an advanced stage of tumour at the time of diagnosis. Measures to improve the rate of globe preservation and patient survival by early diagnosis and intervention are the need of the hour

Effects of Artisan aphakic intraocular lens on central corneal thickness and intra ocular pressure in pediatric eyes with crystalline subluxated lenses

To study effects of Artisan iris fixated intraocular lens [IOL] on central corneal thickness [CCT] and intraocular pressure [IOP] in pediatric eyes with crystalline subluxated lenses. The study included 17 eyes undergoing Artisan aphakic IOL implantation after lensectomy for subluxated crystalline lenses. CCT and IOP measurements were recorded pre-operatively and post-operatively taking the mean of 4 post-operative visits. Patients were divided into Group A [n = 8] including patients with lensectomy and iris fixation of Artisan IOL as a primary procedure and Group B [n = 9] including patients in which lensectomy was carried out as a primary surgery and Artisan IOL fixation as a secondary procedure. Children ranged in age from 08 years to 16 years, mean 11.59 +/- 2.96 years. Follow-up period ranged from 7 months to 16 months, mean 11.24 months +/- 4.27. Mean pre-operative and post-operative IOP in Group A was 14.88 +/- 2.80 and 14.16 +/- 0.59 respectively [P = 0.528]. In Group B it was 12.44 +/- 2.79 and 14.44 +/- 1.15 respectively [P = 0.080]. Mean pre-operative and post-operative CCT in Group A was 529.13 +/- 24.23 and 529.87 +/- 17.46 respectively [P = 0.674]. In Group B it was 567.33 +/- 29.13 and 568.83 +/- 25.69 respectively [P = 0.859]. Primary and secondary Artisan aphakic IOL implantation did not cause any significant changes in corneal thickness or IOP during the follow-up period

Monocular elevation deficiency with associated dextrocardia and situs inversus

A patient having monocular elevation deficiency with associated dextrocardia and situs inversus is reported. Review of the literature regarding ocular features described in association with dextrocardia is also presented

Visual outcome of scleral fixation of posterior chamber intraocular lens in eyes with inadequate capsular support

To evaluate visual outcome and complications of scleral fixation of posterior chamber intraocular lens [SF-IOL] in eyes with inadequate capsular support. This is a prospective case series which consists of eighteen eyes of 13 patients. These were divided into group A having traumatic subluxation of lens or inadequate posterior capsular support and group B with idiopathic, familial and syndromic ectopia lentis having zonular weakness more than 180[degree]. Lensectomy and SF-IOL was performed. Best corrected visual acuity [BCVA], intraocular pressure [IOP], intraocular lens [IOL] positioning, anterior and posterior segment examination was performed on every follow up visit. Mean age was 15.05 +/- 8.99 years. Mean follow up was 18.88 months +/- 15.07. Mean preoperative logMAR BCVA in 18 eyes was 0.93 +/- 0.76 and mean postoperative log MAR BCVA was 0.41 +/- 0.24[p=0.01]. Mean postoperative logMAR BCVA in group A was 0.27 +/- 0.27 and group B was 0.48 +/- 0.20. Twelve eyes [66.7%] did not show complications. Fourteen eyes [77.8%] did not require second surgery after SF-IOL. SF-IOL is a safe procedure in eyes with inadequate posterior capsular support and ectopia lentis with more than 180[degree] of zonular weakness.

Post operative refractive outcomes in scleral fixated intraocular lenses

Purpose: To compare the predicted and actual postoperative refractive outcomes in patients with scleral fixation of intra ocular lenses [SF-IOL]

Subjects and Methods: 20 eyes of 14 patients having inadequate posterior capsular support were included in the study. The pre operative spherical equivalent was recorded and patients were divided into 2 groups on the basis of hyperopic [pupil mostly rendered aphakic] or myopic refractive error [milder subluxation with phakic part in visual axis]. SF-IOL was implanted and group wise comparison was made with spherical equivalent of post operative refractive error. Target refraction and actual post operative refraction were also compared between these groups. Similarly the change in astigmatic correction was also compared

Results: In the group of patients having preoperative myopic refractive error due to subluxated lens still in the pupil area this difference was 1.100 +/- 2.157 diopters. It was 1.207 +/- 1.465 diopters in the group of patients having pre operative hyperopic refractive error due to aphakic pupil area. Comparison of target refraction and actual post operative spherical equivalent between these groups was not statistically significant [p=0.384 and p=0.039 respectively]. Pre operative cylinder correction in the myopic group ranged from 0.00 to -6.0 DC [mean -1.00 +/- 2.23DC] compared to post op cylindrical correction in this group ranging from -1.0 to 1.50 DC [mean 0.14 +/- 1.18 DC] with p=0.328. The preoperative astigmatic correction in the hypermetropic refraction group ranged from 0.00 to 1.5 [mean 0.13 +/- 0.45 DC] compared to post operative reading ranging from 0.00 to -5.0 [mean -1.75 +/- 1.85 DC] with a significant difference of p=0.009

Conclusion: Our study shows a moderate agreement between the predicted and actual postoperative refractive result in children with SF-IOL

Toxic optic neuropathy and bilateral symmetrical putamen infarcts

The presented case describes the correlation of ocular findings with those of neuroimaging in a patient having a history of methanol ingestion prior to development of painless loss of vision

Comparison of recurrence rate in recurrent pterygium excision with conjunctival autograft and Mitomycin C application

Purpose: To compare the rate of recurrence in recurrent pterygium excision with conjunctival autograft and Mitomycin C application

Subjects and Methods: A comparative study was done over a period of one year, at Al-Shifa Trust Eye Hospital, which is a tertiary care eye hospital in Rawalpindi. Patients between 16 and 65 years of age were included in the study. They were divided into two age groups, one ranging from 16 - 40 years and the other ranging from 41-65 years. A total of 50 patients with recurrent pterygium were operated. Half of the patients were treated with Mitomycin C [MMC] application and half with free conjunctival autograft [CAGT] from the superotemporal bulbar conjunctiva of the same eye by one surgeon. All patients were followed up to 6 months after the surgery

Results: Both of the procedures showed a lower recurrence rate i.e. 16% with CAGT and 12% with MMC

Conclusions: Males showed more recurrences in both groups as compared to females. Younger age group is more susceptible to recurrences as compared to older age group. Most of the recurrences occurred within 6 to 12 weeks of surgery

Distribution of corneal haze after Photorefractive Keratectomy in myopic eyes

Objective: To assess the incidence and distribution of corneal haze after photorefractive keratectomy [PRK] in low, moderate and high myopia in Pakistani population

Study Design: A prospective interventional study conducted during one year at Al-Shifa Trust Eye Hospital, Rawalpindi

Participants and Methods: Excimer laser PRK was performed on 118 eyes of sixty patients. 84 corneas were treated with multizone PRK in a single step, using three zones. Standard PRK was performed on 34 corneas. Cases were followed up to three to six months. Haze was graded subjectively on a scale of 1 to 4

Results: At the end of six months after PRK, one [8.34%] eye from low myopia group, 2 [5.71%] eyes from moderate myopia group and 6 [13.96 %] eyes from high myopia group had grade 1 corneal haze. Grade 2 corneal haze was found in 5 [14.30%] eyes from moderate myopia group and 6 [13.96%] eyes from high myopia group. Similarly 4 [11.42%] eyes and 10 [23.25%] eyes had grade 3 corneal haze from moderate and high myopia groups respectively. Grade 4 corneal haze developed in 21 [48.83%] eyes in high myopia group. The eyes undergone single zone PRK required deeper ablations with relatively denser postoperative corneal haze as compared to the eyes treated with multiple zone PRK

Conclusion: It is concluded that deeper the ablation required to correct myopia higher the incidence of corneal haze. Haze can be reduced by using such techniques which would correct more degrees of myopia with less depth of ablation

Cyclic oculomotor spasm and third nerve palsy

In the present report, cyclic oculomotor spasm occurring in a patient with third nerve paresis is described, which is a rare occurrence. An 11 year old female presented with decreased vision of the right eye and drooping of the right upper lid since early childhood. Third nerve paresis was seen with limited adduction and elevation. During examination the right exotropic eye became esotropic, over which the patient had no voluntary control. After orthoptic assessment, right superior oblique resection and transposition close to the medial rectus, with a large lateral rectus recession was done

Hemifacial spasm in an infant

Hemifacial spasm in infants is a rare condition. An 8 months old female patient was noticed to have contraction of right side of the face by her mother. Her anterior segment and fundus examination were within normal limits. No neurological signs were present apart from the hemi facial spasm that occurred multiple times daily. She was advised follow up, to monitor the disease and assess need for any imaging studies

Low vision rehabilitation for patients with Age-related Macular Degeneration

To assess the effectiveness of low vision rehabilitation in the management of age related macular degeneration. The study was carried out at Al-Shifa Trust Eye Hospital Rawalpindi. All consecutive newly diagnosed patients of both sexes, 55 years of age and above, with observable lesions of age-related macular degeneration [AMD], presenting to the retina clinic, over a period of one year were included in the study. Patients having best corrected visual acuity less than 6/18 in the better eye were referred to the low vision clinic. During the duration of study 79 patients presenting to the retina clinic met the inclusion criteria. Lesions gradable as early AMD were found in 54 eyes and those graded as late AMD were found in 69 eyes. Twenty four [30%] patients received intra vitreal therapy with anti-vascular endothelial growth factor [Bevacizumab] +/- Triamcinolone acetonide and/or Argon laser treatment. Thirty seven [47%] patients were referred to the low vision clinic, while 18 [23%] patients were taught self-monitoring of symptoms and kept under observation. Appropriate low vision aids were used in 37 patients. Extremely statistically significant improvement in near vision was seen from mean 14M to 4M [p <0.0001] in 36 patients. Low vision aids improve residual visual function in patients of AMD, more so for near. The patients are able to continue most of the usual activity of their daily life

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

Late bilateralization of retinoblastoma -a case report

We report the growth, clinical course and laser treatment of retinoblastoma in the fellow eye of a patient seen at an interval of 9 years after one eye was enucleated for retinoblastoma at the age of 3 months