Correlation of intraocular pressure with ocular axial length after intravitreal injection of bevacizumab in diabetic macular edema

Objective: To determine the effect of Intravitreal injection of Bevacizumab on IOP in eyes of different axial lengths. Study Design: Cross sectional study. Place and Duration of Study: This study was conducted at AFIO Rawalpindi, from Sep 2013 to Jan 2014

Material and Methods: In this study 55 patients scheduled for intravitreal injection of bevacizumab for the treatment of diabetic macular edema were enrolled. An informed written consent was taken from all the patients. All patients underwent clinical ophthalmic examination including uncorrected distance visual acuity, corrected distance visual acuity, slit lamp bio-microscopy and fundus examination with 90 diopter lens. Axial length was measured before IVB using IOL master. Intra Ocular Pressure [IOP] was measured before and after 1 minute of administration of Intravitreal Bevacizumab [IVB] using Tono-Pen

Result: The mean age of patients was 54.51 +/- 7.53 years with minimum age of 43 years and maximum age of 70 years. There were 26 [47.3%] male and 29 [52.7%] female patients. The mean axial length of the examined eyes was 21.12 +/- 1.80 with range of 6 mm. Mean IOP before IVB was 13.09 +/- 1.62 mmHg. After 1 minute of IVB, mean IOP was 32.8 +/- 6.19 mmHg. A good correlation was observed between the axial length and intraocular pressure rise after 1 min i.e. Pearson correlation [r.] = -0.914 [p-value <0.001] with R2 = 0.835

Conclusion: There is significant rise in IOP after intravitreal injection of bevacizumab in patients with short axial length as compared to long axial length

Effect on Corneal Dioptric power in patients undergoing 23G Suture less plana vitrectomy

Objective: To determine the effect of 23-gauge pars plana vitrectomy on corneal dioptric power through a comparison of difference in pre- and post- surgery keratometry

Study Design: Prospective non-comparative interventional type

Place and Duration of Study: The study was conducted at the Armed Forces Institute of Ophthalmology [AFIO] Rawalpindi from Dec 2016 to Jul 2017

Material and Methods: We studied 33 patients [33 eyes] who underwent 23-gauge vitrectomy with mean age of 46.4 +/- 12.8 years. Among them 13 were females and 20 were males. These patients were divided in four groups on the basis of pre-surgical diagnosis. 18 [55%] patients had rhegmatogenous retinal detachment, 9 [27%] had macular holes 3 [9%] with Vitreous hemorrhage and last 3 [9%] had dislocation of intraocular lens. Total vitrectomy was performed in all patients by standard 23G pars plana vitrectomy [PPV] procedure as used with three scleratomies and tunnel shaped incision. Keratometry readings before the surgery and at the end of 1st, 6th and 12th post procedural weeks were recorded in horizontal [K1] and vertical meridian [K2] by utilizing topcon auto kerato-refractometer

Results: The pre-operative dioptric power of cornea in horizontal and vertical meridian [K1 and K2 respectively] was statistically compared with post- operative dioptric power of cornea at the end of 1st, 6th and 12th postoperative weeks. At the end of first post- operative week there was significant difference between pre and post-operative corneal dioptric power with horizontal p-value<0.05 and vertical <0.04; leading to astigmatism. However, at the end of 6th and 12th post procedural weeks there was no significant difference between pre and post-operative corneal dioptric power which is evident with insignificant p-values. The p-value at the end of 6[th] post-operative week was 0.521 and 0.57 for K1 and K2 respectively. At the end of 12th post-procedural week these values are 0.854 and 0.941 for K1 and K2 respectively. Clinically these patients did not have any sign or symptoms of astigmatism

Conclusion: 23G was found safe procedure in vitreoretinal surgery with no insignificant change in corneal dioptric power except in cases in which silicone oil was used. However, due to small study group and short follow up further studies with longer follow-ups are required to establish the long-term changes in corneal dioptric power after 23G suture less vitrectomy

Efficacy of intravitreal bevacizumab combined with pan retinal photocoagulation versus panretinal photocoagulation alone in treatment of proliferative diabetic retinopathy

Objective: To compare effectiveness of pan-retinal photocoagulation alone versus panretinal photocoagulation combined with intravitreal bevacizumab on visual acuity and central macular thickness in patients presenting with proliferative diabetic retinopathy

Methods: This Randomized controlled trial was carried out at Armed Forces Institute of ophthalmology, Pakistan from Jan 2016 to Aug 2016. Seventy six eyes of 50 patients having proliferative diabetic retinopathy and diabetic macular edema were included in the study. All the patients were subjected to detailed clinical examination that included Uncorrected visual acuity [UCVA], best corrected visual acuity [BCVA], slit lamp examination of anterior and posterior segments. Optical coherence tomography [OCT] and fundus fluorescein angiography [FFA] were carried out and patients were divided in two groups [GP and GI]. Three monthly sessions of Pan retinal photocoagulation [PRP] using Pattern Scan Laser [PASCAL] alone was performed in group GP while PRP along with three monthly intravitreal bevacizumab [IVB] was performed in group GI. BCVA and CMT was recorded 04 weeks after the third PRP session in both the groups

Results: Seventy six eyes of 50 patients [38 in each group] were treated with three sessions of PRP alone and PRP with IVB in Group GP and GI respectively. Mean age of the patient in group GP was 57.47 +/- 6.08 years while that in group GI was 55.69 +/- 6.58. The magnitude of induced change in BCVA was 0.09 +/- 0.15 in GP while 0.22 + 0.04 in GI groups while mean induced change in CMT after treatment was 77.44 +/- 92.30 um and 117.50 +/- 93.82 um in group GP and GI

Conclusion: Laser PRP combined with IVB has superior visual and anatomical outcome than PRP alone in patients with combined presentation of PDR and DME

Comparison of clinical characteristics of rhegmatogenous retinal detachment in pseudophakic and phakic eyes

Objective: To compare the clinical profile, systemic risk factors, and characteristics of rhegmatogenous retinal detachment [RRD] in pseudophakic and phakic eyes

Study Design: Cross-sectional comparative study

Place and Duration of Study: Armed Forces Institute of Ophthalmology, Rawalpindi from August 2013 to August 2015

Methodology: A total of 164 eyes [96 pseudophakic patients and 68 phakic patients] with RRD were analyzed. Demographic data and associated known risk factors of study population were acquired. Retinal examination was done by single experienced retinal surgeon using indirect ophthalmoscopy for type of retinal break, location and number of retinal breaks, status of macula, morphological extent of RRD and retinal degenerations. All the findings were endorsed on a pre-devised proforma

Results: Mean age of patients in pseudophakic and phakic groups was 61.18 +/- 10.39 and 59.27 +/- 9.57 years, respectively. Frequency of male patients in pseudophakic and phakic groups was 74% and 57.4%, respectively. Mean axial length in pseudophakic and phakic groups was 23.13 +/- 2.18 mm and 21.9 +/- 2.01 mm, respectively. Difference in axial length and gender distribution between two groups was statistically significant [p < 0.05]. Difference in frequency of patients with history of hypertension and myopia between two groups was statistically significant [p < 0.05]. Characteristics of RRD [type, location and number of retinal breaks, macula status, and extent of RRD] between groups were not statistically significant

Conclusion: RRD is more common in pseudophakic patients with male gender, increased axial length, myopia, and hypertension

Comparison of effect of silicon oil on central corneal thickness and corneal endothelial-cell density

Objective: To compare the mean changes in central corneal thickness [CCT] and corneal endothelial-cell density [CED] after removal of silicon oil [ROSO] using anterior [limbal] versus posterior [pars plana] approach in aphakic patients following successful retinal re attachment surgery

Study Design: Randomized controlled trial

Place and Duration of Study: Armed Forces Institute of Ophthalmology [AFIO] Rawalpindi, from Dec 2014 to Aug 2015

Material and Methods: Sixty eyes of 60 aphakic patients who underwent removal of silicon oil from December 2014 to August 2015 in AFIO after successful retinal re-attachment surgery were analysed. Thirty eyes underwent removal of silicon oil through anterior [limbal] approach [groupl] and 30 eyes through posterior [pars plana] approach [group-2]. Pre-operative central corneal thickness and corneal endothelial-cell density was measured and compared with central corneal thickness and corneal endothelial-cell density measurements 3 months after removal of silicon oil

Results: Mean age of study population was 49.93 +/- 5.18 years. Both groups were age and sex matched [p=0.694 and p=0.80 respectively]. In group 1, mean change in CCT was 1.80 +/- 6.58 micro meters [jum] and mean change in CED was 196.30 +/- 33.78 cells per millimetres square [mm[2]], while in group 2, mean change in CCT was 1.63 +/- 8.96 microm and mean change in CED was 60.20 +/- 39.75 cells/mm2 after 3 months of ROSO. Mean change in CCT between two groups was not statistically significant [p=0.935], however, mean change in CED between two groups was statistically significant [p<0.001]

Conclusion: Removal of silicon oil through anterior [limbal] approach causes significant reduction in CED, as compared to posterior [pars plana] approach in aphakic patients following successful retinal re attachment surgery

Change in central corneal thickness, corneal endothelial cell density, anterior chamber depth and axial length after repair of rhegmatogenous retinal detachment

Objective: To compare the effects of Pars Plana Vitrectomy [PPV] and Scleral Buckling [SB] with reference to Central Corneal Thickness [CCT], Corneal Endothelial-Cell Density [CED], Anterior Chamber Depth [ACD] and Axial Length [AL] in repair of Rhegmatogenous Retinal Detachment[RRD]

Methods: This comparative cross sectional analytical study was conducted at Armed Forces Institute of Ophthalmology [AFIO], Rawalpindi from July 2013 to July 2015. A total of 69 eyes of 69 patients which underwent repair of RRD by either PPV or SB were analyzed to compare mean change in CCT, CED, ACD and AL between two groups

Results: Mean age of patients was 56.23+/-5.22 years. Mean pre-operative CCT, CED, ACD and AL in PPV group was 533.06+/-13.28micro m, 2231.67+/-164.57Cells/mm[2], 3.37+/-0.18mm and 23.66+/-0.76mm respectively. Mean post-operative CCT, CED, ACD and AL in PPV group was 534.81+/-11.83micro m, 2037.19+/-167.83 Cells/ mm[2], 3.24+/-0.13mm and 23.88+/-0.80mm respectively. Change in CED, ACD and AL from pre-operative value after PPV was statistically significant [p<0.001]. Mean pre-operative CCT, CED, ACD and AL in SB group was 530.73+/-12.59 micro m, 2161.79+/-161.96 Cells/mm[2], 3.343+/-0.14mm and 23.67+/-0.82mm respectively. Mean post-operative CCT, CED, ACD and AL in SB group was 532.76+/-7.74 micro m, 2158.27+/-156.58 Cells/mm[2], 3.24+/-0.10mmand 25.71+/-0.86mm respectively. Change in ACD and AL from pre-operative value after SB was statistically significant [p<0.001]. Mean change of CED, ACD and AL between two groups was also statistically significant [p<0.001]

Conclusion: Rhegmatogenous retinal detachment repair causes ocular changes, with significantly more decrease in corneal endothelial cell density after pars plana vitrectomy, and more increase in anterior chamber depth and axial length after scleral buckling

High altitude retinopathy presenting as central retinal vein occlusion in a soldier

A 33-year soldier, deployed at an altitude of 3,350 meters for two years, developed unilateral Central Retinal Vein Occlusion [CRVO] in the left eye. He had no risk factor for thrombosis and all thrombophilia screenings were negative. The patient was managed with intravitreal injections of anti-VEGF [Bevacizumab] every four weeks. He showed gradual improvement in the visual acuity over the next 3 months. Best corrected visual acuity [BCVA] after three months was 6/7.5; whereas, initially it was limited to hand movements only. This case illustrates that prolonged exposure to high altitude is a risk factor for CRVO, too. Frequent eye examination, including fundus, should be carried out among people living at such altitudes

Effect of pan retinal photocoagulation on central macular thickness and visual acuity in proliferative diabetic retinopathy

Objective: To evaluate the effect of pan-retinal photocoagulation with Pattern Scan Laser [pascal] on best corrected visual acuity and central macular thickness in patients having proliferative diabetic retinopathy [PDR]

Methods: This study was conducted at AFIO, Rawalpindi, Pakistan from Oct 2014 to Jul 2015. Sixty seven eyes of 46 patients having proliferative diabetic retinopathy were included in the study. All patients underwent ophthalmic clinical examination including uncorrected distant visual acuity [UCVA], best corrected visual acuity [BCVA], fundus examination with slit lamp and optical coherence tomography to document the pretreatment central macular thickness [CMT]. Two sessions of PRP using Pattern Scan Laser were performed 04 weeks apart and OCT was repeated 04 weeks after the 2[nd] session. Central macular thickness and BCVA were documented

Results: Sixty seven eyes of 46 patients [29 females and 17 males] with mean age of 57.45 +/- 5.78 years underwent treatment with two sessions of laser PRP. Mean pretreatment BCVA was 0.67 +/- 0.43 and mean post-treatment BCVA was 0.57 +/- 0.3. Mean central macular thickness [CMT] as measured by OCT was 391.93 +/- 170.43 before treatment and 316.91 +/- 90.42 um after treatment. The magnitude of induced change in CMT after treatment was 75.01 +/- 90.75 and BCVA was 0.09 +/- 0.14

Conclusion: Laser PRP with Pattern scan laser alone in patients with combined presentation of PDR and DME is safe and effective

Nd YAG laser embolysis in a young woman with hemiretinal artery occlusion

Retinal artery occlusion is an uncommon condition but can lead to grave consequences if not managed in time

Elderly population with other comorbid conditions like hypertension, ischemic heart disease, hyperlipidemia and stroke are commonly affected. However, this condition may affect younger population with entirely different systemic associations

Thromboembolism, which usually takes place secondary to cardiac emboli or hypercoagulable states cause retinal artery occlusion in young population

A 24-year lady presented with a short history of unilateral altitudinal visual loss

On examination, she was found to have hemiretinal artery occlusion. Ocular massage, anterior chamber paracentesis was performed initially, followed by Nd YAG laser embolysis, which led to successful restoration of retinal circulation and significant improvement in visual field loss

Detailed evaluation and systemic investigations were carried out to identify the underlying cause, but no systemic association could be found

Oguchi disease - two patients with variable gene mutation and optical coherence tomography findings

Oguchi disease is a rare form of congenital stationary night blindness which has autosomal recessive inheritance. It is characterized by typical clinical features in which there is golden yellow tapetal reflex over the fundus which disappears after prolonged dark adaptation. This clinical characteristic is known as "Mizuo-Nakamura phenomenon". Patients with Oguchi disease present with night blindness which is non-progressive and not associated with decreased vision, colour desaturation or visual field defects. We examined two patients who presented with night blindness since childhood. A 4 year boy and a 6 year old girl when examined in detail revealed Mizuo Nakamura phenomenon on fundus examination. They were further investigated with electrophysiological tests, optical coherence tomography and genetic studies to make a diagnosis of Oguchi's disease

Anatomical success in patients after retinectomy for complex retinal detachment

To evaluate the efficacy of primary and redo retinectomy in eyes with complex retinal detachment. Quasi-experimental study. Armed Forces Institute of Ophthalmology Rawalpindi from Jan 2012 to June 2013. Fifty eight eyes [patients] underwent relaxing retinectomies for complex retinal detachment with proliferative vitreoretinopathy or intrinsic retinal shortening. Operative technique included pars plana vitrectomy, proliferative vitreoretinopathy management, use of intraoperative perfluorocarbon liquid, retinectomy, endolaser and intraocular temponade. The main outcome was anatomic success, defined as complete retinal reattachment at four months follow up. Eighteen eyes out of the same primary group underwent second retinectomy because of anatomical failure. Mean age of study population was 53.78 +/- 15.11 years, 56.9% of patients were male[s]. Anatomic success rate after 1[st] retinectomy was achieved in 68.96% [40 eyes out of 58]. In eighteen eyes that underwent 2[nd] retinectomy, anatomic success rate was 72.22% [13 eyes out of 18]. Overall success rate was 91.3% [53 eyes out of 58] in our study. Relaxing retinectomies for retinal shortening can improve the anatomical success rate in patients with complex RD

Effect of cataract extraction on intraocular pressure in patients with pseudoexfoliation

To evaluate the Intraocular Pressure lowering effect of cataract extraction in eyes with pseudoexfoliation in patients attending ophthalmology department Combined Military hospital Hyderabad. This interventional study of 06 months [from May to Oct 2009] in Eye department Combined Military Hospital Kharian and Hyderabad. A total of 60 patients were included. Preoperative IOP was recorded for every patient using Goldmann Applanation Tonometer with Fluorescein. Cataract extraction was performed under topical or local anesthesia with posterior chamber intraocular lens implantation after aspiration of lens matter. Postoperative IOP on 7[th], 14[th] and 28[th] postoperative days were recorded for every patient. 28[th] post operative day IOP of cases [13.96 +/- 2.74] was significantly [p<0.05] less than pre operative IOP [17.5 +/- 2.75]. Frequency of cases with >3 mm Hg drop was 50 [83.33%] Cataract extraction results in clinically significant lowering of IOP levels in cases of PXS

Choroidal metastasis from renal cell carcinoma presenting with cataract

We report a case of rare involvement of the eye with choroidal metastasis from renal cell carcinoma presenting 08 years after the primary tumor was removed. The patient initially presented with cataract most probably induced by the tumor. After cataract extraction, tumor was detected when it induced vitreous involvement and retinal detachment. Enucleation was performed and an extraocular mass was also excised. Histopathology confirmed the diagnosis of metastasis from renal cell carcinoma in the ocular tumor, extraocular mass and the vitreous