Posterior assisted levitation [PAL] by using akahoshi/wahab irrigating pars plana levitator

To assess the outcome of irrigating Akahoshi/Wahab pars plana levitator for posterior assisted levitation in dropped nucleus during phacoemulsification. A case series. Ophthalmology Unit-III, Dow University of Health Sciences at Sindh Government Lyari General Hospital and Al-Noor Eye Hospital, Karachi, from January 2008 to December 2009. Cases of dropped nucleus during phacoemulsification were recruited. Predisposing factors and stage of phacoemulsification at which dropped nucleus were recognized. Levitator was inserted through pars plana after vitrectomy around nucleus and levitation was carried out. Follow-up was done till 6 months. Thirty two patients including 18 males [56.3%] and 14 females [43.8%] underwent pars plana levitation. Predisposing factors were pupillary miosis in 9 cases, Brunescent cataract in 7 cases, pseudoexfoliation in another 7 cases, hypermature cataract in 5 cases and extended capsulorrhexis in 4 cases. Posterior capsular rent occurred in 22 [68.8%] cases while zonular dehiscence / rupture were found in 10 cases [31.3%]. Nuclei were dropped during quadrant aspiration in 10 cases [31.3%] and during chopping in 8 cases [25%]. Another 5 cases [15.6%] occurred during each hydrodissection and chopping while 4 cases [12.5%] were found during sculpting of nuclei. Final best corrected visual acuity was 6/12 and better in 22 cases [68.8%] while in 10 cases [31.3%] it was 6/18 to 6/36. No complication related to pars plana levitator was observed. Posterior assisted levitation of dropped nucleus during phacoemulsification by irrigating Akahoshi/Wahab pars plana levitator is a fast and safe surgical technique

long term follow-up of laser peripheral iridotomy in acute primary angle closure

To determine the success rate and complications of YAG laser peripheral iridotomy during a long term follow up in patients of acute primary angle closure glaucoma. Descriptive prospective case series using a combination of quantitative and qualitative analysis. Study was conducted at the Department of Ophthalmology Dow University of Health Sciences; Eye Unit 1, Civil Hospital Karachi between October 2005 and September 2010. Patients were recruited from the outpatient department with a diagnosis of acute primary angle closure. After medical control of intraocular pressure forty eight patients underwent YAG laser peripheral iridotomy with pulse energies ranging from 5-8 mJ. Patients were examined at 1 hour, 1 day, one week, two weeks and 1, 3, 6, months, one year and after two to three years. Findings were recorded on proforma and statistically analyzed. Mean age was 54.6 [ +/- 6.7, range = 45 -74] years. Mean duration of attack was 2.65 [ +/- 1.4, range 1-6] days. The commonest intra-operative complication was bleeding from the iris in 33.3% eyes. Mean follow-up period was 48.81[ +/- 9.03, range 32-65] months. Thirty six [75%] eyes developed significant cataract. Iridotomy was closed in six [12.6%] eyes. Complete success was observed in 12 [24.5%] eyes. Twenty two [44.9%] eyes required additional anti-glaucoma medication [partial success] while complete failure was observed in 14 [28.6%] eyes. YAG laser peripheral iridotomy is associated with a significant number of short term and long term complications in Asian eyes. Other alternative methods should be taken into consideration to prevent blindness in this part of the world

Retinoblastoma: clinical picture and grouping at the time of first presentation

To study the clinical picture and staging of retinoblastoma at the time of first presentation. This prospective study of consecutive case series was conducted in the department of ophthalmology, Dow University of Health Sciences and Civil Hospital, Karachi, from October 2007 to September 2009. Twenty patients with unilateral or bilateral retinoblastoma were examined during this period. Parents of every patient were interviewed in detail. Patients were examined under general anesthesia to measure corneal diameter, anterior chamber examination with hand held slit lamp. IOP was recorded with Perkin's tonometer; fundoscopy with indentation was performed with indirect ophthalmoscope. International intraocular classification of retinoblastoma [IICR] was used for grouping of retinoblastoma. Ultrasonography and neuroimaging were performed in all cases. Twenty patients were found to have retinoblastoma with a mean age of 3.86 years [SD=2.56] with a minimum of one year and maximum of 12 years. Out of 20 patients there were 12 [60%] male and 08 [40%] female. Thirteen [65%] were from urban and 07 patients [35%] from rural areas. Family history of retinoblastoma was positive in two patients [10%].Bilateral retinoblastoma was present in 10 patients [50%] and unilateral retinoblastoma in other 10 patients [50%].The most common clinical presentation of retinoblastoma was Leukocoria that was seen in 12 patients [60%] followed by anterior segment involvement in three patients [15%], orbital Cellulitis in three patients [15%], strabismus in one patient [5%] and phthisis bulbi in one patient [5%]. Among 10 patients with unilateral retinoblastoma 60% had group E, 20% had group D and another 20% with group C of IICR at the time of presentation. Twenty eyes of 10 patients with bilateral retinoblastoma showed group E in 13 eyes [65%], group D in four eyes [20%], group C in two eyes [10%] and group A in one eye [5%]. Leukocoria is the commonest clinical presentation of retinoblastoma. In developed countries 95% of children with retinoblastoma present with limited stage disease and are cured while in our set-up most patients still present with advanced diseases and cure rates are very low. Educational programs are required to educate general public, parents of retinoblastoma patients. Collaboration with pediatricians to check red reflex on every well baby visit is mandatory for early diagnosis

Stargardt's disease: clinical presentation and fundus fluorescein angiographic findings

Objective: To document the clinical presentation and fundus fluorescein angiographic findings in Stargardt's disease

Methodology: This descriptive study was conducted at the Department of Ophthalmology Unit-I Civil Hospital Karachi and Unit III Lyari General Hospital Karachi of Dow University of Health Sciences from June 2004 to May 2008. Patients were selected from the out patient department of Sindh Govt. Lyari General Hospital and Civil Hospital Karachi fulfilling the inclusion criteria. Sociodemographic data and family history were obtained and patients subjected to complete ophthalmic examination of anterior and posterior segment and Fundus Fluorescein Angiography

Results: Thirty patient were found to have Stargardt's disease. Mean age was 18.4 +/- 6.9 years. Twenty two [73.4%] patients were found to be 20 years of age or below. Males [18 [60%]] outnumbered the females [12[40%]]. Visual acuity at presentation revealed a symmetric loss of vision in right and left eyes [P=0.410 at 99% CI]. Macula showed atrophic lesion in 12 cases [40%], beaten bronze in 13 [43.3%] cases and varnished appearance in 5 [16.7%] cases. Retinal flecks were found in 18 [60%] patients only. Fundus fluorescein angiography revealed dark choroids and elliptical hyperfluorescent lesion at the macula in all the patients. Tiny hyperfluorescent areas not corresponding to the area of flecks were found only in 18 [60%] patients

Conclusion: We conclude that Stargardt's disease has varied presentation and there is a familial and genetic predilection

Frequency of contralateral patent processus vaginalis in children presenting with unilateral hernias

To determine the frequency of contralateral patent processus vaginalis [PPV] in children who presented with unilateral inguinal hernias. A Descriptive Study. Department of Paediatric Surgery, Military Hospital Rawalpindi, from November 2006 to November 2007. All children under the age of 6 years and presenting with unilateral inguinal hernia were included. Those children who had a hernia on the contralateral side, or a history of swelling in the past, previous operations on the contralateral side, associated conditions like connective tissue disorders, ascites or VP shunts were also excluded. A standard Rehbein procedure was carried out for hernia repair on both sides. The results were analyzed and presented as mean [range] or mean +/- SD. There were 76 patients who underwent bilateral inguinal explorations. Males were 66 [86.8%] and 10 [10.8%] were female. Almost two thirds [n=52, 68.4%] were children younger than two years of age [mean age 1 year and 9 months]. There was a preponderance of left sided hernias [45 vs. 31, 59.2% vs. 40.8%]. The asymptomatic contralateral side exploration showed the presence of a definite PPV in 5 [6.6%] patients. The mean operating time was 35 + 10.4 minutes. The risk of contralateral hernia, in children presenting with one sided inguinal hernia is quite low. This does not justify routine exploration of the contralateral groin to prevent only a few clinical hernia developments later on

Frequency of different types of paediatric ocular trauma attending a tertiary care paediatric ophthalmology department

To assess the etiological factors and circumstances associated with the occurrence of eye injuries in children attending a tertiary care pediatric ophthalmology department. This study was conducted at the Department of Pediatric Ophthalmology, Civil Hospital, Karachi from August 2007 to July 2009. Personal information, clinical findings and management plan was recorded on a prescribed performa. Variables studied included: age, sex, date of injury, place of injury, involved eye, circumstance and mechanism of injury, initial visual acuity and immediate management. A total of 462 patients under the age of 16 years presented with ocular trauma. There were 297[64.3%] males and 165[35.7%] females. Mean age was 7.03 +/- 3.61 years. Most cases 198 [42.9%] belonged to the schoolgoing age group [6 to 11years]. The injuries occurred most frequently at home [215 patients, 46.5%].Blunt trauma occurred in 228[49.4%] cases followed by penetrating in 162[35.1%] cases. Injuries restricted to the eyelid occurred in 61 [13.2%] accidents, closed globe injury occurred in 338 [73.1%] and open globe injury in 63 [13.7%] accidents. Visual acuity was better than 6/12 in 245 [53.0%] children. Two hundred and fifteen children [46.5%] were prescribed only general measures like pressure patching, warm or cold compresses antibiotics or lubricant eye drops. Surgical management was required in 121[26.2%] patients. This study has shown frequencies of different type of ocular trauma which can be minimized by taking preventive measures as adopted in developed countries

Role of trabeculectomy in the management of hypertensive traumatic total hyphaema

To assess the visual outcome and complications after trabeculectomy in patients of hypertensive traumatic total hyphaema. Case series. Department of Ophthalmology, Dow University of Health Sciences, Karachi, from June 2004 to May 2008. Patients with total hyphaema admitted in eye ward were included. Socio-demographic data was recorded. Complete ophthalmic examination and B-scan ultrasonography were undertaken. Trabeculectomy was performed. Visual outcome, intraocular pressure reduction and complications were recorded. Descriptive statistics were calculated. Twenty two patients underwent trabeculectomy with mean age was 23.18 +/- 12.67 years. Male to female ratio was 3.26:1. Toy gun pellet injury was present in 6 [27.3%] cases. The average intraocular pressure before surgery was 40.86 mm of Hg. All the patients had a visual acuity of light perception with an accurate projection. Evidence of corneal blood staining was observed in 16 [72.7%] patients. Mean intraocular pressure at last follow-up was 15.1 +/- 2.11 mm of Hg with a minimum of 12 mm and maximum of 20 mm of Hg in 19 [86.3%] patients [complete success]. Three patients were on additional anti-glaucoma medications. Filtering bleb was functional in only 4 [18.2%] patients. Visual acuity was 6/18 or better in 18 [81.8%] patients at last follow-up. Trabeculectomy was a satisfactory procedure for traumatic hyphaema for restoring good vision, if undertaken earlier. This procedure is not associated with significant complications and is very useful in reducing raised intraocular pressure

Prevalence of diabetic retinopathy and influence factors among newly diagnosed diabetics in rural and urban areas of Pakistan: data analysis from the Pakistan national blindness and visual impairment surgery 2003

To estimate the prevalence of diabetic retinopathy among newly diagnosed adult diabetics from the data set of Pakistan National Blindness survey 2003. We analyzed the data collected from the Pakistan National Blindness Survey, a population based survey with regards to diabetic retinopathy and its risk factors. Descriptive information for each of the variable was derived and distribution was assessed by simple tabulation and cross tabulation. We used Odds Ratio [using Mantel-Haenszel technique] and 95% confidence interval to assess association between the variables. Among the 16507 subjects [95.3% response rate] 660 [4%] were found to be diabetic. Out of these, one hundred one [15.3%] had diabetic retinopathy. We found a low prevalence of diabetic retinopathy [0.6%] among the subjects aged 30 and above. The risk of diabetic retinopathy was higher in urban diabetic subjects [OR 2.7, with 95% CI 1.08-4.1] as compared to rural areas of Sindh. In addition it was higher in hypertensive [OR 2.77 with 95% CI 1.0-4.1] and in obese [OR 2.2 with 95% CI 1.7-4.2] as compared to subjects with normal body mass index [BMI]. The prevalence of blindness in diabetic subjects was 5.9%. There were three hundred forty four [52%] subjects with diabetes with normal vision, 149[22%] subjects were with moderate visual impairment, thirty six [5.9%] subjects were blind and twenty two [3.3%] subjects were with severe visual impairment. About 214 diabetics have hypertension [32.4%], one hundred forty one [21.3%] diabetics are obese. Our study data suggests lower prevalence of Diabetic Retinopathy as compared to other part of the region. There is great need to collect and monitor epidemiological data at district hospital level in order to develop a national annual retinal screening program for diabetic patients in Pakistan

study of diabetic foot syndrome

This study was carried out to determine the number and predisposing factor of foot infection in the adult onset diabetes mellitus. An observational study. The study was carried out at PAF Hospital Islamabad, from June 2003 to June 2005. A total of 130 patients with adult onset diabetes mellitus were included in this study. The population was mixed. Clinical profile and investigations were recorded. Patients were managed as indoor cases. Plain insulin was used to control the diabetes. Broad-spectrum antibiotics and serial debridments, where required, were carried out. A total of 18.5% of the hospitalized diabetic population was due to foot infection. Males were affected 1.5 times more than the females. The disease was bilateral in 4% cases. Poor control of diabetes, bad foot hygiene, peripheral neuropathy, trauma, ingrowing toenails, callosities and corns were implicated as predisposing factors in majority of cases. Foot infection in diabetics is a common occurrence and both sexes are involved though males more commonly than females. Majority of the patients were elderly and have poor knowledge and insight of their disease

Anesthesia crisis resource management

The critical scenario in which rapid response is needed, for example. Malignant Hyperthermia, occurs rarely. Hence conducting training about such clinical events leaves no alternative but to use simulation. The aims of anesthesia crisis resources management [ACRM] training are to learn principles of complex problem solving, decision making, resource management and team work behavior to improve medical and technical skills. In medical training, simulator can substitute for actual patients and recreate actual clinical environment for anesthesiologists, surgeons, radiologists, cardiologists, gynecologists, etc. for their training. Simulators range from simple mannequin to high fidelity simulators. Mannequin represents the patient, and the participants act as surgeons, anesthetists and operating room assistants in a replica of operation theatre. The high fidelity simulators are programmed to create a special situation which the trainees are required to diagnose and manage the situation and resources accordingly. A panel consisting of consultants and instructors trained in this field are observing and recording all the details on the video tape which is used later on for the debriefing sessions. Simulators have high face validity because they ease trainees' transition to actual patient. Simulators can effectively identify errors and appropriateness of decision making. There is a risk that clinician might acquire inappropriate behavior or develop a false sense of security in their skills that could theoretically lead to harm the patient. The trainees develop an underst and ing that how stresses contribute to the occurrence of error. The ACRM training is an effort to improve our underst and ing about the crisis management aiming at reducing error and ultimately improve patient safety

Role of fundus fluorescein angiography in the diagnosis of central serous chorioretinopathy

This study was carried out in the Department of Ophthalmology, Dow Medical College and Civil Hospital, Karachi, to ascertain the role of Fundus Fluorescein Angiography [FFA] in the diagnosis of Central Serous Chorioretinopathy [CSCR] and to see the various patterns of CSCR on FFA. In the outpatient department 33 patients were diagnosed as having CSCR on the basis of careful history taking and thorough clinical examination. They included 28 [84.85%] males and 5 [15.15%] females with a sex incidence of 6 Male.- 1Female. Majority of cases i.e. 28[84.85%] were between 20-40 years of age, whereas only 3[9.09%] were in the late teens and 2[6.06%] above the age of 40 years. Right eye was involved in 15 [45.45%] and left eye in 18 [54.55%] cases. The presenting clinical features were blurred vision, micropsia, metamorphopsia and positive central scotoma. At the time of presentation a visual acuity of 6/12 or better was seen in 25 [75.75%] cases, and 6/18 or less in 8 [24.25%] cases. FFA showed 21[63.64%]cases with ink-blot and 11[33.33%] with smoke-stack pattern, whereas one [3.03 %] case turned out as Sub-Retinal Neovascular Membrane [SRNVM]

Postobstructive pulmonary edema associated with biting a laryngeal mask airway

Laryngeal mask airway [LMA] has established itself as a reliable mode of maintaining a patent airway; however, it is associated with a few complications. This case report describes the presentation, diagnosis, management and treatment of an unusual complication associated with the use of LMA, that is postobstructive pulmonary edema [POPE], which is a potentially life-threatening complication of acute airway obstruction. It develops rapidly but responds quickly to the therapy