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

Changes in Central Corneal Thickness and Endothelial Cell Count following pediatric cataract surgery

Objective: To evaluate the mean changes in Central Corneal Thickness [CCT] and Endothelial Cell Count [ECC] in eyes after pediatric cataract surgery with foldable intraocular lens using scleral tunnel incision micro-surgical technique

Study Design: Qausi experimental study

Place and Duration of Study: Department of Pediatric Ophthalmology and Strabismus, Al-Shifa Trust Eye Hospital, Rawalpindi, from May 2011 to March 2012

Methodology: Fifty-two eyes of 37 children with pediatric cataract were included in the study. Extracapsular Cataract Extraction [ECE] with foldable Intra Ocular Lens [IOL] implantation using sclera tunnel incision was performed in all children. Endothelial Cell Count [ECC] and Central Corneal Thickness [CCT] were recorded before surgery and 1 month, 3 months and 6 months after surgery and the effect of currently practiced surgical technique on ECC and CCT was Evaluated

Results: The mean age at the time of surgery was 8.8 +/- 2.7 years [range: 4 to 15 years]. The postoperative ECC and CCT were significantly different from the pre-operative values. Mean pre-operative ECC was 3175.3 +/- 218.4 cell/mm[2] and in first postoperative month the mean ECC was 3113.4 +/- 210.8 cell/mm[2] [p<0.0001]. In the 3rd and 6th month postoperative means ECC were 3052 +/- 202.5 cell/mm[2] [p<0.0001] and 3015 +/- 190.6 cell/mm[2] [p<0.0001], respectively. The mean cell loss at first postoperative month was 1.95% and at 3rd and 6th postoperative month were 3.9% and 5.05%, respectively. Mean pre-operative CCT was 514 +/- 49.9 [micro]m and first postoperative mean CCT after 1 month was 524.1 +/- 25 [micro]m [p = 0.084]. After the 3rd and 6th months postoperative, mean CCT were 527.3 +/- 24.6 [micro]m, and 530 +/- 24.5 [micro]m, respectively. Third and 6thmonths postoperative means were significantly higher than baseline CCT, p = 0.024 and 0.007, respectively

Conclusion: Endothelial cell loss with closed chamber micro-surgical technique using scleral tunnel incision is within acceptable limits and within the range of normal ECC in children

Visual improvement in children with low vision using low vision devices

To observe the effect of low vision devices [LVDs] i.e. 2.5x vista view, 4x telescope and magnifying glasses on distance visual acuity of children with low vision. This observational study was conducted in the department of Pediatric Ophthalmology and Low Vision Clinic at Al-Shifa Trust Eye Hospital. 40 children with impaired visual acuity from ages 5 to 18 years were included in the study. All children had detailed anterior and posterior segment examination by pediatric ophthalmologists while LVDs were prescribed in low vision clinic. All children fulfilling WHO criteria for low vision were provided with 2.5 X vista view, 4x telescopes and magnifying glasses for improving far vision. ANOVA was used to find out which low vision device is more effective in visual improvement either glasses or telescopes i.e. vista view and 4X. Out of 40 children 20[50%] children were males and 20 [50%] were females. Main cause of low vision in our study came out to be albinism. Our study states that 4x telescope is the most effective device to improve distant visual acuity in children with low vision. Low vision aids are essential and effective for the children with low vision. They not only improve the visual acuity but also help in the education through visual rehabilitation

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

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

Visual outcome and complications after modified Cionni endocapsular tension ring and intraocular lens implantation in eyes with subluxated lenses

To evaluate the visual outcome and complications after modified capsular tension ring [CTR] and intraocular lens implantation [IOL] in eyes with subluxated lenses. This is a prospective case series managed at Al Shifa Trust Eye Hospital, Rawalpindi, Pakistan. Thirty three eyes with subluxated lenses having zonular weakness less than 180 degrees were implanted modified CTR and IOL implant after lens matter aspiration. Main outcome measures were postoperative best-corrected visual acuity [BCVA], IOL centration, and complications. The age of 24 patients ranged from 2.5 to 38 years, mean 13.34 +/- 9.8 years. The follow up period was 20.87 +/- 2.40 months. The mean pre operative logMAR BCVA was 0.98 +/- 0.52 SD and the mean post operative logMAR BCVA was 0.38 +/- 0.32 SD [p value 0.000]. Intractable secondary glaucoma was seen in 01[03%] eye. One eye [03%] needed surgical anterior capsulotomy for anterior capsular phimosis. At the last follow-up visit, the modified CTR provided excellent centration and positioning in all cases. Modified CTR and primary IOL implantation in the capsular bag gives good visual outcome with no serious complications. However, it requires a highly experienced surgeon and sufficient patience for a relatively time-consuming procedure

Presentation of amblyopia at a tertiary care hospital in Karachi

To study the type and density of amblyopia in children visiting pediatric ophthalmology and strabismus unit in the department of ophthalmology at Civil Hospital Karachi. This prospective study was conducted in pediatric ophthalmology and strabismus unit of department of ophthalmology Civil Hospital Karachi, from June 2009 to May 2010. All children under 15 years of age diagnosed with different types of amblyopia underwent standard procedure of orthoptic assessment and were divided into four pediatric age groups. Statistical analysis by simple descriptive analysis was carried out. During the study period, 239 patients were diagnosed with different types of amblyopia including 128 [53.55%] cases with refractive amblyopia, 58 [24.26%] cases with strabismic amblyopia and 53 [22.17%] cases with deprivation amblyopia. Severe amblyopia was seen in 59 [24.68%] cases with refractive errors, 25 [10.46%] cases with strabismus while all 53 [22.17%] cases with deprivation amblyopia had severe density of amblyopia. Amblyopia is a common cause of visual impairment in pediatric age group. Refractive amblyopia is the most frequent type while children with stimulus deprivation have higher chances of having severe density amblyopia. Children with amblyopia should be diagnosed at an early age for successful treatment. An effective screening program for early diagnosis and prompt treatment is recommended to prevent our future generation from visual impairment

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

Ocular manifestations of Acute Lymphoid Leukemia in children

To study various ocular manifestations of Acute Lymphoid Leukemia [ALL] in children. A prospective non interventional study. This study was carried out at the department of Pediatric ophthalmology Al-Shifa Trust Eye Hospital Rawalpindi from January 2008 to June 2010. Patients with diagnosis of ALL were referred from Combined Military Hospital and Pakistan Institute of Medical Sciences. Evaluation of patients included detailed history, vision assessment, IOP recording, anterior and posterior segment examination. Children under 4 years of age were examined under sedation for IOP recording, fundus examination and fundus photography with Retcam. Out of 13 patients with ALL, 7 were male and 6 female. The age of children ranged between 2.8 years to 15 years [Mean 8.5 years]. Anterior segment involvement or iris infiltration was seen in 4 [30.76%] patients. Disc swelling along with venous dilation and tortuosity, round and flame shaped hemorrhages was present in 05 [38.46%] patients, while papilledema without other fundus findings was seen in 1 [7.69%] patient. One [7.69%] patient was found to have bilateral optic atrophy secondary to vincristine toxicity. One [7.69%] patient presented with pseudohypopyon in anterior chamber and choroidal detachment. Secondary acute leukemia due to etoposide toxicity was diagnosed in 01 [7.69%] patient. Presence of ocular involvement is associated with poor prognosis in acute childhood leukemia. It is important to consider an ophthalmic evaluation at the time of diagnosis of acute leukemia in children and adults

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