Optical Coherence Tomography Macular Findings after Successful Scleral Buckling in Eyes with Compromised Visual Status.

OBJECTIVE: To determine the optical coherence tomography (OCT) macular findings after successful scleral buckling in eyes with compromised visual status. STUDY DESIGN: Descriptive cross-sectional study. PLACE AND DURATION OF STUDY: Department of Clinical Ophthalmology, Khyber Institute of Ophthalmic Medical Sciences, Postgraduate Medical Institute, Hayatabad Medical Complex, Peshawar, Pakistan, from February 2015 to November 2016. METHODOLOGY: Patients with postoperative best corrected visual acuity (BCVA) less than 6/6, successful scleral buckling, and flat macula clinically, aged 18-70 years, were included. OCT scan (OCT-Spectralis, Heidelberg Engineering, GmbH 69121) of central 30 degrees around fovea was performed three months postoperatively. Foveal detachment, epimacular membrane (EMM) and cystoid macular edema (CME), were studied on OCT after successful buckling surgery in eyes with compromised visual status. RESULTS: A total of 164 eyes of 164 patients (92 males 72 females) were assessed with OCT. Foveal detachment (FD) was present in 54 cases (32.9%), cystoid macular edema (CME) in 30 (18.3%), and epimacular membrane (EMM) in 11 cases (6.7%); while no abnormality was detected in 69 (42.1%) cases on OCT. CONCLUSION: OCT is very helpful in identifying the cause of limited visual recovery after successful retinal detachment (RD) surgery.

Intravitreal Bevacizumab: Indications And Complications.

BACKGROUND: Bevacizmab is still an unlicensed drug for intraocular use in spite of the fact that it has shown comparable efficacy to other anti-vascular endothelial growth factors (anti-VEGF) medications in some large sample randomized control trails. Although repackaged bevacizumab has got safety concerns but its use is growing because of easy availability and low cost. Our study focuses on the diverse and growing indications of intravitreal bevacizumab (IVB) and its ocular complications in our geographical setting. METHODS: This interventional case series was carried out at my private practice in Said Anwar Medical Complex, Dabgari, Peshawar, from January 2008 to July 2015. Total of 6107 injections were given to 4352 eyes. Intravitreal bevacizumab was injected in proper operating room setting. Bevacizumab injections were prepared from same vial by multiple withdrawals taking care of aseptic precautions. Follow up was done at 1 week and 20 days and adverse effects were noted. RESULTS: Diabetic macular oedema (36%), central retinal vein occlusion (17.6%) and branched retinal vein occlusion (11%) were the top three indications of IVB. Other common indications were proliferative diabetic retinopathy (9.6%), neo-vascular glaucoma (5.9%), proliferative diabetic retinopathy with vitreous bleed (4.4%), proliferative diabetic retinopathy with tractional retinal detachment (3.7%), neo-vascular age related macular degeneration (2.9%), central serous retinopathy (1.48%) and Eale's disease (1.48%). Endohthalmitis occurred in 3 eyes (0.069%) while retinal detachment was found in only 2 eyes (0.046%). CONCLUSIONS: Common indications of bevacizumab are diabetic macular oedema, central retinal vein occlusion and branched retinal vein occlusion. Complications like endophthalmitis and retinal detachment are rare.

Retinal Detachment Due to Retinal Dialysis: Surgical Outcome After Scleral Buckling.

PURPOSE: The aim of this study was to determine the efficacy and safety of scleral buckling surgery in retinal detachment due to retinal dialysis. DESIGN: This study was a prospective, interventional case series. METHODS: A total of 48 eyes of 48 consecutive patients were included after obtaining informed written consent. Besides taking a thorough history, all eyes were examined by a retinal surgeon. The macula status, site, and extent of retinal dialysis and rhegmatogenous retinal detachment (RRD) were particularly noted. Proliferative vitreoretinopathy grading was done. Buckling was performed by a single surgeon. At every follow-up, visual acuity, intraocular pressure, retina status, and buckle position were noted. Any complication found was recorded. Follow-up was done for at least 6 months. SPSS version 16 was used for data analysis. RESULTS: We included 48 cases of RRD due to retinal dialysis. The mean ± SD age of the patients was 26.85 ± 15.1 years. The macula was detached in 85.4% of the cases, and proliferative vitreoretinopathy grade C was found in 25% of the cases. A surgical reattachment rate of 95.8% was attained after a single primary buckling procedure. Final Snellen best-corrected visual acuity of 6/18 or better was attained in 12.5% of the cases. However, 62.5% of the cases had best-corrected visual acuity in the range of 6/24 to 6/60. Subretinal hemorrhage occurred in 8.3% of cases intraoperatively after subretinal fluid drainage. CONCLUSIONS: We conclude that scleral buckling has a definite role in the management of RRD due to retinal dialysis.

Comparison between panretinal photocoagulation and panretinal photocoagulation plus intravitreal bevacizumab in proliferative diabetic retinopathy.

BACKGROUND: Patients with diabetes often develop ocular complications. The most common and most blinding of these complications, however, is diabetic retinopathy. The objective of this study was to compare the retinal neovessels regression in Proliferative Diabetic Retinopathy (PDR) treated with Pan Retinal Photocoagulation (PRP) versus panretinal photocoagulation plus Intra Vitreal Bevacizumab (IVB). METHODS: A comparative study was conducted at Khyber Institute of Ophthalmic Medical Sciences, Hayatabad Medical Complex, Peshawar from 1st October 2010 to 31st August 2011. A total of 54 eyes were randomised into two groups. Neovessels status was assessed before and at every follow up visit. Neo Vessels on the Disc (NVDs) were assessed as per percentage of NVD occupying the disc surface whereas Neo Vessels Elsewhere (NVE) were also assessed as per reference to disc surface diameter. RESULTS: Neovascularization on the disc was 40 +/- 5% at presentation which increased to 50 +/- 7% on 30th day and stabilised to 40 +/- 6% on day 90 in PRP group. In PRP-plus group, 40 +/- 7% NVD regressed to 10 +/- 5% on 30th day and 11 +/- 3% on day 90. The NVE in PRP group was 2 +/- 0.75% at baseline, 2.25 +/- 0.75% on 30th day, and 2.00 +/- 0.50% on day 90. In PRP-plus group it was 2 +/- 0.50% at baseline, 1 +/- 0.5% on day 30, and 0.75 +/- 0.25% on day 90. On day 90 both the groups had highly significant different NVD (p = 0.00008) and NVE (p = 0.0001). CONCLUSION: Intra Vitreal Bevacizumab in short term is effective as adjunctive treatment to PRP with early and higher rate of retinal neovessels regression than PRP alone in PDR patients.

Complications of conventional scleral buckling occuring during and after treatment of rhegmatogenous retinal detachment.

OBJECTIVE: To identify and determine the frequency of the intra-operative and early postoperative complications of Conventional Scleral Buckling (CSB) as the primary surgical intervention in patients with Rhegmatogenous Retinal Detachment (RRD). STUDY DESIGN: A quasi-interventional study. PLACE AND DURATION OF STUDY: Khyber Institute of Ophthalmic Medical Sciences (KIOMS), Postgraduate Medical Institute (PGMI), Hayatabad Medial Complex (HMC), Peshawar, from April 2005 to June 2006. METHODOLOGY: Fifty consecutive patients who underwent CSB and fulfilled the inclusion criteria, were included in the study. Operative details and any intra-operative complications were noted. The patients underwent another detailed clinical examination and pain assessment on the first postoperative day. All the patients were followed-up minimum for 3 months. Postoperative complications were identified and recorded. The data was analyzed on SPSS 12.0 for measures of central tendency and dispersion. RESULTS: There were 36 male and 14 female subjects. Mean age was 37.18 + or - 20.045 years. Encirclement (56%) was the most frequently used CSB technique. Sixteen (32%) patients had at least one intra-operative complication. Intra-operative complications were iatrogenic scleral break (2%), accidental Sub Retinal Fluid (SRF) drainage (8%), choroidal haemorrhage (2%), subretinal haemorrhage (14%), retinal incarceration (2%), vitreous haemorrhage (6%), raised (4%) or very low (2%), intra-operative IOP and hyphema (2%). Postoperative complications included systemic complications (24%), choroidal detachment (8%), vitreous haemorrahge (16%), raised IOP (22%), angle closure (2%), conjunctivitis (4%), orbital cellulitis (2%), suspected endophthalmitis (2%), ocular movement disorders (2%) and explant exposure (6%). Mean refractive change in spherical equivalent was -1.478 + or - 0.698 D. Final re-attachment rate was (82%) and final BCVA of > 6/60 was achieved in 62% of the subjects in the treated eyes. CONCLUSION: CSB is a safe and effective option for treating uncomplicated RRD, but it is associated with certain complications. Sub-retinal bleed was the most common intra-operative complication. Raised IOP was most the common early postoperative complication followed by choroidal detachment.

Outcome of scleral buckling procedures for primary rhegmatogenous retinal detachment.

OBJECTIVE: To study the outcome of conventional scleral buckling procedures performed for primary rhegmatogenous retinal detachment. METHODS: This prospective study was conducted at Khyber Institute of Ophthalmic Medical Sciences, Hayatabad Medical Complex, Peshawar, Pakistan from 02-08-2008 to 29-04-2009. The outcome of fifty-six consecutive cases, operated in nine months duration, for primary rhegmatogenous retinal detachment using scleral buckling procedures, were analyzed prospectively. The main outcome measure was anatomically reattached retina at two weeks postoperative follow-up. RESULTS: Overall success rate was 85.71% (48 of 56 cases) at 2-weeks post-operative follow-up. The most common intra-operative complication was sub-retinal haemorrhage (23.21% cases), and the most common complication at first post-operative day was increased intra-ocular pressure (IOP), (21.43% cases). The raised pressure was transient in most cases, and only 2 (3.57%) had elevated IOP at 2-weeks post-op follow-up. Choroidal detachment was the second commonest post-operative complication (10.7%) The un-aided visual acuity was PL or HM in 32 (57.14%) cases and better than 6/60 in 3 (5.36%) cases pre-operatively. This improved to PL/HM in 12 (21.43%) and better than 6/60 in 16 (28.57%) cases post-operatively. Not very significant improvement in vision despite flat retina was found to be due to late presentation of patients, high grade PVR (Grade-C) in 24 (42.86%) cases and pre-operative 'off' macula in 52 (92.86%) cases, at a short-term follow up. CONCLUSION: Scleral buckling procedures are still effective in the treatment of primary rhegmatogenous retinal detachment even in high-grade PVR cases. A fairly good success rate can be achieved by adopting the appropriate procedures.

Conventional retinal reattachment surgery.

OBJECTIVE: To evaluate the surgical outcome in rhegmatogenous retinal detachment (RRD) cases operated by conventional retinal reattachment techniques. DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: This study was conducted at Eye Unit, Hayatabad Medical Complex (HMC), KIOMS, Peshawar, from July, 2002 to December, 2002. MATERIALS AND METHODS: A retrospective analysis of ophthalmic record of rhegmatogenous retinal detachment operated by conventional retinal reattachment surgery was done. Anatomic outcome was evaluated in relation to duration of presentation and pre-operative proliferative vitreoretinopathy (PVR). Postoperative visual acuity (VA) was compared to pre-operative VA. Complications and causes of failure of anatomic success were also analyzed. RESULTS: A total of 40 cases were studied. Male to female ratio was approx 2:1. Retinal breaks were localized in 70% cases, 37.5 % cases had single break while 32.5 % cases had more than one retinal breaks. Forty two percent had total retinal detachment while 57.5 % had less than total retinal detachment. Five percent had attached macula at presentation. Immediate postoperative retinal reattachment was attained in 80% cases but ultimate anatomic success after at least 6 months of follow up was 72.5%. Patients who presented earlier (upto 1 year) had 75% anatomic success while those who presented later than 1 year had 50% success rate. Postoperative visual improvement was noted in 80 % cases with flat macula, 65% had VA 6/60 or better after surgery. Most common cause of failure of anatomical reattachment was PVR (63.63% of failed conventional surgery). Most common postoperative complication was raised intraocular pressure ( > 21 mmHg) in 25 cases. CONCLUSION: There is more chance of retinal reattachment and visual restoration in cases that present earlier. PVR is the main cause of failure of conventional retinal reattachment surgery. Postoperative visual improvement is directly related to surgical reattachment of the macula.

Ocular emergencies.

OBJECTIVE: To describe clinical data about ocular emergencies (OE) and their management. DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: This study was conducted from 1st January, 2000 to 31st December, 2002 at the Department of Ophthalmology, Khyber institute of Ophthalmic Medical Sciences, Lady Reading Hospital, Peshawar. MATERIAL AND METHODS: A comprehensive analysis of the computer record available for admitted ocular emergencies was undertaken in terms of gender, age, etiology, procedure performed and hospital stay. RESULTS: Ocular emergencies (1961) were 18.49% of total admissions. Male to female ratio was 2:1. Non-traumatic ocular emergencies were 1058 (53.95%) with male to female ratio of 1.47:1. In the non-traumatic ocular emergencies, majority (67.2%) were 40 years or above. Traumatic ocular emergencies were 925 (47.16%) with male to female ratio of 2.77:1. Majority (83.78%) of traumatic ocular emergencies were below 40 years and 562 (60.75%) below 20 years of age. Only 150 (16.21%) cases were 40 years and above. Corneal ulcers (44.51%) and glaucoma (24.38%) were the most common non-traumatic ocular emergencies, whereas, open globe injuries (73.4%) were leading the traumatic ocular emergencies. Total surgical procedures performed were 1382 (13.7% of total major ophthalmic surgery). Average stay in hospital was 5.5 days. CONCLUSION: Ocular emergencies predominantly affected the males in this series. Trauma related OE are almost as common as non-traumatic. Majority of OE need surgical intervention and the average hospital stay is longer than routine admissions.

Corneal complications of vernal catarrh.

OBJECTIVE: To identify the magnitude and types of corneal complications of vernal catarrh and the extent of visual impairment caused by them. DESIGN: A cross-sectional study. PLACE AND DURATION OF STUDY: Khyber Institute of Ophthalmic Medical Sciences (KIOMS), Hayatabad Medical Complex (HMC), Peshawar, from March, 1999 to May, 2000. SUBJECTS AND METHODS: All cases of vernal catarrh who agreed to an informed consent were included in the study. Patients who were difficult to be examined by a slit lamp were excluded from the study. The diagnosis was made mainly on the basis of history and clinical examination. Slit lamp examination was done in every case together with fluorescein staining of cornea. The variables were recorded and statistically analyzed. RESULTS: Superficial punctate keratitis (45%) was the most common corneal complication. Visual impairment was more pronounced in cases with shield ulcers (14%) and corneal plaques (8%). A strong association with keratoconus (15%) was also noted. Corneal opacification (9%), hydrops (6%) and pseudogerentoxon (3%) were also found. CONCLUSION: Corneal complications in VKC are common, potentially serious and may cause marked visual impairment.

Hyphaema due to blunt trauma.

OBJECTIVE: To study the causes, clinical presentation, complications and visual outcome of hyphaema following closed globe injury. DESIGN: Prospective study. PLACE AND DURATION OF STUDY: The study was conducted at the Department of Ophthalmology, Postgraduate Medical Institute, Lady Reading Hospital, Peshawar, Pakistan, from May, 1996 to June 1997. PATIENTS AND METHODS: All cases of hyphaema, due to closed globe injury, were included and history of patients was recorded on a comprehensive proforma designed for this purpose. All cases were admitted for at least 5 days. Ocular examination included checking visual acuity (VA), intraocular pressure (IOP), slit lamp and fundus examination. Patients were treated accordingly and followed up for 90 days. RESULTS: Thirty-six eyes of 36 patients with hyphaema were included in our study. Out of this, 88.89% were males and 11.11% females while 86% were 20 years of age or below. Almost 91.66% presented with primary hyphaema, 44.44% received trauma with stone and 27.77% with tennis ball while playing cricket. Trauma during playing was noted in 66.66% of cases. Almost 62% of cases were having visual acuity in the range of CF to perception of light with good projection. IOP was raised initially in 41.66% cases. Only 33.33% needed surgical intervention. Secondary glaucoma was present in 13.88% and 5.55% had corneal blood staining. Majority of patients (75%) improved to VA range of 6/6 to 6/12 and 19% patients in our study ended up with legal blindness in the affected eyes. CONCLUSION: Traumatic hyphaema is more frequently found among children and young male. Angle recession, traumatic cataract and maculopathy were common co-morbidities. Secondary glaucoma and corneal staining were the main complications. Nearly 1/5th of patients ended up with legal blindness in the affected eyes.