Clinical Presentation of Carotid-Cavernous Fistula and Outcomes of Endovascular Balloon Embolization

Objectives: To describe the clinical presentation of carotico-cavernous fistula (CCF) and outcomes of endovascular balloon embolization in a tertiary care center in a developing country. Materials and Methods: This retrospective interventional case series included 18 patients who underwent endovascular balloon embolization from 2019 to 2022 at Lahore General Hospital in Lahore, Pakistan. The analyzed data consisted of age, gender, cause and type of CCF, clinical presentation, diagnostic technique used, intervention, and the results of two-month follow-up. Patients with incomplete records and coil embolization were excluded. Digital subtraction angiography was done in all cases followed by endo-arterial balloon embolization. Procedures were carried out under general anesthesia via femoral artery approach. A single balloon was sufficient to close the fistula in all cases. Results: There were 18 patients who met the inclusion criteria. Sixteen patients had direct CCF, and the mean age of the patients was 27.2±12.6 years. The commonest cause of CCF was trauma, and the mean time of presentation after trauma was 7.89±7.19 months. The male-to-female ratio was 8:1. Preoperative visual acuity was worse than 6/60 in 8 patients, between 6/60 and 6/18 in 7 patients, and better than 6/18 in 3 patients. The mean intraocular pressure was 16.06±3.37 mmHg preoperatively and 14.83±3.49 mmHg postoperatively (p=0.005). Endovascular embolization was successful in 15 patients (83.3%). One patient developed epidural hematoma as a complication of the procedure, which was drained later. There was no mortality related with the procedure. Conclusion: Balloon embolization via the femoral artery is an efficient technique in direct as well as indirect CCF. It is safe and simple with very good results if performed in a timely manner.

Virtual patients versus standardized patients for improving clinical reasoning skills in ophthalmology residents. A randomized controlled trial.

BACKGROUND: History taking and clinical reasoning are important skills that require knowledge, cognition and meta-cognition. It is important that a trainee must experience multiple encounters with different patients to practice these skills. However, patient safety is also important, and trainees are not allowed to handle critically ill patients. To address this issue, a randomized controlled trial was conducted to determine the effectiveness of using Virtual Patients (VP) versus Standardized Patients (SP) in acquiring clinical reasoning skills in ophthalmology postgraduate residents. METHODS: Postgraduate residents from two hospitals in Lahore, Pakistan, were randomized to either the VP group or the SP group and were exposed to clinical reasoning exercise via the VP or SP for 30 min after the pretest. This was followed by a posttest. One month after this activity, a follow-up posttest was conducted. The data were collected and analysed using IBM-SPSS version 25. Repeated measures ANOVA was used to track the effect of learning skills over time. RESULTS: The mean age of the residents was 28.5 ± 3 years. The male to female ratio was 1:1.1. For the SP group, the mean scores were 12.6 ± 3.08, 16.39 ± 3.01 and 15.39 ± 2.95, and for the VP group, the mean scores were 12.7 ± 3.84, 16.30 ± 3.19 and 15.65 ± 3.18 for the pretest, posttest and follow-up posttest, respectively (p value < 0.00). However, the difference between the VP and SP groups was not statistically significant (p = 0.896). Moreover, there was no statistically significant difference between the VP and SP groups regarding the retention of clinical reasoning ability. In terms of learning gain, compared with the VP group, the SP group had a score of 51.46% immediately after clinical reasoning exercise as compared to VP group, in which it was 49.1%. After one month, it was 38.01 in SP and 40.12% in VP group. CONCLUSION: VPs can be used for learning clinical reasoning skills in postgraduate ophthalmology residents in a safe environment. These devices can be used repeatedly without any risk to the real patient. Although similarly useful, SP is limited by its nonavailability for repeated exercises.

Clinical Patterns And Outcomes Of Retinoblastoma In A Tertiary Care Centre Of A Developing Country.

A retrospective study was conducted for which records of patients with Retinoblastoma (RB), treated at Lahore General Hospital between 2017 and 2021, were retrieved on February 1, 2022. Staging of RB, neuroimaging, RetCam images, and treatment were analysed. The study included 47 patients (22 females and 25 males). Mean age of presentation was 26.5±15 months. Records of 84 eyes (37 bilateral and 10 unilateral) were examined. Family history was positive in only (n=3) 6.3% cases. Mean follow-up was 22.94±14.4 months. Leucocoria was the commonest presentation, seen in 72 (85.7%) eyes, proptosis in 8 (9.5%), huge fungating mass in 2 (2.4%), while tumour was diagnosed because of screening in 2 (2.4%) patients. Posttreatment complications included cataract in two patients, Ischaemic chorioretinal toxicity, transient macular oedema, orbital oedema and transient intra cranial oedema in one patient each. Two patients had metastasis and underwent systemic chemotherapy. The study showed that patients with retinoblastoma can achieve better results if diagnosed early and treated with newer treatment options.

Comparison of changes in retinal nerve fiber layer thickness and intraocular pressure between glaucoma and non-glaucoma patients after phacoemulsification.

Objective: To compare the changes in Retinal Nerve Fiber Layer (RNFL) thickness and Intraocular Pressure (IOP) after phacoemulsification in patients with glaucoma versus without glaucoma. Methods: This was a quasi-experimental study, done at Lahore General Hospital, from January 2021 to December 2021. Patients with senile cataract were divided into two groups. One group included 40 patients, with ≥40 years of age and diagnosed with primary open angle glaucoma compared with a second group of 40 age-matched controls without glaucoma, undergoing phacoemulsification and Intraocular Lens Implantation (IOL). Goldman Applanation Tonometer (GAT) and Spectral Domain Optical Coherence Tomography (SD-OCT) were used to record IOP and RNFL thickness, before surgery, at one week and one month after surgery. The results were compared with baseline readings and also between the two groups. Results: A total of 80 patients were included in the study. Mean age was 60.3±7.9 years with male to female ratio of 1:1. Mean change in RNFL thickness in glaucomatous eyes group and non-glaucomatous Eyes group from pre-operative baseline was 11.33±4.30µm and 4.08±2.59µm respectively after one month (p-value<0.001). Difference of mean change in RNFL thickness from baseline was statistically significant between both groups (p< 0.001). Difference of mean change in IOP from baseline at four weeks was statistically significant in the individual groups but between both groups was statistically insignificant (p= 0.234). Conclusion: Phacoemulsification results in increase in RNFL thickness and decrease in IOP, which are good prognostic factors in control of glaucoma. However, a mean change of IOP of 1mmHg in glaucoma patient does not affect management of glaucoma.

A comparison of SRK/T formula with Hill RBF 2 and Barrett Universal II in the calculation of intraocular lens power.

OBJECTIVE: To compare the accuracy of SRK/T, Barrett Universal II and Hill radial basis activation function-2 formulas in intraocular lens power calculation using different axial lengths. METHODS: The retrospective study was conducted at the Lahore General Hospital, Lahore, Pakistan, and comprised data from June to December 2020 of patients who underwent phacoemulsification with non-toric, monofocal intraocular lens implantation. Data was sorted in 3 groups on the basis of axial length; group 1 22-25mm, group 2>25mm, and group 3 <22mm. Intraocular lens power was calculated using SRK/T with IOL Master, while online calculators were used for Barrett Universal II and Hill radial basis activation function-2 formulas. Data was analysed using SPSS 21. RESULTS: Of the 100 patients, 47(347%) were males and 53(53%) were females. There were 49(49%) diabetics, and 57(57%) were right eyes. There were 77(77%) patients with mean age 62.38±9.5 in group 1, 17(17%) patients with mean age 52.59±12.78 in group 2, and 6(6%) patients with mean age 61.33+7.61 years in group 3. Mean axial length in group 1 was 23.55±0.81mm with anterior chamber depth of 3.1± 0.37mm. In group 2, mean axial length was 27.54±2.8mm, with anterior chamber depth of 3.4±0.15mm. In group 3, mean axial length was 21.74mm, with anterior chamber depth of 3.14±0.44mm. Mean prediction error of SRK/T versus Barrett Universal II was 0.092±0.041D (p=0.078), SRK/T versus Hill radial basis activation function-2 was 0.066±0.037D (p=0.221) and Barrett Universal versus Hill radial basis activation function-2 was -0.025±0.019D (p=0.553). Mean prediction error of group 1 versus group 2 was -0.105±0.14D, group 2 versus group 3 was 0.046±0.216D and group 2 versus group 3 was 0.151±0.243D (p=1.0). In 74% eyes, absolute prediction error was within ±0.5D in group 1, 64% in group 2 and 50% in group 3 for all formulas. CONCLUSIONS: SRK/T formula was found to be as reliable as Barrett Universal II and Hill radial basis activation function-2 in terms of calculating intra ocular lens power for all axial lengths.

Simple Congenital Hamartoma of Retinal Pigment Epithelium.

A 45-year female presented in the Outpatient Department of a tertiary care hospital of Lahore with dimness of vision in the right eye. Her history revealed that the patient had noticed decreased vision since her childhood. Fundus examination revealed a jet-black slightly raised lesion about the size of »-disc diameter, located in the centre of macula. Optical coherence tomography (OCT) showed a highly hyper-reflective lesion at the fovea with sharp steep shadowing of the underlying structures due to backscattering. We excluded congenital hypertrophy of the retinal pigment epithelium (CHRPE) from our differential diagnosis, as solitary CHRPE is a flat well-demarcated lesion at the level of retinal pigment epithelium (RPE). Adenoma of RPE was eliminated as it has a large feeding and draining blood vessels with intra- and sub-retinal exudation. Choroid and surrounding retina was normal in our patient, which was helpful in differentiating it from choroidal nevus/choroidal melanoma. Our final diagnosis was simple congenital hamartoma of RPE. Key Words: Hamartoma, Retinal pigment epithelium, Macula.

Association of Dry Eye Disease with Diabetic Retinopathy.

OBJECTIVE: To find out the relationship of dry eye disease with diabetic retinopathy, duration of diabetes and blood sugar levels in patients of type 2 diabetes using ocular surface disease index (OSDI). STUDY DESIGN: Cross sectional observational study. PLACE AND DURATION OF STUDY: Rashid Latif Medical College / Arif Memorial Teaching Hospital,  Lahore, Pakistan, from January to June 2019. METHODOLOGY: One hundred and thirty-six patients of type 2 diabetes, ages between 25 and 80 years of either gender, were selected from Outpatient Department of the Hospital. After clinical history, complete ocular examination including fundoscopy for diabetic retinopathy was performed. Random blood sugar levels were measured using Glucometer. OSDI was used to grade the dry eye disease (normal, mild, moderate and severe). Statistical analysis was done using SPSS version 25. ANOVA and Post-hoc Tukey test were used to find out the significance of the results. RESULTS: Among the 136 participants, 45 (33.10%) were males and 91 (66.90%) were females. Average age was 51.01 ±11.69 years. Association of dry eye symptoms with increasing age and diabetic retinopathy was statistically significant (p=0.031 and p=0.009 respectively). Gender, duration of diabetes, tear meniscus height and blood sugar random (BSR) were not significantly related with dry eye symptoms (p=0.580, 0.121, 0.285 and 0.536, respectively). CONCLUSION: Diabetic retinopathy and older age is significantly associated with dry eye disease. Diabetic patients who complain of dry eye should be referred to the ophthalmologists for fundoscopy to find out diabetic retinopathy. Key Words: Dry eye disease, Ocular surface diseast index (OSDI), Diabetic retinopathy, Meibomian gland dysfunction, DEWS II.

Effect of intravitreal bevacizumab on macular thickness: exploring serum and vitreous proangiogenic biomarkers in patients with diabetic macular edema

Background/aim: This study evaluates diabetic macular-edema (DME) patients for the effect of intravitreal bevacizumab (IVB) injection on macular thickness and proangiogenic biomarkers in serum and vitreous. Materials and methods: Forty DME patients were analyzed for macular thickness (MT). Twelve proangiogenic biomarkers in serum and vitreous were analyzed before and after IVB. Results: Significant decrease in MT with vitreal vascular endothelial growth factor-A (VEGF-A) was observed as expected after IVB, while serum VEGF-A did not follow a decreasing trend in contrast to VEGF-C, which decreased both in serum and vitreous. Other vitreal factors like bone morphogenetic protein-9 (BMP9) and fibroblast growth factor (FGF) were also significantly decreased, while endothelial growth factor (EGF) increased following IVB. Before IVB, significant negative correlations were vitreous BMP9 with serum FGF, vitreous human growth factor (HGF) and interleukin-8 (IL-8) with serum endothelin, and vitreous and serum FGF and serum placental growth factor (PLGF) with EGF. After IVB, negative correlations in serum vs. vitreous were found for both HGF and PLGF with BMP9, and angiopoietin with FGF. Cube average thickness was negatively correlated with serum FGF and positively correlated with vitreous PLGF and endothelin. Conclusion: Vascular endothelial growth factors are not the only factors that cause macular edema in diabetic patients. The effect of IVB on different proangiogenic biomarkers indicated a complex interplay of other factors in DME.

Comparative Analysis of Serum Proangiogenic Biomarkers between those with and without Diabetic Retinopathy.

OBJECTIVE: To compare the serum proangiogenic biomarkers in diabetic patients suffering from with and without diabetic retinopathy (DR). STUDY DESIGN: An observational study. PLACE AND DURATION OF STUDY: Arif Memorial Teaching Hospital, Lahore, Pakistan and Institute of Molecular Biology and Biotechnology/Centre for Research in Molecular Medicine, The University of Lahore, Lahore, Pakistan, from March to December 2017. METHODOLOGY: Forty patients with DR were included in group A and 15 patients without retinopathy (controls) were included in group B. Twelve serum pro-angiogenic biomarkers [Angiopoietin 2, Human Growth Factor (HGF), Epidermal Growth Factor (EGF), Fibroblast Growth Factor (FGF), Placental Growth Factor (PLGF), Vascular Endothelial Growth Factor-A and C (VEGF-A and VEGF-C), Bone Morphogenetic Protein 9 (BMP9), Follistatin, Leptin, Interleukin-8 (IL8), Endothelin (ET)] were analysed by xMAP flow cytometry technique, results were compared between the two groups and statistical analysis was done using Mann-Whitney U test. RESULTS: Serum ET, Follistatin and EGF were significantly raised in group A as compared to group B having p-values of 0.001, <0.001, and 0.033, respectively. Serum BMP9, Leptin, HGF, FGF and VEGF-C had p <0.001, 0.023, 0.020, and 0.009, respectively and were higher in group B than group A. CONCLUSION: Serum ET, Follistatin and EGF were significantly higher in DR patients as compared to those without DR and should be considered to be significant biomarkers of retinal complications in diabetes mellitus.

Ocular ischemic syndrome and ischemic optic neuropathy in Takayasu arteritis.

Ocular Ischemic Syndrome (OIS) is a disorder, which consists of constellation of signs and symptoms secondary to chronic ocular hypoperfusion. We report a case of 35 years old Pakistani female who presented to us with gradual fall of vision in both eyes. On examination, she had bilateral OIS and ischemic optic neuropathy. The patient had past history of transient ischemic attack and facial palsy almost 20 years back. We referred her to physician for the diagnosis of Takayasu arteritis associated with relapsing polychondritis. She was given 60 mg of dexamethasone per day as initial treatment. At her last follow-up after approximately 3 months, she was quite comfortable systemically and her general condition was improved. Unfortunately, her vision did not improve. These two autoimmune diseases are rarely reported together in the same patient in Pakistan. Whether this association is rare or is underdiagnosed still remains to be answered.

Pityriasis alba with poliosis.

Pityriasis alba is a skin disease, commonly seen in children and young adults. This case presents the ocular association of this disease in a 10 years old Pakistani male. Ocular features in this case were poliosis, tilted disc, high myopia and chorioretinal degeneration. Tilted discs and high myopia can be coincidental but poliosis and decreased pigment in retinal pigment epithelium are closely related with the hypopigmentation seen in this disease.

Weber's syndrome with vertical gaze palsy.

Weber's syndrome with vertical gaze palsy is rarely reported in literature. We present a case of a 47-year-old female who developed sudden onset of left exotropia, right sided hemiplegia and vertical gaze palsy. Magnetic resonance imaging (MRI) showed multiple infarcts involving both thalami and extending caudally into the midbrain. This case presents the diverse clinical picture following midbrain infarcts.

Increased corneal curvature with posterior nanophthalmos.

Posterior microphthalmos is a rare condition which is characterized by the disproportionately small size of the posterior segment of the eye. The corneal diameter, central anterior chamber depth and the lens thickness are all within the normal range. We present a case of posterior microphthalmos with all normal anterior segment measurements except increased corneal curvature.