Mean Ocular Perfusion Pressure Effect During Pars Plana Vitrectomy on the Foveal Avascular Zone: A Pilot Study.

Purpose: To evaluate the effect of mean ocular perfusion pressure on the foveal avascular zone (FAZ) area in eyes with successful retinal detachment (RD) surgery. Methods: This prospective pilot fellow eye-controlled study measured the intraoperative mean ocular perfusion pressure in eyes having surgery for rhegmatogenous RD (RRD). Postoperatively, the FAZ area was measured; the change was calculated as the difference in the FAZ area between the operated eye and the contralateral control eye. Results: The study comprised 8 patients with a mean age (±SD) of 53.38 ± 13.92 years. The mean superficial FAZ area was not different between operated eyes and control eyes, while the deep FAZ area was significantly larger in operated eyes. There was a strong negative correlation between the mean ocular perfusion pressure and the change in the deep FAZ area (Spearman ρ, -0.73; P = .04); the correlation between the mean ocular perfusion pressure and the change in the superficial FAZ area was not significant (Spearman ρ, -0.24; P = .57). A significant linear regression was found between the mean ocular perfusion pressure and the change in the deep FAZ area (R2 = 0.388). The predicted enlargement of the deep FAZ area was 0.03 mm with every 1 mm Hg decrease in the mean ocular perfusion pressure. Conclusions: Lower intraoperative mean ocular perfusion pressure is associated with enlargement of the deep FAZ area in eyes having successful RRD surgery.

Role of Prophylactic Oral Antibiotics in the Prevention of Post-cataract Surgery Acute Infective Endophthalmitis.

Purpose To evaluate the role of perioperative oral antibiotics in the prevention of acute infective endophthalmitis (IE) after cataract surgery. Methods A prospective cohort study of patients older than 18 years of age undergoing uncomplicated phacoemulsification was conducted. Group A was given post-op oral ciprofloxacin for three days, whereas Group B was not. Both groups received 5% povidone-iodine (PVI) preparation for five minutes in the conjunctival cul-de-sac, and intracameral (IC) 0.5% moxifloxacin was administered at the end of the procedure as prophylaxis. The minimum post-op follow-up period was six weeks. Results Out of 2161 patients, 859 (39.8%) were included in Group A, and 1302 (60.2%) were included in Group B. No significant difference in anterior chamber (AC) reaction was found on day 1 (p = 0.67), day 14 (p = 0.03), or day 45 (p = 0.1). One patient developed acute post-op IE (0.04%) and two patients developed toxic anterior segment syndrome (TASS) from Group A. The non-oral antibiotic group had no serious complications. Conclusion Perioperative oral antibiotic use in routine clinical practice is not recommended for the prevention of acute post-op IE. Pre-op conjunctival PVI 5% for five minutes and IC moxifloxacin at the end of surgery were proven to be effective prophylactic measures in our study.

Suprachoroidal silicone oil migration following 27 gauge 3 ports pars plana vitrectomy - a rare complication and its management.

Suprachoroidal silicone oil migration is an unusual complication of small gauge 3 ports Pars plana vitrectomy (3PPV) system. Our objective is to report a retrospective, observational case of an intra-operative suprachoroidal silicone oil (SO) migration during 27 gauge 3PPV and its successful surgical management. A 49 years old male patient with type 2 diabetes, presented to the ophthalmology outpatient department with reduced visual acuity in his right eye. He was diagnosed as having tractional retinal detachment involving macula. During combined phaco-vitrectomy following injection of SO, peripheral choroidal elevations were noted suggesting suprachoroidal SO migration. In an attempt to drain this intra-operatively nasal sclerotomy was enlarged. Post-operative B scan showed significant choroidal detachment for which patient was re-scheduled for surgery after 1 day. Three radial trans-scleral incisions (2 nasal and 1 temporal) for drainage were made at the site of maximum choroidal detachment. By massaging and widening these scleral incisions, suprachoroidal haemorrhage and SO was successfully drained with good post-operative visual improvement.

The Anatomical and Functional Outcomes of 27-Gauge Pars Plana Vitrectomy in Diabetic Tractional Retinal Detachments in the South Asian Population.

Objective The objective of this article was to report the clinical and surgical outcomes of diabetic tractional retinal detachment (TRD) with 27-gauge plus pars plana vitrectomy (27G+ PPV) Methods This is a retrospective, consecutive cohort study of 196 eyes of 176 patients that underwent 27G+ PPV for TRD from July 2015 to June 2019 at the ophthalmology department of Shifa International Hospital, Islamabad. The outcomes include primary and secondary anatomical attachment of the retina, best-corrected visual acuity, and post-operative complications. Results The mean age of the patients in this study was 55.3 ± 11.3 years. Out of 176 patients, there were 47.2% (n=83) females. The mean operating time calculated was 60 ± 36 min (range 22-130 min). Of 196 eyes, 64.3% (n=126) also combined phacoemulsification with lens implantation. Internal limiting membrane peeling was done in 11.7% (n=23) of the cases. Post-operatively, 98% (n=192) achieved primary retinal attachment, and 1.5% (n=3) underwent a second procedure to achieve retinal attachment. At three months follow-up, the mean best corrected visual acuity (BCVA) remarkably improved from 1.86 ± 0.59 to 0.54 ± 0.32 logarithm of the minimal angle of resolution (logMAR) (p-value<0.001). Among complications, one patient had intra-operative suprachoroidal oil migration, which was managed successfully, while post-operatively, 11 patients (5.6%) developed a transient rise in intraocular pressure, which was controlled with anti-glaucoma drugs, and one patient had vitreous cavity hemorrhage which resolved on its own with time. Conclusion This study strongly suggests that the 27G+ PPV offers successful repair of eyes with diabetic TRD with statistically significant improvement in visual acuity and minimal rate of complications.

Frequency and Outcome of Retinopathy of Prematurity at Tertiary Care Hospital in Pakistan.

OBJECTIVE: To describe the frequency and outcome of Retinopathy of prematurity (ROP). STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: Ophthalmology Department, Shifa International Hospital (SIH) Islamabad from May 2014 to December 2019. METHODOLOGY: All preterm infants with gestational age ≤35 weeks and/or birth weight ≤2000g were included while those born at greater than 35 weeks of gestation and having a gestational weight more than 2000g were excluded from this study. Studied variables included gender, gestational age, birth weight, form and duration of supplemental oxygen, systemic diseases, presence or absence of ROP, ROP stage, treatment, and outcome. RESULTS: Six hundred and twenty-two met the inclusion criteria out of whom 316 were screened. The majority (n=202, 64%) of the screened infants were males. Supplemental oxygen was given to 244 (77.2%) infants. The mean gestational age was 31.94 ± 2.2 weeks. The mean birth weight was 1632 ± 446 g. ROP was diagnosed in 10 (3.2%) infants with stage 1 in 3 (0.9%) infants, stage 2 in 1 (0.3%), stage 3 in 5 (1.5%), and stage 4B in 1 (0.3%) infant. In the infants diagnosed with ROP, mean gestational age was 30.4 ± 2.9 weeks, and mean birth weight was 1393 ± 416 g. ROP regressed spontaneously in 3 infants with stage 1 and 1 infant with stage 2 disease. Infants with stage 3 disease also had disease regression after treatment with intravitreal Ranibizumab (n=3) or intravitreal Bevacizumab (n=2) injection along with concurrent laser photocoagulation (n=1). The infant with 4B ROP underwent bilateral vitrectomy with the complete attachment of retina on follow-up. CONCLUSION: There was a low frequency of 3.2 % of ROP reported in this study. The infants diagnosed with ROP had favorable outcomes following timely treatment of this dreadful disease. KEY WORDS: Retinopathy of prematurity, Eye, Retina, Supplemental oxygen, Screening.

The Clinical and Safety Outcomes of 27 Gauge Pars Plana Vitrectomy in Eyes With Macular Hole.

Objective To report the clinical, visual, and safety outcomes of 27 gauge pars plana vitrectomy (27G PPV) in eyes with full thickness and lamellar macular hole (MH).  Methodology This retrospective cross-sectional study, conducted at the ophthalmology department of Shifa International Hospital, Islamabad, was done on 89 eyes of 85 patients who underwent 27G PPV for full-thickness and lamellar MH with a postoperative follow-up period of six months.  Results The mean age was 61.9 ± 17.3 years with 57.3% being males. Most of the eyes had idiopathic stage III full-thickness MH (n=34, 38.2 %). The total mean operating time was 42.5 ± 19.8 minutes. During surgery, 48 (53.9%) eyes had concurrent phacoemulsification. Hexafluoroethane was the most commonly used tamponade agent (n=81, 91%). Postoperatively, the primary closure rate was 93.2% (n=83) while the final closure rate was 100% (n=6) either by prolonged posturing (n=3, 3.3%) or by an additional procedure involving autologous internal limiting membrane (ILM) transplant (n=3, 3.3%). The complication rate was 2.2% including iatrogenic retinal tear (n=1, 1.1%) and raised IOP (n=1, 1.1%). The overall best-corrected visual acuity (BCVA) improved significantly from 1.20 ± 0.67 to 0.31 ±0.17 (p=<0.001). Conclusion As per this study, 27G PPV is a practical and efficient surgical system with substantial anatomical success, minimal complication, and considerable visual recovery rates in eyes with full thickness and lamellar MH. We suggest 27G PPV with ILM peeling and medium-acting intraocular gas as the standard procedure for MH.

Efficacy and Safety Profile of 25-Gauge Pars Plana Vitrectomy in Rhegmatogenous Retinal Detachment in Pakistan: A Multicenter Retrospective Study.

Introduction This study aims to evaluate the primary anatomical success and visual outcomes of 25-gauge pars plana vitrectomy (25g PPV) in patients with rhegmatogenous retinal detachment (RRD) in Pakistan. Design This is a five-year retrospective, interventional cohort study conducted at tertiary care hospitals in Pakistan from October 2013 to October 2018. Methods This is a retrospective, interventional cohort study of 418 consecutive patients with RRD who underwent 25g PPV. All surgeries were performed by two experienced surgeons at tertiary care hospitals in Pakistan. Consecutive patients who underwent 25g PPV surgery as the treatment for RRD from October 2013 to October 2018 were included. We excluded patients who had a history of previous retinal surgery or did not complete the 4-8 weeks of primary outcome visit. We used the Statistical Package for the Social Sciences (SPSS) version 23.0 (IBM Corporation, Armonk, NY, USA) for statistical analysis. A p-value of <0.05 was considered significant. Results We identified 452 patients through the coding system of our hospitals who underwent 25g PPV surgery for RRD during the study period. A total of 441 patient files were reviewed for the study, of which 418 patients met the criteria for final analysis. The mean age was 49 ± 15.8 years. There was a higher number of males (n = 284, 67.9%). In our study, 186 (44.4%) patients were phakic at the time of presentation. The macula was detached in 361 (86.4%) patients. At the primary outcome visit (4-8 weeks of follow-up), the primary anatomical success rate was 89.47%. The most common cause of failure was proliferative vitreoretinopathy (PVR) (n = 20), followed by missed breaks (n = 5). Conclusions The surgical outcomes of RRD with 25g PPV surgery in our study were similar to the outcomes reported in the developed world. We propose a prospective multicenter national study to prospectively evaluate the risk factors for RRD surgical failure in the Pakistani population.

Comprehensive overview of IRVAN syndrome: a structured review of Case Reports and Case Series.

Idiopathic retinal vasculitis, aneurysms, and neuroretinitis (IRVAN) syndrome is a rare spectrum of retinal vasculitis, aneurysms, and neuroretinitis affecting young individuals in their third decade. Most of our current knowledge is based on case reports, case series, and a handful of collaborative studies. There is much diversity in treatment approaches and outcomes in the reported literature. We have aggregated published case reports and case series into quantitative and narrative synthesis to draw evidence-based conclusions toward clinical features, atypical and rare findings, systemic associations, disease course, and treatment outcomes. The analysis suggested the disease mostly affects young individuals with a female predilection. Anterior chamber and vitreous inflammation are common than previously believed. The most prevalent pattern of retinal vasculitis in IRVAN eyes is mixed vasculitis, followed by arteritis and phlebitis. Most eyes at the time of presentation have capillary nonperfusion and require treatment. Most eyes retain good visual acuity; however, treatment is required to maintain visual function. Intravitreal antivascular endothelial growth factors administered as an adjunct to retinal laser photocoagulation are more likely to improve visual outcomes. Besides, we have discussed the different hypotheses on the etiopathogenesis of the disease and stronger evidence suggests an inflammatory origin of the disease.

Do affluent nations value a clean environment and preserve it? Evaluating the N-shaped environmental Kuznets curve.

Since industrialization, the world has been under great strain from rising temperatures. Economies work hard to boost economic growth by sacrificing natural surroundings that are degrading owing to increased carbon emissions from unsustainable production and consumption. The race-to-the-bottom strategy is seen in different parts of the globalized world, corroborating the pollution haven concept and energy-related emissions. The study assumed that once affluent nations reached a particular economic level, they would concentrate on environmental reforms to safeguard environmental and natural resources. The study built a model of the emissions-growth nexus by controlling inward FDI, information and communication technology, research and development expenditures, and renewable energy using aggregated data from high-income nations from 1976 to 2019. The study verified the N-shaped environmental Kuznets curve using a three-degree polynomial factor of per capita income. On the other hand, inward FDI was assessed as having the potential to support the pollution haven hypothesis (PHH) by increasing carbon emissions. The data show that the square and cubic forms of per capita income have a significant negative and positive effect on carbon emissions in the long run, corroborating the short-peak V-shaped EKC hypothesis. However, the N-shaped EKC hypothesis between income and emissions is verified in the short run. The PHH confirmed that more inward FDI is associated with higher long-term carbon emissions. For decreasing global carbon emissions and unclean production, stringent and incentive-based regulations are preferable.

Impact of COVID-19 lockdown on Retinal Surgeries.

OBJECTIVES: To determine the frequency and severity of surgical Vitreo-Retinal diseases during COVID-19 lockdown period (LP) and compare it with same period last year. METHODS: Single hospital based retrospective Cohort Study. Data of the patients that underwent retinal surgeries during the COVID-19 LP i.e., 23-03-2020 till 23-06-2020 and same period last year i.e., 23-03-2019 till 23-06-2019 was analyzed. RESULTS: One hundred thirty-six eyes of 105 patients were included. Among these eyes, 48 (35.3%) were operated during the COVID-19 LP while 88 (64.7%) were operated during the same time last year. A decline of 45.5% (p=0.023) was observed in the frequency of surgeries during the LP. Mean age of patients during the LP was 43.2 ± 20.3 years compared to 48.4 ± 17.9 years last year. There was reduction in the surgeries for Diabetic Tractional Retinal Detachment (11.4% vs 4.2% during LP, p=0.166), Vitreous hemorrhage (10.2 % vs 8.3% during LP, p=0.04), Full thickness macular hole (3.4% vs 0% during LP) and Epiretinal membrane (12.5% vs 0% during LP). While Rhegmatogenous retinal detachment (27.3% vs 58.3% during LP, p<0.001) among other disorders had a higher proportion during the LP. CONCLUSION: The decline in the frequency of retinal surgeries during the LP is indicative of complex pathologies presenting later with more advanced disease. However, earlier presentation and an increase trend in surgeries for RRD during the LP shows the positive impact of free time on the health concerns of our population.

Outcomes of 27gauge pars plana vitrectomy for a variety of posterior segment diseases.

OBJECTIVE: To report outcomes of 27 gauge pars plana vitrectomy for the management of a variety of simple to complex posterior segment disorders. METHODS: This retrospective cohort study was conducted at the Shifa International Hospital, Islamabad, Pakistan, and comprised data of all patients who underwent 27 gauge pars plana vitrectomy between July 1, 2015, and June 30, 2019, for a variety of indications. Data noted included age, gender, laterality, diagnosis, pre-operative visual acuity, date of surgery and surgical details, including operating time and complications. Best corrected visual acuity at 3 months was also recorded. Data was analysed using SPSS 21. RESULTS: Of the 574 patients, 355(62%) were males and 219(38%) were females. The overall mean age was 55±16.9 years. There were total 665 eyes as 91(15.8%) patients underwent bilateral surgeries. The most common surgical indications were diabetic tractional retinal detachment 196(29.5%) and vitreous haemorrhage 191(28.7%). Mean operating time was 62± 37 minutes. With the exception of 0.34% cases where 20 gauge fragmatome was used, no case required conversion to 20 gauge system, while 25 gauge trocar was used for silicon oil injection. Per-operative complications included iatrogenic retinal tear 2(0.3%) eyes and supra choroidal silicon oil migration 1(0.15%) eye. Post-operative complications were raised intraocular pressure 7(1.05%), endophthalmitis 1(0.15%) eye, haemorrhagic occlusive retinal vasculitis 1(0.15%) eye and rhegmatogenous retinal detachment 2(0.3%) eyes. Mean best corrected visual acuity improved from 1.62± 0.68 to 0.4± 0.38 logarithm of minimum angle of resolution (p<0.001). CONCLUSIONS: The 27 gauge pars plana vitrectomy was found to be a safe and effective procedure for both simple and complex retinal pathologies requiring significant surgical manipulation.

Various Spectrum Of Ocular Tuberculosis.

Mycobacterium Tuberculosis may infect any organ in the body, when it affects ocular tissue symptoms are vague and hence diagnosis is challenging, through a number of cases reported in our clinic it is emphasized to make quantiferon test as part of routine investigation for cases of presenting with uveitis thus leading to timely diagnosis and accurate treatment.

Incidence of endophthalmitis following intravitreal anti VEGF injections at a tertiary care hospital in Pakistan.

OBJECTIVE: To assess the rate of infectious endophthalmitis with anti-vascular endothelial growth factor injection, and to evaluate institutional procedure protocol in this regard. METHODS: The retrospective consecutive case series was conducted at Shifa International Hospital, Islamabad, Pakistan, from August 2018 to January 2019, and comprised 5-year data from August 2014 to July 2019 related to patients who underwent intravitreal anti-vascular endothelial growth factor injections. Data was analysed using SPSS 21. RESULTS: Of the 7,542 injections administered to 2,734 patients, 5,976(79.2%) were bevacizumab, 1,081(14.3%) ranibizumab and 485(6.4%) aflibercept. There was 1(0.01%) case of infectious endophthalmitis which was treated with 25 gauge pars plana vitrectomy. CONCLUSIONS: The institutional procedure protocol was found to be effective as the rate of infectious endophthalmitis was lower than what is reported in literature.