Microsporidial Keratitis - First Case Series of a Rare Pathogen in the Wake of Flood Disasters of 2022 in Pakistan.

The recent monsoon rains in Pakistan were unprecedented and caused flooding all over Pakistan, especially in Sindh and Balochistan. Following this national disaster, various water-borne and contagious diseases started erupting all over the country. In such a calamity-struck city of Jacobabad, we started receiving cases with a peculiar set of ocular complaints mimicking viral keratoconjunctivitis. Failure to respond to traditional treatment and the unique appearance of these corneal opacities led to a rare diagnosis of Microsporidial Keratoconjunctivitis, which was later confirmed by microscopy and staining of corneal scrapings of the most affected case. In line with published literature, all cases were treated with topical fluoroquinolone and topical anti-fungal therapy, following which the disease was cleared within a week. The disease has seen an upward trend the world over, especially among Asia. To the best of our knowledge, no such cases have been reported in Pakistan as yet. In this case series, we highlight the strong correlation of emergence of microsporidial keratitis in patients following exposure to pooled water bodies after the monsoon rainy season and floods. Moreover, this report will help create awareness in eye professionals regarding the prevention, timely diagnosis and treatment of these rare and emerging cases. Key Words: Keratitis, Spores, Water-borne diseases, Microsporidia.

Visual outcome and its prognostic factors in patients presenting with ocular war injuries at an army hospital in Pakistan.

OBJECTIVE: To determine the visual outcome and its prognostic factors in patients presenting with ocular war injuries. METHODS: This descriptive, observational study was conducted at the Combined Military Hospital, Peshawar, Pakistan, from June 2012 to March 2016, and comprised soldiers with ocular war injuries. Informed consent was obtained from all participants. A predesigned proforma was used to record patient's demographic details along with the cause, side, type and severity of injury. Injuries were classified as open globe or closed globe injuries. Ocular trauma score grade was used to describe the severity of injury. RESULTS: There were 210 participants with an overall mean age of 29.34±5.35 years (range: 20-43 years). All of them were male. Left side was more frequently involved, i.e. in 126(60%) cases. The most frequent underlying cause was improvised explosive device blast injury 114(54.3%), followed by blunt trauma 42(20%) and road traffic accidents 24(11.4%). Closed globe injuries were more frequent and were recorded in 120(57.1%) patients. The visual outcome was good in 62(29.5%) patients, followed by fair in 51(24.3%) patients while 51(24.3%) patients had worst visual outcome. When stratified, there was no significant difference of worst visual outcome with patient's age (p=0.279). However, improvised explosive device blast (p=0.002), open globe injury (p=0.000), ocular trauma score grade 1; open globe (p=0.049), closed globe (p=0.003) were associated with significantly higher frequency of worst visual outcome. Zone-III injury was also prognostic of worst visual outcome, but the difference was significant only in case of open globe injury (p=0.003). CONCLUSIONS: Improvised explosive device blast, open globe injury and ocular trauma score grade 1 were poor prognostic features and resulted in significantly higher frequency of poor visual outcome.

Determining the efficacy of corneal crosslinking in progressive keratoconus.

OBJECTIVE: To determine the Efficacy of Corneal Crosslinkage (CXL), using Corneal Topography, in eyes with progressive Keratoconus. METHODS: This randomized control trial was conducted at Armed Forces Institute of Ophthalmology, Rawalpindi, Pakistan from October 2013 to April 2014. A total of 60 eyes of 30 patients were included who presented with bilateral progressive Keratoconus. Each eye of the patient was randomized either to a treatment group (Group-A) or control untreated group (Group-B) of 30 eyes each. A written informed consent was obtained from each patient, following which corneal crosslinkage (CXL) with topical riboflavin eye drops was performed. Follow up visit was done at three months post operatively, Corneal topography was repeated and recorded. RESULTS: The mean age of the patients was 23.13±7.62 years (range 13 to 39 years). There were 26 males and 34 females patients. The mean simK value at the start of study was 50.94±4.84 diopters in Group-A and 49.73±5.24 diopters in Group-B. At three months follow-up, the mean simK value was significantly lower in Group-A (48.28±4.47) as compared to Group-B (51.11±4.85). Keratoconus improved/ remained stable in 34 (56.7%) eyes while progressive disease was noted in 26 (43.3%) eyes. When compared between the groups, the frequency of efficacy was significantly higher in Group-A (86.7% vs. 26.7%; p=.000) as compared to Group-B. CONCLUSION: Corneal Crosslinking was found effective in causing regression or halting the progression of disease in patients with progressive Keratoconus at three months follow-up, however, the efficacy of corneal crosslinking was unaffected by patient's age and gender.

Etiology and severity of various forms of ocular war injuries in patients presenting at an Army Hospital in Pakistan.

OBJECTIVE: To determine the etiology and severity of various forms of ocular war injuries in patients presenting at an Army Hospital in Pakistan. METHODS: This cross sectional study was conducted at the Department of Ophthalmology, Combined Military Hospital, Peshawar over four years period from June 2012 through March 2016, Two hundred ten consecutive soldiers who presented with ocular war injuries were included for analysis after taking written informed consent. A predesigned proforma was used to record patient's demographic details along with the cause, side, type and severity of injury, ocular trauma score was also recorded at presentation. RESULTS: The mean age of the patients was 29.34±5.35 years. All of them were males. Left side was more frequently involved (n=126, 60.0%) and the most frequent underlying cause was IED blast injury (n=114, 54.3%). Closed globe injuries were more frequent and were recorded in 120 (57.1%) patients. Upon assigning Ocular Trauma Score, Grade-V (28.6%) injuries were the most frequent followed by Grade-I (25.7%), Grade III (25.7%), Grade II (11.4%) and Grade IV (8.6%). When stratified for the type of injury, OTS Grade I injuries were highest (60.0%) among patients with open globe injuries, hence poorer prognosis, while OTS Grade V injuries were highest (50.0%) among patients with closed globe injuries (p=0.000). CONCLUSION: IED blast injuries are most frequently encountered ocular war injuries often involving soldiers in the age group 20-30 years. These open globe injuries had worst clinical presentation to begin with and poorer prognosis than closed globe injuries.