Outcomes of Maximum Levator Resection in Severe Upper Eyelid Ptosis at a Tertiary Oculoplastic Service

Purpose: To investigate the surgical outcomes of maximum Levator resection in cases of severe upper eyelid ptosis at a tertiary oculoplastic service. Study Design: Interventional case series. Place and Duration of Study: Department of Ophthalmology, Lady Reading Hospital, Medical Teaching Hospital, Peshawar January 2013 to December 2017. Methods: One hundred and twenty three eyes of 107 patients, who underwent maximum levator resection for severe congenital ptosis were included. Patients with missing or incomplete notes, patients with previous ptosis surgery and ptosis other than congenital were excluded. Maximum levator resection of the muscle above the Whitnall ligament was performed under local/general anesthesia. All patients had a minimum of 6 months and maximum of 5 years followup. The postoperative complications were recorded and followed. Post operative followup was done at day one, week one and at four weekly intervals till the end of the study. Results: Out of 123 eyes, satisfactory results (excellent or good) were obtained in 111 (90.1%) eyes. Majority of the patients (56.09%) were females. Mean Preoperative Levator function was 2.3 ± 1.1mm. Mean Preoperative MRD1 was ?0.1 ± 1.5 mm and mean postoperative MRD1 was 3.9 ± 01.0 mm. The commonest complication was over correction which occurred in 5 (4.06%) cases, under correction in 4 (3.25%), crease abnormality in 2 (1.62%) cases and entropion was seen in only one (0.81%) case. Success rate was 90.1% at 6 months to 5-years followup. Key Words: Blepharoptosis; Levator resection; Levator function.

Outcome of Amniotic Membrane Transplant in Persistent Corneal Epithelial Defects

Purpose: To determine the outcome of amniotic membrane transplant in patients with ocular surface disease. Study Design: Interventional Case series study Place and Duration of Study: Layton Rahmatullah Benevolent Trust Eye Hospital, Korangi 2½, Karachi, from January, 2019 to July 2019. Methods: Patients with an age range of 20–45 years, either gender and who had persistent corneal epithelial defects as a consequence of keratitis, chemical injuries, bullous keratopathy and Mooren’s ulcers were included. Informed consent was obtained. Preserved amniotic membrane was used in all patients and they were followed at 1 week, 1, 3 and finally at 6 months and results were evaluated in terms of stable, healed and pain-free cornea. Results: Mean age of the patients was 37.94 ± 6.78 years. Majority of the patients (60.0%) were less than 40 years of age. Out of 58 patients, 45 (77.6%) were males and 13 (22.4%) were females. Mean duration of injury was 7.67 ± 2.28 weeks with majority of patients i.e. 62% were with less than 8 weeks of duration. Most common cause of persistent corneal epithelial defect was bacterial keratitis (17.2%) followed by vegetative trauma (13.8%). Successful surgical outcome as healed cornea was observed in 53 (91.4%) patients. Conclusion: Amniotic membrane transplant is an effective treatment for persistent corneal epithelial defects unresponsive to standard medical treatment. This surgical technique is effective in terms of healing and resolving the inflammation and preserving the useful vision. Key Words: Persistant corneal epithelial defect, Amniotic Membrane, Bullous keratopathy.

Implementation of Standard Operating Procedure in Ophthalmic Practice during Covid 19 Era across Pakistan

Purpose: To analyze the implementation of standard operating procedures (SOP) in different ophthalmic settings of Pakistan during Covid 19. Study Design: Cross sectional online survey. Place and Duration of Study: Baqai Medical University & Karachi Medical and Dental College, from 11th to 25th January 2021. Methods: This online survey included doctors working as consultants, medical officers and trainees in ophthalmology setups. A self-designed questionnaire on Google forms was sent online to see the implementation of standard operating procedures during COVID 19. Results: A total of 400 participants were selected by snowball sampling technique. A response rate was 105 (26.5%). Females were 66 (62.86%). Among all participants, 36.19% responded that they always screened patients for COVID 19 at reception. Doctors who always wore masks were 96.19%. Out of those who responded, 16.19% and 11.43% always wore protective goggles and disposable gowns respectively. Only 55.24% practiced hand sanitization, 18.10% washed hands with soap and 30.48% cleaned slit lamps after seeing each patient. Doctors who always asked for PCR before ocular surgery under general anesthesia were 65 (61.90%) and for local anesthesia were 36 (34.29%). Direct Ophthalmoscopy, tonometry, and gonioscopy were performed when necessary by 56.19%, 80.00%, 80.00% of doctors respectively. Only 69.5% were satisfied with precautionary measures. Conclusion: Clinic management needs improvement in implementing SOPs among patients in an eye OPD. Fifty percent of the ophthalmologists received PPE by their administration. Only 69.5% doctors were satisfied with precautionary measures. Key Words: COVID 19, standard operating procedures, Pakistan, Ophthalmology

A National Survey of Endophthalmitis Prophylaxis during Cataract Surgery in Pakistan: A 2020 Perspective

Purpose: To assess national endophthalmitis prophylaxis practice patterns during phacoemulsification surgery in Pakistan. Study Design: Cross sectional survey. Place and Duration of Study: Eye units registered with the British Pakistani Ophthalmic Society (BPOS) between September and November 2020. Methods: A survey-based cross sectional study was conducted in Pakistan between September and November 2020. A proforma was designed using a survey client (Survey Monkey) and distributed to the eye units registered with the British Pakistani Ophthalmic Society (BPOS). The survey explored demographic factors, current antibiotic prophylaxis practice during cataract surgery and audit practice in Pakistan. Results: A total of 339 respondents completed the survey. The survey was representative of ophthalmic surgeons working in the major provinces of Pakistan. A small majority of ophthalmic surgeons provided some form of routine antibiotic prophylaxis (n = 140, 53.8%). Povidone iodine 5% (PVP-I) solution on skin and in the conjunctival sac proved the most popular protocol (n = 163, 66.3%). This was followed by immediate postoperative topical antibiotics (n = 101, 41.1%). Intracameral antibiotic prophylaxis accounted for less than half of current antibiotic practice during cataract surgery in Pakistan (n=99, 40.3%). Most of the respondents did not conduct any audit regarding endophthalmitis (n = 119, 55.6%). Conclusion: Our survey provides an up-to-date view on the state of antibiotic prophylaxis during cataract surgery in Pakistan and highlights several areas for improvement. This includes policy changes to increase adherence to gold standard antibiotic prophylaxis guidelines, improvement in transparency of surgical outcomes and to audit current postoperative outcomes. Key Words: Acute postoperative endophthalmitis, Surgical wound infection, Antibiotic, Cataract, Pakistan.

What Should the Earliest Age be for Clinical Trials of Corneal Crosslinking for Keratoconus?

Keratoconus is often diagnosed in the second or third decade of life, with a younger mean age at diagnosis more likely among those of Middle Eastern and Asian descent (1). Studies have shown that patients with severe forms of keratoconus present at a younger age (usually in the second decade of life), and these patients have more rapid progression of disease (2-6). Pediatric keratoconus is generally attributed to disease manifesting in those less than 18 years of age, however studies that looked at progression in different age groups used varying age criteria. Léoni-Mesplié et al. found that at diagnosis, keratoconus is often more advanced in children (defined as ?15 years) than in adults (?27 years), while Tuft et al. found that patients ?18 years at time of diagnosis progressed to transplantation faster than patients >18 years of age (5-6). McMahon et al. found that the rate of change in corneal curvature was substantially greater in patients <20 years old and slowed down dramatically in those ?20 years old (7). Until the late 1990s when corneal crosslinking (CXL) was initially developed (8) there were no effective means to halt or slow progression, and keratoplasty was the definitive treatment. There was some assertion in the literature that certain contact lenses and intracorneal rings may help slow progression, but no definitive evidence was ever presented (9-11). Ring segments have been shown to improve best corrected visual acuity as well as contact lens tolerance, but do not alter progression of disease (9, 11).

Laser Assisted In Situ Keratomileusis (Lasik) Versus Trans Epithelial Photorefractive Keratectomy (T-Prk) In Astigmatic Patients

Purpose: To compare the results of LASIK versus Trans Epithelial Photorefractive Keratectomy (T-PRK) in correcting astigmatic refractive error. Study Design: Quasi experimental study. Place and Duration of Study: Lahore Medicare Hospital from January to October 2018. Methods: One hundred and twenty six eyes of 63 patients, age 18 to 35 years, either gender, presenting with astigmatism were enrolled in this study. Myopes with spherical equivalent (SE) ? -13.0 diopter sphere (DS), hyperopes with SE ? +5.0 DS and astigmatism ? 1.5 D with visual acuity better or equal to 0.3 LogMAR were included. Astigmatic eyes with < 1.5D and with any other ocular pathology were excluded. Refractive status was assessed by Canon Autorefractor and Heine Retinoscope. Average reading of both methods was taken. Patients were divided into two groups (31: LASIK; 32: trans-PRK) by spin of a coin method. Refractive surgery was done in both groups. Data was analyzed by SPSS 20. Normality of quantitative data was checked by Shapiro Wilk test. Mann Whitney-U test was used for non-parametric data. P-value ? 0.05 was taken as significant. Results: Mean age of the patients was 25.83 ± 3.09 years. The difference in residual sphere, amount of cylinder, axis of cylinder and CCT (central corneal thickness) after surgery in two groups was insignificant. P values were as follows; for sphere p = 0.85, amount of cylinder p = 0.22, axis of cylinder P = 0.46 and CCT p = 0.07. Conclusion: Both techniques are equally good in correcting astigmatism (p = 0.22). LASIK or T?PRK can be done alternatively in patients with astigmatism. Key Words: LASIK, Trans epithelial PRK, Astigmatism.

Knowledge, Attitude and Practice about Diabetic Retinopathy among Medical Students

Purpose: The study was conducted with the aim to decipher knowledge, attitude and practice of diabetic retinopathy among MBBS students of a medical college. Study Design: A cross sectional survey. Place and Duration of Study: Dow Medical College, from October 2019 to March 2020. Methods: A cross sectional study was conducted among 3rd and 4th year medical students. A total of 133 students were questioned through specific questionnaire. After informed consent, demographic details were noted. Apart from source of information of students’ knowledge, set of 14 questions were asked. In the first 7 questions information of knowledge of diabetic retinopathy was addressed. Four questions were about attitude and 3 regarding practice towards diabetic retinopathy. Windows MS Excel was used for quantitative and qualitative analysis. Results: The mean of the overall KAP score for all students was 53.3 ± 1.2 (maximum, 70). Male students scored better in knowledge (24.8 vs 23.7) and attitude (17.3 vs 16.5). Students scored poor in identifying correct values of HbA1c and prevalence of diabetes in our country in the knowledge section. Students also lacked in identifying proper time of followup for screening of diabetic retinopathy. Many students thought uneducated people develop diabetic retinopathy earlier than educated. Conclusion: Our study pointed out weakness in knowledge and practice of medical students regarding prevention and management of diabetic retinopathy. Proper training and teaching of students is required for improved management and counselling of diabetic retinopathy.

Acute Rhino-orbital-cerebral Mucormycosis in a Patient with COVID – 19

COVID-19 patients are known to have immunosuppression due to decreased lymphocytes and increased susceptibility to co-infections (Bacterial and fungal). We present a case of 61-year-old patient who had diabetes, hypertension and ischemic heart disease with COVID-19 infection admitted after RT-PCR positive result. He developed rhino-orbital Mucormycosis during treatment. He received Remdesivir with parenteral Methylprednisolone and Meropenem. While admitted in the ward, he developed signs of orbital cellulitis. Magnetic resonance imaging (MRI) of the brain, orbits, and paranasal sinuses revealed right frontal, ethmoidal, and maxillary sinusitis with the extension of the sinisuidal disease to the orbit. A nasal biopsy revealed broad aseptate filamentous fungal hyphae suggestive of Mucormycosis. Long-term use of steroids/monoclonal antibodies/broad-spectrum antibiotics may contribute to the predisposition to fungal disease. Early diagnosis and prompt management are warranted to avoid morbidity. Key Words: Mucormycosis, COVID – 19, Orbital Cellulitis.

Eye Camp Surgery

Cataract surgery is the most frequently performed operative procedure in the human body.1 In Pakistan, we have very meagre trained Human Resources and equipment.2 At onetime, eye-camp surgery was promoted by the government to tackle the growing burden of cataract-related blindness. As time passed on, we developed public and private health care delivery services. Now we have ample resources to deal with an ever-growing number of cataracts. In the current scenario, eye camp surgery is not justified. But it seems as if government and regulatory bodies have no intentions to focus on this point.

Effect of Supra-Choroidal Triamcinolone Injection on Best-Corrected Visual Acuity and Central Retinal Thickness in Patients with Macular Edema Secondary to Retinal Vein Occlusion

Purpose: To find out the effect of suprachoroidal Triamcinolone injection on best corrected visual acuity (BCVA) and central retinal thickness (CRT) in patients with macular edema secondary to retinal vein occlusion. Study Design: Interventional case series. Place and Duration of Study: College of Ophthalmology and Allied vision Sciences, Ophthalmology department, Unit II Mayo hospital, Lahore, from September 2019 to January 2020. Methods: This study included 45 patients diagnosed with unilateral, retinal vein occlusion associated with macular edema. Patients with previous anti-vascular endothelial growth factor injection or any steroid injection received in the last 3 months or macular edema due to any other cause were excluded from the study. Only one eye of each patient was enrolled. The patients were treated with suprachoroidal triamcinolone injection (4 mg/100µL concentration). Patients with baseline central retinal thickness (CRT) of > 300 µm were included in the study. Serial changes in this parameter were evaluated at 1 week, 1 month and 3?months after suprachoroidal triamcinolone injection. Final CRT and Best-corrected visual acuity (BCVA) was recorded after three months. Results: Out of 45 patients, 26 (57.7%) were males and 19 (42.2%) were females. Majority of the patients (35.4%) were 51–60 years old. During first week the visual acuity was 0.321 ± 0.273 LogMAR, after one month it was 0.468 ± 0.291 and 0.406 ± 0.318 after 03 months with a p value of 0.003. After three months significant decrease in CRT was observed. With a p-value of 0.002. Conclusions: Suprachoroidal injection significantly improves BCVA and decreases CRT in patients with macular edema due to retinal vein Occlusion. Keywords: Retinal vein occlusion, suprachoroidal injection, triamcinolone acetonide.