Comparison of Corneal Stromal Demarcation Line Depth in Epi-off and Epi-on Corneal CrossLinking Using Anterior Segment Optical Coherence Tomograph

Objective: To compare the corneal stromal demarcation line depth after Epithelium-On and Epithelium-Off corneal crosslinking in patients with keratoconus using anterior segment Optical Coherence Tomography (AS-OCT). Study design: Quasi-experimental study. Place and Duration of Study: Armed Forces Institute of Ophthalmology, Rawalpindi Pakistan from Jun 2018 to Jun 2019. Methodology: This study included patients (60 eyes) with progressive keratoconus treated with procedure CXL (corneal cross linkage). There were 30 eyes in each group. Two different protocols of Corneal cross linkage were performed, and patients were divided into two groups according to protocol: 1) epithelium-on Corneal cross-linkage, 2) epithelium-off Corneal crosslinkage. In the First-Group, epithelium-on Corneal cross-linkage,corneal epithelium was not removed, riboflavin solution was instilled on the cornea for one hour, and the cornea was exposed to Ultraviolet A rays. In Epithelium off Corneal cross-linkage,after epithelium was removed by spatula, riboflavin solution was instilled for 30 minutes, and Ultraviolet-A rays were focused on the cornea. After one month of the procedure, Anterior segment Optical Coherence Tomography was performed.Demarcation line depth was measured in treated corneas in all patients from both groups, and findings were compared. Results: The stromal demarcation line depth was similar in both groups, and there was no statistical difference between the groups. The mean value of demarcation line depth was 277.13±107.09 цm (p>0.05). Conclusion: Corneal stromal demarcation line depth after both procedures was similar in both groups after one month of Corneal cross-linkage, so it was concluded that epithelium-on Corneal cross-linkage was comparable to epithelium-off Corneal cross-linkage.

INHIBITION OF SURGICALLY INDUCED MIOSIS WITH NEPAFENAC

Objective: To assess the efficacy of prophylactic administration of 0.1% nepafenac in the maintenance of trans-operative mydriasis following cataract surgery. Study Design: Quasi-experimental study. Place and Duration of Study: Armed Forces Institute of Ophthalmology, Rawalpindi, from Oct 2018 to Mar 2019. Methodology: A total of 70 patients undergoing cataract surgery phacoemulsification were randomly placed in either the control group or the nepafenac group. Nepafenac eye drops were administered as one drop 8 hourly, 3 days before surgery. Control group didn’t receive any medication preoperatively Mydriasis was measured trans-operatively before surgery, after aspiration of the cortex, and then at the end of surgery. Patients of both groups received tobradex 2 weeks post-surgery. Results: Post-surgery statistically significant (0.001) difference was observed in the mean pupil size between the nepafenac group (7.88 ± 0.49) and the control group (6.57 ± 0.92 mm). Conclusion: Use of nepafenac prophylactically was very effective in maintenance of trans-operative mydriasis in cataract surgery.

Painless Posterior Scleritis: A Rare Presentation

Posterior scleritis is an underdiagnosed condition due to its rarity and is frequently misdiagnosed due to its varied presentation.1 Therefore, it is imperative to know that it can present clinically as exudative retinal detachment, proptosis, disc oedema, choroidal folds, subretinal mass, and myositis. We report a case of 48-year female who presented with gradual, progressive loss of vision in left eye. There were multiple exudative retinal detachments with choroidal folds and disc oedema. Ultrasonography (USG) B scan and contrast enhanced magnetic resonance imaging (MRI) orbit revealed the classic T-sign. With oral steroids, she improved clinically. Posterior scleritis is a painful condition, but the patient did not report any pain in or around the globe, which makes this case a unique experience. Key Words: Posterior scleritis, Exudative retinal detachment, T-sign.

FREQUENCY OF REFRACTIVE ERROR AND AMBLYOPIA IN STRABISMUS IN PEDIATRIC AGE GROUP

Objective: To see the frequency and compare the type of refractive error and strabismus in amblyopic versus non amblyopic children. Study Design: Comparative cross sectional study. Place and Duration of Study: Armed Forces Institute of Ophthalmology, Rawalpindi, from Jan to Jul 2019. Methodology: The sample population comprised of 250 patients of new or previously diagnosed children with refractive error and strabismus presenting at children eye outdoor patient department of armed forces institute of ophthalmology. Strabismus was diagnosed by the consultant eye specialist on the basis of heterotropia at near or distance fixation. Amblyopia and refracttive error was assessed by a trained optometrist. Patients were classified into amblyopia and non- amblyopia groups. The type of squint and refractive error was noted down along with demographic details. Chi square test was used to assess thesignificance of association between various categorical variables. Results: A total of 250 participants were included with a mean age of 5.00 ± 1.07 years. Out of total, 132 (52.8%) were males while 118 (47.2%) were females. One hundred and fifty (59.5%) patients were suffering from amblyopia while 100 (39.5%) patients were normal with comparable vision in both the eyes. Out of 150 amblyopic patients 134 (89.3%) were suffering from unilateral amblyopia while 16 (10.6%) patients had amblyopia in both the eyes. Out of refractive errors astigmatism was present in 83 (55.3 %) of amblyopia patients while hypermetropia was present in 54 (36%) of the patients. Out of total patients of strabismus, 95 (63.3%) of non-alternating esotropic patients..........

Comparison of High Intensity Accelerated Corneal Cross Linking Protocols in Treatment of Progressive Keratoconus;

Purpose:  To compare the safety and efficacy of Accelerated Corneal Cross Linking (AXL) protocols ,9mW/cm2 for 10 min with 18mW/cm2 for 5 min in terms of refractive and topographic keratometric indices in patients with progressive keratoconus over 3, 6, 12 and 18 months follow-up. Study Design:  Quasi experimental study. Place and Duration of Study:  Armed Forces Institute of Ophthalmology Rawalpindi Pakistan, from Nov 2016 to Jun 2018. Material and Methods:  Sixty eyes, 30 in each group, of 55 consecutive patients diagnosed with progressive keratoconus were enrolled through convenience sampling and were subjected to AXL with irradiance protocols of 18 watt/cm2 for 5 minutes in group 1 and 9mwatt/cm2 for 10 minutes in group 2. All patients underwent a comprehensive ophthalmic examination at baseline and postoperative follow up visits at 3, 6, 12 and 18 months. Primary outcome parameter was disease stability defined as increase in maximum keratometry over baseline K max of no more than 1 diopter at 1 year after AXL. Statistical analysis of data was performed with IBM SPSS software (version 20.0 SPSS). P value of < 0.05 was considered as statistically significant. Results:  Disease stability was 96 % in each group. At the final time point of 18 months, group 2 (AXL 9mmwatt/cm2 for 10 min) was superior as compared to group 1 (AXL 18mmwatt/cm2 for 5 min) in terms of flattening of steep and sim K (p = 0.007, 0.023 respectively). Conclusion:  The two AXL protocols are safe and appear to show comparable efficacy in disease stability. They can be used alternatively in the treatment of progressive keratoconus.

Data on fundus images for vessels segmentation, detection of hypertensive retinopathy, diabetic retinopathy and papilledema

This paper presents a dataset that contains 100 high quality fundus images which are acquired from Armed Forces Institute of Ophthalmology (AFIO), Rawalpindi Pakistan. The dataset has been marked by four expert ophthalmologists to aid clinicians and researchers in screening hypertensive retinopathy, diabetic retinopathy and papilledema cases. Moreover, it contains highly detailed annotations for retinal blood vascular patterns, arteries and veins to calculate arteriovenous ratio (AVR), optic nerve head (ONH) region and other retinal anomalies such as hard exudates and cotton wool spots etc. The dataset is extremely useful for the researchers who are working in the ophthalmic image analysis.

Awareness and Preventative Behaviours Regarding Toxoplasma, Listeria and Cytomegalovirus Among Pregnant Women

Aim Infection with toxoplasma, listeria and cytomegalovirus (CMV) infections can negatively affect pregnancy outcomes. Awareness of these infections, knowledge of preventive practices and pertinent behaviours was assessed. Methods A survey of patients at antenatal clinics in a Dublin maternity hospital was conducted over a six month period. Analysis was undertaken using SPSS. Results The response rate was 36% (287/800). One in two respondents were aware of toxoplasma, one in four of Listeria but only 1 in 10 of CMV. Overall, knowledge was highest among older, more educated pregnant women. Nativity had a significant effect on knowledge and behaviour, but increasing parity did not. However the majority practised key safe behaviours. Conclusion Information must be conveyed to pregnant women in a user friendly format and in a culturally sensitive way.

Safety Of High Intensity Accelerated Corneal Collagen Cross-Linking In Keratoconus Patients On Basis Of Endothelial Cell Density

BACKGROUND

This study was conducted to evaluate the safety of accelerated corneal collagen crosslinking (CXL) in keratoconus patients on basis of endothelial cell density measurements.

METHODS

We studied 24 patients (42 eyes) with diagnosed keratoconus who underwent accelerated CXL with 9 Mw/cm2 UVA irradiance for 10minutes. All patients underwent detailed examination and video keratography (VKG) for classification and confirmation of keratoconus. Patients with central corneal thickness (CCT) of ≥400μ were included in the study. Specular microscopy was done to note endothelial cell density (ECD) preoperatively and then at the end of 1st, 4th and 12th weeks' post-operative period.

RESULTS

The study included 24 patients (42 eyes) from October 2016 to June 2017. Among these 13 were females and 11 males with mean age of 20.15±6.73 years. Eighteen patients underwent the procedure in both eyes while 6 had the procedure in one eye. The pre-operative ECD mean±SD of right eye was 2743.97±542.77/mm2 and left eye was 2763.35±532.57/mm2. The post-operative ECD mean±SD of right and left eyes at the end of 12th post-op weak were 2806.34±520.11/mm2 and 2823.30±628.57/mm2 respectively. The pre and post-op ECD comparison showed p-values at first week post-op are 0.474 and 0.683 for right and left eyes respectively. Similarly, the p-values at 4th and 12 weeks post-op for right eye are 0.266 and 0.280 respectively. The p-values at 4th and 12th weeks for left eye are 0.913 and 0.404 respectively.

CONCLUSIONS

Accelerated CXL protocols is safe and effective procedure and did not lead to significant change in ECD in our study population in three months post-procedural follow up. However further research is required to determine the effect of high intensity UVA radiation on other ocular structures with larger group of patients and long-term follow up.

Unilateral-external Ophthalmoplegia: ARare Presentation of Myasthenia Gravis

Myasthenia gravis (MG) is a disease of autoimmunity with variable and diverse clinical presentations. The target tissue is neuromuscular junction of skeletal muscles, where efficient nerve impulse transmission is hampered leading to less effective muscle contraction. Patients of MG usually present with bilateral ptosis, diplopia and fatigability, which may or may not coexist with generalised weakness, dysphagia and dysarthria. A46-year male presented with unilateral ptosis and diplopia. Except for unilateral moderate ptosis and restriction of extraocular movements, ocular and systemic examination was normal. Both ice pack and tensilon tests revealed improvement in ptosis. Patient was advised tablet pyridostigmine and prednisolone; and a remarkable improvement was noticed within a week.

Corneal Collagen Cross Linking (CXL) in treatment of Pseudophakic Bullous Keratopathy

Objective:

To determine mean change in visual acuity, central corneal thickness and symptoms in patients with pseudophakic bullous keratopathy after treatment with corneal collagen crosslinking.

Methods:

This quasi experimental study was conducted at Armed Forces Institute of Ophthalmology, Rawalpindi, Pakistan from April 2015 to Nov 2015. A total of 24 eyes of 24 patients were included in the study. Visual symptoms were graded in five grades (Grade 1-5), Grade-1 being very mild with decreased vision only while patients with all five symptoms (decreased vision, foreign body sensations, pain, watering and photophobia) were graded as Grade-5. Corneal collagen cross linking using topical isotonic riboflavin followed by UVA radiations (3mW/cm² for 10 minutes) was performed in all the patients. Visual acuity (VA), visual symptoms and central corneal thickness (CCT) were recorded before and 04 weeks after the treatment.

Results:

A total of 24 eyes of 24 patients (18 male and 6 females) underwent surgery. Age of the patients ranged from 55 to 75 years with mean age 65.83 + 3.89 years. Mean visual acuity was 2.09 + 0.23 before treatment while after treatment it was 2.13 + 0.22. Mean CCT as measured by optical pachymetry (Galilae G6) was 753.96 + 55.16 and 641+ 29.25 before and after surgery respectively. Improvement of clinical symptoms was seen in all the patients.

Conclusion:

Corneal collagen cross linking is a temporary but effective symptomatic treatment of pseudophakic bullous keratopathy.

Automated detection of glaucoma using structural and non structural features

Glaucoma is a chronic disease often called “silent thief of sight” as it has no symptoms and if not detected at an early stage it may cause permanent blindness. Glaucoma progression precedes some structural changes in the retina which aid ophthalmologists to detect glaucoma at an early stage and stop its progression. Fundoscopy is among one of the biomedical imaging techniques to analyze the internal structure of retina. Our proposed technique provides a novel algorithm to detect glaucoma from digital fundus image using a hybrid feature set. This paper proposes a novel combination of structural (cup to disc ratio) and non-structural (texture and intensity) features to improve the accuracy of automated diagnosis of glaucoma. The proposed method introduces a suspect class in automated diagnosis in case of any conflict in decision from structural and non-structural features. The evaluation of proposed algorithm is performed using a local database containing fundus images from 100 patients. This system is designed to refer glaucoma cases from rural areas to specialists and the motivation behind introducing suspect class is to ensure high sensitivity of proposed system. The average sensitivity and specificity of proposed system are 100 and 87 % respectively.

Comparison of primary versus recurrent pterygium after intralesional 5-Fluorouracil

OBJECTIVE

To compare the mean change in corneal astigmatism and clinical appearance after intralesional injection of 5-Fluorouracil in primary and recurrent pterygia.

METHODS

The quasi-experimental study was conducted at the Armed Forces Institute of Ophthalmology, Rawalpindi, Pakistan, from June 2014 to April 2015. The patients were categorised into two groups. Group1 named GP comprised primary pterygia patients, while those of recurrent pterygia were in Group 2 named GR. All the patients were treated with 0.1ml intralesional 5-Fluorouracil 5mg weekly injections for 04 weeks. Ophthalmic clinical evaluation included uncorrected distant visual acuity, keratometery and slit lamp examination was performed before and 04 weeks after the treatment.

RESULTS

There were 86 eyes of 64 patients in the study. Mean uncorrected distant visual acuity of patients was 0.12±0.13 in GP and 0.26±0.17 in GR. Mean astigmatism before treatment was 1.75±1.08 in GP and 2.92±2.28 in GR. Same parameters 04 weeks after last injection were 1.66±1.17 and 2.64±1.78 in GP and GR respectively. All eyes had a statistically significant change in clinical appearance.

CONCLUSIONS

Intralesional 5-Fluorouracil injection improved cosmesis of primary as well as recurrent pterygia, but did not have statistically significant effect on corneal astigmatism.

Effect of intralesional 5 fluorouracil injection in primary pterygium

Objective:

To determine mean change in visual acuity, corneal astigmatism and clinical appearance of pterygium after intralesional injection of 5-Fluorouracil.

Methods:

This was a Quasi experimental study conducted at Armed Forces Institute of Ophthalmology, Rawalpindi, Pakistan from June 2014 to May 2015. Total 68 eyes of 54 patients were included in the study. Patients were treated by injecting 0.1 ml of 5-FU (5mg) weekly injections for 04 weeks. All the patients underwent ophthalmic clinical examination that included Uncorrected distant visual acuity (UCVA), corrected distant visual acuity (CDVA), keratometery with Auto Ref-keratometer (RK-F1, Canon) and slit lamp examination before and 04 weeks after the last injection.

Results:

Total 68 eyes of 54 patients (18 females and 36 males) were treated with intralesional injection of 5 FU. Out of total, 30 were right eyes while 38 were left eyes. Age of patients ranged from 23 to 53 years with mean age of 39.2 ± 4.90 years. Mean UCVA and corneal astigmatism before treatment were 0.162 ± 0.167 and 2.12 ± 1.53 respectively while the same parameters 04 weeks after last injection of 5 FU were 0.166 ± 0.168 and 1.92±1.45 respectively. The magnitude of induced change in astigmatism was (0.235 ± 1.35). Ninety seven percent of the patients showed improvement in clinical appearance.

Conclusion:

Intralesional 5-FU injection results in significant clinical and cosmetic improvement of primary pterygium.

Mode of conception of triplets and high order multiple pregnancies

A retrospective audit was performed of all high order multiple pregnancies (HOMPs) delivered in three maternity hospitals in Dublin between 1999 and 2008. The mode of conception for each pregnancy was established with a view to determining means of reducing their incidence. A total of 101 HOMPs occurred, 93 triplet, 7 quadruplet and 1 quintuplet. Information regarding the mode of conception was available for 78 (81%) pregnancies. Twenty eight (27.7%) were spontaneous, 34 (33.7%) followedlVF/ICSI/FET treatment (in-vitro fertilisation, intracytoplasmic sperm injection, frozen embryo transfer), 16 (15.8%) resulted from Clomiphene Citrate treatment and 6 (6%) followed ovulation induction with gonadotrophins. Triplet and HOMPs are a major cause of maternal, feta land neonatal morbidity. Many are iatrogenic, arising from fertility treatments including Clomiphene. Reducing the numbers of embryos transferred will address IVF/ICSI/FET-related multiple pregnancy rates and this is currently happening in Ireland. Clomiphene and gonadotrophins should only be prescribed when appropriate resources are available to monitor patients adequately.