Comparison of Intraocular Pressure Measurement by Goldmann Applanation Tonometer and Non-Contact Airpuff Tonometer

Purpose: To compare between the intra-ocular pressure (IOP) measured by Goldmann applanation tonometer (GAT) and non-contact air-puff tonometer (APT) considering GAT as gold standard. Study Design: Comparative analytical study Place and Duration of Study: Al-Shifa trust eye Hospital, Rawalpindi from January 2018 to June 2018 Methods: Five hundred individuals, 223 glaucoma patients and 277 non glaucoma control subjects were recruited. After taking a detailed history, slit-lamp examination and fundoscopy was performed to check glaucoma status of the eyes. Retinal nerve fiber layer (RNFL) was checked with optical coherence tomography. Non-contact air-puff tonometry of both eyes were performed. Using a drop of local anesthetic and small amount of fluorescein, intra-ocular pressure was measured with GAT (Haag Streit Diagnostics).Central corneal thickness was measured for correction of IOP measurement with GAT. Paired sample correlations were performed to compare the mean IOP with APT and GAT with and without correction factor. Sensitivity and specificity for measurement of IOP by APT was calculated considering GAT as gold standard. Results: Mean age of the male and female participants was 49.87+18.70years and 45.53+16.91years respectively. Mean IOP in glaucomatous eyes measured by GAT (after applying correction factor) and APT was 16.01+5.57 mmHg and 17.31+7.22 mmHg respectively. The sensitivity and specificity of APT for measuring IOP in glaucomatous eyes were 84.04% and 73.53% respectively. Conclusion: Non-contact air-puff tonometer has good sensitivity and specificity and can be used reliably for measurement of IOP in out-patient department and for mass screening of the population.

Utility of teleconsultation in accessing eye care in a developing country during COVID-19 pandemic

OBJECTIVE

To evaluate the utility of teleconsultation in the provision of eye care services during the COVID-19 lockdown. Disparities in the consultation burden of sub-specialities and socio-demographic differences in teleconsultation utilization were also assessed.

METHODS

Al-Shifa Trust Eye Hospital Rawalpindi began audio and video teleconsultation using broadband telecommunication services during the lockdown. Patients' and consultations' data gathered during the first three weeks after the commencement of this programme were compared with data from the four weeks prior to lockdown. The weekly consultation ratio and overall consultation burden of sub-specialities were measured. Chi-Square tests of association determined the relationship between different variables (socioeconomic status and consultation characteristics) and consultation modality (on-site vs online).

RESULTS

In total, 17507 on-site consultations (4377/week) were conducted compared to 1431 teleconsultations (477/week), which maintained 10.89% of the weekly pre-lockdown eye care services. The post-lockdown teleconsultation programme saw a relatively higher percentage of service utility among female (47.09% vs 44.71%), younger-age (31.33±19.45 vs 41.25±23.32 years) and higher-socioeconomic-status (32.21% vs 0.30%) patients compared to pre-lockdown on-site consultations. The most common indication for teleconsultation was red-eye (16.70%). While cornea and glaucoma clinics maintained most of the pre-lockdown services (30.42% and 29% respectively), the highest dropout was seen in optometric and vitreoretinal services supporting only 5.54% and 8.28% of pre-lockdown services, respectively.

CONCLUSION

Digital initiatives could partially maintain eye care services during the lockdown. Focused strategies to improve teleconsultation utilization are required during the pandemic and beyond.

Assessment of diabetic retinopathy and diabetes management systems in Pakistan using a WHO tool

Using WHO questionnaire known as TADDS(Tool for Assessment of Diabetic Retinopathy and Diabetes Management System), a country wide survey was conducted to assess the health care system for diabetes mellitus (DM) and diabetic retinopathy (DR). This would also provide any evidence of the presence and usefulness of links between the two. A total of 190 key informants for DR and DM services from 47 districts were interviewed. The answers were reviewed and any disagreement was resolved through discussion with stakeholders'. The final results were disseminated. The results showed that diabetes is listed as a priority; national plan exists but programme has not been implemented. Health professionals are unaware about Ministry of Health guidelines. There is infrequent networking between DM and DR care providers. Transport and cost are the main barriers for accessing these services. Out of pocket expenses provide 55% of health care financing.

Spectrum of Biopsy Proven Extraocular Muscle Tumours of Non-Thyroid Origin

OBJECTIVE

To describe different types of primary extraocular muscle (EOM) tumours based on the results of imaging studies, peroperative clinical picture and their histopathological diagnosis.

STUDY DESIGN

Case series.

PLACE AND DURATION OF STUDY

Al-Shifa Trust Eye Hospital, Rawalpindi, from July 2001 to January 2017.

METHODOLOGY

A retrospective analysis of 640 diagnosed orbital tumours was carried out using non-randomised sampling technique, and the prevalence of primary EOM tumours was determined. Based on the results of imaging studies, the clinical picture observed during surgery (orbitotomy) and the histopathological diagnosis, primary EOM tumours were divided into different types, accordingly.

RESULTS

Nineteen (n=19) primary EOM tumours (frequency of 2.96%) had 12 types of histopathological diagnoses, and were categorised into inflammatory tumours (n=8, 42%), vascular tumours (n=4, 21%), lymphoproliferative tumours (n=3, 16%), neurogenic tumours (n=2, 10.5%) and myogenic tumours (n=2, 10.5%). The recti were involved more frequently than obliques (n=15, 78.94% and n=4, 21.06%, respectively). All the patients presented with proptosis of varying degree with some degree of globe rotation and had surgical excision/appropriate management. Visual acuity was not affected in any of the patients. Four (n=4, 21.05%) tumours were malignant (NHL, ASPS, myeloid sarcoma and rhabdomyosarcoma) and these patients underwent chemotherapy and/or radiotherapy.

CONCLUSION

Biopsy-proven primary EOM tumours were devisable into five broad categories. Patients with primary EOM tumours presented with proptosis and impaired ocular motiliy. The primary EOM tumours involved both the recti and the obliques and were excised surgically with favourable outcomes in most cases.

Pediatric Orbital Primitive Neuroectodermal Tumors

PURPOSE

To present the clinical, radiological, histopathological, immunohistochemical features and the follow-up of orbital primitive neuroectodermal tumors (PNETs) in pediatric patients along with a review of the literature.

METHODS

A retrospective analysis of all diagnosed cases of orbital PNET was done. Patients' ophthalmic findings, imaging, immunohistochemistry, metastatic work-up, treatment, globe salvation, and survival were documented and a mini literature review of orbital PNET was performed.

RESULTS

Four diagnosed cases of orbital PNET presented with proptosis and visual impairment were treated during the study period. The radiological imaging showed primary orbital involvement. There were three males and one female with a mean age of 63.75 months (range: 3 to 244 months). Histopathology of all studied patients showed round malignant cells with hyperchromatic nuclei, increased nuclear cytoplasmic ratio, and positive test results for CD99 and FLI-1. The studied patients underwent orbital surgery for excision of tumors followed by chemotherapy. One of the patients also had external radiation in addition to chemotherapy after a second recurrence. The follow-up period of these patients varied from 1 to 5 years. Only one child who had recurrence twice was followed up to 5 years, but was lost to follow-up after that.

CONCLUSIONS

The authors believe that most orbital peripheral PNET tumors present as well-defined masses on both imaging and perioperatively and are easily removed surgically. The apparently disguised "benign profile" of orbital PNET may prove deceptive and the shorter duration of symptoms remains a strong reminder of the malignant nature of the lesion. [J Pediatr Ophthalmol Strabismus. 2018;55(2):93-99.].

Bilateral orbital glial heterotopia: A rare case report

Glial heterotopia is a rare congenital mass that often presents as a unilateral mass lesion in or around the nose. Complete surgical excision is the treatment of choice. However, before any surgical intervention for suspected glial heterotopia, distinction should be made both clinically and radiologically from the pathologically related encephalocele to prevent the risk of cerebrospinal fluid leak and meningitis. Here, we report a rare case of bilateral orbital glial heterotopia in a 2-year-old child with review of the literature.

Knowledge and practices of teachers associated with eye health of primary school children in Rawalpindi, Pakistan

PURPOSE

Teachers' perspectives on eye health can be limited, particularly in developing countries. The aim of this study was to assess teachers' knowledge and practices associated with eye health of primary students in Rawalpindi, Pakistan.

METHODS

This was a cross-sectional survey of primary school teachers. Simple random sampling technique was used to select 443 participants from 34 private and 17 public schools. A self-administered questionnaire was used.

RESULTS

Teachers' knowledge ranged from "high" (35.89%), "moderate" (49.89%), and "low" (14.22%). Teachers' practices associated with students' eye health ranged from "high" (10.16%), "moderate" (23.02%), and "low" (66.82%). The teachers' knowledge index scores increased 4.28 points with successive age groups and increased 2.41 points with each successive level of education. For teachers whose close relatives experienced eye disease, their knowledge index score was 4.51 points higher than those teachers whose relatives never had any eye disease. Teachers' age, education level, and their close relatives experiencing eye disease were significant predictors of their knowledge (R² = 0.087, P < 0.001). Female teachers' practices index score was 10.35 points higher than the male teachers and public school teachers had 10.13 points higher than the private school teachers. Teachers' gender and type of school were significant predictors of their practices (R² = 0.06, P < 0.001).

CONCLUSION

There was a significant gap among primary school teachers' knowledge and practices related to students' eye health. Innovative strategies are needed to improve how teachers address students' eye health issues in the classroom.

Types of orbital osteoma - A descriptive analysis

AIMS

This study describes different types of orbital osteoma based on clinical per-operative morphology and radiological findings to facilitate communication between ophthalmologists and surgical management for a better patient outcome.

MATERIALS AND METHODS

The study was conducted in the Orbit and Oculoplastics Department of Al-Shifa Trust Eye Hospital, Rawalpindi, Pakistan, from July 1, 2001 to June 30, 2014. A retrospective analysis of 520 diagnosed orbital tumours who presented to us was carried out and the prevalence of orbital osteoma was determined. The sampling technique was non-randomized sampling. Based on the clinical morphology observed during surgical intervention as well as the radiological findings of the orbital osteoma, a simple yet useful description of orbital osteoma was introduced.

RESULTS

The retrospective analysis of 520 diagnosed orbital tumours revealed a prevalence of 2.3% (n = 12) of orbital osteoma. Based on our observation of the 12 (n = 12) cases of orbital osteoma, we have classified orbital osteoma into a combination of seven types: "sessile" or broad-based osteoma; "pedunculated" or mushroom osteoma with a thin cylindrical stalk of origin; "dumb-bell"-shaped osteoma with the simultaneous presence in orbital and adjoining sinus/nasal cavity; "wrapped" osteoma, covered by a thin cartilaginous layer; "naked" osteoma, without any such covering; "homogenous" or uniformly dense osteoma; and "heterogeneous", soft-dense osteoma with varying areas of density.

CONCLUSION

This study attempts to introduce a simple description of different types of orbital osteoma based on clinical per-operative morphology and radiological findings for the first time to facilitate the surgical removal of orbital osteoma.

Preventing Long-Term Ocular Complications of Trachoma With Topical Azithromycin: A 3-Year Follow-up Study

PURPOSE

To determine the role of a single cycle of topical azithromycin in preventing long-term trachoma complications in children from an area with endemic trachoma.

DESIGN

A longitudinal cohort study.

METHODS

Two hundred thirty-eight (n = 238) children with active trachoma were enrolled in the current study. They were aged 1 to 10 years, with trachomatous inflammation based on the simplified World Health Organization grading system. These children were identified out of a survey of 8600 children from 7 villages in Punjab, Pakistan, where trachoma was endemic. The studied patients with active trachoma were treated with a single regimen of azithromycin 1.5% eye drops, given twice daily for 3 days, and were followed up for 3 years. The long-term effects of this therapy were documented for the first time in an endemic area.

RESULTS

Two hundred fourteen children (90%) were present at 1-year follow-up with 10% dropout, and 178 (75%) were present at 3-year follow-up with 25% dropout. Of these, 23% and 11% had active trachoma at 1 and 3 years, respectively. Active trachoma was minimized from 100% at baseline to 11% at the end of 3 years. The reinfection rate was 4%. None of the patients developed trachoma-related ocular complications during the study period.

CONCLUSIONS

A single cycle of topical azithromycin can be used as an effective and safe option for treating active trachoma in children in endemic areas. This study also documented that a single cycle of topical azithromycin prevents trachoma-related ocular complications in an endemic area.

Conjunctival Leiomyoma; a Rare Tumor of the Ocular Surface

PURPOSE

To report a case of conjuctival leiomyoma.

CASE REPORT

An 18-year-old female patient presented with a conjunctival growth in the left eye for a 2-year-period with no change in size. She merely presented for cosmetic reasons. Visual acuity was 20/20 in each eye. The lesion had prominent vessels and was not adherent to the sclera. The growth resembled a benign lesion of the conjunctiva. The tough and vascular tissue was excised and sent for histopathology. The defect was covered by an end to end conjunctival suturing. Histopathology showed the lesion to be conjunctival leiomyoma. Trichome was used to highlight the spindle shaped cells and immuno-histochemistry using anti-smooth muscle actin antibody and Vimentin was applied to confirm the diagnosis.

CONCLUSION

This case adds to the total number of cases of conjuctival leiomyoma reported in the literature to date. An ophthalmologist needs to think beyond a common mass when encountering a conjunctival growth extending onto the cornea.

Can a dermoid cyst lead to an abnormal origin of an extraocular muscle?

A 5-year-old boy presented with a large 5 cm × 5 cm cyst covering the left eye completely since birth. The cyst was excised in toto and was sent for histopathological examination. During the surgery, the inferior oblique (IO) muscle was seen originating from medial orbital wall, 10-12 mm behind the medial orbital margin, just posterior to the lacrimal bone and moving laterally, downward, and posteriorly from its origin making a more acute angle - around 20° to its site of origin. The insertion of the IO to sclera was at its normal site. The abnormal origin of IO was confirmed later by magnetic resonance imaging. The ocular movements of the left eye were tested 2 weeks after the surgery and were found to be normal in all directions. However, the child was hypertrophic and amblyopic. The histopathological findings showed the orbital cyst to contain dermal elements, respiratory, and intestinal epithelium.

Microphthalmos, orbital cyst, and missing thumbs: A rare case report

A 5-month-old girl was presented to us with a right orbital cyst covering a microphthalmic eye, absent digits (thumbs) in both hands, and absence of right radius and left kidney. The hematological profile of the patient was within normal limits. The patient had a family history of leukemia and the chromosomal analysis was suggestive of Fanconi's anemia (FA). The cyst was excised in toto and sent for histopathology. To the best of our knowledge, this is the first case report of an orbital cyst covering a microphthalmic eye in a patient with FA. This case report also stresses the fact that FA can be missed by ophthalmologists in the patients with congenital microphthalmos and missing thumbs and efforts should be made to avoid doing so.

Screening for diabetic retinopathy: a comparative study between hospital and community based screening and between paying and non-paying patients

BACKGROUND

Prevalence of diabetes and diabetic retinopathy varies in the population considering the background and financial status.

METHODS

A total of 79,194 people more than 40 years, were screened for diabetes both in the community and eye hospital setting. Initial screening was carried out by urine dipstick followed by random blood sugar examination. A value > or =140 mg/dl of blood sugar was considered positive for diabetes. All the diabetics were then examined for any evidence of diabetic retinopathy through indirect ophthalmoscopy in a dilated pupil by a midlevel ophthalmologist. Health education campaign at public, patient and professional level was also conducted.

RESULTS

The results of screening were analyzed for three distinct groups; rural population, hospital based free patients and hospital based paying patients. The prevalence of diabetes was found to be 9.12%, 10.34% and 18.57% in rural community, poor hospital and affluent hospital groups respectively. The prevalence of diabetic retinopathy in the total screened population in these three subgroups was 1.92%, 2.52% and 4.42% respectively, while this prevalence in the diabetic population was 21.05%, 24.39% and 23.80% respectively. The cost per person screened was $2.6-3.4, while the cost per diabetic identified was $26-28 and the cost per patient of diabetic retinopathy identified was $ 108-135. CONCLUSION; The prevalence of diabetic retinopathy was two times more in the affluent hospital patients as compared to poor hospital patients or rural population. For each known diabetic, there were four previously undiscovered diabetics in the rural population, and two previously undiscovered diabetics in hospital based population.

Clinical and microbiological diagnosis of trachoma in children living in rural areas in the district of Attock, Punjab, Pakistan

BACKGROUND

Trachoma is a sight-threatening process triggered by infection of the conjunctiva with Chlamydiae. When this infection becomes chronic and is associated with poverty it triggers trachoma, the prime cause of infectious blindness in the world. Since the 1958 report indicating that the highest incidence of trachoma in Pakistan was found in the province of Punjab, no new trials have been published. In the present study, we assessed the prevalence of trachoma in 3968 children living in 11 rural villages in the district of Attock, Punjab, Pakistan. The children with trachoma were sampled to detect C. trachomatis by PCR.

METHODS

Children in rural villages in the district of Attock were examined for trachoma in February 2004. Samples were obtained by scraping, and DNA was extracted (MagnaPure-LC Robot) and amplified to detect C. trachomatis (Amplicor-Roche). The quality of sampling was assessed by quantifying the number of cells by real-time PCR.

RESULTS

The prevalence of trachoma was 3.7% (0 to 6.2%). PCR was positive in 20% of samples from trachomatous children and the number of cells was always > 100/sample. The income levels, illiteracy, use of latrines, water supply, and the presence of animals close to dwellings were similar in all the villages. In Sujjenda, the prevalence was doubled in the warmest season.

CONCLUSIONS

Trachoma was diagnosed in 3.7% of the children aged < 10 years. The low rates for positive PCR may be due to loss of the plasmid, the involvement of other Chlamydiae, or their absence in chronic infections. The results obtained here underestimate the prevalence of trachoma because most of the mothers (and babies) were not tested in the district of Attock.

Efficacy and safety of short duration azithromycin eye drops versus azithromycin single oral dose for the treatment of trachoma in children: a randomised, controlled, double-masked clinical trial

AIMS

Efficacy and safety of a short-duration treatment of azithromycin 1.5% eye drops versus oral azithromycin to treat active trachoma.

METHODS

Randomised, controlled, double-masked, double-dummy, non-inferiority explanatory study including 670 children from Guinea Conakry and Pakistan if: 1-10 years old; active trachoma (TF+TI0 or TF+TI+ on simplified World Health Organisation (WHO) scale). Three groups received either: azithromycin 1.5% eye drops twice daily for 2 days, for 3 days or azithromycin single 20 mg/kg oral dose. Patients' contacts were treated whenever possible. Clinical evaluation was performed using a binocular loupe. Primary efficacy variable was the cure (no active trachoma (TF0)) at day 60. Non-inferiority margin for difference between cure rates was 10%.

RESULTS

Cure rate in per protocol set was as follows: 93.0%, 96.3% and 96.6% in 2-day group 3-day group, and oral treatment group, respectively. Azithromycin 1.5% groups were non-inferior to oral azithromycin. The intend to treat (ITT) analysis supported the results. Clinical re-emergence rate was low: 4.2%. Ocular tolerance was similar for all groups. No treatment related adverse events were reported. Logistic regression analyses found prognostic factors such as: country (p<0.001) and trachoma severity (p = 0.003).

CONCLUSIONS

In active trachoma, azithromycin eye drops twice daily for 2 or 3 days are as efficient as the WHO's reference treatment and represent an innovative alternative to oral azithromycin.