Retinoblastoma presenting as total hyphema: Three year follow-up

Retinoblastoma very rarely presents as total hyphema. Our patient presented at an early age of 7 months. Follow-up of 3 years shows that unilateral group E retinoblastoma was treated successfully with enucleation and adjuvant chemotherapy. The fellow eye remained normal during this period. The factors associated with delay in treatment are also described. Reports like the present case add to the information available about advanced staging of retinoblastoma at the time of presentation, seen in cases with spontaneous hyphema due to the tumor.

Variants in the PRPF8 Gene are Associated with Glaucoma

Glaucoma is the cause of irreversible blindness worldwide. Mutations in six genes have been associated with juvenile- and adult-onset familial primary open angle glaucoma (POAG) prior to this report but they explain only a small proportion of the genetic load. The aim of the study is to identify the novel genetic cause of the POAG in the families with adult-onset glaucoma. Whole exome sequencing (WES) was performed on DNA of two affected individuals, and predicted pathogenic variants were evaluated for segregation in four affected and three unaffected Dutch family members by Sanger sequencing. We identified a pathogenic variant (p.Val956Gly) in the PRPF8 gene, which segregates with the disease in Dutch family. Targeted Sanger sequencing of PRPF8 in a panel of 40 POAG families (18 Pakistani and 22 Dutch) revealed two additional nonsynonymous variants (p.Pro13Leu and p.Met25Thr), which segregate with the disease in two other Pakistani families. Both variants were then analyzed in a case-control cohort consisting of Pakistani 320 POAG cases and 250 matched controls. The p.Pro13Leu and p.Met25Thr variants were identified in 14 and 20 cases, respectively, while they were not detected in controls (p values 0.0004 and 0.0001, respectively). Previously, PRPF8 mutations have been associated with autosomal dominant retinitis pigmentosa (RP). The PRPF8 variants associated with POAG are located at the N-terminus, while all RP-associated mutations cluster at the C-terminus, dictating a clear genotype-phenotype correlation.

Tumor Regression Patterns in Retinoblastoma

OBJECTIVE

To observe the types of tumor regression after treatment, and identify the common pattern of regression in our patients.

STUDY DESIGN

Descriptive study.

PLACE AND DURATION OF STUDY

Department of Pediatric Ophthalmology and Strabismus, Al-Shifa Trust Eye Hospital, Rawalpindi, Pakistan, from October 2011 to October 2014.

METHODOLOGY

Children with unilateral and bilateral retinoblastoma were included in the study. Patients were referred to Pakistan Institute of Medical Sciences, Islamabad, for chemotherapy. After every cycle of chemotherapy, dilated fundus examination under anesthesia was performed to record response of the treatment. Regression patterns were recorded on RetCam II.

RESULTS

Seventy-four tumors were included in the study. Out of 74 tumors, 3 were ICRB group A tumors, 43 were ICRB group B tumors, 14 tumors belonged to ICRB group C, and remaining 14 were ICRB group D tumors. Type IV regression was seen in 39.1% (n=29) tumors, type II in 29.7% (n=22), type III in 25.6% (n=19), and type I in 5.4% (n=4). All group A tumors (100%) showed type IV regression. Seventeen (39.5%) group B tumors showed type IV regression. In group C, 5 tumors (35.7%) showed type II regression and 5 tumors (35.7%) showed type IV regression. In group D, 6 tumors (42.9%) regressed to type II non-calcified remnants.

CONCLUSION

The response and success of the focal and systemic treatment, as judged by the appearance of different patterns of tumor regression, varies with the ICRB grouping of the tumor.

Anisometropia and Ptosis in Patients with Monocular Elevation Deficiency

OBJECTIVE

To determine the effect of ptosis on the refractive error in eyes having monocular elevation deficiency.

STUDY DESIGN

Case series.

PLACE AND DURATION OF STUDY

Al-Shifa Trust Eye Hospital, Rawalpindi, from January 2011 to January 2014.

METHODOLOGY

Visual acuity, refraction, orthoptic assessment and ptosis evaluation of all patients having monocular elevation deficiency (MED) were recorded. Shapiro-Wilk test was used for tests of normality. Median and interquartile range (IQR) was calculated for the data. Non-parametric variables were compared, using the Wilcoxon signed ranks test. P-values of <0.05 were considered significant.

RESULTS

Atotal of of 41 MED patients were assessed during the study period. Best corrected visual acuity (BCVA) and refractive error was compared between the eyes having MED and the unaffected eyes of the same patient. The refractive status of patients having ptosis with MED were also compared with those having MED without ptosis. Astigmatic correction and vision had significant difference between both the eyes of the patients. Vision was significantly different between the two eyes of patients in both the groups having either presence or absence of ptosis (p=0.04 and p < 0.001, respectively).

CONCLUSION

Significant difference in vision and anisoastigmatism was noted between the two eyes of patients with MED in this study. The presence or absence of ptosis affected the vision but did not have a significant effect on the spherical equivalent (SE) and astigmatic correction between both the eyes.

A Novel Homozygous Mutation in FOXC1 Causes Axenfeld Rieger Syndrome with Congenital Glaucoma

BACKGROUND

Anterior segment dysgenesis (ASD) disorders are a group of clinically and genetically heterogeneous phenotypes in which frequently cornea, iris, and lens are affected. This study aimed to identify novel mutations in PAX6, PITX2 and FOXC1 in families with anterior segment dysgenesis disorders.

METHODS

We studied 14 Pakistani and one Mexican family with Axenfeld Rieger syndrome (ARS; n = 10) or aniridia (n = 5). All affected and unaffected family members underwent full ophthalmologic and general examinations. Total genomic DNA was isolated from peripheral blood. PCR and Sanger sequencing were performed for the exons and intron-exon boundaries of the FOXC1, PAX6, and PITX2 genes.

RESULTS

Mutations were identified in five of the 15 probands; four variants were novel and one variant was described previously. A novel de novo variant (c.225C>A; p.Tyr75*) was identified in the PAX6 gene in two unrelated probands with aniridia. In addition, a known variant (c.649C>T; p.Arg217*) in PAX6 segregated in a family with aniridia. In the FOXC1 gene, a novel heterozygous variant (c.454T>C; p.Trp152Arg) segregated with the disease in a Mexican family with ARS. A novel homozygous variant (c.92_100del; p.Ala31_Ala33del) in the FOXC1 gene segregated in a Pakistani family with ARS and congenital glaucoma.

CONCLUSIONS

Our study expands the mutation spectrum of the PAX6 and FOXC1 genes in individuals with anterior segment dysgenesis disorders. In addition, our study suggests that FOXC1 mutations, besides typical autosomal dominant ARS, can also cause ARS with congenital glaucoma through an autosomal recessive inheritance pattern. Our results thus expand the disease spectrum of FOXC1, and may lead to a better understanding of the role of FOXC1 in development.

Ophthalmic manifestations of linear nevus sebaceous/organoid nevus syndrome

Linear Nevus Sebaceous Syndrome (LNSS) is a rare sporadic oculoneurocutaneous disorder, also classified as Organoid Nevus Syndrome. It consists of a triad of midline facial linear nevus sebaceous, central nervous system and ocular abnormalities. To the best of authors' knowledge ophthalmic features of LNSS have never been reported in Pakistani population. We report two cases of LNSS, associated with multiple cutaneous nevus sebaceous lesions, complex ocular choristomas and rare bilateral presentation in one patient. Ocular choristomas included limbal dermoids, dermolipomas at superior fornices and chroidal choristoma. Ocular surface was successfully reconstructed by excision of limbal dermoids, partial keratectomy and amniotic membrane transplant.

Congenital Cataract, Nasolacrimal Duct Obstruction, and Methicillin-Resistant Staphylococcus aureus Conjunctivitis: When to Operate?

Methicillin-resistant Staphylococcus aureus is one of the toughest organisms to treat, especially in cases where intraocular surgery is contemplated, because the risks are aggravated. Conjunctival swab culture and sensitivity tests are significant when there is history of recent hospitalization. In this report, an infant with successful cataract surgery after elimination of the organism is presented.

Whole exome sequencing identifies a heterozygous missense variant in the PRDM5 gene in a family with Axenfeld-Rieger syndrome

Axenfeld–Rieger syndrome (ARS) is a disorder affecting the anterior segment of the eye, often leading to secondary glaucoma and several systemic malformations. It is inherited in an autosomal dominant fashion that has been associated with genetic defects in PITX2 and FOXC1. Known genes CYP1b1, PITX2, and FOXC1 were excluded by Sanger sequencing. The purpose of current study is to identify the underlying genetic causes in ARS family by whole exome sequencing (WES). WES was performed for affected proband of family, and variants were prioritized based on in silico analyses. Segregation analysis of candidate variants was performed in family members. A novel heterozygous PRDM5 missense variant (c.877A>G; p.Lys293Glu) was found to segregate with the disease in an autosomal dominant fashion. The novel missense variant was absent from population-matched controls, the Exome Variant Server, and an in-house exome variant database. The Lys293Glu variant is predicted to be pathogenic and affects a lysine residue that is conserved in different species. Variants in the PRDM5 gene were previously identified in anterior segment defects, i.e., autosomal recessive brittle cornea syndrome and keratoconus. The results of this study suggest that genetic variants in PRDM5 can lead to various syndromic and nonsyndromic disorders affecting the anterior segment of the eye.

Duane's syndrome: surgical outcome and non ophthalmologic associations

BACKGROUND

Duane retraction syndrome (DRS) is the most common of the ocular congenital cranial dysinnervation disorders .This study evaluates the types of Duane syndrome and its management in patients presenting to the paediatric and strabismus unit of a tertiary care eye hospital.

METHODS

This case series study involved 41 patients diagnosed with Duane syndrome between January 2007 and December 2009. History of presenting complaints, past treatment and family history were recorded. Ocular examination and orthoptic assessment was carried out

RESULTS

Forty one patients were included in this case series study. It involved 10 right eyes, 27 left eyes and both eyes of 4 patients. There were 26 females and 15 males. Type-1 Duane syndrome was present in 28 (68.3%), type 2 in 8 (19.5%), Type-3 in 4 (9.8%) and type-4 with synergistic divergence was present in 1 (2.4%) patient. Comorbidity was present in 6(14.6%) patients. Surgery was carried out in 26 (63.4%) patients either for  abnormal head posturing or significant upshoots or down shoots. Upshoots noted in 21 eyes, were completely or partially resolved in 15 cases. Among 4 patients with down shoots on adduction, complete resolution was seen in 1. The pre and post-operative measurements of horizontal deviation showed statistically significant difference in Duane type-1 and 2, where as in Duane type-3 it was not significant. One patient with type-4 Duane did not undergo surgery.

CONCLUSIONS

Recession of the horizontal recti is more effective in treating the upshoot or down shoot associated with DRS as compared to recession and y-split of the horizontal muscle.

Monocular elevation deficiency with associated dextrocardia and situs inversus

A patient having monocular elevation deficiency with associated dextrocardia and situs inversus is reported. Review of the literature regarding ocular features described in association with dextrocardia is also presented.

Retinal detachment in paediatric patients

OBJECTIVE

To assess the causes of retinal detachment in children and the various operative procedures requiring vitreoretinal surgical intervention for the same.

STUDY DESIGN

Case series.

PLACE AND DURATION OF STUDY

Department of Ophthalmology, Al-Shifa Trust Eye Hospital, Rawalpindi, from January 2006 to May 2009.

METHODOLOGY

A total of 281 eyes of 258 patients, (aged 0-18 years) who underwent vitreo-retinal surgical intervention for retinal detachment were included. Surgical log was searched for the type of retinal detachment and its causes. Frequencies of various interventions done in these patients viz. vitrectomy, scleral buckle, use of tamponading agents, laser photocoagulation and cryotherapy were noted. Results were described as descriptive statistics.

RESULTS

Myopia was the cause in 62 (22.1%) and trauma in 51 (18.1%) of the eyes. Total retinal detachment (RD) was treated in 94 (33.5%) eyes, sub total RD in 36 (12.8%), recurrent RD in 32 (11.4%), giant retinal tear in 28 (10%), tractional RD in 15 (5.3%) and exudative RD in 2 (0.7%). Prophylactic laser or cryotherapy was applied in 74 (26.3%) of the eyes. Pars plana vitrectomy (PPV) was carried out in 159 (56.6%) eyes while scleral buckle procedure was done in 129 (45.9%) eyes. Silicon oil was used in 149 (53%), perfluorocarbon liquid in 32 (11.4%) and gas tamponade in 20 (7.1%) eyes.

CONCLUSION

The most common cause of retinal detachment in paediatric patients was myopia, followed by trauma. Total RD was more common as compared to the other types. The most common procedure adopted was pars plana vitrectomy followed by scleral buckle procedure.

Factors associated with breast arterial calcification on mammography

OBJECTIVE

To determine the frequency of breast arterial calcifications (BAC) as seen on mammographic examination and to determine the association between BAC and hypertension, age, parity and weight of the person.

STUDY DESIGN

Cross-sectional analytic study.

PLACE AND DURATION OF STUDY

Department of Diagnostic Radiology, Military Hospital, Rawalpindi, from January 2006 to January 2007.

METHODOLOGY

Two hundred patients undergoing mammography were studied to evaluate the association of BAC with raised blood pressure, age and parity. Previous history of lactation and the patients' weight were also recorded. Proportions of classes were compared using chi-square test.

RESULTS

13.5% of the subjects (n = 200) were positive for BAC on mammograms. Mean age of the BAC positive subjects was higher than their counterparts found negative for BAC. Women bearing 5 - 6 children showed the highest frequency of BAC. Seventy seven (10.38%) of the BAC positive cases had previous history of lactation, whereas 15.44% (n = 123) had not breast fed their children and showed BAC. No significant association of presence of BAC was noted with the weight of the subjects.

CONCLUSION

The frequency of presence of BAC on mammography was associated with systemic hypertension and higher age. It also increased with the reproductive parameters of a woman.

Clinical course of retinoblastoma

OBJECTIVE

To determine the clinical manifestations and results of current treatment for patients with retinoblastoma (Rb) in a tertiary care eye hospital in the north west of Pakistan.

STUDY DESIGN

Case series.

PLACE AND DURATION OF STUDY

Al-Shifa Trust Eye Hospital, Rawalpindi, Pakistan, from January 2006 and December 2009.

METHODOLOGY

The data of 139 patients diagnosed as having retinoblastoma was collected. Gender, age at diagnosis, laterality, presenting sign, classification of tumour, treatment modality and outcome were noted.

RESULTS

The mean age of presentation in this patients ranged from 6 to 50 months (mean: 24.05 ± 10.74 months). The most common presenting sign was leucocoria in 78 eyes (44.1%). One hundred and one (72.7%) patients had unilateral retinoblastoma. Using the International Classification of Retinoblastoma (ICRB), 135 (76.3%) eyes were placed in group-E. one hundred and twenty four (77.5%) eyes were enucleated or exenterated while globe preservation was achieved by chemoreduction and/or focal therapy in the rest of the treated eyes (n = 36, 22.5%). Twenty three (16.5%) cases were lost to follow-up before one year. Ninety two (66.2%) patients survived, being free of tumour, at least one year after the completion of treatment.

CONCLUSION

Most children with Rb showed an advanced stage of tumour at the time of diagnosis. Measures to improve the rate of globe preservation and patient survival by early diagnosis and intervention are the need of the hour.

Retinoblastoma in an adult

Background

Retinoblastoma is the most common pediatric ocular tumour. It may rarely present in adults. The present case adds to the number of 26 cases already published in literature since 1919 till 2013. Our aim is to highlight the rare occurrence of retinoblastoma in adults along with its features which differentiate it from paediatric retinoblastoma.

Case presentation

We describe a case of adult onset retinoblastoma (group E, according to the international classification of retinoblastoma) occurring in a 25 year old male. He presented with decreasing visual acuity in the right eye of 4 months duration. He had neo-vascular glaucoma and pseudohypopyon. B scan ultrsonography of his right eye showed intraocular growth without any calcification. The CT scan of the orbits and brain showed intraocular growth in the right eye with no calcification. Enucleation of the right eye was carried out. Retinoblastoma was confirmed on histopathology of the enuleated globe.

Conclusions

The present case adds to the number of adult Rb patients reported in literature. Early detection to salvage the life can be made possible if the clinician keeps a high index of suspicion when observing retinal mass of adult onset. Proper counselling of the patient in order to seek his full involvement in management may help in improving the prognosis of the disease.

Effects of Artisan aphakic intraocular lens on central corneal thickness and intra ocular pressure in pediatric eyes with crystalline subluxated lenses

PURPOSE

To study effects of Artisan iris fixated intraocular lens (IOL) on central corneal thickness (CCT) and intraocular pressure (IOP) in pediatric eyes with crystalline subluxated lenses.

MATERIALS AND METHODS

The study included 17 eyes undergoing Artisan aphakic IOL implantation after lensectomy for subluxated crystalline lenses. CCT and IOP measurements were recorded pre-operatively and post-operatively taking the mean of 4 post-operative visits. Patients were divided into Group A (n = 8) including patients with lensectomy and iris fixation of Artisan IOL as a primary procedure and Group B (n = 9) including patients in which lensectomy was carried out as a primary surgery and Artisan IOL fixation as a secondary procedure.

RESULTS

Children ranged in age from 08 years to 16 years, mean 11.59 ± 2.96 years. Follow-up period ranged from 7 months to 16 months, mean 11.24 months ± 4.27. Mean pre-operative and post-operative IOP in Group A was 14.88 ± 2.80 and 14.16 ± 0.59 respectively (P = 0.528). In Group B it was 12.44 ± 2.79 and 14.44 ± 1.15 respectively (P = 0.080). Mean pre-operative and post-operative CCT in Group A was 529.13 ± 24.23 and 529.87 ± 17.46 respectively (P = 0.674). In Group B it was 567.33 ± 29.13 and 568.83 ± 25.69 respectively (P = 0.859).

CONCLUSIONS

Primary and secondary Artisan aphakic IOL implantation did not cause any significant changes in corneal thickness or IOP during the follow-up period.

Outcome of selective non-operative management of penetrating abdominal injuries from the North American National Trauma Database

BACKGROUND

The aim of this study was to investigate trends in the practice of selective non-operative management (SNOM) for penetrating abdominal injury (PAI) and to determine factors associated with its failure.

METHODS

The National Trauma Data Bank for 2002-2008 was reviewed. Patients with PAI were categorized as those who underwent successful SNOM (operative management not required) and those who failed SNOM (surgery required more than 4 h after admission). Yearly rates of SNOM versus non-therapeutic laparotomy (NTL) were plotted. Multivariable regression analysis was performed to identify factors associated with failed SNOM and mortality.

RESULTS

A total of 12 707 patients with abdominal gunshot and 13 030 with stab wounds were identified. Rates of SNOM were 22.2 per cent for gunshot and 33.9 per cent for stab wounds, and increased with time (P < 0.001). There was a strong correlation between the rise in SNOM and the decline in NTL (r = - 0.70). SNOM failed in 20.8 and 15.2 per cent of patients with gunshot and stab wounds respectively. Factors predicting failure included the need for blood transfusion (odds ratio (OR) 1.96, 95 per cent confidence interval 1.11 to 3.46) and a higher injury score. Failed SNOM was independently associated with mortality in both the gunshot (OR 4.48, 2.07 to 9.70) and stab (OR 9.83, 3.44 to 28.00) wound groups.

CONCLUSION

The practice of SNOM is increasing, with an associated decrease in the rate of NTL for PAI. In most instances SNOM is successful; however, its failure is associated with increased mortality. Careful patient selection and adherence to protocols designed to decrease the failure rate of SNOM are recommended.

Outcome of surgical treatment of monocular elevation deficiency

OBJECTIVE

To assess the outcome of surgical treatment in patients with monocular elevation deficiency.

METHODS

This prospective study included 36 patients of monocular elevation deficiency surgically treated from January 2006 to June 2009, at a tertiary care eye hospital in Rawalpindi, Pakistan. Corrected visual acuity, refractive error, ocular examination, orthoptic assessment and ptosis evaluation were recorded. Strabismus surgery was performed according to the results of forced duction test (FDT). Ptosis surgery, if required, was performed after the strabismus surgery. Patients having any restrictive cause or previous strabismus surgery were excluded. The study conformed to all local laws and was compliant with the principles of the Declaration of Helsinki and had the approval of the Hospital Ethics Committee.

RESULTS

The 36 patients were treated surgically and completed the required follow-up. The forced duction test was positive for inferior rectus (IR) of the involved eye in 20 of the 36 eyes (55.55%). Twelve patients had inferior rectus recession with or without one horizontal muscle recession or resection, 12 had Knapp procedure correcting for any horizontal deviation if present, 10 had inferior rectus recession followed by Knapp surgery, with or without recession or resection of horizontal recti, 1 patient had horizontal correction only, while one patient had ptosis correction only without squint surgery. Of the 36 patients, 33 had post-operative (PO) hypotropia within 10 prism diopters (PD). Three patients developed consecutive hypertropia.

CONCLUSION

Careful pre-operative evaluation can lead to satisfactory cosmetic improvement after surgery in monocular elevation deficiency. The forced duction test should be performed in both eyes so that any associated oblique muscle laxity (OML) can be noted.

A case of systemic lupus erythematosus with aplastic anaemia

Systemic lupus erythematosus is an autoimmune disorder, which has a rare association with aplastic anaemia. A young 26 years old lady who presented with a history of intermittent fever, microcytic anaemia, joint pains and mild degree of splenomegaly was investigated. Bone marrow examination showed aplasia. Serological tests revealed positive antinuclear antibody and anti double-stranded DNA tests. Patient was diagnosed as having aplastic anaemia with Systemic lupus erythematosus, managed with steroids and being followed up for monitoring the response.

Variable retinal presentations in nanophthalmos

Nanophthalmos is an uncommon developmental ocular disorder characterized by a small eye with short axial length, high hyperopia and high lens/eye volume ratio due to arrested development of the globe in all directions. Different types of fundus changes can rarely occur with nanophthalmos. We describe five cases of nanophthalmos, each of them presenting with a different fundus appearance. Our case series highlights variability of pigmentary changes from retinal flecks to bone spicules and bull's eye maculopathy, which are rare in the combinations described here.

Ptosis associated with monocular elevation deficiency

OBJECTIVE

To document the various clinical features of ptosis associated with monocular elevation deficiency (MED) seen in patients, presenting to the Paediatric and Strabismus Unit, over a period of 2 years.

METHODS

All patients seen with monocular elevation deficiency presenting to the Strabismus Clinic from January 2006 to December 2007 were examined and evaluated for presence of associated ptosis, jaw winking phenomenon and pseudoptosis. Patients having acquired causes of monocular limitation in elevation were excluded.

RESULTS

A total of 22 patients having MED were seen. Out of these 50% were males (N = 11) and 50% females (N = 11). Twelve (54.54%) had MED in the left eye and 10 (45.45%) had MED in the right eye. Ptosis was present in the eye affected with MED in 16 (72.72%) patients. Pseudoptosis was seen in 4 (18.18%) patients whereas no associated ptosis was noticed in 2 (9.09%) patients. Jaw winking phenomenon was present in 9 (40.90%) which comprise almost half (56%) the MED cases with ptosis.

CONCLUSION

Careful clinical assessment for ptosis, pseudoptosis and jaw winking phenomenon before forced duction test, can help in planning the correct order of surgical management of patients having monocular elevation deficiency. The patient needs to be counseled regarding the multiple surgeries required according to associated clinical features present with MED.

Ocular manifestations of xeroderma pigmentosum

Xeroderma pigmentosum (XP) is an autosomal recessive (AR) condition characterized by photosensitivity and inability to repair ultra-violet (UV) induced DNA damage. Patients diagnosed with XP, presenting to the Paediatric ophthalmology department of Al-Shifa Trust Eye Hospital, Rawalpindi, were evaluated and followed-up over a period of one year, for the effects of the disease process on vision and for the development of ocular tumours. Excision of the tumours, if present, was performed under general anaesthesia. Counselling of the patients was done. Referral to oncologist and dermatologist was made, if so warranted, after histopathology of excision biopsy.