Document 6428402

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Document 6428402

Contents
EDITORIAL

Computer Related: Eye Strains, Headaches & other Health Problems
Madiha Durrani-----------------------------------------------------------------------------------------------------------------------------------------1
ORIGINAL ARTICLES
Contact Lens Induced Keratitis
Naveed Ahmad Shah et al ----------------------------------------------------------------------------------------------------------------------------- 4

Correlation between Central Corneal Thickness & Diabetes in Pakistani Population

Effectiveness of first Probing in Children with Congenital Nasolacrimal Duct Obstruction & its
Pattern in different age Groups
Nuzhat Rahil et al ---------------------------------------------------------------------------------------------------------------------10

Per-operative use & Safety of 0.5% Intracameral Moxifloxacin Ophthalmic solution
as a Prophylaxis during Cataract Surgery to prevent early Post-operative Endophthalmitis
Junaid F. Wazir et al ------------------------------------------------------------------------------------------------------------------14

IOP and Fundus Changes in Pregnancy

To Determine the frequency of Common Complications
following Cataract Surgery by an experienced Surgeon in Diabetic Patients

Danish Zafar et al -------------------------------------------------------------------------------------------------------------------------------------18
Afzal Qadir et al ---------------------------------------------------------------------------------------------------------------------------------------22
Prevalence of Refractive Errors in School going Children in Battagram (KPK),
Age Group of 11-15 Years
Manzoor Hussain et al -------------------------------------------------------------------------------------------------------------------------------27

Pre- operative Screening of Patients for Hepatitis B &C Virus
(A Sero-survey at the Eye Department in DHQ Teaching Hospital Mirpur, AJK.)

Comparison of Surgically Induced Astigmatism after
Phacoemulsification vs Extra Capsular Cataract Extraction

Waseem Ahmed Khan et al ---------------------------------------------------------------------------------------------------------------------------30
Zaheer Umer et al -------------------------------------------------------------------------------------------------------------------------------------33
To Compare the Incidence of Oculocardiac Reflex with
Pre-Medication & Without Premedication in Strabismus Surgery
Junaid Faisal Wazir et al -----------------------------------------------------------------------------------------------------------------------------37
Comparison of Effects on Corneal Endothelium of A Low Cost &
Expensive Combination of Viscoelastic Material & Irrigating Solution in Phacoemulsification
Muhammad Rafiq et al ------------------------------------------------------------------------------------------------------------------------------ 40

Comparison of Astigmatism in two Incision Sites in Manual Small Incision Cataract Surgery

Comparison of Recurrencerate & Complications after Pterygium Excision with
Bare Sclera Technique & Amniotic Membrane Graft
Mumtaz Alam et al ---------------------------------------------------------------------------------------------------------------------------------- 49
ii
Danish Zafar et al --------------------------------------------------------------------------------------------------------------------------------------7
Afzal Qadir et al -------------------------------------------------------------------------------------------------------------------------------------- 43
Ophthalmology Update Vol. 12. No. 1, January-March 2014

Myopia and its relation with Central Corneal Thickness (CCT) & Intraocular Pressure (IOP)
Imran Ahmad et al ------------------------------------------------------------------------------------------------------------------------------------52

Comparison of Results of Pterygium Excision Through Bare Sclera Technique
& Conjunctival Autograft
Muhammad Rafiq et al -------------------------------------------------------------------------------------------------------------------------------55

Changes in Retinal Nerve Fiber Layer & Optic Disc Algorithms by Optical
Coherence Tomography in Glaucomatous Arab Subjects
Dr. Ferial M Zeried et al ----------------------------------------------------------------------------------------------------------------------------58
GENERAL SECTION

Diabetic Neuropathies: as Indicators of Oxiative Stress & their Correlation to Glucose-6-phosphate
Dehydrogenase Activities
Jariya Wajahat et al ----------------------------------------------------------------------------------------------------------------------------------- 62

Emerging Teaching Methodologies in Medical Biochemistry & the need to Implement these
in Pakistani Medical Colleges Fatahiya Kashif et al ---------------------------------------------------------------------------------------------------------------------------------- 66

Open Heamorrhoidectomy under Local Anaesthesia
Yousaf Jan et al ---------------------------------------------------------------------------------------------------------------------------------------- 69

Frequency of Achilles’ Tenotomy in Club Foot treated by Ponseti Method
Muhammad Khalid Khan et al ----------------------------------------------------------------------------------------------------------------------72

Comparative Effectiveness of Early Vs Delayed Oral Feeding after Elective Intestinal Anastomosis
Abid Halim et al ---------------------------------------------------------------------------------------------------------------------------------------75

Frequency of Early Non-Infectious Wound Complications after Clean Surgery
for Inguinal Hernia Repair
Yousaf Jan Shinwari et al ----------------------------------------------------------------------------------------------------------------------------79

Frequency of Radial Nerve Injury in Patients with Closed Fracture of Humerus Shaft
Muhammad Khalid Khan et al ----------------------------------------------------------------------------------------------------------------------83
SHORT COMMUNICATION

Scleral Edge, Not Optic Disc or Retina, Is The Primary Site of Injury In Chronic Glaucoma
Syed S. Hasnain M.D. --------------------------------------------------------------------------------------------------------------------------------86
CASE REPORT

New Trends for Infantile Haemangioma
Mazhar U Zaman Soomro----------------------------------------------------------------------------------------------------------------------------87
OPHTHALMOLOGY NOTEBOOK

Attention! Contributors and Readers ---------------------------------------------------------------------------------------------------89
iii
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Editorial
Computer Related: Eye Strains,
Headaches & other Health Problems
Over indulgence in TV and computers can produce visual, physical,
and mental problems with moral hazards.
COMPUTER is a technological breakthrough
in every field of life and it has attracted enormous
amount of attention right from scientist to an elementary student. It has a tremendous growth popularity,
influencing our society so much so that the exposure
to computer has become indispensable for homes,
teaching institutions and organizations in every field
of life. It has firmly been established that the computer games are most likened mode of entertainment for
children as well as the elderly people. In fact these
computers (especially the laptops) have captured our
lives and made us completely dependent on them.
Laptops are, now a days, getting very popular due to
a handy apparatus, small screen and inbuilt pointing
devices i.e., key board, small portable mouse and a
touch pad. These are being used as the main computers in the offices as an essential tool in place of normal
desktop computers. With the increased and improper
usage, a number of health and safety concerns related
to the vision and body has arisen, especially a laptop
needs more concentration and causes mental exhaustion, visual fatigue and at times headaches. which are
preventable by simple corrective methods after greater
awareness. However computer related problems never cause permanent damage, yet temporary discomfort can reduce productivity, loss of work-time and
job satisfaction. Therefore, the use of laptop should be
restricted and if necessary it is advisable to use as an
additional tool.
With the changing life style, youngsters and children are crazy in spending more time in indoor activities and less in outdoor sports like activities. Parents
have noticed that their children are playing computer
games for a longer period and they hardly listen to
them. Reaching home after schooling, children spend
most of their time in front of TV or playing most popuOphthalmology Update Vol. 12. No. 1, January-March 2014
lar computer games. They often complain of frequent
headaches, watery eyes, back ache, emotional upsets
and lack of concentration in their studies.
Most of the complaints from computer usage are:
Musculoskeletal problems are generalized stiffness
of the body, discomfort, tingling sensation, body aches
with burning sensation and skin rashes
Visual problems are fatigue, blurring , eye strain, lack
of concentration, double vision, dry eyes and may be excessive watering in certain cases with frequent changes
in glasses prescription especially in school children.
Computer Vision Syndrome’(CVS): Focusing on a
screen is not a straight forward process and is not as
simple as we think. The distance between the front of
the monitor and our eyes is called the ‘working distance’. Interestingly our eyes actually want to relax at
a point that is farther away from the screen. We call that
location ‘the resting point of accommodation (RPA), which certainly lies behind the monitor screen. In order
to see things clearly, our brain constantly readjust its
focus between RPA and monitor screen. The struggle
leads to fatigue resulting in ‘eye strain’ which eventually triggers headache. Scientifically speaking we call
it a ‘Computer Vision Syndrome’. Now CVS is very
common all over the world. People who spend several hours a day on computers without a break often
complain head ache, blurry vision, dry eyes, pain in
the neck, shoulders, back of the chest, lumbosacral region due to bad posture and leaning for hours over the
computers. It has been proved that CVS may lead to
myopia, glaucoma like symptoms, obesity, early smoking in children, loss of appetite and even insomnia.
Doctors have observed increasing incidence of
worldwide myopia with physical and emotional changes leading to moral turpitude especially in younger
generation. There is an alarming rise of myopia to the
1
Editorial
extent of an epidemic form especially in countries with
advanced information technology. For example in Singapore and Israel, 30 years ago, the incidence of myopia
in teen agers and school going children was just 30-35%
which has now jumped to 80%, as the state has laid
more stress on the book reading. According to a study
in Pakistan, most of the children who are book worms
and are involved in memorizing process suffer from
myopia. There could be other reasons like under nutrition, genetics, prolonged illness apart from increasing
burden of studies right from the tender age of 8 to 12
years which is the most vulnerable period to suffer myopia. In a recent study in USA, the incidence of myopia
in children of non-myopic patients is 6%, in a single
myopic parent it is 18% and in both myopic parents it
is 33%.
The question arises how myopia develops? What
is its relation with computers and what happens anatomically. According to one school of thought the explanation appears to be quite relevant, that during the
developing age, children spend more time focusing on
closer objects such as studying book, focusing on TV
and computers for longer hours. The eye is thought
to grow longer and longer as less effort is needed to
see near objects clearly, but an elongated eye will no
longer focus distant objects thus inducing myopia
which explains the prominence of myopic eyes. On the
contrary, the children who take more interest in physical activities or games are less susceptible to myopia
as it tends to involve more focusing on distant objects
rather near objects, thus protecting the eye ball from
abnormal growth. The best example is the youngsters
playing tennis are less likely to suffer from myopia.
Myopia is rising at a fastest rate in the far-eastern
countries but the western world is equally worried
about it. Recently a team of scientists have found a
strange linkage of myopia to diet rich in sugar and
refined starch including white bread , rice and cereals.
They argue that such foods may affect the development
of eyes by stimulating the production of high level of
insulin and reduction of protein-3, which is thought to
be responsible for the growth of the eye ball and lens.
The evidence of North American-Canadian Eskimos
where incidence of myopia is hardly 1-2%; the reason
scientist believe that they eat fish, tuberous plants and
coconut rather than bread, rice and cereals. However
this needs further study.
It is also postulated that apart from myopia they
get glaucoma like symptoms with field changes in the
long run. Moreover, scientists with the help of magnetic resonance imaging (MRI) are able to document altered brain response after play of violent video games.
These changes are exactly on the pattern of ‘Disruptive
Behavior Disorders’, and those who play continuously
2
a decreased activity of prefrontal cortex-areas controlling emotions and aggressive behavior has been noted.
These changes are likely to become permanent at some
point and if parents are concerned scientists advise to
limit the period of playing violent games.
Some advances have also been demonstrated that
playing video games may induce functional plasticity
and spatial resolution which improves the irreversible
Amblyopia in adults. Let us see when a child should
start using a computer? Is it at the age of 3 years? The
very fact cannot be ignored that the computer usage
improves children’s performance in reading and writing but involvement at an early age may expose them
to the development of myopia and many other health
problems in the long run. It is important to understand
that the child should start using computers when he
has attained the school going age or sufficient perceptive ability to grasp or recognize letters and that mostly lies between the age of 4 and 5 years.
Computer as Best Friend. When we return home
after spending long hours in the office we need to relax
in the bed for a short time. Instead we find computer as
our best friend and we spend few more hours in surfing
the internet and playing computer games. Today it has
become an interesting way of modern life to tax the
already overtaxed mind and we never give rest to the
brain cells to regain normality, hence the vicious circle
of visual engagement continues uninterrupted.
Protect your children: A recent study has revealed
that every four out of five youngsters hide internet
activity that parents may think inappropriate. How
you can save the children from such activities. It is
worth checking with your broadband Internet Service
Provider (ISP) about blocking the sites. The biggest ISP
include BT, Virgin Media, Sky and Talk-Talk which
have made it easier to launch parental control to block
suspicious sites. This free software can be easily downloaded from the web as it provides remotely the control
for Windows and PC Users, using a web filter. Moreover, one can install a software via AVG website which
will protect wide range of devices including PC, Macs,
iPhones, Pads and window phones even limiting specific times that children can log on, enabling parents to
access from anywhere. One can remotely block websites, restrict phone numbers and set daily time limits
and this is how you can protect your children.
Summary: There are some useful guidelines for
parents, students, teachers and computer users to operate the computers as an opportunity to talk, listen and
share experiences to make computer a real life objective. We must reduce the time spending on computers
especially the children on computer games or watching TV to the extent of less than an hour a day and
encouraging them to spend more time in out-door acOphthalmology Update Vol. 12. No. 1, January-March 2014
Editorial
tivities. Other computer users must observe frequent
short breaks and walk about to relax the body during
their continuous hand on computers, this is absolutely
important.
In by-gone days, people preferred health foods
with energy drinks and not the junk foods with cokes
and candies, refrigerated and micro-wave processed
diet. They led a real healthy life style. The parents must
ensure that their children take balanced diet with energy drinks and have a good uninterrupted sleep which
will improve their appetite, increase their perceptive
ability with freshness to take more interest in their
studies and day to day work. Finally, listen to your
body when it tells you ‘enough is enough’. The ancient
rule seems unchanged, if you want to be smart, eat
wisely and exercise generously.
REFERENCES:
1.
Chen, J. C.; Schmid, K. L.; Brown, B. (2003). “The autonomic
control of accommodation and implications for human myopia development: A review”. Ophthalmic & physiological optics :
the journal of the British College of Ophthalmic Opticians (Optometrists) 23 (5): 401–422. doi:10.1046/j.1475 1313.2003.00135.x. P
MID 12950887. edit
2.
Zhu, Xiaoying; Tae Woo Park, Jonathan Winawer, and
Josh Wallman (2005). “In a Matter of Minutes, the Eye Can
Know Which Way to Grow”. Investigative Ophthalmology and
Visual Science 46 (7): 2238–2241. doi:10.1167/iovs.04-0956.
PMID 15980206.
3.
Wallman, J; MD Gottlieb, V Rajaram, LA Fugate-Wentzek
(1987). “Local retinal regions control local eye growth and my-
4.
5.
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7.
8.
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10.
opia”. Science 237 (4810): 7377.doi:10.1126/science.3603011. JSTOR 1699607.PMID 3603011.
Ong, E; KJ Ciuffreda (1995). “Nearwork-induced transient
myopia: a critical review”. Doc Ophthalmol. 91 (1): 57–85.
doi:10.1007/BF01204624. PMID 8861637.
Ciuffreda, KJ; B. Vasudevan (2008). “Nearwork-induced
transient myopia (NITM) and permanent myopia—is there
a link?”. Ophthalmic Physiol Opt. 28 (2): 103–114.doi:10.1111/
j.1475-1313.2008.00550.x. PMID 18339041.
“More Information on Glaucoma.” AgingEye Times. Retrieved
27 August 2006.
Morgan I, Rose K (January 2005). “How genetic is school
myopia?”. Prog Retin Eye Res 24 (1): 1–38.doi:10.1016/j.preteyeres.2004.06.004. PMID 15555525.
Chung K, Mohidin N, O’Leary DJ (October 2002). “Undercorrection of myopia enhances rather than inhibits myopia
progression”. Vision Res. 42 (22): 2555–9.doi:10.1016/S00426989(02)00258-4. PMID 12445849.
The Wildoset Lab. “Controlling Myopia Progression – A Confusing Story”. Archived from the original on 25 December
2005. Retrieved 1 September 2006.
Siatkowski R, Cotter S, Miller J, Scher C, Crockett R, Novack G
(2004). “Safety and efficacy of 2% pirenzepine ophthalmic gel
in children with myopia: a 1-year, multicenter, double-masked,
placebo-controlled parallel study”. Arch Ophthalmol 122 (11):
1667–74. doi:10.1001/archopht.122.11.1667.PMID 15534128.
Dr. Madiha Durrani, MBBS, MCPS, FRCS
Editor, International Advisory Board, UAE
Phone: 0092 333 5158885
E.Mail>[email protected]
Website:www.ophthalmologyupdate.com
The Management of
Ophthalmology Update
wishes its readers
a Happy New Year
3
ORIGINAL ARTICLE
Naveed Ahmad
Naveed Ahmad Shah FCPS1, Abdul Ghafoor FCPS2
Iftikhar Ahmad FCPS3
ABSTRACT:
Objective: The purpose of this study was to evaluate the microbiological picture of keratitis associated with contact lens
wearing.
Material and Method: The study comprised all consecutive patients presenting with contact lens related presumed microbial keratitis during a 12-month period at our department. Detailed demographic data, type of contact lens, duration of lens
wear, wearing schedule and lens hygiene were derived from a self-administered questionnaire. Severity of ulcer, corneal
scrapings, treatment and final outcome were evaluated.
Results: Gram-negative bacilli and Acanthamoeba were recovered from the corneal scrapes of all 35 patients (97% ) were
having gram negative bacteria. There was a significantly higher number of Pseudomonas aeruginosa ( 73.68%) and (3%)
were having Acanthamoeba infection .
Conclusion: Disposable contact lenses seem to have been a predisposing factor for contact lens induced keratitis also
when used on a daily wear schedule. Insufficient contact lens care products and/or manufacturing characteristics may be
responsible for keratitis, which is also observed in otherwise compliant contact lens users. In 3 of our patients with keratitis,
keratoplasty became necessary, indicating that contact lens induced keratitis may result in severe corneal complications.
Keywords: Contact lens-associated keratitis, incidence, contact lens, microbial contamination of contact lens-care product, P. aeruginosa INTRODUCTION
Keratitis is a sight-threatening contact lens complication.1- 12 Severe bacterial keratitis may result in
perforation and endophthalmitis.10,13 Contact lens (CL)
wear is the main risk factor,3,6,14,15 and sleeping with
contact lenses is the major risk factor among contact
lens wearers.4,8,9 A corneal ulcer is defined by a corneal infiltrate
associated with an overlying epithelial defect.12,14,15
Corneal ulcers generally occur when the normal eye’s
natural resistance to infection has been compromised
from either trauma or contact lens wear.10 Bacterial
infection accounts for approximately 90% of microbial
keratitis.9 Microbial keratitis increased in prevalence
following the introduction of soft lenses in the
1970s.3 The most common pathogens implicated are
staphylococci and pseudomonas.5,6,11,13,14,17-19
Acanthamoeba keratitis manifests as an extremely
painful ring-shaped infiltrate possibly associated with
either swimming while wearing contact lenses12,18 or
generally poor contact lens disinfection (the use of either tap water or saline instead of multipurpose solution).13 The patient usually has severe pain disproporConsultant Ophthalmologist, Mardan Medical Complex, Teaching Hospital,
Mardan. 2Consultant Ophthalmologist, Distt. Hospital, Batagram. 3Assistant
Professor Ophthalmology, International Medical College, Abbottabad
1
Correspondence: Dr. Naveed Ahmad Shah, House: 11, St:1 Tariq
Colony, Shamsi Road, Mardan. E.Mail>[email protected]
Cell : 0300-9177974
Received: Nov’12
4
Accepted: Dec’2013
tionate to clinical findings.12 The condition develops
over a period of several weeks.18
MATERIALS AND METHODS
To evaluate the microbiological profile of keratitis associated with contact lens (CL) wear, 35 patients
were studied at Mardan Medical Complex from Jan
2011 to Jan 2012 . Each patient was examined at the
slit-lamp; clinical features were noted and drawing
was made for patient’s records. A corneal scrape was
performed using flame-sterilized Kimura spatula or
Bard-Parker blade (# 15) following instillation of 0.5%
proparacaine hydrochloride. The material obtained
was subjected to direct microscopic examinations (10%
potassium hydroxide wet mount and Gram-stain) and
culture (on 7% sheep blood agar, chocolate agar, Sabouraud dextrose agar, non-nutrient agar, thioglycollate
medium and brain heart infusion broth media). In addition to corneal scrapes, CL storage cases along with
lenses and lens care solution bottles were collected at
the time of presentation and were subjected to microbiological evaluation for determining the microbial
contamination of lens care product.
Additional specimens were inoculated directly onto sheep blood agar, thioglycolate broth, Sabouraud’s dextrose agar, and non nutrient agar with an
overlay of E..coli . Ten percent potassium hydroxide
wet mount at 450 x magnification revealed polygonal
double-walled cyst, and similar cysts were also noticed
in Giemsa stain. On the fourth day following Acanthamoeba inoculation in non-nutrient agar. The inoculum from the contact lens and the container was sterile.
Detailed information on the type of CL, duration
of wear, schedule and lens hygiene was derived from a
self-administered questionnaire. “Extended wear” was
defined as a 24-hour use at least once per week, less
frequent overnight wear was defined as “daily wear”.
In accordance with the clinical aspects (the site of the
major part of the keratitis), patients were assigned to
one of two categories, namely central keratitis, presenting in a central, approximately 6 mm diameter zone of
the cornea, and peripheral keratitis, manifesting within
2 mm of the limbus.
Initially, therapy management comprised an empirical first line broad-spectrum antimicrobial treatment with topical moxifloxacin or ciprofloxacin. In case
of severe anterior segment inflammation with hypopyon, an additional systemic broad-spectrum antimicrobial substance with vancomycin was administered.
Additional microbiological tests (Acanthamoeba) was
also performed if the disease was progressive and treatment considered a failure. With positive microbial culture findings, treatment was modified accordingly.
RESULTS
A total of 42 bacterial pathogens were recovered from 35 ulcerative cornea, of which 28(73.68%)
were Pseudomonas aeruginosa (28 were isolated as single
species and the remaining two were mixed with Acanthamoeba.) . The culture of CL storage cases (total of 70
wells) and the lens care solution of 35 patients yielded
positive bacterial growth in all 70 wells and six of the
35 bottles of lens care solution respectively. Bacterial
pathogens recovered from CL storage cases were identical with the bacterial species recovered from the corneal scrapes of the respective infected eyes. Out of 35
patients with contact lens induced keratitis (CLIK) due
to contact lens wear, 25 patients had a central ulcerative
keratitis and 10 have peripheral one.
DISCUSSION
With growth of soft CL wear, the incidence of CLassociated microbial keratitis has increased up to 30% of
all keratitis in developed countries,20 , 21 whereas in this
present study, it was found to be 1%. This low incidence
in the present study may be attributed to the limited
number of people wearing CL in our region due to economic factor. The microbes responsible for CL-associated keratitis include gram-negative bacteria and rarely,
gram-positive bacteria and fungi, whereas Acanthamoeba predominated in the developed countries.20 Several CL-related and non-CL-related factors were attributed to the higher incidence of Acanthamoeba keratitis
among CL wearers in developed nations.22 In contrast,
bacteria was found to be the major pathogen for all
CL-associated keratitis in this study. Pseudomonas aeruginosa was reported to be the most common organism
isolated from CL wearers in the developing world.23
All CL storage cases and six lens care solution
bottles were found to be contaminated with potential
gram-negative bacilli in this study and the bacterial
pathogens recovered from the corneal scrapes were
identical with the bacterial pathogens isolated from the
CL storage case wells of corresponding infected eyes. It
Microorganisms isolated from corneal scrapes, contact lens cassette wells and contact
lens care solutions of 35 patients with contact lens-associated microbial keratitis
Name of isolates
Name of corneal
Name of contact lens
No of lens care
scraping with positive cassette wells with positive solutions with positive
cultures(%)
bacterial growth(%)
bacterial growth(%)
Pseudomona aeruginosa
28(73.68)
54 (77.14)
6 (17.14)
Acanthamoeba
3 (7.89)
6 (8.57)
0
Klebsiella spp
1 (2.63)
0
0
Alcaligens spp
1(2.63)
0
0
Serratia sp
1 (2.63)
0
0
Both PA and Ac spp
2 (5.26)
2 (2.86)
0
Both PA and Alcaligens spp
0
2 (2.86)
0
Both PA and Serratia spp
0
2 (2.86)
0
Both PA and Klebsiella spp
0
2 (2.86)
0
Both Ac and Klebsiella spp
2
2 (2.86)
0
38 (100)
70 (100)
6(17.14)
0
0
29(82.86)
38(100)
70(100)
35(100)
No of culture positive corneal scrapings or CL
cassette wells or lens care solution
No of culture negative eyes or CL cassette wells
or lens care solution
Total no of eyes or CL cassette wells or lens care
solution were cultured
PA. Pseudomona aeruginosa, CL , contact lens, Ac, Acanthamoeba
5
can be assumed that the source of contamination was
the CL storage cases. In developing countries like Pakistan, commonly used water is contaminated by gut
commensals, especially Pseudomonas. Contact of CLs
and CL storage cases with water can cause contamination by Pseudomonas , which survives well in the moist
environment offered by CLs, CL storage cases and lens
care solutions. Contaminated CLs which were used
by the patients, acted as a vector for transmitting the
microbes from the CL storage cases to the patients’
conjunctiva and cornea by forming polysaccharidecontaining bio-film on the posterior surface of soft CLs
by bacterial adherence. Bacterial adherence to artificial
surface is also thought to be mediated by hydrophobic bonding and relatively hydrophobic strains adhere
very readily to CLs. In addition, more acidic environment due to raised level of lactic acid and carbonic acid
in the tear film could reduce the pH and increase bacterial adhesion.24 Although Pseudomonas adhere poorly
to intact corneal epithelium, corneal surface damage
due to trauma by poorly maintained CLs during the insertion and removal of CLs provide entry into the cornea leading to keratitis by Pseudomonas. The type of micro-organisms recovered from the corneal scrapes and
CL-care products- P.aeruginosa , Enterobacter sp, Klebsiella sp, Alcaligens sp. and Serratia sp, are not part of
the resident ocular flora and are widely distributed in
soil, water, sewage, gastrointestinal tract of humans
and their presence indicates that the source of contamination is external in nature.25
CONCLUSION
In conclusion, the incidence of CL-induced microbial keratitis is lower than the incidence due to other
risk factors in our region. Undoubtedly the microbial
contamination of CL storage cases was a great risk
for gram-negative corneal infection among soft CLwearers. Pseudomonas spp. were the dominant causative agents. Increased awareness of adequate lens care
and disinfection practices, continuous supervision of
all CL-wearers and frequent replacement of CL storage
cases would greatly help to reduce this risk of infection
on cornea.
REFERENCES:
1. Garg P. Diagnosis of microbial keratitis. Br J Ophthalmol.
2010;94:961-2.
2.
Sharma S, Taneja M, Gupta R, et-al. Comparison of clinical and
microbiological profiles in smear-positive and smear-negative
cases of suspected microbial keratitis. Indian J Ophthalmol.
2007;55:21-5.
3.
Fleiszig SM, The Glenn A. Fry award lecture 2005. The
pathogenesis of contact lens-related keratitis. Optom Vis Sci.
2006;83:866-73.
4.
Stapleton F, Keay L, Edwards K, et-al. The incidence of contact
lens-related microbial keratitis in Australia. Ophthalmology.
2008;115:1655-62.
6
5.
Narsani AK, Jatoi SM, Khanzada MA, Lohana MK. Etiological
diagnosis of microbial keratitis. J Coll Physicians Surg Pak.
2010;20:604-7.
6. Al-Yousuf N. Microbial keratitis in kingdom of Bahrain:
clinical and microbiology study. Middle East Afr J Ophthalmol.
2009;16:3-7. 7.
Wu YT, Zhu H, Harmis NY, Iskandar SY, Willcox M, Stapleton
F. Profile and frequency of microbial contamination of contact
lens cases. Optom Vis Sci. 2010;87:153-8.
Shah VM, Tandon R, Satpathy G, et-al. Randomized clinical
8.
study for comparative evaluation of fourth-generation
fluoroquinolones with the combination of fortified antibiotics in
the treatment of bacterial corneal ulcers. Cornea. 2010;29:751-7. 9.
Musa F, Tailor R, Gao A, Hutley E, Rauz S, Scott RA. Contact
lens-related microbial keratitis in deployed British military
personnel. BR J Ophthalmol. 2010;94:988-93.
10. American Academy of Ophthalmology Cornea/external
disease panel. Preferred Practice Patterns Guidelines.
Bacterial keratitis. San Francisco, CA: American Academy of
Ophthalmology; 2008. Available at: http://one.aao.org/CE/
PracticeGuidelines/PPP.
11. Ahn M, Yoon KC, Ryu SK, Cho NC, You IC. Clinical aspects
and prognosis of mixed microbial (bacterial and fungal)
keratitis. Cornea. 2011;30:409-13.
12. Friedman NJ, Kaiser PK, Pineda R. The Massachusetts eye and
ear infirmary illustrated manual of ophthalmology. 2009. 13. Kanski JJ. Clinical ophthalmology: a synopsis. 2009.
14. Ibrahim YW, Boase DL, Cree IA. Epidemiological characteristics,
predisposing factors and microbiological profiles of infectious
corneal ulcers: the Portsmouth corneal ulcer study. Br J
Ophthalmol. 2009;93:1319-24.
15. Jeng BH, Gritz DC, Kumar AB, et-al. Epidemiology of
ulcerative keratitis in Northern California. Arch Ophthalmol.
2010;128:1022-8.
16. Hsu HY, Nacke R, Song JC, Yoo SH, Alfonso EC, Israel HA.
Community opinions in the management of corneal ulcers and
ophthalmic antibiotics: a survey of 4 states. Eye Contact Lens.
2010;36:195-200.
17. Giraldez MJ, Resua CG, Lira M, et-al. Contact lens
hydrophobicity and roughness effects on bacterial adhesion.
Optom Vis Sci. 2010;87:E426-31.
18. Ehlers JP, Shah CP. The Wills eye manual: office and emergency
room diagnosis and treatment of eye disease. 2008. 19. Chawla B, Agarwal P, Tandon R, et-al. In vitro susceptibility
of bacterial keratitis isolates to fourth-generation
fluoroquinolones. Eur J Ophthalmol. 2010;20:300-5. 20. Whitcher JP, Srinivasan M, Upadhyay MP. Microbial
keratitis. In : Johnson GJ, Minassian DC, Weale RA, West SK,
editors. The Epidemiology of Eye Dieases . 2nd ed. Arnold:
London; 2003. p. 190-5.
21. Mah-Sadorra JH, Yavuz SG, Najjar DM, Laibson PR,
Rapuano CJ, Cohen EJ. Trends in contact lens-related corneal
ulcers. Cornea 2005;24:51-8.
22. Illingworth CD, Cook SD. Acanthamoeba keratitis. Surv
Ophthalmol 1998;42:493-508.
23. Sharma S, Gopalakrishnan S, Aasuri A, Garg P, Rao GN.
Trends in contact lens-associated microbial keratitis in southern India. Ophthalmology 2003;110:138-43.
24. Raskin EM, Speaker MG, McCormick SA, Wong D, Menikoff
JA, Pelton-Henrion K. Influence of haptic materials on the adherence of Staphylococci to intraocular lenses. Arch Ophthalmol 1993;111:250-3.
25. Sankaridurg PR, Vuppala N, Sreedharan A, Vadlamudi J, Rao
GN. Gram-negative bacteria and contact lens induced acute
red eye. Indian J Ophthalmol1996;44:29-32. Ophthalmology Update Vol. 12. No. 1, January-March 2014
ORIGINAL ARTICLE
Danish Zafar
Correlation between Central
Corneal Thickness & Diabetes in
Pakistani Population
Danish Zafar FCPS1, Abdus Salam Arif FCPS2, Iftikhar AhmedFCPS3
ABSTRACT
Objective: To evaluate the role of blood glucose levels on central corneal thickness (CCT) in diabetic and non-diabetic
population.
Materials and Methods: This study was conducted in Ayub Teaching Hospital from July 2011 to Dec 2011. 93 cases of
diabetes and 90 of non-diabetic subjects were randomly selected from the patients attending ophthalmology outpatient department. There were 43 males and 50 females in diabetic group. The CCT was recorded with optical pachymeter (Optikon).
Average of 3 consecutive recordings of CCT was taken for analyses. Blood samples were collected simultaneously when
CCT measurement were taken. Blood glucose levels were measured by using glucose oxidase and peroxidase method.
Results: Average CCT in diabetic population was 529.8 micron and in non--diabetic patients was 524.7 microns. Blood glucose levels ranged between 90mg% to 460mg% in diabetic population with a mean value of 214mg%, while in non-diabetics
it ranged between 80mg% to 160mg% with a mean of 134mg%. CCT in diabetic patients was not significantly different from
that in non-diabetic patients. The variation of CCT at different levels of blood glucose levels averaged 4 microns. There was
no significant correlation between blood glucose levels and the CCT values (p= 0.062).
Discussion: Our study reveals that diabetic patients had cornea thicker than non-diabetics by 5.1 microns, though it did not
attain statistical significance. CCT levels were higher in uncontrolled diabetic population. There was no significant change in
CCT levels on short term fluctuations in blood glucose levels. CCT levels correlate with long term control of blood glucose
levels and thus requires to be correlated with glycosylated hemoglobin (HbA1c levels) which indicates control over last 3
months period. Racial variation influences CCT. This implies that every population will have a unique CCT reading. The
implications of this difference in average CCT are significant in terms of the correct determination of elevated IOP in our
population. Glaucoma patients in our population will need to maintain a lower level of IOP.
Conclusion: CCT values in diabetic population is not significantly higher than in non-diabetic population. Blood glucose
levels do not significantly affect CCT values.
Key Words: CCT ( Central Corneal thickness), Optical pachymeter, Non-diabetic and Diabetic population.
INTRODUCTION
Accurate intraocular pressure (IOP) measurement is one of the most important steps in ophthalmic
practice, especially in the diagnosis and assessment of
the effectiveness of glaucoma treatments. The current
gold standard to measure IOP is Goldmann applanation tonometry (GAT). However, it has been clearly
documented that GAT measurements can be affected
by several ocular factors such as corneal curvature, axial length (AL), and central corneal thickness (CCT).1-6
Recent studies focusing on ocular hypertension have
reconfirmed the importance of CCT in IOP measurements.1,2.7 On the other hand, during the past decade, it
has been proposed that CCT is just one of several corneal biomechanical properties that affect IOP measurement. Those biomechanical properties include corneal
viscosity, elasticity, hydration, connective tissue composition, and regional pachymetry.8,9 In a recent study,
Assistant Professor, Northern Institute of Medical Sciences,
Abbottabad 2Assistant Prof. Ophthalmology, Women Medical
College, Abbottabad, 3.Associate Prof. International Medical College,
Abbottabad
1
Correspondence: Dr. Danish Zafar, House:13, St:2, Police Housing
Colony,
Mirpur
Abbottabad.
E.Mail:[email protected]
Cell: 0315 9110555
Received: Oct’2013
it was shown that the level of corneal elasticity may influence the effect of CCT on IOP measurement.9
Various structural and functional abnormalities
of the cornea in patients with diabetes mellitus, called
diabetic keratopathy, have been reported, including
impaired epithelial and endothelial function, recurrent corneal erosions, punctate keratitis, and delayed
wound healing.10 Non-enzymatic glycosylation (glycation) of proteins (the Maillard reaction) results in the
formation of advanced glycosylation end products
(AGEs), and this process exhibits several harmful reactions including the liquefaction of the vitreous body
leading to diabetic retinopathy and retinal detachment,
the corneal rigidity, and retinal microvascular alterations. It has also been reported that glucose can act as
a collagen cross-linking agent with the help of AGEs.
Advanced Maillard products accumulate in collagen
proteins, result in the formation of covalent cross-linking bonds, and may lead to increased corneal thickening and biomechanical changes. These changes may affect the measurement of IOP in an unexpected manner,
such as an overestimation of the “true” IOP.
Measurement of central corneal thickness (CCT)
is an important component of a complete ocular examination, particularly for patients being evaluated for
the risk of developing primary open angle glaucoma.11
Diabetes mellitus is a very common disease world7
wide having a significant health impact on society.12
Studies have shown that diabetic patients have a significantly increased central corneal thickness compared
with healthy controls.13,14 Diabetes mellitus affects biomechanical parameters of human corneas, including
increased corneal hysteresis, corneal resistance factor
and CCT.15 Diabetic patients are at increased risk of
developing glaucoma. The implications of this in the
clinical management and understanding of glaucoma is
still not clear. Singapore Malay Eye Study has showed
that diabetes and hyperglycaemia are associated with
thicker central corneas, independent of age and IOP
levels.16,17 To our best knowledge there are no studies in
published literature on the role of blood glucose levels
at different points of time and its correlation with CCT
recorded simultaneously in our set up
This study was conducted in Ayub Teaching Hospital from July 2011 to Dec 2011. 93 cases of diabetes
and 90 of non-diabetic subjects were randomly selected
from the patients attending ophthalmology outpatient
department. There were 43 males and 50 females in diabetic group. The duration of diabetes mellitus ranged
from one to fifteen years. The CCT was recorded with
optical pachymeter (Optikon). Average of 3 consecutive recordings of CCT was taken for analyses. Blood
samples were collected simultaneously when CCT
measurement were taken. Blood glucose levels were
measured by using glucose oxidase and peroxidase
method.
The same procedure was repeated thrice in each
patient few days apart. The measurements were taken
in the morning hours. Blood glucose levels were correlated with CCT values. Statistical analysis was performed using t-test, univariate analysis.
RESULTS
The age group of the patient was from 42 to 74
years in diabetic group with 10 patients between 40-50
age group, 30 in 50-60 age group, 42 in 60-70 age group
and 11 in 70 to 80 age group. Non diabetics included 8
patients in 40 to 50 group, 26 in 50-60 age group, 35 in
60 -70 age group and 21 in 70 to 80 age group. Average CCT in diabetic population was 529.8 micron and
in nondiabetic patients was 524.7 microns. Blood glucose levels ranged between 90mg% to 460mg% in diabetic population with a mean value of 214mg%, while
in non-diabetics it ranged between 80mg% to 160mg%
with a mean of 134mg%. CCT in diabetic patients was
not significantly different from that in non-diabetic patients. We also noted that diabetic patients (included 6
patients) with high blood glucose levels (blood glucose
> 400mg%) had an average CCT value of 534 microns.
The variation of CCT at different levels of blood glucose levels averaged 4 microns. There was no signifi8
cant correlation between blood glucose levels and the
CCT values (p= 0.062).
Table showing total number of patients.
Age Group
No of DM Pts
No of Non-DM Pts
40- 50
10
08
50-60
30
26
60-70
42
35
70- 80
Total number
of Patients
11
21
93
90
DISCUSSION
There has been considerable interest in the impact of some corneal parameters, especially CCT, as a
potential determinant of measured IOP and glaucoma
risk and/or progression.2,7 Measured IOP is affected
by CCT in different tonometers.3-6 However, this relationship has not been precisely specified, and has been
thought to be nonlinear in the range of typical IOP.
Our study reveals that diabetic patients had cornea thicker than non-diabetics by 5.1 microns, though
it did not attain statistical significance. CCT levels were
higher in uncontrolled diabetic population. The European Glaucoma Prevention Study showed that persons
with diabetes had thicker central corneas than persons
without diabetes (588 versus 571microns).18 Larger patient base is necessary which includes larger proportion of uncontrolled diabetic patients to establish the
high variation in CCT levels in uncontrolled diabetic
patients. There was no significant change in CCT levels
on short term fluctuations in blood glucose levels. CCT
levels correlate with long term control of blood glucose
levels and thus requires to be correlated with glycosylated hemoglobin (HbA1c levels) which indicates
control over last 3 months period.
Racial variation influences CCT. This implies that
every population will have a unique CCT reading.
The varied population bases used by different studies
make comparison difficult. However, average CCT of
our population (531+ 33 µm)19 closely matches that of
the African Americans (531.0 ± 36.3 µm),20 the Japanese
(531.7 µm),21 the Indians (537 ± 34 µm) but is significantly different from that of the Caucasian population (558
+ 34.5 µm). Population surveys done on Caucasians
have been the basis for the definition of the “normal”
range of IOP.22 16 The implications of this difference in
average CCT are significant in terms of the correct determination of elevated IOP in our population. Glaucoma patients in our population will need to maintain
a lower level of IOP.
CONCLUSION
CCT values in diabetic population is not signifiOphthalmology Update Vol. 12. No. 1, January-March 2014
cantly higher than in non-diabetic population. Blood
glucose levels do not significantly affect CCT values.
RFERENCES
1. Herndon LW, Choudhri SA, Cox T, Damji KF, Shields MB,
Allingham RR. Central corneal thickness in normal, glaucomatous, and ocular hypertensive eyes. Arch Ophthalmol.
1997;115:1137–1141. Abstract/FREE Full Text
2
Argus WA. Ocular hypertension and central corneal thickness.
Ophthalmology. 1995;102:1810–1812. MedlineWeb of Science
3
Herndon LW. Measuring intraocular pressure-adjustments for
corneal thickness and new technologies. Curr Opin Ophthalmol. 2006;17:115–119. CrossRefMedlineWeb of Science
4
Whitacre MM, Stein R. Sources of error with use of Goldmanntype tonometers. Surv Ophthalmol. 1993;38:1–30. CrossRefMedline
5
Whitacre MM, Stein RA, Hassanein K. The effect of corneal thickness on applanation tonometry. Am J Ophthalmol.
1993;115:592–596. MedlineWeb of Science
6
Doughty MJ, Zaman ML. Human corneal thickness and its
impact on intraocular pressure measures: a review and metaanalysis approach. Surv Ophthalmol. 2000;44:367–408. CrossRefMedlineWeb of Science
7
Brandt JD, Beiser JA, Kass MA, Gordon MO. Central corneal
thickness in the Ocular Hypertension Treatment Study (OHTS).
Ophthalmology. 2001;108:1779–1788. CrossRefMedlineWeb of
Science
8
Chang DH, Stulting RD. Change in intraocular pressure measurements after LASIK the effect of the refractive correction and
the lamellar flap. Ophthalmology. 2005;112:1009–1016. CrossRefMedlineWeb of Science
9
Liu J, Roberts CJ. Influence of corneal biomechanical properties on
intraocular pressure measurement: quantitative analysis. J Cataract Refract Surg. 2005;31:146–155. CrossRefMedlineWeb of Scien
10. Gekka M, Miyata K, Nagai Y, et al. Corneal epithelial barrier
function in diabetic patients. Cornea. 2004;23:35–37. CrossRefMedlineWeb of Science
11. Dueker DK, Singh K, Lin SC, Fechtner RD, Minckler DS, Samples JR, et al. Corneal thickness measurement in the management of primary open-angle glaucoma: a report by the
12. 13.
14. 15. 16. 17. 18. 19.
20. 21.
22.
American Academy of
Ophthalmology. Ophthalmology
2007;114:1779-87.
Goday A. Epidemiology of diabetes and its non-coronary complications. Rev Esp Cardiol 2002;55:657-70
Busted N, Olsen T, Schmitz O. Clinical observation on the corneal thickness and the corneal endothelium in diabetes mellitus. Br J Ophthalmol 1981;65:687-90.
Claramonte PJ, Ruiz-Monero JM, Sańchez-Pe´rez SP, et al.
Variation of central corneal thickness in diabetic patients as
detected by ultrasonic pachymetry. Arch Soc Esp Oftalmol
2006;81:523-6.
Goldich Y, Barkana Y, Gerber Y, Rasko A, Morad Y, et al. Effect
of diabetes mellitus on biomechanical parameters of the cornea. Cataract Refract Surg. 2009;35:715-9.
Daniel H W, Tien Y W, Paul J F, Wan T T, et al. Central corneal thickness and its associations with ocular and systemic
factors: The Singapore Malay eye study. Am J Ophthalmol
2009;147:709–16.
Sahin A, Bayer A, Ozge G, Mumcuoğlu T, et al. Corneal biomechanical changes in diabetes mellitus and their influence on
intraocular pressure measurements. Invest Ophthalmol Vis Sci.
2009; 50:4597-604. Epub 2009 May .
European Glaucoma Prevention Study Group. Central corneal
thickness in the European Glaucoma Prevention Study. Ophthalmology 2007;114:454-9.
Roomasa Channa, Fazia Mir,Mahnaz Naveed.Central corneal
thickness in pakistani adults. JPMA 59:225; 2009
La Rosa FA, Gross RL, Orengo-Nania S. Central corneal thickness of caucasians and African Americans in glaucomatous
and nonglaucomatous populations. Arch Ophthalmol 2001;
119: 23-7.
Aghaian E, Choe JE, Lin S, Stamper RL, et al. Central corneal
thickness of Caucasians, Chinese, Hispanics, Filipinos, African
Americans, and Japanese in a glaucoma clinic. Ophthalmology
2004; 111: 2211-9.
Thomas R, Korah S, Muliyil J. The role of central corneal thickness in the diagnosis of glaucoma. Indian J Ophthalmol 2000;
48: 107-11.
9
ORIGINAL ARTICLE
Effectiveness of first Probing in Children
with Congenital Nasolacrimal Duct Obstruction
& its Pattern in different age Groups
Nuzhat Rahil
Nuzhat Rahil FCPS1, AdnanAhmed FCPS2, Rahil Aumir Malik FCPS3
ABSTRACT
Objective: To determine the effectiveness of first probing in children with congenital nasolacrimal duct obstruction and its
pattern in different age groups.
Materials & Methods: This descriptive case series study was conducted at Eye Operation Theatre, Eye Department, Lady
Reading Hospital Peshawar. Duration of the Study was 6 months (from October 2011 to March 2012), in which a total of
165 patients were observed, using success rate of first probing for CNLDO to be 70%,with 95% confidence interval and
7% margin of error under WHO sample size calculations, in which a consecutive (Non probability) sampling technique was
used. Effectiveness of first probing procedure among 165 childrens was analyzed.
Results: In this study, 66(40%) childrens were in the age range of 1-2 years, 53(32%) childrens were in age range 3-4 years
and 46(28%) childrens were in age 4-5 years. Mean age was 3 years with standared deviation ±1.28. Ninety six (58%)
childrens were male while 69(42%) childrens were female. Effectiveness of first probing procedure among 165 childrens
was analyzed. First probing procedure was effective in 134(81%) childrens while it was not effective in 31(19%) childrens.
Conclusion: Congenital nasolacrimal duct obstruction is a common paediatric pathology seen in ophthalmology out patient.
Probing is carried out in unresponsive cases after the age of 6 months and had very good results. We recommend that
parents should be properly guided about conservative treatment and lacrimal sac passage probing should be performed in
those cases where there is no improvement with proper continuous conservative treatment.
Key Words: First probing, congenital nasolacrimal duct,
INTRODUCTION:
Congenital nasolacrimal duct obstruction (CNLDO) is a common disorder of the lacrimal system.
(CNLDO) affecting up to 20% of all newborns. The
nasolacrimal duct usually canalises at 8 months of fetal
life 1 but there is commonly a delay in this developmental process which can result in residual membrane tissue or stenosis at any level in the nasolacrimal system
- from the canaliculi to the extreme end of the nasolacrimal duct underneath the inferior turbinate.2 Persistent membranous obstruction at the bottom end of
the nasolacrimal duct occurs in up to 70% of neonates
(dacryostenosis).3 However, only 2-4% of newborns exhibit the clinical phenomena of nasolacrimal duct obstruction.
Rarely, there may be other associated abnormalities like agenesis or abnormalities of the puncta, lacrimal sac, duct or absence of valves (valve of Hasner ±
valve of Rosenmüller). Very pronounced/severe obstruction is associated with systemic abnormalities in
25% of cases.2 Epiphora which develops within 6 weeks
of birth,4 sticky eyes, recurrent conjunctivitis, crusting
of the eyelids, ± baggy swelling over the inner canthal
region from which it may be possible to express pus.
Consultant Ophthalmologist. 2Medical Officer.
Lady Reading Hospital, Peshawar
1
3
Senior Registrar,
Correspondence: Dr. Nuzhat Rahil E.Mail: [email protected]
House: 47, Army Housing Scheme, Askari-IV, Warsak Road, Peshawar
Cantt. Cell: 0333-9106959
10
Accepted: Nov’20313
These infants may less commonly present for the first
time with dacryocystitis. It is bilateral in one third of
cases.4 If congenital nasolacrimal duct obstruction does
not resolve spontaneously, standard surgical procedure is nasolacrimal duct probing with a variable success rate.
The timing of surgical intervention is tricky. The
fact that spontaneous resolution is likely has to be
balanced with the fact that surgical success decreases
with age.6 Current practice is to defer surgery until
12 months of age. At that point, probing of the ducts
under a very light anaesthesia may be done. Naso-endoscopy allows direct visualisation of the lower end of
the nasolacrimal duct, which increases the accuracy of
the procedure. This will clear 95% of those cases where
resolution doesn’t occur spontaneously. 2
Probing may occasionally be considered before
age one year if the patient is very symptomatic. ‘Early
probing’ results in symptoms resolving immediately
in almost all cases (optimum time seems between 4-6
months)5,7 - but the long-term consequences of adopting this ‘unnecessary’ procedure are currently unknown and the child is faced with the usual risks associated with simply having a general anaesthetic. If still
unsuccessful after 2-3 probing attempts, then a dacryocystorhinostomy (DCR) is performed. Balloon catheter
dilation is another, less invasive approach.8 Nasolacrimal duct probing is advocated as a primary treatment
in children younger than 9 years of age with success
rate of 88% before proceeding to more complex treatment options. Unsuccessful probing may result from
Effectiveness of first Probing in Children with Congenital Nasolacrimal Duct Obstructio
the selection of non membranous (complex) obstructions rather than the increased age of the patients.
The objective of our study was to determine the effectiveness of first probing in children presenting with
congenital nasolacrimal duct obstruction. This study
shall be quite helpful in our self audit and making recommendations for redevising surgical guidelines in
case the success rate comes out to be significantly low
but in case the success rate comes out to be significantly
high, the results than shall be shared among all health
professionals and recommendations can be given regarding use of first probing as first line therapy with
full confidence. Additionally, this study also focusses
on the pattern of effectiveness in different age groups
among children under 5 years of age and based upon
such pattern we shall be able to conclude and suggest
the first probing in particular age group where we find
the highest effectiveness rate in our population.
MATERIALS & METHODS
This descriptive case series study was conducted
at Eye Operation Theatre, Eye Unit of Lady Reading
Hospital, Peshawar. Before we start the study, permission from the hospital ethical committee was obtained.
An informed written consent was obtained from the
parents of patient. The patient was evaluated for inclusion criteria and exclusion criteria as follows.
Inclusion Criteria: All children, both male and female,
between one to five years of age, having congenital
nasolacrimal duct obstruction, not responding to conservative treatment. Children with simple obstruction
i.e. associated with dacryostenosis (detected by clinical
examination and nasal speculum examination).
Exclusion criteria: Children with complex obstruction
i.e. punctual agenesis, congenital lacrimal fistula and
craniofacial defects (detected by clinical examination
and slit lamp examination), children with acute dacryocystitis secondary to infection were excluded. The
above mentioned conditions acts as confounders and if
included will introduce bias in study results.
A special data collection proforma was filled for
each patient having a detailed record of the disease including name, age, gender, address, and presence of
congenital nasolacrimal duct obstruction. Diagnoses
were made according to the patients’ history, clinical
examination like the state of the punctum, the canaliculus, the sac, and the nasolacrimal duct. Diagnostic
criteria were based upon positive regurgitation test
and Fluorescein dye disappearance test. For a dye disappearance test, topical anesthesia was instilled, moistened fluorescein paper was placed into the inferior
fornix, excess was wiped away and each eye was evaluated for clearance of the dye at 5 min in a semi darkened room with blue filter light of slit lamp or indirect
ophthalmoscope.
The probing was performed under general anesOphthalmology Update Vol. 12. No. 1, January-March 2014
thesia after dilatation of upper punctum. Post operatively the patient was given antibiotic and steroid eye
drops, 4 times daily, for 1 week; the patient was evaluated after one month in the eye out patient department
to determine the effectiveness in terms of absence of
even a single drop of tear on pressing the lacrimal sac.
All the analysis was done in SPSS version 10. Frequencies and percentages were calculated for categorical variables like gender and effectiveness. Mean ±
Standard deviation was computed for numerical variables like age. Effectiveness was stratified among age
and gender to see the effect modifications. All the results were presented in the form of tables and graphs.
RESULTS
This study was conducted at eye Department,
Lady Reading Hospital Peshawar in which 165 patients were included. The results were analyzed as:
Age distribution among 165 childrens was analyzed
as n=66(40%) childrens were in age range 1-2 years,
n=53(32%) childrens were in age range 3-4 years and
n=46(28%) childrens were in age 5 years. Mean age was
3 years with standared deviation ±1.28. (as shown in
Table no 1) Gender distribution among 165 childrens
was analyzed as n=96(58%) childrens were male and
n=69(42%) childrens were female. Effectiveness of first
proding proceudre among 165 childrens was analyzed
as first proding procedure was effective in n=134(81%)
childrens while it was not effective in n=31(19%) childrens. ( as shown in Table no. 3)
Association of effectiveness of first proding procedure in age groups was analyzed as among 134(81%)
childrens in which the first proding procedure was
effective 53 childrens were in age range 1-2 years, 43
childrens were in age range 3-4 years and 38 childrens
were in 5 years. ( as shown in Table no. 4) Association
of effectiveness of first probing procedure in gender
was analyzed as among 134(81%) childrens in which
the first probing procedure was effective 78 childrens
were male and 56 childrens were female.
TABLE 1: age distribution (n=165)
Age Groups
Frequency
Percentage
1 - 2 years
66
40%
3 -4 years
53
32%
5 years
46
28%
165
100%
Total
Mean age was 3 years with standared deviation ±1.28
TABLE 2: Gender Distribution (n=165)
Gender Groups
Male
Frequency
Percentage
96
58%
Female
69
42%
Total
165
100%
11
TABLE 3: Effectiveness of Procedure (n=165)
Effectiveness of
Procedure
Effective
Frequency
Percentage
134
81%
Not effective
31
19%
Total
165
100%
TABLE 4: Association of effectiveness of procedure
in age distribution (n=165)
Association of
Effectiveness of
Procedure in age
group
1-2
years
3-4
years
5
years
Total
Effective
53
43
38
134
Not effective
13
10
8
31
66
53
46
165
Total
Chi Square Test was applied in which P Value was 0.003
DISCUSSION
Congenital nasolacrimal duct obstruction (CNLDO) is a common disorder of the lacrimal system.Our
study shows that 40% childrens were in age range 1-2
years, 32% childrens were in age range 3-4 years and
28% childrens were in age 5 years. Mean age was 3
years with standared deviation ±1.28. More over 58%
childrens were male and 42% childrens were female.
These results coincide with the study done by Halipota
et al.9 Similar results were found in study done by Sturrock SM et al10 in which the long term results of probing for congenital nasolacrimal duct obstruction were
reviewed using a parental questionnaire issued to both
treated and age-matched control groups.
Probing had apparently reduced the symptom rate to a level close to normal for the age group
concerned. All studies on the incidence of congenital
nasolacrimal duct obstruction must be interpreted with
reference to the known high rate of spontaneous resolution as a clear trend has been demonstrated towards a
lower incidence of symptoms the longer the follow up
after probing.
Our study shows that first probing procedure was
effective in 134(81%) childrens while it was not effective in 19% childrens.Similarly a study done by Honavar et al11 shows that one attempt at probing resulted in
resolution in 73.3% (44 of 60) patients. Sixteen patients
needed a repeat procedure. The overall success rate
was 80% (48 of 60). Two specific types of obstructions of
the nasolacrimal duct were recognized on probing by
the auther: membranous and firm. Factors predictive of
failure of probing were age older than 36 months, bilateral affection failed conservative therapy, failed earlier
probing dilated lacrimal sac and firm obstruction.
Results indicate that probing is a viable primary
surgical option for congenital nasolacrimal duct obstruction in children who present between 2 and 3 years
12
of age, and identify factors predictive of poor prognosis.11 Similar observation were noted in study done by
Gheman T et al12
Our results shows that among 81% childrens in
which the first proding procedure was effective 53
childrens were in age range 1-2 years, 43 childrens
were in age range 3-4 years and 38 childrens were in
5 years. While 78 children were male and 56 children
were female.The study conducted by Mannor et al13
on 142 children showed success of nasolacrimal duct
probing was negatively correlated with increasing age:
92%, 89%, 80%, 71%, and 42% at age 12, 24, 36, 48, and
60 months, respectively (P = .001 at each interval). Increasing severity of epiphora was correlated with increased failure of nasolacrimal duct probing .Although
the success of nasolacrimal duct probing declines with
age, probing in older children can remain the first line
of treatment. Because increasing frequency of epiphora
correlates with failure of nasolacrimal duct probing,
children with daily epiphora should undergo early
nasolacrimal duct probing.13 Similar results were found
in study done by Halipota FM et al14, Robb R et al15
In our study we observed that with increasing age
especially beyond 14 months, the success rate of probing decreased. Beyond the age of 2 years the failure rate
is almost 100%. Kashkouli MB et al16 observed 94% success in patients of less than 9 months of age. The success rate decreased to 84% in the children older than 9
months of age.
Other studies have also shown that probing failure
risk increases with increasing age.17,18 Delay in probing
past 12 months of age is associated with decreased success rate as noted by Clark RA.19 Results of probing
after 18 months of age are comparatively poor as observed by Velthoven.20 On the contrary, some studies
have reported success with probing in children upto 5
years of age15-18. After probing we continued with lacrimal massage and instillation of antibiotic eye drops
and waited for 3 months before the subsequent intervention. Some of the patients with residual symptoms
were relieved with this treatment. Sturrock, MacEvan
and Young also observed that after successful probing
there might be some residual symptoms in upto 30% of
patients,21,22
CONCLUSION
Congenital nasolacrimal duct obstruction is a common paediatric pathology seen in ophthalmology out
patient. Conservative treatment in these cases is very
effective with massage of lacrimal sac area followed by
topical antibiotic eye drops. Probing is carried out in
unresponsive cases after the age of 6 months and has
very good results.
RECOMMENDATION
We recommend that parents should be properly
guided about conservative treatment and lacrimal sac
message probing should be performed in those cases
where there is no improvement with proper continuous
conservative treatment.
REFERENCES
1. Jackson TL; Moorfields Manual of Ophthalmology, Mosby
(2008)
2. Bashour M; Nasolacrimal Duct, Congenital Anomalies, eMedicine (June 2009).
3.
Cassady JV; Developmental anatomy of nasolacrimal duct;
AMA Arch Ophthalmol. 1952 Feb;47(2):141-58.
4. Willshaw H, Scotcher S, Beatty S. A Handbook of Paediatric
Ophthalmology, HE Willshaw (2000).
5. Young JD, MacEwen CJ; Managing congenital lacrimal obstruction in general practice. BMJ. 1997 Aug 2;315(7103):293-6.
6. Takahashi Y, Kakizaki H, Chan WO, et al; Management of congenital nasolacrimal duct obstruction. Acta Ophthalmol. 2009
Jul 21.
7. Paul TO, Shepherd R; Congenital nasolacrimal duct obstruction: natural history and the timing of optimal intervention; J
Pediatr Ophthalmol Strabismus. 1994 Nov-Dec;31(6):362-7.
8. Repka MX, Melia BM, Beck RW, et al; Primary treatment of
nasolacrimal duct obstruction with balloon catheter dilation J
AAPOS. 2008 Oct;12(5):451-5
9. Halipota FM, Dahri GR, Anjum N. Results of lacrimal probing
in infants and children. Pak J Ophthalmol. 2000;6:47-50.
10. Sturrock SM, Mac Ewan CJ, Young JD. Long-term .results after probing for congenital nasolacrimal duct obstruction. Br J
Ophthalmol. 1994; 78: 892-94.
11. Honavar SG, Prakash VE, Rao GN. Outcome of probing for
congenital nasolacrimal duct obstruction in older children.
Acta Ophthalmol. 2010 Aug;88(5):506-13.
12. Ghuman T, Gonzales C, Mazon ML. Treatment of congenital
nasolacrimal duct obstruction. Am J Orthopt. 1999; 49: 161-6. .
13. Mannor GE, Rose GE, Frimpong-Ansah K, Ezra E. Factors
affecting the success of nasolacrimal duct probing for congenital nasolacrimal duct obstruction. Am J Ophthalmol. 2000
Jul;130(1):42-8.
14. Halipota FM, Dahri GR, Anjum N. Results of lacrimal probing
in infants and children. Pak J Ophthalmol. 2000;6:47-50.
15. Robb R. Success rates of Nasolacrimal Duct probing at time intervals after one year of age. Ophthalmology.1998;105:1307-0.
16. Kashkouli MB, Kassaee A, Tabatabaee Z. Intial nasolacrimal
duct probing in children under age 5: cure rate and factors affecting success. J AAPOS 2002; 6: 360-3.
17. Katowitz JA, Welsh MG. Timing of initial probing and irrigation in congenital nasolacrimal duct obstruction. Ophthalmology 1987;94:698-705.
18. Havins WE, Wilkin RB. A useful alternative to silicone intubation in congenital nasolacrimal duct obstruction. Ophthalmic
Surg. 1983; 14: 666-70.
19. Clark RA. Dilatation probing as primary treatment for congenital nasolacrimal duct obstruction. J AAPOS 2002; 6: 364-7
20. Velthoven ME, Wittebol PD, Berendschot TT. Lacrimal duct
probing in young children with a congenital nasolacrimal duct
obstruction at the Utrecht Medical Center: generally an effective treatment. Ned Tijdschr Genecskd. 2003; 19: 764-8.
21. Sing BG, Sing BH. Repeated probing results in the treatment
of congenital nasolacrimal duct obstruction. Eur J Ophthalmol.
2004; 14: 185-92.
22. Hanavar SG, Prakash VE, Rao GN. Outcome of probing for
congenital nasolacrimal duct obstruction in older children. Am
J Ophthalmol. 2000; 130: 42-8.
Myeloid Sarcoma
Juan Montoro, M.D., & Mar Tormo, M.D.
Hospital Clinico Universitario, Valencia, Spain A 17-year-old boy presented with a 1-week history
of proptosis of the left eye. Physical examination
revealed a tumor involving the periorbital region (Panel
A). Magnetic resonance imaging revealed an orbital
mass (Panel B). Laboratory test results included a
hemoglobin level of 89 g per liter, a platelet count of
90,000 per cubic millimeter, and a leukocyte count of
1100 per cubic millimeter. Morphologic examination
of a bone marrow aspirate revealed 30% myeloblasts
(Panel C, arrow). There were no circulating
myeloblasts. A biopsy specimen of the orbital mass
showed myeloid sarcoma.
Myeloid sarcoma is a tumor composed of myeloid
blasts that occurs at an extramedullary site. Myeloid
sarcoma may occur on its own or concurrently with a myelodysplastic syndrome, myeloproliferative disease, or
acute myeloid leukemia (AML), as seen in this case; on rare occasions, myeloid sarcoma precedes a diagnosis
of AML by months or years. After the patient underwent induction chemotherapy, the mass disappeared and
the eye returned to its normal position (Panel D). He subsequently underwent cord-blood transplantation, and
at the 6-year follow-up, there was no evidence of recurrence of AML. (Courtesy: NEJM-UK)
13
ORIGINAL ARTICLE
Junaid F.Wazir
Per-operative use & Safety of 0.5% Intracameral
Moxifloxacin Ophthalmic solution as a Prophylaxis
during Cataract Surgery to prevent early
Post-operative Endophthalmitis
Junaid F. Wazir FCPS, M.Sc1, Imran Ahmed MBBS2
Inayat U. Khan FCPS3, Janzeb FCPS4
ABSTRACT:
Purpose: To evaluate the per-operative use of 0.5% intracameral moxifloxacin ophthalmic solution as a prophylaxis during
cataract surgery to prevent early postoperative endophthalmitis and safety.
Material and Methods: This prospective study was conducted in the Department of Ophthalmology Khyber Teaching Hospital, Peshawar, from October, 2010 to September 2011 and comprised of 200 patients. The patients were divided into two
groups. Group 1 received 0.1 ml of intracameral moxifloxacin 0.5 % ophthalmic solution at the conclusion of the surgery
and the patients in the group 2 were not given the intracameral antibiotic. None of the patients was given postoperative sub
conjunctival antibiotic and steroid injection. All patients were examined for AC reaction and pachymetry was done preoperatively and postoperatively (first day, first week and fourth week postoperatively). Anterior chamber reaction and pachymetry
values between the two groups were compared .Statistical analysis was done by using paired sample t test. P- value of less
than 0.05 was taken as significant.
Results: There was no statistically significant difference in corneal oedema (measured by pachymetry) between the two
groups on the first postoperative day (p=624), and one month postoperatively (p=0.186). Anterior chamber reaction on the
1st postoperative day was not different in both groups (p=0.610). At 4 weeks there was no reaction in any patients and
corneal thickness was also restored to preoperative level.
Conclusion: Intracameral moxifloxacin 0.5% ophthalmic solution seems to be safe in terms of AC reaction and endothelial
toxicity.
INTRODUCTION
Postoperative endophthalmitis is one of the most
feared complications of cataract surgery as it seriously
compromises vision. Although timely diagnosis and
delivery of appropriate treatment do help in management,1 but in our set up the diagnosis is usually delayed as patients present late due to multiple reasons.
It is in the last two decades that the prevalence of the
staphylococcus epidermidis as a common cause of
endophthalmitis has been recognized. The organisms
which were previously considered to be harmless commensals are quite capable of causing endopthalmitis.2
Multiple studies have been carried out to evaluate the
bacterial contamination of anterior chamber fluid aspirates after surgery. Srinivasan R and colleagues found
15% of AC aspirates to be positive for bacterial growth
in which the staphylococci species were the commonest.3 None of their patients developed infection as probably the inoculum size, host response, prophylactic
antibiotics and improvement in the surgical technique
have their role. Improvements in technique of surgery
Medical Officer, Eye A-Ward, Khyber Teaching Hospital, Peshawar.
Trainee Medical Officer, Ophthalmology, Khyber Teaching Hospital,
Peshawar. 3Ophthalmologist, PIMS, Islamabad. 4Medical Officer,
Miran Shah Agency (KPK)
1
2
Correspondence: Dr. Junaid F. Wazir, Doctors Lodge, Opp: Kauser
Mosque, St: 4, Canal Colony. P.O. Peshawar University, Tel: 0333 9105154, E.Mail: [email protected]
Received: Sep’ 2013
14
Accepted: Nov’ 2013
and prophylactic measures have had a beneficial effect,
but despite this the incidence of endophthalmitis after
cataract surgery has increased from 1994-2001 with reported incidence of 2.15 per 1000 cases.4 Thus there still
remains the need for protective antibiotics to combat
the rise in the incidence of endophthalmitis and to treat
the patients in a better way.
In addition to topical antibiotics many surgeons
use intracameral antibiotics to prevent the infection.
Among the antibiotics which are given through intracameral route, most common are vancomycin and cefuroxime.5 Although retrospective analysis suggests
that there has been decrease in the risk of endophthalmitis with vancomycin.6 Vancomycin has also been
shown to increase the risk of cystoid macular oedema
after cataract surgery.7 Moreover, there are reports of
emergence of resistant strains of many bacteria.8 Because of all these facts the routine prophylactic use of
vancomycin in cataract surgery is now discouraged
worldwide.9 Cefuroxime and cefazoline are two other
medicines which are being used as intracameral antibiotics. The recent publication of ESCRS study has demonstrated that cefuroxime significantly decreases the
risk for developing endophthalmitis after phacoemulsification cataract surgery.10 Both of these as well as vancomycin are available as systemic preparations. They
have to be reconstituted before delivery into the eye.
Reconstitution of a drug increases the risk of toxic anterior segment syndrome (TASS).11 TASS is an acute inOphthalmology Update Vol. 12. No. 1, January-March 2014
Per-operative use & Safety of 0.5% Intracameral Moxifloxacin Ophthalmic solution as a Prophylaxi
flammation of anterior segment after cataract surgery.
A variety of substances have been implicated including
inappropriately reconstituted intraocular preparations.
Incorrect PH and incorrect osmolality can also cause
TASS. Another problem with vancomycin and cephalosporin is that they have time dependant efficacy. As
the concentration of drug in AC decreases four times in
first hour, so, this makes them a poor choice.
Considering the problems associated with the
vancomycin and cephalosporin, the new antibiotic
under consideration is moxifloxacin which is a fourth
generation fluoroquinolone. Forth generation quinolones have already surpassed the second generation as
the antibiotics of choice in cataract surgery.12 They have
a wide spectrum of activity and they carry a lower risk
of resistance developing against them. Moxifloxacin is
available as self preserved ophthalmic solution. The
self preserved nature of the medicine has led to its use
as prophylactic intracameral injection. Fluoroquinolones are concentration dependant drugs. If they are put
in AC in high enough dose they rapidly kill the bacteria. No special preparation is required for intracameral
delivery, no millipore filter is needed and the syringe
is easily identifiable by the faint yellow colour of the
solution. Earlier studies had shown no toxicity with intracameral or intra-vitreal injection of Moxifloxacin in
animal eye.13 The aim of this study is to check the safety
profile of 0.5% moxifloxacin available as self-preserved
vagamox and given as intracameral injection during
cataract surgery.
MATERIAL AND METHODS
This case control comparative study was conducted at Khyber Teaching Hospital, Peshawar from October, 2010 to September, 2011. 200 patients were enrolled
for the study. 100 patients were injected intracameral
moxifloxacin at the end of the surgery and they were
put in group 1 whereas 100 patients (controls) were
operated in routine way and were placed in group 2.
None of the patients were given sub conjunctival antibiotic and steroid injection at the end of the surgery.
Patients with glaucoma, retinopathy, maculopathy,
media opacity other than cataract, uveitis and corneal
endothelial disease were not included in the study. Patients who suffered intra-operative complications or
those who had prolonged or complicated surgery were
also excluded from the study.
Preoperative examination included uncorrected
and corrected visual acuity, slit lamp examination,
tonometry, fundoscopy and pachymetry. All patients
were admitted one day prior to surgery. Biometry was
done on the day of admission. On the day of surgery
pupils were dilated with 1% tropicamide and 10% phenylephrine. Fifty two percent of surgeries were performed under local and 48% were done in topical anOphthalmology Update Vol. 12. No. 1, January-March 2014
esthesia. Phacoemulsification was performed by single
surgeon through 3.2 mm clear corneal incision and 5.25
mm PPMA IOL was implanted after enlarging the incision. No suture was applied in any case.
The prophylactic regimen to reduce the risk of infection included topical 10% povidone-iodine on the
periorbital skin, 5% povidone iodine in the conjunctival
sac and eye lashes, draping of the eyelashes and periorbital region, topical antibiotic drops one day prior to
and on the day of surgery. At the start of the operating day a new bottle of moxifloxacin was opened and
the contents of newly opened bottle were aspirated in
10cc syringe by the operating assistant. 0.1 ml of 0.5%
pure moxifloxacin was aspirated in each of 1 cc tuberculin syringe before every case. The undiluted solution
was injected in the anterior chamber at the end of the
surgery. Postoperatively, for the infection control, the
patients were given combination of topical 3 mg/ml tobramycin with 1 mg/ml dexamethasone every 2 hours
along with systemic ciprofloxacin 500 mg twice daily
for five days.
Patients were examined on the first postoperative day and further visits were scheduled at 1 week
and 4 weeks interval. On each visit visual acuity was
recorded, slit lamp examination was done for AC reaction. It was expressed as cells and flare and graded
using Hogan and Kimura grading system. Pachymetry
was done on each visit. Data was entered and analyzed
using SPSS version.14 Student t-test was used to analyze
the data. A p-value of less than 0.05 was considered
significant.
RESULTS
All patients completed the follow up. Mean age of
our patients in group 1 was 59 ± 6.22 (SD) and 58.75 ±
6.86 (SD) in group 2. All patients had variable corneal
oedema on 1st postoperative day as demonstrated by
pachymetry. The mean preoperative pachymetry in
group 1 was 519.56 ± 25.52 and group 2 was 517.30 ±
22.80. On first postoperative day it was 552.29 ± 26.26
in group 1 and 550.90 ± 21.30 in group 2. The difference
in preoperative and postoperative 1st day pachymetry
was significant in both groups (p=0.00). At one month,
the pachymetry was 531.01 ± 26.76 group1 and 517.68
± 21.87 in group 2. The difference between the preoperative and one month post operative corneal thickness was insignificant (p=0.32 and 0.672 respectively).
Corneal thickness of two groups after 1st day and one
month of surgery was almost the same, and the difference was found to be statistically insignificant (p=0.624
and p=0.186).
The difference in anterior chamber reaction in
terms of cells and flare in both groups is insignificant
(p=0.610 for cells and p=0.566 for flare) on the first postoperative day. At final visit there was no reaction in any
patients.
15
Table 1: Corneal thickness observed by
pachymetry (in micrometers) (n=100)
Means and Standard Deviation
Group 1
Pre operative
Group 2
Mean
SD
Mean
SD
519.56
25.52
517.30
22.80
Post operative 1 month 552.29
26.26
550.90
21.30
Post operative 1 day
st
Table 2: Anterior chamber reaction observed as
cells and flare (n=100)
Means and Standard Deviation
Group 1
Group 2
Mean
SD
Mean
SD
Cells
1.97
0.76
1.92
0.74
Flare
1.34
0.59
1.33
0.57
Table 3: Paired sample t test (n=100)
Means, Standard Deviation and Significance
Group-1 verses Group-2
Post operative corneal
thickness (1st day)
Post operative corneal
thickness ( 1 month)
Cells
Mean
SD
Significance
1.390
28.26
0.624
4.080
30.64
0.186
0.050
0.978
0.610
Flare
0.010
0.174
0.566
DISCUSSION
The first report of successful prophylactic intracameral antibiotic injection was published in 197714. It did
not receive significant attention and despite of the efficacy of this technique it was not considered until 2002
when Montan et al published their report in which they
described a decreased rate of postoperative endophthalmitis with intracameral injection of 1 mg of cefuroxime.15
Of the prophylactic methods for cataract surgery
only povidone iodine is recommended.16 If applied
alone it reduces conjunctival flora by 91% for colony
forming and 51% for species. If it is used along with
topical antibiotic, it produces synergistic effect and
leads to sterilization of 83% of the eye.17 Despite its efficacy the rate of endophthalmitis increased after 1994.
So, there was a need for protective antibiotic to check
this rise in the rate of endophthalmitis. Topical antibiotics which gained popularity in the last few years for
infection prophylaxis after cataract surgery were fluoroquinolones.
In 2002 survey of the members of American Society of Cataract and Refractive surgery, Leaning noted
that 86% of respondents were using second generation fluoroquinolones,18 whereas in a 2003 survey, only
21% were using second generation and 61% were using
16
fourth generation fluoroquinolones.19 The reason for
this change was increasing resistance towards the second generation drugs. Kowalski et al reported in 2001
that none of the staphylococcus aureus isolated from
endophthalmitis isolates were sensitive to second generation fluoroquinolones.20 These problems led to the
development of forth generation antibiotics. These antibiotics have got a wider spectrum of activity against
gram positive organisms which are the most common
pathogens causing endopthalmitis. In addition they
have a good coverage against gram negative organisms
and anaerobes.12 Moxifloxacin is found to be superior in
terms of potency to gatifloxacin.21 It seems to be a better
choice as a prophylactic antibiotic as it has got lowest
minimal inhibitory concentration (MIC). Mather et al
did a retrospective study of 93 bacterial endophthalmitis isolates. He found that the MIC levels for Moxifloxacin ranged from 0.06-0.19 mg/ml12. Lindsay has shown
in his study that Moxifloxacin has good aqueous penetration when given four times a day starting two days
prior to surgery and that its concentration exceeds MIC
levels for most common pathogens.22 This shows that
moxifloxacin can be an effective prophylactic antibiotic even given through topical route. But another important consideration is prevention of development of
resistant strains which may develop with prophylactic
use of an antibiotic. The drug level at which the development of resistant strains can be prevented is called
mutation prevention concentration (MPC).
It is another parameter of evaluation of potency of
an antibiotic. Frequent and suboptimal use of an antibiotic increases the risk of development of resistant mutants. The MPC of fluoroquinolones is 8-10 times their
MIC.23 Achieving concentrations higher than this almost ensures the prevention of mutation. With topical
use the aqueous concentration of Moxifloxacin levels
or slightly exceeds its MPC, whereas with intracameral
injection it achieves and ensures much higher concentration than its MPC (0.38 - 2.16mg/ml). We injected
0.1 ml of pure vigamox 0.5% ophthalmic solution without dilution in the AC at the end of the surgery. This is
equivalent to 0.5 mg of moxifloxacin. Bolinao and his
collegues used the same concentration and calculated
the concentration of Moxifloxacin in AC to be 952 mg/
ml, which is 300 times its MIC and at least 30 times its
MPC.23
Our concern was to check the effect of intracameral Moxifloxacin on cornea for which we examined the
cornea clinically for striate and quantitatively by performing pachymetry before and after surgery. The other concern was effect of Moxifloxacin on blood aqueous
barrier and whether it causes inflammation or not. The
patients were examined for aqueous flare and cells on
the first post operative day and on the scheduled visOphthalmology Update Vol. 12. No. 1, January-March 2014
its. The patients were followed for four weeks because
in previous studies it has been suggested that wound
healing is complete in four weeks and preoperative
corneal thickness is also restored in four weeks. Moreover as the eye is usually quiet and the patients have no
problem after that time, we loose follow up mostly after
4-6 weeks of surgery.
We found that the patients who were injected with
intracameral Moxifloxacin had almost the same AC reaction as controls and that the corneal thickness that occurred after the surgery was not significantly different
in two groups. Corneal thickness was restored to the pre
operative levels and there was no sign of inflammation
in AC at four weeks of surgery. This suggests that intracameral Moxifloxacin is not toxic to endothelium and
it does not cause significant inflammation. The results
of our study are supported by Espiratu et al who used
the same concentration of intracameral moxifloxacin.23
Sleve A. Arshinoff has also recommended the routine
use of intracameral Moxifloxacin although he has used
much lesser concentration of the antibiotic in AC.24
CONCLUSION
Intracameral Moxifloxacin 0.5% ophthalmic solution appears to be non toxic to eye in terms of AC reaction and endothelial damage.
REFERENCES
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Jonson MW, Doft BH, Kelsey SF. The Endophthalmitis Vitrectomy study; relationship between clinical presentation and
microbiologic spectrum; The endophthalmitis Study Group.
Ophthalmology 1997;104: 261-72.
2.
Walker CB, Claoue CM. Incidence of conjunctival colonization
by bacteria capable of causing postoperative endophthalmitis.
J R Soc Med. 1986; 79: 520-21.
3.
Srinivasan R, Reddy RA, Rene S, et al. Bacterial contamination
of anterior chamber during IOL surgery. IJO 1999; 47: 185-9.
4.
West ES, Behrens A, McDonnell PJ, et al. The incidence of endophthalmitis after cataract surgery among the U.S. Medicare
population between 1994 and 2001. Ophthalmology 2005; 112:
1388-94.
5.
Gimbel HV, Sun R, de Brof BM. Prophylactic intracameral antibiotics during cataract surgery: the incidence of endophthalmitis
ad endothelial cell loss. Eur J Implant Refract Surg. 1994; 6: 280-5.
6.
Masket S. Preventing, diagnosing, and treating endophthal
mitis (guest editorial). J Cataract Refract Surg. 1998; 24: 725-6.
7.
Gimbel HV, Sun R. Prophylactic intracameral vancomycin and
CME (letter). Ophthalmology. 2000; 107: 1614-5.
8.
Seppala H, Al-juhaish M, Jarvinen H, et al. Effect of prophylac-
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tic antibiotics on antimicrobial resistance of viridans streptococci in the normal flora of cataract surgery patients. J Cataract
Refract Surg. 2004; 30: 307-15.
Centers for Disease Control. Staphylococcus aureus resistance
to vancomycin- United States, 2002. MMWR Morb Mortal
Wkly Rep 2002; 51:565-67.
Seal DV, Barry P, Gettinby G, et al. ESCRS study of prophylaxis
of postoperative endophthalmitis after cataract surgery: case
for a European multicenter study; the ESCRS Endophthalmitis
Study Group. J Cataract Refract Surg. 2006; 32: 396-406.
Holley GP, Alam A, Kiri A, et al. Effect of Indocyanine green
intraocular stain on human and rabbit corneal endothelial
structure and viability; an invitro study. J Cataract Refract
Surg. 2002; 28: 1027-33.
Mather R, Karenchak LM, Romanowski EG, et al. Forth generation fluoroquinolones: new weapons in the arsenal of ophthalmic antibiotics. Am J Ophthalmol. 2002; 133: 463-6.
Kowalski RP, Romanowski EG, Mah FS, et al. Intracameral vigamox (moxifloxacin 0.5%) is non toxic and effective in preventing endophthalmitis in a rabbit model. Am J Ophthalmol.
2005; 140: 497-504.
Peyman GA, Sathar ML, May DR. Intraocular gentamicin as
intraoperative prophylaxis in south India eye camps. Br J Ophthalmol. 1977; 61: 260-2.
Montan PG, Wejde G, Koranyi G, et al. Prophylactic intracameral cefuroxime; efficacy in preventing endophthalmitis after
cataract surgery. J Cataract Refract Surg. 2002; 28: 977-981.
Ciulla TA, Starr MB, Masket S. Bacterial endophthalmitis prophylaxis for cataract surgery; an evidence based update. Ophthalmology. 2002; 109: 13-24.
Isenberg SJ, Apt L, Yoshimoro R. Efficacy of topical povidoneiodine during the first week after ophthalmic surgery. Am J
Ophthalmol. 1997; 124: 31-5.
Leaming DV. Practice styles and preferences of ASCRS members- 2002 survey. J Cataract Refract Surg. 2003; 29: 141220.
Learning DV. Practice styles and preferences of ASCRS members- 2003 survey. J Cataract Refract Surg. 2004; 30: 892900.
Kowalski RP, Karenchak LM, Romanowski EG. Infectious
diseases: changing antibiotic susceptibility. Ophthalmol Clin
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Kim DM, Stark WJ, Obrien TP, et al. Aqueous penetration and
biological activity of Moxifloxacin 0.5% ophthalmic solution
and Gatifloxacin 0.3% solution in cataract surgery patients.
Ophthalmology. 2005; 112: 1992-6.
Ong-Tone L. Aqueous humor penetration of gatifloxacin and
moxifloxacin eye drops given by different methods before cataract surgery. J Cataract Refract Surg. 2007; 33: 59-62.
Espiritu CRG, Caparas VL, Bolinao JG. Safety of intracameral
Moxifloxacin 0.5% ophthalmic solution in cataract surgery patients. J Cataract Refract Surg. 2007; 33: 63-8.
Obrien OT, Arshinoff S, Mah F. Perspectives on antibiotics for
postoperative endophthalmitis prophylaxis: potential role of
Moxifloxacin. J Cataract Refract Surg. 2007; 33: 1790-180.
17
ORIGINAL ARTICLE
Danish Zafar
Danish Zafar FCPS1, Zulfiqar Ali FCPS2, Abdus Salam Arif3
ABSTRACT
Objective: Pregnancy results in a lot of hormonal changes in the body and the eyes are no exception. These ocular changes could be physiologic, pathologic or a modification of a pre-existing condition. Pregnancy represents a real challenge
to all body systems. Physiological changes can involve any of the body organs including the eye and visual system. The
ocular effect of pregnancy involves a wide spectrum of physiologic and pathologic changes. The latter might be presenting
for the first time during pregnancy such as corneal melting and corneal ectasia, or an already existing ocular pathologies
that are modified by pregnancy such as diabetic retinopathy and glaucoma. In addition, pregnancy can affect vision through
systemic disease that are either specific to the pregnant state itself such as the pre‑eclampsia/eclampsia and Sheehan’s
syndrome or systemic diseases that occur more frequently in relation to pregnancy such as Graves’ disease, idiopathic
intracranial hypertension, anti‑phospholipid syndrome, and disseminated intravascular coagulation. The aim of this study
was to determine ocular changes that are associated with pregnancy .
Materials and Methods: A total of 150 women were followed longitudinally throughout the course of their pregnancy and 6
weeks postpartum. The women were recruited at 8 weeks of pregnancy at the anti-natal clinic in the Department of Obstetrics and Gynecology, Howta Sudair Hospital, Riyadh ,Saudi Arabia. The women were aged between 20 and 38 years. Tests
carried out included visual acuity, ophthalmoscopy, and tonometry. The tests were carried out in each of the three trimesters
of pregnancy and 6 weeks postpartum.
Results: There was a fall in intraocular pressure across the trimesters and this was very significant (P<0.0001). During
postpartum, the intraocular pressure began to rise. The difference between the third trimester and post-partum values were
also statistically significant (P< 0.0001). 22 patients had pre-eclampsia and out of which 6 patients developed full blown
eclampsia with fits, all these patients with pre-eclampsia showed mild hypertensive retinopathy, 1 out of 4 eclamptic patients
had CSR. 68 patients were known diabetics, out of which 58 have non-proliferative diabetic retinopathy (NPDR), and 10
patients had early proliferative changes, which worsened during the course of the disease, for which they underwent PRP.
10 patients had raised blood sugar for first time during pregnancy with no fundus changes.
Conclusion: Ocular changes associated with pregnancy are transient and most tend to resolve during postpartum period,
proliferative diabetic changes enhanced during the course of pregnancy, so they should be closely observed.
Key Words: ocular, pregnancy, intraocular pressure, CSR
INTRODUCTION
Differences in ocular physiopathology exist between males and females. These differences can be observed in the lacrimal and other eye-associated glands,
the ocular surface, the crystalline lens, and the retinochoroid complexes. Literature on the subject revealed
that because of sex steroid hormone (estrogen, progesterone, and androgen) actions, various physiological
conditions such as age, menstrual cycle, pregnancy, and
menopause, where the hormone milieu changes, affect
vision.1 Pregnancy results in a lot of hormonal changes
in the body and the eyes are of no exception. These ocular changes could be physiologic, pathologic, or it could
be a modification of a existing condition, the most common being proliferative diabetic retinopathy.2,3 Most of
the physiologic changes that occur as a result of pregAssistant Professor, Northern Institute of Medical Sciences,
Abbottabad 2Assistant Professor, Ayub Medical College, Abbottabad
3
Assistant Prof. Ophthalmology, Women Medical College, Abbottabad.
1
Correspondence: Dr. Danish Zafar, House: 13, St:2, Police Housing
Colony, Mirpur Abbottabad. E.Mail: [email protected]
Cell: 0315 9110555
Received” Oct’2013
18
nancy are usually marked in the third trimester. This is
because at this period, hormonal activity is at its peak.
However, these changes are transient because several
weeks at postpartum, all hormonal activities return to
their pre-pregnant state.4 studies have shown that because of hormonal influences, pregnancy brings about
changes in refractive status, cornea sensitivity, visual
acuity, and intraocular pressure.5-6 Reports of ocular
changes during pregnancy have been mostly presented
anecdotally or in small case series. While most of the
described changes are transient in nature, others extend
beyond delivery and may lead to permanent visual impairment.7-9 Therefore, it is important to be aware of
physiologic changes as well as of the potential effects
on pre-existing disease and complications in order to
counsel and advice women who currently are, or are
planning to become pregnant.
This study was a longitudinal one. One hundred
and fifty pregnant women in their first trimester of
pregnancy were followed throughout the course of
pregnancy. These women were recruited in the 8th and
10th week of pregnancy. 150 pregnant women were recruited at the antenatal clinic of the Department of ObOphthalmology Update Vol. 12. No. 1, January-March 2014
stetrics and Gynecology, Howta Sudair Hospital, Saudi
Arabia. The pregnant women were between the ages
of 20 to 38years, while some were primigravidae, others were multigravidae. Examinations were conducted
in the three trimesters of pregnancy and 6 weeks postpartum. all information was gathered through detail
performa and informed consent. After measuring systolic and diastolic blood pressure, a full ophthalmic
examination was carried out on them. This included
measurement of distant visual acuity (VA) using the
Snellen’s chart. Ophthalmoscopy was done using the
monocular direct ophthalmoscope, indirect 90 D S/L
examination and finally, intraocular pressure was
measured using the Goldman applanation tonometer,
with 0.5% proparacaine topical anesthetic. Random
blood sugar was also done All tests were done between
the hours of 8 am .10 am on every anti-natal clinic visit,
to avoid diurnal variation in intraocular pressure. Data
was analyzed through SPSS version 10 standard, mean
and p value were calculated for IOP.
RESULTS
There was a fall in intraocular pressure (IOP)
across the three trimesters of pregnancy and this was
extremely significant P<0.0001. The difference between
the values in the third trimester and 6 weeks postpartum was also statistically significant P<0.0001. [Table
1, Figure 1]. 22 patients had pre-eclampsia and out of
which 6 patients developed full blown eclampsia with
fits. All these patients with pre-eclampsia showed mild
hypertensive retinopathy, 1 out of 6 eclamptic patients
had CSR. 68 patients were known diabetics, out of
which 58 have non proliferative diabetic retinopathy
(NPDR), and 10 patients had early proliferative changes, which worsened during the course of the pregnancy,
for which they underwent PRP. 10 patients had raised
blood sugar for the first time during pregnancy with
no fundus changes.
Fig: 1
Table: 1
First
Trimester
Statistics
Second
Third
Postpartum
Trimester Trimester
Mean IOP(mmHg
14.70
13.20
11.00
14.20
SD
2.20
2.00
1.30
1.80
SEM
0.24
0.22
0.14
0.19
N
150
150
150
150
IOP =Intraocular pressure; SD=Standard deviation; SEM = Standard
error of mean; N= Number of subjects
Table 2: Fundus Changes in pregnancy
No of
patients
Hyperstensive
No/Mild
Non
retinopathy
Proliferative
fundus
Proliferative
CSR
Pre-eclampsia/
Changes
changes
Changes
Eclampsia
22
---------
16/6
---------
---------
1
68
---------
---------
58
10
------
60
60
---------
---------
---------
------
Total number of patients= 150
DISCUSSION
During pregnancy, various physiological changes
take place in the body due to the hormonal effects of
the placenta. These placental hormones have effects on
most organ systems, including the eyes. In this study,
The changes in intraocular pressure (IOP) during pregnancy were significant in this study. IOP was found to
reduce consistently during the different trimesters, as
the pregnancy advances, with the lowest pressure in
the third trimester. The finding that the third trimester
of pregnancy has an ocular hypotensive effect is consistent with other studies.10-14 The normal intra-ocular
pressure may decrease slightly due to certain hormonal
and circulatory changes. This could be advantageous
to patients suffering from glaucoma, a condition where
the raised intra-ocular pressure damages the optic
nerve that transmits visual information to the brain.15,16
The physiological mechanism responsible for the decrease in IOP during pregnancy is not well known.
A number of mechanisms have been postulated.
Among them is that decreased IOP in pregnancy is due
to elevated hormonal levels which cause an increase in
fluid outflow conduction without altering the rate of
fluid entry.17 It is well documented that levels of progesterone and estrogen change during pregnancy. Estrogen causes dilatation of the vessels of the circulatory
system leading to decreased arterial pressure and thus a
reduction in aqueous humor production.17,18 This could
explain the reduced intraocular pressure reported in
this study. During pregnancy, the extreme quantities
of estrogens cause the release of relaxin which softens
the pelvic ligaments of the mother, so that the sacroiliac
joints become relatively limber and the symphysis pubis becomes elastic.19,20 These changes make for easier
19
passage of the fetus through the birth canal. Philips and
Gore18 suggested that this softening of ligaments in late
pregnancy might extend to the ligament of the corneoscleral envelope to produce reduced corneo-scleral rigidity and therefore cause a fall in IOP.
The number of women with diabetes in pregnancy
is increasing, partly as a reflection of increasing obesity
in women of child‑bearing age.21 DR is the most common ocular condition modified by pregnancy and is
associated with an increased risk of development and
progression of DR.21-24 DR developing during pregnancy may show a high‑rate of spontaneous regression after delivery. In a study of patients with no DR at onset,
developed mild non‑proliferative DR (NPDR) during
pregnancy, 50% had complete regression, and 30% had
partial regression of DR after delivery.25 Factors that
have been shown to influence the progression of DR in
pregnancy include, the pregnant state itself, duration
of diabetes, degree of retinopathy at time of conception, metabolic control of diabetes, and the presence
of co‑existing hypertension.26 The exact pathogenesis
for the progression of DR during pregnancy remains
controversial. Some studies demonstrated a decrease in
retinal venous diameter and volumetric blood flow in
diabetic patients during pregnancy and hypothesized
that this may exacerbate retinal ischemia and hypoxia.27,28 On the other hand, several studies have reported
an increase in retinal blood flow in diabetic patients
during pregnancy and suggested that this hyper‑perfusion causes an added stress to an already compromised retinal circulation leading to the progression of
Diabetic retinopathy (DR).29
Several studies have shown that higher glycosylated hemoglobin (HbA1C) levels at conception and the
rapid tightening of glycemic control during pregnancy
have been associated with a higher risk of DR progression. The diabetes in early pregnancy study showed
that elevated HbA1C at baseline was associated with a
higher risk of retinopathy progression and the rates of
progression almost doubled in women with HbA1 levels greater than 6 standard deviation above the control
mean.29 Diabetic women in child‑bearing age should
be counseled regarding the risk of development and
progression of DR. The risk of retinopathy progression
during pregnancy is higher in patients with inadequate
glycemic control, thus, whenever possible, tight glycemic control should be attained before conception.30
Patients with severe NPDR or proliferative DR (PDR)
are at a higher risk of progression during pregnancy
thus, it is advisable to postpone conception until stabilization of their ocular disease.30 Diabetic patients
with PDR during pregnancy should be managed the
same way as non‑pregnant patient. The prevalence of
GDM(Gestational diagnosed DM) in a population is re20
flective of the prevalence of type 2 diabetes in that population. In low-risk populations, such as those found in
Sweden, the prevalence in population-based studies is
lower than 2% even when universal testing is offered,
while studies in high-risk populations, such as the
Native American Cree, Northern Californian Hispanics and Northern Californian Asians, reported prevalence rates ranging from 4.9% to 12.8%. Prevalence
rates for GDM obtained from hospital-based studies
similarly reflect the risk of type 2 diabetes in a population with a single hospital-based study in Australia reporting prevalence ranging from 3.0% in Anglo-Celtic
women to 17.0% in Indian women. In our studies the
incidence of newly diagnosed cases during pregnancy
is 15% which is quite high as compared to other studies. It can be because of high obesity rate in Saudis and
limited number of studied population. Central serous
chorio-retinopathy (CSR) is an idiopathic disease characterized by serous detachment of the neurosensory
retina in the macular region secondary to a focal retinal
pigment epithelial defect. CSR predominantly affects
young and middle-aged males between 20 and 50 years
of age. However, there are reports of CSR in females.31-35
Although CSR is generally unilateral, bilateral cases
can occur. The presenting symptoms are often blurred
vision, central scotoma, micropsia, or metamorphopsia.
The disease is generally self-limited, with spontaneous
resolution within 3 months.36 Risk factors for CSR include stress, steroids, pregnancy, systemic hypertension.There is a unique association between pregnancy
and CSR; however, studies on the incidence of CSR in
pregnant women are rare. Interestingly, the literature
is rife with case reports about pregnant women with
CSR. Kitzmann et al.,37 reported the results of a population based study on the incidence of CSR in Olmsted,
Minnesota from 1980 to 2002 and found 11 females with
CSR confirmed by fluorescein angiography, one of who
was pregnant (9%), Kitzmann et al.37 also reported nine
cases of CSR without confirmation by fluorescein angiography, pregnancy was one of the risk factors affecting this group (one patient). In our study we have
only 1 patient with serous detachment at posterior pole,
known diabetic and with history of eclampsia. She had
spontaneous resolution after 3 month follow up.
CONCLUSION
Ocular changes are common in pregnancy. Although these changes are transient and resolve at
postpartum, it can have an impact on the course of a
pre-existing ocular disease, or it can be associated with
the development of a new disorder, like central serous
chorio-retinopathy and diabetes. Family physicians
and obstetricians who take care of these women should
have a firm understanding of the various ocular changes associated with pregnancy and the implication they
may have for management.
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14. Horven I, Gjonnaess H. Cornea indentation pulse and intraocular pressure in pregnancy. Arch Opthalmol 1974; 91:92-8.
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17. Omoti AE, Waziri-Erameh JM, Okeigbemen VM. A review of the
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69:117-9.
20. Cho EY, Moon JI. Intraocular pressure change in the pregnant
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22. Sheth BP. Does pregnancy accelerate the rate of progression of
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Retinal blood flow changes during pregnancy in women with
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21
ORIGINAL ARTICLE
Afzal Qadir
To Determine the frequency of Common
Complications following Cataract Surgery
by an experienced Surgeon in Diabetic Patients
Afzal Qadir FCPS1, Irfanullah Shah MBBS2, Mohammad Bilal MBBS3
Umer Khan MBBS4, Lal Mohammad5, Muhammad Kashif Kamran6
ABSTRACT
Objectives: To determine the frequency of common complications following cataract surgery by experienced surgeon in
diabetic patients in our setup.
Material and Methods: A prospective descriptive interventional case series. Department of Ophthalmology, Khyber Institute
of Ophthalmic Medical Sciences (KIOMS), Hayatabad Medical Complex, Peshawar, from June 2011 to September 2012.
One hundred and twenty nine eyes of 129 patients were selected for this study.
Results: Of the total 129 eyes of the diabetic patients above 40 years of age and duration of diabetes at least 5 years, fifty
nine (45.7%) were males and seventy (54.3%) were females. MSICS was performed in all the eyes. Uveitis was the most
common complication found in twenty (15.50%) eyes, while progression of Diabetic Retinopathy being the least common
found in only ten (7.75%) eyes. Worse visual acuity was observed in fourteen (10.85%) eyes. Striate Keratopathy and
posterior capsule opacification were found in sixteen (12.40%) and fifteen (11.62%) eyes respectively.
Conclusion: The most common complication observed was Uveitis accounting for 15.50% of the cases, followed by striate
keratopathy (12.40%), posterior capsule opacification (11.62%), worse visual acuity (10.85%) and progression of Diabetic
Retinopathy the least common found in only 7.75% eyes.
Key words: Cataract, Diabetes Mellitus, Uveitis, Posterior capsule opacification, Striate Keratopathy, Progression of
Diabetic Retinopathy.
INTRODUCTION
Epidemiologic data suggests that there is an increasing incidence of Diabetes Mellitus (DM) in developing countries.1 The global prevalence of DM was
estimated to be 2.8% in the year 2000 and is expected
to reach 4.4% by 2030.2 In Pakistan 17.50% of the adult
population has DM.3 Individuals with diabetes are 25
times more likely to become blind than individuals
without this disease.3 Cataract occurs at a relatively
younger age and 2-5 times more frequently in patients
with DM. Hence the cataract surgery is often carried
out earlier in diabetics especially in developing countries.4 Besides visual improvement, diabetic patients
needs cataract surgery for the assessment of retinopathy and to allow laser therapy if needed.1 Therefore the
rate of cataract surgery is correspondingly higher in
these patients. Overall up to 20% of all cataract surgeries are estimated to be performed in diabetic patients.1
In normal individuals, the visual outcome following cataract surgery is generally excellent, but in diaDr Afzal Qadir, Senior Registrar Ophthalmology, Hayatabad
Medical Complex, Peshawar, 2Trainee Medical Officer, Hayatabad
Medical Complex, Peshawar, 3Medical Officer, DHQ Hospital,
Mardan, 4Senior Registrar, Hayatabad Medical Complex, Peshawar,
5
Associate Professor, Kohat, 6Trainee Medical Officer, Hayatabad
Medical Complex, Peshawar.
1.
Correspondence: Dr Afzal Qadir, Registrar Ophthalmology Department,
Hayatabad Medical Complex Peshawar, Email:[email protected]
Cell No.0321-9128247, Fax No.091-9217189, Postal Address; House
No 40, Street 2, N/4, Phase 4, Hayatabad, Peshawar.
Received: Oct’2013 22
betic patients the cataract surgery is more challenging.
Patients with diabetes may have poor visual outcome
and higher complication rates than normal individuals.1 A recent study has reported improvement in visual
acuity in 84.2% of the diabetics and in 90% of the nondiabetics following cataract surgery.1 Hence the visual
outcome was worse in diabetics (15.8%) as compared
to non-diabetic (10%) patients.1 Ivancic, et al have reported post-operative keratopathy in 28%, uveitis in
20%, posterior capsular opacification in 22% (mild)
and 16% (severe), progression of diabetic retinopathy
in 14% and development of diabetic maculopathy in
6% of patients.5 Some studies had reported that cataract surgery in diabetic patients is more frequently accompanied by increased incidence of post-operative
inflammation, infective endophthalmitis and posterior
capsular opacification.6,7 At the same time progression
of retinopathy, rubeosis iridis, increased incidence and
severity of macular edema with ultimate increase in
visual morbidity is also reported.8,9
The cataract related visual morbidity in diabetic
population at an earlier age has a significant impact
on the working age individuals, which may have ultimate profound adverse effect on the socioeconomic
conditions of our society. Furthermore, the increasing
incidence of DM in developing countries like Pakistan
necessitates an assessment of the surgical outcome of
diabetic cataract among the affected subjects. The aim
of this study was to investigate the frequency of common complications following cataract surgery in diaOphthalmology Update Vol. 12. No. 1, January-March 2014
To Determine the frequency of Common Complications following Cataract Surgery
betic patients. The rationale of the study is that, if in
our study the frequency of complications following
cataract surgery in diabetic patients comes out significantly higher as compared to other studies, then it can
lead to reconsideration of the existing guidelines of the
pre-operative assessment, operative techniques and
post-operative care of the diabetic patients undergoing
cataract surgery.
A prospective descriptive interventional case series. Department of Ophthalmology, Khyber Institute
of Ophthalmic Medical Sciences, Hayatabad Medical
Complex, Peshawar, from June 10, 2011 to September
20, 2012. One hundred and twenty nine eyes of 129 patients. Inclusion criteria all the diabetic patients with
duration of diabetes ≥5 years and having cataract with
best corrected visual acuity (BCVA) of < 6/18 were included. Eyes with mild, moderate or severe NPDR or
PDR stage of diabetic retinopathy were included. Patients from both gender and age more than 40 years
were included. Exclusion criteria were any patient with
co-morbidities if detected pre-operatively during slit
lamp examination like vascular occlusions, optic atrophy, maculopathy due to myopia or age related macular degeneration (ARMD), corneal opacities and corneal curvature abnormalities, which may affect ultimate
visual prognosis, was excluded. Patients with traumatic
and complicated cataracts were excluded through history and slit lamp examination. The above mentioned
conditions act as confounders and if included will introduce error in the study results.
All the patients meeting the inclusion criteria were
admitted in eye ward through the Out Patient Department (OPD). Diagnostic criteria for inclusion was
known diabetics or fasting plasma glucose level of ≥
126mg/dl or random plasma glucose level ≥ 200mg/
dl on laboratory investigations and opacification in
the crystalline lens with baseline BCVA of <6/18 and
Diabetic Retinopathy (DR) of mild, moderate, severe
NPDR or PDR stage. Informed written consent was obtained from all the study patients. The patient’s history
and VA was recorded at presentation. Both eyes of the
patient including detailed fundus examination were
performed by consultant ophthalmologist with the slit
lamp biomicroscope using 78D lens. Routine investigations were performed for all the study patients on the
day of admission.
The patients were operated on the next operation
theater (OT) list. Manual Small Incision Cataract Surgery (MSICS) was performed by a single well experienced surgeon. After being operated, all the patients
were followed at 1st post-operative day to detect striate
keratopathy and uveitis, and then on 40th post-operative
day to detect worse visual outcome, posterior capsular
opacification and progression of diabetic retinopathy.
All the follow-up assessments were carried out under supervision of the single ophthalmologist. All the
above mentioned information including the patient’s
name, age, sex, address and duration of diabetes were
recorded in a proforma. Strict exclusion criteria was
followed to control confounders and bias in the study
results. post-operative complications including Worse
Visual Outcome (WVO), Striate Keratopathy (SK), Uveitis (Uv), Posterior Capsular Opacification (PCO) and
Progression of Diabetic Retinopathy (PODR). Results
were stratified among age, sex and duration of DM to
see the effect modification. All the results were presented in the form of tables and graphs.
RESULTS
One hundred and twenty nine eyes of 129 diabetic
patients above 40 years of age diagnosed as having
cataract and fulfilling the inclusion criteria were
included in this study. All the study patients completed
the 40 days follow-up period. The study was conducted
at KIOMS Hayatabad Medical Complex, Peshawar from
June 2011 to June 2012. The minimum age at which the
patient presented was 42 years while the oldest patient
was 85 years of age with a mean of 57.9 and SD ±8.7.
Sixty one (47.3%) patients presented in the age group
of 51-60 years, making it the most common decade of
presentation for diabetic patients with cataract. Details
regarding age of our study population are given in
Table I.
Among the study patients, the minimum duration of diabetes was 5 years while the maximum was 22
years, with mean of 9.7 and SD ±3.9. Sixty nine (53.6%)
patients presented with duration of diabetes ranging
from 6 to 10 years. Details regarding duration of DM in
our study patients are given in Table II. Out of the total
129 patients, fifty nine (45.7%) were males and seventy
(54.3%) were females. The male to female ratio was
1:1.2.
Complications following cataract surgery: Out
of the total 129 patients, Uveitis was the most common
complication found in twenty (15.50%) eyes, while
PODR being the least common found in only ten (7.75%)
eyes. Worse visual acuity was observed in fourteen
(10.85%) eyes, hence there was improvement in visual
acuity in 89.15% of the study cases. Striate Kertopathy
and PCO were found in sixteen (12.40%) and fifteen
(11.62%) eyes respectively. Among the study patients,
15.7% were found to have more than one complication
during their follow-up visits. Eighty eight (68.2%) eyes
were found to have none of the defined complications
(Table III, IV). Complications were observed more frequently in the age group 51-60 years as compared to
23
the other age groups. Among the study cases, fourteen
(23.72%) male and twenty seven (38.57%) female patients were observed to have complications following
cataract surgery. Hence the female gender was associated with more frequent complications as compared to
the male.
The frequency of complications was highest in patients with 10 years duration of diabetes.
Table I: Distribution of age (N=129)
Age (years)
F requency (n)
Percent (%)
41-50
51-60
61-70
71-80
81-90
32
61
26
8
2
24.8
47.3
20.2
6.2
1.6
Total
129
100.0
TABLE II: Duration of diabetes mellitus (DM) (n=129)
Duration of DM (years)
Frequency (n)
Percent (%)
5.00
6-10
11-15
16-20
>20
20
69
26
12
2
15.5
53.6
20.2
9.4
1.6
Total
129
100.0
TABLE III: Frequency of complications (n=129)
Complications
Frequency (n)
WVO
SK
Uv
PCO
PODR
Percent (%)
14
16
20
15
10
10.85
12.40
15.50
11.62
7.75
WVO= worse visual outcome; SK= striate keratopathy; Uv= uveitis; PCO=
posterior capsular opacification; PODR= progression of diabetic retinopathy
DISCUSSION
In my study the indication for surgery in all the
patients was for visual improvement or to augment
retinal assessment and laser application. Therefore, cataract surgery has meanings of visual rehabilitation, diagnostic and therapeutic purposes in diabetic patients.
Advanced cataract presenting for surgical removal is
still widespread in this region similar to that reported
previously.10 This poses a challenge in the management
of this group of patients since diabetic maculopathy
and retinopathy are common causes for poor visual
outcome following cataract extraction in diabetics.11-13
In fact cataract surgery should be performed earlier in
diabetic patients before the development of diabetic
maculopathy or retinopathy as compared to their nondiabetic counterparts.11 This will ensure both the timely
assessment of the status of retina in diabetic patients
and prevent progression of DR as cataract surgery itself
is a recognized risk factor for the development and progression of DR and diabetic macular edema.11
A recent study had reported WVO in 15.8% of the
diabetic patients followed for 6 months after cataract
surgery.1 Hence there was improvement in post-operative VA in 84.2% of the cases.1 In contrast, the results are
encouraging in our study in which WVO was observed
in 10.85% of the cases with subsequent improvement in
post-operative VA in 89.15% of the patients. This difference in results may be due to the short follow-up in
our study. This finding supports previous reports that
diabetic patients, those with maculopathy and retinopathy may have valuable visual improvement after
cataract surgery.14 Schrey et al reported WVO in 16.2%
and improvement in VA in 83.8% of the eyes followed
for up to 3 years.15 Similarly krepler et al had reported
WVO in 15% with improvement in VA in 85% of the
cases.16 Corneal sensitivity is decreased in proportion
TABLE IV: Diabetes duration vs complications
Complications
5
6
8
9
0
0
0
2
0
0
0
0
0
0
WO/SK/PCO
WVO/PODR
SK
Uv
PCO
PODR
Nill
Uv/SK
Uv/PODR
WVO/Uv/SK/PCO
0
0
2
2
0
0
14
2
0
0
0
0
0
0
4
0
10
0
0
0
2
0
0
1
2
0
15
0
2
4
Total
20
14
26
2
Duration of Diabetes (Years)
10
11
12
15
16
18
20
22
Total
0
4
0
2
0
2
17
0
0
2
0
0
0
0
0
0
4
0
0
0
0
0
2
1
0
0
11
0
0
0
0
0
0
0
0
0
6
2
0
0
0
2
0
0
0
0
6
0
0
0
0
0
0
0
0
0
2
0
0
0
0
0
0
0
0
0
2
0
0
0
0
0
0
0
1
0
1
0
0
0
2
6
4
8
7
2
88
4
2
6
27
4
14
8
8
2
2
2
129
WVO= worse visual outcome; SK= striate keratopathy; Uv= uveitis; PCO= posterior capsular opacification; PODR= progression of diabetic retinopathy
24
to both the duration of the disease and the severity of
the retinopathy.14 Corneal abrasions are more common
in people with diabetes, presumably because adhesion
between the basement membrane of the corneal epithelium and the corneal stroma is not as firm as that found
in normal corneas.14
Following ocular surgery, recurrent corneal erosions and striate keratopathy are more common in diabetics than in non-diabetics. Ivancic et al had reported
post-operative keratopathy in 28% of the diabetic patients, which is much higher than 12.40% in our study.5
Onakpoya et al reported that the post-operative complications were more frequent among diabetic patients especially the posterior capsular rent, striate keratopathy
(21.21%) and fibrinous exudation.1 The association of
DM and Uv has long been known. Like cataract, retinopathy and glaucoma, DM also increases the chances of
uveitis. Rothova et al had reported DM in 6% of cases
with anterior uveitis.17 In our study Uv was detected in
15.50% of the patients following cataract surgery. Onakpoya et al reported Uv in 12% of the cases after cataract
surgery.1 Menchini et al reported intraocular inflammation and its sequelae as the most common complication
in their study.18 Similarly Ivancic et al reported that inflammatory reactions and bleeding, which resulted in
post-operative keratopathy, fibrinous uveitis and posterior capsule opacity, were the common complications
of cataract surgery amongst diabetics.5
Opacification of the posterior capsule which is
thought to be caused by the postoperative proliferation
of lens epithelial cells in the capsular bag remains the
most frequent complication of cataract extraction with
IOL implantation.19,20 The patients with diabetes mellitus develop PCO earlier after cataract surgery than
their non-diabetic counterparts.21 Only 11.62% of our
patients develop PCO after cataract surgery which is
lower than 16% reported by Ivancic et al but higher
than 6.06% reported by Onakpoya et al in their study.1,5
The PODR is suggested to be caused by the disruption of the blood retinal barrier during surgery and
the enhanced inflammation following cataract extraction in diabetic patients. PODR was seen in 7.75% of
eyes in our study. This percentage is quite lower than
that seen in many recent series of phacoemulsification
and ECCE in diabetic patients (Antcliff et al, 34%;22 Pollack et al, 38%;23 and Henricsson et al, 43%24) however,
conclusions drawn from comparison between studies
with different patient populations and levels of preoperative retinopathy were not free of errors.
Diabetics with co-existing cataract presenting for
surgery have an overall good visual outcome and cataract surgery should not be discouraged in these patients. However, proper pre-operative assessment is
needed and extra precaution needs to be taken intraoperatively as well as adequate post-operative monitoring is recommended. In addition, treatment of existing diabetic retinopathy or maculopathy should be
performed to improve visual outcome and reduce postoperative complications.
Although the frequency of post-operative complications were lower than most of the studies conducted
world-wide, these results cannot be extrapolated to the
general population due to smaller sample size and short
follow-up, therefore we recommend better randomized
studies on a larger sample size with longer follow-up.
CONCLUSION
The most common complication found in our
study was uveitis accounting for 15.50% of the cases,
followed by striate keratopathy (12.40%), posterior
capsule opacification (11.62%), worse visual outcome
(10.85%) and progression of diabetic retinopathy being
the least common observed in only 7.75% eyes. Complications were observed more frequently in female gender and in the age group of 51-60 years. The frequency
of complications was highest in patients with 10 years
duration of diabetes and 15.7% of the eyes were found
to have more than one complication.
REFERENCES
1.
Onakpoya OH, Bekibele CO, Adegbehingbe SA. Cataract surgical outcomes in diabetic patients: case control study. Middle
East Afr J Ophthalmol 2009;16:88-91.
2.
Hossain P, Kawar B, Nahas M EI. Obesity and diabetes in
the developing world- a growing challenge. N Eng J Med
2007;356:213-5.
3.
Din J, Qureshi MB, Khan AJ, Khan MD, Ahmad K. Prevalence
of diabetic retinopathy among individuals screened positive
for diabetes in five community-based eye camps in northern
Karachi, Pakistan. J Ayub Med Coll Abbottabad 2006;18(3):5265.
4.
Javadi MA, Ghanavati SZ. Cataracts in diabetic patients: a review article. J Ophthalmol Vis Res 2008;3(1);52-65.
5.
Ivancic D, Mandic Z, Barac J, Kopic M. Cataract surgery and
postoperative complications in diabetic patients. Coll Antropol
2005;29:55-8.
6.
Mozaffarieh M, Heinz H, Sacu S, Wedrich A. Clinical outcomes
of phacoemulsification cataract surgery in diabetic patients:
Visual function (VF_14), visual acuity and patient satisfaction.
Acta Ophthalmol Scand 2005;83(2):176-83.
7.
Jancevski M, Foster CS. Cataracts and uveitis. Curr Opin Ophthalmol 2010;21:10-4.
8.
Shah AS, Chen SH. Cataract surgery and diabetes. Curr Opin
Ophthalmol 2010;21:4-9.
9.
Hong T, Mitchell P, De Loryn T, Rochtchina E, Cugati S, Wang
JJ, et al. Development and progression of diabetic retinopathy12 months after phacoemulsification cataract surgery. Ophthalmology 2009;116:1510-14.
10. Salman A, Parmar P, Vanila CG, Thomas PA, Nelsen Jesudasan
CA. Is ultrasonography essential before surgery in eyes with
advanced cataract? J Postgrad Med 2006;52:19-22. 11. Mechini U, Cappelli S, Virgili G. Cataract surgery and diabetic
retinopathy. Semin Ophthalmol 2003;18:103-08.
12. Ivancic D, Mandic Z, Barac C, Kopic M. Cataract surgery and
post-operative complication in diabetic patients. Coll Antropol
2005;29:55-8.
25
13.
14.
15.
16.
17.
18.
Dowler JG, Hykin PG, Lightman SL, Hamilton AM. Visual acuity following extracapsular cataract extraction in diabetics: A
meta-analysis. Eye 1995;9:313-17.
Cunliffe IA, Flanagan DW, George NDL, Aggarwaal RJ, Moore
AT. Extracapsular cataract surgery with lens implantation in
diabetics with or without proliferative retinopathy. Br J Ophthalmol1991;75:9–12.
Schrey S, Krepler K, Biowski R, Wedrich A. Midterm Visual
Outcome and Progression of Diabetic Retinopathy following
Cataract Surgery. Ophthalmologica 2002;216:337-40.
Krepler K, Biowski R, Schrey S, Jandrasits K, Wedrich A. Cataract surgery in patients with diabetic retinopathy: visual outcome, progression of diabetic retinopathy, and incidence of
diabetic macular oedema. Graefes Arch Clin Exp Ophthalmol
2002;240(9):735-38.
Rothova A, Meenken C, Michels RP, Kijlstra A. Uveitis and diabetes mellitus. Am J Ophthalmol1988 Jul 15;106(1):17-20.
Mechini U, Cappelli S, Virgili G. Cataract surgery and diabetic
19.
20.
21.
22.
23.
24.
retinopathy. Semin Ophthalmol 2003;18:103–08.
Apple DJ. Influence of intraocular lens material and design on
postoperative intracapsular cellular reactivity. Trans Am Ophthalmol Soc 2000;98:257-83.
Werner L, Apple DJ, Pandey SK. Postoperative proliferation
of anterior and equatorial lens epithelial cells: A comparison
between various foldable IOL designs. In: Buratto L, Osher
R, Masket S, editors, Cataract Surgery in Complicated Cases.
Thorofare NJ, Slack Inc. 2000;pp399-417. Ebihara Y, Kato S, Oshika T, Yoshizaki M, Sugita G. Posterior
capsule opacification after cataract surgery in patients with diabetes mellitus. J Cataract Refract Surg 2006;32(7):1184-87.
Antcliff RJ, Poulson A, Flanagan DW. Phacoemulsification in
diabetics. Eye 1996;10737-41.
Pollack A, Dotan S, Oliver M. Progression of diabetic retinopathy after cataract extraction. Br J Ophthalmol 1991;75547-51.
Henricsson M, Heijl A, JanzonL. Diabetic retinopathy before
and after cataract surgery. Br J Ophthalmol 1996;80789-93.
Vitreous Base Avulsion
Rona Lyn Esquejo-Leon, CRA, Travis A. Meredith, MD, & Hart B. Moss, MD,
Kittner Eye Center, University of North Carolina. USA
A 27-year-old woman presented three days after
experiencing blunt trauma to her left eye during a
domestic violence incident. She complained of blurred
vision and a “stringy” floater in the eye. Slit-lamp
examination and indirect ophthalmoscopy revealed a
pigmented, ribbon like floater in the anterior vitreous,
but no retinal tears, detachments or dialyses seen.
Vitreous base avulsions are sometimes referred to as
the “bucket-handle sign,” named for the floating opacity
over the peripheral retina. They have been considered
pathognomonic for blunt ocular trauma, but they have
also been reported spontaneously in young patients
with infero-temporal retinal dialysis and in a patient with neurofibromatosis.
Although commonly associated with retinal dialysis, iris trauma or hyphema, no treatment is indicated in the
absence of associated ocular pathology.
26
ORIGINAL ARTICLE
Prevalence of Refractive Errors in
School going Children in Battagram (KPK),
Age Group of 11-15 Years
Manzoor Hussain
Manzoor Hussain, B.Sc (Vision & Biological Sciences)1
Saber Mohammad FCPS2, Abdul Ghafoor FCPS3, Arshad Raza MBBS4
ABSTRACT
Objective: To determine the prevalence, the type and gender wise distribution of refractive error in school going children
at the age of 11-15 years.
Material and Methods:
Study Design: This was a cross sectional descriptive study.
Setting: This study was conducted in Out Patient Department of Eye unit DHQ Hospital, Batagram of KPK.
Sample Size: Sample size was 1700 children.
Results: In our study total of 1700 children were examined, only 78(4.58%) children had refractive error with uncorrected
visual acuity of < 6/12 in both eyes. In which 34(2%) were male and 44 (2.58%) were female children. Out of 78 school
children, 54 (3.17%) were myopic, 13 (0.76%) were Hypermetropes and 11 (0.64%) were the cases of astigmatism.
Regarding the type of refractive error, the prevalence of myopia in male was 2.36% and in female 3.97%, hypermetropia in
male was 0.591% and in female was 0.94% while the astigmatism in male was 0.47% and in female was 0.82%.
Conclusions: Our study suggest that refractive error particularly Myopia is the major cause of ocular morbidity among the
school going children in Distract Batagram. Provision of spectacles to rehabilitate them to normal.
Key Words: Refractive error, myopia, hypermetropia, astigmatism.
INTRODUCTION
Refractive error is the 3rd major cause of avoidable
blindness. The prevalence of childhood blindness in the
world is estimated as 1.5 million (0.75/1000) while in
Pakistan it is 1/1000.3 The refractive error in Pakistan
was 11.4% according to the national survey conducted
in 1987-1990 and found that the refractive errors was
the major cause of avoidable/preventable blindness. In
children, causes of blindness are-corneal scarring due
to vitamin A deficiency, measles, cataract, glaucoma,
trauma, meningeal infections, retinopathy of prematurity and refractive errors.
Although school health services are available
in developed countries but still they use community
health workers and optometrist to help them to detect
refractive error and refer them for visual correction.
In Pakistan no such services are available. No regular
screening program is known to exist in the country.
The school teachers are the key person to detect refractive error in such children and refer them to hospitals.
Unfortunately the literacy ratio is so low particularly
in female children that majority of children are left as
they are. A lot of information can be collected from parents, teachers and relatives to watch children who keep
books close to their eyes, watch television or doing computer games at close distances than normal. This study
was designed to detect and to determine the prevalence
of refractive error and their correction in children who
come to OPD of DHQ Hospital, Batagram (KPK).
All the children coming to OPD were screened. The
age group 11 to 15 years were selected for this study.
Written consent was taken from all children or parents
who were included in the study. Unaided visual acuity was tested in both eyes, if it was 6/12. Cycloplegic
refraction was conducted if vision improved with pinhole. However, children who needed further treatment
were referred and examined by the ophthalmologist.
Myopia ranging from -0.5 to -8.0 diopters, Hypermetropia form +1.0 to +8.0 diopters and Astigmatism from
-0.50D and more were recorded and coded. Children
needed glasses were provided and performa were filled
up for all the children screened.
Table 1. Prevalence of refractive error in school children
Optometrist, Department of Ophthalmology, Khyber Teaching Hospital,
Peshawar. 2Registrar Eye B ward, Department of Ophthalmology,
Khyber Teaching Hospital, Peshawar. 3Eye Specialist, DHQ, Battagram
4
Senior Registrar, Peshawar Medical College.
1
Correspondence: Manzoor Hussain, Paramedical Hostel Room No, 33,
Khyber Teaching Hospital, Peshawar. Email: [email protected]
Ph.0345-9175524
Received: Nov’21013
Accepted Dec’2013
27
Prevalence of Refractive Errors in School going Children in Battagram (KPK), Age Group of 11-15 Years
Table: 2 Gender wise prevalence of refractive
error in school children
Table No, 3
RESULTS
1700 school children in age group 11 to 15 years
registered in government as well as in private schools
were examined in District Batagram KPK. Among 1700
children 845 were male and 855 were female. Refractive error was detected in 78 children. Male children
were 34 (2%) and female children were 44(2.58%). It reveals that the prevalence of refractive error is more in
females’ school children than the male. Out of 78 school
children, Myopes were 54 (3.17%), hypermetropes
13(0.76%) and astigmatism in 11 (0.64%) cases as shown
in table 1. The prevalence of myopia in male students
was 2.36% and in female it was 3.97%. Hypermetropia
in male was 0.59% and in female was 0.93%. The astigmatism in male was 0.47% and in female it was 0.0.93%
shown in table 2. Out of 1700 children, there were 1622
(95%) with normal vision and needed no treatment but
78(4.58%) with refractive error were prescribed glasses
as shown in table 3. Total students were 1700, Total
male were 845 (49.70%) and female were 855(50.29%).
DISCUSSION
Childhood visual disability is a serious public
health issue. Refractive errors are the third commonest
cause of blindness in Pakistan being 11.4%, after cataract 66% and corneal opacity 12.6%. Refractive errors
in childhood leading to visual disability impacts on
learning capability, educational potential and personality development of the child. On other hand detection,
correction of refractive error is the easiest and effective
way of management by involving community and optometrist.
The impact of refractive error on the individual
28
and on the community cannot be ignored. In our study
total 1700 children were screened, where 78 (4.58%)
had refractive error. While study conducted in Khyber
Teaching Hospital had refractive error in 12.7%.1 The
reason for this could be that this was on large scale and
with large sample size.
The prevalence of refractive error in our study
population is 4.58%, which is less than the prevalence
in China2 and Chile.3 i.e. 12.8% and 15.8% respectively.
The reason for this could be that studies in China and
Chile were conducted on large scale and large sample
size. In our study myopia was 54 (3.17%), hypermetropia was 3 (0.76) and astigmatism was 11 (.64%). In
other study the refractive error was 3.98% conducted in
union council Batkhela Malakand Division.4 The reason
for this could be that it was conducted on small sample
size as compared to our study.
The prevalence of refractive error in Benin city,
southern Nigeria is 3.9%, This is all because of possible reason that this study was done on 571 females of
age 11 to 21years. This study was conducted on females
only.5 An Indian study has found that refractive error
were responsible for 12.5% of the blindness and 59.4 %
moderate visual impairment,6 which is higher than the
prevalence of refractive error as compared to our study.
The study in Singapore and Japan showed that the
prevalence of refractive errors increased with increasing literacy rate (most prevalent in medical students)7
In the ref error study done in La Florida Chille myopia
increases with increasing age 19.4% in males and 14.7%
in females by the age 15 years.8 In our study. The prevalence of myopia is also increased with increasing age It
reveals that myopia is also associated with older age.
In other study done in Kathmandu (Nepal)
showed refractive error was (4.3%). The prevalence of
myopia is low as compared to this study, because it include all the children of the school visited irrespective
of age.9 In other study conducted in Pakistan showed
that astigmatism was 1.78% and also slightly more in
female.10 In our study the astigmatism is high in females as compared to males school children. In other
study conducted in Lady Reading Hospital, Peshawar
Shah, S,11 study showed that hypermetropia is higher
than myopia while in our study myopia is greater than
hypermetropia. Study done in Katmandu showed
that myopia is the commonest cause of refractive error
(4.3%).12
In other study conducted in Ethiopia, the prevalence of refractive errors in either eye was present in
(9.4%) of children.13 In this study myopia was greater
than hyperopia, which is similar to our study. While
in study conducted by Afghani., T, in Pakistan showed
that astigmatism was 1.78% and also slightly more in
female.14 In this study the astigmatism was high in feOphthalmology Update Vol. 12. No. 1, January-March 2014
Prevalence of Refractive Errors in School going Children in Battagram (KPK), Age Group of 11-15 Years
males as compared to males’ school children.
In other study conducted in China, Chile and Nepal, where both myopia and hypermetropia were significantly higher in females than males.15-17 In our study
myopia is large in females as compared to males. Study
conducted in school children in Karachi. 1000 children
were examined, refractive error was 8.9%.18 being high
as compared to our study.
CONCLUSION & RECOMMENDATIONS:
Our study showed that the refractive error is the
major cause of ocular morbidity among the school going children in Distt. Batagram of Hazara Division. It
creates a lot of problems in the growing children. So
early detection and its management may improve their
learning capability, educational potential and career.
There is lack of acceptable, affordable, accessible
and equitable eye health care particularly optical services enabling children to make their spectacles, because most of the children are poor and cannot afford to
purchase the expensive glasses. Screening of children
for refractive errors should be conducted at community
level and integrated into school health program accompanied by educational and awareness campaign to ensure that the corrections are used and cultural barriers
to compliance are redressed and removed.
REFERENCES:
1.
Sethi S,Sethi MJ, Husssain.Causes of amblyo-pia in children
coming to ophthalmology out patient department, Khyber
Teaching Hospital, Peshawar J Pak Med Assoc 2008. 58: 125-7
2.
Zhau J. the progression of refractive error in school aged children. Shungi district, china. Elsevier science. 2002;735-743.
3.
Euginio, Refractive Error studies in children: Result form Leflore, chile AJO.2000;129:445-454
4.
M.Rahil , R Nuzhat, K Umar Prevalence of Refractive errors in
school going children in age group of 11-15 years ophthalmology update Vol.9 No.3 page No.26 to 29
5.
Neigeria ldeh V.C.U MBBS; FMC (opt):FWACS: Oahu A.1;
6.
7.
8.
9.
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11.
12.
13.
14.
15.
16.
17.
18.
AMUE; Oseji M.AKpanP; Dawodu. 25th international congress
of the medical women’s international association visual screening of school children in Benin-city edo state.
Dandona L, Dandona R, Naduvlath TJ, Srinawas M,Mc
Carty CA,Rao GN. Burden of moderate visual impairment
in an urban population in southern India .Ophthalmology
1999.;106:497-504
Afghani T, Vine HA Bhatti A, Qadir MS, Akhtar J, Tehzib M,
Al-Shifa-al Noor (ASAN) refractive error study of one million
school children. Pakistan J Ophthalmol 2003 Oct; 19(4):101-7.
Eugenio, Maul, Barroso S.Sergio R.Munor, Roer D.Sperdut and
leon B. Refractive error study in children; result from La forida,
chile.American Journal of ophthalmology app 200;volume 129.
NO4-454
Nepal BP,koirala S.Adhikary SA and Sharma AK.Ocular Morbidity in school children in Kathmandu. Brittsh Journal of Ophthalmology 2003.87:531-534.
Afghani T, VineHA, Bhatti MA.Shifa Al, Noor Al.Refractive error study for one million school children Pakistan journal of
Ophthalmology (19) No;4, October 2003
Shah M. Prevalence and presentation of childhood squint [dissertation] Peshawar, Lady reading hospital,1998.
Gopal P,POkharel,A Dominique Negrel,Sergio R.Munzo and
Leon B.Ellwein Refractive study in children :Result from Zon
Nepal ,American journal of Ophthalmology 2000;436 -44.
AW yared, WT Belaynew,S Destaye,T Ayanaw,E ZelalemPrevalence of refractive errors among school children in Gondar
town, northwest Ethiopia.
Afghani T,Vine HA,Bhatti MA.Shifa Al,noor Al,Refractive error study for one million school children in Pakistan journal of
Ophthalmology (19) No:4,October 2003
Zhao J, Pan X, Sui R, Munoz SR, Sperdut RD Ellwein LB. Refractive error study in children: results from shunyi district,
China. Am J Ophthalmol 2000;129:427-35.
Maul E, Barroso S, Munoz SR, Sperduto RD,Ellwein Lb. Refractive error study in children: results from La Florida, Chile.Am J
Ophthalmol 2000;129:455-54.
Pokharel SP, Negerel D, Munoz SR, Ellwein LB. Refractive
error study in children: results form Machi-Zone Nepal.Am J
Ophthalmol 2000;129: 436-44
Alum H,Siddiqui I M,Ahmad jafri I S ,Khan S A ,Jaffar M,
prevalence of refractive error in school children of Karachi
journal of Pakistan Medical Association.
29
ORIGINAL ARTICLE
Pre-operative Screening of
Patients for Hepatitis B&C Virus
Waseem Ahmed
(A Sero-survey at the Eye Department in DHQ Teaching Hospital Mirpur, AJK.)
Waseem Ahmed Khan FCPS, FRCS1, Dr. Madiha Durrani FRCS2,
Riaz Ahmed Chaudhry FCPS Surgery3, Saba Haider Tarar MCPS4
ABSTRACT:
Purpose: To screen hepatitis B&C among patients undergoing ocular surgery.
Background: Both hepatitis B and C are a common example of nosocomial infections. These are blood borne infections
commonly transmitted from health care settings. They are also a source of health hazard to health care professionals. Our
aim was to identify the prevalence and risk factors associated with hepatitis B and C among patients with eye diseases.
Materials and Methods:This was a prospective observational study, conducted from Jan 2012 to December 2012 in
Department of Ophthalmology, DHQ Teaching Hospital, Mirpur, AJK. A total of 1120 patients admitted in eye ward, were
screened for hepatitis B&C by immune-chromatographic method. The patients were divided into various ocular groups
based on primary diagnosis
Results: Out of total 530 patients admitted in eye ward, 289 of them were male and 241 were female. A total of 37 patients
(6.98%) approximately 7% were found to be serologically positive for HCV and 15 (2.83%) were found to be serologically
positive for HBV, which makes a prevalence of 6.98% and 2.83% respectively. The risk of hepatitis C was increased with
advancing age.
Conclusion: Prevalence of hepatitis B &C in eye patients is quite high. Therefore, all patients, who need surgery should
be routinely screened for hepatitis B & C. This is an alarming not only for patients but for health workers as well. This
information should be used to highlight the need for health education and requirement of better and effective universal
safety precautions to prevent the spread of HBV and HCV in our hospitals.
Key words: prevalence. hepatitis B &C. eye ward.
INTRODUCTION
Both Hepatitis B virus (HBV) and Hepatitis C
virus(HCV) are a potential threat to health care professionals, not only in Pakistan but all over the world as
well. Majority of the carriers are asymptomatic but usually progress to chronic liver disease and hepatocellular
carcinoma.1,2
HBV was discovered in 1963 and its serological
marker, hepatitis B surface antigen (HBSag), which is
most commonly used for screening purpose, was identified by Blumberg.3,4 Approximately, there are more
than 350 million HBV carriers in the world and roughly more than one million people die each year due to
HBV involved liver disease.5 HCV was isolated in 1987
and infected nearly 500 million people in the world 6.
Hepatitis can be transmitted through either blood or
fluids (serous, saliva or vaginal secretion),7,8 but HCV is
spread only by blood and blood products.9
Both these infection present with non-specific
Assistant Professor, Department of Ophthalmology. Mohi-ud-din
Islamic Medical College, Mirpur & Divisional Teaching
2
Hospital,
Mirpur,
AJK.
Ophthalmologist,
UAE,
3
Assistant Professor, Department of Surgery, Mohi-ud-din Islamic
Medical College, Mirpur & Divisional Teaching Hospital, Mirpur, AJK
4
Registrar Pediatrics, Combined Military Hospital, Kharian.
1.
Correspondence: Dr. Waseem Ahmed Khan. FCPS, FRCS. Assistant
Professor, Department of Ophthalmology, Mohi-ud-din Islamic
Medical College, Mirpur & Divisional Teaching Hospital, Mirpur, AJK.
Email: [email protected] Cell: 0300-9563324.
30
symptoms like malaise, anorexia, abdominal pain and
jaundice but at times there are no symptoms ,till the development of chronic liver disease with cirrhosis, portal
hypertension, esophageal varices, ascities, encephalopathy or liver malignancy.10,11
Although, there is a vaccine available for hepatitis
B which is now incorporated in immunization schedule
worldwide but unfortunately, once contracted, these
infections poorly respond to the treatment modalities
available, therefore to avoid the disease spread strict
precautionary methods are advisable,12. In ophthalmology, there are chances of exposure to HBV and HCV
during out-patient (OPD) procedures like syringing,
biometry, Tonometry and indoor OT procedures during administration of anaesthesia, handling of sharp
instruments (Blade, side-port, needles etc) and during
sterilization and exchange of instruments and finally
during disposal of biomedical waste.13
Various prevalence rates of HCV have been
reported both local and international ranging from
0.4% to 24%.14 A surgeon’s chances of acquiring
HBV infection is from 1% to 13%.It is important that
all surgeon know these HBV profiles. As vaccine is
available against HBV, therefore it should be given to
all those surgeons, who are partially or completely nonimmunized
This study was carried out at Department of Ophthalmology, Divisional Teaching Hospital, Mohi-udOphthalmology Update Vol. 12. No. 1, January-March 2014
Pre-operative Screening of Patients for Hepatitis B&C Virus
Din Islamic Medical College, Mirpur. It is a teaching
Hospital providing tertiary care ophthalmic services
in AJK. All the patients admitted for eye surgery were
screened for HBs antigen and Anti HCV antibodies using immune-chromatographic (ICT) method. The results were recorded on a pre-designed proforma and
analyzed at the end of study. Universal surgical precautions were taken for patients who were positive for
hepatitis B and C screening like hand free transfer of
sharp surgical instruments and wearing double gloves.
RESULTS
Out of total 530 patient admitted in eye ward, 289
(54.52%) were male and 241(45.47%) were females.
Their ages ranged from 2 to 80 years. Out of 530 screened
patients 15 (2.83%) were positive for HBS Ag and 37
(6.98%) were positive for ant HCV. Among 15 HBS
Ag positive patients 9 (60%) were male and 6 (40%)
were female. The gender distribution is shown in table
I. Furthermore out of 37 anti HCV positive patients , 25
were male (67.56%) and 12 (32.4%) were female. Their
age distribution is shown in table II.
Table I. Gender Distribution for Hepatitis
B and C positive Patients.
Total
HCV(%)
HBS(%)
Male
289
21(%)
10(%)
Female
241
16(%)
5(%)
Table II. Age Distribution for
Hepatitis B and C positive Patients.
Age
No, of pats.
HCV+VE
HBSV+VE
>20
12
0
0
21-30
37
1(2.70)
0
31-40
51
3
0
41-50
93
4(8.11)%
2(13.3)%
51-60
154
13(35.13)%
6(40)%
61-70
126
9(24.52)%
5(33.3)%
>70
57
7(18.9)%
2(13.3)%
530
37
15
DISCUSSION
Hepatitis B and HCV are among the global
diseases that are endemic all over the world.15 In our
study, the incidence of HBV infection amongst patient
admitted was 7% as compared to hepatitis C which is
2.83%. Incidence of these viruses. in general Pakistani
population ranges between 4-20%.16
These results of our study are comparable to study
have done in different units of Pakistan. Karachi, HBV
(2.1%) and HCV (11.1%)17, Rawalpindi (12.8) HBV
and HCV (7.5%)18 Kharian 2.35% for HBV and 6.3%for
HCV19and Khanpur HBV 2.33% and HCV 18.33%.20
Two studies had been carried out in Japan,
one shows HBV (1.8%) and HCV (7.1%) and HCV
(16.9%).21,22 Similarly,in another study done in ocular
patients in Nigeria, incidence of HBV was 1.7%,23
which resemble our study, like wise in southern China
prevalence of HBV remained 9.7% whereas that of HCV
was 0.99%.24
Considering the gender, an increased prevalence
is observed in males in all the above mentioned studies,
whether national or international. A Pakistani study has
mentioned that males have more freedom and mobility
as compared to females.15
Highest age specific prevalence in our study was
between 51-70 years of age. This phenomenon can be
partly attributed to the fact cataract formation is most
commonly observed in this age group. This fact is also
unanimously observed in above mentioned studies.
Although a number of factors may lead to
transmission of HBV and HCV but contaminated
syringes and blood products that are not properly
screened are major risk factors.25 it is reported
that contaminated syringes and infected surgical
instruments can transmit this infection even a month
after being in contact with the virus.26 In a study from
USA ,parenteral drug use was reported to be the major
risk factor in majority of HCV positive cases.27
Screening for hepatitis B & C is not routinely
carried out in most of the public health settings as well
as government hospitals, because of lack of awareness,
inadequate health education, non-availability of test
facilities and high cost of screening tests. Due to heavy
surgical work load, operation theatres can be the
source of transmission of HBV and HCV. Operation
theatre staff should be properly screened for HBV and
HCV so that any infected personnel should take special
precautionary measures28 Routine serological screening
prior to surgery should be made mandatory so that
asymptomatic patients would no longer pose a threat
to its spread.
Isolation of hepatitis B&C virus from tear fluids
and aqueous humor raises a very serious concern of
transfer of hepatitis C virus, during the course of an
ophthalmological examination, that is during Goldman
Tonometry and trial contact lens fitting.29 Certain
studies have discovered that the concentration of
hepatitis C virus in human tear fluid is independent of
the severity of hepatitis infection.30 Other studies have
reported that hepatitis C virus RNA is found in higher
concentration in tear fluid compared with plasma,31
It has also been found that splashing blood or other
body fluids from patient who are HCV positive, in to
the face and eyes of a healthy person is a risk factor
of hepatitis C virus transmission.32 The high incidence
of hepatitis B and HCV in Pakistan is alarming and
peri-operative screening is highly recommended as
31
Pre-operative Screening of Patients for Hepatitis B&C Virus
early screening would not only allow timely initiation
of therapy as well as decreased rate of mortality and
morbidity. Surgery can be then carried out with special
precautionary measures so as to limit the spread of
these deadly diseases.
CONCLUSION
After observing a high prevalence of hepatitis
B&C in ophthalmic patients, we recommend routine
screening of all patients before surgery. Hepatitis
C should be even of more concern to public health
authorities. Screening should be a part of preventive
measures and it should be implemented and monitored
to control disease transmission Public health education
and awareness should be done through electronic and
print media.
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(1) 74-81
2. Ali SA, Donahue RM, Qureshi H, Vermund SH. Hepatitis B
and hepatitis C in Pakistan: prevalence and risk factors. Int J
Infect Dis. 2009 Jan;13(1):9-19.
3. Cusheri A. Acute and chronic viral hepatitis. In: Cusheri A,
Steele JC, Moosa AR. Eds 2002 Essential surgical practice.
5th edition. Oxford University Press. 334-5.
4. Blumberg BS. Australia antigen and the biology of hepatitis B.
Science. 1977 Jul 1;197(4298):17-25.
5. Tanwani K, Ahmad N. Prevalence of Hepatitis B surface
antigen and Anti-Hepatitis C virus in laboratory based data at
Islamabad. J Surg 2000; 19(20):25-9.
6. Weiss ES, Makary MA, Wang T, Syin D, Pronovost PJ, et al.
Prevalence of blood-borne pathogens in an urban, universitybased general surgical practice. Ann Surg. 2005 May; 241
(5):803-7
7. Erden S, Buyukozturk S, Calangu S, Yilmaz G, Palanduz S,
Badur S. Study of serological markers of Hepatitis B and C in
Istanbul, Turkey. Med Princ Pract 2003; 12(3): 184-8.
8. Russel RCG, Williams NS, Bulstode CJK,The liver,Bailey and
Love short practice of Surgery.24th ed. London. Chapman and
Haili; 2004: 1016
9.
Maheshwari A, Thuluvath PJ: Management of acute hepatitis
C. Clinics in liver disease 2010, 14(1):169–176. 8.
10. Cusheri A, Steele JC, Moosa AR. Essential surgical practice of
medicine. 19th ed. Philadelphia; Churchill living.2002
11. Habib M, Mohamed MK, Abdel-Aziz F, Magder LS, AbdelHamid M etal. Hepatitis C virus infection in a community in
the Nile Delta: risk factors for seropositivity. Hepatology. 2001
Jan;33(1):248-53.
12. Vandamme P, Van Herck K: A review of the long-term
protection after hepatitis A and B vaccination. Travel Medicine
and Infectious Disease 2007, 5(2):79–84
13 Sowbhagya HN, Kumar LK, Nikhil N, Raj K, Liji P, Patil P, Rafi
A , Sushruth. A. IMPORTANCE OF SEROLOGICAL WORKUP
IN CATARACT CASES OF OUT-REACH PROGRAMMES.
JEMDS: april 2013
14. Tariq W,Hussain AB,Karamat KA.Demographic aspects of
Hepatitis C in North Pakistan. Journ Pak med assoc 1999; 189201
32
15. Naeem SS, Siddiqui EU, Kazi AN, Khan ST, Abdullah FE
et al. Prevalence of Hepatitis ‘B’ and Hepatitis ‘C’ among
preoperative cataract patients in Karachi. BMC Research Notes
2012, 5:492
16. Nangrejo KM, Qureshi MA, Sahto AA, Siddiqui SJ. Prevalence
of Hepatitis B and C in the Patients Undergoing Cataract
Surgery at Eye Camps. Pak J Ophthalmol 2011; 27(1)17.Zubia
M, Masood J, Khan RA, Shafir ur Rehman.Screening for
Hepatitis B and C: a routine Pre- operative investigation? Pak J
Med Sciences 2005;21 (4): 455-59
18. Chaudhry IA, Khan SS,Majrooh MA, Alvi AA. Seropravalence
of Hepatitis B and C among the patients reporting at surgical
OPD at Fauji Foundation Hospital, Rawalpindi. Pak Journ med
Sci 2007;23 (4):514-17
19. Hameed A. Frequency of hepatitis B & C in elective eye surgery.
RMJ. 2013; 38(1): 15-17
20. Soomro MZ, Mahmood R. Prevalence of Hepatitis B and
Hepatitis C in Elective Ocular Surgery (rural origin) at Shifa
Eye Hospital, Khanpur. Pak J Ophthalmol 2013, Vol. 29 No.
1 21. Taguchi S, Nishioka k, Kawaguchi R. Epidemiological
study of Hepatitis B and C in 34,336 operated at Hiroshima
Perfecturial hospital, during the period from 1993 to 2000.
Masui 2004; 53(6):696-700
22. Yanaga K,Wakiyama S, Soejimay.Hepatitis C virus Infection
among Japanese General surgical patients.World Journ Surg
1995;19(5):694-97
23. Alhassan MB, Unung P, Adejor GO. HIV and HBsAg
Seropositivity Amongst Patients Presenting for Ocular Surgery
at a Tertiary Eye Care Hospital in Nigeria. Open Ophthalmol J.
2013; 7: 18–19.
24. Duan F, Huang Q, Liao J, Pang D, Lin X, Kaili Wu. How Often
Are Major Blood-Borne Pathogens Found in Eye Patients? A
Serosurvey at an Eye Hospital in Southern China. PLoS One.
2013; 8(9): e73994.
25. Bosques-Padilla FJ, Vázquez-Elizondo G, Villaseñor-Todd
A, Garza-González E, Gonzalez-Gonzalez JA, et al. Hepatitis
C virus infection in health-care settings: medical and ethical
implications. Ann Hepatol. 2010;9:132-40.
26. Yousaf A, Mahmood A, Ishaq M.Can we afford to operate on patients
without Hbs Ag screening? J Coll Physicians Surg Pak.1996;9:98100
27. Alter MJ, Kruszon-Moran D, Nainan OV, McQuillan GM, Gao
F, et al. The prevalence of hepatitis C virus infection in the
United States, 1988 through 1994. N Engl J Med. 1999 Aug
19;341(8):556-62.
28. Haider ZH, Ahmad N, Yasrab M, Malik AM, Javed M.
Screening for hepatitis B & C: A prerequisite for all invasive
procedures. Professional Med J 2006; 13: 460-3.
29. Segal WA, Pirnazar JR, Arens M, Pepose JS. Disinfection of
Goldmann tonometers after contamination with hepatitis C
virus. Am J Ophthalmol. 2001 Feb;131(2):184-7.
30. Su CS, Bowden S, Fong LP, Taylor HR. Detection of hepatitis
B virus DNA in tears by polymerase chain reaction. Arch
Ophthalmol. 1994 May;112(5):621-5.
31. Feucht HH, Polywka S, Zöllner B, Laufs R. Greater amount
of HCV-RNA in tears compared to blood. Microbiol
Immunol. 1994;38(2):157-8.
32. Hosoglu S, Celen MK, Akalin S, Geyik MF, Soyoral Y, et al.
Transmission of hepatitis C by blood splash into conjunctiva in
a nurse. Am J Infect Control. 2003 Dec;31(8):502-4.
ORIGINAL ARTICLE
Zaheer Umer
Comparison of Surgically Induced
Astigmatism after Phacoemulsification
Vs Extra Capsular Cataract Extraction
Zaheer Umer, MCPS, M.S. (Ophthalmology)1*, Dr. Abdul Haleem Mirani FCPS2
Ghulam Muhammad Mahar Medical College, Sukkur
ABSTRACT
Purpose of study: To compare the results of surgically induced astigmatism (SIA) in patients who underwent Phacoemulsification and extra capsular cataract extraction with posterior chamber intraocular lens implant.
Setting: Isra Postgraduate Institute of Ophthalmology, Karachi
Methods: This prospective study comprised of 200 patient, 100 eyes (100 patients) underwent phacoemulsification through
clear corneal 3.2 mm incision with foldable IOL implantation, while in 100 eyes (100 patients) ECCE with a superior corneal
section 8.00 to 10.00mm in size was performed with 6.5 mm optic size posterior chamber PMMA IOL implantation. Automated keratometery was performed preoperatively and post operatively on 1st day, 2nd week, 6th week and 12th week. Surgically induced astigmatism was calculated with computer based software SIA calculator version 2.1 The software utilized the
Cartesian co-ordinates based method as suggested by Dr. Holladay.
Results: The mean SIA was 0.74 D x 171 for patients undergoing conventional ECCE Surgery and 0.42 D x 43 for patients
having Phacoemulsification Surgery (p <0.001) at three month of follow up.
Conclusion: Phacoemulsification with intraocular lens implantation results in lower SIA than ECCE surgery and faster
visual rehabilitation than conventional extracapsular cataract extraction.
Key Words: Phacoemulsification, Extracapsular cataract extraction, Surgically induced Astigmatism (SIA)
INTRODUCTION
Cataract extraction constitutes the largest surgical
workload in ophthalmic units throughout the world.
Extra capsular cataract extraction (ECCE) is still the
most widely used method. The basic advantage of
phacoemulsification over the conventional ECCE is that
it involves a very small incision compared to 8.00mm10.00 mm of (ECCE)1-2
A significant improvement in results due to reduction in SIA was observed in the early nineties with the
transition from planned extra capsular cataract extraction to phacoemulsification. The major reason for the
transition was the good control of low postoperative
astigmatism after phacoemulsification and there was a
need for an effort to control astigmatism in the relevant
1
Assistant Professor Ophthalmology. 2Senior Registrar, *Formerly
worked as Ophthalmologist at Isra Post Graduate Institute, Karachi.
Correspondence: Dr. Zaheer Umer, Assistant Professor,
Ophthalmology, Ghulam Muhammad Mahar Medical College,Sukkur. E.Mail: [email protected] Cell: 0300 3130412, Dr Zaheer Umer
Shaikh, Umer Eye Clinic, Station Road, Sukkur
Acknowledgement: The subject is the dissertation topic of the
Principal author for M.S. Ophthalmology. It was supervised by Prof
Saleh Memon FRCS, Project Director, Isra Ophthalmic & Research
Development Centre, Karachi. It was reviewed by Dr Saurabh
Sawhney, Ophthalmic Surgeon, Insight Eye Clinic, New Delhi, India ,
and by Mr Nadeem of SPDC, consultant on research; finally by Dr.
Jack T. Holladay M.D., and colleagues who developed the doubleangle polar plot specifically for astigmatism analysis. Data Analysis
was done by Muhammad Faisal Fahim, Statistician, Al-Ibrahim Eye
Hospital Karachi, Isra Ophthalmic Research & Development Center,
Karachi
Received: Nov’ 2013
Accepted: Dec’ 2013
method for assessment of SIA.3 Surgical procedure, the
cataract surgeon must know as much as possible about
the source of the astigmatism. Basic astigmatism of eye
is predominantly due to corneal and lenticular astigmatism,2 whereas any procedure that alters the patient’s
inherent astigmatism causes SIA.
Surgically induced astigmatism (SIA) is the one of
the most important complications of cataract surgery.4
The postoperative astigmatism delays visual rehabilitation and limits the final visual outcome.5 Phacoemulsification (PHACO) reduces the post-operative astigmatism and gives faster visual rehabilitation of patients
when compared with conventional extra-capsular
cataract extraction(ECCE).6 -7 Analysis of astigmatic
data presents a complex problem both the magnitude
and the direction need to be assessed simultaneously.
This problem is resolved by converting the astigmatic
data into a Cartesian coordinates system, where each
astigmatic vector is assigned a position represented
by(x, y) values for use in statistical analysis. These data
were also displayed and analyzed using double angle
plots(DAP) as depicted in (figures).
A highly localized clustering of points on the DAP
indicated a homogenous group with true representative of its centroid with a high predicative value.
Analysis of SIA allows the surgeon to evaluate his
own technique and also to maximize his potential for
obtaining a consistently good surgical outcome. It further allows the surgeon to choose the right axis, right
length, right site and right nature of incision over a pe33
Comparison of Surgically Induced Astigmatism after Phacoemulsificatio
riod of time. This is especially important while planning for correction of preexisting corneal astigmatism
during any type of cataract surgery. This study was carried out with two objectives:
1. to assess whether or not PHACO actually yielded
less surgically induced astigmatism (SIA) than
ECCE and
2. to evaluate astigmatism by using clinically relevant methods.
MATERIALS & METHODS
This study was carried out at Department
of Ophthalmology Isra Post-graduate Institute of
Ophthalmology, Karachi.
Duration of Study: nine months (January 2011 to
September 2011)
Sample Size: 200 patients(100 in PHACO-group and
100 in ECCE-group)
They were subdivided randomly into two groups of
100 eyes each. Group A received Extracapsular cataract
extraction, group B received cataract extraction through
Phacoemulsification surgery.
Sampling Technique: non-probability randomized.
Inclusion Criteria: senile cataract age above 40 years.
Exclusion Criteria: Those patients with complicated
34
and traumatic cataract, previous refractive surgery, Corneal disease (corneal opacity scar or adherent leukoma),
pterygium, filtering blebs were excluded from the study.
Pre-operative examination: Complete ocular examination including visual acuity aided and unaided, intraocular pressure measurement, fundus examination,
keratometry and A-scan biometry was done along with
general and systemic examination. A written consent
was taken by every patient prior to surgery. All surgeries were performed under local anaesthesia.
Surgical Technique: 100 eyes(100 patients) underwent
phacoemulsification through clear cornea 3.2 mm incision with foldable IOL implantation, while 100 eyes
(100 patients) had ECCE with a corneal section 8.00 to
10.00mm in size superiorly, 6.5 mm posterior chamber
PMMA IOL was implanted.
Postoperative follow-up: Patients were assessed postoperatively on 1st day after surgery, 2nd week, 6th week
and 12th week. Final recovery was assessed at 12 week
after surgery. At each follow-up visit, patients were assessed under following parameters:
1. Visual acuity
2. Slit lamp examination
3. Refraction status assessed at 6 weeks.
4. Automated keratometery (AUTO-REF Kerato
System(Rekto ORK-11)
5. Fundoscopy 6. Measurement of intraocular pressure
Recording of Astigmatism: The corneal astigmatism
was measured preoperatively and on subsequent follow-up postoperative visits by means of an automated
keratometer.
All data were stored and analyzed by means of a computer data base.
Analysis of Data: Surgically induced astigmatism was
calculated with computer based software SIA calculator version 2.17 pre and the postoperative keratometric values were calculated for evaluating surgically
induced astigmatism as suggested by Holladay et al.,8
The software utilized the Cartesian co-ordinates based
method.
RESULTS
We found that the surgically induced corneal
astigmatism was considerably lighter after PHACO
than after ECCE up to at least 12th week after the operation Moreover, shortly after the operation (i.e., up to
at least 6 weeks postoperatively) corneal astigmatism
was, on average, with-the-rule.
The magnitude of preoperative astigmatism was
higher in group B 0.66 ± 0.53 than in group A 0.59 ± 0.63
[Table - 1]. The magnitude of postoperative astigmatism
[Table - 1] was higher in group B (1.43 ± 0.83) than in
group A (1.06 ± 0.58). The magnitude of surgically induced astigmatism [Table - 1] was also higher in group B
Table 1: Magnitude of astigmatism
Magnitude of astigmatism
Ecce Group Phaco Group
Mean Preoperative magnitude 0.59 ± 0.63
Mean postoperative magnitude 1.43 ± 0.83
1.41 ± 0.84
Mean SIA magnitude
0.66 ± 0.53
1.06 ± 0.58
1.01 ± 0.54
(1.41 ± 0.84) than in group A (1.01 ± 0.54).
Table-1 shows Magnitude of astigmatism.
Analysis of the SIA centroids[Table – 2] shows that 0.74
of horizontal steepening (or vertical flattening) was
induced by making a superior incision. Surgically induced astigmatism in the Phaco group was 0.42 D at 43°
which shows 0.42 D of flattening at the site of clear cornea incision and the axis orthogonal to it is steepened
(actually shows 0.21 D of flattening at the incision and
0.21 D of steepening orthogonally for a total of 0.42 D).
Table 2: Centroids
Centroids Holladay
Ecce Group Phaco Group
Mean Preoperative centroid
Mean postoperative centroid
Mean SIA centroid
0.11 X 4
0.84 X 173
0.74 X 170
0.24 X 4
0.52 x 30
0.42 X 43
It is evident that more astigmatism is being induced
by ECCE than PHACO. Both sets of data have a reasonable level of coherence(measure of spread of vector) for
SIA, and more importantly, the coherence percentage
for SIA is almost equal. This means that the data can be
compared directly, since the amount of vector spread is
similar and any effects of vector cancellation on the centroid (mean SIA vector )are equivalent for both groups.
The SIA vector in ECCE group on the Double Angle Plot( figure 3) shows clustering, employing high
predicative value of the centroid obtained, that is 0.74
x 170 this indicate that making a superior incision consistently induced an average of 0.74 steepening. The
SIA vector in PHACO group are also well clustered
employing a high predicative value and incision induced a flattening of about 0.42 @ 43. The results are
summarized in Fig. 1, with respect to the magnitude of
the induced corneal astigmatism regardless of the axis.
Fig: 1
35
It is evident that the change in magnitude of the
corneal astigmatism was markedly smaller after PHACO than after ECCE during the entire follow-up period. This difference is statistically significant. The final
induced post-operative astigmatism was significantly
less between the groups at 0.42 D x 43 for patients
undergoing phacoemulsification surgery and 0.74 D x
171 for patients having conventional ECCE Surgery (p
<0.001, paired Student t-test).
Fig : 2
values. The postoperative astigmatism declined over
time.12 Talamo et al. had made similar observations in
patients who had undergone ECCE. Their follow-up period ranged from 6 to 48 months. Interestingly, their data
suggested that the against-the-rule astigmatism grew
larger in time, by about 0.3 D per year.13 Wang L et al.
indicated long-term wound remodeling15 that may affect
SIA. Long term data is required to analyses changes by
the procedure. However, if against-the-rule astigmatism
indeed becomes larger with time, this might, in future,
prompt us to adjust our surgical techniques.
CONCLUSION
The results obtained during this study significantly indicate that Phacoemulsification with intraocular lens implantation results in lower induced corneal
astigmatism following surgery and shorter post-operative recovery than conventional extracapsular cataract
extraction. The basic advantage of this method over the
conventional ECCE is that it involves a very small incision. This small incision results in faster wound healing
without suturing.
DISCUSSION
It has been demonstrated in this study that the surgically induced corneal astigmatism following cataract
surgery is considerably slighter after phacoemulsification than conventional extracapsular cataract extraction during at least the first six weeks postoperatively.
Phacoemulsification as compared to ECCE, with respect to surgically induced corneal astigmatism, yielding earlier visual rehabilitation of the patient.
Naseer Raja and M. Khizer Niazi reported in their
study that the mean postoperative astigmatism in ECCE
group was +2.25 (±1.7) as compared to +0.5 (±0.49)
phacoemulsification group at 3 months follow up. They
suggest phacoemulsification as first choice for cataract
surgery due to fast recovery and less astigmatism in
early weeks of surgery.9 Dam Johnson M. Olsen T et al
studied the changes in refractive error resulting after
Phacoemulsification and ECCE; reported the mean surgically induced astigmatism to be 0.91D in the phacoemulsification and 1.36 D in ECCE group. He concluded
that phacoemulsification improves the surgical control
of refractive outcome of cataract surgery.10 These results
are very near to those which are obtained during this
study. Another study by Watson A. and Sunder Raj P.
had reported similar results that less astigmatism was
induced by phacoemulsification than ECCE. 11
Furthermore, we observed marked with-the-rule
astigmatism shortly after the operation; in ECCE group
particularly. The long incisions can induce initial large
amounts of WTR astigmatism. Ken Ninn-Pedresen
made similar observation that there was a marked withthe-rule astigmatism in the early postoperative period,
both the total as well as the induced, assessed as polar
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8.
Sawhney S, Aggarwal A, The SIA calculator Version 2.1–
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[Internet]. [Cited 2012 May 10]. Available from:http://www.
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9. Holladay JT, Dudeja DR, Koch DD. Evaluating and reporting
astigmatism for individual and aggregate data. J Cataract Refract
Surg 1998;24:57-65.
10. Naseer Raja, Muhammad Khizar Niazi. Phacoemulsification
versus Extracapsular Cataract extraction: the visual outcome.
Pak J Surg Oct - Dec 2003;19(2):77-81. Department of Ophthalmology, Military Hospital, Rawalpindi
11. Dam-Johansen M, Olsen. Refractive results after phacoemulsification and ECCE. A comparative study. ActaOphthalmol (Copenh) 1993; 71: 382-7.
12. Watson A, Sunderraj P.,Comparison of small-incision phacoemulsification with standard extracapsular cataract surgery: post-operative astigmatism and visual recovery. Eye 1992; 6 (Pt 6): 626-9.
13. Ken Ninn-Pedersen ,Cataract patients in a defined Swedish population 1986-1990- 1996-23 pages - Snippet view
14. Talamo JH, Stark WJ, Gottsch JD, Goodman DF, Pratzer K, Cravy
TV, Enger C. Natural history of corneal astigmatism after cataract surgery. J Cataract Refract Surgery 1991; 17: 313-18.
15. Wang L, Dixit L, Weikert MP, Jenkins RB, Koch DD. Incisional
healing changes of clear corneal cataract incisions evaluated using Fourier-domain optical coherence tomography. J Cataract Refract Surg. 2012 Apr;38(4):660-5. doi: 10.1016/j.jcrs.2011.10.030.
Epub 2012 Feb 10.
36
ORIGINAL ARTICLE
To Compare the Incidence of Oculocardiac
Reflex with Pre-Medication & Without Premedication
in Strabismus Surgery
Junaid Faisal
Junaid Faisal Wazir FCPS, M.Sc.1 Inayat Ullah Khan FCPS2, Imran Ahmed FCPS3
Sadia Sethi FCPS, (Fellow Strabismology)4
Abstract
Objective: To compare the Incidence of Oculocardiac Reflex With Pre-Medication and Without Premedication In Strabismus Surgery
Material and Methods: This study was a randomized control trial performed in the Department of Ophthalmology at Khyber Teaching Hospital, Peshawar form February, 2011 to October, 2011. Eighty patients of ages between 10 to 18 years
were randomly divided into two groups. The patients in Group A were pre-medicated with an anticholinergic drug (atropine
sulphate) while the patients in group B were not administered any pre-medications. Patients in both the groups were anesthetized with similar drugs during horizontal strabismus surgeries. Patients were monitored using blood pressure, electrocardiography and heart rate monitor. Dysrhythmias occurring during anesthesia were identified and documented in each
group with collaboration with Anesthesiology Department.
Results: Dysrhythmias were observed in both the groups but the incidence was very high among patients from group B. In
group A 2 patients (5 percent) while in group B 25 patients (65 percent) developed dysrhythmias. In both the groups only 2
patients (3 percent) developed ventricular ectopics while 25 patients (31 percent) developed bradychardia.
Conclusion: This study shows that the incidence of oculocardiac reflex is very high in patients who were not pre-medicated
with an anticholinergic drug. Hence, all the patients requiring general anesthesia for eye surgeries specially squint surgery
involving medial rectus should have a proper anticholinergic pre-medication.
Key Words: General Anesthesia, Oculocardiac, Reflex, Anticholinergics, Strabismus.
INTRODUCTION
Oculocardiac reflex or Aschners reflex was first
recognized in 1908.1 Studies establishing this reflex as a
complication of ocular surgery have been documented
in the west but no such study has been conducted in
our province, which is necessary to confirm any variation of its incidence with respect to environmental and
racial factors.
Dysrhythmia is a change in the normal physiological rhythm of the heart so the Oculocardiac reflex is defined as occurrence of dysrhythmia when pressure is
applied on the eye ball or extraocular muscles specially
medial rectus muscle. Inhalational anesthetic agents
make the heart vulnerable to increased vagal tone especially in the young. Oculocardiac reflex is mediated
via trigeminal-vagal reflex arc. The afferent division of
the arc is ophthalmic branch of trigeminal nerve and
efferent division is vagus nerve. This reflex is predominantly seen in pediatric patients but is not uncommon
in adults1 either. This reflex is stimulated in a variety
of ocular surgeries like strabismus, cataract, enucleaMedical Officer Eye A Ward, Khyber Teaching Hospital, Peshawar
(KPK), 2Consultant Ophthalmologist, PIMS, Islamabad. 3Trainee M.O.
B-Eye Ward, Khyber Teaching Hospital, Peshawar, 4Associate Prof.
Khyber Teaching Hospital, Peshawar
1
Correspondence: Dr. Junaid Faisal Wazir, Doctors Lodge Opp Kausar
Masjid Street 4, Canal Colony, P/O Peshawar University, Peshawar.
Tel No. 03339105154 Email: [email protected]
Received; Nov’2013
tion and retinal detachment.2 It has been observed that
patients with gray and blue irises are less prone to this
reflex than patients having brown and hazel coloured
irises3. Dysrhythmias are elicited by applying pressure
on the extra ocular muscles or eyeball. They may be in
the form of nodal rhythm, premature ventricular beats,
bradycardia, ventricular fibrillation or cardiac arrest.4
Oculocardiac reflex can also develop in conscious patients under local anesthesia. In these patients in addition to dysrhythmias nausea, vomiting and somnolence
is experienced. It is observed more commonly in anesthetized patients and in ninety percent of children not
receiving prophylaxis for its preventiuon.5
This randomized control study was performed in
the eye operation theatre by the Ophthalmology Department with collaboration of Anesthesiology Department of Khyber Teaching Hospital, Peshawar. Study
duration was from February, 2011 to October, 2011.
Convenient sampling was applied in this study. The
sample included a total of 80 patients divided into two
groups, A and B. Group A patients were administered
Atropine, while the Group B patients were not administered Atropine. Inclusion Criteria was age 10-15 years,
patients with ASA class I and II (American Society of
Anesthesiology), all patients undergoing strabismus
surgery. While exclusion Criteria included patients
who were having glaucoma, tachycardia, fever and
dysrhythmia. Preoperative assessment and informed
consent was taken from the patients.
37
To Compare the Incidence of Oculocardiac Reflex with Pre-Medication & Without Premedicatio
Heart rate, blood pressure, heart rhythm and respiratory rate were monitored throughout the surgery.
Any change in these variables due to oculocardiac reflex was documented on a standard proforma. Bradycardia was defined as a heart rate of 60 or less than 60
beats per minute. Patients in group A were administered Atropine Sulphate in a dose of 0.02 mgs/ kg body
weight, just before the induction of anesthesia while no
Atropine was given to patients belonging to group B.
Patients in both groups were induced with intravenous
Propofol in a dose of 2 mgs/kg body weight and a nondepolarizing muscle relaxant atracurium in a dose of
0.5 mgs/kg body weight. After endotracheal intubation
anesthesia was maintained with oxygen and isoflurane.
Tramadol 1 mg/kg was used as an analgesic. Data analysis was done using IBM SPSS version 2.0. Graphs were
made using Microsoft excel 2010.
RESULTS
Oculocardiac reflex occurred in both the groups
but the percentage was higher in group B (non-medicated), shown in figure 1. The types of Dysrhythmias
that occurred and there frequency is shown in figure
2. In both the groups heart rate did not decrease more
than 35 beats per minute. Mild decrease in Blood pressure was observed in patients of group B during the
reflex. Data was considered significant with a p value
of <0.05 calculated by applying chi square test.
when given just prior to surgery are more effective than
when given intramuscular.7 Atropine sulphate is one of
the anticholinergic drugs, it blocks muscarinic acetylcholine receptors in clinical doses and produces its effects in accordance with the distribution of muscarinic
receptors in different organs. Blockage of muscarinic
receptors in the sino-atrial node leads to tachycardia.
This effect is especially important in reversing the bradycardia associated with vagal reflexes like baroreceptor
reflex, peritoneal stimulation or oculocardiac reflex.8
The use of anticholinergic medicines may be hazardous
in some patients like patients with tachycardia, hyperthyroidism, angle closure glaucoma.
Fig 1: Comparison of Dysrhythmias frequency
between premedicated, non-premedicated patients
and elderly with coronary artery disease. Retrobulbar
block with local anesthetic agents has been used
in the past for the prevention of this reflex but
instead was found to be a causative factor9.
DISCUSSION
Oculocardiac reflex describes that the pressure and
traction applied on the eyeball can produce a variety
of cardiac dysrhythmias which includes sinus bradycardia, ventricular ectopic beats, ventricular fibrillation
and even sinus arrest by activation of vagal nerve fibers
in the sinus node. The more aggressive the manipulation of extra ocular muscle the higher the chances of
oculocardiac reflex6. Anticholinergic medication like
atropine and glycopyrolate are helpful in preventing this reflex. Intravenous Atropine or glycopyrolate
38
In our study we found that incident of dysrhythmias in group A was 5%. In group B the incident was
65%. In group A only bradycardia was detected and
there was no change in the blood pressure of the patients. While in group B significant dysrhythmias were
noted with mild fall in blood pressure. Luckily serious
dysrhythmias like ventricular fibrillation or cardiac arrest were not detected. In group B two types of dysrhythmias were noted bradycardia and ventricular ectopic beats, patients were not allowed to be in a state
of dysrhythmia for a longer period of time even bradycardia was treated immediately that is why we did not
observed any serious dysrhythmia.
The incidence of dysrhythmia was quite high in
the past,10 due to advanced monitoring, safe anesthetic
agents and in time detection, the incidence of morbidity
and mortality associated with this reflex has decreased.
Moreover the routine use of an anticholinergic drug
like Atropine sulphate as pre-medication in ocular surgery has also decreased the incidence of oculocardiac
reflex.11
To Compare the Incidence of Oculocardiac Reflex with Pre-Medication & Without Premedicatio
The occurrence of dysrhythmias is not limited to
strabismus surgeries alone, study done by Yang shows
that intra ocular foreign bodies can also elicit this reflex12. Likewise diseases of the choroid can also produce
the oculocardiac reflex.13
In terms of general anesthesia as being an important risk factor of this reflex, study done by Grover
and Bhardwaj14 showed that local anesthesia produces
less bradycardia and ectopic arrhythmias and accordingly they have urged the use of local anesthesia over
general anesthesia in surgeries involving extra ocular
muscle manipulation. Karhunen15 compared atropine
and glycopyrolate effectiveness in preventing dysrhythmias and he found atropine to be more efficacious as
a first line choice of pre-medication for strabismus surgery. Bosomworth16 emphasizes the need of continuous
monitoring of the cardiac rate and rhythm of the patient
undergoing eye muscle surgery. According to Buchwald17 and Victor18 general anesthesia is the single most
important cause of all types of dysrhythmias that have
been reported to occur in oculocardiac reflex. According
to a study published by Sing and Roy ketamine when
used as a topical anesthetist in rabbits, effectively prevented the occurrence of oculocardiac reflex.19 On the
other hand study done by Baek and Park20 showed that
oculocardiac reflex can occur during endoscopic sinus
surgery and is not limited to Ocular surgeries only. And
a case reported by Mezitis showed that oculocardiac reflex can follow insertion of a bilateral nasal balloon catheter for controlling bleeding following head trauma.
CONCLUSION
Pre-medication are extremely important in preventing oculocardiac reflex in patients undergoing
general anesthesia. Proper intra operative monitoring
is mandatory in all the patients during surgery.
REFERENCES
1.
Myers EF. Anesthesiology. Oculcardiac reflex in Paediatric patients. Anesthesiology 1979; 51; 350-55.
2.
Robideaux V. oculcardiac reflex and general anestheisa in paediatric patients. Anesthesiology. 1978; 49; 433-37.
3.
Kwick RS. Anesthesia dysrythemias in ocular surgery. Anesthesia 1980; 33; 46.
4.
Kerr WJ, Vance J. dysrythemias in ocular surgery. Anesthesia
1983; 38; 883.
5.
6.
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9.
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20.
McGoldrick K. E. Anesthesia for Ophthalamic Otolaryngologic
surgery. BMJ 1992, 23, 331-39.
Rosenfeld S, Litinsky S, Snyder D. Effectiveness of monitored
anesthesia care in cataract surgery. Oph thalmology 1999; 106
; 1256-60.
Alexander JP Reflex disturbances of cardiac rhythm during ophthalmic surgery. British Journal of Ophthalmology 1973; 59; 51824.
Mirakhur R. K, Jones C. J, Dundee J. W, Archer D. B. IM or IV
Atropine or Glycopyrolate for the prevention of oculocardiac
reflex in children undergoing squint surgery. British Journal of
Anesthesia 1982; 54; 1059-63.
Blanc VF, Hardy J, Milat J, Jacob J. The oculocardiac reflex: a
graphic and statistical analy sis in infant and children. Canadian
Anesthetists Society Journal 1983; 30, 360-69.
Mirakhur RK, Shepherd W, Jones C. J. Ventilation and the oculocardiac reflex. Prevention of oculocardiac reflex during surgery
for squints. Role of controlled ventilation and anticholinergic
drugs. Anesthesia 1986; 41, 825-58.
Hyun Y Eun D. A Case of Delayed Oculocardiac Reflex Induced
by an Intraorbital Foreign Body. Ophthalmic Plastic & Reconstructive Surgery: 2011; 27(1), 2-4.
Steinmetz A, Ellenberger K, Marz I, Ludewig E, Oechtering G.
Oculocardiac Reflex in a Dog Caused by a Choroidal Melanoma
with Orbital Extension. Anesthesiology 2013 ; 41 (3), 155-62.
Grover V K, Bhardwaj N, Shobana N, Grewal P Oculocardiac
reflex during retinal surgery using peribulbar block and nitrous
narcotic anesthesia. Ophthalmic Surgery and Lasers. Department of Anaesthesia, Postgraduate Institute of Medical Education and Research, Chandigarh, India, 1998, 29(3): 207-12.
Karhunen U, Cozanitis D. The oculocardiac reflex in adults
a dose response study of glycopyrrolate and atropine. JAA of
Great Britian and Ireland. 1984;39 (6). 524-28.
Bosomworth H, Peter P, Ziegler I, Carolynh A, Jacob Y The Oculo-Cardiac Reflex in Eye Muscle Surgery. Anethesiology 1958,
19(1). 7-9.
Gold R. S, Pollard Z, Buchwald P Asystole due to the oculocardiac reflex during strabismus surgery: a report of two cases. Annals of Ophthalmology 1988, 20(12): 473-25.
Faria B, Hardy F, Milot J, Jacob L. The oculocardiac reflex: a
graphic and statistical analysis in infants and children. Canadian
Journal of Anesthesia, 1983, 30 (4) 360-69.
Sing J, Roy S, Mukherjee P Konar D, Hazra S. Influence of topical
anesthetics on oculocardiac reflex and corneal healing in rabbits.
International Journal of ophthalmology. 2010; 3(1): 14-18.
Baek HI, Park BC, Kim WH, Son WS. Oculocardiac reflex during
the endoscopic sinus surgery. American Journal of Otolaryngology - Head and Neck Medicine and Surgery. 2010; Volume 31(2):
136-30.
Stathopoulos P Mezitis M, Kostakis G, Rallis G. Iatrogenic Oculocardiac Reflex in a Patient with Head Injury. Cranial Maxillofacial Trauma Reconstruction 2012; 05(04): 235-
While acknowledging a lapse!
In the last Oct’ 2013 issue of OU, the excerpts of an article from EyeNet was published inadvertently
without permission, perhaps due to some misunderstanding or failed electronic (E.mail) transmission.
The management of OU very much regrets this lapse. However, one must respect a universal law and
take a lenient view of using a scientific material for the benefit of the humanity at large (of course with
a proper acknowledgement, without trespassing the copyrights). The Ophthalmology Update strictly
follows this rule ………………………Chief Editor
39
Muhammad Rafiq
Comparison of Effects on Corneal
Endothelium of A Low Cost & Expensive
Combination of Viscoelastic Material &
Irrigating Solution in Phacoemulsification
ORIGINAL ARTICLE
Muhammad Rafiq FCPS1, Imran Ahmad MBBS2, Habib Ullah MBBS3
ABSTRACT
Purpose: To see the protective effect on corneal endothelium of a cheap and an expensive combination of a dispersive
viscoelastic material and an irrigating solution in phacoemulsification.
Setting: Department of Ophthalmology, Rehman Medical Institute, Peshawar.
Methods: In this prospective randomized study, we selected 90 eyes of 45 consecutive patients with senile cataracts bilaterally. The first eye of each patient randomly received hydroxypropyl-methylcellulose 2% and Ringer’s solution (low-cost
combination)or sodium chondroitin sulfate 4%–sodium hyaluronate 3% and an enriched balanced salt solution (BSS Plus®)
(expensive combination) during phacoemulsification. While the contralateral eye received the other treatment. Endothelial
cell function was evaluated by measuring corneal thickness (CT) using pachymetry and endothelial cell counts by specular
microscope.
Results: Postoperative increase in CT was +9.5µm in the low-cost group and +10.3µm in the expensive group; the difference between groups was insignificant. After 1 month, the CT still differed significantly from the baseline in the low-cost
group while in the expensive group, recovery was good. Three months after surgery, the CT had returned to baseline values
in both groups and at this stage, there was no significant difference between the groups.
Conclusions: During phacoemulsification in a non-selected patient population, there was no difference in acute postoperative corneal edema and endothelial cell counts at 3 months between an expensive and a low cost combination. Eyes which
received the expensive combination had faster recovery of corneal swelling at 1 month. However, the cost of expensive
combination is 6-7 times that of low-cost combination.
INTRODUCTION
The endothelium is a monolayer of cells on the
posterior aspect of cornea having no ability for regeneration after injury. The active fluid pump present in
endothelium keeps the cornea transparent and in a relatively dehydrated state.1,2 The natural loss of human
endothelial cells is approximately 0.5% each year.3Any
type of Intraocular manipulation such as phacoemulsification, causes fluid and lens fragment turbulence
leading to endothelial cell damage.4–8
Solutions initially used for cataract surgery were
salt solution, Ringer’s solution and plasma-lyte 148. Subsequently, in 1960, more physiological solutions with
ionic composition, pH and osmolality similar to aqueous
humour were developed and received the name of balanced salt solution (BSS).9 In 1973, a third generation of
irrigation solution, named BSS Plus, was developed after
studies by Edelhauser and coauthors,10-12 who verified
that the addition of glutathione, glucose and bicarbonate
to the irrigation solution would contribute to endothelial
cell function and survival in vitro.
Viscoelastic materials have assumed an important
role in cataract surgery since the introduction of sodium
hyaluronate in early 1970s. New viscoelastic materials
Senior Registrar, Eye Unit, Rehman Medical Institute, Peshawar
Medical Officer, Eye Unit, Khyber Teaching Hospital, Peshawar
3
Medical Officer, Ophthalmology Unit, RMI, Peshawar
1
2
Correspondence: Dr. Muhammad Rafiq: [email protected]
Cell: 03224882534 House: 67, Street No-3, Sector F-10, Phase-6
Hayatabad, Peshawar, KPK.
Received & Accepted: December 2014
40
have emerged in order to improve corneal endothelial
protection during cataract surgery. There are 2 main
types of viscoelastic materials for enhanced protection
of the corneal endothelium: (1) high-viscosity, cohesive materials (e.g, sodium hyaluronate), and (2) lowviscosity, dispersive materials (eg,sodium chondroitin
sulfate 4%–sodium hyaluronate3%such as Viscoat and
hydroxypropyl methylcellulose 2% such as Eyefill),
which adhere to the corneal endothelium, providing a
protective layer. Such materials are often used in patients with a low preoperative endothelial cell count.
We compared the endothelial protective effect
during phacoemulsification of a low-cost combination
of a viscoelastic material and an irrigating solution,
Eyefill and Ringer’s solution, with a more expensive
combination of Viscoat and BSS Plus, which costs approximately 6-7 times more. We analyzed their effect
on corneal thickness (CT) and corneal endothelial cell
count during phacoemulsification.
This prospective randomized study comprised 90
eyes of 45 consecutive patients with bilateral age-related cataracts who underwent phacoemulsification. The
median age of the patients was 62 years (range 50 to 68
years). First eye of each patient was randomly assigned
to low-cost group or expensive group. The contralateral
eye received the alternative treatment. Central corneal
thickness was measured with corneal pachymeter preoperatively and at day 1, day 7, and day 30 and day 90
postoperatively. Ten measurements per eye were obtained at each observation with the examiner masked
Comparison of Effects on Corneal Endothelium of A Low Cost & Expensive
to the combination used.
Corneal endothelium was examined with a specular microscope preoperatively and 3 months after surgery. Three endothelial cell photographs were taken
per eye at each examination. The mean of the 3 photographs was calculated. In all cases, the ultrasound time
(seconds) and amount of irrigating solution used (milliliters) during surgery were also noted.
All patients were operated by the same surgeon.
Pupils were dilated with phenylephrine 2.5%, tropicamide 0.5%. Anesthesia used was peribulbar. A temporal 3.5 mm limbal incision was created. The assigned
viscoelastic material was then instilled before capsulorhexis was done. Hydro-dissection was done. Phacoemulsification of the nucleus was carried out with an
Oertli unit. Cortical matter was aspirated. Ringer’s solution or BSS Plus, depending on the randomization,
was used for irrigation.
The capsular bag was expanded with the assigned
viscoelastic material, and a foldable single piece acrylic
IOL was implanted in the capsular bag. The viscoelastic material was aspirated thoroughly from the anterior
chamber and behind the IOL with an irrigation/aspiration (I/A) tip.
The incision was left sutureless. Decadron injection was given subconjunctivally and eye was patched
with polyfax eye ointment. After 24 hours of surgery,
patch was removed and patient started on diclofenac
tablets and steroid and antibiotic eye drops.
RESULTS
Central corneal thickness and endothelial cell counts
were done preoperatively and postoperatively at day 1,
day 7, day 30 and day 90. The mean phacoemulsification
time was 18 seconds + 12 (SD) in the low cost group and
16 seconds + 9 in the expensive group. Corneal thickness
was found to be more in low cost group as compared to
the expensive group in early postoperative period. But
ultimately at 03 months, there was no significant difference between the two groups in terms of corneal thickness and endothelial cell counts.( Table 1 )
DISCUSSION
Phacoemulsification time was equal between the
groups and irrigation volume was only slightly higher
in the low-cost group in our study. Corneal thickness,
though increased acutely in the immediate postopera-
tive period, it steadily decreased reaching to baseline
level in 01 month in the expensive combination group
and in 03 months in low cost group. In the same way, endothelial cell loss was not significantly different between
the two combinations at 03 months postoperatively.
Corneal pachymetry, by measuring corneal thickness, indicates the amount of trauma induced to the
endothelial cells during surgery.2 Other authors have
also reported an acute reversible increase in central CT
as was found in our study.13-16 With the development
of viscoelastic materials, different observations about
their protection provided to the endothelium have been
made. Compared to Healon (sodium hyaluronate 1%),
Viscoat, a dispersive (adhesive) viscoelastic material,
coats the corneal endothelium more readily and tends to
remain in the eye intraoperatively.17,18 Therefore, it has
been suggested that Viscoat offers greater endothelial
protection during phacoemulsification.19 A difference
in acute corneal swelling has been observed between
Viscoat and Healon GV (sodium hyaluronate 1.4%)15
and Ocucoat and Healon.16 Ravalico et al.20 found a significant difference in change in CT between Viscoat and
hydroxypropyl methylcellulose 2%. Most investigators could not find any difference between viscoelastic
materials over long term.15,20–24 Corneal endothelial cell
loss has been reported to be 1.4% for hydroxypropylmethylellulose (Eyefill) and 0.3% for Viscoat25 after 3
months, similar to our results. Contradictory reports of
changes in endothelial cell counts with different viscoelastic materials have been published. Lane et al.26 got
similar results for endothelial cell loss in eyes receiving
Healon, Viscoat, and Ocucoat. However, Glasser and
coauthors19 observed that endothelial cell loss was less
in eyes who were treated with Viscoat and Ocucoat as
compared to Healon, which was confirmed by Monson et al.27 In contrast, Ravalico et al.20 found greater
endothelial permeability and a more active pump after
30 days with hydroxyl-propylmethlycellulose 2% than
with Viscoat. In our study, we observed no significant
differences in endothelial cell density between the two
groups. In contrast to the studies mentioned, our study
used a randomized “bilateral” study design with intraindividual comparison between eyes.
We observed no correlation in either group between corneal endothelial cell loss and CT in contrast
Table: 1
Low cost
Expensive
Exam
CT (µm)
CT (%)
P value
CT (µm)
CT (%)
P value
Preop
525+28.0
-
-
523+26.0
-
-
Postop
1 day
+9.5+11
+1.7
<.01
+10.3+11.3
+1.9
<.01
1 wk
+8.2+10.8
+1.3
<.01
+8+9.7
+1.1
<.01
1month
+4+6.9
+0.7
<.01
+2.2+8.1
+0.2
.22
3months
+1.3+4.8
+0.2
0.1
+0.002+4.2
+0.001
.65
41
Comparison of Effects on Corneal Endothelium of A Low Cost & Expensive
to previous studies.28 In studies of irrigating solutions
used during phacoemulsification, BSS Plus caused
significantly less corneal swelling on the first postoperative day than citrate–acetate bicarbonate solution29
or Ringer’s solution.30 A study of corneal endothelial
cell size preoperatively and 2 months after ECCE and
IOL implantation showed a non-statistically significant
trend in favor of BSS Plus over dextrose bicarbonate
lactated Ringer’s solution.31 Araie32 suggests that BSS
Plus and glutathione bicarbonate Ringer’s solution are
less toxic to the endothelial barrier function than a citrate–acetate bicarbonate solution.
Our study indicates that different combinations of
viscoelastic materials with Ringer’s solution or BSS Plus
do not cause significant differences in the acute change
in CT and only a slight change in the recovery of corneal
swelling resulting from a marginally higher change from
baseline to 3months postoperatively in the Ringer’s solution and Eyefill group. No difference in endothelial cell
counts between the two irrigating solutions was observed.
All our patients had a corneal cell density within the
normal range. In compromised corneal endothelium like
cornea guttata, Dispersive visco-elastics such as Viscoat
may still be the first-line agent. We have not compared
endothelial cell protection with these 2 combinations in
patients with compromised endothelial cell counts.
CONCLUSION
More expensive combination of viscoat and BSS plus
might be slightly more effective in helping the eye recover from corneal stress. The low-cost combination, Eyefill
and Ringer’s solution, was similar to the more expensive
combination with regard to acute corneal swelling and
changes in corneal endothelial cell count during smallincision cataract surgery with foldable IOL implantation
in patients with normal endothelial cell counts.
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Mishima S. Clinical investigations on the corneal endothelium.
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Assia EI, Apple DJ, Lim ES, et al. Removal of viscoelasticmaterials after experimental cataract surgery in vitro.J Cataract Refract
Surg 1992;18:3–6.
Poyer JF, Chan KY, Arshinoff SA. New method to measurethe
retention of viscoelastic agents on a rabbit cornealendothelial
cell line after irrigation and aspiration.J Cataract Refract Surg
1998;24:84–90.
Glasser DB, Osborn DC, Nordeen JF, Min Y-I. Endothelialprotection and viscoelastic retention duringphacoemulsification and
intraocular lens implantation.Arch Ophthalmol 1991;109:1438–40.
Ravalico G, Tognetto D, Palomba MA, et al. Cornealendothelial
function after extracapsular cataract extractionand phacoemulsification. J Cataract Refract Surg1997;23:1000–1005.
Henry JC, Olander K. Comparison of the effect of fourviscoelastic agents on early postoperative intraocularpressure. J Cataract
Refract Surg 1996;22:960–66.
Fry LL, Yee RW. Healon GV in extracapsular cataractextraction with intraocular lens implantation. J CataractRefract Surg
1993;19:409–12.
Davis EA, Lindstrom RL. Corneal thickness and visualacuity after phacoemulsification with 3 viscoelastic materials.J Cataract
Refract Surg 2000;26:1505–09.
Lehmann R, Brint S, Stewart R, et al. Clinical comparisonof
Provisc and Healon in cataract surgery. J CataractRefract Surg
1995;21:543–47.
Craig MT, Olson RJ, Mamalis N, Olson RJ. Air bubbleendothelial
damage during phacoemulsification in humaneye bank eyes: the
protective effects of Healon andViscoat. J Cataract Refract Surg
1990;16:597–602.
Lane SS, Naylor DW, Kullerstrand LJ, et al. Prospectivecomparison of the effects of Occucoat, Viscoat, and Healonon intraocular pressure and endothelial cell loss.J Cataract Refract Surg
1991;17:21–26.
Monson MC, Tamura M, Mamalis N, et al. Protectiveeffects of
Healon and Occucoat against air bubble endothelialdamage
during ultrasonic agitation of the anteriorchamber. J Cataract
Refract Surg 1991;17:613–16.
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of corneal thickness and endothelial cell loss;serial measurements after cataract surgery. Arch Ophthalmol1988;106:920–22.
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effects of intraocular irrigating solutions on the cornealendothelium in intraocular lens implantation. Br JOphthalmol
1991;75:476–79.
Joussen AM, Barth U, Ç ubuk H, Koch H-R. Effect ofirrigating
solution and irrigation temperature on the corneaand pupil during phacoemulsification. J Cataract RefractSurg 2000;26:392–97.
Kramer KK, Thomassen T, Evaul J. Intraocular irrigatingsolutions: a clinical study of BSS Plus and dextrose bicarbonatelactated Ringer’s solution. Ann Ophthalmol1991;23:101–05.
Araie M. Barrier function of corneal endothelium and theintraocular irrigating solutions. Arch Ophthalmol 1986;104:435–38.
ORIGINAL ARTICLE
Afzal Qadir
Comparison of Astigmatism in two
Incision Sites in Manual Small Incision
Cataract Surgery
Afzal Qadir FCPS1, Irfanullah Shah MBBS2, Mahooz 3, Lal Mohammad4
Muhammad Kashif Kamran5
ABSTRACT
Objective: To determine the frequency of common complications after manual small incision cataract surgery.
Materials and Methods: Descriptive cross sectional study was conducted at the Khyber Institute of Ophthalmic Medical
Sciences (KIOMS), Hayatabad Medical Complex, Peshawar from 2nd April 2009 till 30 April 2010. All 106 patients were
included in this study. Corneal astigmatism was measured by Helm Holtz keratometer (Topcon OM-4) (k-values were taken
in diopter). All surgeries were performed under peribulbar anesthesia. An 8mm & Scleral incision was applied in both the
groups, 1.5 mm away from the limbus; incision was made centered at 12 o‘clock position in superior incision group and
centered at 3 o’clock or 9 o‘clock position in left and right eye respectively in temporal incision group. Corneal astigmatism was measured pre operatively then at 1st post-operative day, at 2 week then at 6 weeks in both groups using same
keratometer. Using preop and 6 weeks keratometric astigmatism readings, SIA was calculated by subtraction method. Axis
of astigmatism was determined by comparing K readings in diopters. K1 > K2 means with-the-rule astigmatism, K2 > K1
means against-the-rule astigmatism, while K1 = K2 means neutral astigmatism.
Results: One hundred and six eyes of 106 patients above 50 years of age were included in this study, 53 patients in superior incision group and 53 pts in temporal incision group. 41.5% patients were in age range 50-55yrs and 58 (54.7%) patients
entering the study were male. Keratometries were performed on all patients preoperatively at 1st post-op day, at 2 weeks and
at 6 weeks. Mean SIA at 6 weeks post-op was 0.367 ± 0.669 D in superior incision group and 0.225 ± 0.529 D in temporal
incision group, difference in both groups was statistically insignificant (p = 0.257). Both incision sites significantly changed
the axis of astigmatism at 6 weeks in relation to preop astigmatism (p = 0.005 for superior incision group) and (p = 0.021 for
temporal incision group). Mean Astigmatism in both the groups at 6 weeks was found to be similar in magnitude, 0.892 D in
superior incision group vs. 0.894 D in temporal incision group.
Conclusion: Both incisions resulted in same amount of mean astigmatism at 6 weeks and difference in mean SIA was
found to be statistically insignificant. Temporal incision had the trend of inducing with-the-rule astigmatism.
Key Words: Astigmatism; Surgically Induced Astigmatism; Manual Small Incision Cataract Surgery, Extra capsular cataract
extraction; Cataract visual-outcome; Keratometry
INTRODUCTION
Cataract is the main cause of avoidable blindness
worldwide, with the developing world harboring three
quarters of blindness. Despite the 10 to 12 million cataract operations performed globally, cataract blindness
is still thought to be increasing by 1–2 million/year.1 In
Pakistan current all-age blindness prevalence estimate
is 0.9% (95% CI, 0.8%–1.0%) according to Pakistan National Blindness and Visual Impairment Survey.2
The goal of cataract surgery is to restore the best
possible uncorrected visual acuity, and minimum postoperative astigmatism.3 Surgically induced astigmatism
(SIA) is still a common obstacle for achieving excellent
uncorrected visual acuity.4 SIA is related to the incision
length, incision location, incision architecture, and suRegistrar Ophthalmology Senior Registrar, Hayatabad Medical
Complex, Peshawar, 2Trainee Medical Officer, Hayatabad Medical
Complex Peshawar, 3Medical Officer LRBT Hospital, Mansehra
4
Associate Professor, Kohat, 5Trainee Medical Officer, Hayatabad
Medical Complex, Peshawar.
1
Correspondence: Dr Afzal Qadir, Registrar Ophthalmology Department,
Hayatabad Medical Complex Peshawar, Email:[email protected]
Cell No.0321-9128247, Fax No.091-9217189, Postal Address; House
No 40, Street 2, N/4, Phase 4, Hayatabad, Peshawar.
Received: Oct’2013 Accepted: Dec’2013
ture closure technique.5 Many authors have reported
that the opening in the clear temporal cornea causes
less SIA versus superior incision, and result in less SIA
due to the greater distance from corneal apex.4 Adopting temporal incision is not difficult for bimanual surgeon, and is best approached by surgeon due to limitation superiorly by orbital margin and it also obviates
need for bridal suture due to good exposure of surgical
site.6 In a study conducted in India, it was reported that
mean surgically induced astigmatism was high in superior incision group (1.36±1.03) than temporal group
(0.40±0.40).7
It is generally noticed that the incidence of postoperative astigmatism is more when cataract extraction is
done through the corneal incision and the more anterior the incision, the greater the induced astigmatism.8
Conventional extracapsular cataract surgery (ECCE),
Manual small incision cataract surgery (MSICS), and
phacoemulsification are the three popular forms of cataract surgery in Pakistan. In more affluent areas of the
world, phacoemulsification has become the preferred
and popular method of performing extracapsular cataract surgery. There are, however, many regions, possibly harbouring the major load of cataract blindness
in the world today, where phacoemulsification is not
43
cost effective. This is because of the density of cataracts
involved, the cost and maintenance demands of the
equipment.
Nowadays there is a growing trend in developing countries towards suturesless surgery especially
MSICS. Manual small incision cataract surgery is a
surgical technique where cataract is removed through
a small incision without the use of expensive consumables and equipment. This technique involves designing
three step sclerocorneal tunnel, capsulotomy, hydrodissection and nucleus extraction. Unfortunately limited data exists in our region regarding SIA caused by
site of incision in MSICS cataract surgery and to our
knowledge is almost nonexistent nationally. As MSICS
is an alternative technique to phacoemulsification in
developing countries so more insight is needed, therefore this study was designed to see the effect of incision
site on postoperative astigmatism in MSICS.
Descriptive cross sectional study was conducted
at the Khyber Institute of Ophthalmic Medical Sciences
(KIOMS), Hayatabad medical complex, Peshawar. The
study was conducted from 2nd April 2009 till 30 April
2010. 106 eyes of 106 patients, 53 in each group Simple random sampling was used to assign patients to the
treatment groups.
Inclusion criteria: Primary age related cataract in
patients 50 yrs or above. Cataract was diagnosed on slit
lamp examination by presence of lens opacity which
was dense enough to visually impair the patient compromising his daily living activities and which could
not be corrected by retinoscopy. Preoperative keratometric astigmatism of 1.5D or less. Exclusion criteria
eyes with corneal opacities, anterior synechiae, pterygium, corneal degenerations or dystrophies were excluded from our study on slit lamp examination. Eyes with
history of any previous surgery or with complications
during surgery like (vitreous loss or iris prolapse) were
excluded. Cases in which suture had to be applied to
secure the wound integrity or in which combined surgery was performed like trabeculectomy together with
cataract extraction were also excluded.
Patients were selected through out-patient department (OPD) after taking informed written consent.
Personal bio data was taken on predesigned proforma.
Corneal astigmatism was measured by Helm Holtz
keratometer (Topcon OM-4) (k values were taken in diopter). First patient was randomly allocated to a group
by lottery method and subsequent patients were alternatively assigned to interventional groups by systematic sampling. Patients were divided into two groups;
Superior incision group and temporal incision group.
All the patients were operated by a single experienced surgeon using manual small incision cataract sur44
gery technique. Incision site was determined according
to group being operated. All surgeries were performed
under peribulbar anaesthesia. A 8 mm scleral incision
was applied in both the groups, 1.5 mm away from the
limbus. Incision was made centered at 12 o‘clock position in superior incision group and centered at 3 o’clock
or 9 o‘clock position in left and right eye respectively
in temporal incision group. Corneal astigmatism was
measured pre operatively then at 1st post-operative
day, at 2 weeks then at 6 weeks in both groups using
same keratometer by myself.
RESULTS
One hundred and six eyes of 106 patients above 50
years of age diagnosed as having age related cataract
and fulfilling the inclusion criteria were included in this
study. Fifty three eyes (100%) in superior incision group
and 53 eyes (100%) in temporal incision group completed the 6 weeks follow-up. This study was conducted at
KIOMS Hayatabad Medical Complex, Peshawar from
2nd April 2009 till 30 April 2010. The minimum age at
which the patient presented was 50 years while the
oldest patient was 80 years of age. 41.5% patients were
in age range 50-55yrs in superior incision group while
32.1% were in age range 50-55yrs in temporal incision
group. Detailed age distribution is shown in table I & II.
Fifty eight patients (54.7%) entering the study were
male and 48 patients (45.3%) were female. The group
wise gender distribution is shown in figure 1. Keratometries were performed on all eyes preoperatively at 1st
postop day, at 2 weeks and at 6 weeks. Mean preoperative astigmatism was 0.524 ± 0.361 D in superior incision group. Type of preop astigmatism was with the
rule in 45.3% eyes, against the rule in 47.2% eyes and
neutral astigmatism in 7.5% eyes in superior incision
group preoperatively shown in table III. Mean preoperative astigmatism was 0.670 ± 0.501 D for patients in
temporal incision group. Type of preoperative astigmatism was with the rule in 37.7% eyes, against the rule in
50.9% eyes and 11.3% had neutral astigmatism in temporal incision group shown in table IV. Mean postoperative astigmatism was 0.709 ± 0.463 D, 0.839 ± 0.585
D, and 0.892 ± 0.645 D at 1st postoperative day, 2 weeks
and 6 weeks postoperatively respectively in superior
incision group shown in table V. Mean postoperative
astigmatism was 0.829 ± 0.671 D, 0.911 ± 0.620 D, and
0.894 ± 0.538 D at 1st postoperative day, 2 weeks and 6
weeks respectively in temporal incision group shown
in table VI. It can be seen that mean postop astigmatism
was higher in temporal incision group at 1st postop day
and 2 weeks but it was almost equal in both groups at 6
weeks.
Mean SIA at 6 weeks postop was 0.367 ± 0.669 D in
superior incision group and 0.225 ± 0.529 D in temporal
incision group as shown in figure 2, this difference in
both groups was statistically insignificant (p = 0.257).
Paired t test was applied on preop astigmatism and
postop astigmatism at 6 weeks in both superior and
temporal incision groups.
In superior incision group, site of superior incision
was insignificantly affecting the amount of postop astigmatism at 6 weeks when compared with preop astigmatism (p value 0.139), while in temporal incision group,
site of temporal incision showed a significant change
in the amount of postop astigmatism at 6 weeks when
compared with preop astigmatism (p value <0.001) as
shown in table VII & VIII. When T test was applied to
pre and postop astigmatism in both the groups, no significant difference was seen (p-value 0.089 and .990 for
pre and postop astigmatism respectively) table IX.
Regarding type of postop astigmatism in terms
of axis, in superior incision group, 7 eyes (13.2%) had
with-the-rule astigmatism, 43 eyes (81.1%) had againstthe-rule astigmatism and 3 eyes (5.7%) had neutral
astigmatism. In temporal incision group, 46 eyes
(86.8%) had postop with-the-rule astigmatism, 7 eyes
(13.2%) had against-the-rule astigmatism and none of
the eyes in this group had neutral astigmatism.
Cross tabulation was performed among two variables
i.e.; type of preop astigmatism and type of postop astigmatism to determine the significance of incision type
on change in type of astigmatism in terms of axis, chisquare test was applied on these categorical variables
and a p value less than 0.05 was taken as significant.
Results showed that in superior incision group,
out of 24 eyes who had preop with-the-rule astigmatism, 7 eyes (29.1%) retained postop with-the-rule astigmatism, 14 eyes (58.3%) developed an against-the-rule
astigmatism, and 3 eyes (12.5%) developed neutral
astigmatism. All the 25 eyes (100%) who had preop
against-the-rule astigmatism retained against-the-rule
astigmatism postoperatively. Four eyes (100%) that had
a preop neutral astigmatism developed against-therule astigmatism postoperatively details shown in table
X. Chi-square test yielded a strong correlation among
these variables when superior incision was applied (p =
0.005)
In temporal incision group, 20 eyes (100%) retained with-the-rule astigmatism postoperatively, 20
eyes (74%) that had preop against-the-rule astigmatism
developed with-the-rule astigmatism postoperatively,
and 6 eyes (100%) that had preop neutral astigmatism
developed with-the-rule astigmatism postoperatively
details shown in table XI. Chi-square test yielded a
strong correlation among these variables when temporal incision was applied (p = 0.021). When Chi-square
test was applied to type of astigmatism in both the
groups, 81.1% eyes showed against the rule shift in superior incision group while 86.8% eyes showed with
the rule shift in temporal incision group. This change in
type of astigmatism was found to be statistically significant (p=0.000).
Table I: Age distribution in superior
incision group (n = 53)
Age Group (Years)
Number of eyes n (%)
50-55
22 (41.5)
56-60
8 (15.1)
61-65
7 (13.2)
66-70
6 (11.3)
71-75
7 (13.2)
>75
3 (5.7)
n = Number, > = More than, % = Percentage
Table II: Age distribution in temporal incision group (n = 53)
Age Group (Years)
Number of eyes n (%)
50-55
17 (32.1)
56-60
10 (18.9)
61-65
5 (9.4)
66-70
12 (22.6)
71-75
6 (11.3)
>75
3 (5.7)
n = Number, > = More than, % = Percentage
Figure1: Gender distribution
Table III: Type of preoperative astigmatism
in superior incision group. (n = 53)
Type of astigmatism
Frequency
Percent
with the rule
24
45.3
against the rule
25
47.2
no astigmatism
4
7.5
Total
53
100.0
Table IV: Types of preoperative astigmatism
in temporal incision groups. (n=53)
Type of astigmatism
Frequency
Percent
with the rule
20
37.7
against the rule
27
50.9
no astigmatism
6
11.3
Total
53
100.0
45
Table V: T test (pre and post op astigmatism in both the groups)
Superior Incision Group
Outcome Variable
Temporal Incision Group
P-value
n
Mean
Std.Deviation
n
Mean
Std.Deviation
Preop astigmatism
53
.5240
.3610
53
.6700
.5014
.089
Post Op(at 6 Weeks)
53
.8927
.6456
53
.8942
.5390
.990
Preop = Preoperative, Postop = Postoperative, Std = Standard, n = Number
Figure No. 2: Mean Surgically Induced
Astigmatism (SIA) at 6 weeks
TABLE- VI: Chi-square test (type of
postop astigmatism in both the groups)
Superior
Incision Group
Temporal
Incision Group
With the rule
7
13.2%
46
86.8%
Against the Rule
43
81.1%
Neutral astigmatism
3
5.7%
7
13.2%
0
0.0%
Type of astigmatism
Total
53
100.0%
53
100.0%
Postop = postoperative
DISCUSSION
Globally, treatment of choice for visually disabling
cataract is surgical intervention. Extracapsular cataract
extraction (ECCE) through a conventional large limbal or corneal incision and through a small incision
are the two main surgical options available for surgical intervention required in the management of age related cataract in the developing countries. Advocates of
phacoemulsification and MSICS cataract surgery report
less postsurgical astigmatism along with earlier stabilization of refraction, visual acuity and early spectacle
correction.9 MSICS technique was introduced by Ruit et
al in 2000, and since then, this technique has grown in
popularity in developing countries.10 The basic aim of
this study was to compare the surgically induced astigmatism at two incision sites in manual small incision
cataract surgery.
Cataract surgery has transformed into a refractive
surgical procedure. Incision location in cataract surgery
46
can affect the corneal astigmatism and ultimate visual
outcome. In clear corneal surgery, placement of the
incision on steep axis can help to reduce astigmatism
within the meridian.11,12 In a keratorefractive surgery it
was seen that astigmatism as low as 0.75 D may leave
a patient symptomatic with visual blur, ghosting and
halos.13
In a study conducted on 1500 patients mean surgically induced astigmatism in MSICS at 6 weeks postop
was found to be 0.3 D,14 another study showed a SIA of
0.69 D15 but these studies did not compare SIA at different incision sites. In our study mean SIA at 6 weeks
in superior incision group was 0.367 ± 0.669 D which
is comparable to earlier studies. In temporal incision
group mean SIA at 6 weeks was 0.225 ±0.529 D, it can be
seen here that temporal incision induced less mean SIA
than superior incision but this difference was statistically insignificant (p value 0.257). A study conducted in
India had found temporal incision to induce less SIA as
compared with superior incision for MSICS, the mean
SIA was 1.28 D for superior incision and 0.37 D for temporal incision group. The authors believed that temporal incisions were the farthest from the visual axis and
gravity together with eyelid blink would create a drag
on the superior incisions.7
In our study, SIA was calculated by subtraction
method, it is seen that superior incision group resulted
in a higher SIA at 6 weeks. Exact cause is undetermined
but it is possible that less mean preop astigmatism resulted in a higher SIA in this group. When only mean
astigmatism present at 6 weeks was compared both
groups had equal amount of astigmatism (0.892 D in
superior incision group vs. 0.894 D in temporal incision
group). In 2007, Ruit et al compared MSICS with Phacoemulsification, in their series all MSICS surgeries were
performed by a temporal incision; mean astigmatism
was 0.88 D which is comparable to mean astigmatism
in temporal group of our study at 6 weeks.10 However
another study showed higher mean postop astigmatism in superior incision than in temporal incision 1.45
D versus 0.43 D respectively.7
In superior incision group out of 24 eyes who had
preop with-the-rule astigmatism, 7 eyes (29.1%) retained with-the-rule astigmatism they had preop astigOphthalmology Update Vol. 12. No. 1, January-March 2014
matism equal to or more than 0.75 D. Fourteen eyes
(58.3%) developed against-the-rule astigmatism along
with 3 eyes (12.5%) with neutral astigmatism postoperatively. These 17 eyes were having preop astigmatism
0.5 D or less. All the 25 eyes having preop against-therule astigmatism, retained against-the-rule astigmatism
postoperatively. Astigmatism shift was seen in those
patients in superior incision group with a preop astigmatism of 0.5 D or less. Tejedor and Murube, in a study
of patients having with-the-rule astigmatism, recommended at least 1.5 diopters of corneal astigmatism in a
superior incision in order to avoid a change in axis.16
In temporal incision group 20 eyes (100%) with
preop with-the-rule astigmatism, retained with-therule astigmatism postoperatively. While 20 eyes (74%)
having preop against-the-rule astigmatism along with
6 eyes (100%) having neutral preop astigmatism had a
postop axis shift to with-the-rule astigmatism. Seventy
three percent of patients with axis shift were having
preop astigmatism of 0.75 D or less. In one of the study,
Seventy five percent of cases who had against-the-rule
astigmatism and who underwent surgery through a
temporal incision for an astigmatism axis shift of 90 degrees were found to have a preoperative astigmatism
magnitude of less than 0.75 diopters.16 These results are
comparable to our study and chi-square test showed a
significant relationship between incision site and axis
shift in astigmatism (P value 0.021). When both the
groups were compared using chi-square test, a significant difference in type of postop astigmatism was noted with 81.1% of eyes in superior incision group having
against-the-rule shift while 86.8% of eyes in temporal
incision group having with-the-rule shift (p value 0.000)
Studies have shown that if the magnitude of astigmatism is significantly reduced, the patient’s visual
acuity could improve, even if axis shift occurs. However, it is generally accepted that reducing astigmatism
without significantly changing the axis is well tolerated
and should be the goal.17, 18
In our study 50% patients in temporal incision
group had against the rule astigmatism preoperatively
which reduced to 13.2% postoperatively. Actual impact
of this change could not be assessed because visual
acuity assessment was not performed in this study.
In a study conducted by Huang and Tseng from Taiwan, surgically induced astigmatism was compared
between two groups of patients in which sutureless
temporal clear corneal and sutureless temporal scleral
frown incisions were given. It was concluded that scleral frown incision resulted in a much lesser amount of
surgically-induced corneal astigmatism as compared to
the clear corneal incision, which caused greater WTR
astigmatism. This study also proved that corneal stability was achieved one week after scleral frown incisions
as compared to clear corneal incisions in which case,
stabilization of refraction delayed to 1 – 3 months postoperatively.19
In our study, the magnitude of the preoperative
astigmatism did not affect the magnitude of the postop
astigmatism at 6 weeks. Surgically induced astigmatism was higher in superior incision group, one possible
cause of which can be less mean preop astigmatism in
this group. Further research with astigmatism matched
groups is required to provide a statistically significant
association. We also analyzed that both incision sites
had a statistically significant effect on postoperative
axis shift.
Although the results of this study are significant
and were comparable with most of the studies conducted world-wide, these results cannot be extrapolated to
whole population due to smaller sample size and short
follow-up, therefore we recommend long-term randomized studies on a larger and astigmatism matched
sample size with longer follow-up.
CONCLUSION
Both superior and temporal incisions in MSICS
resulted in almost same amount of mean astigmatism
at 6 weeks (final follow-up) and mean SIA was found
to be insignificantly different in both groups. Temporal
incision group had the advantage of achieving withthe-rule astigmatism. It was seen in this study that applying superior incision on patients with preexisting
with-the-rule corneal astigmatism could lead to axis
shift to against-the-rule astigmatism. So selection of
site of incision should be guided by amount and type of
preoperative astigmatism.
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2006;83(5):311-5.
Hennig A, Kumar J, Yorston D, Foster A. Sutureless cataract
surgery with nucleus extraction: outcome of a prospective
study in Nepal. Br J Ophthalmol 2003;87:266-70.
Dermatologic Signs of Multiple Myeloma
W. Harris Green, M.D., and Robert Hill Schosser, M.D.
East Carolina University, Greenville, NC
An 87-year-old woman presented for evaluation of progressive, non-pruritic, waxy papules and atraumatic
ecchymoses in a periorbital (“raccoon eyes,” Panel A) and perioral distribution. She was otherwise asymptomatic. Examination of a biopsy specimen of a representative lesion revealed a nodular deposition of a hyalinized, amorphous material in the superficial dermis. Positive Congo red staining and apple-green birefringence
under polarized light (Panel B) confirmed the presence of amyloid fibrils. Serum and urine electrophoresis
with immunofixation revealed monoclonal kappa light-chain proteins. Levels of hemoglobin and serum calcium were unremarkable, as were the results of a radiographic skeletal survey. Renal function was stable,
with only a mildly reduced glomerular filtration rate. Biopsy samples of bone marrow revealed that 22% of
marrow cellularity consisted of plasma cells that stained predominantly for kappa light-chain proteins. A diagnosis of kappa light-chain multiple myeloma with systemic amyloidosis was made. After initial treatment
with melphalan and prednisone, the patient’s condition stabilized, and at 2 years of follow-up she continued
treatment with bortezomib alone. (Courtesy: NEJM-UK)
48
Mumtaz Alam
Comparison of Recurrencerate &
Complications after Pterygium Excision
with Bare Sclera Technique & Amniotic
Membrane Graft
ORIGINAL ARTICLE
Mumtaz Alam FCPS1, Akbar Khan MBBS2, Sher Akbar Khan MBBS3
ABSTRACT
Objective: To compare the recurrence rate and complications after pterygium excision with bare sclera technique and
amniotic membrane graft.
Design: It was a prospective, randomized control trial.
Place and Duration of Study: The study was conducted at the Department of Ophthalmology Khyber Teaching Hospital
Peshawar, from January 2010 to December 2011.
Patients and Methods: Total of 100 patients were included in the study. Pre-operatively detailed history was taken from the
patients and complete ocular examination was done. 50 patients were operated with bare sclera technique and 50 with amniotic membrane grafting. Post-operatively patients were followed up at 1 week, 1 month, 3 months and 6 months. At each
visit patients were examined for any complications or recurrence.
Results: Out of the 100 patients, 73 were male and 27 were female. Mean age of the patients was 46.5 years. In the bare
sclera group 17 patients (34%) had recurrence and in the amniotic membrane group 4 patients (8%) had recurrence (P
value = 0.0026). With the bare sclera technique 15 patients had complications while in the amniotic membrane group 6
patients had complications.
Conclusion: Pterygium excision with bare sclera technique has high recurrence rate. Excision with amniotic membrane
grafting decreases the recurrence rate and is associated with lower incidence of complications.
Key Words: Pterygium, Bare sclera technique, Amniotic membrane transplantation ocular, pregnancy, intraocular pressure, CSR.
INTRODUCTION
Pterygium is a fibrovascular lesion of the ocular
surface. It is triangular in shape and has a head, body
and tail. It is located in the inter-palpebral region, along
the horizontal axis of cornea, usually nasally but occasionally also temporally or both nasally and temporally.
Histologically there is bowman’s membrane damage,
fibrovascular growth as well as elastotic degeneration
of various connective tissue elements.1
There is a strong correlation between pterygium
development and sun exposure. Therefore it is assumed
that solar radiation may have a pathogenetic role.2,3 Ultraviolet radiations, particularly ultraviolet radiation-A
(UVR-A) and ultraviolet radiation-B (UVR-B) may play
a role.4 They induce ocular surface changes especially
affecting the limbal stem cells and cause alterations in
the expression of tumor suppressor genes, proto-oncogene mutations, induction of matrix metalloproteinases (MMPs) as well as alterations in the expression of
various growth factors.1 Pterygium is characterized by
chronic ocular surface inflammation, tearing, astigmatism and blurred vision due to involvement of visual
Senior Registrar Ophthalmology Department, Peshawar Medical
College, Kuwait Teaching Hospital, Peshawar. 2Medical Officer,
Khyber Eye Foundation, Peshawar. 3Medical Officer, LRBT Hospital
Akora Khattak, KPK
1
Correspondence: Dr. Mumtaz Alam, Senior Registrar Ophthalmology
Department, Kuwait Teaching Hospital, Peshawar, House No
310, Street No 5, Sector E-4, Phase 7, Hayatabad, Peshawar
Phone No: 0334-9094241,E-mail: [email protected]
Accepted: Nov’2013
axis.5 The natural history of the condition is variable,
sometimes it can be static and may be associated with
corneal linear iron deposition (Stocker’s line) along
pterygium head.6 However, most of the pterygia exhibit
progressive growth, especially those affecting younger
individuals, and often require surgical excision.7,8
Early pterygium removal technique was the ‘bare
sclera’ technique.9 However, up to 50% of recurrence
rate following a successful removal have been reported.7 A number of modifications have been made in the
surgical technique in order to reduce the recurrence
rate. These included conjunctival flap transposition,10,11
free conjunctival graft,12,13 or the use of preserved amniotic membrane.14 Other ways of reducing the risk of recurrence include the use of beta irradiation,15,16 antimetabolites e.g. mitomycin-C (MMC),7,12 alkylating agent
Thiotepa7 and 5-fluorouracil (5-FU).7,17 Some studies
have also evaluated the use of anti-vascular endothelial
growth factor (anti-VEGF) antibodies such as Bevacizumab in pterygium management.18,19
The purpose of our study was to compare the recurrence rate and complications after pterygium excision with bare sclera technique and amniotic membrane graft.
METHODS
It was a prospective, randomized control trial.
The study was conducted over a period of two years
from January 2010 to December 2011, in Department of
Ophthalmology, Khyber Teaching Hospital Peshawar.
Diagnosis of pterygium was done on slit lamp exami49
Comparison of Recurrencerate & Complications after Pterygium Excision
nation. A total of 100 eyes were included in the study
i.e. 50 for each group.
Inclusion criteria:
1. Unilateral or bilateral nasal or temporal pterygium
2. Both genders
3. All age groups
4. At least 2mm growth onto the cornea
Exclusion criteria:
1. Recurrent pterygium after surgical excision
2. Ocular surface disease
Written informed consent was taken from all
the patients. Detailed history was taken from the
patients. Questions were asked about the patient’s
chief complaints, occupation, living area, sun exposure,
duration and rapidity of growth and any ocular or
systemic co-morbidity. Complete ocular examination
was done. Patients were randomly allocated into the
two groups. 50 patients were operated with bare sclera
technique and 50 with amniotic membrane grafting.
All the surgeries were performed under operating
microscope, using topical plus subconjuctival
anesthesia, by the same surgeon. All patients were
followed up at 1 week, 1 month, 3 months and 6 months
post-operatively. At each follow up visit patients
were examined for any complications or recurrence.
Recurrence of pterygium was defined as a growth of
2mm or more over the cornea, after pterygium excision.
SPSS-11 was used for data analysis.
RESULTS
A total of 100 patients were included in the study
including 73 male and 27 female. Mean age of the patients was 46.5 years, with a range of 22-64 years. Age
distribution of patients is shown in Figure 1. Gender
distribution of patients in each group is shown in Figure 2. The patients were operated either by bare sclera
technique or with amniotic membrane graft i.e. 50 patients for each group. All patients were followed up
for 6 months. Recurrence of pterygium was noted in
21 out of 100 patients. The difference between the two
surgical techniques was statistically significant (P value
= 0.0026). In the bare sclera group 17 patients (34%)
and in the amniotic membrane group 4 patients (8%)
had recurrence (Table 1). A number of postoperative
complications were noted with bare sclera technique
including conjunctival granuloma in 6 patients, conjunctival cyst in 3 patients, symblepharon in 3 patients,
corneal thinning in 2 patients and scleral thinning in
1 patient. In the amniotic membrane group 1 patient
had corneal thinning and 5 patients had graft retraction
before 10 days. Thus pterygium excision with amniotic
membrane grafting had significantly lower complication rate as compared to bare sclera technique (P value
= 0.0479). All the surgical complications were properly
managed.
50
Figure 1: Age distribution of patients
Figure 2: Gender distribution of patients
Table 1: Recurrence of pterygium
Bare sclera
technique
Amniotic
membrane graft
Total
Male
11/34 (32.3%)
03/39 (7.69%)
14/73 (19.1%)
Female
06/16 (37.5%)
01/11 (9.1%)
07/17 (25.9%)
17/50
04/50
21/100
Total
DISCUSSION
Pterygium excision is considered as a simple surgical procedure, however it has a high recurrence rate
and recurrence is often more aggressive than the initial
lesion.20 The simplest technique for pterygium excision
is the bare sclera procedure which was described by
Ombrain.21
Bare sclera technique is an easy method but is
associated with a high recurrence rate. In one study22
the recurrence rate after this technique was 36.6%. In a
study conducted by Ashaye23 there was 40% recurrence
rate while Dash and Bapor24 observed 25% recurrence
rate. One study showed recurrence rate as high as 89%.7
In our study the recurrence rate was 34% which was
similar to some of the older studies. Thus recurrence
rate after pterygium excision with bare sclera technique
is very high. A number of techniques have been emOphthalmology Update Vol. 12. No. 1, January-March 2014
Comparison of Recurrencerate & Complications after Pterygium Excision
ployed to reduce the recurrence rate after pterygium
excision including amniotic membrane transplantation.
Amniotic membrane was first used in ophthalmology by De Roth for conjunctival surface reconstruction.25
The possible mechanisms by which it prevents pterygium recurrence include promotion of conjunctival epithelium, inhibition of inflammation by inhibiting chemokine
expression by fibroblasts26,27 and interleukin-1 expression
by epithelial cells, and inhibition of neovascularization
by inhibiting vascular endothelial cell growth.28
The recurrence rate after amniotic membrane
transplantation was initially reported to be 10.9% for
primary and 37.5% for recurrent pterygia.29 After modifying the surgical technique, these values were reduced
to 3% and 9.5% respectively,30 which is superior to that
of the bare sclera technique. In a study conducted by
Katbab et al, the recurrence rate following amniotic
membrane graft for primary pterygium excision was
2% over a 12-month follow-up period.31 In our study
the recurrence rate was 8%. The difference in recurrence rate between the two surgical techniques was statistically significant (P value = 0.0026).
Recurrence occurred in 14 out of the 73 male
(19.17%) and 7 out of 27 female (25.92%). The difference
in recurrence rate between male and female was not
statistically significant (P value = 0.5807). A number of
postoperative complications were noted with bare sclera
technique including conjunctival granuloma in 6 patients
(12%), conjunctival cyst in 3 patients (6%), symblepharon
in 3 patients (6%), corneal thinning in 2 patients (4%) and
scleral thinning in 1 patient (2%). In the amniotic membrane group 1 patient had corneal thinning (2%) and 5
patients (10%) had graft retraction before 10 days. Thus
pterygium excision with amniotic membrane grafting
has significantly lower complication rate as compared to
bare sclera technique (P value = 0.0479). All the complications in our patients were properly managed.
Amniotic membrane grafting is not routinely performed in pterygium excision surgery. Despite lack
of experience with amniotic membrane grafting, we
found lower rate of recurrence and complications with
this technique. Therefore pterygium excision with amniotic membrane grafting could be considered as a very
good alternative in the management of pterygium.
CONCLUSION
Pterygium excision is a common surgical procedure. Pterygium excision with bare sclera technique
has a very high recurrence rate. Excision with amniotic
membrane grafting is a simple and easy surgical technique, reduces the risk of recurrence and has a lower
incidence of post-operative complications.
REFERENCES:
1.
Detorakis ET, Spandidos DA. Pathogenetic mechanisms and treatment options for ophthalmic pterygium: Trends and perspectives
(Review). Int J Mol Med 2009;23:439-47.
2.
Hilgers J. Pterygium: its incidence, heredity and etiology. Am J OphOphthalmology Update Vol. 12. No. 1, January-March 2014
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thalmol 1960;50:635-44.
Coroneo MT. Pterygium as an early indicator of ultraviolet insolation: a hypothesis. Br J Ophthalmol 1993;77:734-9.
Taylor HR, West SK, Rosenthal FS, Munoz B, Newland HS and Emmett EA. Corneal changes associated with chronic UV irradiation.
Arch Ophthalmol 1989;107:1481-4.
Detorakis ET, Sourvinos G, Tsamparlakis J and Spandidos DA. Evaluation of loss of heterozygosity and microsatellite instability in human pterygium: clinical correlations. Br J Ophthalmol 1998;82:13248.
Hansen A and Norn M. Astigmatism and surface phenomena in
pterygium. Acta Ophthalmol 1980;58:174-81.
Hirst LW. The treatment of pterygium. Surv Ophthalmol
2003;48:145-80.
Díaz L, Villegas VM, Emanuelli A and Izquierdo NJ. Efficacy and
safety of intraoperative mitomycin C as adjunct therapy for pterygium surgery. Cornea 2008;27:1119-21.
De Ocampo G and Fojas MR. Studies on the bare sclera technique of
pterygium operation. Philipp J Surg 1960;15:327-32.
Tomas T. Sliding flap of conjunctival limbus to prevent recurrence
of pterygium. Refract Corneal Surg 1992;8:394-5.
Anduze AL. Conjunctival flaps for pterygium surgery. Ann Ophthalmol 2006;38:219-23.
Ang LP, Chua JL and Tan DT. Current concepts and techniques in
pterygium treatment. Curr Opin Ophthalmol 2007;18:308-13.
Basti S and Rao SK. Current status of limbal conjunctival autograft.
Curr Opin Ophthalmol 2000;11:224-32.
Memarzadeh F, Fahd AK, Shamie N and Chuck RS. Comparison of
de-epithelialized amniotic membrane transplantation and conjunctival autograft after primary pterygium excision. Eye 2008;22:107-12.
Rosenthal JW: Beta radiation therapy of pterygium. AMA Arch
Wilson B. Beta irradiation of pterygia. Trans Ophthalmol Soc Aust
1963;23:96-100.
Akarsu C, Taner P and Ergin A. 5-Fluorouracil as chemoadjuvant for
primary ptrygium surgery: preliminary report. Cornea 2003;22:5226.
Hosseini H, Nejabat M and Khalili MR. Bevacizumab (Avastin) as
a potential novel adjunct in the management of pterygia. Med Hypotheses 2007;69:925-7.
Bahar I, Kaiserman I, McAllum P, Rootman D and Slomovic A. Subconjunctival bevacizumab injection for corneal neovascularization
in recurrent pterygium. Curr Eye Res 2008;33:23-8.
Kanski JJ. Conjunctiva. In: Kanski JJ Clinical Ophthalmology. A systemic approach 6th ed. Butterworth Heinemann Elsevier 2007:215-48.
Ombrain A. The surgical treatment of pterygium. Br J Ophthalmol
1948;32:65.
Nazullah, Shah A , Ahmed M, Baseer A, Marwat SK, Saeed N. Recurrence rate of pterygiun: A comparison of bare sclera technique
and free conjunctival autograft. J Med Sci 2010;18(1):36-9.
Ashye AO. Pterygium in Ibadan West Afr J Med 1991;10:232-43.
Dash RG, Bopari MS. Pterygium, evaluation & management. Indian
J Ophthalmol 1986;34:7-10.
De Roth A. Plastic repair of conjunctival defects with fetal membranes. Arch Ophthalmol 1940;23:522-5.
Bultmann S, You L, Spandau U, Rohrschneider K, Volcker HE,
Kruse FE. Amniotic membrane down-regulates chemokine expression in human keratocytes. Invest Ophthalmol Vis Sci 1999;40:S578.
Tseng SCG, Li DG, Ma X. Suppression of transforming growth
factor-beta isoforms, TGF-B receptor type II, and myofibroblast differentiation in cultured human corneal and limbal fibroblast by amniotic membrane matrix. J Cell Physiol 1999;179:325-35.
Kobayashi A, Inana G, Meller D. Differential gene expression by
human cultured umbilical vein endothelial cells on amniotic membrane. Presented at the 4th Ocular Surface and Tear Conference; 14
May 1999, Miami, Florida, USA.
Prabhasawat P, Barton K, Burkett G. Comparison of conjunctival autograft, amniotic membrane grafts, and primary closure for pterygium excision. Ophthalmology 1997;104:974-85.
Solomon A, Pires RT, Tseng SCG. Amniotic membrane transplantation after extensive removal of primary and recurrent pterygia.
Ophthalmology 2001;108:449-60.
Katbab A, Ardekani HA, Khoshniyat H, Hosseini HJ. Amniotic
membrane transplantation for primary pterygium surgery. J Ophthalmic Vis Res 2008;3(1):23-7.
51
ORIGINAL ARTICLE
Myopia and its relation with
Central Corneal Thickness (CCT)
& Intraocular Pressure (IOP)
Imran Ahmad
Imran Ahmad FCPS1, Muhammad Rafiq FCPS2, Mubashir Rehman FCPS3
Jahanzeb Khan FCPS4, Zeeshan Tahir MBBS5
ABSTRACT
Objective: To determine the relationship of myopia with central corneal thickness (CCT) and intraocular pressure (IOP).
Study design: Prospective, descriptive observational study
Material and Methods: The study was conducted from November 2011 to October 2012. A total of 400 eyes of 200 myopic
patients were included in the study. Measurements of refractive status were detected by autorefractor and then confirmed
by retinoscopy and spherical equivalent, was calculated of astigmatic patients. Patients were divided into three groups
depending the amount of myopia as group I (-0.5 to -3.0D), group II (-3.25 to -6.0D) and group III (-6.25 or more). The IOP
was measured with Goldman applanation tomometer. CCT was measured with pachymeter.
Results: In 400 eyes 55.75% were male and 44.25% were females. The incidence of mild myopia was 74.25%, moderate
myopia was 20% and high myopia was 5.75%.The mean CCT and IOP in group I was (CCT=548.5+31.24, IOP=15.40+2.75),
groupII ( CCT=539.3+ 30.74, IOP= 15.63+ 2.72), group III (542.7+ 30.87, IOP=16.12+2.84). No significant relationship of
myopia was established with CCT (r=0.18, p>0.05) and IOP (r=0.03, p>0.05).
Conclusion: There is no significant relationship of mild, moderate or severe myopia with CCT and IOP.
INTRODUCTION
Myopia is one of the most frequent refractive errors in general population. Its prevalence ranges from
17-65% and varies according to age, gender and race.1,2
The complications of high myopia include macular degeneration, retinal detachment, glaucoma and cataract.
The aetiology of myopia is unknown but the cornea is
responsible for approximately two-third of optical refraction.2 The myopic eye has a steeper central corneal
curvature and is longer than normal emmetropic eye.3
If this is the result of general growth, then one might expect the cornea to have grown to be thicker than normal
and a correlation with body mass index (BMI) might
exist. It has been reported that thinner corneas results
in artificially lower intraocular pressure readings and
thicker corneas cause elevated IOP readings4. Central
corneal thickness of ocular hypertensive patients are
reported to be greater than normal controls while it is
much thinner in eyes with normal tension glaucoma.5
In eyes with thinner corneas there is an increased risk
of conversion from ocular hypertension to glaucoma.6
A direct relationship between the central corneal thickness and refractive error has been reported but the proMedical Officer, Khyber Teaching Hospital, Peshawar. 2 Senior
Registrar, Rehman Medical Institute, Peshawar. 3Medical Officer,
Lady Reading Hospital, Peshawar. 4Medical Officer, Khyber Teaching
Hospital, Peshawar 5Medical Officer, Lady Reading Hospital,
Peshawar
1
Correspondence: Dr. Imran Ahmad House No 40, Street No 2,
Sector H1, Phase 2, Hayatabad, Peshawar. Cell: 0333-9255244
0321-9255244 e-mail: [email protected]
Received: November 2013
52
Accepted: December 2013
cess by which myopia progresses does not influence
the central corneal thickness to a measurable degree.7,8
Over time it has been shown that myopic refractive errors are associated with thin central corneal thickness.
The prevalence of glaucoma is high in myopic eyes
and studies have shown that myopic eyes had a 1.6 to
3.3 times increased risk of glaucoma.9 The reason for
this is suggested to be that intraocular pressure is higher in myopic eyes than in normal and these eyes are
more susceptible to the effects of elevated intraocular
pressure.10 It has been also proposed that myopic eye
have abnormal connective tissues that could predispose
to glaucoma.11 For a given IOP in eyes with glaucoma,
optic nerve damage appear to be more pronounced in
highly myopic eyes with large optic disc than in nonmyopic eyes.12 This suggests a higher susceptibility
for glaucomatous optic nerve fiber loss in myopic eyes
compared with non-myopic eyes.13 In some studies a
significant relationship has been reported between intraocular pressure and refractive error whereas in other
studies no such correlation is established.14,15
The purpose of the study is to determine the relationship of myopia with intraocular pressure and central corneal thickness in our population. Establishing
these parameters are important because CCT affect IOP
and in decision making for glaucoma treatment. These
are also important for refractive surgery because CCT
and IOP may indicate whether a particular refractive
surgical procedure is to be applied or not.
METHODS
The study was carried out in Khyber Teaching
Hospital and Rehman Medical Instituate Peshawar
from November 2011 to October 2012. Patients with
known myopia or newly diagnosed myopia were included in the study. Those with emmetropia, corneal
or lenticular opacities, pseudophakic, aphakic, myopia less than 0.5D and astigmatism of more than 3D or
other ocular surface disease were excluded from the
study. All Patients were first refracted to determine
their refractive status. Measurements of refractive
status were taken with Cannon MR-3100 autorefractometer. Readings were then confirmed subjectively
using Heine retinoscope and the spherical equivalent
of the refractive error was obtained. Central corneal
thickness was assessed with pachymeter (Packot 2
Quantel Medical SR-2171) by placing the probe on
the anaesthetized cornea. Measured central corneal
thickness for the subject was taken as the average of
three different readings and recorded in micrometer.
The IOP was assessed with Haag-Streit slit-lamp biomicroscope mounted Goldman applanation tonometery and staining the eye with fluorescein strip after
anesthetizing cornea. Three consecutive readings are
taken and the average recorded as measured IOP in
mmHg.
Patients are categorized into 3 groups depending
upon the amount of myopia, in group I patients with
low myopia (-0.5D to -3D), in group II moderate myopia ( >-3D to -6D) and in group III patients with high
myopia ( >-6D) were included. The statistical tests used
in this study were t-test, Pearsons correlation coefficient and P value with a value less than or equal to 0.05
(5%) were considered statistically significant.
RESULTS
A total of 400 eyes of 200 myopic subjects were
enrolled in the study fulfilling the inclusion criteria.
There were 223 (55.75%) male and 177 (44.25%) female.
Age range was 10-65 years with a mean age of 26.37 +
9.60 years). The incidence of low myopia (Group I) was
297 (74.25%) with 172 (57.91%) male patients and 125
(42.08%) female patients. Patients with moderate myo-
pia (Group II) were 80 (20%) with 42 (52.5%) male and
38 (47.5%) female patients. The incidence of high myopia (Group III) was 23(5.75%) with 9 (39.13%) male and
14 (60.87%) female patients. Patients with low myopia
have a mean IOP of 15.40+ 2.75, that of moderate myopia has 15.63 + 2.72 and patients with high myopia have
a mean IOP of 16.12 + 2.84. The mean central corneal
thickness in group I was 548.5 + 31.24 micrometer, in
group II was 539.3+ 30.74 micrometer and in group III
was 542.7+ 28.37 micrometer (Table 1).
DISCUSSION:
Numerous studies have been carried out showing
the relationship of myopia with central corneal thickness and intraocular pressure with conflicting results.
In a study done by VonBahr reported myopic corneas
to be slightly thinner than normal,16 whereas in another study done by Nomura H and collegeus stated that
moderate to high myope corneas are thicker than hypermetropes or emmetropes.17
Goldman applanation tonometery is widely accepted as international gold standard for intraocular
pressure measurement and is the most commonly used
method.18 Intraocular pressure with Goldman tomometer varies with thickness of the cornea, the thicker the
cornea, the higher the intraocular pressure.19 Hoffman
Table 1: Mean CCT and IOP in mild, moderate and severe myopia
Myopia Type
Group I (Mild Myopia)
Group II (Moderate Myopia)
Group III (High Myopia)
Number of patients
Mean Myopia
Mean CCT
Mean IOP
297 (74.25%)
-1.25 D
548.5 + 31.24
15.40+ 2.75
539.3+ 30.74
15.63+ 2.72
542.7+ 30.87
16.12+2.84
80 (20%)
23 (5.75%)
-
3.75D
-7.50D
Table 2: Gender wise distribution of mean IOP and CCT
Mean CCT
Mean IOP
Gender
Group I
Group II
Group III
Group I
Group II
Group III
Male
549.4+33.21
544.6+29.62
543.7+28.64
15.4+2.17
16.5+2.71
16.4+3.08
Female
545.5+31.40
543.3+29.37
541.5+27.74
14.6+2.14
15.3+2.56
16.5+2.88
53
et al reported a normal range of corneal thickness to
be 530-555 micrometer.20 The inter-patient variation in
CCT could be a source of error with Goldman tonometery, where thick corneas causes an overestimation
of IOP. Patients with normal tension glaucoma have
a high incidence of thinner corneas. Population based
studies have shown that there is an increased incidence
of glaucoma in myopic patients. In our study Pearson
correlation coefficient showed that there was no significant association between myopia and IOP (mean IOP
in Group I= 15.40 + 2.75, Group II= 15.63 + 2.72, Group
III= 16.12 + 2.84 mmHg) with (r=0.03, p>0.05). These
finding in our study was consistent with study of Lee
et al and another study done by Valiki and colleagues
which showed no significant association between refractive error and IOP.21,22 Our study showed a slight
relationship between different groups of myopia and
central corneal thickness (mean CCT in Group I=548.5
+ 31.24, Group II=539.3 + 30.74, Group III=542.7 + 30.87
micrometer) with (r=0.18, p>0.05) but it was not clinically significant. Similar observation was also in study
of Prince and colleagues who claimed that CCT is not
significantly affected by refractive errors.23 In our study
it was also showed that there is no significant difference between the mean CCT of males (Group I=549.4 +
33.21, Group II=544.6 + 29.62, Group III=543.7 + 28.64
micrometers) and female (Group I=545.5 + 31.4, Group
II=543.3 + 29.37, Group III=541.5 + 27.74 micrometer)
in all three groups of myopia (t=1.03, p>0.05). Similarly
no significant difference was detected in mean IOP of
males (16.2+ 2.81) and females (15.5+ 2.73) in all myopia
groups (p>0.05). So neither CCT nor IOP was significantly affected by gender similar to the study of Lleo et
al who reported no significant difference in mean IOP
between males and females.24 In our study very mild
relationship was found between CCT and IOP (r=0.106,
p<0.005), but that was not clinically significant.
CONCLUSION
There is no significant relationship of mild, moderate
or severe myopia on central corneal thickness and intraocular pressure. Similarly Central corneal thickness
and intraocular pressure is not affected by gender.
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Nangia V, Jonas JB, Sinha A, Matin A, Kulkarni M. Refractive
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Goldschmidt E. The mystery of myopia. Acta Ophthalmol
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Sci.1997.38:311-20.
Doughty MJ, Laiquzzaman M, Muller A, Oblack E, Button NF.
Central corneal thickness in European (White) individuals,
especially children and the elderly and assessment of its possible
importance in clinical measures of intraocular pressure. Ophthal
Physiol Opt 2002.22:491-504.
Bayraktar S, Bayraktar Z. Central corneal thickness and
intraocular pressure relationship in eyes with and without
previous LASIK: Comparison of goldman applanation tonometer
with pneumotonometer. Eur J Ophthalmol 2005;15:81-8.
Ocular Hypertension Treatment Study Group. The ocular
hypertension treatment study. Arch Ophthalmol 2002;120:701-13.
Nemesure B, Wu SY, Hennis A et al. Corneal thickness and
intraocular pressure in the Barbados Eye Studies. Arch
Ophthalmol 2003;1211:240-4.
Lene P, Jesper H, Neils E. Central corneal thickness in high
myopia. Acta Ophthalmologica Scand 2005;83(5):539-541.
Wong TY, Klein BE, Klein R, Knudtson M, Lee KE. Refractive
errors, intraocular pressure and glaucoma in a white population.
Ophthalmology 2003.110:211-7.
Mitchell P, Hourihan F, Sandbach J, Wang JJ. The relationship
between glaucoma and myopia: the blue mountains eye study.
Ophthalmology 1999.106:2010-5.
Perkins ES, Phelps CD. Open angle glaucoma, ocular
hypertension and refraction. Arch Ophthalmol 1982;100(9):14647.
Daubs JG, Crick RP. Effect of refractive error on the risk of ocular
hypertension and open angle glaucoma. Trans Ophthalmol Soc
UK 1981;101(1):121-6.
Casson RJ, Gupta A, Newland HS. Risk factors for primary
open angle glaucoma in a Burmese population: the MeiktilaEye
Study. Clin Experiment Ophthalmol 2007;35(8):739-44.
Hidek N, Fujiko A, Noakina N, Hiroshi S, Yozo M. The
relationship between intraocular pressure and refractive errors
adjusting for age and central corneal thickness. Ophthal Physiol
Opt 2004;24(1):41-5.
Ahmad J, Memon MF. Central corneal thickness and its relation
with myopia. J Liaquat Uni Med Health Sci. 2008;7(1):4-6.
Nomura H, Ando F, Niino N, Shimokata H, Miyake Y. The
relationship between intraocular pressure and refractive error
adjusting for age and central corneal thickness. Ophthalmic and
Physiological Optics. 2004;24(1):41-5.
Kotecha A. Centralcorneal thickness and IOP: Novel
measurement methods. Instrument insight 2005:22-3.
Kaufmann C, Thiel MA, Seiler T. Pressure measurements after
Laser in situ keratomileusis: A comparison between Goldman
applanation tonometery and dynamic contour tonometery: SOG
Switzerland 2002.
Hoffmann EM, Grus FH, Pfeiffer N. Intraocular pressure and
ocular pulse amplitude using dynamic contour tonometery and
contact lens tonometery. BMC Ophthalmol 2004;4:4.
Valiki R, Choudhri SA, Tauber S, Shield MB. Effects of mild to
moderate myopic correction by laser assisted keratomileusis
on the intraocular pressure measurements with Goldman
applanation tonometery. Tono-pen and pneumotonometer.
Glaucoma 2001;11:493-6.
Lee AJ, Saw SM, Gazzard G, Cheng A, Tan DT. Intraocular
pressure association with refractive error and axial length in
children. Br J Ophthalmol 2004;88(1):5-7.
Price FW, Koller DL, Price MO. Central corneal pachymetry in
patients undergoing laser in situ keratomileusis. Ophthalmology
1999;106:2216-20.
Lleo A, Marcos A, Calafayud M, Alonso L, Rahhal SM. The
relationship between central corneal thickness and Goldman
applanation tonometery. Clin Exp Optom 2003;86(2):104-8.
ORIGINAL ARTICLE
Muhammad Rafiq
Comparison of Results of Pterygium
Excision Through Bare Sclera Technique
& Conjunctival Autograft
Muhammad Rafiq FCPS1, Imran Ahmed MBBS2, Akbar Khan MBBS3
Zaman Shah FCPS4, Prof. Naimat Ullah Kundi FCPS5
ABSTRACT
Objective: To study the results of primary pterygium excision through bare sclera technique and conjunctival autograft.
Study design: This was an analytical study.
Setting and Duration: This study was conducted at Eye A unit, Khyber Teaching Hospital, Peshawar from May,2007 to
April,2009.
Methodology: One hundred patients with primary pterygium were selected from Ophthalmology Deptt. OPD at Khyber
Teaching Hospital, Peshawar. Detailed history was taken. Complete ocular examination done and those fulfilling inclusion
criteria were included in the study. Anesthesia used was topical proparacaine 0.5% and local infiltration of 2% lignocaine.
In 50 patients, pterygium was excised through bare sclera technique while conjunctival autograft was transplanted in the
remaining. Patients were followed up till three months.
Results: In bare sclera group, recurrence rate was 70% (35 patients) while in conjunctival autograft group, it was 08% (04
patients).There was one case of conjunctival granuloma in bare sclera group.
Conclusion: Pterygium excision through simple bare sclera technique has significantly high recurrence rate as compared to
conjunctival autograft transplantation.
INTRODUCTION
Pterygium, with a prevalence rate ranging from
0.3 to 29%, is a common disorder in many parts of the
world. Chronic exposure to sunlight has been associated with pterygium formation. Epidemiological studies
have revealed increased pterygium prevalence within
a periequatorial ‘pterygium belt’ of latitudes of 37 deg
north and south of the equator.1,2
Pterygium is characterized by elastic degeneration of collagen and fibrovascular proliferation with an
overlying covering of epithelium. Histopathology of
abnormal collagen shows basophilia with hematoxylin
and eosin stain.3,4
Several techniques have been developed for treatment of pterygium which are;5
1. Simple bare sclera technique
2. Excision with adjunctive therapy like MMC
3. Conjunctival autografting
Pterygium recurrence has been significantly reduced from 30-80% with bare sclera technique6,7,8 to almost 5.3% (9) with conjunctival autograft. Conjunctival
autografting, described by Kenyon in 1985,9differs from
Senior Registrar, Eye Unit, Rehman Medical Institute, Peshawar,
Trainee Medical Officer, Eye Unit, Khyber Teaching Hospital,
Peshawar, 3Trainee Medical Officer, Eye Unit, Khyber Teaching
Hospital, Peshawar, 4Senior Registrar, Eye Unit, Khyber Teaching
Hospital, Peshawar, 5Professor, Eye Unit, Khyber Teaching Hospital
Peshawar.
1
2
Correspondence: Dr. Muhammad Rafiq: [email protected]
Cell: 03224882534 House: 67, Street No-3, Sector F-10, Phase-6
Hayatabad, Peshawar, KPK
Received November 2013
Accepted: December 2014
bare sclera resection in that a free conjunctival graft,
usually originated from superotemporal bulbar conjunctiva, is sutured over denuded sclera after pterygium resection.10,11
The corneal epithelial integrity is maintained by
the epithelial stem cells which are believed to be located in the basal cell layer of the peripheral cornea. These
stem cells undergo continuous turn over throughout
adult life.12,13,14
Hundred patients with primary pterygium were
selected from eye OPD at Khyber Teaching Hospital.
They were randomly distributed in two groups. In
group A, were included the patients who underwent
bare sclera resection. While in group B, patients were
operated with conjunctival autograft.
Detailed history was taken enquiring the patients
about their symptoms and duration, occupation, outdoor activity, exposure to sunlight glaucoma, diabetes mellitus and hypertension. They were thoroughly
examined measuring visual acuity, extraocular movements assessment, slit lamp examination of the pterygium and ocular surface, fundoscopy and IOP measurement.
Inclusion Criteria:
• Age between 21-60 years
• Both sexes
• Primary pterygium encroaching 2mm or more
over the cornea
• Pterygium causing decreased vision
• Pterygium with repeated episodes of congestion
and grittiness
55
Exclusion Criteria:
• Diabetes Mellitus
• Collagen Vascular Disease
• Ocular surface disease like dry eye syndrome
• Uncontrolled glaucoma
Those fulfilling inclusion criteria were operated
under microscope. Anesthesia used was topical
proparacaine hydrochloride 0.5% and subconjunctival
inj of lignocaine hydrochloride 2% in the pterygium
bed. Pterygium was peeled off its bed. Cornea was
scraped with number 15 bard parker blade. In group A,
sclera was left bare after pterygium resection. In group
B, an autograft was taken from the superotemporal
bulbar conjunctiva of the same eye and transplanted at
the denuded sclera in a way that the limbal side of the
graft was oriented towards the limbus of the previously
pterygium site. Conjunctiva was stitched with 10/0
nylon leaving the knot ends long so as not to cause
irritation.
Antibiotic-steroid combination was given 4 times
daily for one month postoperatively. patients were reexamined at postoperative day 1,14,30,60 and 90. Recurrence was defined as fibrovascular growth encroaching
over the cornea 1mm or more. Data were analysed using SPSS version 10.0.
RESULTS
Hundred patients were operated. Seventy five
(75%) patients were male while twenty five (25%) were
female. Thus male to female ratio was 3:1. (Figure)
FIGURE: Gender distribution
The patients’ age range was 21-60 years with mean
value of 40 years. Majority of the patients (40%) were in
the age range of 31-40 years. There was a vast majority
(85%) of outdoor workers with an exposure to ultraviolet radiation.
Recurrence was noted in 35 patients (70%) in
group A, while in group B, recurrence was observed
in 4 patients (08%).There was one case of conjunctival
granuloma noted in group A. No undesirable effect
was seen at the bare donor conjunctival site. And dur56
ing the follow up period, it was seen to be covered by
the growth of the adjacent tissue. (Table)
TABLE: Recurrence rate
Total patients
Recurrence
Percentage
Group A
50
35
70%
Group B
50
4
8%
DISCUSSION
Clinically, pterygium is a wing shaped fibrovascular growth arising from the bulbar conjunctiva onto
the cornea. It is composed of a body which overlies the
sclera and a head which conforms the leading edge.15
Pterygium has been treated using different surgical modalities. The unacceptably high rate of recurrence
has been the main problem for the surgeons.16 Recurrence rates following bare sclera resection range from
24% to 89%, following bare sclera resection with Mitomycine application between 3% to 37.5% and following
pterygium resection with conjunctival graft placement
between 2% and 39%.17-22 In this study, we compared
bare sclera resection with conjunctival autograft placement. Our study was comprised by 75% males. Male to
female ratio was 3:1. The same ratio was observed by
Baig in his study.23
Our patients were mostly outdoor workers who
were exposed to ultraviolet radiations and the dry,
dusty and hot weather. This was also noted by Rasool
in his study while comparing conjunctival autograft
with bare sclera resection.24
CONCLUSION
In our study, we found recurrence rate of 70% in
group A and 08% in group B. Fahmi et al reported a recurrence rate of 13.3% with conjunctival autograft.25 Lewallen presented the results of conjunctival autografting in his study. He documented lower recurrence rate
(21%) in conjunctival autograft cases compared with
bare sclera resection (37%).26 Allan et al was in support
of Lewallen documenting a recurrence rate of 14% in
conjunctival autograft cases.27 A positive relationship
was suggested between youth and pterygium recurrence, while advancing age has a protective effect. This
trend was also seen by Rasool.24
REFERENCES
1.
Moran DJ, Hollows FC. Pterygium and ultraviolet radiation: a
positive correlation. Br J Ophthalmol 1984;68:343-6.
2.
Taylor HR, West S, Munoz B, et al. The longterm effects of visible light on the eye. Arch Ophthalmol 1992;110:99-104.
3.
Akhtar MS. Degenerative changes in the conjunctiva in: Basic
Ophthalmology 1st ed Pakistan, combined printer.2002:127-9.
4.
Apple DJ, Raab MF. Ocular Pathology. 4th ed. St Louis: Mosby
year Book 2000.
5.
Tan DTH, Chee SP, DEAR KBG, Lim ASM. Effect of pterygium
morphology on pterygium recurrence in a controlled trial comparing conjunctival autografting with bare sclera excision. Archive of Ophthalmol. 1997;115(10):1235-40.
6.
Frutch-pery J, Charalambos SS, Isar M. Intraoperative applica-
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tion of topical mitomycine C for pterygium surgery. Ophthalmology 1996;103:674-77.
Lam DS, Wong AK, Fan DS, et al. Intraoperative mitomycine C
to prevent recurrence of pterygium after excision: A 30-month
follow up study. Ophthalmology 1998;105:901-4.
Gupta VP, Saxena T. Comparison of single drop mitomycine
C Regime with other mitomycine C regimes in pterygium surgery. Ind J Ophth 2003;51:59-65.
Rao SK, Lekha T, Mukesh BN, Sitalakshmi G, Padmanabhan
P. Conjunctival-Limbal autografts for primary and recurrent pterygia: Technique and results. Indian J Ophthalmol
1998;46:203-9.
Serrano F. Plastia conjunctival libre en la cirugia del pterigion.
Arch Soc Am Oftalm optom 1977;2:12-97.
Kenyon K, Wagoner MD, Hettinger ME. Conjunctival autograft transplantation and recurrent pterygium. Ophthalmology
1985;92:1461-70.
Archila EA, Aremas MC. Etiopathology of pinguecula and
pterygium cornea 1995;14:543-4.
Mackenzie FD, Hirst LW, Battistuta D, Green A. Risk analysis
in the development of pterygia. Ophthalmology 1992;99:105661.
Wong VA, Law FC. Use of mitomycine C with conjunctival autograft in pterygium surgery in Asia. Canadians Ophthalmology 1999;106(8):1512-15.
Insler MS, Caldwell DR, Leach DH. Pterygium. In: Brightbill
FS,ed. Corneal surgery: Theory, technique and tissue,2nd ed. St.
Louis: Mosby Year Book,1993:336-8.
Frau E, Labetoulle M, Lautier-Frau M, Hutchinson S, Offret H.
17.
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Corneo-conjunctival autograft transplantation for pterygium
surgery. Acta Ophthalmol Scand.2004;82(1):59-63.
Sebban A, Hirst LW. Treatment of pterygia in Queensland.
Aust NZ J Ophthalmol 1991;19:123-7.
Chen PP, Ariyasu RG, Kaza MD, et al. A randomized trial comparing mitomycine c and conjunctival autograft after excision
of primary pterygium. Am J Ophthalmol 1995;120:151-60.
Jaros PA, DeLuise VP. Pingueculae and pterygia. Surv Ophthalmol 1998;33:41-9.
Singh G, Wilson CS, Foster CS. Mitomycine eye drops as treatment for pterygium. Ophthalmology 1988;95:813-21.
Hayasaka S, Noda S, Yamamoto Y, et al. Postoperative instillation of low-dose mitomycine C in the treatment of primary
pterygium. Am J Ophthalmol 1988;106:715-8.
Mahar PS, Nwokora GE. Role of mitomycine C in pterygium
surgery.Br J Ophthalmol 1993;77:433-5.
Baig MSA, Khokhar AR, Ali MA, Khan MS, Ahmed I. Pakistan
Journal of Surgery 2008;24(3):173-6.
Rasool AU, Ahmad CN, Khan AA. Recurrence of pterygium in
patients having conjunctival autograft and bare sclera surgery.
Annals 2010;16(4):242-6.
Fahmi MS, Sayed J, Ali M. After removal of pterygium,role of
mitomycine C and conjunctival autograft. Ann Abbasi Shaheed
Hosp. Karachi Med. Dent. Coll.2005;10:757-61.
Lewallen S. A randomized trial of conjunctival autografting for
pterygium in the tropics. Ophthalmol 1989;96:1612-4.
Allan BD, Short P, Crawford GJ, Barrett GD and constable IJ.
Pterygium excision with conjunctival autografting: An effective and safe technique. Br J Ophthalmol 1993;77(11):698-701.
57
EXCERPTS FROM
ORIGINAL ARTICLE
Changes in Retinal Nerve Fiber Layer &
Optic Disc Algorithms by Optical Coherence Tomography
in Glaucomatous Arab Subjects
Dr. Ferial M Zeried MD., & Dr. Uchechukwu L Osuagwu MD.,
INTRODUCTION
Glaucoma is the second-leading cause of blindness worldwide, accounting for around 12.3% of total
blinding cases1 and estimated to affect about 66.8 million people.2Among the population aged 40 years and
above, the prevalence could increase from 2.65% in
2010 to 2.86% in 2020.3 In our region, glaucoma contributes to about 11% of total blinding causes, ranking
as the second-biggest cause of blindness after cataract
(49%),4,2,3 In one study, it was reported that 44.5% of the
glaucoma patients in the country had no prior knowledge of their condition, and 11.3% of them were bilaterally legally blind,5 and it is no doubt a worrying situation. The global burden of glaucoma is heavy, and it is
even heavier in Saudi Arabia because of the high rate of
consanguinity.1,4–6,7 Understanding the pattern and the
associated characteristics of glaucoma is an essential
and crucial step for early diagnosis and proper management of the disease.
Evaluation of the retinal nerve fiber layer (RNFL)
and optic disc are fundamental for diagnosing and
managing glaucoma. Evaluation of these areas is currently the standard procedure for detection of early
glaucomatous retinal damage, as well as monitoring
the progression of the disease.8 However, new imaging
techniques have been introduced for the early detection, management, and monitoring of glaucomatous
damage.9
Optical coherence tomography (OCT) is one of
the promising technologies capable of discriminating
between glaucomatous and healthy eyes using various
algorithms.8–15 Despite the recent introduction of spectral domain OCT, Stratus OCT 3000 is one of the new
generation of instruments with improved capabilities.
The number of measurements per scan was increased
up to 768 A-scans per image, and the axial resolution
Correspondence: Dr. Ferial M Zeried, Assistant Professor,
Department of Optometry & Vision Sciences, College of Applied
Medical Sciences, King Saud University, Riyadh, Kingdom of Saudi
Arabia E.Mail>[email protected]
Acknowledgement: The Editor of Ophthalmology Update feels highly
gratified to Dr. Ferial M Zeried, the principal author who has permitted
us to reprint the whole article to benefit our ophthalmic community
with wider readership through his E. mail dated: 19th Nov’2013
58
improved from 100 μ to 10 μ, in order to enhance the
ease of instrument use. In addition, the Stratus OCT
also incorporates 18 different protocols that are used
for image acquisition, and an algorithm to assess the
optic nerve head (ONH). It is also equipped with multiple RNFL and ONH asymmetry parameters that are
used for detection of glaucoma.
MATERIAL & METHODS
A total of 65 patients (36 glaucoma and 29 normal patients) aged 50.1 ± 7.7 years (range 40–67 years)
met the following criteria: age ≥40 years, visual acuity
≥20/40, spherical refractive error between −6 and +6
diopters (D), astigmatism ≤3 D, an open angle, goodquality OCT images, and reliable visual field indices
obtained from the Program 32 dynamic strategy (Octopus 101 automated perimeter). Normal eyes had
intraocular pressure (IOP) >8 mmHg but <18 mmHg
measured on at least three different days before the
time of OCT examination. Glaucoma patients had
Goldmann applanation tonometer IOP >21 mmHg on
at least three different occasions and a glaucomatous
visual field (Program 32 dynamic test result showing
a cluster of four or more contiguous points on the corrected comparison plot and a probability value of <5%
confirmed on at least one visual field).
Patients were excluded if they had other intraocular or neurologic diseases that affected the RNFL, optic disc, or visual field; secondary causes of increased
IOP; non-glaucomatous disc abnormalities; corneal
opacities; advanced cataract; or a history of ophthalmic
surgery. One eye of each patient was enrolled. If both
eyes met the inclusion criteria, one eye was randomly
selected.
Examination Procedure
All patients underwent a complete ophthalmic examination, including medical and family history, visual
acuity measurement, tonometry, slit-lamp examination
of the anterior and posterior segments, and the Program 32 dynamic strategy. The Stratus OCT was used
for ocular imaging in subjects after dilation with one
drop of tropicamide 1%. Cross-sectional images from
the macula, ONH, and peri-papillary regions were obtained in all patients on the same visit.
Changes in Retinal Nerve Fiber Layer & Optic Disc Algorithms by Optical Coherence Tomography
The RNFL thickness was obtained by the Stratus
OCT using a near infrared low-coherence diode laser
(840 nm) and a Michelson-type interferometer.16,17 Three
images consisting of 256 A-scans along a 3.4 mm diameter circular ring around the optic disc were acquired
over 1.92 seconds for each patient.
To ensure the good quality of RNFL images, a
minimum of five scans were taken and the best three
were chosen for this study.
RESULTS
The demographic data of all patients and the results of unpaired t-test comparison between-group
demographics have been represented in Table 1. The
mean ages of patients with glaucoma (51.9 ± 8.5 years),
and normal patients (47.7 ± 6.0 years) were not statistically significantly different (P = 0.12), thereby controlling any age-related effects on analysis. Average
spherical equivalent ± standard deviation (SD) refractive error was −0.3 ± 1.0 D for normal eyes, and −0.5
± 1.9 D for glaucomatous eyes (P = 0.57). The average
RNFL thickness was not statistically significantly associated with age of normal (R2 = 0.001, P = 0.86) and
glaucomatous (R2 =0.002,P = 0.79) patients. Also, the
mean RNFL thicknesses measured at the four quadrants were not statistically significantly associated with
age of both groups. The R2 values (P-values) for the
mean RNFL thicknesses at the four quadrants in normal patients were temporal 0.10 (P = 0.09), nasal 0.07
(P = 0.16), superior 0.03 (P = 0.39), and inferior 0.02 (P =
0.44). None of the optic nerve parameters (the rim area,
average nerve width at disc, disc diameter, cup diameter, rim length, VIRA, HIRW, disc area, cup area, C/D
area ratio, horizontal C/D ratio, and vertical C/D ratio)
was significantly associated with age of normal (R2 <
0.10, P > 0.05; for all) and glaucomatous (R2 < 0.14, P >
0.05; for all) patients.
Table 1: Demographic characteristics of the study
sample (65 patients [36 glaucoma and 29 normal patients])
Control
Glaucoma
P-Value
Right
15 (51.7%)
20(55.8%)
0.758
Left
14(48.3%)
16(44.4%)
47.7(±6.0)
51.9 (±8.5)
40-60
40-67
Total no of eyes
Age(y)
Mean (± standard deviation)
Range
0.116*
Sex
Male
14(48.3%)
20(55.6%)
Female
15(51.7%)
16(44.4%)
Mean Defect
Mean (± standard deviation)
1.2 (± 1.4)
-2.5 (±1.5)
0.738
<0.01-*
Intergroup Comparison of Fast Rnfl Algorithm:
The greatest percentage changes in RNFL thickness were observed at the inferior (39.5%) and superior
(39.3%) quadrants. A plot of RNFL thickness variation across the twelve clock hour sector in both groups
showed that the greatest percentage reductions in
RNFL thickness in the glaucomatous eyes in relation to
the normal eyes occurred at the 1 o’clock (43%) and 5
o’clock (40%) sectors.
Figure 1:Mean retinal nerve fiber layer (RNFL)
thickness measured at each clock hour sector in normal and
glaucomatous eyes, and the percentage change that occurred
in the glaucomatous eyes in relation to normal eyes.
Intergroup Comparison of Fast Optic Disc Algorithm
The disc area, cup area, and mean C/D ratio were
significantly (P < 0.01, for all) larger in glaucomatous
eyes than in normal eyes (Table 1). The corresponding
mean differences were 0.46 mm,2 1.51 mm,2 and 0.45
mm.2 In addition, the vertical and horizontal C/D ratios were also significantly greater in the glaucomatous
eyes than in the normal eyes by an average of 0.34 (P <
0.0001). However, the VIRA, HIRW, and rim area were
significantly (P < 0.001, for all) smaller in glaucomatous
eyes than in normal eyes. The corresponding mean differences were 0.25 mm,3 0.64 mm,2 and 1.04 mm.2 The
cup area and the VIRA showed the greatest percentage
changes in the glaucomatous eyes from normal eyes
(66.6% increase and 62.2% decrease, respectively)
Intragroup Comparison of Parameters
There were statistically significant differences in
mean RNFL measured at all quadrants in the control
and glaucomatous eyes. Greater differences in RNFL
thickness were observed when superior and inferior
quadrants were compared with the temporal quadrant
in the control eyes (57.9 μm and 56.8 μm; superior minus temporal, inferior minus temporal, respectively),
and in the glaucomatous eyes.
Greater differences in RNFL thickness were
observed when superior and inferior quadrants were
compared with the temporal quadrant in the control
eyes (57.9 μm and 56.8 μm; superior minus temporal,
59
inferior minus temporal, respectively, and in the
glaucomatous eyes.
Across the twelve 30o clock hours, the RNFL in
normal eyes was thickest at 6 o’clock hour sectors and
thinnest at 9 o’clock hour sectors. For the glaucoma eyes,
it was the thickest at the 6 o’clock hour sector with 3
o’clock and 9 o’clock hour sectors being the thinnest.
DISCUSSION
OCT has been widely used to characterize multiple pathologic conditions and collect morphological
information for clinical and surgical decision making.13 Studies have reported the usefulness of OCT in
diagnosing and managing glaucoma elsewhere in the
world but not in Saudi Arabia.10–15,18 RNFL thickness
was reported to decrease significantly with age,13,18–
20
with an estimated loss of approximately 5,000 axons
per year from birth to death reported in humans.21 Using OCT, Girkin et al19 also observed that age was associated with rim area, RNFL thickness, and inner retinal
thickness. On the contrary, and similar to an observational, cross-sectional study conducted on 119 eyes of
60 normal Indian subjects,22 the current study found
that age was not predictive of RNFL measurements.
In the current study, the average RNFL was thinner in glaucomatous eyes by about 36.7%. The percentage thinning of the RNFL was greater at 1 o’clock and
5 o’clock hour sectors, the inferior and superior quadrants. These results are consistent with those of previous studies8–10,12,22–25 in which the RNFL thinning in the
inferior quadrant had the best discriminating ability for
detection of glaucoma. Medeiros et al9 showed that the
RNFL thickness of the Stratus OCT performed better
than the ONH and macular parameters in discriminating eyes that progressed by visual fields and/or optic
disc stereo-photographs from eyes that did not. Nouri
Mahdavi et al11 found the superior quadrant RNFL
thickness at the 11 o’clock position to be the best parameter for detection of early glaucomatous change,
whereas Kanamori et al23 found the inferior quadrant
and global RNFL thickness to be the best discriminating parameter. Similarly, in the current study, it was
observed that the inferior quadrant and the 1 O’clock
hour sector thickness of the RNFL algorithm showed
the greatest changes in thickness in the early glaucomatous eyes. These changes in the inferior RNFL are
in agreement with the expected pattern of damage in
glaucomatous optic neuropathy.
Previous reports have found Stratus OCT fast optic disc algorithms to be reproducible,26–29 reasonably
accurate,30 and to perform well in discriminating eyes
with glaucomatous visual field loss from healthy eyes.
However, in one longitudinal study,9 the fast optic disc
parameters performed poorly in their ability to differentiate between progressing and non-progressing glaucomatous eyes. Anton et al13 and Zangwill et al31 also
60
found significant differences between normal eyes and
ocular hypertensive eyes in optic disc parameters. The
current study also observed significant differences in
the optic disc parameters in glaucomatous eyes in relation to normal eyes. The disc area, cup area, and mean
C/D ratio were significantly larger by 15.5%, 66.6%,
and 60.4%, respectively, whereas the VIRA, HIRW, and
rim area were significantly smaller by 62.2%, 37.0%,
and 59.0% in the glaucomatous eyes, in relation to normal eyes. The current study also showed that except for
the disc area, other ONH parameters performed well
in differentiating early glaucomatous eyes from normal
eyes. The vertical elongation of the optic disc observed
here is thought to be due to severance and depletion of
the superior and inferior arcuate fibers, which occurs in
early stages of glaucoma.32
The results presented here also showed that both
group eyes obeyed the ISNT rule (Inferior, Superior,
Nasal, Temporal) in a similar pattern in relation to
RNFL thickness. In both groups, significant differences
in quadrant RNFL thickness were observed, with the
thickest and thinnest RNFL quadrants being the inferior and temporal quadrants, respectively. It also confirms that the severance of the nerve fibers and excavation of the disc are unique features of glaucoma.32
The findings of the current study are limited to
patients with early glaucoma and, as such, cannot be
applied to ocular hypertensive patients and/or patients
with a more advanced glaucoma. Also, the ages of our
subjects were much younger than is generally anticipated for glaucoma. However, the study presents for
the first time the diagnostic importance of the device
in discriminating between glaucomatous damage and
normal subjects of Saudi Arabian origin. A future study
in the region should consider recruiting a larger number of subjects of a wider age range as well, in order
to investigate the discriminating ability of both algorithms and the effects of age of retinal measurements.
It is important to note that because the calculation
of the ONH parameters was estimated based on six linear scans cutting cross-sectionally over the optic disc,
disc areas lying between the scan lines were not subject
to the analysis. As a result, the sensitivity in detecting a
highly localized optic disc abnormality may be reduced
in the OCT. Second, with the current version of the
analysis software, it is not yet possible to get individual
clock hour ONH measurements. On the other hand,
comparing the performance of Stratus and its latest version (Cirrus OCT) revealed that the two devices have
similar diagnostic potentials in pre-perimetric glaucoma.33 The study33also noted that in a subset of patients a
total of 16 RNFL defects that were not seen in the RNFL
photography of the Stratus OCT were detected in the
Cirrus OCT deviation-from-normal maps. It was not
clear whether these defects were false-positive findings
or whether they represent true RNFL losses. Though the
true nature of these OCT defects may be confirmed by a
follow-up assessment, the performance of OCT in such
cases should be re-evaluated through a prospective longitudinal study. Thus, if a definite glaucomatous change
occurs in the case in which OCT had previously detected
an abnormality, OCT may predict the future development of glaucoma in these questionable cases.
CONCLUSION:
Both algorithms were capable of differentiating
early glaucomatous eyes from normal eyes, with the
best parameters being the RNFL algorithm in the inferior, superior, and 1 o’clock hour sector; the cup area;
and VIRA (optic disc algorithm). A combination of the
results from both algorithms of a patient will lead to a
better diagnostic precision. The use of this device or its
newer generation should be encouraged in glaucoma
clinics in Saudi Arabia.
REFERENCES
1. Resnikoff S, Pascolini D, Etya’ale D, et al. Global data on
visual impairment in the year 2002. Bull World Health Organ. 2004;82(11):844–851. 2. Quigley HA. Number of people with glaucoma worldwide. Br
J Ophthalmol.1996;80:389–393. 3. Quigley HA, Broman AT. The number of people with glaucoma
worldwide in 2010 and 2020. Br J Ophthalmol. 2006;90(3):262–267. 4. Tabbara KF, Ross-Degnan D. Blindness in Saudi Arabia. JAMA.1986;255(24):3378–3384. 5. Eid TM, El-Hawary I, El-Menawy W. Prevalence of glaucoma
types and legal blindness from glaucoma in Western region of
Saudi Arabia. Int Ophthalmol.2009;29(6):477–483. 6. Kong X, Chen Y, Chen X, Sun X. Influence of family history
as a risk factor on primary angle closure and primary open
angle glaucoma in a Chinese population.Ophthalmic Epidemiol. 2011;18(5):226–232. 7. Tabbara K. Blindness in the eastern Mediterranean countries. Br J Ophthalmol.2001;85(7):771–775. 8. Manassakorn A, Nouri-Mahdavi K, Caprioli J. Comparison of
retinal nerve fiber layer thickness and optic disk algorithms
with optical coherence tomography to detect glaucoma. Am J
Ophthalmol. 2006;141(1):105–115. 9. Medeiros FA, Zangwill LM, Alencar LM, et al. Detection of
glaucoma progression with Stratus OCT retinal nerve fiber layer, optic nerve head, and macular thickness measurements. Invest Ophthalmol Vis Sci. 2009;50(12):5741–5748
10. Zangwill LM, Bowd C, Berry CC, et al. Discriminating between
normal and glaucomatous eyes using the Heidelberg Retina
Tomograph, GDx Nerve Fiber Analyzer, and Optical Coherence Tomograph. Arch Ophthalmol. 2001;119(7):985–993. 11. Nouri-Mahdavi K, Hoffman D, Tannenbaum DP, Law SK,
Caprioli J. Identifying early glaucoma with optical coherence
tomography. Am J Ophthalmol.2004;137(2):228–235. 12. Wollstein G, Ishikawa H, Wang J, Beaton SA, Schuman JS.
Comparison of three optical coherence tomography scanning
areas for detection of glaucomatous damage.Am J Ophthalmol. 2005;139(1):39–43. 13. Anton A, Moreno-Montañes J, Blázquez F, Alvarez A, Martín
B, Molina B. Usefulness of optical coherence tomography parameters of the optic disc and the retinal nerve fiber layer to
differentiate glaucomatous, ocular hypertensive, and normal
eyes. J Glaucoma. 2007;16(1):1–8. 14. Sung KR, Kim JS, Wollstein G, Folio L, Kook MS, Schuman JS.
Imaging of the retinal nerve fiber layer with spectral domain
optical coherence tomography for glaucoma diagnosis. Br J
Ophthalmol. 2011;95(7):909–914. Ophthalmology Update Vol. 12. No. 1, January-March 2014
15. Na JH, Sung KR, Lee JR, et al. Detection of glaucomatous
progression by spectral-domain optical coherence tomography. Ophthalmology. 2013;120(7):1388–1395.
16. Fercher AF, Hitzenberger CK, Drexler W, Kamp G, Sattmann
H. In vivo optical coherence tomography. Am J Ophthalmol. 1993;116(1):113–114. 17. Swanson EA, Izatt JA, Hee MR, et al. In vivo retinal imaging by
optical coherence tomography. Opt Lett. 1993;18(21):1864–1866. 18. Lee JY, Hwang YH, Lee SM, Kim YY. Age and retinal nerve
fiber layer thickness measured by spectral domain optical coherence tomography. Korean J Ophthalmol.2012;26(3):163–168. 19. Girkin CA, McGwin G, Jr, Sinai MJ, et al. Variation in optic
nerve and macular structure with age and race with spectral-domain optical coherence tomography.Ophthalmology. 2011;118(12):2403–2408. 20. Cheung CY, Chen D, Wong TY, et al. Determinants of quantitative optic nerve measurements using spectral domain
optical coherence tomography in a population-based sample of non-glaucomatous subjects. Invest Ophthalmol Vis
Sci.2011;52(13):9629–9635. 21. Budenz DL, Anderson DR,
Varma R, et al. Determinants of normal retinal nerve fiber
layer thickness measured by Stratus OCT. Ophthalmology. 2007;114(6):1046–1052. 22. Rao HL, Kumar AU, Babu JG, Kumar A, Senthil S, Garudadri
CS. Predictors of normal optic nerve head, retinal nerve fiber
layer, and macular parameters measured by spectral domain optical coherence tomography. Invest Ophthalmol Vis
Sci.2011;52(2):1103–1110. 23. Kanamori A, Nakamura M, Escano MF, Seya R, Maeda H, Negi
A. Evaluation of the glaucomatous damage on retinal nerve
fiber layer thickness measured by optical coherence tomography. Am J Ophthalmol. 2003;135(4):513–520. 24. Wollstein G, Schuman JS, Price LL, et al. Optical coherence tomography (OCT) macular and peripapillary retinal nerve fiber
layer measurements and automated visual fields. Am J Ophthalmol. 2004;138(2):218–225. 25. Medeiros FA, Zangwill LM, Bowd C, Vessani RM, Susanna R,
Jr, Weinreb RN. Evaluation of retinal nerve fiber layer, optic
nerve head, and macular thickness measurements for glaucoma detection using optical coherence tomography. Am J Ophthalmol. 2005;139(1):44–55. 26. Budenz DL, Michael A, Chang RT, McSoley J, Katz J. Sensitivity and specificity of the StratusOCT for perimetric glaucoma. Ophthalmology. 2005;112(1):3–9.
27. Sommer A, Katz J, Quigley HA, et al. Clinically detectable
nerve fiber atrophy precedes the onset of glaucomatous field
loss. Arch Ophthalmol. 1991;109(1):77–83.
28. Kass MA, Heuer DK, Higginbotham EJ, et al. The Ocular Hypertension Treatment Study: a randomized trial determines
that topical ocular hypotensive medication delays or prevents
the onset of primary open-angle glaucoma. Arch Ophthalmol.2002;120(6):701–713. 29. Leung CK, Cheung CY, Lin D, Pang CP, Lam DS, Weinreb RN.
Longitudinal variability of optic disc and retinal nerve fiber layer
measurements. Invest Ophthalmol Vis Sci. 2008;49(11):4886–4892. 30. Lai E, Wollstein G, Price LL, et al. Optical coherence tomography disc assessment in optic nerves with peripapillary atrophy. Ophthalmic Surg Lasers Imaging.2003;34(6):498–504. 31. Zangwill LM, van Horn S, de Souza Lima M, Sample PA, Weinreb RN. Optic nerve head topography in ocular hypertensive
eyes using confocal scanning laser ophthalmoscopy. Am J
Ophthalmol. 1996;122(4):520–525. 32. Hasnain SS. Scleral edge, not optic disc or retina, is the primary site of injury in chronic glaucoma. Med Hypotheses. 2006;67(6):1320–1325. 33. Jeoung JW, Park KH. Comparison of Cirrus OCT and Stratus
OCT on the ability to detect localized retinal nerve fiber layer
defects in preperimetric glaucoma. Invest Ophthalmol Vis
Sci. 2010;51(2):938–945. 61
GENERAL SECTION
ORIGINAL ARTICLE
Diabetic Neuropathies: as Indicators of Oxiative
Stress & their Correlation to Glucose-6-phosphate
Dehydrogenase Activities
Jariya Wajahat
Jariya Wajahat, MBBS, M. Phil,1 Fatahiya Kashif, MBBS, M.Phil2
ABSTRACT:
Objective: Today diabetes is a major cause of mortality and morbidity. Diabetic complications like neuropathies, are manifestations of oxidative stress. Glucose-6-phosphate dehydrogenase (G6PD) actively plays an important role in oxidative
stress by providing NADPH, which helps to fight against oxidative stress.
Material & Methods: This study was conducted from March 2009 till February 2010. Eighty subjects were selected from
the people who came to get their fasting glucose level checked. These were categorized as controls, high risk individuals, diabetics or metabolic syndrome (MS) sufferers on basis of WHO criteria. The subjects were tested for G6PD
activities. G6PD activities were correlated to the extent of development of neuropathies according to Michigan Neuropathy
Screening Instrument (MNSI).
Results: For MNSI scores showed that mean values of Diabetic and MS groups were significantly higher than that of controls.
MNSI scores were correlated to G6PD values. The higher MNSI scores tend to correspond with lower values of G6PD.
Conclusion: It may imply that low G6PD activities contribute towards development of complications like diabetic neuropathies or possibly G6PD supplements may help diabetics to prevent development of neuropathies. Further studies including
NADPH and Glutathione ratio may help confirm exact role of G6PD in preventing diabetic complications.
Key words: Diabetic neuropathies, Glucose-6-phosphate dehydrogenase, NADP, Metabolic Syndrome X
INTRODUCTION
Diabetic neuropathy is the damage to nerves
caused by diabetes. It affects about 50% people
with diabetes, its common symptoms are tingling
pain, numbness or weakness in feet and hands.1 Data
regarding glucose, nerve dysfunction and oxidative
stress from cell culture studies are still limited, but
few data,2 which are available indicate that there is
impaired antioxidant activity which can be a cause of
oxidative stress. Microvascular changes are the final
common pathway for development of late diabetic
complications, including peripheral and autonomic
neuropathies.3 Oxidative stress leading to nerve damage is illustrated in Fig: 1.
SUBJECTS AND METHODS
The subjects were selected from the ambulatory
patients who came to get their fasting glucose level
checked, on outpatient basis, at pathology laboratory of Combined Military Hospital (CMH), Lahore.
Eighty patients were enrolled for assessment of the
spectrum of disease and were categorized as controls, high risk individuals, diabetics or metabolic
syndrome (MS) sufferers on basis of history, physical
Assistant Professor, Department of Biochemistry, Rawal Institute
of Health Sciences, Islamabad, 2Assistant Professor, Department of
Biochemistry, Islamic Medical and Dental College, Sialkot
1
Correspondence: Dr Jariya Wajahat, Assistant Professor, Department
of Biochemistry, Rawal Institute of Health Sciences, Islamabad.
Email: [email protected] Cell: 03015385056, 03215097063,
Address: W/o Col Wajahat Ali , Flat 1-A, MO Flats, Cobb Lines, Near
Qasim Market Rawalpindi
Received & Accepted: Dec’2014
62
Fig: 1 Oxidative stress leading to nerve damage
examination and baseline lab investigations for fasting
glucose and lipid profile. An informed written consent
was obtained from all subjects recruited in this study.
The study was approved by the Advanced Studies and
Research Board of the University of Health Sciences,
Lahore.
Individuals were identified as high risk in accordance with the criteria laid down by WHO:1 High
risk individuals were identified as being high risk on
fulfilling any one of the following criteria: over weight
(BMI > 25) or hypertensive (BP > 140/90) or having
HDL cholesterol less than 0.9 mmol/L (<35mg/dl) or
triglyceride higher than 2.82 mmol/L (>250mg/dL) or
having impaired fasting glucose 5.5-6.9 mmol/L (100125mg/dL after overnight fast) or impaired glucose
tolerance 7.7-11mmol/L (140-199 mg/dL after 2 hr glucose tolerance test)
Diabetics were selected according to the following WHO criteria: (i) Fasting plasma glucose
Diabetic Neuropathies: as Indicators of Oxiative Stress
greater than or equal to 7mmol/L (126mg/dL) or
post prandial plasma glucose greater than or equal
to 11.1mmol/L (200mg/dL). Subjects who had central
abdominal obesity, defined as waist circumference,
measured at midpoint between lower rib and anterior superior iliac spine (cut off point: waist circumference ≥ 90 cm for males and ≥80 cm for females) or
BMI ≥ 30 plus any two of the following according
to IDF criteria, were labeled as MS patients: (ii) Serum triglycerides ≥ 150mg/dL (1.7mmol/L) or specific treatment for this abnormality. (ii) Low HDL
cholesterol ≤ 40mg/dL (1.03 mmol/L) in males or ≤
50mg/dL (1.29mmol/L) in females, or specific treatment for this abnormality. (iii) Raised systolic BP ≥
130 mmHg or diastolic BP ≥ 85 mmHg or treatment
of previously diagnosed hypertension. (iv) Raised
fasting plasma glucose ≥ 100 mg/dL (5.6 mmol/L)
or previously diagnosed type 2 diabetes mellitus.
Twenty unrelated healthy subjects without history
of diabetes or hypertension, matched for age and
gender with high risks, diabetics and MS patients
were randomly selected from general population to
serve as controls. Patients were tested for touch and
vibration sense using common pin, cotton wool and
tuning fork and MNSI score which is a screening criteria for diabetic neuropathy was noted. Patients having any other morbidity due to some chronic infection
or disease like cancer were excluded. In our sample
three patients turned out to be hepatitis C positive,
they were excluded and one patient had tuberculosis,
he was also excluded.
The participants in control group were healthy
individuals and exclusion criteria included over
weight, or impaired fasting glucose. Mean age for all
participants was 35 ±1 SD, in all groups male to female
ratio was 7: 3.
Sensory system examination included testing
for: pain sensation (pin prick), light touch sensation
(brush), position sense, stereognosis and graphesthesia.
Pain and Light Touch: Subjects were allowed to touch
the common pin needle and cotton wool ball prior
to beginning to alleviate any fear of being hurt during the examination. The subjects were instructed to
lie supine on examination couch with the eyes closed
and were told to raise index finger when they felt the
pin/cotton wool sensation. The subjects were tested
alternately with pin- needle and cotton wool at intervals of roughly 5 seconds. Examination was begun
rostrally and worked towards the feet. The subjects
were instructed to tell if they notice a difference in
the strength of sensation on each side of body. Alternating between pin prick and light touch the subjects
were tested in following locations. One part of body
tested was followed by corresponding part on the
other side. The corresponding nerve root for each area
tested is indicated in parenthesis.
1. Posterior aspect of shoulders (C4)
2. Lateral aspect of upper arm (C5)
3. Medial aspect of lower arms (T1)
4. Tip of thumb (C6)
5. Tip of middle finger (C7)
6. Tip of little finger (C8)
7. Thorax , nipple level (T5)
8. Thorax, umbilical level (T10)
9. Upper part of upper leg (L2)
10. Lower medial part of upper leg (L3)
11. Medial lower leg (L4)
12. Lateral lower leg (L5)
13. Sole of foot (S1)
In case if any sensory loss was detected, vibration and temperature sensation was tested with tuning fork.
Position Sense: Position sense was tested by asking
the subjects to keep eyes closed and report if their
large toe is up or down, when their toe was moved
manually in respective direction by the examiner
(self). Same procedure was repeated on opposite side
and compared. Toes were held on sides because holding the top or bottom provides pressure cues to
patient and makes the test invalid.
Fine touch, position sense (proprioception) and vibration sense are conducted together in dorsal column
system. Rough touch, temperature and pain sensation
are conducted via spinothalamic tract.5
Michigan Neuropathy Screening Instrument: Michigan
Neuropathy screening instrument (MNSI) is based
on simple tests administered by diabetologists. MNSI
score is used by diabetologists as screening tool for
diabetic neuropathy, a score of 2.5 or above indicates
presence of neuropathy. The patients who had sensory
loss were graded according to MNSI.6
Michigan Neuropathy Screening Instrument Score
Appearance of feet
Ulceration
Ankle reflexes
Vibration perception
at great toe
Right
Left
Normal = 0
Normal = 0
Abnormal = 1
Abnormal = 1
----------------------------↓
(Deformed / dry skin / callus / infection
/ fissure)
Absent = 0
Absent = 0
Present = 1
Present = 1
Present = 0
Present/
Reinforced. = 0.5
Absent = 1
Present = 0
Present/
Reinforced. = 0.5
Absent = 1
Present = 0
Reduced. = 0.5
Absent = 1
Present = 0
Reduced. = 0.5
Absent = 1
Maximum score can be 8, a score of 2.5 or more
signifies presence of neuropathy. For screening
of diabetic peripheral neuropathy, Michigan
physical assessment is very useful1
63
Statistical Analysis: The statistical analysis was done
using MATLAB® Version7.2. Simple descriptive statistics were evaluated and presented using bar plots,
pie charts and stacked bar plots. Descriptive statistics requiring calculation of parameters such as
mean, median, percentiles, range and outliers etc.
were evaluated and presented using a combination
of box and dot plots as well as using One Way Analysis of Variance (ANOVA).
The reason for using a combination of box and dot
plots for data representation (as against only showing
group means and ± standard deviation SD) is that data
on some parameters were not normally distributed
(i.e., they did not have a “Gaussian distribution”). Estimates of mean values can be biased if the distributions
are non-Gaussian. The number showing ± SD becomes
less meaningful as it generally applies to Gaussian distribution. When data are skewed or biased, the box
plots are more robust and a better way of understanding the data. However, for general comparison,
mean and ± SD for each group is shown with a vertical
bar outside of each box. The square marker in the middle of the vertical bar represents the mean value. The
extent of the bar on either side of the mean shows ±1 x
SD. While differences of median values with 95% confidence can be inferred from the box plots right away,
the difference of mean values using One Way ANOVA
was evaluated, also at 95% confidence, and shown on
separate plots.
RESULTS
Fig: 2 given below, shows these scores in a qualitative manner. It can be seen that the score for most individuals was zero in the control and high risk groups.
All diabetics have a score of at least 1, while a score of
1.0 or more dominates the other two groups. The subjects with highest scores in our study all belonged to the
diabetics group.
Fig-2: MNSI scores among the groups
Fig: 3 given below, compares the MNSI scores in a
quantitative manner between the groups. It can be seen
that median values of Diabetic and MS groups are high64
er than the control with a significance value of p < 0.05.
Fig: 3 ANOVA for mean MNSI Scores
Fig: 4 Group wise comparison of MNSI Scores
For fig 4 given above the horizontal line inside
the box represents the median value for the data, i.e.,
exactly half of the data samples are above this value
and half below it. It is also called 50th % ile. The
extent of a ‘notch’ around the median represents 95%
confidence interval for the median value The notch and
the median are very important statistics for comparison
of groups. While comparing any two or more groups,
if their notches do not overlap, we can say with 95%
confidence that their median values are different from
each other. Here we can see that median values for diabetics and MS sufferers are significantly different from
controls. For general comparison, mean and ± SD for
each group is shown with a vertical bar outside of each
box. The square marker in the middle of the vertical bar
represents the mean value. The extent of the bar on either side of the mean shows ±1 x SD.
For MNSI scores, discrete values of 0,0.5,1,1.5,2
and 2.5 are compared with G6PD values as shown in
Figure 5 given below.
CONCLUSIONS
1. G6PD activities are decreased in patients with peripheral neuropathies.
2. G6PD may serve as a therapeutic target to delay or
prevent development of neuropathies.
Figure 5: The score of 1 is fairly distributed along the whole
band of G6PD values, with maximum concentration around 7-9.
Scores of 2 & 2.5 also correlate with lower activities of G6PD.
DISCUSSION
In our study group the development of neuropathies corresponds with lower values of G6PD. This can
be explained in light of findings that diabetes causes
inhibition of G6PD activity in experimental animal
models. Further, researchers have suggested that increasing G6PD activity can serve as a potential therapeutic target to avoid development of diabetic complications. Around fifty percent people with diabetes
develop neuropathies, these ultimately may lead to
foot ulcers and amputation. Reactive oxygen species
(ROS) play part in causing oxidative stress which leads
to diabetic complications.Our findings suggest that
G6PD can serve as a therapeutic target to delay or prevent diabetic complications.And lot of suffering, morbidity and health care burden can be avoided However
some researchers argue that G6PD derived NADPH is
diverted into pathway for producing ROS. If this study
is repeated with glutathione ratio and NADPH levels
exact role of G6PD may be described.
REFERENCES
1. Wolff SP. Diabetes mellitus and free radicals. Free radicals, transition metals and oxidative stress in etiology of diabetes mellitus
and complications. Br Med Bull. 1993;49:642-652.
2. Russel JW, Sullivan KA, Winderbank AJ, Herrmann DN, Feldman EL. Neurons undergo apoptosis in animal and cell culture
models of diabetes. Neurobiol Dis. 1999;6:347-363.
3. Van PS. Oxidative stress and diabetic neuropathy: pathophysiological mechanisms and treatment perspectives. Diabetes Metab Res Rev. 2002;18:176-184.
4. International diabetes federation idf.org[home page on the internet].Brussels Belgium: The Federation; c2009 [updated 2006
Feb 24; cited 2006 Nov 7]. Preventing chronic diseases: a vital investment [about 1 screen] Available from:http://www.idf.org/
webdata/docs/background_dis_final.pdf
5. Russel S, Triola M. Sensory system.In: Kelly P,editor The precise neurological exam. New York. McGraw Hill;2006 [About 2
screens ] Available from http://edinfo.med.nyu.edu/courseware/neurosurgery/sensory.html
6. Feldman EL, Stevens MJ, Thomas PK, Brown MB, Canal N and
Greene DA. A practical two step quantitative clinical and electrophysiological assessment for the diagnosis and staging of
diabetic neuropathy. Diabetes Care.1994;11:1281-1289.
7. Boyraz O and Saracoglu M.The effect of obesity on the assessment of diabetic peripheral neuropathy: a comparison of
Michigan patient version and Michigan physical assessment.
Diabetes Res Clin Pract. 2010 Dec;90(3):256-60. doi: 10.1016/j.
diabres.2010.09.014. Epub 2010 Oct 12.
8. Xu Y, Osborne BW, Stanton RC. Diabetes causes inhibition of
glucose-6-phosphate dehydrogenase via activation of PKA,
which contributes to oxidative stress in rat kidney cortex. Am J
Physiol Renal Physiol. 2005;289:1040-1047.
9. Rees DA, Alcolado JC. Animal models of diabetes mellitus. Diabet Med. 2005;22:359–370.
10. Sytze P, Cotter MA, Bravenboer B and Cameron NE. Pathogenesis of diabetic neuropathy: Focus on neurovascular mechanisms. Eur J Pharmacol. 2013 Jul 17. pii: S0014-2999(13)00533-.
doi: 10.1016/j.ejphar.2013.07.017. [Epub ahead of print]
11. Gupte SA, Kaminski PM, Floyd B, Agarwal R, Ali N, Ahmed
M et al. Cytosolic NADPH may regulate differences on basal
Nox oxidase-derived super oxide generation in bovine coronary and pulmonary arteries. Am J Physiol Heart Circ Physiol.
2005;288:13-21.
65
GENERAL SECTION
ORIGINAL ARTICLE
Emerging Teaching Methodologies in Medical
Biochemistry & the need to Implement these
in Pakistani Medical Colleges
Fatahiya Kashif
Fatahiya Kashif, MBBS, M. Phil1., Jariya Wajahat, MBBS, M.Phil2
ABSTRACT:
The basic medical sciences are taught in the first two years of medical colleges. Methods used in the teaching of human
anatomy like cadaver dissection, microscopy, and imaging techniques have made it easy for the students to grasp the concepts. Learning physiology is also not problematic because they can visualize the phenomenon as they learn. The challenge
arises when it comes to the teaching of medical biochemistry. Since it is the study of life at molecular level, it is not easy to
envisage everything that is being imparted. With the advent of the information age, there is not only remarkable increase
in the degree of advancement in the field of biochemistry and molecular biology, also the teaching methodologies have
revolutionized. Following is a brief introduction to the rich list of educational resources that are augmenting the traditional
textbook and lecture based approaches across the world. To keep pace with the advancing world we must work towards
implementing these into Pakistani medical colleges. The conventional old syllabi should be replaced by these cutting edge
techniques and software.
Key words: Biochemistry, Molecular Biology, teaching methods, molecular models, molecular dynamics simulation
INTRODUCTION
As the discipline of biochemistry and molecular
biology advances, its teaching approaches also turn out
to be more and more challenging. Following is a brief
review of the contemporary technologies that are being
used today to complement the standard learning practices.
Physical modeling: The goal is to help the medical students understand the fundamental biological
processes at molecular level. Traditional approaches
of teaching about the molecular machinery of cell are
limited to the extent of information that can be conveyed in two dimensions only. Modeling assists in this
understanding by providing a perceptible way of telling a story. It allows the students to fully explore the
intricacies of protein structure and interactions e.g., cell
signaling pathways.
Computer assisted design software (CAD) has
helped in the manufacture of three dimensional replicas of proteins and other biomolecules by rapid prototyping technologies.1 These models which are based on
the structural data from protein data bank (PDB) help
the students to see and feel the molecules as tactile objects. These models are available in certain model lending libraries as well as online stores of educational supplies.
The MOLYMOD construction kits are an excellent
resource in learning about the simpler subunits of biomolecules and construction of polymers. The students
can explore the hierarchy of protein structure by using the AMINO ACID STARTER KIT. Toobers are soft,
flexible, inexpensive foam plastic rods. The amino acid
models are made of synthetic material with imbedded
magnets that allow their side chains to be affixed to a
toober backbone. The students can understand the effect of mutations on protein folding by means of this kit.
ALPHA HELIX AND BETA SHEET
Construction Kits: are available to educators from
the MSOE model lending library. Each kit contains selfassembling amino acid backbone units for alpha helix
or beta sheet. The MEMBRANE TRANSPORT COLLECTION KITs help the students explore how different
substrates move across the lipid bilayer. This is especially helpful in understanding the filtration system of
the kidney and the action potential in muscles.2
Assistant Professor, Department of Biochemistry, Islam Medical
and Dental College, Sialkot, 2Assistant Professor, Department of
Biochemistry, Rawal Institute of Health Sciences, Islamabad.
1
Correspondence: Dr Fatahiya Kashif,
Assistant Professor,
Department of Biochemistry, Islam Medical and Dental College, Pasrur
Road, Sialkot, Email:[email protected] Cell:+923215829272
Address: House: 18, Main Ghazi Road, Sialkot Cantt -51300
66
Figure: Membrane transport collection kit by
MSOE center for bio-molecular modeling.
Computer modeling: Computer generated images are
used synergistically with physical modeling tools to
aid in understanding of difficult concepts. In contrast
to physical modeling kits, these can be freely accessed
online from any part of the world.
JMOL is an excellent resource to study molecular
structure and function. JMOL tutorials are freely available. The software can be easily installed in any operating system. The students can examine the molecules
in wireframe, alpha carbon backbone, space filled or
ribbon diagrams. With the help of mouse, they can actually rotate the molecule and observe its three dimensional structure. It is even possible to highlight specific
parts of the molecule by clicking on the menu on the left
side of Jmol window. In this way the students can actually probe into the active site of an enzyme and picture
its kinetics.1
Most of the textbooks of biochemistry are now accompanied by a CD ROM which contains links to the
Jmol images of the molecules. While Jmol is appropriate for use at the undergraduate level, RasMol (a more
advanced software which can be used to design your
own protein by getting the information from the protein data bank) can be used at the post graduate level.
The protein data bank (PDB) archive: It is a constantly expanding database for understanding the biochemistry of proteins and some other important macromolecules. It is an equally good resource for research
as well as education. Structures are available for most
of the proteins and nucleic acids involved in processes
that are central to life, like ribosomes, oncogenes, drug
targets and some pathogenic viruses.2
Virtual genetics lab: Virtual labs have also transformed the teaching approaches. This one is a simulation of transmission genetics and the goal is to help
students understand how traits are inherited. Tests of
epistasis and complementation can be performed to
study gene interactions. In order to make a cross, the
students can select male and female parents from any
generation and press the cross button. This virtual platform keeps track of the genotypes of the parents and
generates their offspring probabilistically. Students can
cross hypothetical creatures with up to 2000 offspring
for getting statistically significant ratios. It is a user
friendly color graphical user interface (GUI) compatible with Mac, UNIX/Linux and PC.3
Other virtual labs: The computer simulated labs
have made it possible for the students to learn the principles of sophisticated techniques like DNA extraction,
gel electrophoresis, polymerase chain reaction and microarray right from their desktop. The objective is to
familiarize the students with experimentation, problem
solving, data collection and scientific analysis.
Online learning initiative: Many of the top universities across the world are now offering online courses
in many subjects including biochemistry and genetics.
Most of these courses are free and come under the category of Massively Open Online Courseware (MOOCs).
All you need is a computer and internet access and the
leading scholars from the best ranked academia come
at your doorstep to teach you.
The gene explorer: This application is an interactive simulation of gene expression. The students can
explore a sample gene, appreciate the correspondence
between DNA, pre-mRNA, mature mRNA and protein; map the functional elements of a gene and design
a gene of their choice and see how it is expressed.
The protein investigator: Molecular visualization
software does not allow a student to make hypotheses
about interactions between different side chains of amino acids in a protein and how these affect the folding
behavior. The protein investigator is designed to help
the students test a predictable hypothesis by typing
an amino acid sequence and observing its effect on the
shape of the protein. It is intended to demonstrate the
major principles involved in protein folding like hydrophobicity, charge and hydrogen bonding capacity, and
folding of proteins under oxidizing or reducing conditions.
jsMolCalc: It is a molecular editing software
which calculates the hydrophobicity and the molecular formula of molecules drawn by the user. It is very
simple to use and allows the students to learn about
the stereochemistry of biomolecules. The software also
presents the user with editing challenges; the objective
is to familiarize them with the basics of hydrophobicity
and polarity of different functional groups. Once they
are acquainted with these concepts it becomes easy for
them to comprehend the behavior of lipids in aqueous
environment, micelle formation and the basis of lipid
bilayers; also the role of amino acid side chains in determining the final conformation of a protein can be better
understood.4
Online educational games: Although the process
of protein synthesis is reasonably well understood,
prediction of its native conformation into a functioning protein is computationally demanding. Released in
2008, “Foldit” is challenging software designed to learn
the principles of three dimensional protein folding. It
is an online game in which multiple online players are
presented with a folding puzzle; each player uses a
different strategy to solve the same problem. The data
generated in this way is used by the scientists for the
“Critical assessment of techniques for protein structure
67
prediction (CASP)”experiments. So it is serving the
purpose of research as well as education as this helps
the students to conceptualize protein folding.
This is just a few of the rich list of scholastic resources that are being offered to the educators as well
as independent learners of biochemistry and molecular
biology. Most of the online resources are freely accessible. This article is anticipated to inform the medical students about the advantages of the information age that
they are living in and how they can truly benefit from it
and understand the basis of molecular medicine.
CONCLUSION
In Pakistani medical colleges, biochemistry
and molecular biology is portrayed as a boring and
dull subject. Learning of anatomy and physiology is
overstressed, while biochemistry is usually considered
as an aggregate of inconceivable facts that can be
crammed just before exams. That is the reason why the
students usually feel lost and are easily misled to study
poorly illustrated substandard books which further
drops their interest in the subject. Biochemistry lies at
the foundation of the revolutionary research which is
going on in molecular medicine. We are living in the
beginning of an era when it has become possible to edit
the individual genes in a person’s genome. The precise
biochemical basis of previously untreatable disorders is
unfolding. Drugs are being designed to target specific
proteins.
If we want our medical graduates to play a role
in the future of molecular medicine, we must radically
improve the curriculum as well as the training
approaches in the field of medical biochemistry and
molecular biology.
• In medical colleges biochemistry should be the
most important major subject, as all the research is
taking place at molecular level.
• It is important that we provide our students with a
strong base of molecular level so that they can take
leading roles in research.
• All available techniques, resources, kits and software should be utilized by teaching faculty to help
students understand molecular basis of life. Only
then we can emerge as a leading nation.
REFERENCES
1.
“Welcome to the CBM!” MSOE Center for BioMolecular Modeling.
N.p., 2013. Web. 07 Dec. 2013. <http://cbm.msoe.edu/>.
2.
“Products Catalog (October 2012).” 3-D Molecular Designs. N.p.,
n.d. Web. 07 Dec. 2013. <http://www.3dmoleculardesigns.
com/news2.php>.
3.
“Amino Acid Tutor.” MSOE Center for BioMolecular Modeling.
N.p., n.d. Web. 09 Aug. 2013. <http://cbm.msoe.edu/
includes/jmol/amino.php>.
4.
“Biological Macromolecular Resource.” RCSB Protein Data
Bank. N.p., n.d. Web. 06 Sept. 2013. <http://www.rcsb.org/
pdb/home/home.do>.
5.
White, Brian. “VIRTUAL GENETICS LAB.” VIRTUAL
GENETICS LAB. N.p., n.d. Web. 2012. <http://vgl.umb.edu/>.
6.
White, Brian. “Software for Learning Biochemistry.” Home Page
Professor Brian White. N.p., n.d. Web. 2013. <http://intro.bio.
umb.edu/BW/>.
APRIL’2014 SPECIAL EDITION
OF OPHTHALMOLOGY UPDATE ON
RETINOBLASTOMA
The next April’ 2014 issue of Ophthalmology Update will be a special edition on
‘Retinoblastoma’ including deliberations of the Symposium on Retinoblastoma recently
held at Shaukat Khanum Memorial Hospital & Research Centre Lahore.
Those who are interested to contribute their articles on the subject may please send their
papers/review articles by 15th March’2014.
68
GENERAL SECTION
Yousaf Jan
ORIGINAL ARTICLE
Open Heamorrhoidectomy under
Local Anaesthesia
Yousaf Jan FCPS (General Surgery)1, Aurangzeb Khan MBBS2,
Waqas MBBS3, Ahmad Din MBBS4
ABSTRACT
Objective: Haemorrhoids are engorged vascular cushions found within the submucosa of the anal canal. They consist of a
sacculated venous plexus with a rich arterial supply supported by a fibromuscular connective tissue. The exact prevalence
is unknown as many peoples do not seek medical attention; however, it may be somewhere in the region of 4-36% depending on population. The incidence is higher in Western populations and is low in sub-Saharan Africa. They normally contribute
to the anal continence and protection of the sphincter mechanism during defecation and are found at constant positions
within the anal canal (3, 7 and 11 o clock positions). The objective of my study is to assess the feasibility and tolerability of
open haemorrhoidectomy under local anesthesia.
Materials and Methods: This study was conducted in general surgery ward Hayatabad Medical Complex Peshawar after
taking permission from research and ethical committee of the hospital. Through a prospective cross sectional study design,
65 patients were included in the study between March 2009 to March 2010. All patients underwent open haemorrhoidectomy by the same surgeon having more than five years experience. Both males and females were included in the study.
Follow up was done after the surgery and the data were collected.
Results: 65 patients with 3rd and 4th degree hemorrhoids underwent open haemorrhoidectomy under local anesthesia and
including both male and female patients. The mean age was 44.4 ± 12.2 SD (21-72). Mean operating time was 20.7 min ±
(9.9SD) (5-60min) SD. Only 5 patients (7%) had severe pain which needed general or spinal anesthesia.
Conclusion: Hemorrhoidectomy under local anesthesia is feasible, effective, well tolerated and safe method in all age groups. It
should be an alternative approach in treatment of haemorrhoidal disease who are unwilling or unfit for other forms of anesthesia.
Key Words: Open hemorrhoidectomy, local anesthesia (LA).
INTRODUCTION
Hemorrhoids are dilatation of internal venous
plexus with an enlarged, displaced anal cushions1. It is
believed to be one of the most widely spread human
suffering ranking first among diseases of the rectum
and large gut.2
Symptoms resulting from hemorrhoids are commonly bright red bleeding per rectum, mucosal prolapse or protrusion, pruritus ani. Pain is not characteristic unless there has been thrombosis or strangulation of
the hemorrhoids which possibly can lead to gangrene.3
The incidence of symptomatic hemorrhoids could be as
high as 36.4%.4
There are many treatment options available depending on the degree of haemorrhoidal disease. Nevertheless the best treatment is prevention by avoiding
constipation, intake of high fiber diet, adequate fluids
and administration of bulk laxatives.5-7
In most instances haemorrhoids are treated conservatively. Hemorrhoidectomy is indicated when
Surgical Specialist, AHQ Hospital Landi Kotal, KPK. 2Registrar
Surgery, Rehman Medical Institute, Peshawar. 3Trainee Medical
Officer, Hayatabad Medical Complex, Peshawar. 4Senior Medical
Officer, North West General Hospital, Peshawar.
1
Correspondence: Dr. Yousaf Jan Shinwari, Surgical Specialist,
AHQ
Hospital
Landi
Kotal,
(KPK)
Cell:0333-9279312
Email: [email protected]. Address: H. No: 89, St: 2,
Sector K5, Phase 3 Hayatabad, Peshawar.
Received: Oct’13
Accepted: Dec’13
conservative management have failed or complications have occured.8 Hemorrhoidectomy is usually
performed under general or spinal anesthesia, the complications resulting from anesthesia can hide a successful operation.9-10 Surgeries done under LA have some
important advantages, like early ambulation and subsequent discharge from hospital, reduction in total cost
of the procedure and it encourages doctor patients interaction during the procedure.11 Low total cost of the procedure and assurance of being awake during the procedure enhanced our patients acceptability of surgery.12-13
This study was conducted in general surgery ward
Hayatabad Medical Complex Peshawar from March
2009 to March 2010 including 65 patients after taking
permission from the local research and ethical committee. Patients who presented with 3rd & 4th degree haemorrhoids and consented for haemorrhoidectomy under
local anesthesia were recruited into the study.
A patient would be excluded from the present study
for one of the following reasons: allergic to local anesthetic agents (on history), consent refusal, antiplatelet drug
or anti-coagulant usage, with bladder outlets obstruction, previous anorectal surgery, colorectal tumors and
others anorectal disorders (on history and examination).
A detailed history was taken from all patients. A
part from general physical and systemic examination,
local examination including inspection, digital rectal
examination and proctoscopy was performed. Flexible
69
sigmoidoscopy and colonoscopy were performed in
patients above 40 years with history of recurrent bleeding per rectum to rule out other anorectal pathologies.
Pre-operatively all patients had the following investigations, complete blood count (CBC), blood grouping
and Rh factor, random blood sugar (RBS), Liver function tests (LFT), serum creatinine, coagulation profile,
X-ray chest and ECG if the patient above 35 years or
history of cardiac problem. All patients were given
phosphate enema at least 3 hours before operation.
Informed written consent were taken from all
patients. Before starting operation I/V line and pulse
oximetery monitoring were maintained but no intravenous fluids administered, except single dose of 1
gm ceftriaxone and single 100 ml Flagyl infusion were
given, as the patient was put in lithotomy position. A
40 ml local anesthetic mixture was prepared using 10
ml of 0.5% bupivacaine, 10 ml of 1% lidocaine with
adrenaline 1:10000 and 20 ml of distilled water. A 30
ml of this solution was infiltrated by the surgeon into
the left/right anterolateral aspect of perianal region,
the remaining 5-10 ml was infiltrated into the submucosal area beneath the internal haemorrhoids, and all
patients underwent open haemorrhoidectomy. Intraoperatively pain assessment was done using visual analogue score. Six Patients (7%) could not tolerate local
anesthesia were converted to general anaesthesia.
At the end of surgery, the anal canal was packed
with lignocaine gel impregnated guaze for haemostasis and some analgesia. All patients were evaluated
postoperatively for pain assessment at 30 min, 90min,
6h and 24 h through visual analogue scoring system.
Further postoperative analgesic was achieved by use of
intravenous ketorolac 30 mg SOS for the first 24 hours,
and all patients were placed on perioperative metronidazole for 24 hours. Postoperative analgesia was classified as excellent if no analgesia was needed, satisfactory
if one dose was required, and poor if two or more doses
were needed. Anal pack was removed and patient discharged on 1st post op day and advised warm sit-bath
twice daily and after each defecation, oral NSAIDs, oral
ciprofloxacin 500 mg plus metronidazole, 5% lignocaine
ointment and laxatives for 5 days postoperatively.
RESULTS
A total of 65 patients with 55(84%) males and
10(16%) females were included in the study. Age range
was 21-72 years with mean age of 44.4 years ± 12.2 SD
as in table 1. Out of 65 patients, 45 (69%) had 3rd degree
haemorrhoids and 20 (31%) had 4th degree haemorrhoids
as in table 2 . In this study 47 patients(72.3%) had experienced no pain during the procedure. 10 patients (15.3%)
had mild intraoperative pain (VAS 1-4) and only 5 patients (7.7%) had severe pain which needed additional
anesthesia in the form of GA or spinal as shown in table 3.
The mean operating time was 20.7 min ± (9.9 SD).
Only 3 patients(4.6%) had bleeding on 1st post operative
70
day, but only one needed re-surgery for bleeding control, and 2 patients (3.07%) went into urinary retention
needed catheterization as shown in table 4. No mortality was noted in the study group.
TABLE 1: Age range
Frequency
21-30
31-40
41-50
51-60
61-70
Sex
8
15
20
15
7
TABLE 2: Degree of hemorrhoids
Degree
3rd degree
4th degree
Total
Frequency/Percentage
45 (69%)
20 (31%)
65 (100%)
TABLE 3: Intra operative pain assessment,
Visual analogue score (P value = 0.010)
0
1-4
No pain
Mild
47 (72.3%)
10 (15.38% )
5-7
Moderate
3 (4.61%)
8-10
Severe (converted to GA)
5 (7.7% )
Total
65 (100%)
DISCUSSION
Haemorrhoidectomy involves surgery on sensitive anoderm, which is rich in nerve endings. Several
ways of reducing pain and discomfort have been proposed, including the use of multimodal analgesics, restricted surgery to one hemorrhoid at a time, avoiding
a closed technique, rectal metronidazole application,
pre-emptive analgesia, caudal block, preoperative lactulose, pudendal perineal blocks, stapled anopexy and
Doppler guided hemorrhoid artery ligation.
Local anesthesia was first introduced to surgical
procedure done for hemorrhoids with the aim of controlling pain which usually complicate the procedure.
Subsequently it was considered that the procedure can
be done completely under LA. Surgeries done under
LA have some important advantages, like early ambulation and subsequent discharge from hospital, reduction in total cost of the procedure and it encourages
doctor patients interaction during the procedure.11
All these advantages are much more relevant in
our environments where most of the patients belong to
low socio-economic status. Caudal or spinal anesthesia
can be used but they require a trained anesthesiologist
and can create numerous known complications14. For
patients with hemorrhoids unwilling or unfit for other
forms of anesthesia, ring block with LA may be employed with good results and patient tolerance.
Some recent studies had shown that adequate pain
control can be achieved with the use of local anesthesia when patients are medically fit and psychologically
prepared for the procedure.15-16
Pain is the most common complication of hemorrhoidectomy. C. W. Sobrado17 regards pain to be the
most common disturbance, complicating postoperative period of anorectal surgery. Local anesthesia with
perianal and anal canal blocks gives adequate duration
and depth of anesthesia and results in excellent relaxation of the anal canal.18 A short acting local anesthetic
lidocaine provides excellent initial pain relief and long
acting local anesthetics bupivacaine provides several
hours of anesthesia post operatively. The presence of
adrenaline in the lidocaine provides enough time for
not only haemorrhoidectomy but also helpful to reduce
intraoperative bleeding.19
One randomized controlled study,20 comparing
haemorrhoidectomy under local versus general anesthesia showed statistically similar pain scores for patients in both groups. In another study by Imbelloni
and colleagues,21 also showed better pain relief during
the first 24 hours after surgery under local anesthesia
for haemorrhoidectomy, as also shown in our study.
In a study by Nystrom and his colleagues,22
showed that the perianal block is easy to apply and effective as a sole method of anesthesia for proctological
operations including haemorrhoidectomy.
Intraoperative pain assessment by visual analogue
score during haemorrhoidectomy in our study showed
that 47 patients (72.3%) out of 65 patients had surgery
completed without any pain, while only 5 patients (7%)
had severe pain during procedure needed completion
of surgery under general anesthesia as shown in table
3. Postoperative analgesia assessment was done for
24 hours and was classified as excellent if no analgesia was needed, satisfactory if one dose was required,
and poor if two or more doses were needed. Our result
showed that postoperative analgesia was excellent in
54 patients (83%), satisfactory in 7 patients(10.7%) and
poor in 4 patients (6.15%).
Postoperative complications were assessed for
first 24 hours in our study including bleeding and urinary retention. Only 3 patients(4.6%) had bleeding on
1st post operative day, but only one needed re-surgery
for bleeding control, and only 2 patients (3.07%) went
into urinary retention needed catheterization.
Preoperative counseling and adequate information about the expected postoperative course after
haemorrhoidectomy under local anesthesia is essential for a successful outcome. It is hoped that this work
though with a small number of patients may prompt
more surgeons to offer local anesthesia to patients undergoing hemorrhoidectomy, as this may encourage
early presentation to hospital.
CONCLUSION
In our conclusion, hemorrhoidectomy under
LA block is convenient, effective, safe and acceptable
to most patients of all age with fewer complications,
which supports the routine use of local anesthesia for
haemorrhoidectomy. This can be used in those patients
who are unwilling or unfit for other forms of anesthesia
and should be on alternative approach in the treatment
of haemorhoides disease.
REFERENCES
1.
Sheikh Ms, Afzal M, Yaqoob M, Iqbal MI. Haemorrhoidectomy. APMC 2008;2:21-9.
2.
Khan N, Malik MA, Injection sclerotherapy versus elctrocoagulation in the management outcomes of early haemorrhoids. J
Pak Med Assoc 2005; 56:579-82.
3.
Charles FM, Hyder SA, Middleton SB. Modern surgical management of harmorrhoids pelviperineology 2008;27:139-142.
4.
Davies RJ. Haemorrhoids. Clinical evidence. 2006;15:1-2.
5.
Salvati EP. Non operative management of haemorrhoids. Dis
Colon rectum 1999;42:989-93.
6.
MacRae HM, Mcleod RS. Comparison of haemorrhoidal treatment modalities: a meta analysis. Dis colon rectum 1995;38:687-94.
7.
Brisimda G, Civello IM, Maria G. Haemorrhoidectomy. Painful
choice. Lancet 2000;335:2253.
8.
Holzheimer RG. Haemorrhoidectomy: indications and risks.
Eur J Med Res 2004;9:18-36.
9.
Charuluxahanan S. Sriprajittichai P, Strichotvithya Kon P. Factors related to patient satisfaction regarding spinal anesthesia. J
Med Ass Thai 2003; 86 (Suppl 2): S338-43.
10. LiS, Coloma M, White PF, Watcha MW, Chiu JW, LIH, et al.
Comparison of the costs and recovery profiles of three anesthetic techniques for ambulatory anorectal surgery. Aneshtesiol 2000;93:1225-30.
11. Mutihir JT, Aisien AO, Ujah IA. Anaesthesic experience in female sterilization at Jos university teaching hospital Nigeria.
East African Medical Journal. 2007;84:374-378.
12. Odusanya OO, Babafemi JO. Patterns of delays amongst pulmonary tuberculosis patients in Lagos, Nigeria BMC Public
Health. 2004:4:18.
13. Adegboyega AA, Onayade AA, Salawu O. Care seeking behaviour of caregivers for common childhood illnesses in Lagos Islan Local Government Area, Nigeria Nigerian Journal of
Medicine 2005;14:65-71.
14. Kushwaha R, Hutching W, Davies C, Rao NG. Randomized
clinical trial comparing day-care open haemorroidectomy under
local versus general anesthesia . Br J Surg. 2008; 95(5) 555-63.
15. Vinson Vonnet B, Coltat JC, Fingerhut A, Bonnet F. Local infiltration with ropivacaine improves immediate postoperative
pain control after haemorrhoidal surgery. Diseases of the colon
and rectum. 2002:45:104-108.
16. Ong CH, Boon Foo EC, Keng FV. Ambulatory circular stapled
Haemorrhoidectomy under LA versus circular stapled Haemorrhoidectomy under regional anaesthesia. ANZ Journal of
surgery. 2005;75:184-186.
17. Sobrado CW, Habr- Gama A. Hook needle puncture. A new
technique of local anesthesia for anorectal surgery. Dis Colon
Rectum 1996;39(11):1330-1.
18. Foo E, Sim R, Med M, Lim HY, Chan STF, Ng BK. Ambulatory anorectal surgery –is it feasible locally? Ann Acad Med
Singapore. 1998;27:512-14 .
19. Potchavit A. Perianal block for ambulatory haemorroidectomy,
an easy technique for general surgeon. J Med Assoc Thai.
2009;92(2): 195-97 .
20. Younis MA, Gad SA. Stapled haemorroidopexy local versus
general anesthesia. EJS, vol, 32, No 1, jan 2013: 20-24 .
21. Imbelloni LE, Vieira EM, Gouveia MA, Netinho JG, Spirandelli LD, Cordeiro JA. Pudendal block with bupivacaine for
postoperative pain relief. Dis Colon Rectum. 2007;50:1656-61 .
22. Nystrom P, Derwinger K, Gerjy R. Local perianal block for
anal surgery. Tech Coloproctol. 2004;8(1):23-26 .
71
GENERAL SECTION
ORIGINAL ARTICLE
Frequency of Achilles’ Tenotomy in
Club Foot treated by Ponseti Method
Khalid Khan
Muhammad Khalid Khan FCPS1, Samir Khan Kabir MBBS2
Javed Iqbal MBBS3, Prof. Zaffar Durrani FRCS4
ABSTRACT
Objectives: To determine the frequency of Achilles’ tendon tenotomy in Ponseti technique for idiopathic clubfoot.
Club foot is one of the most common congenital deformities affecting about one infant in every 750 births. Some equinovarus
deformity after Ponseti technique application requires Achilles’ tenotomy and tenotomy of the Achilles tendon is an integral
part of the Ponseti technique of clubfoot correction.
Study Design: This study was conducted on 70 patients with club foot deformity from September 2009 to 2010. Patient’s
foot was scored according to pirani scoring system and then Ponseti protocol of manipulation and casting was followed. This
process continued weekly up to fourth cast and at fifth visit, the uncorrected equinovarus was corrected by percutaneous
Achilles’ tenotomy under local anaesthesia cast applied for three weeks. Improvement in the score was noted. Data was
analyzed by SPSS version 10.0.
Results: There were 43 (61.4%) males and 27 (38.6%) females. Achilles’ tenotomy was done in 43(61.4%) patients for the
correction of equinovarus. Achilles’ tenotomy was done in 30 (69.77%) males and 13 (30.23%) females. Tenotomy in the
age group of 5-8 months was 29 (67.44%) and in the age group of 1-4months was 14(32.56%). There were 27 (38.57%)
and 43 (61.43%) patients with bilateral and unilateral CTEV patients respectively and tenotomy was done in 15 (34.88%)
and 28 (65.11%) patients in bilateral and unilateral CTEV patients respectively.
Conclusion: Achilles’ tenotomy is quite common in our set up while treating patients with CTEV up to 8 months of age by
Ponseti technique of manipulation and serial casting.
Key Words: Congenital talipes equinovarus, Ponseti technique, Achilles’ tenotomy.
INTRODUCTION
Idiopathic clubfoot is the most common musculoskeletal birth defect affecting an average of 1 in 750
newborn.1 The deformity has four components namely
cavus of the midfoot, adductus of the forefoot, varus of
the hind foot and equinovarus.2 Pirani scoring system
is used for assessment of severity of clubfoot deformity
and its response to treatment.3
Treatment of clubfoot with the Ponseti method is
successful when performed immediately after birth,4
but this technique is reported to be effective in children
up to two years of age even after previous unsuccessful
non-surgical treatment.5 The success rate with Ponseti
method has been reported 93%.6
The Ponseti method is safe and effective treatment
for congenital idiopathic clubfoot and radically decreases the need for extensive corrective surgery.7 It is
reported to provide a lower complication rate, less pain
and better function as the patient ages as compared to
operative treatment.8 Correction of the deformity is in
Registrar, 2,3PG Trainees, 4Professor & Head of the Department,
Orthopaedics & Trauma Unit, Khyber Teaching Hospital, KPK.
1
Correspondence: Dr. Muhammad Khalid Khan, Registrar, Orthopaedic
& Trauma Unit, Khyber Teaching Hospital, Peshawar, KPK.
Email:
[email protected],
[email protected]
Cell: 0321-9081319 Address: Room: 92, New Doctors’ Hostel,
Khyber Teaching Hospital, Peshawar.
72
the order of Cave; cavus is corrected first followed by
adductus, varus and equinovarus at last. At this point
there is often a residual equinovarus which requires
percutaneous Achilles’ tenotomy.9
Ponseti casting has proven successful in reducing
the number of patients requiring extensive surgical releases and as a result become integral part of paedriatic
orthopaedic practice.10 However, some equinovarus deformity is left which requires Achilles’ tenotomy11 and
percutaneous tenotomy of the Achilles tendon is an integral part of the Ponseti technique of clubfoot correction.12
Ponseti clubfoot management requires percutaneous tenotomy in 70-91% of cases, typically with local anesthesia
by low dose of lidocaine as recommended by Ponseti but
it can be performed under general anaesthesia as well.13
In our setup, majority of patients with congenital clubfoot deformity from outpatient department are
treated by Ponseti treatment, but the local statistics of
Achilles’ tenotomy in this type of treatment are not
known. Also parents and family members of patients
can’t be clearly counseled without knowing local frequency of tenotomy and the end result is that in case of
tenotomy, the procedure might be more stressful for the
infant, the surgeon and the parents or family members.
This descriptive cross sectional study was conducted in Department of Orthopedics and Traumatology,
Khyber Teaching Hospital, Peshawar from September
2009 to September 2010 including 70 patients having
CTEV. Patients of CTEV both unilateral and bilateral
between birth and eight months of age of both sexes
were included in the study. All the patients having age
of more than 8 months, with other congenital anomalies
like arthrogryposis, meningomylocele, spinabifida and
previously treated non surgically or surgically were excluded from the study.
All the patients of clubfoot were taken from the
OPD, meeting the inclusion and exclusion criteria. The
parents of the patient were told in detail about the Poseti method and results, and a written informed consent was taken from the parents. After consent selected
patient’s foot were scored according to Pirani scoring
system and entered into the proforma, then Ponseti
protocol of manipulation and casting was followed.
Each cast remained for 7 days. This process continued
weekly up to fourth cast, any extra cast needed was
noted in the proforma. At fifth visit if the equinovarus
was not corrected, percutaneous Achilles’ tenotomy
under local anaesthesia, using 3ml of 2% lignocaine diluted in 2ml of distilled water was done, patients were
observed for any bleeding from the incision site, vascular compromise of the corresponding foot by palpating
the dorsalis pedis and posterior tibial artery pulsations,
when confirmed then cast was applied for three weeks.
Before tenotomy, clotting time and bleeding time of
each child was done. On each visit, Pirani score was
noted after removal of cast. Improvement in the score
was noted. Separate proforma was used for each cast
and each foot. The need of Achilles’ tenotomy was noted at the last visit if the equinovarus was not corrected.
Data was analyzed by SPSS version 10. Frequencies of Achilles’ tenotomy were stratified among gender, age groups and side of involvement. Data was presented in the form of tables and graphs.
RESULTS
There were 70 patients comprising of 43 (61.4%)
males and 27 (38.6%) females. The mean, mode and median for the age were 4.73 months, 5 months and 5.00
months respectively. The minimum age was 1 month
while the maximum age was 8 months.
Achilles’ tenotomy was done in 43 (61.4%) patients
for the correction of equinovarus. (Table No. 1). Gender distribution of Achilles’ tenotomy was 30 (69.77%)
males and 13 (30.23%) females while the tenotomy was
done maximum in the age group of 5-8 months i.e. 29
(67.44%) followed by the age group of 1-4months (14
(32.56%)). (Table No. 2)
There were 27 (38.57%) and 43 (61.43%) patients
with bilateral and unilateral CTEV patients respectively and tenotomy was done in 15 (34.88%) and 28
(65.11%) patients in bilateral and unilateral CTEV patients respectively. Detail is shown in Table No. 3
Table No. 1 Achilles’ tenotomy in CTEV treated
by Ponseti method
Achilles’ Tenotomy
Frequency n(%)
Yes
43 (61.4%)
No
27 (38.56%)
Total
70 (100%)
n= number of observed patients, %=Percentage
Table No. 2 Achilles’ tenotomy in CTEV treated
by Ponseti method according to gender and age
Achilles’ tenotomy n(%)
Gender wise distribution
Male
N=43 (61.4%)
Female
N=27 (38.6%)
30 (69.77%)
13(30.23%)
Age wise distribution
1-4months
N= 31 (44.29%)
5-8months
N= 39 (55.71%)
14(32.56%)
29(67.44%)
N= Total number of patients, n= number of observed patients, %=Percentage
Table No. 3: Achilles’ tenotomy in CTEV treated by
Ponseti method according to gender and age
Right foot n(%) Left foot n(%)
Total
Unilateral CTEV
N=27(38.57%)
20 (46.51%)
8 (18.60%)
28
(65.11%)
Bilateral CTEV
N=43(61.43%)
10 (23.26%)
5 (11.62%)
15
(34.88%)
N= Total number of patients, n= number of observed patients, %=Percentage
DISCUSSION
In the management of clubfoot, a trend over the
last decade has been a movement away from extensive
soft-tissue release surgery for definitive clubfoot management and toward less invasive strategies focused
more on manipulation and castings.14
In our study a total of 70 patients with clubfeet were
included. Among these 43(61.4%) were males while
27(38.6%) were female. Twenty seven (38.6%) were bilateral club feet and 43(61.4%) were unilateral clubfeet.
A study of Royal College of Surgeon reported 38
male and 12 female of clubfoot with bilateral involvement in 27 patients.15 A local study has reported 30%
patients with bilateral deformity, 12.5% males and
17.5% females16. Our results are in accordance to other
studies showing predominance of male gender and
unilateral involvement of CTEV.
Achilles, tenotomy was done in 43(61.4%) patients
for the correction of equinovarus while 27(38.6) patients
achieved corrected foot with Ponseti casting without
tenotomy in our study. With the exception of tenotomy, no other surgical procedure was done in our study
to correct the deformities. Tenotomies were performed
73
on 55 of the 71 feet or 77.5% in Elshenawy EM et al,17
while Bor N et al,18 documented that twenty-four (32%)
babies underwent additional surgical procedures other
than tenotomy, including 21% who underwent tibialis
anterior tendon transfer in their study. Kampa R,19 recorded Achilles’ tenotomy in 46% of his patients, while
Abbas M et al,20 recorded a percutaneous tenotomy in
96% of patients and a repeat tenotomy was required in
5% of patients because of inability to get a satisfactory
amount of dorsiflexion after the first tenotomy in their
study. Gupta A et al,21 did tenotomy in 146 feet (95%)
and most of these had Pirani scores of more than 5.
Niki H et al,22 investigated the issue of negative
effect of Achilles tenotomy on clubfoot associated calfmuscle atrophy by ultrasonographic examination and
found that Achilles tenotomy had no significant negative short-term effects on calf-muscle atrophy associated with clubfoot. Parada SA, et al,23 has advocated that
percutaneous tendoachilles tenotomy under general
anesthesia offers the potential advantages of better pain
control, the ability to perform the procedure in a more
controlled manner, and the possibility of lessening the
pain response of the infant and nearly all patients can
be discharged on the day of surgery. Dogan A, et al,24
has advocated that that direct visualizing of the tendon
with mini-open incision may reduce the risk of neurovascular injury, especially for surgeons who are not experienced. Label E, et al,25 evaluated the safety of this
practice for the treatment of clubfoot when performed
as an “office procedure” without sedation or general
anesthesia during the final stage of the serial casting
protocol by retrospectively collecting data. They found
that tenotomy as an office procedure using topical and
local anesthesia is a safe procedure; do not incur a substantial rate of readmission to the emergency room. We
also done percutaneous Achilles’ tenotomy under local
anaesthesia using diluted 2% lignocaine and encountered no complications stated above by other authors.
The limitations of our study were a small number
of patients, wide range of their age and short follow-up
period. We also didn’t study the long term effects of
tenotomies on calf-muscle size and power. Further research should be undertaken to document the affects of
tenotomies on calf-muscle with similar groups and the
incidence of associated neurovascular complications.
CONCLUSION
Achilles’ tenotomy is quite common in our set up
while treating patients with CTEV up to 8 months of
age by Ponseti technique of manipulation and serial
casting. It must be fully discussed with the parents of
child with CTEV before starting Ponseti technique of
manipulation and serial casting for CTEV.
REFERENCES
1.
Lafargue GT, Morcuende JA. Effect of cast removal timing in
the correction of idiopathic clubfoot by ponseti method. Lowa
Orthop J 2007;27:24 -7.
74
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
Dao TT, Marin F, Bensahel H, Ho Ba Tho MC. Computer-aided
decision system for the clubfeet deformities. Adv Exp Med Biol
2011;696:623-35.
Dyer PJ, Davis N. The role of the Pirani scoring system in the
management of club foot by the Ponseti method. J Bone Joint
Surg Br 2006 Aug;88(8):1082-4.
Bor, Noam, Herzenberg, John E, Frick, Steven L. Ponseti management of clubfoot in older infants. Clini Orthop Related Res
2006;444:224–8.
Morcuende JA, Dolan LA, Dietz FR, Ponseti IV. Radical reduction in the rate of extensive corrective surgery for clubfoot using the ponseti method. Low J Paed 2004;113:376-8.
Atef AA, Wallace BL, Bosse V, Harold JP. Treatment of idiopathic clubfoot using ponseti method. minimum 2 years follow
up. J Paeds Orthop B 2007;16:98-105.
Iqbal J. Management of clubfoot using ponseti method. Pak
Paed J 2007;31:201- 5.
Agarwal RA, Suresh, Agarwal R. Treatment of congenital clubfoot with ponseti method. Ind J Orthop 2005;39:244 –7.
de Gheldere A, Docquier PL.Analytical radiography of clubfoot after tenotomy. J Pediatr Orthop 2008 Sep;28(6):691-4.
Faulky S, Luther B. Changing paradigm for the treatment of
clubfeet. Orthop Nr 2005;24:25-30.
Cummings R, Lowel W. Current concepts of operative treatment of CC. JBJS 1988;70:1108-12.
Sharma S, Butt MF, Singh M, Sharma S. The posterior to anterior controlled technique of percutaneous Achilles tenotomy in
the correction of idiopathic clubfoot: a technical report. J Pediatr Orthop B 2013 May;22(3):249-51.
Bor N, Katz Y, Vofsi O, Herzenberg JE, Zuckerberg AL. Sedation protocols for Ponseti clubfoot Achilles tenotomy. J Child
Orthop 2007 December;1(6):333–5.
Dobbs MB. Clubfoot: etiology and treatment. Clin Orthop Relat
Res 2009;467:111.
Charles LS, Kiely NT. Ponseti treatment in the management of
clubfoot deformity: a continuing role for paediatric orthopaedic
services in secondary centres. Ann R Coll Surg Engl 2007;89:510-2.
Hussain S, Inam M, Arif M, Sattar A, Saeed M. Turco’s posteromedial release for congenital talipes equinovarus. Gomal J Med
Sci 2007;5(2):51-4.
Elshenawy EM, Hassanen EY, Ramadam AI, IbrahimMM, The
Mansoura experience in treatment of clubfoot using the Ponseti
technique. Acta Orthop Belg 2008;5:74.
Noam, Bor, Julie A. Coplan, HerzenbergJE. Ponseti treatment
for Idiopathic Clubfoot Minimum 5-year Followup. Clin Orthop Relat Res 2009;467:1263–70.
Kampa R, Binks K ,Dunkley M, Coates C. Multidisciplinary
management of clubfeet using the Ponseti method in a district
general hospital setting. J Child Orthop 2008;2:463–7.
Abbas M, Qureshi OA, Jeelani LZ, Azam Q, Khan AQ, Sabir
AB. Management of Congenital Talipes Equinovarus by Ponseti Technique: a clinical study. J Foot Ankle Surg 2008;47:6.
Gupta A, Singh S, Patel P, Patel J, Varshney MK. Evaluation of
the utility of the Ponseti method of correction of clubfoot deformity in a developing nation. Inter Orthop (SICOT) 2008;32:75-9.
Niki H, Nakajima H, Hirano T, Okada H, Beppu M. Effect of Achilles tenotomy on congenital clubfoot-associated calf-muscle atrophy: an ultrasonographic study. J Orthop Sci 2013 Jul;18(4):552-6.
Parada SA, Baird GO, Auffant RA, Tompkins BJ, Caskey PM.
Safety of percutaneous tendoachilles tenotomy performed under general anesthesia on infants with idiopathic clubfoot. J
Pediatr Orthop 2009 Dec;29(8):916-9.
Dogan A, Kalender AM, Seramet E, Uslu M, Sebik A. Miniopen technique for the achilles tenotomy in correction of idiopathic clubfoot: a report of 25 cases. J Am Podiatr Med Assoc
2008 Sep-Oct;98(5):414-7.
Lebel E, Karasik M, Bernstein-Weyel M, Mishukov Y, Peyser A.
Achilles tenotomy as an office procedure: safety and efficacy as
part of the Ponseti serial casting protocol for clubfoot. J Pediatr
Orthop 2012 Jun;32(4):412-5.
GENERAL SECTION
Abid Halim
ORIGINAL ARTICLE
Comparative Effectiveness
of Early vs Delayed Oral Feeding
after Elective Intestinal Anastomosis
Abid Halim FCPS, FRCS1, Kamran Ahmad FCPS2, Prof. Ijaz Ahmad FCPS3
ABSTRACT
Objective: The objective of this study was to know the effectiveness of early versus conventional delayed enteral feeding
in intestinal anastomosis in terms of anastomotic leak.
Materials and Methods: 28 patients in each group were included in study to compare the effectiveness of early enteral
feeding (Group A) and conventional enteral feeding (Group B) for intestinal anastomosis in terms of anastomotic leak on
5th postoperative day. Data was entered in software SPSS version 10.0. T test was applied to compare the effectiveness of
both groups keeping p value < 0.05 as significant.
Results: The mean ages of group A and B patients were 36.8 years + 10.2SD and 37.1 years + 25.0SD (P value = 0.9036).
In group A, Ileostomy closure was done in 15 (53.57%) and ileocolic anastomosis was done in 13 (46.43%) patients. In
group B, Ileostomy closure was performed in 19 (67.86%) patients and ileocolic anastomosis was done in 9 (32.14%) patients. (P value = 0.412). In group A, the intestinal anastomotic leak was observed in 1 (3.57%) patients and in group B with
delayed enteral feeding, it was noted in 9 (32.14%) patients (P=0.012).
Conclusion: The early feeding in patients with intestinal anastomosis is tolerable, as significantly small number of patients
developed leak as compared to conventional group.
Key Words: Intestinal Anastomosis; Early feeding; Conventional feeding; Anastomotic Leak.
INTRODUCTION
Gut anastomosis is one of the most commonly
performed surgeries in both emergency and elective
cases like traumatic rupture of gut, benign or malignant perforation or obstruction and in certain other
inflammatory conditions.1,2 After surgical procedure,
the loss or reduction of motility in the gut is common
and this transient condition lasts from a few hours to
few days and is inappropriately called paralytic ileus,
nondynamic ileus or even post-operative ileus (PI).3,4
It is characterized by abdominal distention, absence or
reduction of bowel sounds (BS); failure to pass flatus
and open bowels; nausea and vomiting; and abdominal
pain.5,6
A ‘nil by mouth’ (NBM) approach after gut anastomosis surgery has been well known for many years
due to transient paralytic ileus. Early enteral nutrition
(EN) has become very popular and received increasing attention in recent years.7 Many prospective randomized trials performed in recent years evaluating the
effects of nasogastric intubation have suggested that it
may be unnecessary, itself delaying passage of flatus
and bowel movements as well as lengthening the duration of hospital stay.8 There is no universal answer
Associate Prof of Surgery, 2Medical Officer, 3Prof. & Head of Surgery,
Surgical Unit, Khyber Teaching Hospital, Peshawar
1
Correspondence: Dr. Abid Halim, House: 134, St: 4, Sector K-1,
Phase: III, Hayatabad, Peshawar. Email: [email protected]
Cell: 03005865657
to the question of how much early enteral feeding is
safe? The complications of early and delayed enteral
feeding have been reported with controversies. Some
claims that early enteral feeding has better results than
delayed enteral feeding in terms of wound and respiratory infections, hospital stay, mortality and vice versa.
Ahmet Dag, et al has reported the superiority of early
enteral feeding and observed that the rate of wound infection (5.05% vs. 7.00%), Mean hospital stay (5.55 VS.
9.0) and anastomotic leakage (2.02% vs 6.00%) were less
in the early feeding group.9 On the other hand, Chatterjee S, et al has showed that in early feeding group the
rate of nausea and vomiting (20% vs 13.33%), wound
infection and dehiscence (25% vs 13.33%), respiratory
tract infection (16.67% vs 8.33%) anastomotic leakage
(13.33% vs 5%) and mortality (6.67% vs 1.67%) was
more than delayed enteral feeding group.10
The current study was designed to determine the
effectiveness of early and delayed enteral feeding for
patients undergoing elective intestinal anastomosis in
our local population.
This comparative study was carried out at Department of General Surgery, Khyber Teaching Hospital,
Peshawar, KPK from January to December, 2012 recruiting 28 patients in each group by consecutive non
probability sampling. The inclusion criteria adopted
was; patients between 13 and 60 years of either gender
who underwent intestinal anastomosis for Ileostomy
closure and Ileocolic anastomosis. The exclusion criteria was; all the emergency cases in which signs of peri75
Comparative Effectiveness of Early vs Delayed Oral Feeding after Elective Intestinal Anastomosis
tonitis were present like abdominal distension, pain abdomen, fever, absent bowel sounds, Diabetes mellitus,
uremia and malignancy, those who were using steroids
and anemic patients. All the above conditions could alter the healing process of anastomosis, acting as confounders and hence they were excluded from the study.
The patients were admitted through OPD. The
purpose of the study was explained to the patients.
Informed written consent was taken from those who
agreed to participate in the study. History, clinical
examination and routine pre-op investigations (FBC,
Blood urea/Sugar, serum creatinine, serum electrolytes, urine R/E, ECG) and distal loopogram were
performed and the names of patients were put on the
next elective operation theater (OT) list. In all patients,
single layer interrupted intestinal anastomosis with
2/0 vicryl was done. Patient in group A received early
enteral feeding after 24 hours starting from clear fluid
sips. On tolerating the fluid they were started on free
fluids, semi solid food and then solid food gradually.
Patients in group B were kept nothing by mouth and
nasogastric tube (NGT) was placed immediately postoperatively for 72 hours. They were started on enteral
feeding after removing the NGT when the output was
less than 50-100 ml/day after 72 hours and there was
no paralytic ileus and when bowl sounds were audible.
The patients were gradually shifted from liquid to semisolid and then to solid normal diet. Anastomotic leak
was diagnosed clinically by the presence of all of the
signs and symptoms of abdominal pain, raised pulse
(>100/minutes) and temperature (>100F0), abdominal
tenderness and absent bowel sounds and leak apparent on gastrointestinal contrast study (Barium follow
through) or gut contents, either discharging from the
wound or the anastomotic site (on re exploration). In
both group injection Ceftriaxone 1gm and infusion
Metronidazole 500ml was given at the time of anesthesia induction and then post operatively, Ceftriaxone
1gm was given 12 hourly and infusion Matrinadazole
500ml was given 8 hourly intravenously. Standard protocols of aseptic techniques were practiced while doing
intestinal anastomosis in both groups. After anastomosis, skin was closed with prolene 2/0 by interrupted suture technique. All the surgeries were performed by an
experience surgical team. A closed system of drainage
was applied, needed for hematoma prevention intraperitoneally. N/G tube was kept for 24 hours in both
groups.
Post operative patients were assessed for signs of
intestinal leak; 12 hourly and information about the
anastomosis was recorded on pre designed proforma
up to the 5th post operative day. Effectiveness was determined if there was no anastomosis leak till 5th post76
operative day. The patients were discharged on 6th
postoperative day if indicated. Exclusion criteria was
strictly followed to control confounders and bias in the
study results.
The data was analyzed in SPSS version 10.0. Percentages and frequencies were calculated for categorical variables like gender and procedure effectiveness
while mean and standard deviation were calculated for
numeric variables like age. Results were presented in
the form of tables and graphs. P value < 0.05 was considered significant.
RESULTS
Total number of patients in each group was 28: 20
(71.42%) males and 8 (28.57%) females in Group A and
18 (64.29%) males and 10 (35.71%) females in group B (P
value = 0.775) (Graph no 1). The mean ages of group A
and B patients were 36.8 years + 10.2SD and 37.1 years
+ 25.0SD (P value = 0.9036).
In group A, Ileostomy closure was done in 15
(53.57%) and ileocolic anastomosis was done in 13
(46.43%) patients. In group B, Ileostomy closure was
performed in 19 (67.86%) patients and ileocolic anastomosis was done in 9 (32.14%) patients. (P value = 0.412)
(Graph no. 2)
In group A, the intestinal anastomotic leak was
observed in 1 (3.57%) patients and in group B with
delayed enteral feeding, it was noted in 9 (32.14%) patients. The P value was statistically significant; 0.012.
(Table 1). The only single case of intestinal anastomosis
leak in group A was observed in patient with ileocolic anastomosis while in group B, intestinal leak was
noted in 2 (7.14%) patients with ileostomy closure and
7 (25.00%) patients of ileocolic anastomosis. (Table No.
2). Age and gender distribution is shown in detail in
table no. 2.
Graph 1: Gender distribution of patients
in group A (early enteral feeding) & B
(delayed enteral feeding) after elective
intestinal anastomosis
(P value = 0.775)
Graph-2: Procedures done in patients with intestinal
anastomosis – group A (early enteral feeding) & B
(delayed enteral feeding) after elective intestinal
anastomosis
P value = 0.412
Table-1: Intestinal anastomosis leakage in group A
(early enteral feeding) & B (delayed enteral feeding) after
elective intestinal anastomosis
Intestinal Leakage
Group A
Group B
Yes
1 (3.57%)
9 (32.14%)
No
27 (96.43%)
19 (67.86%)
P value
0.012
Table-2: Intestinal anastomosis leakage in group A
(early enteral feeding) & B (delayed enteral feeding)
according to type of procedure, gender and age groups
after elective intestinal anastomosis
Intestinal Leakage
Ileostomy closure
Ileocolic anastomosis
Group A
Group B
0 (0%)
2 (7.14%)
1 (3.57%)
7 (25.00%)
P value
1.000
Gender
Male
0 (0%)
4 (14.29%)
1 (3.57%)
5 (17.86%)
13-30
0 (0%)
1 (3.57%)
31-40
0 (0%)
1 (3.57%)
41-50
0 (0%)
3 (10.71%)
51-60
1 (3.57%)
4 (14.29%)
Female
1.000
Age groups (years)
1.000
DISCUSSION
Intestinal anastomosis is frequently performed as
an emergency and elective procedure due to traumatic
rupture, benign or malignant perforation or obstruction and in certain other inflammatory conditions. As
a conventional practice after gut anastomosis, patients
are kept “nothing by mouth” till bowel sounds return.
During this time period, patient remains with nasogastric tube for decompression of stomach and providing
rest to the gut. As Adequate nutrition has always been
a major goal in postoperative care and early oral intake
has also been suggested to reduce sepsis risk because of
decreased bacterial colonization and decreased translocation through defects in the bowel mucosa into the
blood circulation. our this study was based on the fact
that wound healing as well as anastomotic strength improves in patients of early oral feeding and the concept
of withholding oral intake postoperatively does not
seem to be reasonable.11
In our study, intestinal anastomotic leak was observed in 1 (3.57%) patients in early feeding group. This
only single case of intestinal anastomosis was with ileocolic anastomosis. In patients with delayed enteral
feeding, 9 (32.14%) patients developed anastomosis
leak; 2 with ileostomy closure and 7 patients of ileocolic
anastomosis. (P= 0.012). Roy A et al,12 studied the early
oral feeding early enteral feeding by giving clear water 18 hours after gut anastomosis in 51 patients. They
found that only 3 patients (5.88%) of 51 developed clinical evidence of anastomotic leakage. One out of these
three died due to electrolyte imbalance. In our study,
only one patient in group B died due to sepsis and DIC.
All the patients of both groups showing clinical evidence of intestinal leak were re-explored and repeat ileostomy were done. Similarly Thapa pb et al,13 reported
only one patient with anastomotic leak in early feeding
group and in the control group 2 patients. Also return
of bowel sounds, lesser episodes of vomiting, shorter
hospital stay postoperatively were better in the early
feeding group compared with conventional feeding
group.
On the other hand some researchers10 have claimed
that conventional enteral feeding has significantly low
anastomotic leakage (5%), as compared to early feeding
group (13.33%) (p = 0.206). Some claim that both methods of enteral feeding has same effects regarding abdominal diameter, bowel sounds, flatulence and bowel
opening, presence or absence of abdominal pain, nausea and/or vomiting. Patients in both the test group
and the control group did not show any difference as
to the period of hospital stay, recovery time of postoperative ileus and diet tolerance. some authors advocate that ‘nothing by mouth’ and gastric decompression
prevent postoperative nausea and vomiting and protect the anastomosis, allowing time to heal before being
stressed by food. Results of our study were against this
concept. Also, there is no evidence that bowel rest and
‘nothing by mouth’ are beneficial for healing of wounds
and anastomotic integrity. Indeed, the evidence is that
luminal nutrition may enhance wound healing and increase anastomotic strength, with reduction in perioperative infection, better maintenance of nitrogen balance and shorter hospital stay.15,16,17,18,19
The method of early feeding after intestinal anastomosis is more economical in terms of hospital stay,
cost of treatment and rehabilitation. These parameters
are of great significance in our setting as reduced post77
operative stay may be beneficial for the patient psychologically. Our study was limited by the small sample size as we included only 28 patients in each group.
Perhaps the use of a larger sample would enable and
encourages to see the positive effects of the study in a
more comprehensive manner.16
The other limitations of the study were; we did
not assess the long term effects of early feeding such as
wound infection and intra-abdominal sepsis. Although
the data are significantly clear to conclude that early
enteral feeding is of proved benefit in terms of anastomotic leak, we understand the need of further extended
studies to clarify the issue of early feeding in intestinal
anastomosis.
CONCLUSION
The findings in the present study in terms of anastomotic leakage conclude that early feeding in patients
with intestinal anastomosis is tolerable, as significantly
small number of patients developed leak as compared
to conventional group.
REFERENCES
1.
Oprescu C, Beuran M, Nicolau AE,Negoi I, Venter MD, Morteanu S, et al. Anastomotic dehiscence (AD) in colorectal cancer
surgery: mechanical anastomosis versus manual anastomosis. J
Med Life 2012 December 15;5(4):444-51.
Sciumè C, Geraci G, Pisello F, Arnone E, Romeo M, Modica G.
Mechanical versus manual anastomoses in colorectal surgery.
Personal experience. G Chir. 2008 Nov-Dec;29(11-12):505-10.
Bernardes LFM, Filho AD. Early enteral feeding after upper digestive tract surgeries and clinical assessment of post-operative
ileus. Biosci J 2008 Oct-Dec;24:4:100-7.
[Neutzling CB, Lustosa SA, Proenca IM, da Silva EM, Matos D.
Stapled versus handsewn methods for colorectal anastomosis
surgery. Cochrane Database Syst Rev. 2012 Feb 15;2:CD003144.]
Carroll J, Alavi K. Pathogenesis and management of postoperative ileus. Clin Colon Rectal Surg 2009 February;22(1):47–50.
[Oprescu C, Beuran M, Nicolau AE, Negoi I, Venter MD, Morteanu S, et al. Anastomotic dehiscence (AD) in colorectal cancer
surgery: mechanical anastomosis versus manual anastomosis. J
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Shrikhande SV, Shetty GS, Singh K, Ingle S. Is early feeding after major gastrointestinal surgery a fashion or an advance? evidence-based review of literature. J Can Res Ther 2009;5:232-9.
S. Marwah, R. Godara, R. Goyal, N. Marwah, R. Karwasra:
Early enteral nutrition following gastrointestinal anastomosis.
Internet J Gastroenterol 2008;7(1):DOI: 10.5580/225.
Dag A, Colak T, Turkmenoglu O, Gundogdu R, Aydin S. A
randomized controlled trial evaluating early versus traditional
oral feeding after colorectal surgery. Clinics 2011;66(12):2001-5.
Chatterjee S, Bala SK, Chakraborty P, Dey R, Sinha S, Ray R, et
al. A comparative study between early enteral feeding (within 24 hours) versus conventional enteral feeding after enteric
anastomosis. Bangladesh J Med Sci 2012 Oct;11(04):273-83.
Ng WQ, Neill J. Evidence for early oral feeding of patients after elective open colorectal surgery: a literature review. J Clin
Nurs. 2006 Jun;15(6):696-709.
Roy A, Ghosal D, Jana A. Early enteral feeding following small
gut anastomosis; an institution based prospective study. J Surg
Arts 2013;6(1):4-7
Thapa PB, Nagarkoti K, Lama T, Maharjan DK, Tuladhar M.
Early enteral feeding in intestinal anastomosis. J Nepal Health
Res Counc 2011 april;9(18):1-5.
Bernardes LFM, Filho AD. Early enteral feeding after upper digestive tract surgeries and clinical assessment of post-operative
ileus. Biosci J 2008 Oct/Dec;24(4):100-7.
Silk DBA. Postoperative starvation after gastrointestinal surgery: Early feeding is beneficial. BMJ 2001 October
6;323(7316):761–2.
Lewis SJ, Egger M, Sylvester PA, Thomas S. Early enteral
feeding versus “nil by mouth” after gastrointestinal surgery:
systematic review and meta-analysis of controlled trials. BMJ.
2001 October 6;323(7316):773.
Andersen HK, Lewis SJ, Thomas S. Early enteral nutrition
within 24h of colorectal surgery versus later commencement
of feeding for postoperative complications. Cochrane Database
Syst Rev. 2006 Oct 18;(4):CD004080.
Osland E, Yunus RM, Khan S, Memon MA. Early versus traditional postoperative feeding in patients undergoing resectional
gastrointestinal surgery: a meta-analysis. JPEN J Parenter Enteral Nutr. 2011 Jul;35(4):473-87.
Shrikhande SV, Shetty GS, Singh K, Ingle S. Is early feeding
after major gastrointestinal surgery a fashion or an advance?
Evidence-based review of literature. J Cancer Res Ther 2009
Oct-Dec;5(4):232-9.
IMPORTANT NOTE:
Authors of articles and the subscribers are requested to collect the copies of Ophthalmology Update
from representatives of the concerned area according to the following:
78
SR #
Name
Area
Number
1
2
3
4
5
6
Aamir Zaib
Waqas Majeed
Waseem Ejaz
Syed Arshad Ali
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Khalid Mehmood
Peshawar
Rawalpindi
Lahore
Faisalabad
Multan
Karachi
03337771210
03337771248
03337771288
03337771290
03337771303
03337771343
GENERAL SECTION
Yousaf Jan
ORIGINAL ARTICLE
Frequency of Early Non-Infectious
Wound Complications after Clean Surgery
for Inguinal Hernia Repair
Yousaf Jan Shinwari, FCPS (General Surgery)1, Waqas MBBS2
Muhammad Imran Khan MCPS3
ABSTRACT
Objective: Clean wounds are defined as elective, non-emergency, non-traumatic, made under sterile aseptic surgical
condition and in which respiratory, gastrointestinal, genitourinary tracts are not entered. Post-operative complications of
wounds can be divided into early, intermediate and late. Early complications are those that occur within 30 days of operation. To determine the frequency and common factors leading to early non-infectious wound complications after clean incised
surgical wounds for inguinal hernia repair.
Materials and Methods: Necessary workup was done including complete physical examination and data collection regarding confounding factors. All baseline and needful investigations were done and recorded. After surgery, patients were followed on 0, 2nd, 7th, 14th, and 30thpost operative day. Any complications observed were recorded on a proforma.
Results: A total of 206 patients were included in the study. Average age of the patients was 47.16years+12.84SD with range
of 19-73 years. Majority of patients had haematoma which was found in 19% patients.
Conclusions: Haematoma was the major early complication while obesity is the major factor leading to early complications
in our study.
Key words: Inguinal hernia, Haematoma, Seroma, Wound dehiscence.
INTRODUCTION
Despite the advances that has been made in the
fields of medicine and surgery over the past century,
post-operative wound complications remains an inevitable consequence of any surgery. Whenever there is a
complication it means increased length of hospital stay,
delay in recovery, lost time from work, greater cost to
the patient and health care system.1
In surgical practice wounds are classified as
clean, clean contaminated, contaminated and dirty
wounds.2 Clean wounds are defined as elective,
non- emergency, non-traumatic, made under sterile
aseptic surgical conditions and in which respiratory,
gastrointestinal, genitourinary tracts were not entered.3 Post-operative complications of wounds can be
divided into early, intermediate and late4. Early complications are those that occur within 30 days of operation.4,5 Early complications may be infectious or non
infectious.6 Common non-infectious complications are
haematoma, seroma and wound dehiscence.2 Noninfectious wound complications are frequent and often confused with and treated as infection.6 A number of risk factors are responsible for
increased occurrence of non-infectious wound
1
Surgical Specialist at AHQ Hospital, Landi Kotal, 2Trainee Medical Officer
(Gen Surgery), 3Medical Officer Khyber Teaching Hospital, Peshawar
Correspondence: Dr. Yousaf Jan, District Specialist, AHQ Hospital
Landi Kotal, Cell: 0333-9279312, Email:[email protected]
Address: H # 89, St # 2, Sector K5, Phase 3 Hayatabad Peshawar
Received: August’13
Accepted: September’13
complications like age>75 years, obesity, drugs like
steroid, chemotherapeutic agents, anticoagulants,
immune-suppressants, anemia, malignancy, jaundice,
ascites, uraemia, pulmonary disease, vascular disease,
hypertension, smoking, length of incision, depth of
incision, foreign body, site of incision and wound
closure technique.7.8
Inguinal hernia repair is the most common clean
surgical procedure world wide.9 Inguinal hernia affects both men and women but is more common in
men who comprise 90% of operated patients.9 The life
time prevalence rate is 47% for men up to the age of 75
years.9 Worldwide about 20 million hernia repairs are
done every year.10 Inguinal hernia can only be cured by
surgery.9 Among 70 operative techniques, today only
three are considered as the best evidence based treatment options: suture repair according to Shouldice, flat
open mesh repair according to Lichtenstein and the
laparoscopic/endoscopic methods.10 The most common method is Lichtenstein using heavy weight, polypropylene (80g/m2) mesh.10
In literature the reported rates of seroma formation after open mesh repair for inguinal hernia surgery
varies from 1.6% to 12.6%.11 In one study of all the patient who developed seroma, 36% had a BMI of more
than 25kg/m2 and 25% were smokers.2,13
The economic impact of inguinal hernia surgery is
high on the health care system, yet there is scarcity of
literature regarding early non-infectious wound complications and associated risk factors. Much of the em79
Frequency of Early Non-Infectious Wound Complications after Clean Surgery for Inguinal Hernia Repair
phasis is being given on infection in prosthetic surgery,
though non-infectious complications are much more
common and misdiagnosed and treated as infection.
The finding of seroma or haematoma in inguinal hernia surgery is regularly associated with post-operative
pain and patient discomfort and in particular can lead
to severe infection with increased risk of hernia recurrence and mesh removal. These complications also
cause increased length of hospital stay, frequent visits
to the hospital and in some cases percutaneous drainage or surgical intervention, all increasing extra burden
on health care system. The aim of the present study is to
describe the most common early non-infectious complications in clean incised surgical wounds like open mesh
hernioplasty and common factors leading to these complications. This study will not only identify the magnitude of the problem but also the recognition of the risk
factors which will help the surgical team in adopting
proper preventive measures and also effective management strategies of these complications. In our opinion
it will improve outcome, improve quality of treatment,
decrease morbidity and decrease extra burden on hospitals.
MATERIALS & METHODS
This case series study was conducted 0ver 206 patients in Hayatabad Medical Complex Peshawar from
June 2009 to June 2010. All patients undergoing Lichtenstein mesh repair for inguinal hernia admitted
through OPD and planned to be subjected to hernia
repair on elective list after obtaining written informed
consent.
Patient’s demographic data were recorded on proforma. Necessary workup was done including complete physical examination and data collection regarding confounding factors. All baseline and needful
investigations were done and recorded. All patients
were operated under strict aseptic technique by a single surgeon.
The patients were followed on 0, 2nd, 7th, 14th, and
th
30 post operative day. Any complications observed
were recorded on a proforma. Patients developing noninfectious complications like hematoma, wound dehiscence and seroma were carefully scrutinized for common factors like obesity, anemia, prolong duration of
surgery and hypertension.
Patients with bleeding disorders, diabetes mellitus, using oral, intravenous or inhalational steroids or
history of steroid use within three months of presentation and wounds developing surgical site infection post
operatively within 30 days of surgery were excluded
from the study. Exclusion criteria were followed strictly to control confounders and bias in the study results.
RESULTS
A total of 206 patients with clean incised surgical
wounds for inguinal hernia repair were included in the
80
study. All the patients were male and there was no female patient.
Average age of the patients was 47.16years+12.84SD
with range of 19-73 years. Patient’s age was divided in
four categories, out of which most common age group
for inguinal hernia repair was 46-60 years in our study.
There were 33 (16%) patients of the age less than or
equal to 30 years, 40 (19.4%) patients were in the age
range of 31-45 years, 105 (51.0%) were of age range 4660 years, 28 (13.6%) presented at age more than 60 years
of age. Early non-infectious complications showed that
majority of patients had haematoma which was found
in 19.41% patients. (Fig 1)
Fig No 1: Early non-infectious complications
The common factors leading to early non-infectious wound complications in clean incised surgical
wounds were observed, in which 61 (29.6%) were obesity, 31 (15%) were anemia, 16 (7.8%) have hypertension and 53 (25.7%) were prolonged surgery. Early noninfectious wound complications were more common in
middle and old age as compared to younger age in our
study. Fig 2 Risk factor wise distribution of early noninfectious wound complications shows that risk factors
have no major role over complication. Table 1
Table 1: Age wise distribution of common factors
Prolonged surgery
21.2%
40.0%
27.60%
3.6%
Hypertension
3.0%
12.5%
7.60%
7.1%
Anaemia
6.1%
12.5%
18.10%
17.9%
Obesity
21.2%
40.0%
30.50%
21.4%
<=
30
31-45
46-60
+60
Table 2: Age wise distribution of early non-infectious
wound complications
Seroma
18.2%
12.5%
12.40%
17.9%
Wound dehiscence
6.1%
2.5%
2.9%
10.7%
Hematoma
15.2%
20.0%
20.0%
28.6%
<=
30
31-45
46-60
+60
Table 3: Risk factors wise distribution of early non infectious wound complications Haematoma
Yes
Obesity
Anemia
Hypertension
Prolonged Surgery
Wound Dehiscence
No
Yes
No
Seroma
Yes
No
%
%
%
%
%
%
Yes
35.7%
28.0%
11.1%
30.5%
17.2%
31.6%
No
64.3%
72.0%
88.9%
69.5%
82.8%
68.4%
Yes
21.4%
13.4%
11.1%
15.2%
6.9%
16.4%
No
78.6%
86.6%
88.9%
84.8%
93.1%
83.6%
Yes
7.1%
7.9%
.0%
8.1%
6.9%
7.9%
No
92.9%
92.1%
100.0%
91.9%
93.1%
92.1%
Yes
21.4%
26.8%
33.3%
25.4%
10.3%
28.2%
No
78.6%
73.2%
66.7%
74.6%
89.7%
71.8%
DISCUSSION
Hernia mesh repair is associated with both infectious and non-infectious wound complications.2 The
composition and type of mesh seems to be responsible
for these complications. The repair of abdominal wall
defects in potentially contaminated or grossly infected
fields presents a difficult clinical problem. Polypropylene mesh is relatively contraindicated in these settings
because of the potential for chronic infection.14
Inguinal hernia is more likely to occur in men than
in women because the spermatic cord passes through
the abdominal wall in the inguinal region, leaving a site
of natural weakness prone to hernia formation.4 Results
of a local study conducted at Lady Reading Hospital,
Peshawar, also selected male patients.15
Old age cannot be considered as an absolute risk
factor in the surgical treatment of inguinal hernia,
which can also be stated for the majority of elderly people pathologies. The modern tension-free techniques
have demonstrated in cardiopathic patients, the same
advantages which have been observed in elderly non
cardiopathic patients.17 In our series of 206 patients
mean age was 47.16years+12.84SD , which is comparable to some local studies.6,8 In our study there were 45%
patients in the age ranges of 51-80 years. There was no
mortality in any age group in this series. Same results
were also reported by a local study, which was conducted at Lady Reading Hospital, Peshawar, in which all
patients were male with mean age of 49 years.16 While
few local and international studies reported mean age
of > 60 years in their studies,16,18,19 differences in mean
ages are probably due to sample selection criteria of
various studies according to their inclusion criteria, as
we have included patients from 19 years to 73 years,
whereas in few studies they included older age patients
e.g. from 40 to 90 years.
The goals of a successful hernia repair include low
recurrence rates, permanent relief of pain or discomfort
and low incidence of peri and postoperative complicaOphthalmology Update Vol. 12. No. 1, January-March 2014
tions, such as wound infections and intra-abdominal
adhesions.20
Wound dehiscence was observed in our study in
4.36% patients at follow up. Wound infection was superficial and was managed with antiseptic dressing
and antibiotics. No patient required mesh removal for
control of infection. Our finding were comparable with
a local study in which the incidence of wound infection
was reported as 7.5%.13,7 In few other local studies the
incidence of wound infection has been reported from
1% to 4% cases.5,21,23-25 Wound hematoma was recorded in 19.41% cases and seroma in 14.07% cases in our
study.
The risks of infection are there but use of antibiotics has overcome these problems.24 Infection rate in
our study was much more than reported at local and
international levels. Reasons for this being poor hygienic environment in operating rooms and wards,
overcrowding in hospitals, and majority of operations
were performed by less experienced surgeons. The
other reason is from the patient’s side, as majority of
our patients belonged to low socioeconomic status and
they were living in poor and unhygienic conditions. In
our province as transportation is a big and unaffordable matter, major portion of our patients living in the
far-flung areas were unable to come for early treatment
and remedy of their infections.
Results of another local study showed that wound
seroma developed in 8.4% patients in Lichtenstein tension free mesh repair and 3.1% patients developed
haematoma. Abscess formation was noticed in 1.9%
patients and urinary retention developed in 4.6% patients. Numbness or pain in the groin was complained
by 10% patients and recurrence developed in 2(0.8%)
patients.5 Another local study reported that minor
wound infection was noted in two cases and seroma
formation in one case. There were two cases of recurrence during initial follow up of one year. At the end
they concluded that tension free mesh repair is the pro81
cedure of choice for inguinal hernia repair.25
Duration of hospital stay is another risk factor for
acquiring infections during this period. In our study
majority of our patients stayed in hospital from 3 to 5
days with mean hospital stay of 3.5 + 0.63 days. More
or less same results are reported in various national and
international studies.5,26
CONCLUSION
Mesh repair is an easy and safe procedure for different types of hernias. Although it is an efficient method of hernia repair but associated with a number of
complications. These complications can be prevented
with good surgical techniques, aseptic measures and
effective prophylactic antibiotics. It is strongly recommended that mesh repair is the first treatment option
for patients with primary and recurrent inguinal hernias with good antibiotics cover preoperatively.
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Perkins JD, Pattillo RA. How to avert postoperative wound
complications and treat it when it occurs. OBG management
2009;21(10):43-53
2.
Paral J, Ferko A, Varga J, Antos F, Plods M , Lochman P, et al.
Comparison of sutured versus non sutured subcutaneous fat
tissue in abdominal surgery. Eur Surg Res. 2007;39:350-8
3.
Rosenthal R, Weber WP, Marti WR, Misteli H, Reck S, Dangel
M, et all. Surveillance of surgical site infections by surgeons. J
Hospital infect. 2010;75(3):178-82
4.
Skroubis G, Karamanakos S, Sakellaropoulos G, Panagopoulos
K, Kafarentzos F. Comparison of early and late complications
after various bariatic procedures; Incidence and treatment during 15 years at a single institution. World J Surg.2011;35:93-101
5.
Takeshi T, Takao K, Hiroyuki I, Yoko Y, Hiroshi Y, Hirofumi
K, et all. Management of biliary complications in patients with
gallbladder stones in situ after endoscopic papillary balloon
dilatation. Eu J Gastroenterol hepatol. 2009;21(4):466-70
6.
Uckay I, Agostinho A, Belaieff W, Toutous-Trello L, SchererPietramaqqiori S, Andres A, et al. Non-infectious wound complications in clean surgery:epidemiology, risk factors, and association with antibiotic use. World J Surg. 2011;35(5):973-80
7.
Abbas SM, Hill AG. Smoking is a major risk factors for wound
dehiscence after midline abdominal incision; case-control
study. ANZ J Surg. 2009;79:247–50
8.
Stannard JP, Atkins BZ, Malley DO, Singh H, Bernstein B, Fahey
M, et all. Use of negative pressure therapy on closed surgical
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9.
Eklund A. Laparoscopic or open inguinal hernia repair-which
is best for the patient? Acta Universitatis Upsaliensis. Digital
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Bittner R, Schwarz J. Inguinal hernia repair: current surgical
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case procedure. J Surg Pak. 2011;16(1):18-21
Kliuk CD, Blinnebosel M, Lucas AH, Schachtrupp A, Grommes
J, Conze J, et all. Serum analysis for protein, albumin and 1L-1.
RA serve as reliable predictors for seroma formation after incisional hernia repair. Hernia. 2011;15:69-73.
Kendall C, Murray S. Is watchful waiting a reasonable approach for men with minimally symptomatic inguinal hernia?
Can Med Assoc J. 2006;174:1263-4.
Ueno T, Pickett LC, de la Fuente SG, Lawson DC, Pappas TN.
Clinical application of porcine small intestinal submucosa in
the management of infected or potentially contaminated abdominal defects. J Gastrointest Surg. 2004;8:109-12.
Naeem M, Khan SM, Qayyum A, Jan WA, Jehanzeb M, Mehmood K. Recurrence of inguinal hernia mesh repair. J
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Suzuki S, Furui S, Okinaga K, Sakamoto T, Murata J, Furukawa A, et al. Differentiation of femoral versus inguinal hernia:
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Frazzetta M, Di Gesu G . Inguinal hernia perforly on elderly cardiopath patients. Acta Biomed Ateneo Parmense.
2005;76(1):42-5.
Malik AM, Khan A, Talpur KAH, Laghari AA. Factors influencing morbidity and mortality in elderly population undergoing inguinal hernia surgery. J Pak Med Assoc. 2010;60:45-7.
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Goldenberg A, Matone J, Marcondes W, Herbella FA, Farah JF.
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Koukorou A, Lyon W, Rice J, Wattchow DA. Prospective randomized trial of polypropylene mesh compared with nylon darn
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Baluch GMK. Inguinal hernia repair under local anaesthesia. J
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Jan WA, Ghani A. Synthetic mesh repair of inguinal hernia under local anaesthesia. J Postgrad Med Inst. 2001;15:157-60.
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Hernia. 2010;14:143-8.
GENERAL SECTION
Khalid Khan
ORIGINAL ARTICLE
Frequency of Radial Nerve Injury
in Patients with Closed Fracture
of Humerus Shaft
Muhammad Khalid Khan, FCPS1, Abbas Ali Khan, MBBS2
Muhammad Shoaib Khan, FCPS3, Javed Iqbal MBBS4
Orthopaedics &Trauma Unit, Khyber Teaching Hospital, Peshawar, KPK
ABSTARCT
Background: Radial nerve palsy is a common condition occurring in patients with traumatic humeral fractures.
Objective: to determine the Frequency of radial nerve injury in patients presenting with closed fracture of the shaft of
humerus.
Study Design: This descriptive cross sectional study was done at Department of Orthopedics and Traumatology Unit of
Khyber Teaching Hospital Peshawar, from September, 2011 to September 2013 recruiting 164 patients. Patients were
managed initially by fracture stabilization and analgesia requirement then they were carefully assessed to detect radial
nerve injury on the basis of wrist drop with no extension of wrist, finger and thumb. Data was analyzed with the help of
SPSS version 10.00.
Results: There were 100 (60.97%) males and 64 (39.03%) females. There were 60 (36.58%) spiral fracture, 40 (24.39%)
transverse fracture, 34 (20.73%) comminuted fracture and 30 (18.29%) segmental fracture. Radial nerve injury was present
in 14 (8.53%) patients; 7 (11.66%) in spiral, 3 (7.55%) in transverse, 2 (5.88%) in comminuted and 2 (6.66%) in segmental
fractures of humerus shaft.
Conclusion: The frequency of radial nerve injury is more in patients with spiral and transverse closed fracture of the
humerus shaft.
Key words: Radial nerve injury, closed humerus shaft fracture
INTRODUCTION
Radial nerve palsy is a common condition occurring in patients with traumatic humeral fractures.1,2
It is due to the anatomic location of the radial nerve
which turns around the distal portion of the humeral
shaft and is separated from it by a layer of triceps fibers.
When the radial nerve pierces the lateral intramuscular
septum to enter the anterior compartment of the arm, it
is relatively more fixed and susceptible to injury.3,4
Radial nerve palsies with humeral fractures may
be primary or secondary. Primary nerve palsies that
occur at the time of the injury.5 Secondary palsies are
those that occur with closed reduction and manipulation or open reduction and internal fixation. Only a few
cases of radial palsy due to humeral fracture are reported in the literature.6
If the radial nerve gets damaged there is difficulty
extending the arm past the elbow, difficulty maneuvering the wrist, numbness, a decrease in sensation,
tingling, burning sensations and pain.7 Humeral shaft
1
Registrar 2PG Trainee 3Assistant Prof. 4PG Trainee
Correspondence: Dr. Muhammad Khalid Khan, Registrar,
Orthopaedics and Trauma Unit, Khyber Teaching Hospital, Peshawar,
KPK.
Email:
[email protected],
[email protected]
Cell: +92-321-9081319 Address: Room: 92, New Doctors’ Hostel,
Khyber Teaching Hospital, Peshawar
fracture with radial nerve palsy and its management
has been the subject of debate.8 since this entity was
originally described by Holstein and Lewis in 1963.9,10
In the last years a conservative treatment of a humeral
fracture is the exception and only used after straight
indications. The operative therapy nowadays is the
gold standard because of the development of new intramedullar and rotation stable implants in addition to
the classical osteosynthesis with the plate.11 This study
was designed to know the current frequency of radial
nerve injury in closed humeral shaft fracture so that in
the light of this frequency we may be able to design certain guidelines and recommendations in early workup
for radial nerve injury in patients with closed fracture
of humerus shaft.
This study was conducted in Department of Orthopedics and Emergency room, Khyber Teaching Hospital, Peshawar from Sept, 2011 to Sept, 2012 recruiting
164 patients from OPD of orthopedic department and
emergency room. All patients of both genders between
20-60 years having closed fracture of shaft of humerus
were included in the study. Those patients having open
fracture or pathological fracture of shaft of humerus,
poly trauma patients with multiple fracture of the same
limb and those having history of previous neurological
deficit of the same limb were excluded from the study. 83
The diagnosis of humerus shaft fracture was done
on the basis of break in the continuity of shaft of humerus as seen on x-ray. The diagnosis of radial nerve
injury was established clinically on the basis of examination findings of whether the patient was able to extend finger and wrist or not, if unable to extend finger
and wrist it was recorded as radial nerve injury positive
and vice versa. The purpose and benefits of the study
was explained to the patient and a written informed
consent was obtained. All the patients were worked up
with detailed history and clinical examination. Standard ward protocol was followed to manage the patients
initially including fracture stabilization and analgesia
requirement. All the patients were carefully assessed to
detect radial nerve injury. The data analysis was done
through software SPSS version 10.0.
RESULTS
There were 100 (60.97%) males and 64 (39.03%)
females. The age range was 20 to 60 years and mean
age of males and females was 41.62 ± 10.3463 and 42.43
± 7.0640 respectively with oveall mean age ± SD was
41.93 ± 9.1903. There were 60 (36.58%) cases of spiral
fracture, 40 (24.39%) cases of transverse fracture, 34
(20.73%) cases of communized fracture and 30 (18.29%)
cases of segmental fracture. (Table No. 1) Radial nerve
injury was present in 14 (8.53%) patients. Out of total
14 cases of radial nerve injury, 3 (21.42%) were females
and 11 (78.57%) were males. (Table No. 2 & 3) Out of
these 14 cases of radial nerve injury; 7 (50%) cases were
recorded in patients with spiral closed fracture of midshaft of humerus, 3 (21.42%) cases were recorded in
transverse closed fracture of humerus shaft, 2 (14.28%)
cases in comminuted closed fracture of mid shaft of humerus and 2(14.28%) cases were recorded in segmental
closed fracture of humeru shaft. (Table No. 4)
Table 1. Types of closed humeral shaft fractures
n = 164
Types of fracture
Frequency
%
Spiral fracture
60
36.58%
Transverse fracture
40
24.39%
Comminuted fracture
34
20.73%
Segmental fracture
30
18.29%
Total:
164
100%
Table 2. Radial nerve Injury in closed humeral
shaft fracture
n= 164
Radial nerve injury
Frequency
%
14
8.53%
No
150
91.46%
Total:
164
100%
Yes
84
Table-3: Radial nerve injury distribution
according to gender
n= 164
radial nerve
injury
Frequency
Male
Female
n
n(%)
n(%)
yes
14 (8.5%)
11 (78.6%)
3 (21.4%)
No
150 (91.4%)
89 (59.3%)
61 (40.7%)
164
100
64
Total:
Table 4. Radial nerve injury distribution according
to type of humeral shaft closed fracture
n= 164
type of
fracture
frequency
n
radial nerve injury
yes
no
n (%)
n (%)
Spiral
60
7 (11.66%)
53 (88.34%)
Transverse
40
3 (7.55%)
37 (92.45%)
Communized
34
2 (5.88%)
32 (94.12%)
Segmental
30
2 (6.66%)
28 (93.34%)
Total:
164
14 (8.53%)
150 (91.46%)
DISCUSSION
Radial nerve injuries associated with fracture shaft
of humerus are the most common peripheral nerve injuries in long bone fractures and it is due to the fracturing force, by the fractured ends or by traction when the
fractured ends are forcibly separated.12,13
Radial nerve injury in closed humeral shaft fractures is commonly encountered in orthopedics department. In our study with a sample size of 164, we recorded 14 cases of radial nerve injury while according to a
review of 21 papers the overall prevalence was of radial
nerve injury due to humerus shaft fractures was 11.8%
with the middle and middle-distal parts of shaft having
a significantly higher association of radial nerve palsy.14
In a systematic literature review, Shao et al,15 identified
532 radial nerve palsies in 4517 humeral shaft fractures;
an 11.8% incidence of radial nerve palsy.14 In a local retrospective descriptive study conducted at Combined
Military Hospital (CMH) Multan, fracture of humerus
were second most common (21% each) cause of radial
nerve injury. This observation also is in agreement with
stern.16 Our study also focuses on the same concept of
frequency of radial nerve injury due to closed humerus
shaft fractures.
Among trauma patients, a radial nerve injury associated with a humeral shaft fracture is an important
injury. Radial nerve palsy is the most common peripheral nerve injury associated with this fracture. In our
study, spiral fracture was most common (36.58%), followed by transverse fracture (24.39%), comminuted
fracture (20.73%) and segmental fracture (18.29%). This
corresponds with another study in which the frequency
of simple transverse fracture was (18.3%) and simple
spiral fracture was (17.1%) which were both situated
in the middle third of the diaphysis, were twice as frequent as any other fracture and between them made up
more than one third of the total humerus fractures.17
Out of the 14 cases of radial nerve injury in our
study, the incidence of radial nerve injury was also
maximum in spiral fracture (50%) followed by transverse fracture (7.55%), comminuted fracture (5.88%)
and segmental fracture (6.66%). The greater frequency
of radial nerve injury in spiral fractures of humerus
is due to the fact that radial nerve enters the anterior
compartment in the mid shaft and here it is relatively
more fixed and susceptible to injury1. The finding and
observation recorded in another study is “most commonly, radial nerve injuries are associated with middle
one-third spiral humeral shaft fractures.18 Also another study has reported the overall prevalence of radial
nerve injury more with transverse and spiral fractures
than comminuted and oblique fractures.14 This is in
agreement with our study.
We performed this study in a community setting
with patients of various socioeconomic classes and participants’ compliance was high. In our study, statistical
analyses were straight forward and missing data analysis was not required. It must also be noted that the
short follow up period was the limitation of our study.
Further research is needed of longer duration and comparison may be needed to confirm our result.
CONCLUSION
Radial nerve injury is a common complication
of closed humeral shaft fractures and its frequency is
more with spiral and transverse fracture patterns than
with oblique and comminuted fractures.
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Carlan D, Pratt J, Patterson JM, Weiland AJ, Boyer MI, Gelberman RH. The radial nerve in the brachium: anatomic study in
human cadavers. J Hand Surg Am 2007 Oct;32(8):1177-82.
Ring D, Chin K, Jupiter JB. Radial nerve palsy associated with
high-energy humeral shaft fractures. J Hand Surg Am 2004
Jan;29(1):144-7.
Clavert P, Lutz JC, Adam P, Wolfram-Gabel R, Liverneaux P,
Kahn JL. Frohse’s arcade is not the exclusive compression site
of the radial nerve in its tunnel. Orthop Traumatol Surg Res
Apr 2009;95(2):114-8.
Fric V, Pazdírek P, Bartonícek J. Unreamed locking intramedullary nailing of humeral fractures--basic evaluation of a patient
group]. Acta Chir Orthop Traumatol Cech 2001;68(6):345-56.
DeFranco MJ, Lawton JN. Radial nerve injuries associated with
humeral fractures. J Hand Surg Am 2006 Apr;31(4):655-63.
Elton SG, Rizzo M. Management of radial nerve injury associated with humeral shaft fractures: an evidence-based approach. J
Reconstr Microsurg 2008 Nov;24(8):569-73.
Thomsen NO, Dahlin LB. Injury to the radial nerve caused by
fracture of the humeral shaft: timing and neurobiological aspects related to treatment and diagnosis. Scand J Plast Reconstr
Surg Hand Surg 2007;41(4):153-7.
Sasha R, Robert JS, Melvin PR. Treatment of nerve dysfunction after trauma around the elbow. Clinl Orthop Related Res
2000;(370):138-53.
Schittko A. Humeral shaft fractures. Chirurg 2004
Aug;75(8):833-46.
Ring D, Chin K, Jupiter JB. Radial nerve palsy associated with
high-energy humeral shaft fractures. J Hand Surg Am 2004
Jan;29(1):144-7.
Venouziou AI, Dailiana ZH, Varitimidis SE, Hantes ME, Gougoulias NE, Malizos KN. Radial nerve palsy associated with
humeral shaft fracture. Is the energy of trauma a prognostic
factor? Injury 2011 Nov;42(11):1289-93.
Byrd RG, Byrd RP Jr, Roy TM. Axillary artery injuries after proximal fracture of the humerus. Am J Emerg Med
1998;16(2):154-6.
Shao YC, Harwood P, Grotz MR, Limb D, Giannoudis PV.
Radial nerve palsy associated with fractures of the shaft of
the humerus: a systematic review. J Bone Joint Surg Br 2005
Dec;87(12):1647-52.
Tytherleigh-Strong G, Walls N, McQueen MM.The epidemiology of humeral shaft fractures. J Bone Joint Surg Br 1998
Mar;80(2):249-53.
Grass G, Kabir K, Ohse J, Rangger C, Besch L, Mathiak G.
Primary exploration of radial nerve is not required for radial
nerve palsy while treating humerus shaft fractures with Unreamed Humerus Nails (UHN). Open Orthop J 2011;5:319–23.
Canale ST. Fracture of humeral shaft with radial nerve palsy.
In: Canale ST ed. Campbell’s operative orthopaedics Vol. 3, 10th
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SHORT COMMUNICATION
SCLERAL EDGE, NOT OPTIC DISC OR RETINA,
IS THE PRIMARY SITE OF INJURY IN CHRONIC GLAUCOMA
Dr. Syed S. Hasnain M.D.
ABSTRACT
In chronic glaucoma, there is a gradual painless
loss of vision, early manifestation of arcuate field defect
and typical atrophy of the optic disc known as ‘cupping’. Chronic glaucoma is classified into high-tension
glaucoma (HTG) and normal-tension glaucoma (NTG).
Although both types manifest with the same typical
visual field defect and cupping of the optic disc, hightension glaucoma has elevated intraocular pressure
whereas in normal-tension glaucoma the intraocular pressure (IOP) is within the normal range (10-21
mmHg). There are several theories about the pathogenesis of chronic glaucoma ranging from high intraocular pressure directly damaging the optic disc to programmed death (apoptosis) of the ganglion cells. But
none of them satisfactorily explain the manifestation of
the early arcuate field defect which is a pathognomonic
feature of both types of chronic glaucoma.
The article (in reference, see October’2013 issue)
focuses on two main issues. First, how and why the arcuate field defects are produced in the early stages of
glaucoma and secondly to find out the common ground
in the pathogenesis of both high and normal tension
glaucoma. The early arcuate field defects are an important lead in discovering the pathogenesis of glaucoma,
therefore if any factor or site which could not possibly
produce initial sharply defined arcuate field defects
was ruled out. This article presents an unconventional
approach to the pathogenesis of glaucoma. Instead of
looking for various factors causing glaucoma, emphasis
was placed on determining the primary site of injury
which could produce the initial arcuate field defects.
Keeping the arcuate visual field defects in mind, the
primary site of injury appears to be at the scleral edge
and not the optic disc or the retina in chronic glaucoma.
The border tissue which separates the sclera and choroid from the nerve fibers would atrophy due to chronic ischemia as a result of high intraocular pressure in
HTG, whereas due to poor systemic circulation in NTG.
In both types of chronic glaucoma, the ciliary circulation supplying the pre-laminar and border tissue is
compromised. As a result of atrophy of the border tissue, the optic disc sinks as a whole beginning temporalCorrespondence: General Ophthalmology, 560 W. Putnam Ave. Suite
#6 Porterville, CA 93257USA. Tel: 559.781.7482 Fax: 559.781.8446
Web: www.hasnaineye.com, E.Mail: [email protected]
86
ly due to its tilted position and causing nerve fibers to
stretch, kink, and cut at the scleral edge. This process of
optic disc sinking would accelerate due to loss of nerve
fibers which also provides anchorage to the optic disc.
This cycle would continue until all the nerve fibers are
cut at the scleral edge and the optic disc is destroyed.
REFERENCE:
Hasnain SS. Scleral edge, not optic disc or retina, is the primary site
of injury in chronic glaucoma. Med Hypotheses. 2006;67(6):1320–
1325. 2006;67(6):1320-5. Epub 2006 Jul 7. Clin Ophthalmol. 2013; 7:
1941–1949.
Letters to the Editor
Dear Prof. Durrani,
I have just received the new Oct’ 2013 issue of
Ophthalmology by regular mail, I am expressing my
deep gratitude for publication of my paper. One more
time I would like to emphasize the high level of contents
and knowledge ability of the articles, starting from Your
Editorial. It was also very interesting to read Historical
Review on Ophthalmic surgery by Dr. Madiha Durrani. Discovering the world of beautiful flowers, animals
and birds on SAARC Issue was very impressive also.
Let’s good luck accompany all your and your family
members projects.
Warmest regards
Prof. Marianne Shahsuvaryan
Armenia
Dear Brother Yasin,
AOA. After I emailed you earlier I went to my office and found your OCT-December issue in mail. This
Journal is indeed one of the best with full of very nice
articles. You have projected my theory extremely well
for which I don’t have enough words to express my
thanks and gratitude. I particularly liked the article on
“History of Ophthalmic Surgery & Contribution of Muslim Scholars” written by Dr. Madiha Durrani. May Allah always bless you and your family. Best regards.
Syed S. Hasnain M.D.
General Ophthalmology
560 W. Putnam Ave. Suite #6Porterville, CA 93257
Tel: 559.781.7482
Email: [email protected]
Web: www.hasnaineye.com
CASE REPORT
Mazhar U Zaman
Mazhar U Zaman Soomro1, Sidra Riaz2, Mohammad Arshad3
ABSTRACT:
New modality for treatment of infantile haemangioma can be considered with B-blocker mainly atenolol given orally. The
mode of action of these drugs are thought to be vasoconstrictor , regulating angiogenic pathways and inducing apoptosis
of vascular endothelial cells. Now a days B- blockers are used for the treatment before initiation of other mode of treatment
like steroids, laser, resection etc. Although B-blockers are not widely approved indication for infantile haemangioma (IHs)
but becoming a promising new modality. Before starting the therapy all cases should be assessed by a cardiologist and
follow up should be scheduled.
CASE REPORT
A baby aged 2 months was examined at the clinic
with a complaint of reddish mass at upper right lid.
On external examination of the baby there was a multilobed mass (infantile haemangioma) of about 3.5 x 3
mm reddish in color involving medial half of eye brow
and upper lid. Due to this mass baby could not open
his other eye. Under biomicroscopic examination no
abnormality was found in conjunctiva, cornea and anterior chamber. Size of both eye balls was symmetrical. Also other eye was within normal limits. Consent
was taken before the start of treatment. The regimen of
treatment was 0.5 mg/kg per day for 7 days and then 1
mg/kg of atenolol given orally. Ophthalmic as well as
cardiac follow up was done every 2 months and it was
found that the lesion started regressing after 2 months
and baby was able to open his eye. Follow up of further
10 month showed further regression of the haemangioma. The drug was stopped at the age of 10 months
DISCUSSION
Infantile haemangiomas (IHs) are benign vascular
tumours found in approximately 4–10% of Caucasian
infants1, 2. IHs can impede the function or development
of neighbouring structures or organs necessitating treatment3. Infantile haemangioma(IHs) is a benign vascular
that has three phases of development: Haemangioma
proliferates in first phase, the second phase is rest phase
and the third phase is involution. In most of cases these
haemangioma undergo spontaneous resolution and
small proportion need intervention. The unanimous
opinion is that these haemangioma should be treated in
proliferative phase under following condition: vision is
Ophthalmologist, Eye Infirmary, Khanpur, 2Assistant Professor,
Akhter Saeed Medical College, Lahore, 3Registrar, Eye Ward,
Bahawal Victoria Hospital, Bahawalpur
1
Correspondence: Dr. Mazhar U Zaman Soomro, Ophthalmologist, Eye
Infirmary, Khanpur. E.Mail [email protected],Cell: 03006702740
affected or might be due to amblyopia secondary to induced astigmatism, anisometropia and occlusion, optic
nerve compression, exposure kertopathy,or severe cosmetic blemish, necrosis or infection, visceral involvement may become life threatening, rapid growth leads
to anatomical distortion that may resolve partially and
tumor is causing congestive cardiac failure.
Since the report of Léauté-Labrèze et al., the treatment of IH with beta-blockers has become the treatment
of choice4,5,6. As far as we know, only one randomized
controlled trial (RCT) has proven the effectiveness of
propranolol7. Nevertheless, there seems to be a general
agreement that propranolol is effective in IH treatment
and studies now focus on optimal treatment regimen
and on beta-blockers with a more favorable balance
between efficacy and side effects8. The results of this
study confirm that atenolol is effective in the treatment
of IH. Moreover, when compared to a historical control
group, atenolol seems to be as effective as propranolol
but appears associated with fewer side effects. Itinteang
et al9 suggested that propranolol acts via the renin–angiotensin system in regulating accelerated involution of
proliferating IH by decreasing renin production in the
kidneys. As the kidneys predominantly express beta1 receptors, the renin–angiotensin–aldosterone system
(RAAS) is most likely the missing link in understanding the working mechanism of both beta-blockers and
angiotensin-converting enzyme (ACE) inhibitors in the
treatment of IH10. Atenolol is a hydrophilic, selective
beta-1 blocker and therefore is not associated with side
effects attributable to beta-2 activity and lipophilicity
observed with propranolol. It has a terminal half-life of
6–8 h and therefore has to be administered only once
daily, which may improve patient compliance.
There are different ways to treat these haemangioma like laser , steroid injection, systemic steroids,
systemic B-blockers and Local resection. Laser should
be applied close to blood vessels in superficial skin lesion less than 2 mm thickness. Steroid injection of 40
87
Before treatment
After 4 months
After 10 months
mg/ml in to lesion but there are risk of central artery
occlusion, depigmentation, bleeding, fat atrophy, adrenal suppression and failure to thrive. Systemic steroids
may be used if there is large orbital component. Local
resection with cautery may reduce the bulk of circumscribed tumor but it is usually reserved for late inactive stage. Other modality is systemic B-Blocker and we
opt it for the management of the infantile haemangiona
(IHs) as it is simple, convenient, economical and less
88
hazardous to other model ties. Systemic therapy of Bblocker shows rapid action and make it most likely encourage compliance.
In this case an aggressive approach was adopted in order to prevent amblyopia. The haemangioma
showed better response as it started regression within
two months and baby was able to open his eye. The
time for innitiation of therapy was ideal for the baby of
2 month age as Infantile haemangioma is in proliferative phase ( 1-6 months) may result to faster resolution.
The therapy was stopped at the age of 10 months as
this is the appropriate time of haemangioma to regress
naturally.
CONCLUSION
Alternate way of treatment of infantile haemangioma is B blocker like atenolol as compared to intraleisional injection and surgery. Atenolol seems to be
less frequently associated with potentially (life) threatening side effects. Further clinical studies are necessary
to confirm the described effects and safety of atenolol.
REFERENCES
1. Kilcline C, Frieden IJ. Infantile hemangiomas: how common
are they? A systematic review of the medical literature. Pediatr
Dermatol. 2008 Mar;25(2):168–173
2. Hoornweg MJ, Smeulders MJ, Ubbink DT, van der Horst CM.
The prevalence and risk factors of infantile haemangiomas: a
case-control study in the Dutch population. Paediatr Perinat
Epidemiol. 2012 Mar;26(2):156–162
3.
Drolet BA, Esterly NB, Frieden IJ. Hemangiomas in children. N
Engl J Med. 1999 Jul 15;341(3):173–181
4.
Leaute-Labreze C, Dumas de la RE, Hubiche T, Boralevi F,
Thambo JB, Taieb A. Propranolol for severe hemangiomas of
infancy. N Engl J Med. 2008 Jun 12;358(24):2649–2651
5
Starkey E, Shahidullah H. Propranolol for infantile haemangiomas: a review. Arch Dis Child. 2011 Sep;96(9):890–893
6
Drolet BA, Frommelt PC, Chamlin SL, et al. Initiation and use
of propranolol for infantile hemangioma: report of a consensus
conference. Pediatrics. 2013 Jan;131(1):128–140
7
Hogeling M, Adams S, Wargon O. A randomized controlled
trial of propranolol for infantile hemangiomas. Pediatrics. 2011
Aug;128(2):e259–e266
8
Raphael MF, de Graaf M, Breugem CC, Pasmans SG,
Breur JM. Atenolol: a promising alternative to propranolol
for the treatment of hemangiomas. J Am Acad Dermatol. 2011
Aug;65(2):420–421
9
Itinteang T, Brasch HD, Tan ST, Day DJ. Expression of components of the renin-angiotensin system in proliferating infantile haemangioma may account for the propranolol-induced
accelerated involution. J Plast Reconstr Aesthet Surg. 2011
Jun;64(6):759–765
10 Tan ST, Itinteang T, Day DJ, O’Donnell C, Mathy JA, Leadbitter P. Treatment of infantile haemangioma with captopril. Br J
Dermatol. 2012 Sep;167(3):619–624
Ophthalmology Notebook
News, views, letters and events
Attention! Contributors and Readers
While writing an article or a research paper
With the advent of internet facility there has been
an increasing trend of plagiarism in every field of life especially the research field of education sector. We are not
surprised to see that most of the young doctors aspiring
for their promotions, research degrees or a doctorate, are
busy in writing articles, research papers or a thesis and to
get them recognized by hook or crook through publication
in scientific journals, is a very lamenting affair. We have
also noticed that they embark on such subjects which
have already been undertaken by many other authors and
their results are well established and fully documented
in the text books as a solid theorem and does not require
further research except in very few corners which need extended ‘probe in’. They never try new fields in academics
as it entails lot of time and hard work, even their supervisors or heads of the departments never bother to advise
them not to select such hackneyed topics or a stereotyped
attempt on a particular subject.
To quote few examples in the field of ophthalmology
we hardly need any research work in finding the complications of cataract surgery, a small incision cataract
surgery in phacoemulsification, comparing the efficacy of
many antibiotic eye drops, modes of local anesthesia in ocular surgery, corneal repair through amniotic membrane,
incidence of hepatitis B & C in intending ocular surgery
especially the cataract surgery and finally the incidence of
refractive errors in school going children etc. etc. There is
no doubt that these are very important fields in ophthalmic horizon but one can find thousands of papers written
on these topics. We are not at all critical on this point and
we do not mean to discourage our young ophthalmologists either. Our aim is that the supervisors, heads of the
department, reviewers and the editors of the scientific
journals should guide them collectively to select from an
array of available topics so that they can select and produce quality work with at least some originality and we
would certainly like to publish such peer-reviewed papers
without any hesitation.
We are very much conscious of the fact that PMDC
requires a number of papers to be published on their account in order to compete for their next promotion. Simply to write an article on an established theorem in the
text books as the requirement of PMDC is not justified.
The reviewers and the editors of the scientific journals are
mostly experienced teachers and they are well versed with
the various topics intended for publication and undertaken by the researchers. Therefore the writer should avoid
such repetition of facts in order to avoid disappointment if
the topic is rejected, which will be a wastage of time and
energy. In fact we consider it a dereliction of responsibility on the part of a supervisor who should be very careful
in selecting and approving the subject for their trainees,
keeping an eye on the instructions streamlined by Higher
Education Commission, Pakistan Medical & Dental Council, College of Physicians & Surgeons, Pakistan and Ethical
Committee of the hospital. In fact every teaching hospital/institution should have an Ethical Committee and the
PMDC should regularly watch its research activities.
College of Physicians & Surgeons used to hold mandatory workshops on research methodology for the postgraduates and junior consultants in the past and we wonder if the College still hold these workshops, if not, should
resume them immediately as these workshops impart basic training for writing papers and conducting research.
In this context, the Ophthalmology Update has
adopted a very strict policy to discourage the plagiarized
material or repetition of the established facts in their articles. Hence the researchers should be very careful in sending us their article which will be returned to them after review, causing great disappointment to the writer. Hence, it
is extremely important for them to discuss with the heads
of the department or some senior professor before finally
selecting the topic. They should get their papers reviewed
by them from time to time and finally get it approved by
the Ethical Committee to be forwarded to the journal for
publication. There is also a word of advice to the reviewers to find time from their leisure to critically review the
paper, thinking it to be their academic activity as well as a
prime national duty.
The question arises, where the fault lies? The answer
is very simple. Our generation which includes doctors and
scientists has great potential in terms of manpower, equipment and finances and unfortunately, this capacity has
ever remained under-utilized. Our universities and professional institutions are the seats of excellence in higher
learning and we must focus our attention on promotion
of academic and research activities besides producing best
physicians and surgeons. Our history tells us that “these
seats of higher learning are suffering from stagnation” and
we must pledge to break this stagnancy to make progress
through research which is the only way to achieve excellence in any field.
. . . . . . . . Chief Editor
89