THE TRUSTED JOURNAL OF OPHTHALMIC SCIENCES

ISSN 1993-2863
Official Journal of Peshawar Medical College

INTERNATIONAL

Approved & Indexed by:

Pakistan Medical and Dental Council &
Update
Higher Education Commission

SEE PAGE 169

A Quarterly Publication of Established 1998

Vol. 11, No. 2 April - June 2013

 THE TRUSTED JOURNAL OF OPHTHALMIC SCIENCES

Established 1998 ISSN 1993-2863

INTERNATIONAL

Approved and Indexed by Pakistan Medical and Dental Council

& Higher Education Commission Update
Vol. 11. No. 2 ABC Certified April-June 2013

AN OFFICIAL JOURNAL OF PESHAWAR MEDICAL COLLEGE

Published quarterly by Ophthalmic CHIEF ADVISER CHIEF EDITOR

Newsnet from 267-A, St: 53, F-10/4 Prof. Najib ul Haq Prof. M.Yasin Khan Durrani
Islamabad - Pakistan
Phone: 051-2222922 Ext. 1255 OPHTHALMIC SECTION
Fax: 051-2299113
Mob: 0333-5158885
INTERNATIONAL BOARD
E-mail:
Prof. Arthur S.M. Lim (Singapore)
[email protected]
Prof. Robert N. Weinrub (USA)
[email protected]
Prof. Khalid Tabbara (S. Arabia)
Website: www.ophthalmologyupdate.com
Dr. Syed Sikandar Hasnain (USA)
www.prime.edu.com
Prof. Marianne L. Shahsuvaryan (Armenia)
Prof. Emeritus Diljeet Singh (India)
Art & Calligraphy
Dr. Sakkaf Ahmed Aftab (UK)
Ahsan Zeb Durrani
Dr. Madiha Durrani (UAE)
Subscription: Rs. 800/– Yearly
International: US $ 100/- Yearly ASSOCIATE EDITORS
Ophthalmology Update is a controlled Prof. Syed Imtiaz Ali, Prof. Hafeez ur Rehman
circulation journal for Medical profession. Prof. Akbar Hyder Soomro, Prof. Jahangir Akhtar
It does not guarantee, directly or indirectly Prof. Shahid Wahab
the quality and efficacy of any product or
service described in the advertisement or ASSISTANT EDITORS
other material which is commercial or Prof. Nadeem Qureshi, Prof. Naqaish Sadiq
otherwise in this issue. Prof. B.A. Naeem, Prof. Imran Azam Butt
Dr. Ghulam Sabir, Dr. Inam ul Haq Khan
Registration: 3405/2/(63) under Press and Dr. Liaqat Ali Shaikh, Dr. Munira Shakir
Publication Ordinance ‘98, Govt. of Paki- Dr. Syeda Aisha Bukhari, Prof. Niamatullah Kundi
stan. Dr. Mahfooz Hussain, Dr. Zeeshan Kamil
Dr. Shakir Zafar, Balbir Singh Bhura
All rights reserved. No part of this
publication may be reproduced, stored in
GENERAL SECTION
a retrieved system or transmitted in any
or by any other means, electronic,
mechanical, photo-copying, recording or ASSISTANT EDITORS
otherwise without prior permission from Prof. Zahoor Ullah, Prof. Zafar Iqbal
the managing editor. Dr. Faiz-ur-Rehman
Dr. Misbah Durrani
Circulation: Schazoo Pharmaceutical
Lab. (Pvt) Ltd., Lahore by Mr. Omer Safdar, MANAGING EDITOR
Business Manager Dr. Jahanzeb Durrani

Ophthalmology Update Vol. 11. No. 1, January-March 2013 i

Printed at PanGraphics (Pvt) Ltd., Islamabad.
 Contents
EDITORIAL

Q Nano-ophthalmology - A nascent yet a burgeoning field at Nano Frontiers

Prof. M. Y. K. Durrani ---------------------------------------------------------------------------------------------------------------- 97

OBITUARY . . . . Prof. Syed Ali Haider ------------------------------------------------------------------------------------------- 99

Q ORIGINAL ARTICLES

Q Computerized Documentation & Analysis of the Pseudo-isochromatic

Plate Colour Vision Test Results
Prof. Syed Amjad Rizvi ----------------------------------------------------------------------------------------------------------- 100

Q Visual Outcome after Endolaser vs Cryopexy

in Vitrectomy for Retinal Detachment
Mir Ali Shah et al ------------------------------------------------------------------------------------------------------------------ 103

Q Effectiveness of using Topical Antihistamine & Decongestant During an Epidemic of

Adenoviral Conjunctivitis
Dilshad Alam Khan et al ---------------------------------------------------------------------------------------------------------- 106

Q The Frequency of Amblyopia & Results of Squint Surgery in Patients admitted in

Khyber Teaching Hospital, Peshawar
Ayat Shah et al ---------------------------------------------------------------------------------------------------------------------- 109

Q Success Rate of Surgical Correction of Essential Esotropia

Humaira Mahboob et al ------------------------------------------------------------------------------------------------------------ 112

Q Visual outcome of Ocular Trauma in patients of Rural & Urban areas

managed at a Tertiary Eye Hospital
Munawar Ahmed et al -------------------------------------------------------------------------------------------------------------- 115

Q Ranibizumab as an adjunct to Laser for Macular Edema secondary to Branch Retinal

Vein Occlusion
Naveed Ahmad Shah et al --------------------------------------------------------------------------------------------------------- 120

Q Manual Small Incision Cataract Surgery, comparison of Sub-tenon Anesthesia with

Peribulbar Anesthesia: Study on Pain Evaluation & Surgical outcome
Mushtaq Ahmad et al -------------------------------------------------------------------------------------------------------------- 119

Q Management of Amblyopia in Children after Cataract Surgery

Sadia S. Bukhari et al --------------------------------------------------------------------------------------------------------------- 123

Q Incidence of Pupillary Involvement, Course of Anisocoria & Ophthalmoplegia

in Diabetic Oculomotor Nerve Palsy
Naveed Ahmad Shah et al --------------------------------------------------------------------------------------------------------- 131

Q CASE REPORT

Q Vertical Strabismus after Conjunctival Scarring

Masquerading as Superior Oblique Palsy
Saemah Nuzhat Zafar et al -------------------------------------------------------------------------------------------------------- 136

ii Ophthalmology Update Vol. 11. No. 1, January-March 2013

Contents

Q REVIEW ARTICLES

Q Anti-Angiogenics in Vaso-Occlusive Disorder of Retinal Vein

Prof. Marianne L. Shahsuvaryan ------------------------------------------------------------------------------------------------- 138

Q Frequency of Intraocular Pressure Changes after Phacoemulsification in Patients

having Age Related Cataract (A study of 130 patients)
Amir Naseem et al ------------------------------------------------------------------------------------------------------------------- 146

Q Manual Extracapsular Cataract surgery, review of 1150 cases operated in

District Headquarter Hospital, Battagram
Ihsan Ullah et al -------------------------------------------------------------------------------------------------------------------- 150

Q Visual acuity and Intraocular Pressure changes after

Nd: YAG Laser Posterior Capsulotomy
Faisal Nawaz Khan et al ----------------------------------------------------------------------------------------------------------- 154

Q Major Review of the Applications of Femtosecond Laser in Ophthalmology

Rao M. Rashad Qamar et al ------------------------------------------------------------------------------------------------------- 159

Q GENERAL SECTION

Q Asymptomatic Bacteriuria in Pregnant Women

Rubina Akhtar et al ----------------------------------------------------------------------------------------------------------------- 170

Q OPHTHALMOLOGY NOTEBOOK

Q Letter to the Editor --------------------------------------------------------------------------------------------------------------- 172

Q Pomegranate (PUNICA GRANATUM)

A symbol of health, fertility and long life
Zainab Inam ------------------------------------------------------------------------------------------------------------------------- 153

Ophthalmology Update Vol. 11. No. 1, January-March 2013 iii

Instructions to the authors

Instructions to the Authors

All materials submitted for publication should be viewers.
sent to the journal ‘Ophthalmology Update’. Articles/ Abstract: Abstract of original article should be in
research papers which have already been published or structured format with the following sub-headings:
accepted elsewhere for publication should not be Objective, Design, Place and duration of Study, Patients
submitted. A paper that has been presented at a & Methods, Result and Conclusion.
scientific meeting, if not published in full in proceeding Introduction: This should include the purpose of
or similar publication may be submitted. Press reports the article. The rationale for the study or observation
of meetings will not be considered as breach of this should be summarized.
rule. Methods: Study design and sampling methods
Ethical Aspects: If articles, tables, illustrations or should be mentioned. The selection of the observational
photographs, which have already been published, are or experimental subjects (patients or experimental
included, a letter of permission for republication (or animals, including controls) should be described
its excerpts) should be obtained from the author(s) as clearly. The methods and the apparatus used should
well as the editor of the journal where it was previously be identified and procedures described in sufficient
published. details to allow other workers to reproduce the results
Material for Publication: The material submitted and references to established methods. All drugs and
for publication may be in the form of original research, chemicals used should be identified precisely,
a review article, short communications, a case report, including generic names, doses, routes of
recent advances, new techniques, review on clinical/ administration.
medical/ophthalmic education, a letter to the editor, Results: These should be presented in a logical
medical quiz, Ophthalmic highlights/update, news sequence in the text, tables and illustrations. Only
and views related to the field of medical sciences. important observations should be emphasized or
Editorials are written by invitation. Report on summarized.
Ophthalmic obituaries should be concise. Author Discussion: The author’s comments on the result,
should keep one copy of the manuscript for reference, supported with contemporary references, including
and send three copies (laser or inkjet) to the Managing arguments and analysis of identical work done by
Editor, Ophthalmology Update through E-mail/CD or others. Brief acknowledgement may be made at the end.
by post in MS word. Photocopies are not accepted. Any Conclusion: Conclusion should be provided under
illustrations or photographs should also be sent in separate heading and highlighting new aspects arising
duplicate. Authors from outside Pakistan can also e- from the study. It should be in accordance with the
mail their manuscript. It should include a title page, E- study.
mail address, fax and phone numbers of the Copyright: Material printed in this journal is the
corresponding author. There should be no more than copyright of the publisher of Ophthalmic Newsnet/
40 references in an original/review article. If prepared Ophthalmology Update and may not be reproduced
on computer, a CD should be sent with the manuscript. without the permission of the editor/publisher. The
Dissertation/Thesis Based Article: An article publisher only accepts the original material for
based on dissertation submitted as part of the publication with the understanding that except for
requirement for a Fellowship can be sent for abstracts, no part of the data has ycccccccccccc been
publication after it has been approved by the relevant published or will be submitted for publication
institution. Dissertation based article should be re- elsewhere before appearing in the journal. The Editorial
written in accordance with the instructions to authors. Board makes every effort to ensure the accuracy and
References: References should be numbered in the authenticity of the material printed in the journal.
order in which they are called in the text. At the end of However, conclusions and statements expressed are the
the article, the full list of references should give the views of the authors and do not necessarily reflect the
names and initials of all authors in Vancouver style opinions of the Editorial Board. Publishing of
based on the format used by the NLM in Index advertising material does not imply an endorsement
Medicus. It verify the references against the original by the Ophthlmic Newsnet /Ophthalmology Update.
documents before submitting the article. Address for Correspondence: The Chief Editor,
Peer Review: Every paper will be read by at least Ophthalmology Update, 267-A, St: 53, F-10/4, Islamabad,
two staff editors of the editorial board. The paper Pakistan. E-mail: [email protected]
selected will then be sent to one or more external

iv Ophthalmology Update Vol. 11. No. 1, January-March 2013

Editorial
Nano-ophthalmology
A nascent yet a burgeoning field at Nano Frontiers
The tiny world of Nano-science may one day stand shoulder to shoulder with Nanotechnology in
the gigantic field of industry and medicine, it is a fast emerging technology of immense socio-
economic value……….Nano experts

Though in early stages, nanotechnology is integrated into the contact lens.

underway to Ophthalmology. It involves materials and One early innovation is a biosensor DNA tied to a
devices of incredibly small size —less than 100 nm, magnetic nanoparticle. The antioxidant biosensor could
known as Nanoceria. (to compare, a strand of DNA is 2 provide a means for clinician to identify patients likely
nm wide). Nanoparticles are colloidal carrier systems to need therapy e.g. Retinopathy of Prematurity who
that can improve the efficacy of drug delivery by will need photocoagulation or other treatment at a time
overcoming diffusion barriers, permitting reduced before clinical manifestations of a severe disease are
dosing (through more efficient tissue targeting) as well evident. Currently, the technology is undergoing a
as allowing sustained delivery. In fact, it is an significant development in controlling the therapeutic
interesting and minimally invasive field of gene therapy as well. One such application is the
Ophthalmology. Although molecular technology is still treatment of various retinopathies caused by oxidative
in infancy, yet it is no longer a speculative field which stress. This will allow the regeneration of diseased cells,
may revolutionize the future of Medicine as it unfolds not killing the healthy cells in order to get rid of every
the mysteries of this exciting field. However, the bad cell as happens while treating with radiation or
accomplishments are tremendous and the future chemotherapy.
prospects are wide open. A further advance in Regenerative Ophthalmic
Much progress has been achieved in the field of Medicine would be to replace damaged or dead retinal
nanotechnology and its applications to ophthalmology. neurones in patients with chronic retinal detachment,
Drug discovery, delivery, gene therapy, implantable
devices and regenerative medicine are some of the key
areas of active research in Nano-ophthalmology which
may soon be available in the clinician’s armamentarium
to maintain and restore the eye sight.
Currently, Biopharmaceuticals and diagnostic
tools are some of the areas getting importance in this
field. Moreover, Nanotechnology is also playing an
important role in the treatment of conditions associated
with the oxidative damage particularly AMD, diabetic
retinopathy and degenerative disorders like Retinitis
Pigmentosa. The technology allows new and inno-
vative monitoring approaches e.g. one non-invasive
approach to IOP monitoring involves the use of
wireless, silicone contact lens with a sensor to measure
changes in the corneal curvature related to IOP changes
with the help of a microprocessor and an antenna

Ophthalmology Update Vol. 11. No. 2, April-June 2013 97

Editorial

RP, AMD and allied disorders. Regenerative Medicine under the guidance of Prof. Emeritus Dr. N. M. Butt, a
is no doubt a nascent yet a burgeoning field of renowned atomic scientist as its chairman. Any student
Ophthalmology, certainly not insurmountable. interested in the field of Nano-science can join such
According to Prof. Marco A. Zarbin, PhD., Institute of institution. Recently, Quaid-e-Azam University,
Ophthalmology and Visual Science, University of Islamabad held an international conference on Nano-
Medicine & Dentistry of New Jersey., “Biodegradable science & Technology. Eminent teachers from Pakistani
(poly) lactic-co-glycolic Acid (PLGA) microspheres and foreign Universities participated in the conference,
loaded with intra-vitreal glial-derived neuro-trophic discussing the impact this technology on vast number
factor (approved by FDA for human use) provides of fields and the future prospects of applications in
sustained ganglion cell protection in Glaucoma. The Pakistan. Another tripartite seminar was jointly
prospects are very exciting for the physicians solving organized by the Preston Institute of Nano-Science &
their multi-faceted problems by offering a control over; Technology (PINSAT) and the International
how molecules interact with one another in giving them Development Research Centre (IDRC) Canada, in which
ability to respond to their environment with sapient scientists from Sri Lanka, India and Pakistan strongly
behaviour. emphasized that Pakistan should seriously consider
In fact, nano-materials have large surface area to development of Nano technology manpower in the
interact and to bring a chemical reaction. They have country.
altered functionality like 100 times stronger than steel In this context, Ophthalmology Update can also
and can melt gold at room temperature. It has a provide guidance to young aspirantswho wish to
molecular self-assembly basically putting molecules specialize in the progressive field of Medicine especially
where you want them to be, what you want them to do in Nano-Ophthalmology, which will provide them
and when you want them to do. Nano-technology is invaluable opportunities to diagnose and treat their
the art of designing and building machines in which patients on better lines. Ophthalmic medicine of the
the specifications are determined down to molecule. The future could find new tools for the problems considered
technology is very cost-effective allowing mass intractable. The application of this rapidly growing field
production at a lowest cost even for a therapyof longer will ultimately ensuring the healthful longevity of life.
duration by delivering minute quantities to precise
target having few or no side effects. Dr. Madiha Durrani
Pakistan has already entered into the field of MBBS., MCPS., FRCS.
Nanotechnology and it is very encouraging to learn that Ophthalmic Surgeon & Associate Editor
the Preston University in Islamabad has started a BS – Dubai, UAE.
4 years degree course at undergraduate degree level at E. Mail> [email protected]
the Institute of Nano-science & Technology (PINSET)

SAARC Ophthalmic Conference -2013

to be held from 11-15 Sep’2013
at Pearl Continental Hotel, Bhurban (Murree)
under the auspices of OSP, Federal Branch, Islamabad
Please contact:
Brig. Dr. Muhammad Amer Yaqub
General Secretary
Ophthalmological Society of Pakistan, Federal Branch,
Secretariat: No: 19, Office: 13, 1st Floor
Farhan Plaza, G-11, Markaz, Islamabad
Cell: 0333 5153206, 0300 53234066, 0300 5147275
E.Mail> [email protected]

98 Ophthalmology Update Vol. 11. No. 2, April-June 2013

Obityary: Prof. Syed Ali Haider

OBITUARY

Ah! Prof. Syed Ali Haider

A great friend, a great teacher and a best vitreo retinal surgeon……
Prof. Nadeem Hafeez Butt

The whole medical community in general and the ophthalmic community in particular is deeply
shocked at the sad and sudden demise of Prof. Ali and his son. They were brutally martyred recently
in Lahore.
Dr. Syed Ali Haider was the only son of Prof. Zafar Haider and Professor Tahira Bokhari. He
graduated from K.E.M.C in 1987 and proceeded to the UK to complete his FRCS in Ophthalmology.
He returned to serve his country with dedication and devotion. Prof. Ali had a brilliant record of
academic eminence in pursuit of knowledge in the field of Ophthalmic Sciences. It speaks volumes
of his creditable contributions to take the Pakistan Journal of Ophthalmology to enviable heights as
the Editor in Chief. He worked very hard to achieve professional excellence and earned a prestigious
place in the Ophthalmic community as Professor of Ophthalmology and a venerated academician
at Lahore General Hospital.
Dr. M Afzal Bodla from Multan knows him from the very childhood as a student at Nishter
Medical College, Multan, as he grew with all capabilities of his father Prof Syed Zafar Haider. Besides
these qualities of head and heart he was an extraordinary human being and a soft spoken gentleman.
We pray that God may give courage to the family to face this irreparable loss.

According to Dr. Syed S. Hasnain from California USA, he is survived by his wife, a teenaged
son and a six month old daughter. He will be sorely missed by his family, friends, relatives, and
thousands of patients. May Allah grant him peace in paradise.
The brotherly Afghan ophthalmologists have expressed their profound grief over the untimely
death of Prof. Ali Haider at a very young age. He was extremely kind and caring to the Afghan
patients being referred to him for vitreo-retinal consultation.
The management and the editorial board Ophthalmology Update offer sincerest condolences
to his family, his students, colleagues and whole ophthalmic community.

Prof. M. Yasin Khan Durrani,

Editor in Chief, Ophthalmology Update,
Islamabad

Ophthalmology Update Vol. 11. No. 2, April-June 2013 99

 Original Article

Computerized Documentation & Analysis of

the Pseudo-isochromatic
Plate Colour Vision Test Results
Prof. Amjad Rizvi
(A software for colour vision testing)

Prof. Syed Amjad Rizvi FCPS1, Prof. Jameel Ahmed FRCP2,

Prof. Emeritus, Khwaja Shareeful Hasan FRCS, FRCOphth3
Department of Ophthalmology & Department of General Medicine
Baqai Medical College, Baqai Medical University, Karachi.

ABSTRACT
Background: Computerized recording and analysis of conventional colour vision test results is desirable, and software
has been developed for colour matching tests. However, the need exists for such software for pseudo-isochromatic plate
tests (PIPT).
Methods: A software written in Microsoft Visual Basic for the purpose of recording and interpretation of conventional
PIPT results is described in detail.
Conclusion: The prototype software has a potential to be utilized in routine clinical practice and epidemiological studies,
and the large amount of data thus obtained may be efficiently recorded, interpreted and archived in short time and with
very few resources.
Key Words; Colour Vision, Computers in Medicine, Optic nerve

INTRODUCTION: to have adverse effects on the optic nerve to rule out

Accurate determination and recording of the existing color defects and hence avoid later confusions.7
colour vision (CV) is important in many clinical settings. The volume of CV testing is thus quite large.
Apart from its well established value in the Maintenance of the record of response to every
determination of optic nerve damage and congenital individual plate in every test makes the task
CV deficits, gradual deterioration in color vision can considerably complex. Similarly, to utilize the feature
help to detect several diseases in very early stages e.g. of these tests to determine the type of CV defects, correct
diabetic retinopathy,1 Parkinson’s disease,2 multiple interpretation of the response to each plate is essential.
sclerosis,3 etc. Full utilization of PIPT is thus time consuming and may
The pseudo-isochromatic plates test (PIPT) is the not be possible in a busy out -patient clinic.
most popular and convenient technique for screening As the availability of personal computers is now
and diagnosis of abnormal CV, 4 the Ishihara5 and common in the clinics, any software which allow quick
Hardy-Rand-Rittler6 being the most familiar of these recording of the response of the patient to each plate in
tests. In spite of being simple to carry out, these tests every testing session, can interpret the faulty response
can consume significant time in the out patient clinics as specific to a known type of color vision deficiency,
because of the frequency with which they have to be and retrieve prior results for comparison, can be useful
carried out. Apart from the large number of tests in this regard. Such software could be used in many
performed for screening, repeated testing and plate-to- specialties of medical sciences besides ophthalmology,
plate comparison of the results with prior ones is particularly neurology, general medicine, pediatrics
necessary to detect change in optic nerve function. and in mass screening by the medical or non-medical
Furthermore, a baseline CV test needs to be performed staff.
in all patients prior to the initiation of the drugs known Description of an application developed for
————————————————————————————————
recording, interpretation and retrieval of the patient’s
1.
Professor of Ophthalmology, Baqai Medical College, Karachi. response to each plate in the conventional Ishihara test
2.
Professor of Medicine, Baqai Medical College, Karachi. 3.Professor is presented in this article.
Emeritus of Ophthalmology, Baqai Medical College, Karachi METHODS
————————————————————————————————
Correspondence: Prof Amjad Rizvi, A–11, Block 9, FB Area, Karachi.
Description of Software: The software is written
Email: [email protected]. Tel: 0313-2321942 in Microsoft Visual Basic.6 (Microsoft Corporation,
———————————————————————————————— Redmond, Washington), by one of the authors (SAR)
Received: Jan’2013 Accepted: Feb’2013 Software Algorithm: The software is based on
————————————————————————————————

100 Ophthalmology Update Vol. 11. No. 2, April-June 2013

Computerized Documentation & Analysis of the Pseudo-isochromatic Plate Colour Vision Test Results

Ishihara [38 plate Edition – 1973, Kanehara Shuppan test is entered in the retrieval box and the retrieval
Co., Ltd. Tokyo, Japan] and the first 25 plates are taken button clicked.
as the standard test. Interpretation of response as INTERPRETATION
normal, specific abnormal, or non-specific abnormal is If a response to a slide is incorrect and specific to
done by the application after matching each response any known type of CV deficit, the fact is mentioned by
according to the information in the booklet provided the software on the result screen beside that plate
with the test book. number, otherwise this is remarked as ‘Incorrect: Non
The software is distributed as a zipped file, named: Specific’. The correct response is remarked ‘Correct’.
“Rizvi’s CVR&AS.zip” contents of which are first Figure 1 shows the test results of a Red-Green deficient
extracted in a known folder. The ‘Setup.exe’ file in that person
folder is then clicked to complete the installation DISCUSSION
process. Minimum screen resolution required is 1024 X Computer assisted analysis of the results of a
768 pixels. In windows 7, writing “rizvi” in the program conventional test is not a new idea. The most familiar
search box will retrieve the application, and in windows example is the software developed for the Farnsworth-
XP it will be listed in the start program menu. The Munsell 100 Hue test.8 Recording and computation of
software can be obtained free of charge via email to the results in the PIPTs is not as complex as in the FM 100
corresponding author or downloaded from the Hue test, yet software for these tests is needed because
following link: http://rapidshare.com/files/633714883/ they are performed far more frequently in clinical
Rizvi’s CVR%26AS.zip practice. This prototype software was based on the
The start page offers the option of either starting Ishihara PIPT, but it can be written for any PIPT using
a new test, or retrieval of results of a test done the same principle.
previously. This software is quite comprehensive, but there is
For the new test, the patient’s particulars are much potential for upgrading. e.g. a database software
entered and the button captioned ‘Start Test’ is clicked. can be incorporated, making the test very useful for
The second screen then appears, where there are 25 epidemiological studies, and can be carried out even
buttons on the left of the screen representing the first by non medical personnel, e.g., school teachers.
25 plates in the Ishihara PIPT in sequence. The standard Similarly, the results can be linked to the patient’s
Ishihara book is given to the patient and the electronic MR, which is rapidly becoming the standard
conventional test is started. When the patient gives the of medical record keeping.
response to the fist plate, the button no. 1 is clicked and CONCLUSION
the patient’s response entered in the entry box, which At present, the images of the PIPT appearing on
appears beside the button. This is repeated for the rest the computer screen are solely for identification purpose
of the 25 plates. At each button press, an image of the for the examiner, the test being carried out
corresponding plate appears on the computer screen, conventionally as usual. However, personal computer
which is only for the examiner, to make sure that the monitor is being evaluated as a potential medium for
correct sequence of plates is entered. At the completion the patient to discriminate the colours.9, 10If significant
of the test the ‘FINISH’ button at the bottom of the evidence of the accuracy of this method becomes
screen is clicked, which leads to the final results screen. available, the need for the conventional printed plates
The results contain the patient’s response, the correct may be obviated completely after standardization and
answer, and the interpretation of each plate. The overall calibration of the color display in the computer monitor.
score is also mentioned as number of plates correctly REFERENCES
identified. The examiner gives the results a file name 1. Shoji T, Sakurai Y, Sato H, Chihara E, Takeuchi M. Do type 2
diabetes patients without diabetic retinopathy or subjects
in the appropriate box, to be saved for the future with impaired fasting glucose have impaired colour vision?
reference. If desired, comments are entered in the The Okubo Color Study Report. Diabet Med. 2011;28(7):865-
‘Comments’ box. A print out can be taken at this stage 71.
to be included in the patient’s medical record (MR) file. 2. Oh YS, Kim JS, Chung SW, Song IU, Kim YD, Kim YI, et al.
Color vision in Parkinson’s disease and essential tremor. Eur
Any file name can be allotted to a test result but it is J Neurol. 2011;18(4):577-83.
useful to include the patients MR number and the date 3. Shaygannejad V, Golabchi K, Dehghani A, Ashtari F,
on which the test was performed. For example, the file Haghighi S, Mirzendehdel M, et al. Color blindness among
name for a test performed by a patient with a MR multiple sclerosis patients in Isfahan. J Res Med Sci.
2012;17(3):254-7.
number ‘123abc’ on the 12th of June 2012 can be ‘123abc- 4. Hyon JY, Lee JH, Wee WR. Shift of colorimetric values in
120612’. All the files are saved in the installation ishiharapseudoisochromatic plates with plate aging. Korean
directory by default. J Ophthalmol. 2005;19(2):145-8.
For retrieval of prior results, the file name for that 5. Birch J. Identification of red-green colour deficiency:

Ophthalmology Update Vol. 11. No. 2, April-June 2013 101

Computerized Documentation & Analysis of the Pseudo-isochromatic Plate Colour Vision Test Results

sensitivity of the Ishihara and American Optical Company 8. Hidajat RR, Hidayat JR, McLay JL, Elder MJ, Goode DH,
(Hard, Rand and Rittler) pseudo-isochromatic plates to Pointon RC. A fast system for reporting the Farnsworth-
identify slight anomalous trichromatism. Ophthalmic Physiol Munsell 100-hue colour vision test. Doc Ophthalmol.
Opt. 2010;30(5):667-71. 2004;109(2):109-14.
6. Cole BL, Lian KY, Lakkis C. The new Richmond HRR 9. Rabin J, Gooch J, Ivan D. Rapid quantification of color vision:
pseudoisochromatic test for colour vision is better than the the cone contrast test. Invest Ophthalmol Vis Sci.
Ishihara test. ClinExpOptom. 2006;89(2):73-80. 2011;52(2):816-20.
7. Lim SA. Ethambutol-associated optic neuropathy. Ann Acad 10. Toufeeq A. Specifying colours for colour vision testing using
Med Singapore. 2006;35(4):274-8. computer graphics. Eye (Lond). 2004;18(10):1001-5.

102 Ophthalmology Update Vol. 11. No. 2, April-June 2013

 Original Article

Visual Outcome after Endolaser versus Cryopexy

in Vitrectomy for Retinal Detachment

Dr. Mir Ali Shah

Mir Ali Shah FCPS1, Nuzhat Rahil FCPS2, RahilMalik FCPS3
Mohammad Jawad MBBS4, Asif Iqbal MBBS5
ABSTRACT
Purpose: To analyze the postoperative visual outcome after Endolaser and Cryopexy in patients undergoing parsplana
vitrectomy for rhegmatogenous retinal detachment.
Material and Method: This retrospective study was conducted to know visual outcome after retinal cryo and endolaser
during pars plana vitrectomy on all patients between age 16 years and 60 years admitted with the diagnosis of
rhegmatogenous retinal detachment with PVR grade C in Khyber Institute of Ophthalmic Medical Sciences, Lady Reading
Hospital Peshawar in 2008 and 2009. Cryopexy to breaks and/ or retinal degenerations was applied when endolaser was
not available in 2008 while Endolaser was used in 2009.The visual outcome was assessed in terms of preoperative and
first postoperative visual acuity and any improvement, loss or no change was recorded.
Results; The total number of patients was 85. Out of these 61 were male and 24 were female. The preoperative visual
acuity was light perception (PL) with good projection in 40% of patients, 42.35% of patients presented with hand motion
(HM) while 11.76% patients had the vision of counting finger (CF) close to eye. The rest of 4.76% patients had vision of
1/60 and better. Endolaser was performed to the breaks in 43 patients while cryo-retinopexy was performed in 42 patients.
The visual acuity on 10 th postoperative day improved in 51.16% of patients and deteriorated in 34.88% of patients with
Endolaser. In those patients who received cryo the vision improved in 40.47% and deteriorated in 35.71%.
Conclusion; Endolaser retinopexy around the tear is relatively easy to perform for retinal surgeons. Endolaser and
cryopexy around the tear after pars plana vitrectomy and internal tamponade has no significant difference regarding
affect on the visual outcome.
Key words: endolaser, retinal cryo, rhegmatogenous retinal detachment, parsplana vitrectomy

INTRODUCTION Retinal surgeons frequently uses retinopexy as a means

The surgical management of reghmatogenous of creating an extra strong adhesions between retina
retinal detachment has evolved dramatically during the and retinal pigment epithelium(RPE) that will
past two decades. Investigators have introduced and strengthen attachments 1.Phtocoagulation produces a
refined alternative techniques to scleral buckling bond that approaches normal adhesive strength within
surgery including primary pars plana vitrectomy (PPV). 24 hrs2,3,4. Cryotherapy however weakens adhesions for
Rapid parallel developments in instrumentation, the first few days after which the adhesive forces rises
including wide-angle viewing systems, per to the level as with other form of retinopexy. Thus all
fluorocarbon liquids, novel vitrectomy machines, forms of retinopexy appear to be equally effective in
intraocular tamponade, and Endolaser photo the long term, however if rapid bond is required, laser
coagulators have lead to increased sophistication in photocoagulation is preferable. One potential
primary PPV surgical techniques for the treatment of disadvantage of cryo therapy is dispersion of RPE cells
rhegmatogenous complicated retinal detachments. which is capable of causing PVR. 5,6,7 In addition
cryopexy does not permanently damage the choroid ,it
————————————————————————————————
1
Associate Professor, Deptt. of Ophthalmology, Postgraduate
does produce choriodal congestion.8 It also causes
Medical Institute, Lady Reading Hospital, Peshawar, 2Registrar, postoperative cystoid macular oedema which is mostly
Deptt. of Ophthalmology, Postgraduate Medical Institute, Lady responsible for low vision .9,10 . Photocoagulation
Reading Hospital, Peshawar. 3 Senior Registrar, Deptt. of compared with cryopexy causes less breakdown of the
Ophthalmology, Postgraduate Medical Institute, Lady Reading
Hospital, Peshawar, 4 ,5Trainee VR Fellowship, Deptt. of
blood ocular–barrier 9 and the thermal effect is confined
Ophthalmology, Postgraduate Medical Institute, Lady Reading predominantly to the retina and pigment epithelium
Hospital, Peshawar with little or no effect on the choroid and sclera.10. Finally
———————————————————————————————— photocoagulation produces an adhesive effect between
Correspondence: Dr Mir Ali Shah, Fellowship Vitreoretina( Holland),
Associate Professor, Deptt. of Ophthalmology, Postgraduate Medical
the retina and pigment epithelium within hours. Cryo
Institute, Lady Reading Hospital, Peshawar, E mail: is more painful under local anesthesia and produces
[email protected] Cell: 03005948091 Postal address: lid oedema and conjunctival chemosis.
Old Bunglow No. 1, Doctors Colony, Lady Reading Hospital, The purpose of this study was to assess the first
Peshawar
————————————————————————————————
postoperative visual acuity in those patients who
Received: Nov’2012 Accepted: Feb’2012 underwent pars plana vitrectomy with cryopexy or
———————————————————————————————— endolaser as mode of inducing adhesive effect.

Ophthalmology Update Vol. 11. No. 2, April-June 2013 103

Visual Outcome after Endolaser versus Cryopex in Vitrectomy for Retinal Detachment

MATERIAL AND METHODS. Figure

It was a prospective study of visual out come after Male & Female Ratio
cryo and Endolaser during pars plana vitrectomy on
all consecutive patient between age 16 years and 60
years admitted with the diagnosis of rhegamatogenous
retinal detachment with PVR grade C in Khyber
Institute of Ophthalmic Medical Sciences, Lady Reading
Hospital ,Peshawar in year 2008 and 2009.All these
cases were operated by single surgeon(MAS) The
inclusion criteria comprised of all those patients who
had rhegamatogenous retinal detachment and had PVR
grade C and in whom PPV was done with endo laser or
cryopexy was performed for adhesive purposes.
Exclusion criteria included those patients below
16 yrs of age, repeat surgery and PVR Grade A and B.
Files of all the patients were reviewed to get
Table-1
informations on detailed preoperative assessment Pre-Op Visual Acuity
including visual acuity, detail dilated fundoscopy using
indirect and 78 or 90 diopter lens and assessment of the Light Hand Close to 1/60 or
retinal detachment including extent, type of break and Perception Motion Eye better
assessment of PVR. After three port pars plana
vitrectomy, fluid air exchange and silicone oil (1000 Table-2
Post-Op Visual Acuity- Cryo
Centi stokes) and application of endolaser or cryo to
the break, the visual acuity on 10th post operative day
Improved Deteriorated No Change
was assessed and the visual outcome was determined
in terms of improvement, deterioration and no change 40% 36% 24%
was recorded. Data analysis was done by SPSS
Table-3
(10.0).Related frequencies and percentages were
Post-Op Visual Acuity – Endolaser
calculated.
RESULS:
Improved Deteriorated No Change
Out of these 85 patients 61(71.76%) were male and
24 (28.23%) were female(Figure). The preoperative 51% 35% 14%
visual acuity was perception of light in 34 (40.00%),
hand motion in 36 (42.35 %) while 10 (11.76 %) patients endolaser and cryopexy to the break.
had the vision of counting finger close to eye and 4 (4.76 The total number of treated patients who were
%) patients had vision of 1/60 and better(Table 1). operated for RD with PPV was 85. In a study done by
Cryopexy was the adhesive procedure in 42( 49.41%) Yeh et al eighty-one eyes in 71 patients who had
and endolaser was used to the break in 43 (50.58%) undergone PPV were included in the study. The results
patients(Table 2). Out of 42 patients who received cryo were better in the group where cryo was applied to
for adhesion of retina during PPV the vision improved peripheral retina and sclerotomy sites, although all
in 17 (40.47%) patients and deteriorated in 15 (35.71%). patients were diabetic in this study.11 In another study
No improvement or loss was recorded in 10 (23.80%) done by Kwok et al in 25 myopic patients with macular
eyes. The visual acuity after endolaser improved in 22 hole and RD, a single row of argon laser around macular
(51.16%) patients and deteriorated in 15 (34.88%) hole was compared with no laser and no significant
patients and no change in visual status was observed difference was noted.12
in 6 (13.95%) (Table 3). In this study 70 patients presented with the
DISCUSSION preoperative vision of HM or only perceptoin of light.
Primary PPV offers potential advantages in the The late presentation, trauma and comorbidity were the
treatment of rhegmatogenous RD, accurate internal reasons behind most of such cases. In a study done by
search for breaks, good visual and anatomical result, Garthy et al on 114 eyes 56% of pateints had the
and higher reattachment rate with endolaser or preoperative VA of 1/60 and better.13Our study showed
cryopexy to the break. that in those patients who received endolaser to the
This study was conducted to find out any break, the visual acuity improved in 22 (51.16%) patients
significant difference in the visual acuity after PPV with and deteriorated in 15 (34.88%) patients and no change

104 Ophthalmology Update Vol. 11. No. 2, April-June 2013

Visual Outcome after Endolaser versus Cryopex in Vitrectomy for Retinal Detachment

in visual status was observed in 6 (13.95%) . In a study photocoagulation in rabbits, Yonsei Med j 36:243-250,1995.
done by Garthy et al best corrected visual acuity was 5. Hilton, GF: Subretinal pigment migration: effect of
cryosurgical retinal reattachment, Arch Ophthalmol 91: 445-
improved in 92 eyes (81%), unchanged in 14(12%), and 450, 1974.
worse in eight (7%) after PPV.13 6. Sudarsky,RD,and Yannnuzzi,LA: Cryomarcation line and
In our study those patients who received cryo to migrationafter retinal cryosurgery, Arch ophthalmol 83:395-
the break during PPV, the vision improved in 17 401, 1970.
7. Campochiaro,PA,Kaden, IH, Vidurri-Leal, and Glaser, BM:
(40.47%) patients and deteriorated in 15 ( 35.71%). No Cryotherapy enhances intravitreal dispersion of viable retinal
improvement or loss was recorded in 10 (23.80%) eyes. pigment epithelial cells, Arch Ophthalmol 103:434-436,1985.
This is almost similar to the study by Brazitikos in which 8. Oosterhuis, JA, Brihaye, M, AB: A comparative study of
the mean and final best-corrected visual acuity (log experimental transscleral cryocoagulation by solid carbon
dioxide and diathermocoagulation of the retina
MAR) was 0.33 in the PPV group with cryopexy 14. Our ,Ophthalmologica 156:38-78, 1999.
study result does not reveal significant difference in the 9. Jaccoma, EH: Conway, BP and Compochiaro,PA: cryotherapy
two groups but the literature is quite deficient in such causes extensive breakdown of the blood retinal barrier: a
comparisons of these two adhesive procedures. comparison with argon photocoagulation, Arch Ophthalmol
103: 1728-1730, 1985.
CONCLUSION 10. Ackerman, AL, and Tiplow, HW: A reduce incidence of
Endolaser retinopexy around the tear is relatively cystoid macular oedema following retinal detachment
easy to perform for retina surgeons. Endolaser and surgery using diathermy, Ophthalmology92:1092-1095,1985.
cryopexy around the tear after pars plana vitrectomy 11. Yeh PT, Yang CM, Yang CH, Huang JS. Cryotherapy of the
anterior retina and sclerotomy sites in diabetic vitrectomy to
and internal tamponade has no significant difference prevent recurrent vitreous hemorrhage: an ultrasound
regarding affect on the visual outcome. biomicroscopy study. Ophthalmology. 2005
REFERENCES: Dec;112(12):2095-102. Epub 2005 Oct 12.
1. Yoon,YH and Marmor,MF: rapid enhancement of retinal 12. Kwok AK, Cheng LL, Gopal L, Sharma T, Lam DS. Endolaser
adhesion by laser photocoagulation,Ophthalmology 95:1385- around macular hole in the management of associated retinal
1388,1988. detachment in highly myopic eyes.Retina. 2000;20(5):439-44.
2. Kita,M, Negi, A,Kawano,SI,and Honda,Y:Photothermal, 13. Garthy DS,Chingnell AH, Frank and WA, Wang D.Pars plana
cryogenic,and diathermic effect on retinal adhesive force in vitrectomy for the treatment of rhegmatogeous retinal
vivo, Retina 11:441-444,1991. detachment uncomplicated by advance proliferative
3. Kita,M, Negi, A,Kawano,SI,and Honda, Y and Meagawa, S: vitroretinopathy. Br J Ophthamol 1993:77 199-203.
Measurment of retinal adhesive forces in the vivo rabbit eye, 14. Brazitkos, Periklisd, Androudi,Sofia,Christen,Willaim G,
Invest Ophthalmol Vis Sci 31:624-628,1990. Nikolaos TR.Primary pars plana vitrectomy vesus scleral
4. Kwon,OW, and Kim, SY:Changes in adhesive forcebetween buckle surgery for the treatment of puedophakic retinal
the retina and the retinal pigment epithelium by laser detachment. Retina 2005 : 957-965.

Khyber Eye Symposium

to be held at Nathiagali
from 28-30 June 2013

Please Contact:
Dr. Mir Ali Shah
General Secretary
Ophthalmological Society of Pakistan
Peshawar. Khyber Pukhtoonkhwa
Cell: 0300-5948091

Ophthalmology Update Vol. 11. No. 2, April-June 2013 105

 Original Article

Effectiveness of using Topical Antihistamine

& Decongestant During an Epidemic of
Adenoviral Conjunctivitis
Dr Dilshad

Dilshad Alam Khan DO, FCPS*

ABSTRACT
Objective: This study was conducted to evaluate the effectiveness of using topical antihistamine (pheniramine maleate)
and decongestant (naphazoline) eye drops in reducing the severity and complications of adenoviral conjunctivitis during
an epidemic.
Study design: Randomized controlled trial (RCT)
Place and duration of study: Three months study from June 2012 to august 2012 was conducted at ophthalmology
department, Combined Military Hospital, Abbottabad.
Patients and Method: A total 1570 cases of adenoviral conjunctivitis were documented during the months of June, July
and august 2012. By simple randomization 200 patients were selected and divided into two groups on the basis of
treatment. Group 1 (treatment group) 40% patients were given topical antihistamine and decongestant drops whereas
Group 2(control group) 60% patients were managed conservatively by washing eyes with cold water and applying ice
packs on the eyes.
Results: In most cases (90%) both eyes were affected. Acute illness lasted from4.50 days in group1 and 7.65 days in
group2. Commonly observed symptoms included redness, watering, itching, burning and pain in the eyes and photophobia.
The duration of illness was less and the severity was mild in group1 as compared to group2 patients. This was found to be
statistically significant using Chi-square test (p<0.05). None of the case reported any complication after recovering from
the infection.
Conclusion: Adenoviral conjunctivitis is a highly contagious disease and often spreads in epidemics particularly in crowded
communities with poor hygiene. Prevention of the transmission is the most important therapeutic measure. Although the
disease is benign and self-limiting, the use of topical antihistamine and decongestant drops markedly reduce the severity
and duration of the symptoms.
Keywords: adenoviral, epidemic, antihistamine, decongestant

INTRODUCTION conjunctival chemosis and mechanical ptosis.

The viral conjunctivitis is caused by many viruses Conjunctival follicles and fine tarso-conjunctival
but adenovirus is the commonly causative organism.1 papillae of the lower lid are mainly involved.8,9 Corneal
The incubation period of the disease is one week and is involvement causes intense photophobia due to
highly contagious for several weeks after the onset of punctuate epithelial lesions.10 Later on sub-epithelial
symptoms.2 Generally adenoviral conjunctivitis is infiltrates appear at the level of the Bowman membrane
benign and self-limiting disease. Epidemic as a hypersensitivity reaction to the viral antigens. These
keratoconjunctivitis (EKC) is commonly associated with sub-epithelial infiltrates may coalesce to form deep
sub-types 8, 19 and sometimes 37.3,4 Adults between the lesions called nummular keratitis.11,12 Preauricular
ages 20 to 30 are commonly affected. The EKC spreads lymphadenopathy is a common sequel.
in epidemics by person to person contact particularly Diagnosis is mainly based on the clinical features
in crowded communities with poor hygiene e.g., alone. However, other causes of follicular conjunctivitis
schools, swimming pools and military camps.5,6 The e.g., herpes simplex virus13 and chlamydial infection
conjunctival infection causes extreme watering, redness should be excluded.14 Adenoviral enzyme immunoassay
and foreign body sensation called catarrhal is a specific and confirmative test.15
conjunctivitis.7 On examination there is lid edema, The prevention of transmission is the most
important therapeutic measure particularly in the
————————————————————————————————
*Classified Eye Specialist, Department of Ophthalmology ophthalmic clinics of the hospitals. Hand washing with
Combined Military Hospital, Abbottabad. soap and water before and after examining each patient,
———————————————————————————————— thorough sterilization of the instruments touching the
Correspondence: Lt. Col. Dr. Dilshad Alam Khan, Combined
patient’s eye and frequent changing of multi-use eye
Military Hospital, Abbottabad, Ph: 0992-342897 Cell: 0300-
3503920, e-mail: [email protected] drops is extremely important.6 Affected patients must
———————————————————————————————— be isolated for at least two weeks. Cold compresses,
Received : Dec’2012 Accepted ; Feb’2013 topical antihistamines, decongestants and non-steroidal
————————————————————————————————

106 Ophthalmology Update Vol. 11. No. 2, April-June 2013

Effectiveness of using Topical Antihistamine & Decongestant During an Epidemic of Adenoviral Conjunctivitis

anti-inflammatory agents reduce severity of the Table1

symptoms. Topical steroids should be avoided in the Cases of viral conjunctivitis (Year 2012)
(n=1570)
conjunctival infection as they are known to prolong the
course of the disease.15
Months June July August
PATIENTS AND METHODS
This study was conducted in the ophthalmology Department 2012 2012 2012
department of combined military hospital, Abbottabad Staff Surgeon Department 14 102 130
from 01 June 2012 to 31 august 2012; the time when an
Medical Reception Centre 47 380 330
epidemic spread in Abbottabad area.
A record of all officers, troops, their families and Family OPD 19 50 30
civilians who suffered from the viral conjunctivitis was PMA Hospital 53 262 153
maintained at staff surgeon, medical reception
TOTAL 133 794 643
center(MRC), family outpatient department(family
OPD) of combined military hospital, Abbottabad,
Table 2
Pakistan Military Academy Hospital, Kakul and other Distribution of unilateral or bilateral eye involvement
military establishments throughout Abbottabad during (n= 200)
the months of June, July and august 2012.
A questionnaire was designed and response was Sr. No Distribution Number Percentage
obtained from 200 randomly selected army personnel
1 Unilateral involvement 20 10%
and their families and children who suffered from
adenoviral conjunctivitis during the epidemic. The 2 Bilateral involvement 180 90%
questionnaire was pre-tested on a sample to ensure
clarity of interpretation and ease of completion to Table 3
improve validity of the responses. Symptoms with duration
Patients (n=200) were divided into two groups on
the basis of treatment. Group 1 patients (n=80) were S. No Symptoms Duration in Duration in
treated with topical antihistamine/decongestant treatment group control group
(pheniramine maleate 0.3% and naphazoline 1 Redness of eyes 5 days 8 days
hydrochloride 0.025%) whereas Group 2 patients 2 Watering of eyes 4 days 7 days
(n=120) were treated conservatively by washing eyes
3 Pain, itching, burning 4 days 6 days
with cold water and applying ice packs on the eyes.
RESULTS 4 Photophobia 3 days 5 days
Highest incidence of the disease was seen in the
month of July 2012 (Table 1). Out of a total of 200 after complete recovery from adenoviral conjunctivitis.
selected patients, both eyes were affected in 180 (90%) DISCUSSION
patients whereas single eye was affected only in 20 Adenoviral conjunctivitis is the commonest type
(10%) patients. (Table 2) of viral conjunctivitis that frequently appears in
Mean duration of illness in group 1 was 4.50 days epidemics. Although it is benign and self-limited, it is
whereas it was 7.65 days in group 2. Most commonly highly contagious and spreads by exposure to the
observed symptoms noted amongst the respondents affected person particularly through health care
included redness of eyes, watering, pain (including workers.5,6 Conjunctival infection causes extreme
itching and burning) and photophobia. All the watering, redness and foreign body sensation called
symptoms were graded from grade 0 to 3 depending catarrhal conjunctivitis. Epidemic keratoconjunctivitis
upon the severity. is commonly responsible for epidemics and is usually
Grade 0 Absence of any complaint associated with sub-types 8 and 19.8 Purpose of this
Grade 1 Mild (+1) study was to minimize the patient’s discomfort by using
Grade 2 Moderate (+2) topical antihistamine and decongestant eye drops.
Grade 3 Severe (+3) Patients were divided into two groups on the bases of
The duration of symptoms in group 1 and 2 are treatment. Patients in group 1 (40%) were treated with
depicted in table 3. Duration of the illness as well as topical antihistamine and decongestant (pheniramine
severity of the symptoms was less and statistically maleate 0.3% and naphazoline hydrochloride 0.025%)
significant in group 1 patients as compared to group 2 while group 2 patients (60%) were treated
(p < 0.05). Chi-square test was used for statistical data conservatively by washing eyes with cold water and
analysis. None of the patients reported any complication applying ice packs on the eyes. Highest incidence of

Ophthalmology Update Vol. 11. No. 2, April-June 2013 107

Effectiveness of using Topical Antihistamine & Decongestant During an Epidemic of Adenoviral Conjunctivitis

the disease was seen in the month of July 2012 when 4. Smolin G, Thoft RA: Viral Keratitis and Conjunctivitis.In:
humidity was at its peak. In 90% cases both eyes were Cornea:Scientific Foundations and Clinical Practice.3 rd
edition. Boston. Little Browns &Co. 1994;215-22.
affected. Most commonly observed symptoms were 5. Buerhler JW, Finton RJ, Goodman RA, Choi K, Hierholzer jc,
redness of eyes, watering, itching, burning, Sikes RK, et al. Epidemic Keratoconjunctivitis report of an
photophobia and pain in the eyes. Duration of the illness outbreak in an ophthalmic practice & recommendations for
as well as severity of the symptoms was mild and prevention. Infect Control 1984;5:390-4.
6. Wilhelmus KR. Viral infections. In: American Academy of
statistically significant in group 1 patients as compared Ophthalmology Basic & Clinical Science Course (section 8)
to group 2 (p < 0.05). Results were comparable with 1999;136-40.
similar studies of Buerhler et al and Rosenbach et al.5,16 7. Wright KW, Liesegang TJ: Conjunctiva. In: Textbook of
CONCLUSION Ophthalmology. First Edition. Baltimore: Williams & Wilkins
1997;665-90.
Adenoviral conjunctivitis is a highly contagious 8. Darougar S, Quinlan MP, Gibson JA et at: Epidemic
disease and often spreads in epidemics particularly in Keratoconjunctivitis and chronic papillary conjunctivitis in
crowded communities with poor hygiene. It is London due to adenovirus type 19. Br J Ophthalmol 1977;665-
extremely important to teach the masses about the 90.
9. Sarangapani S and Corbet MC: Stellate tarsoconjunctival
nature of disease, treatment and prevention of its lesions in ocular adenoviral infection. Br J Ophthalmol
spread. Prevention of transmission is the most 2002;86:594.
important therapeutic measure by avoiding close 10. Leibowitz HM, Waring GO: Superficial punctuate
contact of the affected person and not sharing towel keratopathy. In: Clinical Disorders of eye: Clinical Diagnosis
and Management. 2nd edition. St. Louis CVV. Mosby & Co.
used by him. In the ophthalmic clinics of the hospitals 1998;445-7.
hands must be washed with soap and water before and 11. Hodge W, Wohl T, Whitcher JP, Margolis TP. Corneal sub-
after examining the patient. Thorough sterilization of epithelial infiltrate recurrence with adenovirus. Cornea
instruments touching the patient’s eye must be carried 1995;14:324-5.
12. Petit TH, Holland MM: Chronic keratoconjunctivitis
out and frequent changing of multi use eye drops is associated with ocular adenoviral infection. Am J Ophthalmol
extremely important. 1979;88:748-51.
Although the disease is benign and self limiting, 13. Uchio F, Takeuchi S, Itoh N, Matsuura N, Ohno S, Aoki K.
cold compresses and topical antihistamine and Clinical and epidemiological features of Acute Follicular
Conjunctivitis with special reference to that caused by herpes
decongestant eye drops markedly reduce the simplex virus type 1.Br J Opthalmol 2000;84;968-72.
discomfort, severity and duration of the adenoviral 14. Mellman-Rubin TL, Kowalski RP, Uhrin M, Gordon YJ.
conjunctivitis during an epidemic. Incidence of adenoviral,chlamydial coinfection in acute
REFERENCES follicular conjunctivitis. Am J Ophthalmol 1995;119:652-4.
1. Krashmer JH, Mannis MJ, Holland E: Conjunctivitis: an 15. Gordon JS: Adenovirus and other non-herpetic viral diseases.
overview and classification of viral conjunctivitis. Cornea In: Smolin G, Thoft RA (ed): The Cornea.Third Edition.
1995;5:750-51, 773-4. Boston: Little Brown & Co 1994;215-27.
2. Kaufman HE, Barron BA, Me Donald MB; Nonherpetic viral 16. Rosenbach KA, Nadiminti U, Vincent AL et al: An outbreak
infections, Cornea 1998;1:303-6. of adenoviral keratoconjunctivitis. Infect Med 2002;19:436-
3. Tasman W, Jaeger EA: Epidemic keratoconjunctivitis. 8.
Duanne’s Clinical Ophthalmology 1998;4;5-8

STAY ON TOP WITH

Quarterly

Update
Approved & indexed by PMDC, PakMedinet & H.E.C

108 Ophthalmology Update Vol. 11. No. 2, April-June 2013

 Original Article

The Frequency of Amblyopia & Results of

Squint Surgery in Patients admitted in
Khyber Teaching Hospital, Peshawar*
Dr Ayat Shah
Ayat Shah1, Sadia Sethi FCPS2, Omer Ilyas,MBBS.3, Zaman Shah, FCPS,4

ABSTRACT:
Objectives: The objectives of the study were to find out the frequency of Amblyopia and post operative ocular alignment
of squint patients.
Material and Methods: This prospective study was conducted in Eye A ward of Khyber Teaching Hospital Peshawar from
1st Jan 2012 till 30th Oct 2012. Patients were examined over 9 months.
The details of each patient were recorded by orthoptist pre operatively and then at approximately 1 week interval post
operatively. At each visit a full orthoptic assessment was done including visual acuity, prism cover test, and assessment
of binocular single vision using tests appropriate for the age. Other parameters were also recorded by orthoptist but have
not been analyzed in this study. Eyes with alignment of 10 prism diopters were considered as straight and all the rest
would be considered as misaligned.
Results: Total of 115 patients were analyzed pre operatively. Out of these 115, 92 patients (80%) were esotropic of which
63 (54.78%) were of unilateral esotropia and 29 (25.22%) were of alternating esotropia. Remaining 24(20%) were of
exotropia of which 13 patients (11.30%) were of unilateral exotropia and remaining 11 (9.56%) were of alternating exotropia.
Of these pre operative patients 54(46.91%) were males and 61(53.04%) were females. There were total of 35 patients up
to 10 years of age(30.43%), from 10-16 years were 33(28.70%),from 16-25 years were 34(29.56%) and above 25 years
were 13(11.30%) in number. Patients in whom complete post operative assessment was done were 95 in number and rest
were lost in follow up.
Out of these 95 patients that have been assessed post operatively 85(89.47%) patients were having straight eyes
at 1 week post operatively i.e., deviation within 10 prism diopters of straight, residual squint was found in 8 patients
(8.42%) and consecutive squint was found in 2(2.11%) patients. Out of 115 patients, 38(33.04%) patients were having
amblyopia. Amblyopia was checked by visual acuity chart (Longmar visual acuity chart, Snellen chart and correction of
refractive error). Stereopsis was absent both pre and post operatively in 44(46.32%) checked by Titmus Fly test, Lang
test, Frisby test. Suppression and post operative diplopia was checked by Worth four light test and Bagolini test.
Conclusion: The study shows that most of patients with unilateral squint were having amblyopia, having frequency
33.04%. The results of squint surgery were satisfactory. The ratio of female was greater than male.
Key Words: Amblyopia, Residual Squint, Consecutive Squint

INTRODUCTION vision, 2) improvement of three dimensional vision, 3)

Strabismus is a common problem in expansion of visual field, 4) elimination of abnormal
ophthalmology, the prevalence ranges from 3-5%1. The head posture, 5) improvement of psychological
first documented treatment for strabismus occurred in function, 6) improvement of vocation status4.
1839 and was performed by Johann Friedereich The accuracy of strabismus surgery is usually
Dieffenbach, a general surgeon 2 .A substantial assessed in terms of alignment within 10 prism diopters
information exists demonstrating that accurate of straight5. Most of these operations are corrections of
alignment will lead to a better long term outcome with horizontal eye position by relocating the insertion of
regard to both binocular function and cosmesis3.The one eye muscle on the eye a few millimeters backward
indications for surgery are 1) elimination of double (recession) and resecting the tendon of its antagonist
————————————————————————————————
(resection).The treatment goals for strabismus surgery
*Acknowledgement: This study was conducted with financial
assistance of Fred Hollows Foundation Pakistan.
in adult patients is to alleviate double vision (diplopia)
———————————————————————————————— and to improve cosmetic appearance. In children the
1
Optometrist/orthoptist, Department of Ophthalmology, Khyber treatment goals are to preserve binocular vision in
Teaching Hospital,Peshawar , 2Associate Professor, 3Postgraduate worsening or short-onset strabismus and to improve
Trainee, 4Senior Registrar, Department of Ophthalmology, Khyber
cosmesis6. Strabismus usually results in normal vision
Teaching Hospital, Peshawar.
———————————————————————————————— in the preferred sighting (or fellow) eye (patients prefers
Correspondence: Ayat shah, Optometrist/orthoptist, Department to use), but may cause abnormal vision in the deviating
of Ophthalmology, Khyber teaching Hospital, Peshawar or strabismic eye due to the difference between the
Cell no. 0321-9030996, 0344-9856913
images projecting to the brain from the two eyes7.
————————————————————————————————
Received: Jan’2013 Accepted: Feb’2013 Strabismic amblyopia is treated by clarifying the visual
————————————————————————————————

Ophthalmology Update Vol. 11. No. 2, April-June 2013 109

The Frequency of Amblyopia & Results of Squint Surgery in Patients admitted in Khyber Teaching Hospital, Peshawar

image with glasses, and/or encouraging use of the Result of Squint surgeries
amblyopic eye with an eye patch over the dominant
eye or pharmacologic penalization of the better eye. S.No Postoperative Status Quantity Percentage
Penalization usually consists of applying atropine drops 1 Straight Eyes 85 89.47%
to temporarily dilate the pupil, which leads to blurring
2 Residual 08 8.42%
of vision in the good eye. This helps to prevent the
bullying and teasing associated with wearing a patch, 3 Consecutive 02 2.11%
although application of the eye drops is more Total 95 100%
challenging. The ocular alignment itself may be treated
with surgical or non-surgical methods, depending on
Frequency of Amblyopia
the type and severity of the strabismus8.
MATERIALS AND METHODS
This prospective study was conducted in Eye A-
ward of Khyber Teaching Hospital Peshawar from 1st
February 2012 till 30 the October 2012. Patients were
recruited over 9 months. One surgeon was asked to
indicate the intended post operative surgical alignment.
The decision was based on the clinical judgment of
surgeon involved. Since only the accuracy of ocular
alignment was being analyzed, no attempt was made
to standardize the surgical objectives or techniques
among the participating surgeons. 38(33.04%) patients were having amblyopia.
The details of each patient were recorded by DISCUSSION:
orthoptist pre-operatively and then at approximately 1 In our study total 115 patients of squint were
week interval post operatively. At each visit a full examined. Out of them, 95 were post operatively
orthoptist assessment was done including visual acuity, examined. The frequency of Amblyopia was 33.04% (38)
prism cover test at 1 meter, and assessment of binocular patients. The successful results of squint surgery were
single vision using tests appropriate for the age. Other 89.47% (85) patients (having post operatively straight
parameters were also recorded by orthoptist but have eyes). Residual squint was 8.42% (8) patients. 2.11%
not been analyzed in this study. Eyes with alignment were having consecutive squint (2) patients.
of 10 prism diopters of straight would be considered as Out of 115 patients, 54 (46.91%) Patients were male
straight and all the rest would be considered as 61(53.04%) were female.
misaligned. The success or failure of a surgical approach can’t
RESULTS: be evaluated within a short follow-up period. The
Total of 115 patients were analyzed pre consecutive exotropia may not develop until years after
operatively. Out of these 92 patients (80%) were the surgery for esotropia. However our study was based
esotropic of which 63 (54.78%) were of unilateral on short follow-up period.
esotropia and 29 (25.22%) were of alternating esotropia. Two patients had large angle esotropia and
Remaining 24(20%) were of exotropia of which 13 bilateral medial rectus recession was done and results
patients (11.30%) were of unilateral exotropia and were residual esotropia. In our study there were two
remaining 11 (9.56%) were of alternating exotropia. Of patients (2.11%) with consecutive squint. According to
these pre operative patients 54(46.91%) were males and a study the incidence of consecutive exotropia ranged
61(53.04%) were females. There were total of 35 patients from 4%9 to 20%10. A study done in Korea shows that
up to 10 years of age(30.43%), from 10-16 years were consecutive esotropia developed in 13.8% of patients
33(28.70%),from 16-25 years were 34(29.56%) and above with immediate overcorrection of at least 17 PD.11 A
25 years were 13(11.30%) in number. Patients in whom study done in Department of Ophthalmology and Lions
complete post operative assessment was done were 95 Eye Institute, Albany Medical College, Albany, New
in number and rest were lost in follow up. York USA shows 60% successful result (straight eyes)
Out of these 95 patients that have been assessed 32% residual esotropia and 8% consecutive exotropia.12
post operatively 85(89.47%) patients were having In our study (71.58%) were children. A study done in
straight eyes at 1 week post operatively i.e., deviation London shows infants undergo early surgical
within 10 prism diopters of straight, residual strabismus intervention, they have a chance of better alignment and
was found in 8 patients (8.42%) and consecutive squint stereopsis outcomes. Multiple surgeries may be needed
was found in 2(2.11%) patients. Out of 115 patients,

110 Ophthalmology Update Vol. 11. No. 2, April-June 2013

The Frequency of Amblyopia & Results of Squint Surgery in Patients admitted in Khyber Teaching Hospital, Peshawar

to correct large angle of the esotropia. The number of Outcomes of Horizontal Strabismus Surgery and Influencing
children requiring a second operation varies between Factors of the Surgical Success. J Med Assoc Thai 2005; 88
(Suppl 9): S94-9
15-30%.13 5. Scott WE, Reese PD, Hirsh CR, Flabetich CA. Surgery for
Another study done on comitant esotropia shows, large angle congenital esotropia. Arch Ophthalmol 1986; 104:
close follow-up was required especially in cross fixating 374-7.
children as amblyopia in one eye usually presents after 6. Simonsz HJ, Kolling GH, Unnebrink K .Final report of the
early vs. late infantile strabismus surgery study (ELISSS), a
surgical alignment.14 controlled, prospective, multicenter study. 2005; 13(4):169–
A study done on surgical management of residual 199.
or recurrent esotropia shows that difference in surgical 7. Wright, Kenneth W.; Spiegel, Peter H.; Thompson, Lisa S.
response per millimeter of unilateral lateral rectus (2006). Handbook of Pediatric Strabismus and Amblyopia.
New York, New York: Springer. ISBN 978-0387-27924-4.
resection were not significant. Bilateral lateral rectus 8. Holmes, Repka, Kraker & Clarke (2006). “The treatment of
resection of 5, 6 and 7 mm resulted in a mean correction amblyopia”. Strabismus 15(1): 37-42. Doi: 10, 1080/
of 19.75, 28.75 and 33.05 prism diopters, respectively.15 09273970500536227. PMID 16513568.
A study done on bilateral lateral rectus resection 9. Bietti GB, Baglioni B. Problems related to surgical
overcorrections in strabismus surgery. J Pediatr ophthalmol
in patients with residual esotropia, showing successful 1965; 2:11-4.
alignment in 68% under correction in 28% and 10. Dunnington JH. Regan EF factor influencing the
overcorrection in 4% cases, six month after surgery.16 postoperative result in concomitant convergent strabismus.
In our study the frequency of amblyopia was (33.04%) Arch ophthalmol 1950; 44:813-22.
11. Yoonae A.Cho, MD. Department of Ophthalmology, Anam
which is quite different from, a study done in Hospital, College of Medicine, Korea University.January 25,
Department of Ophthalmology, Postgraduate Institute 2007; Accepted August 02, 2007.
of Medical Education and Research, Chandigarh, India 12. Gunasekera LS, Simon JW, Zobal-Ratner J, Linninger LL.
shows the frequency of amblyopia were 61.3%.17 Department of Ophthalmology and Lions Eye Institute,
Albany Medical College, Albany, New York 12208, USA.
CONCLUSION: 2002 Fab; 6(1): 21-5.
The study shows that most of patients with 13. Elston J. Concomitant strabismus. In: Taylor D. Pediatric
unilateral squint were having amblyopia, with ophthalmology. 2nd ed. London: Blackwell sciences: 1997.
frequency of 33.04%. The results of squint surgery were p. 925-36.
14. Raab EL, comitant esotropia. In: Wilson ME, Sunders RA,
good. Trivedi RH. Pediatric Ophthalmology: current thoughts and
The ratio of female was greater than male. The practical guide. Leipzig. Springer: 2009. p. 85-112.
ratio of unilateral esotropia was greater than alternating 15. David G. Morrison, MD; Matthew Emanuel, MD; Sean P.
esotropia, and the ratio of esotropia was greater than Donahue, MD, PhD. Surgical management of residual or
recurrent esotropia following maximal bilateral medial rectus
exotropia. recession free. Arch Ophthalmol. 2010; 129(2): 173-175.
REFERENCES: 16. Gyu Jin Jng, MD, Mi Ra Park, MD, Soo Chul Park, MD.
1. Arora A, Williums B, Arora AK. Decreasing strabismus Bilateral lateral rectus resection in patients with residual
surgery. Br J Ophthalmol 2005; 89: 409-12. esotropia. Department of Ophthalmology, St. Mary’s
2. Cooper J, Medow N. Major review, Intermittent Hospital, Kngnam St. Mary’s Hospital, School of Medicine,
exotropia,Basic and Divergence Excess Type.Binocular Vision The Catholic University of Korea, Seoul, Korea. Korean J
Eye Muscle Surgery Qtrly 1993;8: 185-216. Ophthalmol 2004; 18: 161-167.
3. Willshaw HE, Keenen JM. Strabismus surgery in children: 17. Kanwar Mohan MS, Ashok Sharma MS, S.S Panday MS.
the prospects for binocular single vision. Eye 1991; 5: 338-43. Department of Ophthalmology, postgraduate Institute of
4. Kampanartsanyakorn S, Surachatkumtonekul T, Medical Education and Research and Squint centre,
Dulayajinda D, Jumroendararasmee M, Tongsae S.The Chandigarh, India. 2006.01.182.

Ophthalmology Update Vol. 11. No. 2, April-June 2013 111

 Original Article

Success Rate of Surgical Correction of

Essential Esotropia
Humaira Mahboob MBBS1, Arif Rabbani DO2, Alyscia M. Cheema FCPS, FRCS3
Dr. Humaira Umair Qidwai FICS4, Asim Atiq MBBS5

ABSTRACT
Aim:To measure the degree of esotropia postoperatively and determine the success of surgical outcome for congenital
esotropia managed in a tertiary care hospital.
Material and Method: A total of 53 patients were included in this Quasi Experimental Study carried out at the Department
of Ophthalmology, Jinnah Post Graduate Medical Centre, Karachi. The patients congenital esotropia underwent a bilateral
medial rectus recession by Parks cul-de-sac approach by researcher under supervision of consultant ophthalmologist
who has at least 5 years of clinical experience. Patients were re-evaluated by the researcher one week and then one
month post operatively. The results interpreted in the light of postoperative prism cover test measurements. Final outcome
was considered at the end of one month at which achievement of <10 PD of residual esotropia will be deemed as
success. Duration of study was 6 months.
Results :The age group of patients was between 1 and 27 years with a mean age of 7.98 yrs and a standard deviation of
6.72. The male patients were 35 in number and the female patients were 18. The maximum postoperative esotropia after
one month was 25 and the mean being 9.06 with a standard deviation of 5.806. Among the 53 patients 39 had a residual
esotropia of less than 10 PD and this constitutes for an overall success rate of 73.6% of the cases.
Conclusion:In conclusion, in eyes with congenital esotropia the surgical corrections proved that the results become
better after one month with a residual esotropia of 5 prism diopters which by definition is a successful outcome. The
surgical outcome of congenital esotropia in a tertiary care hospital had an overall success rate of 73.6% and an
undercorrection occurring for 26.4% of the patients.
Keywords: ,Esotropia, Rectus Muscle Recessions, Strabismus, Prism diopters

INTRODUCTION uses left eye in right gaze and right eye in left gaze.4
Congenital esotropia is one of the most common Other than strabismus, children with congenital
forms of strabismus 1 an ocular misalignment. esotropia are usually normal.5
Prevalence estimates of strabismus range from 1% to The goal of treatment in congenital esotropia is to
6% in different populations, with esotropia reported five reduce the deviation to orthophoria or as close as
times more frequently than exotropia in a country like possible.5 It is widely accepted that infantile esotropia
Ireland and twice as frequently in Australia. 2 It is associated with severe deficits of stereopsis and
represents more than half the ocular deviations in fusion. 6 The critical period of binocular visual
childhood.3 Congenital esotropia has been referred to development occurs around the first 4 to 6 months of
as infantile esotropia or essential esotropia.1Early onset life.7 The visual outcomes of patients with infantile
(congenital, essential, infantile) esotropia is an esotropia are substantially improved if the mis-
idiopathic condition developing within the first six alignment is corrected surgically early in life.9 Recent
months of life in an otherwise normal infant with no reports suggest that early muscle surgery is associated
significant refractive error and no limitations of ocular with greater prevalence of stereopsis and fusion.7-9
movements.4 Congenital esotropia never develops later Ideally, the eyes should be surgically aligned by the
than 6 months of age and more often develops at 2-3 age of 12months and at the latest by age of 2 year, but
months.1 only after ambylopia or significant refractive errors have
The misalignment is often readily apparent and been corrected. 4 The most common procedure is
the deviation is characteristically larger than 30 recession of both medial rectus muscles. The overall
diopters. 5 There is cross fixating in side gaze. The child success rate with one operation was 83.5 %.10
———————————————————————————————— There hardly exists any study pertaining to the
1,2,5
Postgraduates in Ophthalmology, 3Associate Professor, 4Medical success rate on the subject. of surgical outcome for
Officer, Jinnah Postgraduate Medical Centre, Karachi congenital esotropia. This study will help the result of
————————————————————————————————
Correspondence: Dr. Arif Rabbani, House 38/III, St. 32, Phase V bilateral medial rectus recessions in all patients coming
Extension. DHA, Karachi. E-mail: [email protected] for treatment.
Cell: 0300-2234128 MATERIALS AND METHODS
———————————————————————————————— This was a Quasi Experimental Study carried out
Received: Dec’2012 Accepted: Feb’2013
———————————————————————————————— at the Department of Ophthalmology, Jinnah Post

112 Ophthalmology Update Vol. 11. No. 2, April-June 2013

Success Rate of Surgical Correction of Essential Esotropia

Graduate Medical Centre, Karachi for 6 months from of 5.806. Amongst 53 patients 39 had a residual
February 2011 to August 2011. 53 patients were esotropia of less than 10 PD and this constitutes for an
included in the study [Z = Level of confidence : 95% ,P overall success rate of 73.6% of the cases. 14 cases had a
= Prevalence of success rate : 83.5% (0.83), D = Margin residual esotropia of more than 10 PD which was 26%
of error: 10% (0.10) ]. (Non-probability purposive of the sample size and required a second stage surgery.
sampling technique was used). The graphs consist of a comparison between
The patients coming to the squint clinic of Jinnah preoperative degrees of esotropia and postoperative
Post Graduate Medical Centre were selected on the basis esotropia after one week as well as a comparison
of main complaints of ocular misalignment due to between degree of postoperative esotropia after one
congenital esotropia(present by the age of 6 months) of week and degree of postoperative esotropia after one
either gender, were included in the study, while patients month respectively.
with previous extraocular or intraocular surgery, central DISCUSSION
nervous system abnormalities, organic eye disease and Many studies have been conducted on surgical
esotropia due to other causes were excluded.The outcome on congenital esotropia. Several authors
informed written consent was taken from the subjects reported high rates of success, from 70 to 91%, in large-
for the surgical correction and they were enrolled in angle congenital esotropia with large medial rectus
the squint clinic for our study. All underwent a bilateral recessions, and no significant adduction limitations.11,12
medial rectus recession by Parks cul-de-sac approach Our study was conducted within a period of 6
by experienced ophthalmologist. Patients were re- months at Jinnah Postgraduate Medical Centre with a
evaluated by the researcher one week and then one sample size of 53 patients. A study was conducted by
month post operatively. The results were interpreted Dr Lihua Wang in China. It consisted of a sample size
in the light of postoperative prism cover test
measurement as explained earlier. Final outcome was Figure 1
considered at the end of one month at which
achievement of <10 PD of residual esotropiawas
deemed as success. This information was entered in the Success rate after surgery
performa attached. The database was analyzed on SPSS
version 12.0 on computer. The groups of success (PD
<10) and failure (PD > 10) was compared by Fisher’s
exact test or chi-square test. The age group of patients
were stratified to know the confounding effect of these
variables. The continuous variables such as age (in yrs)
and degree of esotropia (in PD) pre and post operatively
was presented as mean ±SD. The result were considered
significant with P < 0.05
RESULTS
53 patients were selected in the study,the age
group of patients were between 1 to 27 years, with a
mean age of 7.98 yrs and a standard deviation of 6.72.
The male patients were 35 in number and the female
patients were 18. The frequency of the male gender was
66% out of the 53 patients and 34% were females. On
assessment with prism cover test, the preoperative Figure 2
degree of esotropia ranged between a minimum of 30
and maximum 95 prism diopters. The prism cover tests
were done one week and one month postoperatively.
ESOTROPIS IN PD
The postoperative degree of esotropia after one week
was a minimum of 5 diopters to a maximum of 25 prism
diopters residual esotropia which has a mean of 9.72
and a standard deviation of 6.078. The results proved
to become better after one month where most of the
cases had a residual esotropia of 5 prism diopters. The
maximum postoperative esotropia after one month was
25 and the mean being 9.06 with a standard deviation

Ophthalmology Update Vol. 11. No. 2, April-June 2013 113

Success Rate of Surgical Correction of Essential Esotropia

of 102 patients. His study was a retrospective study in decision making.

which he collected data from a period of three years13 CONCLUSION
whereas we conducted a prospective study on all the This study of surgical treatment of congenital
cases which came to the squint clinic in Jinnah esotropia revealed success rates in Karachi similar to
Postgraduate Medical Centre within a short period of those seen internationally, with satisfactory rates of
six months. orthotropia 6 months postoperatively. A further
In our study the preoperative degree of esotropia research on the exploration of binocularity seen in
ranged between a minimum of 30 and maximum 95 postoperative patients of congenital esotropia could be
prism diopters with a mean of 54.43. This is slightly the objective of further research including more cases
less than preoperative degrees of esotropia seen in from the country’s tertiary and paediatric hospitals.15
international studies. The study conducted by Tatiana Ideally, these institutions should participate in
Millán and Keila Monteiro in Brazil had preoperative determining prevalence of congenital esotropia in
degrees of esotropia ranging from minimum 40 prism Karachi and assessing surgical outcomes and other
diopters to a maximum of 100 prism diopters treatment options.
respectively with a mean deviation of 59.2 14. This REFERENCES
difference in mean deviations in our study is probably 1. Szymd SM, Nelson LB, Calhoun JC, Spratt C. Large bimedial
rectus recessions in congenital esotropia. Br J Ophthalmol
due to anatomical and geographical differences 1985;69:271-274.
between the two races. 2. Morad Y, Lee H, Westall C, Kraft SP, Panton C, Pichhadze
The postoperative degree of esotropia after one RS, et al. Dynamic fusionalvergence eye movements in
week was a minimum of 5 diopters to a maximum of congenital esotropia. Open Opthalmol J. 2008;2:9-14.
3. American Academy of Ophthalmology.Preferred practice
25 prism diopters residual esotropia which has a mean pattern guidelines. San Francisco: American Academy of
of 9.72 and a standard deviation of 6.078. This is fairly Ophthalmology; 2007.
better than the postoperative results seen in the study 4. Billson FA. Childhood onset of strabismus. In: Fundamentals
conducted by Tatiana Millán and Keila Monteiro which of clinical ophthalmology strabismus. London: BMJ; 2003;23-
43
have a minimum postoperative degree of esotropia of 5. Kanski JJ. Strabismus.In: Clinical ophthalmology a systemis
5 prism diopters and a maximum of 55 prism diopters approach. Philadelphia: Elsevier; 2007;735-784.
and a mean of 16.11 with a standard deviation of 13.29. 6. Simon JW, Aaby AA, DRack AV, Hutchison AK, Olitsky SE,
This may be due to the large angles of esotropia present PLager DA, et al. Esodeviations. In: Pediatric Opthalmology
and Strabismus. Section 6. American Academy of
in the patients of Tatiana and Kiela’s study which leaves Ophthalmology; Sanfrancisco; 2008:97-108.
a greater degree of residual esotropia postoperatively. 7. Birch EE, Stager DR. Long-term motor and sensory outcomes
The difference in surgical techniques of the researchers after early surgery for infantile esotropia. J AAPOS.
may also play a vital role in the surgical outcomes. 2006;10:409-13.
8. Wong AM. Timing of surgery for infantile esotropia: motor
The results of our study were proved to be better and sensory outcomes. Can J Ophthalmol.2008;43(6):643-51.
after one month postoperatively. Among the 53 patients 9. Drover JR, Stager DR, Morale SE, Leffler JN, Birch EE.
39 had a residual esotropia of less than 10 PD and this Improvement in motor development following surgery for
constitutes for an overall success rate of 73.6%. All this infantile esotropia.J AAPOS. 2008;12(2):136-40.
10. Simonz HJ, Kolling GH, Unnebrink K. Final report of the
is consistent with results of other studies assessing early versus late infantile strabismus surgery study (ELISSS),
evolution at 6 months to one year, reporting success a controlled, prospective, multicenter study. Strabis-
rates of 70–80%.15-17 mus.2005;13:169-99.
The success rate is greater if the degree of 11. Szmyd SM, Nelson LB, Calhoun JH, Spratt C. Large bimedial
rectus recession in congenital esotropia. Br J Ophthalmol.
esotropia is small preoperatively. Prieto Díaz and others 1985;69(4):271–4.
suggest that if the earlier ocular alignment is achieved, 12. Grin TR, Nelson LB. Large unilateral medial rectus recession
the better the final surgical outcome will be obtained.17 for treatment of esotropia. Br J Ophthalmol. 1987;71:377–9.
This study also has several limitations. The period 13. Prieto-Díaz J, Souza-Dias C. Esotropia. São Paulo: Livraria
Santos Editora; 2002: 149–99.
of the study is too short to permit assessment of long 14. Castro PD,Pedroso A , Hernández L , NaranjoRM,Méndez
term stability in surgical outcome and its affect on visual TJ, Arias A.Results of surgery for conjenital esotropia.
outcome. Additionally, this was a unicenteral study MEDICC Review 2011; 13(1):18-22.
with a small sample size of 53 patients. A multicenter 15. Millán T, Carvalho KM, MinguiniN.Results of monocular
surgery under peribulbar anesthesia for large-angle
study with a larger sample size and different surgical horizontal strabismus.Clinics. 2009; 64(4): 303–308.
techniques could provide a better understanding of the 16. Wright WK. Pediatric Ophthalmology and Strabismus. St.
possible surgical outcome. Louis: Mosby; 1995.179–93
Our study is unique in the sense it provides simple 17. Nucci P, Serafi no M, Trivedi RH, Saunders RA. One-muscle
Surgery in small-angle residual esotropia.J AAPOS. 2007
data on congenital esotropia surgical outcome that can June;11(3):269–72.
be used by practitioners as a starting point for surgical

114 Ophthalmology Update Vol. 11. No. 2, April-June 2013

 Original Article

Visual outcome of Ocular Trauma

in patients of Rural & Urban areas
managed at a Tertiary Eye Hospital
Dr. Munawar
Munawar Ahmed FCPS1, Muhammad Arshad Mahmood FCPS2
Muhammad SaeedFCPS3
ABSTRACT
Objective: To determine cause and type of ocular injury and visual outcome in urban and rural patients admitted for
management of ocular trauma.
Study design: Observational clinical analysis
Setting and Period: Study conducted at a tertiary eye care center, between Nov: 2009 and Jan: 2012
Material and Methods: Independent randomly selected 104 patients of either sex having ocular trauma reported at eye
department were registered and admitted. Detailed history was taken regarding cause, site, duration of injury, and area of
residence. Complete ocular examination was carried out including visual acuity, slit lamp examination of anterior segment
especially the area involved and posterior segment with 90 D if possible. After necessary investigations of admitted
patients, surgical intervention was carried out. Final visual acuity was noted after removal of sutures. Follow up was done
for three months.
Results:88 subjects with average age of 18.43 years completed follow up of three months. Among these patients, male
were 66 and female 22, rural 50, and urban 38. Closed globe injury was noted in 18(20.4%) patients and open globe injury
in 47 (53.4%), lid trauma 12 (13.6%), and periocular insult was found in 11 (12.5%) patients. Endophthalmitis occurred in
07 (14.89%) patients with open globe injury. Two children had bilateral eye injury due to fire cracker. Mean visual outcome
in rural patients was 0.250(6/24) and 0.337(6/18) in urban. After management, vision improved in 77(87.5%) patients.
Conclusion: Ocular trauma was more common among rural population where commonest causes of eye injury were
wooden stick, thorn and sickle. Open globe injury was the most common type of ocular trauma. The incidence of visual
disability due to trauma can be reduced by education, awareness and better management.
Key Words: Management; Ocular injuries; Tertiary eye care center; Visual outcome.

INTRODUCTION ocular trauma is most common2.

The eyes are exposed to external environment, According to WHO, blindness is defined as best
hence vulnerable to trauma. Being delicate structure, corrected visual acuity less than 6/60 in better eye and
minor force can result in big damage. Incidence of ocular visual impairment is defined as best corrected visual
injury varies in different countries. In Pakistan, hospital acuity less than 6/12 in better eye3. It is estimated that
based data revealed that 9.54% of total ophthalmic approximately 55 million eyes suffer from ocular
admissions are due to ocular trauma1. Victims of ocular injuries every year worldwide, including 200,000 with
trauma are predominantly males of younger age group open globe injury. About 1.6 million become blind, 2.3
who are unskilled and do not take preventive measures million with bilateral low vision and almost 19 million
during their work. Delay in presentation, use of with unilateral blindness or low vision4. In America
traditional eye medicine and lake of facility at primary alone over 2.5 million people annually suffer from eye
health care level result in poor visual outcome. Mono- injuries5.
In rural areas most frequently eye injuries are
————————————————————————————————
Assistant Professor of Ophthalmology Liaquat University Eye
caused by wooden stick or thorn, where as in urban/
Hospital, Liaquat University of Medical and Health Sciences/ industrial areas eye injuries occur in road accident or
Jamshoro 2 Associate Professor of Ophthalmology, University at work place6.Factors which affect alertness or behavior
Medical and Dental college Lahore 3. Associate Professor of can increase the incidence of ocular injury. Countries
Ophthalmology, Azra Naheed Medical College Lahore
————————————————————————————————
where alcohol is used in excess, ocular trauma is more
Correspondence: Dr. Munawar Ahmed FCPS, Assistant Professor common. Ocular injury is also more common in workers
of Ophthalmology, Liaquat University Eye Hospital, Liaquat University who are unskilled and do not take safety measures.
of Medical and Health Sciences, Jamshoro, Hyderabad. Recovery of vision depends on site of entry wound,
Mobile 03337026523, E-mail address: [email protected]
Postal Address: Flat no. 50 New doctor’s colony Nawabshah,
location of intra ocular foreign body and secondary
Sindh retinal detachment7. Results also depend on duration
———————————————————————————————— of trauma, severity of injury, intra ocular infection, and
Received: Jan’2013 Accepted: Feb’2013 timely proper management. Ocular injuries in such
————————————————————————————————

Ophthalmology Update Vol. 11. No. 2, April-June 2013 115

Visual outcome of Ocular Trauma in patients of Rural & Urban areas, managed at a Tertiary Eye Hospital

cases have unusual presentation and devastating visual 8/0 absorbable suture and corneal wounds with 10/0
results8. nylon. In case of sever corneal damage soft bandage
Ocular injury is more common in the rural contact lens was also applied after repair for one week.
residents where injury is usually related to agricultural Associated traumatic cataract was managed in
work. In city area eye injury occurs during travelling selected cases during primary repair and in others after
or at work places. In both these areas, eye injury is more 3-4 weeks. Intravitreal injection of vancomycin and
common in unskilled young persons. The commonest amikacin were given in case of endophthalmitis.
form of ocular insult is penetrating open globe injury. Patients with retinal detachment or intravitreal foreign
Younger age, male gender, addiction and lack of body were referred to vitreoretinal surgeon after
protective measures were the major risk factors for primary repair. Skin sutures were removed after 7 days
ocular trauma. The main purpose of this study was to and corneal sutures were removed after 6 to 8 weeks
identify the causes and type of eye injuries in rural and depending on the wound condition.
urban patients, to save sight with proper management, Visual acuity and slit lamp examination was done
and put forward suggestions to control risk factors on first post-operative day and on each follow up, on
which lead to ocular injuries. day seven, day fifteen, one month, two months and
PATIENTS AND METHODS: three months.
Independent randomly selected 104 patients DATA ANALYSIS
(simple random sample) of either sex from 3 to 60 years SPSS 14.0 (Statistical Package for Social Sciences)
of age having acute ocular injury were registered. The was used for statistical analysis. Paired t-test was used
sample size for 95% confidence interval and reliability to assess visual acuity in numbers of eyes before and
was calculated with formula N= (SD/SE)2 where N is after management of ocular injury in rural and urban
sample size, SD is standard deviation and SE is standard patients. For data analysis visual acuity was used in
error of the mean. Every patient with ocular injury was decimals. Mean visual acuity before management was
prospectively interviewed, examined, and admitted for 0.1 and after management was 0.4, independent sample
management. History about pattern of work and test was performed to see significant difference between
preventive measures taken during work, any history urban and rural patients. There was no significant
of alcohol, drug, and tobacco or gutka addiction was difference in visual outcome between urban and rural
also noted. patients, P-value 0.281. However there was significant
Inclusion criteria: Patients with ocular injury improvement in vision in both groups after
presented for the first time within 30 days of trauma management of ocular injury P-value 0.002. Mean
were included in the study. difference between presenting and final visual outcome
Exclusion criteria: Patients with history of after management was 0.3. Standard deviation 0.19 and
previous treatment elsewhere, old ocular trauma, and standard error mean 0.02.
with mild injury (corneal/conjunctival foreign bodies RESULTS
and abrasion) were not included in the study. Ocular Out of 104 registered patients 88 completed three
trauma with severe head injury was also excluded from months follow up. There were 66(75%) male and
the study. Verbal / written consent was taken from the 22(25%) female patients, with male to female ratio of
patients. In case of children counseling was done with 3:1. The mean age was 18.43 years, ranging from 03 to
the parents and consent obtained. The examination was 60 years. Rural patients were 50(56.8%) and urban 38
done starting with name, age, sex, gender, residency,
cause of ocular injury and duration. Table No. 1: Demographic Data of Patients
Visual acuity was taken and if possible anterior
and posterior segment examination was performed with Features No: of patients
slit lamp and 90D condensing lens. The intraocular Total patients 88
pressure was taken in co-operative patients with closed 15 years and less 51
glob injury. The site and extent of ocular trauma was Above 15 years 37
localized on slit lamp. Necessary investigations like B- Mean age (in years) 18.43
Scan ocular ultrasound and x-ray orbit was done in Range(in years) 3-60
selected cases, complete blood count, and blood glucose Male 66
levels were also performed. The photographic record Female 22
of all the subjects was maintained before and after Male to female ratio 3:1
surgical intervention. The surgical repair was carried Urban 38
out as early as possible. Lid laceration and periocular Rural 50
injuries were sutured with 6/0 vicryl, scleral cuts with Addicts 18

116 Ophthalmology Update Vol. 11. No. 2, April-June 2013

Visual outcome of Ocular Trauma in patients of Rural & Urban areas, managed at a Tertiary Eye Hospital

(43.18%). Demographic data is given in table 1. The most Table No: 4 Associated Findings of Ocular Trauma
common cause of ocular injury was wooden stick; these
patients were mainly from rural areas. The details of Open globe injury No. of Closed eye injuries No. of
causes are mentioned in table no: 2. n=47 Patients n=18 Patients
Commonest type (53.41%) was open globe injury Iris prolapse 19 Cataract 07
(penetrating, perforating, rupture). Patterns of ocular Cataract 17 Hyphema 05
injuries are shown in table No 3. Notable associated Hyphaema 15 Vit: hemorrhage 03
findings of closed and open globe injury were traumatic
Vit: hemorrhage 14 RD 01
cataract, hyphema, and optic nerve damage in some
patients. Only 11(20.45%) patients took preventive Endophthalmitis 07 Glaucoma 01
measures like wearing helmet during driving and Uveal prolapse 06 Iridodialysis 01
protective glasses during their work. Optic Nerve damage 02 Macular edema 02
Over all at initial presentation, mean visual acuity
was 0.1 (6/60) and final mean visual acuity after
Table No: 5 Visual Acuity Before and After Management n=88
management was 0.4 (6/18). Average vision improved
by three lines of Snellen’s chart.There was no significant No: of patients No of patients
difference in visual outcome between rural and urban V/A Before After P-Value
patients, P-value 0.281. Average visual outcome was management management
slightly better in urban patients by one line of snellen’s 6/6 04 10
6/9 to 6/18 06 26
chart.Visual acuity before and after management is 6/24 to 6/60 09 35 .002
given in table no: 5 CF 14 03
HM 18 01
Pl+ 24 02
Table No: 2 Causes of Ocular Trauma n=88- NPL 13 11
Note: Paired-ttest was used for visual acuity before and after
Source N/o eyes (%) under 15yrs above 15yrs management.
Stick 18 (20.45%) 10 08
RTA 12 (13.63%) 05 07
Pencil 08 (09.09%) 07 01
Stone 07 (07.95%) 03 04
Fall 06 (06.81%) 04 02
Glass 05 (05.68%) 02 03
Knife 05 (05.68%) 04 01
Sickle 05 (05.68%) 04 01
Fig. 1A: Penetrating trauma Fig. 1B: After repair
Fire cracker 05 (05.68%) 04 01 (Open globe)
Scissor 04 (04.54%) 03 01
Screw driver 03 (03.41%) 03 00
Finger nail 03 (03.41%) 02 01
Chisel iron piece 03 (03.41%) 00 03
Electric wire 02 (02.27%) 00 02
Fishing hook 01 (01.14%) 00 01
Gunshot 01 (01.14%) 00 01
Total 88 51 37

Table No: 3 Pattern of Ocular Injuries n=88

Type of injury No of patients Percentage %

Open globe 47 53.41 Fig. 2A: Before repair Fig. 2A: After repair

Closed globe 18 20.45 Endophthalmitis with open globe injury occurred

Lid cut 12 13.63 in 07 (14.89%) patients. Only two children had bilateral
Periocular injury 11 12.50 eye injury due to fire cracker. Patients with 6/6 vision

Ophthalmology Update Vol. 11. No. 2, April-June 2013 117

Visual outcome of Ocular Trauma in patients of Rural & Urban areas, managed at a Tertiary Eye Hospital

after trauma had periocular injury, where eye ball was areas of Pakistan do suffer from blast injuries to eye.
not affected. After Afghanistan and Russian war, eye injuries due to
DISCUSSION mine blast resulted in 37.37% blindness and 47.1% were
Trauma to the eyes is common in males of all ages left with visual impairment15.
but frequently occurs in younger and active age group Work related injuries also vary in different areas
including children. It causes great impact on vision and of Pakistan. In Khairpur and Turbat people receive
cosmetic appearance so patient shows much concern injuries from leaves of date palms mainly during
about it.In addition to being a public health problem, summer season when they take fruits. Most of the
blindness and severe visual impairment resulting from injuries of our patients are work related (agriculture/
the injuries have important socioeconomic implications. industries) or accidental. Penetrating ocular injuries
Because eye injuries affect young working persons, were more common in our study, comparable to one
therefore it will affect their earnings for the whole life study in Lahore16.
and rather than supporting will become a dependent Criminally negligent attitudes, lack of protective
person. Although ocular trauma is commonest cause devices and playing of children with artificial weapons
of mono ocular blindness9 even then affected persons rather than with toys can make new generation more
face difficulties in getting jobs. Equally important are aggressive which will increase the incidence of ocular
indirect costs resulting from loss of productivity, trauma. This attitude is more common in under-
hospitalstay10 and initial anxiety of patients and parents. developed countries. In one study in Ghana ocular
In case of visual disability the cost of rehabilitation and trauma in children result in blindness in 54.2% of cases.17
care are also tremendous. The causes of eye injuries are also related to
The average age at presentation with ocular physical and psychosocial development. Children of
trauma in our study was 18.43 years as compared to younger age like to imitate adult behavior without the
one study in neighboring country India which is awareness of possible risks. School-aged children who
28.21.years11. This may be due to involvement of our are more physically active tend to take more risks to
children in labor than in education. gain acceptance by their peers. Severity and type of
The commonest cause of visual loss in our study injury are prognostic factors of final vision. Involvement
was infection. Post-traumatic endophthalmitis is a of vital structures of eye ball in the anterior and
catastrophic complication of penetrating eye injury posterior segment can jeopardize visual outcome or can
which occurs mainly due to agricultural trauma, stones even lead to blindness. Optimum management of
and intraocular foreign bodies. In one of the study, trauma is related to improvement of visual recovery18.
infection occurred in 36(10.9%) patients12. In our study Ocular injury in our area is common in young
19.31% resulted in blindness in effected eyes (VA less unskilled persons or in those who do not take
than 6/60). Loss of vision in these patients was due to preventive measure during their work. In other
endophthalmitis or optic nerve/retinal injury. Most of countries eye injuries are common in persons who drink
these patients reached hospital after four days. alcohol19. Primary repair is possible in most of the cases
The annual rate of hospitalized eye injuries in with superficial damage with better visual outcome,
Australia is 25.5 per 100,000 population, 17% of these while the severely damaged eyes require enucleation,
are penetrating. Males between 20-24 have higher rates microsurgical secondary repairs or vitreoretinal
of hospitalization than females and interpersonal procedures20. In our study we have not done any
violence is the most common type of injury mechanism enucleation, severely damaged eyes were referred to
(27.4%). The home is also the most common specified vitreoretinal surgeon after primary repair.
location of the incident and eye injuries were identified Due to limited resources and lack of facilities at
as work-related in 9.8% of cases.13. In our region rural primary eye care level patients do not receive proper
women, working in agricultural lands receive ocular treatment well in time. Therefore patients from remote
injuries; therefore male to female ratio is 3:1 in this areas reach tertiary eye hospital late and many of them
region. ignore follow up which affects results of treatment and
Cause or mechanism of injury and male to female problem in data collection.
ratio of ocular injuries may vary in different Availability of treatment facilities at primary
countries.The most common cause of eye injury in rural health care centers and prevention of ocular injuries are
is by wooden stick which occurs during agricultural the mainstay of the management and various protective
labor. Agricultural trauma is also common in rural areas measures are advocated in the form of training, wearing
of neighboring country. In one of the studies it was protective clothes; protective eyewear20and keeping safe
46.9%.14 In our study one patient suffered from fire arm working distance.22
injury with loss of eye. However peoples of war affected CONCLUSION

118 Ophthalmology Update Vol. 11. No. 2, April-June 2013

Visual outcome of Ocular Trauma in patients of Rural & Urban areas, managed at a Tertiary Eye Hospital

The incidence of ocular trauma is more among rural intraocular C3F8

population mainly children, where agriculture related Eye, 2009; 23: 1234–1235
10. Baig MSA, Zafar MU, Anwar M, Rab M, Khokar AR. Major
injury with wooden stick/ thorn or sickle is more ocular trauma. An analysis of 98 admitted cases. Pak J
common. In urban area the injuries are mostly related Ophthalmol 2004; 20: 148-52.
to kitchen job, mechanical work, or road accidents. In 11. Vats S, Murthy G, Chandra M, Gupta SK, Vashist P, Gogoi
majority of cases the reason is negligence and M.
Epidemiological study of ocular trauma in an urban slum
unawareness. population in Delhi, India.
RECOMMENDATIONS Indian J Ophthalmol 2008;56:313-6
1. Public awareness by using all means of media and 12. Iqbal A, Jan S, Khan N, Khan S, Mohd S. Admitted ocular
teaching in schools emergencies: A Four Year Review. Pak J Ophthalmol 2007;
23: 58-62.
2. People at risk should wear protective eye wear. 13. Glynn Jennifer Long, Rebecca Mitchell
3. Provision of better eye care services at the primary Hospitalised Eye Injuries in New South Wales, Australia
level. The Open Epidemiology Journal, 2009; 2:1-7
4. One chapter relating to preventive measures must 14. Praveen K Nirmalan, joanne Katz, James M tielsch, Aalan L
Robin, Ravilla D, thulasiraj, et al.
be included in the syllabus at school level Ocular trauma in a rural south India population
REFERENCES Ophthamology 2004, 111(9); 1778-1781
1. RahilAumir Malik, Nuzhatrahil, MehfoozHussain, Ali Wajid, 15. WaqarMuzaffar, M Dawood, Khan, M K Akbar, A Majeed
Mir Zaman Frequency and visual outcome of anterior Malik, Omar M Durani Mine blast injuries, ocular, and social
segment involvement in accidental ocular trauma in children. aspects Br J Ophthalmol 2000; 84: 626-630
JPMI 2011; 25 (1): 44-48 16. Muhammad YasirArfat, Hamid Mahmood Butt Visual
2. Aghadoost D, Fazel MR, Aghadoost HR. Pediatric Ocular outcome after anterior segment trauma of the eye. Pak J
Trauma in Kashan. Arch Trauma Res. 2012; 1(1):35-7. Ophthalmol 2010; 26(2): 74-78.
3. Rupert Bourne, B Dineen, Z Jadoon et al. Cases of blindness 17. ME Gyasi, WMK Amoaku, and MA Adjuik Epidemiology of
and visual impairment in Pakistan Br J Ophthalmol. 2007; Hospitalized Ocular Injuries in the Upper East Region of
91(8): 1005-1010 Ghana
4. Jin D. Wang, Liang Xu, Ya X. Wang, Qi S. You, Jing S. Zhang Ghana Med J. 2007; 41(4): 171–175.
and Jost B. Jonas 18. Ching-Hsing Lee, Wan-Ya Su1, Lan Lee, Meng-Ling Yang.
Prevalence and incidence of ocular trauma in North China. Pediatric Ocular Trauma in Taiwan
ActaOphthalmol. 2012; 90: e61–e67 Chang Gung Med J, 2008; 31 (1): 59-65
5. IrfanQayyum Malik, Zeshan Ali, A. Rehman, M. Moin, 19. Mohammad JunaidSethi, SadiaSethi, Tajamul Khan, Rashid
MumtazHussain Epidemiology of Penetrating Ocular Iqbal occurrence of ocular trauma in patients admitted in
Trauma Pak J Ophthalmol 2012, Vol; 28 (1):14-16 eye department khyber teaching hospital Peshawar. J. Med.
6. 1. Miller WF. Mechanical injuries of the eye: incidence, Sci, 2009; 17(2): 106-109
structure and possibilities for prevention. Jovanoviæ M, 20. Rostomian K, Thach AB, Isfahani A, Pakkar A, Pakkar R,
Stefanoviæ I. Vojnosanit Pregl 2010; 67(12): 983-990. Borchert M. Open globe injuries in children. J AAPOS 1998;
7. Chiquet C, Zech JC, Denis P, Adeleine P, Trepsat C. 2: 234-8.
Intraocular foreign bodies. Factors influencing final visual 21. Vasu U, Vasnaik A, Battu RR, Kurian M, George S.
outcome. ActaOphthalmolScand 1999; 77: 321-5. Occupational open globe injuries. Indian J Ophthalmol 2001;
8. Sobaci G, Akyn T, Mutlu FM, Karagul S, Bayraktar MZ. 49: 43-7
Terror-related open-globe injuries: A 10-year review. Am J 22. FaizurRahman, Haroon Rashid, AbidNaseem Ocular sequlae
Ophthalmol 2005; 139: 937-9. of blast injuries: experience at a teaching hospital Pak J Med
9. S Kashani, K Mireskandari, E Gotzaridis, H Jayaram and Res, 2008 ; 47(2): 15-18
Z Gregor
Management of perforating globe injury from a nail gun with

Ophthalmology Update Vol. 11. No. 2, April-June 2013 119

 Original Article

Ranibizumab as an adjunct to Laser for

Macular Edema secondary to Branch Retinal
Dr. Naveed
Vein Occlusion

Naveed Ahmad Shah1, Iftikhar Ahmad2, Abdul Ghafoor3

ABSTRACT:
Purpose: To compare the safety, efficacy, and dosing regimen of intravitreal ranibizumab as an adjunct to laser therapy
for the treatment of macular edema secondary to branch retinal vein occlusion (BRVO).
Materials and Methods: Thirty eyes of 30 patients of BRVO of at least 6 weeks duration were randomized into three
groups: Group 1 received grid laser treatment alone, Group 2 received a single dose of intravitreal injection of ranibizumab
(0.5 mg / 0.05 ml) followed by grid laser treatment on 7th day following injection, while Group 3 received three loading
doses of intravitreal ranibizumab at monthly interval (i.e. 0, 1, & 2 months) + standard laser treatment 7 days after the 1 st
injection. Outcome measure noted at 6 months follow-up were the improvement in best corrected visual acuity (BCVA)
and central macular thickness (CMT).
Results: At 6 months follow-up, there was an average gain of 12 letters (P=0.05), 17.5 letters (P=0.05) and 19 letters
(P=0.05) in groups 1, 2, and 3, respectively, with the decrease in CMT being 208.7 μm (P=0.05), 312.9 μm (P= 0.05) and
326.8 μm (P=0.05) respectively, in these groups. Gain in BCVA of more than 3 lines was noted in 1/10 patients in Group
1(10%) as compared to 3/10 (30%) and 4/10 (40%) patients in groups 2 and 3 respectively.
Conclusion: The gain in BCVA and reduction in CMT were better with combination therapy (single and triple dose
regimen) compared to grid laser alone. Single dose of intravitreal ranibizumab with grid laser seems to be an effective
therapy.
Keywords: Branch retinal vein occlusion, laser, Lucentis, macular edema

INTRODUCTION: study has been done comparing the effectiveness of

Retinal vein occlusion disease is estimated to be combination therapy of laser with ranibizumab with
the second most common cause of retinal vascular standard grid laser treatment alone in persistent
disease.1 Macular edema is a frequent cause of visual macular edema secondary to BRVO. We believe that
acuity loss from branch retinal vein occlusion (BRVO). unlike with age-related macular degeneration (AMD)
The Branch Vein Occlusion study demonstrated that and Diabetic Retinopathy treatment, retinal vein
argon laser photocoagulation improved the visual occlusion (RVO) is an inner retinal disease, and a
outcome significantly in eyes with perfused BRVO of passive edema in the inner retina does not result in
3-18 months duration and reduced visual acuity of 20/ photoreceptor damage as rapidly as in AMD or DR,
40 to 20/200 due to macular edema. As the disease was and there is lesser demand for frequent intravitreal
seen to resolve spontaneously in one third of the injections. Moreover, as RVO is a result of acute process,
patients, treatment was delayed for at least 3 months unlike AMD and DR which are the result of chronic
to permit maximum resorption of intra-retinal blood disease process, the treatment required will be less
and edema. aggressive.
During the last decade, anti-vascular endothelial Hence, with the hypothesis in background that an
growth factor (anti- VEGF) therapy evolved as a major injection of anti-VEGF further decreases the macular
treatment modality. The BRAVO study found edema, allowing effective laser uptake at a lower power,
intravitreal ranibizumab to be effective in the treatment a small, prospective, randomized, controlled trial was
of macular edema secondary to BRVO.2 However, no carried out to compare the safety and efficacy of intra-
———————————————————————————————— vitreal ranibizumab (0.5 mg/0.05 ml) as an adjunct to
1
Consultant ophthalmologist Mardan Medical Complex Teaching laser treatment with standard laser treatment in patients
Hospital Mardan. 2 Assistant Professor Abbottabad International with visual impairment due to macular edema
Medical College Abbottabad. 3 Consultant ophthalmologist Distt secondary to BRVO.
Hospital Batagram.
———————————————————————————————— MATERIALS AND METHODS:
Correspondence: Dr. Naveed Ahmad Shah, , Consultant This is prospective, comparative study .The
Ophthalmologist , Mardan Medical Complex Teaching Hospital, patients included had BRVO of at least 6 weeks
Mardan. [email protected] Cell : 0300-9177974 duration, perfused as confirmed on fluorescein
————————————————————————————————
Received: Dec’2012 Accepted: Feb’2013 angiography, with central macular thickness (CMT) of
———————————————————————————————— >250 μm, and baseline visual acuity of 20/40 or worse.

120 Ophthalmology Update Vol. 11. No. 2, April-June 2013

Ranibizumab as an adjunct to Laser for Macular Edema secondary to Branch Retinal Vein Occlusion

Perfused BRVO was defined as lacking evidence of Table 1: Baseline characteristics of patients in three groups
neovascularization in the retina or iris, with no obvious
macular ischemia. The exclusion criteria were previous Group 1 Group 2 Group 3
treatment for BRVO, such as intravitreal injection, Duration of occlusion
subtenon injection, or laser photocoagulation, since the at entry into study (in
time of onset of BRVO, a history of glaucoma, macular months)
edema secondary to other causes, such as age-related 1.5 – 12 10 10 09
macular degeneration and diabetic retinopathy. >12 0 0 1
After obtaining an informed consent and Age (in years)
explaining the treatment outcomes, the patients were 40 – 49 2 1 3
randomized into three groups. The baseline 50 – 59 1 1 0
characteristics of the patients in three groups were >60 7 8 7
comparable as shown in Tab:1 Group 1 received Sex
standard grid laser treatment alone. Group 2 received M 6 5 6
a single intravitreal injection of ranibizumab (Lucentis; F 4 5 4
Genentech, San Francisco, CA, USA ) (0.5 mg / 0.05 Study eye
ml) on Day 0 followed by grid laser treatment on Day L 2 4 3
7, while Group 3 received three doses of intravitreal R 8 6 7
ranibizumab at monthly interval (i.e. 0, 1, and 2 months) Hypertension
with grid laser treatment on the 7th day following the Yes 7 6 7
first injection. At baseline, all the patients under- went No 3 4 3
a thorough ophthalmological examination, including Mean BCVA 0.158+0.01 0.18+0.04 0.144+0.02
best corrected visual acuity (BCVA) measurement with (in decimal system)
a Snellen chart and Early Treatment Diabetic Mean OCT thickness 500.2+141 493.2+140 515.7+126
Retinopathy (ETDRS) chart, applanation, tonometry, (in μm)
ophthalmoscopy, slit- lamp examination with 90D,
fluorescein angiography, and optical coherence Fisher’s exact test, as appropriate. The data were
tomography. analyzed via repeated measures analysis of variance
For grid laser therapy, the guidelines followed were: with a Bonferroni correction. The level of statistical
• Spot size: 50 - 100 ìm significance was set at 0.05 (two sided) in all statistical
• Exposure: 0.05 - 0.1 second tests.
• Burn intensity: Mild RESULTS:
• Number: As per areas of diffuse retinal thickening Visual acuity outcomes
• Placement: 1 - 2 burn-widths apart (500 - 3000 ìm In Group 1, mean BCVA improved from 0.158±
from center of fovea) 0.01 at baseline to 0.162±0.02 at 1 month, 0.192± 0.01 at
• Wavelength: Green 3 months, and 0.289 at 6 months, i.e., there was a BCVA
Eyes that were randomized into groups 2 and 3 improvement of 11± 3 letters at 1 month to 11.5± 5 letters
received intravitreal ranibizumab ( 0.5 mg/ 0.05 ml) at 3 months and 12± 5 letters at the end of 6 months
under sterile conditions. After the injection, a topical (P= 0.05). In Group 2, the response was rapid after the
antibiotic was applied and the patients were monitored intravitreal injection, with a mean BCVA improvement
for potential injection related complications. The main of 16± 4 letters at 1 month from baseline (from 0.18±
parameters evaluated were BCVA and CMT on OCT at 0.04 at baseline to 0.433± 0.02 at 1 month). After 3
1, 3, and 6 months after the initial injection. Fluorescein months, the mean BCVA improved by 17± 5 letters
angiography was performed at baseline and at each (0.439± 0.02), and at 6 months the gain increased to 17.5±
monthly visit for 6 months. Blood pressure was 5 letters (0.459± 0.02) (P= 0.05).In Group 3, there was
measured at baseline and at each monthly visit. an average gain of 15.8± 2 letters at the end of 1 month
Statistical analysis was performed using a (from 0.144± 0.02 at baseline to 0.306± 0.02 at 1 month),
commercially available statistical software package which increased to 17.7± 3 letters at the end of 3 months
(SPSS for Windows, version 16.0; SPSS, Chicago, IL, (0.338± 0.02) and was sustained at 18± 4 letters (0.432±
USA). Visual acuity was converted into the logarithm 0.02) at the end of 6 months (P= 0.05). Intergroup
of the minimum angle of resolution (logMAR) and comparison for BCVA at months 1, 3, and 6 was not
decimal system for statistical calculations. Univariate statically significant, but in Group 1, the mean
categorical analysis was performed using the two- improvement in BCVA of more than 3 lines was noted
paired t-test, Chi-square test, Mann Whitney U test, or in only 10% of the patients as compared to 40% in Group

Ophthalmology Update Vol. 11. No. 2, April-June 2013 121

Ranibizumab as an adjunct to Laser for Macular Edema secondary to Branch Retinal Vein Occlusion

2 and 30% in Group 3. A comparison of outcomes end of 6 months, Group 1 showed a decrease in CMT
between the three groups is depicted in Figure 1. of 208.7 μm as compared to 312.9 and 326.8 μm in groups
Imaging outcomes 2 and 3, respectively. The changes in the mean OCT
Paralleling the improvement in BCVA, thickness in the three groups have been illustrated in
ranibizumab treatment led to a rapid reduction in the Fig:2
(CMT). Similar responses were observed in single and DISCUSSION
triple dose regimens. In Group 1, center point thickness The natural history of macular edema secondary
decreased from a mean of 500.2± 141μm at baseline to to BRVO was delineated in the Branch Vein Occlusion
389.6± 120μm at 1 month, 334.6± 117μm at 3 months Study (BVOS).1 BVOS also demonstrated a benefit with
and 291.5± 109μm at 6 months (P= 0.05). In Group 2 grid photocoagulation in eyes with BRVO of 3-18
(single-dose regimen), there was a rapid decrease in months duration and visual acuity of 20/40 to 20/200.
mean CRT from 493.2± 140μm at baseline to 230.3± Treated eyes were more likely to gain 2 lines of visual
96μm at 1 month, 200.3± 92 μm at 3 months that further acuity (65%) compared with the untreated eyes (37%).
decreased to 180.3± 78 μm at 6 months (P= 0.05). In Furthermore, treated eyes were more likely to have 20/
Group 3, (triple dose regimen) mean CMT decreased 40 or better vision at 3 years follow-up (60% vs. 34%
from 515.7± 126 μm at baseline to 386.2± 97 μm at 1 untreated), with a mean visual acuity improvement of
month, 286.4± 87 μm at 3 months, and was sustained at 1.3 lines ETDRS versus 0.2 lines in the untreated group.
188.9± 76 μm at 6 months (P= 0.05). Though intergroup The rationale for the use of anti VEGF to treat
comparison results were not statically significant, at the macular edema secondary to BRVO follows from the
Figure 1: Comparison of visual outcomes between Group 1
observation that the increase in retinal capillary
(laser alone), Group 2 (single loading dose with laser), and Group permeability that results in macular edema may be
3 (triple loading dose with laser) over a period of 6 month caused by a breakdown of the blood retina barrier,
mediated in part by VEGF,3 a 45-kDa glycoprotein.
Therefore, attenuation of the effects of VEGF may
reduce macular edema associated with BRVO. Anti
VEGF has been demonstrated to bind and neutralize
all the biologically active forms of VEGF, and therefore
may be an effective therapy for macular edema.
The BRAVO trial (a phase 3, multicenter,
randomized, sham injection-controlled study of the
efficacy and safety of ranibizumab injection compared
with sham in patients with macular edema secondary
to BRVO) assessed the safety and efficacy of
ranibizumab in patients with BRVO.3 Patients included
in the study had macular edema involving the foveal
center secondary to BRVO, central subfield macular
thickness of 250 μm or greater on OCT, and BCVA of
Figure 2: Changes in the mean OCT thickness in the
20/40 to 20/400. Patients were randomly assigned to
three groups over 6 months following treatment six monthly injections of ranibizumab, either 0.3 mg or
0.5 mg, or to sham injection. In 397 patients randomized,
the mean gain from baseline at month 6 was 16.6 letters
in patients receiving 0.3 mg of ranibizumab, 18.3 letters
in those receiving 0.5 mg, and 7.3 in those receiving
sham injections. By month 6, most patients in the two
ranibizumab groups gained at least 3 lines of BCVA
(55.2% in the 0.3 mg group and 61.1% in the 0.5 mg
group), while most of those in the sham group did not
(28.8%). This trial, however, enrolled all comers,
irrespective of the duration of their disease.
We believe that as the disease was seen to resolve
spontaneously in one-third of the patients in the BVOS
study, treatment can be delayed for at least 6 weeks to
permit maximum resorption of intra-retinal blood and
edema. In this small, randomized, controlled study,

122 Ophthalmology Update Vol. 11. No. 2, April-June 2013

Ranibizumab as an adjunct to Laser for Macular Edema secondary to Branch Retinal Vein Occlusion

intravitreal ranibizumab at 4 weeks interval along with difference for a gain in BCVA was noted in the three
grid laser provided rapid and sustained improvement treatment groups, the fact that gain in BCVA of more
of BCVA in subjects with BRVO for 6 months period. than 3 lines was noted in 40% patients of combination
40% of the subjects gained at least 3 lines of vision in 24 therapy compared to 10% patient in standard laser
weeks. The rapid improvement in vision was paralleled group helped us conclude that ranibizumab may be
by reductions in macular thickness. Almost similar used as an effective and safe adjunct to laser in the
improvements were observed in the single and the triple treatment of macular edema secondary to BRVO. Since
dose groups. economics plays a major role in treatment involving
It is our belief that the endpoint gain in BCVA anti-VEGF administration, this alternative treatment
would be greater if an anti-VEGF is used prior to laser modality may prove to be a viable option in the
therapy. Anti-VEGF would decrease the macular developing countries.
thickness, allowing effective laser uptake at a lower Limitation of this study includes the small study
power. The results in Groups 2 and 3 of our study population. Despite this limitation, the results of this
illustrate this point (as 70% of the treated eyes gained study suggest that intravitreal ranibizumab is an
and maintained 2 or more lines of BCVA from baseline). effective option for the treatment of BRVO and that
In BRAVO study, after six doses of intravitreal larger, more definitive, randomized clinical trial are
ranibizumab at the end of 6 months, there was a gain warranted to determine the optimal treatment interval
of 16.6 letters and 18.3 letters and the mean changes in and duration.
CMT were 337.2 and 345.2 μm in 0.3 and 0.5 mg groups, REFERENCES:
respectively. Although a direct comparison cannot be 1. The Branch Vein Occlusion Study Group. Argon Laser
photocoagulation for macular edema in Branch vein
made because of difference in the study design, it is occlusion. Am J Ophthalmol 1984;98:271-82.
worth while noting that in our study the mean 2. Campochiaro PA, Heier JS, Feiner L, Gray S, Saroj N, Rundle
improvement in BCVA was 17.5 letters in Group 2 and CA, et al.; BRAVO investigators. Ranibizumab for Macular
18 letters in Group 3 at the end of 6 months. Similarly, Oedema following BRVO: Six month primary end point
results of a phase 3 study. Ophthalmology 2010;117:1102-12.
a decrease in CRT of 312.9 and 326.8 ìm in groups 2 3. Campochiaro PA, Hafiz G, Shah SM, Vguyen QD, Ying H,
and 3, respectively was noted. Do DV, et al. Ranibizumab for macular oedema due to retinal
CONCLUSION: vein occlusions; implications of VEGF as a critical stimulator.
In our study design, though no significant Mol Ther 2008;16:791-9.

Kayser–Fleischer Rings in Wilson’s Disease

Dr. Anette Schrag, Ph.D., F.R.C.P.&Jonathan M. Schott, M.D., M.R.C.P.
University College London, London, United Kingdom

This 18-year-old patient had a postural tremor of her arms and legs, mild dysphagia
and dysarthria, and bradykinesia. Measurement of urinary copper and ceruloplasmin
confirmed the diagnosis of Wilson’s disease. The rings resolved following chelation
therapy.
An 18-year-old woman presented with color and temperature changes in her hands,
as well as intermittent tremor of the hands since the age of 15 years. She also reported
involuntary right arm movements and difficulties with concentration. Physical examination
of the eyes revealed bilateral Kayser–Fleischer rings. Neurologic examination revealed
dystonia of the right arm, a postural tremor of her arms and legs, mild dysphagia and
dysarthria, and bradykinesia. Laboratory tests revealed elevated serum levels of alanine aminotransferase, aspartate
aminotransferase, and γ-glutamyltransferase, as well as low serum levels of ceruloplasmin (0.02 g per liter; reference
range, 0.2 to 0.5) and copper (4.1 μmol per liter; reference range, 11 to 22); the urinary copper excretion was elevated, at
12.8 μmol per 24 hours (reference range, 0 to 1). Magnetic resonance imaging of the patient’s brain revealed widespread
signal change, gliosis, and atrophy in the basal ganglia, thalami, and brain stem. A diagnosis of Wilson’s disease was
made and confirmed on genetic testing by a result of a compound heterozygous mutation in the gene ATP7B. Approximately
5 years after the initiation of copper-chelating treatment, the Kayser–Fleischer rings had resolved almost completely, and
there was stabilization in neurologic status and MRI findings.
(Curtesy: NEJM-UK.)

Ophthalmology Update Vol. 11. No. 2, April-June 2013 123

 Original Article

Manual Small Incision Cataract Surgery,

comparison of Sub-tenon Anesthesia with
Peribulbar Anesthesia: Study on Pain Evaluation
Dr. Mushtaq & Surgical outcome

Mushtaq Ahmad FCPS1, Muhammad Naeem2, Lal Muhammad FCPS3

ABSTRACT
Purpose: To compare the safety and efficacy of subtenon anaesthesia with peribulbar anaesthesia in manual small
incision cataract surgery using a randomised control clinical trial.
Material & Method:Ninety patients were randomized to subtenon and peribulbar groups with preset criteria after informed
consent. All surgeries were performed by a single surgeon. Pain during administration of anaesthesia, during surgery and
4 hour after surgery was graded on a visual analogue pain scale and compared for both the techniques. Sub-conjuntival
haemorrhage, chemosis, akinesia after administration of anaesthesia and positive pressure during surgery were also
compared. Patients were followed up for 6 weeks postoperatively.
Results: About 78/90(86.66%) patients completed the six-week follow-up.Fifteen out of 45(33.33%) patients of peribulbar
group and thirty four out of 45(75.55%) patients of subtenon group experienced no pain during administration of anaesthesia.
There was no significant difference in pain during and 4 hour after surgery. Subtenon group had slightly more sub-
conjunctival haemorrhage. About 32(71.11%) patients of the peribulbar group had absolute akinesia during surgery as
compared to none (0%) in sub-tenon group. There was no difference in intraoperative and postoperative complications
and final visual acuity.
Conclusion: Sub-tenon anaesthesia is safe and as effective as peribulbar anaesthesia and is more comfortable to the
patient at the time of administration.
Keywords: manual small incision cataract surgery; peribulbar anaesthesia; sub-tenon anaesthesia

INTRODUCTION resulting in the use of shorter acting anaesthetic agents

Cataract is the main and biggest cause of curable with less invasive methods of administration.9 Sub-
blindness worldwide.1 Cataract extractions is one of tenon anaesthesia 10 involves trans-conjunctival
the most cost-effective of all surgical interventionsin infiltration of local anaesthetic agent directly to the
terms of quality of life restored. The only treatment subtenons space, after instillation of local anaesthetic
option for cataract is the surgical removal of the opaque drop in the conjunctiva which takes away the pain from,
lens and the implantation of an artificial lens.2Peribulbar the needle prick. This technique has been used for
anaesthesia for cataract surgery was the most popular conventional extracapsular cataract extraction (ECCE)
technique in the previous decade 3 but it is not with posterior chamber intraocular lens implantation
completely free from complications. 4 Retrobulbar (PCIOL) and phacoemulsification 11 Manual small
anaesthesia, which was used for almost a century, was incision cataract surgery (MSICS) has become popular
associated with a number of potentially sight- in developing countries as it gives better uncorrected
threatening complications.5Alternative anaesthesia vision as compared to ECCE12 and at an affordable cost.
procedures have been developed to reduce the risk of A comparison of subtenon anaesthesia with the more
injuring intraorbital structures 6,7,8. Advances in cataract popular peribulbar anaesthesia for MSICS could not be
surgery including the use of a smaller, self-sealing found by us in the literature. The study aimed to
incision have shortened the duration of surgery compare the two methods of anaesthesia in MSICS with
respect to pain, akinesia, intraocular pressure control,
————————————————————————————————
1
Senior Registrar, Ophthalmology Department, Hayatabad Medical surgeon’s comfort and complications, using a
Complex, Peshawar, 2Post graduate Trainee, Ophthalmology randomised control clinical trial.
Department, Hayatabad Medical Complex, Peshawar, 3 Associate MATERIALS AND METHODS
Professor, Kohat Medical College, Kohat All the patients admitted for cataract surgery,
————————————————————————————————
Correspondence:Dr Mushtaq Ahmad, House no 31B, street no 2, were asked to participate in the trial. The first 90, who
sector N4, Phase 4, Hayat Abad,Peshawar agreed to informed consent, were randomised to either
E.Mail>[email protected], 03339119605 subtenon or peribulbar technique.
———————————————————————————————— The exclusion criteria were:
Received: Dec’2012 Accepted: Feb’2013
———————————————————————————————— 1. Age < 30 or > 90 years

124 Ophthalmology Update Vol. 11. No. 2, April-June 2013

Manual small incision Cataract Surgery, comparison of Sub-tenon Anesthesia with Peribulbar Anesthesia

2. Sensitivity to Xylocaine using a 24G needle at junction of middle and outer third
3. History of convulsion, epilepsy of the lower orbital margin with the needle directed
4. Inability to give informed consent towards floor of orbit. A supplementary injection of 1
5. People who preferred phacoemulcification ml was given at the supra orbital notch. The eyelid was
or conventional extracapsular surgery then closed and pressure was applied for 5 min.Visual
6. Previous intraocular injury, inflammation or analog pain scale used tograde the pain they felt on a
surgery linear scale of 0-4
7. Pupil <5 mm in diameter No pain = grade 0,
8. Inability to understand the visual analogue Mild pain= grade 1,
pain scale. Moderate pain =grade 2,
Assuming 90% power and 5% level of significance Severe pain = grade 3 and
and assuming that there would be no pain in 40% and Maximum pain imaginable = grade 4.
60% of cases by either technique (difference of Patients were asked to grade separately for pain
proportions), each arm should have a minimum of 31 during administration of anaesthesia, pain during
patients. Assuming loss of 20% to follow-up, the study surgery and pain 4 h after surgery. The last was taken
aimed to randomize at least 77 patients. Permission was when the patient was shifted to the wards. The
obtained from the ethical committee of the hospital. ophthalmologists also graded for chemosis,
Both techniques of anaesthesia are acceptable standards subconjunctival haemorrhage after administration of
of care and have been in use for more than a decade. anaesthesia and positive pressure during surgery on a
The consent form and information sheets for the patients scale of 0-4, of increasing severity. ‘Akinesia’ was scored
were designed as per the Helsinki protocol guide lines on a scale designed to measure ocular movements in
and translated into urdu. Informed consent was each quadrant (no movement = score 0, mild = 1,
obtained from all the patients who participated. Each moderate = 2, severe = 3 in each quadrant, minimum
patient was randomly assigned by opening an envelope score possible = 0, maximum score possible = 3 x 4 =
on entering the recovery (pre-anaesthetic) room. The 12). The surgeon also graded for the ‘discomfort’ he felt
peribulbar anaesthesia was administered by the during surgery (grade 0 = no discomfort, grade 1 = mild
anaesthetist and the subtenon anaesthesia was given discomfort, grade 2 = moderate, grade 3 = severe, grade
by the surgeon on table. Any extra anaesthetic needed 4 = surgery not possible).
was noted. The patients and the surgeon were masked RESULTS
till 10 min before surgery. The patient was asked to About 78/90(86.66%) patients completed the six-
gauge for the pain during administration of the week follow-up. About 90 patients underwent MSICS
anaesthetic, pain during surgery and after it was between July 2010 to June 2011 and were operated upon
completed. Postoperative pain after 4 h was also by a single surgeon.25/45(55.55%) were males, in
recorded. After each surgery the surgeon was asked to peribulbar group and 27/45(60.00%) in the subtenon
score for akinesia and to grade for positive pressure group. Average age in the two groups was 58 and 56
during surgery, chemosis, subconjunctival years, respectively. There was no statistically significant
haemorrhage and overall discomfort. Intraoperative difference between the two groups with respect to age
complications were noted. All patients underwent ( p = 0.133) and sex. ( p = 0.213).The various grades of
MSICS; any change in technique, if needed, was pains during anaesthesia are depicted in Table -1. Chi
noted.The patients were followed on the first square test shows that there is a significant difference
postoperative day, first week and sixth week after between both the groups with regards to pain on
surgery. The postoperative complications were noted, administration of the anaesthesia for grades 0 and 1
as also the best corrected postoperative visual acuity (p< 0.0001). p = 0.09 for grade 2, p = 2 for grade 3 by
and refraction.The eye to be operated was painted with figure exact test, there being no statistically significant
povidone iodine. After draping, a lid speculum was difference for grade 2 or more. The average for pain
applied and two drops of topical 4% lignocaine were during anaesthesia was grade 0.82 for the peribulbar
instilled. group and 0.26 for subtenon group on a range of 0-4.
Conjunctival forceps were used to grip the Table - 2 shows the various grades of pain during
conjunctiva and a curved subtenon cannula was then surgery in both the groups. Average for pain during
inserted on to bare sclera and glided along the contour surgery was 0.15 for peribulbar and 0.07 for subtenon
of the globe. One ml of 2% lignocaine with 1:10 000 on a range 0-4. Table -3 describes the various scores of
adrenaline was injected slowly in the posterior subtenon ocular movement after anaesthesia. 43 out of 45(95.5%)
space.Technique of peribulbar anaesthesia was, four ml of patients in peribulbar group had scores of 4 or less;
of 2% lignocaine with 1:10 000 adrenaline was injected 41/45(91.1%) of patients of subtenon group scores of 6

Ophthalmology Update Vol. 11. No. 2, April-June 2013 125

Manual small incision Cataract Surgery, comparison of Sub-tenon Anesthesia with Peribulbar Anesthesia

or more, with the mode score of 10. The mode for Table 3: Ocular movements during surgery
peribulbar group was 0. This was statistically very
Akinesia(score) Peribulbar: Subtenon: Total
significant ( p< 0.0001). Average score for akinesia was
95% CI 95% CI
1.2 in peribulbar group and 8.4 in subtenon group on a
range0-12.About 45/45 (100%) patients of peribulbar 0 29(64.4%) 0 29(32.2%)
group and 44/45(97.7%) patients of subtenon group did 2 7(15.5%) 0 7(7.7%)
not have any positive pressure during surgery. Only 4 7(15.5%) 5(11.1%) 12(13.3%)
one patient of subtenon group had minimal pressure 6 1(2.2%) 4(8.8%) 5(5.5%)
rise.Various grades of subconjunctival haemorrhage in 8 1(2.2%) 17(37.7%) 18(20.0%)
both the groups is described in Table - 4 whereas
10 0 18(40.0%) 18(20.0%)
Table - 5 describes various grades of conjunctival
chemosis in both the groups. In 43/45(95.5%) surgeries 12 0 1(2.2% 1(1.1%)
under peribulbar anaesthesia and in 39/45(86.6%) Total 45(100%) 45(100%) 90(100%)
surgeries under subtenon anaesthesia, the surgeons
experienced no discomfort. All patients of the Table 4: Subconjunctival heamorrhage after
peribulbar group (45/45) reported no pain for 4 hours administration of anesthesia
after surgery compared to (44/45) patients in the Subconjunctival Peribulbar Subtenon Total
subtenon group. There were two posterior capsular
heamorrhage
rents in the peribulbar group. One patient in the
Grade0 27 18 45
subtenon group had button holing during scleral tunnel
creation. The incidence of postoperative complication Grade1 11 21 32
in both arms was similar. There was no significant Grade2 6 6 12
difference in both the groups with regards to Grade3 1 0 1
uncorrected and corrected visual acuity after 6 weeks Grade4 0 0 0
postoperatively. 42/45(93.3%) of patients in peribulbar
Total 45 45 90
group and 41/45(91.1%) in subtenon group had
postoperative corrected visual acuity >6/9. No patient
had visual acuity less than 6/60. One patient in the Table 5: Chemosis after administration of anesthesia
peribulbar group needed additional anaesthesia of 3cm3
Chemosis Peribulbar Subtenon Total
Grade0 29 28 57
Table 1: Pain during anesthesia
Grade1 9 13 22
Peribulbar: Subtenon: Total Grade2 6 4 10
95% CI 95% CI Grade3 1 0 1
Grade0(no pain) 16 (35.5%) 32 (71.1%) 48(53.3%) Grade4 0 0 0
Grade1(mild pain) 23 (51.4%) 10 (22.2%) 33( 36.6%) Total 45 45 90
Grade2(moderate) 4 (8.8%) 2(4.4%) 6 (6.6%)
Grade3(severe) 1 (2.2%) 1(2.2%) 2 (2.2%) of 2% xylocaine. One MSICS in subtenon group was
Grade4(max imaginable) 1 (2.2%) (0) 1 (1.1%) converted to ECCE due to difficulty in delivering the
Total 45(100%) 45(100%) 90 (100%) nucleus.
CI: Confidence Interval DISCUSSION
Subtenon anaesthesia was more comfortable for
Table 2: Pain during surgery the patient at the time of anaesthetic administration.
They also had good analgesia intraoperatively, but the
Peribulbar: Subtenon: Total
surgeons had to operate with incomplete akinesia,
95% CI 95% CI
which some may find discomforting. The incidence of
Grade0(no pain) 39(86.6%) 40(88.8%) 79(87.7%)
subconjunctival haemorrhage was also slightly more as
Grade1 (mild pain) 4(8.8%) 45(11.1%) 9(16.6%) compared to the peribulbar group. The surgery was
Grade2 (moderate) 0 0 0 started immediately after administration of anaesthesia
Grade3 (severe) 2(4.4%) 0 2(2.2%) in subtenon group. As lesser amount of the anaesthetic
Grade4 (max imaginable) 0 0 0 agent was used for subtenon, the chances of adverse
effects are also minimized. In a large hospital or in a
Total 45(100%) 45(100%) 90(100%)
CI: Confidence Interval
community eye care setting, the cost would also be less.

126 Ophthalmology Update Vol. 11. No. 2, April-June 2013

Manual small incision Cataract Surgery, comparison of Sub-tenon Anesthesia with Peribulbar Anesthesia

There was no difference in chemosis, positive pressure anaesthesia during MSICS is as safe as the peribulbar
rise during surgery and postoperative pain between technique giving equally good analgesia during and
both the techniques of anaesthesia. An audit of subtenon after the surgery. It is recommended as a safe and
and peribulbar anesthesia for cataract surgery in UK effective alternative to peribulbar anaesthesia for
demonstrated sub-Tenon’s methods to be more effective MSICS.
than the peribulbar technique, with significantly fewer REFERENCES
patients experiencing unacceptable levels of pain.10 It 1. Minasian DC, Mehera V. 3.8 Million blinded by cataract each
year: Projections of the first epidemiological study of
was significantly less uncomfortable on administration incidence of cataract blindness in India. Br J Ophthalmol
than the peribulbar methods and reduced the interval 1990;74:341-3.
between administration of anaesthesia and surgery. On 2. Marseille E. Cost-effectiveness of cataract surgery in a public
the range of 1-10, pain on administration of anaesthetic health eye care program in Nepal. World Health Organ Bull
OMS 1996;74:319-24.
had a mean of 2.4 for the peribulbar group and 1.4 for 3. Davis DB, Mandel MR. Efficacy and complication rate of
the subtenon group. This correlated with results of our 16,224 causative peribulbar blocks. A postoperative multi
study. The subtenon technique appeared to be the safest Centre study. J Cataract Refract surg 1994;20:327-37.
method of introducing anaesthetic fluid into the 4. Mount AM, Seward HC. Sceral perforations during
peribulbar anesthesia. Eye 1993;7:766-7.
retrobulbar space without the potential complication 5. Murdoch IE. Peribulbar versus retro bulbar anesthesia. Eye
of a sharp needle injection.13 But a single case of globe 1990;4:445-9.
perforation was reported 14 in a patient who had 6. Stevens JD. A new local anesthetics techniques for cataract
underwent detachment surgery and had thinned extraction by one quadrant sub-Tenon’s infiltration. Br J
Ophthalmol 1992;76:670-4.
sclera.It is likely that subtenons anaesthesia offers a 7. de la Marnieere E, Maye R, Albertim, Batissc JL, Baltenneck.
significantly reduced risk of complication such as scleral Comparison between Greenbachs Parabulbar Anaesthesia
perforation, retro bulbar haemorrhage, optic nerve and Ripart’s subtenon anaesthesia in the anterior. segment
injury and injection of anaesthetic solution into the surgery. J Fr Ophthalmol 2002;25:161-5.
8. Hansen EA, Mein CE, Mazzoli R. Ocular anesthesia for
subarachnoid space, as no sharp instrument is passed cataract surgery: a direct sub-Tenons’s approach. Ophthalmic
into the orbit. It should, however, be used with caution Surg 1990; 21 :696-9.
in patients with compromised sclera. A randomised 9. Gogate PM, Deshpande M, Wormald RP. Is manual small
study in Denmark comparing retrobulbar, subtenon incision cataract surgery affordable to developing countries?
A cost comparison with extra capsular cataract extraction.
and topical anaesthesia for phacoemulcification found Br J Ophthalmol 2003;87:843-6.
retrobulbar techniques had less discomfort/pain during 10. Briggs MC, Back SA, Esakowitz L. Subtenons versus
surgery but patient preferred subtenon or topical peribulbar anesthesia for cataract . Eye 1997; 11 :611-43.
anaesthesia, as it did not involve the needle prick during 11. Davis DB, Mandel MR. Nileson PJ Alerod CW. Evaluation
of local anesthesia technique for small incision cataract
anaesthesia.11 Subtenon anaesthesia has also been used surgery. J Cataract Refract Surg 1998;24:1136-44.
for optic nerve sheath fenestration. 15 Subtenon 12. Gogate PM, Deshpande M, Wormald RP, Deshpande RD,
anaesthesia has been found to be more comfortable for Kulkarni SK. Extra capsular cataract surgery compared with
the patient, reliable, long lasting and with deeper manual small incision cataract surgery in community eye care
setting in western India: a randomized control trial. Br J
anaesthesia as compared to topical anaesthesia for Ophthalmol 2003;87:667-72.
phacoemulcification patients. It was also more 13. Loinder S, Walka SB, Atth HR. Ultrasonic localization of
comfortable for the surgeon with better pupillary anesthetic fluid in subtenon, peribulbar and retro bulbar
dilatation.16 A randomised trial in the UK17 found the techniques. J Cataract Refract Surg 1949;25:56.
14. Freiman BJ. Friedberg MA. Globe Perforation associated with
difference between the pain score in the subtenon and sub tenon’s anesthesia. Am J Ophthalmol 2001;131 : 520-1.
topical groups to be highly statistically significant, with 15. Rizzuto PR, Spoor TC, Ramock JM, McHenry JG. Subtenon’s
subtenon being more pain free, for phacoemulcification local anesthesia for optic nerve sheath fenestration. Am J
patients.Limitations of the study include subjective Ophthalmol 1996;121:326-7.
16. Vielpeau I, Billotte L, Kreidie J, Lecoq P. Comparative study
nature of the visual analog pain scales and that the field of topical anesthesia and subtenon anesthesia for cataract
testing or optic nerve damage analysis was not done. surgery. J Fr Ophthalmol 1999;22:48-51.
But past studies and postoperative visual acuity results 17. Manner TB, Burton RL. Randomized trial of topical versus
indicate that it would not be significant. subtenon local anesthesia for small incision cataract surgery.
Eye 1997;10:367-20.
CONCLUSION
The subtenon’s technique for administration of

Ophthalmology Update Vol. 11. No. 2, April-June 2013 127

 Original Article

Management of Amblyopia in Children

after Cataract Surgery
Dr. Sadia Sadia S. Bukhari FCPS,1 Umair A.Qidwai FRCS., FCPS,2
A. Sami MemonFCPS,3 Israr A. Bhutto FCPS4
ABSTRACT
Purpose:To evaluate the outcome of management of amblyopia in children with unilateral cataract.
Material and Methods:The prospective case series, performed at Al Ibrahim eye hospital, Karachi. Children aged between
2-10 years, with unilateral cataract were included in the study. All underwent cataract surgery and then amblyopia therapy
if needed. The visual acuity before surgery, after surgery and after amblyopia therapy was compared.
Results:The total number of 410 patients was included in the study. Different types of cataracts were observed during the
study of which congenital cataract was the most frequent among all the other types of cataracts seen. The comparison of
pre surgical and post-surgical visual acuity showed significant improvement (p<0.05). Most common cause of decreased
vision was amblyopia which was seen in 214 (52.2%) of patients. 148 (69.15%) patients out of 214 patients who were
given amblyopic therapy showed improvement in visual acuity.
Conclusion:Congenital cataract is the most common type of cataract seen in children, and it is along with other type of
cataracts can be successfully managed by performing surgery resulting in good visual improvement. Amblyopia is the
most frequent cause of decreased vision in such patients which can be managed successfully with good motivation.
Keywords:Congenital, cataract, amblyopia

INTRODUCTION difficult to manage, and need extreme motivation to

Cataract in childhood is the most significant cause do so.
of visual impairment and blindness. Diminution of In this study we have tried to find out the
vision in early years of life, can adversely affect overall effectiveness of cataract surgery in children with
development of child with far reaching effects on unilateral cataract and causes of decreased vision if
personal, educational, work-related and social present after the surgery. We also evaluated the
aspects.1As a result early recognition and treatment is frequency of amblyopia development after unilateral
very crucial for maximizing visual development. 2 cataract and the effectiveness of its management with
Treatment of congenital/developmental cataract poses amblyopia therapy.
a dare to ophthalmic society, patients and parents in MATERIAL AND METHODS
terms of treatment, visual development and visual A total of 410 successive children aged 2- 10 years
rehabilitation of these patients. 3Advances and with unilateral cataract treated and followed up at our
development of new microsurgical techniques and institution between March 1st, 2010 and March 30th,
amblyopic management have improved the safety and 2012, were included in this prospective study. The study
usefulness of pediatric cataract treatment.4,5On the other was done at Al-Ibrahim Eye Hospital, Karachi.
hand, management of congenital cataracts remains a Informed consent was taken from the guardians of the
challenge as postoperative complications are still patients included in the study. Patients with visually
common. 6,7 One of the most common causes of significant cataract, and needing cataract surgery were
decreased vision after cataract surgery especially in included in the study while patients who had ocular
unilateral cataracts is amblyopia, which is an extremely infection, previous ocular surgery and prematurity or
other systemic diseases making it impossible to undergo
————————————————————————————————
1
Assistant Professor, Pediatric Ophthalmologist ,Isra Postgraduate
general anesthesia, were excluded from the study. All
Institute of Ophthalmology/Al Ibrahim Eye Hospital, Karachi. 2Senior those patients who were selected underwent relevant
Registrar, Isra Postgraduate Institute of Ophthalmology/Al Ibrahim investigations, ophthalmic checkup including visual
Eye Hospital, Karachi. 3.4 Assistant Professors, Isra Postgraduate acuity, slit lamp examination, fundus examination,
Institute of Ophthalmology/Al Ibrahim Eye Hospital, Karachi.
————————————————————————————————
retinoscopy, keratometery, B-scan ultrasonography and
Correspondence: Dr. Sadia Bukhari, Assistant Professor, Al-Ibrahim intra ocular lens power calculation wherever possible
Eye Hospital, Old Thana, Malir, Karachi. Cell: 0321-2417913 were done. Intra ocular lens power was calculated by
E-mail: [email protected] using SRK II formula. Dilatation of pupil was done with
R-176, Abid Town, Gulshan-e-Iqbal, Block 1&2, Karachi
————————————————————————————————
cyclopentolate 1% at 90, 60, 30 and 15 minutes
Received: Dec’2012 Accepted: Feb’2013 preoperatively. Surgical procedure includes irrigation
———————————————————————————————— and aspiration with wide anterior capsulotomy.

128 Ophthalmology Update Vol. 11. No. 2, April-June 2013

Management of Amblyopia in Children after Cataract Surgery

Primary posterior capsulotomy and anterior vitrectomy of managing after pediatric cataract. A significant
was done in all eyes. In children with bilateral lens (p<0.05) improvement in visual acuity was observed
opacities requiring surgery and the eyes with poorer after cataract surgery. Most frequent cause of decrease
vision was operated first and surgery for second eye vision after cataract surgery was amblyopia, which was
was performed three weeks later. All cases remained managed by occlusion therapy. A significant (p<0.05)
on topical steroids eye drops for six weeks. Patients improvement in visual acuity was observed after
were followed one day and one week for early occlusion therapy. We also tried to find out the possible
postoperative complications. Patients were also causes of cataract development among children, and
followed after 1 month and 2 months. Visual acuity was we observed that congenital cataract was the most
checked on the follow up after 1 month,especially those common type of cataract followed by traumatic cataract.
patients who had started on amblyopia therapy.All Amblyopia a common cause of decreased vision
those patients undergoing therapy were followed every in children after unilateral cataract and has been
two weeks.Final outcome was considered after 3 reported in many studies.8-10 In our study we also
months of therapy. Visual acuity was compared with
Table1: Multiple Associated Features along with Cataract
the visual acuity before amblyopia therapy (occlusion
of the good eye). Visual acuity was evaluated using Associated Features Frequency
the Teller Acuity Cards Test or the Lea Test depending Nystagmus 30
on the age and with one eye occluded. All refraction Microphthalmos 10
readings were taken after instillation of cyclopentolate Corneal Opacity 16
1%. Retinal Pathology 2
Data analysis was done using SPSS version 19. Subluxated Lens 20
Frequencies of gender, age, and complications were Ruptured Lens Capsule 8
recorded. Statistical analysis of the frequency of several Corneal tear 2
postoperative complications was performed by the Corneal edema 2
Fisher exact test. All tests were two-tailed, and Micro Cornea 4
acceptable significance was recorded when P values Esotropia 6
were less than 0.05. Paired t test will be used to compare
the visual acuity before and after amblyopic therapy. Figure1 Pre-Treatment (Baseline) and Post Surgery Visual Acuity
RESULTS Distribution
A total number of 410 patients were included in n = 410p-value <0.05
the study. Minimum age of the patient included in the
study was 2 months while the maximum age was 10
years, with mean age of 67.23 (standard deviation=56.4).
Out of 410 patients, 251 (61.2%) were male while 159
(38.8%) were female.Different types of cataracts were
observed during the study, congenital cataract was the
most frequent among all the other types of cataracts
seen. Multiple associated features were also observed
along with cataract in the patients, most common of
these were nystagmus, which was seen in 30 patients.
Others common associated features and their
VA= visual acuity
frequencies are shown in table-1. Right eye was HM=hand movement
involved in 211 patients, while left eye was involved in FC=finger counting
199 patients.The comparison of pre-surgical and post- Pl=perception of light
surgical visual acuity is in (Fig. 1).Amblyopia was the
Table 2:
most frequent cause of decreased vision among the Causes of Decreased Vision Post Operatively (VA < 6/18)
patients with best corrected visual acuity less than 6/
18, other causes (table 2). Amblyopia was seen in 214 Causes Frequencies
(52.2%) of patients. Best corrected visual acuity before Amblyopia 214
and after amblyopic therapy (Fig. 2). 148 (69.15%) Uveitis 2
patients out of 214 patients who were given amblyopic Retinal scar 5
therapy showed improvement in visual acuity (Fig. 3). Corneal opacities 6
DISCUSSION Others 2
In this study, we have tried to share our experience Total 210

Ophthalmology Update Vol. 11. No. 2, April-June 2013 129

Management of Amblyopia in Children after Cataract Surgery

Figure 2: Pre-Treatment (Amblyopia Therapy) and Post the fellow eye 2-4 hours/day), children between 4- 6
Treatment Best Corrected Visual Acuity Distribution months of age (patching the fellow eye 4-6 hours/day),
n = 214p-value<0.05
children older than 6 months (patching 50% of the day).8
As all the patients in our study were older than 6 months
we guided them to do the patching for 50% of the day.
Outcome of therapy was largely dependent on the
compliance of the therapy.We assessed compliance on
the basis of information given by the parents. If child
underwent occlusion therapy daily and almost fully as
desired it was rated as excellent, while if the child
underwent occlusion daily but not up to the hours
desired it was rated as good to fair. But if child skipped
days between the therapies it was rated as poor
compliance. We noted that highest number of children
who were rated as excellent in compliance showed
Figure 3: Improvement in Visual Acuity after Amblyopia Therapy improvement in visual acuity. On the other hand
children rated with poor compliance showed negligible
improvement in the visual acuity.Further research will
be required to investigate the ideal timing in pediatric
cataract surgery and hence prevention in the
development of amblyopia.
CONCLUSION
Congenital cataract is the most common type of
cataract seen in children, and it is along with other type
of cataracts can be successfully managed by performing
surgery , resulting in good visual improvement and
prevention in amblyopia.
REFRENCES
1. Wilson ME, Pandey SK, Thakur J.Paediatric cataract
blindness in the developing world: Surgical technique and
intraocular lenses in new millenium. Br J Opthalmol2003; 87:
noticed that the most frequent cause of decreased vision 14-19.
2. Lambort SP. Management of monocular congenital cataract.
postoperatively. It might be defined as interference of Eye 1999; 13: 474-79.
visual acuity development caused by short of stimuli 3. Angra, Mohan SK. Management of Rubella cataract. Ind J
or insufficient stimuli during critical periods of Ophthalmol 1982; 302: 13-16.
development. It can be classified as strabismic, 4. Lundvall A, Kugelberg U. Outcome after treatment of
congenital bilateral cataract. ActaOphthalmolScand 2002;
anisometropic or sensory deprivationdue to congenital 80:593–597.
cataracts. The treatment of infantile cataract is based 5. Robb RM, Petersen RA. Outcome of treatment for bilateral
on two major approaches: surgical removal of the congenital cataracts. Ophthalmic Surg 1992;23:650 –656.
opacified lens and optical therapy. Optical therapy or 6. Keech RV, Tongue AC, Scott WE. Complications after surgery
for congenital and infantile cataracts. Am J Ophthalmol
rehabilitation can be achieved with intraocular lens 1989;108:136 –141.
(IOL) implantation plus optical correction or optical 7. Lundvall A, Zetterström C. Complications after early surgery
correction without IOL implant.11 There are many ways for congenital cataracts. ActaOphthalmolScand 1999;77: 677–
of treating after sensory deprivation which includes first 680.
8. Ejzenbaum F,Salomão S.R, Berezovsky A, et al.After
removing the cause of sensory deprivation, afterwards, unilateral infantile cataract extraction after six weeks of age.
either occlusion therapy or penalization could be Arq Bras Oftalmol. 2009;72(5):645-9
performed. In our study we used the method of 9. Tanna AP, Abraham C, Lai J, et al.Impact of cataract on the
occlusion. We gave training to the parents for one week results of frequency-doubling technology perimetry.
Ophthalmology2004;111:1504–7
when they started occlusion therapy along with the 10. Desai P,Reidy A, Minassian DC.Profile of patients presenting
counseling regarding the importance of this therapy. for cataract surgery in the UK: National data collection. Br J
As a result 69% of the children had improvement of a Ophthalmol1999;83:893–96
single line or more after they underwent this occlusion 11. Hassan M, Qidwai U. Complication and Visual Outcome after
Peadiatric Cataract Surgery with or Without Intra Ocular
therapy. Patching therapy was prescribed after optical Lens Implantation, Pak J Ophthalmol 2011, Vol. 27 No. 1
correction our study used the following scheme of
patching children between 2-4 months of age (patching

130 Ophthalmology Update Vol. 11. No. 2, April-June 2013

 Original Article

Incidence of Pupillary Involvement,

Course of Anisocoria & Ophthalmoplegia
Dr. Naveed
in Diabetic Oculomotor Nerve Palsy
Naveed Ahmad Shah1, Iftikhar Ahmad2, Abdul Ghafoor3
ABSTRACT:
Aims : To derive a reliable estimate of the frequency of pupillary involvement and to study the patterns and course of
anisocoria in conjunction with ophthalmoplegia in diabetes-associated oculomotor nerve palsy.
Materials and Methods: In this prospective analytical study, standardized enrolment criteria were employed to identify
35 consecutive patients with diabetes-associated oculomotor nerve palsy who were subjected to a comprehensive ocular
examination. Standardized methods were used to evaluate pupil size, shape, and reflexes. The degree of anisocoria, if
present and the degree of ophthalmoplegia was recorded at each visit.
Results: Pupillary involvement was found to be present in 25.7% of the total number of subjects with diabetic oculomotor
nerve palsy. The measure of anisocoria was < 2 mm, and pupil was variably reactive at least to some extent in all cases
with pupillary involvement. Majority of patients in both the pupil-involved and pupil-spared group showed a regressive
pattern of ophthalmoplegia, reversed much earlier and more significantly when compared to anisocoria.
Conclusions: Pupillary involvement in diabetes-associated oculomotor nerve palsy occurs in about 1/4 th of all cases.
Certain characteristics of the pupil help us to differentiate an ischemic insult from an aneurysmal injury to the 3rd nerve.
Ophthalmoplegia resolves much earlier than anisocoria in diabetic oculomotor nerve palsies.
Keywords: Anisocoria, diabetic oculomotor nerve palsy, ophthalmoplegia

INTRODUCTION outcomes, a dilemma arises in patients with pupil

Diabetics are predisposed to certain acute involving oculomotor nerve palsies with diabetes. The
mononeuropathies, including cranial neuropathies, reported frequency of pupil involvement based on
which could involve oculomotor nerves. The retrospective analysis ranges from 14% to 32%.1,3,6,7,8 The
oculomotor nerve is quite commonly involved in purpose of this study was to derive a more reliable
diabetes.1,2 estimate of the frequency of pupil involvement and to
The size and reactivity of the ipsilateral pupil is study the course of anisocoria and ophthalmoplegia in
generally considered a useful guide to help clinicians patients with diabetes-associated oculomotor nerve
distinguish oculomotor nerve injury, caused by palsy. Finding the correct incidence could help in
aneurysmal compression (dilated and poorly reacting deciding the need for extensive investigative
pupil) from peripheral nerve infarction in which the procedures like an MRI brain.
pupil is usually spared.3,4,5 MATERIALS AND METHODS:
While pupil involvement is a sensitive predictor The study population consisted of 35 consecutive
of aneurysmal compression, the specificity of this sign patients with diabetes-associated oculomotor nerve
remains less clear in regard to diabetes-associated palsy. All patients with oculomotor nerve palsy due to
infarction. In the recent past, it has been noted that more diabetes as diagnosed clinically and documented
patients present with pupillary involvement in diabetes- appropriately with Hess charting and diplopia charting
associated oculomotor nerve palsy. Similarly, there have were recruited for the study. Other conditions such as
been incidences of oculomotor nerve palsy associated head trauma, compressive lesions, intracranial
with aneurysms but presenting with sparing of the aneurysm, space occupying lesions, carotid-cavernous
pupil. As oculomotor nerve palsy caused by posterior fistula, vasculitic infarction such as giant cell arteritis,
communicating artery aneurysm can lead to devastating meningeal inflammation, herpes zoster, cavernous
————————————————————————————————
1
Consultant Ophthalmologist, Mardan Medical Complex Teaching
sinus thrombosis, ophthalmoplegic migraine and post-
Hospital, Mardan. 2Assistant Professor, Abbottabad International viral demyelination were excluded from the study.
Medical College, Abbottabad. 3Consultant Ophthalmologist, Distt. Similarly, patients with oculomotor nerve palsy due to
Hospital, Batagram. diabetes along with one or more of the above-mentioned
————————————————————————————————
Correspondence: Dr. Naveed Ahmad Shah, Consultant
conditions were also excluded.
Ophthalmologist, Mardan Medical Complex Teaching Hospital, A detailed medical history and past history of the
Mardan. [email protected] Cell : 0300-9177974 subjects was taken. All patients were subjected to a
———————————————————————————————— comprehensive ocular examination, which included
Received: Dec’2012 Accepted: Feb’2013
————————————————————————————————
visual acuity and slit lamp biomicroscopy. Particular

Ophthalmology Update Vol. 11. No. 2, April-June 2013 131

Incidence of Pupillary Involvement, Course of Anisocoria & Ophthalmoplegia in Diabetic Oculomotor Nerve Palsy

attention was paid towards lid examination, pupillary brain was normal in all the cases. None of the patients
reflexes, and extraocular movements. had isolated weakness of extraocular muscles
Ptosis, if present, was graded. Pupils were checked innervated by only the superior or inferior division of
for size, shape, and light reflexes. Pupillary involvement the oculomotor nerve.
was scrutinized by measuring the pupil size and its Among the other risk factors associated with the
reactivity to light. Standardized methods were used to development of vasculopathic oculomotor nerve palsy,
measure pupil size. Patients were instructed to look at hypertension was seen most frequently (42.8%),
a target kept 6 meters away under stable room light followed by hypercholesterolemia (40%), smoking
conditions. A pupil gauge accurate to within 0.5 mm (28.57%), coronary artery disease (14.2%) and
was used to measure the pupil diameters. The patients alcoholism (11.3%).
were engaged in conversation to ensure that they were 9 patients (25.7%) were found to have an internal
alert. The degree of anisocoria, if present, was recorded. ophthalmoplegia along with external ophthalmoplegia.
Anisocoria, if present, was again measured under The mean age in this group was 57.56 ± 11.98 years
dim light conditions to rule out simple (physiological) (ranging from 40 to 78 years), and mean duration of
anisocoria. An anisocoria was termed as simple if it diabetes was 7.27 ± 5.7 years. Patients presented to us
remained similar in room light as well as in dim light. on an average 9.1 ± 6.5 days after the onset of symptoms.
The quality of direct pupillary light reaction was also Some degree of anisocoria (pathological and simple
recorded. anisocoria) was measured in 31.1% of the patients at
Hess charting and diplopia charting were done presentation. Based on pupillary findings at the final
in all cases to confirm oculomotor nerve palsy. visit, 4 kinds of patterns could be identified in all
Standardized method to quantify the degree of subjects
ophthalmoplegia by recording the relative limitation of In 9 patients, the measure of anisocoria ranged
ocular ductions of the superior, inferior, medial recti from 1 mm to 2 mm (median size 1.5 mm) with the
muscles and inferior oblique using a 0 to 4 scale was frequency distributed equally between 1, 1.5, and 2 mm
used.9 0 represented full duction; 4 complete absence of anisocoria (33.3%). None of these patients had a fully-
of function; and 1, 2 and 3, 25%, 50% and 75 % dilated, non-reactive pupil.
impairment of duction, respectively. A single Figure 1 represents the course of anisocoria at
ophthalmoplegia grade was determined by calculating each visit for each of the 9 patients (A - I) who had
the arithmetic mean of the relative limitation of ocular pupillary involvement. In patients with incomplete
ductions of the involved 4 muscles. resolution, residual anisocoria was <1 mm. The direct
Patients were subjected to a fundus examination pupillary reaction was impaired variably in all subjects
with a 78 D lens to document any signs of diabetic during the 1st 2 visits, but the reaction normalized or
retinopathy. MRI of brain were done in all cases to rule near normalized as ophthalmoplegia resolved. Patient
out surgical lesions. Blood pressure measurement, ‘C’ and ‘E’ were lost to follow-up at 2nd and 3rd visit,
random blood sugar, erythrocyte sedimentation rate respectively.
and serum cholesterol were recorded in all cases. They Comparison of anisocoria at different visits (Post
were treated with oral methylcobalamin.10 They were Hoc tests) revealed that there was a significant
advised to control diabetes and other associated difference in the degree of anisocoria between the
systemic disorders and to undergo ocular 1st and 3rd visits (P = 0.02) and the 2nd and 3rd visits
physiotherapy. They were reviewed again after 2 weeks (P = 0.02). In most of the patients with pupillary
and 8 weeks from the baseline visit. Lid position, extra- involvement, the maximum anisocoria developed
ocular movements, pupil size, and reaction to light were within the 1st 2 weeks after the onset of symptoms. Mean
recorded at every visit. time between the onset of symptoms and maximum
The data collected from the patients were coded anisocoria was 9 days.
and tabulated. Appropriate inferential, descriptive Figure 2: Time taken to develop maximum
statistics, analysis of variance (ANOVA), and anisocoria (the last data point plotted for each patient
correlation were compiled using Statistical Package for (A-I) represents the maximum anisocoria recorded). In
the Social Sciences (SPSS) version 17. The results of the 62.5% of the patients with pupillary involve-
analysis were presented in the form of tables and ment Figure 3, a complete resolution of ophthal-
graphs. The statistical significance is tested at 5% level moplegia was seen (A, B, C, D, and F). Comparison of
(P d<0.05). grades of ophthalmoplegia between different visits by
RESULTS: the Post Hoc test revealed that there was a significant
Of the total 35 subjects screened, none had difference in the ophthalmoplegia grades between the
bilateral oculomotor nerve involvement, and MRI of 1 st and 2nd visit (P = 0.033), the 2 nd and 3 rd visit

132 Ophthalmology Update Vol. 11. No. 2, April-June 2013

Incidence of Pupillary Involvement, Course of Anisocoria & Ophthalmoplegia in Diabetic Oculomotor Nerve Palsy

(P = 0.002) and the 1st and 3rd visit (P = 0.00). Correlation were done after minimizing variables, which could
analysis (Pearson correlation) didn’t reveal any influence the size of the pupil. The level of scrutiny was
significant association between the course of anisocoria increased by measuring pupil size to the nearest of
and ophthalmoplegia (P = 0.086). Majority of patients 0.5mm in all patients. Additionally, the course of
with pupil involvement didn’t have diabetic anisocoria was compared with that of ophthalmoplegia.
retinopathy changes Table 3. Analysis of data shows that the incidence of pupillary
DISCUSSION: involvement was 25.7%. In a similar study by Jacobson,
The present study was aimed at deriving a reliable
Figure 1
estimate of incidence of pupillary involvement in
diabetes-associated oculomotor nerve palsy. It was
unique in that it was a prospective study unlike many
other previous studies and that pupillary measurements

Table 1 shows demographic and clinical characteristics of all the

35 patients recruited in the study.

Characteristis Value

Gender, No (%) of patients

M 22 (63)
F 13 (37)
Mean age in years(range) 60.9 (40-80)
Mean duration of diabetes in years (range) 7.7 (1-20)
No (%) of patients with established diabetes
Figure 2: Time taken to develop maximum anisocoria
Type 1 11 (31)
(The last data point plotted for each patient (A-I)
Type 2 24 (69)
represents the maximum anisocoria recorded)
Mean duration of symptoms in days (rtange) 8 (2-23()
Symptoms (%)
Headache 27 (77)
Diplopia 22 (62.8)
Periocular pain 17 (48.5)

Table 2: Pattern and degree of anisocoria

Number Percentage

Pattern
None 24 68.5
Completely resolved 5 14.29
Incompletely resolved 3 8.57
Simple 2 5.71
Lost to follow-up 1 2.8
Total 35 100 Figure 3: Course of ophthalmoplegia
Degree of anisocoria (mm) [The graph represents the grades of ophthalmoplegia of each of the
1 3 33.3 9 patients (A-I) with pupillary involvement at each visit. Patient ‘C’
1.5 3 33.3 and ‘E’ were missed for follow-up at 2nd and 3rd visit, respectively]
2 3 33.3

Table 3: Diabetic retinopathy and internal ophthalmoplegia

Number Percentage

No DR 6 66.6
Mild NPDR 2 22.2
Moderate NPDR 0 0
Severe NPDR 1 11.1
PDR 0 0
Total 9 100
DR: Diabetic Retinopathy, NPDR: Non Proliferative diabetic
retinopathy,
PDR: Proliferative diabetic retinopathy

Ophthalmology Update Vol. 11. No. 2, April-June 2013 133

Incidence of Pupillary Involvement, Course of Anisocoria & Ophthalmoplegia in Diabetic Oculomotor Nerve Palsy

the incidence was found to be 22.7%. 11 But, the ophthalmoplegia over the initial 2 visits. This is in
difference in the incidences, found on comparing our contrast to a study by Jacobson and Broste where an
study with that of Jacobson, was statistically not early progression of ophthalmoplegia was seen in 69%
significant on doing chi square test (P = 0.288). Most of the individuals and mentions that early progression
previous studies quote much lower incidences than that may not be recognized as a common characteristic if
derived from this study and the study by Jacobson.1,3,6,7 the patient is first seen after 1 week of onset of double
The reason for this could be two fold. Most vision.9 The reason for discrepancy between the findings
previous studies chose pupillary reaction to light as the of this study and that of the above-stated study might
primary end point for defining pupil involvement. This be due to the fact that majority of subjects in our study
could have led to underestimation of the pupillary presented to us after 1 week of onset of their symptoms
involvement as reaction of pupil to light could be and also that the subjects were followed up 2 weeks
influenced by various factors, like brightness of light, after their initial visit. Ophthalmoplegia would have
emotional stimuli and accommodation. In this study, already-progressed and then recovered by the time we
the primary end point was anisocoria rather than identified a change from the previous visit to a
pupillary reaction to light. As all other external factors subsequent evaluation. Had all patients been seen on a
which could influence the pupillary size were daily basis, the progression would have been probably
controlled, the difference in size of the involved pupil more evident. It was also inferred that ophthalmoplegia
and the fellow pupil was more accurate in predicting recovers relatively more significantly and much earlier
pupillary involvement than pupillary reaction alone. than anisocoria.
Secondly, in our study, the level of accuracy of pupillary No statistically significant difference was found
measurement was increased by using a pupil gauge between the course of anisocoria and ophthalmoplegia
with a unit measurement of 0.5 mm. Most patients although clinically both anisocoria and ophthalmo-
developed maximum anisocoria within the 1st 2 weeks plegia showed an improvement and resolution at the
after onset of symptoms, which is also similar to the 3rd visit in majority of the subjects. Although the P value
observation in Jacobson’s study.11 However, this time was not significant (P value 0.086), it was close to 0.05,
interval could have been artifactually prolonged as which denotes that a statistically significant association
patients were not followed up on a daily basis. Had all would have been seen had the sample size been more
patients been seen on a daily basis, the maximum in the present series.
anisocoria might have been detected at a much earlier Majority of the patients with pupillary
stage. involvement showed no diabetic retinopathy changes
A fully-dilated, non-reactive pupil is found in 51% or had less severe grades of diabetic retinopathy. A
to 71% of patients with aneurysmal compression of Similar result was reported in a study by Acaroglu et
oculomotor nerve.5,12 In aneurysms compressing the al., in which presence and level of diabetic retinopathy
3rd nerve, anisocoria progresses and the pupil becomes was found to be significantly lower in diabetics with
maximally dilated within the 1 st 2 weeks of the cranial nerve palsy than in the age, sex, and disease-
presentation. A certain number of patients in this study duration-matched controls.13 The relatively milder form
too showed progression of anisocoria during the 1st 2 of diabetic retinopathy could be accounted for by the
weeks of presentation. But, the pupil remained shorter duration of diabetes in the majority of subjects
incompletely involved and variably reactive in all (Mean 7.27 years).
patients in this study. Additionally, none of the patients CONCLUSION:
had an anisocoria of > 2 mm. These characteristics of Pupil involvement in patients with diabetes-
the pupil help to distinguish diabetic from aneurysmal associated oculomotor nerve palsy occurs in about
injury of the oculomotor nerve. From the statistical 1/4th of all cases. Although pupil may be involved in
analysis performed on the course of anisocoria, it can both, certain pupil characteristics like an incomplete
be inferred that the degree of anisocoria normalized involvement and anisocoria < 2 mm may help to
maximally by the 3rd visit (after 8 weeks) as compared distinguish diabetic (ischemic) from aneurysmal
to the 2nd visit (after 2 weeks). While 1 patient was lost (compressive) injury of the oculomotor nerve. Imaging
to follow-up, pupil normalized in a majority of patients may not be required in pupil-sparing oculomotor nerve
(55.5%). The direct pupillary reaction, which was palsies in patients over 50 years with known
impaired during the initial 2 visits, normalized or near vasculopathic risk factors although this is associated
normalized as the ophthalmoplegia reversed and the with the rare risk of missing an aneurysm sparing the
pupil came back to its original size. pupils. These patients could be just treated
Majority of subjects in both pupil-involved and conservatively and followed up on a regular basis, if
pupil-spared groups showed a recovery of possible almost daily for 2 weeks for progression of

134 Ophthalmology Update Vol. 11. No. 2, April-June 2013

Incidence of Pupillary Involvement, Course of Anisocoria & Ophthalmoplegia in Diabetic Oculomotor Nerve Palsy

anisocoria and ophthalmoplegia to diagnose an early 600.

aneurysm as mortality rate due to aneurysm rupture 4. Trobe JD. Third nerve palsy and the pupil. Arch Ophthalmol
1988;106:601-2.
could reach up to 86% and 20% of untreated aneurysms 5. Keane JR. Aneurysms and third nerve palsies. Ann Neurol
will re-bleed within 2 weeks of the 1st bleed.14.15 1983;14:696-7.
Imaging should be considered in those cases of 6. Green WR, Hackett ER, Schlezinger NS. Neuro-ophthalmic
pupil-involved oculomotor nerve palsies if patient evaluation of oculomotor nerve paralysis. Arch Ophthalmol
1964;72:154-67.
presents with additional cranial nerve palsy or 7. Zorrilla E, Kozak GP. Ophthalmoplegia in diabetes mellitus.
neurological abnormalities and pupil shows Ann Intern Med 1967;67:968-76.
characteristics of a compressive lesion even if history is 8. Teuscher AU, Meienberg O. Ischaemic oculomotor nerve
suggestive of an ischemic lesion. Majority of cases of palsy; Clinical features and vascular risk factors in 23 patients.
J Neurol 1985;232:144-9.
ischemic oculomotor nerve palsy show spontaneous 9. Jacobson DM, Broste SK. Early progression of
resolution with medical treatment alone in contrast to ophthalmoplegia in patients with ischemic oculomotor nerve
nerve palsy due to aneurysmal injury where earliest palsies. Arch Ophthalmol 1995;113:1535-7.
possible surgical intervention is required. 10. Yaqub BA, Siddique A. Effects of methylcobalamin on
diabetic neuropathy. Clin Neurol Neurosurg 1992;94:105-11.
Limitations of this study include the following 11. Jacobson DM. Pupil involvement in patients with diabetes-
issues. The incidence could have been more accurate associated oculomotor nerve palsy. Arch Ophthalmol
had the sample size been more than that in the current 1998;116:723-7.
study. The course of ophthalmoplegia and anisocoria 12. Kissel JT, Burde RM, Klingele TG, Zeiger HE. Pupil sparing
oculomotor palsies with internal carotid-posterior
could have been more precisely-studied had the communicating aneurysms. Ann Neurol 1983;13:149-54.
patients been followed up at closer intervals or even on 13. Acaroglu G, Akinci A, Zilelioglu O. Retinopathy in patients
a daily basis. with diabetic ophthalmoplegia. Ophthalmologica
REFERENCES: 2008;222:225-8.
1. Rucker CW. Paralysis of the third, fourth and sixth cranial 14. Tsutsumi K, Ueki K, Morita A, Kirino T. Risk of rupture from
nerves. Am J Ophthalmol 1958;46:787-94. incidental cerebral aneurysms. J Neurosurg 2000;93:550-3.
2. Rucker CW. The causes of paralysis of the third, fourth and 15. Locksley HB. Natural history of subarachnoid hemorrhage,
sixth cranial nerves. Am J Ophthalmol 1966;61:1293. intracranial aneurysms and arteriovenous malformations.
3. Goldstein JE, Cogan DG. Diabetic third nerve palsy with Based on 6368 cases in the Cooperative Study. J Neurosurg
special reference to the pupil. Arch Ophthalmol 1960;64:592- 1966;25:321-68.

More on Line
Read the latest research in Ophthalmology at the following website

www.ophthalmologyupdate.com

Where all of ophthalmology goes to connect.

The trusted source of information in visual sciences.

Where evidence meets experience,

You will find

Update

Ophthalmology Update Vol. 11. No. 2, April-June 2013 135

 Case Report

Vertical Strabismus after Conjunctival Scarring

Masquerading as Superior Oblique Palsy
Saemah Nuzhat Zafar, FCPS, FRCS1 Sorath Noorani Siddiqui, FCPS2

ABSTRACT:
A patient, who presented with diplopia after a history of dog bite to the supero-medial part of the eye, had conjunctival
scarring over the medial rectus insertion and symblepharon. He had limitation of depression in adduction, simulating
superior oblique palsy. Unreliability of a three step test in vertical strabismus when there are scars is highlighted.
Key Words: superior oblique palsy; canine tooth syndrome; vertical strabismus; diplopia.

INTRODUCTION: hypotropia of 20 PD, on prism cover test. The

Superior oblique muscle is affected frequently in orthoptist’s notes stated that right hypertropia
acquired extraocular muscle palsy. Strengthening the increased to 30 PD on left gaze and on right head tilt to
muscle requires caution, to avoid iatrogenic side effects 25 PD. He had a limitation of depression in adduction
of restricted elevation in adduction.1 The choice of the of -3.5 (Figure 1), on a scale of -1 to -4, indicating -1 as
correct surgical procedure depends on the results of minimum limitation of depression and -4 as no
the traction testing of the superior oblique tendon depression. He also had a slight over action of right
preoperatively. inferior oblique, measuring +0.75, on a scale of 0 to 4.
The typical ‘canine tooth syndrome’ was On up-gaze, exotropia increased to 16 PD while on
classified as type 7 superior oblique palsy by Knapp in down gaze it remained 10 PD. Right hypertropia on
which there is weakness of the superior oblique muscle down gaze was 30 PD and left hypotropia on down gaze
evident by the failure of depression in adduction along measured 30 PD. Diplopia was present in down-gaze
with inability to elevate the eye in adduction.2 The and on dextro and laevo-depression. Hess test showed
management of such a case is presented where some under action of the right superior oblique and the right
clinical features resembled the canine tooth syndrome. medial rectus.
CASE REPORT: In the operating room, scar mark over the brow,
A 52 year old patient presented to the pediatric lid margin defect, symblepheron and conjunctival
and strabismus unit of our tertiary care eye hospital scarring were noted, more so at the site of insertion of
with complaints of diplopia on down gaze. He had a the medial rectus (Figure 2). Positive forced duction test
history of repair for the extensive trauma to the right (FDT) was +2 for the right medial rectus on attempted
upper lid and brow area, after a dog bite to the supero- abduction, and negative for all other muscles. Normal
medial part of the right eye, 2 years ago. The patient’s ‘bump’ of the right superior oblique tendon was felt
systemic examination and laboratory reports of blood and did not reveal any laxity. FDT was negative for all
glucose and complete blood count were within normal extra ocular muscles in the left eye.
limits. On ocular examination he had a slight head tilt The lid notch was repaired along with releasing
towards the left. His visual acuity was 6/6 with normal the symblepheron. Pedicle conjunctival graft was
fundus and normal foveal position in both eyes (OU). sutured over the bare sclera resulting from released
He had an exotropia (XT) of 10 prism diopters (PD) with bands of conjunctival fibrosis. An adjustable suture
right hypertropia of 18 PD and 12 PD XT with left recession of the yoke inferior rectus of the contra lateral
————————————————————————————————
eye was performed. Minimal diplopia was appreciable
1
.Dr Saemah Nuzhat Zafar, Associate Professor & Clinical Fellow on the first post operative day with correction of left
in Pediatric Ophthalmology and Strabismus 2. Clinical Fellow in hypotropia. Patient became symptom free on follow up.
Pediatric Ophthalmology and Strabismus, Al-Shifa Trust Eye DISCUSSION:
Hospital, Rawalpindi.
————————————————————————————————
Our patient differed from the typical presentation
Correspondence: Dr Saemah Nuzhat Zafar, Associate Professor described in canine tooth syndrome3 or the dog bite
& Clinical Fellow in Pediatric Ophthalmology and Strabismus Al- syndrome, 4 in that, the paradoxical limitation of
Shifa Trust Eye Hospital, Rawalpindi elevation in adduction was not evident enough and
Email: [email protected]
————————————————————————————————
there was no superior oblique palsy, as became evident
Received: Jan’2013 Accepted: Feb’2013 on forced duction test. Parks three step test which is
————————————————————————————————

136 Ophthalmology Update Vol. 11. No. 2, April-June 2013

Vertical Strabismus after Conjunctival Scarring Masquerading as Superior Oblique Palsy

Figure 1: Limitation of depression in adduction leading to erroneous diagnosis of a superior oblique

‘palsy’ when in fact, scarring of the anterior orbital
tissues caused a restrictive motility deficit cured by the
removal of the scar. The limitation in our report is that
we however did a simultaneous adjustable suture
recession of the inferior rectus of the contra-lateral eye
(the yoke muscle of the superior oblique). Our report
would have been better authenticated if a two stage
surgery with initial release of symblepharon was carried
out to establish conjunctival fibrosis as a cause of vertical
strabismus. The patient coming from far with monetary
constraints was one factor to correct the hypotropia in
a single surgery using the adjustable suture technique.
Figure 2: Conjunctival scarring and symblepharon
This was done as a safety measure, in case the removal
of the long standing conjunctival fibrosis was not
adequate enough to correct the vertical strabismus. Our
patient had all the classical features of a right superior
oblique palsy (slight head tilt towards the left, a right
hypertropia which increased in left gaze and on right
head tilt, a significant limitation of depression in
useful in identifying a single under acting muscle in adduction, a slight overaction of the right inferior
vertical and tortional deviations, proved deceptive in oblique, and an underaction of the right superior
our patient having restrictive etiology. Forced duction oblique on Hess test. The authors considered the fact
test in the operating room however helped in making that a normal superior oblique tendon on FDT is present
the surgical decision by ruling out the superior oblique in acquired palsies was.7 However, it was the release of
weakness. the fibrotic conjunctival scars that lead to improvement
Spontaneous recovery may occur in canine tooth of the restrictive strabismus post operatively.
REFERENCES:
syndrome, during the first 4 to 6 months when 1. Kaeser PF, Klainguti G, Kolling GH. Inferior oblique muscle
management is by conservative observation.5 Two years recession with and without superior oblique tendon tuck for
had already passed after the initial injury and surgical treatment of unilateral congenital superior oblique palsy. J
intervention was planned when the patient presented AAPOS.2012;16(1):26-31
2. Knapp P. Classification and treatment of superior oblique
to us with a stable angle of deviation. There was palsy. Am Orthopt J 1974;24-18-22
conjunctival fibrosis at the insertion of the medial rectus 3. Lee WB, O’Halloran HS. A report of canine tooth syndrome.
but the muscle was found intact in our patient. Such a Orbit 2004;23(1):53-7
bite however can result in muscle being severed. 6 The 4. Wise J, Kraus D, Goldberg LL. Dog-bite syndrome: an
approach to its management. Can J Ophthalmol
present case highlights a restrictive etiology of features 1982;17(6):262-65
after dog bite injury, without the commonly described 5. Pediatric Ophthalmology and Strabismus.fSpringer by
superior oblique muscle palsy in such a scenario. This Kenneth Weston Wright, Peter H. Spiegel 2003; page 248
case demonstrates how unreliable the three step head 6. Reese PD, Judisch GF. Severed musculus rectus internus
caused by a dog bite. Klin Monbl Augenheilkd
tilt test is in cases of orbital scars particularly when 1988;193(5):504-5
involving cyclovertical muscles. Ophthalmologists 7. Plager DA. Traction testing in superior oblique palsy. J
should be conscious of such faulty use of this test Pediatr Ophthalmol Strabismus 1990 ; 27 : 136-140

Ophthalmology Update Vol. 11. No. 2, April-June 2013 137

 Review Article

Anti-Angiogenics in Vaso-Occlusive Disorder of

Retinal Vein
Prof. Marianne
Prof. Marianne L. Shahsuvaryan D.Sc.,Ph.D.,
Professor of Ophthalmology, Yerevan State Medical University,
Republic of Armenia

ABSTRACT
Back Ground: Vascular Endothelial Growth Factor (VEGF) appears to be essential for development and maintenance of
functionally efficient retinal vasculature as well as for integrity of the retinal pigment epithelium , Bruch’s membrane and
choroidal endothelial cells. Tissue hypoxia due to primary vascular occlusive disease is the most common driver of VEGF
synthesis and as retinal vein occlusion is associated with increased levels of VEGF, therapy by anti-angiogenics or
vascular endothelial growth factor inhibitors (anti-VEGF) was proposed to be a promising strategy for retinal vein occlusion.
Consequently, several anti-angiogenics have been developed for the treatment of vaso-occlusive disease of retinal vein,
and ophthalmology has witnessed an explosion in the number of intravitreal injections delivered to patients over the past
10 years, driven in large part by the introduction and rapid incorporation of therapy with anti-VEGF agents.
The objective of this review is to evaluate the efficacy of pharmacotherapy by VEGF inhibitors in vaso-occlusive
disorder of retinal vein , in the light of our current scientific knowledge about this disorder.
Key words: vascular endothelial growth factor, vascular endothelial growth factor inhibitors, pharmacotherapy, retinal
vein occlusion.

INTRODUCTION US-FDA approval.

The role of VEGF in the growth of both regular The objective of this review is to evaluate the
and abnormal blood vessels was identified in the 1980s, efficacy of pharmacotherapy by anti-VEGF in vaso-
and agents that could block the angiogenic cascade first occlusive disorder of retinal vein, in the light of our
came on the scene for cancer treatments in the early current scientific knowledge about this disorder.
1990s. Monoclonal antibodies against VEGF were first VEGF in the Eye : Physiology and Pathophysiology:
developed as an intravenous treatment for metastatic VEGF is produced by retinal pigment epithelial
colorectal cancer1,2. cells, neurons, glial cells, endothelial cells, ganglion
The increase in VEGF, a cytokine, is triggered by cells, Muller cells, and smooth muscle cells. VEGF
hypoxia in pathological conditions. Human eyes with appears to be essential for development and
central retinal vein occlusion (CRVO) showed evidence maintenance of functionally efficient retinal vasculature
of intra-retinal upregulated expression of VEGF as well as for integrity of the retinal pigment epithelium
mRNA3. Indeed, raised levels of VEGF have been (RPE), Bruch’s membrane and choroidal endothelial
reported in both the aqueous and vitreous fluid of cells 7. Although VEGF affects all cells within the retina,
patients with ischemic CRVO, and are responsible for its primary targets are vascular endothelial cells. VEGF
the increase in vascular permeability that leads to plays an important role in the patho-physiology of
macular edema (ME).4.Aqueous and vitreous levels of retinal vein occlusion and contributes to increased
VEGF were significantly correlated with the severity permeability across both the blood-retinal and blood-
of ME 5,6. The development of therapy with anti- brain barriers.
angiogenics or vascular endothelial growth factor In central retinal vein occlusion (CRVO) there is
inhibitors (anti-VEGF) has marked the beginning of a increased intraluminal and interstitial pressure
new era in eye diseases treatment. After 2 decades of throughout the retina drained by the obstructed vessels,
extensive research into the VEGF families and receptors, resulting in reduced arterial perfusion, which is
specific molecules have been targeted for drug exacerbated by pre-existent arterial insufficiency, and
development, and several medications have received in variable amounts of retinal ischemia. Retinal ischemia
causes increased production of vascular endothelial
————————————————————————————————
Correspondence: Professor of Ophthalmology 8th Hospital,
growth factor (VEGF), which causes vascular leakage
Yerevan State Medical University, 7 Ap., 1 Entr.,26 Sayat-Nova and macular edema. High levels of VEGF also promote
Avenue, Yerevan, 0001, Republic of Armenia retinal hemorrhages and exacerbate capillary
———————————————————————————————— nonperfusion. 8 Raised levels of VEGF have been
Received Nov. 2012 Accepted: Feb. 2013
————————————————————————————————
reported in both the aqueous and vitreous fluid of

138 Ophthalmology Update Vol. 11. No. 2, April-June 2013

Anti-Angiogenics in Vaso-Occlusive Disorder of Retinal Vein

patients with ischemic CRVO, and are responsible for eligible if they had foveal-involved macular edema from
the increase in vascular permeability that leads to ME4. a BRVO occurring within 12 months of study. Starting
Branch retinal vein occlusion (BRVO) also leads at month 3, patients were eligible for grid laser
to retinal ischemia that induces the production of treatment if hemorrhages had cleared sufficiently to
cytokines such as VEGF by retinal cells such as glial allow safe application of laser.
cells and vascular endothelial cells in the occluded Based upon the NEI VFQ-25 survey, patients who
region affected by anoxia. These cytokines interact with received ranibizumab felt they had greater
each other (cytokine network) and this results in improvement. There was greater reduction of macular
impairment of the blood-retinal barrier and an increase edema in the ranibizumab groups because CPT was
of vascular permeability, considered important in the reduced by 337.3 ìm (0.3 mg) and 345.2 ìm (0.5 mg)
development of macular edema associated with BRVO9. compared to 157.7 ìm in the sham group. In the CRUISE
ANTI-ANGIOGENICS IN RETINAL VEIN Study12, 392 patients with macular edema following
OCCLUSION THERAPY: central retinal vein occlusion (CRVO) were randomized
The term anti-angiogenic therapy was born more to receive monthly intraocular injections of 0.3 mg
than 35 years ago by J. Folkman, who hypothesized that (n = 132) or 0.5 mg (n = 130) of ranibizumab or sham
cancer may be treated by abolishing the nutrients and injections (n = 130).Patients were eligible if they had
oxygen-providing blood vessels and bevacizumab foveal-involved macular edema from a CRVO occurring
became the first therapy approved by the US - FDA within 12 months of study. Patients were excluded if
designed to inhibit angiogenesis in tumors. As retinal they had a brisk afferent pupil defect, had scatter laser
vein occlusion is associated with increased levels of photocoagulation within 3 months, an intraocular
VEGF, anti-VEGF therapy was proposed to be a injection of steroid or a VEGF antagonist within 3
promising strategy for retinal vein occlusion. months, or had an improvement of >10 ETDRS letters
Intraocular injections of a VEGF-binding protein in BCVA between screening and baseline.
reduce vascular leakage, resulting in improvement in Baseline characteristics were well balanced among
macular edema, accelerate resorption of retinal the three groups; the mean age was 68 years, mean
hemorrhages, and prevent worsening of capillary BCVA was 20/100, the mean time from diagnosis of
nonperfusion8,10 There are 4 anti-VEGF agents that are CRVO was 3.3 months, and the mean center point
either approved or in common use in ophthalmology, thickness (CPT) was 685 ìm. Based upon the 25-item
namely ranibizumab (Lucentis-Novartis),bevacizumab National Eye Institute Visual Function Questionnaire
(Avastin-Roche), pegaptanib (Macugen-Pfizer), and NEI VFQ-25 survey, patients who received ranibizumab
aflibercept or VEGF Trap-Eye (EYLEA- Bayer). felt they had greater improvement (improvement from
Lucentis. baseline in NEI VFQ score: 7.1, 0.3 mg; 6.2, 0.5 mg: 2.8,
In June 2006, Lucentis (ranibizumab, Roche/ sham)13. There was greater reduction of macular edema
Genentech) has first received FDA approval for the in the ranibizumab groups because CPT was reduced
treatment of macular edema due to both CRVO and by 433.7 μm (0.3 mg) and 452.3 μm (0.5 mg) compared
BRVO. to 167.7 μm in the sham group. This study demonstrated
Ranibizumab is a humanized, affinity-matured that six sessions of monthly injections of 0.3 mg or 0.5
VEGF antibody fragment that binds to and neutralizes mg reduced macular edema and provided substantial
all isoforms of VEGF.Two phase III multicenter, visual benefit in patients with CRVO.
prospective clinical trials assessing the safety, After the primary endpoint in the CRUISE and
tolerability and efficacy of intravitreal ranibizumab BRAVO trials, patients were evaluated every month and
injections in the treatment of macular edema secondary if study eye Snellen equivalent BCVA was <20/40 or
to BRVO and CRVO 10 were finished. They are called mean CST was >250 μm, they received an injection of
BRAVO (study of the efficacy and safety of ranibizumab ranibizumab; patients in the ranibizumab groups
injection compared with sham in patients with macular received their assigned dose and patients in the sham
edema due to BRVO)11 and CRUISE (study of the group received 0.5 mg. In patients with CRVO, the mean
efficacy and safety of ranibizumab injection compared number of ranibizumab injections during the
with sham in patients with macular edema due to observation period was 3.9, 3.6, and 4.2 in the 0.3 mg,
CRVO) 12. 0.5 mg, and sham/0.5 mg groups; and the percentage
In the BRAVO study 11 397 patients with macular of patients that did not receive any injections during
edema following branch retinal vein occlusion (BRVO) the observation period was 7.0, 6.7, and 4.3,
were randomized to receive monthly intraocular respectively14. At month 12 in the ranibizumab groups,
injections of 0.3 mg (n = 134) or 0.5 mg (n = 131) of the improvement from baseline in ETDRS letter score
ranibizumab or sham injections (n=132). Patients were was 13.9, very similar to the month 6 results, indicating

Ophthalmology Update Vol. 11. No. 2, April-June 2013 139

Anti-Angiogenics in Vaso-Occlusive Disorder of Retinal Vein

that vision is well maintained when injections are given (branch RVO) and 2.9, 3.8, and 3.5 (central RVO),
only if there is recurrent or residual macular edema. respectively. The incidence of study eye ocular serious
Patients in the sham group showed substantial adverse events and systemic adverse events potentially
improvement during the observation period when they related to systemic VEGF inhibition across treatment
were able to receive ranibizumab; improvement from arms was 2% to 9% and 1% to 6%, respectively. The
baseline in letter score was 0.8 at month 6 and 7.3 at mean change from baseline BCVA letter score at month
month 12. The percentage of patients who had an 12 in branch RVO patients was 0.9 (sham/0.5 mg), -2.3
improvement from baseline BCVA letter score >15 at (0.3/0.5 mg), and -0.7 (0.5 mg), respectively. The authors
month 12 was 47.0% (0.3 mg) and 50.8% (0.5 mg) in the concluded that no new safety events were identified
ranibizumab groups, almost identical to the month 6 with long-term use of ranibizumab; rates of systemic
results. In the sham group, 33.1% of patients improved adverse events potentially related to treatment were
from baseline >15 in letter score at month 12 compared consistent with prior ranibizumab trials. Reduced
to 16.9% at month 6. At month 12, 43% of patients in follow-up and fewer ranibizumab injections in the
the two ranibizumab groups had a Snellen equivalent second year of treatment were associated with a decline
BCVA of 20/40 compared to 35% in the sham/0.5 mg in vision in central RVO patients, but vision in branch
group. RVO patients remained stable. Results suggest that
In patients with BRVO, the mean number of during the second year of ranibizumab treatment of
ranibizumab injections during the observation period RVO patients, follow-up and injections should be
was 2.9, 2.8, and 3.8 in the 0.3 mg, 0.5 mg, and sham/ individualized and, on average, central RVO patients
0.5 mg groups; and the percentage of patients that did may require more frequent follow-up than every 3
not receive any injections during the observation period months.
was 17.2, 20.0, and 6.5, respectively15. At month 12 in In addition, the sub-analyses in BRAVO and
the ranibizumab groups, the improvement from CRUISE study generally confirmed that patients with
baseline in ETDRS letter score was 16.4 (0.3 mg) and BRVO or CRVO who were younger or who had worse
18.3 (0.5 mg), very similar to the month 6 results, vision and greater retinal thickness at baseline fared
indicating that vision is well maintained when injections better. Patients with BRVO fared better if time from
are given only if there is recurrent or residual macular diagnosis to treatment was less than 3 months. Patients
edema. Patients in the sham group showed substantial with CRVO had similar results regardless of time to
improvement during the observation period when they treatment.
were able to receive ranibizumab; improvement from In general, then, in BRVO, patients who needed
baseline in letter score was 7.3 at month 6 and 12.1 at fewer therapies, such as laser or other previous
month 12. The percentage of patients who had an treatments, probably had milder RVO requiring less
improvement from baseline BCVA letter score >15 at treatment. Patients who were younger did better than
month 12 was 55.2% (0.3 mg) and 61.1% (0.5 mg) in the those who were older,and patients with CRVO had a
ranibizumab groups, almost identical to the month 6 more unpredictable course than those with BRVO, and
results. In the sham group, 43.9% of patients improved therefore warrant even closer observation than those
from baseline >15 in letter score at month 12 compared with BRVO 38.
to 28.8% at month 6. At month 12, 67.9% (0.3 mg) and Avastin:
64.4% (0.5 mg) of patients in the ranibizumab groups Avastin(bevacizumab (Avastin), is FDA-
had a Snellen equivalent BCVA of 20/40 compared to approved for the treatment of colorectal cancer.
56.8% in the sham/0.5 mg group. Thus, in both CRUISE However, because the agent costs substantially less per
and BRAVO, patients in the sham groups showed a dose than Lucentis, it has been widely used off-label
substantial improvement in vision during the second 6 since 2004 to treat several retinal diseases, including
months when they were able to receive ranibizumab as retinal vein occlusion.Bevacizumab is a recombinant
needed, but their vision at month 12 was not as good as humanized monoclonal antibody directed against
that in patients in the ranibizumab groups. This raises VEGF. Recently, Ghayooret al.18 evaluated the effect of
a question as to whether delay in treatment carries a Avastin (mean 2.8 injections) in 8 eyes with CRVO- and
visual penalty. 22 with BRVO-associated macular edema and claimed
The results from open-label extension trial of the that significant improvement in best corrected VA was
12-month Ranibizumab assessing long-term safety and observed at 6th week of follow-up. At 6th month more
efficacy in BRAVO and CRUISE trials 16 evidenced that than 60% showed improvement in best corrected visual
in patients who completed month 12, the mean number acuity, similarly 70% patients had complete resolution
of injections (excluding month 12 injection) in the sham/ of macular edema. The authors concluded that anti-
0.5-, 0.3/0.5-, and 0.5-mg groups was 2.0, 2.4, and 2.1 VEGF therapy should be further evaluated in large,

140 Ophthalmology Update Vol. 11. No. 2, April-June 2013

Anti-Angiogenics in Vaso-Occlusive Disorder of Retinal Vein

prospective, controlled clinical studies. 0.3 or 1 mg at baseline and at weeks 6 and 12 with
At the latest prospective study Dallen et al.19 subsequent injections at 6-week intervals at the
evaluating the 12-month outcome and predictive factors discretion of the investigator until week 48. He also
of visual acuity (VA) changes following bevacizumab found improvements in VA and macular thickness in
therapy for CRVO concluded that early injections of this study with a 54-week follow-up. Therefore, the
bevacizumab in young patients in whom VA is authors consider that intravitreal pegaptanib offers a
relatively preserved leads to a significant improvement promising alternative for macular edema secondary to
in VA. Ischaemic CRVO and poor baseline VA are BRVO.
associated with non-response to such therapy. VEGF Trap:
Epstein et al.20 conducted the latest prospective The VEGF trap is another novel anti-VEGF agent
double-masked clinical trial of 60 patients with macular aflibercept (Eylea, Regeneron) . It is essentially a small
edema secondary to CRVO randomized 1:1 to receive fully human, soluble VEGF receptor that acts as a decoy
intraocular injections of bevacizumab or sham injection receptor binding-free VEGF. Aflibercept was approved
every 6 weeks for 6 months.Results evidenced that the for macular edema following CRVO in September 2012.
treatment improve VA and reduce macular edema The VEGF trap eye is currently under evaluation in two
significantly compared with sham.The International phase III studies on CRVO (GALILEO and
Intravitreal Bevacizumab Safety Survey gathered COPERNICUS Studies) with 6-monthly injections of
adverse events from doctors around the world via the drug or sham-controlled injections. The latest six-
internet 21 and showed all ocular and systemic side months results of the Phase 3 from COPERNICUS
effects to be under 0.21% including corneal abrasion, Study - multicenter, randomized, prospective,
lens injury, endophthalmitis, retinal detachment, controlled trial 25,26 assessing the efficacy and safety of
inflammation or uveitis, cataract progression, acute intravitreal Trap-Eye in 189 eyes with macular edema
vision loss, central retinal artery occlusion, sub-retinal secondary to central retinal vein occlusion (CRVO)
haemorrhage, retinal pigment epithelium tears, blood randomized 3:2 to receive VEGF Trap-Eye 2 mg or sham
pressure elevation, transient ischaemic attack, injection monthly for 6 months evidenced that at week
cerebrovascular accident and death. Fung. et al. 21 24, 56.1% of VEGF Trap-Eye treated eyes gained 15
concluded that self-reporting of adverse events after letters or more from baseline versus 12.3% of sham-
intravitreal bevacizumab injections did not show an treated eyes (P<0.001). The VEGF Trap-Eye treated eyes
increased rate of potential drug-related ocular or gained a mean of 17.3 letters versus sham-treated eyes,
systemic events and these short-term results suggest which lost 4.0 letters (P<0.001). Central retinal thickness
that intravitreal bevacizumab seems to be safe. decreased by 457.2 ìm in eyes treated with VEGF Trap-
Macugen: Eye versus 144.8 ìm in sham-treated eyes (P<0.001), and
In 2004, Macugen (pegaptanib sodium-Pfizer and progression to any neovascularization occurred in 0 and
OSI/Eyetech Pharmaceuticals, Inc.) was the first anti- 5 (6.8%) of eyes treated with VEGF Trap-Eye and sham-
VEGF agent to receive FDA approval for the treatment treated eyes, respectively (P = 0.006). Conjunctival
of neovascular age-related macular degeneration hemorrhage, reduced visual acuity, and eye pain were
(AMD). Macugen is a selective anti-VEGF compound the most common adverse events .Serious adverse
that is designed to inhibit one strain of VEGF. It should effects ocular were reported by 3.5% of VEGF Trap-Eye
be administered via intravitreal injection every six patients and 13.5% of sham patients. Incidences of
weeks. Although the use of Macugen has declined with nonocular serious adverse events generally were well
the release of newer anti-VEGF agents, such as Lucentis balanced between both groups. The authors concluded
and Avastin, it appears to be making a comeback that at 24 weeks, monthly intravitreal injection of VEGF
because of its more favorable dosing frequency (e.g., Trap-Eye 2 mg in eyes with macular edema resulting
every six weeks vs. every four weeks). Additionally, from CRVO improved visual acuity and central retinal
Macugen is associated with a lower risk of stroke than thickness, eliminated progression resulting from
either Lucentis or Avastin22. The pegaptanib sodium is neovascularization, and was associated with a low rate
still not well studied in RVO. Bennet23 performed a pilot of ocular adverse events related to treatment. Dr.
study where Macugen treatment achieved a decrease Korobe lnik presented the results on behalf of the
in macular thickness and an improvement in VA and GALILEO investigators at the annual meeting of the
retinal perfusion. But this study had enrolled only 7 American Academy of Ophthalmology 27 GALILEO is
patients with 6 months of follow-up and it had no a double-masked study conducted at 62 centers in
control group. On the other hand, Wroblewski et al. 24 Europe and Asia. It randomly assigned 177 patients 3:2
conducted a study where subjects with BRVO were to receive intravitreal aflibercept 2 mg or sham every 4
randomized 3:1 to intravitreal injections of pegaptanib weeks until week 24. Between week 24 and 52, patients

Ophthalmology Update Vol. 11. No. 2, April-June 2013 141

Anti-Angiogenics in Vaso-Occlusive Disorder of Retinal Vein

continued monthly monitoring, but the aflibercept eyes earlier reports of multicentre studies, outcome of
received treatment as needed while the sham group patients is relatively poor in the current treatment
continued to receive sham treatment every 4 weeks. settings 30 .
From weeks 52 to 76, the inter-visit interval was The preparation of the intravitreal injection site
extended to 8 weeks and sham patients were eligible with topical povidone-iodine is the preferred
for aflibercept. Nearly three-fourths of sham eyes and prophylactic method to minimize the risk of
85% of the aflibercept eyes completed 76 weeks of endophthalmitis. There is no need for topical antibiotic
follow-up. During the first 24 weeks of GALILEO, use after intravitreal injection. Additional infrequent
monthly aflibercept treatment resulted in rapid and complication includeanaphylactic reaction to the agent
sustained gains in best-corrected visual acuity28. The injected in the vitreous. A 2006 national survey in USA
improvement was largely maintained through week 52, Complications reported following complications rate
but declined some between weeks 52 and 76. Similar associated with intravitreal injections: endophthalmitis
temporal patterns were seen in analyses of changes in - 31%, increased IOP - 26%, cataract - 11%,other - 16%
central retinal thickness (CRT) and proportion of eyes 31. The most important adverse local effects related to
without retinal fluid in the aflibercept treatment group. anti-VEGF agents include uveitis, retinal detachment
After becoming eligible for aflibercept, eyes in the and cataracts.
sham group gained vision and had decreased CRT. The latest study32 on the rate of serious adverse
However, outcomes at week 76 were superior in the effects in a series of bevacizumab and ranibizumab
eyes that had been treated with aflibercept since entry. injections revealed that subjects who received
Results from follow-up to 76 weeks in the phase III bevacizumab were 12 times more likely to develop
GALILEO study show that intravitreal injection of severe intraocular inflammation following each
aflibercept (Eylea, Regeneron Pharmaceuticals) injection than were those who received ranibizumab.
provides marked improvement in visual acuity in One of acute intraocular inflammation following
treatment-naive eyes with macular edema secondary ranibizumab injection was mild and not associated with
to central retinal vein occlusion. However, the data also vision loss. No other serious ocular complications were
suggest the value of close monitoring and early noted. A trend was also noted toward an increased risk
treatment. The results of GALILEO and COPERNICUS for arterial thrombo embolic events in patients receiving
are encouraging for patients with central retinal vein bevacizumab, although the confidence interval was
occlusion. wide. In conclusion, authors stated that significant
Potential Hazards of Anti-VEGF Therapy: concern still exists regarding the safety of off-label use
Local adverse effects: Intravitreal injections of of intravitreal bevacizumab. Patients receiving
various agents have been studied extensively. The bevacizumab should be counseled regarding a possible
overall risk of complications are low when the injection increased risk for serious adverse events. Anti-VEGF
is administered by experienced ophthalmologists. therapy may therefore have adverse effects on ocular
Known risks of intravitreal injections can be vision blood flow. Von Hanno et al.33 presented two cases of
threatening and require prompt diagnosis and retinal artery occlusion after intravitreal injection of
treatment, possibly surgical intervention. The most bevacizumab (Avastin) and ranibizumab (Lucentis)
serious but rarely occurring injection-related respectively and concluded that the therapeutic
complications include acute-onset endophthalmitis, principle may be associated with an increased risk of
pseudo-endophthalmitis, cataract development/ retinal arterial occlusions.
progression, retinal detachment, and hemorrhage. Leung et al.34 presented a series of three patients
Additional infrequent complications include hypotony, of the nearly 200 patients with CRVO who suffered
angle closure, hemi-retinal vein occlusion, retinal apparent macular infarction within weeks of intravitreal
pigment epithelial tears, iritis/uveitis, optic disc administration of bevacizumab. The authors stated that
atrophy, corneal epitheliopathy, maculopathy central this has not been described in the natural history of the
retinal artery occlusion.The latest study 29 revealed that disease and is associated with poor visual outcomes.In
endophthalmitis following intravitreal injection is Manousaridis and Talks35 opinion worsening of macular
associated with an increased incidence of Streptococcus ischaemia in the long term cannot be definitely
spp. infection, earlier presentation and poorer visual excluded, particularly in eyes with significant ischaemia
outcomes when compared with endophthalmitis at baseline and after repeated intraocular anti-VEGF
following cataract surgery. Irigoyenet al.30 concluded injections. The decision to offer prolonged anti-VEGF
that the overall numbers of patients with treatment in cases of significant coexisting macular
endophthalmitis following intravitreal injections has ischaemia should not be based only on measurements
risen dramatically over the past years. In contrast to of macular thickness; instead repeat fluorescein

142 Ophthalmology Update Vol. 11. No. 2, April-June 2013

Anti-Angiogenics in Vaso-Occlusive Disorder of Retinal Vein

angiograms should be performed. In conclusion, the agents, ophthalmologists and nephrologists should be
overall risk of complications is low when the injection aware of the associated risk of kidney disease. Early
is administered by experienced ophthalmologists . detection is crucial so that intravitreal injections can be
Tachyphylaxis/tolerance: stopped before severe kidney disease occurs. In
The worldwide use of intravitreal application of Sorenson and Sheibani41 opinion perhaps baseline and
anti-vascular growth factor and the realisation that renal function during treatment (serum creatinine and
regular applications over long periods of time are urinary protein levels, blood pressure) should be
necessary to maintain vision in these eyes, has revealed carefully monitored to ensure that the improved visual
the problem of tolerance/tachyphylaxy36. Binder S.36 acuity is not at the expense of renal function.
recommended different options to prevent Concerns with anti-VEGF therapy:
tachyphylaxis/tolerance: (1) to increase the dosage or Major concerns with anti-VEGF therapy for ocular
shorten treatment intervals if tolerance has developed; diseases include: repeat intravitreal injections; risk of
(2) to pause treatment if tachyphylaxis has occurred; cardiovascular complications; possible retinal and
(3) to combine drugs with different modes of action; or neural toxicity due to cumulative dosing; interference
(4) to switch to a similar drug with different properties with physiologic functions of VEGF; and economic and
(bevacizumab and ranibizumab differ in molecular size, cost-effectiveness concerns. Tailoring treatment to the
affinity and absorption). individual patient should increase the chance of
Systemic adverse effects: treatment success, while sparing patients from
While used intravitreally, the systemic absorption unnecessary drug exposure and risk of adverse events.
is minimal, however, a trend has been observed towards Furthermore, avoiding unnecessary treatment also has
a higher risk of stroke among patients with a history of the potential to improve the cost-effectiveness of
heart disease24. Campbell et al.37 assessing the risk of treatment 42.
systemic adverse events associated with intravitreal Lang43 also stated that it is important to make
injections of VEGF inhibiting drugs in the nested case- decisions about the best treatment in retinal vein
control study have found that intravitreal injections of occlusion, which necessitates knowledge of the
bevacizumab and ranibizumab were not associated posology of the drug and assessment of the advantages
with significant risks of ischaemic stroke, acute and risks of the different treatment modalities.
myocardial infarction, congestive heart failure, or Therefore it is important to know the efficacy and safety
venous thrombo embolism. Clinical evaluation of data of the therapy. In conclusion, patients should
ranibizumab (Lucentis) based on two double-blind discuss the potential risks and benefits of
randomised trials comparing ranibizumab (0.3 mg or intravitrealpharma-cotherapy with their physicians
0.5 mg) versus placebo in a total of 795 patients revealed before receiving treatment.
that the incidence of heart failure and transient CONCLUSION
ischaemic attacks was higher during the second year of Vascular endothelial growth factor, a key
ranibizumab therapy than during the first year of regulator of angiogenesis and vascular permeability has
treatment 38. Patients should be informed of the potential been implicated in the pathogenesis of retinal diseases
adverse effects and uncertainties and be reminded that associated with neo-vascularisation and edema. As
this condition improves spontaneously in about 50% of retinal vein occlusion is associated with increased levels
cases 38 or almost in one quarter of affected eyes at 3 of VEGF, anti-VEGF therapy was proposed to be a
years 39 further controlled and prospective studies are promising strategy for retinal vein occlusion.
necessary to compare treatment by Lucentis to the Consequently, several anti-angiogenics have been
natural course with a longer follow-up39 There is some developed for the treatment of vaso-occlusive disease
evidence that intravitreal anti-VEGF injections may of retinal vein. Treatment regimens have evolved
result in systemic absorption, with the potential for through experience gained in clinical trials and clinical
injury in organs that are reliant on VEGF, such as the practice. The current treatment regimen for RVO should
kidney. Pellé et al.40 reported the first case of a patient reflect an individualized treatment approach designed
who developed an acute decrease in kidney function, to treat patients when they could benefit the most while
non-immune micro-angiopathic hemolytic anemia with minimizing the number of unnecessary intravitreal
schistocytes, and thrombocytopenia after 4 intravitreal injections, and hence the risk of adverse events.
injections of ranibizumab. Light microscopy of a kidney Selection of appropriate therapeutic procedure
biopsy specimen showed segmental duplications of based on the evidence- based medicine, to protect and
glomerular basement membranes with endothelial improve visual function of patients with retinal vein
swelling and several recanalized arteriolar thrombi. occlusion are the important project of clinicians and
Because of the increasing use of intravitreal anti-VEGF require further exploration and investigation

Ophthalmology Update Vol. 11. No. 2, April-June 2013 143

Anti-Angiogenics in Vaso-Occlusive Disorder of Retinal Vein

REFERENCE: Occlusions.Retina today; June 2011.

1. Homsi J, Daud AI. Spectrum of activity and mechanism of 18. Ghayoor I, Bokhari SA, Kamil Z, Shakir M, Zafar S, Khan
action of VEGF/PDGF inhibitors. Cancer Control 2007;14(3), MA. To assess the effect of intravitrealBevacizumab (Avastin)
285–294 . in the treatment of macular edema secondary to retinal vein
2. Los M, Roodhart JM, Voest EE. Target practice: lessons from occlusion. Ophthalmology Update 2012;10(1):7-13.
Phase III trials with bevacizumab and vatalanib in the 19. Daien V, Navarre S, Fesler P, Vergely L, Villain M, Schneider
treatment of advanced colorectal cancer. Oncologist C.Visual acuity outcome and predictive factors after
2007;12(4), 443–450 . bevacizumab for central retinal vein occlusion .Eur J
3. Pe’er J, Folberg R, ItinA et al. Vascular endothelial growth Ophthalmol 2012;
factor upregulation in human central retinal vein occlusion. 22(6): 1013 – 1018.
Ophthalmology 1998;105(3), 412–416 . 20. Epstein DL, Algvere PV, von Wendt G, Seregard S, Kvanta
4. Noma H, Funatsu H, Mimura T, Harino S, Sone T, Hori S. A. Bevacizumab for Macular Edema in Central Retinal Vein
Increase of vascular endothelial growth factor and Occlusion: A Prospective, Randomized, Double-Masked
interleukin-6 in the aqueous humour of patients with macular Clinical Study. Ophthalmology 2012; 119(6):1184-9.
oedema and central retinal vein occlusion. Acta. Ophthalmol. 21. Fung AE, Rosenfeld PJ, Reichel E. The International
2010;88(6), 646–651 . IntravitrealBevacizumab Safety Survey: using the internet to
5. Noma H, Funatsu H, Mimura T, Eguchi S, Shimada K. Role assess drug safety worldwide. Br J Ophthalmol 2006;90:1344-
of soluble vascular endothelial growth factor receptor-2 in 134.
macular oedema with central retinal vein occlusion. Br. J. 22. Tolentino M. Systemic and ocular safety of intravitreal anti-
Ophthalmol. 2011;95(6), 788–792 . VEGF therapies for ocular neovascular disease
6. Funk M, Kriechbaum K, Prager F et al. Intraocular SurvOphthalmol. 2011;56(2):95-113.
concentrations of growth factors and cytokines in retinal vein 23. Bennet MD. Pegaptanib for the treatment of ischemic
occlusion and the effect of therapy with bevacizumab. Invest. retinopathy in patients with diabetes and retinal vascular
Ophthalmol. Vis. Sci. 2009;50(3), 1025–1032 . occlusive disorders. Retina Today 2009;4:63–66.
7. HomayouniM.Vascular Endothelial Growth Factors and 24. Wroblewski JJ, Wells JA 3rd, Gonzales CR. Pegaptanib
Their Inhibitors in Ocular Neovascular Disorders. J sodium for macular edema secondary to branch retinal vein
Ophthalmic Vis Res. 2009; 4(2): 105–114. occlusion. Am J Ophthalmol 2010;149:147–154.
8. CampochiaroPA.Anti-vascular endothelial growth factor 25. Boyer DM. Anti-VEGF therapy for CRVO: COPERNICUS
treatment for retinal vein occlusions. Ophthalmologica. study. Paper presented at: Angiogenesis, Exudation and
2012;227Suppl 1:30-5. Degeneration 2011; February 12, 2011; Miami, FL.
9. Noma H, Funatsu H, Harino S, Nagaoka T, Yamashita H, 26. Boyer D, Heier J, Brown DM, Clark WL, Vitti R, Berliner AJ,
Hori S. Pathogenesis of macular edema associated with Groetzbach G, Zeitz O, Sandbrink R, Zhu X, Beckmann K,
branch retinal vein occlusion and strategy for treatment. Haller JA. Vascular Endothelial Growth Factor Trap-Eye for
Nihon GankaGakkaiZasshi. 2010;114(7):577-91. Macular Edema Secondary to Central Retinal Vein Occlusion:
10. Pieramici D. Intravitrealranibizumab for treatment of Six-Month Results of the Phase 3 COPERNICUS Study.
macular edema secondary to retinal vein occlusion. Retina Ophthalmology 2012; Mar 20.
Today 2009;4:44–46. 27. Ophthalmology Times Staff Reports. GALILEO: Aflibercept
11. Campochiaro PA, Heier JS, Feiner L, Gray S, Saroj N, Rundle provides marked improvement in visual acuity in results
AC, Murahashi WY, Rubio RG. BRAVO Investigators: from follow-up to 76 weeks. Nov 13, 2012
Ranibizumab for macular edema following branch retinal 28. Holz FG, Roider J, Ogura Y, Korobelnik JF, Simader C,
vein occlusion six-month primary end point results of a phase Groetzbach G, Vitti R, Berliner AJ, Hiemeyer F, Beckmann
III study. Ophthalmology 2010;117:1102–1112. K, Zeitz O, Sandbrink R. VEGF Trap-Eye for macular oedema
12. Brown DM, Campochiaro PA, Singh RP, Li Z, Saroj N, Rundle secondary to central retinal vein occlusion: 6-month results
AC, Rubio RG, Murahashi WY. CRUISE Investigators: of the phase III GALILEO study. Br. J Ophthalmol 2013;Jan
Ranibizumab for macular edema following central retinal 29. Simunovic MP, Rush RB, Hunyor AP, Chang AA.
vein occlusion six-month primary end point results of a phase Endophthalmitis following intravitreal injection versus
III study. Ophthalmology 2010;117:1124–1133. endophthalmitis following cataract surgery: clinical features,
13. Varma R, Bressler NM, Suñer I, Lee P, Dolan CM, Ward J, causative organisms and post-treatment outcomes. Br J
Colman S, Rubio RG; BRAVO and CRUISE Study Groups. Ophthalmol 2012;96:862–6.
Improved Vision-Related Function after Ranibizumab for 30. Irigoyen C, Ziahosseini K, Morphis G. Endophthalmitis
Macular Edema after Retinal Vein Occlusion: Results from following intravitreal injections. Graefe’s Archive for Clinical
the BRAVO and CRUISE Trials. Ophthalmology. and Experimental Ophthalmology 2012;250 (4), 499-505.
2012;119(10):2108-18. 31. Intravitreal Injection Survey.Retinalphisycian.July 2006.
14. Campochiaro PA, Brown DM, Awh CC, et al. Sustained 32. Sharma S, Johnson D, Abouammoh M, Hollands S, Brissette
benefits from ranibizumab for macular edema following A. Rate of serious adverse effects in a series of bevacizumab
central retinal vein occlusion: 12-month outcomes of a phase and ranibizumab injections. Can J Ophthalmol.
III study. Ophthalmology 2011;118(10):2041-9. 2012;47(3):275-9.
15. Brown DM, Campochiaro PA, Bhisitkul RB, et al. Sustained 33. von Hanno T, Kinge B, FossenK.Retinal artery occlusion
benefits from ranibizumab for macular edema following following intravitreal anti-VEGF therapy. ActaOphthalmol.
branch retinal vein occlusion: 12-month outcomes of a phase 2010 Mar;88(2):263-6.
III study. Ophthalmology 2011; 118(8):1594-602. 34. Leung LS, Silva RA, Blumenkranz MS, Flynn HW Jr, Sanislo
16. Heier JS, Campochiaro PA, Yau L, Li Z, Saroj N, Rubio RG, SR: Macular infarction following intravitrealbevacizumab for
Lai P. Ranibizumab for Macular Edema Due to Retinal Vein treatment of central retinal vein occlusion. Ophthalmic Surg
Occlusions Long-term Follow-up in the HORIZON Trial. Lasers Imaging; 2012;43:e73-9
Ophthalmology 2012;11 (2):145-57. 35. Manousaridis K, Talks J.Macularischaemia: a
17. Fung AE.Influence of Baseline Characteristics and Dosing on contraindication for anti-VEGF treatment in retinal vascular
Outcomes of Anti-VEGF Therapy for Retinal Vein disease? Br J Ophthalmol. 2012 Feb;96(2):179-84

144 Ophthalmology Update Vol. 11. No. 2, April-June 2013

Anti-Angiogenics in Vaso-Occlusive Disorder of Retinal Vein

36. Binder S.Loss of reactivity in intravitreal anti-VEGF therapy: S, Frémeaux-Bacchi V, Hiesse C, Delahousse M. Systemic
tachyphylaxis or tolerance? Br J Ophthalmol 2012;96:1-2. and kidney toxicity of intraocular administration of vascular
37. Campbell RJ, Gill SS, E Bronskill SE, Paterson JM, Whitehead endothelial growth factor inhibitors. Am J Kidney Dis
M, Bell CM. Adverse events with intravitreal injection of 2011.;57(5):756-9
vascular endothelial growth factor inhibitors: nested case- 41. Sorenson CM, Sheibani N. Anti–Vascular Endothelial Growth
control study. BMJ2012;345:e4203 Factor Therapy and Renal Thrombotic Microangiopathy.
38. Ranibizumab and retinal vein occlusion. Too many ArchOphthalmol2011.;129(8):1082.doi:10.1001/archo-
outstanding questions. Prescrire Int. 2012;21(130):207. phthalmol. 2011.199.
39. Puche N, Glacet A, Mimoun G, Zourdani A, Coscas G, 42. Brand CS. Management of retinal vascular diseases: a patient-
SoubraneG.Intravitrealranibizumab for macular oedema centric approach. Eye (Lond). 2012; 26(S2): S1–S16
secondary to retinal vein occlusion: a retrospective study of 43. Lang GE. New developments in the pharmacological
34 eyes. ActaOphthalmol. 2012 Jun;90(4):357-61. treatment of macular oedema due to retinal vein occlusion.
40. Pellé G, Shweke N, Duong Van Huyen JP, Tricot L, Hessaïne Klin Monbl Augenheilkd. 2011 Sep;228(9):793-800.

Mydriasis in the
Garden
Aaron Vunda, M.D.
Gabriel Alcoba, M.d.
University Hospitals of Geneva
Geneva, Switzerland

A healthy 3-year old boy was

brought to our emergency
department because of an acutely
dilated right pupil, which
developed after he had played in
the garden. Half an hour before
presentation his parents noticed
he had been crying. They reported no fall and no ocular or head trauma. The right eye showed no
pupillary light reflex and no accommodation. Physical examination was otherwise normal. A detailed
history revealed that he had touched and held a flower from an angel’s trumpet plant and then
rubbed his right eye. Angel’s trumpet, a member of the genus brugmansia, is an ornamental plant
from South America that is increasingly found worldwide and contains para-sympatholytic alkaloids
such as scopolamine, hyoscyamine, and atropine. In cases of sudden, unilateral, non-reactive
mydriasis in healthy children, exposure to angel’s trumpet should be suspected. Severe intoxication
resulting from ingestion can lead to hallucinations, hyperthermia, convulsions, flaccid paralysis, and
death. In the absence of any other sign of toxicity, we reassured the parents and discharged the
child. The mydriasis disappeared spontaneously within 3 days.

Ophthalmology Update Vol. 11. No. 2, April-June 2013 145

 Review Article

Frequency of Intraocular Pressure Changes

after Phacoemulsification in Patients
having Age Related Cataract
Dr Amir Naseem
(A study of 130 patients)
Amir Naseem MBBS1, Naseer Ahmad DOMS2, Faisal Nawaz Khan FCPS3
Romana Rahman MBBS4, Muhammad Idris MBBS5

ABSTRACT
Objective: To determine the frequency of Intraocular pressure changes after Phacoemulsification in patients having age
related cataract.
Materials and Methods: This study was conducted at ophthalmology department, PGMI, Lady Reading Hospital, Peshawar,
from 15 th Sep, 2010 to 15 th June, 2011. 130 patients suffering from age-related cataract with age range from 45 to 75years
were selected, mean age of the patients were 52 years with standard deviation ± 2.57,in which 69 (53%) were male and
61 (47%) were female. Informed consent was obtained from each patient. A proper proforma was designed for evaluation
and documentation of patients. Anterior segment and if possible posterior segment examination was done with direct,
indirect ophthalmoscope and slit lamp bimicroscopy. Biometry and viral profile was done. All the patients were operated
by Phacoemulsification and intraocular lens were implanted in the capsular bag. Pre and postoperative intraocular pressure
was measured with the help of applanation tonometer. The first postoperative intraocular pressure was taken as final
reading.
Results:In this study mean age of the patients was 52 years with standard deviation ± 2.57, 53% patients were male and
47% patients were female. Pre operative intra ocular pressure was analyzed as 42% patients had IOP ranged from 11-16
mmHg and 58% patients had IOP ranged from 17-21 mmHg. Post operatively change in the intra ocular pressure was
increased in 36% patients by 5 mmHg or more while in 64% patients IOP remained the same.
Conclusion: Increase in intraocular pressure occurs frequently after uncomplicated phacoemulsification cataract surgery
performed for patients with age related cataract. This rise in intraocular pressure can cause damage to the ocular structures.
Intraocular pressure is not routinely measured after phacoemulsification. It is recommended that intraocular pressure
should be measured on the first postoperative day after phacoemulsification routinely. Moreover, the patients should also
be given pressure lowering medicines in the postoperative period after phacoemulsification to prevent ocular damage
due to intraocular pressure spikes.
Key words:
Intraocular Pressure, phacoemulsification, age related cataract.

INTRODUCTION by the year 20102. Cataract is also the most common

Any congenital or acquired opacity in lens capsule cause of blindness (51.5%) in Pakistan3. According to a
or its substance, irrespective of the effect on vision is study the prevalence of age related cataract in Pakistan
called cataract. It is divided mainly into congenital and is 20.9%4.
acquired types of the acquired type the most is age Visually significant cataracts can lower quality of
related cataract. Age related cataract is the one which life related to health due to its effects on visual,
is associated with aging1. functional, and psychological disability5 .Cataract
Cataract is the leading cause of blindness in the surgery is the most common refractive surgery
world affecting approximately 20 million people and performed in aging individuals6.Three main methods
this figure was expected to increase to 50 million people of surgery for management of cataract are
phacoemulsification, extra capsular cataract extraction
————————————————————————————————
1.2.
Resident Medical Officer LRBT Secondary Free Eye Hospital
and manual small incision cataract surgery 1 .
Mansehra .3.Associate Ophthalmologist LRBT Secondary Free Eye Phacoemulsification, which was introduced by Kelman
Hospital Mansehra 4. Trainee Medical Officer, Ophthalmology, PGMI, in 1967, has become the main surgical procedure for
Lady Reading Hospital, Peshawar5.Medical Officer, Ophthalmology, the management of cataract7.Rise in intraocular pressure
PGMI, Lady Reading Hospital, Peshawar.
————————————————————————————————
(IOP) occurs frequently after uncomplicated
Corresponding address: Dr. Amir Naseem, Resident Medical Officer phacoemulsification surgery8.Pressure rise to more than
LRBT Secondary Free Eye Hospital Mansehra. 30 mm Hg with in the first 24 hours post operatively
E.Mail>[email protected] are also well reported9.Ophthalmic visco surgical
————————————————————————————————
Received : Dec’2012 Accepted ; March’2012
devices (OVDs) plays many important functions in
———————————————————————————————— phacoemulsification, which includes facilitation of

146 Ophthalmology Update Vol. 11. No. 2, April-June 2013

Frequency of Intraocular Pressure Changes after Phacoemulsification in Patients having Age Related Cataract

capsulorrhexis, maintenance of anterior chamber, mostly in age range from 51-60 years followed by
protection of corneal endothelium, acting as temponade 37(28%) patients above 60 years and 34(26%) patients
for intraocular structures, protection of posterior were in age range from 40-50 years. Mean age was 52
capsule from sharp edge of broken nuclear fragments, years with standard deviation ± 2.57. (Table I) Gender
and filling of capsular bag before Intraocular lens distribution among patients 69 (53%) were male while
implantation OVDs used in phacoemulsification can 61(47%) patients were female. (Table II)
cause various adverse effects, the most common and Visual acuity findings among patients 102 (78%)
potentially dangerous of them is the transient rise in ranged from < 6/18 – 6/60 while 28(22%) patients had
IOP in post-operative period. OVDs cause elevation of visual acuity ranged from counting fingers to
IOP in the postoperative period due to clogging of perception of light. (Table III)
trabecular meshwork10. Preoperative intra ocular pressure (IOP) in 55
Phacoemulsification is the surgical procedure of (42%) patients ranged from 11-16 mmHg while in 75
choice for management of age related cataract and rise (58%) patients it was from 17-21 mmHg. Mean intra
in IOP is one of the common complications of this type ocular pressure (IOP) was 17 mmHg with standard
of surgery. IOP is not routinely checked after deviation ± 1.34 (Table IV). Post operatively change in
phacoemulsification. The rationale of our study is to the intra ocular pressure was analyzed as in 47 (36%)
find out the change in IOP postoperatively in patients patients intra ocular pressure had increased by 5 mmHg
having age related cataract undergoing or more. while in 83 (64%) patients Intra ocular pressure
phacoemulsification and to make it a routine practice was not changed. Mean intra ocular pressure after the
to check IOP postoperatively because high IOP may change was 19 mmHg with standard deviation ± 2.78
damage the ocular structures and this damage may be (Table V)
irreversible. Postoperative change in the intra ocular pressure
MATERIALS AND METHODS among 47(36%) patients was compared with age
This cross sectional study was conducted in distribution as IOP was increased by 5mmHg or more
department of Ophthalmology, PGMI, Lady Reading in 10(8%) patients who were in age range between 40-
Hospital, Peshawar, from 15th Sep, 2010 to 15th June, 50 years, 24(18%) patients who were in age range from
2011. 130 patients suffering from age related cataract 51-60 years and 13(10%) patients who were above 60
with age range from 45 to 75years were selected, mean years of age. (Table VI)
age of the patients were 52 years with standard Postoperative change in the intra ocular pressure
deviation ± 2.57, in which 69 (53%) were male and 61 among 47(36%) patients was compared with gender
(47%) were female (Table II). distribution as IOP was increased by 5mmHg or more
Preoperative visual acuity (Table III) and in 23(18%) male patients and in 24(18%) female patients.
intraocular pressure (Table IV) were checked. Informed (Table VII) Postoperative change in the intra ocular
consent was obtained from each patient. A proper pressure among 47(36%) patients was further analyzed
proforma was designed for evaluation and as IOP was increased by 5mmHg or more in 22(17%)
documentation of patients. patients who had IOP ranged from 11-16 mmHg and
Anterior segment and if possible posterior 25(19%) patients who had IOP ranged from 17-21
segment examination was done with direct, indirect mmHg. (Table VIII)
ophthalmoscope and slit lamp bimicroscopy. Biometry
and viral profile was done. All the patients were Table I showing age wise distribution. Total 130
operated by Phacoemulsification and IOL were
implanted in the posterior chamber. Diabetics, Age wise distribution Frequency Percentage
hypertensive, glaucomatous, old cases of ocular trauma 40 to 50 years 34 26%
and co-ocular morbidity patients were excluded from
51-60 years 59 46%
the study.
Pre and postoperative intraocular pressure was More than 60 years 37 28%
measured with the help of applanation tonometer. The Total 130 100%
first postoperative intraocular pressure was taken as a
Table II showing gender wise distribution. Total 130
final reading.
RESULTS
Gender Frequency Percentage
This study was conducted at Department of
Male 69 53%
Ophthalmology, PGMI, Lady Reading Hospital,
Peshawar. A total of 130 patients were included in this Female 61 47%
study. Age distribution among patients 59(46%) were Total 130 100%

Ophthalmology Update Vol. 11. No. 2, April-June 2013 147

Frequency of Intraocular Pressure Changes after Phacoemulsification in Patients having Age Related Cataract

DISCUSSION the first 24 hours post operatively.

Our study shows that increase in intraocular Our results shown that most of the patients 46%
pressure (IOP) occurs frequently after uneventful were in age ranged from 51-60 years, 28% patients were
phacoemulsification surgery. IOP raises in the above 60 years and 26% patients were in age ranged
postoperative period after phacoemulsification, with a from 40-50 years. Similar results were found in study
mean increase between 5mm Hg and 13 mm Hg. done by Waseem et al in which 50% patients were in
Pressure spikes to even more than 30 mm Hg with in age ranged from 51-60 years, 22% patients were above
60 years and 28% patients were in age ranged from 40-
Table III showing preoperative visual acuity. Total 130
50 years.10
Visual acuity Frequency Percentage
In our study there was no significant difference
in gender distribution as 53% patients were male and
< 6/18 – 6/60 102 78% 47% patients were female. Similar results were found
CF – PL +ve 28 22% in study conducted by Waseem et al in which 50%
Total 130 100%
patients were male and 50% patients were female.10
Our results shows that 78% patients had visual
Table IV showing Preoperative IOP distribution. Total 130 acuity ranged from <6/18 – 6/60 while 22% patients
had visual acuity ranged from counting fingers to
Pre-operative IOP Frequency Percentage perception of light. Similar concept has been explained
in Unal M et al.8 In his study 80% patients had visual
11-16 mmHg 55 42%
acuity ranged from < 6/18 – 6/60 while 20% patients
17-21 mmHg 75 58% had visual acuity ranged from counting fingers to
Total 130 100% perception of light.8
Our study shows that 42% patients had Intra
Table V showing Postoperative IOP change. Total 130 ocular pressure (pre operatively) ranged from 11-16
mmHg while 58% patients had Intra ocular pressure
Change in Frequency Percentage (pre operatively) ranged from 17-21 mmHg. Similar
Pos-operative IOP results were coated in study done by Antano SF et al in
Yes 47 36% which 38% patients had Intra ocular pressure (pre
No 83 64% operatively) ranged from 11-16 mmHg while 62%
patients had Intra ocular pressure (pre operatively)
Total 130 100%
ranged from 17-21 mmHg.9 Unal M et al had shown
Table VI showing Post operative change in IOP versus Age wise distribution

Change in IOP Versus Age distribution Pts with no change in IOP Pts with change in IOP Total Patients

40 to 50 years 24 (18%) 10 (8%) 34 (26%)

51-60 years 35 (28%) 24 (18%) 59 (46%)

More than 60 years 24 (18%) 13(10%) 37(28%)

Table VII showing Postoperative change in IOP versus gender distribution

Change in IOP versus Gender distribution Patients with no change in IOP Patients with change in IOP Total Patients

Male 46 (35%) 23 (18%) 69 (53%)

Female 37 (29%) 24 (18%) 61 (47%)

Total 83 (64%) 47(36%) 130

Table VIII showing Post operative change in IOP

Change in IOP Patients with no change in IOP Patients with change in IOP Total Patients
11- 16 mmHg 33 (25%) 22 (17%) 55 (42%)

17- 21 mmHg 50 (39%) 25 (19%) 75 (58%)

Total 83 (64%) 47(36%) 130

148 Ophthalmology Update Vol. 11. No. 2, April-June 2013

Frequency of Intraocular Pressure Changes after Phacoemulsification in Patients having Age Related Cataract

that occurrence of intraocular pressure rise after CONCLUSION

phacoemulsification is (9 out of 43 patients) which was Increase in intraocular pressure occurs frequently
nearly 21%.8 Our results shows that rise in intra ocular after uncomplicated phacoemulsification surgery
pressure was found in 36% patients which was due to performed in patients with age related cataract. This
lack of knowledge and facilities. Similar results were rise in intraocular pressure can damage ocular
also coated in another study done by Antano SF et al in structures. Intraocular pressure is not routinely
which 25% incidence of rise in intraocular pressure after measured after phacoemulsification. It is recommended
phacoemulsification was recorded.9 that intraocular pressure should be measured on the
Our results shown that there is no significance of first post operative day that is 24 hours after
age in rising intra ocular pressure after phacoemulsification routinely. More over the patients
phacoemulsification because in our study IOP was should also be given pressure lowering medicines in
increased by 5mmHg or more in 8% patients who were the post operative period after phacoemulsification to
in age ranged from 40-50 years, 18% patients who were prevent ocular damage due to intraocular pressure
in age ranged from 51-60 years and 10% patients who spikes.
were above 60 years of age. Similar concept was REFERENCES:
explained in study done by Unal M and Antano in their 1. Kanski JJ. Lens. Kanski. Clinical Ophthalmology. 7 th ed.
Philadelphia (USA). Elsevier. 2011:7(9),269-309.
studies.8, 9 2. Zaman M, Iqbal S, Khan YM, Khan MT, Jadoon MZ, Qureshi
Our study also shows that there is no significant MB, et al. Manual small incision cataract surgery (MSICS).
difference of gender in rising intra ocular pressure after Review of first 500 cases operated in microsurgical training
phacoemulsification because in our study IOP was center. Pak J Ophthalmol. 2006; 22:14-22.
3. Dineen B, Bourne RR, Jadoon Z, Shah SP, Khan MA, Foster
increased by 5mmHg or more in 18% male patients A, et al. Cause of blindness and visual impairment in
while on the other hand IOP was increased by 5 mmHg Pakistan. The Pakistan National Blindness and Visual
or more in 18% female patients. Similar finding were Impairment Survey. Br J Ophthalmol. 2007; 91:1005-10.
observed in study done by Unal M in which IOP was 4. Shah SP, Dineen B, Jadoon Z, Bourne RR, Khan MA, Johnson
GJ, et al. Lens opacities in adults in Pakistan prevalence and
increased up to 6mmHg in 20% male patients and 17% risk factors. Ophthalmic Epidemiology. 2007; 14:381-9.
in female patients.8 In another study done by Antano 5. Grace M, Richter BA, Jessica C, Stanley P. Prevalence of
had shown increase in IOP was found in 22% male visually significant cataract and factors associated with
patients and 23% in female patients. 9 unmet need for cataract surgery. Ophthalmology. 2009;
116(12):2327–35.
Our study shows that IOP was increased by 6. Bellan L. The evolution of cataract surgery: The most common
5mmHg or more in 17% patients who had IOP ranged eye procedure in older adults. Geriatrics Aging. 2008; 11:328-
from 11-16 mmHg and 19% patients who had IOP 32.
ranged from 17-21 mmHg. Similar results were shown 7. Asbell PA, Dualan I, Mindel J, Brocks D, Ahmed M, Epstein
S. Age-related cataract. Lancet 2005; 365(59):599-609.
in study done by Antano in which IOP was increased 8. Unal M, Yücel I. Effect of bimatoprost on intraocular pressure
by 5mmHg or more in 16% patients who had IOP after cataract surgery. Can J Ophthalmol 2008; 43(6):712-6.
ranged from 11-16 mmHg and 14% patients who had 9. Antano SF, Kasaby H. Evaluation of intraocular pressure at
IOP ranged from 17-21 mm Hg.9 Similar results were the end of cataract surgery. J Cataract Refract Surg 2008;
34:258-61.
also quoted in another study done by Waseem et al in 10. Waseem M, Rustam N, Islam QU. Intraocular pressure after
which IOP was increased up to 5mm Hg in 15% patients phacoemulsification using hydroxyl propyl methylcellulose
who had IOP ranged from 11-16 mm Hg and 13% and sodium hyaluronate as viscoelastics. J Ayub Med College
patients who had IOP ranged from 17-21 mm Hg.10 2007; 19(1):42-5.

Ophthalmology Update Vol. 11. No. 2, April-June 2013 149

 Review Article

Manual Extracapsular Cataract surgery,

review of 1150 cases operated in
Dr. Ihsan Ullah
District Headquarter Hospital, Battagram
Ihsan Ullah, FCPS 1, Prof. Syed Ashfaq Ali Shah, FCPS 2

ABSTRACT
Purpose: To evaluate complications and visual improvement in patients undergone extracapsular cataract extraction in
District Head Quarter Hospital, Battagram, Khyber Pakhtoonkhawa.
Material and Methods: A total of 1150 patients having cataracts were examined from outpatient department of District
Head Quarter Hospital, Battagram from October 2009 to December 2010. Patients were thoroughly examined and
investigated. All patients underwent manual extracapsular cataract extraction with intraocular lens implantation by the
same surgeon. Intraoperative, postoperative complications and visual acuity at the end of 1 st, 2nd , 4th, 6th week and after
removal stitches, were noted.
Results: Of the total 1150 patients 972 completed 6 weeks for follow up period. The most common intraoperative
complication was posterior capsular rent that occurred in 23(2%) cases followed by rise of intraocular pressure in 7
(0.6%) cases. Corneal edema was the most common postoperative complication, occurred in 26(2.26%) cases followed
by iris prolapse 9(0.78%), inflammatory glaucoma 3(0.26%), IOL drop 2(0.17%) and endophthalmitis in 2(0.173%) cases.
Visual acuity of better then 6/60 achieved in 94.54% of patients.
Conclusion: Manual extracapsular cataract extraction with IOL is a safe and effective technique for the treatment of
cataract in peripheral set up.

INTRODUCTION extraction at country hospital are not excellent, but the

Cataract accounts for 80% cases of avoidable surgical complications are minimal. On the other hand
blindness affecting an estimated 20 million people 1. the visual outcomes of patients who undergo
Cataract surgery is possibly the oldest surgical phacoemulsification are good, but the complications
procedure and now is the most frequently performed rates are slightly higher 6. Extracapsular cataract
surgical procedure in the world 2. Cataract surgery extraction can result in various intraoperative and
continue to evolve over time, embracing smaller incision postoperative complications. Intraoperative
that allow quicker recovery, better wound strength and complications can be posterior capsular rent with or
increased surgical control, resulting in lower without vitreous prolapse, posterior loss of lens
complication rate and better visual outcomes3. To fragments, posterior dislocation of intraocular lens,
manage the large backlog of cataract blindness sudden rise of intraocular pressure or even
effectively, cost effective, high quality and high volume suprachoroidal hemorrhage 7, 8 . Postoperative
surgery is needed in community eye care centers. The complications can be corneal edema, iris prolapse,
cost effectiveness is related to short operative time, inflammatory glaucoma, endophthalmitis, posterior
potential for high volume, high success rates and the capsular opacification, malpositioning of intraocular
low cost of consumables 4. However when success rates lens, cystoid macular edema or even retinal
are low, cost effectiveness is reduced 5. Procedures detachment7, 9.
which are affordable, practicable, applicable and The aim of this study is to review various
sustainable everywhere can be adopted to obtain good complications which have occurred intraoperatively or
surgical and visual outcomes in the setting of postoperatively and final visual outcome in patients
developing countries. The visual outcomes of patients undergoing extracapsular cataract extraction in our
who undergo conventional extracapsular cataract rural setting.
MATERIAL AND METHODS.
————————————————————————————————
1
.District Ophthalmologist, District Headquarters Hospital, This non-randomized interventional study was
Battagram.2. Professor of Ophthalmology, Ayub Medical Complex, conducted at Comprehensive Eye Care Unit of District
Abbot Abad Head Quarter Hospital, Battagram, Khyber
————————————————————————————————
Pakhtoonkhawa from October 2009 to December 2010.
Correspondence: Dr. Ihsan Ullah, FCPS District Ophthalmologist,
District Head Quarter Hospital, Battagram KPK A total of 1150 patients were operated by a single
———————————————————————————————— surgeon using the same technique for all the patients,
Received: Dec’2012 Accepted Feb’2013 included after obtaining their informed consent.
————————————————————————————————

150 Ophthalmology Update Vol. 11. No. 2, April-June 2013

Manual Extracapsular Cataract surgery review of 1150 cases operated in District Headquarter Hospital Battagram

Inclusion criteria: these patients the most common cause was cough and
All patients with operable cataracts in one or both breathing difficulty (Table 5).
eyes affecting their routine activities. Postoperative complications were in following
Exclusion criteria: order of frequency, Corneal edema 26 (2.26%), iris
i. Patients with afferent papillary defect, total and prolapse 9 (0.78%), endophthalmitis 2(0.173%), pupil
relative. block inflammatory glaucoma 3(0.26%) and Intraocular
ii. Central corneal opacities lens drop 2(0.17%). (Table: 6)
Patients were admitted through OPD. Thorough Final visual acuity achieved at 6th weeks after
preoperative evaluation was carried out with Snellen removal of stitches were good in (6/6- 6/9) in
chart or light perception or projection, Slit lamp, direct 677(69.65%) patients, fair (6/9-6/18) and in 184
and indirect ophthalmoscopes. (18.93%) these patients had either developed
Systemic evaluation including blood pressure
check up and diabetes screening were done. Blood Table 1: Gender distribution
samples of all patients were tested for Hepatitis B and
C viruses. Keratometry and intraocular lens powers Sex Number of patients %age
were calculated. Two types of anesthesia was used i.e. Male 656 57.04%
peribulbar and subconjunctival anesthesia depending
Female 494 42.90%
upon the patients choice and tolerability. In cases of
peribulbar anesthesia ocular compression was achieved Table 2: Visual impairment at presentation
through compressed cotton balls.
Conventional extracapsular cataract extraction Level of visual impairment Number of patients %age
with posterior chamber intra ocular lens implantation
was the surgical procedure. Intraoperative Severe (6/60 or worse) 897 78%
complications were noted. Post operative follow up was Moderate(6/24-6/18) 207 18%
carried out on 1st, 2nd, 4th and 6th weeks. Final visual Mild (6/18-6/9) 46 4%
acuity on the last follow up after removal of stitches
was noted. Table 3: Cataract morphological presentation
RESULTS
Total of 1150 patients were operated. Out of these Type of cataract Number of patients %age
656 (57.04%) were male and 494(42.9%) were females
Mature 908 78.9%
(Table 1). Mean age was 58 years. Hence comprehensive
eye care unit of District Headquarters Hospital, Cortical 138 12%
Battagram is a unit where all surgical consumables like Nuclear 69 6%
intraocular lenses, sutures, viscoelastics etc are
Sub capsular 35 3.04%
provided free of cost. To get benefits of these free
facilities patients come from far flung areas. Table 4: Associated co-morbidities
Preoperative visual acuity of 6/60 or less was
noted in 78%, 6/18-6/60 in 18% and 6/9-6/18 in 4% of Morbidities Number %age
cases (Table 2). Mature cataract was the most common
Systemic hypertension 59 5.12%
presentation i.e. 908 (78.9%) of cases, followed by
cortical 138 (12%), nuclear 69 (6%) and posterior sub- Diabetes mellitus 41 3.6%
capsular in 35 (3.04%) of cases (Table 3). Glaucoma 36 3.12%
The most common associated diseases were
Pterygium 20 1.73%
systemic hypertension in 59 (5.12%), diabetes mellitus
in 41 (3.6%), glaucoma in 36 (3.12%), pterygium in 20 Chronic Dacryocystitis 26 2.26%
(1.73%) and chronic dacryocystitis in 26 (2.26%). HBsAg Hepatitis B +ve 9 0.78%
positive was positive in 9(0.78%) and HcV positive were
Hepatitis C +ve 93 8.03%
93 (8.03%).( Table 4)
Posterior capsular rent was the most common Table 5: Intraoperative complications
intraoperative complication occurring in 23 (2%)
patients, with out vitreous prolapse in 14 (1.21%) and Complications Number %age
with vitreous prolapse in 9 (0.78%), followed by sudden
Posterior capsular rent 23 2.0%
rise of intraocular pressure and shallowing of anterior
chamber without vitreous loss in 7(0.6%) patients, in Rise of intraocular pressure 7 0.6%

Ophthalmology Update Vol. 11. No. 2, April-June 2013 151

Manual Extracapsular Cataract surgery review of 1150 cases operated in District Headquarter Hospital Battagram

Table 6: Postoperative complications expression technique, however, is still widely used in

developing countries with large number of patients and
Complications Number %age limited hospital budgets 1, 14.
Corneal edema 26 2.26% In our study we found that incidence of
intraoperative complications closely compare with
Iris prolapse 9 0.78%
studies done by Chetkara and Smerdon .i.e. posterior
Endophthalmitis 2 0.173% capsular rupture was the most common complication
Pupil block inflammatory glaucoma 3 0.26% accounting for 2% and raise of intraocular pressure and
iris prolapse 0.6%. Ionides and Minnisan have also
Intraocular drop of lens 2 0.17%
studied intraoperative complications during
Table 7: Visual acuity after removal of stitches extracapsular cataract extraction and have noted the
posterior capsular rent to be 4% .i.e. higher that in our
Visual acuity Number %age study 15, 16. We did not come across other intraoperative
complications like posterior loss of lens fragments,
Good (6/6-6/9) 677 69.65%
nucleus drop or suprachoroidal hemorrhage.
Fair (6/9-6/18) 184 18.93% Postoperative complications with in 6 weeks of
surgery which we have encountered in our study were
intraoperative or postoperative complications or had corneal edema, iris prolapse, endophthalmitis,
some ocular disease like corneal opacity or age related inflammatory glaucoma and intraocular lens drop.
macular degeneration, poor (6/24-6/60), in 58(5.96%) Allen and Zhang in their study” extracapsular cataract
in these causes were the same as mentioned earlier, very extraction: prognosis and complications with and
poor (6/60), hand movement in 41(4.21%) and just without posterior chamber intraocular lens
perception of light in 12(1.26%) in these patients causes implantation “ have also noted these complications
were retinal detachment, advanced age related macular nearly in the same rate as in our study except an
degeneration and optic atrophy.( Table. 7) were the inflammatory glaucoma which they have not
main causes of total 1150 patients; 178 patients did not observed 17 . In our study the only reason for
complete their follow up. inflammatory glaucoma, pupil block, was non-
DISCUSSION compliance of those patients with postoperative
In developing countries blindness caused by medications.
cataract accounts for 90% of cases 10 . Even though lots In our study we have looked for the visual acuity
of medical treatment for cataract have been studied and after 6 weeks and removal of stitches. Most of patients
many treatment modalities are described 11 there is no i.e. 71.8% have achieved good vision, 20.98% fair vision,
medical treatment that has definitely been proven to 5.96% poor vision, these patients had mostly
delay, prevent or reverse the development of cataract preoperative reasons for poor vision like corneal
in adults. Currently, therefore, the only treatment opacities, age related macular degeneration or
available for cataract is surgery. glaucoma. Few patients had poor vision due to
The first extra capsular cataract extraction was intraoperative or postoperative complications. These
performed by a French surgeon Jacques Daviel in 175312. results are comparable with studies conducted by
In 1865, the German Ophthalmologist Von Graefe Tesfaye and his co-workers and Albanis and Earnes.
refined the operation by removing the lens through a CONCLUSION
much smaller linear incision in the sclera. The two Manual Extracapsular Cataract Extraction with
inventions that made extracapsular cataract extraction intraocular lens implantation is a safe and effective
preferable again were the operating microscope and the technique for the treatment of cataract in peripheral set
intraocular lens. The first eye surgery performed with up.
an operating microscope was done in Portland, Oregon, REFERENCES
in 1948; in the same year, a British Ophthalmologist 1. Zaman M, Iqbal S, Tariq M. Manual small incision cataract
surgery review of 500 cases operated in microsurgical training
named Harold Ridely implanted the first intraocular center. Pak J Ophthalmol 2006; 22: 14.
lens in the eye of cataract patient13. Between 1948 and 2. Yortson D, Gichuhi S. Does prospective monitoring improve
1980s, manual expression was the standard form of cataract surgery outcome in Africa. Br J Ophthalmol 86; 534:
extracapsular cataract extraction. Although phaco- 1-1.
3. Mark R, Willikin S. Use of glasses common after cataract
emulsification was first introduced in 1967, it was not surgery.Br Med J 2000; 321: 1304.
widely accepted at first because it requires special 4. Limbert H, Foster A, Gilbert C. Routine monitoring of visual
technique that takes time for the surgeon to learn as outcome of cataract surgery. Br J Ophthalmol 2005; 84: 45.
well as expensive specialized equipments. The manual 5. Sing AJ, Garner P, Floyed K. Cost effectiveness of public

152 Ophthalmology Update Vol. 11. No. 2, April-June 2013

Manual Extracapsular Cataract surgery review of 1150 cases operated in District Headquarter Hospital Battagram

funded option for cataract surgery in Mysore, India. Lanset phacoemulsification and manual extracapsular cataract
2000. 355: 180-4. extraction. J Cataract Refract Surg 2003; 532-36.
6. Albanis CV, Dwyer MA, Earnes JT. Outcomes of ECCE and 13. Guzek J Ching A. Small-incision Manual Extracapsular
phacoemulsification performed in university training Cataract Surgery in Ghana, West Africa. J Cataract Refract
program. Ophthalmic Surg Laser 1998; 29(8): 643-8 Surg 2003; 57-64.
7. Kanski JJ. Lens. Kanski JJ Clinical Ophthalmology: A systemic 14. Alexandraxis G, Balachander R. Simultaneous bilateral
approach. 6th ed. Edinburg: Butterworth Henmann 2006; 12: Extracapsular Cataract extraction. Ann Ophthalmol 1987; 21:
313-67. 564-68.
8. Mpyet C. Extracapsular cataract extraction with and without 15. Chitkara DK, Smerdon DL. Risk factors, complications and
IOL implantation: Visual outcomes and complications. results in Extracapsular Cataract extraction. J Cataract Refract
Nigerian J Ophthalmol; 14: 9-12. Surg 1997; 24(4): 570-4.
9. Dorothy S, Fan P, Kenneth K. Retinal complications after 16. Ionides A, Minnasain D, Tuft S. Visual outcome following
cataract extraction in patients with high myopia. Ophsource posterior capsular rupture during cataract surgery. Br J
1998; 1069(4):688-92. Ophthalmol 2001; 85: 222-4.
10. Thylefors B. Avoidable blindness. Bull World Health Org 17. Allen AW, Zhang HR. Extracapsular cataract extraction:
1999; 77(6): 453. prognosis and complications with and without posterior
11. West SK, Valmadrid CT. Epidemiology of risk factors for age chamber intraocular lens implantation. Ann Ophthalmol
related cataract. Surv Ophthalmol 1995; 39: 323-34. 1987; 19(9) : 329-33
12. Basti S, Garg M. Posterior capsular dehiscence during

Medicinal Value of Fruits

Pomegranate (Punica Granatum)

A symbol of health, fertility and long life
Zainab Inam, Nowshera
Powerful Health Benefits of the Pomegranate
Originally, a native fruit of Persia, it is a dense, antioxidant rich fruit whichhas been recognized as a symbol
of health, fertility and long life. It contains high levels of flavonoids and polyphenols, potent antioxidants offering
protection against heart disease and cancer. A glass of pomegranate juice has more antioxidants than green
tea, blueberries, and cranberries.
This fantastic little fruit is full of compounds called punicalagins, to benefit the heart and blood vessels.
They not only lower cholesterol, but also lower blood pressure and increase the speed at which heart blockages
(atherosclerosis) melt away.
Recent medical research studied heart patients with severe carotid artery blockages. They were given an
ounce of pomegranate juice each day for a year. Not only did the participants’ blood pressure lower by over 12
percent, but there was a 30 percent reduction in atherosclerotic plaque. In another studies, potent antioxidant
compounds found in pomegranates have shown to reduce platelet aggregation and naturally lower blood pressure,
factors that prevent both heart attacks and strokes.
Not only are pomegranates good for your heart and blood vessels, they have been shown to inhibit breast
cancer, prostate cancer, colon cancer, leukemia and to prevent vascular changes that promote tumor growth in
lab animals. Several in vitro studies have shown this remarkable anti-cancer effect. Pomegranate juice contains
phytochemical compounds that stimulate serotonin and estrogen receptors, improving symptoms of depression
and increasing bone mass in lab animals. Those who are looking to prevent these ailments incorporate the
powerful components of pomegranates into their diet.
• Most powerful anti-oxidant of all fruits
• Potent anti-cancer and immune supporting effects
• Inhibits abnormal platelet aggregation that could cause heart attacks, strokes and embolic disease
• Lowers cholesterol and other cardiac risk factors
• Lowers blood pressure
• Shown to promote reversal of atherosclerotic plaque in human studies
• May have benefits to relieve or protect against depression and osteoporosis.
For those who still have LDL cholesterol above 100 mg/dl after dietary intervention, Scientists designed
the mixture of high quality plant sterols and pomegranate (LDL Protect) as cholesterol-lowering and cardiac
protective compounds. No other product in the market offers this combination of ingredients.

Ophthalmology Update Vol. 11. No. 2, April-June 2013 153

 Review Article

Visual acuity and Intraocular Pressure changes after

Nd: YAG Laser Posterior Capsulotomy
Dr. Faisal Nawaz
Faisal Nawaz Khan1, Naseer Ahmad2, Mohammad Alam3, Amir Naseem4
Mohammad Idris5

ABSTRACT
Objective: To evaluate the change in visual acuity and IOP after Nd: YAG laser posterior capsulotomy.
Material and Method: This cross sectional study was conducted at out patient department of LRBT Free Secondary Eye
Hospital Mansehra from May to November 2012. In this study 200 patients were included who had posterior capsular
opacity (PCO) after cataract surgery. All the patients had undergone Nd: YAG laser posterior capsulotomy, Visual acuity
and IOP were checked before the procedure, one hour after the procedure and one week after the procedure (as a final
reading of visual acuity and IOP).
Results: In this study the mean age of the patients was 58.58 years with standard deviation ±11.56 SD.60% patients
were male while 40% patients were female. Improvement in the final visual acuity was present in 84.5% of the patients
while 15.5% patients showed no improvement in the final visual acuity. Regarding the change in IOP after NdYAG laser
posterior capsulotomy, 104(52%) patients showed no change in IOP, 68 (34%) patients showed 1-4 mmHg increase in
IOP,while 28(14%) patients showed increase of more than 5mmHg in IOP which needed special attention and regular
follow up till IOP was controlled.
Conclusion: The results of the study suggests that visual acuity in patients who had developed posterior capsular opacity
after cataract extraction with posterior chamber intraocular lens implantation is better after Nd: YAG laser posterior
capsulotomy than the visual acuity before the use of Nd: YAG laser posterior capsulotomy. Regarding the change in IOP
after Nd:YAG laser posterior capsulotomy, 104(52%)of the patients showed no change in IOP, 68 (34%) patients showed
1-4 mmHg increase in IOP, while 28(14%) patients showed increase of more than 5mmHg in IOP which needed special
attention and regular follow up till IOP was controlled.
Abbreviation / Key words: IOP (Intra ocular pressure), Nd: YAG laser (Neodymium: Yatrium Aluminium Garnet laser),
PCO (Posterior Capsular Opacity), VA (Visual Acuity)

INTRODUCTION: Nd: YAG laser works on the principle of

Posterior capsular opacification is one of the major photodisruption. The laser shots produce plasma
complications after the extracapsular cataract extraction around the target spot which bursts producing a shock
or phacoemulsification 1. Posterior capsular wave resulting in a hole in the posterior capsule6. The
opacification is caused by proliferation and migration Nd: YAG laser in pulse mode was adopted for use in
of residual lens epithelial cells which can produce visual ophthalmology, and the first posterior capsulotomy in
loss through two mechanisms2. They can form swollen, the human eye was performed 7. The Nd: YAG laser
abnormal shaped lens cell called Elschnig’s pearls, capsulotomy is a very simple procedure which can be
which migrate over the posterior capsule onto the visual performed on outdoor basis, it saves a lot of effort and
axis3. Capsular fibrosis, due to fibrous metaplasia of time both on the part of surgeon as well as patient. The
epithelial cells, is less common and usually appears rise in intraocular pressure can be controlled by using
earlier than Elschnig’s pearls. Standard treatment of topical ß-blockers 8. Topical 0.5% timolol maleate and
posterior capsular opacification consists of making an 0.5% levobunolol are ß-blockers, which are known to
opening in the posterior capsule using Neodymium: effectively control the rise of intraocular pressure 9 and
YatriumAluminium Garnet laser (Nd: YAG laser)4,5. are used twice daily. All the ß-blockers are the preferred
———————————————————————————————— medication in lowering IOP after YAG laser
1.
Associate Ophthalmologist LRBT Free Secondary Eye Hospital capsulotomy because of their easy dosage and reliable
Mansehra2.Resident Medical Officer LRBT Free Secondary Eye results. This study was conducted to evaluate the
Hospital Mansehra3. Senior Registrar Ophthalmology department
PGMI, Lady Reading Hospital Peshawar,4.Resident Medical Officer
change in visual acuity and intra ocular pressure (IOP)
LRBT Free Secondary Eye Hospital Mansehra KPK.5.Medical officer, after Nd: YAG laser posterior capsulotomy.
Ophthalmology Department PGMI, Lady Reading Hospital Peshawar MATERIAL AND METHODS:
———————————————————————————————— This study was conducted at out patient
Correspondence:Dr.Faisal Nawaz Khan Associate Ophthalmologist
LRBT Free Secondary Eye Hospital Mansehra
department of LRBT Free Secondary Eye Hospital
———————————————————————————————— Mansehra from May to November 2012. A total of 200
Received: Dec’2012 Accepted: Feb’2013 patients undergoing Nd: YAG laser posterior
————————————————————————————————

154 Ophthalmology Update Vol. 11. No. 2, April-June 2013

Visual acuity and Intraocular Pressure changes after Nd: YAG Laser Posterior Capsulotomy

capsulotomy were included in the study. Purposive according to thickness of capsule until an opening was
(non- probability sampling) technique was used in this achieved.
study. Following the capsulotomy 0.1% diclofenic
Inclusion criteria sodium (Naclof) eye drops were advised thrice in a day
1. All patients having uneventful cataract surgery for one week and anti glaucoma therapy advised when
with posterior chamber IOL implant followed by needed. Then patients were reviewed for assessment
development of posterior capsular opacification. of visual acuity and measurement of IOP one hour
2. Patients having more than six month’s follow-up after and one week after the laser treatment.
after cataract surgery. The cases that satisfied the inclusion criteria were
Exclusion criteria included. Data was entered and analyzed using SPSS
1. Patients below 20 years of age. version 10. Mean and standard deviation were
2. Patients having less than six month’s follow-up calculated for numerical variable i.e. age wise
after cataract surgery. percentages and frequencies were computed for
3. Extra capsular cataract extraction without IOL categorical variable like age of the patients and sex etc.
implantation. The entire variables were presented in the form of tables
4. Known cases of glaucoma like POAG and primary and charts. A p-value <0.05 was considered as
angle closure glaucoma (PACG) statistically significant.
5. Dislocated/sub-luxated IOL. RESULTS:
6. IOL implant in traumatic cataract. This study was conducted at out-patient
7. Patients having combined procedure department of LRBT Free Secondary Eye Hospital
(Trabeculectomy with PC IOL). Mansehra in which a total of 200 patients undergoing
8. Patients diagnosed as a case of diabetic Nd: YAG laser posterior capsulotomy were included
retinopathy or any other retinal disease. in the study and the results were analyzed.
9. Cases with postoperative complications such as Age distribution among 200 patients were
endophthalmitis. analyzed as n=48 (24%) patients were in age ranged
Approval was taken from ethical committee of between 40 – 49 years, n=50 (25%) in age range between
LRBT Central office Karachi, before starting the study. 50-59 years, n=70 (35%) in age range between 60 -69
200 patients suffering from posterior capsular opacity years and n=32(16%) in age equal or above 70 years.
in which 128 (60 %) were male and 72 (40 %) were Mean age was 58.58 years with standard deviation
female (Table I) with age ranging from 40 to 83 years ±11.56 SD. Minimum age was 40 years while maximum
were selected in which most patients (35%) were in the age was 83 years.
age ranging between 60 to 69 years (Table II). The gender distribution among 200 patients was
An informed written consent was obtained from analyzed as n= 128(60%) patients were males while
the patient. After enrollment in the study, detailed n=72(40%) patients were females. There were
history, visual acuity using Snellen’s visual acuity chart, n=113(56.5%) patients with PCO in the right eye while
slit lamp examination, IOP by Goldman applanation n=87(43.5%) patients had PCO in the left eye after
tonometer, direct and indirect ophthalmoscopy, and B cataract extraction with posterior chamber intraocular
Scan ultrasonography done in cases of dense PCO lens implantation.
carried out before YAG laser capsulotomy. The patients The pre Nd:YAG laser posterior capsulotomy ,
evaluated for inclusion criteria. Patients were properly visual acuity of the patients was 6/12 in n=26(13%)
educated about the procedure. patients, 6/18 in n= 37(18.5%) patients, 6/24 in
The patients were subjected to measurement of n=45(22.5%) patients, 6/36 in n=67(33.5%) patients,
visual acuity by standard Snellen’s acuity chart and 6/60 in n=13(6.5%) patients and visual acuity worse
intraocular pressure measurements in mm of Hg on than 6/60 in n=12(6%) patients.(Table III).
Goldman’s applanation tonometer every time by same The visual acquity after one week of Nd:YAG laser
person and on the same apparatus. Before treatment posterior capsulotomy ,was 6/6 in n=23 (11.5%)
1% tropicamide (Mydriacyl) eye drops were instilled patients,6/9 in n= 34 (17%) patients, 6/12 in n=67
to dilate the pupil and the cornea was anaesthetized (33.5%) patients, 6/18 in n=33 (16.5%) patients, 6/24 in
with topical application of 0.5% proparacaine n=21 (10.5%) patients, 6/36 in n=13 (6.5%) patients and
hydrochloride (Alcaine) eye drops. Q- Switched Nd: 6/60 in n=9 (4.5%) patients. (Table IV)
YAG laser (SYL9000 YAG laser system) was used with There was improvement in visual acuity of two
Abraham’s posterior capsulotomy lens to make a hole or more lines on Snellen’s chart following Nd:YAG laser
of 3-4mm in the posterior capsule using 1.5 to 5mJ per posterior capsulotomy in n=169(84.5%) patients
pulse. The energy and pulses were increased gradually whereas n=31 (15.5%) patients showed no

Ophthalmology Update Vol. 11. No. 2, April-June 2013 155

Visual acuity and Intraocular Pressure changes after Nd: YAG Laser Posterior Capsulotomy

improvement.( Table V ) Table III: Pre Nd: YAG laser Visual Acuity (N=200)
The pre Nd: YAG laser posterior capsulotomy,
Pre YAG visual acuity No of Patients Percentage
intraocular pressure with Goldman applanation
tonometer of the patients was 6 -10 mmHg in n= 48 (24 6/12 26 13 %
%) patients, 11-15mmHg in n= 124 (62 %) patients, 16- 6/18 37 18.5 %
20 mmHg in n= 28(14%) patients and IOP more than 20 6/24 45 22.5 %
mmHg was zero. (Table VI), so all those patients were 6/36 67 33.5 %
included who were having pre treatment IOP between 6/60 13 6.5 %
6 and 20mmHg.
Worse than 6/60 12 6%
The results after one week of Nd: YAG laser
posterior capsulotomy,assessment of change in Total 200 100 %
intraocular pressure measured with Goldman Table IV: One week after Nd: YAG laser Visual acuity (N=200)
applanation tonometer showed no change in IOP in
n=104 (52 %),increase of 1-2 mmHg IOP in n=36(18%) Pre YAG visual acuity No of Patients Percentage
patients, 3-4 mmHg in n= 32 (16 %) patients, 5-6 mmHg 6/6 23 11.5%
in n= 10 ( 5%) patients, 7-8 mmHg in n= 8 (4%) patients, 6/9 34 17%
9-10 mmHg in n=6 (3%) patients and increase in IOP
6/12 67 33.5%
more than 10 mmHg in n= 4 ( 2%). (Table VII)
The above result shows that 52% of the patients 6/18 33 16.5%
showed no change in IOP after Nd: YAG laser posterior 6/24 21 10.5%
capsulotomy while the remaining 48% patients showed 6/36 13 6.5%
some degree of change in IOP after Nd: YAG laser 6/60 9 4.5%
posterior capsulotomy in which most of the increase Total 200 100 %
was in the range of 1-4 mm Hg in n=68(34%) patients
and only 14% of the patients showed increase in IOP Table V: Distribution of Post Nd: YAG laser visual acuity (N=200)
more than 5mmHg which needed special attention and
regular follow up for proper control of IOP. Post YAG laser visual acuity No of Patients Percentage
DISCUSSION: Improved 169 84.5%
In ophthalmology, Nd: YAG laser posterior Not improved 31 15.5%
capsulotomy is a routine procedure, since up to 40% of Total 200 100%
the patients submitted to cataract surgery with IOL
implantation develop posterior capsule opacification Table VI: Pre Nd: YAG laser IOP measurement (N=200)
despite the progress made in surgical techniques1,3.
Pre YAG laser IOP No of Patients Percentage
Although Nd: YAG laser is considered to be a safe
procedure, it can cause several complications, namely 0-5mmHg 0 0%
retinal detachment, iritis, macular edema, IOL cracks 6-10 mmHg 48 24%
and pits and IOP spike1, 2. In the present study we 11-15 mmHg 124 62%
16-20 mmHg 28 14%
Table 1I: Showing gender distribution (N=200) > 20 mmHg 0 0%
Total 200 100
Gender No of Patients % age
Male 128 60% Table VII: IOP after one week of Nd: YAG laser Capsulotomy (N=200)
Female 72 40%
Increase in IOP No of Patients Percentage
Total 200 100%
No change in IOP 104 52%
Table II: Age range of the respondents (N=200) 1-2 mmHg 36 18%
3-4 mmHg 32 16%
Age Frequency Percentage
5-6 mmHg 10 5%
40 to 49 years 48 24 %
7-8 mmHg 8 4%
50 to 59 years 50 25 %
9-10 mmHg 6 3%
60 to 69 years 70 35 %
> 10mm Hg 4 2%
e” 70 years 32 16 %
Total 200 100%
Total 200 100%

156 Ophthalmology Update Vol. 11. No. 2, April-June 2013

Visual acuity and Intraocular Pressure changes after Nd: YAG Laser Posterior Capsulotomy

compare the change in IOP and visual acuity in patients and vitrectomy surgery. 12 A national study of
undergoing Nd: YAG laser for posterior capsule Hyderabad showed that there were no patients that had
opacification after extracapsular cataract extraction/ VA 6/6 – 6/12 pre-treatment but after treatment there
phacoemulcification and posterior chamber intraocular were 372 (74.4%) patients who had VA 6/6 – 6/12.19
lens implantation. Regarding the improvement in the final VA of two
There are 200 patients included in our study with or more lines on Snellen’s chart, 169(84.5% ) patients
mean age range of patients of 58.58 ±11.56 years. The showed improvement while only 31 (15.5%) patients
mean age of such patients in one international study had no improvement in this study. Similar results were
done in Manchester Eye hospital, UK was 75.2 years. 10 also found in a recently conducted study in LRH
The mean age of patients in one national study Peshawar, which showed similar improvements in 91%
conducted at PGMI/LRH Peshawar was 54.78 ±13.51 of patients whereas, 9% of patients showed no
years.11 improvement in the final visual acuity.1
According to our study the mean duration CONCLUSION:
between the cataract surgery and Nd: YAG laser In our study it is concluded that visual acuity in
posterior capsulotomy was found to be 2.143± 1.223 patients who had developed posterior capsular opacity
years. In an another study it was found that the duration after cataract extraction with posterior chamber
between the cataract surgery and Nd:YAG laser intraocular lens implantation is better after Nd: YAG
posterior capsulotomy was between 10 to 15 months.12 laser posterior capsulotomy than the visual acuity
The majority of the patients (46%) had posterior before treatment with Nd: YAG laser posterior
capsular opacification between 3 months to 12 months capsulotomy. Regarding the change in IOP after
post operatively.13 Nd:YAG laser posterior capsulotomy,104(52% )of the
Apple DJ has noted that the incidence of PCO up patients showed no change in IOP, 68 (34% ) patients
to 50% by two years post operatively, 14 while other showed 1-4 mmHg increase in IOP, while 28(14% )
authors have reported the incidence of PCO up to 43% patients showed increase more than 5mmHg rise in IOP
in five years duration after extra capsular cataract which needed special attention and regular follow up
extraction 15 and in study of 369 eyes noted the till IOP was controlled.
frequency of PCO in 1.6%, 12.3% and 26.5% after REFERENCES
cataract surgery in the duration of 1, 2 and 3 years 1. Karezewicz D, Pinikowska-Machoy E, Modrzeyewska M,
etal.Posterior capsular opacification as a complication of the
respectively 16. posterior chamber intraocular lens implantation. KlinOczna.
The pre Nd:YAG laser posterior capsulotomy, 2004; 106:19-22.
distant visual acuity of the patients was 6/12 in 2. Hayashi K, Hayashi H, Nakao F, etal.Correlation between
n=26(13%) patients,6/18 in n= 37(18.5%) patients, posterior capsular opacification and visual functions before
and after Nd-YAG laser posterior capsulotomy. Am J
6/24 in n=45(22.5%) patients, 6/36 in n=67(33.5%) Ophthalmol.2003; 136: 720-6.
patients, 6/60 in n=13(6.5%) patients and visual acuity 3. Kurosaka D, Kato K, Kurosaka H, et al.Elschnig pearl
worse than 6/60 in n=12(6%) patients while in an formation along Nd-YAG laser posterior capsulotomy
international study of Greece,2.9% patients had VA margin, long term follow up. J Cataract Refract Surg. 2002;
28: 1809-13.
between 20/32 and 20/60,20.6% patients had VA 4. Aslam TM, Denlin H, DhilonB.Use of Nd-YAG laser
20/40,14.7% had VA between 20/50 and 20/60,20.6% capsulotomy. SurvOphthalmol. 2003; 48: 594-612.
had VA 20/80 and 26.6% had VA 20/100.17 While in a 5. Baratz KH, Cook BE, Hodge DO. Probability of Nd-YAG laser
local national study,80.4 % of patients had pre Nd: YAG capsulotomy after cataract surgery in Olmsted country
Minnesota. Am J Ophthalmol.2001; 131: 161-6.
laser VA > 6/9, among them 52.4 % had VA better than 6. Polak M, Zasnowaski T, ZargorskiZ.Results of Nd-YAG laser
6/60.18 capsulotomy in posterior capsule opacification. Ann
In our study the post Nd:YAG laser posterior UnivMariac Curie Sklodowska.2002; 57: 357-63.
capsulotomy ,the distant visual acuity of the patients 7. Daniele AR.Performing the posterior capsulotomy.
Highlights of ophthalmology (letter).1989;17: 7-11.
was 6/6 in n=23 (11.5%) patients,6/9 in n= 34 (17%) 8. Seong GJ, Lee YG, Lee JH, etal.Effect of 0.2% bromonidine in
patients, 6/12 in n=67 (33.5%) patients, 6/18 in n=33 preventing intraocular pressure elevation after Nd-YAG laser
(16.5%) patients, 6/24 in n=21 (10.5%) patients, 6/36 in posterior capsulotomy. Ophthalmic Surg Laser.2000; 31: 308-
n=13 (6.5%) patients and 6/60 in n=9 (4.5%) patients. 14.
9. Rakafsky S, Koch DD, Faulkner JD, etal.Levobunolol 0.5%
The study of Greece showed that out of 34 patients only and timolol maleate 0.5% to prevent intraocular pressure
1(2.9%) had post treatment VA 20/80 while other elevations after Nd-YAG laser posterior capsulotomy. J
patients (85.3%) had VA better than 20/60 and Cataract Refract Surg. 1997; 23: 1075- 80.
concluded that Nd: YAG laser capsulotomy seems to 10. Aslam TM, Patton N. Methods of assessment of patients for
Nd: YAG laser capsulotomy that correlate with final
be a safe and effective procedure for eyes that have visualimprovement.BMCOphthalmol 2004; 4:13.
previously undergone combined phacoemulsification 11. Rahil N, Rehman R, Malik R. Visual outcome after the use of

Ophthalmology Update Vol. 11. No. 2, April-June 2013 157

Visual acuity and Intraocular Pressure changes after Nd: YAG Laser Posterior Capsulotomy

Neodymium – Yttrium Garnet (YAG) application for years after extracapsular cataract extraction.J Cataract Refract
posterior capsular opacification. IntOphthalmol Update 2012; Surg 1999; 25: 246-50.
11(1):40-43. 16. Erie JC, Hardwig PW, Hodge DO. Effect of intra ocular lens
12. Georgalas I, Petrou P, Kalantzis G, Papaconstantinuo D et design on Neodymium: YAG laser capsulotomy rates. J
al.Nd:YAG laser capsulotomy for posterior capsule Cataract Refract Surg 1998; 24: 1239-42.
opacification after combined clear corneal 17. Yeo KT, Lim ASM, Ling SL. Mass screening for diabetic
Phacoemulsification and vitrectomy.Therapeutics and retinopathy in the prevention of blindness. Asia Pacific J
Clinical Risk Management 2009;5:133-7. Ophthalmol 1995; 7:2-10.
13. Khanzada MA, Jatoi SM, Nasrani AK, Dabir SA, Gul S. 18. Kayani H, Rehan N, Ullah N. Frequency of retinopathy
Experience of Nd: YAG laser posterior capsulotomy in 500 among diabetic s admitted in a teaching hospital of Lahore.
cases. J LiaqatUni Med Health Sci 2007; 6: 109-15. J Ayub Med Coll Abbottabad 2003; 15(4):53-6.
14. Apple DJ, Solomon KD, Tetz MR. Posterior capsule 19. Kohner EN, Porta M. Screening for Diabetic Retinopathy in
opacification.SurvOphthalmol 1992; 37:73-116. Europe: A Field Guide Book. Copenhagen: WHO Regional
15. Sundelin K, Sjostrand J. Posterior capsule opacification 5 office for Europe, 1992.

Optic Disc may be Sinking in Glaucoma & not Cupping

Syed S. Hasnain M.D. Porterville California, U.S.A

You will find pictures A and B of the optic disc taken

from Becker-Shaffer’s Diagnosis and Therapy of the
Glaucomas by Kolker and Hetherington (Mosby
1976) page 169.

A The caption underneath the pictures reads: Progressive

cupping of left eye in a 18-year old woman. A, 0.4 disc -
diameter progressed to B, 0.7 disc-diameter at pressures
of 38 to 46 mmHg. If the findings stating that the 0.4 cup in
A has progressed to 0.7 in B are true, then the 150-year
old cupping theory is correct.

Let us closely observe these two pictures again.

Picture B is 24 % larger image size compared to picture A
(photographer’s error). Therefore, because of this
B discrepancy in viewing, the cup size in B would be larger.
In actuality, the contour and margins of said cup are intact
in B, therefore, the cup size in B has neither enlarged nor
distorted.

Then what happened?

Let us look again: The blood vessels on the entire disc
margin in B are not straight as they were in A. Instead, the
blood vessels are curving inward in pursuit of the sinking disc, more noticeable the superior vessels. This
inward turning of the blood vessels clearly indicate that disc is sinking, and not cupping (as mistakenly
described in the textbook).

158 Ophthalmology Update Vol. 11. No. 2, April-June 2013

 Review Article

Major Review of the Applications of

Femtosecond Laser in Ophthalmology

Rao M. Rashad Qamar FCPS, FRCS1, M. Imran Saleem MBBS2

Muhammad Farhan Saleeem MBBS3
Dr. Rashad Dr. Imran
Qamar Saleem

ABSTRACT
Objective: The objective of this study was to review the current ophthalmic literature regarding the applications of
femtosecond laser in the field of ophthalmology.
Study Design:Literature Review.
Setting: Eye Unit-I, B.V. Hospital, Bahawalpur; Pakistan.
Results: Femtosecond lasers offer the ophthalmologist an ability to cut the tissues at various depths, with different
patterns and minimal collateral tissue injury. This technology has dramatically changed the corneal refractive surgery and
is anticipated to do the same for the cataract surgery as well. The companies i.e. the IntraLase, the FEMTEC, the
OptiMedica, the LenSx and the LensAR have developed their femtosecond laser systems to be used for different ophthalmic
surgical procedures. These systems can perform the corneal incisions, the capsulotomy, and the lens fragmentation.
Conclusion:Femtosecond laser provides a more precise and safer approach towards ocular surgery.
Key Words: Cataract surgery; corneal refractive surgery; Femtosecond laser

INTRODUCTION: emulsification of the crystalline lens. Peyman and Katoh

Lasers are being used in the field of through their work showed that when laser light is
ophthalmology since early 70s. Kransov 1 in 1975 focused directly onto the nucleus of the crystalline lens,
reported the use of ruby laser (wavelength 694nm) to an optical breakdown of the lens material is observed6.
create micro-puncture of the anterior capsule of the Erbium-YAG lasers were subsequently used by
crystalline lens, allowing the release of the lens matter different researchers with systems of varying energy
and gradually leading to resorption of the cataract. levels and pulse duration in order to decrease the
Ultraviolet lasers having wavelength between 193 and energy use and resultant decline in incidence of
351 were the next target of investigators to look into as endothelial cell damage2. Photolysis system were
an aid for corneal and cataract surgery. The infrared subsequently introduced by Dodick. In these systems,
part of the spectrum was finally adopted in 1980s as a laser energy is transferred to a titanium target which is
safer mode for ocular surgeries2. Nd-YAG laser was the installed within a laser/aspiration handpiece 7. This
first laser to be used for peripheral iridotomy, posterior leads to the formation of plasma at the tip of the target.
capsulotomy and pupillary membrane lysis. Aron-Rosa The plasma thus formed causes the optical as well as
and Aron were the pioneers in this field as they used acoustic breakdown of the material through shockwave
Nd-YAG laser to perform anterior and posterior production8.
capsulotomy in order to prevent the development of a Clinical trials performed on these systems report
Posterior Capsular Opacification (PCO) after cataract a high success rate, decreased complication rate and a
surgery. Laser assisted anterior capsulotomy never shorter operation time9. However adoption among the
gained popularity owing to complications of intraocular ophthalmologists is not widespread as phaco-
inflammation, increase in intraocular pressure and post- emulsification is the preferred method of cataract
laser poor mydriasis.2 removal.Femtosecond laser uses a shorter pulse time
Lasers havebeen applied to photolysis and photo- (10-15 seconds versus 10-9 seconds) when compared to
————————————————————————————————
argon (photocoagulation), excimer (phtoablation), and
1
Associate Professor, 2,3 Medical Officer/Registrar, Nd-YAG (photodisruption) lasers. A shorter pulse time
B.V. Hospital, Bahawalpur decreases the energy per unit time thus leading to a
———————————————————————————————— decreased energy output for a given effect10. This
Correspondence: Dr. Muhammad Imran Saleem,15-B.V. Hospital
property of femtosecond laser is especially important
Colony, Bahawalpur 63100; Pakistan. Phone: +923366764084
for corneal refractive surgery and cataract surgery. This
E-mail: [email protected]
———————————————————————————————— allows the surgeon to preserve the ocular structures
Received Jan’2013 Accepted: Feb’2013 including cornea, iris and capsular bag from untoward
———————————————————————————————— complications of conventional procedures and

Ophthalmology Update Vol. 11. No. 2, April-June 2013 159

Major Review of the Applications of Femtosecond Laser in Ophthalmology

subsequently leads to a better visual outcome. capsulorrhexis of <5.5mm has been shown to cause
Femtosecond laser works essentially by anterior capsular phimosis and postoperative hyperopic
vaporizing the targeted tissues through the formation shift18. At the same time, a too large capsulorrhexis leads
of plasma and micro-cavitation bubbles. These lasers to insufficient overlap of the intraocular lens by the
became available for the first time in 2001. Initial capsule thus increasing the incidence of postoperative
application of the femtosecond laser was limited to the lens tilt, decentration and posterior capsular
creation of corneal flaps during Laser Assisted In-situ opacification, sometimes needing a lens exchange19-21.
Keratomileusis (LASIK) 11,12 . Flaps created by Creating a precise and predictable capsulotomy should
femtosecond laser were observed to be reproducible, reduce the incidence of aforementioned complications
uniform, well centered and closer to their intended (Fig. 2) The construction of a capsulotomy is also
thickness when compared to the flaps created manually important in estimating the effective lens position (ELP).
with the help of a microkeratome. Since then, use of ELP is a value derived from empirical data of the A-
femtosecond lasers has been expanded to other constant and the surgeon’s factor.
procedures including customized trephination The size of the capsulorrhexis has a direct relation
penetrating keratoplasty (PKP), anterior/posterior with the ELP28. Inappropriate estimation of the ELP is
lamellar keratoplasty, tunnel creation for intracorneal the biggest source of error in intraocular lens power
ring segements, astigmatic keratotomy. Most recently, calculation29. A difference of 1mm in ELP can lead to a
femtosecond laser has been applied to cataract surgery. refractive error of about 1.25 diopters18,30,31. For toric and
Femtosecond laser-assisted cataract surgery: multifocal intraocular lenses, the window for error is
Cataract surgery is the most commonly performed even smaller. Tilt, decentration or rotation of these
ocular procedure throughout the world14. Approxi- lenses in-situ can cause significant optical aberrations
mately 3 million cataract surgeries were performed in including halos and coma effect which are extremely
the USA during the year 2006 and this number will difficult to tolerate 21,32,33. With current technology, no
continue to grow as the population ages. The eye disease tools exist to guide perfect centration of the
prevalence research group in 2004 estimated that 20.5 capsulotomy/capsulorrhexis except the anatomical
million Americans and 30.1 million Americans by 2020, landmarks e.g. the borders of a dilated pupil or the
will have catarct15. Until recently, the primary outcome limbal edge, making the patients having irregularly
of cataract surgery has been functional vision of 20/40 dilated pupils or corneal haze challenging in this
or better with accuracy of +1 diopter. However, with respect. Predictable and controlled positioning of the
current biometry and surgical methods, studies report intraocular lens can be achieved more often when the
that only 45% of the patients are within 0.5 diopters of capsulorrhexis size incision is perfectly sized and
their targeted postoperative refraction, and 6% have precisely centered. This is possible through the use of
more than 2 diopters of residual refractive error 17. With femtosecond lasers (Fig. 3).
the advent of multifocal and accommodative intraocular Femtosecond Laser-Assisted Lens Fragmenta-
lenses, more and more patients are opting for earlier tion: Femtosecond lasers can be used to fragment the
cataract surgery with less tolerance for visual crystalline lens nucleus. This allows the operating
impairment. At the same time ophthalmologists are surgeon to skip the difficult steps of phaco-
facing increasingly high patient expectations for emulsification i.e. the sculpting/ chopping which is a
postoperative refractive outcome. Today, the goal of common source of complications during surgery34-36.
cataract surgery is to achieve near emmetropia. For this Additionally, patterns of cuts can be placed on the
reason, femtosecond lasers can improve the results of nucleus in order to soften a harder cataract (Fig. 4).
cataract surgery due to remarkable reproducibility, These maneuvers are a means to reduce the need for
centration, and safety during cataract surgery. To date, ultrasound energy from the phaco-tip thereby
the femtosecond laser systems are engineered to minimizing the risk of capsular complications and
perform four groups of incisions i.e. the capsulotomy, corneal endothelial injury37-39. There is an added safety
the lens fragmentation, the limbal relaxing incisions and benefit of reducing the unnecessary instrumentation
the clear corneal incisions. and manipulation of the crystalline lens during surgery.
Femtosecond laser-assisted capsulorrhexis:Use Finally, the femtosecond laser treatments may be
of femtosecond lasers for capsulotomy or laser assisted optimized for the irrigation/aspiration phaco-dynamics
capsulorrhexis (Fig. 1) has the potential to revolutionize to reduce the aspiration flow rate (AFR) and the
the cataract surgery. Studies show that the size of the intraoperative iris prolapse.
capsulorrhexis is of immense importance for an optimal Steps in Femtosecond Laser-Assisted Cataract
lens positioning and intraocular lens performance. With Surgery: There are four primary steps of femtosecond
single-piece aspheric intraocular lens, a small laser assisted cataract surgery i.e. the planning, the

160 Ophthalmology Update Vol. 11. No. 2, April-June 2013

Major Review of the Applications of Femtosecond Laser in Ophthalmology

engagement, the visualization, customization and the above-mentioned complications and also prevents
treatment. Two sub-systems that are of critical corneal folds that occur with suction ring. This allows
importance during laser assisted cataract surgery for a precise laser focus, thus, minimizing the energy,
include the docking system (for engagement step) and reducing the cavitation bubble formation and
the image guidance system (for visualization and optimizing the treatment results.
customization steps). The approach towards these steps All the three systems i.e. the OptiMedica, the
is slightly variable between the LenSx, the LensAR, and LenSx and the LensAR have proved to be effective in
the OptiMedica laser systems. Some of the salient stabilizing the globe and minimizing the risk of
features are discussed here. intraocular pressure spikes during the surgery.
A-The Planning: Before embarking upon cataract However the method and device for docking appears
surgery, the individual variations in pupil size, the lens to be different for each laser platform. OptiMedica
thickness, the corneal thickness are to be measured. employs liquid optics interface which causes a pressure
After initial planning, adjustments are made in real-time rise of only 8-12mmHg and has good stabilization of
by using drag and drop interface with incisional the globe during the engagement step. LenSx has a
overlays on video as well as cross sectional images.For curved lens and suction system. LensAR has a non-
performing the capsulorrhexis, the planning parameters contact, non-applanating water-bath suction and
include the size, the shape and the required centration fixation device49.
of the incision. Primary driver for the capsulotomy C-The Visualization and Customization: The
planning is the intraocular lens. image guidance system is a critical part of femtosecond
For performing the lens fragmentation, the assisted cataract surgery as it determines the location
parameters of importance are the depth, the pattern and and dimensions of the ocular structures i.e. the cornea,
the diameter of the cuts. These are indirectly dependent the iris and the crystalline lens capsule. This system
upon the density and thickness of the cataract. These allows the operating ophthalmologist to customize the
parameters can be matched to the surgeon’s preferred zones for placement of laser assisted incisions and lens
technique of surgery and thus reduce the phaco time fragmentation. The corneal thickness should be
and energy.For performing the limbal relaxing incisions determined so that the architecture of relaxing and
(LRIs), traditional nomograms are used for planning. surgical incisions can be properly customized for each
However, as the effect of pneumo-dissection from patient. The system used must be able to detect the iris
cavitation bubbles is quantified. For clear corneal boundaries in order to safely direct the laser within even
incisions (CCIs), the planning parameters include the the asymmetrically dilated pupil. They must also
location, the depth and the architecture of incision. generate a reference for the size and centration of the
B-The Engagement: Prior to delivering the laser, capsulorrhexis/capsulotomy. It is also critical to detect
it is necessary to stabilize the patient’s eye relative to the posterior surface of crystalline lens in order to
the optical system of the laser. During refractive surgery maintain a safety zone, preventing any inadvertent cuts
it is accomplished through the use of a suction ring in the posterior lens capsule.
which causes distortion of the globe. Studies comparing The LenSx and the OptiMedica use Fourier-
the real-time changes in intraocular pressure during this Domain Optical Cohorence Tomography (FD-OCT) for
maneuver between femtosecond assisted surgery three dimensional viewing of ocular structures. This
versus mechanical keratome assisted surgery have allows for real-time, high resolution measurements of
shown that the IntraLase interface (Abbot Medical the corneal thickness, the lens position, the iris
Optics, California, USA) can cause a rise of about boundaries and the irido-corneal angle49-52. The LensAR
90mmHg while the VisuMax interface (Carl-Zeiss uses a three dimensional confocal illumination-scanning
Meditec, California, USA) causes a rise of 82mmHg in transmitter, a technology similar to Schiempflug camera
intraocular pressure47,48. Altohough this much amount system49. Schiempflug camera systems are capable of
of pressure rise is well tolerated during refractive determining corneal power elevation maps, the anterior
surgery, the elderly patients having cataract and chamber depth and the corneal wave-front analysis53,54.
coexisting glaucoma or other ocular comorbidity have The lens density can also be evaluated and quantified,
an increased risk of retinal nerve fibre layer damage allowing lens fragmentation settings to be selected
due to transient ischemia of the retinal tissues during automatically55. A preview of the software for each
the engagement process. An ideal interface would be system indicates that size of safety zones vary among
one which stabilizes the globe without causing any each system to ensure that the laser energy does not
distortion of the eye or an increase in intraocular adversely affect the ocular structures (Fig. 6).
pressure. The interface employing a liquid cushion D-The Treatment: This is the final step of the laser
between the eye and the laser system minimizes the assisted cataract surgery. The laser spot pattern for a

Ophthalmology Update Vol. 11. No. 2, April-June 2013 161

Major Review of the Applications of Femtosecond Laser in Ophthalmology

single incision is applied from posterior to anterior. This to the manual (Fig. 6). To date, LensAR has not reported
maneuver maintains precise focus, avoiding scatter of on centration of the intraocular lens.
the laser beam and also reduces the amount of Studies are still underway to optimize the
radiations reaching the retina72. available patterns of lens fragmentation for each
The three systems differ in the order of incision commercial system56,63. To assess the efficacy of laser
delivery. The OptiMedica offers the capsulotomy/ assisted lens fragmentation, all the three companies
capsulorrhexis first and then the lens fragmentation. looked at the ultrasound energy output of the
This sequence of events reduces the risk of a capsular phacoemulsification in lenses treated with laser or not
tear or zonular dehiscence because the lens is allowed and showed a marked reduction in ultrasound energy
to relax as it is fragmented. In the LenSx system, initially for all grades of cataracts. The percentage of energy
the nucleus is fragmented and the capsulorrhexis is reduction was variable among the three laser systems
performed afterwards56. but was 33% atleast.62,63,64
Clinical Outcomes of the Femtosecond Laser- Femtosecond Laser-Assisted Limbal Relaxing
Assisted Cataract Surgery: Incisions (iris): Femtosecond laser systems can perform
Nagy et al first published the results of cataract corneal or limbal relaxing incisions (LRIs) to correct
surgery using the LenSx femtosecond laser system in up to 3.5 diopters of astigmatism. The laser causes
2009. They compared the manual capsulorrhexis to laser flattening of the steeper meridian of the cornea thus
assisted capsulorrhexis in porcine eyes on the basis of eliminating the source of refractive error40. However at
reproducibility and maximum resistance to stretching. present, only a small number of patients are undergoing
Their results showed that the laser assisted manual limbal relaxing incisions. This is because the
capsulotomies were much more reproducible, uniform manual incisions are technically demanding and have
and precisely placed 57 . Scanning laser electron unpredictable results. Inconsistency in the outcomes of
microscopy revealed that the edges of such manual limbal relaxing incisions is often related to
capsulotomies were smooth and the strength of the discrepancies in depth, axis, arc length and optic zone
rhexis edge could tolerate a higher stretching force of the incision. It has been stated that an axis
before rupture. They also showed that the lens misalignment of just 50 results in 17% reduction in
fragmentation via femtosecond laser led to a 43% effect40. These problems have been solved by the advent
reduction in phaco power and a 51% reduction in time. of femtosecond lasers. The superior accuracy afforded
The corneal edema and the anterior chamber activity by this laser over manual procedures could lead to an
were mild in laser treated eyes during the first improvement in outcomes of limbal relaxing incisions.
postoperative day and these findings resolved Femtosecond Laser-Assisted Clear Corneal
completely by first week post surgery57. Although the Incisions (CCIS):The self-sealing clear corneal incision
study employed only a limited number of patients, yet is now the preferred method of entry into anterior
the femtosecond laser assisted cataract surgery chamber of the eye. Recent studies report that about
appeared to be well tolerated for use in this study. 75% of the cataract surgeons in the USA are using the
OptiMedica59,62 reported capsulotomy diameters clear corneal incision during cataract surgery in an order
within 27 microns (SD, 25microns) of the intended to achieve a superior visual outcome and faster visual
diameter (Fig. 5). This is compared with 183 microns recovery41,42. The drawbacks of the manually created
(SD, 246microns) for LensAR60. LenSx reported that all clear corneal incisions include an increased incidence
capsulotomies were within 250microns of the intended of postoperative endophthalmitis 43, gaping at the
diameter61. All the three companies found that the laser internal aspect of the wound and a risk of Descmet’s
capsulotomies were more precise than manual membrane detachment44. Femtosecond laser assisted
capsulorrhexes with OptiMedica59 reporting manual clear corneal incisions show less features of damage and
results at 339microns (SD, 248microns), and the LensAR faster healing rate. This may be due to special properties
reporting nearly 500microns for manual of such wounds or from reduction in the mechanical
capsulorrhexes60. For the capsulotomy, each company stresses during the operation45,46.
used different measurement techniques, a direct Femtosecond Laser-Assisted Penetrating
comparison of the three companies is not easily Keratoplasty (PKP):Earlier investigations involving
assessed. femtosecond laser for penetrating keratoplasty incisions
For capsulotomy position, OptiMedica reported revealed that a “top-hat” shaped incision led to better
the intraocular lens centration within 86microns (SD, wound stability with seven-fold increased resistance to
51microns) of the intended placement59. The LenSx leakage and a possible decrease in risk of postoperative
reported intraocular lens centration was significantly astigmatism when compared to wounds created
better (p=0.027) in laser assisted group61 as compared through conventional trephination72,73. In subsequent

162 Ophthalmology Update Vol. 11. No. 2, April-June 2013

Major Review of the Applications of Femtosecond Laser in Ophthalmology

studies on femtosecond laser assisted corneal incisions, healing rate and astigmatism control was
a variety of other wound configurations were identified. superior with femtosecond laser assisted top-hat
These include the “mushroom”, the “zigzag” and the incision when compared to manual top-hat incision.
“Christmas tree” shapes (Fig. 7C-E). From a mechanical Results of the studies conducted by Burrato and Bohm75
strength stand point, all of these wound configurations were also in line with findings of the above mentioned
create more stable wound when compared to the researchers.Femtosecond assisted zigzag incision when
traditional “butt” joint (Fig. 7A) created through compared to conventional trephination incision, had a
standard corneal trephination. Optical distortion and more rapid visual recovery and less induced
poor visual outcome following penetrating keratoplasty astigmatism83. There was a significant difference in
are often a result of misalignment of the donor-host average astigmatism between the two groups at
cornea, rotational misalignment, uneven suture tension postoperative month 1 and 3 (3D in laser assisted
and postoperative slow and uneven wound healing. The incision versus 4.46D in conventional incision). Also,
goal of femtosecond laser assisted corneal incision the number of patients achieving the visual acuity of
during penetrating keratoplasty is the creation of a 20/40 at three months was statistically higher (p<0.03)
structurally stable and predictable wound configuration in laser assisted group when compared to the manual
with the objective of rapid visual rehabilitation and trephination group (81% versus 45%).
higher optical quality compared with conventional The mechanism thought to be responsible for
blade assisted trephination. higher success rate of laser assisted incisions is the
Earlier results of outcomes with the femtosecond angled edge of the zigzag cuts, which provides a smooth
laser assisted keratoplasty show better alignment of the anterior transition between the host-donor interfaces,
donor-host surface. Improved sealing of the incision leading to hermetic wound healing. This improved
permits the ophthalmologist to use only optimal suture natural alignment intrinsically produces less optical
tension to keep the incision opposed without undue distortion, watertight seal and less suture tension and
distortion of the cornea. In addition, increased surface resultant lesser amounts of astigmatism. Alternatively,
area of these incisions leads to increased tensile strength there is rapid recovery of wound edema in femtosecond
of the wound, improving both patient safety and group due to less tissue manipulation and trauma as
allowance of an earlier suture removal (Fig. 8). This in compared to conventional trephination83.
turn leads to a rapid visual recovery and lesser The top-hat and the zigzag incisions are the two
astigmatism than traditional blade assisted most popular femtosecond laser assisted incisions due
keratoplasty74-78. to their enhanced accuracy over conventional incisions.
The first femtosedcond laser platform to For the same reason, from a biomechanical stand point,
accomplish the full thickness cuts was the IntraLase the zigzag cuts may prove to be the most stable74. This
(IntraLase Femtosecond Laser, Irvine, California, USA). type of incision allows for consistent suture placement
With the use of this platform, penetrating keratoplasty at about 50% of stromal depth at the position where
is now better known as IntraLase Enabled Keratoplasty the posterior cuts and the lamellar incisions intersect.
(IEK). With top-hat incision, suture placement may vary
FEMTEC (20/10 perfect vision, Heidelberg, leading to a possibility of posterior wound gape with a
Germany) is the second platform by which stable full negative impact on postoperative visual outcome.
thickness keratoplasty can be performed. Preliminary Recently, software has been developed allowing
studies performed on this system demonstrate that the application of radial alignment marks on the donor/
short time visual results of this system are analogous host cornea. This helps more precise suture placement
to other femtosecond assisted penetrating keratoplasty with an improved tissue distribution and a tendency
systems.Price et al76 through their study demonstrated towards lesser astigmatism in eyes undergoing
that the endothelial cell loss at one year after femtosecond assisted keratoplasty. Another technique
femtosecond laser assisted keratoplasty was analogous to the radial alignment marks is the
comparable to that in conventional keratoplasty. A application of orientation teeth. This technique showed
rapid wound healing rate was observed in this study low-moderate astigmatism postoperatively84.
with mean time for suture removal of seven months. Femtosecond Laser-Assisted Deep Anterior
Hoffartet al82 used the FEMTEC laser and showed that Lamellar Keratoplasty (Dalk):The femtosecond laser
the visual and refractive outcome of this system was technology is recently being expanded to aid in other
comparable to the other laser systems. It is also worth corneal transplantation techniques. Deep Anterior
mentioning that the FEMTEC system currently allows Lamellar Keratoplasty (DALK) with ‘big-bubble’
only the straight cuts. Bahar et al78 used the IntraLase technique is now preferred procedure for anterior
system and showed that the visual outcome, wound corneal disease. This technique has been employed

Ophthalmology Update Vol. 11. No. 2, April-June 2013 163

Major Review of the Applications of Femtosecond Laser in Ophthalmology

Figure 1: Laser capsulotomy. Figure 2: Intraocular lens as seen through the laser capsulotomy.
View of an accurately sized and precisely shaped laser Slit-lamp view of a laser capsulotomy having uniform overlap of
capsulotomy seen through the catalys tm precision laser system. the intraocular lens optic.

Figure 3: One month postoperative.

Slit lamp view after one month of the manual (left) and laser-assisted (right) capsulorrhexis.

Figure 4: Laser-assisted lens fragmentation.

View of the laser-assisted lens fragmentation through the catalystm precision laser system
(left) and through the operating microscope (right).

164 Ophthalmology Update Vol. 11. No. 2, April-June 2013

Major Review of the Applications of Femtosecond Laser in Ophthalmology

Figure 5: Capsule discs Figure 6: Capsulotomy centration.

Excised samples of the lens capsule discs demonstrating the Overlay graph of the capsulotomy centre in relation to the centre
repeatability of size and shape of the manual (a) and the laser- of the dilated pupil as seen through the catalys tmprecision laser
assisted capsulorrhexis (b). system.

Figure 7: Laser-assisted penetrating keratoplasty.

Schema of the differrent types of femtosecond laser assisted incisions for penetrating keratoplasty (pkp):
(a)-”traditional”; (b)-”top-hat” ; (c)-”mushroom”; (d)-”zigzag”; and (e)- “christmas tree” incisions.

successfully for treating the keratoconus as well as for originally by Anwar et al requires a 60-80% trephination
the management of anterior stromal pathology in cases followed by intracameral injection of air and lamellar
having a healthy endothelium. Anwar et al85 applied dissection of the anterior stroma manually in order to
big-bubble technique for baring of descemet’s identify and reach the posterior stroma. Posterior
membrane during maximum depth anterior lamellar stroma is then excised carefully over a blunt iris spatula
keratoplasty in patients having keratoconus. In a series in order to protect the Descmet’s membrane from the
of 181 eyes which underwent this procedure, 89% sharp tip 85 . The newer technique employing
achieved visual acuity of 20/40 or better. femtosecond laser avoids the manual trephination and
Big-bubble technique DALK has several allows precise identification of tissue depth and
advantages over conventional penetrating keratoplasty. injection of air by following a plane between the lamellar
These include the safety of extraocular procedure, low and posterior side cuts of the zigzag wound92,93. Injection
risk of endothelial rejection and a shorter course of of a big-bubble at this depth facilitates full baring of
postoperative corticosteroid use91. the Descmet’s membrane.
The big-bubble DALK technique described The femtosecond DALK procedure has also been

Ophthalmology Update Vol. 11. No. 2, April-June 2013 165

Major Review of the Applications of Femtosecond Laser in Ophthalmology

Figure 8: Femtosecond laser assisted keratoplasaty

Optical coherence tompography (OCT) of the cornea showing precision and uniformity of the femtosecond laser assisted corneal incisions.

used successfully using mushroom shaped incision94. of femtosecond laser. Additionally the femtosecond
The reference radial incision marks created by the laser laser treated eyes had a greater incidence of endothelial
allow precise suturing of the tissue to optimize cell loss when compared to the eyes undergoing
postoperative astigmatism and minimize the corneal conventional keratoplasty95. Studies are ongoing to look
distortion. at the energy level and the spot size patterns of the
Penetrating keratoplasty for ectatic corneal femtosecond laser in order to minimize interface haze
conditions is traditionally known to have the most and distortions. This may improve the results of the
success rate in terms of visual recovery and healing. FLEK in near future.
However, as these patients are usually younger, the risk Future Prospects of Femtosecond Lasers in
of endothelial graft rejection is higher. The ideal Ophthalmology:Ultrasound Biomicroscopy (UBM)
procedure in such patients would be one that can images of the normal accommodation in young eyes
maintain patient’s own endothelium and replaces only demonstrates that predominant effect on intact lens is
the diseased part of the stroma along with a superior at the level of the anterior capsule62. Laser assisted
wound approximation and minimal induced cataract surgery, with its improved precision and
astigmatism. The femtosecond laser assisted custom accuracy, may allow a better preservation of the
shaped cuts combined with the big-bubble DALK biomechanical properties of the lens capsule, enabling
technique successfully achieves this goal. This method the creation of better accommodative intraocular lenses.
also preserves the option to perform a full thickness Some studies are also investigating the femtosecond
penetrating keratoplasty with the benefits of lasers to restore accommodation in presbyopic eyes by
femtosecond laser incision if the dissection of Descmet’s increasing the flexibility of the lens either by separating
membrane fails during the surgery. the collagen fibrils, or by applying the laser assisted
Femtosecond Laser-Assisted Endothelial incisions that act as gliding planes65,66-68.
Keratoplasty (FLEK): Use of femtosecond lasers for Other applicatons of the femtosecond lasers are
endothelial keratoplasty (FLEK) has yielded mixed being evaluated, expanding the patient population for
results 94,95. Cheng et al performed a randomized which cataract surgery and lens exchange procedures
controlled trial on a group of 80 eyes comparing are possible. Lee et al69 described a technique by which
femtosecond laser endothelial keratoplasty (FLEK) to they created a flap to remove the corneal opacities,
conventional keratoplasty (PKP) and found that the allowing better visualization of a cataractous lens and
patients undergoing femtosecond laser assisted surgery greater ease of maneuvering the difficult cases.
had a significantly lower postoperative astigmatism. At Nishimotoet al 70 describe using an intentionally
the same time it was also observed by the researchers decentered intraocular lens for managing the cases
that the best corrected visual acuity was significantly having vertical diplopia.
lower in group treated with laser assisted keratoplasty. There are a group of investigators which is
This finding may be due to interface haze resulting from attempting to use the femtosecond laser to reverse some
roughened collagen fibrils produced by the application of the accumulated damages which lead to cataract and

166 Ophthalmology Update Vol. 11. No. 2, April-June 2013

Major Review of the Applications of Femtosecond Laser in Ophthalmology

presbyopia. Keesel et al have recently shown that the United States. Arch Ophthalmol2004; 122:487–494.
senile yellowing of the crystalline lens can be reduced 16. Gale RP, Saldana M, Johnston RL, et al. Benchmark standards
for refractive outcomes after NHS cataract surgery. Eye
by femtosecond laser assisted photolysis71. (Lond) 2009; 23:149–152.
CONCLUSION: 17. Murphy C, Tuft SJ, Minassian DC. Refractive error and visual
The future of the cataract surgery may be the outcome after cataract extraction. J Cataract Refract
treatment options that allow the lens to be extracted Surg.2002; 28:62–66.
18. Sanders DR, Higginbotham RW, Opatowsky IE, Confino J.
within a wholly intact capsule which could then be Hyperopic shift in refraction associated with implantation
replaced with an injectable polymer. It may be that the of the single-piece Collamer intraocular lens. J Cataract
natural crystalline lens can have its optical properties Refract Surg.2006; 32:2110–2112.
restored with femtosecond laser modifications. 19. Wallace RB 3rd. Capsulotomy diameter mark. J Cataract
Refract Surg.2003; 29:1866–1868.
Throughout all these applications, the new femtosecond 20. Ravalico G, Tognetto D, Palomba M, et al. Capsulorhexis size
laser systems can emerge in the near future and bring and posterior capsule opacification. J Cataract Refract Surg
the practicing ophthalmologist one step closer to an 1996; 22:98–103.
ideal surgery that corrects cataract, astigmatism and 21. Walkow T, Anders N, Pham DT, Wollensak J. Causes of
severe decentration and subluxation of intraocular lenses.
presbyopia all in single step. Graefes Arch ClinExp Ophthalmol1998; 236:9–12.
REFERENCES: 22. McLeod SD, Vargas LG, Portney V, Ting A. Synchrony dual-
1. Krasnov MM. Laser-phakopuncture in the treatment of soft optic accommodating intraocular lens. Part 1: Optical and
cataracts. Br J Ophthalmol.1975;59:96–8. biomechanical principles and design considerations. J
2. Dodick JM, Pahlavi IA. Lasers in small-incision cataract Cataract Refract Surg 2007; 33:37–46.
surgery. In: Fankhauser F, Kwasniewska S, editors. Lasers in 23. Ossma IL, Galvis A, Vargas LG, et al. Synchrony dual-optic
ophthalmology: basic diagnostic and surgical aspects. accommodating intraocular lens. Part 2: Pilot clinical
Amsterdam, the Netherlands: Kugler Publications; 2003. pp. evaluation. J Cataract Refract Surg.2007; 33:47–52.
395–402. 24. Vargas LG, Auffarth GU, Becker KA, et al. Performance of
3. Fankhauser F, Roussel P, Steffen J, et al. Clinical studies on the 1CU accommodating intraocular lens in relation to
the efficiency of high power laser radiation upon some capsulorhexis size. J Cataract Refract Surg.2005; 31:363–368.
structures of the anterior segment of the eye. First experiences 25. Sacu S, Findl O, Menapace R, Buehl W. Influence of optic
of the treatment of some pathological conditions of the edge design, optic material, and haptic design on capsular
anterior segment of the human eye by means of a Q-switched bend configuration. J Cataract Refract Surg.2005; 31:1888–
laser system. Int Ophthalmol.1981; 3:129–139. 1894.
4. Aron-Rosa D, Aron JJ, Griesemann M, Thyzel R. Use of the 26. Park TK, Chung SK, Baek NH. Changes in the area of the
neodymium-YAG laser to open the posterior capsule after anterior capsule opening after intraocular lens implantation.
lens implant surgery: a preliminary report. J Am Intraocul J Cataract Refract Surg 2002; 28:1613–1617.
Implant Soc.1980; 6:352–354. 27. Gonvers M, Sickenberg M, van Melle G. Change in
5. Aron-Rosa DS, Aron JJ. Effect of preoperative YAG laser capsulorhexis size after implantation of three types of
anterior capsulotomy on the incidence of posterior capsule intraocular lenses. J Cataract Refract Surg1997; 23:231–238.
opacification: ten year follow-up. J Cataract Refract 28. Cekic O, Batman C. The relationship between capsulorhexis
Surg.1992; 18:559–561. size and anterior chamber depth relation. Ophthalmic Surg
6. PeymanGA, Katoh N. Effects of an erbium: YAG laser on Lasers.1999; 30:185–190.
ocular structures. IntOphthalmol 1987; 10:245–253. 29. Norrby S. Sources of error in intraocular lens power
7. Dodick JM. Laser phacolysis of the human cataractous lens. calculation. J Cataract Refract Surg 2008; 34:368–376.
Dev Ophthalmol1991; 22:58–64. 30. Lakshminarayanan V, Enoch JM, Raasch T, et al. Refractive
8. Seibel BS. Phacodynamics: mastering the tools and techniques changes induced by intraocular lens tilt and longitudinal
of phacoemulsification surgery. 4th ed. Thorofare, New displacement. Arch Ophthalmol.1986;104:90–92.
Jersey: SLACK Incorporated; 2005. 31. Erickson P. Effects of intraocular lens position errors on
9. Kanellopoulos AJ. Laser cataract surgery: a prospective postoperative refractive error. J Cataract Refract Surg 1990;
clinical evaluation of 1000 consecutive laser cataract 16:305–311.
procedures using the Dodick photolysis Nd:YAG system. 32. Baumeister M, Buhren J, Kohnen T. Tilt and decentration of
Ophthalmology 2001; 108:649–654; discussion 654–655. spherical and aspheric intraocular lenses: effect on higher-
10. Sugar A. Ultrafast (femtosecond) laser refractive surgery. order aberrations. J Cataract Refract Surg 2009; 35:1006–1012.
CurrOpin Ophthalmol2002; 13:246 249. 33. Buckhurst PJ, Wolffsohn JS, Naroo SA, Davies LN. Rotational
11. Nordan LT, Slade SG, Baker RN, et al. Femtosecond laser and centration stability of an aspheric intraocular lens with
flap creation for laser in situ keratomileusis: six-month a simulated toric design. J Cataract Refract Surg.2010;
follow-up of initial U.S. clinical series. J Refract Surg.2003; 36:1523–1528.
19:8–14. 34. Artzen D, Lundstrom M, Behndig A, et al. Capsule
12. Salomao MQ, Wilson SE. Femtosecond laser in laser in situ complication during cataract surgery: case-control study of
keratomileusis. J Cataract Refract Surg 2010; 36:1024–1032. preoperative and intraoperative risk factors – Swedish
13. Farid M, Steinert RF. Femtosecond laser-assisted corneal Capsule Rupture Study Group report 2. J Cataract Refract
surgery. CurrOpinOphthalmol 2010; 21:288–292. Surg 2009; 35:1688–1693.
14. Cullen KA, Hall MJ, Golosinskiy A. Ambulatory surgery in 35. Gauba V, Tsangaris P, Tossounis C, et al. Human reliability
the United States, 2006. Natl Health Stat Report 2009; (11):1– analysis of cataract surgery. Arch Ophthalmol 2008; 126:173–
25. 177.
15. Congdon N, Vingerling JR, Klein BE, et al. Prevalence of 36. Bellini LP, Brum GS, Grossi RS, Borowsky C. Cataract surgery
cataract and pseudophakia/aphakia among adults in the complication rates. Ophthalmology 2008; 115:1432; author

Ophthalmology Update Vol. 11. No. 2, April-June 2013 167

Major Review of the Applications of Femtosecond Laser in Ophthalmology

reply 1432–1433. US clinical experience in a premium IOL practice [abstract].

37. Johansson B, Lundstrom M, Montan P, et al. Capsule In: Program and Abstracts of XXVIII Congress of ESCRS; 4–
complication during cataract surgery: long-term outcomes – 8 September 2010; Paris.
Swedish Capsule Rupture Study Group report 3. J Cataract 57. Nagy Z, Takacs A, Filkorn T, Sarayba M. Initial clinical
Refract Surg 2009; 35:1694–1698. evaluation of an intraocular femtosecond laser in cataract
38. Richard J, Hoffart L, Chavane F, et al. Corneal endothelial surgery. J Refract Surg 2009; 25:1053–1060.
cell loss after cataract extraction by using ultrasound 58. Nichamin LS, Teuma EV. The use of femtosecond lasers to
phacoemulsification versus a fluidbased system. Cornea 2008; create corneal incisions [abstract]. In: Program and Abstracts
27:17–21. of American Society of Cataract and Refractive Surgeons
39. Hayashi K, Hayashi H, Nakao F, Hayashi F. Risk factors for Symposium on Cataract, IOL and Refractive Surgery; 9–14
corneal endothelial injury during phacoemulsification. J April 2010; Boston, Massachusetts.
Cataract Refract Surg 1996; 22:1079–1084. 59. Batlle J. Prospective study of size and shape accuracy of
40. Nichamin LD. Astigmatism control. OphthalmolClin North OptiMedica Femtosecond Laser Capsulotomy vs. manual
Am.2006;19:485–493. capsulorohexis [abstract]. In: Program and Abstracts of
41. Leaming DV. Practice styles and preferences of ASCRS XXVIII Congress of the ESCRS; 4–8 September 2010; Paris,
members: 2002 survey. J Cataract Refract Surg 2003; 29:1412– France.
1420. 60. Nichamin LD, NaranjoTackman R, VillarKuri J, Fishkind W.
42. Fine IH. Clear corneal incisions. IntOphthalmol Clin.1994; Laser capsulotomy with the LensAR laser system [abstract].
34:59–72. In: Program and Abstracts of XXVIII Congress of the ESCRS;
43. Taban M, Behrens A, Newcomb RL, et al. Acute 4–8 September 2010; Paris, France.
endophthalmitis following cataract surgery: a systematic 61. Nagy Z. Comparative analysis of femtolaser-assisted and
review of the literature. Arch Ophthalmol.2005;123:613–620. manual capsulorhexis during phacoemulsification [abstract].
44. Xia Y, Liu X, Luo L, et al. Early changes in clear cornea In: Program and Abstracts of XXVIII Congress of the ESCRS;
incision after phacoemulsification: an anterior segment 4–8 September 2010; Paris, France.
optical coherence tomographystudy. ActaOphthalmol 2009; 62. Vukich J. The role of precise anterior capsulotomies in
87:764–768. premium lens performance objectives [abstract]. In: Program
45. Masket S, Sarayba M, Ignacio T, Fram N. Femtosecond laser- and Abstracts of XXVIII Congress of the ESCRS; 4–8
assisted cataract incisions: architectural stability and September 2010; Paris, France.
reproducibility. J Cataract Refract Surg 2010; 36:1048–1049. 63. Fishkind W, Uy H, Tackman RN, Kuri JV. Alternative
46. Stonecipher K, Ignacio TS, Stonecipher M. Advances in fragmentation patterns in femtosecond laser cataract surgery
refractive surgery: microkeratome and femtosecond laser flap [abstract]. In: Program and Abstracts of American Society of
creation in relation to safety, efficacy, predictability, and Cataract and Refractive Surgeons Symposium on Cataract,
biomechanical stability. CurrOpin Ophthalmol2006; 17:368– IOL and Refractive Surgery; 9–14 April 2010; Boston,
372. Massachusetts.
47. Herna´ndez-Verdejo JL, Teus MA, Roma´n JM, Bolý´var G. 64. Koch DD, Batlle J, Feliz R, et al. The use of OCT-guided
Porcine model to compare real-time intraocular pressure femtosecond laser to facilitate cataract nuclear disassembly
during LASIK with a mechanical microkeratome and and aspiration [abstract]. In: Program and Abstracts of XXVIII
femtosecond laser. Invest Ophthalmol Vis Sci 2007; 48:68– Congress of the ESCRS; 4–8 September 2010; Paris, France.
72. 65. Krueger RR, Kuszak J, Lubatschowski H, et al. First safety
48. Chaurasia SS, LuengoGimeno F, Tan K, et al. In vivo real- study of femtosecond laser photodisruption in animal lenses:
time intraocular pressure variations during LASIK flap tissue morphology and cataractogenesis. J Cataract Refract
creation. Invest Ophthalmol Vis Sci2010; 51:4641–4645. Surg 2005; 31:2386–2394.
49. Slade SG, Culbertson WW, Krueger RR. Femtosecond lasers 66. Stachs O, Schumacher S, Hovakimyan M, et al. Visualization
for refractive cataract surgery. Cataract Refract Surg Today; of femtosecond laser pulse-induced microincisions inside
August 2010. pp. 67–73. crystalline lens tissue. J Cataract Refract Surg 2009; 35:1979–
50. Doors M, Berendschot TT, de Brabander J, et al. Value of 1983.
optical coherence tomography for anterior segment surgery. 67. Ripken T, Oberheide U, Fromm M, et al. Fs-laser induced
J Cataract Refract Surg2010;36:1213–1229. elasticity changes to improve presbyopic lens
51. Wylegala E, Teper S, Nowinska AK, et al. Anterior segment accommodation. Graefes Arch ClinExp Ophthalmol2008;
imaging: Fourierdomain optical coherence tomography 246:897–906.
versus time-domain optical coherence tomography. J Cataract 68. Krueger RR, Sun XK, Stroh J, Myers R. Experimental increase
Refract Surg 2009; 35:1410–1414. in accommodative potential after neodymium: yttrium-
52. Kim HY, Budenz DL, Lee PS, et al. Comparison of central aluminum-garnet laser photodisruption of paired cadaver
corneal thickness using anterior segment optical coherence lenses. Ophthalmology 2001; 108:2122–2129.
tomography vs ultrasound pachymetry.Am J Ophthalmol 69. Lee D, Kim JH, Oh SH, et al. Femtosecond laser lamellar
2008; 145:228–232. keratoplasty to aid visualization for cataract surgery. J Refract
53. Konstantopoulos A, Hossain P, Anderson DF. Recent Surg 2009; 25:902–904.
advances in ophthalmic anterior segment imaging: a new era 70. Nishimoto H, Shimizu K, Ishikawa H, Uozato H. New
for ophthalmic diagnosis? Br J Ophthalmol2007; 91:551–557. approach for treating vertical strabismus: decentered
54. Swartz T, Marten L, Wang M. Measuring the cornea: the latest intraocular lenses. J Cataract Refract Surg2007; 33:993–998.
developments in corneal topography. CurrOpinOphthalmol 71. Kessel L, Eskildsen L, van der Poel M, Larsen M. Noninvasive
2007; 18:325–333. bleaching of the human lens by femtosecond laser photolysis.
55. Nixon D. Preoperative cataract grading by Scheimpflug PLoS One 2010; 5:e9711.
imaging and effect on operative fluidics and 72. Ignacio TS, Nguyen TB, Chuck RS, Kurtz RM, Sarayba MA.
phacoemulsification energy. J Cataract Refract Surg2010; Top hat wound configuration for penetrating keratoplasty
36:242–246. using the femtosecond laser: a laboratory model.Cornea.2006
56. Slade S. Refractive cataract surgery with a femtosecond laser: Apr; 25(3):336-40.

168 Ophthalmology Update Vol. 11. No. 2, April-June 2013

Major Review of the Applications of Femtosecond Laser in Ophthalmology

73. Steinert RF, Ignacio TS, Sarayba MA.”Top hat”-shaped penetrating keratoplasty. Am J Ophthalmol.2008 Jul;
penetrating keratoplasty using the femtosecond laser. Am J 146(1):46-49.
Ophthalmol.2007 Apr; 143(4):689-91. 85. Anwar M, Teichmann KD. Deep lamellar keratoplasty:
74. Farid M, Kim M, Steinert RF. Results of penetrating surgical techniques for anterior lamellar keratoplasty with
keratoplasty performed with a femtosecond laser zigzag and without baring of Descemet’s membrane.
incision initial report. Ophthalmology.2007 Dec; Cornea.2002 May;21(4):374-83.
114(12):2208-12. 86. Tan DT, Parthasarathy A. Deep anterior lamellar keratoplasty
75. Buratto L, Böhm E. The use of the femtosecond laser in for keratoconus. Cornea.2007 Sep; 26(8):1025; author
penetrating keratoplasty. Am J Ophthalmol. 2007 reply 1025-6.
May;143(5):737-742. Epub 2007 Mar 19. 87. Park KA, Ki CS, Chung ES, et al. Deep anterior lamellar
76. Price FW Jr, Price MO. Femtosecond laser shaped penetrating keratoplasty in Korean patients with Avellino dystrophy.
keratoplasty: one-year results utilizing a top-hat Cornea.2007 Oct; 26(9):1132-5.
configuration. Am J Ophthalmol.2008 Feb;145(2):210-214. 88. Parthasarathy A, Tan DT. Deep lamellar keratoplasty for
77. Cheng YY, Tahzib NG, van Rij G, et al. Femtosecond laser- acanthamoeba keratitis. Cornea.2007 Sep; 26(8):1021-3
assisted inverted mushroom keratoplasty. Cornea.2008 Jul; 89. Villarrubia A, Pérez-Santonja JJ, Palacín E, et al. Deep anterior
27(6):679-85. lamellar keratoplasty in post-laser in situ
78. Bahar I, Kaiserman I, Lange AP, et al. Femtosecond laser keratomileusiskeratectasia. J Cataract Refract Surg. 2007 May;
versus manual dissection for top hat penetrating keratoplasty. 33(5):773-8.
Br J Ophthalmol.2009 Jan; 93(1):73-8. 90. Colin J, Velou S. Current surgical options for keratoconus. J
79. Seitz B, Brünner H, Viestenz A, et al.Inverse mushroom- Cataract Refract Surg.2003 Feb; 29(2):379-86.
shaped nonmechanical penetrating keratoplasty using a 91. Farid M, Steinert RF. Deep anterior lamellar keratoplasty
femtosecond laser. Am J Ophthalmol.2005 May; 139(5):941- performed with the femtosecond laser zigzag incision for the
4. treatment of stromal corneal pathology and ectatic disease. J
80. Meltendorf C, Schroeter J, Bug R, et al. Corneal trephination Cataract Refract Surg. 2009 May; 35(5):809-13.
with the femtosecond laser. Cornea.2006 Oct; 25(9):1090-2. 92. Price FW Jr, Price MO, Grandin JC, et al. Deep anterior
81. Holzer MP, Rabsilber TM, Auffarth GU. Penetrating lamellar keratoplasty with femtosecond-laser zigzag
keratoplasty using femtosecond laser. Am J incisions. J Cataract Refract Surg. 2009 May; 35(5):804-8.
Ophthalmol.2007 Mar; 143(3):524-6. 93. Chan CC, Ritenour RJ, Kumar NL, et al. Femtosecond laser-
82. Hoffart L, Proust H, Matonti F, et al. Short-term results of assisted mushroom configuration deep anterior lamellar
penetrating keratoplasty performed with the Femtec keratoplasty. Cornea.2010 Mar; 29(3):290-5.
femtosecond laser. Am J Ophthalmol.2008 Jul;146(1):50-55 94. Cheng YY, Schouten JS, Tahzib NG, et al. Efficacy and safety
83. Farid M, Steinert RF, Gaster RN, et al. Comparison of of femtosecond laser-assisted corneal endothelial
penetrating keratoplasty performed with a femtosecond laser keratoplasty: a randomized multicenter clinical trial.
zig-zag incision versus conventional blade trephination. Transplantation.2009 Dec 15; 88(11):1294-302.
Ophthalmology.2009 Sep; 116(9):1638-43. 95. Cheng YY, Hendrikse F, Pels E, et al. Preliminary results of
84. Mastropasqua L, Nubile M, Lanzini M, et al. Orientation teeth femtosecond laser-assisted descemet stripping endothelial
in nonmechanical femtosecond laser corneal trephination for keratoplasty. Arch Ophthalmol.2008 Oct; 126(10):1351-6.

Vitreous Cyst
Dr. Naveed Ahmad Qureshi
Assistant Professor, Al-Shifa Trust Eye Hospital, Rawalpindi

A 22 years old female presented with night blindness and

reduced vision from early childhood presented with large object floating
in front of left eye. BCVA, OD-6/24 OS-6/18.A small cyst clear fluid
inside covered with pigments freely floating in mid vitreous.
Regarding origin of congenital vitreous cysts, it is said that pigmented
ones originate from pars ciliaris epithelium where as non-pigmented
arise from hyloid vascular system.

DD.Cysticercosis, mobile pigmented vitrous cyst

Treatment options include argon laser or yagphotocystostomy for small and PPV for large cysts.
(on line)

Ophthalmology Update Vol. 11. No. 2, April-June 2013 169

 Original Article
General Section

Asymptomatic Bacteriuria in Pregnant Women

Rubina Akhtar MBBS1, Hina Mehwish Khan MBBS2

ABSTRACT
Objectives:To determine the prevalence of asymptomatic bacteriuria in pregnant Women. Dr. Rubina
Study design, setting and duration:This descriptive study was conducted at Department of Obstetrics & Gynecology
Unit “B” of Hayatabad Medical Complex Peshawar from January 2012 to December 2012. It is one of the three tertiary
care hospitals in Khyber Pakhtunkhwa.
Materials & Method:A total of 780 pregnant women with no clinical features suggestive of urinary tract infections attending
the Out Patient Department (OPD) were included in the study. Women with history of urinary tract infection (UTI) symptoms,
medical problems (like diabetes, hypertension or renal disease), and those who had taken antibiotics in the last two
weeks or those with active regional bleeding were not considered. Urine specimens were collected for culture. The
organism was identified by routine methods from the samples showing significant bacteriuria.
Results:Among the total of 780 pregnant women, 78 (10%) were found with bacteriuria. Majority of the patients (58%)
having bacteriuria were in the age group between 25 to 35 years. Escherichia coli (32%) were the largest organism
followed by Klebsiella pneumonia (28%) and Proteus mirabilis (14%).
Conclusion:Asymptomatic bacteriuria is a common infection during pregnancy and may have adverse effects on mother
and child, if left, undiagnosed. Routine urine cultural test should be carried out on all pregnant in order to identify any
unsuspecting infection. There is need on the part of health care providers to realize the importance of screening pregnant
women for ASB. This measure will help greatly in dropping maternal and obstetric complications associated with pregnancy.
Key words: Bacteriuria, Pregnancy, urine culture, organism.

INTRODUCTION children’s health in UK11.

Special attention to the pregnant women is one of Urinary tract infections (UTI) affects all age
the most important points in health care. One of the groups, but women particularly pregnant women are
problems in pregnancy is urinary tract infection (UTI).1,2 more susceptible than men, due to short urethra,
The prevalence of asymptomatic UTI has been reported pregnancy, easy contamination of urinary tract with
to be 2% to 11% in pregnant women (6% to 8% in fecal flora.11 UTI are a common problem in pregnancy.
average).3-7 Due to the increase in sex hormones and It is of two types, symptomatic or asymptomatic.
the anatomic and physiologic changes during Asymptomatic bacteriuria (ASB) is defined as the
pregnancy, bladder and kidney infection is more likely “presence of actively multiplying bacteria within the
and may result in hypertension, pre-eclampsia, low urinary tract excluding the distal urethra”, at a time
birth weight, prematurity, septicemia, and maternal when the patient has no urinary symptoms.10
death.2,4,5,8,9 The most common infecting organism is
Risk of pre-term delivery or low birth weight escherichia coli,which is responsible for 75-90% of
babies and development of pyelonephritis decreased bacteriuria during pregnancy. 40% of the asymptomatic
in the treatment group of asymptomatic bacteriuria bacteriuria cases develop into acute symptomatic UTI.
compared with placebo or no treatment10. Routine Hence early detection and treatment is of considerable
screening for asymptomatic bacteriuria by midstream importance not only to forestall acute pyelonephritis
urine culture early in pregnancy is recommended as and chronic renal failure in the mother, but also to
routine care for the healthy pregnant women by reduce prematurity and fetal mortality in the
national collaborating center for women’s and offspring.12
———————————————————————————————— MATERIAL AND METHOD
1.
Resident (Obstetrics & Gynaecology) Gynae B Unit, Hayatabad
Medical Complex, Peshawar. 2. Post graduate Trainee Radiology
This descriptive study based on sample of
Department Hayatabad Medical Complex, Peshawar. convenience was conducted on women who attended
———————————————————————————————— outpatient department of Obstetrics & Gynecology of
Correspondence:DrRubinaAkhtar, House No. 485, Street No. 5, Hayatabad Medical Complex Peshawar from January’
Sector F9, Phase 6, Hayatabad, Peshawar.
E.Mail: [email protected] Mobile +92 300 9339930
2012 to December’ 2012. The inclusion criteria set for
Res. +92 91 5860126 this study was to include all pregnant women having
———————————————————————————————— no clinical features suggestive of urinary tract infection.
Received: Oct’2012 Accepted: Jan’2013 Informed consent was taken from all the patients and
————————————————————————————————

170 Ophthalmology Update Vol. 11. No. 2, April-June 2013

Asymptomatic Bacteriuria in Pregnant Women

the requisite information were entered in the pre- DISCUSSION

designed proforma. Patients with the following features Asymptomatic bacteriuria is common during
were not considered for this study. pregnancy15. Relationship between the incidence of
Exclusion criteria: asymptomatic bacteriuria and pregnancy has always
i. Women with history of UTI Symptoms been a subject of interest. The frequency of ASB in my
ii. Women with medical problem like diabetes, study was 10%. This figure falls within 2-10% range of
hypertension or renal disease prevalence in the population quoted in epidemiological
iii. Women who had taken antibiotics in the last two studies.16,17
weeks In the present study, it is observed that pregnant
iv. Women with active regional bleeding. women in the age group 25-35 years had highest
Urine samples were collected from the pregnant percentage of infection (58%). This results correlates
women qualifying the inclusion criteria in a tightly with Imade et al.18 Advanced maternal age was reported
sealable sterile container. Microscopic as risk factor for asymptomatic bacteriuria in pregnancy
examination of a wet film of un-centrifuged urine and also could be due to the fact that many women
was carried out to detect the presence of pus cells, within this age group are likely to have had many
erythrocytes, microorganisms, casts etc. The children and it has been reported that multiparity is a
samples were processed using standard risk factor for acquiring asymptomatic bacteriuria in
microbiological procedures. Culture results were pregnancy.19,20
interpreted as being significant and insignificant, Most cases of asymptomatic bacteriuria were
according to the standard criteria. The organism found during 3rd trimester (41%) of pregnancy. This
was identified by routine methods from the results correlates with other studies.21In our study
samples showing significant bacteriuria.13,14The significant growth was found in (10%) cases and (90%)
results were analyzed using mean, median and samples were sterile. These results were consistent with
Chi-square test. P (predictive) value of <0.05 were reports of the recent studies.11,12,18,22,23 The presence of
considered as a significant association between the significant bacteriuria indicates the significance of
variables tested. microbiological culture to clinch the diagnosis of urinary
RESULT tract infection. Bacterial isolates have been changing
The study revealed that according to the age from time to time and from place to place. In our study
distribution the highest number of culture positive cases organisms isolated, correlated with various others
(58%) among pregnant women were in the age group studies.11,12,18,22,23
25-35 years. 18 (23%) of the patients were in the age The antimicrobial sensitivity and resistance
group of 18-24 years and 19% in the age group of 36-45 pattern varies from hospital to hospital. This is because
years. of emergence of resistant strains as a result of
unselective use of antibiotics. In our study isolates
Table 1. Age distribution of the culture –positive cases showed 100% sensitivity to imipenem. Among the
Age Total no. of Culture %age aminoglycosides, amikacin demonstrated (85%)
Group Positive Cases in years sensitivity. Nitrofurantoin (68%) showed increased
18-24 18 23 sensitivity when compared to ceftazidime (62%) and
25-35 58 58 cefotaxime (62%). Ampicillin was found to be least
36-45 18 19 sensitive (11%). Our Anti-biogram pattern correlates
Total 78 100 with others studies.11,18,22 The upsurge in antibiotic
resistant pattern could be due to antibiotic abuse and
With respect to trimester the culture positive cases self-medication. Also low cost and availability of
are as shown in Table 2. drugs could be another contributing factor for
antibiotic resistance.
Table 2 CONCLUSION
Asymptomatic bacteriuria is a common infection
Trimester Total no. ofCulture %age
PositiveCases
during pregnancy and may have adverse effects on
First 16 20.5
mother and child, if left, undiagnosed. Routine urine
Second 30 38.5
cultural test should be carried out on all pregnant in
Third 32 41
order to identify any unsuspecting infection. There is
need on the part of health care providers to realize the
Total 78 100
importance of screening pregnant women for ASB. This
measure will help greatly in dropping maternal and

Ophthalmology Update Vol. 11. No. 2, April-June 2013 171

Asymptomatic Bacteriuria in Pregnant Women

obstetric complications associated with pregnancy. Hospital, India. JCDR 2010;4(4):2702-2706.

REFERENCES 13. Collee JG, Duguid JP, Fraser AG, Marmion BP, Simmons A.
1. Mittal P, Wing DA. Urinary tract infections in pregnancy. Laboratory strategy in the diagnosis of infective syndromes.
ClinPerinatol. 2005;32:749-64. In: Collee JG, Fraser AG, Marmion BP, Simmons A, editors.
2. Saidi A, Delaporte V, Lechevallier E. [Urological problems Mackie and McCartney, practical medical microbiology. 14th
encountered during pregnancy]. Prog Urol.2005;15:1-5. ed. Edinburgh: Churchill Livingstone; 1996. p. 84-90.
French. 14. Praveen R, Saha SK, Shamshuzzaman SM, Rashid AL,
3. Kutlay S, Kutlay B, Karaahmetoglu O, Ak C, Chaudhury A, Muazzam N. Detection of uropathogen by
ErkayaS.Prevalence, detection and treatment of using chromogenic media (Hicrome UTI agar), CLED agar
asymptomatic bacteriuria in a Turkish obstetric population. and other conventional media. Faridpur Med Coll. J.
J Reprod Med. 2003;48:627-30. 2011;6(1): 46-50.
4. Delzell JE Jr, Lefevre ML. Urinary tract infections during 15. Maclean AB. Urinary tract infection in pregnancy. Int J
pregnancy. Am Fam Physician. 2000;61:713-21. Antimicrob Agents 2001; 17: 273-6.
5. Abyad A. Screening for asymptomatic bacteriuria in 16. Larry C, Gilstrap LC, Susan M, Ramin MD. Urinary tract
pregnancy: urinalysis vs urine culture. J infections during pregnancy. ObstetGynecol 2001; 28: 1-9.
FamPract.1991;33:471-4. 17. Kennedy E. Pregnancy, urinary tract infections. E Med 2001;
6. Christensen B. Which antibiotics are appropriate for treating 7: 1-10.
bacteriuria in pregnancy? J AntimicrobChemother. 18. Imade PE, Izekor PE, Eghafona NO, Enabulele OI, Ophori E.
2000;46:29-34. Asymptomatic bacteriuria among pregnant women. North
7. McIsaac W, Carroll JC, Biringer A, et al. Screening for Am J Med Sci 2010;2(6):263-266.
asymptomatic bacteriuria in pregnancy. J ObstetGynaecol 19. Akinloye O, Ogbolu DO, Akinloye OM, Terryalli OA.
Can. 2005;27:20-4. Asymptomatic bacteriuria in pregnancy in Ibadan, Nigeria:
8. Klein LL, Gibbs RS. Use of microbial cultures and antibiotics a re-assessment. Br J Biomed Sci 2006;63(3):109-112.
in the prevention of infection-associated preterm birth. Am J 20. Fatima N, Ishrat S. Frequency and risk factors of
Obstet Gynecol. 2004;190:1493-502. asymptomatic bacteriuria during pregnancy. J Coll
9. Grio R, Porpiglia M, Vetro E, et al. Asymptomatic bacteriuria Physicians Surg Pak 2006;16(4):273-275.
in pregnancy: a diagnostic and therapeutic approach. 21. Saeed S, Tariq P. Symptomatic and Asymptomatic Urinary
Panminerva Med. 1994;36:195-7. Tract Infections during pregnancy. Intl.J.Microbiol.Res
10. Jayalakshmi J, Jayaram VS. Evaluation of various screening 2011;2(2): 101-104.
tests to detect asymptomatic bacteriuria in pregnant women. 22. Abdullah AA, Al-Moslih MI. Prevalence of asymptomatic
Indian J PatholMicrobiol 2008;51 (3):379-381. bacteriuria in pregnant women in Sharjah, United Arab
11. Enayat K, Fariba F, Bahram N. Asymptomatic bacteriuria Emirates. Eastern editerranean Health Journal
among pregnant women referred to outpatient clinics in 2005;11(5):1045-1052.
Sanandaj, Iran. IntBraz J Urol. 2008; 34(6):699-707. 23. Khattak AM, Khattak S, Khan H, Ashiq B, Mohammad D,
12. Gayathree L, Shetty S, Deshpande SR, Venkatesh DT. Rafiq M. Prevalence of asymptomatic bacteriuria in pregnant
Screening for asymptomatic bacteriuria in pregnancy: An women. Pak J Med Sci 2006;22(2):162-166.
evaluation of various screening tests in Hassan District

Letter to the Editor:

Dear Prof. Yasin Durrani

I am writing to express my deep gratitude to you for sending me in December, the latest issue of
Ophthalmology Update - Jan-March 2013, which I have just received. Quick look on the Journal have
shown me that I shall read the whole content with great interest as it happens always reading
Ophthalmology Update under your Editorship. With many thanks one more time, wishing you
continued fruitful work and prosperity. Warmest regards,

Prof. Marianne Shahsuvaryan

Prof. of Ophthalmology,
Armenia

172 Ophthalmology Update Vol. 11. No. 2, April-June 2013