Homocystinuria in a 14-year old girl manifesting as central retinal artery occlusion: A case report.

Central retinal artery occlusion (CRAO) is one of the causes of sudden loss of vision. Homocystinuria is an autosomal recessive inherited disorder and is characterized by increased levels of homocysteine in the urine and blood. We present a case of homocyistinuria in a 14-year girl, presenting as CRAO with a family history of vascular thrombotic events. The patient did not have any local predisposing factors or prior history of thromboembolic episodes. Left eye fundus examination revealed a pale retina with sparing of cilioretinal artery. On examination Visual acuity of the right eye was 6/6 and left eye was completely blind with no perception of light. Homocysteine level on admission was 34.60umol/l. Patient was started on Rivaroxaban 10mg, Vitamin B6 , Vitamin B12 and folic acid. On follow up examination after 2 months the visual acuity in the left eye was 6/9. The dramatic improvement in the visual acuity can be attributed to the sparing of the cilioretinal artery. Followup Homocysteine levels after two months of treatment was 12umol/l. Ophthalmologist should be aware of this rare manifestation of homocystinuria as CRAO as they can play an important role of diagnosing the underlying medical illness.

Low toxicological impact of wastewaters on drinking water sources.

Surface waters may contain varying levels of wastewater effluent associated with de facto reuse, which may influence their toxicological properties both prior to and following treatment. This study examined the genotoxic response of three surface waters containing a range of wastewater effluent (5%, 10%, and 25% by volume). The SOS Chromotest™ was used to assay the genotoxicity of both chlorinated and unchlorinated mixtures. Chlorinated mixtures were also analyzed for trihalomethanes (THMs), haloacetonitriles (HANs), and halonitromethanes (HNMs); their concentrations were used to calculate a relative toxicity index for each sample, based on published potencies in the comet assay and subsequently referred to as predicted genotoxicity. Wastewater effluents were observed to be reactive in the genotoxicity assay, whereas raw and chlorinated surface waters were not. Upon chlorination, surface waters containing 5% or 10% wastewater did not elicit a response and only modest effects were observed for higher wastewater ratios (25%). The measured SOS responses correlated well with predicted genotoxicity (R = 0.92) and THM concentrations (R = 0.92). This is important since THMs themselves are non-reactive in either the SOS or comet genotoxic assays, but their formation may serve as surrogates for non-regulated DBPs which drive toxic effects.

Systemic Lupus Erythematosus Presenting as Optic Neuropathy: A Case Report.

Systemic lupus erythematosus (SLE) is a chronic inflammatory disease with a wide variety of clinical presentations as a result of its effect on several organ systems. Optic nerve involvement in SLE is very uncommon, but optic neuritis can be the initial manifestation of SLE. A previously healthy 47-year-old woman developed blurring of vision in the left eye for the last three weeks and associated periorbital pain that worsened with eye movement. On a review of systems, she reported a photosensitivity rash, painless oral ulcers, and generalized arthralgia. On examination, she had relative afferent pupillary defect (RAPD) in the left eye. A visual field analysis revealed bilateral arcuate defects. Positive antinuclear antibodies (ANA), anti-beta2-glycoprotein I, and low complement levels of C4 were found consistent with the diagnosis of SLE. We present a case of optic neuropathy as the initial manifestation of SLE in a 47-year-old lady and an associated review of the literature.

A case of Vogt Koyanagi Harada disease in a 16 year old girl.

Vogt Koyanagi Harada (VKH) is an autoimmune disease with widespread systemic manifestations. It typically presents with bilateral sudden painless loss of vision. It is mainly characterized by serous retinal detachment, iridocyclitis and choroidal swelling. The disease is more common in females and maximus incidence occurs in the age group of 30 to 40 years. We present a case of a 16-year-old girl who presented with sudden bilateral painless loss of vision. Fundus examination and OCT scanning confirmed bilateral serous retinal detachment. Patient was started on IV methylprednisolone and the patient showed excellent response with marked improvement in visual acuity. VKH is very uncommon in children and is usually missed. It is important for general practitioners and ophthalmologists to know about this rare cause of painless loss of vision so that it could be managed adequately.

Non arteritic anterior ischemic optic neuropathy; does Anticoagulation help?

BACKGROUND: Non Arteritic Anterior Ischemic Optic Neuropathy (NAION) is the most common acute optic neuropathy in patients over 50 years of age. This study was conducted to determine the beneficial effects of anticoagulation with Heparin and Warfarin in patients with NAION presenting within 4 weeks of onset of symptoms. METHODS: A prospective, interventional, pilot study was conducted in Eye- A unit of Khyber Teaching Hospital from July 2010 onwards on patients with NAION presenting within 4 weeks of onset of symptoms. Patients underwent complete ophthalmological examination including Snellen's visual acuity (latter converted to Log MAR), pupil examination, fundus examination and automated Humphrey visual field analysis. Hematologic tests, Thrombophilia screening, Echocardiography and carotid Doppler ultrasound were carried on patients. All patients were anticoagulated with Heparin and Warfarin after obtaining informed written consent. Patients were examined at 1 Month, 3 months and 6 months' time period. Primary parameter measured was improvement in visual acuity. RESULTS: Total number of patients in our study was 24. Regarding visual outcome total number of patients having significant improvement of visual acuity in our study was 16 (66.6%), while 4 (16.7%) patients had marginal improvement of visual acuity. Three (12.5%) patients maintained stable visual acuity of 6/6 throughout the study period in presence of thrombophilic disorders. One patient (4.1%) suffered a decline in visual acuity compared to VA at baseline presentation. CONCLUSIONS: Anticoagulation using heparin and warfarin does benefit patients with NAION presenting within 4 weeks of onset of symptoms. In our study a higher proportion of patients experienced significant improvement of visual acuity following anticoagulation as compared to the highest reported spontaneous improvement in such patients.

Comparison of the efficacy of subtenon with peribulbar local anesthesia without hyaluronidase in patients undergoing cataract surgery.

OBJECTIVE: To compare the efficacy of subtenon with peribulbar local anesthesia without hyaluronidase in patients undergoing cataract surgery. STUDY DESIGN: A randomized controlled trial. PLACE AND DURATION OF STUDY: Eye "B" Unit, Khyber Teaching Hospital, Peshawar, from October 2009 to October 2010. METHODOLOGY: Patients undergoing cataract surgery were divided into two groups. Group A received subtenon anesthesia and group B received peribulbar anesthesia. Pain score, akinesia and intraocular pressure were compared in the two groups. Statistical Package for Social Sciences-14.0 was used for data analysis. RESULTS: There were 304 patients, 152 patients in each group. At the time of injection, there was less pain in group A as compared to group B (p < 0.001). At the time of surgery and till 90 minutes after administration of anesthesia, there was no significant difference in pain between the 2 groups (p = 0.999 and 0.59 respectively). Group A had better akinesia as compared to group B (p = 0.04). There was a greater rise in mean intraocular pressure just after injection in group B as compared to group A (p < 0.001); in both groups, the intraocular pressure declined to its base level 10 minutes after the injection (p = 0.52). CONCLUSION: Subtenon anesthesia is less painful at the time of its administration, provides better akinesia and leads to smaller rise in intraocular pressure just after the injection than peribulbar anesthesia.

Vogt Koyanagi Harada disease: treatment and visual prognosis.

Vogt Koyanagi Harada (VKH) disease is a chronic, bilateral, granulomatous panuveitis associated with central nervous system, auditory and integumentary manifestations. The study was conducted from January 2001 to December 2010 at the Department of Ophthalmology, Khyber Teaching Hospital, Peshawar. A total of 9 patients with diagnosis of Vogt Koyanagi Harada disease were included in the study. Extracted data included age, gender, duration of disease, initial and final visual acuities, treatment and complications. Initial visual acuity was ranging from 6/24 to perception of light. All the patients were treated with systemic and topical corticosteroids. In addition, one patient also received cytotoxic therapy. Final visual acuity was 6/18 or better in all cases (100%). One patient developed bilateral cataract, glaucoma and subretinal fibrosis at the macula. The cataract and glaucoma were managed as per established protocols. The visual prognosis of Vogt Koyanagi Harada disease is generally favourable if the disease is identified early and adequately treated and the associated complications are addressed properly.

Ocular injuries in blast victims.

OBJECTIVE: To study the type and severity of ocular injuries in blast victims. METHODS: It was a descriptive case series. The study was conducted at the Department of Ophthalmology, Khyber Teaching Hospital and Iqbal Eye Clinic Peshawar from March 2010 to May 2011. Detailed history was taken and complete ocular examination was done. B-scan was done to know about any posterior segment pathology (when required). Digital X-ray orbit and/or computed tomography were done to rule out intraocular foreign body. The treatment and follow up varied according to the type and extent of eye injury. RESULTS: Total number of patients were 79, 78 (98.73%) males and 1 (1.26%) female. Mean age of patients was 23.43 +/- 10.67 years. Ocular injury was unilateral in 50 (63.29%) and bilateral in 29 (36.70%) patients. Forty-one (37.96%) eyes had closed globe injury and 67 (62.03%) had open globe injury. The most common type of injury was corneal/scleral perforation (48.14%) followed by vitreous haemorrhage (38.88%) and traumatic cataract (30.55%). The most commonly performed surgery was corneal/scleral repair (in 33 eyes). Final best corrected visual acuity (BCVA) improved in 56 (51.85%) eyes, remained unchanged in 49 (45.37%) eyes and worsened in 03 (2.77%) eyes. CONCLUSION: Blast related ocular injuries are becoming increasingly common. In severely injured eyes the visual prognosis remains poor despite development of advanced microsurgical techniques and better methods of visual rehabilitation.

Non-viral microbial keratitis: etiology, clinical features and visual outcome.

OBJECTIVE: To determine the etiology, clinical features and visual outcome in non-viral microbial keratitis. STUDY DESIGN: An observational study (case series). PLACE AND DURATION OF STUDY: Department of Ophthalmology, Khyber Teaching Hospital, Peshawar, Pakistan, from January 2007 to December 2009. METHODOLOGY: Charts of all patients with infective keratitis treated at the department were reviewed. The data collected and recorded on a standardized form included age, gender, predisposing factors, microbiology results of culture and sensitivity, clinical features, treatment given, complications and visual acuity at last follow-up (at least 2 months). RESULTS: Among a total of 228 cases, 148 were male (64.9%) and 80 were female (35.1%). Mean age of the patients was 42.8 ± 21.9 years. Trauma was the most common (31.5%) predisposing factor followed by previous ocular surgery (8.8%) and use of topical steroids (6.6%). The most common isolate among positive cultures was Staphylococcus aureus isolated in 31.4% (11/35) eyes followed by fungal hyphae in 25.7% (9/35) and Gram negative bacilli in 17.1% (6/35) eyes. Visual outcome was good (> 6/18) in 19.6 %, moderate (< 6/18 to ³ 6/60) in 22% and poor (< 6/60) in 58.4%. CONCLUSION: The main predisposing factors in the studied group of patients with non-viral keratitis were ocular trauma and injudicious use of topical steroids. The most common microorganism involved was Staphylococcus aureus. Visual outcome was moderate to poor even after successful treatment.