Vitamin D deficiency: A risk factor for myopia in children - a cross sectional study in a tertiary care centre.

Objective: To study the role of vitamin D deficiency as a risk factor for myopia in children aged 5-15 years. METHODS: The cross-sectional observational study was conducted from January to September 2019 at the Ophthalmology and Paediatric departments of Shifa Foundation Community Health Centre, Islamabad, Pakista. It comprised patients with suspected / symptomatic vitamin D deficiency who were enrolled from the paediatric outpatient department and referred to the ophthalmology clinics for eye exam. Apart from taking detailed ocular history, slit lamp examination, Snellen's distance visual acuity, auto-refraction to calculate spherical equivalent, and amplitude scan for measuring the axial length were performed. An average of 3 measurements was taken for both refraction and axial length calculation. Myopia was labelled if mean spherical equivalent was ≤0.25 dioptres. Vitamin D deficiency was defined as serum 25-hydroxyvitamin D level < 20ng/ml. Data was analysed using SPSS 23. RESULTS: There were 72 subjects with a mean age of 10.11±2.69 years; 37(51.4%) boys and 35(48.6%) girls. Myopia was seen in 40(55.6%) patients, while 32(44.4%) were emmetropic. The overall mean vitamin D level was 20.25±12.18 ng/ml. There was no significant association between myopia and vitamin D deficiency (p=0.115). Significant associations were found between myopia and relatively older age (p=0.005), higher height (p=0.001), more weight (p=0.001) and higher body mass index value (p=0.008). Conclusion: Low vitamin D levels were not significantly associated with myopia in children aged 5-15 years, but significant associations were found between myopia and relatively older age, and various anthropometric measures.

Results of endoscopic endonasal dacryocystorhinostomy: A prospective cohort study.

OBJECTIVE: To evaluate the success rate of endoscopic endonasal dacryocystorhinostomy. METHODS: The prospective cohort study was conducted at the Ophthalmology and Otorhinolaryngology departments, Shifa Foundation Community Health Centre, Islamabad, Pakistan, from October 2017 to September 2019, and comprised chronic dacryocystitis patients who underwent endoscopic endonasal dacryocystorhinostomy. Endoscopic dacryocystorhinostomy with or without lacrimal intubation was performed under general anaesthesia. The patients were followed up post-operative at 1 week, 1 month, 6 months and 12 months. Data was analysed using SPSS 20. RESULTS: Of the 47 patients, 41(87.2%) were females. The overall mean age was 40.70±10.84 years (range: 25-66 years). Lacrimal intubation was performed in 31(66%) patients. Surgical success was achieved in 46(97.9%) patients. Of them, 37(78.7%) patients were completely symptom-free, while 9(19.1%) were partially symptomatic and were managed conservatively. Treatment failure requiring repeat surgical procedure was the case with 1(2.1%) patient. Procedure failure was more likely in patients with previous attacks of acute dacryocystitis (p=0.003). CONCLUSIONS: Endoscopic dacryocystorhinostomy was found to be a safe procedure with good anatomical and functional outcomes in chronic dacryocystitis patients.

Effect of refractive errors/axial length on peripapillary retinal nerve fibre layer thickness (RNFL) measured by Topcon SD-OCT.

OBJECTIVE: To evaluate the effect of refractive error and axial length on peripapillary retinal nerve fibre layer thickness in myopic, hypermetropic and emmetropic eyes by Topcon spectral domain optical coherence tomography. METHODS: This cross-sectional study was conducted at the ophthalmology clinic of Shifa Foundation Falahee Clinic, Islamabad, Pakistan, from January to December 2016, and comprised eye patients including emmetropes, hypermetropes and myopes. All participants underwent detailed ophthalmic examination including axial lengths measurements, auto refraction andretinal nerve fibre layer thickness analysis. Retinal nerve fibre layer thickness was obtained from the peripapillary quadrants: temporal, superior, nasal and inferior and 12 sub-quadrants using Topcon spectral domain optical coherence tomography. Pearson correlation coefficients (r) were calculated to evaluate relationships between the retinal nerve fibre layer thickness and axial length before and after adjustment for ocular magnification by using Littmann's formula. RESULTS: Of the total 93 eyes of as many patients, 46(49.5%) were right eyes and 47(51.5%) left eyes. There were 35(37.6%) myopes, 29(31.2%) hypermetropes and 29(31.2%) emmetropes. Mean age was 30.45±7.86years. Mean axial length was 23.40±1.25mm.Mean retinal nerve fibre layer thickness after correction of magnification effect was 100.59±9.25 µm. Correlation analyses showed that the average retinal nerve fibre layer thickness and mean thickness of major superior and nasal quadrants and also in nasal, upper nasal, superonasal, inferior and inferonasal sub-quadrants had negative correlation with axial length. However, correction of the magnification effect by applying Littmann's formula eliminated the relationship between the two.. CONCLUSIONS: Retinal nerve fibre layer thickness measurements were found to vary with refractive status and axial length of the eye. Ocular magnification significantly affected the retinal nerve fibre layer thickness, and it should be considered in diagnosing glaucoma.

Best Vitelliform Macular Dystrophy In Afghan Twins.

Best vitelliform macular dystrophy is the second most common type of hereditary fundus dystrophies. Our case report describes twin brothers of Afghan family who developed Best vitelliform macular dystrophy. One of them developed choroidal neovascularization in one eye which was treated with single intravitreal injection of bevacizumab. The patient showed stable vision and did not have any recurrence until 3 years of follow up. Many cases of familial Best vitelliform macular dystrophy have been described in medical literature but our report is unique as it presents twin brothers with Best vitelliform macular dystrophy which has never been described before.

Pain management with retrobulbar alcohol injection in absolute glaucoma.

Ocular pain can be multi-factorial and often refractory to treatment, in spite of the myriad options available to the ophthalmologist for its management. Initial therapy entails the use of topical and systemic pressure lowering agents as well as anti-inflammatory/analgesics for the provision of relief. Those refractory to medical therapy may require surgical intervention in the form of cyclodestructive procedures, retrobulbar injection of absolute alcohol and evisceration or enucleation. A case series of 5 patients of absolute glaucoma who were successfully treated with retrobulbar alcohol injection is reported. Pain was recorded on a verbal analogue score (VAS).All the patients were pain free twelve months after the injection. No significant long term complications were observed. This case series emphasizes the fact that retrobulbar alcohol injection can play an important role in the alleviation of pain in patients with absolute glaucoma.

Management of anisometropic abmlyopia in adults.

Amblyopia is characterised by decrease in vision in one or both eyes as a result of processing defect in the visual pathways of the brain. It is considered an irreversible process if detected in the adult age group. This study was conducted from July 1 to December 31, 2010, at Shifa Foundation Community Health Centre, Islamabad, to determine if anisometropic amblyopia detected in adults can be reversed. A total of 15 adults, 11 (73.33%) males and 4 (26.66%) females, were managed for anisometropic amblyopia. All the patients were prescribed full cycloplegic correction in the anisometropic eye simultaneously with part-time occlusion therapy. Success was defined as visual acuity of 6/18 or better at the end of the therapy. All patients were required to complete a structured questionnaire regarding their experiences with the therapy. Reversal of amblyopia was observed in 11 (73.33%) patients who felt more confident about performing tasks for which they had earlier considered themselves unsuitable. Poor compliance was responsible for not producing the desired outcome in 4 (26.66%) patients. Anisometropic amblyopia in adults is reversible with dedicated efforts on behalf of both the ophthalmologist and the patient.

Preseptal Cellulitis Due To Impetigo - A Case Report Of Uncommon Presentation In Pakistan.

We present the case of a 30-year-old woman who presented with 8-month history of intermittent fever, joint pains with morning stiffness, recurrent oral ulcers, photosensitivity, weight loss and hair fall. For the last 2 months, she had developed a dry cough with progressive shortening of breath. On examination, a cachexic lady with malar hyperpigmentation, alopecia, pallor, nail dystrophy and erythema over her hands and feet were noted. There were multiple punched-out skin ulcers of variable size over legs, arms and abdomen usually round in shape with well-defined even wound margins and scant serous discharge. Musculoskeletal examination revealed synovitis of both elbows and a few metacarpophalangeal and proximal interphalangeal joints. Chest X-ray and HRCT showed bilateral ground-glass opacification. Anti-Nuclear Antibody (ANA) was positive, 1:320, homogenous nuclear pattern. Anti-Ro antibody was highly positive and serum complement (C3, C4) levels were reduced. She was diagnosed with Lupus Vasculitis and started on steroids, mycophenolate mofetil and hydroxychloroquine.

Epidemiological Aspects Of Allergic Conjunctivitis.

BACKGROUND: Allergic conjunctivitis is a common ocular disease which not only affects vision but can also compromise the quality of life of patients to a greater extent. If it is not properly managed it can lead to decreased vision due to corneal complications. This study was conducted to evaluate the epidemiological aspects of allergic conjunctivitis. METHODS: This cross-sectional study was carried out in the Ophthalmology department of Federal General Hospital, from June 2018 to June 2020. We enrolled 236 patients of allergic conjunctivitis. Data collection form consisted of a structured questionnaire, records of ocular findings using slit lamp biomicroscope and skin prick test results. Data analysis was done using SPSS version 23.0. RESULTS: The mean age (±SD) of study population was 22.71±13.11 years, 60.2% were females. Most common type of conjunctivitis was vernal keratoconjunctivitis (VKC) 46.2%, followed by perennial (27.1%), seasonal (17.4%) and atopic (9.3%). There was significant association of type of conjunctivitis with the age, pvalue< 0.001. VKC was prevalent in patients of age <20 years. There was a significant association of gender with type of conjunctivitis, p-value =0.000. Perennial variety was more prevalent in females while VKC was common in males. Collateral atopy was present in 52.1% patients. Corneal involvement was seen in 17.8% patients. There was a significant association between corneal involvement and interference with daily visual activities, p-value 0.034. SPT was positive in 79.7% patients. CONCLUSIONS: Ocular allergies/ conjunctivitis was more prevalent in female population. VKC is the most common type of allergic conjunctivitis, prevalent in males of age <20 yrs. Allergic rhinitis was the most common co-morbidity followed by dermatitis.

Vision-related quality of life in Pakistani subjects with early or moderate glaucoma.

Background: The aim of this study was to report the vision-related quality of life (QoL) in Pakistani subjects with early or moderate glaucoma. Methods: This case control study was conducted at Al-Shifa Trust Eye Hospital, Pakistan, from 1 January 2014 to 31 December 2015. All the patients having early or moderate glaucoma, with a disease duration of at least 6 mo, and presenting during the study period, were included. Subjects in the control group were recruited from the hospital volunteer staff, spouses and friends of patients. QoL assessment was done using the NEIVFQ25 questionnaire translated into the Urdu language. A two-tailed t-test was used to test the significance of difference between the mean QoL scores and a p-value of ≤0.05 was considered significant. Multiple linear regression was carried out to assess the predictors of QoL scores. Results: A total of 698 participants were enrolled, including 247 cases and 451 controls. The mean QoL score was higher in controls 81.31 (mean=81.31, SD=26.33) than in cases (mean=53.89, SD=30.32), p<0.001. The lowest NEIVFQ-25 scores for glaucoma patients were for mental health (mean=23.88, SD=28.80) followed by general vision (mean=27.73, SD=29.74). The difference in all the mean subscale scores of two groups was statistically significant (p<0.001). Conclusion: QoL scores are significantly reduced in Pakistani glaucoma patients with early and moderate glaucoma, with more pronounced effect on mental health and general vision.

Peripapillary Retinal Nerve Fiber Layer (RNFL) Thickness Measurements by Topcon SD-OCT in Myopic Patients.

OBJECTIVE: To evaluate the effect of low-to-moderate myopia on peripapillary retinal nerve fiber layer (RNFL) thickness measured by Topcon SD optical coherence tomography (OCT). STUDY DESIGN: Cross-sectional study. PLACE AND DURATION OF STUDY: Ophthalmology Department, Shifa Foundation Falahee Clinic, over a period of one year starting from June 2015. METHODOLOGY: A total of 43 eyes of 43 patients, having mild to moderate myopic refractive error, were enrolled in the study. Refractive error/spherical equivalent was calculated. RNFL thickness was obtained from all four peripapillary quadrants: temporal, superior, nasal, and inferior; and 12 sub-quadrants using Topcon SD OCT. Pearson correlation coefficients (r) were calculated to evaluate relationships between the RNFL thickness and spherical equivalent (SE) before and after adjustment for ocular magnification. RESULTS: The study included 51.2% females and 48.8% males. Mean age was 30.9 ±6.45 years. Mean axial length was 24.25 ±0.91 mm. Mean SE was -3.25 ±1.93 DS. Mean of average RNFL thickness (with Littmann's correction) was 97.28 ±8.15 µm. Correlation analysis among all subjects showed that the average, mean nasal quadrant, upper nasal, and inferonasal sub-quadrant RNFL thickness had positive correlation with spherical equivalent (r = 0.31, p = 0.045).However, correction of the magnification effect by applying Littmann formula eliminated this effect. CONCLUSION: In low-to-moderate myopia, RNFL measurements vary with refractive error of the eye. Since ocular magnification significantly affects the RNFL measurement, it should be considered in diagnosing glaucoma.

Transient Corneal Edema After Phacoemulsification.

OBJECTIVE: To determine the association between pre-operative and intra-operative factors leading to transient corneal edema after phacoemulsification. STUDY DESIGN: Cohort study. PLACE AND DURATION OF STUDY: Department of Ophthalmology, Shifa Foundation Community Health Centre, Islamabad, from October 2011 to September 2012. METHODOLOGY: Patients undergoing phacoemulsification and Intraocular Lens (IOL) implantation were enrolled in the study using consecutive non-probability sampling. Pre-operative risk factors including peripheral corneal degenerations, the type and density of cataract were documented. Surgical risk factors included the incision site, the type of intraocular lens, the phacotechnique and the phacopower time. Postoperatively the patients were assessed for corneal clarity and the degree of striate keratopathy. Statistical analysis was done using SPSS version 17. RESULTS: There were 43% male and 57% female patients (n = 182). Mean age was 58.92 ± 13.00 years (median and mode-60 years). Factors which increased the risk of transient corneal edema after phacoemulsification included hypertension (p = 0.022), dense nuclear cataracts (p=0.006), divide and conquer technique (p = 0.008), duration of phacopower use (p < 0.001) and peripheral corneal degenerations (p < 0.001). CONCLUSION: Patients with peripheral corneal degenerations and dense nuclear cataracts had significantly higher rates of postoperative corneal edema. Use of phaco-chop technique and less phaco-power time helps in decreasing corneal edema.

Ophthalmic manifestations of linear nevus sebaceous/organoid nevus syndrome.

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

Reducing postoperative pterygium recurrence: comparison of free conjunctival auto-graft and conjunctival rotation flap techniques.

OBJECTIVE: To compare the recurrence of pterygium between free conjunctival auto-graft and conjunctival rotation flap following simple surgical excision of pterygium. STUDY DESIGN: Quasi-experimental study. PLACE AND DURATION OF STUDY: Shifa Foundation Community Health Clinic, Shifa College of Medicine, Islamabad, from January to November 2012. METHODOLOGY: Fifty seven cases aged above 18 years, with a pterygium corneal encroachment of ³ 2 mm which was responsible for visual disability or was cosmetically undesirable were recruited for the study and randomly assigned to conjunctival auto-graft group and conjunctival rotation flap group. Cases with a history of glaucoma or glaucoma suspect, prior pterygium surgery, pterygium with concurrent ocular surface and lid disease, conjunctival inflammation and scarring, pseudo-pterygium or collagen vascular disease were excluded. After simple pterygium excision conjunctival auto-graft group (n=26) cases received a free conjunctival flap was transplanted, while conjunctival rotation flap group (n=31) cases received a conjunctival rotation flap. All cases were followed-up for 6 months after surgery for recurrence and complications. Frequency distribution and significance of association of recurrence using Fisher's exact test and Mann-Whitney U-test was carried out using Statistical Package for Social Sciences (SPSS) version 20. RESULTS: The median (and inter-quartile range) age and surgery duration in conjunctival auto-graft group and conjunctival rotation flap group were 60 (51.50-63.00) and 57 (45.00-60.00) years, 28.50 (27.00-30.50) and 16.00 (15.00-17.00) minutes respectively. Recurrence was seen in 2 (7.96%) and 3 (9.76%) cases in auto-graft and rotation flap groups respectively. No significant difference was seen in postoperative complications between the two groups (p=0.60). CONCLUSION: The surgical time for conjunctival rotation flap procedure is less as compared to free auto-graft, while their recurrence and complications are comparable.

Hypermetropia as a presentation of diffuse choroidal haemangioma in sturge-weber syndrome.

A 16 years old male patient of Sturge-Weber syndrome was referred to glaucoma clinic for the management of unilateral glaucoma. There was also an ipsilateral hypermetropic shift. On detailed investigations, a diffuse choroidal haemangioma was diagnosed which induced this hypermetropic shift. Anisometropia in Sturge-Weber syndrome can give us clue regarding some underlying pathology, so unilateral myopia or hypermetropia should be thoroughly evaluated in such patients.