Surgical training in ophthalmology: Role of EyeSi in the era of simulation-based learning.

Recent advancements in surgical training methods have escalated the need for simulators. The EyeSi simulation has played a major role in Ophthalmology training by providing opportunity to the novice residents to grasp the surgical steps of the procedure and master the skill by repeated attempts. Participants were assessed on single level of cataract module and their consecutive scores were assessed with each attempt. It was found that repetitive practice on simulator can help develop proficiency in the desired steps that can ultimately prepare the surgical trainees for real life surgery.

Bowman's layer transplantation in advanced keratoconus; 18-months outcomes.

PURPOSE: To assess the outcome of isolated Bowman's layer transplantation (BLT) in advanced keratoconus in the patients not suitable for ultra violet cross-linking and intra stromal corneal ring segments. STUDY DESIGN: Nonrandomized Quasi-Experimental. MATERIALS AND METHODS: Mid corneal stromal dissection followed by implantation of manually isolated bowman layer from a donor into the recipient stromal pocket was performed in the Department of Ophthalmology Khyber Teaching Hospital Peshawar from September 2018 to October 2018 and followed up over 18 months. RESULTS: Eleven eyes of 11 patients, 8 male and 3 female within the age range of 7-28 years with progressive keratoconus went under BLT All keratometry values decreased after surgery. Mean anterior pre-operative SimK changed from 69.05 ± 10.85 D to 61.14 ± 6.23 D at 18 months post-operatively (P = 0.005). Means pre-operative Kmax value decreased from 77.24 ± 7.58 D to 71.07 ± 5.37 D at 18 months post-operatively (p = 0.060). The mean pre-operative posterior keratometry value changed from - 10.03 ± 0.88 to - 8.96 ± 1.06 D at 18 months post-operatively (P = 0.002). Mean pre-operative thinnest corneal thickness increased from 281.64 ± 196.86 um to 355.27 ± 19.17 um at 18th months post-operatively (P = 0.001). Pachymetry p-value pre-operative to 18 months (P = 0.001) was statistically significant. Mean anterior SimK at 6 months post-operatively, 60.55 ± 5.56D changed to 61.14 ± 6.23D at 18 months post-operatively (P = 0.000), Kmax at 6 months postoperative 71.60 ± 5.01 D changed to 71.07 ± 5.37 D at 18 months post-operatively (P = 0.008). Both anterior K values at 6 months and 18 months post-operatively showed less significant change, and the same was true for Kmax data at 6 months and 18 months post-operatively. P-values at 6 months to 18 months post-operatively for cornea back data remained (P = 0.001) unchanged. No complications were observed intra-operatively or post-operatively. CONCLUSION: Bowman layer transplantation is a unique surgical treatment for advanced keratoconus to stabilize progressive ectasia with fewer complications avoiding the need for penetrating or deep anterior lamellar keratoplasty.

Role of Optical Coherence Tomography Angiography to differentiate Intraretinal microvascular abnormalities and retinal neovascularization in Diabetic Retinopathy.

OBJECTIVE: To assess proliferative diabetic retinopathy (PDR) and to describe the difference in angiographic representation of new vessels (NVs) and Intra retinal microvascular abnormalities (IRMA) on optical coherence tomography angiography (OCTA). METHODS: A cross-sectional observational study was performed at ISRA Postgraduate Institute of Ophthalmology, Karachi, from March 2018 to September 2018. Forty-two eyes of 21 patients with history of diabetes mellitus (DM) were examined. Twenty-eight eyes with a clinical diagnosis of severe non proliferative diabetic retinopathy (NPDR) or proliferative diabetic retinopathy (PDR) according to early treatment diabetic retinopathy study (ETDRS) were included and evaluated using Swept source optical coherence tomography angiography (SS-OCTA). Then face wide field SS-OCTA images and co registered structural optical coherence tomography (OCT) with flow overlay were used to distinguish the features of IRMA and retinal NVs. RESULTS: Forty-two eyes (21 patients) were examined clinically. Fourteen eyes had moderate NPDR, 15 had severe NPDR and 13 eyes had changes consistent with PDR. After clinical diagnosis, we included 28 eyes in our study based on inclusion criteria. These 28 eyes went through SS-OCTA evaluation and we observed 15 cases with PDR and 13 with severe NPDR changes. The OCTA and clinical diagnosis were similar except in 2 eyes, which is critical but not statically significant showing the importance of this noninvasive technology. CONCLUSIONS: Widefield OCTA can work as an alternative to fundus fluorescein angiography (FFA) in the diagnosis of diabetic retinopathy (DR). As it is a non-invasive and depth encoded technique so can be used frequently to monitor the retinal changes and their progression.

Efficacy of locally produced Latanoprost in the control of intraocular pressure in patients with primary open-angle glaucoma.

PURPOSE: To determine the efficacy of locally produced Latanoprost in reducing the intraocular pressure (IOP) in patients with Primary open-angle glaucoma (POAG). DESIGN: Open-label, non-comparative, observational case study with non-probability purposive sampling. METHODS: A total of 48 patients (94 eyes) of either gender were recruited from glaucoma clinic with the diagnosis of POAG, having IOP of more than 21 mmHg. Patients were commenced on locally produced Latanoprost (Vislat 0.005%). IOP was subsequently measured at 4 weeks and 12 weeks, respectively. The primary end point was reduction in IOP at 12 weeks after the initiation of treatment. RESULTS: A total of 48 patients (94 eyes) were recruited from glaucoma clinic. The average IOP of our patients at baseline was 28.6 ± 8.1 mmHg, decreasing to 21.3 ± 10.6 mmHg at 4 weeks, indicating a drop of 19.1% (P < 0.001). IOP further decreased to 20.3 ± 8.7 mmHg after 3 months of treatment indicating a decrease of 23.3% (P < 0.001). A decrease in IOP occurred in 51 eyes (71.8%) at 4 weeks after treatment, improving to 54 eyes (76%) at 3-month follow-up. Twenty eyes (28.1%) did not show any change in IOP at 4 weeks. However, after 3-month follow-up only 17 eyes (23.9%) did not reveal any change in IOP. CONCLUSION: Our results showed a decrease in IOP of 19.1% after 4 weeks, increasing to 23.3% at 12 weeks in cohort of 37 patients (72 eyes) treated with locally produced Latanoprost (Vislat 0.005%).

Raised intraocular pressure following Intravitreal Triamcinolone Acetonide in diabetic versus non-diabetic patients.

OBJECTIVE: To determine the frequency of an increase in intraocular pressure (IOP) after intravitreal triamcinolone acetonide (IVTA) in diabetic versus non-diabetic patients with various chorio-retinal disorders. METHODS: This prospective, interventional comparative case series was conducted at Isra Postgraduate Institute of Ophthalmology, Al-Ibrahim Eye Hospital, Karachi from May 2012 to April 2014. Two hundred thirty seven eyes of 180 patients were enrolled with 90 patients each in diabetic and non-diabetic group, requiring IVTA. IVTA 4mg/0.1ml was injected and IOP was measured at one week, one month, three months and six months in both groups of patients. RESULTS: In diabetic group, 43 patients were male (47.8%) and 47 were female (52.2%), while in non-diabetic group, 56 (62.2%) patients were male and 34 (37.8%) were female. Mean age of patients in diabetic group was 52.21 ± 9.6 years and in non-diabetic group was 51.13 ± 10.75 years. The mean preoperative IOP was 13.6 ± 2.8 mmHg and 14.1 ± 2.4 mmHg in diabetic and non-diabetic group respectively. In diabetic group, mean (±SD) IOP was 16.4 ±4.9 mmHg, 14.6 ±3.6 mmHg, 17.6 ± 9.7 mmHg and 15.5 ± 7.09 mmHg at one week, one month, three months and 6 months post injection. While in non-diabetic cases, mean (±SD) IOP was 14.8 ± 3.33 mmHg, 15.9 ± 4.2 mmHg, 15.5 ± 4.2 mmHg and 14.1 ± 3.2 mmHg at one week, one month, three months and 6 months follow up. The raised IOP was observed in 117 eyes (49%) in both groups of patients, with 78 eyes (65%) in diabetic group and 39 eyes (33%) in non-diabetic group. CONCLUSIONS: After IVTA, an IOP rise was observed more in diabetics than non-diabetic patients.

Age-related cataract and its types in patients with and without type 2 diabetes mellitus: A Hospital-based comparative study.

OBJECTIVE: To determine the frequency and types of age-related cataract in type 2 diabetic patients compared to non-diabetics. METHODS: This comparative, cross-sectional study was carried out at Al-Ibrahim Eye Hospital, Karachi, from July 2014 to June 2015, and comprised both diabetics and non-diabetics. All patients were selected from the out-patient department and had their full ocular examination done, including retinal screening of diabetic patients with non-mydriatic fundus camera. The criterion for diagnosis of cataract was sufficiently advanced lens opacity that caused impaired vision/un-gradable images. Cataract was classified on a morphological basis into cortical, nuclear, posterior sub-capsular and mixed types. RESULTS: Of the 49,384 patients, 4,556(9.2%) were diabetics and 44,828(90.8%) were non-diabetics. Among the diabetics, cataract was found in 1,956(42.9%) compared to 7,050(15.7%) in non-diabetics. Adjusted odds ratio (95% confidence interval) between the two groups was 4.40 (range: 4.11-4.71) (p<0.001). Male-to-female adjusted odds ratio (95% confidence interval) was 2.05 (range: 1.95-2.15) (p<0.001). Nuclear sclerosis was the commonest type in 2,123(46.6%) cataract cases in diabetics whereas posterior sub-capsular cataract was the commonest type in 14,480(32.3%) cases among the non-diabetics. CONCLUSIONS: Cataract was four times more common in diabetics and twice more frequent in men. Nuclear sclerosis was the commonest type of cataract in diabetic patients.

Efficacy Of Diode Laser In The Management Of Glaucoma Following Intravitreal Silicone Oil Injection In Complicated Retinal Detachment.

BACKGROUND: Intravitreal silicone oil injection has been used to manage complicated retinal detachment. This study aims to analyse the efficacy of diode laser (TSCPC) in the management of secondary glaucoma following intravitreal silicone oil injection in complex retinal detachment surgery. METHODS: The medical records of 58 eyes of 58 patients retrospectively were reviewed. Patients who underwent TSCPC for the management of secondary glaucoma following intravitreal silicone oil injection in complex retinal detachment were included. Procedure performed under local anaesthesia. The laser power was set at 1500-2200 mW for 2 sec. At each follow-up visit, patients went under charting of their IOP measurements with anterior segment and fundus examination. Post procedural follow up visits were carried out as; at 1 week, 1st, 3rdand 6thmonths. The efficacy was measured as reduction in IOP up to ≤20 mmHg without further needs for medications at 6 months. RESULTS: The IOP was reduced up to 19.26±10.15 mmHg. Comparisons of IOP at each interval with pre-treatment showed significant difference with p<0.0001. The efficacy of procedure was achieved in 77.6% patients. Age, gender and pre-operative IOP showed significant association with p<0.05. CONCLUSIONS: Diode laser TSCPC was effective and safe in reducing IOP. The IOP decreases gradually over six month follow up. The procedure is simple and cost-effective yet reasonably afforded by patients in low resources population. In spite of the retained intravitreal silicon oil patients with failed medical treatment for uncontrolled IOP can be treated with TSCPS.

Bilateral choroidal neovascularization after pegylated interferon therapy.

A 30-year-old male presented with gradual decrease in vision in his both eyes after the use of interferon alpha for his hepatitis-C. Ocular examination of patient included, Best Corrected Visual Acuity (BCVA), fundus photographs, Fundus Fluorescein Angiography (FFA) and Optical Coherence Tomography (OCT). His BCVA was recorded as 6/18 in the right eye and 6/12 in the left eye. The anterior segments were unremarkable, with normal intraocular Pressure (IOP) in his both eyes. Both fundi revealed the presence of bilateral Choroidal Neovascularization (CNV), confirmed on FFA and OCT. To the best of authors' knowledge, simultaneous presence of CNV in both eyes is not reported in the literature.

Pterygium recurrence related to its size and corneal involvement.

OBJECTIVE: To establish the usefulness of grading system based on the size and extent of corneal involvement in predicting recurrence in patients undergoing primary pterygium excision with intraoperative use of adjunctive topical Mitomycin-C (MMC). STUDY DESIGN: A case series. PLACE AND DURATION OF STUDY: Section of Ophthalmology, the Aga Khan University Hospital, Karachi, from 2005 till 2010. METHODOLOGY: One hundred and twenty male patients (120 eyes) underwent surgical removal of pterygium using bare sclera method with MMC in concentration of 0.2 mg/ml (0.02%) with exposure time of 3 minutes. Classification of subjects was done according to the grading of pterygium. Patients were followed at 3 months interval for a minimum period of 1 year to record any recurrence. RESULTS: The pterygium recurrence rate was 6.7% at a follow-up of 1 year. There was no significant association of pterygium recurrence with younger age (p = 0.14). A higher level of corneal involvement by the pterygium at presentation correlated significantly with the recurrence (p = 0.01). CONCLUSION: These results suggest that a higher grade of pterygium at presentation in patients leads to increased rate of recurrence after surgical excision. Hence, early excision of pterygium is recommended to decrease its recurrence rate.

Frequency and management of raised intraocular pressure following intravitreal triamcinolone acetonide.

OBJECTIVE: To determine the frequency and management of intraocular pressure (IOP) elevation following intravitreal triamcinolone acetonide (IVTA). STUDY DESIGN: Case series. PLACE AND DURATION OF STUDY: Isra Postgraduate Institute of Ophthalmology/Al-Ibrahim Eye Hospital, Karachi, from May 2007 to May 2008. METHODOLOGY: In this study, 198 eyes of 150 patients requiring IVTA injection, were included. Pre-injection assessment comprised of detailed history, general and ocular examination including anterior and posterior segment examination with IOP measurements with Goldmann tonometer. After informed consent, IVTA 4 mg/0.1 ml was injected through pars plana and IOP was measured at 1 week, 1 month, 3 months and 6 months and if raised, treated accordingly. RESULTS: Out of 150 patients, 82 were male (54.7%) and 68 were female (45.3%) (M: F = 1.2: 1). Mean age was 50.61 ± 10.59 years. Raised IOP value after IVTA, higher than 21 mmHg was observed at one week in 28 eyes (14.1%), at 1 month n 48 eyes (24.2%), at 3 months in 76 eyes (38.4%) and at 6 months in 25 eyes (12.6%). Raised IOP was controlled by topical beta blockers alone or in combination with carbonic anhydrase inhibitors in 58 eyes (76.3%). CONCLUSION: Elevation of IOP after IVTA injection occurred in 76 eyes (38.3%). It may take an extended period of time to manifest raised IOP. In majority of the patients, raised IOP was managed with topical medications.