A comparative analysis of postoperative visual outcomes following cataract surgery with different brands of Monofocal Intraocular Lenses.

Objective: To compare visual outcomes after cataract surgery using three intraocular lenses (IOL) of different prices but similar properties. Methods: A comparative study with retrospective data of patients operated for phacoemulsification with monofocal IOL implants was carried out at Al-Ibrahim Eye Hospital (AIEH) from April 2021 to Feb 2022. Patients with diabetes, any preoperative ocular morbidity and unclear diagnosis were excluded from the study. Pre and post-operative best corrected visual acuity (BCVA) on 1st day, 7th day and 4-6 weeks were analyzed. IOLs were categorized on the basis of price into economical, standard and premium lenses. To minimize surgical bias, data was further stratified on the basis of surgical expertise. Results: Data of 3237 patients was analyzed. Economical lens (A) was implanted in 2647, standard (B) in 254 and premium (C) in 336 patients. On average BCVA (6/6 to 6/12) was achieved in 88.2% of patients. No significant difference was found at third follow up among BCVA of three IOls operated by senior surgeon, χ2(2) = 3.216, p = 0.20, with median (IQR) is 0.2(0.2) logMAR for Group-A, 0.1(0.2) logMAR for Group-B and 0.2(0.1) logMAR for Group-C. When results of the rest of the surgeons was considered, significant difference was found among BCVA at 3rd follow-up, χ2(2) = 6.661, p = 0.036, with median (IQR) is 0.3(0.2) logMAR for Group-A, 0.2(0.1) logMAR for Group-B and 0.2(0.3) logMAR for Group-C. Conclusion: When surgical factors mainly, surgeon bias is removed, all three types of monofocal IOL had similar visual outcomes.

Ocular Complications Associated With Diabetes And The Risk Of Sustainable Blindness; A Real World Analysis.

OBJECTIVE: To evaluate the frequencies of ocular comorbidities among patients with type II diabetes, and the association with multiple systemic factors. METHODS: The retrospective, cross-sectional study was conducted at the Al Ibrahim Eye Hospital, Karachi, and comprised diabetic eye clinic data from April 2014 to February 2022. Demographic, biochemical and ophthalmic findings of the patients were recorded. Ocular findings analysed were best-corrected visual acuity, lens status, corneal changes, optic disc assessment, intraocular pressure and signs of retinopathy and its grading. Data was analysed using SPSS 22. RESULTS: Of the 43,723 subjects, 22,677(51.86%) were males and 21,046(48.13%). The overall mean age was 54.14±10.68 years. There were 21,680(49.58%) patients with diabetes duration 5-10 years. Overall, 33,876(77.5%), had some ocular morbidity, while 9,847(22.5%) had no such complaints. The commonest morbidity was cataract12,607(28.8%), followed by refractive errors 8,508(19.5%), vision-threatening diabetic retinopathy 2,553(5.83%) and suspected glaucoma 1,211(2.76%). Vision 28 threatening diabetic retinopathy and suspected glaucoma represented sustained blindness risk 3,764(8.6%). Increasing levels of low-density lipoprotein were significantly associated with advanced diabetic eye disease and clinically significant macular oedema (p<0.05), while glycated haemoglobin >6.4 was associated significantly with diabetic retinopathy and suspected glaucoma (p<0.05). CONCLUSIONS: Diabetes caused some or the other ocular morbidity that needed intervention. Poor control of biochemical parameters was seen to increase frequency of ocular complications.

iMIGS: An innovative AI based prediction system for selecting the best patient-specific glaucoma treatment.

The use of AI-based techniques in healthcare are becoming more and more common and more disease-specific. Glaucoma is a disorder in eye that causes damage to the optic nerve which can lead to permanent blindness. It is caused by the elevated pressure inside the eye due to the obstruction to the flow of the drainage fluid (aqueous humor). Most recent treatment options involve minimally invasive glaucoma surgery (MIGS) in which a stent is placed to improve drainage of aqueous humor from the eye. Each MIGS surgery has a different mechanism of action, and the relative efficacy and chance of success is dependent on multiple patient-specific factors. Hence the ophthalmologists are faced with the critical question; which method would be better for a specific patient, both in terms of glaucoma control but also taking into consideration patient quality of life? In this paper, an Adaptive Neuro-Fuzzy Inference System (ANFIS) has been developed in the form of a Treatment Advice prediction system that will offer the clinician a suggested MIGS treatment from the baseline clinical parameters. ANFIS was used with a real-world MIGS data set which was a retrospective case series of 372 patients who underwent either of the four MIGS procedures from July 2016 till May 2020 at a single center in the UK.•Inputs used: Clinical measurements of Age, Visual Acuity, Intraocular Pressure (IOP), and Visual Field, etc.•Output Classes: iStent, iStent and Endoscopic Cyclophotocoagulation (ICE2), PreserFlo MicroShunt (PMS) and XEN-45).•Results: The proposed ANFIS system was found to be 91% accurate with high Sensitivity (80%) and Specificity (90%).

Impact of minimally invasive glaucoma surgery on the ocular surface and quality of life in patients with glaucoma.

Background: Minimally invasive glaucoma procedures are emerging as clinically effective and safe glaucoma management approaches; however, evidence regarding quality-of-life outcomes is limited. Objectives: To explore the impact of minimally invasive glaucoma surgery (MIGS) combined with phacoemulsification on patient-reported outcomes and clinical parameters related to ocular surface disease in people with glaucoma. Design: Retrospective observational study. Methods: Fifty-seven consecutive patients were examined prior to undergoing iStent combined with phacoemulsification with or without adjunctive endocyclophotocoagulation and at 4-month follow-up. Results: At follow-up, on average patients returned statistically significantly improved scores on glaucoma-specific (GQL-15, p < 0.001; GSS, p < 0.001), general health (EQ-5D, p = 0.02) and ocular surface PROMs (OSDI, p = 0.001). Patients were using fewer eye drops on average after MIGS compared with before surgery (1.1 ± 0.9 versus 1.8 ± 0.8; p < 0.001). Undergoing MIGS was associated with improved tear film break-up time (p < 0.001) and reduced corneal fluorescein staining (p < 0.001). Conclusion: This retrospective audit shows quality of life and clinical parameters related to the ocular surface are improved following MIGS combined with phacoemulsification in patients previously treated with anti-glaucoma therapy.

A comparison of iStent combined with phacoemulsification and endocyclophotocoagulation (ICE2) with the PreserFlo MicroShunt and XEN-45 implants.

Background: Minimally invasive glaucoma surgery (MIGS), including minimally invasive bleb surgery (MIBS), is a rapidly evolving area of research and clinical interest in ophthalmology. The growing number of devices has necessitated evaluations to identify subtle differences in outcomes between treatments. Objectives: To compare clinical effectiveness and safety outcomes of iStent combined with endoscopic cyclophotocoagulation (ICE2) with bleb forming PreserFlo MicroShunt (PMS) and XEN-45 gel implant in a 24-month retrospective review. Design: A retrospective review of patient records. Methods: We compared outcomes of 247 patients undergoing one of three glaucoma procedures (ICE2 = 162; PMS = 48; XEN-45 = 37) at a single facility in the United Kingdom. Clinical records were reviewed retrospectively between July 2016 and May 2020. Pairwise comparisons and within group analyses were performed to assess intraocular pressure (IOP), best-corrected LogMAR visual acuity (BCVA), the Humphrey visual fields and antiglaucoma medication outcomes across the three treatment groups. Results: No statistically significantly differences in IOP between the groups at day 7, 6 months, 12 months and 24 months. PMS had statistically significantly change in IOP between baseline and day 7 compared with ICE2 (p = 0.003). BCVA was statistically significant different at 24 months between the ICE2 compared with PMS group (0.12 versus 0.33 LogMAR; p = 0.002). PMS group achieved the largest decline in medication usage between baseline a 24-month follow-up (2.9 versus 0.9; p < 0.001), with no statistically significant difference in the number of antiglaucoma medications being used between groups at 24 months. Postoperative complications in all three groups were transient and could be resolved with office-based interventions. Conclusion: Real-world outcomes after 24 months were similar between patients undergoing MIGS and MIBS procedures.

Smart AMD prognosis through cellphone: an innovative localized AI-based prediction system for anti-VEGF treatment prognosis in nonagenarians and centenarians.

BACKGROUND AND OBJECTIVE: Age-related macular degeneration (AMD) is one of the most common reasons for blindness in the world today. The most common treatment for wet AMD is the intravitreal injections for inhibiting vascular-endothelial-derived growth factor (VEGF). This treatment usually involves multiple injections and thus multiple clinic visits, which not only causes increased cost on national health services but also causes exposure to the hospital environment, which is sometimes high risk considering current COVID crisis. The treatment, in spite of the above concerns, is usually effective. However, in some cases, either the medicine fails to produce the anticipated favourable outcome, resulting in waste of time, medication, efforts, and above all, psychological distress to the patients. Hence, early predictability of anatomical as well as functional effectiveness of the treatment appears to be a very desirable capability to have. METHOD: A machine learning approach using adaptive neuro-fuzzy inference system (ANFIS) of two-sample prediction model has been presented that requires only the baseline measurements and changes in visual acuity (VA) as well as macular thickness (MAC) after four months of treatment to estimate the values of VA and MAC at 8 and 12 months. In contrast to most of the AI techniques, ANFIS approach has shown the capability of the algorithm to work with very small dataset as well, which makes it a perfect candidate for the presented solution. RESULTS: The presented model has shown to have a very high accuracy (> 92%) and works in near-real-time scenarios. It has been converted into a smart phone App, OphnosisAMD, for convenient usage. With this App, the clinician can visualize the progression of the patient for a specific treatment and can decide on continuing or changing the treatment accordingly. The complete AI engine developed with the ANFIS algorithm is localized to the phone through the App, implying that there is no need for internet or cloud connectivity for this App to function. This makes it ideal for remote usage, especially under the current COVID scenarios. CONCLUSIONS: With a smart AI-based App on their fingertips, the presented system provides ample opportunity to the doctors to make a better decision based on the estimated progression, if the same drug is continued with (good/fair prognosis) or alternate treatment should be sought (bad prognosis). From a functional point of view, a prediction algorithm is triggered through simple entry of the relevant parameters (baseline and 4 months only). No internet/cloud connectivity is needed since the algorithm and the trained network are fully embedded in the App locally. Hence, using the App in remote and/or non-connected isolated areas is possible, especially in the secluded patients during the COVID scenarios.

A multicentre review of the histology of 1012 periocular basal cell carcinomas.

AIMS: To evaluate primary periocular basal cell carcinomas (BCCs) in depth including comparing histological margins with subtype, location and surgical specialty after wide local excision. METHODS: A retrospective review was performed for all BCCs excised from three hospitals over 5 years, covering a population of just over 1 million. Tumours were classified according to histological subtype location. Incomplete excision rates and margins were analysed in detail and comparisons made. RESULTS: The most common subtype found was nodular followed by infiltrative. Lesions were most commonly located at the lower lid. Infiltrative BCCs were associated with perineural invasion and incomplete excision despite the largest peripheral margins. Superficial BCCs had the smallest mean peripheral margin but the largest mean deep margin. 2 mm histological margins gave an 83.7% complete excision rate, 6.4% incomplete excision rate and 7.1% where the clearance margin was 0.3 mm or less. CONCLUSION: Distribution of eyelid BCCs based on subtype and periocular location mirrored the general consensus. Infiltrative BCCs should be excised with wider margins or referred for Mohs surgery, especially if the medial canthus is involved. Superficial BCCs should be excised with wider but shallower surgical margins. Ophthalmologists were more likely than dermatologists or plastic surgeons to incompletely excise a periocular BCC, which is reflective of their more difficult case mix.

Bilateral, vertical supranuclear gaze palsy following unilateral midbrain infarct.

A 60-year-old man recently admitted for bipedal oedema, endocarditis and a persistently positive COVID-19 swab with a history of anticoagulation on rivaroxaban for atrial fibrillation, transitional cell carcinoma, cerebral amyloid angiopathy, diabetes and hypertension presented with sudden onset diplopia and vertical gaze palsy. Vestibulo-ocular reflex was preserved. Simultaneously, he developed a scotoma and sudden visual loss, and was found to have a right branch retinal artery occlusion. MRI head demonstrated a unilateral midbrain infarct. This case demonstrates a rare unilateral cause of bilateral supranuclear palsy which spares the posterior commisure. The case also raises a question about the contribution of COVID-19 to the procoagulant status of the patient which already includes atrial fibrillation and endocarditis, and presents a complex treatment dilemma regarding anticoagulation.

INTRAVITREL BEVACIZUMAB IN DIFFERENT TYPE OF RETINAL VEIN OCCLUSIONS.

BACKGROUND: Retinal vein occlusion is frequent cause of visual loss with insufficient treatment options. Many treatment options have been tried in the past including intravitreal triamcenoloneacetonide injection. This study was conducted to evaluate the efficacy and complications of intravitreal injection of Bevacizumab in different types of retinal vein occlusion. METHODS: This interventional study was carried out at Al Ibrahim eye hospital, Karachi from July 2011 to December 2012. Patients diagnosed with retinal vein occlusion of any type were included in the study using non-probability purposive sampling technique, after informed written consent. Patients were injected intra-vitreally with Bevacizumab 1.25 mg/0.05 ml under sterilized technique in operation room. Best corrected visual acuity and optical coherence tomography was repeated in every follow up along with the detailed fundoscopy and intraocular pressure measurement. Data analysis was done using SPSS-20.0. RESULTS: A total 278 patients were included in the study according to the inclusion and exclusion criteria. Mean age of the patients was 54.28 years (SD=5.62). Out of 278 patients included in the study, 132 had BRVO, 141 had CRVO while 5 had HRVO. Mean visual acuity before injection was 2.309 lines of Snellen's acuity chart read, with minimum of 1 line read and maximum of 4 lines read (standard deviation=l.00). After 12 weeks post injection, 92 patients read 7 lines (6/6) of Snellen's visual acuity chart. Mean visual acuity was 4.75 lines of Snellen's acuity chart read, with minimum of 1 line read and maximum of 7 lines read (standard deviation=1.00). 77% of the patients had visual improvement after injection (p<0.05). CONCLUSION: Intravitreal bevacizumab injection is very effective in reducing macular thickness as well in improving visual acuity in all types of retinal vein occlusion.

Success of surgical correction in constant and intermittent exotropias.

OBJECTIVE: To evaluate the success rate of surgical corrections of constant and intermittent exotropias. STUDY DESIGN: A case series. PLACE AND DURATION OF STUDY: Al-Ibrahim Eye Hospital, Karachi, from July 2011 to December 2012. METHODOLOGY: Patients having primary exotropia (deviation 15 - 45 prism diopters [PD]) were included. Patients with either constant exotropia or basic intermittent exotropia underwent unilateral surgery of lateral rectus recession (maximum up to 10 mm) and medial rectus resection (up to 6 mm). Similarly, when patients had intermittent distance exotropia, underwent bilateral lateral rectus recession (maximum up to 10 mm). Final outcome was considered at the end of 2 months at which achievement of ² 10 PD of exotropia was considered as a success. RESULTS: Out of 248 patients, 170 (68.5%) had either constant exotropia or basic intermittent exotropia, while 78 (31.5%) had intermittent distance exotropia. Mean angle of deviation before surgery was 49.23 prism diopters while after surgery, mean angle of deviation was 8.54 prism diopters. Overall success rate was 81.45% (n=202). In case of unilateral lateral rectus recession and medial rectus resection surgery, the success rate was 85.14% while success rate in case of bilateral lateral rectus recession was 65.21% (p=0.001). CONCLUSION: Unilateral lateral rectus recession and medial rectus resection for surgical correction of exotropia had better surgical success rate as compared to bilateral lateral rectus recession.

Isolated inferior oblique myectomy for hypertropia.

BACKGROUND: Hypertropia is a condition in which one eye is elevated relative to the other, either intermittently or constantly. It causes significant problem either cosmetically or by abnormal head posture and thus needs to be corrected surgically. This study was conducted to evaluate the success rate and complications of isolated inferior oblique myectomy in patients with hypertropia. METHODS: Patients having hypertropia (Deviation > 6 prism diopters [PD]) associated with inferior oblique over-action were included in this observational Case-series, conducted from July 2011 to December 2012, at Al Ibrahim eye Hospital, Karachi. Patients underwent unilateral inferior oblique myectomy. Final outcome was considered at the end of three months at which achievement of ≤ 2 PD of hypertropia was considered as a success. RESULTS: During the study period, 58 patients were included. Hypertropia was most commonly associated with exotropias 23 (39.7%) followed by esotropias in 18 (31%). Mean angle of hypertropia was reduced from 13.55 ± 4.43 prism diopters to 0.48 ± 1.08 prism diopters. Out of 58 patients, 55 (94.8%) had achieved success after surgery while only 3 (5.2%) patients had residual hypertropia of greater than 2 prism diopters (p = 0.001). No direct complications of procedure observed intra-operatively or up to 3 months post operatively but significant overcorrection of residual horizontal deviation observed after horizontal squint surgery in these eyes. CONCLUSION: Isolated inferior oblique myectomy is highly successful and safe surgical procedure for correction of hypertropia.

Efficacy of topical bevacizumab in high-risk corneal transplant survival.

OBJECTIVE: To evaluate the effectiveness of topical Bevacizumab in preventing neovascularisation on high risk corneal grafts. METHODOLOGY: This study was a randomized, controlled, parallel group study, carried out from February 2008 to April 2012 (51 months) at Isra Postgraduate Institute of Ophthalmology and Yasin eye hospital, Karachi. Eyes with high risk corneal transplantation with corneal neovascularization were included in this interventional study/randomized clinical trial. Patients were randomly allocated to 2 groups. Group A and Group B. After penetrating keratoplasty, group A patients received topical bevacizumab (2.5%, 25 mg/ml) which was self-administered 4 times a day for 24 week while group B patients received only sham eye drops. Group B was the control group. Corneal neovascular invasion area i.e. the fraction of area on transplanted cornea in which vessels were present was measured using mathematical software program MatLab. Data analyses was done using SPSS version 19. Frequencies of age gender and groups were measured. Neovascular invasion area and change in visual acuity was compared between the 2 groups using paired t test . P value of less than 0.05 was considered significant. RESULTS: Among the 2 groups mean Corneal neo vascular invasion area was minimum in group A (6.23%) while in group B it was (26.7%). Maximum number of patients (26) attained visual acuity of 6/36 or better in the topical bevacizumab group compared to 17 sham group. CONCLUSION: When topical Bevacizumab is used, it reduces the recurrence of neovascularisation and thus helps increasing the frequency of graft survival in cases of high risk corneal transplants.

Visual outcome and complications in Ab-externo scleral fixation IOL in aphakia in pediatric age group.

OBJECTIVE: To assess the visual outcome and complications in patients after Ab-externo scleral fixation of intraocular lens in pediatric age group (15 years or less). METHODS: This quasi experimental study was conducted at Isra Postgraduate Institute of Ophthalmology, Al-Ibrahim Eye Hospital, Karachi, from January 2012 to December 2012. All cases included were worked up according to the protocol. All patients underwent Ab-externo scleral fixation of IOL under general anesthesia. Patients were followed up at 1(st)day, 1(st)week, 1(st)month, 2(nd)month and 3(rd)month. Complete eye examination including best-corrected visual acuity and complications were noted on each visit. RESULTS: Thirty patients were included in the study, with mean age of 8.6 years (±3.93569). Most of the patients, 20 (66.7%), had visual acuities of 6/18 or better. No complication was seen in 18 (60%) of the patients intra operatively while soft eye was observed in 7 (23.3%) of the patients. Another complication noted was vitreous hemorrhage, which was seen in 5 (16.7%) patients. Most common post-operative complication was Uveitis followed by astigmatism. Lens dislocation and iris abnormalities were seen in only one patient. Most of the patients showed significant visual improvement after surgery. CONCLUSION: Ab-externo scleral fixation of an IOL was found to be safe and showed favorable postoperative results with fewer complications.

Efficacy of sub-conjunctival and topical bevacizumab in high-risk corneal transplant survival.

OBJECTIVE: To evaluate the effectiveness of subconjunctival bevacizumab and topical bevacizumab in preventing neovascularisation on high-risk corneal grafts. METHODS: The randomised, controlled, parallel group study was carried out from February 2008 to April 2012 at Isra Postgraduate Institute of Ophthalmology and Yasin Eye Hospital, Karachi. Eyes with high-risk corneal transplantation with corneal neovascularisation were included in the trial. Patients were randomly allocated to 3 groups: A, B and C. After penetrating keratoplasty, Group A patients received subconjunctival bevacizumab (2.5 mg/ 0.1 ml), Group B, patients received sham injection, while Group C patients received topical bevacizumab (2.5%, 25 mg/ml). lt was self-administered 4 times a day for 24 weeks. Group B was the control group. Corneal neovascular invasion area was measured using mathematical software programme Mat Lab. Data analyses were done using SPSS version 19. RESULTS: Of the total 122 patients, there were 41 (33.88%) each in Group A and B, while Group C had 40 (32.78%) patients. Among the 3 groups, mean corneal neovascular invasion area was minimum in Group A (n = 3; 6.23%), while in Group B it was 12.3% (n = 5). Group C had the maximum corneal neovascular invasion area after 24 weks (n = 11; 26.7%). Maximum number of patients (n = 36; 87.80%) attained visual acuity of 6/36 or better in Group Afollowed by Group C (n = 26; 65%) and Group B (n = 17; 41.46%). CONCLUSION: Subconjunctival bevacizumab reduces the recurrence of neovascularisation and, thus, helps increasing the frequency of graft survival in cases of high-risk corneal transplants. When used topically, it is less effective.