Optic nerve sheath fenestration for salvaging acutely threatened vision in Idiopathic Intracranial Hypertension - A two-year completed follow up.

Objectives: To determine the efficacy and safety of Optic Nerve Sheath Fenestration (ONSF) for salvaging acutely threatened vision in patients of Idiopathic Intracranial Hypertension (IIH). Methods: This retrospective, interventional case series study was performed at Institute of Ophthalmology Mayo Hospital Lahore from September 2017 to September 2019. Nine patients diagnosed with Idiopathic Intracranial Hypertension as per Modified Dandy Criteria, underwent medial trans-conjunctival ONSF. Pre-operative and 1st day, 1st week, 1st month, 1st year, and 2nd year postoperative best-corrected logMAR visual acuities (BCVA) were recorded. Mean BCVA were calculated and compared using paired t-test. P-value <0.05 was taken as significant. Results: All nine patients were female with a mean age of 24 years. The average best-corrected pre-operative logMAR visual acuity (BCVA) in the better eye was 0.5 ± 0.28 and in the worse eye was 1.0 ± 0.57. After the worse eye ONSF, at 1st week mean BCVA in better eyes was 0.27 ± 0.32 (p-value=0.001), while it was 0.43 ± 0.63 (p-value=0.006) in the worse eyes. At 2nd year follow-up after optic nerve sheath fenestration mean BCVA in better eyes was 0.30 ± 0.30 (p-value=0.002) and in worse eyes was 0.44 ± 0.63 (p-value=0.007). Four patients (44.4%) had a subconjunctival hemorrhage, two patients (22.2%) had binocular diplopia, one patient (11.1%) pre-septal cellulitis, and one patient (11.1%) had no improvement in vision because of pre-operative secondary optic atrophy. All patients had unilateral fenestration and bilateral improvement, six patients (66.67%) reported improvement in headache and successful tapering of medical therapy. Conclusion: Optic nerve sheath fenestration is effective as well as a safe surgical procedure to salvage acutely threatened vision in patients of Idiopathic Intracranial Hypertension on maximal medical treatment.

Comparison of residual silicone oil index after removal of silicone oil with fluid-air versus oil-fluid exchange.

Objectives: To compare the effectiveness of fluid-air exchange with silicone oil-fluid exchange in reducing the residual silicone oil (SO) droplets after the removal of SO. Methods: This was a prospective, quasi-experimental study conducted from October 2021 to February 2022 at Eye Unit-III, COAVS, Mayo Hospital, Lahore. Sixty-one patients with siliconized eyes underwent removal of SO with two different techniques and were divided into fluid-air exchange and oil-fluid exchange groups. To quantify the residual silicone droplets objectively, B-scan echographic images were analyzed within seven days of surgery. Silicone oil index (SOI) which is the amount of residual SO droplets/vitreal area in the images was calculated with the help of imagej software. Results: The residual SOI of the fluid-air exchange group (0.99 ± 1.76%) was significantly lower than the oil-fluid exchange group (3.25 ± 3.85%). The SOI is positively correlated with the duration of tamponade, preoperative intraocular- pressure and axial length. Persistent IOP elevation post-operatively was seen in 16.67% individuals in the fluid-air exchange group and 54.8% individuals in the oil-fluid exchange group. Conclusion: Fluid-air exchange group was found to be superior in reducing residual SO droplets than the oil-fluid exchange group.

Effect of panretinal photocoagulation on optic nerve head blood flow with OCT angiography in patients with diabetic retinopathy.

OBJECTIVE: To investigate the effect of pan retinal photocoagulation (PRP) on Optic nerve head blood flow with OCT angiography in patients with proliferative diabetic retinopathy. METHODS: This prospective interventional study was conducted at Eye Unit III, Institute of Ophthalmology, Mayo Hospital, Lahore, over a period of seven months i.e. from 10th May 2019 to 10th November 2019. Thirty-five patients having proliferative diabetic retinopathy were included in this study. Ocular blood flow was measured with OCT Angiography, then pan retinal photocoagulation was performed and patients were called for follow-up after one month and ocular blood flow was measured again with OCT Angiography. The difference in the blood flow was calculated. Frequencies and percentages were calculated for the categorical data and mean and standard deviations were calculated for the continuous data. Wilcoxon matched-pairs signed rank test was performed and effects of PRP on blood flow were compared. Significance level was taken as p≤0.05. RESULTS: Out of 35 patients, 30 patients (85.71%) had decreased post PRP blood flow, four patients (11.43%) had increased post PRP blood flow and one patient (2.86%) did not have any effect. CONCLUSION: OCT angiography revealed there is significantly reduced optic nerve head blood flow in PRP treated eyes compared to non-PRP treated eyes.

Efficacy of inverted internal limiting membrane flap for large idiopathic macular holes.

OBJECTIVE: To evaluate the effectiveness of inverted internal limiting membrane flap in large idiopathic macular holes. METHODS: Twelve patients diagnosed with idiopathic macular holes larger than 400um underwent 23 gauge Pars Plana Vitrectomy (PPV) with inverted internal limiting flap and gas tamponade at Al-Ehsan Eye Welfare Eye Hospital, Lahore from February 2017 to February 2018. All cases were diagnosed on Spectral Domain Optical Coherence Tomography (SD-OCT) and were followed up for 6 months. At every follow-up, best corrected visual acuity and SD-OCT was done. RESULTS: We achieved macular hole closure in 91.6% (11/12) patients with idiopathic macular holes larger than 400um. Five out of 12 patients underwent combined phacoemulsification and PPV. One patient has flat hole closure which was considered failure. One patient was excluded from the study due to per-operative flap loss. This patient was not included in final data analysis of 12 patients. There was statistically significant gain in best corrected visual acuity after successful macular hole closure. We did not report any untoward events during or in the post-operative period. CONCLUSION: Inverted internal limiting flap is an effective method for repairing large macular holes.

Comparison of 23 Gauge Transconjunctival releasable Suture Vitrectomy with standard 20 gauge Vitrectomy.

OBJECTIVE: To compare effectiveness of releasable transconjunctival sutures in 23 gauge vitrectomy and standard 20 gauge vitrectomy. METHODS: This prospective comparative study was conducted in Department of Vitreoretinal Surgery, Al Ehsan Eye Hospital, Lahore from June 2016 to March 2017. It included 84 patients in total (Group-A: 42 patients underwent 23 gauge releasable suture vitrectomy; Group-B: 42 patients who underwent standard 20 gauge vitrectomy). Pre operative and post operative best corrected visual acuity, surgical duration, pre and post operative intraocular pressure and complication profile was compared between two groups. RESULTS: The leading cause for vitrectomy was vitreous haemorrhage. (Group-A; n=15 ;35.71%; Group-B; n=17; 40.47%). There was statistically significant improvement in preoperative and postoperative BCVA in both groups (Group A: P-value < 0.05; Group B P-value < 0.05) but there was no significant difference in post operative BCVA between two groups at 3 months (P-value > 0.05). Surgical time for 23G vitrectomy Group was statistically less than 20 G vitrectomy Group (51 +/-18 minutes for Group-A versus 78 +/- 13 minutes for Group-B; p-value < 0.05). Visual analog score for pain / discomfort was also significantly less for Group-A than Group-B. There was no significant difference in intraocular pressures between the two groups. CONCLUSIONS: Releasable suture technique for small gauge vitrectomy is a safe and easily adaptable technique that has certain significant advantages over 20G absorbable suture vitrectomy.

Clinical outcome of 23g Trans-Conjunctival pars plana vitrectomy - a prospective comparison of Phaco-Vitrectomy with only vitrectomy in phakic eyes.

OBJECTIVE: To evaluate the effectiveness and safety profile of combined phacoemulsification with 23G pars plana vitrectomy when compared to pars plana vitrectomy alone in phakic patients. METHODS: This study was performed at Al-Ehsan Eye Hospital (tertiary care eye hospital in Lahore, Pakistan) from January 2016 to August 2016. A total of 40 eyes in two equal groups of 20 eyes each, were enrolled in this prospective study. Group-A underwent combined phaco-vitrectomy, whereas Group-B underwent vitrectomy only for various vitreoretinal pathologies. We evaluated the safety of combined surgery, intra-operative and postoperative complications and short term surgical outcome. RESULTS: The most common reason for vitreoretinal intervention was rhegmatogenous retinal detachment followed by vitreous haemorrhage in combined study population. There was statistically significant difference in best corrected visual acuity pre-operatively and post operatively within the groups and between the groups. The most significant immediate post operative observation in Group-A was enhanced anterior chamber inflammation as compared to Group-B, whereas most signification observation in Group-B was development of visually significant cataract (35%) at 6 months follow-up. There was no other significant sequel or complication difference between both groups. CONCLUSIONS: Combined phaco-vitrectomy is a safe and effective procedure with minimum complication profile and it avoids the need of subsequent cataract surgery.

Analysis of orbital malignancies presenting in a tertiary care hospital in Pakistan.

OBJECTIVE: To determine the frequencies of various orbital malignancies amongst orbital lesions in patients presenting in a tertiary care hospital in Pakistan. METHODS: A retrospective analysis of 666 orbital cases with an established histopathological diagnosis of malignant tumors treated in Mayo Hospital Lahore from 1996 to 2015 (20 years). RESULTS: About 66% of the malignant tumors were primary, 25% secondary, 8% haematopoietic and 1% metastatic. Almost 50% of the cases were children. Retinoblastoma is the commonest tumor (43% overall and 87% among children). Squamous cell carcinoma is the second commonest (15.6% overall and 31% among adults). These are then followed by Adenoid cystic carcinoma of Lacrimal Gland (9%), Lymphoma/Leukaemia (8%) and Rhabdomyosarcoma (6.3%). CONCLUSION: Frequencies of various orbital malignancies show geographical variation in both paediatric and adult population.

Gender differences in the surgical management of trachomatous trichiasis: an exploratory analysis of global trachoma survey data, 2015-2019.

BACKGROUND: Trachomatous trichiasis (TT) is a painful, potentially blinding eye condition that can be managed through epilation or surgery. Women are affected by TT approximately twice as often as men and are believed to face gendered barriers to receiving surgical care to prevent vision loss. METHODS: We used data from 817 cross-sectional surveys conducted during 2015-2019 in 20 African countries to estimate the prevalence difference (PD) between female and male eyes for four outcomes potentially indicating gender-related differences in TT management: (1) received surgery and developed postoperative TT (PTT), (2) never offered surgery, (3) offered surgery but declined it, and (4) offered epilation but never offered surgery. RESULTS: The prevalence was modestly elevated among female eyes compared with male eyes for having PTT (PD:1.8 [95% confidence limits (CL): 0.6, 3.0]) and having declined surgery for the eye (PD: 6.2 [95% CL: 1.8, 10.7]). The proportion offered epilation was similar by gender (PD:0.5 [95% CL: -0.4, 1.3]), while never having been offered surgery was somewhat more prevalent among male eyes (PD: -2.1 [95% CL: -3.5, -0.7]). CONCLUSIONS: Our results suggest potential gender differences in TT management. More research is needed to determine the causes and implications of the observed differences.

Improving equity, efficiency and adherence to referral in Pakistan's eye health programmes: Pre- and post-pandemic onset.

Background: Over one billion people worldwide live with avoidable blindness or vision impairment. Eye Health Programmes tackle this by providing screening, primary eye care, refractive correction, and referral to hospital eye services. One point where patients can be lost in the treatment journey is adherence to hospital referral. Context: Peek Vision's software solutions have been used in Pakistan with the goal of increasing eye health programme coverage and effectiveness. This involved collaboration between health system stakeholders, international partners, local community leaders, social organizers and "Lady Health Workers". Results: From the beginning of the programmes in November 2018, to the end of December 2021, 393,759 people have been screened, 26% of whom (n = 101,236) needed refractive services or secondary eye care, and so were referred onwards to the triage centers or hospital services. Except for a short period affected heavily by COVID-19 pandemic, the programmes reached an increasing number of people over time: screening coverage improved from 774 people per month to over 28,300 people per month. Gathering and discussing data regularly with stakeholders and implementers has enabled continuous improvement to service delivery. The quality of screening and adherence to hospital visits, gender balance differences and waiting time to hospital visits were also improved. Overall attendance to hospital appointments improved in 2020 compared to 2019 from 45% (95% CI: 42-48%) to 78% (95% CI: 76-80%) in women, and from 48% (95% CI: 45-52%) to 70% (95% CI: 68-73%) in men. These patients also accessed treatment more quickly: 30-day hospital referral adherence improved from 12% in 2019 to 66% in 2020. This approach helped to utilize refractive services more efficiently, reducing false positive referrals to triage from 10.6 to 5.9%. Hospital-based services were also utilized more efficiently, as primary eye care services and refractive services were mainly delivered at the primary healthcare level. Discussion: Despite various challenges, we demonstrate how data-driven decisions can lead to health programme systems changes, including patient counseling and appointment reminders, which can effectively improve adherence to referral, allowing programmes to better meet their community's needs.

Global progress toward the elimination of active trachoma: an analysis of 38 countries.

BACKGROUND: Global elimination of trachoma as a public health problem was targeted for 2020. We reviewed progress towards the elimination of active trachoma by country and geographical group. METHODS: In this retrospective analysis of national survey and implementation data, all countries ever known to be endemic for trachoma that had either implemented at least one trachoma impact survey shown in the publicly available Trachoma Atlas, or are in Africa were invited to participate in this study. Scale-up was described according to the number of known endemic implementation units and mass drug administration implementation over time. The prevalence of active trachoma-follicular among children aged 1-9 years (TF1-9) from baseline, impact, and surveillance surveys was categorised and used to show programme progress towards reaching the elimination threshold (TF1-9 <5%) using dot maps, spaghetti plots, and boxplots. FINDINGS: We included data until Nov 10, 2021, for 38 countries, representing 2097 ever-endemic implementation units. Of these, 1923 (91·7%) have had mass drug administration. Of 1731 implementation units with a trachoma impact survey, the prevalence of TF1-9 had reduced by at least 50% in 1465 (84·6%) implementation units and 1182 (56·4%) of 2097 ever-endemic implementation units had reached the elimination threshold. 2 years after reaching a TF1-9 prevalence below 5%, most implementation units sustained this target; however, 58 (56·3%) of 103 implementation units in Ethiopia showed recrudescence. INTERPRETATION: Global elimination of trachoma as a public health problem by 2020 was not possible, but this finding masks the great progress achieved. Implementation units in high baseline categories and recrudescent TF1-9 might prolong the attainment of elimination of active trachoma. Elimination is delayed but, with an understanding of the patterns and timelines to reaching elimination targets and a commitment toward meeting future targets, global elimination can still be achieved by 2030. FUNDING: None.

Prevalence of Trachoma in Pakistan: Results of 42 Population-Based Prevalence Surveys from the Global Trachoma Mapping Project.

Purpose: Previous phases of trachoma mapping in Pakistan completed baseline surveys in 38 districts. To help guide national trachoma elimination planning, we set out to estimate trachoma prevalence in 43 suspected-endemic evaluation units (EUs) of 15 further districts.Methods: We planned a population-based trachoma prevalence survey in each EU. Two-stage cluster sampling was employed, using the systems and approaches of the Global Trachoma Mapping Project. In each EU, residents aged ≥1 year living in 30 households in each of 26 villages were invited to be examined by trained, certified trachoma graders. Questionnaires and direct observation were used to evaluate household-level access to water and sanitation.Results: One EU was not completed due to insecurity. Of the remaining 42, three EUs had trichiasis prevalence estimates in ≥15-year-olds ≥0.2%, and six (different) EUs had prevalence estimates of trachomatous inflammation-follicular (TF) in 1-9-year-olds ≥5%; each EU requires trichiasis and TF prevalence estimates below these thresholds to achieve elimination of trachoma as a public health problem. All six EUs with TF prevalences ≥5% were in Khyber Pakhtunkhwa Province. Household-level access to improved sanitation ranged by EU from 6% to 100%. Household-level access to an improved source of water for face and hand washing ranged by EU from 37% to 100%.Conclusion: Trachoma was a public health problem in 21% (9/42) of the EUs. Because the current outbreak of extremely drug-resistant typhoid in Pakistan limits domestic use of azithromycin mass drug administration, other interventions against active trachoma should be considered here.

The global burden of trichiasis in 2016.

BACKGROUND: Trichiasis is present when one or more eyelashes touches the eye. Uncorrected, it can cause blindness. Accurate estimates of numbers affected, and their geographical distribution, help guide resource allocation. METHODS: We obtained district-level trichiasis prevalence estimates in adults for 44 endemic and previously-endemic countries. We used (1) the most recent data for a district, if more than one estimate was available; (2) age- and sex-standardized corrections of historic estimates, where raw data were available; (3) historic estimates adjusted using a mean adjustment factor for districts where raw data were unavailable; and (4) expert assessment of available data for districts for which no prevalence estimates were available. FINDINGS: Internally age- and sex-standardized data represented 1,355 districts and contributed 662 thousand cases (95% confidence interval [CI] 324 thousand-1.1 million) to the global total. Age- and sex-standardized district-level prevalence estimates differed from raw estimates by a mean factor of 0.45 (range 0.03-2.28). Previously non- stratified estimates for 398 districts, adjusted by ×0.45, contributed a further 411 thousand cases (95% CI 283-557 thousand). Eight countries retained previous estimates, contributing 848 thousand cases (95% CI 225 thousand-1.7 million). New expert assessments in 14 countries contributed 862 thousand cases (95% CI 228 thousand-1.7 million). The global trichiasis burden in 2016 was 2.8 million cases (95% CI 1.1-5.2 million). INTERPRETATION: The 2016 estimate is lower than previous estimates, probably due to more and better data; scale-up of trichiasis management services; and reductions in incidence due to lower active trachoma prevalence.

The cost of mapping trachoma: Data from the Global Trachoma Mapping Project.

BACKGROUND: The Global Trachoma Mapping Project (GTMP) was implemented with the aim of completing the baseline map of trachoma globally. Over 2.6 million people were examined in 1,546 districts across 29 countries between December 2012 and January 2016. The aim of the analysis was to estimate the unit cost and to identify the key cost drivers of trachoma prevalence surveys conducted as part of GTMP. METHODOLOGY AND PRINCIPAL FINDINGS: In-country and global support costs were obtained using GTMP financial records. In-country expenditure was analysed for 1,164 districts across 17 countries. The mean survey cost was $13,113 per district [median: $11,675; IQR = $8,365-$14,618], $17,566 per evaluation unit [median: $15,839; IQR = $10,773-$19,915], $692 per cluster [median: $625; IQR = $452-$847] and $6.0 per person screened [median: $4.9; IQR = $3.7-$7.9]. Survey unit costs varied substantially across settings, and were driven by parameters such as geographic location, demographic characteristics, seasonal effects, and local operational constraints. Analysis by activities showed that fieldwork constituted the largest share of in-country survey costs (74%), followed by training of survey teams (11%). The main drivers of in-country survey costs were personnel (49%) and transportation (44%). Global support expenditure for all surveyed districts amounted to $5.1m, which included grant management, epidemiological support, and data stewardship. CONCLUSION: This study provides the most extensive analysis of the cost of conducting trachoma prevalence surveys to date. The findings can aid planning and budgeting for future trachoma surveys required to measure the impact of trachoma elimination activities. Furthermore, the results of this study can also be used as a cost basis for other disease mapping programmes, where disease or context-specific survey cost data are not available.

Retinopathy of prematurity in Pakistan.

Screening guidelines for retinopathy of prematurity recommended by the American Academy of Pediatrics and the American Association for Pediatric Ophthalmology and Strabismus suggest screening infants of birth weight of ≤1500 g and/or 32 weeks' gestational age or less. In developing and middle-income countries, ROP has been reported in older and/or heavier infants. We prospectively studied 172 infants of gestational age 36 weeks and younger and/or birth weight of ≤3000 g over a period of 16 months. ROP was identified in 4 infants >32 weeks of age, 1 infant having a birth weight of 2000 g. ROP was diagnosed in premature babies heavier than those seen internationally.

Epithelial Ingrowth after Penetrating Trauma.

This is a case report about the anterior segment findings of epithelial ingrowth in a young female patient after penetrating trauma. The patient underwent multiple surgeries after penetrating trauma and epithelial ingrowth was noted on regular follow-up. Epithelial ingrowth was noted along the inner surface of corneal endothelium along with the presence of cysts. These findings suggest that epithelium penetrated through the site of perforation and grew along endothelium. Although epithelial ingrowth is a commonly reported complication of photorefractive surgery, it is rarely reported after trauma to eye. To authors' knowledge, this is the first reported case of epithelial ingrowth in Pakistan.