Al-Shifa Trust Eye Hospital Research Articles

Barriers to Low Vision Services and Challenges Faced by The Providers in Pakistan

Objective. There were two objectives of the study, first was to identify the barriers as perceived by the patients and providers to access the low vision services and second was to identify the challenges faced by the main providers. Study design. Structured questionnaire based interviews of patients and providers Methodology. To find out the barriers to access of low vision services, the interviews based on structured questionnaire were conducted for two patient groups. The first group consisted of 97 visually impaired individuals attending the department of low vision services at Al-Shifa Trust Eye Hospital Rawalpindi while the second group included 56 visually impaired individuals attending the four rehabilitation centers/schools for the blind in Rawalpindi/Islamabad. To identify the barriers as perceived by the main providers of low vision services and challenges faced by them the interviews based on structured questionnaire were conducted for 19 low vision service providers. Results. From patients point of view, major barrier to low vision services identified was inability to visit hospital /rehabilitation center alone - 29.8% in hospital group and 33.9% in rehabilitation centers group, while the lack of social support, lack of family support, cost of travelling, long distance, afford ability, hesitation in using devices and lack of satisfaction were other important barriers identified. From providers’ point of view, major barrier to uptake of services was the need for repeated follow-ups. Optometrists were the main provider of low vision services contributing to 47.4% of the providers. The major challenge faced by the providers was motivation of patients to use low vision devices. Conclusion. The major barrier to low vision services according to the patients is inability to visit the hospital alone, while according to providers, it is the need for repeated follow up which proves major barrier towards uptake of services. The motivation is the major challenge faced by providers, majority of which are optometrists.

Corneal collagen cross-linking for keratoconus: Results of 3-year follow-up in Pakistani population

ObjectiveTo assess the effectiveness and safety of corneal collagen cross-linking with riboflavin and ultraviolet A (UV-A) light in arresting the progression of keratoconus. DesignProspective, nonrandomized experimental study. ParticipantsSeventy-one eyes of 66 patients with progressive keratoconus. MethodsCorneal cross-linking was carried out with riboflavin and UV-A light in patients with progressive keratoconus at Al-Shifa Trust Eye Hospital, Pakistan. Standard protocol of cross-linking comprising epithelial debridement, instillation of isotonic riboflavin (0.1%) for 30 minutes, followed by application of UV-A light for 30 minutes with riboflavin was followed. Variables of interest were uncorrected and best corrected visual acuity (BCVA) with spectacles, spherical equivalent refraction, maximum keratometric reading, and central corneal thickness. Three-year results of these variables after cross-linking were analyzed. ResultsMean age of patients was 19.79 ± 3.71 years; 75.8% were male and 24.2% were female. After 3 years, uncorrected visual acuity improved in 31.0% by mean 2.0 ± 1.06 Snellen lines, remained same in 64.8%, and deteriorated in 4.2% by mean 1.33 ± 0.57 lines. BCVA improved in 56.3% by mean 2.37 ± 1.10 Snellen lines, remained the same in 40.8%, and deteriorated in 2.8% by mean 1.50 ± 0.70 lines. Spherical equivalent refraction decreased in 33.8% by mean 2.29 ± 1.48 D, remained stable in 60.6%, and increased in 5.6% by mean 1.43 ± 0.42 D. Maximum keratometric reading showed mean regression of 2.64 ± 1.42 D in 60.6%, stabilization in 35.2%, and mean progression of 2.0 ± 0.17 D in 4.2%. In 95.8% of cases, progression of keratoconus halted. Central corneal thickness was decreased by mean 10.32 ± 21.19 µm. ConclusionsCross-linking is an effective and safe treatment option in halting the progression of keratoconus.

Comparison of pre-operative central corneal thickness in pediatric cataract cases versus normal.

To compare the pre-operative central corneal thickness (CCT) in paediatric cataract patients with reference to normal control group. A case control study. Paediatric Ophthalmology Clinic of Al-Shifa Trust Eye Hospital (ASTEH), Rawalpindi, from November 2009 to May 2010. The study included 116 subjects with equal number of cases and controls. Demographic profile of all the subjects was noted followed by history and detailed ophthalmic examination. CCT was measured using an ultrasonic pachymeter (model Pac Scan 300). The mean of three measurements from the central cornea were recorded in microns. RESULTS were analyzed using SPSS version 17.0. Mean CCT values of the cases was 566.83 ± 37.646 microns while the control group had a mean CCT of 535.81 ± 24.466 microns. Difference between the CCT values of the two groups was highly significant (p < 0.001). Eyes with congenital cataracts have greater CCT values as compared to normal paediatric population. This factor must be kept in mind while interpreting intra-ocular pressure in such patients.

Clinical course of retinoblastoma.

To determine the clinical manifestations and results of current treatment for patients with retinoblastoma (Rb) in a tertiary care eye hospital in the north west of Pakistan. Case series. Al-Shifa Trust Eye Hospital, Rawalpindi, Pakistan, from January 2006 and December 2009. The data of 139 patients diagnosed as having retinoblastoma was collected. Gender, age at diagnosis, laterality, presenting sign, classification of tumour, treatment modality and outcome were noted. The mean age of presentation in this patients ranged from 6 to 50 months (mean: 24.05 ± 10.74 months). The most common presenting sign was leucocoria in 78 eyes (44.1%). One hundred and one (72.7%) patients had unilateral retinoblastoma. Using the International Classification of Retinoblastoma (ICRB), 135 (76.3%) eyes were placed in group-E. one hundred and twenty four (77.5%) eyes were enucleated or exenterated while globe preservation was achieved by chemoreduction and/or focal therapy in the rest of the treated eyes (n = 36, 22.5%). Twenty three (16.5%) cases were lost to follow-up before one year. Ninety two (66.2%) patients survived, being free of tumour, at least one year after the completion of treatment. Most children with Rb showed an advanced stage of tumour at the time of diagnosis. Measures to improve the rate of globe preservation and patient survival by early diagnosis and intervention are the need of the hour.

Retinal detachment in paediatric patients.

To assess the causes of retinal detachment in children and the various operative procedures requiring vitreoretinal surgical intervention for the same. Case series. Department of Ophthalmology, Al-Shifa Trust Eye Hospital, Rawalpindi, from January 2006 to May 2009. A total of 281 eyes of 258 patients, (aged 0-18 years) who underwent vitreo-retinal surgical intervention for retinal detachment were included. Surgical log was searched for the type of retinal detachment and its causes. Frequencies of various interventions done in these patients viz. vitrectomy, scleral buckle, use of tamponading agents, laser photocoagulation and cryotherapy were noted. Results were described as descriptive statistics. Myopia was the cause in 62 (22.1%) and trauma in 51 (18.1%) of the eyes. Total retinal detachment (RD) was treated in 94 (33.5%) eyes, sub total RD in 36 (12.8%), recurrent RD in 32 (11.4%), giant retinal tear in 28 (10%), tractional RD in 15 (5.3%) and exudative RD in 2 (0.7%). Prophylactic laser or cryotherapy was applied in 74 (26.3%) of the eyes. Pars plana vitrectomy (PPV) was carried out in 159 (56.6%) eyes while scleral buckle procedure was done in 129 (45.9%) eyes. Silicon oil was used in 149 (53%), perfluorocarbon liquid in 32 (11.4%) and gas tamponade in 20 (7.1%) eyes. The most common cause of retinal detachment in paediatric patients was myopia, followed by trauma. Total RD was more common as compared to the other types. The most common procedure adopted was pars plana vitrectomy followed by scleral buckle procedure.

Retinal thickness evaluation in healthy eyes from north-west Punjab through optical coherence tomography.

To determine the mean retinal thickness in healthy eyes from north-west Punjab through commercially available optical coherence tomography (OCT) mapping software, version 3.0, from the Stratus OCT (OCT3). Descriptive study. Al-Shifa Trust Eye Hospital, Rawalpindi, from August 2008 to February 2009. One hundred and two eyes of 75 healthy north-west Punjabis, fulfilling inclusion criteria were enrolled from OPD of Al-Shifa Trust Eye Hospital. After informed consent, demographic detail was taken. Best-corrected Snellen visual acuity was recorded. OCT was performed by using Stratus Carl Zeiss OCT through dilated pupil by an experienced operator. The retinal thickness was divided into 9 sections and displayed as three concentric circles including a central circle at fovea (1 mm), an inner ring (3 mm) and an outer ring (6 mm), each ring being divided into four quadrants. OCT parameters of macular thickness were analysed with baseline variables including age, gender and best corrected visual acuity. The mean central foveal thickness (at foveola) was 166.30 ± 24.95 μm while the mean foveal thickness (in central 1000 microns) was 194.89±21.33 μm. There was no correlation between macular thickness and either age (r=0.109, p=0.275) or gender (Eta=0.128) or best corrected visual acuity (Eta=0.234). Reference values were determined for mean retinal thickness in healthy eyes from north-west Punjab through OCT. These measurements were upto 54-μm higher and upto 29 μm lower than some previously reported healthy retinal thickness values. Therefore, normative database should be determined for the population under study based on regional and ethnic differences.

EXCIMER LASER

Objectives: To evaluate the efficacy and safety of excimer laserphotorefractive keratectomy for myopia in Pakistani people. Design: Prospective study. Setting: At Al-Shifa Trust EyeHospital Rawalpindi. Period: October, 1995 and Febrauray, 1996. Material &amp; Methods: The study group of thirteenpatients, comprises of 25 eyes, with refractive error ranging from -1.50 to -3.50 D.S (diopters sphere) and less than-1.50 D.C (diopters cylinder).Results: Thirteen eyes (52%) lost to follow up after three months. Only twelve eyes (48%)could be reviewed at six months after photorefractive keratectomy. At one month, eleven eyes (44%) and at threemonths, eight eyes (32%) were hypermetropic within +0.25 to +1.00 diopters of spherical equivalent .At six months onlythree eyes (25%) had hypermetropia within +0.25 to +1.00 diopters spherical equivalent. None of the eyes had anykind of astigmatism more than 1.00 diopter. No over correction of more than +1.00 diopter of spherical equivalent wasobserved in any case. At one month, three months and six months after photo-refractive keratectomy, 88%, 80% and100% eyes had 6/6 visual acuity respectively, without any optical aid. Hundred percent of the eyes showed completehealing of the epithelium on third post operative day. Moderate to severe postoperative pain was experienced by everyone for three days with gradual reduction in intensity. Only one eye (8.33%) had grade 1 haze at six months. Restsof the eyes were clear .No vision threatening complications occurred. Despite the short term follow up, photorefractivekeratectomy appears to be an effective and safe procedure with good predictability for the correction of low myopia.Conclusion: Despite relatively short term follow up of the study; photo refractive keratectomy (PRK) appears to be safeand quite predictable procedure for correction of low myopia.

Glaucoma Related Morbidity at A Tertiary Care Eye Hospital

Purpose: To report pattern and burden of glaucoma related morbidity in terms of visual impairment and structural damage to optic nerve in patients presenting for the first time at glaucoma clinic of a tertiary care eye hospital. Design of Study: A cross sectional observational study. Participants: All patients aged above 16 years reporting for the first time at glaucoma clinic of Al-Shifa Trust Eye Hospital, Rawalpindi from 1st July 2006 to 30th June 2007. Methods : After taking history, a detailed ocular examination of all the patients including visual acuity using snellen chart, refraction trial for best corrected visual acuity, slit lamp examination, applanation tonometry (with tonopen in unco-operative patients), gonioscopy (with four mirror Posner lens), stereoscopic assessment of the cup disc ratio ( with Heidelberg retinal tomogram) and visual field (Humphery static perimetery, 30-2 program and Frequency doubling technique) testing was performed. All data was recorded on a special proforma and then assessed using statistical software SPSS version 12.0. Results: A total number of 800 new patients were examined in the glaucoma clinic from 1st July 2006 to 30th June 2007. Among these 800 patients, 487 (60.9%) were male and 313 (39.1%) were female. 132 subjects (16.5%) were identified as blind with a visual acuity of <3/60 in both eyes while an additional 325 subjects (40.6%) had a visual acuity of <3/60 in one eye. Crude estimate of the frequency of blindness (Table 2) was slightly higher in women as compared to men (OR, 1.07; 95% CI, 0.87-1.27). Blindness was associated with illiteracy (OR, 2.80; 95% CI, 2.15-3.45), age of patients 60 years and above (OR, 1.38; 95% CI, 1.07-1.69) and advanced cupping in both eyes (OR, 2.75; 95% CI, 2.18-3.32). Blindness was more frequent in patients of neovascular and pseudoexfoliation glaucoma. Regarding the structural damage, 33% of the pati-ents presented to us when the cup disc ratio in their better eye had worsened to 0.8 or more. Conclusion: Glaucoma is leading cause of blindness, and warrents detailed investigation of strategies for prevention. As It is a fact that advanced stage of glaucoma at diagnosis has been one of the most important factors for glaucoma caused blind-ness, targeted screening, breaking down barriers to access and a campaign to create awareness among the people regarding importance of regular eye examinations may be effective in reducing the number of patients going blind from glaucoma. Using the available data from the health surveys, improving awareness, case detection, and early treatment of glaucoma are the fields which need our attention. In short, a combined effort by governments, NGOs, ophthalmologists and primary health care providers can be helpful to prevent the world from glaucoma related blindness.

Ocular manifestations of xeroderma pigmentosum.

Xeroderma pigmentosum (XP) is an autosomal recessive (AR) condition characterized by photosensitivity and inability to repair ultra-violet (UV) induced DNA damage. Patients diagnosed with XP, presenting to the Paediatric ophthalmology department of Al-Shifa Trust Eye Hospital, Rawalpindi, were evaluated and followed-up over a period of one year, for the effects of the disease process on vision and for the development of ocular tumours. Excision of the tumours, if present, was performed under general anaesthesia. Counselling of the patients was done. Referral to oncologist and dermatologist was made, if so warranted, after histopathology of excision biopsy.