Apr-Jun 20141515569692

Ophthalmology Update Vol. 12. No.
2, April-June 2014 i
Contents
EDITORIAL
The Prospect of Treating Retinoblastoma in Pakistan
Ibrahim Qaddoumi -----------------------------------------------------------------------------------------------------------------------------------90
OPHTHALMIC SECTION / ORIGINAL ARTICLES

Evaluation of Functional & Psycho-social Impact in Adult Strabismus
Muhammad Nazim et al ----------------------------------------------------------------------------------------------------------------------------- 92
Problems and Complications faced by Ophthalmic Residents during Cataract

Surgery with Intraocular Lens Implantation
Mohammad Idris et al --------------------------------------------------------------------------------------------------------------------------------95
Effect of Yag Laser Energy in Mille Joules (Mj) for Change in IOP after Yag
Laser Posterior Capsulotomy
Bilal Khan et al ----------------------------------------------------------------------------------------------------------------------------------------98
Nd-Yag Laser Capsulotomy Efficacy vs Complications

Waseem Ahmed et al --------------------------------------------------------------------------------------------------------------------------------101
Clinical Presentation and Management of Patients with Congenital Fibrosis of Extraocular Muscles
Sameera Irfan et al -----------------------------------------------------------------------------------------------------------------------------------104
Efficacy of Stem Cell Graft in Preventing the Recurrences of Pterygium

Waqar Ahmed et al ----------------------------------------------------------------------------------------------------------------------------------109
What for we are looking in Psuedoexfoliation: A Clinical Presentation of the Patients

Mohammad Idris et al -------------------------------------------------------------------------------------------------------------------------------113
Comparison of Visual Outcome with single Suture Vs Sutureless Clear Corneal

Phacoemulsification by using 5.5 PMMA IOL’s
Mohammad Siddique et al --------------------------------------------------------------------------------------------------------------------------117
Post-operative Diplopia in Children with Horizontal Strabismus

Abdul Qayyum et al --------------------------------------------------------------------------------------------------------------------------------121

Team Management, Twinning & Telemedicine in Retinoblastoma: A 3-Tier
Approach Implemented in thefirst Eye Salvage Program in Jordan
Ibrahim Qaddoumi et al -----------------------------------------------------------------------------------------------------------------------------127
Primary Pterygium Excision: A Better Technique to avoid Recurrences

Waseem Ahmed et al -------------------------------------------------------------------------------------------------------------------------------- 131
GENERAL SECTION / ORIGINAL ARTICLES
Current Pattern of Mechanical Intestinal Obstruction in Adults (A Hospital Based Study)

Yousaf Jan et al -------------------------------------------------------------------------------------------------------------------------------------- 135
Frequency of Vaginal Candidiasis amongst Pregnant Women & Effect of Predisposing Factors
Rahat Jabeen et al ------------------------------------------------------------------------------------------------------------------------------------ 140
ii Ophthalmology Update Vol. 12. No. 2, April-June 2014

Short Term Results of Local Steroid & Anaesthetic Injection in the Management of Planter Fasciitis
Muhammad Imran Khan et al --------------------------------------------------------------------------------------------------------------------- 144
Post Dural Puncture Headache (PDPH): Comparison of 25G Quincke & Whitacre
Spinal Needles in Caesarean Sections
Roheena Wadood et al ------------------------------------------------------------------------------------------------------------------------------ 147
Incidence of Prostate Cancer following Trans-Urethral Resection of Prostate (TURP) for

Clinically Benign Symptomatic Enlarged Prostate with Normal Prostatic Specific Antigen (PSA)
Yousaf Jan et al -------------------------------------------------------------------------------------------------------------------------------------- 151
Accuracy of Diffusion-weighted MRI in Localization of Undescended Testes

Zubair Janan et al ----------------------------------------------------------------------------------------------------------------------------------- 156
Effectiveness of Autologous Blood Injection in Patients with Lateral Epicondylitis (Tennis Elbow)
Muhammad Khalid et al ---------------------------------------------------------------------------------------------------------------------------- 159
Ophthalmology Update Vol. 12. No. 2, April-June 2014 iii

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iv Ophthalmology Update Vol. 12. No. 2, April-June 2014

Editorial
The Prospect of Treating
Retinoblastoma in Pakistan
Retinoblastoma is the most common ocular tumor other hand, the literature also pro-
in children, occurring in 1 in every 20,000 live births. Is vides hope for patients with retino-
it one of the most curable malignancies in children in blastoma, as many healthcare pro-
the developed world, with patients who undergo enu- viders from different disciplines,
cleation and radiation therapy having 5-year overall especially epidemiology, pathol-
survival rates of more than 90% achieved three decades ogy, and ophthalmology, have a
earlier.(1) Such superior survival rates have prompted research interest in this disease.
a paradigm shift in the treatment of retinoblastoma The authors propose some
in the developed world, with an emphasis on eye sal- steps for their colleagues in Pakistan for improving
vage, vision preservation, and quality of life without the outcomes for children with retinoblastoma. First,
compromising the excellent survival. To achieve these conduct a nationwide review of retinoblastoma cases
goals, new concepts such as a multidisciplinary team among major treating centers to identify accurate es-
(including the ophthalmologist, the oncologist, the timates on incidence, presenting symptoms, age at di-
pathologist, the radiation oncologist, and many other agnosis, laterality status, treatment modalities, patho-
disciplines) and multimodality treatment (including logic presentation, and, most importantly, survival
chemotherapy, focal treatment, and radiation therapy) data. Second, establish an advocacy group from differ-
have been introduced. Also, because of the rarity of ent relevant specialties. Retinoblastoma is a very rare
the disease, the concept of centralization of treatment disease, and without active advocacy from healthcare
in major cancer centers has become the standard of care providers and families, it will be very difficult to allo-
in the developed world. For example, France, with a cate resources for children with this disease. In Paki-
population of 66 million, has only 1 dedicated retino- stan, reported birth rates suggest that 230 cases of ret-
blastoma center at Institute Curie in Paris. inoblastoma are expected every year. In contrast, there
Unfortunately, the scenario for children with retin- are approximately 40,000 deaths every year in Pakistan
oblastoma is not as promising in the developing world. from breast cancer alone. Therefore, unless retinoblas-
The major obstacles to achieving high cure rates in de- toma supporters pressurize the Pakistani Health Au-
veloping nations are late diagnosis, advanced disease, thorities government and the society, retinoblastoma
lack of a team approach, deficiency in major treatment will not be considered a priority. Third, the treatment
modalities, insufficient pathologic services, and poor of retinoblastoma in Pakistan should be consolidated
outcome, being the norm in most of these countries.(2 in 3 or 4 major pediatric cancer centers in main cities

In a search in PubMed for literature on retinoblas- such as Islamabad, Lahore, Karachi, and Peshawar.
toma in Pakistan, the authors found 23 articles. Table 1 These centers should focus on strategies to improve
summarizes data from some of the key publications on survival and quality of life. Use of a team approach,
retinoblastoma from Pakistan.(3-7) It is evident that there correct pathologic staging, and good-quality prostheses
are many challenges facing the treatment of retinoblas- should be top the priorities for these centers. This third
toma in Pakistan. It is difficult to get accurate data on step should also include a thorough review to identify
age at diagnosis, laterality, treatment modalities, and available relevant expertise and resources in each city
outcome data. Late diagnosis and advanced disease in order to facilitate the successful pairing of differ-
with distant metastases are common problems. Lack of ent specialties needed for achieving optimal outcomes
long-term follow up to accurately estimate long-term for children with retinoblastoma.(8) Fourth, a national
survival and quality of life is another challenge. On the awareness campaign for early detection and referral
Ophthalmology Update Vol. 12. No. 2, April-June 2014 90

Editorial
Table-1: Summary of literature related to retinoblastoma in Pakistan
Total Bilateral Age at Diagnosis,

Source Presentation Enucleation Pathology Outcome
Cases(N) Cases (N) Range
Leukocoria 44.3% 8/31a had Orbital recurrence
3.8 yr
Arif (2010)(3) 176 NA Proptosis 29.5% 77.4% pathology 22.7% 3/31a had
(1–10 yr)
Fungating mass 17.8% report follow up
Leukocoria 5.7% 4 yr
Bhurgri (2004)(4) 101 9 (9%) 100% ON (60%) NA
Mass 70% 9% diagnosed> 7 yr old
Arif (2010)(5) 80 40 (50%) Mets 20% 3.5 (7 m –12 yr) 46% ON (27%b) NA
0–4 yr (60%)
Bhurgri 2003(6) 60 NA NA NA NA NA
5–9 yr (37.5%)
Khan (2000)(7) 23 NA NA NA 100%c ON (60%)
Abbreviations: NA, not available; yr, year; ON, optic nerve; mets, metastases; m, month.
a
Pathology and follow up data in this study were reported only on 31 cases with orbital recurrence.
b
ON was involved in 10/37 cases.
c
Data provided only for cases of enucleation.
should be launched that targets healthcare providers as 7 Soomro I, Khan MN, Muzaffar S, Kayani N, et al. Retinoblas-
toma tells the story of our health care system. J Pak Med Assoc.
well as the general population.
2000; 50: 410-411.
Many of these strategies have proven successful 8 Chantada G, Luna-Fineman S, Sitorus RS, Kruger M, et al.
in a short time period in developing countries such as SIOP-PODC recommendations for graduated-intensity treat-
Honduras,(9) Jordan,(10) and Kenya.(11) Thus, the prospect ment of retinoblastoma in developing countries. Pediatr Blood
Cancer. 2013; 60: 719-727.
of duplicating such successes in Pakistan is bright. 9 Leander C, Fu LC, Peña A, Howard SC, et al. Impact of an edu-
REFERENCES cation program on late diagnosis of retinoblastoma in Hondu-
1 Pui CH, Gajjar AJ, Kane JR, Qaddoumi I, et al. Challenging is- ras. Pediatr Blood Cancer. 2007; 49: 817-819.
sues in pediatric oncology. Nat Rev Clin Oncol. 2011; 8: 540- 10 Qaddoumi I, Nawaiseh I, Mehyar M, Razzouk B, et al. Team
549. management, twinning, and telemedicine in retinoblastoma: a
2 Canturk S, Qaddoumi I, Khetan V, Ma Z, et al. Survival of ret- 3-tier approach implemented in the first eye salvage program
inoblastoma in less-developed countries impact of socioeco- in Jordan. Pediatr Blood Cancer. 2008; 51: 241-244.
nomic and health-related indicators. Br J Ophthalmol. 2010; 94: 11 Dimaras H, Kimani K, Dimba EA, Gronsdahl P, et al. Retino-
1432-1436. blastoma. Lancet. 2012; 379: 1436-1446.
3 Arif M, Islam Z. Retinoblastoma: postenucleation orbital recur-
rence. Can J Ophthalmol. 2010; 45: 606-609. Dr. Ibrahim Qaddoumi, MD, MS
4 Bhurgri Y, Muzaffar S, Ahmed R, Ahmed N, et al. Retinoblas- St. Jude Children’s Research Hospital
toma in Karachi, Pakistan. Asian Pac J Cancer Prev. 2004; 5:
159-163.
Memphis, TN, USA
5 Arif M, Iqbal Z, Zia-ul-Islam. Retinoblastoma presenting as E.Mail: Ibrahim.Qaddoumi@stjude.org
metastasis. J Ayub Med Coll Abbottabad. 2010; 22: 109-111.
6 Bhurgri Y, Bhurgri H, Usman A, Faridi N, et al. Epidemiology Dr. Guillermo Chantada, MD
of ocular malignancies in Karachi. Asian Pac J Cancer Prev.
2003; 4: 352-357.
Guille Hospital JP Garrahan, Buenos Aires, Argentina
17th ANNUAL CONGRESS OF OPHTHALMOLOGY

under the aupices of Federal Branch of
Ophthalmological Society of Pakistan, Islamabad
to be held at Bhurban (Murree) 2-4 May 2014
Please Contact:
Brig. Dr. Aamir Yaqub FRCS
General Secretary, OSP Federal Branch, Islamabad
Cell: 0321-5365434, E-Mail: mayaqub@gmail.com
91 Ophthalmology Update Vol. 12. No. 2, April-June 2014

OPHTHALMIC SECTION
ORIGINAL ARTICLE
Evaluation of Functional &

Psycho-social Impact in Adult Strabismus
Muhammad Nazim
Muhammad Nazim FCPS1, Muhammad Bilal MBBS2, Lal Muhammad FCPS3

Muhammad Naeem MBBS4, Mushtaq Ahmad FCPS5, Bilal Bashir FCPS6
ABSTRACT
Objective: To evaluate functional and psychosocial impact of strabismus in adult patients using adult strabismus 20 ques-
tionnaire (AS-20).
Material and Methods: Patients were selected from in and out patient of Hayatabad Medical Complex from March 2012
to January 2013. 26 non-diplopiac strabismic patients, aged 17 years and above were interviewed using AS-20 question-
naire (10 psychosocial items and 10 functional items). Questions were presented in a simple understandable way. Patients
responses were recorded using 5-point Likert scale (never =100, rarely =75, sometimes =50, often =25 and always =0).
Mean overall, psychosocial and functional scores were recorded (Lower score worse impact). Scores were also recorded
for both genders and different age groups.
Results: The mean overall, psychosocial and functional scores were 51, 39 and 63 (mean score 84 for normal non stra-
bismic). The difference between male and female group were not statistically significant (p-value >0.05). The mean psy-
chosocial score in patient group above 30 years was 30 while it was 45 in below 30 years. This difference was statistically
significant (p value < 0.05).
Conclusion: AS-20 is a good tool for evaluation of psychosocial and function impact in adult strabismic patients. Affected
patients may be considered for proper psychological counseling.
Key words: Adult, strabismus, psychosocial, function, health related quality of life (HRQOL), questionnaire.
INTRODUCTION connection was made by Hatt et al, the so called ‘adult

Strabismus effects health related quality of life strabismus 20 (AS-20) questionnaire’.1 In this study we
(HRQOL) in adults.1 Strabismus has been shown to have used their questionnaire for evaluation of HRQOL
have a more detrimental effect on patients’ quality of in our adult strabismus patients (table I). To our knowl-
life than diabetic retinopathy, with levels similar to that edge such effort has not been made so far in our region.
seen with macular degeneration or following a mild METHODOLOGY
cerebrovascular accident.2 It has psychosocial and func- The AS-20 questionnaire contained 20 items com-
tional impacts on patient’s health including self-image, prising of psychosocial and function subscales, each
interpersonal relations, securing employment, school, containing 10 items. For each question a 5-point Likert
work and sports etc.2-6 These problems do not go away scale was used for responses: never (score 100), rarely
after childhood rather they intensify in adult life.2 Al- (score75), sometimes (score 50), often (score 25), always
though evaluation of HRQOL is increasingly consid- (score 0). For each patient we calculated a mean overall
ered an important part of strabismus management but score (mean of 20 items), Mean psychological subscale
in routine clinical practice it is not usually done. 7-8 and mean functional subscale scores (mean of 10 items
Currently only a few questionnaires exist for the for each subscale). Lower score showed worse HRQOL.
assessment of psychosocial and function impairment The mean score for a normal non-strabismic is 84.
in adult strabismus patients.1,9-12 One good effort in this Twenty six patients of both the genders aged 17
1
Ophthlgmologist, Khyber Institute of Ophthalmic Medical Sciences years or above having strabismus without diplopia
(KIOMS), Hayatabad Medical Complex (HMC) Peshawar. 2Post grad- were included in the study. Questions were asked by
uate Trainee Ophthalmology Department,Hayatabad Medical Com- two well-trained doctors very fluent in native language.
plex, Peshawar. 3Associate Professor & Incharge Ophthalmology
Department Khyber Medical University, Institute of Medical Sciences, The interviewers made sure that every question is well
KDA Hospital Kohat, KPK. 4Post graduate Trainee, Ophthalmology understood and answered.
Department,Hayatabad Medical Complex, Peshawar. 5Senior Regis-
RESULTS
trar Ophthalmology Department, HMC, Peshawar. 6Medical Officer,
Ophthalmology Department, Lady Reading Hospital, Peshawar. There were 12 (46%) females, mean age 27.6 years
and 14 (54%) males mean age 26.64 years. For the 26
Correspondence: Dr Mushtaq Ahmad, House No 31B, Street No 2, sec-
tor N4, Phase 4, Hayatabad, Peshawar. Mushtaq_1ktk@hotmail.com
patients diagnosis were, infantile esotropia (n=9, 34%),
Cell:03339119605 congenital esotropia (n=6, 23%), intermittent decom-
pensated exotropia (n=4, 15%), post sclera buckle ex-
Received: Jan’2014 Accepted March’2014
otropia (n=1, 3.84%), sensory exotropia (n=6, 23%, 2

post-traumatic, 2 absolute glaucoma and one congeni- Table II Mean overall, psychosocial and
tal cataract). Visual acuity ranged from 6/6 to 1/60 for functional score for male and female groups
the worse eye and 6/6 to 2/24 Snellens for better eye. MALE (n=14) FEMALE (n=12)
For 15 (58%) patients with primary esotropia the angle
Score Types Below Above Below above
of deviation on alternate prism cover test ranged from mean 30 30 mean 30 30 p-value
15pd to 40pd (median 27.5pd) at distance and 15pd to (n=4) (n=10) (n=4) (n=8)
50pd (32.5pd) at near. For 11 patient (43%) with prima- Mean overall 53 55 51 50 54 46 >0.05
ry exodeviation angle of deviation ranged from 15pd to Psychosocial 38 45 30.5 40 44 32 <0.05
50pd (mean 32.5) at distance. Functional 63 65 65 62.5 63 61 >0.05
For the 26 patients the mean overall score for the
questionnaire was 51. It was 39 for psychological sub-
scale and 63 for the function scale. For both the genders DISCUSSION
and age groups the mean overall, psychological and Adult strabismus is a common eye problem which
function scores are presented in table II were 50, 40 and affects the health related quality of life.1 Functional
62.5. For 4 female patients above 30 this score was 46, 32 impacts of strabismus on life are long known but now
and 61. For 8 patients below 30 this score was 54, 44 and there is overwhelming evidence that adult strabismus
63. For 14 male patients the mean overall, psychosocial also negatively effects psychosocial aspects of life2. It
score were 53, 38 and 63. For 4 male patients above 30 effects self-image, relationships, job prospects, educa-
this score was 51, 30.5 and 65. For 10 patients below 30 tion, sports and may result in psychiatric disturbanc-
score was 55, 45 and 65. es. These problems increase with increasing age and
increasing degree of strabismus especially above 25
Table-1: Questionnaire: prism diopters.2
Psychosocial and functional subscales The evaluation and quantification of functional
and psychosocial impact of strabismus in adults is con-
Psycho-social Subscale: sidered important in clinical practice.1, 9-12 It may help
1. I worry about what people will think about my identify those patients who require psychosocial coun-
eyes. seling1. Until recently there was no strabismus specific
2. I feel that people are thinking about my eyes even questionnaire dealing with psychological aspects of
when they are not saying anything. strabismus.2 In amblyopia and strabismus question-
3. I feel uncomfortable when people are looking at naire (ASQ) there were just 4 questions out of 24 for
me because of my eyes. psychosocial elements of strabismus. The 20-item Adult
4. I wonder what people are thinking when they are Strabismus questionnaire (AS-20) has been made avail-
looking at me because of my eyes able. It was developed by distilling down a 181-item
5. People do not give me opportunities because of questionnaire, gained from patient interviews, 231 to 20
my eyes. questions, 10 dealing with the psychosocial elements of
6. I am self-conscious about my eyes. strabismus and 10 with the functional problems. The
7. People avoid looking at me because of my eyes. questions used are the best discriminators. The AS-20 is
8. I feel inferior to others because of my eyes.
a freely available (QOL) questionnaire developed spe-
9. People react differently to me because of my eyes.
cifically for strabismic adults. The overall score is the
10. I find it hard to initiate contact with people I do
mean of all the questions answered, with a score from 0
not know because of my eyes.
to 100 (0 being worst and 100 being best). The threshold
Functional Subscale:
for a normal, non-strabismic, score is 84.The test-retest
1. I cover or close one eye to see things better.
reliability of the AS-20 is good, indicating its potential
2. I avoid reading because of my eyes.
3. I stop doing things because my eyes make it dif- use in assessing changes in strabismus over a long time
ficult to concentrate. period.2 We used AS-20 to evaluate functional and psy-
4. I have problems with depth perception. chosocial impact of strabismus in our patients.
5. My eyes feel strained. The mean overall score in our study was 51. It was
6. I have problem reading because of my eye condi- 39 and 63 for psychological and function subscales. The
tion. average score for a visually normal non strabismic adult
7. I feel stressed because of my eyes. was 84 in study conducted by Hatt et al using AS-20
8. I worry about my eyes. questionnaire.2 It clearly shows that strabismus dents
9. I cannot enjoy hobbies because of my eyes. the psychosocial and function aspects of our adult pop-
10. I need to take frequent breaks when reading be- ulation. It also shows that AS-20 questionnaire is sensi-
cause of my eyes. tive enough to evaluate health related life impairment

in our patients. For non-diplopic strabismus patients, REFERENCES

1. Hatt SR, Leske DA, Bradely EA, Cole SR, Holmes JM. Develop-
the mean overall, psychological and functional scores
ment of a quality of life questionnaire for adults with strabis-
given by Hatt et al were 59, 66 and 60 respectively. mus. Ophthalmology 2009; 116: 113-44.
Our function score are comparable to their study but 2. Satterfield D, Keltner JL, Morrison TL. Psychosocial aspects of
we got lower psychosocial subscale score (showing strabismus study. Arch Ophthalmol 1993;111: 1100-5.
3. Burke JP, Leach M, Davis H. Psychosocial implications of stra-
worse HRQOL). This shows the gravity of psycho- bismus surgery in adults. J Pediatr Ophthalmol Strabismus
social issues in our adult strabismus patients and the 1997; 34: 159-64.
very need of addressing them in clinical practice by 4. Menon V, Saha J, Tandon R. Study of psychosocial aspects of
strabismus. J Pediatr Ophthalmol Strabismus 2002; 39:203-8.s
proper psychological counseling. A large size study
5. Coats DK, Paysse EA, Towler AJ, Dipboye RL. Impact of large
would be needed to further elaborate this point in angle horizontal strabismus on the ability to obtain employ-
our patients. ment. Ophthalmology 2000; 107: 402-5.
The mean psychosocial score in patient group 6. Olistky SE, Sudesh S, GrazianoA. The negative pschycosocial
impact of strabismus in adults. J AAPOS 1999; 3: 20-11.
above 30 years was 30 while it was 45 in below 30 years 7. Beauchamp GR, Black BC, Coats DK. The management of stra-
(p value <0.05). This is in accordance with other stud- bismus in adults-III. The effect on disability. J AAPOS 2005; 9:
ies which show that psychosocial difficulties increase 455-9.
8. Jackson S, Harrad RA, Morris M, Rumsey N. Psychosocial ben-
with increasing age of adult strabismus patients.2 The
efits of corrective surgery for adults with strabismus. Br J Oph-
mean overall, psychosocial and function scores were thalmol 2006; 90: 883-8.
not very different between male and female groups in 9. Patric DL, Deyo RA. Generic and disease specific measures in as-
our study (p value > 0.05). Studies have shown that fe- sessing health status and quality of life. Med Care 1989; 27: 217-32.
10. Morgolis MK, Coyne K, Kenedy-Martin T. Vision specific in-
males strabismus patients are more negatively reported strument for the assessment of health related quality of life and
than males 13-15. Moreover because of added social is- visual functioning: a literature review. Pharmacoeconomics
sues related to female gender in our population we too 2002; 20: 791-812.
11. Hatt SR, Leske DA, Kirgis PA. The effect of strabismus on qual-
were expecting a lower score in female group. A large
ity of life in adults. Am J Ophthalmol 2007; 144: 643-7.
size study would be needed in future to elaborate this 12. Felius J, Beauchamp GR, Stager DR. The amblyopia and stra-
point. bismus questionnaire: English translation, validations and sub-
CONCLUSION scales. Am J Ophthalmol 2007; 143: 305-10.
13. Mojon-Azzi SM, Potnik W, Mojon DS. Opinions of dating
Thus we have seen that, AS-20 questionnaire is a useful agents about strabismic subject’s ability to find a partner. Br J
tool and can be used in our adult strabismus popula- Ophthalmol 2008; 92:765-9.
tion to assess and quantify the functional and psycho- 14. 445 Goff M, Suhr A, Ward J et al. Effect of adult strabismus
on ratings of official U.S army photographs. J AAPOS 2006;
social impacts of strabismus. It will help select patients
10:400-3.
for proper psychological counseling. Moreover, the 15. Coats D, Paysse E, Towler A et al. Impact of large angle hori-
benefit of surgery in terms of reducing the functional zontal strabismus on ability to obtain employment. Ophthal-
and psychological issues can also be assessed. mol2000; 107:402-5.

ORIGINAL ARTICLE
Problems and Complications faced by

Ophthalmic Residents during Cataract Surgery
with Intraocular Lens Implantation
Mohammad Idris
Mohammad Idris FCPS1, Sardar Ali DOMS2, Anwar Ali FCPS3, Adnan Alam MBBS4
Jawad AftabMBBS5, Mohammad Alam FCPS6
ABSTRACT
Objective: To determine the problems and complications faced by ophthalmology residents during cataract surgery with
intraocular lens implantation in the ophthalmology unit, Lady Reading Hospital, Peshawar.
Introduction: Cataract is any lens opacity, partial or complete, of one or both eyes, impairing vision. Complication during
extra capsular cataract surgery includes posterior capsule rent, vitreous loss, corneal edema; corneal striate etc. Extra
capsular cataract extraction surgery is relatively simple and straight forward cataract surgery to learn without investment in
expensive equipment compared to other surgical procedures like phacoemulsification.
Methodology: The study was conducted at Eye Department, Lady Reading Hospital, Peshawar, from 25th June 2011 to
25th December 2011. It was cross sectional interventional study. Non probability purposive sampling technique was used.
Results: Out of 150 cases selected for study posterior capsular rent occurred in 15 (10%), cases, vitreous loss was in11
(7.3%), cases striate keratitis in 21 (14%) cases, there was no expulsive hemorrhage in any case.
Conclusion: The commonest complications observed in the study were striate keratitis (14%), Posterior Capsule rent
(10%) and Vitreous loss (7.3%).
Key words: peroperative complications, posterior capsular rent, vitreous loss, striate keratitis.
INTRODUCTION corneal striate etc. posterior capsular rent and vitreous

Cataract is any lens opacity, partial or complete, loss are serious complications.9 These events are more
of one or both eyes, impairing vision. There are many common in old patients.10 The aim of this study is to
causes of cataract. Cataract is classified by their mor- determine problems and complications faced by oph-
phology like size, shape, location or etiology. Age re- thalmology residents (trainees) during cataract surgery
lated cataract is the one related with old age. with intraocular lens implantation in the ophthalmol-
Age related cataract remains the leading cause of ogy unit, Lady Reading Hospital, Peshawar
preventable blindness worldwide accounting for 47.8% METHODOLGY
of all cases of blindness.1 Pakistan faces the same situa- This cross sectional interventional study was con-
tion with cataract being the leading cause of blindness ducted at Eye Department, Lady Reading Hospital,
contributing to 50%.2,3 of the treatable blindness. In a Peshawar from 25th June 2011 to 25th December 2011
survey conducted in three districts of Indian Punjab, over 150 patients, under significance level of 0.05 with
age related cataract was found in 15.3% in people with prevalence of 10%, using WHO sample size calcula-
age 40 years which was markedly increased to 67% in tor. This was a non-probability purposive sampling. An
older age group of 70 years and above.4,5 informed written consent was obtained from all the pa-
Definitive management of age related cataract tient. The patients were evaluated for inclusion criteria.
is lens extraction.6 Extra capsular cataract extraction A special data collection proforma was filled for each
(ECCE) surgery is relatively simple and straight for- patient having a detailed record of the disease includ-
ward to learn without investment in expensive equip- ing name, age, gender, address. The study sample was
ment compared to other surgical procedure like phaco- collected from Ophthalmology Unit Department, Lady
emulsification (Phaco)6 Main complications during Reading Hospital, Peshawar. First of all, cases with
Extra capsular cataract surgery include posterior cap- age related cataract were identified, after detailed his-
sule rent (5.4%), vitreous loss (3.2%), corneal edema, tory and ocular examination including visual acuity on
Snellen’s chart, slit lamp examination, intraocular pres-
1
Medical Officer Eye Unit, Lady Reading Hospital, Peshawar.
2
Lecturer Community Medicine, Saidu Medical College, Swat. sure with Goldman Tonometer, macular function test
3
Associate Prof, Ophthalmology, PIMS, Islamabad. 4.5Trainee Medical (Maddox rod and color vision), fundus examination
Officers Eye Unit, Lady Reading Hospital, Peshawar. 6Senior Regis-
trar, Lady Reading Hospital, Peshawar
with both direct and indirect ophthalmoscope (90D
and 78D indirect lens), consecutive cases that satis-
Correspondence: Dr. Mohammad Idris, Medical Officer, Eye Unit, fied the inclusion and exclusion criteria were included.
Leading Reading Hospital, Peshawar. Cell No: 0333-9417051
E.mail: idrisdaud80@gmail.com After admission, investigations (HBsAg, HCVAb, and
RBS) were done before surgery. Patients were assessed
Received: Nov’2013 Accepted: Jan’2013
possibly for intraoperative complications. All patients
Problems and Complications faced by Ophthalmic Residents during Cataract Surgery with Intraocular Lens Implantation
other than age related cataract, for example, traumatic Table-2: Total complications to 3rd year
cataract, and diabetic cataract and patients admitted residents in different age groups
for cataract surgery other than extra capsular cataract PC Rent Vitreous Corneal
Patients
extraction were excluded. The data was analyzed with Variables No No=9 loss No=6 Striate No=10
age
12% 8% 13.3%
SPSS 10.0. 40-50 1 12.5 1 12.22 2 16.66
RESULTS 51-60 3 15.6 2 28.5 3 25.00
3rd year
This study was conducted on 150 patients above Residents
4 61-70 4 13.3 2 28.5 5 33.33
71-80 0 0.00 0 0.00 0 00.0
the age of 40 years, diagnosed as having cataract. The
81-90 1 33.3 1 12.22 0 00.0
demographic distribution is shown in Tab: 1. The mini- PC: posterior capsule
mum age at which the patient presented was 40 years
Table-3: Total complications to the 4th year residents:
while the oldest patient was 90 years of age. Mean age
Patients PC Rent Vitreous loss Corneal Striate
of the sample was 64 years with standard deviation of ± Variables No
age No=6 8 % No=4 5.3% No=9 12%
5.6 years. The male and female are equal in number that 40-50 0 0.00% 0 0.00% 1 11.11%
is 75(50%) male and 75(50%) female. Further analysis 51-60 2 33.3% 1 25.0% 2 22.22%
4th year
of the age distribution is also shown in Table No. 1.In residents
4 61-70 3 50.0% 2 50.0% 4 44.44%
this table the no of patients are divided in different age 71-80 0 0.00% 1 25.0% 2 22.22%
81-90 1 15.8% 0 0.00% 0 0.00%
groups. The table shows equal number of residents, 4
residents from 3rd year and 4 from 4th year. Table-4: Total corneal striate to the 3rd and 4th year residents:
In Tab: 2 the total per operative complications of
Age group Corneal Striate N=21 14.00%
posterior capsular rent to the 3rd year residents were 40-50 2 1.33%
9(12%), vitreous loss was 6 (8%) and corneal striate 51-60 6 4.00%
were 10 (13.3%). 61-70 8 5.33%
There was no single case of supra choroidal hem- 71-80 3 2.00%
orrhage. Table No3, shows that the total per operative 81-90 2 1.33%
complication of PC rent to the 4th year residents were
6 (8%), Vitreous loss was 5 (5.3%) and Corneal Striate Table-5: Total vitreous losses to the 3rd and 4th year residents:
were 9 (12%). In 21 (14.00%) cases total corneal striate Age group Vitreous Loss N=11 7.3%
to the 3rd and 4th year residents are shown in Table No 40-50 2 1.3%
4. Total vitreous loss to the 3rd and 4th year residents 51-60 3 2.0%
took place in 11 (7.3%) cases (Tab: 5). total PC-tear to 61-70 4 2.6%
the 3rd and 4th year residents occurred in 10 (15 %) cases. 71-80 1 0.66%
81-90 1 0.66%
(Tab:6) The total operative complications are given in
table No. 7. Out of 150 cases posterior capsular rent oc- Table-6: Total PC-tear to the 3rd and 4th year residents:
curred in 15 (10%), cases, Vitreous loss was in 11 (7.3%), Age group PC-Tear N=15 10%
cases, striate keratitis were in 21 (14%) cases and there 40-50 2 1.3%
was no expulsive hemorrhage. According to this table, 51-60 4 2.6%
complications rate is more in 3rd year residents. 61-70 6 3.9%
71-80 3 2.0%
Table-1: Demographic/ clinical characteristics
of the study group 81-90 1 0.66%
Variables N=100(%) Mean ±SD TABLE-7: Combined table of complication N =150

Total 150(100)
Male 75(50) Patients PC Rent Vitreous loss Corneal Striate
Variables No
age No: 15% No:11% No: 21%
Female 75(50)
40-50 1 12.5 1 12.22 2 16.66
3rd Year Residents 4
4th Year Residents 4 50-60 3 15.6 2 28.5 3 25.00
3rd year
4 60-70 4 13.3 3 42.85 5 33.33
Patients Age groups 64±5.6 Residents
70-80 0 0.00 0 0.00 1 8.33
40-50 16 80-90 1 33.3 1 12.22 1 8.33
51-60 38 40-50 0 0.00 0 0.00 1 11.11
61-70 60 50-60 2 33.33 1 25.00 2 22.22
4th year
71-80 30 4 60-70 3 50.00 2 50.00 4 44.44
residents
70-80 0 0.00 1 25.00 2 22.22
81-90 6 80-90 1 15.8 0 0.00 0 0.00

Problems and Complications faced by Ophthalmic Residents during Cataract Surgery with Intraocular Lens Implantation
DISCUSSION belongs to backwards areas of our province and FATA

Main purpose of the age related cataract manage- (federal administered tribal areas). If surgery is per-
ment is to improve the vision and to treat avoidable formed under proper supervision then risk of compli-
blindness and in conditions when it is adversely affect- cations are low. Complications were low by senior 4th
ing the health of the eye. year residents. Commonest complication was striate
Cataract extraction surgery for age related cataract keratitis.
constitutes the largest workload in ophthalmic units RECOMMENDATIONS
throughout the world. In our setup, treatment of choice Blindness is almost inevitable, if left unmanaged.
is surgical intervention mainly by extra capsular cata- Proper surgical training under close supervision of the
ract extractions (ECCE), which is done through a large residents, timely and appropriate care of the patients
corneal limbal incision while the more advanced tech- can decrease the ocular morbidity, visual impairment
nique called Phaco in which a small incision is needed.11 and blindness associated with postoperative complica-
The greater size of corneal incision in ECCE also influ- tions after ECCE performed by the residents. Therefore
ences the post-operative wound healing and the in- keeping these things in mind, we can prevent the se-
flammatory reactions. To reduce these problems the quel of severe blindness in already burdened economy.
small incision (Phaco) surgery is a feasible alternative REFERENCES
1. Thylefors B, Negral AD, Parajasegaram R, Dadzie KY.Global
12
. In developing countries, this mode of surgery is now data on blindness. Bull World Org 1995; 73:115-21.
gaining popularity13 although mature cataracts present 2. Khan AQ, Qureshi B, Khan D. Rapid assessment of cataract
special challenge to the surgeon. blindness in age 40 years and above in district Skardu, Balth-
istan, Northern Areas of Pakistan. Pakistan J ophthalmol 2003;
Our study includes 150 eyes of 150 patients. In 150
19:84-9.
eyes (100%), extra capsular cataract extraction surgery 3. Dineen B, Bourne RRA, Jadoon Z, Shah SP, Khan MA, Foster
with IOL implantation was carried out. The basic aim A, et al. On behalf of the Pakistan national blindness and vis-
of the study was to observe different types of compli- ual impairment in Pakistan. The Pakistan National Blindness
and Visual impairment Survey. Br J Ophthalmol. 2007 Aug;
cations which occur during surgery, particularly to the 91(8):1005-10.
residents in learning stage. In this study 50% patients 4. World Health Organization: Global initiative for the elimina-
were male and 50% patients were female. The male to tion of avoidable blindness, Geneva. Community Eye Health.
1998; 11(25):1-3.
female ratio is equal. Among all the patients included 5. Shah SP, Dineen B, Jadoon Z, Bourne R, Khan MA, Johnson GJ,
in the study 60% of the patients had an age between 60- et al. Lens opacities in adults in Pakistan: prevalence and risk
70 years. The oldest patient was 90 years of age and the factors. Ophthalmic epidemiol 2007; 14:381-9.
6. Kanskii JJ. Extra capsular cataract extraction in: Lens. Elsevier
youngest patient was 40 years of age. Butterworth-Heinemann. 6th ed.2006: 337-67.
Per operatively posterior capsular rupture was ob- 7. Dandona L, Dandona R, Naduvilath TJ, McCarty CA, Mandal
served in 15 (10%), vitreous loss was 11(7.3%), corneal P, Srinivas M et al. Population-based assessment of the out-
striate were 21 (14%), there was no single case of supra- comes of cataract surgery in an urban population in Southern
India. Am J Ophthalmol 1999; 127:650-5
choroidal hemorrhage to the 3rd and 4th year residents in 8. He M, Xu J, Li S, Wu K, Munoz SR, Ellwein LB. Visual acuity
Lady Reading Hospital Peshawar. In a study which has and quality of life in patients with cataract in Doumen County,
been done by S Zia, A Raza, S Ali in Pakistan in 2010, China. Ophthalmology 1999; 106:1609-15.
9. Lumme P, Laatikainen LT. Risk factors for intraoperative and
they have found 2% PC rent and 3% corneal strait in early postoperative complications in extracapsular cataract
ECCE surgery.14 In another study in which PC rent was surgery. Eur J Ophthalmol. 1994 Jul-Sep;4(3):151-8.
seen in 4% cases, while suprachoroidal hemorrhage was 10. Berler DK. Intraoperative complications during cataract sur-
gery in the very old..Trans Am Ophthalmol Soc. 2000; 98:127-
seen in 0.4% cases.15 In a study which is done by P M 30; discussion 130-2.
Gagul et al, the P C Rent was occurred in 10 (2.6%), vit- 11. Hodge WG, Whitcher JP, Satariano W. Risk factors for age-
reous Loss was 6 cases (1.6%).16 Another study showed related cataracts. Epidemiol Rev 1995; 17:336-46.
that PC rent was found in 6.5% cases in ECCE Surgery.17 12. Harif H, Irshad H. Phacoemulsification results and complica-
tions during the learning curve. Pak J Ophthalmol 1997; 13: 32-6.
This is less than we found in our study. 13. Jaffe NS, Jaffe MS, Jaffe GF. Cataract surgery and its complica�-
In summary, our data is comparable with most of the tions St. Louis: CV Mosby, 1990: 34.
studies conducted world-wide. If surgery is performed 14. Zia S , Raza A, Ali S I , Comparison of small incision cataract
surgery with extra capsular cataract extraction. J Rawal Med
under proper supervision then the risk of complica- Coll 2010;14(2):84-6.
tions are low. 15. D C Minassim, P Rosan, KG Dert,A Reidy, M Sidhu,ECCE
CONCLUSION compare with Small Iincission surgery by phacoemelsification
a randomized trial ,B J ophthal 2001,85,822-29
Age related cataract is a common vision threatening 16. P M Gogale et all ECCE compare with M Small Iincission sur-
condition affecting both sexes occurring in old age. In gery in community eye care setting in western India. Br J Oph-
our setup patients usually present with mature cata- thal 2003; 87;667-72.
17. Dr. Neekra A, Trived HL,DR, Todker H, Comparetive study of
ract, and the treatment of choice is surgical interven-
PC Rent in cases of routine ECCE, Jr B Ophthal ASSO Vol .12.
tion only. ECCE is the choice of surgery for poor who no 1.

ORIGINAL ARTICLE
Effect of Yag Laser Energy in Mille Joules (Mj)

for Change in IOP after Yag Laser Posterior Capsulotomy
Bilal Khan
Bilal Khan FCPS1, Asif Iqbal FCPS2, Nuzhat Rahil FCPS3
Muhammad Aetizaz DOMS4, Mohammad Idris FCPS5, Rahil Aumer Malik FCPS6
ABSTRACT
Objectives: To determine the effect of YAG laser energy in Mj. for changes in intraocular pressure after YAG laser posterior
capsulotomy.
Material and Methods: This observational cross sectional study was conducted at outpatient department of Khyber Eye
Foundation Gulbahar No 4 Peshawar from Jun 2011 to September 2012. In this study a total of 120 pseudophakic eyes
were observed and assessed for the rise of IOP after different energy levels of a YAG laser capsulotomy carried out for
secondary posterior capsular opacification that had developed after cataract surgery. Preoperative IOP was recorded. Then
2-3 mm size capsulotomy was done with Q-switched Nd: YAG Laser after topical anesthesia, by using 1.5 to 8mj of energy
and fewest numbers of pulses. Patients were followed for assessment of IOP after one hour. The IOP and VA were checked
on the 10th day again.
Result: Out of 120 patients 71 (59.16%) were male and 49 (40.83%) were females. In this study 90 patients had normal
or low IOP in whom Yag laser capsulotomy was done on less than 2.5mj .While 30 patients had rise of 2 – 15 mm Hg in
intraocular pressure after 3 mj of Yag laser .The rise noted when Yag laser was done on more than 3mj, the more the energy,
the more rise in IOP observed.
Discussion: The results of this study showed that frequency of ‘raised IOP’ was certainly associated with the high amount
of laser energy delivered to the eyes and must be expected to be greater in patients who receive excessive amount of YAG
laser energy. An IOP elevation of 10 mm Hg or more within two hours of laser surgery was seen in 15 eyes (4.4%) that had a
capsulotomy. Though the mechanism(s) remained undetermined, the possible mechanisms would be: the more the energy
used during the procedure, the more particles liberated from posterior capsular breakdown, resulted in the clogging of angle
of anterior chamber and lead to the raised IOP. Additionally, the acoustic shock waves released inflammatory mediators that
altered the trabecular meshwork and the aqueous dynamics and resulted in an IOP rise.
Conclusion: Raised IOP was a frequent complication of Nd: YAG laser posterior capsulotomy. The higher the energy used,
the greater the frequency of raised IOP following capsulotomy. Hence, it is recommended that each patient undergoing
Nd: YAG laser capsulotomy should receive minimum possible laser energy and must be followed up for raised intraocular
pressure.
Key words: Intraocular pressure. Nd: YAG laser. Posterior capsular opacification. Mille Joules (Mj)
ITRODUCTION safer, more effective and an out-patient procedure. The

Neodymium-doped yttrium aluminum garnet decreased rate of complications and faster recovery has
(Nd: YAG) laser capsulotomy is a relatively noninva- made Nd: YAG laser capsulotomy a popular approach
sive procedure that is used in the treatment of poste- for the treatment of PCO.2 Some authors consider the
rior capsular opacification. Posterior capsular opacifi- increased risk of complication to be as a result of open-
cation is a common long-term complication of cataract ing the capsule and not a specific complication of the
surgery that causes decreased vision, glare, and other laser procedure itself.2, 3 ,4
symptoms similar to that of the original cataract.1 Nd: YAG Laser posterior capsulotomy is frequent-
Laser capsulotomy uses a quick-pulsed Nd: YAG ly performed in our hospital but no work has been done
laser to apply a series of focal ablations in the posterior on the subject in the recent past. This study has been de-
capsule and create a small circular opening in the visual signed to determine the changes in IOP after different
axis.Treatment were performed to produce small cen- frequencies of energy of Nd: YAG laser capsulotomy in
tral capsulotomy of size approximately 2-3 mm diame- patients with PCO.
ter . Today PCO is treated with Nd: YAG laser, which is METERIALS AND METHODS
Medical Officer, Lady Reading Hospital, Peshawar. 2Trainee
1,5 This cross sectional study was conducted at outpa-
Medical Officer, Hayatabad Medical Complex, Peshawar, 3Consultant tient department of Khyber Eye Foundation Gulbahar
Ophthalmologists, Lady Reading Hospital,Peshawar, 4Medical Officer,
Khyber Eye Foundation, Gulbahar No: 4, Peshawar. 6Senior Registrar, No 4 Peshawar from June 2012 to September 2013. Pa-
Lady Reading Hospital, Peshawar. tients of more than 40 years were selected; both males
Correspondence: Dr. Bilal Khan FCPS. Trainee Medical Officer and females were included.120 pseudophakic eyes
(Vitreo-Retina) Room No: B-17, Old Trainee Medical Officers having decreased vision due to capsular opacity were
Hostel, Lady Reading Hospital, Peshawar, Cell:03459710671 taken. The VA was assessed and all patients were ex-
E.Mail: drbilalokz@gmail.com
amined on slit lamp for IOP and fundus examination
Received: Jan’ 2014 Accepted March’ 2014 was done to rule out the causes for reduced vision and

Effect of Yag Laser Energy in Mille Joules (Mj) for Change in IOP after Yag Laser Posterior Capsulotomy
raise IOP other than PCO. Prior to the start, permission RESULTS
from hospital ethical committee was obtained. Patients Out of 120 patients 71 (59.16%) were male and 49
were included in the study after fulfilling inclusion and (40.83%) were females. Their mean age was (60 years)
diagnostic criteria. The patients were evaluated for in- ranging from 45 years to 90 years. Mean age was 54
clusion and exclusion criteria. A special data collection years with standard deviation+13.51. There were 52
proforma was filled for each patient and had a detailed (43.33%) patients had posterior lens capsule opacifica-
record of the disease including name, age, gender, ad- tion in the right eye while 68 (56.66%) patients had pos-
dress etc. terior lens capsule opacification in the left eye after ext-
After enrollment in the study, detailed history, vis- racapsular cataract extraction and phacoemulsification
ual acuity (VA) using standard Snellen’s visual acuity with posterior chamber intraocular lens implantation.
chart, slit lamp examination, IOP by Goldmann appla- After applying 2.5 mj or less of YAG laser in18 pa-
nation tonometer, direct and indirect ophthalmoscopy, tient the IOP recorded after 1 hour was 16mm of Hg
and B-scan Ultrasonography in cases of dense PCO was and in 38 patients the IOP was 18 mm of Hg while in
carried out by same senior surgeon before YAG laser 34 patient the IOP was 20 mm Hg .So in total 90 patients
capsulotomy to control bias in the study. showed low or normal IOP after 1 hour of application
Patients were dilated and properly prepared prior of 2.5 mj of YAG laser for PCO. In rest of the 30 pa-
to the procedure. Proper instructions were given to the tients 16 patients had the IOP of 24mmHg with 3mj
patients before the procedure. . Then 2-3 mm size cap- of Yag and 7 patient the IOP recorded was 28mmHg
sulotomy was done with Q-switched Nd: YAG Laser with 4.5mj of Yag energy but in other 7 patients who
after topical anesthesia, by using 1.5 to 8mj of energy had thick PCO and the energy of Yag had to increase
and fewest numbers of pulses. Capsulotomy was done up to 6.5mj the IOP increased up to 35 mm Hg after 1
by same senior surgeon using same laser machine to hour of laser capsulotomy as shown in table No.1. The
control bias in the study, but was enlarged and differ- rise noted when YAG laser was done on more than 3mj,
ent energy level were used depending upon the clinical the more the energy, the more rise in IOP observed.
conditions. Some patients who had increased IOP were put on Lev-
Confounders and bias were controlled by strictly obenelol .After 10 days IOP was between 16 and 18 mm
following exclusion and by proper follow up. PCO pa- Hg in 73 patients while 17 patients had the recorded
tients were followed for assessment of IOP after one
IOP of 21 mmHg.
hour and 10 days. Those patients whose IOP was in-
creased just after one hour after capsulotomy done Table No: 1
by increased energy was put on levobenelol .5% for
No of patients Energy In mJs IOP in mm Hg
ten days. The IOP and VA were checked on the 10th
18 2.5 16
day again. On follow up the IOP was checked again
38 2.5 18
with Goldsman’s tonometer. The data was recorded in
34 2.5 20
typed proforma attached hereby. All the analysis was
16 3.0 24
done in SPSS 10.1. Frequency and percentage were cal-
culated for categorical variables like gender, IOP. Mean 7 4.5 28
+ standard deviation was computed for numerical vari- 7 6.5 35

ables like age, and pre procedure V.A. All the results
were presented in the form of graphs and tables. DISCUSSION
Inclusion Criteria: There were 120 patients involved in the study with
1. All patients whether male or female, above 40 mean age range of 54.78+13.51 years. The mean age of
years of age having PCO and IOP of less than 20 such patients in one study done in Manchester eye hos-
mm of Hg. pital, UK was 75.2 years.5 while in another study the
2. Pseudophakic patients of more than 6 months du- mean age range was 65.08+10.475 this is because all pa-
ration of cataract surgery with posterior chamber tients had age-related cataract which was operated and
intraocular lens. they developed PCO.6
Exclusion Criteria:

Out of total 120 patients, 71 (59.16%) were male
1. Infants, children less than 10 years of age and very and 49 (40.83%) were females in our study. There were
old patients who are unable to cooperate because 14 (53.8%) females and 12 (46.2%) males in a study done
it is not possible to perform Nd: YAG laser capsu- in UK.5And 46% male and 54% females in study done in
lotomy in them. Eye hospital Hyderabad.6,7 There were 19 (55.9%) male
2. Patients with high IOP and those who were using and 15 (44.1%) females in study done in Greece.8 In
any type of anti-glaucoma medication and patient this study, ‘raised IOP’ was found in 30 patients (25%).
who had trabeculectomy. While in 90 patients the IOP was normal or low. The

Effect of Yag Laser Energy in Mille Joules (Mj) for Change in IOP after Yag Laser Posterior Capsulotomy
results of this study showed that frequency of ‘raised receive minimum possible laser energy and must be
IOP’ was certainly associated with the high amount of followed up for raised intraocular pressure.
laser energy delivered to the eyes and must be expected REFERENCES
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substantiates results of the present study. Though the 1999;25:246-50
9. Migliori ME, Beckman H, Channell MM. Intraocular pressure
mechanism(s) remained undetermined, the possible changes after neodymium: YAG laser capsulotomy in eyes pre-
mechanisms would be: the more the energy used dur- treated with timolol. Arch Ophthalmol 1987; 105:473-5.
ing the procedure, the more particles liberated from 10. Silverstone DE, Brint SF, Olander KW, Taylor RB, McCarty
GR, deFaller JM, et al.Prophylactic use of apraclonidine for
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Additionally, the acoustic shock waves released inflam- Ophthalmol 1992; 114:377-9.
11. Holweger RR, Marefat B. Intraocular pressure changes af-
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and the aqueous dynamics and resulted in an IOP rise.14 Surg1997;23:115-21.
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Nd: YAG laser posterior capsulotomy. Arch Ophthalmol 1984;
pronounced when higher single-pulse energy rather
102:1024-6.-
than higher total energy was used.15-16 Durham and 13. Shani, L.; David, R.; Tessler, Z.; Rosen, S.; Schneck, M.; Yas-
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otomies.17 Slomovic and Parrish found that 55% of pa- treatments in the anterior segment. Journal of Cataract & Re-
fractive Surgery. 20(4): 455-458
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therapy.18 . 2009 [cited 2009 Mar 3].
CONCLUSION 15. Aron-Rosa DS, Aron JJ, Cohn HC. Use of a pulsed picosec-
ond Nd:YAG laser in 6,664 cases. J Am Intraocular Implant
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YAG laser posterior capsulotomy which occurred as 16. Slomovic AR, Parrish RK, 2nd, Forster RK, Cubillas A.
an isolated complication in an otherwise normal pro- Neodymium:YAG laser posterior capsulotomy. Central corne-
al endothelial cell density. Arch Ophthalmol 1986;104:536-538.
cedure and could not be neglected. Most of the times, it
17. Durham DG, Gills JP. Three thousand YAG lasers in posterior-
is depended upon the amount of laser energy delivered capsulotomies: an analysis of complications and comparison of
to the eye during the procedure. The higher the energy polishing and surgical discussions. Trans Am Ophthalmol Soc
used, the greater the frequency of raised IOP follow- 1985;83:218-35.
18. Slomovic AR, Parrish RK 2nd. Acute elevations of intraocu-
ing capsulotomy. Hence, it is recommended that each lar pressure following Nd: YAG laser posterior capsulotomy.
patient undergoing Nd: YAG laser capsulotomy should Ophthalmology 1985; 92:973-6.

ORIGINAL ARTICLE
Nd-Yag Laser Capsulotomy

Efficacy vs Complications
Waseem Khan
Dr. Waseem Ahmed Khan FCPS, FRCS1, Dr. Saba Haider Tarar MCPS2
ABSTRACT
Objective: To evaluate efficacy and complications of Nd YAG laser capsulotomy in patients of posterior capsular opacification.
Materials and Methods: This prospective case study was conducted at the Department of Ophthalmology, Divisional
Headquarters Teaching Hospital affiliated with Mohi-ud-Din Medical College, Mirpur, Pakistan over a period of 10 months
i-e from December 2012 to Sep 2013.Two hundred patients with significant posterior capsular opacity, were subjected to
laser treatment after performing pre laser visual assessment. Nd YAG laser posterior capsulotomy was carried out with Q-
switched SYL 9000 YAG laser system under topical anesthesia with Abrahams capsulatomy lense. These patients were as-
sessed for post laser visual acuity and possible complications. Post laser treatment was advised to each patient as needed.
Results: Out of 200 patients, 80 (40%) were male and 120(60%) were female. The patients were subdivided into various
age groups. The age group 1 was from 11 to 30 years, age group 2 was between 31-40 years, age group 3 was from 41
-50 years and last group i.e., 4 included patients who were more than 50 years of age. The age group 1,2,3 and 4 had
frequency of PCO of about 5 patients( 2.5%),12 patients( 6%), 17 patients (8.5%) and166 patients( 83%) respectively. The
time interval between cataract surgery and laser was from 03 months to 4 years. The best corrected visual acuity of 6/9-6/6
was achieved from zero to 76.5% whereas the frequency of poor best corrected visual acuity (6/60-CF) was reduced from
67.5% to 3% only.
Discussion: During and following Nd YAG laser capsulotomy, out of 200 patients, 44 (22%) of the patients developed com-
plications while 156(78%) patients remained free of any complication. About 30 patients (15%) developed intra ocular lens
pitting. 10 patients (5%) developed rise in IOP. 02 patients (1%) showed rupture of anterior vitreous face, 02(1%) patients
developed cystoid macular edema.
Conclusion: The Nd YAG laser procedure is absolutely safe and effective. It has additional benefit of being carried out on
OPD basis to create an opening in opaque posterior capsule and leads to marked improvement in vision.
Key words: Nd, YAG laser, Posterior capsular opacification, Intra ocular lens, Pakistan.
INTRODUCTION play an important role in fibrous proliferation of LECs

Cataract is the most common cause of avoidable via an autocrine pathway, paracrine pathway, or both.5
blindness in the world.1 Extra capsular cataract extrac-
Posterior capsular opacification is a frequently en-
tion (ECCE) with posterior chamber intraocular lens countered complication of cataract surgery that leads to
implant (PCIOL) is the most frequent surgical tech- decreased visual acuity, glare due to scattering of light,
nique since the past decade.2 Posterior capsular opaci- uni-ocular diplopia and other symptoms similar to that
fication (PCO) is a frequent complication of cataract of the original cataract.6 The reported frequency of PCO
extraction.3 The term posterior capsular opacification is varies from 8.7% to 33.4%.7 Before the advent of Nd
actually a misnomer. It is not the capsule which opaci- YAG laser, the treatment of PCO was surgical capsulot-
fies, rather an opaque membrane develops as retained omy after which the patients had serious complications
lens epithelial cells proliferate and migrate on the pos- including endophthalmitis.8 Introduced by Dr. Aron-
terior capsular surface.4 PCO usually develops second- Rosa and Dr. Fankhauser in 1980s, Laser capsulotomy
ary to inflammatory process in which lens epithelial involves a quick-pulsed Nd YAG laser to apply a series
cells (LECs) proliferate in response to many factors. of focal ablations in the posterior capsule and create a
Past research suggests that surgical trauma stimulates small circular opening in the visual axis.9 Topical anes-
residual LECs to produce cytokines such as interleu- thesia can be used to perform Nd YAG capsulotomies
kin-1 (IL-1), IL-6, IL-8, basic fibroblast growth factor and it is performed at a slit lamp equipped with a YAG
and transforming growth factor. These cytokines may laser, while the patient is in a seated position.10 Most
frequently encountered complications include tran-
1
Assistant Professor, Department of Ophthalmology. Mohi-ud-din
Islamic Medical College, Mirpur., Divisional Teaching Hospital,Mirpur, sient intraocular pressure elevation, iritis, retinal tears
AJK. 2Registrar Pediatrics, Combined Military Hospital, Kharian. and detachments, macular edema, corneal edema, In-
Correspondence: Dr. Waseem Ahmed Khan FCPS, FRCS. Assistant
traocular lens dislocation into the vitreous and pitting
Professor, Department of Ophthalmology. Mohi-ud-din Islamic of the intraocular lens.11
Medical College, Mirpur, Divisional Teaching Hospital, Mirpur, AJK. The incidence of intraocular pressure elevations
House: D-2, Sector A-5, Officers’ Colony, Mirpur (AK)
E-mail: Waseemabbasi2001@yahoo.com Cell: 0300-9563324. are significantly reduced when patients are pretreat-
ed with apraclonidine which is a sympathomimetic
Received: Feb’ 2014 Accepted: March’ 2014
drug and topical steroids. Intraocular pressure can be

Nd-Yag Laser Capsulotomy Efficacy vs Complication
checked 30-60 minutes postoperatively. Iritis can be RESULTS

present after the capsulotomy, but it is usually self-lim- Out of 200 patients, the females were maximum
ited. It can be treated with a weeklong course of topical 120(60%), while 80 (40%) were male. The duration
steroids (1% prednisone acetate or 0.5% loteprednol, 4 between cataract surgery and laser was more than 03
times daily).12 According to past research, the Nd YAG months to 4 years. The age group 1 was from 11 to 30
laser capsulotomy is a safe, effective outpatient proce- years, age group 2 was between 31-40 years, age group
dure to create an opening in opaque posterior capsule 3 was from 41 -50 years and last group i.e 4 included
for the improvement in vision13 patients who were more than 50 years of age. The age
MATERIALS AND METHODS group 1,2,3 and 4 had frequency of PCO of about 5 pa-
For this study, two hundred patients were ran- tients (2.5%) ,12 patients(6%), 17 patients (8.5%) and166
domly selected from the OPD of Department of Oph- patients(83%) respectively. This shows that PCO is
thalmology, Divisional Headquarters Teaching Hos- most commonly seen in patients were more than 50
pital affiliated with Mohi-ud-Din Medical College, years of age, however, cases are reported in low age
Mirpur, Pakistan. It was a prospective study done over group as well.
a period of 10 months i.e from December 2012 to Sep Table-1: Age Distribution of Patients.
2013. The patients with a remarkable posterior capsu-
Sr. No AGE GROUP AGE IN YEARS NO. OF PATIENTS
lar opacity, were subjected to laser treatment after per-
forming a proper pre-laser visual assessment. Nd,YAG 1. 1 11-30 5 (2.5%)
laser posterior capsulatomy was carried out with Q- 2. 2 31-40 12 (6%)
switched SYL 9000 YAG laser system under topical an- 3. 3 41-50 17 (8.5%)
esthesia with Abrahams capsulatomy lens. Only those 4. 4 >50 166 (83%)
patients who had significant PCO and meeting the fol-
lowing inclusion and exclusion criteria were included. The best corrected visual acuity of 6/9-6/6 was
Inclusion creteria. achieved from zero to 76.5% whereas the frequency of
1. Clinically significant PCO leading to decreased poorly best corrected visual acuity (6/60-CF) was re-
visual acuity. duced from 67.5% to 3% only.
2. Satisfactory immediate post (cataract)operative
visual acuity. Table-2: Visual acuity assessment before and after therapy.
3. No other corneal/retinal organic pathology. Best Corrected Before Nd YAG Laser After Nd YAG Laser
Exclusion criteria. visual Acuity Capsulotomy Capsulotomy
1. Duration less than 03 month post cataract surgery No. of cases % No. of cases %
2. Amblyopia 6/6 -- 6/9 0 0% 153 76.5%
3. Presence of Optic atrophy 6/12 -- 6/18 15 7.5% 25 12.5%
MATERIAL & METHODS 6/24 -- 6/36 50 25% 16 8%
The patients were assessed for Pre laser best cor- 6/60 -- CF 135 67.5% 6 3%
rected visual acuity with standard Senellen chart .On Total 200 100% 200 100%
slit lamp examination (SLE), ,intra ocular pressure was
Table 3. Complications Observed after
monitored with Hag Streit applanation tonometery. Nd YAG laser Capsulotomy
Any abnormal findings on examination of anterior
Sr. No Complication No. of patients %
and posterior segment were recorded on a printed pre-
1. Pitting of IOL 30 15%
designed proforma. After performing pre-laser visual
2. Raised IOP 10 05%
assessment, the patients were subjected to laser treat-
3. Rupture of anterior vitreous face 02 01%
ment. Before treatment, 1% tropicamide (mydriacyl)
eye drops were instilled to dilate the pupil and the 4. Cystoid macular edema 02 01%
cornea was anesthetized with topical application of 5. Retinal detachment 00 00%

proparacain (alcaine). Along with Abraham’s poste-
rior capsulotomy lens in place, Q-switched Nd yag la- As far as complications were concerned, out of 200
ser SYL9000 yag laser system was used to make a hole patients, 22% (n=44) of the patients developed compli-
of 2-3 mm in posterior capsule, using 1.5 to 5mg per cations while 78% (n=156) remained free of any compli-
pulse. The energy and pulses were increased gradually cations. Intra ocular lens pitting was the most frequent-
according to thickness of capsule until an opening was ly encountered complication, accounting for about 15%
achieved. Following the capsulotomy, all patient were (n=30). About 5%patients (n=10) developed rise in IOP.
routinely given topical antibiotics, steroid combination Only 02 patients (1%) showed ruptured of anterior vit-
and topical anti-glaucoma drops. These patients were reous face and similarly 02(1%) patients developed cys-
reviewed for complications on follow up visits. toid macular edema. No other complications like reti-

Nd-Yag Laser Capsulotomy Efficacy vs Complication
nal detachment were observed in this study. is evident that the Nd; Yag Laser is very effective, cheap
DISCUSSION and easy mode of treatment for PCO with minimal post
A total of 200 patients having PCO after cataract laser complications.19
surgery were evaluated in this study. Gender distribu- CONCLUSION
tion showed more females as compared to males hav- This procedure although very effective and safe,
ing PCO comparable to other studies.14 is not 100% free from complications. The Minimum pe-

Patients were divided into various age groups. The riod for posterior capsulotomy after surgery should not
patients of 10-30 years were given a single group be- be less than three months after cataract surgery. Use
cause of less frequency observed in this age group. Rest of Abraham’s lens is recommended. The beam should
of the groups spanned over a period of ten years while be focused behind the lens. Use of topical steroids and
the fourth group included patient about 50 years. The beta blocker eye drops is usually required. Follow up
age group 1,2,3 and 4 had frequency of PCO of about should be regular and meticulous fundus examination
5 patients(2.5%),12 patients(6%), 17 patients (8.5%) should be done before and after posterior capsulotomy.
and166 patients( 83%) respectively. Maximum no. of REFERENCES
1. Thylefors B, Negrel AD, Pararajasegram R. Global data on
patients was over 50 years of age. Burq Et al showed
blindness. Bull World Health Organ 1996; 74: 319–24.
a mean age of 59.5 ± 6.2 years.11 Other studies also cor- 2. Natchiar G, Robin AL, Thulasira R. Attacking the backlog of
related with our results with maximum number of pa- India’s curable blind; the Arvind Eye Hospital model. Arch
tients presenting around 50 years of age and above.7 Ophthalmol 1994; 112: 987–93.
3. Georgalas I, Petrou P, Kalantzis G, Papaconstantinou D, Kout-
In our study, the time interval between cataract sandrea C, Ladas I. Nd: YAG capsulotomy for posterior cap-
surgery and laser was from 03 months to 4 years. The sule opacification after combined clear corneal phacoemulsifi-
best corrected visual acuity of 6/9-6/6 was achieved cation and vitrectomy. Ther Clin Risk Manag. 2009; 5: 133–7.
from nil to 76.5% whereas the frequency of poorly best 4. Francis L’ Esperence (1983) Neodynium-YAG laser, Ophtha
mic lasers. Mosby, 2nd edition, 79-83.
corrected visual acuity (6/60-CF) was reduced from 5. Nishi O, Nishi K, Fujiwara T, et al. Effects of the cytokines on
67.5% to 3% only. In our study, during and following the proliferation of and collagen synthesis by human cataract
Nd YAG laser capsulotomy, out of 200 patients, 44 lens epithelial cells. Br J Ophthalmol. 1996; 80: 63–68.
(22%) of the patients developed complications while 6. Aslam TM, Patton N. Methods of assessment of patients for
Nd:YAG laser capsulotomy that correlate with final visual im-
156(78%) patients remained free of any complications. provement. BMC Ophthalmol. Sep 23 2004; 4:13.
About 30 patients (15%) developed intra ocular lens pit- 7. Muhammad L, Jabeen M, Wazir F, Qadir A, Salim M, Ahmad
ting. 10 patients (5%) developed rise in IOP. 02 patients I. Efficacy of Nd:YAG laser posterior capsulotomy in visual im-
provement of patients having posterior capsular opacification.
(1%) showed rupture of anterior vitreous face, 02(1%)
Gomal Journal of Medical Sciences 2013, 11(1): 97-100
patients developed cystoid macular edema. None of 8. Awan MT, Khan MA, Al-Khairy S, Malik S. Improvement of
the patients showed retinal detachment in our study. visual acuity in diabetic and nondiabetic patients after Nd:YAG
In a study carried out by Hasan et al visual laser capsulotomy. Clin Ophthalmol. 2013; 7: 2011-7.
9. Aron-Rosa D, Aron JJ, Griesemann M, Thyzel R. Use of the
improvement was noted in all patients. 20 eyes (23.25%) neodymium-YAG laser to open the posterior capsule after lens
showed a significant rise in intraocular pressure (IOP) implant surgery: a preliminary report. J Am Intraocul Implant
of more than 5 mm Hg. IOP In all these eyes returned to Soc. 1980;6(4):352-4.
baseline level after one week of treatment with topical 10. Longmuir S, Titler S, Johnson T, Kitzmann A. Nd:YAG laser
capsulotomy under general anesthesia in the sitting position. J
beta blockers.15 Dawood et al reported that after Nd AAPOS. 2013;17(4):417-9.
yag laser capsulotomy, the visual acuity improved in 11. Burq MA, Taqui AM. Frequency of Retinal Detachment and
93.92% and no improvement was seen in 6.08% patients. Other Complications after Neodymium: Yag Laser Capsuloto-
my. JPMA 2008; 58(10): 550-28.
The main complications were temporary increase
12. Aslam TM, Devlin H, Dhillon B, Use of Nd:YAG laser capsul-
in intraocular pressure while 2 patients developed cys- otomy. Survey of Ophthalmology 2003; 48(6): 594–612
toid macular edema.16 For post laser rise of IOP, topical 13. Khanzada MA, Jatoi SM, Narsani AK, Dabir SA, Gul S. Is the
steroids and beta blockers were used which proved to Nd: YAG Laser a Safe Procedure for Posterior Capsulotomy?
Pak J Ophthalmol 2008, 24(2) :73-8 14. Raza A. Complications
be beneficial. Awan et al All showed that post laser IOP after Nd YAG Posterior Capsulotomy. JRMC; 2007; 11(1): 27-29
rise that was controlled by topical beta-blockers and 15. Hasan KS, Adhi MI, Aziz M, Shah N, Farooqui M. Nd: YAG
steroids effectively.17 Laser Posterior Capsulotomy. Pak J Ophthalmol 1996;12(1):3-7.
In another comparable larger study carried out in 16. Dawood Z, Mirza SA, Qadeer A. Review of 560 cases of Yag
laser capsulotomy. J Liaquat Uni Med Health Sci 2007;6(1):3-7
500 patients, 8.0% patients developed the complications 17. Awan AA, Kazmi SH, Bukhari SA. Intraocular Pressure
due to YAG laser which included IOL pitting in 5.40% Changes after ND-YAG Laser Capsulotomy. J Ayub Med Coll
eyes, raised IOP in 0.80%, vitreous in anterior chamber Abottabad 2001;13(2):3-4
in 0.40%, and cystoid macular edema (CME) in 0.20% 18. Khanzada MA, Jatoi SM, Narsani AK, Dabir SA, Gul S. Experi-
ence of ND: YAG laser posterior Capsulotomy in 500 cases. J
patient’s eyes. None of the eye developed sight threat- Liaquat Uni Med Health Sci 2007;6(3):109-15
ening complications like retinal detachment or macular 19. Javed EA, Sultan M, Ahmad ZD. Nd: Yag laser capsulotomy
hole like in our study.18 Based on the above discussion it and complications. Professional Med J 2007;14(4):616-9.

ORIGINAL ARTICLE
Clinical Presentation and Management

of Patients with Congenital Fibrosis of
Extraocular Muscles
Sameera Irfan
Sameera Irfan FRCS1, Irfan Shehzad FCPS2
ABSTRACT
Background: The aim of this study was to describe a myriad of clinical presentations and management of cases with con-
genital fibrosis of the extraocular muscles (CFEOM).
Materials and Methods: This is a prospective study of 12 consecutive cases presenting at Mughal Eye Hospital Trust, La-
hore, from 01-01-2011 to 01-09-2013. There were 7 males and 5 females, between the age of 3-51 years (median 10 years).
All of them were referred for abnormal positioning of the head and eyes since birth. After taking a complete history, detailed
ophthalmic and orthoptic assessment was done. Dense amblyopia was detected in the deviated eye for which refractive
glasses were prescribed for six weeks. Strabismus surgery was performed comprising of maximum recession with hang-
loose technique of the involved rectus muscles. The residual amblyopia was then managed with full-time occlusion of the
good eye and active use of the amblyopic eye with the refractive correction. They were also prescribed a rigid cervical collar
to get rid of the abnormal head posture. All cases were followed-up at 1st, 2nd week, 1st, 2nd, 3rd and 6th month post-operatively.
On each visit, ophthalmic and orthoptic assessment was done.
Results: All cases had an improvement in the cosmetic appearance after squint surgery with restoration of satisfactory
binocular alignment. 8 (66.66%) out of 12 patients were orthophoric in primary position, two cases (16.6%) had a residual
10Δ exotropia and 2 cases (16.6%) had 10Δ residual hypotropia. There was a mild improvement in extra ocular motility. The
abnormal head posture (AHP) improved over a period of 6 weeks. The amblyopia in the deviating eye was fully corrected
in all case.
Conclusion: Horizontal or vertical muscle recession was effective for strabismus correction. The AHP improved with a
combination of surgery and cervical collar. Refractive glasses combined with full time patching of the good eye improved
visual acuity in the amblyopic eye.
INTRODUCTION peripheral neuropathy (a form of Charcot-Marie-Tooth

Congenital fibrosis of the extra ocular muscles disease).
was first described by Baumgarten in 1840 as ptosis Cases of Congenital fibrosis have been reported
in association with restricted ocular motility which from all over the world without prevalence in any
was non-progressive in nature. In 1879, Heuck found specific race or population. Three genetic loci causing
out its familial occurrence. Aebli1 introduced the term CFEOM have been identified (CFEOM1–3).5,6,7 Family
congenital fibrosis of extra ocular muscles in 1933. In history is consistent either with an autosomal dominant
1950, Brown2 named the condition of fibrosis of three inheritance or simplex cases (i.e., a single occurrence in
or more extra ocular muscles as the “General fibrosis a family) may be observed. Parental germline mosai-
syndrome.3,4 cism can mimic autosomal recessive inheritance.
CEFOM is due to malformation of the oculomo- The classic CFEOM5,6,7,8 has been described as hav-
tor nuclear complex affecting all or a part of it,3,4,5 the ing the features of congenital non-progressive bilateral
oculomotor nerve and its innervated muscles (superior, external ophthalmoplegia, bilateral ptosis, primary
medial, and inferior recti, inferior oblique, and levator vertical position of each eye: infraducted (downward),
palpebrae superioris) or the trochlear nucleus, trochlear inability to elevate the eyes above the horizontal mid-
nerve and its innervated muscle (the superior oblique). line, the eye may be orthophoric, exotropic or esotropic.
Patients may present with horizontal or vertical strabis- Horizontal eye movements may be normal or severely
mus depending upon the muscles involved. The eyes restricted along with aberrant eye movements espe-
are fixed in an abnormal position, frequently resulting cially both eyes turning inward on attempted upgaze.
in a compensatory APH and amblyopia in the deviated Forced duction test (to assess passive movement of
eye. Such individuals may also have an intellectual or the globe to determine if the extraocular muscles are
social disability, facial weakness, and/or a progressive restricted) are positive for restriction. Binocular vision
1
.Consultant Oculoplastic Surgeon & Strabismologist, 2.Ophthalmologist
is usually absent. Refractive errors are common and
frequently high astigmatism present resulting in am-
Correspondence: Dr. Sameera Irfan, FRCS Consultant Oculoplas- blyopia which may be strabismic or refractive in na-
tic Surgeon & Strabismologist, Mughal Eye Trust Hospital, 301
H3 Block, Johar Town, Lahore. E-mail: sam.irfan48@gmail.com ture. Pupils are normal. Some individuals have been
Cell: 0336-4500901 reported to have central nervous system malforma-
Received: Jan’ 2014 Accepted March’ 2014 tions, including agenesis of the corpus callosum, brain

stem atrophy, cerebellar hemisphere atrophy, absence positions of gaze; documentation vertical or horizontal
of the cerebral peduncle in the midbrain, colpocephaly, gaze restriction, presence of aberrant eye movements
hypoplasia of the cerebellar vermis, expansion of the i.e. Marcus Gunn jaw winking or synergistic globe re-
ventricular system, pachygyria, encephalocele and/or traction with convergence/divergence and palpebral
hydrancephaly. These may manifest as facial paralysis, fissure size measurement in different positions of gaze.
spasticity, cognitive and behavioral impairments, and With regards to ptosis, measurement of levator func-
a later-onset progressive peripheral sensori-motor ax- tion, Bell’s phenomenon, orbicularis muscle tone, slit-
onal polyneuropathy. The Marcus Gunn jaw winking lamp evaluation of corneas to detect predisposition to
phenomenon is observed in some cases comprising of a corneal dryness and fundus examination was done. Af-
momentary elevation of ptotic upper eyelid with specif- ter checking the status of pupils and pupillary reaction
ic movements of the jaw, noted in young infants when to light, cycloplegic refraction and the best corrected
they are feeding. It results from aberrant innervation visual acuity was performed. MRI scan was performed
of the levator palpebrae superioris muscle by axons in all cases to view orbital anatomy. Photographs were
intended to run in the motor branch of the trigeminal taken to document how much cosmetic improvement
nerve and to innervate the pterygoid muscle. The as- had occurred following treatment.
sociation of this phenomenon with CFEOM provides
additional evidence that these syndromes are primarily
neurogenic in cause.
Aim of treatment for CFEOM is elimination or
improvement of abnormal head posture, correction
of ocular misalignment to bring the eyes into primary
position, correction of ptosis and the resultant amblyo-
pia. The restricted ocular motility cannot be completely
corrected as the healthy muscle tissue is replaced by fi-
brous tissue.9,10 Different surgical procedures used for
strabismus correction in these patients are recession,
disinsertion, myectomy, tenotomy, transpositioning or
resection of muscles along with conjunctival recession.
General rule is maximum correction with an aggressive
approach that will bring both eyes into alignment.11,12,13
Binocular vision is usually not attained even after a All cases were prescribed refractive glasses for 6
good surgery, and multiple surgeries are often re- weeks after which strabismus surgery was performed
quired. Ptosis correction is often done with frontalis by a single surgeon (SI). A forced duction test was per-
suspension.14 formed per-operatively under general anesthesia prior
The aim of this study was to present the clinical, to surgery to assess which rectus muscles were restrict-
surgical and post-operative management in these very ed. Maximum recession of the restricted rectus muscle,
challenging cases as practiced in our institution. 8-10 mm for the medial rectus and 10-14 mm for the lat-
MATERIALS AND METHODS eral rectus was performed with hang-loose technique
This is a prospective study of 12 consecutive cases using 6/0 vicryl suture to correct the deviation. This
presenting at Mughal Eye Hospital Trust, Lahore, a was combined with conjunctival recession. For correc-
tertiary referral center, from 01-01-2011 to 01-09-2013. tion of associated hypertropia due to inferior oblique
There were 7 males and 5 females, between the age of over-action, inferior oblique myectomy was performed.
3-51 years (median 10 years). All of them were referred In cases of inferior rectus contracture, the lateral
for abnormal positioning of the head and eyes since and medial extensions of Lockwood ligament were di-
birth. A detailed history was taken regarding birth vided along both edges of the inferior rectus muscle
trauma, developmental milestones, the age at which and then it was recessed with a hang-loose technique to
strabismus and abnormal head posture was noted, any 8-10 mm. In cases with uni-ocular involvement (7 out
problem noted regarding the child’s vision and a fam- of 12 cases), the residual amblyopia was then managed
ily history of strabismus. Then a detailed ophthalmic with full-time occlusion of the good eye and active use
and orthoptic assessment was performed which in- of the amblyopic eye with the refractive correction.
cluded pre-operative pictures to document the AHP In cases with binocular muscle restriction (5 out of 12
and the position of eyes. Assessment of strabismus cases), no occlusion therapy was done; they were only
was done by Hirschberg test, cover/uncover, alternate prescribed full-time refractive glasses. All cases were
cover test and prism cover tests, ocular motility in nine asked to wear a rigid cervical collar to get rid of the

abnormal head posture. The follow-up was performed only 2 (17% ) out of the 12 cases. 8 patients (67%) had an
at 1st, 2nd week,1st, 2nd, 3rd and 6th month post-operative- AHP; 2 had chin elevation, 6 patients had a face turn. A
ly. On each visit, ophthalmic and orthoptic assessment positive family history for strabismus was present in 4
was performed. cases (33%) only.
RESULTS All patients had a significant refractive error as
12 patients were included in study. 7 cases (58%) well as amblyopia. Full refractive correction with glass-
were male and 5 (42%) were female as shown in es was prescribed in all cases. 7 cases (58%) of unilateral
(Table 1). strabismus had a dense amblyopia in the deviated eye;
once that eye was rendered orthophoric with surgery,
Table 1: Gender Distribution
full time patching of the good eye was then started
Gender No of Pt. %
along with wearing of refractive glasses and near vis-
Male 07 58
ual activities for 3-4 hours / day. Final VA improved
Female 05 42 from 6/24 to 6/6 in all 5 cases with bilateral strabismus
Total 12 while in the 5 unilateral cases, VA in the amblyopic eye
All age groups were involved ranging from 3 years to improved from 6/36 to 6/9 in 3 cases and 6/12 in two
51 years (Table 2). cases.
Strabismus was the most common finding in all The results of strabismus surgery were quite satis-
cases. 7 out of 12 cases (58%) had a unilateral constant factory as 8 (66.66%) out of the 12 cases were orthophor-
strabismus while the remaining 5 cases (42%) had a bi- ic while 2 cases (16.6%) had a residual 10Δ exotropia
lateral involvement. 4 patients (33%) presented with and 2 (16.6%) had 10Δ residual hypotropia. Extraocular
both eyes fixed in convergence; they turned their head movements of the involved eyes improved slightly in
rather than their eyes for side-gaze. In 1 patient (8%), all operated cases. 2 cases with bilateral ptosis were
both eyes were fixed in divergence and hypertropia. 3 managed with Gore-tex sling by a double Crawford’s
out of 7 patients with unilateral involvement (25% of to- technique. They developed punctate corneal staining
tal) had exotropia with hypertropia, 2 (17% of total) had two weeks post-operatively because of an absent Bell’s
exotropia with hypotropia, 1 patient(8%) had esotropia phenomenon. This was managed by lubricant eye gel
with hypertropia and 1 patient (8%) had esotropia with every two hours during the day and an ointment with
hypotropia. Extra ocular motility was restricted in in- taping the lids at night for a month. None of the other
volved eyes of all cases. Bilateral ptosis was present in cases had any other postoperative complication. Treat-
Table 2: Patient Data
Pt Age Post
Sex Refraction BCVA Preop squint Squint surgery
No. (Years) op Squint
R -0.50×180° R6/36 Rt XT 25Δ +Hypotropia RtHypotropia Rt LR Recession 10mm +IR
1 19 M
L-0.50×20° L 6/6 45Δ 10Δ Recession 8mm (Hang-loose)
R -2.50×65° R6/36 Rt ET60Δ
2 13 M Rt ET 10Δ Bimedial recession 10mm _
L-0.50×85° Lt CF Lt ET40Δ
R+2.75+1.50×165° R6/24
3 10 F B/L ET30Δ Hypotropia40Δ NIL Bimedial recession 6mm
L+1.25-0.75×65° L6/12
R-2.25-0.50×80 °
R6/12p Rt XT50 Hypertropia40
Δ Δ
Lt XT10 Δ
B/L LR 12mm recession with hang
4 5 M
L-3.75+1.25×160° L6/18 Lt XT60Δ loose Right SR Recession 6mm
R+2.75+0.25×130° R6/24 Rt ET30Δ
51 F NIL Bimedial recession 7mm
5 L-1.50+0.50×145° L6/18p Lt ET40Δ
R+3.25+1.00×55 °
R 6/36 Rt ET60 Δ
6 3 F NIL B/L maximum MR Recession
L+2.25+0.75×70° L 6/24 Lt ET30Δ
R+2.75+1.25×85° R6/12p Rt XT25ΔRt Rt. LR recession 8mm + inferior
7 6 M Nil
L+0.50-0.25×150° L6/6p Hypertropia20Δ oblique myectomy_
R-3.50+1.75×135° R6/24 Rt LR recession 10mm + inf
8 9 M Rt XT 40ΔHypertropia20Δ
L-1.00-0.75×60° L6/6p Nil oblique myectomy
R+0.50 R 6/6 Lt SR Recession 6mm LR
9 10 M Lt XT25Δ Hypertropia20Δ NIL
L+2.75+2.00×100° L6/12P Recession 8mm
R-0.75 R 6/9 LtET45Δ Lt MR Recession 12 mm Lt IR
10 30 F Nil
L-1.75-1.25×70° Lt CF Hypotropia40Δ Recession 6 mm
R+1.25+0.75×95° R 6/9 Lt ET20Δ Lt MR recession 8mm + inf oblique
11 3 F Nil
L+0.75-1.75×160° L 6/36 Hypertropia40Δ myectomy
R-2.50+1.25×70° R6/24 Rt XT˃50Δ Rt LR Recession 10mm
12 33 M Nil
L-0.75-0.50×140° L6/6p Hypotropia 30Δ Rt IR Recession 6 mm

ing AHP was difficult in some patients. Patients with medial rectus and/or lateral rectus were performed to
AHP were advised to wear neck collar pot-operatively correct esotropia or exotropia, respectively. The idea of
for few weeks. strabismus surgery in CFEOM is to bring the two eyes
DISCUSSION into primary position; whether this is achieved by an
Congenital fibrosis of the extra ocular muscles augmented recession or a myectomy depends upon the
(CEFOM) is a group of disorder characterized by non- experience and preference of the surgeon.
progressive restrictive external ophthalmoplegia; the Once ocular alignment was achieved surgically, it
strabismus is incomitant in nature, in which the mis- was important to hold the recti in place by keeping the
alignment varies with gaze direction. The patients have head in a primary position. Long standing abnormal
either one or both eyes fixed in an abnormal position head posture may cause secondary changes in the neck
and they move their head rather than their eyes to fix- muscles or the cervical spine or it may be only habitual.
ate or track objects with either eye alternately in bilat- Hence, appropriate counseling of the patient and the
eral strabismus. However, in unilateral involvement, parents was done and the patient was insisted upon to
the strabismic eye is not used for fixation and frequent- wear a rigid cervical collar for at least six weeks post-
ly becomes densely amblyopic. In most of the clinical operatively to allow the recessed rectus muscle stay
studies, the usual phenotypic presentation is that of where it was desired intra-operatively.
exotropia combined with hypertropia. In our study, the The next important challenging task is the man-
cases with bilateral involvement had their eyes fixed in agement of amblyopia. Both eyes will stay aligned
convergence while those with unilateral involvement, long-term if there is equal vision in either eye. In our
the eye was fixed in an upward and outward position study, mild to moderate amblyopia was detected in bi-
(exotropia and hypertropia). lateral cases and dense amblyopia in unilateral cases.
Management of these cases, as highlighted in this It was fully corrected in all cases by correction of re-
study, was most challenging; strabismus was associat- fractive errors and full-time occlusion therapy for 2-3
ed with dense amblyopia and a marked abnormal head months. This again required appropriate counseling of
posture to achieve foveal fixation at least in one good the patient and the parents so that full compliance to
eye. Hence a step-wise approach to correct all three therapy and follow-up was ensured.
abnormalities was mandatory for achieving long term Since the disease is inherited in an autosomal
success. Strabismus surgery was particularly difficult in dominant manner, genetic counseling was also offered
these cases as the involved rectus muscle was replaced since each child of an affected parent has a 50% chance
by fibrous tissue which does not contract or relax and of inheriting the condition. However, CFEOM can also
was closely adherent to the underlying sclera. Engag- result from germline mosaicism in one parent, resulting
ing such a muscle over the squint hook intra-operative- in more than one affected offspring of unaffected par-
ly was not easy. Extreme care was taken while pass- ents. It is important to keep in mind certain important
ing the suture through the muscle since there was not points regarding management of these cases:
enough space between the muscle and the underlying 1) Orbital imaging should be done before surgery to
sclera and inadvertent scleral perforation could easily assess muscle size and position.
occur. Strabismus surgery was performed with maxi- 2) Surgery may be technically difficult because of
mum recession with a hang-back suture; since the mus- tightness of rectus muscles.
cle did not contract / relax and its action was already 3) Resections tend to be ineffective. Recessions need
compromised; recessing it maximally did not cause any to be larger than indicated by standard tables.
added limitation of ocular motility. This was combined 4) Adjustable sutures allow “supra-maximal” reces-
with conjunctival recession. This view is supported sion.
by a study13 conducted at the Institute of Ophthalmol- 5) Profound weakening procedures (such as sutur-
ogy, Belgrade, Serbia, Stankovic B, et al. recommended ing muscle to orbital rim) may sometimes become
Graded Hang Back Recession of MR for correcting eso- necessary.
tropia and Super Maximum Hang Back Recession of in- 6) Prevention of Secondary Complications: Amblyo-
ferior rectus for correcting hypotropia. However, in our pia therapy to prevent visual loss in the less-pre-
study, where hyper / hypotropia was not associated ferred eye, lubricating eye drops during the day
with fibrosis of the vertical recti, we performed hori- and ointment at night to avoid dry eyes, particu-
zontal muscle transpositioning along with recession of larly following ptosis surgery but also after suc-
the involved recti. In another study conducted by Lei cessful strabismus surgery. Wearing of a rigid
Chen Wei, et al14 in Chang Gung Memorial Hospital, cervical collar post-operatively to correct a chronic
they performed myectomies of the inferior rectus mus- abnormal head posture.
cle to correct hypotropia and recession / resection of 7) CFEOM can often be diagnosed on clinical find-

ings within the first months of life; early diagnosis Ophthalmol. Strabismus 26:159, 1989.
5. Engle EC, Kunkel LM, Specht LA, Beggs AH: Mapping a gene
can result in prevention of secondary complica-
for congenital fibrosis of the extraocular muscles to the centro-
tions. Because of a familial predisposition and a meric region of chromosome 12.Nat Genet 1994, 7:69-73.
variable genetic inheritance, examination of fam- 6. Venkatesh CP, Pillai VS, Raghunath A, Prakash VS, Vathsala R,
ily members may provide early diagnosis of risk Pericak-Vance MA, Kumar A: Clinical phenotype and linkage
analysis of the congenital fibrosis of the extraocular muscles in
factors for amblyopia in mild cases. an Indian family. Mol Vis 2002, 8:294-297.
CONCLUSION 7. Traboulsi EI, Jaafar MS, Kattan H, Parks MM: Congenital fibro-
CFEOM is not as rare a condition as is believed sis of the extraocular muscles: Report of 24 cases illustrating
the clinical spectrum and surgical management. AmOrthop J
but is mostly under-diagnosed. Its management is
1993, 43:45-53.
most challenging for a strabismologist but an accurate 8. Apt L, Axelord RN: Generalized fibrosis of the extraocular
clinical assessment and a planned step-wise approach muscles. Am J Ophtalmol 1978, 85:822-829.
is mandatory to obtain perfect ocular alignment and 9. Ferrer JA: General Fibrosis Syndrome. Second Congress of the
International Strabismological Association. Paris: DiffusGéné-
visual rehabilitation. rale de Librairie 1976, 352-361.
REFERENCES 10. Ferrer JA: Letters to Editor:Congenital Fibrosis of the Extraocu-
1. Aebli R. Retraction Syndrome. Arch Ophthalmol 1933; 10:602-10. lar Muscles. Ophthalmology 1996, 63(10):1517-1518.
2. Brown, H.W.: Congenital structural muscle anomalies. In Al- 11. Hertle WH, Katowitz JA, Young TL, Quinn GE, Farber MG:
len, J.H., editor: Symposium on Strabismus: Transactions of Congenital unilateral fibrosis, blepharoptosis, and enophthal-
the New Orleans Academy of Ophthalmology, St. Louis, C.V. mos syndrome. Ophthalmology 1992, 99(3):347-355.
Mosby Company, 1950, p. 205. 12. Houtman WA, van Weerden TW, Robinson PH, de Vries B,
3. Engle,E.C. et al: Oculomotor nerve and muscle abnormalities Hoogenraad TU: Hereditary congenital external ophthalmo-
in congenital fibrosis of the extraocular muscles, Ann. Neurol. plegia. Ophthalmologica 1986, 193:207-218.
41:314, 1997 13. Stankovic B at al. Vonjosanit Pregl 2006; 63(9):835-839.
4. Brodsky,M.C. et al: Neural misdirection in congenital ocular 14. Li-Chen Wei at al. The surgical outcome of GFS. Chang chung
fibrosis syndrome: Implications and pathogenesis, J. Pediatr. Med J Vol. 28 NO.3 March 2005; 28:159-165.
OSP Khyber Pakhtunkhawa, Peshawar
8th KHYBER EYE SYMPOSIUM, 13-15 June’ 2014

at Nathia Gali
Subject: ORBIT & OCULOPLASTY

Contact: Dr. Mir Ali Shah, Gen. Secretary, OSP KPK &
Dr. Muhammad Tariq Khan Marwat
E-Mail: doctormarwat@yahoo.com

ORIGINAL ARTICLE
Efficacy of Stem Cell Graft in

Preventing the Recurrences of Pterygium
Waqar Ahmed
Waqar Ahmed MBBS1, Zubair Saleem FCPS2, Fahd Kamal Akhtar MCPS, DOMS3
Amna Adil FCPS, FRCS,4 Zahid Kamal Siddiqui FCPS, FRCS5
ABSTRACT
Objective: To determine the efficacy of stem cell graft in the prevention of recurrence of pterygium.
Study design: Descriptive case series.
Setting: The study was carried out at Department of ophthalmology, Lahore General Hospital which is a tertiary care hos-
pital affiliated with Post Graduate Medical Institute Lahore.
Duration of Study: Period of study was six months starting from March 13, 2012.
Subjects and Methods: 85 eyes of the patients with Primary Pterygia were selected. Patients were informed about the
benefits and risks of the study after taking the consent. Permission from the ethical committee of the institution was taken
before the commencement of study. Surgeries were performed under local anesthesia and the Pterygium was excised up
to the medial rectus muscle. Conjunctival stem cell graft was taken from the suprotemporal limbus of the same eye and
stitched with 10/0 nylon onto the pterygium area. Dressing was removed after three days and topical antibiotic with steroid
drops were started. Patients were then called for regular follow ups till six months. All the information was collected through
a proforma.
Results: 85 selected eyes were operated upon using uniform surgical technique. No recurrence was noted in 80 eyes
(94.11%) while 5 eyes ( 5.89%) showed recurrence of pterygium.
Conclusion: Stem cell graft is an effective treatment modality for the prevention of recurrence of pterygium.
Keywords: Pterygium, Conjunctival Stem cell graft, Recurrent pterygium, Conjunctival autograft.
INTRODUCTION more common in tropical and subtropical countries.

The pterygium (also known as web eye) is a wing It is more common in those who work outside in the
shaped triangular patch of hypertrophied subconjunc- fields especially in farmers and is more often seen in
tival fibrovascular tissue extending from the medial or men rather than women.4
lateral canthus of the eye to the limbus a border area of Ultraviolet radiation especially UVB (290-320 nm)4
the cornea or beyond, with the apex pointing towards is a major environmental risk factor for the develop-
the pupil.1 Patients with pterygium complain of foreign ment of pterygium. Other risk factors include genetic
body sensation, visual loss due to corneal astigmatism predisposition, dry eyes, low humidity, and chronic
or growth over the pupillary area with cosmetic prob- micro-trauma caused by cigarette smoke, dust and
lems2. The main histopathological change in primary sand particles.5
pterygium is elastodysplasia and elastodystrophy of Treatment of pterygium is surgical excision but
sub-epithelial connective tissue resulting from break- simple excision of pterygium is associated with a high
down of collagen and destruction of basement mem- recurrence rate ranging from 30 to 70%.6,7 To reduce this
brane3. Studies have been conducted to determine the different methods like, beta irradiation, intraoperative
rate of prevalence of pterygium and although rate is or post-operative use of anti-metabolites, and amniotic
different in different parts of the world, it would be membrane transplantation have been used 7, 8. Howev-
reasonable to say that some degree of pterygium exer, besides being associated with significant recurrence
ists in 5–10% of the population in most of the studies.4 rates, serious complications such as keratoconjunctivi-
Thus distribution of pterygium is worldwide, being tis sicca, cataract,10,11 secondary glaucoma, uveitis, scl-
eromalacia and corneal perforation are associated with
1
Medical Officer, Eye Unit 1, Lahore General Hospital. 2Assistant
Professor, Eye Unit 1, Post Graduate Medical Institute (PGMI), some of these methods.9
Lahore General Hospital. 3Resident Medical Offiocer, Post Gradu- Conjunctival Limbal Autografting: The first pub-
ate Medical Institute (PGMI), 4Medical Officer Post Graduate Medical
Institute (PGMI), 5Associate Professor of Ophthalmology, Services
lished data on the use of conjunctival autograft trans-
Hospital, Lahore plantation for the prevention of recurrence of pterygium
came from Kenyon et al in 1985.12 This technique of con-
Correspondence: Dr. Waqar Ahmed, Medical Officer, Eye Unit 1,
Lahore General Hospital, House 759, Askari 9, Zarar Shaheed junctival limbal autograft includes excision of the main
Road, Cantt, Lahore. E-Mail: Drwaqarian@hotmail.com and bulk of pterygium and closure of the gap between the
Dr. Amna Adil Hasni, 45A Street 16, Cavalry Ground. Lahore.
E-Mail: usmanlhe@hotmail.com Cell: 03214631600
limbus and the residual conjunctiva with a free limbal
conjunctival graft harvested from another area of the
Received: Jan’ 2014 Accepted. March’ 2014 same eye or the fellow eye. This technique was accepted

Efficacy of Stem Cell Graft in Preventing the Recurrences of Pterygiu
by many surgeons due to a relatively low recurrence rate Statistical Analysis: The data was entered by SPSS
and lack of potential, vision threatening complications. version 17. Non recurrence or recurrence of pterygium
Conjunctival limbal autografting is also advocated be- was the variable of interest and was presented by cal-
cause it has the advantages of a more normal anatomical culating frequency and prevention. Mean and standard
and physiological reconstruction of the surgical area and deviation was also calculated for the quantitative vari-
potentially a better cosmetic result than other surgical able like age and gender.
methods. Disadvantages of this technique are low, in- RESULTS
cluding greater disruption of the ocular surface, prolong A total of 85 eyes were reviewed following surgery
surgical time and increased patient discomfort. with a follow up period of 6 months. The range of the
MATERIALS AND METHODS ages of the patients was from 28 years to 80 years. The
Our study is a single center descriptive case series mean age was calculated to be 52.95 with SD + 12.016.
and was carried out at Department of Ophthalmology, The majority of the patients were between ages 40 years
Lahore General Hospital, a tertiary care hospital affili- to 60 years (58 pts) while only 9 patients were below the
ated with Post Graduate Medical Institute Lahore be- age of 40 years and 18 above 60 years. 57 patients were
tween Jan 2011 to June 2012. A total of 85 cases were op- male (67.1%) and 28 were females (32.9%). The male to
erated upon during the study period and all the cases female ratio was 2.035:1.
were reviewed for atleast six months to look for signs Post operatively, generalized conjunctival con-
of recurrence. All the patients were pre operatively ex- gestion was noted in all the patients and complained
amined on slit lamp and patients with either a pseudo- of mild foreign body sensation which was attributed
pterygium or inflamed eyes or with previous failed to the irritation caused by the stitches. A few patients
grafts were excluded from the study. The risks and ben- (24) complained of excessive watering. Those patients
efits of the study were discussed with the patients. All who were bothered by the foreign body sensation and
the data was recorded on a pre-designed proforma. watering were prescribed lubrication for comfort. Stem
Surgical Technique: All the surgeries were per- cell graft was found to be in place in all the eyes. Upon
formed employing a uniform surgical technique. All follow up after 1st week, there was conjunctival conges-
the surgeries were performed under local anesthesia tion but its intensity had decreased. The foreign body
which comprised of equal volumes of lidocaine mixed sensation and watering had almost settled. The graft
with bupivacaine. Anesthetic was injected with a 27g was in place but its color was found to be whitish as
needle just above the body of pterygium into the sub- compared to the surrounding conjunctiva which was
conjunctival space. A nick was then given in the con- red due to congestion. Upon visit on 2nd week post-op-
junctiva over the neck of the pterygium with the help eratively, the subjective complaints had resolved. The
of corneal scissors. Pterygium was then separated from conjunctival congestion had not resolved completely.
the underlying sclera by blunt dissection. Head of the The graft was in place and its color had now started
pterygium was shaved off from the cornea. Whole of to change from white to pink which was a sign of graft
the pterygium was then excised with the help of cor- uptake. The stitches were then removed.
neal scissors. Care was taken not to damage medial rec- Then the patients were reviewed after one month
tus muscle while excising the pterygium. Local anes- post-operatively. There was no subjective complaint. The
thetic was then injected into the suprotemporal limbus conjunctival congestion had completely resolved. The
to raise a balloon of limbal conjunctiva containing stem color of the graft now resembled to that of conjunctiva
cells. The width of the strip of limbal conjunctiva was and topical medication was stopped. At 2nd month, the
always taken 2mm while length was measured accord- graft had now become the part of surrounding conjunc-
ing to wound gap. The excised conjunctival strip con- tiva. It was noted that in 5 eyes, the vasculature overly-
taining stem cells was then shifted to nasal limbus. Care ing the graft was dilated and showed a mild degree of
was taken to keep the limbal side of the strip towards congestion. So in these cases, we continued topical medi-
the nasal limbus. The strip was then anchored with the cation. These patients were called for examination at 2
help of interrupted 10/0 nylon sutures. Eye pad was weeks intervals. In these cases, the amount of conjuncti-
then placed for 3 days to give the graft sufficient time val congestion worsened at every subsequent follow up.
to anchor onto the nasal limbus and underlying sclera. Finally at 6th month post operatively, 80 eyes were
Topical antibiotics and steroids were administered af- found to be free of any signs of recurrence of pterygi-
ter removal of bandage. Patients were then regularly um. The conjunctiva and graft had merged successfully
called for follow up after one week, two weeks, one without any inflammatory activity. While in 5 eyes,
month, two months and then finally after six months. there was excessive fibrosis and congestion of the con-
Follow up examination was done under slit lamp. junctiva and conjunctival tissue had started invading
Stitches were removed after two weeks of surgery. the cornea despite the application of graft. In our study,

80 eyes out of 85 showed no recurrence of pterygium Mitomycin C drops, use of amniotic membrane graft
which is 94.1% of the sample size while 5 eyes showed and beta irradiation etc have been tried.
recurrence which is 5.9% of the sample. Thus, in this Though the above mentioned techniques have suc-
study, the percentage of efficacy of stem cell graft in the cessfully lowered the recurrence rates but these tech-
prevention of recurrence of pterygium in a sample size niques have their own drawbacks. Keeping in mind the
of 85 cases with a mean follow up period of six months complication rates and difficulty of gathering the mate-
is found to be 94.1%, which is more than the expected rials for surgery, there was a need to devise a method
percentage of efficacy i.e. 86.2% calculated for a sam- that is easy to perform and learn, has low complication
ple size of 85 cases with a mean follow up period of 6 rates, near to the anatomy and physiology of the limbus
months. and at the same time effective in reducing the recur-
Table 1: Age Analysis of the Study rence rate of pterygium. All these conditions were met
AGE GROUP (YEARS) FREQUENCY PERCENTAGE with a new surgical technique of conjunctival limbal
< 40 9 10.5%
autograft. Since the pathogenesis of pterygium reveals
40 - 60 58 68.2%
UV dependent stem cell damage, replacement of defec-
►► 60 18 21.1%
tive stem cells with the healthy ones should serve the
purpose.
Mean 52.95 Standard Deviation 12.016 The concept of replacing damaged stem cells with
the healthy ones to prevent the recurrence of pterygium
Figure 1: Gender Distribution
was first advocated by Kenyon et al in 1985. There is
widespread acceptance of conjunctival auto grafting,
since its introduction by Thoft in 1977 and application
to pterygium by Vastine et al. and Kenyon et al. Kenyon
was the first surgeon to use conjunctival autograft for
the prevention of recurrence of pterygium. In his sam-
ple size of 57 eyes, 16 eyes had primary pterygia while
41 eyes had recurrent pterygia. During his mean fol-
low up period of 24months only 3 pterygia recurred
(5.3%). In a similar study conducted by Ashok K. Shar-
ma and his colleagues, they evaluated 150 eyes who
had received conjunctival autograft with follow up of 6
Table 2: Recurrence of Pterygium
months. Recurrence was noted only in 4 eyes (2.6 %).13
RECURRENCE FREQUENCY PERCENTAGE In another study conducted by Walid M Abdalla,
NO 80 94.1 40 eyes underwent pterygium excision and limbal con-
YES 5 5.9 junctival transplantation with stem cell. After a follow
TOTAL 85 100 up of 12 months, only 3 eyes developed recurrence
(7.5%).13 Col KN Jha evaluated 32 eyes who underwent
DISCUSSION conjunctival limbal autograft procedure and cases were
A pterygium is a wing shaped; fibro vascular, de- reviewed for 6–18 months postoperatively. No recur-
generative subconjunctival tissue that grows over the rence was noted in these cases and all of them were free
limbus and encroaches onto the cornea. It is a disease from any major postoperative complications.14
of the tropical and subtropical regions where exposure Johan Eksteen et al. and Andries A Stulting et al.
to sunlight containing UV radiation is thought to play a conducted a comparative study on the role of rota-
major role in its pathogenesis. As it progresses it causes tional conjunctival flap in the prevention of recurrence
symptoms of irritation, redness, watering and results in of pterygium and showed that after a follow up of 12
blurred vision due to astigmatism alongwith the cos- months, out of 29 eyes on which rotational conjunctival
metic blemish. If it is left untreated, it grows to invade flap (containing stem cells) was done, 6 eyes showed
the pupillary axis of cornea and results in profound recurrence which is 20.7% as compared to other group
visual loss. in which simple excision was done and recurrence rate
Therefore, pterygium has to be treated before it was found to be 66.7%.15 Yasemin Arslan Katircloglu,
reaches the pupillary axis. The treatment of pterygium Ugur Emrah Altiparmak and Sunay Duman compared
is surgical but simple excision is associated with a very the above mentioned three techniques on 49 eyes of
high recurrence rate ranging from 30 – 70%.6,7 To over- which 25 were treated with conjunctival autograft, 16
come this high rate of recurrence, various options like with amniotic membrane transplantation and 8 eyes
bare sclera technique, peroperative or postoperative received topical mitomycin C peroperatively combined

with conjunctival autograft. The recurrence rate was currence. The complications of the procedure are mini-
calculated to be 16% in conjunctival autograft, 25% in mal. The technique is easy to master and conjunctival
amniotic membrane transplantation and 0% in com- limbal stem cell graft is very much near to the normal
bined topical mitomycin C application and conjunctival anatomy and physiology of the limbus. It is the only
autografting.16 method which prevents the recurrence of pterygium
Nazullah Khan, Mushtaq Ahmed, Abdul Baseer, by addressing the pathogenesis, that is damaged stem
Naimatullah Khan Kundi compared the recurrence rate cells which result in overgrowth of pterygium, are re-
of pterygium with bare sclera, conjunctival autograft placed by healthy stem cells.
and amniotic membrane grafts. They included a total REFERENCES
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junctival autograft and 54 eyes received amniotic mem- currence of pterygium with conjunctival autograft verses mito-
brane graft. The recurrence rate was noted to be 36.6% mycin C. Pak J Ophthalmol 2008. Vol.24 no.1.
3. Austin P, Jakobiec FA. Iwamolot Elastodysplasia and elasto-
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while 7.40% with amniotic membrane graft. They con- guicula. Ophthalmology. 1983;90:96–109
cluded that conjunctival autograft and amniotic mem- 4. Coroneo MT. Pterygium as an early indicator of ultraviolet in-
solation: a hypothesis. Br J Ophthalmol 1993;77:734-739
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5. Saw S, Tan D. Pterygium: prevalence, demography and risk
Ashok Kumar Narsani, Shafi Mohammad Jatoi factors. Ophthalmic Epidemiol 1999;6: 219-228
and colleagues compared the recurrence of pterygium 6. Jaros PA, Deluisa VP. Pinguecula and pterygia. Surv Ophthal-
with conjunctival autograft versus mitomycin C. They mol. 1988;33:41–9.
7. Singh G, Wilson MR, Foster CS. Long term follow up study of
operated upon 112 eyes out of which 70 eyes received mitomycin eye drops as adjunctive treatment for pterygia and
conjunctival autograft while 42 eyes received peroper- its comparison with conjunctival autograft transplantation.
ative Mitomycin C. They found out that there were 4 Cornea. 1990;9:331–4.
recurrences (5.7%) in the conjunctival autograft group 8. Oguz H, Kilitcioglu A, Yasar M. Limbal conjunctival mini-au-
tografting for preventing recurrence after pterygium surgery.
as compared to 8 (19%) in mitomycin group.2 The recur- Eur J Ophthalmol. 2006;16:209–213
rence rate in our study was found to be 5.9% which is 9. Nishimura Y, Nakai A, Yoshimasu T, Yagyu Y, Nakamatsu K,
comparable to other studies. Kenyon found a recurrence Shindo H, et al. Long term results of fractionated strontium-90
radiation therapy for pterygia. Int J Radiat Oncol Biol Phys.
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2000;46:137–41.
and Nazullah 8.8%17 with conjunctival limbal autograft, 10. Wilder RB, et al. Pterygium treated with excision and postoper-
to list a few. We also found out that recurrence occurred ative beta irradiation. Int J Radiat Oncol Biol Phys 1992; 23:533.
in relatively younger patients, all the patients being 50 11. Jurgenlienk-Schultz IM, et al. Prevention of pterygium recur-
rence by post-operative single dose beta irradiation: a perspec-
years old or younger. The cause of this recurrence in tive randomized clinical double-blind trial. Int J Radiat Oncol
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Most common complaint that we came across fol- 12. Kenyon KR, Wagoner MD, Hettinger ME. Conjunctival auto-
lowing surgery was foreign body sensation and most graft transplantation for advanced and recurrent pterygium.
Ophthalmology. 1985;92:1461–70.
common sign was conjunctival congestion. Both these 13. Ashok K. Sharma, Vijay Wali, Archna Pandita. Corneo con-
problems were relieved as stitches were removed after junctival autografting in pterygium surgery. JK Science, 2004
2 weeks post operatively. We found out that graft took July September Vol 6 No. 3.
14. Col KN Jha. Conjunctival limbal autograft for primary and re-
its place very nicely in all the cases, even in the cases
current pterygium. MJAFI 2008; 64: 337-339.
which met with recurrences. In cases with recurrence, 15. Johan Eksteen, Andries A Stulting. Rotational conjunctival
extensive vascularization of graft had started at almost flap surgery reduces recurrence of pterygium. SAMJ, S. Afr. J.
2 months post operatively and extent of vascularization vol.100 no.11 Cape Town Nov. 2010.
16. Yasemin Arslan Katircloglu, Ugur Emrah Altiparmak, Su-
increased at every follow up despite desperate topical nay Duman. Comparison of three methods for the treatment
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cularization was then followed by scarring and fibro- tograft and conjunctival autograft plus mitomycin C. Issue
sis and eventually lead to re-growth of pterygium. In TOC,2007;26:5-13.
17. Nazullah khan, Mushtaq Ahmed, Abdul Baseer, Naimat Ullah
such cases, a combined conjunctival limbal autograft Khan Kundi. To compare the recurrence rate of pterygium ex-
with topical Mitomycin C was done and the technique cisionwith bare sclera, free conjunctival autograft and amniotic
proved quite successful. membrane graft. Pak J Ophthalmol vol.26 no.3 2010.
18. Petra Kralj, Renata Ivekovic’, Katia Novak – Laus and Zdravko
CONCLUSION
Mandic’. Efficacy of limbal stem cell transplantation in the
Pterygium excision with conjunctival limbal stem treatment of recurrent pterygium. Acta Clin Croat 2008;47(suppl
cell graft is an effective way for the prevention of re- 1) 35 – 37.

ORIGINAL ARTICLE
What for we are looking in Psuedoexfoliation:

A Clinical Presentation of the Patients
Mohammad Idris
Mohammad Idris FCPS1, Mohammad Jawad FCP2, Anwar Ali FCPS3
Sardar Ali DOMS4, Jamal Hussain5, Mohammad Alam FCPS6
ABSTRACT
Objective: To know the frequency of different ocular features of pseudoexfoliation syndrome with cataract. Pseudoexfolia-
tion of the eye, a degenerative condition associated with ongoing ocular inflammation, causes glaucoma and peroperative
complications during cataract surgery. The present study was done to study different ocular features of pseudoexfoliation
syndrome.
Methodology: The study was conducted at lady reading hospital, Peshawar, from 1st March, 2011 to 31st August; 2011. It
was descriptive case series study. Non probability purposive sampling technique was used.
Results: A total number of patients studied were 50. Age of the patients was 58.13+4.16 years. Male to female ratio was
found to be 5.25:1. Normal patients were 24(48%). Eleven 11(22%) patients had zonular fragility, 03(06%) had iridodonesis
and 07(14%) had phacodonesis. In 03(06%) patients, pigment dispersion was seen, out of which 02(66.7%) was present on
lens and 01(33.3%) was present on cornea. Subluxation of lens was seen in 02(04%) patients. the frequency was more in
right eye which was 30 (60%). In left eye the frequency was 20 (40%).
Conclusion: It is evident from the study that PXF is common in male, old age and right eye. Common ocular features in-
clude poor pupil dilation, zonular fragility, and phacodonesis.
Key words: Pseudoexfoliation, pupil dilation, zonular fragility, phacodonesis, intraocular pressure.
INTRODUCTION ma, angle closure glaucoma, poor pupillary dilatation,

Pseudoexfoliation (PXF) is an age-related disease posterior capsule rupture, vitreous loss, phacodonesis3
characterized by bluish white flaky material in the ante- and keratopathy.7 there is atrophy of iris in eyes with
rior segment of the eye and conjunctiva. Pseudoexfolia- pseudo exfoliation especially at the pupillary margin,
tion syndrome is more common in males and increases which is evident by trans-illumination.
with advancing age.1 It is a degenerative disorder which Pseudoexfoliation can cause inflammation in the
may be unilateral or bilateral. It is a familial condition eye which may lead to complicated cataract and sec-
and seems to be genetically inherited.2 The grey white ondary glaucoma.8 PXF results in increased complica-
fibrillogranular material is deposited as small keratic tions during cataract surgery.9 surgical complications
precipitates (KPs), on anterior lens surface, iris border, result from zonular weakness.10 there is an increase
on zonules and in the angle. The fibrillogranular mate- of melanin pigmentation of anterior chamber angle.
rial is also deposited on the lens epithelium, iris stroma Phacodonesis and iridodonesis are common due to
and blood vessels, anterior hyaloid face and subcon- zonular degeneration and disintegration. Spontaneous
junctival tissue. lens dislocation occurs in 16% of patients with pseudo-
The deposit is most prominent on the anterior lens exfoliation.11 Pseudoexfoliation is very common in Pa-
capsule at its center where it is a thick translucent mem- kistan and it is associated with cataract in Hazara Divi-
brane and as granular deposits on the periphery of the sion.12
lens.3 The deposit is prominent at the pupillary margin
Proper diagnosis with detailed examination is nec-
as well.4 Similar material has also been detected in skin essary to rule out every risk factor like pseudoexfolia-
and connective tissue portions of various visceral or- tion in patients with cataract. Phacodonesis and irido-
gans. That is why pseudoexfoliation is described as a donesis, which may be indicating pseudoexfoliation,
systemic disorder.5,6 PXF can cause open angle glauco- are overlooked due to lack of detailed examination.
Research studies need to be generated in busy ophthal-
1
Medical Officer Eye Unit, Lady Reading Hospital, Peshawar. mology departments to prevent the peroperative com-
2
Trainee Medical Officer Eye Unit, Lady Reading Hospital,
Peshawar. 3Associate Prof. Ophthalmology PIMS, Islamabad. plications in PXF patients. The purpose of the present
4
Trainee Medical Officer Eye Unit, Lady Reading Hospital, Peshawar. study, conducted at Lady Reading Hospital Peshawar,
5
Lecturer Community Medicine, Saidu Medical College, Swat.
6
Senior Registrar, Lady Reading Hospital, Peshawar was to determine various ocular features of pseudoex-
foliation syndrome.
Correspondence: Dr. Mohammad Idris, Medical Officer, Eye Unit, METHODOLGY
Leading Reading Hospital, Peshawar. Cell No: 0333-9417051
E.mail: idrisdaud80@gmail.com The study was conducted at Lady Reading Hos-
pital, Peshawar, from 1st March, 2011 to 31st August;
Received: Dec’ 2013 Accepted: Jan’ 2014
2011. It was descriptive case series study. Non prob-

ability purposive sampling technique was used. The was present on cornea. Subluxation of lens was seen in
data was collected through proforma. A detail history 02(04%) patients.
of patient’s ocular features were collected. In ocular Table 3 shows descriptive statistics of age and
examination visual acuity of both aided and unaided IOP. The mean age of patients with senile cataract with
of patients were recorded. Intraocular pressure was pseudoexfoliation was 67 +- 7.68 years. Similarly, the
recorded using Goldman tonometer. Written consent mean IOP was 21.68 +- 2.31 mm Hg.
of all the patients included in the study was taken af- Table 4 shows distribution of frequency and per-
ter fully explaining the procedure and purpose of the centage of right and left eyes in both age groups. In
study to the patients. cataract patients with pseudoexfoliation, the frequency
A detailed proforma was devised containing all was more in right eye which was 30 (60%). In left eye
essential details for each individual. A complete oph- the frequency was 20 (40%).
thalmic history was taken. The patients were asked
about their name, age, sex, occupation and address. A
thorough examination including visual acuity, ante-
rior segment, posterior segment and measurement of
intraocular pressure was performed. Anterior segment
examination was done with Slit lamp and Gonioscope.
Instruments used included Slit lamp and intraocular
pressure was recorded with applanation tonometer.
The diameter of pupil of each patient was measured.
The patients were examined with slip lamp for signs
of pseudo exfoliation syndrome. All those patients who
refuse to give consent for this study were excluded. The
data was analyzed with SPSS 10.0.
RESULTS
Fifty (50) cataract patients with pseudoexfoliation
syndrome were included in this study. The ages of these
50 patients ranged from 50 years to 87 years. The age Graph-1: Distribution of patients by age groups (n=50)
(PEX = Pseudoexfoliation)
distribution is shown in figure 1. Five (10%) patients
were in age group of 80-89. There were 19 (38.77%) pa-
tient in the age group of 70-79, 22 (44%) patients were in
age group of 60-69 years and only 4 (08%) patients were
in age group of 50-59 years.
The distribution of pseudoexfoliation by gender is
shown in figure 2. Forty-two (42) patients that is 84% of
patients were males, while the remaining 8 making 16%
of the patients were females; the male: female ratio was
5.25:1.
Pupil dilatation is shown in Table 1. Intra-opera-
tive maximum pupillary dilatation with mydriasis was
obtained and its size measured. This pupil size was
graded as poor, fair and satisfactory/good. Poor pupil-
lary dilatation meant 2-4 mm and was seen in 24(48%)
patients with pseudoexfoliation and none in senile cat- Graph-2: Distribution of pseudoexfoliation patients
by gender (n = 50)
aract. Fair pupillary dilatation meant 5-6 mm and was
seen in 21 (42%) patients of pseudoexfoliation. Satisfac-
Table-1: pupil dilatation in
tory/good pupillary dilatation meant 7-9 mm and was pseudoexfoliation (n = 50) patients.
seen in 5(10%) patients with pseudo exfoliation.
Pupil dilatation groups (mm) Pseudoexfoliation patients (n = 50)
Table 2 shows preoperative features/findings
of pseudoexfoliation. Normal patients were 24(48%). Poor (2 – 4) 24 (48%)
Eleven 11(22%) patients had zonular fragility, 03(06%) Fair (5 – 6) 21 (42%)
had iridodonesis and 07(14%) had phacodonesis. In Good (7 – 9) 05 (10%)
03(06%) patients, pigment dispersion was seen, out Total 50
of which 02(66.7%) was present on lens and 01(33.3%)

Table-2: Distribution of findings in pseudoexfoliation (n = 50). pseudoexfoliation patients was 67.28 which was higher
Findings Number Percentage than that of senile cataract which was 64.47. Thus pseu-
Normal 24 48 doexfoliation and cataract are diseases of old age. The
Zonular fragility 11 22 prevalence of pseudoexfoliation in a relatively younger
Iridodonesis 03 06 people as compared to cataract has also been reported.17
Phacodonesis 07 14 Pseudoexfoliation can be unilateral or bilateral.
Pigment dispersion 03 06 Our study describes unilateral cases to be 22%. Unilat-
Lens (02) (66.7) eral cases are reported to be 20% in one study11 and 25
Cornea (01) (33.3)
%18 in another study in Pakistan. Our study describes
Subluxation 02 04
unilateral cases to be 22%. The second aspect of unilat-
Total 50 100
eral cases is that it is seen more commonly in younger
Table-3: Descriptive statistics of age and IOP N=50 people as compared to bilateral cases seen in older age
group.19,20
Pseudoexfoliation Variables Mean
Pseudoexfoliation is associated with constricted
age 67.28
pupil. Adequate pupillary dilatation is necessary for
IOP (mmHg) 21.68
standard Extra capsular extraction. Pupillary dilata-
IOP: Intraocular pressure
tion is obtained by topical tropicamide. In the present
Table 4: Distribution of frequency study, pupil size was recorded after installation of
and percentage of right and left eyes (n=50) tropicamide at 10 minutes interval for half an hour.
Pseudoexfoliation Frequency Percent Poor pupillary dilatation was seen in 54% of the pa-
left 20 40.0 tients, adequate in 42% of the patients and good in
right 30 60.0 4% of the patients with pseudoexfoliation. In another
Total 50 100.0 study, 68.75% of pseudo exfoliation patients had poor
to moderate pupillary dilatation.14 these results indicate
DISCUSSION that good/adequate pupil dilatation for standard extra
This study was conducted to see the various clini- capsular cataract extraction is more difficult to be ob-
cal presentations of the patients with cataract pseu- tained in patients with pseudo exfoliation. Constricted
doexfoliation was more commonly seen in males as pupil exposes the patient to more complications21. To
compared to females in the present study, i.e., 84% in obtain adequate dilatation, different methods are in
males and 16% in females. This ratio is approximately use. Bimanual stretching is one of the least time con-
5:1. More frequent occurrence of pseudoexfoliation in suming methods22 and was used in our study. This
males can be explained by two factors. The first factor method is more convenient and cheaper but may lead
is that most of the patients undergoing cataract surgery to iris sphincter damage. Sphincter damage was seen in
are males. Secondly, males are more commonly in- 16% of the patients with pseudoexfoliation. This dam-
volved in outdoor activities while most of the females age leads to anisocoria postoperatively but is of help
are restricted to homes as traditional housewives. This to obtain pupillary dilatation and thus making anterior
particular aspect of restriction to houses partly explains capsulotomy more convenient and of appropriate size.
environmental factors, as there are fewer risks for de- Proper anterior capsulotomy and adequate dilatation
velopment of pseudo exfoliation. This is consistent of pupil help in uneventful surgery. The better option
with the finding of studies done by Mohammad 11 and is to opt for sphincterectomy in patients, which are sus-
Naeem .13 Another study also indicates that the inci- ceptible to sphincter damage. Sphincterectomy thus
dence of the disease is higher among male (67%) than provide more controlled enlargement of pupil and at
female (33%) with the ratio of 2:1.14 the same time better site can be selected.

Pseudoexfoliation in cataract is commonly seen The patients with pseudo exfoliation syndrome
with increasing age. The precise role of age for contri- are more prone to have complications as compared to
bution to development of cataract and pseudo exfolia- patients without pseudoexfoliation.23, 24 In this study,
tion is very difficult to be pinpointed. Pseudo exfolia- only one patient with pseudoexfoliation had this com-
tion is more common after the age of 50 years and its plication.
incidence doubles every ten years after this age. Pseu- Pseudo exfoliation is a source of severe complica-
doexfoliation is reported to be more common during tions in cataract surgery.25 The patients with pseudoexfo-
60 to 70 years of age15. The mean age of patients with liation do have more complications due to zonular weak-
pseudo exfoliation is significantly higher than the mean ness and degeneration that is easily understandable.
age of patients with pseudoexfoliation, which undergo Patients with pseudoexfoliation are at high risk
cataract surgery.16 In the present study, the mean age of for development of complications. Early diagnosis, de-

tailed examination, knowledge of the complications, H. Pseudoexfoliation syndrome. Ocular manifestation of a

systemic disorder? Arch Ophthalmol 1992; 110: 1752-6.
ability to manage these complications are keys of suc-
6. Streeten BW, Li ZY, Wallace RN. Pseudoexfoliative fibrillopa-
cess. Ophthalmologists should stress to increase aware- thy in visceral organs of a patient with pseudoexfoliation syn-
ness among general public for the proper diagnosis and drome.Arch Ophthalmol 1992; 110: 1757-62.
convince patients for proper and regular follow up vis- 7. Nauman GOH, Schlatzer-Schrehardt U. Keratopathy in pseu-
doexfoliation syndrome as a cause of corneal endothelial de-
its to the hospital. compensation. A clinicopathalogic study. Ophthalmology
CONCLUSION 2000; 107:1111-24.
Pseudoexfoliation is frequently associated with 8. Baig MA, Niazi MK, Karamat S. Pseudoexfoliation syndrome
and secondary cataract. Pak Armed Forces Med J 2004; 54:63-6.
glaucoma and poor pupillary dilatation. Phacodonesis, 9. Scorolli L, Campos EC, Bassein L, Meduri RA. Pseudoexfolia� -
iridodonesis and lens subluxation are common in pa- tion syndrome: a cohort study on intraoperative complications
tients with pseudoexfoliation. in cataract surgery. Ophthalmoligica 1998; 212:278-80.
10. Shingleton BJ, Heltzer J, O’Donoghue MW. Outcomes of
RECOMMENDATIONS
phacoemulsification in patients with and without pseudoexfo-
Further research is needed to develop interven- liation syndrome. J Cataract Refract Surg 2003; 29:1080-6.
tions and surgical modalities to decrease these compli- 11. Mohammad S and Kazmi N. Subluxation of lens and ocular
cations in this group of patients. Strict adherence and hypertension in exfoliation syndrome. Pak J Ophthalmol 1986;
2:77-79.
attention should be paid to the already known proto- 12. Khanzada AM. Exfoliation syndrome in Pakistan. Pak J Oph-
cols for minimizing peroperative complications. There- thalmol 1986; 2: 7.
fore keeping these things in mind, we can prevent the 13. Naeem S. Incidence, age of presentation and lenticular changes
in exfoliation syndrome. [Dissertation]. Karachi: College of
complications in PXf patients especially during sur- Physicians & Surgeons; 1997: 149.
gery. 14. Naseem A. Cataract surgery in patients with pseudoexfolia-
REFERENCES tion. [Dissertation]. Karachi: College of Physicians & Surgeons;
1. Kanski JJ. Glaucoma. In: Kanski JJ. Clinical ophthalmology. 5th 2002: 111.
ed. London: Butterworths-Heinemann, 2003:192-268. 15. Albert DM, Jakobeic FA. Principles and Practice of Ophthal-
2. Allingham RR, Loftsdottir M, Gottfredsdottir MS, Thorgeirs- mology. 2nd ed. Philadelphia: WB Saunders, 1994: 82-95.
son E, Jonasson F, Sverisson T, et al. Pseudoexfoliation syn- 16. Susic N, Brajkovic J The prevalence of pseudoexfoliation syn-
drome in Icelandic families. Br J Ophthalmol 2001; 85: 702-7. drome in patients admitited for cataract surgery to the depart-
3. Shafiq I, Sharif-ul-Hasan K. Prevalance of pseudoexfoliation ment of ophthalmology, Sibenik General Hospital.Acta Med
(PEX) Syndrome in a given population. Pak J Ophthalmol Croatica. 2006; 60(2):121-4.
2004; 20:49-52. 17. 17.Teshome T, Regassa K.Prevalence of pseudoexfoliation syn-
4. Prince AM, Ritch R. Clinical signs of the pseudoexfoliation syndrome in Ethiopian patients
drome. Ophthalmology 1986; 93: 803-7. 18. scheduled for cataract surgery. Acta Ophthalmol Scand. 2004
5. Schlotzer-Schrehardt UM, Koca MR, Naumann GO, Volkholz Jun; 82:254-8.
An old male, only eyed, presented with left eye

sudden reduced vision. On examination BCVA
6/36 with -10.0 DS, Myopic degenerations, posterior
staphyloma, macular detachment with large macular
hole. Right eye operated for RD 12 years back with
Pthysical changes and PL only.
NewsNet

ORIGINAL ARTICLE
Comparison of Visual Outcome with
single Suture Vs Sutureless Clear Corneal
Phacoemulsification by using 5.5 PMMA IOL’s
M. Siddique
Mohammad Siddique FCPS1, Faisal Rashid (B.Sc, Hons Optometry)2

Hina Khan FCPS3, Prof. Mahmood Saeed FCPS4
ABSTRACT:
Purpose: To compare the postoperative visual acuity, postoperative astigmatism, peroperative and postoperative complica-
tions in single suture versus sutureless clear corneal phacoemulsification using 5.5 PMMA intraocular lenses.
Study Design: Quasi experimental
Participants and Methods: This study was conducted in Ophthalmology Department Sheikh Zayed Hospital, Rahim Yar
Khan from January 2011 to February 2012. Total of 170 patients from 40 to 90 years were enrolled and divided in two
groups, group A (N=85) and group B (N=85). Both the groups underwent clear corneal phacoemulsification by superior ap-
proach. Group A was left sutureless and in group B one single suture of nylon 10/0 was applied. The patients were followed
up at 1st and 3rd post operative days and then 2nd, 4th and 6th postoperative weeks. On 4th postoperative week the suture of all
the patients of group B was removed. 80 patients in group A and 76 patients in group B completed their 6 weeks follow up.
The post-operative visual acuity, postoperative astigmatism, peroperative and post-operative complications were recorded
at 6 weeks follow up and compared between two groups.
Results: At 6th week post operatively, 40 out of 80 (50%) cases of group A and 55 out of 76 (72.36%) of group B had uncor-
rected visual acuity of 6/18 or better. There was significant difference between two groups (p-value 0.01) while 69 out of
80 (86.25%) of group A and 72 out of 76 (94.73%) of group B had best corrected visual acuity of 6/18 or better. There was
no significant difference in best corrected visual acuity (p-value 0.17). 15 patients out of 76 (19.73%) in group B while 35
patients out of 80 (43.75%) in group A had astigmatism 1.25D to 1.50D (p-value 0.001). against the rule astigmatism was
present in 72.5% of patients in group and 36.84% of the patients in group B (p-value 0.0001). There was not much difference
in intra operative complications however post operative complications were less in sutured group.
Conclusion: Both the techniques of phacoemulsification are safe for cataract surgery. The difference in intra-operative
complications is very small. However the uncorrected post operative visual acuity, post operative complications and post
operative astigmatism is less and safe if single suture is applied in clear corneal superior tunnel phacoemulsification.
INTRODUCTION tive of the method used. Correction of astigmatism is

Cataract is the commonest cause of avoidable possible with optical correction, suture manipulation
blindness and in Pakistan it contributes about 67% of or refractive surgery.7 With the development of mod-
the total blindness.1 Cataract surgery is the leading in- ern cataract surgeries, efforts are made to minimize sur-
traocular surgery being performed these days.2 gically induced astigmatism (SIA). Surgically induced
Phacoemulsification is the preferred technique, astigmatism is mainly influenced by preoperative astig-
the primary mechanism being mechanical cutting of matism as well as shape and length of anterior chamber
nucleus through the direct contact with an oscillating incision, suture technique and wound healing.8 Surgi-
needle tip.3 Self-sealing clear corneal incisions have be- cally induced astigmatism is very small in phacoemul-
come the most common incision type for cataract and sification as compared to conventional cataract surgery.
other anterior segment surgeries.4 The better visual If the incision is placed on the steepest meridian, the
acuity in patients who underwent phacoemulsification corneal astigmatism can be significantly reduced post-
then those who underwent extracapsular cataract ex- operatively.9 Clear corneal incision (CCI) is the most
traction at all postoperative intervals.5 used type of incision in the phacoemulsification sur-
Phacoemulsification is almost universally used gery, because it is less time consuming and does not
today.6 Postoperative astigmatism is the main cause of require cauterization. Temporal CCI induces regular
decreased visual acuity after cataract surgery, irrespec- astigmatism 90 degree away from the incision (with the
1
Senior Registrar, 2Optometrist, 3Senior Registrar, 4Professor of Oph- rule astigmatism) thus minimizing the post-operative
thalmology, Ophthalmology Department, Sh. Zayed Medical College/ astigmatism.10,11 Some authors have shown that a small
Hospital, Rahim Yar Khan
superior CCI induces greater post operative astigma-
Correspondence: Dr. Mohammad Siddique, Senior Registrar Oph- tism than a small supero-oblique CCI, and a small
thalmology Department Sh. Zayed Medical College/ Hospital, Rahim spero-oblique CCI induces higher post operative astig-
Yar Khan Cell: 0300-5800195 E-mail: siddique.chdr@yahoo.com .
matism than a small temporal CCI.12,13 This study was
Received: Feb’ 2014 Accepted: March’ 2014 conducted to compare the results of two techniques of

Comparison of Visual Outcome with single Suture Vs Sutureless Clear Corneal Phacoemulsification by using 5.5 PMMA IOL’
phacoemulsification by applying single suture versus radial 10/0 monofilament nylon suture which was re-
sutureless phacoemulsification by using 5.5 PMMA moved 4th week postoperatively. Postoperatively these
IOL in clear corneal superior tunnel approach. patients were followed after 6th weeks for uncorrected
PARTICIPANTS AND METHODOLOGY visual acuity, corrected visual acuity, post operative
This study was conducted in Ophthalmology De- astigmatism and postoperative complications.
partment Sheikh Zayed Hospital, Rahim Yar Khan from RESULTS
January 2011 to February 2012. Total of 170 patients 80 out of 85 patients (94.11%) in group A (un-su-
from 40 to 90 years (90 were males and 66 females). All tured group) and 76 out of 85 (89.41%) in group B (su-
with operable cataract were enrolled. The inclusion tured) completed their 6 week follow up. Their uncor-
criteria included cataract patients without co-existing rected and corrected visual acuity is given in table 1 &
ocular pathology (anterior and posterior segment) and 2. 40 out of 80 (50%) cases of group A and 55 out of 76
good papillary dilatation. Patients with poorly dilat- (72.36%) of group B had uncorrected visual acuity of
ing pupils, co-existing ocular pathology or any type of 6/18 or better. There is significant difference between
complicated, traumatic cataract, pseudoexfoliation and two groups using CHI square test (p-value 0.01). Simi-
patients under the age of 40 and over the age of 90 were larly a total of 69 out of 80 (86.25%) of group A and 72
excluded from the study. All patients signed informed out of 76 (94.73%) of group B had corrected (after auto-
consent. 156 patients (80 in group A and 76 in group refraction and with subjective refraction) post opera-
B) completed their 6 week study follow up and includ- tive vision of 6/18 or better. There is no significant dif-
ed in the study. Preoperative examination including ference between two groups for corrected visual acuity
visual acuity, detailed slit lamp examination, air puff using CHI square test (p-value 0.17). Five out of 80
tonometery, keratometery, and A-Scan biometry were (6.25%) of group A and 01 out of 76 (1.31%) of group B
performed in all patients. had uncorrected visual acuity less than 6/60. But none
B-Scan and indirect ophthalmoscopy were car- of patients of group B while only 01 patient of group A
ried out where needed. Data was recorded on patient had corrected post operative visual acuity of less than
assessment performa, especially designed for study 6/60. If we observe the post operative astigmatism at
purpose. Patients were divided into two groups. Group 6 week follow up (table no. 3) irrespective of their pre-
A (N=85) left unsutured after phacoemulsification and operative astigmatism, 40 out of 76 (52.63%) in group B
group B (N=85) applied a single radial 10/0 nylon su- while 23 out of 80 (28.75%) in group A had astigmatism
ture. Any peroperative complication was also recorded of 0.75D to 1.00D. 15 out of 76 (19.73%) in group B while
on the performa. All patients were examined on 1st and 35 patients out of 80 (43.75%) in group A had astigma-
3rd postoperative days and then 2nd, 4th and 6th postop- tism of 1.25D to 1.50D (p-value 0.001) which is statisti-
erative weeks. On 4th postoperative week, the suture of cally significant. Regarding range of astigmatism (table
all the patients of group B removed and high follow up no. 4), 28 patients out of 76 (36.84%) of group B while
rate on 6th week was achieved with a strong postopera- 58 patients out of 80 (72.5%) of group A had against
tive counseling. The final recording of postoperative the rule astigmatism (p-value 0.0001%) which is also
visual acuity, magnitude of postoperative astigmatism statistically significant. 54 patients out of 76 (71.05%)
and postoperative complications was made at 6th week in group B and 57 out of 80 (71.25%) in group A were
postoperatively. Results were assessed and compari- without any complications (table: 5). Similarly at 6 week
son between two groups was done by CHI Square test. follow up visit 14 out of 76 (18.42%) of group B while
P<0.05 was considered statistically significant. 23 out of 80 (28.75%) of group A had mild to moder-
Surgical Technique ate post-operative complication. Only one patient in
After adequate mydriasis with tropicamide and group B had corneal decompensation and one patient
phenylpherine 2.5%, peribulbar block was adminis- in group A had post-operative endophthalmitis.
tered. Superior rectus bridal suture was applied only in
Table-1: Uncorrected post operative visual
deep sunken eyes and some other eyes where the globe
acuity at 6th week Follow-up (According to WHO Guidelines)
was not centered. 3.2 mm clear corneal superior tun-
nel was made by using 3.2 mm keratome. Storz protégé Post operative Un-sutured Sutured
machine utilizing venturi pump was used for phaco- Total n=156
Visual acuity Group A n=80 Group B n=76
emulsification. Wound then enlarged with 5.6 mm
6/18 – 6/6 (Good) 40 (50%) 55 (72.36%) 95 (60.89%)
keratome for insertion of a single piece 5.5 PMMA pos-
6/60 – 6/24 (Border line) 35 (43.75%) 20 (26.31%) 55 (35.25%)
terior chamber intraocular lens. In 85 patients (Group
˂ 6/60 (Poor) 05 (6.25%) 01 (1.31%) 06 (3.84%)
A) the wound was left unsutured while in other 85 pa-
Total 80 (100%) 76 (100%) 156 (100%)
tients (Group B), the incision was closed with a single
P-Value=0.01 (P<0.05,significant)

Table-2: Corrected post operative visual acuity at 6th week DISCUSSION

Follow-up (According to WHO Guidelines) There is significant difference between the two
Post operative Un-sutured Sutured Total groups (group A & group B) in terms of uncorrected
Visual acuity Group A n=80 Group B n=76 n=156 visual acuity. 50 % patients of group A and 72.36%
6/18 – 6/6 (Good) 69 (86.25%) 72 (94.73%)
141 patients of group B had postoperative vision of 6/18
(90.38%) or better without spectacles. After best correction
6/60 – 6/24
10 (12.5%) 4 (5.26%) 14 (8.97%) BCVA the figures are 86.25% and 94.73% respectively.
(Border line)
This difference is narrow. This is similar to the
˂ 6/60 (Poor) 01 (1.25%) __ 01 (0.64%)
study of Stan J et al which shows poor uncorrected
Total 80 (100%) 76 (100%) 156 (100%)
visual acuity with superior approach in clear corneal
P-Value=0.17 (P>0.05, insignificant) phacoemulsification.14
Magnitude of astigmatism at 6 week post
Table-3: Magnitude of astigmatism at 6th week post operatively
operatively in group B is less than group A. 52.63% in
Post operative
Un-sutured Sutured
Total group B while 28.75% in group A had astigmatism of
Group A Group B
Astigmatism
n=80 n=76
n=156 0.75D to 1.00D. 7.89% in group B and 15.03% in group
0.25DC – 0.5DC 10 (12.5%) 15 (19.75%) 25 (16.02%) a had post operative astigmatism at 6 week 1.75D to
0.75DC – 1.00DC 23 (28.75%) 40 (52.63%) 63 (40.38%)
3.00D. This compares with the study of Khan & Ahmad
1.25DC – 1.50DC 35 (43.75%) 15 (19.73%) 50 (32.05%)
at institute of Ophthalmology in Mayo Hospital Lahore.
They showed in their study that 16 patients (32%) in the
1.75DC – 3.00DC 12 (15.03%) 06 (7.89%) 18 (11.55%)
un-sutured group and 9 patients (18%) in the sutured
Total 80 (100%) 76 (100%) 156 (100%)
group had post operative astigmatism between 0.75D
P-Value=0.001 (P<0.05, significant) to 1.50D.15
Table:4: Range of astigmatism at 6th week follow-up post operatively
However the study of Iftikhar S and Kiani SA
Range of Non-sutured Sutured
showed no significant difference in post operative
Total astigmatism in both unsutured and sutured groups.
Post-operative Group A Group B
n=156
Astigmatism n=80 n=76 The reason being they used trans-conjunctival limbal
160° - 10° tunnel incision instead of clear corneal incision.16
22 (27.5%) 48 (63.15%) 70 (44.87%)
(with the rule)
Against the rule astigmatism (ATR) which is difficult
120° - 70°
58 (72.5%) 28 (36.84%) 86 (55.12%) to manage is present in 72.5% of the patients in group
(against the rule)
Total 80 (100%) 76 (100%) 156 (100%) A while 36.84% patients in group B. this is comparable
with the study of Azar DT et al who conducted their
P-Value=0.0001 (P<0.05, highly significant)
study at John Hopkins Hospital found that at all follow
Table-5: Intra operative complications up visits sutureless groups had the greatest proportion
Non-sutured Sutured of patients with significant against the rule (ATR)
Total
Complications Group A Group B
n=156 shift.17
n=80 n=76
The intraoperative complications in both the
Posterior capsular rent 10 (12.5%) 08 (10.5%) 18 (11.53%)
groups are comparable however post operative
Improper corneal tunnel 04 (5%) 05 (8%) 09 (5.76%) complications in sutured group are less than unsutured
Descemet’s membrane group. The commonest intraoperative complication in
04 (5%) 03 (3.94%) 07 (4.48%)
detachment
both the groups was posterior capsular rent and the
Iris burn 05 (6.25%) 06 (7.89%) 11 (7.05%)
commonest post operative complication in both the
Total 23 (28.75%) 22 (28.94%) 45 (28.84%)
groups was striate keratopathy which resolved with the
P-Value=0.0001 (P<0.05, highly significant)
treatment. The shallow anterior chamber in 03 patients
Figure-I: Post- operative complications at 6th week follow –up and endophthalmitis in one patient in group A was also
managed conservatively.
CONCLUSION
Both the techniques of phacoemulsification are safe
for cataract surgery. The difference in intra-operative
complications is very small. However the uncorrected
post operative visual acuity, post operative complica-
tions and post operative astigmatism is less and safe if
single suture is applied in clear corneal superior tunnel
phacoemulsificaiton. We recommend the use of single
suture in clear corneal phacoemulsificaiton while using

superior approach. Suture can be removed according to cataract Refract Surg 2001; 37: 108-10
10. Cillino S, Morreale D, Mauceri A. Temporal vs. superior
induced astigmatism. Against the rule astigmatism in
approach phacoemulsificaiton: short term post operative
sutureless incision is difficult to manage. astigmatism. J Cataract Refract Surg 1997; 23: 267-71
REFERENCES 11. Cravy TV. Routine use of lateral approach to cataract extraction
1. Khan AQ, Qureshi B, Khan MD. Rapid assessment of cataract to achieve rapid and sustained stabilization of post operative
blindness in age 40 years and above in distt. Skardu, Baltistan, astigmatism J Cataract Refract Surg 1991; 17: 415-23
Northern areas of Pakistan. Pakistan J Ophthalmol 2003; 19: 84-9 12. Mendivil A. Comparative study of astigmatism through
2. Qazi ZA. Corneal endothelial tissue that demands respect. superior and lateral small incision. Eur J Ophthalmol 1996; 6:
Pakistan J Ophthalmol 2003; 19: 1-2 389-92
3. Packer N, Fishkind WJ, Fine IH, Seibel BS, Hossman RS. The physics 13. Rainer G, Menapace R, Vass C, corneal shape changes after
of phaco: a review. J Cataract Refract surg 2005; 31: 424-431 temporal and superolateral 3 mm clear corneal incision. J
4. pending Cataract Refract Surg 1999; 25: 1121-26
5. WI DH, Sullivan BR. Phacoemulsificaiton with indocyanin 14. Stan J, Roman MD, Francois X et al. surgically induced
green vs. manual expressions Extra capsular cataract extraction astigmatism with superior and temporal incisions in cases of
for advance cataract J Cataract refract surg 2002; 28: 2165-9 with the rule preoperative astigmatism. J Cataract Refract Surg
6. Chakrabarti A, Singh S. Phacoemulsificaiton in eyes with white 1998; 24: 1636-41
cataract. J Cataract Refract surg 2000; 26: 1041-7 15. Khan A, Ahmad S. phacoemulsificaiton: a few comparisons.
7. Nicula C, Nicula D. post operative induced astigmatism. Pakistan Journal of Ophthalmology 1999; 15: 98-101
Oftalmologia 2000; 50: 40-7 16. Iftikhar S, Kiani SA. Suturless phacoemulsificaiton with
8. Susiv N, Brajkovik J, Kalauz L, Surac. Analysis of post operative implantation of 6 mm PMMA IOLs. Pakistan journal of
corneal astigmatism after phacoemulsificaiton through clear Ophthalmology 2004; 20: 74-76.
corneal incision. Acta Clin Croat 2007; 46: 37-40 17. Azar DT, Stark WJ, Dodick J et al. prospective, randomized
9. Zhonghua Yan, Zazhi. Clinical observation of astigmatism vector analysis of astigmatism after three,one, and no suture
induced by corneal incision after phacoemulsificaiton. J phacoemulsificaiton J Cataract Refract Surg 1997; 8; 1164-73
Geographic ulcer in Epithelial Herpetic Keratitis.

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ORIGINAL ARTICLE
Post-operative Diplopia in
Children with Horizontal Strabismus
Abdul Qayyum
Abdul Qayyum MS, Fellow Paediatric Ophthalmology

1
Shaban Khan FCPS, 2Muhammad Afzal FCPS3
ABSTRACT
Purpose: To study predictability of diplopia in patients with horizontal squints undergoing surgery and frequency of postop-
erative diplopia in horizontal squints.
Setting: Department of Ophthalmology, Bolan Medical College, Quetta. The patients were admitted from pediatric Eye OPD
of Bolan Medical College Quetta. 30 eyes were registered for the study.
Materials and Methods: This prospective, non-comparative, interventional study was conducted in the department of Oph-
thalmology, pediatric Ophthalmology clinic, Bolan Medical College, Quetta from February 2013 to January 2014. A total of
30 children (6 to 13 years age) with horizontal squints were registered for the study. Patients with vertical, paralytic squints,
syndromes like Duane’s and Browns were excluded from the study. All the patients had complete ophthalmic examinations
which include family history, ocular history, corrected visual acuity, slit lamp examination, extra ocular movement, cover/
uncover tests, prism cover tests, and postoperative diplopia test and fundus examination. Surgical procedures comprise of
recession/resection of horizontal muscle. Follow-up examination consists of recording best corrected visual acuity, slit lamp
examination, extra ocular movement checkup, and prism cover test. The follow up was carried out at first week, second
week, one month and second month respectively.
Results: Total 30 children were studied whose mean age was 10 years (range from 6-13 years). Out of 30, 6 patients
(20%) were between 6-8 years, 9 patients (30%) were between 9-11 years and 15 patients (50%) were within 12-13 years.
The sex distribution was 18 (60%) male and 12 (40%) female patients. Out of 30, 24 patients (80%) were concerned about
cosmetic correction of strabismus while 6 patients (20%) were concerned about decrease in vision. 15 patients had con-
genital squints and 15 patients had acquired squints. Out of 30 patients, 18 patients (60%) had 6/6-6/9 visual acuity and 12
patients (40%) had 6/12-6/18 visual acuity in right eye. Out of 30 patients, 15 patients (50%) had 6/6-6/9 visual acuity and
15 patients (50%) had 6/12-6/18 visual acuity in left eye. Out of 30 patients, 18 (60%) had esodeviations and 12 (40%) had
exodeviations. Out of 30, 21 patients (70%) did not see double with postoperative diplopia test (preoperative prism test-
ing) during initial examination. The remaining 9 patients (30%) experienced diplopia with postoperative diplopia test. The
difference in the incidence of postoperative diplopia based on preoperative prism testing was significant (P<0.001). All the
patients were subjected to strabismus surgery (recession/resection). Of 30 patients underwent horizontal muscle surgery
for strabismus, 4 patients (13.33%) experienced well-tolerated temporary diplopia after surgery and none of the patients
experienced persistent diplopia.
Conclusion:
1. The incidence of post-operative diplopia is low in children undergoing horizontal muscle surgery for strabismus.
2. The incidence of permanent (intractable) diplopia is extremely low.
3. The preoperative diplopia test can identify patients who are at the risk of developing post-operative diplopia.
INTRODUCTION of extra ocular muscles, when both eyes are still being
The term diplopia is derived from two Greek used.3
words; diplous, meaning double and ops meaning eye.1 The etiology of diplopia is very extensive. It in-
It is a common subjective complain. Diplopia in com- cludes strabismus, anisometropia, disorders involving
mon language is called as double vision. Diplopia is the nuclei and course of the third, fourth or sixth cranial
simultaneous perception of two images of single object nerves, myasthenia gravis, and trauma like fracture of
that maybe displaced in any dimension. Ultimately, im- floor of orbit. An accurate, clear description of symp-
age of same objects fall on non-corresponding retinal toms (e.g. constant or intermittent, variable or un-
points. Diplopia appears mostly as the first symptom changing, at near or far with one eye or with both eyes)
of many disorders such as neurological and muscular.2 is critical to reach at appropriate diagnosis and man-
It is mostly seen in patients with abnormal function agement accordingly. There are two types of diplopia
Associate Professor & Pediatric Ophthalmologist. 2Assistant
1 i.e. monocular and binocular.
Professor, 3Senior Registrar, Department of Ophthalmology, Bolan Binocular diplopia disappears by covering one eye
Medical College, Quetta
while monocular diplopia remains present in one eye
Correspondence: Dr. Abdul Qayyum, Associate Professor & Pediatric even if either eye is covered. The monocular dipopia
Ophthalmologist, Department of Ophthalmology, Bolan Medical College,
Quetta. E-mail: draqayyum2k3@outook.com
observed in conditions effecting within the eye itself
like refractive errors, poorly fitted contact lenses, iris
Received: Feb 2014 Accepted: March 2014 abnormality e.g. iridotomies, iridectomies and sublax-

ation or dislocation of lens4. In esotropia or exotropia, Inclusion Criteria.

Binocular diplopia occurs because of misalignment of • Patients with horizontal squints in whom surgery
two eyes relative to each other.5 was planned.
Kushner reviewed the medical record of 424 pa- • Patient’s age for the study was from 6 years to 13
tients who underwent squint surgery. Out of 424 pa- years.
tients, the diplopia after surgery was discovered in Exclusion criteria:
only 40 patients (9%). This postoperative diplopia was • Vertical and paralytic squints.
resolved in all cases after six weeks. The persistent di- • Amblyopic patients
plopia was only seen in 3 patients (0.8%).6 Scott cited • Syndromes like Duane’s and Brown’s
39% incidence of diplopia in one of his publications • Thyroid ophthalmopathy
(Am.J.Orthop 1994). He mentioned that only 1.4% pa- • Blow out fracture
tients were left with residual diplopia.7 • Non-cooperative patients-
Diplopia present in children is mostly temporary Ophthalmic examination includes:
in nature because they suppress the diplopic image. The Detailed history including brief history of illness,
visual system of children below 6-8 years is having plas- history of previous surgery, family history, history of
ticity. The underlying factor is plasticity of the visual patching, history of using glasses and any history of
system in children under 6-8 years. Suppression is a phe- trauma. Measurement of best corrected visual acuity,
nomenon, in which there is inhibition of confusing image extra ocular movements, cover/uncover test, prism
from the retina of the deviated eye. Diplopia is extermi- cover test, postoperative diplopia test, anterior segment
nated by the phenomenon of suppression in peripheral and Fundus examination.
retina, so image is inhibited from the deviating eye.8 Surgical procedures:
The post-operative diplopia is mostly observed in • Recession/resection was performed accordingly.
patients with monocular deviation, on antisuppression Post-Operative follow up:
therapy and markedly incomitant strabismus. Tempo- All data including preoperative, operative and
rary diplopia is observed often after squint surgery in post-operative recordings was collected in the per-
cases when there is an under or over correction. The forma designed. Follow-up period was extended to 2
diplopia after surgery is mostly seen while viewing in months with visits at 1st week, 2nd week, 1st month and
end gazing positions which later on result in incomi- 2nd month. On every visit, detailed ocular examination
tant strabismus. was conducted including best corrected visual acuity,
The complain about diplopia in young children is slit lamp examination of anterior segment, extra ocular
not seen very often. It is mostly observed in older chil- movement’s checkup, prism cover test, diplopia test-
dren and adults. The preoperative prism test is usually ing, orthoptic examination.
carried out before strabismus surgery for the prediction Data analysis and statistical tests:
of possible postoperative diplopia. Broniarczyk-Loba A Data was recorded on the designed Performa, fed
observed that 48% of patients had diplopia who had on the computer using SPSS version 10.0 software. The
positive postoperative diplopia test for prediction of di- results were analyzed and tabulated using the same
plopia after strabismus surgery. Thus, these tests seem software.
to be quite limited in its reliability.9 RESULTS
The incidence, severity of diplopia and reliability Total 30 children were studied whose mean age
of postoperative diplopia test are not well-document- was 10 years (range from 6-13 years). Out of 30, 6 pa-
ed. Postoperative diplopia can be treated in following tients (20%) were between 6-8 years, 9 patients (30%)
ways: Patching or occlusion, prescribing contact lens were between 9-11 years and 15 patients (50%) were
with high power minus or plus lens, opaque contact within 12-13 years (table 1. graph 1).
lens or high power minus or plus contact lenses and The sex distribution was 18 (60%) male and 12
reoperation of squint. (40%) female patients (table 2. graph 2.) Out of 30, 24 pa-
PATIENTS AND METHODS tients (80%) were concerned about cosmetic correction
This study was carried out at Department of Oph- of strabismus while 6 patients (20%) were concerned
thalmology (Pediatric Ophthalmology Clinic), Bolan about decrease in vision. Fifteen patients had congeni-
Medical College, Quetta. After permission from insti- tal squints and 15 patients had acquired squints (table
tutional ethical committee, the patients were admitted 3. Graph 3) Out of 30 patients, 18 patients (60%) had
from outpatient department of Pediatric Ophthalmol- 6/6-6/9 visual acuity and 12 patients (40%) had 6/12-
ogy Clinic. The duration of the study was 01 year from 6/18 visual acuity in right eye (table 4. Graph 4) Out of
February 2013 to January 2014. 30 patients, 15 patients (50%) had 6/6-6/9 visual acuity

and 15 patients (50%) had 6/12-6/18 visual acuity in Graph-1: Distribution of patients according to age
left eye (table 5. Graph 5) Out of 30 patients, 18 (60%)
had esodeviations and 12 (40%) had exodeviations (ta-
ble 6. Graph 6)During initial examination, 21 patients
(70%) did not show double vision with postoperative
diplopia test. The remaining 9 patients (30%) did expe-
rience diplopia with postoperative diplopia test (pre-
operative prism testing) (table 7. Graph 7). The differ-
ence in the incidence of postoperative diplopia based
on preoperative prism testing was significant (P<0.001).
All the patients were subjected to strabismus surgery Table-2: Distribution of patients according to gender
(recession/resection). Cumulative
Sex No. of patients percent
Of 30 patients underwent horizontal muscle sur- percent
gery, for strabismus, 4 patients (13.33%) experienced Male 18 60 60
temporary diplopia after surgery and none of the pa- Female 12 40 100
tients experienced persistent diplopia (table 8. Graph 8) TOTAL 30 100
Bruton J Kushner reviewed the medical record of 424
patients who underwent squint surgery. Out of 424 Graph-2: Distribution of patients according to gender
patients, the diplopia after surgery was discovered in
only 40 patients (9%). This postoperative diplopia was
resolved in all cases after six weeks. The persistent di-
plopia was only seen in 3 patients (0.8%). Out of 4 pa-
tients experiencing postoperative diplopia, 2 patients
experienced transient well-tolerated diplopia postop-
eratively, this persisted 2 days after surgery.
One female patient (10 years) with esotropia of 35
PD underwent bilateral medial rectus recession. After
surgery, she complained of diplopia. On examination, Table-3: Distribution of patients according to age at onset
she had a 5 PD residual esotropia. The diplopia per- No. of Cumulative
Age at onset percent
sisted for 2 weeks. On the 3rd visit, the diplopia was ab- patients percent
sent. Out of 4, the 4th patient was male (13 years) with Congenital (birth) 15 50 50
divergence excess exotropia. His distant deviation was Acquired (Later age) 15 50 100
35-40 PD and his near deviation was 15-20 PD. This pa- TOTAL 30 100
tient went under bilateral lateral rectus recession. On 1st
postoperative day, he complained of diplopia, on ex- Graph-3: Distribution of patients according to age at onset
amination with cover test, the eye was turning in. On
2nd visit (2nd week), there was a 12 PD esotropia and it
was increasing on left gaze, the patient complained of
double vision. At the 3rd visit (1 month), the child did
not complain of diplopia. On examination, the esotro-
pia was reduced to within 10 PD which is almost de-
sirable goal in exotropic patients. All of the 4 patients
described their postoperative symptoms in a similar
manner. Specifically, the patients were unable to clearly
and describe the location of second image with respect
to primary image, and they could not determine wheth-
er they had crossed or uncrossed diplopia.
Table-4: Distribution of patients according to
Table-1: Distribution of patients according to age visual acuity in right eye
Visual Cumulative
Age (years) No. of patients percent Cumulative percent No of patients percent
acuity percent
6-8 6 20 20
6/6-6/9 18 60 60
9-11 9 30 50
6/12-6/18 12 40 100
12-13 15 50 100
TOTAL 30 100 TOTAL 30 100

Graph-4: Distribution of patients according to Table-7: Distriburion of patients

visual acuity in right eye according to postoperative diplopia test
Post-operative No. of Cumulative
percent
diplopia test patients percent
Negative 21 70 70
Positive 9 30 100
TOTAL 30 100
Graph-7: Distriburion of patients

according to postoperative diplopia test
Table-5: Distribution of patients according

to visual acuity in the left eye
Visual acuity No. of patients percent Cumulative percent

6/6-6/9 15 50 50
6/12-6/18 15 50 100
TOTAL 30 100
Graph-5: Distribution of patients Table-8: Distribution of patients

experienced diplopia after surgery
according to visual acuity in the left eye
Post-operative No. of Cumulative
percent
diplopia patients percent
present 4 13.33 13.33
not present 26 86.67 100
TOTAL 30 100
Graph-8: Distribution of patients

experienced diplopia after surgery
Table-6: Distribution according to deviation on cover test

No. of Cumulative
Type of deviation percent
patients percent
Esodeviation 18 60 60
Exodeviation 12 40 100
TOTAL 30 100
Graph-6: Distribution according to deviation on cover test
DISCUSSION
Von Graefe had given recognition to diplopia oc-
curring after surgery in one of his publications since
1854.10 In case diplopia remains present after squint
surgery, and especially in those cases in which it was
not expected. This situation is very much disturbing to
the surgeon as well as the patient.
In many instances, diplopia can be a foreseeable
situation after squint surgery e.g.One would expect di-
plopia to be present after surgery when the surgeon is

not able to re-align the eyes. It is seen in patients of ac- seen for a few days after surgery of squint. Mostly it
quired squint, in them the visual system is very much does not remain longer. After surgery, there is a change
mature.11 In cases of adult exotropia, sometimes a situ- in localization with changes in fixation.
ation does arise that patient though did not see diplo- Diplopia may be observed specially after squint
pia before surgery, but due to over-correction of squint, surgery in adult patients which have been over-correct-
patient may experience diplopia.12 The postoperative ed. Younger patients below 10 years of age can suppress
diplopia test was positive in 21patients (70%) and 9 pa- the image whereas older patients have no suppression
tients (30%) did see double with postoperative diplopia at all or if suppression is present preoperatively, it is
test (preoperative prism testing). It indicates that post- not able to cover over correction so scotoma cannot be
operative diplopia test is an important mode of identifi- finished.16 The imperfect alignment of the eyes in those
cation of those patients which may experience diplopia patients which exhibit good vision in each eye may
after squint surgery. The importance of preoperative present with diplopia. The single image is difficult to
diplopia testing is also mentioned in a study carried achieve specially in case of smaller misalignments be-
out by Bruton J Kushner, MD in the department of oph- cause in them, fusion is not possible. In rare cases, in-
thalmology and visual sciences, university of Wiscon- stead of well-alignment after surgery, patient may be
sin, Medison. He is of the opinion that in theory, prisms unable to fuse.17
can be used before squint surgery so the desired opera- The various authors documented the prevalence
tive alignment of the eyes can be stimulated optically. of over-correction of squint surgery in patient with ex-
It may be helpful for those patients which can develop odeviation which varies between (6%, 8%, 10%, 11%,
constant diplopia. Moreover, Bruton J Kushner says 17% and 20%) respectively. There is a need of imme-
that use of prisms before surgery is not also a reliable diate re-operation of squint surgery in those patients
indicator for diplopia occurring after squint surgery. which have a large overcorrection and exhibit major
According to Bruton J Kushner, there are no prop- limitations in ocular movements in the eye which is op-
erly guided parameters or casual risk factors present in erated.18
literature that which patient may suffer with constant It is a desirable goal which is achieved if the devia-
postoperative diplopia.13 Bronairczyk-Loba A, ET all tion after surgery is within the range of 10-15 PD. It will
reviews the record of 22 patients operated for squints. completely disappear with the passage of time. In case
13 subjects presented diplopia only for 1-2 days after if there is larger deviation after surgery it will not disap-
surgery, 8 had intermittent with good tolerance and pear. The re-operation should not be carried out before
1 acquired constant diplopia. Diplopia may occur fol- six months of the previous surgery. It is only indicated
lowing surgery for correction of constant strabismus. when there is increased limitation in the movements of
Young children rarely complain of diplopia because the eye which is operated because it will lead to incomi-
of plasticity of their visual system and development of tance in lateral gaze. Many treatment measures can be
rapid suppression. However, older children and adults considered to reduce the postoperative deviation and
postoperatively may present with diplopia either as a maintains the fusion, so that comfort of the patient can
transient well tolerated phenomena or occasionally ter- be achieved.
rible. Mostly various tests are carried out before surgery No therapeutic intervention is advised for small-
to predict the risk of postoperative diplopia. Diplopia er squints with slight overcorrection for the first two
was found in 48% patients who had positive tests pre- weeks after surgery. After first two weeks, if diplopia
dicting the risk of postoperative diplopia. Thus, these remains present, the following options may be con-
tests seem to be quite limited in its reliability and prior sidered. It includes: miotics and hypermetropic error
to surgery, the patient should be thoroughly informed may be corrected so that these measures may reduce
about possibility of diplopia.14 the deviation and the patient will be able to fuse the
Paradoxical diplopia may be observed after surgi- image. The hypermetropic refractive error associated
cal correction of squint in those patients which exhibit with high AC/A ratio can be prescribed with slightly
ARC in a study carried out by Castleberry C and Ar- overcorrected lenses. The option of alternative occlu-
nord.15 sion may be tried, in case the above therapeutic meas-
In my study, the two patients had transient-well ures fail. It will reduce the angle of deviation as well as
tolerated postoperative diplopia and one esotropic pa- eliminate the diplopia. In managing the esodeviation,
tient had postoperative diplopia which lasted up to 4 which are consecutive require much of patience by the
weeks. The postoperative diplopia in these patients surgeon.19 In my study, 1 exotropic patient had postop-
may be attributed to unharmonious abnormal retinal erative diplopia which lasted up to 4 weeks. The post-
correspondence i.e. paradoxical diplopia. The paradox- operative diplopia may be attributed to misalignment
ical diplopia is a temporary phenomenon which is only or overcorrection. There are many treatment options

are available for those patients which develop constant 2. O’Sullivan, SB & Schmitz T.J 2007. Physical rehabilitation Phil-
adelphia PA: Davis ISBN-13:978.0-8036-1247-1
diplopia after surgery. It includes, prescribing the con-
3. Rucker JC. (2007) occulomotor disorder. Semi Neurol 27(3).244-
tact lenses of high plus power so the one eye is fogged 56.
or an occluder contact lens may be advised. They can 4. Kernich, CA (2006) Diplopia. The Neurologist, 12(4):229-230
be reoperated but the conservative approach may be 5. Philips PH (2007). Treatment of diplopia. The Neurologist
13(5):445-450
more beneficial. It is a good fortune for the patients be- 6. Kushner BJ, Preslan Mw, Vrabe.M.Incidence of diplopia in
cause the constant diplopia is very rare. It usually does adults strabismus.J. Pediatric oph & strabismus 1987, 24; 159-64.
not cripple the older children and adult patients with 7. Scott WE. Kutschke P, Leew. Diplopia in adult strabismus,
squint of longer duration. Ame.orthop.J 1994; 44:66-99.
8. David Taylor and Creig S Hoyt.Strabismus surgery in: David
CONCLUSION Taylor and Creig S Hoyt editor. Pediatric Opthalmology, 3rded.
1. The incidence of post-operative diplopia is low in Oxford. Elsevier Saunders, 2005.962-984.
children undergoing horizontal muscle surgery 9. Broniarczyk-Loba, Nowakowska O, Geotz J.Klin Ocanza, 1996
March, 98(3); 185-9.Diplopia as a complication after surgery in
for strabismus.
Adolescents and adults.
2. The incidence of permanent (intractable) diplopia 10. Von Graefe A. Beitrage zur physiologie und pathologie der
is extremely low. shiefen augenmusken. Albrecht Von Grafes Arch Ophthalmol.
3. The postoperative diplopia test can identify 1854;1:1-81.
11. Schlossman A, Muchnick RS, Stern KS. The surgical manage-
patients who are at the risk of developing post- ment of intermittent exotropia in adults. Ophthalmology 1983;
operative diplopia. 90:1166-1171.
RECOMMENDATIONS 12. Keech RV, Stewart SA. The surgical overcorrection of inermittent
1. Postoperative diplopia test should be carried out in exoropia. J Pediatric Ophthalmol Strabismus. 1990;27:218-220.
13. Burton J. Kushner, intractable Diplopia after Strabismus
every patient especially in adults undergoing stra- Surgery in Adults Arch Ophthalmol.2002; 120:1498-1504.
bismus surgery for the prediction of postoperative (online),cited 19th Sep2008 http://archopht.amaassn.org/cgi/
diplopia. content/full/120/11/1498.
14. Broniarczyk-Loba A, Nowakowska O, Goetz J Katedry I Klini-
2. Patients should be investigated for ARC because
ki Chorob Oczu AM w Lodzi Diplopia as a complicaaion after
deeply entrenched ARC can lead the patient into surgery for strabismus in adolescents and adults. Klin Oczna.
diplopic condition after surgery. 1996 Mar; 98(3):18-9.Available at URL:http://www.ncbi.nlm.
3. The patients with intermittent exotropia under- nih.gov/pubmed/9019585.
15. Castleberry C, And Arnoldi K, Predicting Postoperative Para-
going strabismus surgery may result in consecu- doxical Diplopia.
tive esotropia. If it is within 10 PD, in most cases, 16. Simon JW intractable diplopia after over correction of strabis-
it usually resolves within 1-2 weeks, wait for 6 mus. Am J Ophthalmol.1994;117: 675-676.
17. Rustein RP, Bessant B. Horror fusionis: a report of 5 patients.
months and during this period, treat the patients
J Am Optom
with hypermetropic glasses or prisms. Additional 18. Dunlap EA: Overcorrections in horizontal strabismus surgery.
surgery may be required if diplopia does not re- In symposium on strabismus. Transactions of the New Orlean’s
solve with the above treatments. Academy of Ophthalmology. St Louis Mosby, 1921, p 255.
REFERENCES 19. Meyer E, Noorden GK von: Management of consecutive eso-
1. Diplopia. Dorland’s, illustrated medical dictionary. 28th ed. tropia. In Moore S, eds, Orthoptics: research and practices, Lon-
Philadelphia : W.B.Sauders, 1994:475. don, H Kimpton, 1981, p 236.

EXCERPTS FROM ORIGINAL ARTICLE
Team Management, Twinning & Telemedicine in
Retinoblastoma: A 3-Tier Approach Implemented in
the first Eye Salvage Program in Jordan
Ibrahim Qaddoumi
Ibrahim Qaddoumi, MD, MS1, Ibrahim Nawaiseh, MD2, Mustafa Mehyar, MD2
Bassem Razzouk, MD3, Barrett G. Haik, MD, FACS5,7, Saamir Kharma, MD2, Imad Jaradat, MD6
Carlos Rodriguez-Galindo, MD3, and Matthew W. Wilson, MD, FACS7
Background: This study evaluated the outcome of retinoblastoma patients, when employing a telemedicine-based twinning
program in Jordan.
Procedure: This cohort study included patients at the King Hussein Cancer Centre (KHCC; Amman, Jordan) who received
consultations for retinoblastoma. A collaborative program was established with the International Outreach Program at St.
Jude Children’s Research Hospital in Memphis, Tennessee. Cases were discussed using an internet consultation service
where fundus images, clinical history, and proposed treatment were reviewed. Selected cases were further discussed via
videoconferencing and electronic mail.
Results: Thirty-three children with retinoblastoma (20 bilateral) were treated at KHCC.
The median age at diagnosis was 7 months for patients with bilateral retinoblastoma and 35 months for patients with unilat-
eral retinoblastoma. Of the 20 patients with bilateral disease, 12 were newly diagnosed and 8 had received prior treatment.
Our success in the bilateral cases was most evident in the previously untreated group, in which only six eyes (25%) were
enucleated and four eyes (17%) were irradiated. Of the 13 patients with unilateral retinoblastoma, 12 underwent enuclea-
tion, and 6 required radiation. Neither group experienced mortality.
Conclusions: Twinning has positively impacted survival and ocular salvage in Jordan. By partnering a team of professionals
with mentors willing to provide close supervision, the highly specialized management of retinoblastoma can be successfully
implemented in a developing country.
Key words: cancer; developing countries; retinoblastoma; telemedicine; twinning
INTRODUCTION even in patients with bilateral retinoblastoma a situ-

Retinoblastoma is the most common primary in- ation we encountered in Jordan. At the King Hussein
traocular malignancy in children. The management Cancer Centre (KHCC), we have partnered with St. Jude
must be directed first at saving lives, then at eyes and Children’s Research Hospital (SJCRH) and the Hamil-
vision. For each goal, different treatment modalities ton Eye Institute at the University of Tennessee Health
are implemented, adding to the complexity of manage- Science Center (Memphis, TN), to create a regional
ment. Survival rates exceed 95%in developed countries. center of excellence. Using twinning and telemedicine,
Unfortunately, the outcome in developing countries is we developed a multidisciplinary service inclusive of
much worse, with mortality rates significantly higher. skilled pediatric oncology, ophthalmology, and radia-
Moreover, enucleation and radiation therapy remain tion oncology, the results of which we present here.
the only available treatments in developing countries, METHODS
1
Department of Pediatric Oncology, King Hussein Cancer Centre Development of the Retinoblastoma Program:
(KHCC), Amman, Jordan, 2Department of Surgery, Division of In March 2003, a retinoblastoma service was cre-
Ophthalmology, King Hussein Cancer Centre (KHCC), Amman,
Jordan, 3Department of Oncology, St. Jude Children’s Research ated with the active coordination of a pediatric oncolo-
Hospital, Memphis, Tennessee, 4Department of Pathology, St. Jude gist, vitreoretinal surgeon, pediatric ophthalmic plastic
Children’s Research Hospital, Memphis, Tennessee, 5Department and reconstructive surgeon, ophthalmologist, radiation
of Ophthalmology, Hamilton Eye Institute, University of Tennessee
Health Science Center, Memphis, Tennessee, 6Department of oncologist and medical physicist was appointed to de-
Radiation Oncology, King Hussein Cancer Centre (KHCC), Amman, velop a plaque brachytherapy program - retinoblastoma
Jordan, 7Department of Surgery, Division of Ophthalmology, St. Jude
Children’s Research Hospital, Memphis, Tennessee service at KHCC. (King Hussain Cancer Centre) The
ocular oncology service at SJCRH (St. John Children’s
Correspondence to: Ibrahim Qaddoumi, St. Jude’s Research Hospital,
332 N. Lauderdale St., Memphis, TN 38105.
Research Hospital) was chosen as the mentor due to the
E-mail: ibrahim.qaddoumi@stjude.org hospital’s pre-existing relationship with KHCC. Men-
toring included internet consultations, videoconfer-
Acknowledgement: The management of Ophthalmology Update
feels highly gratified to Dr. Ibrahim Qaddoumi, principal author of ences, and exchange visits. The program later evolved
the article from the Department of Pediatric Oncology, King Hussein to systematically use the ORBIS e-consultation program
Cancer Centre (KHCC), Amman, Jordan for permitting us to take ex-
cerpts from his article published in Pediatric Blood Cancer Journal (www.orbis.org). 80 ORBIS consultations were made
Ref: 2008;51:241–244, in order to give wider readership to ophthal- on 40 patients. Thirteen consults on 11 patients, 10 non-
mologists especially in the developing countries. retinoblastoma and 1 bilateral retinoblastoma, were ex-

Team Management, Twinning & Telemedicine in Retinoblastoma: A 3-Tier Approach Implemented in the first Eye Salvage Program in Jorda
cluded from the study. Thus, a total of 66 consultations (median¼-7 cycles (range 0–10) per patient). TTT and
on 29 patients were reviewed; 18 of the 20 bilateral cases cryotherapy were applied as needed to consolidate
(90%) and 11 of the 13 unilateral cases (85%) were in- the responses. There were 53 sessions of TTT, with a
cluded. The team policy was to consult on every new median of 1.5 per eye (range, 0–10), and 23 sessions of
case and for every major therapeutic decision. cryotherapy, with a median of 0.5 per eye (range, 0–4).
At inception of the KHCC retinoblastoma pro- There were also six sessions of argon laser photocoagu-
gram, the only available treatment modalities were sys- lation in four patients and four sessions of sub-conjunc-
temic chemotherapy, external-beam radiation therapy tival carboplatin in three patients. EBRT was required
(EBRT), and enucleation. Children were classified as in nine eyes. Median follow-up was 16.5 months (range,
Reese-Ellsworth (RE) Groups I–III received carboplatin 1–42 months).
and vincristine. A total of 6–8 cycles were given. Etopo-
side was added for patients with RE Group IV- V eyes. Table-I: Characteristics of Retinoblastoma cases at
the King Hussein Cancer Centre
For patients undergoing enucleation and with
high-risk histological features (i.e., massive deep choroi-
dal invasion, involvement of the ciliary body, iris, and/ Bilateral Unilateral
Characteristic Total (N ¼ 33)
(n ¼ 20) (n ¼ 13)
or anterior chamber, extra-scleral extension, and optic
Sex
nerve invasion beyond the lamina cribosa), adjuvant
Male 13 7 20
chemotherapy was given using alternating cycles of
Female 7 6 13
carboplatin/etoposide/vincristine with doxorubicin/
cyclophosphamide/vincristine. For EBRT, a linear ac- Nationality
celerator was used. Typically, doses of 44–45 Gy, using Jordanian 13 7 20

photon energy of <-6 million volts, were given. Patients Non-Jordanian 7b 6c 13
with bilateral disease requiring focal therapies were ini- Age, median (range), month 7 (0.5–30) 35 (2–76) ...
tially referred to other hospitals, where ophthalmolo- Family history, n (%) 2 (10) 0 ...
gist would perform the necessary cryotherapy and la- Compliance, n (%) 18 (90) 12/13 (92) 30/33 (91)
ser photocoagulation. A diode laser (Oculight SLX) and Chromosome 13
2 (10) 0 ...
large spot size indirect ophthalmoscope adapter were deletion, n (%)
used to allow for trans-pupillary thermotherapy (TTT). RE group, number of eyes
Furthermore, subconjunctival chemotherapy using car- I–III 12
2 (both
14
Group III)
boplatin (20 mg/2 mL) was instituted for the treatment
11 (all
of refractory vitreous seeds. Currently, we are in the pro- IV–V 12
Group V)
23
cess of implementing a plaque brachytherapy program.
Evaluation of the Retinoblastoma Program: TABLE II: Recommended changes made early in the
KHCC Implementation of the Eye Salvage Program (series 1)
A review of the retinoblastoma service was per-
compared with recommended changes made later in the
formed to evaluate the clinical characteristics and treat- implementation (Series 2)
ment received, assignment of health care professionals
to the retinoblastoma service, number of internet and Variable Series 1 Series 2
video-conference consults, and impact of such consults No. of consultations 33 33
on patient care. Secondary comparisons between pri- No. (%) of consultations in which 18 (55%) 7 (21%)
marily and secondarily treated patients were made.
changes were recommended
Outcomes measured were (1) the development of a
No. of changes recommended
multidisciplinary team; (2) equipment acquisition; (3)
the impact of exchange visits, internet consults, and Total 23 8
videoconferences on patient management; and (4) pa- Diagnostic changes 6 0
tient and ocular survival. Need for enucleation 7 2
RESULTS
Need for radiation 3 3
Our analysis included 33 patients (20 bilateral)
treated over 42 months, 29 (88%) of whom were dis- Need for focal therapy 4 0
cussed using the ORBIS e-consulting service. Out of 20 Need for chemotherapy 2 0
patients with bilateral retinoblastoma, demographic Need for cryotherapy 0 1
characteristics of the 20 patients with bilateral retino- Administration of subconjunctival 1 0
blastoma, eight patients (16 eyes) had been treated (7
chemotherapy
eyes enucleated) prior to referral to KHCC. The 20
patients received a total of 129 chemotherapy cycles Diagnostic discrepancy 0 2

Seven of these eight previously treated patients mentation was due to family refusal in two and KHCC
were referred after the enucleation of one eye. One was team decision in one. As shown in Table II, the number
referred after a failed regimen of prolonged chemo- of recommended changes over time decreased as the
therapy and cryotherapy, and both eyes were enucle- team at KHCC gained expertise.
ated at the time of consultation. Of the remaining seven DISCUSSION
eyes, only one was saved using focal therapies and Our experience at KHCC shows how a multidisci-
chemotherapy alone. Five eyes required EBRT. One plinary approach coupled with twinning and telemedi-
patient eventually had his second eye enucleated after cine can positively impact the outcome of children with
attempts to control his intraocular disease failed; thus, retinoblastoma in developing countries. Although our
for patients previously treated at other institutions, 10 numbers are small and the median follow up short, we
of 16 eyes ultimately were enucleated. have reduced mortality rate, enucleation, and radiation
Of the 12 patients diagnosed at KHCC, none un- therapy2,6–10. The prospective use of both twinning and
derwent bilateral enucleation. There were 5 eyes RE telemedicine provided quality assurance and served
Group I, 2 eyes Group II, 5 eyes Group III, 2 eyes Group to correct any deviations before harm was done to pa-
IV, and 10 eyes Group V. Four of the 10 RE Group IV–V tients. A mentor from SJCRH reviewed all clinical data
eyes (40%) were treated with EBRT. Only 6 of the 24 and proposed treatment plans. Initial consults were
treated eyes treated initially at KHCC, all RE Group corrected 55% of the time, but later decreased to 21% as
IV–V, were enucleated. There were no deaths and the the retinoblastoma team at KHCC evolved.
compliance rate was 90%. Only two non-Jordanian pa- The impact of telemedicine becomes even more
tients were lost to follow-up, both, we suspect, owing apparent when considering that only four exchange
to refusal of enucleation. visits totaling 10 weeks occurred between both teams.
Patients with unilateral retinoblastoma. The prior proper training of the members of the KHCC
Demographic characteristics of the 13 patients team in their specialties greatly facilitated the learning
with unilateral retinoblastoma are shown in Table I. All process. Such skilled individuals are not rare in many
but two were referred to KHCC before any treatment developing countries. What is lacking is a structure that
was given. A total of 12 eyes were eventually enucle- allows them to work as part of a multidisciplinary team,
ated (92%). Of the 11 cases referred prior to enucleation each lending their own expertise. Our approach of
or any treatment, only 4 eyes were enucleated primar- identifying such appropriately skilled physicians and
ily by the KHCC team. In seven cases (three females, involving them in a multidisciplinary team is a model
four males), rather than have the parents abandon that can be followed by other developing countries. The
treatment, we initiated conservative treatment with use of pre-existing clinical abilities not only serves as
chemotherapy, all the while persuading the parents a means of ‘‘jump starting’’ a retinoblastoma program,
of the need for enucleation. The 13 unilateral patients but also is highly cost-effective as the physicians do not
received 42 chemotherapy cycles (median, 2 cycles; need to be sent abroad for extended periods of fellow-
range, 0–8 cycles). Six patients received EBRT (46%), ship training. Their pre-existing clinical skills can be
5 for high-risk histological features following enuclea- adapted to the care of retinoblastoma patients. Howev-
tion. The lone eye (RE Group III) saved was treated er, we do not believe our approach should replace tra-
with chemotherapy and focal therapy. Median follow- ditional fellowship programs; we consider it as a cor-
up was 10 months (range, 2–54 months). Parental com- nerstone upon which developing countries can build.
pliance rate was 92%, with only one (non-Jordanian) Analysis of our results clearly shows that early re-
patient lost to follow-up. ferral of retinoblastoma patients significantly affected
Impact of Electronic Consultation on Patient their outcome. Patients with bilateral retinoblastoma
Management diagnosed and treated at KHCC had results superior
We evaluated the impact of electronic consulta- to those who had failed treatment elsewhere. Of the 24
tion by reviewing the 66 consults performed using the eyes in 12 patients with bilateral retinoblastoma treated
e-consultation service at www.orbis.org. As a direct solely at KHCC, 75% were saved. Only 17% of eyes re-
result of the electronic consultations and videoconfer- quired EBRT, all of which were RE Group IV–Veyes. Of
ences, 31 major recommendations from 25 consults the eight patients with bilateral retinoblastoma referred
were made. A major recommendation was defined as after treatment elsewhere, two lost both eyes, and 71%
additional treatment, omitting treatment, or diagnostic of the treated eyes required EBRT. Although the worse
discrepancy. In 22 consults (88%), these recommenda- outcomes seen in the previously treated patients may
tions were carried out by the treating team in Jordan. reflect a referral bias of patients with more aggressive
In the three cases when the recommendations (all in- disease, we believe the outcomes further underscore
cluded enucleation) were not implemented, non-imple- the need to have a designated center for treating retino-

blastoma patients. cine- based twinning, as shown by our experience, can

Even with a comprehensive service of physician improve the care of patients with retinoblastoma in de-
and support staff, we still face many obstacles in the veloping countries.
treatment of retinoblastoma. In Jordan, enucleation REFERENCES
1. Shields CL, Shields JA. Recent developments in the manage-
still carries a negative stigma, particularly for wom- ment of retinoblastoma. J Pediatr Ophthalmol Strabismus
en, and the risk of treatment abandonment is very 1993;36:8– 18.
high when enucleation is proposed. In select cases we 2. Gombos DS. Current management of retinoblastoma. Retina
started chemotherapy while educating parents about 2004;24:825–827.
3. Leal-Leal C, Rivera-Luna R, Tovar-Guzman V, et al. Risk of dy-
the disease and the successful outcomes that could be ing of retinoblastoma in Mexican children. Med Pediatr Oncol
achieved with enucleation. By first gaining their trust, 2002;28:211–213.
we were eventually able to proceed with removal of the 4. Gu¨nlap I`, Gu¨ndu¨z K, Arslan Y. Retinoblastoma in Turkey—
diseased eye in most cases. Treatment and prognosis. Jpn J Ophthalmol 1996;40:95–102.
5. Chantada GL, Fandin˜o AC, Raslawski EC, et al. Experience
The sophisticated management of retinoblastoma with chemoreduction and focal therapy for intraocular ret-
can be financially prohibitive due to high cost of equip- inoblastoma in a developing country. Pediatr Blood Cancer
ment like laser, cryotherapy unit and fundus camera, 2005;44:455–460.
yet valuable support through donations wad the only 6. Shields CL, Honavar SG, Meadows AT, et al. Chemoreduction
plus focal therapy for retinoblastoma: factors predictive of need
alternative to accomplish such management. for treatment with external beam radiotherapy or enucleation.
CONCLUSIONS Am J Ophthalmol 2002;133:657–664.
Twinning has positively impacted survival and 7. Shields CL, Mashayekhi A, Demerci H, et al. Practical ap-
ocular salvage in Jordan. By partnering a team of proach to management of retinoblastoma. Arch Ophthalmol
2004;122:729– 735.
professionals with mentors willing to provide close 8. Friedman DL, Himelstein B, Shields CL, et al. Chemo-reduction
supervision, the highly specialized management of and local ophthalmic therapy for intraocular retinoblastoma. J
retinoblastoma can be successfully implemented in a Clin Oncol 2000;18:12–17.
developing country. 9. Rodriguez-Galindo C, Wilson MW, Haik BG, et al. Treatment
of intraocular retinoblastoma with vincristine and carboplatin.
Vast amounts of money argue further for the need J Clin Oncol 2003;21:2019–2025.
of consolidation of resources to provide comprehensive 10. Wilson MW, Haik BG, Liu T, et al. Effect on ocular survival of
care in a single setting. The majority of cases of retino- adding early intensive focal treatments to a two-drug chemo-
blastoma occur in developing countries. Telemedi- therapy regimen in patients with retinoblastoma. Am J Oph-
thalmol 2005; 140:397–406.

ORIGINAL ARTICLE
Primary Pterygium Excision:

A Better Technique to avoid Recurrences
Waseem Ahmed
Dr. Waseem Ahmed Khan FCPS, FRCS1, Inam ul Haq Khan, FCPS2
Madiha Durrani FRCS3
ABSTRACT
Objective To compare the results of primary pterygium excision by bare sclera technique and conjunctival autograft.
Study Design: It was a prospective interventional case series.
Materials and Methods: This study was conducted at the Department of Ophthalmology, Divisional Headquarters Teaching
Hospital affiliated with Mohi-ud-Din Islamic Medical College, Mirpur, Pakistan over a period of 6 months i.e from April 2013
to September 2013. A total of 50 patients were included in this study after a comprehensive history and a detailed ocular
examination. Patients were anesthetized by topical proparacaine 0.5% followed by local infiltration with Lignocaine 2%. 25
patients were treated by bare sclera technique while the other half was treated with conjunctival autograft . Patients were
checked for results and complications in follow up visits done after 1 day, 1 week, 1 month and 6 months respectively. All the
information was recorded on a predesigned proforma. The data was analyzed by SPSS version 17.
Results: Out of 50 patients, 36 (72%) were male while 14 (28%) were female. The patients were divided into various age
groups. The age group 1 included patients between 21-30 years, age group 2 included 31-40 years, age group 3 spanned
over 41-50 years whereas age group 5 included patients over 50 years of age. Age group 1 included 4 (8%) patients, age
group 2 had 12 (24%), age group 3 had 16 (32%) while age group 4 had 19 (38%) patients. The mean age was 45.92 Years
while the median age was 46 years. The total recurrence rate was 26%.The recurrence rate in Bare Sclera technique was
36% whereas it was 16% in case of conjunctival autograft.
Conclusion: In primary pterygium excision, conjunctival autograft. Technique is superior and has less recurrence rate as
compared to bare sclera technique.
Key words: Pterygium, Bare Sclera Technique, Conjunctival Autograft, Recurrence, Pakistan.
INTRODUCTION poral region as well.2 A stromal overgrowth of fibro-

Pterygium is a wing-shaped fibrovascular growth blast and blood vessels is accompanied by an inflam-
of conjunctival connective tissue encroaching over the matory cell infiltrate and abnormal extracellular matrix
cornea resulting in cosmetic problems, decrease in vis- accumulation.3 Past research has focused on ultravio-
ual acuity secondary to astigmatism and blockage of let rays whether it could lead to any changes in limbal
the optical axis. It can cause flattening of the cornea to stem cell.4 Although several hypothesis have been asso-
the leading apex.1 It is a triangular shaped lesion with a ciated with etiology, its pathology still remains to be ex-
head, body and tail. It is located at the inter- palpebral plained.5 Certain occupational groups seem to be more
region, along the horizontal axis of cornea, usually in susceptible like drivers, welders, and carpenters, peo-
nasal quadrant but occasionally it can present in tem- ple living in rural areas, the countries with relatively
1
Assistant Professor, Department of Ophthalmology. Mohi-ud-din high exposure to ultraviolet radiation and the hot and
Islamic Medical College, Mirpur, Divisional Teaching Hospital, Mirpur, dusty climates.4,5 The body of the pterygium remains
AJK. 2Lt. Col. Classified Eye Specialist, CMH Nowshera (KPK) on the sclera but the head advances onto the cornea in
3
Ophthalmologist, Dubai UAE
many cases affecting vision, causing general discom-
Correspondence: Dr. Waseem Ahmed Khan, FCPS, FRCS. Assistant fort, and becoming a cosmetic nuisance.6
Professor, Department of Ophthalmology. Mohi-ud-din Islamic Prevalence rates range from 0.7% to 31% in various
Medical College, Mirpur, Divisional Teaching Hospital, Mirpur, AJK. populations around the world.7 In general, conserva-
House: D-2, Sector A-5, Officers’ Colony, Mirpur (AK)
Waseemabbasi2001@yahoo.com Cell: 0300-9563324. tive therapy for pterygium is advised unless one of the
following circumstances arises: loss of visual acuity ei-
Note: Dr. Waseem has undertaken this study, originally at Al-Nahdha ther because of induced astigmatism or encroachment
University Hospital, Muscat, Oman and later on Lt. Col. Inam ul Haq
onto the visual axis, marked cosmetic deformity lead-
Khan (working at CMH Muzaffarabad (AJK) and Dr. Madiha Durrani
(temporarily at Muzaffarabad) have joined the study in AJK. The ing to personal disliking, marked discomfort and irrita-
subject has been researched by many authors in the past. The tion unrelieved by medical management, limitation of
management as a matter of its policy has always encouraged the ocular motility secondary to restriction, or documented
young ophthalmologists to undertake the already researched articles
progressive growth toward the visual axis so that ulti-
but from different angles, so that they get experience to undertake
more serious studies in the future. mate loss of vision can reasonably be assumed. In such
circumstances, surgical intervention is required. As re-
Received: Feb’ 2014 Accepted: March’ 2014 currences after pterygia excision are frequent and ag-

gressive, firm indications for surgical removal should Exclusion criteria.

be present before primary excision. The fact that nu- 1. Uncontrolled Glaucoma
merous different techniques exist for the surgical treat- 2. Uncontrolled Diabetes Mellitus
ment of pterygium leads to the impression that no sin- 3. Collagen Vascular diseases
gle approach is universally 100% successful.8 4. Dry eye syndrome
Numerous surgical approaches have been at- 5. Immunocompromised patients /using immuno-
tempted.9 The various surgical techniques such as bare suppressive drugs
sclera, conjunctival autografting, primary conjuncti- Patients were anesthetized by topical proparacaine
val closure, intraoperative Mitomycin C application, 0.5% followed by local infiltration with Lignocaine 2%.
and amniotic membrane transplantation have been 25 patients were treated by bare sclera technique while
applied.10,11 After excision, the resulting defect can be the other half was treated with conjunctival autograft.
left exposed (bare sclera excision),12 or covered by sur- Patients were checked for results and complications in
rounding conjunctiva (primary closure)13 or a pedicle follow up visits done after 1 day, 1 week, 1 month and 6
flap14 or by transposition of the pterygium head.15 The months respectively. All the information was recorded
defect can also be covered by a conjunctival autograft on a predesigned proforma. The data was analyzed by
without the limbus,16 or with the limbus,17 or using other SPSS version 17.
tissue sources such as buccal mucous membrane grafts, In group A, Sclera was left bare after pterygium
lamellar keratoplasty,18 penetrating keratoplasty19 or excision while in group B, conjunctival autografting
sclerokeratoplasty.20 The other techniques include Yt- was done in which the pterygium was extracted as com-
trium–Aluminium–Garnet (YAG) laser treatment 21 and plete resection, and the dimensions of bare sclera was
a polishing technique as advocated by Barraquer.22 measured. Superior temporal conjunctiva of the same
Koranyi et al23 published a cut‐and‐paste tech- eye, approximately 1 mm greater than bare sclera size,
nique in primary pterygium using fibrin glue, which was measured and marked. The area under the marked
showed markedly less postoperative pain and short- space was inflated with lidocaine. The aim of this proce-
ened surgery time. The recurrence rate was only 5.3%. dure was to obtain the thinnest possible conjunctiva. Af-
Without covering the defect, adjunctive treatment such terwards, it was dissected as thinly as possible from the
as β‐radiation,24 Mitomycin C,25 5‐fluorouracil,26 Cy- underlying adhesions. During the incising process we
closporin A27 or Daunorubicin28 is used to reduce the paid close attention to leaving the marked area within
recurrence rate. These adjunctive treatments are as- the autograft. In due course the autograft was freed by
sociated with complications, including poor epithelial cutting the limbal edge of the conjunctiva. The autograft
healing, superficial punctate keratitis, late‐onset scleral was flattened in place, and transferred to the receiver
ulceration, microbial infection, glaucoma and endoph- area by handling from the two limbal edges. The limbal
thalmitis. Owing to these potential complications, con- side of the autograft was placed on the limbal area in
junctival autografting has been widely adopted in the the receiver area. As the autograft regularly flattened, it
management of pterygium. This method has reduced was sutured to the adjacent conjunctiva with interrupt-
the recurrence rate29 Post operatively topical antibiotics ed vicryl 7/0 (absorbable) sutures and fixed to sclera at
and steroids are recommended for better results.30 the limbus level. The autograft was also sutured around
MATERIALS AND METHODS the adjacent conjunctiva, and the eye closed after appli-
This prospective case study was conducted cation of antibiotic ointment application.
at the Department of Ophthalmology, Divisional RESULTS
Headquarters Teaching Hospital affiliated with Mohi- Out of 50 patients, 36 (72%) were male while 14
ud-Din Islamic Medical College, Mirpur, Pakistan over (28%) were female. The patients were divided into vari-
a period of 6 months i.e from April 2013 to September ous age groups. The age group 1 included patients be-
2013. A total of 50 patients were included in this study tween 21-30 years, age group 2 included 31-40 years, age
after a comprehensive history and a detailed ocular group 3 spanned over 41-50 years whereas age group 5
examination. The patients were enrolled regardless of included patients over 50 years of age. Age group 1 in-
age and sex. The inclusion and exclusion criteria were cluded 6% (n=03) patients, age group 2 had 24% (n=12),
as follows, age group 3 had 32% (n=16) while age group 4 had 38%
Inclusion creteria. (n=19) patients. The mean age was 45.92 Years while
1. Primary pterigium encroaching 2mm or more over the median age was 46 years.
cornea Half of the patients (n=25) were operated by Bare
2. Pterigium leading to decreased visual acuity sclera Technique while other 25 patients were operated
3. Pterigium causing mechanical discomfort, conges- by conjunctival autograft technique. The total rate of
tion and gritty sensation recurrence was 26% including both methods. The re-

currence rate in Bare Sclera technique was 36% (n=09 Fig-3: Rate of recurrence
out of 25) whereas it was 16% (n=04 out of 25) in case of
conjunctival autograft.
Table-1: Gender distribution
Gender Frequency Percent Valid Percent

male 36 72.0 72.0
female 14 28.0 28.0
Total 50 100.0 100.0
Table-2: Age distribution
Valid Cumulative
Frequency Percent
Percent Percent DISCUSSION
21-30 3 6.0 6.0 6.0 In this study, a total of 50 patients were evaluated.
31-40 12 24.0 24.0 30.0 The gender distribution demonstrated a male prepon-
Valid
41-50 16 32.0 32.0 62.0 derance i.e, 72% as compared to females which was
>50 19 38.0 38.0 100.0
28%. This male predominance is comparable to past re-
search.9 Mashhoor et al also demonstrated a male pre-
Total 50 100.0 100.0
dominance.31
We divided the patients into various age groups
Table-3: Recurrence rate
for the ease of analysis. The age group 1 included pa-
Valid Cumulative tients between 21-30 years, age group 2 included 31-40
Frequency Percent
Percent Percent
years, age group 3 spanned over 41-50 years whereas
Nil 37 74.0 74.0 74.0
Valid age group 5 included patients over 50 years of age.
yes 13 26.0 26.0 100.0 Age group 1 included 6% (n=03) patients, age group 2
Total 50 100.0 100.0 had 24% (n=12), age group 3 had 32% (n=16) while age
group 4 had 38% (n=19) patients. The mean age was
Figure-1: Pie Chart demonstrating gender distribution 45.92 Years while the median age was 46 years. Aslan et
al demonstrated a mean age of 45.25 years which is sim-
ilar to our study 32 and Luanratanakorn et al showed a
mean age of 44.75 years which is also comparable to our
study,9 However the p-value for age was non-signifi-
cant for recurrence (0.338). Aslan et al also showed that
there was not any statistically significant difference in
age and gender distributions of groups.32
Half of the patients (n=25) were operated by Bare
sclera Technique while other 25 patients were operated
by conjunctival autograft technique. The total rate of
recurrence was 26% including both methods. In an-
other study done on 77 patients by Alpay et al, recur-
Figure-2: Age distribution
rence was observed in 22 cases, with an overall rate of
28% which is comparable to our study.7 The recurrence
rate in Bare Sclera technique was 36% (n=09), while
another study showed 38.09% recurrence in the bare
sclera group which is comparable to our study while
it was 3.8% in conjunctival autograft7 in another study
that is lower. Recurrence rate was 16% (n=4) in case
of conjunctival autograft. In another study, the con-
junctival autograft recurrence rate was lower 12.3%,
as compared to our study.9 The local statistics reveal a
low recurrence (10%) with conjunctival autograft and
(60%) in Bare Sclera technique,33 whereas Haroon et al
depicted that recurrences occurred in 9.52%34 Rafiq at

al displayed that recurrence was noted in 70% in Bare paring mitomycin C and conjunctival autograft after excision
Sclera technique, while in conjunctival autograft, recur- of primary pterygium. Am J Ophthalmol 1995. 120151–60.
17. Rao S K, Lekha T, Mukesh B N. et al Conjunctival autograft for
rence was observed in 08%30 So, finally summarizing primary and recurrent pterygia: technique and results. Indian J
up, though there is a great variation pterygium surgi- Ophthalmol 1998. 46203– 9
cal pattern, excision with conjunctival autograft trans- 18. Busin M, Halliday B L, Arffa R C. et al Precarved lyophilized
plantation is the major preferential practice. Recurrent tissue for lamellar keratoplasty in recurrent pterygium. Am J
Ophthalmol 1986. 102222–7.
pterygium is the most common complication.35 19. Adamis A P, Starck T, Kenyon K R. The management of pteryg-
CONCLUSION ium. Ophthalmol Clin North Am 1990. 3611–23.
It is concluded that there is low recurrence, insignifi- 20. Suveges I. Sclerokeratoplasty in recurrent pterygium. Ger J
cant complications, rapid surface healing and restoration Ophthalmol 1992. 1114– 6
21. Nakamura K, Bissen-Miyajima H, Shimmura S, Tsubota
of cosmetically acceptable appearance following conjunc- K. Clinical application of Er:YAG laser for the treatment of
tival autograft as compared to bare sclera technique pterygium. Ophthalmic Surg Lasers. 2000 ;31(1):8-12.
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GENERAL SECTION
ORIGINAL ARTICLE
Current Pattern of Mechanical
Intestinal Obstruction in Adults
(A Hospital Based Study)
Yousaf Jan
Yousaf Jan FCPS (General Surgery)1, Waqas MBBS 2, Aurangzeb Khan MBBS3
Rumman Khan MBBS4, Ahmad Din MBBS5
ABSTRACT
Background: Intestinal obstruction occurs when the normal flow of intestinal contents is interrupted. Classically there are
four cardinal features, i.e. abdominal pain, vomiting, distension and constipation.
Objective: To determine the various aetiological factors of mechanical bowel obstruction in adults in local setting.
Materials and Methods: This descriptive study was conducted from March 2009 to September 2010 in Hayatabad Medical
Complex Peshawar. All patients presenting with intestinal obstruction and above the age of 12 years were included in the
study. Ethical approval to conduct the study was obtained from relevant authorities.
Results: One hundred and twenty two patients presented with intestinal obstruction and underwent surgical exploration
during the study period. Seventy seven (63.1%) were males and forty five (36.8%) were females with male to female ratio of
1.71:1. The ages of the patients ranged from 13-80 years with mean age of (37.4±19.7). (Table 1) showed the age and sex
distribution. Out of one hundred and twenty two cases, 108 (88.5%) were admitted through Accident and Emergency De-
partment and 14 patients (11.4%) through surgical OPD. Pain was the most common (100%) symptom of presentation fol-
lowed by abdominal distension (92.2%), vomiting (84.4%), absolute constipation (83.6%) and relative constipation (16.3%)
as shown in (Table 2). Forty two patients (34.4%) had abdominal tuberculosis and was the most common cause of intestinal
obstruction in our study. Bands and adhesions were found in 34 patients (27.8%) and was the second most common cause
of obstruction after tuberculosis in our study. In 18 patients (14.7%) bowel malignancy was the cause of intestinal obstruc-
tion (Table 3). In 16 patients (13.1%) the cause of obstruction were hernias. Of them, 9 (56.2%) had obstructed/strangulated
inguinal hernias, 6 (37.5%) obstructed/strangulated umbilical and para umbilical hernias and one (6.2%) had obstructed
femoral hernia. Among other cause of obstruction, sigmoid volvulus was found in 7 cases (5.73%), worms’ obstruction in
3 cases (2.45%) and faecal impaction in 2 cases (1.63%). Postoperative complications were found in 27(22.1%) patients.
The pulmonary complications occurred in 8 patients (6.5%) including atelectasis 50%, pneumonia 25% and both in 25%
patients. Twelve patients (9.83%) developed wound infection treated by C/S of discharge, daily dressing and antibiotics.
Four patients (3.27%) had anastomotic leak with pelvic abscesses in 3 cases and interloop abscess in 1 case, 2 (66.6%) of
them developed sepsis and DIC. Three patients died, 2 because of sepsis and DIC due to anastomotic leak on ninth and
eleventh post-operative days, and the third one due to electrolyte imbalance on fourth postoperative day. So the overall
mortality was 2.45% (Table 4).
Conclusion: Despite all the improvements in health care systems, abdominal Tuberculosis are the commonest cause of
mechanical intestinal obstruction, followed by Adhesions and Bowel malignancy in our setup.
Keywords: Intestinal Obstruction,
INTRODUCTION cardinal features of intestinal obstruction.2 Obstruction

Intestinal obstruction continues to remain a chal- of the bowel may be dynamic (mechanical) or adynam-
lenge to surgeon despite advances in fields of medicine, ic (non-mechanical) obstruction in which no true peri-
pathophysiology, surgical techniques and conservative stalsis is seen.3 Mechanical intestinal obstruction form
management. Acute abdomen is a significant cause of important part of pathologies which necessitates emer-
mortality in many developing countries.1 Acute intesti- gent surgical intervention.4
nal obstruction is one of the wide varieties of abdomi- The diagnosis of intestinal obstruction is not al-
nal conditions responsible for these deaths. ways easy and indication for surgery needs high index
Abdominal pain, vomiting, constipation and ab- of suspicion. Detailed history and thorough physical
dominal distension and failure to pass flatus are the examination are helpful to make a working diagnosis
Surgical Specialist, AHQ Hospital, Landikotal. 2Medical Officer
1
and planning treatment. Abdominal x-ray film and Ul-
Surgery, Satellite Hospital, Pabbi. 3Junior Registrar Surgery, Rehman trasonography has advantage in diagnosis of intestinal
Medical Institute, Phase 5, Hayatabad, Peshawar. 4Trainee Medical
Officer General Surgery, Hayatabad Medical Complex, 5Medical obstruction. Computed tomography (CT) has a sensi-
Officer, North West General Hospital, Hayatabad, Peshawar. tivity of 81% for high- grade and 48% for low- grade
Correspondence: Dr Yousaf Jan (FCPS General Surgery), obstruction and has the additional benefit of defining
Surgical District Specialist, AHQ Hospital, Landi Kotal. House the cause and level of obstruction in many patients.5 An
No 89, Street No 2, Sector K5, Phase 3 Hayatabad, Peshawar.
E-Mail: dr.yousaf.shinwari@gmail.com, Cell:03339279312 estimated 20% of hospital general surgical emergency
admissions are for the management of intestinal ob-
Received: Feb’ 2014 Accepted: March’ 2014 struction.6 Managing intestinal obstruction is a continu-

Current Pattern of Mechanical Intestinal Obstruction in Adults
ous challenge to surgeons all over the world.7 of any previous surgery. After clinical diagnosis was
The aetiology of intestinal obstruction varies re- made, investigations were performed included com-
markably from country to country. While the most fre- plete blood count with differential, serum blood sugar,
quent cause of intestinal obstruction is postoperative urea and creatinine, liver function tests, serum albu-
adhesions in developed countries, strangulated hernias min, serum electrolytes, ECG, chest x-ray and Erect ab-
are more common in developing countries.8,9 Intestinal dominal x-ray. When abdominal mass was suspected,
obstruction may be caused by variety of conditions, abdominal ultrasound was performed. CT scan and
such as external hernias (19%), volvulus (11%), tuber- contrast studies were done in selected stable patients.
culosis (20%), malignancy (19%) and post-operative or All such data was recorded in a proforma.
inflammatory adhesions (26%) as the most common Once the clinical diagnosis of obstruction was
cause of intestinal obstruction.10 Tuberculosis (36%) is confirmed with abdominal x-ray, the initial treatment
the leading cause of dynamic intestinal obstruction in comprising N/G decompression, intravenous fluids,
Pakistan. Clinically it is possible to distinguish strangu- bladder catheterization, intake and output record, anti-
lated obstruction from simple intestinal obstruction de- biotic and adequate analgesia was started in all patients.
pending upon severity of clinical features. Tenderness, Blood was arranged depending upon the haemoglobin
guarding and rigidity with signs of hypovolemic shock level. In cases of complete obstruction, strangulated /
are more prominent in strangulated obstruction. obstructed hernias or hemodynamic instability, im-
Patients with intestinal obstruction are often seri- mediate laparotomy was attempted after initial assess-
ously ill and require frequent assessment, monitoring of ment, investigations and resuscitations. Laparotomy
vital signs and clinical progress to determine the need for was also performed in those cases who did not im-
surgical intervention.10 Successful management requires prove with conservative measures after 48-72 hours.
early diagnosis and treatment with meticulous fluid, At time of induction of anaesthesia, single dose injec-
electrolyte balance and timely surgical intervention.11 tion ceftriaxone with metronidazole was given. Lapa-
Global as well as regional variations in the pat- rotomy was performed through midline incisions ex-
tern of intestinal obstruction and changes in the disease cept in obstructed/strangulated inguinal hernia cases
pattern over the years are well documented in the lit- that were approached through inguinoscrotal incision.
erature12.This make it essential that the studies should Biopsy was taken where needed for histopathological
be conducted periodically in every region to define the confirmation. The underlying pathology identified and
causes with idea of improving surgical health services. treated accordingly. Operative details, e.g., causes, site
Thus this study was conducted to find out the pattern of obstruction and operative procedure, postoperative
of mechanical intestinal obstruction in our set up. complications, outcome and mortality were recorded.
MATERIAL AND METHODS The patients were followed for six weeks for postopera-
This descriptive study was conducted from tive complications and mortality. The data were ana-
march 2009 to September 2010 in Hayatabad Medical lyzed using SPSS version-10. Results were presented in
Complex Peshawar after approval from local hospital the form of tables.
ethical and research committee. All patients present- RESULTS
ing with intestinal obstruction who were admitted to One hundred and twenty two patients presented
surgical ward Hayatabad Medical Complex, Peshawar with intestinal obstruction and underwent surgical ex-
through OPD, casualty, consulting clinics and referrals ploration during the study period. Seventy seven were
from medical wards and above the age of 12 years were males (63.1%) and forty five (36.8%) were females with
included in the study. Children’s less than twelve years male to female ratio of 1.71:1. The ages of the patients
of age, patients with paralytic ileus and other non-me- ranged from 13-80 years with mean age of (37.4±19.7).
chanical causes of obstruction, those who responded (Table 1) shows the age and sex distribution.
to conservative measures and patients presenting with
Table 1: Age and sex distributions (N=122)
obstruction due to obstructed inguinal hernia with no
evidence of strangulation that reduced spontaneously Age Male Female Total
were excluded from study. 12-20 7(63.6%) 4 (36.3%) 11 (9%)
From all patients presenting with features of intes- 21-30 17 (68%) 8 (32%) 25 (20.4%)
tinal obstruction, complete history was taken especially 31-40 22 (66.6%) 11 (33.3%) 33 (27%)
about cardinal features of intestinal obstruction and 41-50 17 (60.7%) 11 (39.2%) 28 (22.9%)
any previous surgery history. Then followed by thor-
51-60 6 (54.5%) 5 (45.5%) 11 (9%)
ough physical examination looking for dehydration,
61-70 5 (62.5%) 3 (37.5%) 8 (6.5%)
hemodynamic instability, hernial orifices, abdominal
distension, palpable masses, bowel sounds and scars 71-80 3 (50%) 3 (50%) 6 (4.9%)

Out of one hundred and twenty two cases, 108 Table-3: Causes of intestinal obstruction (N=122)
(88.5%) were admitted through Accident and Emer- Aetiology Number (%)
gency Department and 14 patients (11.4%) through sur- Intestinal tuberculosis 42 (34.4%)
gical OPD. Pain was the most common (100%) symp- Adhesions 34 (27.8%)
tom of presentation followed by abdominal distension Bowel malignancy 18 (14.7%)
(92.2%), vomiting (84.4%), absolute constipation (83.6%) Hernias 16 (13.1%)
and relative constipation (16.3%) as shown in (Table 2). Sigmoid volvulus 7 (5.7%)
Abdominal tenderness and rebound tenderness were Worms 3 (2.4%)
found in 107 (87.7%) patients, while 5 patients (4.09%) Faecal impaction 2 (1.6%)
presented in shock states. A total of 43 patients (35.2%)
In 16 patients (13.1%) the cause of obstruction were her-
had fever on arrival, 23 patients (18.8%) had history of
nias. Of them, 9 (56.2%) had obstructed/strangulated
weight loss and 9 patients (7.3%) had history of bleed-
inguinal hernias, 6 (37.5%) obstructed/strangulated
ing per rectum (Table 2).
umbilical and para umbilical hernias and one (6.2%)
Table-2: Clinical features had obstructed femoral hernia. Among other cause
Symptoms/Signs N0. Percentage of obstruction sigmoid volvulus was found in 7 cases
Abdominal pain 122 100 (5.7%), worm’s obstruction in 3 cases (2.4%) and faecal
Vomiting 115 94.2 impaction in 2 cases (1.6%), as shown in (Table 3).
Abdominal distension 103 84.4
Postoperative complications were found in 23
Absolute constipation 102 83.6
patients (18.8%).The pulmonary complications in oc-
curred in 8 patients (6.5%) including atelectasis (50%),
Relative constipation 20 16.3
pneumonia (25%) and both in (25%) patients. Twelve
Abdominal tenderness 107 87.7
patients (9.8%) developed wound infection treated by
Rebound tenderness 107 87.7
C/S of discharge, daily dressing and antibiotics. Four
Shock 5 4.09
patients (3.2%) had anastomotic leak with pelvic ab-
Fever 43 35.2
scesses in 3 cases and interloop abscess in 1 case, 2 of
Weight loss 23 18.8
them developed sepsis and DIC. The pelvic abscesses
Bleeding per rectum 9 7.3
were drained per rectally and interloop abscess under-
Irregular and tender swelling in inguinal
16 13.1 went re-exploration and drainage of abscess. Three pa-
and umbilical region
tients (2.45%) died, 2 because of sepsis and DIC due to

anastomotic leak on ninth and eleventh post-operative
Forty two patients (34.4%) had abdominal tuber-
days, and the third one due to electrolyte imbalance on
culosis and was the most common cause of intestinal
fourth postoperative day. So the overall mortality was
obstruction in our study. In 8 patients (19%) there were
2.45% (Table 4).
multiple strictures in ileum, in 4 patients (9.5%) there
were associated strictures in the jejunum besides ileum, Table-4: Post-operative complications
while in 13 patients (30.9%) there was single stricture Complications Number (%)
in distal ileum. Ileocecal mass causing small bowel ob- Pulmonary (atelectasis, pneumonia) 8 (6.5%)
struction was found in 17 patients (40.4%) as shown in Wound infection 12 (9.8%)
(Table 3). In our study, 13 patients (30.9%) were found Anastomotic leak 4 (3.2%)
to have associated pulmonary tuberculosis. Mortality 3 (2.4%)
Bands and adhesions were found in 34 patients
(27.8%) and was the second most common cause of ob- DISCUSSION
struction after tuberculosis in our study. 31 (91.1%) out Intestinal obstruction is a common surgical emer-
of 34 patients had history of previous laparotomy. In 18 gency and has various causes. The diagnosis of intes-
patients (14.7%) malignancy was the cause of mechani- tinal obstruction is based on the classic features of ab-
cal bowel obstruction. Among them, 6 patients (33.3%) dominal pain, vomiting, distension and constipation13.
had small bowel carcinoma which included 4 non- The relative magnitude of each differs according to the
Hodgkins lymphoma ileum (66.6%) and 2 adenocarci- cause and site of intestinal obstruction.
noma ileum (33.3%). In remaining 12 patients (66.6%) The ages of the patient in current study ranged
the cause was carcinoma colon. Out of them, 2 patients from 13-80 years with mean age of (37.4±19.7) years
(16.6%) had carcinoma cecum and ascending colon, 4 which is almost comparable with the study conducted
(33.3%) had carcinoma sigmoid colon and 6 (50%) had by Ismail et al (37.5)3. Maximum cases were seen from
adenocarcinoma recto sigmoid junction and rectum third to fifth decades of life (Table 1). Seventy seven
(Table 3). (63.1%) were males and forty five (36.8%) were fe-

males with male to female ratio of 1.71:1, which is al- studies conducted by Bloch NA, et al (15.9%)14 and by
most same as reported by Qureshi MI et al.7 Out of one Lawal OO, et al (12.12%).18 In his study by Asad A,et
hundred and twenty two cases, 108 (88.5%) were ad- al,16 showed (5.6%) incidence of bowel malignancy.
mitted through Accident and Emergency Department Among 18 cases of malignancy, 6 patients (33.3%) had
and 14 patients (11.4%) through surgical OPD. Pain small bowel carcinoma which included 4 non-Hodgkins
was the most common (100%) symptom of presenta- lymphoma ileum (66.6%) and 2 adenocarcinoma ileum
tion followed by abdominal distension (92.2%), vomit- (33.3%). In 12 patients (66.6%) the cause was carcinoma
ing (84.4%), absolute constipation (83.6%) and relative colon. Out of them, 2 patients (16.6%) had carcinoma
constipation (16.3%) as shown in (Table 2). Abdominal cecum and ascending colon, 4 (33.3%) had carcinoma
tenderness and rebound tenderness were found in 107 sigmoid colon and 6 (50%) had adenocarcinoma recto
(87.7%) patients, while 5 patients (4.09%) presented in sigmoid junction and rectum (Table 3).
shock states. A total of 43 patients (35.2%) had fever on In 16 patients (13.1%) the cause of obstruction
arrival, 23 patients (18.8%) had history of weight loss were hernias. This is comparable to studies conducted
and 9 patients (7.3%) had history of bleeding per rec- by Asad S, et al (13.9%),16 Lawal OO, et al (11.1%)18 and
tum (Table 2). Baloch NA, et al (17.5%).14 In their study by Khan JS, et
The most common cause of intestinal obstruction al19, found high incidence of hernia as a cause of intesti-
in our study was intestinal tuberculosis (34.4%), which nal obstruction (35%). Out of 16 patients, 9 (56.2%) had
is comparable to a study conducted by Baloch NA et al obstructed/strangulated inguinal hernias, 6 (37.5%)
(30.6%)14, which also showed that tuberculosis was the obstructed/strangulated umbilical and Para umbilical
leading cause of intestinal obstruction. In another study hernias and one (6.25%) had obstructed femoral hernia.
by Chalya PL et al15, also showed that tuberculosis Among other cause of obstruction, sigmoid volvulus
(22.4%) was the leading cause of intestinal obstruction. was found in 7 cases (5.73%), in contrast to studies by
The male to female ratio of abdominal tuberculosis in Asad S, et al (13.9%),16 Lawal OO, et al (15.15%)18 and
our study was 1.8:1, which is comparable to M:F ratio of Khan JS, et al (6%).19 Out of 7 cases of volvulus, 4 (57.1%)
1.8:1 in a study by Chalya PL et al15.The frequency of ab- underwent resection and end to end anastomosis and
dominal tuberculosis as a cause of bowel obstruction in in remaining 3 (42.8%) Hartmann procedure was done.
our region is quite high as compared to our studies. The Worms obstruction were found in 3 cases (2.45%) which
obvious reasons are the poor socioeconomic conditions is in contrast to a study by Asad S, et al (5.65%).16 Faecal
and noncompliance of the patients to the anti- tubercu- impaction responsible for 2 cases (1.63%), comparable to
losis treatment. In 8 patients (19%) there were multiple (2.8%) in his study by Asad S, et al.16
strictures in ileum, in 4 patients (9.5%) there were as- Postoperative complications were found in 23
sociated strictures in the jejunum besides ileum, while patients (18.8%). The most common was pulmonary
in 13 patients (30.9%) there was single stricture in distal complications in 8 patients (6.5%) including atelecta-
ileum. Ileocecal mass causing small bowel obstruction sis (50%), pneumonia (25%) and both in (25%) patients
was found in 17 patients (40.4%) as shown in (Table 3). treated by chest physiotherapy, Oxygen inhalation and
The right hemicolectomy with ileo-transverse anasto- antibiotics. In their studies by Ramrao BS, et al (4.59%)17
mosis was the most frequent procedure performed in and Baloch NA, et al (4.76%),14 developed postopera-
19 cases (45.2%). Small bowel resection and end to end tive pulmonary complications. 12 patients (9.8%) in
anastomosis was performed in 12 patients (28.5%), and our study developed wound infection treated by C/S
stricturoplasty in 11 patients (26.1%). Postoperatively of discharge, daily dressing and antibiotics, as com-
all the patients received ant tuberculosis drugs for a pe-
pared to wound infections rate in studies by Asad S,
riod of one year.
et al (25%),16 Baloch NA, et al (8.3%),14 Ramrao BS, et
Bands and adhesions were found in 34 patients
al (10.34%)17 and Khan JS, et al (12%).19 Four patients
(27.8%) and was the second most common cause of
(3.27%) had anastomotic leak with pelvic abscesses in
obstruction after tuberculosis in our study. 31 patients
3 cases and interloop abscess in 1 case, 2 (50%) of them
(91.1%) out of 34 patients had history of previous lapa-
rotomies and 3 patients (8.8%) had laparotomy for developed sepsis and DIC. In comparison, different
the first time and congenital bands were the cause of anastomotic leak were found in different studies by
obstruction in all three cases. As compared to current Asad S, et al (2.8%),16 Baloch NA, et al (5%).14 The two
study, adhesion as a cause of intestinal obstruction were patients with leak had resection and end to end anas-
showed in their studies by Baloch NA, et al (22.6%),14 tomosis due to multiple small bowel strictures because
Asad S, et al (36.1%)16 and Ramrao BS, et al (25.5%).17 of Tuberculosis, re-explored and ileostomy were done.
In 18 patients (14.75%) malignancy was the cause of The third anastomotic leak patient had resection and
mechanical bowel obstruction, which is comparable to primary anastomosis for an un-complicated sigmoid

Table-5: Comparisons of different studies

Aetiology Present study Asads, et al16 Baloch NA, et al14 Khan JS, et al19 Chalya PL, et al15 Ramrao BS, et al17
Intestinal tuberculosis 34.4% 19.4% 30.6% - 22.4% -
25.5%
Adhesions and Bands 27.8% 36.1% 22.6% 39% -
14.75% 15.9% -
Malignancy 5.6% - -
Hernias 13.1% 13.9% 17.5% 35% - 17%
Sigmoid volvulus 5.3% 13.9% 7.5% 6% - 12.4%
Worms - 2.45% 5.6% - - -
1.6%
Faecal impaction 2.8% - - - -
Mortality 2.4% 2.8% 2.4% 7% - 6.2%
volvulus, re-explored and Hartman procedure was 3. Ismail, Khan M, Shah SA, Ali N. Pattern of dynamic intestinal
obstruction in adults. J Postgrad Med Inst 2005;19(2):157-62.
done. The pelvic abscesses were drained per rectally 4. Akcakaya A, Alimoglu O, Hevenk T, Bas G, Sahim M.
and interloop abscess underwent re-exploration and Mechanical intestinal obstruction caused by wall hernias. Ulus
drainage of abscess. Three patients (2.45%) died, 2 pa- Trauma Derg 2000;6:260-5.
5. Furukawa A, Yamasaki M, Furuichi K, et al. Helical CT in
tients(66.6%) because of sepsis and DIC due to anasto- the diagnosis of small bowel obstruction. Radiographics.
motic leak on ninth and eleventh post-operative days, 2001;21(2):341-355.
and the third one (33.3%) due to electrolyte imbalance 6. Baloch NA, Babar KM, Mengal MA, Babar SAA. Spectrum of
mechanical intestinal obstruction. Pak J Surg 2002;7(1):7-9.
on fourth postoperative day. So the overall mortality 7. Qureshi MI, Anwar I, Dar HM, Ahmad A, Durrani KM.
was (2.45%), as compared to mortality rates in studies Managing small intestinal obstruction: Proceeding Shaikh
by Khan JS, et al (7%),19 Asad, S et al (2.8%),16 Baloch, Zayed Postgrad Med Inst 2005;19(1):19-23.
8. Miller G, Boman J, Shrier I, Gordon PH. Etiology of small bowel
NA et al (2.4%)14 and Ramrao BS, et al (6.20%).17 Table
obstruction. Am J Surg2000;180:33-6.
5 shows comparison of intestinal obstruction causes by 9. Shittu OB, Gana JY, Alawale EO, Ogundiran TO. Pattern of
different studies with the current study. mechanical intestinal obstruction in Ibadan : a ten year review.
Based upon the observations of the present study, Afr J Med Sci 2001;30:17-21.
10. Chouhery AK, Azam M. An etiological spectrum of mechanical
it is evident that the spectrum of bowel obstruction var- intestinal obstruction. Pak Armed Forces Med J 2004;54(1):19-
ies from time to time in the smaller geographical areas 24.
of the country. Intestinal Tuberculosis is still a major 11. Macutkiewicz C, Carlson GL. Intestinal obstruction. Surgery
Int 2005;70:10-4.
health problem, and contributes significantly to high 12. Atiq A. Aetiological aspects of dynamic intestinal obstruction,
morbidity and mortality. Therefore a high index of sus- a Mayo Hospital experience. Pak Surg 1996;12:118-9.
picion, proper evaluation and therapeutic trial in sus- 13. Kirk RM, Williamson RCN. Laparotomy for intestinal
obstruction in Kirk RM General Surgical Operations, 4th edition,
pected patients is essential for an early diagnosis and
Churchill living Stone Edinburgh 2000;97-102.
timely definitive treatment, in order to decrease the 14. Baloch NA, Mohammad D, Qureshi SA. Current pattern of
morbidity and mortality associated with this disease. mechanical bowel obstruction in adults. Journal of Surgery
CONCLUSION Pakistan (Int) 2011;16:38-40.
15. Chalya PL, Mchembe MD, Mshana SE, Rambau P, et al.
We conclude from this study that tuberculosis is Tuberculous bowel obstruction at a university teaching
a leading cause of mechanical intestinal obstruction in hospital in Northwestern Tanzania: a surgical experience with
our local set up and contributes significantly to high 118 cases. WJES 2013;8:1-15.
16. Asad S, Khan H, Khan IA, Ali S, Ghaffar S, Rehman ZU.
morbidity and mortality, followed by adhesions and Aetiological factors in mechanical intestinal obstruction. JAMC
bowel malignancy. Late presentation with advanced 2011;23(3):26-27.
stage of disease are the causes of high mortality. 17. Ramrao BS, Ekanath JS, Marutirao NA. A prospective study of
intestinal obstruction in a rural hospital in india. Indian Journal
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1. McConkey SJ. Case series of acute abdominal surgery in rural
18. Lawal OO, Olayinka OS, Bankole JO. Spectrum of causes
Sierra Leone. World J Surg.2002;26:509-13. of intestinal obstruction in adults Nigerian patients. SAJS
2. Evers BM. Small Intestine. In: Townsend CM, Beauchamp RD, 2005;43(92):34-36.
Evers BM, Mattox KL. Sabiston Textbook of Surgery. 17thedi. 19. Khan JS, Alam J, Hassan H, Iqbal M. Pattern of intestinal
Philadelphia. Saunders Elsevier;2004:1323-42. obstruction A hospital based study. PAFMJ 2007;4:1-5.

ORIGINAL ARTICLE
Frequency of Vaginal Candidiasis
amongst Pregnant Women & Effect of
Predisposing Factors
Rahat Jabeen
Rahat Jabeen FCPS1, Ilyas Siddiqi FCPS2
ABSTRACT
Background: Pregnancy represents a risk factor in the occurrence of vaginal candidiasis.
Objective: The aim of this study was to determine the frequency of Candida species present in the vaginas of both
symptomatic and non-symptomatic pregnant women attending antenatal clinics and examine the role of age of subjects
and age of pregnancy on the occurrence of Candida infection
Material and Methods: This prospective study was conducted at antenatal clinic of Gynaecology and Obstetrics depart-
ment at Hayatabad Medical Complex, Peshawar from Jan 2010 to Jan 2011. A total of 145 pregnant patients fulfilling the
inclusion criteria were included in the study. Data were collected regarding patients demographic, information on parity,
trimester of pregnancy, presence of vaginal discharge and the presence or absence of diabetes. Vulva and vagina were
inspected for signs of inflammation and discharge with sterile speculum and vaginal specimens were collected with sterile
cotton tipped swabs and were subjected to gram staining and examined microscopically for the diagnosis of candidiasis and
how some predisposing factors would affect the frequency of isolation of species.
Results: The frequency of vaginal candidiasis during pregnancy was found to be 60%, in which 35.1% were symptomatic
and 24.8% were asymptomatic group. Women in the second trimester of pregnancy had the highest occurrence (59.9%).
Increased ratio of age distribution of patients with Candida showed isolation rates of 46.8%, 29.6% and 23.4% among
age 17-23, 24-30 and 31-37 years, respectively. Increased ratio of infection was observed in multigravida and diabetic
women.
Conclusion: Although there is generally a high frequency of vaginal candidiasis, an increased ratio of vaginal candidiasis
in multigravida and diabetic pregnant women requires these women to be routinely screened for vaginal candidiasis regard-
less of symptomatic status.
Keywords: Candidiasis, Pregnancy, Vaginal swabs.
INTRODUCTION Approximately 40-50% of women have repeated infec-

Candida or yeast is a normal commensal organ- tion. Less than 5% of adult female population receives
ism colonizing in the vagina, particularly the albicans repeated, frequent attacks of recurrent vulvovaginal
species. Normally their overgrowth is prevented by the candidiasis.8 Twenty five to 40% of women who are cul-
Lactobacilli.1,2 The fungus Candida lives in small num- ture positive for Candida species in the vaginal area are
bers in a healthy vagina, rectum and mouth.3 About asymptomatic carriers. The natural history of asymp-
75% of women generally harbour this fungus without tomatic colonization is unknown, although limited
it causing harm to them.4 Some of the factors which human studies suggest that vaginal carriage may
predispose women to vaginal candidiasis are change continue for several months and perhaps years.8
in pH, use of oral contraceptives and corticosteroids, Itching, burning, irritation of the vulva, vagina
tight clothing, HIV/AIDS and personal hygiene.4,5 and curdy white vaginal discharge usually odourless
In pregnancy, vaginal candidiasis is common due with dysuria and dyspareunia are the most common
to altered pH and sugar content of vaginal secretions. symptoms.6,7 Vaginal candidiasis can cause abortion,
Increased estrogen level during pregnancy produces Candida chorioamnionitis and subsequent pre-term de-
more glycogen in the vagina and it also has direct ef- livery. Premature neonates are severely endangered by
fect on yeast cells, causing it to grow faster and stick generalized fungal infection because of their immature
more easily with the walls of vagina.6,7 Women around immune system. During delivery, transmission can oc-
the world get diagnosed of vaginal candidiasis. It is cur from the vagina of infected mother to the newborn,
estimated that 75% of women during the fertile pe- giving rise to congenital candida infection. Infants with
riod have at least one episode of vaginal candidiasis. the oral thrush can give rise to nipple candidiasis in
1
Medical Officer, Department of Obstetrics & Gynaecology, Hayat- breastfeeding mothers.9 Clinical manifestation and re-
abad Medical Complex, Peshawar, 2Assistant Professor, Department sponse to therapy is largely based on empiric diagnosis
of Obstetrics & Gynaecology, Lady Reading Hospital, Peshawar.
of disease.10 Therefore, certain important investigations
Correspondence: Dr. Rahat Jabeen: H No 30, Sec N2, Main Street, are required, like KOH (potassium hydroxide) prepara-
Phase 4, Hayatabad, Peshawar, Email: dr_rahatjabeen@hotmail.com tion test in which scraping or swab of affected area is
Cell: 03339102544
placed on glass slide and a single drop of 10% KOH is
Received: Feb’2014. Accepted: March’2014 put on it then viewed under microscope, the presence

of hyphae, pseudohyphae are suggestive of yeast infec- maining 60 (41.4%) were between 31 to 40 years (Table
tion.1,2 Swab and culture test is the most sensitive meth- 1). Increased ratio of age distribution of patients with
od but it takes longer time to make definite diagnosis. Candida showed isolation rates of 46.8%, 29.6% and
Clinicians are required to make immediate diagnosis, 23.4% among age 17-23, 24-30 and 31-37 years, respec-
so the gram stain smear is reliable and rapid method in tively.
order to treat the patient at their initial attendance.11 About 81 patients (55.8%) had characteristic
Numerous studies around the world show that symptoms of vaginal candidiasis, while the remain-
Candida albicans is responsible for the largest number ing 64 (44.2%) were asymptomatic patients (Table 1).
of symptomatic episodes of vaginal candidiasis. Non- Out of 145 patients, 98 (67.5%) were multigravida and
albicans species are most commonly represented the remaining of 47 (32.5%) were primigravida (Ta-
by Candida glabrata, Candida Krusie and Candida ble 1). Their parity was from 1 to 8 with mean of 3.92
tropicalis.8 It was the view that every pregnant woman, SD ±0.92. On clinical examinations, 89 (61.3%) wom-
symptomatic or asymptomatic, suffers from vaginal en had vaginal discharge and rest, 56 (38.7%) had no
candidiasis, hence, the current study was undertaken discharge. Gram staining showed that 87 (60%) of the
to evaluate this assumption. microscopically examined vaginal specimen were posi-
MATERIALS AND METHODS tive for Candida and other 58 (40%) were negative. Out
After obtaining consent from the local ethical and of these total 87 positive cases, 51 (35.1%) were from
research committee, this study was conducted at the symptomatic group and remaining 36 (24.8%) were
antenatal clinic of Gynaecology and Obstetrics unit from asymptomatic (Table 1).
Hayatabad Medical Complex, Peshawar from Jan 2010 Out of 145 patients, 59 (40.7%) were in their second
to Jan 2011. A total of 145 volunteer pregnant women trimester of pregnancy and 86 (59.3%) in third trimester
were screened after informed consent. Women in their (Table 1). From the total 145 pregnant patients, 13 (9%)
2nd or 3rd trimester of pregnancy, both primigravida were diabetic and the remaining 132 (91%) were non-
or multigravida, both diabetic and non-diabetic, irre- diabetic. Among diabetic patients, 8 were symptomatic
spective of age, were included. Women in their first and 5 among them had positive microbiological diag-
trimester of pregnancy, those not willing to participate nosis of fungus (Table 1).
in the study and those who had recently received the
treatment for vaginal candidiasis were excluded. Data Table-I: Distribution of patients according to age,
parity, trimester of pregnancy and presence of diabetes
were collected regarding patients demographic, infor- and symptoms
mation on parity, trimester of pregnancy, presence of Variable Group N (%) Symptomatic Asymptomatic
vaginal discharge and the presence or absence of dia-
15-30 years 85/58.6 56/65.9% 29/34.1
betes. Vulva and vagina were inspected for signs of Age
31-40 years 60/41.4 25/40.3% 35/59.7
inflammation and discharge with sterile speculum and Primigravida 47/32.5 13/27.6% 34/72.4%
Parity
high vaginal specimens were collected with sterile cot- Multigravida 98/67.5 68/69.3% 30/30.7%
ton tipped swabs and were subjected to gram staining Pregnancy Second 59/40.7 26/44% 33/56%
and examined microscopically for the diagnosis of can- trimester Third 86/59.3 55/64% 31/36%
didiasis. This was done in local microbiology depart- Present 13/9 8/61.5% 5/38.5%
Diabetes
Absent 132/91 73/55.3% 59/44.7
ment of the hospital by the senior microbiologist. All
Present 81(55.8%)
pregnant women with positive candida test were treat- Symptoms 81/145 64/145
Absent 64(44.2%)
ed with topical antifungal vaginal agents in the form of Gram’s Positive 87(60%) 51(35.1%) 36(24.8%)
creams, suppositories and tablets and were reviewed stain Negative 58(40%) 41(28.2%) 17(11.7%)
after one week in out-patients department to see the ef-
fectiveness of therapy. DISCUSSSION
All data were collected and analysed on SPSS-11, Candida species in the vaginal mucosa was found
and frequencies were calculated. Chi- square test was in 35% of healthy women. Numerous studies world-
used for the assessment of p-values and p-value of wide show that Candida albicans are responsible for
<0.05 was considered to be statistically significant. the greatest number of symptoms associated with the
RESULTS vaginal candidiasis.8 Vaginal candidiasis during preg-
A total of 145 pregnant women were enrolled in nancy is the second most common cause of vaginal
this study and the results were analysed according to infection after the bacterial vaginosis.7 Hamad at al,12
their age, parity, trimester of pregnancy and presence examined the ability of oestrogens to induce of
or absence of diabetes. All age patients were included vaginal candidiasis in the case when there is no
with a mean age of 26.3±0.49 years. 0ut of 145 patients, infection, or if it already exists. The obtained results
85 (58.6%) were between the 15 to 30 years and the re- clearly indicate that oestrogens are able to disrupt

the relationship between Candida species and host multigravida suffered significantly more. These may
and lead to infection. be due to early marriages in our population and by
In current study, all age patients were included the time they reached 30 years of age, they become the
with a mean age of 26.3±0.49 years. 0ut of 145 patients, multigravida. Marcano and Feo17 and Jordon, et al,18
85 (58.6%) were between the 15 to 30 years and the re- showed incidence of vaginal candidiasis in pregnancy
maining 60 (41.4%) were between 31 to 40 years (Table of 60% and 68.2%, comparable to our current study of
1). In a study by Parveen N, et al patient ages ranged 60% incidence. Babic M,8 showed 40.9% vaginal candid-
from 18-40 years with mean of 28.24 SD±6.14 years9. iasis incidence among pregnant patients, as compared
Increased ratio of age distribution of patients with Can- to 51.5% in a study by Enweani at al.19 On the other
dida showed isolation rates of 46.8%,29.6% and 23.4% hand, low results of 14.9% of vaginal candidiasis also
among age 17-23, 24-30 and 31-37 years, respectively, as revealed in the study carried out at Combined Military
compared to isolation rates of 51.7%,43.5% and 36.4% Hospital, Rawalpindi, Pakistan, but it was basically for
among age 17-23, 24-30 and 31-37 years in a study by bacterial vaginosis.20
Oviasogie FE, et al.13 In the current study, multigravida suffered signifi-
Out of 145 patients, 81 patients (55.8%) were cantly more from vaginal candidiasis than the primi-
symptomatic and 64 (44.2%) were asymptomatic, as gravida. This finding can be explained as multigravida
compared to 46.3% and 53.6% incidence of symptomat- have longer sexual history and also number of preg-
ic and asymptomatic patients in a study by Parveen N, nancies that make them more prone to develop vaginal
et al9. On clinical examinations, 84 (57.9%) women had candidiasis than primigravida who have less sexual ex-
vaginal discharge and rest, 61 (42.1%) had no discharge. posure. Although, no significant relationship was seen
In a study by Parveen N, et al, 80.9% women had vagi- with respect to age and trimester of pregnancy, it was
nal discharge and rest 19.09% had no discharge respec- observed that most of the women were in their third
tively9. Out of 145 patients, 98 (67.5%) were multigrav- trimester of pregnancy and belonged to younger age
ida and the remaining of 47 (32.5%) were primigravida group (18-30 years). High prevalence of vaginal can-
(Table 1). Their parity was from 1 to 8 with mean of 3.92 didiasis was seen in developing countries as compared
SD ±0.92 as compared to 82.7% and 17.2% incidence of to developed countries where public awareness of fe-
multigravida and primigravida with mean parity of male hygiene and contraception was well pronounced.
4.19 SD ±2.74 by Parveen N, et al.9 Multigravida were CONCLUSION
also more involved than primigravida in a study by In current study, the overall incidence of vaginal
Omar, et al,11 as also in our study. Out of 145 patients, candidiasis was 60% during pregnancy, 35.1% from
59 (40.7%) were in their second trimester of pregnancy symptomatic and 24.8% from asymptomatic group.
and 86 (59.3%) in third trimester (Table 1), as compared Gram staining test was observed a valuable method for
to high incidence in the second trimester (68.8%) in a rapid and specific diagnosis. Multigravida and diabetic
study by Oviasogie FE, et al.13 From the total 145 preg- pregnant women were found to have significantly in-
nant patients, 13 (9%) were diabetic and the remaining creased infection ratio, therefore, we recommend that
132 (91%) were non-diabetic. Among diabetic patients, multigravida and diabetic women, clinically sympto-
8 (61.5%) were symptomatic and 5 (38.5%) among them matic or asymptomatic, should be routinely screened
had positive microbiological diagnosis of fungus (Table for vaginal candidiasis during pregnancy.
1). In a study by Parveen N, et al,9 out of 7 diabetic pa- REFERENCES
tients, 6 were symptomatic, 2 among them had positive 1 Patient UK [home page on internet] Kavanagh S. Vaginal and
vulval candidiasis. Patient UK, EMIS; c1997-2006 [updated
laboratory diagnoses for fungus (p=0.031). One study 2005 November 2; cited 2006 April 5]. Available from:http://
conducted in Poland, reported high prevalence, 40.4%, www.patient.co.uk.
of vaginal candidiasis, according to the study, it select- 2 Wikipedia: the free encyclopedia [Internet]. San Francisco
ed all the pregnant women with diabetes.14 Grigoriou15, (CA): Wikipedia foundation, Inc.; 2001-2007. Candidiasis; [up-
dated 2006 May 1; cited 2006 June 22]. Available from: http://
evaluated pregnancy with diabetes mellitus, a possible en.wikipedia.org/wiki/Candidiasis.
risk factor in their study. 3 Carlsen G. The CandidaYeast Answer. Candida Wellness Cent-
In this study, 60% of vaginal candidiasis was er, Provo. 2001.
found during pregnancy, as compared to 38% inci- 4 Dam M. Poch F. Levin D. High rate of vaginal infections
caused by non Candida albicans Candida species among
dence in a study by Parveen N, et al.9 In another study, asymptomatic women: Med. Mycol. 2002, 40 (4): 383-386.
by Feyi-Waboso and Ahmadi,16 where 42.9% of vagi- 5 Enweani IB, Gugnani HC, Okobia R. Ojo SB. Effect of contra-
nal candidiasis was found during pregnancy. They also ceptives on the prevalence of vaginal colonization with Can-
observed that primigravida and younger age group dida species in Edo State, Nigeria: Rev. Iberoam. Micol. 2000,
18: 171–173.
suffered more from vaginal candidiasis. On the other 6 Moon Dragons Obgyn information: gynecological and obstet-
hand, we noted younger age group, 15-30 years, and rical information discussion. [Internet]. Moon Dragons Ob-

gyn Information and Discussion Inc; 1996-2007 [updated 2006 ski J. Prevalence of fungi in the vagina, rectum and oral cavity
March 1]. Available from: http://www.moondragon.org/. in pregnant diabetic women: relation to gestational age and
7 Yeast infections during pregnancy. Baby centre [Internet]; 1997- symptoms. Acta Obstet Gynecol Scand2004;83: 251-6.
2007 [updated 2005 March 13]. Available from: http://www. 15 Grigoriou O, Baka S, Makrakis E, Hassiakos D, Kapparos G,
babycentre.com/0-yeast-infections-during-pregnancy-485.bc. Kouskouni E. Prevalence of clinical vaginal candidiasis in a
8 Babic M, Hukic M. Candida Albicans and non Albicans species university hospital and possible risk factors. Eur J Obstet Gy-
as etilogical agent of vaginitis in pregnant and non-pregnant necol Reprod Biol 2006; 126: 121-5.
woman. Bosnian Journal of Basic Medical Scinces 2010;10(1):89- 16 Feyi-Waboso PA, Amadi AN. The prevalence and pattern of
97. vaginal candidiasis in pregnancy in Aba. J Med Invest Prac
9 Parveen N, Munir AA, Din I, Majeed R. Frequency of vaginal 2001; 2:25-7.
candidiasis in pregnant women attending routine antenatal 17 Marcano C, Feo M. Effectiveness of econazole on pregnant
clinic. JCPSP 2008;18(3):154-157. women with vulvo-vaginal candidiasis. Mycopathologia
10 Xu J, Sobel JD. Candida vulvovaginitis in pregnancy. Curr In- 1983;81:65-70.
fect Dis Rep2004; 6: 445-9. 18 Abu-Elteen KH, Abdul Malek AM, Abdul Wahid NA. Preva-
11 Omar AA. Gram stain versus culture in the diagnosis of vulvo- lence and susceptibility of vaginal yeast isolates in Jordan. My-
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12 Hamad M. Estrogen–dependent induction of persistent vaginal 19 Enweani I.B, Gugnani H.C, Okobia R, Ojo S.B. Effect of con-
Candidosis in naive mice. Mycoses,2004;47(7):304-306. traceptives on the prevalence of vaginal colonization with
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nant women in benign city, Nigeria: Effect of predisposing fac- 2001;18:171.
tors. AFR. J. CLN.EXPER. MICROBIOL,2009;10(2): 92-98. 20 Azaz S, Chaudry A, Kareem F. Bacterial vaginosis in patients at
14 Nowakowska D, Kurnatowska A, Stray-Pedersen B, Wilczyn- MH Rawalpindi. Pak Armed Forces Med J 2005; 55: 24-8.

ORIGINAL ARTICLE
Short Term Results of Local Steroid &
Anaesthetic Injection in the Management
of Planter Fasciitis
Muhammad Imran
Muhammad Imran Khan1, Khail Wali2, Muhammad Saqib3, Muhammad Ayaz Khan4
ABSTRACT
Objective: To investigate the effectiveness of corticosteroid injection in the treatment of plantar fasciitis.
Settings and Designs: Prospective study.
Materials and Methods: The study was carried out between May 2012 and November 2013, 50 patients (22 males, 28
females), otherwise healthy individuals with the diagnosis of unilateral plantar fasciitis were selected from the out-patient
clinic of Agency Headquarters Hospital Landikotal. A mixture of steroid with the local anaesthetic was given over the most
tender spot medially. Clinical evaluations were performed before the injection and 1 and 3 months after the injection; the
evaluation consisted of patient-assessed pain using a VAS on a scale of 0 to 10. Patient satisfaction was measured ac-
cording to the Roles and Maudsley score.
Results: A total of 50 patients were eligible for the study. The study participants included 28 (56%) women and 22 (44%)
men. A total of 28 (56%) left and 22 (44%) right feet were studied. The follow-up period was 3 months. Using the VAS,
mean pretreatment pain score was 7.97, and mean 1- and 3-months post treatment pain scores decreased to 2.97 and
3.17, respectively. According to the criteria of the Roles and Maudsley score results were rated as excellent in 11 (22%)
patients, good in 21 (42%), acceptable in 11 (22%), and poor in 7 (14%) at 3-months follow-up
Conclusion: In the current study corticosteroid injection was found effective and successful in treating the condition but its
effectiveness in the long term should be explored in future studies.
Key words: planter fasciitis, steroid injection.
INTRODUCTION approximately 75% of respondents used and/or rec-

Plantar fasciitis is the most common cause of foot ommended this intervention. In addition, a systematic
pain and accounts for up to 15% of all foot symptoms review found that corticosteroid injection is the second
requiring professional care among adults.1 The in- most frequently described treatment for plantar fascii-
cidence peaks between the ages of 40 and 60 y in the tis in the medical literature. Corticosteroids have been
general population and earlier in runners, and approxi- shown to inhibit fibroblast proliferation and expres-
mately one third of cases are bilateral.2 Etiopathological sion of ground substance proteins. It is possible that
studies have shown that it is a degenerative process (eg, these known effects may be of benefit in the treatment
non-inflammatory fasciitis, fasciosis) of the plantar fas- of plantar fasciitis, as increased fibroblast proliferation
cia that results from repeated trauma at its origin site and excessive secretion of proteoglycans are commonly
on the calcaneus.6 The cause of degeneration is recur- reported features of the condition.11, 12 There are draw-
rent microtears of the plantar fascia that overcome the backs in injecting the heel with steroids: mainly rupture
body’s capacity to repair itself.3 of the planter fascia and atrophy of the fat pad.13
Plantar fasciitis is commonly described in the lit- The aims of our study is to find out whether ster-
erature as a self limiting condition.4 This view is sup- oid injections should be used in the treatment of plantar
ported by the findings of a systematic review, in which fasciitis and whether it improves outcome or not.
plantar heel pain, on average, resolved after 12 months MATERIAL AND METHODS
regardless of treatment type (including placebo).5 Between May 2012 and November 2013, 50 pa-
Many interventions are used for the management of tients (22 males, 28 females), otherwise healthy indi-
plantar fasciitis7 and corticosteroid injection is a com- viduals with the diagnosis of unilateral plantar fascii-
mon choice among clinicians. Surveys of American po- tis were selected from the out-patient clinic of Agency
diatrists8 and orthopaedic surgeons9 have reported that Headquarters hospital Landikotal. Exclusion criteria
1
District Specialist Orthopaedics, Agency Headquarter Hospital for the study included: patients with rheumatolog-
Landikotal. 2Medical Officer Agency Headquarter Hospital, Landikotal. ic disease; pregnant patients; patients who had re-
3
Trainee Medical Officer Orthopaedics, Khyber Teaching Hospital
Peshawar. 4Associate Professor Orthopaedics, Khyber Teaching ceived steroid injections within the last three months
Hospital Peshawar for any reason; patients on steroids for any reason, pa-
Correspondence: Dr. Muhammad Imran Khan, House No- tients with other conditions causing foot pain that
292, street- 10, Sector N-1, Phase 4, Hayatabad, Peshawar. was either due to trauma, arthritis or neurologic con-
E-mail: immykhan655@googlemail.com, Cell: 0333 5055042
ditions; and patients unable to give consent. Inclusion
Received: March, 2014 Accepted: March, 2014 criteria were: (1) symptomatic heel pain of greater than

6 months duration and (2) unsuccessful response to The follow-up period was 3 months. Using the
conservative treatment with NSAIDS and stretch exer- VAS, mean pretreatment pain score was 7.97, and mean
cises. All patients provided written informed consent, 1-and 3-months post treatment pain scores decreased
and the study was approved by the local institutional to 2.97 and 3.17, respectively. According to the crite-
ethics committee. ria of the Roles and Maudsley score results were rated
The diagnosis of planter fasciitis was made upon as excellent in 11 (22%) patients, good in 21 (42%), ac-
the finding of tenderness to pressure at the origin of the ceptable in 11 (22%), and poor in 7 (14%) at 3-months
plantar fascia on the medial tubercle of the calcaneus, follow-up.
as well as complaint of sharp shooting inferior foot DISCUSSION
pain, made worse with activity and/or upon arising in Many therapies have been used to treat plantar
the morning. fasciitis, but none has provided a high level of effica-
Patient were placed in the supine position. The cy. The conservative treatment methods described for
medial approach was used when the injection was ad- plantar fasciitis include stretching, changes in daily
ministered. The most painful site of the medial aspect activities, taping, orthoses, NSAID therapy, and local
of heel was identified by palpation. Proper preparation steroid injections 15,16. A recent review noted that the
with antiseptic solution of the skin overlying this point natural history of the disease was self limiting within
was performed. Subsequently 2 mL of steroid (1 mL of 12 months in more than 80% of patients, regardless of
methylprednisolone and 1 mL of lidocaine) were in- the type of treatment. Approximately 5% of patients re-
jected using a 22-gauge needle into the plantar fasciitis quired surgical intervention when symptoms persisted
After the injection, patients were kept in the sitting po- for more than 6–12 months2. A single study examined
sition without moving the foot for 10 minutes. Patients outcomes in 91 patients treated with corticosteroids or
were released with orders to limit the use of their feet local anesthetics or by local anesthetic injection alone
for approximately 4 weeks. After 48 hours, patients by a medial approach5. No difference was found be-
were given the stretching protocol . Four weeks after tween the 2 treatments at 3 and 6 months using a visual
the injection, patients were allowed to proceed with analog pain score. Regardless of these results, injection
normal sports or recreational activities as tolerated. of corticosteroids or local anesthetics remains a conven-
Any type of foot orthoses was not encouraged. Clini- ient form of therapy, particularly as it is quick and may
cal evaluations were performed before the injection be performed as an office procedure.
and 1 and 3 months after the injection; the evaluation F Crawford’s17 comparison of outcome at 1 month
consisted of patient-assessed pain using a VAS on a shows a statistical difference in favour of treatment
scale of 0 to 10. On this scale, 0 reflected a total absence with steroid while no statistically significant differ-
of symptoms and 10 indicated the worst imaginable ence in pain reduction could be detected between the
pain. Patient satisfaction was measured according to injected substances for pain outcomes taken at 3 and 6
the Roles and Maudsley score14 (Table 1). months which is comparable to our study in the short
term. In another study done by M Abdihakin18 there
TABLE-1: Satisfaction according to the was a significant drop in mean pain scores at one and
roles and Maudsley Score then at two months after steroid injection.
Level Roles and Maudsley Score The most important limitation of the current study
is the short follow-up period in the study group. Studies
Excellent No pain, full movement, full activity with longer followup are required to find out longterm
Good Occasional discomfort, full movement, full activity effectiveness of this mode of treatment.
CONCLUSION
Acceptable Some discomfort after prolonged activities
In the current study corticosteroid injection was
Poor Pain limiting activity effective and successful in treating the condition on
short term basis. But its effectiveness in the long term
RESULTS should be explored in future studies.
A total of 52 patients were eligible for the study. REFERENCES
No patient chose to withdraw; however, 2 patients 1. Riddle DL, Pulisic M, Sparrow K. Impact of demographic and
impairmentrelated variables on disability associated with plan-
who did not regularly attend the follow-up visits were tar fasciitis. Foot Ankle Int. 2004 May;25(5):311-17.
omitted from the study. A total of 50 patients who 2. Buchbinder R. Clinical practice: plantar fasciitis.N Engl J
were regularly followed up completed the study. The Med.2004;350:2159–2166.
3. Barrett SJ, O’Malley R. Plantar fasciitis and other causes of heel
study participants included 28 (56%) women and 22 pain. Am Fam Physician. 1999; 59(8):2200-2206.
(44%) men. A total of 28 (56%) left and 22 (44%) right 4. Singh D, Angel J, Bentley G, Trevino S. Fortnightly review:
feet were studied. plantar fasciitis. BMJ 1997;315:172-5.

5. Crawford F, Thomson C. Interventions for treating plantar heel 12. Alvarez R. Preliminary results on the safety and efficacy of
pain. Cochrane Database Syst Rev 2003; 3:CD000416. the Ossatron for treatment of plantr fasciitis. Foot Ankle Int
6. Lemont H, Ammirati KM, Usen N. Plantar fasciitis: a degen- 2002;23(3):197–203.
erative process (fasciosis) without inflammation. J Am Podiatr 13. Selman JR. Planter fascia rupture associated with corticosteroid
Med Assoc. 2003; 93(3):234-237. injection. Foot Ankle Int 1994;15:376-81.
7. Landorf K, Menz H: Plantar heel pain and fasciitis. Clin 14. Roles NC, Maudsley RH. Radial tunnel syndrome: resistant
Evid2008, 02:1111. tennis elbow as a nerve entrapment. J Bone Joint Surg Br. 1972;
8. Pribut SM: Current approaches to the management of plantar 54:499-508.
heel pain syndrome, including the role of injectable corticos- 15. Young CC, Rutherford DS, Niedfeldt MW. Treatment of plan-
teroids. J Am Podiatr Med Assoc2007, 97(1):68-74. tar fasciitis. Am Fam Physician. 2001; 63:467-474.
9. Hill JJ, Trapp RG, Colliver JA: Survey on the use of corticos- 16. Lynch DM, Goforth WP, Martin JE, Odom RD, Preece CK, Kot-
teroid injections by orthopaedists. Contemp Orthop1989, ter MW. Conservative treatment of plantar fasciitis: a prospec-
18(1):39-45. tive study. J Am Podiatr Med Assoc. 1998; 88(8):375-380.
10. Atkins D, Crawford F, Edwards J, Lambert M: A systematic re- 17. Crawford F, Young P, Atkins D, Edwards J. steroid injection for
view of treatments for the painful heel. Rheumatology1999, heal pain: evidence of short term effectiveness. A randomized
38:968-973. control trial. British society of rheumatology. 1999;38: 974-77.
11. Keating C, Burke S, Walsh A, Kearns S. Injection of local anaes- 18. Abdihakin M, Wafula K, Hasan S, Macleod I. A randomized
thetic and steroids for the treatment of plantar fasciitis under controlled trial of steroid injection in the management of plant-
general anaesthetic.J Bone Joint Surg2010;92-B(I):48. er fasciitis. SA Orthopaedic journal summer 2012;11(4):33-38.

ORIGINAL ARTICLE
Post Dural Puncture Headache (PDPH):
Comparison of 25G Quincke & Whitacre
Spinal Needles in Caesarean Sections
Roheena Wadood
Roheena Wadood D.A, FCPS1, Jawad Khan D.A2
Prof. Fayyaz Akhtar Qureshi FCPS, M.Sc (Pain)3
ABSTRACT
Objective: To compare the frequency of post dural puncture headache in obstetric patients using 25 G Quincke and 25G
Whitacre spinal needles.
Design: Cross sectional, comparative study.
Place and duration of study: Department of Anaesthesia, Post Graduate Medical Institute Hayatabad Medical Complex
Peshawar from January 2010 to December 2010
Patients of Methods: Two hundred, full term pregnant women, fulfilling, the American society of Anaesthesiologist (ASA) 1
and II criteria,18 to 40 years of age, scheduled for elective caesarean section, under spinal anaesthesia, were randomized
into two groups and the results of PDPH in both groups were compared and chi-square test was applied. The level of sig-
nificance was significant, if P- value was less than 0.05.
Result: The occurrence of PDPH was more in group A i.e. 40% while it was comparatively lower in group B i.e. 20%
(p=0.002)
Conclusion: when using 25 G Whitacre spinal needle, the frequency of PDPH was significantly lower than when a 25G
Quincke spinal needle was used.
Keywords: Caesarean section, spinal anaesthesia, post dural puncture headache, Quincke spinal needle, Whitacre spinal
needle.
INTRODUCTION thesia.3 A PDPH is caused by leakage of the cerebrospi-

Caesarean section (CS) under spinal anaesthesia nal fluid through the dural hole formed by the spinal
(S.A) is practised worldwide, due to several advan- needle. Therefore decreasing the size of the hole may
tage over epidural or general anaesthesia. The great- be logical solution to decreasing the incidence of PDPH
est drawback of S.A is post dural puncture headache as suggested by different studies.4-6 In this study, we
(PDPH). It was the third most common claim, account- compare 25 gauged Quincke and Whitacre needles for
ing for 15% of the obstetric claims, after undergoing the occurrence of PDPH in young patients undergoing
C.S with spinal anaesthesia.1 Post partal mothers may CS under S.A.
develop spinal headache like, due to leakage of CSF PATIENTS AND METHODS
at the puncture site leading to traction on the cranial A cross sectional, comparative study was done
contents, giving rise to reflex cerebral vasodilatation. in the Department of Anaesthesia. Hayatabad Medi-
This type of headache is mild and self limiting but may cal Complex, Peshawar, during a period of one year
be persistent and severe at time. PDPH, also called spi- i.e from January 2010 to December 2010.Two hundred
nal headache, is a characteristic headache and begins patients of ASA I and II, fulfilling our inclusion criteria
within 12-24 hours and may last a week or more. It is were recruited for the study. They were divided into
postural, being made worse by raising the head and re- two groups randomly by lottery method. A subarach-
lieved by lying down. It is often occipital and may be noid injection of 2ml of 0.75% hyperbaric bupivacaine
associated with a stiff neck. It is frequently accompa- at L4-L5 interspace was administered by using a 25G
nied by nausea, vomiting, dizziness, tinnitus, vertigo, Quincke or Whitacre spinal needle with the patient in
hearing loss, visual disturbances such as photophobias the sitting position. Patients were evaluated for occur-
or cortical blindness and paraesthesia of the scalp and rance of PDPH in both groups, on 1st, 2nd post operative
upper and lower limb pain.2 It is more common in the days.
younger women undergoing CS under spinal anaes- Patients having history of preoperative headache
1
Asstt. Prof. Anaesthesiology, 2Medical Officer Anaesthesiology, 3Pro- and contraindication for spinal anaesthesia i.e patients
fessor & Head of Anaesthesiology, Anaesthesia Department, Hayat� - with neurological deficits, psychological ailment, co-
abad Medical Complex, Peshawar.
agulation disorders, haemodynamically unstable,
Correspondence: Dr. Roheena Wadood, 19-Park Road, University eclempsia and those requiring 2nd attempt for spinal
Town Peshawar. Cell:0332-9239215
Email:roheenawadud60@gmail.com block procedure were excluded from the study. Af-
ter taking informed consent, the patient was examined
Received: Jan’ 2014 Accepted: March’ 2014 physically, particularly the spine was examined. Any

Post Dural Puncture Headache (PDPH): Comparison of 25G Quincke & Whitacre Spinal Needles in Caesarean Sections
indicated laboratory tests done, were also checked to pared among the two groups, it was found 40% in
be within the normal limits. The technique of spinal group A while 20% in group B which was highly sig-
Anaesthesia included lumber puncture (LP) with the nificant with p-value 0.002. Table 1.
spinal needle 25G Quincke or Whitacre, using standard
Table-1: Comparison of PDPH in both the groups
procedure, precautions and positions.
The patients were placed in lying position, im- Group
Total
mediately with wedge under right buttock after giv- A (25,G) Q B (25,G) W
ing spinal anaesthetics, to achieve the desired level of 40 20 60
block. Blood pressure was checked automatically at Present
40.0% 20.0% 30.0%
one minute interval for first 5 minutes and then every PDPH
60 80 140
5 minutes throughout the procedure. Level of sensory Absent
60.0% 80.0% 70.0%
block was assessed immediately prior to the incision, Total 100 100 200
using absence of touch or temperature sensation. Each 100.0% 100.0% 100.0%
patient was visited on the 1st and 2nd post-operative day
to check for post-dural puncture headache (PDPH),
Graph-1: As a status in both the groups
whether aggravated by sitting, standing or straining,
and relieved by lying down.
Severity of headache was gauged by using a visual
analogue scale, ranging from 0-4, ‘O’ being the absence
of headache, 4 being the worst headache.Patients were
observed for PDPH in the recovery room and then in
the ward for the first and second post-operative days.
Patient having complained of postdural puncture
headache, were treated with conventional methods in-
cluding lying flat, giving I/V fluids and avoidance of
straining. Those patients who were not relieved were
given oral analgesics (mefanamic Acid 500mg).
The results of PDPH in both groups were com-
pared and chi square test was applied. The level of sig-
nificance was kept at p- value less than 0.05. DISCUSSIONS
RESULTS Post dural puncture headache (PDPH) still haunts
Patients were divided in two equal groups ran- the anaesthetist who practice spinal anaesthesia and
domly through lottery method. Patients in Group “A” the surgeons who face the complaint next morning by
were managed by using 25 G Quincke and another some patients.7 Currently subarachnoid block or spinal
Group “B” of patients were going through 25G Whi- anaesthesia is popular, safe and most frequently used
tacre spinal needles. Average age was 27.12 years+ mode of anaesthesia for lower segment caesarean sec-
5.11SD in Group A and contains 20% patients having tion.8 Among other complications of spinal anaesthe-
less than 20 years, 42% patients 21-26 years, 36% pa- sia, the PDPH is the most common and distressing
tients 27-32 years and 2% patients’ lies in age of more complication particularly in obstetric patients because
than 32 years. While Group B have average age of 25.5 of their inherent risk from young age and female gen-
years +4.8SD and contains 13% patients in less than 20 der.9,10 Sex bound difference is caused by emotional
years, 38% in 21-26 years, 38% in 27-32 years and 11% and hormonal factors.11 Therefore, PDPH remains a
patients have age more than 32 years of age. The overall big problem for the anaesthesiologist in caesarean sec-
average of the patients was 26.35 years +5.01SD. The tion. After delivery of the foetus, the reduced epidural
age distribution among the group was also insignifi- pressure increases the rate of CSF leakage through the
cant with p-value 0.264. dural opening leading to loss of buoyant support of the
Average weight and height of the patients in group brain, thereby causing traction on the meninges, a pain
A was 60 kg+11.31SD, 160 cm+12.4SD, while in group sensitive structure. In addition as a consequence of the
B it was 62kg+10.44SD and 159kg+10.4SD which were decreased CSF volume, there is compensatory vasodi-
insignificant with p-value of 0.234 and 0.464 respec- lation and increase of intracranial volume, according to
tively. ASA status shows that majority of the patients(i. Monro Kellie Hypthesis, leading to a headache12
e 75%,70%) were observed with ASA1 which were in- Although smaller gauge needles reduce the inci-
significant with p-value of 0.428. graph1 dence of PDPH, attempts to eliminate it by using nee-
When post-dural puncture headache was com- dles as small as 29 to 32 gauge have had limited success

since they are associated with high incidence of failed PDPH. Hart, and Whitacre claimed a decrease in in-
anaesthesia or multiple attemps.4,13,14 If there are mul- cidence of PDPH from 5-2%, using pencil point 20G
tiple holes in the dura, no matter how small, they will needle.24 Vallego et al, in patients undergoing elective
increase the incidence of headache and defeat the pur- caesarean delivery studied the difference in incidence
pose of using the smaller gauge needle.15,16 of PDPH using five different types of spinal needles

So obstetric patient with a past history of PDPH or and found that 25G Quincke needle had a higher fre-
migraine or requiring more than one attempt to achieve quency of PDPH compared to the pencil point needles
lumber puncture were excluded from the study as they including 25G Whitacre. They concluded that in addi-
were at an increased risk of headache in the post-oper- tion to PDPH, cost consideration ease of insertion rate
ative period. of CSF flow and the ease with which the needle bends
The most effective way to reduce the incidence of or breaks when excessive forward force is applied, be
PDPH is the use of small bore needles for administer- taken into consideration when choosing the spinal nee-
ing spinal anaesthesia. So in high risk obstretic patients, dle.25
the use of finer gauge needles is justified. Even as the Hwang et al, in their study using 25G Whitacre
incidence of PDPH is 2% with 29G Quincke needle, fail- and 25G and 26G Quincke needles, found that 25G
ure of SA is common due to technical difficulties with Whitacre caused a lower incidence of PDPH, but their
finer gauge needles.4,6,17 Westbrook et al and Holst et results were not statistically significant.26 Shaikh et al,
al showed that the CSF leakage from pencil point nee- used 25G and 27G Quincke and 27G Whitacre spinal
dles is significantly less than that from Quincke needles needles in caesarean sections and found that 27G Whi-
of the corresponding size.18,19 Pencil point needles are tacre spinal needles had better outcomes27.In another
thought to produce less damage to dural fibres, allow- study, PDPH in parturient was 14.3%10 In our study,
ing the hole to close up more readily. We chose the 25G there was reduction in the frequency of PDPH by us-
spinal needle because of the technical ease of insertion ing the pencil point 25G Whitacre spinal needle i.e.
over the finer spinal needles. 20% as compared to the 25 G Quincke spinal needle i.e.
Shah VR & Bhosale GP data shows that a 25 G 40%. Our study shows that a 25 gauge Whitacre needle
Whitacre needle would be best choice with regard to would be the best choice with regard to high success
high success rate and low PDPH rate as compared to rate and low PDPH rate as compared to other needles
other needles, since it was associated with low inci- since it was associated with low frequency of PDPH
dence of PDPH without adding technical difficulties. without adding technical difficulties. Single dose of in-
The 27 gauge needles were difficult to use as they re- travenous Aminophylline 1mg/kg after cord clamping
quired multiple attempts and the use of an introducer. decreases the incidence of PDPH in elective CS.28
The 25G Quincke needle was technically easy to use
In our study,intensity of headache was mild to
but produced a high incidence 14% of PDPH20. Kang moderate and was easily relieved by conventional tech-
SB and Colleagues noted that some PDPH were severe niques and oral analgesics.
enough to require an epidural patch.21 CONCLUSION
The therapy of epidural patch is invasive, cum- The 25G Whitacre spinal needle is recommended
bersome and hazardous. Thus, there is no doubt, that for spinal anaesthesia in the caesarean section to reduce
prevention is a better option than definative therapy. the incidence of PDPH.
None of our patients in either group required an epi- REFERENCES
1. Chadwick HS obstetric anaesthesia closed claim update II-ASA
dural blood patch. Our study showed that a Quincke newsletter 1999;63:6.
needle, even when introduced with bevel parallel to 2. Karkada.Post Dural Puncture Headache following Spinal An-
the direction of the dural fibres, results in higher fre- aesthesia for Caeserian Section. NJOG. 2011;6(2):60-61.
quency of PDPH, compared to pencil point needle. 3. Flatten H, Berg CM, Brekke S, Holmass G, Natvik C, Varughese
K. Effect of experience with spinal anaesthesia on the develop-
Though Quincke needles, if introduced with the bev- ment of post dural puncture complications. Acta anaesthesio-
el parallel to the longitudinal axis of the dural fibres, logica Scandinavica. 1999; 43(1):37-41.
as standard technique, could reduce the incidence of 4. Flaatten H, Rodt SA. Vamnes J, Rosland j. Wisborg T, Koller
PDPH.4,22 However, Cruikshank and colleagues could ME. PostDural Puncture Headache: A comparison between 26
and 29 gauges needles in young patients. Anaesthesia 1989; 44:
not demonstrate any significant difference in CSF leak- 147-9.
age by aligning the bevel of the needle either parallel 5. Dahl JB, Schultz E, Anker moller E, Christensen EF, Staunstrup
and across the dural fibres, in vitro and their observa- HG, carlsson P. Spinal Anaesthesia in young patients using 29
tions was that the CSF leakage rate was related to the gauge needles: Technical considerations and an evaluation of
post operative complaints compared with general anaesthesia
needle size.23 Br JAnaesth. 1990;64:178-82..
Several studies were done with different spi- 6. Lesser P, Bembridge M, Lyons G, Macdonald R. An evaluation
nal needles, to find out any difference in incidence of of 30 gauge needle for spinal anaesthesia for caesarean section.

Anaesthesia 1990; 45: 767-8. 18. West Brook JL, Uncles DR, Sitzman BT et al. Comparison of the
7. Kuczkowski KM,Benumof .JL Once a post dural puncture force required for dural puncture with different spinal needles
headache patient always post dural puncture headache pa- and subsequent leakage of cerebrospinal fluid. Anesth Analg
tient? Acta Anaesthesiol belg. 2003;54 (2): 167-8. 1994;79:769-729.
8. Kori G, smedstad. Dealing with post dural puncture headache. 19. Holst D, Mollmann M, Ebel C, et al. Invitro investigation of
Is it different in obstetrics? Can J anaesth 1998; 45: 6-9. cerebrospinal fluid leakage after dural puncture with various
9. DK Turnbill, DB shepned. Post dural puncture headache patho- spinal needles. Anaesth analg 1998, 87: 1331-5.
genesis, prevention and treatment. BJA 2003; 91 (5): 718-29. 20. Shah VR,Bhosale G.P.Spinal Anaesthesia in youg patients.
10. Dagmar Oberhofer et al. Period biol,2013;115(2):203-208. S.AFR J. Anaesthesiol Analg 2010;16(3):24-28.
11. Behzad S, ASJAD S,Ahmad A. Post spinal puncture headache, 21. Kang SB, Good enough DE, Lee YK, Olson RA. Comparison
comparison between lumber puncture needle No. 25G and of 26 and 27G needles for spinal anaesthesia for ambulatory
27G. Professional Med J Mar 2011;18(1): 51-56. surgery patients. Anaesthesiology
12. Grant R, Condon B, Hart I, Teasdale G.M, Changes in inrtracra- 22. 1992;76:734-8.
nial CSF volume after lumber puncture and their relationship 23. CORBEY M.P, Bach AB, Lech K, Frorup AM. Grading of sever-
to post L.P headache. J Neurol Neurosurg, Psychiatry 1991: 54: ity of post dural puncture headache after 27 gauge Quincke
440-2. and whitacre needles. Acta Anaesthesiol scand 1997; 41: 779-84.
13. Lynch J, Ashelger S, Krings EI. Post dural puncture headache 24. Cruickshank RH, Hopkinson JM.Fluid flow though dural
in young orthopaedic in patients; Comparison of 29 gauge puncture sites: An in vitro comparison
quincke type with 22 gauge whitacre spinal needle in 200 pa- of needle point types. Anaesthesia 1989; 44: 415-8.
tients. Acta Anaesthesiol scand 1992; 36: 58-61. 25. Hart JR, Whitacre RJ. Pencil point needle in prevention of post
14. Hoskin MF, Spinal Anaesthesia- the current trend towards nar- spinal headache. JAM MED Assoc. 1951; 147: 657-8.
row gauge atraumatic (pencil point) needles. Case Report and 26. Vallego MC. Mandell GL, Sabo DP. Ramanathan S. Post dural
review. Anaesth intens care. 1998; 26: 96-106. puncture headache: A randomized comparison of five spinal
15. Lybecker H, Moller JT, May O, Nielson HK. Incidence and pre- needles in obstetric patients. Anesth Analg 2000; 91: 916-20.
diction of Post dural puncture: A prospective study of 1021 spi- 27. Hwang JJ, HoST, Wang JJ. Liu HS. Post dural puncture head-
nal anaesthesia. Anaesth analg 1990;70:389-94. ache in Caserian section: Comparison of 25 gauge whitacre
16. Seeberger MD. Kautmane M, Staender S, et al. Repeated dural with 25 and 26 gauge quincke needles. Acta Anesthesiol Sin
puncture increase the incidence of post dural puncture head- 1997; 35: 33-7.
ache. Anaesth Analg 1996;82:302-5. 28. Sheikh JM,Memon MA,Khan m,Post dural puncture headache
17. Geurts SW, Haanschoten MC, Van Wijk RM, Kraak H, Besse after spinal anaesthesia for caesarean section: Acomparison
TC, Post dural puncture headache in young patients: A com- of 25gQuinke,27g Quinke and 27g whitacre spinal needles. J
parative study between the use of 0.52 mm (25 gauge) and Ayub Med Coll abbottabad 2008;20:10-3.
0.33mm (29 gauge) spinal needles. Acta Anesthesiol scand 29. Seyed EbrahimSadeghi et al.World J Med.Sci.2012:7(1)13-16.
1990;34:350-3.
A corneal perforation with iris prolapse,

resulting in an irregular pupil, is visible.
Corneal perforation can be associated
with fungal or viral keratitis, but in this
case was associated with an autoimmune
disease, rheumatoid arthritis. NewsNet

ORIGINAL ARTICLE
Incidence of Prostate Cancer following
Trans-Urethral Resection of Prostate (TURP) for
Clinically Benign Symptomatic Enlarged Prostate
Yousaf Jan with Normal Prostatic Specific Antigen (PSA)
Yousaf Jan FCPS (General Surgery)1, Waqas Khattak MBBS 2, Aurangzeb Khan MBBS3
Shaukat Hussain MBBS4, Irfan ul Islam Nasir MBBS5
ABSTRACT:
Background: Carcinoma of the prostate is one of the common tumours of old age in men . Both BPH and Prostate cancer
share some characteristics: increasing incidence in aging male, dependence on androgens for growth and response to
androgen deprivation therapy.
Objective: To determine the frequency of carcinoma prostate following TURP for clinically benign prostatic hyperplasia
patients with normal serum PSA .
Material and Methods: This study was conducted at Hayatabad Medical Complex Peshawar from Feb 2009 to Feb 2011.
A total of 135 patients were included in the study. Prostatic Specific Antigen (PSA) was measured pre-operatively and all
patients underwent transurethral resection of prostate (TURP) and prostatic tissues were sent to histopathology.
Results: A total of 135 patients were included in the study from Feb 2009 to Feb 2011. Patient ages ranged from 50 to 80
years with mean age of 65.67±6.25years. Out of all the patients, 14 patients (10.37%) presented with acute urinary reten-
tion, 5 patients (3.70%) with haematuria and 116 patients (85.92%) with Lower Urinary Tract Symptoms (LUTS) . Out of all
patients, 25 (18.51%) had serum PSA level less than or equal to 2ng/ml, 48 patients (35.55%) had serum PSA between
more than 2 to 3ng/ml and 62 patients (45.92%) had serum PSA of more than 3ng/ml. Histopathology results of 4 patients
(2.96%) turned out as adenocarcinoma prostate .Out of these 4 patients, one had carcinoma in situ and 3 having definitive
well differentiated adenocarcinoma prostate. Three patients(75%) with malignancy were more than 65 years old while one
patient(25%) was aged 59 years .
Conclusion: The incidence of carcinoma prostate in clinically Benign Prostate Hypertrophy (BPH) patients with normal PSA
is low. Low incidence in present study revealed the usefulness of serum PSA screening method. To avoid unusual systemic
needle biopsy for diagnostic purpose serum PSA measurement should be done.
Keywords: Transurethral Resection of Prostate (TURP) , Prostate cancer , Benign Prostatic hyperplasia (BPH)
INTRODUCTION the time of the original TURP, if the presence of cancer

Carcinoma of the prostate is the most common is unsuspected, which may lead to an inaccurate assess-
malignancy in males over the age of 65 years,1 with ment of tumour volume.5
an estimated 41,000 Americans dying from prostate The interventions performed for the treatment
cancer annually.2 The incidence rates shows a 63 fold of Benign Prostatic Hyperplasia (BPH) remains to be
difference between countries, being lowest in Far East the most common surgical interventions around the
countries like China and highest in US blacks who have world.4 Even though the discovery of Prostatic Specific
two fold higher incidence rate than that for US whites.3 Antigen (PSA) is a revolutionary development in the
Prostate cancer is extremely rare in Asians.4 differential diagnosis of BPH and carcinoma, inciden-
The incidental carcinomas includes those cases of pros- tal carcinoma is found in histopathology specimens in
tate cancers that are neither suspected nor detected 3-16% of patients undergoing BPH surgery.6-8 This can-
clinically , are diagnosed by histopathological examina- cer may remain latent and never progress, or may pro-
tion of tissue harvested by TURP, or transvesical pros- gress, metastasize and kill the host, depending upon its
tatectomy of clinically BPH patients. Most prostatic initial size and grade.9
carcinoma arise from the peripheral zone of the gland, There is no consensus on what type of treatment
and there is considerable scope for sampling error at should be administered in these patients once cancer
1
Surgical Specialist AHQ Hospital Landikotal, 2Medical officer Sur- diagnosed. While some researchers advocate aggres-
gery, Satellite Hospital Pabbi, 3Junior Registrar Surgery, Rehman sive treatment, others believe that follow up would be
Medical Institute Phase Hayatabad, Peshawar, 4Trainee Medical
Officer General Surgery, Hayatabad Medical Complex, Peshawar more appropriate. Radical prostatectomy remains the
5
Medical officer, Tehsil Headquarter Hospital, Takht- e-Nasrati, Karak most effective therapy for the treatment of prostate can-
Correspondence: Dr Yousaf Jan ( FCPS General Surgery) Surgical cer in patients with life expectancy of over 10 years.10
District Specialist, AHQ Hospital, Landikotal. House No 89, Street No Most cancers arise in prostates with concomitant BPH
2, Sector K5, Phase 3, Hayatabad, Peshawar.
E-Mail: dr.yousaf.shinwari@gmail.com, Cell:03339279312
(83.3%), and cancer is found incidentally in a signifi-
cant number of TURP specimens (10%). The clinical
Received: Dec’ 2012 Accepted: Jan’ 2014 incidence of cancer arising in patients with surgically

Incidence of Prostate Cancer following Trans-Urethral Resection of Prostate (TURP) for Clinically Benign Symptomatic Enlarged Prostate
treated BPH is approximately 3%.11 cer. All patients fulfilling the inclusion criteria were ad-
It is important to exclude cancer in patients pre- mitted through an OPD and prepared for surgery after
senting with symptoms of bladder outlet obstruction initial routine preoperative investigations and written
presumably due to BPH. For such cases, digital rectal informed consent were taken. A single preoperative
examination (DRE) and at least in high risk patients, dose of one gram intravenous Rociphen was given and
serum PSA measurement is recommended . Transrec- all patients underwent TURP under spinal anaesthesia.
tal ultrasound (TRUS) should be employed in patients Prostatic chippings collected at TURP from each pa-
with elevated PSA level to find the volume of the pros- tients were sent as routine for histopathological evalu-
tate, the relative contribution of BPH to volume and ation. Biopsy results were traced in all the patients. All
the PSA density (ratio of PSA level to volume). Biopsy the data were checked and edited after collection.
should be obtained from any areas suspicious for can- RESULTS
cer. Early detection and treatment of localized cancer A total of 135 patients were included in the study
offers the greatest chance of cure.8 from Feb 2009 to Feb 2011. Patients ages ranged from
PSA used as a tumour marker have occurred since 50 to 80 years with mean age of 65.67±6.25 years. Major-
1980s and widely used as a clinical marker of prostate ity of patients were noted in 60 to 70 years age groups
cancer by 1988.12 Before the widespread use of PSA (Table 1).
screening, frequency of incidental carcinoma in pros-
tate chips were more.13 Nowadays incidental findings Table-1: Age distribution of the patients (n=135)
of prostate carcinoma decreases markedly due to strict Age (years) Frequency Percent
and purposive screening by PSA as well as DRE and > 60 28 20.74
trans-abdominal ultrasound. Considering cut off value 60-70 85 62.96
4ng/ml of PSA we can exclude suspicious cases and > 70 22 16.29
can avoid inadvertent operative procedures in case of Total 135 100
BPH patients.
The aim of this study is to know the actual prevalence Out of all the patients, 14 patients (10.37%) presented
rate of incidental carcinoma prostate of BPH patients with acute urinary retention, 5 patients (3.70%) with
having PSA level less than 4ng/ml, obtained through haematuria and 116 patients (85.92%) with Lower Uri-
histopathological examinations of the prostatic biopsy nary Tract Symptoms (Table 2).
specimens who underwent TURP in Hayatabad Medi-
Table-2: Clinical feature of patients presented with BPH(n=135)
cal Complex Peshawar from Feb 2009 to Feb 2011.
MATERIALS AND METHODS Symptoms No of patients Percent
This study was conducted at Hayatabad Medical LUTS 116 85.92
Complex Peshawar from Feb 2009 to Feb 2011. A to- Acute Urinary Obstruction 14 10.37
tal of 135 patients were included in the study. Patients Hematuria 5 3.70
presented with lower urinary tract symptoms (LUTS)
were collected from the out-patient department and Out of all patients, 25 (18.51%) had serum PSA level
were interviewed on International Prostate Symptoms less than or equal to 2ng/ml , 48 patients (35.55%) had
Score (IPSS) proforma. The IPSS developed by WHO serum PSA between more than 2 to 3ng/ml and 62 pa-
has been widely used in assessing Lower Urinary Tract tients (45.92%) had serum PSA of more than 3ng/ml
Symptoms in many countries. Patients data, clinical (Table 3).
history, physical examination including DRE and IPSS
Table-3: Serum PSA level of BPH patients (n=135)
score were carefully evaluated and recorded. Post void
residual volume and Prostate volume were measured Serum PSA level (ng/ml) Frequency Percent
by simple pelvic ultrasonography and Uroflowmetry < 2.00 25 18.51
was done in all patients to find Peak urine flow rate 2.01-3.00 48 35.55
(Qmax). Serum PSA was checked in all patients with >3.01-4.00 62 45.92
cut off value of 4ng/ml. Total 135 100.0
Inclusion criteria were IPSS >20, postvoid residu- On Pelvic ultrasonography, 42 patients (31.1%) had pro-
al volume >100ml, Peak urine flow rate (Qmax) <10ml/ static volume of less than 40 gram, 64 patients (47.4%)
sec, Serum PSA <4ng/ml, Patients age between 51 -80 had 40 to 60 gram and 29 patients (21.4%) had more
years and absence of carcinoma signs on DRE. Exclu- than 60 grams. On DRE, prostate was enlarged in all
sion criteria were postvoid residual volume <100ml, cases. Of them 25 patients (18.51%) had mild enlarge-
age <50 or >80 years, serum PSA > 4ng/ml, Patients ment, 82 patients (60.7%) had moderate enlargement
with hard nodule on DRE or suspicious of prostate can- and 28 patients (20.7%) had huge prostate enlargement

(Table 4). conventional procedure of sampling the prostatic tissue

for routine histopathology. Inadequate sampling rath-
Table-4: Prostatic findings by digital rectal examination (n=135)
er than inaccurate pathological evaluation is the most
Enlarged Frequency Percent frequent problem in the diagnosis of prostate cancer.
Mild 25 18.51 TURP provides much tissues for extensive pathological
Moderate 82 60.7 evaluation which is not usually done in routine histo-
Huge 28 20.7 logical practice.
Total 135 100.0 The gold standard triad for diagnosing prostate
cancer comprised DRE, PSA level and trans-rectal ul-
Histopathology results of 4 patients (2.96%) turned out trasonography.17 The DRE is neither sensitive nor spe-
as adenocarcinoma prostate. Out of these 4 patients, cific enough to detect prostate cancer and is unlikely
one had carcinoma in situ and 3 having definitive well to be improved.18 The positive predictive value of DRE
differentiated adenocarcinoma prostate. Three pa- is approximately 21-53% and these low values are the
tients(75%) with malignancy were more than 65 years one reason that DRE may not be satisfactory for pros-
old while one patient(25%) was aged 59 years. Histopa- tate cancer screening. Also the ability of DRE to detect
thology also showed 105 patients (77.7%) had nodular localized potentially curable cancer may be limited15.
hyperplasia only and 26 patients (19.25%) nodular hy- To improve the detection rate of prostate cancer, the
perplasia with prostatitis(Table 5). DRE should be supplemented by a test with high sensi-
tivity. PSA testing provides such a method, being very
Table-5: Distribution of the respondents by sensitive.18 Cancers of the prostate are a common fea-
histopathological findings (n=135)
ture in the elderly population and many go undetect-
Histological findings Frequency Percent
ed throughout life, but in the era of PSA testing, more
Nodular hyperplasia with prostatitis 26 19.25
cancers tend to be detected before death.19 Even though
Nodular hyperplasia
(no evidence of malignancy)
105 77.7 the use of PSA in urological practice led to important
changes in the differential diagnosis of BPH and Pros-
Carcinoma in Situ 1 0.74
tate carcinoma, about 27% patients with PSA levels be-
Frank Adenocarcinoma 3 2.22
tween 0 and 4ng/ml have prostate carcinoma. Several
Total 135 100.0
advanced level prostate carcinomas had PSA levels in
the normal range, thus limiting the usefulness of these
DISCUSSION measures including PSA for staging.20
The term Prostate cancer is a combination of three The average age of the patients of present series
entities: Clinical prostate cancer, which may become was 65.67 years with age ranged from 51 to 80 years. The
symptomatic and whose diagnosis is made clinically; highest incidence of BPH was noted in 60 to 70 years
Occult prostate cancer, in which the primary lesion re- age group(Table 1). Similar observation was made in
mains small or hidden, but which produces clinically Shaikh et al (2000),21 in which the average age of pa-
overt metastases; and latent prostate cancer , which is tients treated with TURP in their study was 66 years
clinically unrecognizable through signs and symptoms (range 54-80) and maximum patients were belonged to
and is generally an incidental finding at prostatectomy 61 to 70 years age range.
for benign prostatic hyperplasia (BPH), or which is LUTS (85.92%) was commonest complaint at
screen-detected in asymptomatic individuals.14 There- presentation followed by retention of urine (10.3%)
fore the rate of prostate cancer detection depends also and haematuria (3.70%)(Table 2). DRE findings in all
on factors such as a high rate of performing prostatecto- patients were enlarged prostate, firm in consistency,
mies for benign disease and the conduction of popula- palpable median groove and freely mobile rectal mu-
tion based screening programs. cosa over prostate with no nodularity in prostate. 18.5%
Benign prostatic hyperplasia is a growing global showed mild enlargement, 60.7% moderate and 20.7%
health burden. Carcinoma of prostate is common can- with huge enlargement on DRE (Table 4). Serum PSA
cer in Pakistan due to increasing elderly population and level were lower than 4ng/ml in all patients as shown
relatively better diagnostic method15. Transurethral re- in (Table 3).
section of prostate (TURP) has been the gold standard Histopathological examinations of the specimens
for active treatment of BPH since the 1970s.16 A large of TURP chips showed 77.7% nodular hyperplasia with
number of investigations have shown that examina- no malignancy,19.25% nodular hyperplasia with pros-
tion of every fragments of TURPs or serial sectioning in tatitis, 0.74% carcinoma in situ and 2.22% frank adeno-
retro-pubic prostatectomy specimens can detect many carcinoma, with overall incidence of prostate carcino-
prostatic carcinoma which are mostly undetected in ma of 2.96%. This is comparable to a study by Karim,

et al11 and his colleagues, in which they found 2% pros- REFERENCES

tate carcinoma in histological specimens of 100 TURP 1 Neal D. The prostate and seminal vesicles. In: Mann CV ,Rus-
sel RCG , William NS , eds. Bailey and Love’s short practice of
specimens done for BPH with normal serum PSA lev- surgery. 22nd ed. Chapman Hall; London: 1995. 970-85.
el. Another study by Ishtiaq, et al22 and his colleagues 2 Cal C ,Gunaydin G , Ozyurt C , Omay S . Doxazosin: A new
showed same 2% prostate carcinoma in 100 prostatec- cytotoxic agent for prostate cancer. Br J Urol 2000; 85: 672-5.
3 StevensA , Milne R , Stein K , Robertson J. The diagnosis, man-
tomy specimens done for BPH patients. The incidence
agement and costs of prostate cancer in England and Wale,
of carcinoma prostate in the study of Cooneret al23was Health Technology Assessment 1997; 3: 1-70 .
14% in the prostatectomy specimens for benign disease. 4 Rassweiler J , Teber D , Kuntz R , Hofmann R. Complications of
In his study Shah24 reported 4% incidence of carcinoma transurethral resection of the prostate (TURP)- incidence, man-
agement and prevention. EurUrol 2006 Nov; 50(5): 969-79.
prostate. Javaid et al25 and Hamid A26 reported 6% and 5 Ford TF , Cameron KM , Parkinson MC , 1984, ‛ Incidental Car-
4% incidence of carcinoma prostate in their studies .In cinoma of the Prostate: Treatment Selection by Second-Look
his study by Iqbal Sial K,15 showed 8% incidence of pro- TURP’ , British Journal of Urology, vol. 56, pp-582-86.
static carcinoma in a study done on 126 patients in his- 6 H.Lepor , R. S. Owens , V.Rogenes , E. Kuhn . Detection of pros-
tate cancer in males with prostatism . The Prostate , vol. 25, No.
tological specimens for BPH. 3, 1994: 132-40.
Jones et al (2009)27 showed a comparison between 7 R. M. Merrill and C. L.Wiggins . Incidental Detection of Popu-
pre-PSA era (1986-1987) and the PSA era (1994-2000), lation Based Prostate Cancer Incidence Rates through Tran-
surethral Resection Of the Prostate. European Urology, vol. 7,
excluding patients with known carcinoma prostate. A
No. 5, 2002: 213-219.
total of 228 men without a known history of prostate 8 D.G.Bostwick , W.H.Cooner , L. Denis , G. W. Jones ,
cancer underwent TURP during the pre-PSA era time P.T.Scardino and G. P. Murphy .The Association of Benign Pro-
frame and 501 underwent the procedure during the static Hyperplasia and Cancer of the Prostate .Cancer, vol. 70,
No. S1, 1992: 291-301.
PSA era time frame. Malignancy diagnosed at the time 9 Kozlowski JM ,Grayhack JT . Carcinoma of the prostate. In: Gil-
of TURP decreases from 14.9% to 5.2% of patients in the lenwaterJY ,Grathack JT , Howards SS , Ducket JW , editors.
pre-PSA era and PSA-eras, respectively. In our study Adlts and PediatricUrology .3rd edition. USA: M. Mosby Year
we have excluded all the patients having serum PSA Book, 1996.
10 F. J. BiancoJr , P. T. Scardino and J. A. Eastham . Radical Pros-
level of more than 4ng/ml and probably this was the tatectomy : Long-Term Cancer Control and Recovery of Sexual
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11 HF Karim , MN Hooda , MS Islam , MAK Sarker , KR Abedin,
Table-6: Comparison of carcinoma prostate et al . Incidence of chips positive Carcinoma of Prostate follow-
incidence in different literatures and our study ing TURP for clinically Benign Prostate Hypeplasia patients
with normal PSA. Bangladesh Journal of Urology, vol. 14, No.
Author Prostate carcinoma on biopsy 1, 2011: 14-18.
Karim et al11 2% 12 MatlagaBR ,Eskew LA , McCullough DL, 2003, ‛Prostate bi-
Ishtiaq et al 22
2% opsy: Indications and technique’ , The Journal of Urology, vol.
169, pp-12-19.
Shah24 4%
13 Merrill RM ,Feuer EJ , Warren JL , Schussler N and Stephenson
Javaid et al25 6% RA, 1999, ‛Role of Transurethral Resection of the prostate in
Cooner et al23 14 % Population based Prostate Cancer Incidence Rates’ , Am JEpi-
demiol, vol. 150, PP-848-60.
Hamid A 26
4%
14 Boyle P ,Maisonneuve P , Napalkov P. Geographical and tem-
Iqbal Sial K15 6% poral pattern of incidence and mortality from prostate cancer.
Our study 2.96% Urology 1995; 46(suppl 3A):47-55.
15 IqbalSA ,Sial K . Problems in the management of carcinoma
of prostate .A study of 44 cases. Specialist Pak J Med Sci.
CONCLUSION 1995;11:96-10 .
Before the widespread use of PSA screening, fre- 16 MosliHA , ‛Survey of urological centres and review of the cur-
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ease in the Kingdom of Saudi Arabia’ , Saudi Med J, 1996; pp-
and signs of benign prostatic hypertrophy on DRE do
718-24.
not exclude the possibility of prostate cancer. In this 17 Franco O E ,Arimak , Yanagwa M and Kawamura J . The use-
study along with DRE and pelvic ultrasound we have fulness of Power Doppler Ultrasonography for diagnosing
used PSA as a screening method at a cut off value of prostate cancer: histological correlation of each biopsy site. Br J
Urol 2000;85:1049-52.
4ng/ml and patients having below this level were en- 18 U NalD ,SedelaarAarnik. Three dimensional contest enhanced
rolled here only. Lower rate of incidental carcinoma Power Doppler Ultrasonography and conventional examina-
prostate in our study revealed the usefulness to follow tion method: the value of diagnostic predictors of prostate can-
the preoperative screening methods that is DRE, USD cers. Br J Urol 2000;86:54-8.
19 KonetyBR , Bird VY , Deorah S , Dahmoush L. Compari-
and PSA. To avoid unusual systemic needle biopsy and son of the incidence of latent prostate cancer detected at au-
TURP for diagnostic purposes PSA should be done. topsy before and after the prosate specific antigen era. J Urol

2005;174:1785-1788. ment.UroClin North Am 1993;20:653-63.

20 Krahn MD , Mahoney JE , Eckman MH , Trachtenberg J , Pauk- 24 Shah I. Incidence of malignancy in prostatic enlargement at
er SG , Detsky AS. Screening for prostate cancer; decision ana- Liaquat Medical College Hospital, Hyderabad. 1996:105.
lytic view. JAMA 1994;272:773-80. 25 JavaidMS ,Tasncem RA , Manan A. Diagnosis of carcinoma.
21 Shaikh AR , Siyal AR , Shaikh NA. Transurethral resection The yield of serum PSA , DRE & TRUS. Pak J Surg 1996;12:91-
of prostate; Early experience in rural sindh. The Professional 104.
2000;vol. 07, No 02. 26 Hamid A. Percentage of patients with carcinoma prostate pre-
22 Khan IA , Nasir M , Akbar M , Khattak ID, Khan AN , Jan A , senting clinically as BPH. Abbottabad .1998-72.
Asif S , Rehman Z. Carcinoma of prostate in clinically benign 27 Jones JS , Follis HW, Johnson JR. Probability of findings T1a and
enlarged gland. J Ayub Med Coll Abbottabad 2008;20(2):90-92. T1b (incidental) prostate cancer during TURP has decreased in
23 Seaman E ,Whang M , Olsson CA , Katz A , Cooner WH, et al. the PSA era, Prostate Cancer and Prostatic Diseases. 2009, vol.
PSA Density (PSAD). Role in patient evaluation and Manage- 12, pp57-60.
Valsalva Retinopathy
A young woman at 11 weeks of gestation presented
with sudden, painless, central “dark”vision after
an episode of forceful vomiting. Visual acuity
was 20/80 in the left eye. Funduscopy revealed
preretinal hemorrhage enclosed by a dome-
shaped preretinal membrane, features consistent
with Valsalva retinopathy eye were normal, as
were the blood pressure, complete blood count,
prothrombin time, activated partial-thromboplastin
time, and fasting blood glucose level. Improvement
was seen at 2 weeks, 2 months, and 5 months
after presentation, and the hemorrhage finally
resolved. Visual acuity in the left eye improved to
20/25. Typically self-limiting, Valsalva retinopathy is
caused by retinal capillary rupture after abrupt rises
in intraocular venous pressure, which may occur
with violent coughing or vomiting. Subhyaloid and
internal-limiting-membrane hemorrhages can also
occur with hematologic dyscrasias and cancers,
hypertension, the rupture of a retinal macroaneurysm, subarachnoid hemorrhage. Treatment options are
laser membranotomy, vitrectomy, or as in this patient, observation. (NewsNet)

ORIGINAL ARTICLE
Accuracy of Diffusion-weighted
MRI in Localization of Undescended Testes
Zubair Janan
Zubair Janan FCPS1, Misbah Durrani2, Mehmood Akhtar FCPS3
ABSTRACT
Objective: To determine the role of DW MRI in localization of undescended testes.
Study Design: Cross sectional study.
Place and duration of study: Radiology department, Mardan Medical Complex Mardan, from September 2013 to Febru-
ary 2014.
Methodology: Eighteen boys with undescended testes underwent preoperative abdominal and pelvic MRI to identify the
location of the testes. MRI included free-breathing diffusion-weighted imaging (DWI), a T1-weighted turbo spin-echo se-
quence, and a T2-weighted fat-suppressed turbo spin-echo sequence. Post operative findings were reviewed. Sensitivity
and accuracy in the identification of nonpalpable undescended testes were calculated for conventional MRI alone and in
combination with DWI.
Results: Study included 18 patients, using conventional MRI only 15 testis were correctly identified and located whereas
when DWI was added 17 testes were correctly located.
Conclusion: Use of DWI with a high b value yields information that complements conventional MRI findings, improving
identification and location of nonpalpable undescended testes.
Key Words: Undescended testes, diffusion weighted MRI.
INTRODUCTION exists on accuracy of DWI in evaluating undescended

Cryptorchidism is the absence of one or both testes testes.
in the scrotum and is generally synonymous with un- METHODOLOGY
descended testis.1 In approximately 4% of patients, the All MRI examinations were performed with a 1.5-
undescended testis is nonpalpable because it is intra- T MRI system (Toshiba exelert vintage). Before DWI,
abdominal or intra-canalicular or possibly atrophic or the patients underwent MRI spin-echo T1-weighted
absent. The testis usually descend into scrotum around sequence, axial and coronal fat-suppressed turbo spin
the 8th month of fetal life. Most of undescended testis echo T2-weighted sequence, and an axial DWI. DWI
will be corrected spontaneously by the age of 1 year, was performed with b values of 50, 400, and 800 s/
but 0.8% of boys continue to have undescended testis.2 mm2. MR images of both normal and undescended
The most problematic aspect of undescended tes- testes show ovoid appearance which is hypointense to
tis is the diagnosis and management of nonpalpable fat on T1-weighted images while on T2-weighted im-
testes. Accurate diagnosis and appropriate treatment ages typically they are hyperintense or iso-intense to fat
lead to the highest chance of proper testicular function with surrounding black out-line. In routine DWI of the
in an endocrine capacity, that is, with regard to fertil- scrotum, the testes have high signal intensity, probably
ity; in addition, accurate diagnosis can facilitate early owing to their high cell density. At DWI, the abdomen
detection of malignant tumors.3 was imaged for focal areas of hyperintensity. Elliptic
The current algorithm for searching for a nonpal- areas of hyperintensity were recorded as testes, and the
pable testis is to perform abdominal scrotal ultrasound location of a nonpalpable testis was classified into three
and if the ultrasound findings are non-diagnostic to anatomic regions: intracanalicular, pelvic, abdominal.
perform MRI, which yields excellent tissue contrast All of the patients underwent surgery within 4 weeks
even on unenhanced images.4 To the best of authors of the preoperative MRI examination. On DW images,
knowledge, no published local (Pakistani-based) data testes were recorded for focal areas of hyperintensity
that did not represent T2 shinethrough from fluid-con-
Senior Registrar, Department of Radiology, Bacha Khan Medical
1
taining structures.
College & Mardan Medical Complex, Mardan, 2Assisatant Professor,
Department of Radiology Bacha Khan Medical College & Mardan RESULTS
Medical Complex, 3Assistant Professor, Department of Radiology, This study included 18 boys with suspected di-
Kohat Institute of Medical Sciences, Kohat.
agnosis of undescended testes ,(mean age, 7 ± 1.9 [SD]
Correspondence: Dr Zubair Janan, Senior Registrar, Radiology years; range, 4 months–13 years) who underwent ab-
Department Mardan Medical Complex, Mardan, E-mail: zjaurakzai@ dominal and pelvic MRI. On per-operative evaluation,
hotmail.com House No 27, Sector T, Sheikh Malton Town, Mardan
testes were identified in intracanalicular locations in
Received: Feb’ 2014 Accepted March’ 2014 9 (50.0%), pelvic location in 4 (22.2%), and abdomi-

nal locations in 2 (5.5%).The combination of DWI and signal intensity.9 We therefore added DWI to routine
conventional MRI was sensitive and the accurate tech- MRI to identify non-palpable undescended testes. With
nique, facilitating visualization and location of 17 tes- MRI alone, the sensitivity was .83% ,accuracy was .83%.
tes, with sensitivity of 0.94 and accuracy of 0.94 (p < However, when we added DWI to conventional MRI,
0.05). Using conventional MRI alone, observers located both the sensitivity and accuracy were raised to 0.94
15 testes (sensitivity, 0.83; accuracy, 0.83). A focus misi- and 0.94 respectively. Kantarci et al10 also studied DW
dentified as testis in the pelvis turned out to be infected imaging for detecting undescended testes and found
lymph node, resulting in one false positive result. that sensitivity and accuracy increased when DWI was
added to conventional MRI Sequences. Our results con-
firm that DWI findings complement the information on
the location of undescended testes obtained with con-
ventional MRI.
Patient A, Fig-1: T2W selected axial section show a hypointense

signal mass lesion in right inguinal region-undescended testis
DISCUSSION
A widely accepted approach to the management
of nonpalpable undescended testes remains controver-
sial. Various approaches to identifying an impalpable
testis, including CT, sonography, MRI, and laparos- Patient A, Fig-2: Paired diffusion weighted image show
copy.5 Laparoscopy has been established as the most conspicuous right inguinal mass lesion-undescended testis
reliable diagnostic technique for the identification of
non-palpable undescended testes,6 however, it is inva-
sive. MRI is a noninvasive diagnostic technique and
holds great potential for abdominal imaging. It does
not entail ionizing radiation or intravascular contrast
medium.6,7,11 Kanemoto et al.4 used MRI for the diag-
nosis of nonpalpable testis and found that MRI can
be expected to have an accuracy of 85%, sensitivity of
86%, and specificity of 79%. Sarihan et al.8 found that
MRI had sensitivity of 78.6% and specificity of 100% in
the detection of nonpalpable undescended testis. Only
conventional MRI techniques were used in those stud-
ies. Intra abdominal testes are considerably more cel-
lular than the adjacent organs and tissues and can be Patient B, Pic-1: showing a hyperintense structure in left
detected easily on DW images owing to their increased pelvic region adjacent to urinary bladder on T2W FATSAT image

infected lymph node. This handicap is valid not only

for DWI but also for conventional MRI. Our study has
the following limitation. First, the patient sample was
relatively small. Second, patients younger than 6 years
needed sedation or general anesthesia for an optimal
MRI examination.
CONCLUSION
Based on the present results we recommend the
use of DWI in addition to conventional MRI to increase
the preoperative sensitivity and accuracy of identifying
and locating non-palpable undescended testes.
REFERENCES
1. Barthold JS, González R. The epidemiology of congenital
Patient B, PIC-2: coronal T2WFATSAT image cryptorchidism, testicular ascent and orchiopexy. J Urol.
2003;170:2396–2401.
2. Williams EV, Appanna T, Foster ME, et al. Management of the
impalpable testis: a six year review together with a national ex-
perience. Postgrad MedJ 2001; 77:320–322.
3. Thorup J, Haugen S, Kollin C, et al. Surgical treatment of unde-
scended testes. Acta Paediatr 2007; 96:631–637.
4. Kanemoto K, Hayashi Y, Kojima Y, et al. Accuracy of ultra-
sonography and magnetic resonance imaging in the diagnosis
of nonpalpable testis. Int J Urol 2005; 12:668–672.
5. Encyclopaedia of medical imaging (Net), (2003) Vol.2A-
Fritzsche P.I., Hricak H., Kogan B.A.,Winkler M.L.,& Tanagho
E.A.: Undescended testis: Value of MR imaging, (987), Radiol-
ogy, Vol. 164, 169-173.
6. Argos Rodriguez MD, Unda Freire A, Ruiz Orpez A, Garcia
Lorenzo C. Diagnostic and therapeutic laparoscopy for nonpal-
pable testis. Surg Endosc 2003; 17:1756–1758.
7. Mathers MJ, Sperling H, Rübben H, et al. The undescended
testis: diagnosis, treatment and longterm consequences. Dtsch
Patient B, Pic-3: Corresponding DW image Arztebl Int 2009; 106: 527–532.
confirms the finding. 8. Sarihan H, Sari A, Abeş M, et al. Nonpalpable undescended
testis: value of magnetic resonance imaging. Minerva Urol Nef-
In this study, we assumed that on DW images all el- rol 1998; 50:233–236.
liptic areas in the abdomen or inguinal region that had 9. Koh DM, Collins DJ. Diffusion-weighted MRI in the body: ap-
plications and challenges in oncology. AJR 2007; 188:1622–1635.
high signal intensity represented testes. However, the
10. Kantarci M, Doganay S, Yalcin A, Aksoy Y, Yilmaz-Cankaya B,
finding of an elliptic area of high signal intensity is Salman B. Diagnostic performance of diffusion-weighted MRI
not always specific for undescended testis. For exam- in the detection of nonpalpable undescended testes: compari-
ple, lymph nodes and adjacent fluid containing areas son with conventional MRI and surgical findings. AJR Am J
Roentgenol.2010;195(4):268-73.
also can be seen as areas of high signal intensity on
11. Ritzén EM, Kollin C. Management of undescended testes: how
DW images. We had a false positive result due to an and when? Pediatr Endocrinol Rev. 2009;7(1):32–37.

ORIGINAL ARTICLE
Effectiveness of Autologous Blood Injection in

Patients with Lateral Epicondylitis (Tennis Elbow)
M. Khalid Khan
Muhammad Khalid Khan1, Samir Khan Kabir MBBS2, Sikander Hayat FCPS3
ABSTRACT
Introduction: Lateral epicondylitis is a painful musculoskeletal condition. Autologous blood injection is one of the conserva-
tive treatments with the concept that it provides the necessary cellular and humoral mediators to induce a healing cascade.
Objective: To determine the effectiveness of autologous blood injection in patients with lateral epicondylitis.
Material and Methods: This descriptive cross sectional study was carried out at Department of Orthopedics and Trauma,
Khyber Teaching Hospital, Peshawar from September, 2012 to August, 2013 recruiting 54 patients from OPD. Lateral
epicondyl was infiltrated with 2 ml of autologous blood mixed with 2ml of Xylocaine 2%. Effectiveness of autologous blood
injection was determined in terms of improvement in at least one grade of pain on Visual Analogue Scale at 12 weeks follow
up. Data was entered in software SPSS version10.0.
Results: There were 22 (40.74%) males and 32 (59.26%) females. At 12 weeks follow up, the overall effectiveness of ABI
was in 41 (75.92%) patients. The baseline grade of pain by VAS before autologous blood injection was moderate in 24
(44.44%) patients and severe in 30 (55.56%) patients. After ABI, 19 (35.18%) patients improved from moderate pain to no
pain and mild pain (Grade 0 &1) while 22 (40.74%) patients with severe pain (Grade 3) showed improvement to no pain
(grade 0), mild and moderate pain (Grade 1 and 2).
Conclusion: Autologous blood injection is very effective to control the pain of Lateral epicondylitis as evident by the de-
crease in the baseline grades of VAS at 12 weeks follow up.
Key words: Autologous blood Injection; Lateral Epicondylitis; Visual analogue Scale
INTRODUCTION tions have been described, there is little clear consensus

Lateral epicondylitis, or tennis elbow, is a com- on which modality works best, for both conservative
mon cause of elbow pain in the general population1 and operative options.7 Nonsurgical treatment is con-
with an annual incidence of 1 to 3 percent; the condi- sidered as the mainstay of management by various
tion affects men and women equally.2 The incidence authors and involves a myriad of options, including
rate of medical consultations has been estimated at 0.3- rest, non-steroidal anti-inflammatory drugs, physical
1.1 for lateral epicondylitis per year per 100 subjects of therapy, corticosteroid injection, aoutolougus blood
general practice populations. Forceful activities, high and botulinum toxin injections, supportive forearm
force combined with high repetition or awkward pos- bracing, and local modalities.8
ture and awkward postures are associated with lateral In 1993 Edwards and Calandruchio published
epicondylitis. Lateral epicondylitis has been attributed their paper regarding use of autologous blood in treat-
to degeneration of the extensor carpi radialis brevis ori- ment of TE even in those patients that were not cured
gin and it appears to be multifaceted,4 involving hypo- by other methods. It is stated that blood contains hu-
vascular zones, eccentric tendon stresses, and a micro- meral and cellular mediators that initiate an inflamma-
scopic degenerative response, although some authors tory process in the injured tissue and result in repair.9
has contributed the underlying collateral ligamentous Delivery of autologous blood derived growth factors to
complex and joint capsule in its implication.5 Lateral the site of disease has also been shown to significantly
epicondylitis presents as a history of occupation or ac- help the healing process in tennis elbow.10 These growth
tivity related pain just distal to the lateral epicondyle factors can be delivered by an injection of whole blood
over the extensor tendon mass. Symptoms are usually or platelet concentrate. However scientific clinical evi-
reproduced with resisted supination or wrist dorsiflex- dence supporting incorporation of such modalities into
ion, particularly with the arm in full extension.6 routine clinical practice is scanty at present.11
Evidence based literature has failed to support a single The aim of the study was to know the effectiveness
treatment modality. Over 40 different treatment op- of ABI in lateral epicondylitis. The results of this study
will also help other health professionals and suggestions
1
Registrar, 2PG Trainee, 3Assistant Prof.
will be given for rationale use ABI for LE. This will fur-
Correspondence: Dr. Muhammad Khalid Khan, Registrar,Orthopedics ther help us in reducing the cost of treatment, outdoor
& Trauma Unit Khyber Teaching Hospital, Peshawar, Room No: 92 hospital visits of patients and early rehabilitation.
New Doctor Hostel, Khyber Teaching Hospital Peshawar.
E-Mail: drkkafridi@gmail.com Cell: 03219081319 MATERIAL AND METHODS
This interventional non randomized control trial was
Received: Jan’ 2014 Accepted: March’ 2014
carried out during September, 2012 to August, 2013 at

Orthopaedics and Trauma Unit, Khyber Teaching Hos- logue Scale at 12 weeks follow up. The demographic
pital, Peshawar, recruiting 54 patients by consecutive variables were gender, age in years, age grouping &
(non-probability) sampling technique. Lateral Epicon- duration of symptoms and the research variables were
dylitis was diagnosed clinically as pain on outer (later- grade of pain before injection and grade of Pain after
al) part of the elbow with a point of maximum tender- injection. Qualitative variable were analyzed as num-
ness present for at least 6 weeks and becoming worse ber (frequency) and percentages (relative frequencies)
by wrist extension against resistance in a pronated and quantitative variables were analyzed as mean, SD,
hand (Cozen’s Test). All patients of either gender with minimum & maximum.
lateral epicondylitis with moderate to severe pain be- Exclusion criteria was followed strictly to control
tween 20 to 70 years of age were included in the study. confounding variables and bias in the study results.
The exclusion criteria adopted was; patients with prior Data was analyzed by SPSS version10.0. Effectiveness
surgery of elbow, dislocation, tendon ruptures, frac- was stratified among age, sex and duration of elbow
tures, cervical, shoulder and wrist pathology, local pain to see the effect modification. The results were
skin infection or osteomyelitis, patients receiving presented as tables and graphs. Statistical tests like wil-
steroid injections within three months and previously coxon test/Fisher’s test/ Chi-square test were applied
treated by surgery for lateral epicondylitis. The pur- where required for significance and the p value > 0.05
pose, benefits and drawbacks of the study were ex- was considered significant.
plained to the patient and a written informed consent RESULTS
was obtained. For injection infiltration, the patients There were 54 patients comprising of 22 (40.74%)
were placed in a supine position with the affected males and 32 (59.26%) females with the mean ages of
arm resting at the side of the body and the elbow was 33.61 years + 7.56SD. Age distribution of patients was;
flexed to 45 degrees and the wrist pronated. The most 20 to 30 years were 11 (20.37%), from 31 to 40 years were
tender point of the epicondyl was identified by gen- 26 (48.15%), from 41 to 50 years of age were 10 (18.51%)
tle palpation and infiltrated with 2 ml of autologous and from 51 years and above were 7 (12.96%). Age
blood drawn from contra lateral upper limb cubital range was from 20 to 59years. The distribution of dura-
vein mixed with 2ml of Xylocaine 2%. The needle was tion of symptoms was; 6 to 12 weeks were 21 (38.33%)
inserted at 90 degrees down to the level of the bone and more than 12 weeks were 33 (61.11%). The mean
and then pulled back 1 to 2 mm. After injection, the duration of symptoms was 59.61 days + 35.09SD. The
patients were kept for 30 minutes under observation range of duration of symptoms was from 45 days to 95
in the OPD for hemodynamic stability and then the days. At 12 weeks follow up, the overall effectiveness
patients were discharged. of ABI was in 41 (75.92%) patients with improvement
A detailed history was taken followed by detailed of at least 1 baseline grade of pain on visual analogue
physical and systemic examination. Pain was assessed scale. The baseline grade of pain by VAS before autolo-
by visual analogue score (VAS) using a 10cm stripe as gous blood injection was moderate in 24 (44.44%) pa-
shown below; tients and severe in 30 (55.56%) patients. After ABI, 19
(35.18%) patients improved from moderate pain to no
pain and mild pain (Grade 0 and 1) at 12 weeks follow
up, while 22 (40.74%) patients showed improvement to
no pain (grade 0), mild and moderate pain (Grade 1 and
2) from severe pain. The p = 0.753 which is considered
to be not statistically significant. Full detail is shown in
Table:1
The maximum number of patients were 26
(48.15%) from the age group of 31-40 years and the
effectiveness of autologous blood injections at 12
weeks follow up was 16 (29.62%) in this age group.
Maximum effectiveness was also observed in this
According to visual analogue scale (VAS), the age group. According to gender, 15 (27.78%) males
pain of the lateral epicondylitis was graded as follows: and 26 ((48.15%)) females showed effectiveness. Chi
Grade 0: no pain (VAS 0), Grade 1: Mild pain (VAS 1-3), squared equals 0.034 with 1 degrees of freedom. The
Grade 2: Moderate pain (VAS 4-7), Grade 3: Severe two-tailed P value equals 0.8540, which is consid-
pain (VAS 8-10). Effectiveness of autologous blood in ered to be not statistically significant. Age and gen-
patients with lateral epicondylitis was determined by der wise effectiveness of autologous blood injection
improvement in at one grade of pain on Visual Ana- is shown in detail in Table:2

TABLE-1: Effectiveness of autolougus blood injection in terms of

improvement of pain on vas at 12 weeks follow up in lateral epicondylitis
After ABI
Before ABI Effectiveness
No Pain Mild Pain Moderate Pain Severe Pain
Moderate Pain
9 (16.67%) 10 (18.51%) 5 (9.26%) 0 (%) 19 (35.18%)
N=24 (44.44%)
Severe Pain
10 (18.51%) 8 (14.81%) 4 (7.41%) 8 (14.81%) 22 (40.74%)
N=30 (55.56%)
Total
19 (35.18%) 18 (33.33%) 9 (16.67%) 8 (14.81%) 41 (75.92%)
N=54
P = 0.753
TABLE-2: Age and gender wise distribution of

effectiveness of autologous blood injection in patients with lateral epicondylitis
Age No Pain Mild Pain Moderate Pain Severe Pain Effectiveness p value
20-30 years
4 (7.41%) 5 (9.26%) 2 (3.70%) 0 (0%) 10 (18.51%)
N=11 (20.37%)
31-40 years
10 (18.51%) 5 (9.26%) 3 (5.56%) 8 (14.81%) 16 (29.62%)
N=26 (48.15%)
0.858
41-50 years
4 (7.41%) 4 (7.41%) 2 (3.70%) 0 (0%) 9 (16.67%)
N=10 (18.51%)
51 and above
1 (1.85%) 4 (7.41%) 2 (3.70%) 0 (0%) 6 (11.11%)
N=7 (12.96%)
Gender
Male
6 (11.11%) 7 (12.96%) 4 (7.41%) 5 (9.26%) 15 (27.78%)
N=22 (40.74%)
Female
13 (24.07%) 11 (20.37%) 5 (9.26%) 3 (5.56%) 26 (48.15%) 0.832
N=32 (59.26%)
Total 19 (35.18%) 18 (33.33%) 9 (16.67%) 8 (14.81%) 41 (75.92%)
DISCUSSION of autologous blood injection was 75.92%. Several stud-

Tennis elbow is one of the commonest painful con- ies have investigated the effectiveness of AB injection
ditions, originally described as an inflammatory pro- in the treatment of LE and our findings are consistent
cess, the current consensus is that lateral epicondylitis with those of other studies. In a local study by Shah FA
is initiated as a micro tear, most often within the origin et al2 has reported that after a single injection of AB,
of extensor carpi radialis brevis (ECRB).12 Conservative 77.2% patients resulted in lowering their mean pre-in-
treatment includes non-steroidal anti-inflammatory jection pain score and Nirschl score of 6.2 and 6 to 0.1
drugs (NSAIDS), exercises, restriction from manual and 1.1 post-injection respectively.
work, local steroid injection, lithotripsy and autologous Edward SG, et al,10 has reported that AB injection
blood injection, Autologous blood and steroid injec- in LE after the average follow-up of 9.5 months relieved
tions can bring quick relief of pain and improve func- completely of pain even during strenuous activity in
tion of the elbow and early resumption of daily work.13 79% of patients. Mishra A, et al,16 after a follow-up of 26
We observed female predominance with male to female weeks observed a significant decrease in pain sensation
ration 1:1.6. A local study at Ayub Teaching Hospital in AB group. Similar to our results, no side effect was
has also documented female predominance with lateral reported in either group. Kazemi M, et al,17 in a single
epicondylitis.14 Bharti A et al has reported 78% females blind, randomized clinical trial showed that at 8 weeks,
mostly house wives with lateral epicondylitis.15 autologous blood was more effective in severity of pain
Addressing our research questions, we found within last 24 hours; limb function; pain and strength
good evidence of effectiveness of AB for LET at 12 in maximum grip; disabilities of the arm, shoulder, and
weeks period follow up. Our study showed that AB hand quick questionnaire (Quick DASH) scores; modi-
diminished the severity of symptoms and effectiveness fied Nirschl scores; and pressure pain threshold.

Our this study was based on the fact that Autolo- TD. Treatment of lateral epicondylitis. Am Fam Physi-
gous blood injection for LE is based on the histopatho- cian 2007 Sep 15;76(6):843-8.
6. Chumbley EM, O’Connor FG, Nirschl RP. Evaluation of overuse el-
logical observation that angio-fibroblastic degeneration, bow injuries. Am Fam Physician. 2000;61:691–700.
more commonly known as tendinosis, is characterized 7. Faro F, Wolf JM. Lateral epicondylitis: review and current con-
by invasion of blood vessels, fibroblasts and lymphatics cepts. J Hand Surg Am. 2007 Oct;32(8):1271-9.
into the symptomatic area of the extensor carpi radialis 8. Smidt N, van der Windt DA, Assendelft WJ, Devillé WL, Ko-
rthals-de Bos IB, Bouter LM. Corticosteroid injections, physi-
brevis. The injection of autologous blood is thought to otherapy, or a wait-and-see policy for lateral epicondylitis: a
provide the necessary cellular and humoral mediators randomised controlled trial. Lancet 2002 Feb 23;359(9307):657-
to induce a healing cascade.18 This has been observed 62.
by some authors ultrasonically like Connell DA, et al,19 9. Mobarakeh MK, Nemati A, Fazli A, Fallahi A, Safari S. Autol-
ogous blood injection for treatment of tennis elbow. Trauma
who sonographically demonstrated reduction in the Monthly 2013 January;17(4):393-5.
total number of interstitial cleft formations, an echoic 10. Edwards SG, Calandruccio JH: Autologous blood injections for
foci, tendon thickness, hypo-echoic change, and neo- refractory lateral epicondylitis. J Hand Surg 2003;28A:272–8.
vascularity at 6th month after injection. The study sug- 11. Jindal N, Gaury Y, Banshiwal RC, Lamoria R, Bachhal V. Com-
parison of short term results of single injection of autologous
gested that AB injection be a primary technique for the blood and steroid injection in tennis elbow: a prospective
treatment of LE and that sonography can be used to study. J Orthop Surg Res 2013;8:10.
guide injections and monitor changes to the common 12. Bisset L, Paungmali A, Vicenzino B, Beller E. A systemic review
extensor origin. and meta-analysis of clinical trials on physical interventions for
lateral epicondylalgia. Br J Sports Med 2005;39:411-22.
The main limitation of our study was the short 13. Torp-Pedersen TE, Torp-Pedersen ST, Qvistgaard E, Blid-
follow-up period keeping. Further research is needed dal H. Effect of glucocorticosteroid injections in tennis elbow
to establish long-term effectiveness and also to know verified on colour Doppler ultrasound evidence of inflamma-
about the complications of AB injection in LE. During tion. Br J Sports Med 2008;42(12):978-82.
14. Khan MS, Kamran H, Khan SA, Ahmed M, Khan A, Younas
this short follow up, we didn’t encounter any early com- M et al. Outcome of modified surgery in tennis elbow. J Ayub
plications like infection. It was due to our strict proto- Med Coll Abbottabad 2007;19:50-2.
col for aseptic technique but we were not able to know 15. Bharti A, Sachin A. Clinical assessment of functional outcome
the late complications like rupture or weakness of the in lateral epicondylitis managed by local infiltration of autolo-
gous blood. Internet J Med Update 2010 January;5(1):20-24.
extensor carpi radialis brevis tendon and atrophies of 16. Mishra A, Pavelko T: Treatment of chronic elbow tendi-
subcutaneous fat tissue in the long term. Further stud- nosis with buffered platelet-rich plasma. Am J Sport Med
ies should be conducted to know about these complica- 2006;34:1774–8.
tions. Overall, we have noticed that ABI is effective for 17. Kazemi M, Azma K, Tavana B, Rezaiee Moghaddam F, Panahi
A. Autologous blood versus corticosteroid local injection in
LE. Although the p = 0.753 which is considered to be the short term treatment of lateral elbow tendinopathy: a ran-
not statistically significant. We performed the study on domized clinical trial of efficacy. Am J Phys Med Rehabil 2010
patients of various socioeconomic classes whose com- Aug;89(8):660-7.
pliance was high. In our study, statistical analyses were 18. Nirschl RP, Ashman ES. Tennis elbow tendinosis (epicondyli-
tis). Instr Course Lect 2004;53:587–98.
straightforward, and missing data analysis was not re- 19. Connell DA, Ali KE, Ahmad M. Ultrasoundguided autologous
quired. blood injection for tennis elbow. Skeletal Radiol 2006;35:371–7.
CONCLUSIONS 20. 08 Jan;16(1):19-29.
From the results of this study it is concluded that 21. Shah FA, Khan H, Kifayatullah. Chronic tennis elbow; Out-
come of autologous blood injections for the treatment. Profes-
autologous blood injection is very effective to control the sional Med J 2011 Dec;18(4):621-5.
pain of lateral epicondylitis as evident by the decrease 22. Waseem M, Nuhmani S, Ram CS, Sachin Y. Lateral epicondy-
in the baseline grades of VAS at 12 weeks follow up. Al- litis: a review of the literature. J Back Musculoskelet Rehabil
though this is statistically insignificant, it should be rec- 2012;25(2):131-42.
23. Trudel D, Duley J, Zastrow I, Kerr EW, Davidson R, MacDer-
ommend to be adopted as a routine treatment for LE. mid JC.Rehabilitation for patients with lateral epicondylitis: a
REFERENCES systematic review. J Hand Ther 2004 Apr-Jun;17(2):243-66.
1. Calfee RP, Patel A, DaSilva MF, Akelman E.Management of 24. Johnson GW, Cadwallader K, Scheffel SB, Epperly
lateral epicondylitis: current concepts. J Am Acad Orthop Surg TD. Treatment of lateral epicondylitis. Am Fam Physi-
2008 Jan;16(1):19-29. cian 2007 Sep 15;76(6):843-8.
2. Shah FA, Khan H, Kifayatullah. Chronic tennis elbow; Out- 25. Chumbley EM, O’Connor FG, Nirschl RP. Evaluation of overuse el-
come of autologous blood injections for the treatment. Profes- bow injuries. Am Fam Physician. 2000;61:691–700.
sional Med J 2011 Dec;18(4):621-5. 26. Faro F, Wolf JM. Lateral epicondylitis: review and current con-
3. Waseem M, Nuhmani S, Ram CS, Sachin Y. Lateral epicondy- cepts. J Hand Surg Am. 2007 Oct;32(8):1271-9.
litis: a review of the literature. J Back Musculoskelet Rehabil 27. Smidt N, van der Windt DA, Assendelft WJ, Devillé WL, Ko-
2012;25(2):131-42. rthals-de Bos IB, Bouter LM. Corticosteroid injections, physi-
4. Trudel D, Duley J, Zastrow I, Kerr EW, Davidson R, MacDer- otherapy, or a wait-and-see policy for lateral epicondylitis: a
mid JC.Rehabilitation for patients with lateral epicondylitis: a randomised controlled trial. Lancet 2002 Feb 23;359(9307):657-
systematic review. J Hand Ther 2004 Apr-Jun;17(2):243-66. 62.
5. Johnson GW, Cadwallader K, Scheffel SB, Epperly

28. Mobarakeh MK, Nemati A, Fazli A, Fallahi A, Safari S. Autol- M et al. Outcome of modified surgery in tennis elbow. J Ayub
ogous blood injection for treatment of tennis elbow. Trauma Med Coll Abbottabad 2007;19:50-2.
Monthly 2013 January;17(4):393-5. 34. Bharti A, Sachin A. Clinical assessment of functional outcome
29. Edwards SG, Calandruccio JH: Autologous blood injections for in lateral epicondylitis managed by local infiltration of autolo-
refractory lateral epicondylitis. J Hand Surg 2003;28A:272–8. gous blood. Internet J Med Update 2010 January;5(1):20-24.
30. Jindal N, Gaury Y, Banshiwal RC, Lamoria R, Bachhal V. Com- 35. Mishra A, Pavelko T: Treatment of chronic elbow tendi-
parison of short term results of single injection of autologous nosis with buffered platelet-rich plasma. Am J Sport Med
blood and steroid injection in tennis elbow: a prospective 2006;34:1774–8.
study. J Orthop Surg Res 2013;8:10. 36. Kazemi M, Azma K, Tavana B, Rezaiee Moghaddam F, Panahi
31. Bisset L, Paungmali A, Vicenzino B, Beller E. A systemic review A. Autologous blood versus corticosteroid local injection in
and meta-analysis of clinical trials on physical interventions for the short term treatment of lateral elbow tendinopathy: a ran-
lateral epicondylalgia. Br J Sports Med 2005;39:411-22. domized clinical trial of efficacy. Am J Phys Med Rehabil 2010
32. Torp-Pedersen TE, Torp-Pedersen ST, Qvistgaard E, Blid- Aug;89(8):660-7.
dal H. Effect of glucocorticosteroid injections in tennis elbow 37. Nirschl RP, Ashman ES. Tennis elbow tendinosis (epicondyli-
verified on colour Doppler ultrasound evidence of inflamma- tis). Instr Course Lect 2004;53:587–98.
tion. Br J Sports Med 2008;42(12):978-82. 38. Connell DA, Ali KE, Ahmad M. Ultrasoundguided autologous
33. Khan MS, Kamran H, Khan SA, Ahmed M, Khan A, Younas blood injection for tennis elbow. Skeletal Radiol 2006;35:371–7.
Letter to the Editor

Dear Sir, enough words to express my thanks and gratitude.
It is pleasure for me to write these lines. I am I do feel now that our colleagues are taking notice
confident that your guidance will elevate me aca- of my hypothesis. No exaggeration, you have not
demically which will be beneficial to the patients. The only been extremely supportive of my views from
standard of the Ophthalmology update is high start- day one but have projected tremendously in your
ing from editorial. The photograph of patients may Ophthalmology Update which makes me feel very
be published in color. These may be more impressive proud of Pakistan. Our Pakistan is surviving only
and attractive. because of dedicated persons like you. I particularly
liked the article on “History of Ophthalmic Surgery
With regards, & Contribution of Muslim Scholars” written by Dr.
Dr. Mazhar Zaman Soomro Madiha Durrani. May Allah always bless you and
Eye Infirmary, Khanpur your family.
Best regards
Dear Prof. Durrani, Syed S. Hasnain
I went to my office and found your Oct-Decem- M.D. General Ophthalmology
ber issue in mail. This Journal is indeed one of the 560 W, Putnam Ave. Suite #6
best with full of very nice articles. You have project- Porterville, CA 93257
ed my theory extremely well for which I don’t have Email: hasnain40@sbcglobal.net

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Ophthalmology Update Vol. 12. No.

 OPHTHALMIC SECTION / ORIGINAL ARTICLES

 Problems and Complications faced by Ophthalmic Residents during Cataract

 Nd-Yag Laser Capsulotomy Efficacy vs Complications

 Efficacy of Stem Cell Graft in Preventing the Recurrences of Pterygium

 What for we are looking in Psuedoexfoliation: A Clinical Presentation of the Patients

 Comparison of Visual Outcome with single Suture Vs Sutureless Clear Corneal

 Post-operative Diplopia in Children with Horizontal Strabismus

 Primary Pterygium Excision: A Better Technique to avoid Recurrences

 GENERAL SECTION / ORIGINAL ARTICLES

 Current Pattern of Mechanical Intestinal Obstruction in Adults (A Hospital Based Study)

ii Ophthalmology Update Vol. 12. No. 2, April-June 2014

 Incidence of Prostate Cancer following Trans-Urethral Resection of Prostate (TURP) for

 Accuracy of Diffusion-weighted MRI in Localization of Undescended Testes

Ophthalmology Update Vol. 12. No. 2, April-June 2014 iii

Instructions to the Authors

iv Ophthalmology Update Vol. 12. No. 2, April-June 2014

Ophthalmology Update Vol. 12. No. 2, April-June 2014 90

Table-1: Summary of literature related to retinoblastoma in Pakistan

Total Bilateral Age at Diagnosis,

17th ANNUAL CONGRESS OF OPHTHALMOLOGY

91 Ophthalmology Update Vol. 12. No. 2, April-June 2014

Evaluation of Functional &

Muhammad Nazim FCPS1, Muhammad Bilal MBBS2, Lal Muhammad FCPS3

INTRODUCTION connection was made by Hatt et al, the so called ‘adult

Ophthalmology Update Vol. 12. No. 2, April-June 2014 92

93 Ophthalmology Update Vol. 12. No. 2, April-June 2014

in our patients. For non-diplopic strabismus patients, REFERENCES

Ophthalmology Update Vol. 12. No. 2, April-June 2014 94

Problems and Complications faced by

INTRODUCTION corneal striate etc. posterior capsular rent and vitreous

Variables N=100(%) Mean ±SD TABLE-7: Combined table of complication N =150

Ophthalmology Update Vol. 12. No. 2, April-June 2014 96

DISCUSSION belongs to backwards areas of our province and FATA

97 Ophthalmology Update Vol. 12. No. 2, April-June 2014

Effect of Yag Laser Energy in Mille Joules (Mj)

ITRODUCTION safer, more effective and an out-patient procedure. The

Ophthalmology Update Vol. 12. No. 2, April-June 2014 98

+ standard deviation was computed for numerical vari- 7 6.5 35

99 Ophthalmology Update Vol. 12. No. 2, April-June 2014

Ophthalmology Update Vol. 12. No. 2, April-June 2014 100

Nd-Yag Laser Capsulotomy

INTRODUCTION play an important role in fibrous proliferation of LECs

101 Ophthalmology Update Vol. 12. No. 2, April-June 2014

checked 30-60 minutes postoperatively. Iritis can be RESULTS

cornea was anesthetized with topical application of 5. Retinal detachment 00 00%

Ophthalmology Update Vol. 12. No. 2, April-June 2014 102

103 Ophthalmology Update Vol. 12. No. 2, April-June 2014

Clinical Presentation and Management

INTRODUCTION peripheral neuropathy (a form of Charcot-Marie-Tooth

Ophthalmology Update Vol. 12. No. 2, April-June 2014 104

105 Ophthalmology Update Vol. 12. No. 2, April-June 2014

Table 2: Patient Data

Ophthalmology Update Vol. 12. No. 2, April-June 2014 106

107 Ophthalmology Update Vol. 12. No. 2, April-June 2014

OSP Khyber Pakhtunkhawa, Peshawar

8th KHYBER EYE SYMPOSIUM, 13-15 June’ 2014

Subject: ORBIT & OCULOPLASTY

Ophthalmology Update Vol. 12. No. 2, April-June 2014 108

Efficacy of Stem Cell Graft in

INTRODUCTION more common in tropical and subtropical countries.

109 Ophthalmology Update Vol. 12. No. 2, April-June 2014

Ophthalmology Update Vol. 12. No. 2, April-June 2014 110

111 Ophthalmology Update Vol. 12. No. 2, April-June 2014

OPHTHALMIC SECTION / ORIGINAL ARTICLES

Problems and Complications faced by Ophthalmic Residents during Cataract

Nd-Yag Laser Capsulotomy Efficacy vs Complications

Efficacy of Stem Cell Graft in Preventing the Recurrences of Pterygium

What for we are looking in Psuedoexfoliation: A Clinical Presentation of the Patients

Comparison of Visual Outcome with single Suture Vs Sutureless Clear Corneal

Post-operative Diplopia in Children with Horizontal Strabismus

Primary Pterygium Excision: A Better Technique to avoid Recurrences

GENERAL SECTION / ORIGINAL ARTICLES

Current Pattern of Mechanical Intestinal Obstruction in Adults (A Hospital Based Study)

Incidence of Prostate Cancer following Trans-Urethral Resection of Prostate (TURP) for

Accuracy of Diffusion-weighted MRI in Localization of Undescended Testes