Coral reef aorta: a rare form of obstruction of the ascending aorta in adolescent with aortopathy- case report

BACKGROUND

Supra aortic obstruction in children is uncommon and is seen in certain unique conditions. While intraluminal obstruction due to heavy calcification is seen in older populations, it is not described in pediatric populations. The coral reef aorta is a rare and distinct calcifying disease causing luminal obstruction of the suprarenal aorta in adults. The definition of this diagnosis relies entirely on the unique aspects and consistency of the lesions, which are rock-hard, irregular, gritty plaques with a white luminal surface resembling a coral reef. However, no such case has been described in children.

CASE PRESENTATION

We present an adolescent boy who presented with a heavily calcified ascending aortic lesion associated with aortopathy and hypertension, 12 years after an aortic coarctation repair. The investigations included echocardiography, magnetic resonance and computer-tomographic imaging. A 3-D model was printed in order to visualize and plan surgical steps in advance for safe placement of clamps and defining the extent of resection. In addition, it provided an idea about tissue quality, thickness, spatial relationship, and orientation in relation to surrounding structures. Successful resection and replacement of the diseased segment of the aorta were achieved on cardiopulmonary bypass support. Post-operative recovery was uneventful, and at 6-month follow-up, the patient is doing well. In this report, various aspects of such lesions have been discussed, including clinical presentations, complications, planning and conduct of a safe cardiopulmonary bypass, and precautions during surgery for a successful outcome.

CONCLUSION

Complicated obstructive aortic lesions in children require careful assessment, appropriate advanced imaging, and the use of 3-D printing technology in order to plan and perform safe and effective surgical management. The etiology of severe calcified aorta in children may be related to metabolic factors, previous surgery, use of a homograft, or an inflammatory process. However, it has yet to be proven.

Multi-ancestry genetic analysis of gene regulation in coronary arteries prioritizes disease risk loci

Genome-wide association studies (GWASs) have identified hundreds of risk loci for coronary artery disease (CAD). However, non-European populations are underrepresented in GWASs, and the causal gene-regulatory mechanisms of these risk loci during atherosclerosis remain unclear. We incorporated local ancestry and haplotypes to identify quantitative trait loci for expression (eQTLs) and splicing (sQTLs) in coronary arteries from 138 ancestrally diverse Americans. Of 2,132 eQTL-associated genes (eGenes), 47% were previously unreported in coronary artery; 19% exhibited cell-type-specific expression. Colocalization revealed subgroups of eGenes unique to CAD and blood pressure GWAS. Fine-mapping highlighted additional eGenes, including TBX20 and IL5. We also identified sQTLs for 1,690 genes, among which TOR1AIP1 and ULK3 sQTLs demonstrated the importance of evaluating splicing to accurately identify disease-relevant isoform expression. Our work provides a patient-derived coronary artery eQTL resource and exemplifies the need for diverse study populations and multifaceted approaches to characterize gene regulation in disease processes.

FHL5 Controls Vascular Disease-Associated Gene Programs in Smooth Muscle Cells

BACKGROUND

Genome-wide association studies have identified hundreds of loci associated with common vascular diseases, such as coronary artery disease, myocardial infarction, and hypertension. However, the lack of mechanistic insights for many GWAS loci limits their translation into the clinic. Among these loci with unknown functions is UFL1-four-and-a-half LIM (LIN-11, Isl-1, MEC-3) domain 5 (FHL5; chr6q16.1), which reached genome-wide significance in a recent coronary artery disease/ myocardial infarction GWAS meta-analysis. UFL1-FHL5 is also associated with several vascular diseases, consistent with the widespread pleiotropy observed for GWAS loci.

METHODS

We apply a multimodal approach leveraging statistical fine-mapping, epigenomic profiling, and ex vivo analysis of human coronary artery tissues to implicate FHL5 as the top candidate causal gene. We unravel the molecular mechanisms of the cross-phenotype genetic associations through in vitro functional analyses and epigenomic profiling experiments in coronary artery smooth muscle cells.

RESULTS

We prioritized FHL5 as the top candidate causal gene at the UFL1-FHL5 locus through expression quantitative trait locus colocalization methods. FHL5 gene expression was enriched in the smooth muscle cells and pericyte population in human artery tissues with coexpression network analyses supporting a functional role in regulating smooth muscle cell contraction. Unexpectedly, under procalcifying conditions, FHL5 overexpression promoted vascular calcification and dysregulated processes related to extracellular matrix organization and calcium handling. Lastly, by mapping FHL5 binding sites and inferring FHL5 target gene function using artery tissue gene regulatory network analyses, we highlight regulatory interactions between FHL5 and downstream coronary artery disease/myocardial infarction loci, such as FOXL1 and FN1 that have roles in vascular remodeling.

CONCLUSIONS

Taken together, these studies provide mechanistic insights into the pleiotropic genetic associations of UFL1-FHL5. We show that FHL5 mediates vascular disease risk through transcriptional regulation of downstream vascular remodeling gene programs. These transacting mechanisms may explain a portion of the heritable risk for complex vascular diseases.

Integrative multi-ancestry genetic analysis of gene regulation in coronary arteries prioritizes disease risk loci

Genome-wide association studies (GWAS) have identified hundreds of genetic risk loci for coronary artery disease (CAD). However, non-European populations are underrepresented in GWAS and the causal gene-regulatory mechanisms of these risk loci during atherosclerosis remain unclear. We incorporated local ancestry and haplotype information to identify quantitative trait loci (QTL) for gene expression and splicing in coronary arteries obtained from 138 ancestrally diverse Americans. Of 2,132 eQTL-associated genes (eGenes), 47% were previously unreported in coronary arteries and 19% exhibited cell-type-specific expression. Colocalization analysis with GWAS identified subgroups of eGenes unique to CAD and blood pressure. Fine-mapping highlighted additional eGenes of interest, including TBX20 and IL5 . Splicing (s)QTLs for 1,690 genes were also identified, among which TOR1AIP1 and ULK3 sQTLs demonstrated the importance of evaluating splicing events to accurately identify disease-relevant gene expression. Our work provides the first human coronary artery eQTL resource from a patient sample and exemplifies the necessity of diverse study populations and multi-omic approaches to characterize gene regulation in critical disease processes.

Study Design Overview

Genetic Regulation of SMC Gene Expression and Splicing Predict Causal CAD Genes

BACKGROUND

Coronary artery disease (CAD) is the leading cause of death worldwide. Recent meta-analyses of genome-wide association studies have identified over 175 loci associated with CAD. The majority of these loci are in noncoding regions and are predicted to regulate gene expression. Given that vascular smooth muscle cells (SMCs) play critical roles in the development and progression of CAD, we aimed to identify the subset of the CAD loci associated with the regulation of transcription in distinct SMC phenotypes.

METHODS

We measured gene expression in SMCs isolated from the ascending aortas of 151 heart transplant donors of various genetic ancestries in quiescent or proliferative conditions and calculated the association of their expression and splicing with ~6.3 million imputed single-nucleotide polymorphism markers across the genome.

RESULTS

We identified 4910 expression and 4412 splicing quantitative trait loci (sQTLs) representing regions of the genome associated with transcript abundance and splicing. A total of 3660 expression quantitative trait loci (eQTLs) had not been observed in the publicly available Genotype-Tissue Expression dataset. Further, 29 and 880 eQTLs were SMC-specific and sex-biased, respectively. We made these results available for public query on a user-friendly website. To identify the effector transcript(s) regulated by CAD loci, we used 4 distinct colocalization approaches. We identified 84 eQTL and 164 sQTL that colocalized with CAD loci, highlighting the importance of genetic regulation of mRNA splicing as a molecular mechanism for CAD genetic risk. Notably, 20% and 35% of the eQTLs were unique to quiescent or proliferative SMCs, respectively. One CAD locus colocalized with a sex-specific eQTL (TERF2IP), and another locus colocalized with SMC-specific eQTL (ALKBH8). The most significantly associated CAD locus, 9p21, was an sQTL for the long noncoding RNA CDKN2B-AS1, also known as ANRIL, in proliferative SMCs.

CONCLUSIONS

Collectively, our results provide evidence for the molecular mechanisms of genetic susceptibility to CAD in distinct SMC phenotypes.

Transcriptomic-based clustering of human atherosclerotic plaques identifies subgroups with different underlying biology and clinical presentation

Histopathological studies have revealed key processes of atherosclerotic plaque thrombosis. However, the diversity and complexity of lesion types highlight the need for improved sub-phenotyping. Here we analyze the gene expression profiles of 654 advanced human carotid plaques. The unsupervised, transcriptome-driven clustering revealed five dominant plaque types. These plaque phenotypes were associated with clinical presentation and showed differences in cellular compositions. Validation in coronary segments showed that the molecular signature of these plaques was linked to coronary ischemia. One of the plaque types with the most severe clinical symptoms pointed to both inflammatory and fibrotic cell lineages. Further, we did a preliminary analysis of potential circulating biomarkers that mark the different plaques phenotypes. In conclusion, the definition of the plaque at risk for a thrombotic event can be fine-tuned by in-depth transcriptomic-based phenotyping. These differential plaque phenotypes prove clinically relevant for both carotid and coronary artery plaques and point to distinct underlying biology of symptomatic lesions.

Early TB case detection by community-based mobile X-ray screening and Xpert testing in Balochistan

SETTING

This survey was conducted at 35 sites of 20 cities in 15 districts with low programmatic TB case notifications in the past years in Balochistan.

OBJECTIVE

To assess the effectiveness of the systemic community-based screening and diagnosis for early detection of TB; and 2) to describe the characteristics and understand the strengths and weaknesses of the intervention in Balochistan, and sociodemographic factors associated with it.

DESIGN

This cross-sectional descriptive study was conducted using a mobile van equipped with a digital X-ray machine with computer-aided detection for TB (CAD4TB) software for screening, followed by confirmatory high sensitivity Xpert® MTB/RIF assay testing.

RESULTS

A total of 236 (3.4%) TB cases was detected out of 6,899 screened. About 1,168 (17%) presumptive TB cases were identified and 1,065 (91%) sputum samples were tested on Xpert. Among those diagnosed, 166 (70%) were Mycobacterium tuberculosis-positive and 70 (30%) were with clinical suspicion. Of the sputum samples tested, 87% (923/1065) had a probability score of >70 on CAD4TB.

CONCLUSION

Community-based screening with innovative activities, comprising sensitive screening and diagnostic tools, effectively improves TB case detection, which might suffice to reduce the prevalence of TB and break the chain of infection transmission in the at-risk population.

Abstract MP39: FHL5 , A Novel Cofactor Associated With Coronary Artery Disease, Regulates Smooth Muscle Cell Function Through A Transcriptional Network Linking Multiple Risk Loci

Introduction: Coronary artery disease (CAD) is the leading cause of death worldwide with an estimated heritability of ~50%. The most recent genome wide association study (GWAS) for CAD and myocardial infarction (MI) identified over 200 loci. One such novel CAD/MI locus, UFL1-FHL5 (P = 1.1E-8), is associated with additional vascular pathologies, including hypertension, migraines, and coronary calcification. We previously showed through statistical fine-mapping that FHL5 is the top candidate causal gene underlying each of these vascular trait associations and highly enriched in the contractile mural cell populations in the artery. These preliminary studies motivate our hypothesis that FHL5 functions as a transcriptional regulator of SMC contractility to affect vascular disease risk.

Methods and Results: Given the reported role of FHL5 as a cofactor, we mapped 17,201 candidate FHL5 binding sites in coronary artery SMCs using the Cleavage Under Targets and Release Using Nuclease (CUT&RUN) method. Binding sites were enriched for AP-1 family motifs and strongly overlapped CREB binding sites and H3K27ac enhancer marks. FHL5 target genes were functionally enriched in well characterized CAD pathways, such as extracellular matrix organization (P=5.2E-15, OR=2.1) and TGF-beta signaling (P=8.0E-5, OR=2.0). Interestingly, FHL5 binding sites were also enriched for CAD (P=1.8E-7, OR=2.3) and blood pressure (BP) risk variants (P=0.04, OR=1.2), thereby linking FHL5 with the regulation of multiple downstream CAD/BP loci. Weighted gene co-expression network and key driver analyses of human coronary artery transcriptomic data further support this regulatory role. Lastly, we validated these findings by performing confocal based calcium imaging and collagen gel contraction assays. Consistent with our functional genomic analyses, overexpression of FHL5 elevated intracellular calcium levels 2.5X and increased SMC contractility by ~45%.

Conclusion: Taken together, our results provide evidence that FHL5 may impact CAD risk by regulating a network of disease-associated genes mediating SMC functions. These findings further contribute to our understanding of the heritable risk for multiple vascular diseases.

Continuous and bounded linear operators in neutrosophic normed spaces

In this article, we show that the addition and scalar multiplication in neutrosophic normed spaces are continuous. The neutrosophic boundedness and continuity of linear operators between neutrosophic normed spaces are examined. Moreover, we analyzed that the set of all neutrosophic continuous linear operators and the set of all neutrosophic bounded linear operators from neutrosophic normed spaces into another are vector spaces.

Genome-wide analysis identifies novel susceptibility loci for myocardial infarction

AIMS

While most patients with myocardial infarction (MI) have underlying coronary atherosclerosis, not all patients with coronary artery disease (CAD) develop MI. We sought to address the hypothesis that some of the genetic factors which establish atherosclerosis may be distinct from those that predispose to vulnerable plaques and thrombus formation.

METHODS AND RESULTS

We carried out a genome-wide association study for MI in the UK Biobank (n∼472 000), followed by a meta-analysis with summary statistics from the CARDIoGRAMplusC4D Consortium (n∼167 000). Multiple independent replication analyses and functional approaches were used to prioritize loci and evaluate positional candidate genes. Eight novel regions were identified for MI at the genome wide significance level, of which effect sizes at six loci were more robust for MI than for CAD without the presence of MI. Confirmatory evidence for association of a locus on chromosome 1p21.3 harbouring choline-like transporter 3 (SLC44A3) with MI in the context of CAD, but not with coronary atherosclerosis itself, was obtained in Biobank Japan (n∼165 000) and 16 independent angiography-based cohorts (n∼27 000). Follow-up analyses did not reveal association of the SLC44A3 locus with CAD risk factors, biomarkers of coagulation, other thrombotic diseases, or plasma levels of a broad array of metabolites, including choline, trimethylamine N-oxide, and betaine. However, aortic expression of SLC44A3 was increased in carriers of the MI risk allele at chromosome 1p21.3, increased in ischaemic (vs. non-diseased) coronary arteries, up-regulated in human aortic endothelial cells treated with interleukin-1β (vs. vehicle), and associated with smooth muscle cell migration in vitro.

CONCLUSIONS

A large-scale analysis comprising ∼831 000 subjects revealed novel genetic determinants of MI and implicated SLC44A3 in the pathophysiology of vulnerable plaques.

Prognostication of the abdominal aortic aneurysm with a novel three-dimensional ultrasonographic analysis system and its comparison with computed tomography

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): Self

Introduction

An abdominal aortic aneurysm is a life-threatening condition and the risk of rupture is higher with the increased maximum diameter (Dmax) and expansion rate. Therefore, AAAs require regular monitoring of Dmax. The most commonly used imaging technique for measuring AAA size is two-dimensional ultrasonography (2-D US), closely followed by computed tomography (CT).

Purpose :

This study sought to evaluate the accuracy of a novel semi-automated 3-D ultrasonography (3-D US) system and its comparison CT as a reference.

Methods :

A total of 66 patients with abdominal aortic aneurysm were prospectively recruited in an outpatient setting. Two-dimensional ultrasonography (2-D US) and 3-D US images were attained with a single-sweep volumetric transducer. Dmax and the vessel area of the Dmax slice were measured with 2-D US, 3-D US, and CT. The vessel, lumen, and thrombus areas of the Dmax slice were also measured using 3-D US and CT.

Results :

It was found that the Dmax values from the 3-D US demonstrate better agreement (R2 = 0.971) with the CT values than with the 2-D US values (R2 = 0.929). Overall, 2-D US underestimated Dmax compared with 3-D US (30.8 ± 13.1mm vs. 34.4 ± 11.6 mm). The vessel, lumen, and thrombus areas all demonstrated better agreement with CT than with 2-D US (R2 = 0.988 vs. 0.961 for the vessel, R2 = 0.879 vs. 0.829 for the lumen, and R2 = 0.963 vs. 0.849 for the thrombus).

Conclusion :

Our study concludes that our novel semi-automated 3-D US analysis system provides more accurate Dmax values and volumetric data as compared to the 2-D US. The application of the semi-automated 3-D US analysis system in an abdominal aorta assessment is easy and accurate.

Abstract Figure. Comparison of AAA on three modalities

Identification and prognostication of the substrate of ventricular arrhythmia with cardiac magnetic resonance (CMR) imaging in patients with normal echocardiography

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): Self

Introduction

Malignant ventricular arrhythmia contributes to approximately half of the sudden cardiac deaths. In common practice, echocardiography is used to identify structural heart diseases that are the most frequent substrate of VA. Identification and prognostication of structural heart diseases are very important as they are the main determinant of poor prognosis of ventricular arrhythmia.

Purpose :

The objective of this study is to determine whether cardiac magnetic resonance (CMR) may identify structural heart disease (SHD) in patients with ventricular arrhythmia who had no pathology observed on echocardiography.

Methods :

A total of 864 consecutive patients were enrolled in this single-center prospective study with significant ventricular arrhythmia. VA was characterized as >1000 ventricular ectopic beats per 24 hours, non-sustained ventricular arrhythmia, sustained ventricular arrhythmia, and no pathological lesion on echocardiography. The primary endpoint was the detection of SHD with CMR. Secondary endpoints were a composite of CMR detection of SHD and abnormal findings not specific for a definite SHD diagnosis.

Results :

CMR studies were used to diagnose SHD in 212 patients (24.5%) and abnormal findings not specific for a definite SHD diagnosis in 153 patients (17.7%). Myocarditis (n = 84) was the more frequent disease, followed by arrhythmogenic cardiomyopathy (n = 51), ischemic heart disease (n = 32), dilated cardiomyopathy (n = 17), hypertrophic cardiomyopathy (n = 12), congenital cardiac disease (n = 08), left ventricle noncompaction (n = 5), and pericarditis (n = 3). The strongest univariate and multivariate predictors of SHD on CMR images were chest pain (odds ratios [OR]: 2.5 and 2.33, respectively) and sustained ventricular tachycardia (ORs: 2.62 and 2.21, respectively).

Conclusion : Our study concludes that SHD was able to be identified on CMR imaging in a significant number of patients with malignant VA and completely normal echocardiography. Chest pain and sustained ventricular tachycardia were the two strongest predictors of positive CMR imaging results.

Abstract Figure. Distribution of different SHD

Special Report OSP

This report highlights recent developments in OSP in the field of ophthalmic Medical Education including Professionalism, Research and Development, Publications and Eye Health Care service delivery system. In the year 2016, Prof. Zia ul Islam was elected as the new President of OSP. In the inaugural meeting of the central council, chaired by the newly elected Honorable President, it was observed that despite achieving major milestones since the birth of the country in 1947 and the birth of the Ophthalmological Society in 1957, there are still serious gaps in eye care in Pakistan in terms of equitability, cost, uptake, comprehensiveness, quality and sustainability.

Development of novel MnO2 coated carbon felt cathode for microbial electroreduction of CO2 to biofuels

Fabrication of superior and cost-effective cathodic materials is vital in manufacturing sustainable microbial electrolysis cells (MECs) for biofuels production. In the present study, a novel manganese dioxide (MnO₂) coated felt cathode (Mn/CF) has been developed for MECs using electrodeposition method via potentiostat. MnO₂ is considered to encourage exogenous electron exchange and, in this way, improves the reduction of carbon dioxide (CO₂). MnO₂, as a cathodic catalyst, enhances the rate of biofuel production, electron transfer, and significantly reduces the cost of MECs. A maximum stabilized current density of 3.70 ± 0.5 mA/m² was obtained in case of MnO₂-coated Mn/CF based MEC, which was more than double the non-coated carbon felt (CF) cathode (1.70 ± 0.5 mA/m²). The dual chamber Mn/CF-MEC achieved the highest production rate of acetic acid (37.9 mmol/L) that was significantly higher (43.0%) in comparison to the non-coated CF-MEC. The cyclic voltammograms further verified the substantial enhancement in the electron transfer between the MnO₂ coated cathode and microbes. The obtained results demonstrate that MnO₂ interacted electrochemically with microbial cells and enhanced the extracellular electron transfer, therefore validating its potential role in biofuel production. The MnO₂ coated CF further offered higher electrode surface area and better electron transfer efficiency, suggesting its applicability in the large-scale MECs.

Multi-Omics Approaches to Study Long Non-coding RNA Function in Atherosclerosis

Atherosclerosis is a complex inflammatory disease of the vessel wall involving the interplay of multiple cell types including vascular smooth muscle cells, endothelial cells, and macrophages. Large-scale genome-wide association studies (GWAS) and the advancement of next generation sequencing technologies have rapidly expanded the number of long non-coding RNA (lncRNA) transcripts predicted to play critical roles in the pathogenesis of the disease. In this review, we highlight several lncRNAs whose functional role in atherosclerosis is well-documented through traditional biochemical approaches as well as those identified through RNA-sequencing and other high-throughput assays. We describe novel genomics approaches to study both evolutionarily conserved and divergent lncRNA functions and interactions with DNA, RNA, and proteins. We also highlight assays to resolve the complex spatial and temporal regulation of lncRNAs. Finally, we summarize the latest suite of computational tools designed to improve genomic and functional annotation of these transcripts in the human genome. Deep characterization of lncRNAs is fundamental to unravel coronary atherosclerosis and other cardiovascular diseases, as these regulatory molecules represent a new class of potential therapeutic targets and/or diagnostic markers to mitigate both genetic and environmental risk factors.

Titrated Cyclocryopexy - A report on long term results

Objective: To determine the efficacy and safety of a titrated cyclocryopexy in advanced glaucomatous eyes in term of intraocular pressure control and complications. Material and Methods: Retrospective Cohort analysis of a titrated cyclocryopexy in 30 eyes of 25 patients with uncontrolled glaucoma during July 1996 to July 2003 at Hayatabad Medical Complex, Peshawar. Inclusion criteria applied was; patients having uncontrolled IOP with maximum medical therapy, previous trabeculectomy and a minimum follow-up of 2 years. All patients were assessed for glaucoma. Numbers of cryoapplications were determined according to the IOP. Four to 12 applications in one sitting were used. Repeat cryoapplication were applied at least after six-weeks of previous therapy if IOP was not controlled. Results: A total of 30 eyes of 25 patients were studied. IOP control of less than 21 mm Hg was achieved in 83% of the eyes. Mean IOP was reduced from 29 ± 4.96 pre-op to 17 ± 7.36 at two years follow-up. Forty percent of the eyes ne eded single session, 40% received 2 sessions and other 20% needed sessions. All the patients lost at least one line of Snellen chart at 2 years follow-up, 70% retained useful vision, 20% retained light perception and 10% lost perception of light. Serious complications included phthisis, persistent vitreous hemorrhage with retinal detachment, and total retinal detachment and persistent vitreous hemorrhage in 1 eye each. Conclusion: Cyclocryopexy appears to be an effective procedure in cases of advanced glaucoma with an acceptable risk / benefit ratio. If done in a titrated manner the number of complications are reduced in severity.

Stent dilatation of atretic aortic coarctation in an adult-case report and literature review

Background

Patients with functional aortic interruption of the descending thoracic aorta at the isthmus due to severe coarctation in association with atretic lumen are extremely rare in the adult population. The management is challenging and carries high morbidity and mortality.

Case presentation

We describe successful percutaneous reconstruction using a covered stent in a similar patient who is doing well two-years after intervention. A literature search was done to explore management strategies and their long-term outcomes for better understanding.

Conclusions

This report is an attempt to highlight the role of minimal invasive approach in the management of rare, severe coarctation of the aorta in adult patients to avoid morbidity and mortality associated with more invasive procedures.

Large cardiac fibroma and teratoma in children- case reports

Primary cardiac tumours in paediatric population are an unusual occurrence. Although, majority of such tumours are benign (90%), the frequency and type of cardiac tumours in this age group is different from the adult population. There are several consecutive series published in the last decade on cardiac neoplasms. Therefore, this is not only an effort to contribute to the existing literature for better understanding and management of similar patients but also to highlight the importance of early detection either by prenatal imaging or careful evaluation of differential diagnosis of common symptoms. We herein, describe two infants with large cardiac tumours (fibroma and teratoma) both arising from the interventricular septum and underwent surgical excision. A possible role of cardiac remodeling in myocardial tissue healing after extensive tissue resection in such patients is hypothesised through available experimental or limited clinical information.

Status of Ophthalmic Education and the Eye Health Workforce in South Asian Association for Regional Cooperation Countries

PURPOSE

This study aimed to assess the capacity for ophthalmic education in the 8 South Asian Association for Regional Cooperation (SAARC) countries and to determine the need and future projections of eye health professionals in the region.

DESIGN

This was a retrospective study and comprised desk review and Web-based questionnaire.

METHODS

Developed in the Asia Pacific region, the Capacity Assessment Tool for SAARC Eye Care Education, a Web-based survey mechanism derived from a 12-point framework, was used to collect data on the number of ophthalmologists and other eye care personnel, training institutions, and capacity for training in each SAARC country.

RESULTS

There are an estimated 17,568 practicing ophthalmologists and 4086 ophthalmic subspecialists in the SAARC region. The population per ophthalmologist is approximately 92,270. Allied eye health professionals constitute an important element of the eye health workforce and have a population per allied eye health professional of approximately 99,852; the ophthalmologist to doctor (physician) ratio is 1:61. There are more than 510 centers providing ophthalmology training and more than 32 centers providing subspecialty training; ophthalmic subspecialty training varies from a 3-month observership to a 12-month hands-on training.

CONCLUSIONS

In the SAARC region, the challenge is to sustain and increase the eye health workforce to meet the needs of a growing and aging population. The demographic transitions, improved child survival and life expectancy rates, and emerging noncommunicable disease trends require training of ophthalmic subspecialists and supporting eye care teams to meet the service delivery demands of changing eye health paradigms.

The Duke Elder lecture: the challenge of equitable eye care in Pakistan

PURPOSE

Pakistan, like many other developing countries, is caught in the vicious cycle of poverty, illiteracy, violence, and disease. Right from its inception, it has been facing serious challenges of fast growing population, longevity, unemployment, wars, floods, double burden of diseases including blindness, as well as earthquakes, insurgencies, and political instability. Despite such challenges, the country has managed to reduce the burden of blindness from 1.78% in 1987-88 to 0.9% in 2003.This paper will highlight the methods used to achieve such a difficult goal.

METHODS

The country used the report of the World Health Organization (WHO) temporary consultant as the initial tool for advocacy to obtain political and professional commitment. Results from the first National Blindness Survey 1987-1990 were used as baseline for development of the programme. Under the Ministry of Health, national and provincial committees with respective coordinators were constituted. To ensure access and equity, the national programme was developed on the basis of district comprehensive eye care services. The concept was carefully tested in a laboratory and then piloted in a real district before it was rolled over to the country. Strong national institutes for human resource development, research and development, and service delivery were established. A strong network of high-quality national institutes was set up and run by powerful national non-governmental organizations. The second National Blindness Survey evaluated the achievements of the programme in 2001-2003.

CONCLUSION

National prevalence of blindness was reduced by 100% by improving the uptake of services at the district level, especially by females.

Complications of conventional scleral buckling occuring during and after treatment of rhegmatogenous retinal detachment

OBJECTIVE

To identify and determine the frequency of the intra-operative and early postoperative complications of Conventional Scleral Buckling (CSB) as the primary surgical intervention in patients with Rhegmatogenous Retinal Detachment (RRD).

STUDY DESIGN

A quasi-interventional study.

PLACE AND DURATION OF STUDY

Khyber Institute of Ophthalmic Medical Sciences (KIOMS), Postgraduate Medical Institute (PGMI), Hayatabad Medial Complex (HMC), Peshawar, from April 2005 to June 2006.

METHODOLOGY

Fifty consecutive patients who underwent CSB and fulfilled the inclusion criteria, were included in the study. Operative details and any intra-operative complications were noted. The patients underwent another detailed clinical examination and pain assessment on the first postoperative day. All the patients were followed-up minimum for 3 months. Postoperative complications were identified and recorded. The data was analyzed on SPSS 12.0 for measures of central tendency and dispersion.

RESULTS

There were 36 male and 14 female subjects. Mean age was 37.18 + or - 20.045 years. Encirclement (56%) was the most frequently used CSB technique. Sixteen (32%) patients had at least one intra-operative complication. Intra-operative complications were iatrogenic scleral break (2%), accidental Sub Retinal Fluid (SRF) drainage (8%), choroidal haemorrhage (2%), subretinal haemorrhage (14%), retinal incarceration (2%), vitreous haemorrhage (6%), raised (4%) or very low (2%), intra-operative IOP and hyphema (2%). Postoperative complications included systemic complications (24%), choroidal detachment (8%), vitreous haemorrahge (16%), raised IOP (22%), angle closure (2%), conjunctivitis (4%), orbital cellulitis (2%), suspected endophthalmitis (2%), ocular movement disorders (2%) and explant exposure (6%). Mean refractive change in spherical equivalent was -1.478 + or - 0.698 D. Final re-attachment rate was (82%) and final BCVA of > 6/60 was achieved in 62% of the subjects in the treated eyes.

CONCLUSION

CSB is a safe and effective option for treating uncomplicated RRD, but it is associated with certain complications. Sub-retinal bleed was the most common intra-operative complication. Raised IOP was most the common early postoperative complication followed by choroidal detachment.

Endophthalmitis: magnitude, treatment and visual outcome in northwest frontier province of Pakistan

BACKGROUND

Many cases of post-operative and posttraumatic endophthalmitis are being managed at the Khyber Institute of Ophthalmic Medical Sciences, Peshawar in Pakistan but no study has been done to ascertain the magnitude of the disease and to also evaluate the visual outcome after management.

METHODS

The case notes of 39 patients diagnosed with posttraumatic and postoperative endophthalmitis between May 2006 and April 2007 were analyzed and clinical characteristics obtained were documented and tabulated.

RESULTS

During the study period, 2474 patients were admitted in both the male and female wards. Of these, 39 (1.6%) had endophthalmitis due to surgical and traumatic complications. In all, 6 (12.4%) patients had evisceration, while 21 (53.8%) patients who had topical antibiotics consisting of ofloxacin, 0.1% corticosteroids, fortified cetazoline and 1% atropine along with intravitreal antibiotics, a combination of 0.1 mg vancomycin and 0.4 mg amikacin, were discharged home with a visual acuity of counting fingers to light perception.

CONCLUSION

Endophthalmitis is a serious ocular complication of open globe injury and intraocular surgery. The frequency in this center has been noted to be very high as compared to other places. Its management is very challenging and often leads to devastating structural and functional damage to the eye; causing severe frustration to both the patient and the attending physician. Efforts must be made to prevent the condition.

A review of 50 cases of aphakic detachment in Peshawar, North West Frontier Province of Pakistan

BACKGROUND

This prospective study was conducted at Khyber Teaching Hospital Peshawar, North West Frontier Province (NWFP) of Pakistan over the period of 16 months. It was to assess the demographic pattern, mode of presentation, treatment modalities and postoperative result of aphakic retinal detachment. This study also compared the incidence of aphakic retinal detachment in intracapsular versus extracapsular cataract extraction as well as the duration between cataract surgery and retinal detachment.

PATIENTS AND METHOD

A total of 50 patients were recruited in this prospective study. A Proforma was specially designed for this purpose. Detailed history with reference to age, sex, presenting complaints, spectacle wear, previous ocular surgery, duration of surgery/laser treatment, systemic and family history was taken. All patients had detailed ophthalmic examination, underwent conventional retinal reattachment surgery, and were followed up for 6 months.

RESULTS

Of the total number studied, 86% of the patients were males; only 14% were females, with a mean age of 58 years. The overall anatomical success was achieved in 40 (80%) eyes. The visual acuity of 6/12 and better was achieved in 8 (16%) eyes. 20 (40%) eyes attained a vision of 6/18 to 6/36. 12 (24%) eyes had a vision between 6/60 to CF 3m. The vision could not be improved beyond CF 3m in 10 (20%) eyes.

CONCLUSION

Vitreous loss during cataract surgery is the most common cause of aphakic retinal detachment. The risk is maximal in the first and second year. The overall anatomical attachment achieved through conventional retinal detachment surgery is 80%.

Prevalence and Causes of Blindness and Low Vision in a Rural Setting in Pakistan

PURPOSE

To determine the prevalence and causes of blindness and visual impairment in people 40 years of age and older in Budni, Peshawar, Pakistan.

METHODS

A population-based cross-sectional study was carried out involving 1,106 men and women 40 years of age and older in a rural area in Pakistan's North West Frontier Province (NWFP). All subjects with a presenting visual acuity < 6/18 in either eye were referred to a centralized clinic for a standardized eye examination that included refraction and dilated fundal examination. The main outcome was blindness (presenting visual acuity < 3/60 in the better eye) and low vision (presenting VA < 6/18-3/60 in the better eye).

RESULTS

Of 1,106 people examined, 21 (1.9%; 95% CI: 1.1-2.7%) were blind, while another 27 (2.4%) and 62 (5.5%) subjects had severe visual impairment (< 6/60-3/60) and visual impairment (< 6/18-6/60), respectively. Women, as compared to men, had a higher prevalence of visual impairment and severe visual impairment; but they had a lower prevalence of blindness (1.6 vs. 2.2%); however, the difference was not statistically significant (0.6%; 95% CI: -0.9-2.1%). Similarly farmers had the highest prevalence of blindness. The leading cause of blindness and low vision was cataract, which accounted for 14 of 21 (66.6%) cases of blindness and 49 of 89 (55.5%) cases of low vision. The second leading cause of blindness was uncorrected aphakia.

CONCLUSION

Much of the blindness was due to unoperated cataract and uncorrected aphakia. Thus, there is an urgent need to develop ways in which cataract surgical output could be increased, and glasses provided to those who need them.

Glaucoma Admissions and Surgery in Public Sector Tertiary Care Hospitals in Pakistan: Results of a National Study

PURPOSE

To assess the annual number of glaucoma operations and admissions in the public sector tertiary care hospitals in Pakistan.

METHODS

Eye departments in all 18 public tertiary care centers in the country were requested to provide data on the number of glaucoma operations and admissions during 1998. Of these, 13 hospitals agreed to participate. Eye departments' log books or patients' records were used to collect data retrospectively on the total number of eye admissions, the total number of glaucoma admissions, the type of glaucoma, and the total number and type of glaucoma operations.

RESULTS

Glaucoma accounted for 8.1% (1,942/23,931) of all eye admissions. Open-angle glaucoma was responsible for 37.6% or 731 glaucoma admissions followed by secondary glaucoma (35.0%) and angle-closure glaucoma (18.2%). During 1998, 1,407 glaucoma-related operations were performed in the selected hospitals. The mean (+/-SD) and the median number of operations performed were 108.2 (+/-59.6) and 112 (range: 17-206), respectively. Trabeculectomies accounted for 1,043 (74.1 %) of all procedures. Their number ranged from 16 to 170 (median: 84) in the selected hospitals.

CONCLUSIONS

We believe that the annual number of glaucoma operations performed in the public tertiary care hospitals in Pakistan is far less than required. In-depth research is therefore needed to explain if this is because of gaps in service provision or a genuine shift to medical management of glaucoma on an outpatient basis.

Risk factors of preseptal and orbital cellulitis

OBJECTIVE

To estimate the frequency and major risk factors of preseptal and orbital cellulitis.

STUDY DESIGN

A cross-sectional analytical study.

PLACE AND DURATION OF STUDY

The Khyber Institute of Ophthalmic Medical Sciences, Hayatabad Medical Complex, Peshawar from July 2003 to December 2006.

METHODOLOGY

All consecutive patients between ages 6 and 40 years, admitted to the institute with the diagnosis of preseptal and orbital cellulitis were included in the study. The patients were divided into two groups. Group I included patients with ages 6-16 years and group II with ages 17-40 years. The clinical features, diagnosis and risk factors were entered on a specially-designed proforma. The risk factors included were trauma, insect bite, localized or systemic infection and postsurgical. Odd ratio and p-values were calculated for potential risk factors.

RESULTS

The frequency of orbital cellulitis was 0.1% of total admission. Out of 26 patients, 42.30% patients were in group I and 57 in group II. In group I, insect bite was the most common risk factor identified in 40% of patients with preseptal cellulitis and trauma as a common cause in 50% with orbital cellulitis. In group II, trauma was the leading cause in 50% of patients with preseptal cellulitis and sinusitis as a common cause in 18.1% with those of orbital cellulitis. In both groups the p-values were found insignificant (p>0.5). Complications included cicatricial ectropion in 44.4% and orbital abscess in 41.1%.

CONCLUSION

For preseptal cellulitis, insect bite was the most common cause in group I and trauma was the leading cause in group II. For orbital cellulitis, trauma was important cause in group I and sinusitis in group II.

Incidence of blinding vitamin A deficiency in North West Frontier Province and its adjoining Federally Administered Tribal Areas, Pakistan

PURPOSE

To identify children aged 0-72 months with blinding xerophthalmia in the North West Frontier Province (NWFP) and its adjoining Federally Administered Tribal Areas (FATA) in Pakistan, using a new surveillance system, and to describe socio-economic and other characteristics of reported cases.

METHODS

All ophthalmologists in district headquarter hospitals in NWFP and agency headquarter hospitals in FATA were requested to participate in a surveillance programme for the detection of blinding xerophthalmia (corneal xerosis, corneal ulcers, keratomalacia and corneal scars related to vitamin A deficiency) for children aged 0-72 months. The surveillance included reporting of each case of blinding xerophthalmia presenting to the participating eye units over a period of 12 months and recording their socio-economic and other related characteristics.

RESULTS

Seventy six cases of blinding xerophthalmia were reported and there was almost no gender difference. Children came from 19 of 31 districts and agencies in NWFP and FATA with a working ophthalmologist. The commonest age at presentation was 25-48 months and almost half of them belonged to households with a monthly income of < Pak Rs. 1200 (US $ < 20). Precipitating systemic illnesses were diarrhea and fever with cough in 63.2% and 56.6% cases, respectively. Almost a third of children aged > 9 months had not been immunized against measles. A quarter of all children had not been adequately breast-fed, and 7 children (9%) had never been breastfed. Majority of the cases presented during summer and autumn months.

CONCLUSIONS

Our surveillance data provide evidence that blinding xerophthalmia does occur in children in NWFP and its adjoining FATA. The surveillance system identified high risk age groups, systemic illnesses, seasons and community groups. The detection system detects minimal numbers of cases and it is likely that the problem is even more severe.

Lens opacities in adults in Pakistan: prevalence and risk factors

PURPOSE

To investigate the prevalence and risk factors for lens opacity (LO) amongst a nationally representative sample of the adult population of Pakistan.

METHODS

This national study of blindness and visual impairment (adults > or =30 years) used multistage, stratified, cluster random sampling. Grading of LO was conducted using the Mehra/Minassian classification system. LO, partly or wholly obscuring the red reflex, or previous cataract surgery were indicators of opacity.

RESULTS

16,402 (94.7%) adults were included in this analysis (study conducted 2002-2003). A total of 4,096 (standardized prevalence 20.9%, 95%CI: 20.3, 21.5%) adults were found to have LO. The highest prevalence of LO was found in Punjab province (22.2%), the lowest in Balochistan Province (18.0%). Significant positive associations were increasing age (multivariable odds ratio (OR) 3.2: 95%CI: 3.1, 3.4), hypertension (OR 1.2, 95%CI: 1.1, 1.3), history of diabetes (OR 2.6: 95%CI 2.0, 3.2) and smoking (OR 1.3: 95%CI: 1.1, 1.5). Higher body mass index (BMI) (OR 0.8: 95%CI 0.7, 0.9, heavy vs. normal BMI) and attendance to school (OR 0.6: 95%CI: 0.5, 0.8) were associated with lower risk of LO. Individuals in districts classified as hot were at significantly increased risk (OR 1.3: 95%CI: 1.1, 1.5), and those in wet districts (> 600 mm annual rainfall) had lower odds than individuals living in dry districts (OR 0.7: 95%CI: 0.6, 0.8).

CONCLUSIONS

Almost a fifth of the adult population had LO. Significant positive associations were age, smoking status, hypertension, diabetes, and increased deprivation level. Protective factors included high BMI and educational achievement. The climatic associations offer novel hypothesis for further research into cataractogenesis.

Poverty and blindness in Pakistan: results from the Pakistan national blindness and visual impairment survey

OBJECTIVE

To explore the association between blindness and deprivation in a nationally representative sample of adults in Pakistan.

DESIGN

Cross sectional population based survey.

SETTING

221 rural and urban clusters selected randomly throughout Pakistan.

PARTICIPANTS

Nationally representative sample of 16 507 adults aged 30 or above (95.3% response rate).

MAIN OUTCOME MEASURES

Associations between visual impairment and poverty assessed by a cluster level deprivation index and a household level poverty indicator; prevalence and causes of blindness; measures of the rate of uptake and quality of eye care services.

RESULTS

561 blind participants (<3/60 in the better eye) were identified during the survey. Clusters in urban Sindh province were the most affluent, whereas rural areas in Balochistan were the poorest. The prevalence of blindness in adults living in affluent clusters was 2.2%, compared with 3.7% in medium clusters and 3.9% in poor clusters (P<0.001 for affluent v poor). The highest prevalence of blindness was found in rural Balochistan (5.2%). The prevalence of total blindness (bilateral no light perception) was more than three times higher in poor clusters than in affluent clusters (0.24% v 0.07%, P<0.001). The prevalences of blindness caused by cataract, glaucoma, and corneal opacity were lower in affluent clusters and households. Reflecting access to eye care services, cataract surgical coverage was higher in affluent clusters (80.6%) than in medium (76.8%) and poor areas (75.1%). Intraocular lens implantation rates were significantly lower in participants from poorer households. 10.2% of adults living in affluent clusters presented to the examination station wearing spectacles, compared with 6.7% in medium clusters and 4.4% in poor cluster areas. Spectacle coverage in affluent areas was more than double that in poor clusters (23.5% v 11.1%, P<0.001).

CONCLUSION

Blindness is associated with poverty in Pakistan; lower access to eye care services was one contributory factor. To reduce blindness, strategies targeting poor people will be needed. These interventions may have an impact on deprivation in Pakistan.

Frequency and causes of bilateral occular trauma

OBJECTIVE

To determine the frequency and causes of bilateral ocular trauma.

DESIGN

A descriptive case series.

PLACE AND DURATION OF STUDY

Khyber Institute of Ophthalmic Medical Sciences, Hayatabad Medical Complex, Peshawar from October 1999 to September 2006.

PATIENTS AND METHODS

All patients coming to the hospital with bilateral eye trauma and requiring admission were recruited into the study. The details of patients' demographics, risk factors, ocular examination, treatment offered and final visual acuity were noted and described as frequency and percentages.

RESULTS

Out of a total of 1551 patients of hospitalized ocular trauma, 46 (2.9%, 92 eyes) had bilateral ocular trauma. The majority (54.3%) were due to landmine blast injuries followed by dynamite blast in 10.8%, coalmine blast and firearm injury in 6.5% each. Pressure cooker explosion and road traffic accident was the cause in 4.3% each. Gas cylinder and automobile battery explosion, alkali and acid burn, assault and incidental trauma occurred in 2.1%. Sixty three percent were between 16 and 40 years of age. Males were affected in 93.4%. Corneal and / or scleral repair was done in 58.6%, conjunctival and or corneal foreign body removal in 26% and extracapular cataract extraction with intraocular lens implantation in 16.3%. The visual acuity was in the range of 6/60 and perception of light in 54.3%, while in 21.7%, there was no perception of light at the time of admission. Due to severity of injury, the final visual acuity was poor and only 28.2% regained vision between 6/18 and 6/60.

CONCLUSION

In this series, landmine, dynamite and coalmine blasts were the major causes of bilateral ocular trauma. Victims were usually young males. Due to severity of ocular trauma, majority had poor visual outcome.

Spectrum of ocular surface squamous neoplasia

OBJECTIVE

To describe the pattern of ocular surface squamous neoplasia (OSSN), clinical presentations, the risk factors and treatment options.

DESIGN

An observational case series.

PLACE AND DURATION OF STUDY

Khyber Institute of Ophthalmic Medical Sciences, Hayatabad Medical Complex, Peshawar, from April 2003 till August 2006.

PATIENTS AND METHODS

The study included 36 eyes of 35 patients with biopsy-proven ocular surface neoplasia. The details of patients regarding age, gender, laterality and risk factors were entered into a specially-designed proforma. Each patient was also assessed biomicroscopically for type and complications of ocular surface neoplasia.

RESULTS

The frequency of OSSN was 0.37 among admitted hospital patients. Among 36 cases of OSSN, squamous cell carcinoma of the conjunctiva was the most common type of OSSN seen in 63.9%, followed by carcinoma in situ of conjunctiva in 25% and carcinoma in situ of cornea in 11.1%. Male patients outnumbered female (65.7% vs 34.3%) with 71.42% of patients above 60 years of age. The risk factors identified were: old age, ultraviolet B exposure and xeroderma pigmentosa. Treatment consisted of local resection with or without adjuvant therapy in 61.1%, exenteration in 30.5%, enucleation in 5.5% and chemo/radiotherapy in 2.7%. Intraocular invasion was seen in 5.5% and orbital spread in 30.5%.

CONCLUSION

The frequency of OSSN was 0.37% among admitted patients. Identification of exact etiological factors will enable to formulate strategies that are likely to decrease the incidence of this disease and the associated morbidity and mortality.

Patterns of ocular trauma

OBJECTIVE

To describe the patterns of ocular trauma, cause of injury and its effects on eye.

DESIGN

A retrospective case series.

PLACE AND DURATION OF STUDY

Khyber Institute of Ophthalmic Medical Sciences, Hayatabad Medical Complex, Peshawar, from January 1999 to June 2004.

PATIENTS AND METHODS

Medical records of 1105 patients admitted with ocular trauma were reviewed. The details of patients regarding age, gender, literacy, cause of injury and its effects on eye were entered into specially-designed performa. Sample selection consisted of all patients with history of ocular trauma and who were admitted to hospital. Population details consisted patients who were referred to the hospital from all parts of N.W.F.P. Thus, the frequency of trauma in the hospital admissions was analysed.

RESULTS

Ophthalmic trauma comprised 6.78% of the hospital admission. One thousand one hundred and five patients presented with eye injuries. Out of them, 21 patients suffered from trauma to both eyes. Almost 80% patients were male and 69% patients were below 30 years of age. Delayed presentation was more common and 63.61% patients presented after one week. Open globe injuries were more common [520 eyes (46.18%)] than closed globe injuries [484 eyes (42.98%)]. 23.26% of open globe injuries were associated with intraocular and intra-orbital foreign bodies. Superficial non-perforating, eyelid and adnexal and burns were seen in 122 eyes (10.83%). Among the complications, lens damage and hyphema was seen in more than 50% of the patients, 16.60% eyes were infected at the time of admission and 4.88% of eyes needed enucleation or evisceration. The common causes of injury were violence in 37.37%, occupational in 24.43% and domestic accidents in 19.18%.

CONCLUSION

Ophthalmic trauma is a major public health problem. Majority of the involved are male and under 30 years of age. Delayed presentation is more common. Open globe injuries are more frequent. Violence and occupational injuries are the major causes.

Cataract prevalence, cataract surgical coverage and barriers to uptake of cataract surgical services in Pakistan: the Pakistan National Blindness and Visual Impairment Survey

AIM

To estimate the prevalence of visual impairment and blindness caused by cataract, the prevalence of aphakia/pseudophakia, cataract surgical coverage (CSC) and to identify barriers to the uptake of cataract services among adults aged >or=30 years in Pakistan.

METHODS

Probability proportional-to-size procedures were used to select a nationally representative sample of adults. Each subject underwent interview, visual acuity measurement, autorefraction, biometry and ophthalmic examination. Those that saw <6/12 in either eye underwent a more intensive examination procedure including corrected visual acuity, slit lamp and dilated fundus examination. CSC was calculated for different levels of visual loss by person and by eye. Individuals with <6/60 in the better eye as a result of cataract were interviewed regarding barriers.

RESULTS

16 507 Adults were examined (95.5% response rate). The crude prevalence of blindness (presenting <3/60 in the better eye) caused by bilateral cataract was 1.75% (95% CI 1.55%, 1.96%). 1317 Participants (633 men; 684 women) had undergone cataract surgery in one or both eyes, giving a crude prevalence of 8.0% (95% CI 7.6%, 8.4%). The CSC (persons) at <3/60, <6/60 and <6/18 were 77.1%, 69.3% and 43.7%, respectively. The CSC (eyes) at <3/60, <6/60 and <6/18 were 61.4%, 52.2% and 40.7%, respectively. Cost of surgery (76.1%) was the main barrier to surgery.

CONCLUSION

Approximately 570 000 adults are estimated to be blind (<3/60) as a result of cataract in Pakistan, and 3,560000 eyes have a visual acuity of <6/60 because of cataract. Overall, the national surgical coverage is good but underserved populations have been identified.

Causes of blindness and visual impairment in Pakistan. The Pakistan national blindness and visual impairment survey

OBJECTIVE

To determine the causes of blindness and visual impairment in adults (> or =30 years old) in Pakistan, and to explore socio-demographic variations in cause.

METHODS

A multi-stage, stratified, cluster random sampling survey was used to select a nationally representative sample of adults. Each subject was interviewed, had their visual acuity measured and underwent autorefraction and fundus/optic disc examination. Those with a visual acuity of <6/12 in either eye underwent a more detailed ophthalmic examination. Causes of visual impairment were classified according to the accepted World Health Organization (WHO) methodology. An exploration of demographic variables was conducted using regression modeling.

RESULTS

A sample of 16 507 adults (95.5% of those enumerated) was examined. Cataract was the most common cause of blindness (51.5%; defined as <3/60 in the better eye on presentation) followed by corneal opacity (11.8%), uncorrected aphakia (8.6%) and glaucoma (7.1%). Posterior capsular opacification accounted for 3.6% of blindness. Among the moderately visually impaired (<6/18 to > or =6/60), refractive error was the most common cause (43%), followed by cataract (42%). Refractive error as a cause of severe visual impairment/blindness was significantly higher in rural dwellers than in urban dwellers (odds ratio (OR) 3.5, 95% CI 1.1 to 11.7). Significant provincial differences were also identified. Overall we estimate that 85.5% of causes were avoidable and that 904 000 adults in Pakistan have cataract (<6/60) requiring surgical intervention.

CONCLUSIONS

This comprehensive survey provides reliable estimates of the causes of blindness and visual impairment in Pakistan. Despite expanded surgical services, cataract still accounts for over half of the cases of blindness in Pakistan. One in eight blind adults has visual loss from sequelae of cataract surgery. Services for refractive errors need to be further expanded and integrated into eye care services, particularly those serving rural populations.

Prevalence of diabetic retinopathy among individuals screened positive for diabetes in five community-based eye camps in northern Karachi, Pakistan

BACKGROUND

Population-based data on the prevalence of diabetic retinopathy in Pakistan are lacking. We determined the prevalence of diabetic retinopathy among individuals screened positive for diabetes in five community-based eye camps in northern Karachi, Pakistan.

METHODS

In summer 2002, five community-based eye camps were set up in Karachi, Pakistan's largest city. All individuals aged 30 years or older who visited the camps were requested to participate in the study. Those who agreed were screened for diabetes and those found to have the disease were referred to an eye hospital for diabetic retinopathy screening. Verbal informed consent was obtained from all participants at the examination site. Our main outcome measure was diabetic retinopathy, which was classified as non-proliferative diabetic retinopathy (NPDR), severe NPDR, and proliferative diabetic retinopathy (PDR). Our grading was based on clinical examination.

RESULTS

A total of 912 subjects were screened for diabetes mellitus. Of these, 160 (17.5%) had diabetes- 1.8% had type I diabetes and 15.9% had type II diabetes. One hundred and eight individuals visited the hospital for ophthalmic examination. Of them, 15.7% had diabetic retinopathy. The prevalence of diabetic retinopathy was higher among individuals with type I diabetes, with greater duration of diabetes, and among women. The commonest form of diabetic retinopathy was non-proliferative (76.5% [mild: 35.3%, moderate: 29.4%, and severe: 11.8%]), followed by maculopathy (17.6%) and proliferative diabetic retinopathy (5.9%).

CONCLUSION

More systematic and population-based research is needed to estimate the prevalence of and identify risk factors for diabetic retinopathy in Pakistan.

Perceptions of eye health in schools in Pakistan

Background

Research exploring children's and their teachers' perceptions of eye health is lacking. This paper reports for the first time on perceptions of primary schoolchildren and their teachers of healthy and diseased eyes, things that keep eyes healthy and damage them, and what actions to be taken in case of an eye injury.

Methods

Using draw and write technique, 160 boys and girls (9–12 years old) attending four primary schools in Abbottabad district, northern Pakistan, were invited to draw pictures in response to a set of semi-structured questions and then label them. Sixteen teachers who were currently teaching the selected students were interviewed one-on-one.

Results

Analysis of text accompanying 800 drawings and of the interview scripts revealed that most children and teachers perceived healthy eyes to be those which could see well, and diseased eyes to be those which have redness, watering, dirty discharge, pain, and itching; or those which have "weak eyesight" and blindness. Among things that students and teachers thought damage the eyes included sun, television, and sharp pointed objects, particularly pencils. Teachers noted that children with eye problems "have difficulty seeing the blackboard well", "screw up their eyes", and "hold their books too close".

Conclusion

We conclude that schoolchildren and their teachers had a good knowledge of eye health, but many of them had serious misconceptions e.g., use of kohl, medicines and eye drops keeps eyes healthy. Kohl is an important source of lead and can reduce children's intelligence even at low blood levels. Health education in schools must take into account children's existing knowledge of and misconceptions about various aspects of eye health. Such steps if taken could improve the relevance of eye health education to schoolchildren.

Cataract blindness and visual outcome of cataract surgery in a tribal area in Pakistan

AIM

To estimate the rates of cataract blindness and cataract surgical coverage and to assess the visual outcome of cataract surgery among individuals aged > or =50 years in Orakzai Agency, Pakistan.

METHODS

1600 individuals aged > or =50 years were selected using probability proportional to size sampling. The main outcome measure was bilateral cataract blindness which was defined as visual acuity of <3/60 in the better eye with best available correction and with obvious central lens opacities/absence of red reflex in both eyes.

RESULTS

A total of 1549 people were examined; the coverage rate was 96.8%. Of individuals who were examined, 958 (61.8%) were men. The overall prevalence of bilateral cataract blindness was 4.8% (95% CI: 3.8% to 5.9%). Women had a 2.1-fold greater prevalence of bilateral cataract blindness than men (7.1% (5.0% to 9.2%) v 3.4% (2.3% to 4.6%); p = <0.0001). However, cataract surgical coverage rates were lower for women than men. The overall quality of previous cataract surgery was poor: 43.1% eyes with cataract surgery had VA <6/60. 73.3% people with bilateral cataract blindness reported they could not undergo cataract surgery because they were too poor to afford its cost.

CONCLUSION

The unacceptably high rates of cataract blindness and poor affordability and visual outcome of cataract surgery calls for the establishment, in the agency, of static cataract surgical services that are high quality, affordable, and gender sensitive.

Classification of 154 clinical cases of vitamin A deficiency in children (0-15 years) in a tertiary hospital in North West Frontier Province Pakistan

OBJECTIVE

To share our experience of 154 cases of clinical vitamin A deficiency in Pakistani children.

METHODS AND RESULTS

The data on age, sex, date of presentation and clinical stage of vitamin A deficiency was recorded. A total of 154 children aged 0-15 years suffering from clinical vitamin A deficiency (xerophthalmia) were recorded. One hundred and twenty three (79.9%) children were 0-6 years with 99 (64.3%) male children. Blinding xerophthalmia (corneal xerosis, corneal ulcers ad keratomalacia) was present in 94 (61%) children. Thirty nine percent children presented in summer, 28% in autumn, 20% in winter and 13% in spring respectively.

CONCLUSION

This report indicates that clinical cases of vitamin A deficiency in children do occur in Pakistan. Children under 6 years of age are the most vulnerable age group and there is a seasonal variation in presentation. Both life and sight of these children are at risk. Community based studies may be helpful to identify the magnitude of the problem and possible risk factors at national, provincial and district levels.

Conventional retinal reattachment surgery

OBJECTIVE

To evaluate the surgical outcome in rhegmatogenous retinal detachment (RRD) cases operated by conventional retinal reattachment techniques.

DESIGN

Descriptive study.

PLACE AND DURATION OF STUDY

This study was conducted at Eye Unit, Hayatabad Medical Complex (HMC), KIOMS, Peshawar, from July, 2002 to December, 2002.

MATERIALS AND METHODS

A retrospective analysis of ophthalmic record of rhegmatogenous retinal detachment operated by conventional retinal reattachment surgery was done. Anatomic outcome was evaluated in relation to duration of presentation and pre-operative proliferative vitreoretinopathy (PVR). Postoperative visual acuity (VA) was compared to pre-operative VA. Complications and causes of failure of anatomic success were also analyzed.

RESULTS

A total of 40 cases were studied. Male to female ratio was approx 2:1. Retinal breaks were localized in 70% cases, 37.5 % cases had single break while 32.5 % cases had more than one retinal breaks. Forty two percent had total retinal detachment while 57.5 % had less than total retinal detachment. Five percent had attached macula at presentation. Immediate postoperative retinal reattachment was attained in 80% cases but ultimate anatomic success after at least 6 months of follow up was 72.5%. Patients who presented earlier (upto 1 year) had 75% anatomic success while those who presented later than 1 year had 50% success rate. Postoperative visual improvement was noted in 80 % cases with flat macula, 65% had VA 6/60 or better after surgery. Most common cause of failure of anatomical reattachment was PVR (63.63% of failed conventional surgery). Most common postoperative complication was raised intraocular pressure ( > 21 mmHg) in 25 cases.

CONCLUSION

There is more chance of retinal reattachment and visual restoration in cases that present earlier. PVR is the main cause of failure of conventional retinal reattachment surgery. Postoperative visual improvement is directly related to surgical reattachment of the macula.

Mine blast injuries: ocular and social aspects

BACKGROUND/AIMS

Landmines have long been used in conventional warfare. These are antipersonnel mines which continue to injure people long after a ceasefire without differentiating between friend or foe, soldier or civilian, women or children. This study focuses on Afghan non-combatants engaged in mine clearing operations in Afghanistan in the aftermath of the Russo-Afghan war. The patterns and types of injuries seen are described and experiences in their management, ways, and means to prevent them, and recommendations for the rehabilitation of the affected individuals are given.

METHODS

It is a retrospective and analytical study of 84 patients aged 19-56 years who sustained mine blast injuries during mine clearing operations in Afghanistan from November 1992 to January 1996. The study was carried out at a military hospital with tertiary care facilities. The patients were divided into three groups on the basis of their injuries. Group 1 required only general surgical attention, group 2 sustained only ocular injuries, while group 3 had combined ocular and general injuries. Patients in groups 2 and 3 were treated in two phases. The first phase aimed at immediate restoration of the anatomy, while restoration of function wherever possible was done in subsequent surgical procedures in the second phase.

RESULTS

It was observed that 51 out of 84 patients (60.7%) had sustained ocular trauma of a variable degree as a result of the blasts. The mean age of the victims was 29 years and they were all male. A total of 91 eyes of 51 patients (89.2%) had been damaged. Bilaterality of damage was seen in 40 (78.4%) patients. Most, 34 (37.3%), eyes became totally blind (NPL). Only a few escaped with injury mild enough not to impair vision. Foreign bodies, small and multiple, were found in the majority of eyes; most, however, were found in the anterior segment, and posterior segment injuries were proportionally less.

CONCLUSIONS

The prevalence of blindness caused by mine blast injuries is quite high. The resulting psychosocial trauma to the patients and their families is tremendous and has not been adequately highlighted. These injuries are a great drain on the country's resources. Enforcement of preventive measures and the use of protective gear and sophisticated equipment by the mine clearing personnel would prove to be far more economical in terms of human life as well as medical and economic resources. There is also need for greater attention towards the establishment of support groups and rehabilitation programmes for these individuals.

Incidence of keratoconus in spring catarrh

Five hundred and thirty cases of spring catarrh were studied at the Department of Ophthalmology, Khyber Hospital Peshawar, Pakistan. Corneal complications occurred in 259 patients, of which 48 cases were of keratoconus, consisting of 41 male and seven female patients. Most of the patients affected (37) were between the ages of 10 and 30 years. Six patients developed acute hydrops, which in one case affected both eyes, though after an interval of a few months. Keratoconus was progressive in many patients, resulting in gross visual loss, often not correctable with glasses or contact lenses and thus requiring keratoplasty. The importance of association of keratoconus with atopic disorders is discussed and its association with spring catarrh is stressed.

A 6 1/2-years survey of intraocular and intraorbital foreign bodies in the North-west Frontier Province, Pakistan

A survey of 198 patients (210 eyes) with intraocular or intraorbital foreign bodies is presented. Most were males between 16 and 30 years of age, and 6.1% of cases were bilateral. The commonest cause was a flying particle while using a hand hammer, followed by fragments of bomb and mine blasts. Intraorbital foreign bodies occurred in 78 eyes and intraocular foreign bodies in 132 eyes. Irreparable damage caused 13 eyes (6.2%) to be enucleated. Ten eyes developed severe endophthalmitis or panophthalmitis requiring evisceration. One hundred and thirty-four (63.8%) foreign bodies were removed, and 76 (36.2%) foreign bodies could not be removed. The causes of non-removal, the various complications, and the pattern of foreign bodies in the eye or orbit in Pakistan are discussed and compared with those of other regions.