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Global elimination of trachoma as a public health problem was targeted for 2020. We reviewed progress towards the elimination of active trachoma by country and geographical group.In this retrospective analysis of national survey and implementation data, all countries ever known to be endemic for trachoma that had either implemented at least one trachoma impact survey shown in the publicly available Trachoma Atlas, or are in Africa were invited to participate in this study. Scale-up was described according to the number of known endemic implementation units and mass drug administration implementation over time. The prevalence of active trachoma-follicular among children aged 1-9 years (TFWe included data until Nov 10, 2021, for 38 countries, representing 2097 ever-endemic implementation units. Of these, 1923 (91·7%) have had mass drug administration. Of 1731 implementation units with a trachoma impact survey, the prevalence of TFGlobal elimination of trachoma as a public health problem by 2020 was not possible, but this finding masks the great progress achieved. Implementation units in high baseline categories and recrudescent TFNone.

Objectives: To compare the effectiveness of fluid-air exchange with silicone oil-fluid exchange in reducing the residual silicone oil (SO) droplets after the removal of SO. Methods: This was a prospective, quasi-experimental study conducted from October 2021 to February 2022 at Eye Unit-III, COAVS, Mayo Hospital, Lahore. Sixty-one patients with siliconized eyes underwent removal of SO with two different techniques and were divided into fluid-air exchange and oil-fluid exchange groups. To quantify the residual silicone droplets objectively, B-scan echographic images were analyzed within seven days of surgery. Silicone oil index (SOI) which is the amount of residual SO droplets/vitreal area in the images was calculated with the help of imagej software. Results: The residual SOI of the fluid-air exchange group (0.99 ± 1.76%) was significantly lower than the oil-fluid exchange group (3.25 ± 3.85%). The SOI is positively correlated with the duration of tamponade, preoperative intraocular- pressure and axial length. Persistent IOP elevation post-operatively was seen in 16.67% individuals in the fluid-air exchange group and 54.8% individuals in the oil-fluid exchange group. Conclusion: Fluid-air exchange group was found to be superior in reducing residual SO droplets than the oil-fluid exchange group. doi: https://doi.org/10.12669/pjms.39.2.6243 How to cite this: Rizwan A, Javaid RMM, Latif S, Sarwar MS, Khan AA. Comparison of residual silicone oil index after removal of silicone oil with fluid-air versus oil-fluid exchange. Pak J Med Sci. 2023;39(2):---------. doi: https://doi.org/10.12669/pjms.39.2.6243 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Objective: Present study aims to compare the efficacy of single dose triamcinolone acetonide suspension in suprachoroidal space and intravitreal bevacizumab in primary diabetic macular edema patients. Study design: Prospective observational study Study duration and settings: Study was conducted at department of ophthalmology, Eye Unit III, Mayo hospital Lahore (KEMU) from March 2020 to August 2020. Material and methods: The WHO calculator was used to estimate a sample size of 136 patients (66 patients in each group). Non-probability sequential sampling was used to identify patients.. Intravitreal bevacizumab injections (2.5 mg/0.1 mL) were given to patients in Group A, and triamcinolone acetonide was given to patients in Group B, all at random. After one and three months, patients were reassessed. Results: Total 135 patients were included in study. There were 71(52.2%) male and 65(47.8%) female. Mean age of patients was 41.1±6.9SD. BCVA improved 5 letters after 3 month was significantly high in TA group as compared to IVB (P=0.002). Moreover, CSF decreased at least 10% from baseline after one and three months was comparatively high in TA group (p=0.01 and p=0.04 respectively). Among all the patients in IVB group, 29.5% showed efficacy while in group TA, 37.5% showed efficacy (p=0.03) Conclusion: Triamcinolone acetonide is an efficient drug for management of diabetic macular edema. Triamcinolone had long standing effect as compared to intravitreal bevacizumab on structural and functional outcome of the patients with primary diabetic macular odema. Both interventions are associated with limited complications. Keywords: Triamcinolone acetonide, Diabetic macular edema, Intravitral bevacizumab

Objective: Objective of our study was to determine accuracy of IOL Master and A scan acoustic biometry in silicon filled eyes in terms mean difference of axial length pre-operatively and mean post-operative refractive error Study design: Comparative cross sectional study Study settings and duration: Study was conducted at department of Ophthalmology (Eye Unit III) Mayo hospital Lahore (KEMU) from November 2019 to April 2020. Material and methods: WHO calculator was used for calculation of patient sample (N=34). Patients were randomly divide in two groups Group I underwent preoperative axial length (AXL) measurement by using IOL Master and by acoustic a-scan ultrasound in Siliconized mode. Results: Total 34 patients were included in study. There were 18(52.9%) male and 16(47.1%) female. Mean age of patients was 44.2±6.4 years. Patients undergone biometry with Master IOL showed better visual acuity (Log Mar) (0.25±0.7, 0.63±0.09, p=0.000), less post-operative refractive error (0.22±0.02, 0.72±0.17, p=0.000) as compared to those in which A scan acoustic biometry was done. A significant difference in post-operative axial length was reported (p=0.04) Conclusion: IOL master is more accurate and reliable method of IOL power calculation resulting in better visual outcomes and less post-operative refractive error as compared to A scan acoustic biometry in silicon filled eyes. Keywords: A scan Acoustic biometry, Axial length, IOL Master

Objectives: The objective of the study is to assess the retinal redetachment after early and late removal of silicone oil. Place and Duration of Study: Department of ophthalmology eye unit 3, KEMU /Mayo hospital, Lahore from February 2021 to July 2021 . Study: Quasi experimental trial. Patients and Methods: Time of silicone oil removal of first group (29 patients) at 6 weeks and second group (29 patients) at 12 weeks post-operatively. Presence of 360 barrage laser. The two groups were compared as to the condition of the eye at the time of SOR at 1st day 1st week, 1st months.3rd month following SOR. Inclusion Criteria PPV for rhegemantogenous RD with all types of breaks with silicon oil tamponade, both gender 360 barrage laser. Exclusion criteria bands keratopathy grade c PVR, presence of cataract, GRT, only eye Results: The risk of retinal re-detachment was similar in both groups. Conclusion: The danger of re-detachment was not increased by early removal of silicone oil after six weeks, and higher compliance with the removal period was ensured. In patients who are less likely to follow a procedure for delayed removal, it is especially advised..

Purpose: To determine frequency of post-operative macular edema in diabetic retinopathy patients having received preoperative intravitreal bevacizumab, after phacoemulsification cataract surgery while compared with the controls. Study Design: Quasi experimental trial Place and Duration of Study: Department of ophthalmology eye unit 3, KEMU /Mayo hospital, Lahore from March 2020 to August 2020. Methods: A total of 60 patients were included in the study and randomly divided into two groups. Patients of study group were given 1.25mg bevacizumab injection by IV route two weeks priority to surgery while nothing was administered in the control group. Before one week of surgery ocular examination and OCT were perfumed and it was repeated after every month of performance of surgery. Allocation of patients was even not known to the researcher to avoid biasness. Components of monthly examination were best correct visual acuity, slit lamp examination and central macular thickness quantification with OCT. Standard cataract surgery was performed in all the patients (phacoemulsification and implantation of monofocal intraocular lens (IOL)). Post-operatively, all patients were given standard treatment i.e moxifloxacin-dexamethasone). Follow up of all the patients was made for consecutive three months on monthly basis to assess outcome variables i.e macular edema was observed keeping in view central macular thickness. Results: In patients of study group, 16.66% had developed macular edema while in control group it was observed in 46% patients. While comparing macular edema between side of eye, study group had 02 (13.33%) patients belonging to right eye while 03(20.0%) had left eye. However, in control group it was 08 (53.33%) and 06 (40.0%) for right and left eyes respectively. Group A had 230.23 ± 32.16 µm central macular thickness while it was 274.21 ± 25.34 µm in group B. Conclusion: In macular edema prophylaxis using preoperative intravitreal bevacizumab is efficacious in comparison with the controls in patients with mild-moderate edema. Keywords: NPDR, Macular edema, Intravitreal Bevacizumab, Phacoemulsification Surgery, Diabetic Retinopathy.

Objectives. This study aimed to assess and make a pattern of factors causing stroke leading to cerebral haemorrhage in male patients as well as to assess association of demographic characteristics, diet and disease with haemorrhagic stroke in Quetta, Balochistan, Pakistan. Methods. In a cross sectional questionnaire based interviewing study, a questionnaire was designed to access the pattern of factors causing stroke leading to cerebral haemorrhage in male patients. Total 339 cases (adult male who had haemorrhagic stroke) were identified from two government and four private hospitals in Quetta City, Province Balochistan, Pakistan. The study was conducted within the time period of 9 months, from March to November, 2015. The data was piloted and then final data was analysed by using IBM SPSS 22. Results. In demographic characteristic study of patients, majority 219 (64.6%) were among the age group between 51 years and above, 330 (97.3%) were married, majority 186 (54.9%) were having urban residence and 277 (81.7%) were having own residence ownership, 127 (37.5%) were having addiction to smoking and 120 (35.4%) were addicted to tobacco and snuff. 124 (36.6%) were reluctant to mention whether their patients were either smokers or not. Among total 339 patients, majority 284 (83.8%) were not doing physical exercise routinely or if they were recommended by the physician. Among the 339 patients, all 339 (100%) of patients selected the multiple options among all given options (headache, unconscious/loss of consciousness, pain in neck). Conclusions. Demographic characteristics, low level of education, low income, urban residence in combined family setup, married, increased number of children are associated with hemorrhagic stroke. Smoking, tobacco and snuffing may also cause stroke. Lack of physical exercise, past history of stroke, diabetes mellitus, cardiovascular disease, hypertension (personal or family) of any type does not significantly cause stroke but may increase the risk of stroke. The order of events suddenly happened to the hemorrhagic patients are headache, pain in neck, vomiting and finally state of unconsciousness.

Background: Malnutrition continues to be a major public health problem in developing countries. It is the most important risk factor for the burden of diseases. There was lack of information regarding the prevalence, level and factors associated with malnutrition among children of under-five years of age from Baluchistan, Pakistan. Objective: Therefore, the current study was conducted to evaluate the prevalence, associated factors and parents’ awareness with malnutrition among children of under-five years of age. Methods: This cross-sectional analytical study was carried out at Basic Health Unit (BHU), Nawa Killi, BHU Killi Deba, BHU Spini Road, Mubarak Chowk, Sheikh Zahid Hospital Quetta, Rehnuma Center Satellite Town Quetta. A self-developed validated questionnaire was used to evaluate the parents’ awareness regarding children nutrition status. The mean mid upper-arm circumference (MUAC) value of the children was used to categorize the children nutritional status. Children with MUAC value < 12 cm were classified as malnourished, MUAC value =11-12 cm was considered as Moderate Acute Malnutrition (MAM) and, MUAC value < 11 cm was considered as Severely Acute Malnutrition (SAM). Data was analyzed by using Statistical Package for Social Sciences (SPSS version 20). Multivariate binary logistic regression was used to find factors associated with the presence of malnutrition. A p-value

Introduction Separation of Neurosensory retina from RPE(Retinal Pigment Epithelium) is described as retinal detachment. Recently Pars plana vitrectomy has emerged as a preferred surgical treatment for management of uncomplicated primary rhegmatogenous retinal detachment. Various studies have evaluated the results of combined phaco-vitrectomy, the combined approach allows faster visual recovery and has cost effectivity for patient. The rationale of this study is to compare the anatomical and visual outcome of combined phacoemulsification and vitrectomy vs vitrectomy alone Materials and methods This prospective randomized controlled trial was performed at Eye Unit II Mayo Hospital Lahore (tertiary care eye hospital in Lahore), Pakistan from August 2019 to February 2020. 36 patients full filling the inclusion criteria were divided into two groups 18 patients each. Group A was of combined Phaco-vitrectomy and Group B was of vitrectomy only. The Mann-whitney test as test of significance was applied and P≤0.05 was considered statistically significant. Results BCVA done Pre-operatively for Group A and B, P-value was > 0.05 which was insignificant. Best corrected visual acuity at first week post operatively was significantly lower in patients in which we used gasses as internal tamponade as compared those in which we used silicon oil as tamponade. The BCVA at 1 month showed improvements in both groups, however the BCVA in group B was significantly lower than group A, P-value being < 0.05. The BCVA at 3 month showed improvements in both groups, however the BCVA in group B was significantly lower than group A, P-value being < 0.05. Anatomical Outcome was seen as weather retina was attached or detached. In Group A detachment was present in all follow-ups in 2/18 patients while in Group B detachment was present in all follow-ups in 3/18 patients. The P-value was >0.05 and thus the difference between two groups was insignificant. Conclusion visual acuity did not differ among the two groups preoperatively and on first follow-up at 1 week. The P value being >0.05 in both. However there was significant difference between the two group at 1 month and 3 months follow up, P value being < 0.05 in each. The visual acuity was significantly better in Group A i.e combined phaco- vitrectomy. For anatomical outcome no difference was seen between the groups. The P value was > 0.05. So the visual outcome of group A was significantly better than group B while the anatomical outcome was the same. Keywords Phacoemulsification, Three ports pars plana vitrectomy, best corrected visual acuity, retinal detachment.

Retinoblastoma is most common intraocular malignancy of childhood all over the world including Pakistan. Recent advances in the treatment of disease has improved the survival rates worldwide. Objective: To compare regression of retinoblastoma lesion after monotherapy (chemotherapy) vs combined therapy (chemotherapy + local consolidative therapy). Study Design: Randomized Control trial. Setting: Department of Pediatric Ophthalmology at College of Ophthalmology and Allied Vision Sciences/ King Edward Medical University, Mayo Hospital Lahore, Pakistan. Period: January 2015 to June 2016. Material & Methods: 43 patients with retinoblastoma (group C & D) were included in the study. Chemotherapy was given to patients in group1 and chemotherapy followed by local consolidative therapy was given to patients in group2. The percentage of regression of baseline lesion was noted after 6 cycles of chemotherapy. Results: The mean regression of lesion in group 1 was 24.5% and in group2 was 59.9%, after six months of treatment. The value t-test was 36.02 with p value 0.00 (

Background: Refractive errors and eye diseases are the main core issues in the jail inmates in Pakistan and especially in Punjab province but with best efforts the ophthalmic disorders can be controlled with the help of better screening process for refractive errors, presbyopia, low vision and the general ophthalmic disorders that are found among the jail inmates. The over burden of these ailments can be minimized following a comprehensive screening methods time to time using slandered guidelines approved by WHO. Methodology: A plan was executed for basic necessary screening process to find out the ophthalmic diseases and vision problems. A team of ophthalmologist, optometrists and ophthalmic technicians visited inmates in the jail who presented with any eye problem in this 1-day screening. Auto refraction and manual retinoscopy was done. Visual cut off point was 6/12. Ophthalmic eye medication and glasses (spectacles) was provided free of cost. Results: a total of 270 inmates were examined in the eye camp. The study showed prevalence of refractive errors 4% with a significant high ratio of presbyopia 34% as 79%of inmates were more than 40 year of age. Prevalence of other main eye disease was: conjunctivitis 3%, glaucoma 1% and cataract 2%. Conclusions: There is an urgent need to look into matter of presence the eye diseases and refractive errors found among jail inmates as they fall in the category of marginalized community and the health care provided with ease has no provision the general eye health care. So it is an important issue to lodge a comprehensive effective initiative for the provision of that need mentioned above and a training program for the medical staff of jail hospitals to screen out this community for effective screening knowledge in Primary Eye care.

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

Coronaviruses are a huge family of viruses that originate disease extending from the common cold tofurther fatal maladies. Objective: The study was conducted to determine the gender baseddifferences in COVID-19 patients. Methods: Study included total 150 participants visiting Departmentof Medicine, Mayo Hospital, Lahore, Pakistan. Data were collected through self-structured questionnaireusing non-probability convenient sampling. Prior written informed consents were taken from theparticipants. Ethical approval was taken from The University of Lahore, Lahore. Data were analyzedthrough SPSS version 25.0. Results: Results showed that among the comorbidities hypertension wasmost common in COVID-19 patients followed by diabetes mellitus, especially in females. Whereas renaldisorders and asthma were most reported in males. Analysis revealed that there was a significantassociation (p=0.001) between disease severity and gender. Conclusion: Study concluded that therewas significant association between gender and disease severity.Key words: COVID-19, gender based differences, comorbidities

OBJECTIVE: To compare the retinal nerve fiber layer (RNFL) thickness changes in patients of primary open-angle glaucoma after trabeculectomy versus anti-glaucoma medication. METHODS: This quasi-experimental study was conducted from 10th February, 2017 to 28th February, 2018 on 60 patients presenting to the Institute of Ophthalmology, Mayo Hospital, Lahore, Pakistan using non-probability consecutive sampling. Patients were assigned to two equal groups: group A (n=30) patients underwent trabeculectomy while group B (n=30) patients were put on anti-glaucoma medication. Pre-treatment and three months post-treatment RNFL thickness was recorded and then analyzed using SPPSv.18.0. RESULTS: Out of 60 patients, Group A (n=30) had 14 (46.71%) males and 16 (53.31%) females, while Group B (n=30) had 16 (53.31%) males and 14 (46.71%) females. The mean age was 55.901±4.221 and 55.431±3.971 years in Group A and Group B respectively (p=0.661). In age group, 16 (53.31%) each in Group A and Group B were

Objective: To investigate the effect of pan retinal photocoagulation (PRP) on Optic nerve head blood flow with OCT angiography in patients with proliferative diabetic retinopathy. Methods: This prospective interventional study was conducted at Eye Unit III, Institute of Ophthalmology, Mayo Hospital, Lahore, over a period of seven months i.e. from 10th May 2019 to 10th November 2019. Thirty-five patients having proliferative diabetic retinopathy were included in this study. Ocular blood flow was measured with OCT Angiography, then pan retinal photocoagulation was performed and patients were called for follow-up after one month and ocular blood flow was measured again with OCT Angiography. The difference in the blood flow was calculated. Frequencies and percentages were calculated for the categorical data and mean and standard deviations were calculated for the continuous data. Wilcoxon matched-pairs signed rank test was performed and effects of PRP on blood flow were compared. Significance level was taken as p≤0.05. Results: Out of 35 patients, 30 patients (85.71%) had decreased post PRP blood flow, four patients (11.43%) had increased post PRP blood flow and one patient (2.86%) did not have any effect. Conclusion: OCT angiography revealed there is significantly reduced optic nerve head blood flow in PRP treated eyes compared to non-PRP treated eyes. doi: https://doi.org/10.12669/pjms.36.5.2190 How to cite this:Amanat SA, Khan AA, Tayyab H, Sarwar S. Effect of panretinal photocoagulation on optic nerve head blood flow with OCT angiography in patients with diabetic retinopathy. Pak J Med Sci. 2020;36(5):1075-1078. doi: https://doi.org/10.12669/pjms.36.5.2190 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Purpose: Evaluation of efficacy and safety of 23 – guage five ports vitrectomy versus 23 – guage three portspars plana vitrectomy (PPV) in diabetic tractional retinal detachment.Study Design: Prospective Interventional case series.Place and Duration of Study: Mayo hospital and Services hospital, Lahore, from February 2018 to December2018.Material and Methods: Forty eyes of forty patients were equally divided into two groups. One group whichunderwent five ports PPV and the other group had three ports PPV. Patients with tractional retinal detachment(TRD) with fibrovascular membranes were included and patients who had undergone previous ocular surgery(except cataract surgery) or having TRD due to other ocular diseases were excluded. Preoperative work-upincluded visual acuity, intra ocular pressure measurement and slit lamp examination of anterior and posteriorsegment. Gender, age, pre-operative and post-operative BCVA and intraocular pressure presented by calculatingfrequency and percentages.Results: Pre-operative BCVA improved from 1.11 ± 0.5 to 0.66 ± 0.5 in 3-port groups and from 1.7 ± 0.9 to 0.87± 0.8 in 5-port groups. Duration of surgery was 74.40 ± 5.4 and 53.40 ± 2.5 minutes in 3 ports and 5-ports grouprespectively. Iatrogenic retinal tear developed in two patients in each group. Per-operative vitreous hemorrhagedeveloped in three patients in 3-ports group and in two patients in 5-ports group. Two patients in each groupdeveloped post vitrectomy cavity hemorrhage.Conclusion: Bimanual 5- ports 23-guage vitrectomy is a faster procedure than three ports 23 – guage vitrectomyin diabetic tractional retinal detachment.

Purpose: To determine the mean change in refractive status after Levator muscle resection in patients of simple congenital ptosis. Study Design: Quasi Experimental study. Place and Duration of Study: This study was carried out at Institute of Ophthalmology, King Edward Medical University, Mayo Hospital Lahore, from 2014 to 2015. Material & Methods: Fifty patients were selected under the age of 12 years with no sex predilection presenting with simple congenital ptosis of pupil sparing type. Patients with neurogenic, aponeurotic ptosis, mechanical ptosis, Blepharophimosis syndrome, patients with previous failed ptosis surgery and patients with corneal anomalies were excluded. After history and examination, Cycloplegic retinoscopy was done, which was repeated after surgical intervention. All interventions were done by a single ophthalmic surgeon. The patients were examined and discharged on the second post operative day. All data including preoperative and postoperative recordings of spherical and cylindrical values were collected on a self-designed proforma. Follow up period was extended to 3 months. At 3rd month cycloplegic retinoscopy was done and change in character of refractive status was analyzed. Mean change in refractive status was calculated by difference of preoperative and postoperative sphere and cylinder values. Results: Mean age of patients was 4.26 ± 3.78 years. Mean change in spherical value after treatment was 0.447 ± 0.339. This difference was statistically significant with p-value = 0.000. While mean change in cylindrical value after treatment was 0.640 ± 0.580. This difference in cylinder value after treatment was also statistically significant with p-value = 0.000. Conclusion: Levator muscle resection has a significant effect on refractive status of the patients with congenital ptosis.

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

Intravitreal injection of Bevacizumab for various retinal vascular disorders has become the mainstay of treatment. The injection of Bevacizumab is usually dispensed through local pharmacies after formulating from a larger vial under sterile conditions. We report an interesting finding of silicone oil bubble in vitreal cavity after intravitreal Bevacizumab injection. This is attributed to the fact that the syringes used for dispensing bevacizumab are coated with silicone oil that acts as a lubricant. These silicone oil droplets can lead to floaters and other possible complications. We report two cases of such occurrence and propose strategies to avoid this complication. Keywords: Bevacizumab, diabetic macular edema, silicone oil, ranibizumab.

Objective: To evaluate the effectiveness of inverted internal limiting membrane flap in large idiopathic macular holes. Methods: Twelve patients diagnosed with idiopathic macular holes larger than 400um underwent 23 gauge Pars Plana Vitrectomy (PPV) with inverted internal limiting flap and gas tamponade at Al-Ehsan Eye Welfare Eye Hospital, Lahore from February 2017 to February 2018. All cases were diagnosed on Spectral Domain Optical Coherence Tomography (SD-OCT) and were followed up for 6 months. At every follow-up, best corrected visual acuity and SD-OCT was done. Results: We achieved macular hole closure in 91.6% (11/12) patients with idiopathic macular holes larger than 400um. Five out of 12 patients underwent combined phacoemulsification and PPV. One patient has flat hole closure which was considered failure. One patient was excluded from the study due to per-operative flap loss. This patient was not included in final data analysis of 12 patients. There was statistically significant gain in best corrected visual acuity after successful macular hole closure. We did not report any untoward events during or in the post-operative period. Conclusion: Inverted internal limiting flap is an effective method for repairing large macular holes. How to cite this:Tayyab H, Khan AA, Jahangir S. Efficacy of inverted internal limiting membrane flap for large idiopathic macular holes. Pak J Med Sci. 2019;35(2):315-319. doi: https://doi.org/10.12669/pjms.35.2.689 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background Trichiasis is present when one or more eyelashes touches the eye. Uncorrected, it can cause blindness. Accurate estimates of numbers affected, and their geographical distribution, help guide resource allocation. Methods We obtained district-level trichiasis prevalence estimates in adults for 44 endemic and previously-endemic countries. We used (1) the most recent data for a district, if more than one estimate was available; (2) age- and sex-standardized corrections of historic estimates, where raw data were available; (3) historic estimates adjusted using a mean adjustment factor for districts where raw data were unavailable; and (4) expert assessment of available data for districts for which no prevalence estimates were available. Findings Internally age- and sex-standardized data represented 1,355 districts and contributed 662 thousand cases (95% confidence interval [CI] 324 thousand–1.1 million) to the global total. Age- and sex-standardized district-level prevalence estimates differed from raw estimates by a mean factor of 0.45 (range 0.03–2.28). Previously non- stratified estimates for 398 districts, adjusted by ×0.45, contributed a further 411 thousand cases (95% CI 283–557 thousand). Eight countries retained previous estimates, contributing 848 thousand cases (95% CI 225 thousand-1.7 million). New expert assessments in 14 countries contributed 862 thousand cases (95% CI 228 thousand–1.7 million). The global trichiasis burden in 2016 was 2.8 million cases (95% CI 1.1–5.2 million). Interpretation The 2016 estimate is lower than previous estimates, probably due to more and better data; scale-up of trichiasis management services; and reductions in incidence due to lower active trachoma prevalence., Author summary As an individual with trichiasis blinks, the eyelashes abrade the cornea, which can lead to corneal opacity and blindness. Through high quality surgery, which involves altering the position of the eyelid margin, it is possible to reduce the number of people with trichiasis. Accurate estimates of the number of persons with trichiasis and their geographical distribution are needed in order to effectively align resources for surgery and other necessary services. We obtained district-level trichiasis prevalence estimates for 44 endemic and previously-endemic countries. We used the most recently available data and expert assessments to estimate the global burden of trichiasis. We estimated that in 2016 the global burden was 2.8 million cases (95% CI 1.1–5.2 million). The 2016 estimate is lower than previous estimates, probably due to more and better data; scale-up of trichiasis management services; and reductions in incidence due to lower active trachoma prevalence.

BackgroundTrichiasis is present when one or more eyelashes touches the eye. Uncorrected, it can cause blindness. Accurate estimates of numbers affected, and their geographical distribution, help guide resource allocation.MethodsWe obtained district-level trichiasis prevalence estimates for 44 endemic and previously-endemic countries. We used (1) the most recent data for a district, if more than one estimate was available; (2) age- and sex-standardized corrections of historic estimates, where raw data were available; (3) historic estimates adjusted using a mean adjustment factor for districts where raw data were unavailable; and (4) expert assessment of available data for districts for which no prevalence estimates were available.FindingsInternally age- and sex-standardized data represented 1,355 districts and contributed 662 thousand cases (95% confidence interval [CI] 324 thousand-1.1 million) to the global total. age- and sex-standardized district-level prevalence estimates differed from raw estimates by a mean factor of 0.45 (range 0.03-2.28). Previously non-standardized estimates for 398 districts, adjusted by ×0.45, contributed a further 411 thousand cases (95% CI 283-557 thousand). Eight countries retained previous estimates, contributing 848 thousand cases (95% CI 225 thousand-1.7 million). New expert assessments in 14 countries contributed 862 thousand cases (95% CI 228 thousand-1.7 million). The global trichiasis burden in 2016 was 2.8 million cases (95% CI 1.1-5.2 million).InterpretationThe 2016 estimate is lower than previous estimates, probably due to more and better data; scale-up of trichiasis management services; and reductions in incidence due to lower active trachoma prevalence.Author SummaryAs an individual with trichiasis blinks, the eyelashes abrade the cornea, which can lead to corneal opacity and blindness. Through high quality surgery, which involves correcting the position of the in-turned eyelid, it is possible to reduce the number of people with trichiasis. An accurate estimate of the number of persons with trichiasis and their geographical distribution are needed in order to effectively align resources for surgery and other necessary services. We obtained district-level trichiasis prevalence estimates for 44 endemic and previously-endemic countries. We used the most recently available data and expert assessments to estimate the global burden of trichiasis. We estimated that in 2016 the global burden was 2.8 million cases (95% CI 1.1-5.2 million).The 2016 estimate is lower than previous estimates, probably due to more and better data; scale-up of trichiasis management services; and reductions in incidence due to lower active trachoma prevalence.

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

Diabetic macular edema is one of the leading causes of visual loss in diabetic patients. However, the impact of medicinal treatment on the occurrence of macular edema remained elusive. Objectives: This study was designed to determine the effect of intravitreal bevacizumab in patients of diabetic macular edema.Methods: An interventional study was conducted on patients that underwent pre-injection and one-month post-injection OCT for RNFL thickness. OCT was performed by researchers and findings were recorded accordingly. The retinal nerve fiber layer thickness was measured in superior, inferior halves and total average thickness. Pre- and post-injection OCT were conduced and macular thickness were documented. Results: The mean retinal nerve fiber layer thickness was decreased in superior and inferior halves as well as in the total thickness. Conclusion: Intra vitreal bevacizumab decreases the retinal nerve fiber layer thickness. Large randomized controlled trials are required to establish or rule out any association between this decrease in thickness and incidence if glaucoma in such patients.

Purpose: The aim of this study is to present an analysis of orbital lesions by classifying them according to the site of origin in patients of all ages presenting at a tertiary care eye hospital from 1996 till 2012. Methods: 1637 patients were initially enrolled in this descriptive case series. Clinical data of 1246 patients who completed the study during 17 years were analyzed. Orbital lesions of the patients were examined and managed medically or surgically as per requirement. The histopathological reports of these patients were used to classify the lesions. Results: Out of all cases 54.57% (n = 680) were neoplastic and 45.42% (n = 566) were nonneoplastic lesions. Amongst the neoplastic lesions 86.17% (n = 586) were malignant and 13.82% (n = 94) were benign. Primary orbital lesions were the most common orbital lesions being 963 (77.29%) followed by secondary orbital lesions being 232 (18.62%), hematopoietic reticuloendothelial being 47 (3.77%) and metastatic lesions being 04 (0.32%). Conclusion: Orbital lesions are more common in adults as compared to children. Neoplastic lesions are more common than nonneoplastic lesions, and amongst the neoplastic lesions malignant lesions are more common than benign ones. Primary orbital lesions are the most common orbital lesions followed by secondary orbital lesions, lesions of the hematopoietic reticuloendothelial system and metastatic lesions.

Background The Global Trachoma Mapping Project (GTMP) was implemented with the aim of completing the baseline map of trachoma globally. Over 2.6 million people were examined in 1,546 districts across 29 countries between December 2012 and January 2016. The aim of the analysis was to estimate the unit cost and to identify the key cost drivers of trachoma prevalence surveys conducted as part of GTMP. Methodology and principal findings In-country and global support costs were obtained using GTMP financial records. In-country expenditure was analysed for 1,164 districts across 17 countries. The mean survey cost was $13,113 per district [median: $11,675; IQR = $8,365-$14,618], $17,566 per evaluation unit [median: $15,839; IQR = $10,773-$19,915], $692 per cluster [median: $625; IQR = $452-$847] and $6.0 per person screened [median: $4.9; IQR = $3.7-$7.9]. Survey unit costs varied substantially across settings, and were driven by parameters such as geographic location, demographic characteristics, seasonal effects, and local operational constraints. Analysis by activities showed that fieldwork constituted the largest share of in-country survey costs (74%), followed by training of survey teams (11%). The main drivers of in-country survey costs were personnel (49%) and transportation (44%). Global support expenditure for all surveyed districts amounted to $5.1m, which included grant management, epidemiological support, and data stewardship. Conclusion This study provides the most extensive analysis of the cost of conducting trachoma prevalence surveys to date. The findings can aid planning and budgeting for future trachoma surveys required to measure the impact of trachoma elimination activities. Furthermore, the results of this study can also be used as a cost basis for other disease mapping programmes, where disease or context-specific survey cost data are not available., Author summary There are currently few data sets available to aid programmes in planning and budgeting for population-based surveys in low- and middle- income countries. With the objective of identifying cost drivers and key variables influencing prevalence survey costs, the authors collected expenses incurred during the Global Trachoma Mapping Project (GTMP) which surveyed 2.6 million people across 29 countries. Expenditure from surveying 1,164 districts in 17 countries was analysed. Our results showed that the majority of in-country expenditure was spent on personnel (per diems, accommodation, meals and beverages) (49%) and local transportation (44%) and that the median survey expenditure was US$11,675 per district (or US$15,839 per evaluation unit, US$625 per cluster and US$4.9 per person examined). There were large variations in survey unit costs across settings, based on local geographic, demographic, seasonal effects and local operational characteristics. In addition, the resources required for the global support and coordination of the GTMP were analysed and amounted to US$5.1m (US$3,318 per district or US$5,668 per EU). Global support expenses can be substantial for a large multi-country mapping exercise conducted in a limited period of time such as the GTMP. Findings from this study can be used to inform other disease mapping projects, and to inform planning and budgeting for the prevalence surveys that will assess the impact of trachoma elimination interventions.

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

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

Hepatocellular carcinoma (HCC) is among the most common malignancies worldwide, particularly in South and South East Asia. Unfortunately due to lack of appropriate facilities and awareness only limited information is available about its early diagnosis. Aim of the present study was to determine the efficacy of p53 by immunohistochemistry and Argyrophilicnucleolar organizer regions (AgNORs) in diagnosis of HCC and cirrhosis of liver. A total of 100 liver biopsies were studied, it included 20 cases of HCC, 60 cases of cirrhosis of the liver and 20 cases of normal liver from autopsy specimens as a control. Out of 20 cases of HCC, 15 were positive for p53 stain and 5 were negative. None of the 60 cases of cirrhosis or 20 with normal histology revealed p53 expression. A statistically significant (p . It helps in differentiation from well differentiated to moderately and to poorly differentiated HCC.

A study was conducted to see the association of retinoblastoma with age, bilaterism, Tumor size, site, grades, involvement of anterior chamber, iris, ciliary body, choroid, sclera and optic nerve, and extraocular extension. This was a retrospective descriptive analytical study. The records of the Institute of Ophthalmology, King Edward Medical University/Mayo hospital, Lahore: Pakistan January 2006-Dec 2011 was analyzed. Five years biopsies (June 2006 to June 2012) of the retinoblastoma, from the Pathology department, was retrieved to see optic nerve involvement in all the retrieved specimens. The mean age was 3.54 ± 1.686 years. There were 15 cases of bilateral retinoblastoma and 37 cases with unilateral neoplasms. The age range of bilateral tumors was 2 - 6 years while the range in unilateral tumor was 1 - 10 years male to female ratio was 1:1.5. Among 52 cases, 37 (71.2%) patients were unilateral retinoblastoma and 15 (28.28%) patients were with bilateral disease. On radiological examination of patients suffering from retinoblastoma by B-Scan (Ultrasound), there were 33 (63.5%) cases with exophytic presentation while 18 (34.6%) cases showed endophytic morphology. On clinical examinations, 28 patients presented with proptosis of (it was the most common presenting sign in our patients, accounting for about 53.8% of cases), 20 cases presented with leucocoria eye with strabismus. 29/52 patients showed involvement with optic nerve, 17 were from 1 - 3 years age and 12 were from 4 - 6 years. Statistically there was no difference in the involvement of optic nerve, disc involvement and extra ocular extension with the age of patients (p = 0.217). There was also no statistical difference seen in age and gender for but a strong association was seen with patient’s presentation, symptoms and size of the tumors and anterior chamber, iris, ciliary body, choroid, sclera and optic nerve, and extra ocular extension. We concluded that a positive association was seen with tumor size and tumor extension (optic nerve, and extraocular extension). No Association was seen with age, gender and laterality of the tumors.

Retinoblastoma (Rb) was reported firstly by Benedict is the commonest pediatric intraocular malignant tumor in children younger than 5 years of age. The study was conducted to detect the RB-1 gene for prognostic evaluation in retinoblastoma and to see the frequency of RB-1 gene in our population. This was a retrospective descriptive analytical study. Five years biopsies (January, 2006 to December 2011) of the retinoblastoma, from the Pathology department, was retrieved to see optic nerve involvement in all the retrieved specimens. The study was taken to see the mutation of RB1 gene by immunohistochemistry and PCR. The study plan was approved from Institutional Review Board (IRB) of the University. All the cases showed positivity of abnormal Rb-1 gene proteins expression by Immunohistochemistry staining. On PCR, 51/52 (98%) tumors expressed gene mutation as compared to 100% expression shown by IHC. Out of these, 28/51 (55%) cases showed ONI and ODI with positivity for mutated RB gene. A positive association was seen among RB gene mutation with ONI and ODI (p = 0.05). There were 33/51 (65%) cases who did not show any EOE but showed PCR positivity for RB gene mutation. While there were 18/51 (35%) cases who showed EOE and positivity of PCR for Rb-1 gene mutation and a positive association was seen with EOE and gene mutation (p = 0.005). The most common sequence of mutation was on 13 with 33 cases for double mutation, 12 cases for single and 6 patients for triple pattern of mutation. Most of the double and triple sequences of mutations were associated with ONI, ODI and EOE. We concluded that mutation of RB-1 gene is responsible in causation of the tumors with a positive association with tumor size and tumor extension (optic nerve, and extraocular extension), and mutation affects patients with all ages, both gender and unilateral and bilateral tumors.

Hundred eyes of 97 patients were operated for determining complications and visual outcome of Sclerally Fixed Posterior Chamber Intraocular Lenses at Institute of Ophthalmology, Mayo Hospital, Lahore from January 2002 till December 2002. Those operated either had ICCE done previously, per-operated large rent in posterior capsules, dislocated lens and t raumatic subluxated cataractous Iens. Immediate complications were transient rise in IOP, corneal edema, striate keratopathy. Late complications noted had decentration of IOL ( 4%), Cystoid Macular edema 4%, suture erosion (2%) and lens tilt (1%). 80% patients had Post-operative V/A of 6/6-6/12 and 20% had V/A 6/18- 6/60 as compared to Pre-Operative V/A of 56% in 6/6-6/12, 10% in 6/18-6/60 and 34% in 3/60-PL+ ve. Encouraging results favour this procedure.

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

This is a case report about the anterior segment findings of epithelial ingrowth in a young female patient after penetrating trauma. The patient underwent multiple surgeries after penetrating trauma and epithelial ingrowth was noted on regular follow-up. Epithelial ingrowth was noted along the inner surface of corneal endothelium along with the presence of cysts. These findings suggest that epithelium penetrated through the site of perforation and grew along endothelium. Although epithelial ingrowth is a commonly reported complication of photorefractive surgery, it is rarely reported after trauma to eye. To authors#039; knowledge, this is the first reported case of epithelial ingrowth in Pakistan.

Purpose: To evaluate the outcome of scleral buckling surgery using a wide – angle non-contact viewing system and chandelier endoillumination for per-operative fundus visualization in patients with non-complex rhegmatogenous retinal detachments. Materials and Methods: This was a prospective, interventional study carried out at the Department of Ophthalmology, Mayo Hospital Lahore over a period of six months. Non-probability convenience sampling technique was employed. Fifteen eyes of fifteen pati-ents underwent modified scleral buckling procedure for rhegmatogenous retinal detachment using a 25G Awh Chandelier (inserted into the sclera through the pars plana) and wide angle viewing system to view the fundus intraoperatively instead of the conventional Indirect Ophthalmoscope. Results: The mean age of the patients in this study group was 41.9 ± 12.4 years. Out of fifteen patients, 13 had flat retinas postoperatively. Two patients had to undergo pars plana vitrectomy with silicone oil tamponade due to development of retinal detachment secon-dary to PVR. Conclusion: Modified scleral buckling with the con-current use of a chandelier light and wide angle viewing system provides an easier and more convenient means of visualizing the fundus under panoramic viewing conditions intraoperatively. Key Words: Wide – angle viewing system. Retinal detachment. Scleral buckling. Endoillumination.

BP Pakistan has been laying cross-country pipelines to produce oil and gas in the Badin concession for the last 20 years, and has gained considerable experience with conventional carbon steel material. The average time required to lay a 4" diameter × 5000 ft long steel pipeline has been around 4 weeks. There was a desire to reduce this time to improve put-on-production (POP) time. Other factors driving us to think out of the box were corrosion, high operating and life cycle cost etc. A project consisting of laying 4"-1500 psig × 5000 ft Spoolable Reinforced Composite (SRC) pipeline from wellhead to facility was initiated in consultation with BP Exploration & Production Technology Group (EPTG). EPTG was actively involved in the development of this new technology in the wider BP world, and this was seen as an opportunity to test the material in Pakistan. Testing of the material for potential use in high-pressure (HP) gas was also envisaged. In order to ensure rigorous testing of new material and technology, one of the toughest construction location (high water table, collapsing trench, three major crossings, a number of minor crossings, etc.) was selected. Since most of the potential risks to delivery were evaluated upfront, the result was a record laying time of 0.5 km / hr. The project was completed with great success and learnings for the use of this technology in future, and to share with others who choose to use the same material and technology. This paper provides a brief overview of this new material, its physical properties, potential use, characteristics, advantages over conventional carbon steel and installation experience at BP Pakistan and recommendations for future utilization in oil and gas industry.