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Objective To evaluate key corneal tomography parameters for screening mixed astigmatism and hyperopic males and females for refractive surgery and to compare the data to a previously studied myopic group in Pakistani population. Study design Cross-sectional, observational study. Place and duration of study Armed Forces Institute of Ophthalmology AFIO, National University of Medical Sciences, Rawalpindi, Pakistan, from August 2013 to August 2018. Methodology WaveLight Allegro Oculyzer II diagnostic device was used to examine eyes of 106 adult hyperopic patients in order to determine normal values of 20 parameters, which are considered most clinically applicable for refractive surgery screening. Kolmogorov-Smirnov test was used to evaluate normality of data. Results for outliers were displayed as 2.5%, 5%, 95% and 97.5% percentiles. Results Two hundred and nine eyes were examined; 110 men and 99 women with overall mean age of 31+11.7 years. Normal mean anterior segment values included: flat simulated keratometry (K1) 42.1±1.84 diopters (D), steep K2 43.8 ± 1.93 D, K maximum 44.4 ± 1.93 D, K mean 42.9 ± 1.75 D, astigmatism -1.3 ± 1.75 D, pachymetry at thinnest point 546.9 ± 33.3 um, front elevation at thinnest point 5.2 ± 3.47 um, and at the back was 14.1 ± 6.60 um, Ambrosio relational thickness maximum 472.0 ± 88.73, progression index (PI) maximum 1.2 ± 0.18, and anterior chamber depth (ACD) 2.7 ± 0.35 mm. Conclusion Hyperopic patients had greater front and back elevation and pachymetry but lesser keratometry, anterior chamber depth and chamber volume as compared to myopic patients in Pakistani population. Front and back elevation data in this hyperopic study population was slightly higher than previously published studies. Key Words: Refractive surgery, Corneal tomography, Screening, Hyperope.

To determine the refractive outcomes of wavefront optimized photo refractive keratectomy (PRK) in patients having myopia and myopic astigmatism in terms of efficacy, safety, accuracy, stability and predictability of the procedure.Quasi-experimental study.Refractive Surgical Unit, Armed Forces Institute of Ophthalmology, National University of Medical Sciences, Rawalpindi, Pakistan, from October 2013 to August 2018.Patients having myopia and myopic astigmatism, consented to be a part of the study, underwent meticulous screening consisting of detailed medical history, ocular examination and investigations. Each case was compiled and evaluated. Those who satisfied the criteria for refractive surgery were subjected to PRK procedure. Postoperative follow-up was carried out and parameters were recorded at designated intervals of 1 week, 1, 3, 6 and 12 months.This study included 208 eyes of 106 patients with mean age of 25.33 + 5.196 years. At the end of one year, 97% (202 out of 208) eyes had uncorrected distance visual acuity (UDVA) better than 20/25 with efficacy index of 1.009 ± 0.132 and safety index of 1.019 ± 0.126. None of the eyes lost two or more lines. In this study, 207 out of 208 eyes remained within + 0.50 diopter (D) of intended spherical equivalent (SEQ). Results showed 100% accuracy of procedure since all the study patients achieved SEQ within + 1D.PRK is an effective, predictable, and safe treatment procedure for correcting myopia and myopic astigmatism. Key Words: Photorefractive keratectomy, Myopia, Refractive surgery, Myopic astigmatism, Uncorrected distance visual acuity.

To evaluate key corneal tomography parameters for screening mixed astigmatism and hyperopic males and females for refractive surgery and to compare the data to a previously studied myopic group in Pakistani population.Cross-sectional, observational study.Armed Forces Institute of Ophthalmology AFIO, National University of Medical Sciences, Rawalpindi, Pakistan, from August 2013 to August 2018.WaveLight Allegro Oculyzer II diagnostic device was used to examine eyes of 106 adult hyperopic patients in order to determine normal values of 20 parameters, which are considered most clinically applicable for refractive surgery screening. Kolmogorov-Smirnov test was used to evaluate normality of data. Results for outliers were displayed as 2.5%, 5%, 95% and 97.5% percentiles.Two hundred and nine eyes were examined; 110 men and 99 women with overall mean age of 31+11.7 years. Normal mean anterior segment values included: flat simulated keratometry (K1) 42.1±1.84 diopters (D), steep K2 43.8 ± 1.93 D, K maximum 44.4 ± 1.93 D, K mean 42.9 ± 1.75 D, astigmatism -1.3 ± 1.75 D, pachymetry at thinnest point 546.9 ± 33.3 um, front elevation at thinnest point 5.2 ± 3.47 um, and at the back was 14.1 ± 6.60 um, Ambrosio relational thickness maximum 472.0 ± 88.73, progression index (PI) maximum 1.2 ± 0.18, and anterior chamber depth (ACD) 2.7 ± 0.35 mm.Hyperopic patients had greater front and back elevation and pachymetry but lesser keratometry, anterior chamber depth and chamber volume as compared to myopic patients in Pakistani population. Front and back elevation data in this hyperopic study population was slightly higher than previously published studies. Key Words: Refractive surgery, Corneal tomography, Screening, Hyperope.

The 9p21 ANRIL (antisense non-coding RNA in INK4 locus) polymorphisms had reported association with type 2 diabetes mellitus (T2DM) and its induced macro/microvascular complications. However, the ANRIL single nucleotide polymorphism (SNP) rs1333049 has never been studied for its role in diabetic retinopathy; we therefore assessed its role in Pakistani population suffering from diabetes-induced retinopathy. The rs1333049 was genotyped in 806 individuals including 504 T2DM cases [206 patients without retinopathy (DNR) and 298 with retinopathy (DR) (non-proliferative DR (NPDR):147; proliferative DR (PDR): 151)] and 302 unaffected controls using allele-refractory mutation system (ARMS) polymerase chain reaction (PCR). The statistical analysis including genetic power estimation, χ2 test and Fisher's exact test were performed for the studied panel. Genetic power estimation showed that 504 T2DM cases and 302 controls had > 80% power to detect the association between ANRIL rs1333049 variant and diabetes patients with retinopathy in Pakistani population. An association was found between rs1333049 CC genotype and T2DM [χ2 = 13.9 (p = 0.0015); recessive model (RM): odds ratio (OR) = 2.36, 95% confidence interval (95%CI) = 1.42–3.95, p = 0.001], DNR [χ2 = 14.2 (p = 0.00081); RM: p = 0.001, OR = 2.66, 95%CI = 1.48–4.79, dominant model (DM): p = 0.02 OR = 1.68, 95%CI = 1.07–2.63], DR: (χ2 = 6.5, p = 0.0381; OR = 2.16, 95%CI = 1.23–3.79, p = 0.006), NPDR (χ2 = 4.25, p = 0.03; OR = 2.02, 95%CI = 1.03–3.96, p = 0.03) and PDR (χ2 = 8.11, p = 0.02; OR = 2.29, 95%CI = 1.19–4.39, p = 0.01) when compared with the healthy control subjects. The minor allele C was found to be associated with T2DM (OR = 1.32, 95%CI = 1.07–1.63, p = 0.009) and DNR (OR = 1.49, 95%CI = 1.15–1.94, p = 0.002). The ANRIL rs1333049 CC genotype is found to have a pathogenic role in the onset of T2DM and its induced retinopathy complication.

PURPOSE: The purpose of this study is to compare the safety and efficacy of transepithelial corneal crosslinking (CXL) with epithelium-off crosslinking (epithelium-off CXL) in the treatment of progressive keratoconus in adult Pakistani population. MATERIALS AND METHODS: Sixty-four eyes of 64 consecutive patients of progressive keratoconus were included in this quasi-experimental study. Thirty-two eyes received transepithelial CXL with Peschke TE (0.25% riboflavin (Vitamin B2), 1.2% hydroxypropyl methylcellulose (HPMC), 0.01% benzalkonium chloride) and 32 eyes received epithelium-off CXL with Peschke M (0.1% riboflavin (Vitamin B2) 0.1%, HPMC 1.1%.) The cornea was then exposed to ultraviolet A light at an irradiance of 3 mW/cm2 for 30 min. The primary outcome measure, clinical stabilization of keratoconus was defined as an increase of no more than 1D in Kmax at 1 year. Other parameters evaluated at baseline and 3, 6, 12, and 18 months postoperatively were uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), spherical equivalent (SE), astigmatism (Ast), simulated keratometry, steep keratmetry (steep K), and corneal thickness at thinnest point (pachy thin). RESULTS: Both epithelium-off CXL and transepithelial CXL groups showed a significant reduction in Kmax, steep K, simulated K, corneal pachymetry at all test points (P < 0.05) with significantly greater reductions achieved in epithelium-off CXL group at 18 months follow-up. The mean UDVA, CDVA, SE, Ast significantly improved in both groups (P < 0.05). The mean postoperative UDVA and CDVA between the groups were not significant at 12 months (P = 0.650, 0.018, respectively). Clinical stabilization was achieved in 94% of eyes in epithelium-off CXL and 75% of eyes in transepithelial CXL. In epithelium-off CXL, three eyes exhibited stromal haze resolved by corticosteroid treatment. No complication was documented in transepithelial CXL group. CONCLUSION: Transepithelial CXL is not recommended to be replaced completely by standard epithelium-off CXL due to continued ectatic progression in 25% of cases. However, thin corneas, unfit for standard epithelium-off CXL, can benefit from transepithelial CXL.

This study was conducted to evaluate the safety of accelerated corneal collagen crosslinking (CXL) in keratoconus patients on basis of endothelial cell density measurements.We studied 24 patients (42 eyes) with diagnosed keratoconus who underwent accelerated CXL with 9 Mw/cm2 UVA irradiance for 10minutes. All patients underwent detailed examination and video keratography (VKG) for classification and confirmation of keratoconus. Patients with central corneal thickness (CCT) of ≥400μ were included in the study. Specular microscopy was done to note endothelial cell density (ECD) preoperatively and then at the end of 1st, 4th and 12th weeks' post-operative period.The study included 24 patients (42 eyes) from October 2016 to June 2017. Among these 13 were females and 11 males with mean age of 20.15±6.73 years. Eighteen patients underwent the procedure in both eyes while 6 had the procedure in one eye. The pre-operative ECD mean±SD of right eye was 2743.97±542.77/mm2 and left eye was 2763.35±532.57/mm2. The post-operative ECD mean±SD of right and left eyes at the end of 12th post-op weak were 2806.34±520.11/mm2 and 2823.30±628.57/mm2 respectively. The pre and post-op ECD comparison showed p-values at first week post-op are 0.474 and 0.683 for right and left eyes respectively. Similarly, the p-values at 4th and 12 weeks post-op for right eye are 0.266 and 0.280 respectively. The p-values at 4th and 12th weeks for left eye are 0.913 and 0.404 respectively.Accelerated CXL protocols is safe and effective procedure and did not lead to significant change in ECD in our study population in three months post-procedural follow up. However further research is required to determine the effect of high intensity UVA radiation on other ocular structures with larger group of patients and long-term follow up.

Objective To determine mean change in visual acuity, central corneal thickness and symptoms in patients with pseudophakic bullous keratopathy after treatment with corneal collagen crosslinking. Methods This quasi experimental study was conducted at Armed Forces Institute of Ophthalmology, Rawalpindi, Pakistan from April 2015 to Nov 2015. A total of 24 eyes of 24 patients were included in the study. Visual symptoms were graded in five grades (Grade 1-5), Grade-1 being very mild with decreased vision only while patients with all five symptoms (decreased vision, foreign body sensations, pain, watering and photophobia) were graded as Grade-5. Corneal collagen cross linking using topical isotonic riboflavin followed by UVA radiations (3mW/cm(2) for 10 minutes) was performed in all the patients. Visual acuity (VA), visual symptoms and central corneal thickness (CCT) were recorded before and 04 weeks after the treatment. Results A total of 24 eyes of 24 patients (18 male and 6 females) underwent surgery. Age of the patients ranged from 55 to 75 years with mean age 65.83 + 3.89 years. Mean visual acuity was 2.09 + 0.23 before treatment while after treatment it was 2.13 + 0.22. Mean CCT as measured by optical pachymetry (Galilae G6) was 753.96 + 55.16 and 641+ 29.25 before and after surgery respectively. Improvement of clinical symptoms was seen in all the patients. Conclusion Corneal collagen cross linking is a temporary but effective symptomatic treatment of pseudophakic bullous keratopathy.

Objective: To study Agreement between Keratometric readings by VERION image guided System, Galilei G4 and Pentacam. Methods: The quasi experimental study was conducted at Armed Forces Institute of Ophthalmology, Rawalpindi, Pakistan from August 2016 to December 2016. Twenty five patients fulfilling the inclusion criteria participated in the study. All Patients were subjected to Keratometric assessment using Galilei G4 Dual Scheimpflug analyzer (Ziemer, Switzerland), Wavelight Oculyzer II (Pentacam, Germany) and Verion image guided system (Alcon). Steep and flat meridian and diopter of astigmatism by three systems were recorded and endorsed. All readings were taken by the same observer. Statistical Program for Social Sciences (SPSS) version 22.0 was used for statistical analysis. Results analyzed for significance by t-tests and Interclass correlation analysis. In t tests, P values of 0.7 was considered acceptable. Results: Fifty eyes of twenty-five patients (22 male, 28 female) with mean age of 29.50 ± 3.46 years were studied. Flat K, steep K and dioptric power of astigmatism were measured with verion, pentacam and Galilei G4. Interclass correlation analysis showed agreement between individual variables measured by the three devices, while one sample t test showed no significant difference between dioptric power of astigmatism between Verion-Pentacam and Verion- Galilei group. (p 0.178 for former and 0.622 for later group). Conclusion: Verion image guided system is comparable to other instruments used currently for keratometry. Verion can be interchangeably used with Pentacam and Galilee G4 in assessing corneal astigmatism.

Non-traumatic ectopia lentis has been associated with genetic diseases in a European population; however, no data are present in regards to this in a Pakistani demographic. In third world countries such as Pakistan, due to the lack of screening tests, this disease has the potential to remain undiagnosed till a later age, at which point the eye through the finding of ectopia lentis has potential to lead to the right diagnosis. Our purpose was to investigate Pakistani patients presenting with ectopia lentis who have underlying homocystinuria and establish a relationship between the two. Additionally, we elicited various systemic and ophthalmic features in these settings. Ten Pakistani patients presenting with decreased vision and ectopia lentis with concomitant homocystinuria were included in the study. Assessment of systemic and ophthalmic features was performed. All patients presented with visual deterioration. All 20 (100 %) eyes had ectopia lentis, of which, 15 (75 %) eyes had inferior subluxation, whereas five (25 %) eyes had anterior subluxation of the crystalline lens. Ectopia lentis and homocystinuria appear to have a strong correlation in Pakistani population. Ectopia lentis has the potential to serve as an important clue to its diagnosis, which may in turn lead to decreased morbidity if diagnosed in a timely fashion.

Objective To compare post-operative pain relieving effect of topical diclofenac 0.1% versus ketorolac 0.5% in Corneal Collagen Cross Linking (CXL) for patients diagnosed with keratoconus. Methods This randomized controlled trial was carried out for six months from October 2016 to March 2017. We included young patients having keratoconus with k-readings greater than 47D and central corneal thickness more than 400 microns. All the patients received single dose one drop of topical diclofenac 0.1% to (Group-A) and ketorolac 0.5% to (Group-B) 30 minutes in advance of the corneal collagen cross linking (CXL) procedure. The CXL was performed with topical 0.1% riboflavin eye drops in 20% dextran as a photo sensitizer. After 36 hours of the CXL procedure, the postoperative intensity of pain was assessed verbally by patients with the help of visual analog scale (VAS) numbers from zero to five where 0 designated no pain & 5 symbolized worst pain. Results The study comprised sixty eyes of forty one patients. Out of total 16 were male while 25 female patients. The mean age of the patients was 24.27 ± 2.93 years (range 20 to 29 years). In the conclusive analysis, diclofenac 0.1% was used on 30 patients in Group-A and ketorolac 0.5% on 30 subjects in Group-B. Pain relieving scores in Group-A (diclofenac 0.1%) was 2.57 ± 0.67 while in Group-B (ketorolac 0.4% treated arm) was 3.20 ± 0.61. Conclusion Topical diclofenac 0.1% is statistically comparable to topical ketorolac 0.5% in precluding severity of pain after corneal collagen cross linkage operation.

Objective: To compare the effects of Pars Plana Vitrectomy (PPV) and Scleral Buckling (SB) with reference to Central Corneal Thickness (CCT), Corneal Endothelial-Cell Density (CED), Anterior Chamber Depth (ACD) and Axial Length (AL) in repair of Rhegmatogenous Retinal Detachment (RRD). Methods: This comparative cross sectional analytical study was conducted at Armed Forces Institute of Ophthalmology (AFIO), Rawalpindi from July 2013 to July 2015. A total of 69 eyes of 69 patients which underwent repair of RRD by either PPV or SB were analyzed to compare mean change in CCT, CED, ACD and AL between two groups. Results: Mean age of patients was 56.23±5.22 years. Mean pre-operative CCT, CED, ACD and AL in PPV group was 533.06±13.28µm, 2231.67±164.57Cells/mm2, 3.37±0.18mm and 23.66±0.76mm respectively. Mean post-operative CCT, CED, ACD and AL in PPV group was 534.81±11.83µm, 2037.19±167.83 Cells/mm2, 3.24±0.13mm and 23.88±0.80mm respectively. Change in CED, ACD and AL from pre-operative value after PPV was statistically significant (p

Prediction of final visual outcome in ocular injuries is of paramount importance and various prognostic models have been proposed to predict final visual outcome. The objective of this study was to validate the predictive value of ocular trauma score (OTS) in patients with combat related open globe injuries and to evaluate the factors affecting the final visual outcome.Data of 93 patients admitted in AFIO Rawalpindi between Jan 2010 to June 2014 with combat related open globe ocular injuries was analysed. Initial and final best corrected visual acuity (BCVA) was categorized as No Light Perception (NLP), Light Perception (LP) to Hand Movement (HM), 1/200-19/200, 20/200-20/50, and ≥20/40. OTS was calculated for each eye by assigning numerical raw points to six variables and then scores were stratified into five OTS categories.Mean age of study population was 28.77±8.37 years. Presenting visual acuity was20/200 (6/60) in 103 (96.23%) eyes. However, final BCVA of ≥20/40 (6/12) was achieved in 18 (16.82%) eyes, while 72 (67.28%) eyes had final BCVA of20/200 (6/60). Final visual outcome in our study were similar to those in OTS study, except for NLP in category 1 (81% vs. 74%) and ≥20/40 in category 3 (30% vs. 41%). The OTS model predicted visual survival (LP or better) with a sensitivity of 94.80% and predicted no vision (NLP) with a specificity of 100%.OTS is a reliable tool for assessment of ocular injuries and predicting final visual outcome at the outset.

Objective The purpose of this study was to evaluate the safety and efficacy of transepithelial corneal collagen cross linking (TE-CXL) with modified riboflavin and accelerated UVA irradiance in thin corneas with pachymetry less than 400 microns at thinnest point, untreatable by epithelium off corneal collagen cross linking (CXL) in adult Pakistani population with progressive keratoconus. Methods This quasi experimental study included twenty six eyes of 26 patients with progressive keratoconus who underwent accelerated transepithelial CXL in Armed forced institute of ophthalmology with 12 months follow up. Modified riboflavin, ParaCel ((riboflavin 0.25%, Benzalkonium chloride, EDTA, Trometamol, hydroxypropyl methylcellulose) and vibeX Xtra (riboflavin 0.25%) (Avedro, USA)) were applied to cornea in two stages. Uncorrected and Corrected Distant Visual Acuities (UDVA, CDVA), spherical equivalent (SE), astigmatism, pachymetry at thinnest point (Pachy thin), apex keratometry (Kmax), simulated and steep keratometry (Sim K, steep K) were measured at baseline and at 3, 6 and 12 months post operatively. The cornea was then exposed to accelerated UVA irradiance of 9mW/cm2 for 10 min (total dose 30 mW/cm2). Results The mean age of the patient was 24.54±5.16 years. UDVA, CDVA, SE, astigmatism significantly improved at all postoperative test points (p=0.000, 0.004, 0.000, 0.004 respectively). Kmax and pachy thin were significantly reduced over baseline at 1 year (p=0.000, 0.004 respectively). Topographic indices Sim K and steep K did not show significant changes. No intra or post-operative complications were reported. Conclusion Transepithelial accelerated CXL with modified riboflavin is a safe and effective procedure which halt disease progression in thin corneas with progressive keratoconus.

To study visual outcome in patients of high altitude retinopathy presenting with retinal venous occlusion.The randomised clinical trial study was conducted at the Armed Forces Institute of Ophthalmology, Rawalpindi, Pakistan, from January 2013 to December 2015, and comprised eyes of lowlanders. Patients staying at high altitude (8,000 feet above sea level) as part of their service duty and presented with retinal venous occlusive disease were included. Patients with history of diabetes, hypertension, glaucoma, any pre-existing retinal disease or age-related conditions responsible for decreased vision were excluded. Detailed ocular as well as systemic examination was carried out to establish the diagnosis of retinal venous occlusion. Patients were divided into two groups. First group was observed over a period of 6 months and labelled as control group, whereas the second group was treated with intravitrealbevacizumab and labelled as intervention group. Complete ocular examination was carried out in all patients at 4 weeks, 3 months and 6 months. SPSS 21 was used for data analysis.A series of 32 eyes of 28 male patients were included. The overall mean age was 31.40±3.40 years. The mean altitude of their temporary stay was 4,120±941 metres above sea level and the mean duration of stay was 6.80±4.13months. Besides, 21(75%) subjects were smokers. Moreover, 26(81.25%) eyes had central retinal vein occlusion while branch retinal vein occlusion was seen in 6(18.75%) eyes. The mean visual acuity in the control group was 0.70±0.56 on Logarithm of the Minimum Angle of Resolution chart at the presentation while it was 0.26±0.87, 0.20±0.32 and 0.15±0.23 after 4 weeks, 3 months and 6 months, respectively. The mean best corrected visual acuity in intervention group was 0.68 ± 0.46 before treatment and 0.15±0.11, 0.12±0.11 and 0.10±0.08 at 4 weeks, 3 months and 6 months, respectively. Significant post-intervention change was observed in best corrected visual acuity at 6 months (p0.05) in patients who presented with severe visual loss.Treatment with intravitrealbevacizumab may be considered in patients with severe visual loss at presentation.

Objective: To determine the Efficacy of Corneal Crosslinkage (CXL), using Corneal Topography, in eyes with progressive Keratoconus. Methods: This randomized control trial was conducted at Armed Forces Institute of Ophthalmology, Rawalpindi, Pakistan from October 2013 to April 2014. A total of 60 eyes of 30 patients were included who presented with bilateral progressive Keratoconus. Each eye of the patient was randomized either to a treatment group (Group-A) or control untreated group (Group-B) of 30 eyes each. A written informed consent was obtained from each patient, following which corneal crosslinkage (CXL) with topical riboflavin eye drops was performed. Follow up visit was done at three months post operatively, Corneal topography was repeated and recorded. Results: The mean age of the patients was 23.13±7.62 years (range 13 to 39 years). There were 26 males and 34 females patients. The mean simK value at the start of study was 50.94±4.84 diopters in Group-A and 49.73±5.24 diopters in Group-B. At three months follow-up, the mean simK value was significantly lower in Group-A (48.28±4.47) as compared to Group-B (51.11±4.85). Keratoconus improved/ remained stable in 34 (56.7%) eyes while progressive disease was noted in 26 (43.3%) eyes. When compared between the groups, the frequency of efficacy was significantly higher in Group-A (86.7% vs. 26.7%; p=.000) as compared to Group-B. Conclusion: Corneal Crosslinking was found effective in causing regression or halting the progression of disease in patients with progressive Keratoconus at three months follow-up, however, the efficacy of corneal crosslinking was unaffected by patient’s age and gender.

To analyse the pattern, visual and anatomical outcome of closed globe combat-related ocular injuries sustained by troops.This retrospective study was conducted at Armed Forces Institute of Ophthalmology, Rawalpindi, Pakistan, and comprised patients with ocular injuries from January 2010 to June 2014. Record of each patient was evaluated and demography, mode and type of injury, initial and final visual acuity, associated globe injuries, concomitant non-ocular injuries, type of surgical procedures and complications were endorsed on a pre-devised proforma. Statistical analysis was done using SPSS 13.Overall, 49 eyes of 44 male participants were analysed. The overall mean age was 27.59±6.89 years. The most common mode of injury was improvised explosive device blast responsible for 22(50%) casualties. Ocular contusion was the most frequent closed-globe injury occurring in 35(71.42%) eyes. Most frequent ocular findings in all injured eyes were vitreous haemorrhage 16(32.65%), cataract 12(24.48%), retinal detachment 8(16.32%) and commotio retinae 8(16.32%). A total of 48(97.96%) intra-ocular/adnexal surgeries were performed with pars plana vitrectomy 17(34.69%), cataract surgery 16(32.65%), intraocular lens implantation 8(16.32%), and adnexal surgery 5(10.20%) being the most frequently performed procedures. Overall visual improvement at the final follow-up was statistically significant in all injured eyes irrespective of mode of treatment (p =0.001).The functional and anatomical outcome was better in closed-globe combat ocular injuries compared to open-globe injuries.

Objective To compare effectiveness of pan-retinal photocoagulation alone versus panretinal photocoagulation combined with intravitreal bevacizumab on visual acuity and central macular thickness in patients presenting with proliferative diabetic retinopathy. Methods This Randomized controlled trial was carried out at Armed Forces Institute of ophthalmology, Pakistan from Jan 2016 to Aug 2016. Seventy six eyes of 50 patients having proliferative diabetic retinopathy and diabetic macular edema were included in the study. All the patients were subjected to detailed clinical examination that included Uncorrected visual acuity (UCVA), best corrected visual acuity (BCVA), slit lamp examination of anterior and posterior segments. Optical coherence tomography (OCT) and fundus fluorescein angiography (FFA) were carried out and patients were divided in two groups (GP and GI). Three monthly sessions of Pan retinal photocoagulation (PRP) using Pattern Scan Laser (PASCAL) alone was performed in group GP while PRP along with three monthly intravitreal bevacizumab (IVB) was performed in group GI. BCVA and CMT was recorded 04 weeks after the third PRP session in both the groups. Results Seventy six eyes of 50 patients (38 in each group) were treated with three sessions of PRP alone and PRP with IVB in Group GP and GI respectively. Mean age of the patient in group GP was 57.47± 6.08 years while that in group GI was 55.69 ±6.58. The magnitude of induced change in BCVA was 0.09 ± 0.15 in GP while 0.22 + 0.04 in GI groups while mean induced change in CMT after treatment was 77.44 ± 92.30 um and 117.50 ± 93.82 um in group GP and GI. Conclusion Laser PRP combined with IVB has superior visual and anatomical outcome than PRP alone in patients with combined presentation of PDR and DME.

To compare the change in endothelial cell count after femtosecond laser-assisted cataract surgery (FLACS) versus conventional phacoemulsification.Randomized controlled clinical trial.Armed Forces Institute of Ophthalmology, Rawalpindi, Pakistan from January 2016 to August 2017.Patients with senile cataract and age ranging from 40 to 80 years were included in the study. Patients with any other cause of endothelial cell loss, history of trauma, documented diabetes millitis, hypertention and glaucoma were excluded. Preoperative detailed ocular examination, including both anterior and posterior examination, was carried out. Patients were distributed into two groups. Group GP were planned for conventional phacoemulsification, while group GF underwent FLACS. All the surgeries were performed under local anesthesia by same ophthalmic surgeon. Specular microscope (Topcon specular microscope sp-3000p) was utilized to measure the endothelial cell count (ECC) before and 4 weeks after the surgery.Fifty eyes (25 in each group) of 48 patients underwent cataract surgery by phacoemulsification or FLACS. Twenty-five (52.08%) out of the total were females while 23 (47.91%) were males. Median age of the participants in phacoemulsification group was 55 years (IQR 20.50), while in FLACS group it was 54 years (IQR 8). The median change in endothelial cell count was 228 (IQR 532) in Phaco group, while 23 (IQR 35) in FLACS group. (p0.05 Mann Whitney U-test).FLACS is a safe and effective modality for cataract treatment and it induces significantly less endothelial cell loss than conventional phacoemulsification.

To compare the clinical profile, systemic risk factors, and characteristics of rhegmatogenous retinal detachment (RRD) in pseudophakic and phakic eyes.Cross-sectional comparative study.Armed Forces Institute of Ophthalmology, Rawalpindi from August 2013 to August 2015.A total of 164 eyes (96 pseudophakic patients and 68 phakic patients) with RRD were analyzed. Demographic data and associated known risk factors of study population were acquired. Retinal examination was done by single experienced retinal surgeon using indirect ophthalmoscopy for type of retinal break, location and number of retinal breaks, status of macula, morphological extent of RRD and retinal degenerations. All the findings were endorsed on a pre-devised proforma.Mean age of patients in pseudophakic and phakic groups was 61.18 ±10.39 and 59.27 ±9.57 years, respectively. Frequency of male patients in pseudophakic and phakic groups was 74% and 57.4%, respectively. Mean axial length in pseudophakic and phakic groups was 23.13 ±2.18 mm and 21.9 ±2.01 mm, respectively. Difference in axial length and gender distribution between two groups was statistically significant (p0.05). Difference in frequency of patients with history of hypertension and myopia between two groups was statistically significant (p0.05). Characteristics of RRD (type, location and number of retinal breaks, macula status, and extent of RRD) between groups were not statistically significant.RRD is more common in pseudophakic patients with male gender, increased axial length, myopia, and hypertension.

Objective To determine mean change induced in root mean square value of higher order aberrations in myopic patients undergoing wavefront optimized laser assisted in situ keratomileusis. Methods This quasi experimental study was conducted at Armed Forces Institute of Ophthalmology, Rawalpindi, Pakistan from Jan 2014 to Dec 2014. Sixty eyes of 35 myopic patients were included in the study. All patients underwent wavefront optimized (WFO) laser assisted in situ keratomileusis (LASIK) using femtosecond laser (FM 200Wavelight technologies) and excimer laser (Ew 500Wavelight technologies). Higher order aberrations (HOAs) were measured with aberrometer (Wavelight allegro analyzer version 1073) during preoperative assessment and one month after surgery. Results All 35 patients ranged from 20 to 32 years with a mean age of 24 ± 3.41 years. Refractive error ranged from -1.00 to -9.50 DS with a mean spherical equivalent (SE) of -3.73 ± 1.95 before surgery and - 0.36 ± 1.50DS one month after LASIK. Uncorrected visual acuity (UCVA) was improved to 0.00 or better in all 60 eyes. An increase of 1.56 fold was observed in RMS of total HOAs. Among the HOAs, a statistically significant positive correlation was observed between spherical aberrations (4(th) order aberration) and preoperative spherical equivalent. Conclusion In spite of excellent improvement in refractive error, significant amount of higher order aberrations were induced after WFO LASIK.

OBJECTIVE: To compare the mean root mean square (RMS) of total higher order aberrations (HOAs), coma and spherical aberrations in individuals with myopia, hypermetropia and myopic astigmatism. METHODS: This prospective analytical study was conducted at Armed Forces Institute of Ophthalmology, Rawalpindi, Pakistan from Jan 2014 to Dec 2014. Two hundred eyes of 121 patients with age ranging from 18-40 years were included in the study. Patients were divided into 4 group namely Low myopia, High myopia, Astigmatism and Hypermetropia on the basis of refractive error. Included were the patients who had refractive error more than ± 0.5D and best corrected visual acuity (BCVA) of 0.00 or better. Patients who had history of surgery and / or eye disease were excluded from the study. Visual acuity (VA), Spherical equivalent (SE) of refractive error, RMS value of total HOAs, coma and spherical aberrations were evaluated. HOAs were measured with aberrometer (Wavelight analyzer version 1073) at 6 mm pupil size. RESULTS: Age of the patients ranged from 18 years to 40 years with mean age of 29.10±10.6 years. Seventy one (35.5%) were males and 129 (64.5%) were female. Mean RMS value of HOAs, coma and spherical aberrations was calculated in all four groups. RMS of total HOAs and spherical aberrations in hypermetropia was 0.96±0.96 and 0.30±0.42 respectively and it was higher than other three groups. CONCLUSIONS: In overall comparison the mean RMS of total HOAs and spherical aberrations was significantly increased in hypermetropia group and there was a statistically significant negative correlation of SE of hypermetropia with RMS of total HOAs and spherical aberration.

Macular coloboma is a rare entity and its concomitance with Usher syndrome is described here. A 14 years male child was studied in detail along with other family members. He underwent two complete ophthalmologic examinations (4-years follow-up), including visual assessment, orthoptic evaluation, colour vision test, visual fields, corneal topography, Optical coherence tomography, fluorescein angiography, and electroretinography. Detailed ophthalmic examination was also conducted on other asymptomatic members of the same family. Patient had sensorineural deafness, poor visual acuity, and progressive visual field impairment in both eyes, bilaterally presenting macular coloboma and atypical retinitis pigmentosa pattern. The other investigated relatives did not show any specific and/or significant ocular disorder. This concurrence represents no genetic pattern and is observed in sporadic cases.

To compare the long- and short-term fluctuations of frequency doubling technology perimetry between peripheral and paracentral zone and determine the relationship between threshold sensitivity and long- and short-term fluctuation within peripheral and paracentral zone of visual field.Descriptive study.Eye Department, United Nations, Pakistan Field Hospital Level-3 Darfur, Sudan, from February to July 2015.Normal eyes of 30 volunteers were recruited. Frequency doubling technology perimetry, program N-30, full threshold was employed. Each subject was tested at weekly intervals, once in the 1st, 3rd and 4th sessions and three times in the 2nd session. Visual field was divided into paracentral, superior, and inferior zones. Short-term and long-term fluctuation as well as threshold sensitivity were calculated for each patient as the mean fluctuation and mean sensitivity value. Mann-Whitney U-test was used to compare each zone in terms of their short- and long-term fluctuations and Spearman's rho correlation test for determining the relationship of threshold sensitivity with short- and long-term fluctuations.Long-term fluctuation values differences were insignificant between superior and paracentral zones. Short-term fluctuation values were statistically insignificant between all three zones. Short-term fluctuation and threshold sensitivity in each zone did not correlate. Long-term fluctuation and threshold sensitivity had a very weak negative, statistically insignificant correlation in superior and paracentral zones.Frequency doubling perimetry exhibits uniform short- and long-term fluctuations in peripheral and paracentral zones of visual field in normal subjects. Threshold sensitivity and long- and short-term fluctuations are independent of each other in peripheral and paracentral zones of visual field.

To compare the effectiveness of preoperative subconjunctival injection of Mitomycin-C at 24-hour and at one month before primary pterygium excision.Randomised controlled trial.Eye Department, Combined Military Hospital, Sargodha, from January to December 2014.Eyes of 60 patients were randomly allocated into two equal groups (A and B) of 30 each. In group A Mitomycin-C was injected into the pterygium one month before, and in group B Mitomycin-C was injected 24 hours before excision. All pterygia received 0.1 ml of Mitomycin-C in a concentration of 0.15 mg/ml. Primary pterygia greater or equal to 2.5 mm were selected and excised as a bare sclera technique. Postoperatively, all patients were followed-up for 06 months. The recurrence and corneoscleral complications were recorded. Pearson chi-square test was used to compare the recurrence between group A and group B.The recurrence of pterygium in group A was 3.3%; and in group B, it was 6.7%. Comparison of the recurrences between both the groups was statistically insignificant, (p=0.554).Postoperatively, no serious corneoscleral complications occurred in either group.The preoperative subconjunctival injection of Mitomycin-C in a dose of 0.15 mg/ml given 24 hours prior to excision is as effective as 01 month preoperative injection for primary pterygium surgery with bare sclera technique.

Retinal artery occlusion is an uncommon condition but can lead to grave consequences if not managed in time. Elderly population with other comorbid conditions like hypertension, ischemic heart disease, hyperlipidemia and stroke are commonly affected. However, this condition may affect younger population with entirely different systemic associations. Thromboembolism, which usually takes place secondary to cardiac emboli or hypercoagulable states cause retinal artery occlusion in young population. A24-year lady presented with a short history of unilateral altitudinal visual loss. On examination, she was found to have hemiretinal artery occlusion. Ocular massage, anterior chamber paracentesis was performed initially, followed by Nd YAG laser embolysis, which led to successful restoration of retinal circulation and significant improvement in visual field loss. Detailed evaluation and systemic investigations were carried out to identify the underlying cause, but no systemic association could be found.

To date keratoconus (KC) pathogenesis is undefined; however, the involvement of inflammatory pathways in disease development is becoming apparent. In the present study, we investigated the role of a promoter region polymorphism rs1800629 (-308GA) in the inflammatory pathway component TNF-α and its effects on the expression of TNF-α and downstream molecules tumor necrosis factor receptor 1 and 2 (TNFR1 and TNFR2), v-rel avian reticuloendotheliosis viral oncogene homolog A (RELA), and interleukin 6 (IL-6) in KC development.TNF-α promoter polymorphism rs1800629 (-308GA), was genotyped in 257 sporadic KC patients and 253 healthy controls. Enzyme-linked immunosorbent assay (ELISA) was performed to assess for the -308GA genotypes. Quantitative polymerase chain reaction (qPCR) was carried out to compare the mRNA expression of TNF-α, TNFR1, TNFR2, RELA, and IL6 in the corneal tissues of 20 KC patients and 20 donor controls.The -308GA genotype GA was found to be significantly associated with KC development (dominant model [odds ratio (OR) = 6.67 (95% confidence interval [CI] = 4.28-10.42), P0.001]) and allele-A (OR = 4.30, 95%CI = 2.93-6.34, P0.001). TNF-α serum levels were significantly raised in patients with GA genotype (196.5 ± 69.5 pg/mL) compared to reference genotype GG (21.7 ± 8.2 pg/mL) (P0.0001). There was a significant overexpression of TNF-α (P = 0.002), TNFR2 (P = 0.0001), RELA (P = 0.0117), and IL6 (P = 0.0007) in the KC corneal tissues as compared to the control.The GA genotype of the TNF-α -308GA polymorphism is a significant genetic risk factor for the pathogenesis of KC. Moreover, this single nucleotide polymorphism (SNP) was observed to be associated with deregulated expression of downstream molecules, thus further reinforcing the role of the inflammatory pathway components in the development of KC.

Albinism is an inherited abnormality of melanin synthesis with incidence of one per 20,000 births. Its clinical manifestations are related to the reduction or absence of pigmentation in the visual system and/or the skin and teguments. The clinical spectrum of Oculocutaneous Albinism (OCA) has four types ranging from OCA 1 - 4, of which OCA 1, A-1 is the most severe form. Partial cutaneous albinism which is a subtype of OCA is associated with systemic immunodeficiency disorders like Chediak Higashi (CHS), Griscelli (GS) and Hermansky-Pudlak (HPS) syndromes. A7 years boy was labeled initially as a case of Hermansky Pudlak syndrome at the age of 01 year. He as well as his 4 years old younger brother when examined in detail along with audiological investigations were diagnosed as a rare presentation of both Hermansky Pudlak and Waardenburg's syndrome.

Proptosis due to carotid cavernous fistula is rare sequelae of head injury. We report a case of post-traumatic, direct high flow carotid cavernous fistula that resolved spontaneously 06 weeks after carotid angiography. It however, resulted in loss of vision due to delay in early treatment. In the cases of post-traumatic proptosis, carotid cavernous fistula should be kept in mind.

Eales' disease is an idiopathic retinal vasculitis common in Saudi Arabia effecting young adults, usually men. This chronic disorder is extremely difficult to treat. Treatment modalities in current practice are oral steroids, panretinal photocoagulation and pars plana vitrectomy. One eye of a diagnosed patient with Eales' disease at Vitreoretinal Clinics, Department Of Ophthalmology, Military Hospital, Rawalpindi was administered intravitreal triamcinolone. Preoperative and one month post operative fluorescein fundus angiograms were performed. The post-operative fluorescein fundus angiogram showed decreased perivascular leakage of the fluorescein dye as compared to the preoperative fluorescein fundus angiogram. Our report validated a similar report from the Indo-Pak subcontinent. Intravitreal triamcinolone appears to be a promising treatment modality for retinal vasculitis.

In the present study we determined the association of angiotensin converting enzyme (ACE) and plasminogen activator inhibitor-1 (PAI-1) gene polymorphisms with diabetic retinopathy (DR) and its sub-clinical classes in Pakistani type 2 diabetic patients. A total of 353 diabetic subjects including 160 DR and 193 diabetic non retinopathy (DNR) as well as 198 healthy controls were genotyped by allele specific polymerase chain reaction (PCR) for ACE Insertion/Deletion (ID) polymorphism, rs4646994 in intron 16 and PAI-1 4G/5G (deletion/insertion) polymorphism, rs1799768 in promoter region of the gene. To statistically assess the genotype-phenotype association, multivariate logistic regression analysis was applied to the genotype data of DR, DNR and control individuals as well as the subtypes of DR. The ACE genotype ID was found to be significantly associated with DR (p = 0.009, odds ratio (OR) 1.870 [95% confidence interval (CI) = 1.04-3.36]) and its sub-clinical class non-proliferative DR (NPDR) (p = 0.006, OR 2.250 [95% CI = 1.098-4.620]), while PAI polymorphism did not show any association with DR in the current cohort. In conclusion in Pakistani population the ACE ID polymorphism was observed to be significantly associated with DR and NPDR, but not with the severe form of the disease i.e. proliferative DR (PDR).

To determine any predisposition of haplotypes with Eales disease.A case control study.This study was started in February 2002 and data collected till April 2003 at Eye Department of Military Hospital, Rawalpindi.The frequency of HLA antigens both class-I and II by complement dependent standard lymphocytotoxicity test was studied in 32 patients of Eales disease (group-I) and 32 age and gender matched normal persons as controls (group-II). Both patients and controls underwent complete ocular and clinical examination and were followed up for one year.Mean age was 30.8 years. HLA DR3 was found in 20 patients of group-I and none in group-II. HLA types A1, B8, B5 (51) and DR 15 (2) were found in 12 out of 32 patients of eales disease and none in controls. HLA DQ2 and DR52 was found in 28 cases of group-I as compared to 18 cases of group-II (p = .005).HLA phenotypes HLA DR3, A1, B8, B5 (51) and DR 15 (2) occurred in majority of cases of Eales disease, whereas these were not found in controls which was statistically significant. Similarly, HLA DQ2, DR52 and Bw6 was found in higher frequency in Eales patients and thus strongly associated with it. We conclude that certain HLA haplotypes have a possible predilection for Eales disease.

Objective To evaluate the effect of pan-retinal photocoagulation with Pattern Scan Laser (pascal)on best corrected visual acuity and central macular thickness in patients having proliferative diabetic retinopathy (PDR). Methods This study was conducted at AFIO, Rawalpindi, Pakistan from Oct 2014 to Jul 2015. Sixty seven eyes of 46 patients having proliferative diabetic retinopathy were included in the study. All patients underwent ophthalmic clinical examination including uncorrected distant visual acuity (UCVA), best corrected visual acuity (BCVA), fundus examination with slit lamp and optical coherence tomography to document the pretreatment central macular thickness (CMT). Two sessions of PRP using Pattern Scan Laser were performed 04 weeks apart and OCT was repeated 04 weeks after the 2(nd) session. Central macular thickness and BCVA were documented. Results Sixty seven eyes of 46 patients (29 females and 17 males) with mean age of 57.45 ± 5.78 years underwent treatment with two sessions of laser PRP. Mean pretreatment BCVA was 0.67 ± 0.43 and mean post-treatment BCVA was 0.57 ± 0.3. Mean central macular thickness (CMT)as measured by OCT was 391.93 ± 170.43 before treatment and 316.91 ± 90.42 um after treatment. The magnitude of induced change in CMT after treatment was 75.01 ± 90.75 and BCVA was 0.09 ± 0.14. Conclusion Laser PRP with Pattern scan laser alone in patients with combined presentation of PDR and DME is safe and effective.