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Ophthalmology Update Vol. 12. No. 3, July-September 2014
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Contents
„„ EDITORIAL
ƒƒ
Current Concepts in the Etiology & Therapy of Amblyopia
Sameera Irfan ----------------------------------------------------------------------------------------------------------------------------------------164
„„ OPHTHALMIC SECTION / ORIGINAL ARTICLES
ƒƒ Increased Risk of Co-Morbid Systemic Disease in Branch Retinal Vein Occlusion
Prof. Marianne Shahsuvaryan ---------------------------------------------------------------------------------------------------------------------166
ƒƒ
Success Rate of Surgical Correction Methods in Esotropias
Sadia Bukhari et al -----------------------------------------------------------------------------------------------------------------------------------169
ƒƒ
A Study of Disease Pattern in Oculoplasty Department of a Tertiary Care Hospital, in KPK
Mohammad Idris et al -------------------------------------------------------------------------------------------------------------------------------172
ƒƒ
Comparison of outcome of Dacryocystorhinostomy with Intubation against
Dacryocystorhinostomy with Mitomycin-C (MMC) application Intraoperatively
ƒƒ
Saber Mohammad et al ------------------------------------------------------------------------------------------------------------------------------175
ƒƒ
Morphological Appearance of Retinal Breaks associated with or without Rhegmatogenous Retinal
Detachments presenting in Ophthalmology Department of Hayatabad Medical Complex, Peshawar
ƒƒ
Afzal Qadir et al -------------------------------------------------------------------------------------------------------------------------------------179
Analysis of Visual Outcome & Safety of Laser-Assisted Sub-Epithelial Keratectomy (Lasek) for
the Treatment of Moderate to Severe Myopia & Myopic Astigmatism by using Mitomycin–C
M. Saeed Zafar Khan et al ------------------------------------------------------------------------------------------------------------------------- 182
„„ BOOK REVIEW
ƒƒ
Concise Ophthalmology
Prof. Dr. Syed Imtiaz Ali Shah ------------------------------------------------------------------------------------------------------------------- 185
ƒƒ
Surgical Management of Strabismus, our Experience
Sadia Bukhari et al ---------------------------------------------------------------------------------------------------------------------------------- 186
ƒƒ
Postoperative Complications of
Levator Resection in Congenital Blephroptosis with Poor Levator Function
Mohammad Idris et al -------------------------------------------------------------------------------------------------------------------------------192
ƒƒ
Behavior of Custom Designed, Light Weight Ocular Prosthesis
Sidrah Riaz et al -------------------------------------------------------------------------------------------------------------------------------------195
„„ PROFILE
ƒƒ
Prof. Dr. Muhammad Umar & Prof. Dr. Hamama Tul Bushra Khaar -------------------------------------------------------------198
„„ OPHTHALMOLOGY NOTEBOOK
ƒƒ
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Workshop on Basic & Advanced Endoscopy held at Centre for liver & digestive diseases, Holy Family
Hospital, Rawalpindi ------------------------------------------------------------------------------------------------------------------------ 197
Ophthalmology Update Vol. 12. No. 3, July-September 2014
„„ GENERAL SECTION / ORIGINAL ARTICLES
ƒƒ
Predictive value of Pirani Scoring system for Achilles Tenotomy in Ponseti Technique
Muhammad Imran et al ---------------------------------------------------------------------------------------------------------------------------- 199
ƒƒ
Choice of Operative Technique for Emergency Cases of Sigmoid Volvulus & its Outcome
Yousaf Jan et al -------------------------------------------------------------------------------------------------------------------------------------- 201
ƒƒ
Risk Factors of Early Pregnancy Complications
Rahat Jabeen et al ----------------------------------------------------------------------------------------------------------------------------------- 205
ƒƒ
Comparison of Efficacy of Low Pressure
Vs Standard Pressure Pneumoperitoneum During Laparoscopic Cholecystectomy
Muhammad Shah et al ------------------------------------------------------------------------------------------------------------------------------ 209
ƒƒ
Treatment of Femoral Fractures with early Hip Spica in Children
Muhammad Imran Khan et al -------------------------------------------------------------------------------------------------------------------- 213
ƒƒ
Management of Penile Fracture and its Outcome
Yousaf Jan et al -------------------------------------------------------------------------------------------------------------------------------------- 217
ƒƒ
Frequency, Risk Factors and Feto-Maternal Outcome in Abruptio Placenta Cases
Rahat Jabeen et al ----------------------------------------------------------------------------------------------------------------------------------- 221
ƒƒ
Comparison of Efficacy of Primary Anastomosis of Large Bowel
with Bowel Preparation Vs without Bowel Preparation
Waqas et al ------------------------------------------------------------------------------------------------------------------------------------------- 225
ƒƒ
Outcome of Open Reduction & Internal Fixation in Displaced
Supracondylar Humeral Fractures in Children
Muhammad Imran Khan et al --------------------------------------------------------------------------------------------------------------------- 230
ƒƒ
Nature of Eyelid Trauma in a Tertiary Care Hospital of Peshawar, KPK
Mohammad Idris et al ------------------------------------------------------------------------------------------------------------------------------ 233
ƒƒ
Endoscopic Dilatation for stricture Oesophagus in Children
(an experience at Lady Reading Hospital, Peshawar)
Muhammad Uzair et al ---------------------------------------------------------------------------------------------------------------------------- 236
ƒƒ
Role of Prophylactic Antibiotic in Prevention of Wound Infections
following Lichtenstein Inguinal Hernioplasty
Siddique Ahmad et al ------------------------------------------------------------------------------------------------------------------------------- 240
„„ CASE REPORT
ƒƒ
Cessation of Leakage from Disc Neovascularization in a Patient with Proliferative
Diabetic Retinopathy following a Single Intravitreal Bevacizumab injection
Shahzad Waseem et al ------------------------------------------------------------------------------------------------------------------------------ 246
Ophthalmology Update Vol. 12. No. 3, July-September 2014
iii
A Comprehensive Guide for parents and
students joining medical college for MBBS/BDS degrees
WHY SHOULD I BECOME A DOCTOR?
(First Edition)
By
Prof. Dr. M. Yasin Khan Durrani
MBBS.,DO.,MD.,FRCOphth (lond)
Former: Prof. of Ophthalmology and Consultant Eye Surgeon
Rawalpindi Medical College & Islamic Int’l Medical College, Rawalpindi,
Honorary Prof. of Ophthalmology, First National University, Tianjin, China
Recipient of Presidential award, Government of Pakistan
an experienced professor, with 40 years of teaching experience
SOON AVAILABLE AT THE
LEADING BOOKSTALLS OF THE COUNTRY
Further information: Managing Editor, Ophthalmology Update
267-A, ST: 53, F-10/4, Islamabad. Cell: 0333 5158885
Editorial
Current Concepts in the
Etiology & Therapy of Amblyopia
Amblyopia, commonly referred to as “The Lazy
Eye” is a disorder characterized by an impaired vision
in an eye that otherwise appears normal, or the visual
loss is out of proportion to the associated structural
abnormalities of the eye. It has been estimated to affect
1-5% of the general population which means that it is
responsible for more visual loss in children and young
adults than all the other causes put together. According
to the Visual Acuity Impairment Survey sponsored by
the National Eye Institute (NEI, USA), amblyopia was
shown to be the leading cause of monocular visual loss
in adults aged 20-70 years or older.
Only children can get amblyopia as it is believed
to result from disuse or inadequate foveal stimulation
during the critical periods of human visual acuity
development.1,2 During these time periods, vision can
be affected by various mechanisms to cause or reverse
amblyopia. The development of visual acuity from the
6/60 range to 6/6 occurs from birth to the age of 3-5
years. The period of the highest risk of deprivation
amblyopia is from a few months age to 7 or 8 years. If it
is not treated during this period, it can cause permanent
loss of vision.
The decrease in vision results when one or both
eyes, send a blurry image to the brain. The brain then
“learns” to see only a blurred image from that eye
resulting in visual loss in that eye. Even when correcting
glasses are used later in life, it cannot interpret the clear
image that is being projected by the glasses. However,
the brain can be “re-trained” to see that clear image and
then only the vision may improve.
Why a blurred image is communicated to the
brain?3,4,5,6 This occurs when either the visual impulses
are poorly transmitted through a healthy optic nerve
to the brain for a continuous period of time resulting
in “ Stimulus Deprivation Amblyopia” as seen in
complete congenital ptosis, corneal opacity, congenital
cataract or the brain “turns off” the visual processing
of one eye to prevent double-vision as in strabismus
where two dissimilar images are projected to the brain,
“Strabismic Amblyopia” or in gross anisometropia,
“Anisometropic Amblyopia”, seen with astigmatism
Ophthalmology Update Vol. 12. No. 3, July-September 2014
of 1D or more, myopia of 5D or
more and hypermetropia of more
than 1.5 D.
Diagnosis of the presence of
amblyopia and its cause is very
important to plan its treatment.
A patient may present with
strabismus or poor vision in one
eye. In a non-verbal child, poor
vision in one eye can be gauged if the child protests
covering the good eye, the other eye may be amblyopic
or if there is a fixation preference where the child looks
at the torch light with one eye only (the good eye) and
the other eye is strabismic (it does not take up fixation).
Amblyopia therapy is a 3 stepped approach:
1 As a first step, the cause is treated i.e. ptosis
blocking the visual axis,7 or congenital cataract.
2 Then the refractive glasses are given8. In the
presence of strabismus, the refractive error is
fully corrected i.e. myopia, hypermetropia and
astigmatism are fully corrected. Without the
strabismus, the cylindrical error is fully corrected
as it gives clarity of form of vision while the
myopic and hypermetropic correction is given
after a subjective refraction. The correcting glasses
are worn constantly for 6 weeks. This corrects
about 20-30% of the amblyopia.
3 After constant spectacle wear for one month to six
weeks, active therapy for the remainder of visual
loss is started. This involves occlusion of the good
eye combined with active use of the bad eye.
Many people5-13 recommend part-time occlusion
therapy. In our recent study14, we found out that
with full-time occlusion of the good eye for 8 - 10
weeks, 100% restoration of visual acuity along
with improvement in stereopsis is achieved. On
the other hand, only a partial visual recovery has
been achieved in all the studies published to date.
It is important to understand the cause of this
difference in results. The visual pathway comprises of
3 neurons: the bipolar cells (first-order neurons) receive
visual impulses from rods and cones and transmit them
164
Editorial
to the retinal ganglion cells (second- order neurons).
The ganglion cell axons constitute the optic nerve fibers
which cross in the optic chiasma and terminate in the
lateral geniculate body. The fibers of LGB constitute
the optic radiation and terminate in the neurons of
occipital lobe for visual processing. Histological studies
on kittens showed shrinkage of LGB neurons in the
amblyopic eye. The nerve cells in this three neural
pathway are not dead (apoptosed) but only shrunken;
they can be made to work again by active stimulation
while removing the inhibitory influence of the good eye
over the amblyopic eye. Only with full-time occlusion
therapy, this inhibitory influence of the good eye is
removed, the neuronal connections start functioning
without any interference from the good eye and
achieve their full potential in a short time (2-3 months).
With part-time occlusion therapy, these connections
and neural transmission from the amblyopic eye is
inhibited once the good eye is allowed to see as soon as
the eye patch is removed. Hence visual recovery with
part-time occlusion therapy is partial and takes a much
longer time (6 - 9 months).
To achieve a full visual potential in an amblyopic
eye, its active use is mandatory. This is achieved by
reading books of a larger print initially and then shifting
to smaller prints as visual improvement occurs, playing
computer games on cell-phones, coloring, drawing.
For all these activities, counselling and motivation
of parents as well as the patient is very important.
Compliance is the main hindrance in improvement
of vision by full-time occlusion therapy. Hence, as a
treating ophthalmologists, it is our duty to provide time
for such patients. Remember, by treating amblyopia,
we are restoring sight for the remainder 50 - 60 years of
a child’s life.
REFERENCES
1
Daw NW. Critical periods and amblyopia. Arch Ophthalmol.
Apr 1998;116(4):502-5.
2
Kirschen DG. Understanding Sensory Evaluation. In: Rosen-
165
3
4
5
6
7
8
9
10 11 12 13 14 baum AL, Santiago AP, eds. Clinical Strabismus Management:
Principles and Practice. 1999: 22-35.
Kushner, BJ. Amblyopia. In: Nelson LB, ed. Harley’s Pediatric
Ophthalmology. 1998:125-39.
American Academy of Ophthalmology. Amblyopia. In: Basic
and Clinical Science Course: Pediatric Ophthalmology and
Strabismus. 1997: 259-65.
Bruce A, Pacey IE, Bradbury JA, Scally AJ, Barrett BT. Bilateral
Changes in Foveal Structure in Individuals with Amblyopia.
Ophthalmology. Sep 29 2012;[Medline].
von Noorden GK. Binocular Vision and Ocular Motility: Theory and Management. 1996;216-54.
Lin LK, Uzcategui N, Chang EL. Effect of surgical correction of
congenital ptosis on amblyopia. Ophthal Plast Reconstr Surg.
Nov-Dec 2008;24(6):434-6. [Medline].
Flynn JT. Amblyopia: its treatment today and its portent for
the future. Binocul Vis Strabismus Q. Summer 2000;15(2):109.
[Medline].
Flynn JT, Woodruff G, Thompson JR, et al. The therapy of amblyopia: an analysis comparing the results of amblyopia therapy utilizing two pooled data sets. Trans Am Ophthalmol Soc.
1999;97:373-90; discussion 390-5. [Medline].
Holmes JM, Kraker RT, Beck RW, et al. A randomized trial of
prescribed patching regimens for treatment of severe amblyopia in children. Ophthalmology. Nov 2003;110(11):2075-87.
[Medline].
Repka MX. How much amblyopia treatment is enough?. Arch
Ophthalmol. Jul 2008;126(7):990-1. [Medline].
Levartovsky S, Oliver M, Gottesman N, Shimshoni M. Factors
affecting long term results of successfully treated amblyopia:
initial visual acuity and type of amblyopia. Br J Ophthalmol.
Mar 1995;79(3):225-8. [Medline].
Wallace DK, Edwards AR, Cotter SA, Beck RW, Arnold RW,
Astle WF, et al. A randomized trial to evaluate 2 hours of daily
patching for strabismic and anisometropic amblyopia in children. Ophthalmology. Jun 2006;113(6):904-12. [Medline]
Irfan S. “Determining the efficacy of full-time occlusion therapy in severe amblyopia at different ages”, published as F1000
research article, reference: http://f1000research.com/articles/2-149/v1
Dr. Sameera Irfan, FRCS
Consultant Oculoplastic Surgeon & Strabismologist
Mughal Eye Trust Hospital, Lahore
Website: www.sameerairfan.com
E.Mail: [email protected]
Ophthalmology Update Vol. 12. No. 3, July-September 2014
OPHTHALMIC SECTION
ORIGINAL ARTICLE
Increased Risk of Co-Morbid Systemic
Disease in Branch Retinal Vein Occlusion
Prof. Marianne
Prof. Marianne Shahsuvaryan, MD, Ph.D, D.Sc (Medicine)
Professor of Ophthalmology, Yerevan State Medical University, Republic of Armenia
ABSTRACT
Aim: To investigate relationship between branch retinal vein occlusion (BRVO) and co-morbidity represented as a kidney
disease.
Methods: The study was a clinic based case-control study of 158 patients with a clinical presentation of BRVO and 500
controls, all aged 31 years and older. Excluded from case and control group were persons with severe myopia, vasoproliferative retinopathy, and intermediate or posterior intraocular inflammatory disease. At the baseline examination urine
samples were tested and proteinuria was defined. A commercially available statistical software package was used for tabulations and statistical analyses.
Results: We found that kidney disease was significantly more common among our cases than controls. After adjusting for
age and sex kidney disease was significantly associated with BRVO. In multivariate analysis, kidney disease (odds ratio
OR=34.25, 95% confidence interval CI: 4.42-727.44 ) remained independently significant risk factor for BRVO. Likely explanations for an elevated prevalence of kidney disease in BRVO cases is that kidney disease may cause renal origin arterial
hypertension, which is significantly associated with BRVO.
Conclusions: The results from this case-control study provide important evidence of a link between kidney disease and
BRVO and suggest that kidney disease affects ocular circulation. Our data also support the potential value of medical treatment of underlying medical condition in preventing occurrence of BRVO.
Key words: Retinal vein, branch retinal vein occlusion, risk factors, systemic co-morbidity
INTRODUCTION
Branch retinal vein occlusion (BRVO) is the most
common retinal vascular disorder after diabetic retinopathy and is a significant cause of visual handicap.1,2
BRVO is more common than central retinal vein occlusion, with a 5-year incidence in 0.6% of the general
population, compared with a 0.2%; 5-year incidence of
central retinal vein occlusion (CRVO).3 The 9-year cumulative incidence of BRVO was 2.7% for BRVO and
0.3% for CRVO in a General Japanese Population.4
BRVO can affect approximately four to five people per
1,000 of the population.5
The first case of branch retinal vein occlusion was
reported by Leber in 1877.6
The pathogenesis of retinal vein occlusion is multifactorial while BRVO may be due to a combination of
three primary mechanisms:
i. compression of the vein at the arteriovenous
(A/V) crossing,
ii. degenerative changes of the vessel wall, and
iii. abnormal hematological factors.
Koyanagi in 1928 first reported the association between BRVO and A/V crossing,7 and now it is estab*Professor of Ophthalmology, Yerevan State Medical University
Correspondence: Prof. Marianne Shahsuvaryan, Professor of
Ophthalmology 8th Hospital, Yerevan State Medical University, 7 Ap.,
1 Entr.,26 Sayat-Nova Avenue, Yerevan, 0001, Republic of Armenia
E-Mail: [email protected], Phone: 37410 523468
Received: March 2014
Accepted: May 2014
Ophthalmology Update Vol. 12. No. 3, July-September 2014
lished that mechanical narrowing of the venous lumen
at these intersections plays a role in the pathogenesis
of BRVO.8-10 Systemic hypertension, hyperlipidemia,
diabetes mellitus, atherosclerosis, and smoking are reported to be more common in patients with BRVO.8,11-13
Sclerosis of the retinal artery which is associated
with these systemic disorders may result in further
compression of the vein, when the increased rigidity of
arterial wall and contraction of the adventitial sheath
shared by artery and vein occur. Mechanical obstruction of the vein through the rigid artery in the A/V
crossing may result in turbulent blood flow producing damage to venous endothelium and intima media
and the sequence of events leading to occlusion of the
vein.14,15 Some studies have revealed an association between BRVO and hyperviscosity due to high hematocrit.16,17 thrombophilia and hypercoagulation,13 thrombocyte aggregation.18 Higher blood viscosity increases
under conditions of low blood flow and erythrocyte
aggregation.17 It is thus very important to identify systemic risk factors of the branch retinal vein occlusion to
develop preventive measures for the disease. The aim
of this study was to investigate relationship between
branch retinal vein occlusion (BRVO) and co-morbidity
represented as a kidney disease.
MATERIALS AND METHODS
The study was a clinic based case-control study
of 158 patients with a clinical presentation of BRVO
and 500 controls, all aged 31 years and older. Signs
of BRVO included characteristic clinical features with
166
Increased Risk of Co-Morbid Systemic Disease in Branch Retinal Vein Occlusion
flame-shaped, dot and blot hemorrhage, soft and hard
exudates, retinal edema, and dilated, tortuous vein in
a segmental distribution. The diagnosis is based on
clinical examination under slit lamp and fundoscopy
in artificial mydriasis. Excluded from case and control
group were persons with severe myopia, vasoproliferative retinopathy, and intermediate or posterior intraocular inflammatory disease. At the baseline examination
urine samples were tested and proteinuria was defined
We considered the following risk factors for BRVO:
age, sex, hypertension, systolic blood pressure, diastolic blood pressure, diabetes, chronic kidney disease Age,
systolic blood pressure, diastolic blood pressure, were
treated as continuous variables and the others as categorical variables. Each categorical variable was coded
as either 1 or 0, depending on the presence or absence
of the factor, respectively. A commercially available
statistical software package was used for tabulations
and statistical analyses.
RESULTS
A total of 158 patients with BRVO and 500 controls were included in the study. All cases and controls
were white ( European origin). Sex distribution among
BRVO cases and controls was male 49.5% and 61.1%;
female 50.5 and 38.9% respectively. The most common
diagnoses among controls (n=500) were as follows:
i. corneal disorders 46%,
ii. cataract 29%,
iii. refractive error 22%.
Several risk factors were significantly associated
with BRVO in the screening analyses. We calculated
odds ratios to assess the magnitude of these associations, grouping the values for each characteristic. Patients 70 years and older represent the selected population with less likelihood of active vascular event,
compared with the 61- to 70-year-old group 9 in our
population , average life expectancy varies between 50
and 60 years.
The mean values of systolic and diastolic blood
pressures and the frequencies of hypertension and kidney disease were higher in subjects with BRVO than
values in subjects without BRVO. After adjusting for age
and sex, higher diastolic blood pressure (per 10 mm Hg)
(OR, 1.55; 95% CI, 1.16 to 2.05) was significant risk factors for the development of BRVO. In the hypertensive
group, higher diastolic blood pressure and kidney disease significantly increased the risk of BRVO, We found
that kidney disease was significantly more common
among our cases than controls. After adjusting for age
and sex kidney disease was significantly associated with
BRVO. In multivariate analysis, kidney disease (odds ratio OR=34.25, 95% confidence interval CI: 4.42-727.44 )
remained independently significant risk factor for BRVO.
DISCUSSION
167
In this clinic-based case-control study we identified that kidney disease was significantly more common among our cases than controls. Increased risk was
found with systemic hypertension also. The present
study found that higher diastolic blood pressure was
significantly associated with BRVO and that higher
systolic blood pressure was also associated with RVO.
Likely explanations for an elevated prevalence of kidney disease in BRVO cases is that kidney disease may
cause renal origin arterial hypertension, which is significantly associated with BRVO. Although the etiology and pathogenesis of BRVO are largely unknown,
the consistent association with elevated blood pressure
found in this study is in accordance with the findings
from many other studies19-22 confirming the blood pressure–related nature of the disease. We found that a kidney disease was associated with BRVO, independent of
age, sex. Previously only three population-based cohort
studies have reported on the association between renal
dysfunction and retinal vein occlusion (RVO), and the
results have been inconsistent. In the Blue Mountains
Eye Study, the serum creatinine level was not associated with the development of RVO in a 10-year followup perio.1
On the other hand, higher serum creatinine levels constituted a significant risk factor for RVO over 15
years of follow-up in the Beaver Dam Eye Study; persons with elevated creatinine levels (≥1.4 mg/dL) were
shown to have a 60% higher risk of RVO.2 In our study,
kidney disease increased the risk of developing BRVO
by 2.2-fold even after adjustment for other confounding
factors. These discrepancies in the association between
renal dysfunction and RVO may be partly due to differences in study populations, or study methods. One
possible reason is that serum creatinine was used as a
measure of renal function in both the Blue Mountains
Eye Study and the Beaver Dam Eye Study thus, an association in low-risk general populations may be less
detectable when serum creatinine is used. After all, our
findings provide important evidence of a link between
kidney disease and BRVO and suggest that it affects
ocular circulation.
Renal dysfunction and RVO are both closely related to hypertension19,23 This fact indicates concomitant
damage in the retinal and renal vasculature by hypertension. In this study, however, chronic kidney disease
(CKD) was an independent risk factor for the development of RVO, even after adjustment for age, sex, and
diastolic blood pressure. Similar results were presented
by Arakawa et al.4 We also demonstrated that the risk
of BRVO is higher in subjects with than that in subjects
without kidney disease in both the non-hypertension
and the hypertension groups These findings suggest
that kidney disease was an independent risk factor for
Ophthalmology Update Vol. 12. No. 3, July-September 2014
Increased Risk of Co-Morbid Systemic Disease in Branch Retinal Vein Occlusion
the development of BRVO regardless of hypertension
status, and that hypertension is not the key factor connecting kidney disease and BRVO. It is well recognized
that renal arteriosclerosis and glomerular sclerosis are
closely related to systemic
atherosclerosis,24 with the severity of coronary atherosclerosis.25 Based on these findings, it is speculated that
CKD is a strong risk factor for systemic arteriosclerosis, including retinal arteriosclerosis, and that retinal
sclerotic arteriolar walls may compress the underlying
veins at arteriovenous crossings, leading to reduced
blood flow, which in turn could facilitate the development of a thrombus and downstream venous occlusion
and thereby of RVO.
CONCLUSION
The results from this case-control study provide
important evidence of a link between kidney disease
and BRVO and suggest that kidney disease affects
ocular circulation. Our data also support the potential
value of medical treatment of underlying medical condition in preventing occurrence of BRVO.
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1. Cugati S, Wang JJ, Rochtchina E, Mitchell P. Ten-year incidence
of retinal vein occlusion in an older population: the Blue Mountains Eye Study. Arch Ophthalmol. 2006;124(5):726-732.
2. Klein R, Moss SE, Meuer SM, Klein BE. The 15-year cumulative
incidence of retinal vein occlusion: the Beaver Dam Eye Study.
Arch Ophthalmol. 2008;126(4):513-518.
3. Rehak J, Rehak M. Branch retinal vein occlusion: pathogenesis,
visual prognosis, and treatment modalities. Current Eye Res.
2008;33(2):111-131.
4. Arakawa S, Yasuda M, Nagata M, Ninomiya T, Hirakawa Y,
Doi Y. Nine-Year Incidence and Risk Factors for Retinal Vein
Occlusion in a General Japanese Population: The Hisayama
Study. Invest. Ophthalmol. Vis. Sci. 2011 52 ( 8): 5905-5909.
5. Mitry D, Bunce C, Charteris D. Anti-vascular endothelial
growth factor for macular oedema secondary to branch retinal
vein occlusion. Cochrane Database of Systematic Reviews 2013,
Issue 1. Art. No.: CD009510. DOI: 10.1002/14651858.CD009510.
pub2. 6. Leber T. Graefe-Saemisch. Handbuch der Gesamten Augenheikunde. Leipzig: Verlag von Wilhelm Engelmann; 1877. Die
Krankheite der Netzhaut und des Sehnerven; p. 531.
7. Koyanagi Y. The role of arteriovenous crossing for occuring
of retinal branch vein occlusion. Klin Monatsbl Augenheilkd.
1928;81:219–231.
8. Bertelsen M, Linneberg A, Rosenberg T, Christoffersen N,
Vorum H, Gade E, Larsen M. Comorbidity in patients with
branch retinal vein occlusion: case-control study BMJ. 2012
Nov 30;345:e7885. doi: 10.1136/bmj.e7885.
9. Kawasaki R, Nagano E, Uno M, Okada M, Kawasaki Y,
Kitamura A. Retinal vascular features associated with risk of
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10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21.
22. 23. 24. 25. branch retinal vein occlusion. Current Eye Research 38(9):989
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Mitry D, Bunce C, Charteris D. Anti-vascular endothelial
growth factor for macular oedema secondary to branch retinal
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retinal vein occlusion in Australia. The Blue Mountains Eye
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Klein R, Klein BE, Moss SE, Meuer SM. The epidemiology of
retinal vein occlusion: The Beaver Dam Eye Study. Trans Am
Ophthalmol Soc. 2000;98:133–141.
Jaulim A, Ahmed B, Khanam T, Chatziralli IP. Branch retinal
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Zhao J, Sastry SM, Sperduto RD, Chew EY, Remaley NA. Arteriovenous crossing patterns in branch retinal vein occlusion.
Ophthalmology. 1993;100:423–428.
Jefferies P, Clemett R, Day T. An anatomical study of retinal arteriovenous crossings and their role in the pathogenesis of retinal branch vein occlusions. AustNZJ Ophthalmol. 1993;21:213–
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McGrath MA, Wechsler F, Hunyor AB, Penny R. Systemic factors contributory to retinal vein occlusion. Arch Intern Med.
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Trope GE, Lowe GD, McArdle BM, Douglas JT, Forbes CD,
Prentice CM, Foulds WS. Abnormal blood viscosity and haemostasis in long-standing retinal vein occlusion. Br J Ophthalmol. 1983;67:137–142.
Onder HI, Kilic AC, Kaya M, Bulur S, Onder E, Tunc M. Relation between platelet indices and branch retinal vein occlusion
in hypertensive patients. Indian Journal of Ophthalmology
61(4):160 (2013) PMID 23619481 .
Wong TY, Larsen EKM, Klein R. Cardiovascular risk factors for
retinal vein occlusion and arteriolar emboli: the Atherosclerosis
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Liu W, Xu L, Jonas JB. Vein occlusion in Chinese subjects. Oph�thalmology. 2007;114:1795–1796
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168
ORIGINAL ARTICLE
Sadia Bukhari
Success Rate of Surgical
Correction Methods in Esotropias
Sadia Bukhari FCPS1, Abdul Sami Memon FCPS2, Umair Qidwai FCPS3
ABSTRACT:
Aim: The objective of our study is to compare the surgical outcome of different techniques of surgery in patients with
esotropia.
Methods: It was an observational case-series, conducted from January 2007 to December 2012. Patients were selected
using non-probability purposive sampling. Patients having primary esotropia (deviation 15-75 PD) were included in the
study. After informed written consent the patients were selected from the squint clinic of Al-Ibrahim Eye Hospital, Karachi.
All the patients underwent detailed ophthalmic examination and underwent either bi medial rectus recession or unilateral
medial rectus recession or unilateral medial rectus recession along with lateral rectus resection procedures. Patients were
re-evaluated at one week, one month and two months post operatively. Final outcome was considered at the end of two
months at which achievement of ≤10 PD of exotropia was considered as a success. Analysis was done using SPSS version
20.0.
Results: In this study, 272 patients were included. Out of these, 130 (47.8%) were male, while rest of the 142 (52.2%) were
female. Mean deviation after surgery was 9.73 prism diopters (±12.03). Surgical success as described as residual deviation
of less than 10 prism diopters was seen in 202 (74.3%) of the patients, while residual refraction of greater than 10 prism
diopters was noted in 44 (16.2%) of the patients. Remaining 26(9.6%) of the patients had residual refraction of greater than
20 prism diopters and were advised second surgery. The patients, who underwent bi medial rectus recession, 36 (85.71 %)
had successful surgery with no residual refraction. Similarly, 18 (90%) and 148 (70.47%) had successful surgery with less
than 10 prism diopters of residual refraction after unilateral medial rectus recession and unilateral medial rectus recession
combined with lateral rectus resection respectively.
Conclusion: Unilateral medial rectus recession, bi medial rectus recession and unilateral medial rectus recession with
lateral rectus resection, no matter which procedure is adopted for surgical correction of different forms of esotropias, almost
similar success results in terms of residual angle and no of successful surgeries.
Key Words: Esotropia, Surgery, Deviation
INTRODUCTION
Squint is an ocular condition of deviation or misalignment of both or single eye. Its prevalence among
children is 2-4 %1 inward deviation of eyes is called esodeviation which accounts for over half of total ocular
deviations.2 Many causes of esodeviation has been reported including anatomical causes, neurological causes,
genetic and accommodative.3 Amblyopia is among the
consequences if esodeviation is not corrected earlier in
life.4Constant squints have been reported as a main cause
of amblyopia by many authors.5 Early treatment of Amblyopia is very important to prevent permanent impairment in visual acuity6 it has been recommended by many
authors that early surgical correction of esodeviation can
prevent or treat amblyopia.7 Thus specific surgical procedure is needed for perfect surgical alignment of the eyes.
Multiple surgical procedures are used by different
surgeons. All have variable success rates. Mostly constant esotropia surgical treatment is based on weakening the medial rectus muscles to avert ultimate loss of
cortical shyness of hyperactive convergence.8
1,2
Associate Professor of Ophthalmology, 3Ophthalmologist
Correspondence: Dr Umair Qidwai, Ophthalmologist, Isra Postgraduate Institute of Ophthalmology E-Mail: [email protected]
Cell: 0321 2585976
Received: April 2014
169
Accepted: May 2014
This principle is used for bilateral and unilateral recession of the medial rectus muscles. Similarly another
approach is also used in which simultaneous lateral rectus muscle resection is also performed along with unilateral medial rectus recession.9 Different surgical success rates have been reported by different authors using
all these techniques.10 To our knowledge, no such study
has been done in our local setup. The rationale of this
study is that we wanted to identify the best technique
which should be used in future in our local settings.
The objective of our study is to compare the surgical outcome of different techniques of surgery in patients with constant esotropia.
METHODOLOGY
It was an observational case-series, conducted
from January 2007 to December 2012, at Al Ibrahim Eye
Hospital, Karachi. Patients were selected using nonprobability purposive sampling. Ethical approval was
taken from the ethical committee of Isra Postgraduate
Institute of Ophthalmology. Patients having primary
esotropia (deviation 15-75 PD) were included in the
study, while, patients with history of previous extraocular muscle surgery, paralytic esotropia and Any
other ocular disease such as congenital cataract, retinal detachment and any other cause of sensory visual
deprivation were excluded from the study. After informed written consent the patients were selected from
Ophthalmology Update Vol. 12. No. 3, July-September 2014
Success Rate of Surgical Correction Methods in Esotropias
the squint clinic of Al-Ibrahim Eye Hospital, Karachi,
diagnosed and reconfirmed by the consultant ophthalmologist. All the patients underwent detailed ophthalmic examination including best corrected visual acuity
(BCVA), cycloplegic refraction, fundoscopy and squint
assessment including measurement of squint using
prism cover technique. Patients with constant esotropia
underwent either bi medial rectus recession or unilateral medial rectus recession or unilateral medial rectus
recession along with lateral rectus resection procedures.
Surgery was done under local anesthesia in adults but
children were operated under general anesthesia.
Patients were re-evaluated at one week, one
month and two months post operatively. Final outcome
was considered at the end of two months at which
achievement of ≤10 PD of exotropia was considered as
a success. Data was entered on a preformed proforma.
Analysis was done using SPSS version 20.0. Qualitative data such as gender and success were presented
by their frequencies along with percentages. The continuous variables such as age and degree of esotropia in
prism diopters before and after surgery was presented
as mean ±SD. Stratification was done with regards to
age, gender, degree of esotropia (in prism diopter) and
the types of surgical procedure adopted. Chi square
test will be used for the analysis of the data. P value of
less than 0.05 will be considered as significant.
RESULTS
In this study, 272 patients were included. Out
of these, 130 (47.8%) were male, while rest of the 142
(52.2%) were female. Mean age of the patients was 12.19
years (±8.813), with minimum age of 1 year and maximum age of 43 years. Most of the patients 216 (79.4%)
had constant esotropias. Essential /infantile esotropia
was present in 32 (11.8%) of the patients. Partially accommodative esotropia was present in 24 (8.8%) of patients. Mean angle of deviation was 53.71 prism diopters (±17.18). Minimum angle of deviation was 20 prism
diopters while the maximum angle was 90 prism diopters. Out of these 272 patients, 210 (77.2%) of patients
underwent medial rectus recession and lateral rectus
resection in a one eye. Bilateral medial rectus recession
was done in 42 (15.4 %) of patients and unilateral medial rectus recession was done in 20 (7.4%) of patients.
Mean deviation after surgery was 9.73 prism diopters
(±12.03). Minimum deviation after surgery was 10
prism diopters while maximum deviation after surgery
was 60 prism diopters. Mean deviations with respect to
surgical treatments are shown in table-1. Surgical success as described as residual deviation of less than 10
prism diopters was seen in 202 (74.3%) of the patients,
while residual refraction of greater than 10 prism diopters was noted in 44 (16.2%) of the patients. Remaining 26(9.6%) of the patients had residual refraction of
greater than 20 prism diopters and were advised secOphthalmology Update Vol. 12. No. 3, July-September 2014
ond surgery. The patients, who underwent bi medial rectus recession, 36 (85.71%) had successful surgery with no
residual refraction. Similarly, 18 (90%) and 148 (70.47%)
had successful surgery with less than 10 prism diopters
of residual refraction after unilateral medial rectus recession and unilateral medial rectus recession combined
with lateral rectus resection respectively (figure-1-3)
Table-1: postoperative residual
deviation with respect to surgical treatment offered
TYPE OF SURGERY
BI-MEDIAL RECTUS
RECESSION
UNILATERAL
MEDIAL RECTUS
RECESSION
UNILATERAL
MEDIAL RECTUS
RECESSION +
LATERAL RECTUS
RESECTION
STATISTICS
PRISM DIOPTERS
Mean
7.1905
Std. Deviation
8.48309
Minimum
.00
Maximum
40.00
Mean
7.5000
Std. Deviation
13.22876
Minimum
.00
Maximum
45.00
Mean
10.4381
Std. Deviation
12.46923
Minimum
-10.00
Maximum
60.00
Figure-1
Figure-2: Comparison of success rates of different
types of surgeries performed in terms on number of patients
170
Success Rate of Surgical Correction Methods in Esotropias
Figure-3 Comparison of success rates of different types of
surgeries performed in terms of percent of patients
DISCUSSION
There has been extreme variability of individual
response to esotropia extra-ocular muscle surgery.
Although, comparison of the effectiveness to different surgical techniques is very difficult in statistical
analysis. Nevertheless, the comparison of effectiveness
among the surgical techniques fails to show any significant statistically significant differences. Although bi
medial rectus recession has been slightly superior over
residual deviation compared to the other techniques.
Many other researchers reported similar results
separately in their studies. one such study was done by
Willshaw et al, showed in forty-six children bilateral
medial rectus recession to correct large angle esotropia
successfully.1 Grint et al showed success of unilateral
medial rectus recession for moderate angle esotropias.
In this study, sixteen patients with moderate angle esotropia of 30 to 35 prism diopters were treated with a
unilateral medial rectus muscle recession of 6 or 6.5
mm, thirteen of sixteen patients (80%) were straight
postoperatively or had 12 prism diopters or less of esotropia.2
In another study, they compared different surgical
procedures for the treatment of children or adults with
esotropia. They also showed the success of medial rectus recession procedures either performed unilaterally
or bilaterally.3 Similarly, successful results have been
shown when simultaneous medial rectus recession is
performed along with lateral rectus resection.4 Like any
other study our study also had many limitations. One
of the main limitation was that it was performed in a
171
single center thus patients belonging to single ethnic
background were included.
CONCLUSION
Unilateral medial rectus recession, bi medial rectus
recession and unilateral medial rectus recession with
lateral rectus resection, no matter which procedure is
adopted for surgical correction of constant esotropia,
almost similar success results in terms of residual angle
and number of successful surgeries.
REFERENCES
1.
Mohney BG, Greenberg AE, Diehl NN. Age at strabismus
diagnosis in an incidence cohort of children. Am J Ophthalmol.
2007 Sep;144(3):467–9.
2.
Grand GM. Basic and clinical science course. Pediatric
Ophthalmology and strabismus. San Francisco: American
Academy of Ophthalmol; 1998–1999.
3.
Chew E, Remaley NA, Tamboli A, Zhao J, Podgor MJ, Klebanoff
M. Risk factors for esotropia and exotropia. Arch Ophthalmol.
1994 Oct;112(10):1349–55.
4.
Skuta GL. Basic and clinical Science Course. Pediatric
Ophthalmology and Strabismus. San Francisco: American
Academy of Ophthalmology; 2008–2009.
5.
Arias Díaz A, Pons Castro L. Ambliopía: consideraciones
terapéuticas actuales. In: Río Torres M. Oftalmología. Criterios
y Tendencias Actuales. Havana: Editorial Ciencias Médicas;
2009. p.727–32.
6.
Adán–Hurtado EE, Arroyo–Yllanes ME. Frecuencia de los
diferentes tipos de estrabismo en el servicio de Oftalmología
del Hospital General de México. Rev Mexicana Oftalmol. 2009
Nov– Dec;83(6):340–8.
7.
Prieto–Diaz J, Souza–Diaz C. Estrabismo. 5th ed. Buenos Aires:
Científi ca Argentina; 2005. p. 160–78.
8.
Perea J. Estrabismo. 1st ed. Toledo(ES): Artes Gráfi cas Toledo,
S.A.U; 2006. p. 233–40.
9.
El Instituto Cubano de Oftalmología Ramón Pando Ferrer
[Ramón Pando Ferrer Ophthalmology Institute] [homepage
on the Internet]. Havana: The Institute; [cited 2010 Nov 29].
Available from: http://www.pando.sld.cu. Spanish
10. Castro P.D. Pedroso P.Hernández L. Naranjo R.M. Méndez T.
Arias A.Results of Surgery for Congenital Esotropia. MEDICC
Review, January 2011, Vol 13, No 1:18-23
11. H E WILLSHAW, N MASHHOUDI, AND S POWELL.
Augmented medial rectus recession in the management of
esotropia. British Journal of Ophthalmology, 1986, 70, 840-843
12. GRIN T.R. NELSON L.B.Large unilateral medial rectus
recession for the treatment of esotropia. British Journal of
Ophthalmology, 1987, 71, 377-379
13. Ellis GS Jr, Pritchard CH, Baham L, Babiuch A.Medial
rectus surgery for convergence excess esotropia with an
accommodative component: a comparison of augmented
recession, slanted recession, and recession with posterior
fixation. Am Orthopt J. 2012;62:50-60.
14. Kushner BJ , Fisher MR , Lucchese NJ , Morton GV . Factors
influencing response to strabismus surgery . Arch Ophthalmol.
1993;111:75–79
Ophthalmology Update Vol. 12. No. 3, July-September 2014
ORIGINAL ARTICLE
Mohammad Idris
A Study of Disease Pattern in
Oculoplasty Department of a Tertiary
Care Hospital, in KPK
Mohammad Idris FCPS1, Muhammad Junaid Sethi FCPS, FRCS2, Mohammad Alam FCPS3
Sadia Ayaz MBBS4, Zubair ullah FCPS5
ABSTRACT
Objective: To evaluate the pattern of eyelid diseases as observed in oculoplasty OPD for surgical management in a
tertiary care hospital of KPK.
Material and Methods: A prospective study of interventional case series was carried out at Department of Ophthalmology,
Govt Lady Reading Hospital, Peshawar from July 2011 to Jan 2013. We studied 450 cases from the outdoor department for
surgical management. Nonprobability convenience sampling technique was used. Data was collected on special proforma
and was analyzed with the help of SPSS Version16.
Results: The study comprised 450 cases of eyelid trauma, age ranged between 01 to 40 years (Mean = 25 years). About
47.2% patients were between age of 21 and 40 years. The most common cause of eyelid lesion presented was eyelid
trauma (36.2%). Tumors (23.3%), chronic dacryocystitis (12%), ptosis (14%), entropion (8.6%) and ectropion (4.2%).
Conclusion: Commonest presentation of eyelid lesion in our setup is eyelid trauma. Benign tumors are common than
malignant and have better cosmetic outcome. Late presentation is common in malignant tumors. Good outcome was seen
in young patients. Lid trauma and malignant eyelid tumors need special care while operating for surgical reconstruction
because these are the challenging disorders to be repaired as early as possible.
Key words: eyelid diseases, surgical outcome, eyelid trauma.
INTRODUCTION
There are different oculoplastic conditions we
commonly deal with. i.e., trauma, tumors, blephroptosis, blocked nasolacrimal duct, entropion and ectropion
are the key conditions visiting oculoplasty OPD. There
are different causes of eyelid trauma, road traffic accidents (RTA) are the most frequent cause; other causes
include domestic violence, accidental fall and sports
like activities. Bomb blast injuries (BBI) though rare but
comparatively more common in our part of the world.
Our unit is one of easy approachable and an important center to receive maximum trauma cases. Injuries
of the eye lid ranges from simple lacerations to complex trauma involving lid margin, lacrimal apparatus
and orbital bone and intra-orbital structures1,2 admitted
for surgical reconstruction.
Blephroptosis of the upper eyelid is also a commonest condition among patients presenting for oculoplastic surgery. Although there are many types of
ptosis, the two most frequent clinical cases are simple
congenital ptosis in young patients and senile ptosis in
older patients. The examination is important part of the
Medical Officer, Ophthalmology Unit, PGMI, Lady Reading Hospital, Peshawar, 2,3Senior Registrars, Ophthalmology Unit, PGMI, Lady
Reading Hospital, Peshawar, 4House Officer, PGMI, Lady Reading
Hospital, Peshawar, 5In charge Ophthalmologist, Mission Hospital,
Peshawar.
1
Correspondence: Mohammad Idris Medical Officer, Ophthalmology
Unit, PGMI, Lady Reading Hospital, Peshawar Cell: 0333 9417051
E-Mail: [email protected]
Received: May 2014
Accepted: June 2014
Ophthalmology Update Vol. 12. No. 3, July-September 2014
diagnosis to distinguish these from other more infrequent types of ptosis, such as neurogenic, myogenic
and post-traumatic. The latter cases may require specific therapeutic strategies which can usually be corrected surgically.3
In the orbital region the variety of tumors is so
vast that even an expert oculoplastic surgeon may be
deceived. The various tumors may be classified as benign, precancerous and malignant. Approximately
5-10% of all skin cancers occur in the eyelids and basal
cell carcinoma being the commonest malignant eyelid tumor, followed by squamous cell carcinoma, sebaceous gland carcinoma and malignant melanoma.
Malignant neoplasms represent the leading cause of
plastic reconstruction in orbital region, followed by
cicatricial retraction, post-traumatic loss of tissue, congenital colobomas.4
Common cause of epiphora is blocked nasolacrimal duct. External dacryocystorhinostomy (DCR) is
considered the gold standard for the treatment of lacrimal duct stenoses.5 Ectropion, entropion and trichiasis eyelid pathologies are characterized by common
symptoms (redness, excessive tearing and irritation of
the eye) and by altered balance of the anterior and posterior lamellae of the eyelids. They involve more frequently the inferior eyelid and the therapy is mainly
surgical.6
METHODOLOGY
Objective: To evaluate pattern of eyelid diseases in oculoplasty OPD for surgical management in a tertiary
care hospital of KPK.
172
A Study of Disease Pattern in Oculoplasty Department of a Tertiary Care Hospital, in KPK
Study Design: prospective, interventional case series.
Place and duration: The study was conducted at the
Department of Ophthalmology, Govt Lady Reading
Hospital, Peshawar from July 2011 to Jan 2013.
Sampling Technique: Convenience (non-probability
sampling).
Sample size: 450 patients having eyelid lesions presented to us for surgical management.
Data Collection Procedures: Patients were selected
from the Ophthalmology Out Patients Department of
the Govt Lady Reading Hospital, Peshawar according to selection criteria. Patients were admitted to the
Ophthalmology Department of the hospital. Diagnosis
was based on history and routine ophthalmic examination. Detail assessment of eyelid as well as of face, neck
and intraocular structures were made. Written consent
of all the patients included in the study was taken after fully explaining the procedure and purpose of the
study to the patients.
Follow-ups: Patients had a follow-up on day one, at 4
month, 6 months and then last follow up at 1 year after
surgery.
Data analysis: The data were analyzed by software
SPSS (version 10.0). Frequencies and percentages were
calculated for the type of lesion, gender and age distribution.
RESULTS
We evaluated 450 patients, admitted for surgery
from the oculoplasty OPD for surgical management,
from July 2011 to Jan 2013. Most of our patients were
female with the exception of trauma and blephroptosis, which were more common in male (table 1). Age
was divided into three main groups in years for ease
of description. majority of the patients were adult. 165
(36.66%) patients were in the age ranging from 1 to 20
years, 180 (40%) cases were having age from 21 to 40
years and 105 (23.35) cases, the patients were in the
age 41 years or more. (Table 2) out of these 450 cases;
trauma was most commonly seen (Table 3). As seen in
163 (36.2%) cases.
RTA was commonest reason for eyelid trauma in
60 (36.8%) cases. tumors of eyelid comprises 105 (23.3%)
cases and amongst these, 79 (17.5%) cases were having
benign tumors and the dermoid cyst being frequently
seen. 24(22.8%) cases were presented with malignant
eyelid tumors and basal cell carcinoma was the most
common malignant tumor. 54 (12%) patients visited
with complaint of epiphora and after sac wash, nasolacrimal duct was found to be blocked. These patients
were then booked for surgery, 39(8.6%) of entropion
were repaired as the orbicularis oculi over-rides with
horizontal lid laxity.
63 (14%) cases were presented with blephroptosis,
majority were having poor levator function and were
173
moderate to severe blephroptosis. Ectropion were seen
in 19(4.2%) cases and common cause was senile lid laxity. We received 09 (2%) cases of empty socket.
Table-1: Age distribution (N=450)
Age group
frequency
percentage
1 to 20
165
36.66
21 to 40
180
40
More than 40
105
23.3
total
450
100
Table-2: Gender distribution (N=450)
Type of
Oculoplasty
disease
N
Gender
N
percentage
Trauma
163
Male
Female
107
57
65.6
34.9
Tumors
105
Male
Female
51
54
48.5
51.4
blephroptosis
63
Male
Female
21
10
67.7
32.2
CDC
54
Male
Female
22
32
40.7
59.2
Entropion
39
Male
Female
19
20
48.7
51.2
Ectropion
19
Male
Female
07
12
36.8
63.1
Empty socket
09
Male
Female
03
06
33.3
66.6
Table-3: Diseases diagnosed in oculoplasty clinic (N=450)
Type of oculoplasty disease
frequency
percentage
Eyelid trauma
Road traffic accidents
Sports and accidental fall
Bomb blast injuries
Domestic violence and assault
163
60
45
34
27
36.8
27.6
20.8
16.56
Eyelid tumor
Benign
malignant
105
79
24
75.2
22.8
blephroptosis
63
14
Chronic dacryocystitis
54
12
Entropion
39
8.7
Ectropion
19
4.3
Empty socket
09
2
DISCUSSION
Oculoplasty is an important and specialized field
of ophthalmology. Gautam P et al reported ocular tumors as commonest reasons for admission for surgery
(39.53%) followed by trauma (37.2%).7 in our study;
trauma was the commonest reason for surgery of patients visiting oculoplasty OPD. Due to increasing incidence of trauma and different sorts of violence, lid injuries are on the rise.8 among the trauma cases of eyelids,
RTA are commonest reason for admission in hospital
Ophthalmology Update Vol. 12. No. 3, July-September 2014
A Study of Disease Pattern in Oculoplasty Department of a Tertiary Care Hospital, in KPK
for repair and reconstruction of defects, most of these
injuries are accompanied with face involvmnt.9 other
important causes of eyelid trauma are violence sports
and BBI. BBI are common in our part of the world.10
Tumors were the second most important indication for admission for surgery. Benign tumors of the
eyelids are common than malignant ones,11 its prognosis and surgical cosmetic outcome was better. Commonest tumor in this regard was lid dermoid. Others
include cyst and chalazion. Among malignant tumors,
basal cell carcinoma (BCC) was the commonest tumor
and we received most of the BCCs at quite advanced
stages. Men and women are equally affected.9 In our
study malignancy was more in female patients. Most
of such patients were belonging to far off areas of our
province,12 the surgical and cosmetic results of these tumors were unsatisfactory.13 Those involving the medial
canthus have the poor prognosis and the results of surgery. One patient died due to very advanced squamous
cell carcinoma who presented with proptosis. Patients
presented with epiphora were mostly patients around
40 and above. We did sac wash and mostly we found
these patients had blocked nasolacrimal duct. Blephroptosis patients were mostly young as commonest
cause of ptosis is congenital.14 In our study congenital
ptosis was the most common cause followed by traumatic blephroptosis. We admitted entropion for surgical correction and most common presenting was older
age group. According to different studies, it is common
in old age also.15 in our study, entropion was mostly
because of orbicularis override. For entropion repair,
and we did Weiss and Quickert procedure, according
to clinical assessment. Recurrence rate was less with
Quickert procedure.16 Ectropion was seen and commonest type was cicatrizing. Senile ectropion was due
to laxity of lower lid retractors. We received 09 cases of
empty socket which were mostly operated for secondary ball implant and conformer was placed to form fornix. Commonest reason for empty socket was traumatic
globe rupture. Results of surgery were mostly good.
CONCLUSION
Commonest presentation of eyelid disease in our
setup is eyelid trauma. Benign tumors are common
than malignant and have better cosmetic outcome. Late
presentation is common in malignant tumors. Good
outcome was seen in young patients. Lid trauma and
malignant lid tumors need special care while operating
for surgical reconstruction because they are challenging cases. Trauma cases should be repaired as early as
Ophthalmology Update Vol. 12. No. 3, July-September 2014
possible. Early referral and timely repair offer the best
results and to educate the masses regarding preventive
measures are the best means to reduce its incidence.
REFERENCES
1.
Lee H, Ahn J, Lee TE, Lee JM, Shin H, Chi M, Park M, Baek S.
Clinical characteristics and treatment of blow-out fracture accompanied by canalicular laceration. J Craniofac Surg. 2012
Sep; 23(5):1399-403.
2.
Woo JH, Sundar G. Eye injuries in Singapore--don’t risk it. Do
more. A prospective study. Ann Acad Med Singapore. 2006
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De Sanctis U1, Alovisi C, Actis AG, Vinai L, Penna R, Fea
A, Actis G, Grignolo F.
4.
Blepharoptosis. Minerva Chir. 2013 Dec; 68(6 Suppl 1):37-47.
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Actis AG1, Actis G, De Sanctis U, Fea A, Rolle T, Grignolo
FM.Eyelid benign and malignant tumors: issues in classification, excision and reconstruction. Minerva Chir. 2013 Dec; 68(6
Suppl 1):11-25.
6.
Keerl R1, Weber R. [Dacryocystorhinostomy - state of the art, indications, results]. Laryngorhinootologie. 2004 Jan;83(1):40-50.
7.
Fea A1, Turco D, Actis AG, De Sanctis U, Actis G, Grignolo FM.
8.
Ectropion, entropion, trichiasis. Minerva Chir. 2013 Dec; 68(6
Suppl 1):27-35.
9.
Gautam P1, Adhikari RK, Sharma BR.A profile of eye-lid conditions requiring reconstruction among the patients attending
an oculoplasty clinic in mid-western region of Nepal. Nepal J
Ophthalmol. 2011 Jan-Jun;3(1):49-51.
10. Ophthal Plast Reconstr Surg. 2010 Sep-Oct;26(5):315-22. Spectrum of orbital disease in South India: an aravind study of 6328
consecutive patients.
11. Kim UR1, Khazaei H, Stewart WB, Shah AD.
12. Krengli M1, Masini L, Comoli AM, Negri E, Deantonio
L, Filomeno A, Gambaro G.
13. Interstitial brachytherapy for eyelid carcinoma: Outcome analysis in 60 patients. Strahlenther Onkol. 2014 Mar;190:245-249.
14. Schein OD, Hibberd PL, Shingleton BJ, Kunzweiler T, Frambach DA, Seddon JM, et al. The spectrum and burden of ocular
injury. Ophthalmology 1988. Mar;95(3):300-305. 15. Wang CJ1, Zhang HN, Wu H, Shi X, Xie JJ, He JJ, Kook KH, Lee
SY, Ye J.
16. Clinicopathologic features and prognostic factors of malignant eyelid tumors. Int J Ophthalmol. 2013 Aug 18;6(4):442-7.
17. Boboridis KG1, Bunce C. Interventions for involutional
lower lid entropion. Cochrane Database Syst Rev. 2011 Dec
7;(12):CD002221.
18. Knani L1, Romdhane O2, Ben Rayana N2, Mahjoub H2, Ben
Hadj Hamida F2.
19. Clinical study and risk factors for recurrence of basal cell carcinoma of the eyelid: Results of a Tunisian series and review of
the literature J Fr Ophtalmol. 2014 Feb;37(2):107-14.
20. Actis AG1, Actis G, De Sanctis U, Fea A, Rolle T, Grignolo FM.
21. Eyelid benign and malignant tumors: issues in classification,
excision and reconstruction.
22. Minerva Chir. 2013 Dec;68(6 Suppl 1):11-25.
23. Schaudig U1, Heidari P, Schumacher S. Lower lid entropion
and ectropion. Indication, technique and key points of “classical” surgical methods. Ophthalmologe. 2012 May; 109(5):443-9.
24. Cook BE Jr1, Bartley GB. Epidemiologic characteristics and
clinical course of patients with malignant eyelid tumors in an
incidence cohort in Olmsted County, Minnesota. Ophthalmology. 1999 Apr; 106(4):746-50.
174
ORIGINAL ARTICLE
Saber Mohammad
Comparison of outcome of Dacryocystorhinostomy
with Intubation against Dacryocystorhinostomy with
Mitomycin-C (MMC) application Intraoperatively
Saber Mohammad, FCPS1, Sanaullah Khan, FCPS2, Zaman Shah, FCPS3, Sadia Sethi FCPS4
Lal Mohammad FCPS5, Badar Mahmood MBBS6
ABSTRACT
Objective: To compare the surgical outcome of Dacryocystorhinostomy (DCR)
With Intubation against Dacryocystorhinostomy with Mitomycin C (MMC) application in patients of nasolacrimal duct
blockage (NLDB).
Material and Methods: This study was conducted in Eye A ward ophthalmology department Khyber teaching Hospital,
Peshawar from 1st January 2011 to 30th June 2012. This prospective comparative study was performed on 100 patients
who presented with CDC. All patients were equally and randomly divided into two groups. In Group A patients underwent
DCR with intubation while in group B DCR with MMC application intra-operatively for 5 minutes. Patients were followed for
06 months. The main outcomes of surgery were on the basis of assessment of regurgitation and the patency of lacrimal
drainage system.
Results: 100 patients of CDC included in this study. Out of 50 patients in group A, 46 (92%) patients remained symptom
free whereas, 4 (8%) showed failed syringing with positive regurgitation test at the end of 6 months. However, out of
the 50 patients in-group B, 44 (88%) patients remained symptom free and 6 (12%) showed failed syringing with positive
regurgitation test at the end of six months.
Conclusion: Silicon tube and MMC, both yield equally successful results with DCR surgery. However, use of MMC is more
cost and time effective than silicon tube and also associated with lesser intra-operative and post-operative complications.
INTRODUCTION
Watering and discharge due to blockage in the
distal part of the Nasolacrimal apparatus is the major
indication of external DCR. This procedure was first
performed by Adei Toti and is still the gold standard
against which other methods are compared.1, 2
The idea of anastomosis of the flaps of the lacrimal
sac and nasal mucosa was first introduced by Dupuy
Dutemps, Bourguet’s and Ohm’s.3,4 Iliff’s suggestion
of placing a rubber catheter into the sac5 and Older’s
suggestion of using a silicon tube6. Success rate of DCR
has been found to be 90%.7 10% of cases however, still
fail with persistent excessive tearing and inability to irrigate7. The two commonest causes of DCR failure are
obstruction of the common canaliculus and closure of
the osteotomy site.7 Anti-proliferative agents like MMC
are used to prevent fibrous tissue growth and scarring.
This overall decreases the failure rate of DCR.7 Success rates achieved with the adjunctive use of MMC in
Assistant Professor, Department of Ophthalmology, Khalifa Gul
Nawaz Teaching Hospital, Bannu Medical College,Bannu, 2Associate
Professor, Khalifa Gul Nawaz Teaching Hospital, Bannu, 3Senior
Registrar, Eye A ward, Khyber Teaching Hospital, Peshawar 4Associate
Professor, Department of Ophthalmology, Khyber Teaching Hospital,
Peshawar 5Professor of Ophthalmology, Kohat Medical College, 6TMO
Medicine Department, Khyber Teaching Hospital, Peshawar
1
Correspondence: Dr. Saber Mohammad, FCPS Room No:14 Doctor
Hostel, Khalifa Gul Nawaz Teaching Hospital, Bannu Medical College,
Bannu. Email- [email protected], Cell: 0346-9155303
Received: March’2014
175
Accepted: June’2014
various studies are 95.5%, 95% and 97.7%7-9 and those
with silicon tube are 83% and 97.5%.10-11 The aim of this
study is to compare the surgical outcome of both these
procedures.
MATERIAL AND METHODS
The study was carried out in Eye A Ward Ophthalmology Department Khyber Teaching Hospital,
Peshawar from 1st January 2011 to 30th June 2012. Patients were followed post-operatively from July 2012
to December 2012. 100 patients of both gender and belonging to any age group presenting to the OPD with
complaints of watering / epiphora and fulfilling the
inclusion criteria were subjected to the planned ocular
examination and investigation.
Inclusion criteria was complete NLD obstruction
and chronic Dacryocystitis. The patients were randomly divided into 2 groups, each group consisting of 50
patients.
Exclusion criteria included failed DCR, children
less than 10 years of age, acute on chronic dacryocystitis, and patients who were unable to follow up for six
months. A specific performa was maintained for all the
registered patients to assess the post-operative results.
The patients were evaluated pre-operatively via history
and examination. A detailed history regarding watering, swelling near the medial canthus, mucopurulent
discharge was obtained. History of hypertension and
any blood disorder were also taken. Ocular as well as
nasal examination was done in all patients. Ocular examination was done to assess for Entropion, Ectropion,
Ophthalmology Update Vol. 12. No. 3, July-September 2014
Comparison of outcome of Dacryocystorhinostomy
Trichiasis or Blepharitis, Punctal malposition, stenosis,
agenesis or accessory puncta, canaliculitis, conjunctivitis, keratitis or any fistulae near medial canthus. Regurgitation test was performed and reflux of mucus
or mucopurulent material through the canaliculus and
puncta was noted. Nasal cavity was examined in all patients to exclude any nasal disease and patients with
nasal problem were referred to otolaryngologist for
treatment before performing DCR surgery. Preoperatively patients were investigated for any bleeding diatheses via blood complete picture, blood sugar levels,
bleeding and clotting time, HBsAg and anti-HCV.
Surgical Technique: DCR was performed under
local or general anesthesia as per patient’s need or request. Informed written consent was taken after thorough explanation of the procedure, its risks and benefits to the patient. The nasal mucosa was anesthesized
and vasoconstricted by packing the respective nasal
cavity of all patients with ribbon gauze soaked in 4%
xylocaine and adrenaline (1:100,000). After anesthesia and draping, a vertical straight skin incision 8 mm
away from the medial canthus was made to expose the
anterior lacrimal crest. Four traction sutures with 4/0
silk were made through the skin to expose the area
of surgery. The periosteum over the anterior lacrimal
crest was elevated towards the bridge of the nose for
about 5 – 6 mm. The lacrimal fossa was exposed. The
suture between the lacrimal bone and frontal process of
maxilla lying in the posterior half of fossa was identified and broken. An oval osteotomy, approximately 12
x 10 mm in size, with smooth edges and round corners,
was created. Small anterior and larger posterior flaps
of sac were made. An H-shaped incision was made in
the nasal mucosa forming a larger anterior and smaller
posterior flap.
In the DCR with MMC group, a piece of gauze
soaked with 0.2 mg/ml MMC. It was then placed over
the anastomosed posterior flaps and osteotomy site for
5 minutes and washed with normal saline thoroughly.
Meanwhile the anterior nasal and lacrimal sac flaps
were anastomosed with 2 interrupted 6/0 vicryl sutures on short ½ circle needles. Traction sutures were
then removed and the bridge of flaps sutured to the
muscle layer with 1-2 suture of 6/0 vicryl to avoid collapse of bridge.
The periosteum with orbicularis oculi and skin
wounds were closed in separate layers with interrupted 6/0 sutures. Steps for DCR with intubation
were identical to the DCR with MMC upto the point of
fashioning of the mucosal flaps. A fine silicon tube attached to malleable metal bodkins was then introduced
through both upper and lower canaliculi and brought
out through DCR skin incision. After passing through
the punctum, the tube ends were passed into the nose
Ophthalmology Update Vol. 12. No. 3, July-September 2014
and out through the nostril. The tube loops were then
tied together and left in the nasal cavity near the external nostril without fixing it to the nasal wall. Pressure bandage and nasal packing with gauze soaked in
antibiotic ointment was done in all patients to control
bleeding post-operatively. Post-operatively all patients were kept in ward for 24 hours. The nasal pack
and bandage were removed on the following day.
Skin sutures were removed after one week. All patients were kept on oral broad-spectrum systemic antibiotics, non-steroidal anti-inflammatory medicines
for one week to prevent post-operative soft tissue infection. They were also kept on topical moxifloxacin
eye drops, QID for one month and polymyxin B, bacitracin eye ointment, OD for local application over the
wound.
Follow-up Protocol: Follow-up was maintained
for 6 months for the evaluation of abnormal overflow
of tears and the patency of the lacrimal drainage system by syringing. After discharging from the ward, 1st
follow up was done after one week, and then at 1st,
3rd and 6th month post-operatively. Skin sutures were
removed on first postoperative week. Outcome of the
surgery was measured on the basis of these subjective
and objective findings. The surgery was considered
successful if the patient had no tearing or significant
improvement in tearing in a patient with patent lacrimal drainage system at the last follow-up. Patients
having persistent epiphora with non-patent LDS were
classified as failed DCR. At the end of follow-up period
of 06 months results of DCR with MMC and DCR with
intubation were compiled and compared with national
and international results.
RESULTS
A total of 100 patients of nasolacrimal duct obstruction were included in our study. Patients were
equally and randomly divided into two groups. In
group A, patients were treated with Mitomycin C and
in-group B, patients were treated with intubations.
Age distribution of the patients is presented in Figure I. The average age of the patients was 30.68 ± 5.6
Years.
Out of 100 cases, 41 (41%) were male and 59 (59%)
were female as presented in Table II. Proportion of gender difference was also not significant between groups
(p = 0.214).Out of 50 patients in group A, 46 (92%) patients remained symptom free whereas, 4 (8%) showed
failed syringing with positive regurgitation test at the
end of 6 months. However, out of 50 patients in-group
B, 44 (88%) patients remained symptom free and 6
(12%) showed failed syringing with positive regurgitation test at the end of 6 months was shown in Figure
No, III. The rate of surgical outcome was not statistically significant between the groups.
176
Comparison of outcome of Dacryocystorhinostomy
Figure: I
Figure: II
Figure: III
DISCUSSION
As compared to other procedures, external DCR is
the gold standard procedure for relief of NLD obstruction.2 Success rate of DCR has been found to be 90%.12-14
However, 10% of cases still failed with persistent excessive tearing and inability to irrigate the lacrimal drainage system.7 The two commonest causes of DCR failure
are obstruction of the common canaliculus and closure
of the osteotomy site.15-17 Fibrous tissue growth, scarring and granulation tissue formation during the healing process decrease the created surface area of the osteotomy site, leading to surgical failure.7 Thus, if we can
reduce fibrous proliferation at the osteotomy site and
at the anastomosed flaps, the success rate of DCRs may
become much higher.7 In our study the overall success
rate of DCR with MMC and intubations was 90% while
10% of cases still failed with persistent excessive tearing and inability to irrigate. The assessment criteria included symptomatic relief of epiphora and syringing at
1st day, 1st week and then at 3rd and 6th month.
In our study we attained a success rate of 92% and
a failure rate of 8% in the DCR with intubation group.
177
46 patients were labeled as successful on the basis of
absence of epiphora confirmed by positive syringing.
Four patients however revealed persistent epiphora
confirmed by failed syringing. Various other studies
have previously been conducted to assess the surgical outcome of DCR with silicon tube. Zaman M et al
showed a success rate of 97.5%10 whereas, Ilff reported
90%5 and Tarbat and Custer reported 95% success results.12 In a comparative study Hussain et al reported
94.7% success results in intubated series.18 Similarly
Advani et al reported a success rate of 95% in intubated
cases.19 A study by Y M Delaney and R Khooshabeh
showed that patent DCR system to irrigation and a
positive dye test was achieved in 90% of procedures.20
Nawaz et al were successful by 93.33%.11 The DCR with
MMC group showed a success rate of 88% and failure
rate of 12%. 44 patients remained symptom free. This
was confirmed on syringing. Six patients however revealed persistence of epiphora confirmed on failed syringing. From amongst the various studies previously
conducted to assess the surgical outcome of DCR with
MMC, Shu L Liao et al showed 95.5% success rate,7 Yildrim C et al gave a success rate of 95% and Rahman A
et al achieved a success rate of 97.77%.8,9
Kao et al showed 100% success with MMC in
maintaining patency and a larger osteotomy site.7 You
in 2001, Roozitalab in 2004 and Akhund in 2005 applied
Mitomycin-C over the anastomosed flaps and achieved
a success rate of 100%, 90.5% and 99%; respectively.21,22
Mitomycin C, an anticancer agent isolated from Streptomyces caespitosus, has the ability to significantly
suppress fibrosis and vascular in growth. Application
of MMC over the osteotomy site and the flaps reduces
the fibrous adhesion between the osteotomy site and
the nasal septum as well as inhibits scarring around
the opening of the common canaliculus.7 In our study
most of the patients fell between 40-50 years of age. In
the study by Zaman et al the majority of patients were
between 41 and 60 years10 whereas, that in the study
by Rahman A et al were between 41 and 50 years of
age.9 This shows that the commonest age group to suffer from NLDB range between 30 and 60 years of age.
In our study there were 59 (59%) females and 41
(41%) males. It is known that chronic dacryocystitis
most commonly affects the women of post-meno-pausal age.23 This female predominance is possibly due to
the narrow lumens of bony lacrimal canal and NLD in
women, osteoporosis, hormonal changes and a heightened immune response.24 In the study by Zaman et al
there were 62% females,10 by Rahman A et al there were
76% females,9 by Nawaz et al. there were 85% females,11
by Ali A et al. there were 79% females.25 We found from
our study that both silicon tube and MMC are equal
in yielding successful results with DCR. The difference
Ophthalmology Update Vol. 12. No. 3, July-September 2014
Comparison of outcome of Dacryocystorhinostomy
in the results achieved is not statistically significant for
surgical outcome as well as for gender and thereby,
both the adjuncts namely MMC and Silicon tube can be
advised to patients undergoing DCR. However, the use
of MMC is cost and time effective and the patient does
not have to come for removal of the tube, neither does
the patient have to suffer any irritation from the tube.
This study is the first of its type, to compare the surgical outcome of the two adjuncts used in DCR, namely,
MMC and Silicon tube. We suggest that further studies
be done to confirm these results.
CONCLUSION
Our study showed that there is no significant difference between the success results achieved with these
two comparative studies. Therefore, both the adjuncts
can be used with DCR. However, MMC is more cost
and time effective. The surgical outcome is totally depend on surgeon experience.
REFERENCES
1. Shun Sin GA, Thurairajan G. External dacryocystorhinostomy
and end of an era? (Commentary). Br J Ophthalmol. 1997; 81:
716-7.
2. Seppa H, Grenman R, Hartikeinen J. Endonasal CO2–
Nd: YAG laser dacryocystorhinostomy. Acta Ophthalmol
Copenh.1994;72:703-6.
3. Dupuy-Dutemps L, Bourguet J. Method of plastic dacryocystorhinostomy and results. Ann Ocul J. 1921; 158: 241-61.
4. Ohm J. Nerbesserungen an meinen Nystagmo-graphen.
Klin Monatsble Augenheilk. 1926; 1: 791-4. 5.ILIFF CE.A
simplified
dacryocystorhinostomy
1954-1970.Arch
Ophthalmol.1971;85:586-91.
6. Older JJ. Routine use of silicone stent in a dacryocystorhinostomy.
Ophthalmic Surg. 1982; 13: 911-5.
7. Liao SL, Kao SC, Tseng JH, et al. Results of intraoperative
mitomycin C application in dacryocystorhinostomy. Br J
Ophthalmol. 2000; 84: 903-6.
8. Yildrim C, Yaylali V, Esme A. Long-term results of adjunctive
use of mitomycin C in external dacryocystorhinostomy.
International Ophthalmology. 2007; 27: 31-5.
9. Rahman A, Channa S, Niazi JH, et al.. Dacryocystorhinostomy
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without intubation with intraoperative Mitomycin-C. J Coll
Physicians Surg Pak. 2006; 16: 476-8.
Zaman M, Babar TF, Abdullah A. Prospective Randomized
Comparison of Dacryocystorhinostomy (DCR) with and
without intubation. Pak J Med. Res. 2005; 44: 75-8.
Nawaz M, Sultan MS, Hanif Q, et al. Dacryocystorhinostomy;
a comparative study of the results with and without silicon
intubation in Pakistani patients of chronic dacryocystitis.
Professional Med J Mar. 2008; 15: 81-6.
Tarbet KJ, Custer PL. External dacryocystorhinostomy:
surgical success, patient satisfaction, and economic cost.
Ophthalmology. 4; 102: 1065–70.
Walland MJ, Rose GE. Factors affecting the success rate of open
lacrimal surgery. Br J Ophthalmol. 1994; 78: 888–91.
Becker BB. Dacryocystorhinostomy without flaps. Ophthalmic
Surg. 1988; 19: 419–27.
Allen K, Berlin AJ. Dacryocystorhinostomy failure: association
with silicon intubation. Ophthalmic Surg. 1989; 20: 486-9.
Rosen N, Sharir M, Moverman DC, et al. Dacryocystorhinostomy
with silicone tubes: evaluation of 253 cases. Ophthalmic
Surg.1989; 20: 115–9.
McLachlan DL, Shannon GM, Flanagan JC. Results of
dacryocystorhinostomy: analysis of the reoperations.
Ophthalmic Surg. 1980; 11: 427–30.
Hussain M, Akhtar S, Awan S. Dacryocystorhinostomy with or
without intubations. Ann King Edward Med Uni.1998; 4: 34-6.
Advani RK, Halepota FM, Shah SIA, et al. Comparative results
of dacryocystorhinostomy with and without silicon intubation.
Pak J Ophthalmol. 2004; 20: 29-34.
Khooshabeh R. External dacrycystorhinostomy for the
treatment of acquired partial nasolacrimal duct obstruction in
adults. Br J Ophthalmol. 2002; 86: 533-5.
You YA, Fang CT. Intraoperative Mitomycin C in DCR.
Ophthal Plast Recons Surge. 2001; 17: 115-9.
Roozitalab MH, Amirahmedi M, Namazi MR. Results
of the application of intraoperative Mitomycin-C in
dacryocystorhinostomy. Eur J Ophthalmol. 2004; 14: 461-3.
Babar TF, Masud MZ, Saeed N, et al. An analysis of patients
with chronic dacryocystitis. Pak J Ophthalmol. 2003; 19: 77-83.
Mortimore S, Banhegyi GY, Eancaster JE et al. Endoscopic
dacryocytorhinostomy without silicon stenting. J R Coll. Surg
Edinb. 1999; 44: 371-3.
Ali A, Ahmed T. Dacryocystorhinostomy (A review of 51 cases)
Pak J Ophthalmol. 2001; 17: 122-8.
33rd LAHORE OPHTHALMO
to be held
from 5-7, December’2014 at Pearl Continental Hotel, Lahore
For conference details,
Please contact: Prof. Nadeem Riaz, Phone: 042 36363325
E-Mail: [email protected]
Ophthalmology Update Vol. 12. No. 3, July-September 2014
178
ORIGINAL ARTICLE
Afzal Qadir
Morphological Appearance of Retinal
Breaks associated with or without Rhegmatogenous
Retinal Detachments presenting in Ophthalmology
Department of Hayatabad Medical Complex, Peshawar
Afzal Qadir1, Umer Khan2, Lal Mohammad3, Muhammad Kashif Kamran4
ABSTRACT
Objective: To evaluate the morphological appearance of retinal breaks associated with or without rhegmatogenous retinal
detachments in our population.
Material and Method: This observational study was conducted at the teaching hospital Khyber institute of Ophthalmic
Medical Sciences Hayatabad Medical Complex, Peshawar Khyber Pakhtoonkhwha from January 2012 to December 2012.
A total number of 227 eyes were diagnosed as retinal breaks with or without rhegmatogenous retinal detachments. Retinal
diagrams were drawn in all these cases. Detail history of ocular and systemic diseases, age, gender, and duration of
symptoms were noted. Detailed ocular and systemic examinations were performed, anterior and posterior segment with
direct and indirect ophthalmoscope. To record the type, size, location and number of breaks, visual acuity, intraocular
pressure, refraction, predisposing factors was recorded.
Results: The most common type of breaks was horse shoe shape tears with vitreous traction (52.0%) followed by retinal
holes (25.0%), dialysis (15.0%) and giant retinal tears (05.0%) of cases were observed. The most commonly located tear
was superior-temporal in (65.0%) of cases, followed by superior-nasal in (20.0%) of the eyes. Age ranges from 20 to 80
years. 80.0% of the cases were male. Bilateral rhegmatogenous retinal detachments were observed only with 2.0% of
cases. No other identifiable risk factor for retinal detachment was found in 25% of cases.
Conclusion: The horse shoe shape tears and retinal holes were the most common types of retinal breaks in our setup and
the common location of the break was superior-temporal. This will help us in the management of vitreo-retinal surgery.
Key words: Retinal breaks, tear, holes, retinal detachment, retinal degeneration, dialysis, giant retinal tear.
INTRODUCTION
Retinal break or breaks development is closely related to changes in the fibrillar structure of the aging
vitreous culminating in posterior vitreous detachment
with regions of persistent and tangential vitreoretinal
traction predisposing to retinal tear formation leading
to retinal detachment. Rhegmatogenous retinal detachment is common in all forms of retinal detachments and
potentially blinding condition.1 A complex interplay of
factors such as weakening of vitreoretinal adhesion,
posterior migration of the vitreous base, and molecular changes at the vitreoretinal interface are important
in predisposing to focal areas of vitreoretinal traction
precipitating rhegmatogenous retinal detachment.
Once formed, the passage of liquefied vitreous through
a retinal break may overwhelm normal neurosensoryretinal pigment epithelium adhesion perpetuating and
extending detachment and causing visual loss. Such
condition usually occurs after trauma, after intra-ocular surgery, in patients with myopia or with peripheral
degenerative changes especially in lattice degenerative,
and acute posterior vitreous detachment.2,3 And some
Senior Registrar, HMC, Peshawar, 3Assistant Professor, Kohat Eye
Medical College, 4Resident Ophthalmology HMC Peshawar.
1,2
Correspondence: Dr Afzal Qadir, Registrar Ophthalmology Department
Hayatabad Medical Complex Peshawar, Email: [email protected]
Cell: 0321-9128247, Fax: 091-9217189 Mailing Address; House no 40,
Street 2, N/4, Phase 4, Hayatabad, Peshawar
Received: March 2014
179
Accepted: June 2014
time we found retinal break without identifiable risk
factors. Clear media is necessary for the examination
to diagnose and for the treatment purpose. Corneal
opacity and lens status, aphakia and pseudophakia are
known risk factors for developing retinal detachment.4
Surgical approach also depends upon the status of the
lens. An epidemiological study suggests that heavy
manual lifting at work may also lead to develop retinal
detachment.5
Retinal detachment is an ophthalmic emergency.
Presenting with sign and symptoms of floaters, photopsia and field loss. Retinal detachment depends upon the
type, size and location of the break or breaks, whereas
the visual acuity outcome depends upon the macular
involvement and duration of the retinal detachment.
Better Visual prognosis and physiological outcomes are
also expected if anatomy is restored within six weeks of
the retinal detachment. Delay in the surgical interventions is due to unawareness of the patients, delay in access to the vitro-retinal facilities, patients overload over
the department, less number of specialized surgeon in
the field of vitro-retina. Due to pre retinal, intra-retinal,
and sub-retinal proliferation lead to fibrosis known as
proliferative vitro-retinopathy (PVR).
The purpose of this study is to look for morphological appearance of the break or breaks, which will
help us in the management of retinal detachment.
METHOD AND MATERIAL
227 eyes with retinal break were selected in this
Ophthalmology Update Vol. 12. No. 3, July-September 2014
Morphological Appearance of Retinal Breaks associated with or without Rhegmatogenous
study. All patients were attended at the department of
vitreo-retina Khyber Institute of Ophthalmic Medical
Sciences, Hayatabad Medical Complex, Peshawar. Inclusion criteria involved all eyes with retinal breaks, within
the age group of 20 – 80 years of age. Those patients who
had past history of retinal detachment surgery and media opacity were excluded from the study. All patients
were properly examined with documentation and detailed history of ocular and systemic diseases and the
previous management were taken into account. Specially predisposing factors (history of previous intraocular
surgery, trauma, family history of retinal detachment,
detachment in the fellow eye, previous use of glasses,
myopic degeneration) lens status (phakia, pseudophakic or aphakic) history of YAG laser capsulotomy, age,
gender, profession and duration of sign and symptoms
(floaters, flashes of light, field loss). Detailed examination of the anterior and with well dilated pupil, posterior
segment examination with indentation was performed
with help of Schepen binocular indirect ophthalmoscopy in smaller magnification which gives better overall
view of the fundus to obtain stereoscopic view showing sharper contrast between features such like holes
and hemorrhage. Greater magnification was obtained
with slit lamp biomiroscopy or direct ophthalmoscope
where doubtful lesions were discovered. The types and
numbers break or breaks were noted (opercule, horseshoe shape tear hole, perforated lattice, retinal dialysis
or giant retinal tear) position or location of the break was
noted (anterior to the equator, equatorial, posterior to
the equator) with quadrant and size of the break. Retinal
detachment was analyzed with respect to macular status
(macula off/on) extent (number of quadrant involved)
location (which quadrant were involved) and to draw
the retinal diagram. Visual acuity, intraocular pressure,
refraction were recorded. Data was entered in statistical
package for social sciences (SPSS) version 15.
RESULTS
Total no of patients were 227. 182 (80.17%) of cases
were male. Age ranges from 20 to 80 years (Figure-1).
Sixty-three (27.75%) patients had presented with retinal break or breaks without retinal detachment. Thirtyfive (15.41%) of patients had unilateral retinal break
or breaks without retinal detachment. Twenty-eight
(12.0%) of patients had bilateral retinal break or beaks
without retinal detachment. One-hundred and sixty
four (72.24%) patients presented with retinal break or
breaks with retinal detachment (Table-1). The most
common type of breaks was horse shoe shape tears
with vitreous traction in 118 (52.0%) of cases followed
by retinal holes in 57 (25.0%) of patients, dialysis in
34 (15.0%) cases and giant retinal tears in 11 (05.0%)
cases were observed (Table-2). The most commonly
located tear was superior-temporal in 148 (65.0%), followed by superior-nasal in 45 (20.0%) patients. Twenty
Ophthalmology Update Vol. 12. No. 3, July-September 2014
three (10.0%) patients had inferio-nasal and 11 (5.0%)
patients had inferio-temporal retinal break or breaks
(Table-3). Bilateral rhegmatogenous retinal detachments were observed only with 6 (2.60%) of cases. No
identifiable risk factor was found in 57 (25.0%) cases.
Ninety eight (43.0%) patients had single retinal break
and 152 (67.0%) patients had two or more than two retinal breaks. Most of the patient had equatorial retinal
breaks followed by pre-equatorial breaks.
The most common risk factor in patient with rhegmatogenous retinal detachment was trauma followed
by intraocular surgeries, refractive error (high myopia),
peripheral lattice degeneration and posterior vitreous
detachment (PVD). Patients were presented within 24
hours to six months after trauma. Common presentation was at first month after trauma.
Figure-1: No of patients
Table-1: Breaks and retinal detachment
Breaks and
Retinal detachment
Breaks without RD
Breaks with RD
Numbers of patients (%)
unilateral
bilateral
35 (15.41)
28 (12)
164 (72.24)
Table-2: Types of Break
Types of Breaks
Numbers of patients (%)
Horse shoe shape
118 (52)
Retinal holes
57 (25)
Retinal Dialysis
34 (15)
Giant retinal tears
11 (5)
Table-3: Location of Break
Location of Break
Number of patients (%)
Superio- temporal
148 (65)
Superio-nasal
45 (20)
Inferio-temporal
11 (5)
Inferio-nasal
23 (10)
DISCUSSION
In this series, 98 (43.0%) had a single retinal break and
152 (67.0%) of eyes had two or more than two breaks.
In comparisons of 38.3% one break and 29.9% eyes two
or more breaks were present6,7. The most common type
were horse shoe shaped tear with vitreous traction in
118 (52.0%) of cases as compare to J H Muhammad et
180
Morphological Appearance of Retinal Breaks associated with or without Rhegmatogenous
al had also showed the most common type which were
(42.1%).8 As well as Williamson TH et al also showed
high frequency of U shape tears.9 Giant retinal tears
were more common in patients with high myopia.10
Common site of retinal break or breaks were superio-temporl in 148 (65.0%), Followed by superior-nasal
in 45 (20.0%) patients. Twenty three (10.0%) patients
had inferio-nasal and 11 (5.0%) patients had inferiotemporal retinal break or breaks as compares with
Arevalo JF et al that retinal breaks were occurred in the
temporal quadrants in (71.4%) of cases, (31.0%) inferiotemporaly and (28.0%) were located nasally.11 While
W G Eeverett et al showed more breaks at (70.9%) temporal hemi-quadrant followed by (29.1%) nasal hemiquadrent.12
Identifiable risk factors were observed in (75.0%)
of cases. The most common risk factor in patient with
retinal break or breaks was trauma, followed by intraocular surgeries, refractive error (high myopia),
Peripheral lattice degeneration, posterior vitreous detachment (PVD) as compare with Gariano et al.13 Burton reported that patients with lattice degeneration and
low to moderate degrees of myopia tend to develop
detachment between 40 and 60 years of age caused by
premature posterior vitreous separation and tractional
tears.14 Valsalva manure including weightlifting lead to
rhegmatogenous retinal detachment was also reported
by Dickerman.15 No identifiable risk factor for retinal
break or breaks was found in 57 (25.0%) cases, as compared to 26.7% by Jamil et al.8
Presentation of the patient with sign and symptoms with retinal break or breaks with retinal detachment caused by trauma were presented earlier within
first two weeks. Then the other risk factors which lead
to delay presentation because of poverty, lack of education, and limited clinical resources are likely contributory factors. Sub-total or total detachment was
the most common presentation. Similar presentation
of total rhegmatogenous retinal detachment by Rajendran16. Most of the patient had macula off at the time of
presentation as by jamil8. Sanaullah jan reported 95.0%
macula-off detachments in his study.17 While Adhi had
found macula-off in 80.0% of his cases.18
Bilateral rhegmatogenous retinal detachments
were observed only with 6 (2.60%) of our cases. As
compared to Jamil,8 age of presentation ranges from 20
to 80 years. 182 (80.17%) of cases were male. Male gender being more prone to trauma, due to outdoor activity and intraocular surgery were performed mainly in
male patients in our society (Pakistan) as well as shown
by Lewallen.19
CONCLUSION
Rhegmatogenous retinal detachment is common
181
in patient with ocular trauma, intraocular surgery, lattice degeneration and myopia. They need proper attention regarding fundus examination with fully dilated
pupil to look for the peripheral retina, an educated
patient report earlier regarding his retinal detachment
symptoms direct to vitro-retinal surgeon.
REFERENCES
1.
D Mitry, DG Charteris, B W Fleck, H Campbell: The epidemiology of rhegmatogenous retinal detachment : geographical
variation and clinical association. B J Ophthalmol 2010: 94; 678
– 684.
2.
Mitry, Danny MB, Ch.B; Fleck, Brian W FRCOphth, Wright,
Alan F PhD, Campbell, Harry FFPHM. PATHOGENESIS OF
RHEGMATOGENOUS RETINAL DETACHMENT: Predisposing Anatomy and Cell Biology. Retina. Nov/Dec 2010 - Vol
30;10:1561-1572
3.
Machermer R, Aaberg TM, Freeman M, An update classification of retinal detachment with proliferation vitreoretinopath.
American Journal of Ophthalmology 1991, 112 (2): 159 – 165.
4.
Haug, S. J: Bhisitkul Rb(2012). “Risk factors for retinal detachment following cataract surgery”. Current Opinion in Ophthalmology 23 (1): 7 – 11.
5.
Mattioli, S.; Curti, S.; De Fazio, R.; Farioli, A.; Cooke, R. M.
T.; Zanardi, F.; Violante, F. S. (2009). “Risk Factors for Retinal
Detachment”. Epidemiology 20 (3): 465–466.
6.
Chong YY, Wong E, Wong D. Retinal detachment in change
Genral Hospital: retrospective study from 1997-2004.
7.
Laatikainen L, Tolppanen EM. Characteristics of rhegmatogenous retinal detachment. Acta Ophthalmolgica 1985; 63:146-54.
8.
Jamil H M, Farooq N, Khan T M, Jamil A Z. Characteristics
and pattern of Rhegmatogenous Retinal Detachment in Pakistan. Journal of the college of physicians and surgeons Pakistan
2012, 22 (8): 501-504.
9.
Williamson TH. Different Presentations of Rhegmatogenous
Retinal Detachments.Vitreoretinal Surgery. 2013; 163-187.
10. Ghosh YK, Banerjee1 S, Savant V, Kotamarthi V, Benson MT,
Scott RAH, Tyagi AK. Surgical treatment and outcome of patients with giant retinal tears. Eye. 2004; 18: 996–1000.
11. Arevalo JF, Ramirez E, Suarez E, Cortez R, Antzoulatos G,
Morales-Stopello J, Ramirez G, Torres F, Gonzalez-Viva R.
Rhegmatogenous retinal detachment in myopic eyes after laser
in situ keratomileusis: Frequency, characteristics, and mechanism. Journal of Cataract & Refractive Surgery. 2001; 27(5):
674-680.
12. W G Everett, D Katzin. Meridional distribution of retinal
breaks in aphakic retinal detachment.Trans Am Ophthalmol
Soc. 1968; 66: 196–205.
13. Gariano RF, Kim CH. Evaluation and management of suspected retinal detachment. Am Fam Physician 2004; 69:1691-9.
14. Burton TC. The influence of refractive error and lattice degeration on the incidence of retinal detachment. Trans Am Ophthalmol Soc 1989; 143-57.
15. Dickerman RD, Smith GH, Langham-Roof L, McConathy WJ,
East JW, Smith AB (1999). Intra-ocular pressure changes during
maximal isometric contraction: does this reflect intra-cranial
pressure or retinal venous pressure. Neurol. Res. 21 (3): 243–6.
16. Rajendran B, Pradeep B, Sitaramanjaneyulu B. Retinal detachments in phakics and aphakics: a clinical study. Indian J Ophthalmol 1983; 31:1060-3.
17. Jan S, Iqbal A, Saeed N, Ishaq A, Khan MD. Conventional
retinal re-attachment surgery. J Coll Physician Surg Pak 2004;
14:470-3.
18. Adhi MI, Jan MA, Ali A, Rizvi F, Aziz MU, Hasan KS. Retinal
detachment surgery by scleral buckling procedure: experience
in 175 cases. Pak J Ophthalmol 1996; 12:85-90.
19. Lewallen S, Mousa A, Bassett K, Courtright P. Cataract surgical
coverage remains lower in women. Br J Ophthalmol 2009; 93: 295-8.
Ophthalmology Update Vol. 12. No. 3, July-September 2014
ORIGINAL ARTICLE
M. Saeed Zafar
Analysis of Visual Outcome & Safety of
Laser-Assisted Sub-Epithelial Keratectomy (Lasek)
for the Treatment of Moderate to Severe Myopia &
Myopic Astigmatism by using Mitomycin–C
M. Saeed Zafar Khan FCPS1, Zahid Kamal Sidduqi FRCS2, Prof Akram Riaz FRC Ophth.3
ABSTRACT
Purpose: The purpose of this study was to report the visual outcomes and rate of complications of laser assisted subepithelial keratectomy(LASEK) for the treatment of myopia up to -12.00 diopters spherical and Myopic astigmatism of up to
-3.50 diopters by using intra -operative 0.02% Mitomycin C.
Materials and Methods: A prospective case series of 64 eyes of 32 patients who under went the laser sub-epithelial
keratectomy for the treatment of myopia were studied. Parameters for study included Preoperative uncorrected visual
acuity (UCVA), best corrected visual acuity (BCVA), Mitomycin C concentration and exposure time, pain, corneal haze and
epithelial healing.
Results Mean baseline spherical equivalent refraction was ranged -3.75 to -12.50+‑ 3.50 diopters. Pre operative best
corrected vision ( BCVA) was 6/9 or better in 46(71.8%) eyes and 12 (18.7%) had 6/9 to 6/12 whereas 6 (9.3%) eyes had
visual acuity of less then 6/12. Mean spherical equivalent refraction after lasek surgery was +_ 0.75 diopter .At last follow up
post laser un -corrected visual acuity (UCVA) was 6/9 or better in 52 ( 81.2% ) eyes, 8 (12%) eyes had 6/9 to 6/12 while 4
(6.4%) eyes had visual acuity of 6/12 or worse. Complete epithelialization and removal of bandage contact lens took place
in 4.75 +- 2.89 days (range was 3 -8 days). At the last follow up visit of patients 50 (78%) eyes had clear cornea and Grade
I haze developed in 7 (10.9%) eyes whereas Grade II haze was seen in only 2 eyes (3.1%), none of the eyes developed
grade III or IV haze.
Conclusions: Laser sub epithelial keratomelisus with intra operative application of 0.02 % mitomycin c was effective and
safe procedure which resulted in excellent visual outcomes with few complications.
Key words: Myopia, Astigmatism, Laser sub epitelial keratomelisus, Mitomycin C
INTRODUCTION
After the introduction of excimer lasers for the correction of refractive errors the surgical advancements
are continuously struggling to achieve the best visual
outcomes with minimal complications. Photorefractive
keratectomy was a standard procedure in early 90s1,2
for refractive surgery patients. Soon this procedure lost
its popularity due to severe pain and corneal haze. Laser In-Situ-Keratomelisus (LASIK)34 which involves the
ablation to deeper stromal tissues after the creation of
corneal flap was commonly practiced, however the flap
related complications like free caps, button holes, thin
flaps etc and late corneal ectasia were commonly reported.5,6,7 Laser subepithelial keratectomy (lasek) was
a serious effort to modify the surface treatments in order to control the drawbacks of both photo refractive
keratectomy and Laser-in-situ kertectomy.­­8,9
After experimental studies on monkeys for at least
nine years, the study of Excimer laser photo keratectomy with application of Mitomycin C has revealed
satisfactory results by modulating the corneal healing
Consultant Eye Surgeon, Iqra Medical Complex, Lahore, 2Associate
Professor, Department of Ophthalmology, Services Institute Medical
Sciences, Lahore, 3Professor Department of Ophthalmology
1
Correspondence: Dr. Saeed Zafar Khan Niazi, Consultant Eye Surgeon, Iqra Medical Complex, Lahore 2. Cell: 03344073664 E-Mail:
[email protected], House 95-E-II, Johar Town, Lahore.
Received: March 2014
Accepted: May 2014
Ophthalmology Update Vol. 12. No. 3, July-September 2014
and preventing corneal haze.10, 11 In this study we used
0.02% MMC after Lasek with good visual outcome and
minimal complications.
MATERIALS & METHODS
The patients for this prospective study were selected from out patient department of Chaudary Rehmat Memorial Hospital/Continental Medical College
Lahore from July 2009 to June 2011. All Surgical procedure were performed at Lahore Medicare Eye Institute
by same surgeon (M.S.Z.). A prior approval was obtained from the institutional ethical committee for this
study.
Patients of either sex with minimal age of 18 years
and upto 45 years were selecte. All patients had -3.00
diopters to -12.00 diopters of myopia with up to -3.50
diopters of astigmatism. patients who met the above
criteria were thoroughly evaluated by checking uncorrected visual acuity (UCVA), manifest refraction,
cycloplegic refraction, extra ocular muscle balance,
pupil reaction, slit lamp biomicroscopy, applanatation
tonometery, keratometery, computerized video-keratography by Orbscan unit, dilated fundus examination
was performed in every case prior to refractive surgery.
The post operative haze was graded as tracer (0.5), 1.0,
2.0, 3.0 or 4.0 according to the Fantes scale 12. All the
analysis was done in SPSS version 10.0.
Patients with significant ocular pathologies like
anterior and posterior keratoconus, chronic vernal catarrh, juvenile and pre senile cataract, glaucoma and
182
Analysis of Visual Outcome & Safety of Laser-Assisted Sub-Epithelial Keratectomy (Lasek)
vitreo retinal diseases were excluded. Similarly patients
with systemic diseases like diabetes mellitus, hypertension, rheumatoid arthritis and pregnant and lactating
mothers were excluded from the study. Patients wearing soft contact lenses advised to leave at least 1 week
and hard contact lenses for 2 weeks prior to the surgery.
Procedure: The eyes were anesthetized with proparacine hydrochloride 0.5 % eye drops instilled every
5 minutes before the procedure for four to five times,
the area is sterilized with 10% povidine iodine solution, and properly draped lid speculum was applied
and marks were applied on corneal surface with Gention violet, area washed with ringer lactate solution, a
trephine with deep well of 7 to 8 mm is centrally placed
on the cornea, 20% alcohol solution is placed for 20 seconds ,later on it is absorbed with Merocel sponge followed by downward pressure applied with slight rotation to create an incision in to the corneal epithelium,
the loosened corneal flap was peeled back with hockey
spatula toward 12 o’clock position .the raw surface is
thoroughly dried and standard laser ablation by TECHNOLAS 217 Z EXCIMER LASER SYSTEM (BAUSCH
& LOMB Rochester USA) was performed, the Merocel
sponge soaked in 0.02% Mitomycin C was placed over
the ablated cornea for 20 seconds in every case. Later
on corneal surface was thoroughly irrigated with copious amount of ringer lactate solution, extreme care
was taken to avoid contact of limbus or conjunctiva to
the Mitomycin C . The epithelium was carefully repositioned with alignment of the preplaced marks and
allowed to dry, followed by instillation of antibiotic
moxifloxacin 0.5% eye drops ,a 14 mm bandage contact
lens was placed over the cornea to protect the flap and
post operative pain due to the mechanical rubbing of
the lids.
The patient was allowed to go home with post
operative regimen of antibiotics moxifloxacin 0.5% eye
drops and Steroids Prednisolone Acetate 1.0%, non
steroid anti inflammatory drug Naclof sodium 0.3%,
and lubricants Tears Naturale-II were continued on tapering dose. After compete epithelialization of cornea
the bandage contact lens were removed. Patients were
followed up at 1 week, 2 weeks, 1 month, 3 months, 6
months and 1year.
RESULTS
Thirty two patients were enrolled in this study,
twenty four (75%) were females and eight (25 %) were
males (figure 2). The majority of these patients i.e.
twenty (62.5%) were contact lens user while eight (25%)
were using spectacles/glasses as a visual aid where as
four (12.5%) not using any visual aid (figure 1). Mean
age was ranging from 20 to 45 years. Pre-operative best
corrected vision (BCVA ) was 6/9 or better in 46 eyes
183
(71.8%) and 12 eyes(18.7%) had visual acuity of 6/9 to
6/12 whereas six eyes (9.3%) had 6/12 or less (figure
3). Visual acuity 6 months post laser was 6/9 or better
in 52 (81.2%) of eyes, 8 eyes (12.5%) had 6/9 to 6/12, 4
eyes (6.4%) had visual acuity up to 6/12 or less (figure
4). Mean pre operative baseline spherical equivalent
was -8.50 +- 3.50 diopters. A single ablation zone of 6.00
mm was used. Mean spherical equivalent refraction after lasek surgery was +_0.75 diopters.
Fig - 1
Fig - 2
Fig - 3
Fig - 4
Ophthalmology Update Vol. 12. No. 3, July-September 2014
Analysis of Visual Outcome & Safety of Laser-Assisted Sub-Epithelial Keratectomy (Lasek)
At the end of one year follow up 50eyes (78.1%)
had clear cornea whereas corneal stromal haze of grade
0.5 according to Fantess grading system was seen in 7
eyes(10.93%) and grade 1 haze was seen in 3 eyes (4.6%)
whereas no haze of grade 2 and 3 were seen in any eyes.
Complete epithelialization and removal of contact lens
took place in 4.75 +- 2.89 days (range was 3 -9 days).Major post operative complication was mild pain which
occurred on 21 (65.6%) patients, while foreign body
sensation and discomfort was seen in 6 (18.7%) of eyes,
moderate pain requiring one analgesic was seen in 3
(9.3%) patients and 2 (6.25%) required two or more analgesics to relive the pain.
DISCUSSION
Visual outcome six month post laser was 6/9 or
better in 81.2% of the eyes, 12.5% of eyes had 6/9 to
6/12 and only 6.4% of eyes had 6/12 or less vision, in a
study by Dong H Lee et al13 ­­­­­­­­­­­­­­reported a series of more
then five hundred cases with a mean follow up more
then one year with 86% had 20/20 or better visual acuity and 98 % were having visual acuity 20/40 or better.
similar results reported by Argento et al14 they reported
in MMC group uncorrected visual acuity UNCVA of
20 /40 in 93.3% of cases and in 89.3% of cases in no Mitomycin group, uncorrected visual acuity of more then
or equal to 20/25 was achieved in 76.6% of cases in the
MitomycinC group and in 71.4% of cases in the no MitomycinC group.
Numerous studies have found the favorable visual outcome in cases of laser sub epithelial keratectomy
and photo refractive keratectomy with Mitomycin C in
preventing the haze. It is speculated that because of its
anti-mitotic properties MMC inhibits the proliferation
and differentiation of fibroblasts, and therefore blocking the formation of myofibroblasts which is responsible for the corneal haze. Therefore the prophylactic use
of MMC has been the routine practice for the correction
of high refractive errors.15, 16, 17
Furthermore the laboratory investigators during
the experimental studies on rabbit eyes have demonstrated the reduction of haze with the 0.02% topical
application of Mitomycin C used for variable exposure
time after refractive surgery. These studies had shown
the keratocyte apoptosis leading to the depletion of
keratocytes in rabbit corneas after one to six months.18
In our study, at the end of one year follow-up 78%
had clear cornea while stromal haze of grade 0.5 was
seen in 10.93% of eyes and grade 1 haze was seen in
4.6% of eyes whereas study by Bahri Aydin et al19 reported all eyes with preoperative SE between -8.6 and
-12.0 D developed haze in treating myopia without
MMC. Haze and myopic regression limited the success
of LASEK in eyes with preoperative SE of -12 D and
greater.
Ophthalmology Update Vol. 12. No. 3, July-September 2014
In another study by Argento et al14 in retrospective
analysis of 30 eyes with Mitomycin C found 0% incidence of haze in all the cases, while in cases with no
MMC group, trace of haze was seen in 17.9% of cases,
grade 1 haze in 3.6% of cases whereas no eye had grade
II, III and IV haze postoperatively and concluded that
prophylactic use of intra-operative Mitomycin C in
LASEK significantly reduced haze. Similarly Camellin
M20 had used Mitomycin C in higher concentration of
0.01% and found significant decreased sub epithelial
haze, on the other hand Thornton I et al21 found that
eyes treated with low dose of 0.002% MMC had demonstrated statistically less haze at all postoperative follow up. In a study by Lee H Dong13 reported grade 1
haze in 3.17% of case, whereas 3 eyes had grade II and 2
eyes has grade III haze. In our study complete epithelialization occurred in 4.75 +_2.89 days where as in study
by Lee Dong H13 2% eyes had delayed epithelialization
CONCLUSION
In conclusion, Laser sub-epithelial keratectomy
with Mitomycin c is a safe and effective procedure for
the treatment of moderate to severe myopia and myopic astigmatism, however further studies about the
safety and efficacy of Lasek with Mitomycin C with
larger sample size and longer follow-up is required.
REFRENCES
1. Seiler T, Wollennsak J. Myopic photoreractive keratectomy with excimer laser; one year follow up. Ophthalmoogy
1991;98:1156-63
2. Epstwin D, F agerhollm, Hamberg-Nystrroem H, Tengroth.
Twenty four month follow up of excimer laser photorefractive
keratectomy for myopia;refractive and visual results.Ophthalmolgy 1004;101:1558-63
3.
Pallikrais IG,Papatzaki ME, Signos DS, T silmbris MK. A cornearl flap technique for laser in situ keratomileusis. Humen
studies. Archives Ophthalmology 1991;109:1699-702.
4. Herish PS, Brint SF, Malony RK, etal. Photorefractive keractomy versus laser in situ keratomilesus for moderate to high
myopia ; a randomozed prospective study. Ophthalmology
1998;105:1512-22
5. Pallikrais IG,Ketsanveki VJ, Panaglopoulou SI. Lasre in situ
keratomelisus intraoperative coplications using one type of microkeatome.Ophthalmology 2002;109(1):57-63.
6. Melaki SA ,Azar DT. LASIK complications:Etiology,manageme
nt,and prevenation.Surv Ophthalmology2001(2);46:95-116
7. Pallikrais IG, Kamionis GD, AstrakakasNI.Corneal ectasia induced by laser in situ kratomilesus. J Cataract Refractive Surg
2001;27(11):1796-802.
8. Camellin M, Cimberle M. LASEK technique promosing after
one year of experience.OcularSurgeryNews 2000;18(1):14-17.
9. Chalita MR, Tekiwani NH, Kreuger RR, Laser epithelial
keratomilusis;outcome of the initial cases performed by an experienced surgon. J ournal Refract Surg 2003;19:412-15.
10. Taneri S, Zeiski JD , Azar DT. Evolution,clinical outcomes and
pathophysiology of LASIK;review of litreture.Survey Ophthalmology2004;49(6);576-602.
11. Zhao LQ, Wei RL, Ma XY, Zhu H. Effect of intraoperative mitomycin-c on healthy corneal endothelium after laser- assisted sub epithelial keratectomy. J Cataract Refract
Surg.2008;34(34):1715-9.
12. F .E. Fantes, K. D.Hanna, G.O.Waring,Y Pouliquen Thom-
184
Analysis of Visual Outcome & Safety of Laser-Assisted Sub-Epithelial Keratectomy (Lasek)
son .M Savoldhelhi. Wound healing after excimer laser Kearatomilesus (phohotorefractivekeratectomy)in Monkeys. Arch
Ophthalmol , 108 (1990):665-675.
Lee Dong H et all. photorefractive keratectomy with intra operative Mitomycin C application. J Cataract R efractive Surg.
2005;31(120) :2293-2298.
Argento Carlos, Maria Jose Cosnito,Marcela Gangly.Comparasion of laser epithelial keatomilusi with an without the use of
Mitomycic C . Jornal of Refract surg 2006(22):782-786.
Madhavan S Rajan, David P S Obrat, Anne Patmore, JohnMarshal. Celluar effects of Mtomycin c on humen corneas after
photorefractive keratectomy. J ournal of Cataract &Refractive
surgery. 2006;32(10)1741-1747.
Edoardo Midena ,Catia Gambato, Alessandra Ghirlando.Long
-term Efects on Corneal Keratocytes of Mitomycin c During
photorefractive srgery:A randomized contalateral Eye Conofocal MicroscopicStudy.Journal of Refractive Surgery.2007(23)
13. 14. 15. 16. 1289-95.
De Benito-L lopis L, Teus MA, Sanchez-Pina JM.Comparasion
between LASEK with MMC and LSIK for the correction of high
myopia. J Cataract Refract Surg 2004 ;30 1405 -11.
18. De Benito-Llopis L, Teus MA, Hernandaz -Verdejo JL. Comparasion between three- and six- month ostoperative refractive
visual results after laser epithelial keratomileusis with mitomycin c.Am J Ophthalmol. 2009 jan ;147 (1):71-76.
19. Aydin B, Cagil N ,Erdogan S,Erdrumus M, Hasiripi H. Effectiveness of laser- assisted sub epithelial keratectomy without
mitomycin c for the tyreatment of high myopia. J Cataract Refract Surg. 2008 ;34 (8):1280-7.
20. C amellin M. Laser epithelial keraomilesus with mitomycin C:
indications and limits. J Refract Surg. 2004 ;20(5)693-8.
21. Thorton I, Puri A , Xu M, Krueger RR. Low dose mitomyin C as
a prophylaxis for corneal haze in myopic surface ablation. Am
J Ophthalmol.2007 ;144 (5):673-681.
17.
Book Review
CONCISE OPHTHALMOLOGY
(4th Edition)
By
Prof. Dr. Syed Imtiaz Ali Shah, FCPS
Prof. of Ophthalmology, Chandka Medical College & Hospital,
Dean, SMBB Medical University, Larkana (Sindh)
Medical knowledge is constantly proliferating with incredible advancement. As
new information becomes available like changes in clinical procedures, equipment
and treatment it becomes necessary to incorporate in the standard books being
published with new editions.
“Concise Ophthalmology” is an attempt in the right direction. Prof. Syed Imtiaz
Ali is a well-known academician and a doyen of Ophthalmology in the country.
He is, in fact, a pragmatic personality with research oriented mind, a dedicated
professional with academic prominence in the field. We heartily congratulate him for his untiring efforts in producing
the fourth edition. In fact, writing a book is the true test of one’s patience with challenges.
Prof. Imtiaz has given excellent theoretical details on the clinical presentation supported by illustrations on ocular
diseases in Pakistani population. He has researched changes to his new hypothesis that “ Aging” is responsible
for most of eye diseases, with new chapters on bleeding Pterygium, Vit A deficiency and assessment of Infantile
visual acuity. He has done a commendable job by updating almost all the chapters to make it a very comprehensive
book. This book is an excellent venture and a handy atlas for the budding Ophthalmologists, under graduates post
-graduates, students, nurses and Ophthalmic technicians. We recommend them to keep this book as a ready reference
on their tables …………………………..Chief Editor
185
Ophthalmology Update Vol. 12. No. 3, July-September 2014
ORIGINAL ARTICLE
Sadia Bukhari
Surgical Management
of Strabismus, our Experience
Sadia Bukhari FCPS1, Abdul Sami Memon FCPS2, Umair Qidwai FCPS3
ABSTRACT
Objective: To evaluate the effectiveness of multiple surgical techniques in different types of strabismus
Study design: Observational case series.
Place & Duration of Study: Al Ibrahim Eye Hospital, Karachi, from July 2007 to December 2012.
Methodology: It was an observational Case-series, Patients having either primary exotropia (deviation 15-45 PD), constant
esotropia or hypertropias were included in the study. Patients with either constant exotropia or basic intermittent exotropia
underwent unilateral surgery of lateral rectus recession (maximum up to 10mm) and medial rectus resection (up to 6mm).
Similarly, when patients had intermittent distance exotropia, underwent bilateral lateral rectus recession ((maximum up to
10mm). Patients with constant esotropia underwent either bi-medial rectus recession or unilateral medial rectus recession
or unilateral medial rectus recession along with lateral rectus resection procedures. Patients with hypertropia underwent
inferior oblique myectomy. Patients were re-evaluated at one week, one month and two months post operatively. Final
outcome was considered at the end of two months at which achievement of ≤10 PD of exotropia/esotropia was considered
as a success. Analysis was done using SPSS version 20.0.
Results: 578 patients were included in the study according to inclusion and exclusion criteria. Out of these 578 patients,
283 (48.96%) were male while rest of 295 (51.04%) were female. Out of these, 248 patients had exotropia. Mean angle
of deviation observed before surgical correction was 49.23 prism diopters (standard deviation=10.43). After surgical
correction, mean angle of deviation was 8.54 prism diopters (standard deviation=9.55). Overall success rate was 81.45%
(202 patients) in cases of exotropia. Overall 272 patients with esotropia were included. Mean angle of deviation was 53.71
prism diopters (±17.18). Minimum angle of deviation was 20 prism diopters while the maximum angle was 90 prism diopters.
Mean deviation after surgery was 9.73 prism diopters (±12.03).Surgical success as described as residual deviation of
less than 10 prism diopters was seen in 202 (74.3%) of the patients. During the study period, 58 patients with hypertropia
were included. The mean age of the patients included in study was 11.71 years (±7.95). Mean angle of hypertropia before
surgery was 13.55 prism diopters (± 4.43). This reduced to 0.48 prism diopters after surgery. Out of 58 patients, 55 (94.8%)
had achieved success after surgery while only 3 (5.2%) patients had residual hypertropia of greater than 2 prism diopters
(p=0.001).
Conclusion: In this study we have compared the different methods of surgical corrections of exotropia/esotropia and
vertical deviations. It has been observed that one method that is unilateral lateral rectus recession and medial rectus
resection has better surgical success rate as compared to the other method which is bilateral lateral rectus recession in
exotropia correction. On the other hand no significant difference was observed in the success rate of different surgeries in
esotropia. Isolated inferior oblique myectomy is highly successful and safe surgical procedure for correction of hypertropia.
Key words: Exotropia, Esotropia, success rate
INTRODUCTION
Squint is an ocular condition of deviation or misalignment of both or single eye. Its prevalence among
children is 2-4%1 inward deviation of eyes is called Esodeviation which accounts for over half of total ocular
deviations2 followed by exodeviation, which is outward deviation of eyes.3 One population based study
reported an annual age- and gender adjusted incidence
of 64.1/100,000 patients younger than 19 years of age.4
When one eye is elevated relative to the other, either
intermittently or constantly, is termed as hypertropia.
Hypertropia is much less common than horizontal deviations, but even then, it can cause significant problem
1,2
Associate Professor of Ophthalmology, 3Ophthalmologist
Correspondence: Dr Umair Qidwai, Ophthalmologist, Isra Postgraduate Institute Of Ophthalmology, Karachi
E-Mail: [email protected], Cell: 0321-2585976
Received: April 2014
Accepted: May 2014
Ophthalmology Update Vol. 12. No. 3, July-September 2014
either cosmetically or by abnormal head posture and
thus needs to be corrected surgically. In one study, the
incidence of hypertropia in patients younger than 19
years of age was reported to be 12.9 per 100 000 patients.5
Untreated strabismus along with cosmetic disfigurement can also result in significant amblyopia,6
Constant squints have been reported as a main cause
of amblyopia by many authors.7 Early treatment of
amblyopia is very important to prevent permanent impairment in visual acuity,8 it has been recommended by
many authors that early surgical correction of strabismus can prevent or treat amblyopia.9
One of the best management options for correction of squints is its surgical correction.10,11 Surgical
correction has always been a challenge. Which type of
surgery is to be selected largely depends on the surgeon’s preferences and personal experiences. For horizontal squints either exotropia or esotropia, recession
186
Surgical Management of Strabismus, our Experience
or/and resection of horizontal muscles is usually performed.12,13,14,15 For hypertropias, Inferior oblique myectomies are performed by many surgeons with variable
success rates.16, 17
The main objective of our study is to find out the
success rates of different types of surgical corrections in
different types of horizontal and vertical squints. The
rationale of the study is that, by identifying the most
successful surgical procedure, it could be preferred
over the other choices in order to achieve best surgical
correction of squints. This study will help in developing and recommending a standard procedure in order
to achieve ocular alignment in patients with squints.
METHODOLOGY
It was an observational case-series, conducted
from January 2007 to December 2012, at Al Ibrahim Eye
Hospital, Karachi. Patients were selected using Nonprobability purposive sampling. Ethical approval was
taken from the ethical committee of Isra Postgraduate
Institute of Ophthalmology. Patients having either primary exotropia (deviation 15-45 PD), constant esotropia or hypertropias were included in the study, while,
patients with history of previous extra-ocular muscle
surgery, Paralytic exotropia/esotropia and any other
ocular disease such as congenital cataract, retinal detachment and any other cause of sensory visual deprivation were excluded from the study. After informed
written consent the patients were selected from the
squint clinic of Al-Ibrahim eye hospital, Karachi, diagnosed and reconfirmed by the consultant ophthalmologist. Patients were divided into either constant, basic
intermittent or intermittent distance exotropias. All
the patients underwent detailed ophthalmic examination including best corrected visual acuity, cycloplegic
refraction, fundoscopy and squint assessment including measurement of squint using prism cover technique. Patients with either constant exotropia or basic
intermittent exotropia underwent unilateral surgery
of lateral rectus recession (maximum up to 10mm) and
medial rectus resection (up to 6mm). Similarly, when
patients had intermittent distance exotropia, underwent bilateral lateral rectus recession ((maximum up
to 10mm). Patients with constant esotropia underwent
either bi medial rectus recession or unilateral medial
rectus recession or unilateral medial rectus recession
along with lateral rectus resection procedures. Patients
with hypertropia underwent inferior oblique myectomy, concomitant horizontal deviation was corrected 2
weeks after vertical correction. All Surgery was done
under local anesthesia in adults but children were operated under general anesthesia.
Patients were reevaluated at one week, one month
and two months post operatively. Final outcome was
considered at the end of two months at which achieve187
ment of ≤10 PD of exotropia/esotropia was considered
as a success. Data was entered on a preformed proforma.
Analysis was done using SPSS version 20.0. Qualitative
data such as gender and success were presented by their
frequencies along with percentages. The continuous variables such as age and degree of exotropia/esotropia in
prism diopters before and after surgery was presented
as mean ±SD. Stratification was done with regards to
age, gender, degree of exotropia (in prism diopter) and
the types of primary exotropia/esotropia in order to see
the impact of these variable on the outcome. Chi square
test will be used for the analysis of the data. P value of
less than 0.05 will be considered as significant.
RESULTS
578 patients were included in the study according
to inclusion and exclusion criteria. Out of these 578 patients, 283 (48.96%) were male while rest of 295 (51.04%)
were female.
For Exotropia correction: Out of these, 248 patients
had exotropia. Among these patients mean age was
17.49 years (standard deviation=10.26). Among these
248 patients, 170 (68.5%) had either constant exotropia
or basic intermittent exotropia, while 78 (31.5%) had intermittent distance exotropia. Mean angle of deviation
observed before surgical correction was 49.23 prism
diopters (standard deviation=10.43). Similarly after
surgical correction, mean angle of deviation was 8.54
prism diopters (standard deviation=9.55). Overall success rate was 81.45% (202 patients) in cases of exotropia,
while success was variable when success rates were assessed on the basis of type of surgery performed. In
case of unilateral lateral rectus recession and medial
rectus resection surgery the success rate was 85.14 %
(172 patients out of 202) while success rate in case of
bilateral lateral rectus recession was 65.21% (30 patients
out of 46). Success rates of different types of surgical
procedures are shown in table-1. Success rates in relation to type of squint are shown in table-2. No statistical significant difference was seen in success rates of
squint surgery in different age groups (p=0.5071). Success rates in different age groups are shown in table-3.
Table-1: Success rate of different types of surgeries
TYPE OF SURGERY
Bilateral
Medial Rectus
Lateral Rectus Resection + Lateral
Recession
Rectus Recession
SUCCESS
Total
YES
30 (65.21%)
172 (85.14 %)
202 (81.45%)
NO
16 (34.78%)
30 (14.86%)
46 (18.55%)
46
202
248
Total
P = 0.0017 (Chi square test)
For Esotropia correction: Overall 272 patients with esotropia were included. Mean age of the patients among
these 272 was 12.19 years (±8.813), with minimum age
Ophthalmology Update Vol. 12. No. 3, July-September 2014
Surgical Management of Strabismus, our Experience
of 1 year and maximum age of 43 years.
Table-2: Success rate according to type of exotropia
Type Of Exotropia
Constant
Exotropia
Intermittent
Exotropia
Total
SUCCESSFUL
142 (83.52%)
60 (76.92%)
202 (81.45 %)
UNSUCCESSFUL
28(16.48%)
18 (23.07%)
46 (18.55%)
170
78
248
P=0.214 (Chi square test)
Table-3: Success rate of squint surgeries in different age groups
AGE GROUPS
>25 years
yes
52
(83.87%)
104
(78.78%)
46
(85.18%)
202
(81.45%)
no
10
(16.13%)
28
(21.21%)
8
(14.82%)
46
(18.55%)
62
132
54
248
success
Total
Total
<10 years 10-25 years
shown in table-4. Surgical success as described as residual deviation of less than 10 prism diopters was seen in
202 (74.3%) of the patients, while residual refraction of
greater than 10 prism diopters was noted in 44 (16.2%)
of the patients. Remaining 26(9.6%) of the patients had
residual refraction of greater than 20 prism diopters
and were advised second surgery. The patients, who
underwent bi medial rectus recession, 36 (85.71%) had
successful surgery with no residual refraction. Similarly, 18 (90%) and 148 (70.47%) had successful surgery
with less than 10 prism diopters of residual refraction
after unilateral medial rectus recession and unilateral
medial rectus recession combined with lateral rectus
resection respectively (figure-1-2).
Figure - 1
P=0.5071 (Pearson chi square)
Table-4: Postoperative residual deviation with respect to
surgical treatment offered
TYPE OF SURGERY
BI-MEDIAL RECTUS
RECESSION
UNILATERAL MEDIAL
RECTUS RECESSION
UNILATERAL MEDIAL
RECTUS RECESSION
+LATERAL RECTUS
RESECTION
STATISTICS
PRISM DIOPTERS
Mean
7.1905
Std. Deviation
8.48309
Minimum
.00
Maximum
40.00
Mean
7.5000
Std. Deviation
13.22876
Minimum
.00
Maximum
45.00
Mean
10.4381
Std. Deviation
12.46923
Minimum
-10.00
Maximum
60.00
Most of the patients 216 (79.4%) had constant esotropias.
Essential /Infantile esotropia was present in 32 (11.8%)
of the patients. Partially accommodative esotropia was
present in 24 (8.8%) of patients. Mean angle of deviation was 53.71 prism diopters (±17.18). Minimum angle
of deviation was 20 prism diopters while the maximum
angle was 90 prism diopters. Out of these 272 patients,
210 (77.2%) of patients underwent Medial rectus recession and Lateral rectus resection in a one eye. Bilateral
medial rectus recession was done in 42 (15.4%) of patients and unilateral medial rectus recession was done
in 20 (7.4%) of patients. Mean deviation after surgery
was 9.73 prism diopters (±12.03). Minimum deviation
after surgery was 10 prism diopters while maximum
deviation after surgery was 60 prism diopters. Mean
deviations with respect to surgical treatments are
Ophthalmology Update Vol. 12. No. 3, July-September 2014
Figure-2: Comparison of success rates of different types of
surgeries performed in terms of percent of patients
Figure-3: Conditions associated with hypertropia
N=58
For Vertical deviation: During the study period,
58 patients with hypertropia were included. The mean
188
Surgical Management of Strabismus, our Experience
age of the patients included in study was 11.71 years
(±7.95). Hypertropia was most commonly associated
with exotropias followed by esotropias. Exotropia was
associated in 23 (39.7%) of patients while esotropia was
associated in 18 (31%) of patients. Other associated
conditions are shown in figure-3. Mean angle of hypertropia before surgery was 13.55 prism diopters (±
4.43). This reduced to 0.48 prism diopters after surgery.
Out of 58 patients, 55 (94.8%) had achieved success after surgery while only 3 (5.2%) patients had residual
hypertropia of greater than 2 prism diopters (p=0.001).
Success rate with respect to age and associated conditions is shown in table-5 & 6 respectively. Among the
complications observed, residual deviation in horizontal deviation after surgical correction was observed in
7 (12.1%). These patients were managed by orthoptic
exercises and if residual deviation persists, than repeat
of horizontal muscle surgery was done. Other complications were subconjunctival hemorrhage and conjunctival granulomas, both were successfully treated with
topical drops. Complications are shown in table-7.
treatment of strabismus is necessary. Surgical correction has variable success rate, resulting in preferring
one type of surgical method over other in different
types of exotropias/esotropias.3,4
In our study we found out that the overall success
rate for exotropia surgery was 81.45 %, while success
was variable when success rates were assessed on the
basis of type of surgery performed. When unilateral
surgery was performed involving lateral rectus recession and medial rectus resection the success rate was
85.14 % while success rate reduced to 65.21% when
bilateral lateral rectus recession was performed. Success rates were higher in age groups of greater than 25
years. Similarly more success was observed in constant
exotropias compared to intermittent exotropias.
Extremely variable success rates have been reported earlier in different studies. Choi J reported higher
success rate of bilateral lateral rectus recession (58.2%)
compared to unilateral lateral rectus recession and medial rectus resection (27.4%) in patients with exotropia.5
One study by Quah B.L, showed that the patients who
underwent unilateral lateral rectus recession and medial rectus resection had a success rate of 74.2% compared
to 42.2%, when bilateral lateral rectus recession was
performed.6Another study by Jeoung JW, reported that,
satisfactory outcome was achieved in 83.3% when unilateral lateral rectus recession and medial rectus resection,
while satisfactory outcome was achieved in 48.3% when
bilateral lateral rectus recession was performed.7 One
study by Oriel Spierer reported a success rate of 74 %
when bilateral lateral rectus recession was performed
for intermittent exotropia.8
There has been extreme variability of individual
response to esotropia extra-ocular muscle surgery.
Table-5: Success of inferior oblique
myectomy in different age groups
AGE GROUPS
<10 years
10-25 years >25 years
Total
Successful surgery
32
19
4
55
Residual hypertropia
of > 2 PD
2
1
0
3
34
20
4
58
DISCUSSION
Childhood squints when present can cause significant visual impairment due to amblyopia.1,2 In order to
prevent amblyopia development early and appropriate
Table-6: Success of inferior oblique myectome with respect to associated conditions
ASSOCIATED CONDITIONS
TOTAL
EXOTROPIA
ESOTROPIA
BROWN
SYNDROME
INFERIOR OBLIQUE
OVERACTION
4TH NERVE
PALSY
OTHERS
Successful surgery
22
18
2
6
4
3
55
Residual hypertropia of > 2 PD
1
0
0
1
0
1
3
23
18
2
7
4
4
58
Table-7: Complications of isolated inferior oblique myectomy
COMPLICATION
Subconjunctival hemmorhage
Residual hypertropia
FERQUENCY (%)
5 (8.62%)
3 (2 PD in 2 patients & 4 PD in one)
MANAGEMENT
Topical Steroids And Lubricants
Only Counseled As Abnormal Head Posture Was
Removed With No Abnormal Cosmetics
Conjunctival granuloma
1 (1.7 %)
Successfully Treated With Mild Topical Steroids
Residual horizontal deviation after
correction of horizontal deviation
7 (12.1%)
Orthoptic exercise, Re-Peat of Horizontal Surgery
189
Ophthalmology Update Vol. 12. No. 3, July-September 2014
Surgical Management of Strabismus, our Experience
Although, comparison of the effectiveness to different surgical techniques is very difficult in statistical
analysis. Nevertheless, the comparison of effectiveness
among the surgical techniques fails to show any significant statistically significant differences. Although bi
medial rectus recession has been slightly superior over
residual deviation compared to the other techniques.
Many other researchers reported similar results
separately in their studies. one such study was done by
Willshaw et al, showed in Forty-six children bilateral
medial rectus recession to correct large angle esotropia
successfully.9 Grint et al showed success of unilateral
medial rectus recession for moderate angle esotropias.
In this study, sixteen patients with moderate angle esotropia of 30 to 35 prism diopters were treated with a
unilateral medial rectus muscle recession of 6 or 6.5
mm, thirteen of sixteen patients (80%) were straight
postoperatively or had 12 prism diopters or less of esotropia.10
In another study, they compared different surgical
procedures for the treatment of children or adults with
esotropia. They also showed the success of medial rectus recession procedures either performed unilaterally
or bilaterally.11
Similarly, successful results have been shown
when simultaneous medial rectus recession is performed along with lateral rectus resection.12
Multiple surgical options have been attempted by
many researchers to treat hypertropia. In one study,
effects of isolated inferior oblique myectomy was observed in patients with superior oblique palsy, and the
concluded an improvement of 11.91 prism diopters +/1.38 in all positions of gaze and for all age groups and
both genders.13 They recommended inferior oblique
myectomy as a primary treatment for superior oblique
palsy. In another study, they compared the efficacy of
inferior oblique myectomy with recession procedures.14
They showed that the patients of inferior oblique myectomy had less postoperative hypertropia (p<0.001)
compared to the patients who underwent recession
procedure. The patients who underwent the myectomy
had higher success rate as far as residual hypertropia is
concerned (p=0.056). But they also pointed out that the
difference in success between the two procedures even
more was pronounced (p=0.005) when patients had
small-moderate hypertropia before surgery and this
statistical difference was lost when patients had large
hypertropia before surgery. In another study they concluded that isolated inferior oblique muscle weakening
is an effective treatment, mean hypertropia decreased
from 15 (+/-9) to 4 (+/-4) at the 1-year follow-up postoperatively.15 These results are comparable to results
Ophthalmology Update Vol. 12. No. 3, July-September 2014
in our study which showed reduction of mean hypertropia of 13.55 prism diopters (± 4.43) to 0.48 prism diopters (± 1.08) postoperatively. These results and the
results of study shows that isolated inferior oblique
myectomy can successfully treat hypertropia without
the need of any further surgical interventions.
Thus different success rates have been reported by different researchers all over the world. No such data is
available for our community, thus this paper is significant in selecting the best surgical procedure for exotropia/esotropia/vertical deviations. The main limitation
of our study was that, it was conducted in a single institute and only patients belonging to same race were
included.
CONCLUSION
In this study we have compared the different
methods of surgical corrections of exotropia/esotropia and vertical deviations. It has been observed that
one method that is unilateral lateral rectus recession
and medial rectus resection has better surgical success
rate as compared to the other method which is bilateral
lateral rectus recession in exotropia correction. On the
other hand no significant difference was observed in the
success rate of different surgeries in esotropia. Isolated
inferior oblique myectomy is highly successful and safe
surgical procedure for correction of hypertropia.
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Govindan M, Mohney BG, Diehl NN, Burke JP. Incidence and
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Simon JW, Aaby AA, Drack AV, Hutchison AK, Olitsky SE,
Plager DA, et al. Pediatric Ophthalmology and Strabismus.
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Tollefson M.M. Mohney B.G. Diehl N.N. Burke J.P.Incidence
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Omoti AE.Hereditary wide angle exotropia in a nigerian family. Niger Postgrad Med J. 2007 Mar;14(1):76-8.
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Adán–Hurtado EE, Arroyo–Yllanes ME. Frecuencia de los
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Prieto–Diaz J, Souza–Diaz C. Estrabismo. 5th ed. Buenos Aires:
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10. Donaldson MJ, Forrest MP, Gole GA. The surgical management of consecutive exotropia.2004; 8(3):230-6.
11. Chia A. Seenyen L. Long Q.B.A Retrospective Review of 287
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Gezer A. Sezen F. Nasri N. Gözüm N. Factors influencing the
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GRIN T.R. NELSON L.B.Large unilateral medial rectus recession for the treatment of esotropia. British Journal of Ophthalmology, 1987, 71, 377-379.
oosi SH, von Noorden GK. Effect of isolated inferior oblique
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Hatz KB, Brodsky MC, Killer HE.When is isolated inferior oblique muscle surgery an appropriate treatment
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and Bilateral Rectus Muscle Recession. Ophthalmic Surg Lasers Imaging 2010;41:355-59.
H E WILLSHAW, N MASHHOUDI, AND S POWELL. Augmented medial rectus recession in the management of esotropia. British Journal of Ophthalmology, 1986, 70, 840-843
GRIN T.R. NELSON L.B.Large unilateral medial rectus recession for the treatment of esotropia. British Journal of Ophthalmology, 1987, 71, 377-379
Ellis GS Jr, Pritchard CH, Baham L, Babiuch A.Medial rectus
surgery for convergence excess esotropia with an accommodative component: a comparison of augmented recession, slanted
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muscle myectomy in the management of superior oblique muscle palsy. Am J Ophthalmol. 1979 Sep;88(3 Pt 2):602-8
Reecha S B,Andreas Marcotty, Paul J R,Elias I T.Comparison
of inferior oblique myectomy to recession for the treatment of
superior oblique palsy. Br J Ophthalmol doi:10.1136/bjophthalmol-2012-301485
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There are large, flat-topped, confluent cobblestone papillae in the upper palpebral conjunctiva
in the eye. Tarsal conjunctiva shows loss of architecture, scarring, and hyperemia. These findings
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keratoconjunctivitis. The patient responded well
to a supratarsal injection of triamcinolone acetonide. (NewsNet Service)
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Ophthalmology Update Vol. 12. No. 3, July-September 2014
ORIGINAL ARTICLE
Mohammad Idris
Postoperative Complications
of Levator Resection in Congenital
Blephroptosis with Poor Levator Function
Mohammad Idris FCPS1, Muhammad Junaid Sethi FCPS, FRCS2
Nuzhat Rahil FCPS3, Mohammad Alam FCPS4, Rahil Aumer Malik FCPS5
ABSTRACT
Objective: to evaluate the postoperative complications of levator resection in congenital blephroptosis with poor levator
function.
Material and Methods: prospective, interventional case series. The study was carried out at Department of Ophthalmology,
Govt Lady Reading Hospital, Peshawar from July 2011 to Jan 2013. We selected 52 cases from outdoor department by
universal sampling technique. Levator resection was carried out in all 52 cases (eyes) of congenital blephroptosis (with 09
bilateral cases) with poor levator function (less than 4mm) after taking informed written consent. Patients were subjected
to local / general anesthesia according to age. Data was collected on special proforma and was analyzed with the help of
SPSS Version16.
Results: The study population comprised of 52 eyes of 43 cases of congenital blephroptosis. Male were in majority (59.6%).
Age ranged between 05-35 years. About 65.3 % patients were between 5 and 15 years. The results were excellent in
majority (82.69%) with complete lid closure. The commonest postoperative complication was lagophthalmose and it was
seen in 18 (34.6%) cases.
Conclusion: Levator resection, compare to frontalis suspension, in congenital blephroptosis with poor levator function is
an option for achieving good cosmesis. It has few complications compare to frontalis suspension. Lagophthalmose is the
commonest postoperative complication after Levator resection.
Key words: congenital blephroptosis, Levator function, Levator resection, post operative complications.
INTRODUCTION
Anatomically ptosis may be classified as neurogenic (third nerve palsy, Horner syndrome, and Marcus Gunn Jaw-winking syndrome), myogenic (myasthenia gravis, myotonic dystrophy, ocular myopathy,
simple congenital, or blepharophimosis syndrome),
aponeurotic (involutional, postoperative), and mechanical (dermatochalasis, tumors, edema, anterior orbital
lesions, and scarring) 3
Congenital blephroptosis is a common condition
in pediatric population visiting oculoplasty clinic. It is
more common than acquired blephroptosis.1 Congenital blepharoptosis presents within the first year of life
either in isolation or as a part of many different ocular
or systemic disorders. Surgical repair is challenging,
and recurrence necessitating more than one operation
is not uncommon. Not all patients with congenital ptosis require surgery, but children with amblyopia due
to astigmatic anisometropia or deprivation may benefit from early surgical correction. A variety of surgical procedures to correct congenital ptosis have been
described. The choice of procedure depends on a numMedical Officer, Ophthalmology UNIT, PGMI, LRH Peshawar,
Senior Registrar, Ophthalmology Unit, PGMI, LRH Peshawar,
3
Consultant, Ophthalmology Unit, PGMI, LRH Peshawar, 5Medical
Officer, Ophthalmology PGMI, LRH Peshawar
1
2,4
Correspondence: Dr. Mohammad Idris FCPS Medical Officer,
Ophthalmology PGMI, LRH Peshawar, Cell: 0092-333-9417051
Email: [email protected]
Received: March 2014 Accepted: June 2014
Ophthalmology Update Vol. 12. No. 3, July-September 2014
ber of patient-specific factors, such as degree of ptosis
and levator function, as well as surgeons’ preference
and resource availability.9 it is commonly unilateral
and commonly involve the left eye2 It is challenging to
manage congenital blepharoptosis, especially unilateral, because symmetry is difficult to achieve under general anesthesia.10 The definitive treatment of congenital
blephroptosis is surgery; different types of surgical options are in practice. The decision of surgery is based on
Levator function mainly. Levator function is graded as
poor (4mm or less), fair (5-11mm), good (12-15mm) and
excellent (> 15mm). For severity of blephroptosis, it is
graded as mild (1-2mm) moderate (3-4mm) and severe
(>4mm). For blephroptosis in which levator function is
poor and severe, generally frontalis suspension procedure is performed. In cases with good levator function
and moderate blephroptosis, levator resection is considered as choice of surgery. In minimal blephroptosis,
Fasanella Sarvat procedure is preferred.3 the primary
aim of surgery is symmetry of the upper lids.4 Levator
resection can effectively correct severe blephroptosis
with Levator function and is comparable with frontalis
suspension certain complication like excessive contraction & eye lid deformity are more commonly seen in
frontalis suspension procedure. Levator resection has
some complication as well. The most common complication is under correction.5 we selected 52 cases of congenital blephroptosis with poor levator function and
evaluated their results in term of surgical outcome and
complications.
192
Postoperative Complications of Levator Resection in Congenital Blephroptosis with Poor Levator Function
METHODOLOGY
Study Design: prospective, interventional case series.
Place and duration: The study was conducted at
the Department of Ophthalmology, Govt Lady Reading
Hospital, Peshawar from July 2011 to Jan 2013.
Sample size: 53 eyes of 43 patients having poor
levator function, good Bell’s phenomenon and normal
corneal sensitivity.
Diagnosis was based on history, old photographs,
and routine ophthalmic examination. Oculoplastic examination specific to blephroptosis was performed by
the operating surgeon, this included, vertical palpebral
fissure height, marginal reflex distance (MRD), levator function, lid crease height, Bells phenomenon and
ocular motility. All patients included were diagnosed
as congenital blephroptosis with poor levator function.
It also included checking head position, chin elevation, brow position, and brow action in attempted up
gaze. All the patients had detailed systemic evaluation
to rule out secondary causes of the blephroptosis. Age
range was 05-35 years (mean: 14 years).
Exclusion criteria were absent Bell’s phenomenon, disturbed or absent corneal sensitivity and dry
eyes. All patients were explained about the procedure
and informed consent obtained.
Technique of surgical intervention: Levator resection was carried out through anterior approach. All
patients were subjected to local/general anesthesia.
After preparing and draping, an incision was marked
at a level symmetric with the opposite eyelid usually
8-10 mm above the lid margin. A cut was made along
the marked line using #15 scalpel blades. A blunt dissection was carried out towards lid margin to expose
tarsal plate for re-attachment of levator at the end of
the surgery. The post orbicular facial plane was entered
and orbital septum was exposed and confirmed by applying inward pressure at lower part of globe and preaponeurotic fat popped up under septum. The septum
was incised with sharp scissors and the attachments between the septum and aponeurosis were separated to
prevent postoperative lagophthalmos. The aponeurosis
and Whitnall’s ligament were revealed by brushing the
pre-aponeurotic fat pockets upward. This was followed
by disinsertion of the aponeurosis from the tarsus. Carrying blunt dissection, the muscle was dissected all the
way to the Whitnall’s ligament. A 6.0 vicryl was passed
through partial thickness of the tarsus, 3 mm from its
upper border and above the central pupil posterior to
the aponeurosis and retrieved through the Whitnall’s.
Two additional sutures were added between the tarsus
and Whitnall’s and placed medially and laterally. The
three sutures were adjusted as needed. Finally, the skin
incision was closed with running 6.0 vicryl sutures.
Follow-ups: Patients had a follow-up on day one,
at 4 weeks, 6 months and then last follow up at 1 year.
193
RESULTS
We evaluated 52 Eyes of 43 patients with 09 patients have bilateral congenital blephroptosis with poor
levator function in term of surgical correction and our
goal was to achieve satisfactory alignment of eye lids
with minimal complication. Most of the patients with
congenital blephroptosis with poor Levator function
were in the age ranges from5 to 10 years. so common
age group was 05-10 years and seen in 20 (38.4) cases.14(26.9%) patients were having age ranges from 11
to 15 years, 11 (21.1%) patients were having age ranges
from 16 to 20 years and only 7 (13.4%) patients had age
of 20 or more years in our study sample. (Table 1) .most
of our patients were male and in majority.31 (59.6%) patients were male and only 21 (40.3%) patients were female. (Table 2). Regarding postoperative complications
after levator resection, the commonest complication
was lagophthalmose it occurred in 18 (34.6%) cases, under correction was noted in 7 (13.4%) cases and crease
abnormality in 6 (11.5%) cases and overcorrection was
seen in only 2 (3.8%) cases. (Table 3).
Table-I: Age distribution in years (N=52)
Age in years
frequency
Percentage
05-10
20
38.4
11-15
14
26.9
16-20
11
21.1
20 or more
07
13.4
Total
52
100
Table II: Gender distribution (N=52)
Gender
frequency
Percentage
Male
31
59.6
Female
21
40.3
Total
52
100
Table-III: Postoperative complications
after levator resection in congenital blephroptosis
with poor levator function (N=52)
Complications
frequency
Percentage
Lagophthalmose
18
34.6
Under correction
07
13.4
Crease abnormality
06
11.5
Overcorrection
02
3.8
Table IV: Surgical outcome (N=52)
Surgical outcome
frequency
Percentage
Satisfactory
43
82.69
unsatisfactory
09
17.3
Total
52
100
In majority of our cases, results of surgery were
good and symmetry in vertical fissure height and shape
Ophthalmology Update Vol. 12. No. 3, July-September 2014
Postoperative Complications of Levator Resection in Congenital Blephroptosis with Poor Levator Function
were achieved. It was seen in 43 (82.69%) cases and in
only 9 (17.3%) cases; results were unsatisfactory due to
postoperative complications. (Table 4)
Figure-1: Preoperative
Figure-2: Postoperative
Figure-3: Postoperative
Figure-4: Postoperative and with complete lid closure
DISCUSSION
Ptosis repair can be both challenging and frustrating, especially given ever-increasing demands for an
optimal cosmetic surgical result.11 The diagnosis of and
therapy for pediatric ptosis present challenges because
of difficulties in performing preoperative examinations
and the inability of the patient to provide intraoperative cooperation for proper lid placement.12 The timing
for surgical treatment varies depending on age, severity and laterality.14 The ideal procedures in ptosis surgery are those that disturbs normal anatomy the least
and also allow for good results.13 In this study an anterior approach was selected, thus avoiding conjunctiva,
lacrimal gland and tarsus. In blephroptosis surgery,
good cosmetic outcome is main goal and different surgical techniques are used to achieve this goal. Levator
Ophthalmology Update Vol. 12. No. 3, July-September 2014
resection is considered treatment of choice in cases of
blephroptosis with a levator function of 5 or more and
moderate blephroptosis.8 although some studies suggest levator resection preferred over other procedure
like frontalis sling in cases of poor levator functions
and severe blephroptosis.5 In our study good cosmesis
was achieved in majority (82.69%) of the cases. According to a study, the success of Levator resection in case
of severe blephroptosis with poor levator function was
(81.8%).6 In another study by Qamar et al,15 success of
surgery was 85.65%. In our study, the most common
complication of levator resection was lagophthalmos
(34.6%). In literature the common most complication is
under correction.7 other common complications include
crease abnormality and over correction. Blephroptosis
is common in male and is commonly unilateral, left eye
commonly affected. In our study male to female ratio
was 3:1 with 87% cases involving the left eye. We found
levator resection as safe procedure and have good cosmetic outcome in seven blephroptosis with few complications.
REFERENCES
1.
Thapa R1, Karmacharya PC, Nepal BP. Etiological pattern
of blepharoptosis among patients presenting in teaching hospital. Apr-Jun; 45:218-22.
2.
El Essawy R1, Elsada MA.Clinical and demographic characteristics of ptosis in children: a national tertiary hospital study.
Eur J Ophthalmol. 2013 May-Jun;23:356-60.
3.
Finsterer J. Ptosis: causes, presentation, and management. Aesthetic Plast Surg. 2003 May-Jun; 27:193-204.
4. Ungerechts R1, Grenzebach U, Harder B, Emmerich KH.
Causes, diagnostics and therapy for paediatric ptosis. Klin
Monbl Augenheilkd. 2012 Jan;229:21-7.
5.
Park DH1, Choi WS, Yoon SH, Shim JS. Comparison of levator resection and frontalis muscle transfer in the treatment of
severe blepharoptosis. Ann Plast Surg. 2007 Oct;59:388-92.
6.
Press UP, Hübner H. Maximal levator resection in the treatment of unilateral congenital ptosis with poor levator function.
Orbit. 2001 Jun; 20:125-129.
7.
Benia L.A retrospective study of 1,500 personal cases of ptosis.
J Fr Ophtalmol. 1999 May; 22:541-4.
8.
Whitehouse GM, Grigg JR, Martin FJ.Congenital ptosis: results
of surgical management. Aust N Z J Ophthalmol. 1995 Nov;
23:309-14.
9. Soohoo JR1, Davies BW1, Allard FD2, Durairaj VD3. Congenital
ptosis. Surv Ophthalmol. 2014 Feb 5. pii: S0039-6257(14)00027-7.
10. Wu SY1, Ma L, Huang HH, Tsai YJ. Analysis of visual outcomes
and complications following levator resection for unilateral
congenital blepharoptosis without strabismus. Biomed J. 2013
Jul-Aug;36:179-87.
11. Ng J, Hauck MJ. Ptosis repair. Facial Plast Surg. 2013
Feb;29(1):22-5
12. Ungerechts R, Grenzebach U, Harder B, Emmerich KH.Causes,
diagnostics and therapy for paediatric ptosis. Klin Monbl Augenheilkd. 2012 Jan;229(1):21-7.
13. Jones LT. The anatomy of the upper eyelid and its relationship
to ptosis surgery. Am J Ophthalmol. 1964; 57: 943-59.
14. Mesa Gutiérrez JC1, Mascaró Zamora F, Muñoz Quiñones
S, Prat Bertomeu J, Arruga Ginebreda J. Upper eyelid surgery
for treatment of congenital blepharoptosis. Cir Pediatr. 2007
;20:91-5.
15. Outcome of Levator Resection in Congenital Ptosis with PoorLevator Function Qamar RM, , Tahir MY, Latif A, Latif E. Pak
J Ophthalmol 2011 ;. 27: 128-31
194
ORIGINAL ARTICLE
Sidrah Riaz
Behavior of Custom Designed,
Light Weight Ocular Prosthesis
Sidrah Riaz FCPS1, Mazhar Zaman Soomro DOMS2
Imran Attaullah DOMS3, Zahid Hafeez4
ABSTRACT
Purpose: To assess the behavior of light weight ocular prosthesis in improving mobility and cosmoses.
Materials and Methods: A prospective analysis is performed on the behavior of custom designed light weight ocular prosthesis
in 44 patients from July 2006 to March 2013. The basic raw materials used for prosthesis are polymethylmethacrylate and
methylmethacrylate which were mixed by heat initiated polymerization along with coating of glycol dimethacrylate. In order
to reduce weight, the prosthesis is made hollow.
Results: An average 35.07% weight reduction in ocular prosthesis was obtained. Mobility is recorded as good in all patients
(100%). The patient satisfactory score was 5 in 34.1%, 4 in 52.3% and 3 in 13.6%. None of patient was unsatisfied
Conclusion: The light weight custom designed ocular prosthesis provides satisfactory weight reduction, good functional
mobility and cosmoses/aesthetics with reduced discharge rate. It also carries a high satisfactory score of the patients.
INTRODUCTION
The loss of an eye can be very traumatic event in
a person’s life. The disfigurement associated with loss
of an eye can cause significant physical and emotional
problems.1 The rehabilitation of patient requires a prosthesis that will provide optimum cosmetic and functional result. The history of ocular prosthesis dates back to
2900-2800BC when first evidence of use of ocular prosthesis was found in an Iranian woman.2,3 It was 2.5cm
in diameter made up of light material probably Bitumen paste. Romans and Egyptian priests were known
to have produced artificial eyes as early as fifth century
constructed from painted clay.4 Germans introduced
the art of making artificial eyes from glass and later in
USA artificial eyes of acrylic paste were used. Today
wide varieties of ocular prosthesis are available. Unlike
stock based prosthesis which is not individualized for
each patient, custom designed prosthesis is prepared
with exact measurement of size and shape with help of
accurate instruments. It is an innovative design which
offers exact fitting of prosthesis on orbital socket providing improved motility. An important change added
to this prosthesis is weight reduction achieved by making it hollow.
MATERIALS AND METHOD
A prospective study was conducted on 44 patients
(15 male and 29 females) from July 2006 to March 2013
1
2
3
Assistant Professor, Akhter Saeed Medical & Dental College, Lahore,
Mazhar Zaman Soomro, Ophthalmologist, Eye Infirmary, Khanpur
THQ Hospital, Haroonabad, 4Ocularist, SIGHTS Anarkali Lahore
Correspondence: Dr Sidrah Riaz FCPS, Assistant Professor,
Akhter Saeed Medical & Dental College Lahore. Cell: 03224367303
E-Mail: [email protected]
Received: April 2014
195
Accepted: June 2014
on behavior of light weight custom designed ocular
prosthesis. All these patients were anophthalmic (enucleation or evisceration). In fact, enucleation allows for
full volume restoration of anophthalmic socket and better cosmetic result.5 Intra-orbital implants were used
during evisceration or enucleation to reduce potential
for contracture and volume deficit and the better cosmetic result.5
Ocular prosthesis were fabricated 6 to 8 weeks following surgery to allow for healing of socket. During
that time, a temporary acrylic conformer was worn to
keep the fornices formed and to prevent contracture.6
The steps of ocular prosthesis involve exact impression
through selected trays, socket impression for exact scleral shell preparation, precise iris positioning and iris
color matching. The patients were followed monthly
and satisfactory score is noted. Ocularist also instructed
the patient how to place and clean the prosthesis.
Data analysis: The data was analyzed using SPSS
17. The data were described in term of mean +- SD
(standard deviation) for quantitative variables. Frequencies and percentages were given for qualitative
variables. A p value of <0.05 was considered statistically significant.
RESULTS
A total 44 patients were included in study and
behavior of light weight custom designed ocular prosthesis is studied. An average 35.07 % weight reduction
was obtained. Mobility was noted good in all patients.
The majority of patients were either fairly satisfied or
highly satisfied except a small minority who did not
feel any difference.
Patient satisfactory score was 5 in 15(34.1%), 4 in
23(52.3%), 3 in 6 (13.6%), 2 in 0(0%) and 1 in 0 (0%)
Ophthalmology Update Vol. 12. No. 3, July-September 2014
Behavior of Custom Designed, Light Weight Ocular Prosthesis
non-absorbent surface, high luster, negligible discharge
and absolutely inert prosthesis.8 With development of
these new materials the socket can be finely recorded
more accurately on which custom made acrylic prosthesis can be fabricated with exact fit and esthetics with
improved mobility coordinated with natural eye.10
Although the use of stock ocular prosthesis cannot be
neglected due to its less coast and easy availability, a
custom made ocular prosthesis provide better results
functionally as well as aesthetically.11, 12
CONCLUSION
The light weight custom designed prosthesis provides satisfactory weight reduction of prosthesis, good
functional mobility and cosmoses with reduced inflammation and discharge. It also carries high patient satisfactory score. Although patient cannot see with ocular
prosthesis, it has definite role in restoration of patient
self-esteem and confidence.
DISCUSSION
The raw materials used for light weight ocular
prosthesis are polymethylmethacrylate (PMMA-polymer) and methylmethacrylate (monomer). PMMA
is transparent thermoplastic available for use as ocular prosthesis and it has good degree of compatibility
with human tissues much more than glass.6 Available stock prosthesis are fabricated from either glass
or methymethacrylate but methyl methacrylate is a
preferred product because glass is particularly subject
to surface damage and deterioration and usually lasts
only about 2 years.7 Methyl methacrylate is more durable, has a longer life expectancy, and better tissue
compatibility. Complication rate (exposure, extrusion,
discharge) of porous implants is much more as compare to non-porous implants.8 In order to render prosthesis non-porous heat initiated polymerization process is used instead of per oxidase polymerization.9 7%
glycol methacrylate is cross linked with polymer and
monomer to produce thick molecular structure ,smooth
Ophthalmology Update Vol. 12. No. 3, July-September 2014
REFERENCE
1.
Lbbbkin V, Sloan. S:Enucleation and psychic trauma. Advances
in Plastic and Recontructive surgery 1990; 8; 259-262.
2.
London Times (February 20, 2007). “5000 years old artificial eye
found on Iran-Afghan border.”
3.
3rd millennium B C artificial eye ball discovered in Burnt city
Dec. 10, 2008.
4.
Frequently asked questions, American Society of Ocularist
5.
Nunnery, William R. , John D. Ng, and Kathy J. Hetzler. “Enucleation and Evisceration.” In :Spaeth, George, ed. Ophthamic
Surgery: Principles and practice 3rd ed. Philadelphia, PA: Elsvier,2003.485-507.
6.
Patel, Bhupendra C.K. , Nigel A. Sapp, and J. Richard O. Collin. “Cosmetic Conformer.”Ophthalmic Stersurgery & Lasers
28(1997): 171-173.OVID.
7.
Patil , Sanjayagouda B., Roseline Meshramkar , B. H. Naveen,
and N.P. Patil. “Ocular Prosthesis:A brief reviw and fabrication
of an Ocular Prosthesis for a Geriatric Patient.” Gerontology
25(2008): 57-62. OVID.
8.
Restorative Dental Materials by Robert G. Carig and Tohn M.
Powers; polymer and polymerization p 141-142, 152
9.
Custer, Philip L., Robert H. Kennedy, John J. Woog , Sara
A. Kaltreider, and Dale R. Meyer. “Orbital implants in
Enucleation Surgery: a report by American Academy of
Ophthalmology.”Ophthalmology 110(2003): 2054-2061. OVID
10. Sykes LM: Custom made Ocular Prosthesis: A clinical report.
The Journal of Prosthetic Dentistry, 1996;75(1) 1-3.
11. Doshi PJ, Aruna B: Prosthetic management of patient with ocular
defect. The Journal of prosthodontic Society, 2005 :5(1): 37-38.
12. Cain JR: Custom Ocular Prosthetic management of patient with
ocular defect. The journal of indian prosthodontics Society,
2005 :5(1):37-38.
196
Ophthalmology Notebook
News, views, letters and events
Workshop on Basic & Advanced Endoscopy
held at Centre for liver & digestive diseases,
Holy Family Hospital, Rawalpindi
Thousands of patients suffering from advanced
Gastrointestinal (GI) and Liver Cancer, Hepatitis B & C,
Peptic Ulcer and Hepatopancreato-Biliary diseases are
being treated freely at the Centre for Liver and Digestive Diseases (CLD) apart from imparting training to
Gastroenterologists and postgraduates of the country.
The Centre for Liver and Digestive Diseases (CLD) is
a center of excellence and a part of the Holy Family
Hospital, Rawalpindi Medical College. It was established in 2012 by Prof. Dr. Muhammad Umar and Prof.
Dr. Hamama Tul Bushra Khaar, both doyens of Gastroenterology and superb academicians of international
repute. It has the credit of becoming the first national
Centre to do Peroral Endoscopic Myotomy (POEM).
Renowned faculty on the subject participated
from USA, UK, China and India. The participants
from all over Pakistan had full interaction with the
faculty in 2 days’ international workshop i.e. 4th Basic
and Advanced Endoscopy workshop recently held at
Holy Family Hospital, Rawalpindi under the patronage of these two Professors. The training course was
also joined by the 4th Endoscopic Ultrasound (EUS)
Course, and 6th Advanced Endoscopic Retrograde
Cholangio-pancreatotomy Course (ERCP)
The course co-coordinators were senior consultant
of Gastroenterology, Prof. Amir Ghafoor Khan, Prof.
(Gen) Tassawar Hussain, Brig. Amjad Salamat and
Prof. Sharbat Khan from Quetta. During the workshop
international consultants along with national experts
performed the procedures to give hand-on training to
the local consultants and postgraduates.
During the workshop, a joint team of Holy Family
Hospital Gastroenterologists and Prof. Fan from China
197
performed 4 Endoscopic Myotomy procedures on the
patients suffering from Dysphagia.
Other procedures performed during this workshop were Advanced Endoscopic Retrograde Cholangio-pancreatotomy Course (ERCP), Endoscopic
Ultrasound Course (EUS), Fibroscan, Manometry and
Colonoscopy. National Faculty for these courses were
Prof. Amir Ghafoor Khan, President Society for Gastroenterology Prof. Sharbat Khan, Col. Farrukh from Quetta and Prof. Mati ullah Khan, Brig. Dr. Masood Ahmed
and Dr. Tshfeen Adam. The course was designed in
such a way that all the participants were exposed to the
foreign faculty and they fully benefitted from their rich
experiences. It is worth mentioning that a most senior
Liver Transplant surgeon Prof. A. Soin from India also
examined those patients requiring Liver Transplant.
A regular training program on Gastroenterology
is being run in the Centre for Liver and Digestive Diseases at Holy Family Hospital. The nation, especially the
medical community of Pakistan is proud of the establishment of such an advanced center. The Government
of Pakistan has eulogized this academic venture at the
national level, through the efforts of Government of
Punjab, Prof. Muhammad Umar FRCP, Prof. Dr. Hamama Tul Bushra Khaar, who are a senior consultants in
the country. They have written scores of research papers and articles in the national international indexed
journals and have represented the country at various
forums in renowned universities all over the world.
At the end of the workshop Prof. Umar apprised
the audience regarding the trial of drug Sovaldi, on
Hepatitis ‘C’ patients in order to treat them with the
modern drugs…………………(Newsnet service)
Ophthalmology Update Vol. 12. No. 3, July-September 2014
PROFILE
Prof. Dr. Muhammad Umar, FCPS, FRCP
Prof. Dr. Hamama Tul Bushra Khaar, FCPS, FRCP
I feel honored to inscribe a brief profile of Prof.
Muhammaf Umar and Prof. Hamama Tul Bushra
Khaar both are Physicians par excellence and doyens of medicine. They are Professors of Medicine,
Gastroenterologists & Hepatologists in Rawalpindi
Medical College & Holy Family Hospital, Rawalpindi. They are holding many honors, awards and
medals for academic achievements, unparalleled research contributions and having served the nation to
their best.
Fortunately both the Professors are my students
ever since they joined Rawalpindi Medical College as
first year medical students in
1976 where I was serving as
Professor of Ophthalmology.
I have watched them rising and shining in every examination with flying colors.
While writing a brief profile
I feel that I am giving a cursory outlook of their accomplished work, unparalleled task hardly done by few
professors in the history of medicine, as such I am not
doing full justice in elaborating their contribution. Prof.
Umar and Prof. Bushra, both are a charismatic, young
pair as well as an embodiment of simplicity.
They joined the medical college in 1976 and qualified MBBS in 1981 adjudged as the best graduates of
our college, bestowed with presidential award, talented medals and many creditable distinctions in their
professional life. They qualified FCPS 1985 and were
granted Fellowship (FRCP) from the Royal College of
Britain in 2007 apart from Fellowships from other Universities of advanced countries like UK and USA.
Prof. Umar is currently serving as Principal of
Rawalpindi Medical College and Chief Executive of Allied Hospitals apart from holding important positions
in many Societies and indexed journals including the
Ophthalmology Update Vol. 12. No. 3, July-September 2014
position of an adviser of ‘Ophthalmology Update’ an
international scientific journal being published from
Islamabad. Both of them have authored many books
relevant to their specialty especially an authentic publication on Hepatitis ‘C’, written in a very lucid manner
and being extoled by students, patients and professionals alike. They have the credit of writing scores of
research papers and represented the country on many
international forums. They are the examiners of various
universities in Pakistan and abroad.
Both the professors have worked very hard to
establish a very advanced
Centre of Gastroenterology
& Hepatology in Holy Family Hospital. It is not possible
to document their academic
contributions in a short description and is not a proper
tribute to their services rendered
in ameliorating the
sufferings of ailing humanity.
In short they have a brilliant
record of academic eminence in the pursuit of knowledge in the field of medicine which speaks volumes of
their devotion and dedication to achieve professional
excellence and a prestigious place in the comity of venerated academicians.
Prof. Bushra being a pragmatic simple lady and a
perfect house wife adorned with multiple qualities of
head and heart. She is very adept in cooking very tasteful and sumptuous dishes. God has gifted them with
a beautiful daughter and a very handsome son who
are treading the same path of the parents in academics activities. May Allah bless them enough vigor and
strength to continue serving the sick humanity to their
best. .Amin!
Prof. Yasin Durrani
Chief Editor
198
GENERAL SECTION
ORIGINAL ARTICLE
Predictive value of Pirani Scoring system
for Achilles Tenotomy in Ponseti Technique
M. Imran Khan
Muhammad Imran Khan FCPS1, Muhammad Saqib MBBS2, Khial Wali MS3
ABSTRACT
The purpose of this study is to assess the predictive value of Pirani scoring system for Achilles tenotomy in Ponseti
technique.
Patients & Methods: A total number of 25 feet in 15 patients of clubfoot were treated at Agency Headquarter Hospital
Landikotal during the period from May 2012 to November 2013 by Ponseti method. The severity of the deformity was
evaluated by Pirani scoring system. The data of all these successfully treated patients were analyzed and a correlation was
found between the initial Pirani score and whether Achilles tenotomy will be required or not.
Results: Out of 13 feet with a Pirani score greater than or equal to 5.0 at initial presentation, 12 feet (92%) required
tenotomy. Of the 9 feet with Pirani score between 3.0 and 4.5, five feet (55.5%) required a tenotomy and 4 feet (44.5%) did
not. Finally, 3 feet with initial Pirani severity scores between 1 and 2.5, none needed a tenotomy.
Conclusion: The Pirani scoring system is reliable, quick, and easy to use, and provides a good forecast about the likely
treatment for an individual foot but a low score does not exclude the possibility that a tenotomy may be required.
Key Words: Idiopathic Clubfoot, Ponseti scoring system, peadiatric deformities.
INTRODUCTION
Talipes equinovarus, or clubfoot deformity is a
combination of forefoot adduction and supination,
midfoot cavus, heel varus, and ankle equinus. It develops during the second trimester of pregnancy and
is detectable in sonograms. It usually occurs in otherwise healthy fetuses. Annually over 100,000 babies are
born with idiopathic clubfoot worldwide.1 During the
second half of the twentieth century, the deformity was
used to be managed with manipulations, castings and
surgical correction but preference was given to surgical treatment as it was considered a method that could
obtain full and lasting correction. Over time and based
on long-term follow up studies surgeons realized that
the results of surgical intervention are unpredictable.2, 3
Since the initial description by ponseti in 1963,4
several short-term and long-term studies have documented very impressive success rates and functional
outcome,5 and as a consequence, non-operative Ponseti method of manipulation and casting has become
increasingly accepted worldwide as the standard of
care for clubfoot deformity in infancy. The ponseti technique is based on the thorough understanding of the
anatomy and pathology of clubfoot. It involves a fairly
small number of manipulations and usually requires
performing an Achilles tendon tenotomy under local
District Specialist, Orthopaedic Unit, Agency Headquarter Hospital
Landikotal, 2Medical Officer, Orthopaedic Unit, Khyber Teaching
Hospital, Peshawar, 3Medical officer, Orthopaedic Unit, Agency
Headquarter Hospital, Landikotal
1
Correspondence: Dr. Muhammad Imran Khan, House No 292,
Street-10, Sector N-1, Phase-4, Hayatabad, Peshawar.
Phone:0333505504, E-Mail Address: [email protected]
Received: December 2013
199
Accepted: March 2014
anaesthesia to bring about complete correction of the
deformity.6 A long term assessment of Ponseti’s technique by Cooper and Dietz7 revealed that good and excellent functional results were obtained in 78% of clubfeet at a mean follow-up of 30 years.
There are many ways of grading the severity of
the deformity, among which Pirani scoring system is
gaining popularity due to its ease of application. Pirani8
devised a simple scoring system based on six clinical
signs of contracture. Each is scored according to the following principle: 0, no abnormality; 0.5, moderate abnormality1, severe abnormality. The six signs are separated into three related to the hind foot (severity of the
posterior crease, emptiness of the heel and rigidity of
the equinus), and three related to the mid foot (curvature of the lateral border of the foot, severity of the medial crease and position of the lateral part of the head of
the talus). Thus, each foot can receive a hind foot score
between 0 and 3, a midfoot score between 0 and 3 and a
total score between 0 and 6.
The purpose of this study is to assess the predictive value of Pirani scoring system for Achilles tenotomy in Ponseti technique.
MATERIALS AND METHODS
A total number of 25 feet in 15 patients of clubfoot
were treated at Agency Headquarter Hospital Landikotal during the period from May 2012 to November 2013
by Ponseti method. The severity of the deformity was
evaluated by Pirani scoring system. Exclusion criteria
was;
• Patient of clubfoot associated with other congenital deformities eg Spina bifida, Arthrogryphosis
multiplexa congenital.
• Cerebral palsy.
Ophthalmology Update Vol. 12. No. 3, July-September 2014
Predictive value of Pirani Scoring system for Achilles Tenotomy in Ponseti Technique
• Myelomeningocele were excluded from the study.
Patients with only idiopathic clubfoot were included in the study. After exclusion study was conducted
on 15 patients with 25 clubfeet. Written informed consent was obtained from all individuals. Data collected
for each patient included sex, right or left foot, age at
treatment onset. Each foot was rated according to Pirani scoring system. The data of all these successfully
treated patients were analyzed and a correlation was
found between the initial Pirani score and whether
Achilles tenotomy will be required or not.
RESULTS
Out of 15 patients, 9 (60%) patients were male and
6 (40%) were female. Bilateral foot involvement was in
10 (33.3%) patients, right foot was involved in 3 patients
and left foot was involved in 2 patients. Mean age at initial casting was 4.2 weeks (1-17 weeks), mean number
of casts applied were 5.5 (4-9). Mean duration of casting
was 30 months.
The mean number of the casts required was significantly greater for the group that required a tenotomy,
than the group that did not required a tenotomy,. Out
of 13 feet with a Pirani score greater than or equal to 5.0
at initial presentation, 12 feet (92%) required tenotomy.
Of the 9 feet with Pirani score between 3.0 and 4.5, 5 feet
(55.5%) required a tenotomy and 7 feet (44.5%) did not.
Finally, 3 feet with initial Pirani severity scores between
1 and 2.5, none needed a tenotomy (fig-I).
Figure-I: Pirani score at initial evaluation
DISCUSSION
This study shows that the Pirani scoring system
can be used to clarify the need for tenotomy. Which is
an integral part of the Ponseti’s technique for the treatment of idiopathic clubfoot. The indication for the tenotomy has been clearly described and is reported to be
necessary in approximately 70-80% of the patients9,10 although the effectiveness of the Ponseti technique has
been made clear in multiple publications over the past
30 years, whether we can predict the need of tenotomy and number of the casts before the initiation of the
Ophthalmology Update Vol. 12. No. 3, July-September 2014
treatment is not yet being cleared.11
Our study found a significantly higher initial Pi
rani score in feet requiring a tenotomy, which also
required significantly more casts, suggesting that the
better feet having low Ponseti score correct without
the need for surgical intervention. M Porecha12 and P.
J. Dyer13 had the same conclusion in their studies about
the predictive value of Pirani scoring system for forecasting Achilles tenotomy.
Those feet which required tenotomies were as
supple and plantigrade as those which did not undergo tenotomies which conclude that tenotomy does not
suggest a poor result. Proper application of the Ponseti
technique can successfully treat the severe idiopathic
clubfeet. At the end of the treatment, feet from both
groups had equivalent overall Pirani severity scores,
reflecting supple and plantigrade feet. However, the
true functional outcome of these two groups cannot be
determined until the child has completed the growth,
and perhaps not until later in life.
CONCLUSION
The Pirani scoring system is reliable, quick, and
easy to use, and provides a good forecast about the likely
treatment for an individual foot but a low score does not
exclude the possibility that a tenotomy may be required.
REFERENCES
1.
Staheli L, Ed. Ponseti Management of Clubfeet. Seattle: GlobalHELP.org. 2003.
2.
Ippolito E, Farsetti P, Caterini R, Tudisco C. Long-term comparative results in patients with congenital clubfoot treated
with two different protocols. J Bone Joint Surg Am2003; 85-A:
1286-1294 [PMID: 12851354].
3.
Dobbs MB, Nunley R, Schoenecker PL. Long-term followup of
patients with clubfeet treated with extensive softtissue release.
J Bone Joint Surg Am2006; 88: 986-996 [PMID: 16651573 DOI:
10.2106/JBJS.E.00114].
4.
Ponseti IV, Smoley EN. Congenital club foot: the results of
treatment. J Bone Joint Surg Am1963; 45: 261-275.
5.
Mercuende JA, Dolan LA, Dietz FR, Ponseti IV. Radical reduction in the rate of Extensive corrective surgery for clubfoot using ponseti method. Pediaterics 2004;113:376-80.
6.
Ponseti IV. Current concept review: treatment of congenital
clubfoot. J Bone and Joint Surg (Am) 1992;74-A:448-54.
7.
Cooper DM, Dietz FR. Treatment of idiopathic clubfoot. A thirtyyear follow-up note. J Bone Joint Surg Am1995; 77: 1477-1489.
8.
Pirani S, Outerbridge HK, Sawatzky B, Stothers K. A reliable
method of clinically evaluating a virgin clubfoot evaluation.
21st SICOT Congress 1999.
9.
SJ Laaveg & IV Ponseti IV. (1980). Long term results of treatment
of congenital club foot. J. Bone Joint Surgery, Am 1980; 62:23-31.
10. Ponseti IV. Treatment of congenital club foot. J Bone Joint Surg
Am. 1992;74:448-454.
11. David M. Scher, David S. Feldman, Harold J.P. van Bosse, Debra A. Sala, MS, PT and Wallace B. Lehman, MD. Predicting
the need for tenotomy in the Ponseti method for correction of
clubfeet. J pediatr orthop 2004;24:349-52.
12. Porecha M, Parma Dr. The Predictive Value of Pirani Scoring System in the Management of Idiopathic Club Foot by Ponseti Method.
The Internet Journal of Orthopedic Surgery. 2008; 11(2).
13. Dyer PJ, Davis N. The role of the Pirani scoring system in the
management of club foot by the Ponseti method. The journal
of bone and joint surgery. 2006; 88B (8): 1082-84.
200
ORIGINAL ARTICLE
Choice of Operative Technique for Emergency
Cases of Sigmoid Volvulus & its Outcome
Yousaf Jan
Yousaf Jan FCPS1, Waqas MBBS2, Shaukat Hussain MBBS3, Muhammad Shah MBBS4
ABSTRACT
Background: Sigmoid volvulus is a common cause of intestinal obstruction in developing countries where it affects relatively
young people. Most common presenting symptom is abdominal pain and constipation.
Objective: The objective of this study is to describe the emergency management of sigmoid volvulus with reference to the
type of surgical procedures performed and to determine the prognosis of sigmoid volvulus.
Materials and Methods: All patients presenting with volvulus and needing emergency operative intervention during one
and a half years duration from January 2010 to July 2011 were included in this study. Demographics, laboratory and
treatment results, mortality and complications were recorded. Total 54 patients were included in the study of which 21
presented with gangrenous sigmoid colon on laparotomy and viable sigmoid colon was present in the remaining 33 cases.
Results: A total of 54 patients were studied. Their age ranged from 20-70 years with a mean of 47.3±17.4 years. There was
a preponderance of male (83.3%) with a male to female sex ratio of 5:1 (Table 1). Twenty one patients (38.9%) presented
with peritonitis. About 71.1% of the patients were treated with primary resection and anastomosis, 17.3% with Hartmann and
7.6% had Mikulicz procedure (Table 2). About 7.7% had anastomotic leak and 11.5% had wound infections. The average
hospital stay was 8 days. Overall mortality rate was 5.7% and of the patients who died, all had primary resection and
anastomosis for gangrenous bowel (Table 3).
Conclusion: Bowel viability is the most important determinant of the outcome in a patient with sigmoid volvulus. Hartmann’s
procedure goes a long way in decreasing mortality due to sigmoid volvulus (especially in gangrenous bowel) in the
emergency setting.
Keywords: Sigmoid volvulus (SV), primary resection, intestinal obstruction.
INTRODUCTION
Sigmoid volvulus (SV), the wrapping of the
sigmoid colon around itself and its mesentery, is an
unusual but serious type of intestinal obstruction1.
Both luminal obstruction and vascular occlusion are
important pathophysiological consequences that arise
in SV. Increased intracolonic pressure that decreases
capillary perfusion coupled with mechanical occlusion,
and vessel thrombosis contribute to mucosal ischemia,
resulting in bowel gangrene.1,2
It is the third common cause for intestinal
obstruction after cancer and diverticular disease
and only 2–4% intestinal obstruction is caused by
sigmoid volvulus.3 The cause of sigmoid volvulus is
not known. Primary predisposing factors include a
long congenital sigmoid with a short mesenteric base,
chronic constipation, high fibre regimen, acquisitive
mega colon, anticholinergic drugs, sedatives, and
anti-Parkinson agents.4 Clinical presentations include
abdominal pain, constipation and abdominal distension.
Junior Registrar Surgical, B Unit, Hayatabad Medical Complex,
Peshawar. 2Senior Medical Officer, Satellite Hospital Pabbi. 3Trainee
Medical Officer, Hayatabad Medical Complex, Peshawar. 4Trainee
Medical Officer, Hayatabad Medical Complex, Peshawar.
1
Correspondence: Dr Yousaf Jan, House No 89, Sector K5, Street 2,
Phase 3, Hayatabad, Peshawar. Cell: 03339279312
E-Mail: [email protected]
Received: January 2014
201
Accepted: March 2014
In older patients receiving psychotropic medications,
pain is not usually common, although it would be
associated with significant abdominal distention.5 The
condition may give rise to complications like gangrene
and perforation of sigmoid colon, because of the tight
compression of mesocolic vessels.6
The diagnosis is usually confirmed with abdominal X-ray examination. Plain abdominal films classically show massive colonic distension on the right or
left side of the abdomen with or without small bowel
dilatation. In patients with equivocal diagnosis, a gastrografin enema demonstrates a pathognomonic sign of
sigmoid torsion (bird’s beak or ace of spades signs).7
After hydration and resuscitation, it should be decided
about type of management which include endoscopic
detorsion or emergent laparotomy. Treatment of sigmoid volvulus may be operative or non-operative. Nonsurgical methods include; per rectal decompression by
flexible or rigid sigmoidoscope or by insertion of flatus
tube. However, in 90% cases recurrence occurs after
non-operative treatment. Operative treatment may be
carried out by doing resection and primary anastomosis (RPA), resection and colostomy, Hartmann’s procedure (HP) or sigmoidopexy.8,9
Sigmoid volvulus is often associated with a high
mortality because it affects elderly patients who may
have severe co morbid conditions. Patients older than
70 years represent a high risk group if subjected to
Ophthalmology Update Vol. 12. No. 3, July-September 2014
Choice of Operative Technique for Emergency Cases of Sigmoid Volvulus & its Outcome
surgical intervention. However, when volvulus necessitates emergency surgery, it also carries a substantial
mortality even in relatively young patients.10 The highest mortality usually occurs in cases of resection and
primary anastomosis of gangrenous sigmoid colon
11
.The ideal treatment in large bowel obstruction due
to sigmoid volvulus should result not only in low mortality and morbidity in the short term, but also in low
recurrence rates in the long term. Since, the condition is
quite commonly found in local setting, this study was
carried out to describe the management of sigmoid volvulus, the type of surgical procedures performed and
to determine the prognosis of sigmoid.
MATERIALS AND METHODS
This prospective study was conducted in Hayatabad Medical Complex, Peshawar from January 2010
to July 2011after taking permission from local ethical
and research committee. All patients presenting with
sigmoid volvulus in the above setting with age ranging
from 20-70 years, were included in the study after informed consent. Patients who died before final diagnosis and treatment and those not fit for anaesthesia were
excluded.
Patients’ age, gender and complete data were
recorded. Accurate history of their disease was elucidated, complete physical examination performed and
investigations carried out. Plain X-rays of abdomen
were carried out as a part of investigations along with
baseline and other relevant investigations required to
correct co-morbidities. All the patients were resuscitated preoperatively and were given injection cefuroxime 1.5 gram BD and infusion metronidazole 500mg
till surgery. Initially rectal tube was placed to relieve
the obstruction; unless the patient had symptoms of
peritonitis then a surgical procedure was adopted after
resuscitation. Those relieved with rectal tube initially
underwent surgery on next elective list.
Laparotomy was performed through midline
incision and the viability of the gut was assessed.
Initially the sigmoid was untwisted manually to
relieve obstruction. Then the surgical patients fell into
four categories: those undergoing volvulus reduction
and sigmoidopexy only, intestinal resection and
anastomosis, Hartmann procedure and other methods.
The pelvic and peritoneal cavities were washed
thoroughly with normal saline and pelvic drain was
routinely placed an all cases. Midline incisions were
closed by mass closure using Vicryl-1. Skin was
closed with interrupted prolene 2/0 stitches. After
discharge patients were followed-up for postoperative
complications, recurrence and mortality for two month.
Data was collected with the help of a proforma. The
analysis was performed using SPSS version 11.
Ophthalmology Update Vol. 12. No. 3, July-September 2014
RESULTS
A total of 54 patients with Sigmoid Volvulus were
evaluated in this study. Amongst them 45 (83.3%) were
males and 9 (16.7%) were females, with male-female
ratio of 5:1. The age range was 20-70 years (mean
47.3±17.4 SD years) Table I. The majority of patients
presented with abdominal pain and distension, and
absolute constipation (Table II), the distension being
asymmetrical in 19 cases. Bleeding per rectum was
seen in 7 (12.9%) cases and guarding and rigidity in 21
(38.9%) cases (Table 1).
At operation 33 patients (61.1%) had a viable gut
whereas in 21 (38.9%) cases the gut was gangrenous.
About 23 (42.5%) patients with no peritonitis
responded to rectal tube placement initially and were
recommended for elective sigmoid resection and 10
patients (18.5%) had an emergency laparotomy after
failed tube decompression. Twenty one patients (38.9%)
with peritonitis underwent laparotomy immediately
after resuscitation.
Out of 33 patients with no peritonitis, 29 (87.8%)
underwent primary resection and end to end anastomosis (10 cases in emergency and 19 cases as elective),
2 (6.1%) had sigmoidopexy after detorsion while 2
patients (6.1%) did not give consent for surgery after
successful initial rectal tube placement. Twenty one
patients (38.9%) with peritonitis underwent immediate
surgery after informed consent. Six (11.5%) of them had
primary resection and end to end anastomosis without covering stoma, two (3.8%) had primary resection
and end to end anastomosis with covering stoma, nine
(17.3%) had Hartmann’s procedure and Mikulicz procedure in four patients (7.6%)(Table 2).
The average hospital stay of the patients was 8
days. Post-operative complications were noted more in
gangrenous cases. Four cases (7.7%) had anastomotic
leak, six patients (11.5%) had superficial wound
infection and 3 patients (5.7%) had died, so the overall
mortality was 5.7%.(Table 3).
Table-1: Characteristics and clinical features of patients (n=54)
Variables
Age (years)
<40
40-50
50-60
60-70
Sex
Male
Female
Clinical features
Pain abdomen
Abdominal distension
Constipation
Nausea and vomiting
Bleeding per rectum
Guarding/rigidity
Number
of patients
Percentage
4
9
17
24
45
9
7.4
16.6
31.4
44.4
83.3
16.7
54
54
54
23
7
21
100
100
100
42.5
12.9
38.9
202
Choice of Operative Technique for Emergency Cases of Sigmoid Volvulus & its Outcome
Table-2: Procedures performed for 52 sigmoid
volvulus patients and its death
Procedure performed
Cases (%)
Death (%)
Primary resection
anastomosis
37 (71.1)
3(100%)all cases
with gangrene
Hartmann procedure
9 (17.3)
0
Mikulicz procedure
4 (7.6)
0
Sigmoidopexy
2 (3.8)
0
52
3 (5.7)
Total
Table-3: Postoperative complications
Variables
No of patients
Percentage
Total patients
52
-
Anastomotic leak
4
7.7
Wound infection
6
11.5
Mortality
3
5.7
8 days
-
Average hospital stay
DISCUSSION
Sigmoid volvulus is a common cause of large gut
obstruction in our country. When early laparotomy is
performed the gut is usually found viable in most (80%)
of the patients.12 This disease is very common in specific regions such as Asia, Africa, Middle East, Eastern
Europe, and South America. In our study the diagnosis
was mainly based on clinical and radiological findings.
Diagnosis was later confirmed on operative findings.
Diagnostic accuracy in this study was 94% which is
comparable to literature.13
There is the higher prevalence of sigmoid volvulus in men than women. According to reports this
preference exists in many developing countries, while
in developed countries having an equal proportion of
men and women or a little preference for men.14 In this
study, 83.3% patients were men and 16.7% were women, as compared to 70% and 30%of men and women in
his study by Naseer A.15 Another matter of importance
is the difference in age of the patients with sigmoid volvulus. In western countries, it mostly occurs at the age
of 70 and 80 years, while in developing countries the
age of occurrence is between 40 and 60 years.16 The present study showed an average age of 47.3±17.4 years, as
compared to mean age of 52.2±15.9 years in his study
by Okello TR.10
Based on clinical presentations, sigmoid volvulus has been classically divided into two types of acute
type in which the disease occurs with a sudden onset
and the patients are admitted with colon obstruction;
and subacute type in which mild symptoms are seen
and the duration of the disease is longer. Symptoms
such as ischemia and gangrene are common in the first
type, but in the second type which has been mostly seen
in the elderly, symptoms are milder.17 In our study 48
203
patients (88.8%) had acute obstruction while 6 (11.2%)
presented with chronic subacute obstruction.
Sigmoid volvulus treatment can be done with
different types of therapies including non-surgical decompression or surgical treatments. However, the most
acceptable method is sigmoid non-surgical decompression with a long rectal tube via sigmoidoscopy and
elective sigmoid resection through open or laparoscopic approaches.18 In our study 42.5% responded to rectal
tube placement, as compared to 38.6% in his study by
Maddah G.19
Though primary resection and anastomosis has
been recommended in several studies, because of risk
of anastomotic leakage, it is still controversial. The incidence of anastomotic leakage following this surgery
greatly varies in the literature.20,21 In this study, primary anastomosis was performed in 37 (71.1%) cases
(29 for viable gut and 8 for gangrenous volvulus),of
them 3 (8.1%) cases died because of anastomotic leakage and all cases from them was sigmoid gangrene. In
his study by Maddah G,19 performed 40 (29.2%) cases
of primary resection and anastomosis, 4 (10%) of them
died because of anastomotic leakage and 2 (5%) of them
was from gangrenous group. Therefore if gangrene of
the sigmoid colon is noticed during laparotomy, the
most appropriate method would be resection and end
colostomy with Hartmann procedure.22 In our study 9
(17.3%) patients underwent Hartmann procedure for
gangrenous volvulus and none of them had died, as
compared to 47 (34.3%) Hartmann procedures and 14
(63.6%) died of them in a study by Maddah G.19 However if the surgeon is experienced and there is no systemic factors like diabetes, shock, renal failure and steroid consumption, primary resection and anastomosis
would be a fruitful procedure. Double barrel colostomy
(Paul Mikulicz’s procedure) was conducted in 4(7.6%)
of patients and no one died as compared to 9 (6.5%)
patients and only in one (11.1%) case death occurred in
a study by Maddah G19. The fault for this method is that
patient needs a two-stage surgical procedure, although
it seems that if the intestinal gangrene does not extend
into the distal sigmoid colon, this method would be
confident.
Post-operative complications were noted more in
gangrenous cases. Four cases (7.7%) had anastomotic
leak, as compared to 2.4% and 3.3% in their studies by
Iqbal T23 and Naseer A15 respectively. In our study all
three died patients had primary resection and anastomosis for gangrenous sigmoid volvulus. Six patients
(11.5%) had superficial wound infection, as compared
to 16%, 13.3% and 34.1% in their studies by Iqbal T,23
Naseer A15 and Upendra P24 respectively. Patients with
gangrenous sigmoid volvulus had more wound infections as also in our study. In current study 3 patients
Ophthalmology Update Vol. 12. No. 3, July-September 2014
Choice of Operative Technique for Emergency Cases of Sigmoid Volvulus & its Outcome
(5.7%) had died, so the overall mortality was 5.7%, as
compared to 3.3% and19.5%mortality rates by Iqbal T23
and Naseer A.15 Highest mortality was noticed in patients with gangrenous sigmoid volvulus.
CONCLUSION
Bowel viability is the most important determinant
of the outcome in a patient with sigmoid volvulus. The
initial treatment of sigmoid colon volvulus is sigmoidoscopy with rectal tube placement. Primary resection
and anastomosis for gangrenous sigmoid volvulus has
high morbidity and mortality, therefore if emergency
surgery is indicated, Hartmann’s procedure should be
the procedure of choice especially in gangrenous and
co-morbid conditions as it decreases the morbidity and
mortality in emergency setting.
REFERENCES
1.
Atamanalp SS. Sigmoid volvulus. EAJM 2010;42:144-9.
2.
Raveenthiran V, Madiba TE, Atamanalp SS, De U. Volvulus of
the sigmoid colon. Colorectal dis 2010;12:e1-e17.
3.
Jangjoo A, Soltani E, Fazelifar S, Saremi E, AfzalAghaei M.
Proper management of sigmoid colon volvulus: our experience
with 75 cases. Int J Colorectal Dis 2010; 25:407-9.
4.
Fry RD, Mahmoud N, Maron DJ, Ross HM, Rombeau J.
Colon and rectum. In: Sabiston textbook of surgery. Saunders
Elsevier:2008; 18th ed: 1369-71.
5.
Hellinger MD, Steinhagen RM. Colonic volvulus. In: Wolff BG,
Fleshman JW, Beck DE, Pemberton JH, Wexner SD, editors.
The ASCRS textbook of colon and rectal surgery. New York:
Springer, 2008; 2nd ed: 291-4.
6.
Russel RCG, William NS, Bulstrode CJK. Bailey and love’s
short practice of surgery. 24th ed. London; Arnold Publication;
2004.
7.
Nivatvongs S. Volvulus of the colon. In: Gordon PhH,
Nivatvongs S, editors. Principles and practice of surgery for the
colon, rectum, and anus.Informa Healthcare USA, 2008; 3rded:
971-8.
8.
Cuschieri A, Steele RJC, Moossa AR. Essential surgical practice.
4th ed. London: Arnold Publication; 2002.
9.
Farquharson M, Moran B. Farquharson’s textbook of operative
general surgery. 9th ed. London: Hodder Arnold;2005.
Ophthalmology Update Vol. 12. No. 3, July-September 2014
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
Okello TR, Ogwang DM, Kisa P, Komagum P. Sigmoid
Volvulus and Ileosigmoid knotting at St. Mary´s Hospital
Lacor in Gulu, Uganda. East Cent. Afr. J. Surg, 2009;14(2):58-64.
Bhuiyan M.M, Machowski Z A, Linyama B.S, Madiba M.C, S
Management of sigmoid volvulus in Polokwane-Mankweng
Hospital. (Afr J Surg 2005 Feb; 43(1):17-9.
Bach O, Rudloff U, Pos S. Modification of Mesosigmoidoplasty
for nongangrenous Sigmoid Volvulus. World J Surg 2003;
27(12): 1329-32.
Nizamuddin S, Qureshi S, Ghazanfar S. Six years experience of
sigmoid volvulus. Pak J Surg 2008; 24:5-8.
Heis H, Bani-Hani K, Rabadi D, Elheis M, Bani-Hani B,
Mazahreh T, et al. Sigmoid volvulus in the Middle East. World
J Surg 2008; 32:459-64.
Naseer A, Ahmad S, Naeem M, Safirullah. One stage emergency
resection and primary anastomosis for sigmoid volvulus.
JCPSP 2010;20(5):307-309.
Khan AN, Howat J, McDonald S. Sigmoid volvulus. Accessed
22 April 2007.
Cirocchi R, Farinella E, La Mura F, Morelli U, Trastulli S, Milani
D, et al. The sigmoid volvulus: surgical timing and mortality
for different clinical types. World J Emerg Surg2010; 5:1.
Turan M, Sen M, Karadayi K, Koyuncu A, Topcu O, Yildirir
C, et al. Our sigmoid colon volvulus experience and benefits
of colonoscope in detortion process. Rev ESP Enferm Dig
2004;96:32-5.
Maddah G, Kazemzadeh GH, Abdollahi A, Bahar MM,
Tavassoli A, Shabahang H. Management of sigmoid volvulus:
Options and prognosis. JCPSP 2014;14(1):13-17.
Tiah L, Gon SH. Sigmoid volvulus. Eur J Emerg Med 2006;
13:84-7.
Oren D, Atamanalp SS, Aydinli B, Yildirgan MI, Basoglu M,
Polat KY, et al. An algorithm for the management to sigmoid
colon volvulus and the safety of primary resection experience
with 827 cases. Dis Colon Rectum2007; 50:489-97.
Bhatnagar BN, Sharma CL, Gautam A, Kakar A, Reddy DC.
Gangrenous sigmoid volvulus: a clinical study of 76 patients.
Int J Colorectal Dis 2004; 19:134-42.
Iqbal T, Zarin M, Iqbal A, Tahir F, Iqbal J, Wazir MA. Results of
primary closure in the management of gangrenous and viable
sigmoid volvulus. Pak J Surg 2007;23(2):118-121.
Atamanalp SS, Kisaoglu A, Ozogul B. Factors affecting bowel
gangrene development in patients with sigmoid volvulus. Ann
Saudi Med 2013; 33(2): 144-148.
204
ORIGINAL ARTICLE
Risk Factors of Early Pregnancy Complications
Rahat Jabeen
Rahat Jabeen FCPS1, Ilyas Siddiqi FCPS2
ABSTRACT
Objective: To determine the underlying risk factors in early pregnancy complications and outcome.
Methodology: This case study was conducted at Obstetrics and Gynaecology DepartmentHayatabad Medical Complex,
Peshawar from April 2011 to April 2012 after taking permission from local hospital ethical and research committee. All
the women with first trimester pregnancy with different complications were included in this study. The inducted women
were registered on pre-designed proforma. Data were collected regarding demographic details, gestational period, type of
complications, risk factors, treatment and outcome. All data were analysed on SPSS-11, and frequencies were calculated.
Chi- square test was used for the assessment of p-values and p-value of <0.05 was considered to be statistically significant.
Results: A total of 132 patients with different early pregnancy complications were assessed. Their mean age was 26.5±3.75
years. Commonest complications found were abortion in 93 (70.4%) cases. The underlying risk factors found in abortion
were anti-phospholipid syndrome in 7 (7.5%) cases, Diabetes mellitus in 10 (10.7%) cases, hypertension in 19 (20.4%)
cases, polycystic ovarian syndrome 13 (13.9%) and infection in 9 (9.6%) cases. Most of the cases 83 (62.8%) were treated
by minor surgical procedures, and 31 (23.4%) cases responded with conservative medical therapy. Outcome were anaemia
in 83 (62.8%) cases, psychological upset in 79 (59.8%), infection in 45 (34%) cases and coagulopathy in 7 (5.3%) cases.
Conclusion: Abortion was found as the most frequent early pregnancy complication and the most frequent underlying risk
factor was hypertension. Outcome included anaemia, psychological upset and infection.
Keywords: Abortion, Anemia, Early pregnancy, complications.
INTRODUCTION
Acute complications of pregnancy can appear in all
trimesters; their diagnosis and management are great
challenges.1 Factors affecting pregnancy outcome are
socioeconomic status, smoking status and other health
related conditions and behaviours.2 Different types of
early pregnancy complications are abortion, gestational
trophoblastic disease, ectopic pregnancy and hyperemesis gravidarum.
Miscarriage is a common complication of pregnancy occurring in 15% to 20% of all clinically recognized
pregnancies. It is associated with chromosomal abnormality of the conceptus in over 50% of cases. Abortion
is the most common complication encountered during
early pregnancy.3-5 It has serious impact on the life of
women as well as its consequences like depression and
anxiety. Bleeding can be excessive, leading to shock and
death, a known complication in developing countries
but very rare in developed countries.6 The treatment;
either expectant management, vacuum aspirator, surgical emptying of uterus has its own complications.7 Common risk factors are extreme of age, multiparty, different
medical problems like Diabetes mellitus, hypertension,
Registrar, Gynae “A” Unit, Hyatabad Medical Complex, Peshawar
Assistant Prof. Department of Gynae & Obstetrics, Lady Reading
Hospital, Peshawar
1
2
Correspondence: Dr. Rahat Jabeen, Registrar, Gynae “A” Unit,
Hyatabad Medical Complex, Peshawar. Contact No:0333-4693821
Email: [email protected]
Received. March 2014
205
Accepted. May 2014
infection, genetic factors, polycystic ovarian syndrome,
thyroid disorders, autoimmune disorders and antiphospholipid syndrome. In many cases, the cause of
miscarriage cannot be identified in a large number of
women
Ectopic pregnancy is one of the common early
pregnancy complications. It is another frequent, problem that poses a major health risk to women during
child bearing years, and accounts for about 9% of all
pregnancy related deaths in the United States.8 It is
the third leading cause of maternal death responsible
for 6% of maternal mortality.1 Underlying risk factors
are pelvic inflammatory disease and previous surgeries. Other complications of early pregnancy include
hyperemesis gravidarum and gestational trophoblastic disease. Identifications of risk factors in early pregnancy complications are of great help in treatment of
underlying pathology prior to future conception. The
objective of this study was to find out various risk factors and their influence on early pregnancy complications and treatment outcome.
MATERIALS AND METHODS
This study was conducted at Obstetrics and Gynaecology Department of Hayatabad Medical Complex, Peshawar from April 2011 to April 2012. During the study
period all the admitted women with early pregnancy
complication were included in the study while those
with an uneventful first trimester were excluded from
the study. After taking detailed history, thorough clinical examination was done. All women were investigatOphthalmology Update Vol. 12. No. 3, July-September 2014
Risk Factors of Early Pregnancy Complications
ed for different risk factors like anti-cardiolipin antibodies, anti-phospholipid antibodies for anti-phospholipid
syndrome, blood sugar level for screening of Diabetes,
serum FSH, LH ratio and serum fasting insulin level for
polycystic ovarian syndrome. Serum progesterone level
in cases of threatened abortion, blood complete picture,
midstream urine analysis and high vaginal swab for infection. The treatment options adopted after counselling
were medical that is conservative medical therapy for
treatment of underlying risk factor like hypertension
and diabetes, supportive therapy and hormonal supplements (such as progestogen) in cases of polycystic ovarian syndrome and threatened abortion. Those women
who had missed or incomplete abortion were treated by
misoprostol or minor surgical procedure (dilatation-curettage and evacuation), while women with gestational
trophoblastic disease were treated by suction curettage.
Major surgical procedure (laparotomy) was performed
in cases of septic abortion. The case records of these
women were maintained on the predesigned proforma
having demographic details, gestational period, and
type of complications underlying risk factors, treatment
modalities, outcome and follow-up. Data was analysed
on SPSS version 11; other variables were calculated for
frequencies and percentages.
RESULTS
Patients’ demographic characteristics and frequency of early pregnancy complications with risk factors
are summarized in Table I and II respectively. Mean
age of early pregnancy complication was 26.5±3.75
years. Majority cases were above 30 years (n=68, 51.5%)
and between 21 and 30 years (n=47, 35.6%). Early pregnancy complications commonly occurred in multiparous women i.e. in 57 (43.1%) cases, parity was above
4 while 33(25%) cases were primiparous. Frequency of
early pregnancy complication was high up to 8 weeks
gestational period in87 (65.9%) cases.
Presenting symptoms were bleeding per vaginum in 121 (91.6%) cases, pain in lower abdomen in 85
(64.3%) cases, vomiting in 47 (35.6%) cases and shock in
37 (28%) cases (Table I). Abortion was the frequent complication of early pregnancy found in 93 (70.4%) cases.
The underlying risk factors found in abortion were
anti-phospholipid syndrome in 7 (7.5%) cases, Diabetes
mellitus in 10 (10.7%) cases, hypertension in 19 (20.4%)
cases, polycystic ovarian syndrome 13 (13.9%) and infection in 9 (9.6%) cases. Other complications were gestational trophoblastic disease in 13 (9.8%) cases, ectopic
pregnancy in 10(7.5%) cases and hyperemesis gravidarum in 15 (11.3%) cases. In case of ectopic pregnancy,6
(60%) were associated with infection, while 2 (20%) cases had previous surgery (Table II). Most of the cases 83
(62.8%) were treated by minor surgical procedures, and
31 (23.4%) cases responded with conservative medical
therapy and 18 (13.6%) patients had laparotomy.
Outcome of early pregnancy complications was
psychological upset in 79 (59.8%) cases, infection in 45
(34%) cases, anaemia in 83 (62.8%) cases, coagulopathy
in 7 (5.3%) cases, and septicaemia in 11 (8.3%) cases.
Table-1: Personal characteristics and clinical
presentation of respondent (n=132)
Demographic features
Age distribution
a) Upto 20 years
b) Between 21-30 years
c) Above 31 years
Parity
a) Primary
b) Para 1-4
c) > 4
Symptomatology
1) Bleeding
2) Pain
3) Gestation period
a) Upto 8 weeks
b) Between 8-12 weeks
4) Vomiting
5) Shock
Number of cases Percentage
17
47
68
12.8
35.6
51.5
33
42
57
25
31.8
43.1
121
85
91.6
64.3
87
45
47
37
65.9
34.1
35.6
28
DISCUSSION
Early pregnancy complications are most commonly encountered during first trimester and abortion being
the commonest one 93 (70.4%). This study shows that
mean age for abortion was 26.5±3.75 years; according
to the abortion surveillance report in the United States
50% of abortion occurred at less than 25 years.9 The frequency of risk factors in abortion was higher, found in
Table: 2 Type of early pregnancy complications with underlying risk factors (n=132)
Frequency of risk factors
Complication
Undetected
Antiphospholipid
syndrome
Diabetes
Hypertension
Polycystic
ovarian
syndrome
Infection
Previous
surgery
Total
35(37.6)
7(7.5%)
10(10.7%)
19(20.4%)
13(13.9%)
9(9.6%)
-
93(70.4%)
11(84.6%)
-
-
2
-
-
-
13(9.8%)
Ectopic pregnancy
2(20%)
-
-
-
-
6(60%)
2(20%)
10(7.5%)
Hyperemesis
gravidarum
12(80%)
-
2(13.3%)
1(6.6%)
-
-
-
15(11.3%)
Abortion
Gestational
Trophoblastic disease
Ophthalmology Update Vol. 12. No. 3, July-September 2014
206
Risk Factors of Early Pregnancy Complications
58 (62.3%) cases. The same is reported by Jaleel.10 The
ideal time for the correction of underlying medical risk
factor is before conception and these women should be
properly followed.
Pelvic inflammatory disease was found in 9.6%
cases in comparison with Wamwana et al. where inflammatory disease was a common risk factor for
abortion in 43% cases.11 This vast difference could be
due to social and cultural attitude. Polycystic ovarian
syndrome was another high risk factor found in abortion (13.9%); same is reported by Cocksedgeet al12 and
Khakheli Met al13 (12.5%). Pregnancy failure in cases
of polycystic ovarian syndrome is because of excessive
androgens or obesity. Anti-phospholipid syndrome
was found less significant risk factor in cases of abortion i.e. (7.5%). This is in contrast with Cervera et al,
study where anti-phospholipid syndrome was highly
associated with early pregnancy loss.14 In another study
by Khaskheli Met al,13 anti-phospholipid syndrome was
found in 5.68% cases of abortion. This needs further
work-up in our part of world to find the actual prevalence of anti-phospholipid syndrome and its complications. The main problem in this regard is the cost of
investigations, poor latency rate and lack of awareness
in patients.
In this study, most of the women who came with
threatened abortion were successfully treated by conservative management like treatment of underlying
medical problem and progesterone supplement. The
role of progesterone in preparing the uterus for implantation of the embryo and its role in maintaining the
pregnancy has been known for long-time.15
Those women who had incomplete abortion or
missed abortion underwent mostly surgical evacuation
in 83 (62.8%) cases. Same is reported by Petrous et al,16
KhaskheliM et al13 and the European study.17 Evacuation with vacuum aspiration is a safe alternative.18 In
this study, 17 (18.2%) cases had medical abortion. Vaginal misoprostol is found to be an effective treatment in
cases of early pregnancy failure and has been a safe option as reported by Zhang et al and Sotiriades et al.19,20
In this study ectopic pregnancy accounted for 10 (7.5%)
cases, pelvic inflammatory disease was found in (60%)
cases of ectopic pregnancy, which is consistent with
the studies by Menonet al21 and Khaskheli Met al.13 Hyperemesis gravidarum is a frequent pathology and can
be the cause of serious neurological complications.22
The present study also showed a high frequency of hyperemesis gravidarum (11.3%) as compared to (9.5%)
incidence in a study by Khaskheli Met al13 but in majority of cases no underlying risk factor was found. Early
vitamin supplementation is helpful in pregnancy-related hyperemesis.23
The different outcome measures found were the
207
psychological upset in (59.8%)as compared to 62.1%
incidence in a study by KhaskheliMet al.13 Majority of
those patients had mild depression. For that they were
well counselled and reassured. Only 3 patients (4.1%)
had major psychosis and were referred to psychologist.
In our study, anaemia and coagulopathy were found
in 62.8% and 5.3% patients as compared to 79.3% and
7.8% by KhaskheliMet al.13
Infection rate was found in current study(34%),as
compared to Nanda et al7 and Sturchler et al,24 where
the infection rate was also high following surgical emptying of uterus. Khaskhelietal,13 also showed 44% incidence of infection in her study. About 8.3% patients
had septicaemia.
CONCLUSION
Abortion was found to be the most frequent early
pregnancy complication with many risk factors commonest being hypertension. Outcome was anaemia,
psychological upset and infection. Early diagnosis of
risk factors and their prompt treatment is likely to improve the outcome.
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Marx JA, Hockberger RS, Walls RM, editors. Rosen’s emergency medicine: concepts and clinical practice. 6th ed. Philadelphia: Mosby; 2006.
2.
Mandelson MT, Maden CB, Daling JR. Low birth weight in
relation to multiple induced abortion. Am J Public Health
1992;82:391-4.
3.
Virk J, Zhang J, Oslen J. Medical abortion and the risk of subsequent adverse pregnancy outcomes. N Engl J Med2007;357:64853.
4.
Stenchever MA, Droegemueller W, Herbst A, Mischell DR Jr.
Comprehensive gynecology. 4th ed. St. Louis: Mosby; 2001.
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Chen BA, Creinin MD. Contemporary management of early
pregnancy failure.ClinObstetGynecol 2007; 50:67-88.
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Goyaux N, Alihonou E, Diadhiou F, Thonneau PF. Complications of induced abortion and miscarriage in three African
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2001;80:568–73.
7.
Nanda K, Peloggia A, Grimes D, Lopez L, Nanda G. Expectant
care versus surgical treatment for miscarriage. Cochrane Database Syst Rev2006; (2):CD003518.
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Centres for Disease Control end Prevention. Current trends ectopic pregnancy - United States, 1990-1992. Atlanta: Centres for
Disease Controlend Prevention;1995.
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Gamble SB, Strauss LT, Parker WY, Cook DA, Zane SB, Hamdans; Centres for diseae control and prevention (CDC) Abortion surveillance-United States, 2005. MMWR SurveillSumm
2008; 57:1-32.
10. Jaleel R. impact of maternal obesity on pregnancy outcome, J
Surg Pak 2009; 14:2-6.
11. Wamwana EB, Nadavi PM, Gichangi PB, Karanja JG, Muia
EG, Jaldesa GW. Sociodemographic characteristics of patients
admitted with gynaecological emergency condition at the
provincial general hospital Kakamega, Kenya. East Afr Med J
2006;83:659-65.
12. Cocksedge KA, Li TC, Saravelos SH, Metwally M. A reappraisal of the role of polycystic ovary syndrome in recurrent miscarriage.Repord Biomed Online2008; 17:151-60.
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Khaskheli M, Baloch S, Baloch AS. Risk Factors in Early Pregnancy Complications. JCPSP 2010;20(11):744-47.
Cervera RK, Khamashta MA, ShoenFeldy, Camps MT, Jacobsens S, Kiss E, et al. Morbidity and mortality in the antiphospholipid syndrome during a 5 years period: a multicentre prospective study of 1000 patients. Ann Rheum Dis 2009; 68:1428-32.
Epub 2008 Sep 18.
Wahabi H, Abed Althagafi N, Elawad M. Progestogen for
treating threatened miscarriage. Cochrane Database Sys Rev
2007;(3):CD005943.
Petrou S, Mclntosh E. Women’s preference for attributes, of
first trimester miscarriage management: a stated preference
discrete choice experiment. Value Health 2009; 12:551-9.
Hemminki E. Treatment of miscarriage: current practice and
rationale. Obstet Gynecol1998; 91:247-53.
Soulat C, Gelly M. [Immediate complications of surgical abortion]. J GynecolObstetBiolReprod (Paris) 2006; 35:157-62.
Zhang J, Gillas JM, Barnhart K, Creinin MD, Westho FFC, Fred-
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erick MM. A comparison of medical management with misoprostol and surgical management, for early pregnancy failure.
N Engl J Med2005; 353:761-9.
Sotiriadis A, Makrydimas G, Papatheodorou S, Loannidis JP.
Expectant, medical or surgical management of first trimester
miscarriage: a meta analysis. ObstetGynecol 2005;105:1104-13.-5
Menons, Sammel MD, Vichnin M, Barnhert KT. Risk factors for
ectopic pregnancy: a comparision between adult and adolescent women. J PediatrAdolescGynecol 2007; 20:181-5.
E bou’c, Carlier-Guerin C, de La Sayette V, Grall JY, Herlicoveiz M. [A rare complication of vomiting in pregnancy: Wernicke’s encephalopathy]. J GynecolObstetBiolReprod (Paris)
2006; 35:822-5.
Selitsky T, Chandra P, Shiavello HJ. Wernick’s encephalopathy with hyperemesis and keto-acidosis.ObstetGynecol
2006;107:486-90.
Sturchler D, Menegoz F, Daling J. Reproductive history and
intra-partum fever. GynecolObstet Invest 1986; 21:182-6.
A fundus photo showed a deep and total cup with a
retained silicone oil bubble. (NewsNet Service)
Ophthalmology Update Vol. 12. No. 3, July-September 2014
208
ORIGINAL ARTICLE
Muhammad Shah
Comparison of Efficacy of Low Pressure
Vs Standard Pressure Pneumoperitoneum
During Laparoscopic Cholecystectomy
Muhammad Shah MBBS1, Yousaf Jan FCPS2
Shaukat Hussain MBBS3, Waqas MBBS4
ABSTRACT
Introduction: Symptomatic gall stones disease is a common health problem not only in developed nations rather its
incidence is increasing in developing countries probably because of changing dietary habits. Laparoscopic cholecystectomy
is considered as gold standard in its management.
Objective: To compare the efficacy of low pressure (7-10mm Hg) versus standard pressure (12-14mm Hg) pneumoperitoneum
during laparoscopic cholecystectomy.
Materials and Methods: This randomized controlled trial was carried out in surgical unit Hayatabad Medical Complex,
Peshawar from January 2011 to Jan 2013. Total of 106 patients in each group of symptomatic gallstones disease fulfilling
the inclusion criteria were subjected to laparoscopic cholecystectomy and were followed throughout the procedure to see
for any pain.
Results: A total of 212 patients underwent LC during the study period. The mean age was 41.59 years±11.38SD with
range of 19-70 years. Low pressure group showed 95(89.6%) efficacy, whereas standard pressure group showed 82(77.4%)
efficacy. Efficacy in both the group was significant with p-value of 0.016.
Conclusion: Low pressure pneumoperitoneum is more effective than standard pressure pneumoperitoneum in terms of
postoperative pain relief.
Keywords: Low pressure laparoscopic cholecystectomy (LPLC), Standard pressure laparoscopic cholecystectomy (SPLC)
INTRODUCTION
Laparoscopic Cholecystectomy (LC) is one of the
most common laparoscopic surgeries performed in
medical world.1 Cholecystectomy through Laparoscopy is the most common major abdominal procedure
performed worldwide especially in western countries.
It was first reported in Germany and France more
than 2 decades ago which has now become the procedure of choice for routine gallbladder removal.2 In 1985,
Dr. Muhe performed the first LC in Germany using a
laparoscopy device called the galloscope. After 2 years
in 1987, Dr. Mouret of France accomplished the Cholecystectomy through Laparoscopy with an approach
that became the standard technique afterwards3. Laparoscopic Cholecystectomy was called the ‘gold standard’ procedure for gallstone disease for the first time
in 19894 and by 1992 Laparoscopic Cholecystectomy
was endorsed as a legitimate tool for the treatment of
symptomatic cholelithiasis due to which the number of
cholecystectomies increased by 25% to 30%. After 1995
till now, the number of cholecystectomies performed
through laparoscopy reached to 80% of all cholecystectomies.2,5
Trainee Medical Officers, Hayatabad Medical Complex, Peshawar
Junior Registrar, Surgical B Unit, Hayatabad Medical Complex,
Peshawar, 4Medical Officer, Satellite Hospital Pabbi
1,3
2
Correspondence Dr. Muhammad Shah, House No 200, Sector D1,
Main Ghazali Road, Phase 1 Hayatabad Peshawar. 03339129928
[email protected]
Received: April’2014
209
Accepted: June’2014
Besides, many benefits explaining the success of
Laparoscopic Cholecystectomy, like lower morbidity,
shorter hospitalizations, smaller incisions, less postoperative pain and earlier return to normal activity,6
the early pain is the most frequent complaint after
Laparoscopic cholecystectomy and the main reason
for overnight hospital stay in 17-41% of the patients.4,7
Though this postoperative pain is less intense than that
after open surgery, but some patients (13%) still experience considerable discomfort due to its severness.4
Interestingly, the type of pain after laparoscopy differs
considerably from that observed after other surgical
procedures.8 Shoulder pain is a frequent postoperative
observation after laparoscopy and its incidence varies
from 35% to 80% and ranges from mild to severe. In
some cases it has been reported to last more than 72
hours after Laparoscopic cholecystectomy.6 Visceral
pain is also reported as complains after operative laparoscopy.8
The etiology and exact mechanism of post-laparoscopic pain is currently still not understood clearly.9,10
Most authors believe that it is an irritation of the phrenic
nerve causing referred pain of C4 projected to the shoulder.9 Certain factors may influence the degree of pain
after pressure created by the pneumoperitoneum, and
the temperature of insufflated gas.4 Using a CO2-elicited
pneumoperitoneum is appeared to be the current gold
standard for surgical management of cholelithiasis and
low pressure CO2-elicited pneumoperitoneum has been
shown to not only significantly reduce the level of postOphthalmology Update Vol. 12. No. 3, July-September 2014
Comparison of Efficacy of Low Pressure Vs Standard Pressure Pneumoperitoneum During Laparoscopic Cholecystectom
operative pain but accelerate patient’s recovery as well.
Patients have experienced shoulder pain less frequently (7%) after low pressure CO2-elicited pneumoperitoneum LC (93% effectiveness) as compare with gasless
laparoscopic cholecystectomy (28%). The average pain
score at 12 hours for patients who underwent LPLC
was 54.2 ± 8.5 with a minimum 38 and a maximum 69
on visual analogue score of 0-100 mm, while it was observed 62.2 ± 12.0 with a minimum of 35 and maximum
of 100 in patients who underwent SPLC. This difference
observed was statistically significant.11
Pappas-Gogos G, et al found the amount of residual gas correlated with the postoperative pain which
shows that the total volume of CO2 may also be a more
important factor for postoperative pain.12 Low pressure
pneumoperitoneum tended to be better than standard
pressure pneumoperitoneum in terms of lower incidence of shoulder tip pain with efficacy of 72.1% vs
55.7% respectively, but this difference did not reach to
statistical significance following elective laparoscopic
cholecystectomy.13
The post-laparoscopic pain may have a significant
burden on both the patient and health system. Moreover, it leads to make a negative public perception of
ineffectiveness of laparoscopic cholecystectomy. All
these can cause extra psychological and physical stress
on the patients and also needs more hospital stay leading to more financial expenditure. As we are using
standard pressure pneumoperitoneum for laparoscopic cholecystectomy in our setup due to non-availability
of local statistics. In this regard, the current study was
designed to find statistics about the said procedure
in our local population present. Therefore this study
was conducted to compare the efficacy of low pressure
(7-10mm Hg) versus standard pressure (12-14mmHg)
pneumoperitoneum during laparoscopic cholecystectomy.
MATERIAL AND METHODS
This randomized controlled study was conducted
in surgical unit Hayatabad Medical Complex, Peshawar from January 2011 to January 2013 after taking permission from local ethical and research committee. The
inclusion criteria included patients undergoing elective laparoscopic cholecystectomy, patients of either
gender of ≥ 18 years of age and patients undergoing
laparoscopic cholecystectomy with ASA I and ASA II.
Patients having acute cholecystitis needs emergency
cholecystectomy, empyema or mucocele of gallbladder,
patients with acute gallstones pancreatitis and recent
history of ERCP were excluded from the study.
All admitted patients as well as patients from outdepartments with the gall stone meeting the inclusion
criteria were recruited for the study. The diagnoses
of cholelithiasis were based on ultrasound imaging/
Ophthalmology Update Vol. 12. No. 3, July-September 2014
visualization examination and the evaluation was
done clinically. All recruited patients was admitted
and subjected to detailed history and examination. The
purpose and benefits of study and complete procedure
of laparoscopic cholecystectomy using CO2-elicited
pneumoperitoneum as well as the postoperative effects
were explained to the patients in details after informed
consent. The patients were randomly allocated in two
groups by lottery method. Patients in ‘Group-A’ was
subjected to standard pressure pneumoperitoneum
and patients in ‘Group-B’ was subjected to low pressure pneumoperitoneum.
All the laparoscopic surgeries were carried out
under the supervision of highly experienced surgeon
who has extensive experience in laparoscopic surgery.
The degree of the postoperative pain was assessed at 24
hours after surgery, using a visual analog scale (0-10) by
nursing staff who was unaware of the perioperative effects, zero being no pain and ten being the worst possible postoperative pain. The postoperative shoulder tip
pain of less than 3 on visual analogue score observed 24
hours was considered effective. A standard postoperative analgesic regimen was administered to all patients
if needed. The nature and consumption amount of
analgesics was recorded. All the above mentioned information including demographics was obtained on a
pre-designed performa. Exclusion criteria were strictly
followed to control confounders and bias in the study
results.
Data Analysis Procedure: The data collected from
the patients through performa were entered in SPSS
latest version. Mean ± SD were calculated for continuous variable like age. Frequencies and percentages were
calculated for categorical variable like gender, postoperative pain and Efficacy. Chi-square test was applied
to compare the efficacy in both the group. Efficacy was
stratified among age, gender and occupation to see the
effect modifiers. P-value< 0.05 was considered significant. All the results was presented as tables and graphs.
RESULTS
A total of 212 patients underwent laparoscopic
cholycestectomy, which were divided in two equal
groups of low and standard pressures. Patients in low
Group were managed with (7-10mm Hg) pressure and
the patients in standard Group with (12-14mm Hg)
pressure.
Sex wise distribution shows that out of 106 patients 30(28.3%) were males and 76(71.7%) were females in Group A, while group B contains 34(32.1%)
males and 72(67.9%) were females. Male to female ratio
was 0.43:1. Sex distribution among the groups was insignificant with p-value=0.327 (Table 1)
Average age was 41.59 years+ 11.38SD with range
of 19-70 years. Low pressure contained 23(21.7%) pa210
Comparison of Efficacy of Low Pressure Vs Standard Pressure Pneumoperitoneum During Laparoscopic Cholecystectom
tients in less than 30 years, 69(65.1%) patients 31-50
years and 14(13.2%) patients between the ages of more
than 50 years. While Standard pressure group contained
19(17.9%) patients in less than 30 years, 64(60.4%) in 3150 years and 23(21.7%) patients with age more than 50
years. The age distribution among the group was also
insignificant with p-value 0.252 (Table 2)
Low pressure group showed 95(89.6%) efficacy
while non-effective in 11(10.4%) patients. Similarly
standard pressure group showed 82(77.4%) efficacy
while non- effective in 24(22.6%) patients. Efficacy in
both the group was significant with p-value of 0.016
(Table 3).
Table-4: Age wise distribution of efficacy
Efficacy
<= 30
Age
(in years)
31 - 50
51+
Total
Table-1: Sex wise comparison of both the groups
NO
37
5
42
88.1%
11.9%
100.0%
112
21
133
84.2%
15.8%
100.0%
28
9
37
75.7%
24.3%
100.0%
177
35
212
83.5%
16.5%
100.0%
Efficacy
LOW
PRESSURE
(Group B)
Total
34
30
64
32.1%
28.3%
30.2%
72
76
148
67.9%
71.7%
69.8%
106
106
212
100%
100%
100%
Male
Gender
Female
Total
p-value
Male
Gender
Total
Group
Age
(in years)
<= 30
31 - 50
51+
Total
Total
19
23
42
17.9%
21.7%
19.8%
64
69
133
60.4%
65.1%
62.7%
23
14
37
21.7%
13.2%
17.5%
106
106
212
100.0%
100.0%
100.0%
p-value
0.252
Table-3: Efficacy wise distribution of patients in both the groups
Group
YES
Efficacy
NO
Total
211
Total
STANDARD
PRESSURE
(Group A)
LOW
PRESSURE
(Group B)
82
95
177
77.4%
89.6%
83.5%
24
11
35
22.6%
10.4%
16.5%
106
106
212
100.0%
100.0%
100.0%
Female
0.327
Table-2: Age wise distribution in both the groups
STANDARD
LOW
PRESSURE PRESSURE
(Group A)
(Group B)
p-value
0.311
Table-5: Gender wise distribution of efficacy
Group
STANDARD
PRESSURE
(Group A)
Total
YES
p-value
0.016
Total
YES
NO
52
12
64
81.2%
18.8%
100.0%
125
23
148
84.5%
15.5%
100.0%
177
35
212
83.5%
16.5%
100.0%
p-value
0.563
Age wise distribution of efficacy shows that efficacy was greater in younger age group and decreases
with the increase of age. The patients having less than
or equal to 30 years of age have showed efficacy in
37(88.1%) patients while 5(11.9%) patients shows no
efficacy. Patients with 31-50 years of age have shown
efficacy in 112(84.2%) of patients and 21(15.8%) have
shown no efficacy. Similarly 28(75.7%) patients have
shown efficacy and 9(24.3%) patients have no efficacy,
with age more than 50 years of age. The efficacy was
insignificant over age with p-value=0.311 (Table 4).
When efficacy was stratified among the gender it
showed insignificance with p-value=0.563. There were
52(81.2%) male patients showing efficacy while no efficacy in 12(18.8%) male patients. Similarly in female patients, 125(84.5%) gave efficacy while 23(15.5%) showed
no efficacy (Table 5)
DISCUSSION
Cholelithiasis is a common disease with a prevalence of 10-15% in the USA and about 16% in Pakistan.1,2
Patients mostly remain asymptomatic but symptoms
appear when any complication develops.3 Symptomatic gall stone disease can end up with its complications
without prompt surgical intervention. LC became an
attractive treatment modality for cholelithiasis because
of less scarring, shortened hospital stays, earlier returns
to usual activities.14
Our study population was younger; mean age was
40.65±10.35 years, as compared to mean age of 47.2
Ophthalmology Update Vol. 12. No. 3, July-September 2014
Comparison of Efficacy of Low Pressure Vs Standard Pressure Pneumoperitoneum During Laparoscopic Cholecystectom
years and 40 years reported by Daradkeh15 and Bingener16 respectively.
“The higher the pressure, the better the view”
used to be the axiom invoked by surgeons who needed
adequate exposure for laparoscopic procedures. However, the maintenance of elevated intra-abdominal
pressure for the duration of the procedure is associated
with numerous undesirable consequences including
post- operative shoulder tip pain. Laparoscopic cholecystectomy results in less postoperative pain and reduced analgesic consumption as compared with open
cholecystectomy. Nonetheless, pain after laparoscopy
may be moderate or even severe for some patients, and
may require opioid treatment. Shoulder pain is a common complaint following laparoscopic surgery, initially being recognized by gynecologists during early experience with laparoscopic sterilization. The incidence
varies, but is common, being experienced in approximately one third of patients following laparoscopic
cholecystectomy. The pain usually lasts 2-3 days.
In our study the frequency of shoulder tip pain
after standard pressure laparoscopic cholecystectomy
was significantly higher as compared to low pressure
laparoscopic cholecystectomy. Out of 106 patients 24
(22.6%) complained of shoulder tip pain after standard
pressure laparoscopic cholecystectomy as compared
to 11 patients (10.4%) out of 106 in low pressure laparoscopic cholecystectomy. Therefore the incidence of
shoulder tip pain was 2.2 times lower after low pressure laparoscopic cholecystectomy than standard pressure laparoscopic cholecystectomy ( p < 0.05). These results are consistent with the findings of M Barczynski
et al17. In their study 8 patients (10.81%) out of 74 in the
low pressure group complained of shoulder tip pain as
compared to 18 patients (24.32%) in the standard pressure laparoscopic cholecystectomy. The shoulder tip
pain being 2.2 times lower in low pressure as compared
to standard pressure laparoscopic cholecystectomy.
The studies conducted by Faisal Bilal Lodhi et al18 and
Sandhu T et al13 demonstrated similar results.
In one of study the mean intensity of post-operative shoulder tip pain at 4 h, 8 h and 24 h was higher
after standard pressure laparoscopic cholecystectomy
as compared to low pressure laparoscopic cholecystectomy. The mean intensity of post-operative shoulder
tip pain at 4 h was 4.2 + 0.45 in low pressure laparoscopic cholecystectomy and 4.43+ 1.4 in standard pressure laparoscopic cholecystectomy. The mean intensity
of post-operative shoulder tip pain at 8 h was 2.2 +
1.1 in low pressure laparoscopic cholecystectomy and
3.5±0.76 in standard pressure laparoscopic cholecystectomy. The mean intensity of post-operative shoulder
tip pain at 24 h was 0.2 + 0.45 in low pressure laparoscopic cholecystectomy and 0.64 + 0.74 in standard
Ophthalmology Update Vol. 12. No. 3, July-September 2014
pressure laparoscopic cholecystectomy.19 In our study
we measured pain intensity only after 24 hour of surgery in both groups and showed the same result (Table
3).
Esmat et al,20 also concluded that post-operative
shoulder tip pain was significantly less in low pressure
laparoscopic cholecystectomy as compared to standard
pressure laparoscopic cholecystectomy, as also showed
by our own study (p-0.016).
In one study the analgesic (diclofenac) requirements for shoulder tip pain were less in low pressure
laparoscopic cholecystectomy as compared to standard pressure laparoscopic cholecystectomy. The mean
number of analgesic injections was 2.2 + 0.45 in low
pressure laparoscopic cholecystectomy and 2.71 + 0.5
in standard pressure laparoscopic cholecystectomy.
The difference between the two is however statistically
insignificant (p= 0.156).21,22
Shoulder pain is a frequent postoperative observation after laparoscopy and its incidence varies from
35% to 80% and ranges from mild to severe. In some
cases it has been reported to last more than 72 hours after laparoscopic cholecystectomy6. Visceral pain is also
reported as complains after operative laparoscopy.8
Due to a decrease in the effective working space
in low pressure pneumoperitoneum, the major concern
of low intra- abdominal pressure would have been the
operative time and conversion to open surgery. In our
study however the operative time in the two groups
were comparable statistically, although the mean operative time in group B was less than group A.
CONCLUSION
In accordance with earlier studies we conclude
that use of simple expedient of reducing the pressure
of the pneumoperitoneum to 8mmHg results in a significant reduction in both the frequency and the severity of postoperative shoulder tip pain. It decreases the
analgesic demand, reduces the hospital stay and hence
improves the quality of life in the early stage of postoperative rehabilitation. On the basis of these results, the
widespread use of low pressure pneumoperitoneum
during laparoscopic cholecystectomy is recommended.
REFRENCES
1.
Chamberlain RS, Sakpal SV. A Comprehensive Review of Single-Incision Laparoscopic Surgery (SILS) and Natural Orifice
Transluminal Endoscopic Surgery (NOTES) Techniques for
Cholecystectomy. J Gastrointestinal Surg. 2009 Sep;13(9):173340.
2.
Litwin DE, Cahan MA. Laparoscopic Cholecystectomy. Surg
Clin North Am. 2008 Dec;88(6):1295-313.
3.
Marescaux J, Dallemagne B, Perretta S, Wattiez A, Mutter
D, Coumaros D. Surgery Without Scars Report of Transluminal Cholecystectomy in a Human Being. Arch Surg. 2007
Sep;142(9):823-6.
4.
Mentes O, Harlak A, Yigit T, Balkan A, Balkan M, Cosar A, et
al. Effect Of Intraoperative Magnesium Sulphate Infusion On
Pain Relief After Laparoscopic Cholecystectomy. Acta Anaes-
212
Comparison of Efficacy of Low Pressure Vs Standard Pressure Pneumoperitoneum During Laparoscopic Cholecystectom
5.
6.
7.
8.
9.
10.
11.
12.
thesiol Scand. 2008;52:1353-9.
Sherwinter DA. Laparoscopic Cholecystectomy. [Online]. [Cited on Sep 13, 2011]. Available at http://emedicine.medscape.
com/article/1582292-overview.
Phelps P, Cakmakkaya OS, Apfel CC, Radke OC. A Simple
Clinical Maneuver to Reduce Laparoscopy-Induced Shoulder
Pain. Obstet & Gynecol. May 2008;111(5):1155-60.
Agarwal A, Gautam S, Gupta D, Agarwal S, Singh PK, Singh
U. Evaluation Of A Single Preoperative Dose Of Pregabalin For
Attenuation Of Postoperative Pain After Laparoscopic Cholecystectomy. Br J Anaesth. 2008;101(5):700-4.
Angral R, Lachala S, Gupta S. Post-Operative Analgesic Technique In Laparoscopic Cholecystectomy: Comparison Of Local
Instillation With Bupivacaine Vs. Intravenous Butorphanol Vs
Intercostal Nerve Block With Bupivacaine. Sri Lankan J Anesthesiol. 2013;21(1):9-13.
Tsimoyiannis EC, Tsimogiannis KE, Pappas-Gogos G, Farantos
C, Benetatos N, Mavridou P, Manataki A. Different Pain Scores
In Single Transumbilical Incision Laparoscopic Cholecystectomy Versus Classic Laparoscopic Cholecystectomy: A Randomized Controlled Trial. Surg Endosc. 2010;24:1842-8.
Uen YH, Chen Y, Kuo CY, Wen KC, Koay LB. Randomized
Trial of Low-pressure Carbon Dioxide-elicited Pneumoperitoneum Versus Abdominal Wall Lifting for Laparoscopic Cholecystectomy. J Chin Med Assoc. 2007 Aug;70(8):324-30.
Kanwer DB, Kaman L, Nedounsejiane M, Medhi M, Verma
GR,Bala I. Comparative Study Of Low Pressure Versus Standard Pressure Pneumoperitoneum In Laparoscopic Cholecystectomy - A Randomized Controlled Trial. TropicGastroent.
2009;30(3):171-174.
Pappas-Gogos G, Tsimogiannis KE, Zikos N, Nikas K, Manataki A, Tsimoyiannis EC. Pre incisional And Intraperitoneal
Ropivacaine Plus Normal Saline Infusion For Postoperative Pain Relief After Laparoscopic Cholecystectomy: A Randomized Double-Blind Controlled Trial. Surg Endosc. Sep
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
2008;22(9):2036-45.
Sandhu T, Yamada S, Ariykachan V, Chakarb T. Low pressure
pneumoperitoneum versus standard pressure pneumoperitoneum in laparoscopic cholecystectomy-A randomized clinical
trial. Surg endosc. 2009;23(5);1044-7.
Livingston EH, Rege RV.A nationwide study of conversion from laparoscopic to open cholecystectomy. Am J Surg.
2004;188:205–11
Daradkeh S. Laparoscopic cholecystectomy: analytical study of
1208 cases. Hepatogastroenterol. 2005;52:1011-4.
Bingener-Casey J, Richards ML, Strodel WE, Schwesinger
WH, Sirinek KR. Reasons for conversion from laparoscopic to
open cholecystectomy: a 10-year review. J Gastrointest Surg.
2002;6:800-5.
Barczynski M, Herman RM. A prospective randomized trial on
comparison of low-pressure (LP) and standard-pressure (SP)
pneumoperitoneum for laparoscopic cholecystectomy. Surg
Endosc. 2003;17(4):533e8.
Faisal Bilal Lodhi, Riaz Hussain. Laparoscopic cholecystectomy; Low-pressure pneumoperitoneum for shoulder-tip pain.
Prof Med J. 2003;10(4):266e70.
Yasir M, Mehta KS, Banday VH, Aiman A, Masood I, Iqbal B.
Evaluation of post-operative shoulder tip pain in low pressure
versus standard pressure pneumoperitoneum during laparoscopic cholecystectomy. The Surg. 2012;7:1e7 4.
Esmat ME, Elsebae MM, NasrMM, Elsebaie SB. Combined low
pressure pneumoperitoneum and intraperitoneal infusion of
normal saline for reducing shoulder tip pain following laparoscopic cholecystectomy.World J Surg. 2006;30(11):1969-73.
Li LJ, Zheng XM, Jiang DZ, Zhang W, Shen HL, Shan CX, etal.
Progress in laparoscopic anatomy research: A review of the chinese literature. World J Gastroenterol. 2010 May 21;16(19):2341-7
Jorgensen JO, Gillies RB, Hunt DR. A simple and effective way
to reduce postoperative pain after laparoscopic cholecystectomy. Aust NZ J Surg. 1995;65:466-9.
Anterior Dislocation of Lens
A young man complaining of sudden, painful and blurred
vision after vigorous long jump exercise. No history of direct trauma.
DD. Intra ocular tumour. Acquired syphilis, Marfans Syndrome, Homocystenuria, Well Marchesani Syndrome.
Treatment: Surgical removal of the lens, Anterior Vitrectomy, Iris fixed IOL.
Complications: Ocular Hypertonia, Corneal decompensation. Glaucoma. (NewsNet Service)
213
Ophthalmology Update Vol. 12. No. 3, July-September 2014
ORIGINAL ARTICLE
Treatment of Femoral
Fractures with early Hip Spica in Children
M. Imran Khan
Muhammad Imran Khan FCPS1, Muhammad Saqib MBBS 2
ABSTRACT
Objective: To find out the advantages of early spica cast as a treatment for isolated, uncomplicated femoral shaft fracture
in children.
Study design: Prospective study.
Materials and methods: The study was conducted in orthopaedic unit of Agency Headquarter Hospital Landikotal from
May 2012 to November 2013. Twenty five patients were included in the study. All the children of both sexes from 1 to 6 years
of age with fracture shaft of femur presented within 72 hours of injury were included in this study.
Results: Twenty five patients with femur shaft fractures who met inclusion criteria were enrolled for this study. There were
18 males and 7 females. Commonest problems with spica cast were soakage and breakage and reinforcement. Shortening
of fractured limb was seen in 17 out of 25 children. Angulation of femur was seen in 4 children at the time of removal of spica
cast. At 6 months follow up no non-union or mal-union or rotational deformity was noted.
Conclusions: Early spica cast is simple, effective and definite method of treatment in children up to 6 years of age. Early
spica cast allows rapid return of child to family environment and it also avoids complications related to traction and operative
treatment methods
Key words: Peadiatric trauma, femoral fractures, hip spica.
INTRODUCTION
Peadiatric lower limb long bones diaphyseal
fractures are a very common injury, the commonest of
which are femoral fracture that requires hospitalization
as well.1 Femur is the main weight bearing bone of the
body and hence its fracture can be catastrophic for the
child and the family. The main cause of fracture in preschool children is child abuse and fall2 while sporting
events and road traffic accidents are the commonest
causes in older children. As the age increases and bones
are stiffened, fracture causing force must be more
severe.3, 4 There are several ways of treating femoral-shaft
fractures in children, including skeletal or skin traction,
immediate application of a hip spica cast, closed
reduction and minimally invasive plate osteosynthesis,
external fixation, plate fixation, and internal fixation
with intramedullary nails. Selecting the management
strategy is dependent on factors such as the presence
of other associated injuries or multiple trauma, fracture
properties, age, and socioeconomic factors.5, 6, 7 The
preferred method of treatment for femoral shaft fracture
in children younger than six years age is usually by
closed reduction and primary spica cast. For children
more than 11 years age it is by surgery, but there is no
District Specialist, Orthopaedic Unit, Agency Headquarter Hospital
Landikotal, 2Medical Officer, Orthopaedic Unit, Khyber Teaching
Hospital, Peshawar.
1
Correspondence: Dr. Muhammad Imran Khan, House No 292,
street-10, Sector N-1, Phase-4, Hayatabad, Peshawar.
Phone : 0333505504 E mail address: [email protected]
Received: December 2013
Accepted: March 2014
Ophthalmology Update Vol. 12. No. 3, July-September 2014
agreement on definite method of treatment between
ages 6-12 years and both non-operative and surgery
with internal fixation can be used.8, 9, 10
This study was conducted to evaluate the results of
immediate hip spica casting in the treatment of femoral
shaft fractures in children of 1 to 6 years of age.
MATERIALS AND METHODS
The study was conducted in orthopaedic unit of Agency Headquarter Hospital Landikotal from May 2012 to
November 2013. Twenty five patients were included in
the study.
Inclusion criteria was;
• Presentation of injury with in 72 hours.
• Isolated femoral shaft fracture.
• Age range 1-6 years.
Exclusion criteria was;
• Late presentation after 72 hours.
• Pathological, subtrochanteric, supracondylar and
multiple fracture.
• Open fractures.
• Patients less than I year and more than 6 years.
After emergency management and radiological
examination, the patients were admitted to ward and
put on straight leg skin traction and kept nothing by
mouth for 4 hours until spica cast can be applied in the
operation theater under general anaesthesia. Traction
was applied on fractured limb to overcome over riding.
Both hips and knees were kept straight with ankle
in neutral position. Hips were abducted about 30-40
degrees and kept neutral in rotation and one and half
hip spica cast was applied. After spica radiographs
were taken in 2 planes to measure shortening and
214
Treatment of Femoral Fractures with early Hip Spica in Children
angulation. Children were usually discharged on same
day. Patients were followed in outpatient department
at 1, 2, 3, 5, 7 and 10 weeks and then on monthly basis
for 6 months. At every visit hip spica was examined
to note soakage, weakness or breakage of cast and
pressure symptoms. Radiographs were taken to note
overlapping and angulation. If spica had weakened or
broken it was reinforced or changed. In follow-up visit
if x-rays showed more than 2cm overlap or more than 20
degree angulation in anterioposterior plane and more
than 15 degree angulation in medial and lateral planes,
spica was removed and fracture re-manipulation under
general anaesthesia was done and spica re-applied.
After radiological union the patients were encouraged
to start gradual weight bearing.
RESULTS
Twenty five patients with femur shaft fractures
who met inclusion criteria were enrolled for this study.
The mean age of patients were 3.25 years (range 1 year
to 6 years). There were 18 males and 7 females with M:
F ratio of 2.57:1. The most common mode of injury was
fall from height. Thirteen fractures were on right and
12 on left side. There were 16 oblique, 8 transverse and
1 spiral fractures. Five fractures involved the proximal
third, 16 the middle third and 4 distal third of shaft of
femur (Table-I).
All the children were followed till union of fracture
and removal of cast. Period of immobilization in spica
cast ranged from 4 weeks 7 weeks with average of 5.73
weeks. Commonest problems with spica cast were
soakage and breakage, which occurred in 11 out of 25
children (44%). Spica cast was reinforced in 8 (32%)
children and changed in 3 (12%). None of the children
required wedging. At the time of fracture healing i.e. at
removal of spica cast, shortening of fractured limb was
seen in 17 out of 25 children. Shortening ranged from
0.5cm to 2.5cm. Most children had shortening of 2cm
or less, which was acceptable. Angulation of femur was
seen in 4 children at the time of removal of spica cast.
After removal of cast parents were asked to bring their
child on monthly basis up till 6 months post castings.
All children had equal limb lengths and no instances
of malunion, nonunion, or rotational deformities noted
(tab-II). Patient’s age, gender, radiological union of
fracture, out come and complications were recorded.
Data were analyzed using SPSS software.
Table-II: Complications of spica casting
Complications
Number of patients
Spica soakage and breakage
11 (44%)
Spica re-enforcement
8 (32%)
Spica change
3 (12%)
Shorteneing at spica removal
17 (68%)
Shortening at 6 months
0
DISCUSSION
Femoral fractures account for about 1.6% of all
skeletal lesions in children, with a 2.6:1 male to female
ratio and a bimodal distribution with an initial peak in
early infancy. According to age, these fractures can occur as a result of the following: newborns: obstetrical
trauma, children up to 4 years of age: different types
of trauma (30% to 80% due to abuse)11, 12 children over
4 years of age: most frequently, sports trauma, high
energy trauma and road accident trauma. The most
frequent and disabling long term complications are angular rotational deformities; more rarely, late consolidation, pseudoarthrosis and infections can occur.13
Spica cast is simple, safe, effective and definitive
method of treatment. It is cheap and associated with
short hospital stay. The problem with early spica cast
treatment is shortening and deformity of limbs.14, 15 Results of our study are comparable with others.16, 17, 18 Ali
and Raza19 have compared results of Thomas splint and
early hip spica casting in terms of time of union, degree
of shortening and angulations in coronal and sagittal
plane and found no significant difference between the
two groups.
Sugi and Cole have treated 191 children up to 10
years of age by early spica method.18 Shortening at removal of cast was seen in all children of 9mm to 20mm
(ranged from 0 to 10% of femoral length). At late review
only seven children had from 6 to 13mm of shortening. Angular mal-alignment was not seen at late review, while 13 children had 10 degree to 15 degree of
medial rotation of the leg that was not noticed by parents or children. Nine children had complication due
to spica, including pressure effects, mal-alignment of
fracture and breakage of spica. In our patients we did
not remove sole of cast underneath foot and found that
shortening was not affected with presence of sole cast.
In our patients shortening occurred in only 17 out of
25, as compared with all patients of Sugi and Cole at
Table -I: Showing sex, side and site involvement and fracture geometry
Sex
215
Side involved
Fracture geometry
Site involvement– 1/3rd
M
F
L
R
Oblique
spiral
transverse
18
7
12
13
16
1
8
upper
5
middle
16
lower
4
Ophthalmology Update Vol. 12. No. 3, July-September 2014
Treatment of Femoral Fractures with early Hip Spica in Children
time of removal of spica. We do not have follow-up,
therefore long term results cannot be compared. The
main concern in the treatment of femoral shaft fracture
in children is shortening and deformity of the limb. In
children, after fracture, femur grows at an increased
rate. Overgrowth ranging from 1cm to 2.5cm has been
reported by many authors.20,21 This overgrowth phenomenon following femur fracture has allowed acceptance of shortening up to 2cm at time fracture healing.
A retrospective study of 46 children with femoral Shaft fracture treated with immediate hip spica by
Frech-Dorfl er at follow-up, on average 7.5 years after
trauma, only one patient showed a leg length discrepancy greater than 2 cm. One patient showed a minor
valgus and rotational deformity. The study concluded
that the long term outcome for conservatively treated
femoral shaft fractures in preschool children is very
good, even in severely displaced fractures and initial
shortening of up to 2.5 cm can be treated successfully
with a spica cast.22
CONCLUSION
Early spica cast is simple, effective and definite
method of treatment. Children up to 6 years of age can
be safely treated with early spica cast. Early spica cast
allows rapid return of child to family environment,
thus avoiding prolonged separation from parents. Early spica cast also avoids complications related to traction and operative treatment methods.
REFERENCES
1.
Hinton RY, Lincoln A, Crockett MM, Sponseller P, Smith
G. Fractures of the femoral shaft in children. Incidence,
mechanisms, and sociodemographic risk factors. J Bone
JointSurgAm1999;81:500-9.
2.
Blakemore LC, Loder RT, Hensinger RN. Role of intentional
abuse in children 1 to 5 years old with isolated femoral shaft
fractures. J Pedial Orthop 1996;16:585-8.
3.
Daly KE, Calvert PT. Accidental femoral fracture in infants.
Injury 1991;22:337-8.
4.
Loder RT. pediatric polytrauma orthopaedic care and hospital
course. J Orthop Trauma.1987;1:48-54.
5.
Buess E, Kaelin A. One hundred pediatric femoral fractures:
epidemiology, treatment attitudes, and early complications. J
Pediatr Orthop B. 1998;7:186–92.
Ophthalmology Update Vol. 12. No. 3, July-September 2014
6.
7.
8.
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22.
Coyte PC, Bronskill SE, Hirji ZZ. Economic evaluation of 2
treatments for pediatric femoral shaft fractures. Clin Orthop
Relat Res. 1997;336:205–15.
Kasser JR. Femur fractures in children. Instr Course Lect.
1992;41:403–08.
Aronson DD, Singer RM, Higgins RF. Skeletal traction for
fractures of the femoral for fractures of the femoral shaft in
children. J Bone Joint Surg Am 1987;69:1435-9.
Cameron CD, Meek RN, Blachut PA. Intramedullary nailing of
the femoral shaft: A prospective, randomized study. J Orthop
Trauma 1992;6:448-51.
Hughes BF, Sponseller PD, Thompson JD. Pediatric femur
fracture: effect of spica cast treatment on family and community.
J Pediatr Orthop 1995;15:457-60.
Paley D, Herzenberg JE, Tetsworth K, McKie J, Bhave A.
Deformity planning for frontal and sagittal plane corrective
osteotomies. Orthop Clin North Am 1994;25:425-65. 9. Galano GJ, Vitale MA, Kessler MW, Hyman JE, Vitale MG. The
most frequence traumatic orthopaedic injuries from a national
pediatric inpatient population. J Pediatr Orthop 2005;25:39-44. Hedlung R, Lidgren U. The incidence of femoral shaft fractures
in children and adolescents. J Pediatr Orthop 1986;6:47-50.
Jamaluddin M. femoral shaft fractures in children treated by
early hip spica cast: Early results of prospective study. Med J
Malaysia 1995;50:72-5.
Wong J, Boyd R, Keenan NW, Baker R, Selber P, Wright JG et
al. Gait patterns after fracture of the femoral shaft in children,
managed by external fixation or early hip spica cast. J Pediatr
Orthop 2004;24:463-71.
Irani RN, Nicholson JT, Chung SMK. Long term results in the
treatment of femoral fractures in young children by immediate
spica immobilization. J Bone Joint Surg 1976;58A:945-51.
Spinner M, Freundlich BD, Miller IJ. Double spica technique
for primary treatment of fractures of the shaft of the femur
in children and adolescents. Clin Orthop Related Research
1967;53:109-14.
Sugi M, Cole WG. Early plaster treatment for fractures of the
femoral shaft in childhood. J Bone Joint Surg 1987;69-B:743-5.
Ali M, Raza A. Union and complications after Thomas splint
and early hip spica for femoral shaft fractures in children. J Coll
Physician Surg Pakistan 2005;15:799-801.
Edvardsen P, Syversen SM. Overgrowth of the femur after
fracture of shaft in child hood. J Bone Joint Surg 1976;58B:33942.
Clement DA, Colton CL. Overgrowth of the femur after fracture
in child hood. J Bone Joint Surg 1986;68-B:534-6.
Frech-Dorfl er M, Hasler CC, Häcker FM. Immediate hip spica
for unstable femoral shaft fractures in preschool children: still
an efficient and effective option. Eur J Pediatr Surg. 2010;
20(1):18-23.
216
ORIGINAL ARTICLE
Yousaf Jan
Management of Penile Fracture and its Outcome
Yousaf Jan FCPS1, Aziz Ur Rahman FCPS2, Waqas MBBS3
ABSTRACT:
Background: Penile fracture is a rare urological emergency that occurs almost exclusively due to blunt trauma on
erect penis. Coitus and penile manipulations are common predisposing factors.
Objective: To evaluate the clinical presentation, therapeutic options and outcome of the treatment of penile fracture.
Materials and Methods: This descriptive study was conducted in Agency Headquarter Hospital, Landikotal and Hayatabad
Medical Complex Peshawar, from January 2012 to September 2013. Twenty two patients presenting with clinical findings/
features of penile fracture were included. Detailed history was taken and physical examination was done in order to get the
extent of penile hematoma, sign of blood at the meatus and side of curvature. Diagnosis was made on the basis of history
and clinical findings and confirmed with operative findings. In all patients, a sub-coronal circumferential degloving incision
was made. Data analysis was performed to obtain descriptive statistics.
Results: Majority of the patients (72.7%) were married with age range of 14-50years (mean-25 years). Causes of fractures
were manipulation in 5 (22.8%) cases, sexual manoeuvre in 14 (63.7%) cases, rolling or fall on erect penis in 1 (4.5%) and
direct blow on erect penis in 2 (9%) patients. Interval between trauma and presentation varied from 011 hours to 21 days.
The typical findings recorded in 100.0% patients were erection at time of fracture, detumescence, swelling and ecchymosis.
Audible crackling sound and pain was present in 19 (86.3%) patients. 13 (59%) patients had rent in the proximal part of
penile shaft and right lateral tear was present in 16 (72.7%) patients. Complication occurred in 1 (4.5%) patient. The mean
hospital stay was 2 days.
Conclusion: Penis Fracture is not so uncommon as reported. A trauma to erect penis is mandatory for fracture to occur. The
aim of surgical repair was to avoid complications and preserve both sexual and voiding functions which were satisfactorily
achieved in the majority.
Keywords: Penile fracture, Corpus cavernosum, Trauma.
INTRODUCTION
Penile fracture is defined as traumatic rupture of
the tunica albuginea of one or both corpora cavernosa
of an erect penis1. Classically there is a history of snap
sound, pain, detumescence and haematoma of penis
with deformity. Penile fracture has been reported
with sexual intercourse, masturbation, rolling over
the bed or falling on to erect penis.2
The most common cause is violent sexual activity especially in a position of female partner playing
the active role (upper position).3 In flaccid state injury
to the penis is rare because of the thick tunica albuginea
(about 2 mm), but during erection it becomes as thin as
0.5-0.25 mm, becoming more susceptible to fracture or
tearing.4 Many conditions can simulate fractured penis
as dorsal vein tears in penis may mimic penile fracture.5
The true incidence of penile fracture is not known
even in western countries because it is under reported
or hidden probably because of social embracement and
sociocultural taboo, even it is reported to physicians
Junior Registrar Surgical, B Unit, Hayatabad Medical Complex,
Peshawar, 2Senior Medical Officer (Surgery), Hayatabad Medical
Complex, Peshawar, 3Trainee Medical Officer, Hayatabad Medical
Complex Peshawar, 4Trainee Medical Officer
1
Correspondence: Dr Yousaf Jan, House No 89, Sector K5,
Street 2, Phase 3, Hayatabad, Peshawar. Cell: 03339279312
E-Mail: [email protected]
Received: March 2014
217
Accepted: June 2014
it remains undiagnosed or mismanaged.6 The largest
numbers of cases have been reported in Mediterranean
countries including Turkey,7 but a recent study noted
that the number of cases reported in the Middle East
and North Africa was higher than in any other countries, including the USA and Europe.8
The diagnosis is usually straight forward because of stereotypical clinical presentation. Associated
injuries include urethral rupture. Rupture of tunica is
unilateral in most cases although bilateral rupture
associated with urethral rupture also occurs.9
Diagnostic investigation includes ultrasonography
and retrograde urethrogram.10 Presence of haematoma
and breach in tunica albugenia is detected by ultrasonography. Urethrogram is helpful in establishing
rupture of urethra although some authors advocate
flexible urethra cystoscopy to detect any breach in
case of suspicion. Cavernosography is a useful test indoubtful cases. It is invasive with low sensitivity and
there is a risk of contrast reaction, post procedure priapism and corporal fibrosis.11 Magnetic Resonance Imaging (MRI) is a useful investigation that pinpoints the site
and extent of tunica rupture but is expensive and not
readily available, especially in the emergency setup.12
The management of penile fracture has changed
over the years,13 and it is either conservative or surgical.
Conservative measures include splinting, cold compresses, anti-inflammatory agents, analgesia medicaOphthalmology Update Vol. 12. No. 3, July-September 2014
Management of Penile Fracture and its Outcome
tions and anti-fibrinolytics. These are associated with
significant complications such as infected hematoma,
penile deformity and impotence.13,14,7,8 Immediate surgical repair is advocated though suture material is controversial.15,16 Most authors recommended degloving
incision, evacuation of haematoma and repair of rent
of tunica albugenia, with absorbable or non-absorbable suture. The aim of this study was to evaluate the
clinical presentation, therapeutic options and outcome
of the treatment of penile fracture.
MATERIAL AND METHODS
This study was conducted at the Department of
Surgery, Agency Headquarter Hospital, Landikotal
from January 2012 to December 2013. Cases of penile
fracture were admitted in the surgical unit via emergency or out patients departments. Detailed history
was taken and the time between fracture time and presentation at admission was documented for each case.
Patient’s age, marital status, cause of fracture and time
of injury were documented. Physical examination was
done in order to determine the extent of penile hematoma, signs of blood at the external meatus and side of
curvature.
Surgery was planned on the same day of admission after informed written consent. During operation
Foley’s catheter was inserted in all the cases to prevent
inadvertent urethral injury during exploration. A distal circumferential sub coronal incision was made and
followed by degloving of the penis up to base, taking
care not to injure the dorsal neurovascular bundle. The
hematoma with in the Buck’s fascia was evacuated and
the corporal tear was identified. The edges of the tunical laceration were freshened and closed with interrupted 2/0 vicryl sutures. The penile shaft skin was
closed with 3/0 chromic sutures in an interrupted fashion, and pressure dressings were applied. Postoperatively erection was suppressed for 4-5 days and Foley’s
catheter was removed after 24 hours.
Patients were discharged on the second postoperative day with oral antibiotics and analgesics. Compressive dressings were applied for one week and the
patients were advised to abstain from sexual relation
for 8 weeks. Follow-up was done regularly in outpatients department for 4 months.
RESULTS
Sixteen (72.7%) patients were married and the
mean age of the patients was 25 years. The typical findings recorded in all (100.0%) patients had erection at the
time of fracture, rapid detumescence, swelling and ecchymosis (skin haematoma). Audible crackling sound
and pain was present in 19 (86.3%).Thirteen (59%) of
the patients presented in less than 24 hours (Table I).
Causes of fractures were manipulation in 5 (22.8%) cases, sexual manoeuvre in 14 (63.7%) cases, rolling or fall
Ophthalmology Update Vol. 12. No. 3, July-September 2014
on erect penis in 1 (4.5%) and direct blow on erect penis
in 2 (9%) patients (Table 2).
Thirteen patients (59%) patients had rent in proximal part of the shaft of penis, four (18.2%) in the mid of
the shaft of penis and five (22.8%) in the distal penile
shaft (Table 3). Sixteen (72.7%) patients had right lateral
tear and 6 (27.3%) had left lateral tear (Table 3). Size
of the rent ranged from 0.5 – 3 cm, all patients (100%)
had unilateral tear (Table II). Surgical exploration and
repair was done in all patients.
All patients had uneventful recovery with one
(4.5%) patient developed a slight penile curvature, but
that did not affect his sexual activity. All patients were
potent and without any problem of erection or sexual
performance. Duration of hospital stay varied from 02
to 03 days. Follow up ranged from 2-4 months and no
major adverse outcome was noted.
Table-1: Demographic and clinical parameters (n=22)
Parameters
Number of patients
Percentage
Age (years)
14-30
31-40
>40
13
5
4
59
22.7
18.3
Marital status
Married
Unmarried
16
6
72.7
27.3
Duration of presentation
< 24 hours
> 24 hours
13
9
59
41
Erection at trauma time
22
100
Audible crackling sound
19
86.3
Detumescence
22
100
Pain
19
86.3
Swelling + ecchymosis
22
100
Table-2: Causes of penile fracture
Causes
Number of patients
Percentage
Sexual intercourse
14
63.7
Manipulation
5
22.8
Fall/rollover on erect Penis
1
4.5
Direct blow on erect penis
2
9
Total
22
100
Table-3: Site and direction of rent (n=22)
Site of rent
Proximal
Middle
Distal
Direction of rent
Right lateral
Left lateral
Associated urethral injury
No of patients
Percentage
13
4
5
59
18.2
22.8
16
6
72.7
27.3
None
0
218
Management of Penile Fracture and its Outcome
DISCUSSION
Fracture of the penis is a relatively rare condition,
defined as the rupture of the tunica albuginea due to
trauma to erect penis.17 Penilefracture is being reported
with increased frequency in the recent past.18 Sporadic or low reporting gives the impression of this, being
a rare trauma and the reason for this may be that not
every urologist reports their clinical experience of condition. The under reporting may be due to the embarrassing nature and social taboo of the injury and the
circumstances in which injury usually occurs.19
The reported range of the age in different studies is 26 to 41 years and most of their patients were in
their 4th decade.20,21 In this series, the patients were also
young and age range was 14-50 years (mean 25 years).
Majority i.e, 13 (59%) patients of them were in the third
decade of life, which is the decade of maximum sexual
activity.4 Coitus is the main etiological factor in our
series, however non coital factors like masturbation,
direct trauma etc are being reported in literature.10,22 In
contrast, Malik MA, et al10 (84.6%) and Ahmad S, et al23
(41%), also showed coitus as the main cause of penile
fracture in their studies.
In a typical penile fracture, the normal external
appearance is completely obliterated because of significant penile deformity, swelling and ecchymosis (the so
called “egg-plant deformity”)24,25, was present in all of
these cases in current study. Physical examination of
the penis can often detect the side of the corporal tear
by palpating the overlying hematoma. The “rolling
sign” is used to describe a firm, immobile hematoma,
which is palpable as the penile skin is rolled over.24
The fracture was mostly unilateral involving the
right corpora in 16 (72.7%) which is as also stated by
others.9,19,23 Involvement of the left corpus cavernosum
was in 06 (27.3%) patients and no bilateral involvement
was noted in our study. The incidence of urethral injury associated with penile fracture is reported as 1122% in Europe and USA, and 2-3% in Asia and Middle
East26. No urethral injury was found in our study, as
also in the study by Ahmad S, et al.23 In comparison
8.2% and 15.3% incidence of urethral injuries was noted
by Nawaz H, et al1and Malik MA, et al9 in their studies
respectively. In current study thirteen patients (59%)
had rent in proximal part of the shaft of penis, four
(18.2%) in the mid of the shaft of penis and five (22.8%)
in the distal penile shaft, as compared to 71.5%, 23.3%
and 5.1% in proximal, middle and distal penile shaft
involvement in his study by Nawaz H, et al.1
Recent studies and the recommendations of WHO
have demonstrated the clear advantage of early surgical exploration,27 as majority of the penile fracture patients are young, sexually active and highly motivated
to resume sexual activity as soon as the healing pro219
cess is complete. The goals of immediate surgical repair are the relief of painful symptoms, prevent erectile dysfunction, allow normal voiding and minimize
complications from delay in diagnosis. Immediate reapproximation of the torn tissue leads to sooner healing process. Surgery also reduces the complication
rate upto 10%.28 In this study, all the cases were dealt
surgically and the aim of the surgical repair of penile
fracture was the evacuation of the hematoma, identification of the tunical injury, local corpora debridement
and closure of the tunical laceration.
The type and location of incision is operator dependant in treating penile fracture. Some argue that the
most commonly used degloving incision is associated
with neurovascular injury and necrosis. In this study,
degloving incision was used in all the cases and none of
these complications were seen.Advantages of coronal
incision and degloving are relatively good cosmetic results, good exposure and repair with single incision in
case of bilateral tunica rupture and associated urethral
injury.29 Perioperative use of urethral catheterization is
also operator dependant, some advocating its routine
use, while others prohibiting its insertion. In this series,
urethral catheter was inserted perioperatively in all
the cases. The catheter helps intraoperative dissection
without harming the urethra, facilitates the application
of a pressure dressing and prevents wound contamination postoperatively.
Follow-up of four months was obtained in 19
(86.3%) cases, while three patients were lost to follow
up after six weeks. All the patients stated achieving
normal painless erections. Only one (4.5) patient developed a slight penile curvature during erection, but it
did not affect their sexual activities. This was present
in patient who had presented late. In comparison 7.4%
and 5.1% incidence of slight penile curvature was noted
by Nawaz H1 and Ahmad S,23 respectively.No wound
infection was noted in current study.
CONCLUSION
Penile fracture is a true urological emergency.
Awareness of the mode of trauma and clinical features
is all that required for diagnosis and no more investigation is needed. The aim of early surgical repair was
to avoid complications and preserve both sexual and
voiding functions and it was achieved.
REFERENCES
1.
Nawaz H, Khan M, Tareen FM, Khan M. Penile fracture: Presentation and management. JCPSP 2010, Vol. 20 (5): 331-331-34.
2.
Ghilan AM, Al-Asbahi WA, Ghafour MA, Alwan MA and
Al-khanbashi OM. Management of penile fractures, Saudi
Med J. 2008;29(10):1443-7.
3.
Khan RM, Malik MA, Jamil M, Khan D, Shah IH. Penile
fracture; experience at Ayub Teaching Hospital. J Ayub
MedColl Abbottabad.2008; 20(4): 49-50.
4.
Sawh SL, O’Leary MP, Ferreira MD, Berry AM, Maharaj D.
Fractured penis: a review. Int J Impot Res 2008; 20:366-9.
Ophthalmology Update Vol. 12. No. 3, July-September 2014
Management of Penile Fracture and its Outcome
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Bar-Yosef Y, Greenstein A, Beri A, Lidawi G, Matzkin H, Chen
J. Dorsal vein injuries observed during penile exploration for
suspected penile fracture. J Sex Med 2007; 4:1142-1146.
El Atat R, Sfaxi M, Benslama MR, Amine D, Ayed M, Mouelli
SB, et al. Fracture of the penis: Management and long-term
results of surgical treatment. Experience in 300 cases. J Trauma2008; 64:121-125.
Eke N:Fracture of penis.Br J Surg2002,89:555–565.
Atat RE, Sfaxi M, BenslamaMR,et al: Fracture of the penis:
management and long-term results of surgical treatment. Experience in 300 cases. J Trauma2008,64:121–125.
Malik MA, Bashir MT, Malik NA, Hussain M, Sohail M. Penile
fracture; Etiology and management. JUMDC 2011;2(2):11-14.
Nomura JT andSierzenski PR. Ultrasound diagnosis of penile fracture. J Emerg Med. 2010;38(3):362-5.
Beysel M, Tekin A, Gurdal M, Yücebas E, Sengör F. Evaluation
and treatment of penile fracture: Accuracy of clinical diagnosis
and the value of corpus cavernosography. Urol 2002; 60: 49296.
Choi MH, Kim B, Ryu JA, Lee SW, Lee KS. MRI imaging of
acute penile fracture.Radiographics 2000; 20: 1397-405.
Gamal WM, Osman MM, Hammady A, Aldahshoury MZ, Hussein MM, Saleem M:Penile fracture: long-term results of surgical and conservative management.J Trauma2011,71:491–493.
Sawh SL, O’Leary MP, Ferreira MD, Berry AM, Maharaj
D:Fractured penis: a review. Int J Impot Res 2008,20(4):366–369.
Kamdar C, Mooppan UM, Kim H and Gulmi FA. Penile fracture: preoperative evaluation and surgical technique for optimal patient outcome. BJU Int. 2008;102(11):1640-4.
Nasser TA and Mostafa T. Delayed surgical repair of penile
fracture under local anesthesia. J Sex Med. 2008; 5(10): 24649.
Ateyah A, Mostafa T, Nasser TA, Shaeer O, Hadi AA, Al-Gabbar MA. Penile fracture: Surgical repair and late effects on erectile function. J Sex Med2008; 5:1496-1502.
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Agarwal MM, Singh SK, Sharma DK, Ranjan P, Kumar S,
Chandramohan V, Gupta N, Acharya NC, Bhalla V, Mavudura R and Mandal AK. Fracture of Penis: A radiological or
clinical diagnosis? A Case series and literature review. Can
J Urol. 2009;16(2):4568-75.
Zargooshi J. Penile fracture in Kermanshah, Iran: the long-term
results of surgical treatment. BJU Int2003; 89:890-4. Comment
in: BJU Int2003; 91:301-2.
Koifman I, Cavalcanti AG, Manes CH, Filho DR, Favorito
LA. Penile fracture: experience in 56 cases. IntBraz J Urol
2003;29:35-9.
Benefelloun M, Rabii R, Bennani S, Querfani B, Jonal A, El
Mrini MN. Fracture of the corpuscavernosum: report of 123
cases. Afr J Urol2003; 9:1-10.
Dienye PO, Jebbin NJ and Gbeneol PK. Penile fracture following husband abuse: A case report. Am JMens Health.
2009;3(4):330-2.
Ahmad S, Haq Z, Khan M. Clinical diagnosis of penile fracture.
JMedSci 2011,19(4):189-191.
Gregory S, Jack M, Garrawy I, Reznick R, Rajfer J. Current
treatment options for penile fracture. Rev Urol2004; 6:114-20.
Ekwere PD, Al-Rashid M. Trends in incidence, clinical presentation and management of traumatic rupture of the corpus
cavernosum. J Natl Med Assoc 2004; 96:229-33.
Derouche A, Belhaj K, Hentali H, Hafsia G, Shama MR, Chelbil M. Management of penile fractures complicated by urethral
rupture. Int J Impot Res 2008; 20:111-4.
Zarin M, Haider K, Aurangzeb M, RoohhulMuqeem, Hussain
I, MujeeburRehman, et al. Surgical treatment of fractured penis. J Surg Pak 2006; 11:107-9.
Aman Z, Abdul Qayyum, Khan M, Afridi V. Early surgical intervention in penile fracture. J Postgrad Med Inst 2004; 18:4328.
Mensah JE, Morton B and Kyei M. Early surgical repair of
penile fractures. Ghana Med J. 2010;44(3):119-22.
IMPORTANT NOTE
Authors of articles and the subscribers are requested to collect the copies of the Ophthalmology
Update from representatives of the concerned area according to the following:
SR#
Name
Area
Number
1
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Peshawar
03337771210
2
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Rawalpindi
03337771248
3
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Ophthalmology Update Vol. 12. No. 3, July-September 2014
220
ORIGINAL ARTICLE
Rahat Jabeen
Frequency, Risk Factors and Feto-Maternal
Outcome in Abruptio Placenta Cases
Rahat Jabeen FCPS1, Ilyas Siddiqi FCPS2
ABSTRACT:
Background: Abruptio placentae remain a major cause of perinatal morbidity and mortality globally, though of most serious
concern in the developing world. Placental abruption complicates about 1% of pregnancies and is a leading cause of vaginal
bleeding in the latter half of pregnancy.
Objective: To determine the frequency, risk factors and feto-maternal outcome of abruptio placentae at our setup.
Materials and Methods: This is an observational prospective study conducted at obstetrics and gynaecology department
of Hayatabad Medical Complex, Peshawar during one year from June 2012 to June 2013. All patients with diagnosis of
abruptio placenta and gestational age of >24 weeks were included in the study. Women having bleeding due to causes
other than abruption like placenta previa, vasa previa, carcinoma cervix and other local lesions were excluded. All the data
collected through history, examination and investigations were recorded on a predesigned proforma. Data were analysed
using SPSS version 10.0 and results were analysed by calculating percentages.
Results: A total of 122 cases of abruptio placentae were recorded out of 2845 cases admitted for delivery during the study
period constituting the incidence ratio of 4.2%.About 52 women (42.6%) were in the age group of 25-30 years and 44 (36%)
women were more than 30 years of age (Table-I). Incidence was higher in multi-parous, being 87 (71.4%) Table 1. A total
of 76(62.2%)women were anaemic. Pregnancy induced hypertension was seen in fourteen(11.4%), diabetes in eight(6.5%)
and multiple pregnancy in eleven (9%). No risk factor was present in 13(10.6%) women Table 2. As regards mode of delivery, 85(69.6%) women delivered spontaneously vaginally and 37(30.3%) underwent caesarean section. Four patients died
undelivered cause being severely anaemic, shock and disseminated intravascular coagulation (DIC). Major maternal complication seen was hypovolemic shock in 36(29.5%), followed by postpartum haemorrhage in 17(14%), altered coagulation
profile in 7(5.7%) and renal failure in 5(4%) of patients. Maternal mortality was 3.2%. About 80(65.5%) women delivered
alive babies while 42(34.4%) were stillborn. Out of 80 alive born, five died within first week of birth due to prematurity. Overall
perinatal mortality was 38.5% and maternal mortality was 3.2%.
Conclusion: Abruptio placenta is common in women with high parity, advancing age, hypertensive disorders of pregnancy
and smoking. It is associated with high rate of maternal and fetal morbidity and mortality. Antenatal care plays an important
role in decreasing the incidence of abruptio placenta.
Keywords: Abruptio placenta, shock, perinatal mortality.
INTRODUCTION
Abruptio placenta is defined as the premature
separation of the normally implanted placenta from 24
weeks to delivery of baby. Exact aetiology of placental abruption remains unknown, but one hypothesis
is that it is due to the rupture of the uterine spiral artery.1 Bleeding into decidua leads to separation of the
placenta. Hematoma formation further separates the
placenta from the uterine wall, causing compression of
these structures and compromise of blood supply to the
fetus.2
Multiple predisposing risk factors have been identified. These include pregnancy induced hypertension
(PIH), advanced maternal age and polyhydroamnios.3
Anemia, gestational diabetes, preterm labour, preterm
rupture of membranes, chorioamnionitis, oligohydromRegistrar, Gynae “A” Unit, Hyatabad Medical Complex, Peshawar
Assistant Prof. Department of Gynae & Obstetrics, Lady Reading
Hospital, Peshawar
1
2
Correspondence: Dr. Rahat Jabeen, Registrar, Gynae “A” Unit,
Hyatabad Medical Complex, Peshawar. Contact No:0333-4693821
Email: [email protected]
Received. March 2014
221
Accepted. May 2014
nias, obstetric shock, short umbilical cord and velamentous cord insertion are other clinical determinants.4,5 It
has been found that smoking during pregnancy is associated with increased risk of abruption.6 Maternal alcohol consumption and smoking by the partner turned
out to be independent risk factors for placental abruption. Smoking by both partners multiplies the risk.7
Frequency of abruptio placentae is about 1% of all
pregnancies throughout the world.2,8 However different studies have reported variable incidence of abruptio placentae ranging from 0.3%3 to 2%9 of all term deliveries.
The signs and symptoms of abruptio placentae depend on the severity of bleeding and degree of separation of placenta.2 The common signs and symptoms of
abruption are vaginal bleeding, uterine and abdominal
pain and tenderness, abnormal uterine contractions,
premature labour, maternal hemodynamic instability,
fetal distress and fetal death.2,10
Abruptio placentae are a major cause of maternal and perinatal morbidity and mortality.11 Maternal
complications include haemorrhagic shock, coagulopathy and disseminated intravascular coagulation (DIC),
Ophthalmology Update Vol. 12. No. 3, July-September 2014
Frequency, Risk Factors and Feto-Maternal Outcome in Abruptio Placenta Cases
uterine rupture, renal failure, ischemic necrosis of distal organs and death. Neonatal complications include
prematurity, birth asphyxia, fetal growth retardation
and stillbirth.12
It is a major cause of third trimester haemorrhage
and perinatal death. The high maternal morbidity and
mortality is due to severe haemorrhage that follows
this complication. The fetal morbidity and mortality is
due to reduced placental surface area for oxygenation.
To reduce maternal mortality as well as morbidity, correct antenatal follow up, early diagnosis and prompt
evacuation of the uterus are required.13 The objective
of this study is to determine the frequency, risk factors
and feto-maternal outcome of abruptio placentae at our
setup.
MATERIAL AND METHODS
This was an observational prospective study conducted at obstetrics and gynaecology department of
Hayatabad Medical Complex, Peshawar from June
2012 to June 2013. All patients with diagnosis of abruption placenta and gestational age of >24 weeks were
included in the study. Women having bleeding due to
causes other than abruption like placenta previa, vasa
previa, carcinoma cervix and other local lesions were
excluded. Data were collected after informed consent
and included detailed history regarding age, gravida,
parity, gestational age, details of physical examination,
results of investigations, mode of delivery, outcome of
fetus and maternal morbidity and mortality. The diagnosis of placental abruption was made on clinical
ground in the presence of uterine pain, vaginal bleeding, uterine tenderness and hyper tonic uterus.
After history and complete physical examination,
investigations were performed which included complete blood picture, blood grouping, coagulation profile, renal function test, liver function tests, screening
for hepatic virology, urinalysis and ultrasound. Diagnosis was confirmed on the presence of retroplacental
clot, which was used to estimate the amount of bleeding
and severity of abruption. Patients were managed according to the fetal and maternal conditions. All information was gathered on proforma. Data were analysed
using SPSS version 10.0 and results were analysed by
calculating percentages.
RESULTS
Total number of deliveries from June 2011 till June
2012 was 2850 at our unit. Out of 2850, 122 patients of
abruptio placenta were recorded. The majority of patients 92 (75.4%) belonged to the poor socio-economic
group, 26 patients (21.3%) were in the middle (satisfactory) socio-economic group and 4 (3.2%) were from the
upper socio-economic group (Table 1). In current study
52 women (42.6%) were in the age group of 25-30 years
and 44 (36%) women were more than 30 years of age
Ophthalmology Update Vol. 12. No. 3, July-September 2014
(Table-I). Incidence was higher in multi-parous, being
87 (71.4%), while 35 (28.7%) patients were primi-gravida (Table 1). Mainly the abruption was seen in women
with term pregnancy i.e. 74(60.6%) and 48(39.4%) were
before term. Out of these 122 women with abruption,
54 (44.2%) had mild, 39 (31.9%) had moderate and 29
(23.7%) were having severe abruption (Table-II).
Table-1: Demographics of the patients (N=122)
Variables
Number
Percentage
AGE
< 25 years
25-30 years
> 30 years
26
52
44
21.4
42.6
36
GRAVIDA
Primigravidas
Multigravidas
35
87
28.6
71.4
GESTATIONAL AGE
< 37 weeks
> 37 weeks
48
74
39.4
60.6
SOCIOECONOMIC
STATUS
Poor
Middle
Upper
92
26
04
75.4
21.3
3.2
Table-2: Severity of abruption and risk factors
Variables
Mild Abruption
Moderate Abruption
Severe Abruption
Hypertension
Diabetes
Anaemia
Multiple Pregnancy
No Risk Factors
Number
54
39
29
14
8
76
11
13
Percentage
44.4
31.9
23.7
11.4
6.5
62.2
9
10.6
Table: 3 Maternal morbidity and mortality
No of patients
Percentage
Shock
Complications
36
29.5
PPH
17
14
DIC
7
7.5
Renal failure
5
4
Death
4
3.2
Table-4: Fetal outcome
Complications
Number
Percentage
Alive
80
65.5
Stillbirth
42
34.4
Congenital anomalies
7
5.7
A total of 76(62.2%) women were anaemic (Table
2). The cut off value of haemoglobin for the diagnosis of anaemia was 10.5 g/dl. Pregnancy induced hypertension was seen in fourteen (11.4%), diabetes in
eight (6.5%), multiple pregnancy in eleven (9%), while
13(10.6%) women were those in whom no risk factor
was present (Table-2). A total of 6 patients (4.9%) gave
history of addiction, out of which 2 were smokers and
4 patients used Naswar (a locally made narcotic drug,
commonly used in KPK provice) during pregnancy. Severe anaemia with haemoglobin level of less than 7gm/
222
Frequency, Risk Factors and Feto-Maternal Outcome in Abruptio Placenta Cases
dl was present in 31(40.7%) out of 76 anaemic women,
29 (38.1%) were moderately anaemic with haemoglobin
level of 7-10gm/dl, while 16(21%) were mildly anaemic
having haemoglobin levels of 10-10.9gm/dl.
Regarding mode of delivery, 85(69.6%) women
delivered spontaneously vaginally and 37(30.3%) underwent caesarean section. Four patients died undelivered, cause being severe anaemia, shock and DIC. Major maternal complication seen was shock in 36(29.5%),
followed by postpartum haemorrhage in 17(14%), altered coagulation profile in 7 (5.7%) and renal failure
in 5 (4%) of patients. Eighty (65.5%) women delivered
alive babies while forty two (34.4%) were stillborn. Out
of these 80 alive born babies five died in early neonatal
period due to prematurity. Overall perinatal mortality
was 38.5%. The incidence of congenitally malformed
baby was 5.7%, 3 delivered with anencephaly, 3 had
hydrocephalus and one baby delivered with both clip
lip and palate respectively.
DISCUSSION
Abruptio placenta remains a major cause of perinatal morbidity and mortality globally, though of most
serious concern in the developing world. The most important factor is the severity of abruption and its duration. The diagnosis of abruption is a clinical one and the
condition should be suspected in women who present
with vaginal bleeding or abdominal pain or both, a history of trauma, and those who present in otherwise unexplained preterm labor.
The incidence of abruptio placenta in this study
(4.2%) is comparable with a studies conducted by
Jabeen M, et al5 (4.5%) and Sarwar I,et al14 (4.4%) respectively. Increased incidence was seen in patients belonging to rural areas and multipara with advancing age.
This same observation is also evident from other studies3,8,5. Majority of patients (71.2%) were anaemic. These
observations are also seen in other Pakistani studies5,14.
This high frequency of anaemia could be due to preexisting nutritional deficiency anaemia being very common in our setup and then superimposed by abruption.
An association with diabetes (6.5%) and hypertension
(11.4%) was observed in this study, which is also evident from other studies8.15,16. Many other studies highlights the association of pregnancy induced hypertension (PIH), anaemia and diabetes with the occurrence
of placental abruption5,17. A total of 6 patients (4.9%)
gave history of addiction with the use of addictive narcotic NASWAR, out of which 2 were smokers and 4 patients used Naswar during pregnancy.
Sharief and Manther in their study compared 50
hypertensive and 104 normotensive cases of abruption
and concluded that there was an increased incidence of
abruption in hypertensive females9. Delivery outcome
of our study shows that majority of women (69.6%) de223
livered vaginally, caesarean section (30.3%) being only
performed in cases where fetus was alive or there was
very severe abruption. Same observations were also
seen in other studies making vaginal route, the common route of delivery in cases of abruption5,13,14.
Mainly the abruption was seen in women with
term pregnancy i.e. 74(60.7%) and 4839.2%) were before
term. Out of these 122 women with abruption, 54(41.4%)
had mild, 39(31.9%) had moderate and 29(23.7%) were
having severe abruption. In current study, majority of
patients 9275.4%) belonged to the poor socio-economic
group, as also shown by Sarwar I, et al14 (77.4%).
Regarding maternal complications, shock 36
(29.5%) was the most common, followed by postpartum haemorrhage 17 (14%), altered coagulation profile
7 (5.7%) and renal failure 5 (4%). These findings were
compared with a study done by Pitaphorm A et al,
where, in 103 cases of abruption, shock was the leading
complication seen in 19.4% and disseminated intravascular coagulation in 5.8%18. In another study done by
Abbasi RM, et al, postpartum haemorrhage, renal failure and DIC occurred in 16.6%, 6.25% and 4.14% cases
respectively. Maternal mortality was 3.2% in current
study, as compared to 1.32% and 8.33% by Jabeen M,
et al5 and Abbasi RM, et al19 respectively. In our study,
three patients died of DIC and one due to progressive
renal failure. Fetal mortality (38.5%) observed is high,
mainly the intrauterine death, the reason seems to be
abruption itself, its risk factors as well as the prematurity. This high mortality is comparable with other studies.9,14,19,20
The reasons behind high maternal and fetal mortality in current study were late presentations, low socioeconomic status of patients, poor education and ignorance about pregnancy and antenatal care and living
far away from the tertiary care hospitals.
CONCLUSION
A higher than expected frequency of abruptio
placentae exists in our setting and is associated with
high rate of maternal and fetal morbidity and mortality. Because of this association found between placental
abruption and maternal and fetal morbidity and mortality, the conditions predisposing it should be carefully
evaluated in order to reduce the occurrence of placental abruption. Services of the health care providers can
be taken to identify women at risk, early detection and
timely referral of these especially poor socioeconomic
women for proper management.
REFERENCES
1.
Eskes TK. Clotting disorders and placental abruption: homocysteine - a new risk factor. Eur J Obstet Gynaecol Reprod Biol
2001; 95(2):206-12.
2.
Gaufberg SV. Abruptio Placentae. [Online webpage] 2001 Mar
[cited 2003 Jul 15]; [24 screens]. Available from: URL: http://
www.emedicine.com/emerg/topic12.htm.
Ophthalmology Update Vol. 12. No. 3, July-September 2014
Frequency, Risk Factors and Feto-Maternal Outcome in Abruptio Placenta Cases
3.
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Sheiner E, Shoham-Vardi I, Hallak M. Placental abruption in
term pregnancies: clinical significance and obstetric risk factors. J Matern Fetal Neonatal Med. 2003; 13(1):45-9.
Ananth CV. Placental abruption in the United States, 1979
through 2001: temporal trends and potential determinants. Am
J Obstet Gynecol. 2005; 192(1):191-8.
Jabeen M, Gul F. Abruptio Placentae: risk factors and perinatal
outcome. J Postgrad Med Inst. 2004; 18(4): 669-76.
Mortensen JT, Thulstrup AM, Larsen H. Smoking, sex of the
offspring and risk of placental abruption, placenta previa and
preeclampsia: a population based cohort study. Acta Obstet
Gynecol Scand. 2001; 80(10): 894-8.
Tikkanen M, Nuutila M, Hiilesmaa V. Clinical presentation
and risk factors of placental abruption. Acta Obstet Gynecol
Scand. 2006; 85(6): 700-5.
Toivonen S, Heinonen S, Anttile M, Kosma VM, Saarikoski S.
Reproductive risk factors, Doppler findings, and outcome of
affected births in placental abruption. Am J Perinatol 2002; 19
(8): 451-60.
Sharief M, Manther AA. Abruptio placentae: perinatal outcome
in normotensive and hypertensive patients in Basra, Iraq. [serial online] 1998; emhj; 4(2):319-23.
Shah S, Miller PR, Meredith JW, Chang MC. Elevated admission white cell count in pregnant trauma patients: Anindicator
of on going abruption. Am Surg 2002;68(7):644-647.s
11.
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20.
Neilson JP. Interventions for treating placental abruption. J Obstet Gynaecol 2001; 21(5): 443-447.
Hladky K, Yankowitz J, Hansen WF. Placental abruption. Obstet Gynecol Surv 2002; 57: 299-305.
Thieba B, Lankoande J, Akotionga M. Abruption placenta:
Epidiomological, clinical and prognostic aspects with respect
to a 177 case series. Gynecol Obstet Fertil 2003;31(5):429-433.
Sarwar I, Abassi AN, Islam A. Abruptio placentae and its complications at Ayub Teaching Hospital Abbottabad. J Ayub Med
Coll Abbottabad 2006;18(1)27-31.
Oyelese Y, Ananth CV. Placental abruption. Obstet Gynecol
2006;108(4):1005-1016.
Dafallah SE, Babikir HE. Risk factors predisposing to abruption placentae. Maternal and fetal outcome. Saudi Med J
2004;25(9):1237-1240.
Liaquat NF, Shoab T, Shuja S. A study of abruption placentae. J
Surg Pakistan Mar 2006;11(1):27-30.
Pitaphorm A, Sukharoen N. pregnancy outcome in placental
abruption. J Med Assoc Thai 2006;89(10):1572-8.
Abbasi RM, Rizwan N, Mumtaz F, Farooq S. Feto maternal outcome among abruption placenta cases at a university hospital
of Sindh. JLUMHS 2008:106-109.
Qamarunisa, Memon H, Ali M. Frequency, maternal and fetal
outcome of abruption placenta in a rural medical college Hospital, Mirpurkhas Sindh. Pak J Med Sci 2010;26(3):663-66.
Congratulations to Gold Medal Recipients
At the recent Central OSP Meeting at Bhurban, Prof. Zafar ul Islam, Prof Imran Akram Sahaf & Dr. Sameera Irfan
were awarded Gold medals for academic eminence & professional excellence in the field of Ophthalmology.
Dr. Sameera was awarded Gold Medal in Pediatric Ophthalmology.
Ophthalmology Update Vol. 12. No. 3, July-September 2014
224
ORIGINAL ARTICLE
Waqas
Comparison of Efficacy of Primary Anastomosis
of Large Bowel with Bowel Preparation Vs
without Bowel Preparation
Waqas MBBS1, Yousaf Jan FCPS2, Aziz ur Rahman FCPS3, Ahmad Din MBBS4
ABSTRACT
Introduction: Mechanical bowel preparation prior to surgery has been used for many years aiming at cleaning the large
bowel of faecal matter and it is considered important in preventing postoperative complications including wound infection,
intra-abdominal abscess and anastomotic leak.
Objective: To compare the effectiveness of primary anastomosis of large bowel with bowel preparation versus without
bowel preparation.
Materials and Methods: This study was conducted in the Department of Surgery, Hayatabad Medical Complex, Peshawar
from October 2010 to October 2012. Through a randomized controlled trial design of study, a total of 284 patients presenting with carcinoma colon, diverticulitis, volvulus of large bowel and trauma to large bowel were included and randomly
allocated in two groups (group A with pre operative mechanical bowel preparation and group B with no pre operative mechanical bowel preparation). Both groups were subjected to primary anastomosis and were followed for the occurrence of
anastomosis leak.
Results: The mean age of the patients in group A was 41.547 + 7.762 and that of group B was 41.375 + 8.604. In group A,
there were 53.52% males and 46.5% females while in group B there were 48.6% males and 51.4% females. Anastomosis
leak was observed in 16.9% patients of group A and 12% patients of group B representing 83.1% effectiveness of mechanical bowel preparation prior to primary anastomosis and 88% effectiveness of no preparation. The difference was statistically
insignificant (P value 0.238)
Conclusion: Since there was no significant difference in the effectiveness of both the groups, we strongly conclude that
there is no need of any mechanical bowel preparation before primary anastomosis of the large bowel as it will reduce the
burden on our hospitals which are already resource limited.
Key Words: Anastomosis, Bowel Preparation, Anastomotic leak.
INTRODUCTION
The mortality and morbidity from large bowel
surgery often exceeded 20% mainly attributed to sepsis over the past century. However, it has decreased
substantially since then mainly due to modern surgical techniques and improved perioperative care.1 The
repair by suture or resection of diseased colon is one of
the most important skills in general surgery. Untreated
or treated improperly these conditions cause significant morbidity in terms of intra-abdominal infection
or death from generalized peritonitis.2 The ideal treatment of large bowel lesion is primary resection and
anastomosis because it avoids a stoma formation and
the complications related to stoma.3 Anastomosis leak
is the most important post operative complication following colorectal resection.4
Mechanical bowel preparation prior to surgery
has been used for many years aiming at cleaning the
large bowel of faecal matter and it is considered important in preventing postoperative complications inMedical Officer, Satellite Hospital, Pabbi, 2Junior Registrar, Surgical
B Unit, Hayatabad Medical Complex, Peshawar, 3Senior Medical
Officer, Surgical A Unit, Hayatabad Medical Complex, Peshawar,
4
Medical Officer, Northwest General Hospital, Hayatabad, Peshawar
1
Correspondence: Dr. Waqas, Medical Officer, Satellite Hospital
Pabbi, Cell:0333-3888545 Email: [email protected] H No
30, Sec N2, Phase 4 Hayatabad, Peshawar
Received: March’2014
225
Accepted: May’2014
cluding wound infection, intra-abdominal abscess and
anastomotic leak.5 However there are studies showing
increased risk of wound infections in patient who underwent bowel preparation.6 Moreover on table lavage is time consuming and cumbersome procedure
which is associated with increased risk of spillage and
contamination.7 On the other hand many studies have
shown that primary colonic anastomosis is safe without
prior mechanical bowel preparation.8 Varying degree
of anastomotic leaks has been reported in literature. For
example, the rate of anastomotic leak was 12% reported
in one study showing effectiveness of 88% in primary
anastomosis with bowel preparation and was only 4%
revealing effectiveness of 96% in primary anastomosis
without bowel preparation.9 In another study anastomotic leak occurred in 6% (94% effective) of patients
who underwent bowel preparation and in 3.2% (96.8%
effective) of those who did not.10
Large bowel resection with primary anastomosis
is commonly practiced in surgery. Mechanical bowel
preparation is unpleasant and associated with complications such is dehydration, nausea, vomiting and
electrolyte imbalance. It is also cumbersome and costly.
Recently many studies have shown that primary colonic anastomosis is safe even without mechanical bowel
preparation before surgery however the matter remains
controversial as mentioned above through statistics.
Similarly some recent studies have demonstrated that
Ophthalmology Update Vol. 12. No. 3, July-September 2014
Comparison of Efficacy of Primary Anastomosis of Large Bowel with Bowel Preparation Vs without Bowel Preparatio
there is no benefit of mechanical bowel preparation in
colonic surgeries. Finally a Cochrane review concluded
that there is no statistically significant evidence that patients benefit from bowel preparation. However local
statistics about this is quite scarce in our population.
Therefore this study was conducted to compare the effectiveness of primary anastomosis of large bowel with
bowel preparation versus without bowel preparation.
MATERIAL AND METHODS
The study was conducted after approval from
hospitals ethical and research committee. The inclusion criteria included all patients underwent primary
anastomosis of the large bowel (colonic carcinoma, diverticulitis, volvulus and large bowel trauma), ages 20
-60 years and either gender. Patients operated for large
gut pathology in previous two months, patients with
bleeding diathesis, diabetes mellitus, history of intake
of steroids and immunosuppressive therapy and patients having previous bowel operations were all excluded from the study
All patient meeting the inclusion criteria and undergoing primary anastomosis of the large bowel for
indications like colonic carcinoma, diverticulitis, volvulus and large bowel trauma were included in the study
through OPD and ER department. The purpose and
benefits of the study were explained to all patients and
a written informed consent was obtained.
All patients were subjected to detailed history and
clinical examination and routine pre operative investigations were done in all patients. The patients were
randomly allocated in two groups by lottery method.
Patients in group A were subjected to pre operative mechanical bowel preparation (patients were given oral
laxatives and enemas per rectum a day before surgery)
while patients in group B were not subjected to pre-operative mechanical bowel preparation. All the surgeries
were conducted by single experienced general surgeon
having minimum of 5 years of experience. Post operatively patients were kept under observation till 7th post
operative day to determine intervention effectiveness
in terms of anastomotic leak. All the above mentioned
information including name, age, gender and address
were recorded in a pre designed proforma. Strictly exclusion criteria were followed to control confounders
and bias in the study results.
Statistical Analysis: The data was entered into
SPSS version 10.0 for Windows. Mean + SD was calculated for numerical variables like age. Frequencies
and percentages were calculated for categorical variables like gender, indications for primary anastomosis
and effectiveness. Chi square test was used to compare
the effectiveness between two groups while keeping P
value of < 0.05 as significant. Effectiveness is stratified
among age, gender and indication of primary anasOphthalmology Update Vol. 12. No. 3, July-September 2014
tomosis of the large bowel to see the effect modifications. All results are presented in the form of tables and
graphs.
RESULTS
A total of 284 cases were studied. All the patients
were randomly allocated in two groups by lottery
method comprising 142 patients in each group. The
mean age and standard deviation for patients with
bowel preparation (Group A) were 41.547 and 7.762
and for patients without bowel preparation (Group B)
were 41.375 and 8.604 respectively (p value 0.569). The
mean age and standard deviation for the total patient
sample (n = 284) was 41.46 and 8.151 respectively.
All the patients were divided into four groups of
age. In group A, there were 33 (23.2%) patients in the
age group 20-30 years, 41 (28.9%) were in the age group
31-40 years, 46 (32.4%) of patients were in the age group
41-50 years and 22 (15.5%) were in the age group of 5160 years. In group B, there were 27 (19%) of patients
in the age group 20-30 years, 44 (31%) were in the age
group 31-40 years, 47 (33.1%) of patients were in the age
group 41-50 years and 24 (16.9%) were in the age group
51-60 years. (Table 1).
Table-1: Age-wise distribution of sample in both
the groups (n=142 in each group)
Age ranges
[in years]
GROUP A
GROUP B
No. Of
cases
Percentage
No of
Cases
Percentage
20-30
33
23.2%
27
19%
31-40
41
28.9%
44
31%
41-50
46
32.4%
47
33.1%
51-60
22
15.5%
24
16.9%
Total
142
100%
142
100%
Mean Age
with SD
41.547
+ 7.762
41.375
+ 8.604
P 0.569
The frequency of males and females in the study
population was 145 (50.1%) and 139 (49.9%) respectively out of total 284 patients in both groups. Their frequency in the study groups were 76 male (53.52%) and
66 females (46.5%) in Group A, while 69 male (48.6%)
and 73 females (51.4%) in Group B. While distributing
the sample according to indications for primary anastomosis in the two groups, the following distribution was
observed: In group A, Carcinoma Colon was indication
in 55 (%) of patients, Volvulus was the indication in 39
(%) of patients, Diverticulitis was the indication in 19
(%) of patients while trauma was the indication in 29
(%) of patients. Similarly In group B, Carcinoma Colon
was indication in 47 (%) of patients, Volvulus was the
indication in 43 (%) of patients, Diverticulitis was the
indication in 17 (%) of patients while trauma was the
indication in 35 (%) of patients (Table 2).
226
Comparison of Efficacy of Primary Anastomosis of Large Bowel with Bowel Preparation Vs without Bowel Preparatio
Table-2: Indication of primary anastomosis wise distribution
of sample between both the groups: (n = 142 in each group)
GROUP A
Indication
GROUP B
No.
of cases Percentage
No of
Cases
Percentage
31-40 years, 63.6% in the age group 41-50 years while
67% effectiveness of the procedure was found in the
age group 51-60 years (Table 5).
Table-5: Age wise stratification
of effectiveness in group a: (n = 142)
Carcinoma Colon
55
38.7%
47
33.1%
Volvulus
39
27.5%
43
30.3%
Diverticulitis
19
13.4%
17
12%
Age ranges
[in years]
Trauma
29
20.4%
35
24.6%
20-30
No. of
cases
55
Total
142
100%
142
100%
31-40
39
41-50
51-60
Out of total sample population anastomotic leak
was seen in 41 patients while in 243 patients anastomotic remained patent. The percentage of anastomotic leak
in the total study population was 14.4 %. The frequency
of anastomotic leak in the individual groups i.e. A and
B was 24 (16.9%) and 17 (12%) respectively (Table 3).
Table-3: Frequency of anastomosis leak in
both groups: (n = 142 in each group)
Anastomosis
Leak
GROUP A
GROUP B
No. of
Cases
Percentage
No of
Cases
Percentage
Yes
24
No
118
16.9%
17
12%
83.1%
125
88%
Total
142
100%
142
100%
While comparing the effectiveness between two
groups, which was defined by the absence of anastomosis leak, 83.1% of patients in group A did not develop
the anastomosis leak representing effectiveness of pre
operative mechanical bowel preparation while 88% of
patients in group B who were not subjected to mechanical bowel preparation did not develop the anastomosis
leak representing its effectiveness. Chi square test was
applied to compare the effectiveness between both the
groups generating which showed statistically insignificant difference with a p value of 0.238 (Table 4).
Table-4: Comparison of effectiveness
between two groups:(n = 142 in each group)
GROUP A
EffecNo.
of
tiveness
Percentage
Cases
GROUP B
No of
Cases
Percentage
No
24
16.9%
17
12%
Yes
118
83.1%
125
88%
Total
142
100%
142
100%
P Value
0.238
While stratifying the effectiveness according to
age groups, in Group A with pre operative bowel preparation, most of the anastomotic leaks were observed
in advance age groups (representing less effectiveness)
while less anastomotic leaks were found in younger age
groups (representing more effectiveness). In group A,
92.7% of the patients had effective procedure in the age
group 20-30 years, 89.7% effectiveness in the age group
227
Anastomosis Leak
Effectiveness
Yes
No
4
51
92.7%
4
35
89.7%
19
7
12
63.6%
29
9
20
67%
In group B, advance age seem to no factor threatening effectiveness in terms of anastomosis leak. In
Group A, most of the anastomotic leaks were observed
in advance age groups (representing less effectiveness)
while less anastomotic leaks were found in younger age
groups (representing more effectiveness). In group A,
88.9% of the patients had effective procedure in the age
group 20-30 years, 88.6% effectiveness in the age group
31-40 years, 91.5% in the age group 41-50 years while
79.2% effectiveness of the procedure was found in the
age group 51-60 years (Table 6).
Table-6: Age wise stratification
of effectiveness in group b: (n = 142)
Age ranges
[in years]
Anastomosis Leak
Effectiveness
20-30
No. of
cases
27
3
24
88.9%
31-40
44
5
39
88.6%
41-50
47
4
43
91.5%
51-60
24
5
19
79.2%
Yes
No
We also stratified the effectiveness according to
indication of primary anastomosis wise and couldn’t
find much difference in the effectiveness of bowel
preparation and no preparation with only trauma being the most prominent in group A where anastomosis
leak was found high as compared to other indications
and lower effectiveness. In group A, Colon carcinoma
showed an effectiveness of 83.6%, volvulus showed
97.4%, diverticulitis showed 89.5% and trauma showed
and effectiveness of 89.5%. In group B, Colon carcinoma showed an effectiveness of 87.2%, volvulus showed
93%, diverticulitis showed 94.1% and trauma showed
and effectiveness of 80% (Table 7).
DISCUSSION
Bowel preparation prior to elective colorectal surgery can include a variety or a combination of interventions, such as, preoperative dietary modifications,
oral laxative solutions and the use of enemas as there
are no strict guidelines available regarding the method
of choice and much is left on the operating surgeon’s
Ophthalmology Update Vol. 12. No. 3, July-September 2014
Comparison of Efficacy of Primary Anastomosis of Large Bowel with Bowel Preparation Vs without Bowel Preparatio
Table-7: Indication of primary anastomosis wise stratification of effectiveness between two groups: (n = 142 in each group)
Indication
GROUP A
GROUP B
No of cases
Anastomosis Leak
Effectiv eness
No of Cases
Anastomosis Leak
Effective ness
Colon Carcinoma
55
9
83.6%
47
6
87.2%
Volvulus
39
1
97.4%
43
3
93%
Diverticulitis
19
2
89.5%
17
1
94.1%
Trauma
29
12
58.6%
35
7
80%
discretion. It was believed that since bowel preparation
decreases intra-luminal fecal mass and resultantly decreased bacterial load in the bowel, it appeared to be
a logical argument that this decrease in fecal load and
bacterial contents would also reduce the rates of infectious postoperative complications such as surgical site
infections, deep intra-abdominal infections and anastomotic dehiscence or disruption of the surgical anastomosis. All these theories, however, have been based
largely on clinical experience and expert opinion.11
The mean age and standard deviation for patients with bowel preparation (Group A) were 41.547
and 7.762 and for patients without bowel preparation
(Group B) were 41.375 and 8.604 respectively (p value
0.569). The mean age and standard deviation for the
total patient sample (n = 284) was 41.46 and 8.151 respectively. There were 76 male (53.52%) and 66 females
(46.5%) in Group A, while 69 male (48.6%) and 73 females (51.4%) in Group B.
Butcher P, et al,12 in a Randomized controlled trial
in 2005, divided patients in two groups on the basis of
bowel preparation and no preparation was made comprising of 78 and 75 patients respectively. The anastomotic leak rate was 6.4% in the group with bowel preparation while in the unprepared bowel leak rate was
found to be 1.3%, similarly the infectious complications
were 13% and 4% respectively in the prepared and unprepared group. The findings of this study are very
much comparable to current study in which 284 patients in total were divided in two equal groups of 142
patients each. The anastomotic leak rate in the group
with prepared bowel was 16.9% and in the unprepared
bowel group was 12%.
In another RCT conducted by Ram E et al13, 0.6%
of the patients from prepared group developed anastomotic leak while 1.2% of the patients from the unprepared group developed anastomotic leak although in
this study the leak rate was more in the unprepared
group but it was statistically not significant. Zmora,O
et al,14 in a randomized controlled trial also showed
anastomotic leak rate 4.2%, and 2.3%, in the prep and
non-prep group, respectively which was not significant,
as compared to 16.9% and 12% in the prepared versus
non prepared groups in current study which was also
not statistically significant (p=0.238).
Ophthalmology Update Vol. 12. No. 3, July-September 2014
Ali M,15 studied the effect of bowel preparation
on 211 patients in an RCT which contained two groups
of 109 cases with prepared bowel while in 101 patients
bowel was not prepared and all the cases were subjected to colonic surgery at various levels. His result
showed a high percentage of anastomotic leaks in the
prepared group that was 5.5% in comparison to 1%, as
also showed by high leak rate in prepared group (16.9%)
than non- prepared group (12%) in our current study.
CONCLUSION
Since there was no significant difference in the effectiveness of both the groups, we strongly conclude
that there is no need of any mechanical bowel preparation before primary anastomosis of the large bowel as
it will reduce the burden on our hospitals which are
already resource limited.
REFERENCES
1.
Bucher P, Gervaz P, Soravia C, Mermillod B, Erne M, Morel
P. Randamoised clinical trial of mechanical bowel preparation
versus no preparation before elective left sided colorectal surgery. British J Surj. 2008;92:409-14
2.
Ostrow B. When is primary anastomosis safe in the colon. Br J
Surg. 2007; 88:201-10.
3.
Sule AZ, Misauno M, Opaluwa AS, Ojo E. One stage treatment
of left sided large bowel emergencies. East African Med J. 2008;
85:80-4.
4.
Coban S, Yilmaz M, Terzi A, Yildiz F, Ozgor D. Resection and
primary anastomosis with or without modified blow-hole
colostomy for sigmoid volvulus.World J Gastroenterol. 2008;
14:5590-4.
5.
Mc-Coubrey AS. The use of mechanical bowel preparation in
elective colorectal surgery. Ulster Med J. 2007; 76:127-30.
6.
Oludiran OO, Osime OC. Emergency one-stage resection without mechanical bowel preparation for acute sigmoid volvulus.
J of Biomed sci. 2008; 3:86-90.
7.
Asfar SK, Al-sayer HM, Juma TH. Exteriorized colon anastomosis
for unprepared bowel. World J Gastro enterol. 2007; 13:3215-20.
8.
Scabini S, Rimini E, Romairone E, Scordamaglia R, Damiani G,
Pertile D. Colon and rectal surgery for cancer without mechanical bowel preparation. World J Surg Oncology. 2010; 8:35.
9.
Pena-soria MJ, Mayol JM, Anala-fernandez R. Mechanical bowel preparation for elective colorectal surgery with primary intraperitonial anastomosis by a single surgeon interim analysis
of prospective single blinded randomized trial. J Gastrointest
surg. 2007; 11:562-7.
10. Jame ED, Christie MQ. Bowel preparatio:current status. Clin
colon rectal surg. 2009; 22:14-20.
11. Nichols RL, Gorbach SL, Condon RE. Alteration of intestinal
microflora following preoperative mechanical preparation of
the colon. Dis Colon Rectum. 1971; 14(2):123-7.
12. Bucher P, Gervaz P, Soravia C, Mermillod B, Erné M, Morel P.
Randomized clinical trial of mechanical bowel preparation ver-
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Comparison of Efficacy of Primary Anastomosis of Large Bowel with Bowel Preparation Vs without Bowel Preparatio
sus no preparation before elective left-sided colorectal surgery.
Br J Surg. 2005; 92:409-14.
Ram E, Sherman Y, Weil R, Vishne T, Kravarusic D, Dreznik Z. Is
mechanical bowel preparation mandatory for elective colon surgery? A prospective randomized study. Arch Surg. 2005; 40(3):285-8.
Zmora O, Mahajna A, Bar-Zakai B, Hershko D, Shabtai M,
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15.
Krausz MM, et al. Is mechanical bowel preparation mandatory
for left-sided colonic anastomosis? Results of a prospective randomized trial. Tech Coloproctol. 2006; 10(2):131-5.
Ali M. Randomized prospective clinical trial of no preparation
versus mechanical bowel preparation before elective colorectal
surgery. Med Channel. 2007; 13:32-5.
Attention! Contributors and Researchers
While writing an article or a research paper
With the advent of internet facility there has been
an increasing trend of plagiarism in every field of life
especially the research field of education sector. We
are not surprised to see that most of the young doctors
aspiring for their promotions, research degrees or a
doctorate are busy in writing articles, research papers
or a thesis and to get them recognized by hook or crook
through publications in scientific journals, is a very
lamenting affair. We have also noticed that they embark
on such subjects which have already been undertaken by
many other authors and their results are well established
and fully documented in the text books as a solid theorem
and does not require further research except in very few
corners which need extended ‘probe in’. They never try
new fields in academics as it entails lot of time and hard
work, even their supervisors or heads of the departments
never bother to advise them not to select such hackneyed
topics or a stereotyped attempt on a particular subject.
To quote few examples in the field of ophthalmology
we hardly need any research work in finding the
complications of cataract surgery, a small incision cataract
surgery in phacoemulsification, comparing the efficacy
of many antibiotic eye drops, modes of local anesthesia
in ocular surgery, corneal repair through amniotic
membrane, incidence of hepatitis B & C in intending
ocular surgery especially the cataract surgery and finally
the incidence of refractive errors in school going children
etc etc., There is no doubt that these are very important
fields in ophthalmic horizon but one can find thousands
of papers written on these topics. We are not at all critical
on this point and we do not mean to discourage our young
ophthalmologists either. Our aim is that the supervisors,
heads of the department, reviewers and the editors of
the scientific journals should guide them to select from
an array of available topics so that they can select and
produce quality work with at least some originality and
we would certainly like to publish such peer-reviewed
papers without any hesitation.
We are very much conscious of the fact that PMDC
requires a number of papers to be published on their
account in order to compete for their next promotion.
Simply to write an article on an established theorem in
the text books is not a desirable act. The reviewers and the
editors of the scientific journals are mostly experienced
teachers and they are well versed with the various topics
intended for publication.
229
Therefore the writer should avoid such repetition
of facts in order to avoid disappointment if the article
is rejected, which will be a wastage of time and energy.
In fact we consider it a dereliction of responsibility on
the part of a supervisor who should be very careful in
selecting and approving the subject for their trainees,
keeping an eye on the instructions streamlined by Higher
Education Commission, Pakistan Medical & Dental
Council, College of Physicians & Surgeons, Pakistan and
Ethical Committee of the hospital. In fact every teaching
hospital/institution should have an Ethical Committee
and the PMDC should regularly watch its research
activities. College of Physicians & Surgeons used to hold
mandatory workshops on research methodology for the
postgraduates and junior consultants in the past imparting
basic training for writing papers and conducting research
which are no longer practiced.
In this context, the Ophthalmology Update has
adopted a very strict policy to discourage the plagiarized
material or repetition of the established facts in their
articles. Hence the researchers should be very careful in
sending us their article which will be returned to them
after review, causing great disappointment to the writer.
Hence, it is extremely important for them to discuss with
the heads of the department or some senior professor
before finally selecting the topic. They should get their
papers reviewed by them from time to time and finally
get it approved by the Ethical Committee to be forwarded
to the journal for publication. There is also a word of
advice to the reviewers to find time from their leisure to
critically review the paper, thinking it to be their academic
activity as well as a prime national duty.
The question arises, where the fault lies? The answer
is very simple. Our generation which includes doctors
and scientists have great potential in terms of manpower,
equipment and finances. Unfortunately, this capacity
has ever remained under-utilized. Our universities and
professional institutions are the seats of excellence in
higher learning and we must focus our attention on
promotion of academic and research activities besides
producing best physicians and surgeons. Our history tells
us that “these seats of higher learning are suffering from
stagnation” and we must pledge to break this attitude to
make progress through research which is the only way to
achieve excellence in any field
Chief Editor
Ophthalmology Update Vol. 12. No. 3, July-September 2014
ORIGINAL ARTICLE
M. Imran Khan
Outcome of Open Reduction & Internal
Fixation in Displaced Supracondylar Humeral
Fractures in Children
Muhammad Imran Khan FCPS1, Muhammad Saqib MBBS2
Muhammad Ayaz Khan FCPS3
ABSTRACT
Aim: This prospective study was conducted to know the outcome of open reduction and internal fixation in the management
of displaced supracondylar fracture of humerus in children.
Settings and Designs: Prospective study.
Materials and Methods: Fifty patients with displaced supracondylar fractures admitted between May 2012 and November
2013 were recruited into the study. All patients were operated under general anesthesia within 24 h after trauma. Results
were analyzed using Flynn’s criteria. All patients were followed up to 3 months post-operatively.
Results: Fifty displaced supracondylar fractures of humerus, aged between 5 year and 12 years, were treated using open
reduction and (K) wire fixation. Above elbow plaster of paris back slab was applied in all cases for at least 3 weeks. The slab
was removed at 3 weeks and the K-wires were removed after 6 weeks and elbow range of motion exercise was started.
92% had excellent, 8% good, 0% fair and 0 had poor results at 12 th weeks. There was no iatrogenic neurological injury
either for the ulnar or for the radial nerves. Only one patient had ulnar nerve palsy which improved after wire removal after
3 months. 3 patients developed superficial pin tract infection postoperatively and were treated conservatively with good
healing and no long-term sequelae.
Conclusion: Open reduction and internal fixation with cross pinning proved an efficient, reliable, and safe method in the
treatment of displaced supracondylar fractures of the humerus in children.
Key words: Supracondylar fracture humerus, Flynn criteria, open reduction and internal fixation
INTRODUCTION
Supracondylar fractures of the distal humerus are
the most common (60%) of elbow fracture in children
and represents approximately 16.6% of all fractures in
children.1,2,3 Closed reduction and percutaneous pinning under fluoroscopic guidance is the procedure of
choice for the treatment of these fractures whenever
possible.4,5,6 The commonest type is the extension fracture, in which the condylar complex shifts postero-medially or postero-laterally after a fall on the outstretched
arm, but in 2% the condylar complex shifts antero-laterally: the flexion type fracture3 with complications, such
as neurovascular injury and compartment syndrome.
There is fear of perioperative and late postoperative
complications like iatrogenic nerve injury, Volkmann’s
ischemic contracture, cubitus varus deformity, elbow
stiffness and myositis ossificans. Other studies have described high perioperative complication rate with delayed elective surgery but none has evaluated the long
term functional outcome of the patients.7
A variety of methods of treatment for displaced
fractures has been recommended including closed
District Specialist, Orthopaedics, Agency Headquarter Hospital,
Landikotal, 2Medical Officer, Khyber Teaching Hospital, Peshawar,
3
Associate Professor, Orthopaedics, Khyber Teaching Hospital,
Peshawar
1
Correspondence: Dr. Muhammad Imran Khan, House No-292, Street
10, Sector 1, Phase 4, Hayatabad, Peshawar.
Phone No. 03335055042
Received. January 2014
Accepted. March 2014
Ophthalmology Update Vol. 12. No. 3, July-September 2014
reduction and immobilisation,8 traction by various
methods9 and closed5 or open reduction10 stabilised by
Kirschner (K-) wires. Although some authors are not
in favour of closed reduction and immobilization,11
particularly for severe injuries, this treatment remains
popular. Others recommend stabilization by K-wires
for all displaced fractures.12
The aim of this study was to analyze the outcomes of open reduction and internal fixation with two
crossed k-wire fixation for completely displaced supracondylar fractures in children in agency headquarter
hospital Landikotal, FATA.
MATERIAL AND METHODS
In this study we included 50 children, aged 5-12
years having displaced supracondylar humeral fracture presenting with in first week of trauma. Patients
having open supracondylar fracture or associated with
vascular or nerve injury were not included in the study.
All patients were operated from May 2012 to November
2013 in agency headquarter hospital Landikotal FATA.
All the children underwent open reduction and crossed
K-wire fixation with two (1-mm) K-wire. In classifying
the fractures Gartland classification of the supracondylar fractures of the humerus was used.
50 patients who presented to emergency with displaced supracondylar fracture of humerus meeting our
inclusion criteria were admitted in the hospital. Radiographs of affected side were performed in antero-posterior and lateral projections. Evaluation of vascular and
neurological status was carried out. After explanation
230
Outcome of Open Reduction & Internal Fixation in Displaced Supracondylar Humeral Fractures in Children
of the procedure, the informed consent was taken for
the surgery and study. All baseline investigations were
performed. Operative intervention was performed on
either same day or the following morning.
All the patients were kept nothing by mouth
for 6 hours before induction of general anesthesia. The patients were placed on lateral dequbitus
position. After thorough scrubbing and draping of
injured elbow the fracture site was approached from
posterior through midline. The fracture was exposed,
cleaned, reduced and fixed with two cross K-wires.
Skin was closed and poster splint was given at 90 degree flexion for 3 weeks. After discharge, all the patients were followed up at outpatient department. At
3rd postoperative week slint was removed and assessed with antero-posterior and lateral radiographs.
Baumans angle and anterior humeral lines were
drawn on the x rays and values were compared
with normal side. After the removal of the back slab
gentle range of motion exercises of the operated
elbow were started. At 6th week the K-wires were
removed. At 12th week the elbow was xrayed again
and compared with normal side and the functional
and radiological outcome was assessed according to
Flynn criteria.13
Table 1: Flynn Criteria for Reduction Assessment
Cosmetic factor-Loss
of carrying angle
(degrees)
Functional
factor-loss of motion
(degree)
Excellent
0-5
0-5
Good
6-10
6-10
Fair
11-15
11-15
Poor
>15
>15
RESULTS
Among the fifty patients with displaced supracondylar fractures there were 33 (66%) males and 17(34%)
females with their mean age of 7 years (range 5–12 years).
Left side were involved in 35 patients (70%) and right
side in 15 patients (30%). None of the patients was lost
to follow-up. Forty six (92%) patients were found to
have excellent results while 4 (8%) patients had good
outcome according to Flynn criteria. None had either fair
or poor results. Three patients developed pin sites infection that resolved with local care and oral antibiotics.
One patient developed transient ulnar nerve palsy after
K–wire removal, which resolved after 3 months.
DISCUSSION
The many different methods advocated for supracondylar fractures of the humerus in children suggest
that no single technique is suitable for all types of fracture. The displaced supracondylar fracture represents
a spectrum of injury from type IIA with minor swell231
ing of soft tissues to type III with considerable swelling
and potential neurovascular complications. A selective
approach to treatment is required based on the classification of the fracture and the soft-tissue complications
present.
The indications for open reduction and pin fixation include a fracture which is irreducible by closed
methods; an open fracture and vascular injury. Open
reduction has been advocated as the primary procedure in all cases. Others have condemned this approach
because of concerns about infection and loss of movement.14 Those series which demonstrated significant
loss of movement, however, were reported by surgeons
who used a posterior approach or resorted to surgery
only after repeated closed manipulations.15 Open reduction was done in all patients and stabilised by Kwires. There were no episodes of superficial or deep
infection and no functional loss of movement.
We evaluated our results according to Flynn criteria and achieved excellent results in 46 patients
(92%) and good results in 4 patients (8%) which is
comparable with the results of Ababneh et al 16 and
Umer et al,17 who reported 87% and 100% excellent
results respectively. In another study18 on 71 patients,
boys were 47 (66.2%) and girls were 24 (33.8%) with
left elbow in 22 (30.9%) patients and having good to
excellent results in 91.8% which is comparable to this
study.
CONCLUSION
Open reduction and internal fixation is a better
treatment option in type III displaced supraconylar
fractures of the humerus in patients. There is low complication and high union rates
REFERENCES
1.
Otsuka NY , Kasser JR. Supracondylar fractures of the humerus
in children. J Am Acad Or thop Surg. 1997; 5:19-26.
2.
Dim´eglio A. Growth in pediatric orthopaedics. In: Morrissy RT ,
Weinstein SL, editors. Lovell and winter’s pedi at r i c or t hopaedi cs.
Phi l adel phi a: Li ppi ncot t Williams and Wilkins; 2005. p. 35-65.
3.
Cheng JC, Ng BK, Ying SY , Lam PK. A 10-year study of the
changes in the pattern and treatment of 6,493 fractures. J
Pediatr Or thop. 1999; 19:344-50.
4.
Jones KG. Percutaneous pin fixation of fractures of the lower end of the humerus. Cli n Orthop Relat Res 1967; 50:53-69.
5.
Swenson AL. Thetreatment of supracondylar fractures of the
humerus by Ki rschner wi retransfixion. J Bone Joint Surg Am
1948; 30(4):993-997.
6.
LINK W, HENNIG F, SCHMID J, BARANOWSKI D, Aktuelle
Traumatol, 16 (1986) 17.
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Lee SS, Mahar AT, Miesen D, Newton PO. Displaced pediatric supracondylar humerus fractures: biomechanical analysis of percutaneous pinning techniques. J Pediatr Orthop. 2002;22:440-43.
8.
Hadlow AT, Devane P, Nicol RO. A selective treatment approach to supracondylar fracture of the humerus in children. J
Pediatr Orthop 1996;16:104-6.
9.
Palmer EE, Niemann KMW, Vesely D, Armstrong JH. Supracondylar fracture of the humerus in children. J Bone Joint Surg
[Am] 1978;60-A:653-6.
10. Furrer M, Mark G, Ruedi T. Management of displaced supraconOphthalmology Update Vol. 12. No. 3, July-September 2014
Outcome of Open Reduction & Internal Fixation in Displaced Supracondylar Humeral Fractures in Children
11.
12.
13.
14.
15.
dylar fractures of the humerus in children. Injury 1991;22:259-62.
Pirone AM, Graham HK, Krajbich JI. Management of displaced
extension-type supracondylar fractures of the humerus in children. J Bone Joint Surg [Am] 1988;70-A:641-50.
Wilkins KE. Supracondylar fractures of the humerus. In: Operative management of upper extremity fractures in children.
AA monograph series, 1994.
O, Hara IJ. Barlow JW. Clarke NM. Displaced supracondylar fractures of the humerus in childrens. Audit changes
practice. J Bone Joint Surg Br 2000;82:204–10.
Mitchell WJ, Adams JP. Supracondylar fractures of the humerus in children: a ten-year review. JAMA 1961;175:573-7.
Weiland AJ, Meyer S, Tolo VT, Berg HL, Mueller J. Surgical
16.
17.
18.
treatment of displaced supracondylar fractures of the humerus
in children: analysis of fifty-two cases followed up for five to
fifteen years. J Bone Joint Surg [Am] 1978;60-A:657-61.
Ababneh M. Shannak A, Agabi S, Hadadi S.The treatment of
displaced supracondylar fractures of the humerus in children. A
comparison of three methods. Int Orthop 1998;22:263–5.
Umar M, DeSousa OP. Supracondylar fractures of humerus
in children. An analysis of different treatment modalities at
the Aga Khan University Hospital Karachi. Pakistan. Pak J
Surg 1991;7:16–22.
Diri B, Tomak Y, Karaismailoglu TN. The treatment of displaced
fractures of the humerus in children (an evalution of three
different treatment methods). Ulus Trauma Derg 2003;9(1):62–9.
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Ophthalmology Update Vol. 12. No. 3, July-September 2014
232
ORIGINAL ARTICLE
Mohammad Idris
Nature of Eyelid Trauma in a Tertiary
Care Hospital of Peshawar, KPK
Mohammad Idris FCPS1, Muhammad Junaid Sethi FCPS,FRCS2, Mohammad Alam FCPS3
Sadia Ayaz MBBS4, Zubair ullahFCPS5
ABSTRACT:
Objective: To evaluate the pattern of eyelid trauma presented in a tertiary care Hospital of KPK.
Material and Methods: prospective, interventional case series. The study was carried out at the Department of
Ophthalmology, Govt. Lady Reading Hospital, Peshawar from July 2011 to Jan 2013. We received 163 cases from outdoor
department for surgical management. Data was collected on special proforma and was analyzed with the help of SPSS
Version16.
Results: The study comprised of 163 cases of eyelid trauma. Male to female ratio was 1.5:1. Age ranged between 01 to 40
years (Mean = 25 years). About 47.2 % patients were between 21 and 40 years. The most common cause of eyelid trauma
was road traffic accident 36.8%, lower lid was commonly involved 80.9%, globe perforation was noted in 14.1% cases.
Conclusion: Commonest cause of eyelid trauma in our setup is RTA. BBI related lacerations have poorest surgical
outcome. Lower lid was commonest location and intraorbital injury was seen in BBI and RTA related trauma. Early referral
and timely repair offer the best outcome and to educate the masses regarding preventive measures to reduce its incidence.
Key words: eyelid trauma, road traffic accidents, bomb blast injury.
INTRODUCTION
Eyelids are the most exposed parts of the orbit
and serves as a protective shield for the intraorbital
structures. some injuries are so severe that intraorbital
structures are damaged.1 therefore it is mandatory to
properly evaluate cases of eyelid trauma.2 there are different causes of eyelid trauma. Road traffic accidents
(RTA) are the most frequent cause, other causes include
domestic violence, accidental fall and sports like activities. Bomb Blast Injuries (BBI) although rare but comparatively more common in our part of the world. Our
unit is one of the easiest approachable and an important center to receive maximum trauma cases. Injuries
of the eye lid ranges from simple lacerations to complex trauma involving lid margin, lacrimal apparatus,
orbital bone and intraorbital structures.3,4 Complicated
injures are also common and include those having tissue loss, multiple foreign bodies and wound contamination. Treatment of such complex group of injuries
are quite challenging in terms of surgical outcome. It
is quite common in young age group and is seen commonly in male gender.5 eye lid injuries are commonly
seen with head and face involvement.6 in these cases
other departments must be involved to mange patient
Medical Officer, Ophthalmology Unit, PGMI, Lady Reading Hospital, Peshawar, 2,3Senior Registrars, Ophthalmology Unit, PGMI, Lady
Reading Hospital, Peshawar, 4House Officer. PGMI, Lady Reading
Hospital, Peshawar, 5In charge Ophthalmologist, Mission Hospital,
Peshawar.
1
Correspondence: Mohammad Idris Medical Officer, Ophthalmology
Unit, PGMI, Lady Reading Hospital, Peshawar, Cell:0333 9417051
E-Mail: [email protected]
Received: May 2014
233
Accepted: June 2014
properly.7
Considering its prevalence and the possible serious complications of eyelid trauma, such as orbital
fractures and involvement of intraocular structures, educating the masses for preventive measures play an important role which can help reduce its incidence.8 our
study highlighted the anatomical features of the eyelid
trauma, in terms of location, size, depth of laceration
and complications such as bone fracture and globe perforation. Also we determined the association between
cause and surgical outcome of eyelid repair.
METHODOLOGY
Objective: To evaluate pattern of eyelid trauma presented in a tertiary care hospital of KPK.
Study Design: prospective, interventional case series.
Place and duration: The study was conducted at the
Department of Ophthalmology, Govt Lady Reading
Hospital, Peshawar from July 2011 to Jan 2013.
Sampling Technique: Convenience (non-probability
sampling).
Sample size: 163 patients having eyelid trauma attended the Ophthalmology Department for management.
Data Collection Procedures: Patients were selected
from the Ophthalmology Out Patients Department of
the Govt Lady Reading Hospital, Peshawar according
to selection criteria. Diagnosis was based on history and
routine ophthalmic examination. Detail assessment of
eyelid as well as of face, neck and intraocular structures
were made. Written consent of all the patients included
in the study was taken after fully explaining the procedure and purpose of the study to the patients.
Follow-ups: Patients had a follow-up on day one, at 4
month, 6 months and then last follow up at 1 year.
Ophthalmology Update Vol. 12. No. 3, July-September 2014
Nature of Eyelid Trauma in a Tertiary Care Hospital of Peshawar, KPK
Data analysis: The data were analyzed by software
SPSS (version 10.0).Frequencies and percentages were
calculated for cause, anatomical location of eyelid injury, associated involvement of lacrimal apparatus, globe
and face.
RESULTS
We evaluated 163 cases of eyelid trauma patients
for management. We admitted 85 patients for emergency repair. The rest of the cases were managed in the operation theatre without admission. The most common
cause of trauma was RTA and it was seen in 60 (36.8%)
cases followed by sports related injury which were seen
in 45 (27.6%) cases. BBI were seen in 34 (20.8%) cases
of domestic violence contributed 27(16.5%) cases. (table 1). Majority 98 (60.1%) cases of our patients were
male (table 2) and have age ranges from one to 40 years.
(84%) (Table 3); right eye was involved in most cases.
Regarding pattern of eyelid trauma, lower lid was most
common location of eyelid trauma. (80.9%). Upper lid
was involved in only 19% cases. Canalicular involvement was noted in 39 (23.9%) cases. tissue loss was
seen in 61 (37.4%) cases. foreign bodies were seen in 29
(1.22%) cases. wound contamination was seen in those
cases mainly who presented late and constitute 22.6%
cases; lid margin was seen in 49(30.6%) cases. Globe
perforation was noted in 55 (33.7%) cases and orbital
fracture in 23 (14.1%) cases. (Table 4)
Table-1: Cause of eyelid injury (n=163)
Cause
frequency
percentage
Road traffic accidents
60
36.8
Sports and accidental fall
45
27.6
Bomb blast injuries
34
20.8
Domestic violence and assault
27
16.56
total
163
100
Table-2: Gender distribution (N=163)
gender
frequency
percentage
male
98
60.1
female
65
39.8
total
163
100
Table-3: Age distribution (N=163)
Age group
frequency
percentage
1 to 20
60
36.8
21 to 40
77
47.2
More than 40
26
15.8
total
163
100
Ophthalmology Update Vol. 12. No. 3, July-September 2014
Table 4 : Pattern and Anatomical
distribution of eyelid trauma (N=163)
Features of eyelid trauma
and anatomical distribution
frequency
percentage
Lower eyelid
132
80.9
Upper eyelid
31
19
Tissue loss
61
37.4
Margin involvement
49
30
Canalicular laceration
39
23.9
Foreign bodies in the wound
29
17.7
Wound contamination
37
22.6
Globe perforation
55
33.7
Orbital fracture
23
14.1
DISCUSSION
In our study we evaluated 163 cases of eyelid trauma presented to our unit in one and half years. Most
of these injuries were mild to moderate and only simple laceration without any additional co-morbidity was
seen. There are different causes of eyelid trauma. RTA
is the most common cause.9 In our study, we noted RTA
(36.8%) is the most common cause followed by BBI
(20.8%). The other most frequent cause is domestic violence and sports related trauma. BBI represent a challenge as it causes multiple complex injury ranges from
lid laceration to globe rupture. In 67.3% cases of eyelid
wounds, ocular injuries coexisted.1 In our study globe
perforation was noted in 33.7% cases. Secondly, extensive tissue loss as well as foreign bodies and wound
contamination was commonly seen in BBI. In many
studies, most common location in eyelid trauma is upper lid10 but in our study the most common location
of eyelid trauma is lower lid. Involvement of lacrimal
apparatus is also common and represents a challenge11
and we saw these injuries in 23.9% cases. The surgical
outcome of injury involving eyelid structure other than
lower lid was also seen. Late presentation was seen in
51 cases and in these cases we noted wound contamination and infection. Trauma is commonly seen in young,
productive age as these people of the society are more
exposed to outside environment.12,13 there is also an
increased prevalence seen in male patients 61.1% and
more than 80% cases of our patients have age ranges
from one year to 40 years.
CONCLUSION
Commonest cause of eyelid trauma in our setup is
RTA. BBI related lacerations have poorest surgical outcome. Lower lid was commonest location and intraorbital injury was commonly seen in BBI and RTA related
trauma. Early referral and timely repair offer the best
outcome and to educate masses for preventive measures are the best means to reduce its incidence.
234
Nature of Eyelid Trauma in a Tertiary Care Hospital of Peshawar, KPK
REFERENCES
1.
Lima-Gómez V, Mora-Pérez E.Ocular lesions associated
with lid wounds with or without tearduct affection. Cir
Cir. 2006 Jan-Feb;74(1):11-4.
2.
Murchison AP, Bilyk JR. Management of eyelid injuries. Facial
Plast Surg. 2010 Dec;26(6):464-81.
3.
Lee H, Ahn J, Lee TE, Lee JM, Shin H, Chi M, Park M, Baek
S. Clinical characteristics and treatment of blow-out fracture
accompanied by canalicular laceration. J Craniofac Surg. 2012
Sep;23(5):1399-403.
4.
Woo JH, Sundar G. Eye injuries in Singapore--don’t risk it. Do
more. A prospective study. Ann Acad Med Singapore. 2006
Oct; 35(10):706-18.
5.
Tabatabaei A, Kasaei A, Nikdel M, Shoar S, Esmaeili S, Mafi
M, Moradi M, Mansouri M, Eshraghi B, Tabatabaei Z. Clinical
characteristics and causality of eye lid laceration in iran. Oman
Med J. 2013 Mar;28(2):97-101.
6.
Odebode TO, Ademola-Popoola DS, Ojo TA, Ayanniyi
AA. Ocular and visual complications of head injury.
Eye (Lond). 2005 May;19(5):561-6.
7.
Lipke KJ, Gümbel HO. Management of injuries of the eye and
8.
9.
10.
11.
12.
13.
its adnexa. Facial Plast Surg. 2013 Aug;29(4):310-5.
Tabatabaei A, Kasaei A, Nikdel M, Shoar S, Esmaeili S, Mafi
M, Moradi M, Mansouri M, Eshraghi B, Tabatabaei Z.Clinical
characteristics and causality of eye lid laceration in iran. Oman
Med J. 2013 Mar;28(2):97-101.
Schein OD, Hibberd PL, Shingleton BJ, Kunzweiler T,
Frambach DA, Seddon JM, et al. The spectrum and burden of
ocular injury. Ophthalmology 1988. Mar;95(3):300-305. Ko MJ, Morris CK, Kim JW, Lad SP, Arrigo RT, Lad EM.
Orbital fractures: national inpatient trends and complications.
Ophthal Plast Reconstr Surg. 2013 Jul-Aug;29(4):298-303.
Struck HG. Lacrimal system lacerations and their surgical
repair. Ophthalmologe. 2009 Mar;106(3):223-8
Wong TY, Klein BE, Klein R. The prevalence and 5-year
incidence of ocular trauma. The Beaver Dam Eye
Study. Ophthalmology 2000. Dec;107(12):2196-2202
Dandona L, Dandona R, Srinivas M, John RK, McCarty CA,
Rao GN. Ocular trauma in an urban population in southern
India: the Andhra Pradesh Eye Disease Study. Clin Experiment
Ophthalmol2000. Oct;28(5):350-56
Toy Laser Burn – Maculopathy
Children developed maculopathy following exposure to
these laser devices, with a vitelliform-like maculopathy
in the acute phase. Similar macular disturbance has
been reported following exposure to laser pointers in
children. (NewsNet Service)
235
Ophthalmology Update Vol. 12. No. 3, July-September 2014
ORIGINAL ARTICLE
Endoscopic Dilatation
for stricture Oesophagus in Children
(an experience at Lady Reading Hospital, Peshawar)
Muhammad Uzair
Muhammad Uzair FCPS (Peads. surgery)1, Prof. Kifayat Khan FCPS (Peads Surgery)2
Muhammad Khan Wazir FCPS (General Surgery)3, Afzal Khan MBBS4, Arshad Kamal FCPS5
Mussarat Hussain FCPS (General Surgery)6, Hafzurrehman MBBS7, Muhammad Fayyaz MBBS8
Muhammad Younus Khan FCPS (Peads surgery)9
ABSTRACT
Objective: To determine the safety and effectiveness of endoscopic oesophageal dilatation in stricture oesophagus in
children.
Material and Methods: This descriptive study was conducted in the department of paediatric surgery, Postgraduate
Medical Institute Lady Reading Hospital Peshawar from January 2011 to December 2013. All patients in whom diagnosis of
stricture esophagus was confirmed by barium meal were included. Patients were admitted to hospital and informed consent
taken from parents/caregivers. After an overnight fasting, under general endotracheal anaesthesia, a guide wire was passed
under endoscopic guidance across the stricture. Savary Gillard dilators were passed over the guide wire of increasing size.
Follow up sessions were scheduled according to development of dysphagia.
Results: A total of 32 patients aged between 6 months to 11 years were studied during this period. Two patients lost follow up
and were excluded from study, out of these 30 patients 08 females and 22 males patients, mean age being 3.66±2.23 years.
The types of stricture noted were; post corrosive intake 17 (56.6%) patients, peptic 7 (23.3%), postoperative 4 (13.3%),
and congenital stricture in 2 (6.6%) patients. Successful dilatation up to 15mm was achieved in 27 (90.0%) patients. Two
patients underwent surgery following treatment failure and one was refractory to multiple sessions of dilatation and was
planned for surgery. No major morbidity nor any mortality was noted during study period.
Conclusion: Endoscopic dilatation of stricture oesophagus in children is an effective and safe way of management for
stricture oesophagus of variant aetiologies and is easy to perform and offer great relief of dysphagia with low rate of
complications.
INTRODUCTION
Oesophageal strictures in children may be congenital or acquired. Acquired form results from injuries to
the oesophageal wall with subsequent thickening of its
layers and eventual development of fibrosis. Patients
have high morbidity with severe consequences such as
malnutrition, food impaction and pulmonary aspiration.1 The aim of the treatment of oesophageal stricture
is to alleviate dysphagia and to prevent recurrence and
oesophageal narrowing and its complications.2
The treatment options include endoscopic dilatation, use of removable self-expanding intraluminal
stents and surgical management. Surgical intervention has high mortality and uncertain results and is
Registrar, Peads Surgery Unit, Lady Reading Hospital, Peshawar,
Professor / In charge Peads Surgery Unit, Lady Reading Hospital,
Peshawar, 3Assistant Professor, Peshawar Institute of Medical
Sciences, Peshawar, 4Medical Officer, Lady Reading Hospital,
Peshawar, 5Senior Registrar, Peads Surgery Unit, Lady Reading
Hospital, Peshawar, 6Medical Officer, Surgical ˝D˝ Unit, Lady Reading
Hospital, Peshawar, 7Trainee Medical Officer Pediatric Surgery Unit,
Lady Reading Hospital, Peshawar, 8Junior Registrar Peads Surgery
Unit, Lady Reading Hospital, Peshawar, 9Assistant Professor,
Pediatric Surgery, Lady Reading Hospital, Peshawar
1
2
Correspondence: Dr. Muhammad Uzair, Registrar, Peads Surgery
Unit, Lady Reading Hospital, Peshawar. Cell No: 0345-9087189
E. Mail:[email protected]
Received: April 2014
Accepted: June 2014
Ophthalmology Update Vol. 12. No. 3, July-September 2014
therefore reserve for cases not responsive to endoscopic dilatation.3 Endoscopic wire guided dilatation
is preferred for oesophageal aetiologies, as it is easy
to use and offer great relief of dysphagia with low rate
of complication.4 The aim of this study is to assess the
safety and effectiveness of endoscopic wire guided dilatation of oesophageal stricture of various aetiologies
in children.
MATERIAL AND METHODS
This prospective descriptive study was conducted
in the department of Paediatric Surgery, Postgraduate
Medical Institute, Lady Reading Hospital, Peshawar
from January 2011 to December 2013. A total of 30 patients were studied during this period (two patients
excluded because of lost follow up). Initial assessment
consisted of detail history, clinical examination and
review of contrast enhanced radiological examination
of the oesophagus. All these patients were admitted to
paediatric surgery ward after explaining to parents the
whole protocol; disease diagnosis, management and
possible complications of the procedure, that might
arise during treatment or after. An informed written
consent was taken before the procedure. After an overnight fasting all these patients underwent general endotracheal anaesthesia, soft tip metallic guide wire was
passed across the stricture with the help of endoscope
236
Endoscopic Dilatation for stricture Oesophagus in Children
without fluoroscopy. Savary Gillard plastic dilator of
increasing size were passed over the soft tip guide wire,
started from smallest diameter (5mm) and the session
continue with progressive increase in dilator size according to age of patient and relief of symptoms. The
ideal final diameter of oesophageal lumen based on
clinical parameters used in the follow up period were
relief of dysphagia, weight gain and the interval between dilatation sessions. Patients were considered
cured when not needing endoscopic dilatation for 4
months.
After the procedure nasogastric tube was passed
and patients were kept nothing by mouth for 8-12
hours. Nasogastric tube was removed on 1st post-operative day and gradual introduction of liquid sips, semisolid food and finally fully allowed oral diets. All patients were advised follow up to outdoor department at
interval of 2 weeks and earlier if develops dysphagia or
vomiting. Post-operatively all patients were put on oral
antibiotics for 7 days and oral proton pump inhibitors
for 4 weeks to prevent GERD and to decrease stricture
recurrence and need for repeat dilatation.
RESULTS
A total of 30 patients were included, age ranging between 6 months and 11 years, with mean age
3.66±2.23 years. 08 (26.6%) were females and 22(73.3%)
were male. These patients were subjected to 197 sessions with a range of 2-15 sessions per patients (Mean
6.56 sessions). Predominant cause of stricture oesophagus was secondary to corrosive intake 17 patients
(56.6%), followed by peptic stricture 7 patients (23.3%),
postoperative stricture 4 (13.3%) of these two patients
were post trachea-oesophageal fistula repair surgery
(6.6%), one operated for inflammatory psuedotumor of
esophagus (3.3%) and one post fundoplication for achalasia cardia (3.3%), and congenital stricture 2 patients
(6.6%).
Successful dilatation up to 15 mm size of dilator
was achieved in 27 patients (90%) and were discharged
from dilatation sessions before the end of this study,
two patients (6.6%) underwent surgery because of no
response to endoscopic dilatations. One post operative
patient in whom surgery was performed for inflammatory psuedotumor of esophagus is under sessions
of dilatation with poor response even after 13 sessions.
02 patients managed for oesophageal stricture during
this study period were not included because of lost follow up after first successful sessions. Generally patients
with corrosive strictures were resistant to dilatation
and needed more sessions compared to other types of
stricture ie postoperative, GERD induced and congenital strictures. Aetiology, mean age of presentation and
outcome are presented in table 1 & 2.
237
Table-1: Etiological classification and mean age of presentation
Frequency
Age of
presentation (yrs)
Corrosive induced
17 (56.6%)
4.5
GERD associated
07 (23.33%)
2.28
Post surgical
04 (13.33%)
3.75
Congenital
02 (6.66%)
1.25
Type of stricture
Table-2: Dilatation sessions required
and Outcome of endoscopic dilatation
characteristic
Corrosive
GERD
Post
congenital
induced associated surgical
Number of patients
17
07
04
02
Number of dilatation
sessions
137
30
23
07
Sessions/case
8.05
4.3
5,75
3.5
Successfully treated
cases
15
07
03
02
Required surgery
02
00
01
00
Perforation as
complication
00
00
00
00
88.23%
100%
75%
100%
Overall success
DISCUSSION
Oesophageal strictures in children are varied; the
majority cases of stricture oesophagus are congenital,
post corrosive intake, post-operative and peptic due
to GERD5. Corrosive intake is the commonest cause of
stricture oesophagus in developing country like Pakistan and India5,6, while in developed countries it is the
postoperative, with highest prevalance1,7,8.
Management of oesophageal strictures in children
are still a challenge to the paediatrician, surgeon and
the gastroenterologist inspite of the great advances and
different therapeutic options currently in use. The last
decade witnessed a shift to more interventional endoscopic dilatation on the expense of surgical replacement9, most authority recommend that every effort
should be made to preserve patients own oesophagus.
Our study describes a developing country experience
with semi-rigid guide wire guided Savoury Gillard Dilator in children.
Corrosive oesophageal strictures in children are
predominant, and in our study 17 cases 56.6% were
corrosive induced, similar reports are present from
other developing countries6,10,11. These strictures tend to
be long, tortuous, and rigid and require more sessions
of dilatation as compared to postoperative or peptic
strictures, and as seen in Adnan MH et al study that
corrosive strictures required more dilatation sessions
(7.9±5.5) and lower discharge rate (77%) as compared
to other causes of stricture. Further, corrosive stricture
carry more risk for perforation10,12,13.
Gastro-esophageal reflux (GER) is a common disorder in children; however, only 1.5% children with
Ophthalmology Update Vol. 12. No. 3, July-September 2014
Endoscopic Dilatation for stricture Oesophagus in Children
severe gastro oesophageal reflux are reported to have
stricture esophsgus.12 In our series 23.33% patients had
strictures secondary to GER. Generally peptic strictures
show a good response to endoscopic dilatation with
combination of proton pump inhibitors14. However if
esophagitis persists and there is associated hiatal hernia, response to endoscopic dilatation is poor.15
Strictures secondary to surgical repair of oesophageal atresia or surgical treatment of corrosive strictures
usually show better response to endoscopic dilatation,
requiring less sessions of dilatation to achieve the desired oesophageal intraluminal diameter.10 Postoperative oesophageal stricture was managed in 13.33% of
children in our study. In these patients prior surgeries
were performed for tracheoesophageal fistula (2 patients), inflammatory psuedotumor of oesophagus (one
patient) and one post fundoplication for achalasia cardia.
Congenital oesophageal strictures are relatively
uncommon with incidence of 1:25000 to 50000 live
births with various aetiology.1 Different studies with
echoendoscopy have been used to find aetiology and
plan management. Conservative management yields
good results and surgery is reserved for refractory cases.16 In two of our patients the underlying cause of oesophageal stricture was congenital. All were managed
with Savoury Gillard Dilator.
Oesophageal rupture is the most serious complication of oesophageal dilatation.3,5,11,12 In our study, fortunately, we didn’t encounter this complication. Generally the incidence of this complication is low and reported
to be 0.8% in a large series of 257 dilatations performed
by Adnan MH et al. In his study both cases were diagnosed early and were recovered with conservative
management.12 Early diagnosis of oesophageal perforation with rapid implementation of treatment is the most
important prognostic factor for reducing morbidity and
mortality among these patients.17
Treatment failure, cost and rate of complications
are the major limiting factors in application of different
procedure in the management of oesophageal stricture.
Oesophageal strictures can be dilated with balloons or
boogies without much difference regarding efficacy
and rate of complications. However, Balloons are more
costly than durable boogies but less traumatic. The anatomical and endoscopic characteristics of the stricture,
the experience of the endoscopist and the time of presentation of the stricture whether early or delayed also
effects the preference for choice of instrument used.13,18
Other techniques reported in the literature for management of oesophageal stricture in children are injection
of corticosteroids into the stricture or topical Mitomycin
C application and temporary non-metal stents. These
have primarily been reported for use in the setting of
Ophthalmology Update Vol. 12. No. 3, July-September 2014
refractory strictures.19,20
Endoscopic dilatation is very effective way of
treating stricture oesophagus in children.21 Efficacy reported is in strictures secondary to corrosive ingestion
which ranges 60 to 80%.22,23 In our study it was 88.2%
successful in corrosive induced stricture oesophagus
while overall efficacy is 90%. In addition to corrosive
induced stricture one patient who has postoperative
stricture who had failed to cure with endoscopic dilatation. In this patient surgery was performed initially for
inflammatory psuedotumor of oesophagus and now
having complaints of dysphagia even after 13 dilatation
sessions and is planned to treat with surgery. However,
GERD induced and congenital oesophageal strictures
responded well to endoscopic dilatation and all these
patients cured in our study without complications.
CONCLUSION
Our study shows that endoscopic dilatation of
stricture oesophagus in children is an effective and safe
way of management for stricture oesophagus of variant
aetiologies. It is easy to perform and offer great relief
of dysphagia and has low rate of complications. Low
cost and short hospital stay make this procedure more
attractive specially for resource-limited countries like
ours.
REFRENCES
1.
Paulo Fernando et al. endoscopic dilatation of esophageal strictures in children and adolesescents. J d pediatr 2006;82(2):12731.
2.
Complications of Esophageal stricture. Right Diagnosis.[Feb
23, 2014] available from.http://www.rightdiagnosis.com/e/
esophageal_stricture/complic.htm.
3.
Broto J, Asenia M, Vernet JMG. Results of a new technique in
the treatment of severe esophageal stenosis in children. Poliflex
stents. J pediatr Gastroenterol nutr 2003;37:203-6.
4.
Riley SA, Attwood SEA. Guidelines on the use of esophageal
dilatation in clinical practice. Gut 2004; 53(suppl-1):01-06.
5.
Poddar U, Thapa BR. Benign esophageal stricture in infants
and children: results of sarvay gillerd bounge dilatation in 107
indian children. Gastrointest endosc 2001;54:480-484.
6.
Cheema HA. Endoscopic balloon dilatation of esophageal stricture in children 2006;12(4):574-5.
7.
Mahmood M, Akhter AN, Ismael S, Yousaf S, Husain Z, Bangash MR. guidewire dilatation of anastomotic stricture secondary to surgical repair of esophageal atresia. RMJ 2013;38:18-21.
8.
Qureshi S, Ghaznafer S, Leghari A, Tariq F, Qureshi SM, Niaz
KS. JPMI 2010. 60:8-.
9.
De Peppo FD, Zaccara L, Dall’Oglio L, Federici di Abriola G, Ponticelli A, Marchetti P, et al. Stenting for caustic
strictures:Esophageal replacement replaced. J Pediatr Surg
1998;33(1):54-7.
10. Broor SL, Lahoti D, Bose PP, Ramesh GN, Raju GS, Kumar A. Benign esophageal strictures in children and adolescents:etiology,
clinical profile, and results of endoscopic dilation. Gastrintest
Endsc 1996;43(5):474-7.
11. Daradka I. Esophageal injury: A study of caustic ingestion in 83
children. Jordan Med J 2005;39(2):149-57.
12. Adnan MH, Taha A, Aras A, Azad J. Endoscopic dilatation of
esophageal strictures in children:causes and outcome in 47 patients.Duhok Med J 2010;4(2):30-38.
13. Ekberg O, Borgstorm A, Fork FT, Lovadahl E.Endoscopic bal-
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14.
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loon dilatation of benign esophageal strictures:A nonhazardous procedure? Diagn Ther Endosc 1993;1(2):93-7.
Hassall E, Israel D, Shepherd R, Rdke M, Dalvag A, Scold B, et
al. Omeprazole for the treatment of chronic erosive esophagitis
in children:a multicenter study of efficacy, safty, tolerability,
and dose requirements. J Pediatr 2000;137(7):800-7.
Said A, Brust DJ, Gaumnitz EA, Reichederfer M. Predictors of
early recurrence of benign esophageal stricture. Am J Gastroenterol 2003;98(6):1252-6.
Romeo E, Foschia F, Angelis P,Abriola GF, Caldaro T, Gambitta
R et al. Endoscopic management of congenital esophageal stenosis. J Pediatr Surg 2011;46(5):838-41.
Martinez L, Rivas S, Hernandez, Avila LF, Lassaletta L, Murica
J, et al. Aggressive conservative treatment of esophageal perforations in children. J Pediatr Surg2003;38(5):685-9.
Long T, Hummer HP, Behrens R. Balloon dilation is preferable
to bouginage in children with esophageal atresia. Endoscopy
19.
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2001;33(4):329-35.
Kochhar R, Makharia GK. Usefulness of intraleisonal triamcinolone in treatment of benign esophageal strictures. Gastrointest Endosc 2002;56(6):829-34.
Heran M, Baird R, Skarsgard ED. Topical Mitomycin-C for
recalcitrant esophageal stricture: a novel endoscopic/fluoroscopic technique for safe endoluminal delivery. J Pediatr Surg
2008;43(5):815-8.
Shehata SM, Enaba ME. Endoscopic dilatation for benign oesophageal strictures in infants and toddlers: Experience of an
expectant protocol from North African tertiary centre . Afr J
Paediatr Surg 2012;9:187-92..
Hamza AF, Abdelhay S, Sherif H, Hasan T,Soliman H, Kabesh
A, et al. Caustic esophageal strictures in children: 30 years experience. J Pediatr Surg2003;38:828-33.
Rehman S, Hameed K, Khan IM. Endoscopic dilatation for
caustic esophageal strictures.JPMI2007;21(4):292-95.
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239
Ophthalmology Update Vol. 12. No. 3, July-September 2014
ORIGINAL ARTICLE
Role of Prophylactic Antibiotic in
Prevention of Wound Infections following
Lichtenstein Inguinal Hernioplasty
Siddique Ahmad
Siddique Ahmad FCPS (General Surgery)1, Yousaf Jan FCPS (General Surgery)2
Waqas MBBS3, Shaukat Hussain MBBS4, Aurangzeb Khan MBBS5
ABSTRACT:
Background: Inguinal hernia is one of commonest condition encountered in clinical practice. Mesh repair is becoming
the most popular technique for inguinal hernia repair. The use of antibiotic prophylaxis during Lichtenstein inguinal hernia
surgery is controversial.
Objective: To determine the role of single dose intravenous antibiotic prophylaxis over no antibiotic prophylaxis in the
prevention of wound infection following Lichtenstein inguinal hernioplasty in patients with no other co-morbid conditions.
Methods: This prospective study was conducted at surgical unit Hayatabad Medical Complex Peshawar from March 2010
to August 2011. A total of first consecutive 150 cases of inguinal hernia were randomized to receive 1.5 gram intravenous
cefuroxime (group-A) before the incision or an equal volume of placebo (group-B). All patients underwent Lichtenstein
inguinal hernioplasty with prolene mesh electively under spinal anaesthesia .
Results: A total of 150 patients were included in the study. Minimum age of patients in this study was 20 years and
maximum 75 years with a mean of 44.06 in group A and 44.84 in group B. The total number of wound infections was 7
(4.0%), 2 (2.66%) in the group A and 6 (8%) in group B.
Conclusion: We conclude that there is no benefit of intravenous single dose antibiotic prophylaxis in the prevention of
wound infection following Lichtenstein inguinal hernioplasty in patients with no other co-morbid conditions.
Keywords: Inguinal hernia, Lichtenstein repair, antibiotic prophylaxis.
INTRODUCTION
Hernia constitutes 10-15% of all surgical procedures, 80% being inguinal.1 It is more common in
males than females in a ratio of 20:1.2 Of the various
methods for adult inguinal hernia repair, mesh repair
is rapidly becoming the most popular technique. Of
the open mesh repair technique, Lichtenstein hernia repair is most frequently performed. This technique is a
tension free repair of weakened inguinal floor using a
polypropylene mesh.3
Antibiotic prophylaxis refers to a very brief course
of an antimicrobial agent initiated just before an operation begins.4 Intravenous route is the mode of prophylactic antibiotic delivery used most often in modern
surgical practice.5 The ideal timing in prophylaxis for
optimal serum drug level is 30-60 min before surgical
incision,6 and postoperative administration of antibiotics is now generally considered to be of no benefit in
routine practice.7 Recommendations are clear for their
use in contaminated and clean-contaminated cases but
Assistant Professor Surgery A ward HMC Peshawar, 2Registrar
Surgical B unit HMC Peshawar, 3Medical Officer DHQ Hospital
Nowshera, 4Trainee Medical Officer Surgical B unit HMC Peshawar,
5
Registrar Surgical Unit Rehman Medical Institute Hayatabad
Peshawar.
1
Correspondence: Dr. Siddique Ahmad (FCPS Gen Surgery) Assistant
Professor Surgical “A” Unit HMC Peshawar. Cell: 0345-9415719
Email: [email protected]
Received: March’2014
Accepted: June:2014
Ophthalmology Update Vol. 12. No. 3, July-September 2014
picture is not so clear in clean surgical cases. Open inguinal hernia repair using prosthetic mesh is an example of such clean cases where the preoperative use of
antibiotics is debated.
Surgical site infection (SSI) is the most frequent
complication in inguinal henrioraphy.8 Reported rate
of wound infection following inguinal hernioplasty
vary from 0%-9%.9 To prevent this mesh infection, antibiotic prophylaxis is often indicated and recommended.10 The use of antibiotics for prophylaxis is becoming a serious problem due to the risk of contribution
to developing bacterial resistance and the significant
increase in health care costs.11 Effective prophylaxis can
almost always be achieved with a single dose of antibiotic.12 Wound infection after hernia repair has been
associated with a four – fold increase in the recurrence
rate.13
There is no clear consensus on whether or not
antibiotic prophylaxis is effective in elective inguinal
hernia repair. The European Hernia Guidelines advise
that there is no indication for routine use of antibiotic
prophylaxis in elective open or laparoscopic groin hernia repair in low risk patients, but that prophylaxis
should be considered for patients with risk factors for
wound infections14 like age > 70 years, with co-morbidities, duration of surgery and routine use of drainage and prosthesis. One randomised controlled trial
recently found no significant difference in risk of infection between use of prophylaxis and placebo.15
240
Role of Prophylactic Antibiotic in Prevention of Wound Infections following Lichtenstein Inguinal Hernioplasty
In an effort to clarify the effectiveness of antibiotic
prophylaxis, we conducted this study to document the
effect of pre-operative antibiotics in the wound infections after Lichtenstein hernia repair.
Objective: To determine the role of single dose intravenous antibiotic prophylaxis over no antibiotic prophylaxis in the prevention of wound infection following
Lichtenstein inguinal hernioplasty in patients with no
other co-morbid conditions.
MATERIAL AND METHODS
After having permission from the Ethical committee of the hospital, this prospective study was conducted at Hayatabad Medical Complex Peshawar from
March 2010 to August 2011. A total of 150 patients with
inguinal hernia, never had an allergy to cephalosporin.
Those aged over 20 years–old were included after informed consents obtained. Patients with age < 20 years,
obstructed/strangulated/recurrent hernia, allergic to
injection cefuroxime, immunosuppressive diseases (diabetes mellitus, HIV, malignancy), known liver or renal impairment, patients on steroid or antibiotic within
a week before surgery, huge or scrotal hernia were
exclude from the study.
All patients were admitted in the ward through
an OPD and evaluated carefully preoperatively. These
patients underwent a thorough physical and clinical examination, noting the history of illness, site of
hernia, duration and type of hernia. Routine investigations were sent in all patients and fitness for general
anaesthesia was assessed. The patients were guided
and explained about the nature of the study. Risks and
benefits of the prophylactic antibiotics were discussed
and informed consent to be included was taken.
All included patients were equally divided into
two groups by simple random sampling technique.
Group A (n=75) antibiotic prophylaxis group and
Group B (n=75) no antibiotic prophylaxis group (placebo ). Group A patients (trial group) were given 1.5
gram cefuroxime in 10 ml distilled water intravenously 30 minutes before surgery after test dose , and
group B (placebo group) were given 10 ml normal
saline as placebo at the same time. Under strict aseptic
conditions and spinal anaesthesia, all patients underwent open Lichtenstein inguinal hernioplasty using
monofilament polypropylene mesh which was fixed
with 2/0 prolene by senior registrars or consultants.
Operative findings and time was recorded.
Patients were discharged on second postoperative day, and the wounds were inspected at the time of
discharge while the first dressing changed. They were
called in the out-patient department for follow up at
8 days, 2 weeks and 30 days postoperatively for assessment of wound infection and other complications.
During each follow up visit, detailed history regard241
ing presence or absence of pain over the incision site,
redness, local bulging, any discharge from the wound
were taken, and local examination was done to look
for erythema, heat, tenderness and any discharge
from the wound for C/S. Any patient showing signs
of wound infection was appropriately treated and all
records were maintained.
Wound infection : It was defined as following,16
• purulent discharge from the incision site, with or
without positive culture and sensitivity report
• Non purulent discharge from incision site with
positive culture and sensitivity report.
• Incision site deliberately opened by surgeons in
the presence of least one of the following signs or
symptoms of infection: pain or tenderness, localized swelling, redness or heat.
• Diagnosis of infection by the surgeon.
Category of wound infection:
• Superficial incisional surgical site infection: Infection occurring within 30 days after surgery
involved only skin and/or subcutaneous tissue.
• Deep incisional surgical site infection: Infection
occurring within 1 year after surgery involving
fascial muscle layers and also the mesh.
RESULTS
Total of 150 patients, seventy five in each group
were enrolled into the study. All of the patients were
males. Minimum age of patients in this study was 20
years and maximum 75 years with a mean of 44.06 in
group A and 44.84 in group B. Maximum number of
patients were between 31 years to 60 years of age (Table
1). Duration of illness ranged from 3 month to 17 years.
Surgery duration ranged from 45 minutes to 75 minutes. Out of 150 patients, 97 (64.6%) patients had right
sided, 52 (34.6%) patients had left sided and 26(17.3%)
had bilateral hernia (Table-1)
Postoperative complications during hospital stay:
Out of 150 patients, 5 patients (3.28%) went into urinary
retention needed Foleys catheterization in the ward.
Three patients (2%) developed scrotal hematoma treated by scrotal elevation. Four patients (5.33%) in group
A and 3 (4%) in group B had increasing wound pain
subsided with oral analgesics. None of the patient had
wound infection or systemic complication like chest
infection, DVT during hospital stay (Table-2)
Treatment outcome at first follow up at 8 day: Out
of 75 patients in group A, only one patient (1.33%)
had purulent wound discharge as compared to
three patients (4%) in group B. Suture were opened,
pus drained and sent for gram stain and culture
sensitivity. Patients was advised for oral cefuroxime
250 mg for 5 days with daily dressing. On follow up culture showed no growth except in one
patient showing growth of staphylococcus aureus
Ophthalmology Update Vol. 12. No. 3, July-September 2014
Role of Prophylactic Antibiotic in Prevention of Wound Infections following Lichtenstein Inguinal Hernioplasty
sensitive to Nafcillin and Augmentin. Three patients
(4%) in group A had wound tenderness with edema
treated conservatively (Table 3). Two patients (2.66%)
in group A and one patient (1.33%) in group B had
bruises around the wound. Two out of three patients with scrotal hematoma developed during hospital stay subsided at first follow up and stitches were
removed.
Table-1: Baseline characteristics of both groups
Characteristics
Group A (n=75)
Group B (n=75)
Total (n=150)
p-value
21 - 30
31 - 40
41 - 50
51 - 60
60 – 70
> 70
08 (10.6%)
20 (26.6%)
22 (29.3%)
25 (33.3%)
12 (16%)
10 (13.3%)
06 (8%)
12 (16%)
24 (32%)
20 (26.6%)
08(10.6%)
08 (10.6%)
14 (9.3%
32 (21.3%)
46 (30.6%)
45 (30%)
20 (13.3%)
18 (12%)
0.8614
Sex distribution
Males
Females
75 (100%)
0 (0%)
75 (100%)
0 (0%)
150 (100%)
0 (0%)
1.000
Duration of illness in years
< 1 year
> 1 year
45 (60%)
62 (82.6%)
36 (48%)
32 (42.6%)
81 (54%)
94 (62.6%)
0.1659
Side distribution of hernia
Right
Left
Bilateral
60 (80%)
35 (46.6%)
15 (20%)
37 (49.3%)
17 (22.6%)
11 (14.6%)
97 (64.6%)
52 (34.6%)
26 (17.3%)
0.6771
< 50
> 50
58 (77.3%)
17 (22.6%)
52 (69.3%)
23 (30.6%)
75 (50%)
75 (50%)
0.3560
Age in years
Duration of surgery in mint
Table-2: Post op complications during hospital stay
Complications
Group A ( n = 75)
Group B ( n =75 )
Total ( n = 150)
P- value
Urinary retention
2 (2.66%)
3 (4%)
5 (3.33%)
0.6492
Scrotal hematoma
1 (1.33%)
2 (2.66%)
3 (2%)
0.5598
Wound discharge
Wound pain
Wound infection
0
0
0
1.00
4 (5.33%)
3 (4%)
7 (4.66%)
0.6987
0
0
0
1.000
Table-3: Complications at first follow up
Antibiotic prophylaxis
group (n = 75)
No antibiotic prophylaxis
group (n =75)
Total n =150
p-value
1 (1.33%)
3 (4%)
4(2.66%)
0.3128
3 (4%)
0
3 (2%)
1.000
Wound bruises
2 (2.66%)
1 (1.33%)
3 (2%)
0.5598
Wound discharge
1 (1.33%)
3 (4%)
4 (2.66%)
0.3128
Scrotal hematoma
0
0
0
Complications
Wound infection
Wound tenderness and edema
Treatment outcome at second follow up at 14
days: None of the patients from both groups had
wound infection at this follow up. One patient from
Group A and three patients from Group B who
had wound infections during first follow up were
also fine and there were no persistence of infection.
Three patients (2%) one from group A (1.33%) and
two from group B (2.66%) had intermittent wound
pain treated with oral diclofenac sodium 75 mg. None
of the patient in both groups had scrotal hematoma
or wound discharge.
Treatment outcome at third follow up at 30 days:
There were total of 150 patients 75 in each group.
Ophthalmology Update Vol. 12. No. 3, July-September 2014
Three patients ( 4%) from group B and one patient
(1.33%) from group A had non purulent wound discharge. On C/S report, 2 patients out of three in group
B and one patient from group A had positive results
with growth of staphylococcus epidermidis in each
patient from both groups and Escherichia Coli in second group B patient. All three wound infections were
treated with oral vancomycin and ciprofloxacin respectively according to sensitivity report and sutured
were opened. None of the patients from both groups
had hernia recurrence, testicular atrophy and scrotal
hematoma.
The overall rate of wound infection was 7 (4.66%),
242
Role of Prophylactic Antibiotic in Prevention of Wound Infections following Lichtenstein Inguinal Hernioplasty
two (2.66%) in group A and five (6.66%) in group B. Although not included in the study three patients (2%)
developed scrotal hematoma, one (1.33%) in group A
and two (2.66%) in group B. Eight patients (5.33%) had
wound discharge, two (2.66%) in group A and six (8%)
in group B. Three patients (2%) had wound bruises,
one (1.33%) in group A and two (2.66%) in group B (Table-4)
Table-4: Overall comparison of complications in both groups
Complications
Group A (n=75)
Group B (n=75)
Wound infection
2 (2.66%)
5 (6.66%)
7 (04%)
0.2462
Scrotal hematoma
1 (1.33%)
2 (2.66%)
3 (02%)
0.5598
Wound discharge
2 (2.66%)
6 (08%)
8 (5.33%)
0.1412
Wound pain
5 (6.66%)
5 (6.66%)
10 (6.66%)
1.000
DISCUSSION
Inguinal hernia is the commonest problem amongst
all external hernias and surgery for inguinal hernia is
one of the most common procedures performed in a
general surgical service, accounting for approximately
one-third of all interventions.17 The age incidence is
distributed in all decades of life. Incidence of inguinal
hernia is race related and is at least three times more
common in black Africans than in the white populations.18 Although many patients with hernia are asymptomatic, most of them have local symptoms and if left
untreated, hernia itself has potential complications like
irreducibility, strangulation, peritonitis and sepsis.19
Of the various method for adult inguinal hernia
repair, mesh repair is rapidly becoming the most popular technique. Of the open mesh repair technique, Lichtenstein hernia repair is most frequently performed.
The Lichtenstein technique is a tension free repair of
weakened inguinal floor using a polypropylene mesh.3
Recommendations are clear about prophylactic antibiotic for their use in contaminated and clean-contaminated cases but picture is not so clear in clean surgical cases. Open inguinal hernia repair using prosthetic
mesh is an example of such clean cases where the preoperative use of antibiotics is debated.
Surgical site infection (SSI) is the most frequent
complication in inguinal henrioraphy.8 Reported rate
of wound infection following inguinal hernioplasty
vary from 0%-9%.9 To prevent this mesh infection, antibiotic prophylaxis is often indicated and recommended.10 The use of antibiotics for prophylaxis is becoming a serious problem due to the risk of contribution to
developing bacterial resistance and the significant increase in health care costs.11 The low rate of wound infection and the straightforward treatment if they occur
at all are the main arguments against routine antibiotic
coverage during inguinal hernia surgery.20 However
even under most scrupulous aseptic conditions and
with a careful technique, post- operative wound infection still present a very serious problem.
243
Total
(n=150)
p-value
Minimum age of patients in this study was 20
years and maximum 75 years with a mean of 44.06 in
group A and 44.84 in group B. Maximum number of
patients were between 31 years to 60 years of age (Table
1). Duration of illness ranged from 3 month to 17 years.
Surgery duration ranged from 45 minutes to 75 minutes. Out of 150 patients, 97(63.6%) patients had right
sided, 52 (34.6%) patients had left sided and 26(17.3%)
had bilateral hernia(Table 1)
Therefore, we conducted this study to document
the effectiveness of prophylactic antibiotics in preventing wound infection following Lichtenstein inguinal
hernioplasty. Total 150 patients were evaluated and
they were randomized to have antibiotic prophylaxis
group A (n=75) and no antibiotic prophylaxis group
B (n=75). The overall rate of wound infection was 7
(4.60%), 2 (2.66%) in group A and 5(6.66%) in group
B in our study. Statistical analysis showed no significance of pre-operative antibiotic prophylaxis (p-value
= 0.2462).
During the first follow up, out of 150 patients
(75 in each group), 1 patient (1.33%) from group A
and 3 patients (4%) from group B developed wound
infections. During second follow up at 14 days, none
of the patients from both groups had wound infections, as compared to 1 patients (1.33%) from group A
and 2 patients (2.66%) from group B developed wound
infections at 30 days follow up. Therefore the overall
rate of wound infection was 7 (4.0%), 2 (2.66%) in group
A and 5 (6.66%) in group B in our study. A study conducted by Anfenacker and his colleagues,21 reported
1.7% of wound infection after Lichtenstein open mesh
repair and there is no significance difference between
antibiotic prophylaxis and placebo group. Taylor
et al,22 conducted a prospective randomized double
blind, multicentre study of 619 patients, and showed
there was no statistically significant difference between antibiotic and placebo group in each centre.
Perez et al24 and Aamir et al,26 also showed that there
was no statistically significant difference between antiOphthalmology Update Vol. 12. No. 3, July-September 2014
Role of Prophylactic Antibiotic in Prevention of Wound Infections following Lichtenstein Inguinal Hernioplasty
biotic and placebo group and therefore routine use of
prophylactic antibiotic in Lichtenstein mesh hernioplasty is of no benefit (Table 5)
The overall rate of wound infection in our study
was 7 (4.60%). This is comparable to wound infections
in various studies by Aufenacker et al21 (1.7%), Yerdel
et al23 (4.83%), Perez et al24 (3.03%), Otezia et al25 (0.40%,
Aamirijaz et al26 (7%) Table 5.
Table-5: Our wound infection rate comparison with different studies in both groups
Antibiotic (group A)
No antibiotic (group B)
Total
Aufenacker et al21
8 (1.6%) n=503
9 (1.8%) n=505
17(1.7%) n=1008
Yerdel et al
1 (0.7%) n=136
12 (9%) n=133
13(4.8%) n= 269
4 (2.2%) n=180
7 (3.9%) n=180
11(3.03%) n=360
1 (0.8%) n=124
O (0%) n=123
1(0.40%) n=247
2 (4%) n=50
5 (10%) n=5o
7(7%) n=100
2 (2.6%) n=75
5 (6.6%) n=75
7(4.0%) n=175
Perez et al
23
24
Otezia et al
Aamir et al
25
26
Our study
The pus samples taken from all seven patients
with wound infections were cultured and showed
growth of Staphylococcus aureus in one case, Staphylococcus epidermidis in two cases and Escherichia
Coli in one case with no growth in three cases. All
patients were treated with oral antibiotics according
to C/S report with drainage of the wound and mesh
removal was not needed in any of the infected cases.
Although not included in the study three patients (2%)
developed scrotal hematoma, one (1.33%) in group A
and two (2.66%) in group B. Eight patients (5.33%) had
wound discharge, two (2.66%) in group A and six (8%)
in group B. Three patients (2%) had wound bruises,
one (1.33%) in group A and two (2.66%) in group B (Table 4). No recurrence of the hernia was noted because
of the short follow up of the study.
At present, there is still no definite benefit from
preoperative prophylactic antibiotic for prevention of
post inguinal hernioplasty wound infections. This surgical procedure still has many measures for infection
prevention like proper surgical site skin preparation,
aseptic technique, patient selection, surgical technique,
type of mesh graft and finallyduration of surgery. From
this study the authors could only explain about superficial surgical site infection. For deep surgical site infection, which is a primary end point, one year follow up
is still needed to be done, for completion of CDC criteria.16
The shortcoming of our study was a small sample
size; perhaps a large sample size could give us more
thorough insight into the problem. Another subject
that must be assessed in antibiotic prophylaxis is cost
effectiveness. Wound infection rate could be as low
as 1% in some centres, therefore the costs of antibiotic
prophylaxis in such cases must be carefully evaluated
against the potentials benefits.
CONCLUSION
There is no benefit of intravenous single dose
Ophthalmology Update Vol. 12. No. 3, July-September 2014
antibiotic prophylaxis in the prevention of wound infection following Lichtenstein tension free inguinal
hernioplasty in patients with no other co-morbid conditions. Because large number of inguinal hernia repair performed in low risk patients (estimated 70% of
all hernias) discarding the use of single dose antibiotic
prophylaxis will reduce the overall financial costs of
the hospitals.
Therefore we conclude from this study that in
Lichtenstein inguinal hernia repair routine use of prophylactic antibiotics is not needed, except in some high
risk patients such as immune-compromised or poorly
controlled diabetes mellitus.
REFERENCES
1
Ali M, Habiba U, Hussain A, Hadi G. The outcome of darning method of inguinal hernia repair using polypropylene in
a district general hospital. J Postgrad MedInst 2003 ;17 : 42-45.
2
Khan M, Khan SM, Sharafat S, Khan Z. Inguinal herniorrhaphy
with Vicryl darn: experience with 1150 cases. J Postgrad MedInst 2006; 20: 44-47.
3
Lichtenstein IL, Shulman AG, Amid PK, et al. The tensionfree hernioplasty. Am JSurg 1989; 157: 188-93.
4
Platt R. Guidelines for perioperative antibiotic prophylaxis.
In: Abrutyn E, Goldmann DA. Saunders infection control reference service. Philadelphia: W. B. Saunders 1997; 229-234
5
Nichols RL. Surgical antibiotic prophylaxis. Med Clin North
Am 1995 ; 79 :509-22.
6
Bratzler DW, Houck PM . Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis 2004 ; 38(12): 1706-1712
7
Hedrick TL, Sawyer RJ. The end of postoperative antimicrobial prophylaxis? Lancet Infect Dis 2012 ; 12(5) : 357-58 .
8
Bendavid R . Complications of groin hernia surgery . SurgClin North Am . 1998 ; 78 : 1089-1103 .
9
Stephenson BM . Complications of open groin hernia repair.
SurgClin North Am 2003 ; 83 : 1255-78 .
10 Dickenson AJ , Leaper DJ . Wound dehiscence and incisional
hernia . Surgery 1999 ; 17 : 229-3 .
11 Terzi C. Antimicrobial prophylaxis in clean surgery with special focus on inguinal hernia repair with mesh. J Hosp
Infect 2006 ; 62 : 427-36 .
12 Barie PS . Modern surgical antibiotic prophylaxis and therapy - less is more . Surg Infect (Larchmt) 2000 ; 1(1) : 23-9 .
13 EU Hernia Trialists Collaboration. Repair of groin hernia with
synthetic mesh: meta-analysis of randomized controlled trials.
Ann Surg 2002 ; 235 : 322-32 .
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20 Simon MP, et al . European Hernia Society guidelines on the
treatment of inguinal hernia in adult patients. Hernia2009;
13 (4) : 343-403 .
Ergul Z, et al . Prophylactic antibiotic use in elective inguinal hernioplasty in a trauma center. Hernia 2012 ; 16 (2) :
145-151 .
Horan TC, Gaynes RP , Martone WJ , et al. CDC definitions of
nosocomial surgical site infections , 1992 : a modification of
CDC definitions of surgical wound infection . Infect ControlHospEpidemiol 1992 ; 13 : 606-8 .
Devereux DF, O’Connell SM , Liesch JB , et al . Induction of
leukocyte activation by meshes surgically implanted in the
peritoneal cavity. Am JSurg 1991; 162 : 243-46 .
Davis N, Thomas M, Mcllroy B, Kingsworth AN . Early results with Lichtenstein tension free hernia repair . Br JSurg
1994 ; 81 : 1478-79.
Sanabria A, Dominguez L, Valdivieso E, et al . Prophylactic antibiotics for mesh inguinal hernioplasty. A meta-analysis. Ann
Surg 2007 ; 245 : 392-96 .
Glassow F . Is postoperative wound infection following simple inguinal herniorraphy a predisposing cause for recurrent
21 22 23 24 25
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hernia ? Can JSurg 1964 ; 91 : 870-71 .
Najamulhaq R, Chaudhry IA, Khan BA, Afzal M. Groin
sepsis following Lichtenstein inguinal hernioplasty without
antibiotic prophylaxis: a review of 100 cases . Pak J Med Sci
2006 ; 22 : 416-19 .
Taylor EW, Byrne DJ, Leaper DJ . Antibiotic prophylaxis and
open groin hernia repair. World J Surg. 1997 ; 21 : 811-15 .
Yerdel MA, Akin EB, Dolalan S, et al . Effect of single dose
prophylactic ampicillin and sulbactam on wound infectionafter tension free inguinal hernia repair with polypropylene
mesh: the randomized , double blind , prospective trial . Ann
Surg 2001 ; 233 : 26-33 .
Perez AR, Roxas MF , Hilwano SS. A randomized , double
blind, placebo controlled trial to determine effectiveness of
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Otezia F, Ciga MA, Ortiz H . Antibiotic prophylaxis in inguinal hernioplasty. Cir Esp 2004; 75 : 69-71 .
Ijaz A, Amer S. Post operative wound infection ; Prevention“
The role of antibiotic prophylaxis in Lichtenstein hernia repair”. Professional Med J 2010 ; 17(2) : 174-79.
Letter to the Editor
Dear Prof. Yasin Durrani,
I have just received the new issue of Ophthalmology Update and have found the interesting articles as
ALWAYS and also new features incorporated - case presentations with color photo, which will have a great
impact for practicing ophthalmologists. I am happy that the drugs representing the latest advances in ocular
pharmacotherapy are available in Pakistan. With many thanks and very, very best wishes,
Warmest regards,
Prof. Marianne Shahsuvaryan,
MD, Ph.D, D.Sc (Medicine)
Professor of Ophthalmology,
Yerevan State Medical University,
Republic of Armenia
245
Ophthalmology Update Vol. 12. No. 3, July-September 2014
CASE REPORT
Shahzad Waseem
Cessation of Leakage from Disc
Neovascularization in a Patient with
Proliferative Diabetic Retinopathy following a
Single Intravitreal Bevacizumab injection
Shahzad Waseem FCPS*
INTRODUCTION
Bevacizumab (Avastin) is a recombinant humanized monoclonal IgG1 antibody that inhibits human
vascular endothelial growth factor (VEGF). It has been
administered intravitreally in VEGF-mediated diseases
such as proliferative diabetic retinopathy, choroidal
neovascularization1 and central retinal vein occlusion.2
VEGF plays a major role in mediating neovascularization in eyes with proliferative diabetic retinopathy
(PDR).3 We describe a patient who had cessation of retinal neovascularization in proliferative diabetic retinopathy, one week following adjunctive intravitreal bevacizumab.
CASE REPORT
A 50-year-old, non-insulin dependent diabetic
male patient presented in eye OPD with NVDs despite
pan-retinal photocoagulation (PRP). On presentation,
his vision was 20/25 OD and 20/20 OS. Fundus examination showed intraretinal hemorrhages in four
quadrants, moderate PRP, and small macular oedema
OD. There were flat new vessels on the disc (NVD) OD.
There was ½ disc area of NVD, and NVEs OS.
Five weeks after further PRP, vision decreased to
20/40 OD. The examination OD showed flat NVDs. .
The NVDs OS had regressed following laser and vision
was stable. Fluorescein angiography (Fig.1) showed extensive leakage from NVDs OD.
As the patient had persistent leakage from NVDs
after aggressive PRP, he was offered intravitreal bevacizumab OD, after a full discussion of its off-label nature and potential risks. Using a sterile protocol,4 0.05 cc
(1.25 mg) of bevacizumab was injected intravitreally
OD. One week later, vision measured 20/25 OD and
the NVDs appeared less vascularized OD. Fluorescein
angiography (Fig.2) showed cessation of leakage from
NVDs. Patient’s last follow up was six weeks after injection, and on FFA, It still showed no leakage.
* Assistant professor, Department of ophthalmology, Foundation University
Medical College, Rawalpindi
Correspondence: Dr. Shahzad Waseem, Eye Department, Foundation
University Medical College, Rawalpindi
E-Mail: [email protected], Cell: 0333-5697701
Received: May’2014
Figure-1: Leaking NVDs
on FFA (OD)
Figure-2: Cessation of
leakage after IVA
DISCUSSION / COMMENTS
This case illustrates cessation of leakage from
NVDs 1 week following adjunctive intravitreal bevacizumab. Although it may be argued that PRP caused
regression of NVDs. As PRP is the standard of care for
high-risk PDR,5 it was only after maximal PRP that we
offered the patient adjunctive treatment. As mentioned
earlier that six weeks after injection, there was no leakage, so it can be a good adjunctive treatment along with
PRP. Further studies are needed to determine the role
of bevacizumab in the management of PDR.
REFERENCES
1.
Rosenfeld PJ, Moshfeghi AA, Puliafito CA. Optical coherence
tomography findings after an intravitreal injection of
bevacizumab (avastin) for neovascular age-related macular
degeneration. Ophthalmic Surg Lasers Imaging 2005; 36: 331–
335.
2.
Rosenfeld PJ, Fung AE, Puliafito CA. Optical coherence
tomography findings after an intravitreal injection of
bevacizumab (avastin) for macular edema from central retinal
vein occlusion. Ophthalmic Surg Lasers Imaging 2005; 36: 336–
339.
3.
Aiello LP, Avery RL, Arrigg PG, Keyt BA, Jampel HD, Shah
ST et al. Vascular endothelial growth factor in ocular fluid of
patients with diabetic retinopathy and other retinal disorders.
N Engl J Med 1994; 331: 1480–1487.
4.
Aiello LP, Brucker AJ, Chang S, Cunningham Jr ET, D’Amico
DJ, Flynn Jr HW et al. Evolving guidelines for intravitreous
injections. Retina 2004; 24(5 Suppl): S3–S19. |Early
treatment diabetic retinopathy study research group. Early
photocoagulation for diabetic retinopathy. ETDRS report
number 9. Ophthalmology 1991; 98(5 Suppl): 766–785
Accepted June’2014
Ophthalmology Update Vol. 12. No. 3, July-September 2014
246
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