Chandrasekhar Garudadri

Prevalence and Risk Factors for Primary Glaucomas in Adult Urban and Rural Populations in the Andhra Pradesh Eye Disease Study

PURPOSE To compare the prevalence of and risk factors for primary open-angle glaucoma (POAG) and primary angle-closure glaucoma (PACG) in urban and rural populations in the Andhra Pradesh Eye Disease Study. DESIGN A population-based, cross-sectional study using a stratified, random, cluster, and systematic sampling strategy. PARTICIPANTS Between 1996 and 2000, participants from 94 clusters in 1 urban and 3 rural areas representative of the population were included. METHODS We performed a detailed eye examination, including applanation tonometry, gonioscopy, and dilated fundus evaluation after ruling out risk of angle closure. Humphrey threshold 24-2 visual fields were performed when indicated. MAIN OUTCOME MEASURES Glaucoma was diagnosed and categorized using International Society of Geographical and Epidemiological Ophthalmology criteria. The prevalence and risk factors for POAG and PACG in subjects aged > or = 40 years were compared between the urban and rural cohorts. RESULTS There were 3724 subjects > or = 40 years, with 934 in the urban and 2790 in the rural cohort. The prevalence of POAG was greater in the urban compared with the rural cohort (4% vs 1.6%; P<0.001). Age and intraocular pressure (IOP) were risk factors for POAG in both cohorts. Blindness owing to POAG was 11.1% in the rural and 2.7% in the urban cohort. The prevalence of PACG (1.8% vs 0.7%; P<0.01), primary angle closure (PAC) (0.8% vs 0.2%; P = 0.02) and primary angle closure suspect (PACS; 3.5% vs 1.5%; P<0.01) were significantly different between the urban and rural cohorts. Increasing age was a risk factor in the urban cohort. Intraocular pressure was a risk factor in both the populations. Blindness owing to PACG was equal (20%) in both the populations. Female gender was a risk factor in the rural cohort (P = 0.032). CONCLUSIONS The prevalence of both POAG and PACG was greater in urban than in the rural population. Intraocular pressure was a significant risk factor for both POAG and PACG in both cohorts. Increasing age was a significant risk factor for POAG in both cohorts and for PACG in the urban cohort. Female gender was a risk factor for PACG in the rural cohort. There was more blindness owing to PACG than to POAG. FINANCIAL DISCLOSURE(S) The authors have no proprietary or commercial interest in any of the materials discussed in this article.

Angle Closure in the Andhra Pradesh Eye Disease Study

OBJECTIVE To estimate the prevalence and associated risk factors for primary angle-closure glaucoma (PACG), primary angle closure (PAC), and primary angle-closure suspects (PACS) in the Indian state of Andhra Pradesh. DESIGN A population-based, cross-sectional study using a stratified, random, cluster, and systematic sampling strategy. PARTICIPANTS Between 1996 and 2000, participants aged > or =40 years from 94 clusters in 1 urban and 3 rural areas were included. METHODS Trained professionals performed a detailed eye examination, including visual acuity, refraction, slit-lamp biomicroscopy, applanation tonometry, gonioscopy, and dilated fundus evaluation after ruling out risk of angle closure. Humphrey threshold 24-2 visual fields (VFs) were performed when indicated by disc criteria or if intraocular pressure (IOP) was > or =22 mmHg. MAIN OUTCOME MEASURES Angle closure was diagnosed and categorized using International Society of Geographical and Epidemiological Ophthalmology criteria. RESULTS Primary angle-closure glaucoma was present in 35 of 3724 subjects aged > or =40 years, an age- and gender-adjusted prevalence of 0.94% (95% confidence interval [CI], 0.63-1.24). Primary angle closure was present in 12 subjects (0.3%; 95% CI, 0.1-0.5), and PACS was present in 71 subjects (2%; 95% CI, 1.5-2.3). The prevalence of angle-closure disease (ACD=PACG+PAC) was 1.26% (95% CI, 0.90-1.62). Forty-one of 47 subjects (87.2%) with ACD were unaware of their disease. The prevalence of PACG increased from 0.56% (0.17-0.94) in the fourth decade to 2.5% (0.87-4.12) in the seventh decade. Seven (20%) of the 35 subjects with PACG were blind (visual acuity <3/60). Intraocular pressure increase (odds ratio [OR] 1.16; 95% CI, 1.11-1.22; P<0.001), diabetes mellitus (OR 3.18l; 95% CI, 1.34-7.58; P=0.001), and female gender (OR 2.07; 95% CI, 1.09-3.93; P=0.025) were significantly associated with angle-closure disease. No significant association was found with systemic hypertension (P=0.24) and hyperopia (P=0.05). CONCLUSIONS The prevalence of PACG in this population was 0.94%. Increasing age, increasing IOP, diabetes mellitus, and female gender were significantly associated with angle-closure disease. Blindness due to PACG was 20%.

Bilateral simultaneous acute angle closure caused by sulphonamide derivatives: A case series

The sulphonamide group of drugs is implicated in bilateral acute angle closure (AAC) due to an idiosyncratic response. We report a series of three cases with bilateral AAC caused by different sulphonamide derivatives, their presentation and management.

An outbreak of acute post-cataract surgery Pseudomonas sp. endophthalmitis caused by contaminated hydrophilic intraocular lens solution

OBJECTIVE To report the investigation for the source of infection and the clinical course and treatment response of 11 cases of acute post-cataract surgery endophthalmitis that developed during an outbreak. DESIGN Retrospective, consecutive, interventional case series. PARTICIPANTS Eleven patients who developed acute postoperative endophthalmitis after an uneventful cataract surgery with intraocular lens implantation from September 6 to 29, 2010, at a tertiary eye care center in South India. METHODS Aqueous aspirates, vitreous aspirates, and environmental surveillance specimens were sampled. All specimens were subjected to smear and culture. Positive cultures were subjected to antibiotic susceptibility. Genotypic diversity was determined by polymerase chain reaction (PCR) with enterobacterial repetitive intergenic consensus (ERIC) primers of each strain and was used to establish the clonal relationship between clinical and environmental isolates. The clinical patterns were analyzed. MAIN OUTCOME MEASURES Positive microbiology, molecular diagnostic similarity among the culture positive endophthalmitis cases, and surveillance specimens. RESULTS Aqueous and vitreous samples showed gram-negative bacilli in the smears of 8 of 11 eyes, and cultures grew Pseudomonas aeruginosa in 5 of 11 eyes. Among the samples from various surveillance specimens cultured, only the hydrophilic acrylic intraocular lenses and their solution grew P. aeruginosa, with antibiotic susceptibility pattern identical to the clinical isolates. The isolates from the patients and the intraocular lens solution revealed matching patterns similar to an American Type Culture Collection (ATCC) strain of P. aeruginosa on ERIC-PCR. The intraocular lenses of the same make were discontinued at our hospital, and the endophthalmitis did not recur. The final visual acuity improved to ≥ 20/50 in 8 of 11 patients (72.7%). One patient developed retinal detachment, but was treated successfully, and 2 other patients progressed to phthisis bulbi. CONCLUSIONS Positive microbiology and the ERIC-PCR results proved that contamination of hydrophilic intraocular lenses and the preservative solution was the source of infection in this outbreak. Early detection and a planned approach during the outbreak helped us to achieve good visual and anatomic outcomes, even though the offending organism was identified as P. aeruginosa.

Misleading Goldmann applanation tonometry in a post-LASIK eye with interface fluid syndrome

A 21-year-old myope presented with decreased vision and corneal edema following vitreoretinal surgery for retinal detachment. While intraocular pressure (IOP) measurement with Goldmann applanation tonometer (GAT) was low, the digital tonometry indicated raised pressures. An interface fluid syndrome (IFS) was suspected and confirmed by clinical exam and optical coherence tomography. A tonopen used to measure IOP through the peripheral cornea revealed elevated IOP which was the cause of the interface fluid. Treatment with IOP-lowering agents resulted in complete resolution of the interface fluid. This case is being reported to highlight the fact that IFS should be suspected when there is LASIK flap edema and IOP readings using GAT are low and that GAT is not an optimal method to measure IOP in this condition. Alternative methods like tonopen or Schiotz tonometry can be used.

Late postoperative choroidal detachment following an uneventful cataract surgery in a patient on topical latanoprost

Topical latanoprost is a most effective and commonly used antiglaucoma medication. Use of prostaglandin analogues (PGA) in the early postoperative period is controversial due to its proinflammatory properties. We report a case of a 64-year-old man with primary open angle glaucoma, post-trabeculectomy 17 years prior, with good intraocular pressure (IOP) control on topical levobunolol 0.5% and latanoprost 0.005%. He underwent a clear corneal phacoemulsification surgery in his left eye and the PGA was stopped. He had an uneventful postoperative course and was prescribed eyeglasses at 4-week follow-up. Two weeks later, he presented to the emergency department with decreased vision in the left eye, flat anterior chamber, IOP of 00 mm Hg and 360° choroidal detachment. The continued use of topical latanoprost in the operated eye was implicated as the cause. This case illustrates the serious vision-threatening side effect of PGA when used in the early postoperative period.

Evidence-based approach to glaucoma management

Evidence-based medicine is an evolving new paradigm. With the advent of numerous new diagnostic techniques and therapeutic interventions, one needs to critically evaluate and validate them by appropriate methods before adopting them into day-to-day patient care. The concepts involved in the evaluation of diagnostic tests and therapy are discussed. For delivering the highest level of clinical care, evidence alone is not sufficient. Integrating individual clinical experience and patients’ perspectives with the best available external evidence is essential.

Role of oral doxycycline and large diameter bandage contact lens in the management of early post-trabeculectomy bleb leak

A 27-year-old man with juvenile open angle glaucoma and medically uncontrolled intraocular pressure (IOP) underwent a trabeculectomy with mitomycin C in his right eye. One week postoperatively, he developed ischaemic necrosis of the conjunctiva with a bleb leak. This was managed conservatively with oral doxycycline 100 mg twice daily along with a topical low-dose steroid, antibiotic and cycloplegic and a large diameter bandage contact lens (BCL). There was dramatic improvement in the bleb appearance, the necrosis healed and the leak resolved. The patient had well-controlled IOP with a diffuse healthy bleb at 4 weeks, which was maintained at 2 years. This case illustrates the utility and importance of oral doxycycline in the management of early post-trabeculectomy conjunctival necrosis and the use of BCL in the management of a bleb leak. This safe and non-invasive method not only hastened the recovery but also helped in maintaining good bleb function.