Gunjan Prakash

Diabetic retinopathy: time for action. No complacency please!

Editor – The importance of diabetic retinopathy as a cause of blindness has increased because of longevity and decline in the other preventable causes of blindness in developing countries (1). A diabetic can have a serious eye disease and not even know it until irreversible vision loss has occurred. It is estimated that by the year 2010 the world diabetic population will have doubled, reaching an estimated 221 million (2). The timely diagnosis and referral for management of diabetic retinopathy can prevent 98% of severe visual loss (3). Early diagnosis and treatment of diabetic retinopathy in Sweden has resulted in the virtual elimination of blindness due to diabetic retinopathy (4). An estimated 2–5% of diabetics have proliferative diabetic retinopathy (5) which, if not treated, causes blindness in more than 50% (6). Therefore it would be correct to state that the underlying cause of blindness in the majority of diabetic patients is not diabetic retinopathy but the misdiagnosis of diabetic retinopathy. To achieve near universal coverage, the screening method should be community-based and the point of delivery within easy reach of the population. Currently, yearly dilated direct ophthalmoscopic examination seems the best approach but the number of ophthalmologists available is the limiting factor in initiating an ophthalmologistbased screening service inmost countries. Because of this, screening will have to be organized in an ‘‘ophthalmologist-led’’ system rather than an ‘‘ophthalmologistbased’’ one in most communities. It is a sad state of affairs that a strategy which is cost-effective and has proved its worth (4) is not being implemented by many countries. Despite the fact that most diabetic patients attend some sort of health facility, their eye disease remains undetected because it is not looked for until the patient is symptomatic. Clearly, a ‘‘team’’ approach to screening, detecting, managing and monitoring the complex facets of this disease will serve the best interests of the patient. The present need is to make screening for diabetic retinopathy mandatory by all sufficiently trained health care providers, at least for all diabetic patients attending any sort of health care clinic. We must respond now, not with excuses but with action. n

Visual outcome and electron microscopic features of indocyanine green-assisted internal limiting membrane peeling from macular hole of various aetiologies

PURPOSE To describe the visual outcome of internal limiting membrane (ILM) peeling for macular hole of various aetiologies and ultrastructural features of the ILM. MATERIALS AND METHODS The study was conducted on 40 eyes of 38 patients. Thirty eyes with full thickness macular hole were treated with vitrectomy and removal of ILM. Ten eyes with retinal detachment served as negative controls and these patients underwent vitrectomy and ILM removal. The surgical specimens were examined by transmission electron microscopy. RESULTS The anatomical success rate of the first operation was 90% in idiopathic and myopic groups, whereas it was 100% in traumatic macular hole group. Visual improvement of (3) two lines was noted in 80% of the cases. Electron microscopy revealed the presence of ILM in all surgical specimens. Proliferation of astrocytes and synthesis of new collagen along the inner surface of ILM was noted in the surgical specimens. CONCLUSION Our findings suggest that the ILM removal helps in closure of the macular hole and retinal reattachment. Vitrectomy with ILM peeling is a reasonable surgical approach to treat macular holes of idiopathic, myopic and traumatic aetiology.

Comparison of serum apolipoproteins and traditional lipids in eyes with diabetic retinopathy in Indian population: A case series

Purpose: To review the associations of serum lipoproteins and apolipoproteins with diabetic retinopathy (DR). Materials and Methods: This was a cross-sectional study of patients of DR. DR was graded according to modified Airlie House Classification system. Traditional serum lipids (total, low-density lipoprotein [LDL], and high-density lipoprotein [HDL] cholesterol and triglycerides [TGs]), apolipoprotein AI (apoAI), apolipoprotein B (apoB), and apoB-to-apoAI ratios were assessed. The analysis of variance test was applied. P < 0.05 was considered statistically significant, and P < 0.001 was considered highly significant. Results: Twenty-four patients with DR were evaluated. Serum apoAI was statistically significantly associated with a reduced likelihood of having more severe DR levels (P < 0.001). Increasing levels of apoB (P < 0.001) and apoB-to-apoAI ratio (P < 0.001) were statistically significantly associated with increasing DR severity levels. The association of total (P > 0.05) and LDL cholesterol (P > 0.05) with severity of DR was not statistically significant. HDL cholesterol levels were inversely associated with the severity of DR (P < 0.05). TGs were also statistically significantly associated with the severity of DR (P < 0.05). Conclusion: Serum apolipoprotein levels may be stronger biomarkers of DR than traditional lipids.

Vogt-Koyanagi-Harada syndrome with intracranial meningioma: an as yet unreported association

CASE REPORT We document a previously unreported association of Vogt-Koyanagi-Harada (VKH) syndrome with intracranial meningioma. A female patient with diminished vision, exudative retinal detachment, and headache was diagnosed with VKH syndrome, more precisely a Harada form of disease with intracranial meningioma, on the basis of exudative retinal detachment, typical fundus fluorescein findings, and magnetic resonance imaging. With intravenous steroid therapy, visual acuity improved and the detachment settled within a week. At 3 months, the detachment recurred but improved after retreatment. At 1 year, the tumour was unchanged in size. COMMENTS VKH syndrome may be associated with intracranial meningioma that may affect the patients overall morbidity or mortality.

Retinitis pigmentosa and congenital toxoplasmosis: A rare coexistence

We describe a previously unreported co-existence of retinitis pigmentosa and congenital toxoplasmosis. An eight year old male presented to our center with complaints of decreased night vision. Fundus evaluations in both the eyes demonstrated features typical of retinitis pigmentosa. There were well-defined punched out healed chorio-retinal scars suggestive of congenital toxoplasmosis. On the basis of history, clinical findings and reduction of a and b wave amplitudes on scotopic and photopic electroretinograph, a diagnosis of retinitis pigmentosa with congenital toxoplasmosis was made. Retinitis pigmentosa may co-exist with congenital toxoplasmosis that may affect the patients overall ocular morbidity and visual acuity.

Unusual cause for non-detection of retained metallic foreign body on ocular ultrasonography

Ultrasound biomicroscopy has become a valuable adjunct in the evaluationof occult ocular foreign bodies. An unusual cause for non‐detectionof a metallic retained intraocular foreign body is described. Inthis case, the usual ‘shadowing’ was not discernibleas the foreign body was lying just over the optic disc.

Case Series: Lipid profile in diabetic retinopathy: A North Indian study

Objective: To study the role of serum lipids in diabetic retinopathy. Materials and Method: Cross-sectional study of 48 consecutive patients of diabetic clinic. Diabetic retinopathy (DR) was graded according to modified Airlie House Classification system. Serum lipids (total, LDL, and HDL cholesterol and triglycerides) were assessed. Results: Triglyceride was associated with an increase likelihood of having more severe diabetic retinopathy levels (P<0.05). Also HDL showed significant association (P<0.05). Association of total (P>0.05) and LDL cholesterol (P>0.05) with diabetic retinopathy was insignificant. Conclusions: The significant association of triglycerides and HDL with DR shown by this study indicates, along with glycemic control, correction of hyperlipidemia is important in preventing the development of DR.