Jyotirmay Biswas

Eales Disease—An Update

Eales disease, first described by Henry Eales in 1880, remains an enigma. The disease, observed more commonly in the Indian subcontinent than in the rest of the world, occurs in young healthy adult males, initially presenting as retinal periphlebitis and later as retinal ischemia that may lead to vascular alterations and neovascularization. Recurrent vitreous hemorrhage with or without retinal detachment is the common sequelae. In recent years, immunological, molecular biological, and biochemical studies have indicated the role of human leukocyte antigen, retinal autoimmunity, mycobacterium tuberculosis genome, and free radical mediated damage in the etiopathogenesis of this disease. However, its etiology appears to be multifactorial. The management depends on the stage of the disease and consists of medical treatment with oral corticosteroids in the active inflammatory stage and laser photocoagulation in the advanced retinal ischemia and neovascularization stages. The results of vitreoretinal surgery have been found to be satisfactory in case of vitreous hemorrhage with or without retinal detachment.

Ocular lesions associated with HIV infection in India: a series of 100 consecutive patients evaluated at a referral center

PURPOSE To document the ocular disorders seen in patients known to be infected with human immunodeficiency (HIV) virus at a referral eye clinic in India. METHODS The first 100 individuals known to be HIV-positive at a referral eye clinic between 1993 and 1998 were enrolled in a prospective study. They underwent complete ocular and systemic evaluation. RESULTS Most of the patients (76%) were in the 20-to 40-year age group. Heterosexual exposure to commercial sex workers was the most common risk factor (70%) for HIV infection. Cytomegalovirus (CMV) retinitis (17%) and HIV retinopathy (15%) were the most common HIV-associated ophthalmic lesions. Pulmonary tuberculosis (67%) and oropharyngeal candidiasis (66%) were the most commonly associated systemic infections. Ocular involvement was most common in children who contracted the disease through perinatal transmission (66.7%) and in homosexual patients (60%). Ocular involvement was comparatively less common in patients who contracted the disease through blood transfusions (33%) or exposure to commercial sex workers (24.3%). CONCLUSIONS This study shows that the spectrum of ocular lesions associated with HIV infection in India is different from that seen elsewhere in the world. The prevalence of CMV retinitis and HIV retinopathy is lower in India, and there have been no cases of ocular Kaposi sarcoma. Adnexal infections, albeit rare, were seen in our series. The nonavailability and cost of therapy influenced the visual prognosis in these patients.

Solitary fibrous tumor of the orbit: a clinicopathologic study of six cases with review of the literature☆

Solitary fibrous tumor of the orbit is a rare spindle cell neoplasm. There are 42 cases of solitary fibrous tumor of the orbit available in the literature. We present six more cases of orbital solitary fibrous tumors, which presented to our institute between 1999 and 2001. We highlight the need for clinical recognition of these tumors as a distinct entity and inclusion of this tumor in the etiological differential diagnosis of well-circumscribed orbital lesions presenting as unilateral proptosis in both children and in adults. The diagnosis may be suspected based on radiological features supported by histopathologic and immunohistochemical study. The strong CD34 immunoreactivity of this tumor supports its diagnosis. Complete surgical resection is the most important prognostic factor of this tumor.

Use of polymerase chain reaction in detection of Mycobacterium tuberculosis complex DNA from vitreous sample of Eales' disease

Editor,—Eales’ disease, first described by Henry Eales in 1880 is a primary retinal perivasculitis that predominantly affects the peripheral retina of young and otherwise healthy adults in the age group 15–40 years. Of the several aetiologies proposed, most favoured are tuberculosis and hypersensitivity to tuberculoprotein.1 Since polymerase chain reaction (PCR) using primers for the insertion sequence of IS6110 consisting of upstream primer: 5′ CCTGCGAGCGTAGGCGT CGG3′ and downstream primer: 5′CTC GTCCAGCGCCGCTTCGG 3′ …

Intraocular cysticercosis: clinical characteristics and visual outcome after vitreoretinal surgery

PURPOSE To report the clinical characteristics of, discuss the surgical options for, and analyze the factors affecting the anatomic and visual outcome of intraocular cysticercosis. DESIGN Retrospective, noncomparative, interventional case series. PARTICIPANTS Forty-five eyes of 44 Indian patients with posterior segment intraocular cysticercosis. METHODS The charts of 45 eyes, in which intraocular cysticercosis was removed by vitreoretinal surgery (either transscleral or transvitreal), were reviewed. MAIN OUTCOME MEASURES These included the postoperative retinal status and the best-corrected Snellen visual acuity. RESULTS Intraocular cysticercosis was present in the vitreous cavity of 27 eyes (60%) and in the subretinal space of 18 eyes (40%). Anterior segment inflammation was seen in 13 eyes (28.8%) and vitreous inflammation in 38 eyes (84.4%). Retinal detachment was observed in 22 eyes (48.8%), with proliferative vitreoretinopathy in 13 eyes (59.09%). Subretinal cysts anterior to the equator (4 eyes) were removed transsclerally, whereas subretinal cysts posterior to the equator and intravitreal cysts (41 eyes) were removed transvitreally. The mean follow-up was 10.5 months. At the last follow-up, the retina was attached in 39 eyes (86.6%); visual acuity of >/=5/200 was achieved in 67.5%. CONCLUSIONS Current vitreoretinal surgical techniques enable removal of intraocular cysticercosis in all cases, with reattachment of the retina in 86.6% and recovery of ambulatory vision in approximately 67% of cases.

Analysis of 87 Cases with Vogt-Koyanagi-Harada Disease

PURPOSE Vogt-Koyanagi-Harada (VKH) disease is known to have varied manifestations in different ethnic groups. In order to analyze the clinical profile of VKH cases in the Indian population, we studied 87 consecutive cases of VKH disease treated in an uveitis clinic in South India between 1985 and 1996. METHODS Retrospective analysis and review of charts of consecutive new VKH cases diagnosed in a referral clinic. RESULTS VKH disease comprised 2.2% of all uveitis referrals. Extraocular symptoms or signs were seen in 64% of cases at the time of presentation. Most common was meningism (95.9%). However, subsequently all patients developed extraocular manifestations. Panuveitis (92%) was the commonest presentation. Systemic corticosteroid was the usual form of therapy (50.3%) followed by immunosuppressive therapy (39%); surgical treatment was needed in 8% of the cases. Complicated cataract (33%) and glaucoma (24%) were major complications. Final vision was between 6/60 and 6/18 in 88% of the cases and 6/18 and better in 15.4%; there was no improvement in 11% of the cases. CONCLUSIONS VKH disease occurs less frequently in India than in Japan and about as commonly as in the United States. Extraocular signs are far less common than in the Japanese population. Visual prognosis is good in patients presenting within 1 month of onset of symptoms. Immunosuppressive agents and vitreoretinal surgery are needed in advanced cases and in cases reported later. Jpn J Ophthalmol 2000;44:296-301

Phacoemulsification with intraocular lens implantation in cases of pars planitis

Purpose: To analyze the results of phacoemulsification cataract surgery with implantation of posterior chamber intraocular lenses (IOLs) of different biomaterials in eyes with pars planitis. Setting: Medical and Vision Research Foundations, Sankara Nethralaya, Chennai, India. Methods: The records of 86 patients (100 eyes) with pars planitis who had phacoemulsification with IOL implantation between January 1997 and April 2003 were retrospectively analyzed. The eyes were divided into 3 groups depending on IOL biomaterial: poly(methyl methacrylate) (PMMA) (n = 32), heparin‐surface‐modified PMMA (n = 39), or acrylic (n = 29). The postoperative visual outcome and complications in each group were analyzed. Results: Forty‐seven patients were men and 39, women. The mean age was 38 years (range 10 to 65 years) and the mean follow‐up, 19.67 months (range 3.00 to 54.53 months). At the final follow‐up, 91 eyes (91%) had better visual acuity than preoperatively; 79 had an improvement of 2 or more Snellen lines, 12 had an improvement of 1 Snellen line, 4 had no change, and 5 had a decrease as a result of reactivation of the pars planitis and progression of cystoid macular edema (CME). Significant posterior capsule opacification occurred in 10 eyes (10%), CME in 50 eyes (50%), reactivation of pars planitis in 51 eyes (51%), IOL deposits in 29 eyes (29%), IOL decentration in 1 eye (1%), and anterior capsule fibrosis in 14 eyes (14%). The most frequent cause of poor visual recovery was CME, submacular fibrosis, and epiretinal membrane. There was no statistically significant difference in these complications between the 3 groups. Conclusions: Phacoemulsification with IOL implantation in eyes with pars planitis was safe and led to good visual outcomes in most cases. The factors in surgical success were control of inflammation, meticulous surgery, in‐the‐bag IOL implantation, and vigilant postoperative care.

Expression of Epidermal Growth Factor Receptor, Ezrin, Hepatocyte Growth Factor, and c-Met in Uveal Melanoma: An Immunohistochemical Study

The immunoreactivity of epidermal growth factor receptor (EGFR) ezrin, hepatocyte growth factor receptor (HGF), and c-Met was studied in 60 uveal melanomas and was correlated with clinicopathologic parameters. Metastases were diagnosed in the patients with uveal melanoma between 5 years and 8 years (median, 6.5 years) after enucleation. Using Kaplan-Meier statistical analysis, we found a significant association between high c-Met expression and death due to uveal melanoma (p < 0.03). EGFR was expressed in 18 of 60 (30%) tumors; ezrin was expressed in 30 of 60 (50%) tumors. Tumors with liver metastasis (n = 6) showed higher expression of c-Met (p = 0.0009) compared with the tumors with no extension/extrascleral extension without liver metastasis (groups A-45 and B-9). HGF was negative in all the six tumors that had liver metastasis. Further studies are required to understand the possible mechanism of ligand-independent c-Met activation in patients with uveal melanoma.

Pattern of uveitis in a referral uveitis clinic in India

The pattern of uveitis changes over time with the emergence or identification of new uveitic entities. The aim of this prospective study was to obtain a correct incidence pattern and aetiology of uveitis cases seen in a uveitis clinic. We studied all new uveitic cases seen in a-one year period. A standard clinical protocol was followed for each case. Of the 465 new uveitic cases, anterior uveitis was most commonly encountered (170 cases, 36.5%), followed by posterior uveitis (132 cases, 28.4%), intermediate uveitis (92 cases, 19.8%) and panuveitis (71 cases, 15.3%). The aetiology remained undetermined in majority of the cases (58.7%): anterior uveitis (48.8%), posterior uveitis (45.45%), panuveitis (53.52%). The most common cause was collagen disease (29.4%) in anterior uveitis; toxoplasmosis (30.3%) in posterior uveitis; and Vogt-Koyanagi Haradas disease (25.35%) in panuveitis.This report describes a retrospective study of all new patients in our uveitis clinic between January 1992 and December 1994, undertaken to identify the pattern of uveitis in the Indian subcontinent. A standard clinical protocol, and the naming-meshing system with tailored laboratory investigations were used to arrive at a final uveitic diagnosis. Uveitis comprised 1.5% of new cases seen at the centre. Out of 1273 uveitis cases, anterior uveitis was the most common type (39.28%), followed by posterior uveitis (28.75%), intermediate uveitis (17.44%), and panuveitis (14.53%). The most commonly affected age group were patients in their forties (23.57%). Uveitis was less common in children below 10 years (3.61%) and in adults over 60 years of age (6.44%). Men (62.21%) were more commonly affected than women (37.79%). Aetiology remained undetermined in 59.31% of cases. Anterior uveitis was most commonly idiopathic (58.6%). The most common cause of posterior uveitis was toxoplasmosis (27.87%), and that of panuveitis was the Vogt-Koyanagi-Harada syndrome (21.08%). A higher incidence of microbiologically proven tubercular uveitis (5 cases), and uveitis due to live intraocular nematode (4 cases), and malaria (1 case), were seen, in contrast to other studies. Only 2 cases of AIDS with ocular lesions were seen. This paper reveals the pattern of uveitis seen at a major referral eye institute in India.

Histopathologic analysis of 232 eyes with retinoblastoma conducted in an Indian tertiary-care ophthalmic center

Purpose: To study the histopathologic features of 232 enucleated eyes with retinoblastoma. Materials and Methods: Two hundred thirty-two enucleated eyes with retinoblastoma in a tertiary-care institute from 1982 to 2001 were reviewed. Data were collected and analyzed about the type of growth and the presence or absence of vitreous or subretinal seeding, rosettes and fleurettes, necrosis, calcification, iris neovascularization, and invasion of the anterior chamber, iris, choroid, optic nerve, and sclera. Choroidal invasion was graded using a new system. Results were analyzed for statistical significance. Results: The endophytic growth pattern was common in 118 (51%) of the eyes. Vitreous seeds were present in 109 (47%) of the tumors, 23 (10%) of the tumors had subretinal seeds, and 14 (6%) of the tumors had both. Poorly differentiated tumors were present in 134 (58%) of the eyes. Iris neovascularization was noted in 71 (31%) of the eyes and choroidal invasion was observed in 78 (34%) of the eyes. Of these 78 eyes, full-thickness (stage 4) choroidal invasion was present in 51 (65%). Optic nerve invasion was observed in 75 (32%) of the eyes, of which prelaminar involvement occurred in 40 (53%) and postlaminar involvement occurred in 22 (29%). Conclusion: A higher incidence of choroidal and optic nerve infiltration was noted among Asian Indian children than among children from the West. This could be due to delayed diagnosis or to a difference in the biological behavior of tumors occurring in the Asian Indian population.