Rajvardhan Azad

Pars plana vitrectomy with or without silicone oil endotamponade in post-traumatic endophthalmitis

BackgroundResults of core vitrectomy in post-traumatic endophthalmitis are poor. Our initial results of complete vitrectomy with primary silicone oil endotamponade were promising. A comparative study of this procedure with conventional core vitrectomy was therefore carried out.MethodsA prospective randomized controlled study of 24 consecutive cases of post-traumatic endophthalmitis was conducted. Patients were randomized into two groups in the absence of clinical improvement after primary tap and treatment with intravitreal vancomycin and amikacin: group 1 consisted of patients who underwent core vitrectomy alone, group 2 of patients who underwent complete vitrectomy with silicone oil endotamponade. All patients included in the study received intravenous antibiotics and underwent lensectomy. Patients were followed up 1, 2, 4 and 12 weeks postoperatively. In all patients of group 2, silicone oil was removed 6 weeks after primary surgery. The mean duration of follow-up was 112±55 days.ResultsVision of 20/400 or better was obtained in 58.33% of cases (14/24). Visual acuity of only one patient in group 1 was ≥20/200, compared with that of 58.3% of patients (7/12) in group 2 (P=0.02). Intra-operative retinal breaks were found in 50% (6/12) of the patients belonging to group 1, but did not affect the final visual outcome. In group 1, 33.33% (4/12) developed rhegmatogenous retinal detachment in the immediate post-operative period. Only one of these patients had useful final visual outcome after resurgery.ConclusionComplete vitrectomy with primary silicone oil endotamponade is a useful treatment modality which improves the anatomical and functional results in post-traumatic endophthalmitis.

Subthreshold Micropulse Diode Laser and Double Frequency Neodymium: YAG Laser in Treatment of Diabetic Macular Edema: A Prospective, Randomized Study Using Multifocal Electroretinography

OBJECTIVE The purpose of this study was to compare the efficacy of subthreshold micropulse diode (SDM) laser with double-frequency neodymium YAG (Nd:YAG) laser in treatment of clinically significant diabetic macular edema. METHODS Forty-six eyes of 33 patients with clinically significant macular edema (CSME) caused by diabetic retinopathy were randomized to either SDM (810?nm) laser or the conventional double-frequency Nd:YAG (532?nm) laser. Primary outcome measures were: change in the central macular thickness as measured by optical coherence tomography (OCT) and change in macular retinal sensitivity measured using multifocal electroretinography (MfERG). Secondary outcomes were: change in best corrected visual acuity (BCVA) and contrast sensitivity. RESULTS The group was divided in half, with 23 eyes assigned to SDM laser and 23 eyes assigned to double-frequency Nd:YAG laser. Mean follow-up period was 6 months. No statistically significant difference was noted in either the primary or the secondary outcome measures between the two groups. Macular thickness decreased from the baseline measures of 298.5?49.3 and 312.9?45.8??m to 274.9?62.9 and 286.7?32.8??m in the SDM laser and Nd:YAG laser groups, respectively. On MfERG, P1 implicit wave time delay at baseline changed from 46.27?4.9 to 45.27?3.4?ms in the SDM group and from 46.55?4.9 to 45.27?4.1?ms in the Nd:YAG group. MfERG recordings of 18 of the 23 eyes treated with double-frequency Nd:YAG laser showed areas of signal void as compared to 4 eyes treated with the SDM laser. CONCLUSIONS SDM laser photocoagulation showed an equally good effect on visual acuity, contrast sensitivity, and reduction of diabetic macular edema (DME) as compared to conventional Nd:YAG laser photocoagulation. MfERG recordings, however, suggest that SDM laser results in better preservation of electrophysiological indices.

Correlation between Clinical Features, Magnetic Resonance Imaging, and Histopathologic Findings in Retinoblastoma: A Prospective Study

OBJECTIVE To correlate clinical features with histopathology findings in advanced intraocular retinoblastoma and to determine the diagnostic accuracy of magnetic resonance imaging (MRI) in detecting tumor invasion. DESIGN Prospective, nonrandomized case series. PARTICIPANTS We included 75 patients with group E retinoblastoma. METHODS Demographic and clinical features were recorded at presentation. Contrast-enhanced MRI was performed to study tumor characteristics and extent of invasion. Primary enucleation was performed and histopathologic features noted. Statistical analysis was done using the Kruskal-Wallis test to determine correlation between clinical features and histopathology. Sensitivity, specificity, and accuracy of MRI in detecting tumor invasion were determined. MAIN OUTCOME MEASURES Significant associations between clinical findings at presentation and high-risk histopathology, and correlation between MRI results and histopathologic evidence of tumor invasion. RESULTS A significant association was found between iris neovascularization and choroidal invasion (P = 0.032), intraocular pressure and optic nerve invasion (P = 0.034), and shallow anterior chamber and iris invasion (P = 0.021). Corneal diameter did not show any significant correlation with high-risk histopathology. On MRI, tumor volume showed a significant association with optic nerve invasion (P = 0.023). The accuracy of MRI in detecting choroidal invasion was 68% (sensitivity, 60%; specificity, 80%). Prelaminar invasion was correctly identified in 9 out of 15 eyes (accuracy, 84%; sensitivity, 60%; specificity, 90%), whereas the accuracy of MRI in detecting postlaminar invasion was 76% (sensitivity, 61.9%; specificity, 81.5%). Ciliary body invasion was correctly identified in 5 out of 7 eyes (accuracy, 93.3%; specificity, 95.6%) and scleral invasion in 5 out of 6 eyes (accuracy, 98.7%; specificity, 100%). CONCLUSIONS As far as we are aware, this is the first prospective study on the correlation of clinical features and MRI findings with histopathologic risk factors in eyes primarily enucleated for retinoblastoma. Neovascularization of iris, intraocular pressure, shallow anterior chamber, and tumor volume correlated well with high-risk histopathology. Because MRI has limitations in reliably predicting microscopic infiltration of the choroid and optic nerve, decision in favor of neoadjuvant chemotherapy on the basis of suspected postlaminar invasion on MRI is not justified in the absence of histopathologic evidence of disease.

Changing profile of retinopathy of prematurity.

The aim of this study was to determine the evolving trends of retinopathy of prematurity (ROP) at a tertiary neonatal intensive care unit. In an ongoing screening programme for ROP, we estimated the incidence of ROP among at-risk neonates in a tertiary care unit. We compared our data over the last 12 months (1999-2000; period II) to the previously published data (1993-94; period I) to study changes in the spectrum of the disease. The overall incidence of ROP in period II was not significantly different from the incidence in period I (32 vs. 20 per cent, p > 0.05). However, a decreasing trend in the proportion of severe ROP (stage III) from 46 to 21 per cent in the later period was noted. The need for cryotherapy also dropped significantly compared with the earlier period (8 vs. 46 per cent respectively, p < 0.05). On multivariate analysis, apnea (p < 0.001; RR = 12.5; 95 per cent CI, 3.03-50.9; clinical sepsis (p < 0.001; RR = 5.7; 95 per cent CI, 1.6-20.7); and male sex (p < 0.001; RR = 6.3; 95 per cent CI 1.6-25.5) emerged as significant risk factors. Although the incidence of ROP is static, the more severe form of the disease (stage III) is showing a decline. Our data suggests that efficient management of apnea and sepsis may be crucial in further minimizing the risk of ROP.

Role of Intravenous Fluorescein Angiography in Early Detection and Regression of Retinopathy of Prematurity

PURPOSE To study the role of intravenous fluorescein angiography in early detection and regression of retinopathy of prematurity. METHODS The Retcam 120 (Massie Research Laboratories, Dublin, CA) was used to perform intravenous fluorescein angiography in 40 eyes of 20 children diagnosed as having treatable retinopathy of prematurity as per Early Treatment for Retinopathy of Prematurity Cooperative Group guidelines and treated with laser photocoagulation. RESULTS Fluorescein angiography enabled easy visualization of the retinal vasculature and helped to identify early flat neovascularization in zone 1/2 retinopathy of prematurity, detect previously missed areas of active retinopathy of prematurity in the peripheral retina, and identify skip areas following laser photocoagulation, which resulted in good management outcomes. There were no side effects related to sodium fluorescein or the procedure. CONCLUSIONS Retcam-assisted intravenous fluorescein angiography is safe and helps in the early diagnosis, prompt management, and complete regression of retinopathy of prematurity.

Conservative treatment modalities in retinoblastoma

Retinoblastoma is the most common primary intraocular malignancy of childhood. A potentially curable cancer, its treatment has improved significantly over the last few decades. The purpose of this article is to review the literature on various conservative treatment modalities available for the treatment of retinoblastoma and their effectiveness, when used alone or in combination. Pubmed, Medline, Embase, and the Cochrane library were searched through 2012 for published peer reviewed data on conservative treatment modalities for retinoblastoma. Various studies show that while enucleation remains the standard of care for advanced intraocular tumors, conservative modalities that can result in globe salvage and preservation of useful vision are being increasingly employed. Such modalities include systemic chemotherapy, focal consolidation with transpupillary thermotherapy, laser photocoagulation and cryotherapy, plaque brachytherapy, and delivery of local chemotherapy using subconjunctival, sub-tenon, or intra-arterial routes. When used alone or in combination, these treatment modalities can help in avoidance of external beam radiotherapy or enucleation, thus reducing the potential for long-term side effects, while salvaging useful vision. Radioactive plaque brachytherapy has an established role in selected patients with intraocular retinoblastoma. Local injections of chemotherapeutic agents via the sub-tenon or sub-conjunctival route have been used with varying degrees of success, usually as an adjunct to systemic chemotherapy. Intra-arterial ophthalmic artery delivery of melphalan has shown promising results. It is important to recognize that today, several treatment options are available that can obviate the need for enucleation, and cure the cancer with preservation of functional vision. A thorough knowledge and understanding of these conservative treatment modalities is essential for appropriate management.

Retinopathy of prematurity: Mutations in the Norrie disease gene and the risk of progression to advanced stages

Abstract Background : Retinopathy of prematurity (ROP) is a retinal vascular disease that occurs in infants with short gestational age and low birth weight and may lead to retinal detachment and blindness. Missense mutations in the Norrie disease (ND) gene have been associated with the risk of progression to advanced stages in cases of ROP from the US and also in clinically similar ND and familial exudative vitreoretinopathy.

Valsalva and Purtscher's retinopathy with optic neuropathy in compressive thoracic injury.

Compressive thorax injury is commonly observed in road traffic accidents which leads to a variety of posterior segment ocular abnormalities, of which rarely seen are Purtscher’s retinopathy, Valsalva retinopathy, and traumatic optic neuropathy. We report a rare case with compressive chest injury which led to Purtscher’s retinopathy with traumatic optic neuropathy in one eye and Valsalva retinopathy in the other.

Rate of and Risk Factors Associated with Retinopathy of Prematurity: A Prospective Study from Kuwait

Objective: To determine the rate of retinopathy of prematurity (ROP) among a population of preterm infants in Kuwait, and to review the risk factors associated with the disease. Methodology: A prospective cohort study of all preterm infants of less than 2,000 g birth weight and/or 36 weeks gestational age who were screened for ROP during 1995 at the neonatal unit of the Maternity Hospital in Kuwait. The rate of and some of the possible risk factors associated with the disease were determined. Results: A total of 130 babies were screened of which 59 (45.4%) developed some stage of ROP. The frequency of blindness was 3 (2.3%). Low birth weight, oxygen therapy, patent ductus arteriosus, intraventricular hemorrhage and blood transfusion were the risk factors found to be associated with the disease. However, with logistic regression analysis, only low birth weight and oxygen were independently associated with ROP. Conclusion: The rate of ROP in our unit is not different from that of the other centers, and low birth weight and oxygen therapy are the main risk factors associated with the disease.

Clinical presentation and survival of retinoblastoma in Indian children

Objective To study the clinical presentation and survival among Indian children with retinoblastoma (RB) and to determine factors predictive of poor outcome. Methods A retrospective review of children newly diagnosed with RB at a tertiary referral centre was undertaken. Demographic and clinical characteristics and treatment outcomes were studied. Results A total of 600 patients (unilateral 67.6%, bilateral 32.4%) was studied. 61% was boys. The median age at presentation was 29 months (18 months vs 36 months in bilateral and unilateral cases, respectively, p<0.001). leukocoria was most common (83%), followed by proptosis (17%). Tumours were intraocular in 72.3% and extraocular in 27.7% cases. In the intraocular group, 78% were advanced Group D or E disease. Metastasis to the central nervous system was noted in 15.7% of extraocular cases. A statistically significant difference was seen between intraocular and extraocular groups in the median age (24 months vs 37.5 months, p<0.001) and median lag period (2.5 months vs 7 months, p<0.001). The Kaplan-Meier survival probability was 83%, 73% and 65% at 1 year, 2 years and 5 years, respectively. On univariate analysis, age >2 years (p=0.002), lag period >6 months (p=0.004) and extraocular stage (p<0.001) were associated with poor outcome. On multivariate analysis, extraocular invasion was predictive of low survival (HR 5.04, p<0.001). Conclusions Delayed presentation is a matter of concern. Improving awareness about the early signs and creating facilities for diagnosing and treating RB at the primary and secondary levels of healthcare are required to reduce mortality and morbidity, and lead to improved outcomes that are comparable with the developed nations.