Ranju Kharel

Changing uveitis patterns in South India - Comparison between two decades

Purpose: Changing pattern of uveitis in a subset of a population is an important ocular health indicator. Methods: A comparative study was done between uveitis patients of 2013 and 1995 using two proportions Z-test. Results: In 2013, 352 new uveitis cases were examined. Males 56%, females 44%; unilateral 30.4%; bilateral in 69.6%. A specific diagnosis achieved in 66.2%. Anterior uveitis was seen in 35.22%, intermediate uveitis in 30.11%, posterior uveitis in 25%, and panuveitis in 9.65%. There was no significant difference in the incidence of new uveitic cases (1.04% vs. 1.8%). A decline in male preponderance from 64% to 56% (P = 0.0187) was observed. In both studies, anterior uveitis was the most common but human leukocyte antigen-B27 positivity uveitis had increased (29.83% vs. 14.5%; P < 0.05). Intermediate uveitis was the second-most common type instead of posterior uveitis (P = 0.0006). In posterior uveitis cases, etiology was established in 88.6% versus 56.06% cases (P < 0.05). The most common cause of posterior uveitis was tuberculosis (TB) (35.2%). Viral retinitis had increased to 6.81% from 0.76% (P < 0.05). However, a declining trend in cases of toxoplasmosis was observed (P = 0.0545). The cause of panuveitis was comparable in both studies. The prevalence of TB has significantly increased in the present era (22.5% vs. 0.64%; P < 0.0001) and was the proven etiological cause of uveitis in overall 22.5% of which 4.8% cases were of anterior uveitis cases, 7.1% cases of intermediate uveitis cases, 8.8% cases of posterior uveitis cases, and 1.8% of panuveitis cases. Conclusion: A shifting paradigm of uveitis over the past two decades was observed.

A Case of Orbital Myiasis in Recurrent Eyelid Basal Cell Carcinoma Invasive into the Orbit.

Introduction. Orbital myiasis is the infestation of the orbital tissues by fly larvae or maggots. Compromise of periorbital tissues by malignant disease, surgery, ischemia, or infection may predispose the patient to orbital myiasis. Case Report. A 73-year-old male patient with neglected recurrent basal cell carcinoma of the eyelid invasive into the orbit presented with complaints of intense itching and crawling sensation with maggots wriggling and falling from the wound of left orbit. The patient improved following manual removal of the maggots along with oral Ivermectin treatment. Recurrence of the basal cell carcinoma was confirmed by punch biopsy from the wound and extended exenteration of the orbit followed by reconstructive surgery was done. Conclusion. Orbital myiasis is a rare and preventable ocular morbidity that can complicate the malignancies resulting in widespread tissue destruction. The broad spectrum antiparasitic agent, Ivermectin, can be used as noninvasive means to treat orbital myiasis. In massive orbital myiasis and those associated with malignancies, exenteration of the orbit must be seriously considered.

Change in Visual Function in Uveitis Patients after Treatment: An Experience from Nepal

ABSTRACT Purpose: To assess the change in visual function in uveitis patients after treatment. Materials and methods: This one and a half year prospective study was conducted among 180 new uveitis patients. A questionnaire was used to assess the visual function in uveitis cases and analysis of effect size change was also done. Results: The male to female ratio was 1.3:1. The mean vision at presentation was 0.49 logMAR units, which improved to 0.39 logMAR units and 0.35 logMAR units by the 1st and 4th week but deteriorated to 0.62 logMAR units at the 6th week. Anterior uveitis and posterior uveitis patients had significant improvement (p≤0.001) in all three scales but panuveitis and intermediate uveitis had significant improvement (p<0.05) in two scales. The effect size showed small to large change in all three scales. Conclusions: Visual function is adversely affected by uveitis, which can be improved after treatment.

Pathology of Endophthalmitis

Endophthalmitis is a serious intraocular inflammatory disorder affecting the vitreous cavity that can result from exogenous or endogenous spread of infecting organisms into the eye [1]. It may be categorized by clinical course (acute versus chronic), by etiology (infectious versus noninfectious), by the route of entry of the causative agent (exogenous versus endogenous), and by the organism(s) causing the infection (bacteria, fungi, parasites, and, rarely, viruses). Certain organisms tend to be associated with particular clinical settings, means of intraocular access, and types of inflammation (acute, chronic non-granulomatous, chronic granulomatous, or mixed cellular response) [2].

Outcome of polymerase chain reaction (PCR) analysis in 100 suspected cases of infectious uveitis

BackgroundPolymerase chain reaction (PCR) analysis is an important tool in the diagnosis of infectious uveitis. A retrospective, interventional study of PCR analysis of ocular fluid in suspected infectious uveitis cases between January 2014 to July 2016 was done. Nested, real-time and broad range PCR was performed for detection of the genome of Mycobacterium tuberculosis, herpes virus family, Chikungunya virus, Toxoplasma gondii, fungus, eubacterium and propionibacterium acne.ResultsTotal of 100 cases included, mean age was 39.2 ± 15.4 years. Uveitis was unilateral in 82% and granulomatous in 40%. Mean visual acuity at the initial visit and final visit was 0.73 logMar and 0.63 logMar respectively. PCR analysis confirmed the clinical diagnosis in 70.1% patients. The sensitivity, specificity, positive predictive value and negative predictive value of PCR analysis was 90.2%, 93.9%, 93.9% and 90.2% respectively. The quantitative value of real-time M. tb. Positive PCR ranged from 32c/ml to 2722 c/ml.ConclusionsPCR assay is an accurate technique with high sensitivity and specificity to diagnose the DNA genome in infectious uveitis.

Toxoplasma gondii bradyzoites and tachyzoites isolation from vitreous of atypical necrotizing retinitis

BackgroundDetection of Toxoplasma gondii cysts in vitreous of immunocompetent patient with necrotizing retinitis is extremely rare. We herein report the isolation of Toxoplasma bradyzoites and tachyzoites from the vitreous of healthy person.ResultsA 19-year-old immunocompetent female presented with sudden loss of vision in left eye since 1 week. The BCVA was 6/6 and HM in right and left eye. The left eye finding was suggestive of diffuse necrotizing retinitis with retinal detachment. The IgM and IgG for TORCH infection were negative and HIV, HCV and HBsAg tests were also non reactive. The patient underwent diagnostic and therapeutic vitrectomy with silicon oil installation.The vitreous toxoplasma IgG titre was found to be significantly raised to 1:16. Bradyzoites of toxoplasma were identified in H&E staining and tachyzoites of Toxoplasma were identified in Giemsa staining of vitreous sample. She received oral clindamycin and oral corticosteroid but the vision could not be restored in left eye.ConclusionHence, atypical toxoplasmosis with necrotizing retinitis is a fulminant condition with the diagnostic and therapeutic challenge.

Quantitative polymerase chain reaction analysis of serpiginous choroiditis with biopsy-proven testicular tuberculosis

We report a case of a 47-year-old male patient presenting with diminution of vision in the left eye. The left eye fundus showed yellowish lesions with indistinct geographical margin extending over the posterior pole just abutting the macula, suggestive of diffuse choroiditis. The patient gave a history of testicular swelling for the past 2 years. Aqueous tap for polymerase chain reaction analysis was positive for IS6110 mycobacterial tuberculosis (TB) genome, and a biopsy of testicular sac was suggestive of tubercular epididymitis. A diagnosis of TB-multifocal serpiginoid choroiditis was established and was managed with anti-tubercular therapy and systemic steroids.

Management of Ocular Tuberculosis

TB is one of the leading causes of morbidity and mortality worldwide. The causative agent of tuberculosis is Mycobacterium tuberculosis (MTB), discovered by Robert Koch in the year 1882. The World Health Organization (WHO) declared TB as a global health emergency in the year 1993. India is the country with the highest burden of TB. The World Health Organization statistics for 2015 gave an estimated incidence figure of 2.2 million cases of TB for India out of a global incidence of 9.6 million. The estimated TB prevalence in India for the year 2015 is about 2.5 million cases.

Retinal necrosis as the initial presentation of primary intraocular lymphoma

A 72 years old female presented with bilateral painless progressive loss of vision over one year. She was diagnosed as non-resolving bilateral panuveitis. Her visual acuity in right eye was hand movement close to face and left eye was perception of light with inaccurate projection of rays. Bilateral anterior chamber had 1+ cells and flares. Vitreous cells had 1+ cells and haze in right eye but the left eye had 3+ vitreous cells and haze. Right eye fundus had multiple, discrete sub retinal yellowish deposits with subretinal haemorrhage and macular edema with perivascular infiltrates. In left eye, disc was just visible. The patient underwent diagnostic vitrectomy in left eye and undiluted vitreous sample on cytology showed reactive large lymphoid cells with necrotic background pattern suggestive of intraocular lymphoma. Patient underwent external beam radiotherapy and chemotherapy.

Presumed Vogt-Koyanagi-Harada (VKH) disease in Nepalese population: A rare entity

Vogt-Koyanagi-Harada (VKH) disease is a granulomatous inflammatory disorder affecting the eyes, auditory system, meninges, and skin. It typically affects those of more pigmented groups, such as Hispanics, Asians, Native Americans, Middle Easterners, and Asian Indians and is rare among Nepalese population. Hereby, we report a series of eight VKH cases with bilateral ocular involvement, of which six were females. The mean age of the patients was 38.13 ± 11.53 years. The acute uveitic stage was the commonest stage of presentation (4/8). Posterior segment involvement was in the form of disc edema (9/16), serous retinal detachment (5/16), and multifocal choroiditis (5/16). The extraocular manifestations were present in seven cases; neurological manifestations being the commonest.