Reema Bansal

Ocular Signs Predictive of Tubercular Uveitis

PURPOSE To determine ocular signs predictive of tubercular uveitis. DESIGN Retrospective, nonrandomized, comparative interventional case study. METHODS Three hundred eighty-six patients with active uveitis were treated at a tertiary care single-center uveitis practice. Uveitis was presumed to be tubercular in patients who showed evidence of latent or manifest tuberculosis without any other known cause and who did not show recurrence of uveitis after 12 months of antitubercular therapy. One hundred eighty-two patients who thus obtained clinical diagnoses of presumed tubercular uveitis were enrolled in group A. Two hundred four patients with uveitis resulting from a nontubercular cause were enrolled in group B. Patients were monitored for the presence of types of keratic precipitates (mutton fat or fine), posterior synechiae (broad based or filiform), iris nodules, snowballs, snow banking, vasculitis (with or without choroiditis), serpiginous-like choroiditis, and other types of posterior uveitis (choroidal abscess, retinochoroiditis, or exudative retinal detachment) which were compared between the 2 groups. Statistical analysis was carried out at a 5% level of significance. The main outcome measures were clinical signs significantly associated with tubercular uveitis. RESULTS Broad-based posterior synechiae, retinal vasculitis with or without choroiditis, and serpiginous-like choroiditis were seen significantly more commonly in patients with tubercular uveitis. Filiform posterior synechiae were more frequent in eyes with nontubercular uveitis. CONCLUSIONS Broad-based posterior synechiae, retinal vasculitis with or without choroiditis, and serpiginous-like choroiditis in patients with latent or manifest tuberculosis in tuberculosis-endemic areas are suggestive of a tubercular cause of uveitis and merit specific treatment.

Role of Anti-Tubercular Therapy in Uveitis With Latent/Manifest Tuberculosis

PURPOSE To assess the role of anti-tubercular therapy in uveitis with latent/manifest tuberculosis (TB). DESIGN Retrospective, interventional case series. METHODS A total of 360 patients from uveitis clinic with following inclusion criteria were studied: 1) complete clinical records of visual acuity, slit-lamp biomicroscopic examination, intraocular pressure, complications if any, and treatment records at the baseline and at all follow-up visits; 2) a documented positive tuberculin skin test (10 mm of induration or more) at 48 to 72 hours; 3) evidence of active uveitis, i.e., cellular reaction in the anterior chamber with or without keratic precipitates, and/or active vitreous inflammation, retinal vasculitis, choroiditis, or neuroretinitis; 4) all known causes of infectious uveitis except TB and known noninfectious uveitic syndromes ruled out; and 5) a minimum one year of follow-up from the initiation of treatment. Of these, 216 patients (Group A) received four-drug anti-tubercular therapy and corticosteroids, and 144 patients (Group B) received corticosteroids alone. The main outcome measure was recurrence of inflammation after minimum six months of initiating treatment in each group. RESULTS Recurrences reduced significantly (P < .001) in Group A (15.74%) as compared to Group B (46.53%) over a median follow-up of 24 and 31 months, respectively. The patients treated with anti-tubercular therapy with corticosteroids had decreased risk of developing recurrence of uveitis by approximately two-thirds as compared to those treated with corticosteroids alone. CONCLUSION Addition of anti-tubercular therapy to corticosteroids in uveitis patients with latent/manifest TB led to significant reduction in recurrences of uveitis.

Classification of Intraocular Tuberculosis

Abstract Tuberculosis in the TB endemic countries commonly manifests in the eye as tuberculous uveitis. There is a wide spectrum of the clinical manifestations of intraocular tuberculosis (IOTB). For want of any gold standard diagnostic tests or diagnostic criteria, the estimates of IOTB prevalence have varied greatly. None of the previously suggested guidelines for diagnosis of IOTB have been validated. We give definitions of clinical signs and diagnostic tests that have been used in the literature. Based on these, we propose a classification of IOTB comprising “confirmed IOTB,” “probable IOTB,” and “possible IOTB.” This of necessity needs consensus among experts before carrying out studies to validate this classification.

Tubercular serpiginous-like choroiditis presenting as multifocal serpiginoid choroiditis.

PURPOSE To describe the clinical features, course, and outcome in tubercular serpiginous-like choroiditis. DESIGN Retrospective cohort study. PARTICIPANTS A total of 105 patients (141 eyes) between May 2002 and July 2010. METHODS Patients had the following inclusion criteria: (1) complete clinical records and digital fundus images at baseline and follow-up visits, (2) positive tuberculin skin test or QuantiFERON-TB Gold (Cellestis International Pty Ltd. Chadstone, Victoria, Australia) test result, (3) active serpiginous-like choroiditis in at least 1 eye, (4) all known causes of infectious (except tuberculosis) and noninfectious uveitis ruled out, and (5) a minimum of 9 months of follow-up from initiation of treatment that included antitubercular therapy (ATT) with oral corticosteroids (93 patients) or corticosteroids alone (12 patients). MAIN OUTCOME MEASURES Clinical characteristics and evolution of choroiditis lesions from the acute to healed stage, recurrence, visual outcome, and complications. RESULTS Mean age was 33 ± 9.3 years (range, 12-54 years; 75 male and 30 female patients). Serpiginous-like choroiditis was bilateral (at least 1 eye active) in 66 patients (62.9%). Of 171 affected eyes, 141 (82.45%) had active lesions at presentation. Of 141 eyes, 115 (81.56%) showed vitreous inflammation. Lesions were multifocal in 133 eyes (94.3%), were noncontiguous to optic disc in 122 eyes (86.52%), and involved the macula in 125 eyes (88.65%). Of patients receiving ATT, all showed resolution of lesions and 9 (9.7%) developed recurrences (median follow-up, 21 months). In addition, 12 patients (12.9%) showed continued progression over a median 3.5 weeks after initiation of therapy. Of 12 patients treated with corticosteroids alone, none showed progression but 9 (75%) developed recurrence (median, 26.5 months). Final visual acuity of ≥ 6/12 was achieved in 108 eyes (76.60%) versus 72 eyes (51.06%) before treatment. Fovea was spared in 95 of 125 eyes (76%) with macular involvement. Five eyes (3.5%) developed choroidal neovascular membrane. CONCLUSIONS Tubercular serpiginous-like choroiditis presented as multifocal serpiginoid choroiditis affecting predominantly young to middle-aged men. It was frequently bilateral with vitreous inflammation and characterized by multifocal lesions that were noncontiguous to the optic disc and showed serpiginoid spread. Antitubercular therapy significantly reduced recurrences. Lesions responded to combined antitubercular and steroid therapy, usually spared fovea, and had a good final visual acuity.

Novel multi-targeted polymerase chain reaction for diagnosis of presumed tubercular uveitis.

BackgroundThe objective of this study was to report the use of multi-targeted polymerase chain reaction (PCR) in the diagnosis of presumed tubercular uveitis. Multi-targeted PCR using three targets specific for Mycobacterium tuberculosis, i.e., IS6110, MPB64, and protein b, was performed on intraocular fluid samples of 25 subjects. Nine had presumed tubercular uveitis, six had intraocular inflammation secondary to a nontubercular etiology (disease controls), and ten had no evidence of intraocular inflammation (normal controls). As described previously, response to antitubercular therapy was considered as the gold standard.ResultsMulti-targeted PCR was positive in seven out of nine patients with presumed tubercular uveitis and negative in all normal and disease controls. The sensitivity and specificity were 77.77% and 100%, respectively. For the diagnosis of presumed tubercular uveitis, multi-targeted PCR had a positive predictive value of 100% and a negative predictive value of 88.88%.ConclusionMulti-targeted PCR can be a valuable tool for diagnosing presumed tubercular uveitis.

Continuous Progression of Tubercular Serpiginous-like Choroiditis After Initiating Antituberculosis Treatment

PURPOSE To describe the frequency, risk factors, management, and outcome of eyes with tubercular serpiginous-like choroiditis showing continued progression following initiation of antituberculosis treatment. DESIGN Retrospective, comparative, interventional case series. METHODS SETTING Institutional. PATIENT POPULATION One hundred ten patients of serpiginous-like choroiditis with 1) complete records, 2) tuberculin skin test, 3) active lesions in at least 1 eye, and 4) minimum 18 months follow-up. INTERVENTION Based on the positivity of tuberculin skin test, the patients were categorized in Group A (84 patients with positive tuberculin test) and Group B (26 patients with negative tuberculin test). Of the 84 patients in Group A, 19 received systemic corticosteroids while 65 also received 4-drug antituberculosis treatment in addition. All patients in Group B received corticosteroids. Patients with continued progression received an increased dose of corticosteroids with or without immunosuppressive agents. MAIN OUTCOME MEASURE Development of continued progression. RESULTS There were 61 men and 23 women in Group A and 19 men and 7 women in Group B. Continued progression was observed in 12 patients (14.28%) in Group A and none in Group B (P = .04). Of the 12 patients in Group A showing progression, 11 (16.9%) were receiving antituberculosis treatment and corticosteroids. The lesions responded in all eyes, and final visual acuity of 20/40 or better could be achieved in 10 eyes (75%). CONCLUSION Continued progression of choroiditis lesions occurs in 14% of patients after initiating antituberculosis treatment in tubercular serpiginous-like choroiditis. Increased immunosuppression with continuation of antituberculosis treatment resulted in good outcome.

Natural course of intraocular pressure after cataract extraction and the effect of intracameral carbachol

ABSTRACT Intraocular pressure (IOP) is known to increase after intracapsular cataract extraction, extracapsular cataract extraction (ECCE), and ECCE with intraocular lens (IOL) implantation. Many pharmacological agents have heen used to prevent this IOP rise. We conducted a two‐phase, randomized, prospective study to evaluate the natural behavior of IOP after cataract surgery and the effect of intraoperative intracameral carbachol on it. In phase 1, 102 cases were randomly assigned to three groups for recording IOP at 24, 48, or 72 hours after ECCE. The IOP at 24 (mean 20.3 mm Hg) and 48 hours (mean 22.3 mm Hg) was significantly higher than the preoperative IOP (mean 16.1 mm Hg); 26.3% of cases in group 1A (24 hours) and 44.1% of cases in group 1 B (48 hours) had IOPs ≥ 25 mm Hg. In phase II, intracameral carbachol (0.01%) was used in 30 cases of ECCE and in 30 cases of ECCE with IOL implantation. The IOP at 24 hours (mean 16.3 mm Hg) was not significantly higher than the preoperative IOP and only 11.6% of the cases had IOPs ≥ 25 mm Hg. The mean IOP at 24 hours without carbachol was significantly higher than the mean IOP at 24 hours with it. There was no statistically significant difference between IOP in the two groups one week after surgery.

Fundus autofluorescence in serpiginouslike choroiditis.

Purpose: To report the fundus autofluorescence characteristics in serpiginouslike choroiditis. Methods: Twenty-nine patients with presumed tubercular serpiginouslike choroiditis between November 2008 and January 2010 underwent fundus autofluorescence imaging during the acute stage and at regular intervals till the lesions healed. All patients received antitubercular therapy with oral corticosteroids. The autofluorescence images were compared with color fundus photography and fundus fluorescein angiography. The main outcome measure was fundus autofluorescence characteristics of lesions during the course of the disease. Results: The pattern of fundus autofluorescence changed as the lesions evolved from the acute to the healed stage. In acute stage, the lesions showed an ill-defined halo of increased autofluorescence (hyperautofluorescence), giving it a diffuse, amorphous appearance (Stage I, acute). As the lesions began to heal, a thin rim of decreased autofluorescence (hypoautofluorescence) surrounded the lesion, defining its edges. The lesions showed predominantly hyperautofluorescence with stippled pattern (Stage II, subacute). With further healing, the hypoautofluorescence progressed and the lesion appeared predominantly hypoautofluorescent with stippled pattern (Stage III, nearly resolved). On complete healing, the lesions became uniformly hypoautofluorescent (Stage IV, completely resolved). Conclusion: Fundus autofluorescence highlighted the areas of disease activity and was a quick imaging tool for monitoring the course of lesions in serpiginouslike choroiditis.

Human amniotic membrane transplantation with fibrin glue in management of primary pterygia: a new tuck-in technique.

Purpose: To report the use of fibrin glue for attaching the human amniotic membrane graft with a tuck-in technique after primary pterygium excision. Methods: Twelve patients with primary pterygium (grade 2 or 3) underwent pterygium excision. The bare sclera was covered with an oversized human amniotic membrane graft by using fibrin glue for graft adherence. The edges of the graft were tucked underneath the adjacent free margin of conjunctiva on 3 sides. Various parameters such as operative time, patients postoperative comfort, graft adherence, time of graft epithelialization, and recurrence of pterygium were assessed. Results: The amniotic membrane graft adhered successfully in 11 patients. Average surgical time was 15.5 minutes (range, 13-21 minutes). The postoperative period was generally comfortable. Epithelialization of the graft was rapid, occurring within 7 days in 11 eyes. In 1 patient, the graft was found dislodged partially on the first postoperative day. Eleven eyes showed no recurrence at the end of 1-year follow-up. Conclusions: Use of fibrin glue for attaching human amniotic membrane graft in primary pterygium surgery is effective. It not only reduces the surgical time but also minimizes postoperative discomfort and complications.

Ultrasound biomicroscopic quantification of the change in anterior chamber angle following laser peripheral iridotomy in early chronic primary angle closure glaucoma

AimsTo prospectively evaluate by ultrasound biomicroscopy (UBM) and gonioscopy the anterior chamber angle widening following laser peripheral iridotomy (LPI) in eyes with early chronic primary angle closure glaucoma (CACG).MethodsA total of 55 eyes of 55 patients with CACG presenting with less than 180° peripheral anterior synechiae (PAS) were enrolled in the study. Angles were assessed by gonioscopy (Shaffers grading) and UBM, before and 4 weeks after LPI. The angle opening distance at 250 and 500 μm from the scleral spur (AOD 250 and AOD 500) was computed. Results were analysed using the Wilcoxon signed-rank test.ResultsIn the quadrant with LPI, the mean gonioscopy grade increased significantly from 0.45 to 1.45 (P<0.001) and the mean AOD 250 and AOD 500 increased from 38.5±25.9 to 83.5±48.4 μm (P<0.001) and 110.2±80.9 to 170.6±83.4 μm (P<0.001), respectively. The angles widened significantly in the opposite quadrant on UBM (AOD 250: 48.8±31.5–82.7±43.9 μm, P<0.001; AOD 500:117.2±65.5–172.2±81.7 μm; P<0.001), but the median gonioscopy grade remained unchanged.ConclusionsLPI significantly widened the anterior chamber angle in the quadrant with LPI and the quadrant furthest away in patients of CACG with established glaucomatous damage. This change was much better appreciated by the UBM than gonioscopy.