Rishita Nutheti

Outcome of surgery on infants younger than 1 month with congenital glaucoma.

PURPOSE To determine the visual outcomes and surgical and anesthetic complication rates of patients with newborn glaucoma operated within 1 month of age. DESIGN Retrospective, consecutive, noncomparative case series. PARTICIPANTS All children with newborn glaucoma who underwent surgery between January 1990 and December 2000 were included. METHODS The medical records of 25 consecutive patients (47 eyes) who underwent primary combined trabeculotomy and trabeculectomy either bilaterally in a single session or unilaterally were reviewed retrospectively. Outcomes were evaluated using Kaplan-Meier survival analysis. MAIN OUTCOME MEASURES Clinical outcome assessment included corneal clarity, intraocular pressure (IOP), bleb characteristics, visual acuity, refractive errors, and identification of surgical and anesthetic complications. RESULTS The mean follow-up was 3.1+/-1.8 years (range, 9.5 months-7.4 years). The mean preoperative IOP was 26.9+/-5.2 mmHg (range, 14-42 mmHg). At the final follow-up visit, the mean IOP was 14.5+/-3.8 mmHg (range, 8-28 mmHg). The percentage reduction in IOP was 43.3+/-21.5 (P<0.0001). Twelve-, 24-, and 36-month survival rates for complete success for IOP control were 89.4%, 83.6%, and 71.7%, respectively, which were maintained for 7 years of follow-up. After surgery, complete clearance of corneal edema was achieved in 66% of the eyes. Data on visual acuity was available for 19 patients. Final best spectacle-corrected visual acuity was 20/40 or better in the better eye in 5 patients (26.3%), 7 patients (36.8%) obtained 20/60 or better in the better eye, 8 patients (42.1%) achieved final visual acuity of less than 20/60 to 20/200 in the better eye (low vision), and four patients obtained less than 20/400 visual acuity in the better eye (blind) according to World Health Organization criteria. However, there was no eye with absent perception of light in the better eye. Myopia (mean spherical equivalent, 4.6+/-3.2 diopters) was the most common refractive error, present in approximately half of the eyes (n = 23; 53.8%). There were no significant intraoperative or postoperative complications in any patient. Anesthesia-related complications developed in 2 patients; however, they were resuscitated successfully. CONCLUSIONS Primary combined trabeculotomy-trabeculectomy offers a viable surgical option in infants that have cloudy corneas at birth as a result of congenital glaucoma. It is associated with a favorable visual outcome and a low rate of anesthetic complications in an Indian population.

An ultrasound biomicroscopic study of the anterior segment in Indian eyes with primary angle-closure glaucoma.

PurposeTo evaluate the presence of plateau iris in eyes with primary angle-closure glaucoma (PACG) after laser peripheral iridotomy by gonioscopy and ultrasound biomicroscopy and to evaluate the pathogenesis of this condition by comparing the UBM parameters of these eyes with those in normal subjects. Patients and MethodsThis prospective study was carried out in the Glaucoma clinic of a tertiary eye care center. A detailed clinical examination including applanation tonometry, indentation gonioscopy with a Sussman four-mirror gonioscope, and ultrasound biomicroscopic examination in one randomly selected eye of 55 patients (55 eyes) with PACG who had undergone laser peripheral iridotomy and 22 normal subjects (22 eyes). ResultsAmong the PACG eyes, 40% (22/55) had an open angle (angle opening distance > 130 microns) and 60% (33/55) eyes had a narrow angle (angle opening distance ≤ 130 microns). A large anteriorly placed ciliary process with a narrow ciliary sulcus was found in 9 of the 22 eyes with open angle (40.9%), and 22 of the 33 eyes with narrow angles (66.66%). Trabecular ciliary process distance was significantly larger in the eyes with open angles compared with those with narrow angles (P = 0.001). ConclusionsPlateau iris was common in the clinic population studied. Anteriorly directed ciliary processes were seen both in eyes with plateau iris as well as in eyes with PACG that had deep anterior chambers after iridotomy.

Trabeculectomy with or without mitomycin-C for paediatric glaucoma in aphakia and pseudophakia following congenital cataract surgery.

AbstractPurpose To evaluate the safety and efficacy of trabeculectomy with or without mitomycin-C (MMC) in the management of glaucoma in aphakia and pseudophakia following congenital cataract surgery.Patients and methods All patients of glaucoma with aphakia or pseudophakia who underwent trabeculectomy with or without MMC from January 1989 to April 2000 were included. The medical records of 19 consecutive patients (23 eyes) were reviewed. Data collected from a retrospective chart review were analysed. Outcome measures were evaluated using Kaplan–Meier survival analysis. Pre- and postoperative intraocular pressures (IOPs), visual acuities, success rate, bleb characteristics, surgical failure and complications were the main outcome measures. Successful IOP control was defined as an IOP between 6 and 21 mmHg, without antiglaucoma medications, without further antiglaucoma surgery and without any sight-threatening complication.Results The mean age of patients was 8.8±5.5 years at the time of trabeculectomy with MMC compared to 11.0±12.4 years for trabeculectomy without MMC. Eight patients underwent trabeculectomy with MMC and 11 patients underwent trabeculectomy without MMC. There was no statistically significant difference between the two groups in terms of visual acuity, IOP, antiglaucoma medications, age at cataract surgery and at trabeculectomy. The IOP reduced from a preoperative level of 34.2±8.9 mmHg (range: 20–52) to a postoperative level of 18.4±12.2 mmHg (range: 2–60) with a mean follow-up of 24.2±17.9 months. The mean reduction in IOP in the MMC group was 15.5±17.3 and 16.3±13.8 mmHg in the other group (P=0.967). Overall, complete success was achieved in 36.8%, qualified success in 21.1% and surgical failure in 42.1% of patients with a mean follow-up of 24.2±17.9 months. There was no difference in the success between the two groups at the last follow-up. One patient developed bleb-related endophthalmitis in both eyes following trabeculectomy with MMC.Conclusions The success rate of trabeculectomy in glaucoma following congenital cataract surgery was 36.8% at the end of 3 years. The present study proves a poor success rate of trabeculectomy in a small series of aphakic Asian Indian patients even with the use of MMC.

Activity of newer fluoroquinolones against gram-positive and gram-negative bacteria isolated from ocular infections: An in vitro comparison

BACKGROUND To determine the antibacterial activity of newer fluoroquinolones and compare their activity between ciprofloxacin-susceptible and resistant bacterial isolates from patients with keratitis and endophthalmitis. MATERIALS AND METHODS The minimum inhibitory concentration (MIC) of ciprofloxacin, ofloxacin, levofloxacin, gatifloxacin and moxifloxacin was determined for 123 bacterial isolates, using E test. Among the 123 isolates, 68 were gram-positive (Staphylococcus spp, Streptococcus spp, Corynebacterium spp, Bacillus spp.) and 55 were gram-negative (Pseudomonas aeruginosa). The bacterial isolates were divided into three groups: susceptible/intermediate/resistant to ciprofloxacin. The MIC values for various fluoroquinolones were compared between the three groups and between gram-positive and gram-negative bacteria. RESULTS For gram-positive isolates, median MICs of fourth generation fluoroquinolones were lower than second generation. The median MIC was lowest for gatifloxacin and moxifloxacin (0.094 mg/ml) in ciprofloxacin-susceptible isolates of gram-positive bacteria. For ciprofloxacin-susceptible gram-negative bacteria, the median MIC of ciprofloxacin (0.19 mg/ml) was significantly lower than ofloxacin, levofloxacin, gatifloxacin and moxifloxacin (1.5, 0.5, 0.5 and 2 mg/ml respectively). Ciprofloxacin-resistant isolates of gram-positive bacteria showed higher MIC of levofloxacin, moxifloxacin and gatifloxacin though they remained susceptible to them. None of the fluoroquinolones were effective against ciprofloxacin-resistant gram-negative bacteria. Overall, for gram-positive bacteria, median MICs of levofloxacin, moxifloxacin and gatifloxacin were below ciprofloxacin, the MIC of gatifloxacin and moxifloxacin was equal for gram-positive bacteria. CONCLUSIONS Levofloxacin, gatifloxacin and moxifloxacin are statistically more effective against gram-positive bacteria, the latter two being equally effective. Ciprofloxacin remains the most effective fluoroquinolone against gram-negative bacteria.

Planning low vision services in India. A population-based perspective

OBJECTIVE To assess the prevalence and causes of low vision in a population in southern India for planning low vision services. DESIGN Population-based, cross-sectional study. PARTICIPANTS A total of 10,293 persons of all ages from 94 clusters representative of the population of the Indian state of Andhra Pradesh. METHODS The participants underwent a detailed eye examination, including measurement of visual acuity with logarithm of the minimum angle of resolution charts, refraction, slit-lamp biomicroscopy, applanation tonometry, gonioscopy, and stereoscopic dilated fundus evaluation. Automated threshold visual fields and slit-lamp and fundus photography were done when indicated using predefined criteria. MAIN OUTCOME MEASURES Low vision was defined as permanent visual impairment that was not correctable with refractive error correction or surgical intervention. The participants with best-corrected distance visual acuity <6/18 to perception of light or central visual field <10 degrees because of an untreatable cause in both eyes were considered as having low vision. RESULTS Low vision was present in 144 participants, an age, gender, and urban-rural distribution adjusted prevalence of 1.05% (95% confidence interval, 0.82%-1.28%). The most frequent causes of low vision included retinal diseases (35.2%), amblyopia (25.7%), optic atrophy (14.3%), glaucoma (11.4%), and corneal diseases (8.6%). Multivariate analysis showed that the prevalence of low vision was significantly higher with increasing age, and there was a trend for higher prevalence with decreasing socioeconomic status. Extrapolating these data to the estimated 1014 million population of India in the year 2000, 10.6 (95% confidence interval, 8.4-12.8) million people would have low vision. CONCLUSIONS These data imply that there is a significant burden of low vision in this population, suggesting the need for low vision services.

Surgical outcome of primary developmental glaucoma : a single surgeon's long-term experience from a tertiary eye care centre in India

PurposeTo determine the surgical outcome after initial surgery in children with primary developmental glaucoma (PDG).MethodsSix hundred and twenty-four eyes of 360 consecutive patients who underwent primary combined trabeculotomy–trabeculectomy (CTT) for PDG from January 1990 to June 2004 were studied. The main outcome measures were pre- and postoperative intraocular pressures (IOPs), corneal clarity, visual acuities, refractive errors, success rate, time of surgical failure, complications, and factors associated with poor outcome.ResultsIOP reduced from 28.1±7.5 to 14.9±5.9 mmHg (P<0.0001). Probability of success (IOP<21 mmHg) was 85.2, 80.4, 77.2, 72.6, 66.2, and 57.5% at first, second, third, fourth, fifth, and sixth years, respectively (Kaplan–Meier analysis). The mean follow-up period was 20.3±25.6 months (median, 6 months). Preoperatively, 243 eyes (67.5%) had significant corneal oedema. Postoperatively, normal corneal transparency was achieved in 162 eyes (46.0%). Data on Snellen visual acuity were available in 100 patients (27.8%). At the final follow-up visit, 42 patients (42.0%) had normal visual acuity (≥20/60). Myopia (mean spherical equivalent, 6.1 D) was the most common (75.0%) refractive error. In multivariate analyses, failure increased by three-fold in the presence of preoperative IOP>35 mmHg (hazards ratio (HR)=3.12; 95% confidence interval (CI), 1.4–6.7) and two-fold in cases with a history of prior glaucoma surgery (HR=2.57; 95% CI, 1.1–6.0). There were no major intraoperative complications, bleb-related infection, or endophthalmitis.ConclusionsThis series shows that prolonged IOP control can be achieved in patients with PDG and 42% of the patients gained normal visual acuity.

Combined trabeculotomy and trabeculectomy in advanced primary developmental glaucoma with corneal diameter of 14 mm or more.

PurposeTo report the safety and efficacy of combined trabeculotomy and trabeculectomy (CTT) in advanced primary developmental glaucoma with corneal diameter 14 mm or more.Patients and MethodsA total of 74 (121 eyes) consecutive patients aged 3 days–100 months (median, 10 months) with advanced developmental glaucoma were included. Primary CTT was performed by a single surgeon at a tertiary eye care centre in India over a 13-year period. The main outcome measures were changes in and final levels of intraocular pressure (IOP), corneal clarity, visual acuity, and refractive status.ResultsMean preoperative IOP was 29.4±7.6 mmHg (range, 10–56 mmHg) and mean postoperative IOP was 15.5±6.6 mmHg (range, 6–38 mmHg) (P<0.0001) with percentage reduction of 44.5±27.1. Kaplan–Meier survival analysis revealed 3-, 6-, 9-, 12-, 24-, 48-, and 72-month success rates of 86.5, 80.5, 78.1, 75.5, 71.1, and 60.5%, respectively. Majority (80.5%) of the patients were myopes with mean spherical equivalent of 5.8±4.5D (range, 0.75–22.0D). Using various age-appropriate testing procedures, at the final follow-up visit, 14 patients (41.2%) had age-appropriate normal visual acuity and 20 patients (58.8%) had subnormal visual acuity. Best-spectacle-corrected visual acuity of ⩾20/60 was achieved in seven patients (26.9%). There were no sight-threatening intraoperative and postoperative complications.ConclusionCTT is safe and effective in patients with advanced primary developmental glaucoma. It offers good IOP control with a low complication rate, with about one-third of patients achieving a visual acuity of 20/60 or better.

Comparison of mean macular thickness using optical coherence tomography and visual acuity in diabetic retinopathy

Background:  The purpose of the present study was to quantitatively assess the mean macular thickness in diabetic patients using optical coherence tomography and its correlation with visual acuity.

Clinical experience with N-butyl cyanoacrylate tissue adhesive in fungal keratitis.

Purpose. To evaluate the role of tissue adhesive in the management of corneal thinning or perforation associated with active fungal keratitis. Design. Retrospective noncomparative interventional case series. Methods. Seventy-three eyes of 73 patients with microbiologically proven keratomycosis associated with thinning or perforation participated in the study. N-Butyl cyanoacrylate tissue adhesive (medical grade) and bandage contact lens were applied in addition to topical and systemic antifungal therapy. Our outcome measures included resolution of the infiltrate and preservation of the structural integrity of the globe. Results. Outcome data were available for 66 eyes. The infiltrate resolved with scar formation in 42 (63.6%) eyes. In an additional eight (12.1%) eyes, tissue adhesive maintained the structural integrity of the globe while the patients awaited penetrating keratoplasty. Sixteen (24.2%) eyes showed progressive worsening or persistence of the infiltrate after application of tissue adhesive. Twenty-five (37.8%) eyes required multiple applications of tissue adhesive. The outcome was better in cases where the infiltrate measured less than 30 mm2 at the time of presentation and application of tissue adhesive (P < 0.01). Conclusion. In view of the poor outcome of penetrating keratoplasty in active fungal keratitis, N-butyl cyanoacrylate tissue adhesive is a useful modality for the management of progressive thinning or perforation associated with active fungal keratitis. However, close observation is mandatory to assess the progression of disease.

Low vision rehabilitation in patients with age-related macular degeneration at a tertiary eye care centre in southern India

Purpose: To evaluate the specific needs and types of low vision devices (LVDs) in patients with age‐related macular degeneration (AMD) so as to use the residual vision effectively.