Satpal Garg

Ophthalmic manifestations of HIV infections in India in the era of HAART: analysis of 100 consecutive patients evaluated at a tertiary eye care center in India.

Purpose: To evaluate ophthalmic manifestations in patients with Human Immunodeficiency Virus (HIV) infection in the era of highly active antiretroviral therapy (HAART) at the apex institute for eye healthcare in India. Method: This prospective study was undertaken between October 2004 and December 2005. A complete ophthalmological and systemic examination was performed on each patient. Relevant investigations were carried out in selected patients. Results: One hundred consecutive HIV infected patients (199 eyes) were examined for ophthalmic manifestations. Of these 17% (17/100) had Category A HIV infection (asymptomatic or acute HIV or persistent generalized lymphadenopathy), 23%(23/100) had Category B HIV infection (symptomatic, not A or C), 60%(60/100) had Category C HIV infection (AIDS indicator condition).76%(70/100) were male and 24%(24/100) were female. The median age of patients was 34 years and 52%(52/100) were in the fourth decade. 68%(68/100) patients were on HAART. 45% (45/100) patients had ophthalmic manifestations, the most common being cytomegalovirus (CMV) retinitis (20%) (20/100). Retinal detachment was seen in 70% (14/20) of CMV retinitis patients. HIV vasculopathy was seen in 11% (11/100) of patients. Other lesions included immune recovery uveitis (IRU) (5%)(5/100), acute retinal necrosis (ARN) (3%)(3/100), choroiditis (2%)(2/100), neuro-ophthalmic manifestations (12%)(12/100), complicated cataract (6%)(6/100), keratouveitis (1%)(1/100) and corneal ulcer (1%)(1/100). 7%(7/100) patients presented to us with ophthalmic manifestation as the only presenting sign of HIV infection. Amongst those who had ophthalmic involvement, about 50% (19/40) patients had CD4 count below 100 cells/micro liter and 70% (28/40) patients had CD4 count below 200 cells/micro liter. Conclusions: CMV Retinitis (20%) (20/100) is still the most common manifestation of HIV infection in this series, even in the era of HAART, and is more common than HIV vasculopathy. Immune recovery uveitis is appears to be more common with the introduction of HAART in absence of affordable anti CMV therapy in India. 7% (7/100) of patients present with ophthalmological features as the initial manifestation of HIV. As before, most (70%) (28/40) of the ophthalmic manifestations of HIV infection are present when CD4 count is less than 200 cells/micro liter.

Safety and efficacy of intraoperative intravitreal injection of triamcinolone acetonide injection after phacoemulsification in cases of uveitic cataract

PURPOSE: To evaluate the safety and efficacy of a single intraoperative intravitreal injection of triamcinolone acetonide after phacoemulsification in patients with chronic idiopathic anterior uveitis or intermediate uveitis. SETTING: Dr. R.P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India. METHODS: This prospective randomized controlled study included 40 eyes (40 patients) with chronic idiopathic anterior uveitis or intermediate uveitis that had phacoemulsification with intraocular lens implantation. Twenty eyes received an intravitreal injection of triamcinolone acetonide (4 mg/0.1 mL) intraoperatively (triamcinolone acetonide group), and 20 received oral steroids (steroid group) postoperatively. Outcome measures were Early Treatment Diabetic Retinopathy Study best corrected visual acuity (BCVA), anterior chamber reaction, intraocular pressure (IOP) by applanation tonometry, and central macular thickness by optical coherence tomography. RESULTS: The mean BCVA (decimal) improved from a baseline of 0.13 ± 0.14 to 0.64 ± 0.32 in the triamcinolone acetonide group and from 0.05 ± 0.06 to 0.61 ± 0.36 in the steroid group (P = .74). There were no statistically significant differences between the 2 groups in postoperative anterior chamber reaction, IOP, or central macular thickness. Four patients in the triamcinolone acetonide group and 5 in the steroid group had recurrence of uveitis; 5 patients in the triamcinolone acetonide group had ocular hypertension. One patient in the triamcinolone acetonide group and 3 in the steroid group had cystoid macular edema postoperatively. CONCLUSION: A single intraoperative intravitreal injection of triamcinolone acetonide seemed to be a safe and efficacious route of steroid delivery during phacoemulsification in patients with chronic idiopathic anterior uveitis or intermediate uveitis and is recommended as a substitute for postoperative oral steroid administration.

Management of Coats disease with bevacizumab in 2 patients.

Coats disease, first described by George Coats in 1907, is characterized by telangiectatic and aneurysmal blood vessels associated with intraretinal and subretinal exudation, and progresses to exudative retinal detachment and rubeosis iridis with painful secondary glaucoma, if left untreated.1 Even after various treatments, the visual prognosis is dismal because of persistent foveal subretinal fluid, exudation, and (or) fibrosis.2 Elevated vascular endothelial growth factor (VEGF) levels in Coats disease, and rapid response to pegaptanib sodium, have been reported recently by Sun et al.3 However, the more commonly used anti-VEGF agent, bevacizumab (Avastin, Genentech Inc, San Francisco, Calif.), has not been studied in this retinal vascular disease. We report the results of intravitreal bevacizumab in 2 cases of Coats disease. Two girls (14 and 16 years old) presented with unilateral Coats disease with macular edema and exudates of more than 6 months’ duration. A complete evaluation was done, including best-corrected visual acuity, slit-lamp biomicroscopy, fundus fluorescein angiography (FFA), and optical coherence tomography (OCT). After taking informed consent, intravitreal bevacizumab (1.25 mg/0.05 mL) was injected as primary treatment in both patients. While the first patient had no change in visual acuity (hand movement) and persistent macular edema, the second patient had vision improvement from hand movement to 20/800 and a

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.

Ultrasound biomicroscopy findings of 25 G Transconjuctival sutureless (TSV) and conventional (20G) pars plana sclerotomy in the same patient

BackgroundTransconjunctival Sutureless Vitrectomy (TSV) is a recent advancement in vitreo-retinal surgical techniques involving the use of 25 G instruments through self-sealing sclerotomies. It has been hypothesized that there may be less chance of vitreous and retinal herniation in the scleral wound as compared to conventional sclerotomy incision. However there are no reports on differences in 20 gauge and 25 gauge sclerotomies using ultrasound biomicroscopy (UBM). We report herein the differences in sclerotomies undertaken with 20 gauge (G) and 25 gauge instruments in the same patient.Case presentationUltrasound biomicroscopy of the sclerotomy sites was done in the same patient in whom both 20 G and 25 G sclerotomies had to be constructed during pars plana vitrectomy and the differences were studied.On day 2, we observed a wide gape at the site that had been enlarged using a 20G MVR blade. In contrast, the other two sites made transconjunctivally using the 25G trocar showed only a mild gape. Significant gape continued to persist at the subsequent evaluations on day 7 and day 14 only at the port, which had been enlarged.ConclusionHealing of a 25 G sclerotomy is expectedly quite rapid, with inability to detect the site of sclerotomy in a short duration of 2 weeks post-operatively. This is as opposed to conventional sclerotomies, which might take up to 6–8 weeks post-operatively for complete opposition.

Comparison of the Efficacy and Safety of Different Methods of Posterior Subtenon Injection

Purpose: To compare the safety and efficacy of different methods of posterior subtenon (PST) injection of corticosteroids in the treatment of cystoid macular edema secondary to intermediate uveitis. Design: Prospective comparative randomized interventional study. Participants: A total number of 30 eyes with cystoid macular edema secondary to intermediate uveitis were examined. Methods: Patients were randomized into 3 treatment groups of 10 eyes each. Each group received PST injection of triamcinolone acetonide 0.5 mL (20 mg) by one of three methods: cannula method (group 1), Smith and Nozik method (group 2), or orbital floor injection method (group 3). Patients underwent Snellens and ETDRS visual acuity (VA) testing, clinical evaluation, optical coherence tomography (OCT), and fundus fluorescein angiography (FFA) at baseline and follow-up visits. Outcome measures: Changes in Snellen and ETDRS VA, OCT retinal thickness and assessments of safety were recorded in follow-up visits. Results: Postintervention patients were followed up at the 1st, 2nd, 6th, and 12th weeks. Statistically significant (p = .00) improvement in VA was present in group1 from 0.25 ± 0.08 (mean ± standard deviation) to 0.75 ± 0.24, in group 2 from 0.29 ± 0.12 to 0.78 ± 0.23, and in group 3 from 0.24 ± 0.10 to 0.72 ± 0.27. Statistically significant decrease in OCT central macular thickness (43.97% in group 1, 32.46% in group 2, and 29.75% in group 3) was noted at 12 weeks. However, the difference between individual groups at each visit did not reach statistical significance. Steroid-induced rise in intraocular pressure was observed in all the three groups with no statistical difference between individual groups. Conclusions: The different methods of PST injection are equally efficacious in terms of improving visual acuity. However, the cannula method achieves the greatest quantitative reduction in macular thickness. As the cannula method is as efficacious as Smith and Nozik method it may be a preferable method to deliver posterior subtenon injection of corticosteroids.

Rhegmatogenous retinal detachments in children in India: Clinical characteristics, risk factors, and surgical outcomes

PURPOSE To describe the spectrum of clinical features and surgical outcomes in children with rhegmatogenous retinal detachments in a tertiary-care hospital in northern India. METHODS In this retrospective interventional case series, 230 eyes of 216 children 18 years of age or younger undergoing surgery for rhegmatogenous retinal detachment were included. Detailed history and complete ophthalmic and systemic examination was performed when essential. Risk factors for retinal detachment were noted. Surgical intervention consisted of scleral buckling alone or standard 3-port pars plana vitrectomy with silicone oil tamponade. Rate of anatomical attachment and status of postoperative visual acuity were noted. RESULTS Mean age was 11.12 +/- 3.56 years. Most patients (81.9%) were boys. Thirty-five (16.2%) patients had bilateral retinal detachment at presentation. Detachments tended to be complex, with 54.3% (125/230 eyes) having some form of proliferative vitreoretinopathy. Mean follow-up was 12.3 months. Complete retinal reattachment was achieved in 88.7% of eyes; however, visual recovery was modest. CONCLUSIONS The most common conditions predisposing to rhegmatogenous retinal detachment were peripheral retinal degeneration and trauma. Rhegmatogenous retinal detachments secondary to iridofundal coloboma may be more common than previously reported. A combination of buckling and vitreoretinal techniques helped achieve retinal reattachment in most cases. The presence of anterior proliferative vitreoretinopathy is a poor prognostic factor in terms of both anatomic success as well as visual improvement.

Intravitreal bevacizumab (avastin) for circumscribed choroidal hemangioma.

Circumscribed choroidal hemangiomas are rare ophthalmic entities that cause diminution in vision due to accumulation of subretinal and/or intraretinal fluid in the macular area. Various treatment options ranging from conventional laser to photodynamic therapy have been employed to destroy the tumor and reduce the exudation; however, either the inability to penetrate through the exudative fluid or the collateral retinal damage induced by these treatment modalities make them unsuitable for lesions within the macula. We evaluated the role of intravitreal bevacizumab, a pan-vascular endothelial growth factor (VEGF) inhibitor, in reducing the sub- and intraretinal fluid in three patients with circumscribed choroidal hemangiomas. All the patients had complete resolution of the serous retinal detachment that was maintained till at least 12 months after the first injection. Intravitreal bevacizumab may be used in combination with thermal laser or photodynamic therapy in treating circumscribed choroidal hemangiomas with subretinal fluid.

The role of environmental factors and hereditary predisposition in the causation of low myopia.

Abstract. Various environmental factors have been implicated in the etiology of myopia. An attempt was made quantitatively to estimate some such environmental factors, as based on the presence or absence of a family history of myopia. Age range was 10–21 years. The 200 subjects included in the study were further divided according to emmetropia/myopia. The factors studied in the four subgroups were amount of near work done per day, head posture and illumination level while doing near work, acute fevers, chronic illness, acute or recurrent diarrhea, nutritional status, and income levels. A correlation was found between myopia and near work, head posture and income levels.

Primary vascular occlusion in IRVAN (idiopathic retinal vasculitis, aneurysms, neuroretinitis) syndrome.

IRVAN is a rare retinal vascular disease characterized by the presence of aneurysmal dilations along the retinal arteriolar tree. Visual loss occurs from sequelae to proliferative changes or due to severe macular exudation and rarely from secondary vascular occlusion following laser photocoagulation of the aneurysms. We herein report a patient with a primary vascular occlusion in a patient with IRVAN and suggest that such patients may already have a natural predisposition to develop a vascular occlusion.