Shefali Parikh

Diagnostic capability of Macular parameters of Stratus OCT 3 in detection of early glaucoma

Aim To report the diagnostic capability of Stratus OCT macular parameters in early glaucoma. Material and methods In a cross-sectional observational study, two groups of subjects (early glaucoma and normals) who satisfied the inclusion and exclusion criteria were recruited. The diagnosis of early glaucoma was based on a glaucomatous appearance of the optic disc correlating with visual-field defects (fulfilling at least two of three Anderson and Patella criteria, with a mean deviation better than or equal to −6 dB. All patients underwent a complete ophthalmic evaluation including visual-field examination (24−2/30−2 SITA standard programme) and imaging with Stratus OCT 3. The macular thickness map in Stratus OCT includes the fovea, inner macula and outer macula, with diameters of 1, 3 and 6 mm, a total of nine sectors. Sensitivity, specificity, area under the receiving operating characteristic curve (AUROC) and likelihood ratio were calculated for volume and thickness parameters in these nine sectors. Results 56 eyes (56 patients) with early glaucoma and 75 eyes (75 normals) were analysed. Only two parameters, the outer inferior average volume (p = 0.003) and the outer inferior average thickness (p = 0.002), were statistically significantly lower in the glaucoma group. Outer inferior average volume had a “best combination” of sensitivity and specificity (56% and 79% respectively). Both outer inferior average volume and thickness parameters yielded the best AUROCs of 0.66. Conclusions Outer inferior macular thickness and volume parameters in early glaucoma are significantly different from normals. The moderate sensitivity and specificity suggest that the role of macular parameters in the diagnosis of early glaucoma is limited.

Likelihood ratios: Clinical application in day-to-day practice

In this article we provide an introduction to the use of likelihood ratios in clinical ophthalmology. Likelihood ratios permit the best use of clinical test results to establish diagnoses for the individual patient. Examples and step-by-step calculations demonstrate the estimation of pretest probability, pretest odds, and calculation of posttest odds and posttest probability using likelihood ratios. The benefits and limitations of this approach are discussed.

Practical approach to medical management of glaucoma

Primary open angle glaucoma (POAG) is usually a chronic, slowly progressive disease. At present, all resources are directed towards reduction of intraocular pressure (IOP), the only known causal and treatable risk factor for glaucoma, and medical management is frequently the first choice in most cases. With the introduction of innovative tools for early diagnosis and newer medications for treatment, decision-making in diagnosis and treatment of glaucoma has become more complex. The philosophy of glaucoma management is to preserve the visual function and quality of life (QOL) of the individual with minimum effects on QOL in terms of cost, side effects, treatment regime, follow-up schedules as well as socioeconomic burden. Our aim should be not to treat just the IOP, optic disc or visual field, but to treat the patient as a whole so as to provide maximum benefit with minimal side effects. In this article, we describe the scientific approach to medical management, mainly of POAG.

Choroidal drainage in the management of acute angle closure after topiramate toxicity.

PurposeTo report the role of choroidal drainage in patient with acute bilateral angle closure secondary to cilio-choroidal effusion with Topiramate. DesignInterventional case report. MethodsTwo weeks after commencing tablet Topiramate (Sulfamate derivative) for management of epilepsy, a patient developed bilateral acute angle closure secondary to cilio-choroidal effusion with lenticulo-corneal touches for which choroidal drainage was performed in 1 eye. ResultsAfter choroidal drainage, anterior chamber deepened, corneal edema resolved, choroidals started resolving, and intraocular pressure was controlled without medication. ConclusionsIn patients presenting with acute angle closure secondary to Topiramate toxicity, choroidal drainage if indicated, is a safe and effective interventional procedure.

Ocular Manifestation in Treated Multibacillary Hansen's Disease

PURPOSE To report the prevalence of ocular morbidity in patients with treated multibacillary Hansens disease (HD) using modern ophthalmic diagnostic techniques in a rural community endemic for HD. DESIGN Cross-sectional, observation study. PARTICIPANTS All patients with multibacillary HD who had completed their multidrug therapy and who resided in 4 defined geographical areas in Vellore, Tamil Nadu, India. METHODS All participants underwent a complete eye examination that included slit-lamp examination, esthesiometry, gonioscopy, applanation tonometry, and dilated fundus examination, including a stereobiomicroscopic examination of the fundus at an ophthalmic center set up for that purpose. Glaucoma suspects underwent automated perimetry using a Humphrey Field Analyzer (Humphrey Instruments, San Leandro, CA). MAIN OUTCOME MEASURES The prevalence of various ocular disease parameters were reported as mean value with 95% confidence interval. The difference of disease prevalence between various leprosy groups was compared using an unpaired t test. The association between eye symptoms and potentially sight-threatening complications was analyzed using the chi-square test. RESULTS Three hundred eighty-six of the 446 patients with multibacillary HD residing in the defined areas were evaluated. Four patients (1.04%; 95% confidence interval [CI], 0.0%-2.0%) were bilaterally blind; 33 (8.55%; 95% CI, 5.8%-11.3%) had unilateral blindness. Mean intraocular pressure was 12 mmHg (standard deviation, 4.1 mmHg), and prevalence of glaucoma was 3.6% (95% CI, 1.8%-5.5%). Potentially sight-threatening (PST) pathologic features (corneal anesthesia, lagophthalmos, uveitis, scleritis, and advanced glaucoma) were present in 10.4% (95% CI, 7.4%-13.4%) of patients. Significant cataracts occurred 3 times more frequently in those with polar lepromatous leprosy. The odds ratio for PST pathology in the presence of patient-reported symptoms (pain, redness, inability to close eye, burning, and irritation) was 2.9 (95% CI, 1.34-6.26). CONCLUSIONS Patients who have completed treatment for multibacillary HD continue to have significant ocular morbidity. A history of specific eye symptoms can be the basis for referral by field staff.

Alternative therapy in glaucoma management: Is there any role?

Glaucoma is one of the leading causes of blindness worldwide. Various randomized controlled clinical trials have shown that lowering intraocular pressure (IOP) does reduce progression of primary open-angle glaucoma. However, there is lots of interest in nonpharmacological options that includes lifestyle adjustment and alternative and complementary therapy (ACT). At least 5% glaucoma population uses ACT. Various lifestyle activities like exercise and alcohol can reduce IOP by 1 to 2 mm Hg but would have small effect on glaucoma. The psychological stress can increase IOP. Hypothetically and few studies do show neuroprotective effect (or effect on ocular blood flow) of alcohol, Gingko biloba, bilberry, but the current evidence is weak for its routine use. We must also remember the side effects of ‘medications’ (e.g., marijuana, alcohol) before promoting as remedy for glaucoma. In current armamentarium of glaucoma management, ACT cannot substitute the conventional treatment available to lower IOP.

Unusual presentation in Axenfeld-Rieger syndrome.

We report an unusual presentation of a case of Axenfeld-Rieger (A-R) syndrome. A 14-year-old male presented with gradual dimness of vision for 1 year and redness of left eye for 3 days. The patient had megalocornea with Haabs striae in the right eye and posterior embryotoxon in both the eyes. In the left eye, there was a white cord-like structure traversing the anterior chamber with adhesions to iris tissue along its course. On two antiglaucoma medications, his intraocular pressure (IOP) was 22 mm Hg in the right eye and 18 mm Hg in the left eye. Gonioscopy revealed a cord-like structure originating at the level of Schwalbes line. He underwent right eye trabeculectomy with mitomycin-C. This case highlights a rare presentation of a strange cord-like structure, a rare presentation of A-R syndrome.

Aniridia associated with congenital aphakia and secondary glaucoma.

We report a case of aniridia associated with congenital aphakia and secondary glaucoma. A 35-year-old male presented with aniridia, congenital aphakia and secondary glaucoma in both eyes. After an unsuccessful medical management, he underwent trabeculectomy with mitomycin C and anterior vitrectomy under local anesthesia in his left eye. Postoperatively, at the end of six months, intraocular pressure (IOP) in his left eye was controlled without medications. This case highlights the rare association of aniridia with congenital aphakia and secondary glaucoma.