Sridharan Sudharshan

Current approach in the diagnosis and management of posterior uveitis.

Posterior uveitic entities are varied entities that are infective or non-infective in etiology. They can affect the adjacent structures such as the retina, vitreous, optic nerve head and retinal blood vessels. Thorough clinical evaluation gives a clue to the diagnosis while ancillary investigations and laboratory tests assist in confirming the diagnosis. Newer evolving techniques in the investigations and management have increased the diagnostic yield. In case of diagnostic dilemma, intraocular fluid evaluation for polymerase chain testing for the genome and antibody testing against the causative agent provide greater diagnostic ability.

Clinical Profile, Treatment, and Visual Outcome of Ampiginous Choroiditis

The purpose of this study was to report the clinical profile and management of patients with serpiginous choroiditis in a tertiary care referral center in India. In a retrospective cohort study, 107 eyes of 70 patients with serpiginous choroiditis seen between January 1995 and December 2002 were analyzed. Systemic steroids and immunosuppressives were the mainstay of therapy. Antituberculous and antiviral drugs were used in selected cases. There was male preponderance (7:3). Age at presentation ranged from 11 years to 52 years (mean 30.3 ± 9 years); 52.9% had bilateral involvement. Vision improved or maintained in 86% eyes and deteriorated in 15 eyes (14%). The main cause of decrease of vision was macular involvement. Improvement in vision and resolution of lesions in patients with serpiginous choroiditis can occur with combination therapy of systemic steroids and immunosuppressive agents. Serial examination at regular intervals is needed to monitor the disease progression, recurrences, and involvement of the other eye.

Anterior segment manifestations of human immunodeficiency virus/acquired immune deficiency syndrome.

Ocular complications are known to occur as a result of human immunodeficiency virus (HIV) disease. They can be severe leading to ocular morbidity and visual handicap. Cytomegalovirus (CMV) retinitis is the commonest ocular opportunistic infection seen in acquired immune deficiency syndrome (AIDS). Though posterior segment lesions can be more vision-threatening, there are varied anterior segment manifestations which can also lead to ocular morbidity and more so can affect the quality of life of a HIV-positive person. Effective antiretroviral therapy and improved prophylaxis and treatment of opportunistic infections have led to an increase in the survival of an individual afflicted with AIDS. This in turn has led to an increase in the prevalence of anterior segment and adnexal disorders. Common lesions include relatively benign conditions such as blepharitis and dry eye, to infections such as herpes zoster ophthalmicus and molluscum contagiosum and malignancies such as squamous cell carcinoma and Kaposi′s sarcoma. With the advent of highly active antiretroviral therapy, a new phenomenon known as immune recovery uveitis which presents with increased inflammation, has been noted to be on the rise. Several drugs used in the management of AIDS such as nevirapine or indinavir can themselves lead to severe inflammation in the anterior segment and adnexa of the eye. This article is a comprehensive update of the important anterior segment and adnexal manifestations in HIV-positive patients with special reference to their prevalence in the Indian population.

Ocular lesions in 1,000 consecutive HIV-positive patients in India: a long-term study

BackgroundOcular lesions in patients on highly active antiretroviral therapy (HAART) have shown changes in disease prevalence and pattern. Although they have been described in the Western population, there are not many such studies in the HAART era from India. This study aims to present the clinical profile, systemic correlation, and visual outcome in HIV-positive patients in relation to HAART in comparison with pre-HAART Indian studies and current Western data. Ocular findings and systemic correlation in 1,000 consecutive patients with HIV seen at a tertiary eye care center were analyzed. This study uses a prospective observational case series design.ResultsAge range of the patients was 1.5 to 75 years. Ocular lesions were seen in 68.5% of the patients (cytomegalovirus (CMV) retinitis was the commonest). The commonest systemic disease was pulmonary TB. Mean interval between HIV diagnosis and onset of ocular lesions was 2.43 years. CD4 counts range from 2 to 1,110 cells/mm3. Immune recovery uveitis (IRU) was seen in 17.4%. Interval between HAART initiation and IRU was 4 months to 2.5 years. Recurrence of ocular infection was seen in 2.53% (post-HAART) and > 20% (pre-HAART). Overall visual outcome showed improvement in about 14.3% and was maintained in 71.6% of the patients.ConclusionsCMV retinitis is the commonest ocular opportunistic infection in India, even in the HAART era. Newer manifestations of known diseases and newer ocular lesions are being seen. In contrast to Western studies, in our patients on HAART, ocular lesions do not always behave as in immunocompetent individuals. Ocular TB needs to be kept in mind in India, as well as other neuro-ophthalmic manifestations related to cryptococci, especially in gravely ill patients. Occurrence and frequency of various ocular opportunistic infections in developing nations such as India have significant variations from those reported in Western literature and need to be managed accordingly.

Phacoemulsification with Intraocular Lens Implantation in Juvenile Idiopathic Arthritis

BACKGROUND AND OBJECTIVE To evaluate outcomes of phacoemulsification cataract surgery with intraocular lens (IOL) implantation in children and adults with juvenile idiopathic arthritis-associated uveitis. PATIENTS AND METHODS Charts of 7 patients (10 eyes) with juvenile idiopathic arthritis-associated uveitis who had phacoemulsification cataract surgery between December 2002 and March 2005 were analyzed. RESULTS Ten eyes of 7 patients had phacoemulsification with IOL implantation done by a single surgeon. A heparin surface modified IOL was used in 7 eyes and a foldable acrylic IOL was used in 3 eyes. At final follow-up, 70% of eyes had a visual acuity of 20/40 or better and 30% had improved visual acuity to 20/60. Posterior capsular opacification was found in 2 eyes and anterior capsular fibrosis in 1 eye. CONCLUSION Keys to success following cataract surgery in juvenile idiopathic arthritis are the age of the child, the absence of amblyopia, and strict preoperative and postoperative control of inflammation.

Analysis of juvenile idiopathic arthritis associated uveitis in India over the last 16 years

AIM Juvenile idiopathic arthritis (JIA) associated uveitis is one of the most common causes of visual morbidity in children. We report the systemic, clinical and investigational features of a cohort of all cases of JIA associated uveitis seen at our referral uveitis clinic between 1988 and 2004. STUDY DESIGN Retrospective case series MATERIALS AND METHODS All patients of JIA seen at the uveitis clinic of tertiary eye care hospital, between 1988 and 2004 with minimum follow up of 3 months were included. Complete history and ophthalmic evaluation and findings on each visit were noted. Ocular complications were identified and recorded. Results of laboratory investigations and diagnostic as well as therapeutic procedures were analyzed. A rheumatologist managed systemic status. RESULTS There were 40 patients (64 eyes) with JIA. Thirty four patients (85%) had pauciarticular type and 6 patients (15%) had polyarticular type of JIA. Complicated cataract and band shaped keratopathy were seen in 38 eyes (63%) and 37 eyes (62%) respectively. Twenty-two patients (17 bilateral and 5 unilateral) were treated with immunosuppressives and in 19 of these patients, the disease went into remission. Twenty-three eyes (38%) had improvement in visual acuity while in 27 eyes (45%), the vision remained stable and in 10 eyes (17%), vision deteriorated despite therapy. CONCLUSION In India, JIA associated uveitis commonly presented in pauciarticular type with preponderance in males. Rheumatoid arthritis factor and anti nuclear antibodies were not as common as compared to the western population. Among long-term treatment options, immunosuppressives are a better choice. Ocular surgery was performed when mandatory for visual rehabilitation.

Quality of life in non-infectious uveitis patients on immunosuppressive therapy.

Purpose: To assess visual function and vision related quality of life in patients with non-infectious posterior or panuveitis treated with immunosuppressives. Materials and Methods: Forty-three patients with non-inflammatory posterior or panuveitis were enrolled in this prospective study. All subjects underwent a detailed interview, complete ophthalmic examination, quality of life assessment using National Eye Institute Visual Function Questionnaire (VFQ-25), visual function evaluation (visual acuity and visual field) at baseline and at a sixth month follow up visit. Results: The mean NEI-VFQ 25 composite score of the subjects with posterior or panuveitis was 58.0 (±24.1). There was a statistically significant improvement (P = 0.004) in the composite score following treatment from 58.0 (±24.1) to 74.3 (±22.0) with effect size of 1.03. The psychological well-being and general health subscales showed significant improvement in the mean score following immunosuppressive therapy. While considering the visual function tests, there was a three-line improvement in the visual acuity score and changeover in the visual field severity from moderate to early defect with corresponding improvement in the visual field pattern. Though most of the patients complained of side effects such as tiredness, gastrointestinal upset and weight gain, there was improvement in the general health subscale. Conclusion: The significant improvement in the general health subscale despite side-effects shows that the benefit of immunosuppressive outweighs the risks of the therapy and this may also reflect the relatively low impact of these side-effects on the quality of life. This study shows that the use of immunosuppressives improves the quality of life of the individual.

Introduction and immunopathogenesis of acquired immune deficiency syndrome

India has a large number of patients with acquired immune deficiency syndrome (AIDS), the third largest population of this group in the world. This disease was first described in patients with Pneumocystis pneumonia in 1981. Ocular lesions can occur at any stage of the disease but are more commonly seen at the late stages. Human immunodeficiency virus (HIV), the causative agent of AIDS is a retrovirus with RNA genome and a unique ′Reverse transcriptase enzyme′ and is of two types, HIV-1 and 2. Most human diseases are caused by HIV-1. The HIV-1 subtypes prevalent in India are A, B and C. They act predominantly by reducing the CD4+ cells and thus the patient becomes susceptible to opportunistic infections. High viral titers in the peripheral blood during primary infection lead to decrease in the number of CD4+ T lymphocytes. Onset of HIV-1-specific cellular immune response with synthesis of HIV-1 specific antibodies leads to the decline of plasma viral load and chronification of HIV-1 infection. However, the asymptomatic stage of infection may lead to persistent viral replication and a rapid turnover of plasma virions which is the clinical latency. During this period, there is further decrease in the CD4+ counts which makes the patient′s immune system incapable of controlling opportunistic pathogens and thus life-threatening AIDS-defining diseases emerge. Advent of highly active antiretroviral treatment (HAART) has revolutionized the management of AIDS though there is associated increased development of immune recovery uveitis in a few of these patients.

Bilateral Hypopyon as the Presenting Feature of Chronic Myeloid Leukemia

Purpose: To report bilateral hypopyon as an unusual presenting feature of chronic myeloid leukemia (CML). Design: Observational case report. Methods: A 68-year-old male presenting with bilateral hypopyon uveitis underwent hematological investigations and cytology of hypopyon. Results: Blood smear revealed increased leucocyte count with presence of abnormal cells (myelocytes, band forms, and promyelocytes) suggestive of CML. Cytopathology of hypopyon revealed predominance of lymphocytes and few plasma cells. CML was confirmed by hematological investigations. Patient was initiated on chemotherapy under the care of an oncologist and is stable. Conclusions: Elderly patients presenting with hypopyon uveitis should be investigated to rule out masquerade syndrome.

Recurrent Posterior Scleritis—Report of a Case

Posterior scleritis is a serious ocular inflammatory and potentially blinding disorder. It is uncommon and often under-recognized due to its varied presentations, and general ophthalmologists are not familiar with it. Posterior scleritis may be idiopathic or associated with systemic diseases. Visual disturbances such as blurring or distortion are the commonest symptoms. There may be pain, tenderness, and deep-seated discomfort in and around the orbit. One study reported a 49% recurrence rate of posterior scleritis. Posterior scleritis responds well to systemic nonsteroidal anti-inflammatory agents, systemic steroids, and immunosuppressive agents. Recurrences are known to occur despite therapy. However, multiple recurrences in posterior scleritis are uncommon. We report a patient with posterior scleritis who had one episode in the right eye and four episodes in the left eye over a 35-month period.