Subashini Kaliaperumal

Retinopathy in preeclampsia: association with birth weight and uric acid level.

Purpose: In a retrospective study of patients with preeclampsia and patients with pregnancy-induced hypertension (PIH) who delivered at term, the association of retinopathy with various clinical and laboratory manifestations and fetal birth weight was evaluated. Methods: Medical records of patients with preeclampsia and patients with PIH who delivered at term between January 2003 and December 2004 were reviewed. Patients with preterm delivery, eclampsia, intrauterine fetal death, congenital defect in the fetus, and other systemic disorders were excluded. Parameters analyzed were retinopathy, systolic and diastolic blood pressure (BP), fetal birth weight, and various biochemical parameters. Multivariable linear regression was used for statistical analysis. P ≤ 0.05 was considered significant. Results: Forty patients were included in the preeclampsia group (study group) as well as in the PIH group (control group). Severity of retinopathy was found to be inversely related to fetal birth weight (P = 0.044) and positively related to serum uric acid level (P = 0.022) in the preeclampsia group. All other variables in the preeclampsia group including systolic BP (mean, 154.6 mmHg; P = 0.792) and diastolic BP (mean, 105.7 mmHg; P = 0.102) were found to have no significant association with retinopathy. In the PIH group, none of the parameters analyzed were significantly associated with ocular changes. Conclusions: The severity of retinopathy in preeclampsia is directly related to the level of placental insufficiency and intrauterine growth retardation. The severity of retinopathy might be independent of systemic BP.

Efficacy of intraoperative vancomycin in irrigating solutions on aqueous contamination during phacoemulsification

Purpose: To study the efficacy of adding vancomycin in irrigating solutions, in comparison to topical antibiotic given preoperatively for a day, during phacoemulsification, in reducing the anterior chamber (AC) contamination. Settings and Design: This was a prospective, interventional, hospital-based study. Materials and Methods: This was a study involving 400 eyes of 400 paitens, undergoing routine phacoemulsification between January 2004 and June 2006. The patients were non-randomly assigned to two groups: Group 1 included 180 patients, who received topical ciprofloxacin eye-drops (four-hourly) for a day preoperatively and Group 2 included 220 patients, who underwent phacoemulsification with vancomycin (20 µg/ml) in the irrigating solution. Anterior chamber aspirate obtained at the end of the surgery was sent for microbial workup. The number of positive cultures in both the groups was determined. Statistical analysis: This was performed using Chi-square test. Results: Aqueous samples showed microbial growth in 38 (21.1%) out of 180 eyes in Group 1 and in 17 (7.7%) out of 220 eyes in Group 2 (P = 0.001). Coagulase-negative staphylococcus was the most common organism in both the groups. Aqueous samples from four eyes in group 1 showed multiple organisms, while none of the sample from group 2 showed more than one organism. None of the eyes in either group showed fungal contamination. One patient in Group 1 developed endophthalmitis, and the causative organism was Alcaligenes faecalis. All patients were followed up for a minimum of six months (range: 6 to 14 months and mean: 9.3 months). Conclusion: Addition of vancomycin in irrigating solutions is more efficacious in reducing AC contamination in comparison to topical antibiotic administered a day preoperatively.

Neuroretinitis, a great mimicker

Neuroretinitis is a less-known clinical entity, which can be funduscopically confused with papillitis or papilledema and with hypertensive, renal and infiltrative retinopathies as well as with retinal vein occlusion or anterior ischemic optic neuropathy. Report: Two young patients presented with sudden onset of blurring of vision. Ophthalmic evaluation revealed a characteristic picture of neuroretinitis. Detailed study of the cases failed to indicate any specific etiology, thereby suggesting the diagnosis of idiopathic neuroretinitis. Although funduscopy showed marked inflammatory changes in the retina and optic nerve head, the recovery following medical treatment was remarkable. Comment: Familiarity with the fundus picture and awareness of the specific causes of neuroretinitis among neurologists and physicians may enable a prompt clinical diagnosis, avoidance of expensive brain imaging studies and early referral for appropriate and effective therapy. A brief review of the literature is presented suggesting a need for further studies to establish specific environmentally determined etiological factors such as infections and the effectiveness of the current modalities of treatment.

Bilateral cataract following lightning injury.

Purpose To report a case of bilateral cataract with posterior vitreous detachment induced by lightning injury. Methods A case report of 30 year old man injured by lightning. Results The patient developed visually significant bilateral cataract after four years of the initial insult on the scalp. The exit wound was noted on the right foot. Fundus evaluation after cataract extraction revealed posterior vitreous detachment. Conclusions Lightning can induce various ocular complications. Decrease in vision due to cataract is usually seen years after the initial lightning injury as the initial changes are in the mid-periphery and often missed in the acute setting. Posterior vitreous detachment induced by lightning can rarely lead to retinal tear formation and subsequently retinal detachment. The severity of entry and exit may not give a true picture of the internal organ damage.

Relationship between systemic hypertension, perfusion pressure and glaucoma: A comparative study in an adult Indian population

Aims: To study the relationship between blood pressure (BP), intraocular pressure (IOP), mean ocular perfusion pressure (MOPP) and primary open angle glaucoma (POAG) in patients with hypertension and compare it to a control group of normotensives. Design: Cross-sectional observational study. Materials and Methods: A total of 108 subjects with primary hypertension and 100 age-matched controls without hypertension were enrolled for the study. IOP measurement using Noncontact Tonometer and dilated fundus evaluation using + 90 D lens were done for all cases. Single recording of BP was taken. Gonioscopy, Humphreys central visual fields, optical coherence tomography and pachymetry were done for all subjects with IOP > 21 mm Hg or C: D ratio ≥ 0.5 or asymmetry of > 0.2. Statistical Analysis: Univariate and multivariate multinomial regression models were used to determine the association between covariates and risk of glaucoma or glaucoma suspect. Results: There was no difference in the glaucoma status between subjects with and without hypertension. Subjects on antihypertensive medications were 1½ times more likely to have suspicious glaucoma (odds ratio [OR] =1.56] and nearly twice as likely to have POAG (OR = 1.85). In addition, we found a 31% and 12% reduction in risk of having POAG (95% confidence interval [CI] =13–45%, P = 0.001) and glaucoma suspect (95% CI = 2–21%, P = 0.03) respectively with every 1 mm Hg increment in MOPP. Conclusion: Subjects on antihypertensive medications are more likely to have either glaucoma or glaucoma suspect, and higher ocular perfusion pressure offers relative protection from glaucomatous damage.

Fetal birthweight and diastolic blood pressure: Association with retinopathy in severe preeclampsia

Purpose To find the association of retinopathy in preeclampsia with fetal birthweight and systolic and diastolic blood pressure (BP) in patients with mild and severe preeclampsia. Methods Medical records of patients with preeclampsia who delivered at term between January 2002 and December 2006 were included in the study Patients with preterm delivery, eclampsia, intrauterine fetal death, congenital defect in the fetus, and other systemic disorders were excluded. Parameters analyzed were retinopathy, systolic and diastolic BP, and fetal birthweight. Multivariable linear regression was used for statistical analysis. p value ≤0.05 was considered significant. Results The patients were divided into two groups: mild preeclampsia (MP) and severe preeclampsia (SP). The MP had 156 patients and SP had 104 patients. The mean systolic BP in MP and SP was 147.2 mmHg and 164.6 mmHg, while the mean diastolic BP in MP and SP was 98.6 mmHg and 112.7 mmHg. Severity of retinopathy was inversely associated with fetal birthweight (p=0.022) in SP, while it was insignificant in the MP (p=0.082). Low birthweight was due to intrauterine growth retardation of the fetus. Diastolic BP in the SP showed significant correlation with retinopathy (p=0.041). The systolic (p=0.55) and diastolic BP (p=0.248) in MP and systolic BP (p=0.803) in SP were insignificantly correlated with the retinopathy. Conclusions Retinopathy in preeclampsia may indirectly indicate the level of placental insufficiency and intrauterine growth retardation. The severity of retinopathy is more closely related with diastolic BP rather than systolic BP and the significance of this correlation increases in severe preeclampsia.

Varied phenotypic presentations of homocystinuria in two siblings.

Dear Editor, Homocystinuria caused by cystathionine-β-synthase deficiency is a genetic disorder with autosomal recessive inheritance resulting in elevated homocysteine levels. The main ocular feature is ectopia lentis.[1] Megalocornea, microspherophakia in association with homocystinuria are rarely reported in literature.[2] We report two siblings of Indian origin and born out of second degree consanguity with homocystinuria who had variable ocular and systemic involvement. One sibling aged 6 years presented with best corrected visual acuity (BCVA) of 4/60 in both eyes (BE) with 15 degrees of exotropia in the left eye (LE). Corneas were clear with vertical and horizontal diameters 12.5 and 13 mm, respectively, in BE qualifying for megalocornea. Anterior chamber was irregularly shallow in BE. Iridophacodonesis was present in BE and the edge of clear lens was visible temporally in LE [Fig. 1]. Intraocular pressure (IOP) was 13 mmHg (RE) and 16 mmHg (LE). Gonioscopy showed narrow angles. Dilated evaluation of each eye revealed superonasal subluxation of a small lens with increased anteroposterior thickness suggestive of microspherophakia. Axial lengths were 22.08 mm (BE). Serum homocysteine levels were elevated (16.02 μmol/l by using Chemiluminescence ADVIA Centaur CP Immunoassay System (Siemens Health care Diagnostic, Germany). Systemic evaluation revealed global developmental delay and umbilical hernia [Fig. 2]. Pilocarpine eye drops instilled prior to laser iridotomy to prevent pupillary block resulted in inverse glaucoma RE, further strengthening the diagnosis of microspherophakia. Figure 1 Subluxated lens seen in undilated eye with shallow anterior chamber in first child Figure 2 The first child with poor built and umbilical hernia The other sibling was 9-years-old with BCVA 20/200 (BE). Corneas were clear and the corneal diameters were 12 mm horizontally and 11.5 mm vertically in BE. Anterior chamber was shallow, more nasally in BE. IOP was 12 mmHg (RE) and 14 mmHg (LE). Only dilated examination revealed nasal subluxation of the lens of about 6 clock hours in BE [Fig. 3]. The child had increased serum homocysteine (18 μmol/l levels) and systemic evaluation revealed scar of inguinal hernia repair. Fundus examination was normal in both the siblings. Figure 3 Second child showing nasal subluxation of the lens only after dilatation Of the phenotypic variants recognized in homocystinuria, our siblings were probably B6 responsive type because they had mild systemic involvement with normal intelligent quotient (IQ). The major findings in classic homocystinuria are developmental delay, intellectual disability, and skeletal abnormalities such as excessive height and length of the limbs, vascular abnormalities in the form of thromboembolism. The first child had developmental delay and umbilical hernia, while the second child had only inguinal hernia. Ectopia lentis is reported to occur in 90% of patients. Homocysteinylation of fibrillin-1 leads to alterations of self-interaction properties due to a reduction of disulfide-bonded C-terminal fibrillin-1 multimers[3] leading to the weak zonules and progressive ectopia lentis. Mulvihill et al., in their study have shown that ectopia lentis in homocystinuria develops after 1 year and maximum by 8 years of age.[4] Both the siblings in this study developed ectopia lentis by 8 years of age. The superonasal subluxation was also atypical as the common type of subluxation seen is nasal or inferior.[5] Other ocular features include optic atrophy, iris atrophy, anterior staphylomas, and corneal opacities. Retinal detachments occur in 5-10%. The first sibling had a MESH (megalocornea, ectopia lentis, spherophakia, homocystinuria) association, but the second sibling did not have this association. The cases are presented because of the atypical ocular and systemic features with varying phenotypic presentations. Presence of abdominal hernia in children may be associated with collagen disorders and hence an ocular examination may be sought in view of development of glaucoma and ambyopia secondary to a subluxated lens.

Case Reports of Three Patients Showing Optic Nerve Head Melanocytoma and Systemic Hypertension

Purpose: To report the association of optic disk melanocytoma with systemic hypertension. Cases: Ocular examination of 3 asymptomatic hypertensive patients revealed a pigmented lesion over the optic disk. After clinical examination and radiological evaluation a diagnosis of optic disk melanocytoma was made. One patient had a mild decrease in visual acuity associated with an increase in size of the lesion during the follow-up. Systemic evaluation revealed increased urinary vanillylmandelic acid in all the patients. MRI showed diffuse adrenal hyperplasia while a 131I-MIBG scan showed increased uptake in 1 case. Conclusions: Optic disk melanocytoma is a benign tumor though the lesion may increase in size with the resultant decrease in visual acuity over few years. It may be associated with systemic hypertension secondary to increased levels of catecholamines in the body, which is related to the common neural crest origin of melanocytes, adrenal medullary cells and chromaffin cells.

Microbial cultures in open globe injuries in southern India

Purpose:  To determine the risk factors leading to positive intraocular culture in patients with open globe injury.

Outbreak of Adenovirus serotype 8 keratoconjunctivitis in Puducherry, South India: a molecular epidemiological study

Dear Editor, The present study reports an outbreak of conjunctivitis due to human adenovirus serotype 8 (HAdV-8) for the first time from India. HAdV-8, was detected in 16 samples by Multiplex PCR. Eleven strains were sequenced, analysed by phylogenetic tree with pre-epidemic and global isolates and revealed no variation with pre-epidemic strains. Acute viral conjunctivitis is the most common cause of infectious conjunctivitis. It can be caused by several viruses such as Human adenoviruses (HAdV), Herpes virus, Enterovirus 70 and Coxsackie virus A24 [1]. Adenovirus is the most common agent of viral conjunctivitis representing 15%-70% of all cases of conjunctivitis worldwide [2]. HAdV (Adenoviridae family) is divided into 7 species (A to G) and 68 serotypes [3]. Serotypes 3, 4, 7, 8, 19 and 37 are responsible for 89% of the cases of viral conjunctivitis worldwide [4]. Adenoviruses are non-enveloped and show resistance to both physical and chemical agents of disinfection. Their stability against such agents make them more infectious and facilitates their transmission in the community through fomites, ophthalmic instruments and even through ocular drops [5]. Information on the monthly incidence of adenoviral conjunctivitis is essential to prevent further infection [6]. In the month of October and November 2014, an outbreak of acute viral conjunctivitis occurred in Puducherry, India, during the rainy season. In this context, the aim of the present study was: to detect adenovirus by (i) viral culture, (ii) immunofluorescence assay (IFA) and (iii) multiplex polymerase chain reaction (PCR). We also conducted a molecular epidemiological study on adenovirus and its serotypes.