Sumeet Khanduja

Recent trends: Medical management of infectious keratitis

This review article highlights the newer diagnostic modalities and approaches in the medical management of infectious keratitis. A Medline literature search conducted to March 2014 has been included. Recent studies or publications were selected from international indexed journals using suitable key words. Development of specular microscopy and polymerase chain reaction (PCR) has a promising role as diagnostic modalities in infectious keratitis, especially in refractory cases. Previously fortified antibiotics have been the mainstay of treatment for bacterial keratitis. Recently, the advent of fourth-generation fluoroquinolones monotherapy has shown promising results in the management of bacterial keratitis. Corneal collagen cross-linking is being considered in the refractory cases. Topical natamycin and amphotericin B should be considered as the first choice anti-fungal agents in suspected filamentous or yeast infection respectively. Voriconazole and newer routes of administration such as intrastromal and intracameral injection of conventional anti-fungal agents have demonstrated a positive clinical response. Ganciclovir is a newer anti-viral agent with promising results in herpes simplex keratitis. Thus, introduction of newer diagnostic modalities and collagen cross-linking along with fourth-generation fluoroquinolones and newer azoles have a promising role in the management of infectious keratitis.

Small gauge vitrectomy: Recent update

Small gauge vitrectomy, also known as minimally invasive vitreous surgery (MIVS), is a classic example of progress in biomedical engineering. Disparity in conjunctival and scleral wound location and reduction in wound diameter are its core principles. Fluidic changes include increased pressure head loss with consequent reduction in infusional flow rate and use of higher aspiration vacuum at the cutter port. Increase An increase in port open/port closed time maintains an adequate rate of vitreous removal. High Intensity Discharge (HID) lamps maintain adequate illumination in spite of a decrease in the number of fiberoptic fibers. The advantages of MIVS are, a shorter surgical time, minimal conjunctival damage, and early postoperative recovery. Most complications are centered on wound stability and risk of postoperative hypotony, endophthalmitis, and port site retinal break formation. MIVS is suited in most cases, however, it can cause dehiscence of recent cataract wounds. Retraction of the infusion cannula in the suprachoroidal space may occur in eyes with scleral thinning. As a lot has been published and discussed about sutureless vitrectomy a review of this subject is necessary. A PubMed search was performed in December 2011 with terms small gauge vitrectomy, 23-gauge vitrectomy, 25-gauge vitrectomy, and 27 gauge vitrectomy, which were revised in August 2012. There were no restrictions on the date of publication but it was restricted to articles in English or other languages, if there abstracts were available in English.

Rapid assessment of trachoma among children living in rural Northern India.

ABSTRACTPurpose: Rapid assessment of active trachoma in children aged 1–9 years in a previously hyperendemic rural area in Haryana, India. Methods: Ten disadvantaged villages each with a population of 3000–5000 were chosen by cluster random sampling. One thousand children from 500 households in the most underdeveloped parts of the villages—identified by observation and consultation, between the ages of 1–9 years—were examined for signs of Trachomatous inflammation follicular (TF) and Trachomatous inflammation intense (TI). Assessment was done in a health care unit. Examination of both eyes for signs of trachoma and its complications was done with the aid of binocular loupe (2.5X magnification). Tarsal conjunctival swabs from patients of active trachoma were analyzed by direct immunoflourescence assay and polymerase chain reaction for Chlamydia trachomatis antigen. Results: Forty children (males 21, females 19) had signs of active trachoma that included TF (33) and TI (7). At least one ocular morbidity was...

Brilliant blue G-assisted peeling of the internal limiting membrane in macular hole surgery.

Dye-assisted internal limiting membrane (ILM) peeling and gas tamponade is the surgery of choice for idiopathic macular holes. Indocyanine green and trypan blue have been extensively used to stain the ILM. However, the retinal toxicity of indocyanine green and non-uniform staining with trypan blue has necessitated development of newer vital dyes. Brilliant blue G has recently been introduced as one such dye with adequate ILM staining and no reported retinal toxicity. We performed a 23-gauge pars plana vitrectomy with brilliant blue G-assisted ILM peeling in six patients with idiopathic macular holes, to assess the staining characteristics and short-term adverse effects of this dye. Adequate staining assisted in the complete removal of ILM and closure of macular holes in all cases. There was no evidence of intraoperative or postoperative dye-related toxicity. Brilliant blue G appears to be safe dye for ILM staining in macular hole surgery.

Therapeutic vitrectomy for vitreal recurrence of intraocular lymphoma resistant to intravitreal methotrexate post systemic chemotherapy

A 49-year-old female with biopsy proven primary vitreoretinal lymphoma and primary central nervous system lymphoma (PCNSL) presented with asymmetric involvement of both eyes. Right eye had primarily retinal and optic nerve involvement with no light perception while the left eye had purely vitreal form of the disease with visual acuity of 6/18. She was treated with recommended DeAngelis protocol for PCNSL and achieved complete remission of CNS disease and in the right eye and responded only partially to the systemic chemotherapy in the left eye. She received multiple intravitreal methotrexate injections (400 μg/0.1 ml) for persisting disease in the left eye. However, she developed resistance to the same after repeated injections for which therapeutic vitrectomy was performed. She achieved final visual acuity of 6/12 in the right eye and 6/18 in the left eye and did not relapse until last follow-up of 2 years.

Trachoma prevalence in women living in rural northern India: rapid assessment findings.

Purpose: Rapid assessment of cicatricial trachoma in adult females aged over 15 years in a previously hyperendemic rural area in Haryana, North India. Methods: Ten disadvantaged villages each with a population of 3000–5000 were chosen by cluster random sampling. One thousand females, 500 between 15–30 years and the rest over 30 years in the underdeveloped parts of the villages, identified by observation and consultation, were examined for signs of trachomatous scarring (TS), trachomatous trichiasis (TT) and trachomatous corneal opacity (TCO). Examinations of both eyes were performed with the aid of a binocular loupe (2.5x magnification) for signs of trachoma, its complications and other ocular morbidities. Results: Bilateral examination was carried out in all participants. About two-thirds (n = 650; 65%) of subjects did not have any signs of trachoma. The percentages of trachoma stages TS, TT and TCO were found to be 26.4%, 5.4% and 3.2% respectively. Trichiasis was observed in 54 subjects, all in the age group >30 years, and highest in the age group 66–75 years (22.8%). Females in the age group >30 years had significantly higher cicatricial trachoma compared to females <30 years (p < 0.001). Overall 59.3% of affected females had not received any treatment. Epilation and entropion surgery had been performed in 30.3% and 10.4% of affected females, respectively. Conclusion: The results of our rapid assessment suggest that the presence of cicatricial trachoma remains an important health issue in females over 15 years of age.

Preferred clinical practice in convergence insufficiency in India: A survey

Purpose Convergence insufficiency (CI) is a common binocular vision disorder. However, there is a lack of consensus regarding the treatment most appropriate for CI. The aim of the study was to investigate the treatment for CI by surveying the ophthalmologists regarding the most common treatment modalities used in India. Materials and Methods: Four hundred questionnaires were distributed amongst ophthalmologists attending different sessions of the Delhi Ophthalmological Society annual conference held in April 2007. Two hundred and three ophthalmologists responded (response rate 50.75%). The responders included 109 private practitioners, 57 consultants attached to teaching institutes and 37 residents. Results: The majority of ophthalmologists (66.7%) claimed encountering >5% outpatient department patients with CI. Pencil push-ups therapy (PPT) was the most common first line of treatment offered by ophthalmologists (79%) followed by synoptophore exercises (18%). Only 3% referred the patients to optometrists. Thirty per cent ophthalmologists claimed good results with PPT, which was significantly higher in private practitioners (35%). Only 26% ophthalmologists explained physiological diplopia to patients on a regular basis and reported significantly higher percentage of patients (46.3%) with good results. Only 12.3% ophthalmologists needed to refer >30% patients for synoptophore exercises. For failure of PPT 86.7% considered lack of compliance as the major reason as perceived by ophthalmologists. Conclusions: This survey suggested that most ophthalmic practitioners prescribed PPT as the initial treatment for CI and had satisfactory results with PPT. The majority of the practitioners did not explain to the patient about physiological diplopia. Explaining physiological diplopia may improve outcome, as perceived from the survey.

High-resolution Fourier-domain optical coherence tomography findings in subretinal cysticercosis.

We present the optical coherence tomography features of subretinal cysticercosis in a 12-year-old boy with presenting visual acuity of 4/60. The cyst was imaged using high-resolution Fourier-domain optical coherence tomography system (Cirrus; Zeiss Meditec, Inc, Dublin, CA). Clinical examination revealed a subretinal, domeshaped, cystic lesion below the inferotemporal arcade (Figure 1). Within the cyst, a white opacity with contractile motility was seen during examination (the scolex). Fourier-domain optical coherence tomography revealed a hyporeflective cystic subretinal lesion (Figure 2). The cyst wall facing the vitreal side was continuous and well defined (long arrow, Figure 2) while that abutting the pigment epithelial layer was discontinuous and poorly defined as a result of shadowing (arrow head, Figure 2). The scolex produced a comet-shaped echo with anterior broad hyperreflectivity and a gradually tapering hyporeflective tail (marked “S”; Figure 2). The cyst was removed using standard 3-port 23-G pars plana vitrectomy. Vitrectomy was completed after posterior vitreous detachment induction, and retinotomy was made over the area of the Fig. 1. Fundus photographs of the right eye showing sub retinal cysticercosis below the inferotemporal arcade with overlying retinal vasculature. Scolex is seen within the cyst cavity as a white opacity (arrow).

Evaluation of Discrepancies Between Fluorescein Angiography and Optical Coherence Tomography in Macular Edema in Uveitis

THIS LETTER REFERS TO THE ARTICLE ‘‘DISCREPANCIES between Fluorescein Angiography and Optical Coherence Tomography in Macular Edema in Uveitis,’’ by Ossewaarde-van Norel and associates. The authors analyzed the time-domain optical coherence tomography (TD OCT) and fluorescein angiography (FA) scans of 112 eyes with active or inactive uveitis for the presence of macular edema and observed discrepancies between the findings of the 2 investigational tools in nearly 46% of eyes. We congratulate the authors for the concept of the study, but have a few comments to make. First, the authors did not mention the TDOCT scanning protocol that was used for image capturing and analysis. Using TD OCT, 6 radial line scan images can be acquired using 2 protocols: the fast macular thickness protocol in which 128 A-scans for 1 line scan are obtained and the macular thickness protocol in which 512 A-scans for 1 line scan are acquired. The fast macular thickness protocol decreases the chances of motion blur, but compromises on image resolution. If the fast macular thickness protocol was the sole protocol used for image acquisition and analysis, it may have led to an increase in false-negative results (higher chances of cysts being missed) and would be a serious limitation of the study. Second, we also believe that a high proportion of FA-positive and TD OCT-negative reporting could be the result of missing cysts in the perifoveal area. The 6 radial line scan protocol has a propensity of missing perifoveal pathologic features, which are present in the intervening area between the 2 line scans. Third, the authors’ statement regarding their inability to test their hypothesis of atrophic retinas withmacular edema and negative TD OCT results because of increased central retinal thickness being a selection criterion may not be entirely true, because it was not the only selection criterion and in all the patient subgroups (FApositive/TDOCTpositive, FA positive/TDOCTnegative, FA negative/TDOCT positive), the lower range of thickness was less than 249mm (the defining thickness for macular edema in this study). Fourth, the clinical application of the study would be more relevant if the pattern of discrepancies in eyes with an initial episode of intraocular inflammation, a recurrent episode of uveitis, and inactive uveitis were described separately.

Role of topical nepafenac in prevention and treatment of macular edema after vitreoretinal surgery.

Purpose To evaluate the effects of topical nepafenac in patients undergoing vitreoretinal surgery. Methods One hundred and twenty eyes of 120 patients undergoing vitreoretinal surgery were randomized to receive either topical nepafenac 0.1% (60 eyes) or placebo (60 eyes) in this investigator-masked, randomized, comparative case series. Eyes were evaluated for Day 1 postoperative inflammation and 2-, 4-, 6-, and 8-week postoperative retinal thickness and best-corrected visual acuity. Results Mean Day 1 inflammation grades of 0.95 ± 0.6 and 1.78 ± 0.7 were noted in patients taking nepafenac and placebo, respectively (P = 0.002). The nepafenac and placebo groups had mean central macular subfield thickness of 228.44 ± 29.27 &mgr;m and 236.21 ± 29.44 &mgr;m at 4 weeks (P = 0.172) and 205.35 ± 25.25 &mgr;m and 205.37 ± 24.90 &mgr;m at 8 weeks (P = 0.971), respectively. At 1 month, there was no statistically significant difference in the mean visual acuity between the nepafenac group (0.55 ± 0.16 decimal units) and placebo group (0.52 ± 0.17 decimal units). Conclusion Topical nepafenac was safe and reduced postoperative pain and inflammation in patients undergoing vitreoretinal surgery. However, its effect on reducing postoperative macular edema and improving visual acuity as compared with that of the standard postvitrectomy therapeutic regimen was equivocal.