Suneetha Nithyanandam

Microalbuminuria and low hemoglobin as risk factors for the occurrence and increasing severity of diabetic retinopathy.

Aim: To assess the influence of urinary microalbuminuria and hemoglobin concentration on the occurrence and severity of diabetic retinopathy (DR), clinically significant macular edema (CSME) and hard exudate formation. Materials and Methods: In this prospective cross-sectional study carried out over a period of 2 years, type 2 diabetic patients seeking ocular evaluation for DR were assessed for presence and severity of DR, presence of hard exudates and CSME. Retinal findings were correlated to severity of microalbuminuria, hemoglobin concentration and other systemic risk factors using linear regression analysis. Results: Three hundred and six patients were included in the study. DR of any grade was seen in 132 (43%) patients, hard exudate formation in 93/306 (30.4%) patients, CSME in 50/306 (16.3%) patients and proliferative DR in 26/306 (8.5%) patients. Duration of diabetes (P <0.001), microalbuminuria (P <0.001) and low hemoglobin (P = 0.001) were found to be highly significant risk factors for the development and increasing severity of DR as well as for CSME and hard exudate formation. Conclusion: Microalbuminuria and low hemoglobin are strong predictors for DR, CSME and hard exudate formation in type 2 diabetics even after correcting for duration of diabetes and other systemic risk factors. Although not directly involved in the pathogenesis, microalbuminuria can help in identifying patients at risk for more severe diabetic eye disease. Microalbuminuria warrants intensive monitoring of both retinal and renal status. The hemoglobin levels should be monitored regularly in diabetic patients to detect and treat anemia, thereby reducing one risk factor for DR.

Optic nerve sheath decompression for visual loss in intracranial hypertension: report from a tertiary care center in South India.

Aim: Severe visual loss is the only serious complication of intracranial hypertension secondary to idiopathic intracranial hypertension (IIH) and some cases of cerebral venous thrombosis (CVT). Optic nerve sheath decompression (ONSD) has been shown to improve or stabilize visual function in patients with IIH, while its role in CVT is yet to be established. We report our experience with optic nerve sheath decompression for visual loss in IIH and CVT. Materials and Methods: In this prospective noncomparative, interventional study, 41 eyes of 21 patients with IIH and CVT and visual loss underwent ONSD. The main outcome measures included best-corrected visual acuity (BCVA), visual fields, pupillary light reflex, optic nerve sheath diameter on B-scan and resolution of papilledema which were evaluated preoperatively and at follow-up at four days, two weeks, one month, three months and final follow-up. In 7/41 eyes with absent light perception preoperatively, the functional outcome was analyzed separately. Results: Following ONSD BCVA and visual fields stabilized or improved in 32/34 (94%) eyes. Statistically significant improvement in BCVA, visual fields and pupillary light reflex occurred over the three month follow- up period. Surgical success was indicated by reduction in optic nerve diameter and papilledema resolution occurred in all patients. The outcome in the IIH and CVT groups was comparable. Four eyes with absent light perception showed marginal improvement in visual acuity. Four eyes had transient benign complications. Conclusion: Optic nerve sheath decompression is an effective and safe procedure to improve or stabilize vision in patients with visual loss caused by IIH and CVT.

Factors affecting visual outcome in herpes zoster ophthalmicus: a prospective study.

Purpose:  To evaluate visual outcome and factors affecting visual outcome in herpes zoster ophthalmicus (HZO).

Serum lipids and diabetic retinopathy: A cross-sectional study.

Aim: To evaluate the association of elevated serum lipids with retinal hard exudates formation, the occurrence clinically significant macular edema (CSME), occurrence and severity of diabetic retinopathy (DR) and loss of vision in type 2 diabetics. Materials and Methods: Type 2 diabetic patients seeking ocular evaluation for diabetic retinopathy were included in this cross-sectional study. They were assessed for presence and severity of diabetic retinopathy (DR), presence of hard exudates, clinically significant macular oedema (CSME) and best corrected visual acuity (BCVA). Retinal findings were correlated to serum lipids levels using univariate and multivariate analysis. Results: Totally 330 patients were included, of which 141/330 had diabetic retinopathy of any grade. Retinal hard exudate formation, was found to have statistically significant correlation with the presence of dyslipidemia (p=0.02), increased total cholesterol (p=0.002) and LDL levels (p=0.001). On multivariate analysis, after correcting for duration, glycemic control and albuminuria, increased cholesterol remained significantly associated with increased hard exudate formation (p=0.02). Elevated cholesterol also showed independent association with visual loss (p=0.04). The occurrence CSME showed a statistically significant correlation with dyslipidemia (p=0.04) and increased LDL levels (0.04), which did not persist on multivariate analysis. However the there was no correlation with the occurrence and severity of diabetic retinopathy Conclusion: Elevated serum lipids showed a significant association with retinal hard exudate formation, CSME and loss of vision in type 2 diabetics. Lipid lowering agents may help in reducing the occurrence of these retinal findings and loss of vision in diabetic patients.

Eruption severity and characteristics in herpes zoster ophthalmicus: correlation with visual outcome, ocular complications, and postherpetic neuralgia.

Introduction  Herpes zoster ophthalmicus (HZO) is characterized by a typical vesicular eruption affecting the distribution of the ophthalmic division of the trigeminal nerve which can be of varying severity. The correlation of eruption severity and ocular involvement and subsequent visual loss is still to be established. In this prospective longitudinal study we evaluated the correlation of eruption severity with ocular complications, visual outcome and postherpetic neuralgia.

Ocular complications and loss of vision due to herpes zoster ophthalmicus in patients with HIV infection and a comparison with HIV-negative patients

The aim of the work is to describe the occurrence of ocular complications and loss of vision due to herpes zoster ophthalmicus (HZO) in HIV-positive patients who received early antiviral therapy for HZO. This is a post hoc analysis of prospectively collected data. Twenty-four HIV-positive patients with HZO were included in this report; male to female ratio was 3.8:1; mean age was 33.5 (±14.9) years. The visual outcome was good, with 14/24 patients having 6/6 vision; severe vision loss (≤6/60) occurred in only 2/24. There was no statistical difference in the visual outcome between the HIV-positive and -negative patients (P = 0.69), although severe vision loss was more likely in HIV-infected patients. The ocular complications of HZO in HIV-infected patients were: reduced corneal sensation (17/24), corneal epithelial lesions (14/24), uveitis (12/24), elevated intraocular pressure (10/24) and extra-ocular muscle palsy (3/24). The severity of rash was similar in the two groups but multidermatomal rash occurred only in HIV-infected patients (4/24). There was no difference in the occurrence of ocular complications of HZO between HIV-positive and HIV-negative patients. HZO associated ocular complications and visual loss is low in HIV-infected patients if treated with HZO antiviral therapy and was comparable with HIV-negative patients. Early institution of HZO antiviral therapy is recommended to reduce ocular complication and vision loss.

Topical Anesthesia or Oral Dextrose for the Relief of Pain in Screening for Retinopathy of Prematurity: a Randomized Controlled Double-blinded Trial

OBJECTIVE Compare efficacy of 0.5% proparacaine eye drops and oral 25% dextrose in reducing pain during screening for retinopathy of prematurity (ROP). PATIENTS AND METHODS Double-blinded randomized controlled trial. Twenty eligible babies were randomized. Group I received 0.5% proparacaine eye drops at first ROP screening, while Group II received 25% dextrose orally. At second examination, babies received no intervention. Pain was assessed using Premature Infant Pain Profile (PIPP) score. RESULTS The mean ( ± SD) PIPP during procedure in Group I were 15.5 ± 2.06 and 14 ± 2.4 at first and second screening (p = 0.259). The mean ( ± SD) PIPP in Group II were 14.2 ± 1. 8 and 14.9 ± 2.5 at the first and second screening (p = 0.428). Differences were not statistically significant. The PIPP scores of Group I and Group II at the first screening were also not significantly different (p = 0.165). CONCLUSION ROP screening causes moderate to severe pain and neither proparacaine nor dextrose is an effective analgesic.

Paradoxical Growth of Presumed Optochiasmatic Tuberculomas Following Medical Therapy

IMPORTANCE Tuberculosis is an endemic infectious disease in developing countries. Patients receiving treatment for systemic tuberculosis may develop paradoxical growth of tuberculomas in the brain, which can lead to vision loss. OBSERVATIONS We describe 3 patients who had paradoxical development of tuberculomas in the anterior optic pathway during treatment for tuberculosis and presented with acute vision loss. These optochiasmatic tuberculomas were not present at the initial presentation of tuberculosis and appeared on brain magnetic resonance imaging at the time of presentation with vision loss. Vision improved on instituting systemic corticosteroids in addition to antituberculous treatment. CONCLUSIONS AND RELEVANCE As there was visual recovery after patients began receiving systemic corticosteroids and there was no worsening of the systemic condition, it is reasonable to assume that the optochiasmatic tuberculomas resulted from a paradoxical reaction. It is important to recognize this condition and initiate prompt treatment to reduce visual morbidity.

Co-trimoxazole-induced myopia in an HIV-positive patient.

Co-trimoxazole is a commonly used drug in the treatment and prophylaxis of opportunistic infections in HIV seropositive patients. We report a case of a 35-year-old HIV-infected man who presented with blurring of vision one week following initiation of co-trimoxazole therapy. A diagnosis of co-trimoxazole-induced myopia, a known idiosyncratic drug reaction, was made. The drug was withheld and the myopia resolved completely. Although in this patient the ocular condition resolved completely, serious ocular adverse reactions have also been reported with co-trimoxazole. This case report highlights the occurrence of ocular adverse drug reactions (ADRs) in HIV-infected patients on co-trimoxazole and the complexity of drug interactions.

Role of antimetabolites in recalcitrant idiopathic orbital inflammatory syndrome.

Background: High-dose systemic steroids are the primary modality of treatment for idiopathic orbital inflammatory syndrome (IOIS). Occasionally patients experience a relapse of symptoms on tapering steroids or require large doses of steroid, predisposing them to the adverse effects of steroids. Aim: We present our experience with the management of three patients with recalcitrant IOIS, with immunosuppressive therapy, using antimetabolites. Materials and Methods: A retrospective review of the medical records of the patients being reported. Results: Two patients were treated with Methotrexate and one with Azathioprine for a duration of 6-24 months. Two patients were symptom-free three years after stopping the medication. One was doing well clinically with methotrexate therapy alone, when he was lost to follow-up after six months. No adverse effects of immunosuppressive therapy were encountered. Conclusion: High-dose systemic steroid therapy is the first-line treatment for IOIS, but in refractory or steroid-dependent cases, immunosuppressive therapy with antimetabolites is a safe and effective treatment alternative to steroids. However, treatment with antimetabolites warrants close monitoring for complications like bone marrow suppression and liver dysfunction, especially because long-term treatment is required.