Talvir Sidhu

AZOOSPERMIA FACTOR DELETIONS IN VARICOCELE CASES WITH SEVERE OLIGOZOOSPERMIA

BACKGROUND Varicocele is the most common cause of male infertility. The etiology and pathophysiology of varicocele are multifactorial. When low sperm counts are associated with varicocele, varicocelectomy can partially restore spermatogenesis and fertility. Few recent studies have reported that in some varicocele cases, there may be an associated genetic etiology. Presence of a genetic factor like azoospermia factor microdeletions may lead to irreversible spermatogenic arrest in these cases, but very few reports support these findings. However, it is still not understood why some cases improve after varicocelectomy and why some cases show no improvement in semen parameters postoperatively. AIM It is important to distinguish varicocele cases from Yq microdeletions as these cases have irreversible testicular damage and thus carry a poor prognosis after varicocelectomy. SETTINGS Research and Referral tertiary care hospital. DESIGN Prospective study. MATERIALS AND METHODS Seventy-two infertile men with varicocele were referred for Yq microdeletion analysis from the infertility clinic of AIIMS and Army Research and Referral Hospital. Genomic DNA was isolated from blood and polymerase chain reaction microdeletion screening was done in these cases to determine the presence or deletion of AZF loci. RESULTS In this study 7 (9.7%) varicocele cases harbored Yq microdeletion. The sperm count in cases which harbored Yq microdeletion was significantly lower than in cases without Yq microdeletion. CONCLUSION Varicocele cases with Yq microdeletion do not show improvement in semen parameters post-varicocelectomy. Detection of Yq microdeletion determines prognosis and future management in such cases.

Pediatric orbital and ocular lymphomas

To theEditor: Pediatric orbital non-Hodgkin’s lymphoma (NHL) is rare and has not been studied as a separate entity;most cases being cited as case reports. Therefore, exact incidence and outcome of ocular/orbital lymphomas in children is unknown. Here we share our experience of primary pediatric ocular/orbital lymphomas at a tertiary cancer center. From June 03 to December 06, 53 cases of de novo childhood NHL (42 advanced-stage and 11 early-stage) were registered; there were 5 (9.4%) with ocular or orbital involvement (Supplemental Table I). Patient 1 had a conjunctival mass; patient 2 had bilateral proptosis, whereas other 3 patients had unilateral proptosis as their presenting manifestation. Mean age of presentation was 8 years and 8 months (range 4.5 months to 15 years). Patient 1 was treated with excision of conjunctival mass; remaining 4 patients received chemotherapy alone. Four of 5 patients are in complete remission with a median follow-up of 18.5 months (range: 7–34 months); all survivors except patient 4 have normal vision who even prior to developing lymphoma had lost vision in the affected eye due to previous trauma resulting in phthisical eye. This is the first series of its kind that focuses on pediatric ocular and orbital lymphomas. Orbital/ocular NHL in our series constituted 9.4% of all pediatric NHL; further, amongst early-stage NHL, incidence was 36% (4/11). A previous study on early-stage NHL from Pediatric Oncology Group had 2% (4/184) orbital lymphomas [2]. African Burkitt lymphoma, the predominant lymphoma in Africa, has orbital involvement in 16–20% of cases [3,4], although this would not represent the exact incidence of orbital involvement in all lymphomas in that region. It appears interesting to note that the orbital involvement in lymphomas is higher in the developingworld. This difference cannot be entirely explained on the basis of increased Burkitt lymphoma as this was not the predominant subtype in our series. Although Chlamydia has been associated with low-grade orbital lymphomas, a recent study indicated geographic heterogeneity in the pathogenesis of these lymphomas rather than infection [5]. We did not study the role of infections in our cases; further, only 1/5 of cases showed low-grade lymphoma. Lymphoma is the commonest malignancy of orbit in adulthood; B-NHL constituting virtually all orbital/ocular lymphomas [6]. In our series, 4/5 cases were B-NHL and one T-NHL. The B-NHL subgroup was also not constituted by any one particular type; one was Burkitt’s and another diffuse large B-cell lymphoma. The other type of B-NHL in our series, B-precursor lymphoblastic lymphoma, is an uncommon subtype of lymphoblastic lymphoma and its orbital involvement has been reported as isolated case reports [7,8]; our case of 4.5 months is perhaps the youngest child with this disease. Fig. 1. Zygomycetes in tissue histological sample stained by hematoxylin/eosin (originalmagnification 100). [Color figure can beviewed in the online issue, which is available at www.interscience.wiley.com.]

Clinical utility of anterior segment swept-source optical coherence tomography in glaucoma

Optical coherence tomography (OCT), a noninvasive imaging modality that uses low-coherence light to obtain a high-resolution cross-section of biological structures, has evolved dramatically over the years. The Swept-source OCT (SS-OCT) makes use of a single detector with a rapidly tunable laser as a light source. The Casia SS-1000 OCT is a Fourier-domain, SS-OCT designed specifically for imaging the anterior segment. This system achieves high resolution imaging of 10΅m (Axial) and 30΅m (Transverse) and high speed scanning of 30,000 A-scans per second. With a substantial improvement in scan speed, the anterior chamber angles can be imaged 360 degrees in 128 cross sections (each with 512 A-scans) in about 2.4 seconds. We summarize the clinical applications of anterior segment SS-OCT in Glaucoma. Literature search: We searched PubMed and included Medline using the phrases anterior segment optical coherence tomography in ophthalmology, swept-source OCT, use of AS-OCT in glaucoma, use of swept-source AS-OCT in glaucoma, quantitative assessment of angle, filtering bleb in AS-OCT, comparison of AS-OCT with gonioscopy and comparison of AS-OCT with UBM. Search was made for articles dating 1990 to August 2015.

Intraoperative optical coherence tomography guided bleb needling

Two patients with history of trabeculectomy presented with uncontrolled intraocular pressure (IOP) postoperatively. The first patient had a flat and vasularized bleb 10 weeks after the surgery, and the second subject developed encapsulated bleb 3 months postoperatively. Both patients were taken to the operating room and intraoperative optical coherence tomography (OCT) guided bleb needling was performed to restore aqueous egress into the subconjunctival space. Postoperatively, IOP of the operated eyes ranged 14-18 mmHg at week 6 and month 3. None of the eyes had any intraoperative or postoperative complications. This novel application of the intraoperative OCT for bleb needling facilitates precision surgery under direct visualization and reduces the risk of complications.

Effect of phacoemulsification on measurement of retinal nerve fiber layer and optic nerve head parameters using spectral-domain-optical coherence tomography

PURPOSE: The purpose of this study is to determine the effect of phacoemulsification cataract extraction on measurement of retinal nerve fiber layer and optic nerve head parameters using spectral domain optical coherence tomography. MATERIAL AND METHODS: A prospective, hospital-based study of 100 patients of 40 years of age and above, with no other ocular morbidity except cataract and planned for phacoemulsification with IOL implantation (SN60WF) at a tertiary centre at AIIMS, New Delhi, India. All patients underwent imaging with Cirrus SD-OCT model 400 and the optic disc cube 200x200 protocol at baseline and at 1 month follow up. Paired sample t-test was used to compare the RNFL parameters and ONH parameters. RESULTS: The mean age of subjects was 56.6 ± 12.3 years (70 males, 30 females). The average RNFL increased from 92.6 ± 5.4 μm to 101.3 ± 5.6 μm after phacoemulsification, an increase of 9% (P = 0.003) and the signal strength increased from 5.6 ± 0.5 to 7.6 ± 0.7, increasing by 35.7% (P = 0.004). There was a significant increase in the disc area (P = 0.004) and rim area (P = 0.004) but no significant change in vertical cup-disc ratio (P = 0.45) or average cup-disc ratio (P = 0.075). The quadrant-wise RNFL thickness increase in inferior, superior, nasal, and temporal quadrants was 12.6% (P = 0.001), 10% (P = 0.001), 5.6% (P = 0.001), and 3.2% (P = 0.001), respectively. The change in RNFL thickness was maximum in posterior subcapsular cataract (P = 0.001) followed by cortical (P = 0.001) and nuclear (P = 0.001) subtypes. CONCLUSIONS: A significant increase in RNFL thickness and signal strength was observed after cataract surgery using SD-OCT. The maximum change in RNFL thickness was in the inferior quadrant, where RNFL thinning is a significant predictor of glaucoma progression. The posterior subcapsular cataract interfered with RNFL measurement maximally due to its density and proximity to nodal point. After the cataract surgery, a new baseline needs to be established by obtaining fresh OCT images for assessing the longitudinal follow-up of a glaucoma patient.

Innovations in glaucoma surgery from Dr. Rajendra Prasad Centre for Ophthalmic Sciences

Trabeculectomy surgery is the current standard of care in glaucoma for achieving a low target intraocular pressure if medical therapy is not adequate. Augmentation of trabeculectomy with antimetabolites brought a revolutionary change in the long-term success rates of trabeculectomy, but along with it came a plethora of complications. There still is a big window for therapeutic innovations on this subject. The foremost target for these innovations is to modulate the wound healing response after glaucoma drainage surgery. Achieving the desired balance between long-term success of filtering blebs versus early failure due to scarring of blebs and hypotony due to dysfunctional filtering blebs poses a unique challenge to the ophthalmologists. Alternatives to trabeculectomy such as glaucoma drainage devices and minimally invasive glaucoma surgeries cannot solve the problem of glaucoma blindness in our country, mainly due to their unpredictable results and unfavorable cost-benefit ratio. In this article, we present a summary of our innovations in glaucoma surgery to advance patient care by making it more effective, safer, and economical.

Prognosis of different glaucomas seen at a tertiary center: A 10-year overview

Aim: This study aims to determine treatment patterns, long-term intraocular pressure (IOP) and perimetric control in different glaucomas seen at a tertiary eye center. Settings and Design: Hospital-based, cross-sectional chart review of patients routinely following up at an outpatient glaucoma service. Methods: Patients with a follow-up of at least 10 years were evaluated. Their mean IOP, visual field (VF) status, and medications/surgery required at final assessment were noted. Statistical Analysis: Descriptive statistics (mean, standard deviation, and range) were used for all parameters. Results: A total of 230 patients met our inclusion and exclusion criteria, 79 having ocular hypertension with open angles or primary angle closure (PAC), 35 primary open angle glaucoma (POAG), 50 PAC glaucoma (PACG), 20 primary congenital glaucoma (PCG), 46 secondary glaucoma patients. Ocular hypertensives with open angles showed progression to POAG in 3.7%, those with PAC in 5.2%, at a mean IOP of 17.3 ± 3.37 mmHg and 17.13 ± 4.41 mmHg, respectively. A progression on Humphrey Field Analyzer was seen in 11% of POAG and PACG eyes at a mean IOP of 13.50 ± 5.07 and 13.09 ± 3.95 mmHg, respectively. Fifteen percent of primary congenital glaucomas (PCGs) showed a glaucomatous VF defect after 10 years. In secondary glaucoma eyes, the mean IOP at last follow-up visit was 12.38 ± 3.74 mmHg, with progression noted in 7.69% of eyes. Conclusion: This study provides evidence that routine delivery of care can provide well controlled IOP in glaucomas, both primary and secondary, and the VF stabilized in about 90% of patients over a period of 10 years, with the currently available glaucoma medications and trabeculectomy.