Thomas Naduvilath

Chemoreduction plus focal therapy for retinoblastoma: factors predictive of need for treatment with external beam radiotherapy or enucleation.

PURPOSE To report the results of chemoreduction and focal therapy for retinoblastoma with determination of factors predictive of the need for treatment with external beam radiotherapy or enucleation. DESIGN Interventional case series. METHODS One-hundred three patients with retinoblastoma (158 eyes with 364 tumors) at the Ocular Oncology Service at Wills Eye Hospital of Thomas Jefferson University in conjunction with the Division of Oncology at Childrens Hospital of Philadelphia from June 1994 to August 1999 were enrolled for this prospective clinical trial. The patients received treatment for retinoblastoma with six planned cycles (one cycle per month) of chemoreduction using vincristine, etoposide, and carboplatin combined with focal treatments (cryotherapy, thermotherapy, or plaque radiotherapy). The two main outcome measures after chemoreduction and focal therapy were the need for external beam radiotherapy and the need for enucleation. The clinical features at the time of patient presentation were analyzed for impact on the main outcome measures using a series of Cox proportional hazards regressions. RESULTS Using Reese-Ellsworth (RE) staging for retinoblastoma, there were nine (6%) eyes with group I disease, 26 (16%) eyes with group II disease, 16 (10%) eyes with group III disease, 32 (20%) eyes with group IV disease, and 75 (48%) eyes with group V retinoblastoma. All eyes showed initial favorable response with tumor regression. The median follow-up was 28 months (range, 2-63 months). Failure of chemoreduction and need for treatment with external beam radiotherapy occurred in 25% of eyes at 1 year, 27% at 3 years, and no further increase at 5 years. More specifically, external beam radiotherapy was necessary at 5 years in 10% of RE groups I-IV eyes and 47% of RE group V eyes. Multivariate factors predictive of treatment with external beam radiotherapy included non-Caucasian race, male sex, and RE group V disease. Failure of chemoreduction and the need for treatment with enucleation occurred in 13% eyes at 1 year, 29% at 3 years, and 34% at 5 years. More specifically, enucleation was necessary in 15% of RE groups I-IV eyes at 5 years and in 53% of RE group V at 5 years. Multivariate factors predictive of treatment with enucleation included patient age older than 12 months, single tumor in eye, and tumor proximity to foveola within 2 mm. Overall, of the 158 eyes, 50% required external beam radiotherapy or enucleation and 50% were successfully managed without these treatments. No patient developed retinoblastoma metastasis, pinealoblastoma, or second malignant neoplasms over the 5-year follow up. CONCLUSIONS Chemoreduction offers satisfactory retinoblastoma control for RE groups I-IV eyes, with treatment failure necessitating additional external beam radiotherapy in only 10% of eyes and enucleation in 15% of eyes at 5-year follow-up. Patients with RE group V eyes require external beam radiotherapy in 47% and enucleation in 53% at 5 years.

Decrease in Rate of Myopia Progression with a Contact Lens Designed to Reduce Relative Peripheral Hyperopia: One-Year Results

PURPOSE To determine whether a novel optical treatment using contact lenses to reduce relative peripheral hyperopia can slow the rate of progress of myopia. METHODS Chinese children, aged 7 to 14 years, with baseline myopia from sphere -0.75 to -3.50 D and cylinder ≤1.00 D, were fitted with novel contact lenses (n = 45) and followed up for 12 months, and their progress was compared with that of a group (n = 40) matched for age, sex, refractive error, axial length, and parental myopia wearing normal, single-vision, spherocylindrical spectacles. RESULTS On adjusting for parental myopia, sex, age, baseline spherical equivalent (SphE) values, and compliance, the estimated progression in SphE at 12 months was 34% less, at -0.57 D, with the novel contact lenses (95% confidence interval [CI], -0.45 -0.69 D) than at -0.86 D, with spectacle lenses (95% CI, -0.74 to -0.99 D). For an average baseline age of 11.2 years, baseline SphE of -2.10 D, a baseline axial length of 24.6 mm, and 320 days of compliant lens wear, the estimated increase in axial length (AL) was 33% less at 0.27 mm (95% CI, 0.22-0.32 mm) than at 0.40 mm (95% CI, 0.35-0.45 mm) for the contact lens and spectacle lens groups, respectively. CONCLUSIONS The 12-month data support the hypothesis that reducing peripheral hyperopia can alter central refractive development and reduce the rate of progress of myopia. (chictr.org number, chiCTR-TRC-00000029 or chiCTR-TRC-00000032.).

Is current eye-care-policy focus almost exclusively on cataract adequate to deal with blindness in India?

BACKGROUND Indias National Programme for Control of Blindness focuses almost exclusively on cataract, based on a national survey done in the 1980s which reported that cataract caused 80% of the blindness in India. No current population-based data on the causes of blindness in India are available. We assessed the rate and causes of blindness in an urban population in southern India. METHODS We selected 2954 participants by stratified, random, cluster, systematic sampling from Hyderabad city. Eligible participants were interviewed and given a detailed ocular assessment, including visual acuity, refraction, slitlamp biomicroscopy, applanation intraocular pressure, gonioscopy, dilatation, grading of cataract, stereoscopic fundus assessment, and automated-threshold visual fields. FINDINGS 2522 participants, including 1399 aged 30 years or more, were assessed. 49 participants (all aged > or =30 years) were blind (presenting distance visual acuity <6/60 or central visual field <200 in the better eye). The rate of blindness among those aged 30 years or more, adjusted for age and sex, was 3.08% ([95% CI 1.95-4.21]). Causes included cataract (29.7%), retinal disease (17.1%), corneal disease (15.4%), refractive error (12.5%), glaucoma (12.1%), and optic atrophy (11.0%). 15.7% of the blindness caused by visual-field constriction would have been missed without visual-field examination. Also without visual-field and detailed dilated-fundus assessments, blindness attributed to cataract would have been overestimated by up to 75.8%. If the use of cataract surgery in this urban population was half that found in this study, which simulates the situation in rural India, cataract would have caused 51.8% (39.4-64.2) of blindness, significantly less than the 80% accepted by current policy. INTERPRETATION Much of the blindness in this Indian population was due to non-cataract causes. The previous national survey did not include detailed dilated-fundus assessment and visual-field examination which could have led to overestimation of cataract as a cause of blindness in India. Policy-makers in India should encourage well-designed population-based epidemiological studies from which to develop a comprehensive long-term policy on blindness in addition to dealing with cataract.

Intravitreal dexamethasone in exogenous bacterial endophthalmitis: results of a prospective randomised study

AIM To evaluate the efficacy of intravitreal dexamethasone co-administered with intravitreal antibiotics along with vitrectomy in the management of exogenous bacterial endophthalmitis. METHODS In a prospective randomised clinical trial, 63 patients (63 eyes) with suspected bacterial endophthalmitis (postoperative and post-traumatic) were treated with vitrectomy and intravitreal antibiotics and randomised to intravitreal dexamethasone (IOAB with = 29 eyes) and no dexamethasone (IOAB without = 34 eyes). Inflammation score (IS) and visual acuity were measured by two masked observers before surgery, and at 1, 4, and 12 weeks after surgery in both the groups. RESULTS There was significant reduction (p <0.0001) in IS at 1, 4, and 12 weeks after the surgery in the “IOAB with” group; there was temporary but significant increase (p <0.01) in IS at 1 week in the “IOAB without” group, before decline (p <0.001) of IS at 4 and 12 weeks. The magnitude and relative percentage change in IS between the two groups were found to be significant at 1 (p <0.0001), and 4 (p <0.01) weeks, and not at 12 weeks. The visual acuity at 12 weeks was comparable in both the IOAB with and IOAB without groups. CONCLUSION Intravitreal dexamethasone helps in early reduction of inflammation in exogenous bacterial endophthalmitis, but has no independent influence on the visual outcome. In selected patients with endophthalmitis where oral corticosteroids cannot be given for medical reasons intravitreal corticosteroids could be beneficial; in other situations they could be complementary to oral corticosteroid therapy.

Solution toxicity in soft contact lens daily wear is associated with corneal inflammation

Purpose. Contact lens-associated solution toxicity manifests as generalized, mild punctate epithelial fluorescein staining and usually is widely reported as asymptomatic, with no substantial clinical sequelae. This study examined the relationship between solution toxicity and corneal infiltrative events (CIEs) in soft contact lens daily wear. Methods. Several nonrandomized interventional clinical trials conducted between May and November 2005 were analyzed retrospectively. Subjects wore commercially available soft contact lenses bilaterally, on a daily schedule, disinfected overnight using marketed lens care solutions for 3 months with monthly disposal. Solution toxicity was defined as diffuse punctate staining in at least four of five areas of the cornea after instillation of sodium fluorescein. First events of corneal staining or corneal infiltrates were used to calculate incidence (per 100 eye months). Results. Toxic staining was detected in 77 of 609 subjects and all CIEs were mild and symptomatic or asymptomatic. The incidence of CIEs in eyes with a predisposition to toxic staining was 6.7% and in unaffected eyes was 2.3%. CIEs were 3-times more likely to occur in eyes that exhibited solution toxicity compared to unaffected eyes (odds ratio = 3.08, p = 0.008, 95% CI 1.40 to 6.76). Previous events of limbal redness (≥grade 2.0) were not associated with CIEs (odds ratio = 1.53, p = 0.364, 95% CI 0.63 to 3.70). The rate of CIEs increased as the rate of toxic staining increased for specific lens type-solution combinations (Spearman’s rho = 0.558, p = 0.025, n = 16), and peroxide-based solutions consistently resulted in the lowest rates of toxic staining and corneal inflammation. Conclusions. Eyes that experience solution toxicity are more likely to experience a CIE. Daily wear soft lens wearers should be routinely examined with sodium fluorescein soon after lenses are inserted and alternative solution/lens type combinations should be investigated if toxic staining is detected.

Population-based assessment of the outcome of cataract surgery in an urban population in southern India

PURPOSE To assess the outcome of cataract surgery in an urban population in southern India. METHODS As part of a population-based cross-sectional epidemiologic study, the Andhra Pradesh Eye Disease Study, 2,522 people of all ages, including 1,399 individuals 30 years of age or older, from 24 clusters representative of the population of Hyderabad in southern India underwent a detailed interview and ocular evaluation including logarithm of minimal angle of resolution (logMAR) visual acuity, refraction, slit-lamp biomicroscopy, applanation tonometry, gonioscopy, dilation, cataract grading, aphakia/pseudophakia status, and stereoscopic fundus evaluation. Automated threshold visual fields and slit-lamp and fundus photography were performed when indicated by standardized criteria. Very poor outcome in an eye that had undergone cataract surgery was defined as presenting distance visual acuity worse than 20/200, and poor outcome was defined as visual acuity worse than 20/60 to 20/200. RESULTS In subjects 50 years of age or older, after adjustment for age and sex distribution, the rate of having had cataract surgery in one or both eyes was 14.6% (95% confidence interval [CI], 11.4% to 17.8%). Of 131 eyes (91 subjects) that had undergone cataract surgery, 28 (21.4%; 95% CI, 14.4% to 28.4%) had very poor outcome and another 40 (30.5%; 95% CI, 22.6% to 38.4%) had poor outcome. The very poor outcome in 20 (71.4%) of 28 eyes and poor outcome in 23 (57.5%) of 40 eyes could be attributed to surgery-related causes or inadequate refractive correction. With multivariate analysis, very poor outcome as a result of surgery-related causes or inadequate refractive correction was more likely to be associated with intracapsular cataract extraction than with extracapsular cataract extraction (odds ratio, 9.34; 95% CI, 2.49 to 35.06) in subjects belonging to the lowest socioeconomic status (odds ratio, 4.92; 95% CI, 1.16 to 20.93) and with date of surgery 3 or fewer years before the survey than with more than 3 years (odds ratio, 4.52; 95% CI, 1.33 to 15.39). Also, very poor or poor outcome as a result of surgery-related causes or inadequate refractive correction was associated with women (odds ratio, 2.55; 95% CI, 1.06 to 6.16). CONCLUSIONS The very high rate of very poor and poor visual outcome, predominantly as a result of surgery-related causes and inadequate refractive correction, in this urban population of India suggests that more attention is needed to improve the visual outcome of cataract surgery. In order to deal with cataract-related visual impairment in India, as much emphasis on surgical quality, refractive correction, and follow-up care is necessary as on the number of surgeries.

Survival analysis and visual outcome in a large series of corneal transplants in India

AIM/BACKGROUND The public health significance of corneal transplantation in dealing with corneal blindness in the developing world would depend upon the survival rate of transplants. This study was done to analyse the survival rate of corneal transplants in a large series in India, and to evaluate the influence of various risk factors on transplant survival. METHODS The records of a series of 1725 cases of corneal transplants carried out during 1987–95 at a tertiary eye care institution in India were reviewed. The Kaplan–Meier method was used to determine 5 year survival rates of corneal transplants performed for the various categories of preoperative diagnosis. Multivariate Cox proportional hazards regression was used to assess how preoperative diagnosis, socioeconomic status, age, sex, vascularisation of host cornea, quality of donor cornea, and training status of surgeon influenced transplant survival. The effect of these variables on visual outcome was assessed using multiple logistic regression. RESULTS The survival rates at 1, 2, and 5 years for all corneal transplants performed for the first time in 1389 cases were 79.6% (95% confidence interval = 77.3–81.9%), 68.7% (65.7–71.7%) and 46.5% (41.7–51.3%). The 5 year survival rate was highest if the corneal transplant was done for keratoconus (95.1% (84.8–100%)) and lowest if carried out for previous transplant failure (21.2% (13.8–28.6%)). The relative risk of transplant failure was higher if the preoperative diagnosis was previous transplant failure (2.04 (1.62–2.55)), aphakic bullous keratopathy (1.78 (1.38–2.28)), corneal clouding due to miscellaneous causes including congenital conditions and glaucoma (1.63 (1.21–2.19)), or adherent leucoma (1.11 (0.81–1.51)) than for the other preoperative diagnoses. Patients with lower socioeconomic status had higher relative risk of transplant failure (1.28 (1.16–1.42)), as did patients <10 years of age (1.42 (1.23–1.64)). Higher relative risk of transplant failure was associated with vascularisation of the host cornea before transplantation (1.15 (1.04–1.27)), and with the use of fair quality donor cornea for transplantation compared with excellent, very good, or good quality donor cornea (1.26 (1.06–1.52)). Before corneal transplant 80.2% of the eyes were blind (visual acuity <3/60), whereas at last follow up 41.8% eyes were blind. The odds of having visual acuity >6/18 were higher if the transplant was done for keratoconus (9.99 (6.10–16.36)) or corneal dystrophies (1.77 (1.21–2.58)) than for the other preoperative diagnoses. CONCLUSION Reasonable success with corneal transplantation is possible in the developing world if data from this part of the world regarding the different survival rates for the various preoperative diagnoses and the influence of risk factors on transplant survival and visual outcome are taken into account while determining priority for transplant cases in the present situation of limited availability of donor corneas.

Population based assessment of diabetic retinopathy in an urban population in southern India

AIM To assess the prevalence of diabetic retinopathy and the visual impairment caused by it in an urban population in southern India in order to determine its public health significance. METHODS 2522 subjects (85.4% of those eligible), a representative sample of the population of Hyderabad city in southern India, underwent interview and detailed dilated eye examination during 1996–7 as part of the Andhra Pradesh Eye Disease Study. RESULTS 124 subjects, all ⩾30 years old, reported that they had diabetes, an age-sex adjusted prevalence of 7.82% (95% confidence interval (CI) 5.76–9.88%) in this age group. Diabetes was diagnosed at age ⩾30 years in all but two subjects. The duration since diagnosis of diabetes was <10 years in 75.6% and ⩾15 years in 6.7%. Diabetic retinopathy was present in 28 subjects, 1.78% (95% CI 1.09–2.48%) of those ⩾30 years old. Most of the diabetic retinopathy was of the mild (50%) or moderate (39.3%) non-proliferative type; one subject (3.6%) had proliferative retinopathy. Multiple logistic regression revealed that the odds of having diabetic retinopathy were significantly higher in those ⩾50 years than in those 30–49 years old (odds ratio 7.78, 95% CI 2.92–20.73). Three subjects had visual impairment between 6/12 and 6/38 in either eye due to diabetic retinopathy, 0.19% (95% CI 0–0.41%) of those ⩾30 years old. CONCLUSION Visual impairment due to diabetic retinopathy was relatively uncommon in this urban Indian population in 1996–7. However, this could change in the near future with an increase in duration of diabetes because of the anticipated aging of India’s population and the recent suggestion of increase in diabetes prevalence in urban India, and therefore should be monitored.

Correction of refractive error and presbyopia in Timor-Leste

Aim: To investigate the aspects of spectacle correction of vision-impairing refractive error and presbyopia in those aged ⩾40 years in Timor-Leste. Method: A population-based cross-sectional survey with cluster random sampling was used to select 50 clusters of 30 people. Those who had uncorrected or undercorrected refractive error (presenting acuity worse than 6/18, but at least 6/18 with pinhole), uncorrected or undercorrected presbyopia (near vision worse than N8), and/or who were using or had used spectacles were identified. Dispensing history, willingness to wear and willingness to pay for spectacles were elicited. Results: Of 1470 people enumerated, 1414 were examined (96.2%). The “met refractive error need” in the sample was 2.2%, and the “unmet refractive error need” was 11.7%. The “refractive error correction coverage” was 15.7%. The “met presbyopic need” was 11.5%, and the “unmet presbyopic need” was 32.3%. The “presbyopia correction coverage” was 26.2%. Lower correction coverage was associated with rural domicile, illiteracy and farming. Of the sample, 96.0% were willing to wear spectacles correcting impaired vision. Of these, 17.0% were willing to pay US

Evaluation of agent and host factors in progression of mycotic keratitis ☆: A histologic and microbiologic study of 167 corneal buttons

3 (£1.52, €2.24) for spectacles, whereas 50.2% were unwilling to pay US