Upreet Dhaliwal

Retinopathy of Prematurity- Risk Factors

Objective: Improved survival of low birth weight, premature babies have increased the incidence of retinopathy of prematurity. This hospital-based, prospective, study was undertaken to determine its incidence and risk factors in our neonatal unit.Methods: Neonates with gestational age ≤ 35 weeks and/or birth weight ≤ 1500 gm born over a one-year period were examined by indirect ophthalmoscopy between 2 to 4 weeks after birth, and followed up till retinal vascularisation was complete. Maternal and neonatal risk factors were noted and data analyzed by statistical package SPSS-10.0.Results: Sixty babies were thus examined. The incidence of retinopathy was 21.7% in the cohort, 33.3% in babies ≤32 weeks gestation and 36.4% in babies weighing ≤1250 gm. Oxygen (p=0.01), sepsis (p=0.04) and apnoea (p=0.02) were independent risk factors. Retinopathy was significantly more severe in babies with hyaline membrane disease (p=0.02) and lower birth weight (p=0.02). Severe disease was never seen before 6.5 weeks of age.Conclusion: Indirect ophthalmoscopy should be performed at 4 weeks of post natal age in all preterm babies with birth weight ≤ 1500 gm, and intensified in the presence of risk factors like oxygen administration, apnoea and septicemia.

Masters theses from a university medical college: Publication in indexed scientific journals

Background: The thesis is an integral part of postgraduate medical education in India. Publication of the results of the thesis in an indexed journal is desirable; it validates the research and makes results available to researchers worldwide. Aims: To determine publication rates in indexed journals, of works derived from theses, and factors affecting publication. Settings and Design: Postgraduate theses submitted over a five-year period (2001-05) in a university medical college were analyzed in a retrospective, observational study. Materials and Methods: Data retrieved included name and gender of postgraduate student, names, department and hierarchy of supervisor and co-supervisor(s), year submitted, study design, sample size, and statistically significant difference between groups. To determine subsequent publication in an indexed journal, Medline search was performed up to December 2007. Statistical Analysis: Chi square test was used to compare publication rates based on categorical variables; Students t-test was used to compare differences based on continuous variables. Results: One hundred and sixty theses were retrieved, forty-eight (30%) were published. Papers were published 8-74 (33.7 ± 17.33) months after thesis submission; the postgraduate student was first author in papers from 26 (54%) of the published theses. Gender of the student, department of origin, year of thesis submission, hierarchy of the supervisor, number and department of co-supervisors, and thesis characteristics did not influence publication rates. Conclusions: Rate of publication in indexed journals, of papers derived from postgraduate theses is 30%. In this study we were unable to identify factors that promote publication.

Barriers to the uptake of cataract surgery in patients presenting to a hospital

PURPOSE To assess the barriers for the acceptance of surgery among patients with cataract and visual disability. MATERIALS AND METHODS A short-term descriptive study was conducted in patients with cataract presenting to a hospital. Socio-demographic data were entered in a proforma. An interviewer-assisted questionnaire, surveying knowledge about cataract and barriers to cataract surgery, was administered by one of the authors (SKG) in the local language (Hindi). RESULTS There were 100 patients (53 men and 47 women); 14 were bilaterally blind (vision < 10/200 in the better eye). Attitudinal barriers included: could manage daily work (71%), cataract not mature (68%), could see clearly with the other eye (64%), too busy (57%), female gender (37%), fear of surgery (34%), fear of surgery causing blindness (33%) or death (13%), old age (33%), it is Gods will (29%) and worry about cost of surgery (27%). The barriers relating to service delivery, cost and affordability included: insufficient family income (76%), not knowing another person who had undergone cataract surgery (26%), no one to accompany (20%), distance from hospital (20%) or from a main road (9%) and lack of transport (7%). CONCLUSIONS Attitudinal barriers were reported more often, rather than issues of accessibility or cost. Eye care providers should address the identified barriers for increasing acceptance of surgery in the study area.

Phlyctenular Eye Disease : A Reappraisal

PURPOSE Phlyctenular keratoconjunctivitis is a nonspecific allergic response in the cornea and/or conjunctiva to a variety of distinct conditions. Tuberculosis as an etiological association is being supplanted by staphylococcal infection and worm infestation in developed countries. Our aim was to determine the relative frequency of the various known etiological factors of phlyctenular keratoconjunctivitis, and the clinical profile of the disease as it exists today in India, a country where tuberculosis is still highly prevalent. CASES This is a prospective study of 112 consecutive patients with phlyctenular eye disease seen over a 2-year period. OBSERVATIONS In 86 patients (76.7%), phlyctenular eye disease was associated with tuberculosis. Worm infestation was found in 14 patients (12.4%), whereas 7 (6.2%) had staphylococcal blepharitis. Thirteen patients had evidence of multiple etiology, of which one causative factor was always tuberculosis. When tuberculosis was the only association, 37% patients had severe lesions, whereas only 11. 5% patients without tuberculosis had such lesions. When tuberculosis along with another etiological factor was present, the incidence of severe lesions increased to 84.6%. Recurrence on follow-up was seen in three patients who were already on multidrug therapy for tuberculosis, and two who had tubercular allergy. CONCLUSIONS Our study shows that tuberculosis is still a major cause of phlyctenular eye disease in India. Severe lesions are more common in patients with tuberculosis, especially when another etiological factor is associated. Recurrences are more common in patients with tuberculosis. Corneal lesions are less extensive than described in the literature and are no longer a significant cause of blindness.

Health-Related Quality of Life in Patients with Trachomatous Trichiasis or Entropion

Purpose: To determine the health-related quality of life in patients with trachomatous trichiasis or entropion, before and after intervention. Methods: A prospective, case-control, interventional study. Health-related quality of life was evaluated in 60 patients with trachomatous trichiasis or entropion, before and after intervention, and 60 age- and gender-matched controls without trichiasis or entropion, using the WHOQOL-Bref questionnaire. Thirty patients and controls had vision < 6/18, while 30 had vision ≥ 6/18 in the better eye. The WHOQOL-Bref assesses four domains of quality of life: physical health (1), psychological health (2), social relationships (3), and environment (4). Domain scores of patients and controls and of patients before and after intervention were compared using Students t-test. Patient characteristics were correlated with domain scores using Pearsons correlation. Results: Quality of life was poorer than that of controls in domains 1 and 2 for patients with vision < 6/18 in the better eye (p < 0.001, p = 0.001, respectively), and in domains 1, 2 and 4 for patients with vision ≥ 6/18 (p < 0.001, p < 0.001, p = 0.01, respectively). Scores improved after intervention in all domains except domain 3, even though vision did not improve. Conclusions: Patients with trachomatous trichiasis or entropion suffer in the physical, psychological and environmental domains of health-related quality of life even when vision is normal. Timely intervention is essential not only to prevent corneal blindness but also to reduce the suffering caused by the non-visual symptoms. Future studies must identify barriers to therapeutic intervention, and attempts should be directed at overcoming them so as to reduce the non-blinding burden of trachoma.

Comparison of three surgical procedures of differing complexity in the correction of trachomatous upper lid entropion: a prospective study.

objective To compare the efficacy of three common surgical procedures of increasing complexity in the correction of trachomatous entropion. materials and methods In a prospective study, lids with moderate or severe (without lid gap) trachomatous entropion were randomly allocated to undergo either terminal tarsal rotation (I, n = 30), tarsal rotation with tarso-conjunctival advancement (II, n = 30), or anterior lamellar repositioning with lid margin split and wedge resection of tarsus (III, n = 30). The procedures were compared for improvement of symptoms, duration of surgery, cosmesis, rate and type of complications, anatomical correction, failure and recurrence. One-way and repeated-measure ANOVA, Chi-square and Fishers exact tests were used. results The study included 90 eyes of 77 patients (age range: 30-85 years). Symptomatic improvement was comparable after each procedure (p > 0.05). Procedure I, the simplest in technique, took significantly less time (p < 0.001). The three procedures were comparable in achieving cosmesis (p = 1.0), anatomical correction (p = 0.35), and rate of complications (p = 0.43). Failure of surgery was seen in two lids (procedure II), and recurrence in one lid (procedure III). conclusion In developing countries, where manpower and other resources are limited and patient-load high, ophthalmic surgeons should choose a procedure that is simple, quick and effective. This study suggests that terminal tarsal rotation after transverse tarsotomy should be the procedure of choice in the correction of moderate or severe (without lid gap) trachomatous entropion.

Medical students’ perception of the educational environment in a medical college in India: a cross-sectional study using the Dundee Ready Education Environment questionnaire

Purpose: The objective of this study was to assess student perceptions of the environment in this medical college using the Dundee Ready Educational Environment Measure (DREEM). Methods: Cross-sectional study; 348 medical student volunteers (68.1%) of all semesters participated (511 enrolled). DREEM has 50 items, each rated from 0–4 (Likert scale: 0, strongly disagree to 4, strongly agree), that measure five domains: students’ perceptions of learning; perceptions of teachers; academic self-perception; perceptions of the atmosphere; and social self-perception. Mean item scores, domain scores, and global scores were computed. Results: The three highest rated items were knowledgeable teachers, having good friends, and confidence about passing; the three most problematic items were a poor support system for stressed students, inability to memorize everything, and over-emphasis on factual learning. The percentage score for perception of learning (47.26± 14.85) was significantly lower than that for teachers (52.28± 9.91; P< 0.001); academic self-perception (52.14 ± 15.21; P < 0.001); perception of the atmosphere (51.21 ± 13.60; P = 0.001); and social self-perception (50.63± 13.90; P= 0.010). The global scores were lowest for eighth-semester students (89.8± 21.24) when compared to second (101.33± 21.05; P= 0.003), fourth (107.69± 18.96; P< 0.001), and sixth (100.07± 20.61; P= 0.020). Conclusion: Improvement is required across all domains of the educational environment at this institution. Students, particularly of the eighth semester, perceived the teaching negatively. The lowest scores were given to the support system, burdensome course content, and factual learning; thus, a hybrid curriculum that includes problem-based learning might provide students with stimulating learning; structured clinical teaching with specific curricular objectives, as well as mentoring of senior students by faculty and near-peers, might improve the learning environment for senior students.

Paradoxical reaction in tubercular meningitis resulting in involvement of optic radiation

A 25-year-old woman was diagnosed to have tubercular meningitis (TBM) with a right parietal infarct. She responded well to four-drug anti-tubercular treatment (ATT), systemic steroids and pyridoxine. Steroids were tapered off in one and a half months; she was put on two-drug ATT after two months. Six months after initial diagnosis she presented with sudden, bilateral visual loss. Vision was 3/200 with afferent pupillary defect and un-recordable field in the right eye; vision was 20/60 in the left eye, pupillary reaction was sluggish and the field showed a temporal hemianopia. On reintroduction of systemic corticosteroids vision improved (20/120 in right eye and 20/30 in left eye) within three days; the field defects improved sequentially to a left homonymous hemianopia, then a left homonymous inferior quadrantonopia. A diagnosis of TBM, on treatment, with bilateral optic neuritis, and right optic radiation involvement was made. Since the patient had been off ethambutol for four months, the optic neuritis and optic radiation lesion were attributed to a paradoxical reaction to tubercular allergen, corroborated by prompt recovery in response to corticosteroids. This is the first report of optic radiation involvement in a paradoxical reaction in neuro-tuberculosis in a young adult.

A Rationale for Therapeutic Decision-Making in Chalazia

Background: Cytologically, a chalazion may be either a mixed-cell or a suppurating granuloma. Treatment includes incision & curettage or intralesional steroid injection. The choice of treatment is based on clinical experience. Objective: To determine whether the cytological type of chalazion has any bearing on its response to treatment. Materials and methods: Prospective study of 62 clinically suspected cases of chalazia subjected to fine-needle aspiration cytology followed by either incision & curettage or intralesional steroid injection. The outcome measure was the size of the residual lesion at one week and one month post-intervention. The relationship between cytology and age, duration, size of lesion, type of treatment and response was analyzed by means of Students t-test, the chi-square test and discriminant analysis. Results: Thirty-five (56.5%) patients underwent incision & curettage while 27 (43.5%) received intralesional steroid injections. Cytology revealed mixed-cell granuloma in 41 (66.1%) and suppurating granuloma in 21 (33.9%) of the lesions. Patients aged ≥ 35.1 years, lesions with duration ≥ 8.5 months, and lesion sizes ≥ 11.4 mm (correctly classified in 66.1%, 66.7% and 71.0% of the cases, respectively) were likely to have/be suppurating granulomas. Mixed-cell granulomas responded equally well to the two therapeutic modalities, while suppurating granulomas responded significantly better to incision & curettage (p = 0.008). Conclusion: Mixed-cell granulomas may be treated by either of the two therapeutic modalities. However, suppurating granulomas should be treated by incision & curettage. Incision & curettage should also be the procedure of choice in patients ≥ 35.1 years of age, lesions with duration ≥ 8.5 months, and lesions ≥ 11.4 mm in size.

Clinical and cytopathologic correlation in chronic inflammations of the orbit and ocular adnexa: A review of 55 cases

Fine-needle aspiration cytology has been used for the diagnosis of neoplastic lesions of the orbit and ocular adnexa with some success. However, inflammatory conditions have not received much attention. This is a retrospective study of fine-needle aspirations of chronic inflammations of the orbit and ocular adnexa over a 15-year period from January 1988 through December 2002. Clinical records and stained smears were reviewed. There were 55 chronic inflammations, presenting as masses, cysts, abscesses, discharging sinuses and dermal plaques and nodules. Forty-two were granulomatous inflammations comprising chalazion (18), tuberculosis (5), Cysticercus cellulosae (3), ruptured epidermal cysts (2), actinomycosis (1) and leprosy (13). Thirteen patients had chronic non-specific inflammations. Fine-needle aspiration cytology is a useful diagnostic procedure in chronic inflammations of the ocular adnexa. Specific diagnosis is possible in many granulomatous inflammations, allowing appropriate, individualized therapy to be initiated.