Varun Gogia

Compliance in Retinoblastoma

ObjectiveTo evaluate disease is advanced, compliance in retinoblastoma.MethodsThis is a retrospective descriptive study of patients of retinoblastoma registered at our cancer center from June 2003–February 2007 to study compliance.ResultsSociodemographic data of 177 patients revealed rural:urban ratio of 2:1, median age 36 months (unilateral disease) and 24 months (bilateral disease); median symptom duration 7.2 months. Overall, 84/141 evalued cases took adequate therapy; follow-up could be achieved in 67/141 (47.5%) cases in comparison to 92.4% in Hodgkin’s lymphoma (p=0.001), 62.8% in acute myeloid leukemia (p=0.036) and 72.7% in non Hodgkin’s lymphoma (p=0.001). There was no significant impact of any sociodemographic factors on compliance. Amongst those offered enucleation upfront for intraocular disease, it was accepted in 86/93 (92.5%) eyes.ConclusionThis is one of the largest studies in relation to sociodemographic factors and clinical spectrum, and the only study from Asia evaluating compliance with recommended therapy in retinoblastoma. In order to improve ocular and patient salvage rates in Asian countries, exact causes for poor compliance in retinoblastoma need to be closely examined through a prospective study.

Epidemiology and intermediate-term outcomes of open- and closed-globe injuries in traumatic childhood cataract

Purpose To study epidemiology and intermediate-term outcomes of open- and closed-globe injuries (CGI) in traumatic childhood cataract. Methods In this retrospective interventional case series, demographic parameters and history including type of injury of 57 children younger than 16 years with traumatic cataract were recorded; ocular examination included best-corrected visual acuity (BCVA), slit-lamp biomicroscopy, and posterior segment evaluation. Patients underwent cataract surgery with or without intraocular lens (IOL) implantation. Main surgical outcomes at 6 months comprised BCVA, residual refractive spherical error (SE), and postoperative complications, namely visual axis opacification (VAO) and amblyopia. Results Bow and arrow was the most common causal agent. Open-globe injury (OGI) was 3 times more frequent than CGI. There was a significant visual gain from baseline in both groups after cataract surgery (p<0.001); residual SE was greater in OGI (1.6 ± 0.95 SD) compared to blunt trauma (0.8 ± 0.55 SD; p = 0.001). Incidence of corneal scarring, iris distortion, posterior synechiae, and intraoperative posterior capsular tear was greater with OGI (p<0.05). A total of 86% of patients were rehabilitated with a primary/secondary IOL. Single-piece IOL implantation rate (p = 0.004) was significantly greater in CGI, with no statistical difference for in-the-bag IOL (p = 0.053) and IOL implantation rate (p = 0.16). Final BCVA was significantly better for in-the-bag IOL implantation compared to sulcus fixation. Postoperative complications included amblyopia (51%) and VAO (12%). Conclusions Bow and arrow injury caused the maximum cases of traumatic cataract; cataract extraction resulted in significant visual improvement; and CGI tended to have better prognosis in pediatric traumatic cataracts.

Comparative evaluation of 23- and 25-gauge microincision vitrectomy surgery in management of diabetic macular traction retinal detachment.

Purpose To compare the efficacy, outcomes, and complications of 23-G and 25-G microincision vitrectomy surgery (MIVS) in cases of diabetic tractional retinal detachment (TRD). Methods This is a prospective, single-blinded, randomized, comparative study. Fifty eyes of 50 patients with diabetic TRD involving or threatening macula were randomized into 2 groups of 25 each. Group 1 underwent 23-G MIVS and group 2 underwent 25-G MIVS. Patients were followed up at 1 day, 1 week, 1 month, 3 months, 6 months, and 1 year after surgery. The primary outcome measure was anatomic and visual success after surgery. We also compared the 2 alternative MIVS systems and assessed various intraoperative and postoperative parameters. Results Anatomic achievement was achieved in all eyes and both groups showed a significant improvement in vision after surgery (p = 0.033 and p = 0.004, respectively) and were comparable (p = 0.584). Mean surgical time in 25-G surgery was significantly longer than in 23-G surgery by 4.60 minutes (p<0.001). Postoperative mean astigmatism was comparable in the 2 groups and postoperative hypotony was not encountered in either group. No port-related breaks were seen in either group; however, iatrogenic breaks occurred in 4 eyes in the 23-G group and 5 eyes in the 25-G group (p = 1.000). There was significantly less immediate postoperative pain and foreign body sensation in the 25-G group compared with the 23-G group. Conclusions Both 23-G and 25-G MIVS have comparable visual and anatomic results for diabetic TRD; however, 25-G surgery may be associated with less postoperative pain and discomfort than 23-G surgery.

Clinical presentation and surgical outcomes in primary myopic macular hole retinal detachment.

Purpose To describe the clinical presentation of primary macular hole retinal detachment (MHRD) secondary to high myopia and to evaluate the surgical outcomes. Methods Nine eyes of 9 patients with primary myopic MHRD (axial length ≥26.5 mm) were enrolled. A standardized surgical protocol was performed using vitrectomy with preservative-free triamcinolone acetonide–assisted internal limiting membrane (ILM) peeling and silicone oil tamponade and were followed for at least 6 months from the first surgery. Results There were 6 women and 3 men with a median age of 52 years. Six (66.6%) patients presented with inferior bullous configuration and 3 had subtotal retinal detachment. The mean preoperative refractive error (spherical equivalent) and mean axial length was 12±3.553 D (range 8.50-19.50) and 28.13±1.65 mm (range 26.50-31.50), respectively. The patients were followed up for a period of at least 6 months. The retina was attached and macular hole closed in all the eyes. There was significant visual acuity improvement from mean preoperative visual acuity of logMAR 1.85±0.11 (range 1.76-1.93) to postoperative visual acuity of logMAR 0.95±0.14 (range 0.84-1.06) (p<0.001). Conclusions Retinal detachment in highly myopic eyes can often be secondary to a macular hole with predominance of inferior bullous configuration and primary vitrectomy with ILM peeling with silicone oil tamponade results in good anatomic and functional outcomes.

Role of voriconazole in combined acanthamoeba and fungal corneal ulcer

We report a case of a 21 year old male who presented with smear-proven fungal corneal ulcer in left eye, refractory to treatment with topical natamycin. Corneal smears and culture were taken along with anterior chamber tap for microbiological investigations and intracameral 1% voriconazole was injected followed by institution of oral as well as topical voriconazole drops. Corneal and aqueous smear as well as culture confirmed the presence of acanthamoeba. The keratitis responded favourably to voriconazole therapy which was instituted along with topical trophicidal drugs and anterior chamber became quiet by 7th day. The patient was slowly tapered from voriconazole and was off the drug by 6 months. At one year follow up, he continues to remain asymptomatic. The possibility exists that the fungal organisms had either partially or completely responded to natamycin eye drops and voriconazole therapy further inhibited their growth along with being highly efficacious in suppressing acanthamoeba trophozoites. Voriconazole may be specifically instrumental in corneal ulcers with coinfection of acanthamoeba and fungal organisms and preventing recrudescence of both. Normal saline wet mount and 10% KOH mount of paracentesis sample for suspicious cases of refractory corneal ulcers to specifically look for trophozoites in order to institute timely treatment are recommended.

Recent Advances in Management of Diabetic Macular Edema

Diabetic macular edema (DME) is the leading cause of moderate vision loss in diabetics. Modalities to image and monitor DME have evolved much in the last decade. Systemic control is the most important part of management. Available ocular management options include intravitreal antivascular endothelial growth factor (anti-VEGF) agents, laser, steroids (intravitreal or peribulbar), vitrectomy, topical medications and others. Anti-VEGF agents are increasingly being used in clinical practice with good clinical response and are currently the preferred mode of treatment worldwide.

Serial ultra wide field imaging for following up acute retinal necrosis cases

We describe two cases of acute retinal necrosis (ARN) in a post renal transplant diabetic patient and a pregnant female in the first trimester. Serial ultra wide field imaging (UWFI) with comprehensive ocular examination was done to monitor the progression of the disease. All the cases responded favorably with intravenous followed by oral acyclovir, which was captured with UWFI. UWFI provides objective proof of response to therapy in ARN. UWFI may also improve patient education and counseling for this peripheral retinal disorder.

Endoilluminator-assisted scleral buckling: Our results

Aims: The aim was to evaluate the long-term surgical outcomes of endoillumination assisted scleral buckling (EASB) in primary rhegmatogenous retinal detachment (RRD). Methods: Twenty-five eyes of 25 patients with primary RRD and proliferative vitreoretinopathy ≤C2 where any preoperative break could not be localised, were included. All patients underwent 25 gauge endoilluminator assisted rhegma localisation. Successful break determination was followed by cryopexy and standard scleral buckling under surgical microscope. Anatomical and functional outcomes were evaluated at the end of 2 years. Results: At least one intraoperative break could be localized in 23 of 25 (92%) eyes. Median age of these patients was 46 years (range: 17-72). Thirteen eyes (56.52%) were phakic, 8 (34.78%) were pseudophakic and 2 (8.6%) were aphakic. Anatomical success (attachment of retina) was achieved in 22 (95.63%) of 23 eyes with EASB. All eyes remained attached at the end of 2 years. Significant improvement in mean visual acuity (VA) was achieved at the end of follow-up (1.09 ± 0.46 log of the minimum angle of resolution [logMAR]) compared with preoperative VA (1.77 ± 0.28 logMAR) (P < 0.001). Conclusion: EASB can be considered an effective alternative to vitreoretinal surgery in simple retinal detachment cases with the added advantage of enhanced microscopic magnification and wide field illumination.

A preliminary descriptive analysis of Corneal Transplant Registry of National Eye Bank in India.

PURPOSE To describe and analyze the Corneal Transplant Registry of National Eye Bank and also evaluate graft outcomes in India. METHODS All patients who underwent corneal transplant at our center within six months of setting up of Corneal Transplant Registry and installation of database at National Eye Bank were included in the study. The established database was analyzed for utilization, donor and recipient details and graft outcomes. Outcome was assessed at the end of one year follow up. The influence of various donor and recipient factors affecting outcome were evaluated. Visual outcome was analyzed in terms of shift in visual handicap category. Statistical tests like analysis of variance, Kruskal-Wallis test and Chi square tests were applied for determination of clinical significance wherever required. RESULTS 326 corneas were received from 168 donors; of these, 234 (71.7%) were utilized for transplantation. Out of 177 patients with adequate (one year) follow up (75.6% patients), optical corneal replacement was performed in106 patients and therapeutic keratoplasty in71. 78% (82/106) patients in the optical group retained clear grafts at the end of follow up. 59.7% (49 of 82) of patients who attained clear grafts belonged to visual disability category 3 or worse pre-operatively. 59.1% of these achieved BCVA of ≥6/60 at the end of follow up; thus shifting up their visual handicap category. Primary graft failure was found to be associated with full thickness keratoplasty and not with lamellar procedures (p<0.05) and occurred in 4.2% patients (5) with optical corneal replacement whereas 7.5% patients (8) developed secondary graft failure. Age of donor (p=0.54), death enucleation time (p>0.05), cause of donor death (p=0.15), type of surgical procedures (p=0.538) and indication for surgery did not have any significant effect on outcome. 76% patients who underwent therapeutic graft achieved elimination of corneal infection. CONCLUSIONS The development of corneal graft registry established an effective means to evaluate our corneal transplantation services. Outcomes of sight restoring corneal transplants performed were comparable to results of graft registries from developed nations.

Prevailing clinical practices regarding screening for retinopathy of prematurity among pediatricians in India: A pilot survey

Aims: To evaluate the prevailing practices for proper screening and referral scheme among Indian pediatricians for retinopathy of prematurity (ROP). Materials and Methods: Pediatricians registered with Indian Academy of Pediatrics from six states of India were selected randomly and were telephonically interviewed in accordance with a preformed questionnaire which comprised of questions regarding demographic factors, number of premature children seen per month, awareness and referral scheme to ophthalmologist; responses thus obtained were analyzed. Results: Hundred percent knowledge about ROP and need for screening in premature babies was observed among the respondents. However, only 135 (58%) pediatricians always referred for ROP screening, 19 (8%) referred only sometimes and 80 (34%) did not refer at all. Consistent referral protocols taking into account all plausible risk factors for ROP were followed by only 25% of those who always referred. Major deterrent in ROP screening was perceived as non-availability of trained ophthalmologists. Conclusions: Only 14.5% of total pediatricians contacted were following international recommendations for ROP referral. Screening for ROP remains dismal as observed in this pilot survey as a consequence of non-availability of trained ophthalmologists as well as inconsistent screening guidelines.