Systemic biomarkers of retinopathy of prematurity in preterm babies.

PURPOSE: Retinopathy of prematurity (ROP) progression is an inter-play of various perinatal and neonatal angiogenic and inflammatory cytokines. A small subset of ROP progresses to ROP requiring treatment. The present study was conducted with the aim to determine whether levels of IL-6, IL-8 and VEGF in serum and urine at the time of first ROP screening visit could be a biomarker for the prediction of development of treatable ROP. METHOD: Prospective single-center observational study of preterm babies screened for ROP. Blood and urine samples were collected as a part of routine sampling at initial ROP screening visit and stored at -80 °C for further processing. The babies were followed up and grouped into 'Group A' comprising of 35 babies who developed treatable ROP and 'Group B' comprising of 36 babies with regressed ROP or no ROP. The evaluation of blood and urine samples was done for IL6, IL8 and VEGF by solid-phase sandwich RayBio® Human ELISA kit. RESULTS: The median serum values for IL-6, IL-8 and VEGF in Group A and Group B were 5.8 pg/ml (IQR 1.5,128.5) and 8.7 pg/ml (IQR 1.5,30.5), 55.9 pg/ml (IQR 28.0, 392.9) and 27.0 pg/ml (IQR 20.5,444.9) and 26.6 pg/ml (IQR 6.3, 39.4) and 30.0 pg/ml (IQR9.2,70.3), respectively. Group A had significantly increased levels of IL-8 (p < 0.05). However, AUROC curve for serum IL-8 demonstrated suboptimal discriminating ability. CONCLUSION: Babies developing ROP requiring treatment had significantly increased levels of IL-8 in the serum at the time of initial screening. However, it could not serve as predictor for treatable ROP.

Toll-like receptors in acute post-cataract surgery endophthalmitis.

OBJECTIVE: To evaluate the expression of toll-like receptor 2 (TLR2) and toll-like receptor 4 (TLR4) on CD14 + cells in vitreous and blood of post-cataract surgery acute endophthalmitis. DESIGN: This prospective case-control pilot study enrolled 16 patients of post-cataract surgery endophthalmitis. All the cases were subjected to 23 G pars plana vitrectomy (PPV). Ten patients undergoing 23 G PPV for non-infectious conditions were taken as controls. METHODS: 23 G PPV was performed, and three undiluted vitreous samples were collected in heparinized syringes from the cases and the controls. Simultaneous venous blood sample was taken, and flow cytometry was performed to detect the expression of TLR2 and TLR4 in vitreous and blood samples. The vitreous and blood samples were incubated with fluorescein isothicyanate (FITC) conjugated anti-TLR2 monoclonal antibody Alexafluor (AX) 647 and anti-TLR4 monoclonal antibody phycoerythrin. Data acquisition was done on a pre-calibrated flow cytometer. TLR analysis of the acquired flow cytometry data was then performed. Mean channel fluorescence intensity (MFI) derived from fluorescence histogram was used to study the level of cell surface TLR expression. MFI was calculated as a ratio and recorded as the MFI of the TLR2 or -4 antibody divided by the MFI of the isotype-matched negative control antibody. Core vitrectomy was done as per the comfort of the surgeon, and intravitreal antibiotics vancomycin (1 mg/0.1 ml) and ceftazidime (2.25 mg/0.1 ml) were injected. The cytological examination was done on vitreous and blood sample. STATISTICAL ANALYSIS: The median TLR 2 and TLR4 values between cases and controls were compared by Mann-Whitney U test. Spearman's rank correlation test was used to assess the correlation between TLR expression and disease activity. RESULTS: Vitreous cytology evaluation showed the presence of neutrophils (81.25%, n = 13), monocytes (68.75%, n = 11) and lymphocytes (62.50%, n = 10). The level of expression of TLR2 in vitreous showed a statistically significant correlation with an increase in the time interval of cataract surgery and intervention for endophthalmitis (p < 0.05), but the same was not observed for TLR4. A drift toward higher level of expression of TLR2 and TLR4 in vitreous was observed in patients with poor outcome. CONCLUSION: TLR2 levels increase with the delay in presentation; thus, TLR2 ligands in vitreous could serve as a good target for the treatment of endophthalmitis.

Intravitreal bevacizumab versus posterior subtenon triamcinolone in diffuse diabetic macular edema.

The aim of the study was to compare intravitreal bevacizumab (IVB) and posterior subtenon triamcinolone (PST) as an adjunct to laser treatment in diffuse diabetic macular edema (Diffuse DME). Prospective-randomized control trial of 30 eyes of 30 diabetic patients having Diffuse DME with maximum retinal thickness (MRT) was more than or equal to 350 µm. The subjects were randomly allocated into two groups. Group A (12 eyes) received IVB and group B received PST (18 patients) before laser treatment. Grid laser treatment was done when the MRT decreased to less than 350 µm. OCT thickness-guided repeat injections were given if required. The patients had minimum follow-up of 6 months. At 6-month follow-up, the two groups were compared for (1) Maximum change in visual acuity letter score using logMAR chart (2) Reduction in MRT on OCT. The mean logMAR visual acuity at baseline was 0.63 ± 0.45 (0-1.6) in group A and was 0.76 ± 0.38 (0.2-1.3) in group B. The mean logMAR visual acuity at 6 month in group A was 0.34 ± 0.21 (0-0.6) and in group B was 0.64 ± 0.37 (0.3-1.3). The mean visual acuity at last follow-up was significantly better in group A than group B (p = 0.02). The mean change in MRT in Group A and Group B was 177.8 ± 85.64 and 156.07 ± 102.86, respectively, which was significantly better than the baseline in both the groups and was comparable in both groups. The study provides evidence to support the use of IVB over PST in diffuse diabetic macular edema.

Role of brimonidine in the treatment of clinically significant macular edema with ischemic changes in diabetic maculopathy.

To evaluate the role of brimonidine (BMD), an alpha-2 agonist, in the management of clinically significant macular edema (CSME) in diabetic maculopathy with ischemic changes. A prospective, randomized controlled trial including 30 eyes of 30 metabolically stable diabetic patients with CSME showing fundus fluorescein angiography documented ischemic changes. Group I included 17 eyes of patients who received topical BMD (0.2 %) twice daily for 6 months while Group II included 13 eyes of age-matched patients who were kept under observation and acted as controls. The mean change in logMAR visual acuity and any change in the grade of the foveal avascular zone (FAZ) size, outline, capillary non-perfusion, or capillary dilatation was noted in the two groups and compared at the end of 6 months. The FAZ area and radius was significantly less in the study group than the control group. However, no significant difference in FAZ capillary outline, FAZ capillary loss, FAZ capillary dilatation and overall grade of ischemia between the two groups was seen. There was improvement in visual acuity from baseline to 6 months but it was comparable between the two groups (p = 0.02). BMD may have a role in the treatment of ischemic macula in CSME since the FAZ area and radius were significantly less in the study group. However, a larger sample size and a longer follow-up are needed to further authenticate the results of this pilot study.

Effect of pterygium on contrast sensitivity.

The purpose of this study is to evaluate the effect of pterygium on contrast sensitivity. Thirty-six eyes with pterygium and 18 eyes without pterygium were included in the study. The size of the pterygium was measured on the slit lamp both vertically at the limbus and categorized into three groups (≤3, 3.1 to ≤5, >5 mm), and horizontally on the cornea and categorized into two groups (0.5 to ≤2, >2 mm), and the area calculated by multiplying the two measurements was then categorized into three groups (≤7, 7.1 to ≤14, >14 mm(2)). Contrast sensitivity was measured using CSV-1000E charts (Vector Vision) at 3, 6, 12 and 18 cycles per degree under photopic and mesopic conditions. The mean vertical length of pterygium was 4.41 ± 1.12 mm, mean horizontal width was 2.09 ± 0.68 mm and mean area was 9.7 ± 5.01 mm(2). Significant differences in both photopic and mesopic contrast sensitivities at all frequencies were noted between normal eyes and vertical length of pterygium >3 mm, horizontal width ≥0.5 mm and area >7 mm(2). Contrast sensitivity had significant negative correlation with all three parameters. Pterygium with vertical length >3 mm, horizontal width ≥0.5 mm and area >7 mm(2) caused a significant decrease in both photopic and mesopic contrast sensitivity at all spatial frequencies. Contrast sensitivity had significant negative correlation with all three parameters.

Iodine-125 brachytherapy for choroidal melanoma by using Ocuprosta seeds with indigenous non-collimated plaques: Our initial experience.

PURPOSE: Brachytherapy is the gold-standard treatment for choroidal melanoma. This study evaluated iodine-125 brachytherapy by using Ocuprosta seeds with indigenous non-collimated plaques in Asian patients. METHODS: Retrospective single-center study in a tertiary care hospital of 12 eyes with choroidal melanoma in 12 Asian patients who underwent brachytherapy with Ocuprosta seeds fixed on non-collimated plaques and had a follow-up of at least 32 months (mean: 42.4 ± 9.5 months; median: 40 months). Radiotherapy was planned after developing the digital 3D model of the tumor within the eye by using radiological images and clinical pictures. Ocuprosta iodine-125 seeds were used on indigenous non-collimated gold plaques to deliver the radiation for precalculated time. "Successful outcome" was taken as a decrease in the volume of the tumor, and "unsuccessful outcome" was defined as no change in the tumor volume or increase in the tumor volume at 24 months after brachytherapy. RESULTS: The mean decrease in tumor volume was 21% (914.5 ± 912.2 mm3 to 495.7 ± 633.6 mm3) after brachytherapy, which correlated with the baseline volume of the tumor. Ten eyes (83.3%) showed a reduction in tumor volume, whereas two eyes showed an increase in the volume of the tumor after brachytherapy. One of the cases with a reduction in tumor size developed neovascular glaucoma. Enucleation was done in three eyes. A globe salvage rate of 75% and tumor regression rate of 83% were seen in the present study using Ocuprosta seeds. CONCLUSIONS: Iodine-125 brachytherapy with uncollimated indigenous gold plaques is an effective treatment modality for choroidal melanomas in Asian patients.

Five-year study of ocular injuries due to fireworks in India.

To study the demographic profile, cause, type and severity of ocular injuries, their complications and final visual outcome following fireworks around the time of Deepawali in India. Case records of patients who presented with firework-related injuries during 2005-2009 at the time of Deepawali were reviewed. Data with respect to demographic profile of patients, cause and time of injury, time of presentation and types of intervention were analyzed. Visual acuity at presentation and final follow-up, anterior and posterior segment findings, and any diagnostic and surgical interventions carried out were noted. One hundred and one patients presented with firework-related ocular injuries, of which 77.5 % were male. The mean age was 17.60 ± 11.9 years, with 54 % being ≤14 years of age. The mean time of presentation was 8.9 h. Seventeen patients had open globe injury (OGI) and 84 had closed globe injury (CGI). Fountains were the most common cause of CGI and bullet bombs were the most common cause of OGI. Mean log MAR visual acuity at presentation was 0.64 and 1.22 and at last follow-up was 0.09 and 0.58 for CGI and OGI, respectively (p < 0.05). Patients with CGI had a better visual outcome. Three patients with OGI developed permanent blindness. Factors associated with poor visual outcome included poor initial visual acuity, OGI, intraocular foreign body (IOFB), retinal detachment and development of endophthalmitis. Firework injuries were seen mostly in males and children. Poor visual outcome was associated with poor initial visual acuity, OGI, IOFB, retinal detachment and development of endophthalmitis, while most patients with CGI regained good vision.

Concomitant multiple subretinal cysticerci in neurocysticercosis.

We present a unique case of asymptomatic NCC that was accidently diagnosed on radiological investigations after a road traffic accident. An Ophthalmologic consult was sought to rule out intraocular or optic nerve cysticercosis. Fundoscopy showed multiple white-pale yellow lesions in the right eye which on ultrasonography confirmed cyst lined by a cyst wall consistent with subretinal cysticercosis. The patient was treated with diode laser photocoagulation. A high index of suspicion is required to diagnose NCCin endemic areas. In the right eye which on ultrasonography confirmed cyst lined by a cyst wall consistent with subretinal cysticercosis. The patient was treated with diode laser photocoagulation.

Predictors of long-term visual outcome after chemoreduction for management of intraocular retinoblastoma.

BACKGROUND: To determine the predictors of long-term visual outcome after chemoreduction for management of intraocular retinoblastoma. DESIGN: Retrospective case series. PARTICIPANTS: One hundred and forty eyes of 96 new retinoblastoma patients. METHODS: The clinical records were reviewed for demographical profile, tumour characteristics, treatment methods, treatment side effects and final visual outcome. Multivariate analysis was used to evaluate factors predictive of final visual acuity. MAIN OUTCOME MEASURE: The clinical data were analysed for main outcome measures of good vision (visual acuity ≥6/12) or ambulatory vision (visual acuity ≥6/60). The correlation among predictor variables was determined using Pearson's product moment correlation for continuous variables, and t-test and analysis of variance test for categorical baseline variables. RESULTS: Follow-up ranged from 2 years to 14 years (median 75 months). The final mean logarithm of minimum angle of resolution visual acuity was 0.79. Ambulatory vision (≥6/60) was achieved in 100 of 140 (71%) eyes, and vision of ≥6/12 was seen in 52 eyes (37%). Extrafoveolar tumour and greater number of tumours in the eye were the only predictors of visual acuity ≥20/40. Greater number of tumours correlated with smaller mean basal tumour diameter. The mean basal tumour diameter was 9.8 mm in eyes with multiple tumours and 12.2 mm in eyes with single tumours (P = 0.03). CONCLUSION: Long-term ambulatory vision (≥6/60) was achieved in the majority (71%) of retinoblastoma containing eyes not requiring enucleation after treatment with chemoreduction and adjunctive therapy. Absence of foveolar involvement and greater number of tumours were the predictor of long- term visual outcome of 6/12 or better.

Fundus fluorescein angiography in retinopathy of prematurity.

BACKGROUND/OBJECTIVES: Retinopathy of prematurity (ROP) is a potentially blinding disease of immature retinal vasculature. ROP regresses in majority of the cases and very few go on to develop ROP needing treatment. Fundus fluorescein angiography (FFA) is the gold standard technique to study retinal vasculature. The present study was undertaken with the objective to identify the FFA findings associated with the progression of ROP. SUBJECT/METHODS: Prospective single centre study in a tertiary care hospital of 99 eyes of 50 preterm babies. Fundus fluorescein angiography (FFA) was performed in all babies using RetCam 3 at the first detection of ROP. The babies were followed up for the progression of ROP. The FFA predictors for the progression of ROP were evaluated using the Mann-Whitney U test and Fisher's test. RESULTS: Thirty-eight eyes were Type 1 ROP at initial presentation and were lasered. Amongst the rest, 24 eyes showed features of stage 3 ROP with intense leakage on FFA and were designated as FFA-treatable ROP and were also lasered. Amongst the rest of the 37 eyes, the disease progression was seen in 13 eyes and the disease regression was seen in 24 eyes. The baseline FFA findings associated with the progression of ROP were delayed retinal arterial perfusion (p = 0.037) and popcorn lesions (p = 0.042). The post hoc analysis was done using a validated FFA scoring system. CONCLUSIONS: FFA may be added in the classification of ROP and delayed retinal arterial perfusion and popcorn lesions on FFA may predict the progression of ROP.

Rhegmatogenous retinal detachment with giant retinal tear in a child with Marfan's syndrome: a rare ocular emergency.

A 7-year-old boy with Marfanoid habitus presented with sudden and painless decrease in the vision of the right eye. Ocular examination revealed rhegmatogenous retinal detachment with 360° giant retinal tear in the right eye and small peripheral retinal breaks with lattice degeneration in the left eye. The patient underwent a 23-gauge pars plana vitrectomy with scleral buckling in the right eye and laser around the breaks in the left eye. At 1-week follow-up visit, the child presented with similar complaints in the left eye as were seen in the right eye. This was later managed effectively with 23-gauge pars plana vitrectomy only. So, with our case report, we would like to highlight the need for aggressive screening in children who are diagnosed with Marfan's syndrome and the need for prophylactic treatment in the unaffected eye.

Metastatic endophthalmitis presenting as subretinal abscess following a forearm furuncle.

Metastatic endophthalmitis (ME) is rare form of secondary uveitis commonly prevalent in immunocompromised patients. A 55-year-old immunocompetent woman presented with painful decrease in left eye vision (referred to us as cytomegalovirus retinochoroiditis). Ocular examination revealed diffuse yellowish-white retinitis lesion (diagnosed as subretinal abscess on macular optical coherence tomography). Vitreous tap was unremarkable, but vitreous biopsy from the posterior vitreous overlying the subretinal abscess confirmed the growth of methicillin-sensitive Staphylococcus aureus (MSSA). Detailed systemic examination revealed a forearm furuncle, which yielded MSSA on culture. The infection followed relentless course despite aggressive treatment with pars plana vitrectomy and antibiotics (topical, systemic and intravitreal). This case is presented due to rarity of presentation of ME as subretinal abscess following skin infection, which became a management challenge. Due to its rapid progression and irreversible damage to ocular tissue, high index of suspicion and aggressive management is needed in such cases. The disease course, management and prognosis of such cases are dismal in majority of the patients.

Unusual case of intraocular medulloepithelioma in an adult male.

Medulloepithelioma is a rare tumor of the eye, arising from the posterior segment. This embryonic tumor is mostly seen in children and is very rare in adult population. This case report presents the case of a 39-year-old Indian male, who had gradual vision loss over 4 years in his left eye with new onset of pain. He was referred to our center in view of secondary cataract and intraocular mass. Vision in right eye was 20/ 20 while left eye had no light perception at presentation. Ocular examination of the left eye revealed shallow anterior chamber, florid iris neovascularization, raised intraocular pressure and cataractous lens. B-scan ultrasonography showed a heterogenous mass filling the entire globe. MRI scan confirmed the finding, showing a mass hyper-intense to vitreous. No invasion of optic nerve or sclera was observed. Left eye enucleation with PMMA implant placement was performed and histopathology confirmed the diagnosis of benign teratoid medulloepithelioma. At the time of submission of this report, the patient was still under follow-up and had no detectable metastases at 15 months follow-up. This report highlights a very rare case of embryonic tumor in adult male, which could be managed successfully with a high index of suspicion and timely intervention.

Plaque brachytherapy for choroidal melanoma with vitreous haemorrhage: a therapeutic challenge.

A 47-year-old man presented with profound loss of vision in right eye and relative afferent pupillary defect. On fundus examination, posterior pole details were obscured due to dense vitreous haemorrhage. B-scan ultrasonography was performed that revealed a mushroom-shaped hyperechoic lesion with medium internal reflectivity on A-scan ultrasonography. After performing contrast-enhanced MRI of the orbit, a diagnosis of choroidal melanoma was established. Patient was managed using plaque brachytherapy based on multiplanar MRI. This was followed 10 months later by pars plana vitrectomy and cataract extraction. Vision postoperatively improved to 20/60. A systematic clinical assessment along with supportive ancillary investigations augments diagnostic accuracy and reduces delay in definitive management.

Use of an online screening algorithm - Weight, Insulin-derived growth factor 1, Neonatal Retinopathy of Prematurity (WINROP) for predicting retinopathy of prematurity in Indian preterm babies.

Purpose: Inopathy of prematurity (WINROP) Weight, insulin-derived growth factor 1, neonatal ROP algorithm is an online tool that has been validated as a predictor of retinopathy of prematurity (ROP) in various countries. The current study was designed to evaluate the predictive ability of WINROP algorithm (http://winrop.com) using postnatal weight gain in detecting Type 1 ROP in Indian babies. Methods: Prospective single centre observational study of 153 consecutive preterm babies who were eligible for screening for ROP as per the standard guidelines. Sixteen babies were excluded from the study because of various reasons. Thirty-five babies had gestational age ≥32 weeks and were ineligible for WINROP algorithm. Online WINROP algorithm was used for 102 babies with gestation at birth less than 32 weeks. The alarms triggered by WINROP were documented. Results: Laser treatment was done in 30 babies who developed Type 1 ROP. Of these, WINROP alarm was signaled in 24 babies and 6 babies developed ROP without any WINROP alarm. These babies had associated comorbidities like respiratory distress syndrome, patent ductus arteriosus, bacterial sepsis, and ventilatory support. WINROP alarm was significantly associated with Type 1 ROP (P < 0.001). The sensitivity of WINROP was 80% and specificity was 80.6% with a positive predictive value of 63.2% and negative predictive value of 90.6% in detecting Type 1 ROP. In the present study, no baby who was ineligible for WINROP developed Type 1 ROP. Conclusion: WINROP provides a novel online monitoring screening tool for identifying babies at risk of developing Type 1 ROP. In our cohort, none of the babies whose period of gestation was more than or equal to 32 weeks developed sight threatening Type 1 ROP. WINROP algorithm may also be useful in Indian population.

Avascular island in the vascularised retina in zone II ROP.

We describe an atypical form of avascular island demarcated by a ridge in the vascularised retina of retinopathy of prematurity. Fundus fluorescein angiography showed an unusual finding of an avascular island demarcated by shunt vessels in vascularised retina posterior to the ridge. There is a need to document this finding as this could throw some light on the aetiopathogenesis of the disease.

Unusual presentation of Retinoblastoma.

Most cases of retinoblastoma are diagnosed before the age of 5 years. The cases in older age groups can have variable presentations leading to misdiagnosis and management challenges. We report a case of retinoblastoma in an 8-year-old female who was primarily referred as a case of sympathetic ophthalmia due to a co-incidental misleading history of penetrating eye injury to other eye 3 weeks prior. The patient complained of decreased vision in the left eye after 3 weeks of repair of the corneo-scleral laceration in the right eye. Visual acuity in the right and left eye was 3/60 and light perception respectively. The anterior segment examination showed moderate sized keratic precipitates, intense inflammatory cellular reaction with large fluffy cells, hypopyon and dense vitreous exudates. Ultrasonography showed abundant hyperechoic contents within the vitreous cavity in the left globe. The retino-choroid was thickened. The possibility of endophthalmitis and sympathetic ophthalmia was considered. Diagnostic vitrectomy was planned. Intraoperatively, after clearing the exudates, a yellowish white mass lesion was seen superiorly. Post- operatively contrast-enhanced MRI scan confirmed the presence of an enhancing mass lesion in the globe consistent with the diagnosis of intraocular retinoblastoma. Enucleation of left globe was done after chemotherapy. Thus, a high risk of suspicion has to be kept for this malignant tumour in children with unexplained visual loss.