External Limiting Membrane, Photoreceptor Ellipsoid Zone Disruption, and Retinal Pigment Epithelium Alterations in Diabetic Retinopathy

Objective?Diabetic retinopathy (DR), a microvascular complication of diabetes, is a leading cause of preventable blindness. Spectral domain optical coherence tomography (SD-OCT) provides cross-sectional and topographical imaging of the retina. SD-OCT resolves outer retinal layers into three hyperreflective bands—external limiting membrane (ELM), ellipsoid zone (EZ), and retinal pigment epithelium (RPE). In this article, we have studied the role of these outer retinal layers in structural and molecular changes taking place in DR. Materials and Methods?Articles with clinical features, pathogenesis, diagnosis, and treatment of DR were thoroughly studied. Articles were searched on PubMed, MEDLINE, and Cochrane Library from 2000 to 2020. Studies focusing on the role of ELM, EZ, and RPE in pathogenesis of DR based on SD-OCT were included. Results?The long-standing hyperglycemia leads to protein glycosylation resulting in formation of advanced glycation end products (AGEs). AGEs have an impact through their effect on retinal microvasculature, vascular endothelial growth factor (VEGF), intercellular adhesion molecule-1, nitrosative and oxidative stress, and vitamin D and calcium metabolism. All these factors have been linked with disruption of outer retinal layers. AGEs lead to vascular endothelial dysfunction and release of proangiogenic factors by increasing the expression of VEGF in retinal pericytes and RPE cells. This leads to leakage and fluid accumulation resulting in diabetic macular edema (DME). In DME, there is sequential disruption of ELM and EZ and decrease in visual acuity (VA). The RPE alterations have been reported to be associated with the severity of DR and decrease in VA. Anti-VEGF therapy, most common treatment of DME, leads to restoration of barrier effect of ELM, it was found to be restored first followed by EZ restoration. Newer anti-AGEs agents and their receptor blockers are being developed which have a positive effect on maintaining the health of RPE. Conclusion?A complex molecular association exists between the structural changes in ELM, EZ, and RPE in DR. SD-OCT is an indispensable tool to study these changes as integrity of these outer layers of retina is essential for maintaining visual function of retina in DR.

To Study the Clinical Spectrum and Prognostic Factors of Scrub Typhus Fever In a Tertiary Care Centre in Kumoun Region of Uttrakhand.

Background: Scrub typhus is caused by Orentia (formerly Rickettsia) tsutsugamushi. It is an infectious disease of variable severity .Scrub typhus has a wide geographical distribution. Scrub typhus is grossly under diagnosed in India due to its nonspecific clinical presentation, limited awareness and low index of suspicion. Methods: This study was a cross sectional observational study conducted in Department of Medicine Government Medical College, Haldwani .The duration of this study was two years i.e. from November 2013 to October 2015 and 103 patients included in study. Results: 36 patients were found to be scrub typhus positive. It was commonly seen in males in the age group of 20-30 years. Besides fever, cough, myalgia and headache were the common presenting symptoms. Scrub typhus was seen most commonly in farm worker in our study. Most common complication was hepatitis followed by multiorgan dysfunction. In our study, out of 36 positive patients, 5 (13.8%) patients died and 31 patients ultimately recovered completely without any complication whatsoever. Conclusion: Scrub typhus is not a uncommon disease in India more so in hilly areas. So high index of suspicion should be there while dealing a patient of fever in these regions.

Aetiological Spectrum of Acute Renal Failure in Kumaon Region of Uttarakhand.

Background: Acute renal failure (ARF) or acute kidney injury (AKI) is a clinical condition in which rapid decline in glomerular filtration rate over an hour to days. It is an important clinical condition and common cause of mortality in hospitalized patients. Aims: To analyze the aetiological spectrum and outcome of ARF in Kumaon region of Uttarakhand and to compare data with that of other parts of country. Settings and Design: Hospital based observational analytic study. Methods: This study was conducted on patients admitted to Government Medical College & associated Dr. Susheela Tiwari Memorial Hospital Haldwani from November 2011 to October 2012 with ARF irrespective of the cause. ARF was defined according to AKIN criteria. Statistical analysis used: Statistical analysis of data was performed using SPSS V.20.0 (Windows). All data was summarized and expressed as mean ± SD or as percentages as appropriate. The chi square test was used to analyze categorical variables while the student T-test used to analyze normally distributed data. Statistical significance was accepted at p<0.05. Results: Out of 100 patients, 77% had community acquired ARF and 23% had hospital acquired ARF. Medical causes were leading contributors (68%), while surgical causes in 20% and obstetrical causes in 12% of patients. 36% patients required hemodialysis. The overall mortality was 21%, and highest mortality was found in celphos poisoning group (100%). Conclusion: ARF is still common in the community and is associated with high mortality. Aetiologies like acute gastroenteritis, septicaemia, snakebite and malaria were the leading cause of ARF in our study.

Biological Effect of Heavy Metal in Drinking Water samples of Western Uttar Pradesh region in India.

Drinking water is a basic requirement for life and a determinant of standard of living. Poor water quality problem has also been observed in more number of habitations. Drinking water, in adequate quantity with safe quality is a basic requirement for life and a determinant of standard of living. Certain health problems are associated with people due to presence of excess of heavy metals and other impurities. The present study was conducted to analyze the various parameters of ground water in Uttar Pradesh India and to check its fitness for drinking. It will also clarify the health hazards imposed on the population of this state. The water samples are collected from Aligarh, Bulandshar, Merrut, MuzaffarNagar & Saharanpur zone of the Western U.P. region. Ten samples of ground water were collected from each of the five regions during the pre-mansoon (Jan-Feb) and post-mansoon (Sept-Oct ) seasons. The pH was estimated by pH meter, acidity, alkalinity, sulphates, chorides, Total hardness(Ca & Mg) were determined by titration methods. The total suspended solid was calculated by the formula. The heavy metals like Mn, Al, Ba, Cd, Cr, Co, Cu, Fe and Pb were determined in the ground water samples by ICP mass spectroscopy. The concentrations of heavy metals, pH, alkalinity, sulphate, chloride, TDS & Total Hardness (TH) were compared with the standards by BIS for Drinking water (IS 10500:2004). The results shows that water pH of all the five regions showed no remarkable variation from the BIS recommended value of pH (6.5-8.5). The alkalinity was above the BIS desirable level of 200mg/l in all the samples, but was less than the maximum permissible limit. The Drinking water of all the regions contains higher amounts of TDS than the desirable limits. Maximum TDS was detected in aligarh(780-820mg/litre). The ground water of Saharanpur region shows total hardness to be above the BIS desirable level of 300mg/l. The chloride content was above the BIS desirable level of 250mg/l in Aligarh only. The sulphate content was highest in aligarh (223mg/l). The Cd, Cr, &Pb content of all the five regions of Uttar Pradesh showed higher the BIS permissible limits of 0.003, 0.05 and 0.01mg/l respectively. The content of Mn, Ba, Cu, Co & Fe are within the permissible limit of BIS standards for drinking water.

New classification system-based visual outcome in Eales' disease.

PURPOSE: A retrospective tertiary care center-based study was undertaken to evaluate the visual outcome in Eales' disease, based on a new classification system, for the first time. MATERIALS AND METHODS: One hundred and fifty-nine consecutive cases of Eales' disease were included. All the eyes were staged according to the new classification: Stage 1: periphlebitis of small (1a) and large (1b) caliber vessels with superficial retinal hemorrhages; Stage 2a: capillary non-perfusion, 2b: neovascularization elsewhere/of the disc; Stage 3a: fibrovascular proliferation, 3b: vitreous hemorrhage; Stage 4a: traction/combined rhegmatogenous retinal detachment and 4b: rubeosis iridis, neovascular glaucoma, complicated cataract and optic atrophy. Visual acuity was graded as: Grade I 20/20 or better; Grade II 20/30 to 20/40; Grade III 20/60 to 20/120 and Grade IV 20/200 or worse. All the cases were managed by medical therapy, photocoagulation and/or vitreoretinal surgery. Visual acuity was converted into decimal scale, denoting 20/20=1 and 20/800=0.01. Paired t-test / Wilcoxon signed-rank tests were used for statistical analysis. RESULTS: Vitreous hemorrhage was the commonest presenting feature (49.32%). Cases with Stages 1 to 3 and 4a and 4b achieved final visual acuity ranging from 20/15 to 20/40; 20/80 to 20/400 and 20/200 to 20/400, respectively. Statistically significant improvement in visual acuities was observed in all the stages of the disease except Stages 1a and 4b. CONCLUSION: Significant improvement in visual acuities was observed in the majority of stages of Eales' disease following treatment. This study adds further to the little available evidences of treatment effects in literature and may have effect on patient care and health policy in Eales' disease.

Management of vitreous haemorrhage.

Vitreous hemorrhage is one of the most common differential diagnoses for sudden painless decrease in vision. Often, it is caused by retinal vascular disorders secondary to common systemic ailments such as diabetes mellitus, systemic hypertension and haematological abnormalities. Sometimes it may be the beginning of a retinal tear and consequent retinal detachment that can be vision threatening if not operated early. This paper lays out practical guidelines for a tailored approach needed to arrive at the aetiology of vitreous haemorrhage so that appropriate, timely treatment can be planned.