A pilot trial for comparison of photodynamic therapy and transpupillary thermotherapy for the management of classic subfoveal choroidal neovascularization secondary to age-related macular degeneration.

AIM: The aim of the study was to compare the visual outcomes of photodynamic therapy (PDT) with verteporfin and transpupillary thermotherapy (TTT) for classic subfoveal choroidal neovascularization (CNVM) secondary to age-related macular degeneration (ARMD). SETTINGS AND DESIGN: Patients with subfoveal classic CNVM caused by ARMD attending vitreo-retinal services at a tertiary care setup were included in this nonrandomized, open label, prospective, clinical, comparative pilot trial. MATERIALS AND METHODS: Standardized refraction, visual acuity testing, evaluation of fundus and serial color photography and fundus fluorescein angiography were carried out to evaluate the effects of treatment in 32 eyes each undergoing either PDT or TTT. Follow-up was carried out at four weeks, 12 weeks and six months. Retreatment if indicated was carried out three months post treatment. RESULTS: Stabilization or improvement occurred in 69% of patients undergoing PDT and 50% patients undergoing TTT at six months of follow-up. Among patients with a pretreatment visual acuity greater than or equal to 20/63, only one out of six patients who underwent PDT had a drop of visual acuity > 2 lines as compared to four patients (100%) who underwent TTT. (P =0.0476, two-tailed Fisher's exact test). CONCLUSION: For short-term preservation of vision in patients of classic CNVM due to ARMD, PDT seems to be better than TTT if the pre-laser best corrected visual acuity is > 20/63 but both are equally effective if pre-laser best corrected visual acuity is < 20/63.

Status of speciality training in ophthalmology in India.

PURPOSE: To systematically evaluate the quality of ophthalmology training in India. METHODS: Questionnaires were sent to existing medical schools and accredited training institutions. Institutions were followed up thrice to obtain responses. Data were analysed using Stata 8.0. RESULTS: Responses were received from 128 (89.5%) of the 143 institutions. Each year, 900 training slots were available across the country. Faculty: student ratios were better in accredited training institutions than in postgraduate medical schools. Fifty three (41.4%) of 128 institutions subscribed to more than 2 international journals. Fewer than 1 in 6 institutions conducted research projects. 11 (8.6%) institutions reported more than five publications in international peer-reviewed journals over three years. Only a third of the responding institutions had a wet lab. CONCLUSIONS: There is a need to improve the training facilities and optimally utilise the infrastructure available in postgraduate medical schools.

Macular thickness evaluation using the optical coherence tomography in normal Indian eyes.

PURPOSE: To determine the normative values for macular thickness and volume by Optical Coherence Tomography (OCT 3) in healthy Indian subjects. METHODS: The macula of 170 consecutive, randomly selected normal subjects was imaged on OCT 3 in this cross-sectional study. OCT parameters of macular thickness were analysed with baseline variables including age, gender, axial length and refractive error. RESULTS: The average foveal thickness in the population under study was 149.16 +/- 21.15 micro. Macular thickness and volume parameters of OCT correlated significantly (Pearson's Correlation coefficient) with age (r=0.23, P<0.01), but not with gender, axial length and refraction. CONCLUSIONS: The macular thickness and volume parameters have a significant correlation with age. This normative database of macular thickness by OCT in Indian eyes may be a useful guideline for management and further research in diseases of the macula and glaucoma.

Transpupillary thermotherapy in subfoveal choroidal neovascular membrane secondary to age-related macular degeneration.

PURPOSE: To report our initial experience in the treatment of subfoveal choroidal neovascular membrane, secondary to age-related macular degeneration (AMD) by transpupillary thermotherapy (TTT). METHODS: Fifty consecutive patients with subfoveal choroidal neovascularisation (CNV) secondary to AMD, were included in the study. The parameters assessed before the TTT were visual acuity by ETDRS chart, scotoma score by Amsler grid chart, reading speed, fundus examination by direct and indirect ophthalmoscope as well as +90 Diopter lens followed by digital fundus photography and fluorescein angiography (FA). RESULTS: The letter visual acuity improved or stabilized in 72% cases up to 12 weeks after TTT. Mean scotoma score decreased from a mean of 47.56, to 43.56 at 6 weeks and to 37 at 12 weeks. Mean reading speed increased from 27.04 words/minute at pretreatment to 34.52 words/minute at 6 weeks and 37.33 words/minute 12 weeks after TTT. CONCLUSION: TTT is not only a cheaper alternative to photodynamic therapy (PDT), but also is an efficacious tool in stabilisation or improvement of visual acuity in the management of subfoveal choroidal neovascular membrane due to AMD.

First contact management of postoperative endophthalmitis. A retrospective analysis.

Records of 37 consecutive patients of postoperative endophthalmitis referred to our centre from North India were retrospectively analysed to study the first contact management profile. Ten (27%) patients had received intravitreal antibiotics as a primary mode of treatment, and 27 (73%) had received only parenteral antibiotics. The outcome was worse in the latter group. This suggests that general ophthalmologists lack the capability to provide adequate treatment to patients with endopthalmitis in Northern India.

Diabetic retinopathy for general practitioners.

The most significant complication of diabetes mellitus involves the eye and which develops 85% of all diabetics eventually to retinopathy. Diabetic retinopathy is the commonest cause of blindness between 4th and 7th decades. It is essentially a microangiopathy with two distinct stages during its evolution, the preclinical and clinical stages. Diabetic maculopathy is the commonest cause of visual loss in diabetics. Progression of the diseases can be retarded by early diagnosis and using appropriate measures. Well known risk factors are diabetes age, metabolic control of hypertension, associated renal disease and pregnancy. The management plan of the secondary level is early diagnosis and laser photocoagulation or surgical intervention. Vitreoretinal surgery is certainly of benefit in patients with advanced diabetic eye disease. The PROMPT factors can be applied to decrease diabetes mellitus related blindness.

Quantification of the retinal nerve fibre layer thickness in normal Indian eyes with optical coherence tomography.

PURPOSE: To quantitatively assess the normative values for peripapillary retinal nerve fibre layer (RNFL) thickness with Optical Coherence Tomography (OCT 3) in Indian subjects. METHODS: The peripapillary retinal nerve fibre layer of 146 normal subjects was imaged on OCT 3 in this cross-sectional study. Thickness of the RNFL around the disc was determined with three 3.4 mm diameter circle OCT scan. The RNFL thickness was measured in four quadrants; superior, nasal, inferior and temporal. The data was analysed using SAS commercial statistical software. Influence of age and gender was evaluated on various measured parameters using unpaired t test, one-way analysis variance (ANOVA) and Pearson's correlation coefficient. RESULTS: One hundred and forty six eyes of 146 patients, 84 males and 62 females were studied. The average RNFL thickness in the sample population under study was 104.27 +/- 8.51 (95% CI 87.25-121). The RNFL was thickest in the inferior quadrant, followed by the superior quadrant, and progressively less in nasal and temporal quadrant. The difference between inferior and superior quadrants was not statistically significant. Age had a significant negative correlation with average RNFL thickness (r = -0.321, P = 0.000) and with average superior (r = -0.233, P = 0.005) and average inferior RNFL thickness (r = -0.234, P = 0.004). There was no effect of gender on various RNFL thickness parameters. CONCLUSIONS: RNFL thickness is significantly correlated with age, but not with gender. This normative database of RNFL thickness with OCT in Indian eyes is similar to previously reported values in normal Asian eyes.

Intraocular live cysticercus larva.

Ocular cysticercosis is one of the most common parasitic infections of the eye in humans. Although the adult pork tapeworm, Taenia solium, resides in the lumen of the intestine, the only structural element of an adult worm is usually found within a tissue cyst in the eye, its adenexa, or other places in the body with a single invaginated scolex. An unusual case is described in which a 13- to 14-mm live cysticercus larva was found, removed from the eye, and confirmed by histopathologic examination.

Comparison of scleral buckling with combined scleral buckling and pars plana vitrectomy in the management of rhegmatogenous retinal detachment with unseen retinal breaks.

BACKGROUND: The purpose of the present paper was to compare the techniques of conventional scleral buckling and combined pars plana vitrectomy and scleral buckling procedures in rhegmatogenous retinal detachments with unseen retinal breaks. METHODS: Forty-four consecutive eyes with uncomplicated, primary rhegmatogenous retinal detachments with a clear media and unseen retinal breaks were randomized to two groups. The scleral buckling group underwent 360 degrees scleral buckling, cryopexy and external subretinal fluid drainage. In the combined surgery group, 360 degrees scleral buckling, pars plana vitrectomy, air-fluid exchange, endolaser and injection of 14% perfluoropropane gas was done. RESULTS: At 3 months follow up the primary reattachment rate was 80% (16/20 cases) in the combined surgery group, and 70% (14/20 cases) in the scleral buckling group (P = 0.716). The visual acuity improved significantly from a preoperative median of hand movement (HM; range: HM to 6/60; similar in both the groups), to a median of 6/60 (range: perception of light to 6/18) in the combined surgery group and a median of 6/36 (range: HM to 6/18) in the scleral buckling group, the difference between the two groups not being statistically significant (P = 0.4). The number of intraoperative and postoperative complications was more in the combined surgery group. (four cases were lost to follow up and were doing well when last examined.) CONCLUSION: Conventional scleral buckling was found to be a safe and effective technique in the primary management of uncomplicated, rhegmatogenous retinal detachments with unseen retinal breaks when the media is clear.

Screening for diabetic retinopathy by non-ophthalmologists: an effective public health tool.

PURPOSE: To investigate and report the reliability of detection and grading of diabetic retinopathy by direct ophthalmoscopy through a dilated pupil by general physicians (non-ophthalmologists) and optometrists who have undergone a short period of training. METHODS: A total of 400 eyes of 200 diabetes patients were examined by two non-ophthalmologists. Their observations were compared with an ophthalmologist's diagnoses for the same patients. RESULTS: The diagnoses made by the general physician (kappa = 0.8381, SE = 0.041) and the optometrist (kappa = 0.7186, SE = 0.051) showed good rates of agreement with the ophthalmologist's diagnoses. CONCLUSIONS: The provision of appropriate screening protocols and follow-up parameters can enable primary care physicians and support personnel to reliably screen individuals for retinopathy in diabetes. This will reduce the workload of tertiary hospitals, and provide optimal services to the huge majority of the Indian population that has limited access to eye care services.

Results of anterior chamber clearance via the pars plana in pseudophakic endophthalmitis.

PURPOSE: Patients with endophthalmitis have extensive fibrinous exudates in the anterior chamber. Clearance of these exudates in pseudophakic patients during vitrectomy is difficult. We evaluated the results of the pars plana approach for clearing these exudates. MATERIAL AND METHODS: Eighteen patients with pseudophakic endophthalmitis underwent clearance of anterior chamber exudates through the pars plana approach after initial creation of a peripheral iridectomy with a vitrectome. RESULTS: The exudates were adequately cleared in all 18 patients with good posterior segment visualization during vitrectomy. Minor punctate iris bleeds (4 patients), intraoperative dislocation of the intraocular lens (IOL) (1 patient) and postoperative dislocation of the IOL following blunt trauma, 9 months after vitrectomy (1 patient) were the complications noted. CONCLUSION: This technique is simple, safe and helps clearing anterior chamber exudates. It also permits excellent visualization during vitrectomy for pseudophakic endophthalmitis.

Role of daunorubicin in inhibiting proliferative vitreoretinopathy after retinal detachment surgery.

PURPOSE: To study the role of daunorubicin in inhibiting proliferative vitreoretinopathy after retinal detachment surgery. METHOD: Thirty eyes of 30 patients with a primary rhegmatogenous retinal detachment and proliferative vitreoretinopathy of stage D1 or more advanced were included in the study. The eyes were randomly assigned to either the experimental or the control group. The eyes in the experimental group received an intravitreal injection of daunorubicin (5 microg) before conclusion of the vitrectomy. The main outcome measures evaluated were: retinal attachment, vitreous activity and visual acuity at 3 months after surgery. RESULT: Complete retinal attachment was achieved in 13 eyes (86.6%) in the daunorubicin group and 10 eyes (66.6%) in the control group, at 3 months. Nine patients (60%) in the daunorubicin group and five patients (33.3%) in the control group had a best-corrected visual acuity of >or=3/60 at 3 months of follow up. There was a statistically significant reduction in vitreous reaction at all times during the postoperative period in the daunorubicin group. CONCLUSION: Daunorubicin may be a useful drug in inhibiting proliferative vitreoretinopathy after surgery for primary rhegmatogenous retinal detachment.

Rapid seroconversion to Treponema pallidum and HIV positivity in a patient with retinal vasculitis.

A patient with idiopathic retinal vasculitis was found to have rapid conversion of serological tests for Treponema pallidum and HIV. The diagnosis was confirmed by Venereal Disease Research Laboratory (VDRL) testing and dark ground illumination for T. pallidum, and enzyme-linked immunosorbent assay (ELISA) and Western blot assay tests for HIV. Following treatment with intravenous penicillin, the fundus lesions resolved and visual acuity recovered from inaccurate light projection to 6/24 in the right eye and from counting fingers close to face to 2/60 in the left eye. Serological tests for T. pallidum in patients with concurrent HIV infection may be unpredictable. Hence, it is important to repeat these tests even in the early treatment phase of patients with retinal vasculitis who have shown initial seronegativity. This enables earlier diagnosis and initiation of specific treatment.

Posterior subtenon injection of corticosteroids using polytetrafluoroethylene (PTFE) intravenous cannula.

Injection of corticosteroids into the posterior subtenon space is a well established and highly effective modality in the treatment of intermediate uveitis. The conventional technique of posterior subtenon injection involves the use of a sharp tipped 26-gauge, 5/8 inch needle that must be inserted up to its hub to obtain adequate placement of the drug into the posterior subtenon space. With this technique the risk of perforation of the globe, although minimal, remains a potential complication. Herein is described a new technique for injection of corticosteroids into the posterior subtenon space using an intravenous cannula made of polytetrafluoroethylene (PFTE) that allows safer delivery of the drug into the posterior subtenon space.