[Show abstract][Hide abstract] ABSTRACT: To assess the prevalence of blindness and visual impairment (VI), their associated causes and underlying risk factors in three tribal areas of Andhra Pradesh, India and compare this data in conjunction with data from other countries with low and middle income settings.
PLoS ONE 07/2014; 9(7):e100644. · 3.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Diabetes and Its related microvascular complications like Diabetic retinopathy are showing an alarming rise in developing countries like Zanzibar. Objective of the present study is to evaluate the impact of integrating eye screening for all subjects attending the diabetes clinic at Mnazi Mmoja Hospital in Zanzibar and to estimate the prevalence of visual impairment and diabetic retinopathy among the subjects.
[Show abstract][Hide abstract] ABSTRACT: Purpose:To compare the laser spot quality between the conventional slit lamp pattern laser (PASCAL) and the navigated pattern laser (NAVILAS) for panretinal photocoagulation (PRP). Methods:Prospective randomized interventional trial of 73 eyes (61 patients) with high-risk proliferative diabetic retinopathy. Eyes underwent PRP using 30ms pulse duration with either PASCAL (16 eyes) or NAVILAS laser (21 eyes); or 100 ms pulse duration with either PASCAL (16 eyes) or NAVILAS laser (20 eyes). Fundus color images of all quadrants were taken five minutes after treatment. Laser burn size (major and minor diameter and area), ellipticity (ratio of minor to major axis) were analyzed across the retina. Treatment time and pain were compared between both groups. Results:The burn size variation in navigated laser 30 ms, 100 ms and conventional pattern 30 ms and single spot 100 ms laser was 22%, 24%, 21% and 35%, respectively. The variation of the laser burn area near the arcade for NAVILAS and for PASCAL was 29% and 22%, respectively (p<0.01). Closer to the equator, burns from the NAVILAS showed even smaller variation of 15% compared to 25% with PASCAL (p<0.005). Laser spots from PASCAL exhibited an increasing elliptical shape towards the periphery while NAVILAS laser spots tended to be more uniform all over the retina. Average treatment duration and pain experience was less with navigated laser compared to pattern laser (p= <0.05). Conclusions:Navigated laser treatment achieves more uniform laser burns with less pain during shorter treatment duration in comparison to conventional pattern laser.
[Show abstract][Hide abstract] ABSTRACT: A premature infant who developed central retinal vein obstruction in one eye during laser therapy for high-risk prethreshold retinopathy of prematurity is described. Systemic investigations were done to detect the cause of such an acute and unreported episode. Acquired deficiency of protein C levels was detected. Premature infants are at risk of thromboembolic episodes due to deranged hematological parameters. Acquired protein C deficiency possibly precipitated acute retinal vein occlusion during laser therapy in this infant. Intravitreal bevacizumab was used successfully to treat the episode of retinal venous occlusion. Retinal vein obstruction during laser treatment for retinopathy of prematurity is reported for the first time.
Copyright 2014, SLACK Incorporated.
[Show abstract][Hide abstract] ABSTRACT: Purpose: To describe the outcomes and clinicomicrobiological profile of 11 years of a protocol-based management in neonatal endogenous endophthalmitis.
Methods: This was a retrospective interventional study of endogenous endophthalmitis in 31 eyes of 26 neonates. The protocol for active infection included systemic antimicrobials, vitreous and/or aqueous tap, and intravitreal antimicrobials under topical or general anesthesia along with core vitrectomy in selected cases. Blood, urine, umbilicus, aqueous, and vitreous samples underwent microbiological evaluation. Retinopathy of prematurity screening and treatment were done when indicated. Primary outcome was anatomic status assessed by comprehensive eye examination and by fundus photography whenever possible.
Results: Twenty-one of 26 babies (81%) were preterm. Two types of presentations included those with a fulminant appearance (24 eyes) and those with focal retinitis detected during routine screening (7 eyes). Vitreous culture was positive in 12/20 eyes (60%). Pseudomonas aeruginosa ( 8 ) was the most common isolate. Incorrect initial diagnosis was common. Treatment included intravitreal injections in 26 eyes, 10 of which also underwent vitrectomy. Twenty-four of the 26 patients (92%) received parenteral antimicrobials and 17 had evidence of systemic infection. All eyes with a fulminant presentation developed phthisis, while all focal fungal cases were salvaged.
Conclusions: Neonatal endogenous endophthalmitis has 2 distinct presentations. Focal retinal infections have good visual and anatomical outcomes while fulminant nosocomial cases do poorly. Management under topical anesthesia can be an alternative strategy for sick babies that cannot undergo surgery under general anesthesia due to systemic morbidity. Awareness about early diagnostic signs may help early referral.
European journal of ophthalmology 11/2013; · 1.06 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Abstract Purpose: To estimate prevalence and risk factors for diabetic retinopathy (DR) in diabetic patients with Non-Arteritic Anterior Ischemic Retinopathy (NA-AION). Methods: This was a retrospective chart review of patients with diabetes diagnosed with NA-AION. Patients with clinical anomalies affecting the optic nerve, diabetic papillopathy, and features suggestive of arteritic AION (raised erythrocyte sedimentation rate/positive temporal artery biopsy) were excluded. Clinical diagrams, notes, and fundus photographs, if available, were evaluated for optic disc edema, optic disc atrophy, presence or absence of small discs, retinal vessel abnormalities, presence of DR, and the presence of sight-threatening DR (STDR). Results: A total of 153 eyes of 109 subjects were included in the study. 82 subjects (75.2%) were men. Mean age of the subjects was 55 ± 9 years. 58 subjects (53.7%) had hypertension and 21 (19.3%) were insulin-dependent. 80 subjects (52.3%) had a duration of diabetes of five years or greater. DR with NA-AION was seen in 46 eyes (30.1%, 95% CI: 22.7 to 37.4) and STDR with NA-AION was seen in 20 eyes (13.1%, 95% CI: 7.7 to 18.5). Logistic regression analysis revealed the duration of diabetes to be significantly associated with both the presence of DR (OR: 1.07, 95% CI: 1.01 to 1.14, p = 0.02) and STDR (OR 1.08, 95% CI: 1.02-1.15, p = 0.01). Conclusions: Prevalence of DR and STDR in eyes with NA-AION was 30.1% and 13.1%, respectively. Duration of diabetes was an important risk factor for both presence and severity of DR in subjects with NA-AION.
Seminars in ophthalmology 10/2013; · 1.09 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Abstract Purpose: To describe a case of choroidal ischemia in a neonate after single, bilateral, intravitreal bevacizumab (IVB) injection for severe zone 1 aggressive posterior retinopathy of prematurity (AP-ROP). Methods: A six-week-old baby, born at a gestation age of 28 weeks and birth weight of 1.08 kg, presented at a postconceptional age of 34 weeks for ROP screening. On examination, both eyes revealed engorged iris new vessels with poorly dilating pupils. Retinal examination showed media haze, severe zone 1 APROP with confluent new vessels, severe plus disease, and early vitreous condensation at the edge of new vessels for 12 clock hours. The child was treated bilaterally, with single IVB injection before laser. After 16 hours, hypotony and exudative retinal detachment with patches of choroidal whitening suggestive of choroidal ischemia were seen. Results: The child was treated with topical steroids and cycloplegic drops and exudative retinal detachment resolved on the tenth day. Initial resolution of new vessels showed recurrence after two weeks and was treated with laser photocoagulation. Stable retinopathy status was noted up to six months follow-up. Conclusion: Choroidal ischemia secondary to a single IVB injection for the treatment of AP-ROP could be an unusual complication which raises the concern of its use as a monotherapy in neonates.
Seminars in ophthalmology 10/2013; · 1.09 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Context: Outcomes of various screening strategies in retinopathy of prematurity are not well reported. Aim: To assess the impact of a city-wide, ROP screening strategy, on the disease presentation and treatment outcome. Materials and Methods: A retrospective case-control study from a prospectively collected ROP data-base was analyzed. Cases (group 1a) included ROP babies that were screened directly in neonatal intensive care units, and controls (group 1b) were babies referred directly to the institute from other neonatal centers during the same period. Historical controls (group 2) were ROP cases seen in the years preceding establishment of this ROP program and database. Primary outcome measure was the risk of eyes presenting with stage 4 or worse ROP, and main secondary outcome measure was the final anatomic outcome. Results: Of the 643 cases screened, 322 eyes of 161 babies had ROP. The median age of 7.19 months at presentation for the 46 patients (92 eyes) in group 2 was higher than the median age of 1.29 months for the 115 patients (230 eyes) in group 1. Within the group 1, group 1a had lower median age at presentation than group 1b (0.91 months versus 2.30 months). The relative risk of an eye presenting in the stage 4 and 5 in group 2 was 4.7 times higher (95% confidence interval 3.07 -7.32) than in group 1. Eyes that could be given treatment in group 2 were significantly less (P < 0.0005) than in group 1. The relative risk of poor outcome in group 2 was 3.83 times higher (95% confidence interval 2.75 -5.34) than in group 1. Group 1a eyes had the best outcomes. Conclusion: Early screening before one month of age in neonatal centers detects the disease early where prompt treatment can lead to favorable outcomes. The study provides early results of a model strategy for ROP screening.
Indian Journal of Ophthalmology 10/2013; · 0.93 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To describe the characteristics and treatment outcomes of an unreported, late vitreous hemorrhage due to anterior hyaloidal fibrovascular proliferation in laser-regressed retinopathy of prematurity (ROP). Interventional case series. In the ongoing Indian Twin Cities ROP study database, consecutive cases with isolated late vitreous hemorrhage at least one year after laser-regressed disease were analyzed retrospectively. Anterior hyaloidal fibrovascular proliferation was diagnosed primarily using scleral depression. Anterior retinal cryopexy with adjunctive treatments was performed. The main outcome measure was clinical resolution of new vessels with no recurrent hemorrhage over a 1-year period. Vitreous hemorrhage, at two to eight years of age, developed in three eyes of three children out of 1,168 ROP lasered eyes. All had received laser for zone I disease as neonates, with no subsequent sequelae. Evaluation revealed filiform new vessels at the posterior vitreous base involving inferior 180° with absence of any other source of hemorrhage. All underwent anterior retinal cryopexy to the affected area. Simultaneous additional treatment, based on intraoperative findings, included one case each of peripheral laser photocoagulation, lens-sparing vitrectomy and intravitreal bevacizumab. All three showed successful regression and non-recurrence of vitreous hemorrhage with improvement of vision >20/40 at an intermediate follow-up of two years. Anterior hyaloidal fibrovascular proliferation is an unreported and rare cause of vitreous hemorrhage, appearing years after laser-regressed ROP. It has a good response to interventional treatment. Meticulous scleral depression of the vitreous base under anesthesia is useful to detect this rare source of vitreous hemorrhage.
[Show abstract][Hide abstract] ABSTRACT: Abstract Purpose: In the developing world, more than 90% of glaucoma is undetected due to the lack of appropriate screening methods. The LV Prasad Eye Institute Glaucoma Epidemiology and Molecular Genetic Study (LVPEI-GLEAMS) is a population-based study which aims to estimate the prevalence of, along with clinical, systemic and genetic risk factors for glaucoma in a rural population sampled from the state of Andhra Pradesh, India. The study aims to develop community screening strategies to diagnose glaucoma. This article describes the methodology adopted in LVPEI-GLEAMS. Methods: A sample of 3833 participants aged 40 years and older has been estimated to be enrolled using a compact segment sampling method with probability proportionate to size. Each participant will undergo a complete medical history and comprehensive eye examination including slit lamp photography, imaging of anterior and posterior segment, frequency doubling technology and standard automated perimetry. Additionally, glycosylated hemoglobin will be measured and a genetic profile based on candidate gene analysis will be undertaken. Clinical, biochemical and genetic data will be stored in a computerized database and analyzed. The novelty of this study lies in the fact that it is conducted at a vision center (primary eye care center serving a population of 50,000) by a vision technician (high school educated rural youth trained in basic ophthalmic techniques for a year). Conclusion: Information from the diagnostic techniques of the study will be used to develop effective community-level screening strategies, and insights from risk factors associated with glaucoma will help develop appropriate detection and management strategies.
[Show abstract][Hide abstract] ABSTRACT: Objective: To present results from a district-wide diabetes prevention programme involving health education for school children and the local community.Method: The model of health education that was utilized aimed to secure lifestyle changes and the identification of diabetes risk by school children (aged 9–12 years). The children acted as health messengers in their families as well as in the neighbouring community. Health education sessions were also held for school teachers, non-governmental organizations, primary health centre physicians, self-help groups and laypeople in the district. All were trained in diabetes risk assessment by using the standardized Indian diabetic risk score and were trained to estimate urine glucose.Results: Over a four-year period (2005–2009) the programme trained 8288 teachers and 119,743 schoolchildren in 679 schools and 30,915 people working in the health and development sectors. Trained school children reached out to 2.4 million people in over 500,000 families, covering 80% of the district population (3 million). The project identified 83,907 (3.5%) people as being at high risk of developing diabetes and these were counselled regarding risk reduction and lifestyle modifications. Among those identified with diabetes risk, 15,868 (19%) people were identified as having positive urine glucose. There were 10,522 (0.4%) people with known diabetes who were referred to identified diabetes care centres in the district.Conclusion: This child-to-family-based lifestyle change and health education intervention, along with community participation, offers a novel approach with substantial coverage of district populations in India.
[Show abstract][Hide abstract] ABSTRACT: AIM: To report serious adverse events and long-term outcomes of initial experience with intraocular bevacizumab in retinopathy of prematurity (ROP). METHODS: Consecutive vascularly active ROP cases treated with bevacizumab, in addition to laser and surgery, were analysed retrospectively from a prospective computerised ROP database. Primary efficacy outcome was regression of new vessels. Secondary outcomes included the anatomic and visual status. Serious systemic and ocular adverse events were documented. RESULTS: 24 ROP eyes in 13 babies, received single intraocular bevacizumab for severe stage 3 plus after failed laser (seven eyes), stage 4A plus (eight eyes), and stage 4B/5 plus (nine eyes). Drug was injected intravitreally in 23 eyes and intracamerally in one eye. New vessels regressed in all eyes. Vision salvage in 14 of 24 eyes and no serious neurodevelopmental abnormalities were noted up to 60 months (mean 30.7 months) follow-up. Complications included macular hole and retinal breaks causing rhegmatogenous retinal detachment (one eye); bilateral, progressive vascular attenuation, perivascular exudation and optic atrophy in one baby, and progression of detachment bilaterally to stage 5 in one baby with missed follow-up. One baby who received intracameral injection developed hepatic dysfunction. One eye of this baby also showed a large choroidal rupture. CONCLUSIONS: Though intraocular bevacizumab, along with laser and surgery salvaged vision in many otherwise progressive cases of ROP, vigilance and reporting of serious adverse events is essential for future rationalised use of the drug. We report one systemic and four ocular adverse events that require consideration in future use of the drug.
Archives of Disease in Childhood - Fetal and Neonatal Edition 12/2012; · 3.86 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: To characterize the electroretinographic response of the macula by multifocal electroretinography (mfERG) in patients with type 2 idiopathic macular telangiectasia (MacTel). METHODS: A prospective study of mfERG in patients with type 2 MacTel was conducted from April 2009 to November 2009. mfERGs were recorded using a visual evoked response imaging system (MonElec2, Metrovision, Perenchies, France). The International Society for Clinical Electrophysiology of Vision (ISCEV) guidelines were followed. Patients with type 2 MacTel confirmed by fundus fluorescein angiography without subretinal neovascularisation were included. For recording purposes, 61 stimulus hexagonal elements were used. The first-order kernel mfERG responses were analyzed. Individual mfERG responses for the hexagons were grouped into concentric rings centered on the fovea for analysis (< 2, 5-10, 10-15 and >15°). Student's t-test and Mann-Whitney U test and linear regression analysis was performed with STATA ver 11.1 (StataCorp, College Station , TX, USA). RESULTS: Twenty eight eyes of 14 patients and 20 eyes of ten normal controls were included in the study. The mean logMAR visual acuity of the patients was 0.51 (Snellen equivalent 20/63). The mean N1 amplitude (nv/deg(2)) of patients were significantly reduced compared to controls and were as follows: 8.91 ± 14.00 vs 43.44 ± 9.55 (p < 0.0001) in less than 2°, 9.24 ± 10.47 vs 22.00 ± 3.87 (p < 0.0001) in 5-10°, 8.57 ± 10.02 vs 15.24 ± 1.89 (p < 0.0001) in 10-15°, and 7.03 ± 6.52 vs 12.47 ± 2.62 in > 15° (p < 0.001). The mean P1 amplitude (nv/deg(2)) was also significantly reduced in patients compared to controls and was as follows: 27.66 ± 37.44 vs 96.20 ± 12.41 (p < 0.0001) in less than 2°, 22.61 ± 19.38 vs 53.78 ± 9.79 (p < 0.0001) in 5-10°, 18.75 ± 20.21 vs 35.22 ± 4.16 (p < 0.001) in 10-15°, and 17.10 ± 12.54 vs 25.71 ± 3.93 (p < 0.001). The implicit time of N1 and P1 were also delayed significantly in all the rings. The mean central foveal thickness assessed by optical coherence tomography (OCT) scan was 84.78 ± 45.12 μm. There was poor correlation between mfERG amplitudes or implicit times with either the visual acuity or OCT central thickness. CONCLUSION: mfERG showed significant reduction in amplitudes and implicit times of the waveforms in patients with type 2 MacTel in all the rings, suggesting a more generalized affection of the macula. The maximum reductions were seen in the <2(o) rings. Although there was poor correlation between the visual acuity and the amplitudes a of the waveforms, mfERG is a useful investigative modality for functional assessment of macula in type 2 MacTel patients.
Albrecht von Graæes Archiv für Ophthalmologie 11/2012; · 1.93 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Acute lymphoblastic leukemia (ALL) can present with various ocular complications but exudative retinal detachment is a rare complication. A 36-year-old healthy young adult male presented with gradual decrease in the vision in both eyes over nearly 2 weeks. His best-corrected visual acuities were 20/50 and 20/25 at distance and N12 and N10 at near in the right and left eyes, respectively. Fluorescein angiography and optical coherence topography indicated bilateral exudative retinal detachment. Systemic workup revealed a marked increase in the number of white blood cells with 30% blast cells and immunophenotyping revealed common acute lymphoblastic leukemia-associated antigen (CALLA) positive precursor B-cell lymphoblastic leukemia. Cerebrospinal fluid (CSF) tap was negative. The patient started systemic chemotherapy and steroids. Bilateral exudative retinal detachment may be a presenting sign of acute lymphoblastic leukemiaALL in an otherwise healthy young adult. Clinicians should be aware of the possibility of leukemia in such patients. A simple blood investigation such as complete blood profile confirms the diagnosis.
Middle East African journal of ophthalmology 10/2012; 19(4):410-2.
[Show abstract][Hide abstract] ABSTRACT: Blindness is a major global public health problem and recent estimates from World Health Organization (WHO) showed that in India there were 62 million visually impaired, of whom 8 million are blind. The Andhra Pradesh Eye Disease Study (APEDS) provided a comprehensive estimate for prevalence and causes of blindness for the state of Andhra Pradesh (AP). It also highlighted that uptake of services was also an issue, predominantly among lower socio-economic groups, women, and rural populations. On the basis of this analysis, L V Prasad Eye Institute (LVPEI) developed a pyramidal model of eye care delivery. This article describes the LVPEI eye care delivery model. The article discusses infrastructure development, human resource development, and service delivery (including prevention and promotion) in the context of primary and secondary care service delivery in rural areas. The article also alludes to opportunities for research at these levels of service delivery and the amenability of the evidence generated at these levels of the LVPEI eye health pyramid for advocacy and policy planning. In addition, management issues related to the sustainability of service delivery in rural areas are discussed. The article highlights the key factors required for the success of the LVPEI rural service delivery model and discusses challenges that need to be overcome to replicate the model. The article concludes by noting the potential to convert these challenges into opportunities by integrating certain aspects of the existing healthcare system into the model. Examples include screening of diabetes and diabetic retinopathy in order to promote higher community participation. The results of such integration can serve as evidence for advocacy and policy.
Indian Journal of Ophthalmology 09/2012; 60(5):396-400. · 0.93 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To report visual outcomes and risk factors for poor outcomes of cataract surgery in three Integrated Tribal Development Agency (ITDA) areas of Andhra Pradesh, India.
Using validated Rapid Assessment of Avoidable Blindness (RAAB) methodology, a population based cross-sectional study, was conducted in three ITDA areas. A two-stage sampling procedure was used to select 7281 participants aged 50 years and above. Vision assessment using a tumbling E chart and standard ocular examinations were completed. Visual outcomes and risk factors for poor outcomes were assessed among subjects undergoing cataract surgery (1548 eyes of 1124 subjects). Mean age at surgery was 67±8 years; Among the operated eyes, presenting visual acuity (PVA) and best corrected visual acuity (BCVA) worse than 6/18 was seen in 492 (31.8%; 95% CI, 29.5-34.2%) and 298 eyes (19.3%; 95% CI, 17.3-21.3%), respectively. Similarly, PVA and BCVA worse than 6/60 was seen in 219 (14.1%; 95% CI, 12.4-16%) and 147 eyes (9.5%; 95% CI, 8.1-11.1%), respectively. When either eye was taken into consideration, the PVA and BCVA worse than 6/18 was seen in 323 (20.1%; 95% CI, 18.9-23%) and 144 subjects (9.3%; 95% CI, 7.9-10.9%), respectively. PVA and BCVA worse than 6/60 was seen in 74 (4.8%; 95% CI, 3.8-6%) and 49 subjects (3.2%; 95% CI, 2.4-4.2%), respectively. Posterior capsular opacification was seen in 51 of 1316 pseudophakic eyes (3.9%; 95% CI, 2.9-5.1%). In multivariable analysis among pseudophakic subjects with PVA worse than 6/18, increasing age (p = 0.002) and undergoing free surgery (p = 0.05) were independent risk factors. Undergoing surgery before 2005 (p = 0.05) and being illiterate (p = 0.05) were independent risk factors for BCVA worse than 6/18.
There are changing trends with improved outcomes in cataract surgery among these tribal populations of India. However, post-operative refractive error correction remains an issue, especially for those undergoing free surgeries.
PLoS ONE 01/2012; 7(5):e35701. · 3.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Purpose: To report the prevalence of visual impairment (VI) and the associated risk factors
in type II diabetic subjects.
Materials and Methods: The study included type II diabetes mellitus subjects who were
enrolled from a cross-sectional study. Participants underwent biochemical testing and
comprehensive ocular examination including stereo fundus photography. The VI was defined
based on the World Health Organization criteria.
Results: The prevalence of VI was 4% in the cohort. The risk factors associated with the
presence of VI included a female gender, age greater than 60 years, low socio-economic status,
hypertension, microalbuminuria, macroalbuminuria, neuropathy, use of insulin and alcohol.
Various ocular risk factors are nuclear sclerosis, subjects who have undergone cataract surgery,
myopia and sight-threatening diabetic retinopathy (STDR). After adjusting for the factors
using stepwise logistic regression analysis, hypertension, use of alcohol, post-cataract surgery
and myopia were not risk factors. Stepwise logistic regression analysis indicated that VI was
higher among subjects older than 60 years (odds ratio (OR): 4.95 [2.67-9.15]) and those who
belonged to a low socio-economic status (OR: 2.91 [1.24-6.85]). The systemic risk factors for VI
included microalbuminuria (OR: 2.91 [1.59-5.33]), macroalbuminuria (OR: 4.65 [1.57-13.77])
and presence of neuropathy (OR: 1.97 [1.09-3.59]) among subjects. Subjects with nuclear
sclerosis (OR: 36.82 [11.12-112.36]) and presence of STDR (OR: 4.17 [1.54-11.29]) were at a
higher risk of VI. Cataract was the most common cause of VI in the cohort.
Conclusion: Visual impairment, among type II diabetic subjects (4%), is a major public health
problem that needs to be addressed. Cataract is the most common reversible cause of vision
impairment in this population.
Middle East African journal of ophthalmology 01/2012; 19(1):129.