Morphological and functional retinal changes in neovascular age-related macular degeneration treated with intravitreal bevacizumab

Purpose: This study was conducted to determine the morphological and functional retinal changes in patients with neovascular age?related macular degeneration (nAMD) treated with intravitreal bevacizumab 1.25 mg. Methods: This was a prospective, nonrandomized, interventional study. Eighteen eyes of 18 subjects with nAMD were treated with intravitreal bevacizumab (1.25 mg) injection. Subjects underwent complete ophthalmic evaluation which included visual acuity, slitlamp examination, tonometry, binocular ophthalmoscopy, optical coherence tomography (OCT), and MP1 microperimetry before the intravitreal injection and the follow?up at 1 and 3 months. Test of significance such as Chi?squared test, paired ttest and oneway analysis of variance (ANOVA) linear trend were used to compare the pre? and post?anti?VEGF outcomes. Intraclass correlation was done to assess the intra observer variability. Results: Mean retinal sensitivity had increased from 3.77 ± 3.13 dB at baseline to 4.93 ± 2.42 dB at 3 months (P = 0.05). Visual acuity improved from 0.62 ± 0.36 at baseline to 0.52 ± 0.36 at 1 month and 0.48 ± 0.34 at 3?month followup, but overall change was not significant (P = 0.40). There was a significant reduction in central foveal thickness (CFT) from 274.61 ± 117.95 at baseline to 179.83 ± 84.18 at 1 month and 179.00 ± 126.55 at 3?month follow?up (P = 0.013). Conclusion: Intravitreal bevacizumab (1.25 mg) injection in nAMD improves retinal function, quantified by retinal sensitivity, scotoma characteristics, fixation stability by MP 1 microperimetry and morphological parameters quantified by CFT in SDOCT. These changes show the effectiveness of treatment with intravitreal bevacizumab in nAMD

Subarachnoid haemorrhage mimicking unstable angina: a case report

Subarachnoid haemorrhage (SAH) is medical emergency caused by bleeding into the subarachnoid space. It is caused by rupture of an aneurysm or arteriovenous malformations (AVM). Symptoms of SAH are severe headache, nausea, vomiting, impaired consciousness and seizures. Neck stiffness and neck pain are relatively uncommon. Risk factors are high blood pressure, smoking, family history, alcoholism and even cocaine use. Diagnosis is mainly made by CT scan of head which should be done within six hours of the onset of symptoms and occasionally lumber puncture can also be done. An electrocardiogram (ECG) of all patients with subarachnoid should be done because patient with SAH can have myocardial ischemia due to increased level of circulating catecholamines or due to autonomic stimulation of the brain. ECG changes associated with SAH primarily reflect repolarisation abnormalities involving ST segment, T wave, U wave and QTc interval. Myocardial ischemia or infarction is often suspected in patients with SAH. Even troponin levels may be raised in these patients. However, suspicion of SAH is a contraindication for thrombolytic and anticoagulant therapy. This is a case of SAH which was initially treated for acute coronary syndrome (ACS) on the basis of symptoms and gradually changing ECG findings but on CT Head, patient was having SAH.

Thyrotoxic Neuropathy - A Case Report

Thyrotoxic neuropathy is a rare entity in literature. The association between thyrotoxicosis and neuropathy is under-recognized. We here present a rare case report in which patient was presented with ascending sensory-motor paralysis coupled with respiratory muscle weakness which closely resembles Guillain–Barré syndrome (GBS). But relevant history suggested thyrotoxic features, thus a timely focused investigation revealed the diagnosis. It was confirmed in nerve conduction studies (NCS) and other necessary investigations ruled out other differential diagnosis. Patient was treated with anti-thyroid drugs. On follow up patient’s power improved and NCS after 6 months came out to be normal which established the diagnosis. Thyrotoxic neuropathy is a close differential diagnosis of LGBS and other commonly encountered neuroparalytic illnesses. So high degree of suspicion is needed to diagnose this potentially treatable neuropathy

A Case Of Cerebral Sinus Venous Thrombosis Resulting In Mortality In Pregnant Woman: Late Diagnosis

Cerebral venous sinus thrombosis (CVST) is a rare condition. The most frequent symptoms and signs are headache, focal seizures with or without secondary generalization, unilateral or bilateral paresis and papilledema. We report a case of CVST in a 30-year-old female that presented with headache, diminution of vision, swelling and pain in both eyes and bilateral restricted extraocular movements. She expired after 3 days of treatment as she was diagnosed late. Due to its diverse and varied clinical presentation, CVST should be considered as differential in almost any brain syndrome.

Rheumatoid Arthritis 1st Time Presenting With Bilateral Pleural Effusion- A Rare Presentation

Rheumatoid arthritis is the most common chronic autoimmune disorder involving joints and extra-axial system. Varied presentations have been described in the literature. Pulmonary involvement is also common. Inflammatory pleural effusions are an uncommon complication and are rarely seen in about 2% to 5% of patients with rheumatoid arthritis. Here, we present an interesting case where the patient presented with bilateral pleural effusion early in the disease. On further evaluation of the patient and the pleural fluid, it was found to be consistent with pleural effusion secondary to rheumatoid arthritis. The patient responded to oral non-steroidal anti-inflammatory drugs along with disease-modifying agents

Liver Cirrhosis First Time Presented With Delirium Unveiled As Accidental Secondary Hypothermia

Liver cirrhosis is a condition which is defined histopathologically but cannot be diagnosed clinically without any non-invasive tests. There are various etiologies of cirrhosis such as alcoholic liver disease, chronic viral hepatitis B, C, and non-alcoholic fatty liver diseases. Liver, not only function as an organ for detoxification, conjugation, and synthesis but also it regulates body heat. Cirrhosis patients thus are prone to body heat loss and hyperthermia. We present a case with undiagnosed liver cirrhosis patient, 1st time presenting with altered sensorium, revealed as accidental secondary hypothermia with ECG changes of hypothermia. The patient treated for hypothermia only after which she recovered.

Pulmonary Embolism As Presenting Feature Of Membranous Nephropathy Induced Nephrotic Syndrome

Severe pulmonary embolism as first-time presentation of Nephrotic syndrome is rare but Nephrotic syndrome secondary to membranous nephropathy (MN) may impose a greater thrombotic risk for unclear reasons. Here, we report the case of a 36-year-old female patient presented with complaints of sudden onset of shortness of breath since 4-5 days and features of right-sided heart failure. There was no preceding history of any chronic disease or renal disease. She was diagnosed as having a bilateral severe pulmonary embolism. Extensive workup and renal biopsy were done which was suggestive of primary membranous nephropathy.

Evaluation of Change in Dento-Skeletal Vertical Dimensions using Two Retraction Methods: A Comparative Study

Introduction: The goal of Orthodontic treatment is toimprove the patient’s life through enhancement of Dentofacialfunctions and esthetics. Paradigms have started to shift inOrthodontic world since the introduction of mini-implantsin the anchorage armamentarium. So the present study wasundertaken to analyse and compare the amount of Intrusionin maxillary anterior teeth segment using one and twominiscrews, while paying an utmost attention to patientscomfort and esthetics during the treatment.Material and Methods: The sample consisted of 20 subjectswith deep overbite and complete root formation with increasedincisor show. Lateral cephlogram and P.A Cephalogram wererecorded before placement of implant. Sample was furtherdivided in to two groups, Group I (Implant group one implantis placed between maxillary central incisors and two implantsplaced between second premolar and first molar) and GroupII (Implant Group with Power arms, one implant is placedbetween maxillary central incisor and power arms fabricatedon first molar bilaterally). Clinical evaluation of intrusion wasrecorded on every six weeks.Results: The mean intrusion achieved is 0.28mm per 6weeks interval of time in both groups suggesting there is nodifference in amount of intrusion achieved in both groups withp value of 0.697 which is statistically non-significant. Changein Frankfort mandibular plane angle was observed with GroupI and Group II.Conclusion: On the base of study it was concluded thatimplant and power arm is better choice for intrusion inmaxillary anterior segment for correction of deep overbite andcorrection of gummy smile with minimal effect on posteriorsegment

Lymphocytic Hypophysitis Masquerading As Transient Secondary Hyperadrenalism Followed By Panhypopituitarism

Lymphocytic hypophysitis (LH) is a rare inflammatory disease of the pituitary gland. This condition strikingly shows female preponderance and commonly affects women during pregnancy or in the post-partum period. It’s a clinical presentation and radiological features may mimic pituitary adenoma. Though its treatment modality is uncertain steroid remains the 1st option for treatment. Here, we report an unusual case of LHin a 21-year-old female patient where initially, the patient presented with hyperadrenalism and secondary hyperthyroidism followed by pan-hypopituitarism (Addisonian crisis) which is attributed to initial autoimmune destruction of the gland followed by subsequent fibrosis. Thus, it is a rare case report which exquisitely explains this rare presentation and such cases should be investigated thoroughly since there are many differential and response to steroids is remarkable

Snakebite Presenting As Acute Coronary Syndrome: An Interesting Diagnosis And Management

Snakebite is a common presentation in India, especially in the Sub-Himalayan region. The most common presentation of snakebite is neurotoxic and hematologic complications. Acute coronary syndrome after a snakebite is rare. This case report explicitly explains a patient presenting as acute coronary syndrome after a snakebite with dynamic electrocardiogram changes. Later on, the anti-snake venom therapy was given to the patient and her condition improved. It should be kept in mind that, since the pathology of snakebite-induced myocardial infarction is different, its management will also be different.

Coats’ disease of adult‑onset in 48 eyes.

Background: Coats’ disease diagnosed in adulthood is an idiopathic, retinal exudative vascular disease without an inciting factor and has retinal features different from the childhood disease. Aim: To describe clinical features, treatment, and outcomes of eyes with Coats’ disease first diagnosed in patients 35 years or older. Materials and Methods: Retrospective chart review of patients first diagnosed with Coats’ disease at the age of 35 years or more at a tertiary eye care center between January 1995 and 2012. Eyes with retinal exudation or Coats’‑like response from secondary causes were excluded. Results: Forty‑five of 646 patients (7%) diagnosed with Coats’ disease had adult‑onset disease. Mean age at presentation was 47 years. Systemic hypertension was the most common (22%) systemic association and decreased vision the predominant presenting feature (83%). Localized (<6 clock h) presentation (74%) was unique to adults as against diffuse involvement (69%) in children (P < 0.001). Eyes were treated with laser photocoagulation 29 (60%), cryotherapy (4%), or both (2%) with surgical intervention in three (6%) eyes. Following treatment eight (35%) eyes improved, 11 (48%) eyes were stable while four (12%) eyes worsened due to complications. Conclusion: Adult‑onset Coats’ disease has less extensive involvement, more benign natural course, and a more favorable treatment outcome as against the childhood‑onset disease. The bilateral presentation emphasizes the need for regular follow‑up to detect possible future involvement of the fellow eye.

Failure to initiate early insulin therapy – A risk factor for diabetic retinopathy in insulin users with Type 2 diabetes mellitus: Sankara Nethralaya-Diabetic Retinopathy Epidemiology and Molecular Genetics Study (SN-DREAMS, Report number 35).

Context: Insulin users have been reported to have a higher incidence of diabetic retinopathy (DR). Aim: The aim was to elucidate the factors associated with DR among insulin users, especially association between duration, prior to initiating insulin for Type 2 diabetes mellitus (DM) and developing DR. Materials and Methods: Retrospective cross‑sectional observational study included 1414 subjects having Type 2 DM. Insulin users were defined as subjects using insulin for glycemic control, and insulin nonusers as those either not using any antidiabetic treatment or using diet control or oral medications. The duration before initiating insulin after diagnosis was calculated by subtracting the duration of insulin usage from the duration of DM. DR was clinically graded using Klein’s classification. SPSS (version 9.0) was used for statistical analysis. Results: Insulin users had more incidence of DR (52.9% vs. 16.3%, P < 0.0001) and sight threatening DR (19.1% vs. 2.4%, P < 0.0001) in comparison to insulin nonusers. Among insulin users, longer duration of DM (odds ratio [OR] 1.12, 95% confidence interval [CI] 1.00–1.25, P = 0.044) and abdominal obesity (OR 1.15, 95% CI 1.02–1.29, P = 0.021) was associated with DR. The presence of DR was significantly associated with longer duration (≥5 years) prior to initiating insulin therapy, overall (38.0% vs. 62.0%, P = 0.013), and in subjects with suboptimal glycemic control (32.5% vs. 67.5%, P = 0.022). Conclusions: The presence of DR is significantly associated with longer duration of diabetes (>5 years) and sub‑optimal glycemic control (glycosylated hemoglobin <7.0%). Among insulin users, abdominal obesity was found to be a significant predictor of DR; DR is associated with longer duration prior to initiating insulin therapy in Type 2 DM subjects with suboptimal glycemic control.

Diabetic retinopathy: An epidemic at home and around the world.

Prevention of blindness due to diabetic retinopathy (DR) requires effective screening strategies, for which eye care providers need to know the magnitude of the burden and the risk factors pertinent in their geographical location. It is estimated that around 72 million of the global adult population (around 8.2%) has diabetes and about one‑fifth of all adults with diabetes lives in the South‑East Asia. In India, around 65 million people have diabetes. As the global prevalence of diabetes increases, so will the number of people with diabetes‑related complications, such as DR; nearly one‑third of them are likely to develop this complication. This article reviews the present status of diabetes and DR in India, the current situation of DR services and the projections on the load of morbidity associated with retinopathy. The article compiles the Indian studies elucidating the risk factors for DR.

Prenatal genetic diagnosis of retinoblastoma – clinical correlates on follow‑up.

Retinoblastoma is the most common malignant intraocular tumor in pediatric age group if undetected leads to ocular mortality. Prenatal diagnosis is an emerging technology to detect fatal diseases in utero such that subsequent management is planned to reduce the ocular morbidity. We describe a case demonstrating the importance of prenatal diagnosis in a child with a strong family history of retinoblastoma and importance of a long‑term clinical follow‑up in these cases.

Sympathetic ophthalmitis following vitreoretinal surgery: Does antecedent trauma make a difference.

Background: Sympathetic ophthalmitis (SO) has been reported following vitrectomy; however, there is a lack of data on the role of antecedent penetrating ocular trauma impacting the disease manifestation in eyes developing SO following vitrectomy. Aim: To report differences in the presentation and outcomes of SO in eyes with or without a history of antecedent penetrating trauma; SO being diagnosed after vitreoretinal (VR) surgery. Design: Comparative case series. Methods: Seventeen consecutive patients presenting with SO following VR surgery, diagnosed between 1995 and 2011 were included. Eyes with and without prior penetrating injury were included in Group I (n = 7) and Group II (n = 10), respectively. All Group I patients had received systemic steroids prior to presentation. Demographic and clinical parameters were evaluated. Results: Differences were observed between Group I and Group II mainly with regards to time interval between VR surgery and diagnosis of SO (1.5 months vs. 8 months, P = 0.10), presence of neurosensory detachments (100% vs. 30%, P = 0.01), and the inciting eye vision at presentation (nil light perception in 28.5% vs. 80%, P = 0.049). Other differences observed though not statistically significant were optic disc and retinal vessel involvement (42% vs. 70%, P = 0.28), Dalen‑Fuchs nodules (localized vs. diffuse) and leaks on fundus fluorescein angiography (pin‑head vs. pin‑point leak). Conclusion: SO in patients with antecedent penetrating ocular trauma present early with the central serous chorioretinopathy‑like picture. Prior use of systemic steroids might have a bearing on the differences in presentation and the visual acuities between the two groups.

An unusual case of trifluoperazine induced hypoglycemia.

Hypoglycemia is a serious condition which if not diagnosed and treated urgently may cause irreversible damage to the brain and may be life threatening. There are various causes attributed to hypoglycemia, but drugs are one of the most important one of them. Various drugs are documented to cause hypoglycemia but we present a rare case report of a 52-year-old male patient with schizoaffective disorder on trifluoperazine who presented in emergency department with documented hypoglycemia and this hypoglycemic episode improved when the drug was withdrawn. When WHO causality assessment scale was applied, trifluoperazine was found as the probable cause of the episodes of hypoglycemia. Therefore, this possibility of hypoglycemia should always be kept in mind while prescribing trifluoperazine.

Microperimetry biofeedback training in a patient with bilateral myopic macular degeneration with central scotoma.

Microperimetry‑1 (MP‑1) evaluation and MP‑1 biofeedback training were done in a case of bilateral myopic macular degeneration with a central scotoma. Fixation behavior, location and stability of preferred retinal locus, eye movement speed, and mean sensitivity were assessed. The mean retinal sensitivities before, after and at 1‑year after training in the right eye were 2.9 dB, 2.9 dB and 3.7 dB and in the left eye were 3.5 dB, 3.7 dB and 1.8 dB. The fixation point in the 2° gravitation circle, improved from 40% to 50% in the right eye and from 43% to 67% in the left eye. The average eye speed before, after and at 1‑year after training in right eye were 0.19°/s, 0.26°/s and 0.25°/s and in left eye were 0.36°/s, 0.25°/s and 0.27°/s. Thus, biofeedback training using MP‑1 can improve the visual function in patients with macular diseases and central scotoma.

Foveal slope measurements in diabetic retinopathy: Can it predict development of sight-threatening retinopathy? Sankara Nethralaya Diabetic Retinopathy Epidemiology and Molecular Genetics Study (SN-DREAMS II, Report no 8).

Aim: The aim was to assess the foveal slope configuration in subjects with type 2 diabetes in a population‑based study. Materials and Methods: A subset of 668 subjects from Sankara Nethralaya Diabetic Retinopathy (DR) Epidemiology and Molecular Genetics Study II, a population‑based study, were included in the current study. All the subjects underwent comprehensive ophthalmic evaluation including spectral domain optical coherence tomography. Foveal thickness was assessed in five central early treatment DR study quadrants from the three‑dimensional scan and foveal slope was calculated in all the four quadrants. Results: Subjects with sight‑threatening DR (STDR) had significantly shallow foveal slope in inferior quadrant (STDR: 7.33 ± 6.26 vs. controls: 10.31 ± 3.44; P = 0.021) when compared to controls and in superior (STDR: 7.62 ± 5.81 vs. no DR: 9.11 ± 2.82; P = 0.033), inferior (STDR: 7.33 ± 6.26 vs. no DR: 8.81 ± 2.81; P = 0.048), and temporal quadrants (STDR: 6.69 ± 5.70 vs. no DR: 7.97 ± 2.33; P = 0.030) when compared to subjects with no DR. Foveal slope was significantly shallow among the older age groups in subjects with no DR (P < 0.001) and non‑STDR (P = 0.027). Average foveal slope in the diabetic subjects was independently and significantly correlated with increase in age (r = −0.241; P < 0.001) and central subfield thickness (r = −0.542; P < 0.001). Conclusion: Changes in foveal slope were seen with increasing age; however, in diabetes these segmental slope changes can be seen in late DR (STDR).

Intra‑arterial chemotherapy for retinoblastoma: First Indian report.

Aim: To describe treatment outcomes and complications of selective intra‑arterial chemotherapy (IAC) for retinoblastoma (RB) in Indian eyes. Materials and Methods: Single center, retrospective interventional case series of 6 eyes with RB who underwent IAC using Melphalan (3 mg/5 mg/7.5 mg) and topetecan (1 mg) (n = 4) or melphalan (3 mg/5 mg/7.5 mg) alone (n = 2) between December 2013 and June 2014. In all, 17 IAC procedures were performed using selective ophthalmic artery cannulation. Treatment outcomes were evaluated in terms of tumor control, vitreous and subretinal seeds control and globe salvage rates. Results: IAC was employed as primary (n = 1) or secondary (n = 5) modality of treatment. Each eye received mean 3 IAC sessions (median: 3; range: 1–4 sessions). Eyes were classified according to international classification of RB as Group B (n = 1), C (n = 1), D (n = 2) and E (n = 2). Following IAC, complete regression of the main tumor was seen in 3 cases (50%), partial regression in 2 (33%), while 1 case (15%) showed no response. Of 4 eyes with subretinal seeds, 1 (25%) eye had complete regression while 3 (75%) eyes had partial regression. Of 5 eyes with vitreous seeds, 2 (40%) eyes had complete regression while 3 (60%) eyes had a partial response. Globe salvage was achieved in 5 of 6 eyes (83%). Diffuse choroidal atrophy and vitreous hemorrhage were observed in 1 (17%) eye, each. No hematologic toxicity or cerebro‑vascular events were observed. Mean follow‑up period was 5.5 months (median: 6 months, range: 1–6 months). Conclusion: IAC is an effective therapy for globe preservation in eyes with RB. Larger studies with longer follow‑up are required to validate these results.