Comparative evaluation of diabetic retinopathy screening programs in regular ophthalmology clinics versus integrated diabetic clinics within rural health-care services.

BACKGROUND: Robust integration of diabetic retinopathy (DR) screening within health systems is essential to prevent DR-related blindness. This, however, remains a challenge in the developing world. The aim of this study was to evaluate two models of DR screening programs within rural general health-care services. MATERIALS AND METHODS: This was a retrospective observational study from two rural health centers. Demographic and clinical data of patients completing DR screening were analyzed. Patients were screened in regular ophthalmology clinics (ROC) or integrated diabetic clinics (IDC). Referral and treatment completion data were retrieved from the clinical charts at the base hospital. RESULTS: A total of 2535 DR screenings were conducted for 2296 patients. The total population prevalence for any DR was 14.2% (95% confidence interval [CI]: 12.8%-15.6%) and vision-threatening DR (VTDR) was 4.7% (95% CI: 3.8%-5.6%). In the ROC and IDC groups, respectively, the prevalence of any DR was 20.4% and 8.2%, VTDR, 7.8% and 1.7%, and blindness, 1.4% and 0.4% (all P < 0.001). Referral completion rates were higher in the ROC group (44.8% vs. 25.2%, P < 0.001), while treatment completion in both was similar (69.6% vs. 70.6%). Referral and treatment completion rates for referable DR were 61.2% and 48.2%, and for VTDR, 62% and 38.8%, respectively. Only 11.45% of patients completed the repeat screening follow-up. CONCLUSIONS: Patients attending IDCs had a significantly lower prevalence of any DR, VTDR, and blindness demonstrating the advantages of integrated diabetic care in a rural setting. However, referral uptake and DR treatment completion need strengthening.

Eye Signs in Stroke.

A large part of the central nervous system is involved in the normal functioning of the vision, and hence vision can be affected in a stroke patient. Transient visual symptoms can likewise be a harbinger of stroke and prompt rapid evaluation for the prevention of recurrent stroke. A carotid artery disease can manifest as transient monocular visual loss (TMVL), central retinal artery occlusion (CRAO), anterior ischemic optic neuropathy or ocular ischemic syndrome (OIS). Stroke posterior to the optic chiasm can cause sectoranopias, quadrantanopias, or hemianopias, which can be either congruous or incongruous. Any stroke involving the dorsal stream (occipito-parietal lobe), or ventral stream (occipito-temporal lobe) can manifest with visuospatial perception deficits. Similarly, different ocular motility abnormalities can result from a stroke affecting the cerebrum, cerebellum, or brainstem. Among these deficits, vision and perception disorders are more difficult to overcome. Clinical, experimental, and neuroimaging studies have helped us to understand the anatomical basis, physiological dysfunction, and the underlying mechanisms of these neuro-ophthalmic signs.

A reappraisal of indirect choroidal rupture using swept-source optical coherence tomography in-vivo pathology images in patients with blunt eye trauma.

PURPOSE: To describe the in-vivo pathology of indirect choroidal rupture (ICR) in patients with recent ocular trauma using swept-source optical coherence tomography (SSOCT). METHODS: Retrospective observational study of the presenting and follow-up OCT images of four consecutive Asian patients with blunt trauma presenting over a period of 6 months and review of OCT descriptions in the literature. RESULTS: The three patients who presented within 2 weeks of injury showed a gap in the Bruch's membrane (BM)/retinal pigment epithelial complex at the site of the ICR. The distance of the gap ranged from 103 to 465 µm. Blood from associated tear in the choriocapillary layer dissected under the photoreceptor layer to lift it off the retinal pigment epithelium (RPE) layer. The Sattler's and Haller's layers of the choroid were not affected. Fibro-vascular proliferation occurring in the reparative phase bridges the gap in the BM, RPE complex. Late fibrous tissue proliferation extends into the Sattler's layer in the choroid and goes up to the outer nuclear layer in the retina disrupting its architecture. CONCLUSION: SSOCT is a useful tool to study the pathology of recent onset ICR as it is capable of imaging through blood. The primary injury in ICR seems to be a break in the Bruch's membrane. The RPE layer and choriocapillaries get disrupted secondary to the break in the BM as their basement membranes are part of the BM. Scarring during the reparative phase disrupts the adjacent layers of the choroid and retina.

Tolosa-Hunt Syndrome: Long-Term Outcome and Role of Steroid-Sparing Agents.

BACKGROUND: Tolosa-Hunt Syndrome (THS) is one of the causes of cavernous sinus syndrome causing painful ophthalmoplegia. Literature on long-term outcome of this rare condition is scarce. AIMS AND OBJECTIVES: The aim is to study the recurrence and role of steroid-sparing agents in THS. METHODOLOGY: All cases of THS treated at a tertiary-level teaching hospital during a 10-year period were studied. Clinical and radiological profile, response to treatment and recurrences were noted. RESULTS: A total of 44 cases were studied. The mean age was 49.5 years, Males constituted 23/44 (52%). The first symptom was pain in 90%. Ptosis with ophthalmoplegia was the most common deficit 29/44 (66%). Lesions confined to cavernous sinus 27/44 (61%) was the most frequent magnetic resonance imaging finding. All patients received steroids as the initial treatment and 15/44 (34%) received steroid-sparing agents. Follow-up ranged from 6 to 120 months (Mean 39 months). Two patients had alternative diagnosis of leptomeningeal malignancy and hypertrophic pachymeningitis on follow-up. Recurrences occurred in 18/37 (48.6%). Time for recurrence varied from 8 months to 7 years. (Mean 18 months). No clinical or radiological predictors for recurrence were identified. Patients who received steroid-sparing agents had a significantly lower recurrence 3/15 (20%) versus 14/26 (53.8%)P < 0.034. CONCLUSIONS: Around 50% of patients with THS can have recurrence. Steroid-sparing agents appear to prevent recurrence. A prospective multicenter randomized controlled trial may help to evaluate the risk and benefits of steroid-sparing therapy and to identify any possible predictors for recurrence.

Spectrum of Visual Impairment in Cerebral Venous Thrombosis: Importance of Tailoring Therapies Based on Pathophysiology.

Visual impairment can complicate cerebral venous thrombosis (CVT). Here, we describe the various pathophysiological mechanisms and treatments available. A retrospective chart review of all patients treated for CVT in a large quaternary teaching hospital was done, and cases with visual impairment due to CVT were identified. The various mechanisms causing visual impairment in CVT were (1) raised intracranial pressure (ICP) caused by venous thrombosis without venous infarcts resulting in a benign intracranial hypertension-like presentation of CVT, (2) venous infarcts involving the occipital cortex, (3) raised ICP following the development of a secondary dural arteriovenous (AV) fistula, and (4) arterial occipital infarcts due to posterior cerebral artery compression secondary to herniation in large venous infarcts. Apart from using systemic anticoagulants to attempt recanalization and drugs with carbonic anhydrase inhibitor activity to reduce the ICPs, treatment modalities employed to save vision were (1) recanalization by local thrombolysis, stenting, or mechanical devices; (2) cerebrospinal fluid diversion procedures such as theco-periotoneal shunting; (3) optic nerve sheath fenestration; and (4) specific treatment for conditions such as dural AV fistula occurring as a late complication. CVT can cause visual impairment through different pathophysiological mechanisms. Depending on the mechanism, treatment strategies need to be tailored. Furthermore, very close monitoring is needed both in the acute and in the follow-up period, as new pathophysiological mechanisms can arise, compromising the vision. This may require a different treatment approach. Literature on this aspect of CVT is lacking.

Presumed Chemotherapy-Induced Optic Neuropathy and Maculopathy: A Case Report.

PURPOSE: With the advent of more aggressive cytotoxic chemotherapy regimens, the incidence of ocular toxicity due to these drugs is also on the rise. We report a case of Presumed Chemotherapy-Induced optic neuropathy and maculopathy secondary to treatment with cytarabine and daunorubicin for Acute Myeloid Leukaemia (AML). CASE REPORT: A 50-year-old man with AML developed sudden decrease in vision in his left eye after three cycles of chemotherapy with cytarabine and daunorubicin. He presented to us six weeks later with bilateral optic atrophy and foveal atrophic changes with early bull's eye maculopathy. A diagnosis of presumed chemotherapy-induced optic neuropathy with maculopathy was made, and the patient was put on an alternative chemotherapeutic regimen. There was no further decrease in vision on follow up. CONCLUSION: To the best of our knowledge, this is the first report of clinically demonstrable macular toxicity in the form of macular atrophic changes and bull's eye maculopathy associated with the use of cytarabine and daunorubicin. Early diagnosis and appropriate management of such cases is imperative to prevent further visual deterioration.

Orbital Metastasis of Cervical Carcinoma - Case Report and Review of Literature.

The orbit is a frequent site of metastasis, particularly from the breast, prostate gland and the lung. Carcinoma of the cervix metastasizing to the orbit is rare. We report a 27-year-old woman with Stage II B cervical cancer who presented with progressive painless protrusion of the left eye of one month duration associated with diplopia. Histology of the orbital mass was similar to that of the cervical cancer and reported as squamous cell carcinoma. She received palliative radiation to the left orbit 30 Gy in 10 fractions along with chemotherapy (Paclitaxel and Carboplatin). This resulted in regression of the proptosis. We review published literature of cases of carcinoma of the uterine cervix with metastasis to the orbit.

Ophthalmic masquerades of the atherosclerotic carotids.

Patients with carotid atherosclerosis can present with ophthalmic symptoms. These symptoms and signs can be due to retinal emboli, hypoperfusion of the retina and choroid, opening up of collateral channels, or chronic hypoperfusion of the globe (ocular ischemic syndrome). These pathological mechanisms can produce many interesting signs and a careful history can bring out important past symptoms pointing toward the carotid as the source of the patient's presenting symptom. Such patients are at high risk for an ischemic stroke, especially in the subsequent few days following their first acute symptom. It is important for clinicians to be familiar with these ophthalmic symptoms and signs caused by carotid atherosclerosis for making an early diagnosis and to take appropriate measures to prevent a stroke. This review elaborates the clinical features, importance, and implications of various ophthalmic symptoms and signs resulting from atherosclerotic carotid artery disease.

Primary conjunctival tuberculosis in a 14 year old girl.

Tuberculosis is a common disease in India. However, tuberculosis primarily affecting the conjuctiva is a rare entity. We report a 14-year-old girl who presented with unilateral eye discharge, watering, redness and itching for two weeks. Giant papillae were present on the upper tarsal conjunctiva. A provisional diagnosis of allergic conjunctivitis was made. Topical therapy with 1% Prednisolone acetate and 2% Sodium cromoglycate was commenced. The patient returned six months later with no improvement in the symptoms. The tarsal conjunctiva had a polypoidal, velvety appearance with giant papillae. A fibrinous membrane was seen over the tarsal conjunctiva and a preauricular node was found. Excision biopsy and histopathologic examination revealed necrotizing granulomatous inflammation suggestive of tuberculosis. Systemic examination and investigations were normal. She was started on anti-tuberculous therapy. In two months she showed complete resolution of symptoms and marked reduction in papillae and conjunctival thickening. Symptoms and signs of unilateral conjunctivitis may masquerade as primary conjunctival tuberculosis. In an endemic country like India, laterality, chronicity and non-resolution of symptoms with steroids are indications for pursuing a biopsy earlier than later. In our patient, the histopathology clinched the diagnosis of conjunctival tuberculosis resulting in a faster and complete resolution of the disease condition.