Visual outcome after endovascular intervention in Takayasu arteritis.

Takayasu arteritis is a chronic multisystem vasculitis which has been known to be associated with myriad of ophthalmological manifestations. Steroids and immunomodulators are the mainstay of medical management in early stages of disease. We report the case of a 15-year-old girl with complaints of diminution of vision in both the eyes. Her ophthalmic examination suggested a diagnosis of Takayasu retinopathy with posterior ischemic optic neuropathy in her left eye and ocular ischemic syndrome in the right eye. Digital subtraction angiography revealed a significant narrowing of major vessels originating from the arch of aorta and the left vertebral artery. She underwent left subclavian artery and left vertebral artery balloon angioplasty followed by left vertebral artery stenting. Her vision improved significantly postprocedure, suggesting that endovascular intervention in the later stages of disease is a promising treatment modality for Takayasu retinopathy.

Evaluation of primary Ahmed Glaucoma valve implantation in post-traumatic angle recession glaucoma in Indian eyes.

PURPOSE: To highlight the efficacy of primary Ahmed glaucoma valve implantation in angle recession glaucoma following blunt ocular trauma in Indian eyes. DESIGN: A retrospective analytical study. MATERIALS AND METHODS: This study included 52 patients of angle recession glaucoma, who presented between Mar 2006 to Feb 2016, out of which 38 patients had undergone primary AGV implantation, while the rest were managed with topical anti-glaucoma medications. Preoperative data included age, sex, type and mode of injury, duration of injury, assessment of best-corrected visual acuity (BCVA) and intraocular pressure (IOP). The extent of angle recession was observed by gonioscopy. The intraocular pressure, visual acuity, and the number of anti-glaucoma medications were measured postoperatively. The success of this technique was analyzed by using a Kaplan-Meier cumulative survival curve. RESULTS: Following AGV implantation, the mean IOP was significantly reduced to 8.7 ± 2.2 at 1st day, 10.1 ± 2.2 at 7th day, 14.2 ± 3.4 at 3rd month, 15.6 ± 3.7 at 1 year, and 15.6 ± 3.6 at 3rd-year follow-up showing statistically significant values (p < 0.001) at each visit. The IOP was successfully controlled at the last follow-up without topical treatment. Mean BCVA at 3 years -post-AGV was 0.144 (0.151) (LogMAR) which was statistically significant (p < 0.001) as compared to the mean BCVA of 0.898 (± 0.205) LogMAR units at presentation. The success rate by Kaplan-Meier survival curve analysis was 90% at the mean follow-up duration of 29.47 ± 3.39 months. Overall surgical complications were noted in the form of prolonged hypotony, hyphema in 7 patients (13.5%). CONCLUSIONS: In medically uncontrolled post-traumatic angle recession glaucoma, primary AGV Implantation is a safe and effective surgical procedure with lesser complication rates providing long-term IOP control in a younger population.

Turbulent Flow in a Cavernous Sinus Lesion: Does It Suggest Something?

A 14-year-old boy who had been complaining of double vision for the previous month was referred for neuro-ophthalmological evaluation. He was carrying a diagnosis of a cavernous sinus haemangioma causing a right VIth nerve palsy, based on imaging elsewhere. He reported having a boil at the angle of his mouth, which was associated with left-sided facial cellulitis, two weeks before the onset of the diplopia. His blood investigations showed a leukocytosis with elevated inflammatory markers. Re-evaluation of the magnetic resonance imaging suggested a sac-like out-pouching in the intracavernous part of the right internal carotid artery with differential intensity suggestive of turbulent flow. On the basis of the clinico-radiological findings, a diagnosis of mycotic aneurysm of the cavernous sinus part of internal carotid artery was made. A high index of suspicion is required to detect this rare clinical entity, which is associated with a potentially catastrophic clinical course.

Corneal biomechanical properties in patients with kidney transplant.

PURPOSE: The purpose of the study was to evaluate the corneal biomechanical properties in patients post kidney transplant and to compare them with healthy age-matched control. MATERIALS AND METHODS: In this cross-sectional study, 68 patients with kidney transplant (study group) and 68 healthy individuals (control group) were analyzed with ocular response analyzer measurements. Only the right eye of each participant was assessed for corneal hysteresis (CH), corneal resistance factor (CRF), corneal-compensated intraocular pressure (IOPcc), and Goldmann-correlated intraocular pressure (IOPg). RESULTS: The mean CH in the study group was 9.70 ± 1.62 mmHg which was significantly lower than the control group with the mean CH of 10.60 ± 1.49 mmHg (P = 0.001). The mean IOPcc was 18.17 ± 4.00 mmHg and 16.00 ± 3.94 mmHg in the study and control groups, respectively (P = 0.002). CRF and IOPg were not significantly different between groups. CONCLUSION: CH and IOPccare altered in kidney transplant patients.

Ahmed valve implantation in childhood glaucoma associated with Sturge-Weber syndrome: our experience.

PURPOSE: To evaluate the efficacy and safety of Ahmed valve implantation in childhood glaucoma associated with Sturge-Weber syndrome (SWS). METHODS: A retrospective chart review of patients who underwent primary Ahmed valve implantation in childhood glaucoma associated with SWS. The outcome measures were success rate (Intraocular pressure (IOP) >5 and <21 mm Hg without additional surgical maneuver), and operative complications. RESULTS: Twenty-four eyes of 18 patients were analyzed. Mean IOP (26.21 ± 3.52 to 12.27 ± 1.27 mm Hg) and mean number of anti-glaucoma medicines (3.92 ± 0.28 to 1.5 ± 1) reduced significantly after the surgery at the mean follow-up of 2.12 ± 0.87 years (P = < 0.05). The cumulative probability of success rate was 75% (Confidence Interval 95%, 60 to 100%) by Kaplan-Meier survival curve analysis. Failed eyes [6 (25%)], hyphema [4 (16.67%)], hypotony [3 (12.5%)], choroidal detachment [3 (12.5%)], tube-cornea touch [2 (8.33%), and visually significant cataract [4 (16.67%)] were the complications observed in post-operative period. CONCLUSION: Primary Ahmed valve implantation may provide a safe and effective option in the management of childhood glaucoma associated with SWS.

Papilledema revisiting after sinus angioplasty of chronic cerebral venous sinus thrombosis.

This case series aimed to review the significance of revisiting papilledema after successful cerebral venous sinus thrombosis (CVST) management with sinus angioplasty. Four patients presented with blurring and transient obscuration of vision with papilledema, headache, tinnitus, and vomiting. On magnetic resonance venography and digital subtraction angiography, chronic transverse sinus thrombosis was diagnosed for which patients underwent endovascular intervention (stenting). After the resolution of CVST, patients developed the recurrence of symptoms which on digital subtraction angiography revealed dural arteriovenous malformation (DAVM). DAVM and papilledema resolved with endovascular embolization. This case series highlights a need of constant monitoring of CVST cases after the endovascular intervention.

Encephalocele presenting as lower lid swelling: A rare case report.

Encephalocele is a rare congenital abnormality characterized by abnormal protrusion of brain and meninges through an opening in the skull. We report an 8-year-old girl who presented with a swelling in the right lower lid for the last 6 years. In her infancy, she had undergone surgery for a very small swelling located in the right nasolacrimal area. On further clinicoradiological evaluation, anterior encephalocele was diagnosed. This case highlights the uncommon site of anterior encephalocele; misdiagnosis and mismanagement of which could result in dreaded complications such as meningitis and cerebrospinal fluid leaking fistula formation.

Leprosy Presenting with Iridocyclitis: A Diagnostic Dilemma.

PURPOSE: To report a case of lepromatous iridocyclitis that posed a diagnostic challenge. CASE REPORT: A 50-yeasr-old male developed profound loss of vision in the right eye, while he was in the hospital with septicemia presenting with fever, dysuria, and abdominal swelling. He also developed erythema nodosum on the legs. Skin incisional biopsy section, upon dermatology consultation, showed a granulomatous nodule in the dermis. The anterior chamber aspirate demonstrated lepra bacilli, which confirmed the diagnosis of lepromatous leprosy with type II reaction. The patient was treated with multidrug therapy and oral and topical steroids. CONCLUSION: This case highlights that the lepromatous iridocyclitis, a serious vision-threatening disorder requires a high index of suspicion for prompt diagnosis in atypical cases particularly in endemic areas. Examination of the aqueous humor can also be helpful in diagnosis.

Endogenous Nocardial Endophthalmitis in an Immunosuppressed Patient: A Serious Warning of an Underlying Life Threatening and Blinding Disorder.

PURPOSE: To report a case of bilateral endogenous nocardial endophthalmitis with central nervous system involvement in an immunocompromised individual with an extremely poor outcome. CASE REPORT: A 35-year-old man with a history of long-term, prescribed oral steroid use for membranoproliferative glomerulonephritis presented with profound bilateral vision loss. Patient's diagnosis of bilateral endogenous nocardial endophthalmitis was delayed. Nocardia was finally isolated from a brain biopsy after a repeat magnetic resonance imaging revealed a brain abscess. With anti-nocardia therapy, patient improved systemically, but the visual outcome was poor, with no light perception in both eyes. CONCLUSION: Ocular nocardiosis is a serious vision and life threatening disorder, particularly in patients on immunosuppressive therapy. A high index of suspicion is required for successful treatment.

Pars Plana-Modified versus Conventional Ahmed Glaucoma Valve in Patients Undergoing Penetrating Keratoplasty: A Prospective Comparative Randomized Study.

PURPOSE: To compare the outcome of pars-plana-modified Ahmed glaucoma valve (AGV) versus limbal-based conventional AGV into the anterior chamber, in patients undergoing penetrating keratoplasty (PK) for glaucoma with coexisting corneal diseases. METHOD: In this prospective randomized clinical trial, 58 eyes of 58 patients with glaucoma and coexisting corneal disease were divided into two groups. Group 1 (29 eyes of 29 patients) included patients undergoing limbal-based conventional AGV into the anterior chamber (AC) along-with PK and group 2 (29 eyes of 29 patients) included those undergoing pars-plana-modified AGV along-with PK. Outcome measures included corneal graft clarity, intraocular pressure (IOP), number of antiglaucoma medications, and postoperative complications. Patients were followed up for a minimum period of 2 years. RESULTS: Out of 58 eyes (58 patients), 50 eyes (50 patients: 25 eyes of 25 patients each in group 1 and group 2) completed the study and were analyzed. Complete success rate for AGV (group 1: 76%; group 2: 72%; p = 0.842) and corneal graft clarity (group 1: 68%; group 2: 76%; p = 0.081) were comparable between the two groups at 2 years. Graft failure was more in conventional AGV (32%) as compared to pars plana-modified AGV (24%) but not statistically significant (p = 0.078) at 2 years. CONCLUSION: Though both procedures were comparable in various outcome measures, pars-plana-modified AGV is a viable option for patients undergoing PK, as it provides a relatively better corneal graft survival rate and lesser complications that were associated with conventional AGV.

Efficacy of Bevacizumab Compared to Mitomycin C Modulated Trabeculectomy in Primary Open Angle Glaucoma: A One-Year Prospective Randomized Controlled Study.

PURPOSE: To compare the efficacy of bevacizumab over mitomycin C (MMC) modulated trabeculectomy in cases of primary open angle glaucoma (POAG). METHOD: In this prospective randomized controlled study, 80 eyes of 80 patients with uncontrolled POAG or intolerant to antiglaucoma medications were randomized to two groups: Group 1 (n = 40) patients underwent trabeculectomy modulated with MMC (0.2 mg/ml), whereas Group 2 (n = 40) patients underwent trabeculectomy modulated with bevacizumab (1.25 mg/0.05 ml). The outcome measures were best corrected visual acuity (BCVA), intraocular pressure (IOP), number of glaucoma medications and bleb morphological features based on Moorfields Bleb Grading System (MBGS). All patients were followed up for one year post trabeculectomy. RESULTS: The mean preoperative IOP in the bevacizumab group improved from 22.41 ±1.08 mm Hg with 3.2 ± 0.9 glaucoma medications to 13.68 ± 0.79 mm Hg with 0.11 ± 0.32 glaucoma medications at one year (P < 0.001). The mean preoperative IOP in the MMC group improved from 22.64 ± 0.90 mm Hg with 3.1 ± 0.8 glaucoma medications to 13.84 ± 0.73 mm Hg with 0.17 ± 0.38 glaucoma medications at one year (P < 0.001). IOP was comparable between two groups at one year (P = 0.43). No significant differences were found in bleb morphological features based on MBGS regarding central bleb area, peripheral bleb area, height and central vascularity between the two groups at six months and one year. However, there was a statistically significant difference in peripheral bleb vascularity and peripheral non-bleb vascularity with bevacizumab group exhibiting a low degree of vascularity at one year (P = 0.029 and 0.004, respectively). CONCLUSION: Adjunctive bevacizumab in trabeculectomy is effective and comparable to MMC for controlling IOP in POAG patients for the first year.

Allogenic cultivated limbal stem cell transplantation versus cadaveric keratolimbal allograft in ocular surface disorder: 1-year outcome.

PURPOSE: To compare the outcome of allogenic ex vivo cultivated limbal stem cell transplantation (LSCT) versus cadaveric keratolimbal allograft in patients with limbal stem cell deficiency (LSCD). METHODS: In this prospective interventional study from Army Hospital Research and Referral in New Delhi, 50 eyes of 40 patients with ocular surface disorder having LSCD underwent either cultivated LSCT (group 1: 25 eyes of 20 patients) or keratolimbal allograft transplantation (group 2: 25 eyes of 20 patients). The outcome measures were gain of two or more lines of best-corrected visual acuity (BCVA), absence of conjunctival vascularization over cornea, corneal neovascularization regression, regression of visually significant corneal opacity (iris details poorly visible), Schirmer's 1 ≥10 s, tear break-up time (TBUT) ≥10 s, and absence of fluorescein staining. RESULTS: At 1 year of follow-up, both groups experienced significant improvement in all outcome measures, but there was no significant difference between both groups in improvement of two or more lines of BCVA (P = 0.841), absence of conjunctival vascularization over cornea (P = 0.812), corneal neovascularization (P = 0.074), visually significant corneal opacity (P = 0.075), Schirmer's 1 ≥10 s (P = 0.814), TBUT ≥10 s (P = 0.382), or absence of fluorescein stain (P = 1.00). CONCLUSION: Both allogenic ex vivo cultivated LSCT and cadaveric keratolimbal allograft transplantation are comparable in terms of visual gain and ocular surface restoration.

Computer and visual display terminals (VDT) vision syndrome (CVDTS).

Computer and visual display terminals have become an essential part of modern lifestyle. The use of these devices has made our life simple in household work as well as in offices. However the prolonged use of these devices is not without any complication. Computer and visual display terminals syndrome is a constellation of symptoms ocular as well as extraocular associated with prolonged use of visual display terminals. This syndrome is gaining importance in this modern era because of the widespread use of technologies in day-to-day life. It is associated with asthenopic symptoms, visual blurring, dry eyes, musculoskeletal symptoms such as neck pain, back pain, shoulder pain, carpal tunnel syndrome, psychosocial factors, venous thromboembolism, shoulder tendonitis, and elbow epicondylitis. Proper identification of symptoms and causative factors are necessary for the accurate diagnosis and management. This article focuses on the various aspects of the computer vision display terminals syndrome described in the previous literature. Further research is needed for the better understanding of the complex pathophysiology and management.

Trabeculectomy with Mitomycin-C in Patients with Iridocorneal Endothelial Syndrome: A Case Series.

Iridocorneal Endothelial syndrome (ICE) is a rare ocular disorder characterized by abnormal endothelization of angle structure and iris producing characteristic manifestations including secondary angle closure glaucoma. We describe the clinical course of three patients with secondary glaucoma due to ICE syndrome who underwent trabeculectomy with mitomycin-C. At last follow-up, all patients had controlled IOP (<18 mm Hg) off drug. Early postoperative period was accompanied by shallowing of anterior chamber, diffuse vascularisation of bleb, frequent episodes of high IOP which were managed successfully. Trabeculectomy with MMC offers a good treatment choice for the management of secondary glaucoma associated with ICE syndrome.

The effect of assisted reproductive technology on ocular assessments.

PURPOSE: The aim was to study the various ocular assessments in women undergoing assisted reproductive techniques (ART). METHODS: A total of 117 women with infertility were enrolled for study and the ART protocol was followed. The outcome measures were intraocular pressure (IOP), central corneal thickness, corneal endothelial cell counts, Schirmer I test done at baseline (V0), post-oral contraceptive (V1), post-GnRH agonist induction phase (V2), post-conception (V3), third trimester of pregnancy (V4) and three months post-partum (V5). Schirmer I test (without topical anaesthesia) less than 10 mm in at least one eye was considered a criterion for dry eye. RESULTS: Out of 117 women enrolled for in vitro fertilisation (IVF), only 48 patients conceived. Sixteen women had abortions and remaining 32 women, who had childbirth were followed until three months post-partum. Baseline mean IOP showed a slight decrement and corneal pachymetry and corneal endothelial cell counts showed slight increment from phases V1 to V4 of ART but statistically they were not significant (p > 0.05). At three months post-partum (V5) mean IOP, corneal pachymetry, corneal endothelial cell counts become closer to baseline in both eyes. The number of patients with at least one eye with dryness (Schirmer I less than 10 mm) significantly increased at the third trimester (p = 0.02) and three months post-partum (p = 0.035), whereas in the rest of the phases, it was comparable to baseline (p > 0.05). CONCLUSION: The ocular physiological changes (IOP, corneal pachymetry and corneal endothelial cell counts) seen in various phases of ART were non-specific. The ART appears to reduce tear secretions as measured by Schirmer I; however, further research would be required to determine the impact of ART on the tear film and whether ART is associated with symptoms and signs of dry eye.

Neurofibromatosis Type 1 Presenting with Ophthalmic Features: A Case Series.

Neurofibromatosis type 1 (NF-1) is an autosomal dominant disorder involving multiple systems and affects approximately 1 out of 3000 persons. Ocular manifestations are lisch nodules, plexiform neurofibroma, optic pathway gliomas. The proper diagnosis of NF-1 is a crucial task for a clinician due to the various clinical manifestations including vision and life threatening malignancies in few patients, which may arise in the different phases of life. The authors report three cases of NF-1, presenting with ophthalmic symptoms in teenager boys. On further ophthalmic and paediatric evaluation the diagnosis of NF-1 was confirmed on the basis of clinical criteria. This series also describe the abnormal facial features like telecanthus and broad nose which has been reported rarely. Case 1 was kept under regular follow-up and Case 2 and Case 3 were planned for the debulking surgery for plexiform neurofibroma of upper eye lid. A multidisciplinary approach is required to diagnose and treat such patients keeping in mind the myriad of clinical manifestations and life-long follow-up is required.

Phacoemulsification at high-altitude Himalayan region: comparison.

PURPOSE: To compare phacoemulsification parameters at different high-altitude regions as well as between peristaltic and Venturi-based machines. METHODS: In this prospective, nonrandomized clinical study, 160 eyes of 160 patients with senile cataract underwent phacoemulsification using either peristaltic or Venturi system at a high-altitude Himalayan region (>10,000 feet). Patients (n = 200, including 100 each with either peristaltic or Venturi system) operated at mean altitude of 1115 feet (Delhi) were included as controls (group 1). At Leh (11,203 feet), 110 patients were operated with peristaltic (62) or Venturi (48) system (group 2), whereas 50 patients (group 3) (peristaltic = 37; Venturi = 13) were operated either with peristaltic (37) or Venturi (13) system at Tangtse (14,106 feet). Intraoperative parameters-i.e., bottle height (BH), vacuum (V), and flow rate (FR)-were compared for different phacoemulsification steps-i.e., central chopping (CC), segment removal (SR), epinucleus removal (ER), and cortex removal (CR)-between all groups and between peristaltic and Venturi pump-based machines in each group. RESULTS: Mean BH, V, and FR for CC, SR, ER, and CR significantly increased with the increment in altitude of surgery (p = 0.000). Venturi and peristaltic-based phacoemulsification showed higher values of the mean BH and V, respectively, for CC, SR, ER, and CR at Leh as well as Tangtse. CONCLUSIONS: At the high-altitude region, the higher setting of BH, FR, and V is required in phacoemulsification.