Predictors of and barriers associated with poor follow-up in patients with glaucoma in South India.

OBJECTIVES: To determine predictors of and reasons for poor longitudinal glaucoma follow-up in South India. METHODS: This 1-to-1, matched, case-control study enrolled 300 patients with established glaucoma. We defined cases (poor follow-up) and controls (good follow-up) based on number of and maximum interval between glaucoma follow-up visits attended in the preceding year. We collected data by oral questionnaire and used stepwise multivariate logistic regression to calculate odds ratios (ORs) for poor follow-up. RESULTS: Adjusting for age and sex, independent predictors of poor follow-up included lack of formal education (adjusted OR, 4.13; 95% confidence interval [CI], 1.44-11.90), no use of prescribed glaucoma medications (adjusted OR, 2.17; 95% CI, 1.06-4.43), and belief that follow-up is less important if one uses glaucoma medications and has no noticeable visual changes (adjusted OR, 10.59; 95% CI, 3.74-29.97). Age, sex, and disease severity were not significant predictors. The most prevalent barriers to follow-up were belief that there was no problem with one's eyes (44.4%) and lack of escort (19.7%). CONCLUSIONS: Knowing predictors of poor follow-up can help identify patients who need individualized strategies to improve follow-up. Because believing one's eyes are problem-free and lacking escorts are significant barriers to follow-up, novel strategies in patient education (eg, intensive counseling, audiovisual aides, and patient support groups) and escort provision may improve longitudinal glaucoma follow-up and disease management.

Speciation of coagulase negative staphylococcus causing bacterial keratitis.

Thirty-five coagulase negative Staphylococcus (CoNS) cultured from corneal ulcer were speciated and antibiotic sensitivity tested. S epidermidis was the commonest isolate and it was sensitive to ampicillin and vancomycin.

Macular ischaemia as a marker for nephropathy in diabetic retinopathy.

PURPOSE: To determine whether diabetic macular ischaemia is associated with ischaemic heart disease (IHD), hyperlipidaemia, hypertension (HTN) and nephropathy. METHODS: Prospective case-control study from January to December 2001, involving 102 type 2 diabetic patients (aged 40-80 years), 59 with unilateral / bilateral macular ischaemia and 43 concurrent controls. Diabetic retinopathy was graded and macular ischaemia assessed by fundus examination, central fundus photography and fluorescein angiography. Systemic examination and laboratory investigations were done to evaluate systemic diseases. The associations were analysed by Chi-square test and Student's t-test. The significance of the variables as independent risk factors was tested by logistic regression analysis. RESULTS: Macular ischaemia was not associated with IHD (P=1.00); HTN (P=1.00) and hyperlipidaemia (P=0.30). Nephropathy was significantly associated with macular ischaemia (P=0.025; odds ratio [OR]: 2.62; 95% confidence interval [CI]: 1.16-5.9). The association remained significant after controlling for age, gender, duration of diabetes, severity of retinopathy, HTN, IHD and hyperlipidaemia. Further, the association with nephropathy was not affected by the presence of macular isachaemia in one or both the eyes (P=0.39). CONCLUSION: Macular ischaemia may serve as a marker for nephropathy in type 2 diabetes mellitus irrespective of the severity of retinopathy.

Quality of life after community-based rehabilitation for blind persons in a rural population of South India.

This study aimed to determine the impact of community-based rehabilitation on the quality of life of blind persons in a rural south Indian population. We performed a population-based survey followed by clinical examinations to identify blind persons in a rural south Indian population. Pre-and-post rehabilitation quality of life of 159 blind persons aged 15 years or above was ascertained through a questionnaire previously validated for use in this population. Post-rehabilitation quality-of-life scales showed some improvement for 151 (95.0%) subjects. The additional benefit from rehabilitation was greatest for the self-care and mobility subscales, ranging from 24.6% to 30.0% for the self care subscale and 37.6% to 44.3% for the mobility subscale with effect sizes of 21.5 and 2.38 respectively. Overall quality of life scores were not significantly different between those who did and did not receive economic rehabilitation (P = 0.1). Blind persons in this rural population benefited considerably from rehabilitation services even if economic rehabilitation is not provided. Initiatives against blindness need to consider rehabilitation of the blind as a priority.

Familial exudative vitreoretinopathy (FEVR). Clinical profile and management.

PURPOSE: To report our experience with the diagnosis and management of Familial Exudative Vitreoretinopathy (FEVR) in a predominantly older Indian population.. METHODS: This prospective interventional non-comparative case series included 38 patients of FEVR and their 23 family members. The diagnosis was established by clinical examination, fluorescein angiography and family screening. Prophylactic photocoagulation/cryotherapy or surgical treatment was done depending on the severity of the disease. RESULTS: The mean age of the patients was 23.6 years. The fundus/fluorescein angiographic findings in 116 eyes of our 61 patients (6 eyes phthisical) were as follows: forty eight (41.4%) eyes had only peripheral avascular zone, 8 (6.9%) eyes had peripheral new vessels, and 35 (30.1%) eyes had retinal detachments (RD)--10 (8.6%) exudative, 5 (4.3%) tractional and 20 (17.2%) rhegmatogenous. Prophylactic photocoagulation or cryotherapy was done in 34 eyes for retinal holes, local exudative detachments and bleeding new vessels. All the eyes retained stable vision over a mean follow-up of 16 months. Only 14 RDs were suitable for surgery: scleral buckling, vitrectomy or both. The reattachment rate was 85.7% (12 of 14) and the best-corrected visual acuity (BCVA) improved to 5/60 or better in 50% of these eyes over a 2-year follow-up. CONCLUSIONS: FEVR appears to be more common than reported. Timely diagnosis and intervention is essential in view of the lifelong progression of the disease, late exacerbations, frequent involvement of family members, and poor surgical results. A high index of suspicion, family screening and early prophylaxis are recommended to prevent avoidable blindness from this underdiagnosed disease.

Evaluation of agent and host factors in progression of mycotic keratitis: A histologic and microbiologic study of 167 corneal buttons.

PURPOSE: To evaluate the host and agent factors in the progression of mycotic keratitis through the microbiologic evaluation and histologic study of human corneal buttons obtained at the time of therapeutic keratoplasty. DESIGN: Retrospective noncomparative consecutive case series. MATERIALS: One hundred sixty-seven corneal buttons from 148 patients of microbiologically diagnosed and treated cases of mycotic keratitis who underwent therapeutic keratoplasty between January 1995 and May 1998. METHODS: Therapeutic penetrating keratoplasty, review of microbiologic results, histopathologic and microbiologic evaluation of the corneal buttons of mycotic keratitis MAIN OUTCOME MEASURES: Histologic evaluation of the buttons for morphologic changes, degree and distribution of inflammatory cells, presence or absence of fungal filaments, and their degree and distribution within the corneal buttons. RESULTS: The diagnosis of fungal infection was made on corneal scrapings in 36 cases; whereas in 131 (78%), the fungus was grown in cultures and identified as Aspergillus in 55 (42%), Fusarium in 42 (32%), unidentified hyaline fungi in 22 (17%), dematiaceous (unidentified) in 4 (3%), and others in 8 (6%). The mean interval between diagnosis and keratoplasty was 19 (+/-40) days. From the keratoplasty specimen, the fungus was identified at histologic examination in 127 of 167 (76%) buttons and grown by culture techniques in 76 of 115 (66%) buttons. The fungal species identified in the corneal button were Fusarium in 30 (39%); Aspergillus in 25 (33%); unidentified hyaline in 19 (25%), and others in 2 (3%). Fungus-positive corneal buttons had early surgery (mean, 15 days) compared with fungus-negative (39 days) corneal buttons (P = 0.0005), with 93% fungus positivity in the buttons removed within 2 weeks and 42% after 2 months. In the fungus-positive buttons, there was an inverse correlation between the degree, distribution of inflammatory cells, and fungal filaments (r = -0.255, P = 0.024; r = -0.199, P = 0.027), respectively. The factors necessitating an early keratoplasty were heavy fungal load, deeper penetration of fungus, and possibly insufficient inflammation to combat infection. A granulomatous reaction was noted in the posterior stroma and around the fragmented Descemet's membrane in 23 buttons (13.8%), independent of fungal species. Inflammation was unaffected by elimination of fungus and increasing interval between diagnosis and treatment. CONCLUSIONS: Rapid progression of mycotic keratitis in the early phases is by agent factors such as heavy load and deeper penetration of the fungus, insufficient inflammatory response, and possibly relative ineffectiveness of antifungal agents. Progression in the later phase of mycotic keratitis need not necessarily be agent mediated; it could be either host-modulated, species-related, or drug resistance, thereby suggesting that ideal treatment regimens should include sensitivity-based antifungal therapy aided by in vivo monitoring of fungal filaments.

Safety and efficacy of simultaneous bilateral primary combined trabeculotomy-trabeculectomy for developmental glaucoma.

PURPOSE: To establish the safety and efficacy of simultaneous bilateral primary combined trabeculotomy-trabeculectomy for developmental glaucoma. METHODS: We studied 109 consecutive patients who underwent planned simultaneous bilateral primary combined trabeculotomy-trabeculectomy for developmental glaucoma by a single surgeon from January 1990 through December 1999. The main outcome measures were postoperative intraocular pressure (IOP), corneal clarity and diameter, visual acuity, bleb characteristics, time of surgical failure and complications. Postoperative complications including endophthalmitis and anaesthetic morbidity and mortality were also analysed. RESULTS: The series consisted of 218 primary combined trabeculotomy-trabeculectomy surgeries during 109 anaesthesias. The mean follow-up period was 16.33 +/- 16.22 months. The IOP reduced from 26.4 +/- 5.9 mmHg to 13.5 +/- 4.5 mmHg, with a mean percentage reduction of 46.2 +/- 23.7 (P < 0.0001). The success (IOP < 16 mmHg) probabilities were 90.9%, 88.0% and 69.3% at first, second and third year respectively (Kaplan-Meier analysis). The success probability of 69.3% obtained at third year was maintained till 6 years of follow-up. One hundred and sixty six (76.1%) eyes had significant corneal oedema. Postoperatively, the cornea cleared in 93 (57.8%) eyes. Clinically, well functioning blebs were present in 114 of 171 eyes (66.6%). Postoperatively, 18 (8.3%) eyes developed shallow anterior chamber and 6 (33.3%) of them required surgical reformation. There was no incidence of endophthalmitis or any other sight-threatening complication. Of the anesthetic complications, apnea occurred in 17 (15.6%) patients and all were successfully resuscitated. The most serious post-anaesthetic complication was cardio-pulmonary arrest that occurred 5 hours postoperatively following aspiration during feeding in one child; this child could not be resuscitated. Two children had delayed recovery (2 and 4 hours respectively). The child who had delayed recovery by 2 hours survived and has completed 3 years of follow-up while the other child expired 48 hours later. CONCLUSION: Simultaneous bilateral primary combined trabeculotomy-trabeculectomy is safe and effective for developmental glaucoma. It obviates the need for long second anaesthesia with its attendant risks. It offers several other benefits to the patients and families.