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   2008| September-October  | Volume 56 | Issue 5  
    Online since August 8, 2008

 
 
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SYMPOSIUM
Anterior segment manifestations of human immunodeficiency virus/acquired immune deficiency syndrome
Jyotirmay Biswas, S Sudharshan
September-October 2008, 56(5):363-375
DOI:10.4103/0301-4738.42412  PMID:18711264
Ocular complications are known to occur as a result of human immunodeficiency virus (HIV) disease. They can be severe leading to ocular morbidity and visual handicap. Cytomegalovirus (CMV) retinitis is the commonest ocular opportunistic infection seen in acquired immune deficiency syndrome (AIDS). Though posterior segment lesions can be more vision-threatening, there are varied anterior segment manifestations which can also lead to ocular morbidity and more so can affect the quality of life of a HIV-positive person. Effective antiretroviral therapy and improved prophylaxis and treatment of opportunistic infections have led to an increase in the survival of an individual afflicted with AIDS. This in turn has led to an increase in the prevalence of anterior segment and adnexal disorders. Common lesions include relatively benign conditions such as blepharitis and dry eye, to infections such as herpes zoster ophthalmicus and molluscum contagiosum and malignancies such as squamous cell carcinoma and Kaposi's sarcoma. With the advent of highly active antiretroviral therapy, a new phenomenon known as immune recovery uveitis which presents with increased inflammation, has been noted to be on the rise. Several drugs used in the management of AIDS such as nevirapine or indinavir can themselves lead to severe inflammation in the anterior segment and adnexa of the eye. This article is a comprehensive update of the important anterior segment and adnexal manifestations in HIV-positive patients with special reference to their prevalence in the Indian population.
  7,142 1,479 13
OPHTHALMOLOGY PRACTICE
How to prevent endophthalmitis in cataract surgeries?
Aditya Kelkar, Jai Kelkar, Winfried Amuaku, Uday Kelkar, Aarofil Shaikh
September-October 2008, 56(5):403-407
DOI:10.4103/0301-4738.42418  PMID:18711270
Postoperative endophthalmitis is a very devastating complication and every step should be taken to reduce its occurrence. Unattended air conditioning filter systems are often the culprits and regular maintenance of the filters is of paramount importance. Shedders of pathogenic organisms amongst the theater personnel should be identified by regular screening and should be promptly treated. In addition to the use of Povidone iodine 5% solution in the conjunctival sac few minutes prior to surgery, proper construction of wound, injectable intraocular lenses, use of prophylactic intracameral antibiotics or prophylactic subconjunctival antibiotic injection at the conclusion of cataract surgery, placing a patch after the surgery for at least 4 h and initiating topical antibiotics from the same day of surgery helps to lower the frequency of postoperative endophthalmitis. Intraoperative posterior capsule rupture and anterior vitrectomy are risk factors for acute endophthalmitis, and utmost care to prevent posterior capsular rent should be taken while performing cataract surgery. Also, in case of such complication, these patients should be closely monitored for early signs of endophthalmitis in the postoperative period. In the unfortunate event of endophthalmitis the diagnosis should be prompt and treatment must be initiated as early as possible.
  7,349 1,234 17
SYMPOSIUM
Introduction and immunopathogenesis of acquired immune deficiency syndrome
S Sudharshan, Jyotirmay Biswas
September-October 2008, 56(5):357-362
DOI:10.4103/0301-4738.42411  PMID:18711263
India has a large number of patients with acquired immune deficiency syndrome (AIDS), the third largest population of this group in the world. This disease was first described in patients with Pneumocystis pneumonia in 1981. Ocular lesions can occur at any stage of the disease but are more commonly seen at the late stages. Human immunodeficiency virus (HIV), the causative agent of AIDS is a retrovirus with RNA genome and a unique 'Reverse transcriptase enzyme' and is of two types, HIV-1 and 2. Most human diseases are caused by HIV-1. The HIV-1 subtypes prevalent in India are A, B and C. They act predominantly by reducing the CD4+ cells and thus the patient becomes susceptible to opportunistic infections. High viral titers in the peripheral blood during primary infection lead to decrease in the number of CD4+ T lymphocytes. Onset of HIV-1-specific cellular immune response with synthesis of HIV-1 specific antibodies leads to the decline of plasma viral load and chronification of HIV-1 infection. However, the asymptomatic stage of infection may lead to persistent viral replication and a rapid turnover of plasma virions which is the clinical latency. During this period, there is further decrease in the CD4+ counts which makes the patient's immune system incapable of controlling opportunistic pathogens and thus life-threatening AIDS-defining diseases emerge. Advent of highly active antiretroviral treatment (HAART) has revolutionized the management of AIDS though there is associated increased development of immune recovery uveitis in a few of these patients.
  5,789 1,247 7
Posterior segment manifestations of human immunodeficiency virus/acquired immune deficiency syndrome
Alay S Banker
September-October 2008, 56(5):377-383
DOI:10.4103/0301-4738.42413  PMID:18711265
Ocular manifestations can occur in up to 50% of human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) patients and posterior segment involvement is the most common presentation. The posterior segment manifestations of AIDS can be divided into four categories: retinal vasculopathy, opportunistic infections, unusual malignancies and neuro-ophthalmologic abnormalities. Retinal microvasculopathy and cytomegalovirus (CMV) retinitis are the most common manifestations, even in the era of highly active anti-retroviral therapy (HAART). Highly active anti-retroviral therapy has been shown to cause regression of CMV retinitis, reduce the incidence of CMV-related retinal detachments, and prolong patient survival. Immune recovery uveitis is a new cause of vision loss in patients on HAART. Diagnosis and treatment are guided by the particular conditions and immune status of the patient.
  4,619 1,108 21
BRIEF COMMUNICATIONS
Which is the best method to learn ophthalmology? Resident doctors' perspective of ophthalmology training
Parikshit Gogate, Madan Deshpande, Sheetal Dharmadhikari
September-October 2008, 56(5):409-412
DOI:10.4103/0301-4738.42419  PMID:18711271
The study aimed to gauge ophthalmology resident doctors' perception of their teaching programs and various methods used in it and to formulate a well structured program for teaching ophthalmology. Closed ended and open-ended questionnaires were used for survey of ophthalmology residents in West Maharashtra, India. Sixty-seven out of 69 residents of seven residency programs completed the questionnaire. On a scale of 0 (most unsatisfactory) to 4 (best), lectures with power point presentation had a median score of 4, didactic lectures 2, seminar 3, case presentation 4, wet lab 3 and journal club 3. There was a discrepancy in the actual number of surgeries performed by the resident doctors and their perception of the number needed to master those surgeries. Phacoemulsification and non-cataract surgery training was neglected in most programs. The residents wanted to be evaluated regularly and taught basic ophthalmic examination, use of equipments and procedures in greater depth.
  4,393 520 6
ORIGINAL ARTICLE
Efficacy of intraoperative vancomycin in irrigating solutions on aqueous contamination during phacoemulsification
Renuka Srinivasan, Arvind Gupta, Subashini Kaliaperumal, Ramesh K Babu, Senthil Kumar Thimmarayan, Harish Narasimha Belgode
September-October 2008, 56(5):399-402
DOI:10.4103/0301-4738.42417  PMID:18711269
Purpose: To study the efficacy of adding vancomycin in irrigating solutions, in comparison to topical antibiotic given preoperatively for a day, during phacoemulsification, in reducing the anterior chamber (AC) contamination. Settings and Design: This was a prospective, interventional, hospital-based study. Materials and Methods: This was a study involving 400 eyes of 400 paitens, undergoing routine phacoemulsification between January 2004 and June 2006. The patients were non-randomly assigned to two groups: Group 1 included 180 patients, who received topical ciprofloxacin eye-drops (four-hourly) for a day preoperatively and Group 2 included 220 patients, who underwent phacoemulsification with vancomycin (20 g/ml) in the irrigating solution. Anterior chamber aspirate obtained at the end of the surgery was sent for microbial workup. The number of positive cultures in both the groups was determined. Statistical analysis: This was performed using Chi-square test. Results: Aqueous samples showed microbial growth in 38 (21.1%) out of 180 eyes in Group 1 and in 17 (7.7%) out of 220 eyes in Group 2 ( P = 0.001). Coagulase-negative staphylococcus was the most common organism in both the groups. Aqueous samples from four eyes in group 1 showed multiple organisms, while none of the sample from group 2 showed more than one organism. None of the eyes in either group showed fungal contamination. One patient in Group 1 developed endophthalmitis, and the causative organism was Alcaligenes faecalis. All patients were followed up for a minimum of six months (range: 6 to 14 months and mean: 9.3 months). Conclusion: Addition of vancomycin in irrigating solutions is more efficacious in reducing AC contamination in comparison to topical antibiotic administered a day preoperatively.
  4,122 465 9
SYMPOSIUM
Medical management of human immunodeficiency virus infection
John H Kempen
September-October 2008, 56(5):385-390
DOI:10.4103/0301-4738.42414  PMID:18711266
The human immunodeficiency virus (HIV)/ acquired immune deficiency syndrome (AIDS) pandemic has pervasive effects on culture, economics, policy, and human development. All organs can be affected by complications of HIV/AIDS, including the eye. When sufficient resources are available and widespread antiretroviral resistance does not exist, the four available classes of antiretroviral agents - nucleoside/nucleotide reverse transcriptase inhibitors, non-nucleoside reverse transcriptase inhibitors, protease inhibitors, and fusion inhibitors - can be combined to provide highly active antiretroviral therapy (HAART). For many (not all) patients, HAART converts an inexorably fatal disease into a chronic disease with a fairly good prognosis. Use of HAART often induces partial immune recovery, which has predominantly beneficial effects on ocular complications of AIDS. However, HAART-induced immune recovery sometimes results in immune recovery inflammatory syndromes, such as immune recovery uveitis. Use of HAART is the single most useful intervention for most patients with ocular complications of AIDS. However, specific ocular therapy is also critical to avoid blindness in the early months before immune recovery can occur, or if HAART is unavailable. Increasing availability of HAART worldwide shows great promise to alleviate one of the world's greatest plagues. However, predictable secular trends in the AIDS epidemic make it likely that the number of cases of ocular complications of AIDS will increase substantially before they decrease. Ophthalmologists worldwide should be familiar with the diagnosis and management of cytomegalovirus retinitis - the most common ocular complication of AIDS - and should establish partnerships with physicians who are able to provide HAART. Research is needed to determine the optimal approach for managing cytomegalovirus retinitis in resource-constrained settings.
  3,464 834 5
GUEST EDITORIAL
Human immunodeficiency virus and the ophthalmologist
Rajeev Soman, Bharat Purandare
September-October 2008, 56(5):355-356
DOI:10.4103/0301-4738.42410  PMID:18711262
  3,180 626 2
SYMPOSIUM
The socioeconomic impact of human immunodeficiency virus / acquired immune deficiency syndrome in India and its relevance to eye care
GVS Murthy
September-October 2008, 56(5):395-397
DOI:10.4103/0301-4738.42416  PMID:18711268
Human immunodeficiency virus (HIV) infection is aptly called the modern day 'plague' and has the potential to decimate people in the productive age group. On the other hand, the increasing life expectancy in developing countries spirals age-related blindness. One therefore reduces economic productivity while the other increases economic dependency. Both lead to increased expenditure of households though in different proportions. Human immunodeficiency virus and blindness are both associated with discrimination, stigma and long-term consequences. They impact the socioeconomic fabric of the affected individuals, communities and countries. The loss in productivity and the cost of support to the affected individuals are seen in both. Each is a potent problem on its own but together they spell disaster in geometric proportions rather than a simple additive effect. Strategies need to be evolved to provide solace and improve the quality of life of an HIV-positive blind individual.
  3,148 394 4
Impact of highly active antiretroviral therapy on ophthalmic manifestations in human immunodeficiency virus / acquired immune deficiency syndrome
Kartik K Venkatesh, J Biswas, N Kumarasamy
September-October 2008, 56(5):391-393
DOI:10.4103/0301-4738.42415  PMID:18711267
Highly active antiretroviral therapy (HAART) has changed the face of human immunodeficiency virus (HIV) acquired immune deficiency syndrome (AIDS) by leading to dramatic decreases in HIV-related morbidity and mortality in the developed as well as developing world. Since the introduction of HAART, the incidence of ocular opportunistic infections causing retinitis has dramatically decreased, and clinicians should be aware of changes in the clinical presentation of ocular manifestations of HIV. As studies of HIV disease after the introduction of HAART continue to become available, more thorough descriptions of treated patients with ocular opportunistic infections will include side-effects and toxicities of therapy. This review focuses on the impact of HAART on the ocular manifestations of HIV.
  2,939 557 6
LETTERS TO THE EDITOR
Contact allergic dermatitis and periocular depigmentation after using olapatidine eye drops
Smitha T Suchi, Arvind Gupta, Renuka Srinivasan
September-October 2008, 56(5):439-440
DOI:10.4103/0301-4738.42431  PMID:18711283
  3,012 232 2
BRIEF COMMUNICATIONS
An unusual variation in the anatomy of the uncinate process in external dacryocystorhinostomy
Anjali Mehta, Nitin Puri
September-October 2008, 56(5):413-416
DOI:10.4103/0301-4738.42420  PMID:18711272
Variations in the bony components of the nose are often encountered. One such variation was found in a 49-year-old male who had undergone conventional external dacryocystorhinostomy for adult onset nasolacrimal duct blockage. Intraoperatively, a thick bar of bone was seen beneath and parallel to the lacrimal sac fossa after a complete osteotomy had been made. Another osteotomy had to be fashioned in this bone to reach the nasal cavity. Postoperative 3D computed tomographic scan revealed the bone to be an anatomical variation of the uncinate process of the ethmoidal bone which was rather anteriorly placed, much thicker than usual, and attached to the nasal roof. The uncinate process is thin, curved and its anterior edge may frequently overlap some part of the lacrimal fossa. However, to our knowledge, the presence of such a large and thick uncinate process necessitating an additional large osteotomy has not been reported.
  2,983 258 1
Bovine pericardium in treating large corneal perforation secondary to alkali injury: A case report
Rajesh K Khanna, Ezanee Mokhtar
September-October 2008, 56(5):429-430
DOI:10.4103/0301-4738.42426  PMID:18711278
To describe use of a locally processed bovine pericardium (BP) to cover a large central corneal perforation following alkali injury and discuss postoperative outcome. A 27-year-old Malay male patient presented two weeks after alkali splashed in his left eye while working. A clinical diagnosis of left central corneal ulcer with limbal ischemia following alkali injury with secondary infection was made. After failed medical therapy, we performed a Gunderson conjunctival flap under local anesthesia that retracted after one week and resulted in a large central corneal perforation with surrounding stromal thinning. The perforation was covered with a locally processed BP xenograft (Lyolemb) supplied by the National Tissue Bank, University Sains Malaysia. Nine months follow-up showed a well-taken graft without any exposure/dehiscence and minimal inflammation. Amniotic membrane transplantation when used as a patch graft needs an urgent tectonic graft to promote corneal stability in patients with severe corneal thinning. The use of processed BP can be a viable option in treating such cases.
  2,982 241 6
Intraocular tissue migration of silicone oil after silicone oil tamponade: A histopathological study of enucleated silicone oil-filled eyes
Jyotirmay Biswas, Aditya Verma, Madhusudan D Davda, Shweta Ahuja, Vaijayanthi Pushparaj
September-October 2008, 56(5):425-428
DOI:10.4103/0301-4738.42425  PMID:18711277
Retrospective clinical and histopathological review of eight silicone oil-filled enucleated eyeballs using light microscopy was carried out in our department of ocular pathology during a period of six years. In all cases, silicone oil vacuoles, both free and incorporated within macrophages were seen in all the retinal layers. Silicone oil vacuoles were seen in the optic nerve, choroid, retinal pigment epithelium, corneal stroma, iris and ciliary body stroma, preretinal and subretinal membranes and retro-corneal membranes. Silicone oil migration could be seen in intraocular tissues as early as two months post surgery. There was no definite histopathological correlation between duration of tamponade and distribution of silicone oil vacuoles. Silicone oil vacuoles were seen in the optic nerve in eyes with neovascular glaucoma. Chronic inflammatory reaction was observed in the retinal tissue in the vicinity of silicone oil vacuoles.
  2,766 293 6
LETTERS TO THE EDITOR
Authors' reply
Arvind Kumar Dubey, Pran Nath Nagpal, Shobhit Chawla, Benu Dubey
September-October 2008, 56(5):441-441
DOI:10.4103/0301-4738.42433  
  2,889 110 -
BRIEF COMMUNICATIONS
Orbital amelanotic melanoma in xeroderma pigmentosum: A rare association
Syed AR Rizvi, Abadan K Amitava, Ghazala Mehdi, Rajeev Sharma, Mohammad S Alam
September-October 2008, 56(5):421-423
DOI:10.4103/0301-4738.42423  PMID:18711275
Xeroderma pigmentosum (XP) is an autosomal recessive genetic disorder of DNA repair in which the body's normal ability to repair damage caused by ultraviolet light is deficient. This leads to a 1000-fold increased risk of cutaneous and ocular neoplasms. Ocular neoplasms occurring in XP in order of frequency are squamous cell carcinoma, basal cell carcinoma and melanoma. Malignant melanomas occur at an early age in patients with XP. We report a case of XP with massive orbital melanoma in an eight-year-old boy which is unique due to its amelanotic presentation confirmed histopathologically.
  2,647 296 3
Histopathological study of ocular erythema nodosum leprosum and post-therapeutic scleral perforation: A case report
SR Rathinam, Hadi M Khazaei, CK Job
September-October 2008, 56(5):417-419
DOI:10.4103/0301-4738.42421  PMID:18711273
Leprosy is a chronic granulomatous disease caused by Mycobacterium leprae , clinically present either as tuberculoid, borderline or lepromatous type. Erythema nodosum leprosum (ENL) is an acute humoral response in the chronic course of lepromatous leprosy. Although very severe ENL reactions are known in systemic leprosy, such severity is rare in ocular tissues. A leprosy uveitis patient suffered from a severe form of post-therapeutic ENL reaction which resulted in perforation of the globe at the site of preexisting subconjunctival leproma. Painful blind eye was enucleated. Histopathological study revealed infiltration of numerous polymorphs and macrophages packed with acid-fast bacilli in the conjunctiva, cornea, ciliary body, ora serrata and sclera. A profuse influx of neutrophils on a background of macrophages packed with M. leprae confirmed the ocular ENL reaction. This case is reported to alert the ophthalmologists to a rare ocular complication of ENL.
  2,691 238 2
Retinal pigment epithelial atrophy following indocyanine green dye-assisted surgery for serous macular detachment
Nazimul Hussain, Subhadra Jalali, Alka Rani, Hema Rawal
September-October 2008, 56(5):423-425
DOI:10.4103/0301-4738.42424  PMID:18711276
To report subretinal migration of indocyanine green dye (ICG) and subsequent retinal pigment epithelial (RPE) atrophy during macular surgery for serous macular detachment. A 65-year-old woman presented with residual epiretinal membrane and serous detachment of the macula following vitreoretinal surgery for epiretinal membrane. She underwent resurgery with ICG-assisted internal limiting membrane peeling and intraocular tamponade. Intraoperatively a large area of subretinal ICG was seen with subsequent RPE mottling and atrophy of the macula in the area involved during follow-up. This case demonstrates that subretinal migration of ICG is possible and can be toxic to RPE.
  2,645 230 2
LETTERS TO THE EDITOR
Diabetic retinopathy: New proposed classification
Prasan M Rao
September-October 2008, 56(5):440-441
DOI:10.4103/0301-4738.42432  PMID:18711284
  2,408 458 1
JOURNAL ABSTRACTS
Ophthalmic manifestations of human immunodeficiency virus infection: Pre- highly active antiretroviral chemotherapy (HAART) and post- HAART era
Rajesh Sinha, Naginder Vashisht, Satpal Garg
September-October 2008, 56(5):443-447
PMID:18711285
  2,233 436 -
BRIEF COMMUNICATIONS
Lateral fixation of sclera to the periosteum with medial rectus disinsertion for severe myopic strabismus fixus
Ramesh Murthy
September-October 2008, 56(5):419-421
DOI:10.4103/0301-4738.42422  PMID:18711274
Myopic strabismus fixus is characterized by severe ocular motility restriction with the development of progressive esotropia and hypotropia. Management of severe cases with strongly positive forced duction test can be challenging. We describe a longstanding case of myopic strabismus fixus, which was managed by bilateral medial rectus disinsertion and scleral fixation laterally to the periosteum.
  2,365 257 -
An unusual ocular presentation of acquired immune deficiency syndrome
Cynthia Arunachalam, Vidya Hegde, Rashmi Jain, Nameeth D'Souza
September-October 2008, 56(5):434-436
DOI:10.4103/0301-4738.42428  PMID:18711280
A 50-year-old male who presented with bilateral keratomalacia and on subsequent evaluation was found to be human immunodeficiency virus (HIV) positive is being reported. A MEDLINE search of the literature did not reveal any report of keratomalacia as the initial presenting feature of HIV/ acquired immune deficiency syndrome.
  2,168 268 -
Familial unilateral Brown syndrome
Nihal Kenawy, Daniela T Pilz, Patrick Watts
September-October 2008, 56(5):430-434
DOI:10.4103/0301-4738.42427  PMID:18711279
We present a two-generation family with Brown syndrome. The proband was a six and a half-year-old female who presented with a history of failure of dextro-elevation of her left eye. A full ophthalmic evaluation was consistent with a left Brown syndrome. Family history revealed that her mother was operated on as a child for left Brown syndrome and examination of her four and a half-year-old sibling showed similar affection in the left eye. Autosomal dominant inheritance has been postulated in this condition. To our knowledge this is the first report of three members of a two-generation family with left-sided Brown syndrome. Genetic counseling of Brown syndrome cases is advised; nevertheless, identification of the responsible gene should shed more light on its genetics.
  1,828 224 -
LETTERS TO THE EDITOR
Management of intralenticular caterpillar setae
Pukhraj Rishi, Mamta Agarwal, Sheshadri Mahajan, Ekta Rishi
September-October 2008, 56(5):437-438
DOI:10.4103/0301-4738.42429  PMID:18711281
  1,704 204 2
Combined photodynamic therapy and intravitreal ranibizumab as primary treatment for choroidal neovascularization associated with age-related macular degeneration in an Indian patient
Pukhraj Rishi, Pratik Ranjan Sen, Daraius Shroff, Jay Chhablani
September-October 2008, 56(5):438-439
DOI:10.4103/0301-4738.42430  PMID:18711282
  1,666 237 1