Referral patterns of children with glaucoma and their caretakers in Northern Tanzania

AIM: To evaluate the efficacy of ruthenium-106 plaque brachytherapy for the treatment of diffuse choroidal hemangioma (DCH) in Sturge-Weber syndrome (SWS). METHODS: A total of 8 patients with DCH in SWS managed with plaque brachytherapy were retrospectively included. Patients were treated with ruthenium-106 plaque therapy (median apex dose: 83 Gy) at the thickest tumor region. On follow-up, we recorded the tumor thickness, the best-corrected visual acuity (BCVA), subretinal fluid (SRF) status, and complications following treatment. RESULTS: At a median follow-up of 43 mo, tumor regression was observed in all cases, with a complete resolution of SRF and reduction in tumor-thickness. No radiation complications were recorded during the follow up time. CONCLUSION: Ruthenium-106 plaque therapy to the thickest portion of the tumor seems to be a useful treatment in patients with DCH in SWS.     

Current concepts in the diagnosis,pathogenesis and management of nonarteritic anterior ischaemic optic neuropathy

Nonarteritic anterior ischaemic optic neuropathy (NAION) is the most common acute optic neuropathy in patients over the age of 50 and is the second most common cause of permanent optic nerve-related visual loss in adults after glaucoma. Patients typically present with acute, painless, unilateral loss of vision associated with a variable visual field defect, a relative afferent pupillary defect, a swollen, hyperaemic optic disc, and one or more flame-shaped peripapillary retinal haemorrhages. The pathogenesis of this condition is unknown, but it occurs primarily in patients with structurally small optic discs that have little or no cup and a variety of underlying vascular disorders that may or may not be known at the time of visual loss. There is no consistently beneficial medical or surgical treatment for the condition, but there are now animal models that allow testing of various potential therapies. About 40% of patients experience spontaneous improvement in visual acuity. Patients in whom NAION occurs in one eye have a 15–19% risk of developing a similar event in the opposite eye over the subsequent 5 years.     

Adamantiades-Behcet disease: diagnosis and current concepts in management of ocular manifestations

Adamantiades-Behcet disease is a relapsing systemic vasculitis that may involve the eyes, skin, and almost all other organ systems. The comprehensive ophthalmologist plays a key role by not only making the diagnosis but also by monitoring inflammatory status to guide systemic therapy. If left untreated, the disease has a high likelihood of causing blindness and death. Adamantiades-Behcet disease with retinal involvement is now considered an absolute indication for systemic immunomodulatory therapy. The diagnostic signs, potential complications, and treatment modalities currently available for ocular Adamantiades-Behcet disease are reviewed.     

Herpes simplex eye infections: Clinical manifestations,pathogenesis and management

Herpes infection of the eye may be acquired as the patient's first exposure to the virus (primary infection) or as involvement of a new anatomical site (the eye) in a patient with previous HSV infection. In either case, patients with herpetic eye infection risk recurrent eye disease throughout their lives. The infective lesions of the corneal epithelium (dendritic and geographic ulcers) occasionally develop into noninfective indolent or trophic ulcers, particularly under the influence of cauterizing chemicals or corticosteroids. Inflammation of the corneal stroma may accompany herpetic epithelial lesions or occur independently. Stromal keratitis probably represents the host's immune response to viral antigens filtering down from epithelial lesions or from viral replication in stromal cells. The clinical manifestations of ocular HSV infection are reviewed, pathogenesis and possible pathways of the infection are analyzed, and some practical guidelines for management and prevention are presented.     

Infantile nystagmus: current concepts in diagnosis and management

This review examines current approaches to the diagnosis and management of congenital forms of nystagmus. Emphasis is placed on diagnostic features that are amenable to clinical identification but those issues that can be addressed only with more detailed investigations, such as eye movement recording, are indicated. Non‐surgical management, including prism spectacles, contact lenses and vision therapy, is discussed, as are surgical approaches. Because many aspects of congenital forms of nystagmus, particularly as experienced by patients with the condition in their normal lives, are poorly addressed in both the clinical and research literature, these limitations are also highlighted.     

Wall‐eyed bilateral internuclear ophthalmoplegia: review of pathogenesis,diagnosis, prognosis and management

Wall‐eyed bilateral internuclear ophthalmoplegia (WEBINO) is an uncommon disorder of ocular motility that possesses a unique spectrum of clinical findings, consisting of primary gaze exotropia, adduction impairment and nystagmus of the abducting eye. WEBINO is a variant of internuclear ophthalmoplegia (INO) sharing similar pathophysiology and aetiologies. Much of the literature published on internuclear ophthalmoplegia and its variants focuses on aetiology and pathophysiology, whereas there has been less information addressing prognosis and management. This review will provide current perspectives on the pathogenesis, prognosis and management of WEBINO syndrome.     

Blood-retinal barrier in hypoxic ischaemic conditions: basic concepts, clinical features and management

The blood–retinal barrier (BRB) plays an important role in the homeostatic regulation of the microenvironment in the retina. It consists of inner and outer components, the inner BRB (iBRB) being formed by the tight junctions between neighbouring retinal capillary endothelial cells and the outer barrier (oBRB) by tight junctions between retinal pigment epithelial cells. Astrocytes, Müller cells and pericytes contribute to the proper functioning of the iBRB. In many clinically important conditions including diabetic retinopathy, ischaemic central retinal vein occlusion, and some respiratory diseases, retinal hypoxia results in a breakdown of the iBRB. Disruption of the iBRB associated with increased vascular permeability, results in vasogenic oedema and tissue damage, with consequent adverse effects upon vision. Factors such as enhanced production of vascular endothelial growth factor (VEGF), NO, oxidative stress and inflammation underlie the increased permeability of the iBRB and inhibition of these factors is beneficial. Experimental studies in our laboratory have shown melatonin to be a protective agent for the iBRB in hypoxic conditions.Although oBRB breakdown can occur in conditions such as accelerated hypertension and the toxaemia of pregnancy, both of which are associated with choroidal ischaemia and in age-related macular degeneration (ARMD), and is a feature of exudative (serous) retinal detachment, our studies have shown that the oBRB remains intact in hypoxic/ischaemic conditions.Clinically, anti-VEGF therapy has been shown to improve vision in diabetic maculopathy and in neovascular ARMD. The visual benefit in both conditions appears to arise from the restoration of BRB integrity with a reduction of retinal oedema.     

Update on thyroid eye disease: Regional variations in prevalence,diagnosis, and management

Thyroid eye disease (TED) is a rare disease that can lead to decreased quality of life, permanent disfigurement, and vision loss. Clinically, TED presents with exophthalmos, periorbital edema, extraocular muscle dysfunction, and eyelid retraction, and can lead to vision-threatening complications such as exposure to keratopathy and dysthyroid optic neuropathy (DON). Over the last several years, significant advancements have been made in the understanding of its pathophysiology as well as optimal management. Ethnic variations in the prevalence, clinical presentation, and risk of vision-threatening complications of TED are summarized, and risk factors associated with TED are discussed. Additionally, significant advances have been made in the management of TED. The management of TED traditionally included anti-inflammatory medications, orbital radiation therapy, orbital surgical decompression, and biologic therapies. Most recently, targeted therapies such as teprotumumab, an insulin-like growth factor-1 receptor antagonist, have been studied in the context of TED, with promising initial data. In this review, updates in the understanding and management of TED are presented with a focus on the international variations in presentation and management.     

Macular hole: improved understanding of pathogenesis,staging, and management based on optical coherence tomography

Optical coherence tomography (OCT) has improved the understanding and management of idiopathic macular hole. Images of precursor lesions and their progression demonstrate that antero-posterior as well as tangential traction are involved in macular hole formation. The staging of macular holes with biomicroscopic examination can be paralleled by optical coherence tomography staging with some modification. OCT is useful in differentiating simulating lesions and in allowing better counseling of patients regarding their disorder. Finally, OCT findings are prognostic of surgical success and can assist in evaluating the results of surgery.     

Dry eye: an update on clinical diagnosis,management and promising new treatments

Dry eye conditions are prevalent with one in four to five patients presenting to eye care practitioners having dry eye signs and/or symptoms. An intimate relationship exists between the ocular surface and the tear film. The cycle of tear film instability and ocular surface damage characteristic of dry eye conditions suggests that dry eye represents a dysfunction of an integrated ocular surface‐lacrimal gland unit. Therefore, dry eye is a multifactorial condition and an approach based on clinical subtypes is required for diagnosis and management. There is increasing evidence that inflammation is a contributing and exacerbating factor in dry eye conditions and anti‐inflammatory or immunomodulatory therapy for chronic dry eye conditions may facilitate ocular surface healing. Other promising new treatments for dry eye include new generation artificial tear polymers and preservative systems, secretagogues, topical androgen supplements and surgical techniques for ocular surface reconstruction.     

Intraoperative floppy iris syndrome in Indian population: A prospective study on incidence,risk factors,and impact on operative performance

Purpose:

The purpose of this study was to evaluate the incidence, risk factors, and impact of intraoperative floppy iris syndrome (IFIS) on surgical performance.

Materials and Methods:

Consecutive cataract surgeries from October 2010 to Feb 2011 (1003 eyes, 980 patients; 568 males, 412 females) were analyzed prospectively. Operating surgeon, masked about medication history, noted the intraoperative details. Cases were identified as IFIS or non-IFIS. Multivariate analysis was performed to find risk factors for IFIS.

Results:

Prevalence of tamsulosin use among men undergoing cataract surgery was 7.0% (41) with incidence of IFIS 4.78% (48). On multivariate analysis, hypertension (OR: 3.2, 95% confidence interval, 95% CI: 1.39-6.57; P = 0.005), use of tamsulosin (OR: 133.32, 95% CI: 50.43-352.48; P < 0.0001), or alfuzosin (OR: 9.36, 95% CI: 2.34-37.50; P = 0.002) were the factors associated with IFIS. Among men taking tamsulosin (n = 41) and alfuzosin (n = 28), 68.3% and 16.6% developed IFIS, respectively. In subgroup analysis of men on tamsulosin, no factor added to the risk posed by tamsulosin. Seventeen of 944 eyes not exposed to any drug had IFIS (0.018%). On subgroup analysis, only risk factor for IFIS was hypertension (OR: 4.67, 95% CI: 1.63-13.35; P = 0.002). Of 48 IFIS eyes, the surgeon observed increased difficulty in 57.1% (21) and additional measures were required in 9 eyes. Mean operative time was increased in IFIS eyes (11.68 ± 3.46 vs. 10.01 ± 0.22 min; P = 0.001). Surgical outcome was good in all cases.

Conclusion:

The prevalence of tamsulosin intake and IFIS incidence is higher in India. Current tamsulosin/alfuzosin use and hypertension are important risk factors. IFIS makes the surgery more difficult, significantly prolongs the operative time, and predisposes for other intraoperative complications. However, with appropriate management, final operative outcome is not affected.