Treatment Outcomes of Primary Combined Trabeculotomy and Trabeculectomy in Early Onset Glaucoma with Sturge-Weber Syndrome

PRECIS

In eyes with Sturge-Weber syndrome with early onset glaucoma, primary combined trabeculotomy and trabeculectomy had good intermediate-term success rate and minimal postoperative complications.

PURPOSE

To report the intermediate-term outcomes of primary combined trabeculotomy with trabeculectomy (CTT) in early onset glaucoma with Sturge-Weber syndrome (SWS).

DESIGN

Retrospective Cohort study.

METHODS

This study included 49 eyes of 49 children (1997-2020) with SWS and early onset glaucoma that underwent primary CTT with at least 1 year postoperative follow-up. Success was defined as complete when intraocular pressure (IOP) was >5 and ≤16 mmHg under general anaesthesia or ≤21 mmHg in the clinic without antiglaucoma medications (AGMs) and as qualified with AGM.

RESULTS

The median age (interquartile range) at CTT was 0.58(0.19, 8.3) years. The median postoperative follow-up was 4.7 years(2.5, 9). Majority were male (31/49, 63%) children. Epilepsy was noted in seven (14.3%) and diffuse choroidal haemangioma in 17 children (35%). At diagnosis, 37 eyes(75%), had corneal oedema and mean (±standard deviation) horizontal corneal diameter was 12.8±0.7 mm. Postoperatively, the median IOP decreased from 26(22, 30) mmHg to 16(12, 20) mmHg (P<0.0001) and the median number of AGM reduced from 1 (0,1) to 0 (0,1) (P<0.01). Complete success probability of CTT was 86%(76, 96) at 1-year and 64%(49, 84) at 5-years. Qualified success was 98%(94, 100) at 1-year and 89%(78, 100) at 5-years. Larger cup-to-disk ratio (P<0.005) was associated with higher risk of surgical failure. Postoperative complications were noted in 9 eyes(18%), all resolved with conservative management except one eye with retinal detachment that ended in phthisis bulbi.

CONCLUSION

CTT as a primary procedure showed good long-term efficacy and safety in in SWS with early-onset glaucoma.

Profile of Newly Diagnosed Childhood Glaucoma in India: Indian Childhood Glaucoma Study (ICGS) Group 1

OBJECTIVE

To report the profile of newly diagnosed childhood glaucoma using the Childhood Glaucoma Research Network (CGRN) classification, presenting over 1 year from across centers in India.

DESIGN

Prospective observational multicentric study.

SUBJECTS

Newly diagnosed children aged < 18 years diagnosed with childhood glaucoma according to CGRN criteria presenting between January and December 2019 to 13 centers across India.

METHODS

All children underwent a comprehensive ocular examination, including examination under anesthesia for younger children, and were diagnosed with childhood glaucoma as per CGRN. Data were entered in a standard Excel chart. Refraction and visual acuity assessments were done when feasible.

MAIN OUTCOME MEASURES

The profile of newly diagnosed childhood glaucoma in different parts of India and the severity of glaucoma at presentation.

RESULTS

A total of 1743 eyes of 1155 children fulfilled the definition of glaucoma and were analyzed. Primary congenital glaucoma (PCG) comprised the single largest group (34.4%), most of which were infantile onset (19%). Neonatal-onset PCG comprised 6.2% of all glaucoma. Secondary glaucoma constituted 53.4% of all glaucoma, one-half of which were acquired conditions (28%), followed by isolated ocular anomalies (14.7%), glaucoma after cataract surgery (6.7%), and glaucoma with nonacquired systemic diseases (4.5%). Of the 1743 eyes with glaucoma, all 3 parameters for severity grading were available in 842 eyes, of which 501 (59.5%) eyes presented with mild, 320 (38%) with moderate, and 21 (2.5%) with severe glaucoma. Nearly one-third of the children (28.5%) were not brought back for follow-up after the initial treatment given.

CONCLUSIONS

Our study has one of the largest numbers of consecutive children with glaucoma classified according to the CGRN classification. Despite a widely diverse population, the profile of childhood glaucoma was relatively uniform across India. Childhood glaucoma is a significant problem in India, primarily treated in tertiary care hospitals. The data presented may be the tip of the iceberg because we have only reported the children who reached the hospitals offering treatment for this challenging disease.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Long-term Outcomes in Patients Undergoing Surgery for Primary Congenital Glaucoma between 1991 and 2000: A Single-Center Database Study

PURPOSE

To estimate the long-term surgical and visual outcomes in patients with primary congenital glaucoma (PCG) who completed at least 20 years of follow-up.

DESIGN

Retrospective study.

PARTICIPANTS

Two hundred twenty eyes of 121 patients undergoing surgery for PCG between January 1991 and December 2000 and who returned for a follow-up visit from January 2021 through January 2022.

METHODS

Retrospective review of medical records of patients who underwent primary combined trabeculotomy-trabeculectomy (CTT) without mitomycin C as an initial procedure. Success was defined as complete when intraocular pressure (IOP) was ≥ 6 mmHg and ≤ 21 mmHg without glaucoma medication and as qualified when up to 2 glaucoma medications were required. Failure was defined as uncontrolled IOP with more than 2 glaucoma medications, need for a second IOP-lowering procedure, chronic hypotony (IOP < 6 mmHg on 2 consecutive visits), or any sight-threatening complication. A mixed-effects model using maximum likelihood estimation was used in estimation of eye-based variables and to make comparisons between different visits. Kaplan-Meier survival analysis was used to estimate the probabilities of surgical and functional successes. Cox proportional hazards regression using sandwich clustered estimation was used to evaluate risk factors for failure and poor visual outcome.

MAIN OUTCOME MEASURES

Primary outcome measure was the proportion of patients who demonstrated complete success over the 20-year follow-up. Secondary outcome measures included rate of surgical failure and need for reoperation for glaucoma, visual acuity, refractive errors, risk factors for poor outcome, and complications.

RESULTS

Kaplan-Meier survival analysis revealed 1-year, 10-year, and 20-year complete success rates of 90.7%, 78.9%, and 44.5%, respectively. In univariate analysis, surgical failure was higher among patients with any additional non-glaucoma intraocular surgery. None of the clinical parameters were associated significantly with failure in multivariable analysis. Overall, the proportion of eyes with good, fair, and poor visual outcomes was 33.2%, 16.4%, and 50.4%, respectively. Myopia was seen in 68.9% eyes. Twenty-eight eyes of those who underwent primary CTT (14.4%) required second surgery for IOP control. No significant intraoperative complications occurred. Six eyes required enucleation because of painful blind eye.

CONCLUSIONS

In this large cohort of patients with PCG, CTT is a useful procedure. It provides good IOP control and moderate visual recovery that remained over a 20-year follow-up after surgery.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Corneal Endothelial Features in Patients Operated for Primary Congenital Glaucoma

PURPOSE

To compare the corneal endothelial cell morphology using specular microscopy imaging between primary congenital glaucoma (PCG) and age-matched healthy controls, and to determine if the endothelial cell parameters vary among different subtypes of PCG.

DESIGN

Retrospective case-control study.

PARTICIPANTS

One hundred forty-five eyes of 145 patients operated for PCG between 1991 and 2018 and who returned for a follow-up visit between June 2021 and May 2022. Three hundred and nineteen age-matched healthy individuals constituted the control group.

METHODS

Corneal endothelial cell layer analysis was performed with EM-3000 (Tomey) noncontact specular microscope. Patients were categorized according to the clinical subtypes of PCG (neonatal, infantile, and late-onset) based on the Childhood Glaucoma Research Network classification.

MAIN OUTCOME MEASURES

Specular microscopic parameters, including endothelial cell density (ECD), average cell size, coefficient of variation (CV), and maximum and minimum cell size, were compared with that of the control group.

RESULTS

Mean ± standard deviation (SD) age of patients at endothelial imaging was 13.5 ± 6.54 years, and there was a male preponderance (n = 88, 61%). The majority of the patients had infantile-onset PCG (n = 67, 46%). Eyes with PCG demonstrated a significantly lower ECD compared with controls (2158.7 ± 636.5 vs. 2840.9 ± 232.5 cells/mm2; P < 0.0001). Other endothelial cell parameters were also significantly worse in PCG compared with controls. The mean ± SD ECD was 2344.3 ± 544.3, 2131.9 ± 626.4, and 2054.2 ± 714.0 cells/mm2 in neonatal onset, infantile, and late-onset PCG groups, respectively. Although the ECD was lowest in the late-onset PCG group, there was no significant difference in the ECD between the 3 subgroups. Except for CV, all the endothelial cell parameters were significantly worse in eyes with Haab striae than in eyes without.

CONCLUSIONS

Patients with PCG have significantly lower ECD compared with healthy controls. Furthermore, other endothelial cell parameters were also significantly worse in the PCG group. These changes in the corneal endothelium in patients with PCG should be considered in long-term medical and surgical management.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Robot-assisted and conventional urology surgical procedures: comparison of average length of stay, economic status, operative time and patient's expenditure in a tertiary care hospital of North India

Robot-assisted surgeries allows the surgeons to operate using remote-controlled robotic arms that are more effective in comparison to conventional (open/laparoscopic) surgeries. However, there is substantial lack of evidence on the effectiveness of robot-assisted surgeries in low to middle income countries (LMICs) like India. A study was conducted with an aim to evaluate the average length of stay (ALOS), Operative time, economic status (patient's) and cost borne by the patient (patient's expenditure) for undergoing robot-assisted surgeries and conventional surgeries. Grouping of the surgical procedures was done wherein patients who were treated with robot-assisted surgical procedures were placed in Group-01 whereas those treated with conventional surgical procedures were placed under Group-02. Comparative evaluation of the two surgical groups revealed that in robot-assisted surgical procedure, the ALOS was less (18.43 vs. 23.14 days, p = 0.06) whereas operative time (316.7 vs. 252.63 min, p = 0.05) and patient's expenditure were more (INR 70,654.29 vs. INR 41,314.73, p = 0.00). However, there was no significant difference between the economic statuses of patients in both groups. The study concluded that in this era of rapidly expanding health care scenario; targeted, regular, rigorous and repeated training programmes in future may shorten the learning curve thereby paving a way to reduce the cost as well as the operative time of robot-assisted surgeries in LMICs.

Glaucoma management in congenital ectropion uveae: Surgical outcomes from a large tertiary referral center in South India

PURPOSE

To evaluate the long-term outcomes of glaucoma management in patients with congenital ectropion uveae (CEU) over a period of three decades at a single large referral tertiary eye care center.

METHODS

Retrospective chart review of all patients with CEU treated surgically from 1990 to 2019 was performed. Primary combined trabeculotomy-trabeculectomy (CTT), trabeculectomy with and without mitomycin-C (MMC) (0.2 mg/mL for 1 min) and transscleral cyclophotocoagulation (TSCPC) were performed. Intraocular pressure (IOP) ≥6 and ≤16 mmHg without medications was considered as complete success and IOP≤ 16 mmHg with the use of upto 2 medications as qualified success.

RESULTS

A total of 26 eyes of 21 patients were identified with a median age of 7 years (range, 6 days to 19 years) at the time of glaucoma surgery. Median follow-up was 51.1 months (range, 7-244.6 months). Primary CTT was performed in 17 eyes (65%), trabeculectomy in 5 eyes (19%) with application of MMC in 2 eyes, and 3 eyes (12%) underwent TSCPC. One painful blind eye (4%) underwent evisceration. Mean IOP reduced from 30.8 ± 7.6 mmHg on a mean of 1.3 ± 0.8 glaucoma medications preoperatively to a mean IOP of 15.2 ± 5.9 mmHg (P < 0.0001) on a mean of 0.2 ± 0.5 medications postoperatively at final follow-up (P = 0.0009). Complete success was achieved in 20 eyes, and qualified success in 2 eyes.

CONCLUSIONS

CTT is a safe and efficacious primary procedure for management of early-onset glaucoma in CEU. Trabeculectomy with or without adjuvant MMC is a viable second line of treatment in late-onset glaucoma with CEU for IOP control.

Illuminated Microcatheter Passage Assisted Circumferential Trabeculotomy and Trabeculectomy (IMPACTT): An improved surgical procedure for Primary Congenital Glaucoma

PURPOSE

To report an improved surgical procedure for primary congenital glaucoma (PCG).

CASE REPORT

An apparently healthy 4-month-old male child was referred by an ophthalmologist with the preliminary diagnosis of congenital glaucoma. Office examination followed by evaluation under anaesthesia confirmed the diagnosis of advanced PCG in both eyes. Horizontal corneal diameter was 13.5 mm in both eyes and intraocular pressure was 36 mmHg in both eyes. The child was operated on both eyes in the same session. An illuminated microcatheter passage assisted circumferential trabeculotomy and trabeculectomy (IMPACTT) was performed. Two months postoperatively, the IOPs were 12 and 10 mmHg in the right and left eye, respectively, and the cornea was clear except for the presence of Haab's striae in both eyes. The child's visual acuity (binocularly) was 4 cycles/degree as recorded with Teller acuity cards.

CONCLUSIONS

Illuminated microcatheter passage assisted circumferential trabeculotomy and trabeculectomy (IMPACTT) is safe and effective and may represent an improved surgical procedure for the management of advanced PCG.

Combined trabeculotomy-trabeculectomy for primary congenital glaucoma: long-term experience from a tertiary referral centre in a developing nation

PURPOSE

To evaluate the long-term visual and surgical outcomes, and associated risk factors for poor outcomes in patients with primary congenital glaucoma (PCG).

METHODS

Retrospective review of medical records of children who underwent combined trabeculotomy-trabeculectomy (CTT) without mitomycin-C as the first surgical procedure by a single surgeon between January 1990 and December 2010. Success was defined as intraocular pressure (IOP) <16 mmHg without (complete) or with (qualified) one glaucoma medication. We used the WHO criteria of vision loss to categorize the levels of vision impairment (VI). For purposes of statistical analysis, we randomly chose one eye of patients for bilateral PCG and affected eye in unilateral PCG.

RESULTS

The cohort included 653 consecutive PCG patients (1128 eyes; mean age, 26 months), of whom 475 (73%) underwent simultaneous bilateral CTT. Kaplan-Meier survival analysis revealed 1-, 5-, 10-, 15-, and 19-year complete success rates of 92.6% (n = 372), 75.5% (n = 173), 55.9% (n = 72), 44.7% (n = 19), and 21.6% (n = 3), respectively. Multivariate analysis revealed independent associations between failure, preoperative corneal clarity, and prior glaucoma surgery. Mean follow-up was 41 ± 51 months (range, 6 months to 19 years; median, 1 year). Of the visual acuity (VA) data in the affected eyes obtained at last follow-up (n = 333, 51%), seventy-four patients (22%) had VA of ≥6/12. Of the remaining 259 patients, 18 (7%) had mild VI, 87 (34%) had moderate VI, 58 (22%) had severe VI, and 96 (37%) were blind. No serious complications were noted.

CONCLUSIONS

Primary CTT may be safely employed to control IOP and may provide long-term benefits in PCG patients.

Outcomes of trabeculectomy in eyes with refractory acute primary angle-closure in Indian eyes

Purpose:

To report the outcomes of trabeculectomy in eyes with refractory acute primary angle-closure attack.

Methods:

Patients with acute primary angle-closure attack and who underwent trabeculectomy for medically uncontrolled intraocular pressure within 2 months of presentation were retrospectively analyzed. Primary outcome was intraocular pressure (IOP). Secondary outcome measures were visual acuity, number of antiglaucoma medication (AGM), complications, and risk factors for failure of trabeculectomy.

Results:

Thirty-five eyes of 31 patients with median (interquartile range) follow-up of 3 (0.5, 9) years were included in the study. Median age at presentation was 55 (47, 60) years. Median duration of symptoms at presentation was 10 (4, 16) days and median time from presentation to surgery was 13 (6, 25) days. Median IOP reduced from 42 (36, 46) to 13 (12, 16) mmHg (P < 0.001) and median number of AGM reduced from 3 (1, 3) to 0 (0, 0) after trabeculectomy at the end of 1 year. The probability of complete and qualified success was 88% (95% confidence interval [CI]: 72%–95%) and was 97% (95% CI: 81%–99%) at 1 year, respectively. Failure was noted in six eyes. Subsequent cataract surgery was needed in 13 eyes (37%) with a median duration from trabeculectomy being 6.75 (1, 11) years. None of the preoperative, intraoperative, or postoperative factors tested were associated with failure (P > 0.10 for all associations on Cox proportional hazard regression analysis).

Conclusion:

In medically unresponsive cases of acute primary angle-closure attack, primary trabeculectomy seems safe and effective in Indian eyes.

Co-existing lacrimal drainage anomalies in eyes with congenital Glaucoma

AIM

To evaluate the occurrence of co-existing congenital nasolacrimal duct obstruction (CNLDO) and other lacrimal anomalies in eyes with congenital glaucoma (CG).

METHODS

Retrospective analysis of children aged ≤1-year with co-existing CG and CNLDO seen between 1998 and 2019, treatment interventions and outcomes.

RESULTS

During the study period, 1993 children had CG and 6203 children had CNLDO, among the children aged 1-year or less. Of these, 51 children (73 eyes) had co-existing CG and CNLDO. The prevalence of CNLDO in CG was 2.5% (51/1993) and the prevalence of CG among CNLDO was 0.8% (51/6203). Median age (Interquartile range, IQR) was 53 days (IQR: 8, 155), when they were diagnosed with CG. Among the children with CNLDO, 68 eyes (93.1%) had simple CNLDO, and 5 eyes (6.9%) had complex CNLDO. Associated lacrimal anomalies were present in 7/73 eyes, including congenital lacrimal fistula in two eyes, upper punctal agenesis and upper mid-canalicular obstruction in two eyes each, and upper single canalicular-wall hypoplasia in one eye. Lacrimal syringing and probing were successful in 69/72 eyes (95.8%), and failed in 3 eyes (4.2%). These 3 eyes had complex CNLDO and underwent Dacryocystorhinostomy (DCR) with Mitomycin-C and intubation. Sixty-two eyes underwent combined trabeculotomy and trabeculectomy, and two eyes underwent trabeculectomy. Median age at glaucoma surgery was 87 days (IQR: 54, 193). Median time delay for glaucoma surgery after probing was 18 days (IQR: 12, 35).

CONCLUSION

Among children aged ≤1-year presenting with congenital glaucoma coexisting lacrimal drainage anomalies was noted in 2.5% and simple CNLDO was the commonest. Early intervention is of paramount importance to prevent sight-threatening intraocular infection with CNLDO, and to minimize the delay of glaucoma surgery. The outcomes of lacrimal probing were excellent, however complex CNLDO required DCR.

Outcomes of Management of Glaucoma in Phacomatosis Pigmentovascularis Over the Last Three Decades: A Single-Center Experience

PURPOSE

To report the clinical outcomes of glaucoma management in patients with phacomatosis pigmentovascularis (PPV) treated over a period of 3 decades.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Fifty-five eyes of 38 patients (21 unilateral and 17 bilateral) with glaucoma in PPV managed at one institution between January 1990 and December 2019 with a minimum follow-up of 1 year.

METHODS

Medical records of children with glaucoma in PPV were reviewed, and demographic and clinical data were collected. Surgical interventions included primary combined trabeculotomy-trabeculectomy (CTT), trabeculectomy with mitomycin C (MMC), and transscleral cyclophotocoagulation (TSCPC). Complete success was defined as intraocular pressure (IOP) ≥ 6 and ≤ 16 mmHg without medications and qualified success as IOP ≤ 16 mmHg with the use of up to 2 medications.

MAIN OUTCOME MEASURES

Intraocular pressure, best-corrected visual acuity (BCVA), corneal clarity, antiglaucoma medications at preoperative and postoperative visits (last visit), and complications.

RESULTS

Median age was 4 months (range, 0.2-252 months) at the time of glaucoma surgery. Thirty-nine eyes (74%) had primary CTT, 10 eyes (19%) had trabeculectomy with MMC, and 4 eyes (7%) with advanced glaucoma had TSCPC. Two eyes (3.6%) received medical treatment. Preoperative IOP reduced from a mean of 25.7 ± 8.4 mmHg on 0.8 ± 0.6 medications to 14.6 ± 5.2 mmHg on 0.4 ± 0.5 medications (P < 0.0001) at last follow-up after surgery (77.7 ± 56.5 months). Thirty-seven eyes (67.3%) required medications preoperatively, and 22 eyes (40%) required medications at the last follow-up. Of 25 patients with available BCVA at last follow-up, 9 (36%) had ≥ 20/60; of these, 6 had > 20/40. Four of 10 eyes that underwent trabeculectomy with MMC developed retinal detachment and were managed surgically; however, all of these eyes had poor visual outcomes. There was no incidence of bleb leakage, bleb-related infection, or endophthalmitis.

CONCLUSIONS

Combined trabeculotomy-trabeculectomy is safe and effective as a primary procedure for management of glaucoma in PPV. Trabeculectomy augmented with MMC as a second procedure was associated with a higher rate of complications.

Outcomes of Primary Combined Trabeculotomy and Trabeculectomy in Early-Onset Glaucoma in Children with Congenital Aniridia

PURPOSE

To report clinical features and treatment outcomes of primary combined trabeculotomy with trabeculectomy (CTT) in congenital aniridia with glaucoma in children 3 years of age or younger.

DESIGN

Retrospective study.

PARTICIPANTS

Sixty-six eyes of 35 children with congenital aniridia and early-onset glaucoma who underwent CTT between May 1997 and June 2015 were included.

METHODS

Success was defined as complete when intraocular pressure (IOP) was more than 5 mmHg and less than or equal to 21 or 16 mmHg without antiglaucoma medications (AGMs), and qualified when AGMs were required. Eyes needing repeat surgery for IOP control were considered as failures.

MAIN OUTCOME MEASURES

IOP control and number of AGMs.

RESULTS

The median age at presentation of 35 children was 26 days (interquartile range [IQR], 7-106 days). There were 22 males (62.9%) and 13 females (37.1%). Parental consanguinity was noted in 11 children (31.4%). Aniridia was total in 52 eyes and partial in 14 eyes. At presentation, there was corneal edema in 30 eyes (45.4%), enlarged corneal diameter in 32 eyes (48.5%), nystagmus in 15 children (23%), limbal stem cell deficiency in 1 eye, cataract in 9 eyes (13.6%), and foveal hypoplasia in 4 eyes. After CTT, median IOP was reduced significantly (P < 0.0001). Corneal edema cleared in 12/30 eyes and cleared with scar in 18/30 eyes. Median follow-up was 5.33 (IQR, 3.05-7.59) years. At latest follow-up, median number of AGMs was 1 (IQR, 0-2) and median visual acuity in logarithm of minimum angle of resolutions (n = 34 eyes) was 1.35 (IQR, 0.80-2.78). The probability of complete success for IOP ≤ 21 mmHg was 79.9% at 1 year and 62.3% between 2 and 10 years; for IOP ≤ 16 mmHg, it was 78.6% at 1 year and decreased to 51.9% at 10 years. Qualified success for IOP ≤ 21 mmHg at 1 year was 82.6% and 81% over 10 years; for IOP ≤ 16 mmHg, it was 81.4% at 1 year and decreased to 63.1% at 10 years. Seven eyes (10.6%) required repeat intervention for IOP control with median time of 3.17 years (IQR, 0.92-6.56) from first surgery.

CONCLUSIONS

CTT showed good success in children with congenital aniridia with early-onset glaucoma.

Cross-Diagnostic Validity of the Congenital Glaucoma Caregiver's Quality of Life Questionnaire (CarCGQoL)

Purpose

The Caregiver's Congenital Glaucoma QoL (CarCGQoL) questionnaire was proposed as a measure of QoL of caregivers with children with primary congenital glaucoma (PCG). Support for its psychometric properties among other diagnostic groups is required for scores to be interpreted in the same manner across groups. Therefore we investigated the measurement properties and cross-diagnostic validity of the CarCGQoL questionnaire among caregivers of children with congenital cataract, retinopathy of prematurity (ROP), and blinding corneal disorders.

Methods

Eight hundred ninety-one caregivers (mean age, 28.3 years; 76% mothers) of children with congenital cataract (n = 407), ROP (n = 272), and blinding corneal disorders (n = 212) completed the CarCGQoL questionnaire. Rasch analysis was used to investigate the psychometric properties. Unidimensionality (by principal components analysis of residuals, PCA) was examined for each group and for pooled sample. Differential item functioning (DIF) was investigated to explore whether bias in responses to the questionnaire existed for certain subgroups as compared to the reference group (PCG).

Results

Across groups, six items necessitated removal because of misfit (two common and four uncommon), after which three different versions of the questionnaire emerged. Measurement precision was adequate for each group and for the pooled sample (0.80). Unidimensionality was observed, albeit with some DIF. Regardless of the level of QoL, caregivers in the pooled sample were more likely to endorse two items reflecting ability to face child's disease, and interest to pursue leisure activity, as compared with caregivers of children with PCG.

Conclusions

Care must be taken when data from the CarCGQoL questionnaire from different pediatric ocular conditions are pooled, given the presence of DIF between the reference group (PCG) and the pooled sample.

Translational Relevance

When evaluating the impact of interventions on the caregiver's QoL using the CarCGQoL questionnaire in a pooled sample of pediatric ocular conditions, cross-diagnostic DIF must be taken into account.

Corrosion performance of various deformed surfaces of implant steel for coronary stent applications: Effect of protein concentration

This work was done to systematically elucidate the corrosion behavior of austenitic stainless steel subjected to various degree of cold deformation (10 %, 20 % & 30 %). The experiments were performed in phosphate buffer saline (PBS) solution having different concentrations of bovine serum albumin (0.2, 0.5, 1.0, 2.0, 4.0 g L^-1). Potentiodynamic polarization tests and electrochemical impedance spectroscopy (EIS) analysis were performed to obtain the corrosion parameters. Scanning electron microscopy with energy dispersive X-ray (SEM-EDX), atomic force microscopy (AFM) and X-ray photoelectron spectroscopy (XPS) were used to determine the surface morphologies and chemical compositions of the surface films. Contact angle analysis was also used to detect the hydrophilic character of sample surfaces. The BSA had a considerable effect of inhibition on the corrosion of SSs in annealed as well as in deformed state due to its adsorption on surface of steel. For annealed samples, at 4.0 g L^-1BSA concentration, the corrosion resistance was drastically decreased but interestingly not for sample with more than 10 % deformation and the concentration effect of BSA is also not very significant after 0.5 g L^-1 for deformed surfaces. The breakdown potential for 30 % deformed sample is quite higher in presence of BSA even at 4.0 g L^-1 while it is lowest for annealed samples in the same condition. The variation in contact angle with deformation is very less after adsorption of BSA. On the basis of the obtained results, mechanism aspect for corrosion of steel in presence of protein is also deliberated.

Management outcomes of secondary glaucoma due to retinopathy of prematurity: A 19-year prospective study at a tertiary eye care Institute. The Indian Twin cities ROP Screening (ITCROPS) database report number 8

PURPOSE

To report the clinical presentation and management outcomes of glaucoma in the "Indian Twin cities retinopathy of prematurity (ROP) Screening database."

METHODS

All children with diagnosis of ROP and glaucoma between 1997 and 2016 from a prospective database were included. Glaucoma was classified as open when anterior chamber (AC) was deep, closed when AC was shallow or flat and neovascular when there was extensive iris neovascularization. ROP was classified based on International classification of ROP.

RESULTS

The prevalence of secondary glaucoma in our cohort was 1.36% (82 eyes of 6000 children). Eighty-two eyes of 54 children with secondary glaucoma due to ROP where included in this study. The distribution of glaucoma among the ROP stages included, stage V (58.5%), stage 1V (24.3%), stage III (2.4%) and stage II (1.2%) eyes. Median (interquartile range) duration from birth to glaucoma diagnosis was 7.8 (4.2, 24.9) months. Type of glaucoma was angle closure in 39 (47.6%), open angle in 35 (42.7%) and neovascular in 8 (9.8%) eyes. Retinal interventions included vitreoretinal surgery in 59 (72%), retinal laser in 14 (17%) and intravitreal bevacizumab injection in 19 (23.1%) eyes. The mean (±standard deviation) IOP at presentation was 22.6 ±11.8 mm Hg. Glaucoma was managed medically in 66 (76%) and surgically in 16 (19.5%) eyes. The mean follow up for the entire cohort was 1.14±2.24 years. At final visit, 37% eyes with ROP and glaucoma had ambulatory vision with mean IOP of 16.0±8.1 mm Hg and 56 eyes (68.2%) needed glaucoma medications.

CONCLUSION

In this large ROP cohort, 1.36% eyes developed secondary glaucoma. Majority of them had stage V or IV ROP and 1/5 of them needed glaucoma surgery. Around 1/3rd of the ROP eyes with glaucoma had ambulatory vision.

Loss of PRSS56 function leads to ocular angle defects and increased susceptibility to high intraocular pressure

Glaucoma is a leading cause of blindness, affecting up to 70 million people worldwide. High intraocular pressure (IOP) is a major risk factor for glaucoma. It is well established that inefficient aqueous humor (AqH) outflow resulting from structural or functional alterations in ocular drainage tissues causes high IOP, but the genes and pathways involved are poorly understood. We previously demonstrated that mutations in the gene encoding the serine protease PRSS56 induces ocular angle closure and high IOP in mice and identified reduced ocular axial length as a potential contributing factor. Here, we show that Prss56-/- mice also exhibit an abnormal iridocorneal angle configuration characterized by a posterior shift of ocular drainage structures relative to the ciliary body and iris. Notably, we show that retina-derived PRSS56 is required between postnatal days 13 and 18 for proper iridocorneal configuration and that abnormal positioning of the ocular drainage tissues is not dependent on ocular size reduction in Prss56-/- mice. Furthermore, we demonstrate that the genetic context modulates the severity of IOP elevation in Prss56 mutant mice and describe a progressive degeneration of ocular drainage tissues that likely contributes to the exacerbation of the high IOP phenotype observed on the C3H/HeJ genetic background. Finally, we identify five rare PRSS56 variants associated with human primary congenital glaucoma, a condition characterized by abnormal development of the ocular drainage structures. Collectively, our findings point to a role for PRSS56 in the development and maintenance of ocular drainage tissues and IOP homeostasis, and provide new insights into glaucoma pathogenesis.

Beyond Intraocular Pressure: Visual Functioning and Quality of Life in Primary Congenital Glaucoma and Secondary Childhood Glaucoma

PURPOSE

To compare the visual functioning (VF) and vision-related QoL (VRQoL) of children 8-18 years old treated for primary congenital glaucoma (PCG) and secondary childhood glaucoma.

DESIGN

Cross-sectional study.

METHODS

A total of 309 children 8-18 years old treated for PCG and secondary childhood glaucoma between 2000 and 2010 by a single pediatric glaucoma specialist were prospectively enrolled at LV Prasad Eye Institute, Hyderabad, India. Children completed 2 questionnaires, the LV Prasad Functional Vision Questionnaire-II (LVP-FVQ-II), and the Impact of Vision Impairment-Children (IVI-C) questionnaire. Rasch-calibrated scores from both these questionnaires were used to compare the VF and VFQoL between the 2 groups.

RESULTS

Mean ages of the children were 12.2 and 12.6 years in the PCG (53%, median age at diagnosis = 5 months) and secondary glaucoma groups (47%, median age at diagnosis = 3 years), respectively. A majority (80%) of children had bilateral glaucoma and underwent filtering surgery (83%). Mean better eye logMAR visual acuity (VA) was comparable between PCG and secondary childhood glaucoma groups (0.49 vs 0.52, respectively; P = 0.59). Children with PCG reported significantly better VF and VRQoL than secondary childhood glaucoma patients. Unadjusted and adjusted childhood glaucoma group comparisons revealed secondary childhood glaucoma to be associated with worse VF and VRQoL compared to PCG (difference for VF, -0.83; 95% confidence interval [CI], -1.34 to 0.31; P = 0.002; 0.39; 95% CI, 0.16-0.62; P = 0.001 for VRQoL).

CONCLUSIONS

Results show that children with treated PCG experience significantly better VF and VRQoL than those with secondary childhood glaucoma, despite comparable VA and IOP.

Profile of childhood glaucoma at a tertiary center in South India

Purpose:

To describe the prevalence of various types of childhood glaucomas, their clinical features and treatment methods.

Methods:

We prospectively included consecutive children with glaucoma presenting to glaucoma clinic for the first time between March 2013 and May 2014. We classified childhood glaucomas as per the classification proposed by Congenital Glaucoma Research Network.

Results:

Of the 275 children (449 eyes) with glaucoma during this period, primary glaucomas constituted 56% (n = 252 eyes of 145 children), including 169 eyes (37.64%) of 97 children with primary congenital glaucoma (PCG), 16 eyes (3.56%) of 10 children with infantile glaucoma, and 67 eyes (14.9%) of 38 children with juvenile open angle glaucoma. Among these, 85% (214 eyes of 107 children) had bilateral involvement. Secondary glaucomas constituted 44%; they were glaucoma associated with ocular anomalies 18% (n = 80 eyes), glaucoma associated with acquired conditions (steroid induced and traumatic glaucoma) 14% (n = 61 eyes), glaucoma following congenital cataract surgery 7.6% (n = 34 eyes), and glaucoma associated with systemic or syndromic conditions 5% (n = 22 eyes). In primary glaucomas, boys and girls were equally affected (1:1), and more boys (3.8:1) had acquired glaucomas. Close to 80% PCG eyes were managed surgically with combined trabeculotomy and trabeculectomy (CTT). Majority of secondary glaucomas were managed medically.

Conclusion:

In our cohort, PCG was the most common childhood glaucoma and CTT was the most common surgery performed in these eyes. Steroid-induced and traumatic glaucomas were the most common acquired glaucomas; appropriate measures should be taken to avert these preventable glaucomas in children.

Quality of life following surgery for congenital glaucoma: findings of the LVPEI congenital glaucoma registry

PURPOSE

To evaluate the health-related quality of life (HRQoL) of children operated for primary congenital glaucoma (PCG) using the Kidscreen-27 questionnaire.

METHODS

A total of 121 children (mean age, 11.8 years; SD, 2.8 years; 51% males) with unilateral or bilateral PCG who underwent glaucoma surgery in infancy (mean duration since surgery, 10.2 years; [SD] 4.2 years) by a single surgeon at a tertiary eye care centre were administered the Kidscreen-27 questionnaire (self-or interviewer administered in a face-to-face interview) during their routine follow-up visit. We investigated the measurement properties of Kidscreen-27 questionnaire using Rasch analysis and generated interval-level estimates of HRQoL. The main outcome measure was HRQoL (i.e., Rasch-derived Kidscreen score). Multivariable linear regression analyses assessed the influence of socio-demographic and clinical variables on the HRQoL of children with PCG.

RESULTS

Majority (83%) of the children had bilateral PCG and congenital type of the disease (79%). Mean presenting acuity (logMAR) in the better eye was 0.32 (SD, 0.36; median, 0.18). Rasch analysis of Kidscreen-27 questionnaire indicated need for minor modifications following which a psychometrically robust unidimensional 23-item Kidscreen questionnaire emerged. In multivariable model, age of the child was independently associated with a 32% (β = -0.24 [95% CI, -0.11, -0.36]) increase in the HRQoL score.

CONCLUSIONS

Despite undergoing successful glaucoma surgery, children with PCG reported reduced HRQoL. Younger children with PCG are more likely to experience this lowered HRQoL and ophthalmologists will need to be alert to this. Efforts must be made to improve the HRQoL of children with PCG.

Parent-Child Agreement on Health-Related Quality of Life in Congenital Glaucoma

Purpose

We assess parent-child agreement regarding child's health-related quality of life (HRQoL) in children operated for congenital glaucoma (CG).

Methods

A total of 121 children aged 8 to 18 years (mean age, 11.8 years) operated for CG (mean duration since surgery, 10.2 years) and their parents (mean age, 36.5 years) completed the child and parent versions of the Kidscreen-27 questionnaire, respectively. Psychometric properties of Kidscreen-27 were assessed using Rasch analysis, and child–parent agreement regarding child's HRQoL was investigated using the Bland-Altman limits of agreement (LoA) method.

Results

Minor modifications in the rating scale and deletion of few misfitting items resulted in a psychometrically robust Kidscreen-23 questionnaire. Average parental HRQoL score was higher than the child's own ratings, with a significant difference between their scores (mean ± standard deviation [SD] difference = 0.53 ± 2.58 logits, P = 0.02; lower LoA [95% CI], −4.52 [−5.31 to −3.72] and upper LoA [95% CI], 5.58 [4.79–6.38]). The range of child–parent agreement was wide and bidirectional, with parents tending to underestimate and overestimate their child's HRQoL. Younger children and girls showed greater discordance in their HRQoL with parental reports than adolescents and boys, respectively.

Conclusions

Discordance between CG child's self-report of HRQoL and parent's report indicate that both groups perceive the broader impact of living with CG very differently.

Translational Relevance

The HRQoL as reported by the child with CG and by his/her parent should be viewed as being complementary, rather than interchangeable. Both assessments should be taken into account in clinical practice and research studies.

Fluidized bed combustion bottom ash: A better and alternative geo-material resource for construction

Though the majority of research on fly ash has proved its worth as a construction material, the utility of bottom ash is yet questionable due to its generation during the pulverized combustion process. The bottom ash produced during the fluidized bed combustion (FBC) process is attracting more attention due to the novelty of coal combustion technology. But, to establish its suitability as construction material, it is necessary to characterize it thoroughly with respect to the geotechnical as well as mineralogical points of view. For fulfilling these objectives, the present study mainly aims at characterizing the FBC bottom ash and its comparison with pulverized coal combustion (PCC) bottom ash, collected from the same origin of coal. Suitability of FBC bottom ash as a dike filter material in contrast to PCC bottom ash in replacing traditional filter material such as sand was also studied. The suitability criteria for utilization of both bottom ash and river sand as filter material on pond ash as a base material were evaluated, and both river sand and FBC bottom ash were found to be satisfactory. The study shows that FBC bottom ash is a better geo-material than PCC bottom ash, and it could be highly recommended as an alternative suitable filter material for constructing ash dikes in place of conventional sand.

Production of thermal insulation blocks from bottom ash of fluidized bed combustion system

The issues of disposal and environmental problems are increased by the generation of bottom ash from the thermal power plants day by day; hence, its recycling is required. The present study aimed to make thermal insulation blocks using as raw material bottom ash and iron ore slime as a binder and to characterize their engineering properties. Two different fineness values of bottom ash were considered with varying amounts of iron ore slime (0-10%) to make the blocks. Blocks were dried followed by firing at 1000, 1100 and 1200°C, respectively. Cold crushing strength, density and thermal conductivity of these fired blocks showed increasing behaviour with firing temperature, fineness of bottom ash and iron ore slime content. In contrast, a reverse trend was observed in the case of porosity. With increasing firing temperature, the formation of lower melting phases like iron silicate followed by iron aluminium silicate was observed, which imparts the strength inside the blocks. The coarser particles of bottom ash increase the interparticle spaces, which enhances the apparent porosity, resulting in higher thermal insulation property in the blocks. Blocks having better thermal insulation property could be possible to make effectively from coarse bottom ash by adding iron ore slime as a binder.

Ureteric injury after lumbosacral microdiscectomy: A case report and review of literature

Microdiscectomy is considered a very safe procedure with few serious complications. Ureteric injury following microdiscectomy is rarely reported in the literature. We report a rare case of iatrogenic ureteric injury following L5-S1 microdiscectomy for prolapsed intervertebral disc which was detected early and managed in time.

Acute Upper Gastrointestinal Bleeding in a Tertiary Care Centre of Nepal

INTRODUCTION

AUGIB is characterized by hematemesis or melena or both. Peptic ulcers and variceal bleed account for majority of cases. Use of proton pump inhibitors in current era is associated with a gradual reduction in burden of peptic ulcer disease. We conducted this study to look into the cause of AUGIB in our community.

METHODS

We studied 100 patients in one year period who presented to us with hematemesis or melena. The study was conducted in department of Gastroenterology, Bir hospital, Kathmandu. We identified the culprit lesions by upper gastrointestinal endoscopy.

RESULTS

The average age of patients with AUGIB was 51.6 years with 59 (59%) males. Duodenal ulcers are most common 29 (29%), followed by varices 23 (23%) and gastric ulcers 14 (14%). More than one lesion was identified in 38 (38%) patients. Patients with variceal bleed were more likely to present with hematemesis alone as compared to those with ulcer bleed (P=0.005). Variceal bleed patients presented earlier to the hospital (P=0.005), had lower MAP at presentation (P=0.0002), had lower hemoglobin level (P=0.0001) and higher serum creatinine level at presentation (P=0.001). Patients with variceal bleed were more likely to have consumed alcohol 20 (86.9%) and patients with ulcer bleed were more likely to be smokers 29 (67.4%) or consume tobacco 14 (32.5%) (P=0.006).

CONCLUSIONS

Ulcer related bleeding is still the most common cause of AUGIB. Many patients with AUGIB have more than one lesions identified during upper gastrointestinal endoscopy.

Outcome of Endoscopic Variceal Band Ligation

INTRODUCTION

Bleeding from esophageal varices in cirrhosis is an emergent condition with high mortality. One of the preferred modality of treating esophageal varices is EVL. We aimed to find out the outcome of EVL in controlling acute esophageal variceal bleeding, prophylactic banding to prevent future bleeding and the number of sessions required for complete eradication of varices.

METHODS

This descriptive observational study was carried out in Gastroenterology and Hepatology unit of Bir Hospital, NAMS from June 2016 to May 2017. Consecutive cases who presented in emergency room with acute variceal bleeding due to liver cirrhosis and cases of liver cirrhosis with large varices and red color signs on endoscopic examination were enrolled. They underwent EVL and subsequent re-endoscope at one month interval till the eradication of varices was achieved.

RESULTS

Among 83 patients, 15 (18.1%) were of Child Pugh class A, 29 (34.9%) B and 39 (47%) were of C. In 20 (24.1%) cases varices could be eradicated in one session of EVL while 57 (68.7%) required two sessions and in 6 (7.2%) cases it took three sessions. Total average EVL session required for obliteration of esophageal varices was 1.84±0.53. There was only one (1.2%) of early re-bleeding post EVL.

CONCLUSIONS

EVL is an effective modality of treatment in controlling acute esophageal variceal bleeding, in preventing future variceal bleeding as well as in eradicating esophageal varices with very few complications.

Efficacy of Prophylactic use of Ciprofloxacin and Metronidazole in Mild and Moderately Severe Acute Pancreatitis

INTRODUCTION

There are new concepts and developments in the diagnosis and management of acute pancreatitis. Current evidence suggests that there is no role of prophylactic antibiotics use in acute pancreatitis. However, it is still a common practice to administer prophylactic antibiotics in a country like Nepal. So, we have conducted a study in mild and moderately severe acute pancreatitis to study the efficacy of prophylactic antibiotics.

METHODS

A case control study was conducted among 76 patients comparing efficacy of prophylactic antibiotics versus no antibiotics in patients with mild and moderately severe acute pancreatitis.

RESULTS

The two most common etiology of acute pancreatitis in AG and NAG were alcohol 21 (55.2%) vs. 24 (63.1%) and biliary 10 (26.3%) vs. 4 (10.5%) respectively. Pancreatic necrosis was seen in five (13.1 %) in AG and four (10.5%) in NAG. Four (10.5%) developed extra pancreatic complications in AG and five (13.1%) in NAG. There was one (2.6%) death in AG and no death in NAG. Abdominal pain improvement seen in AG vs. NAG was 3.2 days vs. 2.4 days (P=0.002). The hospital stay was 7.7±2.23 days in AG and 7.5±1.85 days in NAG (P=0.65).

CONCLUSIONS

The routine use of prophylactic antibiotics for mild and moderately severe acute pancreatitis is not associated with improvement in meaningful clinical outcomes.

Colorectal Cancer in Different Age Groups in a Tertiary Hospital in Nepal

INTRODUCTION

Some studies have suggested that colorectal cancer at a younger age had distinct biological characteristics: different clinical presentations, more advanced stage at time of diagnosis and poorly differentiated carcinoma. The aim of the study is to analyze clinical and histopathological differences between younger (≤40 years of age) and older (>40 years of age) colorectal cancer patients.

METHODS

A cross-sectional analysis was conducted amongst the colorectal cancer patients who visited Bir Hospital between July 2015 and April 2017. All colonoscopically diagnosed and histopathologically proven cases of colon cancer were included. Chi-square test and independent t - test was performed to analyze the difference between clinical presentations and histopathological findings among two groups of patients and P value of <0.05 was considered as significant.

RESULTS

Thirty younger patients and thirty older patients were enrolled without any differences in gender proportion. There were no statistical differences between clinical presentation and histological grade and type in younger and older patients. The younger patients had more complaints of altered bowel habit (P <0.001) while older patients mostly presented with per rectal bleeding (P< 0.008).

CONCLUSIONS

In this study, colorectal cancer at younger ages showed similar characteristics to those of older patients except altered bowel habit was more common in younger patients while per rectal bleeding was more common in older patients. Although colorectal cancer incidence increases with age, younger patients with altered bowel habits, weight loss, anemia and anorexia should also be given due medical attention and undergo evaluation promptly.

Glaucoma associated with iridocorneal endothelial syndrome in 203 Indian subjects

Purpose

To report the demographic profile, clinical features, and prevalence of glaucoma and its management in patients with Iridocorneal endothelial (ICE) syndrome.

Methods

Retrospective review of 203 consecutive subjects with ICE syndrome at a tertiary eye care centre between January 1988 and June 2013.

Results

ICE syndrome was present in 223 eyes of 203 subjects, 124 (61%) were female and 79 (39%) were male. The median age at presentation was 43 years (1^st (Q₁) and 3^rd (Q₃) quartile; 34, 51 years). ICE syndrome was unilateral in 183 (90%) subjects, and bilateral in 20 (10%) subjects. The most common clinical variant was progressive iris atrophy (PIA, 115; 52% eyes), followed by Chandler syndrome (CS, 87; 39% eyes) and Cogan-Reese syndrome (CRS, 21; 9% eyes). Glaucoma was found in 156 eyes (70%) at presentation and the median (Q₁, Q₃) intraocular pressure in eyes with glaucoma was 24 (16, 38) mm Hg. Seven eyes developed glaucoma during the follow-up period, increasing the percentage of eyes with glaucoma to 73%. Intraocular pressure was managed medically in 81 eyes (50%) and the other 82 eyes (50%) required surgical intervention. Corneal edema was present in 124 eyes (56%) of which, 32 eyes (14%) required keratoplasty.

Conclusions

In our study on ICE syndrome in Indian population, the presentation was predominantly uniocular and more common in middle aged women. Progressive iris atrophy was the most common clinical variant. ICE syndrome was associated with glaucoma in over 70% of the eyes and half of the eyes had corneal edema.

Postradiotherapy small cell neuroendocrine carcinoma of base of tongue: An unusual clinical and site presentation

Small cell neuroendocrine carcinoma (NEC) of the tongue is an extremely rare entity with only seven cases reported in literature till date. These are high-grade tumors with a dismal prognosis. There is much ambiguity regarding the classification, treatment protocols and prognostic factors of these tumors due to the paucity of studies. We describe an exceptionally rare and unusual case of small cell NEC of the base of tongue arising in an elderly man 6 years after receiving radiotherapy for the treatment of squamous cell carcinoma at the same site. The diagnosis was confirmed on histopathological examination and supported by immunohistochemical positivity for neuron-specific enolase, synaptophysin, chromogranin, pan-cytokeratin, and cytokeratin 7. To the best of our knowledge, this is the first case of intraoral NEC arising many years later within the irradiated field of the initial tumor.

A Retrospective Analysis of Apheresis Donor Deferral and Adverse Reactions at a Tertiary Care Centre in India

INTRODUCTION

With increasing demand of platelet component each day, blood bank plays a pivotal role in ensuring supply of safe blood as and when required. Plateletpheresis procedure is a relatively simple, safe and important adjunct to blood bank inventory. However, recruitment of healthy blood donors is a challenge that the health industry is facing today.

AIM

To determine the reasons and rates of apheresis donor deferral along with investigation of adverse reactions encountered during the procedure.

MATERIALS AND METHODS

Records of single donor apheresis were retrospectively analysed from 1st January 2010 to 31st December 2014. The study was carried out at Blood Bank, Safdarjung Hospital, New Delhi, India. The donor details that were studied included - age, sex, type of donation (voluntary/replacement/ repeat), reason for donor deferral and type of adverse reaction, if encountered during the procedure.

RESULTS

Among the 478 donors screened for plateletpheresis procedure during a study period of 5 years, 134 (28.03%) were deferred. Temporary deferrals accounted for majority (93.28%) of the deferrals. Low platelet count (50.75%) was the main reason of donor deferral followed by low haemoglobin (20.89%). Amongst the 344 selected donors, 15 (4.36%) had some type of adverse reaction associated with the procedure.

CONCLUSION

We suggest that the selection criteria for plateletpheresis donors should be revised to deal with shortage of apheresis donors. The criteria regarding minimum pre-procedure platelet count (above1.5 lac/μl) and haemoglobin (above 12.5 g/dl) need to be lowered so as to suit the Indian scenario. The lower adverse reaction rates, 14/344 (4.06%) associated with this procedure encourages safety of donors and is important in recruitment of new donors.

Distinct subclonal tumour responses to therapy revealed by circulating cell-free DNA

BACKGROUND

The application of precision medicine in oncology requires in-depth characterisation of a patient's tumours and the dynamics of their responses to treatment.

PATIENTS AND METHODS

We used next-generation sequencing of circulating cell-free DNA (cfDNA) to monitor the response of a KIT p.L576P-mutant metastatic vaginal mucosal melanoma to sequential targeted, immuno- and chemotherapy.

RESULTS

Despite a KIT mutation, the response to imatinib was mixed. Unfortunately, tumours were not accessible for molecular analysis. To study the mechanism underlying the mixed clinical response, we carried out whole-exome sequencing and targeted longitudinal analysis of cfDNA. This revealed two tumour subclones; one with a KIT mutation that responded to imatinib and a second KIT-wild-type subclone that did not respond to imatinib. Notably, the subclones also responded differently to immunotherapy. However, both subclones responded to carboplatin/paclitaxel, and although the KIT-wild-type subclone progressed after chemotherapy, it responded to subsequent re-administration of paclitaxel.

CONCLUSION

We show that cfDNA can reveal tumour evolution and subclonal responses to therapy even when biopsies are not available.

Acute Corneal Hydrops in Children with Primary Infantile Glaucoma: A Report of 31 Cases over 23 Years at the LVPEI

Purpose

Relatively little data exist regarding the outcomes of children with primary infantile glaucoma presenting with acute corneal hydrops. The aim of our study was to determine the surgical outcome of children of infantile glaucoma who presented with acute corneal hydrops.

Methods

In total, 38 eyes of 31 consecutive children of infantile glaucoma presented with acute corneal hydrops who underwent primary combined trabeculotomy-trabeculectomy (CTT) by a single surgeon from January 1990 to December 2012 at the LV Prasad Eye Institute (LVPEI), a tertiary eye care centre in Southern India were enrolled in this retrospective study. Primary outcome measures were intraocular pressure (IOP) control (IOP ≤ 16 mmHg under anaesthesia or IOP ≤ 21 mmHg without anaesthesia) and clearance of corneal edema. Secondary outcome measures were visual acuity (VA), corneal diameter, bleb appearance, intraoperative and postoperative complications.

Results

Mean age at presentation was 6.4 months (range, 2–11 months) and seven eyes (23%) had bilateral affliction. At presentation, all eyes (100%) had moderate to severe degree of corneal edema with a mean preoperative IOP of 25.6 ±5.1 mmHg. Postoperatively, the IOP reduced to 12.0 ± 3.8 mmHg (difference = -13.6, 95% CI = -15.7 to -11.5, t = -13.18, p<0.0001), and the percentage reduction in IOP was 53.05%. Preoperatively 83% of the eyes were on antiglaucoma medication, and postoperatively 2 eyes (5.3%) required 1 antiglaucoma medication for control of IOP. Preoperatively, corneal edema was present in all eyes and postoperatively it cleared in all of them. Significant myopic astigmatism was present in 28 eyes (74%), the commonest being compound myopic astigmatism (75%) followed by simple myopic astigmatism (21%). Normal VA (best-corrected VA; BCVA ≥ 20/60) was achieved in 44.4% of the eyes and 22.2% eyes had low vision (BCVA, <20/60 to 20/400). Complete success (IOP control and clearance of corneal oedema) was obtained in 94.7% eyes. There were no significant intraoperative or postoperative complications. Two thirds of the patients showed low, elevated functional filtering bleb. No patient had any bleb leak, blebitis or bleb related endophthalmitis. The median follow-up was 36 months (range 2–228 months).

Conclusions

Primary CTT is safe and effective in controlling IOP, resulting in complete clearance of corneal edema with modest visual improvement in children of infantile glaucoma presenting with acute corneal hydrops. The outcome of the study will have a positive impact on counseling the parents preoperatively.

Early-onset glaucoma in Axenfeld-Rieger anomaly: long-term surgical results and visual outcome

PurposeTo determine the long-term surgical and visual outcomes in Indian children with early-onset glaucoma associated with Axenfeld-Rieger anomaly (ARA).MethodsThis is a retrospective analysis of 44 eyes of 24 consecutive children with early-onset glaucoma (within 3 years of age) and ARA who underwent glaucoma surgery over a 20-year period (1991-2010) by a single surgeon. Main outcome measures were pre- and postoperative intraocular pressures (IOPs), corneal clarity, visual acuities (VAs), refractive errors, success rate, time of surgical failure, and complications.ResultsThe series consisted of 38 primary combined trabeculotomy-trabeculectomy (CTT) and 6 primary trabeculectomy procedures (Schlemm's canal could not be identified in these eyes). There was a statistically significant reduction in IOP postoperatively (27.07±4.88 vs 14.88±3.62 mm Hg; P<0.0001) with a mean reduction of 45.14%. Success probability by Kaplan-Meier survival analysis was 93% till 5 years, and then 88.1%, 82.3%, 70.5%, 56.4%, and 42.3% at year 6, 7, 8, 9, and 10, respectively. Preoperative corneal edema was present in 43/44 eyes (97.72%) and cleared in 42 eyes (97.67%). There was one case each with intraoperative hyphema and with shallow chamber postoperatively and both were successfully managed successfully. There was no incidence of endophthalmitis or any other sight-threatening complication. Data on VA were available in 34 eyes (77.3%). At final follow-up visit, 15 (44.1%) eyes had best corrected VA ⩾6/18.ConclusionsPrimary CTT is safe and effective for early-onset glaucoma associated with ARA. It leads to excellent IOP control and satisfactory visual outcome.

In treating diabetes, what is important? Glucose levels or outcome measures?

Gaps in knowledge prevail in recognizing which glycemic parameters to order and in determining glycemic control. However glycosylated hemoglobin (HbA1c) is most commonly ordered to determine glycemic control. HbA1c provides information of overtime glycemic control but does not inform post meal glycemic excusions. The latter may be significant in outcome measure such as cardiovascular disorder (CVD), renal failure or amputation in diabetes. In order to obviate the dilemma in the importance between fasting blood glucose (FBG) and 2-h post prandial glucose (2hPPG), we innovated delta (d) which is the difference between 2hPPG minus FBG. There is much information available relating 2hPPG or postprandial hyperglycemia to CVD and some information relating 2hPPG to renal failure or amputation. Thus much emphasis is laid upon glycemic control with little or no emphasis on the complications of diabetes or the outcome measures. The focus of this editorial is to draw attention to outcome measures by ordering fasting and 2-h postprandial (2hPP) basic metabolic panel (BMP) which provides glucose levels, renal function test and electrolytes. HbA1c significantly relates to 2hPPG, thus by ordering F and 2hPP BMP instead of HbA1c alone will serve both purposes: Glycemic control and outcome measure. Delta (d) glucose (dhPPG-FBG) is a stronger predictor than 2hPPG of renal function deterioration.

Chylocolporrhea or chylous vaginal discharge: diagnostic conundrum with therapeutic challenge

BACKGROUND

Chylocolporrhea or chylous vaginal discharge is an extremely rare manifestation of chylous reflux syndrome. Continuous loss of chyle adversely affects quality of life and results in increased morbidity due to the chronic loss of nutrients. Diagnosis and management of this condition is very challenging.

CASE HISTORY

A 35-year-old multiparous lady presented with the chief complaints of excessive milky vaginal discharge for 10 years. Microscopic and biochemical analysis of vaginal discharge along with hysteroscopy confirmed diagnosis of chylocolporrhea. Lymphoscintigraphy along with magnetic resonance imaging revealed site of leakage from the right external iliac lymphatics. She was started on medium-chain triglycerides-rich diet and meticulous ligation of all visible megalymphatics with tension-free lymphovenous anastomosis was done to right external iliac vein.

CONCLUSION

Chylocolporrhea can be managed successfully using operative and nonoperative modalities.

Outcomes of trabeculectomy in juvenile open angle glaucoma

Purpose:

This study was aimed at reporting the outcomes of trabeculectomy in primary juvenile open angle glaucoma (JOAG).

Design:

This study was a retrospective noncomparative case series.

Materials and Methods:

We included 60 eyes of 41 JOAG patients who underwent primary trabeculectomy without mitomycin-C (MMC) between 1995 and 2007. The primary outcome was success, defined as complete, if intraocular pressure (IOP) was >5 and ≤21 mmHg without medications or qualified if IOP was >5 and ≤21 mmHg with or without antiglaucoma medications. Secondary outcome measures were mean and percentage IOP reduction, complications, and risk factors for the failure of trabeculectomy.

Results:

The mean (±standard deviation) age at presentation was 24.1 ± 6.8 years (range, 12–35). Mean follow-up was 67 ± 41 months (range, 12–156). At 1 year, the probability of complete success was 92% (n = 56, 95% CI: 81–96%), at 3 years it was 89% (n = 47, 95% CI: 78–95%), and at the end of 5 years, it was 80% (n = 34, 95% CI: 65–89%). The probability of qualified success was 100% (n = 60) at 1 year, 98% (n = 51, 95% CI: 87–100%) at 3 years, and 96% (n = 36, 95% CI: 84–99%) at the end of 5 years. The mean IOP reduced from 35 ± 10 to 13 ± 2.5 mmHg (P < 0.001) after trabeculectomy. There was no serious postoperative complication. Young age was the only significant risk factor associated with the failure (odds ratio = 0.89, P = 0.03).

Conclusion:

Primary trabeculectomy without MMC has good success rates in JOAG.

Genotype-Phenotype Correlations in CYP1B1-Associated Primary Congenital Glaucoma Patients Representing Two Large Cohorts from India and Brazil

BACKGROUND

Primary congenital glaucoma (PCG), occurs due to the developmental defects in the trabecular meshwork and anterior chamber angle in children. PCG exhibits genetic heterogeneity and the CYP1B1 gene has been widely implicated worldwide. Despite the diverse mutation spectra, the clinical implications of these mutations are yet unclear. The present study attempted to delineate the clinical profile of PCG in the background of CYP1B1 mutations from a large cohort of 901 subjects from India (n=601) and Brazil (n=300).

METHODS

Genotype-phenotype correlations was undertaken on clinically well characterized PCG cases from India (n=301) and Brazil (n=150) to assess the contributions of CYP1B1 mutation on a set of demographic and clinical parameters. The demographic (gender, and history of consanguinity) and quantitative clinical (presenting intraocular pressure [IOP] and corneal diameter [CD]) parameters were considered as binary and continuous variables, respectively, for PCG patients in the background of the overall mutation spectra and also with respect to the prevalent mutations in India (R368H) and Brazil (4340delG). All these variables were fitted in a multivariate logistic regression model using the Akaike Information Criterion (AIC) to estimate the adjusted odds ratio (OR) using the R software (version 2.14.1).

RESULTS

The overall mutation spectrum were similar across the Indian and Brazilian PCG cases, despite significantly higher number of homozygous mutations in the former (p=0.024) and compound heterozygous mutations in the later (p=0.012). A wide allelic heterogeneity was observed and only 6 mutations were infrequently shared between these two populations. The adjusted ORs for the binary (demographic) and continuous (clinical) variables did not indicate any susceptibility to the observed mutations (p>0.05).

CONCLUSIONS

The present study demonstrated a lack of genotype-phenotype correlation of the demographic and clinical traits to CYP1B1 mutations in PCG at presentation. However, the susceptibility of these mutations to the long-term progression of these traits are yet to be deciphered.

Comparing glaucoma progression on 24-2 and 10-2 visual field examinations

PURPOSE

To compare the rate of mean deviation (MD) change on 24-2 versus 10-2 VFs in treated glaucomatous eyes with 5 or more examinations.

METHODS

In a retrospective study, 24-2 and 10-2 VFs of 131 glaucoma patients (167 eyes) who had undergone at least 5 VFs examinations during their follow-up were analyzed. All these patients had VF defects both on 24-2 and 10-2 VFs. Rates of MD change were calculated using best linear unbiased predictions (BLUP).

RESULTS

Median age, MD on 24-2 VF at baseline, number of VFs performed during follow-up and follow-up duration were 55 years, -16.9 dB, 9 and 9 years respectively. Median rate of MD change was significantly greater (p<0.001) on 10-2 VF (-0.26 dB/year; interquartile range [IQR]: -0.47, -0.11) compared to 24-2 VFs (-0.19 dB/year; IQR: -0.41, -0.03). Comparing the rates of MD change in eyes with different severities of VF loss (early [MD better than -6 dB], moderate [-6 dB to -12 dB], advanced [-12 to -20 dB] and severe [MD worse than -20 dB]) at baseline (based on the MD on 24-2 VF), median rate of MD change was comparable between 10-2 and 24-2 VFs in mild (-0.45 dB/year vs. -0.40 dB/year, P = 0.42) and moderate (-0.32 dB/year vs. -0.40 dB/year, P = 0.26) VF loss categories, while the same were significantly greater on 10-2 VFs in advanced (-0.28 dB/year vs. -0.21 dB/year, P = 0.04) and severe (-0.18 dB/year vs. -0.06 dB/year, P<0.001) VF loss categories.

CONCLUSIONS

In patients with VF defects both on 24-2 and 10-2 VFs, evaluating the rate of MD change on 10-2 VFs may help in better estimation of glaucoma progression, especially so in eyes with advanced glaucoma at baseline.

Quality of life of caregivers of children with congenital glaucoma: development and validation of a novel questionnaire (CarCGQoL)

PURPOSE

We developed and validated an instrument to measure the quality of life (QoL) of caregivers of children with primary congenital glaucoma (PCG): the Caregiver's Congenital Glaucoma Quality of Life (CarCGQoL) questionnaire.

METHODS

A total of 70 caregivers of children with PCG under follow-up at a tertiary eye care center in India participated in a series of focus groups, and pre- and pilot testing phases in the development of the 45-item CarCGQoL questionnaire. Subsequently, this instrument was administered to 111 caregivers of children with PCG awaiting glaucoma surgery. Response to each item was rated on a four-category scale. Rasch analysis was used to validate the instrument's psychometric properties, such as unidimensionality (by principal components analysis [PCA] of residuals), item fit to model, measurement precision (by person separation [PS]), response category performance, differential item functioning (DIF), and targeting of items to participant's QoL.

RESULTS

Categories required reorganization resulting in a shortened rating scale of 3 categories. The instrument showed misfit to the Rasch model and lacked unidimensionality. Deleting 15 items (obtained through PCA of residuals) restored unidimensionality, but additional items misfit, necessitating item reduction. In addition, 2 items showed DIF and were deleted. Finally, a 20-item CarCGQoL instrument showed good fit and unidimensionality. Targeting was good (0.69 logits) and PS was 2.51, indicating good measurement precision.

CONCLUSIONS

We have developed a psychometrically robust 20-item caregiver derived questionnaire, the CarCGQoL, that is a valid and reliable measure of QoL of caregivers of children with PCG. Given its brevity, it is quick and easy to administer in the clinic, and has potential for use as an outcome measure in clinical trials of treatment of PCG.

Diagnosis and management of diabetes and the relationship of dglucose to kidney function

This article reviews different glycemic parameters and is aimed to clarify the most dependable glycemic parameter that predicts renal preservation. Glycosylated hemoglobin (HbA1c) and fasting blood glucose (FBG) are the most commonly ordered tests for the diagnosis of diabetes and are also used to indicate prevention of microvascular complications associated with diabetes. Some experts have concluded that HbA1c remains the only test that can predict microvascular complications but HbA1c is misleading with anemia. Other experts have reported that elevation of 2 hour postprandial glucose (2hPPG) or postprandial hyperglycemia is critical for the development of diabetic complications Measurement of parameters under fasting conditions is convenient in both clinical and research settings and are used to establish clinical guidelines for diabetes management and for rating efficacy of management. Despite the use of these diagnostic markers and a plethora of oral antidiabetic agents to treat diabetes, diabetic complications namely; cardiovascular disorders (CVD), end stage renal disease (ESRD) and amputation are on the rise. Although affirmative data on many of the complications are not available, the United States Renal Data System on ESRD is a testimonial to poor diabetes care. We have innovated dglucose (2hPPG-FBG) and found that dglucose relates significantly to renal function change measured by serum creatinine levels or estimated glomerular filtration rate. Our current study on dglucose confirms our previous finding and validates the importance of dglucose to aid in the management of diabetes and prevents diabetic complications. In conclusion, the new finding in this study is dglucose (2h-postprandial glucose-Fasting glucose) which convincingly relates to renal function changes. Since dglucose is a product of 2hPP glucose, keeping 2hPPG under tight control with intensive insulin therapy is fundamentally important. Further blood pressure control avoiding the use of renin-angiotensin inhibitor therapy is additive to renal protection in diabetes.

A rare case of primary renal hydatid cyst

Involvement of the kidney is a rare clinical scenario seen in case of Echinococcus infection, with isolated involvement of the kidney being even rarer. Patient may be asymptomatic or present with symptoms of lumbar region pain, haematuria, and hydatiduria. We present a rare case of primary right renal hydatid cyst with presenting features of right lumbar pain.

KEY WORDS

renal, hydatid cyst.

Extrarenal calyces: a rare renal congenital anomaly

The congenital anomalies of urogenital system are not uncommon. The anomalies of renal collecting system form a complex subset of urogenital anomalies. Among these, extrarenal calyces are one of the infrequently found anomalies of the renal collecting system. Extrarenal calyces may be detected incidentally or when thoroughly investigated for its associated complications. We report two cases of extrarenal calyces characterized by the presence of major calyces and renal pelvis outside the renal parenchyma. The awareness of this anomaly can help in making the definitive preoperative diagnosis and prevent injury to pelvicalyceal system during surgery.