Vol. II No. 2 April 1985

NETHRALAYA INSIGHT

ISSUE HIGHLIGHTS FACETS OF SANKARA NETHRALAYA PROLIFERATIVE EDITORIAL VITREORETINOPATHY 5 HMF IN CATARACT EFFECT OF PANRETINAL MICROSCOPIC STUDY OF PHOTOCOAGULATION VITREOUS ASPIRATE IN PROLIFERATIVE EFFICACY OF PHOTOCOAGULATION DIABETIC RETINOPATHY EDITOR MARY ABRAHAM IN EALES DISEASE

FACETS OF SANKARA NETHRALAYA

For an institution to progress, it requires remendous effort and dedication from all its staff. Little is realized about the various subdivisions that function in our institution, without whose aid, we could never be an integrated whole. In this issue, we wish to highlighten these individuals who work os sincerely and ever so quietly, wise to bring them out into the open and present them to.

THE MEDICAL RECORDS DEPARTMENT:

With Mr.Francis Paul Kirubagaran as the Medical Records Officer, the department has shown great progress since its inception in 1979. He took over the department from Mr.R.Bhat in August 1983. He is a product of CMC, Vellore where he did his graduation in Medical Records. Mr. Kirubagaran and his dedicated team are responsible for indexing coding and filing the data in a most, scientific and systematic manner. The medical records department provides facilities for easy retrieval of records, be it for patient care, study or research purposes. Monthly and yearly statistics are also prepared by the department to show the hospital activity at a glance. Microfilming and computerization of patient information is the next step and is likely to be implemented soon. Mr.Kirubagaran believes that “Good Medical Care means a Good Medical Record”, and to this goal he and his team are striving hard.

MRF LIBRARY:

Though it started in a small way, way back in 1978, MRF is today proud of its library with nearly 550 books. 1010 journals, 1500 reprints 120 research papers besides audio cassettes and video tapes. Mr. G.Lourduswamy, a pleasant soft spoken man has joined us as a librarian in November 1984. He has a vast experience in library science and retired as Asst. Librarian from British Council, Madras. Being a Post Graduate in Economics and a Library consultant to various organizations, his aim is to cater to the needs of the users and make provisions for selective dissemination of information. In the near future, Mr. Lourduswamy intends to computerize information retrieval and thus give its users facilities to study, teach and research at the highest intellectual levels.

COMPUTER (PRAGATI AL 2016)

Miss Padma Ramachandran a young graduate of Chemistry and who has been working with computers for the past 4 years has joined the Nethralaya Staff as Programmer. Her quiet efficiency has been by the way the computer has changed our normal routine. It has completely taken over the fixing of appointments, surgeries, allotting beds and operation theatres for surgeons and producing reports like doctors list, list of patients seen per day and surgery list for the next day.

Since the chief objective of our institution is to render fast and efficient service to patients, computerization in these areas have helped a great deal. Padma hopes that soon the scope of utility of the computer can be extended into other areas as well. To familiarize some of our staff with the concepts of programming, she is conducting classes in this area and expects that in the near future the computer will be as valuable an aid as any latest medical diagnostic or therapeutic equipment.

DEPARTMENT OF BIO STATISTICS

A few years ago we did not believe that a Biostatistician was really necessary in an institution such as ours, but with the increasing number of papers presented and research projects underway, there seems to be growing need for bio statistics.

Mr. K.J. Raman, a young Post graduate in statistics from Madras Christian College leads this department and has been with us since September 1984. Mr. Raman feels that biostatistics in Ophthalmology has a great future and will include selection of samples for a particular treatment pertaining to an eye disease, can assess the important cause of the disease and study its severity and prevalence. This way, the data collected can be analysed tabulated and presented in a clear format. We are quite sure that Mr. Raman with his boundless enthusiasm will make our research oriented projects more meaningful.

DEPARTMENT OF BIO-ENGINEERING Started on 1st June 1983, this department intends to provide inhouse servicing and maintenance for all the imported equipment. Mr. K.Santosh Kumar an engineering graduate from Tumkur College of Engineering, Karnataka started this department in a modest way in 1983, but with the passage of time, it has grown and has been responsible for solving many day. Today minor or semi-major problems. The down time on major breakdowns have also been greatly reduced. The department has been responsible for installation of the second Ocutome – Fragmatome unit, Auto refractometer, Projection vertexometer, Oculo Cerebro Vascular Monitor, YAG laser etc.

Mr. Santhosh Kumar amidst his tight schedule has also submitted two projects on Power Gas Injector and Endoilluminator besides which he has successfully converted our Zeiss Xenon photocoagulator into an

DEPARTMENT OF BIO CHEMISTRY

Was started in August 1983 by Dr. S.Vivekanandan, a Ph.D. in Bio Chemistry from the Institute of Neurology , Madras Medical College. With a deep interest in basic research Dr. Vivekanandan has ample scope in his department and hopes to work out more feasible and easy solutions for various ocular disorders like cataracts, uveitis, etc. He is also responsible for introducing the ELISA test for toxoplasmosis and toxocariasis at this department and hope to start on ameobiasis and cysticercosis soon. Dr. Vivekanandan also hopes to prepare and type HLA antigens in the near future. With his keen interest and enthusiasm, we are quite confident that Dr. Vivekanandan will bring great credence to his department.

We take this opportunity to keep you readers informed of some of our newer departments and would like you to make as much use of these facilities.

At the dinner hosted by Mrs. & Mr. V.Mohan Rao, are soon from left to right – Dr. Mrs. Badrinath, Mrs. Pruett, Dr. R.Pruett, Mr. V. Mohan Rao, Dr. S.S,.Badrinath, Mr. V.Vaidyanathan and Mrs. V. Mohan Rao.

“You must be very proud of what you have accomplished at the Medical Research Foundation. It is truly remarkable that so much has been done in a short time. We also take pride that Dr. Badrinath is one of our graduates from the Retina Foundation.

RONALD C. PRUETT.

RETINA ASSOCIATES, INC. ESTANLISHED 1951 100 Charles River Plaza Cambridge Street, Boston, Massachusetts 02114 (617)523-7810

EDITORIAL :

1985 has had a busy start, January saw a number of conferences. The X Congress of Asia Pacific Academy of Ophthalmology was held at Delhi between January 31 to February 5, 1985. Nethralaya played a very key role and organized 4 preconference courses.Dr. S.S.Badrinath conducted the vitreous surgery preconference course. Dr. Ron C. Pruett of Retina Associates, Boston and Dr. B.M.Khamer of Ahmedabad participated. Dr. Sridhar Rao along with Dr.Nagasubramaniam of Moorfields, London and Dr. N.N.Sood of Delhi conducted a course of Glaucoma surgery. Dr. Chandran Abraham and Dr.Mary Abraham conducted courses on Indirect Ophthalmoscopy and Ultrasonography respectively. Besides the preconference courses which attracted large audiences, 9 free papers were presented. The success of our preconference courses was largely due to the unstinting efforts of our secretarial department who were efficiently managed by Mrs. Vimala Mohan and her successor Mrs. K.Ambika.

While at Delhi, Dr. Chandran Abraham spoke on “Vascular Retinopathies and Macular diseases”, at the Mohan Eye Institute on 30th January as part of their workshop on Laser Diseases.”.Memories of Delhi are still fresh in our minds especially the warm and gracious get-to-gether at the Dr.S.S.Badrinath later addressed the VI All India Steel Medical Officers’ Conference and spoke on “Industrial Ocular Trauma and Management” at Ranchi on 09.02.1985.

Dr. & Mrs. Badrinath handing over a bouquet to Mrs. & Mr. R. Venkataraman (Vice President of India) at a get together at the Vice Presidents house.

1985 has thus far seen a number of important visitors. It started with the visit of Dr.Ostler. Whitcher and Smolin of the Procter Foundation, Los Angeles, USA, who visited us through the kind courtesy of SILOAM, India. This was followedby the visit of Dr.&Mrs. Ron C.Pruett of the Eye Research Institution of Retina Foundation, Boston, Massachusetts, USA. Much to our disappointment Dr.Charies L. Schepens who was to come along had to cancel his trip owing to ill-health. Dr,Pruett’s talks while at Nethralaya and his course at Delhi were outstanding. We look forward to his future visits and would particularly like to wish Dr. Schepens a speedy recovery. Dr. Jay M.Enoch, Dean, School of Optometry, visited us on 17th January 1985. His novel instrument for evaluating opaque media in terms of visual function was explained and displayed.

A wonderful get-to-gether dinner for the two visiting doctors and the Nethralaya staff was organized by the President Mr,V.Mohan Rao, at this residence on 17th January 1985.On January 19th and 20th Dr.Chandran Abraham was invited to deliver a talk on “Natural History and the Management of Diabetic retinopathy” at the Annual conference of the Association of Physicians of India at Bangalore. This was followed by Dr. T.S.Surendran’s visit on 17.2.1985 where he took part in the “Strabismus Workshop” conducted by the Scientific Committee of Karnataka Ophthalmological Society and delivered his talk on “Eso Deviations” Besides this Dr.T.S.Surendran presented papers on “Bangalore Lenses and Septicon System” at the International Congress of The Contact Lens Society Meeting on 28th January 1985 and on “Calibrated Research Clamp” at the Strabismological Society at R.P.Centre on 6.2.1985.

Owing to the growing demand for intra ocular lenses in our country and the availability of lenses, we have decided to launch into it and begin our own IOL work. While on the subject of IOL’s, we are happy to announce that the coherent YAG Laser has been installed and was inaugurated by Dr.S.S.Badrinath on 18.2.85. It is going to be a great boon to all of us following extracapasular surgery and IOL implantation. A Press Conference and TV Coverage this month along with a nice write up in all the leading newspapers highlighted the entire event. The Dharmasala work which began on May 1, 1983 is near completion now and is to be inaugurated on April 13, 1985 by his Excellency Mr. R. Venkataraman, Vice-President of India.

Dr. D.Ramamurthy who has been with us as a consultant for the past one year left us on the 9th of March to start out on his own at Tirupur. The “Thirumurthy Nethralaya was inaugurated by Dr.S.S.Badrinath on 17th March 1985. We wish Dr. Ramamurthy all success in his new venture.

Dr.L.Gopal and Dr.Madhivanan Natarajan have been jointly awarded the V.T.DOSHI gold medal for the “Best Out-going Fellow” for the year 1984. While Dr.Madhivanan has gone into private practice, Dr. Gopal has opted to join us.

We do hope you have been enjoying the “Nethralaya Insight” and we continue to look forward to your suggestions on improving it.

EDITOR.

A Demonstration of the “YAG LASER”

5 HMF IN CATARACT

Dr. S.Vivekanandan

Nonenzymatic glycosylation is a post translational protein modification reaction that has gained considerable interest in recent years. It has now been demonstrated that glucose reacts with a wide variety of proteins such as collagen, erythrocyte membrane proteins, albumin, tubulin and lens crystallins 1.

Proteins which are exposed to glucose and have a relatively slow turn over rate are particularly susceptible to nonenzymatic glycosylation 2.5

This post translational modification may contribute to the formation of diabetic cataracts.

Nonenzymatic glycosylation in lens in vitro was reported and shown to be increased in vivo in diabetic rats (Monnier et al 1979) and humans (Ansari et al 1980; Kasai et al 1983). The present paper communicates the degree paper communicates the degree of nonenzymatic glycosylation in vivo, in non-brunescent and brunescent cataract lenses from diabetics.

MATERIALS AND METHODS:

Cataractous lenses from 22 diabetic patients and 17 senile subjects were studied. Of the 22 cataractous lenses from diabetic patients 11 were yellow and 11 were brown and of the 17 senile subjects ‘ I were yellow in colour and 6 were brown.

METHOD OF STUDY:

Cataractous lenses were surgically extracted from both diabetic and senile subjects. The extracted lenses were rinsed once with sterile normal physiological saline, decapsulated and used immediately. If the assay was not done immediately, decapsulated lenses were stored at – 200 C. Each lens was homogenized with 0.05 M phosphate buffer, PH 7.2 in a mechanical homogeniser. The homogenate was centrifuged at 6,500 X g for 30 minutes at 40 C. The supernatant was used for the assay of nonenzymatic glycosylation rate by the thiobarbituric acid method2. Briefly, the supernatant was incubated with 0.33 M Oxalic acid at 1000 C for 41/2 hours. The hydrolysates were cooled in ice. Ice cold 40 % Trichloroacetic acid was added and the supernatant was incubated with 0.05 M thiobarbituric acid for 30 minutes at 370 C. Released 5 Hydroxy Methyl furfural (5 HMF) was estimated from the absorbance of the samples at 443 nm, using water in place of thiobarbituric acid for blank determinations.

The intra assary coefficient of variation was 6.1% (n = 6) . Protein concentrations were determined with Bovine serum Albumin as standard Result are expressed as mean ± SD. Statistical significance was calculated using the ‘t’ test.

RESULTS: Figure 1 shows the rate of nonenzymatic glycosylation in vivo in senile and diabetic cataractous yellow and brown lenses. Cataractous yellow lenses of diabetes showed significantly higher rate of glycosylation (5 – HMF) 1.260 ± 0.012 nM/mg of protein than the nondiabetics senile yellow lenses (0.738 ± 0.0.33 nM/mg of protein) than the senile nondiabetic brunescent lenses (1.095 ± 0.109 nM/mg protein). (Table 1) In summary cataract lenses of diabetics reveal significantly higher rate of nonenzymatic glycosylation (5 HMF concentration) than the nondiabetic senile cataractous lenses. The rate of glycosylation was found to be related to the brunescence of cataractous lenses.

DISCUSSION:

The present report is in agreement with other in that hyperglycemia may induce an increased glycosylation of lens crystallins in human (Kasai et al 1983) This communication also reports the direct relationship of active nonenzymatic glycosylation (5 HMF concentration) to the brunescence.

Nonenzymatic glycosylation may cause cross linking of lens proteins and rearrangements of sugar protein adducts to form yellow brown pigments. Althought the structures of the pigments and cross like have not been identified, it is likely that 5 HMF may be involved in the browing process 1 The preliminary report support the above suggestion.

REFERENCES :

1.Ansari N.H.Awasthi Y.C and Srivastava S.K. (1980) role of glycosylation in protein disulfide formation and cataractogenesis. Exp. Eye Res. 31 ; 9 – 19.

2.Kasai K. Nakamura T.Kase N.Hiraoka T.Suzuki R.Kogure F and Shimoda S.1 proteins from cataractous lenses in diabetes, Diabetologia, 25 ; 36 – 38.

3.Monnier V.M. Stevens V.J. and Cerami A. (1979), Nonenzymatic glycosylation, sulfhydryl oxidation and aggregation of lens proteins in experimental sugar cataracts. J.Exp. Med. 150 ; 1098 – 1107

4.Monnier V.M. and Cerami A (1981), Nonenzymatic browning in vivo ; possible process for aging of longlived proteins. Science 211 ; 491 – 493

5.Shaklai N.Garlick R.L. and Bunn H.F.(1984). Non- enzymatic glycosylation of Human Serum Albumin alters its confirmation and function. J.Biol. Chem.259;3812 – 3817.

TABLE I

Group Age (Years) Post prandial blood sugar (mgms %) At 1st visit On admission A. Non diabetic Senile Subject 1. Yellow 60.82 ± 9.4 109.1 ± 26.9 109.1 ± 26.9 2. Brown 56.5 ± 12.2 123.3 ± 41.8 123.3 ± 41.8 B. Diabetic Senile Subjects 1. Yellow 58.73 ± 6.7 213.3 ± 105.2 157.2 ± 27.5 2. Brown 55.5 ± 7.7 257.6 ± 84.7 185.9 ± 56.3 (Mean ± SD)

MICROSCOPIC STUDY OF VITREOUS ASPIRATE: A PRELIMINARY STUDY

Dr.Jyotimay Biswas Dr.Maj.Gen.C.S.V. Subramaniam* Dr.K.S.Ratnakar Dr.S.S.Badrinath

The diagnostic value of ocular fluid cytology is well established. Following the advent of vitreous surgery, vitreous specimen can now be directly obtained specimen can now be directly obtained during surgery. Since only a few cells are suspended in the vitreous, conventional smear techniques are not adequate for cytological study. Cytocentrifugation is a form of cellular centrifugation which can be utilized for processing vitreous fluid. It has been reported to be a reliable and rapid technique with good cell recovery. Our observations of the microscopical study of vitreous surgery of 52 eyes is being presented here.

MATERIAL & METHODS :

Vitreous specimen obtained at random during vitreous surgery of 52 eyes at Sankara Nethralaya in the year 1984 was studied microscopically using cytocentrifugation as the form of cellular processing.

We studied vitreous specimens of 10 eyes ( obtained during vitreous surgey) with conventional smear technique initially. As cyto-centirifugation provided us with better cell recovery, (of vitreous specimens) we used this technique for processing the vitreous fluid in all 52 vitreous specimens.

Specimens were collected during vitreous surgery I from Ocutcome – by aspiration tube connected with a 20 cc sterile syringe; ii from collection bottle – attached to the ocutcome system.

Specimens were centrifuged immediately in our laboratory with REMI cooling centrifuge (C – 24) at 1500 – 2000 revolutions per minute equivalent to 250 – 300 g for 30 minutes. Preservative solution prepared by mixing 0.5 % glutaraldehyde and 2% formalin in phosphated buffered solution of pH 7.0 was added in 1 : 2 ratio to the processed fluid. The specimens were then further processed by cyto-centrifugation with cytospin at the Pathology Department of Apollo Hospital Madras Staining of the processed fluid was done routinely with three stains, i.e. haematoxylin and eosin, PAS and papinicolau. Whenever available a paraffin section for histological study of membranes and tissues was done. All the slides were studied under Light Microscope. Representative microphotographs of slides of various vitreo retinal disorders were taken. Patients were followed up from 2 weeks to 8 months and clinicopathological correlations from the microscopic study of vitreous specimens were looked for.

OBSERVATIONS :

Vitreous specimens obtained during vitreous surgery of various vitreo retinal disorders are shown in Table 1 Microscopical findings of vitreous aspirate study are presented in Table 2.

Retinal Detachment with Proliferative vitreo retinopathy:

This group comprised the maximal number. In 9 out of 12 cases, membranes could be well demonstrated microscopically.

The membranes ranged from delicate eosinophillic fibres to thick folded membranes. Pigment epithelial cells were found in the vitreous fluid in 7 out of 12 eyes.

In 9 out of 12 cases plenty of fresh RBC were seen possibly due to haemorrhages which occur intraoperatively. Recurrence of membrane formation was seen clinically in 6 out of 9 cases where membranes were seen microscopically.

Eales’ disease with vitreous haemorrhage:

Most of the specimens showed organized vitreous haemorrhage in the form of erythrocytes entangled in collagen fibres (8 out of 11 cases) Definite membrane formation was seen in 3 cases. Pigmented epithelial cells were seen in 5 out of 11 cases.

Membranes could be well demonstrated in 5 out 6 cases studied. The membranes varied from fine delicate fibres to broad connective tissue bands. In these 5 cases, fibrovascular membranes were seen either preoperatively or intraoperatively.

ENDOPHTHALMITIS

In 5 cases of endophthalmitis, fungal infection was suspected in 3, bacterial in one and in another sterile endophthalmitis. In none of the 5 cases organisms could be demonstrated from the vitreous aspirate study. All cases recurrence of infection in the follow up period. However the eye with bacterial endophthalmitis showed a preponderance of leucocytes. Vitreous aspirate study did not correspond to the clinical diagnosis in 3 out of the 5 cases vitreous aspirate study were comparable. Histiocytes were seen in all of the three suspected fungal endophthalmitis cases denoting an organization process.

Lens induced uveitis:

Out of 2 cases the clinical diagnosis was confirmed by cytological study of vitreous aspirate in one. Ingested lens matter surrounded by polymorphs were seen. The other case showed fungus like organisms. Acute inflammatory cells were seen in both the cases.

TABLE – 1 MICROSCOPIC STUDY OF VITREOUS ASPIRATE

Vitreo-retinal Disorders No. of Eyes Retinal detachment with proliferative vitreo-retinopathy 12 Eales disease with vitreous haemorrhage 11 Proliferative diabetic retinopathy with vitreous haemorrhage 6 Endophthalmitis 5 Lens induced Uveitis 2 Retinal detachment with giant tear 2 Perforating injury with vitreous haemorrhage 4 Blunt injury with vitreous haemorrhage 2 Vitreous haemorrhage of unknown aetiology 6 Miscellaneous 2 Total 52

Perforating injury with vitreous haemorrhage:

Out of 4 cases studied, the retrolental fibrous membrane seen clinically was alos demonstrated microscopically in one.

Blunt injury with vitreous haemorrhage. Two cases were studied. Organised haemorrhage comprising of RBCs and a few pigmented cells spread into a thin membrane was demonstrated in one eye. The second case diagnosed as Terson’s syndrome showed delicate flat collagenous membrane suggestive of post traumatic membrane formation.

Retinal detachment with giant tear:

No significant cytologic findings were seen.

Vitreous haemorrhage of unknown aetiology.

An aetiological diagnosis could not be derived from the microscopical study.

DISCUSSION:

The cytological study of vitreous aspirate helped us to confirm our clinical diagnosis in one out of two lens induced uveitis cases. In endophthalmitis, vitreous aspirate study did not reveal any organism.

In patients with Eales’ disease the vitreous specimen study showed organization of vitreous haemorrhage with evidence of membrane formation. Presence of perivascular round cells was indicative of chronic inflammatory process around vessel wall. In retinal detachment with proliferative vitreoretinopathy, pigment epithelial cells of variable number were seen along with membranes. We feel there may be some association of these pigment epithelial cells with the membrane formation.

Role of vitreous aspirate study in cases of injury helped us to demonstrate the membrane formation suggestive of organization of vitreous haemorrhage. Vitreous aspirate study in patient of diabetic retinopathy was non-specific.

Comparing our initial study of first ten cases of conventional smear study cytocentrifugation provided better cell recovery. Further study of the vitreous specimens of vitreo-retinal disorders may contribute more to explain its clinicopathological correlations.

SUMMARY:

Microscopical study of vitreous aspirate of 52 eyes of 48 patients who had undergone vitreous surgery for various vitreo retinal disorders is reported. The clinicopathological implications of microscopical study of vitreous aspirate are discussed.

REFERENCE:

Jeremy Chess et al, Pathologic processing of vitrectomy specimens, Ophthalmology 1983, 90:1560 – 1564.

TABLE – II

MICROSCOPIC STUDY OF VITREOUS ASPIRATE

WBC Pigment Vitreo-retinal Epithelial Fibro Disorders RBC Neutro Eosino Lympho Macro cells Blasts Membranes Others Retinal detachment ++ - - - - + ± + - with proliferative vitreo retinopathy Eales disease with ++ - - - ± ± Tangled vireous haemorrhage fibres to dense membranes Diabetic retinopathy ++ - - - - ± ± + - with vitreous haemorhage Endophthalmitis + ++ - - - ± - Delicate Histocytes in thread like fungal fibres endophthalmitis Phaco Anaphylactic + ++ - ± - ± - - Uveitis Perforating injury with + ± - - - + - Delicate to vitreous haemorrhage thick membranes Blunt injury with + - - - - + - Thin vitreous haemorrhage membranes EFFICACY OF THE PHC IN EALES’ DISEASE

Dr. L. Gopal Dr.Chandran Abraham

Ealses’ disease is an entity with a potential for visually disabling complications like repeated vitreous haemorrhage, fibrous tissue proliferation, tractional retinal detachment and thrombotic glaucoma. In this study the efficacy of photocagulation in preventing these complications has been studied retrospectively.

MATERIALS & METHODS

157 eyes of 132 patients who underwent photocoagulation for Eales’ disease between 1979 and February 1984 were studied. Patients who had photocoagulation after vitrectomy or prior to planned vitrectomy have been excluded. Fluroescein angiography was performed in 63.7% of eyes while most others had detailed retinal drawing and Fundus florescein ophthalmoscopy. 85.3% had Argon Laser treatment while the rest had xenon arc treatment alone or combined with Argon Laser.

Focal treatment to areas of neovascularisation alone was required in 38 eyes (24.2%) Pan retinal photocoagulation was carried out in 62 eyes (39.5%) while sectorial treatment to areas of capillary closure was done in 40 eyes (25.5%) treatment of fronds in vitreous was done in 74 eyes (41.1%) (Table I). Where required pan retinal photocoagulation was combined with focal treatment, 5 eyes had treatment to areas of capillary closure only in the absence of new vascularisation. Repeat treatment to fresh new vascularization was required in 20 eyes (12.7%). 68.2% of patients had more than 6 months follow up.

CLINICAL FEATURES:

130 of the 132 patients were males. The 21-30 years age group was mostly involved. In 69 patients (52%) the presenting feature was blurred vision, but 23.6% of the eyes were asymptomatic. The clinical features observed are listed in Table II.

101 eyes (64.3%) had 6/6 vision at presentation. 25 patients had bilateral treatment.The status of the fellow eye is given in table III.

RESULT: Disc new vessels regressed in 13 eyes (48.1%) while surface neovascularisation regressed in 96 eyes (88.9%). New vessels in the vitreous regressed in 59 eyes (79.7%). 25 eyes (16%) had fresh vitreous haemorrhages inspite of treatment of which 14 eyes (9%) required vitrectomy. Fibrous proliferation increased in 9 eyes of which 6 (3.8%) went into tractional retinal detachment 4 eyes had macular pucker. One eye with foveal hypoxia improved in vision from 6/24 to 6/12 inspite of an unchanged picture on angiography showed improved capillary perfusion in 11.2% of eyes while 4 out 10 eyes with major vessel leak showed subsidence of the same. None of the eyes treated for capillary closure alone developed new vessels in a follow up ranging from 4 months to 5 years.

Visual acuity was maintained or improved in 80.2% of eyes. (Table IV)

DISCUSSION: The rationale of photocogulation treatment in Eales’ disease is the same as in other vascular retinopathies, i.e. to destroy existing new vessels and to try and prevent a fresh occurrence of the same. New vessels on the surface of retina responded best to treatment (88%). New vessels in the vitreous also regressed in a high percentage of cases (79.7%). Disc new vessels regressed in only 48% of eyes, signifying poorer prognosis for these eyes. In 84% of the eyes photocoagulation has prevented the occurrence or recurrence of vitreous haemorrhage.

All the five eyes treated for capillary closure alone did not develop new vessels. Controlled studies are required however to see whether early treatment can be beneficial in the long run. In the presence of fibrous tissue, photocoagulation can still be done with laser, the purpose being to bring about regression of the vascular component and it is also felt that these eyes may do better should they need vitrectomy later.

Haemorrhage during focal treatment of new vessels is a potential complication and can be avoided by using large spotsizes, avoiding too short exposures and treating from periphery to center. Macular pucker was seen in 2.55% in our series compared to that of Meyer Schwickeraths (Xenon) of 6.25% (Significant at P< 0.2). The overall morphological and visual results definitely prove the efficacy of photocoagulation in the management of Eales’ disease.

REFERENCE:

1. Abraham C. et al – Eales’ Disease: Proc.All India Ophthal Society 1977; Vol.33, P. 226-229 2. Bird A.C.:Eales’ Syndrome in symposium on Medical and surgical diseases of the retina and vitreous – Transactions of new Orleans Academy of Ophthalmology;C.V.Mosby Company, 1983;P.347 3. Boke W – Treatment of Eales’ Disease by Photocoagulation; Concillium Ophthalmologicum Vol. 19, Acta Vol 2, P.872. 4. Francis A L Esperance, Jr.Current Diagnosis and Management of Chorioretinal diseases, St.Louis, the C.V.Mosby Company 1977; PP 159 – 160;PP 219,00513 – 521 5. Gerd.Meyer Schwickerath in - :Light Coagulation” – St. Louis, The C.V.Mosby Company 1960;P.71 6. Walfang H.- “Photocoagulation in Eales’ Disease, AJO;57;139

PROLIFERATIVE VITREO RETINOPATHY – OUR EXPERIENCE

Dr.S.Natarajan Dr.Hemant Doshi Dr.S.S.Badrinath

Proliferative vitreo retinopathy is a condition wherein there is proliferation of membranes on either side of detached retina and no the posterior surface of the detached vitreous gel. The entity in the past was variously known as massive vitreous retraction, massive preretinal retraction or massive periretinal proliferation. In this study proliferative vitreo retinopathy has been classified into different stages as suggested by the Retina Society Terminology committee.1 There are several reports of surgical attempts to deal with this problem. 2,3,4,5 Surgical management of more severe forms of advanced proliferative vitreo retinopathy has been less satisfactory. Our experience with parsplana vitrectomy endodrainage fluid gas exchange, cryopexy and scleral buckling in the management of this complex problem forms the basis of this report.

MATERIAL AND METHODS: 122 eyes of 121 patients with Proliferative Vitreo Retinopathy grades C and D were surgically treated at Sankara Nethralaya between 1979 and 1984. 109 were males and 12 were females. Age ranged between 5 years to 78 years.

All eyes were subjected to acomplete basic ophthalmological examination, vitreo retinal examination with binocular indirect ophthalmoscope along with scleral depression.

Pre-operative visual acuity in 115 eyes out of 122 was limited to hand movements or perception of light only.60 out of 122 eyes had already been subjected to various vitreo retinal surgical procedures once or twice prior to current surgical repair.

Amongst the fellow eyes 40 were normal, 24 were blind. The remaining had varied pathological conditions like proliferative vitreo retinopathy in 20 eyes absent view of fundus in 17 eyes, lattice degeneration in 12 eyes and miscellaneous conditions in rest of them.

SURGICAL TECHNIQUE:

The various surgical procedures were performed using Carl-Zeiss operating microscope and O’ malley Ocutome Fragmatome system. Bimanual pars plana vitrectomy with three separate sclerotomies for infusion, endoillumination and micro instrumentation was carried out. Vitreous base excision was done to relieve anterior loop traction. Minimally adherent epiretinal lmembranes were teased and removed with illuminated membrane pick 6, 7 Segmentation. Delamination technique were reserved for the more adherent membranes, 6,8 in phakic eyes, vitrectomy was preceded by a pars plana lensectomy (42 eyes) or conventional cataract extraction (8 eyes). Apart from these, membranectomy (3 eyes) and Sphincterectomy (3 eyes) were done to facilitate as complete a peripheral vitrectomy as possible to allow a total fluid-air exchange which was done with simultaneous endodrainage of subretinal fluid through any satisfactory pre-existing posterior retinal break or through a planned retinotomy site. We routinely used a foot controlled gas injector for a air injection through the infusion canula, while tapered linear suction controlled extrusion needle was used for fluid egress. Following this 3600 circumferential trans scleral cryopexy was done with Indirect Ophthalmoscopic control. In two eyes endo-cryo coagulation was done. In most of these cases 3600 scleral buckling with solid silicone explants were done. In a few cases conventional trans scleral sub retinal fluid drainage and buckling with solid silicone implant was performed.

RESULTS AND DISCUSSION:

In the 122 eyes with proliferative vitreo retinopathy anatomical reattachment of the retina was achieved in 112 eyes (91.9%) at the conclusion of surgery Duration of the followup has been from more than two months to more than one year. Those with follow up less than 2 months were excluded from the study. In 53 eyes the surgery was successful in the first attempt and in 8 others, further multiple reoperative procedures resulted in successful surgical end result . In short, in this study, out of the 122 eyes in 61 eyes (50%) the surgery was successful (P<0.0001). The post operative visual acuity at last visit was 3/60 to 6 /60 in 16 eyes and 6/26 to 6/9 in 14 eyes. In 19 patients who had anatomical reattachment, though there was only a minimal visual improvement the results were gratifying because this was their only functioning eye.

Macular pathologies were the major causes for poor visual recovery after successful anatomical reattachment.

The important operative complications were accidental iatrogenic breaks, sub retinal fluid persisting with folds and entry of air into subretinal space. We abandoned 7 cases in the course of the surgery as the retina failed to settle down in spite of endodrainage and repeated fluid air exchange.

The causes for late surgical failure were mainly recurrence of proliferative vitreo retinopathy and presence of retinal break posterior to buckle which opened up post-operatively by traciton. Post – operative complications like vitreous haemorrhage, poor fundus view due to hazy media. Choroidal detachment and recurrence of retinal detachment were observed in 42 eyes.

Other complications observed were endophthalmitis in 2 eyes (1.6%) and infected buckle in 8 eyes (6.4%).

We believe that many of these eyes considered in operable by scleral buckling technique alone, benefited from these combined surgical procedures. Otherwise these eyes would have remained blind.

SUMMARY: This report is based on the observation of 122 eyes of Proliferative Vitreo Retinopathy examined in the past five years. Modern surgical expertise in vitreous surgery techniques combined with scleral buckling procedure provided better treatment for these severe cases. We could achieve anatomical reattachment in 50% of cases.

REFERENCE: 1.George Hilton et al : (The Retina Society Terminology Committee). The classification of Retinal Detachment with Proliferative vitreo retinopathy Ophthalmol 1983: 90;121-125.

2.Davide W. Parke, Thomas M Aaberg;Intraocular Argon Laser Phtocoagulation in the Management of severe proliferative vitreo retinopathy; Am J.Ophthalmol 1984;90;434-443

3.Steve-Charles; Vitreous micro surgery ; Baltimore Williams & Wilkins 1981PP 55-106;121- 130

4.Ronald G.Michels, Vitreous surgery:St.Louis The C.V.Mosby Company,1981:PP 237-256

5.Grizzard, W.S. and Hilton, G.F.: Scleral buckling for retinal detachments complicated by periretinal Proliferation Arch Ophthalmol 100: 419,1982

6.Schepens C.L.Clinical and research aspects of sub total open sky vitrectomy Am.J.Ophthalmol 1981;91:143-71

7.Meredith T.A.Kaplan, H.J. Aaberg T.M.’ Pars plana vitrectomy techniques for relief of epiretinal traction by membrane segmentation Am J.Ophthalmol; 1980;89;408-13

8.Clifford M Ratner Ronald G Michels et al;Parsplana vitrectomy for complicated retinal detachments, Ophthalmology (Rosester) 1983: 90:1323 – 1327

TABLE I TREATMENT OF FRONDS INTO VITREOUS

1.Treatment of Retina beneath and beyond fronds 23 eyes 2.Treatment of fronds directly 1 eyes 3.Treatment by occlusion of feeder vessels 6 eyes 4.Combination of above modalities 44 eyes

74 eyes

TABLE II CLINICAL FEATURES

1.Sheathed vessels 137 eyes 87.3% 2.Vitreous haemorrhage 94 “ 59.8% 3.NVE Surface 108 “ 68.8% 4.NE into vitreous 74 “ 47.1% 5.NVD 27 “ 17.2% 6.Fibrous proliferation 84 “ 55.4% 7.Retinal Haemorrhages 61 “ 38.8% 8.Vascular abnormalities 26 “ 16.6% 9.CME 8 “ 5.0% 10.TRD 3 “ 1.9% 11.Neovascular glaucoma 1 “ .6% 12.Rubeosis Iridis 1 “ .6%1 13.Fundus Fluorescein Angiography Feature a. Capillary Closure 86 eyes 54.8% b. Capillary dilatation 27 eyes 17.2% c. Shunt Vessels 11 eyes 7.0% d. Majore vessels lleak 10 eyes 6.40%

TABLE III EFFICACY OF PHOTOCOAGULATION IN EALES’ DISEASE

STATUS OF FELLOW EYE NO.OF EYES PERCENTAGE Normal 43 16.3 Blind-presumably due to Eales’ disease 10 3.8 Vitrectomised 34 12.9 Eales’ disease without Neovascularisation 19 7.2 Almost Total Cataract 1 0.6 Total 107

NOTE: 157 eyes of 132 patients treated includes 25 bilaterally treated cases.

TABLE IV RESULTS OF PHOTOCOAGULATION

VISUAL ACUITY NO.OF EYES PERCENTAGE Improved 22 14.0 Maintained 104 66.3 Deteriorated 30 19.1 No.Follow Up 1 0.6 Total 157 100

PRIMARY SURGERY

Nature of Surgery No.of Eyes Lensectomy + Vitrectomy+Scleral Buckling 31 Membranectomy+Vitrectomy 2

Nature of Surgery No.of Eyes Lensectomy+Vitrectomy+Scleral Buckling 31 Membranectomy+Vitrectomy 2 Cataract+Vitrectomy+Scleral Buckling 6 Vitrectomy+Scleral Buckling 56 Vitrectomy+REV Scleral Buckling 17 REV.Vitrectomy+REV Scleral Buckling 5 Miscellaneous 5 Total 122

RESULTS IN RELATIONS TO GRADES OF PROLIFERATIVE VITREO RETINOPATHY

POST OPERATIVE PROLIFERATIVE VITREO RETINOPATHY GRADES STATUS C1 C2 C3 D1 D2 D3 TOTAL Total No. of eyes 3 19 26 37 15 22 122 Anatomical Success 3 13 16 14 7 8 61 (100%) (68.4%) (61.5%) (37.8%) (46.7%) (36.4%) (50%) EFFECT OF PAN RETINAL PHOTOCOAGULATION IN PROLIFERATIVE DIABETIC RETINOPATHY

Dr.Madhivanan Natarajan Dr.Chandran Abraham

Repeated vitreous haemorrhage, fibrous tissue proliferation, tractional retinal detachment and rubeosis iridis resulting from proliferative diabetic retinopathy are the leading cause of blindness in a diabetic patient.

Pan retinal photocoagulation reduces the risks of severe visual loss during the life time of patients with proliferative diabetic retinopathy.

MATERIAL AND METHODS:

304 eyes of 225 patients between the age of 22 and 73 years who underwent Pan retinal photocoagulation in our insitution between June 1979 and January 1984 were analysed.

Majority of them were males.

The association systemic disease is shown in Table 1

The argon laser was used in 168 eyes and the Xenon are in 36 eyes. Both were employed in 100 eyes. Treatment was divided into 3-6 sittings performed on consequent days. Additional photocoagulation – either a fill in pan retinal photocoagulation or focal treatment photocoagulation or focal treatment to new vessels had to be done in 141 eyes during the follow up period. Cataract, vitreous haemorrhage and machine malfuction hindered treatment in 99 eyes but did not prevent completion of treatment or alter the final outcome.

The period of follow up varied from 3 months to over 1 year (Table II).

CLINICAL FINDINGS:

In 229 eyes (75.4%)the visual acuity at the time of diagnosis and treatment was 6/18 or better.

Documentation of fundus lesions was done with fluorescein angiography (FFA) (192 eyes),fluorescein Ophthalmoscopy(FFO) (88 eyes). Fundus photography or fundus drawing (53 eyes).

Disc neo vascularization (NVD) was present in 113 eyes of which 79 were documented with FFA and 26 with FFO. Neo vascularization elsewhere on the retina (NVE) was present in 261 eyes of which 165 were documented with FFA and 73 with FFO. Vitreous haemorrhage was present in 77 eyes which was not massive enough to prevent adequate treatment.

RESULTS:

Of the 113 eyes which had NVD, 69 eyes(61%) showed complete regression. In 30 eyes (26%) NVD persisted with a marginal decrease in the size after maximum retinal ablation by PRP. In 10 eyes (9%) NVD developed after initial adequate PRP and worsened despite further fill in PRP.

Of the 261 eyes which had NVE 184 eyes (71%) showed complete regression of the new vessels. In 21 eyes (8%) NVE persisted with a slight decrease in size and in another 23 eyes (8.8%) the NVE persisted within the photocoagulated scar tissue. In 8 eyes (3%) florid fresh new vessels developed and worsened rapidly.

Fresh vitreous haemorrhage occurred in 71 eyes of which 38 eyes showed clearing of the haemorrhage with visual improvement and in the rest, the vitreous haemorrhage persisted and the final visual outcome was more than the pre treatment vison. 13 of the 14 eyes with per treatment rubeosis iridis showed total regression and in one eye the neo vascularization worsened. 17 eyes developed rubeosis despite photocoagulation and in 5 of them it regressed after further aggressive treatment. 7 eyes developed neo vascular glaucoma and were lost.

The post treatment visual acuity of 6/18 or better was present as shown in the Table III (a).

On comparing the post treatment visual acuity with the pre treatment visual acuity, the vision improvement, maintained or deteriorated as shown in the Table III (b).

Taking into consideration the visual acuity, the fundus picture and the fluorescein angiographic evidence the retinopathy looked stabilized in 228 eyes (75%). In 31 eyes (10.2%) it looked unaltered and in 20 eyes (6.6%) it worsened. In 25 eyes (8.2%) the retinal status could not be evaluated.

Secondary retinal detachment (11 eyes).choroidal detachment (10 eyes) and haemorrhage from the new vessels (10 eyes) were seen during the course of the treatment. These did not adversely affect the final visual outcome.

Visual acuity was found to be stabilized irrespective of whether the Argon Laser (68.6%) or Xeonon are (59.9%) was used and irrespective of whether NVD (57.1%) or NVE (60.5) was present.

DISCUSSION:

In spite of being a retrospective study the results in this series is gratifying and compares with the work of other authors and with the results of the Diabetic Retinopathy Study Research Group.

We have tried to analyse our results taking stabilization of the disease process as well as maintenance of visual acuity into account as visual acuity by itself need not be a marker of good results.

The worsening of retinopathy in 20 eyes and persistence of N.V.D. after adequate treatment in 30 eyes is however of concern and questions the efficacy of photocoagulation and the manner in which photocoagulation works. A very NVD, NVE and rubeosis iridis in the follow up period after PRP. The rapidity with which the eyes deteriorated have been observed earlier by Kohner. It should be emphasized that both the Argon Laser and the Xenon are are equally effective in achieving comparable results in proliferative diabetic retinopathy and that its prompt recognition in its treatable stage is as important as treatment itself.

SUMMARY:

304 eyes of 225 patients suffering from proliferative diabetic retinopathy who underwent pan retinal photocoagulation have been studied. The pre treatment clinical features, the visual results and stablization of the disease process were analysed and discussed.

REFERENCE:

1.Franks E.P., Kasprazyk J.S. Mcmeel J.W.: Computer enchanced studies of Diabetic Retinopathy I and II – Ophthalmology 1984 Vol 88: No.7,624 - 634

2.The Diabetic Retinopathy Study Research Group: Photocoagulation treatment of proliferative diabetic retinopathy – Ophthalmology 1981 Vol 88: No.7,583 – 600

3.Kingsley R.Ghosh G, Lawson P. Kohner E.M. : Severe diabetic retinopathy in adolescents – BJO 1983 vol. 67: 73 – 79

4.Arnall Pat: Retinal neo vasculanization – Early contributors of Prof.Michaelson and recent observations – BJO. 1984 Vol. 68: 42 – 46 5.Abraham C., Raman, R, Badrinath, S.S.: Fluorescein angiographic study on optic disc neo vascularization – Poona Conference 1983 (Under Publication)

6.Zweng H.C. Little H.L., Peabody R.R.: Diabetic retinopathy, In: Laser photocoagulation and retinal angiography: Mosby . 1969 136 – 168

TABLE – 1 ASSOCIATED SYSTEMIC DISEASES

Eyes Percentage Diabetes mellitus only 169 55.6 Hypertension 99 32.5 Renal Disease 9 3.0 Hypertension+Renal Disease 27 8.9 304 100.0 TABLE – 2 PERIOD OF FOLLOW UP Period Eyes Percentage 3 months 304 100.0 4 – 6 months 248 81.6 7 – 12 months 196 64.5 1 year 157 51.6 TABLE – 3 A VISUAL ACUITY AFTER PRP

Visual Acuity Post PRP Pre PRP 3 Mts 4-6 Mts 7-12 Mts 1 year Eyes % Eyes % Eyes % Eyes % Eyes %

6/18 and better 229 75 211 69 169 68 135 69 99 63 Less than 6/18 75 25 93 41 79 42 61 41 58 47 Total 304 100 304 100 248 100 196 100 157 100

TABLE – 3 A VISUAL ACUITY AFTER PRP

Improved Maintained Deteriorated Total

Follow up Eyes % Eyes % Eyes % Eyes % 3 months 58 19 205 67 41 14 304 100 4 – 6 months 46 18 159 64 43 18 248 100 7-14 months 40 20 112 57 44 23 196 100 1 year 31 16 82 55 44 29 157 100

TABLE - 4 CAUSE OF VISUAL DETERIORATION 3 MTS 4-6 MTS 7-12 MTS 1 YR. Worsening of 15 15 16 10 Retinopathy Vitreous 21 20 16 25 Haemorhage Cataract 5 8 12 9

TABLE - 5 STATUS OF PROLIFERATIVE DIABETIC RETINOPATHY AFTER PAN RETINAL PHOTOCOAGULATION Eyes Percentage Stabilized 228 75.0 Unchanged 31 10.2 Worsened 20 6.6 Cannot Asses 25 8.2 Total 304 100.0

INSTRUMENT DEMAGNETIZER

Dr. Arun Elhence

Surgical instruments often get magnetized after prolonged use. Suturing then becomes a time consuming and tedious procedure, especially, if the needle holder or toothed forceps get magnetized. Fine needles are more difficult to handle because they get attracted to even lightly magnetized instruments.

There is no known reference to demagnetization of surgical instruments. Instrument manufacturers when questioned about demagnetization, generally offer no solution except to buy new ones. It is known, however, that metals can be demagnetized by hammering them or heating them to high temperatures, or placing them in a changing magnetic field.

Using the latter principle, a simple gadget to demagnetize small surgical instruments has been devised. In the demagnetized state. Metals have groups of atoms called domains which are aligned in random directions. When the metal becomes magnetic the domains point to a single direction. If we can realign the domains so that they face randomly again, demagnetization can be achieved.

A 12 volt alternating current at 50 cycles per second is passed through a coil having about 200 turns. This creates a magnetic field within the core of the coil. The magnetic field changes directions 50 times per second. If the instrument is now rapidly withdrawn and taken fairly far away before the current is switched off, the atoms will remain rearranged in a random fashion, thus rendering the metal non-magnetic. If however, the instrument is withdrawn slowly or the current stopped while the instruments is still within the core, demagnetization will not occur. Unfortunately the entire instrument cannot be demagnetized by this method as the core itself is only 2 cm long. This method is particularly useful in terms of demagnetizing the tips of instruments like needle holders etc., which can thus give us trouble free service for quite some time.

CALIBRATED RESECTION CLAMP

Dr. T.S, Surendran

A conventional resection clamp was utilized onto which mm markings were made on the stem of the instrument. These markings enable the surgeon to directly measure off the desired amount of resection without having to use a separate caliper. This also eliminates the need for an assistant and a separate surgical marker. The measurement also becomes more accurate since the reading is made directly on the muscle.

The clamp is slid along the muscle, while the hook holds the eye in adduction or abduction. After the required length of muscle is measured on the instrument it is clamped and the resection procedure completed in the conventional manner.

AVAILABLE ONE YEAR FELLOWSHIP IN VITREO – RETINAL SURGERY

(Including Fundus Fluorescein Angiography, Photocoagulation, Electro-physiology, Ultrasonography, Retinal Detachment and Vitreous Surgery).

Available Feb./May/Aug./Nov Apply with curriculum vitae to :- The Medical Director Medical Research Foundation Sankara Nethralaya 18, College Road, Madras 600 006

Editor: Dr.Mary Abraham – For Private Circulation only. Designed & Produced by ADIMAGE – Madras 86