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Axenfeld-Rieger Syndrome Associated with Congenital Glaucoma and Cytochrome P4501B1 Gene Mutations
Mukesh Tanwar,Tanuj Dada,Rima Dada
Case Reports in Medicine , 2010, DOI: 10.1155/2010/212656
Abstract: Developmental anomalies of the ocular anterior chamber angle may lead to an incomplete development of the structures that form the conventional aqueous outflow pathway. Thus, disorders that present with such dysfunction tend to be associated with glaucoma. Among them, Axenfeld-Rieger (ARS) malformation is a rare clinical entity with an estimated prevalence of one in every 200,000 individuals. The changes in eye morphogenesis in ARS are highly penetrant and are associated with 50% risk of development of glaucoma. Mutations in the cytochrome P4501B1 (CYP1B1) gene have been reported to be associated with primary congenital glaucoma and other forms of glaucoma and mutations in pituitary homeobox 2 (PITX2) gene have been identified in ARS in various studies. This case was negative for PITX2 mutations and compound heterozygote for CYP1B1 mutations. Clinical manifestations of this patient include bilateral elevated intraocular pressure (>40 mmHg) with increased corneal diameter (>14 mm) and corneal opacity. Patient also had iridocorneal adhesions, anteriorly displaced Schwalbe line, anterior insertion of iris, broad nasal bridge and protruding umbilicus. This is the first study from north India reporting CYP1B1 mutations in Axenfeld-Rieger syndrome with bilateral buphthalmos and early onset glaucoma. Result of this study supports the role of CYP1B1 as a causative gene in ASD disorders and its role in oculogenesis.
Insertion of a foldable hydrophobic IOL through the trabeculectomy fistula in cases with Microincision cataract surgery combined with trabeculectomy
Tanuj Dada, Rajamani Muralidhar, Harinder S Sethi
BMC Ophthalmology , 2006, DOI: 10.1186/1471-2415-6-14
Abstract: After completion of MICS through two side port incisions, a 3.2 mm keratome is used to enter the anterior chamber under the previously outlined scleral flap. An Acrysof multi piece IOL (Alcon labs, Fort Worth, Tx) is inserted into the capsular bag through this incision. The scleral flap is then elevated and a 2 × 2 mm fistula made with a Kelly's punch. The scleral flap and conjunctival closure is performed as usual.Five patients with primary open angle glaucoma with a visually significant cataract underwent the above mentioned procedure. An IOL was implated in the capsular bag in all cases with no intraperative complications. After surgery, all patients obtained a best corrected visual acuity of 20/20, IOL was well centered at 4 weeks follow up. The mean IOP (without any antiglaucoma medication) was 13.2 + 2.4 mm Hg at 12 weeks with a well formed diffuse filtering bleb in all the cases.The technique of combining MICS with trabeculectomy and insertion of a foldable IOL through the trabeculectomy fistula is a feasible and valuable technique for cases which require combined cataract and glaucoma surgery.The combined surgical technique of phacotrabeculectomy has become a common technique for management of eyes with co-existent cataract and glaucoma [1,2]. Phacotrabeculectomy is either done as a single site surgery with both phacoemulsification and trabeculectomy performed from the same site or more commonly as a two-site surgery. Separating the two incisions may decrease the inflammation and subsequent fibrosis induced by the surgery leading to a better survival of the filtering bleb [2-4].Microincision cataract surgery (MICS) or Phakonit (implying phacoemulsification performed with a needle) is a recently introduced bimanual technique that permits phacoemulsification via sub 1–1.2 mm incisions. The basic principle is to separate the irrigation from the phacoemulsification handpiece and use an irrigating chopper to maintain the anterior chamber. The advantages of MICS i
Fluticasone propionate raises IOP in susceptible individuals
Sihota Ramanjit,Dada Tanuj,Rai Harminder
Indian Journal of Ophthalmology , 2004,
Closed chamber globe stabilization and needle capsulorhexis using irrigation hand piece of bimanual irrigation and aspiration system
Harinder S Sethi, Tanuj Dada, Harminder K Rai, Prabhpreet Sethi
BMC Ophthalmology , 2005, DOI: 10.1186/1471-2415-5-21
Abstract: Two side ports are made with 20 G MVR 'V' lance knife (Alcon, USA). The irrigation handpiece with irrigation on is introduced into the anterior chamber through one side port and the 26-G cystitome (made from 26-G needle) is introduced through the other. The capsolurhexis is completed with the needle.Needle capsulorhexis with this technique was used in 30 cases of uncomplicated immature senile cataracts. 10 cases were done under peribulbar anaesthesia and 20 under topical anaesthesia. A complete capsulorhexis was achieved in all cases.The irrigating handpiece maintains deep anterior chamber, stabilizes the globe, facilitates pupillary dilatation, and helps in maintaining the eye in the position with optimal red reflex during needle capsulorhexis. This technique is a safe and effective way to perform needle capsulorhexis.The anterior capsulorhexis has got several intra and post operative advantages over can opener or endocapsular capsulotomies and has become the standard capsulotomy technique for phacoemulsification [1-3]. Anterior capsulorhexis can be performed using 26 G bent needle cystitome or Utratas forceps [1,2]. The needle capsulorhexis can be performed through side port incision using a viscoelastic device or an anterior chamber maintainer [1,2,4,5]. During the performance of capsulorhexis, the globe can be stabilized either using a second instrument such as a Sinskey hook, or by holding limbal conjunctiva with a Lim's forceps. Sinskey hook introduced through a separate side port incision can lead to egress of viscoelastic from the eye and hence risk of radial extension of capsular flap. Holding conjunctiva with Lim's forceps can be traumatic or undesirable under topical anaesthesia.The prerequisites for a good capsulorhexis include a deep well maintained anterior chamber, globe stabilization and globe manipulation to achieve best position for a red glow under retroillumination. All these can be achieved by the technique described by us, which is a modificati
Pars plana Ahmed glaucoma valve implantation with triamcinolone-assisted vitrectomy in refractory glaucomas
Dada Tanuj,Bhartiya Shibal,Vanathi Murugesan,Panda Anita
Indian Journal of Ophthalmology , 2010,
Abstract: Glaucoma drainage devices are an option in refractory glaucomas for control of intraocular pressure (IOP). We evaluated the outcome of pars plana Ahmed glaucoma valve along with triamcinolone-assisted vitrectomy in 11 eyes with uncontrolled IOP on maximum tolerable antiglaucoma therapy. The mean preoperative IOP of 33.64 ± 5.99 (range 26 to 44 mmHg) decreased to 17.09 ± 2.26 (range 14 to 20 mmHg) and 17.45 ± 1.81mm of Hg (range 14 to 24 mmHg) at 6 and 12 months following surgery. The mean number of antiglaucoma medications decreased from 3.27 ± 0.05 to 0.64 ± 0.67 and 0.55 ± 0.6 at 6 and 12 months following surgery.
Effect of cataract surgery on retinal nerve fiber layer thickness parameters using scanning laser polarimetry (GDxVCC)
Dada Tanuj,Behera Geeta,Agarwal Anand,Kumar Sanjeev
Indian Journal of Ophthalmology , 2010,
Abstract: Purpose: To study the effect of cataract extraction on the retinal nerve fiber layer (RNFL) thickness, and assessment by scanning laser polarimetry (SLP), with variable corneal compensation (GDx VCC), at the glaucoma service of a tertiary care center in North India. Materials and Methods: Thirty-two eyes of 32 subjects were enrolled in the study. The subjects underwent RNFL analysis by SLP (GDx VCC) before undergoing phacoemulsification cataract extraction with intraocular lens (IOL) implantation (Acrysof SA 60 AT) four weeks following cataract surgery. The RNFL thickness parameters evaluated both before and after surgery included temporal, superior, nasal, inferior, temporal (TSNIT) average, superior average, inferior average, and nerve fiber index (NFI). Results: The mean age of subjects was 57.6 ± 11.7 years (18 males, 14 females). Mean TSNIT average thickness (μm) pre- and post-cataract surgery was 49.2 ± 14.1 and 56.5 ± 7.6 ( P = 0.001). There was a statistically significant increase in RNFL thickness parameters (TSNIT average, superior average, and inferior average) and decrease in NFI post-cataract surgery as compared to the baseline values. Mean NFI pre- and post-cataract surgery was 41.3 ± 15.3 and 21.6 ± 11.8 ( P = 0.001). Conclusions: Measurement of RNFL thickness parameters by scanning laser polarimetry is significantly altered following cataract surgery. Post the cataract surgery, a new baseline needs to be established for assessing the longitudinal follow-up of a glaucoma patient. The presence of cataract may lead to an underestimation of the RNFL thickness, and this should be taken into account when analyzing progression in a glaucoma patient.
Changing concepts of angle closure glaucoma: A review
Sinha Rajesh,Kumar Gaurav,Bali Shveta,Dada Tanuj
Indian Journal of Ophthalmology , 2011,
Post-penetrating keratoplasty glaucoma
Dada Tanuj,Aggarwal Anand,Minudath K,Vanathi M
Indian Journal of Ophthalmology , 2008,
Abstract: Post-penetrating keratoplasty (post-PK) glaucoma is an important cause of irreversible visual loss and graft failure. The etiology for this disorder is multifactorial, and with the use of new diagnostic equipment, it is now possible to elucidate the exact pathophysiology of this condition. A clear understanding of the various mechanisms that operate during different time frames following PK is essential to chalk out the appropriate management algorithms. The various issues with regard to its management, including the putative risk factors, intraocular pressure (IOP) assessment post-PK, difficulties in monitoring with regard to the visual fields and optic nerve evaluation, are discussed. A step-wise approach to management starting from the medical management to surgery with and without metabolites and the various cycloablative procedures in cases of failed filtering procedures and excessive perilimbal scarring is presented. Finally, the important issue of minimizing the incidence of glaucoma following PK, especially through the use of oversized grafts and iris tightening procedures in the form of concomitant iridoplasty are emphasized. It is important to weigh the risk-benefit ratio of any modality used in the treatment of this condition as procedures aimed at IOP reduction, namely trabeculectomy with antimetabolites, and glaucoma drainage devices can trigger graft rejection, whereas cyclodestructive procedures can not only cause graft failure but also precipitate phthisis bulbi. Watchful expectancy and optimal time of intervention can salvage both graft and vision in this challenging condition.
Evaluation of retinal nerve fiber layer thickness measurement following laser in situ keratomileusis using scanning laser polarimetry
Dada Tanuj,Chaudhary Sunil,Muralidhar Rajamani,Nair Soman
Indian Journal of Ophthalmology , 2007,
Abstract: Aim: To evaluate the effect of laser-assisted in situ keratomileusis (LASIK) on the measurement of retinal nerve fiber layer thickness by scanning laser polarimetry using customized corneal compensation in myopes. Materials and Methods: Scanning laser polarimetry was performed on 54 eyes of 54 healthy patients with myopia using the glaucoma diagnostics variable corneal compensation (GDx VCC) instrument (Laser Diagnostic Technologies, San Diego, California) before and a week after LASIK. The various parameters were compared using the Student′s t test. Results: No statistically significant change was observed in any of the retinal nerve fiber layer parameters before and after LASIK. Conclusions: While the measurement of retinal nerve fiber layer thickness by scanning laser polarimetry is affected by anterior segment birefringent properties and LASIK would be expected to produce changes in the same, customized corneal compensation using the GDx VCC seems to adequately compensate for these changes.
Comparison of the diagnostic ability of Moorfield′s regression analysis and glaucoma probability score using Heidelberg retinal tomograph III in eyes with primary open angle glaucoma
Jindal Shveta,Dada Tanuj,Sreenivas V,Gupta Viney
Indian Journal of Ophthalmology , 2010,
Abstract: Purpose: To compare the diagnostic performance of the Heidelberg retinal tomograph (HRT) glaucoma probability score (GPS) with that of Moorfield′s regression analysis (MRA). Materials and Methods: The study included 50 eyes of normal subjects and 50 eyes of subjects with early-to-moderate primary open angle glaucoma. Images were obtained by using HRT version 3.0. Results: The agreement coefficient (weighted k) for the overall MRA and GPS classification was 0.216 (95% CI: 0.119 - 0.315). The sensitivity and specificity were evaluated using the most specific (borderline results included as test negatives) and least specific criteria (borderline results included as test positives). The MRA sensitivity and specificity were 30.61 and 98% (most specific) and 57.14 and 98% (least specific). The GPS sensitivity and specificity were 81.63 and 73.47% (most specific) and 95.92 and 34.69% (least specific). The MRA gave a higher positive likelihood ratio (28.57 vs. 3.08) and the GPS gave a higher negative likelihood ratio (0.25 vs. 0.44).The sensitivity increased with increasing disc size for both MRA and GPS. Conclusions: There was a poor agreement between the overall MRA and GPS classifications. GPS tended to have higher sensitivities, lower specificities, and lower likelihood ratios than the MRA. The disc size should be taken into consideration when interpreting the results of HRT, as both the GPS and MRA showed decreased sensitivity for smaller discs and the GPS showed decreased specificity for larger discs.
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