Rajiv gandhi university of health and sciences bangalore, karnataka. Proforma for registretion of subjects for dessertation



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RAJIV GANDHI UNIVERSITY OF HEALTH AND SCIENCES BANGALORE, KARNATAKA.
PROFORMA FOR REGISTRETION OF SUBJECTS FOR DESSERTATION



1.NAME OF THE CANDIDATE AND ADRESS

DR.SOUMYA GUTTEDAR.

D/O BASSAYYA GUTTEDAR

H-NO 1-867/33/B5, BEHIND KOTARI BHAVAN, MAHAVEER NAGAR, GULBARGA 585102.


2.NAME OF THE INSTITUTION

M.S.RAMAIAH MEDICAL COLLEGE.

M.S.RAMAIAH NAGAR, BANGALORE-560054.



3.COURSE OF STUDY AND

SUBJECTS


M.S (OPHTHALMOLOGY)

4.DATE OF ADMISSION TO COURSE

06-06-2011

5.TITLE OF THE TOPIC

OPHTHALMIC MANIFESTATIONS IN LEUKEMIA.



6.BRIEF RESUME OF THE INTENDED WORK
6.1 INTRODUCTION

The eye can be involved in leukemia by direct invasion of tissue by neoplastic cells or manifestations may be of associated hematological abnormalities like anemia, thrombocytopenia or hyper viscosity states or by opportunistic infections.

In leukemia there can involvement of anterior segment and posterior segment of the eye,orbit and adnexa . Taking into consideration the advances made in the treatment modalities of leukemia,the number of survivors of this diseases is ever increasing and hence more and more patients with intraocular manifestations are likely to present to the ophthalmologist with various sequelae and complications.

Knowledge of intraocular manifestations is thus important because not only does eye reflect the disease state of the body, but also these manifestations may be the initial mode of presentation of systemic illness.

The presence of leukemic intraocular infiltrates appears to correlate with central nervous system involvement and decreased survival.

6.2 NEED OF THE STUDY



  • Ocular and orbital lesions have been reported to be the third most frequent extramedullary location of acute leukemias after the meninges and testicles.

  • As high proportion of patients now achieve initial bone marrow remission with combination chemotherapy.it is important to take a closer look at sites of extramedullary leukemic infiltration,both because of their local morbidity and their site may act as reservoir for proliferation of leukemic cells which may result in systemic relapse.


6.3 AIMS AND OBJECTIVES

  1. To study various ophthalmic manifestation in leukemic patients.

  2. To know severity of ocular involvement in leukemic patients.

  3. To know how many leukemic patients had ocular symptomology as their initial presentation.

  4. To know whether ocular manifestations is associated with relapse of disease.


6.4 REVIEW OF LITERATURE

  • Afekhide E.Omoti,caroline E,omoti,Rita o, Momoh reported that potentially blinding occur in leukemia[1]

  • Jackson and reddy reported that IRH as the commonest retinal lesion,seen in 42% of patients[2].

  • Osama babeeb reported 31cases out of which 17 had ocular manifestations[3]

  • Kincaid and Green reviewed pathology specimens at the wilmer eye institute and reported that 75% of patients with chronic leukemias ,82% of patients with acute leukemia and 80% of patients overall has intraocular involvement at the time of death[4].

  • Cotton wool spots may be presenting abnormality that precipitates the systemic evaluation leading to the diagnosis of leukemia[5].

  • It has been proposed that white centered retinal hemorrhage represent accumulation of leukemic cells[6]

  • Duke-Elder noted that retina is the tissue most commonly involved in leukemic complications[7].

  • Additional manifestation of leukemia include peripheral micro aneurysms,retinal neovascularization and peripheral retinal hemorrhages[8].

  • Whole blood hyper viscosity may lead to veno-occlusive,micro aneurysm formation, retinal hemorrhages and retinal neovascularization. The most common manifestation is a mild or hyper permeable central retinal vein occlusion[9].

  • Schachat and coworkers prospectively correlated the ocular findings with hematological values on presentation in series of 120 cases examined within a few days of diagnosis. They found a strong association between low platelet counts and intraretinal hemorrhages[10].

  • Allen and straatsma5 reported that the choroid is affected more commonly than any other ocular structure[11].

  • Only three cases of leukemic infiltration of vitreous without hemorrhage were found in kincaid’s pathologic study[4]

  • Ridgeway and coworkers concluded that “posterior pole should be included in the radiation therapy portals for prophylaxis of the CNS[12].

  • Glaucoma can occur as a result of leukemic infiltration of trabecular meshwork or angle closure glaucoma secondary to choroidal infiltration and hemorrhage[13].

  • Allen and straatsma’s pathological series demonstrated leukemic infiltration of the limbus but no central corneal involvement,perhaps reflecting the avascularity of this tissue[11].

  • Anterior chamber involvement occurs most commanly in patients with ALL and patients have also presented with greyish yellow pseudohypopyon[14].

  • Cogan summarized the common oportunistc organisms that may manifest in the eyes of immunosuppressed hosts which are viruses like cytomegalo virus,herpes simplex virus,herpes zoster and measels.fungi like candida,aspergillus,mucur and cryptococcus,protozoa like toxoplasma[15].



7. MATERIALS AND METHODS

7.1 source of data- patients attending the medicine, paediatric , oncology, and ophthalmology opd of M.S RAMAIAH hospitals from NOV 2011-MAY 2013.

7.2 METHODS OF COLLECTION OF DATA

INCLUSION CRITERIA

Patient of all age and any sex diagnosed with leukemia of any stage.


EXCLUSION CRITERIA

  • Patients of leukemia who had any previous ocular diseases,or have undergone ocular surgeries.

  • Leukemic patients with associated co-morbid diseases like diabetic,hpertension etc.

Study design: Cross sectional hospital based study.

Methodology

  • Informed consent

  • Patients choosen according to inclusion and exclusion criteria.

  • Detailed history

  • General physical examination included consiousness, orientation, pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema, temperature, pulse rate,respiratory rate, blood pressure.

  • Systemic examination included ,central nervous system, cardiovascular system, respiratory system and per abdoman.

  • Diagnosis of leukemia confirmed by Hematological investigation results like complete blood count,peripheral smear and bone marrow smear were recorded.other investigation findings,which had relevance to ocular involvement like CT scan or CSF study.


OCULAR EXAMINATION

  • Best corrected visual acuity by snellen chart.

  • Slit lamp examination

  • Fundus examination (after mydriasis) by Direct ophthalmoscopy, indirect ophthalmoscopy, 90Dlens.

  • Fundus photograph whereever possible.

  • Applanation tonometry/schiotz tonometry (if needed)

  • Gonioscopy (if needed)




  • B-scan if needed.

  • OCT (whereever possible)

  • Slit lamp pictures (whereever possible)


7.3 DOES THE STUDY REQUIRE ANY INVESTIGATIONS OR INTERVENTIONS TO BE DONE ON PATIENTS OR OTHER HUMANS OR ANIMALS?

  • Yes,as mentioned in 7.2


7.4 Sampling technique

All leukemic patients attending department of pediatric,medicine oncology and ophthalmology during study period


7.5 Sample size:

Study carried out by Andrew p.schachat,et al.ophthalmic manifestations of leukemia[10]. Has indicated that ocular disorders amongst leukemia patient to be around 67%.

The sample size for present study have been estimated based on above studies with Relative precision of 20% and desired confidence level of 95%.the estimated sample size worked out to be 47 patients.thus it is proposed to include 50 patients into the study.
7.8 Statistical Analysis of Data:

All the quantitative parameters will be described through mean and standard deviation.Qualitative variables such as presence of ophthalmic manifestations, etc will be defined through proportion along with 95% confidence interval.

Students- ‘t’ test-will be employed to test for differences in the mean values while chi’square will be used to test for differences in the proportions for statistical significance.
8.BIBLIOGRAPHY


  1. Afekhide E. Omoti, Caroline E. Omoti, Rita O. Momoh. Ocular disorders in Adult leukemia patients in nigeria. Middle east African journal of ophthalmology.April-june 2010,17:165-168.

  2. Jackson, Reddy et al. Macular hemorrhage in adult acute leukemia patients at presentation and the risk of subsequent intracranial hemorrhage. Br J Ophthalmol 1997 July;98 (1),204-9.

  3. Osama Badeeb, Ishraq Tashkandi, Awad omar, Majdi Anwer. Ocular leukemia in king Abdul aziz university Hospital-jeddah.Ann Saudi Med 1995;15(3):222-226.

  4. Kincaid MC, Green WR. Ocular and orbital involvement in leukemia. Surv ophthalmol 1983;27:211-232.

  5. Brown, BensonWG. Cottonwool spots. Retina 1985;5:206-214.

  6. Holt JM, Gordon-smith EC. Retinal abnormalities in diseases of the blood. Br J Ophthalmol 1969;53:145-160.

  7. Duke-Elder S. System of ophthalmology, vol 10.st.Louis,CV Mosby,1967,pp 387-390.

  8. Morse PH, McCready JL. Peripheral retinal neovascularization in chronic myelocytic leukemia. Am J ophthalmol 1971;72:975-978.

  9. Carr R, Henkind P. Retinal findings associated with serum hyperviscosity. Am J Ophthalmol 1963;56:23-31.

  10. Schachat AP, Markowitz JA, Guyer DR. Ophthalmic manifestations of leukemia. Arch ophthalmol 1989;107:697-700.

  11. Allen RA, Straatsma BR. Ocular involvement in leukemia-allied disorders. Arch opthalmol 1961; 66:490-508.

  12. Ridgeway EVV, Jaffe N, Walton DS. Leukemic ophthalmopathy in children. Cancer 1976;38:1744-1749.

  13. Glaser B, Smith JL. Leukaemic glaucoma. Br J ophthalmol 1966;50:92-94.

  14. Rowan PJ, Sloan JB. Iris and anterior chamber involvement in leukaemia. Ann ophthalmol 1976;8:1081-1085.

  15. Cogan DG. Immunosppression and eye disease. Am J Opthalmol 1997;83:777-788.



9.SIGNATURE OF THE CANDIDATE




10.REMARKS OF THE GUIDE


Ocular involvement in leukemia causes morbidity,in some cases it can be sign of relapse of the disease,this study is for knowing the various ocular manifestations of leukemia and their severity.

11.NAME AND DESIGNATION OF

(IN BLOCK LETTERS)






11.1 GUIDE

SIGNATURE



DR.MALAVIKA KRISHNASWAMY.

M.B.B.S,M.S(OPHTHALMOLOGY)

PROFESSOR OF DEPARTMENT OF OPHTHALMOLOGY.

M.S.RAMAIAH MEDICAL COLLEGE AND HOSPITAL.BANGALORE-54.



11.2 CO-GUIDE

SIGNATURE



DR.A.T.K RAU

MBBS,MD,DHA

PROFESSOR AND HOD DEPARTMENT OF PEDIATRICS

M.S.RAMAIAH MEDICAL COLLEGE AND HOSPITAL.BANGALORE-54.




11.3 HEAD OF THE DEPARTMENT

SIGNATURE




DR.C.N.GUPTA.

M.B.B.S,DOMS,MS

PROFESSOR AND HOD

DEPARTMENT OF OPHTHALMOLOGY



M.S.RAMAIAH MEDICAL COLLEGE AND HOSPITAL.BANGALORE-54.


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