RAJIV GANDHI university OF HEALTH SCIENCES,KARNATAKA,BANGALORE

ANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. / Name of the candidates and address
(in block letters) / Dr. MANSI DESAI
POST GRADUATE
DEPARTMENT OF OPHTHALMOLOGY
M.R. MEDICAL COLLEGE,
GULBARGA – 585 105
FAX- 08472 225085
Permanent Address / Dr. MANSI DESAI
VIVEK NURSING HOME & ICCU
GOHAR BAUG,MAHADEV NAGAR
BILIMORA
GUJARAT-396321
PHONE- 8123077220
2. / Name of Institution / H.K.E. SOCIETY’S
MAHADEVAPPA RAMPURE MEDICAL COLLEGE, GULBARGA – 585 105.
3. / Course of study and subjects / M.S (OPHTHALMOLOGY)
4. / Date of admission to the course / 31stMAY 2011
5. / Title of topic / OCULAR MANIFESTATIONS OF TUBERCULOUS MENINGITIS: A
CLINICAL STUDY
6. / Brief Resume of the intended work
6.1 / Need for the study
TBM (Tubercular Meningitis) is the mostdangerous formof tuberculosis infection and also the commonesttype of neurotuberculosis encounteredin children in our country. The frequency ofmeningitis is closely related with the incidenceof primary infection with tubercle bacilli. Tuberculous meningitis in children and adults can have serious manifestations. A patient canpresent with fever, neurologic deficit, lone optic atrophy or may have an acute onset with convulsionsand pyrexia. Since isolation of AFB in cerebrospinal fluid is difficult in our milieuand sophisticated investigations for diagnosis are not available even in major teaching institutions,a high index of suspicion is necessary. Early detection and prompt therapy are the most important factors in prognosis.
Because of the close proximity of the meninges with the optic nerve any inflammation of the meninges can lead to ocular manifestations Viz….Optic neuritis, optic atrophy, papilloedema, papillits, cranial nerve involvement(mainly 3rd and 6th) leading to lateral rectus palsy, ptosis, lagophthalmos etc..Presence of choroidal tubercles (incidence is low),can also lead to papilloedema.Patient can also present with diminished vision. Predictors of vision deteoriation are found to be papilloedema, cranial nerve palsies, raised intracranial tension, optochiasmatic arachnoiditis on MRI.The incidence of ocular motor dysfunction has been found to be in rising trend at par with the presence of CT findings of hydrocephalus and high CSF protein content and low CSF sugar content.
Tuberculosis is still widely prevalent in India. With modern therapy, the survival rate intuberculous meningitis is now increasing. As aresult, neuro-ophthalmic complications whichwere less common due to early mortality several years before, are now reasonably frequent.Optic atrophy may sometimes be theonly primary manifestation of TBM and in somecases it is reversible, if adequate anti-tuberculoustherapy is given in the early stage of the disease
Our study attempts to study the ocular manifestations of tubercular meningitis which is epidemic in India. Tuberculosis is becoming more common and because it is curable,heightened awareness and better understanding of the disease’s ocular manifestations should be of great concern to the ophthalmologists.
6.2 / Review of Literature
In a study by Verma et al, where they studied 50 cases of pediatric tubercular meningitis, they found that 76 % had ophthalmic features. They also found that there is a frequent involvement of third nerve followed by sixth cranial nerve. They found the highest incidence of mortality was with sixth nerve palsy ( probably as it may be indicative of a increased intra-cranial pressure), followed by a complete third nerve palsy, presence of fixed dilated pupils, semidilated pupils, presence of papilledema , and presence of choriodal tubercles.1
A clinico-biomedical study of ocular manifestations of tuberculous meningitis by Lamba PA, Bhalia JS, Mullick DN, where out of the 48 children with TBM, Optic disc changes (papillitis)constituted 62%,cranial nerves(3rd) involvement was 28% and papillary involvement was 48%.2
Madhumati Mishra, et al,analysed 100 consecutive patients of T.B. meningitis, 82 % of these cases developed ocular complications in which 40 % had diminished visual acuity, 22 % papilloedema, 18 % pale disc, 25 % ocular paresis and 10 % choroidal tubercles. Neuro-ophthalmic complications, such as vasculitis, were proved by angiography in 20 % cases; 22 % had evidence of obstructive hydrocephalus shown byventriculogram/C.T. and 12% had evidence of Tuberculoma.3
In a study by DR Manish kumar and colleagues,. Out of 101 patients of T.B. meningitis, 74 patients had normal vision and 27 patients had low vision or blindness at enrollment. Thirteen patients died during the study period. Out of 88 patients who survived at 6months, 68 patients had good vision, 11 patients had low vision and 9 patients had blindness. Predictors of vision deterioration were papilloedema, cranial nerve palsies, raised cerebrospinal fluid protein (>1g/L), and presence of optochiasmatic arachnoiditis in MRI. Predictors of blindness, at 6months, were found to be papilledema, vision acuity <6/18, cranial nerve palsies, tuberculous meningitis stage II or III, raised cerebrospinal fluid protein (>1g/L), optochiasmatic arachnoiditis, and optochiasmal tuberculoma. At 6months, 27 patients had death or severe disability. Predictors of death or severe disability at 6months were vision acuity 6/18, cranial nerve deficits, hemiparesis, clinical stage II or III, and presence of infarct in MRI.4
In a study published in Metabolic Pediatric and systemic ophthalmology journal, the incidence of ocular manifestations in 4102 patients with meningitis was studied during a 15 year period. Pupillary changes were found in 82%, Cranial nerve involvement in 23%,fundus changes in 6%.5
According to Benneggi A et al, A case with severe ocular manifestations in a patient with tuberculous meningitis has been found.6
Anupriya A et al conducted a study on 163 patients and found out that OptochiasmaticArachnoiditis can occir as a complication of T.B. meningitis.7
In another study conducted by Manish Kumar Sinha and his colleagues,optochiasmatic tuberculoma was found to be a major finding. They reported 8 patients with paradoxical visual loss associated with optochiasmatic tuberculoma.8
In a study by Smith,USA, tuberculosis was mediating factor in acquired abducens nerve palsy in children.9.
6.3 / Objectives of the study
  1. To study the ocular complications in patients with diagnosed tubercular meningitis.
  2. To determine the visual prognosis and outcome in those patients.

7. / Materials and methods
7.1 / Source of Data
All children and adults with diagnosed tuberculous meningitis in Basaveshwar Teaching and General Hospital, Gulbarga.
7.2 / Methods of collection of data(including sampling)
1. Place of study : Basaveshwar Hospital, Department of Ophthalmology, M.R. Medical College, Gulbarga.
2. Duration of study : 18 months(Dec2011-May 2013)
3. Sample size : 100
Inclusion Criteria-
  1. All patients, both adults and children, diagnosed with tuberculous meningitis of any age admitted in Basaveshwar teaching and general hospital, Gulbarga.
  2. Both sexes.
Exclusion Criteria-
  1. Other causes of Papilloedema
  2. Viral infections
  3. Other causes of meningitis.

7.3 / Does the study require any investigations or interventions to be conducted on Patients or other humans or animals? If so please describe briefly.
Yes
The following general investigations could be of use:
  1. Hemoglobin percentage, total blood count, differential count(pleocytosis) .
  2. Chest X-ray.(Cavities, pleural effusion, parenchymal changes).
  3. Sputum and Blood culture(presence of Acid fast bacilli).
  4. Cerebrospinal fluid test
  5. Adenosine deaminase
  6. Visual Acuity Testing
  7. Slit Lamp Examination
  8. Indirect Ophthalmoscopy
  9. CT Scan Brain

7.4 / Has ethical clearance been obtained from institution in case of 7.3?
Yes, ethical clearance has been taken from “ethical clearance committee” of the institution.
8 / References
  1. Verma BMD, Srivastav SK, Srivastav JR. Ocular manifestation of tubercular meningitis and their prognostic value in children. IJO. 1981; 29:301-2.
  2. Lamba PA, Bhalla JS, Mullick DN-Ocular Manifestations of tubercular meningitis-A clinico-biochemical study.PMID-3723294.Journal of pediatric ophthalmology and strabismus.1986; 23(3): 123-5.
  3. Neuro-ophthalmic profile in TBM-By Madhumati Mishra, S.Rath, B N Acharya, S Mohanty, B P Panigrahi. Ind.J.Tub. 1985; 23:142.
  4. Manish kumar Sinha, Anuradha HK Atul Aggarwal-Vision Impairement in 27-32.Tuberculous meningitis,Journal of neurological sciences. 2010; 290(1):
  5. Ocular manifestations in 4012 patients with meningitis. Metabolic Pediatric and systemic ophthalmology. 1988; 11(4):160-162.
  6. Benneggi A, Adamoli P, Bernardini E, Branchi M-A case with severe ocular manifestations in a patient with tuberculous meningitis.PMID-8685007. Pediatr Med Chir 1995 Sep-Oct; 17(5):465-9.
  7. Anupriya A , Sunidhi M, Maya T, Goel M, Alexander M, Aaron S-Tuberculous Optochiasmatic Arachnoiditis.Neurology Unit,CMC Vellore. Neurol India. 2010; 58(5):732-5.
  8. Manish Kumar Sinha, Ravikumar Garg, Dept of neurology,Chhatrapati Shahuji Maharaj Medical University,Lucknow-A report of 8 cases of Paradoxical vision loss in optochiasmatic tuberculoma in tuberculous meningitis.(submitted on 19 march 2010).
  9. Smith DE, Blasi A-Dept of peds, MEMPHIS, USA-6th nerve palsy secondary to tuberculosis. Optometry. 2009 Oct; 80(10):567-71.

9. / Signature of Candidates
10. / Remarks of Guide / TBM has ocular manifestations like papillitis.optic atrophy.cranial nerve palsies and this study attempts to highlight the ocular manifestations.
11. / Name and designation of the
(In block letters)
11.1 / Guide / Dr.RAJASHREE REDDY
M.S
associate PROFESSOR,
DEPARTMENT OF Ophthalmology,
M.R.Medical COLLEGe,
GULBARGA-585105
11.2 / Signature
11.3 / Co-guide
11.4 / Signature
11.5 / Head of the Department / Dr. M.R. PUJARI
M.S , doms
Professor & Head,
DEPARTMENT OF ophthalmology,
M.R.Medical COLLEGE,
GULBARGA – 585105
11.6 / Signature
12 / 12.1 / Remarks of the chairman and principal
12.2 / Signature