Publications by authors named "Tushar Sinha"

15 Publications

  • Page 1 of 1

Brolucizumab in Neovascular Age-Related Macular Degeneration - Indian Real-World Experience: The BRAILLE Study.

Clin Ophthalmol 2021 7;15:3787-3795. Epub 2021 Sep 7.

Department of Vitreoretinal Services, Disha Eye Hospitals, Kolkata, West Bengal, India.

Purpose: To assess the short-term efficacy and safety profile of intravitreal brolucizumab injection in Indian eyes with neovascular age-related macular degeneration (nAMD) under real-world conditions.

Patients And Methods: This was a multicenter, retrospective chart review of 94 eyes of 94 patients with nAMD (treatment-naïve and switch-therapy) undergoing brolucizumab therapy. Re-treatment as per pro-re-nata protocol was performed based on fixed visual and tomographic criteria. The main outcome measures were changes in the best-corrected visual acuity (BCVA), intraretinal fluid (IRF), subretinal fluid (SRF), central subfield thickness (CST), and pigment epithelial detachment (PED) along with safety analysis.

Results: Of the 94 eyes, 20 eyes (21.3%) were treatment-naïve, whereas the rest 74 eyes (78.7%) underwent switch therapy. One hundred and twenty-six injections were given over a mean follow-up of 7.3 ± 2.2 (range 5-30) weeks. The BCVA improved significantly from 0.82 ± 0.5 LogMAR at baseline to 0.66 ± 0.5 LogMAR at the final visit (p < 0.0001). Significant reduction in CST was simultaneously noted (Baseline: 408.45 ± 65.63 µm; Final: 281.14 ± 37.74 µm; p < 0.0001). On qualitative analysis, resolution of subretinal fluid (SRF), intraretinal fluid (IRF), and pigment epithelial detachment (PED) was observed in 15.5%, 39.29%, and 23.81% of the eyes, respectively. The mean interval of repeat injection was 10.2 ± 2.1 weeks. Three episodes of ocular adverse drug reaction were reported, including two patients developing subretinal hemorrhage while one having a retinal pigment epithelial (RPE) tear. Notably, no intraocular inflammation (IOI) was seen in any of the eyes, and no systemic side effects were identified.

Conclusion: In a real-world scenario, brolucizumab therapy is efficacious and safe in the management of nAMD over the short term. Further long-term studies are warranted to validate these findings. Additionally, lack of ocular inflammation after 126 brolucizumab injections in our Indian data is peculiar and underlines the necessity to explore the role of race and genetics in predisposing to/safeguarding against brolucizumab-related IOIs.
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http://dx.doi.org/10.2147/OPTH.S328160DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8434835PMC
September 2021

Off-label intravitreal brolucizumab for recalcitrant diabetic macular edema: A real-world case series.

Am J Ophthalmol Case Rep 2021 Dec 1;24:101197. Epub 2021 Sep 1.

Department of Vitreoretinal Services, Disha Eye Hospitals, Kolkata, India.

Purpose: To report the efficacy of intravitreal injection (IVI) of brolucizumab for recalcitrant diabetic macular edema (DME) in a real-world setting.

Observations: This was a single-center, prospective uncontrolled non-randomized case series. Three eyes with recalcitrant DME, who have received a minimum of ten intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections, underwent IVI brolucizumab and were followed-up for minimum of 16 weeks. Patients underwent best-corrected visual acuity (BCVA) testing, ophthalmic examination, and optical coherence tomography at baseline and all the scheduled follow-up visits (Weeks 4, 8, 12, and 16). All three patients demonstrated notable improvement in BCVA and reduction in the fluid on SD-OCT lasting up to week 12. At week 16, all three eyes maintained the visual acuity gains. However, early increase in fluid was noted in all the three cases, for which second dose of IVI brolucizumab was planned. No ocular or systemic adverse events were noted in any of the cases.

Conclusions And Importance: In this real-world case series, treatment with IVI brolucizumab exhibited excellent visual acuity outcomes lasting up to 16 weeks for the treatment of recalcitrant DME. Single dose IVI brolucizumab achieves good anatomical improvement based on SD-OCT persisting up to 12 weeks, followed by early recurrence of fluid at week 16. The results did not show any ocular or systemic safety concerns for IVI brolucizumab.
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http://dx.doi.org/10.1016/j.ajoc.2021.101197DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8414050PMC
December 2021

Real-World Safety Outcomes of Intravitreal Ranibizumab Biosimilar (Razumab) Therapy for Chorioretinal Diseases.

Ophthalmol Ther 2021 Jun 17;10(2):337-348. Epub 2021 Apr 17.

Department of Vitreoretinal Services, Disha Eye Hospitals, Kolkata, 700120, India.

Introduction: To assess the safety profile of the intravitreal ranibizumab biosimilar molecule, Razumab (Intas Pharmaceuticals, Ahmedabad, India) in chorioretinal disorders under real-world conditions.

Methods: This was a multicenter, retrospective chart review which included patients from 15 centers receiving intravitreal Razumab (IVRz) injections from 2016 to 2020. Patient demographics, ocular examination data, and detailed safety information regarding serious adverse events (SAE) or serious adverse drug reactions (sADR), and non-serious AEs (nsAE) or non-serious ADRs (nsADR) occurring within 1 month of IVRz injections were compiled.

Results: A total of 6404 eyes of 6404 patients received 9406 IVRz injections [mean (± SD) = 1.49 (± 0.63)] during 4.25 years. Adverse events were reported after 1978 injections (21.03%): 64.16% nsAE, 32.96% nsADR, 2.37% sADR, and 0.51% SAE. The most frequent adverse events were subconjunctival hemorrhage (8.2% of total injections), transient blurring of vision (6.5% of total injections), and mild ocular pain (5.27% of total injections). Serious ocular (31 cases with retinal pigment epithelial tears [0.33%], two cases of non-infectious vitritis [0.02%], and one case of endophthalmitis [0.01%]) and systemic (seven patients with non-fatal myocardial infarction [0.12%] and six patients with non-fatal cerebrovascular accident [0.09%]) adverse events were infrequent.

Conclusion: The study reports the largest pooled safety data on IVRz use in a real-world scenario. The results did not raise any new ocular or systemic safety concerns for the biosimilar agent, with the incidence and spectrum of adverse reactions similar to those reported with other anti-vascular endothelial growth factor (anti-VEGF) drugs. The real-world evidence suggests that IVRz is a safe anti-VEGF agent in the management of chorioretinal disorders.
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http://dx.doi.org/10.1007/s40123-021-00345-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8079600PMC
June 2021

Modified surgical technique for lamellar macular holes with lamellar hole-associated epiretinal proliferation (LHEP).

Int Ophthalmol 2021 Jun 17;41(6):2197-2204. Epub 2021 Mar 17.

Vitreo-Retina Consultant, DISHA Eye Hospital, 88(63A), Ghoshpara Road, Barrackpore, Kolkata, 700120, West Bengal, India.

Purpose: To evaluate the efficacy and safety of lamellar hole-associated epiretinal proliferation embedding technique with modification in the surgical management of degenerative lamellar macular hole (LMH).

Methods: There is retrospective case series of consecutive eyes who underwent pars plana vitrectomy with LHEP embedding with internal limiting membrane (ILM) inversion technique for degenerative LMH. Primary outcome measure was improvement in foveal contour and central foveal thickness (CFT). Secondary outcome measures were changes in best corrected visual acuity (BCVA), status of outer retinal layers (external limiting membrane-ELM & ellipsoid zone-EZ) and complications.

Results: Ten eyes were operated by modified LHEP embedding technique. Mean age was 65.8 ± 5.3 years with 1:1 male to female ratio. Simultaneous cataract surgery was done in 70% cases. Mean follow-up duration was 7.9 ± 0.87 months. 80% (8/10) eyes had improvement in foveal contour to normal appearance with increase in residual foveal thickness from 90.2 ± 26.83 microns to CFT of 226 ± 35.44 microns at 6 months (p  =  0.0054). Mean BCVA improved from 0.69 ± 0.19 logMAR to 0.32 ± 0.29 logMAR (p  =  0.012). External limiting membrane (ELM) and ellipsoid zone (EZ) defects were present in four eyes (40%) pre-operatively. At the final visit 2 eyes (20%) had persistent defect in both ELM & EZ. None of the eyes progressed to full-thickness macular hole following surgery.

Conclusions: The modified surgical technique of LHEP Embedding with ILM inversion is demonstrated to provide satisfactory results with reduced risk of complications for degenerative LMH. Larger and long-term follow-up studies are needed to establish this technique as standard surgical procedure for LMH with LHEP.
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http://dx.doi.org/10.1007/s10792-021-01780-7DOI Listing
June 2021

Severe Vaso-Occlusive Retinopathy in Systemic Lupus Erythematosus: A Case Series.

Cureus 2021 Jan 30;13(1):e13019. Epub 2021 Jan 30.

Vitreo-Retina, Disha Eye Hospital, Kolkata, IND.

This study aims to describe the clinical profile of severe vaso-occlusive retinal disorders in patients with systemic lupus erythematosus (SLE) and it is a retrospective case series. The clinical characteristics of three patients with SLE with vascular occlusions in four eyes were described. Branch retinal artery occlusion (BRAO) was present in all three patients with combined non-ischemic central retinal vein occlusion (NICRVO) in one patient and evolving ischemic CRVO in another patient. Additional branch retinal artery insufficiency was observed in the other eye of a patient with BRAO. Antinuclear antibody (ANA) titer was elevated in all patients. One patient had a positive lupus anticoagulant with elevated activated partial thromboplastin time (aPTT), and concurrent homocysteinemia was present in another patient. Intravitreal anti-vascular endothelial growth factor (ranibizumab) injection was administered to two eyes. Intravenous methyl prednisolone (IVMP) injection along with oral azathioprine was used in all patients with the need for anticoagulation in two patients along with SLE treatment. Vision in two eyes did not improve to the functional level despite aggressive therapy. Visually blinding severe vaso-occlusive retinopathy in the form of BRAO with or without CRVO can manifest in patients with SLE. Undetected antiphospholipid syndrome and homocysteinemia may be associated risk factors for such ophthalmic complications.
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http://dx.doi.org/10.7759/cureus.13019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7920792PMC
January 2021

A novel video overlay guided enlargement of area of ILM peeled versus inverted flap technique: A long-term study in large macular holes.

Eur J Ophthalmol 2021 Nov 14;31(6):3277-3283. Epub 2020 Dec 14.

Department of Vitreoretina, Disha Eye Hospitals Pvt Ltd, Kolkata, West Bengal, India.

Background/aim: To compare the intra-operative video overlay guided enlargement of Area of ILM peeled (AIP) more than three Disc Diameter (DD) versus the inverted flap technique in large (>400 µm ) Full Thickness Macular Holes (FTMH).

Methods: Retrospectively, 127 cases of large FTMHs divided into two groups (i) Group A ( = 62)-intra-operative video-overlay guided enlargement of AIP > 3DD performed and (ii) Group B ( = 65)-Inverted flap technique was done. Mean Best Corrected Visual Acuity (BCVA), hole closure rate and postoperative foveal anatomy were noted on Optical Coherence Tomography (OCT).

Results: Mean Minimal Diameter of Macular Hole (MDMH) were 632.05 ± 146.62 µm (A) and 677.24 ± 152.08 µm (B). Hole closure rate were 93.55% (A) and 96.92% (B). Mean preoperative BCVA was 1.07 ± 0.37 Log MAR (A) and 0.94 ± 0.23 Log MAR (B). Mean postoperative BCVA at 3 months were 0.73 ± 0.22 Log MAR (A) and 0.83 ± 0.24 Log MAR (B). One-way ANOVA test showed statistically better visual improvement in Group A at 3 months ( = 0.02), 6 months ( = 0.045), 12 months ( = 0.002), and 24 months ( = 0.011). Chi square test revealed Type I pattern of hole closure was statistically more in Group B ( < 0.001). Delayed Recovery of Outer Retinal Layers was more in group B (Pearson Chi square test,  = 0.039).

Conclusion: Anatomically, macular hole closure rate as well as closure pattern was better in Group B. But functional improvement was better in Group A.
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http://dx.doi.org/10.1177/1120672120979904DOI Listing
November 2021

Long-term clinical outcomes of submacular blood removal with isolated autologous retinal pigment epithelium-choroid patch graft transplantation in long-standing large-sized submacular hematomas: An Indian experience.

Indian J Ophthalmol 2020 10;68(10):2148-2153

Vitreo Retina Department, Disha Eye Hospitals Pvt Ltd, Barrackpore, West Bengal, Kolkata, West Bengal, India.

Purpose: To study the outcomes of submacular blood removal with isolated autologous full-thickness retinal pigment epithelial (RPE)-choroid patch graft transplantation in long-standing large-sized submacular hematomas in Indian population.

Methods: A retrospective study was done on eight consecutive patients of long-standing large-sized submacular hematoma from east India. In all cases, 23G vitrectomy was performed with the induction of retinal detachment (performed with or without 38G or 41G subretinal cannula) and a temporal 180° retinectomy was done. Submacular blood along with choroidal neovascular tissue was removed. A full-thickness RPE-choroid autologous patch graft was taken from a relatively healthy quadrant at the mid periphery and then the graft transferred under perfluorocarbon liquid (PFCL) to place it in the subfoveal area. Then, retina was re-attached using PFCL and laser completed. Silicone oil (5000 cst) was used as a tamponade. Post-operatively, wide-field fundus photographs (Optos), serial optical coherence tomography (OCT), indocyanine green angiography (ICGA), and multifocal electroretinography (ERG) were done.

Results: The mean age of the patients at presentation was 67.88 ± 10.03 years. Mean pre-operative best corrected visual acquity (BCVA) was 2.64 ± 0.3 log MAR and mean postoperative BCVA was 1.095 ± 0.27 log MAR (P < 0.05). The mean follow-up was 20 ± 16.57 months. ICG showed re-vascularization of translocated graft in all at 2 months. Multifocal ERG (after 6 months) showed some waveform in all. None of the cases developed re-bleed.

Conclusion: Removal of submacular blood and neovascular membrane with autologous RPE-choroid graft is a viable option in cases with long-standing large submacular hematomas.
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http://dx.doi.org/10.4103/ijo.IJO_1729_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7727931PMC
October 2020

Lenticular burns following PASCAL photocoagulation.

Indian J Ophthalmol 2020 05;68(5):908-909

Department of Vitreo-Retina, Disha Eye Hospital, Kolkata, West Bengal, India.

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http://dx.doi.org/10.4103/ijo.IJO_1433_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7350426PMC
May 2020

Variable clinical profile of foveal hypoplasia in albinism.

Indian J Ophthalmol 2020 04;68(4):649-651

Department of Vitreo.Retina, Disha Eye Hospital, Kolkata, West Bengal, India.

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http://dx.doi.org/10.4103/ijo.IJO_905_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7210865PMC
April 2020

A novel standardized reproducible method to calculate the area of internal limiting membrane peeled intra-operatively in macular hole surgery by using a video overlay-A long-term study in cases of idiopathic macular holes.

Indian J Ophthalmol 2020 01;68(1):157-161

Disha Eye Hospitals Private Limited, Kolkata, West Bengal, India.

Purpose: To calculate AIP and to find correlation between hole closure pattern with AIP in idiopathic full thickness macular hole (FTMH) cases.

Methods: In this prospective, non-randomized, interventional single blind study, 105 eyes of symptomatic FTMH (<6 month duration) were operated. Minimal diameter of macular hole (MDMH) was calculated on OCT, divided into Group I (>400μ, n = 75) and Group II (<400μ, n = 30). 23G vitrectomy with ILM peeling and gas injection were done in all and recorded. Final area of ILM peeled (AIP) was calculated using Adobe Photoshop CS2 (PSD format) in disc diameters (DD) from still frame. Follow up was done at 6 monthly interval up to a maximum of 5 years after surgery.

Results: Macular holes were closed in 92.38% eyes. In Group I, mean pre-operative BCVA was 1.14 ± 0.39 log MAR and was improved to 0.79 ± 0.26 log MAR post-operatively at 6 months. In Group II, mean pre-operative BCVA was 0.95 ± 0.44 log MAR and was improved to 0.60 ± 0.24 log MAR after surgery. When AIP was more than 3DD, Type I and Type II closure were 72.77% and 27.27% in Group I (P value <0.01) and 84.21% and 15.79% in Group II (P value <0.01).

Conclusion: AIP can be calculated using Adobe Photoshop CS2. Type I closure was significantly high with AIP >3DD in both groups. Intra-operatively using video overlay, surgeons can increase the diameter of AIP to get better closure pattern.
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http://dx.doi.org/10.4103/ijo.IJO_589_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6951151PMC
January 2020

New Innovative Approaches for Difficult Retained Intraocular Foreign Bodies.

Ophthalmologica 2018 10;240(3):179-180. Epub 2018 Apr 10.

Disha Eye Hospitals, Sheoraphully, India.

Purpose: To describe innovative ways of removal of complicated difficult large retained intraocular foreign bodies (RIOFBs).

Settings: Both cases were treated at Disha Eye Hospitals, Kolkata, a tertiary eye hospital in eastern India.

Methods: Innovative approaches were taken to remove 2 difficult RIOFBs. In the first case, a large RIOFB was just beyond the posterior exit wound, trapped in the sclera. A 23-G MVR blade was used to create multiple radial releasing scleral nicks and bimanually moving the RIOFB into the vitreous cavity using a bent-tip 24G needle and magnet, and the RIOFB was removed through the limbal section. In the second case, a 21-mm long thick nail was deeply embedded in the superior sclera with partial localised retinal detachment with its bulbous end just behind the clear lens. A lasso technique was used to remove the RIOFB without lens touch.

Results: In the first case, the patient finally achieved logMAR 0.2 vision after silicone oil removal and glued scleral fixation of the intraocular lens. In the second case, the patient finally achieved logMAR 0.3 vision after silicone oil removal and phacoemulsification with intraocular lens implantation.

Conclusion: Each case of RIOFB is unique and challenging. Here, innovative techniques are helpful to rescue these difficult RIOFB situations, which can result in excellent outcomes.
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http://dx.doi.org/10.1159/000487549DOI Listing
October 2018

Patterns and drivers of fish extirpations in rivers of the American Southwest and Southeast.

Glob Chang Biol 2018 03 15;24(3):1175-1185. Epub 2017 Nov 15.

School of Aquatic and Fishery Sciences, University of Washington, Seattle, WA, USA.

Effective conservation of freshwater biodiversity requires spatially explicit investigations of how dams and hydroclimatic alterations among climate regions may interact to drive species to extinction. We investigated how dams and hydroclimatic alterations interact with species ecological and life history traits to influence past extirpation probabilities of native freshwater fishes in the Upper and Lower Colorado River (CR), Alabama-Coosa-Tallapoosa (ACT), and Apalachicola-Chattahoochee-Flint (ACF) basins. Using long-term discharge data for continuously gaged streams and rivers, we quantified streamflow anomalies (i.e., departure "expected" streamflow) at the sub-basin scale over the past half-century. Next, we related extirpation probabilities of native fishes in both regions to streamflow anomalies, river basin characteristics, species traits, and non-native species richness using binomial logistic regression. Sub-basin extirpations in the Southwest (n = 95 Upper CR, n = 130 Lower CR) were highest in lowland mainstem rivers impacted by large dams and in desert springs. Dampened flow seasonality, increased longevity (i.e., delayed reproduction), and decreased fish egg sizes (i.e., lower parental care) were related to elevated fish extirpation probability in the Southwest. Sub-basin extirpations in the Southeast (ACT n = 46, ACF n = 22) were most prevalent in upland rivers, with flow dependency, greater age and length at maturity, isolation by dams, and greater distance upstream. Our results confirm that dams are an overriding driver of native fish species losses, irrespective of basin-wide differences in native or non-native species richness. Dams and hydrologic alterations interact with species traits to influence community disassembly, and very high extirpation risks in the Southeast are due to interactions between high dam density and species restricted ranges. Given global surges in dam building and retrofitting, increased extirpation risks should be expected unless management strategies that balance flow regulation with ecological outcomes are widely implemented.
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http://dx.doi.org/10.1111/gcb.13940DOI Listing
March 2018

Dams in the Cadillac Desert: downstream effects in a geomorphic context.

Ann N Y Acad Sci 2012 Feb 13;1249:227-46. Epub 2012 Feb 13.

School of Life Sciences, Arizona State University, Tempe, Arizona 85287, USA.

This paper was motivated by the 25th anniversary of the publication of Marc Reisner's book, Cadillac Desert: The American West and its Disappearing Water. Dams are ubiquitous on rivers in the United States, and large dams and storage reservoirs are the hallmark of western U.S. riverscapes. The effects of dams on downstream river ecosystems have attracted much attention and are encapsulated in the serial discontinuity concept (SDC). In the SDC, dams create abrupt shifts in continua of downstream changes in physical and biotic properties. In this paper, we develop a framework for understanding how channel geometry and network structure influence how the physical components of habitat and the biota rebound from discontinuities set up by large dams. We apply this framework to data describing the flow regime, temperature, sediment flux, and fish community composition below Garrison Dam on the Missouri River, Glen Canyon Dam on the Colorado River, and Flaming Gorge Dam on the Green River. Sediment flux in dam tailwaters is under strong control by channel geometry. By contrast, dam-related changes in temperature and flow variation are not significantly modulated by channel geometry or tributary inputs if flow volumes are small (Missouri and Colorado River tributaries). Instead, small tributaries provide near-native conditions (flow and temperature variation) and, as such, provide key refuges for biota from novel habitats in mainstem rivers below large dams. Unregulated tributaries that are large relative to their respective mainstem (e.g., Yampa River) provide refuges as well as significant amelioration of flow and temperature effects from upstream dams. Finally, the proportion of native fish increases with distance from dam and exhibits sharp increases near tributary junctions. These results suggest that tributaries-even minor ones in terms of relative discharge-act as key refugia for native species in regulated river networks. Moreover, large, unregulated tributaries are key to restoring continuity in physical habitat and the biota in large regulated rivers.
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http://dx.doi.org/10.1111/j.1749-6632.2011.06411.xDOI Listing
February 2012

Reclaiming freshwater sustainability in the Cadillac Desert.

Proc Natl Acad Sci U S A 2010 Dec 13;107(50):21263-70. Epub 2010 Dec 13.

Faculty of Ecology, Evolution and Environmental Sciences, School of Life Sciences, Arizona State University, PO Box 874501, Tempe, Arizona 85287-4501, USA.

Increasing human appropriation of freshwater resources presents a tangible limit to the sustainability of cities, agriculture, and ecosystems in the western United States. Marc Reisner tackles this theme in his 1986 classic Cadillac Desert: The American West and Its Disappearing Water. Reisner's analysis paints a portrait of region-wide hydrologic dysfunction in the western United States, suggesting that the storage capacity of reservoirs will be impaired by sediment infilling, croplands will be rendered infertile by salt, and water scarcity will pit growing desert cities against agribusiness in the face of dwindling water resources. Here we evaluate these claims using the best available data and scientific tools. Our analysis provides strong scientific support for many of Reisner's claims, except the notion that reservoir storage is imminently threatened by sediment. More broadly, we estimate that the equivalent of nearly 76% of streamflow in the Cadillac Desert region is currently appropriated by humans, and this figure could rise to nearly 86% under a doubling of the region's population. Thus, Reisner's incisive journalism led him to the same conclusions as those rendered by copious data, modern scientific tools, and the application of a more genuine scientific method. We close with a prospectus for reclaiming freshwater sustainability in the Cadillac Desert, including a suite of recommendations for reducing region-wide human appropriation of streamflow to a target level of 60%.
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http://dx.doi.org/10.1073/pnas.1009734108DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3003073PMC
December 2010

Intravitreal live Gnathostoma spinigerum.

Indian J Ophthalmol 2004 Mar;52(1):57-8

Disha Eye Hospitals and Research Centre, Barrackpore, West Bengal, India.

Intraocular infestation by live Gnathostoma spinigerum is a rare occurrence in humans. Most of the published reports are from South-East Asia. We report a case of intravitreal gnathostomiasis, where the worm was removed live and intact by pars plana vitrectomy.
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March 2004
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