Uveitis expert creates awareness about AIDS, Eales’ disease

Issue: August 2008

When Jyotirmay Biswas, MS, FNAMS, entered the field of ophthalmology, he studied vitreoretinal disease, but that led him into two other fields.

Studying under S.S. Badrinath, MD, FRCS, in the vitreoretinal department at Sankara Nethralaya, Dr. Biswas said he was inspired to look further into the fields of uveitis and ophthalmic pathology.

“I did a vitreoretinal fellowship first under Dr. Badrinath, our chairman at that time, and he stimulated me to take up ophthalmic pathology and uveitis,” Dr. Biswas told Ocular Surgery News in a telephone interview.

International training

Jyotirmay Biswas

When Dr. Biswas decided to make that transition, he applied to study at the Doheny Eye Institute in the United States, where he completed a fellowship in ophthalmic pathology under Dr. Narsing Rao.

Upon returning to India, “I brought the new concepts and learning that combined ophthalmic pathology and pathologic studies and immunologic studies in uveitis and brought new insight,” he said.

This fellowship also exposed Dr. Biswas to AIDS patients, a group of patients that, at the time, was overlooked in India.

“I took interest in the AIDS patients, and with the support of Sankara Nethralaya, where we have initially treated the AIDS patients for free, we saw a large number of patients, and we were the first in the country to report a series of a hundred patients with AIDS with ocular lesions,” he said. “Earlier, ophthalmologists were scared to see the AIDS patients.”

Since his early research began, Dr. Biswas has published more than 20 articles in peer-reviewed journals and written a book on ocular lesions in AIDS patients.

Ocular lesions in AIDS patients

Dr. Biswas said physicians and AIDS patients were unaware of many ocular implications that could occur. This lack of awareness, combined with the fear of ophthalmologists and the low socioeconomic status of many AIDS patients, allowed many ocular lesions to go untreated.

“One of the important problems is that they are from low socioeconomic status,” he said. “The treatment for cytomegalovirus retinitis is challenging because of the high cost of intravenous ganciclovir therapy.”

To combat this, Dr. Biswas said intravitreal injections are given to minimize the cost.

“Intravitreally, the cost is less. The injection doesn’t take on the systemic infection, but for ocular conditions, it has worked well,” he said.

Children with AIDS also pose a unique problem, Dr. Biswas said, because they tend to suffer from more lesions but cannot communicate their symptoms at such a young age.

“The ocular lesions are quite more in the children than in the adults and in uveitis patients also,” Dr. Biswas said. “The children cannot complain of vision loss, so they come at an advanced stage of the disease when they can complain.”

He said physicians try to work closely with parents and ask them to come for frequent visits and periodic checkups to minimize the ocular damage to children.

The latest combination therapy of highly active antiretroviral therapy, or HAART, has made progress for AIDS patients, especially in the ocular realm, Dr. Biswas said.

“The ocular lesions have reduced quite a bit,” he said.

Dr. Biswas said his work with AIDS patients and his efforts to raise awareness among his peers and the general public are among his greatest accomplishments.

“I am proud of working on the AIDS patients,” he said. “I have written a book of ocular lesions in AIDS, and I have made the people aware. Awareness of the people has now increased, and people have now started seeing AIDS patients in the country with ocular lesions. … I’m quite happy about that.”

Recruiting uveitis specialists

Within uveitis, Dr. Biswas said the biggest challenge is a lack of numbers in the specialty.

“One of the important problems is that there are not many uveitis specialists in the country, so that patients come from very far places to our center,” he said. “We feel that in a large country of over 1 million people, we need more uveitis specialists so that more people who cannot afford to visit specialized centers … can be followed up.”

One way that Sankara Nethralaya is working to combat this problem is through its training fellowship program in uveitis and retina.

“We have a training fellowship program in uveitis, and also we train our vitreoretinal fellows, those who are doing vitreoretinal diseases. They are posted in the uveitis department to have 1-month training in the uveitis,” Dr. Biswas said.

“Now there are six people in our uveitis department. We see more than 1,000 patients per year, and it is probably one of the largest uveitis centers in the world,” Dr. Biswas said. “I am very proud [of the] 15 people I have trained. I am proud of them and that they are taking care of uveitis across the country.”

In addition, his group has published an atlas on uveitis with photos of various aspects of uveitic patients, so ophthalmologists might read it and identify patients with uveitis.

“This is the first of its kind in India,” he said.

Dr. Biswas was the first Asian member of the International Uveitis Study Group and a past president of the Uveitis Society of India.

“The current [Uveitis Society of India] has around 50 members. We have an annual meeting and that creates awareness among ophthalmologists about uveitis,” he said. “Many other people take part [in the annual meeting]. It is open to all.”

New diagnostic tools

Uveitis due to tuberculosis is another difficult problem facing Indian ophthalmologists, Dr. Biswas said.

“We see a significant percentage of the people suffering from uveitis, from tuberculosis. It’s not that common, but it’s a significant percentage of the patients,” he said.

Unfortunately, uveitis due to tuberculosis is often hard to diagnose. Dr. Biswas said the newest form of diagnostic testing now relies on a polymerase chain reaction of intraocular fluids, which costs about 1,500 Rs.

He is using a test, called the Quanti-FERON-TB Gold test, to identify tubercular uveitis from the blood sample.

“We are going to the AIDS care centers, and those patients who cannot come and are bedridden, we are seeing them in the hospital … and seeing ocular lesions in terminally ill patients with AIDS,” he said.

Eales’ disease

Another disease seen more commonly in India yet without the proper awareness among Indian ophthalmologists is Eales’ disease, Dr. Biswas said.

“It is retinal vasculitis in young adults leading to vitreous hemorrhage subsequently,” he said. “In this subcontinent, Eales’ disease is more common; one in 135 ophthalmic patients in a tertiary care ophthalmic hospital, you’ll see Eales’ disease.”

Still, Dr. Biswas said, the etiology of the disease is a mystery. Recently, he played a key part in solving this mystery by conducting a study in which, through polymerase chain reaction, the gene of Mycobacterium tuberculosis was found to be significantly associated with Eales’ disease.

To raise awareness about Eales’ disease and its available treatments, Dr. Biswas has worked with colleagues to publish an article in the Indian Journal of Ophthalmology and has also written a handout for patients and ophthalmologists.

For more information:

Jyotirmay Biswas, MS, FNAMS, can be reached at Sankara Nethralaya,18, College Road, Nungambakkam, Chennai - 600 006, Tamil Nadu; +91-044-28271302; e-mail: drjb_uveitis@yahoo.co.in.

References:

Das T, Biswas J, et al. Eales’ disease. Indian J Ophthalmol. 1994;42:3-18.

Madhavan HN, Therese KL, et al. Polymerase chain reaction for detection of Mycobacterium tuberculosis in epiretinal membrane in Eales’ disease. Invest Ophthalmol Vis Sci. 2000;41:822-825.

Katrina Altersitz is the Managing Editor of Ocular Surgery News Latin America and India Editions.