Macrophage colony stimulating factor and IL-34 are associated with clinical vestibular schwannoma progression. Investigating the biology behind vestibular schwannoma progression helps understanding tumor growth. Inflammation is important in the microenvironment of neoplasms. Macrophages are major players in the intratumoral infiltrate. These tumor-associated macrophages are known to stimulate angiogenesis and cell growth. M-CSF and IL-34 are cytokines that can regulate tumor-infiltrating macrophages. They are expressed by tumors and form potential targets for therapy. The goal of this study was to investigate these cytokines in vestibular schwannomas and to see if their expression is related to angiogenesis, macrophage numbers, cystic degeneration, and volumetric tumor progression. Immunohistochemical expression of M-CSF and IL-34 was analyzed in ten fast-growing vestibular schwannomas and in ten slow-growing vestibular schwannomas. Expression M-CSF and IL-34 were compared between fast- versus slow-growing and cystic versus non-cystic tumors. Data on macrophage numbers and microvessel density, known from earlier research, was also included. All tumors expressed M-CSF and its expression was higher in fast-growing tumors (p = 0.003) and in cystic tumors (p = 0.035). CD163 expression was higher in tumors with strong M-CSF expression (p = 0.003). All tumors expressed IL-34 as well, but no significant differences were found in relation to clinicopathological characteristics. This study demonstrated the expression of M-CSF and IL-34 in vestibular schwannomas. The results suggest that M-CSF is related to macrophage activity and tumor progression, making it a potential target for therapy. If a similar assumption can be made for IL-34 remains unclear.
Publication date: Available online 21 December 2018
Source: American Journal of Otolaryngology
Author(s): William M. Mendenhall, Primoz Strojan, Jonathan J. Beitler, Johannes A. Langendijk, Carlos Suarez, Anne W. Lee, Alessandra Rinaldo, Juan P. Rodrigo, Robert Smee, Avraham Eisbruch, Louis B. Harrison, June Corry, Alfio Ferlito
Abstract
A wide variety of tumors, both benign and malignant, occur in the parapharyngeal space. Depending on histology and extent, treatment may include surgery and/or radiotherapy (RT). Herein we discuss the role of RT in the management of some of the more commonly encountered neoplasms, including salivary gland tumors, paragangliomas, schwannomas, and soft-tissue sarcomas.
Publication date: Available online 21 December 2018
Source: American Journal of Otolaryngology
Author(s): Rakesh Katna, Nikhil Kalyani, Akshay Deshpande, Mumbai Oncology Group – Head and Neck
Abstract
Aim
Radiation induced hypothyroidism (RIHT) is one of the commonest late side effects of radiation therapy and is seen in more than half of patients and affects quality of life significantly. We report our initial experience on feasibility of free microvascular transfer of thyroid gland out of radiation field to prevent development of RIHT.
Material and methods
A prospective pilot study was undertaken during August 2017 to May 2018. Six Patients with stage III/IV patients of oral cavity cancers who required wide excision/composite resections with microvascular free flap (ALT) reconstruction and adjuvant radiation therapy were enrolled. A written informed consent was obtained from all patients prior to the procedure.
Results
The mean age of cohort was 51 years with tongue most common site of primary cancer. The free transfer of thyroid gland to anterolateral thigh was done using microvascular technique. The mean additional time for procedure was 51 min. All patients had successful transfer with no associated immediate complications. Patients were followed up with Tc99 scan, USG Doppler and biochemical assay at routine intervals in peri and postoperative period to assess the anatomical and physiological function of the transferred gland. At median follow up of 8 months, 5 patients were euthyroid and remaining one had biochemical hypothyroidism. All patients had functional thyroid gland in anetrolateral thigh. Five patient were alive, one patient died due to disease.
Conclusion
This is a small and early feasibility study for free thyroid gland transfer and validates the previously published data. The selected group of patients who have high chances of developing RIHT may benefit from this strategy. Further validation of the technique may be explored in a larger cohort.
1.The BiZact tonsillectomy device, produced by Medtronic (Minneapolis, MN, USA), was approved for market use in Australia by the Therapeutics Good Administration (TGA) in 2016 and is a new device for tonsillectomy
2.Results from this pilot study of 186 patients demonstrate a post‐operative hemorrhage rate of 4.3% similar to rates described by other studies.
3.BiZact tonsillectomy allows for a shortened operative time in the hands of both experienced and training surgeons with a median time of 5.1 minutes (range 1.5 – 26.5 minutes).
4.BiZact tonsillectomy is associated with reduced intraoperative blood loss with less than 1mL of blood loss observed in 71 (38.2%) cases and between 1‐10mL loss observed in 81 (43.5%) cases in this report.
5.This study demonstrates safety and feasibility of this device as a pilot study towards undertaking a prospective randomized trial comparing it to other tonsillectomy techniques.
This article is protected by copyright. All rights reserved.
Publication date: Available online 21 December 2018
Source: International Journal of Pediatric Otorhinolaryngology
Author(s): James Johnston, Michael Hoggard, Kristi Biswas, Carmen Astudillo‐García, Fiona J. Radcliff, Murali Mahadevan, Richard G. Douglas
Abstract
Introduction
Adenotonsillar and middle ear diseases result in some of the most frequently performed operations in the pediatric population worldwide. The pathogen reservoir hypothesis (PRH) suggests that the adenoids act as a reservoir of bacteria which play a potential pathogenic role in otitis media. Evidence supporting this hypothesis is limited. This study sought to comprehensively determine and compare associations between the adenotonsillar and middle ear bacterial microbiota within individual patients via next-generation sequencing and microbial network analyses.
Methods
Bacterial 16S rRNA gene-targeted amplicon sequencing was used to determine the bacterial composition of ten pediatric patients undergoing adenotonsillectomy and ventilation tube insertion for otitis media with effusion. At the time of surgery, swabs were taken from the adenoid surface, tonsil crypts and middle ear clefts (through the myringotomy incision).
Results
The most abundant sequences within the bacterial community at genus level across all anatomical sites were Fusobacterium, Haemophilus, Neisseria, and Porphyromonas. There was an observable difference in the relative abundance of bacterial communities, with a higher proportion of Haemophilus and Moraxella in the adenoid when compared with the middle ear. Furthermore, only one module (consisting of 4 bacterial OTUs) from one patient was identified through microbial network analyses to be significantly associated between middle ear and adenoid. In addition, microbial network analysis revealed that the adenoid and tonsil microbiota share greater similarity than do the adenoid and middle ear.
Conclusion
The results of this study suggest that the adenoid microenvironment does not correlate to the middle ear microenvironment. A future study at the species level, and over time, is required to further investigate whether the differing relationship between the microbiota of the adenoid and middle ear rejects the pathogen reservoir hypothesis.
Author(s): Wendy A. Teft, Eric Winquist, Anthony C. Nichols, Sara Kuruvilla, Suzanne Richter, Christina Parker, Peggy Francis, Maureen Trinnear, Jelena Lukovic, Nedal Bukhari, Yun-Hee Choi, Stephen Welch, David A. Palma, John Yoo, Richard B. Kim
Abstract
Objectives
Cisplatin-induced ototoxicity is a common permanent consequence of curative chemoradiation for locally advanced head and neck squamous cell carcinoma (HNSCC). Predictors of ototoxicity in HNSCC were examined.
Materials and methods
In this prospective, observational cohort study, 206 adult HNSCC patients underwent audiometric testing at baseline, during and after treatment with cisplatin-based chemoradiation. Ototoxicity was defined as ≥grade 2 audiometric change from baseline (CTCAE v4.02). Relationships between clinical and pharmacogenetic (TPMT, COMT, ACYP2, CTR1, OCT2, MATE1, ABCC2, ABCC3, and ABCG2) covariates and ototoxicity, progression-free (PFS) and overall survival (OS) were assessed by Cox regression.
Results
Weekly cisplatin resulted in lower ototoxicity risk while PFS and OS were similar compared to high dose cisplatin (P = 0.00035; HR = 0.18; 95% CI, 0.07–0.46). COMT (rs9332377) carriers had higher ototoxicity risk (P = 0.00556; HR = 1.72; 95% CI, 1.17–2.52) while MATE1 (rs2289669) A/A carriers were protected from ototoxicity (P = 0.01062; HR = 0.46; 95% CI, 0.26–0.84). Absence of the protective MATE1 allele among those who carry the risk allele in COMT predicted increased ototoxicity risk, (P = 0.00414; HR = 3.22; 95% CI, 1.45–7.17 and P = 0.00022; HR = 4.89; 95% CI, 2.11–11.36). Survival outcomes did not differ between carriers of protective or risk alleles.
Conclusions
Weekly cisplatin dosing, COMT and MATE1 are predictors of ototoxicity without affecting treatment efficacy. COMT and MATE1 genotyping and weekly dosing may be a potential strategy for mitigating cisplatin-induced ototoxicity in HNSCC.
Author(s): R.B. Ross, A. Juloori, V. Varra, M.C. Ward, S. Campbell, N.M. Woody, E. Murray, P. Xia, J.F. Greskovich, S.A. Koyfman, N.P. Joshi
Abstract
Introduction
The conformality of modern intensity modulated radiation therapy (IMRT) allows avoidance of the submandibular glands (SMG) in select patients, potentially improving late xerostomia. This study explores the safety and efficacy of this approach in select oropharyngeal carcinoma (OPC) patients.
Methods
Patients with T1-2N+ human papillomavirus (HPV)-associated OPC treated with definitive IMRT at one institution from 2009 to 2014 were identified. Patients were divided into 3 groups: bilateral level IB targeted (A, n = 16), a single level IB targeted (B, n = 61), and bilateral IB spared (C, n = 9). Outcomes were reviewed to identify the rate of level IB regional recurrence. Odds ratios were calculated for xerostomia between groups.
Results
Level Ib was targeted in 93 instances (54.1%) and avoided in 79 instances (45.9%). Mean SMG doses were significantly lower when level IB was spared compared to when targeted (37.5 Gy vs 67.5 Gy; P < 0.0001). Median doses to oral cavity decreased with increasing level Ib sparing (40.7 Gy [A] vs 35.4 Gy [B] vs 30.7 [C]; P = 0.002). The rate of late grade ≥2 xerostomia was significantly lower in patients with bilateral 1b sparing (53% in A vs 0% in C; P = 0.007). Sparing 1b unilaterally resulted in a non-significant decrease in late grade ≥2 xerostomia (P = 0.181). No regional failures were identified in levels IB (median follow up = 59.3 months).
Conclusion
Sparing level IB is safe in T1-2N+ HPV+ OPC. Avoiding level Ib translates into significantly lower SMG and oral cavity doses. Larger studies are needed to validate these findings and the impact of this technique.
This systematic review and meta‐analysis aims to evaluate the effectiveness of palatine tonsillectomy in patients with cervical metastasis from squamous cell carcinoma of unknown primary (SCCUP) origin.
Methods
A systematic review including studies that encompassed palatine tonsillectomy in the SSCUP diagnostic evaluation was conducted. A single arm meta‐analysis was then made to obtain the overall identification rate of tonsillectomy.
Results
Fourteen studies were included, comprising 673 patients who underwent 416 palatine tonsillectomies, 338 preformed during examination under anesthesia (EUA) and 78 managed with transoral robotic surgery (TORS). A total of 140 occult tonsillar malignancies were identified; of these, 124 (89%) were ipsilateral, 2 (1%) contralateral, and 14 (10%) synchronous bilateral. Meta‐analysis of 11 studies showed an overall detection rate of tonsillectomy of 0.34 (99% confidence interval 0.23‐0.46).
Conclusion
Palatine tonsillectomy is a valuable diagnostic tool in the management of patients with head and neck SCCUP. Bilaterality of tonsillectomy should be taken into consideration.
Assess construct validity of a low‐cost medium‐fidelity silicone injection molded model task trainer for endoscopic sinus surgery (ESS) training.
Methods
Fellowship‐trained rhinologists, otolaryngology attendings, and otolaryngology residents at various levels of training performed sinus endoscopy and seven procedures on the model. Construct validity was evaluated by comparing novice to various levels of experienced performance using a validated checklist.
Results
Thirty‐two subjects participated in this study. Otolaryngology attendings and postgraduate year (PGY) 3 to 5 otolaryngology residents significantly outperformed PGY 1 to 2 otolaryngology residents on most tasks in the task‐specific checklist.
Conclusions
This study demonstrated the construct validity of the low‐cost medium‐fidelity ESS model.
Spin, the misrepresentation and distortion of research findings, has been shown to affect clinical decision making. Spin has been found in randomized controlled trials (RCTs) published in various fields of medicine, but no study has tested for the presence of spin in otolaryngology RCTs. The purpose of this study is to evaluate the abstracts of RCTs found in the otolaryngology literature for spin.
Methods
In this cross‐sectional analysis, we analyzed the abstracts of RCTs for spin using a pilot‐tested form. Double data extraction was performed by two blinded authors, and discrepancies were resolved using mutual discussion.
Results
Out of the 534 PubMed citations retrieved by our search string, 162 parallel‐group RCTs with clearly defined primary and secondary endpoints were identified. Further analysis identified 47 trials with nonsignificant primary outcomes, which were then evaluated for spin. Spin was identified in 33 of the 47 (70%) abstracts. Spin was found in the results sections of 25 (53%) of the included abstracts and was found in the conclusion section of 27 (57%) of the abstracts. Spin was not present in the titles of any of the included studies.
Conclusion
Spin was common in our sample of otolaryngology RCTs. Spin may potentially create false impressions about the true validity of a drug or intervention. Further research needs to test for potential clinical implications of spin in the otolaryngology literature.
To compare long‐term oncologic outcomes and adjuvant therapies for patients treated with transoral robotic surgery (TORS), nonrobotic surgery, or transoral laser microsurgery (TLM).
Study Design
A retrospective analysis of the National Cancer Database (2010–2014).
Methods
Patients with clinical tumor (T)1 and T2 oropharyngeal squamous cell carcinomas (OPSCC) were classified into those receiving TORS versus nonrobotic surgery versus TLM. Univariate and multivariate survival analyses were conducted with chi‐square tests; Kaplan‐Meier log‐rank test; and Cox multivariate, logistic regression, and multinomial regression modeling.
Results
We identified 2,224 OPSCC TORS patients; 6,697 nonrobotic surgery patients; and 333 TLM patients. The majority of patients were white males with a mean age of approximately 59 years. No significant difference was noted between the cohorts in tumor stage; however, TORS patients were more likely to have nodal (N)1 to N3 disease than nonrobotic surgery and TLM patients, respectively (69.8% vs. 62.0% vs. 59.7%, P < 0.001).
TORS was associated with a lower likelihood of positive margins when compared to nonrobotic surgery, although not TLM (nonrobotic surgery: hazard ratio [HR] 1.51, P < 0.001, TLM: HR 1.13, P = 0.582). TORS was associated with lower likelihood of postsurgical chemoradiotherapy (TLM: HR 2.07, P < 0.001, nonrobotic surgery: 1.65, P < 0.001) but not adjuvant radiotherapy alone (TLM: HR 1.06, P = 0.569, nonrobotic surgery: 0.96, P = 0.655). On multivariate Cox analysis of overall survival, the use of TORS was not associated with increased survival (TLM: HR 1.31, P = 0.233, nonrobotic surgery: HR 1.12, P < 0.303).
Conclusion
The advantages of TORS for early‐stage OPSCC may be a lower likelihood of postsurgical positive margins and subsequent need for adjuvant chemoradiotherapy.
Intravestibular schwannomas are a rare cause of unilateral sensorineural hearing loss. Management of these tumors involves translabyrinthine resection, for which complete visualization around the angles of the vestibule may be limited under an operating microscope. We present the first reported case of an endoscope‐assisted resection of an intravestibular schwannoma, along with the operative video recording. Using additional information gained from endoscopic examination of the tumor and its resection site, we also propose a mechanism by which this patient's intravestibular schwannoma caused hearing loss. Use of the endoscope in resection of intravestibular schwannomas may have advantages over the traditional operating microscope in improving visualization of the narrow and angled vestibule, confirming the integrity of surrounding structures, and ensuring complete tumor removal. Laryngoscope, 2018
The optimal surgical treatment to improve sleep apnea in children with small tonsils is not known. Drug‐induced sleep endoscopy (DISE) may be useful in selecting effective surgical procedures for this patient population. This study compared polysomnography (PSG) measures before and after DISE‐directed surgery in children with small tonsils. We hypothesize that DISE‐directed surgery improves PSG measures in children with small tonsils. We also aimed to identify the most common surgery performed in this population.
Study Design
Retrospective chart review.
Methods
A retrospective review was performed of subjects who underwent DISE at a single pediatric tertiary care center over a 6‐year period. Inclusion criteria were 1+ tonsils and PSG performed before and after DISE‐directed surgery. Exclusion criteria were previous tonsillectomy and tonsils score 2+ or greater. Pre‐ and postoperative PSG parameters were compared using paired t tests.
Results
Average age was 7 ± 4 years old at the time of surgery. The most common DISE‐directed intervention was supraglottoplasty (n = 23). DISE‐directed surgery significantly improved mean apnea‐hypopnea index (AHI) from 14.4 to 8.0 (P = .02). Although improvements were seen in mean obstructive AHI (12.5 to 5.5), O2 nadir (87.0 to 88.3), and ODI (10.6 to 5.8), these measures did not reach statistical significance.
Conclusions
DISE‐directed surgery significantly improves AHI in children with small tonsils. The most common intervention performed on these children was supraglottoplasty. Interestingly, adenotonsillectomy was rarely performed in this cohort. Additionally, supraglottic collapse, prompting supraglottoplasty, is difficult to accurately assess in an awake child, supporting use of a DISE‐directed approach in this patient population.
To review available information regarding in‐office procedures for benign vocal fold lesions (BVFL).
Methods
PubMed term search on office/awake laryngeal procedures for any of the following specific lesions: Reinke's edema (RE), polyps, nodules, varices, vocal process granuloma, and vocal fold (VF) scar.
Results
In‐office ablative and nonablative laser procedures have been described for BVFL, including RE, polyps, varices, and granuloma. Fiber‐based lasers used include potassium titanyl phosphate, pulsed dye laser, and more recently CO2. In‐office intralesional steroid injection (ISI) for BVFL targets the inflammatory process involved with the lesion and may induce regression of polyps, nodules, RE, and granuloma. Botulinum toxin‐induced "voice rest" has been described as adjunctive treatment for refractory VF nodules or vocal process granuloma. Most in‐office techniques for treating BVFL rely on induction of lesion regression rather than complete lesion removal, as in conventional operative microsurgery. When treating VF scarring, in‐office procedures aim to alter the wound‐healing process; ISI targets the inflammatory phase and angiolytic lasers target the proliferative phase.
Conclusion
In‐office procedures for BVFL apply new technology that can potentially lower risk and cost. Although numerous case series have shown the potential of these procedures, data that thoroughly compares outcomes with those of microlaryngoscopic techniques is needed. Laryngoscope, 2018
To utilize the Surveillance, Epidemiology, and End Results (SEER) database to elucidate differences in predictors of survival in oral tongue squamous cell carcinoma (OTSCC) as stratified by age and sex.
The SEER registry was utilized to calculate survival trends for patients with OTSCC between 1973 and 2012. Patient data were then stratified by age (≤40 years vs. >40 years) and sex, then analyzed with respect to race, stage, grade, and treatment modalities. Overall survival (OS) and disease‐specific survival (DSS) were calculated and compared.
Results
There were 16,423 cases of OTSCC identified, with 526 and 706 young female and male patients, respectively. Young female patients had improved OS and DSS as compared to young male patients (75% vs. 67% at 5 years), which is better than older patients (P < .001). Younger patients were more likely to receive surgery (P < .001) and combination surgery and radiation (P < .001) as compared to older patients. On multivariate analysis, tumor stage was uniformly associated with worse OS and DSS (P < .05), with surgery predicting improved OS and DSS in all groups except young females (P < .05). Higher tumor grade predicted worse OS and DSS in older patients, but not younger patients (P < .05).
Conclusions
OTSCC appears to present with relatively heterogeneous characteristics across different age groups and sexes. Despite the rising incidence of OTSCC in young individuals, our study demonstrates that young patients have improved survival rates compared to older patients.
The time interval at which Nasal Obstruction Symptom Evaluation (NOSE) scores stabilize after functional septorhinoplasty has not been determined. Our goal was to characterize longitudinal trends of patient‐reported outcomes of nasal obstruction using the NOSE survey instrument following functional septorhinoplasty.
Study Design
Prospective longitudinal cohort study.
Methods
Adult patients (≥18 years) with nasal obstruction who underwent functional septorhinoplasty by three different surgeons at a single academic, tertiary referral center were identified. NOSE scores were obtained preoperatively and prospectively during three postoperative intervals defined as early (1–3 months), middle (4–6 months), and late (≥10 months.) Longitudinal analysis included repeated measures analysis of variance and adjustments for multiple comparisons.
Results
A total of 49 patients met inclusion criteria. For the total cohort, mean NOSE scores significantly improved between preoperative and early postoperative evaluations (71.4, standard deviation [SD] ± 17.0 vs. 24.2, SD ± 19.5; P < .001) but did not significantly change between early and middle (20.6, SD ± 19.1; P = .543) or middle and late (23.1, SD ± 24.9; P > .999) time intervals.
Conclusions
Patients with nasal obstruction who undergo functional septorhinoplasty can be expected to have significant improvement in self ‐reported nasal obstruction as early as 1 to 3 months postoperatively with a continued, durable, long‐standing benefit lasting at least 10 months after surgery. Future studies can consider the 3‐month time frame as a proxy for 1 year outcomes to help reduce survey burden.
Types of organisms and in-vitro susceptibility of bacterial isolates from patients with microbial keratitis: A trend analysis of 8 years p. 49 Sujata Das, Ruchipriya Samantaray, Aparajita Mallick, Srikant K Sahu, Savitri Sharma DOI:10.4103/ijo.IJO_500_18 Purpose: To report the distribution and trends of types of organisms and antibiotic susceptibility of the bacterial isolates obtained from patients with microbial keratitis. Methods: Microbiology records of culture-positive microbial keratitis that underwent a diagnostic corneal scraping and cultures were reviewed. Fungal, bacterial, and parasitic culture results and antibiotic susceptibility profile of bacteria were analyzed and comparisons were made between two halves of the study period (2007–2010 vs. 2011–2014). Results: A total of 3981 corneal scrapings were processed during the 8-year study period. Pathogen was recovered in culture in 1914 (48.1%) samples. Fungi, bacteria, and parasites constituted 38.7%, 60%, and 1.3% of the total isolates, respectively. The common fungal isolates were Aspergillus spp. (224/868, 25.8%) and Fusarium spp. (200/868, 23.0%), while common Gram-positive bacteria were Streptococcus pneumoniae (217/1125, 19.3%) and Staphylococcus aureus (185/1125, 16.4%), and common Gram-negative bacteria was Pseudomonas spp. (99/219, 45.2%). There was no significant difference in proportion of bacterial (P = 0.225) and fungal (P = 0.421) keratitis between the first half and second half of the study period. There was a significant increase in proportion of Gram-positive isolates (P = 0.015) [353/758 (46.6%) vs. 772/1482 (52.1%)] and decrease in proportion of Gram-negative organisms (P = 0.044) [88/758 (11.6%) vs. 131/1482 (8.8%)] in the recent years. In-vitro antibiotic susceptibility testing showed decrease in susceptibility to moxifloxacin for Pseudomonas spp. (P = 0.016) in recent years. Conclusion: Prevalence of fungal and bacterial keratitis has remained unchanged over the years. This study shows a significant increase in Gram-positive bacterial infection and decrease in Gram-negative bacterial infection of the cornea in the recent years. http://www.ijo.in/currentissue.asp?sabs=y
Dr. Mohit Dogra Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh - 160 012 India
DOI: 10.4103/ijo.IJO_881_18
A 63-year-old male presented with sudden painless vision loss in his right eye of 2 day duration. He had no perception of light, Relative afferent pupillary defect (RAPD), pale disc edema along with an inferotemporal branch retinal artery occlusion [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d. Clinical diagnosis of arteritic anterior ischemic optic neuropathy was made, and systemic examination revealed repeated bouts of fever and right sided scalp tenderness.[1],[2] Right side temporal artery biopsy revealed giant cell arteritis. The patient was treated with intravenous pulse steroids and immunosuppressive therapy.[2],[3] In cases of severe vision loss with pale disc edema, giant cell arteritis should be kept in mind.[4],[5]
Figure 1: (a) showing pale disc edema (blue arrows) with an inferotemporal branch retinal artery occlusion, (b and c) showing "wedge shaped" equatorial choroidal infarcts on fluorescein angiogram, and (d) right side temporal artery biopsy at 200× magnification showing intimal proliferation with breaks in the internal elastic lamina (yellow arrows) with extravasation of red blood cells in the tunica media (black arrow) with minimal inflammatory cells, suggestive of vasculitis
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Corneal cross-linking (CXL), introduced by Wollensak et al. in 2003, is a minimally invasive procedure to halt the progression of keratoconus. Conventional CXL is recommended in eyes with corneal thickness of at least 400 microns after de-epithelialization to prevent endothelial toxicity. However, most of the keratoconic corneas requiring CXL may not fulfill this preoperative inclusion criterion. Moderate-to-advanced cases are often found to have a pachymetry less than this threshold. There are various modifications to the conventional method to circumvent this issue of CXL thin corneas while avoiding the possible complications. This review is an update on the modifications of conventional CXL for thin corneas.
Duane retraction (or co-contraction) syndrome is a congenital restrictive strabismus which can occur either as an isolated entity or in conjunction with other congenital anomalies and is now listed as a congenital cranial dysinnervation disorder. It is characterized by co-contraction of horizontal recti on attempted adduction causing globe retraction along with variable amounts of upshoots or downshoots. It may have limited abduction or adduction or both and present as esotropic, exotropic, or orthotropic Duane. The diagnosis of this disease is usually clinical. However, recent research has provided a greater insight into the genetic basis of this disease paving a way for a greater role of genetics in the diagnosis and management. This disease can have a varied presentation and hence the treatment plan should be tailor-made for every patient. The indications for surgery are abnormal head posture, deviations in the primary position, retraction and narrowing of palpebral aperture and up- or downshoots during adduction, and sometimes also to improve abduction. The arrival of newer surgical techniques of periosteal fixation (PF) of lateral rectus (LR), partial vertical rectus transposition, or superior or inferior rectus transposition in addition to LR recession with Y-split has vastly improved the management outcomes, providing not only primary position orthophoria but also increased binocular visual fields as well.
Visual electrodiagnostics and eye movement recording are important additional clinical tools in evaluation, diagnosing and management of ophthalmic and neurological disorders. Due to their objectiveness and non-invasiveness they can play an important role in pediatric ophthalmology. The WSPOS (World Society of Pediatric Ophthalmology and Strabismus) consensus statement gives insight into basic principles and highlights the clinical application of both visual electrodiagnostic tests and eye movement recording.
Purpose: Limbal ischemia is an important prognostic factor in the management of ocular burns. In this study, we evaluated the reliability of clinically assessing limbal ischemia among ophthalmic professionals. Methods: This study included 111 ophthalmic professionals who were shown 12 diffuse illumination color slit-lamp photographs of eyes with recent chemical injuries. Respondents were asked whether the photos were assessable and if yes, then to indicate the presence, location, and grade of limbal ischemia in each case. The responses were collected using a standard data collection sheet and the inter-observer agreement was calculated. Results: All participants responded to every question. Of the 1,332 responses, images were deemed assessable in 1,222 (91.7%) instances. The overall agreement (Fleiss' kappa) for the presence of limbal ischemia and severity of limbal ischemia was 0.106 and 0.139, respectively (P < 0.012). Among the four groups of observers, practicing cornea specialists displayed significantly (P < 0.003) higher kappa values (0.201–0.203) when compared to residents (0.131–0.185), fellows (0.086–0.127), and optometrists (0.077–0.102). All indicated a poor level of inter-rater consistency. Conclusion: The results indicate that clinical assessment of limbal ischemia is highly subjective and there is lack of reliability even among cornea specialists who regularly manage patients with ocular burns. A non-invasive, standardized, objective, accurate, and reliable modality for ocular surface angiography is desperately needed for proper assessment and prognostication of ocular burns.
Purpose: To determine the levels of dopamine in tear fluid and demonstrate the use of tear fluid as a non-invasive source for dopamine measurements in humans. Methods: The study cohort included 30 clinically healthy individuals without any pre-existing ocular or systemic conditions. Matched tear fluid (using Schirmer's strips and capillary tubes) and plasma were collected from the subjects. Dopamine levels were evaluated using direct competitive chemiluminescent enzyme-linked immunosorbent assay (ELISA), dopamine kit (Cloud Clone Corp, TX, USA). Results: Significantly higher dopamine levels were found in the tear fluid compared to plasma in the study subjects. The level of dopamine was 97.2 ± 11.80 pg/ml (mean ± SEM), 279 ± 14.8 pg/ml (mean ± SEM), and 470.4 ± 37.64 pg/ml (mean ± SEM) in the plasma and in the tears collected using Schirmer's strips and capillary tubes, respectively. Conclusion: Dopamine was detectable in all the tear fluid samples tested and was also found to be at a higher concentration than in plasma samples. Tear fluid can be used as a non-invasive sample source to monitor dopamine levels.
EDITORIAL
Indian Journal of Ophthalmology – On the right path
Rashmi Deshmukh, Farhad Hafezi, George D Kymionis, Sabine Kling, Rupal Shah, Prema Padmanabhan, Mahipal S Sachdev DOI:10.4103/ijo.IJO_1403_18
Corneal cross-linking (CXL), introduced by Wollensak et al. in 2003, is a minimally invasive procedure to halt the progression of keratoconus. Conventional CXL is recommended in eyes with corneal thickness of at least 400 microns after de-epithelialization to prevent endothelial toxicity. However, most of the keratoconic corneas requiring CXL may not fulfill this preoperative inclusion criterion. Moderate-to-advanced cases are often found to have a pachymetry less than this threshold. There are various modifications to the conventional method to circumvent this issue of CXL thin corneas while avoiding the possible complications. This review is an update on the modifications of conventional CXL for thin corneas.
Duane retraction (or co-contraction) syndrome is a congenital restrictive strabismus which can occur either as an isolated entity or in conjunction with other congenital anomalies and is now listed as a congenital cranial dysinnervation disorder. It is characterized by co-contraction of horizontal recti on attempted adduction causing globe retraction along with variable amounts of upshoots or downshoots. It may have limited abduction or adduction or both and present as esotropic, exotropic, or orthotropic Duane. The diagnosis of this disease is usually clinical. However, recent research has provided a greater insight into the genetic basis of this disease paving a way for a greater role of genetics in the diagnosis and management. This disease can have a varied presentation and hence the treatment plan should be tailor-made for every patient. The indications for surgery are abnormal head posture, deviations in the primary position, retraction and narrowing of palpebral aperture and up- or downshoots during adduction, and sometimes also to improve abduction. The arrival of newer surgical techniques of periosteal fixation (PF) of lateral rectus (LR), partial vertical rectus transposition, or superior or inferior rectus transposition in addition to LR recession with Y-split has vastly improved the management outcomes, providing not only primary position orthophoria but also increased binocular visual fields as well.
Visual electrodiagnostics and eye movement recording - World Society of Pediatric Ophthalmology and Strabismus (WSPOS) consensus statement
p. 23
Manca Tekavcic Pompe, Alki Liasis, Richard Hertle DOI:10.4103/ijo.IJO_1103_18
Visual electrodiagnostics and eye movement recording are important additional clinical tools in evaluation, diagnosing and management of ophthalmic and neurological disorders. Due to their objectiveness and non-invasiveness they can play an important role in pediatric ophthalmology. The WSPOS (World Society of Pediatric Ophthalmology and Strabismus) consensus statement gives insight into basic principles and highlights the clinical application of both visual electrodiagnostic tests and eye movement recording.
Limbal ischemia: Reliability of clinical assessment and implications in the management of ocular burns
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Ka Wai Kam, Chaitali N Patel, Neda Nikpoor, Marco Yu, Sayan Basu DOI:10.4103/ijo.IJO_945_18
Purpose: Limbal ischemia is an important prognostic factor in the management of ocular burns. In this study, we evaluated the reliability of clinically assessing limbal ischemia among ophthalmic professionals. Methods: This study included 111 ophthalmic professionals who were shown 12 diffuse illumination color slit-lamp photographs of eyes with recent chemical injuries. Respondents were asked whether the photos were assessable and if yes, then to indicate the presence, location, and grade of limbal ischemia in each case. The responses were collected using a standard data collection sheet and the inter-observer agreement was calculated. Results: All participants responded to every question. Of the 1,332 responses, images were deemed assessable in 1,222 (91.7%) instances. The overall agreement (Fleiss' kappa) for the presence of limbal ischemia and severity of limbal ischemia was 0.106 and 0.139, respectively (P < 0.012). Among the four groups of observers, practicing cornea specialists displayed significantly (P < 0.003) higher kappa values (0.201–0.203) when compared to residents (0.131–0.185), fellows (0.086–0.127), and optometrists (0.077–0.102). All indicated a poor level of inter-rater consistency. Conclusion: The results indicate that clinical assessment of limbal ischemia is highly subjective and there is lack of reliability even among cornea specialists who regularly manage patients with ocular burns. A non-invasive, standardized, objective, accurate, and reliable modality for ocular surface angiography is desperately needed for proper assessment and prognostication of ocular burns.
Purpose: To determine the levels of dopamine in tear fluid and demonstrate the use of tear fluid as a non-invasive source for dopamine measurements in humans. Methods: The study cohort included 30 clinically healthy individuals without any pre-existing ocular or systemic conditions. Matched tear fluid (using Schirmer's strips and capillary tubes) and plasma were collected from the subjects. Dopamine levels were evaluated using direct competitive chemiluminescent enzyme-linked immunosorbent assay (ELISA), dopamine kit (Cloud Clone Corp, TX, USA). Results: Significantly higher dopamine levels were found in the tear fluid compared to plasma in the study subjects. The level of dopamine was 97.2 ± 11.80 pg/ml (mean ± SEM), 279 ± 14.8 pg/ml (mean ± SEM), and 470.4 ± 37.64 pg/ml (mean ± SEM) in the plasma and in the tears collected using Schirmer's strips and capillary tubes, respectively. Conclusion: Dopamine was detectable in all the tear fluid samples tested and was also found to be at a higher concentration than in plasma samples. Tear fluid can be used as a non-invasive sample source to monitor dopamine levels.
Purpose: To study the demographic profile, clinical features, treatment outcome, and ocular morbidity of microbiologically proven Pythium keratitis in South India. Methods: A retrospective analysis of clinical records of microbiologically proven Pythium keratitis at a tertiary eye care referral center in South India from January 2016 to November 2017 was performed. Demographic details, predisposing risk factors, microbiological investigations, clinical course, and visual outcome were analyzed. Results: Seventy-one patients with microbiologically proven Pythium keratitis were identified. The mean age was 44(±18.2) years with an increase in male preponderance and 50% were farmers. Duration of delay at time of presentation to the hospital was a mean of 14(±7.2) days. The visual acuity at baseline ranged from 6/6 to no light perception (median 2.1 logMAR). A combination of 5% natamycin and 1% voriconazole was given to 42% patients, and natamycin alone was given to 39.4% patients. 1% itraconazole eye drops alone was initiated in 7 (10%) patients and 3 among this group responded. Therapeutic keratoplasty (TPK) was performed in 48 (67.6%) patients. None of the primary grafts remained clear after a period of 1 month. Twenty-six eyes (54.2%) had graft reinfection and all these eyes either developed anterior staphyloma (4) or were eviscerated (3) and 13 eyes became phthisical. The remaining 22 patients who had TPK resulted in failed graft. Among these, re-grafts were performed in 6 patients, of which 5 were doing well at the last follow-up. Conclusion: We report a large series of patients with Pythium keratitis. Promoting early and differential diagnosis, awareness of clinicians and specific treatment options are needed for this devastating corneal disease.
Purpose: To report the distribution and trends of types of organisms and antibiotic susceptibility of the bacterial isolates obtained from patients with microbial keratitis. Methods: Microbiology records of culture-positive microbial keratitis that underwent a diagnostic corneal scraping and cultures were reviewed. Fungal, bacterial, and parasitic culture results and antibiotic susceptibility profile of bacteria were analyzed and comparisons were made between two halves of the study period (2007–2010 vs. 2011–2014). Results: A total of 3981 corneal scrapings were processed during the 8-year study period. Pathogen was recovered in culture in 1914 (48.1%) samples. Fungi, bacteria, and parasites constituted 38.7%, 60%, and 1.3% of the total isolates, respectively. The common fungal isolates were Aspergillus spp. (224/868, 25.8%) and Fusarium spp. (200/868, 23.0%), while common Gram-positive bacteria were Streptococcus pneumoniae (217/1125, 19.3%) and Staphylococcus aureus (185/1125, 16.4%), and common Gram-negative bacteria was Pseudomonasspp. (99/219, 45.2%). There was no significant difference in proportion of bacterial (P = 0.225) and fungal (P = 0.421) keratitis between the first half and second half of the study period. There was a significant increase in proportion of Gram-positive isolates (P = 0.015) [353/758 (46.6%) vs. 772/1482 (52.1%)] and decrease in proportion of Gram-negative organisms (P = 0.044) [88/758 (11.6%) vs. 131/1482 (8.8%)] in the recent years. In-vitro antibiotic susceptibility testing showed decrease in susceptibility to moxifloxacin for Pseudomonas spp. (P = 0.016) in recent years. Conclusion: Prevalence of fungal and bacterial keratitis has remained unchanged over the years. This study shows a significant increase in Gram-positive bacterial infection and decrease in Gram-negative bacterial infection of the cornea in the recent years.
The novel model: Experimental optical coherence tomography–guided anterior segment imaging chick embryo model
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Resat Duman, Tolga Ertekin, Rahmi Duman, Esra Aslan, Mehmet Cem Sabaner, Ersan Çetinkaya DOI:10.4103/ijo.IJO_263_18
Purpose: The aim of this study was to present an experimental optical coherence tomography (OCT)–guided anterior segment (AS) imaging chick embryo model. Through this model, we aimed to reveal similarities and differences between human cornea, AS tissues, and chick embryo tissues by quantitative image analysis. Methods: Ex vivo, the chick embryos' globes were determined by detailed AS camera of spectral-domain (SD)-OCT in 10 fertilized specific pathogen-free eggs on the 20th day. Quantitative image analysis of anterior chamber tissues was performed with SD-OCT in detail. After imaging, cross sections of the chick embryo globes containing cornea with anterior chamber were histologically examined and compared with human tissues. The similarities of our model with data in the human cornea and AS studies in the literature were compared. Results: SD-OCT imaging was able to successfully delineate the AS tissues of chick embryos such as the cornea, iris, lens, pupil, conjunctiva, ciliary body, anterior chamber, and lens. Quantitative semi-automated measurements showed the following: mean central corneal thickness: 213.4 ± 7.05 μm (197–223 μm), mean anterior chamber depth: 878.9 ± 41.74 (804–919 μm), mean anterior chamber area: 2.43 ± 0.16 mm2 (2.17–2.73 mm2), mean corneoscleral junction (limbal) thickness: 322.8 ± 20.05 μm (289–360 μm), and mean iris thickness: 230.4 ± 13.27 μm (203–245 μm). In addition, detailed histological comparisons of the AS tissues with human tissues were evaluated to be very similar. Conclusion: In conclusion, this chick embryo model mimics human tissues and it can be considered as a platform for the study of teratogen-induced malformations and AS dysgenesis during gestation of AS tissues. In addition, this study demonstrates the feasibility of SD-OCT in the quantitative assessment of AS structures in chick embryo model.
Purpose: To compare the visual outcomes and complications between the eyes receiving retropupillary iris claw intraocular lens (IOL) and scleral-fixated IOL (SFIOL) for post-cataract aphakia. Methods: Medical records of consecutive patients who had iris claw IOL and SFIOL surgery from January 2010 to March 2015, with > 1 year of follow up were retrospectively analyzed. The surgical technique was based on individual surgeon preference. The best-corrected distance visual acuity (BCDVA), previous surgery, surgical technique, and complications were analyzed. Results: Retropupillary iris claw IOL was fixated in 48 eyes (46%) and SFIOL was performed in 56 eyes. Iris claw was performed more frequently at the time of primary cataract surgery (56%) compared to SFIOL (14%) (P < 0.001). At 1 month postoperative, BCDVA was significantly better in the SFIOL group [0.7 ± 0.5 logarithm of minimum angle of resolution (logMAR) in iris claw vs. 0.3 ± 0.2 logMAR in SFIOL, P < 0.001] but this difference did not persist at 1 year (0.4 ± 0.4 logMAR in iris claw vs. 0.3 ± 0.2 logMAR in SFIOL, P = 0.56). Eyes with iris claw IOL experienced significantly more postoperative iritis (17%), intraocular pressure spikes (10%), and ovalization of the pupil (16%). Conclusion: Retropupillary iris claw IOL fixation is as safe as SFIOL for visual rehabilitation of post-cataract aphakia. Visual rehabilitation following iris claw IOL might take longer than SFIOL. Ovalization of the pupil is the commonest adverse effect reported with this type of IOL design.
Novel technique of sutureless glueless scleral fixated intraocular lens (SFIOL)
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Shweta Walia, Santosh Kashyap, V Bhaisare, P Rawat, N Kori DOI:10.4103/ijo.IJO_447_18
Purpose: To report results of a novel technique for sutureless, glueless intrascleral fixation of three-piece posterior chamber intraocular lens (IOL) using 26-G needle for management of aphakia. Methods: In this prospective series, 30 eyes of 20 patients with aphakia, subluxated IOL, or crystalline lens were included. 26-G-needle-guided intrascleral fixation of three-piece posterior chamber IOL was performed according to the described technique. The patients were evaluated on day 2, 1 week, 6 weeks, and 3 months postoperatively for change in best-corrected visual acuity (BCVA), intraocular pressure (IOP), IOL centration, and any other complications. The postoperative tilt of the IOL was indirectly measured by determining the lenticular astigmatism which in turn was calculated by the difference between net corneal astigmatism and refractive astigmatism. Paired t-test was used to determine the significance of any association between the preoperative and postoperative BCVA and IOP. P < 0.05 was considered significant. Results: Of 30 eyes (n = 30 patients), 18 were surgical aphakia, 6 traumatic aphakia, 5 subluxated IOL, and 1 ectopia lentis (Marfan syndrome). The mean preoperative BCVA was 1.37 ± 0.37 (logMAR) and postoperative BCVA at 3 months was 0.37 ± 0.29 (logMAR). A significant improvement in the mean BCVA (P < 0.05) was observed after the procedure. The mean IOP preoperatively was 13.33 ± 4.18 and postoperatively at 3 months was 12.82 ± 3.97 (P > 0.05), which was not significant. None of the eyes developed any intraoperative and postoperative complications. The IOLs had appropriate centration and stability. Conclusion: We have developed this new technique for intrascleral IOL fixation which is quite simple, cost-effective, minimally invasive, neither requires glue nor suture and gives consistent outcome.
Safety and efficacy of dexamethasone implant along with phacoemulsification and intraocular lens implantation in children with juvenile idiopathic arthritis associated uveitis
Purpose: To assess the safety and efficacy of intraoperative intravitreal dexamethasone implant in patients of juvenile idiopathic arthritis (JIA)-associated uveitis undergoing phacoemulsification with posterior chamber intraocular lens (PCIOL) implantation. Methods:Retrospectively, data of patients with JIA-associated uveitis undergoing phacoemulsification with PCIOL implantation with intraoperative dexamethasone implant injection were analyzed. Patients with a minimum follow-up of 6 months were included. Primary outcome measures were ocular inflammation, intraocular pressure (IOP), best-corrected visual acuity (BCVA), and worsening of uveitis. Results: 8 eyes of 6 patients were included. BCVA was significantly improved at 1, 3, and 6 months postoperatively 0.20 ± 0.09, P = 0.008; 0.18 ± 0.11, P = 0.008; and 0.24 ± 0.11, P = 0.01, respectively. No statistical difference noted in mean IOP at various follow-up visits. None developed worsening of uveitis or Cystoid macular edema. Conclusion: Intraoperative intravitreal dexamethasone implant is a safe and effective in preventing and managing the postoperative inflammation in children with JIA-associated uveitic cataract.
Linear discriminant score for differentiating early primary open angle glaucoma from glaucoma suspects
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Gunjan A Deshpande, Prashant K Bawankule, Dhananjay V Raje, Moumita Chakraborty DOI:10.4103/ijo.IJO_678_18
Purpose: To determine the diagnostic accuracy of a linear discriminant function (LDF) based on macular ganglion cell complex (GCC), optic nerve head (ONH) and retinal nerve fibre layer (RNFL) for differentiating early primary open-angle glaucoma (POAG) from glaucoma suspects. Methods: In this cross-sectional study, data from consecutive 127 glaucoma suspects and 74 early POAG eyes were analysed. Each patient underwent detailed ocular examination, standard automated perimetry, GCC and ONH and RNFL analysis. After adjusting for age, gender and signal strength using the analysis of covariance; Benjamin–Hochberg multiple testing correction was performed to detect truly significant parameters to calculate the LDF. Subsequently, diagnostic accuracy of GCC and ONH and RNFL were determined. The obtained LDF score was evaluated for diagnostic accuracy in another test set of 32 suspect and 19 glaucomatous eyes. Data were analysed with the R-3.2.1 (R Core Team 2015), analysis of variance, t-test, Chi-square test and receiver operating curve. Results: Among all GCC parameters, infero temporal had the best discriminating power and average RNFL thickness and vertical CDR among ONH and RNFL parameters. LDF scores for GCC had AUROC of 0.809 for a cut-off value 0.07, while scores for ONH and RNFL had AUROC of 0.903 for a cut-off value − 0.24. Analysis on combined parametric space resulted in avg RNFL thickness, vertical CDR, min GCC + IPL and superior GCC + IPL as key parameters. LDF scores obtained had AUROC of 0.924 for a cut-off value 0.1. The LDF was applied to a test set with an accuracy of 84.31%. Conclusion: The LDF had a better accuracy than individual GCC and ONH and RNFL parameters and can be used for diagnosis of glaucoma.
The impact of primary open-angle glaucoma: Comparison of vision-specific (National Eye Institute Visual Function Questionnaire-25) and disease-specific (Glaucoma Quality of Life-15 and Viswanathan 10) patient-reported outcome (PRO) instruments
Purpose: To compare a general vision-specific patient-reported outcomes (PRO) instrument, National Eye Institute Visual Function Questionnaire-25 (NEIVFQ-25) with two disease-specific PRO instruments, Glaucoma Quality of Life-15 (GQL-15), and Viswanathan 10 in patients with varying severity of primary open angle glaucoma (POAG). Methods: This hospital-based, prospective study enrolled 140 glaucoma patients. The patients were classified into mild, moderate, and severe glaucoma based on visual field defects. All these patients were administered the three PRO instruments and the results were statistically analyzed. Results: All the three instruments showed high internal consistency (Cronbach's alpha for GQL-15, NEIVFQ-25, and Viswanathan 10 were 0.918, 0.937, and 0.929, respectively) There was a statistically significant difference between patients with mild, moderate, and severe POAG with all instruments (P ≤ 0.001). The instruments correlated well across several parameters especially the peripheral vision and glare/dark adaptation. The disease-specific scales however are simpler and faster to administer. Conclusion: All three instruments were reliable in assessment of mild, moderate, and severe glaucoma. They correlated strongly with each other in most of the related subscales, domains, and questions. NEIVFQ-25 additionally gave information regarding the general, psychological, and social effects of the disease.
Purpose: To evaluate the effect of acute submaximal exercise on intraocular pressure (IOP) fluctuations in open-angle glaucoma (OAG) subjects using an ocular telemetry sensor (OTS, Sensimed TriggerFish®). Methods: Twelve OAG subjects aged 45–65 years with no medical limitation for exercise were included in this prospective study. A submaximal exercise test was performed using a cycle ergometer for 20 min during which OTS voltages and metabolic parameters were recorded continuously. IOP voltages taken before, during, and after exercise were compared using the Friedman test and correlations with the metabolic parameters were evaluated using the Spearman analysis. Results: In two subjects, the OTS stopped functioning after a few hours. Median OTS measurements were 37.60 mVeq 10 min before exercise [interquartile range (IQR) 137.27], 51.75 (IQR 121.2), 62.35 (IQR 123.72), 54.6 (IQR 141.3), and 59.7 mVeq (IQR 196.7) during exercise (4 time points, 5 min apart), and 50.7 (IQR 147.35) and 64.2 mVeq (IQR 103.25) 10 and 30 min after exercise and the change was statistically non-significant (P = 0.66). No correlations were found between OTS and metabolic parameters measured at the same time points (P > 0.05). Nocturnal acrophase pattern was detected in five subjects (50%), diurnal acrophase in two patients, and double-hump in two patients. Median IOP voltages in the morning, afternoon/evening, and night were 335.84, 149.15, and 341.38 mVeq, respectively (P < 0.001). Conclusion: Continuous IOP monitoring did not reveal a remarkable voltage change in OAG patients during or immediately after exercise, but nocturnal IOP peaks in half of the patients.
Surgical outcomes of repeat trabeculectomy augmented with high dose mitomycin C
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Sharmila Rajendrababu, Sujani Shroff, Sangeeta Vivek Patil, Mohammed Sithiq Uduman, Ashok Vardhan, SR Krishnadas DOI:10.4103/ijo.IJO_682_18
Purpose: To evaluate the surgical outcomes of repeat trabeculectomy augmented with risk factor adjusted mitomycin C (MMC) exposure in eyes with previous failed trabeculectomy. Methods: Case records of 38 eyes of 37 patients with previous failed filter who underwent repeat trabeculectomy with MMC were reviewed retrospectively. Main outcome measures were best-corrected visual acuity (BCVA), intraocular pressure (IOP) reduction, requirement of anti-glaucoma medications, postoperative complications, and surgical success (defined as IOP of ≤21 mmHg and >5 mmHg along with 20% reduction from preoperative IOP with or without adjuvant medications) at 1-year postoperatively. Statistical analysis was done using the STATA 14.1 (Texas, USA). Results: Patient's mean age was 46.41 (±20.43) years and the mean preoperative IOP was 32.73 (±9.26) mmHg which reduced to 16.22 (±7.08) mmHg postoperatively at 12 months (P < 0.001). Mean number of anti-glaucoma medications reduced from 2.76 (±0.83) preoperatively to 1.89 (±0.95) postoperatively (P < 0.001). Surgical success was observed in 81.1% at 1 year (n = 30). Eyes that received MMC >3 min had a postoperative mean IOP of 12.50 (±3.23) mmHg compared to 23.08 (±7.19) mmHg with MMC <3 min (P < 0.001). Seven eyes (18.4%) developed postoperative complications, and all were seen in eyes that received MMC >3 min (P = 0.033). Conclusion: Repeat trabeculectomy with MMC, used in higher concentration and exposure time altered according to individual risk factor plays a crucial role in the success and hence it could be considered as a viable option before planning a tube surgery.
Purpose: To elucidate the clinical profile of visual impairment (VI) and rehabilitation of the uveitic patients with irreversible low vision. Methods: Retrospective analysis of visual rehabilitation of patients with uveitis suffering from poor vision with low vision devices (LVD). Results: Most common cause of uveitis was choroiditis (46.29%), followed by retinitis (25.92%), retinochoroiditis (18.51%), and chronic panuveitis sequelae (9.25%). Of these 54 cases, 35.18% had moderate VI, 25.92% had severe VI, 20.37% had mild VI, and 18.51% had profound VI or blindness. Statistically significant improvement (P < 0.05) in near vision was seen in choroiditis (52%) and retinitis (72%), whereas clinically significant improvement in distance vision was found in patients with choroiditis. Most commonly prescribed LVD was half-eye prismatic spectacle magnifier (22.2%). Conclusion: Rehabilitation of the uveitic patients with low vision is challenging. LVD may be a beneficial tool in these patients to help them perform their day-to-day activities independently.
Response to anti-vascular endothelial growth factor of abnormal retinal vascular net in para foveal telangiectasia group II images on optical coherence tomography-angiography
Purpose: To identify optical coherence tomography-angiography (OCT-A) findings to predict treatment response during anti-vascular endothelial growth factor (VEGF) therapy in eyes with para foveal telangiectasia (PFT) group II. Methods: In this retrospective series, Twelve eyes of seven patients diagnosed with PFT group II without evidence of sub-retinal neovascular membrane (SRNVM) clinically or on spectral domain-OCT (SD-OCT) were included. All patients underwent OCT-A on the Topcon DRI OCT Triton® with 4.5 mm macula scans. The patients with abnormal vascular nets were further classified into type A and B nets and administered intravitreal anti-VEGF therapy. Visual acuity and size of type A and B nets were evaluated pre- and post-injection. Paired t- test and intraclass correlation were used to analyse data. Results: Patients with type A net showed significant improvement in visual acuity (logMAR 0.38, P = 0.0047). The size of type A net showed statistically significant decrease (P = 0.0008) on 6 month follow up. Type B net did not show statistically significant difference in visual acuity or size following anti-VEGF therapy. Conclusion: OCT-A plays an important role in early detection of possible neovascular nets (type A), in the absence of obvious SRNVM. Treatment decisions based on OCT-A may be helpful to achieve better visual outcome.
Clinical and electrophysiological results of eye muscle surgery in 17 patients with downbeat nystagmus
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Richard W Hertle, Ashraf Ahmad DOI:10.4103/ijo.IJO_703_18
Purpose: To test the hypothesis that eye muscle surgery in treatment of patients with acquired downbeat nystagmus results in improvement measures of visual and ocular motor function. Methods: This is a prospective, interventional case series analysis of clinical and electrophyisological data before and after eye muscle surgery in 17 patients with acquired downbeat nystagmus who did not respond to medical treatments. Outcome measures included: 1) routine demography and clinical characteristics, 2) subjective oscillopsia (SO), 3) binocular best-corrected visual acuity in the null position (BVA), 3) primary position strabismic deviation (SD), 5) anomalous head posture (AHP), 6) contrast sensitivity function (CS), and 7) nystagmus slow phase velocity (SPV). All patients were followed at least 12 months. Parametric and non-parametric statistical analysis of outcome measure data above pre- and post-treatment were perfomed using standard software on grouped data using computerized software. Results: Patients' age ranged from 5 to 85 years (average 27 years). About 59% were male. Follow up ranged from 1–10 years (average 2.0 years). Around 70% had an associated central nervous systemic diagnosis, 100% had an AHP, oscillopsia and decreased CS, 53% had other eye disease, and 59% had strabismus. There were no complications from surgery. There were signficant post-treatment improvements in mean/median group BVA, SO, SD, AHP, CS, and SPV. Conclusion: This study supports the hypothesis that eye muscle surgery as treatments for patients with acquired downbeat nystagmus can result in improvements in multiple aspects of ocular motor and visual functions.
Ligneous conjunctivitis (LC) is a rare form of pseudomembranous conjunctivitis seen in children, perhaps due to plasminogen deficiency, which manifest as a chronic refractory pseudomembranous conjunctivitis. LC cases are incapable in maintaining their fibrinolytic activity due to plasminogen deficiency; consequently, transudates of plasma assume as a thick, gelatinous, woody membranes over the mucosal surfaces. This is a short case report on a child with a LC, who presented with recurrent pseudomembranous conjunctivitis in conjunction with progressive congenital hydrocephalus due to aqueductal stenosis (Dandy–Walker syndrome). This rare association was clinically confirmed and prompt corrective surgical measures were instituted.
Treatment of corneal neovascularization with topical aflibercept in a case of exposure keratopathy following cerebellar astrocytoma surgery
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Sibel Aksoy DOI:10.4103/ijo.IJO_418_18
In this report, we report the case of a 7-year-old boy with corneal neovascularization due to exposure keratopathy following cerebellar astrocytoma surgery. Corneal surface healing was achieved with topical treatment and therapeutic contact lens, after which topical steroid was administered for stromal haze and corneal neovascularization. After 2 months of steroid therapy failed, corneal neovascularization responded well to topical aflibercept administration, showing complete regression.
Chelsey A Bravenec, Rahul T Pandit, Hilary A Beaver DOI:10.4103/ijo.IJO_617_18
A 75-year-old male with a right eye history of chronic dry eye syndrome, glaucoma status post tube shunt, and Fuchs dystrophy status post Descemet stripping endothelial keratoplasty followed by penetrating keratoplasty (PKP) presented with a 2.7 × 4.2 mm corneal ulcer, culture positive for Shewanella algae and Klebsiella oxytoca. A topical antibiotic regimen of gentamicin 14 mg/mL and vancomycin 50 mg/mL was administered according to culture sensitivities. There was concurrent use of loteprednol 0.5% (Lotemax Gel, Bausch and Lomb, Rochester, NY, USA) and later addition of erythromycin 0.5% ointment. The corneal ulcer improved with antibiotic therapy but was complicated by poor patient follow-up. Descemetocele formation prompted PKP in the right eye. The graft was successful and visual acuity improved from a low of light perception to maximum of 20/200 Snellen.
A 55-year-old lady developed a corneal ring infiltrate following trauma with a wooden stick. 10% KOH mount of corneal scrapings revealed septate hyaline fungal filaments. White feathery colonies with shiny black dots grew on potato dextrose agar. Characteristic features of Pestalotiopsis spores were seen on Lactophenol cotton blue mount. DNA sequencing showed 99% similarity with Pseudopestalotiopsis theae. Complete resolution was noted with topical and oral antifungals. To the best of our knowledge, this is the first report of Pseudopestalotiopsis keratitis following trauma with vegetative matter highlighting the role of DNA sequencing in identification of rare fungi.
In vivo confocal microscopy and anterior segment optical coherence tomography follow-up of cysteamine treatment in corneal cystinosis
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Huseyin Baran Ozdemir, Mehmet Cüneyt Özmen, Zeynep Aktas, Murat Hasanreisoglu DOI:10.4103/ijo.IJO_736_18
A 36-year-old female presented initially with photophobia and visual deterioration. After examination and laboratory tests, patient was diagnosed with cystinosis. Cysteamine drops 4 × 1 drops/day was given as treatment for 1 year. During follow-up, in vivo confocal microscopy (IVCM) and anterior segment optical coherence tomography (AS-OCT) was performed. Photophobia was relieved and IVCM obtained the decrease in size and density of corneal crystals 1 year after. Depth of corneal crystals did not change but crystal density score reduced with cysteamine treatment.
Femtosecond laser-assisted successful management of subluxated cataractous lens with vitreous in anterior chamber
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Jeewan S Titiyal, Manpreet Kaur, Anubha Rathi, Ruchita Falera DOI:10.4103/ijo.IJO_764_18
Femtosecond laser-assisted cataract surgery was performed in a case of posttraumatic cataract with six clock hours subluxation and vitreous in the anterior chamber (AC). Femtosecond laser pretreatment allowed a closed-chamber creation of corneal incisions, capsulotomy, and lens fragmentation with minimal sudden lens-diaphragm movements and zonular stress. Integrated imaging systems allowed customization of the size and position of capsulotomy and nuclear fragmentation, based on the extent and site of subluxation. Presence of vitreous in AC did not hamper femtosecond laser application. Triamcinolone-assisted vitrectomy was performed before phacoemulsification and after implanting the intraocular lens (IOL). Postoperative uncorrected visual acuity was 20/20 with a stable IOL.
Uma Sharan Tiwari, Ankita Aishwarya, Shashi Gandhi, Priya Sisodia DOI:10.4103/ijo.IJO_843_18
Live worm in anterior chamber is a rare finding. We hereby report a case of ocular Angiostrongylus cantonensis, which, to the best of our knowledge, is the third case report from India. A 70-year-old female presented with the complaints of watering and foreign body sensations in right eye since 2 months. On examination, a translucent worm of approximately 15 mm length was found freely moving in anterior chamber. Patient underwent surgical removal of live worm, which was identified as A. cantonensis. Educating people regarding importance of hygiene is important for prevention of worm infestation.
Acute hypertensive uveitis as the first presentation of multiple sclerosis
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Melissa Kate Shields, Sumu Simon, WengOnn Chan, Jagjit S Gilhotra DOI:10.4103/ijo.IJO_345_18
Ophthalmic manifestations of multiple sclerosis are frequent including acute optic neuritis, ocular motor disturbances and intermediate uveitis. We report an unusual case of multiple sclerosis presenting as acute hypertensive uveitis. A 56-year-old man was referred by his family doctor with a 2-week history of right eye pain and decreased vision. Best-corrected visual acuity was Count Fingers on the right and 6/9-2 on the left. Intraocular pressure was 55mmHg and 14 mmHg on the right and left respectively. He had a right relative pupillary defect and a left internuclear ophthalmoplegia. Vitreous cells were present in the right eye and there was peripheral sclerosis and periphlebitis superior temporally. MRI Brain and Spine revealed multiple T2 hyperintense lesions consistent with multiple sclerosis. Multiple sclerosis may present initially with an acute elevation of intraocular pressure and intermediate uveitis.
Familial Blau syndrome:First molecularly confirmed report from India
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Mahesh Janarthanan, Chanchal Poddar, S Sudharshan, Luis Seabra, Yanick J Crow DOI:10.4103/ijo.IJO_671_18
Blau syndrome (BS) is a rare autoinflammatory disorder characterized by the clinical triad of arthritis, uveitis, and dermatitis due to heterozygous gain-of-function mutations in the NOD2 gene. BS can mimic juvenile idiopathic arthritis (JIA)-associated uveitis, rheumatoid arthritis, and ocular tuberculosis. We report a family comprising a mother and her two children, all presenting with uveitis and arthritis. A NOD2 mutation was confirmed in all the three patients – the first such molecularly proven case report of familial BS from India.
In this report, we describe a rare case of a 44-year-old Asian male with acute central serous chorioretinopathy (CSC) with bullous exudative retinal detachment. Endocrinology evaluation revealed hypothalamic–pituitary–adrenal axis suppression with low serum cortisol. Furthermore, neuroimaging revealed the presence of a pituitary microadenoma. He was treated with systemic eplerenone and hydrocortisone. After 12 weeks, bullous detachment completely resolved. Our case is a unique description of acute CSC with underlying low serum cortisol levels that responded to treatment with mineralocorticoid antagonist. This case highlights the various endocrine abnormalities other than the raised serum cortisol that can occur in patients with CSC.
Comment on: Optical coherence tomography angiography in acute unilateral nonarteritic anterior ischemic optic neuropathy: A comparison with the fellow eye and with eyes with papilledema
Response to comment on: Optical coherence tomography angiography in acute unilateral nonarteritic anterior ischemic optic neuropathy: A comparison with the fellow eye and with eyes with papilledema
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Uppal Gandhi, Jay Chhablani, Preeti P Chhablani DOI:10.4103/ijo.IJO_1771_18
Response to comment on: Feasibility and safety of vitrectomy under topical anesthesia in an office-based setting
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Gloria P Trujillo-Sanchez, Alejandro Gonzalez-De la Rosa, Jose Navarro-Partida, Luis Haro-Morlett, Juan C Altamirano-Vallejo, Arturo Santos DOI:10.4103/ijo.IJO_1516_18
