Role of regional diffusion tensor imaging (DTI)-derived tensor metrics in the evaluation of intracranial gliomas and its histopathological correlation.

Background: The imaging of brain tumours has significantly improved with the use of advanced magnetic resonance (MR) techniques like diffusion tensor imaging (DTI). This study was conducted to analyse the utility of DTI-derived tensor metrics in the evaluation of intracranial gliomas with histopathological correlation and further adoption of these image-data analyses in clinical setting. Methods: A total of 50 patients with suspected diagnosis of intracranial gliomas underwent DTI along with conventional MR examination. The study correlated various DTI parameters in the enhancing part of the tumour and the peritumoral region with the histopathological grades of the intracranial gliomas. Results: The study revealed higher values of Cl (linear anisotropy), Cp (planar anisotropy), AD (axial diffusivity), FA (fractional anisotropy) and RA (relative anisotropy) and lower values of Cs (spherical anisotropy), MD (mean diffusivity) and RD (radial diffusivity) in the enhancing part of the tumour in case of high-grade gliomas. However, in the peritumoral region, the values of Cl, Cp, AD, FA and RA were less whereas values of Cs, MD and RD were more in high-grade gliomas than in the low-grade gliomas. The various cutoff values of these DTI-derived tensor metrics were found to be statistically significant. Conclusion: DTI-derived tensor metrics can be a valuable tool in differentiation between high-grade and low-grade gliomas which might be accepted in clinical practice in near future.

Transnasal Transsphenoidal Approach for Pituitary Tumors: An ENT Perspective.

Endoscopic transnasal transsphenoidal (ETNTS) approach was first described in 1992 and is standard approach for the resection of benign pituitary adenomas. This prospective study aims in incidence and preoperative assessment of extent of the pituitary adenoma, peroperative findings of transnasal transsphenoidal excision, techniques of skull base repair, complications and its management in a tertiary centre. A prospective analysis from Jan 2017 to May 2019, of patients undergoing ETNTS approach of pituitary adenomas was made in terms of incidence in various age-groups, type of adenoma, operative findings including CSF leak, repair of the skull base defect, complications encountered and its management was done in a tertiary care centre and compared with the present literature. A total of 141 patients underwent ETNTS, with highest number of cases found in 41-50 years age-group with mean age of 42.6 years. Male: Female ratio was 1.6. Macroadenoma was in 123 patients while 18 had microadenoma, of these 63.74% were functional adenoma, highest of GH secreting, while 36.26% were non-functional. Mean surgical time was 98.4 min ± 21.2 min. Peroperative CSF leak was in 30.5% cases in various grades. Closure techniques included use of fat, multilayer techniques, Hadad's flap and gasket technique as per the type of CSF leak. Neurological and rhinological complications were 6.38% each. This study is focused on the ENT perspective of the endoscopic transnasal trans-sphenoidal approach for pituitary adenomas. The reduced rate of morbidity and complications is encouraging. The endoscopic skull base defect closure is challenging and requires skill, meticulous approach and synchronised team work in order to achieve a favourable outcome. The incidence of CSF leak can be minimised and if encountered has to be dealt in an organised manner, thus contributing to a reduced rate of complications. The complications encountered must be foreseen and managed with a proficient approach.

Unprecedented complication of odontoid regeneration after transoral odontoidectomy.

Transoral odontoidectomy followed by occipitocervical fixation is a widely used approach to relieve ventral compressions at the craniovertebral junction. Despite the large amount of literature on this approach and its complications, odontoid process regeneration and causing the worsening of symptoms of brainstem dysfunction and upper cervical cord were not found in the English literature. We report the case of odontoid regeneration in a 12-year-old girl. She presented with torticollis and symptoms of brainstem dysfunction and upper cervical cord compression with syringohydromyelia and underwent transoral resection of dens and posterior occipitocervical fusion at the age of 7 years. Post surgery, clinically and radiologically, the resolution was evident till the age of 11 years when the child started to have relapse and worsening of the previous symptoms. The computed tomography/magnetic resonance imaging shows regeneration of the odontoid process compressing the brain stem with an increase in syringohydromyelia. We suggest that there is a need for the removal of the complete odontoid process with periosteum and also beyond the dentocentral synchondrosis to prevent late recurrences of odontoid regeneration.

An unusual cause of progressive quadriparesis.

Thyroid carcinoma is a rare cause of compressive myelopathy. Quadriparesis as the presenting manifestation of follicular carcinoma of thyroid without any preceding features of malignancy is quite uncommon. We describe a case of a 55-year-old woman who presented with progressive quadriparesis of 2 months duration, on evaluation was found to have a large tumor destroying C1, C2 vertebrae and occupying craniovertebral junction. Histopathological examination of excised tumor was follicular thyroid carcinoma. She was successfully managed with surgical excision, stabilization of spine followed by radiotherapy.

Obesity and symptomatic osteoarthritis of the knee.

Given the growing prevalence of obesity around the world and its association with osteoarthritis of the knee, orthopaedic surgeons need to be familiar with the management of the obese patient with degenerative knee pain. The precise mechanism by which obesity leads to osteoarthritis remains unknown, but is likely to be due to a combination of mechanical, humoral and genetic factors. Weight loss has clear medical benefits for the obese patient and seems to be a logical way of relieving joint pain associated with degenerative arthritis. There are a variety of ways in which this may be done including diet and exercise, and treatment with drugs and bariatric surgery. Whether substantial weight loss can delay or even reverse the symptoms associated with osteoarthritis remains to be seen. Surgery for osteoarthritis in the obese patient can be technically more challenging and carries a risk of additional complications. Substantial weight loss before undertaking total knee replacement is advisable. More prospective studies that evaluate the effect of significant weight loss on the evolution of symptomatic osteoarthritis of the knee are needed so that orthopaedic surgeons can treat this patient group appropriately.

Acute corneal hydrops treated by intracameral injection of perfluoropropane (C3F8) gas.

PURPOSE: To report a case of acute hydrops with intrastromal cleft in a patient of keratoconus with associated Marfan's syndrome, treated with intracameral injection of perfluoropropane (C(3)F(8)) gas. DESIGN: Interventional case report. METHODS: A nonexpansile concentration of perfluoropropane gas (0.2 ml) was injected intracamerally in the operating room under aseptic precautions. RESULTS: There was complete and rapid resolution of corneal edema. CONCLUSION: Intracameral perfluoropropane gas in nonexpansile concentration may be a useful modality for treatment of corneal edema in acute corneal hydrops.

Outcome of pterygium surgery: analysis over 14 years.

AIM: To report the outcome of pterygium surgery performed at a tertiary eye care centre in South India. METHODS: Retrospective analysis of medical records of 920 patients (989 eyes) with primary and recurrent pterygia operated between January 1988 and December 2001. The demographic variables, surgical technique (bare sclera, primary closure, amniotic membrane transplantation (AMT), conjunctival autograft (CAG), conjunctival-limbal autograft (CLAG), or surgical adjuvants), recurrences and postoperative complications were analysed. RESULTS: A total of 496 (53.9%) were male and 69 (7.5%) had bilateral pterygia. Bare sclera technique was performed in 267 (27.0%) eyes, primary conjunctival closure in 32 (3.2%), AMG in 123 (12.4%), CAG in 429 (43.4%), and CLAG in 70 (7.1%). Adjuvant mitomycin C was used in 44 (4.4%) cases. The mean duration of follow-up was 8.9+/-17.0 and 5.9+/-8.8 months for unilateral primary and recurrent pterygia, respectively. The overall recurrence rate was 178 (18.0%). Following primary and recurrent unilateral pterygium excision respectively, recurrences were noted in 46 (19.4%) and 1 (33.3%) eyes after bare sclera technique, five (16.7%) and 0 after primary closure, 28 (26.7%) and 0 with AMG, 42 (12.2%) and five (31.3%) with CAG, and nine (17.3%) and two (40%) with CLAG. Recurrences were significantly more in males with primary (23.3 vs 10.7%, P<0.0001) and recurrent (26.7 vs 0%, P=0.034) pterygia, and in those below 40 years (25.2 vs 14.8%, P=0.003). CONCLUSION: CAG appears to be an effective modality for primary and recurrent pterygia. Males and patients below 40 years face greater risk of recurrence. Bare sclera technique has an unacceptably high recurrence. Prospective studies comparing CAG, CLAG, and AMG for primary and recurrent pterygia are needed.

Pellucid marginal corneal degeneration.

OBJECTIVE: To report the clinical features and outcome of patients with pellucid marginal corneal degeneration (PMCD). DESIGN: Retrospective noncomparative case series. METHODS: Retrospective chart review of 116 eyes of 58 patients with PMCD seen between 1990 and 2002 at the Cornea Service at L.V. Prasad Eye Institute, Hyderabad, India. The diagnosis of PMCD was based on the presence of corneal thinning with ectasia of the normal cornea above or below the area of thinning with no evidence of scarring, vascularization, or lipid deposition and typical topographic features whenever topography was performed. A detailed history including the age of presentation, onset of symptoms, systemic diseases, atopy, and relevant family history was reviewed. The visual acuity (VA) at presentation; the location, extent, and degree of thinning; presence of concurrent keratoconus and keratoglobus; and complications, if any, were noted. The mode of visual rehabilitation; surgical procedure, if any; and the final VA achieved were analyzed. MAIN OUTCOME MEASURES: Clinical features, associations, complications, and outcome of treatment. RESULTS: There were 45 males (77.6%) and 13 females (22.4%). All cases were bilateral. In one eye, no clinical features of PMCD were seen, but the diagnosis was made based on topographic features of typical PMCD. The age of the patients ranged from 8 to 66 years, with a mean of 34.0+/-14.8. One patient (1.7%) had associated vernal keratoconjunctivitis (VKC), 1 (1.7%) had Marfan's syndrome, and 1 (1.7%) had ocular hypertension. The degree of astigmatism was <5.0 diopters (D) in 19 eyes (19.2%), 5 to 10 D in 36 (36.4%), 10 to 15 D in 23 (23.2%), 15 to 20 D in 15 (15.2%), and >20 D in 6 (6.1%). Typical inferior PMCD was seen in 99 eyes (85.3%), and superior PMCD was seen in 17 (14.7%). The thinning was commonly seen between the 5-o'clock and 7-o'clock positions. In 12 eyes (10.3%), PMCD was associated with keratoconus, and in 15 eyes (12.9%), keratoglobus was associated. Seven eyes (6.0%) had hydrops. Visual acuity improved in 52 eyes (55.3%) with correction, in 40 eyes (42.6%) it remained the same as that of the initial presentation, and in 2 eyes (2.1%) it worsened relative to the initial presentation. Forty-one eyes (35.3%) received spectacles, and 31 eyes (26.7%) were fitted with rigid gas-permeable contact lenses. Five eyes (4.3%) underwent surgery. Lamellar keratoplasty was performed in 3 eyes, and a crescentic lamellar graft was done in 2 eyes. Visual acuity improved in 4 eyes after surgery with a follow-up of 2 to 37 months. The final astigmatism in the operated eyes at the last follow-up ranged from 4 to 11 D. CONCLUSIONS: Pellucid marginal corneal degeneration was seen predominantly in males in this series, and was not strongly associated with VKC. Keratoconus was seen in approximately 10% of the eyes, and keratoglobus in approximately 13%. Superior PMCD was seen in approximately 15% of the eyes. In our study, patients presented with severe astigmatism, and hydrops was a common complication. The majority of patients were treated with spectacles or contact lens. Surgery for PMCD-lamellar keratoplasty and crescentic lamellar keratoplasty, if indicated-usually results in significant residual astigmatism.

Anterior chamber tap: diagnostic and therapeutic indications in the management of ocular infections.

PURPOSE: To report three cases in which an anterior chamber tap was useful in the management of infection of the eye confined to the anterior segment. METHODS: In the first case, the patient presented with diffuse conjunctival congestion and thick anterior chamber exudates adhering to the back of the cornea. The second case involved fungal keratitis, and the patient was not responding to topical natamycin and systemic ketoconazole. In this patient, infiltrate and thick hypopyon persisted despite medical therapy. The patient in the third case had a persistent thick endothelial exudate, and a retained intracameral foreign body, fungal infection, and a cataract were suspected. In all three cases, an anterior chamber tap was performed. In case 1, the exudate was removed and sent for microbiologic investigation. In case 2, the hypopyon was evacuated and intracameral amphotericin B (5 microg) was injected. In case 3, the exudate contained a wooden foreign body that was sent for culture. Intracameral amphotericin B (5 microg) was injected. RESULTS: In the first case, the culture of the exudate grew Staphylococcus aureus. The eye quieted, and the exudate resolved following treatment with topical fortified cefazolin, fortified gentamicin, and systemic cefazolin. In the second case, smears of corneal scrapings revealed fungal filaments and the culture grew Aspergillus species. The infection resolved following an anterior chamber tap, but the patient developed a cataract. After cataract surgery, visual recovery was limited because of the corneal scar. In the third case, the culture of the foreign body grew an unidentified hyaline fungus. Following an anterior chamber tap, the infection resolved, but the cataract progressed. The patient did well after cataract surgery. CONCLUSIONS: An anterior chamber tap is an extremely useful procedure in the management of ocular infections confined to the anterior segment. The procedure should be performed under strict aseptic conditions. If the infection involves the anterior capsule of the lens, care should be taken to avoid injury to the lens, and the possibility of progression of the cataract should be explained to the patient.

Phototherapeutic keratectomy versus diamond burr polishing of Bowman's membrane in the treatment of recurrent corneal erosions associated with anterior basement membrane dystrophy.

PURPOSE: To compare the efficacy of phototherapeutic keratectomy (PTK) to epithelial debridement and polishing of Bowman's membrane using a diamond burr (DB) in the treatment of recurrent corneal erosions associated with anterior basement membrane (ABM) dystrophy. DESIGN: Retrospective nonrandomized comparative trial. METHODS: Medical records of 39 patients (42 eyes) who underwent a PTK or DB procedure for recurrent corneal erosions associated with ABM dystrophy between March 1992 and June 2000 were reviewed. History of injury, prior treatment received, and the corneal slit-lamp findings were noted in all patients. In both procedures, all loose epithelium was completely removed. In PTK patients, 5 microm of Bowman's membrane was ablated with the excimer laser. In patients who underwent DB treatment, a hand-held battery-driven diamond dusted burr was used to gently and uniformly polish Bowman's membrane in the area of the epithelial defect. MAIN OUTCOME MEASURES: Symptomatic improvement, recurrence of painful erosions, development of haze, and change in the visual acuity. Statistical analysis was performed for comparison of data between the two groups. RESULTS: Fifteen eyes of 14 patients underwent PTK, and 27 eyes of 25 patients underwent epithelial debridement and DB treatment. In the PTK group, mild haze was seen in five (35.7%) eyes. Recurrence of painful erosions was seen in four eyes (26.7%). The mean follow-up was 17.6 +/- 5.7 months (range, 0.7-81.9 months). Best-corrected visual acuity was better in five eyes (35.7%) after the procedure and the same in nine eyes (64.3%). In the DB group, mild haze was seen in seven eyes (25.9%). Recurrence of painful erosions was seen in three eyes (11.1%). The mean duration of follow-up was 6.7 months (range, 1-24.2 months). Best-corrected visual acuity was better in 3 eyes (14.3%), the same in 17 eyes (81%), and worse in 1 eye (4.8%) after the procedure. Final visual acuity was not available for one eye in the PTK group and 6 eyes in the DB group. There was no statistically significant difference in haze (Fisher's exact test, P = 0.38), recurrence of erosions (Kaplan-Meier analysis with log rank, P = 0.73), and vision being better or the same (Fisher's exact test, P = 0.6) between the PTK and DB groups. CONCLUSIONS: Both PTK and DB treatment are effective methods of treating recurrent corneal erosions associated with ABM dystrophy. Diamond burr treatment, being a simpler, less expensive office procedure with a tendency toward lesser incidence of haze and recurrence in this study, seems to have advantages over PTK in the treatment of recurrent corneal erosions. Further prospective studies are required to confirm the long-term efficacy of DB treatment in the management of recurrent corneal erosions associated with ABM dystrophy.

Surgically induced necrotizing scleritis after pterygium excision and conjunctival autograft.

PURPOSE: To report a case of surgically induced necrotizing scleritis (SINS) after pterygium excision and conjunctival autograft. METHODS: A 55-year-old man presented 2 weeks after excision of primary pterygium with conjunctival autograft in the right eye with severe pain in that eye. He had undergone cataract surgery in that eye 8 months before. The graft was pale and white. The underlying sclera was white and avascular. There was marked inflammation adjacent to the site of surgery and graft. A scraping from the graft surface revealed no organisms in smears, and culture revealed no growth. The conjunctival graft was removed. Amniotic membrane transplantation was performed. After surgery, the amniotic membrane was avascular and pale. Systemic steroid therapy was initiated. RESULTS: Three days after initiation of systemic steroid therapy, the graft became vascularized. Over the next 10 days, the eye quietened, conjunctival and scleral inflammation lessened, and the graft was well accepted. CONCLUSIONS: Surgically induced necrotizing scleritis is a rare complication of pterygium excision with conjunctival autograft. A pale graft with underlying avascular sclera and surrounding inflammation should arouse suspicion of this complication.

Indications for penetrating keratoplasty and associated procedures, 1996-2000.

PURPOSE: To identify current indications and trends in indications for penetrating keratoplasty and associated procedures. METHODS: Retrospective chart review of all patients who underwent penetrating keratoplasty at Wills Eye Hospital from January 1, 1996 to December 31, 2000. RESULTS: A total of 1,529 corneal transplants were performed during this 5-year period. The leading indications for penetrating keratoplasty were pseudophakic bullous keratopathy (PBK) in 416 (27.2%) cases, followed by regraft in 276 (18.1%), keratoconus in 236 (15.4%), and Fuchs endothelial dystrophy in 233 (15.2%) cases. Of the 416 PBK cases, 271 (65.1%) were associated with posterior chamber intraocular lenses (PC IOLs), 141 (33.9%) with anterior chamber intraocular lenses (AC IOLs), and four (1%) with iris-fixated lenses. Of these 141 AC IOLs, 107 (75.9%) were closed-loop and 34 (24.1%) were open-loop. Of the 416 PBK cases, in 281 (67.5%) cases, the IOL was not exchanged; in 127 (30.5%) cases, the IOL was exchanged; in six (1.5%) cases, the IOL was repositioned; and in two (0.5%) cases, the IOL was removed at the time of surgery. Of the 271 PC IOLs, 248 (91.5%) were not exchanged and 19 (7.1%) were exchanged. Of the 141 AC IOLs, 33 (23.4%) were not exchanged and 104 (73.7%) were exchanged (p = 0.001). CONCLUSIONS: Pseudophakic bullous keratopathy remains the leading indication for corneal transplantation at our institution followed by regraft. The percentage of PBK cases associated with PC IOLs has increased significantly, whereas the percentage associated with AC IOLs has decreased. The frequency of regraft has also increased significantly.

Accidental self-removal of a flap--a rare complication of laser in situ keratomileusis surgery.

PURPOSE: To report a rare complication in which the patient accidentally removed the laser in situ keratomileusis corneal flap. METHODS: Interventional case report. A 35-year-old woman underwent uncomplicated laser in situ keratomileusis surgery. Ten days after surgery, she inserted a soft contact lens into the right eye to improve her vision. She tried to remove the contact lens, but had pain and bleeding. She was referred 10 days later with a diagnosis of loss of flap. RESULTS: On examination, she had a best-corrected visual acuity of 20/70 in the right eye. The right eye examination revealed no corneal flap, mild corneal edema, and significant haze. A central epithelial defect was found. CONCLUSION: Accidental corneal flap removal can rarely follow laser in situ keratomileusis surgery. This complication provides insight into the weak adhesion of the flap onto the stromal bed after laser in situ keratomileusis surgery and, hence, the inherent risk of traumatic flap dislocation or amputation, which needs to be explained to the patient.

Unilateral corneal lattice dystrophy.

PURPOSE: To report three cases of seemingly unilateral dystrophy indistinguishable from type I classic lattice corneal dystrophy. METHODS: Case study of three patients. Three patients, a 31-year-old man, a 44-year-old woman, and a 41-year-old man had multiple lattice lesions in one eye and an apparently healthy fellow eye. Two of these patients underwent penetrating keratoplasty because of poor vision. RESULTS: Histopathologic examination of the excised corneal button of patient 2 showed amyloid deposits consistent with lattice. In the third patient, lattice lesions were noted in the other eye nearly 13 years after he was first examined. CONCLUSIONS: Lattice corneal dystrophy is rarely unilateral. Lattice, even in unilateral cases, may cause significant vision loss to warrant penetrating keratoplasty. Lattice lesions may develop in the fellow eye many years later. This possibility should be explained to all patients with apparently unilateral lattice corneal dystrophy.

Herpes simplex virus bullous keratitis misdiagnosed as a case of pseudophakic bullous keratopathy with secondary glaucoma: an unusual presentation.

PURPOSE: To report an unusual case of herpetic bullous keratitis misdiagnosed as a case of pseudophakic bullous keratopathy with secondary glaucoma. RESULTS: A retrospective analysis of the case record of a 60-year-old man who had earlier undergone bilateral cataract surgery, was done. He presented with a complaint of decrease in vision in the right eye of 20 days duration. On examination, cornea showed epithelial bullae all over the surface with stromal and epithelial edema. Intraocular pressure was 30 mm of Hg in RE. He was treated with anti-glaucoma medications. Two dendritic lesions were seen in the cornea during a subsequent visit four days later. Virological investigations confirmed a diagnosis of Herpes simplex keratitis. He was treated with topical acyclovir. CONCLUSIONS: This case highlights the fact that herpes simplex keratitis can present initially as a more diffuse corneal stromal and epithelial edema with epithelial bullae mimicking bullous keratopathy. Herpetic bullous keratitis, although unusual, should be considered in the differential diagnosis under such circumstances.

Infectious crystalline keratopathy in an immunosuppressed patient.

PURPOSE: To report a case of infectious crystalline keratopathy (ICK) in a patient with systemic malignancy on immunosuppressive chemotherapy. The patient wore frequent replacement contact lenses on an extended wear basis. METHODS: A 51-year-old female with carcinoma of the breast and systemic metastases was referred for a corneal ulcer. She received intravenous docetaxel, trastuzumab, and systemic dexamethasone. She wore frequent replacement Acuvue lenses on an extended wear basis. Her visual acuity was 20/200 in the right eye and 20/400 in the left eye. The right eye examination revealed diffuse superficial punctate keratopathy. In the left eye, there was a 3.8 x 4.5 mm corneal infiltrate with projecting crystalline processes. Corneal scrapings were performed for smears and cultures. Treatment with topical fortified cefazolin and fortified tobramycin every hour around the clock was initiated. RESULTS: Culture of the corneal scrapings grew Streptococcus anginosus and Staphylococcus aureus. There was a good response to medical therapy. When last seen after 4 weeks of treatment, the infiltrate measured about 1 mm and the visual acuity was 20/40 with pinhole. CONCLUSIONS: Systemic immunosuppression may be a predisposing factor for the development of ICK. This case suggests that debilitated patients may be at risk for unusual infections and should be discouraged from overnight wear of contact lenses.