Toll-like receptors in acute post-cataract surgery endophthalmitis.

OBJECTIVE: To evaluate the expression of toll-like receptor 2 (TLR2) and toll-like receptor 4 (TLR4) on CD14 + cells in vitreous and blood of post-cataract surgery acute endophthalmitis. DESIGN: This prospective case-control pilot study enrolled 16 patients of post-cataract surgery endophthalmitis. All the cases were subjected to 23 G pars plana vitrectomy (PPV). Ten patients undergoing 23 G PPV for non-infectious conditions were taken as controls. METHODS: 23 G PPV was performed, and three undiluted vitreous samples were collected in heparinized syringes from the cases and the controls. Simultaneous venous blood sample was taken, and flow cytometry was performed to detect the expression of TLR2 and TLR4 in vitreous and blood samples. The vitreous and blood samples were incubated with fluorescein isothicyanate (FITC) conjugated anti-TLR2 monoclonal antibody Alexafluor (AX) 647 and anti-TLR4 monoclonal antibody phycoerythrin. Data acquisition was done on a pre-calibrated flow cytometer. TLR analysis of the acquired flow cytometry data was then performed. Mean channel fluorescence intensity (MFI) derived from fluorescence histogram was used to study the level of cell surface TLR expression. MFI was calculated as a ratio and recorded as the MFI of the TLR2 or -4 antibody divided by the MFI of the isotype-matched negative control antibody. Core vitrectomy was done as per the comfort of the surgeon, and intravitreal antibiotics vancomycin (1 mg/0.1 ml) and ceftazidime (2.25 mg/0.1 ml) were injected. The cytological examination was done on vitreous and blood sample. STATISTICAL ANALYSIS: The median TLR 2 and TLR4 values between cases and controls were compared by Mann-Whitney U test. Spearman's rank correlation test was used to assess the correlation between TLR expression and disease activity. RESULTS: Vitreous cytology evaluation showed the presence of neutrophils (81.25%, n = 13), monocytes (68.75%, n = 11) and lymphocytes (62.50%, n = 10). The level of expression of TLR2 in vitreous showed a statistically significant correlation with an increase in the time interval of cataract surgery and intervention for endophthalmitis (p < 0.05), but the same was not observed for TLR4. A drift toward higher level of expression of TLR2 and TLR4 in vitreous was observed in patients with poor outcome. CONCLUSION: TLR2 levels increase with the delay in presentation; thus, TLR2 ligands in vitreous could serve as a good target for the treatment of endophthalmitis.

Fusarium sacchari, a cause of mycotic keratitis among sugarcane farmers - a series of four cases from North India.

The two most common filamentous fungi causing mycotic keratitis are Aspergillus and Fusarium spp. Around 70 Fusarium spp. are involved in causing human infections. In this study, four cases of keratitis in sugarcane farmers in India are being reported, caused by the sugar cane pathogen Fusarium sacchari, a species of the Fusarium fujikuroi species complex. Fusarial keratitis was established by potassium hydroxide/Calcofluor white wet mounts and fungal culture of corneal scrapings on conventional media. Final identification was done by genetic sequencing at CBS-KNAW, Utrecht, The Netherlands. The antifungal susceptibility testing was done using broth microdilution method as per CLSI document M38-A2. Four cases of F. sacchari keratitis were identified. Three of them had trauma with sugarcane leaves, whereas one sugarcane farmer reported trauma by vegetative matter. The morphological similarities among various Fusarium species warrant use of molecular methods for identification of cryptic species. A wide distribution of sugarcane farming could be the possible explanation for emergence of F. sacchari keratitis in India.

Intravitreal bevacizumab versus posterior subtenon triamcinolone in diffuse diabetic macular edema.

The aim of the study was to compare intravitreal bevacizumab (IVB) and posterior subtenon triamcinolone (PST) as an adjunct to laser treatment in diffuse diabetic macular edema (Diffuse DME). Prospective-randomized control trial of 30 eyes of 30 diabetic patients having Diffuse DME with maximum retinal thickness (MRT) was more than or equal to 350 µm. The subjects were randomly allocated into two groups. Group A (12 eyes) received IVB and group B received PST (18 patients) before laser treatment. Grid laser treatment was done when the MRT decreased to less than 350 µm. OCT thickness-guided repeat injections were given if required. The patients had minimum follow-up of 6 months. At 6-month follow-up, the two groups were compared for (1) Maximum change in visual acuity letter score using logMAR chart (2) Reduction in MRT on OCT. The mean logMAR visual acuity at baseline was 0.63 ± 0.45 (0-1.6) in group A and was 0.76 ± 0.38 (0.2-1.3) in group B. The mean logMAR visual acuity at 6 month in group A was 0.34 ± 0.21 (0-0.6) and in group B was 0.64 ± 0.37 (0.3-1.3). The mean visual acuity at last follow-up was significantly better in group A than group B (p = 0.02). The mean change in MRT in Group A and Group B was 177.8 ± 85.64 and 156.07 ± 102.86, respectively, which was significantly better than the baseline in both the groups and was comparable in both groups. The study provides evidence to support the use of IVB over PST in diffuse diabetic macular edema.

Role of brimonidine in the treatment of clinically significant macular edema with ischemic changes in diabetic maculopathy.

To evaluate the role of brimonidine (BMD), an alpha-2 agonist, in the management of clinically significant macular edema (CSME) in diabetic maculopathy with ischemic changes. A prospective, randomized controlled trial including 30 eyes of 30 metabolically stable diabetic patients with CSME showing fundus fluorescein angiography documented ischemic changes. Group I included 17 eyes of patients who received topical BMD (0.2 %) twice daily for 6 months while Group II included 13 eyes of age-matched patients who were kept under observation and acted as controls. The mean change in logMAR visual acuity and any change in the grade of the foveal avascular zone (FAZ) size, outline, capillary non-perfusion, or capillary dilatation was noted in the two groups and compared at the end of 6 months. The FAZ area and radius was significantly less in the study group than the control group. However, no significant difference in FAZ capillary outline, FAZ capillary loss, FAZ capillary dilatation and overall grade of ischemia between the two groups was seen. There was improvement in visual acuity from baseline to 6 months but it was comparable between the two groups (p = 0.02). BMD may have a role in the treatment of ischemic macula in CSME since the FAZ area and radius were significantly less in the study group. However, a larger sample size and a longer follow-up are needed to further authenticate the results of this pilot study.

Ocular morbidity among school-going children in the Union Territory of Chandigarh.

Schoolchildren in India are susceptible to various types of ocular morbidities. Early detection through regular surveys helps in prompt treatment and prevention of blindness. The aim of this study was to estimate the prevalence of ocular morbidity among schoolchildren aged 6-16 years and to determine their socio-demographic risk factors. This cross-sectional study includes government and private schools in Chandigarh. The study was conducted during August 2010 to December 2010. The World Health Organization 30-cluster sampling technique was used to cover an optimum sample size of 9,067 students in 30 schools from 169 schools in Chandigarh with proportional allocation in different classes. Statistical analysis was done using SPSS version 15.0. Qualitative data was analysed using the Chi squared test. Logistic regression analysis was performed to identify risk factors. Prevalence rates of refractive error, colour-blindness, squint, and vitamin A deficiency were found to be 29.3, 1.2, 0.8 and 0.05 %, respectively, with an overall prevalence of ocular morbidity of 30.4 %. The prevalence of ocular morbidity was significantly higher among female students and among those studying in private schools. The prevalence rate increased significantly with age. A high prevalence of treatable or preventable ocular morbidity was observed among school-going children, and refractive error was the most common problem.

Effect of pterygium on contrast sensitivity.

The purpose of this study is to evaluate the effect of pterygium on contrast sensitivity. Thirty-six eyes with pterygium and 18 eyes without pterygium were included in the study. The size of the pterygium was measured on the slit lamp both vertically at the limbus and categorized into three groups (≤3, 3.1 to ≤5, >5 mm), and horizontally on the cornea and categorized into two groups (0.5 to ≤2, >2 mm), and the area calculated by multiplying the two measurements was then categorized into three groups (≤7, 7.1 to ≤14, >14 mm(2)). Contrast sensitivity was measured using CSV-1000E charts (Vector Vision) at 3, 6, 12 and 18 cycles per degree under photopic and mesopic conditions. The mean vertical length of pterygium was 4.41 ± 1.12 mm, mean horizontal width was 2.09 ± 0.68 mm and mean area was 9.7 ± 5.01 mm(2). Significant differences in both photopic and mesopic contrast sensitivities at all frequencies were noted between normal eyes and vertical length of pterygium >3 mm, horizontal width ≥0.5 mm and area >7 mm(2). Contrast sensitivity had significant negative correlation with all three parameters. Pterygium with vertical length >3 mm, horizontal width ≥0.5 mm and area >7 mm(2) caused a significant decrease in both photopic and mesopic contrast sensitivity at all spatial frequencies. Contrast sensitivity had significant negative correlation with all three parameters.

Five-year study of ocular injuries due to fireworks in India.

To study the demographic profile, cause, type and severity of ocular injuries, their complications and final visual outcome following fireworks around the time of Deepawali in India. Case records of patients who presented with firework-related injuries during 2005-2009 at the time of Deepawali were reviewed. Data with respect to demographic profile of patients, cause and time of injury, time of presentation and types of intervention were analyzed. Visual acuity at presentation and final follow-up, anterior and posterior segment findings, and any diagnostic and surgical interventions carried out were noted. One hundred and one patients presented with firework-related ocular injuries, of which 77.5 % were male. The mean age was 17.60 ± 11.9 years, with 54 % being ≤14 years of age. The mean time of presentation was 8.9 h. Seventeen patients had open globe injury (OGI) and 84 had closed globe injury (CGI). Fountains were the most common cause of CGI and bullet bombs were the most common cause of OGI. Mean log MAR visual acuity at presentation was 0.64 and 1.22 and at last follow-up was 0.09 and 0.58 for CGI and OGI, respectively (p < 0.05). Patients with CGI had a better visual outcome. Three patients with OGI developed permanent blindness. Factors associated with poor visual outcome included poor initial visual acuity, OGI, intraocular foreign body (IOFB), retinal detachment and development of endophthalmitis. Firework injuries were seen mostly in males and children. Poor visual outcome was associated with poor initial visual acuity, OGI, IOFB, retinal detachment and development of endophthalmitis, while most patients with CGI regained good vision.

Fusarium sacchari: a cause of exogenous fungal endophthalmitis: first case report and review of literature.

A case of exogenous fungal endophthalmitis due to Fusarium sacchari is being reported. It has never been reported in this clinical entity before; hence, to the best of our knowledge, this is first report of F. sacchari as a cause of exogenous fungal endophthalmitis and also the first time when this fungus has been isolated from an Indian patient.

Capsular contraction syndrome following insertion of hydrophilic acrylic lens.

A 52-year-old female of Asian Indian origin underwent uncomplicated phacoemulsification with insertion of a foldable hydrophilic acrylic single-piece intraocular lens which resulted in good postoperative vision. Five weeks later she presented with decreased vision and examination revealed fibrosis as well as phimosis of the anterior capsular opening. Surgical capsulotomy was performed as there was an extremely thick fibrotic membrane, thereby clearing the visual axis and improving her vision. Capsular contraction syndrome (CCS) is very rare following insertion of hydrophilic acrylic lenses. We describe a case of anterior capsular contraction syndrome following uneventful surgery and without any known predisposing factors.

Isolated cavernous hemangioma of conjunctiva.

A 70-year-old Indian female presented with a lobulated, violet-colored mass in the left eye involving the medial bulbar conjunctiva and caruncle. It was smooth, vascular, compressible, and freely mobile. It was neither reducible nor pulsatile and did not cause any proptosis or dystopia. Any syndromic associations and orbital extension of the lesion were ruled out. Excisional biopsy was performed, and histopathologic examination confirmed the diagnosis of cavernous hemangioma of conjunctiva involving the caruncle.

Successful treatment of choroidal neovascular membrane in retinitis pigmentosa with intravitreal bevacizumab.

We report a rare association of choroidal neovascularization (CNV) with retinitis pigmentosa and note its resolution by intravitreal injection of the anti-vascular endothelial growth factor (VEGF), bevacizumab. A classic choroidal neovascular membrane was seen in the right eye (RE) of a patient with sector retinitis pigmentosa. Bevacizumab 1.25 mg in 0.05 ml was injected intravitreally. The choroidal neovascular membrane was seen to regress following this single intravitreal bevacizumab injection with formation of a scar. CNV has very rarely been seen in association with retinitis pigmentosa. Anti-VEGF drugs have been shown to have a beneficial role in CNV with other causes; in this case their effectiveness in CNV associated with retinal dystrophies, for example retinitis pigmentosa, has been demonstrated.

Multiple myeloma presenting as bilateral orbital proptosis.

A 58-year-old-man presented with painful rapidly progressive bilateral proptosis with restricted ocular movements of 15 days duration. There was history of significant weight loss in the recent past. Computed tomography scan of the head and orbit revealed bilateral multiple, well-defined, round, soft tissue masses, isointense with muscles in intraconal and extraconal space. Fine needle aspiration cytology and incision biopsy from the lesion, urine for Bence-Jones proteins and immunofixation clinched the diagnosis of multiple myeloma. Skeletal survey did not reveal any bony involvement. The diagnosis of multiple myeloma should be kept in mind in cases of bilateral proptosis. Bony involvement is not universal in cases of orbital myeloma. Early diagnosis can be established with extensive biochemical and histopathological investigations and timely treatment is life saving for these patients.

Molecular identification of Fusarium species complex isolated from clinical samples and its antifungal susceptibility patterns.

BACKGROUND AND PURPOSE: More than 300 Fusarium species are grouped into approximately 23 species complexes out of which around 70 are involved in human infections. The nomenclature of these species has undergone considerable changes in recent years. These species cause localized infections in individuals while inducing systemic infections mainly in immunocompromised patients. The present study was conducted to identify Fusarium species in clinical isolates by molecular methods and determine their in vitro minimum inhibitory concentration (MIC) patterns to address the lack of data in this domain in Northern India. MATERIALS AND METHODS: For the purpose of the study, Fusarium isolates obtained from various clinical samples were sent to the Westerdijk Fungal Biodiversity Institute, Utrecht, the Netherlands, for molecular identification. The MIC testing was performed using the microbroth dilution method as per the Clinical and Laboratory Standards Institute reference method (M38-A2). RESULTS: Fusarium was isolated from 33 patients (i.e., 1, 1, 2, 14, and 15 cases with endophthalmitis, sinusitis, pulmonary involvement, onychomycosis, and keratitis, respectively). These 33 isolates belonged to three species complexes, namely F. solani species complex (FSSC; n=13), F. fujikuroi species complex (FFSC; n=13), and F. incarnatum equiseti species complex (FIESC; n=7). The species identified within FSSC, FFSC, and FIESC included F. keratoplasticum (n=6)/F. falciforme (n=6)/F. solani (n=1), F. proliferatum (n=7)/F. sacchari (n=5)/F. anthophilum (n=1), and F. incarnatum SC species (n=6)/F. equiseti SC species (n=1), respectively. The MIC results showed that all isolates had a lower MIC against amphotericin B than against the other antifungal agents.

Vision-related quality of life in children with treated retinopathy of prematurity.

Purpose: To evaluate vision-related quality of life in children treated for retinopathy of prematurity. Methods: Cross sectional observational study of 54 treated ROP babies 2-7 years of age. The study excluded babies with chronic pediatric conditions and babies of parents suffering from mental illness. Detailed examination including visual acuity was done for all. Two versions of CVFQ questionnaire for children under 3 and above 3 years of age were posed to parents in this study. CVFQ contains six subscales: General health, vision health, competence, personality, family impact, and treatment difficulty. The scores ranged from 0 (worst score) to 1 (best score). Results: The study included 54 children with mean birth weight was 1194 grams, mean gestation age 30 weeks. The age, gender, birth weight, and gestational age didn't affect the overall quality of life (P > 0.05). The severity of ROP (stage 4 and 5) had poorer CVFQ scores (personality and family impact subscales). Competence and personality scores were significantly lower in zone I disease. The quality of life especially general vision, competence, personality, and treatment difficulty subscales had significantly lower values in ROP with higher clock hour involvement (P < 0.05). With myopia after ROP treatment, only personality subscale was significantly affected (P 0.02). Mean CVFQ score including the family impact and treatment difficulty subscale score was also significantly lower in amblyopic and anisometropic children (P value < 0.05). Family impact subscale and overall quality of life was significantly lower in children with strabismus than children without strabismus (P 0.001). Conclusion: ROP has negative effect on the vision-related quality of life of children and their parents. The overall quality of life worsened with the increase in the severity of disease and the occurrence of ocular sequelae of ROP. The vision of the baby may not be the only cause of low scores in the quality of life questionnaire in ROP.

Successful management of bee sting induced Aspergillus fumigatus endophthalmitis and scleritis.

Ocular bee stings are known to cause corneal melts, corneal infiltrates, cataracts, and secondary glaucoma. Our patient presented with scleritis, corneal infiltrates, and endophthalmitis after a ocular bee sting. Topical treatment led to resolution of anterior segment inflammation, but the scleritis and vitreous inflammation worsened. Vitrectomy with intravitreal antibiotics was done and scrapings from the scleral abscess showed growth of Aspergillus fumigatus on culture. Repeat vitrectomy with silicone oil was needed for retinal detachment. Oral and intravitreal antifungals led to resolution of inflammation with attached retina. This is the first reported case of bee sting-induced fungal endophthalmitis with scleritis.

Assessment of contrast sensitivity by Spaeth Richman Contrast Sensitivity Test and Pelli Robson Chart Test in patients with varying severity of glaucoma.

PURPOSE: This study was designed to assess the efficacy, reliability and repeatability of SPARCS (Spaeth Richman Contrast Sensitivity Test) as compared to the conventional Pelli Robson Chart Test for the assessment of contrast sensitivity in patients with glaucoma. MATERIALS AND METHODS: We evaluated 135 eyes of 135 patients who were age and sex matched into three groups (controls, disc suspects and glaucoma) of 45 patients each. The glaucoma subgroup was further divided into subgroups of mild, moderate and severe based on the visual field damage. RESULTS: There was a strong positive correlation between Pelli Robson scores and SPARCS scores (S = 0.807, P < 0.001). Intraclass correlation coefficient (ICC) for Pelli Robson Test was 0.952 and 0.988 for SPARCS. The coefficient of repeatability (COR) for mean SPARCS was 5.65%, while COR of Pelli Robson Test was 12.44%. SPARCS was found to have better repeatability than Pelli Robson Test based on COR values. Pelli Robson score had a sensitivity of 80% and a specificity of 65.6% for detecting glaucoma patients as compared to 84.4% and 70%, respectively, for SPARCS scores. CONCLUSION: SPARCS is a better alternative to conventional Pelli Robson Chart Test for assessment of contrast sensitivity in patients with glaucoma. Being independent of the effects of literacy and educational status, it offers a universal way to measure contrast sensitivity. It can also be reliably used in patients with varying severity of glaucoma.

Tubercular dacryoadenitis--a case report and review of literature.

A case of a 56 year old lady presenting clinically with a slow growing painless mass of the left lacrimal gland, the histopathplogical examination of which was consistent with a diagnosis of tubercular dacryoadenitis, is described. Tubercular dacryoadenitis is uncommon, with the diagnosis usually made on histological examination of the lacrimal gland. Other cases of tubercular dacryoadenitis reported in literature are also reviewed.

Bilateral Central Retinal Vein Occlusion as Presenting Feature of Chronic Myeloid Leukemia.

Central retinal vein occlusion (CRVO) is a common pathology of the retinal vasculature. Patients with CRVO usually present with a drop in visual acuity. The condition bears no specific therapy; treatment is aimed at the management of potentially blinding complications, of which there are many. With majority of cases being unilateral, bilateral CRVO is usually associated with an underlying systemic illness such as a hyperviscosity syndrome. Here, we present a case of a patient, who presented with a bilateral drop in vision diagnosed as bilateral CRVO on ophthalmic evaluation. Systemic workup revealed the presence of an underlying undiagnosed chronic myeloid leukemia. An initial presentation to the ophthalmologist is a rare occurrence in leukemic patients. This case report highlights the role of the ophthalmologist in diagnosing a potentially life-threatening hematological illness.

Unilateral visual loss due to central retinal artery occlusion with total ophthalmoplegia following cervical spine surgery in prone position.

BACKGROUND: Blindness after spinal surgery is a rare complication, but it is serious, irreversible and incurable. Central retinal artery occlusion (CRAO) is rare after spinal surgery and ophthalmoplegia is even rarer. CASE: A 52-year-old male patient complained of loss of vision in right eye immediately after cervical spine surgery. On examination, the patient's visual acuity in right eye was absent perception of light. Right eye pupil was dialated and relative afferent pupillary defect (RAPD) was present. Extraocular movements were absent in all gazes in right eye. Intra-ocular pressure (IOP) was 26 mmHg in right eye and 16 mmHg in the left. Posterior segment examination revealed blurred disc margin with ischemic whitening of retina, thin and attenuated retinal arterioles and a central cherry red spot in right eye. Left eye was essentially normal. OBSERVATIONS: The causal factors of blindness in the patient were likely ischemia of the retina after venous congestion or temporary arterial occlusion resulting from changes in pressure to the tissues of the orbit. Factors including prolonged prone positioning with head end dependent position and possibility of orbital compression by the headrest could have contributed to impaired venous drainage, increase in IOP and reduction in perfusion pressure. CONCLUSION: Loss of vision post spinal surgery is a rarest of complication yet grave and irreversible. Because the problem involves mainly prone positioning of the patient, an appropriate position should be found so that facial and ocular compression can be avoided.

Orbital Cysticercosis - masquerading as preseptal cellulitis with ptosis.

We are sharing a case of orbital cysticercosis,which presented to us initially with simple ptosis and later on with upper lid inflammation and restricted ocular motility in upgaze. Human cysticercosis, a parasitic infection caused by Cysticercus cellulosae, the larval form of the cestode, Taenia solium, is a benign infection of the subcutaneous tissues, inter-muscular fascia, muscles and other organs. Though it exists worldwide, it is more prevalent in the developing countries of Latin America, Asia and Africa, especially in areas where under-cooked pork is consumed regularly (Pushker et al, 2001). However, 5 year study of 33 cases of Ocular/Adnexal cysticercosis showed seventy percent of patients were of low socioeconomic group and 70% were strictly vegetarians (Atul et al, 1995). The clinical manifestation of orbital cysticercosis is entirely different from neuro-cysticercosis or cysticercosis of other parts of body. Diagnosis of cysticercosis is mainly based on highly specific radiological signs and history of exposure in endemic areas.