Peripartum hysterectomy clinical characteristics and outcomes- a hospital based retrospective audit study.

INTRODUCTION: The study aims to evaluate and report on the clinical characteristics, incidence, risk factors and associated complications of emergency and planned peripartum hysterectomy in a single training and research tertiary health care centre in Malaysia. MATERIALS AND METHODS: We conducted a 6-year retrospective cross-sectional study from the 1st January 2016 until 31st December 2021. Clinical, demographic characteristics, perioperative parameters, operative indications, blood loss, maternal/neonatal outcomes and complications were analysed. Patients were subdivided, analysed and studied in two subgroups- emergency hysterectomy (EH) and planned hysterectomy (PH). RESULTS: There were 65 cases of peripartum hysterectomy out of total 100,567 deliveries, with a prevalence rate of 0.06%. Overall, the majority of patients were multiparous (96.9%), having previous caesarean scar (73.8%) or diagnosed with placenta praevia (75.4%). More than half of the total patients (61.5%) have both previous caesarean scar and concomitant placenta praevia. EH was carried out in 39(60%) patients while 26(40%) patients underwent PH. The only indication for surgery in the PH group (100%) was abnormal placentation while the most common indication for surgery in the EH group (53.8%) was postpartum haemorrhage related to abnormal placentation. Patients who underwent EH were more likely to have massive blood loss (p=0.001), require ICU admissions (p=0.001), have DIVC cycles transfused (mean [SD] regime: 1.35 [0.95] vs 0.54 [0.99]; p=0.002), have lower postoperative haemoglobin level (mean [standard deviation, SD] haemoglobin: 9.23g/l [SD1.8] vs. 10.8 g/l [SD1.86]; p=0.001) and have higher difference between pre/post operative haemoglobin level (mean [SD] haemoglobin difference: 1.78g/l [SD6.34] vs 0.32g/l [SD1.7]; p=0.008) compared to patients with PH. Red blood cell transfusion, operating time, length of stay, weight of babies and Apgar score between two groups showed no significant differences. A significant reduction of blood loss between the first and the second half duration of the study (mean [SD] blood loss: 6978 ml [SD 4999.45] vs. 4100ml [SD2569.48]; p=0.004) was also observed. In the emergency group, 'non-placental cause' EH required significantly more red blood cell transfusion than 'placental cause' (p<0.05) while in the PH group, no significant difference was observed between the occlusive internal iliac artery 'balloon' and 'no balloon' subgroup in terms of operating time, total blood loss or blood transfusion. Overall complications showed more cases of post operative fever and relaparotomy in the EH group (18.4% vs. 7.6%) while urinary tract injuries including injuries to bladder and ureter occurred only in the PH group (9.4% vs. 0%). CONCLUSION: The majority of peripartum hysterectomy cases are due to placenta accreta spectrum disorders. Planned peripartum hysterectomies have a lower morbidity rate compared to emergency hysterectomies. Therefore, early identification of placenta accreta spectrum disorders and timely planning for elective procedures are crucial to minimise the need for emergency surgery.

Descemet's Membrane Endothelial Keratoplasty in South Asian Population.

PURPOSE: To evaluate visual outcomes, endothelial cell density and complications following Descemet's membrane endothelial keratoplasty (DMEK). METHODS: This study included 40 consecutive eyes that underwent DMEK for various pathologies involving the corneal endothelium. Best corrected visual acuity (BCVA) and endothelial cell density (ECD) were measured and compared before and 6 months after surgery. RESULTS: Out of 40 eyes, 34 eyes (85%) had BCVA ranging from 0.5 to 0.7 LogMAR 6 months postoperatively. Mean donor ECD was 2367.96 ± 47.87 (range, 2314.0-2472.0) cells/mm2 preoperatively, which was reduced to 1798.42 ± 45.79 (range, 1736.0-1902.0) cells/mm2 6 months after DMEK surgery, indicating a mean reduction of 569.54 cells/mm2 (24%) in ECD. CONCLUSION: DMEK is an emerging and a more advanced alternative to penetrating keratoplasty (PKP) and Descemet's stripping endothelial keratoplasty (DSEK) for corneal pathologies involving the corneal endothelium. Compared to PK and DSEK, however, DMEK has a longer learning curve, and its safety and efficacy need to be confirmed through more experience on a large volume of cases.

Non-invasive assessment of tear film stability with a novel corneal topographer in Indian subjects.

The aim of the study is to investigate the applicability of a newly developed corneal topographer in assessing tear film stability in Indian subjects. A prospective comparative study of 25 Indian subjects with dry eyes attending a tertiary eye care clinic in South India and 25 normal control subjects was conducted. The diagnosis of dry eye was made based on ocular surface disease index questionnaire. Non-invasive tear film break-up time (NI-TBUT) was measured using a new method based on a corneal topographer equipped with modified scan software. The correlations between the NI-TBUT and the traditional fluorescein tear film break-up time (F-TBUT), Schirmer I test values were determined. A total of 50 patients (100 eyes) were included. The values of NI-TBUT were significantly lower than the values of F-TBUT in both the cases (NI-TBUT 5.78 ± 0.8 s and F-TBUT 7.56 ± 0.5 s; p < 0.02) and controls (NI-TBUT 11.66 ± 1 s and F-TBUT 12.92 ± 1.2 s; p < 0.01). NI-TBUT values were significantly lower than the corresponding F-TBUT values in the varying grades of dry eyes. The mean NI-TBUT values in mild dry eyes was 6.42 ± 0.2 s, moderate dry eyes was 4.70 ± 0.3 s and in severe dry eyes was 2.32 ± 1.2 s. There was a significant difference in the NI-TBUT values for cases and controls (p < 0.001). There was a good correlation seen between the NI-TBUT values and the F-TBUT values, Schirmer I values and the ODSI scores. NI-TBUT was found to have a sensitivity of 86.1 % and a specificity of 81.1 % when the cut-off value was kept at 6.2 s. We investigated the performance of a non-invasive technique for measuring tear film stability to aid in the diagnosis of dry eye disease. It is a useful non-invasive objective method for the detection of dry eye, and its varying grades and may be useful in monitoring the efficacy of therapies for dry eye.

Simultaneous Descemet's membrane endothelial keratoplasty and posterior iris-claw-fixated intra ocular lens implantation (IOL) in management of aphakic bullous keratopathy.

To evaluate the efficacy of combined procedure of Descemet's membrane endothelial keratoplasty (DMEK) and posterior iris-claw-fixated intra ocular lens (IOL) implantation in the management of aphakic bullous keratopathy (ABK). Sankara eye centre, a tertiary eye care centre. A prospective case series analysis. A prospective study comprised ten eyes of ten patients who underwent DMEK and posterior iris-claw-fixated IOL. Mean follow-up period was 12-36 months. Pre-operative and post-operative best corrected visual acuity (BCVA), endothelial cell density (ECD) and complications were noted. A total ten eyes of ten patients underwent DMEK. Out of ten patients BCVA improved from 1.00 to 1.60 LogMAR with mean and SD of 1.40 ± 0.20 to +0.20-0.40 LogMAR with mean and SD of 0.30 ± 0.07, with a significant p value of <0.001, Mean ECD of the donor tissue pre-operatively was 2367 cells, whereas 24 months post-operatively it was reduced to 1798 cells. Mean reduction in ECD pre procedure and post procedure was 569 (24 %). Iris-fixated IOL appears to offer simplicity in implantation and may be combined with DMEK in ABK. This procedure provides a faster visual recovery than other endothelial keratoplasties with iris-fixated IOL.

Descemet's Stripping Automated Endothelial Keratoplasty versus Descemet's Membrane Endothelial Keratoplasty in the Fellow Eye for Fuchs Endothelial Dystrophy: A Retrospective Study.

AIM: To evaluate visual outcome and endothelial cell density (ECD) after Descemet's Membrane Endothelial Keratoplasty (DMEK) in comparison with Descemet's Stripping Automated Endothelial Keratoplasty (DSAEK) in the fellow eye for Fuchs endothelial dystrophy (FED). DESIGN: Single-centre, retrospective case series. METHODS: 30 eyes of 30 patients undergoing DMEK, who completed a 1-year follow-up, were compared with 30 fellow eyes which underwent DSAEK for bilateral FED. Main outcome measures studied included Best Corrected Visual Acuity (BCVA) and ECD during a 1-year follow-up period. RESULTS: BCVA improved from 0.78 ± 0.35 logMAR, and 0.73 ± 0.31 logMAR before surgery to 0.22 ± 0.1 logMAR and 0.35 ± 0.12 logMAR 6 months after DMEK and DSEK, respectively (P < 0.001). At one year after surgery, the BCVA was maintained at 0.21 ± 0.12 logMAR and 0.34 ± 0.1 logMAR, respectively, after DMEK and DSAEK. A statistically better visual outcome was observed after DMEK compared to DSAEK (P < 0.05) in fellow eyes. CONCLUSIONS: DMEK provided better visual rehabilitation when compared to DSAEK. Nevertheless, there were no significant differences with regard to the ECD within a 1-year follow-up.

Implantable collamer lens V4b and V4c for correction of high myopia.

PURPOSE: To evaluate the visual outcome and intraocular pressure changes after Visian Implantable Collamer Lens (ICL) implantation V4b and V4c (with central hole) for correction of high myopia. METHODS: A prospective, consecutive, interventional comparative case series of V4b and V4c ICL implantation was done in high myopic patients who were unsuitable for laser vision. The main outcome measures studied were uncorrected and corrected distant visual acuity (UDVA, CDVA), ICL vault, intraocular pressure (IOP), endothelial cell count (ECC), and development of subcapsular lens opacities. The patients were evaluated at postoperative 1,3,6, and 9 months. RESULTS: A total of 62 eyes of 32 patients (24.56 ± 4.8 years) underwent V4b ICL implantation (21 non-toric, 41 toric ICL-TICL) with intraoperative peripheral iridectomy (PI), and 10 eyes of 5 patients (26.13 ± 3.8 years) had implantation of V4c ICL (4 non-toric, 6 TICL). The mean preoperative manifest spherical equivalent (MSE) was -9.98 ± 2.8 D and -9.14 ± 2.4 D in the V4b and V4c groups, respectively, which reduced to postoperative values of -0.24 ± 1.3 D and -0.2 ± 1.18 D, respectively. At the end of 9 months follow-up, mean ECC loss was 6.4% and 6.1%, mean vault was 573.13 ± 241.13 µ, and 612 ± 251.14 µ, respectively, in the V4b and V4c groups. Anterior subcapsular opacities were present in 6.9% and 3.14% of eyes with V4b and V4c groups, respectively. Four eyes from V4b (9.75%) and 1 eye from V4c (16.66%) had rotation of more than 30° and required realignment surgery, which was done successfully. Two eyes (3.22%) with V4b ICL implantation had high postoperative IOP (>35 mm Hg) due to blocked PI and required Nd:Yag laser iridotomy, which was done with successful control of IOP. The safety indices were 1.11 and 1.14, and efficacy indices were 1.4 and 1.5 in the V4b and V4c groups, respectively, at the end of 9 months. CONCLUSION: ICL implantation is a safe and effective surgery for correction of high myopia. Implantation of ICL with a central hole showed negligible postoperative IOP fluctuations without a peripheral iridectomy.

Nasal lobular capillary hemangioma.

Nasal lobular capillary hemangioma is a rare benign tumor of the paranasal sinuses. This lesion is believed to grow rapidly in size over time. The exact etiopathogenesis is still a dilemma. We discuss a case of nasal lobular capillary hemangioma presenting with a history of epistaxis. Contrast enhanced computed tomography of paranasal sinuses revealed an intensely enhancing soft-tissue mass in the left nasal cavity and left middle and inferior meati with no obvious bony remodeling or destruction. We present imaging and pathologic features of nasal lobular capillary hemangioma and differentiate it from other entities like nasal angiofibroma.

Correlation of ultrasonographic parameters with serum creatinine in chronic kidney disease.

OBJECTIVE: The purpose of our study is to correlate renal echogenicity with serum creatinine in order to determine the significance of renal echogenicity when it comes to identifying the progression of chronic kidney disease (CKD) and for the sonographic grading of CKD. MATERIALS AND METHODS: Sixty patients above 30 years of age who had been diagnosed with CKD according to the guidelines of the National Kidney Foundation were included in the study. Patients on kidney replacement therapy or with fatty liver findings on ultrasonography were excluded. Ultrasounds of kidneys were performed by two radiologists who were blind to the patients' serum creatinine levels. Renal cortical echogenicity was compared with serum creatinine. Statistical analysis was performed using one-way ANOVA followed by Scheffe's test. The relationship between serum creatinine and sonographic features was assessed by correlation coefficient analysis. A P value less than 0.05 was considered statistically significant. RESULTS: Mean serum creatinine was 2.80 mg/dl for Grade 1 (range: 0.9-9.2 mg/dl), 3.69 mg/dl for Grade 2 (range: 1.2-10.3 mg/dl), 3.86 mg/dl for Grade 3 (range: 1.1-6.5 mg/dl), and 7.90 mg/dl for Grade 4 (range: 3.1-11.4 mg/dl). The grades being determined by cortical echogenicity on imaging A statistically significant, positive correlation was observed between serum creatinine and grading based on cortical echogenicity (P = 0.004). CONCLUSION: Renal echogenicity and its grading correlates better with serum creatinine in CKD than other sonographic parameters such as longitudinal size, parenchymal thickness, and cortical thickness. Hence, renal echogenicity is a better parameter than serum creatinine for estimating renal function in CKD, and has the added advantage of irreversibility.

Imaging in classic form of maple syrup urine disease: a rare metabolic central nervous system.

Maple syrup urine disease (MSUD) is a rare autosomal recessive disorder of branched-chain amino acid metabolism. The condition gets its name from the distinctive sweet odour of affected infants' urine. MSUD is caused by a deficiency of the branched-chain α-ketoacid dehydrogenase enzyme complex, leading to accumulation of the branched-chain amino acids (leucine, isoleucine, and valine) and their toxic by-products (ketoacids) in the blood and urine. Imaging is characterestized by MSUD oedema affecting the myelinated white matter. We present a neonate with classic type of MSUD and its imaging features on computed tomography, conventional magnetic resonance imaging, diffusion-weighted imaging, and magnetic resonance spectroscopy.

Mixed adenoneuroendocrine carcinoma of cecum: a rare entity.

Mixed adenoneuroendocrine carcinoma of cecum (MANEC) was first reported by Cardier in 1924. These tumors are thought to arise from multi-potential stem cells, which have differentiated bidirectionally. Location of the tumor influences the treatment and outcome. We report a rare case of MANEC where the patient presented with abdominal pain and distension. Imaging revealed an ileo colic intussusception with the lead point being a MANEC.