Outbreak of Multidrug-resistant Pseudomonas Aeruginosa Endophthalmitis Due to Contaminated Trypan Blue Solution.

PURPOSE: To report the investigation of an outbreak of multidrug-resistant (MDR) Pseudomonas aeruginosa endophthalmitis in 13 patients after cataract surgery and to emphasize on the importance of clinical profile, risk factors, and treatment outcomes. METHODS: This was a hospital-based, retrospective case study with 13 consecutive patients who had man- ual small-incision cataract surgery with intraocular lens (IOL) implantation and developed acute postoperative Pseudomonas aeruginosa endophthalmitis. The anterior chamber taps, vitreous aspirates, and environ- mental surveillance specimens were inoculated for culturing. Antibiotic susceptibility testing was performed using the agar diffusion method. Pulsed-field gel electrophoresis (PFGE) was used to determine the relation- ship between bacterial isolates recovered from study patients and contaminated surveillance samples. RESULTS: Pseudomonas aeruginosa was isolated from all 13 eyes with acute postoperative endophthalmitis and the trypan blue solutions used during surgery. Sensitivity tests revealed that all isolates had an identical resistance to multiple drugs and were only susceptible to imipenem. Genomic DNA typing of Pseudomonas aeruginosa isolates recovered from patients and trypan blue solutions showed an identical banding pattern on the PFGE. Despite the prompt use of intravitreal antibiotics and early vitrectomy with IOL explantation in some patients, the outcome was poor in about 50% of patients. CONCLUSION: Positive microbiology and genomic DNA typing results proved that the contaminated trypan blue solutions were the source of infection in this outbreak. Postoperative endophthalmitis caused by Pseudomonas aeruginosa is often associated with a poor visual prognosis despite prompt treatment with intravitreal antibiotics.

Safety and efficacy of riboflavin-assisted collagen cross-linking of cornea in progressive keratoconus patients: A prospective study in North East India.

INTRODUCTION: Riboflavin- and ultraviolet (UV)-A-mediated collagen cross-linking of the cornea is a frequently used therapeutic measure for the treatment of progressive keratoconus (PK). First, riboflavin increases cross-linking and second, it serves as a protective shield to other deep ocular structures. However, pharmacogenomic variation in riboflavin efficacy is reported. As the Northeast Indian population represents a genetically diverse group of population compared to mainstream India, we have assessed the efficacy of the procedure in a northeastern population with PK. METHODS: In this study, 78 eyes with PK were included (n = 39 in the treatment arm and n = 39 in the control arm). The primary objective was to evaluate the effect of corneal collagen cross-linking using riboflavin (C3R) (epithelium off) on maximum keratometry. The secondary objectives were evaluation of change in corneal topography parameters, i.e., minimum keratometry (Kmin), simulated keratometry (Sim K), subjective refraction (cylinder power, spherical power, and spherical equivalent [SE]), uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA), and contrast sensitivity (CS) and safety (intraocular pressure, endothelial cell density, and percentage hexagonality) at 1, 3, and 6 months following C3R procedure. RESULTS: Statistically significant improvement was noted in Kmin (6 months), Sim K (3 and 6 months), cylinder power (3 and 6 months), spherical power (3 and 6 months), SE (3 and 6 months), BCVA (6 months), and UCVA (1, 6 months) in the C3R group (n = 39) when compared to the control group (n = 39). The mean CS decreased at 1 month and gradually improved to achieve statistically significant value at 6 months in the C3R group (P < 0.05). CONCLUSION: Riboflavin-assisted C3R treatment showed promising efficacy in the treatment of PK patients in our population. As the collagen turnover rate of cornea is 2-3 years and the progression of PK is highly variable, we need long-term studies to evaluate the efficacy of C3R over time, requirement of repeat therapy, and safety of repeat cross-linking.

Construction and validation of logMAR visual acuity charts in seven Indian languages.

Purpose: The evaluation of visual impairment requires the measurement of visual acuity with a validated and standard logMAR visual acuity chart. We aimed to construct and validate new logMAR visual acuity chart in Indian languages (Hindi, Bengali, Telugu, Urdu, Kannada, Malayalam, and Assamese). Methods: The commonly used font in each language was chosen as the reference and designed to fit the 5 × 5 grid (Adobe Photoshop). Ten letters (easiest to difficult) around median legibility score calculated for each language based on the results of legibility experiment and differing by 10% were selected. The chart was constructed based on the standard recommendations. The repeatability of charts was tested and also compared with a standard English Early Treatment Diabetic Retinopathy Study (ETDRS) logMAR chart for validation. Results: A total of 14 rows (1.0 to -0.3 logMAR) with five letters in each line were designed with the range of row legibility between 4.7 and 5.3 for all the language charts. Each chart showed good repeatability, and a maximum difference of four letters was noted. The median difference in visual acuity was 0.16 logMAR for Urdu and Assamese chart compared to ETDRS English chart. Hindi and Malayalam chart had a median difference of 0.12 logMAR. When compared to the English chart a median difference of 0.14 logMAR was noted in Telugu, Kannada, and Bengali chart. Conclusion: The newly developed Indian language visual acuity charts are designed based on the standard recommendations and will help to assess visual impairment in people of these languages across the country.

Cyclophotocoagulation-induced sympathetic ophthalmia in a Coats' disease patient supported by histopathology and immunohistochemistry.

We describe a case of a 13-year-old male patient of Coats' disease who developed sympathetic ophthalmia (SO) following contact diode laser cyclophotocoagulation. There was no history of invasive surgery or any perforating injuries preceding cyclodestructive therapy. The eye had neovascular glaucoma secondary to Coats' disease, which was treated once with contact cyclophotocoagulation. Subsequently, the intraocular pressure slowly decreased, and the eye became phthisical. Intraocular inflammation developed in the fellow eye and SO was suspected, which was confirmed by characteristic findings seen on fluorescein angiography. The case was successfully managed with the help of topical and systemic immunosuppression. Enucleation with silicone ball implantation was performed in the right phthisical eye and specimen was sent for histopathological examination. Histopathology and immunostaining supported the diagnosis of SO.

Bilateral spontaneous anterior dislocation of intraocular lens with the capsular bag in a patient with pseudoexfoliation.

We report a rare case of bilateral spontaneous anterior partial in-the-bag intraocular lens (IOL) dislocation in a 75-year-old man with pseudoexfoliation (PXF). He underwent uneventful phacoemulsification in both eyes with in-the-bag IOL implantation 9 years back. In the right eye, single piece poly (methyl methacrylate) (PMMA) IOL (+19 D) and in the left eye, single piece acrylic foldable IOL (+19 D) were implanted. An attempt at pharmacological IOL repositioning was unsuccessful. The dislocated IOLs were explanted and exchanged with scleral suture fixated PMMA IOLs. Vision improved to 20/30 in both eyes following surgery, without any associated ocular morbidity. We believe that zonular weakness secondary to PXF, capsular contraction, and myopia together were the predisposing factors for partial anterior dislocation of IOLs and IOL exchange with scleral suture fixation of IOL is a safe and effective treatment option.

Femtosecond laser-assisted keratopigmentation for the management of visual disabilities due to peripheral iridectomies.

PURPOSE: To report the technique and result of keratopigmentation using a femtosecond laser for the treatment of functional visual disabilities caused by peripheral iridectomies. DESIGN: Case report. METHODS: Two eyes of 2 patients underwent femtosecond laser-assisted keratopigmentation (FLAK) for moderate to severe visual dysfunction secondary to peripheral iridectomies. The main outcomes measures of the study were changes in visual-related symptoms, cosmesis, and intraoperative surgical complications. RESULTS: Following FLAK, the visual-related symptoms (ghosting, glare, and monocular diplopia) improved in both cases with significant improvement to total elimination of symptoms. No patient lost any lines of visual acuity, and no significant complications were observed during the follow-up period. The cosmetic appearance was reported as very good. CONCLUSIONS: FLAK is minimally invasive and results in a significant decrease in the subjective glare and photophobia and even in resolution of monocular diplopia. The cosmetic outcome was also favorable. This technique allows surgeons to correct visual disabilities associated with iris defects with a high success rate while avoiding more aggressive intraocular surgery.

Indications for and outcomes of deep anterior lamellar keratoplasty in mucopolysaccharidoses.

PURPOSE: To describe the outcome of deep anterior lamellar keratoplasty (DALK) for visually significant corneal clouding in patients with mucopolysaccharidoses (MPS). METHODS: A retrospective consecutive case series of patients with MPS and corneal clouding were analyzed at a tertiary eye hospital. A review of the English literature regarding MPS and DALK was performed. The main outcomes measures of the study were intraoperative surgical complications, change in visual acuity, and postoperative DALK-related complications. RESULTS: Four eyes from 2 patients with MPS I (Hurler's syndrome and Hurler-Scheie syndrome) and a history of DALK met inclusion criteria for the case series. Using the "big-bubble" technique, DALK was performed successfully in all eyes. Completed Descemet's membrane baring was achieved in 3 or 4 eyes and a pre-Descemet's membrane dissection in 1 eye. The mean age at the time of DALK was 17.3 years (range: 15.4 to 19.5 years). Mean follow-up time after DALK was 16.7 months (range: 6 to 31 months). Mean visual acuity before DALK was 20/80 (0.59 ± 0.12 logMAR). Mean visual acuity at the last visit for all 4 eyes was 20/50 (0.41 ± 0.17 logMAR). Visual acuity improved in all eyes. Recurrence of MPS corneal clouding was not noted in any of the corneal grafts. CONCLUSIONS: DALK is a beneficial and preferable intervention in appropriate patients with significant corneal clouding due to MPS I. Improvement in vision can be obtained with stable, clear corneal grafts, although other ophthalmic manifestations may limit vision.

Mucous membrane grafting for the post-Steven-Johnson syndrome symblepharon: a case report.

An 18-year-old woman was referred with late sequelae of chloroquine-induced Steven-Johnson syndrome. At the time of presentation, the symblepharon was involving the upper lids to almost the whole of the cornea, and part of the lower bulbar conjunctiva with the lower lid bilaterally. Other ocular examinations were not possible due to the symblepharon. B-scan ultrasonography revealed acoustically clear vitreous, normal chorioretinal thickness, and normal optic nerve head, with an attached retina. Conjunctivo-corneal adhesion released by superficial lamellar dissection of the cornea. Ocular surface reconstruction was carried out with a buccal mucous membrane. A bandage contact lens was placed over the cornea followed by the symblepharon ring to prevent further adhesion. The mucosal graft was well taken up along with corneal re-epithelization. Best corrected visual acuity of 20/120 in both sides after 1 month and 20/80 after 3 months was achieved and maintained till the 2.5-year follow-up.

Verteporfin photodynamic therapy of retinal capillary hemangioblastoma in von Hippel-Lindau disease.

An 18-year-old boy presented to us with bilateral retinal hemangioblastoma and von Hippel-Lindau disease with history of cerebral capillary hemangioblastoma and embryonic cell carcinoma of left testes. The vision in the right eye was already lost with development of secondary closed angle glaucoma, optic atrophy with subsequent development of bullous keratopathy. The multiple retinal angiomatous lesions in the seeing left eye were treated with various modalities like triple freeze thaw cryopexy, focal lasers and transpupillary thermo therapy in multiple sittings over a period of almost 20 years since detection. One particular angiomatous lesion in the left eye was showing resistance to all the above mentioned modalities and was finally successfully treated with verteporfin and photodynamic therapy to achieve complete regression without any post-treatment complication and with a sustained 20/20 vision till a follow-up of 15 months.

Clear lens extraction and intraocular lens implantation in a case of microspherophakia with secondary angle closure glaucoma.

Phacoemulsification with implantation of single-piece acrylic foldable intraocular lens (IOL) in a 19-year-old boy with microspherophakia, high myopia and angle closure glaucoma is described. The associated myopia and angle closure glaucoma was severely compromising the quality of life. Post-surgical visual recovery was 20/20 with sustained normal intraocular pressure. Management of such cases at times calls for innovations in current surgical technique.

Indirect optic nerve injury in two-wheeler riders in northeast India.

PURPOSE: To investigate the association of posterior indirect traumatic optic neuropathy and superior temporal orbital rim injury in two-wheeler riders and documentation of the clinical profile of such cases. DESIGN: Retrospective observational study. MATERIALS AND METHODS: Records of all patients reporting with cranio-orbital injury and vision loss following road traffic accidents between October 1994 and April 2006 were reviewed and from them cases with vision loss solely from indirect optic nerve injury were taken up for study. The prognostic significance of different presenting features, role of intravenous methyl prednisolone (IVMP) and relative risk of superior orbital rim injury to posterior indirect traumatic optic neuropathy (at 95% confidence interval) was calculated. RESULTS: Out of 129 consecutive cases of cranio-orbital injury, 35 had posterior indirect traumatic optic neuropathy with minor ipsilateral superior temporal orbital rim trauma and none used any protective headwear. Presenting clinical features like relative afferent pupillary defect ( P = 0.365), optic disc status ( P = 0.518) and visual evoked potential (VEP) ( P = 0.366) were disproportionate to visual loss. Only VEP had prognostic significance. The IVMP did not provide any added therapeutic benefit. The remaining 94 cases sustained direct blinding ocular trauma and 28 of them had associated intracranial pathology. The relative risk of superior temporal orbital rim injury to posterior indirect optic nerve trauma was 2.25. CONCLUSION: Superior temporal orbital rim injury, even when minor, carries a potential risk for development of blindness from indirect posterior indirect traumatic optic neuropathy in two-wheeler drivers. Presenting signs do not correlate with visual status. Only VEP has prognostic significance and the condition is untreatable.

Descemet's membrane detachment caused by inadvertent vancomycin injection.

Descemet's membrane detachment is a condition with a wide range of etiologies. The most common cause is a localized detachment occurring after cataract surgery. We report a case of vancomycin injection-induced Descemet's membrane detachment as a complication following a routine cataract surgery and its management.

Orbital abscess and hemi-occlusion of the central retinal vein in a child.

Orbital abscess is a serious infection which demands immediate and aggressive management. A case of orbital abscess associated with central retinal vein occlusion in a seven year old girl is reported. The diagnosis was established by computerised tomographic scanning and confirmed by bacteriological examination.

Clinical spectrum of spontaneous carotid-cavernous fistula.

A carotid-cavernous fistula (CCF) is an abnormal communication between the cavernous sinus and the carotid arterial system. A CCF is divided into two categories, direct and indirect. Direct fistulas usually account for 70 to 90% of all CCF. Spontaneous, low-flow fistulas are usually associated with atherosclerosis, hypertension and collagen vascular disease or may develop in females during peripartum period. The elderly age group, especially women are at increased risk. We report three cases of spontaneous CCF presenting with ocular manifestations and hypertension, without any collagen vascular disease. One case was a direct variety and the other two were of indirect variety.

Intravitreal gnathostomiasis and review of literature.

Intravitreal gnathostomiasis is a rare disease. To our knowledge, only five case reports are available in the literature wherein the parasites were surgically removed from the vitreous cavity and the species were identified. In this report, we document the clinical features of intravitreal gnathostomiasis along with the route of entry and parasitic migration pattern in ocular tissue, surgical management, and electron microscopic features of the retrieved advanced third-stage larva of Gnathostoma spinigerum (aL3) for a 48-year-old Indian woman with excellent postsurgical visual recovery.

Visual performance: Comparison of foldable intraocular lenses.

PURPOSE: To compare best distance visual acuity, color perception, and contrast sensitivity between eyes with an AcrySof Natural intraocular lens (IOL) (Alcon Laboratories Inc.) and fellow eye with an AcrySof IOL and to compare results in the IOL groups to those in normal, similarly aged patients with clear phakic eyes. SETTING: Sri Sankaradeva Nethralaya, Guwahati, India. METHODS: This prospective randomized parallel group single-center patient-masked examiner-masked study comprised 26 eyes of 13 healthy patients with bilateral age-related cataract. All patients had cataract surgery by phacoemulsification in both eyes; 1 eye received an AcrySof Natural IOL (SN60AT) and the fellow eye, an AcrySof (SA60AT) IOL. Final postoperative examination was performed at the end of 18 months. In addition to other findings, visual acuity, color perception, and contrast sensitivity were recorded. A group of normal, similarly aged phakic individuals with clear lenses was examined for contrast sensitivity. The records thus obtained were analyzed statistically. RESULTS: The AcrySof and AcrySof Natural IOL groups had a statistically significant improvement in visual acuity and color perception in comparison to preoperative status, and this was maintained until the last postoperative follow-up at 18 months. There was no statistically significant difference in the findings between the 2 IOL groups. The AcrySof and the AcrySof Natural IOL groups showed significant improvement in contrast sensitivity from the preoperative to the postoperative period (both P < .001). However, the AcrySof Natural IOL group was better than the AcrySof IOL group when each group was compared separately to similarly aged phakic individuals with clear lenses. CONCLUSIONS: Pseudophakia following AcrySof Natural SN60AT and AcrySof SA60AT IOL implantation led to equivalent visual acuity and color perception. But the contrast sensitivity in the AcrySof Natural group was better and near normal in reference to a healthy, age-matched control group.