Toxic anterior segment syndrome and Urrets-Zavalia syndrome: Spectrum of the same entity?

PURPOSE: The purpose of the study was to analyze the outcomes of patients with toxic anterior segment syndrome (TASS) and Urrets-Zavalia (UZ) syndrome. MATERIALS AND METHODS: The records of all patients with TASS and UZ syndrome were studied. Corrected distance visual acuity (CDVA), intraocular pressure (IOP), and the details of surgeries performed were recorded at 1 and 3 months. We studied the changes in CDVA and IOP using repeated-measure ANOVA and paired t -test, respectively. RESULTS: Four patients (44.4%) developed refractory UZ syndrome, and five (55.6%) patients had TASS. At the end of 3 months of follow-up, all nine patients had concentric rings of iris atrophy and corneal edema. None of the cases had hypopyon or vitritis. Peripheral anterior synechiae (PAS) with secondary glaucoma was present only in cases of UZ syndrome. Among the four cases of UZ syndrome, goniosynechialysis was performed for 2 cases and trabeculectomy for one case. Despite these interventions, IOP could not be controlled. Patients in the TASS group did not exhibit PAS formation, and IOP was normal, but corneal edema and concentric rings of iris atrophy persisted. Descemet's stripping endothelial keratoplasty was performed for all the TASS cases. There was a statistically significant drop in CDVA (P = 0.028) and an increase in IOP (P = 0.029) at 3-month postcataract surgery. CONCLUSION: TASS and UZ syndrome could result in sight-threatening complications. They may be considered diseases of the same entity as both the conditions were found in the same cluster. TASS could be considered as an abortive attack of UZ syndrome.

Varied Presentations of Posterior Keratoconus: A Clinical Case Series.

PURPOSE: To describe the varied presentations of posterior keratoconus. METHODS: This is a 3-year institute-based retrospective study report from June 2015 to June 2018 that describes 13 eyes of 12 patients with varied presentations of posterior keratoconus, evaluating tomographic changes using Scheimpflug corneal tomography and anterior segment optical coherence tomography. Slit-lamp examination revealed circumscribed nebular corneal opacity with posterior corneal depression. RESULTS: Eleven patients had unilateral and one had a bilateral presentation. Five patients presented in the first and second decade with a nebular opacity and circumscribed excavation of the posterior cornea. One patient was a 12-year-old girl who presented with systemic manifestations. Seven others were middle-aged adults with superior, central, or peripheral excavation. Two patients had microcornea. CONCLUSIONS: This is the largest case series on posterior keratoconus, depicting its varied features. Diagnosis of this uncommon condition requires a high index of suspicion, meticulous slit-lamp examination, and systemic evaluation to rule out other associated anomalies. We report a patient of unilateral posterior keratoconus with systemic associations, second such case in the literature.

Risk factors for endothelial cell damage in diabetics after phacoemulsification.

BACKGROUND: To assess the corneal endothelium, central corneal thickness and the factors associated with endothelial cell damage after phacoemulsification in diabetics in comparison with non-diabetics. METHODS: It was a case control study with 80 eyes each in the diabetic group and the control group. Intraoperative mydriasis, effective phaco time (EPT) and postoperative inflammation were measured. Preoperative, 1st week, 6th week and 3rd month postoperative endothelial cell density (ECD), coefficient of variation (CV), hexagonality and central corneal thickness (CCT) were also measured using Konan noncon robo specular microscope (Model - NSP 9900). RESULTS: In the control group, patients in the age group of 60-69 years were 3.8 times more at risk of ECL compared to patients in the age group of 50-59 years. Patients in whom EPT was ≥0.50 min, were 8.8 times more at risk of ECL when compared to patients in whom EPT <0.25 min. In the diabetic group, patients who had an inflammatory score of 1+ in the first postoperative week; also had 5.7 times more risk of ECL when compared to patients in whom the inflammatory score was 0.5+ in the first postoperative week. There was a significant increase in CV (p-0.03) and CCT (p-0.03), significant decrease in the hexagonality (p-0.01) and no statistically significant difference in the endothelial cell loss (ECL) (p-0.34) in diabetics after phacoemulsification when compared to controls. CONCLUSION: The present study reveals postoperative inflammation as a risk factor for ECL in diabetics and not intraoperative mydriasis and EPT.

Ocular Manifestations in Leukemias and Their Correlation with Hematologic Parameters at a Tertiary Care Setting in South India.

PURPOSE: To determine the prevalence of ocular manifestations and the association of these manifestations with hematologic parameters among patients with leukemia attending a hemato-oncology unit at a tertiary care government hospital in South India. DESIGN: This was a cross-sectional observational study. PARTICIPANTS: All patients attending a hemato-oncology unit at a tertiary care government hospital in South India who were diagnosed with acute or chronic leukemia that was confirmed by a bone marrow biopsy. METHODS: Consecutive patients with leukemia presenting at the hematology clinic underwent standardized leukemia blood workup and comprehensive ophthalmic evaluation. Patient demographics, the type of leukemia, ophthalmic features, and hematological parameters such as hemoglobin level, white blood cell count, and platelet counts were recorded. The association between ophthalmic manifestations and blood counts was analyzed using multivariable regression analysis. MAIN OUTCOME MEASURES: The study measured the prevalence of various ocular manifestations in different types of leukemias and their association with hematologic parameters. RESULTS: In total, 133 eyes of 133 patients were examined during the study period. The prevalence of leukemic ophthalmopathy was found to be 68% in cases of acute myeloid leukemia, 42% in cases of acute lymphoid leukemia, 33% in cases of chronic lymphoid leukemia, and 13% in cases of chronic myeloid leukemia. Vision-threatening complications such as subhyaloid hemorrhage involving the posterior pole (20%) and vitreous hemorrhage (10%) were seen exclusively in patients with acute leukemias. Multivariable logistic regression after adjusting for the type of leukemia, patient age, and white blood cell and platelet counts showed that the hemoglobin level was the only factor predictive of developing subhyaloid hemorrhage (every 1-g/L increment increase in hemoglobin level led to a 30% reduction in the likelihood of developing subhyaloid hemorrhage; 95% confidence interval 0.5-0.9; P = 0.02). The probability of developing subhyaloid hemorrhage was reduced by >50% when hemoglobin level improved from 5 to 7 g/L and when platelet count improved from 10 000 to 50 000 cells/mm3 for both types of acute leukemia. There was no association between white blood cell counts and ophthalmic manifestations. CONCLUSION: Leukemic ophthalmopathy is more common in acute and myeloid cases and less common in chronic and lymphoid subtypes. It is predominantly due to secondary rheological changes. Blood transfusion should be considered when hemoglobin level and platelet count decrease below 7 g/L and 50 000 cells/mm3, respectively, to prevent vision-threatening complications. Patients with acute leukemias should undergo ophthalmic screening at baseline and then periodically to prevent visual morbidity.

Isolated Superior Divisional Oculomotor Nerve Palsy and Nystagmus Following Mild Trauma.

Traumatic isolated divisional oculomotor nerve palsy has not been reported following mild head injury. We present an interesting case of a 10-year-old male boy who presented with right-sided ptosis, upgaze palsy, and horizontal nystagmus following a mild head trauma. Magnetic resonance imaging showed right superior rectus muscle atrophy. After observing for 6 months, right inferior rectus recession was done. The abnormal head posture and diplopia got corrected, but nystagmus persisted, although with appreciably decreased amplitude. We here report a rare case of an isolated superior divisional oculomotor nerve palsy following mild head trauma. Nystagmus accompanying a divisional oculomotor nerve palsy has never been reported before, making this case more unique. A critical step-wise approach to the case with possible mechanisms are discussed.

Sequential development of non-arteritic anterior ischemic optic neuropathy in a patient on hemodialysis.

Purpose: Non-arteritic anterior ischemic optic neuropathy (NA-AION) is typically a disorder of patients 50 years and older predisposed to the vascular and structural optic disc risk factors. We present an interesting case of sequential development of NA-AION in a 45-year-old patient with end-stage renal disease undergoing hemodialysis. Methods: Observational case report. Results: A 45-year-old female on hemodialysis for chronic renal failure complained of sequential acute onset sudden painless gross diminution of vision in right eye followed by the left eye. At presentation, fundus examination revealed secondary optic atrophy and a pallid disc edema with few hemorrhage in the right and left eye, respectively. Ambulatory blood pressure recorded nocturnal dips of diastolic blood pressure. Fundus fluorescein angiography showed hypoperfusion of the left optic disc, confirming the diagnosis of NA-AION. She was treated with oral steroids, but with no improvement. Conclusion: Both treating nephrologist and ophthalmologist should be aware of this uncommon but potentially blinding complication, to permit its early recognition and prevent the occurrence in the fellow eye. Also, care should be taken to prevent and treat any hypotensive episodes during and following dialysis therapy in such high-risk patients.

Tuberculous scleral abscess with choroidal detachment.

We present a case of ocular tuberculosis (TB) presenting as scleral abscess with choroidal detachment. A 60-year-old woman presented with intense pain, redness, watering and decreased vision in the right eye (RE) for 1 week duration. Slit lamp examination of RE revealed diffuse scleritis with two pus-pointing areas in the supero-temporal quadrant suggesting scleral abscess. Fundus examination of the RE showed choroidal detachment in the temporal and inferior quadrant. Left eye examination was unremarkable. Ziehl-Neelsen staining of scleral biopsy showed acid-fast bacilli. PCR of the scleral tissue was also positive for Mycobacterium tuberculosis genome. The final diagnosis of tuberculous scleral abscess with choroidal detachment was made and patient showed good response to antitubercular treatment. In countries endemic for TB, it should be considered as a differential diagnosis for scleral abscess, since prompt diagnosis and treatment will ensure good visual outcome as depicted in our case.

Bimatoprost Induced Serous Macular Detachment after Cataract Surgery.

We report a case of bimatoprost induced serous macular detachment and choroidal folds following uneventful cataract surgery. A 66-year-old male using topical bimatoprost in both eyes for open angle glaucoma underwent uneventful cataract surgery in the right eye. Postoperatively, he was restarted on topical bimatoprost and antibiotic-steroids combination drops. One week after surgery, he presented with conjunctival hyperemia, serous macular detachment, and choroidal folds at the posterior pole. Fundus fluorescein angiography showed perifoveal leaks in early stage with pooling of dye in late stage. Discontinuation of bimatoprost led to resolution of serous detachment and choroidal folds within 3 weeks with significant improvement in visual acuity. Occurrence of serous macular detachment and choroidal folds in this case could be probably related to the proinflammatory property of bimatoprost. Hence, it should be used with caution in the immediate postoperative period after cataract surgery.

Clofazimine-induced premaculopathy in a vitiliginous patient.

A 26-year-old male vitiliginous patient presented with decreased visual acuity because of a central scotoma in the left eye with no significant retinal changes on fundus examination. In this case report, a diagnosis of possible drug-induced premaculopathy was made, and the drugs were withdrawn. On the follow-up, after 3 months, the visual acuity in the left eye gradually improved. Early suspicion of drug-induced maculopathy and withdrawal of the drug may prevent the progression of maculopathy.

Concurrent Acute Retinal Necrosis in a Patient With Iridocorneal Endothelial Syndrome.

PURPOSE: To report a rare case of concurrent acute retinal necrosis in a patient with iridocorneal endothelial syndrome (ICE). METHODS: Case report. RESULTS: A 42-year-old woman showed acute diminution of vision in the right eye. Her fundus examination revealed features of acute retinal necrosis. She had also experienced gradual diminution of vision in her left eye for 5 years. The examination of her left eye revealed corneal edema with mild corectopia and increased intraocular pressure with abnormal endothelium on specular microscopy pointing to a diagnosis of ICE. CONCLUSIONS: This is a rare case where concurrent acute retinal necrosis and ICE syndrome are present in the same patient, possibly pointing to a common viral etiology causing both entities.

Anti-vascular endothelial growth factor (VEGF) drugs for treatment of retinopathy of prematurity.

BACKGROUND: Vascular endothelial growth factor (VEGF) plays a key role in angiogenesis in fetal life. Recently, researchers have attempted to use anti-VEGF agents for the treatment of retinopathy of prematurity (ROP), a vasoproliferative disorder. There is currently uncertainty regarding the safety and efficacy of these agents in preterm infants with ROP. OBJECTIVES: To evaluate the efficacy and safety of anti-VEGF drugs when used either as monotherapy, i.e. without concomitant cryotherapy or laser therapy or in combination with planned cryo/laser therapy in preterm infants with type 1 ROP (defined as zone I any stage with plus disease, zone I stage 3 with or without plus disease or zone II stage 2 or 3 with plus disease). SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 1), MEDLINE (1966 to January 1, 2016), EMBASE (1980 to January 1, 2016), CINAHL (1982 to January 1, 2016), conference proceedings, and previous reviews. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials that evaluated the efficacy and safety of administration, or both, of anti-VEGF agents compared with conventional therapy in premature infants with ROP. DATA COLLECTION AND ANALYSIS: We used standard Cochrane and Cochrane Neonatal methods for data collection and analysis. MAIN RESULTS: Three trials, in which 239 infants participated, fulfilled the inclusion criteria. Two trials compared intravitreal bevacizumab with conventional laser therapy (monotherapy) while the third compared intravitreal pegaptanib plus laser treatment with laser and cryotherapy (combination therapy) in infants with type 1 ROP.Of the two studies that evaluated intravitreal bevacizumab, one randomized infants while the other randomized eyes of the infants to the intervention and control groups. The former did not report any difference in the incidence of complete or partial retinal detachment between the groups (143 infants; RR 1.04, 95% CI 0.21 to 5.13; RD 0.00, 95% CI -0.06 to 0.07; very low quality evidence) but reported a significant reduction in the risk of refractive errors - very high myopia - at 30 months of age (211 eyes; RR 0.06, 95% CI 0.02 to 0.20; RD -0.40, 95% CI -0.50 to -0.30; low quality evidence) and recurrence of ROP by 54 weeks' postmenstrual age (143 infants; RR 0.22, 95% CI 0.08 to 0.62; RD -0.20, 95% CI -0.31 to -0.09; moderate quality evidence) in the bevacizumab group. The study found no difference in the risk of mortality before discharge from the hospital (150 infants; RR 1.50; 95% CI 0.26 to 8.75; RD 0.01; 95% CI -0.04 to 0.07; low quality evidence), mortality at 30 months of age (150 infants; RR 0.86, 95% CI 0.30 to 2.45; RD -0.01; 95% CI -0.10 to 0.08; low quality evidence), corneal opacity requiring corneal transplant (286 eyes; RR 0.34, 95% CI 0.01 to 8.26; RD -0.01; 95% CI -0.03 to 0.02; very low quality evidence), or lens opacity requiring cataract removal (286 eyes; RR 0.15, 95% CI 0.01 to 2.79; RD -0.02; 95% CI -0.05 to 0.01; very low quality evidence). The second trial that randomized eyes of the infants did not find any difference in the risk of complete retinal detachment between the eyes randomized to bevacizumab and those that were randomized to laser therapy (13 eyes; RR 0.33, 95% CI 0.01 to 7.50; RD -0.08, 95% CI -0.27 to 0.11).When used in combination with laser therapy, intravitreal pegaptanib was found to reduce the risk of retinal detachment when compared to laser/cryotherapy alone (152 eyes; RR 0.26, 95% CI 0.12 to 0.55; RD -0.29, 95% CI -0.42 to -0.16; low quality evidence). The incidence of recurrence of ROP by 55 weeks' postmenstrual age was also lower in the pegaptanib + laser therapy group (76 infants; RR 0.29, 95% CI 0.12 to 0.7; RD -0.35, 95% CI -0.55 to -0.16; low quality evidence). There was no difference in the risk of perioperative retinal haemorrhages between the two groups (152 eyes; RR 0.62, 95% CI 0.24 to 1.56; RD -0.05, 95% CI -0.16 to 0.05; very low quality evidence). The risk of delayed systemic adverse effects with either of the drugs is, however, not known. IMPLICATIONS FOR PRACTICE: Intravitreal bevacizumab reduces the risk of refractive errors during childhood when used as monotherapy while intravitreal pegaptanib reduces the risk of retinal detachment when used in conjunction with laser therapy in infants with type 1 ROP. Quality of evidence was, however, low for both the outcomes because of the risk of detection and other biases. Effect on other critical outcomes and, more importantly, the long-term systemic adverse effects of the drugs are not known. The insufficient data precludes strong conclusions favouring routine use of intravitreal anti-VEGF agents in preterm infants with type 1 ROP. IMPLICATIONS FOR RESEARCH: Further studies are needed to evaluate the effect of anti-VEGF agents on structural and functional outcomes in childhood and delayed systemic adverse effects such as myocardial dysfunction and adverse neurodevelopmental outcomes.

A Case Report of Vogt's Limbal Girdle and Retinitis Pigmentosa in a Thirteen-Year-Old Boy: A Rare and Unusual Association.

AIM: To describe a rare case of Vogt's limbal girdle in a boy with retinitis pigmentosa. METHODS: A 13-year-old boy from India presented to us with progressive diminution of vision and nyctalopia for 5 years. On examination, he had the characteristic features of retinitis pigmentosa with the fundus showing disc pallor, bony spicules and arteriolar attenuation. His anterior segment examination showed Vogt's limbal girdle in both eyes. RESULTS: Vogt's limbal girdle is a corneal degeneration usually seen in elderly individuals. This is the first time it is seen in association with retinitis pigmentosa. It has also never been reported at such a young age. CONCLUSION: We report a rare case where Vogt's limbal girdle was observed in a 13-year-old boy with retinitis pigmentosa. This gives further insight into the pathogenesis of the disease.

A Case Report of Severe Corneal Toxicity following 0.5% Topical Moxifloxacin Use.

Moxifloxacin is a widely used topical antibiotic in various bacterial infections of the eye. Its safety and efficacy have been proved by many studies. We report a case of a rare adverse effect following its use. A 10-year-old female who had presented with acute bacterial conjunctivitis in both eyes with no corneal involvement was started on preservative-free 0.5% topical moxifloxacin four times a day. The child developed a severe form of corneal toxicity in both eyes with circumcorneal congestion and corneal edema following its use. The child's visual acuity had dropped from 20/20 to 20/400 in both the eyes. Topical moxifloxacin was discontinued, following which the cornea cleared dramatically and the visual acuity became normal. This case indicates that though rare, topical moxifloxacin can cause severe keratitis and that more studies need to be conducted to evaluate its safety.

Ocular manifestations of rheumatoid arthritis and their correlation with anti-cyclic citrullinated peptide antibodies.

PURPOSE: To study the ocular manifestations of rheumatoid arthritis and to correlate the role of anti-cyclic citrullinated peptide antibody (anti-CCP antibody) with the ocular manifestations. METHODS: Three-hundred and ninety-two eyes of the 196 rheumatoid arthritis patients who attended the ophthalmology outpatient department underwent a detailed ocular examination using slit lamp biomicroscopy and ophthalmoscopy. The tear function of all the patients was assessed using Schirmer's test, tear film break-up time and ocular surface staining. The anti-CCP antibody titers for all the rheumatoid arthritis patients were estimated using enzyme-linked immunosorbent assay tests. RESULTS: Seventy-seven patients (135 eyes, 39%) out of the 196 patients studied had ocular manifestations typical of rheumatoid arthritis. Dry eye was the most common manifestation (28%, 54 patients). Of the patients, 78% was females (60 patients). The mean duration of rheumatoid arthritis in patients with ocular manifestations was 5.4±2.7 years and without ocular manifestations was 2.1±1.6years. Three percent of the patients had episcleritis (six patients). Scleritis was present in 2% of the patients (four patients). Peripheral ulcerative keratitis and sclerosing keratitis was present in 1% of the population each (two patients each). Eighty-five percent (66 patients) had bilateral manifestations 15% (eleven patients) had unilateral manifestations. There was a strong association between the presence of anti-CCP antibodies and ocular manifestations of rheumatoid arthritis which was shown by the statistically significant P-value of <0.0001. CONCLUSION: Ocular manifestations are a significant part of the extra-articular manifestation of rheumatoid arthritis. Dry eye was the most common ocular manifestation. There was a statistically significant association between the presence of anti-CCP antibodies specific to rheumatoid arthritis and the ocular manifestations.

Oral gabapentin premedication for elderly patients undergoing intraocular surgery.

AIMS: To compare effects of gabapentin premedication with diazepam in patients undergoing cataract surgery. METHODS: In a randomised double-blind study, the effects of gabapentin premedication as a sedative, anxiolytic, analgesic and oculohypotensive agent were studied in 56 elderly patients undergoing elective intraocular surgery. RESULTS: There was significantly more sedation in the diazepam group than in the gabapentin group. However, there was less subjective anxiety in the gabapentin group than in the control group. There was a significant fall in intraocular pressure (IOP) and significant reduction in mean arterial pressure in the gabapentin group compared with the control group. Perioperatively, significantly more supplementation with intravenous midazolam was given in the control group than in the gabapentin group. A significantly larger number of patients in the gabapentin group scored a postanaesthesia recovery score of 10 compared with the control group. There was a statistically significant difference in the postoperative visual analogue scale scores for pain and number of analgesic requests with gabapentin scoring over diazepam in this regard. CONCLUSIONS: Hence, premedication with oral gabapentin in these elderly patients undergoing elective intraocular surgery produced intraoperative anxiolysis, decreased sedation, a modest decrease in IOPs and improved postoperative recovery.

Floppy iris syndrome with oral imipramine: a case series.

Intraoperative floppy iris syndrome (IFIS) has commonly been seen with long-term use of α1-adrenoceptor blocking agents. We observed IFIS in three patients during phacoemulsification due to oral imipramine therapy. The three patients took imipramine for 25 years, 10 months and 1 year, respectively. However, only the first patient was on oral therapy at the time of surgery, while the other two patients had stopped 4 months and 2 months prior to undergoing phacoemulsification. The first and third patients developed complete IFIS features, while the second had only partial IFIS characteristics. Phacoemulsification could be completed in all three patients without any complication. None of these patients had history of taking any of the α1-adrenoceptor blocking agents. This is the first anecdotal report of IFIS with the oral use of imipramine and hence further evidences are required to ascertain the association of oral imipramine therapy and IFIS. However, ophthalmologists undertaking phacoemulsification on patients on imipramine therapy should be alert for the occurrence of IFIS.

Nine years' review on preseptal and orbital cellulitis and emergence of community-acquired methicillin-resistant Staphylococus aureus in a tertiary hospital in India.

CONTEXT: Preseptal cellulitis is the commonest orbital disease which frequently needs to be differentiated from orbital cellulitis. Prompt diagnosis and treatment with appropriate antibiotics can prevent vision loss and life-threatening complications of orbital cellulitis. AIMS: To describe the clinical profile of cases with preseptal and orbital cellulitis admitted to a tertiary care hospital during a period of nine years. The causative organisms and the clinical outcome were analyzed. SETTINGS AND DESIGN: Retrospective descriptive case study done in a tertiary care hospital in South India. MATERIAL AND METHODS: The in-patient records of patients with preseptal and orbital cellulitis were reviewed from 1998 to 2006. The factors reviewed included ocular findings aiding in the distinction of the two clinical conditions, the duration of symptoms, the duration of hospital stay, microbiological culture report of pus or wound swab, blood culture, drugs used for treatment, the response to therapy and complications. STATISTICAL ANALYSIS USED: Descriptive analysis. RESULTS: One hundred and ten cases, 77 patients with preseptal cellulitis and 33 patients with orbital cellulitis were reviewed. Five percent of children and 21% of adults presented with cutaneous anthrax contributing to preseptal cellulitis. Thirty-nine percent cases with orbital cellulitis were caused by methicillin-resistant Staphylococcus aureus (MRSA). CONCLUSIONS: This study has helped in identifying organisms which cause orbital infections, especially community-acquired MRSA. It indicates the need for modifying our empirical antimicrobial therapy, especially in orbital cellulitis.

Clear lens extraction in Alport syndrome with combined anterior and posterior lenticonus or ruptured anterior lens capsule.

UNLABELLED: We describe the results of clear lens extraction in 7 eyes of 4 Alport-syndrome patients. Three patients (6 eyes) had both anterior and posterior lenticonus; the fourth patient had spontaneous rupture of the anterior lens capsule, resulting in an acute drop in vision. Clear lens extraction was an effective method for visual rehabilitation in Alport syndrome patients. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.