Etiological prevalence and antifungal sensitivity patterns of dermatophytosis in India - A multicentric study.

BACKGROUND: The prevalence of dermatophytes varies with season, geographical area, socio-economic factors and effective management strategies. AIMS: The aim of the study was to assess the prevalence of pathogenic dermatophytes, clinical types of dermatophyte fungal infection, and in vitro antifungal drug susceptibility testing against dermatophytes. METHODS: Three hundred and ninety five patients with dermatophytosis were enrolled from five cities (Mumbai, Delhi, Lucknow, Kolkata and Hyderabad) across India. All patients were subjected to clinical examination and investigations, including potassium hydroxide microscopy, fungal culture and antifungal drug susceptibility testing. RESULTS: Trichophyton rubrum was the most common species identified (68.4%), followed by T. mentagrophytes (29.3%). Within species, T. mentagrophytes was prevalent in humid environmental conditions (Mumbai and Kolkata), whereas T. rubrum was prevalent in noncoastal areas (Delhi, Lucknow and Hyderabad). Tinea corporis (71.4%) and tinea cruris (62.0%) were the common clinical types observed. antifungal drug susceptibility testing data indicated that minimum inhibitory concentration required to inhibit the growth of 90% of organisms (MIC-90) was lowest for griseofulvin (0.25-3.0 µg/mL). Among oral antifungals, the mean MIC of itraconazole was within the range (0.84 [0.252] µg/ mL), whereas high mean MIC values were reported for terbinafine (0.05 [0.043] µg/mL). Among topical agents, lowest mean MIC values were reported for luliconazole (0.29 [0.286] µg/mL), eberconazole (0.32 [0.251]) µg/mL and amorolfine (0.60 [0.306]) µg/mL. LIMITATIONS: Lack of correlation between in vitro antifungal susceptibility and clinical outcome and absence of defined MIC breakpoints. CONCLUSION: T. rubrum was the most common, followed by T. mentagrophytes as an emerging/codominant fungal isolate in India. Tinea corporis was the most common clinical type of dermatophytosis. Mean MIC of terbinafine was above the reference range, while it was within the range for itraconazole; griseofulvin had the lowest mean MIC. Luliconazole presented the lowest mean MIC values across cities.

Ketamine suppresses ischemic injury in the rabbit retina.

Overstimulation of the N-methyl D-aspartate (NMDA) receptor has been implicated as a factor in the pathogenesis of ischemic injury in the central nervous system. The present study was undertaken to determine whether ketamine hydrochloride, a potent NMDA antagonist, could attenuate ischemic injury in the rabbit retina. Retinal ischemia was induced for 60 min in one eye of 18 albino rabbits by raising intraocular pressure above the systolic blood pressure. Three concentrations of ketamine, 0.5, 1.5, 5.0 mumol were dissolved in 20 microliters of saline solution and injected in the midvitreous in each eye of 14 rabbits 1 hr prior to ischemia. Four rabbits received saline solution as controls. The scotopic electroretinogram was monitored in each eye to assess the postischemic recovery of retinal function. A statistically significant reduction in the b-wave was detected in the eyes treated with saline (P less than 0.05), whereas the postischemic recovery of b-wave amplitude was enhanced by pretreatment with lower doses of ketamine. The highest dose depressed b-wave amplitude regardless of ischemia. Six rabbits underwent unilateral ocular ischemia under general anesthesia with ketamine. A small ameliorative effect was seen (P = 0.029). These results suggest that ketamine may alleviate ischemic injury in the rabbit retina, presumably by antagonizing the NMDA receptor-mediated toxicity. Thus, ketamine may have potential in the treatment of retinal vascular occlusive diseases. Moreover, a modified ischemic state may exist in experiments on ischemia conducted under general anesthesia with ketamine hydrochloride.

Phacoemulsification and modern cataract surgery.

The techniques and results of cataract surgery have changed dramatically during the past three decades. In the USA, we have moved from intracapsular cataract extraction as the preferred technique to almost exclusively extracapsular techniques. Smaller incisions have become the standard, with phacoemulsification now being the method of choice for most surgeons. Along with these advances have come improved intraocular lens materials and designs, especially well suited for use with smaller incisions. Phacoemulsification as a method to remove the cataractous lens was first proposed more than 20 years ago. Advances in techniques and equipment have led to a dramatic increase in the popularity of phacoemulsification with increased safety and efficiency. Viscoelastic agents have been developed synchronously with modern phacoemulsification techniques, playing an integral role in the success of this new technology. Improved surgical techniques for removing the anterior lens capsule have decreased the incidence of both intraoperative and postoperative capsular complications. Nucleus removal, formerly performed primarily in the anterior chamber, is now performed in the posterior chamber, decreasing damage to the corneal endothelium. Improved wound construction allows many wounds to be left unsutured, and smaller wounds allow shorter recovery time and greater intraoperative control and safety. Intraocular lenses can have smaller optic sizes and still maintain accurate centration. Foldable intraocular lenses can take advantage of the smaller incision, even further shortening the time to visual recovery. Continual evolution of this technology promises to further improve patient outcomes after cataract surgery.

Intralenticular Candida species abscess in a premature infant.

PURPOSE: To report the clinical and histopathologic findings of a premature infant with severe retinopathy of prematurity complicated by the development of an intralenticular fungal abscess. METHODS: Case report and literature review. RESULTS: A markedly premature infant developed Candida septicemia at 29 weeks postconception. Over the ensuing 10 weeks, cataract and intraocular inflammation developed sequentially in each eye, as did progressive retinopathy of prematurity with tractional retinal detachment. Pars plana vitrectomy and lensectomy revealed intralenticular Candida species abscess. CONCLUSION: Progressive cataract and intraocular inflammation in a low birth weight infant may be caused by endogenous intraocular infection secondary to systemic candidiasis. Cataract secondary to retinopathy of prematurity is rare.

Vortex keratopathy associated with atovaquone.

PURPOSE: We studied a case of vortex keratopathy that was associated with the use of atovaquone. METHOD: A patient with acquired immunodeficiency syndrome (AIDS) with pulmonary Pneumocystis carinii was treated with 750 mg of atovaquone three times a day. RESULTS: Similar to previous findings of drug-induced vortex keratopathy, atovaquone vortex keratopathy is presumably caused by its lipophilic properties. This property is similar to that of other lipophilic agents such as amiodarone, chloroquine, chlorpromazine, quinacrine, and suramin. CONCLUSION: Atovaquone should be added to the list of agents causing vortex keratopathy involving the corneal epithelium.

Branch retinal vein obstruction secondary to retinal arteriovenous communication.

PURPOSE: To document a branch retinal vein obstruction secondary to a congenital arteriovenous communication. METHOD: Case report of a young patient with retinal arteriovenous communication. RESULTS: A 12-year-old girl had a grade 2 retinal arteriovenous communication in her right eye. She was asymptomatic and was subsequently followed up. Magnetic resonance imaging of the brain was normal and disclosed no signs of Wyburn-Mason syndrome. Nine years later, she developed a branch retinal vein obstruction in the area of the arteriovenous communication. Six months later, the patient was free of secondary complications of branch retinal vein obstruction; however, she is being followed up to detect any retinal or iris neovascularization. CONCLUSION: Awareness of retinal vascular obstruction associated with arteriovenous communication may help its timely recognition, as well as prompt treatment of potential complications, such as retinal and iris neovascularization.

Diagnosis of microsporidial keratitis by confocal microscopy and the chromatrope stain.

PURPOSE: To illustrate the value of confocal microscopy and chromatrope stain in the diagnosis of microsporidial keratitis. METHODS: In vivo confocal microscopy was performed on a man with the human immunodeficiency virus who had severe bilateral epithelial keratitis refractory to topical antibacterial medications. The results were compared to conjunctival scrapings stained with the chromatrope-based Weber stain. RESULTS: Confocal microscopy demonstrated many small, intraepithelial opacities of the corneal epithelium, which were suggestive of Microsporidia. Results of the chromatrope stain of conjunctival scrapings confirmed the diagnosis of microsporidial keratitis. CONCLUSIONS: Rapid diagnosis allowed prompt initiation of topical fumagillin, which permitted rapid, long-term control of the symptoms of microsporidial keratitis.

Arteriovenous adventitial sheathotomy for the treatment of macular edema associated with branch retinal vein occlusion.

PURPOSE: To report arteriovenous adventitial sheathotomy for treatment of macular edema associated with branch retinal vein occlusion. METHODS: Case reports with review. Five eyes of five patients with best-corrected visual acuity of less than 20/200 secondary to branch retinal vein occlusion had pars plana vitrectomy and arteriovenous adventitial sheathotomy and were followed postoperatively for a mean of 6.5 years (range, 5 to 7 years). RESULTS: In four of five eyes, the best-corrected visual acuity improved to 20/30 to 20/70. In the remaining eye, visual acuity remained at finger counting secondary to macular ischemia. CONCLUSION: Arteriovenous adventitial sheathotomy may be beneficial for select patients with poor vision secondary to branch retinal vein occlusion.

Optic nerve neovascularization in incontinentia pigmenti.

PURPOSE: To describe the presence of optic disk neovascularization in a child with incontinentia pigmenti. METHODS: A 6-month-old infant with incontinentia pigmenti developed optic disk neovascularization in addition to vascular abnormalities in the peripheral retina. Panretinal photocoagulation was performed. RESULT: The optic disk neovascularization regressed after panretinal photocoagulation. CONCLUSIONS: Optic disk neovascularization is another notable retinal manifestation of incontinentia pigmenti. When optic disk neovascularization is detected, retinal ablation should be considered as treatment.

Validity of the time trade-off and standard gamble methods of utility assessment in retinal patients.

AIM: To assess the validity of the time trade-off (TTO) and standard reference gamble (SRG) techniques of utility assessment in patients with retinal disease. A cross section of eligible patients was studied and validity was determined through their relation with two logical constructs, visual acuity and scores from the Visual Function 14 (VF-14) index. METHODS: The study consisted of eligible patients presenting to a tertiary retinal facility who completed an interview. All patients had best corrected vision of 20/40 or worse in at least one eye. TTO and SRG utilities, as well as a VF-14 questionnaire, were administered through a standardised interview. Demographic and clinical (including Snellen visual acuity) information was also collected. RESULTS: 323 patients met these study criteria. Significant predictors of TTO utilities in the multivariate analysis were vision in the better seeing eye (p<0.01) and VF-14 scores (p<0.01). Significant predictors of standard gamble utilities were also vision in the better seeing eye (p<0.01) and VF-14 scores (p<0.05). CONCLUSION: Both the standard gamble and TTO methods demonstrate strong validity when evaluated against visual acuity in the better seeing eye and the VF-14 score.

Improvement in quality of life from photodynamic therapy: a Canadian perspective.

BACKGROUND: The Treatment of Age-Related Macular Degeneration with Photodynamic Therapy (TAP) Study showed that at 1 year, photodynamic therapy significantly reduced the chances of severe visual loss (15 letters or greater) compared with placebo treatment in patients with "predominantly classic" subfoveal choroidal neovascularization (CNV). We performed a study to determine the expected gain in quality of life associated with photodynamic therapy for the treatment of subfoveal CNV in a Canadian cohort of patients with age-related macular degeneration. METHODS: We created a decision analysis model to determine the incremental gain in quality-adjusted life years (QALYs) associated with photodynamic therapy over placebo over a 2-year period. The analysis was conducted using efficacy data derived from the TAP Study and patient-based utilities collected by means of the time trade-off technique. We conducted one-way and two-way sensitivity analyses to determine the robustness of our model. A Monte Carlo simulation was used to determine whether the observed gain in QALYs with photodynamic therapy was significant. RESULTS: Photodynamic therapy was associated with a relative increase in QALYs of 11.3% compared with placebo. In one-way and two-way sensitivity analyses, the relative increase in quality of life associated with photodynamic therapy ranged from 4.2% to 25.7%. The Monte Carlo simulation showed that the gain in QALYs conferred from photodynamic therapy was statistically significant (p < 0.001). INTERPRETATION: Photodynamic therapy improves the quality of life of Canadians with predominantly classic subfoveal CNV secondary to age-related macular degeneration.

Converting visual acuity to utilities.

BACKGROUND: Utility theory can be used to quantify dysfunction associated with various diseases and thus can represent a "hard" measure of quality of life. By determining utility values, one can compare the quality of life of patients with ocular disease to that of patients with non-ophthalmic problems. We performed a study to determine whether utility values from patients with ocular disease are associated with clinical variables, including visual acuity in the better-seeing eye, and to develop a mathematical method for converting visual acuity to utility value, if there is an association between the two. METHODS: Cross-sectional study. A total of 239 patients from a tertiary care retinal practice with various ocular conditions, including macular degeneration, cataract, glaucoma and diabetic retinopathy, were interviewed under standardized conditions to determine their utility values by the time trade-off technique. Visual acuity, duration of visual loss and number of concomitant conditions were also determined. Multiple linear regression was performed to determine which variables were associated with utility values. RESULTS: The mean acuity in the better-seeing eye was 0.479 (near 20/40 vision). The mean utility value was 0.72. Accordingly, the average patient in our series was willing to trade 2.8 of every 10 remaining years of life to obtain perfect vision in both eyes. Utility value was significantly associated with visual acuity in the better-seeing eye (F = 69.1, p < 0.001). Other variables were not significantly associated with utility value. The association with duration of visual loss approached statistical significance (p = 0.075). Utility values (U) for patients with ocular disease can be derived from the following formula: U = (0.374)(visual acuity in better-seeing eye) + 0.514. INTERPRETATION: Utility values from patients with ocular disease were strongly associated with visual acuity and could be estimated mathematically.

Characteristics of patients presenting with central retinal artery occlusion with and without giant cell arteritis.

BACKGROUND: In patients with concurrent central retinal artery occlusion (CRAO) and giant cell arteritis (GCA), prompt recognition and early treatment are crucial to prevent further visual loss in the contralateral eye. The objective of this study was to describe a series of patients with CRAO resulting from GCA and to compare them with patients with isolated CRAO. METHODS: The patient database for a retina service in Philadelphia was searched to identify patients admitted between 1983 and 1993 with a diagnosis of biopsyproven GCA and CRAO. For every patient with CRAO caused by GCA, the next patient admitted for management of acute isolated CRAO was identified; these latter patients constituted the control group. The visual acuity and baseline characteristics of the two groups were compared. RESULTS: Eleven patients with acute CRAO and GCA were admitted during the study period. In both the case and control groups seven patients (64%) were women and nine patients (82%) were white. Six subjects (54%) in the case group and seven (64%) in the control group had a history of hypertension; the values for diabetes mellitus were two (18%) and zero respectively. Four patients (36%) with CRAO and GCA were cigarette smokers, compared with eight patients (73%) with CRAO alone. None of these differences were statistically significant. Patients with CRAO related to GCA were more likely than those with isolated CRAO to have counting fingers or better vision at presentation (odds ratio 2.22 [95% confidence interval 0.37 to 13.2]), but this trend was not statistically significant. INTERPRETATION: Patients who presented with CRAO related to GCA were more than twice as likely as those with CRAO alone to have counting fingers or better visual acuity at the time of presentation. However, owing to the small sample, the power of this study to detect a true difference between the two groups was limited.

The role of ultrasound biomicroscopy in ocular trauma.

PURPOSE: To demonstrate the usefulness of ultrasound biomicroscopy (UBM) in detecting and localizing small ocular foreign bodies. METHODS: This is a retrospective study of the records of 555 consecutive patients evaluated by UBM by the Visual Physiology Unit of the Wills Eye Hospital from August 1994 to November 1997. RESULTS: In 9 patients, a foreign body was identified. In 6 patients, the history suggested the presence of a foreign body, but one could not be detected by clinical examination. In 2 patients, the referring physicians requested UBM to determine whether or how deep a known foreign body had penetrated the globe. In 1 patient, the foreign body was not suspected clinically. In regard to other diagnostic techniques, CT failed to identify the foreign body in 1 patient. In another, contact B-scan ultrasonography failed. In a third, both CT and contact B-scan ultrasonography failed. The foreign body was intracorneal in 2 eyes, subconjunctival in 2, intrascleral in 3, and intraocular in 2. Six were nonmetallic. Two were metallic. In one case, the foreign body was lost and its composition is unknown. In 5 cases, the UBM findings altered the patient's management. CONCLUSIONS: UBM is a valuable adjunct in the evaluation of small, anteriorly located foreign body that may not be detectable by other methods. UBM may be especially useful for finding nonmetallic foreign bodies.

Posterolateral corner injuries of the knee--a review.

Posterolateral corner injuries of the knee are usually associated with injuries to other structures of the knee. It is not unusual to miss this injury during the initial assessment. Undiagnosed and untreated posterolateral corner knee injury leads to significant morbidity including early osteo-arthritis of the knee. Failure to recognise and reconstruct posterolateral corner injuries is one of the important reasons for the failure of cruciate ligament reconstruction surgery. In this article we have reviewed the literature regarding anatomy, biomechanics, clinical features and treatment of the posterolateral corner injuries of the knee.

Recurrent retinal detachment: does initial treatment matter?

BACKGROUND/AIMS: To evaluate the treatment course of patients with primary rhegmatogenous retinal detachment (RRD) that re-detach after initial retinal detachment surgery. METHODS: Patients were divided into three groups based on initial surgical treatment: scleral buckle procedure (SBP) (63 eyes), pars plana vitrectomy (PPV) (88 eyes) and combined SBP/PPV (135 eyes). Charts were reviewed for a mean follow-up of 12 months. RESULTS: Average number of secondary procedures to achieve anatomical success was lowest in the SBP group (1.1), compared with the PPV group (1.47) and the SBP/PPV group (1.5) (p<0.05). Patients that re-detached after initial PPV/SBP, PPV or SBP required silicone oil injection in 83%, 60% and 22% of the cases and had final best-corrected visual acuity better than or equal to 20/50 in 21%, 33% and 45% of the cases, respectively. Phakic patients that re-detached after initial treatment with PPV/SBP, PPV and SBP required pars plana lensectomy (PPL) in 42%, 25% and 12.5% of the cases, respectively. CONCLUSION: Patients with primary RRD that re-detach after initial treatment with SBP require fewer number of secondary operations and silicone oil injections, show a trend for better visual outcomes and are less likely to develop dense cataract or to require PPL compared to patients that re-detach after initial PPV or PPV/SBP.