Role of regional diffusion tensor imaging (DTI)-derived tensor metrics in the evaluation of intracranial gliomas and its histopathological correlation.

Background: The imaging of brain tumours has significantly improved with the use of advanced magnetic resonance (MR) techniques like diffusion tensor imaging (DTI). This study was conducted to analyse the utility of DTI-derived tensor metrics in the evaluation of intracranial gliomas with histopathological correlation and further adoption of these image-data analyses in clinical setting. Methods: A total of 50 patients with suspected diagnosis of intracranial gliomas underwent DTI along with conventional MR examination. The study correlated various DTI parameters in the enhancing part of the tumour and the peritumoral region with the histopathological grades of the intracranial gliomas. Results: The study revealed higher values of Cl (linear anisotropy), Cp (planar anisotropy), AD (axial diffusivity), FA (fractional anisotropy) and RA (relative anisotropy) and lower values of Cs (spherical anisotropy), MD (mean diffusivity) and RD (radial diffusivity) in the enhancing part of the tumour in case of high-grade gliomas. However, in the peritumoral region, the values of Cl, Cp, AD, FA and RA were less whereas values of Cs, MD and RD were more in high-grade gliomas than in the low-grade gliomas. The various cutoff values of these DTI-derived tensor metrics were found to be statistically significant. Conclusion: DTI-derived tensor metrics can be a valuable tool in differentiation between high-grade and low-grade gliomas which might be accepted in clinical practice in near future.

The Epidemiology of Intensive Care Unit Readmissions and Proposed Discharge Protocol for a Tertiary Care Hospital.

BACKGROUND: Intensive Care Unit (ICU) readmissions during the same hospitalization are associated with increased hospital stays, morbidity and mortality. Whereas mortality rates in patients admitted to the ICU for the first time may range from 10 to 20% depending on various factors, readmission mortality rates can be up to 50 to 70%. Factors leading to readmission in ICU in Indian Armed Forces Hospitals have not been well studied till date. METHODS: This was a record based cross sectional descriptive study conducted at the ICU of a tertiary care Armed Forces hospital. Demographic and clinical data of ICU patients were analysed. ICU admission and discharge data for the duration of last three years were acquired from admission and discharge registers and Hospital Informatics system (HIS) software. The primary outcome was readmission rates to ICU during the same hospitalization. Secondary outcomes included diagnosis at time of index admission (first time admission) to ICU and at readmission, multiple readmissions to ICU and mortality rates in readmitted patients. RESULTS: There were 3021 admissions to the ICU during the study period. 422 patients succumbed to illness during initial admission resulting in a mortality rate of 14%. 198 patients were readmitted to the ICU. The readmission rate to the ICU was 7.8%. The mortality rate in readmitted patients was 31% as compared to the ICU mortality rate of 14%. The triggering factors for readmission were usually respiratory or cardiac decompensations. CONCLUSION: Readmission to ICU occurred in about 7.8 % of all ICU patients in our study. ICU readmissions increase the risk of adverse outcomes. Objective measures in the form of a discharge protocol incorporating the stability and work index for transfer (SWIFT Score) may help minimizing readmission to ICU. Such protocols must be in place while shifting any patients from ICU so as to improve outcomes in patients of tertiary care hospitals.

Transnasal Transsphenoidal Approach for Pituitary Tumors: An ENT Perspective.

Endoscopic transnasal transsphenoidal (ETNTS) approach was first described in 1992 and is standard approach for the resection of benign pituitary adenomas. This prospective study aims in incidence and preoperative assessment of extent of the pituitary adenoma, peroperative findings of transnasal transsphenoidal excision, techniques of skull base repair, complications and its management in a tertiary centre. A prospective analysis from Jan 2017 to May 2019, of patients undergoing ETNTS approach of pituitary adenomas was made in terms of incidence in various age-groups, type of adenoma, operative findings including CSF leak, repair of the skull base defect, complications encountered and its management was done in a tertiary care centre and compared with the present literature. A total of 141 patients underwent ETNTS, with highest number of cases found in 41-50 years age-group with mean age of 42.6 years. Male: Female ratio was 1.6. Macroadenoma was in 123 patients while 18 had microadenoma, of these 63.74% were functional adenoma, highest of GH secreting, while 36.26% were non-functional. Mean surgical time was 98.4 min ± 21.2 min. Peroperative CSF leak was in 30.5% cases in various grades. Closure techniques included use of fat, multilayer techniques, Hadad's flap and gasket technique as per the type of CSF leak. Neurological and rhinological complications were 6.38% each. This study is focused on the ENT perspective of the endoscopic transnasal trans-sphenoidal approach for pituitary adenomas. The reduced rate of morbidity and complications is encouraging. The endoscopic skull base defect closure is challenging and requires skill, meticulous approach and synchronised team work in order to achieve a favourable outcome. The incidence of CSF leak can be minimised and if encountered has to be dealt in an organised manner, thus contributing to a reduced rate of complications. The complications encountered must be foreseen and managed with a proficient approach.

Late onset of deep corneal vascularization: a rare complication of intrastromal corneal ring segments for keratoconus.

PURPOSE: To report deep corneal vascularization noted 3 years after intrastromal corneal ringsegments (Intacs) implantation for the treatment of keratoconus. METHODS: A 33-year-old male keratoconus patient intolerant to rigid gas permeable contact lens in the right eye underwent Intacs implantation. At 2 years postoperatively, slit-lamp examination of the right eye revealed superficial corneal vascularization inferotemporally, extending 1.5 mm from the limbus. At 3 years postoperatively, the slit-lamp examination of the right eye revealed deep stromal vascularization extending to and arborizing along the temporal segment. Also, superficial vascularization was noted along the nasal segment inferiorly. The Intacs segments were then explanted. RESULTS: On post-explantation day 10, the deep vessels regressed to ghost vessels with topica corticosteroid therapy. CONCLUSIONS: The authors present a rare case where deep corneal vascularization was noticed 3 years following Intacs implantation for keratoconus. All patients having superficial vascularization away from the incision site need to be followed for this rare complication.

Unprecedented complication of odontoid regeneration after transoral odontoidectomy.

Transoral odontoidectomy followed by occipitocervical fixation is a widely used approach to relieve ventral compressions at the craniovertebral junction. Despite the large amount of literature on this approach and its complications, odontoid process regeneration and causing the worsening of symptoms of brainstem dysfunction and upper cervical cord were not found in the English literature. We report the case of odontoid regeneration in a 12-year-old girl. She presented with torticollis and symptoms of brainstem dysfunction and upper cervical cord compression with syringohydromyelia and underwent transoral resection of dens and posterior occipitocervical fusion at the age of 7 years. Post surgery, clinically and radiologically, the resolution was evident till the age of 11 years when the child started to have relapse and worsening of the previous symptoms. The computed tomography/magnetic resonance imaging shows regeneration of the odontoid process compressing the brain stem with an increase in syringohydromyelia. We suggest that there is a need for the removal of the complete odontoid process with periosteum and also beyond the dentocentral synchondrosis to prevent late recurrences of odontoid regeneration.

Acute corneal hydrops treated by intracameral injection of perfluoropropane (C3F8) gas.

PURPOSE: To report a case of acute hydrops with intrastromal cleft in a patient of keratoconus with associated Marfan's syndrome, treated with intracameral injection of perfluoropropane (C(3)F(8)) gas. DESIGN: Interventional case report. METHODS: A nonexpansile concentration of perfluoropropane gas (0.2 ml) was injected intracamerally in the operating room under aseptic precautions. RESULTS: There was complete and rapid resolution of corneal edema. CONCLUSION: Intracameral perfluoropropane gas in nonexpansile concentration may be a useful modality for treatment of corneal edema in acute corneal hydrops.

Gloriosa superba ingestion: Hair loss and acute renal failure.

Gloriosa superba is a plant that grows wild in several parts of South India. Tubers of this plant contain several alkaloids. Acute intoxication following the ingestion of G. superba results in gastrointestinal and haematological abnormalities, hepatic and renal insufficiency, cardiotoxicity and hair loss. We present a case with typical features of G superba toxicity.

Ocular nocardia infections with special emphasis on the cornea.

Nocardia are aerobic, gram-positive, nonmotile and branching filamentous bacteria. Corneal infection by Nocardia is rare. Trauma is the most common predisposing factor. Isolated case reports of nocardial infection associated with contact lens wear and laser in situ keratomileusis (LASIK) have been reported. The clinical picture usually consists of superficial patchy infiltrates, which may be arranged in a wreath pattern. Presence of gram-positive, branching, beaded filaments that stain with 1% acid-fast stain (using 1% sulfuric acid, modified Kinyoun's method) in smears of corneal scrapings is suggestive of nocardial infection. Nocardia grow on commonly used media as tiny, white, dry colonies. Available knowledge and clinical experience suggest that although sulfacetamide eyedrops can be tried as the initial drug, trimethoprim-sulfamethoxazole and amikacin are effective drugs. Once therapy is initiated, the infiltrate responds promptly and resolves, forming a corneal scar with or without vascularization, and good visual recovery can be expected.

Microsporidial keratoconjunctivitis in a HIV-seronegative patient treated with debridement and oral itraconazole.

PURPOSE: To report a case of microsporidial keratoconjunctivitis in an HIV-seronegative. METHODS: We report on a 40-year-old woman who presented with acute symptoms of 4 days' duration. Visual acuity was 6/6 in the right eye and 6/6 partial in the left eye. In the left eye, there was diffuse conjunctival congestion with papillary changes. There were multiple raised epithelial lesions in the cornea. RESULTS: Corneal scrapings stained with potassium hydroxide and calcofluor white showed Microsporidium spores in large numbers. These spores with polar staining were also confirmed in Gram stain. One month after initiation of itraconazole, the left eye was quiet. She had a visual acuity of 6/6 in that eye, with faint corneal haze. CONCLUSIONS: We report a rare case of microsporidial keratoconjunctivitis in a HIV-seronegative patient who was treated by debridement and oral itraconazole. Microsporidium should be suspected even in an immunocompetent individual if the corneal examination revealed showed multiple raised epithelial lesions.

Aspergillus flavus keratitis after laser in situ keratomileusis.

PURPOSE: To report a case of fungal keratitis caused by Aspergillus flavus after laser in situ keratomileusis surgery. METHODS: Case report. A 24-year-old woman developed pain, redness, decreased vision, and an infiltrate posterior to the corneal flap in her right eye 3 days after laser in situ keratomileusis. On referral, approximately 3 weeks after laser in situ keratomileusis, examination of the right eye revealed light perception vision, a large full-thickness corneal infiltrate, and hypopyon. Corneal scrapings were taken for direct microscopic examination and culture. RESULTS: Corneal scraping revealed the presence of fungal filaments in smears and in culture. The fungus was identified as A. flavus. Intensive topical natamycin and systemic ketoconazole therapy was initiated. Despite intensive medical treatment, the infiltrate progressed and the patient was subjected to a therapeutic penetrating keratoplasty. There was no recurrence of infection after surgery. At last follow-up 4 months after surgery, the eye was quiet with graft edema. CONCLUSION: Fungal keratitis is a rare complication of laser in situ keratomileusis surgery. In a case that does not respond to medical treatment, early surgical intervention must be considered.

Conjunctival intraepithelial neoplasia presenting as corneal ulcer.

PURPOSE: To report a case of conjunctival intraepithelial neoplasia presenting as corneal ulcer. METHOD: Case report of a 28-year-old man who presented with sudden onset of pain, redness, and watering in the right eye. Examination of right cornea revealed deep stromal infiltrate inferonasally. Adjacent to the infiltrate and straddling the inferonasal limbus, a reddish well-defined sessible lesion with prominent blood vessels was seen. After corneal scraping for microbiological evaluation, the patient was treated with frequent instillation of ciprofloxacin hydrochloride 0.3% eyedrops. RESULTS: Corneal scraping revealed no microorganisms. Infiltrate resolved promptly after excision of the lesion. Histopathologic evaluation of the excised lesion revealed conjunctival intraepithelial neoplasia. CONCLUSIONS: This case highlights the fact that conjunctival intraepithelial neoplasia at the limbus may present as corneal ulcer. This ulcer could have occurred secondary to a dellen formation and epithelial breakdown predisposing to a corneal ulcer.

Epithelial infectious crystalline keratopathy.

PURPOSE: To report 2 cases of epithelial infectious crystalline keratopathy. METHODS: Two patients (2 eyes) with significant meibomitis presented with minimal inflammation and plaque-like lesions on the corneal surface made of fine crystalline structures. Corneal scrapings of these lesions were performed for microbiological evaluation. The patients were treated with topical ciprofloxacin and artificial tears. RESULTS: Smear examination of the corneal scrapings revealed numerous bacteria and keratinized epithelial cells with no inflammatory cells. Culture showed a significant growth of Staphylococcus epidermidis and Corynebacterium species in the first case and Pseudomonas aeroginosa in the second case. The response to treatment was poor, with recurrence of the crystalline lesion. CONCLUSION: Infectious crystalline keratopathy lesions may involve the epithelium and occur on the corneal surface.

Accidental self-removal of a flap--a rare complication of laser in situ keratomileusis surgery.

PURPOSE: To report a rare complication in which the patient accidentally removed the laser in situ keratomileusis corneal flap. METHODS: Interventional case report. A 35-year-old woman underwent uncomplicated laser in situ keratomileusis surgery. Ten days after surgery, she inserted a soft contact lens into the right eye to improve her vision. She tried to remove the contact lens, but had pain and bleeding. She was referred 10 days later with a diagnosis of loss of flap. RESULTS: On examination, she had a best-corrected visual acuity of 20/70 in the right eye. The right eye examination revealed no corneal flap, mild corneal edema, and significant haze. A central epithelial defect was found. CONCLUSION: Accidental corneal flap removal can rarely follow laser in situ keratomileusis surgery. This complication provides insight into the weak adhesion of the flap onto the stromal bed after laser in situ keratomileusis surgery and, hence, the inherent risk of traumatic flap dislocation or amputation, which needs to be explained to the patient.

Amniotic membrane transplantation in acute chemical and thermal injury.

PURPOSE: To present a case of chemical injury and a case of thermal injury treated by amniotic membrane transplantation in acute phase. METHODS: Case reports. An eye with sodium hydroxide injury, opaque cornea, and limbal ischemia of more than 180 degrees and an eye with hot tea injury, opaque cornea, stromal edema, and scarring were treated by amniotic membrane transplantation within the first few weeks of injury. RESULTS: In the eye with sodium hydroxide injury, 4 months after amniotic membrane transplantation, the ocular surface is stable, superficial corneal scarring with vascularization is present, and visual acuity is 20/25. In the eye with thermal injury, 6 months after amniotic membrane transplantation, the ocular surface is stable, but there is superficial scarring and vascularization, and visual acuity is 20/20. CONCLUSIONS: Amniotic membrane transplantation can be considered in chemical injury with severe limbal ischemia and in severe thermal injury in acute phase. Long-term studies are warranted to evaluate further the efficacy of amniotic membrane transplantation in these clinical situations.

Fungal keratitis after laser in situ keratomileusis.

A 22-year-old woman presented with pain, redness, watering, and decrease in vision in her left eye 15 days after laser in situ keratomileusis for myopia. Slitlamp examination showed a central full-thickness infiltrate with hyphate edges. Microscopic examination of corneal scrapings from the edge and underneath the flap showed fungal filaments, and the growth on culture media was identified as Scedosporium apiospermum.

Fungal keratitis associated with vernal keratoconjunctivitis.

PURPOSE: To report a case of fungal keratitis associated with vernal keratoconjunctivitis. CASE REPORT: A 22-year-old man with a history of vernal keratoconjunctivitis since October 1999 developed a shield ulcer in the left eye in June 2000, which resolved with intensive topical steroid therapy. He presented in August 2001 with onset of acute pain, redness, and decreased vision. The tarsal conjunctiva in the left eye showed large papillae. The cornea showed a white plaque-like lesion with an underlying stromal infiltrate involving the upper half of the cornea. The overlying epithelial defect measured 4.5 x 2.5 mm. The anterior chamber showed 1+ flare and cells and hypopyon measuring about 1 mm. RESULTS: Corneal scrapings were performed for microbiologic investigations. Smears of corneal scrapings revealed septate fungal filaments, and the culture showed a significant growth of Aspergillus flavus. CONCLUSIONS: Fungal keratitis may be associated with vernal keratoconjunctivitis. Though rare, fungal keratitis should be considered in the differential diagnosis of infections associated with vernal keratoconjunctivitis.

Corneal triple procedure: indications, complications, and outcomes: a developing country scenario.

PURPOSE: We report the indications, complications, and outcomes of 104 corneal triple procedures in our institute. METHODS: Patient records of 104 consecutive cases of corneal triple procedure (penetrating keratoplasty with extracapsular cataract extraction and intraocular lens implantation) performed by experienced corneal surgeons between January 1992 and December 1997 were retrospectively reviewed. Relevant preoperative, operative, and postoperative data were collected. The outcome was assessed by the graft clarity and visual acuity at the last visit. Survival analysis of these grafts was determined by Kaplan-Meier method. RESULTS: Of 104 patients, 70 were men and 34 were women. Mean age of these patients was 48.5+/-17.1 years (range, 1-75 years). Corneal scarring with cataract was the reason for surgery in 69 (66.4%) cases. The intraoperative complications included vitreous upthrust in seven (6.9%) cases and posterior capsular dehiscence in three (2.9%) cases. The most common early postoperative complications were increased intraocular pressure in 19 (18.3%) and increased anterior chamber reaction in 25 (24%) cases. Posterior capsular opacification was seen in 26 (25%), graft reaction in 15 (14.4%), and secondary glaucoma in 15 (14.4%) cases. These formed the important late postoperative complications. The average postoperative follow-up was 23.7+/-17.6 months (range, 1.6-79.4 months); at which time 72% of the grafts remained clear. At last follow-up, 40% of patients had a visual acuity of > or = 20/40. CONCLUSIONS: Corneal scarring with cataract is the most common reason for triple procedure in this part of the world. This is a safe surgical procedure with good graft clarity and reasonable visual recovery.

Anterior chamber tap: diagnostic and therapeutic indications in the management of ocular infections.

PURPOSE: To report three cases in which an anterior chamber tap was useful in the management of infection of the eye confined to the anterior segment. METHODS: In the first case, the patient presented with diffuse conjunctival congestion and thick anterior chamber exudates adhering to the back of the cornea. The second case involved fungal keratitis, and the patient was not responding to topical natamycin and systemic ketoconazole. In this patient, infiltrate and thick hypopyon persisted despite medical therapy. The patient in the third case had a persistent thick endothelial exudate, and a retained intracameral foreign body, fungal infection, and a cataract were suspected. In all three cases, an anterior chamber tap was performed. In case 1, the exudate was removed and sent for microbiologic investigation. In case 2, the hypopyon was evacuated and intracameral amphotericin B (5 microg) was injected. In case 3, the exudate contained a wooden foreign body that was sent for culture. Intracameral amphotericin B (5 microg) was injected. RESULTS: In the first case, the culture of the exudate grew Staphylococcus aureus. The eye quieted, and the exudate resolved following treatment with topical fortified cefazolin, fortified gentamicin, and systemic cefazolin. In the second case, smears of corneal scrapings revealed fungal filaments and the culture grew Aspergillus species. The infection resolved following an anterior chamber tap, but the patient developed a cataract. After cataract surgery, visual recovery was limited because of the corneal scar. In the third case, the culture of the foreign body grew an unidentified hyaline fungus. Following an anterior chamber tap, the infection resolved, but the cataract progressed. The patient did well after cataract surgery. CONCLUSIONS: An anterior chamber tap is an extremely useful procedure in the management of ocular infections confined to the anterior segment. The procedure should be performed under strict aseptic conditions. If the infection involves the anterior capsule of the lens, care should be taken to avoid injury to the lens, and the possibility of progression of the cataract should be explained to the patient.