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   2003| July-September  | Volume 51 | Issue 3  
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Rhino-Orbito-Cerebral Mucormycosis. A Retrospective Analysis of Clinical Features and Treatment Outcomes
S Nithyanandam, Moire S Jacob, Ravindra R Battu, Reji K Thomas, Majorie A Correa, O D'Souza
July-September 2003, 51(3):231-236
Objective: The conventional management of rhino-orbito-cerebral (ROC) mucormycosis includes control of metabolic abnormality, administration of amphotericin B and surgery that spans simple sinus clearance, radical debridement and orbital exenteration. Recent literature includes anecdotal descriptions of successful treatment with conservative management of involved orbits. We evaluated the clinical features and outcome of treatment for the different stages of ROC mucormycosis. Method: In this retrospective case series, 34 case records of patients with a histopathological diagnosis of ROC mucormycosis treated between 1992 and 2000 were reviewed. Three clinical stages and three treatment groups were identified. Patients with limited sino-nasal disease (Clinical stage I) underwent sino-nasal debridement (Treatment group A). Patients with limited rhino-orbital disease (Clinical stage II) underwent either sino-nasal debridement alone (Treatment group A) or orbital exenteration in addition to sino-nasal debridement (Treatment group B). Patients with rhino-orbito-cerebral disease (Clinical stage III) did not undergo any surgical procedure (Treatment group C). Thirty-three patients received intravenous amphotericin B. Outcome for each group was measured as "Treatment success" (disease free, stable patient with metabolic abnormality under control) and "Treatment failure" (progression of disease with worsening general condition or mortality due to the disease). Results: Uncontrolled diabetes in 30 (88.2%) of 34 patients was the commonest underlying disease and 16 (53.3%) of 30 diabetics had ketoacidosis. Chronic renal failure (n = 4), hepatic disease (n = 3) and idiopathic thrombocytopenia (n = 1) were the other underlying diseases. Eleven patients had stage I disease, 16 patients had stage II disease and seven patients had stage III disease. All 11 patients with stage I disease received treatment A; of 16 patients with stage II disease, 7 received treatment A and the remaining with stage III disease received treatment B; 7 patients with stage II disease received treatment C. Ten of 11 patients (91%) with stage I disease had treatment success. In patients with stage II disease, 7 of 7 (100%) with treatment A and 1 of 9 (11.1%) with treatment B had treatment success. All seven patients with stage III disease had treatment failure. Conclusion: Debridement of the sinuses is necessary in all cases of rhino-orbito-cerebral mucormycosis. Diagnosis in the early stage needs a high degree of suspicion. There is a definite role for retention of orbits in patients whose metabolic derangement is rapidly controlled and orbital involvement is non-progressive.
  12,785 1 41
Intraocular Irrigating Solutions. A Clinical Study of BSS Plus® and Dextrose Bicarbonate Fortified BSS® as an Infusate during Pars Plana Vitrectomy.
Michael A Samuel, Uday R Desai, I Strassman, M Abusamak
July-September 2003, 51(3):237-242
Purpose: To compare the effect of Balanced Salt Solution Plus (BSS Plus, Alcon Laboratories, Fort Worth, Texas, USA) and fortified regular BSS on the cornea and lens, when used for continuous irrigation in pars plana vitrectomy (PPV) surgery. Methods: Prospective, investigator masked, randomised study. Forty patients were randomly assigned to undergo PPV using BSS Plus (n=20) or fortified BSS (n=20) [regular BSS, fortified with 10.5 cc. of dextrose in water (D5W) and 13.1cc. of 8.4% sodium bicarbonate]. Intraoperative features of the corneal epithelium, postoperative changes in the corneal endothelial cell denstiy (ECD) at 3 months, and clarity of the lens during surgery and postoperatively were evaluated. Results: Intraoperative epithelial changes were similar in both groups with 7 (35%) of the cases having the epithelium removed in the BSS Plus group and 8 (40%) in the BSS fortified group (P=0.23). The mean differences in ECD (3 months versus preoperative) in the operated eyes when adjusted for changes in the control eye showed no difference with the type of BSS (P=0.98). Intraoperative lens changes were more significant (P=0.018) in the BSS fortified group. Postoperative lens status at 3 months was similar for both groups. Though there was a trend towards worse postoperative nuclear sclerosis change in the BSS fortified group, it was not significant (P=0.160). Conclusion: Standard BSS fortified with dextrose and bicarbonate is an efficacious infusion fluid during pars plana vitrectomy. Both solutions showed comparable effects on postoperative corneal endothelial cell density and corneal epithelial changes intraoperatively. BSS fortified has more lenticular changes intraoperatively than BSS Plus although no lens had to be removed in either group. The study implications are important since BSS fortified is significantly less expensive than BSS Plus.
  10,955 14 2
Ophthalmic photography using a digital camera.
R Fogla, Srinivas K Rao
July-September 2003, 51(3):269-272
Purpose: To report the application of a digital camera for ophthalmic photography in routine clinical use. Methods: A digital camera (Nikon Coolpix 995) was used both for external macrophotography of the eye and ocular adnexa, and slitlamp photography of the anterior segment of the eye. Results: We were able to take external macrophotographs under high magnification of the eye and ocular adnexa. Slitlamp photography could be performed under diffuse, slit beam, and retroillumination. The structures of the angle, the optic disc and surrounding retina could be photographed using appropriate lenses. The attachment to the operating microscope allowed intra-operative photography. It could also be attached to the laboratory microscope to capture images of various histopathology and microbiology slides. Conclusions: A digital camera is a versatile instrument for ophthalmic photography. It is easy to use in routine clinical practice and provides good quality photographs.
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Ocular Manifestations of Wegener's Granulomatosis.Analysis of Nine Cases
J Biswas, K Babu, L Gopal, S Krishnakumar, S Suresh, S Ramakrishnan
July-September 2003, 51(3):217-223
Purpose: To report a series of nine patients of Wegener's granulomatosis (WG) with diverse ocular and systemic manifestations. Methods: Retrospective analysis of nine consecutive patients seen between 1987 and 2002. Results: The mean age at the time of diagnosis was 43.89 years (range: 33-56 years). Redness, pain and photophobia (8 patients) were the common presenting complaints. Sinusitis (6 patients) and arthralgia (6 patients) were the commonly associated systemic complaints. Necrotising scleritis with peripheral keratopathy (6 patients) was the most common ocular sign. Serum antibodies against the cytoplasmic component of neutrophils and monocytes (cANCA) were positive in 7 of 8 patients. Biopsy diagnosis was done in one patient for whom cANCA was not done. Cyclophosphamide and corticosteroids alleviated the symptoms in 6 patients. Ocular and systemic condition remained stable in 7 patients. One patient expired due to the severity of the disease and another patient was lost to follow-up. Conclusions: Scleritis with peripheral corneal involvement was the most commonly observed ocular manifestation of WG in our series. cANCA was a useful adjunct in the diagnosis of WG. When clinical and serologic findings were inconclusive, biopsy remained indispensable. A combination of cyclophosphamide and corticosteroids is essential and critical not only for the ocular condition but also for the survival of the patient.
  8,128 3 7
In-Vivo Slit Scanning Confocal Microscopy of Normal Corneas in Indian Eyes
M Vanathi, R Tandon, N Sharma, Jeewan S Titiyal, Ravindra M Pandey, Rasik B Vajpayee
July-September 2003, 51(3):225-230
Objective: To study the cellular populations of healthy corneas of Indian eyes using confocal microscopy and to evaluate the correlation with age, gender and laterality. Methods: The central corneas of 100 eyes of 50 healthy subjects were examined using an i n-vivo slit scanning confocal microscope (Confoscan 2). Images were analysed for cell densities of the epithelium, stroma and endothelium. Results: Good quality images enabling analysis of all cell layer populations were obtained in 74 eyes of 43 healthy subjects (22 males and 21 females) with a mean age of 31.89 ± 13.47 (range 19-71 years). The basal epithelial cell density was 3601.38 ± 408.19 cells/mm2 (range 3017.3 -4231.1cells/mm2). The mean keratocyte nuclei density in the anterior stroma was 1005.02 ± 396.86 cells/mm2 (range 571.6 - 1249.6 cells/mm2) and in the posterior stroma was 654.32 ± 147.09 cells/mm2 (range 402.6 - 1049.1 cells/mm2). Posterior keratocyte nuclei density was 30.76% less than the anterior stromal keratocyte nuclei density. The difference in keratocyte nuclei density was statistically significant (P=0.001). The mean endothelial cell density was 2818.1 ± 361.03 cells/mm2 (range 2118.9 - 4434 cells/mm2) and the mean endothelial cell area was found to be 385.44 ± 42.66 mm2 (range 268.9 - 489.2 mm2). Hexagonal cells formed 22.5 - 69.4% of the endothelial cell populations (mean 42.04 ± 11.81%). Mean coefficient of cell size variation was 32.29 ± 3.06 (range 27.2 - 39.2). No statistically significant differences were found in cell densities of any corneal layer either between female and male patients or between right and left eyes. Basal epithelial cell density, anterior stromal keratocyte nuclei and posterior stromal keratocyte nuclei density were unaffected by age (r= 0.12, 0.07, - 0.12 respectively) (P= 0.001). There was a statistically significant negative correlation between mean endothelial cell density and increase in age (r= - 0.42, P=0.001). Coefficient of cell size variation and age were positively correlated (r=0.73, P=0.001). Conclusion: In-vivo slit scanning confocal microscopy is useful for the study of corneal cell populations. Our study provides normative data of these cell populations.
  7,011 3 15
Utilisation of community-based rehabilitation services for incurably blind persons in a rural population of southern India
V Vijayakumar, D Datta, A Karthika, Ravilla D Thulasiraj, Praveen K Nirmalan
July-September 2003, 51(3):273-277
Purpose: To identify barriers in utilisation of community based rehabilitation (CBR) services for incurably blind persons in rural South India. Methods: A community-based rehabilitation programme for incurably blind persons was initiated in Theni district of southern Tamil Nadu in south India. After door-to-door enumeration and preliminary ocular screening by trained workers at the village, identified blind persons were categorised as either curable or incurable by an ophthalmologist. Trained workers provided rehabilitation, including mobility training (OM), training to perform activities of daily living (ADL), and economic rehabilitation for the incurably blind in their respective villages. Results: Of the 460,984 persons surveyed, 400 (0.09%) were certified as incurably blind including 156 (39.00%) persons blind from birth. Social rehabilitation was provided for 268 (67.00%) incurably blind persons. Economic rehabilitation was provided to 96 persons, and integrated education to 22 children. Nearly one-fifth (n=68,17.00%) of incurably blind persons refused the services provided. The major reasons for refusal included old age and other illnesses (41.18%), and multiple handicaps (19.12%). Twenty-seven (6.75%) persons had either migrated or died, and 29 (7.25%) persons were already able to function independently. Conclusion: Although CBR programmes provide useful services to the incurably blind, a better understanding of barriers is required to improve service utilisation. Developing a standardised data collection format for every CBR programme can result in the creation of a national database of ophthalmic diseases.
  6,764 1 6
Sir Nicholas Harold Ridley.He Changed the World, So that We Might Better See It.
Rupal H Trivedi, David J Apple, Suresh K Pandey, L Werner, Andrea M Izak, Abhay R Vasavada, J Ram
July-September 2003, 51(3):211-216
Cataract surgery with intraocular lens (IOL) implantation has become the most common and most successful of all operations in medicine. Sir Harold Ridley's first cataract extraction with implantation of an IOL marked the beginning of a major change in the practice of ophthalmology. Millions of patients worldwide have benefited from Sir Ridley's invention, and are likely to continue to derive benefit from this device. However, the development of the IOL was not without its share of ups and downs. Sir Harold Ridley, the inventor of IOL, died at the age of 94, on 25 May 2001, and ophthalmology lost one of its greatest and most influential practitioners. We are happy that he lived to enjoy the fruits of his labour - to see the amazing improvements and the expansive growth that evolved in the cataract-IOL technique, from early and unsatisfactory operations in previous decades, to the superb results attainable today. The invention of the IOL has not been just the addition of one new form of treatment, but rather, Sir Harold's tiny disc-shaped sliver of plastic has changed the world so that our patients may better see it . This article presents a brief biographical sketch of Sir Harold and lists his major inventions and contributions to ophthalmology.
  5,541 3 2
Does Internal Limiting Membrane Peeling in Macular Hole Surgery Improve Reading Vision?
T Das, S Parida, Ajit B Majji
July-September 2003, 51(3):251-254
Purpose: To document the effect of internal limiting membrane (ILM) peeling in macular hole closure and reading vision. Method: Fifty-four patients with idiopathic and traumatic macular hole underwent standard vitreous surgery and received either ILM peeling (n= 25) or no ILM peeling (n= 29). The hole closure, and Snellen acuity (distant and near) were recorded 12 weeks after surgery and statistically analysed. Results: The macular hole closure rate was 96% (24 of 25) and 72.4% (21 of 29) with and without ILM peeling respectively (P = 0.028). Distant vision improvement of two or more lines was recorded in 64% (16 of 25) and 51.7% (15 of 29) eyes (P = 0.417) with and without ILM peeling respectively. Near vision improvement of two or more lines was seen in 68% (17 of 25) and 41.2% (12 of 29) eyes (P = 0.048) with and without ILM peeling respectively. Conclusion: ILM peeling in macular hole surgery improves the macular hole closure rate and reading vision.
  5,171 12 4
Granulomatous Keratitis following Corneal Tattooing.
A Sharma, P Gupta, Mangat R Dogra, Ahmed A Hidayat, A Gupta
July-September 2003, 51(3):265-267
We report a patient who developed granulomatous keratitis following corneal tattooing
  4,458 0 2
Dermal Cylindroma Presenting as Mass Lesion in Superomedial Orbit.
R Gupta, R Jain, S Sood, H Mohan
July-September 2003, 51(3):257-259
A superomedial orbital dermal cylindroma in an adult female is described.
  3,689 1 1
Transpupillary Thermotherapy for Treatment of Choroidal Neovascularisation Secondary to Age-Related Macular Degeneration in Indian Eyes
M Nagpal, K Nagpal, S Sharma, J Puri, Pran N Nagpal
July-September 2003, 51(3):243-250
Aim: To evaluate the efficacy of transpupillary thermotherapy (TTT) for treatment of subfoveal choroidal neovascularisation (CNV) secondary to age-related macular degeneration (AMD), and to define accurate power settings for this procedure in Indian eyes. Methods: A prospective, nonrandomised study of 160 eyes of 144 patients with subfoveal CNV. The laser settings included 2mm spot and 300mw power or 3mm spot and 400-600mw power. Two separate 3mm spots were used in larger lesions. The treatment was given for 60 seconds at each point. Results: Ninety-nine eyes had classic membranes and 61 eyes had occult membranes. Following treatment, 79 of 99 (79.8%) classic and 52 of 61 (85%) occult membranes regressed. Visual improvement (˛ 2 lines) was seen in 29 (29.3%) eyes and 12 (19.6%) eyes ; visual stabilisation (1 line) in 39 (39.4%) eyes, and 35 (57.4%) eyes; and reduction of vision (­ 2 lines) in 31 (31.3%) eyes and 14 (22.9%) eyes with classic and occult membranes respectively. Mean follow-up was 12 months. One patient suffered inadvertant foveal burn. Conclusion: TTT is effective in the management of subfoveal membranes in Indian eyes. They respond to lower energy levels compared to the Caucasian eyes.
  3,625 24 8
Interface Keratitis due to Mycobacterium fortuitum following Laser In Situ Keratomileusis.
R Fogla, Srinivas K Rao, P Padmanabhan
July-September 2003, 51(3):263-265
A case of unilateral interface keratitis due to Mycobacterium fortuitum following simultaneous bilateral LASIK procedure for low myopia is reported. Excimer phototherapeutic keratectomy was performed to the stromal bed to reduce the infective load. Intensive topical therapy with topical amikacin and ciprofloxacin resulted in resolution of the keratitis.
  3,559 0 2
Malignant Atrophic Papulosis. Report of a Case with Multiple Ophthalmic Findings.
Reji K Thomas, S Nithyanandam, B Abdul Rawoof, SC Rajendran
July-September 2003, 51(3):260-263
Malignant atrophic papulosis is a rare and fatal condition with multiple organ involvement. We describe a patient with progressive ocular and dermatological findings.
  3,482 0 2
Traumatic Wound Dehiscence 14 Years following Penetrating Keratoplasty.
S Maheshwari, M Saswade, A Thool
July-September 2003, 51(3):259-260
Penetrating keratoplasty eyes are at greater risk of laceration than intact corneas due to persistent wound weakness, even years after surgery. We report a case of traumatic wound dehiscence by fingertip injury 14 years following penetrating keratoplasty.
  3,052 0 3
Prolapsed Intraocular Aspergilloma Masquerading as Malignant Melanoma
Mandeep S Bajaj, N Pushker, A Kulkarni, S Kashyap, A Purohit
July-September 2003, 51(3):255-257
We describe an aspergilloma that masqueraded as an intraocular malignant melanoma in an elderly male patient.
  2,952 0 3
Seizure related valsalva-like retinopathy
J Sen, P Palimar
July-September 2003, 51(3):279-279
  2,881 0 -
Phacoemulsification in subluxated cataract
Praveen Krishna Ratnagiri
July-September 2003, 51(3):282-282
  2,620 12 -
Myocilin mutation 1109 C>T (Pro 370 Leu) is the most common gene defect causing early onset primary open angle glaucoma
A Mukhopadhyay, M Acharya, J Ray, M Khan, K Sarkar, Asit Ranjan Banerjee, K Ray
July-September 2003, 51(3):279-281
  2,581 3 4
The Cataract Scene
R Thomas
July-September 2003, 51(3):209-210
  2,324 1 1
Trypan Blue Enhanced Vitrectomy in Clear Gel Vitrectomy
Arvind Kumar Dubey
July-September 2003, 51(3):286-287
  2,281 0 -
In reply
Sanjay Kumar Teotia
July-September 2003, 51(3):283-283
  2,014 2 -
Finer points about intravitreal corticosteroids
V Vedantham
July-September 2003, 51(3):285-285
  1,962 0 -
Astigmatism after ECCE in eastern Nepal. Continuous versus interrupted sutures
P Parmar, A Salman
July-September 2003, 51(3):283-283
  1,676 0 1