Diffuse anterior retinoblastoma masquerading as complicated cataract - A case report

Diffuse anterior retinoblastoma (Rb) is a rare variant of this tumor which may involve the anterior chamber of the eye without any detectable mass in the posterior segment. The initial presentation of this tumor as anterior segment pathology may lead to misdiagnosis and erroneous management eventually delaying the definitive therapy. We describe an 8-year-old child presenting with complicated cataract who underwent lens aspiration and later found to have diffuse anterior Rb.

Acute coronary events in patients with myeloproliferative neoplasms- a nationwide analysis of patient characteristics and in-hospital outcomes

Background

Myeloproliferative neoplasms (MPN) are characterized by clonal expansion of cells belonging to the erythroid and/or myeloid lineages. Concomitant platelet dysfunction and thrombocytosis predispose these patients to arterial thromboses, causing a high burden of morbidity and mortality. With improving survival, an increasing number of patients with MPN are presenting with acute coronary syndromes (ACS). However, data regarding in-hospital outcomes and revascularization strategies utilized in these patients is limited, due to lack of representation in trials and rarity of the disease.

Methods

We conducted a retrospective cohort study using the 2016 Nationwide Inpatient Sample.Adult patients with a primary diagnosis of ACS and a secondary diagnosis of MPN, including essential thrombocytosis, polycythemia vera, primary myelofibrosis or chronic myeloproliferative disorder, were identified using the International Classification of Diseases (ICD) 10th revision codes. Outcomes of interest were compared using a multivariate logistic regression model.

Results

Out of 677,304 patients admitted for ACS, 2,485 also had a secondary diagnosis of MPN. Patients with MPN were less frequently female and diabetic but were more likely to have heart failure. No statistical difference in race, smoking or obesity was noted between the two cohorts. There was no significant difference in the in-hospital mortality in ACS patients with or without MPN. In terms of revascularization, patients with MPN were less likely to undergo percutaneous coronary intervention (PCI) and more likely to undergo coronary arterial bypass grafting (CABG). In addition, patients with MPN had a higher odds of acute pulmonary embolism, cardiogenic shock, and acute kidney injury as well as increased length of stay (LOS) and hospitalization costs

Conclusion

In patients with ACS and concomitant MPN, CABG was the preferred mode of revascularization over PCI, which may account for the increased LOS and total cost. Although the in-hospital mortality was similar, patients with MPN had higher odds of In-hospital complications.

Funding Acknowledgement

Type of funding source: None

"Macular sink hole" with intrachoroidal cavitation in a case of pathological myopia

Intrachoroidal cavitation (ICC) is a morphological feature outlined by optical coherence tomography and is characterized by presence of a hyporeflective space beneath the unaltered retinal pigment epithelium. It can be peripapillary or macular in location. Macular ICCs are reported in both myopic and non-myopic eyes. We report a case of full thickness macular hole with retinal incarceration into the macular ICC in a patient with pathological myopia. The term “Peripapillary sink hole” has been described in the literature. We propose the use of term “Macular sink hole” for our case owing to similar findings in the macula.

Subretinal Hemorrhage Complicating Retinal Angiomatous Proliferation in Tubercular Retinal Vasculitis

PURPOSE

To report a patient with submacular hemorrhage due to retinal angiomatous proliferation (RAP) in tubercular retinal vasculitis (TRV).

METHODS

Case report.

RESULTS

We report a 33-year-old Asian Indian patient of TRV presenting with capillary non-perfusion areas, submacular hemorrhage and venous loops. The patient presented with sudden onset decrease in vision in the right eye. Multimodal imaging revealed presence of retinal vascular anastomosis and stage 2 RAP. Systemic examination was within normal limits. Laboratory evaluation revealed positive Mantoux and interferon gamma release assay. He underwent right eye intravitreal injection of recombinant tissue plasminogen activator (12.5µg/0.1ml) with 100% sulphur hexafluoride (SF6) tamponade. The patient had successful displacement of the submacular hemorrhage with some improvement in visual acuity.

CONCLUSION

This case highlights that rare vascular alterations such as RAP can develop in subjects with ocular tuberculosis.

Clear subretinal fluid in a case of non-neovascular early-onset drusen: Swept-source imaging evaluation

A 50-year-old male presented with recent metamorphopsia in the right eye. Fundus examination revealed bilateral multiple cuticular drusen along with few large colloid drusen (phenotype 3 cuticular drusen). No vitelliform material was evident in the macula in either eye. Fluorescein angiography (FA), indocyanine green angiography (ICGA) did not demonstrate a macular neovascularization (MNV) in either eye. Swept-source optical coherence tomography (SS-OCT) revealed sub-retinal pigment epithelial (RPE) drusen and a clear space beneath the inter-digitation zone and above the RPE-Bruch's complex. SS-OCTA did not reveal MNV in either eye. The patient was kept under observation, and follow-up at 3 months did not reveal any structural change. Among patients with early-onset drusen, vitelliform detachments may occur due to accumulation of yellow pseudo-vitelliform material. However, serous detachments with an "optically clear" subretinal space can occur by the same mechanism without MNV. Such patients do not merit therapy with anti-vascular endothelial growth factor agents.

Early detection of Pseudomonas aeruginosa and Escherichia coli. using zinc tetraphenylporphyrin

The sensory characteristics of food are considerably effected by the metabolic processes of various micro-organisms in the food stored in the field or at ambient temperature. Also, this microbial contamination can pose serious health hazards to public health. Chemical analysis of the complex mixture of volatiles produced during bacterial growth and investigation methods of these microorganisms presents a big challenge. There remains major unmet need to shorten and improve detection methods. Therefore, early detection of the microorganisms will open many frontiers for quality control in the foodstuffs industry. Accordingly, the aim of this study was to assess the feasibility and performance of chemoreceptive sensors for the rapid detection of bacterial pathogens, specifically Pseudomonas aeruginosa and Escherichia coli.

In Uv/vis study, zinc tetraphenyl porphyrin solutions (in DMF) was tested with various volatile compounds, such as propanal, hexanal and heptanal which are commonly found to be released during the growth of bacteria. These sensors were used to detect the bacterial odours of two pathogenic species (E.coli and P.aeruginosa) during their growth cycle at 4 °C and ambient temperature.

Hypochromic shifts in Uv/vis and hydrogen bonding in FT-IR studies confirmed the interaction between the volatiles and porphyrin. The porphyrin used detected the presence of microorganisms after 12 hrs incubation and showed more sensitivity for volatiles released during aerobic activity P. aeruginosa as compared to E. coli at 4 °C and ambient temperature.

Zinc tetraphenyl porphyrin based chemoreceptive membranes has been proved successful for the detection of P. aeruginosa. Hence, the present study proves wide scope of improvement over current laboratory techniques for the detection of pathogens in terms of speed, ease of use, and cost.

Key messages

The developed technique allows rapid detection of spoiled food. Chemoreceptive property of porphyrin has been exploited for the early detection of bacteria.

AB0013 HLA ASSOCIATION WITH SYSTEMIC SCLEROSIS (SSc) IN NORTH INDIAN POPULATION AND FAMILIAL INHERITANCE PATTERNS

Background:

It is widely believed that SSc develops in an individual with a permissive genetic makeup.Genetic influences have long been suspected to impact SSc. In families with a history of SSc, the incidence of disease can range from 1.5 to 1.7% (1). There are several reports of familial occurrence and certain alleles of the HLA system have been associated with the disease (2).No Indian data pertaining to genetic basis of systemic sclerosis is present. Understanding the genetic basis of the disease will help us in defining the biomarkers of the disease in the population that can help in early diagnosis and prognosis.

Objectives:

To study HLA association with Systemic sclerosis (SSc) in North Indian Population and its genetic susceptibility to familial systemic sclerosis.

Methods:

A total of 150 SSc patients diagnosed by following ACR and EULAR criteria and 150 control subjects, were genotyped for HLA-A, B, DRB1, DQB1 loci by Luminex® 200 Instrument (USA). The association of alleles with disease susceptibility was tested by Chi-square test and Fisher’s exact test.

HLA Typing for HLA class I (A, B, C) and II(DR,DQ,DP) for familial study of systemic sclerosis in 2 families was performed by Next Generation Sequencing(NGS) with illumina MiniSeq using MIA FORA NGS Kits from IMMUCOR. Antinuclear patterns (ANA) and specific antibodies were detected by indirect Immunofluorescence and Immunoblot (Euroline, Germany).

Results:

Strong disease associations were observed for haplotypes A*24(OR=1.7;< 0.02), A*32(OR=2.8;< 0.02), B*35(OR=1.7;< 0.03), DRB1*11(OR=2.1;< 0.007). The reduced frequencies of haplotypes A*68(P< 0.05), DRB1*10(P< 0.05), DRB1*12 (P<0.00) among patients suggested a protective association. There was no statistical association found with HLA DQB*1.

Through NGS we observed that in the 1stfamily haplotypes HLA –A*11, 32, 24; B* 51, 55, 35; C*-14, 04; DRB1*15, 04; DQB1*05, 03; DPB1*04, 26 appears in affected family members with serological abnormalities.In the 2ndfamily both mother and daughter had same set of haplotypes except DQB1 with serological abnormalities. The haplotypes DPB1*04 was present in all the diseased individuals of both the families (Fig. 1 and table 1).

Table 1.

NGS HLA typing report

ABCDRB1DQB1DPB1F111 2435 1504 0415 1505 0502 26F211 3251 5514 0415 0405 0304 04F311 2435 5504 0415 1505 0526 04F432 1151 1514 0415 0405 0302 04F524 3335 4404 0715 0705 0226 14F611 2435 5504 0415 1505 0504 26F711 2435 5504 0415 1505 0504 26F824 3251 3514 0404 1503 0526 04F911 3251 5514 0415 0405 0304 04F1011 3344 5207 1211 0702 0304 13F1111 3344 5207 1211 0703 0304 13

Fig. 1

Conclusion:

The risk alleles A*24, 32; B*35; DRB1*11 were found to be associated with North Indian cohort of SSc, while the protecting alleles were A*68; DRB1*10, 12.These risk alleles were present in the SSc affected family members and the protective alleles were absent in the same. Surprisingly, even healthy members carried the same risk alleles but did not manifest the disease or have serological evidence of the same. We have not excluded occurrence of disease at a later age, as presently the healthy siblings are young. Thus our study indicates that though HLA association are found with SSc but many other factors like HLA (HLA *C, DPB1*) or non HLA genes as wells as epigenetic factors might also play a role in disease manifestation and severity.

References:

[1]Luo Y, Wang Y, Wang Q,et al. Systemic sclerosis: genetics and epigenetics. J Autoimmun.2013; 41:161–67.

[2]de Juan MD1, Belzunegui J, Belmonte I, Barado J, Figueroa M, Cancio J, Vidal S, Cuadrado E. An immunogenetic study of familial scleroderma. Ann Rheum Dis. 1994 Sep; 53(9):614-7.

Acknowledgments:

The technical help of Mr.Manoj Kumar and Mr.Vinkesh are hereby gratefully acknowledged Indian Council of Medical Research(Funding of Fellowship)

Disclosure of Interests:

None declared

Paediatric morphoea: a holistic review. Part 1: epidemiology, aetiopathogenesis and clinical classification

Morphoea, also known as localized scleroderma, is a debilitating fibrosing disorder of uncertain aetiology, affecting the skin and subcutaneous tissues. Paediatric-onset disease is not uncommon and is associated with frequent relapses. The disease has complex pathogenetic mechanisms and multiple clinical subtypes, and affects children of all ages. Recent research has focused on elucidating the disease pathophysiology and identifying measures of disease activity. We performed a literature search on PubMed, MEDLINE and Google Scholar, using keywords such as 'pediatric morphea', 'juvenile localised scleroderma' and 'juvenile systemic sclerosis'. Relevant studies, including randomized trials, reviews of standard current guidelines and original research articles, were selected, and results were analysed before being summarized. In the first of this two-part review, we provide a bird's-eye view of the current literature concerning the epidemiology, aetiopathogenesis and clinical classification of paediatric morphoea; in Part 2, we review the diagnosis, markers of disease activity, management and natural history.

Paediatric morphoea: a holistic review. Part 2: diagnosis, measures of disease activity, management and natural history

Paediatric morphoea is a debilitating fibrosing disorder of uncertain aetiology, affecting the skin and subcutaneous tissues. Defining optimum management strategies in paediatric morphoea remains an ongoing challenge, owing to the varied presentations and a relative paucity of paediatric-specific studies. We performed a literature search on PubMed, MEDLINE and Google Scholar, using keywords such as 'pediatric morphea', 'juvenile localised scleroderma' and 'juvenile systemic sclerosis'. Relevant studies, including randomized trials, reviews of standard current guidelines and original research articles, were selected and results analysed before summarizing them. In Part 1 of this review, we described the epidemiology, aetiopathogenesis and clinical classification; in this part, we discuss the diagnosis, markers of disease activity, management and natural history in paediatric morphoea.

Advances in imaging of uveitis

Advances in multimodal imaging have significantly contributed to the management of many uveitis diseases in recent years. The most significant developments include the use of optical coherence tomography to obtain a more accurate and reproducible assessment of ocular inflammation, the application of optical coherence tomography angiography in choroiditis and retinal vasculitis, new possibilities for studying vitritis with ultrawide field imaging, and the most recent applications of fundus autofluorescence in uveitis. In this review, we provide an overview of the most significant advances in multimodal imaging of uveitis achieved in recent years.

Enterobious vermicularis induced infectious keratitis following penetrating keratoplasty

A 28-year-old man with a prior history of penetrating keratoplasty in the left eye for total corneal melt presented with a 3-day history of a red, painful left eye. On examination, he was found to have graft infiltrates. Microscopic examination of wet mount preparation of corneal scrapings revealed the presence of embryonated eggs of E. vermicularis. Cellophane (scotch) tape preparation from perianal region also revealed embryonated eggs of E. vermicularis as well as live adult worms. Ocular and adnexal involvement by E. vermicularis is extremely rare. Here, we report the first case of infection of a corneal graft with E. vermicularis.

Nasal endoscopic features and outcomes of nasal endoscopy guided bicanalicular intubation for complex persistent congenital nasolacrimal duct obstructions

Purpose:

To study the clinical presentation, nasal endoscopic features, and outcomes of nasal endoscopy guided (NEG) bicanalicular intubation (BCI) in children with complex persistent congenital nasolacrimal duct obstruction (pCNLDO).

Methods:

A prospective, interventional study including eligible children (age ≤ 12 years) having complex pCNLDO. The demographics, number of previous probings, nasal endoscopy findings, and outcomes; were noted in all children who underwent NEG-BCI with Crawford's stents. Matting of eyelashes (MoE, upper, and lower eyelid), tear-film height (TFH), and fluorescein dye disappearance test (FDDT) was assessed pre and postoperatively. The minimum stent in-situ period was 12 weeks, and the minimum follow-up was 6 months (after stent removal).

Results:

Total 32 children (36 eyes) including 18 females (56.25%) were studied. At a mean age of 4.9 years, all children had epiphora and discharge with MoE (both upper and lower), raised TFH and positive FDDT. Previously, all children underwent conventional probing (s)- once in 12 (33.3%), twice in 18 (50%) and thrice in 6 (16.7%) eyes. The general ophthalmologists performed the majority (n = 21, 58.33%) of those. The BCI was performed under GA in all eyes, and at a mean follow-up of 8.5 months, the “complete” success was noted in 29 eyes (80.5%), ‘partial’ success in 4 (11.1%) and failure in 3 (8.3%). The stent prolapse was seen in three.

Conclusion:

NEG-BCI may provide a satisfactory resolution to complex pCNLDO after single or multiple failed probings. NEG provides confident and efficient management of coexistent intranasal complexities related to the inferior turbinate and meatus.

Safety and efficacy of 532 nm frequency-doubled Nd-YAG green laser photocoagulation for treatment of retinopathy of prematurity

Purpose

To evaluate the safety and efficacy of 532 nm frequency-doubled Nd-YAG green laser for treatment of retinopathy of prematurity (ROP).

Methods

This retrospective interventional case series included infants undergoing treatment for ROP with 532 nm green laser between January 2012 and March 2017 at a single tertiary-care referral center. Review of clinical records was done to identify baseline ROP characteristics, procedural difficulties, complications related to the laser procedure and outcome of treatment at ≥ 1 year of follow-up.

Results

There are about 347 eyes of 182 infants were included in this present study. ROP presented in zone I in 76 eyes (21.9%) and zone II in 271 eyes (78.1%). Tunica vasculosa lentis (TVL) was present in 43.8% and pre-existing vitreous hemorrhage in 4.6% of the eyes. 532 nm green laser could be performed as a primary procedure in all eyes, including those with TVL. 322 eyes completed a minimum follow up of 1 year with a mean follow up of 22.8 months (range, 12-54 months). At the last follow-up visit, 298 (92.5%) of the 322 eyes had a favorable outcome. On logistic regression analysis, pre-existing fibrovascular proliferation (p = 0.04) and new-onset fibrovascular proliferation after treatment (p = 0.001) were the most significant independent predictors of poor outcome. Complications encountered were new-onset hemorrhage in 36 eyes (11.2%), anterior segment ischemia in two eyes (0.006%) and cataract in one eye (0.003%).

Conclusion

532 nm frequency-doubled Nd-YAG green laser appears to be safe and effective in the treatment of ROP.

Perioperative Propranolol: A Useful Adjunct for Glaucoma Surgery in Sturge-Weber Syndrome

PURPOSE

Ocular manifestations of Sturge-Weber syndrome (SWS) include choroidal hemangioma and glaucoma. Intraocular pressure (IOP) reduction in these patients commonly is associated with sight-threatening choroidal effusions. Oral propranolol is the standard of care for infantile cutaneous hemangioma, but its role in choroidal hemangioma largely is unexplored. We studied the role of perioperative oral propranolol during glaucoma surgery in SWS.

DESIGN

Prospective, nonrandomized case series with historical controls.

PARTICIPANTS

Fourteen eyes of 12 patients with SWS scheduled for glaucoma surgery were included, and the outcomes were compared with those of historical controls without propranolol use (15 eyes of 14 patients).

METHODS

Patients in the prospective cohort received oral propranolol 2 mg/kg of body weight daily in 2 divided doses 1 week before surgery and continued for 6 weeks after surgery. There was no modification (e.g., posterior sclerotomy) in the existing surgical technique. The historical control group was identified from records and SWS diagnosis validated by chart review.

MAIN OUTCOME MEASURES

The incidence and extent of postoperative choroidal effusion, additional procedures required compared with the control group, and adverse effects of the drug in the prospective cohort.

RESULTS

Average follow-up was 25.7±12.1 months (95% confidence interval, 19.3-32.1 months). The intraocular pressure reduced from 25.2±9.7 mmHg at presentation to 16.25±6.2 mmHg, 14.6±4.5 mmHg, 13.7±6.4 mmHg, and 16.5±8.0 mmHg at 1 week, 1 month, 3 months, and 1 year after surgery, respectively. In the perioperative propranolol group, no patient demonstrated sight-threatening choroidal effusion within the vascular arcades. In the 2 patients with bilateral disease, both eyes of each patient showed peripheral choroidal effusion, which settled with medical treatment. Surgery was a repeat procedure in 3 of the 4 eyes. There were no adverse effects of propranolol in any patient. In the control group, 5 of 12 eyes showed peripheral choroidal effusion after primary glaucoma surgery, whereas 5 of 6 eyes that underwent repeat surgery failed demonstrated sight-threatening choroidal effusion requiring surgical intervention.

CONCLUSIONS

Oral propranolol seems to be an effective method to minimize the development of sight-threatening choroidal effusion after glaucoma surgery in SWS.