Oversized corneal grafts for corneal opacities with iridocorneal adhesions

OBJECTIVE

To evaluate the efficacy of 1-mm oversized corneal grafts in patients with acquired corneal opacities and extensive peripheral iridocorneal adhesions.

DESIGN

Prospective noncomparative case series.

PARTICIPANTS

Twenty patients (20 eyes) aged 15 years or older with unilateral or bilateral corneal opacification and a shallow anterior chamber.

INTERVENTION

Penetrating keratoplasty was performed with donor corneal buttons oversized by 1 mm.

MAIN OUTCOME MEASURES

The various parameters evaluated were visual acuity, graft clarity, keratometry, anterior chamber depth, intraocular pressure, and spherical equivalent refraction 12 months after surgery.

RESULTS

The keratoplasties were performed in 15 eyes with a corneo-iridic scar after infectious keratitis (75%) and 5 eyes with failed graft (25%). At the final follow-up, a clear graft was achieved in 17 eyes (85%), and 14 eyes (70%) achieved a best-corrected visual acuity of 6/12 or better. Three of the grafts failed because of rejection. The average keratometry was 44.1 +/- 1.0 diopters (D), and the mean spherical equivalent was -3.23 +/- 2.86 D. The oversized grafts provided a mean anterior chamber depth of 2.36 +/- 0.42 mm, and the mean intraocular pressure at the 12 month follow-up was 16.38 +/- 2.09 mmHg.

CONCLUSIONS

Corneal grafts oversized by 1 mm provide adequate anterior chamber depth and reduce the risk of peripheral anterior synechiae and secondary glaucoma in patients with corneal opacities and extensive peripheral iridocorneal adhesions.

Resistance to treatment in Kala-azar: speciation of isolates from northeast India

Kala-azar in India is becoming increasingly difficult to treat, which may be due to the presence of species other than Leishmania donovani; Leishmania tropica was reported to cause the same clinical syndrome in the area. Over the past 3 years, we have collected samples from 241 patients with visceral leishmaniasis from across the region. Of the 189 isolates that grew on diphasic medium, 159 were successfully transferred to liquid medium for typing. Clinically, 80% of these were resistant to antimony. Lipophosphoglycan-specific monoclonal antibodies were used to distinguish the 2 species by agglutination of promastigotes; all 159 were shown to be L. donovani. Eighty-three isolates were confirmed to be L. donovani by isoenzyme analysis, by amplification of kinetoplast DNA, or both, in comparison with multiple reference strains; none were L. tropica. Thus, the rising incidence of clinical resistance to treatment is unlikely to be due to a different species causing kala-azar in north Bihar.

Hyaline membrane disease in a term neonate

Hyaline membrane disease is primarily a disorder of preterm infants. Its occurrence in term infants is very uncommon and therefore may escape attention. We describe a term infant who developed severe respiratory distress soon after birth. Diagnosis of hyaline membrane disease was revealed at autopsy.

Visual performance of rigid gas permeable contact lenses in patients with corneal opacity

PURPOSE

To evaluate the visual performance of rigid gas permeable (RGP) contact lenses in patients with nebular and nebulo-macular corneal opacity and correlate the improvement in visual acuity with other visual parameters.

METHODS

In a prospective study, visual performance of RGP contact lenses was evaluated in eyes with corneal opacity involving the pupillary area. The baseline visual acuity and other visual parameters with glasses were compared with those recorded with RGP contact lenses. The visual functions evaluated were visual acuity, contrast sensitivity, glare acuity, and mesopic vision. Binocular status with RGP contact lenses was assessed. All patients were followed up for 3 months.

RESULTS

Twenty-eight eyes (26 patients) with nebular or nebulo-macular corneal opacity were included in this study. All eyes (100%) achieved significantly better visual performance with RGP contact lenses than with glasses (P< 0.0020). Visual acuity of 6/9 or better was achieved in 50% of patients with RGP contact lenses compared to none with glasses. RGP contact lenses improved the visual acuity by 0.27 decimals over the baseline value with glasses, butthe improvement for mesopic vision and glare acuity was significantly lower at 0.15 and 0.06 decimals respectively. Similarly, contrast sensitivity did not improve to the same extent as visual acuity. Stereopsis was present only in patients with best corrected visual acuity of 6/9 or better with RGP lenses.

CONCLUSION

RGP contact lenses improved the visual acuity and other visual performance in patients with reduced vision due to nebular or nebulo-macular corneal opacity. However, contrast sensitivity, glare acuity, and mesopic vision did not improve to the same extent as visual acuity.

Strangulation injury, a fatal form of child abuse

Strangulation is a common method of committing murder, though underreported in Indian literature. We managed a girl child, victim of child abuse who later succumbed to its neurological complications. This case report describes the clinical features associated with such injuries and complications which should be anticipated in such cases.

A population-based eye survey of older adults in a rural district of Rajasthan: II. Outcomes of cataract surgery

PURPOSE

To assess the outcomes of cataract surgery in rural northwest India.

DESIGN

Population-based, cross-sectional study.

PARTICIPANTS

A total of 549 cataract-operated persons (723 operated eyes).

METHODS

Cluster sampling was used in randomly selecting a cross-sectional sample of persons 50 years of age or older for visual acuity measurement, refraction, and slit-lamp and direct ophthalmoscope examination early in 1999. Those operated on for cataract were queried as to the date and place of surgery. The principal cause of reduced vision was identified for all examined eyes with presenting visual acuity worse than 6/18.

MAIN OUTCOME MEASURES

Presenting and best-corrected visual acuity and cause of vision loss.

RESULTS

Presenting visual acuity was less than 6/60 in the better eye in 33.7% of cataract-operated persons and greater than or equal to 6/18 in both eyes in 8.2%; 31.7% were bilaterally operated on. Of cataract-operated eyes, 44.1% initially had visual acuity less than 6/60 and 31.5% greater than or equal to 6/18; with best correction, the corresponding percentages were 14.0% and 61.5%. Intracapsular cataract extraction was used in 92% of cases, and 66% had been operated on in surgery camps. Surgical complications were common and a major cause of vision impairment. In multiple logistic regression modeling, female gender and residence in a rural area were associated negatively with both presenting and best-corrected visual acuity outcomes, and surgery conducted before 1990 was associated negatively with best-corrected visual acuity. Place of surgery and subject schooling were not associated with vision outcomes.

CONCLUSIONS

Cataract surgery subjects in rural areas of India that are without adequately equipped facilities and skilled surgeons, and lack of availability of intraocular lenses, are not realizing the full sight-restoring potential of modern-day surgery. Emphasis on the quality of cataract surgery outcomes must be increased to keep pace with that being given to increasing surgical volume.

Perinatal tuberculosis

Perinatal tuberculosis is insufficiently understood. Its early diagnosis is essential but often difficult as the initial manifestations may be delayed. Improved screening of women at risk and sensitivity of the medical community are necessary. A coherent system of cooperation between the hospital and community services and between pediatricians and adult physicians is indispensable to find the index adult case to break the chain of contagion as well as to offer prophylactic therapy to the children at risk. We hereby report a baby with perinatal tuberculosis who was not offered any prophylactic therapy inspite of the mother being diagnosed to have pulmonary tuberculosis.

Pseudohypoparathyroidism in a mother and son: phenotypic variability and associated disorder

A 2-month-old infant with clinical features of hypothyroidism presented with hypocalcemic seizures. The maternal phenotypic features aroused the suspicion of pseudohypoparathyroidism which was confirmed in both by biochemical and endocrinological investigations. Though the child had clinical and radiological features to suggest hypothyroidism he had normal free thyroxine and only slightly elevated thyroid stimulating hormone levels. Special note is made of the intra and interpatient variability of this rare inherited disorder.

The hamster heart is resistant to calcium paradox

Reintroduction of Ca(2+)or modification of internal Ca(2+)stores by caffeine results in widespread irreversible injury. The adult golden hamster, however, is immune to such insult and the present report investigates the phenomenon. Isolated Langendorff perfused hamster and rat heart were subjected to 15 min Ca(2+)-free perfusion followed by 30 min of Ca(2+)perfusion at 37 degrees C. Caffeine was introduced during Ca(2+)-free perfusion in a number of experiments. Papillary muscles were processed for the ultra-structural study. The hamster heart did not exhibit the calcium paradox state whereas rat heart did. Hamster heart treated with caffeine either throughout or 5 min after starting Ca(2+)-free perfusion showed 70%+/-8 or 65%+/-8. 42 recovery, respectively, when Ca(2+)reperfusion was performed. Ultrastructure of muscle from both groups showed relaxed myocytes with slight disorientation of the sarcomere register. This disorientation was not seen in hamster hearts undergoing the conventional calcium paradox protocol. The hamster cardiac muscle is remarkably tolerant to [Ca(2+)]()i loading either induced by Ca(2+)reperfusion or caffeine-induced sarcoplasmic reticulum Ca(2+)release. Structural and functional characterization of Ca(2+)depletion and repletion in the hamster heart have been discussed.

Clinical spectrum of 500 children with neurocysticercosis and response to albendazole therapy

Neurocysticercosis is a major cause of neurologic illness worldwide. Its manifestations are variable, and somewhat different when it occurs in children. Controversy exists regarding anticysticercal therapy. The clinical, laboratory, and radiographic features of 500 consecutive children with neurocysticercosis were studied; the children were then followed prospectively and their response to albendazole therapy was analyzed. Diagnosis of neurocysticercosis was based primarily on neuroimaging. Computed tomographic (CT) scans, neurocysticercosis serology, chest radiographs, and Mantoux tests were done in all children, and magnetic resonance imaging scans in 10%. All children with multiple lesions, and some randomly allocated children with single, small, enhancing CT lesions received albendazole. CT scans were repeated after 3 to 6 months. There were 272 boys and 228 girls, age range 1 6/12 to 12 6/12 years. Seizures were present in 94.8% of cases; 83.7% had focal seizures. Features of raised intracranial pressure were seen in 30% of patients and focal neurodeficit in 4%. Single lesions were seen in 76% of the children, with perilesional edema in 57.4%. Thirty-four children who had multiple cysts and received albendazole underwent serial CT evaluation. Four showed disappearance of lesions and 22 had reductions in the size or number, to give an overall improvement rate of 76%. Serial CT studies were available on 176 children with single lesions, 90 of whom received albendazole. Improvement (disappearance or reduction in the size of lesions) was observed in 91% (82 of 90) of albendazole-treated children versus 85% (73 of 86) of untreated children. This difference was not significant. No significant side-effects of albendazole were reported. These data indicate that partial seizures and single parenchymal cysts are the most frequent clinical and neuroradiographic manifestations of neurocysticercosis in children. Although albendazole therapy should be considered, especially in children with multiple lesions, many children with isolated neurocysticercosis will improve without antiparasitic therapy.

High-affinity maltose binding and transport by the thermophilic anaerobe Thermoanaerobacter ethanolicus 39E

Thermoanaerobacter ethanolicus is a gram-positive thermophile that produces considerable amounts of ethanol from soluble sugars and polymeric substrates, including starch. Growth on maltose, a product of starch hydrolysis, was associated with the production of a prominent membrane-associated protein that had an apparent molecular weight of 43,800 and was not detected in cells grown on xylose or glucose. Filter-binding assays revealed that cell membranes bound maltose with high affinity. Metabolic labeling of T. ethanolicus maltose-grown cells with [(14)C]palmitic acid showed that this protein was posttranslationally acylated. A maltose-binding protein was purified by using an amylose resin affinity column, and the binding constant was 270 nM. Since maltase activity was found only in the cytosol of fractionated cells and unlabeled glucose did not compete with radiolabeled maltose for uptake in whole cells, it appeared that maltose was transported intact. In whole-cell transport assays, the affinity for maltose was approximately 40 nM. Maltotriose and alpha-trehalose competitively inhibited maltose uptake in transport assays, whereas glucose, cellobiose, and a range of disaccharides had little effect. Based on these results, it appears that T. ethanolicus possesses a high-affinity, ABC type transport system that is specific for maltose, maltotriose, and alpha-trehalose.

Inhibition of interferon-gamma signaling by Leishmania donovani

Leishmania infection causes marked down-regulation of interferon (IFN)-gamma-induced gene activity in macrophages, but the mechanism of the blockade has not been fully defined. The IFN-gamma signal transduction pathway was analyzed in Leishmania donovani-infected phorbol-differentiated U937 human promonocytic cells. IFN-gamma stimulation induced marked phosphorylation of its own receptor (IFN-gammaR)-alpha chain. Phosphorylation of the receptor subunit was significantly inhibited after 24 h of infection with the parasite, apparently because of decreased amounts of the receptor subunit. Formation of the IFN-gammaR complex, as assessed by tyrosine phosphorylation and association of Jak2, was strongly inhibited in cells infected for 24 h. Inhibition of the IFN-gammaR complex formation correlated with inhibition of STAT1alpha binding to the IFN-gamma response region. Pretreatment with purified parasite lipophosphoglycan before IFN-gamma stimulation had no effect on tyrosine phosphorylation. Thus, inhibition of tyrosine phosphorylation of the IFN-gammaR-alpha chain and subsequent signal transduction are most likely due to the decreased amount of IFN-gammaR-alpha protein after infection.

The hamster heart: a paradox in itself

Perfusion of all mammalian heart muscle except hamster with Ca(2+)-free Tyrode and thereafter reperfusion with normal Tyrode causes irreversible damage, the calcium paradox. Our study aims at deciphering the role of creatine kinase, high energy phosphates and Ca(2+)influx in the genesis of myocardial injury in the rat and comparing it with the hamster. Isolated hearts from hamster and rats were perfused in the Langendorff mode at 37 degrees C for 30 min with normal Tyrode, for 15 min with Ca(2+)-free Tyrode and thereafter for 30 min of reperfusion with normal Tyrode. The 'high energy phosphate compound' levels were monitored by(31)P-NMR, creatine kinase (CK) release was measured in the perfusate.(45)Ca influx was estimated in the papillary muscle. We observed that in the rat heart: (a) high energy phosphate levels declined significantly within 1 min of Ca(2+)reperfusion; (b) a massive release of CK occurred upon Ca(2+)reperfusion; (c) there was a significant increase of Ca(2+)influx. In the hamster heart, there was preservation of high energy phosphates, CK release was prevented completely and no rise in(45)Ca influx was observed upon Ca(2+)reperfusion. These results suggest that the hamster heart has a remarkable capacity for Ca(2+)homeostasis which protects the heart from Ca(2+)overload.

Synthesis and characterization of pyridine amide cation radical complexes of iron: stabilization due to coordination with low-spin iron(III) center

We reported the synthesis and characterization of peptide complexes of low-spin iron(III) [Fe(bpb)(py)2][ClO4] (1) and Na[Fe(bpb)(CN)2] (2) [H2bpb = 1,2-bis(pyridine-2-carboxamido)benzene; py = pyridine], where iron is coordinated to four nitrogen donors in the equatorial plane with two amide nitrogen anions and two pyridine nitrogen donors (Ray, M.; Mukherjee, R.; Richardson, J. F.; Buchanan, R. M. J. Chem. Soc., Dalton Trans. 1993, 2451). Chemical oxidation of 2 and a new low-spin iron(III) complex Na[Fe(Me6bpb)(CN)2].H2O (4) [synthesized from a new iron(III) complex [Fe(Me6bpb)(py)2][ClO4] (3) (S = 1/2)] [H2Me6bpb = 1,2-bis(3,5-dimethylpyridine2-carboxamido)-4,5-dimethylbenzene) by (NH4)2Ce(NO3)6 afforded isolation of two novel complexes [Fe(bpb)-(CN)2] (5) and [Fe(Me6bpb)(CN)2].H2O (6). All the complexes have been characterized by physicochemical techniques. While 1-4 are brown/green, 5 and 6 are violet/bluish violet. The collective evidence from infrared, electronic, Mössbauer, and 1H NMR spectroscopies, from temperature-dependent magnetic susceptibility data, and from cyclic voltammetric studies provides unambiguous evidence that 5 and 6 are low-spin iron(III) ligand cation radical complexes rather than iron(IV) complexes. Cyclic voltammetric studies on isolated oxidized complexes 5 and 6 display identical behavior (a metal-centered reduction and a ligand-centered oxidation) to that observed for complexes 2 and 4, respectively. The Mössbauer data for 6 are almost identical with those of the parent compound 4, providing compelling evidence that oxidation has occurred at the ligand in a site remote from the iron atom. Strong antiferromagnetic coupling (-2J > or = 450 cm(-1)) of the S = 1/2 iron atom with the S = 1/2 ligand pi-cation radical leads to an effectively S = 0 ground state of 5 and 6. The oxidized complexes display 1H NMR spectra (in CDCl3 solution), characteristic of diamagnetic species.

Granulocyte macrophage-colony stimulating factor (GM-CSF) in neonatal neutropenia

Neutropenia in neonates is often associated with sepsis, prematurity and maternal hypertension with increased risk of mortality. We describe two neonates with neutropenia treated with granulocyte macrophage colony stimulating factor. The total and absolute neutrophil counts showed a marked response and led to a favourable outcome. Human granulocyte macrophage colony stimulating factor may be used as an adjuvant therapy for neonatal neutropenia of different aetiologies.

Focal seizures with single small ring-enhancing lesion

An 8-year-old girl presented with simple partial seizures. The differential diagnosis and evaluation point out the fact that in most of the world, conditions considered rare in the United States are important diagnostic considerations.

Risk factors for pediatric presumed microbial keratitis: a case-control study

PURPOSE

To evaluate risk factors for pediatric presumed microbial keratitis and to describe the clinical picture, microbiologic spectrum, treatment modalities, posttreatment sequelae, and visual outcome in cases of pediatric presumed microbial keratitis.

METHODS

A case-control study design was used to identify the risk factors associated with pediatric presumed microbial keratitis. Fifty cases of fresh corneal ulceration aged 12 years or younger were compared with 50 controls. The study variables included were age, gender, immunization status, nutritional status (weight for height), and socioeconomic status. The clinical presentation of the cases with corneal ulceration, microbiologic spectrum, and treatment modalities also were evaluated. All the cases were followed up for a minimum of 3 months, and the posttreatment sequelae and visual outcome were analyzed.

RESULTS

The mean (+/- standard deviation) age of children with corneal ulceration and controls was 4.8 (+/-3.8) years and 5.1 (+/-2.8) years, respectively. Incomplete immunization status (AOR [95% confidence interval (CI)], 1.34 [0.62-2.9]) and poor nutritional status [AOR (95% CI) 1.06 (0.68-1.6)] were not found to be the predictors of corneal ulceration. Lower socioeconomic status was significantly associated with the occurrence of corneal ulceration [AOR (95% CI) 1.52 (1.1-2.3)]. Corneal trauma (38%) and systemic illness (24%) were the most often associated predisposing factors. Seventy percent of the cases were culture positive. Staphylococcus (70%) species was the most frequently isolated, followed by Pseudomonas aeruginosa (10%). Fungi were isolated in five eyes. Postresolution visual acuity at 3 months could be recorded only in 31 eyes and a visual acuity of 6/18 or better was achieved in 22% of these cases.

CONCLUSION

Corneal ulceration in pediatric age group in India is associated with poverty.

Second laryngeal cancers in previously treated larynges

OBJECTIVES

To review the management and outcome of patients with new second primary cases of laryngeal cancer occurring more than 3 years after the initial cancer was treated.

STUDY DESIGN

Retrospective review of 855 patients with newly diagnosed and treated laryngeal cancers.

METHODS

Charts were reviewed and tabulated for occurrence of second primary laryngeal tumors, method of treatment for the index and second primary laryngeal tumors, and effect of smoking status or cessation of smoking.

RESULTS

Of the 855 patients, 532 patients retained their larynx; of these 377 lived more than 3 years and thus were at risk for a second new primary cancer. Of these 377 patients at risk, 19 or 5.1% developed second primary tumors. The rate of second primary disease was lower in patients whose index laryngeal cancer was treated by irradiation (4.3%) compared with those treated surgically (9.2%). However, surgical treatment of second primary laryngeal tumors resulted in far higher rates of laryngeal voicing (82%) compared with irradiation (33%).

CONCLUSION

When possible, management of the index primary tumor by endoscopic resection has resulted in the highest future retention of laryngeal speech, leaving all treatment options available should a second laryngeal cancer occur. Lifelong follow-up of patients with laryngeal cancer for secondary primary tumors is important. Second primary tumors were equally distributed between patients who continued to smoke and ceased to smoke after their index primary lesion was diagnosed.

Long-term survival of an extremity composite tissue allograft with FK506-mycophenolate mofetil therapy

BACKGROUND

High-dose tacrolimus (FK506) monotherapy has significantly prolonged rat hindlimb allograft survival. With an eye toward direct clinical application, we used a large-animal extremity composite tissue allograft model to assess the antirejection efficacy and systemic toxicity of combination FK506-mycophenolate mofetil (MMF) treatment.

METHODS

Radial forelimb osteomyocutaneous flap transplants were performed between size-matched outbred pigs assigned to one of two groups: 5 control pigs received no immunosuppression and 9 animals received a once-daily oral FK506-MMF-prednisone regimen. Rejection was assessed by visual inspection of flap skin and was correlated with serial histopathologic examination of skin biopsy specimens.

RESULTS

In all control pigs the flap was completely rejected on day 7. Of the 9 pigs receiving treatment, 3 died from pneumonia on days 29, 30, and 83 without signs of rejection and another died from gastric rupture on day 42 with persistent mild rejection. The remaining 5 animals were free of rejection at the end of the 90-day follow-up period (P < 0.005 vs controls). Overall, 5 pigs had pneumonia, 4 septic arthritis, 3 toe abscesses, and 5 diarrhea and decreased weight gain.

CONCLUSIONS

Combination oral FK506-MMF treatment provided a superior antirejection effect but more produced more toxicity than that previously demonstrated with cyclosporin A-MMF therapy in our model. Our results suggest that reduction of FK506 or MMF doses might decrease both infectious and drug-specific side effects while still providing adequate prophylaxis against rejection.

Scoring of skin rejection in a swine composite tissue allograft model

BACKGROUND

For the first time, we define and correlate visual and histologic grading systems of composite tissue allograft (CTA) skin rejection in a large-animal model and determine the utility of these grading systems for early diagnosis and monitoring of rejection.

MATERIALS AND METHODS

Sixteen pairs of outbred swine underwent transplant of a forelimb osteomyocutaneous free flap. Group I (n = 6) did not receive immunosuppressive therapy. Group II (n = 10) received oral cyclosporin A, mycophenolate mofetil, and prednisone. The flap was visually inspected and protocol skin biopsies were taken at frequent intervals over a 90-day period. Visual Grades 0 (no rejection) to 4 (severe rejection) were assigned based on skin color, bleeding from biopsy site, and blister formation. Histologic Grades 0 to 4 were assigned based on the degree of vasculitis, folliculitis, dermal inflammation, and epidermal degeneration present.

RESULTS

All Group I animals progressively rejected their graft by Day 7. Group II grafts survived from 19 and 90 days; 93% of 115 biopsy specimens were read to be within +/-1 histologic score of their assigned flap visual grade. Visual assessment carried an 8% false positive and 39% false negative rate with regard to biopsy-proven rejection. However, 81% of missed rejection specimens were histologic Grade 1. Biopsy, when visually indicated, would detect all rejection episodes when histologically Grade 1 or 2 and still potentially reversible.

CONCLUSIONS

Visual scoring of CTA skin serves as a useful tool for initially detecting rejection, but repeated histologic evaluation is necessary for monitoring the subsequent course of the graft.