An atypical case of bilateral optic neuritis after strabismus surgery under general anesthesia

INTRODUCTION

Strabismus surgery under general anesthesia is a common procedure with rare complications in the form of hemorrhage, infection, slipped muscle, lost muscle, scleral perforation, and anterior segment ischemia. We report a unique case of bilateral optic neuritis following squint surgery under general anesthesia in a 15-year-old girl.

METHODS

A 15-year-old girl presented with accommodative esotropia with V pattern. She underwent uneventful bilateral inferior oblique recession surgery under general anesthesia with Propofol 60 mg, Atracurium 30 mg, and Fentanyl 70 mcg. On the first post-operative day, the patient had an acute onset of temporal headache which was non-radiating. She responded to supportive treatment and was discharged. However, on the 7th postoperative day, she presented with a constant severe headache in the bitemporal region (left > right) for 3 days. She also experienced a painless diminution of vision for 2 days. There was no vomiting, fever, loose stools, diplopia, difficulty in breathing, peripheral sensation loss, generalized weakness, or bowel/bladder incontinence.

RESULTS

The best corrected visual acuity was 6/9 in right eye, and 6/9p in left eye with a relative afferent pupillary defect (RAPD) in the left eye. Both optic discs appeared hyperemic with blurred margins. Magnetic resonance imaging (MRI) of the brain and orbit showed hyperintensity along the intraorbital and intracanalicular parts of bilateral optic nerves on T2 weighted image suggesting bilateral optic neuritis. She received intravenous methylprednisolone pulse therapy followed by oral steroids and responded to the medical treatment with improvement in vision but developed steroid-induced glaucoma requiring medical management over several weeks.

DISCUSSION

Neuro-ophthalmic complication in the form of non-arteritic ischemic optic neuropathy has been reported after various ophthalmic surgeries, but bilateral optic neuritis has not been reported to date. This possibility should be kept in mind if any patient presents with similar symptoms. This report also highlights IOP monitoring in pediatric patients receiving systemic steroids to prevent loss of vision due to steroid-induced glaucoma.

Optimization of biometry for best refractive outcome in cataract surgery

High-precision biometry and accurate intraocular lens (IOL) power calculation have become essential components of cataract surgery. In clinical practice, IOL power calculation involves measuring parameters such as corneal power and axial length and then applying a power calculation formula. The importance of posterior corneal curvature in determining the true power of the cornea is increasingly being recognized, and newer investigative modalities that can estimate both the anterior and posterior corneal power are becoming the standard of care. Optical biometry, especially using swept-source biometers, with an accuracy of 0.01-0.02 mm, has become the state-of-the-art method in biometry. With the evolution of IOL formulas, the ultimate goal of achieving a given target refraction has also moved closer to accuracy. However, despite these technological efforts to standardize and calibrate methods of IOL power calculation, achieving a mean absolute error of zero for every patient undergoing cataract surgery may not be possible. This is due to inherent consistent bias and systematic errors in the measurement devices, IOL formulas, and the individual bias of the surgeon. Optimization and personalization of lens constants allow for the incorporation of these systematic errors as well as individual bias, thereby further improving IOL power prediction accuracy. Our review provides a comprehensive overview of parameters for accurate biometry, along with considerations to enhance IOL power prediction accuracy through optimization and personalization. We conducted a detailed search in PubMed and Google Scholar by using a combination of MeSH terms and specific keywords such as "ocular biometry," "IOL power calculations," "prediction accuracy of refractive outcome in cataract surgery," "effective lens position," "intraocular lens calculation formulas," and "optimization of A-constants" to find relevant literature. We identified and analyzed 121 relevant articles, and their findings were included.

Ocular involvement-An unusual initial presentation of chronic myeloid leukemia: A case report

Chronic myeloid leukemia (CML) patients frequently exhibit systemic symptoms such as fatigue, abdominal discomfort, weight loss, and fever but rarely can have atypical initial presentation in the form of ophthalmic manifestations, which can precede the diagnosis of the primary malignancy. We describe a case of a 29-year-old male who presented in our ophthalmology out-patient department (OPD) with complaints of painless, diminution of vision, which was sudden in onset in right eye (RE) and loss of vision in left eye (LE) for four and seven days, respectively. There had been a history of loss of weight and appetite for the past 2 months. The visual acuity (VA) recorded was finger counting two meters in RE and perception of light in LE with an inaccurate projection of rays in both eyes (BE). The anterior segment evaluation of both eyes (BE) was normal. Fundus revealed multiple elevated yellow subretinal lesions with exudative detachment in the RE and no view in the LE. Ultrasound-Brightness (USG B) scan in the LE revealed multiple hyperreflective echoes likely vitreous hemorrhage. Optical coherence tomography (OCT) showed subretinal hyperreflectivity with surrounding edema in RE suggestive of leukemic infiltrates. On further systemic investigations, chronic myeloid leukemia-chronic phase (CML-CP) was detected; hence, the diagnosis of RE exudative retinal detachment (RD) and LE vitreous hemorrhage with CML-CP was made. Ophthalmic involvement is more often seen in acute than chronic leukemia, which makes the diagnosis challenging. We describe a unique case of a young patient with CML-CP who initially presented with ocular involvement preceding systemic diagnosis. This case report illustrates the importance of a primary care physician or an ophthalmologist in the early diagnosis and prompt management of hematological malignancy, as ophthalmic manifestations may be a rare initial presenting feature in CML-CP. These conditions require urgent referral to a hematologist by a primary care physician in the view of early commencement of therapy.

Varicella Zoster Reactivation Manifesting as Serpiginous Peripheral Keratitis and Disciform Keratitis Occurring After Necrotizing Fasciitis in an Immunocompromised Male: A Case Report

Reactivation of herpes zoster ophthalmicus (HZO) can present as corneal involvement without any precedent neuralgia or characteristic herpetic rash. This form of HZO can be the first manifestation of reactivation of varicella zoster virus and can masquerade as peripheral ulcerative keratitis. A 45-year-old male treated for necrotizing fasciitis (NF) one month back presented with painful diminution of vision in the right eye (RE) for two weeks without any associated vesicular rash or neuralgia. On examination, best-corrected visual acuity in RE was 2/60 with non-marginal upper lid defect, and multiple linear contracture scars involving the upper lid, right temple, and preauricular region. There were associated peripheral corneal ring infiltrates, disc-shaped central stromal edema, and reduced corneal sensation. The patient had a history of chicken pox in childhood and was recently diagnosed with seropositive rheumatoid arthritis (RA). Though corneal scrapings were negative on Tzanck smear, a presumptive clinical diagnosis of herpetic disciform keratitis was made, and the patient was started on oral and topical acyclovir with steroids. This was confirmed with improving clinical course and detection of herpes zoster DNA on polymerase chain reaction from corneal scrapings. Lid reconstruction for associated lid defect was performed using paramedian forehead flap, which was remodeled at 16 weeks. Our case, a seropositive RA patient, had reactivation of varicella zoster manifesting as peripheral serpiginous and disciform keratitis activated after NF. There are a few case reports of periorbital NF following HZO in immunocompromised patients. However, till date, no case of HZO occurring after periorbital NF has been reported. Also, in our case, reactivation of HZO presented as disciform and serpiginous keratitis without any precedent herpetic rash or neuralgia.

Isolated Sixth Nerve Palsy as the First Manifestation of Cavernous Sinus Metastasis From Primary Breast Cancer

Cavernous sinus metastasis is a rare clinical finding, presenting most commonly with complaints of headache, diplopia, visual field defects, facial pain, and progressive neurological deficits. Many patients present with features of III, IV, and VI nerve palsies. We hereby report an unusual case of cavernous sinus metastasis from primary breast cancer in a 40-year-old female, who presented with binocular diplopia due to left VI nerve palsy as the first presenting complaint. The patient had a history of surgery for left breast cancer which was performed at another center. Contrast-enhanced computed tomography (CECT) scan of thorax and abdomen revealed a residual neoplastic left breast mass with satellite nodules, left axillary lymphadenopathy, and hepatic, splenic, and skeletal metastasis. Contrast-enhanced magnetic resonance imaging (CE-MRI) of brain and orbit showed enhancing lesion of 20 mm x 10 mm along the lateral wall of left cavernous sinus and left petrous apex. She was referred to radiation oncology department for further management. This case report highlights the importance of ophthalmologists in such life-threatening conditions, who may first present to them.

Solvent polarity induced structural changes in 2,6-diamino-9,10-anthraquinone dye

Photophysical properties of 2,6-diamino-9,10-anthraquinone (2,6-DAAQ) dye have been investigated in different solvents and solvent mixtures. The fluorescence quantum yields, fluorescence lifetimes, radiative rate constants, nonradiative rate constants and absorption and fluorescence spectral characteristics show unusual deviations in the lower polarity aprotic solvents in comparison to those in other aprotic solvents of medium to higher polarities. The results indicate that the dye exists in different structural forms in the lower and in the medium to higher polarity solvents. Drawing an analogy with the results reported for other amino-substituted dyes, it is inferred that 2,6-DAAQ dye adopts a planar intramolecular charge transfer (ICT) structure in medium to higher polarity solvents, where the amino lone pairs are in good resonance with the anthraquinone pi-cloud. In the lower polarity solvents, however, the dye is inferred to exist in a nonplanar structure where the amino lone pairs are not in good resonance with the anthraquinone pi-cloud. Due to these structural differences, the dye displays significantly different photophysical behavior in the lower polarity solvents than in the other solvents of medium to higher polarities. Supportive evidence for the above structural changes has been obtained from ab initio quantum chemical calculations on the structures of the dye under different conditions. Unusual deviations in the photophysical properties of 2,6-DAAQ dye in protic solvents in comparison to those in aprotic solvents of similar polarities are attributed to the intermolecular hydrogen bonding effect involving the OH groups of the protic solvents and the quinonoid oxygens of the dye.

Host-guest complexation of neutral red with macrocyclic host molecules: contrasting pK(a) shifts and binding affinities for cucurbit[7]uril and beta-cyclodextrin

The photophysical properties of the phenazine-based dye neutral red were investigated in aqueous solution in the presence of the macrocyclic host molecule cucurbit[7]uril (CB7) using ground-state absorption as well as steady-state and time-resolved fluorescence measurements. The results are contrasted to those previously obtained for beta-cyclodextrin (beta-CD; Singh et al. J. Phys. Chem. A 2004, 108, 1465). Both the neutral (NR) and cationic (NRH+) forms of the dye formed inclusion complexes with CB7, with the larger binding constant for the latter (K = 6.5 x 10(3) M(-1) versus 6.0 x 10(5) M(-1)). This result differed from that for beta-CD, where only the neutral form of the dye was reported to undergo sizable inclusion complex formation. From the difference in binding constants and the pK(a) value of protonated neutral red in the absence of CB7 (6.8), an increased pK(a) value of the dye when complexed by CB7 was projected (approximately 8.8). This shift differed again from the behavior of the dye with beta-CD, where a decreased pK(a) value (ca. 6.1) was reported. The photophysical properties of both NR and NRH+ forms showed significant changes in the presence of CB7. Fluorescence anisotropy studies indicated that the inclusion complexes of both forms of the dye rotate as a whole, giving rotational relaxation times much larger than that expected for the free dye in aqueous solution. The thermodynamic parameters for the NRH+.CB7 complex were investigated in temperature-dependent binding studies, suggesting an entropic driving force for complexation related to desolvation of the cation and the removal of high-energy water molecules from the CB7 cavity.

Quality of life in newly diagnosed patients with lung cancer in a developing country: is it important?

There are no data regarding quality of life (QoL) assessments in lung cancer in developing countries like India. Quality of life was evaluated in 76 newly diagnosed lung cancer patients by using the World Health Organization Quality of Life questionnaire in Hindi (WHOQoL-Bref) (men 87%). The mean age was 55 years (SD = 10). Cough, dyspnoea, chest pain and haemoptysis were present in 83%, 72%, 66% and 43% of patients respectively. The median duration of symptoms was 5.9 months (range 1-13). Eighty-nine per cent had non-small cell lung cancer. The median pack-years smoked was 23 (range 0.5-88). Most patients (53%) had a Karnofsky's Performance Status (KPS) of 70 and 83% had stage III or IV disease. Quality of life did not correlate with age, gender, presence or duration of symptoms, histological type, stage of disease or degree of smoking. The physical and psychological domains of QoL correlated significantly with the KPS (P = 0.001 and P = 0.01 respectively). Patients with a KPS of 80 had better physical (P < 0.001), psychological (P < 0.01) and social (P < 0.05) QoL than those with a KPS of 70. In conclusion, patients with lung cancer in a developing country like India have an unsatisfactory QoL. The Karnofsky's Performance Scale is a simple and reliable surrogate marker for assessing QoL in these patients. Larger multi-centric studies may help in providing a more comprehensive evaluation of the effect of various demographic and clinical variables on QoL in this setting.

A randomized placebo-controlled double-blind study of levamisole in the treatment of limited and slowly spreading vitiligo

BACKGROUND

A previous uncontrolled, open trial of levamisole in patients with limited and slowly spreading vitiligo had shown that new lesions did not develop in 94% of patients after 2-4 months of treatment with the drug.

OBJECTIVES

To assess the efficacy of levamisole in the treatment of slowly spreading, limited vitiligo.

METHODS

In a randomized double-blind trial at the Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, India, 60 patients with vitiligo involving < 2% of the body surface area and with slowly spreading disease (defined as one to five new lesions in the previous month or six to 15 new lesions in the previous 3 months) were randomly allocated to receive oral levamisole 150 mg or placebo on two consecutive days in a week. Children received oral levamisole 100 mg. All patients applied mometasone furoate 0.1% cream on the depigmented macules once daily. Patients were evaluated monthly for 6 months. The main outcome measure was the occurrence of new lesions, counted at each monthly visit. The secondary outcome measures comprised: (i) a dermatology-specific instrument, the Dermatology Life Quality Index or Children's Dermatology Life Quality Index questionnaires, which were completed by the patients at baseline and at every visit, and (ii) a general health questionnaire, the World Health Organization Quality of Life Brief Questionnaire, which was completed at baseline and at the end of the study.

RESULTS

Forty-three patients completed 6 months of follow-up. The mean +/- SD number of new lesions that developed during the study period of 6 months was 1.9 +/- 2.0 (range 0-8) in the levamisole group and 1.8 +/- 2.0 (range 0-7) in the placebo group (P = 0.92). The proportion of patients who did not develop any further new lesions for the remainder of the study period was higher in the levamisole group at all the monthly evaluation points, although it was statistically significant (P = 0.05) only at the fourth month. Improvement in quality of life was similar in both groups.

CONCLUSIONS

The study indicates that levamisole is not as effective in arresting disease progression as was observed in a previous open study. A study with a larger sample size is necessary to determine if levamisole is truly superior to placebo in this respect.

Photophysical properties of 2-amino-9,10-anthraquinone: evidence for structural changes in the molecule with solvent polarity

The photophysical properties of 2-amino-9,10-anthraquinone (2AAQ) have been investigated in different solvents and solvent mixtures and correlated with the Lippert-Mataga solvent polarity parameter, Deltaf. In the low solvent polarity region with Deltaf < ca. 0.1, the dye shows unusually high fluorescence quantum yields (Phif) and lifetimes (tauf) in comparison to those in other solvents of medium to high polarities. Similarly, the radiative rate constants (kf) are relatively lower and the non-radiative rate constants (knr) are relatively higher in the low polarity solvents in comparison to those in the medium to high polarity solvents. The current results have been rationalized assuming that the dye adopts different structural forms below and above the Deltaf value of approximately 0.1. It is inferred that in the low solvent polarity region the dye exists in a non-planar structure, with its 2-NH2 plane away from that of the 9,10-anthraquinone moiety in the ground state. In solvents of medium to high polarities, the dye exists in a polar intramolecular charge transfer (ICT) structure, where the amino lone pair of the 2-NH2 group is in strong resonance with the anthraquinone pi-cloud in the ground state. In all the solvents, however the dye is inferred to exist in the ICT structure in its excited (S1) state. Supportive evidence for the above hypothesis has been obtained from the solvent polarity effect on the Stokes' shifts for the dye. Quantum chemical studies on the structures of 2AAQ dye in the gas phase also give qualitative support for the inferences drawn from the photophysical properties of the dye in different solvents.

The relationship between disease activity and quality of life in systemic lupus erythematosus

OBJECTIVE

To determine the quality of life (QOL) in SLE patients and correlate it with disease activity.

METHODS

Lupus patients fulfilling the ACR 1997 criteria for SLE were included in this cross-sectional study. Patients were administered the World Health Organization Quality of Life-Bref (WHOQOL-Bref) to assess their quality of life. Disease activity was measured using Mexican Systemic Lupus Erythematosus Disease Activity Index (Mex-SLEDAI).

RESULTS

The study group comprised 73 lupus patients (70 females and three males) with mean age 35.22 +/- 11.15 yr and mean disease duration 5.62 +/- 5.14 yr. Mean Mex-SLEDAI score was 3.31 +/- 3.19. Higher disease activity scores were associated with lower QOL scores in the physical (P = 0.001) and psychological domains (P = 0.01) but showed no significant correlation with the domains of social and environmental QOL. Patients with clearly active and probably active disease showed significantly lower scores in the physical (P = 0.01) and psychological (P = 0.02) domains than patients with inactive disease. However, no significant difference was found in the domains of social and environmental QOL. Age or disease duration did not affect the QOL in any of the domains.

CONCLUSIONS

Physical and psychological QOL are impaired to a larger extent in active lupus. However, social and environmental QOL do not correlate with the disease activity status in lupus patients.

Electron transfer interaction of dihydroxyquinones with amine quenchers: dependence of the quenching kinetics on the aliphatic and aromatic nature of the amine donors

Studies on the electron transfer (ET) interaction of 1,4-dihydroxy-9,10-anthraquinone and 6,11-dihydroxy-5,12-naphthacenequinone with aliphatic and aromatic amine (AlA and ArA, respectively) donors have been investigated in acetonitrile solutions. Steady-state (SS) measurements show quenching of the quinone fluorescence by amines, without indicating any change in the shape of the fluorescence spectra. No significant change in the absorption spectra of the quinones is also observed in the presence of the amines. For all the quinone-amine pairs, the bimolecular quenching constants (kq) estimated from SS and time-resolved measurements are found to be similar. Variation in the kq values with the oxidation potentials of the amines indicates the involvement of the ET mechanism for the quenching process. A reasonably good correlation between the kq values and the free energy changes (deltaG0) for the ET reactions following Marcus' outer-sphere ET theory also supports this mechanism. It is seen that for both the quinone-ArA and quinone-AlA systems, the kq values initially increase and then get saturated at some diffusion-controlled limiting values (kqDC) as deltaG0 values gradually become more negative. Interestingly, however, it is seen that the kqDC value for the quinone-AlA systems is substantially lower than that for quinone-ArA systems. Such a large difference in the kqDC values between quinone-AlA and quinone-ArA systems is quite unusual. Present results have been rationalized based on the assumption that an orientational restriction is imposed for the encounter complexes in quinone-AlA systems to undergo ET reactions, which arises because of the localized (at amino nitrogen) shapes of the highest-occupied molecular orbitals (HOMO) of AlA in comparison to the pi-like HOMO of the ArA.

Excited singlet (S1)-state interactions of Nile red with aromatic amines

Both steady-state (SS) and time-resolved (TR) studies show that the fluorescence of the dye Nile red (NR) is quenched by various aromatic amines (ArA). Bimolecular quenching constants (kq) from both SS and TR measurements are observed to match well, indicating that the interaction is dynamic in nature. The quenching interaction in the present systems has been attributed to electron transfer (ET) from ArA to excited NR, based on the variations in the kq values with the oxidation potentials of the amines. The kq values calculated within the framework of Marcus' outer-sphere ET theory at different free-energy changes (deltaG0) of the ET reactions match well with the experimental ones, supporting the ET mechanism in the systems studied. The reorganization energy (lambda) estimated from the correlation of the experimental and the calculated kq values is quite similar to the solvent reorganization energy (lambda(s)), calculated on the basis of the solvent dielectric continuum model along with the assumption that the reactants are the effective spheres. Although a modest error is involved in this lambda(s) calculation, the similarity in lambda and lambda(s) values suggests that the solvent reorganization plays a dominant role in governing the ET dynamics in the present systems.

Discriminative value of lipids and apolipoproteins in alcoholics

1. It is important to detect alcohol use in its early stages so that interventions can be planned effectively. In a bid to screen for alcohol use disorders various biochemical assessments have been advocated. 2. It has been seen that moderate to heavy alcohol consumption appears to elevate ApoA1 though the effect of alcohol consumption on ApoB is not well defined. 3. Present study was planned to evaluate the contribution of lipid profile and lipoprotein measures for the diagnosis of alcohol use disorder in 75 alcohol dependent and 45 normal healthy controls. 4. Based on the TC, TG, HDL/LDL-c, HDL-c/TC, ApoA1, ApoB, and ApoA1/ApoB a discriminant equation was developed for classification of alcohol dependent users (alcoholics) and non-users (non-alcoholics) 5. The discriminant equation resulted in 84.7% of subjects being correctly classified. (94.7% in non-users and 81.1% in alcohol dependent users as alcoholics).

Studies on the radiolytically produced transients of neutral red: triplet and reduced radicals

The spectral and kinetic properties of reduced radicals and the triplet state of neutral red (NR), a phenazine-based dye, have been investigated using pulse radiolysis technique. A mixed water-isopropanol-acetone solvent has been used to study the reduced radicals of NR for a wide pH range of about 1-13, due to limitation of solubility of the dye in aqueous solutions particularly above pH 8. From pH-dependent absorption studies it has been established that the reduced radicals of NR can exist in four different prototropic forms in solution. Three pKa values for the corresponding prototropic equilibria have been estimated. The formation and decay rate constants of reduced radicals have also been measured. The triplet state characteristics of the dye have been investigated in neat benzene solutions, both in the presence and in the absence of triplet sensitizers. The T1-->Tn absorption spectrum and decay kinetics of the triplet state have been measured. The triplet state energy (ET) of NR in benzene have been estimated to be within 36-42 kcal mol-1, using an energy transfer method.

Drug use in a rural community in bihar : some psychosocial correlates

Drug use has been an integral part of any culture. The use depends on many factors including the availability. In the present study the drug use in a rural community of Chotanagpur Plateau in the Ranchi district of Bihar is focussed. The sample consisted of 157 inhabitants above the age of 15 yrs of the village Boreya in Kanke block. A sample of drug users was compared with nondrug users of the same community on the measures of stressful life events and locus of control. The results indicate that besides tobacco alcohol in the form of locally brewed 'handia' (rice beer) and 'mahua' (made from mahua flowers) was used by 334 (28.87%) individuals. Cannabis was frequently used (25.15%) Harder drugs were not used at all. There was an increase in stressful life events in the year prior to the use of drugs. The increase in life events was especially seen in the elderly age group (35-50yrs). There was no difference in the locus of control scores between the users and the nonusers. The results indicate the role of significant life events in the current use of drugs.

A follow up study of schizoaffective psyohosis: an appraisal of socio-clinical and diagnostic aspects

Sociodemographic, clinical and outcome characteristics of 29 cases who had the diagnosis of schizoaffective psychosis were studied. On the basis of longitudinal course of the illness, 2 distinct subgroup of patients could be delineated. Patients with episodic illness were more akin to affective disorders while those with continuous course of illness were conceptually closer to schizophrenia. Concordance of the ICD-9 diagnosis of these patients with other well known diagnostic systems tike Research Diagnostic Criteria, DSM-III-R and proposed ICD-10 was studied. Advantages and limitations of these diagnostic systems with regard to the diagnosis of schizoaffective psychosis are discussed.