Intermediate Uveitis with Cystoid Macular Edema as Presentation of Retained Caterpillar Hair in the Vitreous Cavity

PURPOSE

To report an unusual case of retained caterpillar hair in the vitreous cavity presenting as recurrent Intermediate Uveitis with cystoid macular edema.

METHOD

Case Report.

RESULTS

A 40-year-old male presented to our uveitis clinic with recurrent episodes of redness and diminution of vision in his left eye for 3 years. He was diagnosed and treated elsewhere as a case of recurrent intermediate uveitis and was referred to our center for a second opinion to initiate immunosuppressive therapy. A detailed history revealed that a caterpillar had fallen into his left eye 3 years back, followed by severe irritation, pain, and redness. He received topical antibiotics and corticosteroids, and retained caterpillar hair was removed from the ocular surface. During the last 3 years, the patient had multiple episodes of inflammation despite being treated with oral and topical corticosteroids. At the current visit, a meticulous clinical examination at our centre revealed multiple, migrated, retained caterpillar hair in the vitreous cavity. The patient was diagnosed with Ophthalmia Nodosa (Type V) and managed with surgical intervention (vitreous surgery). The case highlights an unusual presentation of ON and the role of pars plana vitrectomy in its successful management.

CONCLUSION

We highlight a rare and unusual presentation of ophthalmia nodosa and its successful management.

Establishing continuum in Transcranial Doppler characteristics of IIH, migraine and healthy controls- An exploratory study

BACKGROUND

IIH is a severe form of headache that often has superimposed migraine and often it is very difficult to distinguish the two forms of headache. Intracranial hemodynamics is a relatively unexplored means of distinguishing between the two forms of headache.

OBJECTIVES

We aimed to study intracranial flow dynamics using Transcranial Doppler in patients with IIH, migraine, and normal controls.

MATERIALS AND METHODS

It was a hospital-based observational study that included 51 people with IIH, 87 people with migraine, and 101 healthy controls and all were subjected to TCD study after detailed clinical examination.

RESULTS

Mean age of patients in three groups were similar with the mean age in IIH being 33.41 ± 10.75 (age in years ± SD). Vision loss was present in 66.67% of patients with IIH, and most common field defect was generalized constriction (27.5%). Neuroimaging was abnormal in 94.11% of patients of IIH with mean CSF pressure was 31.27±5.32 cm of water. Of all the TCD-measured velocities, mean flow velocity (MFV) showed a significant difference in all three groups with (p-value <0.001). The pulsatility index, both for middle cerebral arteries as well as ophthalmic arteries showed a significant difference in the three groups with the highest values in IIH patients (p-value<.001). The mean VMR in IIH (1.11±0.32) was lower than the mean VMR in migraine (1.34±0.43) as well as controls (1.49±0.46).

CONCLUSION

TCD parameters like MFV and PI are useful parameters that show considerable variation and can be used to differentiate between IIH and migraine.

Use of the Aurolab Aqueous Drainage Implant as a buckling element in pediatric retinal detachment with a preexisting glaucoma drainage device

Purpose

To describe a novel technique for repair of rhegmatogenous retinal detachment in an eye with a previous non-valved glaucoma drainage device, the Aurolab Aqueous Drainage Implant (AADI).

Observations

A 5-year-old child with bilateral primary congenital glaucoma presented with an inferior retinal detachment (RD) in the left eye. The left eye had a history of multiple surgical interventions including combined trabeculotomy and trabeculectomy done twice, AADI implantation and subsequently phacoaspiration with IOL implantation, 18 months prior to presentation. The left eye retinal detachment was managed by scleral buckling technique using the plate of the AADI as a buckling element without its explantation.

Conclusions

AND IMPORTANCE: Management of retinal detachment in eyes with a pre-existing glaucoma drainage device (GDD) is uniquely challenging. Explantation of the GDD would likely result in intractable glaucoma post-operatively, requiring another surgery. Use of the trimmed plate of the GDD itself as the buckling element helped in settling the RD and preserving intraocular pressure control.

Peri-articular bone formation involving the temporomandibular joint: a narrative summary and Delphi consensus of a new classification system

Heterotopic ossification (HO) is defined as 'bone where it does not belong'. Given the historical variety of nomenclature and eponyms, there is significant confusion about the etiology, pathogenesis, classification, and treatment of HO related to the temporomandibular joint (TMJ). The existing classifications for TMJ HO have shortcomings: they relate to specific populations, use differing imaging studies and demographic data, do not universally include alloplastic/autologous replacements, are based variously on radiological and/or clinical presentations that cannot always be combined, and were largely developed to assist oral and maxillofacial surgeons in surgical management. These deficiencies make it problematic to compare studies, draw valid conclusions, and pursue research. The aim of this study was to develop a new, more inclusive classification for TMJ HO. Currently available classifications were evaluated and a Delphi-type system used to build consensus from clinicians and researchers to develop a new system. Fourteen unique classifications for TMJ ankylosis/HO were identified. In light of the biological specifics related to heterotopic calcification of extracellular matrix versus heterotopic formation of actual bone, the group recommends a more unambiguous term - peri-articular bone formation - and proposes a new classification. This will help clinicians and researchers to study, describe, and manage various types of ectopic bone associated with the TMJ.

Which comorbid conditions and risk factors affect the outcome of and progression to total temporomandibular joint replacement?

Surgery is an effective modality to reduce pain and increase range of motion (ROM) in TMJ disorders. The aim of this study was to determine which comorbidities and risk factors affect outcomes and progression to total joint replacement (TJR). A retrospective cohort study of patients who underwent TJR between 2000- 2018 at MGH was conducted. Primary outcome was successful vs unsuccessful surgery. Success was defined as pain score ≤ 4 and ROM ≥ 30 mm; failure was defined as lack of either or both. Secondary outcome was differences between patients undergoing TJR only (group A) and those undergoing multiple surgeries progressing to TJR (group B). 99 patients (82 females, 17 males) were included. Mean follow-up was 4.1 years; mean age at first surgery was 34.2 (range 14-71) years. Unsuccessful outcomes were associated with high preoperative pain, low preoperative ROM, and higher number of surgeries. Male sex favored successful outcome. 75.0% group A and 47.6% group B had successful outcome. Group B had more females, higher postoperative pain, lower postoperative ROM, and used more opioids compared to group A. High preoperative pain, low preoperative ROM, and more surgeries were associated with poorer outcomes and frequent opioid use.

Displacement of Submacular Hemorrhage With Vitrectomy Combined With Subretinal Balanced Salt Solution and Air

PURPOSE

To describe a technique of displacement of submacular hemorrhage (SMH) using subretinal injection of balanced salt solution and filtered air.

METHODS

Patients presenting within 2 weeks of massive SMH (>4 disk diameter) were prospectively included. All patients underwent 25-gauge pars plana vitrectomy, posterior vitreous detachment, injection of subretinal balanced salt solution and filtered air followed by partial fluid air exchange, 20% sulfur hexafluoride tamponade, and heads-up positioning postoperatively. Degree of displacement of SMH was assessed at 1 month and change in best-corrected visual acuity was assessed at 3 months.

RESULTS

Ten patients with massive SMH who underwent the aforementioned procedure were included. Complete displacement of bleed from the macula was achieved in nine (90%) of 10 eyes at 1 month. There was significant improvement in best-corrected visual acuity from baseline at 1 month ( P = 0.015) and 3 months ( P = 0.043).

CONCLUSION

Pars plana vitrectomy with injection of subretinal balanced salt solution and filtered air was well-tolerated and efficacious in displacing large and thick SMH in patients operated within 2 weeks of onset of symptoms.

No evidence of resistance to itraconazole in a prospective real-world trial of dermatomycosis in India

BACKGROUND

The prevalence of superficial fungal infections in India is believed to have increased substantially in the past decade. We evaluated the treatment outcomes and risk factors associated with clinical response to a treatment course of itraconazole for the management of dermatomycosis in India.

METHODS

In this real-world, prospective pilot study (August 2019 to March 2020), adult participants (18-60 years), diagnosed with T. cruris or T. corporis, received itraconazole 200 mg/day (any formulation) orally for 7 days, and were followed for an additional 7 days.

RESULTS

The study was terminated early due to the COVID-19 pandemic. Of 40 enrolled participants (mean [SD] age, 35.5 [12.73] years; {62.5%}] male; 37 received itraconazole and 20 (50%) completed the study. The median (range) Clinical Evaluation Tool Signs and Symptoms total score at baseline was 5.5 (2-10). Clinical response of "healed" or "markedly improved" based on the Investigator Global Evaluation Tool at day 7 (primary objective) was 42.9% (12/28; 95% CI: 24.53%, 61.19%). Itraconazole minimum inhibitory concentration for identified microorganisms, T. mentagrophytes species complex (91.7%) and T. rubrum (8.3%), was within the susceptibility range (0.015-0.25 mcg/mL). At day 14, 8/13 (61.5%) participants achieved a mycological response, 2/13 participants (15.4%) had a mycological failure and 90% showed a clinical response.

CONCLUSION

COVID-19 pandemic affected patient recruitment and follow-up, so the findings call for a careful interpretation. Nevertheless, this real-world study reconfirmed the clinical efficacy and microbial susceptibility to itraconazole for the fungi causing dermatophytosis in India.

TRIAL REGISTRATION

Trial registration number: Clinicaltrials.gov NCT03923010.

YELLOW SUBRETINAL PIGMENT EPITHELIUM DEPOSITS: A NOVEL SIGN IN OCULAR TUBERCULOSIS

PURPOSE

To describe a novel clinical and imaging finding in patients with tubercular posterior uveitis.

METHODS

A retrospective review of 3 cases presented at a tertiary referral eye centre in North India was performed between June 2016 and March 2019. All the patients had received an initial diagnosis of noninfective etiologies (sympathetic ophthalmia, necrotizing scleritis, and lymphoma). Fundus photography, fluorescein angiography, fundus autofluorescence, and enhanced-depth imaging optical coherence tomography were reviewed.

RESULTS

Three patients (all Asian Indian women: aged 18, 49, and 52 years) diagnosed with panuveitis were investigated for various etiologies based on the initial clinical suspicion. During the course of therapy, all the patients developed peripheral yellow subretinal pigment epithelium deposits (YSRPE) which appeared hypoautofluorescent on fundus autofluorescence and initially hypofluorescent with late hyperfluorescence on fluorescein angiography. The patients were subjected to detailed systemic evaluation and laboratory tests. All the patients showed acid-fast bacilli on invasive tissue biopsies. After initiation of antitubercular therapy, the lesions resolved in all eyes.

CONCLUSION

Yellow subretinal pigment epithelium deposits represent a novel and important diagnostic sign of tubercular posterior uveitis.

Cluster outbreak of Pseudomonas stutzeri acute endophthalmitis following phacoemulsification: A report of 14 cases from North India

Purpose:

To report clinical features, antibiotic susceptibility profile, management, and outcomes of a cluster outbreak of post-cataract surgery Pseudomonas stutzeri endophthalmitis.

Methods:

This was a hospital-based case series in which 14 patients with acute postoperative endophthalmitis who underwent cataract surgery on the same day were included. Based on severity of presentation, they either underwent pars plana vitrectomy (PPV) with intraocular antibiotics (IOAB) or vitreous tap with IOAB. Vitreous aspirates and environmental surveillance samples were inoculated on culture media and further processed by MALDI-TOF MS for identification and Vitek3 for susceptibility profile.

Results:

There were 8 females and 6 males with a mean age of 62.14 ± 8.08 years. Presenting signs included corneal folds (100%), hypopyon (57.1%) and fibrin (50%). Ten patients with mild presentation underwent vitreous tap with IOAB. Four patients with severe presentation underwent PPV with IOAB. Pseudomonas stutzeri was isolated from the vitreous samples and was pan-sensitive. Six eyes required multiple interventions. Favorable outcome was obtained in 12 eyes, one eye developed phthisis, and one patient was lost to follow-up.

Conclusion:

We report the first ever cluster outbreak of Pseudomonas stutzeri endophthalmitis following phacoemulsification with IOL implantation in a single surgeon setting. Majority of the patients had a mild presentation and responded well to targeted anti-microbial treatment.

Recurrence of tubercular choroiditis following anti-SARS-CoV-2 vaccination

Purpose

To report recurrence of tubercular choroiditis following anti-SARS-CoV-2 vaccination in two patients with quiescent disease activity for more than a year.

Methods

Retrospective observational case reports.

Results

Two patients (one female and one male) under follow-up for posterior uveitis having stable course with absence of ocular inflammation for more than a year presented with recurrence of choroiditis lesions 2–6 weeks following anti-SARS-CoV-2 vaccination. Both the patients were managed with intravitreal dexamethasone implant (Ozurdex®, Allergan, Inc., Irvine, CA, USA) and showed resolution of choroiditis lesions upon follow-up.

Conclusions

Acute onset recurrence of inflammation, in absence of any change in health status or treatment suggests the potential role of vaccination being the trigger of this reactivation. Given large-scale vaccination against novel coronavirus- SARS-CoV-2, careful vigilance is warranted to pick up the disease recurrence in patients with posterior uveitis.

Optical Coherence Tomography Findings of Underlying Choroidal Neovascularization in Punctate Inner Choroidopathy

Purpose: To analyze findings on optical coherence tomography (OCT) suggestive of choroidal neovascularization (CNV) in lesions of punctate inner choroidopathy (PIC).

Methods: In this multi-center retrospective study, clinical data of patients with PIC were retrospectively analyzed. Quantitative data (height, width, and volume of PIC lesions), and qualitative data (disruption of ellipsoid zone (EZ)/Bruch's membrane (BM), outer retinal fuzziness, and choroidal back-shadowing) were compared between CNV+ and CNV– groups using Mann–Whitney U-test and Fischer's exact test.

Results: In total, 35 eyes (29 patients; 21 women; mean age: 33.3 ± 6.5 years) were selected for analysis. Of the 35 PIC lesions studied, 17 had underlying CNV. Lesions with CNV+ had larger height, width, and volume (p < 0.001) and several distinctive features, such as disruption of EZ and BM, outer retinal fuzziness, and hypo-reflective back-shadowing (p < 0.001) compared with CNV—lesions.

Conclusions: Quantitative and qualitative OCT analysis can aid in the prediction of an underlying CNV in the eyes with PIC.

Addition of oral Fexofenadine to topical therapy leads to a significantly greater reduction in the serum IL-31 levels in mild to moderate pediatric atopic dermatitis

BACKGROUND

Recent evidence has suggested that oral antihistamines could have a beneficial role in atopic dermatitis (AD) due to their anti-inflammatory action. Hence, we aimed to evaluate the effectiveness of adding an oral second generation, non-sedating, H1 antihistamine (Fexofenadine) to topical treatment in AD.

MATERIALS AND METHODS

In this prospective randomized study, a total of 50 patients with a diagnosis of mild to moderate atopic dermatitis were recruited and randomized into two groups A (appropriate topical treatment combined with oral fexofenadine) and B (appropriate topical treatment without oral fexofenadine). Both groups received the respective treatments for a duration of 8 weeks.

RESULTS

There was no significant difference between the two groups in terms of SCORAD and the 5-D Itch Score at any of the time points (2 weeks, 4 weeks, 8 weeks). However, the serum IL-31 (ng/ml) decreased significantly from baseline in the fexofenadine group after 8 weeks of treatment.

CONCLUSIONS

Although we could not conclusively confirm the clinical efficacy of adding oral fexofenadine to topical treatment in AD, serological evaluation indicates that fexofenadine treatment can lead to significant lowering of serum IL-31 levels in AD patients.

Upper Eyelid Nodule - An Unusual Presentation of Ocular Demodicosis

Introduction: Demodex mite is an external parasite which is implicated in various ocular conditions like anterior blepharitis, posterior blepharitis, meibomian gland dysfunction, chalazia and others. Although demodex has been shown to be a causative agent of chalazia, occurrence of a solitary inflammatory nodule due to demodex infestation has not been reported in literature. Case: Our case describes the occurrence of an upper eyelid mass in a 62-year-old female which was found to have an associated demodex infestation. Conclusion: This is the first report of demodex infestation presenting as a nodular eyelid mass. This parasite needs to be considered in the differential diagnosis of eyelid masses as this condition requires specific management.

Severe epidermolysis bullosa/Kindler syndrome-like phenotype of an autoinflammatory syndrome in a child

A 5-year-old boy presented with generalized cutaneous erosions, severe scarring, depigmentation and contractures affecting major joints. The lesions had initially affected his ears, nose, feet, and the genital and ocular mucosa, leading to significant depigmentation, scarring, contractures and mutilation. The whole of the trunk and limbs were involved at the time of presentation, with the exception of some islands of spared skin on the proximal thighs, legs, nipples and external genitalia. Electron microscopy revealed a split in the sublamina densa with the absence of anchoring fibrils, suggestive of dystrophic epidermolysis bullosa (EB). Immunofluorescence antigen mapping demonstrated a broad reticulate pattern of staining with collagen IV, VII, and laminin 332 in the floor of the blister, suggestive of Kindler syndrome. Next-generation sequencing revealed a de novo heterozygous missense mutation (a variant of unknown significance) in exon 22 of the phospholipase-C gamma 2 gene (PLCG2), which resulted in a substitution of serine by asparagine at codon 798 (p.Asp798Ser), a result that was validated using Sanger sequencing. The child was diagnosed with PLCG2-associated antibody deficiency and immune dysregulation (PLAID)/autoinflammation and PLCG2-associated antibody deficiency and immune dysregulation (APLAID) syndrome. The cutaneous and corneal erosions, inflammation and scarring of this magnitude, and the eventual result of death have not been described previously for the PLAID/APLAID spectrum previously. In conclusion, this was an unusual acquired autoinflammatory severe EB-like disease that may be associated with de novo PLCG2 mutation.

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.