Ocular surface staining: Current concepts and techniques

The health of the ocular surface is vital for clear vision and comfort. Various factors can adversely influence the ocular surface and tear film homeostasis, and these include procedures like cataract and corneal refractive surgery. It is, therefore, important to assess the integrity of the ocular surface in a rapid, predictable, and consistent manner in the clinic. Various tests and devices have been described, and while these are useful, this article highlights the importance of using fluorescein staining of the ocular surface in detecting changes. This is a simple, inexpensive, rapidly performed test that is available in most eye clinics. However, a proper technique of dye instillation and assessment is important to recognize the changes that can occur. Once detected, these changes can be quantified, and the location and patterns can be used to diagnose the diseases that are present; these changes can also be used to monitor treatment outcomes and disease progression. The article discusses the technique, assessment, and interpretation of fluorescein staining of the ocular surface, along with the role of the two other vital dyes - rose bengal and lissamine green.

Bifocal Stabilisation of Acute Acromioclavicular Joint Dislocation using Suture Anchor and Temporary K-Wires: A Retrospective Analysis

Introduction

The acromioclavicular joint (ACJ) is a major link connecting the upper limb to the torso. The acromioclavicular and coracoclavicular (CC) ligaments help in stabilising the joint. We feel it is prudent to address both these ligament injuries, to achieve optimum result. This study was undertaken to analyse the results of a simple frugal surgical technique we used to deal with this injury considering stabilisation for both these ligaments.

Materials and methods

In this retrospective study, skeletally mature patients with Type III, IV or V ACJ dislocations who underwent open reduction and stabilisation of the joint with temporary K-wires, repair of the capsule and augmentation of CC ligaments with suture anchors were included. Clinico-radiological and functional outcome was evaluated. Functional assessment of the upper limb was analysed using the Disabilities of Arm, Shoulder, and Hand Score (DASH), Constant shoulder score (CSS) and Oxford shoulder score (OSS).

Results

Clinical and radiological evaluation of the 32 patients who had completed two years from the index surgery, was done. Out of the 37 patients included initially, five were lost in follow-up. Majority of the subjects included were males and type V was the most common injury. Mean pre-operative CC distance on the affected side was 13.92±4.94mm. In the immediate post-operative radiograph, it was 7.63±2.08mm and in the final follow- up was 9.36±2.75mm. Measurements were taken by two independent investigators and inter, and intra-observer reliability were analysed by Interclass correlation coefficient. Excellent functional outcome was noted despite the 1.81±1.50mm average loss of correction. At final follow-up, mean DASH score was 4.67±4.18, Oxford shoulder score was 44.06±2.44 and Constant shoulder score was 86.37±5.81. The severity of the injury had no significant effect on the functional outcome post our method of stabilisation and rehabilitation.

Conclusion

Bifocal fixation restores the multidirectional stability of the disrupted ACJ. Adequate radiological reduction, good functional outcome and simplicity of execution make this technique an undemanding one for use in regular practice.

Evaluation of ocular surface and tear function - A review of current approaches for dry eye

An increasing prevalence of dry eye disease in the past decade has resulted in a greater focus on diagnostic methods for this condition. There has been a proliferation of technologies that attempt to quantify various aspects of tear function and ocular surface health. However, a cost-effective, simple, and efficient method remains elusive. In the Indian context, the majority of these patients present to the general ophthalmologist, and a clinical approach that is quick and easy to perform would allow widespread usage for accurate diagnosis. This article reviews currently available methods and their relevance to the general ophthalmologist.

Inflammation and dry eye disease—where are we?

The presence of inflammation in dry eye disease (DED) results in increased patient symptomatology, ocular surface damage and worsening tear dysfunction. It also affects the health of meibomian glands and their secretions which further aggravates ocular surface disease. This article reviews current knowledge regarding ocular surface inflammation in DED and explores the relationships between the vicious cycles of DED, inflammation and meibomian gland dysfunction (MGD). The clinical evaluation of eyes with such changes, markers that identify the presence of inflammation on the ocular surface and current treatment options are discussed.

A 3D Polymer Scaffold Platform for Enhanced in vitro Culture of Human & Rabbit Buccal Epithelial Cells for Cell Therapies

BACKGROUND

Buccal mucosal epithelial cells show promising application for various regenerative medicine approaches. In this study, we examined the feasibility of culturing rabbit and human buccal mucosal epithelial cells in a novel thermoreversible gelation polymer (TGP) scaffold, without feeder layers or other foreign proteins.

METHODS & RESULTS

The results of this 28-day in vitro culture, u sing the conventional technique (2D) and TGP (3D) showed that the epithelial cell morphology could be maintained only in the TGP group while cells in the 2D group de-differentiated to fibroblast morphology in both human and rabbit samples. CK3 expression, a marker for epithelial differentiation was higher in 3D-TGP cultured cells than 2D.

CONCLUSION

TGP based in vitro cell culture is a prospective methodology to culture buccal mucosal epithelial cells efficiently without using foreign biological components for tissue engineering applications.

Is it better to be happy or not depressed? Depression mediates the effect of psychological well-being on adverse health outcomes in older adults

OBJECTIVES

To examine the relationship between psychological well-being and depression in older adults and the relative contribution these psychological factors have on risk of functional disability, frailty, and mortality.

METHODS

This is a secondary analysis of 1668 community-dwelling older adults without dementia who participated in the second wave of the Canadian Study of Health and Aging. Baseline assessments of psychological well-being (Ryff scale) and depression (Geriatric Depression Scale; GDS) were collected. At 5-year follow-up, mortality data were collected; frailty and disability in activities of daily living were evaluated using the frailty index (FI) and the Lawton-Brody scale, respectively.

RESULTS

Area under the receiver-operating characteristic curve indicated that GDS and Ryff scores were able to independently discriminate whether individuals were considered frail (C = 0.66; C = 0.59, respectively), had limitations in basic (C = 0.64; C = 0.57, respectively) or instrumental (C = 0.70; C = 0.57, respectively) activities of daily living, or had died (C = 0.63; C = 0.57) at follow-up (all P < 0.01). Regression models in which the Ryff and GDS were included in the same model demonstrated that the GDS significantly predicted frailty, disability, and mortality, whereas the Ryff effect was not significant. Mediation analysis determined that the effect of psychological well-being on adverse outcomes was fully mediated by depression.

CONCLUSIONS

Our results suggest that although both depression and psychological well-being appear to modulate risk for adverse physical health outcomes, depression mediates this relationship. Detecting and treating depressive symptoms should be of high priority in older patients to mitigate risk of future physical health adversities including mortality. Copyright © 2016 John Wiley & Sons, Ltd.

Abstract P3-08-10: Highly accurate hereditary risk assessment tool for low-income breast cancer patients

Introduction: Genetic testing is known to improve outcomes in high-risk women by finding cancers in the earliest most treatable stage or through prophylactic measures. However, these life-saving services may not be available to low-income women due to lack of insurance or access to genetic providers. To address this need, a collaboration between the Hereditary Cancer Clinic at Vanderbilt-Ingram Cancer Center (VICC) and the Robert E. Hardy Cancer Clinic at Nashville General Hospital at Meharry Medical College (MMC) was established in 2015 to systematically screen all MMC breast cancer patients for hereditary traits and refer them for genetic counseling (1). We hypothesized that high risk women could be accurately identified using this clinic based screening tool.

Methods: MMC clinic staff screened breast cancer patients using a 10-item Family Cancer Risk Assessment tool (RISK) that has been designed for use in a busy clinic environment (2). We tested the accuracy of the RISK by comparing the results to a 3-generation pedigree and the current NCCN guidelines for referral of patients to genetic services (3). The project was approved by the IRBs at each institution and study data were collected and managed using RedCap electronic data capture tools hosted at Vanderbilt University (4). Summary statistics and Chi-square for significance were performed.

Results: 73 breast cancer patients completed the RISK during their clinic visits and 41 (56%) had a high-risk score of 6 or more. All 41 patients have been referred for genetic counseling, with 18 (44%) women having completed a pedigree interview over the phone. 11 of these 18 patients (61%) were African-American; 5 (27.7%) were Caucasian; and one each (5% each) were of Asian and Hispanic ancestry. 9/18 were diagnosed &lt; 50 years (Mean entire group =50 yrs; range 36 -57). 5/18 (27.7%) had triple negative markers on pathology and 2/18 were ER+/PR+/Her2+, and the remainder had ER+/PR+/HER2- cancers. Among the 18 patients with full pedigrees, 17 (95%) patients met current NCCN guidelines based on pedigree analysis. The one outlier had a revised RISK score based on updated information obtained during the pedigree interview. Genetic testing was offered to 10 patients seen in VICC clinic and 1 declined testing. The other 8 patients either failed (n=4) or are awaiting an appointment (n=4). No deleterious mutations were seen in those tested. 4 VUSs (BRCA2, NBN, SMARCA4, and RAD51D) were found in 3 of the 9 tested patients. No significant differences were found in race, age or type of tumor.

Conclusion: Point of care risk assessment using the Family Cancer Risk Assessment screening tool is highly accurate for identifying patients at high genetic risk for hereditary breast cancer. While the tool was completed using pen and paper, it could easily be computerized for ease of administration and calculation of risk scores. This approach benefits the busy oncologist in identifying and referring appropriate patients for genetic testing.

1. Funds awarded by GreaterGood.org. 2. Joseph G. et al. 2012 Public Health Genomics. 3. National Comprehensive Cancer Network: Genetic/High-risk Breast_Ovarian (Version 2.2016). 4. Harris et al. 2009. J Biomed Inform.

Citation Format: Wiesner GL, Rao SK, Ashworth DR, Thomas KA, Lammers PE. Highly accurate hereditary risk assessment tool for low-income breast cancer patients [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-08-10.

Expression of VP1 protein of serotype A and O of foot-and-mouth disease virus in transgenic sunnhemp plants and its immunogenicity for guinea pigs

Recently, transgenic plants expressing immunogenic proteins of foot-and-mouth disease virus (FMDV) have been used as oral or parenteral vaccines against foot-and-mouth disease (FMD). They exhibit advantages like cost effectiveness, absence of processing, thermostability, and easy oral application. FMDV VP1 protein of single serotype has been mostly used as immunogen. Here we report the development of a bivalent vaccine with tandem-linked VP1 proteins of two serotypes, A and O, present in transgenic forage crop Crotalaria juncea. The expression of the bivalent protein in the transgenic plants was confirmed by Western blot analysis. Guinea pig reacted to orally or parenterally applied vaccine by humoral as well as cell-mediated immune responses including serum antibodies and stimulated lymphocytes, respectively. The vaccine protected the animals against a challenge with the virus of serotype A as well as O. This is the first report on the development of a bivalent FMD vaccine using a forage crop.

KEYWORDS

foot-and-mouth disease; sunnhemp; Agrobacterium tumefaciens; FMDV-VP1 gene; serotype O and A; in planta transformation; transgenic plants; bivalent vaccine.

Successful transportation of human corneal endothelial tissues without cool preservation in varying Indian tropical climatic conditions and in vitro cell expansion using a novel polymer

Background:

Though the transplantation of human corneal endothelial tissue (CET) separated from cadaver cornea is in practice, its transportation has not been reported. We report the successful transportation of CET in varying Indian climatic conditions without cool preservation and the in vitro expansion of Human Corneal Endothelial Precursor Cells (HCEPCs) using a novel Thermo-reversible gelation polymer (TGP).

Materials and Methods:

CET from cadaver corneas (n = 67), unsuitable for transplantation, were used. In phase I, CET was transported in Basal Culture Medium (Group I) and TGP (Group II) and in Phase II, in TGP cocktail alone, from three hospitals 250-2500 km away, to a central laboratory. The transportation time ranged from 6 h to 72 h and the outdoor temperature between 20°C and 41°C. On arrival, CET were processed, cells were expanded upto 30 days in basal culture medium (Group A) and TGP scaffold (Group B). Cell viability and morphology were documented and Reverse transcription polymerase chain reaction (RT-PCR) characterization undertaken.

Results:

In Phase I, TGP yielded more viable cells (0.11 × 10⁶ cells) than Group I (0.04 × 10⁶ cells). In Phase II, the average cell count was 5.44 × 10⁴ cells. During expansion, viability of HCEPCs spheres in TGP was maintained for a longer duration. The cells from both the groups tested positive for B-3 tubulin and negative for cytokeratins K3 and K12, thereby proving them to be HCEPCs.

Conclusion:

TGP preserves the CET during transportation without cool preservation and supports in vitro expansion, with a higher yield of HCEPCs, similar to that reported in clinical studies.

Cataract

Cataract is the leading cause of reversible blindness and visual impairment globally. Blindness from cataract is more common in populations with low socioeconomic status and in developing countries than in developed countries. The only treatment for cataract is surgery. Phacoemulsification is the gold standard for cataract surgery in the developed world, whereas manual small incision cataract surgery is used frequently in developing countries. In general, the outcomes of surgery are good and complications, such as endophthalmitis, often can be prevented or have good ouctomes if properly managed. Femtosecond laser-assisted cataract surgery, an advanced technology, can automate several steps; initial data show no superiority of this approach over current techniques, but the results of many large clinical trials are pending. The greatest challenge remains the growing 'backlog' of patients with cataract blindness in the developing world because of lack of access to affordable surgery. Efforts aimed at training additional cataract surgeons in these countries do not keep pace with the increasing demand associated with ageing population demographics. In the absence of strategie that can prevent or delay cataract formation, it is important to focus efforts and resources on developing models for efficient delivery of cataract surgical services in underserved regions. For an illustrated summary of this Primer, visit: http://go.nature.com/eQkKll.

Inter- relationship between rheumatoid arthritis and periodontitis

BACKGROUND

Periodontal medicine defines a rapidly emerging branch of Periodontology focusing on establishing a strong relationship between periodontal health and systemic health. It is speculated that the major common dysregulation which links Periodontitis with Rheumatoid arthritis (RA) is being played by the mediators of immune inflammatory response.

OBJECTIVES

To determine whether there is any relationship between periodontal disease and Rheumatoid arthritis.

METHODS

A total of 100 patients were included for the present study which was divided into two groups: one group (cases) included 50 patients attending the Department of Orthopedics, Kasturba Medical College, Manipal who were diagnosed of Rheumatoid arthritis. Another subject population included 50 patients as controls attending the Department of Oral Medicine, Manipal College of Dental Sciences, Manipal with age and gender matched with those of rheumatoid arthritis group. Specific measures for periodontitis included plaque index, gingival index, number of missing teeth, and radiographic alveolar bone loss scores. Measures of rheumatoid arthritis included health assessment questionaires, levels of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). Various periodontal parameters were compared between the cases and controls.

RESULTS

The average alveolar bone loss was statistically more severe in Rheumatoid arthritis (RA) group than in the controls although there were similar plaque index in both the groups. The gingival index was statistically higher in the RA group. The Erythrocyte Sedimentation Rate (ESR) and C- Reactive Protein (CRP) levels of RA patients were also significantly associated with the severity of periodontal disease.

CONCLUSION

There was a significant association between Rheumatoid arthritis and Periodontitis which may be due to a common underlying deregulation of the inflammatory response in these individuals.

Collagen cross linking: current perspectives

Keratoconus is a common ectatic disorder occurring in more than 1 in 1,000 individuals. The condition typically starts in adolescence and early adulthood. It is a disease with an uncertain cause and its progression is unpredictable, but in extreme cases, vision deteriorates and can require corneal transplant surgery. Corneal collagen cross-linking (CCL) with riboflavin (C3R) is a recent treatment option that can enhance the rigidity of the cornea and prevent disease progression. Since its inception, the procedure has evolved with newer instrumentation, surgical techniques, and is also now performed for expanded indications other than keratoconus. With increasing experience, newer guidelines regarding optimization of patient selection, the spectrum of complications and their management, and combination procedures are being described. This article in conjunction with the others in this issue, will try and explore the uses of collagen cross-linking (CXL) in its current form.

Long-term outcomes of endothelial keratoplasty in Chinese eyes at a University Hospital

BACKGROUND

Endothelial keratoplasty (EK) is used increasingly for the management of cases with endothelial dysfunction. Long-term outcomes of the surgery are not widely reported in the literature. We report our experience of EK in Chinese eyes at a University teaching hospital.

METHODS

Retrospective analysis was performed for all cases of EK performed between 2005 and 2009. Data analyzed included indication for surgery, associated surgical procedures, complications, best-corrected visual acuity (BCVA) and overall graft survival.

RESULTS

Overall, 22 eyes of 21 patients underwent EK (13 males, 8 females, mean age 71.8 ± 11.3 years). Pseudophakic bullous keratopathy was the leading indication for surgery (n = 12) followed by Fuchs' endothelial dystrophy (n = 4), or both (n = 3). Other indications for surgery included failed penetrating keratoplasty (n = 2) and endothelial decompensation due to multiple surgeries (n = 1). Triple procedure was performed in 5 (22.7%) cases. Complications were noted in the form of postoperative interface hemorrhage (n = 2, 9%) and graft dislocation (n = 1, 4.5%). The mean postoperative endothelial cell density was 1069 ± 585.8 cells/mm(2). The mean postoperative pachymetry was 675.8 ± 108.5 μm. The mean preoperative and postoperative intraocular pressure was 11.3 ± 3.2 and 13.9 ± 4.5 mmHg respectively. At the last follow-up (mean, 47.4 ± 13.7 months), BCVA was ≥20/70 in 9 (40.9%) cases. Causes of poor BCVA included primary graft failure (n = 4), graft decompensation (n = 4), advanced glaucoma (n = 2) and irreversible graft rejection (n = 2). Graft remained clear in 12 (54.5%) cases at the last follow-up. Average graft survival was 19.7 ± 17.7 months (median 17.5 months).

CONCLUSIONS

Nearly half of the EK grafts in our study survived over a period of five years. Graft failure, glaucoma and graft rejection were the main causes of poor graft survival.

A new era in corneal transplantation: paradigm shift and evolution of techniques

Penetrating keratoplasty is the replacement of a diseased cornea with a full-thickness donor graft. In the last century, this 'gold standard' procedure was long established as the treatment of choice for various corneal diseases. The classical indications for a penetrating keratoplasty entailed optical, tectonic, therapeutic, and cosmetic issues. Over the past decade however, surgical advances have now enabled operations involving the cornea to be performed with a major shift in emphasis, such that penetrating keratoplasty has given way to lamellar (layered) keratoplasty. This review provides the latest updates on developments in the field of corneal transplantation and the nomenclature of different types of component surgery, particularly from the perspective of Hong Kong.

A single intramuscular injection of rAAV-mediated mutant erythropoietin protects against MPTP-induced parkinsonism

Erythropoietin (Epo) is neuroprotective in a number of preparations, but can lead to unacceptably high and even lethal hematocrit levels. Recent reports show that modified Epo variants confer neuroprotection in models of glaucoma and retinal degeneration without raising hematocrit. In this study, neuroprotective effects of two Epo variants (EpoR76E and EpoS71E) were assessed in a model of Parkinson's disease. The constructs were packaged in recombinant adeno-associated viral (rAAV) vectors and injected intramuscularly. After 3 weeks, mice received five daily injections of 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) and were killed 5 weeks later. The MPTP-lesioned mice pretreated with rAAV.eGFP (negative control) exhibited a 7- to 9-Hz tremor and slower latencies to move on a grid test (akinesia). Both of these symptomatic features were absent in mice pretreated with either modified Epo construct. The rAAV.eGFP-treated mice lesioned with MPTP exhibited a 41% reduction in tyrosine hydroxylase (TH)-positive neurons in the substantia nigra. The rAAV.EpoS71E construct did not protect nigral neurons, but neuronal loss in mice pretreated with rAAV.EpoR76E was only half that of rAAV.eGFP controls. Although dopamine levels were normal in all groups, 3,4-dihydroxyphenylacetic acid (DOPAC) was significantly reduced only in MPTP-lesioned mice pretreated with rAAV.eGFP, indicating reduced dopamine turnover. Analysis of TH-positive fibers in the striatum showed normalized density in MPTP-lesioned mice pretreated with rAAV.EpoS71E, suggesting that enhanced sprouting induced by EpoS71E may have been responsible for normal behavior and dopaminergic tone in these mice. These results show that systemically administered rAAV-generated non-erythropoietic Epo may protect against MPTP-induced parkinsonism by a combination of neuroprotection and enhanced axonal sprouting.

Randomized double-masked controlled trial comparing pain scores with and without the use of supplementary 2% lidocaine gel in LASIK

PURPOSE

To compare pain scores with and without supplementary topical 2% lidocaine gel in patients undergoing simultaneous bilateral laser-assisted in situ keratomileusis (LASIK) under topical anesthesia using 0.5% proparacaine eye drops.

DESIGN

Randomized double-masked placebo-controlled trial.

METHODS

Fifty-one Chinese subjects (102 eyes, with 51 eyes in each arm) were included. One eye was randomly allocated to have supplementary 2% lidocaine gel while the other eye received carbomer gel as control, in addition to topical 0.5% proparacaine. The pain scores for each eye during microkeratome flap creation, during laser ablation, and at 15, 30, and 45 minutes after LASIK were assessed. An overall pain score of the LASIK procedure was also obtained. Primary outcome measures were pain scores during and after LASIK. Secondary outcomes included need for additional topical anesthesia, patient cooperation score, and duration and complications of surgery.

RESULTS

In the 2% lidocaine gel-treated group, the pain scores were significantly lower during microkeratome flap creation and laser ablation, and postoperatively at 30 and 45 minutes (P<.05 for all). Patients in the lidocaine gel group required less additional topical anesthesia (P=.0004) and were more cooperative (P=.019) as compared to the carbomer gel group. No surgical or postoperative complications were observed.

CONCLUSIONS

The use of supplementary 2% lidocaine gel in LASIK is effective in lowering the pain experienced during and up to 45 minutes after LASIK.

Association of hemopexin in tear film and conjunctival macrophages with vernal keratoconjunctivitis

OBJECTIVE

Vernal keratoconjunctivitis (VKC) is a chronic allergic inflammatory disease with unclear etiology and pathogenesis. We investigated the tear film proteome of patients with VKC to understand the pathologic characteristics of VKC.

METHODS

Tear samples were collected from healthy volunteers and patients with VKC. Electrophoresis was performed to display the tear proteomic profiles according to VKC severity. The identities of differentially expressed proteins were analyzed by mass spectrometry and quantified by enzyme-linked immunosorbent assay. Impression cytology was performed on VKC conjunctival samples to demonstrate the cellular protein expression. Allergic sensitization was performed in mice to study the pathologic role of these proteins in VKC.

RESULTS

Hemopexin, an inflammatory protein, was elevated in the tear film of patients with VKC. The increased hemopexin concentration in VKC tears was significantly associated with disease severity. Impression cytology showed specific high hemopexin expression in dekeratinized conjunctival epithelium and necrotic macrophages in patients with VKC. Immunohistochemical examination of normal lacrimal tissues from mice showed that hemopexin was not expressed in any lacrimal apparatus. Under systemic and topical sensitization and challenge using hemopexin in mice, the affected eye had mild to moderate bead discharge, chemosis, and edema with excessive macrophage infiltration and conjunctival necrosis.

CONCLUSION

An association exists between tear hemopexin and the development and pathologic effects of VKC.

CLINICAL RELEVANCE

Increased hemopexin may have a role in the development of VKC.

Effect of tibial tunnel position on arthroscopically assisted anterior cruciate ligament reconstruction using bone-patellar tendon-bone grafts: a prospective study

INTRODUCTION

The aim of this research was to study the effect of the tibial tunnel position in anterior cruciate ligament (ACL) reconstruction using bone-patellar tendon-bone (BPTB) grafts in ensuring optimal knee functioning.

METHODS

A prospective study was conducted on 41 patients who underwent arthroscopically assisted ACL reconstruction using a BPTB graft and who were followed up for a minimum period of two years. The radiographic position of the tibial tunnel was compared with the clinical outcome using the International Knee Documentation Committee (IKDC) and modified Lysholm knee scores at two years after surgery.

RESULTS

Six out of eight patients with a fair outcome based on the modified Lysholm score and five out of eight patients with an abnormal outcome based on the IKDC score had their tibial tunnel within the 10 percent to 25 percent anteroposterior width of the tibial plateau. The tibial tunnel of patients with a fair Lysholm outcome (mean 22.2 percent) was significantly anterior compared to that of those with an excellent (mean 38.1 percent) and good (mean 34.1 percent) outcome (p is less than 0.01). The analysis using the IKDC score showed a similar trend.

CONCLUSION

Placing the tibial tunnel in the anterior 25 percent of the tibial plateau is associated with a poor knee outcome. More predictable results can be achieved through 35 percent to 46 percent anteroposterior placement of the tibial tunnel.

Randomized Clinical Trial on the Efficacy and Side Effects of Tropicamide and Phenylephrine in Mydriasis for Ophthalmoscopy

Purpose

To compare the efficacy and side effects of two combinations of tropicamide and phenylephrine as mydriatics for ophthalmoscopy.

Methods

In this prospective randomized controlled trial, 51 Chinese outpatients were randomized to receive topical tropicamide 1.0% and phenylephrine 2.5% (Regime A), and 50 to receive a fixed combination of tropicamide 0.5% and phenylephrine 0.5% (Regime B). The change in horizontal pupillary diameter, subject discomfort upon instillation and the time elapsed between instillation and recovery from glare and near blur were studied.

Results

After 60 minutes, the mean increase in pupillary diameter was 3.56±0.65 mm with Regime A, and 3.04±0.62 mm with Regime B (P<0.01), but there was no difference in the proportion of subjects having a post-mydriatic pupillary diameter of 6 mm or larger (P=0.54). No subjects required additional instillation. Regime B was better tolerated (P<0.001). The median times elapsed between instillation and recovery from glare or near blur was 7 hours, without a significant difference between the two regimes (P=0.5).

Conclusions

Both regimes were effective and safe for ophthalmoscopy. However, Regime B was better tolerated. Subjects may be reassured that the side effects of glare and near blur are likely to disappear by the following day.

Study of the efficacy of toothpaste containing casein phosphopeptide in the prevention of dental caries: a randomized controlled trial in 12- to 15-year-old high caries risk children in Bangalore, India

Casein phosphopeptide (CPP) has the potential to be added to mouth rinses, gels, toothpastes, chewing gums and confectioneries. Until now CPP has been studied in vitro, in situ and in animals, but clinical trials are lacking. This study was conducted to evaluate the efficacy of CPP-containing toothpaste in preventing dental caries in schoolchildren. The study was conducted among 150 schoolchildren randomly divided into three groups, each using one of three types of toothpastes: (a) containing 2% w/w CPP; (b) containing 1,190 mg/kg fluoride as 0.76% sodium monofluorophosphate (SMFP); (c) placebo toothpaste without CPP or fluoride. Students brushed with the given toothpastes for 24 months. Oral hygiene and caries experience were assessed at baseline, 12 and 24 months. The increments in caries lesions were calculated and analyzed to assess the caries-preventive effect. A significant reduction in caries increment was observed among students using CPP toothpaste or SMFP toothpaste, compared with the group using the placebo toothpaste. The reduction in caries increment was not significantly different between the CPP and SMFP groups. Oral Hygiene Index score increased from the 12-month to the 24-month examination. It is concluded that CPP can be effectively incorporated into calcium carbonate-based toothpaste and that toothpaste containing CPP is effective in preventing caries. Toothpaste containing 2% CPP seemed to have an efficacy similar to paste containing 1,190 mg/kg SMFP in the prevention of caries.

Unilateral ptosis correction with mersilene mesh frontalis sling in infants: thirteen-year follow-up report

PURPOSE

To assess surgical, visual, refractive, and aesthetic outcomes 13 years after mersilene mesh frontalis sling (MMFS) operation for severe unilateral congenital ptosis performed in 10 infants before 1 year of age.

METHODS

Longitudinal follow-up of an interventional case series by structured ocular examinations, external photographs, and questionnaire-based interviews.

RESULTS

Mean age at surgery was 6.9+/-2.7 months. After a mean follow-up of 13.0+/-0.6 years, one patient (10%) had recurrent ptosis with the upper lid 2 mm below the superior limbus at 3 months postoperatively. Best-corrected visual acuities were within two Snellen lines between the two eyes in all patients. Astigmatic errors were 1.20+/-1.00 D and 1.10+/-1.70 D between operated and unoperated eyes. Four patients had 2 mm lid lag on down-gaze and one of them had 2 mm lagophthalmos. Mean satisfaction scores (scale of 1 to 100) for lid position, cosmesis, function, and to the procedure were 83.3+/-11.8, 77.0+/-22.9, 89.4+/-5.5, and 86.8+/-6.3, respectively. No case of overcorrection, sling extrusion, stitch granuloma, or exposure keratopathy was noted.

CONCLUSIONS

In view of the low recurrence rate (10%) and absence of serious complication or need for revision after 13 years, the use of MMFS seems effective and feasible in infants less than 1 year old. Achieving compatible long-term stability, satisfactory aesthetic, and visual outcomes, MMFS may offer an alternative to delaying operations for autogenous fascia lata harvesting in infants requiring early ptosis correction.

Posterior corneal curvature measurements with peripheral fitting zones before and after myopic LASIK using Orbscan II

PURPOSE

To compare pre- and postoperative posterior corneal curvature measurements in peripheral fitting zones using the Orbscan II topographer in patients undergoing myopic LASIK.

METHODS

Retrospective analysis of preoperative and 3-month postoperative Orbscan II data of 194 eyes that underwent myopic LASIK at a university eye center. Posterior corneal power was estimated using the peripheral 7- to 10-mm fitting zones. The pre- and postoperative values were analyzed and compared.

RESULTS

The mean difference in estimated pre- and postoperative power of the posterior cornea was -0.04 +/- 0.16 diopters (P < .01).

CONCLUSIONS

The difference in posterior corneal curvature measurement following myopic LASIK using the peripheral fitting zone with the Orbscan II, as compared to the preoperative values, is clinically insignificant.

Descemet stripping endothelial keratoplasty: effect of the surgical procedure on corneal optics

PURPOSE

To determine the changes in corneal optical performance after posterior lamellar corneal transplantation.

DESIGN

Retrospective case series.

METHODS

The anterior segment in four eyes of four patients who underwent Descemet stripping endothelial keratoplasty (DSEK) with cataract extraction and intraocular lens (IOL) implantation were imaged with the Visante anterior segment optical coherence tomography [OCT] (Carl Zeiss Meditec, Dublin, California, USA). The curvature of the posterior surface of the donor graft was compared with that of the host cornea, and corneal thickness was measured.

RESULTS

All eyes had a hyperopic refractive error after surgery. The posterior corneal curvature after surgery was more than that before surgery. Average preoperative keratometry was 43.4 diopters (D), and after surgery, it was 42.8 D using keratometry. However, when the postsurgical corneal power was calculated using the Gaussian optics method, the average value was 40.8 D.

CONCLUSIONS

The addition of a donor corneal graft to the posterior surface of decompensated corneas may lessen the effective optical power of the cornea and may have implications for IOL power calculations in these eyes.

Calculating graft size and position in rotational corneal autografting: a simplified approach

In eyes with eccentric corneal opacities partially involving the pupillary area, using a rotational corneal autograft, can help restore vision without the immunological complications associated with allografts. In this report, we describe a simple intraoperative method for determining trephine size and placement for rotational corneal autografting. This surgical approach helps in the planning and execution of rotational corneal autografting, to obtain good outcomes.

The effect of parental history of myopia on children's eye size and growth: results of a longitudinal study

PURPOSE

To evaluate the effect of parental myopia on eye size and growth in Chinese children.

METHODS

A school-based, cross-sectional survey was performed in Chinese children 5 to 16 years of age. A longitudinal cohort study was conducted 1 year later. The effects of parental myopia, parental education level, and near work performed by the child on the refractive error and ocular biometry of the child were assessed.

RESULTS

There were 7560 children enrolled in the initial study (response rate: 76.3%). One year later, 4468 children (response rate: 75.9%) in the original cohort (with the exception of those who had completed primary schooling) were evaluated, to determine eye growth. Although children with a stronger parental history of myopia tended to be less hyperopic before the onset of myopia (spherical equivalent refraction [SER] = 0.43 D, 0.67 D, and 0.68 D in children with two, one, and no myopic parents respectively; P = 0.007), the axial lengths did not follow the same pattern (axial length [AL] = 23.11, 23.07, and 23.15 mm; P = 0.429). Eye growth and myopic shift in refraction occurred more rapidly among children with a stronger parental history of myopia (annual AL growth/myopia progression = 0.37 mm/-0.22 D, 0.26 mm/-0.07 D, and 0.20 mm/-0.02 D in children with two, one, and no myopic parents, respectively; P < 0.001).

CONCLUSIONS

Ocular biometric data in Chinese children suggest that parental history of myopia influences the growth rate of the eye, rather than its size before the onset of myopia, as previously reported in Caucasian children. Further longitudinal studies involving children of different ethnicities are warranted.

Monocular blindness due to central retinal artery occlusion in bipolar hemireplacement arthroplasty of the hip

Though rare, perioperative loss of vision after non-ocular surgeries is a disastrous complication. This has been reported after spine surgery or cardiopulmonary bypass surgery. We present an otherwise healthy 54-year-old man who underwent bipolar hemireplacement for a fractured neck of femur, and developed perioperative monocular visual loss due to central retinal artery occlusion, a complication hitherto unreported in hip replacement surgeries. The possible aetiological factors and the measures to prevent this complication are discussed.

Anterior segment ischemia after two-muscle surgery in a patient with radiation-treated nasopharyngeal carcinoma

Anterior segment ischemia after strabismus surgery is a rare occurrence. Risk factors include single-stage surgery of three or more muscles in one eye, dysthyroid eye disease, and advanced age. The authors report a case of anterior segment ischemia after single-stage surgery of two horizontal muscles without previous reported risk factors. However, the patient had received radiotherapy for nasopharyngeal carcinoma more than 20 years ago. The case was successfully treated with systemic steroids but with reduced best-corrected visual acuity. Previous radiotherapy in the related orbital field may be a new risk factor for this condition.

Agreement among 3 Methods to Measure Corneal Thickness: Ultrasound Pachymetry, Orbscan II, and Visante Anterior Segment Optical Coherence Tomography

PURPOSE

To assess the agreement of central and paracentral corneal thickness measurements between ultrasound pachymetry (USP), Orbscan II, and Visante anterior segment optical coherence tomography (ASOCT).

DESIGN

Observational cross-sectional study.

PARTICIPANTS

Seventy eyes of 70 subjects.

METHODS

Each subject underwent Orbscan II (using an acoustic equivalent correction factor of 0.89), ASOCT, and USP examination. Bland-Altman plots were used to evaluate agreement between instruments.

MAIN OUTCOME MEASURES

Central and paracentral corneal thickness measurements by the 3 methods and agreement, as evaluated by 95% limits of agreement (LOA).

RESULTS

The mean measurements of average central corneal thickness by USP, Orbscan II, and ASOCT were 553.5+/-30.26 microm, 553.22+/-25.47 microm, and 538.79+/-26.22 microm, respectively. There was high correlation between instruments: USP with ASOCT (r = 0.936, P<0.001), USP with Orbscan II (r = 0.900, P<0.001) for central corneal thickness measurements, and Orbscan II with ASOCT for average paracentral 2- to 5-mm measurements (r = 0.947, P<0.001). The mean differences (and upper/lower LOA) for central corneal thickness measurements were 0.31+/-13.34 microm (26.44/-25.83) between USP and Orbscan II, 14.74+/-10.84 microm (36.0/-6.51) between USP and ASOCT, and 14.44+/-9.14 microm (32.36/-3.48) between Orbscan II and ASOCT. The average mean difference (and upper/lower LOA) between Orbscan II and ASOCT for paracentral 2- to 5-mm corneal thickness measurements was 10.35+/-8.67 microm (27.35/-6.65).

CONCLUSION

Anterior segment optical coherence tomography underestimated corneal thickness compared with that measured with USP. Anterior segment optical coherence tomography had better agreement with the gold standard USP, as compared with Orbscan II. However, important discrepancies among instruments exist. Clinicians should be aware that corneal thickness measurements are influenced by the method of measurement and that, although highly correlated, these instruments should not be used interchangeably for the assessment of corneal thickness.

Accuracy of Orbscan II in the Assessment of Posterior Curvature in Patients With Myopic LASIK

PURPOSE

To evaluate the accuracy of Orbscan II measurements in assessing posterior corneal curvature in patients undergoing myopic LASIK.

METHODS

Using the Orbscan II, posterior corneal curvature was assessed pre- and postoperatively in 304 eyes that underwent myopic LASIK. The radius of curvature and corneal refractive power in diopters (D) were compared using the paired sample t test.

RESULTS

The mean pre- and postoperative radius of posterior corneal curvature were 6.49 +/- 0.26 mm and 6.35 +/- 0.30 mm, respectively. Mean pre- and postoperative posterior corneal power were -6.17 +/- 0.25 D and -6.32 +/- 0.30 D, respectively, and the difference (0.14 +/- 0.14 D) was statistically significant (P < .01).

CONCLUSIONS

Although the derived value for the power of the postoperative LASIK posterior corneal surface is overestimated using the Orbscan II, this small difference may not be clinically important. Orbscan II measurements can therefore be used (with caution) to measure posterior corneal curvature in patients with myopic LASIK for the assessment of intraocular lens power based on the Gaussian optics formula.

Topical anesthesia-induced keratopathy after laser-assisted subepithelial keratectomy

A 42-year-old woman had uneventful bilateral laser-assisted subepithelial keratectomy (LASEK) to correct myopia. She experienced intense pain in the first postoperative week and obtained topical oxybuprocaine for pain relief. Subsequently, she developed bilateral persistent corneal epithelial defects, epithelial edema, and bullae that failed to heal with bandage contact lens and topical lubricants. Over the next 4 months, there was progressive corneal stromal thinning and descemetocele formation in 1 eye, requiring application of cyanoacrylate glue, and stromal edema and scarring in the other eye, which resulted in a visual acuity of counting fingers. Investigations did not reveal associated infection or an underlying immunological disorder; however, the patient admitted to excessive use of topical anesthetic eyedrops in the post-LASEK period. She subsequently had penetrating keratoplasty and lens extraction with IOL implantation in the right eye. The left eye healed with central corneal scarring. This case illustrates that serious sight-threatening complications may occur after LASEK due to abuse of topical anesthetic agents.

Central corneal thickness measurements using Orbscan II, Visante, ultrasound, and Pentacam pachymetry after laser in situ keratomileusis for myopia

PURPOSE

To compare corneal pachymetry assessment using 4 measurement methods in eyes after laser in situ keratomileusis (LASIK) for myopia.

SETTING

Department of Ophthalmology & Visual Sciences, The Chinese University of Hong Kong, Hong Kong Eye Hospital, Hong Kong SAR.

METHODS

Fifty-two consecutive patients (103 eyes) who had LASIK for the correction of myopia had Orbscan II (Bausch & Lomb), Visante (Carl Zeiss Meditec), Pentacam (Oculus, Inc.), and ultrasound (US) pachymetry (Sonomed, 200P) 6 months after surgery. Data were analyzed using the paired sample t test, Bland-Altman plots, and linear regression.

RESULTS

The mean postoperative pachymetry measured by US, Orbscan (0.89 acoustic factor), Pentacam, and Visante pachymetry were 438.2 microm+/-41.18 (SD), 435.17+/-49.63 microm, 430.66+/-40.23 microm, and 426.56+/-41.6 microm, respectively. Compared with the US measurement, Pentacam and Visante measurements significantly underestimated corneal thickness by a mean of 7.54+/-15.06 microm (P<.01) and 11.64+/-12.87 microm (P<.01), respectively. There was no statistically significant difference between US and Orbscan measurements.

CONCLUSION

Pentacam and Visante measurements of corneal thickness 6 months after LASIK were significantly less than those obtained using Orbscan and US pachymetry, although all 4 measurement methods showed a high correlation with each other.

Repositioning of Free Cap Four Days After LASIK

PURPOSE

To report management and outcome of late repositioning of flap dislodgement after LASIK.

METHODS

A 27-year-old man underwent LASIK in the right eye for correction of myopia, which was complicated by free cap. The flap was repositioned, but dislodged 2 days later. The dislodged flap was stored in balanced salt solution for 48 hours and repositioned 4 days after initial surgery.

RESULTS

Postoperatively, the flap remained apposed, but diffuse lamellar keratitis and epithelial ingrowth developed, which was managed with topical steroids and topical mitomycin C. Stromal haze gradually decreased by 16 months postoperatively, resulting in best spectacle-corrected visual acuity of 20/20.

CONCLUSIONS

Flap dislodgement > 48 hours postoperatively can be repositioned with good visual outcome. The flap should be preserved in the event of such complication.

Perilimbal conjunctival pigmentation in Chinese patients with vernal keratoconjunctivitis

PURPOSE

To document the disease spectrum and evaluate the presence of perilimbal conjunctival pigmentation in Chinese patients with vernal keratoconjunctivitis (VKC).

METHOD

A case-control study was conducted between November 2004 and July 2005. Patients aged 18 or younger with VKC and age-matched children attending our eye clinic for refractive or orthoptic problems were recruited and compared. Detailed slit-lamp examination was performed noting in particular the presence of perilimbal conjunctival pigmentation, the severity of papillary reaction, and corneal complications of VKC.

RESULTS

A total of 19 patients and 23 controls were evaluated. The presence of bilateral large tarsal or limbal papillae and epithelial defect were significantly associated with symptoms severity (Fisher's exact test, P=0.015 and P=0.035 respectively). All VKC patients were found to have perilimbal conjunctival pigmentation in at least one eye. There was a significant correlation in the colour and density of pigments between the two eyes (Sperman's rho=0.93, P<0.001). None of the controls was found to have such perilimbal conjunctival pigmentation (Fisher's exact test, P<0.001).

CONCLUSION

The presence of perilimbal conjunctival pigmentation appears to be a consistent clinical finding in Chinese patients with VKC and may be a useful diagnostic sign for patients with subtle signs or symptoms.

Uncemented primary press-fit total hip arthroplasty: a 3 to 6 years of experience

PURPOSE

To analyse the 3 to 6 years' clinicoradiological outcome of 45 uncemented total hip arthroplasties performed in 37 patients using cementless Spotorno stem and St Nabor cup.

METHODS

The main indications for surgery were avascular necrosis of the femoral head and rheumatoid arthritis. Younger patients with good bone quality and a trumpet-shaped femur were eligible. A single surgeon performed all the operations using a posterolateral approach. Patients were reviewed at 6 weeks, 3 months, 6 months, and yearly thereafter. The clinical status was recorded using the Harris Hip Score. All radiographs were analysed by 2 independent blinded observers on 2 separate occasions.

RESULTS

The mean follow-up period was 49 months and the mean Harris Hip Score at the latest follow-up was 94. Osseointegration in the form of trabeculae running from the endosteum to the prosthesis surface along with tropism of the calcar was evident in 73% of the hips. None of the remaining hips showed any continuous radio-opaque lines suggestive of a lack of bone ongrowth. Patients with endosteal condensation had better Harris Hip Scores. Intra-operative stability of the implants could fairly predict outcome.

CONCLUSION

Initial clinicoradiological results of uncemented total hip arthroplasty are promising in younger patients with good bone quality and a trumpet-shaped femur.

Medial collateral ligament avulsion from both tibial and femoral attachments: a case report

The medial collateral ligament (MCL) is the most commonly injured ligament of the knee joint. Proximal MCL tears occur more frequently than do distal ones. We report a 28-year-old man with a valgus injury of his left knee joint after a fall from a motorcycle. Magnetic resonance imaging of the affected knee joint revealed complete avulsion of the superficial MCL from both its femoral and tibial insertions. The meniscofemoral portion of the deep part of the MCL was also torn and the medial meniscus was subluxated. Such a pattern, an MCL tear with subluxation of the medial meniscus, is rare.

Polyglactin sutures versus nylon sutures for suturing of conjunctival autograft in pterygium surgery: a randomized, controlled trial

PURPOSE

To compare the use of polyglactin sutures versus nylon sutures for conjunctival autograft suturing in pterygium surgery.

METHODS

A prospective, randomized, controlled, clinical trial was conducted, in which 32 eyes of 32 patients with primary nasal pterygium were randomized to undergo pterygium surgery with the use of nylon sutures or polyglactin sutures for conjunctival autograft suturing. Patients were followed up for 3 months. Outcome measures included postoperative discomfort according to a visual analogue scale (VAS), graft hyperaemia, graft oedema and tarsal conjunctival papillary reaction.

RESULTS

There was no significant difference in the postoperative discomfort as assessed by VAS in both groups at all follow-up visits. Patients who had polyglactin sutures for suturing conjunctival autograft were noted to have more tarsal conjunctival papillary reaction at day 1 (p = 0.01) and more graft hyperaemia at week 1 (p = 0.019) after the operation. At 4 weeks postoperatively, significantly more nylon sutures remained on the autograft (p = 0.021), some of which were buried and could not be removed.

CONCLUSIONS

Both polyglactin and nylon are effective suture materials for autograft suturing in pterygium surgery and cause comparable postoperative discomfort. Polyglactin sutures resulted in slightly more conjunctival reaction in the early postoperative period compared with nylon sutures.

Topical Atropine in Retarding Myopic Progression and Axial Length Growth in Children with Moderate to Severe Myopia: A Pilot Study

PURPOSE

To study the safety and efficacy of topical 1% atropine eye ointment in retarding myopic progression in children with moderate to severe myopia.

METHODS

This was an interventional control study. Children (aged 5-10 years) with myopia of -3.00 diopters (D) or more were treated with 1% atropine ointment once daily for 1 year. Baseline and regular assessments of refractive errors by cycloplegic autorefraction and of axial length were done by ultrasound biometry, and the results were compared with data of control subjects.

RESULTS

Twenty-three children (mean age: 7.4 +/- 1.6 years) with moderate to severe myopia, being treated in the Hong Kong Eye Hospital of the Chinese University of Hong Kong, were recruited into the atropine group, and 23 children from the same eye clinic were matched with the study subjects with respect to age, sex, and initial spherical equivalent refraction, as controls. The initial refractive errors were -5.18 +/- 2.05 D and -5.12 +/- 2.33 D in the atropine and the control groups, respectively (P = 0.934). Myopic progression was significantly less (P = 0.005) in the atropine group (+0.06 +/- 0.79 D) than in the control group (-1.19 +/- 2.48 D). Axial length increase was also significantly smaller in the atropine group (0.09 +/- 0.19 mm) than in the control group (0.70 +/- 0.63 mm) (P = 0.004). One child (4.3%) developed an allergic reaction. No other major adverse effects related to the treatment were noted.

CONCLUSION

Topical 1% atropine ointment is a safe and effective treatment for retarding myopic progression in moderate to severe myopia. Further large-scale randomised controlled study with longer follow-up seems warranted.

Corneal Endothelial Cell Density and Morphology in Healthy Chinese Eyes

PURPOSE

To describe corneal endothelial cell density and morphology in healthy Chinese eyes.

METHODS

Specular microscopy was performed in 1329 eyes of 700 healthy volunteers (M:F, 311:389), 10 to 98 years of age. Parameters studied included endothelial cell density (CD), cell area (CA), coefficient of variation (CV) in cell area, and percent hexagonality.

RESULTS

Mean endothelial CD in the study population was 2932 +/- 363 cells/mm2. There was a statistically significant decrease in endothelial CD (P < 0.001; correlation, -0.435) and percentage of hexagonal cells (P < 0.001; correlation, -0.241) with age. Mean CA, CV, and percentage of hexagonal cells were 347 +/- 46 microm2, 33 +/- 5, and 59% +/- 9%, respectively. There was also a statistically significant increase in CA (P < 0.001; correlation, 0.410) and CV (P < 0.001; correlation, 0.251) with increasing age.

CONCLUSIONS

Normative data for the endothelium in the Chinese population are reported. Our data add to the knowledge about endothelial cell parameters in Chinese eyes and serve as a baseline for comparative studies with other populations.

Desmoplastic round cell tumour of the abdomen

Desmoplastic round cell tumour is a very rare tumour of childhood and young adults, and is not usually suspected as an explanation of intraabdominal or pelvic tumour. We report two cases of desmoplastic round cell tumour of the abdomen in the paediatric age group, occurring in two boys, an 11-year-old and a 13-year-old. We aim to demonstrate the imaging findings and to emphasise the importance of including this tumour in the differential diagnosis of childhood intraabdominal and pelvic tumours.