Granulomatous meningoencephalitis and blindness associated with Mycobacterium tuberculosis complex infection in a senile female chimpanzee (Pan troglodytes)

A 40-year old female chimpanzee (Pan troglodytes) developed hyporexia, weight loss, followed by progressive and complete blindness. Tomography demonstrated an intracranial mass in the rostroventral brain involving the optic chiasm, with a presumptive diagnosis of neoplasm. However, histopathology revealed a granulomatous meningoencephalitis, and tissue samples tested positive for Mycobacterium tuberculosis.

Therapeutic contact lens-related infection by a novel pathogenic fungus Coniochaeta hoffmannii-a case report

This study aims to report a rare instance of corneal decompensation brought on by Coniochaeta hoffmannii fungus invasion of a bandage contact lens (BCL). A 71-year-old man with pseudophakic bullous keratopathy (PBK) had BCL treatment for four months to symptomatically reduce pain and itching in his right eye. However, the patient unexpectedly lost his vision. The slit-lamp examination revealed an edematous cornea; the extensive direct inspection raised suspicion of BCL. For morphological characterization, the BCL extracted was inoculated onto 5% sheep blood agar and PDA. By Sanger sequencing method the isolate's genomic DNA was molecularly identified as C. hoffmannii.

Monocaprin eye drop formulation to combat antibiotic resistant gonococcal blindness

Neisseria gonorrhoeae bacteria are acknowledged as an urgent threat to human health because this species has developed resistances to all of the antibiotics used clinically to treat its infections. N. gonorrhoeae causes the sexually transmitted disease gonorrhoea, but also causes blindness when the bacteria infect the eyes. Infants are particularly susceptible, acquiring the infection from their mothers at birth. We have shown that the monoglyceride monocaprin rapidly kills N. gonorrhoeae and other bacterial species and is non-irritating in ocular assays. Here we show that the physical and chemical properties of monocaprin make it ideal for use in a thickened eye drop formulation to combat eye infections. Monocaprin-containing formulations were assessed using analytical techniques and for antimicrobial activity in vitro and in ex vivo infections. Monocaprin-containing formulations retained activity after three years and are non-irritating, unlike preparations of povidone iodine in our assays. A recommended formulation for further development and investigation is 0.25% monocaprin in 1% HPMC with 1% polysorbate 20.

Trachoma in 3 Amerindian Communities, Venezuelan Amazon, 2018

Trachoma is among the most common infectious causes of blindness. During January-May 2018, a total of 4 trachoma cases were diagnosed among Amerindians of the Yanomami ethnic group in 3 communities of southern Venezuela. This country has social and environmental conditions conducive to the endemicity of this neglected tropical disease.

Ophtalmoplegia complicating sino-orbital mucormycosis

PURPOSE

To report a case of complete ophthalmoplegia and blindness in sino-orbital mucormycosis.

CASE REPORT

A 68-year-old woman with history of diabetes and breast cancer presented with sudden onset of fever, orbital pain and blindness in the right eye. The patient was found to have no light perception, complete ophthalmoplegia, chemosis, corneal ulcer and optic nerve atrophy. In rhinologic examination, necrosis was noticed. Brain and orbit magnetic resonance imaging showed diffuse sinusitis with orbital involvement. The result of the clinical examination was reported as sino-orbitalmucormycosis. The diagnosis was confirmed by pathological specimens. The patient underwent extensive surgical debridement and systemic antifungal treatment. Despite treatment, visual acuity did not recover.

CONCLUSION

The sino-orbital form of mucormycosis is a rare and insidious fungal infection. Ocular findings may range from orbital pain to ophtalmoplegia and blindness such as in our case. Black scar tissues seen on the nasal mucosa are pathognomonic. Delay in treatment due to late presentation and complications were major determinants in ocular prognosis and survival outcome.

Blinding Trachoma: Systematic Review of Rates and Risk Factors for Progressive Disease

BACKGROUND

Sight loss from trachoma is the end result of a scarring disease process starting in early childhood and characterised by repeated episodes of conjunctival inflammation (active trachoma). Subsequently, the conjunctiva becomes scarred, causing the eyelashes to turn inwards and scratch the cornea (trichiasis), damaging the corneal surface and leading to corneal opacification and visual impairment. It is thought that this process is initiated and driven by repeated infection with Chlamydia trachomatis. We review published longitudinal studies to re-examine the disease process, its progression rates and risk factors.

METHODOLOGY/PRINCIPAL FINDINGS

We searched PubMed for studies presenting incidence and progression data for the different stages of trachoma natural history. We only included studies reporting longitudinal data and identified 11 publications meeting this criterion. The studies were very heterogeneous in design, disease stage, duration, size and location, precluding meta-analysis. Severe conjunctival inflammation was consistently associated with incident and progressive scarring in five studies in which this was examined. One study reported an association between C. trachomatis infection and incident scarring. No studies have yet demonstrated an association between C. trachomatis infection and progressive scarring. Several studies conducted in regions with low prevalence active disease and C. trachomatis infection found evidence of on-going scarring progression.

CONCLUSIONS/SIGNIFICANCE

Overall, there are few longitudinal studies that provide estimates of progression rates and risk factors, reflecting the challenges of conducting such studies. Our understanding of this disease process and the long-term impact of control measures is partial. Intense conjunctival inflammation was consistently associated with scarring, however, direct evidence demonstrating an association between C. trachomatis and progression is limited. This suggests that on-going chlamydial reinfection may not be mandatory for progression of established scarring, indicating that sight threatening trichiasis may continue to evolve in older people in formerly endemic populations, that will require service provision for years after active disease is controlled.

Serology for trachoma surveillance after cessation of mass drug administration

Background

Trachoma, caused by Chlamydia trachomatis (Ct), is the leading infectious cause of blindness worldwide. Yearly azithromycin mass drug administration (MDA) plays a central role in efforts to eliminate blinding trachoma as a public health problem. Programmatic decision-making is currently based on the prevalence of the clinical sign “trachomatous inflammation-follicular” (TF) in children. We sought to test alternative tools for trachoma surveillance based on serology in the 12-year cohort of Kahe Mpya, Rombo District, Tanzania, where ocular chlamydial infection was eliminated with azithromycin MDA by 2005.

Methodology and Principal Findings

The present study was a community-based cross-sectional survey in Kahe Mpya. Of 989 residents, 571 people aged 6 months to 87 years were enrolled: 58% of the total population and 73% of 1–9 year olds, the key WHO indicator age group. Participants were examined for TF, had conjunctival swabs collected for nucleic acid amplification test (NAAT)-based detection of Ct, and blood collected for analysis of antibodies to the Ct antigens pgp3 and CT694 by multiplex bead-based immunoassay. Seroconversion rate was used to estimate changes in the force of infection in a reversible catalytic model. No conjunctival swabs tested positive for Ct infection by NAAT. Among 1–9 year olds, TF prevalence was 6.5%, whereas only 3.5% were seropositive. Force of infection modelling indicated a 10-fold decrease in seroconversion rate at a time corresponding to MDA commencement. Without baseline serological data, the inferences we can make about antibody status before MDA and the longevity of the antibody response are limited, though our use of catalytic modelling overcomes some of these limitations.

Conclusions/Significance

Serologic tests support NAAT findings of very low to zero prevalence of ocular Ct in this community and have potential to provide objective measures of transmission and useful surveillance tools for trachoma elimination programs.

Trachoma is the leading infectious cause of blindness. The infectious agent, Chlamydia trachomatis, can be treated with a single oral dose of azithromycin. Donated drug is a cornerstone of programs dedicated to the elimination of trachoma as a public health problem. Azithromycin is given to the entire district for 3–5 years when 10% or more of 1–9 year-olds in the district have signs of a defined follicular conjunctivitis in one or both eyes. However, follicles can be difficult to reliably diagnose and can be caused by other pathogens, especially in settings with low trachoma prevalence. More sensitive and specific ways to assess communities for trachoma transmission at program endpoints are needed. Herein we examined antibody responses in children living in a community in Tanzania born after stopping drug treatment 10 years previously. Low antibody levels (3.5% in 1–9 year-olds) reflected the lack of ocular chlamydial infection in these children. We also modelled the data to show that changes in age-specific antibody prevalence occurred when the mass drug treatment stopped. These data suggest that the age-specific prevalence of antibody responses may be of use to programs seeking to demonstrate the impact of interventions against trachoma.

A multi-center, cross-sectional study on the burden of infectious keratitis in China

OBJECTIVE

To understand the prevalence and demographic characteristics of infectious keratitis and infectious corneal blindness.

METHODS

A multi-center, population-based cross-sectional study was conducted from January 1 to August 31, 2010. A total of 191,242 individuals of all age groups from 10 geographically representative provinces were sampled using stratified, multi-stage, random and systematic sampling procedures. A majority, 168,673 (88.2%), of those sampled participated in the study. The examination protocol included a structured interview, visual acuity testing, an external eye examination, and an anterior segment examination using a slit lamp. The causes and sequelae of corneal disease were identified using uniform customized protocols. Blindness in one eye caused by infectious keratitis was defined as infectious corneal blindness.

RESULTS

The prevalence of past and active infectious keratitis was 0.192% (95% confidence interval [CI], 0.171-0.213%), and the prevalence of viral, bacterial, and fungal keratitis was 0.11%, 0.075%, and 0.007%, respectively. There were 138 cases of infectious corneal blindness in at least one eye in the study population (prevalence of 0.082% [95%CI, 0.068%-0.095%]). Statistical analysis suggested that ocular trauma, alcoholic consumption, low socioeconomic levels, advanced age, and poor education were risk factors for infectious corneal blindness.

CONCLUSIONS

Infectious keratitis is the leading cause of corneal blindness in China. Eye care strategies should focus on the prevention and rehabilitation of infectious corneal blindness.

Towards a safe and effective chlamydial vaccine: lessons from the eye

As well as being the most common bacterial sexually transmitted infection, Chlamydia trachomatis (Ct) is the leading infectious cause of blindness. The pathogenesis of ocular chlamydial infection (trachoma) is similar to that of genital infection. In the 1960s the efficacy of Ct vaccines against ocular infection was evaluated in major field trials in Saudi Arabia, Taiwan, The Gambia, India and Ethiopia. These trials showed that it was possible to induce short term immunity to ocular infection, and to reduce the incidence of inflammatory trachoma, by parenteral immunisation with killed or live whole organism vaccines. In one study, it was also shown that the incidence of scarring sequelae was reduced in vaccinated children. Detailed studies in non-human primates conducted at this time suggested that vaccination could lead to more severe inflammatory disease on subsequent challenge. Since that time there have been many studies on the immunological correlates of protective immunity and immunopathology in ocular Ct infection in humans and non-human primates, and on host genetic polymorphisms associated with protection from adverse sequelae. These have provided important information to guide the development and evaluation of a human Ct vaccine.

Fungal endophthalmitis associated with compounded products

Fungal endophthalmitis is a rare but serious infection. In March 2012, several cases of probable and laboratory-confirmed fungal endophthalmitis occurring after invasive ocular procedures were reported nationwide. We identified 47 cases in 9 states: 21 patients had been exposed to the intraocular dye Brilliant Blue G (BBG) during retinal surgery, and the other 26 had received an intravitreal injection containing triamcinolone acetonide. Both drugs were produced by Franck's Compounding Lab (Ocala, FL, USA). Fusarium incarnatum-equiseti species complex mold was identified in specimens from BBG-exposed case-patients and an unopened BBG vial. Bipolaris hawaiiensis mold was identified in specimens from triamcinolone-exposed case-patients. Exposure to either product was the only factor associated with case status. Of 40 case-patients for whom data were available, 39 (98%) lost vision. These concurrent outbreaks, associated with 1 compounding pharmacy, resulted in a product recall. Ensuring safety and integrity of compounded medications is critical for preventing further outbreaks associated with compounded products.

Sudden loss of vision in an Acute Medical Unit

We present a case report of young man with Type 1 diabetes who developed acute visual loss after initially presenting with diabetic ketoacidosis. The diagnosis of invasive paranasal sinusoidal aspergillosis was made following CT and biopsy. Although uncommon, visual loss is a recognised complication of disseminated aspergillosis and is more likely in immune-compromised patients and those with diabetes. Early investigation with appropriate sinus imaging and involvement of the Ear Nose and Throat team in recommended when patients with diabetes develop acute visual loss in the context of a non-specific infective illness.

A liver abscess deprived a healthy adult of eyesight: endogenous endophthalmitis associated with a pyogenic liver abscess caused by serotype K1 Klebsiella pneumonia

Klebsiella pneumonia usually causes urinary tract infections, pneumonia, and other infectious diseases in hospitalized and immunocompromised patients. Among the types of Klebsiella pneumonia, serotype K1 is known to be a highly virulent pathogen. We herein report the case of a healthy 63-year-old man with a pyogenic liver abscess and bilateral endogenous endophthalmitis caused by serotype K1 Klebsiella pneumonia. Although the patient received percutaneous abscess drainage and antibiotic therapy, he lost his eyesight. To improve the poor prognoses of ocular complications, providing both an earlier diagnosis and treatment is critical.

Avastin doesn't blind people, people blind people

PURPOSE

To review the appropriate preparation of bevacizumab for intravitreal injection by compounding pharmacies with specific recommendations designed to prevent microbial contamination.

DESIGN

Perspective.

METHODS

A review and discussion of compounding issues with supporting literature, clinical experience, illustrations, and expert opinion.

RESULTS

Closer examination of the events surrounding the recent clusters of infectious endophthalmitis cases occurring after the intravitreal injection of bevacizumab suggest that the vision loss is not the result of the drug or the injection technique, but rather of the compounding procedures used to prepare the syringes containing the bevacizumab. Noncompliance with recognized standards and poor aseptic technique are the most likely causes of these outbreaks. The key to preventing these catastrophic occurrences depends on the implementation of and strict adherence to United States Pharmacopoeia Chapter 797 requirements.

CONCLUSIONS

Recommendations arising from a root cause analysis of infectious endophthalmitis outbreaks should focus on the procedures used by pharmacies to compound bevacizumab. Microbial contamination of bevacizumab-containing syringes prepared from the same vial of drug can be avoided by using a single vial of bevacizumab for each eye or by following strict adherence to United States Pharmacopoeia Chapter 797 requirements when compounding a single vial of bevacizumab into multiple syringes.

[Clinical evidence of trachoma in Colombian Amerindians of the Vaupés Province]

INTRODUCTION

Trachoma is the leading cause of infectious blindness in the world. In 2008 there were 1,300,000 persons with blindness caused by trachoma and 8 million with trichiasis, which might eventually lead to blindness. In Latin America it has been documented in Brazil, Guatemala and México.

OBJECTIVE

To inform the presence of trachoma for the first time in Colombia, amongst Amerindians of the Department of Vaupés.

MATERIALS AND METHODS

In 2003 and 2006 the Amerindian Makú communities of San Joaquín and Santa Catalina, located 5 km from the border with Brazil, were visited. From 2007 to 2009, San Gerardo, San Gabriel and Nuevo Pueblo, at a 35 km distance from San Joaquín were visited.

RESULTS

In 2006 114 people were examined in Santa Catalina and San Joaquin; 21 patients were clinically diagnosed with trachoma (18.4%), 15 (13.2%) of them children under 15 years old. All trachoma phases were observed. Three women had corneal opacity with poor vision. In the remaining three communities, three women with advanced trachoma with corneal opacity and blindness were detected. The poor quality of living conditions without fresh water and adequate sanitary disposal systems, and the abundance of flies identified as Hippelates sp., are risk factors for the transmission of the disease.

DISCUSSION

Trachoma exists in Colombia, and it is frequent among the studied communities. Its focalized distribution makes it amenable to elimination. It is advisable to search for trachoma in other indigenous communities in Vaupés with similar living conditions.

Antibiotic therapy for trachoma

Trachoma, a major cause of blindness in some of the world's poorest countries, results from repeated or chronic eye infections with Chlamydia trachomatis.

Chorioretinitis of the newborn with herpes simplex virus type 1. Report of a case

A disseminated herpes simplex virus (HSV) infection involving the central nervous system and accompanied by chrioretinitis in a a 3-week-old girl is described. The aetiologic diagnosis was established on the basis of vrius isolated from skin vesicles, and a significant rise in complement fixing antibodies to HSV type 1. The mode of transmission of the virus to the infant apparently was direct contact with an oral lesion in the mother, that was present at the time of delivery. The patient survived but became blind and microcephalic, with severe neurological sequelae. The virus isolated was identified as HSV type 1, which is an infrequent finding in herpetic chorioretinitis of the newborn.

What will happen if we do nothing to control trachoma: health expectancies for blinding trachoma in southern Sudan

Background

Uncontrolled trachoma is a leading cause of blindness. Current global trachoma burden summary measures are presented as disability adjusted life years but have limitations due to inconsistent methods and inadequate population-based data on trachomatous low vision and blindness. We aimed to describe more completely the burden of blinding trachoma in Southern Sudan using health expectancies.

Methodology/Principal Findings

Age and gender specific trachomatous trichiasis (TT) prevalence was estimated from 11 districts in Southern Sudan. The distribution of visual acuity (VA) in persons with TT was recorded in one district. Sudan life tables, TT prevalence, and VA were used to calculate Trichiasis Free Life Expectancy (TTFLE) and Trichiasis Life Expectancy (TTLE) using the Sullivan method. TTLE was broken down by VA to derive TTLE with normal vision, TTLE with low vision, and TTLE with blindness. Total life expectancy at birth in 2001 was 54.2 years for males and 58.1 for females. From our Sullivan models, trichiasis life expectancy at the age of 5 years was estimated to be 7.0 (95% confidence interval [CI] = 6.2–7.8) years (12% [95% CI = 11–14] of remaining life) for males and 10.9 (95% CI = 9.9–11.9 ) years (18% [95% CI = 16–20] of remaining life) for females. Trichiasis life expectancy with low vision or blindness was 5.1 (95% CI = 3.9–6.4) years (9% [95% CI = 7–11] of remaining life) and 7.6 (95% CI = 6.0–9.1) years (12% [95% CI = 10–15] of remaining life) for males and females, respectively. Women were predicted to live longer and spend a greater proportion of their lives with disabling trichiasis, low vision, and blindness compared to men.

Conclusions

The study shows the future burden associated with doing nothing to control trachoma in Southern Sudan, that is, a substantial proportion of remaining life expectancy spent with trichiasis and low vision or blindness for both men and women, with a disproportionate burden falling on women.

Summary measures of population health attempt to express disease burden in terms of a common “currency” and are useful in establishing public health priorities. Disability adjusted life years (DALYs), a health gap measure, have previously been used to estimate burden due to trachoma; however, their methods and results have limitations. This study demonstrates the application of the health expectancies to estimate burden due to trachoma. The study illustrates the future burden associated with doing nothing to control trachoma in Southern Sudan: a substantial proportion of remaining life expectancy spent with trichiasis and low vision or blindness for both men and women, with a disproportionate burden falling on women. The results presented are intuitively meaningful for policy makers and a non-technical audience and compare favourably with other indicators such as mortality and incidence rates or DALYs, which are not generally easily understood. Unless action is taken by further delivery of trachoma control interventions, then populations in Southern Sudan can expect to spend a substantial proportion of their life with low vision or blindness due to trachoma.

Cicatrising conjunctivitis with anti-basement membrane autoantibodies in ectodermal dysplasia

AIMS

To report circulating and mucosa-deposited anti-basement membrane zone autoantibodies in a series of six ectodermal dysplasia patients with severe bilateral cicatrising conjunctivitis and blindness due to both corneal disease and intractable surface inflammation. We also report clinical improvement with steroid-sparing systemic immunosuppression combined with clearance of bacterial colonisation.

METHODS

Conjunctival and buccal immunohistopathology, and serological analysis using a panel of epithelial basement membrane zone proteins including the bullous pemphigoid antigen 180 (BP180) were carried out as part of an ocular pemphigoid work-up in each patient. The degree of photophobia, conjunctival inflammation and visual acuity were monitored to evaluate the response to immunosuppression. The mean duration of follow-up was 31 (SD 6) months.

RESULTS

Four of the six patients showed positive immunopathology: direct immunofluorescence testing of the conjunctiva in one patient demonstrated linear IgA deposition along the basement membrane zone, and IgG and IgM in the buccal mucosa of another patient. Circulating autoantibodies to BP180 were detected in two other patients. Treatment with systemic immunosuppression, combined with clearance of bacterial colonisation, reduced the severity of photophobia and degree of conjunctival inflammation in 5/6 (83%) patients.

CONCLUSIONS

Systemic immunosuppression, used as steroid-sparing therapy, combined with clearance of bacterial colonisation can control inflammation and disabling photophobia, and allow improvement in vision, in a subgroup of ectodermal dysplasia patients who have severe cicatrising conjunctivitis which shares clinical and immunopathological features with ocular mucous membrane pemphigoid.

Characteristics of and risk factors for contact lens-related microbial keratitis in a tertiary referral hospital

AIM

A retrospective case-control study was conducted at a tertiary referral hospital to determine the characteristics of and risk factors for contact lens (CL) related presumed microbial keratitis.

METHODS

Two hundred and ninety-one cases of presumed microbial keratitis were retrospectively identified over a 2-year period. Records were reviewed for a history of CL wear and, where identified, CL, demographic, and clinical data were collected. Lens wearing controls (n=186) were identified by a community telephone survey. Multiple logistic regression estimated risk factors for infection and vision loss.

RESULTS

Ninety-nine (34%) new cases of presumed microbial keratitis were associated with CL wear. Overnight soft CL use was associated with an increased risk of infection compared to daily disposable CL wear (odds ratio (OR): 8.03, 95% confidence interval (CI): 1.82-35.46). Compared with older CL wearers, 15-24 year olds had a 3.5 times greater risk of infection (OR, 95% CI: 1.7-7.4). Of the 84 cases with available data, 24 (29%) lost two or more lines of best-corrected visual acuity. Delaying treatment by 49-72 h had a 4.5 times (OR, 95% CI: 1.4-14.9) greater risk of visual loss compared to seeking treatment early. Of the 99 cases of infection, 88 were scraped and 78% (69/88) of these returned a positive culture. Gram-positive bacteria were the predominant causative organisms.

CONCLUSION

Overnight use of CL and youth carry a greater risk of infection. Practitioners should reinforce the importance of proper CL care at all times, and early presentation following the onset of symptoms.

[The value of aetiology in the diagnosis of infectious keratitis]

Microbial keratitis is one of the major causes of blindness in China. The rapid and unequivocal identification of the causative organism is the key point for the rational antimicrobial therapy and restoration of the vision. It is difficult for the physician to choice the first step in the management of microbial keratitis: starting antimicrobial therapy after the identification of the causative organism, or starting therapy even there is no organism identification. The authors thought that it is urgent to start the antimicrobial therapy for microbial keratitis, however, the causative organism identification should be performed in time. This steps are necessary for the high diagnostic rate and cure rate of microbial keratitis, also for improving physician's consciousness of causative organism diagnosis.

Acute optic nerve infarction demonstrated by diffusion-weighted imaging in a case of rhinocerebral mucormycosis

SUMMARY

A 60-year-old woman developed right-eye vision loss secondary to rhinocerebral mucormycosis. Routine MR imaging sequences including enhanced MR imaging showed normal optic nerves, but a diffusion-weighted sequence and apparent diffusion coefficient maps revealed markedly restricted diffusion in the right optic nerve. This MR imaging abnormality of optic nerve infarction due to mucormycosis has not been reported previously.

Fulminant endogenous Klebsiella pneumoniae endophthalmitis: imaging findings

Endogenous endophthalmitis is a rare but serious complication of Klebsiella pneumoniae infection that has been predominantly reported to occur in diabetic patients of East Asian origin with K. pneumoniae liver abscesses. The clinical symptoms and signs of endogenous endophthalmitis are nonspecific and may mimic other causes of an acute non-traumatic eye. Permanent visual loss and blindness are common sequelae because of delayed diagnosis and treatment. Computed tomography and magnetic resonance imaging can help to differentiate endophthalmitis from other causes of acute non-traumatic eye when the clinical findings are equivocal. Fluid attenuated inversion recovery and diffusion-weighted imaging with apparent diffusion coefficient map are superior to T2-weighted and gadolinium-enhanced T1-weighted sequences in demonstrating intra-ocular abscesses.

Uptake of trichiasis surgical services in Tanzania through two village-based approaches

AIM

To determine the effectiveness of village-based strategies (using school teachers and village leaders) to increase the use of surgical services.

METHODS

A cohort study was conducted in Tanzania using two village strategies (village leader and school teachers); trichiasis surgical uptake and the factors associated with uptake were measured after 1 year.

RESULTS

The trichiasis surgical coverage at baseline was 16.9%; 200 patients who needed surgery were identified. One year later, we were able to re-examine and interview 163 of these patients. The surgical uptake among these patients was 44.8% (95% CI 37.2% to 52.4%). Patients in the school-teacher programme had a 36.5% uptake compared with 52.1% for those in the village-leader programme. No difference was observed in uptake by age or sex. Uptake was highest among those coming from multiple-generation households and those with more household wealth. Of the 90 people who still had not had surgery, 20 (22.2%) reported seeking surgery, but failing to receive it because of barriers at the provider side.

CONCLUSIONS

Improved surgical uptake for trachomatous trichiasis was achieved by using village-based promotion efforts and surgical services at existing health clinics. Even with free surgery at health clinics, indirect costs and social support barriers limit utilisation by the most vulnerable, the poorest and those living in single-generation households. Problems at the provider level also create barriers for patients who need surgery.

Leprosy blindness in Nepal

Leprosy is a systemic disease with highest incidence of ocular complications and one of the important causes of blindness in the world. A comparative cross-sectional study was carried out to see the ocular involvement in leprosy leading to blindness in two groups of patients, one with the active disease and second already cured and thus released from treatment (RFT). Active cases attending Anandaban leprosy clinic, Patan hospital and RFT cases from Khokana leprosarium were included in the study consecutively. Total of 70 active cases and 101 RFT cases were evaluated during the study period. Active group of patients showed more of multibacillary type of disease than in RFT group. The prevalence of ocular manifestations was seen much higher among RFT cases accounting for 66.3% in contrast to active group where only 14.3% had ocular problems. Blindness was frequently seen in multibacillary (MB) leprosy patients in compare to paucibacillary (PB) disease in both the groups. However blindness frequency was seen more often among RFT cases accounting for 24% in compare to only 2.9% among active group. Causes of blindness were mainly corneal and cataract related disorders. Risk of blindness also increased with the increase in duration of illness. RFT group of leprosy patients are at higher risk of developing blindness than the active group thus eye care services should be more focused for this group. Having multibacillary type of disease could also be a risk for development of blindness.

Prevention of blindness in leprosy and the role of the Vision 2020 Programme

Leprosy control programmes are highly successful. As a result, leprosy control will be more and more integrated into the general health services. The existing vertical, specialized control programmes will be dismantled. Eye complications in leprosy have decreased. This is a result of earlier diagnosis and highly effective multidrug treatment (MDT) of leprosy, combined with timely treatment of secondary nerve damage by steroids. Most ocular morbidity is now found among elderly and disabled leprosy patients who were diagnosed before effective MDT treatment became available. Many of these patients live in leprosy settlements. Age-related cataract has become the leading cause of blindness in leprosy. The second cause of blindness is corneal opacification, mainly as a result of neglected exposure keratitis and corneal anaesthesia. The miotic pupils in late multibacillary leprosy, in combination with small central lens opacities, may also lead to blindness. The Vision 2020 Initiative prioritises cataract surgery. Leprosy patients should be actively included. Disabled leprosy patients can also benefit from screening programmes for refractive errors and the provision of spectacles and low vision aids. Determining the most feasible surgical methods for lagophthalmos surgery remains a challenge. For all health and eye care staff, training in leprosy and its eye complications is needed, as well as a change in attitude towards leprosy patients. Staff must be prepared to welcome them in the general health services.

Mapping the global distribution of trachoma

OBJECTIVE

We aimed to summarize and map the existing global population-based data on active trachoma and trichiasis. Detailed distribution maps of various infectious diseases have proved a valuable tool in their control. Such maps play an important role in assessing the magnitude of the problem, defining priority areas for control, monitoring changes, and advocacy. Until now, information on trachoma prevalence at within country levels has not been systematically collated, analysed and reported.

METHODS

We gathered the last 18 years' worth of reported data on active trachoma in children aged less than 10 years, and the last 25 years of reported trichiasis in adults aged 15 years and over from 139 population-based surveys in 33 countries. We collated these data into one database using the "district" (second administrative level) as the standard unit of reporting. We used Geographical Information Systems as a database and cartographic tool to generate a global map of the prevalence of trachoma and trichiasis.

FINDINGS

We obtained data on active trachoma and trichiasis from 18 countries in the WHO African Region, 6 in the Eastern Mediterranean Region, 3 in the South-East Asia Region, 3 in the Western Pacific Region and 2 in the Region of the Americas. In 23 countries suspected of having endemic trachoma no reliable district-level population-based data were available. In China and India, data were limited to a few districts. The data highlighted important regional differences and marked national variations in prevalence of active trachoma and trichiasis.

CONCLUSION

This is the first attempt to summarize and map the existing population-based data on active trachoma and trichiasis. The lack of data in many countries remains an important obstacle to trachoma control efforts.

The epidemiology of trachoma in Eastern Equatoria and Upper Nile States, southern Sudan

OBJECTIVE

Limited surveys and anecdotal data indicate that trachoma is endemic in the states of Eastern Equatoria and Upper Nile in southern Sudan. However, its magnitude and geographical distribution are largely unknown. We conducted surveys to ascertain the prevalence and geographical distribution of trachoma, and to identify targets for control interventions.

METHODS

Population-based cross-sectional surveys were conducted in nine sites in southern Sudan between September 2001 and June 2004. Two-stage random cluster sampling with probability proportional to size was used to select the sample. Trachoma grading was done using the WHO simplified grading system.

FINDINGS

A total of 17 016 persons were examined, a response rate of 86.1% of the enumerated population. Prevalence of signs of active trachoma in children aged 1-9 years was: TF=53.7% (95% confidence interval (CI)=52.1-55.3); TI=42.7% (95% CI=41.2-44.2); TF and/or TI=64.1% (95% CI=62.5-65.5). Prevalence of trichiasis (TT) in children aged less than 15 years was 1.2% (95% CI=0.9-1.4), while TT prevalence in persons aged 15 years and above was 9.2% (95% CI=8.6-9.9). Women were more likely to have trichiasis compared to men (odds ratio (OR)=1.57; 95% CI=1.34-1.84). Tentative extrapolation to the states of Eastern Equatoria and Upper Nile estimates that there is a backlog of 178,250 (lower and upper bounds=156,027-205,995) persons requiring surgery and the entire population, estimated to be over 3.9 million, is in need of the SAFE strategy to control blinding trachoma.

CONCLUSION

Trachoma is a public health problem in all nine of the study sites surveyed. The unusually high prevalence of active trachoma and TT in children points to the severity of the problem. There is urgent need to implement trachoma control interventions in trachoma endemic regions of southern Sudan.

Baisse d’acuité visuelle brutale chez l’enfant

PURPOSE

To evaluate the severity and progression of neuroretinitis in children caused by Bartonella.

PATIENTS AND METHODS

Retrospective study of three consecutive cases. Patients underwent ophthalmological, medical, and radiological evaluations. Bartonella serology was positive. Intravenous treatment was started immediately with antibiotics and steroids. Patients were re-evaluated after visual acuity recovery.

RESULTS

Progression was quickly positive with fosfomycin and fluoroquinolones in all cases.

CONCLUSION

Bartonella induces neuroretinitis even without systemic signs of cat-scratch disease, with sometimes sudden bilateral blindness. Long-term progression is good but urgent medical treatment is necessary.

Characteristics of trichiasis patients presenting for surgery in rural Ethiopia

AIMS

To determine the characteristics of trichiasis patients presenting for surgery in Wolayta Zone of Ethiopia.

METHODS

Patients referred for trichiasis surgery by community health agents were evaluated by trained integrated eye care workers (IECWs) for the presence of trichiasis, locations of inturned lashes, severity of trichiasis, corneal opacity, and visual acuity.

RESULTS

1635 individuals with trichiasis presented for surgery. 82% had bilateral trichiasis; 91% of patients reported trichiasis duration of >2 years. Epilation was practised by over three fourths of the study subjects. A high proportion of patients tested positive for ocular Chlamydia trachomatis at presentation. 17% had monocular blindness and 8% were binocularly blind. Corneal opacity was highly associated with the trichiasis duration and severity and visual loss was associated with corneal opacity.

CONCLUSION

Severe trichiasis reflects the magnitude of the trachoma problem in Ethiopia. Visual impairment due to trichiasis is highly associated with disease severity and duration. Early intervention to correct trichiasis before it become severe is recommended to prevent visual impairment.

Can blinding trachoma be eliminated by 20/20?

Trachoma is the leading cause of preventable blindness in the world today. Long ago eliminated in North America and Europe, the disease is almost unknown, and indeed forgotten, in the West. Nevertheless, it continues to wreak havoc in the poorest parts of Africa, Asia, and other areas throughout the world. The World Health Organization (WHO) estimates that there are currently 7.6 million people who are visually impaired due to trachoma, and 84 million people with active infections. In 1998, WHO passed a resolution calling for member states to take action to eliminate blinding trachoma by the year 2020. The scale of what must be accomplished in order to reach this goal is daunting. However, the work of the International Trachoma Initiative together with national governments as well as other organizations in applying the WHO-recommended SAFE strategy for trachoma control has produced critical successes in challenging settings. This paper gives a brief history and description of trachoma, explains treatment options and the SAFE strategy, and discusses successes from two trachoma control programmes as examples of how to move forward in eliminating this devastating disease.

Bilateral blindness from orbital cellulitis caused by community-acquired methicillin-resistant Staphylococcus aureus

PURPOSE

To describe bilateral blindness resulting from infection with community-acquired methicillin-resistant Staphylococcus aureus (MRSA).

DESIGN

Observational case report.

METHODS

A 44-year-old man developed proptosis, ptosis, ophthalmoplegia, and no light perception vision after attempting to lance a nasal pustule. A nasal culture grew MRSA. Imaging showed bilateral orbital cellulitis, pansinusitis, and cavernous sinus thrombosis. The right fundus showed severe ischemia, but the left fundus was essentially normal.

RESULTS

Despite initiation of appropriate antibiotics early in the course of infection, the patient lost sight in both eyes. Surgical drainage of the paranasal sinuses and use of intravenous corticosteroids and heparin led to the resolution of orbital cellulitis.

CONCLUSIONS

MRSA orbital cellulitis can progress to irreversible blindness despite antibiotic treatment. A new, community-acquired clone of this organism has exhibited increased potential for tissue invasion.

Prevalence of trachomatous trichiasis in the community of Alaba District, Southern Ethiopia

BACKGROUND

Until the burden of active trachoma is reduced for a sustained period, trachomatous trichiasis (TT) will remain one of the major causes of blindness in Ethiopia. The magnitude of trichiasis as well as knowledge, attitude and practice of people with this condition in Alaba District is not known.

OBJECTIVES

To assess the prevalence of trachomatous trichiasis in the community and evaluate the knowledge, attitude and practice (KAP) of these cases.

DESIGN

A community based cross-sectional study.

SETTING

Alaba District, 365 Km from Addis Ababa, Ethiopia.

RESULTS

Out of 3850 people who were screened, 104 (2.7%, 95% confidence interval (CI): 2.2-3.2) cases were found to have trichiasis of which females and males accounted for 79.8 % (83/ 104) and 20.2%, (21/104) respectively. While all cases didn't know the cause and risk factors for trichiasis, nearly all of them, 102 (98.1%), knew that surgical treatment could prevent blindness from trichiasis. Previously operated patients were reported to be the most important source of information regarding its management. Eighty two (78.8%) of them epilate the misdirected cilia. The cost of surgery and distance from eye care service were found to be the two main barriers preventing the cases from having surgery.

CONCLUSION

The prevalence of trichiasis greater than 1%, according to WHO, indicated that the community of Alaba District is facing a blinding trachoma. An increased public awareness regarding this common blinding disorder is required through health education. In addition, affordable and accessible surgical facility for trichiasis is needed in the area in order to prevent blindness.

Can chlamydia be stopped?

Chlamydia is a rampant sexually transmitted disease, the world's leading cause of preventable blindness and a possible contributor to heart disease. Recent discoveries are suggesting new ways to curtail its spread

Unusual presentation of brucellosis in a child: acute blindness

In brucellosis, visual impairment due to optic nerve involvement is rare, and acute onset visual loss is an unusual presenting feature. We report a 15-y-old girl who had pancytopenia and who was admitted to our hospital with acute onset of bilateral blindness and fever. There was no light perception, and anterior segment and fundus examination were normal in both eyes. No other abnormal neurological findings were detected. Increased latencies and decreased amplitudes were found in visual evoked potentials. Cranial MR and CT revealed no abnormality. Blood culture was found to be positive for Brucella melitensis. Anti-Brucella treatment and high-dose metil prednisolon were given. Pancytopenia completely resolved 5 d after anti-Brucella treatment, and at the end of the third month her complaints about impaired vision were resolved.

CONCLUSION

Brucellosis may present with uncommon symptoms in children. Physicians, particularly in areas where the disease is endemic, must consider this in differential diagnosis of a child with acute blindness and pancytopenia.

Gonorrhea and the beginnings of clinical research ethics

Research on ocular inflammation associated with gonorrhea began in conjunction with the entry of trachoma into Europe during the Napoleonic wars. The initial questions involved the cause of the contagiousness of gonorrhea and how the contagion spreads from the genitalia to other sites. Because efforts to infect animals with gonorrheal matter were unsuccessful, all experiments were conducted on human subjects. Once these two causes of blindness were tentatively differentiated, attempts to restore vision in an eye that had been blinded by a trachomatous membrane over the cornea by instilling gonorrheal pus began to be practiced. In 1841, Joseph Piringer described his use of this method to determine infectiousness decades before the discovery of pathogenic bacteria, as well as ethical concerns about the associated endangerment of patients. Beginning in the 1880s, research focused on the identification of the gonococcus and assessment of its pathogenicity. The ethical dilemma of inducing a disease with an unpredictable outcome persisted until the 1940s, when gonorrhea could be reliably cured by penicillin.

Acute disseminated encephalomyelitis presenting with bilateral transient amaurosis

A 4-year-old male presented with acute disseminated encephalomyelitis with seizures and transient amaurosis after initial symptoms of a flulike febrile infection 1 week earlier. Immunoglobulin M type antibody titers against Mycoplasma pneumoniae were significantly increased in serum and cerebrospinal fluid. The patient improved appreciably on immunosuppressive therapy with immunoglobulin. This patient exemplifies a rare case of acute disseminated encephalomyelitis presenting with bilateral transient amaurosis as a complication of M. pneumoniae infection. Aydin A, Atasever S, Cakmakci H. Acute disseminated encephalomyelitis presenting with bilateral transient amaurosis.