Impact of thermo-mechanical skin treatment on refraction and keratometry in patients with dry eye disease and the implications for cataract surgery

PURPOSE

To determine the changes in keratometry measurements and refraction in patients having the thermo-mechanical periorbital skin treatment, Tixel®, to treat dry eye disease (DED).

METHODS

A multi-centre, prospective, non-masked study was conducted. DED patients were recruited in 3 international centres and were evaluated in 5 visits separated by an interval of 2 weeks except for the last visit which took place after 18 weeks from visit 1. The same clinical examination was performed at all visits: OSDI questionnaire, tear stability, keratometry, best corrected visual acuity and refraction. Tixel® treatment was applied at the first 3 visits.

RESULTS

89 participants (24 males/65 females; mean age: 55.0 ± 14.2 years) were included: 20 presented moderate DED symptoms and 69 severe DED symptoms. Significant differences were found for the spherocylindrical refraction (vector analysis) between visit 1 and visits 2 and 3. Following cumulative analysis, 11.86 % and 16.94 % of participants had more than 0.5 dioptre (D) change in mean keratometry and keratometric astigmatism, respectively, at 3 months post-treatment. A total of 5.40 % had a sphere and cylinder change greater than 0.50D and 16.21 % had the axis changed more than 10 degrees (vector analysis). These changes were particularly significant in patients with severe DED symptoms.

CONCLUSIONS

Keratometry readings and refraction can change following thermo-mechanical skin treatment for DED, especially in those patients with severe DED symptoms. This should be considered as potential errors in intraocular lens calculations may be induced.

Pregnancy-induced keractesia - A case series with a review of the literature

We report a case series of patients who developed post-laserassisted in situ keratomileusis (LASIK) ectasia or had a progression of keractesia during pregnancy. We reviewed the medical records of 12 patients (20 eyes) who had reported deterioration of vision during their pregnancy and were diagnosed with keractesia. All 12 patients had experienced symptoms of deterioration of vision between 2 months to 1 year of onset of their pregnancies. A total of 17 eyes of 10 patients had developed post-refractive surgery keractesia. Sixteen of these had undergone LASIK and one had undergone femtosecond lenticule extraction (FLEX). Three eyes of two patients had an exacerbation of keratoconus during pregnancy while one patient had associated hypothyroidism. The results indicate that the hormonal changes that take place in pregnant women can affect the biomechanical stability of the cornea and may trigger the onset of keractesia.

149 Emergency Clot Retrieval and Stenting for Posterior Circulation Stroke

The current literature regarding the morphology and presentations of strokes due to basilar artery stenosis/occlusion is limited. This pathology is a rare cause of stroke and its management is not clearly decided in guidelines or published literature. Moreover, posterior circulation strokes are reported to be more devastating than anterior circulation. We present a case of a 68-year-old male who presented in an acute setting with reduced consciousness, myoclonic jerks, weakness and nausea due to a stroke from an occluded mid-segment basilar artery. MRI showed evidence of left cerebellar and right occipital infarcts. Emergent cerebral angiography was performed, and he was immediately treated by thrombectomy and stenting (Stryker Wingspan stent). The patient made a full recovery within one week and remained well at follow-up 3 months post-procedure. Emergency recanalization of basilar artery strokes, by clot retrieval and stenting, should be considered as a treatment option.

148 Acute Renal Infarcts from Spontaneous Intra-Renal Dissection

Spontaneous renal artery dissection and acute renal infarcts are rare occurrences and often misdiagnosed in clinical practice. We present four male patients, between 30-50 years of age, who have no underlying cardiac conditions, hypertension, or diabetes mellitus. They presented with abdominal/loin/flank pain due to spontaneous renal artery dissection and were all treated with endovascular stenting. Two patients had renal artery fibromuscular dysplasia, confirmed by CT angiogram, a rare pathology which is reported in literature to mostly affect women. All four patients recovered fully from the operation, with no post-operative complications noted. These patients were post-operatively managed medically with anti-platelet therapy for two years and did not experience any post-procedural complications at their 24-month follow up. Classically visceral artery dissection can be managed by anti-platelet therapy alone, however fibromuscular dysplasia can cause spontaneous dissection with renal infarcts and this requires urgent treatment with endovascular stents. Further research is needed on the post-procedural medical management guidelines.

Evaluation of safety and efficacy of different protocols of collagen cross linking for keratoconus

Introduction: Collagen cross-linking is a well-established modality that could stop the keratoconus from progressing. Off late, newer protocols have been suggested for progressive keratoconus, which include the use of hypoosmolar riboflavin for thinner corneas and the use of accelerated CXL protocol to reduce the effective treatment time. Objective: To assess the safety and efficacy of different protocols of conventional CXL, hypoosmolar CXL and accelerated CXL in patients with keratoconus. Materials & methods: It was a prospective, interventional study with minimum of 12 months follow-up. Patients were divided into 3 groups; conventional CXL, CXL using hypotonic riboflavin and accelerated CXL group. Primary outcome measures - For efficacy, Sim Kmax and Sim Kmin (Progression (Kmax > +1 D), stabilization (Kmax +1 D to -1 D) and regression (Kmax > -1 D). For safety - endothelial count evaluation (decrease >10% amounted to compromise the safety of the procedure). Secondary outcome measures - BCVA and adverse events. Results: 32 eyes underwent isotonic CXL treatment. Pre-treatment and post-treatment BCVA were 0.16 +/- 0.15 and 0.10 +/- 0.11 log MAR; specular counts 2782.81 +/- 307.25 (cells/ mm2) and 2708.5 +/- 263.27 (cells/ mm2) (p=0.05); KMax values 55.31 +/- 4.12 D and 53.9 +/- 3.77 D (p=0.0001). 16 eyes underwent hypotonic CXL treatment. Pre-treatment and post-treatment BCVA were 0.15 +/- 0.13 log MAR and 0.14 +/- 0.14; specular count 2701.19 +/- 243.25 (cells/ mm2) and 2713.5 +/- 369 (cells/ mm2) (p= 1) and KMax values 54.74 +/- 7.44 D and 52.74 +/- 6.76 D (p = 0.002). 15 eyes underwent accelerated CXL treatment. Pre-treatment and post-treatment BCVA were 0.16 +/- 0.15 and 0.10 +/- 0.12 log MAR; specular counts 2967.53 +/- 356.48 and 2893.07 +/- 336.55 (cells/ mm2) (p = 0.78) and KMax values 55.19 +/- 5.46 D and 54.24 +/- 5.33 D (p = 0.337). Conclusion: All three protocols appeared safe and efficacious as therapeutic regimen for progressive keratoconus.

Innovative bulls eye drop applicator for self-instillation of eye drops

PURPOSE

To report the role of Bulls eye drop applicator device in self-instillation of eye drops and in prevention of wastage of medicine.

METHODS

A small pocket sized device "Bulls eye drop applicator" was developed, which is a simple, handy, mirror-based attachment which can be attached to any eye drop bottle to help in accurate self-instillation of the drops in the eye. The prototype of this device was tried in ten volunteer subjects (Group 1) and 15 patients (Group 2); they were asked to use lubricating eye drops (5 ml bottle) in one eye without the device (N) and in the other eye with the device (M). The numbers of attempts for the application of eye drops were noted and the residual eye drops in the returned bottles were measured for quantitative assessment.

RESULTS

Ten volunteers and 11/15 patients completed the study. At the completion of the study, there were a total of 232 applications of eye drops in the Group 1 N (without device) and 1 M (with device). To achieve these 232 applications, there were 330 attempts without the device and 266 attempts of instillation were needed with the device (P < 0.0001). In Group 2, there were a total of 544 applications of eye drops; to achieve this, there were 879 attempts in Group 2 N and 685 attempts of instillation in Group 2 M (p < 0.0001). The cumulative quantity of residual drops in the returned bottles collected from Group 2 N was 5.1 ml and it was 19.7 ml in Group 2 M (p = 0.001).

CONCLUSIONS

The number of attempts of instillation reduced significantly with the use of the eye drop applicator device. The use of eye drops applicator device reduced the wastage of drops from 42.2% to 14.6% in Group 1 N Vs Group 1 M and saving of about 35.7 % in Group 2 M compared to Group 2 N.

Contact lens fitting after corneal collagen cross-linking

BACKGROUND:

Contact lenses (CLs) remain the mainstay in improving vision in patients having keratoconus. With corneal collagen cross-linking (CXL) performed worldwide, whether the same CLs can be used or needs replacement needed to be assessed and considered.

AIMS:

The aim of this study was to evaluate the changes in CL fitting following CXL.

SETTINGS AND DESIGN:

This is a retrospective study conducted at a tertiary center.

SUBJECTS AND METHODS:

We analyzed the medical records of patients who underwent CXL and used CL. Data collected included demographics, pre- and post-CXL refraction, corneal topography, anterior-segment examination, and CL [rigid gas permeable(RGP)] fitting details and duration between CXL and RGP fitting.

STATISTICAL ANALYSIS:

Descriptive analysis and paired t-test were used to compare the pre- and post-CXL data on refraction, visual acuity, and CL parameters. The statistical significance was kept at P < 0.05.

RESULTS:

Thirty-four eyes (keratoconus = 32, pellucid marginal degeneration = 1, and post-LASIK ectasia = 1) of 27 patients who used CL before and after undergoing CXL were analyzed. Mean duration between CXL and RGP lens use was 2.53 months. Mean sphere and cylinder post-CXL was −4.11 ± 4.32 D and −3.54 ± 2.51 D, respectively. A mean change of 0.75 ± 3.72 D sphere and 0.71 ± 3.39 D cylinder was noted post-CXL. The post-CXL best spectacle-corrected visual acuity (CVA) was 0.52 ± 0.36 and with RGP lens it was 0.09 ± 0.18. There was no significant difference in pre- and post-CXL RGP lens CVA (0.07 ± 0.09 and 0.09 ± 0.18, respectively; P = 0.556). Pre-CXL, 3-point-touch fitting was in 24 eyes (70.59%) and central fluorescein pooling was in 10 eyes (29.41%). Post-CXL, 30 eyes (88.24%) had 3-point-touch and central fluorescein pooling was found in four eyes (11.76%). One patient had CL intolerance after CXL. Of the 32 keratoconus eyes, 62.5% (n = 20 eyes) were prescribed new lenses; 37.5% (n = 12 eyes) continued using own lenses.

CONCLUSIONS:

There was no significant difference in refraction, topography indices, and RGP lens parameters pre- and post-CXL. However, changes in RGP lens fitting characteristics suggest a possible change in shape or apex location of the cornea after CXL. RGP lenses remain the best option to improve visual acuity after CXL in corneal ectasia.

Micrococcus keratitis following microkeratome-assisted laser in situ keratomileusis

We hereby report a case of infectious keratitis after laser in situ keratomileusis (LASIK) caused by Micrococcus luteus, a commensal, managed successfully in a nonimmunocompromised individual. A 25-year-old healthy male underwent uneventful bilateral simultaneous LASIK for myopia using disposable blades. Postoperatively, topical antibiotic and steroids were advised; he discontinued antibiotic on his own after using for a day. On the 5^th postoperative day, he had pain, redness, decreased vision, and white spot in the left eye (LE) for 1-day duration. Uncorrected visual acuity (UCVA) of LE reduced to 20/80 from postoperative 20/20. Slit-lamp biomicroscopy revealed tiny infiltrate in the interface with reticular haze in the flap and stroma. Gram-positive cocci in pairs and tetrads were found on corneal smears that were collected after lifting the flap from infiltrate, stromal bed, and undersurface of the flap. M. luteus was isolated on culture. The infiltrate resolved with scarring with intensive topical antibiotics. UCVA was 20/25. To the best of our knowledge, this is a first case report of post-LASIK infectious keratitis caused by M. luteus.

A novel technology tool to capture the clinical information of patients across rural vision centers in a three-tier eye care network in India using the eyeSmart EMR App

INTRODUCTION

This article describes the implementation of a novel technology tool to capture demographic distribution and clinical presentation of patients in rural vision centers using the eyeSmart electronic medical record (EMR) app in a three-tier eyecare network in India.

METHODS

A two-year retrospective review of all patients who presented to the rural vision centers of LV Prasad Eye Institute (LVPEI) eyecare network was performed from September 2016 to August 2018 using an in-house developed eyeSmart EMR app.

RESULTS

A total of 501 771 patients were captured on the eyeSmart EMR app across the LVPEI network. The ratio of males (n=273 985, 54.60%) and females (n=227 786, 45.40%) presenting to the rural vision centers was 1.2:1. The most prevalent ocular disorder was refractive errors (n=273 720, 44.32%).

CONCLUSIONS

This study details the demographic distribution and prevalence of ocular disorders in a large cohort of Indian patients and demonstrates the potential for real-time analytics through the use of EMR systems. This provides rigorous evidence for the community and eyecare providers that the use of a web application/tablet app (eyeSmart) aids in providing better eyecare services in rural areas. It helps in creating government policies and improves the treatment strategies for various preventable ocular disorders in India.

Phototherapeutic keratectomy for recurrent granular dystrophy in postpenetrating keratoplasty eyes

Purpose:

The purpose is to assess the clinical and visual outcome after phototherapeutic keratectomy (PTK) procedure in eyes with prior penetrating keratoplasty (PKP) for granular corneal dystrophy (GCD) and the time of performance of repeat PTK for recurrence.

Methods:

PTK was performed for visually significant recurrence: A reduction in best-corrected visual acuity (BCVA) by >2 lines over BCVA before recurrence was considered as visually significant recurrence. Three eyes had amniotic membrane patch performed with PTK. The main outcome measures were a recurrence of GCD, clinical course, and visual outcome. Intervals between repeat PTK procedures were noted.

Results:

Six patients (n = 10 eyes; males: 4, mean age 39 ± 13.97 years) underwent PTK. The mean pachymetry before first PTK was 527.1 ± 34 microns. The mean duration between PKP and first PTK was 85.1 months (range: 37–108 months). Two and three PTK procedures were done for seven and five eyes, respectively. Mean duration between first and second and second and third PTK was 62.12 ± 34.41 and 42.8 ± 13.54 months respectively. The average cut depth was 43.66 ± 19.57, 75 ± 43.30 and 39 ± 19.79 microns after the first, second and third PTK procedures, respectively. All eyes had a corneal haze. Prefirst PTK mean BCVA was 20/200 and improved significantly after the first two PTK procedures to 20/40 and after the third PTK procedure to 20/32 (P < 0.001). Five eyes had hyperopia. One acute graft rejection was managed successfully at 5 months with medical therapy.

Conclusion:

Multiple PTK procedures can be performed safely with improved visual acuity in grafts without compromising graft survival.

Keratoglobus: An experience at a tertiary eye care center in India

Context:

This study was carried out as a part of an internal audit and is the largest series of patients having keratoglobus, published in the literature. Poor visual acuity of the patients indicates the blinding nature of the disease.

Aims:

We report our experience with patients having keratoglobus at a tertiary eye care center in India.

Settings and Design:

Retrospective study.

Materials and Methods:

We analyzed adults and pediatric patients (<16 years) with keratoglobus, seen during 2008–2012. The age, gender, consanguinity, presenting ocular signs, ocular and systemic associations, visual acuity, corneal topography, and surgeries were documented.

Results:

Forty-eight patients (mean age 22 ± 15 years, 31 males) having keratoglobus were analyzed. 21 patients (42 eyes) were <16 years. Twelve eyes (16 events) had positive history of trauma. The presenting clinical signs were corneal scars/scars of tear repair (15 eyes), hydrops, healed and acute (14 eyes) and corneal or globe rupture (9 eyes). Best-corrected visual acuity was >20/40 in 6/42 (14.3%) pediatric eyes and 15/53 (28.30%) adults. Visual acuity ranging from counting of fingers to no light perception was noted in 20/53 (37.74%) adults and 21/42 (50%) pediatric patients; 13/20 (65%) with blue sclera and 8/22 eyes (36.37%) without blue sclera. Vernal keratoconjunctivitis was present in one pediatric patient. Choroidal osteoma, retinitis pigmentosa, and retinal detachment were present in adults. Surgeries performed were corneal tear repair (5 eyes), tissue adhesive application (2 eyes), descematopexy (4 eyes) and penetrating keratoplasty (PK - 8 eyes: Three had post-PK glaucoma, graft failure-one eye, 4 patients wore scleral lens - prosthetic replacement of the ocular surface ecosystem).

Conclusions:

About 50% of pediatric eyes (65% having blue sclera) had no functional vision. Trivial trauma was responsible for corneal rupture indicating need for protective glasses. About 50% patients had post-PK glaucoma though grafts were clear.

Scleral lens for keratoconus: technology update

Scleral lenses are large diameter lenses which rest over the sclera, unlike the conventional contact lenses which rest on the cornea. These lenses are fitted to not touch the cornea and there is a space created between the cornea and the lens. These lenses are inserted in the eyes after filling with sterile isotonic fluid. Generally, scleral contact lenses are used for high irregular astigmatism as seen in various corneal ectatic diseases such as keratoconus, pellucid marginal degeneration, or/and as liquid bandage in ocular surface disorders. In this article, we review the new developments, that have taken place over the years, in the field of scleral contact lenses as regard to new designs, materials, manufacturing technologies, and fitting strategies particularly for keratoconus.

Endothelial Keratoplasty: A Review of Indications at a Tertiary Eye Care Centre in South India

PURPOSE

The objective of this study was to review the indications for endothelial keratoplasty (EK) performed at a tertiary eye care center in South India between January 2007 and December 2011.

DESIGN

This was a hospital-based, cross-sectional study.

METHODS

A retrospective analysis of the indications of EK surgeries between January 2007 and December 2011 was done using the Corneal Tissue Utilization Register available with the Ramayamma International Eye Bank, L. V. Prasad Eye Institute, Hyderabad, India. Additional data such as age, sex, and socioeconomic status of the transplant recipients were obtained from the Medical Records Department, L. V. Prasad Eye Institute.

RESULTS

Data were available for 1048 EK surgeries performed on 978 patients. The number of EK surgeries increased from 40 in 2007 to 232 in 2011. The median age of the patients was 58 years (range, 5 months to 92 years) with a male-female ratio of 1.5:1. The clinical indications for EK were pseudophakic corneal edema (47.9%), failed prior penetrating keratoplasty (20.0%), Fuchs endothelial corneal dystrophy (10.8%), aphakic corneal edema (6.0%), failed prior EK (4.3%), congenital hereditary endothelial dystrophy (1.8%), Descemet membrane detachment/tear (1.6%), iridocorneal endothelial syndrome (1.4%), and corneal edema due to other reasons (6.2%).

CONCLUSIONS

The most common indication for EK was pseudophakic corneal edema, followed by post-penetrating keratoplasty graft failure and Fuchs endothelial corneal dystrophy.

Assessment of rose bengal versus riboflavin photodynamic therapy for inhibition of fungal keratitis isolates

PURPOSE

To compare the in vitro effect of rose bengal and riboflavin as photosensitizing agents for photodynamic therapy (PDT) on fungal isolates that are common causes of fungal keratitis.

DESIGN

Experimental study.

METHODS

Three isolates (Fusarium solani, Aspergillus fumigatus, Candida albicans) recovered from patients with confirmed fungal keratitis were used in the experiments. Isolates were grown on Sabouraud-Dextrose agar, swabbed, and prepared in suspension, and 1 mL aliquots were inoculated onto test plates in triplicate. Test plates were separated into 5 groups: Group 1, no treatment; Group 2, 0.1% rose bengal alone; Group 3, 518 nm irradiation alone; Group 4, riboflavin PDT (riboflavin + 375 nm irradiation); and Group 5, rose bengal PDT (rose bengal + 518 nm irradiation). Irradiation was performed over a circular area using either a green light-emitting diode (LED) array (peak wavelength: 518 nm) or an ultraviolet-A LED array (peak wavelength: 375 nm). Test plates were irradiated with an energy density of 5.4 J/cm(2). Later, plates were placed in a 30 C incubator and observed for growth.

RESULTS

Rose bengal-mediated PDT successfully inhibited the growth of all 3 fungal isolates in the irradiated area. All other groups exhibited unrestricted growth throughout the plate.

CONCLUSIONS

Rose bengal-mediated PDT successfully inhibited the growth of 3 types of fungi. No other experimental groups, including riboflavin-mediated PDT, had any inhibitory effect on the isolates. The results might be useful for the treatment of patients suffering from corneal infection.

The precision of ophthalmic biometry using calipers

OBJECTIVE

The purpose of the study is to determine the precision of whole globe and cornea measurements acquired using calipers, and to quantify the intraoperator and interoperator variance.

DESIGN

Experimental study.

PARTICIPANTS

Ten human donor eyes.

METHODS

Ten human eyes (donor age, 16-54 years) were obtained between 18.5 and 66.5 hours postmortem. The horizontal and vertical diameters and the anteroposterior length of the globe were measured using a digital Vernier caliper. The horizontal and vertical diameters of the cornea were measured using both a digital Vernier caliper and a Castroviejo caliper. The measurements were performed by 3 operators with 5 repeat measurements for each dimension.

RESULTS

No significant differences were observed between measurements of globe anteroposterior length, horizontal diameter, and vertical diameter. Horizontal corneal diameter was greater than vertical diameter with all instruments and all operators. Variability of either instrument did not change with measurement object scale, and was similar across all operators. No significant differences were observed between the variabilities of the 2 devices. The mean intraoperator SD was 0.127 ± 0.023 mm with the digital caliper and 0.094 ± 0.056 mm with the Castroviejo caliper.

CONCLUSIONS

The precision of commercially available calipers in ophthalmic biometry measurements is limited to approximately 0.1 mm.

Symptomatic hepatic hydrothorax successfully treated with transjugular intrahepatic portosystemic shunt (TIPS)–role of titration of portosystemic gradient reduction to avoid post‐TIPS encephalopathy

Key Clinical Message

We describe a challenging case of hepatic hydrothorax secondary to nonalcoholic steatohepatitis cirrhosis. Our management involved successfully treating the hydrothorax with a transjugular intrahepatic porto-systemic shunt but having to manage the subsequent complication of hepatic encephalopathy. We conclude with a review of the available literature.

Outcomes of cataract surgery in ocular cicatricial pemphigoid

PURPOSE

To report the outcomes of cataract surgery in ocular cicatricial pemphigoid (OCP).

SETTING

L. V. Prasad Eye Institute, Hyderabad, India.

DESIGN

Retrospective, interventional case series.

METHODS

Patients diagnosed with OCP who had undergone cataract surgery were included. Staging of disease, type of surgery, pre- and postoperative best-corrected visual acuity (BCVA), and number and duration of topical and systemic medications were recorded. Complications and any exacerbation or worsening of disease were noted.

RESULTS

Nine eyes of 7 patients (3 male, 4 female) were included in the study, with mean age of 60.44 ± 2.6 years (range 56-64 years). Follow-up ranged from 6 months to 10 years (mean 52.9 ± 46.25 months). Surgery performed was extracapsular cataract extraction with posterior chamber intraocular lens implantation (n = 5) or phacoemulsification with posterior chamber intraocular lens implantation (n = 4). Best-corrected visual acuity improved by more than 2 lines in 6 of 9 (66.67%) eyes, which remained stable till the last follow-up. Three eyes had no visual improvement due to corneal scar in 2 patients and preexisting posterior staphyloma in 1 eye. Disease progression was noted in 2 of 9 operated eyes by one stage at the end of 1 year.

CONCLUSION

In this series, cataract surgery could be safely performed with no major intra- or postoperative complications. While the surgical intervention itself was not associated with acute exacerbations of inflammation, progression of disease was noted in some cases over time. In spite of ongoing disease, cataract surgery in OCP was associated with stable visual outcomes.

Short-term outcome of Boston Type 1 keratoprosthesis for bilateral limbal stem cell deficiency

This study reports the short-term functional and anatomical outcome of Boston Type 1 keratoprosthesis (Boston Kpro) implantation for bilateral limbal stem cell deficiency (LCSD). Retrospective analysis was done on eight eyes of eight patients who underwent Boston Kpro implantation between July 2009 and October 2009. The best corrected visual acuity (BCVA) and slit-lamp biomicroscopy findings were assessed at 1, 3 and 6 months postoperatively. All eight eyes retained the prosthesis. BCVA of 20/40 or better was achieved in 8, 6, and 5 eyes at 1, 3, and 6 months, respectively, postoperatively. One patient each developed epithelial defect, sterile stromal melt and fungal keratitis in the late postoperative period associated with antecedent loss of the soft contact lens from the eye. Boston Kpro has good short-term visual and anatomical outcome in patients with bilateral LSCD, provided compliance with postoperative care can be ensured.

Endovascular treatment of isolated systemic arterial supply to normal lung with coil and glue embolisation

Surgery is the standard treatment for the extremely rare pathology of isolated anomalous systemic arterial supply to normal lung (ISSNL). We describe our experience with this anomaly in a 29-year-old male presenting with recurrent haemoptysis that was successfully treated with a combination of metallic coils and cyanoacrylate glue. In addition to contributing to the extremely limited data on endovascular therapeutic options in ISSNL, we also intend to raise the awareness among endovascular therapists of the need to be cautious ofand preserve the radiculomedullary/pial branches arising from an anomalous artery before embolising it.

Endovascular exclusion of aberrant splenic artery aneurysm with covered stent

The splenic artery arising from the superior mesenteric artery is an uncommon anatomical variant. This aberrant origin may rarely be associated with an aneurysm. Previous cases have been managed with surgery and combined surgical/endovascular or endovascular techniques, with the latter involving occlusion of the aneurysm with coils. We report a case of aberrant splenic artery aneurysm that was excluded with a balloon-mounted covered stent, and discuss the technical issues encountered in using this approach. A follow-up computed tomography performed six months after the covered stent placement showed persistent exclusion with marked shrinkage of the aneurysm sac.

Age-dependence of the optomechanical responses of ex vivo human lenses from India and the USA, and the force required to produce these in a lens stretcher: the similarity to in vivo disaccommodation

The purpose of this study was to study the age-dependence of the optomechanical properties of human lenses during simulated disaccommodation in a mechanical lens stretcher, designed to determine accommodative forces as a function of stretch distance, to compare the results with in vivo disaccommodation and to examine whether differences exist between eyes harvested in the USA and India. Postmortem human eyes obtained in the USA (n=46, age=6-83 years) and India (n=91, age=1 day-85 years) were mounted in an optomechanical lens stretching system and dissected to expose the lens complete with its accommodating framework, including zonules, ciliary body, anterior vitreous and a segmented rim of sclera. Disaccommodation was simulated through radial stretching of the sectioned globe by 2mm in increments of 0.25 mm. The load, inner ciliary ring diameter, lens equatorial diameter, central thickness and power were measured at each step. Changes in these parameters were examined as a function of age, as were the dimension/load and power/load responses. Unstretched lens diameter and thickness increased over the whole age range examined and were indistinguishable from those of in vivo lenses as well as those of in vitro lenses freed from zonular attachments. Stretching increased the diameter and decreased the thickness in all lenses examined but the amount of change decreased with age. Unstretched lens power decreased with age and the accommodative amplitude decreased to zero by age 45-50. The load required to produce maximum stretch was independent of age (median 80 mN) whereas the change in lens diameter and power per unit load decreased significantly with age. The age related changes in the properties of human lenses, as observed in the lens stretching device, are similar to those observed in vivo and are consistent with the classical Helmholtz theory of accommodation. The response of lens diameter and power to disaccommodative (stretching) forces decreases with age, consistent with lens nuclear stiffening.

Endovascular revascularisation of popliteal artery occlusions: two complex cases

Peripheral vascular disease-related occlusions of the arteries are complex lesions that can be treated surgically or through endovascular means in symptomatic patients. In this case report, we describe two interesting cases of popliteal occlusion that were revascularised using advanced endovascular techniques to salvage the limb. The first case was a chronic popliteal artery occlusion that required atypical arterial access along with embolisation due to earlier attempted intervention to revascularise the artery. The second case was an acute embolic occlusion that was excluded from the circulation primarily rather than through the typical approach of thrombolysis or mechanical thrombectomy.

Chronic adrenaline treatment fails to down-regulate the Del301-303-alpha2B-adrenoceptor in neuronal cells

BACKGROUND AND PURPOSE

A polymorphism of the human alpha(2B)-adrenoceptor (Del(301-303)-alpha(2B)-adrenoceptor) has been described, and this receptor exhibits reduced G-protein-coupled receptor kinase (GRK) phosphorylation and impaired short-term desensitization. Expression of the Del(301-303)-alpha(2B)-adrenoceptor also is associated with an increased risk for myocardial infarction in humans. Recent evidence from our laboratory suggests a quantitative relationship between cellular GRK3 expression levels and the sensitivity of the alpha(2B)-adrenoceptor to agonist-induced down-regulation. Therefore, the present study was undertaken to study agonist-induced down-regulation of the wild-type (WT)- and Del(301-303)-alpha(2B)-adrenoceptor in a neuronal cell model.

EXPERIMENTAL APPROACH

Haemagglutinin (HA) epitope-tagged WT- and Del(301-303)-alpha(2B)-adrenoceptor containing plasmids were constructed and the receptors were stably or transiently transfected in neuroblastoma/glioma hybrid NG108 cells. The expression levels in stable transfects were approximately 50 fmol x mg(-1). These cells were used to examine agonist-induced down-regulation and phosphorylation of the WT- and Del(301-303)-alpha(2B)-adrenoceptor.

KEY RESULTS

The Del(301-303)-alpha(2B)-adrenoceptor, compared with the WT-alpha(2B-)adrenoceptor, displayed reduced adrenaline-stimulated (20 microM) phosphorylation and did not down-regulate in response to adrenaline (20-1000 microM). Using immunofluorescence labelling, we observed that transiently transfected WT-alpha(2B)-adrenoceptors internalized upon adrenaline treatment whereas the Del(301-303)-alpha(2B)-adrenoceptor did not. Finally, we determined the effect of adrenaline on the Del(301-303)-alpha(2B)-adrenoceptor in cells stably over-expressing GRK3 3-fold. In spite of the GRK3 over-expression, 20-1000 microM ADR failed to down-regulate or to increase phosphorylation of the Del(301-303)-alpha(2B)-adrenoceptor in these cells.

CONCLUSIONS AND IMPLICATIONS

The results suggest that the 301-303 deletion mutation of the alpha(2B)-adrenoceptor eliminates agonist-induced down-regulation, an effect that cannot be overcome by increasing agonist concentration or by modest GRK3 over-expression.

Ultrasonography for detection of early pregnancy following embryo transfer in unknown breed of Bos indicus cows

Real time, B mode ultrasound was used from Days 18 to 64 to detect and monitor the conceptus in 30 unknown breeds of Bos indicus recipients following embryo transfer. The embryonic vesicle was first visible within the uterus between Days 18 and 20 (mean +/- SD 18.5 +/- 0.7d) d). The embryo proper was detected at Day 19.5 +/- 0.7. The heartbeats were detected at Day 22.6 +/- 0.9. The average day of first detection of the allantois, the C - shaped embryo and the amnion was 23.1 +/- 0.8, 23.8 +/- 1.4 and 25.1 +/- 1.4 d, respectively. The fore limb, the limb buds, the spinal cord and the optic area were observed on Days 32.7 +/- 1.3, 32.9 +/- 1.3, 33.0 +/- 1.5 and 33.6 +/- 1.4, respectively. Fetal movements could be detected at Day 50.7 +/- 1.0. Ribs and vertebrae were detected on Day 60.9 +/- 1.7. The mean length of the embryo proper was 4.5 +/- 0.8 mm. on Day 19. At Day 60 it was 52.5 +/- 7.0 mm. The growth of the embryo proper increased steadily until Day 39, growing rapidly thereafter. Embryonic death was detected in one recipient on Day 32. The echogenic area started increasing and recipient appeared in estrus on Day 40. Sixteen recipients exhibited estrus on Days 22 to 24. An increase in intrauterine fluid was observed on Days 18 to 24.

Self-expanding nitinol stents in recanalisation of long-length superficial femoral artery occlusions in patients with critical limb ischaemia

INTRODUCTION

This study aims to evaluate our experience with self-expanding nitinol stent- enabled recanalisation of long-length occlusions (30 cm or more) of the superficial femoral artery (SFA).

METHODS

573 patients underwent 842 lower limb interventions from August 2006 to December 2008. A retrospective review of patients undergoing recanalisation of long-length SFA occlusions with self-expanding nitinol stents and an evaluation of their patency and impact on limb salvage, were done.

RESULTS

22 patients (mean age 62.5 years, male: female ratio 11:11) underwent 22 long-length SFA stenting procedures. The spectrum of critical limb ischaemia included rest pain (five), ulcer (six) and gangrene (11). Length of occlusions varied from 30 cm to 45 cm (average length 36.4 cm). Five patients had stents placed through the ipsilateral popliteal artery approach, and the rest had stents placed through the femoral artery approach. All patients were followed up over an average duration of 12 months. One patient died due to associated medical conditions during this period. Six out of 21 (28.6 percent) of the stents thrombosed completely on one year follow-up. Of these, two patients underwent amputation, one patient had a bypass, and the stent in two patients were recanalised with balloon angioplasty. All remaining patent stents showed varying degrees of stenoses at one year. The overall limb salvage rate at one year following stent placement was 81 percent.

CONCLUSION

Our experience showed the beneficial result of long-length SFA stent placement with good limb salvage outcome. Repeat interventions may be required to maintain the patency of stents in these patients.

Renal vascular injuries following nephron-sparing surgery and their endovascular management

INTRODUCTION

This study aims to describe renal vascular injuries following nephron-sparing surgery and the efficacy of transcatheter embolisation in management of these complications.

METHODS

A retrospective review was performed on 96 patients who underwent nephron-sparing surgery from 2001 to 2005. Selective angiography was performed on all patients referred for significant postoperative haematuria and internal bleeding, followed by embolisation where indicated. Patient presentation, type of vascular injury, embolisation technique and treatment outcome were reviewed in each case. Efficacy of embolisation in preservation of renal function was assessed.

RESULTS

Seven arterial lesions were identified in four patients (three male and one female; age range 47-70 years). Three patients developed pseudoaneurysms (mean size 2.1 cm, range 1.5-3 cm). One patient revealed four separate areas of active contrast extravasations. All patients were successfully treated with coil embolisation with complete symptomatic relief within one to three days. Renal function was preserved in all patients over a follow-up period of 90 days.

CONCLUSION

Renal arterial injuries, especially pseudoaneurysms, are an important though uncommon cause of haematuria following nephron-sparing surgery. Coil embolisation is an effective treatment for management of these iatrogenic injuries.

Comparison of clinical and microbiological profiles in smear-positive and smear-negative cases of suspected microbial keratitis

PURPOSE

To examine the hypothesis that initial smear examination results have a significant bearing on the management and outcome of suspected microbial keratitis.

MATERIALS AND METHODS

One hundred and seventy consecutive patients with suspected microbial keratitis were included in a prospective nonrandomized comparative study and their detailed clinical and microbiological data (smears and cultures of corneal scrapings) were captured on a predesigned corneal ulcer database. Patients were divided into two groups: Group 1 included 68 patients with corneal scrapings negative in smears while Group 2 included 102 patients with corneal scrapings positive in smears. The two groups were compared for their clinico-microbiological profile, management and clinical outcome. The outcome was noted at three months. Fisher's exact test was applied for statistical analysis.

RESULTS

Cultures were sterile in 57.3% of patients in Group 1 compared to 17.6% in Group 2. Scrapings that grew S. pneumoniae, gram-negative organisms, fungi and Acanthamoeba were more often positive in smears (18.6%, 11.8%, 19.6% and 2.9% respectively). While data on duration of prior treatment was not available, prior medication made no significant difference to smear results. More (79.3%) patients of Group 1 had small infiltrate size (

CONCLUSIONS

Initial smear examination helps in instituting specific therapy thereby improving the outcome in cases of microbial keratitis. Positive smears indicate greater severity of disease and prior medication may not be a significant cause of smear negativity.

Penicillium keratitis in vernal Keratoconjunctivitis

We report a case of penicillium keratitis in vernal shield ulcer in the absence of corticosteroid use. This report illustrates super-added infection in vernal shield ulcer by an organism which is otherwise innocuous and forms a part of the normal ocular flora.

Atypical manifestation of dural arteriovenous fistula

A case of secondary dural arteriovenous fistula presenting as infantile stroke, in a fifteen month old boy, is reported. The initial impression on CT scan in this case was misleading, due to the atypical appearance of the pathological periventricular blood vessels, interpreted as periventricular calcification.

Reproductive characteristics of cloned heifers derived from adult somatic cells

This study examined the onset of puberty, follicular dynamics, reproductive hormone profiles, and ability to maintain pregnancy in cloned heifers produced by somatic cell nuclear transfer. Four adult somatic cell-cloned heifers, derived from a 13-yr-old Holstein cow, were compared to 4 individual age- and weight-matched heifers produced by artificial insemination (AI). From 7 to 9 mo of age, jugular venous blood samples were collected twice weekly, and from 10 to 11 or 12 mo of age, blood sampling was carried out every other day. After the heifers reached puberty (defined as the first of 3 consecutive blood samples with peripheral plasma progesterone concentrations of >1 ng/ml), ultrasound examination of ovaries and jugular plasma sample collection were carried out daily for 1 estrous cycle. Cloned heifers reached puberty later than controls (mean +/- SEM, 314.7 +/- 9.6 vs. 272 +/- 4.4 days and 336.7 +/- 13 vs. 302.8 +/- 4.5 kg for clones and controls, respectively; P < 0.05). However, cloned and control heifers were not different in estrous cycle length, ovulatory follicle diameter, number of follicular waves, or profiles of hormonal changes (LH, FSH, estradiol, and progesterone). Three of the 4 clones and all 4 control heifers became pregnant after AI. These results demonstrate that clones from an aged adult have normal reproductive development.

Tubercular endophthalmitis simulating retinoblastoma

PURPOSE

To report a case of tubercular endophthalmitis simulating retinoblastoma.

METHODS

Case report. An 8-year-old female presented with a history of complete loss of vision and a white pupillary reflex in the left eye of 3 month's duration.

RESULTS

Retinoblastoma could not be excluded on the basis of clinical examination and relevant investigational studies. In the left eye, a computed tomography (CT) scan demonstrated a large vitreous mass with foci of calcification. Enucleation in the left eye was performed, and histopathological examination revealed a chronic granulomatous endophthalmitis and acid-fast bacilli consistent with tubercular pathology.

CONCLUSION

This case illustrates that tubercular endophthalmitis with leukocoria and a vitreous mass containing focal calcification may simulate retinoblastoma.

In vitro cultivation of human islets from expanded ductal tissue

A major obstacle to successful islet transplantation for both type 1 and 2 diabetes is an inadequate supply of insulin-producing tissue. This need for transplantable human islets has stimulated efforts to expand existing pancreatic islets and/or grow new ones. To test the hypothesis that human adult duct tissue could be expanded and differentiated in vitro to form islet cells, digested pancreatic tissue that is normally discarded from eight human islet isolations was cultured under conditions that allowed expansion of the ductal cells as a monolayer whereupon the cells were overlaid with a thin layer of Matrigel. With this manipulation, the monolayer of epithelial cells formed three-dimensional structures of ductal cysts from which 50-to 150- micrometer diameter islet-like clusters of pancreatic endocrine cells budded. Over 3-4 weeks culture the insulin content per flask increased 10- to 15-fold as the DNA content increased up to 7-fold. The cultivated human islet buds were shown by immunofluorescence to consist of cytokeratin 19-positive duct cells and hormone-positive islet cells. Double staining of insulin and non-beta cell hormones in occasional cells indicated immature cells still in the process of differentiation. Insulin secretion studies were done over 24 h in culture. Compared with their basal secretion at 5 mM glucose, cysts/cultivated human islet buds exposed to stimulatory 20 mM glucose had a 2.3-fold increase in secreted insulin. Thus, duct tissue from human pancreas can be expanded in culture and then be directed to differentiate into glucose responsive islet tissue in vitro. This approach may provide a potential new source of pancreatic islet cells for transplantation.

Disposable contact lenses in penetrating keratoplasty

PURPOSE

To evaluate the therapeutic efficacy of disposable contact lenses in management of complications after keratoplasty.

METHODS

Twenty-eight patients with various post keratoplasty complications were fit with disposable contact lenses (45% Vifilcon A and 55% water content). Indications for lens use included persistent epithelial defects, wound leak, graft edema, dry eye and protection of normal corneal epithelium.

RESULTS

Success was obtained with the therapeutic use of disposable lenses in 20 of the 28 cases. The best results were seen in maintenance and restoration of healthy ocular surface and small wound leaks. Stromal graft edema with no epithelial involvement was the major area of therapeutic failure.

CONCLUSIONS

Disposable contact lenses are an attractive low cost option in the management of complications after keratoplasty. They are particularly useful in maintaining a healthy ocular surface, providing symptomatic relief and avoiding resurgery in patients with small wound leaks.

Intralenticular foreign bodies: report of eight cases and review of management

PURPOSE

The management of intralenticular foreign bodies (ILFBs) with or without cataract has varied from time to time in the last century. We evaluated the surgical removal of the ILFBs with cataract extraction as a single-stage procedure.

METHODS

Eight consecutive cases with intralenticular foreign bodies presenting to the trauma centre at our institute, were included in the study. Planned ILFB removal with cataract extraction and IOL implantation as a single-stage procedure was done in all the patients. They were followed up from 2 months to 2 years after the surgery.

RESULTS

ILFBs were removed with Kelman-Mcpherson forceps in seven cases and in one it was expressed with the nucleus during extra capsular cataract extraction. Co-existent posterior capsular tears were seen in two eyes, of which only one needed a localized vitrectomy. Posterior chamber intraocular lens implantation was possible without any complication in all the cases. Postoperative uveitis seen in three cases was easily controlled with periocular steroids. Best corrected visual acuity at last examination was 6/9 or better in 7 cases and 6/12 in one case with posterior capsular opacification.

CONCLUSIONS

Timing and necessity of ILFB removal may be adjusted according to the foreign body characteristics and associated ocular trauma, choosing, as far as possible, the least traumatic procedure. Use of forceps rather than magnets is safer for the removal of the ILFB. Co-existent posterior capsular tears need to be anticipated and dealt with when encountered.