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Contents
CORNEA - I
A New Approach to Management of Corneal Ulcers by Debridement---------------- 471
Dr. Debasish Dutta, Dr. Arup Bhaumik, Dr. Ayan Mohanta, Dr. Prashant Kumar Singhal,
Dr. Sabitabrata Basu
Colored Cosmetic Contact Lenses: Cosmesis and Complication, Hand in Hand-475
Dr. Shwetambari Singh, Dr. Ravindra Vhankade, Dr. Dipali Satani, Dr. Amit Patel
Spectrum of Mycotic Keratitis: 5-Year Review of Patients at A Tertiary Eye Care
Center in Tamilnadu------------------------------------------------------------------------------------- 479
Dr. D Chandrasekhar, Dr. J Kaliamurthy, Dr. Pragya Parmar, Dr. C M Kalavathy, Dr. C A
Nelson Jesudasen, Dr. Philip Aloysius Thomas
Effect
of
Subconjunctival
Injection
of
Bevacizumab
on
Corneal
Neovascularization------------------------------------------------------------------------------------- 483
Prof. Dr. K Vasantha, Dr. Rajini Ponraj, Dr. Mohan K, Dr. Niraimozhi
Risk Factors in Management of Bacterial Keratitis------------------------------------------ 485
Dr. Samrat Chatterjee, Dr. Deepshikha Agrawal
A Very Unusual Case of Keratitis------------------------------------------------------------------ 488
Dr. Saroj Gupta
Effect of Pterygium on Contrast Sensitivity---------------------------------------------------- 490
Dr. Archana Malik, Dr. Soniya Bhala, Dr. Anamika Garg, Dr. Sudesh K Arya,
Dr. Sunandan Sood
To Study The Effect of Sub-conjunctival Injection of Bevacizumab on Corneal
Neovascularisation-------------------------------------------------------------------------------------- 493
Dr. Somnath Mukhopadhyay, Dr. Himadri Dutta, Dr. Jayanta Dutta, Dr. Swarnali Sen,
Dr. Pradeep Kumar Panigrahi
Neonatal Infectious Keratitis Five Years Experience at a Tertiary Eye Care Center--
------------------------------------------------------------------------------------------------------------------ 495
Dr. Jatin Ashar, Dr. Muralidyhar R, Dr. Shivani Pahuja, Dr. Sunita Chaurasia,
Dr. Virender Sangwan
Efficacy and Safety of Topical Umbilical Cord Serum Therapy in Persistent Corneal
Epithelial Defects----------------------------------------------------------------------------------------- 498
Dr. Charu Mithal, Dr. Anu Malik, Dr. Sandeep Mithal, Dr. Neha Mithal, Dr. Prateek
Agarwal, Dr. Pallavi Agarwal
Sympathetic Ophthalmitis Following Optical Penetrating Keratoplasty In The Last 9
Years---------------------------------------------------------------------------------------------------------- 502
Dr. Rekha Gyanchand, Dr. Sheetal Hegde
Comparison of Engothelial Cell Count by Manual and Automated Methods in Normal
Cornea and in Fuchs Endothelial Dystrophy------------------------------------------------- 505
Dr. Somasheila I Murthy, Dr. Debarun Dutta, Dr. Tamal Chakraborti, Dr. Pritam Kumar
Streptococcus Pneumoniae Keratitis: Fortified Antibiotics or Fluoroquino-lones?-
------------------------------------------------------------------------------------------------------------------ 508
Dr. Sujata Das, Dr. Savitri Sharma, Dr. Vivek Warkad, Dr. Srikant K Sahu
Fibrin Glue (FG) Augmented Amniotic Membrane Transplantation (FGAMT) in
Peripheral Corneal Perforations---------------------------------------------------------------------511
Dr. Ritu Arora, Dr. Jasneet Kang, Dr. J L Goyal, Dr. Monika Mittal, Dr. Parul Jain
469
CORNEA - I
Chairman: Dr. G Mukherjee; Co-Chairman: Dr. A K Jain
Convenor: Dr. Beena Desai; Moderator: Dr. Prerna Upadhyaya
Dr. DEBASISH DUTTA: MBBS (1995), NRS Medical College, Calcutta
University, Kolkata; MS (2000), MKCG Medical College, Berhampur
University; Fellowship (2004), Sankara Nethralaya, Chennai. Recepiant of
K.R. Dutta award (1999) in EIZOC, Cuttack. Presently, Consultant, Disha
Eye Hospital and Research Centre, Sheoraphuly, Hooghly, WB.
Contact: 09830216532; E-mail: debasish71@yahoo.com
isual disability in the developing nations of Asia , Africa and Middle East
is a major public health issue. Cataract is the most common cause but is
easily manageable. The very second cause is corneal opacity resulting from
corneal ulceration. Central Corneal ulceration is a very common occurrence
in the semi urban and rural population. These patients mostly belong to the
financially weaker sections of the society and are involved in agricultural
activities. There is wide geographic and a etiological variation across the globe
and also from region to region.
In the Indian scenario a huge fraction of the agricultural population is affected
by corneal diseases ranging from simple corneal abrasions to microbial
keratitis. This is not the case where farming is highly mechanized.
Microbial keratitis due to bacteria is decreasing at our Disha Eye Hospital
(Hooghly). Self medication or treatment by village quacks cures many of the
bacterial ulcers. This is mainly because of some potent and cheap antibacterial
formulations, which are available over the counter.
So we are left with the dreaded menace of the mycotic keratitis, which is
unequivocally a major cause of ocular morbidity. The problem of fungal
infection of cornea in India is acute as the weather is hot and humid (Tropical)
and to add to the problem are ignorance, illiteracy and poverty.
Medical management of fungal Keratitis is far from satisfactory. Fungi
implicated in keratomycosis rarely cause systemic mycoses. Therapeutic
protocols applicable for systemic mycoses work poorly when applied to
cornea. Polyenes are natamycin and Ampho-B a zoles include Clotrimazole,
Fluconazole and Voriconazole etc. These are mostly fungistatic and not
fungicidal. The drug of choice for filamentous fungi is natamycin suspension.
471
Patient
All patients with red eye who report to the OPD of the tertiary care eye centre
Disha Eye Hospital (Hooghly) are screened for corneal ulcer. This tertiary care
hospital serves semi urban and rural people of Howrah,Hooghly and Burdwan
districts of West Bengal. The livelihood of majority of patients turning up to
the OPD of this hospital is agriculture based.
Ulcer
472
A common protocol was applied to all cases. Each patient was examined
under Slit Lamp biomicrocope by an ophthalmologist. Ulcer is stained by
Sterile fluorescein strip touched at the lower fornix to make out the extent of
epithelial breech and recorded in mm in its longest and shortest diameter.
Other details like depth, zone of stromal infiltrate, Corneal edema etc are
noted with proper color coding. Hypopyon is measured in mm and number of
days for its resolution is noted.
Healed Ulcer
Exclusion criteria
Scraping
2.
Leading edge of the ulcer and a KOH mount prepared for examination
under microscope first under 10 x and then finally under 40x.
473
lack of availability of media, lack of adequate sample for all media and the
infrastructural cost involved at all places.
Only the patients who test positive for filaments are taken into consideration
(Group 1).
A typical medical regime was formulated and applied to all those patients.
Most patients were examined at 5 days interval and changes noted as per the
protocol.
A subset of these patients in group 1 were randomly taken up for the special
checker board scraping protocol to constitute Group 2.
Corneal thickness is assessed under the slit beam and cheques board pattern
of scraping applied to remove the deep densely infiltrated prenecrotic tissue.
This tissue was not removed by conventional deep scraping. Ulcer is monitored
closely and scraped similarly at subsequent visits.
RESULTS
Patients were randomly divided into group 1 and group 2.
In group 1 standard therapeutic scraping was practised in the beginning and
subsequent follow ups.
In group 2 chequer board scraping was applied similarly.
The impact of nuisance parameters like size of ulcer , site of ulcer etc on the
yield or outcome (number of days required to heal and the final visual acuity
achieved) is eliminated by ANCOVA. Analysis of the data revealed that the
time required to heal is significantly less in group 2 (at 5% level).
But the assumption that quicker healing will cause lesser fibrosis maintaining
better transparency need further evaluation .
DISCUSSION
The impact of fungal keratitis in the Indian subcontinent as a cause of ocular
morbidity is unequivocally substantial . Fungal ulcer account for 30 to 40% (3)
of all cases of microbial keratitis in developing countries. Some studies put the
figure to as high as 50% (1)
The therapeutic protocols of today are far from satisfactory and often fail
to preserve or restore vision after fungal keratitis. Filamentous fungi is the
number one cause at lest in the developing world. Corneal penetrability of
available drugs is an issue. Cost and accessibility to low cost treatment is
extremely important in the Indian subcontinent.
Aim of management is rapid eradication of the organism with control of
inflammation and tissue damage by cytokinins etc, there by preserving
474
REFERENCES
1.
4.
5.
6.
475
RESULTS
Out of 13 patients 8 were male and 5 were female. Mean age of presentation was
19 3.8 years. Eleven patients were nave contact lens users and 4 were minors.
Table 1 outlines the details of contact lens availability, storage and usage.
Table 1
Case Contact lens Storage and Duration of Assistance Sharing Overnight
No. availability
cleaning
storage in
for CL
use
solution unchanged removal
solution
1
Optical shop
2 days
7 days
Relative
CLS
1 month
Friend
CLS
10 days
Optical shop
CLS
2 days
Optical shop
CLS
10 days
Relative
Optical shop
CLS
15 days
Friend
CLS
5 days
10
11 Garbage
CLS
3 days
-
12
Friend
CLS
7 days
13
Optical shop
CLS
5 days
476
20/M
Size of
Organism
Sensitivity
Visual
ulcer
isolated
acuity on
(mm)
presentation
5.5X6
P. aeruginosa
Moxifloxacin
HM
Final
visual
acuity
6/18
15/F
3X4
S. aureus
Amikacin
6/24
6/9
16/F
9X8.5
P. aeruginosa
Cefotaxime
HM
HM
18/M
7X8
P. aeruginosa
Moxifloxacin
PR
NA
19/M
1X2
P. aeruginosa
Moxifloxacin
6/60
6/12
28/M
6X7.5
CF m
CF m
18/F
1X2
S. aureus
Levofloxacin
6/6
6/6
25/M
7.5X8
S. epidermidis
Moxifloxacin
PR
HM
16/M
5X4.5
P. aeruginosa
Amikacin
CFNF
6/24
10
21/F
2X3
S. aureus
Moxifloxacin
6/9
6/6
11
15/F
5X5.5
P. aeruginosa
Moxifloxacin
6/60
6/24
12
20/M
2X3
S. epidermidis
Moxifloxacin
6/9
6/6
13
21/M
7X8
P. aeruginosa
Levofloxacin
PR
6/60
Culture negative
DISCUSSION
The link between microbial keratitis and contact lens wear is beyond question.
Use of contact lenses for therapeutic, refractive or cosmetic purpose will
target different classes of population. The colored cosmetic lenses are non
corrective (zero power or plano) lenses designed and worn solely to change
the appearance of the eye. Emmetropic patients who wear these lenses risk
serious ocular sequelae for the sake of cosmesis alone. In the current study, 13
young individuals developed sight threatening microbial keratitis following
the use of cosmetic contact lenses. As all the patients were from lower to lower
middle socieo-economic class, it points towards the dangerous trend evolving
in the youngsters of these classes. We found that unsterile lens handling and
infrequent change of storage solutions were the two major causes for the
development of infectious keratitis.
Eleven out of 13 patients were using these lenses for the first time. None of
the patient was following sterile contact lens handling or storage technique.
The lenses were stored in a contact lens case with solution or unpreserved
477
REFERENCES
1.
Over the counter decorative contact lenses: cosmetic or medical device? A case
series. Eye Contact Lens: Science and clinical practice. Sept. 2005.
Corneal ulcer associated with cosmetic extended wear soft contact lens.
Ophthalmology Feb. 1987.
4.
478
479
RESULTS
There were 1499 patients of who suspected microbial corneal ulcer underwent
microbiological investigations during the five years from January 2005 to
December 2009. Of these, 64% of them reported trauma by inanimate object,
26% reported prior treatment with eye drops (from Pharmacy/ General
Practitioner/ Ophthalmologist) and 18% reported use of traditional eye
medicine (oil, leaf juice, milk, etc.).
Microorganisms were grown from 1069 (71%) of the 1499 ulcers. There were
542 (51%) fungal isolates and 522 (49%) bacterial isolates. The proportions of
bacterial and fungal isolates recovered from the corneal ulcers for each year
were given in Table -1.
Table 1: The proportions of bacterial and fungal isolates recovered
from the corneal ulcers for each year (2005 to 2009)
Organism
Bacteria
Fungi
No growth
56
Others
63
72
119
120
430
0 2 1 0 2 5
280 257 326 308 328 1499
480
Fusarium solani
5 4 0
0 0 9
Fusaium sp
24
20
60
34
42
180
Fusarium dimerum 7 7 0
0 1 15
Total
204
A.flavus
16
A.fumigatus
10 4 7 3 4 28
Aspergillus spp
20
30
27
101
Aspergillus niger
Total
134
Curvularia sp
4 3 9
4 8 28
Colletotrichum dematium
9 1 0
2 1 13
Exerohilum longistratum
1 0 0
2 4 7
Alternaria alternata 1 0 3
0 0 4
Bipolaris
1 1 1
1 1 5
Lasiodiplodia
2 0 1 0 3
Scedosporium apiospermum
1
0
1
Candida albicans
1
1
2
UI
39 28 39
19 16 141
Total
DISCUSSION
Fungal keratitis is a common cause of corneal infection and blindness after
trauma in the developing world. Because of the widespread distribution of
fungi, human contact with the organism is inevitable and frequent. It has
become increasingly important to gather sufficient data that would project the
gravity of the problem of fungal keratitis of a representative geographic region
in terms of the epidemiology and aetiology, the documentation of which would
serve as a useful guide for practising ophthalmologists. Few studies on fungal
keratitis have been published from India.2,3,5,6 The results of proportion of
fungi and bacteria of the present study are consistent with the earlier reports
from India.5,6 Fungal ulcers are usually seen more in this center. It is primarily
481
REFERENCES
1. Xie LX, Zhong W, Shi W, Sun S. Spectrum of fungal keratitis in North China.
Ophthalmology 2006;113:19438.
2. Chowdhary A, Singh K. Spectrum of fungal keratitis in North India. Cornea 2005;
24:815.
3. Shukla PK, Kumar M, Keshava GB. Mycotic keratitis: an overview of diagnosis and
therapy. Mycoses 2008;51:18399.
4. Wang L, Sun S, Jing Y, Han L, Zhang H, Yue J. Spectrum of fungal keratitis in
central China. Clinical and Experimental Ophthalmology 2009;37:76371.
5. Bharathi MJ, Ramakrishnan R, Meenakshi R, et al. Microbial keratitis in South
India: influence of risk factors, climate, and geographical variation. Ophthalmic
Epidemiol 2007;14:619.
6. Leck AK, Thomas PA, Hagan M, et al. Aetiology of suppurative corneal ulcers
in Ghana and south India, and epidemiology of fungal keratitis. Br J Ophthalmol
2002;86:12115.
7. Gopinathan U, Garg P, Fernandes M, et al. The epidemiological features and
laboratory results of fungal keratitis: a 10-year review at a referral eye care center
in South India. Cornea 2002;21:5559.
482
Inclusion criteria
Vascularised corneas of patients with
Leucomatous opacity following exanthematous fever and post hydrops
Pseudophakic bullous keratopathy
Healed corneal ulcer post trauma and infection
Previously failed Optical keratoplasty
Exclusion criteria
Patients with uncontrolled systemic hypertension with systolic blood
pressure of 150mm Hg or diastolic blood pressure of 90 mm of Hg
Patients with recent Myocardial Infarction
Patients with recent Cerebro Vascular Accidents
Diabetes mellitus
Renal, liver, and coagulation
anticoagulation medications
abnormalities
including
current
Procedure
Anterior segment examination was done with slit lamp biomicroscopy.
Standardized corneal photographs were taken with 10X magnification with
slit lamp biomicroscopy using digital camera.
483
Follow-up
Follow up visits were done on 14th day, 1st, 3rd, and 6th month post injection.
All the 20 patients completed 6 months of follow-up. At each visit patients
were checked for regression of new vessels i.e. reduction in both number and
caliber of the vessel. Patients were also examined for signs of graft rejection
(those who have been operated) and side effects.
ii)
iii)
DISCUSSION
In this study an obvious reduction in established corneal neovascularization
occurred to a different degree in each patient, and subconjunctival
bevacizumab was well tolerated by all these patients. Out of 20 patients in 50%
of patients complete regression of the corneal new vessels noted at the end
of 6th month. Whereas in 30% of patients only partially reduction noted i.e.
reduction in calibre of vessels only, the number of new vessels was constant.
In 20% of patients both number of new vessels and the calibre was constant.
This variable response may be because of the chronicity, extent of corneal
neovascularization, amount of scarring, disease process, formulation and
route of administration of the drug 15 and 16.
Subconjunctival injection of Bevacizumab can be used safely and effectively
for corneal neovascularization resulting from different types of disorders.
484
485
2x2 tables with chi-square or Fishers test as appropriate. Variables that yielded
p value <0.125 were considered for multivariate analysis using multiple logistic
regression. SPSS (version 12 for Windows, SPSS, Chicago, IL) was used for
statistical analysis. A 2-tailed p value less than 0.05 was considered significant.
RESULTS
There were 149 episodes of bacterial keratitis in 142 patients. There was
bilateral involvement in 3 patients and multiple episodes in 4 patients.
Outcome data was available in 117 episodes as rest was lost to follow-up. Of
these 101 (86.32%) episodes healed, 5 (4.27%) required evisceration, 1(0.86%)
underwent therapeutic penetrating keratoplasty, 3(2.56%) eyes became
pthisical and 7(5.98%) eyes had perforation which were un-amenable to
treatment and patients refused evisceration. Factors that were considered to
influence outcome are given in Table. The factor identified by multiple logistic
regression to significantly influence outcome was infiltrate size (p=0.03) while
rest of the factors failed to reach statistical significance.
DISCUSSION
The outcome of bacterial keratitis with medical management is better than
fungal keratitis. In this study 86% cases had good outcome which is better than
the 64% good outcome reported by us in fungal keratitis earlier. [Risk factors
for poor outcome in medical management of fungal keratitis. Chatterjee S,
et al. Paper presented at Annual Conference of All India Ophthalmological
Conference, Kolkata, 2010]. Better outcome in bacterial keratitis compared to
fungal keratitis has been also reported by others.3,5
Previous studies have reported advancing age,1,2 pre-treatment with topical
steroids,1-2 pneumoccoal infection,2 pseudomonas infection, 1 ulcer size,1-4
distance from limbus,4 presence of hypopyon,1 and MIC of antimicrobial
agents,5 to significantly affect outcome. In the present study univariate
analysis found presenting visual acuity <20/200, infiltrate size 12mm2,
involvement of the posterior stroma, perforation or gross corneal thinning,
presence of concurrent endophthalmitis and gram negative bacterial infection
as factors associated with poor outcome. However in multivariate analysis
only infiltrate size reached statistical significance. The reason why other risk
factors did not reach statistical significance in multivariate analysis could
be due to the sample size which may not have been large enough to have
adequate statistical power to detect small differences.
In summary we find that bacterial keratitis has a better outcome than fungal
keratitis. The major risk factor for poor outcome is large ulcer size. Hence
patients with larger ulcers should receive appropriate topical antibiotics
486
Poor
Good TOTAL Odds 95% CI
outcome outcome
ratio
No (%) No (%)
Extreme of age
(0-14 and > 60y)
6(12)
44(88)
50
Others
Male gender
10(15)
57 (85)
67
8(11)
68 (89)
76
Female gender
8 (20)
33 (80)
41
Distance >25kms
8(11)
63(89)
71
Distance 25 kms
8(17)
38(83)
46
4(21)
15(79)
19
1.51
Presentation 21d
12(12)
86(88)
98
73(84)
87
No risk factors
2 (7)
28 (93)
30
Prior consultation
4(13)
28(87)
32
No prior consultation
12(14)
73(86)
85
8(11)
67(79)
75
7
No treatment with
antibiotic prior to
presentation
0.78
0.6
0.6
P
VALUE
0.26- 2.30
0.21-1.74
0.21- 1.74
0.79
0.26
0.41
0.44- 5.19 0.29
0.18- 1.47
0.26
Prior treatment with
8(19)
34 (81)
42
antibiotic
8
0.2849 1.0000
to 3.2449
No treatment with
12(14)
75(86)
87
steroids
9
57 (79)
72
Presenting VA 20/200
1(3)
39(97)
40
15(38)
24(62)
39
1(1)
77(99)
78
16(25)
49(75)
65
infinity
11
Posterior stroma
involvement
Anterior stromal
involvement
0(0) 52(100) 52
12 Presence of hypopyon
4 (10)
36(90)
40
12(16)
65(84)
77
Absence of hypopyon
13 Perforation/thinning
No perforation/thinning
0.18-2.0
5(42)
12
9(9)
96(91)
105
3 (100)
0 (0)
13 (11)
101(89)
7(50)
91(91)
0.6
7 (58)
14 Endophthalmitis
No endophthalmitis
0.0001
9(9)
0.57
0.002
114
14
100
487
REFERENCES
1
Coster DJ, Badenoch PR. Host, microbial and pharmacological factors affecting
outcome of suppurative keratitis. Br J Ophthalmol 1987; 71:96-101.
Gudmundsson OG, Ornerod DL, Kenyon KR, et al. Factors influencing predilection
and outcome in bacterial keratitis. Cornea 1989;8:115-21.
Wong T, Ng TP, Fing K, Tan DT. Risk factors and clinical outcomes between fungal
and bacterial keratitis: a comparative study. CLAO 1997;23:275-81.
here are several reports in the literature, from different parts of the world
describing the spectrum of microbial Keratitis.1-4 The causative agents
described in all these reports are bacteria, fungi and parasite. Among parasite,
only Acanthamoeba has been isolated. We report an unusual case of Keratitis
caused by flagellated protozoa.
Case-report
A 31- year- old male patient presented with complaints of redness, watering
and pain in left eye while working in fields. Following injury, he washed his
eye with dirty stagnant water.
On examination, left eye showed an epithelial defect in centre of cornea
measuring 3.0 mm X 2.5 mm with prominent ring infiltrate surrounding the
defect. The infiltrate extended up to the anterior stroma.
488
DISCUSSION
Cornea infection in this case probably resulted from direct contact with
contaminated water. The rapid motility of trophozoites was suggestive of
flagellated protozoan like Giardia or Chylomastix. The rapid motility and
sterile culture excluded protozoa like Acanthamoeba or Naegleria. Typical
motility of trophozoites on fresh examination is the key for diagnosis.5 Saline
preparation of corneal scraping should be done to exclude motile parasites.
We took opinion from two experts by showing them video of trophozoites.
Both agreed with diagnosis of a flagellated parasite especially Chylomastix.
To best of our knowledge this is the first report in literature (Medline search)
on keratitis by an unusual flagellated parasite.
REFERENCES
1.
Upadhyay MP, Kamachaya PC, Koirala S, Tuladhar N, Bryan LE, Smolin G at al.
Epidemiological characterstics, predisposing factors, and etiologic diagnosis of
corneal ulceration in Nepal. Am J Ophthalmol 1991;111:92-9.
4.
5.
Yaowalark sulkthana. Free living amebic infection: Rare but fetal. Review. J. Trop.
Med. Parasitol. 2006; June:27-36.
489
Statistical analysis
490
ANOVA and post-hoc bonferroni tests. Data was analyzed with SPSS software
(Version 11.0). Differences were considered statistically significant at P < 0.05.
RESULTS
27 patients (15 males and 12 females) were included in the study. 36 eyes had
pterygium and 18 eyes served as controls. Mean age of the patients was 32.06.88.
Number of patients as divided in groups based on vertical length were (Group
1-7, Group 2-18, Group 3-11), horizontal width (GroupA-17, GroupB-19) and
depending on area (GroupI-14, GroupII-15, GroupIII-7). Mean of pterygium
vertically was 4.411.12 (Group 1-2.720.41, Group 2-4.180.50, and Group3-5.86
0.45), horizontally 2.090.68 (GroupA-1.490.31 , GroupB-2.620.42) and of area
was 9.75.01(Group I-4.641.23, GroupII-10.981.93, GroupIII-17.212.20).
The photopic and mesopic contrast sensitivity in the vertical, horizontal and
area wise groups is shown in table 1. All the three parameters had a significant
negative correlation with the contrast sensitivity.
Table 1: Contrast sensitivity of groups as compared with controls
Contrast Vertical length Horizontal width
Area
Control
sensitivity Group1 Group2 Group3 GroupA GroupB GroupI GroupII GroupIII
(pvalue) (pvalue) (pvalue) (pvalue) (pvalue) (pvalue) (pvalue) (pvalue)
Photopic 3 1.520.20 1.450.25 1.250.19 1.520.26 1.300.18 1.570.24 1.320.18 1.240.16 1.690.16
(0.37)
(0.019)( 0.00)
(0.06)
(0.00)
Photopic 6 1.800.20 1.670.28 1.480.34 1.770.23 1.520.31 1.830.21 1.520.28 1.530.35 1.900.18
(0.85)
(0.10)
(0.002)
(0.36)
(0.00)
(0.87)
(0.001)( 0.019)
Photopic12 1.480.22 1.260.24 1.070.32 1.330.23 1.160.31 1.390.23 1.190.27 1.070.31 1.610.20
(0.68)
(0.11)
(0.000) ( 0.000)
Photopic18 0.900.22 0.850.27 0.630.34 0.880.23 0.710.33 0.910.24 0.760.30 0.630.34 1.180.28
(0.22)
(0.10)
(0.002) ( 0.001)
Mesopic3 1.350.14 1.360.22 1.150.25 1.360.19 1.230.25 1.390.19 1.260.22 1.160.28 1.590.21
Mesopic6
(0.14)
(0.14)
(0.002) ( 0.002)
(0.23)
(0.007) ( 0.000)
Mesopic12 1.350.20 1.180.37 0.960.39 1.190.28 1.110.43 1.260.25 1.130.39 0.940.45 1.610.20
(0.33)
Mesopic18 0.840.19 0.820.32 0.520.35 0.810.20 0.660.41 0.850.18 0.760.38 0.450.34 1.170.22
(0.10)
(0.01)
DISCUSSION
Our study shows that the contrast sensitivity of patients in whom the vertical
length of pterygium is 3mm is not significantly different from the controls.
491
REFERENCES
1.
Yagmur M, zcan AA, Sari S, Ersz TR. Visual acuity and corneal topographic
changes related with pterygium surgery. J Refract Surg. 2005;21:16670.
4.
5.
Lin S, Reiter K, Dreher AW, Frucht-Pery J, Feldman ST. The effect of pterygia on
contrast sensitivity and glare disability. Am J Ophthalmol. 1989;107:407-10.
6.
Joo Youn Oh,Won Ryang Wee. The effect of pterygium surgery on contrast
sensitivity and corneal topographic changes. Clinical Ophthalmology 2010;4:3159.
492
493
RESULTS
The mean duration of follow-up was 3 months. The average number of
subconjunctival bevacizumab injections per eye was 2. Preoperative visual
acuity ranged from 20/30 to hand movements. There were no intraoperative
complications. No side effects were reported by the patients, nor was pain
or discomfort induced by the drug injection reported throughout follow-up.
Visual acuity did not change significantly in any patient in this study. Seven
patients (70%) showed partial regression of vessels, whereas 3 patients did not
react to the injection. During 3 months of follow-up, 6 (60%) patients had at
least a 1clock hour decrease in the extent of blood vessels, and 4 (40%) had at
least a 2clock hour decrease in the extent of vessels: Seven (70%) patients had
a decrease of 1 level in density but none showed any decrease in centricity of
blood vessels in the cornea.
DISCUSSION
Different substances have been identified in the past as potential vessel
inhibitors, including steroids, nonsteroid anti-inflammatory drugs, heparin,
cyclosporin A, methotrexate, and thalidomide. Although steroids have been
the mainstay of therapy for corneal neovascularization and corneal graft
rejection in clinical practice, they are not always effective, and chronic use
may cause prominent side effects. VEGFs role in the pathophysiology of
corneal neovascularization has been shown in experimental models of corneal
494
495
Microbiological profile
1. Route of
Vaginal
27/34
79.41%
Pseudomonas-5/27,
delivery
Staphylococcus spp-3/7,
GPC-2/7,Gonococcus-1/7,
HSV-3/7,Fungus-2/7,
No Organism-8/7
Caesarean
7/34 20.5% Pseudomonas-4/7,
Staph. epidermidis-1/7,
GPC-2/7
2. Prematurity
3. Maternal
infections
1/34
2.94%
No organism isolated
Urinary tract
2/34
infection,
vaginal discharge
5.88%
Pseudomonas-1/2, HSV-1/2
4. Prolonged
9/34
26.47%
Pseudomonas- 4/9 (44.4%)
NICU care
Staphylococcus hemolyticus-
1/9 (11.1%)
Fungus-1/9(11.1%)
HSV-1/9 (11.1%)
No organism detected
-2/9(22.2%)
5. Associated Jaundice
4/34
11.7%
Systemic
condition
Seizures
Skin rashes/
2/34
vesicles
Sepsis
Goldenhars
syndrome
Pseudomonas-2/4,
No organism-2/7
5.88%
Pseudomonas-1/2, HSV-1/2
2.94%
No organism
5.88%
Staphylococcus-2
2.94%
No organism
496
RESULTS
Average age at the time of presentation was 16.91 +7.74 days.
Eight patients had bilateral involvement at presentation.
Symptoms at presentation:
Microbiological Results:
Microbiology +:30/42 eyes
Management:
Medical: All
Fortified
Surgical:
497
Outcomes:
DISCUSSION
Neonatal keratitis has diverse clinical presentation and underlying etiology.
Any watering and discharge in this age group should arouse suspicion and
thorough clinical evaluation for early diagnosis. Possible risk factors include
prolonged hospitalization, underlying systemic and ocular diseases. Most
infections (54.76%) in this period were of bacterial origin, with Pseudomonas
being the commonest bacteria isolated. Early identification of risk factors,
aggressive microbiology work-up and appropriate therapy is needed to
decrease ocular morbidity related to infectious keratitis in neonates.
REFERENCES
1.
2. Cruz OA, Sabir SM, Capo H, Alfonso EC. Microbial keratitis in childhood.
Ophthalmology 1993;100:192-6.
498
Inclusion Criteria
Patients of any age group, preferably cooperative for digital photography, were
included with PED of various etiopathogenesis e.g., Chemical burn, Diabetic
neurotrophic ulcer, Bacterial ulcer. Herpetic neurotrophic ulcer, Keratoplasty
(optical and therapeutic), Dry Eye.
Exclusion Criteria
Patients with the following conditions were excluded: Pregnant and lactating
women, Immunological conditions like rheumatoid arthritis, active corneal
ulcer, impending perforation, acute ocular infection, abnormality of eyelid
and adenexa eg trichiasis, blepharitis, ectropion, entropion. Processing Of
Umbilical Cord serum: Umbilical cord blood was collected from mothers of
uncomplicated caesarean deliveries after informed consent and screening for
hepatitis B, C and HIV. No anticoagulants were used during the procedure.
The blood was allowed to clot and was centrifuged at 1500 rpm for 5 min then
diluted in normal saline to make 20% solution. The serum was stored at -4
degrees C. This diluted umbilical cord serum was stored in 5 ml sterilized
vials and was given to patients. Patients were to apply this serum in drop 6
499
times a day and were asked to store it in a cool place, preferably in a refrigerator
or ice box.
RESULTS
(1) Details of Patient Name, age and address of the patient were noted. His/
her diagnosis (cause of persistent epithelial defect) and past treatment was
also recorded. (2) Visual Acuity (both unaided and best corrected). (3) Proper
slit lamp evaluation was carried out to exclude any adenexal abnormalities as
the cause of PED, cornea was evaluated in full detail, emphasis was paid on
the size and site of epithelial defect, the corneal thickness and vascularization.
(4) Schirmers testwas carried out in each and every patient and was repeated
at every follow up. (5) Fluorescein staining (6) Digital IOP was assessed by
the same examiner in every case. The patients were followed up on days 3, 7,
14, 21, 24, 28 and so on for 6 months. The variables recorded at each follow up
visit were the best corrected visual acuity, the maximum size of the epithelial
defect along two perpendicular axes measured with a slit lamp, and also a
photograph of the same, a record of the side effects if any, and the digital
intraocular pressure.
The effectiveness of the treatment was divided into three groups.
1. Effective Those defects that took less than 2 weeks to heal.
2. Partially Effective Those defects that took less than 4 weeks to heal.
3. Ineffective Those defects that took more than 6 weeks to heal or did not
heal at all.
Table 1: Effectivness of The Treatment
Healing Pattern
Number
Percentage (%)
Effective
12
60%
Partially Effective
06
30%
Ineffective
02
10%
In our study we found that out of 20, 12 patients (60%) showed effective
response to umbilical cord serum eye-drops and 6 patients (30%) showed
partially effective response. However, in the later two cases i.e. (10%), healing
was ineffective (took more than 6 weeks to heal).
Table 2: Duration Taken By The Epithelial Defect To Heal
Time (weeks)
Number
1-2
2-3 7
3-4 3
more than 4 weeks
500
Regarding the duration taken by epithelial defects to heal we see that 8 out
of 20 patients had their epithelial defect healed in 2 weeks (40%), and 4 out
of 20 healed within one week, thus a total of 12(60%) healed within 2 weeks
suggesting the treatment to be effective. There have been no side effects noted
during the entire period of our study suggesting the umbilical cord serum
eye-drops to be safe for the use on ocular surface.
Epithelial defect did not recur in patients who responded to umbilical cord
serum eye-drops, after 6 months of follow up showing that epithelial wound
healing was complete.
DISCUSSION
The cornea produces multiple growth factors such as epidermal growth
factor (EGF) and fibroblast growth factor (FGF), neurotrophic growth factor
which contribute to the maintenance of a healthy epithelial surface and its
regeneration. Persistent epithelial defects is rare but has serious complications.
It has been seen that deficiency of essential tears components such as epidermal
growth factors (EGF), vitamin A, neurotrophic growth factors (NGF) such as
substance P, acetylcholine may exacerbate the lesions.
Umbilical cord serum owes its efficacy to the presence of factors such as EGF,
vitamin A, acidic and basic FGF, fibronectin, nerve growth factor, substance P,
antiproteases like 2 macroglobulin, and enhanced mucin expression due to
the serum.7 The mechanism of action of umbilical cord serum is likely to be
the same as that of autologous serum, the difference being probably a higher
concentration of the growth factors, which may in fact stimulate a faster
growth of stem cells and hence lead to a faster re-epithelialisation.
The results are comparable with the study of Yoon et al (2005) who performed
the study on 14 patients with persistent epithelial defect of various etiologies
and found umbilical cord serum to be effective in 6 patients (42.9%) and partially
effective in 6 patients (42.9%). Umbilical serum treatment has several clinical
advantages, firstly,by obtaining a large quantity of umbilical cord blood from
mothers, the serum can be supplied to many patients. Second, umbilical cord
serum eyedrops can be prepared in advance, thereby shortening the waiting
period for the patients. Finally,even when taking the blood from the patients
themselves is difficult due to poor general condition, umbilical cord serum
remains a feasible option.
Recently Vajpayee et al have reported that since umbilical cord serum contains
a higher concentrations of EGF, Vitamin A, acidic and basic FGF, fibronectin,
NGF, substance P, and antiproteases like alpha 2 macroglobulins, it may be
more useful for the treatment of the ocular surface than autologous serum.
They also reported that the recovery was faster using umbilical cord serum,
501
502
RESULTS
All the patients were males between 14-33 years who had history of penetrating
ocular injury and primary surgical treatment (3 cases had primary corneal
tear repair while 2 cases underwent vitrectomy with IOFB removal.)
Injury
Primary
Penetrating
Sympathetic
Injury to
PK to
history
diagnosis Keratoplasty ophthalmia onset SO Time
SO Time
Interval Interval
1994 Leucoma 2001
2009
16yrs 8Yrs
1996
Leucoma
2005
2006
11yrs
1996
Leucoma
2000
2001
7yrs
1yr
2001
Corneal decom- 2005
pensation
(IOFB removal)
2007
7yrs
3yrs
2007
6yrs
1yr
2002
Corneal decom pensation
(IOFB removal)
2006
1Yrs
Clinical Findings
Sympathizing Eye
Exciting (Post-Pk)Eye
Anterior Segment
Granulomatous uveitis-5 cases
rejection- 5 cases
Glaucoma-4 cases
Posterior Segment
Vitritis-5 cases
Dalen Fuchs Nodule-1 case
Exudative RD-1 case
Vision
Sympathizing Eye
On presentation
Sympathizing Eye
After treatment
Exciting Eye
Post PK, Graft rejection
CF CF
6/60
HM+ve
6/12
6/9p
PL+ve, PR accurate
6/12
6/9p
PL+ve, PR accurate
6/60
6/36
PL+ve, PR accurate
CF 1m
6/36p
6/36
503
2 cases with early presentation had excellent recovery while 3 patients had
moderate recovery due to retinal detachment, extensive RPE atrophy and
glaucomatous cupping.
Oral steroids were given in the dose of 1.5mg/kg body weight and the patients
were continued on a maintenance dose for 1 year. 2 patients were started on
Azathioprine 50mg/day while 1 patient was treated with Methotrexate.
DISCUSSION
Sympathic Ophthalmitis has been reported to occur mainly following trauma.
However it has also been reported to occur following ocular surgery like cataract
surgery, scleral buckling, parsplana vitrectomy7, laser photocoagulation Our
study included patients with sympathetic ophthalmitis developing after
penetrating keratoplasty. The indications for keratoplasty were leucomatous
corneal opacity following primary corneal repair (3 patients) and endothelial
decompensation following IOFB removal (2 patients). According to studies,
penetrating keratoplasty for corneal decompensation following IOFB removal
are at high risk for sympathetic ophthalmitis.8
504
REFERENCES
Liddy L, Stuart J. Sympathetic Ophthalmia in Canada. Can J Ophthalmol 1972;7:157-9.
1.
4.
5.
6.
7.
8.
9.
Immunopatho-
ndothelial cells are crucial to maintain corneal health and its count is
important in any endothelial abnormality.1,2,3 The Cell Count software
505
2.
3.
One hundred images from both healthy and Fuchs endothelial dystrophy
were reviewed by single observer.
4.
5.
RESULTS
52 and 65 images were of right healthy and compromised endothelium
eyes respectively.
Based on manual cell count, endothelial cell density of Fuchs dystrophy
slides divided into two groups.
506
Number of Average
Images
auto count
Average
manual count
Average
difference
Cell count
49
more than
1000 cells / mm2
Cell count
51
less than
1000 cells / mm2
average
manual count
average
difference
0.0463
Fuchs
100 1827.73 334.31 1196.71 637.29 633.04 435.03 1631 to 54 cells <0.0001
Dystrophy
In the first group manual count was more than 1000 cells/mm2 (49 images)
and in the second group manual count was less than 1000 cells/mm2 (51
images)
The cell count differences between the two methods were significantly
higher when cell counts were least, which implies that the difference tends
to increase in eyes with extensive endothelial changes.
The results are summarized in Tables 1 and 2.
DISCUSSION
Advantage of automated mode is that there is no inter-observer variability, it
is faster, repetitive and is independent of users experience and skills.5 On the
other hand manual mode is time consuming needs higher level of technical
skills and thereof it is unsuitable in busy clinic. In our study the results
have shown a large variability between the two methods (as much as up to
more than 900 cells/mm2 difference) in advanced cases of Fuchs dystrophy.
Decision on whether a patient need surgery may be affected by whether we do
it in manual or automated mode thus delaying the surgical intervention on the
final outcome. Both the clinician and investigator need to be sensitive to this
fact and patients with diseased corneas should undergo manual count.
Our study shows that while in healthy corneas, both methods showed similar
counts; in the case of diseased cornea, the accuracy of the automated count
decreased with decrease in total cells. Manual count is therefore more reliable
507
REFERENCES
2. Klais CM, Bhren J, Kohnen T. Comparison of endothelial cell count using confocal
and contact specular microscopy. Ophthalmologica. 2003;217:99-103.
3.
4.
5.
6.
508
RESULTS
Among 990 corneal scrapings/corneal tissues from clinically diagnosed cases
of microbial keratitis at our Institute between November 2006 and December
2009, 61 (6.2%) corneal scrapings of sixty patients were culture positive for S
pneumoniae. The mean age was 45.921.3 years (range: 6 months to 78 years,
median: 50). The male to female ratio was 40:20. Most patients were in the age
group 41-70 years (n=36, 60%).
An ocular predisposing condition was identified in 51 eyes. Fourteen had
undergone keratoplasty and 9 had chronic dacryocystitis. Twenty five eyes
(40.9%) had a history of ocular trauma. Fourteen eyes had polymicrobial
infection. Thirty one eyes required an adjunctive procedure. Five eyes
underwent therapeutic keratoplasty, and 20 eyes underwent tissue adhesive
and bandage contact lens application. The in vitro susceptibility of the isolates
by disc diffusion method was 100% to cefazolin, 95.1% to chloramphenicol,
509
DISCUSSION
S pneumoniae is a common cause of bacterial keratitis. It accounts for around
30-40% of all bacterial keratitis.5-7 Chronic dacryocystitis is a well known
risk factor for microbial keratitis due to S pneumoniae.5,7 It is also reported
as a common pathogen isolated from microbial keratitis after corneal
transplantation. Although trauma is not known to be a common predisposing
factor associated with microbial keratitis due to S pneumoniae, it is a major
predisposing risk factor in our series.
Resistance to penicillin, other beta-lactam and non-beta-lactam compounds
have been reported with an increased frequency in recent years among
clinical isolates of S pneumoniae.8 These strains are effectively killed with
new fluoroquinolones.9 Nevertheless, fluroquinolone resistance among the
pneumococcal clinical isolates have been primarily attributed to mutations
in the quinolone resistance-determining regions of the gyrase A and
topoisomerase IV gene.10
Although ciprofloxacin is effective in vitro against S pneumonae, it is felt that
in vivo efficacy may be inadequate, leading to the choice of fortified cefazoline
as the first line of therapy. In our study, in vitro susceptibility of the isolates
was 100% to cefazolin, 95.1% to chloramphenicol, 90.9% to vancomycin, 88.9%
to gatifloxacin and 78.7% to ciprofloxacin. Ramkrishnan et al have compared
in vitro efficacy of fluroquinolones against S pneumoniae isolated from
bacterial keratitis by E-test.11 They have concluded that S pneumoniae are 100%
sensitive to fluoroquinolones. They also concluded that fourth-generation
fluroquinolone, moxifloxacin appeared to be more effective than gatifloxacin,
levofloxacin, ofloxacin and ciprofloxacin.
In our study, sensitivity to gatifloxacin was more than ciprofloxacin. Compared
to earlier studies,5,11 sensitivity to ciprofloxacin was less in our series. Though,
there was zero resistance to cefazoline, preparation and storage of fortified
solution has its own limitation. In contrast, fluroquinolone are cheap and
readily available commercially. Therefore, till the antibiotic sensitivity results
are not available, patients may be continued with fortified cefazoline and
fluroquinolone eye drops. Fortified cefazoline may be discontinued according
to the clinical response and sensitivity.
REFERENCES
1.
510
2. Baum JL. Initial therapy of suspected microbial corneal ulcers. I. Broad antibiotic
therapy based on prevalence of organisms. Surv Ophthalmol 1979;24:97-105.
3.
Jones DB. Initial therapy of suspected microbial corneal ulcers. II. Specific antibiotic
therapy based on corneal smears. Surv Ophthalmol 1979;24:105-16.
4.
Hyndiuk RA, Cockington CD. Bacterial keratitis. In: Tabbara KF, Hyndiuk RA
(eds.). Infections of the eye: diagnosis and management. Little Brown, Boston, 1996:
32347.
5.
6.
7.
8.
9.
511
512
RESULTS
The FG-assisted augmented AMT was performed in 10 patients (6 women, 4
men) with a mean age of 51.5 +/- 15.3 years (range, 2170 years). The average
follow-up was 4.5 +/- 1.2 months (range, 36 months). Mean ulcer diameter
was 2.87 +/- 0.95 mm (range 24 mm). BCVA was 20/120 or more in all patients
at 6 months. All had well formed anterior chambers and 90% showed complete
epithelialization. Mean reepithelialization time was 15.76+/- 3.95 days. In all
patients the anterior chamber was deep, and there was no further leakage
of aqueous fluid; the site of the ulcer showed a subepithelial scar with, in
some cases, a thickening of the stroma, and epithelialization was complete.
Conjunctival inflammation and pain were reduced in all patients. In none of
the patients was there any evidence of recurrent ulceration or perforation and
the stromal thickness at the perforation site seemed normal and stable during
the follow-up period ( as seen on Anterior segment OCT).
DISCUSSION
Fibrin glue in combination with AMT seems helpful in the treatment of
corneal perforations up to 4 mm in diameter. AM contains a mix of growth
factors, neurotrophins, and cytokines that facilitates proliferation of epithelial
cells and reduce the inflammatory response by inhibiting protease activity
and thus reduce vascularization, inflammation, and scarring. These unique
properties of AM make it useful in the treatment of ulcerative corneal disease.8
The AM does not express the antigens HLA-A, B, or DR and therefore poses no
problem of immunological rejection. AMT may allow postponement of corneal
513
grafting until the eye is less inflamed, thereby improving graft survival or even
avoiding it altogether. The presence of the glue enhances scar tissue formation
as it prevents epithelial downgrowth and stimulates fibroblastic activity while
serving as a matrix for fibroblasts and keratocytes.9
Our study demonstrates the effectiveness of the FG-AMT in the treatment of
refractory large peripheral corneal ulcers. There was a reduction in the level
of conjunctival inflammation and pain after AMT. All patients epithelialized
successfully and had a stable scar over time.
This procedure has several advantages in the treatment of corneal perforations,
especially those of large size. The thickness of each augmented AM is equal
to that of healthy cornea allowing it to completely seal the large perforated
wound and prevent any leakage, hence maintaining a stable anterior chamber.
Additionally, it can be easily manipulated because it was a single piece of AM
instead of several sheets which further allows for a secure wound and also
reduces the surgical time. Also there is early reepithelialization of the corneal
surface as compared with a previous multilayer AMT report. This shows
that FG-assisted augmented AMT is more effective than multilayer AMT in
promoting healing of the epithelial layer in large corneal perforations.10
In conclusion, FG-assisted augmented AMT is a stable alternative for treating
large corneal perforationsespecially those 2 mm or larger in sizewith rapid
regeneration of epithelium and stability during the follow up period. This
technique promotes a stable and rapid reconstruction of the ocular surface
and can also be used as a temporary measure in cases requiring penetrating
keratoplasty at a later time when the eye is less inflamed and the corneal
surface has reepithelialized.
REFERENCES
1.
Nobe JR, Moura BT, Robin JB, et al. Results of penetrating keratoplasty for the
treatment of corneal perforations. Arch Ophthalmol. 1990;108: 939941.
4.
5.
Pfister RR, Sommers CI. Fibrin sealant in corneal stem cell transplantation. Cornea.
2005;24:5938.
6.
Duchesne B, Tahi H, Galand A, Use of human fibrin glue and amniotic membrane
transplant in corneal perforation. Cornea. 2001;20:2302.
514
7.
8.
Hao Y, Ma DH-K, Hwang DG, et al. Identification of antiangiogenic and antiinflammatory proteins in human amniotic membrane. Cornea. 2000;19:34852.
9.
Hick S, Demers PE, Brunette I, et al. Amniotic transplantation and fibrin glue in
the management of corneal ulcers and perforations. A review of 33 cases. Cornea.
2005;24:36977.
515