Corneal cross-linking (CXL), introduced by Wollensak et al. in 2003, is a minimally invasive procedure to halt the progression of keratoconus. Conventional CXL is recommended in eyes with corneal thickness of at least 400 microns after de-epithelialization to prevent endothelial toxicity. However, most of the keratoconic corneas requiring CXL may not fulfill this preoperative inclusion criterion. Moderate-to-advanced cases are often found to have a pachymetry less than this threshold. There are various modifications to the conventional method to circumvent this issue of CXL thin corneas while avoiding the possible complications. This review is an update on the modifications of conventional CXL for thin corneas.
Duane retraction (or co-contraction) syndrome is a congenital restrictive strabismus which can occur either as an isolated entity or in conjunction with other congenital anomalies and is now listed as a congenital cranial dysinnervation disorder. It is characterized by co-contraction of horizontal recti on attempted adduction causing globe retraction along with variable amounts of upshoots or downshoots. It may have limited abduction or adduction or both and present as esotropic, exotropic, or orthotropic Duane. The diagnosis of this disease is usually clinical. However, recent research has provided a greater insight into the genetic basis of this disease paving a way for a greater role of genetics in the diagnosis and management. This disease can have a varied presentation and hence the treatment plan should be tailor-made for every patient. The indications for surgery are abnormal head posture, deviations in the primary position, retraction and narrowing of palpebral aperture and up- or downshoots during adduction, and sometimes also to improve abduction. The arrival of newer surgical techniques of periosteal fixation (PF) of lateral rectus (LR), partial vertical rectus transposition, or superior or inferior rectus transposition in addition to LR recession with Y-split has vastly improved the management outcomes, providing not only primary position orthophoria but also increased binocular visual fields as well.
Visual electrodiagnostics and eye movement recording are important additional clinical tools in evaluation, diagnosing and management of ophthalmic and neurological disorders. Due to their objectiveness and non-invasiveness they can play an important role in pediatric ophthalmology. The WSPOS (World Society of Pediatric Ophthalmology and Strabismus) consensus statement gives insight into basic principles and highlights the clinical application of both visual electrodiagnostic tests and eye movement recording.
Purpose: Limbal ischemia is an important prognostic factor in the management of ocular burns. In this study, we evaluated the reliability of clinically assessing limbal ischemia among ophthalmic professionals. Methods: This study included 111 ophthalmic professionals who were shown 12 diffuse illumination color slit-lamp photographs of eyes with recent chemical injuries. Respondents were asked whether the photos were assessable and if yes, then to indicate the presence, location, and grade of limbal ischemia in each case. The responses were collected using a standard data collection sheet and the inter-observer agreement was calculated. Results: All participants responded to every question. Of the 1,332 responses, images were deemed assessable in 1,222 (91.7%) instances. The overall agreement (Fleiss' kappa) for the presence of limbal ischemia and severity of limbal ischemia was 0.106 and 0.139, respectively (P < 0.012). Among the four groups of observers, practicing cornea specialists displayed significantly (P < 0.003) higher kappa values (0.201–0.203) when compared to residents (0.131–0.185), fellows (0.086–0.127), and optometrists (0.077–0.102). All indicated a poor level of inter-rater consistency. Conclusion: The results indicate that clinical assessment of limbal ischemia is highly subjective and there is lack of reliability even among cornea specialists who regularly manage patients with ocular burns. A non-invasive, standardized, objective, accurate, and reliable modality for ocular surface angiography is desperately needed for proper assessment and prognostication of ocular burns.
Purpose: To determine the levels of dopamine in tear fluid and demonstrate the use of tear fluid as a non-invasive source for dopamine measurements in humans. Methods: The study cohort included 30 clinically healthy individuals without any pre-existing ocular or systemic conditions. Matched tear fluid (using Schirmer's strips and capillary tubes) and plasma were collected from the subjects. Dopamine levels were evaluated using direct competitive chemiluminescent enzyme-linked immunosorbent assay (ELISA), dopamine kit (Cloud Clone Corp, TX, USA). Results: Significantly higher dopamine levels were found in the tear fluid compared to plasma in the study subjects. The level of dopamine was 97.2 ± 11.80 pg/ml (mean ± SEM), 279 ± 14.8 pg/ml (mean ± SEM), and 470.4 ± 37.64 pg/ml (mean ± SEM) in the plasma and in the tears collected using Schirmer's strips and capillary tubes, respectively. Conclusion: Dopamine was detectable in all the tear fluid samples tested and was also found to be at a higher concentration than in plasma samples. Tear fluid can be used as a non-invasive sample source to monitor dopamine levels.
EDITORIAL
Indian Journal of Ophthalmology – On the right path
Rashmi Deshmukh, Farhad Hafezi, George D Kymionis, Sabine Kling, Rupal Shah, Prema Padmanabhan, Mahipal S Sachdev DOI:10.4103/ijo.IJO_1403_18
Corneal cross-linking (CXL), introduced by Wollensak et al. in 2003, is a minimally invasive procedure to halt the progression of keratoconus. Conventional CXL is recommended in eyes with corneal thickness of at least 400 microns after de-epithelialization to prevent endothelial toxicity. However, most of the keratoconic corneas requiring CXL may not fulfill this preoperative inclusion criterion. Moderate-to-advanced cases are often found to have a pachymetry less than this threshold. There are various modifications to the conventional method to circumvent this issue of CXL thin corneas while avoiding the possible complications. This review is an update on the modifications of conventional CXL for thin corneas.
Duane retraction (or co-contraction) syndrome is a congenital restrictive strabismus which can occur either as an isolated entity or in conjunction with other congenital anomalies and is now listed as a congenital cranial dysinnervation disorder. It is characterized by co-contraction of horizontal recti on attempted adduction causing globe retraction along with variable amounts of upshoots or downshoots. It may have limited abduction or adduction or both and present as esotropic, exotropic, or orthotropic Duane. The diagnosis of this disease is usually clinical. However, recent research has provided a greater insight into the genetic basis of this disease paving a way for a greater role of genetics in the diagnosis and management. This disease can have a varied presentation and hence the treatment plan should be tailor-made for every patient. The indications for surgery are abnormal head posture, deviations in the primary position, retraction and narrowing of palpebral aperture and up- or downshoots during adduction, and sometimes also to improve abduction. The arrival of newer surgical techniques of periosteal fixation (PF) of lateral rectus (LR), partial vertical rectus transposition, or superior or inferior rectus transposition in addition to LR recession with Y-split has vastly improved the management outcomes, providing not only primary position orthophoria but also increased binocular visual fields as well.
Visual electrodiagnostics and eye movement recording - World Society of Pediatric Ophthalmology and Strabismus (WSPOS) consensus statement
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Manca Tekavcic Pompe, Alki Liasis, Richard Hertle DOI:10.4103/ijo.IJO_1103_18
Visual electrodiagnostics and eye movement recording are important additional clinical tools in evaluation, diagnosing and management of ophthalmic and neurological disorders. Due to their objectiveness and non-invasiveness they can play an important role in pediatric ophthalmology. The WSPOS (World Society of Pediatric Ophthalmology and Strabismus) consensus statement gives insight into basic principles and highlights the clinical application of both visual electrodiagnostic tests and eye movement recording.
Limbal ischemia: Reliability of clinical assessment and implications in the management of ocular burns
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Ka Wai Kam, Chaitali N Patel, Neda Nikpoor, Marco Yu, Sayan Basu DOI:10.4103/ijo.IJO_945_18
Purpose: Limbal ischemia is an important prognostic factor in the management of ocular burns. In this study, we evaluated the reliability of clinically assessing limbal ischemia among ophthalmic professionals. Methods: This study included 111 ophthalmic professionals who were shown 12 diffuse illumination color slit-lamp photographs of eyes with recent chemical injuries. Respondents were asked whether the photos were assessable and if yes, then to indicate the presence, location, and grade of limbal ischemia in each case. The responses were collected using a standard data collection sheet and the inter-observer agreement was calculated. Results: All participants responded to every question. Of the 1,332 responses, images were deemed assessable in 1,222 (91.7%) instances. The overall agreement (Fleiss' kappa) for the presence of limbal ischemia and severity of limbal ischemia was 0.106 and 0.139, respectively (P < 0.012). Among the four groups of observers, practicing cornea specialists displayed significantly (P < 0.003) higher kappa values (0.201–0.203) when compared to residents (0.131–0.185), fellows (0.086–0.127), and optometrists (0.077–0.102). All indicated a poor level of inter-rater consistency. Conclusion: The results indicate that clinical assessment of limbal ischemia is highly subjective and there is lack of reliability even among cornea specialists who regularly manage patients with ocular burns. A non-invasive, standardized, objective, accurate, and reliable modality for ocular surface angiography is desperately needed for proper assessment and prognostication of ocular burns.
Purpose: To determine the levels of dopamine in tear fluid and demonstrate the use of tear fluid as a non-invasive source for dopamine measurements in humans. Methods: The study cohort included 30 clinically healthy individuals without any pre-existing ocular or systemic conditions. Matched tear fluid (using Schirmer's strips and capillary tubes) and plasma were collected from the subjects. Dopamine levels were evaluated using direct competitive chemiluminescent enzyme-linked immunosorbent assay (ELISA), dopamine kit (Cloud Clone Corp, TX, USA). Results: Significantly higher dopamine levels were found in the tear fluid compared to plasma in the study subjects. The level of dopamine was 97.2 ± 11.80 pg/ml (mean ± SEM), 279 ± 14.8 pg/ml (mean ± SEM), and 470.4 ± 37.64 pg/ml (mean ± SEM) in the plasma and in the tears collected using Schirmer's strips and capillary tubes, respectively. Conclusion: Dopamine was detectable in all the tear fluid samples tested and was also found to be at a higher concentration than in plasma samples. Tear fluid can be used as a non-invasive sample source to monitor dopamine levels.
Purpose: To study the demographic profile, clinical features, treatment outcome, and ocular morbidity of microbiologically proven Pythium keratitis in South India. Methods: A retrospective analysis of clinical records of microbiologically proven Pythium keratitis at a tertiary eye care referral center in South India from January 2016 to November 2017 was performed. Demographic details, predisposing risk factors, microbiological investigations, clinical course, and visual outcome were analyzed. Results: Seventy-one patients with microbiologically proven Pythium keratitis were identified. The mean age was 44(±18.2) years with an increase in male preponderance and 50% were farmers. Duration of delay at time of presentation to the hospital was a mean of 14(±7.2) days. The visual acuity at baseline ranged from 6/6 to no light perception (median 2.1 logMAR). A combination of 5% natamycin and 1% voriconazole was given to 42% patients, and natamycin alone was given to 39.4% patients. 1% itraconazole eye drops alone was initiated in 7 (10%) patients and 3 among this group responded. Therapeutic keratoplasty (TPK) was performed in 48 (67.6%) patients. None of the primary grafts remained clear after a period of 1 month. Twenty-six eyes (54.2%) had graft reinfection and all these eyes either developed anterior staphyloma (4) or were eviscerated (3) and 13 eyes became phthisical. The remaining 22 patients who had TPK resulted in failed graft. Among these, re-grafts were performed in 6 patients, of which 5 were doing well at the last follow-up. Conclusion: We report a large series of patients with Pythium keratitis. Promoting early and differential diagnosis, awareness of clinicians and specific treatment options are needed for this devastating corneal disease.
Purpose: To report the distribution and trends of types of organisms and antibiotic susceptibility of the bacterial isolates obtained from patients with microbial keratitis. Methods: Microbiology records of culture-positive microbial keratitis that underwent a diagnostic corneal scraping and cultures were reviewed. Fungal, bacterial, and parasitic culture results and antibiotic susceptibility profile of bacteria were analyzed and comparisons were made between two halves of the study period (2007–2010 vs. 2011–2014). Results: A total of 3981 corneal scrapings were processed during the 8-year study period. Pathogen was recovered in culture in 1914 (48.1%) samples. Fungi, bacteria, and parasites constituted 38.7%, 60%, and 1.3% of the total isolates, respectively. The common fungal isolates were Aspergillus spp. (224/868, 25.8%) and Fusarium spp. (200/868, 23.0%), while common Gram-positive bacteria were Streptococcus pneumoniae (217/1125, 19.3%) and Staphylococcus aureus (185/1125, 16.4%), and common Gram-negative bacteria was Pseudomonasspp. (99/219, 45.2%). There was no significant difference in proportion of bacterial (P = 0.225) and fungal (P = 0.421) keratitis between the first half and second half of the study period. There was a significant increase in proportion of Gram-positive isolates (P = 0.015) [353/758 (46.6%) vs. 772/1482 (52.1%)] and decrease in proportion of Gram-negative organisms (P = 0.044) [88/758 (11.6%) vs. 131/1482 (8.8%)] in the recent years. In-vitro antibiotic susceptibility testing showed decrease in susceptibility to moxifloxacin for Pseudomonas spp. (P = 0.016) in recent years. Conclusion: Prevalence of fungal and bacterial keratitis has remained unchanged over the years. This study shows a significant increase in Gram-positive bacterial infection and decrease in Gram-negative bacterial infection of the cornea in the recent years.
The novel model: Experimental optical coherence tomography–guided anterior segment imaging chick embryo model
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Resat Duman, Tolga Ertekin, Rahmi Duman, Esra Aslan, Mehmet Cem Sabaner, Ersan Çetinkaya DOI:10.4103/ijo.IJO_263_18
Purpose: The aim of this study was to present an experimental optical coherence tomography (OCT)–guided anterior segment (AS) imaging chick embryo model. Through this model, we aimed to reveal similarities and differences between human cornea, AS tissues, and chick embryo tissues by quantitative image analysis. Methods: Ex vivo, the chick embryos' globes were determined by detailed AS camera of spectral-domain (SD)-OCT in 10 fertilized specific pathogen-free eggs on the 20th day. Quantitative image analysis of anterior chamber tissues was performed with SD-OCT in detail. After imaging, cross sections of the chick embryo globes containing cornea with anterior chamber were histologically examined and compared with human tissues. The similarities of our model with data in the human cornea and AS studies in the literature were compared. Results: SD-OCT imaging was able to successfully delineate the AS tissues of chick embryos such as the cornea, iris, lens, pupil, conjunctiva, ciliary body, anterior chamber, and lens. Quantitative semi-automated measurements showed the following: mean central corneal thickness: 213.4 ± 7.05 μm (197–223 μm), mean anterior chamber depth: 878.9 ± 41.74 (804–919 μm), mean anterior chamber area: 2.43 ± 0.16 mm2 (2.17–2.73 mm2), mean corneoscleral junction (limbal) thickness: 322.8 ± 20.05 μm (289–360 μm), and mean iris thickness: 230.4 ± 13.27 μm (203–245 μm). In addition, detailed histological comparisons of the AS tissues with human tissues were evaluated to be very similar. Conclusion: In conclusion, this chick embryo model mimics human tissues and it can be considered as a platform for the study of teratogen-induced malformations and AS dysgenesis during gestation of AS tissues. In addition, this study demonstrates the feasibility of SD-OCT in the quantitative assessment of AS structures in chick embryo model.
Purpose: To compare the visual outcomes and complications between the eyes receiving retropupillary iris claw intraocular lens (IOL) and scleral-fixated IOL (SFIOL) for post-cataract aphakia. Methods: Medical records of consecutive patients who had iris claw IOL and SFIOL surgery from January 2010 to March 2015, with > 1 year of follow up were retrospectively analyzed. The surgical technique was based on individual surgeon preference. The best-corrected distance visual acuity (BCDVA), previous surgery, surgical technique, and complications were analyzed. Results: Retropupillary iris claw IOL was fixated in 48 eyes (46%) and SFIOL was performed in 56 eyes. Iris claw was performed more frequently at the time of primary cataract surgery (56%) compared to SFIOL (14%) (P < 0.001). At 1 month postoperative, BCDVA was significantly better in the SFIOL group [0.7 ± 0.5 logarithm of minimum angle of resolution (logMAR) in iris claw vs. 0.3 ± 0.2 logMAR in SFIOL, P < 0.001] but this difference did not persist at 1 year (0.4 ± 0.4 logMAR in iris claw vs. 0.3 ± 0.2 logMAR in SFIOL, P = 0.56). Eyes with iris claw IOL experienced significantly more postoperative iritis (17%), intraocular pressure spikes (10%), and ovalization of the pupil (16%). Conclusion: Retropupillary iris claw IOL fixation is as safe as SFIOL for visual rehabilitation of post-cataract aphakia. Visual rehabilitation following iris claw IOL might take longer than SFIOL. Ovalization of the pupil is the commonest adverse effect reported with this type of IOL design.
Novel technique of sutureless glueless scleral fixated intraocular lens (SFIOL)
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Shweta Walia, Santosh Kashyap, V Bhaisare, P Rawat, N Kori DOI:10.4103/ijo.IJO_447_18
Purpose: To report results of a novel technique for sutureless, glueless intrascleral fixation of three-piece posterior chamber intraocular lens (IOL) using 26-G needle for management of aphakia. Methods: In this prospective series, 30 eyes of 20 patients with aphakia, subluxated IOL, or crystalline lens were included. 26-G-needle-guided intrascleral fixation of three-piece posterior chamber IOL was performed according to the described technique. The patients were evaluated on day 2, 1 week, 6 weeks, and 3 months postoperatively for change in best-corrected visual acuity (BCVA), intraocular pressure (IOP), IOL centration, and any other complications. The postoperative tilt of the IOL was indirectly measured by determining the lenticular astigmatism which in turn was calculated by the difference between net corneal astigmatism and refractive astigmatism. Paired t-test was used to determine the significance of any association between the preoperative and postoperative BCVA and IOP. P < 0.05 was considered significant. Results: Of 30 eyes (n = 30 patients), 18 were surgical aphakia, 6 traumatic aphakia, 5 subluxated IOL, and 1 ectopia lentis (Marfan syndrome). The mean preoperative BCVA was 1.37 ± 0.37 (logMAR) and postoperative BCVA at 3 months was 0.37 ± 0.29 (logMAR). A significant improvement in the mean BCVA (P < 0.05) was observed after the procedure. The mean IOP preoperatively was 13.33 ± 4.18 and postoperatively at 3 months was 12.82 ± 3.97 (P > 0.05), which was not significant. None of the eyes developed any intraoperative and postoperative complications. The IOLs had appropriate centration and stability. Conclusion: We have developed this new technique for intrascleral IOL fixation which is quite simple, cost-effective, minimally invasive, neither requires glue nor suture and gives consistent outcome.
Safety and efficacy of dexamethasone implant along with phacoemulsification and intraocular lens implantation in children with juvenile idiopathic arthritis associated uveitis
Purpose: To assess the safety and efficacy of intraoperative intravitreal dexamethasone implant in patients of juvenile idiopathic arthritis (JIA)-associated uveitis undergoing phacoemulsification with posterior chamber intraocular lens (PCIOL) implantation. Methods:Retrospectively, data of patients with JIA-associated uveitis undergoing phacoemulsification with PCIOL implantation with intraoperative dexamethasone implant injection were analyzed. Patients with a minimum follow-up of 6 months were included. Primary outcome measures were ocular inflammation, intraocular pressure (IOP), best-corrected visual acuity (BCVA), and worsening of uveitis. Results: 8 eyes of 6 patients were included. BCVA was significantly improved at 1, 3, and 6 months postoperatively 0.20 ± 0.09, P = 0.008; 0.18 ± 0.11, P = 0.008; and 0.24 ± 0.11, P = 0.01, respectively. No statistical difference noted in mean IOP at various follow-up visits. None developed worsening of uveitis or Cystoid macular edema. Conclusion: Intraoperative intravitreal dexamethasone implant is a safe and effective in preventing and managing the postoperative inflammation in children with JIA-associated uveitic cataract.
Linear discriminant score for differentiating early primary open angle glaucoma from glaucoma suspects
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Gunjan A Deshpande, Prashant K Bawankule, Dhananjay V Raje, Moumita Chakraborty DOI:10.4103/ijo.IJO_678_18
Purpose: To determine the diagnostic accuracy of a linear discriminant function (LDF) based on macular ganglion cell complex (GCC), optic nerve head (ONH) and retinal nerve fibre layer (RNFL) for differentiating early primary open-angle glaucoma (POAG) from glaucoma suspects. Methods: In this cross-sectional study, data from consecutive 127 glaucoma suspects and 74 early POAG eyes were analysed. Each patient underwent detailed ocular examination, standard automated perimetry, GCC and ONH and RNFL analysis. After adjusting for age, gender and signal strength using the analysis of covariance; Benjamin–Hochberg multiple testing correction was performed to detect truly significant parameters to calculate the LDF. Subsequently, diagnostic accuracy of GCC and ONH and RNFL were determined. The obtained LDF score was evaluated for diagnostic accuracy in another test set of 32 suspect and 19 glaucomatous eyes. Data were analysed with the R-3.2.1 (R Core Team 2015), analysis of variance, t-test, Chi-square test and receiver operating curve. Results: Among all GCC parameters, infero temporal had the best discriminating power and average RNFL thickness and vertical CDR among ONH and RNFL parameters. LDF scores for GCC had AUROC of 0.809 for a cut-off value 0.07, while scores for ONH and RNFL had AUROC of 0.903 for a cut-off value − 0.24. Analysis on combined parametric space resulted in avg RNFL thickness, vertical CDR, min GCC + IPL and superior GCC + IPL as key parameters. LDF scores obtained had AUROC of 0.924 for a cut-off value 0.1. The LDF was applied to a test set with an accuracy of 84.31%. Conclusion: The LDF had a better accuracy than individual GCC and ONH and RNFL parameters and can be used for diagnosis of glaucoma.
The impact of primary open-angle glaucoma: Comparison of vision-specific (National Eye Institute Visual Function Questionnaire-25) and disease-specific (Glaucoma Quality of Life-15 and Viswanathan 10) patient-reported outcome (PRO) instruments
Purpose: To compare a general vision-specific patient-reported outcomes (PRO) instrument, National Eye Institute Visual Function Questionnaire-25 (NEIVFQ-25) with two disease-specific PRO instruments, Glaucoma Quality of Life-15 (GQL-15), and Viswanathan 10 in patients with varying severity of primary open angle glaucoma (POAG). Methods: This hospital-based, prospective study enrolled 140 glaucoma patients. The patients were classified into mild, moderate, and severe glaucoma based on visual field defects. All these patients were administered the three PRO instruments and the results were statistically analyzed. Results: All the three instruments showed high internal consistency (Cronbach's alpha for GQL-15, NEIVFQ-25, and Viswanathan 10 were 0.918, 0.937, and 0.929, respectively) There was a statistically significant difference between patients with mild, moderate, and severe POAG with all instruments (P ≤ 0.001). The instruments correlated well across several parameters especially the peripheral vision and glare/dark adaptation. The disease-specific scales however are simpler and faster to administer. Conclusion: All three instruments were reliable in assessment of mild, moderate, and severe glaucoma. They correlated strongly with each other in most of the related subscales, domains, and questions. NEIVFQ-25 additionally gave information regarding the general, psychological, and social effects of the disease.
Purpose: To evaluate the effect of acute submaximal exercise on intraocular pressure (IOP) fluctuations in open-angle glaucoma (OAG) subjects using an ocular telemetry sensor (OTS, Sensimed TriggerFish®). Methods: Twelve OAG subjects aged 45–65 years with no medical limitation for exercise were included in this prospective study. A submaximal exercise test was performed using a cycle ergometer for 20 min during which OTS voltages and metabolic parameters were recorded continuously. IOP voltages taken before, during, and after exercise were compared using the Friedman test and correlations with the metabolic parameters were evaluated using the Spearman analysis. Results: In two subjects, the OTS stopped functioning after a few hours. Median OTS measurements were 37.60 mVeq 10 min before exercise [interquartile range (IQR) 137.27], 51.75 (IQR 121.2), 62.35 (IQR 123.72), 54.6 (IQR 141.3), and 59.7 mVeq (IQR 196.7) during exercise (4 time points, 5 min apart), and 50.7 (IQR 147.35) and 64.2 mVeq (IQR 103.25) 10 and 30 min after exercise and the change was statistically non-significant (P = 0.66). No correlations were found between OTS and metabolic parameters measured at the same time points (P > 0.05). Nocturnal acrophase pattern was detected in five subjects (50%), diurnal acrophase in two patients, and double-hump in two patients. Median IOP voltages in the morning, afternoon/evening, and night were 335.84, 149.15, and 341.38 mVeq, respectively (P < 0.001). Conclusion: Continuous IOP monitoring did not reveal a remarkable voltage change in OAG patients during or immediately after exercise, but nocturnal IOP peaks in half of the patients.
Surgical outcomes of repeat trabeculectomy augmented with high dose mitomycin C
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Sharmila Rajendrababu, Sujani Shroff, Sangeeta Vivek Patil, Mohammed Sithiq Uduman, Ashok Vardhan, SR Krishnadas DOI:10.4103/ijo.IJO_682_18
Purpose: To evaluate the surgical outcomes of repeat trabeculectomy augmented with risk factor adjusted mitomycin C (MMC) exposure in eyes with previous failed trabeculectomy. Methods: Case records of 38 eyes of 37 patients with previous failed filter who underwent repeat trabeculectomy with MMC were reviewed retrospectively. Main outcome measures were best-corrected visual acuity (BCVA), intraocular pressure (IOP) reduction, requirement of anti-glaucoma medications, postoperative complications, and surgical success (defined as IOP of ≤21 mmHg and >5 mmHg along with 20% reduction from preoperative IOP with or without adjuvant medications) at 1-year postoperatively. Statistical analysis was done using the STATA 14.1 (Texas, USA). Results: Patient's mean age was 46.41 (±20.43) years and the mean preoperative IOP was 32.73 (±9.26) mmHg which reduced to 16.22 (±7.08) mmHg postoperatively at 12 months (P < 0.001). Mean number of anti-glaucoma medications reduced from 2.76 (±0.83) preoperatively to 1.89 (±0.95) postoperatively (P < 0.001). Surgical success was observed in 81.1% at 1 year (n = 30). Eyes that received MMC >3 min had a postoperative mean IOP of 12.50 (±3.23) mmHg compared to 23.08 (±7.19) mmHg with MMC <3 min (P < 0.001). Seven eyes (18.4%) developed postoperative complications, and all were seen in eyes that received MMC >3 min (P = 0.033). Conclusion: Repeat trabeculectomy with MMC, used in higher concentration and exposure time altered according to individual risk factor plays a crucial role in the success and hence it could be considered as a viable option before planning a tube surgery.
Purpose: To elucidate the clinical profile of visual impairment (VI) and rehabilitation of the uveitic patients with irreversible low vision. Methods: Retrospective analysis of visual rehabilitation of patients with uveitis suffering from poor vision with low vision devices (LVD). Results: Most common cause of uveitis was choroiditis (46.29%), followed by retinitis (25.92%), retinochoroiditis (18.51%), and chronic panuveitis sequelae (9.25%). Of these 54 cases, 35.18% had moderate VI, 25.92% had severe VI, 20.37% had mild VI, and 18.51% had profound VI or blindness. Statistically significant improvement (P < 0.05) in near vision was seen in choroiditis (52%) and retinitis (72%), whereas clinically significant improvement in distance vision was found in patients with choroiditis. Most commonly prescribed LVD was half-eye prismatic spectacle magnifier (22.2%). Conclusion: Rehabilitation of the uveitic patients with low vision is challenging. LVD may be a beneficial tool in these patients to help them perform their day-to-day activities independently.
Response to anti-vascular endothelial growth factor of abnormal retinal vascular net in para foveal telangiectasia group II images on optical coherence tomography-angiography
Purpose: To identify optical coherence tomography-angiography (OCT-A) findings to predict treatment response during anti-vascular endothelial growth factor (VEGF) therapy in eyes with para foveal telangiectasia (PFT) group II. Methods: In this retrospective series, Twelve eyes of seven patients diagnosed with PFT group II without evidence of sub-retinal neovascular membrane (SRNVM) clinically or on spectral domain-OCT (SD-OCT) were included. All patients underwent OCT-A on the Topcon DRI OCT Triton® with 4.5 mm macula scans. The patients with abnormal vascular nets were further classified into type A and B nets and administered intravitreal anti-VEGF therapy. Visual acuity and size of type A and B nets were evaluated pre- and post-injection. Paired t- test and intraclass correlation were used to analyse data. Results: Patients with type A net showed significant improvement in visual acuity (logMAR 0.38, P = 0.0047). The size of type A net showed statistically significant decrease (P = 0.0008) on 6 month follow up. Type B net did not show statistically significant difference in visual acuity or size following anti-VEGF therapy. Conclusion: OCT-A plays an important role in early detection of possible neovascular nets (type A), in the absence of obvious SRNVM. Treatment decisions based on OCT-A may be helpful to achieve better visual outcome.
Clinical and electrophysiological results of eye muscle surgery in 17 patients with downbeat nystagmus
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Richard W Hertle, Ashraf Ahmad DOI:10.4103/ijo.IJO_703_18
Purpose: To test the hypothesis that eye muscle surgery in treatment of patients with acquired downbeat nystagmus results in improvement measures of visual and ocular motor function. Methods: This is a prospective, interventional case series analysis of clinical and electrophyisological data before and after eye muscle surgery in 17 patients with acquired downbeat nystagmus who did not respond to medical treatments. Outcome measures included: 1) routine demography and clinical characteristics, 2) subjective oscillopsia (SO), 3) binocular best-corrected visual acuity in the null position (BVA), 3) primary position strabismic deviation (SD), 5) anomalous head posture (AHP), 6) contrast sensitivity function (CS), and 7) nystagmus slow phase velocity (SPV). All patients were followed at least 12 months. Parametric and non-parametric statistical analysis of outcome measure data above pre- and post-treatment were perfomed using standard software on grouped data using computerized software. Results: Patients' age ranged from 5 to 85 years (average 27 years). About 59% were male. Follow up ranged from 1–10 years (average 2.0 years). Around 70% had an associated central nervous systemic diagnosis, 100% had an AHP, oscillopsia and decreased CS, 53% had other eye disease, and 59% had strabismus. There were no complications from surgery. There were signficant post-treatment improvements in mean/median group BVA, SO, SD, AHP, CS, and SPV. Conclusion: This study supports the hypothesis that eye muscle surgery as treatments for patients with acquired downbeat nystagmus can result in improvements in multiple aspects of ocular motor and visual functions.
Ligneous conjunctivitis (LC) is a rare form of pseudomembranous conjunctivitis seen in children, perhaps due to plasminogen deficiency, which manifest as a chronic refractory pseudomembranous conjunctivitis. LC cases are incapable in maintaining their fibrinolytic activity due to plasminogen deficiency; consequently, transudates of plasma assume as a thick, gelatinous, woody membranes over the mucosal surfaces. This is a short case report on a child with a LC, who presented with recurrent pseudomembranous conjunctivitis in conjunction with progressive congenital hydrocephalus due to aqueductal stenosis (Dandy–Walker syndrome). This rare association was clinically confirmed and prompt corrective surgical measures were instituted.
Treatment of corneal neovascularization with topical aflibercept in a case of exposure keratopathy following cerebellar astrocytoma surgery
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Sibel Aksoy DOI:10.4103/ijo.IJO_418_18
In this report, we report the case of a 7-year-old boy with corneal neovascularization due to exposure keratopathy following cerebellar astrocytoma surgery. Corneal surface healing was achieved with topical treatment and therapeutic contact lens, after which topical steroid was administered for stromal haze and corneal neovascularization. After 2 months of steroid therapy failed, corneal neovascularization responded well to topical aflibercept administration, showing complete regression.
Chelsey A Bravenec, Rahul T Pandit, Hilary A Beaver DOI:10.4103/ijo.IJO_617_18
A 75-year-old male with a right eye history of chronic dry eye syndrome, glaucoma status post tube shunt, and Fuchs dystrophy status post Descemet stripping endothelial keratoplasty followed by penetrating keratoplasty (PKP) presented with a 2.7 × 4.2 mm corneal ulcer, culture positive for Shewanella algae and Klebsiella oxytoca. A topical antibiotic regimen of gentamicin 14 mg/mL and vancomycin 50 mg/mL was administered according to culture sensitivities. There was concurrent use of loteprednol 0.5% (Lotemax Gel, Bausch and Lomb, Rochester, NY, USA) and later addition of erythromycin 0.5% ointment. The corneal ulcer improved with antibiotic therapy but was complicated by poor patient follow-up. Descemetocele formation prompted PKP in the right eye. The graft was successful and visual acuity improved from a low of light perception to maximum of 20/200 Snellen.
A 55-year-old lady developed a corneal ring infiltrate following trauma with a wooden stick. 10% KOH mount of corneal scrapings revealed septate hyaline fungal filaments. White feathery colonies with shiny black dots grew on potato dextrose agar. Characteristic features of Pestalotiopsis spores were seen on Lactophenol cotton blue mount. DNA sequencing showed 99% similarity with Pseudopestalotiopsis theae. Complete resolution was noted with topical and oral antifungals. To the best of our knowledge, this is the first report of Pseudopestalotiopsis keratitis following trauma with vegetative matter highlighting the role of DNA sequencing in identification of rare fungi.
In vivo confocal microscopy and anterior segment optical coherence tomography follow-up of cysteamine treatment in corneal cystinosis
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Huseyin Baran Ozdemir, Mehmet Cüneyt Özmen, Zeynep Aktas, Murat Hasanreisoglu DOI:10.4103/ijo.IJO_736_18
A 36-year-old female presented initially with photophobia and visual deterioration. After examination and laboratory tests, patient was diagnosed with cystinosis. Cysteamine drops 4 × 1 drops/day was given as treatment for 1 year. During follow-up, in vivo confocal microscopy (IVCM) and anterior segment optical coherence tomography (AS-OCT) was performed. Photophobia was relieved and IVCM obtained the decrease in size and density of corneal crystals 1 year after. Depth of corneal crystals did not change but crystal density score reduced with cysteamine treatment.
Femtosecond laser-assisted successful management of subluxated cataractous lens with vitreous in anterior chamber
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Jeewan S Titiyal, Manpreet Kaur, Anubha Rathi, Ruchita Falera DOI:10.4103/ijo.IJO_764_18
Femtosecond laser-assisted cataract surgery was performed in a case of posttraumatic cataract with six clock hours subluxation and vitreous in the anterior chamber (AC). Femtosecond laser pretreatment allowed a closed-chamber creation of corneal incisions, capsulotomy, and lens fragmentation with minimal sudden lens-diaphragm movements and zonular stress. Integrated imaging systems allowed customization of the size and position of capsulotomy and nuclear fragmentation, based on the extent and site of subluxation. Presence of vitreous in AC did not hamper femtosecond laser application. Triamcinolone-assisted vitrectomy was performed before phacoemulsification and after implanting the intraocular lens (IOL). Postoperative uncorrected visual acuity was 20/20 with a stable IOL.
Uma Sharan Tiwari, Ankita Aishwarya, Shashi Gandhi, Priya Sisodia DOI:10.4103/ijo.IJO_843_18
Live worm in anterior chamber is a rare finding. We hereby report a case of ocular Angiostrongylus cantonensis, which, to the best of our knowledge, is the third case report from India. A 70-year-old female presented with the complaints of watering and foreign body sensations in right eye since 2 months. On examination, a translucent worm of approximately 15 mm length was found freely moving in anterior chamber. Patient underwent surgical removal of live worm, which was identified as A. cantonensis. Educating people regarding importance of hygiene is important for prevention of worm infestation.
Acute hypertensive uveitis as the first presentation of multiple sclerosis
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Melissa Kate Shields, Sumu Simon, WengOnn Chan, Jagjit S Gilhotra DOI:10.4103/ijo.IJO_345_18
Ophthalmic manifestations of multiple sclerosis are frequent including acute optic neuritis, ocular motor disturbances and intermediate uveitis. We report an unusual case of multiple sclerosis presenting as acute hypertensive uveitis. A 56-year-old man was referred by his family doctor with a 2-week history of right eye pain and decreased vision. Best-corrected visual acuity was Count Fingers on the right and 6/9-2 on the left. Intraocular pressure was 55mmHg and 14 mmHg on the right and left respectively. He had a right relative pupillary defect and a left internuclear ophthalmoplegia. Vitreous cells were present in the right eye and there was peripheral sclerosis and periphlebitis superior temporally. MRI Brain and Spine revealed multiple T2 hyperintense lesions consistent with multiple sclerosis. Multiple sclerosis may present initially with an acute elevation of intraocular pressure and intermediate uveitis.
Familial Blau syndrome:First molecularly confirmed report from India
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Mahesh Janarthanan, Chanchal Poddar, S Sudharshan, Luis Seabra, Yanick J Crow DOI:10.4103/ijo.IJO_671_18
Blau syndrome (BS) is a rare autoinflammatory disorder characterized by the clinical triad of arthritis, uveitis, and dermatitis due to heterozygous gain-of-function mutations in the NOD2 gene. BS can mimic juvenile idiopathic arthritis (JIA)-associated uveitis, rheumatoid arthritis, and ocular tuberculosis. We report a family comprising a mother and her two children, all presenting with uveitis and arthritis. A NOD2 mutation was confirmed in all the three patients – the first such molecularly proven case report of familial BS from India.
In this report, we describe a rare case of a 44-year-old Asian male with acute central serous chorioretinopathy (CSC) with bullous exudative retinal detachment. Endocrinology evaluation revealed hypothalamic–pituitary–adrenal axis suppression with low serum cortisol. Furthermore, neuroimaging revealed the presence of a pituitary microadenoma. He was treated with systemic eplerenone and hydrocortisone. After 12 weeks, bullous detachment completely resolved. Our case is a unique description of acute CSC with underlying low serum cortisol levels that responded to treatment with mineralocorticoid antagonist. This case highlights the various endocrine abnormalities other than the raised serum cortisol that can occur in patients with CSC.
Comment on: Optical coherence tomography angiography in acute unilateral nonarteritic anterior ischemic optic neuropathy: A comparison with the fellow eye and with eyes with papilledema
Response to comment on: Optical coherence tomography angiography in acute unilateral nonarteritic anterior ischemic optic neuropathy: A comparison with the fellow eye and with eyes with papilledema
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Uppal Gandhi, Jay Chhablani, Preeti P Chhablani DOI:10.4103/ijo.IJO_1771_18
Response to comment on: Feasibility and safety of vitrectomy under topical anesthesia in an office-based setting
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Gloria P Trujillo-Sanchez, Alejandro Gonzalez-De la Rosa, Jose Navarro-Partida, Luis Haro-Morlett, Juan C Altamirano-Vallejo, Arturo Santos DOI:10.4103/ijo.IJO_1516_18
Nawazish Fatma Shaikh, Vinod Kumar Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
Date of Web Publication
21-Dec-2018
Correspondence Address: Dr. Vinod Kumar Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi - 110 029 India
Source of Support: None, Conflict of Interest: None
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DOI: 10.4103/ijo.IJO_1834_18
How to cite this article: Shaikh NF, Kumar V. Hypopigmented fundus in a young male. Indian J Ophthalmol 2019;67:7
How to cite this URL: Shaikh NF, Kumar V. Hypopigmented fundus in a young male. Indian J Ophthalmol [serial online] 2019 [cited 2018 Dec 22];67:7. Available from: http://www.ijo.in/text.asp?2019/67/1/7/248137
Case
A 3-year-old boy presented with alternate convergent squint and abnormal movements of eyes since 1 year. Family and systemic history was unremarkable. The child had a best-corrected visual acuity of 20/100 in both eyes (OU). Ocular examination revealed pendular nystagmus and normal anterior segments in OU. Iris OU was brown-colored. Dilated fundus examination revealed a hypopigmented fundus with prominent choroidal vessels [Figure 1]a, [Figure 1]b. Macular pigments and foveal avascular zone (FAZ) were lacking in OU.
Figure 1: Dilated fundus examination revealed a hypopigmented fundus with prominent choroidal vessels (a and b). Macular pigments and foveal avascular zone (FAZ) were lacking in OU. Swept-source optical coherence tomography revealed an absent foveal contour and preservation of retinal layers in the foveal area (c and d)
The child had a refractive error of + 3D in OU. Color vision was found to be normal for the child. Swept-source OCT revealed an absent foveal contour and preservation of retinal layers in the foveal area [Figure 1]c, [Figure 1]d. A diagnosis of ocular albinism and foveal hypoplasia was made, and the parents were explained about the prognosis. The child was prescribed glasses and was advised regular follow-up in addition to a strabismic evaluation.
Diagnosis
Ocular albinism with foveal hypoplasia
Correct Answer: A.
Discussion
Ocular albinism is an X-linked disorder in contrast to oculocutaneous albinism, which is inherited in a autosomal recessive manner.[1],[2] Patients usually present with a variable decrease in visual acuity (visual acuity ranging from 20/60 to 20/400), nystagmus, strabismus, and photophobia. While oculocutaneous albinism is an easy diagnosis, ocular albinism may pose a diagnostic challenge as iris may not be hypopigmented.[1],[2] The patients are frequently mistaken as having myopia as the fundus is lightly pigmented. Foveal hypoplasia is a frequent association and can be easily missed. Absent foveal reflex, FAZ, and macular pigments indicate foveal hypoplasia, which can be confirmed on OCT (preservation of retinal layers at fovea) or fundus fluorescein angiography (absent FAZ).
Ocular albinism is characterized by mutation in the GPR143 gene leading to dysfunctional melanosome ultimately resulting in macromelanosomes.[1],[2] Melanin acts as an inducer and organizer of the formation of the fovea, optic nerves, optic tracts, and visual cortex. Absence or deficiency of melanin leads to ocular structure malformation and optic tract misrouting.
To conclude, high index of suspicion is required to diagnose ocular albinism as the fundus in these cases is easily confused with myopia.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
De Filippo E, Schiedel AC, Manga P. Interaction between G protein-coupled receptor 143 and tyrosinase: Implications for understanding ocular albinism type 1.J InvestDermatol2017;137:457-65.
The Scientific Journal of Al-Azhar Medical Faculty, Girls 2018 2(3):137-143
Background The magnitude of stress response depends on several factors such as duration and intensity of surgical trauma, patient’s age, surgical method, anesthetic technique, blood loss, and postoperative pain. Aim of the work The aim of this work was to study the effect of intravenous versus intrathecal dexmedetomidine and fentanyl on stress response during laparoscopic cholecystectomy. Patients and methods Sixty patients fulfilling the inclusion criteria who were undergoing laparoscopic cholecystectomies were randomly assigned to receive either intravenous fentanyl and dexmedetomidine (group I) or intrathecal fentanyl and dexmedetomidine (group II). Mean arterial blood pressure and heart rate were recorded before induction of anesthesia (T0), 5 min after intubation (T1), 30 min after start of surgery (T2), at skin closure (T3), 6 h postoperatively (T4), and 24 h postoperatively (T5). The number of patients who required intraoperative intravenous fentanyl and total intraoperative fentanyl consumption (µg), and the number of patients who required intravenous morphine at the end of surgery were recorded. Visual analogue scale and total postoperative morphine consumption (mg) at the end of surgery (M0), and at 6, 12, 18, and 24 h (M1, M2, M3, and M4, respectively) were recorded. Blood interleukin-6, cortisol, and glucose were measured before anesthesia (F0) and after recovery (F1). Postoperative complications were recorded. Results Heart rate and mean arterial blood pressure were statistically lower in group II at T2 and T3. The number of patients requiring intraoperative intravenous fentanyl and total intraoperative fentanyl consumption (µg), and the number of patients requiring intravenous morphine at the end of surgery were statistically lower in group II. Visual analogue scale and postoperative morphine consumption (mg) were statistically lower in group II at M0 and M1. Blood cortisol and blood glucose level were statistically lower in group II at F1. There were no statistical differences as regards complications. Conclusion Apart from lowering heart rate and BP, intrathecal dexmedetomidine and fentanyl was superior to intravenous dexmedetomidine and fentanyl, wherein it lowered pain score and analgesic consumption with attenuation of stress response.
The Scientific Journal of Al-Azhar Medical Faculty, Girls 2018 2(3):144-149
Background Most ophthalmic procedures are performed under local anesthesia, and cataract extraction is the most frequently performed surgery in elderly patients. The aim of this study is to compare the intraoperative hemodynamic variables, efficacy, and efficiency of extraconal block versus subtenon block with low concentration of local anesthetic during cataract surgery. Patients and methods This prospective, randomized, and single-blind study was done on 80 patients American Society of anesthesiologists status I–III undergoing cataract surgery, of which 40 patients underwent subtenon block (group S) and 40 patients underwent extraconal block (group E). Five minutes after the start of anesthetic monitoring care, 5-ml mixture of lidocaine 1% and bupivacaine 0.25% containing 100 IU hyalorunidase, in a mixture ratio of 1 : 1, was injected intraocular slowly. Patients were monitored for intraoperative hemodynamics, ocular movement during surgery, and intraoperative pain sensation as primary outcome, and onset of blockade, pain assessment within 30 min postoperatively, number of patients need rescue dose, surgeon discomfort, and postoperative complications as secondary outcomes. Results Mean arterial blood pressure and heart rate in group S were significantly lower than those in group E but within safety margin. No significant difference was found between the two groups regarding full range of eye movement, surgeon’s discomfort grade during cataract surgery, and also, intraoperative pain sensation. The onset of blockade was significantly faster in group S than group E. Although group S had better postoperative analgesic effect than group E, postoperative rescue dose was of insignificant value. Conclusion Subtenon block seems to be a better local anesthetic technique than extraconal for cataract surgery, as it is faster, has less surgeon discomfort grading, and better postoperative analgesia. However, on the contrary, both subtenon and extraconal blocks are equally effective in pain control during surgery and also have good ocular akinesia during operation.
The Scientific Journal of Al-Azhar Medical Faculty, Girls 2018 2(3):150-155
Context Phosphatase and tensin homolog (PTEN) is a protein that acts as a tumor suppressor by dephosphorylating the lipid second messenger phosphatidylinositol 3,4,5-trisphosphate. Loss of PTEN function and mutation in PTEN gene have been implicated in the pathogenesis of endometrial carcinoma (EC). Objective The aim was to evaluate the immunohistochemical expression of PTEN in endometrial hyperplasia and EC and to evaluate the relationship between its expression and tumor grade in EC. Materials and methods Specimens included 16 cases of endometrial hyperplasia without atypia, six cases of atypical endometrial hyperplasia, and 18 EC specimens. Immunohistochemical staining for PTEN was performed using diaminobenzidine detection kit on formalin-fixed and paraffin-embedded tissue samples. Tumor tissue blocks and clinical data were collected from the files of the Pathology Department of Al-Zahraa University Hospital during the period 2010–2014. Results Immunohistochemistry showed that PTEN was positive for nuclei and cytoplasm of glandular endometrial cells. The PTEN expression was decreased significantly in atypical hyperplasia or EC compared with simple or complex hyperplasia (P0.041). In EC, we proved that PTEN expression is downregulated in high-grade tumors. Conclusion A positive PTEN expression correlates significantly with hyperplasia without atypia and well-differentiated tumors. The downregulation of PTEN indicates a more malignant phenotype.
The Scientific Journal of Al-Azhar Medical Faculty, Girls 2018 2(3):156-162
Introduction Worldwide, sepsis is one of the leading causes of morbidity and mortality. Patients are at high risk for irreversible organ failure and a lethal course. About 60 000 individuals die from sepsis annually, and survivors have a reduced quality of life. In addition, sepsis places a considerable economic burden on the society. Early and comprehensive treatment improves outcome significantly. Brain natriuretic peptides (BNPs) are powerful predictors of death and major events in patients with stable coronary disease and pulmonary embolism. Several prospective studies have been carried out to investigate the potential role of BNPs in predicting mortality in septic patients in ICUs. The aim of this prospective study was to evaluate BNP for the prediction of mortality and myocardial dysfunction in severe sepsis and septic shock. Patients and methods This prospective study was carried out on 50 patients including group I, patients with sepsis, group (II), patients with severe sepsis, and group III, patients with septic shock. This study was carried out in the ICU of the Internal Medicine Department, Al-Zahraa University Hospital, in the period between January 2013 and March 2014 with written consents from our patients according to the ethical committee of the university. BNPs were determined by enzyme-linked immunosorbent assay. Results There was a highly statistical difference in the mean±SD of the BNP levels in group III (901.77±259.6) compared with group II (610.84±102.46), P value less than 0.01; also, there was a statistical difference in the BNP levels in group III (901.77±259.6) compared with group I (217.4±81.16), P value less than 0.01, whereas there was a statistically significant difference in group II (610.84±102.46) compared with group I (217.4±81.16), P value less than 0.05. In terms of the correlation between the BNP levels and other parameters of the patient groups, there was a highly positive significant correlation between BNP levels and the acute physiology and chronic health evaluation (APACHE II) score, the Sequential Organ Failure Assessment score, and white blood cells count. A significant positive correlation was found between BNP levels and prothrombin concentration (PC). There was a nonsignificant correlation between BNP and age, creatine phosphokinase, creatine kinase-MB, serum glutamic oxaloacetic transaminase, serum glutamic pyruvic transaminase, prothrombin time, international normalized ratio, and length of stay. Conclusion Our results suggested that an elevated BNP level may prove to be a powerful predictor of mortality in patients with sepsis. Future larger and more adequately powered prospective studies are warranted to clarify the prognostic value of BNPs in conjunction with other biomarkers.
The Scientific Journal of Al-Azhar Medical Faculty, Girls 2018 2(3):163-170
Objective The aim of this study was to investigate the association of TWIST1 and CD44 in gastric cancer (GC) with clinical parameters and their relation to prognosis, which may be beneficial for targeted therapeutic strategies in the future. Materials and methods The material of this work consisted of 40 primary GC specimens from patients who underwent radical gastrectomy. Patients who received neoadjuvant chemotherapy or chemoradiotherapy, those who presented with other cancers at the same time, or the patients with incomplete clinical data were excluded from the study. Hematoxylin and eosin-stained sections from all cases were re-evaluated and further stained immunohistochemically using antibodies against TWIST1 and CD44. Results TWIST1 and CD44-positive expressions were significantly increased in GC cases of diffuse type (P=0.019 and 0.002, respectively). Moreover, there was a statistically significant correlation between both markers and tumor grade, stage, and lymphovascular invasion (P=0.027 and 0.010, P=0.002 and 0.012, and P=0.001 and 0.005, respectively). A statistically significant correlation was found between TWIST1 and CD44 expressions in GCs (P=0.000). Conclusion The presence of TWIST1-positive carcinoma cells and CD44-positive cancer stem-like cells in GC tissue can be used as a diagnostic tool for GC and regarded as a marker of poor prognosis in patients with GC, which may provide potential targets for GC therapy.
The Scientific Journal of Al-Azhar Medical Faculty, Girls 2018 2(3):171-180
Background Anemia and hypothyroidism are both common diseases in the community. Homocysteine (HCY) levels are increased in patients with hypothyroidism and methylenetetrahydrofolate reductase (MTHFR) deficiency is the most common genetic cause of hyperhomocysteinemia. The aim of the present study was to evaluate the level of serum HCY in patients with hypothyroidism and to study the relation of associated anemia with the serum level of HCY and MTHFR gene in patients with hypothyroidism. Patients and methods The study was conducted on 60 adult women attending the Endocrinology Outpatient Clinic of Al-Zahraa Hospital between September 2014 and June 2015 for proper diagnosis and management. Individuals of the study were divided into two main groups: group I (GI) with 30 hypothyroid patients, where 13 of them were postsurgical cases, and group II (GII) with 30 euthyroid individuals as a control group. Diagnosis was based on thyroid-stimulating hormone level reference values. Patients in GI were further classified into two subgroups: mild hypothyroid (subgroup I) and overt hypothyroid (subgroup II). Patient and control groups also were classified into anemic and nonanemic subgroups according to hemoglobin levels. The selected hypothyroid patients were women under thyroid hormone replacement therapy. Blood sample was obtained for proper investigations. Complete blood count, routine blood chemistry, serum iron level, thyroid function tests, vitamin B12 level, serum homocysteine (HCY), and MTHFR were performed. We performed a pilot study on MTHFR gene polymorphism. The C677T MTHFR gene mutation was detected in three of 10 patients and in two of 10 controls. No evidence of TT MTHFR gene mutation was observed in both patient and control groups. IBM SPSS statistics (version 23.0, USA, 2015) was used for data analysis. Results revealed the presence of anemia according to hemoglobin level (<12 g/dl). In patients group (GI), 50% (15/30) as compared with 13.3% (4/30) in the control group (GII) had anemia. Serum iron level in patients group (GI) was deficient in 40% (11/30), whereas deficient in 16.7% (5/30) in control group (GII). Vitamin B12 deficiency was found to be 44% (11/25) in patients group (GI), whereas in the control group (GII) was 6.7% (2/30). Analysis by Wilcoxon’s rank sum test, homocysteine (HCY) serum level showed a highly significant increase among patients (GI) as compared with control (GII). Ranked Spearman’s correlation test for the patients (GI) and control (GII) showed a significant negative correlation between homocysteine (HCY) and MTHFR serum levels, whereas the correlation with red cell indices parameters was insignificant. Serum iron and B12 levels were significantly correlated in patient group (GI). Pearson χ2 tests were done between both patients and control groups for the presence of anemia, iron deficiency, and elevated serum homocysteine (HCY) level and all revealed statistically significant results. Conclusion There is no significant correlation between homocysteinemia and anemia. However, the strong association between anemia and hypothyroidism is attributed mainly owing to combined iron and vitamin B12 deficiencies. This might explain the decreased response to treatment among the selected hypothyroid patients.
The Scientific Journal of Al-Azhar Medical Faculty, Girls 2018 2(3):181-188
Background and aims In Egypt, ∼14.7% of the population has hepatitis C infection and genotype 4 infection accounts for more than 90% of the hepatitis C virus infections. Available data with newer all-oral regimens in the treatment of genotype 4 infection suggest that sustained virological response (SVR) 12 rates in treatment-naïve cirrhotic and noncirrhotic patients are greater than 95%. The study aimed to evaluate the virological response 12 weeks after treatment (SVR12), change in the model for end-stage liver disease score, and adverse clinical events during the study period. Patients and methods This prospective study included 451 patients with chronic hepatitis C and liver cirrhosis over a 3-month period started at January 2017. And the study was ethically approved by the Medical Research Ethics Committee, Faculty of Medicine, Al-Azhar University. The enrolled patients were classified into three groups: group I included 162 patients with chronic hepatitis C and liver cirrhosis subjected to direct-acting antivirals (DAAs) therapy (100/162 compensated cirrhosis and 62/162 decompensated cirrhosis), group II included 234 patients known to have chronic hepatitis C without liver cirrhosis subjected to DAAs therapy, and group III included 55 patients with chronic hepatitis C and liver cirrhosis not subjected to DAAs therapy according to the national protocol of therapy (as a control group). Treatment was administered for 12 weeks that included variable regimens of DAAs according to the Egyptian Ministry of Health protocol. Results We included 451 patients with chronic hepatitis C infection and liver cirrhosis; 47.8% of the patients were male, 84.4% were treatment naive, and 54.9% had cirrhosis. Of the study participants, 150 patients in group I and 53 patients in group II received sofosbuvir+daclatasvir+ribavirin, 183 patients received daclatasvir+sofosbuvir (group II), seven patients in group II received sofosbuvir+ledipasvir, five patients received sofosbuvir+ledipasvir+ribavirin (in group I), and seven patients in group I and nine patients in group II received ombitasvir/paritaprevir/ritonavir+ribavirin. Twelve weeks after end of treatment (SVR12) were 91.3% and 96.5% observed in group I and group II, respectively irrespective of the regimen of therapy. Treated patients in group I had a mean negative change in model for end-stage liver disease (−0.722; SD, 2.603) representing an improvement in liver function, whereas untreated patients in group III showed a minimal mean positive change (0.00; SD, 2.92) representing a deterioration in liver function (P<0.001). Improvements were observed in the Child-score (Child–Pugh–Turcotte) in group I versus untreated patients in group III. Hepatic encephalopathy was evident in 6.1% of patients in group I after treatment versus 38.1% in untreated patients (group III), and ascites developed in 30.2% of patients after treatment (group I) versus 65.4% in untreated patients (group III). Conclusion Oral regimens of DAAs are effective in the treatment of hepatitis C virus infection even in patients with liver cirrhosis, leading to improvements in liver functions.
The Scientific Journal of Al-Azhar Medical Faculty, Girls 2018 2(3):189-193
Aimof the study The aim of this study is to evaluate the changes of wavefront aberrations after performing neodymium : yttrium aluminum garnet (Nd : YAG) laser posterior capsulotomy for the management of posterior capsular opacifications. Patients and methods This study is a prospective study that was performed on 100 eyes of 87 patients with posterior capsule opacification following phacoemulsification, in the period from March 2017 to October 2017. A complete ophthalmic examination and optical wavefront imaging were performed to every patient. Patients underwent posterior capsulotomy using Nd : YAG laser with a follow-up period of 6 months. Results There were no significant changes in postoperative refraction at P value more than 0.05 still the best-corrected visual acuity showed a clinically significant at P value less than 0.05. The intraocular pressure was statistically significantly increased on the first postoperative day (P<0.05) but not in other postoperative visits. Regarding higher order aberrations there was a statistically significant improvement in total third-order aberrations (P<0.05), coma aberration (P<0.05), total fourth-order aberrations (P<0.05), spherical aberration (P<0.05), and total higher order aberrations (P<0.05) while quadrafoil and fifth-order aberrations showed no statistically significant changes. Conclusion Nd : YAG laser posterior capsulotomy causes a significantly decrease in wavefront aberrations in patients with posterior capsule opacification.
The Scientific Journal of Al-Azhar Medical Faculty, Girls 2018 2(3):194-204
Background and aim Polycystic ovary syndrome (PCOS) is a complex metabolic and endocrine disorder. The influence of different metabolic and endocrine changes in women with PCOS and their relevance to bone status remains to be documented. Irisin is a newly identified adipo-myokine, which may play a role in the etiopathogenesis of PCOS as well as bone metabolism. The aim of the study was to assess bone mineral density (BMD) and serum irisin level in women with PCOS and to determine BMD relationship with irisin and other hormonal parameters. Patients and methods The study enrolled 80 women of reproductive age having PCOS and 15 age-matched and BMI-matched healthy women to serve as controls. A metabolic panel, reproductive hormones, and serum irisin level were measured. In addition, BMD of the spine and femur was also assessed using dual-energy X-ray absorptiometry. Results Serum irisin level, fasting insulin, and homeostatic model assessment of insulin resistance were significantly higher in the PCOS group compared with the control group. Receiver operating characteristic curve for serum irisin was done for the PCOS group and the control group and demonstrated that the cut-off value for serum irisin was 0.161 μg /dl. There was also a statistically significant difference between the PCOS group and the control group in BMD of spine and femur, being higher in the PCOS group. Logistic regression analysis has shown that serum irisin level, waist circumference, and fasting serum insulin were predictors for the z-score of spine in the PCOS group. Conclusion Serum irisin level may be considered as a novel biomarker for PCOS diagnosis. Circulating irisin in PCOS is strongly related to BMD. This suggests that irisin as an adipo-myokine may also be associated with bone metabolism.
The Scientific Journal of Al-Azhar Medical Faculty, Girls 2018 2(3):205-211
Background Hepatitis B virus (HBV) infection is diagnosed when the circulating HBV surface antigen (HBsAg) is serologically detected. Occult HBV infection is defined as the infection state negative for HBsAg serology, but it has shown viral genome persistence in infected individuals. The aim of the study is to determine the prevalence of occult HBV among patients with chronic hepatitis negative to HBsAg in the presence or absence of hepatitis C virus (HCV) infection. Patients and methods This study was conducted on a total number of 55 patients with chronic hepatitis (liver cirrhosis in 44 cases, nonalcoholic fatty liver in six cases) and hepatocellular carcinoma in five cases. All studied cases were subjected to routine liver function tests, HBsAg, HBsAb, hepatitis c virus immunoglobulin G (HbcIgG), α-fetoprotein, HCV RNA, and HBV DNA detection. Result All cases were negative to HBsAg and HBsAb in the presence or absence of HCV infection. HBV DNA detection by real-time RT-PCR confirmed the positivity of HBV infection [occult hepatitis b infection (OBI)] in two (4.5%) out of 44 cases of cirrhotic liver and represented 3.6% of the total cases studied with a viral DNA of 116 and 159 copies/ml, respectively. One case of OBI had a high level of α-fetoprotein (392 Iu/ml) and the second case had high copies of HCV RNA 127 000 copies/ml, that is coinfection. HbcIgG was positive in 31.8% in cirrhotic patients (including one out of the two positive OBI). HCV RNA was negative in 100.0% of nonalcoholic fatty liver, positive in 39 (one was positive OBI) cases with cirrhosis with a median value of 45 000 copies and in four out of the five hepatocellular carcinoma cases with a median value of 1.85E+08. This is statistically significant (P=0.01). We come to the conclusion that occult HBV do exist in our community. The diagnosis of OBI should be based on high sensitivity of HBsAg and HBV DNA testing.
A rare neurological sequelae of chicken pox in an adult p. 268 Kandan Balamurugesan, Prem Davis, Rajangam Ponprabha, Malaimala Sarasveni DOI:10.4103/2221-6189.248032 Chicken pox is a disease of childhood caused by varicella zoster virus belonging to the α-herpesvirus-3 family. But the clinical presentation in adults is uncommon and is usually associated with complications. The complications are more commonly seen in immunocompromised individuals and in people who get infected at the later age group. Since the varicella zoster virus rarely causes cerebellar disease in adults, hence here we report a non-immunized, immune-competent adult patient presented to the emergency department with unsteadiness in gait, profuse sweating, exanthematous vesicular rash. We made a diagnosis of acute cerebellar ataxia due to varicella zoster virus and treated accordingly. http://www.jadweb.org/currentissue.asp?sabs=y
