Bhavna Chawla

Randomized clinical study for comparative evaluation of fourth-generation fluoroquinolones with the combination of fortified antibiotics in the treatment of bacterial corneal ulcers.

Purpose: Comparative evaluation of efficacy of monotherapy with moxifloxacin (0.5%) or gatifloxacin (0.3%) with combination therapy of cefazolin (5%) and tobramycin (1.3%) in treatment of bacterial corneal ulcers. Methods: Patients diagnosed with bacterial keratitis (ulcer diameter 2-8 mm) were randomized to 1 of the 3 treatment groups (tobramycin 1.3% and cefazolin 5%, gatifloxacin 0.3%, or moxifloxacin 0.5%). After obtaining corneal scrapings, assigned study medication was instilled hourly for 48 hours and tapered as per clinical response. Healing of ulcer, duration to cure, adverse reactions, antibiogram profile, treatment failures, final visual acuity, and corneal opacity size were evaluated. Results: A total of 61 patients were enrolled [cefazolin and tobramycin (n = 20), gatifloxacin (n = 21), and moxifloxacin (n = 20)]. Overall, 57 patients (93%) healed on treatment. On comparison of the mean time taken to heal, no statistically significant difference was found among all the 3 treatment groups (P = 0.98). Positive bacterial culture was obtained in only 38 patients (62%). There was no significant difference in the bacterial isolates in each treatment group. There were 4 (7%) treatment failures (perforation or nonhealing ulcer): 1 (5%) each in moxifloxacin and gatifloxacin group and 2 (10%) in fortified antibiotics group. All regimens were well tolerated. Conclusion: The study failed to find a difference in the efficacy of monotherapy with fourth-generation fluoroquinolones in the treatment of bacterial corneal ulcers of 2-8 mm size when compared with combination therapy of fortified antibiotics.

Clinical predictors of high risk histopathology in retinoblastoma.

Previous studies show that clinical features at presentation, in retinoblastoma patients, like glaucoma and neovascularization of iris are associated with a higher incidence of high risk histopathology findings (HRF) in enucleated eyes. Herein, we analyze association between clinical features at time of enucleation and occurrence of HRF including invasion of anterior chamber, iris, ciliary body, choroid (massive), sclera, extrascleral tissue, optic nerve beyond lamina cribrosa, and optic nerve cut end, in a large series of eyes enucleated for retinoblastoma.

Correlation between Clinical Features, Magnetic Resonance Imaging, and Histopathologic Findings in Retinoblastoma: A Prospective Study

OBJECTIVE To correlate clinical features with histopathology findings in advanced intraocular retinoblastoma and to determine the diagnostic accuracy of magnetic resonance imaging (MRI) in detecting tumor invasion. DESIGN Prospective, nonrandomized case series. PARTICIPANTS We included 75 patients with group E retinoblastoma. METHODS Demographic and clinical features were recorded at presentation. Contrast-enhanced MRI was performed to study tumor characteristics and extent of invasion. Primary enucleation was performed and histopathologic features noted. Statistical analysis was done using the Kruskal-Wallis test to determine correlation between clinical features and histopathology. Sensitivity, specificity, and accuracy of MRI in detecting tumor invasion were determined. MAIN OUTCOME MEASURES Significant associations between clinical findings at presentation and high-risk histopathology, and correlation between MRI results and histopathologic evidence of tumor invasion. RESULTS A significant association was found between iris neovascularization and choroidal invasion (P = 0.032), intraocular pressure and optic nerve invasion (P = 0.034), and shallow anterior chamber and iris invasion (P = 0.021). Corneal diameter did not show any significant correlation with high-risk histopathology. On MRI, tumor volume showed a significant association with optic nerve invasion (P = 0.023). The accuracy of MRI in detecting choroidal invasion was 68% (sensitivity, 60%; specificity, 80%). Prelaminar invasion was correctly identified in 9 out of 15 eyes (accuracy, 84%; sensitivity, 60%; specificity, 90%), whereas the accuracy of MRI in detecting postlaminar invasion was 76% (sensitivity, 61.9%; specificity, 81.5%). Ciliary body invasion was correctly identified in 5 out of 7 eyes (accuracy, 93.3%; specificity, 95.6%) and scleral invasion in 5 out of 6 eyes (accuracy, 98.7%; specificity, 100%). CONCLUSIONS As far as we are aware, this is the first prospective study on the correlation of clinical features and MRI findings with histopathologic risk factors in eyes primarily enucleated for retinoblastoma. Neovascularization of iris, intraocular pressure, shallow anterior chamber, and tumor volume correlated well with high-risk histopathology. Because MRI has limitations in reliably predicting microscopic infiltration of the choroid and optic nerve, decision in favor of neoadjuvant chemotherapy on the basis of suspected postlaminar invasion on MRI is not justified in the absence of histopathologic evidence of disease.

Conservative treatment modalities in retinoblastoma

Retinoblastoma is the most common primary intraocular malignancy of childhood. A potentially curable cancer, its treatment has improved significantly over the last few decades. The purpose of this article is to review the literature on various conservative treatment modalities available for the treatment of retinoblastoma and their effectiveness, when used alone or in combination. Pubmed, Medline, Embase, and the Cochrane library were searched through 2012 for published peer reviewed data on conservative treatment modalities for retinoblastoma. Various studies show that while enucleation remains the standard of care for advanced intraocular tumors, conservative modalities that can result in globe salvage and preservation of useful vision are being increasingly employed. Such modalities include systemic chemotherapy, focal consolidation with transpupillary thermotherapy, laser photocoagulation and cryotherapy, plaque brachytherapy, and delivery of local chemotherapy using subconjunctival, sub-tenon, or intra-arterial routes. When used alone or in combination, these treatment modalities can help in avoidance of external beam radiotherapy or enucleation, thus reducing the potential for long-term side effects, while salvaging useful vision. Radioactive plaque brachytherapy has an established role in selected patients with intraocular retinoblastoma. Local injections of chemotherapeutic agents via the sub-tenon or sub-conjunctival route have been used with varying degrees of success, usually as an adjunct to systemic chemotherapy. Intra-arterial ophthalmic artery delivery of melphalan has shown promising results. It is important to recognize that today, several treatment options are available that can obviate the need for enucleation, and cure the cancer with preservation of functional vision. A thorough knowledge and understanding of these conservative treatment modalities is essential for appropriate management.

Orbital schwannoma with cystic degeneration.

Background:  Schwannoma is a benign, slowly growing, painless, peripheral nerve sheath tumour that is uncommon in orbit. Longstanding tumours may develop degenerative changes. Extensive cystic change in orbital schwannoma is quite rare. We conducted this study to analyse the cases of orbital schwannoma, which were predominantly cystic and describe their clinical, imaging and histopathological features.

Expression of pro‐apoptotic Bax and anti‐apoptotic Bcl‐2 proteins in human retinoblastoma

Regulation of apoptosis is a complex process that involves a number of genes, including Bcl‐2, Bcl‐x, Bax and other Bcl‐2 family members. The aim of the present study is to assess the expression of Bcl‐ 2 and Bax in retinoblastoma, and correlate them with clinical and histopathological parameters.

In vitro susceptibility of bacterial keratitis isolates to fourth-generation fluoroquinolones.

Purpose. To study the microbiological profile of bacterial keratitis in Northern India and to determine the antibiotic sensitivity pattern of bacterial keratitis isolates to fourth-generation fluoroquinolones. Methods. Laboratory records of all consecutive cases of clinically suspected bacterial corneal ulcers were retrospectively reviewed. Data noted included microorganism isolated and antibiotic culture sensitivity to cefazolin, tobramycin, gatifloxacin, and moxifloxacin. In vitro susceptibility toward individual antibiotics was determined and compared with the potential in vitro susceptibilities to cefazolin-tobramycin, cefazolin-gatifloxacin, and cefazolin-moxifloxacin combinations. Results. A total of 292 bacterial isolates were identified. Of these, 255 (87.3%) were Gram-positive and 37 (12.7%) were Gram-negative. Staphylococcus epidermidis (n=227, 77.7%) was the most common organism. Overall susceptibility of isolates was 95.52% to gatifloxacin, 92.83% to moxifloxacin, 90.07% to tobramycin, and 83.56% to cefazolin (p<0.000). Organisms which showed resistance to fourth-generation fluoroquinolones included Staphylococcus epidermidis, Pseudomonas aeruginosa, viridans streptococci, Streptococcus pneumoniae, Staphylococcus aureus, and Escherichia coli. Susceptibilities to gatifloxacin and moxifloxacin were comparable with each other (p=0.312) and with potential susceptibilities to cefazolin-tobramycin (p=0.479), gatifloxacin-cefazolin (p=0.134), and moxifloxacin-cefazolin (p=0.412) combinations. Conclusions. Monotherapy with moxifloxacin or gatifloxacin can be an effective alternative to cefazolin-tobramycin combination as a first-line empirical therapy for bacterial keratitis. The addition of cefazolin to a fourth-generation fluoroquinolone is of limited value.

Outcome of treatment of mooren ulcer with topical cyclosporine a 2

Purpose: To study the clinical outcome of treatment of Mooren ulcer with topical cyclosporine A (CsA) 2% as an adjunct to standard therapy. Methods: Seventeen eyes of 15 patients with Mooren ulcer treated with CsA 2% eyedrops were included. Five eyes had undergone a full-thickness patch graft for perforation and were started on topical CsA therapy after surgery. Topical CsA had been started in the other 12 eyes as an adjunct to standard medical therapy after treatment failure. Clinical efficacy was evaluated on the basis of reduction in lesion size, healing of the epithelial defect, visual recovery, and recurrence rate. Results: In 12 eyes to which topical CsA had been given as an adjunct therapy, the ulcers had resolved completely with various degrees of vascularization. The mean healing time including complete epithelization was 34.4 ± 13.1 days (range, 14-56 days). During the follow-up period of 12 months, recurrence had been observed in 1 patient. No recurrence of the ulcer was seen in the 5 eyes that were started on topical CsA therapy after tectonic keratoplasty. A significant (P = 0.004) improvement was seen in the mean best-corrected visual acuity from the pretreatment values at 12 months. No adverse effects attributable to CsA were observed. Conclusions: Topical 2% CsA therapy can be a safe and useful adjunct to standard medical therapy in recalcitrant cases of Mooren ulcer.

Clinicopathologic review of epithelial tumors of the lacrimal gland.

Objective: To study the clinicopathologic features of epithelial tumors of the lacrimal gland diagnosed at a tertiary care center in India during a 10-year period. Methods: Medical records of cases with histopathologically proven epithelial tumors of the lacrimal gland were reviewed for demographic details and clinical features at the time of presentation. For histopathologic findings, slides with hemotoxylin and eosin-stained sections of the tumors were reviewed. Special stains, including histochemical and immunohistochemical stains, and additional sections were studied, whenever needed. Results: Of 66 cases with epithelial tumors of the lacrimal gland identified during the study period, 50 (76%) cases were benign and 16 (24%) cases were malignant tumors. Histopathologic examination was consistent with the diagnosis of pleomorphic adenoma (PA) in all 50 cases of benign tumors. The mean age at diagnosis in PA cases was 37.7 years. Microscopic examination of PA tumors showed cystic degeneration in 18 (36%) cases, squamous metaplasia in 16 (32%) cases, calcification in 6 (12%) cases, and ossification in 1 (2%) case. Among malignant tumors, adenoid cystic carcinoma (ACC) was the most common tumor (n = 12, 18%), with an average age at diagnosis of 32.4 years. Microscopic examination of ACC revealed that most cases were grade I tumors. Solid areas were noted in 4 (33.3%) cases and perineural invasion was identified in 2 (16.7%) cases. Other malignant tumors included 1 case each of carcinoma ex-PA (1.5%), lacrimal duct carcinoma (1.5%), mucoepidermoid carcinoma (1.5%), and basal cell adenocarcinoma (1.5%). Conclusions: As far as the authors are aware, this is the largest series on clinicopathologic features of epithelial tumors of the lacrimal gland from South Asia. The incidence of PA was significantly higher in this study than reported in the Caucasian population. Among malignant tumors, ACCs were the most common, although rare tumors were also identified.

Diagnosis and management of corneal keloid

A 29‐year‐old man presented with a slowly growing mass in his left eye for the past 6 months. He had undergone a lens aspiration for traumatic cataract with an anterior chamber intraocular lens implantation several years ago. On examination, a pearly white mass was seen on the cornea. Ultrasound biomicroscopy revealed a hyperdense mass well demarcated from the underlying corneal tissue. The mass was excised by superficial keratectomy and the bare stroma covered with amniotic membrane. Histopathological examination of the excised mass revealed findings consistent with the diagnosis of a corneal keloid. At follow up after 6 months, no recurrence was observed.