Debraj Shome

Surgically induced necrotizing scleritis after pterygium surgery with conjunctival autograft.

PURPOSE To report a case of surgically induced necrotizing scleritis (SINS) as a complication of conjunctival autograft after pterygium excision. METHODS A 52-year-old man had undergone nasal pterygium excision with conjunctival autograft in the right eye at another facility. He was treated for suspected infective scleritis before presentation. RESULTS The sclera, at the site of prior pterygium excision, showed significant thinning with uveal show. There was active inflammation adjacent to the site of thinning. Systemic studies and the examination were noncontributory. The patient was suspected of having SINS and received pulsed injections of methylprednisolone 1000 mg/d for 3 days. The patient also underwent an emergency scleral patch graft with amniotic membrane graft. Over the next 2 weeks, the scleral graft showed vascularization and was taken well. CONCLUSIONS SINS may develop after pterygium surgery with conjunctival autograft. Evidence of connective tissue disease may or may not be found on clinical examination and on laboratory studies. Early diagnosis, prompt immunosuppression, and scleral patch grafting prevents progression and further devastating complications.

Fungal keratitis with the type 1 Boston keratoprosthesis: early Indian experience.

Purpose: To report 2 cases of fungal keratitis and endophthalmitis in patients with the type 1 Boston keratoprosthesis (KPro) in India. Method: Two patients underwent type 1 Boston KPro with uneventful intraoperative and early postoperative courses. The patients presented with keratitis and endophthalmitis within a few months after surgery. Both patients had soft bandage contact lenses in place and were on maintenance low-dose topical steroids and antibiotic eyedrops. Culture was positive for fungus in both the cases. Results: Despite aggressive antifungal medical therapy and surgical management, one patients eye was eviscerated and the other lost the potential for any useful vision. Conclusions: Fungal infection after KPro surgery can be devastating, negating the extraordinary visual recovery these patients achieve immediately after surgery. Chronic use of topical corticosteroids and broad-spectrum antibiotic and bandage contact lens, although indispensable, may enhance the risk of fungal infection especially in the endemic areas like India. The decision for KPro in such tropical climatic conditions should therefore be taken with absolute caution and frequent patient follow-up. A prophylactic antifungal regime may be mandatory when this procedure is undertaken in fungal endemic areas to improve outcomes.

Choroidal ganglioneuroma in a patient with neurofibromatosis type 1: a case report

Ganglioneuromas are rare, benign tumours, forming part of a spectrum of tumours arising from primordial neural crest cells in the sympathetic nervous system. However, they can dedifferentiate into the malignant neuroblastoma and ganglioneuroblastoma. Choroidal ganglioneuroma is extremely rare. Herein, we report a patient with neurofibromatosis type 1 (NF-1) who underwent evisceration for a painful blind eye, subsequent histopathological examination (HPE) revealing a clinically unsuspected choroidal ganglioneuroma.

Aspergillus Iris Granuloma: A Case Report with Review of Literature

We report the case of a 25-year-old male patient who presented with complaints of redness, photophobia, and decreased vision in the right eye of a weeks duration. Slit-lamp biomicroscopic examination revealed a cream-colored, irregular elevated inferior iris mass, extending on to the anterior lens surface. Differential diagnoses of a fungal granuloma, a medulloepithelioma, and an amelanotic melanoma were considered. An excisional biopsy of the mass was performed through a superior clear corneal incision. Polymerase chain reaction analysis of the aqueous humor showed a positive pan fungal genome. Histopathology of the biopsied mass showed a giant cell granuloma with surrounding numerous branching, septate hyphae. Culture growth revealed Aspergillus fumigatus We report this case because of the rarity of Aspergillus iris granuloma as a primary presentation of endogenous Aspergillosis and review the relevant literature. Absence of a significant systemic history compounded the diagnostic dilemma in our patient. Definitive differentiation of this rare entity from a foreign body, amelanotic melanoma, and other inflammatory conditions such as sarcoidosis and tuberculosis, may be possible only on microbiological and histo-pathological evaluation.

Community-Acquired Methicillin-Resistant Staphylococcus aureus (CAMRSA)—A Rare Cause of Fulminant Orbital Cellulitis

We report a 55-year-old female patient who developed a severe right-sided orbital cellulitis. Past history was significant for a boil on the right upper eyelid 2 days prior. Visual acuity at presentation was perception of light with inaccurate projection. Orbital computed tomography (CT) scan and routine blood investigations, including blood culture, urine examination, and urine culture, were performed. CT scan showed a superonasal orbital mass suggestive of an abscess. Abscess drainage followed by pus culture, sensitivity, and pulsed-field gel electrophoresis revealed community-acquired methicillin-resistant Staphylococcus aureus (CAMRSA) resistant to all antibiotics except vancomycin, cotrimoxazole, and amikacin. The condition completely resolved post antibiotic and steroid therapy. At 3 months follow-up, the vision in the right eye was 6/9. We report this case to highlight CAMRSA as a rare but virulent cause of orbital cellulitis; empiric antibiotic therapy should include coverage for CAMRSA until susceptibilities come back.

Management of an irradiated anophthalmic socket following dermis-fat graft rejection: A case report

Dermis-fat graft (DFG) is often the only promising option in cases of severely contracted sockets. However, there is an increased risk of graft failure in irradiated sockets with decreased vascularity. In such difficult cases, repeat DFG implantation also has higher risks of graft failure. We describe an ingenious method of successful management of an irradiated anophthalmic socket following DFG infection and necrosis, with acceptable cosmetic results. At surgery, an orbital impression was taken with ophthalmic grade alginate. Based on this measurement, a custom-made stem pressure socket-expander made up of high density polymethyl methacrylate (PMMA) was fitted, a week post surgery and kept in situ for six weeks. On review, the fornices had considerably deepened. The expander device was removed and the patient was now fitted with a custom-made thicker prosthesis made up of high-density PMMA. The patient has followed up for a year subsequently and the prosthesis has remained stable.

Aspergillus-induced malignant glaucoma.

Purpose: To report a case of Aspergillus flavus-induced keratomycotic malignant glaucoma. Methods: A 48-year-old woman presented with a severe corneal ulcer. She had received topical steroids for 10 days before presentation. Results: Microbiological studies revealed A. flavus as the offending pathogen. Nonresponsive high intraocular pressure with associated shallow anterior chamber was present. With a diagnosis of keratomycotic malignant glaucoma, the patient underwent therapeutic keratoplasty with cataract extraction with posterior chamber wash. However, there was a recurrence of malignant glaucoma in the postoperative period. Patient underwent limited pars plana vitrectomy. Conclusions: Keratomycotic malignant glaucoma is a rare complication of severe fungal ulcer. We believe that the use of topical steroids in this case probably led to increased fungal penetration, with the formation of a lens-iris fungal mass and subsequent malignant glaucoma. Nonresponse to medical therapy warrants urgent surgical intervention. To the best of our knowledge, Aspergillus-induced keratomycotic glaucoma has never been reported previously. This report also highlights that therapeutic keratoplasty with cataract extraction alone may not be sufficient for management of such cases, and a limited pars plana vitrectomy may be needed.

Botulinum Toxin A: Is it Really that Fragile a Molecule?

BACKGROUND Botulinum toxin A is considered to be an extremely fragile molecule, with recommended usage of some reconstituted botulinum toxin A formulations within 4 hours of reconstitution. Extreme caution is recommended to avoid agitation of the vial. OBJECTIVE To determine whether the effect of reconstituted botulinum toxin A is maintained even when it is agitated vigorously. DESIGN Experimental, comparative, animal study. PARTICIPANTS Sixty‐four white Swiss Webster mice, aged 2 to 4 weeks, arranged in eight separate groups. INTERVENTION Reconstituted onabotulinumtoxinA (2.5 U/0.1 mL) was placed securely in a battery‐operated mechanized apparatus. The apparatus with the vial was placed in the refrigerator, and the apparatus continuously inverted and straightened the onabotulinumtoxinA vial 30 times a minute. Eight mice were each injected intraperitoneally with 1 U of the agitated onabotulinumtoxinA on days 1, 3, 5, 7, 14, 21, 28, and 42, to evaluate the efficacy of the continuously agitated onabotulinumtoxinA. MAIN OUTCOME MEASURE Death of the mice, demonstrating efficacy of the onabotulinumtoxinA molecule. RESULTS Half of each group of mice (4/8 mice) died within 48 hours of the injection (range 16–48 hours). CONCLUSION The effect of botulinum toxin type A is maintained even when it is agitated vigorously for up to 6 weeks. The authors have indicated no significant interest with commercial supporters.

Spectacle-induced ocular trauma: an unusual mechanism.

Purpose: To report an unusual, spectacle-related injury. Methods: A 16-year-old boy wearing spectacles with polycarbonate lenses presented with an unusual, spectacle-related injury. Impact with the ball during a ball sport (cricket) led to extreme torsion of the frame with resultant direct blunt trauma to the right eye by the spectacle arm. On examination, the patient had a 10 × 10-mm area of conjunctivalized scleral dehiscence superiorly in Zones 2 and 3, with uveal prolapse. Superior retinal detachment was also noted. Results: Patient underwent wound repair with a scleral patch graft with transscleral cryotherapy and sulfur hexafluoride injection. Conclusion: Although increased impact resistance of newer spectacle lens materials is assumed to reduce the incidence of ocular trauma, such unusual mechanisms may still lead to severe ocular trauma. We report this case to highlight an unusual mechanism of spectacle injury, hitherto unreported, and to show the continued need for use of eye protection while wearing spectacles.

Phacoemulsification and pars plana vitrectomy: a combined procedure.

AIM To describe the results of a combined procedure including phacoemulsification, insertion of posterior chamber intraocular lens (PCIOL) and pars plana vitrectomy (PPV) in eyes with vitreoretinal pathology and coexisting significant cataract. DESIGN Retrospective, consecutive, noncomparative, interventional case series. MATERIALS AND METHODS Medical records of patients who had undergone phacoemulsification, PPV and PCIOL implantation as a combined procedure between January 2000 and December 2004 were retrospectively reviewed. The main outcome measures were the anatomical success of retina, defined as reattached retina, intraoperative and postoperative complications and functional success in terms of final best corrected visual acuity. RESULTS In all, 65 eyes of 64 patients were included. The mean age of the patients was 50.9 years +/- 17.1 (range, five to 82 years). Vitreous hemorrhage with or without retinal detachment (19 eyes, 29.2%) was the most common indication for the vitreoretinal procedure. Primary anatomical success of retina was achieved in 59 eyes (90.7%). Visual acuity improved in 48 eyes (73.8%), was unchanged in 12 eyes (18.5%) and deteriorated in five eyes (7.7%). Postoperative inflammation was significantly more in the subgroup of previously vitrectomized eyes (42%) (P =0.014, Fisher exact test) compared to those which underwent primary vitrectomy. CONCLUSIONS Combined surgery is a feasible option for patients with vitreoretinal diseases and cataract.