Pushpa Jacob

Intracameral amphotericin B injection in the management of deep keratomycosis

Purpose. To report the use of intracameral amphotericin B in the management of deep keratomycosis. Methods. Four patients with deep keratomycosis unresponsive to conventional medical treatment underwent repeated intracameral injections of 5 &mgr;g amphotericin B in 0.1 mL 5% dextrose through a paracentesis. Three to 13 intracameral injections were given to each patient over 6 to 36 days. Results. Three of the four patients had complete resolution of the ulcer. The fourth patient perforated and required evisceration. Conclusion. Preliminary experience suggests that intracameral injections of amphotericin B may have a role in the management of deep keratomycosis.

An "epidemic" of post cataract surgery endophthalmitis by a new organism

We report a case series of endophthalmitis by an organism hitherto not reported in the eye. Nineteen of 63 cataract patients operated in a high-volume setup were urgently referred to us with acute onset of decreased vision one to two days following cataract surgery. All patients had clinical evidence of acute endophthalmitis with severe anterior chamber exudative reaction. Vitreous tap was done in three representative patients and repeated intravitreal injections were given as per established protocol. The vitreous sample from all three patients grew Enterobacter amnigenus Biogroup II, a gram-negative bacillus which, to the best of our knowledge, has never been reported in the eye. With prompt and accurate microbiological support, it was possible to salvage 17 of these eyes without performing vitrectomy. Six eyes regained 6/200 or better vision.

Rigid gas-permeable contact lenses for visual rehabilitation of traumatized eyes in children.

Purpose: The aim of this study was to investigate the usefulness and tolerance of rigid gas-permeable (RGP) contact lenses in the visual rehabilitation of children postocular trauma. Methods: In this retrospective case series, children below 15 years of age with ocular trauma were included. The best-corrected visual acuity with RGP contact lenses was compared with that of spectacle correction. The factors affecting visual improvement were analyzed, and problems caused by contact lens use were identified. Results: Twelve eyes of 12 boys were included. The mean best-corrected visual acuity was 0.81 ± 0.29 (LogMar equivalent) with spectacles and 0.47 ± 0.27 (LogMar equivalent) with contact lenses (P < 0.001). Seven of the 12 eyes achieved a >2 line increase in visual acuity with contact lens correction as compared with that using spectacle correction. The mean astigmatism in eyes that achieved this improvement in vision was 5.45 ± 1.6 diopters, whereas the mean astigmatism in the eyes that did not improve was 2.6 ± 1.2 diopters, which was statistically significant (P = 0.009). No other factors (age, corneal scar location/density, grade/zone of injury, lens status, and occlusion) seemed to affect visual improvement with contact lenses. The mean follow-up duration was about 15 months during which 91% of the patients continued their contact lens usage. Conclusions: RGP contact lenses offer a useful refractive treatment alternative in traumatized eyes of children. Eyes with high degrees of astigmatism were found to benefit the most. RGP contact lenses were found to be well tolerated in this population.

Tectonic corneal graft for conjunctival rhinosporidiosis with scleral melt.

A 16 year old girl presented with irritation and watering of the right eye for 3 months. On examination, the superior perilimbal sclera was ectatic with incarcerated uveal tissue covered by conjunctiva. The conjunctiva showed discreet, yellow white mucoid spots. Excision biopsy of the conjunctiva showed subepithelial spherules of sporangia containing numerous endospores, suggestive of rhinosporidiosis. Diathermy was applied to flatten the staphyloma. The ectatic area was covered with a corneal patch graft. The patient was started on prednisolone acetate eye drops and oral dapsone for 6 months. Corneal graft was well incorporated and conjunctivalized by 3 months. Since the graft was not seen within the palpebral aperture, there was good cosmetic result. The corneal graft had the added advantage of transparency which allowed visualization of the underlying tissue to diagnose early recurrence. There was no recurrence at 6 months.

Tenons Patch Graft in the Management of Large Corneal Perforations.

Purpose: To describe a technique to manage corneal perforations between 3 and 6 mm in size using autologous Tenons tissue with cyanoacrylate glue and a bandage contact lens. Methods: A thin layer of Tenons capsule harvested from the patients own eye is used to seal the perforation and act as a scaffold. The Tenons patch graft is spread over the perforation and held in place by the application of cyanoacrylate glue. A bandage contact lens is then placed on the eye. Results: A 6-year retrospective review of 28 patients who underwent this procedure was performed. One patient was lost to follow-up. Of the 27 patients who were followed up, 20 healed completely, with an adherent leucoma and preservation of the anterior chamber. The condition of one patient (with a perforated Pseudomonas corneal ulcer) progressively worsened despite maximum medical therapy and had to undergo evisceration. Conclusions: This procedure makes use of easily available autologous Tenons tissue in patients with corneal perforations too large to be managed with cyanoacrylate glue alone, to preserve eyeball morphology. A corneal transplant can then be done when the cornea has healed.

Infectious scleritis: Clinical spectrum and management outcomes in India

In this retrospective case series, we studied the predisposing factors, causative organisms, clinical spectrum, and outcomes of 12 cases of culture-proven infectious scleritis. Nine of 12 patients had a history of preceding trauma (surgical or accidental). Past surgical history included small-incision cataract surgery (4), pterygium surgery (1), and trabeculectomy (1). Six patients had multifocal scleral abscesses due to Pseudomonas, Klebsiella, or Nocardia. Only 2 patients retained useful vision (>6/18). A poor visual acuity at presentation usually resulted in a worse visual outcome (P = 0.005). Four eyes developed phthisis. The addition of surgical intervention did not result in a significantly better visual outcome than medical management alone (P = 0.209), but resulted in a higher globe preservation rate (P = 0.045). Therefore, we concluded that infection must be ruled out in cases of scleritis with preceding history of trauma, and aggressive surgical intervention improves the anatomical outcome but does not change the visual outcome.

Surgical management of glaucoma secondary to idiopathic elevated episcleral venous pressure.

Idiopathic elevated episcleral venous pressure is characterized by dilated episcleral veins and open angle glaucoma. Trabeculectomies in these eyes are often complicated by uveal effusions (intraoperative or postoperative) at nonhypotonous pressures. We highlight the ability to avoid the need for sclerostomies by preventing intraoperative shallowing of the anterior chamber and the use of tight scleral sutures which should be adjusted postsurgery to gradually reach the target intraocular pressure in a step-wise manner.

Management of post-operative Nocardia endophthalmitis.

Post-operative Nocardia endophthalmitis has an aggressive course and poor visual prognosis. It often masquerades as severe post-operative uveitis or toxic anterior segment syndrome due to the absence of vitreous involvement resulting in a delay in diagnosis. The poor prognosis in Nocardia endophthalmitis is due to severe intra-ocular inflammation which may lead to phthisis. Therefore, treatment with corticosteroids after appropriate antibiotics have been initiated may improve the outcome. This is an interventional case report highlighting the typical features of Nocardia endophthalmitis, which when diagnosed early and managed medically with antibiotics and steroids, resulted in an excellent visual outcome in our patient.

Neurotrophic keratitis and congenital insensitivity to pain with anhidrosis--a case report with 10-year follow-up.

Purpose: To report a rare case of congenital insensitivity to pain with anhidrosis. Methods: A 3-year-old girl presented with watering in the right eye for 3 days. Slit-lamp examination showed an epithelial defect and hypopyon in the right eye and a corneal scar with thinning and vascularization in the left eye. There was bilateral reduced corneal sensation and evidence of self-mutilated lips and fingers. Results: Neurological manifestations along with ocular features confirmed the diagnosis of congenital insensitivity to pain with anhidrosis. Conclusions: Patients with congenital insensitivity to pain with anhidrosis are asymptomatic even when they develop corneal ulcer. Parents should be advised regular follow-up and prompt treatment because this is a vision-threatening corneal abnormality.

Disseminated rhinosporidiosis with conjunctival involvement in an immunocompromised patient

Rhinosporidiosis is a granulomatous infection of mucocutaneous tissue caused by Rhinosporidium seeberi that most commonly occurs in the nasal cavity. Ocular rhinosporidiosis affects primarily the conjunctiva. Diagnosis of rhinosporidiosis is based on strong clinical suspicion and is confirmed by histopathological examination. We report a rare case of conjunctival rhinosporidiosis in an immunocompromised patient (human immunodeficiency virus) with disseminated cutaneous rhinosporidiosis. A 44-year-old male presented with a swelling in the right upper eyelid for 6 months. Excision biopsy of the ocular lesion showed multiple thick-walled, variable-sized sporangia containing endospores within the subepithelium suggestive of rhinosporidiosis. A multidrug regimen of systemic cycloserine, ketoconazole, and dapsone was administered to treat disseminated rhinosporidiosis, in addition to antiretroviral therapy. There was good response with reduction in the swellings.