Sabyasachi Sengupta

Incidence and long-term outcomes of toxic anterior segment syndrome at Aravind Eye Hospital

PURPOSE: To determine the incidence and long‐term outcomes of toxic anterior segment syndrome (TASS) at a single institution. SETTING: Aravind Eye Hospital, Pondicherry, India. DESIGN: Case series. METHODS: The records of all eyes developing TASS during a 1‐year period after cataract surgery were retrospectively reviewed. Clinical outcomes, including corrected distance visual acuity (CDVA), intraocular pressure, and complications, were recorded at the 1‐month and 6‐month follow‐up visits. RESULTS: Toxic anterior segment syndrome occurred in 60 eyes (0.22%) in 26u2009408 consecutive cataract surgeries. Although there were 2 identifiable clusters of TASS, 52% of cases were sporadic. The mean duration until resolution of severe iridocyclitis was 6.11 days ± 2.19 (SD). Of the 24 eyes (40%) with a follow‐up of at least 6 months (mean 11.24 ± 2.3 months), 6 (24%) had atrophic iris changes, 1 (4%) had cystoid macular edema, 3 (12.5%) developed anterior capsule phimosis, and 4 (16%) had posterior capsule opacification (PCO). There was no statistically significant difference between the mean CDVA at 1 month (0.08 ± 0.06 logMAR) (n = 60) and the mean final CDVA (0.11 ± 0.1 logMAR, minimum 6 months; n = 24) (P=.42). CONCLUSIONS: Although it is impossible to generalize for all etiologies, this study found that TASS is uncommon but not rare, responded to intensive topical antiinflammatory medication, and was usually associated with a good visual outcome. Anterior capsule contraction and PCO were the principal delayed‐onset complications beyond those present 1 month postoperatively. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Accelerometer-Assessed Physical Activity and Diabetic Retinopathy in the United States

Accelerometer-Assessed Physical Activity and Diabetic Retinopathy in the United States Hemoglobin A1c (HbA1c) and blood pressure currently represent the only reversible risk factors associated with diabetic retinopathy.1 Physical activity (PA) is another potential modifiable risk factor for preventing diabetic ocular complications, although studies investigating this association have produced conflicting results.2 These studies have relied exclusively on self-report to quantify PA, which is prone to considerable error. Herein, we assess whether accelerometer-defined PA is associated with more advanced retinopathy independent of HbA1c level and blood pressure in a nationally representative sample of patients with diabetes mellitus. Methods | Data from the 2005 to 2006 National Health and Nutrition Examination Survey were used. All study procedures were approvedbytheNationalCenterforHealthStatisticsreviewboard, and all participants provided written informed consent. Diabetes was defined by self-report of a previous diabetes diagnosis, use of insulin or diabetes medications, an HbA1c level of 6.5% of total hemoglobin or higher (to convert to proportion of total hemoglobin, multiply by 0.01), or a fasting glucose level of 126 mg/dL or higher (to convert to millimoles per liter, multiply by 0.0555). Retinal imaging was performed using the Canon Nonmydriatic Retinal Camera CR6-45NM, with details reported elsewhere.3 The presence and severity of nonproliferative diabetic retinopathy (NPDR) (none, mild, or moderate to severe) was determined using the Early Treatment Diabetic Retinopathy Study grading criteria.4

Driving habits in older patients with central vision loss

OBJECTIVEnTo determine if central visual loss is associated with driving cessation, driving restriction, or other-driver preference.nnnDESIGNnCross-sectional study.nnnPARTICIPANTSnSixty-four subjects with bilateral visual loss (<20/32 in better eye) or severe unilateral visual loss (<20/200) from age-related macular degeneration (AMD) and 58 normally sighted controls between 60 and 80 years of age.nnnMETHODSnParticipants self-reported driving habits. Other-driver preference was defined as preferring that another drive when there is more than 1 driver in the car. Subjects reporting 2 or more driving limitations were considered to have restricted their driving.nnnMAIN OUTCOME MEASURESnSelf-reported driving cessation, other-driver preference, and driving restriction.nnnRESULTSnAge-related macular degeneration subjects were older (74.7 vs. 69.7 years), had worse visual acuity (VA; mean better-eye VA, 0.43 vs. 0.08 logarithm of minimum angle of resolution [logMAR]) and contrast sensitivity (CS; 1.4 vs. 1.9 log units of CS [logCS]), and were more likely to be white when compared with controls (P<0.001 for all). Drivers with AMD-related vision loss were more likely to avoid driving over longer distances, beyond 1 hour, at night, and in unfamiliar conditions (P < 0.05 for all). In multivariate models, driving cessation was associated with worse better-eye VA (odds ratio [OR], 1.5 per 1-line decrement in VA; P<0.001) and worse binocular CS (OR, 1.36 per 0.1 logCS increment; P = 0.005); however, AMD group status was not associated with driving cessation (OR, 1.9; P = 0.35). Factors predicting driving restriction were AMD (OR, 9.0; P = 0.004), worse vision (OR, 2.5 per line of VA loss; P<0.001), lower CS (OR, 2.2 per 0.1-logCS increment; P<0.001), and female gender (OR, 27.9; P = 0.002). Other-driver preference was more common with worse vision (OR, 1.6 per 0.1-logMAR increment; P = 0.003), female gender (OR, 4.5; P = 0.02), and being married (OR, 3.8; P = 0.04).nnnCONCLUSIONSnMost patients with AMD-related central vision loss continue to drive, but demonstrate significant driving restrictions, especially with more severe VA and CS loss. Future work should determine which driving adaptations the visually impaired best balance safety and independence.

Evaluation of real-world mobility in age-related macular degeneration

BackgroundPrevious research has suggested an association between poor vision and decreased mobility, including restricted levels of physical activity and travel away from home. We sought to determine the impact of age-related macular degeneration (AMD) on these measures of mobility.MethodsFifty-seven AMD patients with bilateral, or severe unilateral, visual impairment were compared to 59 controls with normal vision. All study subjects were between the ages of 60 and 80. Subjects wore accelerometers and cellular network-based tracking devices over 7xa0days of normal activity. Number of steps taken, time spent in moderate-to-vigorous physical activity (MVPA), number of excursions from home, and time spent away from home were the primary outcome measures.ResultsIn multivariate negative binomial regression models adjusted for age, gender, race, comorbidities, and education, AMD participants took fewer steps than controls (18% fewer steps per day, pu2009=u20090.01) and spent significantly less time in MVPA (35% fewer minutes, pu2009<u20090.001). In multivariate logistic regression models adjusting for age, sex, race, cognition, comorbidities, and grip strength, AMD subjects showed an increased likelihood of not leaving their home on a given day (odds ratiou2009=u20091.36, pu2009=u20090.04), but did not show a significant difference in the magnitude of time spent away from home (9% fewer minutes, pu2009=u20090.11).ConclusionAMD patients with poorer vision engage in significantly less physical activity and take fewer excursions away from the home. Further studies identifying the factors mediating the relationship between vision loss and mobility are needed to better understand how to improve mobility among AMD patients.

Acute Postoperative Bacillus cereus Endophthalmitis Mimicking Toxic Anterior Segment Syndrome

OBJECTIVEnTo study the clinicomicrobiologic characteristics and treatment outcomes in eyes with acute postoperative endophthalmitis (APE) owing to Bacillus cereus from a tertiary eye-care center.nnnDESIGNnRetrospective, interventional case series.nnnPARTICIPANTSnCase records of all eyes with culture-proven APE attributable to B cereus from January 2000 to May 2011 were identified from a computerized database and evaluated.nnnMETHODSnClinical features at time of presentation, microbiological characteristics, and treatment measures were recorded. A thorough literature search using PubMed and the Cochrane Library databases was done to identify all cases of APE owing to Bacillus species reported to date and clinical characteristics of these eyes was compared with our series.nnnMAIN OUTCOME MEASURESnStructural (globe salvage) and functional (visual rehabilitation) outcomes at last follow-up visit.nnnRESULTSnWe found 6 sporadic cases that experienced APE during the study period. All eyes had a fulminant onset within the first 24 hours of cataract surgery with extremely high intraocular pressure (IOP) and corneal edema similar to toxic anterior segment syndrome (TASS). However, these eyes progressed rapidly to develop corneal infiltrates, scleral and uveal tissue necrosis with hyphema, brownish exudates in anterior chamber and necrotizing retinitis within hours despite immediate initiation of intravitreal pharmacotherapy and vitrectomy. All eyes demonstrated gram-positive bacilli from the aqueous and B cereus was isolated, which was sensitive to conventional antibiotics except penicillin. Two eyes required therapeutic keratoplasty, combined with a scleral patch graft in 1 eye, 1 eye was eviscerated after 48 hours of onset of symptoms, and 2 eyes experienced phthisical changes within 10 days of onset.nnnCONCLUSIONSnWe found that APE owing to B cereus has an onset within 12 to 24 hours of intraocular surgery and simulates TASS in the first few hours. The clinical course is marked by rapidly worsening necrotizing infection, leading to very poor outcomes despite early institution of appropriate therapy. One must closely observe every case of TASS that presents with intense pain and extremely high IOP and rule out APE owing to B cereus with microbiologic testing.nnnFINANCIAL DISCLOSURE(S)nThe authors have no proprietary or commercial interest in any of the materials discussed in this article.

Manual Small Incision Cataract Surgery: A Review.

AbstractWe aim at reviewing published peer-reviewed studies that evaluate the safety and efficacy of manual small incision cataract surgery (MSICS). Literature searches of the PubMed and the Cochrane Library databases were conducted with no date restrictions; the searches were limited to articles published in English only. All publications with at least level II and III evidence were studied and surgical techniques were analyzed. MSICS was also compared with phacoemulsification and large incision extracapsular cataract surgery (ECCE) with respect to visual outcome, surgery time, cost, intra and postoperative complications and suitability for high volume surgical practices in the developing world.The overall safety profile of MSICS was found to be excellent with intra and postoperative complication rates comparable to phacoemulsification and ECCE. Multiple studies reported the safety and efficacy of MSICS for complicated cases, such as brunescent and white cataract and cataracts associated with phacolytic and phacomorphic glaucoma. Compared to phacoemulsification MSICS was associated with lower and shorter operative times. Visual outcomes were excellent and comparable to phacoemulsification with up to 6 months follow up.The literature provides outcome analysis of a variety of different MSICS techniques. As a whole, MSICS provides excellent outcomes with a low rate of surgical and postoperative complications. Particularly in the developing world, MSICS appears to provide outcomes that are of comparable quality to phacoemulsification at a much lower cost.

Work-related eye injuries: important occupational health problem in northern Thailand

PurposeThis study was aimed to determine demographics, clinical characteristics, and factors associated with work-related eye injury in Northern Thailand. DesignA prospective case series. MethodsEye injuries from any cause treated at a university-based hospital in Northern Thailand from March 2007 to June 2008 were included. In addition to comprehensive eye examination and standard treatments, patients’ occupation, type of activity at the time of injury, alcohol consumption, and eye protection were studied. Eye injuries were classified based on the Birmingham Eye Trauma Terminology System. Demographic and clinical data were documented using a form adapted from the United States Eye Injury Registry. ResultsOf the 101 eyes (97 patients) with work-related injury, 94% were men with a mean age of 39.5 ± 12.9 years (range, 19–72 years). Ninety-eight percent (95/97 patients) did not use protective eyewear. Open-globe injuries were found in 58/101 (57%) eyes. Agricultural workers experienced a higher number of open-globe injuries (37/58 eyes, 64%), whereas construction workers experienced a higher number of closed-globe injuries (25/43 eyes, 58%). In multivariable logistic regression models, nailing (odds ratio, 97.2; 95% confidence interval, 2.6–363.4; P = 0.01) and motorized grass trimming (odds ratio, 14.3; 95% confidence interval, 1.0–206.2; P = 0.05) were significantly associated with open-globe injuries when compared with closed-globe injuries. Significantly greater numbers of eyes with open-globe injuries had final vision equivalent to legal blindness (visual acuity, <3/60) compared with closed-globe injuries (42% vs 12%, P = 0.001). ConclusionsWork-related open-globe injuries are relatively more common among agricultural workers in Northern Thailand. Protective eyewear should be aggressively promoted among workers engaged in nailing and motorized grass trimming.

Mitomycin C-Augmented Trabeculectomy Combined With Single-Site Manual Small-Incision Cataract Surgery Through a Tunnel Flap Technique.

PurposeThe objective of this study was to analyze short-term outcomes of mitomycin C–augmented trabeculectomy combined with manual small-incision cataract surgery (MSICS/Trab). DesignThis was a retrospective, noncomparative single-center case series. MethodsRecords of eyes that underwent MSICS/Trab with mitomycin C performed between January 2006 and May 2007 were reviewed. Manual small-incision cataract surgery was done through a superior scleral tunnel; a Kelly punch was used for the trabeculectomy through the tunnel flap, and after a peripheral iridectomy, the scleral tunnel was opposed with two 10-0 nylon sutures. ResultsOf the 103 patients, 64 (62.1%) had primary open-angle glaucoma (POAG), 23 (22.3%) had secondary open-angle glaucoma (SOAG), and 16 (15.5%) had chronic angle closure glaucoma (CACG). The minimum follow-up was 6 months, and mean follow-up was 12.6 months. Demographics and mean intraocular pressure (IOP) at the time of surgery (30.4 ± 10.3 mm Hg) were comparable in all 3 groups. Significant visual improvement and reduction in IOP levels from baseline were observed at 6 months (16.64 ± 4.75 mm Hg) irrespective of the type of glaucoma (P = 0.035). Subgroup analysis showed a significant difference in IOP levels of CACG group compared with the SOAG group (P = 0.035) at 6 months. However, no statistically significant difference was observed in IOP comparisons between POAG and CACG groups or POAG and SOAG groups. ConclusionsMitomycin C–augmented MSICS/Trab appears to be safe and effective technique in tackling coexistent cataract and glaucoma in developing world.

Cerebral blindness after scorpion sting.

A 40-year-old woman was stung by a scorpion on her left foot. Sharp burning pain at the bite site was followed by a high-grade fever, severe breathlessness, oliguria, and altered sensorium over a period of hours. She was rushed in an unconscious state to a critical care center where blood pressure was 90/60, and she was diagnosed with acute pulmonary edema, myocarditis, and acute renal failure (venom-induced multiorgan failure). After endotracheal intubation, she received low-dose aspirin, enalapril, and supplemental intravenous fluids. Eight hours later, on recovery of consciousness, she reported poor vision in both eyes. On examination 1 week later, visual acuity was light perception in both eyes. Anterior segments were unremarkable, including pupillary reactions. A dilated fundus examination was normal in both eyes. Limb ataxia, dysdiadochokinesis, poor tandem walking, and staccato speech could be elicited. Otherwise the findings from neurological examination appeared to be normal. Brain MRI revealed restricted diffusion in the medial occipital (Fig. 1) and occipitotemporal lobes and cerebellum bilaterally. Results of a coagulation profile, C3 and C4 complement, homocysteine, protein C and S, VDRL, antinuclear antibody (ANA), and antiphospholipid antibody were negative. Cerebrospinal fluid analysis and a color Doppler study of both carotid and vertebral arteries showed normal results. A diagnosis of cerebral and cerebellar infarction was made. No direct treatment occurred. Over 10 days, there was gradual improvement so that the patient was able towalk without support. At the 6-month follow up, visual acuity was light perception in both eyes, the only neurologic deficit. Scorpion bites affect the central nervous system in three ways: altered consciousness, seizures, and infarctions (1). Cerebral and/or cerebellar infarctions have been reported (2–7), with numerous mechanisms advanced to explain them: 1) an acute rise in blood pressure during the autonomic storm that ruptures unprotected or diseased vessels (2); 2) toxic myocarditis that precipitates arrhythmias that give rise to embolic stroke (2); 3) hypercoagulability (3); 4) disseminated intravascular coagulation (4); 5) vasculitis caused by venom (5); and 6) hypotension caused by myocarditis, parasympathetic overactivity, and dehydration (6). Bilateral optic neuropathy (6), transient ophthalmoplegia (8), transient blindness (9), and myelopathy (10) have been documented. We believe that this is the first description of persistent (and severe) cerebral visual loss after a scorpion bite. We cannot be certain of the mechanism, although hypotension seems likely.

Evaluation of Angle Closure as a Risk Factor for Reduced Corneal Endothelial Cell Density

Purpose: Acute angle closure attacks are frequently accompanied by corneal edema. However, little is known about corneal endothelial cell status at different stages of angle closure. Here, we compared endothelial cell density (ECD) in unoperated eyes with that in eyes with open angles (OAs) and various stages of angle closure disease. Materials and Methods: The study was conducted at Aravind Eye Hospitals in India. Masked examiners performed gonioscopy to classify each eye as follows: (1) OA, (2) primary angle closure suspect, or (3) primary angle closure (PAC)/primary angle closure glaucoma (PACG). Specular microscopy was performed and differences in ECD were analyzed using hierarchical models. Results: A total of 407 patients and 814 eyes were studied, including 127 (15.6%), 466 (57.3%), and 221 (27.1%) with PAC/PACG, primary angle closure suspect, and OA, respectively. Participants were predominantly female (69.8%) and the mean age was 49.2 (SD: 8.6) years. Lower ECD was observed with increasing age [&bgr;=−6.3 cells/mm2; 95% confidence interval (CI), −9.3 to −3.3, per year; P<0.001], greater iridotrabecular contact [&bgr;=−15.6 cells/mm2; 95% CI, −28.3 to −2.9, per quadrant of contact; P=0.016), and shallow (<2.5 mm) anterior chamber depth (&bgr;=−40 cells/mm2; compared to deeper ACs (≥2.5 mm), 95% CI, 78.9-1.1; P=0.044). In age-adjusted analyses, angle closure suspects had lower ECD than OA eyes (&bgr;=−54.7 cells/mm2; 95% CI, −47.8 to −85.3; P=0.018), although PAC/PACG eyes were not significantly different from OA eyes (&bgr;=−18.6 cells/mm2; 95% CI, −85.9 to 2.5; P=0.058). Conclusion: In untreated eyes, only mild, clinically insignificant decrement in ECD was noted with angle closure.