Sengamedu S. Badrinath

Comparison of Ciprofloxacin Ophthalmic Solution 0.3% to Fortified Tobramycin-Cefazolin in Treating Bacterial Corneal Ulcers

PURPOSE The purpose of the study is to compare the clinical efficacy and safety of ciprofloxacin ophthalmic solution 0.3% (Ciloxan) with a standard therapy regimen (fortified tobramycin, 1.3%-cefazolin, 5.0%) for treating bacterial corneal ulcers. METHODS This randomized, parallel group, double-masked, multicenter study was conducted in 324 patients at 28 centers in the United States, Europe, and India. Patients were randomized into 2 treatment groups: 160 to ciprofloxacin and 164 to fortified tobramycin-cefazolin. Positive microbiologic cultures were obtained in 188 (58%) of 324 patients. Of these, 176 patients met protocol criteria and were evaluated for treatment efficacy: 82 in the ciprofloxacin group and 94 in the standard therapy group. The dosing schedule for both treatment groups was 1 to 2 drops of the first study medication (ciprofloxacin or fortified tobramycin) every 30 minutes for 6 hours, then hourly for the remainder of day 1; 1 to 2 drops every hour on days 2 and 3; 1 to 2 drops every 2 hours on days 4 and 5, followed by 1 to 2 drops every 4 hours on days 6 to 14. The second medication (ciprofloxacin or cefazolin) was instilled 5 to 15 minutes after the first drug, following the same dosing frequency. Physicians judgment of clinical success, cure rate, changes in ocular sings, and symptoms and the rate of treatment failures were the primary efficacy criteria. RESULTS Topical ciprofloxacin monotherapy is equivalent clinically and statistically to the standard therapy regimen of fortified antibiotics. No statistically significant treatment differences were found between ciprofloxacin (91.5%) and standard therapy (86.2%) in terms of overall clinical efficacy (P = 0.34). Similarly, no differences were noted in resolution of the clinical signs and symptoms (P > 0.08) or the time to cure (P = 0.55). The incidence of treatment failures was less in the ciprofloxacin group (8.5%) compared with the standard therapy group (13.8%). Significantly fewer patients treated with ciprofloxacin reported discomfort than did patients treated with the standard therapy regimen (P = 0.01). CONCLUSION Ciprofloxacin ophthalmic solution 0.3% monotherapy is equivalent clinically and statistically to standard therapy (fortified tobramycin-cefazolin) for the treatment of bacterial corneal ulcers and produces significantly less discomfort.

SURGICAL MANAGEMENT OF RETINAL DETACHMENTS RELATED TO COLOBOMA OF THE CHOROID

OBJECTIVE This study aimed to develop a rationale for the management of retinal detachments related to choroidal coloboma and to study the outcome of their management. DESIGN The study design was a retrospective study. PARTICIPANTS A total of 85 eyes of 81 patients with retinal detachments related to coloboma of the choroid participated. INTERVENTION All eyes underwent pars plana vitrectomy with internal tamponade using silicone oil (80 eyes) or perfluropropane gas (5 eyes). Behavior of the retina on fluid-air exchange was used to guide the further steps of surgery. Endolaser was performed along the coloboma border. Silicone oil was removed in 80% of eyes. The main outcome measures were retinal reattachment and visual recovery. RESULTS Recurrent retinal detachment occurred in 16.3% of silicone oil-filled eyes and 60% of gas-filled eyes. After silicone oil removal, 15.6% of eyes had recurrent retinal detachment. After a mean follow-up of 13.4 months, 81.2% of eyes had attached retina and 69.4% recovered equal to or better than 10/200 visual acuity. CONCLUSION Retinal detachment secondary to coloboma of choroid is treated best by pars plana vitrectomy along with silicone oil tamponade. Gas tamponade has limited indications. Clinical evaluation of the extent of retinal detachment within the colobomatous area and the behavior of the retina on fluid-air exchange help the authors understand the pathogenesis of the retinal detachment and plan a rational therapy.

Inducible nitric oxide synthase gene and diabetic retinopathy in Asian Indian patients.

Nitric oxide, a signal transduction molecule, when modulated causes various diseases including diabetic retinopathy. In diabetes, allelic polymorphism of the inducible nitric oxide synthase (iNOS) gene is associated with retinopathy in the Northern Irish population. In the present study we investigated the Asian Indian population.

Management of Retinal Detachment with Choroidal Coloboma

Seventeen eyes with retinal detachment secondary to retinal breaks in the colobomatous area were managed by vitrectomy procedures. Endodrainage was done through the break in the colobomatous area, with simultaneous fluid-air exchange. Endolaser photocoagulation was performed along the colobomatous margin posteriorly, while the anterior portion was treated by transscleral cryopexy. Silicone oil was then exchanged with air. In nine cases, the silicone oil had to be removed for complications such as emulsification, glaucoma, and keratopathy; in three of these eyes, oil removal resulted in recurrent retinal detachment. At the 2-month follow-up visit, there was 100% anatomic success, and 12 eyes (70.6%) recovered visual acuity of 10/200 or better. Of the 11 eyes with follow-up of more than 6 months, in 9 (81.8%) the retina remained reattached at last-follow up, and in 6 eyes (54.5%) a visual acuity of 10/200 or better was obtained.

Parabulbar Anesthesia for Primary Vitreoretinal Surgery

PURPOSE The efficacy and safety of parabulbar anesthesia was investigated prospectively in 100 patients undergoing primary vitreoretinal surgery. METHODS The technique involved three steps: (1) orbicularis oculi injection, (2) subconjunctival injection, and (3) sub-Tenon irrigation. The effect of anesthesia was graded 0 to 5 depending on inadequate anesthesia-akinesia with or without local supplementation. Ninety-three patients underwent vitrectomy without buckling and 4 with an encircling band; 3 had scleral buckling. Mean duration of surgery was 89.38 minutes. RESULTS In 69% of patients (grades 4 and 5), no supplementation was required and in 31% (grades 1-3), local supplementation was needed for inadequate anesthesia or akinesia or both. No ocular or systemic complication occurred. Early onset of anesthesia correlated with adequate anesthesia throughout the procedure (P < 0.04). CONCLUSIONS Parabulbar anesthesia is a safe and effective technique of local anesthesia in patients undergoing primary vitreoretinal surgery.

Tumor necrosis factor allelic polymorphism with diabetic retinopathy in India

The association of tumor necrosis factor (TNF) with diabetic retinopathy (DR) has been described previously. A total of 207 Asian Indian patients of 15-year duration of type 2 diabetes were identified. This group included (i) 100 patients with DR and (ii) 107 patients without retinopathy (DNR). In this study, we correlated the length of the (GT)n microsatellite di-nucleotide repeat upstream to the promoter region of TNF gene with susceptibility for the development of retinopathy. The microsatellite was polymerase chain reaction amplified and electrophoresed on polyacrylamide gel and silver stained. In our study population, there were 18 alleles ranging from 97 to 131 base pairs (bp). Allele 4 (103 bp) had a higher prevalence (9.81%) in the DNR group compared to that (2.5%) in the DR group (P=0.002). Patients with retinopathy and allele 8 (111 bp) had a tendency to develop proliferative diabetic retinopathy (PDR). In this study of Indian subjects, it is suggested that allele 4 is a low risk allele for developing retinopathy and allele 8 (111 bp) shows an association with PDR.

Subretinal fibrosis and nonrhegmatogenous retinal detachment associated with multifocal central serous chorioretinopathy.

Purpose: To report the rare occurrence of subretinal fibrosis in patients with multifocal central serous chorioretinopathy and evaluate the role of systemic corticosteroids and the effects of laser photocoagulation on multifocal leaks. Methods: A total of 29 patients (mean age, 37.7 years; 89.7% male) treated for subretinal fibrosis and multifocal central serous chorioretinopathy from 1983–1995 were reviewed retrospectively. Mean follow up was 26 months (range, 6.8–81 months). Results: Retinal detachment involved the macula in 72.4% cases. Fluorescein angiography showed a mean of 6.7 (range, 2–22) central serous chorioretinopathy leaks and a mean of 1.8 (range, 1–5) retinal pigment epithelial detachments. The fundus pictures of 23 patients who were taking systemic corticosteroids showed no improvement. Following laser treatment, however, retinal reattachment was obtained in all eyes, and improvement in visual acuity of > 2 Snellen lines was noted in 68.9% of patients. Conclusions: The presence of subretinal fibrosis with secondary retinal detachment in otherwise healthy young patients, particularly in men, should alert the physician to look for multifocal central serous retinopathy leaks. Systemic cortiosteroids did not prove effective in treating these patients, although laser treatment is recommended for each leak identified on an angiogram.

Optic Disc in Fundus Colobama

PURPOSE To categorize and describe the type of optic disc involvement and blood vessel patterns seen in patients with fundus coloboma. METHODS This is a prospective study involving 67 eyes of 40 patients with choroidal coloboma. The evaluation included documentation of fundus details using fundus drawings or photographs, or both. RESULTS Six types of disc involvement were identified: (1) normal disc outside fundus coloboma (27.8%); (2) disc outside the fundus coloboma and abnormal (10.4%); (3) disc outside the fundus coloboma and independently colobomatous (8.9%); (4) disc within the fundus coloboma and normal (5.0%); (5) disc within the fundus coloboma and colobomatous (44.3%); and (6) disc shape not identified but blood vessels seen emanating from the superior border of the large fundus coloboma (2.9%). Visual acuity was better in types I, II, and III compared with IV, V, and VI. Microphthalmos was more common with the more severe anomalies. High myopia was more common in the less severe anomalies. CONCLUSION Optic disc involvement in fundus coloboma is widely variable. Of fundus colobomas, 67.2% are associated with either a frankly colobomatous or an altered disc. Of the discs located outside fundus colobomas, 41% are also abnormal. Visual acuity was better in types I, II, and III.

INTRAOCULAR GNATHOSTOMA SPINIGERUM Clinicopathologic Study of Two Cases with Review of Literature

Background Live intraocular nematode is a rare occurrence that is mostly reported in Southeast Asian countries. Common nematodes that are seen live in the eye are microfilaria, Gnathostoma, and Angiostrongylus. Approximately 12 cases of intraocular gnathostomiasis have been reported in the literature. Method Two cases of intraocular gnathostoma, removed by vitrectomy in the first case and by paracentesis in the second case, are reported. Morphologic study of the parasites in wet preparation was performed under dissecting microscope and fixed in Kamovoskys fixative. Light microscopic and scanning electron microscopic studies were also performed. Results The first patient had anterior uveitis, multiple iris holes, and dense vitreous haze with fibrous proliferation over the optic disc. On resolution of the vitreous haze, a live worm was seen in the vitreous cavity. The second patient had anterior uveitis with secondary glaucoma, multiple iris holes, mild vitritis, and focal subretinal haemorrhage with subretinal tracts. Four days later a live worm was seen in the anterior chamber and removed. Microscopic study of the parasites from both patients revealed typical head bulb with four circumferential rows of hooklets, and fine cuticular spines were seen on the surface of the body. Conclusions Iris holes, uveitis, and subretinal haemorrhage with subretinal tract can be characteristic features of intraocular gnathostomiasis. identification of this parasite can be made by typical features, which can be identified on light and scanning electron microscopic study.

A Case-Control Study of Suprachoroidal Hemorrhage During Pars Plana Vitrectomy

BACKGROUND AND OBJECTIVE To investigate the risk factors associated with suprachoroidal hemorrhage (SCH) during vitrectomy. PATIENTS AND METHODS Of 6971 pars plana vitrectomies performed between May 1988 and December 1994, SCH occurred intraoperatively in 12 (0.17%) cases. Forty-two age- and sex-matched control subjects were selected by computer-generated random numbers. Preoperative and intraoperative variables were subjected to univariate and conditional logistic regression analysis. RESULTS Statistically significant risk factors for SCH after univariate analysis included myopia (P = .048), aphakia or pseudophakia (P = .024), rhegmatogenous retinal detachment (P = .044), scleral buckling and/or encirclage at vitrectomy (P = .029), and longer duration of surgery (P = .044). Multivariate analysis revealed independent risks associated with the absence of a lens and longer duration of the surgery. CONCLUSION A knowledge of the risk factors involved with SCH helps the physician to identify patients who are at a greater risk for this complication.