Surinder Singh Pandav

Fungal endophthalmitis following cataract surgery: clinical presentation, microbiological spectrum, and outcome.

PURPOSE To determine the clinical presentation, microbiological spectrum, and outcome in cases of fungal endophthalmitis following cataract surgery. DESIGN Observational case series. METHODS SETTING Tertiary referral hospital. PATIENTS Retrospective analysis of 27 cases of smear- and culture-proven fungal endophthalmitis. INTERVENTION Pars plana vitrectomy in 18 eyes, where the corneal condition did not preclude the same. All eyes received intravitreal amphotericin B and dexamethasone along with systemic antifungal agents. MAIN OUTCOME MEASURES Functional success: Final visual acuity of 3/60 or better with attached retina. Anatomical success: Final visual acuity of better than light perception with preserved anatomy of globe. RESULTS The majority of the eyes (22 of the 27) had early onset and diffuse presentation (that is, anterior segment as well as posterior vitreous exudates). Substantial corneal involvement was seen in 14 eyes (51.85%). Aspergillus sp. was the most common isolate. Multivariate analysis using forward stepwise logistic regression showed corneal involvement as the single most important risk factor in determining final visual outcome (P =.0429). CONCLUSIONS Early onset and diffuse presentation, which mimics bacterial endophthalmitis, stresses the importance of both bacterial and fungal cultures from intraocular fluids to reach a diagnosis apart from the clinical judgment. Corneal involvement was the most important predictor of outcome in cases of fungal endophthalmitis.

Neuroprotection in glaucoma.

Currently, glaucoma is recognised as an optic neuropathy. Selective death of retinal ganglion cells (RGC) is the hallmark of glaucoma, which is also associated with structural changes in the optic nerve head. The process of RGC death is thought to be biphasic: a primary injury responsible for initiation of damage that is followed by a slower secondary degeneration related to noxious environment surrounding the degenerating cells. For example, retinal ishaemia may establish a cascade of changes that ultimately result in cell death: hypoxia leads to excitotoxic levels of glutamate, which cause a rise in intra-cellular calcium, which in turn, leads to neuronal death due to apoptosis or necrosis. Neuroprotection is a process that attempts to preserve the cells that were spared during the initial insult, but are still vulnerable to damage. Although not yet available, a neuroprotective agent would be of great use in arresting the progression of glaucoma. There is evidence that neuroprotection can be achieved both pharmacologically and immunologically. Pharmacological intervention aims at neutralising some of the effects of the nerve-derived toxic factors, thereby increasing the ability of the spared neurons to cope with stressful conditions. On the other hand, immunological interventions boost the bodys own repair mechanisms for counteracting the toxic effects of various chemicals generated during the cascade. This review, based on a literature search using MEDLINE, focuses on diverse cellular events associated with glaucomatous neurodegeneration, and discusses some pharmacological agents believed to have a neuroprotective role in glaucoma.

Retinal nerve fiber layer thickness in normal, ocular hypertensive, and glaucomatous Indian eyes: an optical coherence tomography study.

PurposeTo determine retinal nerve fiber layer (RNFL) thickness measurements in normal, ocular hypertensive (OHT), and glaucomatous Asian Indian eyes. MethodsThis prospective observational cross-sectional study included patients with OHT, primary open angle glaucoma (POAG), and age-matched normal controls. The global and 4-quadrant average RNFL thickness was measured using the Stratus OCT. The main outcome measures were differences in RNFL thickness measurements between the 3 groups. The discriminating power of each parameter was evaluated by calculating areas under receiver operating characteristic curves (AROCs). ResultsTwenty-three eyes of 23 POAG patients, 24 eyes of 24 OHT, and 48 eyes of 48 normal controls were analyzed. The superior, inferior, and global RNFL measurements were significantly thinner in OHTs compared with normals (P=0.031, 0.019, and 0.022, respectively). All 5 RNFL parameters were significantly thinner in the POAG group compared with OHT group (P<0.001). Parameters with largest AROCs for distinguishing glaucoma from OHT were average and inferior average RNFL measurements (0.989 and 0.979, respectively). Inferior and superior RNFL measurements had largest AROCs (0.717 and 0.700, respectively) to distinguish OHT from normal eyes. ConclusionsStratus OCT detected significant quantitative differences in RNFL thickness between normal, OHT, and glaucomatous Asian Indian eyes.

ANTIOXIDANT ENZYMES IN RBCS AS A BIOLOGICAL INDEX OF AGE RELATED MACULAR DEGENERATION

Abstract The present study was undertaken to assess the levels of antioxidant enzymes in red blood cells of subjects with age‐related macular degeneration and age‐matched controls. The results obtained show a significant decrease in activities of superoxide dismutase (p < 0.001) and glutathione peroxidase (p < 0.001) as compared to the controls. A good correlation (r = ‐0.99) was also observed between age and decreased activity of antioxidant enzymes in controls, and also correlated well with age‐related macular degeneration. In conclusion, oxidative stress as assessed by antioxidant enzymes is more pronounced in subjects with age‐related macular degeneration as compared to age‐matched controls.

Differences in epidemiological and clinical characteristics between various types of Duane retraction syndrome in 331 patients.

PURPOSE To determine the differences in various epidemiologic and clinical characteristics among types I, II, and III of unilateral Duane syndrome and between unilateral and bilateral Duane syndrome. METHODS A retrospective chart review of 331 patients with the Duane syndrome (291 unilateral and 40 bilateral) was performed. Various characteristics studied included sex, age at presentation, laterality, manifest primary position horizontal deviation, upshoot and downshoot, amblyopia, and associated ocular and systemic abnormalities. RESULTS Unilateral types I and III Duane syndrome were more common in the left eye and in female patients, whereas type II had no such predilection. The mean age at presentation was significantly greater in type III patients. Type I patients had an almost-equal frequency of esotropia and exotropia, type II had exotropia, and type III had exotropia more commonly than esotropia. The upshoots and downshoots were more common in types II and III. There was no difference in amblyopia among various types of Duane syndrome. Associated ocular abnormalities were more common in types I and III, and systemic abnormalities were more common in type I. A manifest primary position horizontal deviation was more common in bilateral Duane syndrome. Exotropia was more common in unilateral cases, whereas esotropia was more common in bilateral cases. CONCLUSION Unilateral types I, II, and III Duane syndrome differ in the mean age at presentation, primary position horizontal deviation, upshoot and downshoot, and associated ocular and systemic abnormalities. Bilateral Duane syndrome differs from the unilateral only in the primary position horizontal deviation.

Ultrasound biomicroscopic quantification of the change in anterior chamber angle following laser peripheral iridotomy in early chronic primary angle closure glaucoma

AimsTo prospectively evaluate by ultrasound biomicroscopy (UBM) and gonioscopy the anterior chamber angle widening following laser peripheral iridotomy (LPI) in eyes with early chronic primary angle closure glaucoma (CACG).MethodsA total of 55 eyes of 55 patients with CACG presenting with less than 180° peripheral anterior synechiae (PAS) were enrolled in the study. Angles were assessed by gonioscopy (Shaffers grading) and UBM, before and 4 weeks after LPI. The angle opening distance at 250 and 500 μm from the scleral spur (AOD 250 and AOD 500) was computed. Results were analysed using the Wilcoxon signed-rank test.ResultsIn the quadrant with LPI, the mean gonioscopy grade increased significantly from 0.45 to 1.45 (P<0.001) and the mean AOD 250 and AOD 500 increased from 38.5±25.9 to 83.5±48.4 μm (P<0.001) and 110.2±80.9 to 170.6±83.4 μm (P<0.001), respectively. The angles widened significantly in the opposite quadrant on UBM (AOD 250: 48.8±31.5–82.7±43.9 μm, P<0.001; AOD 500:117.2±65.5–172.2±81.7 μm; P<0.001), but the median gonioscopy grade remained unchanged.ConclusionsLPI significantly widened the anterior chamber angle in the quadrant with LPI and the quadrant furthest away in patients of CACG with established glaucomatous damage. This change was much better appreciated by the UBM than gonioscopy.

Cataract surgery in patients with dry eyes

Purpose: To evaluate the potential causes of postoperative complications and the visual outcome after surgery for age‐related cataract in dry eyes. Setting: Tertiary‐care multidisciplinary referral medical institution. Methods: The records of 15 patients (21 eyes) with age‐related cataract, a Schirmer value of 5.0 mm or less in 5 minutes, and a tear‐film breakup time of 5 seconds or less having complications after cataract surgery were reviewed. Patients were assigned to 1 of 2 groups: dry eye with probable secondary Sjögren’s syndrome (Group 1); dry eye without connective tissue disorders (Group 2). The surgical procedure, preoperative and postoperative medications, postoperative complications, and final visual outcome were analyzed. Results: Ten eyes (8 patients) in Group 1 and 11 (7 patients) in Group 2 had cataract surgery. In Group 1, postoperative endophthalmitis developed in 3 eyes and peripheral keratolysis in 4; 5 eyes attained a visual acuity between 6/60 and 6/18 2 years after surgery. In Group 2, filamentary keratitis developed in 6 eyes and peripheral keratolysis in 2 eyes; 6 eyes achieved a visual acuity of 6/12 or better 2 years after surgery. A significant decrease in visual acuity occurred between 3 months and 2 years postoperatively in both Group 1 (P= .010) and Group 2 (P .0005). Conclusion: Cataract surgery in dry eyes had fewer complications and better visual outcome in patients who did not have connective tissue disease than in those who did.

Bilateral acute angle closure glaucoma as a presentation of isolated microspherophakia in an adult: case report

BackgroundBilateral simultaneous angle closure glaucoma is a rare entity. To our knowledge this is the first reported case of bilateral acute angle-closure glaucoma secondary to isolated microspherophakia in an adult.Case presentationA 45-year-old woman presented with bilateral acute angle closure glaucoma, with a patent iridotomy in one eye. Prolonged miotic use prior to presentation had worsened the pupillary block. The diagnosis was not initially suspected, and the patient was subjected to pars-plana lensectomy and anterior vitrectomy for a presumed ciliary block glaucoma. The small spherical lens was detected intraoperatively, and spherophakia was diagnosed in retrospect. She had no systemic features of any of the known conditions associated with spherophakia. Pars-plana lensectomy both eyes controlled the intraocular pressure successfully.ConclusionThis case demonstrates the importance of considering the diagnosis of isolated microspherophakia in any case of bilateral acute angle closure glaucoma. Lensectomy appears to be an effective first-line strategy for managing these patients.

Reliability of proton and goldmann applanation tonometers in normal and postkeratoplasty eyes

OBJECTIVE To compare the reliability of intraocular pressure (IOP) measurements with the ProTon tonometer and the Goldmann applanation tonometer (GAT) in normal and post-penetrating keratoplasty (post-PK) eyes. DESIGN Prospective, nonrandomized, comparative case series. PARTICIPANTS Twenty-four individuals (48 eyes) with no known ocular disorder and 59 patients (59 eyes) that had undergone penetrating keratoplasty (PK) were included in the normal and post-PK groups, respectively. METHODS Three readings at 5-minute intervals each were obtained with GAT and ProTon in both the groups. Each reading with ProTon was a mean of five accepted readings with the highest accuracy (standard error of mean, <0.5 mmHg). In post-PK eyes with more than 3.00 diopters of astigmatism or with irregular astigmatism, the mean of two readings taken with GAT in the steepest and flattest axis was considered to be the IOP. MAIN OUTCOME MEASURES The IOP measurements in all groups were compared using a two-tail paired t test. The coefficient of repeatability and Cronbachs coefficient alpha were calculated separately for the IOP measured using both instruments in each group. RESULTS There was no significant difference in the second (r1) and third (r2) IOP reading using the GAT and ProTon tonometers in normal and post-PK eyes. The coefficients of repeatability for GAT and ProTon were 2.64 and 2.49 in normal versus 3.72 and 3.47 in the post-PK group. The Cronbachs alpha for GAT and ProTon was 0.94 and 0.95 in the normal group versus 0.95 for both GAT and ProTon in the post-PK group. CONCLUSIONS The results of our study show that the ProTon tonometer is reliable and comparable with GAT for recording IOP in normal and post-PK eyes.

Outcome of in-the-bag implanted square-edge polymethyl methacrylate intraocular lenses with and without primary posterior capsulotomy in pediatric traumatic cataract

Purpose: To study the outcome of in-the-bag implanted square-edge polymethyl methacrylate (PMMA) intraocular lenses (IOL) with and without primary posterior capsulotomy in pediatric traumatic cataract. Materials and Methods: The study was undertaken in a tertiary care center. Thirty eyes of 30 children ranging in age from 4 to 16 years with traumatic cataract which underwent cataract extraction with capsular bag implantation of IOL were prospectively evaluated. Group A included 15 eyes of 15 children where primary posterior capsulotomy (PPC) and anterior vitrectomy with capsular bag implantation of square-edge PMMA IOL (Aurolab SQ3602, Madurai, Tamil Nadu, India) was performed. Group B comprised 15 eyes of 15 children in which the posterior capsule was left intact. Postoperative visual acuity, visual axis opacification (VAO) and possible complications were analyzed. Results: Best corrected visual acuity (BCVA) of 20/40 or better was achieved in 12 of 15 eyes in both groups. Amblyopia was the cause of no improvement in visual acuity in the remaining eyes. Visual axis opacification was significantly high in Group B as compared to Group A (P=0.001). Postoperative fibrinous uveitis occurred in most of the eyes in both groups. Pupillary capture was observed in one eye in each group. Conclusion: Primary posterior capsulotomy and anterior vitrectomy with capsular bag implantation of square-edge PMMA significantly helps to maintain a clear visual axis in children with traumatic cataract.