Vandana Jain

Facial rejuvenation after intradermal botulinum toxin: is it really the botulinum toxin or is it the pricks?

BACKGROUND The use of intradermal botulinum toxin A (onabotulinumtoxinA) remains a relatively new technique and is an off‐label cosmetic application for facial skin rejuvenation. There is little documented clinical evidence of the objective benefits of this therapy. PURPOSE To determine whether intradermal facial onabotulinumtoxinA injection has any benefits. STUDY DESIGN Interventional, comparative, split face clinical trial. METHODS Informed consent was obtained from 10 physicians. One half of the physicians faces were randomly injected with onabotulinumtoxinA (2 U/0.1 mL; 30 facial injections on half of the face, each 0.1 mL) intradermally and the other half of the face with normal saline (30 facial injections on half of the face, each 0.1 mL). The injecting clinician and the subjects were blinded to the contents of the syringes. One and 4 weeks later, two neutral, blinded observers assessed the subjects in person. The patients were also photographed in ambient light surroundings and the same observers compared the halves of their faces in photographs and rated them on a scale of −4 to +4. RESULTS Global improvement in skin texture and tightness was noted in the post‐treatment photographs (the skin appeared to be tenser and smoother), although there was no difference between the two groups and, hence, the changes could not be clinically ascribed to the intradermal botulinum toxin injections. No other meaningful clinical difference could be demonstrated between the two sides of the face, in any of the 10 subjects, in person or in photographs. The small study sample precluded formal statistical analysis. CONCLUSION Intradermal botulinum toxin A injection does not appear to have any benefit in facial rejuvenation. The authors have indicated no significant interest with commercial supporters.

Surgeon point-of-view recording: Using a high-definition head-mounted video camera in the operating room

Objective: To study the utility of a commercially available small, portable ultra-high definition (HD) camera (GoPro Hero 4) for intraoperative recording. Methods: A head mount was used to fix the camera on the operating surgeons head. Due care was taken to protect the patients identity. The recorded video was subsequently edited and used as a teaching tool. This retrospective, noncomparative study was conducted at three tertiary eye care centers. The surgeries recorded were ptosis correction, ectropion correction, dacryocystorhinostomy, angular dermoid excision, enucleation, blepharoplasty and lid tear repair surgery (one each). The recorded videos were reviewed, edited, and checked for clarity, resolution, and reproducibility. Results: The recorded videos were found to be high quality, which allowed for zooming and visualization of the surgical anatomy clearly. Minimal distortion is a drawback that can be effectively addressed during postproduction. The camera, owing to its lightweight and small size, can be mounted on the surgeons head, thus offering a unique surgeon point-of-view. In our experience, the results were of good quality and reproducible. Conclusions: A head-mounted ultra-HD video recording system is a cheap, high quality, and unobtrusive technique to record surgery and can be a useful teaching tool in external facial and ophthalmic plastic surgery.

Does a nanomolecule of Carboplatin injected periocularly help in attaining higher intravitreal concentrations

PURPOSE To compare intravitreal concentration (VC) of commercially available carboplatin (CAC) and the novel nanomolecule carboplatin (NMC), after periocular injection. METHODS The study was a comparative animal study involving 24 white Sprague-Dawley rats, aged between 6 weeks and 3 months. CAC was bound with a nanoparticulate carrier by co-acervation with a biocompatible and biodegradable protein BSA (bovine serum albumin). The particulate size, binding, and structure of the carrier was analyzed with dynamic light-scattering electron microscopy, FTIR (Fourier transform infrared) spectroscopy, and SDS-polyacrylamide gel electrophoresis. Twenty-four white rats were anesthetized. The right eye of each rat was injected with periocular CAC (1 mL) and the left eye with NMC (1 mL) by a trained ophthalmologist. Four mice each were euthanatized at days 1, 2, 3, 5, 7, 14, and 21 and both eyes were enucleated. The intravitreal concentrations of commercial carboplatin and nanomolecule carboplatin were determined with HPLC (high-performance liquid chromatography). Data were analyzed with the paired t-test. The main outcome measure was intravitreal concentrations CAC and NMC over time. RESULTS The NMC vitreal concentration was higher than the CAC concentrations in all animals, until day 7 (P = 0.0001). On days 14 and 21, the CAC vitreal concentration was higher than the NMC concentrations in all animals (P = 0.0002). Overall, the mean vitreal concentration of NMC was greater than CAC. CONCLUSIONS Nanoparticulate-bound carboplatin has greater transscleral transport than commercially available carboplatin, especially in the first week after injection and may help enhance the proven adjuvant efficacy of periocular carboplatin over and above systemic chemotherapy in treating human retinoblastoma, especially those with vitreal seeds. This trial is being published to establish a proof of principle for this method of therapy.

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.

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.

Reactivated herpetic keratitis following laser in situ keratomileusis

A 40-year-old woman presented with an unusual form of corneal herpetic reactivation 5 weeks after laser in situ keratomileusis. The cornea showed diffuse edema and a stromal ring infiltrate (disciform in appearance). Oral antiviral and topical steroids in tapered dosages were administered. The infiltrate disappeared within 6 weeks. Progressive improvement was also seen in all the parameters on Pentacam scans, including the pachymetry, keratometry readings, and elevation on the anterior float. Herpetic reactivation may occur in many forms after excimer laser ablation. Timely diagnosis and management is crucial to maintain good structural and visual outcomes. Pentacam analysis may serve as a useful adjunct in following the progression of herpetic reactivation cases.

Pellucid Marginal Corneal Disease in a Case of Atopic Keratoconjunctivitis

Purpose: To report a case of long-standing atopic dermatitis and atopic keratoconjunctivitis (AKC) with associated pellucid marginal corneal degeneration (PMCD). Design: Noninterventional case report. Method: A 45-year-old man presented with the complaints of frequent change in glass prescriptions over the past 5 years. Erythema, dryness, and scaling were noted over both eyelids and the face. An area of inferior peripheral corneal thinning with ectasia of the normal cornea above it was present. Corneal topography showed the presence of against-the-rule astigmatism with inferior sagging of the horizontal semi-meridians, in both the eyes. Result: The patient was prescribed treatment for AKC and blepharitis and was advised against eye rubbing. Conclusion: Eye rubbing seen in atopic ocular conditions like AKC may be a contributory factor in the development of PMCD. A thorough examination and topographical evaluation of ectatic corneas is necessary to ensure that cases of PMCD are not misdiagnosed as keratoconus.

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.

Periocular necrotizing fasciitis associated with kerato-conjunctivitis and treated with medical management: a case report.

We report a 25-year-old systemically healthy male who presented with periocular necrotizing fasciitis (NF) in the left eyelid. This was associated with the presence of immunologically mediated marginal kerato-conjunctivitis, in the same eye. This potentially dangerous lid infection and the associated ocular surface infection resolved successfully, with medical management. We report this case to highlight the successful conservative management of periocular NF and the hitherto unreported anterior segment involvement.