Vishaal Bhambhwani

Multidrug-resistant Pseudomonas aeruginosa endophthalmitis in a silicone oil-filled eye treated with piperacillin/tazobactam: report of a case and review of literature.

The incidence of endophthalmitis after pars plana vitrectomy is low. Silicone oil is a tamponading agent which has anti-microbial activity. Post-operative endophthalmitis following vitrectomy with silicone oil tamponade has been rarely reported. We describe the case of a young male who underwent pars plana vitrectomy with silicone oil for retinal detachment with a giant retinal tear. He developed a clinical picture suggestive of endophthalmitis on the first post-operative day, and vitreous culture grew multidrug-resistant Pseudomonas aeruginosa. He was treated with intravitreal piperacillin/tazobactam, along with appropriate surgical management. This was followed by resolution of the infection with a remarkable improvement in visual acuity. This is the first case of multidrug-resistant Pseudomonas aeruginosa endophthalmitis following pars plana vitrectomy with silicone oil treated successfully with piperacillin/tazobactam.

Comparison of Transcorneal and Pars Plana Routes in Pediatric Cataract Surgery in Infants Using a 25-Gauge Vitrectomy System.

PURPOSE To demonstrate and compare the performance of the 25-gauge transconjunctival sutureless vitrectomy system via anterior (transcorneal) and posterior (pars plana) routes in congenital cataracts in infants. METHODS In this prospective interventional study, 12 pediatric patients younger than 1 year with bilateral congenital cataract were included to undergo cataract surgery with posterior vitreorhexis and limited anterior vitrectomy using a 25-gauge vitrectomy system. One eye of each patient was operated on by the anterior (transcorneal) route and the other by the posterior (pars plana) route. All eyes were left aphakic. Intraoperative and postoperative (12 months after surgery) results were compared between the two routes, including visual axis opacification and astigmatism. All eyes were rehabilitated with contact lenses or spectacles. RESULTS The 25-gauge vitrectomy system allowed excellent intraoperative control in both groups. Postoperatively, there was minimal conjunctival congestion, corneal edema, and inflammatory reaction. No intra-operative or postoperative complications were noted in any eye. All eyes had a clear visual axis 12 months after surgery. Mean spherical equivalent was 15.50 ± 2.28 diopters (D) and mean astigmatism was 0.25 ± 0.45 D in the transcorneal group, whereas in the pars plana group it was 15.46 ± 2.45 D and 0.16 ± 0.39 D, respectively, at 12 months, the difference being statistically insignificant (P > .05). CONCLUSIONS The 25-gauge vitrectomy system allows sutureless surgery with excellent intraoperative control and minimal postoperative inflammation and astigmatism with clear visual axis by both the transcorneal and pars plana routes.

Foveal neovascularization in a patient with Type 2 diabetes mellitus

Retinal neovascularization in Diabetes mellitus (DM) is commonly seen at the optic disc and mid-periphery. It is rare at the fovea as the fovea is an avascular zone and there are very few case reports of foveal neovascularization in Type 1 DM. We report a case of unilateral foveal neovascularization in Type 2 DM.

Optical coherence tomography classification of indirect choroidal ruptures: conclusive or misleading?

Dear editor We read with interest the article by Nair et al.1 We would like to make the following observations by analyzing a case of indirect choroidal rupture (ICR) which presented at our center, and which may question the authors’ theories. The authors state that there are two types of ruptures distinguishable on optical coherence tomography (OCT). The first type seen (type 1 ICR) was a forward protrusion of the retinal pigment epithelium-choriocapillaris (RPE-CC) layer with an acutely angled pyramid or dome shape. This was associated with either a small loss of continuity of the retinal pigment epithelium layer or elevated RPE-CC projection accompanied by a significant quantity of subretinal hemorrhage. The second type observed (type 2 ICR) was a larger area of disruption of the RPE-CC layer, photoreceptor inner segment/outer segment junction, and external limiting membrane, with a posteriorly directed concave contour depression at that area and downward sliding of tissues into the defect. There was no scenario in which the two types of ICR coexisted, either in the same rupture or in the same eye. Further, the authors hypothesize different mechanisms of injury for these two types and also state differences in the incidence of complications like the development of choroidal neovascularization. We believe that this differentiation, on the basis of OCT findings alone, is artificial. Both types (1 and 2) may be seen in the same rupture as exemplified by the following case which presented at our center. A 20-year-old male, with a history of road traffic accident with blunt trauma to right side of forehead due to fall from a motor vehicle, presented at our center with best corrected visual acuity of finger counting at 4 m right eye and 20/20 left eye. There was bulbar conjunctival congestion with a subconjunctival hemorrhage OD. The rest of the anterior segment was unremarkable. Fundus evaluation OD showed multiple ICRs with sub-retinal blood. One of the ruptures was involving the fovea (Figure 1). Fundus OS was unremarkable. Figure 1 Fundus photo right eye showing multiple indirect choroidal ruptures with sub-retinal blood (black and red arrows). OCT findings of the ICR involving the fovea, we believe, demonstrate features of both type 1 (Figure 2A) and type 2 (Figure 2B) choroidal rupture. In one section there is an elevated RPE-CC projection with small loss of RPE continuity with subretinal hemorrhage. In the other section there is extensive disruption of the RPE-CC layer with photoreceptor layer abnormalities. Thus features of both types, we believe, may be seen in a single rupture. Figure 2 Optical coherence tomography (OCT) of choroidal rupture involving fovea. Thus, in our opinion, the classification of ICRs on the basis of OCT findings alone may be artificial and inconclusive.

Unilateral macular chorioretinitis in subacute sclerosing panencephalitis studied by spectral domain optical coherence tomography

Subacute Sclerosing Panencephalitis (SSPE) was described by Dawson in 1933–34. It is a subacute inflammatory and neurodegenerative encephalitis related to the measles (rubeola) virus and usually affects children and young adults. The ocular manifestations of SSPE were described and classified by Robb and Watters in 1970. These include papillitis, optic atrophy, chorioretinitis and cortical blindness. Various cases of SSPE with chorioretinitis have been reported. However, only a few cases have been described with a unilateral macular chorioretinitis in SSPE. We describe a case of SSPE with a unilateral isolated macular chorioretinitis, studied by Spectral domain Optical coherence tomography. An 11-year-old male child presented with gradual decrease in scholastic performance for 3 months, spontaneous falls without loss of consciousness for 2 months and progressively increasing jerky movements of the body along with slippage of objects from hands for 2 months. The patient also complained of decrease in vision in right eye for 3 months. There was no history of trauma, fever, seizures, limb weakness or bladder/bowel dysfunction. There was a past history of febrile illness with rash 3 years back. The rash started from the face and progressed to the trunk in 1–2 days; and involved the trunk more than the extremities. The patient had never received any vaccination or immunization. On examination, the patient was conscious and oriented to time, place and person. His general physical examination was within normal limits. The neurological examination showed frequent myoclonic jerks of all the limbs, trunk and neck, aggravated with activity. There was no limb weakness, cranial nerve dysfunction or sensory loss. On ocular examination, he had a best corrected visual acuity (BCVA) of 10/200 in the right eye and 20/20 in the left eye. The anterior segment was unremarkable, and there were no cells or flare in the anterior chamber in both the eyes. The lens was clear and there was no vitritis in either eye. The pupils were normal in size and reaction in both the eyes. The fundus of the right eye showed hyperpigmentation at the macula, while the disc, blood vessels and peripheral retina were unremarkable (Fig. 1). The fundus of the left eye was normal. Optical coherence tomography (OCT) of the right eye performed at the fovea (Spectral domain OCT), with six radial scans revealed severe thinning of all layers of retina with photoreceptor damage (Fig. 2). The OCT scan of the left eye was unremarkable. The patient was referred to our neurology department, where a complete neurological examination, haematological examination and a cerebrospinal fluid (CSF) tap was done. The blood picture showed a normal total leucocyte count (TLC) with lymphocytosis (50% lymphocytes). Other blood chemistry studies like liver function tests (LFT), kidney function tests (KFT), serum calcium, magnesium, sodium, potassium, copper and ceruloplasmin levels were normal. The CSF tap showed clear fluid with 2–3 cells/μl, all lymphocytes, and a protein concentration of 47 mg/100 ml. the CSF electrophoresis showed the c-globulin fraction to be 43% and the IgG titres against measles to be 1:512. The patient underwent a magnetic resonance imaging (MRI) of the brain, that revealed a normal study (Fig. 3). On the basis of the clinical and ocular features, the elevated c-globulin levels in CSF, elevated anti-measles IgG

Comparison of Minimally Invasive Strabismus Surgery (MISS) and Conventional Strabismus Surgery Using the Limbal Approach

PURPOSE To compare minimally invasive strabismus surgery (MISS) with conventional strabismus surgery for horizontal recti in terms of functional outcome and complications. METHODS A total of 40 patients requiring surgery for horizontal recti were divided into two groups: those undergoing MISS and those operated on using the conventional limbal technique. In the MISS group, two small keyhole radial cuts were made superior and inferior to the insertion of the muscle margin. Keyhole cut size was almost 1 mm less than the amount of muscle recessed or resected. RESULTS There were significant differences in conjunctival redness and swelling in both groups on postoperative days 1 and 7 and week 3. However, after the third week, both groups had a similar appearance. Visual acuity was decreased at postoperative day 1 in both groups, but the difference was not significant. No significant differences were found for final alignment, binocular single vision, other visual acuities, refractive changes, or complications. CONCLUSIONS This study shows that this new, small incision, minimal dissection technique is feasible. The MISS technique seems to be superior in the immediate postoperative period because there were fewer conjunctival and eyelid swelling complications. Long-term results did not differ between the two groups. [J Pediatr Ophthalmol Strabismus. 2017;54(4):208-215.].

Massive retinal pigment epithelial detachment following acute hypokalemic quadriparesis in dengue fever

Purpose: To describe an unusual retinal manifestation of dengue fever in an endemic region. Case Report: A 35 year old male presenting with acute onset decreased vision in his right eye, was found to have a massive retinal pigment epithelial detachment (PED) extending up to the vascular arcades. He had been diagnosed with acute hypokalemic quadriparesis in dengue fever in the preceding week, which had resolved following treatment. The patient was managed conservatively. At three months follow up, there was spontaneous flattening of the PEDs with improvement in visual acuity. Conclusion: Dengue fever complicated by acute hypokalemic quadriparesis can be associated with PED, which can be large. The condition resolves spontaneously and bears a good prognosis.

Congenital third nerve palsy with synergistic depression on attempted adduction and trigemino-oculomotor synkinesis: Underpinnings of a spectral dysinnervation disorder.

The authors describe a case of congenital partial pupil-sparing third cranial nerve palsy with absent adduction, synergistic depression of globe and widening of palpebral fissure on attempted adduction and synergistic elevation and adduction on mouth opening and sideways thrusting of jaw. The case illustrates trigemino-oculomotor synkinesis associated with congenital third nerve palsy. The possible mechanism of miswiring involving the medial longitudinal fasciculus and trigeminal nuclei is discussed. At least some cases of congenital third cranial nerve palsy may fall in the realm of congenital cranial dysinnervation disorders (CCDDs) sharing a much wider spectrum of presentation.

Comparison of Lateral Rectus Muscle Re-recession and Medial Rectus Muscle Resection for Treatment of Postoperative Exotropia

drainage device implantation may have been performed for eyes with more extensive peripheral anterior synechiae (PAS), and that this could be a reason for the higher graft failure rate. In our series, there were 5 eyes with extensive PAS (3 quadrants or more of anterior chamber angle closure on gonioscopy).Of these, 2 eyes underwent pre-keratoplasty glaucoma surgery.One eye underwent trabeculectomywhile the other had glaucoma drainage device implantation, and both eyes underwent penetrating keratoplasty. The eye with glaucoma drainage device subsequently had graft failure due to graft rejection.We are unable to make anymeaningful conclusion from this single event. Interestingly the intraocular pressure was controlled in these cases and hence was unlikely to contribute to the graft failure. Lastly, Drs Mittal and Senthil asked if intraoperative cell loss would be greater in Descemet stripping automated endothelial keratoplasty (DSAEK) in ICE syndrome. Although we do not have complete data on postoperative endothelial cell counts, the graft survival rates at 1 year and 3 years were 100% and 80% for DSAEK and 93.8% and 75% for PK (both P 1⁄4 1.00). This is in keeping with our results of DSAEK in pseudophakic bullous keratopathy cases but worse than Fuchs endothelial dystrophy. We agree that the surgery is more technically difficult in DSAEK owing to a disorganized anterior chamber, but with an appropriate inserter device similar graft survival rates to uncomplicated pseudophakic bullous keratopathy cases are achievable.

Inverted mucoepidermoid papilloma of conjunctiva in a child

Inverted papillomas are benign epithelial tumors usually arising from the mucous membrane of the sinonasal cavity and the urinary tract. Similar tumors of the conjunctiva are much rarer. We describe a case of juxtalimbal inverted papilloma in an 11-year-old boy who presented with a pigmented lesion that simulated a conjunctival nevus. Excisional biopsy established the diagnosis of inverted papilloma. The patient was carefully followed for 2 years, because the tumors behavior in the conjunctiva is unknown. There was no recurrence of the lesion.