Ocular manifestations of isolated corneal bee sting injury, management strategies, and clinical outcomes

Purpose: The purpose of this study is to describe the presenting features, management strategies, and clinical outcome following bee sting injury to the cornea. Methods: Retrospective case series involving 11 eyes of 11 patients with corneal bee sting injuries who presented over a period of 2 years. Nine of these 11 eyes had the presence of intact bee stinger in the cornea, which was removed immediately under an operating microscope and sent for microbiological and histopathological evaluation. The patients were managed as per the individual treatment protocol of the respective treating physicians. Results: Six eyes (54.5%) had a good clinical outcome (best-corrected visual acuity [BCVA] >20/40) with medical therapy alone with no need for surgical intervention. Five eyes (45.5%) had a poor clinical outcome (BCVA <20/40) with medical therapy and required surgery; of which three required a combined penetrating keratoplasty with cataract surgery, while one required isolated cataract surgery and one underwent penetrating keratoplasty. Glaucoma was present in 3/5 eyes undergoing surgery, one of which required a trabeculectomy. Five of the six eyes who had a good clinical outcome with medical therapy alone had been treated with concomitant oral steroids, along with topical antibiotic-steroid combination therapy. Conclusion: Oral corticosteroid supplementation to the topical steroid antibiotic treatment in patients with corneal bee sting injury where corneal involvement and anterior reaction is severe at presentation or inflammation not ameliorating with topical steroids alone prevents serious vision-threatening complications such as corneal decompensation, cataract, and glaucoma.

Comparative evaluation of the surface tension and the pH of calcium hydroxide mixed with five different vehicles: an in vitro study.

AIM: The aim of this study was to evaluate the surface tension and pH of five different vehicles that are used as potential agents to mix calcium hydroxide in root canal treatments and to compare them with the final surface tension and pH of calcium hydroxide mixed with these vehicles. MATERIALS AND METHODS: The study was carried out in two phases. In Phase I, the surface tension and pH of five vehicles (distilled water, saline, anesthetic solution, chlorhexidine, and glycerin) were evaluated using a Du Nuoy Tensiometer and a pH Meter. In Phase II, a predetermined amount of calcium hydroxide was mixed with the individual vehicles and the surface tension and pH was determined. In each group, seven samples were evaluated. RESULTS: Among the individual vehicles, chlorhexidine had the least surface tension values (39.8+1.1 dynes/cm). Among the various calcium hydroxide mixtures, calcium hydroxide with chlorhexidine showed the least surface tension values (36.4+1.1 dynes/cm). All the vehicles showed an acidic pH ranging from 5 to 6.5. There was a significant increase in the pH values with the addition of calcium hydroxide to the respective vehicles. The calcium hydroxide mixtures had an alkaline pH ranging from 9 to 11.5; the highest pH was observed for calcium hydroxide mixed with distilled water and saline (11.5+0.2). CONCLUSION: The surface tension and pH of the vehicles directly influenced the surface tension and pH of the calcium hydroxide mixtures. Chlorhexidine was found to be a better vehicle for calcium hydroxide when used as an intracanal medicament.

Distinguishing infective versus noninfective keratitis.

For the purpose of this symposium, the term "keratitis" implies suppurative nonviral and viral keratitis. Corneal ulcers have been described in ancient literature. But even today, despite the availability of a wide range of newer antimicrobials and new diagnostic techniques, infective keratitis continues to pose a diagnostic and therapeutic challenge. This article focuses on the key diagnostic clinical features of the most common organisms causing infective keratitis - bacteria, fungi, viruses, nocardia and acanthamoeba - in India. While the clinical features in some cases are fairly straightforward, most cases challenge the clinician. We describe the salient clinical features which can help arrive at a diagnosis to begin appropriate treatment immediately, prior to the laboratory report.

Noise levels in a tertiary care hospital.

High levels of noise in hospitals may interfere with patient care services, the doctor-patient relationship and medical education activities. The aim of this study was to assess the noise level at different places in a tertiary care hospital and suggest measures to reduce the noise. Sound levels of fourteen places inside the hospital were recorded using a Digital Sound Level Meter . A total of 20 readings were taken at three minute intervals between successive recordings during the morning (9 to 10 a.m.) and evening hours (6 to 7 p.m.) and analyzed using simple descriptive statistics. The mean equivalent sound pressure levels (Leq) during the morning and evening hours were 70.38 and 64.46 dB(A) respectively. During the morning hours, the maximum Leq was observed in the mortuary (76.70 dBA) whereas the minimum Leq was in the intensive care unit (I.C.U) (58.34 dBA). The maximum and minimum Leq during evening hours were recorded at O.G (Obstetrics and Gynecology) ward (71.86 dBA) and mortuary (57.08 dBA) respectively. The morning hours showed higher levels of noise in most of the places probably due to overcrowding and higher vehicular movement. This study highlights the need for noise monitoring and control measures inside hospital areas.

Sediment texture and nutrients of Arasalar estuary, Karaikkal, south-east coast of India.

Sediment samples were collected for texture, composition and nutrient such as organic carbon, total nitrogen and total phosphorus for a period of two years from three stations in Arasalar estuary. The sediment temperature, pH and nutrients were higher during summer season and lower during monsoon season. At station 1, sediment texture was loamy sand during summer and premonsoon season. At station 2, clay type soil was recorded. Whereas, at station 3, clay was observed in summer and premonsoon and then it shifted to sandy loam type soil during monsoon. Sediment nutrients were lower than that of values of various ecosystem of India.

A study of the spectrum of Acanthamoeba keratitis: a three-year study at a tertiary eye care referral center in South India.

PURPOSE: To determine the epidemiological and clinical characteristics of Acanthamoeba keratitis and also to determine the sensitivity and specificity of smears in the detection of Acanthamoeba. MATERIALS AND METHODS: A retrospective review of all culture-positive cases of Acanthamoeba keratitis seen between October 1999 and August 2002 was performed. Corneal scrapes were subjected to culture and microscopy using standard protocols. RESULTS: Out of 3183 consecutive patients with clinically diagnosed corneal ulcers evaluated, 33 (1.04%) were found to be due to Acanthamoeba. Twenty-four out of 33 (72.72%) were less than 51 years of age (P<0.001). All patients were from rural areas (P<0.001) and 26 (78.79%) of them were agricultural workers (P=0.031). All 33 had history of corneal injury (P<0.001) and 28 (84.85%) patients had injury with mud (P<0.001). All 33 (100%) patients had previous medical treatment (P=0.009) and 10 (30.3%) had used traditional eye medicines (P=0.183). A clinical pattern of ring infiltrate was characteristic in 15 (45.45%) patients. The diameter of the corneal ulcer was more than 6 mm in 27 (81.82%) eyes (P<0.001). Twenty-six (78.79%) patients had visual acuity of perception of light on initial presentation (P<0.001) and 24 (72.73%) had the same as their final visual outcome. The sensitivity of 10% potassium hydroxide (KOH) preparation was found to be higher (P<0.001) in the detection of Acanthamoeba cysts. CONCLUSION: The incidence of Acanthamoeba keratitis amongst the corneal ulcer patients was 1% in this setting and it was mainly due to corneal injury by mud. The KOH preparation is a sensitive diagnostic tool for the detection of Acanthamoeba. Delayed diagnosis or misdiagnosis and inappropriate antimicrobial therapy results in poor visual outcome.

Anatomical variations of mandibular premolars in Chennai population.

AIM: To analyse the prevalence of anatomical variations of mandibular premolars in Chennai population. METHODOLOGY: It was observed, during the routine treatment of mandibular premolars that aberrations were becoming common. This necessitated an encompassing study on 500 patients, evaluating the occurrence of these aberrations. The parameters of this study included sex predilection, unilateral/ bilateral occurrences, and comparison of the incidence of anatomical variations in mandibular first and second premolar canal configuration. The study pattern was designed to observe these premolars using Radiovisiography (RVG) in different angulations to highlight the anatomical aberrations. The results were subjected to statistical analysis, which were performed using SPSS (Statistical Package for Social Science) statistical program version 10.0.5. Descriptive statistics were computed for all the variables. RESULT: The present study revealed high incidence of anatomical aberrations in mandibular premolars among Chennai population. Out of the 500 patients studied, 123 patients [24.6%] showed anatomical variance in the canal configuration. There was high incidence of Vertucci's Type IV canal configuration as compared to Type V, Type II and Type VIII in the descending order of occurrence. CONCLUSION: Within the limitations of this in-vivo study, it was inferred that the incidence of aberrations in the canal configuration of mandibular premolars is common and due considerations are to be given during endodontic intervention.

Susceptibility trends of pseudomonas species from corneal ulcers.

PURPOSE: To assess the changing trends in the antibiotic susceptibility of Pseudomonas spp . isolated from bacterial keratitis over a nine year period with special emphasis on fluoroquinolone susceptibilities. METHODS: All corneal scraping cultures positive for Pseudomonas spp. (n=585) isolated from patients with bacterial keratitis at the Aravind Eye Hospital, Madurai from 1995-2003 were evaluated. Cultures were performed in liquid and solid media and susceptibility testing was done against amikacin, gentamicin, tobramycin, ciprofloxacin and ofloxacin by Kirby-Bauer disc diffusion method. RESULTS: The susceptibility of Pseudomonas spp. was over 90% from 1995-1998 to ciprofloxacin which decreased to 83% from 1999-2003. The total number of isolates resistant to ciprofloxacin was 51 (9.4%). No statistically significant increase in the number of isolates resistant to ciprofloxacin was noted. Ofloxacin showed 54% susceptibility from 1995-1998 but increased to 64% from 1999-2003. Analysis of in vitro activity of amikacin reveals that there was 43% sensitivity from 1995-1998 but later it increased to 76% from 1999-2003. In case of gentamicin, the sensitivity decreased marginally from 80% to 70% through the years. Tobramycin showed 45% sensitivity from 1995-1998 but increased to 75% from 1999-2003. CONCLUSIONS: The fluoroquinolones remain a good choice in the treatment of ocular infections, with high susceptibility of Pseudomonas spp. Among the aminoglycosides, gentamicin was found to be highly effective against Pseudomonas corneal ulcers when compared to amikacin and tobramycin. The results show a need for continuous monitoring of bacterial resistance trends.

Seasonal distribution of physico- chemical parameters in effluent discharge area of Uppanar estuary, Cuddalore, south-east coast of India.

Seasonal distribution of physico-chemical characteristics such as rainfall, pH, salinity, temperature, light extinction coefficient, dissolved oxygen, biological oxygen demand and nutrients like total phosphorus, inorganic phosphate, nitrite, nitrate and reactive silicate has been studied at two stations of Uppanar estuary in relation to effluent discharges from SIPCOT industries. There are 44 industries discharges their effluents into Uppanar estuary, which may influence the biota. Nutrient concentrations were higher during monsoon season and low during summer season. The mean concentrations of nutrients were high at station 1 than station 2 due to discharges from industries, coconut husk retting grounds near the station 1. In the present study, the physico-chemical characteristic of Uppanar estuary carried out and variations are discussed.

A cluster of cases of Mycobacterium chelonei keratitis following penetrating keratoplasty.

Cluster infection with Mycobacterium chelonei following penetrating keratoplasty is described. All the donor eyes were harvested from the same collection centre. This underscores the importance of adherence to sterile protocols.

Late dislocation of LASIK flap following fingernail injury.

A case of traumatic flap displacement with a fingernail injury four years after LASIK is reported.

Ocular infections due to non-tuberculous mycobacteria.

PURPOSE: To investigate the types and causes of non-tuberculous ocular infections and study their response to topical antibiotic therapy. METHOD: A single center, retrospective review of 18 patients with non-tuberculous mycobacterial ocular infections, seen over a 3 year period was done. Laboratory diagnosis was established by growth on blood agar, LJ medium and Ziehl-Nielsen acid fast stain. RESULTS: Out of 18 patients, six had post corneal graft infection, six had corneal ulcers, three had endogenous endophthalmitis, one had post operative endophthalmitis and two cases were of post surgical wound infection. History of trauma was reported in two cases and surgery in nine cases. M.chelonae was grown in blood agar for all patients. For corneal infections fortified genatmicin and fortified amikacin topical eye drops were given while the cases of endophthalmitis received intravitreal amikacin. Response to treatment was poor in 16 cases (88.9%). Only two cases of corneal ulcer improved after prolonged treatment. There was a misdiagnosis of Corynebacterium spp. on Gram stain in the initial cases. Majority of the isolates were sensitive to gentamicin (72.2%) followed by amikacin (44.4%). CONCLUSIONS: Early clinical recognition and prompt laboratory diagnosis together with aggressive topical antibiotic therapy may shorten morbidity and improve the clinical outcome of non-tuberculous mycobacterial ocular infection.

Simultaneous bilateral fungal keratitis caused by different fungi.

Fungal keratitis is an important cause of corneal disease in the tropical world. We report a rare presentation of simultaneous bilateral corneal ulceration caused by different fungi.

Recognition of cyclooxygenase-2 (COX-2) active site by NSAIDs: a computer modelling study.

The energetics and models of COX-2 complexed with nonsteroidal anti-inflammatory drugs (NSAIDs) having different degrees of selectivity for two isoforms of COX (COX-2 and COX-1) have been studied using computer modelling approach. The models are obtained for complexes of NS398 (NS), a selective COX-2 inhibitor; indoprofen (Ind), a non-selective inhibitor; di-tert-butylbenzofurans (DHDMBFs) with substituents at the 5th position: CONH(CH2)2OMe (BF1), CONH-c-Pr (BF2), 3-methylene-gamma-butyrolactonyl (BF3) and oxicams namely, meloxicam (Mel), piroxicam (Pir) and tenoxicam (Ten). These were optimized using molecular mechanics (MM) and molecular dynamics (MD) techniques. The binding energies and structures were compared with pharmacological parameters and available results with COX-1. In case of NS a larger difference in the binding energies between COX-2 and COX-1 was noticed as compared to that of Ind. It also had stronger interaction with His90 and Tyr355 which is considered important for COX-2 selectivity. There was a difference in the compactness at the channel entrance between COX-2 selective and non-selective ligands. Models with DHDMBFs and oxicams showed a similar correlation. The results were used to design a peptide inhibitor, Tyr-Arg-Cys-Ala-delta Phe-Cys (Pept) which could fit better in the COX-2 cavity. As per our MD simulation results this peptide inhibitor showed both higher activity and COX-2 selectivity.

Sodium bicarbonate--an alternative to hyaluronidase in ocular anaesthesia for cataract surgery.

PURPOSE: To evaluate and compare the safety, efficacy and cost-effectiveness of 7.5% sodium bicarbonate buffered lidocaine (pH 7.2) with hyaluronidase mixed lidocaine (pH 4.6) for local anaesthesia in cataract surgery. METHODS: This prospective study comprised two parts. Part I: We evaluated the ocular and systematic anaesthetic safety and efficacy of 7.5% sodium bicarbonate buffered lidocaine on 112 consecutive patients undergoing cataract extraction with intraocular lens (IOL) implantation. At 12-week postoperative follow up final visual acuity and detailed fundus examination was done. Part II: It was conducted as a double blind, randomized comparative clinical trial involving 120 patients undergoing cataract surgery under retrobulbar anaesthesia. Patients were randomly assigned to one of the two groups: 60 eyes received 2 ml of 2% lidocaine with 1:200,000 epinephrine and 1 ml of 7.5% sodium bicarbonate, (0.299 mmol/ml); the remaining 60 eyes received 2 ml of 2% lidocaine with 1:200,000 epinephrine and 450 units of hyaluronidase (15 U/ml). In the event of incomplete akinesia, retrobulbar blocks were supplemented at 10 minutes. Onset and duration of anaesthesia and akinesia were assessed and compared in both groups. RESULTS: The pH-adjusted lidocaine group did not show any demonstrable variation in blood pressure (BP) or other systemic reaction. No anaesthesia-related adverse ocular effects were observed either during or after surgery. Thirty-one eyes (51.6%) achieved complete anaesthesia and akinesia within 5 minutes compared to 13 eyes (21.6%) in the hyaluronidase group. However, the overall mean onset time of anaesthesia and akinesia, repeat block rate and the duration of the anaesthesia were comparable in both the groups--p: 0.14). Twelve weeks postoperatively 88.39% of patients showed a best corrected visual acuity of 6/18 or better (73.21%-6/12 or better). CONCLUSION: In this study, sodium bicarbonate buffered 2% lidocaine was found to be a safe and effective local anaesthetic, with reduced time of onset, and improved quality of both anaesthesia and akinesia. Sodium bicarbonate (7.5%) may be used as an alternative to hyaluronidase in ocular anaesthesia. It is readily available and is cost effective.

Metabolic programming by nutrition during early development.

Incidence of obesity and diabetes is increasing at an alarming rate not only among the populations of the affluent nations but also amongst the populations of the developing nations. Understanding the mechanisms that cause the onset of these pathological conditions is a requisite to effectively tackling this problem. In this context the role of early nutritional experiences as a causative factor is being extensively investigated. This article briefly reviews the field of metabolic programming vis-a-vis an altered nutritional milieu during perinatal period and consequent adaptive metabolic patterning and metabolic imprinting in adult and/or consequent offspring.

Use of Traditional Eye Medicines by corneal ulcer patients presenting to a hospital in South India.

PURPOSE: To investigate the nature and frequency of use of Traditional Eye Medicine (TEM) for corneal ulcer in patients from predominantly rural background. METHODS: We documented the the use of TEM by corneal ulcer patients presenting to a tertiary eye-care centre in South India during two months of 1996. RESULTS: Of 283 patients enrolled in the study, 135 (47.7%) of the patients used TEM. There was no difference with regard to age and sex distribution of patients using TEM and those who did. Patients with history of trauma were more likely to use TEM. Common forms of TEM used were human breast milk 61(45.2%), leafy matter 40(29.6%), castor oil 16 (11.9%), and hen's blood 8 (5.9%). CONCLUSION: Though the awareness of intraocular lens implantation for cataract surgery is very high in this segment of the population, it is still tragic that an awareness of primary eye care following trauma has not been created. Health education is mandatory to prevent this avoidable cause of blindness.