Advanced keratoconus in a child with juvenile scleroderma

An 18-year-old male presented with complaints of gradually decreasing vision in both eyes for 6 years. He was a diagnosed with juvenile scleroderma at the age of 11 years by a pediatric rheumatologist. Clinical slit lamp examination showed features of ectasia, thinning, Vogt's striae, and apical scarring in both eyes. Bulbar and tarsal conjunctiva was quiet and normal. Corneal tomography revealed mean keratometry 65.8 and 65.4 diopters, thinnest pachymetry of 351 and 224 microns in the right and left eye, respectively. There was no history of itching and eye rubbing in the past. Patients of juvenile scleroderma may have associated keratoconus. The management of advanced keratoconus presents challenges related to handling and insertion of contact lenses in this condition. Keratoplasty is an option in those patients when contact lenses are not acceptable.

Corneal endothelium in unilateral Fuchs heterochromic iridocyclitis

Purpose: To assess the corneal endothelium in patients with Fuchs heterochromic iridocyclitis (FHI) and compare it with the normal fellow eye. Methods: Retrospective, observational, cross-sectional study of 31 patients seen between Jan 2016 to Dec 2018, with clinical diagnosis of Fuchs heterochromic iridocyclitis, was performed. Specular microscopic examination was documented in both eyes. The affected eyes formed the study group and the fellow healthy eyes served as controls. Results: The mean age of the patients was 29.9 ± 8.2 years. The endothelial cell density (P = 0.0001) was significantly lower, whereas average cell size (P = 0.0001), coefficient of variation (P = 0.004), and maximum cell area (P = 0.01) were significantly higher in the affected eye compared to the control eye. In three patients, the affected eye showed guttae, while the healthy fellow eye revealed a normal specular mosaic. Conclusion: Specular microscopic analysis shows endothelial alterations in the affected eyes in FHI.

Outcomes of therapeutic penetrating keratoplasty in 198 eyes with fungal keratitis

Purpose: To study the outcomes of therapeutic penetrating keratoplasty in fungal keratitis. Methods: This retrospective, observational, interventional case series involved an audit of 198 consecutive eyes that underwent therapeutic penetrating keratoplasty (ThPK) for fungal keratitis at L V Prasad Eye Institute between January 2008 and December 2010 was performed. The data on demographics, clinical characteristics, intraoperative, and late postoperative complications were noted. The primary outcome measure was eradication of infection and postoperative anatomical success. Secondary outcome measures were graft survival, risk factors, clinical features, and management of recurrent fungal keratitis post ThPK. Results: Mean follow-up after ThPK was 24 ± 17 months. A total of 178 (89.9%) eyes had complete eradication of fungal infection, whereas 20 (10.1%) eyes developed recurrence. Anatomical restoration was achieved in majority of cases (192 eyes; 97%). Larger infiltrate size was associated with a higher risk of recurrence of infection. The median graft survival rate was 5.9 months. The graft survival was better for grafts <8 mm versus those with >8 mm (P = 0.026) and not found significantly related to the species of fungus. Twenty-seven eyes underwent re-grafting: penetrating keratoplasty in 14 eyes, and Descemet's stripping endothelial keratoplasty in 13 eyes. Conclusion: As larger infiltrate prior to therapeutic keratoplasty had much higher risk of recurrences; timely surgical intervention should be considered in cases not responding to medical therapy. Alternative strategies of management of postoperative inflammation need to be considered to prevent graft failures.

Evaluation of anterior segment parameters with two anterior segment optical coherence tomography systems: Visante and Casia, in primary angle closure disease

Purpose: To determine the comparability of anterior chamber biometric measurements in primary angle closure disease (PACD) patients using two commercially available anterior segment optical coherence tomography machines (ASOCT): Visante and Casia. Methods: This was a cross-sectional observational study, which included clinically, diagnosed cases of PACD. Anterior segment biometric measurements were done using Casia and Visante ASOCT. Parameters studied were central corneal thickness (CCT), anterior chamber depth (ACD), nasal (N) and temporal (T) angle opening distance at 500 ?m (AOD500) and 750 ?m (AOD750), and N and T trabecular iris space area at 500 ?m (TISA500) and 750 ?m (TISA750). Results: Total 36 PACD patients (72 eyes) with average age of 59.48 ± 7.95 years were recruited, out of which 25 were females (69.44%) and 11 males (30.56%). The mean measurements of CCT, ACD, AOD500, and TISA on Casia and Visante machines were 522.5 ± 34.75 ?m and 539.55 ± 29.56 ?m (P = 0.00); ACD- 2.144 ± 0.38 mm and 2.133 ± 0.39 mm (P = 0.487); AOD500-0.27 ± 0.16 ?m and 0.21 ± 0.10 ?m (P = 0.04); and TISA500-0.100 ± 0.07 ?m and 0.063 ± 0.03 ?m (P = 0.00), respectively. A statistically significant difference was noted in CCT, N and T AOD, and TISA. A good corelation for ACD and CCT (ACD = 0.9816 and CCT = 0.772) only were noted between the two machines. The Bland-Altman plot analysis of different parameters between two machines has revealed good agreement of measurement of ACD and CCT but poor agreement for rest of the parameters. Conclusion: It is advisable not use the two machines interchangeably because of the wide limits of agreement and poor correlation of angle measurement values of Casia and Visante ASOCT.

Ligneous conjunctivitis in a Dandy–Walker syndrome: A rare case report

Ligneous conjunctivitis (LC) is a rare form of pseudomembranous conjunctivitis seen in children, perhaps due to plasminogen deficiency, which manifest as a chronic refractory pseudomembranous conjunctivitis. LC cases are incapable in maintaining their fibrinolytic activity due to plasminogen deficiency; consequently, transudates of plasma assume as a thick, gelatinous, woody membranes over the mucosal surfaces. This is a short case report on a child with a LC, who presented with recurrent pseudomembranous conjunctivitis in conjunction with progressive congenital hydrocephalus due to aqueductal stenosis (Dandy–Walker syndrome). This rare association was clinically confirmed and prompt corrective surgical measures were instituted.

Primary graft failure after big bubble deep anterior lamellar keratoplasty in macular corneal dystrophy

Macular corneal dystrophy is autosomal recessive dystrophy characterized by deposits of abnormal glycosaminoglycans in stromal lamellae and within endothelial cells. Deep anterior lamellar keratoplasty is successful in the management of this dystrophy. We herein describe three cases of primary graft failure after uneventful big bubble deep anterior lamellar keratoplasty for macular corneal dystrophy.

Management of Candida glabrata infectious crystalline keratopathy with endophthalmitis following penetrating keratoplasty

A 33-year-old male underwent an optical keratoplasty elsewhere in the right eye following which he developed endophthalmitis and subsequently underwent a pars plana vitrectomy and lensectomy. At presentation, he had a deep stromal crystalline infiltration along the graft–host junction. A large therapeutic keratoplasty was performed, and the excised corneal button was evaluated. Histopathology revealed gram-positive round-to-oval budding structures and microbiology identified the organism as Candida glabrata. He was treated with antifungals in the postoperative period. At 4 months after therapeutic keratoplasty, the patient developed recurrent endophthalmitis, following stoppage of antifungals. The treatment was reinstituted for another year, and the patient did well with a clear graft at 18-month-follow-up period after the recurrence episode. Management of infectious crystalline keratopathy with endophthalmitis is a challenging situation and requires long-term treatment.

Outcomes of keratoplasty in lattice corneal dystrophy in a large cohort of Indian eyes

Purpose: The purpose of this study is to evaluate the outcomes of keratoplasty for lattice corneal dystrophy (LCD) performed at a tertiary eye care center. Methods: A retrospective review of medical records of those patients who were clinically diagnosed to have LCD (72 eyes of 57 patients) and underwent either penetrating keratoplasty (PK, 58 eyes of 46 patients) or deep anterior lamellar keratoplasty (DALK, 14 eyes of 13 patients) between the years 1987 and 2014 was performed. The main outcome measures included demographics, clinical features, and outcomes of keratoplasty. Results: The median follow-up after keratoplasty was 3.1 years (interquartile range [IQR], 9 months to 9 years). The median best-corrected visual acuity (BCVA) was 0.18 (IQR, 0.10�48) (Snellen equivalent 20/30 [IQR, 20/25�/60]) at 4 years postoperatively and 0.65 (IQR, 0.18-0.95) (Snellen equivalent 20/89 [IQR, 20/30�/178]) at 10 years following surgery. DALK eyes had a significantly better BCVA than PK eyes at 2 years following keratoplasty. The median overall survival of grafts was 15.8 years. Late complications included recurrence of LCD (14 eyes), graft infiltrate (23 eyes), graft rejection (15 eyes), graft failure (16 eyes), and glaucoma (14 eyes). Conclusion: The outcomes of graft are similar following PK and deep anterior lamellar keratoplasty; however, the latter appears to provide slightly better visual outcome. Recurrence of dystrophy in the graft and graft infiltrates limit the overall graft survival in both the groups.

High-resolution optical coherence tomography in a case of descemetocele managed with amniotic membrane transplantation

Amniotic membrane transplantation is a useful in the management of corneal melts and descemetocele. We describe high-resolution anterior segment optical coherence tomography (OCT) (Optovue) in a patient with descemetocele who was managed surgically with amniotic membrane transplantation. A 60-year-old female presented with a corneal melt in the right eye. She was a case of rheumatoid arthritis and was on systemic treatment with immunomodulators. Slit lamp examination revealed a severe thinning paracentrally. High-resolution OCT was performed at the site of descemetocele. She underwent amniotic membrane transplantation using fibrin glue and bandage contact lens application. At 6 weeks postoperative, the bandage contact lens was removed. The area of thinning healed with scarring. OCT at the healed site revealed stable surface and an increase in stromal thickness to 281 ? this case describes the utility of amniotic membrane in the healing of sterile corneal melts by providing tectonic support and its integration in the stroma. The stromal healing and increased thickness at the site of descemetocele could be delineated on high-resolution OCT imaging.

Reactivation of herpes simplex viral keratitis following the botulinum toxin injection

We describe a case of 55-year-old male farmer presented with recurrent corneal abrasions with a spastic entropion in the left eye. Superior cornea showed typical nummular opacities suggestive resolved herpetic eye diseases. On further enquiry, he had similar episodes in the past. Contralateral eye was essentially normal. Following the botulinum toxin injection for the management of spastic entropion, subject developed reactivation of herpetic necrotizing stromal keratitis. Diagnostic corneal scrapings were negative for herpes simplex virus-1 antigen by immunofluorescence assay and for DNA by molecular techniques. The case was successfully managed with topical steroids and antiviral medications.

Utilization of Formalin Embalmed Specimens Under Eco-Friendly Conditions by Advanced Plastination Technique.

Preparation of anatomical models and teaching aids is a challenging task in the medical, veterinary and paramedical sciences as like as life form. The successful preservation of conventional methods by embalmed cadavers/ corpse’s are routinely practiced for educational/research purposes. The existing form of preservation technique is not promising to meet the current challenges in the teaching and learning of human/veterinary anatomy. The embalming fluid causes potential health hazards with continuous exposure of formalin fumes. The study was conducted on dissected cadaverous embalmed specimens by using advanced plastination technique. The 10% formalin fixed and preserved specimens of buffalo head and horse limb were subjected to dehydration, impregnation and hardening with clearing, dehydrating and curing agents. Plastination methodology consists of slowly replacing tissue fluids, lipids with a dehydrating agent and replaced with polymer under force impregnation. In these processes, water and lipids in biological tissues are replaced by curable polymers. The yielded specimens are pleasant to handle, non toxic, pliable, dried and don’t smell or decay. These plastinates are well utilized in routine practical demonstrations of gross anatomical observations in institutional teaching as well as learning. The plastinated specimens are today’s milestone in medical education and become an ideal teaching tool not only in anatomy but also in pathology, obstetrics, radiology and surgery. Hence, any methodology or technique that would decrease the level of exposure to formaldehyde should be explored. Plastinates offer this excellent alternative as it lowers the risk of undue exposure to formaldehyde with higher health and safety regulations in our country.

Study of reaction parameters and kinetics of esterification of lauric acid with butanol by immobilized Candida antarctica lipase.

Esterification of lauric acid with n-butanol, catalyzed by immobilized Candida antarctica lipase (CAL) in aqueous-organic biphasic solvent system was studied. Effects of various reaction parameters on esterification were investigated, such as type and amount of solvent, amount of buffer, pH, temperature, speed of agitation, amount of enzyme, butanol and lauric acid. The most suitable reaction conditions for esterification were observed at 50ºC and pH 7.0 using 5000 μmoles of lauric acid, 7000 μmoles of butanol, 0.25 ml phosphate buffer, 1 ml of isooctane as the solvent and 50 mg of immobilized enzyme in the reaction medium at agitation speed of 150 rpm. Maximum esterification of 96.36% was acheived in 600 min of reaction time at n-butanol to lauric acid molar ratio of 1: 0.7. Kinetic study for the esterification of lauric acid with n-butanol using immobilized CAL was carried out and the kinetic constants were estimated by using non-linear regression method. The estimated value of Michaelis kinetic constants for butanol (KmBt) and acid (KmAc) were 451.56 (M) and 4.7 × 10-7(M), respectively and the value of dissociation constant (KBt) of the butanol-lipase complex was 9.41 × 107(M). The estimated constants agreed fairly well with literature data.

A comparative study of clonidine versus a combination of diazepam and atropine for premedication in orthopaedic patients.

Sixty patients in the age group of 18-60 years of A.S.A. Grade I/II risk, scheduled for elective orthopaedic surgeries under general anaesthesia were studied for pre-medication with either oral clonidine or with combination of effects of diazepam & atropine. Patients in Group A (clonidine group) received tablet clonidine 100 mcg (1 tablet) if less than 50 kg in weight and 200 mcg if weighing more than 50 kg two hours before surgery. Patients in Group B (Diazepam-atropine group) received one tablet of Diazepam (10 mg) orally two hours before surgery and injection atropine-sulphate 0.01 mg/kg half an hour preoperatively by intramuscular route. In our study, the sedative and anti-sialogogue effects of clonidine were comparable to those of diazepam-atropine combination, which are commonly used premedicants. The anti-anxiety effect of clonidine was found to be better than that of diazepam-atropine combination. Clonidine also proved to be a better agent for the attenuation of pressor response to laryngoscopy and intubation. Thus, oral clonidine is a better premedicant compared to atropine-diazepam combination. Also, it is a more acceptable agent because of its oral route of administration.

Bacopa monniera Linn. as an antioxidant: mechanism of action.

Bacopa monniera, Linn. (Brahmi: Scrophulariaceae) an Ayurvedic medicine is clinically used for memory enhancing, epilepsy, insomnia and as mild sedative. For the first time the effect of alcohol and hexane fraction of Brahmi has been studied on FeSO4 and cumene hydroperoxide induced lipid peroxidation. Alcohol fraction showed greater protection with both inducers. Results were compared with known antioxidants tris, EDTA and a natural-antioxidant vitamin E. The effect of Brahmi was also examined on hepatic glutathione content. The mechanism of action could be through metal chelation at the initiation level and also as chain breaker. The results suggested that Brahmi is a potent antioxidant. The response of Brahmi was dose dependent. Tris, an hydroxyl trapper did not show any protection in comparison to Brahmi where as EDTA and vitamin E did protect against FeSO4. In experimental conditions 100 micrograms Brahmi extract (alcoholic) was equivalent to 247 micrograms of EDTA (0.66 microM) and 58 micrograms of vitamin E. Interestingly Brahmi only slightly protected the autooxidation and FeSO4 induced oxidation of reduced glutathione on lower doses 100 micrograms/ml and below, but on higher concentrations it enhanced the rate of oxidation.

Antioxidant and anti-inflammatory property of Sandhika: a compound herbal drug.

The present study was envisaged to assess the rationality for the use of "Sandhika", a popular Ayurvedic drug in rheumatoid arthritis. This drug, when tested against carrageenan induced paw oedema and cotton pellet granuloma, showed significant anti-inflammatory activity at the dose of 0.25 g/kg body weight. The antioxidant property was assessed by determining cumene hydroperoxide (CHP) induced lipid peroxidation and reduced glutathione content in rat liver homogenate (in vitro). Experiments show the significant protection against lipid peroxidation at the dose of 80 micrograms/ml, measured as reduction in the level of malondialdehyde (MDA) induced by 1.5 mM cumene hydroperoxide (CHP). This effect was accompanied by the maintained reduced glutathione (GSH) content in drug treated rats. Oral treatment of drug up to 2 g/kg body weight for 15 days did not show any rise in serum transaminases (SGOT and SGPT). The results suggest that "Sandhika" which is an indigenous drug for inflammation with no detectable adverse effect, might be acting through scavenging the free radicals.

Effect of fungicides on the production of amylase by Rhizopus oryzae.

Seven fungicides (Brassicol), captan, Dithane M-45, Fytolan, Parasan, Sulfex and Thiram) were tested for their effect on the production of amylase enzyme by Rhizopus oryzae. The activity of amylase was determined by cup-plate method. All the fungicides were found inhibitory for the synthesis of amylase. Out of these, Parasan was the most effective causing hundred percent inhibition at 0.025% concentration. No amylase production was recorded when Thiram, Fytolan, Brassicol, Captan and Dithane M-45 were used at 0.5, 1.5, 2.0, 2.0, and 2.0% concentration respectively. Sulfex was found to be less effective, as hundred percent inhibition of amylase production has not been recorded even at 3.0% concentration.