Microkeratome-assisted ultrathin Descemet's stripping automated endothelial keratoplasty: A randomized trial comparing single-pass versus double-pass technique

Purpose: To compare the outcomes of two techniques, for preparation of microkeratome-assisted ultrathin grafts for Descemet's stripping automated endothelial keratoplasty (DSAEK). Methods: The study involved 20 eyes of 20 patients with pseudophakic bullous keratopathy, randomized into two groups. Group 1 eyes underwent microkeratome-assisted DSAEK using the single-pass technique for lenticule preparation, whereas group 2 eyes underwent microkeratome-assisted DSAEK using the double-pass technique. Patients were followed up till 6 months, postoperatively. Best-corrected visual acuity (BCVA) at final follow-up was considered as the primary outcome measure, whereas graft thickness (GT) contrast sensitivity and endothelial cell loss were considered as the secondary outcome measures. A P value of <0.05 was considered as statistically significant. Results: Baseline characteristics of two groups were comparable. The mean central GT was comparable in both groups at 6 months follow-up [group 1: 98 ± 24.46 ?m, group 2: 129 ± 31.46 ?m (P = 0.18)]. Both groups fared equally in terms of BCVA (P = 0.33). Contrast sensitivity was significantly better in group 1 eyes (P = 0.045). A statistically significant negative correlation was found between postoperative BCVA and postoperative GT (R = ?0.728, P = 0.016). The percentage endothelial cell loss was slightly higher in group 2 eyes, although not statistically significant. Two eyes in group 2 experienced complications during lenticule preparation. None of the eye experienced any complication in the postoperative period. Conclusion: Both techniques provided grafts with comparable thickness and endothelial cell loss and were associated with comparable BCVA, at final follow-up visit. The contrast sensitivity was, however, better in eyes receiving grafts prepared with the single-pass technique.

Procurement, storage and utilization trends of eye banks in India

Purpose: To study the trends in collection, storage and utilization of donor corneas in eye banks in India. Methods: The data was collected from 12 eye banks in India that collected more than 1000 corneas per year. The retrospective analysis of the parameters like characteristics of the donor and the host, storage media used, number of eyes collected, number of eyes utilized, causes of non-utilization of the tissue and the procedures performed was done. Results: A total of 20,564 eyes were collected by the 12 eye banks during the year 2013–2014. Voluntary eye donation (VED), and hospital cornea retrieval program (HCRP) contributed to 59.6% and 40.4% of tissue procurement respectively. Whole globe enucleation (52.3%) was more commonly performed as compared to in-situ excision of the donor corneas. The most commonly used storage media at all eye banks was McCarey-Kaufman (MK) media (83.3%). The utilization rate of the donor eyes was 50.5%. The most frequent indication for corneal transplantation was infection (active infection - 33.13%, healed infection - 10.78%) followed by Pseudophakic bullous keratopathy (PBK) (13.57%). Full thickness keratoplasty (optical penetrating keratoplasty - 47.23%, therapeutic penetrating keratoplasty - 31.74%) was performed most often followed by endothelial keratoplasty (12.41%) in the developing country. Conclusion: VED still contributes to majority of the donor tissue retrieval in India. The majority of the eye banks still utilize whole globe enucleation technique and store tissues in MK media. Trends from previous years showed a change towards HCRP, in-situ excision technique and preservation in the long-term storage media.

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.

Cushing's disease: management outcome in a tertiary care centre.

Cushing's syndrome (CS) can pose a challenge in diagnosis and management. Successful management of CS needs accurate localization of the site of lesion. Present article narrates experience of a single center dealing with large number of patients with CS and highlights difficulties in diagnosis as well as management of Cushing's disease (CD). METHODS: All patients with CD, where histopathological lesion was documented were studied to evaluate yield from different diagnostic tests. Diagnosis was established by standard 2 days low dose dexamethasone suppression test. Localization of the lesion was achieved with high dose dexamethasone suppression (HDDS) and imaging. Inferior petrosal sinus sampling (IPSS) was used whenever diagnosis was not arrived at with the standard tests. RESULTS: Out of 100 consecutive patients of CS seen, 69 had CD. HDDS had sensitivity of 70% and specificity of 99% in localizing the lesion. Imaging localized the lesion in 68% of patients. Combination of HDDS and imaging localized the lesion in 90% of patients. IPSS helped to localise the lesion in remaining 10% of patients. Transsphenoidal surgery was carried out in 65/69 patients. Cure rate for microadenoma was 77% and for macroadenoma was 36%. Mortality and morbidity rate was 7% and 7% respectively. 2nd TSS, radiotherapy and bilateral adrenalectomy were the additional modalities used in that order, in patients who were not cured or who had recurrence. CONCLUSION: Management of CS is best carried in a center where a team of experienced endocrinologist and neurosurgeon is available.

Lipid peroxidation in bronchial asthma.

OBJECTIVE: To study the levels of free oxygen redicals in children with bronchial asthma during an attack and symptom free interval. METHODS: Serum Malondiadehyde (MDA) levels were studied in 25 children between the age of 6 years-14 years who presented with an acute attack of bronchial asthma. In each patient, serum MDA levels were measured at the time of admission, 24-48 hours after good response to treatment and after a symptom free interval of 3 weeks. Results were compared with control group. RESULTS: In study group serum MDA levels were highest at the time of admission, which decreased significantly at 24-48 hours with treatment. After a 3 weeks symptom free interval serum MDA levels had decreased further but were still higher than healthy control group. CONCLUSION: Lipid peroxidation is increased in bronchial asthma during an acute attack and symptom free period.

Correlation between CT scan and automated perimetry in supratentorial tumors.

An attempt was made to correlate various types of visual field defects on automated perimetry with the findings of computed tomography in 44 patients of supratentorial tumors. All the patients above the age of 10 years were subjected to complete neurological examination including investigations like plain X-rays and CT scan, however, MRI and angiography were performed wherever indicated. Ocular examination particularly pertaining to neuro-ophthalmological profile was carried out with special emphasis on automated perimetry on Humphrey field analyser. The results indicated that automated perimetry was capable of reliably detecting and quantitating the visual field defects and thus established the location of the tumor in 72% patients when compared to CT scan. Hence, any patient with neuro-ophthalmic features should be subjected to automated perimetry for early diagnosis and probable location of intracranial space occupying lesion affecting visual pathways.

Differential modulation of nociceptive responses to mu and kappa opioid receptor directed drugs by blood glucose in experimentally induced diabetes rats.

The study has evaluated the effect of diabetes associated hyperglycaemia on nociception and antinociception induced by morphine, buprenorphine and pentazocine in female albino rats. Rats were allocated into 3 groups of 20 each--group I consisted of control having normal blood glucose levels (BGLs), group II consisted of streptozotocin-induced diabetics (STZ-D) having hyperglycaemia and group III consisted of diabetic rats controlled with insulin treatment. Immediately before and 15, 30 min, 1, 2 and 3 hr after injection with test drugs, rats were subjected to a thermal noxious stimulus using tail withdrawal from hot water and tail-flick latencies (TFL) so generated were recorded. Similarly, before and 30, 45 min and 1 hr after injection with drugs rats were subjected to abdominal writhing with hypertonic saline and number of writhes were counted per 90 sec. In STZ-D animals (BGLs 317.95 +/- 3.8 mg/dl) a decreased TFL with an increase in the number of writhes compared to control and diabetes controlled with insulin treatment was observed. Percent maximum possible effect of morphine (5 mg/kg, s.c.) and buprenorphine (2 mg/kg, s.c.) was significantly lower when compared to control as well as STZ-D controlled with insulin treatment groups. Similarly percent protection from writhing of morphine (0.05 mg/kg, s.c.) and buprenorphine (0.01 mg/kg, s.c.) was significantly less in comparison to control and STZ-D controlled with insulin treatment group. However, percent maximum possible effect of pentazocine (20 mg/kg, s.c.) and percent protection from writhing of pentazocine (1 mg/kg, s.c.) was significantly high in STZ-D rats when compared to control and STZ-D rats controlled with insulin treatment groups. The results suggest that both mu and kappa--opioid receptors may be modulated by blood glucose levels possibly involving cellular energetics mediated change in potassium (KATP) channels in females rats, albeit differentially.

Comparative evaluation of antimicrobial activity of polyvinylpyrrolidone (PVP)-iodine versus topical antibiotics in cataract surgery.

Comparative evaluation of polyvinylpyrrolidone (PVP)-iodine versus topical broad-spectrum antibiotics for disinfecting the eye and surrounding area to prevent postoperative complications was carried out on 100 patients. PVP-iodine proved superior antiseptic for pre-operative preparation of eyes before cataract surgery. It was cheaper, caused minimal side-effects, reduced bacterial counts to a great extent and eliminated fungi completely.

Extradural lipomatosis presenting with paraplegia.

An unusual case with spinal extradural lipomatosis in a non-obese and otherwise healthy man is reported. The patient presented with a history of weakness of legs which progressed to paraplegia over a 40 day period.

Effect of Trigonella foenum graecum (Fenugreek) on blood glucose in normal and diabetic rats.

Trigonella foenum graecum (Fenugreek) was administered at 2 and 8 g/kg dose orally to normal and alloxan induced diabetic rats. It produced a significant fall (P < 0.05) in blood glucose both in the normal as well as diabetic rats and the hypoglycemic effect was dose related.

Respiratory distress in newborn: treated with ventilation in a level II nursery.

Fifty consecutive neonates with respiratory distress persisting beyond 6 h of age were studied during a 18 month period (total deliveries 2000/y). Twenty two neonates were managed with oxygen hood with increasing oxygen concentration, 28 with continuous positive airway pressure (CPAP) ventilation using a nasal cannula. Of these babies on CPAP, 10 were shifted to intermittent positive pressure ventilation (IPPV) on a pressure limited, time cycled ventilator (Neovent, Vickers). Babies were monitored with continuous hemoglobin oxygen saturation (SaO2), hourly blood pressure and vital charting. Radial arterial blood gas analysis (ABG) was done when feasible and especially on clinical deterioration. Oxygen (FiO2 0.95) from an oxygen concentrator was used as a source of continuous supply of oxygen. Commonest cause of respiratory distress was hyaline membrane disease (18%), followed by wet lung syndromes (14%), meconium aspiration (12%), asphyxia (12%) and septicemia (8%). In 8 babies, a lung biopsy (postmortem) was done to confirm the diagnosis. Nineteen of the 50 babies with respiratory distress died, there was a survival of 50% on CPAP and 30% on IPPV. No case of oxygen toxicity or other major complications was encountered. Even with moderate resources, neonatal ventilation in a Level II nursery is a challenging task. Babies less than 1000g require aggressive measures which is not very economical in a special care baby unit (SCBU).

Intraparenchymal schwannoma of the frontal lobe.

A 45 year old woman with bifrontal headaches and progressive diminution in vision over 6 months was found to have bilateral papilloedema. CT scan showed large right frontal lesion with surrounding oedema. Right basal frontotemporal craniotomy was performed to excise the multinodular, intraparenchymatous tumor. Hispathology confirmed the diagnosis of schwannoma. Post-operative course was uneventful with disappearance of pre-operative signs and symptoms.

Dural cavernous haemangioma of posterior cranial fossa.

A rare case of extracerebral dural cavernous angioma sited near the sigmoid sinus is reported. This 60 yr old male patient gave history of episodic ataxia of left sided limbs experienced twice on same day and occasional giddiness. Examination did not reveal any findings. A mass was diagnosed on CT Scan following which angiography was carried out. The features matched with those of a meningioma. Retro-sigmoid craniectomy was performed. Occipital artery was coagulated. Tumor was dissected out. Post-operative course of the patient was uneventful. Histopathology revealed that the mass was a cavernous haemangioma.

Craniopharyngioma: treatment by conservative surgery and radiation therapy.

Benign neoplasms are curable only when excised. This applies even to craniopharyngiomas. The proximity of craniopharyngiomas to the hypothalamus and neurovascular structures makes total excision difficult to achieve. Over the last 3-4 decades, it has become increasingly obvious that craniopharyngiomas respond to radiation therapy. Early, unhappy results with major excisions have prompted us to adopt a policy of conservative surgery and radiation therapy to the residual tumour. Preliminary results suggest a good outcome in 35 of the 63 patients so treated from 1981. Details of the study are presented.

Trans-sphenoidal excision of craniopharyngiomas.

Craniopharyngiomas have been by and large excised by the transcranial route. Since 1982, 11 patients have been operated by the traus-sphensidal route in the department. The clinical features with which they were presented, diagnostic investigations, details of surgical procedures and follow-up analysis is being presented here. A retrospective study of radiological investigation was done to determine the features that help decide the choice of surgical approach to these lesions. Only lesions that were primarily intrasellar, cystic and those that expanded the sella could be treated by the trans-sphenoidal route. Associated suprasellar extensions could also be removed. Predominantly calcified or firm, fleshy tumours lent themselves poorly to removal by the trans-sphenoidal route.