Real-life comparison of three intravitreal antibiotic drug regimens in endophthalmitis

Purpose: Real?life comparison of three intravitreal drug regimens used in cases of endophthalmitis at a tertiary care center in India. Methods: In this prospective, comparative study, patients of bacterial endophthalmitis were grouped according to intravitreal antibiotic drug regimens into Group 1 (ceftazidime and vancomycin), Group 2 (piperacillin + tazobactam and vancomycin), and Group 3 (imipenem and vancomycin). Forty?eight hours after injection nonresponding/worsening patients underwent vitrectomy. Vitreous samples were subjected to microbiological and pharmacokinetic tests. Results: A total of 64 patients were included and divided into Group 1: 29, Group 2: 20, and Group 3: 15 cases. Also, 75% of patients were post?surgical endophthalmitis, whereas 25% were post?traumatic. Improvement in vision (V90?0) and vision at 3 months (V90) were comparable between the three groups. Visual recovery was poorer in post?traumatic cases. In post?surgical cases, visual recovery was poorer in those presenting beyond 72 h of onset of symptoms (P = 0.0002). Polymerase chain reaction (PCR) positivity (66%) was higher than BACTECTM (33%) and culture (14%). Antibiotic resistance was comparable amongst the three groups. Most patients (62/64) further underwent vitrectomy. Ceftazidime and vancomycin achieved vitreous concentrations more than the minimum inhibitory concentration (MIC) at 48 h after the first injection. Conclusion: The choice of antibiotics did not affect the rate of vitrectomy and final vision in a real?life scenario. Ceftazidime and vancomycin can still be used as first?line intravitreal antibiotics owing to their comparable microbial sensitivity profile and adequate ocular bioavailability

An Observation of Risk Factors Associated with Patients with Ischemic Stroke.

Background: Objective: our study was to observe the risk factors in different age group of patients with ischemic stroke. Methods: A total of 120 patients of ischemic stroke were considered on the basis of detail clinical history, laboratory findings and CT Scan/MRI. Results: Data was analyzed by using MS-Office software. Conclusion: Major risk factors associated with ischemic stroke was hypertension, smoking, alcohol consumption, diabetes mellitus, dyslipidemia and obesity.

Study on Type of Stroke with Special Preference to Association of Modifiable Risk Factors in Kosi Zone

Background: Stroke is a global health problem and the second most common cause of death. It also entails a high socioeconomic burden due to increased mortality and morbidity. Despite substantial advances for treatment of stroke, effective primary stroke prevention remains the best means for reducing stroke burden. Methods: It was a cross-sectional study including 100 cerebrovascular patients and hundred non-cerebrovascular accident controls(age-sex matched) who were studied to determine the  incidence of various types of stroke and association of various modifiable risk factors with stroke. Results: Incidence of ischaemic stroke was more than haemorrhagic stroke. Also, strong correlation exists between smoking, hypertension, diabetes, dyslipidemia and stroke. Conclusions: Effective management of these common risk factors can reduce the incidence, mortality and morbidity associated with stroke. Hence, primary prevention of stroke is of immense public health importance.

Ultra‑wide field angiography in the management of Eales disease.

Aims: This study aims to evaluate the use of ultra‑wide field (UWF) angiography in patients with Eales disease (ED). Settings and Design: Prospective observational case series in tertiary eye care center. Subjects and Methods: This study involved 17 patients diagnosed with ED, who underwent UWF fluorescein angiography. The angiograms were analyzed to look for additional information as compared to Early Treatment Diabetic Retinopathy Study seven standard field. The impact of this information in the management of patients was analyzed. Results: 24 eyes of 17 patients with mean age of 26.3 years were diagnosed with ED and underwent UWF angiography. UWF fluorescein angiography was helpful in the documentation of peripheral retinal changes (in 67% of eyes), exact localization of capillary nonperfusion (CNP) (in 54% of eyes), and in determination of vascular involvement (in 21% of eyes). In 33% of eyes, immediate treatment plan changed because of changes picked up on UWF angiography. Conclusions: UWF angiography helped in the better documentation, exact quantification, and location of CNP areas and better determination of disease activity. UWF imaging may play an important part in the management of patients with ED.

Evidence‑based review of diabetic macular edema management: Consensus statement on Indian treatment guidelines.

The purpose of the study was to review the current evidence and design a diabetic macular edema (DME) management guideline specific for India. The published DME guidelines from different organizations and publications were weighed against the practice trends in India. This included the recently approved drugs. DME management consisted of control of diabetes and other associated systemic conditions, such as hypertension and hyperlipidemia, and specific therapy to reduce macular edema. Quantification of macular edema is precisely made with the optical coherence tomography and treatment options include retinal laser, intravitreal anti‑vascular endothelial growth factors (VEGF), and implantable dexamethasone. Specific use of these modalities depends on the presenting vision and extent of macular involvement. Invariable eyes with center‑involving macular edema benefit from intravitreal anti‑VEGF or dexamethasone implant therapy, and eyes with macular edema not involving the macula center benefit from retinal laser. The results are illustrated with adequate case studies and frequently asked questions. This guideline prepared on the current published evidence is meant as a guideline for the treating physicians.

A Pilot, Randomized Sham Control Trial of Autologous Bone Marrow Derived Mononuclear Cells in Acute Ischemic Central Retinal Vein Occlusion.

In this pilot, sham controlled randomized control trial (RCT) in patients with ischemic central retinal vein occlusion (CRVO), we studied the safety and efficacy of intravitreal injection of autologous bone marrow derived mononuclear cells and found that both patients who received stem cell injections did not develop anterior segment neovascularization at 1 year follow up. Except for some sterile inflammatory reaction in the initial follow up, no long term injection related serious adverse events (SAEs) were observed. Based on our observations we recommend a larger, multicentric study to further establish the safety and efficacy of this treatment in patients with ischemic CRVO. Purpose: To study the safety and efficacy of autologous bone marrow derived mononuclear cells injected intravitreally in patients with ischemic CRVO. Study Design: Randomized sham controlled trial. Methods: 4 cases with ischemic CRVO were recruited into the study. 2 cases were randomized into intervention group and 2 into control group. Baseline investigations included best corrected visual acuity (BCVA), intra ocular pressure (IOP), fundus fluorescein angiography (FFA), gonioscopy and optical coherence tomography (OCT). Patients in the intervention group received intravitreal injection of autologous bone marrow derived mononuclear cells (MNCs) and those in control group received sham injection. Patients were followed up over a 12-month period. Main Outcome Measures: Development of anterior segment neovascularization. Results: Both patients in the intervention group did not develop anterior segment neovascularization over a follow up period of 12 months. 1 patient in control group developed neovascularization of iris and elevated intra ocular pressure over a follow up period of 6 weeks and required trabeculectomy for control of IOP. The other patient in control group was lost follow up after 2 weeks. Conclusions: Our initial observations suggest that intravitreal injection of mononuclear cells may reduce the risk of developing anterior segment neovascularization in patients with ischemic central retinal vein occlusion. A larger, multicentric study would be valuable to gain further evidence to our preliminary observations.

Minimal gauge vitrectomy for optic disc pit maculopathy: Our results.

The purpose of the study was to describe the surgical technique and clinical outcomes of pars plana vitrectomy without laser or gas tamponade in cases with optic disc pit maculopathy at our centre. Six eyes of six consecutive patients presenting with unilateral optic disc pit maculopathy were enrolled. Preoperative optical coherence tomography (OCT) was performed to determine the presence and extent of schisis and macular detachment. All eyes underwent 23-gauge pars plana vitrectomy with induction of posterior vitreous detachment (PVD) and internal limiting membrane (ILM) peeling and eyes were closed under fluid. Patients were followed up for at least 12 months post-surgery. Median age of patients was 22.5 years. Five of six eyes had neurosensory detachment (NSD) at the presentation; whereas, inner layer schisis was present in all patients. None of the patients had any evidence of vitreomacular or vitreopapillary adhesion or PVD either clinically or on OCT. Inner and outer retinal schisis resolved in all eyes after follow-up of at least 6 months. Resolution of subretinal fluid in eyes with NSD was seen in 4 of 5 eyes. There was a significant visual acuity improvement from mean preoperative visual acuity of 0.79 logarithm of the minimum angle of resolution (logMAR) units to 0.36 logMAR units at 12 months (P = 0.001). Thus, vitrectomy with ILM peeling and PVD induction alone could achieve good functional outcomes in cases with optic disc pit maculopathy.

Clinical profile and factors associated with microalbuminuria in type 1 diabetes mellitus in children and adolescents.

Background: The aim of this study was to determine the pattern of clinical presentation and factor associated with microalbuminuria. Methods: Urinary albumin excretion of children and adolescents diagnosed with type 1 diabetes mellitus attending diabetic clinic of Katihar medical college hospital over a period of one year. Collected blood and urine samples were analysed for glycated haemoglobin, cholesterol, triglycerides, and for 12 hour urinary albumin concentration. Blood pressures were recorded and clinical data collected. Results: During the study period 215 patients were diagnosed with type1 DM. Out of 215, fourty-three patients (20%) had persistent microalbuminuria. Factor associated with microalbuminuria in diabetic patients include duration of diabetes mellitus, higher blood pressure, higher cholesterol and triglyceride levels. Conclusion: Type 1 DM is treatable and testing is acceptable and accessible to the patients. As microalbuminuria is an early microvascular complications, it is highly recommended to screen all diabetic patients for the incidence of microalbuminuria and modifiable risk factors like dyslipidemia at the onset and then yearly assessment. Efforts need to be intensified in education of health workers and population at large for quick presentation and prompt diagnosis in order to predict overt diabetic nephropathy and also to prevent its progression.

Evaluation of predictors for anatomical success in macular hole surgery in Indian population.

Purpose: The aim was to evaluate outcomes and predictors for anatomical success in macular hole (MH) surgery. Materials and Methods: This was a prospective cohort study of patients operated for idiopathic MH with stages II, III or IV. Patients underwent pars plana vitrectomy with internal limiting membrane (ILM) peeling, internal gas tamponade, and postoperative face down positioning. The primary outcome measure was anatomical closure of MH, while secondary outcome measure was postoperative external limiting membrane (ELM) continuity. Effect of MH size, duration of MH, size of ILM peel, type of gas tamponade (SF6 vs. C3F8) and macular hole index (MHI) on anatomical MH closure was also evaluated. Results: Of the 62 eyes operated, anatomical closure of MH was achieved in 55 eyes (88.7%). The median duration of follow‑up was 8 months (range: 6–15 months). Mean BVCA improved from 0.94 ± 0.26 at baseline to 0.40 ± 0.23 logMAR at last follow‑up (P = 0.01). There was a statistically significant association between size of ILM peel and anatomical closure of MH (P = 0.04). Duration of symptoms, size of MH, type of gas tamponade, MHI had no effect on anatomical closure (P = 0.22, 0.28, 0.40 respectively, Chi‑square test). Postoperative continuity of the ELM was significantly associated with a shorter symptom duration (<6 months) before surgery. Conclusion: Acceptable anatomical closure could be attained with the defined technique. Size of ILM peel is a new predictor of anatomical success while symptom duration affects postoperative ELM continuity.

Phytochemical and Biological Potential of Cassia tora Linn.

Cassia tora Linn. (Caesalpinaceae) is a semi-wild annual herb grown widely in different places of south-east Asia including India, Northern Australia and Americas. This plant species is well known for having potential in traditional medicine practices for the treatment of a variety of disorders and ailments ranging from simple cough, hypertension to diabetes. Recent scientific investigation reveals its phytochemical as well as biological potential. C. tora has been proven to be medicinally effective for having antimicrobial, antiantioxidant, antihypertensive, antidiabetic and antimutagenic activities, just to name a few. This paper encompasses a comprehensive review on phytochemical and biological aspects of Cassia tora L.

Reproductive activities of Heliotropium indicum isolate against Helopeltis theivora and toxicity evaluation in mice.

A new compound E was isolated from the methanolic extract of the leaves of Heliotropium indicum by chromatographic fractionation. In the present study, the effect of the compound E on reproduction of Helopeltis theivora has been evaluated. The acute toxicity study (LD50) and sub-acute toxicity studies (haematological, biochemical and histopathological parameters) in albino Swiss mice were carried out to evaluate the safety aspect of the compound E. The compound showed significant inhibitory effect on the reproductive life of H. theivora. The oviposition period, fecundity and hatching percentage of H. theivora were found to be 15.67days, 39.33 and 28.00 % respectively after treatment with 2% compound E, whereas the control value were found to be 20.33 days, 77.67 and 77.33% respectively. The LD50 of the compound was found to be 780 mg kg-1 in Swiss albino female mice. The compound did not show any toxicity in mice at sub-lethal dose treatment (78 mg kg-1 b. wt., once daily) for 21 days as evident from different haematological, biochemical and histopathological parameters in compound E treated group when compared with control.

Impact of early rise of intraocular pressure on visual outcome following diabetic vitrectomy.

Objective: The objective was to study the incidence and risk factors for an early rise in intraocular pressure (IOP) following pars plana vitrectomy (PPV) for proliferative diabetic retinopathy (PDR) and to correlate its impact on visual outcome. Materials and Methods: This was a longitudinal prospective study. IOP and best corrected visual acuity (BCVA) for 73 cases of PDR (52 males and 21 females) who underwent PPV were recorded at day 1, week 1, and months 1, 3, and 6. Risk factors for the early IOP rise, defined as IOP ≥ 30 mmHg at day 1, were evaluated using cross-tabulation and the t-test. Results: Mean IOP at day 1 was 21.8 ± 9.8 mmHg with 15 cases (20.5%) having an early rise in IOP. Risk factors for the early IOP rise included intraoperative fibrovascular frond removal (P = 0.003), lens removal (P = 0.043), and intraoperative vitreous bleed (P = 0.008). The early rise in IOP was also associated with consistently raised IOP (P = 0.02), defined as IOP > 21 mmHg during first three consecutive follow-up visits. Further, difference in BCVA at 6 months among the two groups, i.e., with and without an early IOP rise was statistically significant (3.11 ± 1.52 logMAR vs. 2.11 ± 1.49 logMAR; P = 0.025). Conclusion: An early rise in IOP is a significant risk factor which compromises the visual outcome of patients undergoing diabetic vitrectomy.

Residual triamcinolone acetonide at macular hole after vitreous surgery.

Post traumatic macular holes have shown successful anatomic outcomes with vitrectomy with internal limiting membrane (ILM) peeling and gas injection. Intraocular use of triamcinolone acetonide (TA) crystals is gaining popularity in patients for visualization of the vitreous cortex, posterior vitreous detachment induction and ILM peeling during macular hole surgery. However, the possibility of residual steroid crystals clogging the hole at the conclusion of surgery exists. In our case, residual TA was observed biomicroscopically in the fovea on the seventh day after surgery, Optical Coherence Tomography (OCT) image of the eye showed a hyper reflective mass corresponding to the TA. However, a repeat OCT carried out four weeks after surgery showed recovery of the foveal morphologic features to an almost normal depression, with closure of the hole. Residual TA crystals in the macular hole post vitreous surgery may not interfere with ultimate macular hole closure or visual improvement.

Combination 20 and 23-gauge transconjunctival vitrectomy: A new approach.

The advent of smaller gauge instrumentation allows for minimally invasive vitreoretinal surgery (MIVS) as compared to conventional pars plana vitrectomy. Sutureless posterior segment surgery has the advantages of faster wound healing, minimal surgical trauma, decreased convalescence period besides reduced postoperative astigmatism; however, slower gel removal and limited peripheral vitreous dissection are disadvantages with smaller gauge systems. We herein describe a new technique combining 23-gauge and 20-gauge vitrectomy to improve the effectiveness and outcomes of vitreoretinal surgery.

Intravitreal bevacizumab (Avastin) treatment of diffuse diabetic macular edema in an Indian population.

BACKGROUND: To report the anatomic and visual acuity response after intravitreal bevacizumab (Avastin) in patients with diffuse diabetic macular edema. Design: Prospective, interventional case series study. MATERIALS AND METHODS: This study included 20 eyes of metabolically stable diabetes mellitus with diffuse diabetic macular edema with a mean age of 59 years who were treated with two intravitreal injections of bevacizumab 1.25 mg in 0.05 ml six weeks apart. Main outcome measures were 1) early treatment diabetic retinopathy study visual acuity, 2) central macular thickness by optical coherence tomography imaging. Each was evaluated at baseline and follow-up visits. RESULTS: All the eyes had received some form of laser photocoagulation before (not less than six months ago), but all of these patients had persistent diffuse macular edema with no improvement in visual acuity. All the patients received two injections of bevacizumab at an interval of six weeks per eye. No adverse events were observed, including endophthalmitis, inflammation and increased intraocular pressure or thromboembolic events in any patient. The mean baseline acuity was 20/494 (log Mar=1.338+/-0.455) and the mean acuity at three months following the second intravitreal injection was 20/295 (log Mar=1.094+/-0.254), a difference that was highly significant ( P =0.008). The mean central macular thickness at baseline was 492 microm which decreased to 369 microm ( P =0.001) at the end of six months. CONCLUSIONS: Initial treatment results of patients with diffuse diabetic macular edema not responding to previous photocoagulation did not reveal any short-term safety concerns. Intravitreal bevacizumab resulted in a significant decrease in macular thickness and improvement in visual acuity at three months but the effect was somewhat blunted, though still statistically significant at the end of six months.

Visual acuity and contrast sensitivity outcomes in Indian eyes undergoing photodynamic therapy with intravitreal injection of triamcinolone acetonide in age-related macular degeneration.

PURPOSE: To evaluate photodynamic therapy (PDT) with verteporfin along with intravitreal triamcinolone acetonide (IVTA) in the treatment of neovascular age-related macular degeneration (AMD). MATERIALS AND METHODS: This prospective interventional case series included 23 patients (23 eyes) of choroidal neovascularization due to neovascular AMD who were treated with PDT with verteporfin followed by an injection of 4 mg IVTA. The main outcome measures were visual acuity (VA), contrast sensitivity, retreatment frequency with PDT (and triamcinolone) and frequency of side-effects. RESULTS: Twenty-three eyes underwent PDT with verteporfin followed by IVTA one week later. All patients were followed up for one year. Initial VA ranged from 20/32 to 20/800 and final VA ranged from 20/40 to 20/500 at the end of 12 months. VA stabilized (that is loss/gain < 2 lines) in 19 (82%) eyes. Contrast sensitivity also improved in 16/23 eyes (70%). Lesion type and patient's age had no influence on the outcome, but baseline VA had a borderline statistically significant effect (P =0.059). Six eyes (27%) had an increase in intraocular pressure that required therapy. There were no cases of endophthalmitis, but four eyes (18%) developed significant cataract that required surgery during the follow-up period. CONCLUSION: The combination of PDT along with IVTA improves contrast sensitivity and stabilizes vision during one-year follow-up.