Xerophthalmia--a potential epidemic on our doorstep?

PURPOSE: Xerophthalmia refers to the ocular manifestations associated with vitamin A deficiency, including xerosis, keratomalacia, nyctalopia and Bitot's spot. Hypovitaminosis A is well-recognised in developing countries, but is rare in the developed world. Most cases in the latter relate to fat malabsorption. Conditions in which vitamin A metabolism or storage is deranged (chronic liver disease, including alcoholism) are also aetiologies. We wanted to see whether this was common in our department. METHODS: Oral vitamin A supplements were given to patients who presented with hypovitaminosis A. RESULTS: All patients were found to have hypovitaminosis A on biochemical testing and responded dramatically to oral vitamin A supplementation, resulting in an improved final visual outcome. DISCUSSION: This series demonstrates that prompt recognition and treatment of xerophthalmia can lead to rapid recovery and avert significant visual morbidity. The prevalence of xerophthalmia is likely to increase in the developed world largely owing to alcoholic liver disease. It is thought by some that we are on the verge of a potential epidemic. We hope that by increasing the profile of this important public health issue, we may be able to influence future prevalence of hypovitaminosis.

New insight into non-healing corneal ulcers: iatrogenic crystals.

AIMS: To characterise and correlate crystalline precipitations implicated in non-healing corneal ulceration in two patients with a previous history of acanthamoeba keratitis. MATERIALS AND METHODS: Persistence of acanthamoeba and secondary bacterial infection was excluded with negative corneal scrapes. Confocal microscopy identified crystal-like deposits within the corneal stroma. To investigate possible precipitating combinations, all concurrent treatments at the time of presentation were mixed in wells, with observation of precipitate formation. Precipitates were observed with phase-contrast microscopy, and subsequently characterised via crystallography techniques and electrospray ionisation mass spectrometry. RESULTS: Combinations of dexamethasone 0.1% minims and chlorhexidine gluconate 0.2% formed an amorphous material characterised by electrospray ionisation mass spectrometry as an insoluble chlorhexidine salt. Combinations of chloramphenicol drops and timolol 0.5% formed a crystal identified via X-ray crystallography as santite (K(B5O6(OH)4).(H2O)2). This is a borate mineral identified in nature, arising from thermal springs, but never reported in biological tissues. Clinical improvement was observed following the cessation of the implicated precipitating combinations. CONCLUSION: Our observations suggest iatrogenic precipitate formation, with a potential deleterious effect upon healing. The substrates for these precipitates include several frequently prescribed topical ophthalmic treatments. These findings shed new light on the aetiopathogenesis of non-healing corneal ulceration, and have broad implications on topical prescribing for this challenging condition.

Changing trends in keratoplasty in the West of Scotland: a 10-year review.

BACKGROUND/AIMS: To review the indications and types of keratoplasty performed in the West of Scotland between 2001 and 2010. METHODS: A retrospective analysis of the histopathological diagnoses of all corneal buttons submitted to the regional Ocular Pathology Laboratory (Glasgow, UK) between January 2001 and December 2010 was performed. RESULTS: Between 2001 and 2010, a total of 921 keratoplasties were performed in the West of Scotland. These included 646 (70.1%) penetrating keratoplasties and 275 (29.9%) lamellar keratoplasties (LK). Keratoconus (n=264, 28.7%) was the leading indication for keratoplasty, followed by graft failure (n=177, 19.2%), Fuch's endothelial dystrophy (n=124, 13.5%), keratitis (n=106, 11.5%), pseudophakic/aphakic bullous keratopathy (n=88, 9.6%), endothelial failure (n=67, 7.3%), non-Fuch's corneal dystrophies (n=21, 2.3%), trauma (n=19, 2.0%), autoimmune/inflammatory diseases (n=16, 1.7%) and others (n=39, 4.2%). A significant increase in the proportion of LK over penetrating keratoplasty was observed during this 10-year period: from 14.1% LK (2001-2005) to 40.4% LK (χ(2)=71.78, p value<0.001). CONCLUSION: Keratoconus was the leading indication for keratoplasty in the West of Scotland. Both anterior LK and endothelial keratoplasty seemed to show an emerging trend as the procedures of choice for dealing with anterior and posterior corneal pathologies, respectively.

Subjective and objective performance of the Lenstec KH-3500 "accommodative" intraocular lens.

AIM: To determine whether eyes implanted with the Lenstec KH-3500 "accommodative" intraocular lenses (IOLs) have improved subjective and objective focusing performance compared to a standard monofocal IOLs. METHODS: 28 participants were implanted monocularly with a KH-3500 "accommodative" IOL and 20 controls with a Softec1 IOL. Outcome measures of refraction, visual acuity, subjective amplitude of accommodation, objective accommodative stimulus response curve, aberrometry, and Scheimpflug imaging were taken at approximately 3 weeks and repeated after 6 months. RESULTS: Best corrected acuity with the KH-3500 was 0.06 (SD 0.13) logMAR at distance and 0.58 (0.20) logMAR at near. Accommodation was 0.39 (0.53) D measured objectively and 3.1 (1.6) D subjectively. Higher order aberrations were 0.87 (0.85) microm and lower order were 0.24 (0.39) microm. Posterior subcapsular light scatter was 0.95% (1.37%) greater than IOL clarity. In comparison, all control group measures were similar except objective (0.17 (0.13) D; p = 0.032) and subjective (2.0 (0.9) D; p = 0.009) amplitude of accommodation. Six months following surgery, posterior subcapsular scatter had increased (p<0.01) in the KH-3500 implanted subjects and near word acuity had decreased (p<0.05). CONCLUSIONS: The objective accommodating effects of the KH-3500 IOL appear to be limited, although the subjective and objective accommodative range is significantly increased compared to control subjects implanted with conventional IOLs. However, this "accommodative" ability of the lens appears to have decreased by 6 months post-surgery.

Corneal pachymetry in normal and keratoconic eyes: Orbscan II versus ultrasound.

PURPOSE: To compare corneal thickness measurements using Orbscan II (OII) and ultrasonic (US) pachymetry in normal and in keratoconic eyes. SETTING: Eye Department, Heartlands and Solihull NHS Trust, Birmingham, United Kingdom. METHODS: Central corneal thickness (CCT) was measured by means of OII and US pachymetry in 1 eye of 72 normal subjects and 36 keratoconus patients. The apical corneal thickness (ACT) in keratoconus patients was also evaluated using each method. The mean of the difference, standard deviation (SD), and 95% limits of agreement (LoA = mean +/- 2 SD), with and without applying the default linear correction factor (LCF), were determined for each sample. The Student t test was used to identify significant differences between methods, and the correlation between methods was determined using the Pearson bivariate correlation. Bland-Altman analysis was performed to confirm that the results of the 2 instruments were clinically comparable. RESULTS: In normal eyes, the mean difference (+/- 95% LoA) in CCT was 1.04 microm +/- 68.52 (SD) (P>.05; r = 0.71) when the LCF was used and 46.73 +/- 75.40 microm (P =.0001; r = 0.71) without the LCF. In keratoconus patients, the mean difference (+/- 95% LoA) in CCT between methods was 42.46 +/- 66.56 microm (P<.0001: r = 0.85) with the LCF, and 2.51 +/- 73.00 microm (P>.05: r = 0.85) without the LCF. The mean difference (+/- 95% LoA) in ACT for this group was 49.24 +/- 60.88 microm (P<.0001: r = 0.89) with the LCF and 12.71 +/- 68.14 microm (P =.0077; r = 0.89) when the LCF was not used. CONCLUSIONS: This study suggests that OII and US pachymetry provide similar readings for CCT in normal subjects when an LCF is used. In keratoconus patients, OII provides a valid clinical tool for the noninvasive assessment of CCT when the LCF is not applied.

Serous retinal detachment at the macula in sarcoidosis.

PURPOSE: To report an unusual case of serous retinal detachment at the macula in a patient with a history of sarcoidosis. METHOD: Case report. In a 44-year-old Caucasian man, the history, clinical features, fluorescein angiography, laboratory and radiological investigations, treatment, and lung autopsy findings are presented. RESULTS: A serous detachment of the retina in the macula of his left eye was observed. He had pulmonary hypertension secondary to active sarcoid granulomas that caused pulmonary angiitis. CONCLUSION: Serous retinal detachment at the macula may occur in association with pulmonary angiitis secondary to sarcoidosis.

Strategy for child survival.

PIP: The rates of infant and under-five mortality are too high in India. Almost half of these child deaths could, however, be avoided with greater primary health care. Evidence from other countries demonstrates the potential of primary health care programs to slash infant mortality by 50-60% over a 1-5 year period. Such programs should consider: prenatal care; delivery by trained birth attendant; care of newborn infants; primary care for diarrhea, acute respiratory infections, and other common diseases; immunizations; prophylaxis against anemia and vitamin and iodine deficiency; growth monitoring and nutritional guidance of staff; and stronger secondary and tertiary care. While components of this program may be in place, inadequate staff training and essential medicines and equipment combine with poor infrastructure, communication, and supervision to produce inadequate service coverage. This paper proposes the employment of female multipurpose workers to provide both primary health care and family planning services to rural communities. Each worker would be responsible for services in 5-6 villages of 5000 inhabitants within a 5-km radius of her headquarters. Elements of the program are discussed in the bulk of the paper.^ieng