Status of Serum Zinc in Multidrug Resistant Tuberculosis.

Zinc plays a vital role in the immune status. Its deficiency affects host defense by reducing the number of circulating T cells and phagocytosis activity of other cells which ultimately impair cell mediated immunity. The cell-mediated immunity plays a major role in the causation of pulmonary tuberculosis. The present study was carried out to estimate serum zinc level in newly detected multidrug resistant tuberculosis (MDR-TB) in adult population. In this study total fifty (50) MDR-TB patients were enrolled conveniently from the in-patients departments of National Institute of Diseases of the Chest Hospital (NIDCH), Bangladesh. Serum zinc was estimated by atomic absorption spectrophotometry method from early morning fasting blood sample. Serum zinc level was assessed according to normal cut-off value 70-120 µgm/dl and 76% studied population were found lower than this value. The mean±SD serum zinc level was observed 60.40±8.91 µgm/dl. No associations were found between serum zinc level with age (p=0.11) and with sex (p=0.085) of the study population respectively. The low level of serum zinc in MDR-TB patients suggested impaired immune status of our study population.

Alanine Aminotransferase and Total Bilirubin Concentration in Preeclampsia and Eclampsia.

Eclampsia is an important cause of maternal mortality in developing countries. This cross-sectional comparative study was conducted in the Departments of Clinical Pathology, Bangabandhu Sheikh Mujib Medical University (BSMMU), and Obstetrics and Gynecology, BSMMU, and Dhaka Medical College Hospital, Dhaka, Bangladesh, from March 2012 to February 2013 and was designed to evaluate liver markers to predict preeclampsia. One hundred fifty (150) women with pregnancy of ≥28 weeks, 50 for each normal, preeclampsia and eclampsia group, were enrolled purposively. The protocol was approved by IRB of BSMMU. Consent was taken from each patient. Serum total Bilirubin and ALT were assessed. Data was collected in a questionnaire and analyzed by SPSS-16. Quantitative data were compared by ANOVA or 't' test and qualitative data by chi-square test. P value <0.05 was considered significant. The patients of all groups were similar in age and gravida. The mean±SD serum total bilirubin and ALT were significantly higher in preeclampsia and eclampsia groups than normal pregnancy. However they were similar in preeclampsia and eclampsia group.

Evaluation of Serum Ferritin Concentration in Mild and Severe Pre-Eclamptic Women.

Pre-eclampsia is one of the most important complications of pregnancy. About 16% of maternal death is associated with pre-eclampsia in Bangladesh. It is necessary to diagnose or to predict pre-eclampsia for minimizing maternal morbidity and mortality. This case control study was carried out in the department of Clinical Pathology, in collaboration with department of Obstetrics and Gynaecology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, from March 2011 to February 2012 which included 20 mild pre-eclamptic and 20 severe pre-eclamptic patients and 30 gestation matched normotensive pregnant women within 28-40 weeks of gestation. Serum iron profile was measured and PBF was done to observe the association of higher concentration of serum ferritin, serum iron, percent saturation of total iron binding capacity, hemoglobin and lower level of total iron binding capacity, increased neutrophil count and decreased platelet count with pre-eclampsia. The mean serum ferritin concentration of mild pre-eclamptic group 99.91±7.84 ng/ml was 5 times and severe pre-eclamptic group 149.59±13.75 ng/ml was 8 times higher than that of control group 18.47±2.03 ng/ml. The mean serum iron level of mild pre-eclamptic group was (114.45±8.72 µg/dl) and in severe pre-eclamptic group was (174.35±13.59 µg/dl) and control group was (72.64±4.72 µg/dl) (p<0.05). The mean TIBC was higher and percent saturation was lower in control group than mild and severe pre-eclamptic group. The mean differences of iron parameters were statistically significant (p<0.05) among the three groups in ANOVA test. Both hemoglobin (gm/dl), total count of WBC and percentage of neutrophil were significantly higher (p<0.05) but platelet count was significantly lower in mild and severe pre-eclamptic group than normal control group. So higher concentration of serum ferritin, serum iron, percent saturation of total iron binding capacity and hemoglobin level increased and total iron binding capacity decreased in mild and severe pre-eclampsia than those of uncomplicated normal pregnancy. Pre-eclampsia is one of the most important complications of pregnancy. About 16% of maternal death is associated with pre-eclampsia in Bangladesh. It is necessary to diagnose or to predict pre-eclampsia for minimizing maternal morbidity and mortality. This case control study was carried out in the department of Clinical Pathology, in collaboration with department of Obstetrics and Gynaecology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, from March 2011 to February 2012 which included 20 mild pre-eclamptic and 20 severe pre-eclamptic patients and 30 gestation matched normotensive pregnant women within 28-40 weeks of gestation. Serum iron profile was measured and PBF was done to observe the association of higher concentration of serum ferritin, serum iron, percent saturation of total iron binding capacity, hemoglobin and lower level of total iron binding capacity, increased neutrophil count and decreased platelet count with pre-eclampsia. The mean serum ferritin concentration of mild pre-eclamptic group 99.91±7.84 ng/ml was 5 times and severe pre-eclamptic group 149.59±13.75 ng/ml was 8 times higher than that of control group 18.47±2.03 ng/ml. The mean serum iron level of mild pre-eclamptic group was (114.45±8.72 µg/dl) and in severe pre-eclamptic group was (174.35±13.59 µg/dl) and control group was (72.64±4.72 µg/dl) (p<0.05). The mean TIBC was higher and percent saturation was lower in control group than mild and severe pre-eclamptic group. The mean differences of iron parameters were statistically significant (p<0.05) among the three groups in ANOVA test. Both hemoglobin (gm/dl), total count of WBC and percentage of neutrophil were significantly higher (p<0.05) but platelet count was significantly lower in mild and severe pre-eclamptic group than normal control group. So higher concentration of serum ferritin, serum iron, percent saturation of total iron binding capacity and hemoglobin level increased and total iron binding capacity decreased in mild and severe pre-eclampsia than those of uncomplicated normal pregnancy.

A comparison of GFR by modified gates method with measured creatinine clearance rate (CCR) & MDRD formula based estimation in type 2 diabetic subjects with nephropathy.

Accurate estimation of the glomerular filtration rate (GFR) is essential for the evaluation of patient with chronic kidney disease (CKD). The present study was a comparison between modified gates GFR with laboratory measured CCR & MDRD formula based estimated GFR method. Pre-diagnosed 180 diabetic nephropathy patients were selected. All the time of evaluation the blood glucose of the patients were controlled and serum creatinine was stable. Then CCR was done and GFR was estimated by Modified Gates method & MDRD method. All the patients were categorized in 5 stages of CKD. They were matched for age, BMI, blood pressure, duration of diabetes, the blood sugar and HbA1C levels. The Gates GFR in stage-2 (70±13) & stage-3 (48±12) was closer with MDRD in stage-2 (77±8) and stage 3 (43±7). The CCR is closer in stage-1 (110±52) & stage-4 (30±10) with MDRD in stage-1 (112±13) and stage-4 (21±4). Association study showed MDRD GFR had highest correlation with Gates GFR (r=0.86; p<0.05). The estimation of glomerular filtration rate (GFR) in different methods varied significantly between each other at different stages of chronic kidney disease (CKD) in type 2 diabetic nephropathy subjects.

Direct healthcare costs of glaucoma treatment.

AIMS: To report the complete lifetime direct healthcare costs of glaucoma treatment in a database of 1136 patients attending the Glaucoma Clinic at Glasgow Royal Infirmary, Glasgow, UK. METHOD: The database was interrogated to identify all patients who had initiated treatment at the Glaucoma Clinic at Glasgow Royal Infirmary, and who had subsequently died of natural causes. The healthcare resource use based cost assessment was based on two aspects of the direct National Health Service cost: drug costs (prescribed medications) and non-drug costs (inpatient or outpatient/and surgical or procedure costs). RESULTS: 106 patients (53 men, 53 women) were identified for whom there were lifetime treatment data. The mean lifespan of the patients was 80.5 years, and the mean number of years attending the glaucoma clinic was 7.05 years (range 1-22 years). The mean cost of glaucoma treatment over the lifetime of the patients was £3001, with an annual mean cost per patient of £475. Non-drug and drug costs made up 66% and 34% respectively, of the lifetime costs. CONCLUSIONS: This is the only study to directly assess the lifetime treatment costs of glaucoma. Awareness of the costs of glaucoma treatment may be of increased importance in these financially challenging times.

Highly fluorescent reticulocyte count is the early predictor of haematopoietic recovery on remission induction phase.

Highly fluorescent reticulocyte count a new routine parameter in the hematology analyzer can give the idea of the earliest morphologic change of bone marrow recovery before other test become positive after chemotherapy. A prospective study was carried out in the Department of Clinical Pathology in collaboration with Paediatric Haematology and Oncology, Bangabandhu Sheikh Mujib Medical University (BSMMU) during a period of one year starting from October 2009 to September 2010 to evaluate the bone marrow recovery in children with acute lymphoblastic leukemia (ALL) by automated reticulocyte analysis. Total fifty patients were enrolled in this study on remission induction phase. All patients were between 8 months to 15 years age range with a mean age of 5.5±3.2. At the end of the study highly fluroscent reticulocyte count recovery occurred earlier than the current practice of absolute neutrophil count (ANC) recovery.

Catatrac: a novel red light-emitting diode device for screening cataracts in the developing world.

BACKGROUND/AIMS: The purpose of this study was to critically evaluate the Catatrac device as a potential tool for rapid cataract screening in the developing world. METHODS: Patients attending the day case unit at Gartnavel General Hospital for routine cataract surgery were recruited into the study, and divided into two groups: those with mild cataracts with LogMAR acuities <0.48, and those with advanced cataracts with LogMAR acuities ≥0.48. The subjects were examined without pharmacological dilation in a dimly lit room independently by two nurses. Each patient was then examined by an ophthalmologist with a slit lamp, after dilation. If present, cataracts were graded objectively according to the LOCS III classification system. RESULTS: One hundred and twenty-two eyes of 73 patients were screened for the presence or absence of cataract using the Catatrac device. Thirty-nine eyes had mild cataracts, 43 eyes had advanced cataracts, and there were 40 control eyes with no cataracts. For detecting advanced cataracts, the two nurses using the Catatrac device had a specificity of 95.0%, a sensitivity between 86.0 and 93.0%, and κ values between 0.81 and 0.88 for agreement with slit lamp assessment. For detecting mild cataracts the two nurses using the Catatrac device again had a specificity of 95%, sensitivity of 71-84.6%, and κ values between 0.67 and 0.80 for agreement with slit lamp assessment. Interobserver agreement between the two nurses had a κ value of 0.61 for mild cataract and 0.74 for advanced cataract. CONCLUSION: The Catatrac device has a high specificity, sensitivity, and interobserver agreement for advanced cataracts. Although having a slightly lower sensitivity for mild cataracts, the authors believe that this study has demonstrated that it may be a low cost and easy to use device for rapid screening of visually significant cataracts in the developing world.

A comparative study of chemical and immunological method of fecal occult blood test in the diagnosis of occult lower gastrointestinal bleeding.

Fecal occult blood test is the most widely used screening test for diagnosis of gastrointestinal bleeding disorders specially colorectal carcinoma. Among the various methods of fecal occult blood tests, chemical method is being used commonly, but the method has some drawbacks like low participation rate, high false positive rate, low sensitivity etc. To overcome these short comings, newer immunological method was introduced. This study evaluated the role of immunological method of fecal blood test in the diagnosis of occult lower GIT bleeding. Stool samples from two hundred patients were examined by both chemical and immunological method. The patients who were positive by any or both methods of occult blood test, were advised for colonoscopy. During colonoscopy tissues were taken for histopathology which was the gold standard of this study. Among 110 OBT positive patients pathological lesions were detected in 65 patients by colonoscopy and histopathology. The diseases detected by colonoscopy and histopathology 18 colorectal polyp, 8 colorectal cancer, 24 ulcerative lesions and 5 inflammatory bowel disease etc. Regarding comparative analysis of chemical and immunological method, the higher sensitivity (95.4% vs. 49.2%), specificity (44.4% vs. 37.8%), accuracy (74.5% vs. 44.5%), PPV (71.3% vs. 53.3%) and NPV (87% vs. 34%) of immunological method than chemical method was observed. Thus immunological method of fecal occult blood test was appeared to be a better alternative to conventional chemical method of fecal occult blood test in the diagnosis of occult lower GIT bleeding.

The effect of pH, dilution, and temperature on the viscosity of ocular lubricants--shift in rheological parameters and potential clinical significance.

OBJECTIVE: To investigate the effect of temperature, dilution, and pH on the viscosity of ocular lubricants. DESIGN: Laboratory based investigation of viscosity. PARTICIPANTS: No human subjects. METHODS: Hypromellose 0.3%, sodium hyaluronate 0.4%, carboxymethylcellulose sodium 0.5%/glycerin 0.9%, and carmellose sodium 0.5% were investigated. Ostwald capillary viscometers were utilised for viscosity measurements. The kinematic viscosity of each lubricant was tested quantitatively from 22 to 40 °C, and over a pH range of 5-8 under isothermal conditions. The kinematic viscosity of each eye drop was also tested under dilution by varying the mass fraction of each eye drop under isothermal conditions. MAIN OUTCOME MEASURE: Changes in kinematic viscosity. RESULTS: Hypromellose 0.3% had an initial pH of 8.34, while the other lubricants had a pH close to neutral. From 22 to 35 °C, the kinematic viscosity of sodium hyaluronate 0.4 fell by 36% from 37.8 to 24.4 mm(2)/s, carboxymethylcellulose sodium 0.5%/glycerin 0.9% fell by 35% from 16.98 to 11.1 mm(2)/s, hypromellose fell by 37% from 6.89 to 3.69 mm(2)/s, and carmellose sodium 0.5% fell by 25% from 2.77 to 1.87 mm(2)/s. At 32 °C only sodium hyaluronate 0.4%, and carboxymethylcellulose sodium 0.5%/glycerin 0.9% retained sufficient kinematic viscosity to maintain precorneal residence. Kinematic viscosities of all the topical lubricants were unaffected by pH but decreased significantly with dilution. CONCLUSIONS: This study suggests that currently used ocular lubricants have limited bioavailability due to reductions in viscosity by temperature and dilutional changes under physiological conditions. Developing lubricants with stable viscosities may maximise therapeutic efficacy.

Early diagnosis of neonatal septicemia by hematologic scoring system, C-reactive protein and serum haptoglobin.

Neonatal septicemia is one of the major health problems throughout the world. Infections are frequent and important cause of morbidity and mortality in neonatal period. The objective of the present study was to find out the role of hematologic scoring system (HSS), C-reactive protein (CRP) and haptoglobin in the early diagnosis of neonatal septicemia. This is a descriptive consisted of 100 neonates admitted at neonatal ICU, BSMMU, who were clinically suspected sepsis. The hematological parameter, C-reactive protein and haptoglobin were measured in all cases. Blood culture was done as the gold standard for diagnosis of neonatal septicemia. There were 12 out of 100 neonates (12%) who had culture proven sepsis and they were predominantly preterm and very low birth weight. On evaluation of various hematological parameters total leukocyte count, total neutrophil count, immature to total neutrophil ratio (>0.2), immature to mature neutrophil ratio (>0.3), total immature count, platelet count were found to have optimal sensitivities and negative predictive values. Using these values hematologic scoring system (HSS) was formulated according to Rodwell et al. Score ≥4 was found sensitivity of 100%, specificity of 60%. C-reactive protein (CRP) had sensitivity of 75%, specificity of 74%. Haptoglobin was not found significant (p<0.05) with sepsis and sensitivity was very low. But Combination of score ≥4 and CRP showed sensitivity of 75%, specificity 85%, positive predictive value (PPV) 41% and negative positive value (NPV) 96%. HSS and CRP are useful test to differentiate the septicemic from non septicemic neonates and also provide a effective guideline to make decisions regarding judicious use of antibiotic therapy. But haptoglobin level was not found useful for screening of sepsis.

Immature reticulocyte fraction as a predictor of bone marrow recovery in children with acute lymphoblastic leukaemia on remission induction phase.

Immature reticulocyte fraction a new routine parameter in the hematology analyzer can give the idea of the earliest morphologic change of bone marrow recovery before other test become positive after chemotherapy. A prospective observational study was carried out in the Department of Clinical Pathology in collaboration with Paediatric Haematology and Oncology, Bangabandhu Sheikh Mujib Medical University during a period of one year starting from October 2009 to September 2010 to evaluate the bone marrow recovery in children with acute lymphoblastic leukaemia by automated reticulocyte analysis. Total fifty patients were enrolled in this study on remission induction phase. All patients were between 8 months to 15 years age range with a mean age of 5.5 +/- 3.2. At the end of the study out of 50 cases, 52% patients showed early immature reticulocyte fraction recovery and concluded that the immature reticulocyte fraction parameter showed earlier haematopoietic recovery than the current practice of absolute neutrophil count recovery.

Usefulness of light emitting diode (LED) fluorescent microscopy as a tool for rapid and effective method for the diagnosis of pulmonary tuberculosis.

BACKGROUND: Tuberculosis remains world's leading cause of death from a single infectious agent. Fluorescence microscopy offers well-described benefits, comparing with brightfield microscopy, for the evaluation sputum smear samples for tuberculosis. We evaluated the diagnostic performance of fluorescence microscopy, using novel Light Emitting Diode (LED) technology as an alternative to the conventional fluorescence microscopy by Auramine stain as well as brightfield microscopy by Ziehl-Neelsen (ZN) stain. OBJECTIVES: The objective of the study was to see the usefulness of LED fluorescent microscopy in the diagnosis of pulmonary tuberculosis. METHODS: This is a prospective study consisted of 150 sputum samples from the patients of NIDCH, Mohakhali. All samples were stained by auramine and ZN stain at BSMMU and culture was done in Lowenstein-Jensen (L-J) media as gold standard at NTRL, Mohakhali. RESULTS: In this study total 66 (44%) out of 150 sputum specimens were positive for Mycobacterium Tuberculosis by culture. Sensitivity and specificity documented for the different modalities were 95.38% and 94.11%, respectively, for the LED assessment; 68.18% and 90.47%, respectively, for the CFM assessment; and 56.06% and 97.61%, respectively, for brightfield microscopy by ZN stain. The difference in their case detection rate was statistically significant (chi2=119.38, p<0.001). CONCLUSION: Fluorescence Microscopy (FM) is more sensitive than ZN for diagnosis of pulmonary tuberculosis. However, since FM is more sensitive and rapid, using this method (LED) in clinical laboratories with large specimen numbers is recommended.

Persistence of glaucoma medical therapy in the Glasgow Glaucoma Database.

AIMS: To report the persistence of glaucoma medical therapy in a database of 1006 patients with ocular hypertension (OHT), normal tension glaucoma (NTG) and primary open-angle glaucoma (POAG) attending the Glaucoma Clinic at Glasgow Royal Infirmary, Glasgow, UK. METHOD: Analyses have been carried out using specially written queries to generate reports relating to initial treatment choice and persistence for individual drugs. Queries were investigated in the database time period from 16 February 1982 to 11 February 2009. When investigating drug persistence, the results from the database were split into two distinct time periods from 1997 to 2001 and from 2002 to 2009 to reflect the available treatment options used. RESULTS: The number of patients with each diagnosis was as follows: POAG 608; OHT 246; NTG 152. The Kaplan-Meier estimate for mean persistence from 1997 to 2001 (time to treatment discontinuation) of latanoprost was 58.8 ± 1.95 months, timolol was 41.8 ± 3.94 months, brimonidine was 24.1 ± 3.05 months, and betaxolol was 22.9 ± 2.04 months. The Kaplan-Meier estimate for mean persistence from 2002 to 2009 of latanoprost (time to treatment discontinuation) was 52.0 ± 2.26 months, bimatoprost was 25.8 ± 2.89 months, and travoprost was 23.0 ± 1.27 months. The Kaplan-Meier estimate for mean persistence of latanoprost (time to treatment change) was 37.5 ± 2.47 months, travoprost was 30.2 ± 2.70 months, and bimatoprost was 17.5 ± 2.88 months. CONCLUSION: The introduction of the first prostaglandin analogue, latanoprost, dramatically improved treatment persistence for glaucoma patients. In the current prostaglandin-rich treatment environment, these data do not show any significant differences between prostaglandins with respect to treatment persistence.

Value of dysmorphic red cells and G1 cells by phase contrast microscopy in the diagnosis of glomerular diseases.

The morphology of red cells by phase-contrast microscopy (PCM) is a useful diagnostic marker for glomerular haematuria. This study evaluated the value of urinary dysmorphic red cells and G1 cells (special type of dysmorphic red cell) count by PCM providing a simple, cost effective and low risk technique in the diagnosis of glomerular diseases. Urine samples of 120 patients with haematuria and proteinuria were examined and the percentage of dysmorphic red cells and G1 cells were calculated. Cases were divided into two groups; group I (>20% dysmorphic red cells- glomerular group) and group II (≤20% dysmorphic red cells as non glomerular group). Renal histopathology was used as the gold standard method for the diagnosis of glomerulonephritis. Results from PCM showed a sensitivity of 92.7%, specificity 100% by the detection of dysmorphic red cell while by the detection of G1 cells, a sensitivity of 97.6% and specificity 100% were observed. The percentage of G1 cells is superior to counting dysmorphic red cells. The high sensitivity of phase contrast microscopy confirms its usefulness for the detection of dysmorphic red cells and G1 cells that can guide clinicians in the identification of the site of haematuria using non invasive tests.

Role of discrimination indices in differentiation of beta thalassaemia trait and iron deficiency anaemia.

Iron deficiency anaemia (IDA) and beta thalassaemia trait (BTT) are the most common causes of microcytic hypochromic anaemias. Several discrimination indices have been introduced to discriminate quickly these similar entities via parameters obtained from automated cell counter. The purpose of the study was to evaluate the value of five discrimination indices in differentiation of BTT and IDA. This study consists of 57 cases of BTT and 72 cases of IDA. Five discrimination indices evaluated in this study for differentiation of BTT and IDA were red blood cell (RBC) count, red blood cell distribution width index (RDWI), Green & King Index (G & K), Mentzer index (MI) and England & Fraser (E & F) index. Sensitivity, specificity, positive and negative predictive values and Youden's index (YI) had been calculated. RBC count and RDWI appears to be reliable and useful index for the differentiation of BTT and IDA, as both of the indices had more than 80% sensitivity, specificity in differentiation of IDA and BTT. Patients with microcytic hypochromic anaemia could be easily screened out for BTT and IDA through these discrimination indices in the absence of other complicated diseases.

Surveillance of glaucoma medical therapy in a Glasgow teaching hospital: 26 years' experience.

AIMS: To report the initial findings of a unique database of 956 patients with ocular hypertension (OHT), normal tension glaucoma (NTG) and primary open angle glaucoma (POAG) attending the Glaucoma Clinic at Glasgow Royal Infirmary, Glasgow, UK. METHOD: The database contains retrospective data from 1981 and prospective data from 1999. Analyses have been carried out using specially written queries to generate reports relating to prescription trends and reasons for treatment discontinuation. RESULTS: The database included the following numbers of patients: POAG 580; OHT 242; NTG 134. Of 2928 treatment-change episodes recorded, failure to reach or maintain a target intraocular pressure (IOP) accounted for 51.9%, while adverse effects accounted for 22.1%. Use of latanoprost has increased sharply since 1996, and that of brimonidine, betaxolol and dorzolamide has declined significantly. Bimatoprost had a higher rate of discontinuation due to adverse effects (25%) than travoprost (16.3%) or latanoprost (12.4%), but this was only statistically significant between latanoprost and bimatoprost (p = 0.0038). In 2000 the database informed the introduction of a new treatment protocol that resulted in a fall in discontinuations due to adverse effects by almost two-thirds. CONCLUSION: A large and unique treatment database has been established at the Glaucoma Clinic of Glasgow Royal Infirmary. Containing data spanning a 26-year period, it promises to be an invaluable resource for audit and research. It has already demonstrated its worth by informing changes in prescribing practice that have resulted in direct patient benefit.

Traumatic wound dehiscence after penetrating keratoplasty-a cause for concern.

AIM: We report the incidence, causes, characteristics, and the outcome of traumatic corneal graft ruptures in a tertiary referral centre in the UK. METHOD: A retrospective analysis of all graft ruptures secondary to trauma that were treated at our centre between 1999 and 2005 was undertaken. Statistical analysis of possible prognostic factors was undertaken using the Fisher's test. RESULTS: Nineteen eyes in 18 patients sustained eye trauma resulting in graft rupture (median age of 53 years; range 27-82; 15 men and four women). Seventeen cases were accidental and two were from violence. The median time interval between grafting and rupture was 8.3 months (range 3 days to 15 years). The 6-year incidence was 3.8%. All graft ruptures occurred at the host-graft junction and ranged from 45 to 270 degrees . Iris prolapse/loss was noticed in 89% and lens loss in 53%. The most common posterior segment complication was vitreous loss (74%), followed by vitreous haemorrhage (32%) and retinal detachment (21%). Grafts with 180 degrees or more of dehiscence were more likely to fail (P<0.001), had more extensive posterior segment damage, and a poorer visual outcome. Grafts without sutures had a more extensive dehiscence (P<0.01). Final visual acuity was worse than 6/60 in 58%. CONCLUSIONS: The risk of traumatic corneal graft rupture is significant and is associated with a poor visual outcome. This fact needs to be clearly emphasised during preoperative counselling and protective measures encouraged.

Microbial contamination of preservative free eye drops in multiple application containers.

BACKGROUND/AIMS: The majority of eye drops used in the United Kingdom contain preservatives and are bottled in plastic containers. Preservative free drops are used to avoid ocular irritation and allergies in certain individuals. The aim of this study was to investigate the incidence of microbial contamination of preservative free drops dispensed from multiusage containers. METHODS: Eye drop bottles were collected from patients attending the Tennent Institute of Ophthalmology outpatient and inpatient departments. The bottles were collected on day 3 (for inpatients) and day 7 (for outpatients) of use. The drops were inoculated onto different culture plates (chocolate agar, blood agar, fungal culture media, and enriched media) and the resulting microbial growth was identified using standard microbial identification techniques. RESULTS: 95 eye drop bottles were collected, containing a variety of 10 different eye drops. Significant bacterial growth was found in eight bottles. In total, seven different types of organism were identified from the eye drops. The organisms identified were Staphylococcus aureus, coagulase negative staphylococcus, Bacillus spp, Serattia spp, Klebsiella oxytoca, Enterobacter cloacae, and alpha streptococcus. Staph aureus was the commonest microbial organism. CONCLUSION: Preservative free eye drops in multiple application containers are at risk of contamination by potentially pathogenic micro-organisms.

Pathogenesis, clinical features and management of recurrent corneal erosions.

Recurrent corneal erosions (RCE) are common. They are characterised by repeated episodes of pain, difficulty in opening the eyes, watering, and photophobia resulting from poor epithelial adhesion. In the majority of patients with RCE, trauma is the initiating factor. Epithelial, stromal, and endothelial corneal dystrophies have all been described in association with RCE. Other causes that may lead to RCE include chemical and thermal injuries, previous herpetic keratitis, meibomian gland dysfunction, ocular rosacea, diabetes mellitus, Salzmann's nodular degeneration, band keratopathy, previous bacterial ulceration, kerato-conjunctivitis sicca, and epidermolysis bullosa. The conditions that are associated with RCE can be either primary or secondary depending on whether the basement membrane complex abnormality is intrinsic or acquired. Primary types tend to be bilateral, symmetrical and develop in multiple corneal locations. The pathogenetic mechanism of this disorder is related to poor adhesion of the corneal epithelium to the underlying stroma. Excessive matrix metalloproteinase (MMP) activity may play a role in the pathogenesis. Although the majority of patients will respond to simple measures such as padding and antibiotic ointment, RCE resistant to simple measures require approaches that are more elaborate. The common goal of these approaches is to encourage proper formation of adhesion complexes between the epithelium and the stroma. The use of long-term contact lenses, autologous serum eye drops, botulinum toxin, induced ptosis, oral MMP inhibitors, diamond burr polishing of Bowman's membrane have been reported with varying degree of success in treating RCE. Anterior stromal puncture with insulin needles or Neodymium : aluminium-yttrium-garnet may enhance the epithelial adhesion to the basement membrane by scar formation and success rates of up to 80% have been reported in the treatment of recalcitrant RCE. Excimer laser photo-therapeutic keratectomy (PTK) is now a well-established treatment modality for RCE and is being used both safely and effectively. Partial ablation of Bowman's layer with PTK gives a smooth surface for the newly generating epithelium to migrate and form adhesion complexes. The pathogenesis, clinical features, and management options of this common disorder are discussed in this review article.

Presentation, treatment and outcome in patients with ampullary tumours.

BACKGROUND: Ampullary tumours are relatively rare, and few large single-centre reports provide information on their treatment and outcome. The aim of this study was to analyse outcome and determine predictors of survival for patients with ampullary tumours treated in a specialist centre. METHODS: Over an 11-year period, 561 patients were treated for periampullary tumours, 88 of whom had a histologically proven ampullary neoplasm. Prospectively gathered data were analysed to assess predictors of survival. RESULTS: The overall resection rate was 92 per cent; there were no postoperative deaths. Median survival was 45.8 months for patients with resectable tumours and 8.0 months for those with irresectable disease (P < 0.001). On univariate analysis, age less than 70 years (P = 0.015) and a bilirubin level of 75 micromol/l or less (P = 0.012) favoured long-term survival. Among 70 patients who underwent cancer resection, factors associated with significantly worse long-term survival on univariate analysis included poorly differentiated tumour (P < 0.001), positive nodes (P < 0.001), perineural invasion (P = 0.001) and invasion of the pancreas (P = 0.018). Multivariate analysis identified positive nodes and bilirubin concentration as independent predictors of survival. CONCLUSION: An aggressive surgical approach to ampullary tumours is justified by the low proportion of benign lesions, the absence of postoperative mortality and improved long-term survival.