Nocardia keratitis: A clinical diagnosis with successful outcome.

Nocardia keratitis is mostly seen in patients with alcoholism, malnutrition, or HIV. Its chronic waxing-and-waning course makes it difficult to diagnose. A 53-year-old male presented with pain and redness in his right eye for the past 3 weeks. The cornea had paracentral ulcer with stromal infiltrates and multiple satellite lesions giving wreath-like appearance suggestive of Nocardia. After corneal scraping, fortified amikacin, moxifloxacin, and cycloplegics were started. Gram stain revealed filamentous, branching Gram-positive bacteria and acid-fast on Ziehl-Neelsen stain confirming our clinical diagnosis. Ulcer completely resolved over 6 weeks. Thus, a high index of clinical suspicion which was further backed by microbiological confirmation aided in expedient management ensuring a successful outcome.

Serum vitamin D level alterations in retinal vascular occlusions.

AIM: To evaluate serum vitamin D levels in sub-types of retinal vascular occlusions and compare the levels in ischemic and non-ischemic presentations. METHODS: This study included 50 patients of retinal vascular occlusions comprising central retinal vein occlusion, branch retinal vein occlusion, central retinal artery occlusion, branch retinal artery occlusion (study group) diagnosed on basis of clinical characteristics as well as investigations and an age and gender-matched healthy control group (control group). The study group was further classified into ischemic and non-ischemic subtypes and serum vitamin D levels were analysed and compared. RESULTS: There were 50 patients of various sub-types of retinal vascular occlusions comprising 13 cases of CRVO, 30 cases of BRVO, 05 cases of CRAO, 02 cases of BRAO and 50 age and sex-matched controls. Mean BCVA and CMT in RVO patients was +1.12 log MAR, 346.72 ± 27.93 µm while in control group was +0.37 log MAR, 236.22 ± 3.71 µm which were statistically significant (p = 0.004; p = 0.002). The mean serum vitamin D value in study group was 18.39 ng/dl as compared to 32.31 ng/dl in control group which was statistically significant (p = 0.001). The difference in the baseline vitamin D value between the ischemic and non -ischemic sub groups among total vascular occlusion was found to be statistically significant (p = 0.010). However, baseline vitamin D levels difference among ischemic and non-ischemic cases in individual sub-types of vascular occlusion was statistically insignificant. CONCLUSION: High prevalence of low serum vitamin D levels is seen in patients of retinal vascular occlusion spectrum diseases. Moreover, ischemic types of retinal vascular occlusion have significantly lower serum vitamin D levels as compared to non - ischemic despite having fewer no of patients in arterial occlusion sub-types. Therefore, vitamin D supplements may be considered as possible future targeted therapy in optimizing the severity of disease.

Toxoplasma Retinochoroiditis Following Intravitreal Dexamethasone Implant Injection for Diabetic Macular Edema: A Rare Complication.

PURPOSE: To report a case of ocular toxoplasmosis as a rare complication of intravitreal dexamethasone implant in a case of diabetic macular edema. METHODS: A 56 years old male, a known case of Proliferative Diabetic Retinopathy, received intravitreal dexamethasone implant for diabetic macular edema in left eye. He developed toxoplasma retinochoroiditis involving the macula with further diminution of vision in his left eye 3 weeks after the injection. His serum titres were positive for Toxoplasma IgG (161 IU/ml). He was treated with oral Sulfamethoxazole 800 mg + Trimethoprim 160 mg 12 hourly for 4 weeks. RESULTS: The visual acuity in left eye improved with resolution of retinochoroiditis after the course of antibiotic therapy. CONCLUSION: It is imperative to follow-up closely after intravitreal steroid implantation, to look for the possible rare complication of infectious retinitis/retinochoroiditis, as timely antimicrobial treatment can lead to a good visual outcome.

Association of serum vitamin D levels with clinical spectrum of central serous chorioretinopathy patients of Indian origin.

BACKGROUND: Vitamin D, a fat-soluble prohormone has been implicated in various ophthalmological diseases such as ocular inflammation, glaucoma, diabetic retinopathy and ocular angiogenesis. Many studies have shown effect of vitamin D on oxidative stress, angiogenesis and retinal circulation. However, there is definitive lack in published literature on effect of vitamin D on central serous chorioretinopathy especially in view of various epidemiological studies reporting risk of vitamin deficiency in up to 40% adult population. OBJECTIVE: To determine serum vitamin D levels in various clinical profiles of central serous chorioretinopathy and their effect on its pathophysiology in Indian population. DESIGN: Case control observational study METHODS: Study included 42 patients (group P) of central serous chorioretinopathy (CSCR) diagnosed with optic coherence tomography (OCT), fundus fluorescein angiography (FFA) which were further sub-grouped into acute(P1), chronic (P2) and recurrent (P3). A total of 44 age & sex-matched healthy control subjects (group C) were also included. The vitamin D levels of both groups were examined and analyzed. RESULTS: No significant difference between the groups P and C in respect of age, gender or baseline best corrected visual acuity (P = 0.153, P = 0.123 and P = 0.08, respectively) was noted. Vitamin D levels were determined as 16.473 ± 7.307 ng/mL in group P and 34.940 ± 8.348 ng/mL in group C and difference was statistically significant(P = 0.001). There were statistically significantly more no of patient in group P (78.57%) with deficient vitamin D levels as compared to normal serum levels (4.76%) (P = 0.04). Patients in group P1(acute CSCR) and P2(Chronic CSCR) also had significant more no of subjects with deficient vitamin D levels as compared to normal serum levels (P = 0.01 and P = 0.03). CONCLUSIONS: The low serum vitamin D levels were determined in all clinical sub-types of central serous chorioretinopathy patients which point to its possible role in the pathophysiology of the disease. There is a need for further studies to determine the changes that could occur with vitamin replacement therapy in CSCR.

Comparison of changes in blood pressure in phacoemulsification cataract surgery performed via topical and peribulbar anaesthesia: A cohort study.

Background: The purpose of study was to compare the changes in blood pressure in patients undergoing phacoemulsification cataract surgery under topical and peribulbar anaesthesia during preoperative, intraoperative and postoperative period. Methods: In this prospective cohort study, 240 patients undergoing phacoemulsification were divided into topical (Group 1) and peribulbar (Group 2) equally. Proparacaine 0.5% drops were used for topical anaesthesia, and Inj lignocaine with Inj bupivacaine were used to give peribulbar anaesthesia. Preoperative blood pressure was taken 30 min before surgery with automated sphygmomanometer. Intraoperative blood pressure was taken during phacoemulsification, and postoperative blood pressure was taken 1 h after surgery. Outcomes assessed were systolic, diastolic and mean blood pressure. Results: Systolic blood pressure in Group 1 was significantly increased in the intraoperative phase, whereas it was significantly decreased in Group 2 in the intraoperative phase. Diastolic and mean blood pressure in Group 1 showed no significant change, whereas in Group 2, both showed significant reduction in intraoperative and postoperative phases. Conclusion: The increase in intraoperative systolic blood pressure in topical group could be due to discomfort from microscope light, iris manipulation, irrigation and aspiration during surgery. The decrease in intraoperative systolic and diastolic blood pressure in peribulbar group could be due to systemic absorption of local anaesthetic. The mean preoperative systolic blood pressure was also higher in the topical group, which could be due to anxiety or stress under topical anaesthesia. The changes in blood pressure need to be observed so that timely intervention can be made to achieve favourable postoperative outcome.

Ray tracing biometry in post radial keratotomy eye.

OBJECTIVE: To report a case of post radial keratotomy (RK) cataract in a 55-year-old lady wherein biometry was done by ray-tracing method incorporated in scheimpflug topographer (Sirius + Scheimpflug Analyzer, CSO, Italy). METHOD: In our case, we performed intraocular lens (IOL) power calculation using a recent concept of ray tracing with scheimpflug topographer and compared with traditional methods available at American Society of Cataract and Refractive Surgery(ASCRS) website (www.ascrs.org) for eyes with prior RK. Phacoemulsification was performed and a monofocal + 24.5D IOL implanted in the capsular bag. RESULT: Manifest refraction at six weeks postoperative period was + 1.0DS/-2.0DC × 75° with spherical equivalence of 0. On comparison of all the methods used to calculate IOL power, the absolute errors of ray tracing and Barrett true K were found to be the least, 0.14 and 0.18 respectively. CONCLUSION: Ray tracing biometry with scheimpflug topographer seems to provide accurate IOL power in post RK eyes.

Purtscher-like retinopathy-unusual initial presentation of rheumatoid arthritis.

Purtscher-like retinopathy is a rare phenomenon reported in disorders including acute pancreatitis, collagen vascular diseases, fat embolism, chronic renal failure, amniotic fluid embolism, battered baby syndrome and several autoimmune diseases. We report an atypical initial feature of rheumatoid arthritis in a middle-aged male. This case will raise awareness among generalists to recognize this disease early.

Tuberculosis and neuromyelitis optica spectrum disorder: A conundrum.

Purpose: Infectious atypical optic neuritis (AON), like tubercular, is a vision threatening condition with phenotypic overlap with Neuromyelitis Optica Spectrum Disorder (NMOSD). The overlapping neurological manifestations and negative AQP4-Ab-assay make it difficult to discover the primary cause of neuritis. Case presentation: We report two paediatric cases with NMOSD that did not fulfil the diagnostic criteria. Moreover, associated undiagnosed tuberculosis at the time of presentation and negative AQP4-Ab clouded the diagnosis and delayed the treatment. The first case was initially diagnosed with infectious optic neuropathy. By the time steroids were started, optic atrophy had already set in. The second case had optic neuritis, LETM, and intracranial-tuberculomas with no signs of pulmonary-tuberculosis with negative CSF-analysis. So, systemic steroids were started promptly. The history of LETM in both cases raised the suspicion of NMOSD. Conclusion: The importance of accurate clinical diagnosis and early intervention in cases of AON was emphasized in a limited resource country, that could potentially result in salutary visual outcomes, especially in the paediatric age group Abbreviations: AON = atypical optic neuritis, TB = tuberculosis, NMOSD = neuromyelitis optica spectrum disorder, LETM = longitudinal extensive transverse myelitis, AQP4-Ab = anti-Aquaporin-4 Antibodies, RE = right eye, LE = left eye, MRI = magnetic resonance imaging, CSF = cerebrospinal fluid, ATT = anti-tubercular treatment, DOV = diminution of vision.

Immediately sequential bilateral cataract surgery in Down syndrome.

The exponential increase in world population and average human lifespan is expected to result in geriatric population globally. The problem of preventable blindness due to cataract will increase manifold. Simultaneous Bilateral cataract surgery (SBCS) is a viable option in such subset of patients. Despite faster visual recovery, economic benefits to patients and health care providers, decreased risk of complications associated with General anaesthesia, there is significant resistance in accepting SBCS as a routine procedure. Bilateral endophthalmitis is the main deterrent in performing ISBCS. This case highlights successful ISBCS in 36 years old female patient with Down's syndrome.

Neuromyelitis optica spectrum disorder with negative aquaporin-4 antibodies and positive anti-myelin oligodendrocyte glycoprotein antibodies: A case report.

Neuromyelitis optica spectrum disorders (NMOSDs) are rare autoimmune-mediated chronic inflammatory disorders involving the central nervous system. The concept of NMOSDs has widened up recently. Its diagnostic criteria have broadened the knowledge of this particular disease including the atypical cases where antiaquaporin-4 antibody is negative and anti-myelin oligodendrocyte glycoprotein (MOG) antibody is positive. Myelin oligodendrocyte glycoprotein is a protein expressed on the outer surface of myelin sheath and oligodendrocytes of the central nervous system. The detection of anti-MOG-Ab is emerging evidence, and thus, research on the role of this antibody in such seronegative cases is still underway. Early diagnosis and adequate therapy is essential in such cases. Here, we report an eight-year-old girl who was diagnosed with NMOSDs and found to have anti-MOG antibodies in place of AQP-4 antibodies.

Acute myeloid leukemia presenting as unilateral central retinal vein occlusion.

Ocular manifestations of leukemia are often bilateral and involve all ocular structures with non-specific features like retinal hemorrhages, cotton wool spots and choroidal infiltrates. We report a rare, atypical initial presentation of acute myeloid leukemia with unilateral central retinal vein occlusion in a middle-aged male. This case will raise awareness among ophthalmologists to recognize and diagnose underlying systemic disease early and decrease systemic morbidity in consultation with a hematologist.

Photodynamic therapy in the treatment of circumscribed choroidal hemangioma: Current perspectives.

Photodynamic therapy (PDT) using verteporfin Visudyne®(Novartis International AG, Basel, Switzerland) is widely used to treat various chorio-retinal diseases. PDT targets choroidal vascular abnormalities and induces selective occlusion of vessels. PDT was originally used in combination with full-dose verteporfin to treat neovascular age-related macular degeneration. Currently, the clinical targets of PDT have shifted to other chorioretinal conditions such as central serous chorioretinopathy, polypoidal choroidal vasculopathy and choroidal hemangioma. Clinical studies have also facilitated the optimization of treatment outcomes in choroidal hemangiomas through changes in protocols including the introduction of reduced treatment settings; such as PDT with half-dose verteporfin and half-fluence PDT. Here, we review various evolving trends in clinical application of PDT and its use for choroidal hemangiomas from a practical perspective.

Tear film abnormalities in pseudoexfoliation syndrome and normal healthy participants: A comparative analysis.

BACKGROUND: Pseudoexfoliative material is being implicated in causing tear film abnormalities, and the aim of the present study was to prove it and to compare with the normal healthy participants. METHODS: A total of 398 eyes of 200 participants were studied, and two groups were formed. The first, pseudoexfoliation syndrome (PEXS) group, included 198 eyes of 100 patients, and the second, age-matched control group, included 200 eyes of 100 participants. Tear film abnormalities were compared in the two groups by tear meniscus height (TMH), Schirmer test I, Schirmer test II and tear film break-up time (TBUT). RESULTS: On comparing the two groups using independent t-test, a significant difference was found in Schirmer test I, Schirmer test II, and TBUT between the PEXS group (Schirmer test I: 23.98 ± 10.68 mm, Schirmer test II: 17.11 ± 8.78 mm, and TBUT: 9.778 ± 5.54 s) and the age-matched control group (Schirmer test I: 27.08 ± 9.58 mm, Schirmer test II: 19.98 ± 8.48 mm, and TBUT: 13.495 ± 5.65 s) (p = 0.003 [Schirmer test I]; p = 0.001 [Schirmer test II]; and p < 0.001 [TBUT]). However, an insignificant difference was found in terms of TMH (p = 0.195) between the two groups. CONCLUSION: PEXS affects tear production and leads to unstable tear film.

Combined cardiac anomalies in Noonan syndrome: A case report.

INTRODUCTION: Noonan syndrome is the second most common syndromic cause of congenital heart disease. Most patients have an autosomal dominant inheritance, but some cases may be sporadic. Pulmonary stenosis is the most common cardiac manifestation in Noonan syndrome, associated with the atrial septal defect and hypertrophic cardiomyopathy. A combination of these three is present only in 5% of patients. PRESENTATION OF CASE: We report a case of a 21-year-old female who presented to our hospital concomitant cardiac lesions associated with pulmonary stenosis, atrial septal defect, and hypertrophic cardiomyopathy. This combination of cardiac defects is an infrequent manifestation of Noonan syndrome. The patient presented with complaints of exertion syncope over the past two years. 2D-Echocardiography showed biventricular hypertrophy, dysplastic pulmonary valve, severe pulmonary stenosis, asymmetric septal hypertrophy and large atrial septal defect. The genetic analysis report showed autosomal dominant inheritance with Ras/MAPK (mitogen-activated protein kinase) Positive. DISCUSSION: Due to the wide spectrum of symptoms and presentations in Noonan cases, accurate clinical and genetic diagnosis, and comprehensive management of the disorder are strongly recommended. CONCLUSION: We have described a case of rare combination of cardiovascular defects in Noonan Syndrome with a view to achieve better insight into the disease course and advantages of timely treatment and follow up. Our patient is currently in follow-up after treatment with percutaneous balloon pulmonary valvuloplasty, has improved symptoms, and is awaiting heart transplant.

Hyperglycaemia as a risk factor for the development of retinopathy of prematurity: A cohort study.

BACKGROUND: Retinopathy of prematurity (ROP) is a preventable cause of childhood blindness. Without treatment, over 45% of eyes can develop permanent visual loss. Hyperglycaemia has recently been described as a risk factor for the development of retinopathy of prematurity (ROP), a proliferative vascular disease of the retina that primarily affects premature infants. The characteristic neoproliferative growth of blood vessels in the retina is very well under stood with the clinical and experimental experiences with Diabetic retinopathy. The purpose of this study was to evaluate a possible relation between glucose levels in VLBW (Very Low Birth Weight) infants and development of ROP. METHOD: All at risk infants of a Neonatal Intensive Care Unit (NICU) of a tertiary care centre in western India were included in the study. The blood sugar values of the neonates were recorded at multiple times during their first week of life. On completion of 31 weeks of gestational age or 04 weeks of birth age, the neonates were subjected to ROP screening as per standard protocols. RESULT: A total of 103 neonates were included in the study and were subjected to ROP screening. A total of 32 neonates developed ROP at the end of the study. It was found with statistical significance that the neonates with higher average blood glucose values in the initial period of life had higher incidence of ROP at the time of screening with a Relative Risk of 2.506 (CI = 1.287, 4.882). CONCLUSION: A high average blood glucose level in neonates during the first week of life is an indicator for developing ROP at a later date. These neonates should be kept under close follow up in order to facilitate timely detection and prompt intervention.

Percutaneous Coronary Intervention in an Octogenarian With Anomalous Origin Arising From Right Sinus: A Rare Case Report.

Anomalous coronary artery origins are not common in routine clinical practice. The incidence of coronary anomalies in patients undergoing coronary angiography is less than 1%. The greatest challenges faced in the management are delays in identification and difficulty engaging the anomalous coronary artery. Operator experience in promptly identifying the anomaly and selection of the appropriate catheter is critical for successful intervention. We are presenting a case of acute inferior and posterior wall myocardial infarction (MI) with an anomalous origin of the left circumflex artery from the right coronary sinus. Learning objective is that percutaneous coronary intervention (PCI) in an anomalous left circumflex can be technically difficult because selective cannulation of the vessel may not be easy. An anomalous left circumflex artery has a rare presentation of ST-elevation myocardial infarction (STEMI). Complicated STEMI with cardiogenic shock is not commonly seen in anomalous coronary artery origin from the right sinus. Percutaneous intervention in patients with STEMI with an anomalous left circumflex artery has a high risk and is technically challenging.

Sheets glide-assisted versus Busin glide-assisted insertion techniques for descemet stripping endothelial keratoplasty (DSEK): A comparative analysis.

BACKGROUND: The donor lenticule insertion techniques play a crucial role in outcomes following descemet stripping endothelial keratoplasty (DSEK) and the current study is aimed to compare two of the commonly performed donor lenticule insertion techniques in DSEK. METHOD: Descemet stripping endothelial keratoplasty was performed in 48 eyes of 48 patients at two tertiary eye care centers from January 2014 to December 2016. At one center (Group 1), 26 patients had Sheets glide-assisted lenticule insertion whereas at other center (Group 2), 22 patients had Busin glide-assisted insertion of donor lenticule. Best corrected visual acuity (BCVA), manifest spherical equivalent, manifest cylinder, endothelial cell density (ECD) and percentage of endothelial cell loss (ECL) were compared between the two groups at 6 months after DSEK. In addition, intraopertaive and postoperative complications were also compared. RESULTS: At 6 months after DSEK, an insignificant difference was observed in BCVA [Group 1: 0.48 logarithm of the minimum angle of resolution (log MAR); Group 2: 0.50 log MAR (p = 0.74)], mean manifest spherical equivalent [Group 1: 0.64 diopter (D); Group 2: 0.59 D (p = 0.74)], mean manifest cylinder [Group 1: 1.35 D; Group 2: 1.32 D (p = 0.92)] and mean ECL [Group 1: 26.75%; Group 2: 28.76 (p = 0.44)] between the two groups. In addition, the rate of complications is similar between the two groups. CONCLUSIONS: Both Sheets glide-assisted and Busin glide-assisted donor lenticule insertion techniques are associated with similar surgical outcomes after DSEK.

A clinical study to describe the corneal topographic pattern and estimation of the prevalence of keratoconus among diagnosed cases of vernal keratoconjunctivitis.

BACKGROUND: Association of keratoconus with vernal keratoconjunctivitis is well known, but there are few topographic studies describing actual prevalence especially in India where it is a common condition. There is also scarce literature on the topographic patterns and subclinical topographic anomalies in cases of vernal catarrh and their relationship with various subtypes. This study was conducted to estimate the prevalence of subclinical keratoconus among Indian subjects with vernal keratoconjunctivitis and describe the various topographic abnormalities which can help in screening for these cases. METHODS: In the cross-sectional study conducted at a tertiary care center, 76 established cases of vernal keratoconjunctivitis were evaluated with placido disc-based videokeratography for topographic abnormalities and early keratoconus based on modified Rabinowitz-McDonnell criteria. RESULTS: Seventeen (11.2%) eyes satisfied both the modified Rabinowitz-McDonnell criteria of keratoconus. Corneal topographic pattern analysis showed asymmetric bowtie with inferior steepening in 17.11% of the patients. None of these patients had clinical evidence of keratoconus. CONCLUSIONS: The study showed 11.2% prevalence of keratoconus in patients suffering from vernal keratoconjunctivitis. The findings highlight the importance of using a simple placido disc-based corneal topography system for screening the patients with vernal keratoconjunctivitis for keratoconus. This can help in early detection and preventive intervention.