Assessment of posterior capsule integrity in posterior polar cataracts using anterior segment OCT.

BACKGROUND: Posterior polar cataracts (PPC) pose a great surgical challenge to ophthalmic surgeons. Main intraoperative surgical concerns are increased risk of posterior capsular rupture (PCR), vitreous loss, and nuclear drop. Traditional assessment of posterior capsule integrity utilizing anterior segment- optical coherence tomography (AS-OCT) requires training, and it is a time-consuming process. Recent techniques of posterior capsule assessment need additional software installation, raising the cost of investigation for the patient. This video demonstrates a time-saving method to assess posterior capsular integrity using regular AS-OCT, which can be learnt and practiced easily in outpatient department (OPD). PURPOSE: Ultrasound and 20 D lens mounted on posterior segment optical coherence tomography (OCT) are some of the popular methods to assess the posterior capsule. Such techniques need training and are laborious. Our technique used to assess posterior capsule integrity in PPC using AS-OCT is simple, time saving, and can be easily practiced. SYNOPSIS: The technique described requires AS-OCT lens to be mounted on the lens aperture. The console panel is set to scan on scleral mode. AS-OCT is advanced to capture the cornea, anterior capsule, and posterior capsule. Intact posterior capsule is visualized as a continuous well-defined hyper-reflective layer, and any break in the continuity of this hyper-reflective layer suggests posterior capsule dehiscence, which can further be studied based on literature classifications. HIGHLIGHTS: (1) Importance of proper preoperative assessment in cases of PPC. (2) Detailed technique of using anterior segment OCT module in acquiring scans of posterior capsule in PPC. (3) How to find whether the posterior capsule is intact versus dehiscent. (4) Clinical cases showing utility of this technique. (5) Uses and benefits. VIDEO LINK: https://youtu.be/AohMG4jT13M.

Prevalence, treatments and outcomes of coronary artery disease in Indians: A systematic review.

AIM: To conduct a systematic review on the prevalence, risk factors, treatments and outcomes of Coronary Artery Disease (CAD) in Indians. METHODS AND RESULTS: We conducted a systematic review of studies in Indians with CAD from Jan 1969 to Oct 2012. Initial search yielded 3885 studies and after review 288 observational studies were included. The prevalence of CAD in urban areas was 2.5%-12.6% and in rural areas, 1.4%-4.6%. The prevalence of risk factors was: smoking (8.9-40.5%), hypertension (13.1-36.9%) and diabetes mellitus (0.2-24.0%). The median time to reach hospital after an MI was 360 min. In hospital rates of drug use were: antiplatelets 68%-97.9%, beta blockers 47.3%-65.8% and ACEIs 27.8-56.8%. CONCLUSIONS: In this first systematic review of CAD in India, prevalence of risk factors is high, treatments delayed and use of evidence based treatments variable.

Prevalence and risk indicators for attachment loss in an urban population of South India.

AIM: To estimate the prevalence and severity of attachment loss in an urban population of South India and to determine related risk indicators. MATERIALS AND METHODS: This population based cross sectional study used a subset of data from a large survey representative of urban population from Chennai city. The sample consisted of 900 subjects in the age range of 17 years to 87 years. Participants were interviewed using a structured proforma and subjected to a full mouth clinical examination of six sites per tooth. The prevalence of clinical attachment level (CAL) and association with various risk indicators was assessed. RESULTS: Out of the 900 subjects examined, 868 (96.4%) had CAL <5 mm and 32 (3.6%) had CAL ≥ 5 mm. Age, smoking, poor oral hygiene were found to be independent risk indicators for CAL (p<0.05). Smoking (pack years) was found to exhibit a dose response effect with CAL (Kendall's Tau coefficient = 0.098) (p<0.05). CONCLUSION: In this urban population, a low prevalence of CAL ≥ 5 mm was observed. Amongst the risk indicators evaluated, age, smoking and poor oral hygiene contribute significantly to attachment loss.

Prevalence, risk factors and awareness of hypertension in India: a systematic review.

Indians have high rates of cardiovascular disease. Hypertension (HTN) is an important modifiable risk factor. There are no comprehensive reviews or a nationally representative study of the burden, treatments and outcomes of HTN in India. A systematic review was conducted to study the trends in prevalence, risk factors and awareness of HTN in India. We searched MEDLINE from January 1969 to July 2011 using prespecified medical subject heading (MeSH) terms. Of 3372 studies, 206 were included for data extraction and 174 were observational studies. Prevalence was reported in 48 studies with sample size varying from 206 to 167 331. A significant positive trend (P<0.0001) was observed over time in prevalence of HTN by region and gender. Awareness and control of HTN (11 studies) ranged from 20 to 54% and 7.5 to 25%, respectively. Increasing age, body mass index, smoking, diabetes and extra salt intake were common risk factors. In conclusion, from this systematic review, we record an increasing trend in prevalence of HTN in India by region and gender. The awareness of HTN in India is low with suboptimal control rates. There are few long-term studies to assess outcomes. Good quality long-term studies will help to understand HTN better and implement effective prevention and management programs.

Amniotic membrane transplantation for acute ocular chemical burns in a child.

An ocular burn injury with calcium hydroxide with opaque cornea and limbal ischaemia of more than 270 degrees which was treated byamniotic membrane transplantation on the 6th day following injury is reported. Postoperatively the ocular surface remained stable with no inflammation, vascularisation or infection. Amniotic membrane restored conjunctival surface much earlier than corneal surface and prevented symblepharon formation. We believe that amniotic membrane transplantation may be considered in acute phase of severe chemical injury for a more favourable prognosis.

Treatment and outcomes of acute coronary syndromes in India (CREATE): a prospective analysis of registry data.

BACKGROUND: India has the highest burden of acute coronary syndromes in the world, yet little is known about the treatments and outcomes of these diseases. We aimed to document the characteristics, treatments, and outcomes of patients with acute coronary syndromes who were admitted to hospitals in India. METHODS: We did a prospective registry study in 89 centres from 10 regions and 50 cities in India. Eligible patients had suspected acute myocardial infarction with definite electrocardiograph changes (whether elevated ST [STEMI] or non-STEMI or unstable angina), or had suspected myocardial infarction without ECG changes but with prior evidence of ischaemic heart disease. We recorded a range of clinical outcomes, and all-cause mortality at 30 days. FINDINGS: We enrolled 20,937 patients. Of the 20,468 patients who were given a definite diagnosis, 12,405 (60.6%) had STEMI. The mean age of these patients was 57.5 (SD 12.1) years; patients with STEMI were younger (56.3 [12.1] years) than were those with non-STEMI or unstable angina (59.3 [11.8] years). Most patients were from lower middle 10,737 (52.5%) and poor 3999 (19.6%) social classes. The median time from symptoms to hospital was 360 (IQR 123-1317) min, with 50 (25-68) min from hospital to thrombolysis. 6226 (30.4%) patients had diabetes; 7720 (37.7%) had hypertension; and 8242 (40.2%) were smokers. Treatments for STEMI differed from those for non-STEMI or unstable angina. More patients with STEMI than with non-STEMI were given anti-platelet drugs (98.2%vs 97.4%); angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB) (60.5%vs 51.2%); and percutaneous coronary interventions (8.0%vs 6.7%, p<0.0001 for all comparisons). Thrombolytics (96.3% streptokinase) were used for 58.5% of patients with STEMI. Conversely, fewer patients with STEMI than those with non-STEMI or unstable angina were given beta blockers (57.5%vs 61.9%); lipid-lowering drugs (50.8%vs 53.9%); and coronary bypass graft surgery (1.9%vs 4.4%, p<0.0001 for all comparisons). The 30-day outcomes for patients with STEMI were death (8.6%), reinfarction (2.3%), and stroke (0.7%). Outcomes for those with non-STEMI or unstable angina were better: death (3.7%), reinfarction (1.2%), and stroke (0.3%, p<0.0001 for all comparisons). Use of key treatments also differed by socioeconomic status: more rich patients than poor patients were given thrombolytics (60.6%vs 52.3%), beta blockers (58.8%vs 49.6%), lipid-lowering drugs (61.2%vs 36.0%), ACE inhibitors or ARB (63.2%vs 54.1%), percutaneous coronary intervention (15.3%vs 2.0%), and coronary artery bypass graft surgery (7.5%vs 0.7%, p<0.0001 for all comparisons). Mortality was higher for poor patients than for rich patients (8.2%vs 5.5%, p<0.0001). Adjustment for treatments (but not risk factors and baseline characteristics) eliminated this difference in mortality. INTERPRETATION: Patients in India who have acute coronary syndromes have a higher rate of STEMI than do patients in developed countries. Since most of these patients were poor, less likely to get evidence-based treatments, and had greater 30-day mortality, reduction of delays in access to hospital and provision of affordable treatments could reduce morbidity and mortality.

Evaluation of subjective and objective cyclodeviation following oblique muscle weakening procedures.

PURPOSE: To evaluate the subjective and objective cyclodeviational changes following different weakening procedures on superior and inferior oblique muscles. DESIGN: Comparative case series. MATERIALS AND METHODS: In a prospective institution based study, 16 cases of A pattern horizontal strabismus having superior oblique overaction were randomized to superior oblique weakening procedures: either silicon expander or translational-recession. Similarly, 20 cases of V pattern horizontal strabismus with inferior oblique overaction were randomized for inferior oblique weakening procedures: either 10 mm Fink's recession or modified Elliot and Nankin's anteropositioning. Cyclodeviation was assessed subjectively with the synoptophore and objectively using the fundus photograph before surgery and 3 months postoperatively. Change in cyclodeviation was measured by subjective and objective methods. The index of surgical effect (ISE) was defined as the net torsional change postoperatively. RESULTS: The difference between the extorsional change induced by the two superior oblique procedures, silicone expander (-6 degrees ) and translational recession (-11.3 degrees), was statistically significant (P=0.001). Translational recession caused more extorsional change (ISE=296%) than silicone expander surgery (ISE=107%). The two inferior oblique weakening procedures, Fink's recession (+2.5 degrees) and modified Elliot and Nankin's anteropositioning (+4.7 degrees) produced equitable amount of intorsional shift with no statistical difference (P=0.93). Objective measurements were significantly more than the subjective measurements. CONCLUSIONS: Different weakening procedures on oblique muscles produce different changes in cyclodeviation, which persists even up to 3 months. Subjective cyclodeviation is less than the objective measurements indicating partial compensation by sensorial adaptations.

Quantitative evaluation of left ventricle performance from two dimensional echo images.

OBJECTIVES: We sought to quantify the left ventricle systolic dysfunction by a geometric index from two-dimensional (2D) echocardiography by implementing an automated fuzzy logic edge detection algorithm for the segmentation. BACKGROUND: The coronary injuries have repercussions on the left ventricle producing changes on wall contractility, the shape of the cavity, and as a whole changes on the ventricular function. METHODS: 2D echocardiogram and M-mode recordings were performed over the control group and those with the dysfunctions. From 2D recordings, individual frames were extracted for at least five cardiac cycles and then segmentation of left ventricle was done by automated fuzzy systems. In each frame, the volumes are measured and a geometric index, eccentricity ratio (ER), was derived. The endocardial fractional shortening (FS), midwall fractional shortening (mFS), and the relative wall thickness (RWT) were also measured in each case. RESULTS: Depressed value of endocardial FS (20.39 +/- 5.43 vs 34.28 +/- 9.36, P = 0.0046), mFS (33 +/- 8.3 vs 52.5 +/- 11.7, P = 0.0047), and the RWT (0.337 +/- 0.096 vs 0.525 +/- 0.119, P = 0.0002) was observed with dysfunction. ER measured at end-diastole (2.86 +/- 0.703 vs 4.14 +/- 0.38) and end-systole (3.14 +/- 0.79 vs 5.48 +/- 0.74) was found to be decreased in the dysfunction group and more significant at the end-systole (P = 0.00017 vs 6.6E-06). CONCLUSION: This work concludes that the regional and global left ventricle systolic dysfunction can be assessed by the ER measured at end-diastole and end-systole from 2D echocardiogram and may contribute to the high rate of cardiovascular disorders.

Percutaneous transluminal coronary angioplasty by right transradial approach in a patient with arteria lusoria.

Though the radial artery is an ideal site of access for coronary interventions, at times anatomical variations make this procedure complicated. We describe one such arterial aberrancy, the retroesophageal right subclavian artery or arteria lusoria, in which the right subclavian artery arises distal to the left subclavian artery. Therefore, approaching through the right radial artery, the catheter has to take a zigzag course through the right subclavian to the descending aorta, and then to the ascending aorta. This often makes it difficult to perform diagnostic angiography. Performing angioplasty by the right transradial approach also becomes a more difficult task and requires greater perseverance and skill. In the case described here, the patient with arteria lusoria had tandem 90% stenosis involving the proximal and mid left anterior descending artery. Percutaneous transluminal coronary angioplasty with stenting of the proximal and mid left anterior descending artery by the right transradial approach was performed, negotiating the loop with two paclitaxel-eluting stents.

Comparison of target concentration intervention strategy with conventional dosing of digoxin.

Digoxin is a widely used drug in patients with congestive heart failure. The present study compared the quality of life of congestive heart failure patients on one year follow-up period with two different dosing of digoxin (5/7 therapy and 7/7 therapy in whom the target serum digoxin concentration is maintained). Quality of life significantly improved in intervention group thus emphasizing the need for continuous dosing of digoxin based on target concentration.

Detection of left ventricle systolic dysfunction from shape deformity.

Coronary artery disease producing ischemic cardiomyopathy is the most frequent cause of left ventricular systolic dysfunction. Non-ischemic cardiomyopathies can also produce systolic dysfunction; they may be inherited as genetic disorders or occur sporadically. These coronary injuries have repercussions on the left ventricle producing changes on wall contractility, the shape of the cavity and also changes on ventricular function. This study is focused on the 2D echocardiograms of the left ventricle. Apical two chamber and four chamber view recordings were performed on normal and systolic dysfunction subjects. Individual frames were extracted for at least five cardiac cycles. After pre-processing these images, segmentation of the left ventricle was performed by Fuzzy systems. Then the volumes were measured by single and biplane methods along with the perimeter, short axis length and long axis length in each frame, from which the two indices Sphericity Index (SI) and Normalized Eccentricity Index (NEI) was determined. It was found that the diastolic phase is short in the case of systolic dysfunction, and its volume variation is not uniform as in the normal case. Also, in the case of systolic dysfunction, the span of either the long or short axis length variation is less than 0.5 cm. This depicts that akinesis is in the corresponding direction; the value of SI is less than 2 for systolic dysfunction. A sharp peak is seen at each systole point in the NEI plot and also its variation is smooth in subjects having LVEF > 45%, which is not the case for dysfunction.

Left ventricular systolic dysfunction identification by motion analysis.

This paper presents a new technique for identification of regional dysfunctions in the left ventricle from 2-D echocardiography. It uses a novel left ventricular border tracking algorithm based on Fuzzy inference system. In this paper we show how the regional dysfunction present in the left ventricle can be identified by tracking the movement of centre of mass of left ventricle in a 2D space. The path pattern of that point traced over the cardiac cycles shows variation between the two groups. The main advantage of this proposed approach is the smaller date handling in regional dysfunction identifications unlike other existing methods. The method is illustrated on the real 2D echocardiograph dataset that includes patients having dysfunctions in the left ventricular wall. The diagnostic potential of this method is explained in detail.

Catheter intervention in valvular obstruction and long-term results.

Percutaneous balloon mitral valvuloplasty has been established as an effective alternative to surgery for the treatment of mitral stenosis. The authors describe their experience in percutaneous mitral commissurotomy with a detailed discussion of the procedures and a brief review of literature.

Dermatofibroma of the eyelid: a case report.

A 5-year-old girl presented with a large swelling measuring 50 x 35 mm in the left upper lid. The mass was firm to hard in consistency. Fine-needle aspiration showed a few spindle-shaped cells arranged in clusters. The mass was excised in toto and the histopathological examination revealed dermatofibroma, which is an extremely rare condition affecting the eyelid.

Retrobulbar optic nerve cysticercosis with surgical removal: a case report.

A 15-year-old boy presented with diminution of vision which rapidly progressed to no perception of light. In the ocular fundus, a neuroretinitis-like picture was seen. On CT-scan & ultrasonography, an optic nerve swelling was detected with a shadow of scolex. Medical therapy in the form of steroids along with albendazole was ineffective. Surgical removal by lateral orbitotomy was done and a complete cyst with scolex was removed, which was confirmed histopathologically as a case of retrobulbar optic nerve cysticercosis.

A Case of Ball Valve Thrombus.

Ball valve thrombus is a very rare cardiac pathological entity; most case reports are postmortem. It is always associated with a very tight rheumatic mitral stenosis. The antemortem diagnosis of ball valve thrombus has become easy with the advent of echocardiography and even easier with biplane or multiplane transesophageal echocardiography, including the three-dimensional acquisition of images. We present the case of a patient with a ball valve thrombus diagnosed during routine echocardiographic examination as a prelude to surgery.