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<strong>Cornea</strong> - I<br />
<strong>Free</strong> <strong>Papers</strong>
Contents<br />
Contents<br />
CORNEA - I<br />
A New Approach to Management of <strong>Cornea</strong>l Ulcers by Debridement---------------- 471<br />
Dr. Debasish Dutta, Dr. Arup Bhaumik, Dr. Ayan Mohanta, Dr. Prashant Kumar Singhal,<br />
Dr. Sabitabrata Basu<br />
Colored Cosmetic Contact Lenses: Cosmesis and Complication, Hand in Hand-475<br />
Dr. Shwetambari Singh, Dr. Ravindra Vhankade, Dr. Dipali Satani, Dr. Amit Patel<br />
Spectrum of Mycotic Keratitis: 5-Year Review of Patients at A Tertiary Eye Care<br />
Center in Tamilnadu------------------------------------------------------------------------------------- 479<br />
Dr. D Chandrasekhar, Dr. J Kaliamurthy, Dr. Pragya Parmar, Dr. C M Kalavathy, Dr. C A<br />
Nelson Jesudasen, Dr. Philip Aloysius Thomas<br />
Effect of Subconjunctival Injection of Bevacizumab on <strong>Cornea</strong>l<br />
Neovascularization------------------------------------------------------------------------------------- 483<br />
Prof. Dr. K Vasantha, Dr. Rajini Ponraj, Dr. Mohan K, Dr. Niraimozhi<br />
Risk Factors in Management of Bacterial Keratitis------------------------------------------ 485<br />
Dr. Samrat Chatterjee, Dr. Deepshikha Agrawal<br />
A Very Unusual Case of Keratitis------------------------------------------------------------------ 488<br />
Dr. Saroj Gupta<br />
Effect of Pterygium on Contrast Sensitivity---------------------------------------------------- 490<br />
Dr. Archana Malik, Dr. Soniya Bhala, Dr. Anamika Garg, Dr. Sudesh K Arya,<br />
Dr. Sunandan Sood<br />
To Study The Effect of Sub-conjunctival Injection of Bevacizumab on <strong>Cornea</strong>l<br />
Neovascularisation-------------------------------------------------------------------------------------- 493<br />
Dr. Somnath Mukhopadhyay, Dr. Himadri Dutta, Dr. Jayanta Dutta, Dr. Swarnali Sen,<br />
Dr. Pradeep Kumar Panigrahi<br />
Neonatal Infectious Keratitis Five Years Experience at a Tertiary Eye Care Center--<br />
------------------------------------------------------------------------------------------------------------------ 495<br />
Dr. Jatin Ashar, Dr. Muralidyhar R, Dr. Shivani Pahuja, Dr. Sunita Chaurasia,<br />
Dr. Virender Sangwan<br />
Efficacy and Safety of Topical Umbilical Cord Serum Therapy in Persistent <strong>Cornea</strong>l<br />
Epithelial Defects----------------------------------------------------------------------------------------- 498<br />
Dr. Charu Mithal, Dr. Anu Malik, Dr. Sandeep Mithal, Dr. Neha Mithal, Dr. Prateek<br />
Agarwal, Dr. Pallavi Agarwal<br />
Sympathetic Ophthalmitis Following Optical Penetrating Keratoplasty In The Last 9<br />
Years---------------------------------------------------------------------------------------------------------- 502<br />
Dr. Rekha Gyanchand, Dr. Sheetal Hegde<br />
Comparison of Engothelial Cell Count by Manual and Automated Methods in Normal<br />
<strong>Cornea</strong> and in Fuchs’ Endothelial Dystrophy------------------------------------------------- 505<br />
Dr. Somasheila I Murthy, Dr. Debarun Dutta, Dr. Tamal Chakraborti, Dr. Pritam Kumar<br />
Streptococcus Pneumoniae Keratitis: Fortified Antibiotics or Fluoroquino-lones?-<br />
------------------------------------------------------------------------------------------------------------------ 508<br />
Dr. Sujata Das, Dr. Savitri Sharma, Dr. Vivek Warkad, Dr. Srikant K Sahu<br />
Fibrin Glue (FG) Augmented Amniotic Membrane Transplantation (FGAMT) in<br />
Peripheral <strong>Cornea</strong>l Perforations---------------------------------------------------------------------511<br />
Dr. Ritu Arora, Dr. Jasneet Kang, Dr. J L Goyal, Dr. Monika Mittal, Dr. Parul Jain<br />
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CORNEA - I<br />
Chairman: Dr. G Mukherjee; Co-Chairman: Dr. A K Jain<br />
Convenor: Dr. Beena Desai; Moderator: Dr. Prerna Upadhyaya<br />
Dr. DEBASISH DUTTA: MBBS (1995), NRS Medical College, Calcutta<br />
University, Kolkata; MS (2000), MKCG Medical College, Berhampur<br />
University; Fellowship (2004), Sankara Nethralaya, Chennai. Recepiant of<br />
K.R. Dutta award (1999) in EIZOC, Cuttack. Presently, Consultant, Disha<br />
Eye Hospital and Research Centre, Sheoraphuly, Hooghly, WB.<br />
Contact: 09830216532; E-mail: debasish71@yahoo.com<br />
A New Approach to Management of <strong>Cornea</strong>l<br />
Ulcers by Debridement<br />
Dr. Debasish Dutta, Dr. Arup Bhaumik, Dr. Ayan Mohanta, Dr. Prashant<br />
Kumar Singhal, Dr. Sabitabrata Basu<br />
Visual disability in the developing nations of Asia , Africa and Middle East<br />
is a major public health issue. Cataract is the most common cause but is<br />
easily manageable. The very second cause is corneal opacity resulting from<br />
corneal ulceration. Central <strong>Cornea</strong>l ulceration is a very common occurrence<br />
in the semi urban and rural population. These patients mostly belong to the<br />
financially weaker sections of the society and are involved in agricultural<br />
activities. There is wide geographic and a etiological variation across the globe<br />
and also from region to region.<br />
In the Indian scenario a huge fraction of the agricultural population is affected<br />
by corneal diseases ranging from simple corneal abrasions to microbial<br />
keratitis. This is not the case where farming is highly mechanized.<br />
Microbial keratitis due to bacteria is decreasing at our Disha Eye Hospital<br />
(Hooghly). Self medication or treatment by village quacks cures many of the<br />
bacterial ulcers. This is mainly because of some potent and cheap antibacterial<br />
formulations, which are available over the counter.<br />
So we are left with the dreaded menace of the mycotic keratitis, which is<br />
unequivocally a major cause of ocular morbidity. The problem of fungal<br />
infection of cornea in India is acute as the weather is hot and humid (Tropical)<br />
and to add to the problem are ignorance, illiteracy and poverty.<br />
Medical management of fungal Keratitis is far from satisfactory. Fungi<br />
implicated in keratomycosis rarely cause systemic mycoses. Therapeutic<br />
protocols applicable for systemic mycoses work poorly when applied to<br />
cornea. Polyenes are natamycin and Ampho-B a zoles include Clotrimazole,<br />
Fluconazole and Voriconazole etc. These are mostly fungistatic and not<br />
fungicidal. The drug of choice for filamentous fungi is natamycin suspension.<br />
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It penetrates the cornea poorly and acts only on superficial keratitis. It is<br />
expensive and requires frequent instillation. It is mostly available in 3ml glass<br />
packing which leak many a times. Amphoterecin B for topical application<br />
is not available off the shelf and has to be prepared fresh. It is available as<br />
injection and as such its penetration of intact epithelium is poor.<br />
The population at risk is located far from tertiary care centers and detailed<br />
microbiological assessment at grass roots level is difficult. So to cut ice the<br />
protocol of management of fungal ulcers should be simple, reproducible and<br />
inexpensive.<br />
The first step in the management of most corneal ulcer is scraping. Standard<br />
scraping encompasses removal of the epithelium with necrotic tissue at the<br />
ulcer and its bed. This decreases load of the organism and improves penetration<br />
and availability of the antifungal agent. Simultaneously scraping acts as a<br />
diagnostic tool in the form of KOH mount preparation to diagnose fungal<br />
filament etc. 10% KOH mount is inexpensive and easy; it requires minimum<br />
infrastructure and results are obtained immediately. A trained technician can<br />
do it. But an ophthalmologist executing the whole exercise himself or herself<br />
increases the yield of the organism. Chances of isolating fungal filaments in<br />
corneal scraping is as high as 90 to 99%, Vis-à-vis 88.75% by Gramstain.<br />
The diagnostic and therapeutic scraping that is practised by most removes the<br />
necrotic tissue but the heavily infiltrated pre necrotic tissue at the ulcer bed is<br />
left behind. This study focuses on a method of deeper scraping whereby this<br />
prenecrotic tissue with its load of infiltration and cytokines is removed to a<br />
great extent. This method is destined to promote better drug availability and<br />
thus quicker healing and lesser scarring.<br />
MATERIALS AND METHODS<br />
It is a predesigned prospective interventional case series of consecutive 153<br />
cases of fungal keratitis with filaments demonstrated in 10% KOH at Disha<br />
Eye Hospital (Hooghly) during January 2008 and December 2009<br />
Patient<br />
All patients with red eye who report to the OPD of the tertiary care eye centre<br />
Disha Eye Hospital (Hooghly) are screened for corneal ulcer. This tertiary care<br />
hospital serves semi urban and rural people of Howrah,Hooghly and Burdwan<br />
districts of West Bengal. The livelihood of majority of patients turning up to<br />
the OPD of this hospital is agriculture based.<br />
Ulcer<br />
Ulcer is defined as breech in corneal epithelium with infiltration of underlying<br />
stroma, with or without hypopyon.<br />
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A common protocol was applied to all cases. Each patient was examined<br />
under Slit Lamp biomicrocope by an ophthalmologist. Ulcer is stained by<br />
Sterile fluorescein strip touched at the lower fornix to make out the extent of<br />
epithelial breech and recorded in mm in its longest and shortest diameter.<br />
Other details like depth, zone of stromal infiltrate, <strong>Cornea</strong>l edema etc are<br />
noted with proper color coding. Hypopyon is measured in mm and number of<br />
days for its resolution is noted.<br />
Healed Ulcer<br />
An ulcer is defined healed where fluorescein staining is negative and there is<br />
no stromal infiltrate.<br />
Meticulous data was collected on the following:<br />
1. Date of first visit.<br />
2. Date at which ulcer has healed .<br />
3. Size of ulcer at first visit<br />
4. Site of ulcer (central , inferior temporal , inferior nasal , superior temporal,<br />
inferior temporal)<br />
5. Hypopyon present on presentation and its resolution time.<br />
6. Best corrected visual acuity at first visit.<br />
7. Best corrected visual acuity at end of treatment.<br />
Exclusion criteria<br />
Associated systemic ailments like Diabetes etc.<br />
Associated ocular conditions like dry eye, dacryocystitis, blepharitis, lid<br />
pathologies etc. Typical viral ulcers, healing ulcers, moorens , interstitial<br />
keratitis, neurotropic ulcer, bullous keratopathy, exposure keratopathy etc.<br />
Scraping<br />
The cornea and conjunctival sac are anesthetized with proparacaine<br />
hydrochloride (0.5%), Epithelium is scraped from over the ulcer and beyond.<br />
Ulcer is scraped by an ophthalmologist under aseptic conditions ,at the slit<br />
lamp, using sterile Bard Parker Blade no 15.<br />
Material is obtained from<br />
1. The bed of the ulcer<br />
2. Leading edge of the ulcer and a KOH mount prepared for examination<br />
under microscope first under 10 x and then finally under 40x.<br />
Detailed microbiological examinations like fungal and bacterial culture etc<br />
are done as part of hospital protocol but has not been taken into consideration<br />
in this study as these are not feasible at the grass roots level. It is obviously<br />
ideal to inoculate into several media but this is not always possible due to<br />
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lack of availability of media, lack of adequate sample for all media and the<br />
infrastructural cost involved at all places.<br />
Only the patients who test positive for filaments are taken into consideration<br />
(Group 1).<br />
A typical medical regime was formulated and applied to all those patients.<br />
Most patients were examined at 5 days interval and changes noted as per the<br />
protocol.<br />
A subset of these patients in group 1 were randomly taken up for the special<br />
checker board scraping protocol to constitute Group 2.<br />
<strong>Cornea</strong>l thickness is assessed under the slit beam and cheques board pattern<br />
of scraping applied to remove the deep densely infiltrated prenecrotic tissue.<br />
This tissue was not removed by conventional deep scraping. Ulcer is monitored<br />
closely and scraped similarly at subsequent visits.<br />
RESULTS<br />
Patients were randomly divided into group 1 and group 2.<br />
In group 1 standard therapeutic scraping was practised in the beginning and<br />
subsequent follow ups.<br />
In group 2 chequer board scraping was applied similarly.<br />
The impact of nuisance parameters like size of ulcer , site of ulcer etc on the<br />
yield or outcome (number of days required to heal and the final visual acuity<br />
achieved) is eliminated by ANCOVA. Analysis of the data revealed that the<br />
time required to heal is significantly less in group 2 (at 5% level).<br />
But the assumption that quicker healing will cause lesser fibrosis maintaining<br />
better transparency need further evaluation .<br />
DISCUSSION<br />
The impact of fungal keratitis in the Indian subcontinent as a cause of ocular<br />
morbidity is unequivocally substantial . Fungal ulcer account for 30 to 40% (3)<br />
of all cases of microbial keratitis in developing countries. Some studies put the<br />
figure to as high as 50% (1)<br />
The therapeutic protocols of today are far from satisfactory and often fail<br />
to preserve or restore vision after fungal keratitis. Filamentous fungi is the<br />
number one cause at lest in the developing world. <strong>Cornea</strong>l penetrability of<br />
available drugs is an issue. Cost and accessibility to low cost treatment is<br />
extremely important in the Indian subcontinent.<br />
Aim of management is rapid eradication of the organism with control of<br />
inflammation and tissue damage by cytokinins etc, there by preserving<br />
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integrity and transparency of the cornea. Under these circumstances checker<br />
board scraping of fungal ulcers calls for no extra infrastructural support. All<br />
that is needed is the existing slit lamp and the Bard Parker Blade no 15. This<br />
New Approach To Management Of <strong>Cornea</strong>l Ulcers By DEBRIDEMENT has<br />
improved healing and decreased morbidity to a great extent; lesser number of<br />
eyes are lost to therapeutic PKs and evisceration .<br />
REFERENCES<br />
1. Basak S K, Basak S, Mohanta A, Bhowmik A, Epidemiological and Microbiological<br />
Diagnosis Of Suppurative Keratitis In Gangetic West Bengal, Eastern India. IJO<br />
2005;53:17-22.<br />
2. Srinivasan M, Gonzales C A,George C et al.: Epidemiology and Aetiological<br />
Diagnosis Of <strong>Cornea</strong>l Ulcer In Madurai. South India . Br J Ophthalmol 1997;81:965-<br />
71.<br />
3. Sharma S, Srinivasan M, George C:The Current Status of Fusarium Species in<br />
Mycotic Keratitis in South India. J Med Microbial 1993;11:140-7.<br />
4. Dunlop A A, Wright E D,Howlader S A, et al.: Suppurative <strong>Cornea</strong>l Ulceration<br />
In Bangladesh: A Study Of 142 Cases Examining The Microbiological Diagnosis,<br />
Clinical And Epidemiological Features of Bacterial and Fungal Keratitis. Aust N Z<br />
J Ophthalmol 1994;22:105-10.<br />
5. Bharathi M J, Ramakrishnan R, Vasu S, et al.:Epidemiological Characteristics and<br />
Laboratory Diagnosis of Fungal Keratitis: A Three-Year Study. Indian J Ophthalmol<br />
2003;51:315-21.<br />
6. Gopinathan U, Garg P,Fernandes M, et al.: The Epidemiological Features and<br />
Laboratory Results of Fungal Keratitis:A 10-Year Review at A Referral Eye Care<br />
Center in South India. <strong>Cornea</strong> 2002;21:555-9.<br />
Colored Cosmetic Contact Lenses: Cosmesis<br />
and Complication, Hand in Hand<br />
Dr. Shwetambari Singh, Dr. Ravindra Vhankade, Dr. Dipali Satani,<br />
Dr. Amit Patel<br />
Use of colored cosmetic contact lens is well known latest fad of young<br />
generation. Manufacturers are targeting and attracting youth market by<br />
providing various colors and patterns of cosmetic contact lenses. Influential<br />
commercials and easy availability has lead to dramatic increase in trend<br />
of wearing cosmetic lenses even in youngsters of middle to lower socioeconomic<br />
classes. Many of these young users are unaware and uninformed<br />
about the proper use and care of contact lenses. Noted here are 13 patients<br />
who developed severe infectious keratitis following use of decorative lenses.<br />
All the patients were ignorant about the precautions, hygiene measures and<br />
complications related to contact lens use.<br />
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MATERIALS AND METHODS<br />
All patients presented at Nagari eye institute from November 2009 to February<br />
2010 with acute pain and redness following use of cosmetic contact lenses<br />
were included in the study. Written consent was taken from the patients before<br />
inclusion. Before clinical examination, a detailed history was obtained relating<br />
to the availability of cosmetic lenses, duration and frequency of wear and type<br />
of cleaning solution used. If available, the contact lenses and solution used by<br />
the patient were obtained and sent for microbiological evaluation.<br />
A slit-lamp biomicroscopic examination was conducted to record the location<br />
and size of the corneal infiltrates. Under topical anesthesia and slit-lamp<br />
magnification, corneal scrapings were obtained from the base and edge of the<br />
ulcer. The samples were inoculated directly onto nutrient agar, sheep blood<br />
agar, chocolate agar and Sabouraud dextrose agar. Gram and Giemsa stained<br />
smears of scraped material were prepared.<br />
According to the clinical picture and smear report, patients were treated with<br />
broad spectrum antibiotics and antiviral drugs. The initial therapy was modified<br />
based on the results of culture and sensitivity testing and the clinical response.<br />
RESULTS<br />
Out of 13 patients 8 were male and 5 were female. Mean age of presentation was<br />
19 ± 3.8 years. Eleven patients were naïve contact lens users and 4 were minors.<br />
Table 1 outlines the details of contact lens availability, storage and usage.<br />
Table 1<br />
Case Contact lens Storage and Duration of Assistance Sharing Overnight<br />
No. availability cleaning storage in for CL use<br />
solution unchanged removal<br />
solution<br />
1 Optical shop CLS 2 days + - -<br />
2 Optical shop CLS +Tape water 7 days - - -<br />
3 Relative CLS 1 month - + -<br />
4 Friend CLS 10 days - + +<br />
5 Optical shop CLS 2 days - - -<br />
6 Optical shop CLS 10 days + - +<br />
7 Relative CLS +Tape water 4 months - + -<br />
8 Optical shop CLS 15 days + - -<br />
9 Friend CLS 5 days - + +<br />
10 Optical shop CLS +Tape water 3 days - - -<br />
11 Garbage - - - - -<br />
12 Friend CLS 7 days + + -<br />
13 Optical shop CLS 5 days - - +<br />
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Laboratory results showed Pseudomonas aeruginosa in 7 cases (54%),<br />
Staphylococcus aureus in 3 cases (25%) and Staphylococcus epidermidis in 2<br />
cases (17%) with one case of viral keratitis. In 62% of cases size of ulcer was<br />
≥ 5 X 5 mm and post treatment corrected visual acuity was 6/24 or less. All<br />
patients responded well to the antimicrobial treatment, eliminating the need<br />
of surgical intervention. Clinical details, culture and sensitivity results and<br />
visual acuity are described in Table 2.<br />
Table 2<br />
Case Age Size of Organism Sensitivity Visual Final<br />
No. (years) / ulcer isolated acuity on visual<br />
gender (mm) presentation acuity<br />
1 20/M 5.5X6 P. aeruginosa Moxifloxacin HM 6/18<br />
2 15/F 3X4 S. aureus Amikacin 6/24 6/9<br />
3 16/F 9X8.5 P. aeruginosa Cefotaxime HM HM<br />
4 18/M 7X8 P. aeruginosa Moxifloxacin PR NA<br />
5 19/M 1X2 P. aeruginosa Moxifloxacin 6/60 6/12<br />
6 28/M 6X7.5 Culture negative CF ½ m CF ½ m<br />
7 18/F 1X2 S. aureus Levofloxacin 6/6 6/6<br />
8 25/M 7.5X8 S. epidermidis Moxifloxacin PR HM<br />
9 16/M 5X4.5 P. aeruginosa Amikacin CFNF 6/24<br />
10 21/F 2X3 S. aureus Moxifloxacin 6/9 6/6<br />
11 15/F 5X5.5 P. aeruginosa Moxifloxacin 6/60 6/24<br />
12 20/M 2X3 S. epidermidis Moxifloxacin 6/9 6/6<br />
13 21/M 7X8 P. aeruginosa Levofloxacin PR 6/60<br />
DISCUSSION<br />
The link between microbial keratitis and contact lens wear is beyond question.<br />
Use of contact lenses for therapeutic, refractive or cosmetic purpose will<br />
target different classes of population. The colored cosmetic lenses are non<br />
corrective (zero power or plano) lenses designed and worn solely to change<br />
the appearance of the eye. Emmetropic patients who wear these lenses risk<br />
serious ocular sequelae for the sake of cosmesis alone. In the current study, 13<br />
young individuals developed sight threatening microbial keratitis following<br />
the use of cosmetic contact lenses. As all the patients were from lower to lower<br />
middle socieo-economic class, it points towards the dangerous trend evolving<br />
in the youngsters of these classes. We found that unsterile lens handling and<br />
infrequent change of storage solutions were the two major causes for the<br />
development of infectious keratitis.<br />
Eleven out of 13 patients were using these lenses for the first time. None of<br />
the patient was following sterile contact lens handling or storage technique.<br />
The lenses were stored in a contact lens case with solution or unpreserved<br />
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saline for weeks or months at a time by 8 patients. Longest duration of storage<br />
in unchanged solution was 4 months. Sharing of these cosmetic lenses is<br />
possible and more frequent as they are of zero refractive power. Five patients<br />
in our study group shared lenses with friends or relatives. None of the patient<br />
was instructed about insertion or removal techniques. Four patients required<br />
assistance of other person for removal of contact lenses. Out of these 4 patients<br />
in 2 cases contact lens was broken while removal and one patient had injury<br />
with finger nail.<br />
Pseudomonas species (especially P. aeruginosa) are reported the world over<br />
as the most common organism associated with contact lens related microbial<br />
keratitis, and so was the case in our study group. Seven out of 13 (54%) cultures<br />
were positive for P. aeruginosa. Young contact lens wearers usually have better<br />
host defense mechanism, which fungi are less efficient to overcome. Several large<br />
series have reported low incidence of fungal keratitis in contact lens wearer<br />
groups. We did not culture a fungi or Acanthamoeba from any of the cases<br />
studied. Small sample size of our study group can be the reason for this result.<br />
Steinmann et al. reported twelve cases of infectious keratitis after wearing<br />
plano decorative contact lenses. None of the lenses were dispensed by eye care<br />
professionals. Authors have highlighted that colored noncorrective lenses are<br />
being dispensed without a prescription or fitting from unlicensed vendors.<br />
Patients who acquire lenses from unauthorized providers are less likely to be<br />
instructed on appropriate lens care and use. Consequently, uninformed lens<br />
wearers are developing sight threatening keratitis.<br />
The widespread advertising of colored cosmetic contact lenses creates<br />
a demand among emmetropic individuals while failing to mention the<br />
associated risks. The patients who wear these lenses intermittently may<br />
perceive their lenses to be merely a cosmetic aid and, therefore, may be more<br />
prone to unsafe practices than daily wearers accustomed to a regular pattern<br />
of contact lens hygiene. Unmonitored wearing and over the counter use of<br />
cosmetic contact lenses is causing serious sight threatening complications in<br />
emmetropic young individuals.<br />
REFERENCES<br />
1. Over the counter decorative contact lenses: cosmetic or medical device? A case<br />
series. Eye Contact Lens: Science and clinical practice. Sept. 2005.<br />
2. Ocular complications associated with use of contact lenses from unlicensed<br />
vendors. Eye Contact Lens: Science and clinical practice Oct 2003.<br />
3. <strong>Cornea</strong>l ulcer associated with cosmetic extended wear soft contact lens.<br />
Ophthalmology Feb. 1987.<br />
4. Ulcerative keratitis associated with contact lens wear. American journal of<br />
Ophthalmology July 1989.<br />
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Spectrum of Mycotic Keratitis: 5-Year Review<br />
of Patients at A Tertiary Eye Care Center in<br />
Tamilnadu<br />
Dr. D Chandrasekhar, Dr. J Kaliamurthy, Dr. Pragya Parmar, Dr. C M<br />
Kalavathy, Dr. C A Nelson Jesudasen, Dr. Philip Aloysius Thomas<br />
Mycotic keratitis (Keratomycosis, Fungal keratitis) refers to a suppurative,<br />
usually ulcerative infection of the cornea that is caused by fungi. Such<br />
an infection may threaten sight and even lead to the loss of the eye. <strong>Cornea</strong>l<br />
infections are the second most common cause of monoocular blindness after<br />
unoperated cataract in some developing countries in the tropics. It has been<br />
increasing recently in India and other developing countries. 1-4 Fungal keratitis<br />
is caused by a large number of saprophytic fungi, and the aetiological agents<br />
of fungal keratitis show a varying pattern with respect to geographic locale<br />
and climatic conditions, additionally, the spectrum of fungal pathogens<br />
causing fungal keratitis changed significantly in different year. To improve<br />
the management of patients with fungal keratitis, it is important for<br />
ophthalmologists to gain information of the common fungal isolates within<br />
their region. This report describes the spectrum of the spectrum of fungi<br />
isolated from corneal ulceration in patients treated at a tertiary eye care center<br />
in Tamilnadu during a 5-year period.<br />
MATERIALS AND METHODS<br />
The study was conducted with the approval of the Institutional Ethics<br />
Committee of the authors’ institution and was designed as a retrospective<br />
review of Microbiological records and the patients’ medical record. Medical<br />
records of all keratitis patients who underwent for microbiological investigation<br />
from January 2005 to December 2009 were reviewed. The predisposing factors<br />
and risk factor were abstracted from the history documented in the medical<br />
record. The microbiological data of all patients with suspected infectious<br />
corneal ulceration who presented to the ocular microbiology service at Joseph<br />
Eye Hospital, Trichy between January 2005 and December 2009 were also<br />
reviewed retrospectively.<br />
Microbiological Investigation: On presentation, corneal specimens from<br />
scrapings were stained with the Gram and also viewed as wet mount<br />
preparations using lactophenol cotton blue (LPCB). The corneal material was<br />
also inoculated directly onto the following media that support the growth of<br />
bacteria, fungi and Acanthamoeba: sheep blood agar, Sabouraud’s dextrose<br />
agar and broth and brain–heart infusion agar and broth. Brain–heart infusion<br />
agar and broth, and blood agar were incubated at 37°C and were examined<br />
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daily and to be discarded after 7 days, if no growth was seen. Sabouraud’s<br />
dextrose agar and the broth were incubated at 28°C and were examined daily<br />
for the first week and twice daily thereafter for 4 weeks. A fungus grown on<br />
the primary isolation medium was subcultured onto various fungal media<br />
and incubated for a considerable period to facilitate sporulation. The cultures<br />
were considered positive if at least one of the following criteria was fulfilled:<br />
a) The growth of the same organism was demonstrated on one or more solid<br />
media and/or if there was confluent growth at the site of inoculation on at<br />
least one solid medium.<br />
b) The growth on one medium was consistent with direct microscopic<br />
findings.<br />
c) The same organism was grown from repeated corneal scrapings.<br />
Fungal species were identified according to the macroscopic characteristics of<br />
the colony morphology, color and growth rate of the moulds, and the microscopic<br />
characteristics of hyphae, spores or conidia, and their relationships.<br />
RESULTS<br />
There were 1499 patients of who suspected microbial corneal ulcer underwent<br />
microbiological investigations during the five years from January 2005 to<br />
December 2009. Of these, 64% of them reported trauma by inanimate object,<br />
26% reported prior treatment with eye drops (from Pharmacy/ General<br />
Practitioner/ Ophthalmologist) and 18% reported use of traditional eye<br />
medicine (oil, leaf juice, milk, etc.).<br />
Microorganisms were grown from 1069 (71%) of the 1499 ulcers. There were<br />
542 (51%) fungal isolates and 522 (49%) bacterial isolates. The proportions of<br />
bacterial and fungal isolates recovered from the corneal ulcers for each year<br />
were given in Table -1.<br />
Table 1: The proportions of bacterial and fungal isolates recovered<br />
from the corneal ulcers for each year (2005 to 2009)<br />
Organism 2009 2008 2007 2006 2005 Total<br />
Bacteria 116 112 110 86 98 522<br />
Fungi 108 80 143 103 108 542<br />
No growth 56 63 72 119 120 430<br />
Others 0 2 1 0 2 5<br />
280 257 326 308 328 1499<br />
The most common fungal pathogens isolated were various species of<br />
Fusarium, representing 204 (37.6%) of all positive fungal cultures, followed<br />
by Aspergillus spp. (134; 24.7%), Curvularia spp (28; 5%), Colletotrichum<br />
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dematium (13; 2%) and Exserohilum longirostratum (7; 1%). Alternaria<br />
alternata, Bipolaris spicifera, Lasiodiplodia theobromae, Scedosporium<br />
apiospermum and Candida albicans were less frequently isolated organisms<br />
in the series. In addition, unidentified dematiaceous fungi accounted for 26%<br />
(141). The spectrum of 542 clinical isolates of fungi for each year (2005 to 2009)<br />
is summarized in Table 2.<br />
Table 2: The spectrum of fungi isolated from the corneal ulcers for the<br />
five year period (2005 to 2009)<br />
Organism 2009 2008 2007 2006 2005 Total<br />
Fusarium solani 5 4 0 0 0 9<br />
Fusaium sp 24 20 60 34 42 180<br />
Fusarium dimerum 7 7 0 0 1 15<br />
Total 204<br />
A.flavus 16 8 20 30 27 101<br />
A.fumigatus 10 4 7 3 4 28<br />
Aspergillus spp 3 1 0 0 4<br />
Aspergillus niger 1 0 0 1<br />
Total 134<br />
Curvularia sp 4 3 9 4 8 28<br />
Colletotrichum dematium 9 1 0 2 1 13<br />
Exerohilum longistratum 1 0 0 2 4 7<br />
Alternaria alternata 1 0 3 0 0 4<br />
Bipolaris 1 1 1 1 1 5<br />
Lasiodiplodia 2 0 1 0 3<br />
Scedosporium apiospermum 1 0 1<br />
Candida albicans 1 1 2<br />
UI 39 28 39 19 16 141<br />
Total 117 81 141 98 105 542<br />
DISCUSSION<br />
Fungal keratitis is a common cause of corneal infection and blindness after<br />
trauma in the developing world. Because of the widespread distribution of<br />
fungi, human contact with the organism is inevitable and frequent. It has<br />
become increasingly important to gather sufficient data that would project the<br />
gravity of the problem of fungal keratitis of a representative geographic region<br />
in terms of the epidemiology and aetiology, the documentation of which would<br />
serve as a useful guide for practising ophthalmologists. Few studies on fungal<br />
keratitis have been published from India. 2,3,5,6 The results of proportion of<br />
fungi and bacteria of the present study are consistent with the earlier reports<br />
from India. 5,6 Fungal ulcers are usually seen more in this center. It is primarily<br />
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the result of the temperate climate because a warm, humid environment<br />
enhances the growth of fungi. In addition, the author’s institution is a tertiary<br />
cornea and external disease referral centre that provides medical service to<br />
all the people in Tiruchirapalli district residing in urban and rural areas.<br />
Other factors that have been correlated with this increasing incidence include<br />
the growing number of trauma cases, widespread abuse of broad-spectrum<br />
antibiotics and steroids. Meanwhile, improvement of the health care system,<br />
increasing awareness of this disease by ophthalmologists and popularization<br />
of the diagnostic methods and instruments also help to identify patients who<br />
otherwise might have been undetected previously.<br />
In the literature, fungi belonging to nearly 56 genera have been reported from<br />
the cases of fungal infections. Filamentous fungi are the principal causes of<br />
corneal infections in most parts of the world; either Fusarium or Aspergillus<br />
are the most common fungal genera. Geographical and environmental<br />
variations, such as humidity and air temperature, have been observed in the<br />
predominant genera of fungi isolated from patients with fungal keratitis.<br />
In this case series, Fusarium was the most frequently isolated pathogen,<br />
and Aspergillus was the second most often one in the cases. There are some<br />
agreements of this study on the spectrum of fungal species in causing fungal<br />
keratitis with others reported from India. 5-7 In conclusion, various species of<br />
Fusarium were the most common fungal aetiological agents isolated, followed<br />
by Aspergillus spp. and unidentified dematiaceous fungi from patients with<br />
keratitis in this setting.<br />
REFERENCES<br />
1. Xie LX, Zhong W, Shi W, Sun S. Spectrum of fungal keratitis in North China.<br />
Ophthalmology 2006;113:1943–8.<br />
2. Chowdhary A, Singh K. Spectrum of fungal keratitis in North India. <strong>Cornea</strong> 2005;<br />
24:8–15.<br />
3. Shukla PK, Kumar M, Keshava GB. Mycotic keratitis: an overview of diagnosis and<br />
therapy. Mycoses 2008;51:183–99.<br />
4. Wang L, Sun S, Jing Y, Han L, Zhang H, Yue J. Spectrum of fungal keratitis in<br />
central China. Clinical and Experimental Ophthalmology 2009;37:763–71.<br />
5. Bharathi MJ, Ramakrishnan R, Meenakshi R, et al. Microbial keratitis in South<br />
India: influence of risk factors, climate, and geographical variation. Ophthalmic<br />
Epidemiol 2007;14:61–9.<br />
6. Leck AK, Thomas PA, Hagan M, et al. Aetiology of suppurative corneal ulcers<br />
in Ghana and south India, and epidemiology of fungal keratitis. Br J Ophthalmol<br />
2002;86:1211–5.<br />
7. Gopinathan U, Garg P, Fernandes M, et al. The epidemiological features and<br />
laboratory results of fungal keratitis: a 10-year review at a referral eye care center<br />
in South India. <strong>Cornea</strong> 2002;21:555–9.<br />
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Effect of Subconjunctival Injection of<br />
Bevacizumab on <strong>Cornea</strong>l Neovascularization<br />
Prof. Dr. K Vasantha, Dr. Rajini Ponraj, Dr. Mohan K, Dr. Niraimozhi<br />
To evaluate regression of new vessels of cornea. To evaluate the safety<br />
and efficacy of subconjunctival injection of Bevacizumab. To evaluate the<br />
outcome of OKP after subconjunctival Bevacizumab<br />
MATERIALS AND METHODS<br />
This study was done in <strong>Cornea</strong> Department Regional Institute of<br />
Ophthalmology and Government Ophthalmic Hospital Chennai during<br />
January 2009 to January 2010. Twenty eyes of twenty patients with corneal<br />
neovascularization due to various pathologies (mentioned below) have been<br />
selected for the study.<br />
Inclusion criteria<br />
Vascularised corneas of patients with<br />
• Leucomatous opacity following exanthematous fever and post hydrops<br />
• Pseudophakic bullous keratopathy<br />
• Healed corneal ulcer post trauma and infection<br />
• Previously failed Optical keratoplasty<br />
Exclusion criteria<br />
• Patients with uncontrolled systemic hypertension with systolic blood<br />
pressure of ≥150mm Hg or diastolic blood pressure of ≥90 mm of Hg<br />
• Patients with recent Myocardial Infarction<br />
• Patients with recent Cerebro Vascular Accidents<br />
• Diabetes mellitus<br />
• Renal, liver, and coagulation abnormalities including current<br />
anticoagulation medications<br />
• Current or recent systemic corticosteroid therapy or periocular<br />
corticosteroids injections to the study eye<br />
• Ocular or periocular malignancy<br />
Procedure<br />
Anterior segment examination was done with slit lamp biomicroscopy.<br />
Standardized corneal photographs were taken with 10X magnification with<br />
slit lamp biomicroscopy using digital camera.<br />
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A commercially available bevacizumab (2.5mg/0.1ml, 100 mg/4 mL) was<br />
prepared for each patient and placed in a tuberculin syringe using aseptic<br />
techniques.<br />
484<br />
• Topical anesthetics ( 4% xylocaine/ paracaine eye drops) and antibiotics<br />
are applied<br />
• The eye had been prepared with 5% povidone iodine in a standard fashion<br />
• Then draped with an eye mask<br />
• Opsite was applied<br />
• Using lid speculum eye was exposed<br />
• Bevacizumab (2.5mg/0.1ml) was injected subconjunctivally in the<br />
quadrant of vascularization 1cm from the limbus<br />
• Patients were instructed to apply antibiotic eye drops for 3 days 4 times a<br />
day<br />
Follow-up<br />
Follow up visits were done on 14th day, 1st, 3rd, and 6th month post injection.<br />
All the 20 patients completed 6 months of follow-up. At each visit patients<br />
were checked for regression of new vessels i.e. reduction in both number and<br />
caliber of the vessel. Patients were also examined for signs of graft rejection<br />
(those who have been operated) and side effects.<br />
Main outcome measures<br />
i) Regression of corneal new vessels<br />
ii)<br />
iii)<br />
Efficacy and safety of subconjunctival Bevacizumab<br />
Outcome of OKP after subconjunctival Bevacizumab injection<br />
DISCUSSION<br />
In this study an obvious reduction in established corneal neovascularization<br />
occurred to a different degree in each patient, and subconjunctival<br />
bevacizumab was well tolerated by all these patients. Out of 20 patients in 50%<br />
of patients complete regression of the corneal new vessels noted at the end<br />
of 6th month. Whereas in 30% of patients only partially reduction noted i.e.<br />
reduction in calibre of vessels only, the number of new vessels was constant.<br />
In 20% of patients both number of new vessels and the calibre was constant.<br />
This variable response may be because of the chronicity, extent of corneal<br />
neovascularization, amount of scarring, disease process, formulation and<br />
route of administration of the drug 15 and 16.<br />
• Subconjunctival injection of Bevacizumab can be used safely and effectively<br />
for corneal neovascularization resulting from different types of disorders.
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• It may provide an additional strategy in improving success of corneal<br />
grafts in these patients.<br />
• This is a short term study. However long-term follow-up is necessary to<br />
determine whether repeat injections are necessary.<br />
Risk Factors in Management of Bacterial Keratitis<br />
Dr. Samrat Chatterjee, Dr. Deepshikha Agrawal<br />
Infectious keratitis continues to be a major cause of corneal blindness in<br />
developing countries. Timely presentation, specific diagnosis and treatment<br />
with appropriate antimicrobial agents can limit ocular morbidity. The<br />
knowledge of risk factors affecting treatment outcome helps in modifying<br />
management protocols and also in prognostication. 1-5 A previous study<br />
from our Institute examined the risk factors affecting outcome after medical<br />
management of fungal keratitis [Risk factors for poor outcome in medical<br />
management of fungal keratitis. Chatterjee S, et al. Paper presented at Annual<br />
Conference of All India Ophthalmological Conference, Kolkata, 2010]. In this<br />
present study, risk factors affecting outcome after medical management of<br />
bacterial keratitis are being examined.<br />
MATERIALS AND METHODS<br />
This was a retrospective, interventional case series which included all<br />
microbiologically proven cases of bacterial keratitis diagnosed at the <strong>Cornea</strong><br />
Services in MGM Eye Institute, Raipur (2005-2009). Medical records were<br />
examined and factors like age, gender, distance from institute, presentation time,<br />
treatment history prior to presentation, steroid use, initial visual acuity, ulcer<br />
size and depth, corneal thinning/perforation, presence of endophthalmitis,<br />
etc were correlated to poor outcome. Poor outcome to medical therapy was<br />
considered when the ulcer failed to heal with medications or progressed to<br />
perforation or required penetrating keratoplasty or underwent evisceration.<br />
Each patient who presented with corneal ulcer at our Institute underwent<br />
corneal scraping and microbiological investigations that included culture in<br />
appropriate media and antibiotic susceptibility by Kirby Bauer disc method.<br />
Medical treatment was with either combined fortified cefazolin eye drops<br />
(50mg/ml) and tobramycin (14mg/ml) or monotherapy with fluoroquinolones.<br />
The initial drug chosen was modified according to antibiotic susceptibility<br />
reports and clinical response. Patients not responding to medical therapy were<br />
considered for therapeutic penetrating keratoplasty. In patients where corneal<br />
integrity was threatened with corneal thinning, descemtocele formation or<br />
perforation, tissue adhesive was applied. Univariate analysis was done with<br />
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2x2 tables with chi-square or Fishers test as appropriate. Variables that yielded<br />
p value
<strong>Cornea</strong> <strong>Free</strong> <strong>Papers</strong><br />
Table: Univariate analysis of risk factors affecting outcome<br />
Sl VARIABLE Poor Good TOTAL Odds 95% CI P<br />
No outcome outcome ratio VALUE<br />
No (%) No (%)<br />
1 Extreme of age 6(12) 44(88) 50 0.78 0.26- 2.30 0.79<br />
(0-14 and > 60y)<br />
Others 10(15) 57 (85) 67<br />
2 Male gender 8(11) 68 (89) 76 0.6 0.21-1.74 0.26<br />
Female gender 8 (20) 33 (80) 41<br />
3 Distance >25kms 8(11) 63(89) 71 0.6 0.21- 1.74 0.41<br />
Distance ≤ 25 kms 8(17) 38(83) 46<br />
4 Presentation > 21d 4(21) 15(79) 19 1.51 0.44- 5.19 0.29<br />
Presentation ≤21d 12(12) 86(88) 98<br />
5 Presence of risk factors 14(16) 73(84) 87 2.68 0.57 - 12.58 0.24<br />
No risk factors 2 (7) 28 (93) 30<br />
6 Prior consultation 4(13) 28(87) 32 0.87 0.26- 2.92 1.000<br />
No prior consultation 12(14) 73(86) 85<br />
7 No treatment with 8(11) 67(79) 75 0.51 0.18- 1.47 0.26<br />
antibiotic prior to<br />
presentation<br />
Prior treatment with 8(19) 34 (81) 42<br />
antibiotic<br />
8 Treated with steroids 4(13) 26(87) 30 0.96 0.2849 1.0000<br />
prior to presentation to 3.2449<br />
No treatment with 12(14) 75(86) 87<br />
steroids<br />
9 Presenting VA 12mm 15(38) 24(62) 39 48.75 6.12-388.40 0.0001<br />
Infiltrate size ≤12mm 1(1) 77(99) 78<br />
11 Posterior stroma<br />
involvement 16(25) 49(75) 65 infinity 0.0001<br />
Anterior stromal<br />
involvement 0(0) 52(100) 52<br />
12 Presence of hypopyon 4 (10) 36(90) 40 0.6 0.18-2.0 0.57<br />
Absence of hypopyon 12(16) 65(84) 77<br />
13 Perforation/thinning 7 (58) 5(42) 12 14.93 3.93-56.78 0.0001<br />
No perforation/thinning 9(9) 96(91) 105<br />
14 Endophthalmitis 3 (100) 0 (0) 3 Infinity 0.002<br />
No endophthalmitis 13 (11) 101(89) 114<br />
16 Gram negative bacteria 7(50) 7(50) 14 10.11 2.89-35.35 0.0006<br />
Gram positive bacteria 9(9) 91(91) 100<br />
* Visual acuity could not be evaluated in 5 children<br />
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intensively, preferably have an antibiotic susceptibility test and be monitored<br />
at frequent intervals. If a facility exists they should be hospitalized. In any<br />
community based empirical treatment, patients should be referred to a higher<br />
center with adequate microbiology laboratory facilities, if the ulcer is more<br />
than 2 mm or those who do not respond to the initial treatment given with<br />
broad spectrum antibiotics at adequate dosages.<br />
REFERENCES<br />
1 Coster DJ, Badenoch PR. Host, microbial and pharmacological factors affecting<br />
outcome of suppurative keratitis. Br J Ophthalmol 1987; 71:96-101.<br />
2 Gudmundsson OG, Ornerod DL, Kenyon KR, et al. Factors influencing predilection<br />
and outcome in bacterial keratitis. <strong>Cornea</strong> 1989;8:115-21.<br />
3 Wong T, Ng TP, Fing K, Tan DT. Risk factors and clinical outcomes between fungal<br />
and bacterial keratitis: a comparative study. CLAO 1997;23:275-81.<br />
4 Kaye S, Tuft S, Neal T, et al. Bacterial susceptibility to topical antimicrobials and<br />
clinical outcome in bacterial keratitis. Invest Ophthalmol Vis Sci 2010; 51:362-8<br />
5 Gopinathan U, Sharma S, Garg P, Rao GN. Review of epidemiological features,<br />
microbiological diagnosis and treatment outcome of microbial keratitis: Experience<br />
of over a decade. Indian J Ophthalmology 2009;57:273-9.<br />
Dr. SAROJ GUPTA: MBBS (1987), MGM Medical College, Indore; MS<br />
(1990), M Y Hospital and Deviahilyavishav Vidlaya, Indore. Recipient of Best<br />
FP Award, Oculoplasty (2008) and Neurophthalmology (2010) in MPSOS<br />
Conference. Presently, Associated Prof. Ophthalmological People’s College<br />
of Medical Sciences and Research Centre, Bhanpur, Bhopal, MP.<br />
Contact: 09926550364; E-mail: sarojini94@yahoo.co.in<br />
A Very Unusual Case of Keratitis<br />
Dr. Saroj Gupta<br />
There are several reports in the literature, from different parts of the world<br />
describing the spectrum of microbial Keratitis. 1-4 The causative agents<br />
described in all these reports are bacteria, fungi and parasite. Among parasite,<br />
only Acanthamoeba has been isolated. We report an unusual case of Keratitis<br />
caused by flagellated protozoa.<br />
Case-report<br />
A 31- year- old male patient presented with complaints of redness, watering<br />
and pain in left eye while working in fields. Following injury, he washed his<br />
eye with dirty stagnant water.<br />
On examination, left eye showed an epithelial defect in centre of cornea<br />
measuring 3.0 mm X 2.5 mm with prominent ring infiltrate surrounding the<br />
defect. The infiltrate extended up to the anterior stroma.<br />
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<strong>Cornea</strong>l scraping was performed with Bard-Parker no. 15 blade. Examination<br />
in normal saline wet mount preparation demonstrated trophozoites. The<br />
trophozoites showed rapid movement suggestive of flagellated protozoan. The<br />
material was also seen in 10% KOH mount. There were no hyphae or other<br />
elements resembling fungal structures. The material was inoculated on nonnutrient<br />
agar overlaid with E. coli for free-living amoebas. No growth was<br />
observed till two weeks of incubation.<br />
Patient was put on topical neomycin, polymyxin B and bacitracin eye drops<br />
one hourly; clotrimazole 1% eye drops two hourly and atropine 1% eye drop<br />
twice a day.<br />
The corneal condition improved within one week of therapy. The<br />
frequency of administration of drops was gradually tapered. At four<br />
weeks follow-up the cornea was clear and without any evidence of sub<br />
epithelial opacification.<br />
DISCUSSION<br />
<strong>Cornea</strong> infection in this case probably resulted from direct contact with<br />
contaminated water. The rapid motility of trophozoites was suggestive of<br />
flagellated protozoan like Giardia or Chylomastix. The rapid motility and<br />
sterile culture excluded protozoa like Acanthamoeba or Naegleria. Typical<br />
motility of trophozoites on fresh examination is the key for diagnosis. 5 Saline<br />
preparation of corneal scraping should be done to exclude motile parasites.<br />
We took opinion from two experts by showing them video of trophozoites.<br />
Both agreed with diagnosis of a flagellated parasite especially Chylomastix.<br />
To best of our knowledge this is the first report in literature (Medline search)<br />
on keratitis by an unusual flagellated parasite.<br />
REFERENCES<br />
1. Usha Gopinathan, Savitri Sharma, Preshant Garg, Gullapalli N Rao. Review of<br />
epidemiological features, microbiological diagnosis and treatment outcome of<br />
microbial keratitis: Experience over a decade. Indian J Ophthalmol 2009;57:273-9.<br />
2. Hagan M, Wright E, Newman M, Dolin P, Johnson G. Causes of suppurative<br />
keratitis in Ghana. Br J Ophthalmol 1995;79:1024-8.<br />
3. Upadhyay MP, Kamachaya PC, Koirala S, Tuladhar N, Bryan LE, Smolin G at al.<br />
Epidemiological characterstics, predisposing factors, and etiologic diagnosis of<br />
corneal ulceration in Nepal. Am J Ophthalmol 1991;111:92-9.<br />
4. Liesegang TJ, Forster RK, Spectrum of microbial keratitis in south Florida. Am J<br />
Ophthalmol 1980;90:38-47.<br />
5. Yaowalark sulkthana. <strong>Free</strong> living amebic infection: Rare but fetal. Review. J. Trop.<br />
Med. Parasitol. 2006; June:27-36.<br />
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Effect of Pterygium on Contrast Sensitivity<br />
Dr. Archana Malik, Dr. Soniya Bhala, Dr. Anamika Garg, Dr. Sudesh K<br />
Arya, Dr. Sunandan Sood<br />
Pterygium is a triangular –shaped growth consisting of bulbar conjunctival<br />
epithelium and hypertrophied subconjunctival connective tissue,<br />
occurring medially and laterally in the palpebral fissure, and encroaching<br />
onto the cornea. Visual acuity may be reduced due to direct invasion of the<br />
visual axis or astigmatism induced by the pterygium. Standard visual acuity<br />
is a crude measurement of visual performance and does not adequately<br />
represent all aspects of visual function. Contrast sensitivity measures two<br />
variables, size and contrast, while visual acuity measures only size. Several<br />
reports have demonstrated that pterygia cause corneal distortion and induce<br />
a significant amount of astigmatism. 1-4 But the effect of pterygium on contrast<br />
sensitivity has not been widely studied. Hence, we performed this study in<br />
order to investigate the effect of pterygium on contrast sensitivity.<br />
MATERIALS AND METHODS<br />
This prospective, nonrandomized trial included 27 patients (36 eyes with<br />
pterygium and 18 eyes without pterygium) with primary pterygia. Complete<br />
ocular examination was done which included visual acuity, refraction,<br />
intraocular pressure, anterior and posterior segment examination. Patients<br />
included were less than 40 years of age. Patients excluded were those with<br />
any ocular pathology other than pterygium which could possibly affect visual<br />
acuity or contrast sensitivity like high myopia, corneal scar, cataract, diabetic<br />
or hypertensive retinopathy, uveitis, macular degeneration, history of past<br />
ocular surgery or trauma. All pterygia were located nasally.<br />
Pterygium was measured on the slit lamp both vertically at the limbus and<br />
horizontally on the cornea and the area was calculated by multiplying the two.<br />
It was categorized into three groups vertically (≤3, 3.1 to≤5, >5mm), two groups<br />
horizontally (0.5 to ≤2, >2mm) and into three groups depending on area (≤7, 7.1<br />
to ≤14, >14mm 2 ). Eyes that had no pterygium were taken as controls.<br />
Contrast sensitivity was measured monocularly with spectacle correction. It<br />
was measured using the CSV-1000E contrast sensitivity charts (Vector Vision)<br />
at 3, 6, 12, and 18 cycles per degrees (cpd) under both photopic (85 cd/m 2 )<br />
and mesopic conditions (5.0 cd/m 2 ). Contrast sensitivity curve was plotted and<br />
converted to log units for each frequency as per Vector Vision guidelines.<br />
Statistical analysis<br />
Data were expressed as means ± standard deviation. The statistical comparison<br />
of contrast sensitivity log units between the three groups was done using<br />
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ANOVA and post-hoc bonferroni tests. Data was analyzed with SPSS software<br />
(Version 11.0). Differences were considered statistically significant at P < 0.05.<br />
RESULTS<br />
27 patients (15 males and 12 females) were included in the study. 36 eyes had<br />
pterygium and 18 eyes served as controls. Mean age of the patients was 32.0±6.88.<br />
Number of patients as divided in groups based on vertical length were (Group<br />
1-7, Group 2-18, Group 3-11), horizontal width (GroupA-17, GroupB-19) and<br />
depending on area (GroupI-14, GroupII-15, GroupIII-7). Mean of pterygium<br />
vertically was 4.41±1.12 (Group 1-2.72±0.41, Group 2-4.18±0.50, and Group3-5.86±<br />
0.45), horizontally 2.09±0.68 (GroupA-1.49±0.31 , GroupB-2.62±0.42) and of area<br />
was 9.7±5.01(Group I-4.64±1.23, GroupII-10.98±1.93, GroupIII-17.21±2.20).<br />
The photopic and mesopic contrast sensitivity in the vertical, horizontal and<br />
area wise groups is shown in table 1. All the three parameters had a significant<br />
negative correlation with the contrast sensitivity.<br />
Table 1: Contrast sensitivity of groups as compared with controls<br />
Contrast Vertical length Horizontal width Area Control<br />
sensitivity Group1 Group2 Group3 GroupA GroupB GroupI GroupII GroupIII<br />
(pvalue) (pvalue) (pvalue) (pvalue) (pvalue) (pvalue) (pvalue) (pvalue)<br />
Photopic 3 1.52±0.20 1.45±0.25 1.25±0.19 1.52±0.26 1.30±0.18 1.57±0.24 1.32±0.18 1.24±0.16 1.69±0.16<br />
٭ (0.000) ٭ (0.000) (0.453) ٭ (0.00) (0.06) ٭ (0.00) ٭(0.019) (0.37)<br />
Photopic 6 1.80±0.20 1.67±0.28 1.48±0.34 1.77±0.23 1.52±0.31 1.83±0.21 1.52±0.28 1.53±0.35 1.90±0.18<br />
٭ (0.019) ٭(0.001) (0.87) ٭(0.00) (0.36) ٭(0.002) (0.10) (0.85)<br />
Photopic12 1.48±0.22 1.26±0.24 1.07±0.32 1.33±0.23 1.16±0.31 1.39±0.23 1.19±0.27 1.07±0.31 1.61±0.20<br />
٭ (0.000) ٭ (0.000) (0.11) ٭ (0.00) ٭ (0.012) ٭ (0.00) ٭ (0.001) (0.68)<br />
Photopic18 0.90±0.22 0.85±0.27 0.63±0.34 0.88±0.23 0.71±0.33 0.91±0.24 0.76±0.30 0.63±0.34 1.18±0.28<br />
٭ (0.001) ٭ (0.002) (0.10) ٭ (0.00) ٭ (0.017) ٭ (0.00) ٭ (0.016) (0.22)<br />
Mesopic3 1.35±0.14 1.36±0.22 1.15±0.25 1.36±0.19 1.23±0.25 1.39±0.19 1.26±0.22 1.16±0.28 1.59±0.21<br />
٭ (0.002) ٭ (0.002) (0.14) ٭ (0.00) ٭ (0.022) ٭ (0.00) ٭ (0.035) (0.14)<br />
Mesopic6 1.71±0.13 1.56±0.28 1.31±0.30 1.58±0.21 1.45±0.36 1.65±0.16 1.50±0.331.28±0.23 1.86±0.26<br />
٭ (0.000) ٭ (0.007) (0.23) ٭ (0.001) ٭ (0.028) ٭ (0.00) ٭ (0.024) (0.70)<br />
Mesopic12 1.35±0.20 1.18±0.37 0.96±0.39 1.19±0.28 1.11±0.43 1.26±0.25 1.13±0.39 0.94±0.45 1.61±0.20<br />
٭ (0.000) ٭ (0.002) ٭ (0.039) ٭ (0.00) ٭ (0.002) ٭ (0.00) ٭ (0.003) (0.33)<br />
Mesopic18 0.84±0.19 0.82±0.32 0.52±0.35 0.81±0.20 0.66±0.41 0.85±0.18 0.76±0.38 0.45±0.34 1.17±0.22<br />
٭ (0.000) ٭ (0.002) ٭ (0.033) ٭ (0.00) ٭ (0.005) ٭ (0.00) ٭ (0.01) (0.10)<br />
DISCUSSION<br />
Our study shows that the contrast sensitivity of patients in whom the vertical<br />
length of pterygium is ≤3mm is not significantly different from the controls.<br />
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But >3mm of vertical length of pterygium caused significant decrease in both<br />
photopic and mesopic contrast sensitivity at mostly all spatial frequencies.<br />
Patients in whom the horizontal extent of the pterygium exceeded 0.5mm<br />
showed a decrease in both photopic and mesopic contrast sensitivity at all<br />
spatial frequencies except in the lower spatial frequencies of 3 and 6 cpd under<br />
photopic conditions.<br />
When the area of the pterygium exceeded 7mm 2 , a significant decrease in both<br />
photopic and mesopic contrast sensitivity was seen at all spatial frequencies.<br />
Pterygium with less than 7mm 2 area had decreased contrast sensitivity only in<br />
higher mesopic spatial frequencies of 12 and 18cpd.<br />
A significant negative correlation was seen between contrast sensitivity and<br />
the vertical, horizontal dimensions and the area of the pterygium. Maximum<br />
correlation was seen with the vertical dimension followed by area and then<br />
the horizontal width.<br />
Only two articles have previously reported the association of pterygium and<br />
contrast sensitivity. One study done by Lin et al in 1989 showed that contrast<br />
sensitivity was lower at all spatial frequencies in the patients with pterygium. 5<br />
Another study showed that contrast sensitivity at medium to-high spatial<br />
frequencies of 6, 12, and 18 cpd significantly improved after pterygium<br />
excision, while contrast sensitivity at low spatial frequencies of 1.5 and 3 cpd<br />
did not change after surgery. 6<br />
Pterygium with vertical length >3mm, horizontal width ≥0.5mm and area<br />
>7 mm 2 caused a significant decrease in both photopic and mesopic contrast<br />
sensitivity at all spatial frequencies. This could be a useful indicator of the<br />
need for pterygium surgery.<br />
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REFERENCES<br />
1. Yagmur M, Özcan AA, Sari S, Ersöz TR. Visual acuity and corneal topographic<br />
changes related with pterygium surgery. J Refract Surg. 2005;21:166–70.<br />
2. Bahar I, Loya N, Weinberger D, Avisar R. Effect of pterygium surgery on corneal<br />
topography: a prospective study. <strong>Cornea</strong>. 2004;23:113–7.<br />
3. Maheshwari S. Pterygium-induced corneal refractive changes. IJO 2007;55:383-6.<br />
4. Cinal A, Yasar T, Demirol A, Topuz H. The effect of pterygium surgery on corneal<br />
topography. Ophthalmic Surg Lasers. 2001;32:35–40.<br />
5. Lin S, Reiter K, Dreher AW, Frucht-Pery J, Feldman ST. The effect of pterygia on<br />
contrast sensitivity and glare disability. Am J Ophthalmol. 1989;107:407-10.<br />
6. Joo Youn Oh,Won Ryang Wee. The effect of pterygium surgery on contrast<br />
sensitivity and corneal topographic changes. Clinical Ophthalmology 2010;4:315–9.
<strong>Cornea</strong> <strong>Free</strong> <strong>Papers</strong><br />
To Study The Effect of Sub-conjunctival Injection<br />
of Bevacizumab on <strong>Cornea</strong>l Neovascularisation<br />
Dr. Somnath Mukhopadhyay, Dr. Himadri Dutta, Dr. Jayanta Dutta,<br />
Dr. Swarnali Sen, Dr. Pradeep Kumar Panigrahi<br />
Neovascularization is a severe complication of ischemic retinal diseases<br />
such as diabetic retinopathy, branch and central retinal vein occlusion,<br />
and retinopathy of prematurity. However, in various inflammatory corneal<br />
diseases, corneal neovascularization may also occur, particularly in the<br />
chronic course of the disease. The consequences of corneal neovascularization<br />
may not only be a severe reduction of visual acuity but also a worse prognosis<br />
for corneal transplantation because of loss of the immunologic privilege of the<br />
avascular cornea.<br />
However, the pathogenesis of corneal angiogenesis has not yet been fully<br />
defined, and the identity and significance of different angiogenic growth factors<br />
are debatable. Several studies have shown that vascular endothelialgrowth<br />
factor (VEGF), which was identified about 1 decade ago, plays a major role in<br />
vasculogenesis and in pathologic neovascularization. This protein stimulates<br />
angiogenesis in a noninflammatory model of neovascularization in the<br />
mouse cornea and was recently identified as a functional endogenous corneal<br />
angiogenic factor required for inflammatory neovascularization in a rat model.<br />
Bevacizumab is a humanized monoclonal antibody to VEGF designed for<br />
intravenous administration and approved for the treatment of colorectal<br />
Bevacizumab is currently injected into the vitreous for the treatment of<br />
proliferative and nonproliferative diabetic retinopathy, agerelated macular<br />
degeneration, and neovascular glaucoma, with successful outcomes and rapid<br />
regression of the pathologic blood vessels.<br />
We report here on our experience with subconjunctival injections of<br />
bevacizumab for corneal neovascularization in human subjects.<br />
MATERIALS AND METHODS<br />
The study group consisted of 10 adults (4 men and 6 women) 32–89 years of<br />
age with vascularized cornea , secondary to post DALK interface opacity(n=5),<br />
contact lens users (n=3), and chemical burn (n=2).<br />
All had extensive superficial and deep vascularization of the cornea and<br />
had a failure of steroid drops trial (4 times daily) for the treatment of these<br />
pathologic vessels. The study was approved by the Institutional Research<br />
Ethics Committee and informed consent was obtained before the procedure.<br />
Eyes were anesthetized with topical proparacaine hydrochloride drops.<br />
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Subconjunctival injection of 2.5 mg/0.1 mL bevacizumab was performed at<br />
the limbus, adjacent to the pathologic blood vessel growth/sprouting into<br />
the cornea. The injection was performed at the slit lamp after application of<br />
a topical anesthetic drop and by using an eyelid speculum. Postoperatively,<br />
patients were treated with topical moxifloxacin eyedrops 4 times daily for 1<br />
week. As per our protocol, all eyes had at least 2 bevacizumab injections.<br />
All eyes were biomicroscopically examined preoperatively,on postoperative<br />
day 7 and at 1,2 and 3 months. At each visit, 2 digital corneal photographs were<br />
taken with a digital camera attached to the slit-lamp microscope.<br />
The photographs were graded for extent, centricity, and density of corneal<br />
vascularization as follows. Extent was defined according to the number<br />
of clock hours affected by neovascularization (score 1–12). Centricity was<br />
defined as the distance the new vessels extended from the limbus toward<br />
the visual axis: 1 = vessel extended a maximum of 2 mm from limbus, 2 =<br />
extended 2–4 mm from limbus, and 3 = vessels extended to involve visual<br />
axis/central 3 mm of cornea. Density was graded 1–4 according to the density<br />
of neovascularization: 1 = very low (1 vessel), 2 = low, 3 = moderate, 4 = high<br />
(compared with standard photographs).<br />
RESULTS<br />
The mean duration of follow-up was 3 months. The average number of<br />
subconjunctival bevacizumab injections per eye was 2. Preoperative visual<br />
acuity ranged from 20/30 to hand movements. There were no intraoperative<br />
complications. No side effects were reported by the patients, nor was pain<br />
or discomfort induced by the drug injection reported throughout follow-up.<br />
Visual acuity did not change significantly in any patient in this study. Seven<br />
patients (70%) showed partial regression of vessels, whereas 3 patients did not<br />
react to the injection. During 3 months of follow-up, 6 (60%) patients had at<br />
least a 1–clock hour decrease in the extent of blood vessels, and 4 (40%) had at<br />
least a 2–clock hour decrease in the extent of vessels: Seven (70%) patients had<br />
a decrease of 1 level in density but none showed any decrease in centricity of<br />
blood vessels in the cornea.<br />
DISCUSSION<br />
Different substances have been identified in the past as potential vessel<br />
inhibitors, including steroids, nonsteroid anti-inflammatory drugs, heparin,<br />
cyclosporin A, methotrexate, and thalidomide. Although steroids have been<br />
the mainstay of therapy for corneal neovascularization and corneal graft<br />
rejection in clinical practice, they are not always effective, and chronic use<br />
may cause prominent side effects. VEGF’s role in the pathophysiology of<br />
corneal neovascularization has been shown in experimental models of corneal<br />
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neovascularization, in experimental herpes simplex keratitis, and in studies<br />
from human corneal buttons.<br />
Also, VEGF inhibition has been shown to reduce corneal neovascularization<br />
and improve corneal graft survival inexperimental animals.<br />
In our study, we assessed the change in the area of pathologic vessels within<br />
the cornea, whereas our grading system evaluated which of the 3 components<br />
(extent, centricity, and density) responded most to the bevacizumab injection.<br />
Indeed, a significant change in extent and density was shown, whereas<br />
centricity of vessels did not react to the subconjunctival injection. Possibly, the<br />
perilimbal application of the drug did not reach the more central part of the<br />
vessel in the deep cornea. It is possible that these central vessels would respond<br />
to a stromal injection rather than a perilimbal subconjunctival injection.<br />
In conclusion, subconjunctival bevacizumab injection is efficacious in limiting<br />
corneal neovascularization in human subjects. Whether this partial regression<br />
of blood vessels is of clinical value needs to be studied in a randomized clinical<br />
trial with a larger sample size and longer follow-up. Bevacizumab may also be<br />
used in the future, as an adjunct to other drugs, for the treatment of corneal<br />
neovascularization.<br />
Neonatal Infectious Keratitis Five Years<br />
Experience at a Tertiary Eye Care Center<br />
Dr. Jatin Ashar, Dr. Muralidyhar R, Dr. Shivani Pahuja, Dr. Sunita<br />
Chaurasia, Dr. Virender Sangwan<br />
Neonatal keratitis is a serious, vision- threatening disease. Infections in this<br />
age group are difficult to diagnose, manage and are uniquely at a grave<br />
risk for secondary amblyopia. Several large studies on microbial keratitis have<br />
been reported in children 1,2 however, literature on neonatal infectious keratitis<br />
is limited.<br />
To study the epidemiology, predisposing factors, clinico-microbial profile and<br />
outcomes of neonatal microbial keratitis.<br />
Study design: Retrospective, non consecutive, interventional case series.<br />
MATERIALS AND METHODS<br />
Medical records of 34 neonates (42 eyes) were analyzed for the age at<br />
presentation, predisposing factors, systemic illness, clinical presentation,<br />
microbiological profile, clinical course and outcomes. Examination was<br />
performed using operating/ portable slit lamp microscope with /without<br />
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anesthesia. <strong>Cornea</strong>l scrapings were sent for microscopic examination using<br />
Gram stain, 10% KOH wet mount, Giemsa stain and cultured on blood agar,<br />
chocolate agar, Non Nutrient agar, and Potato Dextrose agar. IFA and PCR<br />
for HSV were obtained on suspicion of HSV. Microorganisms were identified<br />
on smears or culture and intensive antimicrobial therapy initiated based on<br />
smear results and later modified according to culture, antibiotic sensitivity<br />
pattern and clinical response.<br />
Potential risk No of patients % Microbiological profile<br />
factors<br />
1. Route of Vaginal 27/34 79.41% Pseudomonas-5/27,<br />
delivery<br />
Staphylococcus spp-3/7,<br />
GPC-2/7,Gonococcus-1/7,<br />
HSV-3/7,Fungus-2/7,<br />
No Organism-8/7<br />
Caesarean 7/34 20.5% Pseudomonas-4/7,<br />
Staph. epidermidis-1/7,<br />
GPC-2/7<br />
2. Prematurity 1/34 2.94% No organism isolated<br />
3. Maternal Urinary tract 2/34 5.88% Pseudomonas-1/2, HSV-1/2<br />
infections infection,<br />
vaginal discharge<br />
4. Prolonged 9/34 26.47% Pseudomonas- 4/9 (44.4%)<br />
NICU care<br />
Staphylococcus hemolyticus-<br />
1/9 (11.1%)<br />
Fungus-1/9(11.1%)<br />
HSV-1/9 (11.1%)<br />
No organism detected<br />
-2/9(22.2%)<br />
5. Associated Jaundice 4/34 11.7% Pseudomonas-2/4,<br />
Systemic<br />
No organism-2/7<br />
condition<br />
Seizures 1/34 2.94% Pseudomonas<br />
Skin rashes/ 2/34 5.88% Pseudomonas-1/2, HSV-1/2<br />
vesicles<br />
Sepsis 1/34 2.94% Pseudomonas<br />
Goldenhar’s<br />
syndrome 1/34 2.94% No organism<br />
6. Associated Lid coloboma 2/34 5.88% Staphylococcus-2<br />
ocular with lagophthalabnormality<br />
mos (OU)<br />
Limbal dermoid 1/34 2.94% No organism<br />
with lagophthalmos<br />
(OS)<br />
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RESULTS<br />
Average age at the time of presentation was 16.91 +7.74 days.•<br />
Eight patients had bilateral involvement at presentation.<br />
Symptoms at presentation:<br />
Watering- 5 patients, Discharge- 11 patients, yellowish white spot- 31 patients<br />
Risk factors and potential associations of infection identified were: Prematurity,<br />
route of delivery, • maternal infections, systemic associations and ocular<br />
malformations.<br />
Microbiological Results:<br />
Microbiology +:30/42 eyes<br />
Smears and/or Culture positive: 31/42 eyes<br />
Smears+/Culture- : 18/42 eyes<br />
Smears-/Culture+:18/42 eyes<br />
Smear and Culture +:9/42 eyes<br />
Microbiology: 12/42 eyes<br />
Microbiological profile.<br />
Organism isolated in neonates with prolonged hospitalization: Total=16<br />
patients•<br />
Sensitivity pattern in hospital based infections:<br />
Gram positive (4) - All Sensitive to first line drug, Cefazoline<br />
Gram negative (8) - 3/8 Sensitive to first line drug Ciprofloxacin,<br />
5/8 Resistant to multiple drugs, sensitive only to Imepenam<br />
Management:<br />
Medical: All<br />
Topical antibiotic treatment-<br />
Gram positive: Fortified<br />
cefazoline<br />
Gram Negative: Ciprofloxacin<br />
Fungus: Natamycin<br />
HSV: Acyclovir ointment<br />
Systemic antibiotic- 6 patients<br />
Surgical:<br />
Lid surgery-3 eyes<br />
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69th AIOC Proceedings, Ahmedabad 2011<br />
TA+ BCL- 3 eyes<br />
PK- 3 eyes<br />
Evisceration-1 eye<br />
Outcomes:<br />
Average duration of treatment-33.86<br />
(+ 2) days<br />
Resolved with scar-28 eyes<br />
Anterior staphyloma-2 eyes<br />
Failed graft-3 eyes<br />
India<br />
DISCUSSION<br />
Neonatal keratitis has diverse clinical presentation and underlying etiology.<br />
Any watering and discharge in this age group should arouse suspicion and<br />
thorough clinical evaluation for early diagnosis. Possible risk factors include<br />
prolonged hospitalization, underlying systemic and ocular diseases. Most<br />
infections (54.76%) in this period were of bacterial origin, with Pseudomonas<br />
being the commonest bacteria isolated. Early identification of risk factors,<br />
aggressive microbiology work-up and appropriate therapy is needed to<br />
decrease ocular morbidity related to infectious keratitis in neonates.<br />
REFERENCES<br />
1. Kunimoto DY, Sharma S, Reddy MK et al. Microbial keratitis in children.<br />
Ophthalmology 1998;105:252-7.<br />
2. Cruz OA, Sabir SM, Capo H, Alfonso EC. Microbial keratitis in childhood.<br />
Ophthalmology 1993;100:192-6.<br />
Efficacy and Safety of Topical Umbilical Cord<br />
Serum Therapy in Persistent <strong>Cornea</strong>l Epithelial<br />
Defects<br />
Dr. Charu Mithal, Dr. Anu Malik, Dr. Sandeep Mithal, Dr. Neha Mithal,<br />
Dr. Prateek Agarwal, Dr. Pallavi Agarwal<br />
The corneal epithelium shows a wound healing response in event of<br />
any external injury or insult. Tears have antimicrobial nourishing and<br />
mechanical and optical properties. They contain component such as growth<br />
factors, fibronectin, and vitamins to support proliferation, migration and<br />
differentiation of the corneal and the conjunctival epithelium. A lack of these<br />
epitheliotrophic factors leads to persistent epithelial defects.<br />
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Persistent epithelial defect (PED) is defined as a corneal epithelial defect of<br />
2mm or larger in its greatest dimension persisting for 2 weeks or more despite<br />
of conventional treatment with artificial tears or bandage contact lens usage.<br />
It can be caused by keratoconjunctivitis sicca, exposure keratitis, neurotrophic<br />
keratits, limbal stem cell failure, keratoplasty, chemical burns and corneal<br />
ulcers. It has been seen that deficiency of essential tears components such<br />
as epidermal growth factors (EGF), vitamin A,neurotrophic growth factors<br />
(NGF) such as substance P, acetylcholine may exacerbate the lesions. Umbilical<br />
cord serum which contains various growth factors, Vitamin A and fibronectin<br />
in high concentration is hypothesized as a potent option for the treatment of<br />
persistent epithelial defects resistant to other conventional therapy. This study<br />
is aimed to evaluate the efficacy and safety of umbilical cord serum in cases of<br />
persistent epithelial defects due to various causes.<br />
(1) To study the efficacy and safety of topical umbilical cord serum in persistent<br />
corneal epithelial defects. (2) To study the complications encountered (3) To<br />
study the rate of recurrence.<br />
MATERIALS AND METHODS<br />
Study Design<br />
Prospective, non comparative study, Study population: 20 eyes of 20 patients<br />
with persistent corneal epithelial defects were selected from routine OPD of a<br />
tertiary care centre. Patients were followed for a period of 6 months from the<br />
day of starting the topical umbilical cord serum eye drops.<br />
Inclusion Criteria<br />
Patients of any age group, preferably cooperative for digital photography, were<br />
included with PED of various etiopathogenesis e.g., Chemical burn, Diabetic<br />
neurotrophic ulcer, Bacterial ulcer. Herpetic neurotrophic ulcer, Keratoplasty<br />
(optical and therapeutic), Dry Eye.<br />
Exclusion Criteria<br />
Patients with the following conditions were excluded: Pregnant and lactating<br />
women, Immunological conditions like rheumatoid arthritis, active corneal<br />
ulcer, impending perforation, acute ocular infection, abnormality of eyelid<br />
and adenexa eg – trichiasis, blepharitis, ectropion, entropion. Processing Of<br />
Umbilical Cord serum: Umbilical cord blood was collected from mothers of<br />
uncomplicated caesarean deliveries after informed consent and screening for<br />
hepatitis B, C and HIV. No anticoagulants were used during the procedure.<br />
The blood was allowed to clot and was centrifuged at 1500 rpm for 5 min then<br />
diluted in normal saline to make 20% solution. The serum was stored at -4<br />
degrees C. This diluted umbilical cord serum was stored in 5 ml sterilized<br />
vials and was given to patients. Patients were to apply this serum in drop 6<br />
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times a day and were asked to store it in a cool place, preferably in a refrigerator<br />
or ice box.<br />
RESULTS<br />
(1) Details of Patient – Name, age and address of the patient were noted. His/<br />
her diagnosis (cause of persistent epithelial defect) and past treatment was<br />
also recorded. (2) Visual Acuity (both unaided and best corrected). (3) Proper<br />
slit lamp evaluation was carried out to exclude any adenexal abnormalities as<br />
the cause of PED, cornea was evaluated in full detail, emphasis was paid on<br />
the size and site of epithelial defect, the corneal thickness and vascularization.<br />
(4) Schirmers test–was carried out in each and every patient and was repeated<br />
at every follow up. (5) Fluorescein staining (6) Digital IOP – was assessed by<br />
the same examiner in every case. The patients were followed up on days 3, 7,<br />
14, 21, 24, 28 and so on for 6 months. The variables recorded at each follow up<br />
visit were the best corrected visual acuity, the maximum size of the epithelial<br />
defect along two perpendicular axes measured with a slit lamp, and also a<br />
photograph of the same, a record of the side effects if any, and the digital<br />
intraocular pressure.<br />
The effectiveness of the treatment was divided into three groups.<br />
1. Effective – Those defects that took less than 2 weeks to heal.<br />
2. Partially Effective – Those defects that took less than 4 weeks to heal.<br />
3. Ineffective – Those defects that took more than 6 weeks to heal or did not<br />
heal at all.<br />
Table 1: Effectivness of The Treatment<br />
Healing Pattern Number Percentage (%)<br />
Effective 12 60%<br />
Partially Effective 06 30%<br />
Ineffective 02 10%<br />
In our study we found that out of 20, 12 patients (60%) showed effective<br />
response to umbilical cord serum eye-drops and 6 patients (30%) showed<br />
partially effective response. However, in the later two cases i.e. (10%), healing<br />
was ineffective (took more than 6 weeks to heal).<br />
Table 2: Duration Taken By The Epithelial Defect To Heal<br />
Time (weeks)<br />
Number<br />
Less than 1 week 4<br />
1-2 8<br />
2-3 7<br />
3-4 3<br />
more than 4 weeks 2<br />
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Regarding the duration taken by epithelial defects to heal we see that 8 out<br />
of 20 patients had their epithelial defect healed in 2 weeks (40%), and 4 out<br />
of 20 healed within one week, thus a total of 12(60%) healed within 2 weeks<br />
suggesting the treatment to be effective. There have been no side effects noted<br />
during the entire period of our study suggesting the umbilical cord serum<br />
eye-drops to be safe for the use on ocular surface.<br />
Epithelial defect did not recur in patients who responded to umbilical cord<br />
serum eye-drops, after 6 months of follow up showing that epithelial wound<br />
healing was complete.<br />
DISCUSSION<br />
The cornea produces multiple growth factors such as epidermal growth<br />
factor (EGF) and fibroblast growth factor (FGF), neurotrophic growth factor<br />
which contribute to the maintenance of a healthy epithelial surface and its<br />
regeneration. Persistent epithelial defects is rare but has serious complications.<br />
It has been seen that deficiency of essential tears components such as epidermal<br />
growth factors (EGF), vitamin A, neurotrophic growth factors (NGF) such as<br />
substance P, acetylcholine may exacerbate the lesions.<br />
Umbilical cord serum owes its efficacy to the presence of factors such as EGF,<br />
vitamin A, acidic and basic FGF, fibronectin, nerve growth factor, substance P,<br />
antiproteases like α2 macroglobulin, and enhanced mucin expression due to<br />
the serum. 7 The mechanism of action of umbilical cord serum is likely to be<br />
the same as that of autologous serum, the difference being probably a higher<br />
concentration of the growth factors, which may in fact stimulate a faster<br />
growth of stem cells and hence lead to a faster re-epithelialisation.<br />
The results are comparable with the study of Yoon et al (2005) who performed<br />
the study on 14 patients with persistent epithelial defect of various etiologies<br />
and found umbilical cord serum to be effective in 6 patients (42.9%) and partially<br />
effective in 6 patients (42.9%). Umbilical serum treatment has several clinical<br />
advantages, firstly,by obtaining a large quantity of umbilical cord blood from<br />
mothers, the serum can be supplied to many patients. Second, umbilical cord<br />
serum eyedrops can be prepared in advance, thereby shortening the waiting<br />
period for the patients. Finally,even when taking the blood from the patients<br />
themselves is difficult due to poor general condition, umbilical cord serum<br />
remains a feasible option.<br />
Recently Vajpayee et al have reported that since umbilical cord serum contains<br />
a higher concentrations of EGF, Vitamin A, acidic and basic FGF, fibronectin,<br />
NGF, substance P, and antiproteases like alpha 2 macroglobulins, it may be<br />
more useful for the treatment of the ocular surface than autologous serum.<br />
They also reported that the recovery was faster using umbilical cord serum,<br />
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compared to autologous serum, for persistent corneal epithelial defect<br />
refractory to medical treatment.<br />
Although we have used 20% umbilical cord serum eyedrops in this study,<br />
there is no agreement on the best dilution concentration of serum for use in<br />
ocular surface diseases.<br />
Umbilical cord serum, a preparation that can be easily prepared , is an effective<br />
means of promoting epithelialisation and can be safely used .<br />
Sympathetic Ophthalmitis Following Optical<br />
Penetrating Keratoplasty In The Last 9 Years<br />
Dr. Rekha Gyanchand, Dr. Sheetal Hegde<br />
Sympathetic Ophthalmia is a rare bilateral diffuse autoimmune<br />
granulomatous uveitis occurring in patients who have sustained<br />
penetrating ocular insult either as a result of trauma or as a rare consequence<br />
of ocular surgery. The incidence is 0.2%-0.5% following trauma and less the<br />
0.1% following surgery. Ophthalmic procedures that have been reported to<br />
result in sympathetic ophthalmia include cataract surgery, glaucoma filtering<br />
surgery, scleral buckling, pars plana vitrectomy, laser cyclophotocoagulation 1<br />
and proton beam irradiation. However literature reports very few cases of<br />
sympathetic ophthalmia following penetrating keratoplasty. 2,3<br />
MATERIALS AND METHODS<br />
A retrospective study was done of 5 cases seen from 2001-2009 at the <strong>Cornea</strong><br />
Clinic in Bangalore West Lions Superspeciality Eye Hospital, Bangalore.<br />
All 5 patients had history of penetrating injury and underwent penetrating<br />
keratoplasty (3 cases for leucomatous corneal opacity with vascularization<br />
following primary repair while 2 cases for corneal decompensation following<br />
vitrectomy for IOFB removal).<br />
Bilateral ocular examination on follow-up consisted of visual acuity testing for<br />
distance and near, color vision, anterior segment examination with slit lamp<br />
biomicroscopy, fundus examination and IOP recording. During regular postoperative<br />
follow-up visit, these patients complained of gradual decrease in<br />
visual acuity in the normal eye.<br />
Further investigations done to rule out systemic association for ocular<br />
inflammation were normal. Retinal S antigen was positive in one case.<br />
The history of penetrating eye injury and subsequent surgery, with the finding<br />
of granulomatous inflammation in both eyes raised suspicion of sympathetic<br />
ophthalmitis as a possible diagnosis.<br />
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RESULTS<br />
All the patients were males between 14-33 years who had history of penetrating<br />
ocular injury and primary surgical treatment (3 cases had primary corneal<br />
tear repair while 2 cases underwent vitrectomy with IOFB removal.)<br />
Injury Primary Penetrating Sympathetic Injury to PK to<br />
history diagnosis Keratoplasty ophthalmia onset SO Time SO Time<br />
Interval Interval<br />
1994 Leucoma 2001 2009 16yrs 8Yrs<br />
1996 Leucoma 2005 2006 11yrs 1Yrs<br />
1996 Leucoma 2000 2001 7yrs 1yr<br />
2001 <strong>Cornea</strong>l decom- 2005 2007 7yrs 3yrs<br />
pensation<br />
(IOFB removal)<br />
2002 <strong>Cornea</strong>l decompensation<br />
(IOFB removal) 2006 2007 6yrs 1yr<br />
Clinical Findings<br />
Sympathizing Eye<br />
Anterior Segment<br />
Granulomatous uveitis-5 cases<br />
Koeppe nodule-1 case<br />
Posterior Segment<br />
Vitritis-5 cases<br />
Dalen Fuchs Nodule-1 case<br />
Exudative RD-1 case<br />
Exciting (Post-Pk)Eye<br />
Signs of diffuse endothelial<br />
rejection- 5 cases<br />
Glaucoma-4 cases<br />
There were no significant extra ocular findings in any of these patients.<br />
Following keratoplasty, the onset of sympathetic ophthalmitis varied between<br />
1-8 years and following primary injury the onset varied between 6-16 years.<br />
According to reports sympathetic ophthalmitis developed in 80% patients<br />
within 3 months of injury and in 90% within 1 year. 5 However isolated cases<br />
as early as 1 week or as late as 66 years after initial injury have been reported . 6<br />
Vision<br />
Sympathizing Eye Sympathizing Eye Exciting Eye<br />
On presentation After treatment Post PK, Graft rejection<br />
CF CF 6/60 HM+ve<br />
6/12 6/9p PL+ve, PR accurate<br />
6/12 6/9p PL+ve, PR accurate<br />
6/60 6/36 PL+ve, PR accurate<br />
CF 1m 6/36p 6/36<br />
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2 cases with early presentation had excellent recovery while 3 patients had<br />
moderate recovery due to retinal detachment, extensive RPE atrophy and<br />
glaucomatous cupping.<br />
Oral steroids were given in the dose of 1.5mg/kg body weight and the patients<br />
were continued on a maintenance dose for 1 year. 2 patients were started on<br />
Azathioprine 50mg/day while 1 patient was treated with Methotrexate.<br />
DISCUSSION<br />
Sympathic Ophthalmitis has been reported to occur mainly following trauma.<br />
However it has also been reported to occur following ocular surgery like cataract<br />
surgery, scleral buckling, parsplana vitrectomy 7 , laser photocoagulation Our<br />
study included patients with sympathetic ophthalmitis developing after<br />
penetrating keratoplasty. The indications for keratoplasty were leucomatous<br />
corneal opacity following primary corneal repair (3 patients) and endothelial<br />
decompensation following IOFB removal (2 patients). According to studies,<br />
penetrating keratoplasty for corneal decompensation following IOFB removal<br />
are at high risk for sympathetic ophthalmitis. 8<br />
Dalen Fuchs Spots<br />
The onset of symptoms usually occurs between 3 weeks to 6 months following<br />
surgery. In our study, the symptoms in sympathizing eye occurred between<br />
1-8 years after surgery. The typical presentation of sympathetic ophthalmitis<br />
is a bilateral panuveitis that occurs after ocular<br />
trauma or intraocular surgery. 9 In our study<br />
the sympathizing eye showed mild- moderate<br />
granulomatous anterior uveitis with vitritis<br />
and multifocal choroiditis. Dalen Fuchs spots<br />
with vitritis was present in 1 patient. This is<br />
usually seen in 36%-47% cases. 10<br />
In our study the exciting eye had 1-2 attacks<br />
of endothelial rejection 6-8 months after<br />
corneal grafting. It has been seen that corneal<br />
Figure 1: Dalen Fuchs Spots endothelial rejection does precipitate the<br />
sympathetic ophthalmitis as graft rejection<br />
and sympathetic ophthalmitis have a similar cell- mediated cytotoxic reaction<br />
towards antigens on uveal pigment epithelium. 11<br />
Earlier sympathetic ophthalmitis was considered to be a dreaded disease,<br />
however in our study as well as other recent studies, 1,7 it has been seen that if<br />
treated early and adequately, it has a good visual outcome. Our study stresses<br />
the need for surgeons to fully explain the risks involved to patients undergoing<br />
penetrating keratoplasty in cases with trauma, post vitrectomy or probably<br />
any ocular surgery compromising cornea and which may require penetrating<br />
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keratoplasty, and to be alert to the possibility of sympathetic ophthalmitis in<br />
the event that the patient develops visual complaints in the better eye.<br />
• Delayed onset of Sympathetic ophthalmitis can be suddenly precipitated<br />
by corneal transplantation in eyes with old history of penetrating injury.<br />
• It is important to examine the normal eyes especially in the follow-up visit<br />
in cases of corneal transplantation done for adherent leucoma following<br />
penetrating injury.<br />
REFERENCES<br />
1. Liddy L, Stuart J. Sympathetic Ophthalmia in Canada. Can J Ophthalmol 1972;7:157-9.<br />
2. Sixty years (1913-1978) of sympathetic ophthalmia. Review of 105 cases.<br />
Ophthalmology 1980;7:109-21.<br />
3. Bechrakis NE, Muller Stolzenburg, Helbig H, Foerster MH. Sympathetic<br />
Ophthalmitis following laser cyclocoagulation. Arch Ophthalmol 1994;112:80-4<br />
4. PK for the exciting eye in SO. <strong>Cornea</strong> 2008;27:1080-1.<br />
5. Lubin J, Albert D, Weinstein M. 65 years of SO. A clinicopathological review of 105<br />
cases (1913-1976). Ophthalmology 1980;87:109-21.<br />
6. ZahariaMA, Lamarche J, Laurin M. Sympathetic uveitis 66 years after injury. Can<br />
J Ophthalmol 1984;19:240-3.<br />
7. Pollack AL, McDonald HR et al. Sympathetic Ophthalmitis associated with pars<br />
plana vitrectomy without antecedent penetrating trauma. Retina 2001;21:146-54.<br />
8. BJO 2000 Dara J Kilmartin, retinal risk factor for SO<br />
9. Dada T, Kumar A, Sharma N. Sympathetic Ophthalmia associated with antecedent<br />
adherent leucoma- A rare association. Acta Ophthalmol Scand. 1998;76:380-1.<br />
10. 32 Cases of Sympathetic Ophthalmia. Arch Ophthal. 1995;13.<br />
11. Early stage of Human Sympathetic Ophthalmitis, Histologic and Immunopathologic<br />
findings. Muller HK et al. Arch Ophthalmol 1984;102:1353-7.<br />
Dr. SOMASHEILA I MURTHY: MBBS (1992), TN Medical College; MS<br />
(1996), LTM Medical College, Mumbai University; DOMS, FCPS, Mumbai;<br />
<strong>Cornea</strong> and Anterior Segment fellow (1998), LVPEI, Hyderabad; Uveitis<br />
and Ocular Pathology fellow (2000), Doheny Eye Institute, USA. Presently,<br />
Consultant, <strong>Cornea</strong> and Anterior Segment, Ocular Immunology and Uveitis<br />
Service, LVPEI, Hyderabad. E-mail: smurthy@lvpei.org<br />
Comparision of Endothelial Cell Count by<br />
Manual And Automated Methods in Normal<br />
<strong>Cornea</strong> and in Fuchs’ Endothelial Dystrophy<br />
Dr. Somasheila I Murthy, Dr. Debarun Dutta, Dr. Tamal Chakraborti,<br />
Dr. Pritam Kumar<br />
Endothelial cells are crucial to maintain corneal health and its count is<br />
important in any endothelial abnormality. 1,2,3 The Cell Count software<br />
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69th AIOC Proceedings, Ahmedabad 2011<br />
of NIDEK Confoscan 4 is regularly used to perform corneal endothelial cell<br />
analysis, either automatically or manually. The automatic cell analysis returns<br />
information about the cell density and morphology of a selected Region of<br />
Interest (ROI), while the manual cell analysis can only evaluate the cell density<br />
of a selected ROI. Confoscan results are said to provide 95% of probability to<br />
have a difference between the estimate and the real cell count value lower than<br />
10%. 4 Clinically, while performing cell count, it is important that Confoscan<br />
should provide accurate results even in abnormal endothelium.<br />
The purpose of the study is to evaluate the difference in endothelial cell<br />
count between automated and manual methods in healthy cornea and Fuchs’<br />
endothelial dystrophy.<br />
MATERIALS AND METHODS<br />
1. Study design: retrospective analysis.<br />
2. Data was analysed by single experienced observer.<br />
3. One hundred images from both healthy and Fuchs’ endothelial dystrophy<br />
were reviewed by single observer.<br />
4. Archived images of the endothelium from the NIDEK Confoscan 4<br />
were used to procure endothelial cell counts by automated and manual<br />
methods.<br />
5. The following parameters were required to select the image: Endothelial<br />
images were clear in all the slides and around 50 to 100 cells were taken<br />
in each in slide to count as per manufacture guideline.<br />
• After having selected the Region of Interest, the automatic cell count<br />
was processed by clicking the corresponding button<br />
• For manual count, at first respective cells were selected in the region of<br />
interest. Hence a custom polygonal area drawn along with the wall of<br />
the borderline cells to surround the group of cells. Density information<br />
given by the following formula: Density = cells in polygon / Polygon<br />
area [cells/mm 2 ]4<br />
• Cell count difference between two methods of >250 cells/mm 2 was<br />
considered clinically significant.<br />
RESULTS<br />
• 52 and 65 images were of right healthy and compromised endothelium<br />
eyes respectively.<br />
• Based on manual cell count, endothelial cell density of Fuchs’ dystrophy<br />
slides divided into two groups.<br />
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Table 1: Endothelial cell counts done by automated and manual<br />
methods in images from Fuchs’ dystrophy<br />
Number of Average Average Average Range of cells p value<br />
Images auto count manual count difference (difference)<br />
Cell count 49 2028.73 ± 329.53 1719.82±489.47 312.96±337.27 402 to 2 cells
69th AIOC Proceedings, Ahmedabad 2011<br />
in compromised endothelium as automated count overestimates the results,<br />
and can even give a value in normal range, thus misleading the clinician.<br />
REFERENCES<br />
2. Klais CM, Bühren J, Kohnen T. Comparison of endothelial cell count using confocal<br />
and contact specular microscopy. Ophthalmologica. 2003;217:99-103.<br />
3. Módis L Jr, Langenbucher A, Seitz B. <strong>Cornea</strong>l endothelial cell density and<br />
pachymetry measured by contact and noncontact specular microscopy. J Cataract<br />
Refract Surg. 2002;28:1763-9.<br />
4. Doughty MJ. Toward a quantitative analysis of corneal endothelial cell morphology:<br />
a review of techniques and their application. Optom Vis Sci. 1989;66:626-42.<br />
5. NAVIS for Confoscan 4 Operator’s Manual ©2005-2007.<br />
6. Imre L, Nagymihály A. Reliability and reproducibility of corneal endothelial<br />
image analysis by in vivo confocal microscopy. Graefes Arch Clin Exp Ophthalmol.<br />
2001;239:356-60.<br />
Streptococcus Pneumoniae Keratitis: Fortified<br />
Antibiotics or Fluoroquinolones?<br />
Dr. Sujata Das, Dr. Savitri Sharma, Dr. Vivek Warkad, Dr. Srikant K Sahu<br />
Fortified topical ocular antimicrobial (usually cephalosporin and<br />
aminoglycoside) is frequently administered to cover the maximum<br />
spectrum of bacteria in cases of severe bacterial keratitis. Treatment is modified<br />
according to the clinical response and sensitivity of the microorganism. 1-4<br />
Frequent dosing of multiple antibiotics may result in increased toxicity and<br />
damage to the ocular surface epithelium. 2,3<br />
For antimicrobial therapy to be effective in cases of microbial keratitis, it<br />
should reach the site of corneal infection in sufficient concentration to inhibit<br />
and preferably kill the causative microorganism while causing minimal<br />
or no toxicity to the host. Several factors modulate the interaction between<br />
drug, microorganisms, and the host. The purpose of this study was to test in<br />
vitro susceptibility of Streptococcus pneumoniae isolated from patients with<br />
microbial keratitis in order to determine the most suitable antibiotic for the<br />
treatment of keratitis caused by the organism.<br />
MATERIALS AND METHODS<br />
The medical and laboratory records of all culture-proven cases of S<br />
pneumoniae keratitis diagnosed at the L V Prasad Eye Institute, Bhubaneswar,<br />
India between November 2006 and December 2009 were reviewed<br />
retrospectively. All patients had undergone detailed clinical evaluation and<br />
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slit-lamp examination. <strong>Cornea</strong>l scrapings were obtained from all patients as a<br />
part of a standard protocol and subjected to direct microscopic examination<br />
(Gram and/or Giemsa, potassium hydroxide [10.0%] with calcoflour white)<br />
and inoculation into various culture media such as sheep blood agar (BA),<br />
chocolate agar (CA), Sabouraud dextrose agar (SDA), non-nutrient agar (NNA),<br />
and brain heart infusion (BHI) broth. SDA bottles were incubated at 26±1OC<br />
to enhance the growth of fungi, and the remaining plates were incubated at<br />
36±1OC. While CA plates were incubated with 5% carbon dioxide, BA and BHI<br />
broth were incubated aerobically, and NNA were incubated aerobically with<br />
an added live Escherichia coli suspension. All media were incubated for two<br />
weeks and were examined daily. A culture was considered significant and<br />
was reported if the smears demonstrated morphologically similar organisms<br />
and/or if the same organism grew in more than one medium and/or if there<br />
was growth on at least two streaks on blood agar. In vitro susceptibility of the<br />
isolates was tested by Kirby Bauer disc diffusion method and interpreted as<br />
per CLSI guidelines. Muller Hinton agar with blood and commercial antibiotic<br />
discs (cefazolin, chloramphenicol, vancomycin, ciprofloxacin, ofloxacin,<br />
moxofloxacin, gatifloxacin) from Himedia, Mumbai were used for the test.<br />
Zones of inhibition were noted in millimeter and interpreted as resistant,<br />
sensitive or intermediate as per the chart provided by the company.<br />
Intensive topical medication was started on the basis of the smear result. Topical<br />
medication was modified in some cases depending on the clinical response,<br />
culture report, and sensitivity of the isolated organism. The retrospective<br />
data included patient demography (age, gender, and occupation), disease<br />
history (onset, course, predisposing factors), clinical appearance, antibiotic<br />
susceptibility, treatment and outcome.<br />
RESULTS<br />
Among 990 corneal scrapings/corneal tissues from clinically diagnosed cases<br />
of microbial keratitis at our Institute between November 2006 and December<br />
2009, 61 (6.2%) corneal scrapings of sixty patients were culture positive for S<br />
pneumoniae. The mean age was 45.9±21.3 years (range: 6 months to 78 years,<br />
median: 50). The male to female ratio was 40:20. Most patients were in the age<br />
group 41-70 years (n=36, 60%).<br />
An ocular predisposing condition was identified in 51 eyes. Fourteen had<br />
undergone keratoplasty and 9 had chronic dacryocystitis. Twenty five eyes<br />
(40.9%) had a history of ocular trauma. Fourteen eyes had polymicrobial<br />
infection. Thirty one eyes required an adjunctive procedure. Five eyes<br />
underwent therapeutic keratoplasty, and 20 eyes underwent tissue adhesive<br />
and bandage contact lens application. The in vitro susceptibility of the isolates<br />
by disc diffusion method was 100% to cefazolin, 95.1% to chloramphenicol,<br />
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69th AIOC Proceedings, Ahmedabad 2011<br />
90.9% to vancomycin, 88.9% to gatifloxacin and 78.7% to ciprofloxacin. Six<br />
isolates were resistant to more than one antibiotic.<br />
DISCUSSION<br />
S pneumoniae is a common cause of bacterial keratitis. It accounts for around<br />
30-40% of all bacterial keratitis. 5-7 Chronic dacryocystitis is a well known<br />
risk factor for microbial keratitis due to S pneumoniae. 5,7 It is also reported<br />
as a common pathogen isolated from microbial keratitis after corneal<br />
transplantation. Although trauma is not known to be a common predisposing<br />
factor associated with microbial keratitis due to S pneumoniae, it is a major<br />
predisposing risk factor in our series.<br />
Resistance to penicillin, other beta-lactam and non-beta-lactam compounds<br />
have been reported with an increased frequency in recent years among<br />
clinical isolates of S pneumoniae. 8 These strains are effectively killed with<br />
new fluoroquinolones. 9 Nevertheless, fluroquinolone resistance among the<br />
pneumococcal clinical isolates have been primarily attributed to mutations<br />
in the quinolone resistance-determining regions of the gyrase A and<br />
topoisomerase IV gene. 10<br />
Although ciprofloxacin is effective in vitro against S pneumonae, it is felt that<br />
in vivo efficacy may be inadequate, leading to the choice of fortified cefazoline<br />
as the first line of therapy. In our study, in vitro susceptibility of the isolates<br />
was 100% to cefazolin, 95.1% to chloramphenicol, 90.9% to vancomycin, 88.9%<br />
to gatifloxacin and 78.7% to ciprofloxacin. Ramkrishnan et al have compared<br />
in vitro efficacy of fluroquinolones against S pneumoniae isolated from<br />
bacterial keratitis by E-test. 11 They have concluded that S pneumoniae are 100%<br />
sensitive to fluoroquinolones. They also concluded that fourth-generation<br />
fluroquinolone, moxifloxacin appeared to be more effective than gatifloxacin,<br />
levofloxacin, ofloxacin and ciprofloxacin.<br />
In our study, sensitivity to gatifloxacin was more than ciprofloxacin. Compared<br />
to earlier studies, 5,11 sensitivity to ciprofloxacin was less in our series. Though,<br />
there was zero resistance to cefazoline, preparation and storage of fortified<br />
solution has its own limitation. In contrast, fluroquinolone are cheap and<br />
readily available commercially. Therefore, till the antibiotic sensitivity results<br />
are not available, patients may be continued with fortified cefazoline and<br />
fluroquinolone eye drops. Fortified cefazoline may be discontinued according<br />
to the clinical response and sensitivity.<br />
REFERENCES<br />
1. Baum JL, Barza M, Weinstein L. Preferred routes of antibiotic administration in<br />
treatment of bacterial ulcers of the cornea. Int Ophthalmol Clin 1973;13:31-7.<br />
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2. Baum JL. Initial therapy of suspected microbial corneal ulcers. I. Broad antibiotic<br />
therapy based on prevalence of organisms. Surv Ophthalmol 1979;24:97-105.<br />
3. Jones DB. Initial therapy of suspected microbial corneal ulcers. II. Specific antibiotic<br />
therapy based on corneal smears. Surv Ophthalmol 1979;24:105-16.<br />
4. Hyndiuk RA, Cockington CD. Bacterial keratitis. In: Tabbara KF, Hyndiuk RA<br />
(eds.). Infections of the eye: diagnosis and management. Little Brown, Boston, 1996:<br />
323–47.<br />
5. Parmar P, Salman A, Kalavathy CM, Jesudasan CA, Thomas PA. Pneumococcal<br />
keratitis: a clinical profile. Clin Experiment Ophthalmol 2003;31:44-7.<br />
6. Srinivasan M, Gonzales CA, George C, Cevallos V, Mascarenhas JM, Asokan B,<br />
Wilkins J, Smolin G, Whitcher JP. Epidemiology and aetiological diagnosis of<br />
corneal ulceration in Madurai, south India. Br J Ophthalmol 1997;81:965-71.<br />
7. Aasuri MK, Reddy MK, Sharma S, Rao GN. Co-occurrence of pneumococcal<br />
keratitis and dacryocystitis. <strong>Cornea</strong> 1999;18:273-6.<br />
8. Thornsberry C, Ogilvie P, Kahn J, Mauriz Y. Surveillance of antimicrobial<br />
resistance in Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella<br />
catarrhalis in the United States in 1996-1997 respiratory season. Diagn Microbiol<br />
Infect Dis 1997;29:249-57.<br />
9. Zhanel GG, Walters M, Laing N, Hoban DJ. In vitro pharmacodynamic modelling<br />
simulating free serum concentrations of fluoroquinolones against multidrugresistant<br />
Streptococcus pneumoniae. J Antimicrob Chemother 2001;47:435-40.<br />
10. Tankovic J, Perichon B, Duval J, Courvalin P. Contribution of mutations in gyrA and<br />
parC genes to fluoroquinolone resistance of mutants of Streptococcus pneumoniae<br />
obtained in vivo and in vitro. Antimicrob Agents Chemother 1996;40:2505-10.<br />
11. Ramakrishnan R, Ramesh S, Bharathi MJ, Amuthan M, Viswanathan S.<br />
Comparative in-vitro efficacy of fluoroquinolones against Streptococcus<br />
pneumoniae recovered from bacterial keratitis as determined by E-test.<br />
Indian J Pathol Microbiol 2010;53:276-80.<br />
Fibrin Glue (FG) Augmented Amniotic<br />
Membrane Transplantation (FGAMT) in<br />
Peripheral <strong>Cornea</strong>l Perforations<br />
Dr. Ritu Arora, Dr. Jasneet Kang, Dr. J L Goyal, Dr. Monika Mittal,<br />
Dr. Parul Jain<br />
To evaluate the efficacy of fibrin glue (FG) augmented amniotic membrane<br />
transplantation (AMT) in non infective peripheral corneal perforations.<br />
<strong>Cornea</strong>l perforations can result from a variety of ocular disease states<br />
associated with chronic inflammatory conditions. Regardless of the cause,<br />
perforation is an emergency and prompt treatment is required.<br />
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Many surgical approaches, such as tissue adhesive, bandage contact lens,<br />
transpositional conjunctival flap, and therapeutic penetrating keratoplasty<br />
(PK), have been used to treat corneal perforations. However, these surgical<br />
modalities are associated with a large number of problems eg. tissue<br />
inflammation from glue toxicity, diminished vision, and poor cosmesis with<br />
a conjunctival flap and tarsorrhaphy and graft failure in the setting of an<br />
inflamed or infected eye. 1<br />
Lee and Tseng were the first to propose the use of human amniotic membrane<br />
(AM) for the treatment of corneal epithelial defects. 2 For deep and severe<br />
ulcerations, Kruse et al suggested multi layer AMT and showed rapid epithelial<br />
healing and stromal thickening after multilayer AMT. 3 Solomon et al reported<br />
a favorable clinical outcome in 34 eyes that underwent multi layer AMT for<br />
nontraumatic corneal perforations, descemetoceles, and deep ulcers. 4 The use<br />
of FG for attaching the AM graft has been reported by Pfister and Sommers<br />
in different ocular surface disorders. 5 There have been clinical reports<br />
addressing AM grafts with FG sealant in the treatment of corneal perforations.<br />
Duchesne et al combined the use of amniotic membrane transplantation with<br />
human fibrin glue to repair corneal perforation and found it to be successful<br />
in corneal perforations upto 2 mm in diameter associated with significant loss<br />
of stroma. 6<br />
However in large corneal perforations (upto 4mm diameter) the application of<br />
FG alone as a plug cannot seal the defect completely or stabilize the anterior<br />
chamber. Also, this technique cannot be used in severe clinical circumstances,<br />
such as iris incarceration or collapsed anterior chamber.<br />
To offset these limitations of AM graft with fibrin plug in eyes with large<br />
corneal perforations, FG-assisted augmented AMT may be beneficial. Kim et<br />
al reported it to be a successful procedure in large perforations. 7<br />
The aim of the present study was to assess the efficacy of FG-assisted augmented<br />
AMT in treating large corneal perforations (2 mm or more in diameter) and to<br />
evaluate the long-term stability of the corneal surface.<br />
MATERIALS AND METHODS<br />
10 patients with peripheral corneal perforations upto 4 mm in diameter were<br />
treated with ‘‘FG assisted augmented AMT.’’ The perforated edges of the<br />
ulcer was cleaned and partially necrotic tissue was removed. The augmented<br />
AM was designed 0.5 mm larger than the diameter of the perforation. Five<br />
or 7 designed pieces of AM were prepared. A drop of fibrinogen- thrombin<br />
solution (Tissel glue) was applied to the first AM piece. The second AM was<br />
then transferred onto the first AM. A blunt spatula was used to spread out the<br />
FG between the AM pieces. The procedure was repeated and several pieces<br />
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of AM were pasted to make a thick single piece of multilayered AM called an<br />
‘‘augmented AM.’’ The last pasted AM was positioned with the epithelial side<br />
up to serve as a basement membrane for reepithelialization. This was then<br />
transplanted to the perforated site using 10-0 nylon. The anterior chamber<br />
was reformed with balanced salt solution. If needed, a temporary AM patch<br />
was placed was placed over the entire wound and cornea after securing the<br />
perforated wound with 10-0 nylon placed around the limbus. All corneal<br />
wounds were covered with bandage contact lenses over the AM and topical<br />
antibiotics were used for 3 weeks.<br />
A slit-lamp examination was performed daily to assess graft integrity and<br />
check for signs of inflammation, infection, changes in the ocular surface, and<br />
ulcerated underlying stroma. After complete reepithelialization, follow up<br />
was monthly to assess graft integrity and monitor for any complications.<br />
Surgical success was defined as a negative Seidel test, an adequate anterior<br />
chamber depth, and complete epithelialization through the end of the followup<br />
period.<br />
RESULTS<br />
The FG-assisted augmented AMT was performed in 10 patients (6 women, 4<br />
men) with a mean age of 51.5 +/- 15.3 years (range, 21–70 years). The average<br />
follow-up was 4.5 +/- 1.2 months (range, 3–6 months). Mean ulcer diameter<br />
was 2.87 +/- 0.95 mm (range 2–4 mm). BCVA was 20/120 or more in all patients<br />
at 6 months. All had well formed anterior chambers and 90% showed complete<br />
epithelialization. Mean reepithelialization time was 15.76+/- 3.95 days. In all<br />
patients the anterior chamber was deep, and there was no further leakage<br />
of aqueous fluid; the site of the ulcer showed a subepithelial scar with, in<br />
some cases, a thickening of the stroma, and epithelialization was complete.<br />
Conjunctival inflammation and pain were reduced in all patients. In none of<br />
the patients was there any evidence of recurrent ulceration or perforation and<br />
the stromal thickness at the perforation site seemed normal and stable during<br />
the follow-up period ( as seen on Anterior segment OCT).<br />
DISCUSSION<br />
Fibrin glue in combination with AMT seems helpful in the treatment of<br />
corneal perforations up to 4 mm in diameter. AM contains a mix of growth<br />
factors, neurotrophins, and cytokines that facilitates proliferation of epithelial<br />
cells and reduce the inflammatory response by inhibiting protease activity<br />
and thus reduce vascularization, inflammation, and scarring. These unique<br />
properties of AM make it useful in the treatment of ulcerative corneal disease. 8<br />
The AM does not express the antigens HLA-A, B, or DR and therefore poses no<br />
problem of immunological rejection. AMT may allow postponement of corneal<br />
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grafting until the eye is less inflamed, thereby improving graft survival or even<br />
avoiding it altogether. The presence of the glue enhances scar tissue formation<br />
as it prevents epithelial downgrowth and stimulates fibroblastic activity while<br />
serving as a matrix for fibroblasts and keratocytes. 9<br />
Our study demonstrates the effectiveness of the FG-AMT in the treatment of<br />
refractory large peripheral corneal ulcers. There was a reduction in the level<br />
of conjunctival inflammation and pain after AMT. All patients epithelialized<br />
successfully and had a stable scar over time.<br />
This procedure has several advantages in the treatment of corneal perforations,<br />
especially those of large size. The thickness of each augmented AM is equal<br />
to that of healthy cornea allowing it to completely seal the large perforated<br />
wound and prevent any leakage, hence maintaining a stable anterior chamber.<br />
Additionally, it can be easily manipulated because it was a single piece of AM<br />
instead of several sheets which further allows for a secure wound and also<br />
reduces the surgical time. Also there is early reepithelialization of the corneal<br />
surface as compared with a previous multilayer AMT report. This shows<br />
that FG-assisted augmented AMT is more effective than multilayer AMT in<br />
promoting healing of the epithelial layer in large corneal perforations. 10<br />
In conclusion, FG-assisted augmented AMT is a stable alternative for treating<br />
large corneal perforations—especially those 2 mm or larger in size—with rapid<br />
regeneration of epithelium and stability during the follow up period. This<br />
technique promotes a stable and rapid reconstruction of the ocular surface<br />
and can also be used as a temporary measure in cases requiring penetrating<br />
keratoplasty at a later time when the eye is less inflamed and the corneal<br />
surface has reepithelialized.<br />
REFERENCES<br />
1. Nobe JR, Moura BT, Robin JB, et al. Results of penetrating keratoplasty for the<br />
treatment of corneal perforations. Arch Ophthalmol. 1990;108: 939–941.<br />
2. Lee S, Tseng SCG. Amniotic membrane transplantation for persistent epithelial<br />
defects with ulceration. Am J Ophthalmol. 1997;123:303–12.<br />
3. Kruse F, Rohrschneider K, Volcker H. Multilayer amniotic membrane<br />
transplantation for reconstruction of deep corneal ulcers. Ophthalmology.<br />
1999;106:1504–11.<br />
4. Solomon A, Meller D, Prabhasawat P, et al. Amniotic membrane grafts for non<br />
traumatic corneal perforations, descemetoceles and deep ulcers. Ophthalmology.<br />
2002;109:694–703.<br />
5. Pfister RR, Sommers CI. Fibrin sealant in corneal stem cell transplantation. <strong>Cornea</strong>.<br />
2005;24:593–8.<br />
6. Duchesne B, Tahi H, Galand A, Use of human fibrin glue and amniotic membrane<br />
transplant in corneal perforation. <strong>Cornea</strong>. 2001;20:230–2.<br />
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7. Kim HK, Park HS. Fibrin Glue–Assisted Augmented Amniotic Membrane<br />
Transplantation for the Treatment of Large Noninfectious <strong>Cornea</strong>l Perforations.<br />
<strong>Cornea</strong> 2009;28:170–6.<br />
8. Hao Y, Ma DH-K, Hwang DG, et al. Identification of antiangiogenic and antiinflammatory<br />
proteins in human amniotic membrane. <strong>Cornea</strong>. 2000;19:348–52.<br />
9. Hick S, Demers PE, Brunette I, et al. Amniotic transplantation and fibrin glue in<br />
the management of corneal ulcers and perforations. A review of 33 cases. <strong>Cornea</strong>.<br />
2005;24:369–77.<br />
10. Rodriguez-Ares T, Tourino R, Lopez-Valladares J, et al. Multilayer amniotic<br />
membrane transplantation in the treatment of corneal perforations. <strong>Cornea</strong>.<br />
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Hannibal (247-183 BC):<br />
was a commander of Carthage, defeated the Roman<br />
during the 2nd Punic War in 218 BC. During this<br />
war, he developed corneal ulcer in right eye and<br />
permanently lost his sight.<br />
Jean Paul Sartre (1905-80):<br />
a French author, philosopher, He was awarded the<br />
Nobel Prize for literature in 1964 but he declined it.<br />
At the age of 4 he suffered from corneal ulcer and<br />
developed a right leucoma which led to exotropia.<br />
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