inflamation session - All India Ophthalmological Society

296 AIOC 2009 PROCEEDINGSphenomenon of response of microbes to theselective pressure of an antimicrobial drug. Insystemic infections the emergence of multidrugresistant strains of Gram-negative bacteria(Pseudomonas, Klebsiella, Enterobacter,Acinetobacter, Salmonella species) and Grampositiveorganisms (Staphylococcus,Enterococcus, Streptococcus species) isworrisome in the present therapeutic scenario. Inendophthalmitis, previous studies haveemphasized the changing trends in the antibioticsusceptibility of the causative organisms.Previous studies have shown that Vancomycinretains in vitro efficacy against more than 99% ofgram-positive bacteria and that Ceftazidime iseffective against 100% of gram-negative bacteriatested. The Indian scenario for antibioticsusceptibility of bacteria causingendophthalmitis is different. In postoperativeendophthalmitis while the Gram-positive isolatesare still 100% susceptible to Vancomycin, amongthe Gram-negative isolates 87.5% are susceptibleto Ciprofloxacin, 82.1% to Amikacin and only60.9% are susceptible to Ceftazidime.Withregards to posttraumatic endophthalmitis, it hasbeen shown that in south India only 66.7% of theGram-negative isolates are susceptible toCeftazidime. A high prevalence of resistance ofthe culture isolates to Vancomycin and Amikacinhas also been noted in other studies from SouthIndia.The present study deals with multidrugresistance in bacteria causing endophthalmitis inSouthern India.To determine the prevalence, type of bacteria andthe visual outcome of culture-provenendophthalmitis caused by multidrug resistant(MDR) bacteria in patients seen at a tertiary eyecare centre in southern India.Materials and MethodsA retrospective review of the clinical andmicrobiological records of culture provenconsecutive patients, clinically diagnosed to havebacterial endophthalmitis between January 2000and December 2007, was done. All patients hadbeen treated according to standard guidelinesand their vitreous aspirates were subjected tomicrobiological work-up that included culturefor bacteria and antimicrobial susceptibilitytesting by Kirby-Bauer disc diffusion assay.Resistance to two or more different groups ofantibiotics was defined as MDR. The bestcorrected visual acuity of < 20/200 at the finalfollow-up was defined as a poor visual outcome.ResultsVitreous from 45 (5.5%) of 807 patients yieldedMDR bacteria in culture. Thirty two (72%) ofthese patients had a poor visual outcome. MDRwas more common in gram-negative bacteria (36;78%) compared to gram-positive (9; 22%).Pseudomonas spp. (25 isolates) was thecommonest isolated bacteria. Fifteen (41 %) of the36 gram-negative isolates were resistant toCeftazidime, 18 (50%) to Amikacin and 11 (31%)of these 36 isolates were resistant to bothAmikacin and Ceftazidime.DiscussionMultidrug resistance is not seen frequently inbacteria causing endophthalmitis. Pseudomonasspp. is the commonest multidrug resistantorganism encountered. The visual outcome in amajority of the cases is poor. Alternative newergroup of drugs may be considered for themanagement of these isolated cases.Incidence of Cystoid Macular Oedema Following Manual SICSusing OCTDr. Dimpy Gothwal, Dr. Triveni Grover, Dr. Amit Grover, Dr. Parul Agarwal,Dr. Harjeet Kaur Sidhu, Dr. Ravindra Nath Bhatnagar(Presenting Author: Dr. Dimpy Gothwal)Ocular tissues, like those of other organs,exhibit well-defined morphologic reactionsto local trauma and insult in the form ofhyperemia, vasodilatation, increasedpermeability of blood vessels, and edema. CMEfollowing cataract surgery is one suchmanifestation and is an important sightthreatening late complication of cataract surgery

INFLAMMATION SESSION297that is often missed on regular clinical follow up.This complication has been recognized for over50 years and its incidence varies widely between1-2% using modern cataract extractiontechniques.OCT, an evolving ocular imaging technology israpidly finding a place in the diagnosis of CME.OCT is more sensitive than a clinical examinationin assessing macular edema and is a quantitativetool for documenting changes in macularthickness.1. To detect the incidence of CME followingmanual SICS using Stratus OCT 3.2. To quantify the macular edema followingmanual SICS using Stratus OCT 3.Materials and MethodsStudy was conducted on 100 eyes of 100 patientsof senile cataract undergoing manual SICS in ourhospital between April 2007 and March 2008.Inclusion Criteria: Patients of senile cataractundergoing manual SICS.Exclusion Criteria1. Hazy ocular media that may preclude goodclinical examination, Optical CoherenceTomography (OCT) imaging, and slit lampbiomicroscopy like Corneal opacity,Iridocyclits, Vitreous hemorrhage etc.2. Pre-existing macular pathologies like Macularhole, Macular scar, Macular edema etc.3. Any ocular inflammation.4. Any previous laser treatment of retina.5. IOP > 21 mm of Hg.Detailed history and ocular examinationincluding BCVA, IOP, slit lamp examination ofanterior segment and fundus examination using+78D lens and indirect ophthalmoscopy wasdone pre-op in each subject and a baseline OCTfast macular scan was performed to note themacular thickness in the foveal region, superior,inferior, nasal and temporal quadrants in innerand outer zones. Manual SICS was performed inthe patients with frown incision andimplantation of IOL by the same surgeon. Allpatients were given routine post-op treatmentwith oral analgesics, antibiotics and steroids for 5days and topical anti-inflamatory agents,antibiotics and steroids for 6 wks. Then repeatfast macular OCT scans were performed post opon day 1, 4 wks, 8 wks and 12 wks and the resultsstatistically analyzed.ResultsDemographic Characteristics of StudyPopulationTotal Patients 100Males 44Females 56R/E 62L/E 38Age group55yrs and abovePre-op BCVA 6/60 and worse in all patients.Pre-op mean IOP 14.6mm Hg.Table showing incidence of Macular OedemaPost-op using OCTIncidence of CME at day 1 5%Incidence of CME at 4wks 30%Incidence of CME at 8wks 32%Incidence of CME at 12wks 14%Summary1. Macular thickness was comparable pre-opand at day1 post-op.2. It increased in all patients at 4 wks and 8 wksQuadrants Baseline Pre-Op Day 1 4wks 8wks 12wksFovea 179.15±19.84 181.25±21.05 202.75±25.54 206.2±27.23 183.65±24.15Temporal inner macula 222.25±30.37 223.55±30.72 245.3±30.70 246.8±31.04 225.55±32.10Temporal outer macula 207.4±19.52 208.9±19.51 229.15±20.18 230.7±20.24 210.9±20.91Superior inner macula 252.9±25.38 254.2±25.66 275.4±26.72 277.6±27.21 256.15±26.87Superior outer macula 226.8±18.03 228.35±18.16 244.3±24.32 246.55±24.65 230.15±19.74Nasal inner macula 258.25±24.31 260.2±24.35 282.3±27.30 283.6±27.17 261.9±24.76Nasal outer macula 242.85±19.68 244.2±19.76 266.5±19.65 268.05±19.65 246.1±20.67Inferior inner macula 254.8±21.96 256.6±21.90 278.85±22.96 280.3±23.24 258.6±23.24Inferior outer macula 218.1±18.50 219.3±18.81 238.5±19.29 239.6±19.19 220.6±19.29

298 AIOC 2009 PROCEEDINGSand returned to near pre-op values in mostpts by12 wks.3. It significantly increased compared to pre-opin 5 patients on day1, 30 patients at 4wks, 32patients at 8 wks and 14 patients at 12 wks.4. Significant increase in macular thickness onOCT even at 12 wks was found in 14 out ofthe 100 patients, 8 out of which had clinicallysignificant CME with visual acuity

INFLAMMATION SESSION299approved by the review board of our institution.All patients were informed of the aims of clinicaltrial and a written consent was taken.Refractory to conventional treatment was definedas no response to anti-histamines, topical steroidsand mast cell stabilizers for 1 month.The eligibility for the study was based on clinicaldiagnosis of vernal keratoconjunctivitis i.e.presence of itching, ropy discharge, photophobia,papillae on upper tarsal conjunctiva and limbalchanges.After enrolment the previous ocular topicalmedications were discontinued during a twoweekrun in period. A complete ophthalmicexamination including visual acuity, intraocularpressure measurement and slit lamp biomicroscopywere performed. Symptoms ofitching, watering, burning sensation, photophobiaand ropy discharge were graded according tothe symptom score scale (grade I to III)Clinical signs of conjunctival hyperemia, limbalchanges, palpebral hypertrophy, cobblestonelesions and corneal involvement were gradedaccording to the sign score scale (grade I to III)Patients were randomly divided into threegroups according to concentration of tacrolimusgiven. Group I was given 0.03 % ointment twicedaily, group II was given 0.05% ointment twicedaily and group III was given 0.1% twice dailyfor 3 months.If ocular status improved the frequency ofointment instillation was reduced to once dailyafter 45 days and every other day after 60 days.The assesment was done by the sameophthalmologist (JGC) initially at 1 week andevery 15 days thereafter. Patients were followedup for a period of minimum 3 months. Adverseeffects occurring in the patients, and whetherrequiring discontinuation, were recorded. SGOT,SGPT, Blood urea and serum creatinine weredone at baseline and end of three months.Table-1Group Sex ratio Age Age Type Type TypeMale: femaleMean Range Bulbar Palpebral MixedAll groups 3.6:1 18.4 6-48 yrs 8 7 45I I {0.03%} 5.6:1 18.4 6-48 yrs 2 3 15II {0.05%} 4:1 18.5 7-35 yrs 4 2 14III {0.1%} 2.3:1 15.65 7-26 yrs 2 2 16ResultsThe study group included 60 consecutivepatients of which 47 were male (table 1).By 15days there was significant improvement in all thethree groups and there was no differencebetween the groups statistically. At the end of 7days a trend towards faster improvement wasseen in group II / III which was not statisticallysignificant between the groups. There was nochange observed in the keratinisation of thepalpebral conjunctiva and pigmentation of thefornical conjunctiva.At the start of the study the drug was given twicedaily and effect noted on signs and symptoms.After improvement (Grade 0) in signs andsymptoms the frequency was reduced to oncedaily and thereafter to every alternate day. Ingroup I therapy was reduced to once daily after45 days and every alternate day after 60 days. Ingroup II and III therapy was reduced to oncedaily after 30 days and every alternate day at 60days.The side effects seen in our study were transientburning sensation on instillation present in 21.67% cases, heaviness or swelling of upper lid seenin 11.67 % cases and itching on upper lid in 8.33% cases. Side effects seen were temporary anddid not require discontinuation of drug.There was no significant difference in the pretreatmentand the post-treatment values of, bloodurea nitrogen, serum creatinine, SGOT andSGPT.DiscussionIn our study we observed the effects of threeconcentrations of tacrolimus i.e. 0.03 %, 0.05 %and 0.1%. Based on the outcome of this study, weconclude that all the three concentrations areeffective as therapy for recalcitrant vernalkeratoconjunctivitis. However a faster responseis seen with higher concentrations that is 0.05 %

300 AIOC 2009 PROCEEDINGSand 0.1%. In group I therapy was reduced to oncedaily after 45 days and every alternate day after60 days. In group II and III therapy was reducedto once daily after 30 days and every alternateday at 45 days.By analyzing the results of different groupsstudied we have come to the conclusion that foran initial quick suppression of inflammation inpatients with severe refractory disease, the higherconcentrations (0.1 % and 0.05 %) can be used,switching over to the lower concentration (0.03%) once the disease process is stabilized. Inpatients with mild to moderate disease, as seen1. Abu El-Asrar AM, Tabbara KF, Geboes K, et al. Animmunohistochemical study of topical cyclosporinein vernal keratoconjunctivitis. Am J Ophthalmol1996;121:156-61, Clin Exp Allergy 2000;30:103-9.2. Abu El-Asrar AM, Geboes K, Al-Kharashi S, et al.Adhesion molecules in vernal keratoconjunctivitis.Br J Ophthalmol 1997;81:1099-1106.3. E Maggi, P Biswas, G Del Prete, P Parronchi, DMacchia, C Simonelli, L Emmi, M De Carli, A Tiriand M Ricci Accumulation of Th-2-like helper Tcells in the conjunctiva of patients with vernalconjunctivitis. J. Immunol 1991;146:1169-74.4. Leonardi A, DeFranchis G, Zancanaro F, CrivellariG, De Paoli M, Plebani M, Secchi AG. Identificationof Local Th2 and Th0 Lymphocytes in VernalConjunctivitis by Cytokine Flow Cytometry: InvestOphthalmol Vis Sci. 1999;40:3036-40.5. Ahmed M Abu El-Asrar, Sofie Struyf,Abdulrahman A Al-Mosallam, Luc Missotten, JoVan Damme, Karel Geboes Expression ofchemokine receptors in vernal keratoconjunctivitisBr. J Ophthalmol 2001;85:1357-61.Toxic anterior segment syndrome (TASS) is anacute inflammation of anterior chamber orsegment of eye following cataract surgery. Thereare various substances causing TASS. It includestopical antiseptic and anesthetic agents, talc,topical ophthalmic ointments, preservatives,intraocular preparations, endotoxins oninstruments and denatured ophthalmicReferencesin the winter months, the lower concentration i.e.0.03 % can be given as the initial therapy.No side effects, severe enough to warranty thediscontinuation of the drug were seen in anygroup. Side effects associated with long termsteroid use i.e. cataract and glaucoma were alsonot seen with tacrolimus in our study.So we can conclude that tacrolimus is an effectiveand safe drug and it can be used effectively in notonly refractive vernal keratoconjunctivitispatients but also as a first line of therapy as nountoward side effects are observed even afterlong term use.6. Peters DH, Fitton A, Plosker GL, Faulds D.Tacrolimus: a review of its pharmacology andtherapeutic potential in hepatic and renaltransplantation. Drugs. 1993;46:746-94.7. Kino T, Hatanaka H, Mitaya S, et al. FK506, a novelimmunosuppresant isolated from Streptomyces. II.Immunosuppressive effect of FK506 in vitro. JAntibiot (Tokyo). 1987;40:1256-65.8. Freeman AK, Serle J, VanVeldhuisen P, Lind L,Clarke J, Singer G, Lebwohl M. Tacrolimusointment in the treatment of eyelid dermatitis. Cutis2004;73:267-71.9. Reinhard T, Reis A, Mayweg S, Oberhuber H,Mathis G, Sundmacher R [Topical Fk506 ininflammatory corneal and conjunctival diseases. Apilot study.] Klin Monatsbl Augenheilkd. 2002;219:125-31.10. Nivenius E, van der Ploeg I, Jung K, ChryssanthouE, van Hage M, Montan PG.Tacrolimus ointment vssteroid ointment for eyelid dermatitis in patientswith atopic keratoconjunctivitis. Eye 2006 May 5.Visual Outcome and Management Strategies of Toxic AnteriorSegment Syndrome (TASS)Dr. Prince Eapen, Dr. Selva K Sundaramoorthy, Dr. R. J. Madhusudan,Dr. Virupaksha Samy(Presenting Author: Dr. Prince Eapen)viscosurgical devices (OVD). This was initiallyreferred to as sterile postoperativeendophthalmitis, which is a misnomer as itmainly confines to anterior segment. In 1992Monson et al termed it as Toxic anterior segmentsyndrome (TASS). Some of the TASS cases withlocalized corneal endothelial damage weretermed as toxic endothelial cell destruction

INFLAMMATION SESSION301syndrome (TECDS).TASS most commonly occur acutely followinganterior segment surgery of any kind, but it canhave a delayed onset. Inflammation is sterile.Gram stain and culture will always be negative.Signs and symptoms are similar to infectiousendophthalmitis. Common complaints areblurred vision, ocular pain and redness.Materials and MethodsThis was a retrospective study of 5 eyes of 5patients who developed toxic anterior segmentsyndrome following cataract surgery. All thepatients were evaluated for visual outcome andtreatment strategies. All patients underwent clearcorneal phacoemulsification with foldable IOLimplantation under topical anesthesia.Phacoemulsification was done through a 2.8mmclear corneal incision. 5.5mm rhexis was made.After phacoemulsification, 4 out of 5 patientsreceived hydrophilic IOL and one patient hadhydrophobic IOL from AMO. All surgeries weredone by same surgeon on same day. There wereno intraoperative complications. Out of 6 patientswho underwent surgery on the day 5 patientsdeveloped symptoms of TASS.3 patients presented to us within 24 hours and allby 72 hours of surgery (after requesting them tocome for a review). All the patients wereevaluated by checking the visual acuity, IOP bynon contact tonometer, slit lamp examination,fundus evaluation if view was adequate and USGB scan if required were done. AC tap was done in2 patients.All the patients were treated with topical–prednisolone acetate 1% hourly, homatropine2% 3times /day, subconjuctival antibiotics andsteroids. All patients were also given topicalantibiotics. 3 patients were given oral steroidsand 2 patients were given intravitreal antibiotics,vancomycin and amikacin.ResultsMean age was 57.6± 8.2 (SD). 3 patients weremales and 2 females.3 patients left eye and 2patients right eye were affected. Pre operativelyBCVA in all patients were better than 6/36. 3patients (60%) presented within 24 hours ofsurgery. Other 2(40%) patients came within 48 -72 hours after requesting them for a review. 60%of patients had symptoms of pain, redness anddefective vision. 40% (2 patients) had nocomplaints but on examination they also hadonly hand movement vision with anteriorsegment inflammation. 80% of patients hadeither hand movements (HM) or counting fingerclose to face (CFCF)vision at presentation. Onepatient had 6/60 vision at presentation. Slit lampexamination showed 4 + cells in all patients withhypopyon. All except one patient had fibrinreaction. Fundus was not visible in 80 % (4) ofcases. USG B scan was done in 4 patients. 2patients had clear vitreous and 2 had few anteriorvitreous opacities. AC tap was done in 2 cases. Itwas negative for gram staining and KOH.Culture was also negative.At 1 week all patients had vision better than6/24. 3 patients were 6/24, 1 patient had 6/18and 1 patient had 6/12 by 1 week. At one month2 patients had BCVA of 6/6, 2 had 6/9 and onepatient had 6/12. Pain, redness and hypopyonwere completely resolved by 1 week.DiscussionThe typical hall mark of TASS is an inflammatoryprocess that starts within 24 hours of cataractsurgery. It is usually limited to the anteriorsegment. It is always culture and gram stainnegative and improves with steroid treatment.Inflammation is quite severe. Anothercharacteristic finding is diffuse limbus to limbuscorneal edema. This is due to widespreadendothelial cell damage. TASS also can cause irisand trabecular damage. It will result in pupilwhich dilates and constrict poorly. There isdecreased IOP during early postoperative course.Permanent trabecular damage can causesecondary glaucoma later.It is difficult to differentiate TASS from infectiousendophthalmitis. There are a few differentiatingsigns and symptoms. TASS typically occurswithin 24 hours; where as infectiveendophthalmitis will take 4-7 days. TASS almostalways limited to anterior segment. It usuallyimproves with topical and systemic steroids andcommonly present with diffuse corneal edema.Pain is noted in 75% of infectiousendophthalmitis, along with lid edema,conjunctival chemosis, discharge and diffuseocular injection. Hypopyon and fibrin formationwill be seen in both. None is specific enough todiagnose TASS or rule out infectious etiology.

302 AIOC 2009 PROCEEDINGSThe main treatment for TASS centers onprevention. Once the infectious pathology isruled out mainstay of treatment is topicalsteroids. Careful slit lamp examination allowsurgeon to document resolution of inflammationand corneal edema. IOP also should be closelymonitored. Once cornea clears, gonioscopyshould be done to look for peripheral anteriorsynechiae which indicate chronic trabeculardamage.It is critically important that the entire surgicalteam (surgical nurses, operating roomtechnicians, residents, physicians andpharmacist) knows what is appropriate for use ineye. An outbreak of TASS in a surgical centre isan environmental and toxin control issue thatrequires complete analysis of all medications andfluids used for surgery.TASS is serious and potentially devastatingcomplication of cataract surgery. It is verydifficult to diagnose TASS at presentation. Wemay have to start treatment like in anendophthalmitis. Unlike endophthalmitisresponse to treatment is dramatic in TASS andvisual outcome is generally very good. All stepsbefore during and after the surgery should bereviewed. But it is very difficult to pin point acause for TASS. A strict surgical protocol is amust. Protocol should be reevaluatedperiodically and when a new incidence occurs.AUTHORS’S PROFILE:DR. MD. ATHER: M.B.B.S. (1982), Osmania Medical College, Osmania University, Hyderabad;M.S. (1991), Sarojini Devi Eye hospital, RIO, Hyderabad, AP University of Health sciences;Fellowship in Oculoplasty and orbital disorder (2007), Sarojini Devi eye Hospital, RIO,Hyderabad.Presently, Associate Prof. of Ophthalmology, Regional eye Hospital, Kurnool Medical College,Kurnool. AP.Incidence of Ocular Involvement in HIV Positive ClientsAttending Integrated Counseling and Testing CentreDr. Md. Ather, Dr. Mustafa Ahtesham, Mr. Siva Rama Krishna(Presenting Author: Dr. Md. Ather)25 million people have died of AIDS ever sincethe detection of HIV. It accounts for thehighest number of deaths by any single infectiousagent ever. Every 10 sec 1 patient dies of AIDS inthis world. 5 million patients turn HIV positiveevery year. 95% of these patients are fromdeveloping countries. India has 2.5 million HIVpositive patients, second highest in the world.Among these 21.2% ie. 5.26 lakhs are there inAndhra Pradesh. Guntur district and itsneighbouring district Prakasham on top in theincidence of AIDS in Andhra Pradesh.Factors responsible for rise in HIV/AIDS cases inAndhra Pradesh are:• Low literacy levels leading to low awareness.• Migration of labour to urban areas.• Gender disparities.• Prevalence of Sexually transmitted diseases.Aim and Objective of this study is to determineincidence of Ocular involvement in HIV positiveclients attending Integrated counseling andtesting centre.Materials and MethodsThis prospective study is carried out at Govt.Fever Hospital Guntur, AP, to which Integratedcounseling and testing centre is attached. Govt.Fever hospital is an allied hospital of GunturMedical college, AP where patients sufferingfrom infectious diseases are kept and there isdepartment of Tuberculosis and chest diseases inthe same hospital.Period of study is from April 2007 to February2008. The clients who attend integratedcounseling and testing centre comprise offollowing catogories:1. Cases referred from STD clinic ofGovt.hospital.2. Cases referred from the department of TBand chest diseases.

INFLAMMATION SESSION3033. Cases referred from infectious diseasehospital.4. Cases referred from the department ofObstetrics and Gynecology.5. Persons who voluntarily want to know HIVstatus.6. Female sex workers.7. Intravenous drug abusers8. Truck drivers and migrant population.9. Cases referred by NGO ( Ship, Rotary, Lions)10. Cases whose spouse tested to be HIVpositive.11 Children of HIV positive parents.12. Professionals ( Doctors, Nurses, Labtechnicians, Blood bank workers who reportafter accidental needle prick.)1466 clients who came for HIV testing to ICTCwere subjected to Tridot test. 595 (40.58%) whoturned out to be HIV positive were screened forocular involvement after taking informedconsent. They were tested for Visual acuity, Slitlamp examination, Direct and indirectOphthalmoscopy at the department ofOphthalmology of Guntur Medical college.ResultsOut of 595 HIV positive cases 119 (20%) werefound to be having Ocular involvement. Of 595HIV positive cases 352 (59.15%) were males and243 (40.84%) were females. Among those whowere having ocular involvement 71 (59%) weremales and 48 (41%) were females. Various ocularComparison of StudiesOcular lesion Awan et al Jabs et al Biswas et S.K mandal S.P.Sahoo OurKenya USA al India Et al studyMolluscum * * * * 1.5% 3.36%Herpes Zoster * * * * 4.54% 5.04%Orbital Lymphomas * * * * * 1.68%OSSN * * * * * 9.24%Dendritic ulcer * * * * * 1.68%Fungal ulcer * * * * * 0.84%Iridocyclitis * * * * 4.5% 52.94%Choroiditis * 3% * 0.57% * 2.52%CMV retinitis 3% 4.7% 17% 10.6% 11% 10.92%HIV retinopathy 25% 6.4% 15% 10.65% 12% 9.24%Optic atrophy 3% 5% 7% 3% 3% 0.84%lesions seen were as follows:Ocular lesions No. of cases %(119) of casesMolluscum Contagiosum 4 3.36%Herpes zoster ophthalmicus 6 5.04%Orbital Lymphomas 2 1.68%OSSN 11 9.24%Dendritic ulcer 2 1.68%Fungal keratitis 1 0.84%Iridocyclitis Ac/Ch 63 52.94%Choroiditis 3 2.52%CMV Retinitis 13 10.92%HIV retinopathy 11 9.24%Optic Atrophy 1 0.84%DiscussionThe incidence of iridocyclitis in our study is morewhen compared to other studies. The casesreferred to ICTC were more from department ofSTD and TB and chest diseases. As it is wellknown fact that iridocyclitis is commonly seen inpatient suffering from Syphilis and Tuberculosis.The clients attending ICTC were in majorityreferred by clinicians on suspicion of havingAIDS. And most of the positive cases were fromthat group. The categories from 5 to 11 wereeither referred by voluntary organizations or theclients themselves came for testing on creation ofawareness about AIDS by Govt. or NGOorganizations.

304 AIOC 2009 PROCEEDINGSAUTHORS’S PROFILE:DR. SAMIR MAHAPATRA: M.B.B.S (2003), SCB Medical College, Utkal University, Cuttack,Orissa; M.S. (Ophth) (2009), V.S.S. Medical College, Sambalpur University, Burla, Orissa.Presently, Final Year PG student, V.S.S. Medical College, Sambalpur University, Burla, Orissa.Contact: 9861192452; E-mail : yourssamir@yahoo.co.inEpidemiological and Microbiological Evaluation of MicrobialKeratitis in Western Orissa: A 2 Year Prospective Study in ATertiary Care CentreDr. Samir Mahapatra, Dr. Debendra Kumar Sahu, Dr. Gunasagar Das, Dr. DebendraNath Bhuyan, Dr. Sharmistha Behera, Dr. Sulin Kumar Behera, Dr. H. Maruthi(Presenting Author: Dr. Debendra Kumar Sahu)Microbial keratitis constitutes the mostcommon and serious ocular infection indeveloping countries having a varied geographicpattern and several predisposition. 1 It is theleading cause of corneal blindness in South Asia. 2All over the world bacterial keratitis is morecommon than fungal keratitis but this does nothold true for India and other tropical countries. 3Among several risk factors of corneal ulcer inour country, trauma to cornea accounts for 60-80% of cases. 4 Clinical diagnosis of infectiouskeratitis is crucial because even establishedlaboratories can grow upto 60-70% of ocularpathogens from the material sent for culture. 5 Theclinical diagnosis of microbial keratitis oftenrelies on a thorough history, especially history ofinfectious exposure, epidemiological trends andthe morphological features of cornealinflammation. Ophthalmologists use clinicalclues to recognize ocular surface infection. Somedistinctive signs, though not pathognomic,unique to the causative organism may help todifferentiate bacterial, fungal and amoebicpathogens of the cornea. 6 The etiological andepidemiological pattern of corneal ulcerationvaries significantly with patient population,health of the cornea, geographic region, climate,age and also tends to vary over time. 7The aim of this study was to evaluatedemographic and epidemiological features andthe prevalence of microbial isolates in cases ofmicrobial keratitis in Western Orissa.Materials and Methods1869 presumed cases of microbial keratitis withunilateral affection were subjected to meticuloushistory taking and thorough ocular examinationunder S/L. Samples were collected by scrapingthe ulcer area under topical anaesthesia usingstandard techniques 8 with a BP blade No.-15.Materials obtained was subjected to smearpreparation on glass slides for 10% KOH mountand Gram’s / Giemsa stain. Rest of the materialwas inoculated into SDA, blood agar, chocolateagar, non-nutrient agar, BHI broth andthioglycollate medium and then sent to Dept. ofMicrobiology for detailed evaluation. Onconfirmation of fungal filaments on 10% KOHmount, antifungal treatment with 5% Natamycinwas started to the respective cases. On negative10% KOH mount, empirical treatment withtopical broad spectrum antibiotic drops wasstarted till confirmatory growth pattern onculture was obtained (usually within 72 hrs)along with antibiotic susceptibility reports. Thespecific antibiotic was instituted and response totherapy was evaluated at the end of 3rd week.This prospective study included all patientsattending the OPD of Dept. of Ophthalmology,V.S.S. Medical College, Burla, Sambalpur fromApril 2006 to May 2008. Data pertaining todemography, epidemiology and clinicomicrobiologicalcharacteristics were analysed. Inthe entire study patient’s compliance andcomfort were assured.

INFLAMMATION SESSION305ResultsTable-1: Baseline characteristicsCriteria No of patients (%) TotalMaleFemaleSex ratio 958 (51.26%) 911(48.74%) 1869Age group (in years)0-10 0 0 011-20 29 (03.03%)) 21 (02.31%) 50 (2.68%)21 – 30 133 (13.88%) 129(14.16%) 262 (14.02%)31-40 491(51.25%) 442 (48.52%) 933 (49.92%)41 – 50 198(20.67%) 183(20.09%) 381(20.39%)> 50 107(11.17%) 136(14.93%) 243(13.02%)Geographic distributionRural 823 (57.19%) 616(42.81%) 1439(76.993%)Urban 226(52.56%) 204(47.45%) 430(23.007%)Table -2: Major predisposing factorsNo. of cases% of total casesTrauma 1271 68.004Foreign body 04 (0.21%)Coexisting ocular disorder 429 (22.95%)Coexisting systemic disease 156 (08.35%)Inadvertent use of topical steroids 09 (0.48%)Table-3: Nature of traumaNo. of cases % of trauma cases % of total casesVegetative matter 543 42.72% 29.05%Animal matter 211 16.06% 11.29%Sand / stone 209 16.44% 11.18%Dirt 221 17.39% 11.84%Miscellaneous 87 6.85% 4.65%Table-4: Response to treatment and complication as assessed after 3 weeks of therapyNo. of Cases Favourable Complicationresponse (%) No response (%) Perforation (%) Endophthalmitis (%)Fungal (843) 583(69.16) 33(3.91) 192(22.78) 35(4.15)Bacterial (587) 394(67.12) 42(7.16) 122(20.78) 29(4.94)Mixed (124) 72(58.06) 31(25) 12(9.67) 09(7.26)Acanthoembea (06) 05(83.33) 01(16.67) - -No growth (309) 141(45.63) 121(39.16) 32(10.36) 15(4.85)Total (1869) 1195 (63.94) 228 (12.19) 358 (19.15) 88 (4.71)DiscussionIn our study males (51.26%) were affected morethan females (48.74%) most commonly between31-50 years (70.31%), may be due to moreinvolvement of males in field activities mostly inrural areas (73.93%). Trauma with vegetativematter is the major predisposing factor andresults in maximum number of fungal keratitiscases (54.33% of total cases). Chronicdacryocystitis is the major ocular disorderleading to more number of bacterial ulcer(21.64% of total cases). DM results in 6.4% of totalfungal cases and is the major systemic associationof corneal ulcer (97 of 157 cases, 62.18%).

306 AIOC 2009 PROCEEDINGSTable-5: Microbial isolates (as per culture / smear reports)Fungus No. of cases(843) % of Isolate % of total cases (45.10%)Aspergillus Sp. 498 59.075 26.645Fusarium Sp. 249 29.537 13.323Candida Sp. 84 9.964 4.494Penicillium Sp. 12 1.424 0.642Bacteria Cases(587) % of Isolates % of total cases (31.41%)Staphylococcus Sp. 313 53.322 16.747Streptococcus Sp. 175 29.813 9.363Pseudomonas 59 10.051 3.157E. Coli 19 3.237 1.017Gr. +ve bacilli 21 3.578 1.124Mixed bacterial and fungi 124 - 6.635Acanth oemba 06 - 0.321No definite growth pattern 309 - 16.533Aspergillus is the most common fungal isolatefollowed by Fusarium (59.08% Vs 29.54%) andstaphylococcus. Sp. is more common in bacterialulcer (53.32% of bacterial isolates). Fungusisolated from 45.10% cases Vs 31.41% of bacterialisolates. This proportionate difference may bedue to cultural characteristics of fungus as wellas the role of humidity and temperature inmicrobial growth.Response to treatment was favourable in 63.94%of cases and only 19.15% of patients went toperforation indicating that an early intervention1. Whitcher JP, Srinivasan M, Updhyay MP. InEpidemiology of Eye Disease. Longon Arnold,2003;2:190-5.2. Who reports: 1988.3. Bharati MJ et al. Aetiological diagnosis of microbialkeratitis in South India. A study of 1618 cases. IndianJ. Med. Microbiology 2002;20:19-24.4. Bharathi MJ et al. Epidemiology of bacterial keratitisin a referral centre in India. Indian J. Med. Microbiol.2003;21:239-45.5. Bourcier T et al. Bacterial Keratitis, predisposingTuberculosis (TB) is a communicable diseaseand is a leading infectious cause of morbidityand mortality. 1 Ocular tuberculosis encompasesany infection by mycobacterium tuberculosis orone of the three related species (sp. bovis,Referencesmay retard the progression of corneal ulcer todreadful complications.An epidemiological study supported by standardmicrobiological services will definitely aid inearly detection and effective management ofcases of microbial keratitis. A step forward toincrease the awareness about ocular hygiene andocular diseases in rural population will haveencouraging results in the attempt to reduce themorbidity in such cases and the global burden ofblindness as a whole.factors, Clinical and microbiological review of 300cases. Br. J. Ophth. 2003;87: 805-6.6. Dahlgren MA et al. The clinical diagnosis ofmicrobial Keratitis. Am. J. Ophth. 2007; 143: 940-4.7. Burd EM et al. The corneal scientific foundationsand clinical practice. Boston Little Brown andCompany 1994;3:115-124.8. Bharathi MJ et al. Epidemiological characteristicsand laboratory diagnosis of fungal keratitis. A threeyear study. Indian Journal of Ophthalmology2003;51:315-21.Diversity of Clinical Presentation of Ocular TuberculosisDr. Neha Mithal, Dr. Sandeep Mithal, Dr. Charu Mithal, Dr. Sanjay Sharma,Dr. Alka Gupta, Dr. Priyanka Garg(Presenting Author: Dr. Neha Mithal)africanum and microti ) in, on or around the eye.India has 30% of the total number of infectedpeople in the World and TB is a leading cause ofdeath as an infectious killer in India (WHOreport, 1999). However, even in an endemic

INFLAMMATION SESSION307country like India, TB causing ocular and orbitaldisease has become increasingly rare. 2 Theincidence of ocular tuberculosis in a population isdifficult to estimate. The incidence of tubercularuveitis in India has varied from 2 to 30%. 3,4 Thislarge variation in incidence rate in differentreports possibly suggest the difference indiagnostic criteria.Ocular tuberculosis can be of two types –primary and secondary. The term primary oculartuberculosis has been used when tuberculouslesions are confined to eyes and no systemiclesions are clinically evident. The term has alsobeen used to describe the cases where the eye hasbeen the initial portal of entry. Secondary oculartuberculosis has been defined as ocular infectionresulting from contiguous spread from adjacentstructures or hematogenous spread from lungs.The various clinical presentations of oculartuberculosis are – Uveitis (Anterior andposterior), Episcleritis, Phlyctenular conjunctivitis,Eale’s disease, orbital tuberculosis etc.Definitive diagnosis of ocular tuberculosis can bemade only by demonstrating mycobacteriumtuberculosis in the ocular tissue. However,obtaining ocular tissue for diagnostic purposes isnot only difficult but also associated withsignificant ocular morbidity. Therefore, a highdegree of clinical suspicion is the key to earlydiagnosis.The clinical diagnosis of ocular tuberculosis maybe based on presence of atleast 3 of the following5 feature: (i) Suggestive clinical picture (ii)Exclusion of other aetiologies (iii) PositiveMantoux test (iv) Therapeutic response to antituberculartherapy and (v) Present or past historyof tuberculosis.The pathogenesis of ocular tuberculosis is basedon Rich’s Law which states that : Ocular lesion isdirectly proportional to Number and virulence oforganisms degree of hypersensitivity/Hostresistance.To focus on the diversity of clinical presentationof ocular tuberculosis and discuss the diagnosticapproach and an effective treatment.Materials and MethodsOur study enrolled 30 consecutive patientsduring a period of 1 year. All the cases fulfillingthe diagnostic criteria for ocular tuberculosiswere included in the study. All the casesunderwent detailed ophthalmic evaluationincluding a detailed history, visual assessment,slit lamp biomicroscopy, applanation tonometeryand Indirect ophthalmoscopy with scleralindentation.Systemic investigations included a completeblood count, erythrocyte sedimentation rate(ESR), Mantoux test, Chest X-Ray and detailedevaluation of immunosuppressive disorders forHIV by enzyme linked immunosorbent assay(ELISA). FFA was done wherever required.Diagnosed Pediatric patients of tubercularmeningitis already on ATT, referred to us forophthalmic examination – VEP was advised forchildren with non-reacting pupil and alteredsensorium .In our study, topical steroids, ATT and systemicsteroids wherever necessary gave good results.ResultsTuberculosis of eye were uniocular in 16 patientsand binocular in 14 patients. As per Table-3, thecondition was more in males than females. Themale:female ratio was found to be 1.3:1 . Table 1Table-1Clinical manifestation No.of PercentagePatients %B/L recurrent Chalazia 2 7%Phlyctenular Conjunctivitis 6 20%Episcleritis 5 17%Chr. Granulomatous uveitis 5 17%Choroiditis 4 13%Peripheral uveitis 1 2.5%Eale’s disease 2 7%Recurrent CSR 2 7%MR palsy 1 2.5%Toxic amblyopia sec to ATT 2 7%Table-230 100%Age in years No. of Patients Percentage%0-15 years 7 23%16 – 30 years 19 63%31 - 45 years 4 14%>45 years 30 100%Table-3: Sex incidenceSex No. of Patients Percentage %Male 17 57%Female 13 43%30 100%

308 AIOC 2009 PROCEEDINGSshows that in our study, Phlyctenularconjunctivitis was the commonest manifestation;it involved either the cornea or conjunctiva.However the commonest site of involvement wasthe limbal region. It usually appeared as a smallnodule surrounded by hyperemia. Most of thecases showed recurrent episodes of episcleritis.Patients with uveitis presented with eitherchoroid tubercles, chronic anteriorgranulomatous iridocyclitis, choroiditis orperipheral uveitis. Patients with Eale’s diseasepresented with painless, sudden visual loss inone eye due to vitreous hemorrhage. 2 cases hadh/o recurrent B/L chalazia. 2 cases were ofrecurrent CSR , 1 case presented with Medialrectus palsy. 2 children diagnosed as havingtubercular meningitis were already on ATT whenthey came for ophthalmic examination. Onexamination, they had toxic amblyopiasecondary to ATT, VEP was done for thesepatients and was noted as non-recordable.DiscussionThe diagnosis of ocular TB is frequentlypresumptive. Definitive diagnosis relies ondemonstration of tubercle bacilli in tissue but thisis fraught with the difficulty of obtaining oculartissue for biopsy in seeing eyes due to invasivenature of the procedure. 5 The other approach isto evaluate for systemic evidence of the diseasein a patient with suggestive ocular features, butthe absence of clinically evident systemic TB doesnot rule out ocular TB. In our study oculartuberculosis was suspected when 3 out of thefollowing five features were present. These are:1. Samson MC, Foster CS. Tuberculosis In : Foster CS,Vitale AT (eds). Diagnosis and Treatment of Uveitis.WB Saunders Company: Philadelphia 2002;264-72.2. American Thoracic Society : Diagnostic standardsand classification of tuberculosis of tuberculosis inadults and children: Am J. Rspir. Crit. Care Med 2000;161:1376-95.3. Sen DK. Tuberculosis of the orbit and lacrimalgland. J. Paed Ophthalmol 1980;17:232-8.4. Agarwal PK, Nath J, Jain BS. Orbital involvement intuberculosis. Indian J Ophthalmol 1977;25:12-6.5. Eye doi; 10.1038/sj.eye .6702093; Eye 2006;20:1068–73.References(i) Suggestive clinical picture (ii) Exclusion ofother aetiologies (iii) Positive Mantoux test (iv)Therapeutic response to anti-tubercular therapyand (v) Present or past history of tuberculosis. Inthe present study, the infection was seen mostcommonly in the age group 16-30 years and nonein the age group >45 years. This was unlike theprevious study by Holland published in Surveyof Ophthalmology in 1993 which showed that itcan occur in 1 to 75 years of age. Males wereinfected more than females(1.5:1) in this studywhich is in accordance with previous studies.Ocular TB presents a complex clinical problemdue to a wide spectrum of presentations anddifficulty in diagnosis. In most of the previousstudies done, Uveitis has been the most commonocular manifestation and can be present asanterior, posterior, or panuveitis. 1 In our studypatients with uveitis presented with chronicanterior granulomatous iridocyclitis , multifocalchoroiditis, choroidal tubercles and peripheraluveitis. The spectrum of ocular tuberculosis isstill evolving. Gupta et al (14) recently reported aseries of 7 cases with a serpiginous-likechoroiditis. All 7progressed inspite of steroidtreatment and subsequently responded to ATT. 5There is thus a wide spectrum of presentationsand thus a high index of suspicion is needed,especially in at-risk patients for timely diagnosisand treatment. Further, the dramatic response toATT in these cases justifies empirical treatmentbased on a high index of clinical suspicion andpositive tuberculin test.6. Rosen PH, Spalton DJ, Graham EM. Intraoculartuberculosis. Eye 1990;4:486-92.7. Inhihara M, Ohno S. [Ocular tuberculosis]. NipponRinsho 1998;56:3157-61.8. Biswas J, Madhavan HN, Gopal Badrinath SS.Intraocular tuberculosis. Clinicopathologic study offive cases. Retina 1995;15:461-8.9. Bodaghi B, LeHoang P. Ocular tuberculosis[review]. Curr Opin Ophthalmol 2000;11:443-8.10. Khosla PK, Garg SP : Role of tuberculosis inintraocular inflammation in India. In Shimigu K,Editors – Current aspects in ophthalmology place.1992;1981-2.Discussion comment by Dr Naresh Kumar Yadav : Number of cases very less. The title should havestated presumptive ocular tuberculosis, as no tests were done to isolate and identify the mycobacterium. Non invasivetests like Polymer chain reaction and quantiferon gold test could be done. Attributing Recurrent chalazion andreccurent CSR to tuberculosis is far fetched, at least specimen from chalaiion could have been sent for HP. Thereis no mention about the treatment and its duration given to the patients.

INFLAMMATION SESSION309Analysis of Risk Factors and Visual Outcome in Postoperative andPosttraumatic EndophthalmitisDr. Savita Ramkumar, Dr. Mohan Rajan, Dr. Sujatha Mohan, Dr. Bina John,Dr. Vijayalakshmi(Presenting Author: Dr. Mohan Rajan)The aim of the study was to identify the riskfactors and visual outcome in postoperativeand posttraumatic endophthalmitis. It was aretrospective interventional study, conducted atRajan eye care hospital in Chennai.29 consecutive patients of endophthalmitis wereincluded in the study of which 24 patients werepostoperative and 5 patients were posttraumaticendophthalmitis. The study period was duringJanuary 2004 – December 2007. The inclusioncriteria were all patients who underwent cataractsurgery between the age 20- 80 years and thosewho had ocular trauma. The exclusion criteriawere paediatric cataracts and patientsundergoing other procedures like intravitrealinjections, antiglaucoma surgeries, penetratingkeratoplasty, pterygium, vitrectomy, strabismussurgery and suture removal.Detailed preoperative evaluation includinghistory , visual acuity, slit lamp examination,fundus examination and B scan was done. Aminimal period of follow up was for one year.Out of 29 patients, 14 patients were male and 15were female between 20 – 80 years. 9 patients hadDiabetes. Patients who developedendophthalmitis within 14 days (21 eyes) wasdefined as acute onset and more than 6 weeks (8eyes) was chronic onset. Visual acuity at the timeof presentation for most of the patients was poorand 5 eyes were eviscerated.Among postoperative patients 9 underwentextracapsular cataract extraction, 3 underwentsmall incision cataract surgery and 12 underwentphaco emulsification with intraocular lens. Inposttraumatic patients, 2 had stick injury and oneeach had vegetable, needle and thorn injury.In the postoperative patients, 8 had posteriorcapsular tear and others were uneventful.Surgeries were done by trained as well aspostgraduate doctors of which the latter had aprolonged duration more than 45 minutes.Patients who underwent phacoemulsification,wound was sutured in 6 patients, 5 were notsutured and 1 was scleral incision.Culture positive among postoperative patientswas 75% and in posttraumatic patients was 100%.In culture positive postoperative patients (10eyes) 55% was Gram positive, (6 eyes) 33% wasGram negative and (2 eyes) 11% waspolymicrobial organisms.Secondary complication like retinal detachmentoccurred in 10 eyes (42%) in postoperativeendophthalmitis and 4 eyes (80%) in theposttraumatic endophthalmitis.Average number of interventions which includedvitrectomy and intravitreal injections ofantibiotics were 2 in the Gram positiveendophthalmitis and 3 each in Gram negativeand fungal endophthalmitis.The organisms isolated were susceptible to thecommonly used drugs like vancomycin andaminoglycosides.Visual outcome was categorized as improved,status quo and worse. 8 eyes improved (able toread 2 lines more than at the time ofpresentation), 7 eyes become worse (able to read2 lines less than at the time of presentation) in thesnellen’s chart and 14 eyes remained the same.Anatomical outcome was categorized as good,phthisis and status quo. 7 eyes became phthisicaland 10 eyes remained status quo.Statistical analysis of the study was done usingone sample t test. It was concluded that elderlypatients above 60 years (14 eyes) had badprognosis. Diabetic patients had poorer visualoutcome. Intraoperative complication likeposterior capsular tear with extracapsularextraction had poor prognosis. Prolongedsurgical time, those done by the trainee doctorslead to endophthalmitis. Sutureless clear cornealtemporal phacoemulsification lead toendophthalmitis. Further, culture positive Gramnegative organisms and fungal endophthalmitishad poor visual prognosis. Acute severepresentation had poor visual outcome whereaschronic late onset did reasonably well.Secondary complication like retinal detachment,posttraumatic endophthalmitis and patients withacute severe onset had poor anatomical andvisual outcome.