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CORNEA - I
A New Approach to Management of Corneal Ulcers by Debridement---------------- 471
Dr. Debasish Dutta, Dr. Arup Bhaumik, Dr. Ayan Mohanta, Dr. Prashant Kumar Singhal,
Dr. Sabitabrata Basu
Colored Cosmetic Contact Lenses: Cosmesis and Complication, Hand in Hand-475
Dr. Shwetambari Singh, Dr. Ravindra Vhankade, Dr. Dipali Satani, Dr. Amit Patel
Spectrum of Mycotic Keratitis: 5-Year Review of Patients at A Tertiary Eye Care
Center in Tamilnadu------------------------------------------------------------------------------------- 479
Dr. D Chandrasekhar, Dr. J Kaliamurthy, Dr. Pragya Parmar, Dr. C M Kalavathy, Dr. C A
Nelson Jesudasen, Dr. Philip Aloysius Thomas
Effect
of
Subconjunctival
Injection
of
Bevacizumab
on
Corneal
Neovascularization------------------------------------------------------------------------------------- 483
Prof. Dr. K Vasantha, Dr. Rajini Ponraj, Dr. Mohan K, Dr. Niraimozhi
Risk Factors in Management of Bacterial Keratitis------------------------------------------ 485
Dr. Samrat Chatterjee, Dr. Deepshikha Agrawal
A Very Unusual Case of Keratitis------------------------------------------------------------------ 488
Dr. Saroj Gupta
Effect of Pterygium on Contrast Sensitivity---------------------------------------------------- 490
Dr. Archana Malik, Dr. Soniya Bhala, Dr. Anamika Garg, Dr. Sudesh K Arya,
Dr. Sunandan Sood
To Study The Effect of Sub-conjunctival Injection of Bevacizumab on Corneal
Neovascularisation-------------------------------------------------------------------------------------- 493
Dr. Somnath Mukhopadhyay, Dr. Himadri Dutta, Dr. Jayanta Dutta, Dr. Swarnali Sen,
Dr. Pradeep Kumar Panigrahi
Neonatal Infectious Keratitis Five Years Experience at a Tertiary Eye Care Center--
------------------------------------------------------------------------------------------------------------------ 495
Dr. Jatin Ashar, Dr. Muralidyhar R, Dr. Shivani Pahuja, Dr. Sunita Chaurasia,
Dr. Virender Sangwan
Efficacy and Safety of Topical Umbilical Cord Serum Therapy in Persistent Corneal
Epithelial Defects----------------------------------------------------------------------------------------- 498
Dr. Charu Mithal, Dr. Anu Malik, Dr. Sandeep Mithal, Dr. Neha Mithal, Dr. Prateek
Agarwal, Dr. Pallavi Agarwal
Sympathetic Ophthalmitis Following Optical Penetrating Keratoplasty In The Last 9
Years---------------------------------------------------------------------------------------------------------- 502
Dr. Rekha Gyanchand, Dr. Sheetal Hegde
Comparison of Engothelial Cell Count by Manual and Automated Methods in Normal
Cornea and in Fuchs’ Endothelial Dystrophy------------------------------------------------- 505
Dr. Somasheila I Murthy, Dr. Debarun Dutta, Dr. Tamal Chakraborti, Dr. Pritam Kumar
Streptococcus Pneumoniae Keratitis: Fortified Antibiotics or Fluoroquino-lones?-
------------------------------------------------------------------------------------------------------------------ 508
Dr. Sujata Das, Dr. Savitri Sharma, Dr. Vivek Warkad, Dr. Srikant K Sahu
Fibrin Glue (FG) Augmented Amniotic Membrane Transplantation (FGAMT) in
Peripheral Corneal Perforations---------------------------------------------------------------------511
Dr. Ritu Arora, Dr. Jasneet Kang, Dr. J L Goyal, Dr. Monika Mittal, Dr. Parul Jain
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Cornea Free Papers
CORNEA - I
Chairman: Dr. G Mukherjee; Co-Chairman: Dr. A K Jain
Convenor: Dr. Beena Desai; Moderator: Dr. Prerna Upadhyaya
Dr. DEBASISH DUTTA: MBBS (1995), NRS Medical College, Calcutta
University, Kolkata; MS (2000), MKCG Medical College, Berhampur
University; Fellowship (2004), Sankara Nethralaya, Chennai. Recepiant of
K.R. Dutta award (1999) in EIZOC, Cuttack. Presently, Consultant, Disha
Eye Hospital and Research Centre, Sheoraphuly, Hooghly, WB.
Contact: 09830216532; E-mail: [email protected]
A New Approach to Management of Corneal
Ulcers by Debridement
Dr. Debasish Dutta, Dr. Arup Bhaumik, Dr. Ayan Mohanta, Dr. Prashant
Kumar Singhal, Dr. Sabitabrata Basu
V
isual disability in the developing nations of Asia , Africa and Middle East
is a major public health issue. Cataract is the most common cause but is
easily manageable. The very second cause is corneal opacity resulting from
corneal ulceration. Central Corneal ulceration is a very common occurrence
in the semi urban and rural population. These patients mostly belong to the
financially weaker sections of the society and are involved in agricultural
activities. There is wide geographic and a etiological variation across the globe
and also from region to region.
In the Indian scenario a huge fraction of the agricultural population is affected
by corneal diseases ranging from simple corneal abrasions to microbial
keratitis. This is not the case where farming is highly mechanized.
Microbial keratitis due to bacteria is decreasing at our Disha Eye Hospital
(Hooghly). Self medication or treatment by village quacks cures many of the
bacterial ulcers. This is mainly because of some potent and cheap antibacterial
formulations, which are available over the counter.
So we are left with the dreaded menace of the mycotic keratitis, which is
unequivocally a major cause of ocular morbidity. The problem of fungal
infection of cornea in India is acute as the weather is hot and humid (Tropical)
and to add to the problem are ignorance, illiteracy and poverty.
Medical management of fungal Keratitis is far from satisfactory. Fungi
implicated in keratomycosis rarely cause systemic mycoses. Therapeutic
protocols applicable for systemic mycoses work poorly when applied to
cornea. Polyenes are natamycin and Ampho-B a zoles include Clotrimazole,
Fluconazole and Voriconazole etc. These are mostly fungistatic and not
fungicidal. The drug of choice for filamentous fungi is natamycin suspension.
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69th AIOC Proceedings, Ahmedabad 2011
It penetrates the cornea poorly and acts only on superficial keratitis. It is
expensive and requires frequent instillation. It is mostly available in 3ml glass
packing which leak many a times. Amphoterecin B for topical application
is not available off the shelf and has to be prepared fresh. It is available as
injection and as such its penetration of intact epithelium is poor.
The population at risk is located far from tertiary care centers and detailed
microbiological assessment at grass roots level is difficult. So to cut ice the
protocol of management of fungal ulcers should be simple, reproducible and
inexpensive.
The first step in the management of most corneal ulcer is scraping. Standard
scraping encompasses removal of the epithelium with necrotic tissue at the
ulcer and its bed. This decreases load of the organism and improves penetration
and availability of the antifungal agent. Simultaneously scraping acts as a
diagnostic tool in the form of KOH mount preparation to diagnose fungal
filament etc. 10% KOH mount is inexpensive and easy; it requires minimum
infrastructure and results are obtained immediately. A trained technician can
do it. But an ophthalmologist executing the whole exercise himself or herself
increases the yield of the organism. Chances of isolating fungal filaments in
corneal scraping is as high as 90 to 99%, Vis-à-vis 88.75% by Gramstain.
The diagnostic and therapeutic scraping that is practised by most removes the
necrotic tissue but the heavily infiltrated pre necrotic tissue at the ulcer bed is
left behind. This study focuses on a method of deeper scraping whereby this
prenecrotic tissue with its load of infiltration and cytokines is removed to a
great extent. This method is destined to promote better drug availability and
thus quicker healing and lesser scarring.
MATERIALS AND METHODS
It is a predesigned prospective interventional case series of consecutive 153
cases of fungal keratitis with filaments demonstrated in 10% KOH at Disha
Eye Hospital (Hooghly) during January 2008 and December 2009
Patient
All patients with red eye who report to the OPD of the tertiary care eye centre
Disha Eye Hospital (Hooghly) are screened for corneal ulcer. This tertiary care
hospital serves semi urban and rural people of Howrah,Hooghly and Burdwan
districts of West Bengal. The livelihood of majority of patients turning up to
the OPD of this hospital is agriculture based.
Ulcer
Ulcer is defined as breech in corneal epithelium with infiltration of underlying
stroma, with or without hypopyon.
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A common protocol was applied to all cases. Each patient was examined
under Slit Lamp biomicrocope by an ophthalmologist. Ulcer is stained by
Sterile fluorescein strip touched at the lower fornix to make out the extent of
epithelial breech and recorded in mm in its longest and shortest diameter.
Other details like depth, zone of stromal infiltrate, Corneal edema etc are
noted with proper color coding. Hypopyon is measured in mm and number of
days for its resolution is noted.
Healed Ulcer
An ulcer is defined healed where fluorescein staining is negative and there is
no stromal infiltrate.
Meticulous data was collected on the following:
1. Date of first visit.
2. Date at which ulcer has healed .
3. Size of ulcer at first visit
4. Site of ulcer (central , inferior temporal , inferior nasal , superior temporal,
inferior temporal)
5. Hypopyon present on presentation and its resolution time.
6. Best corrected visual acuity at first visit.
7. Best corrected visual acuity at end of treatment.
Exclusion criteria
Associated systemic ailments like Diabetes etc.
Associated ocular conditions like dry eye, dacryocystitis, blepharitis, lid
pathologies etc. Typical viral ulcers, healing ulcers, moorens , interstitial
keratitis, neurotropic ulcer, bullous keratopathy, exposure keratopathy etc.
Scraping
The cornea and conjunctival sac are anesthetized with proparacaine
hydrochloride (0.5%), Epithelium is scraped from over the ulcer and beyond.
Ulcer is scraped by an ophthalmologist under aseptic conditions ,at the slit
lamp, using sterile Bard Parker Blade no 15.
Material is obtained from
1.
The bed of the ulcer
2.
Leading edge of the ulcer and a KOH mount prepared for examination
under microscope first under 10 x and then finally under 40x.
Detailed microbiological examinations like fungal and bacterial culture etc
are done as part of hospital protocol but has not been taken into consideration
in this study as these are not feasible at the grass roots level. It is obviously
ideal to inoculate into several media but this is not always possible due to
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69th AIOC Proceedings, Ahmedabad 2011
lack of availability of media, lack of adequate sample for all media and the
infrastructural cost involved at all places.
Only the patients who test positive for filaments are taken into consideration
(Group 1).
A typical medical regime was formulated and applied to all those patients.
Most patients were examined at 5 days interval and changes noted as per the
protocol.
A subset of these patients in group 1 were randomly taken up for the special
checker board scraping protocol to constitute Group 2.
Corneal thickness is assessed under the slit beam and cheques board pattern
of scraping applied to remove the deep densely infiltrated prenecrotic tissue.
This tissue was not removed by conventional deep scraping. Ulcer is monitored
closely and scraped similarly at subsequent visits.
RESULTS
Patients were randomly divided into group 1 and group 2.
In group 1 standard therapeutic scraping was practised in the beginning and
subsequent follow ups.
In group 2 chequer board scraping was applied similarly.
The impact of nuisance parameters like size of ulcer , site of ulcer etc on the
yield or outcome (number of days required to heal and the final visual acuity
achieved) is eliminated by ANCOVA. Analysis of the data revealed that the
time required to heal is significantly less in group 2 (at 5% level).
But the assumption that quicker healing will cause lesser fibrosis maintaining
better transparency need further evaluation .
DISCUSSION
The impact of fungal keratitis in the Indian subcontinent as a cause of ocular
morbidity is unequivocally substantial . Fungal ulcer account for 30 to 40% (3)
of all cases of microbial keratitis in developing countries. Some studies put the
figure to as high as 50% (1)
The therapeutic protocols of today are far from satisfactory and often fail
to preserve or restore vision after fungal keratitis. Filamentous fungi is the
number one cause at lest in the developing world. Corneal penetrability of
available drugs is an issue. Cost and accessibility to low cost treatment is
extremely important in the Indian subcontinent.
Aim of management is rapid eradication of the organism with control of
inflammation and tissue damage by cytokinins etc, there by preserving
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integrity and transparency of the cornea. Under these circumstances checker
board scraping of fungal ulcers calls for no extra infrastructural support. All
that is needed is the existing slit lamp and the Bard Parker Blade no 15. This
New Approach To Management Of Corneal Ulcers By DEBRIDEMENT has
improved healing and decreased morbidity to a great extent; lesser number of
eyes are lost to therapeutic PKs and evisceration .
REFERENCES
1.
Basak S K, Basak S, Mohanta A, Bhowmik A, Epidemiological and Microbiological
Diagnosis Of Suppurative Keratitis In Gangetic West Bengal, Eastern India. IJO
2005;53:17-22.
2. Srinivasan M, Gonzales C A,George C et al.: Epidemiology and Aetiological
Diagnosis Of Corneal Ulcer In Madurai. South India . Br J Ophthalmol 1997;81:96571.
3.
Sharma S, Srinivasan M, George C:The Current Status of Fusarium Species in
Mycotic Keratitis in South India. J Med Microbial 1993;11:140-7.
4.
Dunlop A A, Wright E D,Howlader S A, et al.: Suppurative Corneal Ulceration
In Bangladesh: A Study Of 142 Cases Examining The Microbiological Diagnosis,
Clinical And Epidemiological Features of Bacterial and Fungal Keratitis. Aust N Z
J Ophthalmol 1994;22:105-10.
5.
Bharathi M J, Ramakrishnan R, Vasu S, et al.:Epidemiological Characteristics and
Laboratory Diagnosis of Fungal Keratitis: A Three-Year Study. Indian J Ophthalmol
2003;51:315-21.
6.
Gopinathan U, Garg P,Fernandes M, et al.: The Epidemiological Features and
Laboratory Results of Fungal Keratitis:A 10-Year Review at A Referral Eye Care
Center in South India. Cornea 2002;21:555-9.
Colored Cosmetic Contact Lenses: Cosmesis
and Complication, Hand in Hand
Dr. Shwetambari Singh, Dr. Ravindra Vhankade, Dr. Dipali Satani,
Dr. Amit Patel
U
se of colored cosmetic contact lens is well known latest fad of young
generation. Manufacturers are targeting and attracting youth market by
providing various colors and patterns of cosmetic contact lenses. Influential
commercials and easy availability has lead to dramatic increase in trend
of wearing cosmetic lenses even in youngsters of middle to lower socioeconomic classes. Many of these young users are unaware and uninformed
about the proper use and care of contact lenses. Noted here are 13 patients
who developed severe infectious keratitis following use of decorative lenses.
All the patients were ignorant about the precautions, hygiene measures and
complications related to contact lens use.
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69th AIOC Proceedings, Ahmedabad 2011
MATERIALS AND METHODS
All patients presented at Nagari eye institute from November 2009 to February
2010 with acute pain and redness following use of cosmetic contact lenses
were included in the study. Written consent was taken from the patients before
inclusion. Before clinical examination, a detailed history was obtained relating
to the availability of cosmetic lenses, duration and frequency of wear and type
of cleaning solution used. If available, the contact lenses and solution used by
the patient were obtained and sent for microbiological evaluation.
A slit-lamp biomicroscopic examination was conducted to record the location
and size of the corneal infiltrates. Under topical anesthesia and slit-lamp
magnification, corneal scrapings were obtained from the base and edge of the
ulcer. The samples were inoculated directly onto nutrient agar, sheep blood
agar, chocolate agar and Sabouraud dextrose agar. Gram and Giemsa stained
smears of scraped material were prepared.
According to the clinical picture and smear report, patients were treated with
broad spectrum antibiotics and antiviral drugs. The initial therapy was modified
based on the results of culture and sensitivity testing and the clinical response.
RESULTS
Out of 13 patients 8 were male and 5 were female. Mean age of presentation was
19 ± 3.8 years. Eleven patients were naïve contact lens users and 4 were minors.
Table 1 outlines the details of contact lens availability, storage and usage.
Table 1
Case Contact lens Storage and Duration of Assistance Sharing Overnight
No. availability
cleaning
storage in
for CL
use
solution unchanged removal
solution
1
Optical shop
2
Optical shop CLS +Tape water
2 days
+
-
7 days
-
-
3
Relative
-
CLS
1 month
-
+
-
4
Friend
CLS
10 days
-
+
+
5
Optical shop
CLS
2 days
-
-
-
6
Optical shop
CLS
10 days
+
-
+
7
Relative
-
+
-
8
Optical shop
CLS
15 days
+
-
-
9
Friend
CLS
5 days
-
+
+
10
Optical shop CLS +Tape water
11 Garbage
CLS
CLS +Tape water 4 months
-
3 days
-
-
-
-
-
-
-
-
12
Friend
CLS
7 days
+
+
-
13
Optical shop
CLS
5 days
-
-
+
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Laboratory results showed Pseudomonas aeruginosa in 7 cases (54%),
Staphylococcus aureus in 3 cases (25%) and Staphylococcus epidermidis in 2
cases (17%) with one case of viral keratitis. In 62% of cases size of ulcer was
≥ 5 X 5 mm and post treatment corrected visual acuity was 6/24 or less. All
patients responded well to the antimicrobial treatment, eliminating the need
of surgical intervention. Clinical details, culture and sensitivity results and
visual acuity are described in Table 2.
Table 2
Case Age
No. (years) /
gender
1
20/M
Size of
Organism
Sensitivity
Visual
ulcer
isolated
acuity on
(mm)
presentation
5.5X6
P. aeruginosa
Moxifloxacin
HM
Final
visual
acuity
6/18
2
15/F
3X4
S. aureus
Amikacin
6/24
6/9
3
16/F
9X8.5
P. aeruginosa
Cefotaxime
HM
HM
4
18/M
7X8
P. aeruginosa
Moxifloxacin
PR
NA
5
19/M
1X2
P. aeruginosa
Moxifloxacin
6/60
6/12
6
28/M
6X7.5
CF ½ m
CF ½ m
7
18/F
1X2
S. aureus
Levofloxacin
6/6
6/6
8
25/M
7.5X8
S. epidermidis
Moxifloxacin
PR
HM
9
16/M
5X4.5
P. aeruginosa
Amikacin
CFNF
6/24
10
21/F
2X3
S. aureus
Moxifloxacin
6/9
6/6
11
15/F
5X5.5
P. aeruginosa
Moxifloxacin
6/60
6/24
12
20/M
2X3
S. epidermidis
Moxifloxacin
6/9
6/6
13
21/M
7X8
P. aeruginosa
Levofloxacin
PR
6/60
Culture negative
DISCUSSION
The link between microbial keratitis and contact lens wear is beyond question.
Use of contact lenses for therapeutic, refractive or cosmetic purpose will
target different classes of population. The colored cosmetic lenses are non
corrective (zero power or plano) lenses designed and worn solely to change
the appearance of the eye. Emmetropic patients who wear these lenses risk
serious ocular sequelae for the sake of cosmesis alone. In the current study, 13
young individuals developed sight threatening microbial keratitis following
the use of cosmetic contact lenses. As all the patients were from lower to lower
middle socieo-economic class, it points towards the dangerous trend evolving
in the youngsters of these classes. We found that unsterile lens handling and
infrequent change of storage solutions were the two major causes for the
development of infectious keratitis.
Eleven out of 13 patients were using these lenses for the first time. None of
the patient was following sterile contact lens handling or storage technique.
The lenses were stored in a contact lens case with solution or unpreserved
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69th AIOC Proceedings, Ahmedabad 2011
saline for weeks or months at a time by 8 patients. Longest duration of storage
in unchanged solution was 4 months. Sharing of these cosmetic lenses is
possible and more frequent as they are of zero refractive power. Five patients
in our study group shared lenses with friends or relatives. None of the patient
was instructed about insertion or removal techniques. Four patients required
assistance of other person for removal of contact lenses. Out of these 4 patients
in 2 cases contact lens was broken while removal and one patient had injury
with finger nail.
Pseudomonas species (especially P. aeruginosa) are reported the world over
as the most common organism associated with contact lens related microbial
keratitis, and so was the case in our study group. Seven out of 13 (54%) cultures
were positive for P. aeruginosa. Young contact lens wearers usually have better
host defense mechanism, which fungi are less efficient to overcome. Several large
series have reported low incidence of fungal keratitis in contact lens wearer
groups. We did not culture a fungi or Acanthamoeba from any of the cases
studied. Small sample size of our study group can be the reason for this result.
Steinmann et al. reported twelve cases of infectious keratitis after wearing
plano decorative contact lenses. None of the lenses were dispensed by eye care
professionals. Authors have highlighted that colored noncorrective lenses are
being dispensed without a prescription or fitting from unlicensed vendors.
Patients who acquire lenses from unauthorized providers are less likely to be
instructed on appropriate lens care and use. Consequently, uninformed lens
wearers are developing sight threatening keratitis.
The widespread advertising of colored cosmetic contact lenses creates
a demand among emmetropic individuals while failing to mention the
associated risks. The patients who wear these lenses intermittently may
perceive their lenses to be merely a cosmetic aid and, therefore, may be more
prone to unsafe practices than daily wearers accustomed to a regular pattern
of contact lens hygiene. Unmonitored wearing and over the counter use of
cosmetic contact lenses is causing serious sight threatening complications in
emmetropic young individuals.
REFERENCES
1.
Over the counter decorative contact lenses: cosmetic or medical device? A case
series. Eye Contact Lens: Science and clinical practice. Sept. 2005.
2. Ocular complications associated with use of contact lenses from unlicensed
vendors. Eye Contact Lens: Science and clinical practice Oct 2003.
3.
Corneal ulcer associated with cosmetic extended wear soft contact lens.
Ophthalmology Feb. 1987.
4.
Ulcerative keratitis associated with contact lens wear. American journal of
Ophthalmology July 1989.
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Spectrum of Mycotic Keratitis: 5-Year Review
of Patients at A Tertiary Eye Care Center in
Tamilnadu
Dr. D Chandrasekhar, Dr. J Kaliamurthy, Dr. Pragya Parmar, Dr. C M
Kalavathy, Dr. C A Nelson Jesudasen, Dr. Philip Aloysius Thomas
M
ycotic keratitis (Keratomycosis, Fungal keratitis) refers to a suppurative,
usually ulcerative infection of the cornea that is caused by fungi. Such
an infection may threaten sight and even lead to the loss of the eye. Corneal
infections are the second most common cause of monoocular blindness after
unoperated cataract in some developing countries in the tropics. It has been
increasing recently in India and other developing countries.1-4 Fungal keratitis
is caused by a large number of saprophytic fungi, and the aetiological agents
of fungal keratitis show a varying pattern with respect to geographic locale
and climatic conditions, additionally, the spectrum of fungal pathogens
causing fungal keratitis changed significantly in different year. To improve
the management of patients with fungal keratitis, it is important for
ophthalmologists to gain information of the common fungal isolates within
their region. This report describes the spectrum of the spectrum of fungi
isolated from corneal ulceration in patients treated at a tertiary eye care center
in Tamilnadu during a 5-year period.
MATERIALS AND METHODS
The study was conducted with the approval of the Institutional Ethics
Committee of the authors’ institution and was designed as a retrospective
review of Microbiological records and the patients’ medical record. Medical
records of all keratitis patients who underwent for microbiological investigation
from January 2005 to December 2009 were reviewed. The predisposing factors
and risk factor were abstracted from the history documented in the medical
record. The microbiological data of all patients with suspected infectious
corneal ulceration who presented to the ocular microbiology service at Joseph
Eye Hospital, Trichy between January 2005 and December 2009 were also
reviewed retrospectively.
Microbiological Investigation: On presentation, corneal specimens from
scrapings were stained with the Gram and also viewed as wet mount
preparations using lactophenol cotton blue (LPCB). The corneal material was
also inoculated directly onto the following media that support the growth of
bacteria, fungi and Acanthamoeba: sheep blood agar, Sabouraud’s dextrose
agar and broth and brain–heart infusion agar and broth. Brain–heart infusion
agar and broth, and blood agar were incubated at 37°C and were examined
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daily and to be discarded after 7 days, if no growth was seen. Sabouraud’s
dextrose agar and the broth were incubated at 28°C and were examined daily
for the first week and twice daily thereafter for 4 weeks. A fungus grown on
the primary isolation medium was subcultured onto various fungal media
and incubated for a considerable period to facilitate sporulation. The cultures
were considered positive if at least one of the following criteria was fulfilled:
a) The growth of the same organism was demonstrated on one or more solid
media and/or if there was confluent growth at the site of inoculation on at
least one solid medium.
b) The growth on one medium was consistent with direct microscopic
findings.
c) The same organism was grown from repeated corneal scrapings.
Fungal species were identified according to the macroscopic characteristics of
the colony morphology, color and growth rate of the moulds, and the microscopic
characteristics of hyphae, spores or conidia, and their relationships.
RESULTS
There were 1499 patients of who suspected microbial corneal ulcer underwent
microbiological investigations during the five years from January 2005 to
December 2009. Of these, 64% of them reported trauma by inanimate object,
26% reported prior treatment with eye drops (from Pharmacy/ General
Practitioner/ Ophthalmologist) and 18% reported use of traditional eye
medicine (oil, leaf juice, milk, etc.).
Microorganisms were grown from 1069 (71%) of the 1499 ulcers. There were
542 (51%) fungal isolates and 522 (49%) bacterial isolates. The proportions of
bacterial and fungal isolates recovered from the corneal ulcers for each year
were given in Table -1.
Table 1: The proportions of bacterial and fungal isolates recovered
from the corneal ulcers for each year (2005 to 2009)
Organism
2009 2008 2007 2006 2005 Total
Bacteria
116 112 110 86 98 522
Fungi
108 80 143 103 108 542
No growth
56
Others
63
72
119
120
430
0 2 1 0 2 5
280 257 326 308 328 1499
The most common fungal pathogens isolated were various species of
Fusarium, representing 204 (37.6%) of all positive fungal cultures, followed
by Aspergillus spp. (134; 24.7%), Curvularia spp (28; 5%), Colletotrichum
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dematium (13; 2%) and Exserohilum longirostratum (7; 1%). Alternaria
alternata, Bipolaris spicifera, Lasiodiplodia theobromae, Scedosporium
apiospermum and Candida albicans were less frequently isolated organisms
in the series. In addition, unidentified dematiaceous fungi accounted for 26%
(141). The spectrum of 542 clinical isolates of fungi for each year (2005 to 2009)
is summarized in Table 2.
Table 2: The spectrum of fungi isolated from the corneal ulcers for the
five year period (2005 to 2009)
Organism
2009 2008 2007 2006 2005 Total
Fusarium solani
5 4 0
0 0 9
Fusaium sp
24
20
60
34
42
180
Fusarium dimerum 7 7 0
0 1 15
Total
204
A.flavus
16
A.fumigatus
10 4 7 3 4 28
Aspergillus spp
8
20
30
27
101
3
1
0
0
4
Aspergillus niger
1
0
0
1
Total
134
Curvularia sp
4 3 9
4 8 28
Colletotrichum dematium
9 1 0
2 1 13
Exerohilum longistratum
1 0 0
2 4 7
Alternaria alternata 1 0 3
0 0 4
Bipolaris
1 1 1
1 1 5
Lasiodiplodia
2 0 1 0 3
Scedosporium apiospermum
1
0
1
Candida albicans
1
1
2
UI
39 28 39
19 16 141
Total
117 81 141 98 105 542
DISCUSSION
Fungal keratitis is a common cause of corneal infection and blindness after
trauma in the developing world. Because of the widespread distribution of
fungi, human contact with the organism is inevitable and frequent. It has
become increasingly important to gather sufficient data that would project the
gravity of the problem of fungal keratitis of a representative geographic region
in terms of the epidemiology and aetiology, the documentation of which would
serve as a useful guide for practising ophthalmologists. Few studies on fungal
keratitis have been published from India.2,3,5,6 The results of proportion of
fungi and bacteria of the present study are consistent with the earlier reports
from India.5,6 Fungal ulcers are usually seen more in this center. It is primarily
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69th AIOC Proceedings, Ahmedabad 2011
the result of the temperate climate because a warm, humid environment
enhances the growth of fungi. In addition, the author’s institution is a tertiary
cornea and external disease referral centre that provides medical service to
all the people in Tiruchirapalli district residing in urban and rural areas.
Other factors that have been correlated with this increasing incidence include
the growing number of trauma cases, widespread abuse of broad-spectrum
antibiotics and steroids. Meanwhile, improvement of the health care system,
increasing awareness of this disease by ophthalmologists and popularization
of the diagnostic methods and instruments also help to identify patients who
otherwise might have been undetected previously.
In the literature, fungi belonging to nearly 56 genera have been reported from
the cases of fungal infections. Filamentous fungi are the principal causes of
corneal infections in most parts of the world; either Fusarium or Aspergillus
are the most common fungal genera. Geographical and environmental
variations, such as humidity and air temperature, have been observed in the
predominant genera of fungi isolated from patients with fungal keratitis.
In this case series, Fusarium was the most frequently isolated pathogen,
and Aspergillus was the second most often one in the cases. There are some
agreements of this study on the spectrum of fungal species in causing fungal
keratitis with others reported from India.5-7 In conclusion, various species of
Fusarium were the most common fungal aetiological agents isolated, followed
by Aspergillus spp. and unidentified dematiaceous fungi from patients with
keratitis in this setting.
REFERENCES
1. Xie LX, Zhong W, Shi W, Sun S. Spectrum of fungal keratitis in North China.
Ophthalmology 2006;113:1943–8.
2. Chowdhary A, Singh K. Spectrum of fungal keratitis in North India. Cornea 2005;
24:8–15.
3. Shukla PK, Kumar M, Keshava GB. Mycotic keratitis: an overview of diagnosis and
therapy. Mycoses 2008;51:183–99.
4. Wang L, Sun S, Jing Y, Han L, Zhang H, Yue J. Spectrum of fungal keratitis in
central China. Clinical and Experimental Ophthalmology 2009;37:763–71.
5. Bharathi MJ, Ramakrishnan R, Meenakshi R, et al. Microbial keratitis in South
India: influence of risk factors, climate, and geographical variation. Ophthalmic
Epidemiol 2007;14:61–9.
6. Leck AK, Thomas PA, Hagan M, et al. Aetiology of suppurative corneal ulcers
in Ghana and south India, and epidemiology of fungal keratitis. Br J Ophthalmol
2002;86:1211–5.
7. Gopinathan U, Garg P, Fernandes M, et al. The epidemiological features and
laboratory results of fungal keratitis: a 10-year review at a referral eye care center
in South India. Cornea 2002;21:555–9.
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Effect of Subconjunctival Injection of
Bevacizumab on Corneal Neovascularization
Prof. Dr. K Vasantha, Dr. Rajini Ponraj, Dr. Mohan K, Dr. Niraimozhi
T
o evaluate regression of new vessels of cornea. To evaluate the safety
and efficacy of subconjunctival injection of Bevacizumab. To evaluate the
outcome of OKP after subconjunctival Bevacizumab
MATERIALS AND METHODS
This study was done in Cornea Department Regional Institute of
Ophthalmology and Government Ophthalmic Hospital Chennai during
January 2009 to January 2010. Twenty eyes of twenty patients with corneal
neovascularization due to various pathologies (mentioned below) have been
selected for the study.
Inclusion criteria
Vascularised corneas of patients with
• Leucomatous opacity following exanthematous fever and post hydrops
• Pseudophakic bullous keratopathy
• Healed corneal ulcer post trauma and infection
• Previously failed Optical keratoplasty
Exclusion criteria
• Patients with uncontrolled systemic hypertension with systolic blood
pressure of ≥150mm Hg or diastolic blood pressure of ≥90 mm of Hg
• Patients with recent Myocardial Infarction
• Patients with recent Cerebro Vascular Accidents
• Diabetes mellitus
• Renal, liver, and coagulation
anticoagulation medications
abnormalities
including
current
• Current or recent systemic corticosteroid therapy or periocular
corticosteroids injections to the study eye
• Ocular or periocular malignancy
Procedure
Anterior segment examination was done with slit lamp biomicroscopy.
Standardized corneal photographs were taken with 10X magnification with
slit lamp biomicroscopy using digital camera.
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69th AIOC Proceedings, Ahmedabad 2011
A commercially available bevacizumab (2.5mg/0.1ml, 100 mg/4 mL) was
prepared for each patient and placed in a tuberculin syringe using aseptic
techniques.
• Topical anesthetics ( 4% xylocaine/ paracaine eye drops) and antibiotics
are applied
• The eye had been prepared with 5% povidone iodine in a standard fashion
• Then draped with an eye mask
• Opsite was applied
• Using lid speculum eye was exposed
• Bevacizumab (2.5mg/0.1ml) was injected
subconjunctivally in the
quadrant of vascularization 1cm from the limbus
• Patients were instructed to apply antibiotic eye drops for 3 days 4 times a
day
Follow-up
Follow up visits were done on 14th day, 1st, 3rd, and 6th month post injection.
All the 20 patients completed 6 months of follow-up. At each visit patients
were checked for regression of new vessels i.e. reduction in both number and
caliber of the vessel. Patients were also examined for signs of graft rejection
(those who have been operated) and side effects.
Main outcome measures
i)
Regression of corneal new vessels
ii)
Efficacy and safety of subconjunctival Bevacizumab
iii)
Outcome of OKP after subconjunctival Bevacizumab injection
DISCUSSION
In this study an obvious reduction in established corneal neovascularization
occurred to a different degree in each patient, and subconjunctival
bevacizumab was well tolerated by all these patients. Out of 20 patients in 50%
of patients complete regression of the corneal new vessels noted at the end
of 6th month. Whereas in 30% of patients only partially reduction noted i.e.
reduction in calibre of vessels only, the number of new vessels was constant.
In 20% of patients both number of new vessels and the calibre was constant.
This variable response may be because of the chronicity, extent of corneal
neovascularization, amount of scarring, disease process, formulation and
route of administration of the drug 15 and 16.
• Subconjunctival injection of Bevacizumab can be used safely and effectively
for corneal neovascularization resulting from different types of disorders.
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• It may provide an additional strategy in improving success of corneal
grafts in these patients.
• This is a short term study. However long-term follow-up is necessary to
determine whether repeat injections are necessary.
Risk Factors in Management of Bacterial Keratitis
Dr. Samrat Chatterjee, Dr. Deepshikha Agrawal
I
nfectious keratitis continues to be a major cause of corneal blindness in
developing countries. Timely presentation, specific diagnosis and treatment
with appropriate antimicrobial agents can limit ocular morbidity. The
knowledge of risk factors affecting treatment outcome helps in modifying
management protocols and also in prognostication.1-5 A previous study
from our Institute examined the risk factors affecting outcome after medical
management of fungal keratitis [Risk factors for poor outcome in medical
management of fungal keratitis. Chatterjee S, et al. Paper presented at Annual
Conference of All India Ophthalmological Conference, Kolkata, 2010]. In this
present study, risk factors affecting outcome after medical management of
bacterial keratitis are being examined.
MATERIALS AND METHODS
This was a retrospective, interventional case series which included all
microbiologically proven cases of bacterial keratitis diagnosed at the Cornea
Services in MGM Eye Institute, Raipur (2005-2009). Medical records were
examined and factors like age, gender, distance from institute, presentation time,
treatment history prior to presentation, steroid use, initial visual acuity, ulcer
size and depth, corneal thinning/perforation, presence of endophthalmitis,
etc were correlated to poor outcome. Poor outcome to medical therapy was
considered when the ulcer failed to heal with medications or progressed to
perforation or required penetrating keratoplasty or underwent evisceration.
Each patient who presented with corneal ulcer at our Institute underwent
corneal scraping and microbiological investigations that included culture in
appropriate media and antibiotic susceptibility by Kirby Bauer disc method.
Medical treatment was with either combined fortified cefazolin eye drops
(50mg/ml) and tobramycin (14mg/ml) or monotherapy with fluoroquinolones.
The initial drug chosen was modified according to antibiotic susceptibility
reports and clinical response. Patients not responding to medical therapy were
considered for therapeutic penetrating keratoplasty. In patients where corneal
integrity was threatened with corneal thinning, descemtocele formation or
perforation, tissue adhesive was applied. Univariate analysis was done with
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69th AIOC Proceedings, Ahmedabad 2011
2x2 tables with chi-square or Fishers test as appropriate. Variables that yielded
p value <0.125 were considered for multivariate analysis using multiple logistic
regression. SPSS (version 12 for Windows, SPSS, Chicago, IL) was used for
statistical analysis. A 2-tailed p value less than 0.05 was considered significant.
RESULTS
There were 149 episodes of bacterial keratitis in 142 patients. There was
bilateral involvement in 3 patients and multiple episodes in 4 patients.
Outcome data was available in 117 episodes as rest was lost to follow-up. Of
these 101 (86.32%) episodes healed, 5 (4.27%) required evisceration, 1(0.86%)
underwent therapeutic penetrating keratoplasty, 3(2.56%) eyes became
pthisical and 7(5.98%) eyes had perforation which were un-amenable to
treatment and patients refused evisceration. Factors that were considered to
influence outcome are given in Table. The factor identified by multiple logistic
regression to significantly influence outcome was infiltrate size (p=0.03) while
rest of the factors failed to reach statistical significance.
DISCUSSION
The outcome of bacterial keratitis with medical management is better than
fungal keratitis. In this study 86% cases had good outcome which is better than
the 64% good outcome reported by us in fungal keratitis earlier. [Risk factors
for poor outcome in medical management of fungal keratitis. Chatterjee S,
et al. Paper presented at Annual Conference of All India Ophthalmological
Conference, Kolkata, 2010]. Better outcome in bacterial keratitis compared to
fungal keratitis has been also reported by others.3,5
Previous studies have reported advancing age,1,2 pre-treatment with topical
steroids,1-2 pneumoccoal infection,2 pseudomonas infection, 1 ulcer size,1-4
distance from limbus,4 presence of hypopyon,1 and MIC of antimicrobial
agents,5 to significantly affect outcome. In the present study univariate
analysis found presenting visual acuity <20/200, infiltrate size ≥ 12mm2,
involvement of the posterior stroma, perforation or gross corneal thinning,
presence of concurrent endophthalmitis and gram negative bacterial infection
as factors associated with poor outcome. However in multivariate analysis
only infiltrate size reached statistical significance. The reason why other risk
factors did not reach statistical significance in multivariate analysis could
be due to the sample size which may not have been large enough to have
adequate statistical power to detect small differences.
In summary we find that bacterial keratitis has a better outcome than fungal
keratitis. The major risk factor for poor outcome is large ulcer size. Hence
patients with larger ulcers should receive appropriate topical antibiotics
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Table: Univariate analysis of risk factors affecting outcome
Sl VARIABLE
No
Poor
Good TOTAL Odds 95% CI
outcome outcome
ratio
No (%) No (%)
1
Extreme of age
(0-14 and > 60y)
6(12)
44(88)
50
Others
2
Male gender
3
10(15)
57 (85)
67
8(11)
68 (89)
76
Female gender
8 (20)
33 (80)
41
Distance >25kms
8(11)
63(89)
71
Distance ≤ 25 kms
8(17)
38(83)
46
4
Presentation > 21d
4(21)
15(79)
19
1.51
Presentation ≤21d
12(12)
86(88)
98
5
Presence of risk factors 14(16)
73(84)
87
No risk factors
2 (7)
28 (93)
30
6
Prior consultation
4(13)
28(87)
32
No prior consultation
12(14)
73(86)
85
8(11)
67(79)
75
7
No treatment with
antibiotic prior to
presentation
0.78
0.6
0.6
P
VALUE
0.26- 2.30
0.21-1.74
0.21- 1.74
0.79
0.26
0.41
0.44- 5.19 0.29
2.68 0.57 - 12.58 0.24
0.87 0.26- 2.92 1.000
0.51
0.18- 1.47
0.26
Prior treatment with
8(19)
34 (81)
42
antibiotic
8
Treated with steroids
4(13)
26(87)
30
0.96
prior to presentation
0.2849 1.0000
to 3.2449
No treatment with
12(14)
75(86)
87
steroids
9
Presenting VA <20/200* 15(21)
57 (79)
72
Presenting VA ≥20/200
1(3)
39(97)
40
15(38)
24(62)
39
1(1)
77(99)
78
16(25)
49(75)
65
infinity
10 Infiltrate size >12mm
Infiltrate size ≤12mm
11
Posterior stroma
involvement
Anterior stromal
involvement
10.26 1.30- 80.92 0.009
48.75 6.12-388.40 0.0001
0(0) 52(100) 52
12 Presence of hypopyon
4 (10)
36(90)
40
12(16)
65(84)
77
Absence of hypopyon
13 Perforation/thinning
No perforation/thinning
0.18-2.0
5(42)
12
9(9)
96(91)
105
3 (100)
0 (0)
13 (11)
101(89)
16 Gram negative bacteria 7(50)
7(50)
91(91)
Gram positive bacteria
0.6
7 (58)
14 Endophthalmitis
No endophthalmitis
0.0001
9(9)
3
0.57
14.93 3.93-56.78 0.0001
Infinity
0.002
114
14
10.11 2.89-35.35 0.0006
100
* Visual acuity could not be evaluated in 5 children
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intensively, preferably have an antibiotic susceptibility test and be monitored
at frequent intervals. If a facility exists they should be hospitalized. In any
community based empirical treatment, patients should be referred to a higher
center with adequate microbiology laboratory facilities, if the ulcer is more
than 2 mm or those who do not respond to the initial treatment given with
broad spectrum antibiotics at adequate dosages.
REFERENCES
1
Coster DJ, Badenoch PR. Host, microbial and pharmacological factors affecting
outcome of suppurative keratitis. Br J Ophthalmol 1987; 71:96-101.
2
Gudmundsson OG, Ornerod DL, Kenyon KR, et al. Factors influencing predilection
and outcome in bacterial keratitis. Cornea 1989;8:115-21.
3
Wong T, Ng TP, Fing K, Tan DT. Risk factors and clinical outcomes between fungal
and bacterial keratitis: a comparative study. CLAO 1997;23:275-81.
4
Kaye S, Tuft S, Neal T, et al. Bacterial susceptibility to topical antimicrobials and
clinical outcome in bacterial keratitis. Invest Ophthalmol Vis Sci 2010; 51:362-8
5
Gopinathan U, Sharma S, Garg P, Rao GN. Review of epidemiological features,
microbiological diagnosis and treatment outcome of microbial keratitis: Experience
of over a decade. Indian J Ophthalmology 2009;57:273-9.
Dr. SAROJ GUPTA: MBBS (1987), MGM Medical College, Indore; MS
(1990), M Y Hospital and Deviahilyavishav Vidlaya, Indore. Recipient of Best
FP Award, Oculoplasty (2008) and Neurophthalmology (2010) in MPSOS
Conference. Presently, Associated Prof. Ophthalmological People’s College
of Medical Sciences and Research Centre, Bhanpur, Bhopal, MP.
Contact: 09926550364;
E-mail: [email protected]
A Very Unusual Case of Keratitis
Dr. Saroj Gupta
T
here are several reports in the literature, from different parts of the world
describing the spectrum of microbial Keratitis.1-4 The causative agents
described in all these reports are bacteria, fungi and parasite. Among parasite,
only Acanthamoeba has been isolated. We report an unusual case of Keratitis
caused by flagellated protozoa.
Case-report
A 31- year- old male patient presented with complaints of redness, watering
and pain in left eye while working in fields. Following injury, he washed his
eye with dirty stagnant water.
On examination, left eye showed an epithelial defect in centre of cornea
measuring 3.0 mm X 2.5 mm with prominent ring infiltrate surrounding the
defect. The infiltrate extended up to the anterior stroma.
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Corneal scraping was performed with Bard-Parker no. 15 blade. Examination
in normal saline wet mount preparation demonstrated trophozoites. The
trophozoites showed rapid movement suggestive of flagellated protozoan. The
material was also seen in 10% KOH mount. There were no hyphae or other
elements resembling fungal structures. The material was inoculated on nonnutrient agar overlaid with E. coli for free-living amoebas. No growth was
observed till two weeks of incubation.
Patient was put on topical neomycin, polymyxin B and bacitracin eye drops
one hourly; clotrimazole 1% eye drops two hourly and atropine 1% eye drop
twice a day.
The corneal condition improved within one week of therapy. The
frequency of administration of drops was gradually tapered. At four
weeks follow-up the cornea was clear and without any evidence of sub
epithelial opacification.
DISCUSSION
Cornea infection in this case probably resulted from direct contact with
contaminated water. The rapid motility of trophozoites was suggestive of
flagellated protozoan like Giardia or Chylomastix. The rapid motility and
sterile culture excluded protozoa like Acanthamoeba or Naegleria. Typical
motility of trophozoites on fresh examination is the key for diagnosis.5 Saline
preparation of corneal scraping should be done to exclude motile parasites.
We took opinion from two experts by showing them video of trophozoites.
Both agreed with diagnosis of a flagellated parasite especially Chylomastix.
To best of our knowledge this is the first report in literature (Medline search)
on keratitis by an unusual flagellated parasite.
REFERENCES
1.
Usha Gopinathan, Savitri Sharma, Preshant Garg, Gullapalli N Rao. Review of
epidemiological features, microbiological diagnosis and treatment outcome of
microbial keratitis: Experience over a decade. Indian J Ophthalmol 2009;57:273-9.
2. Hagan M, Wright E, Newman M, Dolin P, Johnson G. Causes of suppurative
keratitis in Ghana. Br J Ophthalmol 1995;79:1024-8.
3.
Upadhyay MP, Kamachaya PC, Koirala S, Tuladhar N, Bryan LE, Smolin G at al.
Epidemiological characterstics, predisposing factors, and etiologic diagnosis of
corneal ulceration in Nepal. Am J Ophthalmol 1991;111:92-9.
4.
Liesegang TJ, Forster RK, Spectrum of microbial keratitis in south Florida. Am J
Ophthalmol 1980;90:38-47.
5.
Yaowalark sulkthana. Free living amebic infection: Rare but fetal. Review. J. Trop.
Med. Parasitol. 2006; June:27-36.
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69th AIOC Proceedings, Ahmedabad 2011
Effect of Pterygium on Contrast Sensitivity
Dr. Archana Malik, Dr. Soniya Bhala, Dr. Anamika Garg, Dr. Sudesh K
Arya, Dr. Sunandan Sood
P
terygium is a triangular –shaped growth consisting of bulbar conjunctival
epithelium and hypertrophied subconjunctival connective tissue,
occurring medially and laterally in the palpebral fissure, and encroaching
onto the cornea. Visual acuity may be reduced due to direct invasion of the
visual axis or astigmatism induced by the pterygium. Standard visual acuity
is a crude measurement of visual performance and does not adequately
represent all aspects of visual function. Contrast sensitivity measures two
variables, size and contrast, while visual acuity measures only size. Several
reports have demonstrated that pterygia cause corneal distortion and induce
a significant amount of astigmatism.1-4 But the effect of pterygium on contrast
sensitivity has not been widely studied. Hence, we performed this study in
order to investigate the effect of pterygium on contrast sensitivity.
MATERIALS AND METHODS
This prospective, nonrandomized trial included 27 patients (36 eyes with
pterygium and 18 eyes without pterygium) with primary pterygia. Complete
ocular examination was done which included visual acuity, refraction,
intraocular pressure, anterior and posterior segment examination. Patients
included were less than 40 years of age. Patients excluded were those with
any ocular pathology other than pterygium which could possibly affect visual
acuity or contrast sensitivity like high myopia, corneal scar, cataract, diabetic
or hypertensive retinopathy, uveitis, macular degeneration, history of past
ocular surgery or trauma. All pterygia were located nasally.
Pterygium was measured on the slit lamp both vertically at the limbus and
horizontally on the cornea and the area was calculated by multiplying the two.
It was categorized into three groups vertically (≤3, 3.1 to≤5, >5mm), two groups
horizontally (0.5 to ≤2, >2mm) and into three groups depending on area (≤7, 7.1
to ≤14, >14mm2). Eyes that had no pterygium were taken as controls.
Contrast sensitivity was measured monocularly with spectacle correction. It
was measured using the CSV-1000E contrast sensitivity charts (Vector Vision)
at 3, 6, 12, and 18 cycles per degrees (cpd) under both photopic (85 cd/m 2)
and mesopic conditions (5.0 cd/m2). Contrast sensitivity curve was plotted and
converted to log units for each frequency as per Vector Vision guidelines.
Statistical analysis
Data were expressed as means ± standard deviation. The statistical comparison
of contrast sensitivity log units between the three groups was done using
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ANOVA and post-hoc bonferroni tests. Data was analyzed with SPSS software
(Version 11.0). Differences were considered statistically significant at P < 0.05.
RESULTS
27 patients (15 males and 12 females) were included in the study. 36 eyes had
pterygium and 18 eyes served as controls. Mean age of the patients was 32.0±6.88.
Number of patients as divided in groups based on vertical length were (Group
1-7, Group 2-18, Group 3-11), horizontal width (GroupA-17, GroupB-19) and
depending on area (GroupI-14, GroupII-15, GroupIII-7). Mean of pterygium
vertically was 4.41±1.12 (Group 1-2.72±0.41, Group 2-4.18±0.50, and Group3-5.86±
0.45), horizontally 2.09±0.68 (GroupA-1.49±0.31 , GroupB-2.62±0.42) and of area
was 9.7±5.01(Group I-4.64±1.23, GroupII-10.98±1.93, GroupIII-17.21±2.20).
The photopic and mesopic contrast sensitivity in the vertical, horizontal and
area wise groups is shown in table 1. All the three parameters had a significant
negative correlation with the contrast sensitivity.
Table 1: Contrast sensitivity of groups as compared with controls
Contrast Vertical length Horizontal width
Area
Control
sensitivity Group1 Group2 Group3 GroupA GroupB GroupI GroupII GroupIII
(pvalue) (pvalue) (pvalue) (pvalue) (pvalue) (pvalue) (pvalue) (pvalue)
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
(0.37)
(0.019)‫( Ù‬0.00) ‫ Ù‬
(0.06)
(0.00) ‫ Ù‬
(0.453) (0.000) ‫( Ù‬0.000) ‫ Ù‬
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
(0.85)
(0.10)
(0.002)‫ Ù‬
(0.36)
(0.00)‫ Ù‬
(0.87)
(0.001)‫( Ù‬0.019) ‫ Ù‬
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
(0.68)
(0.001) ‫( Ù‬0.00) ‫( Ù‬0.012) ‫( Ù‬0.00) ‫ Ù‬
(0.11)
(0.000) ‫( Ù‬0.000) ‫ Ù‬
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
(0.22)
(0.016) ‫( Ù‬0.00) ‫( Ù‬0.017) ‫( Ù‬0.00) ‫ Ù‬
(0.10)
(0.002) ‫( Ù‬0.001) ‫ Ù‬
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
Mesopic6
(0.14)
(0.035) ‫( Ù‬0.00) ‫( Ù‬0.022) ‫( Ù‬0.00) ‫ Ù‬
(0.14)
(0.002) ‫( Ù‬0.002) ‫ Ù‬
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±0.33 1.28±0.23 1.86±0.26
(0.70)
(0.024) ‫( Ù‬0.00) ‫( Ù‬0.028) ‫( Ù‬0.001) ‫ Ù‬
(0.23)
(0.007) ‫( Ù‬0.000) ‫ Ù‬
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
(0.33)
(0.003) ‫( Ù‬0.00) ‫( Ù‬0.002) ‫( Ù‬0.00) ‫( Ù‬0.039) ‫( Ù‬0.002) ‫( Ù‬0.000) ‫ Ù‬
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
(0.10)
(0.01) ‫ Ù‬
(0.00) ‫( Ù‬0.005) ‫( Ù‬0.00) ‫( Ù‬0.033) ‫( Ù‬0.002) ‫( Ù‬0.000) ‫ Ù‬
DISCUSSION
Our study shows that the contrast sensitivity of patients in whom the vertical
length of pterygium is ≤3mm is not significantly different from the controls.
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But >3mm of vertical length of pterygium caused significant decrease in both
photopic and mesopic contrast sensitivity at mostly all spatial frequencies.
Patients in whom the horizontal extent of the pterygium exceeded 0.5mm
showed a decrease in both photopic and mesopic contrast sensitivity at all
spatial frequencies except in the lower spatial frequencies of 3 and 6 cpd under
photopic conditions.
When the area of the pterygium exceeded 7mm2, a significant decrease in both
photopic and mesopic contrast sensitivity was seen at all spatial frequencies.
Pterygium with less than 7mm2 area had decreased contrast sensitivity only in
higher mesopic spatial frequencies of 12 and 18cpd.
A significant negative correlation was seen between contrast sensitivity and
the vertical, horizontal dimensions and the area of the pterygium. Maximum
correlation was seen with the vertical dimension followed by area and then
the horizontal width.
Only two articles have previously reported the association of pterygium and
contrast sensitivity. One study done by Lin et al in 1989 showed that contrast
sensitivity was lower at all spatial frequencies in the patients with pterygium.5
Another study showed that contrast sensitivity at medium to-high spatial
frequencies of 6, 12, and 18 cpd significantly improved after pterygium
excision, while contrast sensitivity at low spatial frequencies of 1.5 and 3 cpd
did not change after surgery.6
Pterygium with vertical length >3mm, horizontal width ≥0.5mm and area
>7 mm2 caused a significant decrease in both photopic and mesopic contrast
sensitivity at all spatial frequencies. This could be a useful indicator of the
need for pterygium surgery.
REFERENCES
1.
Yagmur M, Özcan AA, Sari S, Ersöz TR. Visual acuity and corneal topographic
changes related with pterygium surgery. J Refract Surg. 2005;21:166–70.
2. Bahar I, Loya N, Weinberger D, Avisar R. Effect of pterygium surgery on corneal
topography: a prospective study. Cornea. 2004;23:113–7.
3.
Maheshwari S. Pterygium-induced corneal refractive changes. IJO 2007;55:383-6.
4.
Cinal A, Yasar T, Demirol A, Topuz H. The effect of pterygium surgery on corneal
topography. Ophthalmic Surg Lasers. 2001;32:35–40.
5.
Lin S, Reiter K, Dreher AW, Frucht-Pery J, Feldman ST. The effect of pterygia on
contrast sensitivity and glare disability. Am J Ophthalmol. 1989;107:407-10.
6.
Joo Youn Oh,Won Ryang Wee. The effect of pterygium surgery on contrast
sensitivity and corneal topographic changes. Clinical Ophthalmology 2010;4:315–9.
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To Study The Effect of Sub-conjunctival Injection
of Bevacizumab on Corneal Neovascularisation
Dr. Somnath Mukhopadhyay, Dr. Himadri Dutta, Dr. Jayanta Dutta,
Dr. Swarnali Sen, Dr. Pradeep Kumar Panigrahi
N
eovascularization is a severe complication of ischemic retinal diseases
such as diabetic retinopathy, branch and central retinal vein occlusion,
and retinopathy of prematurity. However, in various inflammatory corneal
diseases, corneal neovascularization may also occur, particularly in the
chronic course of the disease. The consequences of corneal neovascularization
may not only be a severe reduction of visual acuity but also a worse prognosis
for corneal transplantation because of loss of the immunologic privilege of the
avascular cornea.
However, the pathogenesis of corneal angiogenesis has not yet been fully
defined, and the identity and significance of different angiogenic growth factors
are debatable. Several studies have shown that vascular endothelialgrowth
factor (VEGF), which was identified about 1 decade ago, plays a major role in
vasculogenesis and in pathologic neovascularization. This protein stimulates
angiogenesis in a noninflammatory model of neovascularization in the
mouse cornea and was recently identified as a functional endogenous corneal
angiogenic factor required for inflammatory neovascularization in a rat model.
Bevacizumab is a humanized monoclonal antibody to VEGF designed for
intravenous administration and approved for the treatment of colorectal
Bevacizumab is currently injected into the vitreous for the treatment of
proliferative and nonproliferative diabetic retinopathy, agerelated macular
degeneration, and neovascular glaucoma, with successful outcomes and rapid
regression of the pathologic blood vessels.
We report here on our experience with subconjunctival injections of
bevacizumab for corneal neovascularization in human subjects.
MATERIALS AND METHODS
The study group consisted of 10 adults (4 men and 6 women) 32–89 years of
age with vascularized cornea , secondary to post DALK interface opacity(n=5),
contact lens users (n=3), and chemical burn (n=2).
All had extensive superficial and deep vascularization of the cornea and
had a failure of steroid drops trial (4 times daily) for the treatment of these
pathologic vessels. The study was approved by the Institutional Research
Ethics Committee and informed consent was obtained before the procedure.
Eyes were anesthetized with topical proparacaine hydrochloride drops.
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69th AIOC Proceedings, Ahmedabad 2011
Subconjunctival injection of 2.5 mg/0.1 mL bevacizumab was performed at
the limbus, adjacent to the pathologic blood vessel growth/sprouting into
the cornea. The injection was performed at the slit lamp after application of
a topical anesthetic drop and by using an eyelid speculum. Postoperatively,
patients were treated with topical moxifloxacin eyedrops 4 times daily for 1
week. As per our protocol, all eyes had at least 2 bevacizumab injections.
All eyes were biomicroscopically examined preoperatively,on postoperative
day 7 and at 1,2 and 3 months. At each visit, 2 digital corneal photographs were
taken with a digital camera attached to the slit-lamp microscope.
The photographs were graded for extent, centricity, and density of corneal
vascularization as follows. Extent was defined according to the number
of clock hours affected by neovascularization (score 1–12). Centricity was
defined as the distance the new vessels extended from the limbus toward
the visual axis: 1 = vessel extended a maximum of 2 mm from limbus, 2 =
extended 2–4 mm from limbus, and 3 = vessels extended to involve visual
axis/central 3 mm of cornea. Density was graded 1–4 according to the density
of neovascularization: 1 = very low (1 vessel), 2 = low, 3 = moderate, 4 = high
(compared with standard photographs).
RESULTS
The mean duration of follow-up was 3 months. The average number of
subconjunctival bevacizumab injections per eye was 2. Preoperative visual
acuity ranged from 20/30 to hand movements. There were no intraoperative
complications. No side effects were reported by the patients, nor was pain
or discomfort induced by the drug injection reported throughout follow-up.
Visual acuity did not change significantly in any patient in this study. Seven
patients (70%) showed partial regression of vessels, whereas 3 patients did not
react to the injection. During 3 months of follow-up, 6 (60%) patients had at
least a 1–clock hour decrease in the extent of blood vessels, and 4 (40%) had at
least a 2–clock hour decrease in the extent of vessels: Seven (70%) patients had
a decrease of 1 level in density but none showed any decrease in centricity of
blood vessels in the cornea.
DISCUSSION
Different substances have been identified in the past as potential vessel
inhibitors, including steroids, nonsteroid anti-inflammatory drugs, heparin,
cyclosporin A, methotrexate, and thalidomide. Although steroids have been
the mainstay of therapy for corneal neovascularization and corneal graft
rejection in clinical practice, they are not always effective, and chronic use
may cause prominent side effects. VEGF’s role in the pathophysiology of
corneal neovascularization has been shown in experimental models of corneal
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neovascularization, in experimental herpes simplex keratitis, and in studies
from human corneal buttons.
Also, VEGF inhibition has been shown to reduce corneal neovascularization
and improve corneal graft survival inexperimental animals.
In our study, we assessed the change in the area of pathologic vessels within
the cornea, whereas our grading system evaluated which of the 3 components
(extent, centricity, and density) responded most to the bevacizumab injection.
Indeed, a significant change in extent and density was shown, whereas
centricity of vessels did not react to the subconjunctival injection. Possibly, the
perilimbal application of the drug did not reach the more central part of the
vessel in the deep cornea. It is possible that these central vessels would respond
to a stromal injection rather than a perilimbal subconjunctival injection.
In conclusion, subconjunctival bevacizumab injection is efficacious in limiting
corneal neovascularization in human subjects. Whether this partial regression
of blood vessels is of clinical value needs to be studied in a randomized clinical
trial with a larger sample size and longer follow-up. Bevacizumab may also be
used in the future, as an adjunct to other drugs, for the treatment of corneal
neovascularization.
Neonatal Infectious Keratitis Five Years
Experience at a Tertiary Eye Care Center
Dr. Jatin Ashar, Dr. Muralidyhar R, Dr. Shivani Pahuja, Dr. Sunita
Chaurasia, Dr. Virender Sangwan
N
eonatal keratitis is a serious, vision- threatening disease. Infections in this
age group are difficult to diagnose, manage and are uniquely at a grave
risk for secondary amblyopia. Several large studies on microbial keratitis have
been reported in children1,2 however, literature on neonatal infectious keratitis
is limited.
To study the epidemiology, predisposing factors, clinico-microbial profile and
outcomes of neonatal microbial keratitis.
Study design: Retrospective, non consecutive, interventional case series.
MATERIALS AND METHODS
Medical records of 34 neonates (42 eyes) were analyzed for the age at
presentation, predisposing factors, systemic illness, clinical presentation,
microbiological profile, clinical course and outcomes. Examination was
performed using operating/ portable slit lamp microscope with /without
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anesthesia. Corneal scrapings were sent for microscopic examination using
Gram stain, 10% KOH wet mount, Giemsa stain and cultured on blood agar,
chocolate agar, Non Nutrient agar, and Potato Dextrose agar. IFA and PCR
for HSV were obtained on suspicion of HSV. Microorganisms were identified
on smears or culture and intensive antimicrobial therapy initiated based on
smear results and later modified according to culture, antibiotic sensitivity
pattern and clinical response.
Potential risk
No of patients
factors
%
Microbiological profile
1. Route of
Vaginal
27/34
79.41%
Pseudomonas-5/27,
delivery
Staphylococcus spp-3/7,
GPC-2/7,Gonococcus-1/7,
HSV-3/7,Fungus-2/7,
No Organism-8/7
Caesarean
7/34 20.5% Pseudomonas-4/7,
Staph. epidermidis-1/7,
GPC-2/7
2. Prematurity
3. Maternal
infections
1/34
2.94%
No organism isolated
Urinary tract
2/34
infection,
vaginal discharge
5.88%
Pseudomonas-1/2, HSV-1/2
4. Prolonged
9/34
26.47%
Pseudomonas- 4/9 (44.4%)
NICU care
Staphylococcus hemolyticus-
1/9 (11.1%)
Fungus-1/9(11.1%)
HSV-1/9 (11.1%)
No organism detected
-2/9(22.2%)
5. Associated Jaundice
4/34
11.7%
Systemic
condition
Seizures
1/34 2.94% Pseudomonas
Skin rashes/
2/34
vesicles
Sepsis
Goldenhar’s
syndrome
Pseudomonas-2/4,
No organism-2/7
5.88%
Pseudomonas-1/2, HSV-1/2
1/34 2.94% Pseudomonas
1/34
2.94%
No organism
6. Associated Lid coloboma
2/34
ocular
with lagophthalabnormality
mos (OU)
5.88%
Staphylococcus-2
2.94%
No organism
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Limbal dermoid 1/34
with lagophthalmos (OS)
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RESULTS
Average age at the time of presentation was 16.91 +7.74 days.•
Eight patients had bilateral involvement at presentation.
Symptoms at presentation:
Watering- 5 patients, Discharge- 11 patients, yellowish white spot- 31 patients
Risk factors and potential associations of infection identified were: Prematurity,
route of delivery, • maternal infections, systemic associations and ocular
malformations.
Microbiological Results:
Microbiology +:30/42 eyes
Smears and/or Culture positive: 31/42 eyes
Smears+/Culture- : 18/42 eyes
Smears-/Culture+:18/42 eyes
Smear and Culture +:9/42 eyes
Microbiology: 12/42 eyes
Microbiological profile.
Organism isolated in neonates with prolonged hospitalization: Total=16
patients•
Sensitivity pattern in hospital based infections:
Gram positive (4) - All Sensitive to first line drug, Cefazoline
Gram negative (8) - 3/8 Sensitive to first line drug Ciprofloxacin,
5/8 Resistant to multiple drugs, sensitive only to Imepenam
Management:
Medical: All
Topical antibiotic treatmentGram
positive:
cefazoline
Fortified
Gram Negative: Ciprofloxacin
Fungus: Natamycin
HSV: Acyclovir ointment
Systemic antibiotic- 6 patients
Surgical:
Lid surgery-3 eyes
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69th AIOC Proceedings, Ahmedabad 2011
TA+ BCL- 3 eyes
PK- 3 eyes
Evisceration-1 eye
Outcomes:
Average duration of treatment-33.86
(+ 2) days
Resolved with scar-28 eyes
Anterior staphyloma-2 eyes
Failed graft-3 eyes
India
DISCUSSION
Neonatal keratitis has diverse clinical presentation and underlying etiology.
Any watering and discharge in this age group should arouse suspicion and
thorough clinical evaluation for early diagnosis. Possible risk factors include
prolonged hospitalization, underlying systemic and ocular diseases. Most
infections (54.76%) in this period were of bacterial origin, with Pseudomonas
being the commonest bacteria isolated. Early identification of risk factors,
aggressive microbiology work-up and appropriate therapy is needed to
decrease ocular morbidity related to infectious keratitis in neonates.
REFERENCES
1.
Kunimoto DY, Sharma S, Reddy MK et al. Microbial keratitis in children.
Ophthalmology 1998;105:252-7.
2. Cruz OA, Sabir SM, Capo H, Alfonso EC. Microbial keratitis in childhood.
Ophthalmology 1993;100:192-6.
Efficacy and Safety of Topical Umbilical Cord
Serum Therapy in Persistent Corneal Epithelial
Defects
Dr. Charu Mithal, Dr. Anu Malik, Dr. Sandeep Mithal, Dr. Neha Mithal,
Dr. Prateek Agarwal, Dr. Pallavi Agarwal
T
he corneal epithelium shows a wound healing response in event of
any external injury or insult. Tears have antimicrobial nourishing and
mechanical and optical properties. They contain component such as growth
factors, fibronectin, and vitamins to support proliferation, migration and
differentiation of the corneal and the conjunctival epithelium. A lack of these
epitheliotrophic factors leads to persistent epithelial defects.
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Persistent epithelial defect (PED) is defined as a corneal epithelial defect of
2mm or larger in its greatest dimension persisting for 2 weeks or more despite
of conventional treatment with artificial tears or bandage contact lens usage.
It can be caused by keratoconjunctivitis sicca, exposure keratitis, neurotrophic
keratits, limbal stem cell failure, keratoplasty, chemical burns and corneal
ulcers. It has been seen that deficiency of essential tears components such
as epidermal growth factors (EGF), vitamin A,neurotrophic growth factors
(NGF) such as substance P, acetylcholine may exacerbate the lesions. Umbilical
cord serum which contains various growth factors, Vitamin A and fibronectin
in high concentration is hypothesized as a potent option for the treatment of
persistent epithelial defects resistant to other conventional therapy. This study
is aimed to evaluate the efficacy and safety of umbilical cord serum in cases of
persistent epithelial defects due to various causes.
(1) To study the efficacy and safety of topical umbilical cord serum in persistent
corneal epithelial defects. (2) To study the complications encountered (3) To
study the rate of recurrence.
MATERIALS AND METHODS
Study Design
Prospective, non comparative study, Study population: 20 eyes of 20 patients
with persistent corneal epithelial defects were selected from routine OPD of a
tertiary care centre. Patients were followed for a period of 6 months from the
day of starting the topical umbilical cord serum eye drops.
Inclusion Criteria
Patients of any age group, preferably cooperative for digital photography, were
included with PED of various etiopathogenesis e.g., Chemical burn, Diabetic
neurotrophic ulcer, Bacterial ulcer. Herpetic neurotrophic ulcer, Keratoplasty
(optical and therapeutic), Dry Eye.
Exclusion Criteria
Patients with the following conditions were excluded: Pregnant and lactating
women, Immunological conditions like rheumatoid arthritis, active corneal
ulcer, impending perforation, acute ocular infection, abnormality of eyelid
and adenexa eg – trichiasis, blepharitis, ectropion, entropion. Processing Of
Umbilical Cord serum: Umbilical cord blood was collected from mothers of
uncomplicated caesarean deliveries after informed consent and screening for
hepatitis B, C and HIV. No anticoagulants were used during the procedure.
The blood was allowed to clot and was centrifuged at 1500 rpm for 5 min then
diluted in normal saline to make 20% solution. The serum was stored at -4
degrees C. This diluted umbilical cord serum was stored in 5 ml sterilized
vials and was given to patients. Patients were to apply this serum in drop 6
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69th AIOC Proceedings, Ahmedabad 2011
times a day and were asked to store it in a cool place, preferably in a refrigerator
or ice box.
RESULTS
(1) Details of Patient – Name, age and address of the patient were noted. His/
her diagnosis (cause of persistent epithelial defect) and past treatment was
also recorded. (2) Visual Acuity (both unaided and best corrected). (3) Proper
slit lamp evaluation was carried out to exclude any adenexal abnormalities as
the cause of PED, cornea was evaluated in full detail, emphasis was paid on
the size and site of epithelial defect, the corneal thickness and vascularization.
(4) Schirmers test–was carried out in each and every patient and was repeated
at every follow up. (5) Fluorescein staining (6) Digital IOP – was assessed by
the same examiner in every case. The patients were followed up on days 3, 7,
14, 21, 24, 28 and so on for 6 months. The variables recorded at each follow up
visit were the best corrected visual acuity, the maximum size of the epithelial
defect along two perpendicular axes measured with a slit lamp, and also a
photograph of the same, a record of the side effects if any, and the digital
intraocular pressure.
The effectiveness of the treatment was divided into three groups.
1. Effective – Those defects that took less than 2 weeks to heal.
2. Partially Effective – Those defects that took less than 4 weeks to heal.
3. Ineffective – Those defects that took more than 6 weeks to heal or did not
heal at all.
Table 1: Effectivness of The Treatment
Healing Pattern
Number
Percentage (%)
Effective
12
60%
Partially Effective
06
30%
Ineffective
02
10%
In our study we found that out of 20, 12 patients (60%) showed effective
response to umbilical cord serum eye-drops and 6 patients (30%) showed
partially effective response. However, in the later two cases i.e. (10%), healing
was ineffective (took more than 6 weeks to heal).
Table 2: Duration Taken By The Epithelial Defect To Heal
Time (weeks)
Number
Less than 1 week
4
1-2
8
2-3 7
3-4 3
more than 4 weeks
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Regarding the duration taken by epithelial defects to heal we see that 8 out
of 20 patients had their epithelial defect healed in 2 weeks (40%), and 4 out
of 20 healed within one week, thus a total of 12(60%) healed within 2 weeks
suggesting the treatment to be effective. There have been no side effects noted
during the entire period of our study suggesting the umbilical cord serum
eye-drops to be safe for the use on ocular surface.
Epithelial defect did not recur in patients who responded to umbilical cord
serum eye-drops, after 6 months of follow up showing that epithelial wound
healing was complete.
DISCUSSION
The cornea produces multiple growth factors such as epidermal growth
factor (EGF) and fibroblast growth factor (FGF), neurotrophic growth factor
which contribute to the maintenance of a healthy epithelial surface and its
regeneration. Persistent epithelial defects is rare but has serious complications.
It has been seen that deficiency of essential tears components such as epidermal
growth factors (EGF), vitamin A, neurotrophic growth factors (NGF) such as
substance P, acetylcholine may exacerbate the lesions.
Umbilical cord serum owes its efficacy to the presence of factors such as EGF,
vitamin A, acidic and basic FGF, fibronectin, nerve growth factor, substance P,
antiproteases like α2 macroglobulin, and enhanced mucin expression due to
the serum.7 The mechanism of action of umbilical cord serum is likely to be
the same as that of autologous serum, the difference being probably a higher
concentration of the growth factors, which may in fact stimulate a faster
growth of stem cells and hence lead to a faster re-epithelialisation.
The results are comparable with the study of Yoon et al (2005) who performed
the study on 14 patients with persistent epithelial defect of various etiologies
and found umbilical cord serum to be effective in 6 patients (42.9%) and partially
effective in 6 patients (42.9%). Umbilical serum treatment has several clinical
advantages, firstly,by obtaining a large quantity of umbilical cord blood from
mothers, the serum can be supplied to many patients. Second, umbilical cord
serum eyedrops can be prepared in advance, thereby shortening the waiting
period for the patients. Finally,even when taking the blood from the patients
themselves is difficult due to poor general condition, umbilical cord serum
remains a feasible option.
Recently Vajpayee et al have reported that since umbilical cord serum contains
a higher concentrations of EGF, Vitamin A, acidic and basic FGF, fibronectin,
NGF, substance P, and antiproteases like alpha 2 macroglobulins, it may be
more useful for the treatment of the ocular surface than autologous serum.
They also reported that the recovery was faster using umbilical cord serum,
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69th AIOC Proceedings, Ahmedabad 2011
compared to autologous serum, for persistent corneal epithelial defect
refractory to medical treatment.
Although we have used 20% umbilical cord serum eyedrops in this study,
there is no agreement on the best dilution concentration of serum for use in
ocular surface diseases.
Umbilical cord serum, a preparation that can be easily prepared , is an effective
means of promoting epithelialisation and can be safely used .
Sympathetic Ophthalmitis Following Optical
Penetrating Keratoplasty In The Last 9 Years
Dr. Rekha Gyanchand, Dr. Sheetal Hegde
S
ympathetic Ophthalmia is a rare bilateral diffuse autoimmune
granulomatous uveitis occurring in patients who have sustained
penetrating ocular insult either as a result of trauma or as a rare consequence
of ocular surgery. The incidence is 0.2%-0.5% following trauma and less the
0.1% following surgery. Ophthalmic procedures that have been reported to
result in sympathetic ophthalmia include cataract surgery, glaucoma filtering
surgery, scleral buckling, pars plana vitrectomy, laser cyclophotocoagulation1
and proton beam irradiation. However literature reports very few cases of
sympathetic ophthalmia following penetrating keratoplasty.2,3
MATERIALS AND METHODS
A retrospective study was done of 5 cases seen from 2001-2009 at the Cornea
Clinic in Bangalore West Lions Superspeciality Eye Hospital, Bangalore.
All 5 patients had history of penetrating injury and underwent penetrating
keratoplasty (3 cases for leucomatous corneal opacity with vascularization
following primary repair while 2 cases for corneal decompensation following
vitrectomy for IOFB removal).
Bilateral ocular examination on follow-up consisted of visual acuity testing for
distance and near, color vision, anterior segment examination with slit lamp
biomicroscopy, fundus examination and IOP recording. During regular postoperative follow-up visit, these patients complained of gradual decrease in
visual acuity in the normal eye.
Further investigations done to rule out systemic association for ocular
inflammation were normal. Retinal S antigen was positive in one case.
The history of penetrating eye injury and subsequent surgery, with the finding
of granulomatous inflammation in both eyes raised suspicion of sympathetic
ophthalmitis as a possible diagnosis.
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RESULTS
All the patients were males between 14-33 years who had history of penetrating
ocular injury and primary surgical treatment (3 cases had primary corneal
tear repair while 2 cases underwent vitrectomy with IOFB removal.)
Injury
Primary
Penetrating
Sympathetic
Injury to
PK to
history
diagnosis Keratoplasty ophthalmia onset SO Time
SO Time
Interval Interval
1994 Leucoma 2001
2009
16yrs 8Yrs
1996
Leucoma
2005
2006
11yrs
1996
Leucoma
2000
2001
7yrs
1yr
2001
Corneal decom- 2005
pensation
(IOFB removal)
2007
7yrs
3yrs
2007
6yrs
1yr
2002
Corneal decom pensation
(IOFB removal)
2006
1Yrs
Clinical Findings
Sympathizing Eye
Exciting (Post-Pk)Eye
Anterior Segment
Granulomatous uveitis-5 cases
Signs of diffuse endothelial
rejection- 5 cases
Koeppe nodule-1 case
Glaucoma-4 cases
Posterior Segment
Vitritis-5 cases
Dalen Fuchs Nodule-1 case
Exudative RD-1 case
There were no significant extra ocular findings in any of these patients.
Following keratoplasty, the onset of sympathetic ophthalmitis varied between
1-8 years and following primary injury the onset varied between 6-16 years.
According to reports sympathetic ophthalmitis developed in 80% patients
within 3 months of injury and in 90% within 1 year.5 However isolated cases
as early as 1 week or as late as 66 years after initial injury have been reported .6
Vision
Sympathizing Eye
On presentation
Sympathizing Eye
After treatment
Exciting Eye
Post PK, Graft rejection
CF CF
6/60
HM+ve
6/12
6/9p
PL+ve, PR accurate
6/12
6/9p
PL+ve, PR accurate
6/60
6/36
PL+ve, PR accurate
CF 1m
6/36p
6/36
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2 cases with early presentation had excellent recovery while 3 patients had
moderate recovery due to retinal detachment, extensive RPE atrophy and
glaucomatous cupping.
Oral steroids were given in the dose of 1.5mg/kg body weight and the patients
were continued on a maintenance dose for 1 year. 2 patients were started on
Azathioprine 50mg/day while 1 patient was treated with Methotrexate.
DISCUSSION
Sympathic Ophthalmitis has been reported to occur mainly following trauma.
However it has also been reported to occur following ocular surgery like cataract
surgery, scleral buckling, parsplana vitrectomy7, laser photocoagulation Our
study included patients with sympathetic ophthalmitis developing after
penetrating keratoplasty. The indications for keratoplasty were leucomatous
corneal opacity following primary corneal repair (3 patients) and endothelial
decompensation following IOFB removal (2 patients). According to studies,
penetrating keratoplasty for corneal decompensation following IOFB removal
are at high risk for sympathetic ophthalmitis.8
Dalen Fuchs Spots
The onset of symptoms usually occurs between 3 weeks to 6 months following
surgery. In our study, the symptoms in sympathizing eye occurred between
1-8 years after surgery. The typical presentation of sympathetic ophthalmitis
is a bilateral panuveitis that occurs after ocular
trauma or intraocular surgery.9 In our study
the sympathizing eye showed mild- moderate
granulomatous anterior uveitis with vitritis
and multifocal choroiditis. Dalen Fuchs spots
with vitritis was present in 1 patient. This is
usually seen in 36%-47% cases.10
In our study the exciting eye had 1-2 attacks
of endothelial rejection 6-8 months after
corneal grafting. It has been seen that corneal
endothelial rejection does precipitate the
Figure 1: Dalen Fuchs Spots
sympathetic ophthalmitis as graft rejection
and sympathetic ophthalmitis have a similar cell- mediated cytotoxic reaction
towards antigens on uveal pigment epithelium.11
Earlier sympathetic ophthalmitis was considered to be a dreaded disease,
however in our study as well as other recent studies,1,7 it has been seen that if
treated early and adequately, it has a good visual outcome. Our study stresses
the need for surgeons to fully explain the risks involved to patients undergoing
penetrating keratoplasty in cases with trauma, post vitrectomy or probably
any ocular surgery compromising cornea and which may require penetrating
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keratoplasty, and to be alert to the possibility of sympathetic ophthalmitis in
the event that the patient develops visual complaints in the better eye.
• Delayed onset of Sympathetic ophthalmitis can be suddenly precipitated
by corneal transplantation in eyes with old history of penetrating injury.
• It is important to examine the normal eyes especially in the follow-up visit
in cases of corneal transplantation done for adherent leucoma following
penetrating injury.
REFERENCES
Liddy L, Stuart J. Sympathetic Ophthalmia in Canada. Can J Ophthalmol 1972;7:157-9.
1.
2. Sixty years (1913-1978) of sympathetic ophthalmia. Review of 105 cases.
Ophthalmology 1980;7:109-21.
3.
Bechrakis NE, Muller Stolzenburg, Helbig H, Foerster MH. Sympathetic
Ophthalmitis following laser cyclocoagulation. Arch Ophthalmol 1994;112:80-4
4.
PK for the exciting eye in SO. Cornea 2008;27:1080-1.
5.
Lubin J, Albert D, Weinstein M. 65 years of SO. A clinicopathological review of 105
cases (1913-1976). Ophthalmology 1980;87:109-21.
6.
ZahariaMA, Lamarche J, Laurin M. Sympathetic uveitis 66 years after injury. Can
J Ophthalmol 1984;19:240-3.
7.
Pollack AL, McDonald HR et al. Sympathetic Ophthalmitis associated with pars
plana vitrectomy without antecedent penetrating trauma. Retina 2001;21:146-54.
8.
BJO 2000 Dara J Kilmartin, retinal risk factor for SO
9.
Dada T, Kumar A, Sharma N. Sympathetic Ophthalmia associated with antecedent
adherent leucoma- A rare association. Acta Ophthalmol Scand. 1998;76:380-1.
10. 32 Cases of Sympathetic Ophthalmia. Arch Ophthal. 1995;13.
11. Early stage of Human Sympathetic Ophthalmitis, Histologic and
logic findings. Muller HK et al. Arch Ophthalmol 1984;102:1353-7.
Immunopatho-
Dr. SOMASHEILA I MURTHY: MBBS (1992), TN Medical College; MS
(1996), LTM Medical College, Mumbai University; DOMS, FCPS, Mumbai;
Cornea and Anterior Segment fellow (1998), LVPEI, Hyderabad; Uveitis
and Ocular Pathology fellow (2000), Doheny Eye Institute, USA. Presently,
Consultant, Cornea and Anterior Segment, Ocular Immunology and Uveitis
Service, LVPEI, Hyderabad. E-mail: [email protected]
Comparision of Endothelial Cell Count by
Manual And Automated Methods in Normal
Cornea and in Fuchs’ Endothelial Dystrophy
Dr. Somasheila I Murthy, Dr. Debarun Dutta, Dr. Tamal Chakraborti,
Dr. Pritam Kumar
E
ndothelial cells are crucial to maintain corneal health and its count is
important in any endothelial abnormality.1,2,3 The Cell Count software
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69th AIOC Proceedings, Ahmedabad 2011
of NIDEK Confoscan 4 is regularly used to perform corneal endothelial cell
analysis, either automatically or manually. The automatic cell analysis returns
information about the cell density and morphology of a selected Region of
Interest (ROI), while the manual cell analysis can only evaluate the cell density
of a selected ROI. Confoscan results are said to provide 95% of probability to
have a difference between the estimate and the real cell count value lower than
10%.4 Clinically, while performing cell count, it is important that Confoscan
should provide accurate results even in abnormal endothelium.
The purpose of the study is to evaluate the difference in endothelial cell
count between automated and manual methods in healthy cornea and Fuchs’
endothelial dystrophy.
MATERIALS AND METHODS
1.
Study design: retrospective analysis.
2.
Data was analysed by single experienced observer.
3.
One hundred images from both healthy and Fuchs’ endothelial dystrophy
were reviewed by single observer.
4.
Archived images of the endothelium from the NIDEK Confoscan 4
were used to procure endothelial cell counts by automated and manual
methods.
5.
The following parameters were required to select the image: Endothelial
images were clear in all the slides and around 50 to 100 cells were taken
in each in slide to count as per manufacture guideline.
• After having selected the Region of Interest, the automatic cell count
was processed by clicking the corresponding button
• For manual count, at first respective cells were selected in the region of
interest. Hence a custom polygonal area drawn along with the wall of
the borderline cells to surround the group of cells. Density information
given by the following formula: Density = cells in polygon / Polygon
area [cells/mm2]4
• Cell count difference between two methods of >250 cells/mm2 was
considered clinically significant.
RESULTS
• 52 and 65 images were of right healthy and compromised endothelium
eyes respectively.
• Based on manual cell count, endothelial cell density of Fuchs’ dystrophy
slides divided into two groups.
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Table 1: Endothelial cell counts done by automated and manual
methods in images from Fuchs’ dystrophy
Number of Average
Images
auto count
Average
manual count
Average
difference
Range of cells p value
(difference)
Cell count
49
more than
1000 cells / mm2
2028.73 ± 329.53 1719.82±489.47 312.96±337.27 402 to 2 cells <0.0001
Cell count
51
less than
1000 cells / mm2
1626.73 ± 186.50 673.62±149.52 953.12±246.70 1631 to 54 cells <0.0001
Table 2: Endothelial cell counts (cells/mm2) in healthy and fuchs’
dystrophy cornea
images
average
auto count
Healthy
Cornea
average
manual count
average
difference
100 2471.24 ± 273.19 2444.50 ± 370.30 125.67 ± 86.9
range of cells p value
(difference)
402 to 2 cells
0.0463
Fuchs’
100 1827.73 ± 334.31 1196.71 ± 637.29 633.04 ± 435.03 1631 to 54 cells <0.0001
Dystrophy
• In the first group manual count was more than 1000 cells/mm2 (49 images)
and in the second group manual count was less than 1000 cells/mm2 (51
images)
• The cell count differences between the two methods were significantly
higher when cell counts were least, which implies that the difference tends
to increase in eyes with extensive endothelial changes.
• The results are summarized in Tables 1 and 2.
DISCUSSION
Advantage of automated mode is that there is no inter-observer variability, it
is faster, repetitive and is independent of users’ experience and skills.5 On the
other hand manual mode is time consuming needs higher level of technical
skills and thereof it is unsuitable in busy clinic. In our study the results
have shown a large variability between the two methods (as much as up to
more than 900 cells/mm2 difference) in advanced cases of Fuchs’ dystrophy.
Decision on whether a patient need surgery may be affected by whether we do
it in manual or automated mode thus delaying the surgical intervention on the
final outcome. Both the clinician and investigator need to be sensitive to this
fact and patients with diseased corneas should undergo manual count.
Our study shows that while in healthy corneas, both methods showed similar
counts; in the case of diseased cornea, the accuracy of the automated count
decreased with decrease in total cells. Manual count is therefore more reliable
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69th AIOC Proceedings, Ahmedabad 2011
in compromised endothelium as automated count overestimates the results,
and can even give a value in normal range, thus misleading the clinician.
REFERENCES
2. Klais CM, Bühren J, Kohnen T. Comparison of endothelial cell count using confocal
and contact specular microscopy. Ophthalmologica. 2003;217:99-103.
3.
Módis L Jr, Langenbucher A, Seitz B. Corneal endothelial cell density and
pachymetry measured by contact and noncontact specular microscopy. J Cataract
Refract Surg. 2002;28:1763-9.
4.
Doughty MJ. Toward a quantitative analysis of corneal endothelial cell morphology:
a review of techniques and their application. Optom Vis Sci. 1989;66:626-42.
5.
NAVIS for Confoscan 4 Operator’s Manual ©2005-2007.
6.
Imre L, Nagymihály A. Reliability and reproducibility of corneal endothelial
image analysis by in vivo confocal microscopy. Graefes Arch Clin Exp Ophthalmol.
2001;239:356-60.
Streptococcus Pneumoniae Keratitis: Fortified
Antibiotics or Fluoroquinolones?
Dr. Sujata Das, Dr. Savitri Sharma, Dr. Vivek Warkad, Dr. Srikant K Sahu
F
ortified topical ocular antimicrobial (usually cephalosporin and
aminoglycoside) is frequently administered to cover the maximum
spectrum of bacteria in cases of severe bacterial keratitis. Treatment is modified
according to the clinical response and sensitivity of the microorganism.1-4
Frequent dosing of multiple antibiotics may result in increased toxicity and
damage to the ocular surface epithelium.2,3
For antimicrobial therapy to be effective in cases of microbial keratitis, it
should reach the site of corneal infection in sufficient concentration to inhibit
and preferably kill the causative microorganism while causing minimal
or no toxicity to the host. Several factors modulate the interaction between
drug, microorganisms, and the host. The purpose of this study was to test in
vitro susceptibility of Streptococcus pneumoniae isolated from patients with
microbial keratitis in order to determine the most suitable antibiotic for the
treatment of keratitis caused by the organism.
MATERIALS AND METHODS
The medical and laboratory records of all culture-proven cases of S
pneumoniae keratitis diagnosed at the L V Prasad Eye Institute, Bhubaneswar,
India between November 2006 and December 2009 were reviewed
retrospectively. All patients had undergone detailed clinical evaluation and
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slit-lamp examination. Corneal scrapings were obtained from all patients as a
part of a standard protocol and subjected to direct microscopic examination
(Gram and/or Giemsa, potassium hydroxide [10.0%] with calcoflour white)
and inoculation into various culture media such as sheep blood agar (BA),
chocolate agar (CA), Sabouraud dextrose agar (SDA), non-nutrient agar (NNA),
and brain heart infusion (BHI) broth. SDA bottles were incubated at 26±1OC
to enhance the growth of fungi, and the remaining plates were incubated at
36±1OC. While CA plates were incubated with 5% carbon dioxide, BA and BHI
broth were incubated aerobically, and NNA were incubated aerobically with
an added live Escherichia coli suspension. All media were incubated for two
weeks and were examined daily. A culture was considered significant and
was reported if the smears demonstrated morphologically similar organisms
and/or if the same organism grew in more than one medium and/or if there
was growth on at least two streaks on blood agar. In vitro susceptibility of the
isolates was tested by Kirby Bauer disc diffusion method and interpreted as
per CLSI guidelines. Muller Hinton agar with blood and commercial antibiotic
discs (cefazolin, chloramphenicol, vancomycin, ciprofloxacin, ofloxacin,
moxofloxacin, gatifloxacin) from Himedia, Mumbai were used for the test.
Zones of inhibition were noted in millimeter and interpreted as resistant,
sensitive or intermediate as per the chart provided by the company.
Intensive topical medication was started on the basis of the smear result. Topical
medication was modified in some cases depending on the clinical response,
culture report, and sensitivity of the isolated organism. The retrospective
data included patient demography (age, gender, and occupation), disease
history (onset, course, predisposing factors), clinical appearance, antibiotic
susceptibility, treatment and outcome.
RESULTS
Among 990 corneal scrapings/corneal tissues from clinically diagnosed cases
of microbial keratitis at our Institute between November 2006 and December
2009, 61 (6.2%) corneal scrapings of sixty patients were culture positive for S
pneumoniae. The mean age was 45.9±21.3 years (range: 6 months to 78 years,
median: 50). The male to female ratio was 40:20. Most patients were in the age
group 41-70 years (n=36, 60%).
An ocular predisposing condition was identified in 51 eyes. Fourteen had
undergone keratoplasty and 9 had chronic dacryocystitis. Twenty five eyes
(40.9%) had a history of ocular trauma. Fourteen eyes had polymicrobial
infection. Thirty one eyes required an adjunctive procedure. Five eyes
underwent therapeutic keratoplasty, and 20 eyes underwent tissue adhesive
and bandage contact lens application. The in vitro susceptibility of the isolates
by disc diffusion method was 100% to cefazolin, 95.1% to chloramphenicol,
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69th AIOC Proceedings, Ahmedabad 2011
90.9% to vancomycin, 88.9% to gatifloxacin and 78.7% to ciprofloxacin. Six
isolates were resistant to more than one antibiotic.
DISCUSSION
S pneumoniae is a common cause of bacterial keratitis. It accounts for around
30-40% of all bacterial keratitis.5-7 Chronic dacryocystitis is a well known
risk factor for microbial keratitis due to S pneumoniae.5,7 It is also reported
as a common pathogen isolated from microbial keratitis after corneal
transplantation. Although trauma is not known to be a common predisposing
factor associated with microbial keratitis due to S pneumoniae, it is a major
predisposing risk factor in our series.
Resistance to penicillin, other beta-lactam and non-beta-lactam compounds
have been reported with an increased frequency in recent years among
clinical isolates of S pneumoniae.8 These strains are effectively killed with
new fluoroquinolones.9 Nevertheless, fluroquinolone resistance among the
pneumococcal clinical isolates have been primarily attributed to mutations
in the quinolone resistance-determining regions of the gyrase A and
topoisomerase IV gene.10
Although ciprofloxacin is effective in vitro against S pneumonae, it is felt that
in vivo efficacy may be inadequate, leading to the choice of fortified cefazoline
as the first line of therapy. In our study, in vitro susceptibility of the isolates
was 100% to cefazolin, 95.1% to chloramphenicol, 90.9% to vancomycin, 88.9%
to gatifloxacin and 78.7% to ciprofloxacin. Ramkrishnan et al have compared
in vitro efficacy of fluroquinolones against S pneumoniae isolated from
bacterial keratitis by E-test.11 They have concluded that S pneumoniae are 100%
sensitive to fluoroquinolones. They also concluded that fourth-generation
fluroquinolone, moxifloxacin appeared to be more effective than gatifloxacin,
levofloxacin, ofloxacin and ciprofloxacin.
In our study, sensitivity to gatifloxacin was more than ciprofloxacin. Compared
to earlier studies,5,11 sensitivity to ciprofloxacin was less in our series. Though,
there was zero resistance to cefazoline, preparation and storage of fortified
solution has its own limitation. In contrast, fluroquinolone are cheap and
readily available commercially. Therefore, till the antibiotic sensitivity results
are not available, patients may be continued with fortified cefazoline and
fluroquinolone eye drops. Fortified cefazoline may be discontinued according
to the clinical response and sensitivity.
REFERENCES
1.
510
Baum JL, Barza M, Weinstein L. Preferred routes of antibiotic administration in
treatment of bacterial ulcers of the cornea. Int Ophthalmol Clin 1973;13:31-7.
Cornea Free Papers
2. Baum JL. Initial therapy of suspected microbial corneal ulcers. I. Broad antibiotic
therapy based on prevalence of organisms. Surv Ophthalmol 1979;24:97-105.
3.
Jones DB. Initial therapy of suspected microbial corneal ulcers. II. Specific antibiotic
therapy based on corneal smears. Surv Ophthalmol 1979;24:105-16.
4.
Hyndiuk RA, Cockington CD. Bacterial keratitis. In: Tabbara KF, Hyndiuk RA
(eds.). Infections of the eye: diagnosis and management. Little Brown, Boston, 1996:
323–47.
5.
Parmar P, Salman A, Kalavathy CM, Jesudasan CA, Thomas PA. Pneumococcal
keratitis: a clinical profile. Clin Experiment Ophthalmol 2003;31:44-7.
6.
Srinivasan M, Gonzales CA, George C, Cevallos V, Mascarenhas JM, Asokan B,
Wilkins J, Smolin G, Whitcher JP. Epidemiology and aetiological diagnosis of
corneal ulceration in Madurai, south India. Br J Ophthalmol 1997;81:965-71.
7.
Aasuri MK, Reddy MK, Sharma S, Rao GN. Co-occurrence of pneumococcal
keratitis and dacryocystitis. Cornea 1999;18:273-6.
8.
Thornsberry C, Ogilvie P, Kahn J, Mauriz Y. Surveillance of antimicrobial
resistance in Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella
catarrhalis in the United States in 1996-1997 respiratory season. Diagn Microbiol
Infect Dis 1997;29:249-57.
9.
Zhanel GG, Walters M, Laing N, Hoban DJ. In vitro pharmacodynamic modelling
simulating free serum concentrations of fluoroquinolones against multidrugresistant Streptococcus pneumoniae. J Antimicrob Chemother 2001;47:435-40.
10. Tankovic J, Perichon B, Duval J, Courvalin P. Contribution of mutations in gyrA and
parC genes to fluoroquinolone resistance of mutants of Streptococcus pneumoniae
obtained in vivo and in vitro. Antimicrob Agents Chemother 1996;40:2505-10.
11. Ramakrishnan R, Ramesh S, Bharathi MJ, Amuthan M, Viswanathan S.
Comparative in-vitro efficacy of fluoroquinolones against Streptococcus
pneumoniae recovered from bacterial keratitis as determined by E-test.
Indian J Pathol Microbiol 2010;53:276-80.
Fibrin Glue (FG) Augmented Amniotic
Membrane Transplantation (FGAMT) in
Peripheral Corneal Perforations
Dr. Ritu Arora, Dr. Jasneet Kang, Dr. J L Goyal, Dr. Monika Mittal,
Dr. Parul Jain
T
o evaluate the efficacy of fibrin glue (FG) augmented amniotic membrane
transplantation (AMT) in non infective peripheral corneal perforations.
Corneal perforations can result from a variety of ocular disease states
associated with chronic inflammatory conditions. Regardless of the cause,
perforation is an emergency and prompt treatment is required.
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69th AIOC Proceedings, Ahmedabad 2011
Many surgical approaches, such as tissue adhesive, bandage contact lens,
transpositional conjunctival flap, and therapeutic penetrating keratoplasty
(PK), have been used to treat corneal perforations. However, these surgical
modalities are associated with a large number of problems eg. tissue
inflammation from glue toxicity, diminished vision, and poor cosmesis with
a conjunctival flap and tarsorrhaphy and graft failure in the setting of an
inflamed or infected eye.1
Lee and Tseng were the first to propose the use of human amniotic membrane
(AM) for the treatment of corneal epithelial defects.2 For deep and severe
ulcerations, Kruse et al suggested multi layer AMT and showed rapid epithelial
healing and stromal thickening after multilayer AMT.3 Solomon et al reported
a favorable clinical outcome in 34 eyes that underwent multi layer AMT for
nontraumatic corneal perforations, descemetoceles, and deep ulcers.4 The use
of FG for attaching the AM graft has been reported by Pfister and Sommers
in different ocular surface disorders.5 There have been clinical reports
addressing AM grafts with FG sealant in the treatment of corneal perforations.
Duchesne et al combined the use of amniotic membrane transplantation with
human fibrin glue to repair corneal perforation and found it to be successful
in corneal perforations upto 2 mm in diameter associated with significant loss
of stroma.6
However in large corneal perforations (upto 4mm diameter) the application of
FG alone as a plug cannot seal the defect completely or stabilize the anterior
chamber. Also, this technique cannot be used in severe clinical circumstances,
such as iris incarceration or collapsed anterior chamber.
To offset these limitations of AM graft with fibrin plug in eyes with large
corneal perforations, FG-assisted augmented AMT may be beneficial. Kim et
al reported it to be a successful procedure in large perforations.7
The aim of the present study was to assess the efficacy of FG-assisted augmented
AMT in treating large corneal perforations (2 mm or more in diameter) and to
evaluate the long-term stability of the corneal surface.
MATERIALS AND METHODS
10 patients with peripheral corneal perforations upto 4 mm in diameter were
treated with ‘‘FG assisted augmented AMT.’’ The perforated edges of the
ulcer was cleaned and partially necrotic tissue was removed. The augmented
AM was designed 0.5 mm larger than the diameter of the perforation. Five
or 7 designed pieces of AM were prepared. A drop of fibrinogen- thrombin
solution (Tissel glue) was applied to the first AM piece. The second AM was
then transferred onto the first AM. A blunt spatula was used to spread out the
FG between the AM pieces. The procedure was repeated and several pieces
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of AM were pasted to make a thick single piece of multilayered AM called an
‘‘augmented AM.’’ The last pasted AM was positioned with the epithelial side
up to serve as a basement membrane for reepithelialization. This was then
transplanted to the perforated site using 10-0 nylon. The anterior chamber
was reformed with balanced salt solution. If needed, a temporary AM patch
was placed was placed over the entire wound and cornea after securing the
perforated wound with 10-0 nylon placed around the limbus. All corneal
wounds were covered with bandage contact lenses over the AM and topical
antibiotics were used for 3 weeks.
A slit-lamp examination was performed daily to assess graft integrity and
check for signs of inflammation, infection, changes in the ocular surface, and
ulcerated underlying stroma. After complete reepithelialization, follow up
was monthly to assess graft integrity and monitor for any complications.
Surgical success was defined as a negative Seidel test, an adequate anterior
chamber depth, and complete epithelialization through the end of the followup period.
RESULTS
The FG-assisted augmented AMT was performed in 10 patients (6 women, 4
men) with a mean age of 51.5 +/- 15.3 years (range, 21–70 years). The average
follow-up was 4.5 +/- 1.2 months (range, 3–6 months). Mean ulcer diameter
was 2.87 +/- 0.95 mm (range 2–4 mm). BCVA was 20/120 or more in all patients
at 6 months. All had well formed anterior chambers and 90% showed complete
epithelialization. Mean reepithelialization time was 15.76+/- 3.95 days. In all
patients the anterior chamber was deep, and there was no further leakage
of aqueous fluid; the site of the ulcer showed a subepithelial scar with, in
some cases, a thickening of the stroma, and epithelialization was complete.
Conjunctival inflammation and pain were reduced in all patients. In none of
the patients was there any evidence of recurrent ulceration or perforation and
the stromal thickness at the perforation site seemed normal and stable during
the follow-up period ( as seen on Anterior segment OCT).
DISCUSSION
Fibrin glue in combination with AMT seems helpful in the treatment of
corneal perforations up to 4 mm in diameter. AM contains a mix of growth
factors, neurotrophins, and cytokines that facilitates proliferation of epithelial
cells and reduce the inflammatory response by inhibiting protease activity
and thus reduce vascularization, inflammation, and scarring. These unique
properties of AM make it useful in the treatment of ulcerative corneal disease.8
The AM does not express the antigens HLA-A, B, or DR and therefore poses no
problem of immunological rejection. AMT may allow postponement of corneal
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69th AIOC Proceedings, Ahmedabad 2011
grafting until the eye is less inflamed, thereby improving graft survival or even
avoiding it altogether. The presence of the glue enhances scar tissue formation
as it prevents epithelial downgrowth and stimulates fibroblastic activity while
serving as a matrix for fibroblasts and keratocytes.9
Our study demonstrates the effectiveness of the FG-AMT in the treatment of
refractory large peripheral corneal ulcers. There was a reduction in the level
of conjunctival inflammation and pain after AMT. All patients epithelialized
successfully and had a stable scar over time.
This procedure has several advantages in the treatment of corneal perforations,
especially those of large size. The thickness of each augmented AM is equal
to that of healthy cornea allowing it to completely seal the large perforated
wound and prevent any leakage, hence maintaining a stable anterior chamber.
Additionally, it can be easily manipulated because it was a single piece of AM
instead of several sheets which further allows for a secure wound and also
reduces the surgical time. Also there is early reepithelialization of the corneal
surface as compared with a previous multilayer AMT report. This shows
that FG-assisted augmented AMT is more effective than multilayer AMT in
promoting healing of the epithelial layer in large corneal perforations.10
In conclusion, FG-assisted augmented AMT is a stable alternative for treating
large corneal perforations—especially those 2 mm or larger in size—with rapid
regeneration of epithelium and stability during the follow up period. This
technique promotes a stable and rapid reconstruction of the ocular surface
and can also be used as a temporary measure in cases requiring penetrating
keratoplasty at a later time when the eye is less inflamed and the corneal
surface has reepithelialized.
REFERENCES
1.
Nobe JR, Moura BT, Robin JB, et al. Results of penetrating keratoplasty for the
treatment of corneal perforations. Arch Ophthalmol. 1990;108: 939–941.
2. Lee S, Tseng SCG. Amniotic membrane transplantation for persistent epithelial
defects with ulceration. Am J Ophthalmol. 1997;123:303–12.
3.
Kruse F, Rohrschneider K, Volcker H. Multilayer amniotic membrane
transplantation for reconstruction of deep corneal ulcers. Ophthalmology.
1999;106:1504–11.
4.
Solomon A, Meller D, Prabhasawat P, et al. Amniotic membrane grafts for non
traumatic corneal perforations, descemetoceles and deep ulcers. Ophthalmology.
2002;109:694–703.
5.
Pfister RR, Sommers CI. Fibrin sealant in corneal stem cell transplantation. Cornea.
2005;24:593–8.
6.
Duchesne B, Tahi H, Galand A, Use of human fibrin glue and amniotic membrane
transplant in corneal perforation. Cornea. 2001;20:230–2.
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7.
Kim HK, Park HS. Fibrin Glue–Assisted Augmented Amniotic Membrane
Transplantation for the Treatment of Large Noninfectious Corneal Perforations.
Cornea 2009;28:170–6.
8.
Hao Y, Ma DH-K, Hwang DG, et al. Identification of antiangiogenic and antiinflammatory proteins in human amniotic membrane. Cornea. 2000;19:348–52.
9.
Hick S, Demers PE, Brunette I, et al. Amniotic transplantation and fibrin glue in
the management of corneal ulcers and perforations. A review of 33 cases. Cornea.
2005;24:369–77.
10. Rodriguez-Ares T, Tourino R, Lopez-Valladares J, et al. Multilayer amniotic
membrane transplantation in the treatment of corneal perforations. Cornea.
2004;23:577–83.
Hannibal (247-183 BC):
was a commander of Carthage, defeated the Roman
during the 2nd Punic War in 218 BC. During this
war, he developed corneal ulcer in right eye and
permanently lost his sight.
Jean Paul Sartre (1905-80):
a French author, philosopher, He was awarded the
Nobel Prize for literature in 1964 but he declined it.
At the age of 4 he suffered from corneal ulcer and
developed a right leucoma which led to exotropia.
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Contents
Contents
CORNEA - I
A New Approach to Management of Corneal Ulcers by Debridement---------------- 471
Dr. Debasish Dutta, Dr. Arup Bhaumik, Dr. Ayan Mohanta, Dr. Prashant Kumar Singhal,
Dr. Sabitabrata Basu
Colored Cosmetic Contact Lenses: Cosmesis and Complication, Hand in Hand-475
Dr. Shwetambari Singh, Dr. Ravindra Vhankade, Dr. Dipali Satani, Dr. Amit Patel
Spectrum of Mycotic Keratitis: 5-Year Review of Patients at A Tertiary Eye Care
Center in Tamilnadu------------------------------------------------------------------------------------- 479
Dr. D Chandrasekhar, Dr. J Kaliamurthy, Dr. Pragya Parmar, Dr. C M Kalavathy, Dr. C A
Nelson Jesudasen, Dr. Philip Aloysius Thomas
Effect
of
Subconjunctival
Injection
of
Bevacizumab
on
Corneal
Neovascularization------------------------------------------------------------------------------------- 483
Prof. Dr. K Vasantha, Dr. Rajini Ponraj, Dr. Mohan K, Dr. Niraimozhi
Risk Factors in Management of Bacterial Keratitis------------------------------------------ 485
Dr. Samrat Chatterjee, Dr. Deepshikha Agrawal
A Very Unusual Case of Keratitis------------------------------------------------------------------ 488
Dr. Saroj Gupta
Effect of Pterygium on Contrast Sensitivity---------------------------------------------------- 490
Dr. Archana Malik, Dr. Soniya Bhala, Dr. Anamika Garg, Dr. Sudesh K Arya,
Dr. Sunandan Sood
To Study The Effect of Sub-conjunctival Injection of Bevacizumab on Corneal
Neovascularisation-------------------------------------------------------------------------------------- 493
Dr. Somnath Mukhopadhyay, Dr. Himadri Dutta, Dr. Jayanta Dutta, Dr. Swarnali Sen,
Dr. Pradeep Kumar Panigrahi
Neonatal Infectious Keratitis Five Years Experience at a Tertiary Eye Care Center--
------------------------------------------------------------------------------------------------------------------ 495
Dr. Jatin Ashar, Dr. Muralidyhar R, Dr. Shivani Pahuja, Dr. Sunita Chaurasia,
Dr. Virender Sangwan
Efficacy and Safety of Topical Umbilical Cord Serum Therapy in Persistent Corneal
Epithelial Defects----------------------------------------------------------------------------------------- 498
Dr. Charu Mithal, Dr. Anu Malik, Dr. Sandeep Mithal, Dr. Neha Mithal, Dr. Prateek
Agarwal, Dr. Pallavi Agarwal
Sympathetic Ophthalmitis Following Optical Penetrating Keratoplasty In The Last 9
Years---------------------------------------------------------------------------------------------------------- 502
Dr. Rekha Gyanchand, Dr. Sheetal Hegde
Comparison of Engothelial Cell Count by Manual and Automated Methods in Normal
Cornea and in Fuchs’ Endothelial Dystrophy------------------------------------------------- 505
Dr. Somasheila I Murthy, Dr. Debarun Dutta, Dr. Tamal Chakraborti, Dr. Pritam Kumar
Streptococcus Pneumoniae Keratitis: Fortified Antibiotics or Fluoroquino-lones?-
------------------------------------------------------------------------------------------------------------------ 508
Dr. Sujata Das, Dr. Savitri Sharma, Dr. Vivek Warkad, Dr. Srikant K Sahu
Fibrin Glue (FG) Augmented Amniotic Membrane Transplantation (FGAMT) in
Peripheral Corneal Perforations---------------------------------------------------------------------511
Dr. Ritu Arora, Dr. Jasneet Kang, Dr. J L Goyal, Dr. Monika Mittal, Dr. Parul Jain
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CORNEA - I
Chairman: Dr. G Mukherjee; Co-Chairman: Dr. A K Jain
Convenor: Dr. Beena Desai; Moderator: Dr. Prerna Upadhyaya
Dr. DEBASISH DUTTA: MBBS (1995), NRS Medical College, Calcutta
University, Kolkata; MS (2000), MKCG Medical College, Berhampur
University; Fellowship (2004), Sankara Nethralaya, Chennai. Recepiant of
K.R. Dutta award (1999) in EIZOC, Cuttack. Presently, Consultant, Disha
Eye Hospital and Research Centre, Sheoraphuly, Hooghly, WB.
Contact: 09830216532; E-mail: [email protected]
A New Approach to Management of Corneal
Ulcers by Debridement
Dr. Debasish Dutta, Dr. Arup Bhaumik, Dr. Ayan Mohanta, Dr. Prashant
Kumar Singhal, Dr. Sabitabrata Basu
V
isual disability in the developing nations of Asia , Africa and Middle East
is a major public health issue. Cataract is the most common cause but is
easily manageable. The very second cause is corneal opacity resulting from
corneal ulceration. Central Corneal ulceration is a very common occurrence
in the semi urban and rural population. These patients mostly belong to the
financially weaker sections of the society and are involved in agricultural
activities. There is wide geographic and a etiological variation across the globe
and also from region to region.
In the Indian scenario a huge fraction of the agricultural population is affected
by corneal diseases ranging from simple corneal abrasions to microbial
keratitis. This is not the case where farming is highly mechanized.
Microbial keratitis due to bacteria is decreasing at our Disha Eye Hospital
(Hooghly). Self medication or treatment by village quacks cures many of the
bacterial ulcers. This is mainly because of some potent and cheap antibacterial
formulations, which are available over the counter.
So we are left with the dreaded menace of the mycotic keratitis, which is
unequivocally a major cause of ocular morbidity. The problem of fungal
infection of cornea in India is acute as the weather is hot and humid (Tropical)
and to add to the problem are ignorance, illiteracy and poverty.
Medical management of fungal Keratitis is far from satisfactory. Fungi
implicated in keratomycosis rarely cause systemic mycoses. Therapeutic
protocols applicable for systemic mycoses work poorly when applied to
cornea. Polyenes are natamycin and Ampho-B a zoles include Clotrimazole,
Fluconazole and Voriconazole etc. These are mostly fungistatic and not
fungicidal. The drug of choice for filamentous fungi is natamycin suspension.
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69th AIOC Proceedings, Ahmedabad 2011
It penetrates the cornea poorly and acts only on superficial keratitis. It is
expensive and requires frequent instillation. It is mostly available in 3ml glass
packing which leak many a times. Amphoterecin B for topical application
is not available off the shelf and has to be prepared fresh. It is available as
injection and as such its penetration of intact epithelium is poor.
The population at risk is located far from tertiary care centers and detailed
microbiological assessment at grass roots level is difficult. So to cut ice the
protocol of management of fungal ulcers should be simple, reproducible and
inexpensive.
The first step in the management of most corneal ulcer is scraping. Standard
scraping encompasses removal of the epithelium with necrotic tissue at the
ulcer and its bed. This decreases load of the organism and improves penetration
and availability of the antifungal agent. Simultaneously scraping acts as a
diagnostic tool in the form of KOH mount preparation to diagnose fungal
filament etc. 10% KOH mount is inexpensive and easy; it requires minimum
infrastructure and results are obtained immediately. A trained technician can
do it. But an ophthalmologist executing the whole exercise himself or herself
increases the yield of the organism. Chances of isolating fungal filaments in
corneal scraping is as high as 90 to 99%, Vis-à-vis 88.75% by Gramstain.
The diagnostic and therapeutic scraping that is practised by most removes the
necrotic tissue but the heavily infiltrated pre necrotic tissue at the ulcer bed is
left behind. This study focuses on a method of deeper scraping whereby this
prenecrotic tissue with its load of infiltration and cytokines is removed to a
great extent. This method is destined to promote better drug availability and
thus quicker healing and lesser scarring.
MATERIALS AND METHODS
It is a predesigned prospective interventional case series of consecutive 153
cases of fungal keratitis with filaments demonstrated in 10% KOH at Disha
Eye Hospital (Hooghly) during January 2008 and December 2009
Patient
All patients with red eye who report to the OPD of the tertiary care eye centre
Disha Eye Hospital (Hooghly) are screened for corneal ulcer. This tertiary care
hospital serves semi urban and rural people of Howrah,Hooghly and Burdwan
districts of West Bengal. The livelihood of majority of patients turning up to
the OPD of this hospital is agriculture based.
Ulcer
Ulcer is defined as breech in corneal epithelium with infiltration of underlying
stroma, with or without hypopyon.
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A common protocol was applied to all cases. Each patient was examined
under Slit Lamp biomicrocope by an ophthalmologist. Ulcer is stained by
Sterile fluorescein strip touched at the lower fornix to make out the extent of
epithelial breech and recorded in mm in its longest and shortest diameter.
Other details like depth, zone of stromal infiltrate, Corneal edema etc are
noted with proper color coding. Hypopyon is measured in mm and number of
days for its resolution is noted.
Healed Ulcer
An ulcer is defined healed where fluorescein staining is negative and there is
no stromal infiltrate.
Meticulous data was collected on the following:
1. Date of first visit.
2. Date at which ulcer has healed .
3. Size of ulcer at first visit
4. Site of ulcer (central , inferior temporal , inferior nasal , superior temporal,
inferior temporal)
5. Hypopyon present on presentation and its resolution time.
6. Best corrected visual acuity at first visit.
7. Best corrected visual acuity at end of treatment.
Exclusion criteria
Associated systemic ailments like Diabetes etc.
Associated ocular conditions like dry eye, dacryocystitis, blepharitis, lid
pathologies etc. Typical viral ulcers, healing ulcers, moorens , interstitial
keratitis, neurotropic ulcer, bullous keratopathy, exposure keratopathy etc.
Scraping
The cornea and conjunctival sac are anesthetized with proparacaine
hydrochloride (0.5%), Epithelium is scraped from over the ulcer and beyond.
Ulcer is scraped by an ophthalmologist under aseptic conditions ,at the slit
lamp, using sterile Bard Parker Blade no 15.
Material is obtained from
1.
The bed of the ulcer
2.
Leading edge of the ulcer and a KOH mount prepared for examination
under microscope first under 10 x and then finally under 40x.
Detailed microbiological examinations like fungal and bacterial culture etc
are done as part of hospital protocol but has not been taken into consideration
in this study as these are not feasible at the grass roots level. It is obviously
ideal to inoculate into several media but this is not always possible due to
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69th AIOC Proceedings, Ahmedabad 2011
lack of availability of media, lack of adequate sample for all media and the
infrastructural cost involved at all places.
Only the patients who test positive for filaments are taken into consideration
(Group 1).
A typical medical regime was formulated and applied to all those patients.
Most patients were examined at 5 days interval and changes noted as per the
protocol.
A subset of these patients in group 1 were randomly taken up for the special
checker board scraping protocol to constitute Group 2.
Corneal thickness is assessed under the slit beam and cheques board pattern
of scraping applied to remove the deep densely infiltrated prenecrotic tissue.
This tissue was not removed by conventional deep scraping. Ulcer is monitored
closely and scraped similarly at subsequent visits.
RESULTS
Patients were randomly divided into group 1 and group 2.
In group 1 standard therapeutic scraping was practised in the beginning and
subsequent follow ups.
In group 2 chequer board scraping was applied similarly.
The impact of nuisance parameters like size of ulcer , site of ulcer etc on the
yield or outcome (number of days required to heal and the final visual acuity
achieved) is eliminated by ANCOVA. Analysis of the data revealed that the
time required to heal is significantly less in group 2 (at 5% level).
But the assumption that quicker healing will cause lesser fibrosis maintaining
better transparency need further evaluation .
DISCUSSION
The impact of fungal keratitis in the Indian subcontinent as a cause of ocular
morbidity is unequivocally substantial . Fungal ulcer account for 30 to 40% (3)
of all cases of microbial keratitis in developing countries. Some studies put the
figure to as high as 50% (1)
The therapeutic protocols of today are far from satisfactory and often fail
to preserve or restore vision after fungal keratitis. Filamentous fungi is the
number one cause at lest in the developing world. Corneal penetrability of
available drugs is an issue. Cost and accessibility to low cost treatment is
extremely important in the Indian subcontinent.
Aim of management is rapid eradication of the organism with control of
inflammation and tissue damage by cytokinins etc, there by preserving
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integrity and transparency of the cornea. Under these circumstances checker
board scraping of fungal ulcers calls for no extra infrastructural support. All
that is needed is the existing slit lamp and the Bard Parker Blade no 15. This
New Approach To Management Of Corneal Ulcers By DEBRIDEMENT has
improved healing and decreased morbidity to a great extent; lesser number of
eyes are lost to therapeutic PKs and evisceration .
REFERENCES
1.
Basak S K, Basak S, Mohanta A, Bhowmik A, Epidemiological and Microbiological
Diagnosis Of Suppurative Keratitis In Gangetic West Bengal, Eastern India. IJO
2005;53:17-22.
2. Srinivasan M, Gonzales C A,George C et al.: Epidemiology and Aetiological
Diagnosis Of Corneal Ulcer In Madurai. South India . Br J Ophthalmol 1997;81:96571.
3.
Sharma S, Srinivasan M, George C:The Current Status of Fusarium Species in
Mycotic Keratitis in South India. J Med Microbial 1993;11:140-7.
4.
Dunlop A A, Wright E D,Howlader S A, et al.: Suppurative Corneal Ulceration
In Bangladesh: A Study Of 142 Cases Examining The Microbiological Diagnosis,
Clinical And Epidemiological Features of Bacterial and Fungal Keratitis. Aust N Z
J Ophthalmol 1994;22:105-10.
5.
Bharathi M J, Ramakrishnan R, Vasu S, et al.:Epidemiological Characteristics and
Laboratory Diagnosis of Fungal Keratitis: A Three-Year Study. Indian J Ophthalmol
2003;51:315-21.
6.
Gopinathan U, Garg P,Fernandes M, et al.: The Epidemiological Features and
Laboratory Results of Fungal Keratitis:A 10-Year Review at A Referral Eye Care
Center in South India. Cornea 2002;21:555-9.
Colored Cosmetic Contact Lenses: Cosmesis
and Complication, Hand in Hand
Dr. Shwetambari Singh, Dr. Ravindra Vhankade, Dr. Dipali Satani,
Dr. Amit Patel
U
se of colored cosmetic contact lens is well known latest fad of young
generation. Manufacturers are targeting and attracting youth market by
providing various colors and patterns of cosmetic contact lenses. Influential
commercials and easy availability has lead to dramatic increase in trend
of wearing cosmetic lenses even in youngsters of middle to lower socioeconomic classes. Many of these young users are unaware and uninformed
about the proper use and care of contact lenses. Noted here are 13 patients
who developed severe infectious keratitis following use of decorative lenses.
All the patients were ignorant about the precautions, hygiene measures and
complications related to contact lens use.
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69th AIOC Proceedings, Ahmedabad 2011
MATERIALS AND METHODS
All patients presented at Nagari eye institute from November 2009 to February
2010 with acute pain and redness following use of cosmetic contact lenses
were included in the study. Written consent was taken from the patients before
inclusion. Before clinical examination, a detailed history was obtained relating
to the availability of cosmetic lenses, duration and frequency of wear and type
of cleaning solution used. If available, the contact lenses and solution used by
the patient were obtained and sent for microbiological evaluation.
A slit-lamp biomicroscopic examination was conducted to record the location
and size of the corneal infiltrates. Under topical anesthesia and slit-lamp
magnification, corneal scrapings were obtained from the base and edge of the
ulcer. The samples were inoculated directly onto nutrient agar, sheep blood
agar, chocolate agar and Sabouraud dextrose agar. Gram and Giemsa stained
smears of scraped material were prepared.
According to the clinical picture and smear report, patients were treated with
broad spectrum antibiotics and antiviral drugs. The initial therapy was modified
based on the results of culture and sensitivity testing and the clinical response.
RESULTS
Out of 13 patients 8 were male and 5 were female. Mean age of presentation was
19 ± 3.8 years. Eleven patients were naïve contact lens users and 4 were minors.
Table 1 outlines the details of contact lens availability, storage and usage.
Table 1
Case Contact lens Storage and Duration of Assistance Sharing Overnight
No. availability
cleaning
storage in
for CL
use
solution unchanged removal
solution
1
Optical shop
2
Optical shop CLS +Tape water
2 days
+
-
7 days
-
-
3
Relative
-
CLS
1 month
-
+
-
4
Friend
CLS
10 days
-
+
+
5
Optical shop
CLS
2 days
-
-
-
6
Optical shop
CLS
10 days
+
-
+
7
Relative
-
+
-
8
Optical shop
CLS
15 days
+
-
-
9
Friend
CLS
5 days
-
+
+
10
Optical shop CLS +Tape water
11 Garbage
CLS
CLS +Tape water 4 months
-
3 days
-
-
-
-
-
-
-
-
12
Friend
CLS
7 days
+
+
-
13
Optical shop
CLS
5 days
-
-
+
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Laboratory results showed Pseudomonas aeruginosa in 7 cases (54%),
Staphylococcus aureus in 3 cases (25%) and Staphylococcus epidermidis in 2
cases (17%) with one case of viral keratitis. In 62% of cases size of ulcer was
≥ 5 X 5 mm and post treatment corrected visual acuity was 6/24 or less. All
patients responded well to the antimicrobial treatment, eliminating the need
of surgical intervention. Clinical details, culture and sensitivity results and
visual acuity are described in Table 2.
Table 2
Case Age
No. (years) /
gender
1
20/M
Size of
Organism
Sensitivity
Visual
ulcer
isolated
acuity on
(mm)
presentation
5.5X6
P. aeruginosa
Moxifloxacin
HM
Final
visual
acuity
6/18
2
15/F
3X4
S. aureus
Amikacin
6/24
6/9
3
16/F
9X8.5
P. aeruginosa
Cefotaxime
HM
HM
4
18/M
7X8
P. aeruginosa
Moxifloxacin
PR
NA
5
19/M
1X2
P. aeruginosa
Moxifloxacin
6/60
6/12
6
28/M
6X7.5
CF ½ m
CF ½ m
7
18/F
1X2
S. aureus
Levofloxacin
6/6
6/6
8
25/M
7.5X8
S. epidermidis
Moxifloxacin
PR
HM
9
16/M
5X4.5
P. aeruginosa
Amikacin
CFNF
6/24
10
21/F
2X3
S. aureus
Moxifloxacin
6/9
6/6
11
15/F
5X5.5
P. aeruginosa
Moxifloxacin
6/60
6/24
12
20/M
2X3
S. epidermidis
Moxifloxacin
6/9
6/6
13
21/M
7X8
P. aeruginosa
Levofloxacin
PR
6/60
Culture negative
DISCUSSION
The link between microbial keratitis and contact lens wear is beyond question.
Use of contact lenses for therapeutic, refractive or cosmetic purpose will
target different classes of population. The colored cosmetic lenses are non
corrective (zero power or plano) lenses designed and worn solely to change
the appearance of the eye. Emmetropic patients who wear these lenses risk
serious ocular sequelae for the sake of cosmesis alone. In the current study, 13
young individuals developed sight threatening microbial keratitis following
the use of cosmetic contact lenses. As all the patients were from lower to lower
middle socieo-economic class, it points towards the dangerous trend evolving
in the youngsters of these classes. We found that unsterile lens handling and
infrequent change of storage solutions were the two major causes for the
development of infectious keratitis.
Eleven out of 13 patients were using these lenses for the first time. None of
the patient was following sterile contact lens handling or storage technique.
The lenses were stored in a contact lens case with solution or unpreserved
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69th AIOC Proceedings, Ahmedabad 2011
saline for weeks or months at a time by 8 patients. Longest duration of storage
in unchanged solution was 4 months. Sharing of these cosmetic lenses is
possible and more frequent as they are of zero refractive power. Five patients
in our study group shared lenses with friends or relatives. None of the patient
was instructed about insertion or removal techniques. Four patients required
assistance of other person for removal of contact lenses. Out of these 4 patients
in 2 cases contact lens was broken while removal and one patient had injury
with finger nail.
Pseudomonas species (especially P. aeruginosa) are reported the world over
as the most common organism associated with contact lens related microbial
keratitis, and so was the case in our study group. Seven out of 13 (54%) cultures
were positive for P. aeruginosa. Young contact lens wearers usually have better
host defense mechanism, which fungi are less efficient to overcome. Several large
series have reported low incidence of fungal keratitis in contact lens wearer
groups. We did not culture a fungi or Acanthamoeba from any of the cases
studied. Small sample size of our study group can be the reason for this result.
Steinmann et al. reported twelve cases of infectious keratitis after wearing
plano decorative contact lenses. None of the lenses were dispensed by eye care
professionals. Authors have highlighted that colored noncorrective lenses are
being dispensed without a prescription or fitting from unlicensed vendors.
Patients who acquire lenses from unauthorized providers are less likely to be
instructed on appropriate lens care and use. Consequently, uninformed lens
wearers are developing sight threatening keratitis.
The widespread advertising of colored cosmetic contact lenses creates
a demand among emmetropic individuals while failing to mention the
associated risks. The patients who wear these lenses intermittently may
perceive their lenses to be merely a cosmetic aid and, therefore, may be more
prone to unsafe practices than daily wearers accustomed to a regular pattern
of contact lens hygiene. Unmonitored wearing and over the counter use of
cosmetic contact lenses is causing serious sight threatening complications in
emmetropic young individuals.
REFERENCES
1.
Over the counter decorative contact lenses: cosmetic or medical device? A case
series. Eye Contact Lens: Science and clinical practice. Sept. 2005.
2. Ocular complications associated with use of contact lenses from unlicensed
vendors. Eye Contact Lens: Science and clinical practice Oct 2003.
3.
Corneal ulcer associated with cosmetic extended wear soft contact lens.
Ophthalmology Feb. 1987.
4.
Ulcerative keratitis associated with contact lens wear. American journal of
Ophthalmology July 1989.
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Spectrum of Mycotic Keratitis: 5-Year Review
of Patients at A Tertiary Eye Care Center in
Tamilnadu
Dr. D Chandrasekhar, Dr. J Kaliamurthy, Dr. Pragya Parmar, Dr. C M
Kalavathy, Dr. C A Nelson Jesudasen, Dr. Philip Aloysius Thomas
M
ycotic keratitis (Keratomycosis, Fungal keratitis) refers to a suppurative,
usually ulcerative infection of the cornea that is caused by fungi. Such
an infection may threaten sight and even lead to the loss of the eye. Corneal
infections are the second most common cause of monoocular blindness after
unoperated cataract in some developing countries in the tropics. It has been
increasing recently in India and other developing countries.1-4 Fungal keratitis
is caused by a large number of saprophytic fungi, and the aetiological agents
of fungal keratitis show a varying pattern with respect to geographic locale
and climatic conditions, additionally, the spectrum of fungal pathogens
causing fungal keratitis changed significantly in different year. To improve
the management of patients with fungal keratitis, it is important for
ophthalmologists to gain information of the common fungal isolates within
their region. This report describes the spectrum of the spectrum of fungi
isolated from corneal ulceration in patients treated at a tertiary eye care center
in Tamilnadu during a 5-year period.
MATERIALS AND METHODS
The study was conducted with the approval of the Institutional Ethics
Committee of the authors’ institution and was designed as a retrospective
review of Microbiological records and the patients’ medical record. Medical
records of all keratitis patients who underwent for microbiological investigation
from January 2005 to December 2009 were reviewed. The predisposing factors
and risk factor were abstracted from the history documented in the medical
record. The microbiological data of all patients with suspected infectious
corneal ulceration who presented to the ocular microbiology service at Joseph
Eye Hospital, Trichy between January 2005 and December 2009 were also
reviewed retrospectively.
Microbiological Investigation: On presentation, corneal specimens from
scrapings were stained with the Gram and also viewed as wet mount
preparations using lactophenol cotton blue (LPCB). The corneal material was
also inoculated directly onto the following media that support the growth of
bacteria, fungi and Acanthamoeba: sheep blood agar, Sabouraud’s dextrose
agar and broth and brain–heart infusion agar and broth. Brain–heart infusion
agar and broth, and blood agar were incubated at 37°C and were examined
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69th AIOC Proceedings, Ahmedabad 2011
daily and to be discarded after 7 days, if no growth was seen. Sabouraud’s
dextrose agar and the broth were incubated at 28°C and were examined daily
for the first week and twice daily thereafter for 4 weeks. A fungus grown on
the primary isolation medium was subcultured onto various fungal media
and incubated for a considerable period to facilitate sporulation. The cultures
were considered positive if at least one of the following criteria was fulfilled:
a) The growth of the same organism was demonstrated on one or more solid
media and/or if there was confluent growth at the site of inoculation on at
least one solid medium.
b) The growth on one medium was consistent with direct microscopic
findings.
c) The same organism was grown from repeated corneal scrapings.
Fungal species were identified according to the macroscopic characteristics of
the colony morphology, color and growth rate of the moulds, and the microscopic
characteristics of hyphae, spores or conidia, and their relationships.
RESULTS
There were 1499 patients of who suspected microbial corneal ulcer underwent
microbiological investigations during the five years from January 2005 to
December 2009. Of these, 64% of them reported trauma by inanimate object,
26% reported prior treatment with eye drops (from Pharmacy/ General
Practitioner/ Ophthalmologist) and 18% reported use of traditional eye
medicine (oil, leaf juice, milk, etc.).
Microorganisms were grown from 1069 (71%) of the 1499 ulcers. There were
542 (51%) fungal isolates and 522 (49%) bacterial isolates. The proportions of
bacterial and fungal isolates recovered from the corneal ulcers for each year
were given in Table -1.
Table 1: The proportions of bacterial and fungal isolates recovered
from the corneal ulcers for each year (2005 to 2009)
Organism
2009 2008 2007 2006 2005 Total
Bacteria
116 112 110 86 98 522
Fungi
108 80 143 103 108 542
No growth
56
Others
63
72
119
120
430
0 2 1 0 2 5
280 257 326 308 328 1499
The most common fungal pathogens isolated were various species of
Fusarium, representing 204 (37.6%) of all positive fungal cultures, followed
by Aspergillus spp. (134; 24.7%), Curvularia spp (28; 5%), Colletotrichum
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dematium (13; 2%) and Exserohilum longirostratum (7; 1%). Alternaria
alternata, Bipolaris spicifera, Lasiodiplodia theobromae, Scedosporium
apiospermum and Candida albicans were less frequently isolated organisms
in the series. In addition, unidentified dematiaceous fungi accounted for 26%
(141). The spectrum of 542 clinical isolates of fungi for each year (2005 to 2009)
is summarized in Table 2.
Table 2: The spectrum of fungi isolated from the corneal ulcers for the
five year period (2005 to 2009)
Organism
2009 2008 2007 2006 2005 Total
Fusarium solani
5 4 0
0 0 9
Fusaium sp
24
20
60
34
42
180
Fusarium dimerum 7 7 0
0 1 15
Total
204
A.flavus
16
A.fumigatus
10 4 7 3 4 28
Aspergillus spp
8
20
30
27
101
3
1
0
0
4
Aspergillus niger
1
0
0
1
Total
134
Curvularia sp
4 3 9
4 8 28
Colletotrichum dematium
9 1 0
2 1 13
Exerohilum longistratum
1 0 0
2 4 7
Alternaria alternata 1 0 3
0 0 4
Bipolaris
1 1 1
1 1 5
Lasiodiplodia
2 0 1 0 3
Scedosporium apiospermum
1
0
1
Candida albicans
1
1
2
UI
39 28 39
19 16 141
Total
117 81 141 98 105 542
DISCUSSION
Fungal keratitis is a common cause of corneal infection and blindness after
trauma in the developing world. Because of the widespread distribution of
fungi, human contact with the organism is inevitable and frequent. It has
become increasingly important to gather sufficient data that would project the
gravity of the problem of fungal keratitis of a representative geographic region
in terms of the epidemiology and aetiology, the documentation of which would
serve as a useful guide for practising ophthalmologists. Few studies on fungal
keratitis have been published from India.2,3,5,6 The results of proportion of
fungi and bacteria of the present study are consistent with the earlier reports
from India.5,6 Fungal ulcers are usually seen more in this center. It is primarily
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69th AIOC Proceedings, Ahmedabad 2011
the result of the temperate climate because a warm, humid environment
enhances the growth of fungi. In addition, the author’s institution is a tertiary
cornea and external disease referral centre that provides medical service to
all the people in Tiruchirapalli district residing in urban and rural areas.
Other factors that have been correlated with this increasing incidence include
the growing number of trauma cases, widespread abuse of broad-spectrum
antibiotics and steroids. Meanwhile, improvement of the health care system,
increasing awareness of this disease by ophthalmologists and popularization
of the diagnostic methods and instruments also help to identify patients who
otherwise might have been undetected previously.
In the literature, fungi belonging to nearly 56 genera have been reported from
the cases of fungal infections. Filamentous fungi are the principal causes of
corneal infections in most parts of the world; either Fusarium or Aspergillus
are the most common fungal genera. Geographical and environmental
variations, such as humidity and air temperature, have been observed in the
predominant genera of fungi isolated from patients with fungal keratitis.
In this case series, Fusarium was the most frequently isolated pathogen,
and Aspergillus was the second most often one in the cases. There are some
agreements of this study on the spectrum of fungal species in causing fungal
keratitis with others reported from India.5-7 In conclusion, various species of
Fusarium were the most common fungal aetiological agents isolated, followed
by Aspergillus spp. and unidentified dematiaceous fungi from patients with
keratitis in this setting.
REFERENCES
1. Xie LX, Zhong W, Shi W, Sun S. Spectrum of fungal keratitis in North China.
Ophthalmology 2006;113:1943–8.
2. Chowdhary A, Singh K. Spectrum of fungal keratitis in North India. Cornea 2005;
24:8–15.
3. Shukla PK, Kumar M, Keshava GB. Mycotic keratitis: an overview of diagnosis and
therapy. Mycoses 2008;51:183–99.
4. Wang L, Sun S, Jing Y, Han L, Zhang H, Yue J. Spectrum of fungal keratitis in
central China. Clinical and Experimental Ophthalmology 2009;37:763–71.
5. Bharathi MJ, Ramakrishnan R, Meenakshi R, et al. Microbial keratitis in South
India: influence of risk factors, climate, and geographical variation. Ophthalmic
Epidemiol 2007;14:61–9.
6. Leck AK, Thomas PA, Hagan M, et al. Aetiology of suppurative corneal ulcers
in Ghana and south India, and epidemiology of fungal keratitis. Br J Ophthalmol
2002;86:1211–5.
7. Gopinathan U, Garg P, Fernandes M, et al. The epidemiological features and
laboratory results of fungal keratitis: a 10-year review at a referral eye care center
in South India. Cornea 2002;21:555–9.
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Effect of Subconjunctival Injection of
Bevacizumab on Corneal Neovascularization
Prof. Dr. K Vasantha, Dr. Rajini Ponraj, Dr. Mohan K, Dr. Niraimozhi
T
o evaluate regression of new vessels of cornea. To evaluate the safety
and efficacy of subconjunctival injection of Bevacizumab. To evaluate the
outcome of OKP after subconjunctival Bevacizumab
MATERIALS AND METHODS
This study was done in Cornea Department Regional Institute of
Ophthalmology and Government Ophthalmic Hospital Chennai during
January 2009 to January 2010. Twenty eyes of twenty patients with corneal
neovascularization due to various pathologies (mentioned below) have been
selected for the study.
Inclusion criteria
Vascularised corneas of patients with
• Leucomatous opacity following exanthematous fever and post hydrops
• Pseudophakic bullous keratopathy
• Healed corneal ulcer post trauma and infection
• Previously failed Optical keratoplasty
Exclusion criteria
• Patients with uncontrolled systemic hypertension with systolic blood
pressure of ≥150mm Hg or diastolic blood pressure of ≥90 mm of Hg
• Patients with recent Myocardial Infarction
• Patients with recent Cerebro Vascular Accidents
• Diabetes mellitus
• Renal, liver, and coagulation
anticoagulation medications
abnormalities
including
current
• Current or recent systemic corticosteroid therapy or periocular
corticosteroids injections to the study eye
• Ocular or periocular malignancy
Procedure
Anterior segment examination was done with slit lamp biomicroscopy.
Standardized corneal photographs were taken with 10X magnification with
slit lamp biomicroscopy using digital camera.
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69th AIOC Proceedings, Ahmedabad 2011
A commercially available bevacizumab (2.5mg/0.1ml, 100 mg/4 mL) was
prepared for each patient and placed in a tuberculin syringe using aseptic
techniques.
• Topical anesthetics ( 4% xylocaine/ paracaine eye drops) and antibiotics
are applied
• The eye had been prepared with 5% povidone iodine in a standard fashion
• Then draped with an eye mask
• Opsite was applied
• Using lid speculum eye was exposed
• Bevacizumab (2.5mg/0.1ml) was injected
subconjunctivally in the
quadrant of vascularization 1cm from the limbus
• Patients were instructed to apply antibiotic eye drops for 3 days 4 times a
day
Follow-up
Follow up visits were done on 14th day, 1st, 3rd, and 6th month post injection.
All the 20 patients completed 6 months of follow-up. At each visit patients
were checked for regression of new vessels i.e. reduction in both number and
caliber of the vessel. Patients were also examined for signs of graft rejection
(those who have been operated) and side effects.
Main outcome measures
i)
Regression of corneal new vessels
ii)
Efficacy and safety of subconjunctival Bevacizumab
iii)
Outcome of OKP after subconjunctival Bevacizumab injection
DISCUSSION
In this study an obvious reduction in established corneal neovascularization
occurred to a different degree in each patient, and subconjunctival
bevacizumab was well tolerated by all these patients. Out of 20 patients in 50%
of patients complete regression of the corneal new vessels noted at the end
of 6th month. Whereas in 30% of patients only partially reduction noted i.e.
reduction in calibre of vessels only, the number of new vessels was constant.
In 20% of patients both number of new vessels and the calibre was constant.
This variable response may be because of the chronicity, extent of corneal
neovascularization, amount of scarring, disease process, formulation and
route of administration of the drug 15 and 16.
• Subconjunctival injection of Bevacizumab can be used safely and effectively
for corneal neovascularization resulting from different types of disorders.
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• It may provide an additional strategy in improving success of corneal
grafts in these patients.
• This is a short term study. However long-term follow-up is necessary to
determine whether repeat injections are necessary.
Risk Factors in Management of Bacterial Keratitis
Dr. Samrat Chatterjee, Dr. Deepshikha Agrawal
I
nfectious keratitis continues to be a major cause of corneal blindness in
developing countries. Timely presentation, specific diagnosis and treatment
with appropriate antimicrobial agents can limit ocular morbidity. The
knowledge of risk factors affecting treatment outcome helps in modifying
management protocols and also in prognostication.1-5 A previous study
from our Institute examined the risk factors affecting outcome after medical
management of fungal keratitis [Risk factors for poor outcome in medical
management of fungal keratitis. Chatterjee S, et al. Paper presented at Annual
Conference of All India Ophthalmological Conference, Kolkata, 2010]. In this
present study, risk factors affecting outcome after medical management of
bacterial keratitis are being examined.
MATERIALS AND METHODS
This was a retrospective, interventional case series which included all
microbiologically proven cases of bacterial keratitis diagnosed at the Cornea
Services in MGM Eye Institute, Raipur (2005-2009). Medical records were
examined and factors like age, gender, distance from institute, presentation time,
treatment history prior to presentation, steroid use, initial visual acuity, ulcer
size and depth, corneal thinning/perforation, presence of endophthalmitis,
etc were correlated to poor outcome. Poor outcome to medical therapy was
considered when the ulcer failed to heal with medications or progressed to
perforation or required penetrating keratoplasty or underwent evisceration.
Each patient who presented with corneal ulcer at our Institute underwent
corneal scraping and microbiological investigations that included culture in
appropriate media and antibiotic susceptibility by Kirby Bauer disc method.
Medical treatment was with either combined fortified cefazolin eye drops
(50mg/ml) and tobramycin (14mg/ml) or monotherapy with fluoroquinolones.
The initial drug chosen was modified according to antibiotic susceptibility
reports and clinical response. Patients not responding to medical therapy were
considered for therapeutic penetrating keratoplasty. In patients where corneal
integrity was threatened with corneal thinning, descemtocele formation or
perforation, tissue adhesive was applied. Univariate analysis was done with
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69th AIOC Proceedings, Ahmedabad 2011
2x2 tables with chi-square or Fishers test as appropriate. Variables that yielded
p value <0.125 were considered for multivariate analysis using multiple logistic
regression. SPSS (version 12 for Windows, SPSS, Chicago, IL) was used for
statistical analysis. A 2-tailed p value less than 0.05 was considered significant.
RESULTS
There were 149 episodes of bacterial keratitis in 142 patients. There was
bilateral involvement in 3 patients and multiple episodes in 4 patients.
Outcome data was available in 117 episodes as rest was lost to follow-up. Of
these 101 (86.32%) episodes healed, 5 (4.27%) required evisceration, 1(0.86%)
underwent therapeutic penetrating keratoplasty, 3(2.56%) eyes became
pthisical and 7(5.98%) eyes had perforation which were un-amenable to
treatment and patients refused evisceration. Factors that were considered to
influence outcome are given in Table. The factor identified by multiple logistic
regression to significantly influence outcome was infiltrate size (p=0.03) while
rest of the factors failed to reach statistical significance.
DISCUSSION
The outcome of bacterial keratitis with medical management is better than
fungal keratitis. In this study 86% cases had good outcome which is better than
the 64% good outcome reported by us in fungal keratitis earlier. [Risk factors
for poor outcome in medical management of fungal keratitis. Chatterjee S,
et al. Paper presented at Annual Conference of All India Ophthalmological
Conference, Kolkata, 2010]. Better outcome in bacterial keratitis compared to
fungal keratitis has been also reported by others.3,5
Previous studies have reported advancing age,1,2 pre-treatment with topical
steroids,1-2 pneumoccoal infection,2 pseudomonas infection, 1 ulcer size,1-4
distance from limbus,4 presence of hypopyon,1 and MIC of antimicrobial
agents,5 to significantly affect outcome. In the present study univariate
analysis found presenting visual acuity <20/200, infiltrate size ≥ 12mm2,
involvement of the posterior stroma, perforation or gross corneal thinning,
presence of concurrent endophthalmitis and gram negative bacterial infection
as factors associated with poor outcome. However in multivariate analysis
only infiltrate size reached statistical significance. The reason why other risk
factors did not reach statistical significance in multivariate analysis could
be due to the sample size which may not have been large enough to have
adequate statistical power to detect small differences.
In summary we find that bacterial keratitis has a better outcome than fungal
keratitis. The major risk factor for poor outcome is large ulcer size. Hence
patients with larger ulcers should receive appropriate topical antibiotics
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Table: Univariate analysis of risk factors affecting outcome
Sl VARIABLE
No
Poor
Good TOTAL Odds 95% CI
outcome outcome
ratio
No (%) No (%)
1
Extreme of age
(0-14 and > 60y)
6(12)
44(88)
50
Others
2
Male gender
3
10(15)
57 (85)
67
8(11)
68 (89)
76
Female gender
8 (20)
33 (80)
41
Distance >25kms
8(11)
63(89)
71
Distance ≤ 25 kms
8(17)
38(83)
46
4
Presentation > 21d
4(21)
15(79)
19
1.51
Presentation ≤21d
12(12)
86(88)
98
5
Presence of risk factors 14(16)
73(84)
87
No risk factors
2 (7)
28 (93)
30
6
Prior consultation
4(13)
28(87)
32
No prior consultation
12(14)
73(86)
85
8(11)
67(79)
75
7
No treatment with
antibiotic prior to
presentation
0.78
0.6
0.6
P
VALUE
0.26- 2.30
0.21-1.74
0.21- 1.74
0.79
0.26
0.41
0.44- 5.19 0.29
2.68 0.57 - 12.58 0.24
0.87 0.26- 2.92 1.000
0.51
0.18- 1.47
0.26
Prior treatment with
8(19)
34 (81)
42
antibiotic
8
Treated with steroids
4(13)
26(87)
30
0.96
prior to presentation
0.2849 1.0000
to 3.2449
No treatment with
12(14)
75(86)
87
steroids
9
Presenting VA <20/200* 15(21)
57 (79)
72
Presenting VA ≥20/200
1(3)
39(97)
40
15(38)
24(62)
39
1(1)
77(99)
78
16(25)
49(75)
65
infinity
10 Infiltrate size >12mm
Infiltrate size ≤12mm
11
Posterior stroma
involvement
Anterior stromal
involvement
10.26 1.30- 80.92 0.009
48.75 6.12-388.40 0.0001
0(0) 52(100) 52
12 Presence of hypopyon
4 (10)
36(90)
40
12(16)
65(84)
77
Absence of hypopyon
13 Perforation/thinning
No perforation/thinning
0.18-2.0
5(42)
12
9(9)
96(91)
105
3 (100)
0 (0)
13 (11)
101(89)
16 Gram negative bacteria 7(50)
7(50)
91(91)
Gram positive bacteria
0.6
7 (58)
14 Endophthalmitis
No endophthalmitis
0.0001
9(9)
3
0.57
14.93 3.93-56.78 0.0001
Infinity
0.002
114
14
10.11 2.89-35.35 0.0006
100
* Visual acuity could not be evaluated in 5 children
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69th AIOC Proceedings, Ahmedabad 2011
intensively, preferably have an antibiotic susceptibility test and be monitored
at frequent intervals. If a facility exists they should be hospitalized. In any
community based empirical treatment, patients should be referred to a higher
center with adequate microbiology laboratory facilities, if the ulcer is more
than 2 mm or those who do not respond to the initial treatment given with
broad spectrum antibiotics at adequate dosages.
REFERENCES
1
Coster DJ, Badenoch PR. Host, microbial and pharmacological factors affecting
outcome of suppurative keratitis. Br J Ophthalmol 1987; 71:96-101.
2
Gudmundsson OG, Ornerod DL, Kenyon KR, et al. Factors influencing predilection
and outcome in bacterial keratitis. Cornea 1989;8:115-21.
3
Wong T, Ng TP, Fing K, Tan DT. Risk factors and clinical outcomes between fungal
and bacterial keratitis: a comparative study. CLAO 1997;23:275-81.
4
Kaye S, Tuft S, Neal T, et al. Bacterial susceptibility to topical antimicrobials and
clinical outcome in bacterial keratitis. Invest Ophthalmol Vis Sci 2010; 51:362-8
5
Gopinathan U, Sharma S, Garg P, Rao GN. Review of epidemiological features,
microbiological diagnosis and treatment outcome of microbial keratitis: Experience
of over a decade. Indian J Ophthalmology 2009;57:273-9.
Dr. SAROJ GUPTA: MBBS (1987), MGM Medical College, Indore; MS
(1990), M Y Hospital and Deviahilyavishav Vidlaya, Indore. Recipient of Best
FP Award, Oculoplasty (2008) and Neurophthalmology (2010) in MPSOS
Conference. Presently, Associated Prof. Ophthalmological People’s College
of Medical Sciences and Research Centre, Bhanpur, Bhopal, MP.
Contact: 09926550364;
E-mail: [email protected]
A Very Unusual Case of Keratitis
Dr. Saroj Gupta
T
here are several reports in the literature, from different parts of the world
describing the spectrum of microbial Keratitis.1-4 The causative agents
described in all these reports are bacteria, fungi and parasite. Among parasite,
only Acanthamoeba has been isolated. We report an unusual case of Keratitis
caused by flagellated protozoa.
Case-report
A 31- year- old male patient presented with complaints of redness, watering
and pain in left eye while working in fields. Following injury, he washed his
eye with dirty stagnant water.
On examination, left eye showed an epithelial defect in centre of cornea
measuring 3.0 mm X 2.5 mm with prominent ring infiltrate surrounding the
defect. The infiltrate extended up to the anterior stroma.
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Corneal scraping was performed with Bard-Parker no. 15 blade. Examination
in normal saline wet mount preparation demonstrated trophozoites. The
trophozoites showed rapid movement suggestive of flagellated protozoan. The
material was also seen in 10% KOH mount. There were no hyphae or other
elements resembling fungal structures. The material was inoculated on nonnutrient agar overlaid with E. coli for free-living amoebas. No growth was
observed till two weeks of incubation.
Patient was put on topical neomycin, polymyxin B and bacitracin eye drops
one hourly; clotrimazole 1% eye drops two hourly and atropine 1% eye drop
twice a day.
The corneal condition improved within one week of therapy. The
frequency of administration of drops was gradually tapered. At four
weeks follow-up the cornea was clear and without any evidence of sub
epithelial opacification.
DISCUSSION
Cornea infection in this case probably resulted from direct contact with
contaminated water. The rapid motility of trophozoites was suggestive of
flagellated protozoan like Giardia or Chylomastix. The rapid motility and
sterile culture excluded protozoa like Acanthamoeba or Naegleria. Typical
motility of trophozoites on fresh examination is the key for diagnosis.5 Saline
preparation of corneal scraping should be done to exclude motile parasites.
We took opinion from two experts by showing them video of trophozoites.
Both agreed with diagnosis of a flagellated parasite especially Chylomastix.
To best of our knowledge this is the first report in literature (Medline search)
on keratitis by an unusual flagellated parasite.
REFERENCES
1.
Usha Gopinathan, Savitri Sharma, Preshant Garg, Gullapalli N Rao. Review of
epidemiological features, microbiological diagnosis and treatment outcome of
microbial keratitis: Experience over a decade. Indian J Ophthalmol 2009;57:273-9.
2. Hagan M, Wright E, Newman M, Dolin P, Johnson G. Causes of suppurative
keratitis in Ghana. Br J Ophthalmol 1995;79:1024-8.
3.
Upadhyay MP, Kamachaya PC, Koirala S, Tuladhar N, Bryan LE, Smolin G at al.
Epidemiological characterstics, predisposing factors, and etiologic diagnosis of
corneal ulceration in Nepal. Am J Ophthalmol 1991;111:92-9.
4.
Liesegang TJ, Forster RK, Spectrum of microbial keratitis in south Florida. Am J
Ophthalmol 1980;90:38-47.
5.
Yaowalark sulkthana. Free living amebic infection: Rare but fetal. Review. J. Trop.
Med. Parasitol. 2006; June:27-36.
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69th AIOC Proceedings, Ahmedabad 2011
Effect of Pterygium on Contrast Sensitivity
Dr. Archana Malik, Dr. Soniya Bhala, Dr. Anamika Garg, Dr. Sudesh K
Arya, Dr. Sunandan Sood
P
terygium is a triangular –shaped growth consisting of bulbar conjunctival
epithelium and hypertrophied subconjunctival connective tissue,
occurring medially and laterally in the palpebral fissure, and encroaching
onto the cornea. Visual acuity may be reduced due to direct invasion of the
visual axis or astigmatism induced by the pterygium. Standard visual acuity
is a crude measurement of visual performance and does not adequately
represent all aspects of visual function. Contrast sensitivity measures two
variables, size and contrast, while visual acuity measures only size. Several
reports have demonstrated that pterygia cause corneal distortion and induce
a significant amount of astigmatism.1-4 But the effect of pterygium on contrast
sensitivity has not been widely studied. Hence, we performed this study in
order to investigate the effect of pterygium on contrast sensitivity.
MATERIALS AND METHODS
This prospective, nonrandomized trial included 27 patients (36 eyes with
pterygium and 18 eyes without pterygium) with primary pterygia. Complete
ocular examination was done which included visual acuity, refraction,
intraocular pressure, anterior and posterior segment examination. Patients
included were less than 40 years of age. Patients excluded were those with
any ocular pathology other than pterygium which could possibly affect visual
acuity or contrast sensitivity like high myopia, corneal scar, cataract, diabetic
or hypertensive retinopathy, uveitis, macular degeneration, history of past
ocular surgery or trauma. All pterygia were located nasally.
Pterygium was measured on the slit lamp both vertically at the limbus and
horizontally on the cornea and the area was calculated by multiplying the two.
It was categorized into three groups vertically (≤3, 3.1 to≤5, >5mm), two groups
horizontally (0.5 to ≤2, >2mm) and into three groups depending on area (≤7, 7.1
to ≤14, >14mm2). Eyes that had no pterygium were taken as controls.
Contrast sensitivity was measured monocularly with spectacle correction. It
was measured using the CSV-1000E contrast sensitivity charts (Vector Vision)
at 3, 6, 12, and 18 cycles per degrees (cpd) under both photopic (85 cd/m 2)
and mesopic conditions (5.0 cd/m2). Contrast sensitivity curve was plotted and
converted to log units for each frequency as per Vector Vision guidelines.
Statistical analysis
Data were expressed as means ± standard deviation. The statistical comparison
of contrast sensitivity log units between the three groups was done using
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ANOVA and post-hoc bonferroni tests. Data was analyzed with SPSS software
(Version 11.0). Differences were considered statistically significant at P < 0.05.
RESULTS
27 patients (15 males and 12 females) were included in the study. 36 eyes had
pterygium and 18 eyes served as controls. Mean age of the patients was 32.0±6.88.
Number of patients as divided in groups based on vertical length were (Group
1-7, Group 2-18, Group 3-11), horizontal width (GroupA-17, GroupB-19) and
depending on area (GroupI-14, GroupII-15, GroupIII-7). Mean of pterygium
vertically was 4.41±1.12 (Group 1-2.72±0.41, Group 2-4.18±0.50, and Group3-5.86±
0.45), horizontally 2.09±0.68 (GroupA-1.49±0.31 , GroupB-2.62±0.42) and of area
was 9.7±5.01(Group I-4.64±1.23, GroupII-10.98±1.93, GroupIII-17.21±2.20).
The photopic and mesopic contrast sensitivity in the vertical, horizontal and
area wise groups is shown in table 1. All the three parameters had a significant
negative correlation with the contrast sensitivity.
Table 1: Contrast sensitivity of groups as compared with controls
Contrast Vertical length Horizontal width
Area
Control
sensitivity Group1 Group2 Group3 GroupA GroupB GroupI GroupII GroupIII
(pvalue) (pvalue) (pvalue) (pvalue) (pvalue) (pvalue) (pvalue) (pvalue)
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
(0.37)
(0.019)‫( Ù‬0.00) ‫ Ù‬
(0.06)
(0.00) ‫ Ù‬
(0.453) (0.000) ‫( Ù‬0.000) ‫ Ù‬
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
(0.85)
(0.10)
(0.002)‫ Ù‬
(0.36)
(0.00)‫ Ù‬
(0.87)
(0.001)‫( Ù‬0.019) ‫ Ù‬
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
(0.68)
(0.001) ‫( Ù‬0.00) ‫( Ù‬0.012) ‫( Ù‬0.00) ‫ Ù‬
(0.11)
(0.000) ‫( Ù‬0.000) ‫ Ù‬
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
(0.22)
(0.016) ‫( Ù‬0.00) ‫( Ù‬0.017) ‫( Ù‬0.00) ‫ Ù‬
(0.10)
(0.002) ‫( Ù‬0.001) ‫ Ù‬
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
Mesopic6
(0.14)
(0.035) ‫( Ù‬0.00) ‫( Ù‬0.022) ‫( Ù‬0.00) ‫ Ù‬
(0.14)
(0.002) ‫( Ù‬0.002) ‫ Ù‬
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±0.33 1.28±0.23 1.86±0.26
(0.70)
(0.024) ‫( Ù‬0.00) ‫( Ù‬0.028) ‫( Ù‬0.001) ‫ Ù‬
(0.23)
(0.007) ‫( Ù‬0.000) ‫ Ù‬
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
(0.33)
(0.003) ‫( Ù‬0.00) ‫( Ù‬0.002) ‫( Ù‬0.00) ‫( Ù‬0.039) ‫( Ù‬0.002) ‫( Ù‬0.000) ‫ Ù‬
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
(0.10)
(0.01) ‫ Ù‬
(0.00) ‫( Ù‬0.005) ‫( Ù‬0.00) ‫( Ù‬0.033) ‫( Ù‬0.002) ‫( Ù‬0.000) ‫ Ù‬
DISCUSSION
Our study shows that the contrast sensitivity of patients in whom the vertical
length of pterygium is ≤3mm is not significantly different from the controls.
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69th AIOC Proceedings, Ahmedabad 2011
But >3mm of vertical length of pterygium caused significant decrease in both
photopic and mesopic contrast sensitivity at mostly all spatial frequencies.
Patients in whom the horizontal extent of the pterygium exceeded 0.5mm
showed a decrease in both photopic and mesopic contrast sensitivity at all
spatial frequencies except in the lower spatial frequencies of 3 and 6 cpd under
photopic conditions.
When the area of the pterygium exceeded 7mm2, a significant decrease in both
photopic and mesopic contrast sensitivity was seen at all spatial frequencies.
Pterygium with less than 7mm2 area had decreased contrast sensitivity only in
higher mesopic spatial frequencies of 12 and 18cpd.
A significant negative correlation was seen between contrast sensitivity and
the vertical, horizontal dimensions and the area of the pterygium. Maximum
correlation was seen with the vertical dimension followed by area and then
the horizontal width.
Only two articles have previously reported the association of pterygium and
contrast sensitivity. One study done by Lin et al in 1989 showed that contrast
sensitivity was lower at all spatial frequencies in the patients with pterygium.5
Another study showed that contrast sensitivity at medium to-high spatial
frequencies of 6, 12, and 18 cpd significantly improved after pterygium
excision, while contrast sensitivity at low spatial frequencies of 1.5 and 3 cpd
did not change after surgery.6
Pterygium with vertical length >3mm, horizontal width ≥0.5mm and area
>7 mm2 caused a significant decrease in both photopic and mesopic contrast
sensitivity at all spatial frequencies. This could be a useful indicator of the
need for pterygium surgery.
REFERENCES
1.
Yagmur M, Özcan AA, Sari S, Ersöz TR. Visual acuity and corneal topographic
changes related with pterygium surgery. J Refract Surg. 2005;21:166–70.
2. Bahar I, Loya N, Weinberger D, Avisar R. Effect of pterygium surgery on corneal
topography: a prospective study. Cornea. 2004;23:113–7.
3.
Maheshwari S. Pterygium-induced corneal refractive changes. IJO 2007;55:383-6.
4.
Cinal A, Yasar T, Demirol A, Topuz H. The effect of pterygium surgery on corneal
topography. Ophthalmic Surg Lasers. 2001;32:35–40.
5.
Lin S, Reiter K, Dreher AW, Frucht-Pery J, Feldman ST. The effect of pterygia on
contrast sensitivity and glare disability. Am J Ophthalmol. 1989;107:407-10.
6.
Joo Youn Oh,Won Ryang Wee. The effect of pterygium surgery on contrast
sensitivity and corneal topographic changes. Clinical Ophthalmology 2010;4:315–9.
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To Study The Effect of Sub-conjunctival Injection
of Bevacizumab on Corneal Neovascularisation
Dr. Somnath Mukhopadhyay, Dr. Himadri Dutta, Dr. Jayanta Dutta,
Dr. Swarnali Sen, Dr. Pradeep Kumar Panigrahi
N
eovascularization is a severe complication of ischemic retinal diseases
such as diabetic retinopathy, branch and central retinal vein occlusion,
and retinopathy of prematurity. However, in various inflammatory corneal
diseases, corneal neovascularization may also occur, particularly in the
chronic course of the disease. The consequences of corneal neovascularization
may not only be a severe reduction of visual acuity but also a worse prognosis
for corneal transplantation because of loss of the immunologic privilege of the
avascular cornea.
However, the pathogenesis of corneal angiogenesis has not yet been fully
defined, and the identity and significance of different angiogenic growth factors
are debatable. Several studies have shown that vascular endothelialgrowth
factor (VEGF), which was identified about 1 decade ago, plays a major role in
vasculogenesis and in pathologic neovascularization. This protein stimulates
angiogenesis in a noninflammatory model of neovascularization in the
mouse cornea and was recently identified as a functional endogenous corneal
angiogenic factor required for inflammatory neovascularization in a rat model.
Bevacizumab is a humanized monoclonal antibody to VEGF designed for
intravenous administration and approved for the treatment of colorectal
Bevacizumab is currently injected into the vitreous for the treatment of
proliferative and nonproliferative diabetic retinopathy, agerelated macular
degeneration, and neovascular glaucoma, with successful outcomes and rapid
regression of the pathologic blood vessels.
We report here on our experience with subconjunctival injections of
bevacizumab for corneal neovascularization in human subjects.
MATERIALS AND METHODS
The study group consisted of 10 adults (4 men and 6 women) 32–89 years of
age with vascularized cornea , secondary to post DALK interface opacity(n=5),
contact lens users (n=3), and chemical burn (n=2).
All had extensive superficial and deep vascularization of the cornea and
had a failure of steroid drops trial (4 times daily) for the treatment of these
pathologic vessels. The study was approved by the Institutional Research
Ethics Committee and informed consent was obtained before the procedure.
Eyes were anesthetized with topical proparacaine hydrochloride drops.
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69th AIOC Proceedings, Ahmedabad 2011
Subconjunctival injection of 2.5 mg/0.1 mL bevacizumab was performed at
the limbus, adjacent to the pathologic blood vessel growth/sprouting into
the cornea. The injection was performed at the slit lamp after application of
a topical anesthetic drop and by using an eyelid speculum. Postoperatively,
patients were treated with topical moxifloxacin eyedrops 4 times daily for 1
week. As per our protocol, all eyes had at least 2 bevacizumab injections.
All eyes were biomicroscopically examined preoperatively,on postoperative
day 7 and at 1,2 and 3 months. At each visit, 2 digital corneal photographs were
taken with a digital camera attached to the slit-lamp microscope.
The photographs were graded for extent, centricity, and density of corneal
vascularization as follows. Extent was defined according to the number
of clock hours affected by neovascularization (score 1–12). Centricity was
defined as the distance the new vessels extended from the limbus toward
the visual axis: 1 = vessel extended a maximum of 2 mm from limbus, 2 =
extended 2–4 mm from limbus, and 3 = vessels extended to involve visual
axis/central 3 mm of cornea. Density was graded 1–4 according to the density
of neovascularization: 1 = very low (1 vessel), 2 = low, 3 = moderate, 4 = high
(compared with standard photographs).
RESULTS
The mean duration of follow-up was 3 months. The average number of
subconjunctival bevacizumab injections per eye was 2. Preoperative visual
acuity ranged from 20/30 to hand movements. There were no intraoperative
complications. No side effects were reported by the patients, nor was pain
or discomfort induced by the drug injection reported throughout follow-up.
Visual acuity did not change significantly in any patient in this study. Seven
patients (70%) showed partial regression of vessels, whereas 3 patients did not
react to the injection. During 3 months of follow-up, 6 (60%) patients had at
least a 1–clock hour decrease in the extent of blood vessels, and 4 (40%) had at
least a 2–clock hour decrease in the extent of vessels: Seven (70%) patients had
a decrease of 1 level in density but none showed any decrease in centricity of
blood vessels in the cornea.
DISCUSSION
Different substances have been identified in the past as potential vessel
inhibitors, including steroids, nonsteroid anti-inflammatory drugs, heparin,
cyclosporin A, methotrexate, and thalidomide. Although steroids have been
the mainstay of therapy for corneal neovascularization and corneal graft
rejection in clinical practice, they are not always effective, and chronic use
may cause prominent side effects. VEGF’s role in the pathophysiology of
corneal neovascularization has been shown in experimental models of corneal
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neovascularization, in experimental herpes simplex keratitis, and in studies
from human corneal buttons.
Also, VEGF inhibition has been shown to reduce corneal neovascularization
and improve corneal graft survival inexperimental animals.
In our study, we assessed the change in the area of pathologic vessels within
the cornea, whereas our grading system evaluated which of the 3 components
(extent, centricity, and density) responded most to the bevacizumab injection.
Indeed, a significant change in extent and density was shown, whereas
centricity of vessels did not react to the subconjunctival injection. Possibly, the
perilimbal application of the drug did not reach the more central part of the
vessel in the deep cornea. It is possible that these central vessels would respond
to a stromal injection rather than a perilimbal subconjunctival injection.
In conclusion, subconjunctival bevacizumab injection is efficacious in limiting
corneal neovascularization in human subjects. Whether this partial regression
of blood vessels is of clinical value needs to be studied in a randomized clinical
trial with a larger sample size and longer follow-up. Bevacizumab may also be
used in the future, as an adjunct to other drugs, for the treatment of corneal
neovascularization.
Neonatal Infectious Keratitis Five Years
Experience at a Tertiary Eye Care Center
Dr. Jatin Ashar, Dr. Muralidyhar R, Dr. Shivani Pahuja, Dr. Sunita
Chaurasia, Dr. Virender Sangwan
N
eonatal keratitis is a serious, vision- threatening disease. Infections in this
age group are difficult to diagnose, manage and are uniquely at a grave
risk for secondary amblyopia. Several large studies on microbial keratitis have
been reported in children1,2 however, literature on neonatal infectious keratitis
is limited.
To study the epidemiology, predisposing factors, clinico-microbial profile and
outcomes of neonatal microbial keratitis.
Study design: Retrospective, non consecutive, interventional case series.
MATERIALS AND METHODS
Medical records of 34 neonates (42 eyes) were analyzed for the age at
presentation, predisposing factors, systemic illness, clinical presentation,
microbiological profile, clinical course and outcomes. Examination was
performed using operating/ portable slit lamp microscope with /without
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anesthesia. Corneal scrapings were sent for microscopic examination using
Gram stain, 10% KOH wet mount, Giemsa stain and cultured on blood agar,
chocolate agar, Non Nutrient agar, and Potato Dextrose agar. IFA and PCR
for HSV were obtained on suspicion of HSV. Microorganisms were identified
on smears or culture and intensive antimicrobial therapy initiated based on
smear results and later modified according to culture, antibiotic sensitivity
pattern and clinical response.
Potential risk
No of patients
factors
%
Microbiological profile
1. Route of
Vaginal
27/34
79.41%
Pseudomonas-5/27,
delivery
Staphylococcus spp-3/7,
GPC-2/7,Gonococcus-1/7,
HSV-3/7,Fungus-2/7,
No Organism-8/7
Caesarean
7/34 20.5% Pseudomonas-4/7,
Staph. epidermidis-1/7,
GPC-2/7
2. Prematurity
3. Maternal
infections
1/34
2.94%
No organism isolated
Urinary tract
2/34
infection,
vaginal discharge
5.88%
Pseudomonas-1/2, HSV-1/2
4. Prolonged
9/34
26.47%
Pseudomonas- 4/9 (44.4%)
NICU care
Staphylococcus hemolyticus-
1/9 (11.1%)
Fungus-1/9(11.1%)
HSV-1/9 (11.1%)
No organism detected
-2/9(22.2%)
5. Associated Jaundice
4/34
11.7%
Systemic
condition
Seizures
1/34 2.94% Pseudomonas
Skin rashes/
2/34
vesicles
Sepsis
Goldenhar’s
syndrome
Pseudomonas-2/4,
No organism-2/7
5.88%
Pseudomonas-1/2, HSV-1/2
1/34 2.94% Pseudomonas
1/34
2.94%
No organism
6. Associated Lid coloboma
2/34
ocular
with lagophthalabnormality
mos (OU)
5.88%
Staphylococcus-2
2.94%
No organism
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Limbal dermoid 1/34
with lagophthalmos (OS)
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RESULTS
Average age at the time of presentation was 16.91 +7.74 days.•
Eight patients had bilateral involvement at presentation.
Symptoms at presentation:
Watering- 5 patients, Discharge- 11 patients, yellowish white spot- 31 patients
Risk factors and potential associations of infection identified were: Prematurity,
route of delivery, • maternal infections, systemic associations and ocular
malformations.
Microbiological Results:
Microbiology +:30/42 eyes
Smears and/or Culture positive: 31/42 eyes
Smears+/Culture- : 18/42 eyes
Smears-/Culture+:18/42 eyes
Smear and Culture +:9/42 eyes
Microbiology: 12/42 eyes
Microbiological profile.
Organism isolated in neonates with prolonged hospitalization: Total=16
patients•
Sensitivity pattern in hospital based infections:
Gram positive (4) - All Sensitive to first line drug, Cefazoline
Gram negative (8) - 3/8 Sensitive to first line drug Ciprofloxacin,
5/8 Resistant to multiple drugs, sensitive only to Imepenam
Management:
Medical: All
Topical antibiotic treatmentGram
positive:
cefazoline
Fortified
Gram Negative: Ciprofloxacin
Fungus: Natamycin
HSV: Acyclovir ointment
Systemic antibiotic- 6 patients
Surgical:
Lid surgery-3 eyes
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TA+ BCL- 3 eyes
PK- 3 eyes
Evisceration-1 eye
Outcomes:
Average duration of treatment-33.86
(+ 2) days
Resolved with scar-28 eyes
Anterior staphyloma-2 eyes
Failed graft-3 eyes
India
DISCUSSION
Neonatal keratitis has diverse clinical presentation and underlying etiology.
Any watering and discharge in this age group should arouse suspicion and
thorough clinical evaluation for early diagnosis. Possible risk factors include
prolonged hospitalization, underlying systemic and ocular diseases. Most
infections (54.76%) in this period were of bacterial origin, with Pseudomonas
being the commonest bacteria isolated. Early identification of risk factors,
aggressive microbiology work-up and appropriate therapy is needed to
decrease ocular morbidity related to infectious keratitis in neonates.
REFERENCES
1.
Kunimoto DY, Sharma S, Reddy MK et al. Microbial keratitis in children.
Ophthalmology 1998;105:252-7.
2. Cruz OA, Sabir SM, Capo H, Alfonso EC. Microbial keratitis in childhood.
Ophthalmology 1993;100:192-6.
Efficacy and Safety of Topical Umbilical Cord
Serum Therapy in Persistent Corneal Epithelial
Defects
Dr. Charu Mithal, Dr. Anu Malik, Dr. Sandeep Mithal, Dr. Neha Mithal,
Dr. Prateek Agarwal, Dr. Pallavi Agarwal
T
he corneal epithelium shows a wound healing response in event of
any external injury or insult. Tears have antimicrobial nourishing and
mechanical and optical properties. They contain component such as growth
factors, fibronectin, and vitamins to support proliferation, migration and
differentiation of the corneal and the conjunctival epithelium. A lack of these
epitheliotrophic factors leads to persistent epithelial defects.
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Persistent epithelial defect (PED) is defined as a corneal epithelial defect of
2mm or larger in its greatest dimension persisting for 2 weeks or more despite
of conventional treatment with artificial tears or bandage contact lens usage.
It can be caused by keratoconjunctivitis sicca, exposure keratitis, neurotrophic
keratits, limbal stem cell failure, keratoplasty, chemical burns and corneal
ulcers. It has been seen that deficiency of essential tears components such
as epidermal growth factors (EGF), vitamin A,neurotrophic growth factors
(NGF) such as substance P, acetylcholine may exacerbate the lesions. Umbilical
cord serum which contains various growth factors, Vitamin A and fibronectin
in high concentration is hypothesized as a potent option for the treatment of
persistent epithelial defects resistant to other conventional therapy. This study
is aimed to evaluate the efficacy and safety of umbilical cord serum in cases of
persistent epithelial defects due to various causes.
(1) To study the efficacy and safety of topical umbilical cord serum in persistent
corneal epithelial defects. (2) To study the complications encountered (3) To
study the rate of recurrence.
MATERIALS AND METHODS
Study Design
Prospective, non comparative study, Study population: 20 eyes of 20 patients
with persistent corneal epithelial defects were selected from routine OPD of a
tertiary care centre. Patients were followed for a period of 6 months from the
day of starting the topical umbilical cord serum eye drops.
Inclusion Criteria
Patients of any age group, preferably cooperative for digital photography, were
included with PED of various etiopathogenesis e.g., Chemical burn, Diabetic
neurotrophic ulcer, Bacterial ulcer. Herpetic neurotrophic ulcer, Keratoplasty
(optical and therapeutic), Dry Eye.
Exclusion Criteria
Patients with the following conditions were excluded: Pregnant and lactating
women, Immunological conditions like rheumatoid arthritis, active corneal
ulcer, impending perforation, acute ocular infection, abnormality of eyelid
and adenexa eg – trichiasis, blepharitis, ectropion, entropion. Processing Of
Umbilical Cord serum: Umbilical cord blood was collected from mothers of
uncomplicated caesarean deliveries after informed consent and screening for
hepatitis B, C and HIV. No anticoagulants were used during the procedure.
The blood was allowed to clot and was centrifuged at 1500 rpm for 5 min then
diluted in normal saline to make 20% solution. The serum was stored at -4
degrees C. This diluted umbilical cord serum was stored in 5 ml sterilized
vials and was given to patients. Patients were to apply this serum in drop 6
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69th AIOC Proceedings, Ahmedabad 2011
times a day and were asked to store it in a cool place, preferably in a refrigerator
or ice box.
RESULTS
(1) Details of Patient – Name, age and address of the patient were noted. His/
her diagnosis (cause of persistent epithelial defect) and past treatment was
also recorded. (2) Visual Acuity (both unaided and best corrected). (3) Proper
slit lamp evaluation was carried out to exclude any adenexal abnormalities as
the cause of PED, cornea was evaluated in full detail, emphasis was paid on
the size and site of epithelial defect, the corneal thickness and vascularization.
(4) Schirmers test–was carried out in each and every patient and was repeated
at every follow up. (5) Fluorescein staining (6) Digital IOP – was assessed by
the same examiner in every case. The patients were followed up on days 3, 7,
14, 21, 24, 28 and so on for 6 months. The variables recorded at each follow up
visit were the best corrected visual acuity, the maximum size of the epithelial
defect along two perpendicular axes measured with a slit lamp, and also a
photograph of the same, a record of the side effects if any, and the digital
intraocular pressure.
The effectiveness of the treatment was divided into three groups.
1. Effective – Those defects that took less than 2 weeks to heal.
2. Partially Effective – Those defects that took less than 4 weeks to heal.
3. Ineffective – Those defects that took more than 6 weeks to heal or did not
heal at all.
Table 1: Effectivness of The Treatment
Healing Pattern
Number
Percentage (%)
Effective
12
60%
Partially Effective
06
30%
Ineffective
02
10%
In our study we found that out of 20, 12 patients (60%) showed effective
response to umbilical cord serum eye-drops and 6 patients (30%) showed
partially effective response. However, in the later two cases i.e. (10%), healing
was ineffective (took more than 6 weeks to heal).
Table 2: Duration Taken By The Epithelial Defect To Heal
Time (weeks)
Number
Less than 1 week
4
1-2
8
2-3 7
3-4 3
more than 4 weeks
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Regarding the duration taken by epithelial defects to heal we see that 8 out
of 20 patients had their epithelial defect healed in 2 weeks (40%), and 4 out
of 20 healed within one week, thus a total of 12(60%) healed within 2 weeks
suggesting the treatment to be effective. There have been no side effects noted
during the entire period of our study suggesting the umbilical cord serum
eye-drops to be safe for the use on ocular surface.
Epithelial defect did not recur in patients who responded to umbilical cord
serum eye-drops, after 6 months of follow up showing that epithelial wound
healing was complete.
DISCUSSION
The cornea produces multiple growth factors such as epidermal growth
factor (EGF) and fibroblast growth factor (FGF), neurotrophic growth factor
which contribute to the maintenance of a healthy epithelial surface and its
regeneration. Persistent epithelial defects is rare but has serious complications.
It has been seen that deficiency of essential tears components such as epidermal
growth factors (EGF), vitamin A, neurotrophic growth factors (NGF) such as
substance P, acetylcholine may exacerbate the lesions.
Umbilical cord serum owes its efficacy to the presence of factors such as EGF,
vitamin A, acidic and basic FGF, fibronectin, nerve growth factor, substance P,
antiproteases like α2 macroglobulin, and enhanced mucin expression due to
the serum.7 The mechanism of action of umbilical cord serum is likely to be
the same as that of autologous serum, the difference being probably a higher
concentration of the growth factors, which may in fact stimulate a faster
growth of stem cells and hence lead to a faster re-epithelialisation.
The results are comparable with the study of Yoon et al (2005) who performed
the study on 14 patients with persistent epithelial defect of various etiologies
and found umbilical cord serum to be effective in 6 patients (42.9%) and partially
effective in 6 patients (42.9%). Umbilical serum treatment has several clinical
advantages, firstly,by obtaining a large quantity of umbilical cord blood from
mothers, the serum can be supplied to many patients. Second, umbilical cord
serum eyedrops can be prepared in advance, thereby shortening the waiting
period for the patients. Finally,even when taking the blood from the patients
themselves is difficult due to poor general condition, umbilical cord serum
remains a feasible option.
Recently Vajpayee et al have reported that since umbilical cord serum contains
a higher concentrations of EGF, Vitamin A, acidic and basic FGF, fibronectin,
NGF, substance P, and antiproteases like alpha 2 macroglobulins, it may be
more useful for the treatment of the ocular surface than autologous serum.
They also reported that the recovery was faster using umbilical cord serum,
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69th AIOC Proceedings, Ahmedabad 2011
compared to autologous serum, for persistent corneal epithelial defect
refractory to medical treatment.
Although we have used 20% umbilical cord serum eyedrops in this study,
there is no agreement on the best dilution concentration of serum for use in
ocular surface diseases.
Umbilical cord serum, a preparation that can be easily prepared , is an effective
means of promoting epithelialisation and can be safely used .
Sympathetic Ophthalmitis Following Optical
Penetrating Keratoplasty In The Last 9 Years
Dr. Rekha Gyanchand, Dr. Sheetal Hegde
S
ympathetic Ophthalmia is a rare bilateral diffuse autoimmune
granulomatous uveitis occurring in patients who have sustained
penetrating ocular insult either as a result of trauma or as a rare consequence
of ocular surgery. The incidence is 0.2%-0.5% following trauma and less the
0.1% following surgery. Ophthalmic procedures that have been reported to
result in sympathetic ophthalmia include cataract surgery, glaucoma filtering
surgery, scleral buckling, pars plana vitrectomy, laser cyclophotocoagulation1
and proton beam irradiation. However literature reports very few cases of
sympathetic ophthalmia following penetrating keratoplasty.2,3
MATERIALS AND METHODS
A retrospective study was done of 5 cases seen from 2001-2009 at the Cornea
Clinic in Bangalore West Lions Superspeciality Eye Hospital, Bangalore.
All 5 patients had history of penetrating injury and underwent penetrating
keratoplasty (3 cases for leucomatous corneal opacity with vascularization
following primary repair while 2 cases for corneal decompensation following
vitrectomy for IOFB removal).
Bilateral ocular examination on follow-up consisted of visual acuity testing for
distance and near, color vision, anterior segment examination with slit lamp
biomicroscopy, fundus examination and IOP recording. During regular postoperative follow-up visit, these patients complained of gradual decrease in
visual acuity in the normal eye.
Further investigations done to rule out systemic association for ocular
inflammation were normal. Retinal S antigen was positive in one case.
The history of penetrating eye injury and subsequent surgery, with the finding
of granulomatous inflammation in both eyes raised suspicion of sympathetic
ophthalmitis as a possible diagnosis.
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RESULTS
All the patients were males between 14-33 years who had history of penetrating
ocular injury and primary surgical treatment (3 cases had primary corneal
tear repair while 2 cases underwent vitrectomy with IOFB removal.)
Injury
Primary
Penetrating
Sympathetic
Injury to
PK to
history
diagnosis Keratoplasty ophthalmia onset SO Time
SO Time
Interval Interval
1994 Leucoma 2001
2009
16yrs 8Yrs
1996
Leucoma
2005
2006
11yrs
1996
Leucoma
2000
2001
7yrs
1yr
2001
Corneal decom- 2005
pensation
(IOFB removal)
2007
7yrs
3yrs
2007
6yrs
1yr
2002
Corneal decom pensation
(IOFB removal)
2006
1Yrs
Clinical Findings
Sympathizing Eye
Exciting (Post-Pk)Eye
Anterior Segment
Granulomatous uveitis-5 cases
Signs of diffuse endothelial
rejection- 5 cases
Koeppe nodule-1 case
Glaucoma-4 cases
Posterior Segment
Vitritis-5 cases
Dalen Fuchs Nodule-1 case
Exudative RD-1 case
There were no significant extra ocular findings in any of these patients.
Following keratoplasty, the onset of sympathetic ophthalmitis varied between
1-8 years and following primary injury the onset varied between 6-16 years.
According to reports sympathetic ophthalmitis developed in 80% patients
within 3 months of injury and in 90% within 1 year.5 However isolated cases
as early as 1 week or as late as 66 years after initial injury have been reported .6
Vision
Sympathizing Eye
On presentation
Sympathizing Eye
After treatment
Exciting Eye
Post PK, Graft rejection
CF CF
6/60
HM+ve
6/12
6/9p
PL+ve, PR accurate
6/12
6/9p
PL+ve, PR accurate
6/60
6/36
PL+ve, PR accurate
CF 1m
6/36p
6/36
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69th AIOC Proceedings, Ahmedabad 2011
2 cases with early presentation had excellent recovery while 3 patients had
moderate recovery due to retinal detachment, extensive RPE atrophy and
glaucomatous cupping.
Oral steroids were given in the dose of 1.5mg/kg body weight and the patients
were continued on a maintenance dose for 1 year. 2 patients were started on
Azathioprine 50mg/day while 1 patient was treated with Methotrexate.
DISCUSSION
Sympathic Ophthalmitis has been reported to occur mainly following trauma.
However it has also been reported to occur following ocular surgery like cataract
surgery, scleral buckling, parsplana vitrectomy7, laser photocoagulation Our
study included patients with sympathetic ophthalmitis developing after
penetrating keratoplasty. The indications for keratoplasty were leucomatous
corneal opacity following primary corneal repair (3 patients) and endothelial
decompensation following IOFB removal (2 patients). According to studies,
penetrating keratoplasty for corneal decompensation following IOFB removal
are at high risk for sympathetic ophthalmitis.8
Dalen Fuchs Spots
The onset of symptoms usually occurs between 3 weeks to 6 months following
surgery. In our study, the symptoms in sympathizing eye occurred between
1-8 years after surgery. The typical presentation of sympathetic ophthalmitis
is a bilateral panuveitis that occurs after ocular
trauma or intraocular surgery.9 In our study
the sympathizing eye showed mild- moderate
granulomatous anterior uveitis with vitritis
and multifocal choroiditis. Dalen Fuchs spots
with vitritis was present in 1 patient. This is
usually seen in 36%-47% cases.10
In our study the exciting eye had 1-2 attacks
of endothelial rejection 6-8 months after
corneal grafting. It has been seen that corneal
endothelial rejection does precipitate the
Figure 1: Dalen Fuchs Spots
sympathetic ophthalmitis as graft rejection
and sympathetic ophthalmitis have a similar cell- mediated cytotoxic reaction
towards antigens on uveal pigment epithelium.11
Earlier sympathetic ophthalmitis was considered to be a dreaded disease,
however in our study as well as other recent studies,1,7 it has been seen that if
treated early and adequately, it has a good visual outcome. Our study stresses
the need for surgeons to fully explain the risks involved to patients undergoing
penetrating keratoplasty in cases with trauma, post vitrectomy or probably
any ocular surgery compromising cornea and which may require penetrating
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keratoplasty, and to be alert to the possibility of sympathetic ophthalmitis in
the event that the patient develops visual complaints in the better eye.
• Delayed onset of Sympathetic ophthalmitis can be suddenly precipitated
by corneal transplantation in eyes with old history of penetrating injury.
• It is important to examine the normal eyes especially in the follow-up visit
in cases of corneal transplantation done for adherent leucoma following
penetrating injury.
REFERENCES
Liddy L, Stuart J. Sympathetic Ophthalmia in Canada. Can J Ophthalmol 1972;7:157-9.
1.
2. Sixty years (1913-1978) of sympathetic ophthalmia. Review of 105 cases.
Ophthalmology 1980;7:109-21.
3.
Bechrakis NE, Muller Stolzenburg, Helbig H, Foerster MH. Sympathetic
Ophthalmitis following laser cyclocoagulation. Arch Ophthalmol 1994;112:80-4
4.
PK for the exciting eye in SO. Cornea 2008;27:1080-1.
5.
Lubin J, Albert D, Weinstein M. 65 years of SO. A clinicopathological review of 105
cases (1913-1976). Ophthalmology 1980;87:109-21.
6.
ZahariaMA, Lamarche J, Laurin M. Sympathetic uveitis 66 years after injury. Can
J Ophthalmol 1984;19:240-3.
7.
Pollack AL, McDonald HR et al. Sympathetic Ophthalmitis associated with pars
plana vitrectomy without antecedent penetrating trauma. Retina 2001;21:146-54.
8.
BJO 2000 Dara J Kilmartin, retinal risk factor for SO
9.
Dada T, Kumar A, Sharma N. Sympathetic Ophthalmia associated with antecedent
adherent leucoma- A rare association. Acta Ophthalmol Scand. 1998;76:380-1.
10. 32 Cases of Sympathetic Ophthalmia. Arch Ophthal. 1995;13.
11. Early stage of Human Sympathetic Ophthalmitis, Histologic and
logic findings. Muller HK et al. Arch Ophthalmol 1984;102:1353-7.
Immunopatho-
Dr. SOMASHEILA I MURTHY: MBBS (1992), TN Medical College; MS
(1996), LTM Medical College, Mumbai University; DOMS, FCPS, Mumbai;
Cornea and Anterior Segment fellow (1998), LVPEI, Hyderabad; Uveitis
and Ocular Pathology fellow (2000), Doheny Eye Institute, USA. Presently,
Consultant, Cornea and Anterior Segment, Ocular Immunology and Uveitis
Service, LVPEI, Hyderabad. E-mail: [email protected]
Comparision of Endothelial Cell Count by
Manual And Automated Methods in Normal
Cornea and in Fuchs’ Endothelial Dystrophy
Dr. Somasheila I Murthy, Dr. Debarun Dutta, Dr. Tamal Chakraborti,
Dr. Pritam Kumar
E
ndothelial cells are crucial to maintain corneal health and its count is
important in any endothelial abnormality.1,2,3 The Cell Count software
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69th AIOC Proceedings, Ahmedabad 2011
of NIDEK Confoscan 4 is regularly used to perform corneal endothelial cell
analysis, either automatically or manually. The automatic cell analysis returns
information about the cell density and morphology of a selected Region of
Interest (ROI), while the manual cell analysis can only evaluate the cell density
of a selected ROI. Confoscan results are said to provide 95% of probability to
have a difference between the estimate and the real cell count value lower than
10%.4 Clinically, while performing cell count, it is important that Confoscan
should provide accurate results even in abnormal endothelium.
The purpose of the study is to evaluate the difference in endothelial cell
count between automated and manual methods in healthy cornea and Fuchs’
endothelial dystrophy.
MATERIALS AND METHODS
1.
Study design: retrospective analysis.
2.
Data was analysed by single experienced observer.
3.
One hundred images from both healthy and Fuchs’ endothelial dystrophy
were reviewed by single observer.
4.
Archived images of the endothelium from the NIDEK Confoscan 4
were used to procure endothelial cell counts by automated and manual
methods.
5.
The following parameters were required to select the image: Endothelial
images were clear in all the slides and around 50 to 100 cells were taken
in each in slide to count as per manufacture guideline.
• After having selected the Region of Interest, the automatic cell count
was processed by clicking the corresponding button
• For manual count, at first respective cells were selected in the region of
interest. Hence a custom polygonal area drawn along with the wall of
the borderline cells to surround the group of cells. Density information
given by the following formula: Density = cells in polygon / Polygon
area [cells/mm2]4
• Cell count difference between two methods of >250 cells/mm2 was
considered clinically significant.
RESULTS
• 52 and 65 images were of right healthy and compromised endothelium
eyes respectively.
• Based on manual cell count, endothelial cell density of Fuchs’ dystrophy
slides divided into two groups.
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Table 1: Endothelial cell counts done by automated and manual
methods in images from Fuchs’ dystrophy
Number of Average
Images
auto count
Average
manual count
Average
difference
Range of cells p value
(difference)
Cell count
49
more than
1000 cells / mm2
2028.73 ± 329.53 1719.82±489.47 312.96±337.27 402 to 2 cells <0.0001
Cell count
51
less than
1000 cells / mm2
1626.73 ± 186.50 673.62±149.52 953.12±246.70 1631 to 54 cells <0.0001
Table 2: Endothelial cell counts (cells/mm2) in healthy and fuchs’
dystrophy cornea
images
average
auto count
Healthy
Cornea
average
manual count
average
difference
100 2471.24 ± 273.19 2444.50 ± 370.30 125.67 ± 86.9
range of cells p value
(difference)
402 to 2 cells
0.0463
Fuchs’
100 1827.73 ± 334.31 1196.71 ± 637.29 633.04 ± 435.03 1631 to 54 cells <0.0001
Dystrophy
• In the first group manual count was more than 1000 cells/mm2 (49 images)
and in the second group manual count was less than 1000 cells/mm2 (51
images)
• The cell count differences between the two methods were significantly
higher when cell counts were least, which implies that the difference tends
to increase in eyes with extensive endothelial changes.
• The results are summarized in Tables 1 and 2.
DISCUSSION
Advantage of automated mode is that there is no inter-observer variability, it
is faster, repetitive and is independent of users’ experience and skills.5 On the
other hand manual mode is time consuming needs higher level of technical
skills and thereof it is unsuitable in busy clinic. In our study the results
have shown a large variability between the two methods (as much as up to
more than 900 cells/mm2 difference) in advanced cases of Fuchs’ dystrophy.
Decision on whether a patient need surgery may be affected by whether we do
it in manual or automated mode thus delaying the surgical intervention on the
final outcome. Both the clinician and investigator need to be sensitive to this
fact and patients with diseased corneas should undergo manual count.
Our study shows that while in healthy corneas, both methods showed similar
counts; in the case of diseased cornea, the accuracy of the automated count
decreased with decrease in total cells. Manual count is therefore more reliable
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69th AIOC Proceedings, Ahmedabad 2011
in compromised endothelium as automated count overestimates the results,
and can even give a value in normal range, thus misleading the clinician.
REFERENCES
2. Klais CM, Bühren J, Kohnen T. Comparison of endothelial cell count using confocal
and contact specular microscopy. Ophthalmologica. 2003;217:99-103.
3.
Módis L Jr, Langenbucher A, Seitz B. Corneal endothelial cell density and
pachymetry measured by contact and noncontact specular microscopy. J Cataract
Refract Surg. 2002;28:1763-9.
4.
Doughty MJ. Toward a quantitative analysis of corneal endothelial cell morphology:
a review of techniques and their application. Optom Vis Sci. 1989;66:626-42.
5.
NAVIS for Confoscan 4 Operator’s Manual ©2005-2007.
6.
Imre L, Nagymihály A. Reliability and reproducibility of corneal endothelial
image analysis by in vivo confocal microscopy. Graefes Arch Clin Exp Ophthalmol.
2001;239:356-60.
Streptococcus Pneumoniae Keratitis: Fortified
Antibiotics or Fluoroquinolones?
Dr. Sujata Das, Dr. Savitri Sharma, Dr. Vivek Warkad, Dr. Srikant K Sahu
F
ortified topical ocular antimicrobial (usually cephalosporin and
aminoglycoside) is frequently administered to cover the maximum
spectrum of bacteria in cases of severe bacterial keratitis. Treatment is modified
according to the clinical response and sensitivity of the microorganism.1-4
Frequent dosing of multiple antibiotics may result in increased toxicity and
damage to the ocular surface epithelium.2,3
For antimicrobial therapy to be effective in cases of microbial keratitis, it
should reach the site of corneal infection in sufficient concentration to inhibit
and preferably kill the causative microorganism while causing minimal
or no toxicity to the host. Several factors modulate the interaction between
drug, microorganisms, and the host. The purpose of this study was to test in
vitro susceptibility of Streptococcus pneumoniae isolated from patients with
microbial keratitis in order to determine the most suitable antibiotic for the
treatment of keratitis caused by the organism.
MATERIALS AND METHODS
The medical and laboratory records of all culture-proven cases of S
pneumoniae keratitis diagnosed at the L V Prasad Eye Institute, Bhubaneswar,
India between November 2006 and December 2009 were reviewed
retrospectively. All patients had undergone detailed clinical evaluation and
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slit-lamp examination. Corneal scrapings were obtained from all patients as a
part of a standard protocol and subjected to direct microscopic examination
(Gram and/or Giemsa, potassium hydroxide [10.0%] with calcoflour white)
and inoculation into various culture media such as sheep blood agar (BA),
chocolate agar (CA), Sabouraud dextrose agar (SDA), non-nutrient agar (NNA),
and brain heart infusion (BHI) broth. SDA bottles were incubated at 26±1OC
to enhance the growth of fungi, and the remaining plates were incubated at
36±1OC. While CA plates were incubated with 5% carbon dioxide, BA and BHI
broth were incubated aerobically, and NNA were incubated aerobically with
an added live Escherichia coli suspension. All media were incubated for two
weeks and were examined daily. A culture was considered significant and
was reported if the smears demonstrated morphologically similar organisms
and/or if the same organism grew in more than one medium and/or if there
was growth on at least two streaks on blood agar. In vitro susceptibility of the
isolates was tested by Kirby Bauer disc diffusion method and interpreted as
per CLSI guidelines. Muller Hinton agar with blood and commercial antibiotic
discs (cefazolin, chloramphenicol, vancomycin, ciprofloxacin, ofloxacin,
moxofloxacin, gatifloxacin) from Himedia, Mumbai were used for the test.
Zones of inhibition were noted in millimeter and interpreted as resistant,
sensitive or intermediate as per the chart provided by the company.
Intensive topical medication was started on the basis of the smear result. Topical
medication was modified in some cases depending on the clinical response,
culture report, and sensitivity of the isolated organism. The retrospective
data included patient demography (age, gender, and occupation), disease
history (onset, course, predisposing factors), clinical appearance, antibiotic
susceptibility, treatment and outcome.
RESULTS
Among 990 corneal scrapings/corneal tissues from clinically diagnosed cases
of microbial keratitis at our Institute between November 2006 and December
2009, 61 (6.2%) corneal scrapings of sixty patients were culture positive for S
pneumoniae. The mean age was 45.9±21.3 years (range: 6 months to 78 years,
median: 50). The male to female ratio was 40:20. Most patients were in the age
group 41-70 years (n=36, 60%).
An ocular predisposing condition was identified in 51 eyes. Fourteen had
undergone keratoplasty and 9 had chronic dacryocystitis. Twenty five eyes
(40.9%) had a history of ocular trauma. Fourteen eyes had polymicrobial
infection. Thirty one eyes required an adjunctive procedure. Five eyes
underwent therapeutic keratoplasty, and 20 eyes underwent tissue adhesive
and bandage contact lens application. The in vitro susceptibility of the isolates
by disc diffusion method was 100% to cefazolin, 95.1% to chloramphenicol,
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90.9% to vancomycin, 88.9% to gatifloxacin and 78.7% to ciprofloxacin. Six
isolates were resistant to more than one antibiotic.
DISCUSSION
S pneumoniae is a common cause of bacterial keratitis. It accounts for around
30-40% of all bacterial keratitis.5-7 Chronic dacryocystitis is a well known
risk factor for microbial keratitis due to S pneumoniae.5,7 It is also reported
as a common pathogen isolated from microbial keratitis after corneal
transplantation. Although trauma is not known to be a common predisposing
factor associated with microbial keratitis due to S pneumoniae, it is a major
predisposing risk factor in our series.
Resistance to penicillin, other beta-lactam and non-beta-lactam compounds
have been reported with an increased frequency in recent years among
clinical isolates of S pneumoniae.8 These strains are effectively killed with
new fluoroquinolones.9 Nevertheless, fluroquinolone resistance among the
pneumococcal clinical isolates have been primarily attributed to mutations
in the quinolone resistance-determining regions of the gyrase A and
topoisomerase IV gene.10
Although ciprofloxacin is effective in vitro against S pneumonae, it is felt that
in vivo efficacy may be inadequate, leading to the choice of fortified cefazoline
as the first line of therapy. In our study, in vitro susceptibility of the isolates
was 100% to cefazolin, 95.1% to chloramphenicol, 90.9% to vancomycin, 88.9%
to gatifloxacin and 78.7% to ciprofloxacin. Ramkrishnan et al have compared
in vitro efficacy of fluroquinolones against S pneumoniae isolated from
bacterial keratitis by E-test.11 They have concluded that S pneumoniae are 100%
sensitive to fluoroquinolones. They also concluded that fourth-generation
fluroquinolone, moxifloxacin appeared to be more effective than gatifloxacin,
levofloxacin, ofloxacin and ciprofloxacin.
In our study, sensitivity to gatifloxacin was more than ciprofloxacin. Compared
to earlier studies,5,11 sensitivity to ciprofloxacin was less in our series. Though,
there was zero resistance to cefazoline, preparation and storage of fortified
solution has its own limitation. In contrast, fluroquinolone are cheap and
readily available commercially. Therefore, till the antibiotic sensitivity results
are not available, patients may be continued with fortified cefazoline and
fluroquinolone eye drops. Fortified cefazoline may be discontinued according
to the clinical response and sensitivity.
REFERENCES
1.
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Baum JL, Barza M, Weinstein L. Preferred routes of antibiotic administration in
treatment of bacterial ulcers of the cornea. Int Ophthalmol Clin 1973;13:31-7.
Cornea Free Papers
2. Baum JL. Initial therapy of suspected microbial corneal ulcers. I. Broad antibiotic
therapy based on prevalence of organisms. Surv Ophthalmol 1979;24:97-105.
3.
Jones DB. Initial therapy of suspected microbial corneal ulcers. II. Specific antibiotic
therapy based on corneal smears. Surv Ophthalmol 1979;24:105-16.
4.
Hyndiuk RA, Cockington CD. Bacterial keratitis. In: Tabbara KF, Hyndiuk RA
(eds.). Infections of the eye: diagnosis and management. Little Brown, Boston, 1996:
323–47.
5.
Parmar P, Salman A, Kalavathy CM, Jesudasan CA, Thomas PA. Pneumococcal
keratitis: a clinical profile. Clin Experiment Ophthalmol 2003;31:44-7.
6.
Srinivasan M, Gonzales CA, George C, Cevallos V, Mascarenhas JM, Asokan B,
Wilkins J, Smolin G, Whitcher JP. Epidemiology and aetiological diagnosis of
corneal ulceration in Madurai, south India. Br J Ophthalmol 1997;81:965-71.
7.
Aasuri MK, Reddy MK, Sharma S, Rao GN. Co-occurrence of pneumococcal
keratitis and dacryocystitis. Cornea 1999;18:273-6.
8.
Thornsberry C, Ogilvie P, Kahn J, Mauriz Y. Surveillance of antimicrobial
resistance in Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella
catarrhalis in the United States in 1996-1997 respiratory season. Diagn Microbiol
Infect Dis 1997;29:249-57.
9.
Zhanel GG, Walters M, Laing N, Hoban DJ. In vitro pharmacodynamic modelling
simulating free serum concentrations of fluoroquinolones against multidrugresistant Streptococcus pneumoniae. J Antimicrob Chemother 2001;47:435-40.
10. Tankovic J, Perichon B, Duval J, Courvalin P. Contribution of mutations in gyrA and
parC genes to fluoroquinolone resistance of mutants of Streptococcus pneumoniae
obtained in vivo and in vitro. Antimicrob Agents Chemother 1996;40:2505-10.
11. Ramakrishnan R, Ramesh S, Bharathi MJ, Amuthan M, Viswanathan S.
Comparative in-vitro efficacy of fluoroquinolones against Streptococcus
pneumoniae recovered from bacterial keratitis as determined by E-test.
Indian J Pathol Microbiol 2010;53:276-80.
Fibrin Glue (FG) Augmented Amniotic
Membrane Transplantation (FGAMT) in
Peripheral Corneal Perforations
Dr. Ritu Arora, Dr. Jasneet Kang, Dr. J L Goyal, Dr. Monika Mittal,
Dr. Parul Jain
T
o evaluate the efficacy of fibrin glue (FG) augmented amniotic membrane
transplantation (AMT) in non infective peripheral corneal perforations.
Corneal perforations can result from a variety of ocular disease states
associated with chronic inflammatory conditions. Regardless of the cause,
perforation is an emergency and prompt treatment is required.
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Many surgical approaches, such as tissue adhesive, bandage contact lens,
transpositional conjunctival flap, and therapeutic penetrating keratoplasty
(PK), have been used to treat corneal perforations. However, these surgical
modalities are associated with a large number of problems eg. tissue
inflammation from glue toxicity, diminished vision, and poor cosmesis with
a conjunctival flap and tarsorrhaphy and graft failure in the setting of an
inflamed or infected eye.1
Lee and Tseng were the first to propose the use of human amniotic membrane
(AM) for the treatment of corneal epithelial defects.2 For deep and severe
ulcerations, Kruse et al suggested multi layer AMT and showed rapid epithelial
healing and stromal thickening after multilayer AMT.3 Solomon et al reported
a favorable clinical outcome in 34 eyes that underwent multi layer AMT for
nontraumatic corneal perforations, descemetoceles, and deep ulcers.4 The use
of FG for attaching the AM graft has been reported by Pfister and Sommers
in different ocular surface disorders.5 There have been clinical reports
addressing AM grafts with FG sealant in the treatment of corneal perforations.
Duchesne et al combined the use of amniotic membrane transplantation with
human fibrin glue to repair corneal perforation and found it to be successful
in corneal perforations upto 2 mm in diameter associated with significant loss
of stroma.6
However in large corneal perforations (upto 4mm diameter) the application of
FG alone as a plug cannot seal the defect completely or stabilize the anterior
chamber. Also, this technique cannot be used in severe clinical circumstances,
such as iris incarceration or collapsed anterior chamber.
To offset these limitations of AM graft with fibrin plug in eyes with large
corneal perforations, FG-assisted augmented AMT may be beneficial. Kim et
al reported it to be a successful procedure in large perforations.7
The aim of the present study was to assess the efficacy of FG-assisted augmented
AMT in treating large corneal perforations (2 mm or more in diameter) and to
evaluate the long-term stability of the corneal surface.
MATERIALS AND METHODS
10 patients with peripheral corneal perforations upto 4 mm in diameter were
treated with ‘‘FG assisted augmented AMT.’’ The perforated edges of the
ulcer was cleaned and partially necrotic tissue was removed. The augmented
AM was designed 0.5 mm larger than the diameter of the perforation. Five
or 7 designed pieces of AM were prepared. A drop of fibrinogen- thrombin
solution (Tissel glue) was applied to the first AM piece. The second AM was
then transferred onto the first AM. A blunt spatula was used to spread out the
FG between the AM pieces. The procedure was repeated and several pieces
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of AM were pasted to make a thick single piece of multilayered AM called an
‘‘augmented AM.’’ The last pasted AM was positioned with the epithelial side
up to serve as a basement membrane for reepithelialization. This was then
transplanted to the perforated site using 10-0 nylon. The anterior chamber
was reformed with balanced salt solution. If needed, a temporary AM patch
was placed was placed over the entire wound and cornea after securing the
perforated wound with 10-0 nylon placed around the limbus. All corneal
wounds were covered with bandage contact lenses over the AM and topical
antibiotics were used for 3 weeks.
A slit-lamp examination was performed daily to assess graft integrity and
check for signs of inflammation, infection, changes in the ocular surface, and
ulcerated underlying stroma. After complete reepithelialization, follow up
was monthly to assess graft integrity and monitor for any complications.
Surgical success was defined as a negative Seidel test, an adequate anterior
chamber depth, and complete epithelialization through the end of the followup period.
RESULTS
The FG-assisted augmented AMT was performed in 10 patients (6 women, 4
men) with a mean age of 51.5 +/- 15.3 years (range, 21–70 years). The average
follow-up was 4.5 +/- 1.2 months (range, 3–6 months). Mean ulcer diameter
was 2.87 +/- 0.95 mm (range 2–4 mm). BCVA was 20/120 or more in all patients
at 6 months. All had well formed anterior chambers and 90% showed complete
epithelialization. Mean reepithelialization time was 15.76+/- 3.95 days. In all
patients the anterior chamber was deep, and there was no further leakage
of aqueous fluid; the site of the ulcer showed a subepithelial scar with, in
some cases, a thickening of the stroma, and epithelialization was complete.
Conjunctival inflammation and pain were reduced in all patients. In none of
the patients was there any evidence of recurrent ulceration or perforation and
the stromal thickness at the perforation site seemed normal and stable during
the follow-up period ( as seen on Anterior segment OCT).
DISCUSSION
Fibrin glue in combination with AMT seems helpful in the treatment of
corneal perforations up to 4 mm in diameter. AM contains a mix of growth
factors, neurotrophins, and cytokines that facilitates proliferation of epithelial
cells and reduce the inflammatory response by inhibiting protease activity
and thus reduce vascularization, inflammation, and scarring. These unique
properties of AM make it useful in the treatment of ulcerative corneal disease.8
The AM does not express the antigens HLA-A, B, or DR and therefore poses no
problem of immunological rejection. AMT may allow postponement of corneal
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grafting until the eye is less inflamed, thereby improving graft survival or even
avoiding it altogether. The presence of the glue enhances scar tissue formation
as it prevents epithelial downgrowth and stimulates fibroblastic activity while
serving as a matrix for fibroblasts and keratocytes.9
Our study demonstrates the effectiveness of the FG-AMT in the treatment of
refractory large peripheral corneal ulcers. There was a reduction in the level
of conjunctival inflammation and pain after AMT. All patients epithelialized
successfully and had a stable scar over time.
This procedure has several advantages in the treatment of corneal perforations,
especially those of large size. The thickness of each augmented AM is equal
to that of healthy cornea allowing it to completely seal the large perforated
wound and prevent any leakage, hence maintaining a stable anterior chamber.
Additionally, it can be easily manipulated because it was a single piece of AM
instead of several sheets which further allows for a secure wound and also
reduces the surgical time. Also there is early reepithelialization of the corneal
surface as compared with a previous multilayer AMT report. This shows
that FG-assisted augmented AMT is more effective than multilayer AMT in
promoting healing of the epithelial layer in large corneal perforations.10
In conclusion, FG-assisted augmented AMT is a stable alternative for treating
large corneal perforations—especially those 2 mm or larger in size—with rapid
regeneration of epithelium and stability during the follow up period. This
technique promotes a stable and rapid reconstruction of the ocular surface
and can also be used as a temporary measure in cases requiring penetrating
keratoplasty at a later time when the eye is less inflamed and the corneal
surface has reepithelialized.
REFERENCES
1.
Nobe JR, Moura BT, Robin JB, et al. Results of penetrating keratoplasty for the
treatment of corneal perforations. Arch Ophthalmol. 1990;108: 939–941.
2. Lee S, Tseng SCG. Amniotic membrane transplantation for persistent epithelial
defects with ulceration. Am J Ophthalmol. 1997;123:303–12.
3.
Kruse F, Rohrschneider K, Volcker H. Multilayer amniotic membrane
transplantation for reconstruction of deep corneal ulcers. Ophthalmology.
1999;106:1504–11.
4.
Solomon A, Meller D, Prabhasawat P, et al. Amniotic membrane grafts for non
traumatic corneal perforations, descemetoceles and deep ulcers. Ophthalmology.
2002;109:694–703.
5.
Pfister RR, Sommers CI. Fibrin sealant in corneal stem cell transplantation. Cornea.
2005;24:593–8.
6.
Duchesne B, Tahi H, Galand A, Use of human fibrin glue and amniotic membrane
transplant in corneal perforation. Cornea. 2001;20:230–2.
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Cornea Free Papers
7.
Kim HK, Park HS. Fibrin Glue–Assisted Augmented Amniotic Membrane
Transplantation for the Treatment of Large Noninfectious Corneal Perforations.
Cornea 2009;28:170–6.
8.
Hao Y, Ma DH-K, Hwang DG, et al. Identification of antiangiogenic and antiinflammatory proteins in human amniotic membrane. Cornea. 2000;19:348–52.
9.
Hick S, Demers PE, Brunette I, et al. Amniotic transplantation and fibrin glue in
the management of corneal ulcers and perforations. A review of 33 cases. Cornea.
2005;24:369–77.
10. Rodriguez-Ares T, Tourino R, Lopez-Valladares J, et al. Multilayer amniotic
membrane transplantation in the treatment of corneal perforations. Cornea.
2004;23:577–83.
Hannibal (247-183 BC):
was a commander of Carthage, defeated the Roman
during the 2nd Punic War in 218 BC. During this
war, he developed corneal ulcer in right eye and
permanently lost his sight.
Jean Paul Sartre (1905-80):
a French author, philosopher, He was awarded the
Nobel Prize for literature in 1964 but he declined it.
At the age of 4 he suffered from corneal ulcer and
developed a right leucoma which led to exotropia.
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