Cornea

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ContentsCORNEA - IA New Approach to Management of Corneal Ulcers by Debridement --------------- 471Dr. 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 475Dr. 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 ------------------------------------------------------------------------------------ 479Dr. 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 ------------------------------------------------------------------------------------ 483Prof. Dr. K Vasantha, Dr. Rajini Ponraj, Dr. Mohan K, Dr. Niraimozhi

Risk Factors in Management of Bacterial Keratitis ----------------------------------------- 485Dr. Samrat Chatterjee, Dr. Deepshikha Agrawal

A Very Unusual Case of Keratitis ----------------------------------------------------------------- 488Dr. Saroj Gupta

Effect of Pterygium on Contrast Sensitivity --------------------------------------------------- 490Dr. 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 ------------------------------------------------------------------------------------- 493Dr. 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 - ------------------------------------------------------------------------------------------------------------------ 495Dr. 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 ---------------------------------------------------------------------------------------- 498Dr. 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 --------------------------------------------------------------------------------------------------------- 502Dr. Rekha Gyanchand, Dr. Sheetal Hegde

Comparison of Engothelial Cell Count by Manual and Automated Methods in Normal Cornea and in Fuchs Endothelial Dystrophy ------------------------------------------------ 505Dr. Somasheila I Murthy, Dr. Debarun Dutta, Dr. Tamal Chakraborti, Dr. Pritam Kumar

Streptococcus Pneumoniae Keratitis: Fortified Antibiotics or Fluoroquino-lones? ------------------------------------------------------------------------------------------------------------------ 508Dr. Sujata Das, Dr. Savitri Sharma, Dr. Vivek Warkad, Dr. Srikant K Sahu

Fibrin Glue (FG) Augmented Amniotic Membrane Transplantation (FGAMT) in Peripheral Corneal Perforations --------------------------------------------------------------------511Dr. Ritu Arora, Dr. Jasneet Kang, Dr. J L Goyal, Dr. Monika Mittal, Dr. Parul Jain

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CORNEA - IChairman: 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 DebridementDr. Debasish Dutta, Dr. Arup Bhaumik, Dr. Ayan Mohanta, Dr. Prashant Kumar Singhal, Dr. Sabitabrata Basu

Visual 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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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--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 METHODSIt 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.

UlcerUlcer 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 UlcerAn 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 criteriaAssociated 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.

ScrapingThe 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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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.

RESULTSPatients 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 .

DISCUSSIONThe 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 .

REFERENCES1. 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;81:965-71.

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 HandDr. Shwetambari Singh, Dr. Ravindra Vhankade, Dr. Dipali Satani, Dr. Amit Patel

Use 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 socio-economic 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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MATERIALS AND METHODSAll 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 nave contact lens users and 4 were minors. Table 1 outlines the details of contact lens availability, storage and usage.

Table 1Case Contact lens Storage and Duration of Assistance Sharing OvernightNo. availability cleaning storage in for CL use solution unchanged removal solution 1 Optical shop CLS 2 days + - -2 Optical shop CLS +Tape water 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 CLS +Tape water 4 months - + -8 Optical shop CLS 15 days + - -9 Friend CLS 5 days - + +10 Optical shop CLS +Tape water 3 days - - -11 Garbage - - - - -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 2Case Age Size of Organism Sensitivity Visual FinalNo. (years) / ulcer isolated acuity on visual gender (mm) presentation acuity1 20/M 5.5X6 P.aeruginosa Moxifloxacin HM 6/182 15/F 3X4 S. aureus Amikacin 6/24 6/93 16/F 9X8.5 P. aeruginosa Cefotaxime HM HM4 18/M 7X8 P.aeruginosa Moxifloxacin PR NA5 19/M 1X2 P.aeruginosa Moxifloxacin 6/60 6/126 28/M 6X7.5 Culture negative CF m CF m7 18/F 1X2 S.aureus Levofloxacin 6/6 6/68 25/M 7.5X8 S.epidermidis Moxifloxacin PR HM9 16/M 5X4.5 P. aeruginosa Amikacin CFNF 6/2410 21/F 2X3 S.aureus Moxifloxacin 6/9 6/611 15/F 5X5.5 P.aeruginosa Moxifloxacin 6/60 6/2412 20/M 2X3 S.epidermidis Moxifloxacin 6/9 6/613 21/M 7X8 P.aeruginosa Levofloxacin PR 6/60

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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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 TamilnaduDr. D Chandrasekhar, Dr. J Kaliamurthy, Dr. Pragya Parmar, Dr. C M Kalavathy, Dr. C A Nelson Jesudasen, Dr. Philip Aloysius Thomas

Mycotic 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 METHODSThe 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, Sabourauds dextrose agar and broth and brainheart infusion agar and broth. Brainheart infusion agar and broth, and blood agar were incubated at 37C and were examined


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daily and to be discarded after 7 days, if no growth was seen. Sabourauds dextrose agar and the broth were incubated at 28C 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.

RESULTSThere 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 TotalBacteria 116 112 110 86 98 522Fungi 108 80 143 103 108 542No growth 56 63 72 119 120 430Others 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 TotalFusarium solani 5 4 0 0 0 9Fusaium sp 24 20 60 34 42 180Fusarium dimerum 7 7 0 0 1 15Total 204A.flavus 16 8 20 30 27 101

A.fumigatus 10 4 7 3 4 28Aspergillus spp 3 1 0 0 4Aspergillus niger 1 0 0 1Total 134Curvularia sp 4 3 9 4 8 28Colletotrichum dematium 9 1 0 2 1 13Exerohilum longistratum 1 0 0 2 4 7Alternaria alternata 1 0 3 0 0 4Bipolaris 1 1 1 1 1 5Lasiodiplodia 2 0 1 0 3Scedosporium apiospermum 1 0 1Candida albicans 1 1 2UI 39 28 39 19 16 141Total 117 81 141 98 105 542

DISCUSSIONFungal 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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the result of the temperate climate because a warm, humid environment enhances the growth of fungi. In addition, the authors 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.

REFERENCES1. Xie LX, Zhong W, Shi W, Sun S. Spectrum of fungal keratitis in North China.

Ophthalmology 2006;113:19438.2. Chowdhary A, Singh K. Spectrum of fungal keratitis in North India. Cornea 2005;

24:815.

3. Shukla PK, Kumar M, Keshava GB. Mycotic keratitis: an overview of diagnosis and therapy. Mycoses 2008;51:18399.

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;37:76371.

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;14:619.

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;86:12115.

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;21:5559.

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Effect of Subconjunctival Injection of Bevacizumab on Corneal NeovascularizationProf. Dr. K Vasantha, Dr. Rajini Ponraj, Dr. Mohan K, Dr. Niraimozhi

To 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 METHODSThis 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 criteriaVascularised 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 abnormalities including current anticoagulation medications

Current or recent systemic corticosteroid therapy or periocular corticosteroids injections to the study eye

Ocular or periocular malignancy

ProcedureAnterior 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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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 measuresi) Regression of corneal new vessels

ii) Efficacy and safety of subconjunctival Bevacizumab

iii) Outcome of OKP after subconjunctival Bevacizumab injection

DISCUSSIONIn 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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Risk Factors in Management of Bacterial KeratitisDr. Samrat Chatterjee, Dr. Deepshikha Agrawal

Infectious 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 METHODSThis 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

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.


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2x2 tables with chi-square or Fishers test as appropriate. Variables that yielded p value

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Table: Univariate analysis of risk factors affecting outcomeSl VARIABLE Poor Good TOTAL Odds 95% CI PNo outcome outcome ratio VALUE No (%) No (%) 1 Extreme of age 6(12) 44(88) 50 0.78 0.26- 2.30 0.79 (0-14 and > 60y) Others 10(15) 57 (85) 67 2 Male gender 8(11) 68 (89) 76 0.6 0.21-1.74 0.26 Female gender 8 (20) 33 (80) 41 3 Distance >25kms 8(11) 63(89) 71 0.6 0.21- 1.74 0.41 Distance25kms 8(17) 38(83) 46 4 Presentation > 21d 4(21) 15(79) 19 1.51 0.44- 5.19 0.29 Presentation21d 12(12) 86(88) 98 5 Presence of risk factors 14(16) 73(84) 87 2.68 0.57 - 12.58 0.24 No risk factors 2 (7) 28 (93) 30 6 Prior consultation 4(13) 28(87) 32 0.87 0.26- 2.92 1.000 No prior consultation 12(14) 73(86) 85 7 No treatment with 8(11) 67(79) 75 0.51 0.18- 1.47 0.26 antibiotic prior to presentation Prior treatment with 8(19) 34 (81) 42 antibiotic 8 Treated with steroids 4(13) 26(87) 30 0.96 0.2849 1.0000 prior to presentation to 3.2449 No treatment with 12(14) 75(86) 87 steroids 9 Presenting VA 12mm 15(38) 24(62) 39 48.75 6.12-388.400.0001 Infiltratesize12mm 1(1) 77(99) 78 11 Posterior stroma involvement 16(25) 49(75) 65 infinity 0.0001 Anterior stromal involvement 0(0) 52(100) 52 12 Presence of hypopyon 4 (10) 36(90) 40 0.6 0.18-2.0 0.57 Absence of hypopyon 12(16) 65(84) 77 13 Perforation/thinning 7 (58) 5(42) 12 14.93 3.93-56.78 0.0001 No perforation/thinning 9(9) 96(91) 105 14 Endophthalmitis 3(100) 0(0) 3 Infinity 0.002 No endophthalmitis 13 (11) 101(89) 114 16 Gram negative bacteria 7(50) 7(50) 14 10.11 2.89-35.35 0.0006 Gram positive bacteria 9(9) 91(91) 100 * Visual acuity could not be evaluated in 5 children


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A Very Unusual Case of Keratitis Dr. Saroj Gupta

There 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-reportA 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.

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.

REFERENCES1 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; 51:362-85 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 Peoples College of Medical Sciences and Research Centre, Bhanpur, Bhopal, MP.Contact: 09926550364; E-mail: [email protected]

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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 non-nutrient 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.

DISCUSSIONCornea 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.

REFERENCES1. 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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Effect of Pterygium on Contrast SensitivityDr. Archana Malik, Dr. Soniya Bhala, Dr. Anamika Garg, Dr. Sudesh K Arya, Dr. Sunandan Sood

Pterygium 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 METHODSThis 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 to5, >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/m2) 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 analysisData 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.

RESULTS27 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 32.06.88. 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 4.411.12 (Group 1-2.720.41, Group 2-4.180.50, and Group3-5.86 0.45), horizontally 2.090.68 (GroupA-1.490.31 , GroupB-2.620.42) and of area was 9.75.01(Group I-4.641.23, GroupII-10.981.93, GroupIII-17.212.20).

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 controlsContrast Vertical length Horizontal width Area Controlsensitivity Group1 Group2 Group3 GroupA GroupB GroupI GroupII GroupIII (pvalue) (pvalue) (pvalue) (pvalue) (pvalue) (pvalue) (pvalue) (pvalue)

Photopic 3 1.520.20 1.450.25 1.250.19 1.520.26 1.300.18 1.570.24 1.320.18 1.240.16 1.690.16 (0.37) (0.019) (0.00) (0.06) (0.00) (0.453) (0.000) (0.000)

Photopic 6 1.800.20 1.670.28 1.480.34 1.770.23 1.520.31 1.830.21 1.520.28 1.530.35 1.900.18 (0.85) (0.10) (0.002) (0.36) (0.00) (0.87) (0.001) (0.019)

Photopic12 1.480.22 1.260.24 1.070.32 1.330.23 1.160.31 1.390.23 1.190.27 1.070.31 1.610.20 (0.68) (0.001) (0.00) (0.012) (0.00) (0.11) (0.000) (0.000)

Photopic18 0.900.22 0.850.27 0.630.34 0.880.23 0.710.33 0.910.24 0.760.30 0.630.34 1.180.28 (0.22) (0.016) (0.00) (0.017) (0.00) (0.10) (0.002) (0.001)

Mesopic3 1.350.14 1.360.22 1.150.25 1.360.19 1.230.25 1.390.19 1.260.22 1.160.28 1.590.21 (0.14) (0.035) (0.00) (0.022) (0.00) (0.14) (0.002) (0.002)

Mesopic6 1.710.13 1.560.28 1.310.30 1.580.21 1.450.36 1.650.16 1.500.33 1.280.23 1.860.26 (0.70) (0.024) (0.00) (0.028) (0.001) (0.23) (0.007) (0.000)

Mesopic12 1.350.20 1.180.37 0.960.39 1.190.28 1.110.43 1.260.25 1.130.39 0.940.45 1.610.20 (0.33) (0.003) (0.00) (0.002) (0.00) (0.039) (0.002) (0.000)

Mesopic18 0.840.19 0.820.32 0.520.35 0.810.20 0.660.41 0.850.18 0.760.38 0.450.34 1.170.22 (0.10) (0.01) (0.00) (0.005) (0.00) (0.033) (0.002) (0.000)

DISCUSSIONOur 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.

REFERENCES1. Yagmur M, zcan AA, Sari S, Ersz TR. Visual acuity and corneal topographic

changes related with pterygium surgery. J Refract Surg. 2005;21:16670.

2. Bahar I, Loya N, Weinberger D, Avisar R. Effect of pterygium surgery on corneal topography: a prospective study. Cornea. 2004;23:1137.

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;32:3540.

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;4:3159.

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To Study The Effect of Sub-conjunctival Injection of Bevacizumab on Corneal NeovascularisationDr. Somnath Mukhopadhyay, Dr. Himadri Dutta, Dr. Jayanta Dutta, Dr. Swarnali Sen, Dr. Pradeep Kumar Panigrahi

Neovascularization 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 METHODSThe study group consisted of 10 adults (4 men and 6 women) 3289 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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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 112). 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 24 mm from limbus, and 3 = vessels extended to involve visual axis/central 3 mm of cornea. Density was graded 14 according to the density of neovascularization: 1 = very low (1 vessel), 2 = low, 3 = moderate, 4 = high (compared with standard photographs).

RESULTSThe 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 1clock hour decrease in the extent of blood vessels, and 4 (40%) had at least a 2clock 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.

DISCUSSIONDifferent 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. VEGFs 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 CenterDr. Jatin Ashar, Dr. Muralidyhar R, Dr. Shivani Pahuja, Dr. Sunita Chaurasia, Dr. Virender Sangwan

Neonatal 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 METHODSMedical 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 % Microbiological profilefactors 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-8/7Caesarean 7/34 20.5% Pseudomonas-4/7, Staph. epidermidis-1/7, GPC-2/72. Prematurity 1/34 2.94% No organism isolated3. Maternal Urinary tract 2/34 5.88% Pseudomonas-1/2, HSV-1/2 infections infection, vaginal discharge 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% Pseudomonas-2/4,Systemic No organism-2/7condition Seizures 1/34 2.94% Pseudomonas Skin rashes/ 2/34 5.88% Pseudomonas-1/2, HSV-1/2 vesicles Sepsis 1/34 2.94% Pseudomonas Goldenhars syndrome 1/34 2.94% No organism6. Associated Lid coloboma 2/34 5.88% Staphylococcus-2ocular with lagophthal-abnormality mos (OU) Limbal dermoid 1/34 2.94% No organism with lagophthal- mos (OS)

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RESULTSAverage 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 treatment- Gram positive: Fortified cefazoline

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 eyesIndia

DISCUSSIONNeonatal 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.

REFERENCES1. 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 DefectsDr. Charu Mithal, Dr. Anu Malik, Dr. Sandeep Mithal, Dr. Neha Mithal, Dr. Prateek Agarwal, Dr. Pallavi Agarwal

The 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 DesignProspective, 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 CriteriaPatients 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 CriteriaPatients 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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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 testwas 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 TreatmentHealing 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 HealTime (weeks) Number Less than 1 week 41-2 82-3 73-4 3more than 4 weeks 2

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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.

DISCUSSIONThe 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 2 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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Sympathetic Ophthalmitis Following Optical Penetrating Keratoplasty In The Last 9 YearsDr. Rekha Gyanchand, Dr. Sheetal Hegde

Sympathetic 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 METHODSA 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 post-operative 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.

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 .

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RESULTSAll 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 tohistory diagnosis Keratoplasty ophthalmia onset SO Time SO Time Interval Interval1994 Leucoma 2001 2009 16yrs 8Yrs1996 Leucoma 2005 2006 11yrs 1Yrs1996 Leucoma 2000 2001 7yrs 1yr2001 Corneal decom- 2005 2007 7yrs 3yrs pensation (IOFB removal)2002 Corneal decompensation (IOFB removal) 2006 2007 6yrs 1yr

Clinical FindingsSympathizing Eye Exciting (Post-Pk)Eye Anterior Segment Granulomatous uveitis-5 cases Signs of diffuse endothelial rejection- 5 casesKoeppe nodule-1 case Glaucoma-4 casesPosterior 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

VisionSympathizing Eye Sympathizing Eye Exciting EyeOn presentation After treatment Post PK, Graft rejectionCF CF 6/60 HM+ve6/12 6/9p PL+ve, PR accurate6/12 6/9p PL+ve, PR accurate6/60 6/36 PL+ve, PR accurateCF 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.

DISCUSSIONSympathic 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 SpotsThe 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 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

Figure 1: Dalen Fuchs Spots

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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.

REFERENCES1. Liddy L, Stuart J. Sympathetic Ophthalmia in Canada. Can J Ophthalmol 1972;7:157-9.2. 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;112:80-44. 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 Immunopatho-

logic findings. Muller HK et al. Arch Ophthalmol 1984;102:1353-7.

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 DystrophyDr. Somasheila I Murthy, Dr. Debarun Dutta, Dr. Tamal Chakraborti, Dr. Pritam Kumar

Endothelial 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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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 METHODS1. 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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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.

DISCUSSIONAdvantage 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

Table 1: Endothelial cell counts done by automated and manual methods in images from Fuchs dystrophy Number of Average Average Average Range of cells p value Images auto count manual count difference (difference) Cell count 49 2028.73 329.53 1719.82489.47 312.96337.27 402 to 2 cells


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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, Bhren J, Kohnen T. Comparison of endothelial cell count using confocal

and contact specular microscopy. Ophthalmologica. 2003;217:99-103.3. Mdis 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 Operators Manual 2005-2007.

6. Imre L, Nagymihly 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

Fortified 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 mi

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