A feasibility study assessing quantitative indocyanine green angiographic predictors of reconstructive complications following nipple-sparing mastectomy

Introduction

Immediate post-mastectomy breast reconstruction offers benefits; however, complications can compromise outcomes. Intraoperative indocyanine green fluorescence angiography (ICGFA) may mitigate perfusion-related complications (PRC); however, its interpretation remains subjective. Here, we examine and develop methods for ICGFA quantification, including machine learning (ML) algorithms for predicting complications.

Methods

ICGFA video recordings of flap perfusion from a previous study of patients undergoing nipple-sparing mastectomy (NSM) with either immediate or staged immediate (delayed by a week due to perfusion insufficiency) reconstructions were analysed. Fluorescence intensity time series data were extracted, and perfusion parameters were interrogated for overall/regional associations with postoperative PRC. A naïve Bayes ML model was subsequently trained on a balanced data subset to predict PRC from the extracted meta-data.

Results

The analysable video dataset of 157 ICGFA featured females (average age 48 years) having oncological/risk-reducing NSM with either immediate (n=90) or staged immediate (n=26) reconstruction. For those delayed, peak brightness at initial ICGFA was lower (p<0.001) and significantly improved (both quicker-onset and brighter p=0.001) one week later. The overall PRC rate in reconstructed patients (n=116) was 11.2%, with such patients demonstrating significantly dimmer (overall, p=0.018, centrally, p=0.03, and medially, p=0.04) and slower-onset (p=0.039) fluorescent peaks with shallower slopes (p=0.012) than uncomplicated patients with ICGFA. Importantly, such relevant parameters were converted into a whole field of view heatmap potentially suitable for intraoperative display. ML predicted PRC with 84.6% sensitivity and 76.9% specificity.

Conclusion

Whole breast quantitative ICGFA assessment reveals statistical associations with PRC that are potentially exploitable via ML.

A multicenter prospective observational study on the use of type and screen method versus conventional type and crossmatch policy for pre-transfusion testing in the Indian population

Despite knowing the benefits of the type and screen (TS) method in pre-transfusion testing (PTT), most transfusion centers in developing countries continue to be reluctant to adopt a TS strategy over the conventional type and antihuman globulin (AHG) crossmatch (TX) policy in their routine laboratory practice because of the cost of obtaining antibody screening reagents. To generate strong evidence, this multicenter, observational study was conducted in which we collected data prospectively over a 1-year period from six major blood centers in India. The primary objective of this study was to identify the discordance between TS and TX results. A secondary objective was to identify the allo-antibody specificity in patients with positive antibody detection tests. All patients with orders for red blood cell transfusion who met patient selection criteria were subjected to parallel testing by column agglutination technology (CAT) for both the antibody detection test (screen) using a commercial three-cell panel and for the AHG crossmatch. A total of 21,842 patients were tested. In 148 patients with incompatible crossmatches, samples from six patients gave negative results with the antibody detection test, whereas the antibody detection test was positive in samples from 118 patients among the 21,694 crossmatch-compatible cases. The TS approach achieved a positive percent agreement of 95.95 and was found to be significantly effective in preventing the transfusion of serologically incompatible blood. The risk associated with abbreviating the AHG crossmatch was found to be 0.009 percent. Most of the identified clinically significant alloantibodies were directed to Rh antigens (D>E>c>C>e), followed by anti-K and anti-M. This study has generated sufficient robust data for the Indian population by including patients from all major geographical areas of the country and concluded a satisfactory agreement level as well as non-inferiority to the current PTT policy. Therefore, TS policy can be implemented in developing countries with no compromise on blood safety, provided sufficient technical and infrastructural support are available.

Peripheral nerve stimulation through a 'dry' peripheral nerve catheter for shoulder analgesia: a case report

Revision shoulder surgery can pose significant analgesic challenges as locoregional blocks are often avoided to enable early recognition of iatrogenic nerve injuries. Our case describes the utilisation of pre-operative and intra-operative low-frequency percutaneous peripheral nerve stimulation via a 'dry' interscalene catheter, inserted pre-operatively for a patient presenting for revision total shoulder arthroplasty who was experiencing significant shoulder joint pain despite a prior total shoulder arthroplasty. The clinical considerations and safety aspects are discussed further.

Response evaluation of locoregional therapies in combined hepatocellular-cholangiocarcinoma and intrahepatic cholangiocarcinoma versus hepatocellular carcinoma: a propensity score matched study

AIM

To evaluate the response of locoregional therapy (LRT) on combined hepatocellular-cholangiocarcinoma (cHCC-CC) and intrahepatic cholangiocarcinoma (IHC) and compare their outcomes with propensity matched hepatocellular carcinoma (HCC) patients.

MATERIALS AND METHODS

From January 2011 to July 2020, 13 patients with cHCC-CC (11 men, two women, median age 56 years) and 15 IHC patients (10 men, five women, median age 60 years) were compared with 101 HCC patients (79 men, 22 women, median age 60 years) after LRT. All tumours were proven histologically. Among the 13 cHCC-CC patients, 11 received transarterial chemoembolisation (TACE), one received microwave ablation (MWA) and one received TACE with radiofrequency ablation (RFA). Of 15 IHC patients, eight received TACE, five received RFA, and one received MWA, and one received TACE with RFA. Propensity score matching (PSM) was done with conditional logistic regression adjusted for age, type of LRT, tumour specific features and Child-Pugh score.

RESULTS

After LRT, on univariate analysis an objective response was seen in 30% of cHCC-CC and 53% of IHC patients. PSM analysis demonstrated shorter progression-free survival (PFS; cHCC-CC versus HCC: 1.5 versus 7.5 months; IHC versus HCC: 6 versus 14 months, p<0.05), overall survival (OS; cHCC-CC versus HCC: 12 versus 28 months; IHC versus HCC: 18 versus 34 months, p<0.005), and poor objective response (cHCC-CC versus HCC: 25% versus 91%; IHC versus HCC: 58% versus 88%, p<0.05) in cHCC-CC and IHC patients versus HCC patients. Hypovascular tumour, macrovascular invasion, and infiltrative appearance were independent prognostic factors for OS in IHC patients.

CONCLUSION

cHCC-CC and IHC are aggressive tumours with a poor objective response, greater distant progression of the disease and shorter PFS and OS post LRT as compared to HCC.

O-230 RCT comparing Recombinant-hcg trigger with Dual-trigger (GnRH-agonist and recombinant-hcg ) in improving clinical outcome in ICSI cycles in women with Diminished Ovarian Reserve

Study question

Does use of Dual-trigger (GnRH-agonist with recombinant-hcg) improve the clinical outcome in women with diminished ovarian reserve as compared to Recombinant-hcg trigger?

Summary answer

Yes, the use of Dual-trigger (GnRH-agonist with recombinant-hcg) improve the clinical outcome in women with diminished ovarian reserve as compared to Recombinant-hcg trigger.

What is known already

The population of poor responders has grown exponentially over the years and their management of ovarian stimulation remains one of the most challenging aspects. In GnRH antagonist down-regulated IVF-ICSI cycles, dual triggering for the final oocyte maturation with GnRH-a and a reduced dose of hCG improves the rate of fertilization and clinical pregnancy in women with diminished ovarian reserve. Further more, the benefit of lowered cycle cancellation rate would also enable greater percentage of patients with diminished ovarian reserve to reach the final stage of their ART treatment, thereby enhancing their chances of achieving a successful pregnancy .

Study design, size, duration

This RCT included GnRH antagonist ICSI cycles from 2018-2019. 82 women with diminished ovarian reserve (AMH ≤ 1.1 ng/ml and AFC ≤5) were included. The primary outcome measured was the oocyte fertilization rate, implantation rate and clinical pregnancy rate per oocyte retrieval cycle. Secondary outcome measured was embryo transfer cancellation rate and abortion rate per oocyte retrieval cycle.

Participants/materials, setting, methods

82 women with diminished ovarian reserve undergoing fresh embryo transfer were included and randomly divided in two groups - Group-A (hCG trigger/control group: n = 41); and Group-B (dual trigger/study group: n = 41). Both patient groups underwent controlled ovarian stimulation using antagonist. The final oocyte maturation was triggered either by recombinant hCG (Group-A) or by a combination of recombinant hCG and GnRH-agonist (Dual trigger) (Group-B).

Main results and the role of chance

The dual-trigger group had significantly higher fertilization rate (62.8 vs. 37.6%), higher clinical pregnancy rate (31.4% vs. 18.1%) as compared to the recombinant-hCG trigger group. In addition, the abortion rate(12.1% vs. 21.3%) and embryo transfer cancellation rate (8.3% vs. 16.1%) were both significantly lower in the dual trigger group. The baseline characteristics for the control and the study group were similar and there was no significant difference in the patient age, serum AMH level, and cause of infertility. The total r-FSH dose, duration of stimulation, endometrial thickness, and serum hormone profile on the day of trigger were also similar between the control and the study group. The main advantage of triggering with GnRH-a is that it induces a mid-cycle FSH surge which resembles the natural ovulatory cycle hormonal changes. Study shows that in GnRH antagonist ART cycles, dual triggering with GnRH-a and hCG could significantly improve the rate of fertilization and clinical pregnancy in diminished ovarian reserve women. Furthermore, the benefit of lowered cycle cancellation rate would also enable greater percentage of patients with diminished ovarian reserve to reach the final stage of their ART treatment thereby enhancing their chance of achieving a successful pregnancy as well as reducing their mental stress.

Limitations, reasons for caution

The main limitation of our study is the low patient number. Triggering with GnRH-a has become a significant part of contemporary ART practice, especially in high responders, oocytes donors and oncology patients. However, more RCTs are required in order to justify the use of GnRH-agonists in poor responders in ART cycles.

Wider implications of the findings

Results of our study concurred with other studies of dual triggering, calls for a possible paradigm shift in ovulation-triggering agent for GnRH-antagonist cycles. Diminished ovarian reserve patients are constituting a large part of clinical ART practice and for such patients, obtaining maximum mature oocytes and good embryos is vitally important.

Trial registration number

not applicable

Clinical presentations, microbiology and management outcomes of culture-proven endogenous endophthalmitis in India

Purpose:

To report the clinical presentation, microbiology, and management outcome of endogenous endophthalmitis in Indian patients.

Methods:

Retrospective chart review of culture-positive (vitreous/urine/blood) endogenous endophthalmitis cases treated in tertiary eye care facility in India was done.

Results:

The study included 173 eyes of 117 patients. Mean patient age was 25.41 ± 20.46 years (median 24 years). Pre-disposing systemic illness could not be elicited in 79 (67.63%) patients. Commonest predisposing systemic condition in patients where it could be detected (n = 79) was pyrexia of unknown origin (25/79 = 32.0%). Following treatment, 45 out of 173 (26.0%) eyes regained vision of ≥20/400. Commonest isolated organism from vitreous was Streptococcus pneumoniae (36 eyes, 20.8%) and fungi were isolated in 24 (13.8%) eyes, the commonest being Candida spp. (8/24, 33.33%). Favorable functional outcome was seen in 26% eyes and favorable anatomic outcome in 43% eyes. Those with an underlying systemic illness were older (P = 0.02), had greater urine culture positivity (P = 0.003), lesser vitreous culture positivity (0.001), greater gram negative etiology (P = 0.0006), and greater fungal etiology (P = 0.01) as compared to those cases without underlying systemic illness.

Conclusion:

Endogenous endophthalmitis in India often presents in young immunocompetent individuals without any underlying systemic illness and with negative blood or urine microbiologic work up. Underlying systemic illness leads to greater gram-negative and fungal etiology. Overall visual outcome is poor inspite of prompt management.

COPD exacerbation rates are higher in non-smoker patients in India

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is common among non-smokers exposed to solid fuel combustion at home. Different clinical characteristics in these patients may have significant therapeutic and prognostic implications.METHODS: We used medical record review and a questionnaire among COPD patients at 15 centres across India to capture data on demographic details, different types of exposures and clinical characteristics. Chest radiography and pulmonary function testing were performed in all 1984 cases; C-reactive protein and exhaled breath nitric oxide were measured wherever available.RESULTS: There were 1388 current or ex-smokers and 596 (30.0%) non-smokers who included 259 (43.5%) male and 337 (56.5%) female patients. Sputum production was significantly more common in smokers with COPD (P < 0.05). The frequency of acute symptomatic worsening, emergency visits and hospitalisation were significantly higher (P < 0.05) in non-smokers with COPD; however, intensive care unit admissions were similar in the two groups. There was no significant difference with respect to the use of bronchodilators, inhalational steroids or home nebulisation among smoker and non-smoker patients. The mean predicted forced expiratory volume in 1 sec in smokers (43.1%) was significantly lower than in non-smokers (46.5%).CONCLUSION: Non-smoker COPD, more commonly observed in women exposed to biomass fuels, was characterised by higher rate of exacerbations and higher healthcare resource utilisation.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Liver failure determines the outcome in patients of acute-on-chronic liver failure (ACLF): comparison of APASL ACLF research consortium (AARC) and CLIF-SOFA models

BACKGROUND AND AIMS

Acute-on-chronic liver failure (ACLF) is a progressive disease associated with rapid clinical worsening and high mortality. Early prediction of mortality and intervention can improve patient outcomes. We aimed to develop a dynamic prognostic model and compare it with the existing models.

METHODS

A total of 1402 ACLF patients, enrolled in the APASL-ACLF Research Consortium (AARC) with 90-day follow-up, were analyzed. An ACLF score was developed in a derivation cohort (n = 480) and was validated (n = 922).

RESULTS

The overall survival of ACLF patients at 28 days was 51.7%, with a median of 26.3 days. Five baseline variables, total bilirubin, creatinine, serum lactate, INR and hepatic encephalopathy, were found to be independent predictors of mortality, with AUROC in derivation and validation cohorts being 0.80 and 0.78, respectively. AARC-ACLF score (range 5-15) was found to be superior to MELD and CLIF SOFA scores in predicting mortality with an AUROC of 0.80. The point scores were categorized into grades of liver failure (Gr I: 5-7; II: 8-10; and III: 11-15 points) with 28-day cumulative mortalities of 12.7, 44.5 and 85.9%, respectively. The mortality risk could be dynamically calculated as, with each unit increase in AARC-ACLF score above 10, the risk increased by 20%. A score of ≥11 at baseline or persisting in the first week was often seen among nonsurvivors (p = 0.001).

CONCLUSIONS

The AARC-ACLF score is easy to use, dynamic and reliable, and superior to the existing prediction models. It can reliably predict the need for interventions, such as liver transplant, within the first week.

Impact of completion of primary biliary procedure on outcome of endoscopic retrograde cholangiopancreatographic related perforation

BACKGROUND AND AIMS

 Perforation is one of the worst complications of therapeutic endoscopic retrograde cholangiopancreatography (ERCP). We aimed to study the epidemiology of ERCP related perforation and the impact of completion of intended procedure on the outcome of this complication.

METHODS

 ERCP records from January 2007 to April 2012 were independently evaluated by two investigators for the occurrence of procedure related perforations. A total of 11 500 patients underwent therapeutic ERCP during the study period. The case records of 171 (1.5 %) patients with ERCP related perforations were reviewed to analyze the epidemiology and risk factors associated with poor outcome.

RESULTS

 Of the 171 patients included in this study, the majority of perforations (n = 129, 75.4 %) were related to use of the needle-knife precut technique. Female gender (1.9 % vs 0.7 %, P  < 0.001), age > 40 years (1.7 % vs 1.1 %, P  < 0.01), and benign disease (1.7 % vs. 1.1 %, P  < 0.01) were risk factors for ERCP related perforation. Most of the perforations (n = 135, 79 %) were detected during the procedure. The majority of patients were managed conservatively (n = 164, 96 %). Although 159 patients recovered, 12 patients (7 %) did not survive. Completion of intended biliary procedure for primary disease was associated with low risk of mortality (2 % vs 15.4 %, P  < 0.001).

CONCLUSIONS

 ERCP related perforation is uncommon. The majority of patients can be managed conservatively. The risk of mortality is low and completion of the intended biliary procedure decreases the risk of mortality.

Immune balance in Hepatitis B Infection: Present and Future Therapies

Chronic hepatitis B virus (HBV) infection affects millions of people worldwide and about half a million people die every year. India represents the second largest pool of chronic HBV infections with an estimated 40 million chronically infected patients. Persistence or clearance of HBV infection mainly depends upon host immune responses. Chronically infected individuals remain in immune tolerant phase unless HBV flares and leads to the development of chronic active hepatitis or acute-on-chronic liver failure. Strategies based on inhibition of viral replication (nucleoside analogues) or immune modulation (interferons) as monotherapy, or in combination in sequential therapies, are currently being used globally for reducing HBV viral load and mediating HBsAg clearance. However, the immune status and current therapies for promoting sustained virological responses in HBV-infected patients remain suboptimal. Elimination of cccDNA is major challenge for future therapies, and new molecules such as NTCP, Toll-like receptor (TLR)7 agonist (GS9620) and cyclophilin have emerged as potential targets for preventing HBV entry and replication. Other than these, HBV cccDNA elimination is the major target for future therapies.

Coexisting choroidal neovascularization and active retinochoroiditis-an uncommon presentation of ocular toxoplasmosis

Background

Choroidal neovascularization during the active stage of Toxoplasma retinochoroiditis is an uncommon clinical presentation. The authors retrospectively reviewed medical charts of patients with coexisting choroidal neovascular membrane and active Toxoplasma retinochoroiditis.

Findings

Three patients presented with coexisting choroidal neovascular membrane and active Toxoplasma retinochoroiditis. All lesions had adjacent subretinal hemorrhage. The diagnosis was confirmed based on clinical presentation, fundus fluorescein angiography (FFA), and optical coherence tomography (OCT) findings. The patients were managed with a combination of treatments including intravitreal injection of anti-vascular endothelial growth factor (anti-VEGF), oral anti-Toxoplasma treatment, and oral corticosteroids. In all patients, the retinitis lesion resolved in 6 weeks and the coexisting choroidal neovascular membrane resolved over 6 to 12 weeks.

Conclusions

Recurrences in Toxoplasma retinochoroiditis are common as satellite lesions adjacent to an old atrophic scar. Coexisting choroidal neovascularization with active Toxoplasma retinochoroiditis is an important presentation and should be suspected in the presence subretinal hemorrhage and managed with a combination of anti-Toxoplasma treatment and intravitreal anti-VEGF.

An outbreak of Ralstonia pickettii endophthalmitis following intravitreal methotrexate injection

Purpose

To report an outbreak of endophthalmitis in three eyes of two patients following intravitreal methotrexate, caused by Ralstonia pickettii.

Design

Retrospective, noncomparative, consecutive case series.

Methods

Medical records and microbiology results of two patients who presented with acute endophthalmitis following intravitreal methotrexate injection in November 2013 were reviewed.

Results

Following intravitreal injections, the patients experienced pain and decrease in vision in the affected eye within 24 hours of receiving intravitreal methotrexate injection. The presenting visual acuity in case 1 was 20/50 in the left eye. The presenting visual acuity in case 2 was hand motions in the right eye and counting fingers at 1 m in the left eye. Both the patients received methotrexate prepared in the same manufacturing facility. Both the patients underwent vitreous biopsy and intravitreal injection of vancomycin 1 mg/0.1 mL, amikacin 400 µg/0.1 mL, and dexamethasone 400 µg/0.1 mL. Microbiology cultures from vitreous, and used and unused vials of methotrexate from the same batch grew R. pickettii. After 8 months of follow-up, both the patients had visual acuity 20/60 or better.

Conclusion

R. pickettii can be rarely associated with outbreak of endophthalmitis. Timely intervention can be associated with good visual outcome in such patients.

The role of intravitreal trimethoprim/sulfamethoxazole in the treatment of toxoplasma retinochoroiditis

The authors evaluate the role of intravitreal trimethoprim/sulfamethoxazole in the treatment of toxoplasma retinochoroiditis (TRC) in four patients. Intravitreal injection of trimethoprim/sulfamethoxazole 1.28 mg/0.08 mL with dexamethasone 400 µg/0.1 mL was injected weekly or biweekly. After the initiation of treatment, a reduction in intraocular inflammation was observed clinically and on optical coherence tomography within 1 week. Three patients regained visual acuity of 20/20, and one patient improved to 20/40 with residual macular scarring. No evidence of retinal toxicity was noted on full-field electroretinogram. Intravitreal trimethoprim/sulfamethoxazole and dexamethasone combination may be an alternative treatment strategy in patients with TRC.

Microbiologic spectrum and susceptibility of isolates in delayed post-cataract surgery endophthalmitis

The objective of this study was to evaluate the microbiological spectrum and antimicrobial susceptibility of isolates in delayed post-cataract surgery endophthalmitis. A retrospective review of 33 consecutive patients with culture proven delayed post-cataract surgery endophthalmitis was done from January 2006 to March 2013. There were 22 bacterial and eleven fungal cases. Common isolates were Streptococci (seven cases), coagulase-negative staphylococci (five), Gram-negative bacilli (seven), Nocardia (two), Aspergillus (five), Candida (five). Gram-positive cocci were most susceptible to vancomycin and gatifloxacin (91.7%). Gram-negative isolates were most susceptible to ofloxacin (85.7%). Fungi being slow growing organisms are an important cause of delayed post-cataract surgery endophthalmitis.

Filamentous fungal endophthalmitis: results of combination therapy with intravitreal amphotericin B and voriconazole

Purpose

To report outcomes of exogenous fungal endophthalmitis treated with combination of intravitreal antifungal agents.

Design

Retrospective, non-randomized, interventional, consecutive case series.

Methods

Twelve eyes of twelve consecutive cases of filamentous fungal endophthalmitis were treated with a combination of intravitreal amphotericin-B and intravitreal voriconazole (AmB-Vo Regime) along with pars plana vitrectomy at a single center. Clinical characteristics, microbiology results, treatment strategy, visual, and anatomical outcomes were analyzed.

Results

Ten cases out of the twelve were postoperative endophthalmitis of which nine were part of a post cataract surgery cluster. The remaining included endophthalmitis following keratitis post pterygium excision (1) and following open globe injury (2). The most common fungus was Aspergillus terreus, which was isolated in 8/12, followed by A. flavus in 2/12 and Fusarium solani in 1/12. The presenting visual acuity ranged from light perception (LP) to counting fingers. The visual acuity at final follow-up was 20/400 or better in 7/12 eyes (58.33%) and 20/60 in 2/12 eyes (range 20/60 to LP). All eyes with corneal involvement had final visual acuity 20/400 or worse. Globe salvage was achieved in all cases.

Conclusion

Combining intravitreal amphotericin-B and voriconazole could be a novel treatment strategy in the management of endophthalmitis caused by filamentous fungus. Eyes with corneal involvement had poor visual outcome either with or without therapeutic penetrating keratoplasty.

Congenital Diaphragmatic Hernia in a Case of Patau Syndrome: A Rare Association

Congenital DiaphragmaticHernia (CDH) occurs in 5-10% associated with chromosomal abnormalities like, Pallister Killian syndrome, Trisomy 18, and certain deletions. Association of CDH with trisomy 13 (Patau syndromes) is very rare. Here, we report such an unusual association, where surgical repair was done, but eventually the case succumbed as a result of multiple fatal co-morbidities.

A novel clinical sign in macular telangiectasia type 2

The objective of the study is to report, and propose a hypothesis for, a novel clinical sign in patients with macular telangiectasia type 2. Nine consecutive patients with macular telangiectasia and visible parafoveal graying were examined. The parafoveal graying decreased in intensity with continuous light exposure from an indirect ophthalmoscope. After dark adaptation for 15 minutes, the intensity of parafoveal graying increased again. This phenomenon appears to be a novel and global sign in patients with macular telangiectasia type 2. It could be a possible photochemical reaction occurring due to the release of chromophores from the abnormal Müller cells.

Acute-onset postoperative endophthalmitis caused by multidrug-resistant Klebsiella pneumoniae

The purpose of this paper is to report outcomes of intravitreal imipenem in the treatment of multidrug-resistant Klebsiella-related postoperative endophthalmitis. This observational case series consists of three eyes from three patients seen between 2013 and 2014. Multidrug-resistant Klebsiella pneumoniae is characterized by a rapid, fulminant course and severe intraocular inflammation. Intravitreal imipenem may be used to treat such infection.

Pharmacokinetics of intravitreal antibiotics in endophthalmitis

Intravitreal antibiotics are the mainstay of treatment in the management of infectious endophthalmitis. Basic knowledge of the commonly used intravitreal antibiotics, which includes their pharmacokinetics, half-life, duration of action and clearance, is essential for elimination of intraocular infection without any iatrogenic adverse effect to the ocular tissue. Various drugs have been studied over the past century to achieve this goal. We performed a comprehensive review of the antibiotics which have been used for intravitreal route and the pharmacokinetic factors influencing the drug delivery and safety profile of these antibiotics. Using online resources like PubMed and Google Scholar, articles were reviewed. The articles were confined to the English language only. We present a broad overview of pharmacokinetic concepts fundamental for use of intravitreal antibiotics in endophthalmitis along with a tabulated compendium of the intravitreal antibiotics using available literature. Recent advances for increasing bioavailability of antibiotics to the posterior segment with the development of controlled drug delivery devices are also described.

Stenotrophomonas maltophilia endogenous endophthalmitis: clinical presentation, antibiotic susceptibility, and outcomes

Objective

To describe clinical presentation, antibiotic susceptibility, and outcomes in patients with Stenotrophomonas maltophilia endogenous endophthalmitis.

Design

Retrospective case series.

Participants

Four eyes of four patients with S. maltophilia endogenous endophthalmitis.

Methods

Retrospective chart review of culture-positive S. maltophilia endogenous endophthalmitis treated at L V Prasad Eye Institute, Hyderabad, India, between January 2007 and December 2012, was done. Collected information included demographic, clinical, and microbiology data.

Results

These four patients with S. maltophilia endogenous endophthalmitis cases accounted for 0.47% (4/836) of total bacterial endophthalmitis cases treated in this period. All patients were from a rural setting and younger than 40 years. Two of the four patients had a history of immune compromise or hospitalization. The visual acuity at presentation was less than 20/320 in all patients. Common presenting features were severe anterior and posterior segment inflammation and hypopyon. All patients underwent vitrectomy with injection of intravitreal antibiotics and dexamethasone. Direct microscopy of the vitreous sample was positive in all cases. All isolates were sensitive to fluoroquinolones and chloramphenicol; sensitivity to aminoglycosides and third-generation cephalosporins was highly variable. The final visual acuity was 20/80 or more in three patients. The time to presentation did not seem to influence the visual or anatomical outcome.

Conclusion

S. maltophilia is a rare cause of endogenous endophthalmitis and usually occurs in young and apparently healthy individuals. Clinical presentation is moderate to severe, and recovery is variable. Fourth-generation fluoroquinolones and chloramphenicol were the most sensitive antibiotics against S. maltophilia in this series of patients.

Macular toxicity following brilliant blue G-assisted macular hole surgery – a report of three cases

Introduction: Brilliant blue G is a new dye used for staining the internal limiting membrane to ease its peeling in cases like a macular hole. Cases: Three patients presented with full-thickness idiopathic macular hole. They underwent pars planavitrectomy, Brilliant Blue G (BBG) stained internal limiting membrane peeling and fluid gas exchange. Observations: Postoperatively,the macular hole closed but foveal thinning and perifoveal hyperpigmentation presumably due to BBG toxicity were observed in all three patients. All of them had a subnormal final best corrected visual acuity. Conclusion:This case series highlights the unusual occurrence of macular toxicity following brillantblue G-assisted macular hole surgery. DOI: http://dx.doi.org/10.3126/nepjoph.v6i1.10779   Nepal J Ophthalmol 2014; 6 (2): 98-101

Intravitreal triamcinolone acetonide as an adjuvant in the management of acute retinal necrosis

OBJECTIVE

To determine the role of intravitreal triamcinolone acetonide (IVTA) as an adjuvant in the management of acute retinal necrosis (ARN).

DESIGN

Interventional case series.

PARTICIPANTS

Four eyes of 4 patients diagnosed with ARN were studied.

METHODS

This pilot case series included 4 patients who presented with clinical features suggestive of ARN. IVTA was injected 1 to 2 weeks after initiation of antiviral therapy and concurrent usage of oral corticosteroids. The disease course and clinical outcome were observed. The patients received additional treatment depending on the sequelae of ARN.

RESULTS

Signs of reduction in vitritis and resolution of retinitis were observed as early as 1 week after IVTA was administered. In all 4 patients, inflammation promptly resolved with no untoward effects like raised intraocular pressure or worsening of the retinitis. A final visual acuity of 20/40 or better was achieved in 3 of 4 patients after appropriate treatment of ARN-related complications.

CONCLUSIONS

Intravitreal triamcinolone under antiviral cover could be a useful adjunct to systemic steroids in the treatment of ARN.

Acrochordons as a cutaneous sign of metabolic syndrome: a case-control study

Background:

Acrochordons (known as skin tags) are benign skin tumors. A few studies with contradictory results have been reported regarding the abnormalities of carbohydrate and/or lipid metabolisms in patients with skin tags.

Aim:

The aim of this study is to determine if the presence of acrochordons could be a marker of Metabolic syndrome by comparing with a control group.

Subjects and Methods:

A total of 110 patients having two or more acrochordons and age- and gender-matched 110 controls were included in the study. Localization, size and the total number of acrochordons were recorded in the patient group. Age, sex, body mass index (BMI), waist circumference, smoking status, fasting plasma glucose (FPG), impaired glucose tolerance (IGT) test, insulin resistance, serum lipids and liver enzyme levels were estimated in cases and controls. Arterial blood pressures were measured in two groups.

Results:

A total of 58 patients and 12 controls were diagnosed with overt diabetes mellitus (DM). 15% (16/110) of patients and 8% (9/110) of controls had an IGT test. The difference was statistically significant for the diagnosis of DM and not significant for the IGT. The mean levels of FPG, BMI, insulin resistance, total cholesterol, low-density lipoprotein cholesterol and triglyceride were significantly higher in patients than those in controls. Serum levels of high-density lipoprotein were less in patients. Patients with acrochordons had higher systolic and diastolic blood pressures than controls.

Conclusion:

Acrochordons may represent a cutaneous sign for Metabolic syndrome. Changing the life-style of these patients may have a beneficial role.

Endophthalmitis after open globe injuries: changes in microbiological spectrum and isolate susceptibility patterns over 14 years

Background

The objective of this study was to evaluate the microbiologic spectrum and antimicrobial susceptibility of isolates in post-traumatic endophthalmitis and compare with our earlier published report. A retrospective review was conducted on 581 consecutive patients with culture-proven post-traumatic endophthalmitis at L. V. Prasad Eye Institute, India, from January 2006 to March 2013.

Findings

A total of 620 isolates from 581 patients were identified (565 bacteria and 55 fungi). The most common isolate was Bacillus spp. (106/620, 17.1%) closely followed by Streptococcus pneumoniae (105/620, 16.9%), and coagulase-negative Staphylococci (97/620, 15.6%). In our earlier report, the commonest bacteria included Streptococcus spp. (30/139, 21.6%) and gram-positive coagulase-negative micrococci (26/139, 18.7%). Gram-positive isolates were usually susceptible to vancomycin (98.2%). Gram-negative isolates were generally susceptible to gatifloxacin (92.9%), ofloxacin (89.4%), chloramphenicol (88.6%, Pseudomonas isolates were often resistant), amikacin (83.5%), and ceftazidime (77.2%). Fourteen years ago, the most sensitive antibiotic was ciprofloxacin for both gram-positive bacteria (95.12%) and gram-negative bacteria (100%).

Conclusions

The microbiological spectrum of post-traumatic endophthalmitis has remained unchanged over the last 14 years, and Bacillus spp. continues as the most common infecting organism. Vancomycin is the drug of choice for empiric coverage of gram-positive bacteria. Susceptibility of gram-negative bacteria to commonly used antimicrobials (amikacin and ciprofloxacin) has decreased by 10% - 15% and to ceftazidime has increased by 10.5%.

Scleral buckle infections: microbiological spectrum and antimicrobial susceptibility

BACKGROUND

The purpose of the present study was to evaluate the microbiological spectrum and antimicrobial susceptibility in patients with scleral buckle infection. Medical records of all the patients diagnosed as buckle infection at L. V. Prasad Eye Institute between July 1992 and June 2012 were reviewed in this non-comparative, consecutive, retrospective case series.

FINDINGS

A total of 132 eyes of 132 patients underwent buckle explantation for buckle infection during the study period. The incidence of buckle infection at our institute during the study period was 0.2% (31 out of 15,022). A total of 124 isolates were identified from 102 positive cultures. The most common etiological agent isolated was Staphylococcus epidermidis (27/124, 21.77%) followed by Mycobacterium sp. (20/124, 16.13%) and Corynebacterium sp. (13/124, 10.48%). The most common gram negative bacilli identified was Pseudomonas aeruginosa (9/124, 7.26%). The median interval between scleral buckling surgery and onset of symptoms of local infection was 30 days. All eyes underwent buckle explantation and median time interval between primary SB surgery and explantation was 13 months. Recurrent retinal detachment was observed in two cases at 7 and 48 months, respectively, after buckle explantation. Gram positive, gram negative, and acid-fast organisms isolated from 2003 to 2012 were most commonly susceptible to vancomycin (100%), ciprofloxacin (100%), and amikacin (89%). Susceptibility to ciprofloxacin during the same time period was observed in 75% (15/20), 100% (13/13), and 87% (7/8) of gram positive, gram negative, and acid-fast isolates, respectively.

CONCLUSION

Scleral buckle infection is relatively rare and has a delayed clinical presentation. It is most commonly caused by gram positive cocci. Based on the current antimicrobial susceptibility, ciprofloxacin can be used as empirical therapy in the management of scleral buckle infections.

Combined ceftazidime and amikacin resistance among Gram-negative isolates in acute-onset postoperative endophthalmitis: prevalence, antimicrobial susceptibilities, and visual acuity outcome

Background

The purpose of this study is to evaluate the prevalence, antimicrobial susceptibilities, and visual acuity outcome of acute-onset postoperative Gram-negative bacterial endophthalmitis cases resistant to both ceftazidime and amikacin seen between 2005 and 2010 at L. V. Prasad Eye Institute, a tertiary care ophthalmic Centre in South India. Medical records of all patients with Gram-negative bacterial endophthalmitis resistant to both amikacin and ceftazidime between 1 January 2005 and 31 December 2010 were reviewed in this non-comparative, consecutive, retrospective case series. Favorable outcome was defined as a best-corrected visual acuity of ≥20/200.

Results

Sixty five (39.6%) of 164 culture-positive postoperative endophthalmitis were caused by Gram-negative organisms. Among these 65 isolates, 32 (49%; 95% confidence interval (CI) 37% to 61%) were resistant to ceftazidime, 17 (26%; 95% CI 15% to 37%) to amikacin, and 12 (18.5%; 95% CI 9% to 27%) to both ceftazidime and amikacin. Eight Pseudomonas isolates, three Enterobacter isolates, and one Haemophilus isolate were resistant to both ceftazidime and amikacin. The isolates were sensitive to fluoroquinolones (42%) and imipenem (50%). Presenting visual acuity was light perception in 10 (83.3%) cases. A final visual acuity ≥20/200 was achieved in 5/12 (41.7%) of these patients.

Conclusion

In the current study, Pseudomonas was the most common Gram-negative bacteria resistant to both amikacin and ceftazidime. The emergence of multidrug-resistant bacteria causing endophthalmitis is a matter of concern in India. Alternative antibiotics like imipenem or fluoroquinolones may be considered for the management of these resistant organisms.

Vancomycin-resistant Gram-positive bacterial endophthalmitis: epidemiology, treatment options, and outcomes

Background

The purpose of this study is to evaluate the microbiological profile and treatment outcomes of vancomycin-resistant Gram-positive bacterial endophthalmitis. Medical records of all patients with Gram-positive bacterial endophthalmitis resistant to vancomycin presenting between 1 January 2005 and 31 December 2010 were reviewed in this noncomparative, consecutive, retrospective case series. Favorable outcome was defined as a best-corrected visual acuity of ≥20/200.

Results

Out of 682 culture-positive endophthalmitis isolates, 448/682 (65.6%) were associated with Gram-positive bacteria. In vitro resistance to vancomycin was noted in 7/448 (1.56%). Three cases were posttraumatic, three were postoperative, and one was endogenous in origin. Four Bacillus isolates, two Staphylococcus isolates, and an Enterococcus isolate were resistant. Isolates resistant to vancomycin were sensitive in vitro to ciprofloxacin in 6/7 (86%) patients. Presenting visual acuity was light perception in all seven cases. Favorable outcome was achieved in only 1/7 (14.3%) cases.

Conclusions

Vancomycin-resistant endophthalmitis is uncommon and usually associated with poor visual outcome. Bacillus sp. is the most frequent Gram-positive bacteria resistant to vancomycin. Fluoroquinolones like ciprofloxacin may be considered as a useful alternative in vancomycin-resistant endophthalmitis.

Subfoveal triamcinolone acetonide following macular hole surgery

BACKGROUND

Triamcinolone acetonide (TA) is commonly used in vitreous surgery to visualize the posterior hyaloid and internal limiting membrane. Some TA can accumulate in the macular hole during surgery which can persist postoperatively.

CASE

A 17-year-old boy underwent successful macular hole surgery with TA-assisted induction of posterior vitreous detachment. Sub-foveal deposit of TA was observed postoperatively, which got absorbed at 7 weeks with complete closure of the macular hole, and best corrected visual acuity improved from 20/100 preoperatively to 20/60.

CONCLUSION

Residual TA after macular hole surgery may not hamper the anatomical and functional outcome. Similar cases have been reported in the literature and most of them show no harmful effect of TA on macular hole closure and visual recovery.

Polymicrobial endophthalmitis: prevalence, causative organisms, and visual outcomes

BACKGROUND

The purpose of the present study is to evaluate the prevalence, causative organisms, and visual acuity outcome in patients with culture-proven polymicrobial endophthalmitis. The method used in this study is the non-comparative, consecutive case series using a retrospective analysis of patients diagnosed with polymicrobial endophthalmitis for the period 2000 to 2010.

RESULTS

Polymicrobial endophthalmitis was identified in 43/1,107 (3.88%) patients. Forty-two patients had two isolates, and one patient had grown three isolates, yielding a total of 87 isolates. Gram-positive cocci were the most common isolate (n = 53; 60.9%) including Staphylococcus epidermidis (n = 14/53; 16.1%) and Streptococcus pneumoniae (n = 13/53; 13.8%). The etiologies included posttraumatic (n = 31/43; 72.1%) and postoperative (n = 9/43; 20.9%) endophthalmitis. Antibiotic susceptibilities among Gram-positive bacteria were vancomycin (100%) and chloramphenicol (96%). Susceptibilities among Gram-negative bacteria were ciprofloxacin (86.4%) and ofloxacin (81.2%). A maximum number of secondary interventions were done in traumatic cases (38.7%) and cases having coinfection with Gram-negative bacteria and fungus (66.7%). Visual acuity (VA) < 20/200 was more frequently observed in posttraumatic cases (n = 27/31; 87.1%) as compared with postoperative cases (n = 4/9; 44.4%). Of the 43 patients, only 9 patients (20.9%) achieved a VA ≥ 20/200 on final follow-up. Four out of twelve patients (33.3%), with fungus as one of the isolates, had a VA ≥ 20/200.

CONCLUSIONS

Although polymicrobial infection in endophthalmitis is uncommon, it is generally associated with poor visual acuity outcomes especially in eyes with open-globe injuries. Coinfection with Gram-negative bacteria or fungi was associated with most unfavorable visual outcome.

Recalcitrant Pseudomonas keratitis after epipolis laser-assisted in situ keratomileusis: case report and review of the literature

We report a case of recalcitrant microbial keratitis after epipolis laser-assisted in situ keratomileusis (epi-LASIK) surgery caused by Pseudomonas aeruginosa and review the literature on resistant Pseudomonas keratitis after excimer laser surgery. Microbial keratitis occurred two weeks after epi-LASIK surgery and was resistant to fluoroquinolones, aminoglycosides and macrolides but sensitive to meropenem. The patient had total corneal melting and required therapeutic penetrating keratoplasty. The globe could be salvaged and the distance visual acuity was 6/60 in the right eye. Recalcitrant Pseudomonas keratitis might require a therapeutic graft and necessitate the use of intravenous meropenem to prevent recurrence of infection.

Immune reconstitution inflammatory syndrome in acquired immunodeficiency syndrome

A 33-year-old male presented with a history of fever and cough and was diagnosed to have pulmonary tuberculosis and acquired immunodeficiency syndrome (AIDS). He was started on antituberculosis therapy (ATT) followed by highly active anti-retroviral treatment (HAART) after one week. He developed an immune reconstitution inflammatory syndrome (IRIS) leading to an exacerbation of the tuberculosis disease. After HAART was stopped his condition improved dramatically.

Ultrasound guided percutaneous nephrostomy for obstructive uropathy in benign and malignant diseases

OBJECTIVE

Analyze the success rate, complications and overall benefit of ultrasound guided percutaneous nephrostomy (PCN) for the relief of obstructive uropathy in benign and malignant diseases.

MATERIALS AND METHODS

PCN was performed in 50 kidneys of 32 patients. It was performed in emergency rooms totally under ultrasound guidance by general surgeons. Seldinger technique was used in all cases. Changes in renal function after the procedure were analyzed using paired t-test.

RESULTS

The procedure was successfully completed in 42 out of 50 kidneys (84%). There has been no major complication and 28% minor complications. The renal function improved significantly when PCN was performed for benign conditions (mean creatinine 3.52 mg/dL before and 2.18 mg/dL after PCN), however in malignancy there has been no significant improvement in renal function (before PCN mean creatinine 6.39 mg/dL and after PCN 5.41 mg/dL).

CONCLUSION

We conclude that PCN can be effectively performed under ultrasound guidance and should be the initial procedure in acutely obstructed kidneys with pyonephrosis and poor renal function. In malignant cases, however, improvement in renal function is possible only if the procedure is carried out at an early stage.

Malignant melanoma of the nasal cavity

Malignant melanomas of the sinonasal mucosa are very uncommon, presenting frequently in advanced stages with usually a fatal course. Diagnosis becomes more difficult if it is amelanotic variety. Radical surgery is constrained because of increased morbidity & cosmesis, moreover radiotherapy and chemotherapy have little role if any to play. A case of 60 years old male who presented with nasal mass and epistaxis finally diagnosed as melanoma on histolopathology. Some other important aspects of this rare tumor are discussed here.

Transesophageal echocardiography in patients with ischemic stroke accurately detects significant coronary artery stenosis and often changes management

OBJECTIVES

TEE is performed in many patients with ischemic stroke, and it is possible to examine the proximal coronaries by TEE in these patients. Our purpose was to (1) determine the accuracy of transesophageal echocardiography (TEE) in the diagnosis of proximal coronary stenosis in patients with ischemic stroke and (2) show that TEE detection of proximal coronary stenosis changed management in a substantial number of patients.

METHODS

Thirty-two patients with ischemic stroke undergoing TEE, in whom the proximal coronaries were examined and who had angiographic results available, were studied.

RESULTS

Proximal coronaries were visualized as follows: left main (LM) in 31 (97%), left anterior descending (LAD) in 32 (100%), left circumflex (LCx) in 30 (94%) and right coronary artery (RCA) in 21 (66%). The sensitivity and specificity of TEE in diagnosing significant coronary stenosis in visualized vessels were as follows: LM 100% and 100%, LAD 100% and 95%, LCx 100% and 96%, and RCA 100% and 100%, respectively. When visualized and nonvisualized segments were considered, TEE detected significant stenosis as follows: 4 of 5 in the LM (80%), 13 of 13 in the LAD (100%), 2 of 3 in the LCx (66%), and 2 of 8 in the RCA (25%). Of the 32 patients, TEE results changed management in 17 patients (53%). Angiographic findings resulted in 10 of the 17 patients (59%) undergoing revascularization.

CONCLUSIONS

TEE was very accurate in diagnosing significant coexisting coronary artery disease in patients with ischemic stroke. TEE diagnosis of these lesions prompted coronary angiography and subsequent revascularization in a substantial number of patients.