Research Papers – Plastic Surgery & Dermatology

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2009

[“+ Implant and Prosthesis Movement after Enucleation A Randomized Controlled Trial.”, “{+ Implant and Prosthesis Movement after Enucleation A Randomized Controlled Trial.”, “hidden”]

Shome D, Honavar SG, Raizada K, Raizada D.

OBJECTIVE: To evaluate implant and prosthesis movement after myoconjunctival enucleation and subsequent polymethyl methacrylate (PMMA) implantation, compared with the traditional enucleation with muscle imbrication using a PMMA implant and with enucleation accompanied by porous polyethylene implantation. DESIGN: Randomized, controlled, observer-masked, interventional study. PARTICIPANTS: One hundred fifty patients, equally and randomly allocated to the 3 groups. INTERVENTION: Group 1 consisted of patients in whom a PMMA implant was used after enucleation with muscle imbrication (traditional PMMA group). Group 2 consisted of patients in whom a PMMA implant was used after enucleation with a myoconjunctival technique (myoconjunctival PMMA group). Group 3 consisted of patients in whom a porous polyethylene implant was used after enucleation by the scleral cap technique (porous polyethylene group). Fifty patients were included in each group. Patients were allocated to 1 of the 3 groups using stratified randomization. Informed consent was obtained. Acrylic prostheses custom made by a trained ocularist were fitted 6 weeks after surgery in all patients. A masked observer measured implant and prosthesis movement 6 weeks after surgery using a slit-lamp device with real-time video and still photographic documentation. Analysis of implant and prosthesis movement was carried out using the Mann-Whitney U test, and a P value of

[“+ Recalcitrant fungal tunnel infection treated with intrastromal injection of voriconazole.”, “+ Recalcitrant fungal tunnel infection treated with intrastromal injection of voriconazole.”, “hidden”]

Jain V, Borse N, Shome D, Natarajan S.

We are reporting a case of recalcitrant fungal tunnel infection treated with intrastromal injection of voriconazole. A 50-year-old woman underwent an uneventful phacoemulsification through a temporal corneal tunnel incision for age-related cataract in her right eye. One month post-surgery, she developed tunnel infection. Microbiological investigations revealed Aspergillus flavus as the offending pathogen. Despite intensive medical treatment, the corneal and anterior chamber infiltrate progressively enlarged. At the end of three and a half weeks, 0.1 ml of 0.05% voriconazole was injected intra-stromally surrounding the central end of the corneal infiltrate. On the subsequent follow-ups, a gradual improvement was noted and slowly it resolved completely. Topical therapy along with a judicious use of intrastromal administration of antifungal drugs may be of immense benefit in such cases prior to embarking on the surgical treatment.

[” + Aspergillus keratitis in vernal shield ulcer-a case report and review.”, “+ Aspergillus keratitis in vernal shield ulcer-a case report and review.”, ” hidden”]

Jain V, Mhatre K, Nair AG, Shome D, Natarajan S.

Abstract An unusual case of vernal shield ulcer with superadded fungal keratitis caused by Aspergillus fumigates is reported. A 26-year-old man, a known case of vernal keratoconjunctivitis (VKC) presented with the complaint of diminution of vision in the right eye. Patient was on topical steroids and anti-allergic treatment for the past two months. In the right eye, a shield ulcer with an elevated plaque was seen. Scrapings from the right cornea revealed fungal filaments on a wet KOH mount and culture revealed growth of Aspergillus fumigatus. The patient was diagnosed as VKC with shield ulcer with secondary fungal keratitis. The patient was treated with topical cyclosporine, topical moxifloxacin, topical natamycin, and topical amphotericin eye drops. The patient responded well and finally recovered to a best spectacle-corrected visual acuity of 20/20 at the end of nine months. The chronic ocular surface changes and induced inflammation in VKC, and the instillation of topical steroids for therapy, may create an environmental milieu favorable for fungal keratitis. Microbiological evaluation should be considered, even in cases of suspected sterile keratitis, to prevent possible worsening of an associated infective corneal condition. This warrants patient education, periodic reviews and a very cautious approach to indiscriminate use of topical corticosteroids in cases of VKC with shield ulcer. In the event of any secondary fungal infection, use of steroid sparing topical agent, for example cyclosporine may be considered.

[” + Does a nanomolecule of carboplatin injected periocularly help in attaining higher intravitreal concentrations?”, ” + Does a nanomolecule of carboplatin injected periocularly help in attaining higher intravitreal concentrations?”, ” hidden”]

Shome D, Poddar N, Sharma V, Sheorey U, Maru G, Ingle A, Sarin R, Banavali S, Dikshit R, Jain V, Honavar SG, BellareJ.

Purpose: To compare intravitreal concentration (VC) of commercially available carboplatin (CAC) & novel nanomolecule carboplatin (NMC), following periocular injection. Design: Experimental, comparative, animal study. Participants: Twenty-four white Sprague-Dawley rats. Intervention: CAC was bound with a nanoparticulate carrier by co-acervation with a bio-compatible & biodegradable protein BSA (bovine serum albumin). The particulate size, binding and structure of the carrier was analyzed with dynamical light scattering, electron microscopy, FTIR spectroscopy & SDS gel electrophoresis. Twenty-four white rats were anaesthetized. The right eye of each rat was injected with periocular CAC (1 ml) & the left eye with NMC (1 ml) by a trained ophthalmologist. Four mice each were euthanized at days 1, 2, 3, 5, 7, 14 & 21 & both eyes enucleated. The intra-vitreal concentrations of commercial carboplatin & that of nano-molecule carboplatin were determined with HPLC (high performance liquid chromatography). Analysis of data was done with the paired t test. Main Outcome Measure: Intravitreal concentrations CAC & NMC over time. Results: The NMC vitreal concentration was higher than the CAC concentrations in all animals, until day 7 (P = 0.0001). On days 14 and 21, the CAC vitreal concentration was higher than the NMC concentrations in all animals (P = 0.0002). Overall, the mean vitreous concentration of NMC was greater than CAC. Conclusion: Nano-particulate bound carboplatin has greater transscleral transport than commercially available carboplatin, especially in the first week. This may help enhance the proven adjuvant efficacy of periocular carboplatin over and above systemic chemotherapy in treating human retinoblastoma, especially those with vitreous seeds

[“+ Descemet’s stripping endothelial keratoplasty: is it an option for congenital hereditary endothelial dystrophy? “, ” + Descemet’s stripping endothelial keratoplasty: is it an option for congenital hereditary endothelial dystrophy? “, ” hidden”]

Pineda R 2nd, Jain V, Shome D, Hunter DC,Natarajan S.

The purpose of this study was to report our experience of an attempted Descemet’s stripping automated endothelial keratoplasty (DSAEK) in a patient with congenital hereditary endothelial dystrophy (CHED). A 7-year-old boy presented with the complaints of decreased vision in his right eye. The left eye had undergone penetrating keratoplasty at the age of 5 years. He was diagnosed as a case of CHED, and a DSAEK was planned for him. Due to technical difficulties during Descemet’s membrane scoring and stripping and poor visualization, the procedure had to be abandoned and converted to a full thickness penetrating keratoplasty. To the best of our knowledge, this is the first reported case of an attempted DSAEK in a patient with CHED. Proper DSAEK case selection should include adequate visualization of the endothelium and anterior chamber. Severe stromal haze and edema may prevent necessary surgical observation during the procedure, and a full thickness penetrating keratoplasty may be required.

[“+ Fungal keratitis associated with ocular rosacea. “, “+ Fungal keratitis associated with ocular rosacea. “, ” hidden”]

Jain V, Shome D, Sajnani M, Natarajan S.

In order to report fungal keratitis in patients of ocular rosacea, a retrospective review of all cases of fungal keratitis was undertaken. Cases in which ocular rosacea coexisted were identified and included in the study. The clinical course of patients thus identified was studied from the medical records and outcomes were evaluated. A total of three cases of fungal keratitis with coexisting ocular rosacea were identified. All three patients were known cases of acne rosacea with an intermittent, irregular treatment for the same. Previous history of contact lens use, ocular surgery or trauma was not present in any of the cases. Microbiological evaluation revealed Aspergillus flavus as the causative organism in two patients and an unidentified hyaline fungus in the third. Patients received simultaneous therapy for fungal keratitis and ocular rosacea. The ocular surface completely stabilized and the infiltrate resolved in all three cases. The chronic ocular surface changes and induced inflammation in ocular rosacea, along with the instillation of topical steroids for therapy, may create an environmental milieu favorable for fungal keratitis. Microbiological evaluation should be considered, even in cases of suspected sterile keratitis, prior to treatment with topical steroids, so as to prevent the possible worsening of an associated infective corneal condition.

[“+ Evaluation of safety and efficacy of topical prostaglandin E2 in treatment of vitiligo. “, “+ Evaluation of safety and efficacy of topical prostaglandin E2 in treatment of vitiligo. “, ” hidden”]

Kapoor R, Phiske MM, Jerajani HR.

BACKGROUND: Prostaglandin E2 (PGE2) has stimulant and immunomodulatory effects on melanocytes and regulates their proliferation. OBJECTIVES: To study the efficacy and safety of topical PGE2 in treating stable vitiligo patches involving <5% body surface area. METHODS: Fifty-six consecutive patients with clinically diagnosed stable vitiligo of types vulgaris, focal, segmental, lip and genital applied a translucent PGE2 (0.25 mg g(-1)) gel twice daily for 6 months. Evaluation was fortnightly for 3 months and monthly thereafter up to 6 months. Assessment was based on degree of repigmentation in treated patches ranging from 0% (no change) to 100% (complete repigmentation). Overall response was graded as: poor, 1-25% repigmentation; moderate, 26-50%; good, 51-75%; excellent, >75%. RESULTS: Vitiligo vulgaris was the most common type (n=22; 39%), followed by focal and lip vitiligo, with lesions being mostly on the face (25%) and lips. Repigmentation was seen in 40 of 56 patients (71%), with mean onset at 2 months. Patients with disease duration of 6 months or less repigmented best, with face and scalp responding earliest (1-1.5 months). Complete clearance occurred in eight of 40 patients, six of the eight having face lesions. Excellent response was seen in 22 of 40 patients. All neck, scalp and trunk lesions, 33% genital, 29% lip vitiligo, 100% segmental and 63% focal patches showed moderate to excellent response. Incidence of side-effects was 18%, mainly a transient burning sensation especially on the lips. CONCLUSIONS: The efficacy and safety of topical PGE2 make it a promising therapy for localized stable vitiligo.

[” + Aspergillus iris granuloma: a case report with review of literature.”, “+ Aspergillus iris granuloma: a case report with review of literature. “, ” hidden”]

Jain V, Dabir S, Shome D, Dadu T, Natarajan S.

We report the case of a 25-year-old male patient who presented with complaints of redness, photophobia, and decreased vision in the right eye of a week’s duration. Slit-lamp biomicroscopic examination revealed a cream-colored, irregular elevated inferior iris mass, extending on to the anterior lens surface. Differential diagnoses of a fungal granuloma, a medulloepithelioma, and an amelanotic melanoma were considered. An excisional biopsy of the mass was performed through a superior clear corneal incision. Polymerase chain reaction analysis of the aqueous humor showed a positive pan fungal genome. Histopathology of the biopsied mass showed a giant cell granuloma with surrounding numerous branching, septate hyphae. Culture growth revealed Aspergillus fumigatus We report this case because of the rarity of Aspergillus iris granuloma as a primary presentation of endogenous Aspergillosis and review the relevant literature. Absence of a significant systemic history compounded the diagnostic dilemma in our patient. Definitive differentiation of this rare entity from a foreign body, amelanotic melanoma, and other inflammatory conditions such as sarcoidosis and tuberculosis, may be possible only on microbiological and histo-pathological evaluation.

2008

[“+ Targeted monoclonal antibody therapy and radioimmunotherapy for lymphoproliferative disorders of the ocular adnexa. “, “+ Targeted monoclonal antibody therapy and radioimmunotherapy for lymphoproliferative disorders of the ocular adnexa. “, ” hidden”]

Shome D, Esmaeli B.

PURPOSE OF REVIEW: The goal of this review is to update ophthalmologists and orbital and adnexal specialists with the emerging role of targeted monoclonal antibody therapy and radioimmunotherapy for orbital and adnexal non-Hodgkin’s lymphoma and other lymphoproliferative disorders of the orbit. RECENT FINDINGS: Rituximab as monotherapy for indolent lymphoma of the orbit and conjunctiva may be associated with good initial response, but the risk of distant relapse is about 50%. Rituximab may be used in combination with conventional chemotherapy, and such combination therapy may be associated with a higher durable response rate and improved progression-free survival compared with chemotherapy alone. Radioimmunotherapy using targeted monoclonal antibodies with radioactive conjugates is also associated with a more durable response rate than monotherapy with rituximab alone and may be an alternative for treatment of ocular adnexal lymphoma. Radioimmunoconjugates are associated with transient pancytopenia during the first 3 months after treatment. Rituximab monotherapy may be considered as an alternative to systemic steroids for treatment of orbital benign lymphoid hyperplasia. SUMMARY: Targeted monoclonal antibody therapy is an intriguing new modality for treatment of orbital, eyelid, or conjunctival lymphoma and can be used in combination with radioimmunotherapy or standard chemotherapy for a more durable response.

[” + Orbital tuberculosis: a review of the literature.”, ” + Orbital tuberculosis: a review of the literature.”, ” hidden”]

Madge SN, Prabhakaran VC, Shome D, Kim U,Honavar S, Selva D.

PURPOSE: To provide an up-to-date review of the clinical presentations,investigations, and management of orbital tuberculosis (OTB).

METHODS:Systematic review of the literature concerning OTB, limiting the results to English-language peer-reviewed journals.

RESULTS:
Seventy-nine patients from 39 publications were identified as cases of OTB. The condition presents in one of five forms: classical periostitis; orbital soft tissue tuberculoma or cold abscess, with no bony involvement; OTB with bony involvement; spread from the paranasal sinuses; and tuberculous dacryoadenitis. The ocular adnexa, including
the nasolacrimal system and overlying skin, may also be involved.

CONCLUSIONS: Diagnosis can be difficult and may necessitate an orbital biopsy, in which acid-fast bacilli (AFB) and characteristic histopathology may be seen. Growth of Mycobacterium tuberculosis (mTB) from such a specimen remains the gold standard for diagnosis. Ancillary investigations include tuberculin skin tests and chest radiography, but more recently alternatives such as whole blood interferon-gamma immunological tests and PCR-based tests of pathological specimens have proven useful. The management of OTB is complex, requiring a stringent
public health strategy and high levels of patient adherence, combined with long courses of multiple anti-tuberculous medications. The interaction of the human immunodeficiency virus (HIV) with TB may further complicate management.

[” + Surgically induced necrotizing scleritis after pterygium surgery with conjunctival autograft. “, “+ Surgically induced necrotizing scleritis after pterygium surgery with conjunctival autograft. “, ” hidden”]

Jain V, Shome D, Natarajan S, Narverkar R.

PURPOSE: To report a case of surgically induced necrotizing scleritis (SINS) as a complication of conjunctival autograft after pterygium excision. METHODS: A 52-year-old man had undergone nasal pterygium excision with conjunctival autograft in the right eye at another facility. He was treated for suspected infective scleritis before presentation. RESULTS: The sclera, at the site of prior pterygium excision, showed significant thinning with uveal show. There was active inflammation adjacent to the site of thinning. Systemic studies and the examination were noncontributory. The patient was suspected of having SINS and received pulsed injections of methylprednisolone 1000 mg/d for 3 days. The patient also underwent an emergency scleral patch graft with amniotic membrane graft. Over the next 2 weeks, the scleral graft showed vascularization and was taken well. CONCLUSIONS: SINS may develop after pterygium surgery with conjunctival autograft. Evidence of connective tissue disease may or may not be found on clinical examination and on laboratory studies. Early diagnosis, prompt immunosuppression, and scleral patch grafting prevents progression and further devastating complications.

[“+ Community-acquired methicillin-resistant Staphylococcus aureus (CAMRSA)–a rare cause of fulminant orbital cellulitis.”, “+ Community-acquired methicillin-resistant Staphylococcus aureus (CAMRSA)–a rare cause of fulminant orbital cellulitis.”, ” hidden”]

Shome D, Jain V, Natarajan S, Agrawal S,Shah K.

We report a 55-year-old female patient who developed a severe right-sided orbital cellulitis. Past history was significant for a boil on the right upper eyelid 2 days prior. Visual acuity at presentation was perception of light with inaccurate projection. Orbital computed tomography (CT) scan and routine blood investigations, including blood culture, urine examination, and urine culture, were performed. CT scan showed a superonasal orbital mass suggestive of an abscess. Abscess drainage followed by pus culture, sensitivity, and pulsed-field gel electrophoresis revealed community-acquired methicillin-resistant Staphylococcus aureus (CAMRSA) resistant to all antibiotics except vancomycin, cotrimoxazole, and amikacin. The condition completely resolved post antibiotic and steroid therapy. At 3 months follow-up, the vision in the right eye was 6/9. We report this case to highlight CAMRSA as a rare but virulent cause of orbital cellulitis; empiric antibiotic therapy should include coverage for CAMRSA until susceptibilities come back.

[“+ Periocular necrotizing fasciitis associated with kerato-conjunctivitis and treated with medical management: a case report. “, “+ Periocular necrotizing fasciitis associated with kerato-conjunctivitis and treated with medical management: a case report. “, ” hidden”]

Shome D, Jain V, Jayadev C, Shah K,Natarajan S.

We report a 25-year-old systemically healthy male who presented with periocular necrotizing fasciitis (NF) in the left eyelid. This was associated with the presence of immunologically mediated marginal kerato-conjunctivitis, in the same eye. This potentially dangerous lid infection and the associated ocular surface infection resolved successfully, with medical management. We report this case to highlight the successful conservative management of periocular NF and the hitherto unreported anterior segment involvement.

[“+ Nevirapine-induced Stevens-Johnson syndrome in an HIV patient. “, “+ Nevirapine-induced Stevens-Johnson syndrome in an HIV patient. “, ” hidden”]

Jain V, Shome D, Natarajan S.

PURPOSE: To report a case of nevirapine-induced Stevens-Johnson syndrome (SJS) misdiagnosed as viral keratitis. METHODS: A 35-year-old AIDS patient, on antiretroviral therapy (ART) with stavudine, nevirapine, and lamivudine, developed bilateral ocular congestion and irritation. He was being treated elsewhere for bilateral herpetic epithelial keratitis. On progressive worsening of symptoms, he presented with complaints of severe photophobia and foreign-body sensation in both eyes. RESULTS: The patient’s history was evaluated in detail. The patient had apparently been on multidrug ART until he developed SJS 3.5 months ago. Nevirapine was subsequently discontinued. No ophthalmologic opinion was sought until a month before. He was diagnosed and was treated for bilateral herpetic epithelial keratitis for 1 month. Ocular surface examination revealed bilateral severe dry eyes, with multiple corneal erosions. The inferior fornices showed cicatricial bands. The patient was suspected to have SJS-induced dry eyes, with associated epithelial defects. The epithelial defect edges were debrided and subjected to viral cell culture and polymerase chain reaction for herpes simplex. The patient was started on hourly preservative-free tear substitutes. Amniotic membrane transplantation (as a patch graft) was performed. A successful response to therapy within 10 days, along with a negative viral culture and polymerase chain reaction report, confirmed our diagnosis. CONCLUSIONS: Ophthalmologists need to be aware of the high risk of development of ocular adverse reactions in AIDS patients on ART before ascribing the ocular symptoms to more severe opportunistic infections.

[“+ Management of an irradiated anophthalmic socket following dermis-fat graft rejection: a case report. “, “+ Management of an irradiated anophthalmic socket following dermis-fat graft rejection: a case report. “, ” hidden”]

Raizada K, Shome D, Honavar SG.

Dermis-fat graft (DFG) is often the only promising option in cases of severely contracted sockets. However, there is an increased risk of graft failure in irradiated sockets with decreased vascularity. In such difficult cases, repeat DFG implantation also has higher risks of graft failure. We describe an ingenious method of successful management of an irradiated anophthalmic socket following DFG infection and necrosis, with acceptable cosmetic results. At surgery, an orbital impression was taken with ophthalmic grade alginate. Based on this measurement, a custom-made stem pressure socket-expander made up of high density polymethyl methacrylate (PMMA) was fitted, a week post surgery and kept in situ for six weeks. On review, the fornices had considerably deepened. The expander device was removed and the patient was now fitted with a custom-made thicker prosthesis made up of high-density PMMA. The patient has followed up for a year subsequently and the prosthesis has remained stable.

[“+ Isolated upper eyelid retraction: a sign of idiopathic inflammatory orbital disease. “, “+ Isolated upper eyelid retraction: a sign of idiopathic inflammatory orbital disease. “, ” hidden”]

Shome D, Toshniwal S, Jain V, Natarajan S,Vemuganti GK.

A 41-year-old woman was examined for left upper eyelid retraction. Remaining ocular and systemic examination was unremarkable. Orbital CT demonstrated an ill-defined, extraconal, superior orbital soft-tissue mass involving the levator palpebrae superioris muscle. Incisional biopsy with histopathology demonstrated idiopathic orbital inflammation. The patient was started on a gradually tapering dose of oral steroids, for 6 weeks. On follow-up, the eyelid retraction had resolved. We report this case to demonstrate that idiopathic inflammatory orbital disease, localized to the superior orbit, may cause isolated upper eyelid retraction without associated proptosis. This condition resolves with medical therapy, leading to symmetrical palpebral apertures.

[“+ Ulcerative keratitis in gastrointestinal stromal tumor patients treated with perifosine.”, “+ Ulcerative keratitis in gastrointestinal stromal tumor patients treated with perifosine.”, ” hidden”]

Shome D, Trent J, Espandar L, Hatef E,Araujo DM, Song CD, Kim SK, Esmaeli B.

PURPOSE: Perifosine is a novel alkylphospholipid with antiproliferative properties attributed to protein kinase B inhibition. The authors describe a form of ulcerative keratitis in 5 patients with advanced gastrointestinal stromal tumor (GIST) enrolled in a phase I/II trial of perifosine in combination with imatinib. DESIGN: Interventional case series. PARTICIPANTS: Five patients (1 man, 4 women) with imatinib-resistant metastatic GIST who received a combination of imatinib and perifosine orally. METHODS: The medical records were reviewed retrospectively. MAIN OUTCOME MEASURES: Ocular toxicity and ulcerative keratitis associated with perifosine. RESULTS: The ocular symptoms included redness, irritation, tearing, photophobia, and a gradual decrease in vision. Slit-lamp biomicroscopy in each case revealed a peripheral, paralimbal, ring-shaped, superficial corneal stromal infiltration and ulcerative keratitis, reminiscent of the autoimmune keratitis in conditions such as rheumatoid arthritis. The ulcerative keratitis was unilateral in 3 and bilateral in 2 patients; it was National Cancer Institute grade II (symptoms interfering with function but not interfering with activities of daily living) in all patients. All 5 patients had imatinib-resistant metastatic GIST and had continued on the highest dose of imatinib tolerated and initiated therapy with perifosine 100 mg daily or 900 mg weekly. A combination of topical steroids, topical antibiotics, and lubricating drops were used to manage ulcerative keratitis. In the first 3 patients, ulcerative keratitis initially was treated with topical antibiotics without improvement, but subsequently they improved significantly after topical steroids were added. CONCLUSIONS: A vision-threatening form of ulcerative keratitis may occur in patients taking perifosine. It is possible that imatinib in combination with perifosine contributes to this corneal toxicity; however, the authors are unaware of this ocular toxicity having been reported for imatinib when used without perifosine. The visual loss associated with perifosine may be reversible if detected and treated early and with judicious early use of topical steroids, topical antibiotic coverage, and lubrication.

2007

[“+ Corneal bee sting misdiagnosed as viral keratitis. “, “+ Corneal bee sting misdiagnosed as viral keratitis. “, ” hidden”]

Jain V, Shome D, Natarajan S.

PURPOSE: To report a case of chronic keratouveitis caused by a missed bee sting injury. METHODS: A 17-year-old boy was referred for management of unresponsive viral keratouveitis. Ocular examination revealed corneal edema and scarring, atrophic patches on the iris, and anterior polar cataracts. Surprisingly, examination also revealed a retained intracorneal bee stinger. A retrospective inquiry confirmed a bee sting injury 2 years ago. RESULTS: The patient was started on medical treatment and underwent operative removal of the bee stinger. Postsurgery, visual acuity improved, and the corneal edema regressed over a 1-month follow-up. CONCLUSIONS: In cases of chronic keratouveitis, a meticulous examination is mandatory to rule out unusual causes like a retained corneal bee stinger. A retained intracorneal bee stinger may result in long-term corneal inflammation, which may not be controlled adequately with topical steroids. It should be removed, irrespective of the duration since the injury.

[“+ Pseudodendritic keratitis in ocular rosacea causing a diagnostic dilemma. “, “+ Pseudodendritic keratitis in ocular rosacea causing a diagnostic dilemma. “, ” hidden”]

[“+ Systemic chemotherapy and tamoxifen induced regression of choroidal metastasis from a breast carcinoma in a male. “, “+ Systemic chemotherapy and tamoxifen induced regression of choroidal metastasis from a breast carcinoma in a male. “, ” hidden”]

Shome D, Jayadev C, Gadgil D, Natarajan S,Jain V.

We report a case of a 55-year-old male patient with breast carcinoma, who developed choroidal metastasis. The patient had undergone mastectomy for carcinoma of right breast, five years ago. The patient was advised close follow-up for the left eye, as he was already on tamoxifen therapy (started a month ago) for spinal metastasis. On last follow-up, a year later, the choroidal lesion had completely scarred, with no recurrences. Systemic hormonal therapy like tamoxifen given for the breast primary and other systemic metastases may cause regression of the choroidal metastasis, thereby avoiding ocular radiotherapy. Medline search revealed only one published case of regression of choroidal metastasis from a male breast primary, on tamoxifen therapy.

[“+ An unusual ocular manifestation in fanconi anaemia: anterior ischaemic syndrome.”, “+ An unusual ocular manifestation in fanconi anaemia: anterior ischaemic syndrome.”, ” hidden”]

[“+ The role of botulinum toxin in correcting frontalis-induced eyelid pseudo-retraction post ptosis surgery.”, “+ The role of botulinum toxin in correcting frontalis-induced eyelid pseudo-retraction post ptosis surgery.”, ” hidden”]

Shome D, Jain V, Natarajan S.

We report a case of a 52-year-old female patient who developed overcorrection, due to brow overuse, post surgery for bilateral aponeurotic ptosis. The patient had undergone levator palpebrae superioris plication bilaterally. Due to brow overuse habituated by long standing ptosis, the patient presented with superior scleral show, post ptosis surgery. The lid contour was normal in both eyes and when brow overaction was blocked mechanically, the palpebral fissure heights were normal, comparable, with no scleral show bilaterally. Despite repeated instructions, when the patient continued brow overuse subconsciously, an injection of botulinum toxin was given just above both brows. This led to elimination of brow overuse within a month, with elimination of superior scleral show. The patient maintained lid and brow symmetry with no overaction, eight months post injection.

[“+ Aspergillus-induced malignant glaucoma.”, ” + Aspergillus-induced malignant glaucoma.”, ” hidden”]

Jain V, Maiti A, Shome D, Borse N, NatarajanS.

PURPOSE: To report a case of Aspergillus flavus-induced keratomycotic malignant glaucoma. METHODS: A 48-year-old woman presented with a severe corneal ulcer. She had received topical steroids for 10 days before presentation. RESULTS: Microbiological studies revealed A. flavus as the offending pathogen. Nonresponsive high intraocular pressure with associated shallow anterior chamber was present. With a diagnosis of keratomycotic malignant glaucoma, the patient underwent therapeutic keratoplasty with cataract extraction with posterior chamber wash. However, there was a recurrence of malignant glaucoma in the postoperative period. Patient underwent limited pars plana vitrectomy. CONCLUSIONS: Keratomycotic malignant glaucoma is a rare complication of severe fungal ulcer. We believe that the use of topical steroids in this case probably led to increased fungal penetration, with the formation of a lens-iris fungal mass and subsequent malignant glaucoma. Nonresponse to medical therapy warrants urgent surgical intervention. To the best of our knowledge, Aspergillus-induced keratomycotic glaucoma has never been reported previously. This report also highlights that therapeutic keratoplasty with cataract extraction alone may not be sufficient for management of such cases, and a limited pars plana vitrectomy may be needed.

[“+ Scleral necrosis in a patient with aplastic anaemia. “, “+ Scleral necrosis in a patient with aplastic anaemia. “, ” hidden”]

[“+ Phacoemulsification and pars plana vitrectomy: a combined procedure. “, “+ Phacoemulsification and pars plana vitrectomy: a combined procedure. “, ” hidden”]

Jain V, Kar D, Natarajan S, Shome D, Mehta H, Jayadev C, Borse N.

AIM: To describe the results of a combined procedure including phacoemulsification, insertion of posterior chamber intraocular lens (PCIOL) and pars plana vitrectomy (PPV) in eyes with vitreoretinal pathology and coexisting significant cataract. DESIGN: Retrospective, consecutive, noncomparative, interventional case series. MATERIALS AND METHODS: Medical records of patients who had undergone phacoemulsification, PPV and PCIOL implantation as a combined procedure between January 2000 and December 2004 were retrospectively reviewed. The main outcome measures were the anatomical success of retina, defined as reattached retina, intraoperative and postoperative complications and functional success in terms of final best corrected visual acuity. RESULTS: In all, 65 eyes of 64 patients were included. The mean age of the patients was 50.9 years +/- 17.1 (range, five to 82 years). Vitreous hemorrhage with or without retinal detachment (19 eyes, 29.2%) was the most common indication for the vitreoretinal procedure. Primary anatomical success of retina was achieved in 59 eyes (90.7%). Visual acuity improved in 48 eyes (73.8%), was unchanged in 12 eyes (18.5%) and deteriorated in five eyes (7.7%). Postoperative inflammation was significantly more in the subgroup of previously vitrectomized eyes (42%) (P =0.014, Fisher exact test) compared to those which underwent primary vitrectomy. CONCLUSIONS: Combined surgery is a feasible option for patients with vitreoretinal diseases and cataract.

[“+ Periosteal fixation in third nerve palsy. “, “+ Periosteal fixation in third nerve palsy. “, ” hidden”]

[“+ Orbital embryonal rhabdomyosarcoma in association with neurofibromatosis type 1. “, “+ Orbital embryonal rhabdomyosarcoma in association with neurofibromatosis type 1. “, ” hidden”]

Shome D, Honavar SG, Reddy VA, Vemuganti GK.

A 20-month-old child with systemic features of neurofibromatosis type 1 presented with sudden-onset proptosis. Biopsy and histopathology confirmed the diagnosis of an embryonal rhabdomyosarcoma. The tumor regressed completely with chemotherapy and external beam radiotherapy. This case highlights the association of rhabdomyosarcoma with neurofibromatosis type 1.

[“+ Metastasis to the eye and orbit from renal cell carcinoma–a report of three cases and review of literature. “, “+ Metastasis to the eye and orbit from renal cell carcinoma–a report of three cases and review of literature. “, ” hidden”]

Shome D, Honavar SG, Gupta P, Vemuganti GK,Reddy PV.

We report three cases of renal cell carcinoma metastatic to the eye and orbit and review the relevant literature. The case reports of a 67-year-old man, a 58-year-old man, and a 23-year-old woman with metastatic renal cell carcinoma are described. The iris mass occurred in a 67-year-old man, a known case of renal cell carcinoma. Whereas the orbital metastasis in the 58-year-old man was the initial presenting sign in a hitherto undiagnosed patient, the orbital metastasis in the 23-year-old female patient was detected following nephrectomy for renal cell carcinoma. Renal cell carcinoma metastasizing to the eye and orbit are very rare, with only 68 cases reported previously. In patients presenting with atypical orbital or ocular masses, the possibility of renal cell carcinoma metastasis should be considered, especially if there is a history of previous renal disorder. Incisional biopsy with histopathological evaluation may be an important means to diagnose this condition and facilitate appropriate therapy.

[“+ New measurement device and technique for assessing implant and prosthetic motility. “, “+ New measurement device and technique for assessing implant and prosthetic motility. “, ” hidden”]

Raizada K, Shome D, Honavar SG.

Implant and prosthetic motility are key aspects of good cosmesis in an anophthalmic socket. Various techniques have been attempted to improve implant and prosthesis motility. However, the attempts at comparing these techniques are incomplete without a simple, objective, reproducible method of motility measurement. We describe a novel, simple, inexpensive, custom-made slit-lamp measurement device and a new technique to measure implant and prosthetic motility objectively for documentation. To the best of our knowledge, no such device or method has been documented or described in the literature.

[“+ Spectacle-induced ocular trauma: an unusual mechanism. “, “+ Spectacle-induced ocular trauma: an unusual mechanism. “, ” hidden”]

Jain V, Natarajan S, Shome D, Gadgil D.

PURPOSE: To report an unusual, spectacle-related injury. METHODS: A 16-year-old boy wearing spectacles with polycarbonate lenses presented with an unusual, spectacle-related injury. Impact with the ball during a ball sport (cricket) led to extreme torsion of the frame with resultant direct blunt trauma to the right eye by the spectacle arm. On examination, the patient had a 10 x 10-mm area of conjunctivalized scleral dehiscence superiorly in Zones 2 and 3, with uveal prolapse. Superior retinal detachment was also noted. RESULTS: Patient underwent wound repair with a scleral patch graft with transscleral cryotherapy and sulfur hexafluoride injection. CONCLUSION: Although increased impact resistance of newer spectacle lens materials is assumed to reduce the incidence of ocular trauma, such unusual mechanisms may still lead to severe ocular trauma. We report this case to highlight an unusual mechanism of spectacle injury, hitherto unreported, and to show the continued need for use of eye protection while wearing spectacles.

2006

[“+ Ptosis caused by orbicularis myokymia and treated with botulinum toxin: a case report. “, “+ Ptosis caused by orbicularis myokymia and treated with botulinum toxin: a case report. “, ” hidden”]

[“+ Orbital tuberculosis manifesting with enophthalmos and causing a diagnostic dilemma. “, “+ Orbital tuberculosis manifesting with enophthalmos and causing a diagnostic dilemma. “, ” hidden”]

Shome D, Honavar SG, Vemuganti GK, Joseph J.

A 60-year-old woman with no known systemic disease was referred with a hard mass in the left orbit and enophthalmos of two months duration. Differential diagnoses of metastasis from an undetected scirrhous carcinoma and sclerosing nonspecific orbital inflammatory disease were considered and a biopsy was performed. Histopathology demonstrated granulomatous inflammation with fibrosis. Subsequent polymerase chain reaction was positive for Mycobacterium tuberculosis deoxyribonucleic acid. There was no evidence of systemic tuberculosis. The patient was treated with four-drug combination anti-tubercular therapy for 6 months. The mass regressed and there was no local recurrence at two years follow-up. Orbital tuberculosis generally manifests with proptosis or osteomyelitis. However, enophthalmos may be caused by the fibrosing variant. Biopsy with histopathologic and microbioloic evaluation is essential to distinguish it from other more common causes of an orbital mass with paradoxical enophthalmos such as metastatic scirrhous carcinoma and sclerosing nonspecific orbital inflammatory disease.

[“+ Choroidal ganglioneuroma in a patient with neurofibromatosis type 1: a case report. “, “+ Choroidal ganglioneuroma in a patient with neurofibromatosis type 1: a case report. “, ” hidden”]

[“+ Ocular surface squamous neoplasia in a renal transplant recipient on immunosuppressive therapy.”, “+ Ocular surface squamous neoplasia in a renal transplant recipient on immunosuppressive therapy.”, ” hidden”]

2005

[“+ Bilateral epithelial defects after laser in situ keratomileusis. Clinical features, management and outcome. “, “+ Bilateral epithelial defects after laser in situ keratomileusis. Clinical features, management and outcome. “, ” hidden”]

Rao SK, Shome D, Iyer GK, Fogla R,Padmanabhan P.

PURPOSE: To describe the preoperative characteristics, intraoperative details, management, and postoperative in patients with bilateral epithelial defects after laser in situ keratomileusis (LASIK). METHODS: Retrospective non-comparative case series. RESULTS: Six patients with bilateral epithelial defects after LASIK were part of a cohort of 605 patients undergoing bilateral LASIK at our center from December 2001 to April 2003. The mean age of the patients (5M:1F) was 28.5 +/- 7.9 years, and the average pretreatment myopic spherical equivalent (SE) refraction was 7.3 +/- 0.7 D (-4, -12.25D). An epithelial flap was present in 6 eyes and an epithelial defect with a mean diameter of 3 mm (2mm, 6mm) was seen in 6 eyes. In four patients the epithelial disturbance was bilaterally similar. All defects occurred in the inferior cornea and the epithelial flaps had the hinge positioned superiorly. None of the patients had ocular or systemic risk factors that could have resulted in this complication. A bandage contact lens was used in 6 eyes. At last follow-up of 5.5 +/- 9.5 months (0.25, 21 months), unaided visual acuity was 6/9 or better in 10 eyes. Best spectacle-corrected visual acuity (BSCVA) was maintained in 8 eyes, while 4 eyes lost one line of BSCVA. Recurrent corneal erosions were not reported in the follow-up period. CONCLUSIONS: These patients represent a hitherto unrecognised group of individuals who appear to have a subclinical weakness of adhesion of the corneal epithelium to the underlying structures, which is not evident on clinical examination. This results in bilateral epithelial disturbances after LASIK. Appropriate management results in satisfactory clinical outcomes. Other options for treatment of the fellow eye of such patients include the use of a different microkeratome, release of suction during the reverse pass of the Hansatome microkeratome, and photorefractive keratectomy if the refractive error is low.

2004

[“+ Thrombosed orbital varix — a correlation between imaging studies and histopathology.”, “+ Thrombosed orbital varix — a correlation between imaging studies and histopathology.”, ” hidden”]

Menon SV, Shome D, Mahesh L, Subramanian N,Krishnakumar S, Biswas J, Noronha OV.

A thrombosed varix in the orbit is comparatively rare. Clinical examination alone is often inadequate for diagnosis. Radio-logical examination, such as a computed tomography (CT) scan of the orbit, is extremely important. Histopathological examination (HPE) after excision biopsy can confirm the diagnosis. The present authors describe a case of proptosis in the left eye of a 45-year-old man. CT-scan and HPE supported the diagnosis of a thrombosed orbital varix. This paper discusses the use of radiological investigations to supplement a clinical suspicion and make the diagnosis. This entity needs to be included in the differential diagnosis of proptosis and requires a coordinated approach for establishment of the diagnosis.

2002

[“+ Choroidal tubercles in disseminated tuberculosis diagnosed by the polymerase chain reaction of aqueous humor. A case report and review of the literature.”, “+ Choroidal tubercles in disseminated tuberculosis diagnosed by the polymerase chain reaction of aqueous humor. A case report and review of the literature.”, ” hidden”]

Biswas J, Shome D.

PURPOSE: Disseminated tuberculosis occurs due to the hematogenous spread of pulmonary tuberculosis systemically. Polymerase chain reaction (PCR) of various body fluids has been found to be beneficial in the diagnosis of disseminated tuberculosis, including intraocular tuberculosis. We describe the role of PCR of the aqueous aspirate in a case of disseminated tuberculosis involving the choroid.

METHODS: Single-step PCR fusing primers coding for the IS6110 gene and nested PCR (nPCR) for the detection of the MPB64 gene were performed on the aqueous aspirate in a case of disseminated tuberculosis with miliary involvement of the choroid.

RESULTS: On PCR, the aqueous aspirate showed the Mycobacterium tuberculosis genome, thereby confirming the diagnosis of intraocular tuberculosis. CONCLUSION: PCR is a highly sensitive and specific diagnostic test and PCR of intraocular specimens like the aqueous can be supportive of the diagnosis of miliary tuberculosis of the choroid.

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