Microbiological and Antibiotic Sensitivity Profile of Postoperative Endophthalmitis in a Tertiary Eye Care Hospital of North India

Introduction: We describe the microbiological profile of postoperative endophthalmitis from northern India and analyse the pattern of antibiotic sensitivity which may have changed due to development of resistance secondary to overuse of antimicrobial drugs. Materials and methods: This is a retrospective study of postoperative endophthalmitis from January 2011 to December 2017 in a tertiary eye hospital of northern India. Any patient developing endophthalmitis within one year of any intraocular procedure was included in the study. According to severity, treatment with a trial of intravitreal antibiotic injections or core vitrectomy was decided. Ocular samples were collected which were either anterior chamber tap or vitreous biopsy and sent for microbiological examination. The samples were stained with Gram’s and KOH stain and cultured on chocolate agar, blood agar, brain heart infusion broth and Sabouraud dextrose agar.Results: A total of 545 patients of postoperative endophthalmitis were analysed which showed a male predilection (60.5%) with maximum patients between the age group 50-69 years. 292 patients (53.5%) were culture negative and 253 patients (46.4%) were culture positive. Most common organism identified was Staphylococcus in 73 patients followed by Pseudomonas in 48 patients. Staphylococcus species was most sensitive to vancomycin (97%) followed by amikacin (91%) followed by gentamicin and moxifloxacin (88% each). Pseudomonas was the second most common isolate which showed maximum sensitivity to imipenem (82%) followed by ciprofloxacin(60%). Polymicrobial infection was noted in 23 patients. The most common fungal isolate was aspergillus in 11 patients, followed by fusarium in 10 patients. Conclusion: Our study shows that gram positive bacteria are the most common organisms in postoperative endophthalmitis and are most sensitive to vancomycin, followed by gram negative bacteria which show increased sensitivity with imipenem than commonly used antibiotic - ceftazidime.

Clinicopathologic Presentation and Management of Malignant Orbito-ocular Tumors at a Tertiary Care Hospital in Nepal

Introduction: This study was conducted to evaluate the clinical presentations and management of various Orbito-ocular malignancies in Nepal. Materials and methods: This is a prospective study of ocular malignant cases conducted at a tertiary care eye hospital in Kathmandu, Nepal. One hundred and seventeen newly diagnosed eyes with ocular malignancy of 106 patients presenting to the clinic in a year from September 2018 to August 2019 were included for analysis. Patients’ demography, clinical features, various types of malignancies seen in eyes and their management were evaluated. Results: The mean age of patients was 30.35 years with a range from 1 month to 84 years and standard deviation of 26.63. 56% of the total were male. Red eyes and visible mass were the most common symptoms in 23% with intraocular contents in 48% being the most common site involved. Different types of ocular malignancies were detected, among which retinoblastoma was the most common in 38% of patients. Diagnosis in most patients was clinical and/or radiological; incision biopsy was required in 1.7% patients only. Surgical excision of the tumor was the most common treatment done in 29% followed by enucleation in 27% of eyes. Bilateral involvement of the eyes was seen in 10% of the patients. Conclusion: Malignant orbito-ocular tumors can be seen in any age group. Retinoblastoma is the commonest malignancy seen. With the help of imaging, diagnosis is near accurate; hence biopsy is not required in most cases before commencing treatment.

Microbial Keratitis

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Et tu Mucor?

Introduction: Recently, the Indian subcontinent has been hard hit by the second wave of COVID-19. Along with it, the region has become a hot spot for mucormycosis infection in patients with COVID-19. The aim of this paper is to provide a scientific overview on the status of mucormycosis in pre-COVID-19 era and on how COVID-19 could have directly or indirectly expose the hidden burden of mucormycosis globally. Materials and methods: This paper is structured as a narrative review and is based on relevant published literature on both COVID-19 and mucormycosis. Conclusion: Mucormycosis in the pre-COVID-19 era was almost a neglected entity. It was because the risk factors for both - More severe COVID-19 infections and Mucormycosis are almost similar – COVID-19 might have helped to expose the true magnitude of the mucormycosis and flagging it as a major public health concern requiring a revisit by medical science.

Association of Thr715Pro P-Selectin Gene Polymorphism in Diabetic Retinopathy in North Indian Population: A Prospective Clinical Study

Introduction: The aim of this study was to evaluate the role of Thr715Pro P-Selectin gene polymorphism in patients with Diabetic Retinopathy in North Indian population and establish its role in the pathophysiology as an independent factor. Materials and methods: This is a prospective clinical study conducted on 60 patients at a tertiary care centre in North India over a period of eighteen months. Sixty patients satisfying the inclusion criteria were selected from the Vitreoretina clinic in the department. They were categorised equally in three groups namely Diabetics with diabetic retinopathy (DwDR), Diabetics without diabetic retinopathy (DwoDR), and non diabetics. The non-diabetics group was further divided into healthy controls, Hypertensive Retinopathy (HR) and Non-exudative Age Related Macular Degeneration (NEAMD). All the patients underwent complete ophthalmic evaluation and blood samples were drawn for the genetic study with their informed consent. Data was analysed using SPSS software version 16. Results: The genotypic analysis between DwDR, DwoDR and the three subgroup of controls comprising of healthy controls, HR and NEAMD showed that Thr715Pro (A/C) polymorphism prevalence was significantly high in DwDR (p = 0.003) and DwoDR (p = 0.003) compared to healthy controls. No significant difference was noted between DwDR, DwoDR and the HR and NEAMD groups. Conclusion: Thr715Pro P-Selectin gene Polymorphism could not be established as an independent factor in the pathogenesis of diabetic retinopathy, as its association is found with other systemic diseases which create a prothrombotic state.

Unusual Tumours Hidden in Blind Eyes

Introduction: This case report describes 3 cases of unsuspected neoplasms in previously blind eyes, with recent onset pain. Cases and observations: Case 1: Female with pain, redness in the non-seeing right eye (R/E) for two months. R/E had total cataract, low intraocular pressure and a well-defined globular mass lesion at the posterior pole, seen on ultrasound. Enucleation with an implant was done. Histopathology clinched the diagnosis of choroidal melanoma. Case 2: A 20-year male, developed pain, redness in left eye (L/E) for two months. L/E was blind since childhood, secondary to trauma. The patient underwent enucleation and detailed histopathological examination and immunohistochemistry supported a diagnosis of ependymoma with vascular malformation. Case 3: A 24-year male with pain, redness in L/E for six months, with decrease in size of eyeball. L/E had low vision since childhood. On examination, L/E was phthisical with diffuse conjunctival congestion, band-shaped keratopathy, cataract, and neovascularization of iris. Imaging revealed a small distorted globe with highly reflective mass along the posterior pole. Histopathology of the enucleated specimen confirmed the diagnosis of choroidal osteoma, with gliosis of the adjacent RPE. Conclusion: In the management of a painful blind eye, it is extremely important to rule out an intraocular malignancy, particularly in patients with recent onset of pain.

Glaucoma Screening in Family Members of Glaucoma Patients at a Tertiary Eye Hospital in Eastern Region of Nepal

Introduction: The second most common cause of blindness in the world is glaucoma. Family history plays an important role in early detection and management of patients with glaucoma. The main objective of this study was to determine the prevalence of glaucoma in first degree relatives of Primary open angle glaucoma (POAG) and Primary angle closure glaucoma (PACG) patients. Glaucoma awareness among the first degree relatives was also assessed. Materials and methods: A cross sectional hospital based study was designed to examine and diagnose glaucoma among first degree relatives of patients with POAG and PACG, attending the outpatient department at Ramlal Golchha Eye Hospital in the Eastern region of Nepal from June 2016 to May 2017. A comprehensive eye examination was conducted by a glaucoma specialist at the hospital. All subjects underwent vision screening, refraction, slit lamp biomicroscopy, intraocular pressure (IOP) measurement, gonioscopy and a dilated fundus examination. All glaucoma suspects and those diagnosed with glaucoma were enrolled for visual field examination.Results: Two hundred and twenty-seven first degree relatives of 72 patients were invited for the examination. Out of 227 individuals, 131 (males 67.94%, females 32.06%) agreed to participate in the study. A total of 23 (17.56%) individuals were diagnosed with glaucoma, 10 (43.47%) as POAG and 13 (56.52%) as PACG. Fourteen percent of parents, 22% of siblings and 9% of off-springs had open angle glaucoma. Among 13 PACG participants, 26.08% of parents, 26.08% of siblings and 4.34% of off-springs had angle closure glaucoma. Awareness among first degree relatives diagnosed with glaucoma was 21.74%. Conclusion: The prevalence of glaucoma among first degree relatives of glaucoma patients was higher than individuals without family history of glaucoma. Promoting awareness on glaucoma and the timely screening of family members can lead to early detection and prevention of blindness from the disease.

Comparison of Ocular Biometry between Primary Open Angle Glaucoma Patients and Normal subjects

Introduction: Glaucoma is one of the major causes of irreversible blindness. In Nepal, the most common type of Glaucoma seen is Primary Open Angle Glaucoma. There are many risk factors associated with Primary Open Angle Glaucoma. The main objective of the study was to compare ocular biometric parameters in patients diagnosed with Primary Open Angle Glaucoma and age matched controls. Material and methods: This is a hospital based cross sectional study done at Mechi Eye Hospital. The study included 137 cases of Primary Open Angle Glaucoma and 75 normal individuals as control. Axial length (AL), anterior chamber depth (ACD), Keratometry ‘K’ value and Central Corneal Thickness (CCT) were measured. Mann – Whitney U test was used for statistical analysis. Results: Mean age in Primary Open Angle Glaucoma group was (55.25 ± 10.16 years) and in the control group was (60.96 ± 10.91 years). Axial length in the Primary Open Angle Glaucoma group (23.16 ±1.19 mm) was deeper as compared to the control group (22.69 ±0.89 mm), the difference was statistically significant (p<0.001). Anterior chamber depth (ACD) was statistically deeper in the Primary Open Angle Glaucoma group (3.05 ±0.51 mm) as compared to the control group (2.86 ±0.46 mm), (p<0.01). Central corneal thickness (CCT) was thinner in the Primary Open Angle Glaucoma group (519.5 ±36.25 um) as compared to the control group (525.40 ±37.77 um) but the difference was not found to be statistically significant (p<0.19). K value in Primary Open Angle Glaucoma (7.54 ±0.41mm) was higher than age-matched controls (7.58 ± 0.33mm) but the difference was not statistically significant (p<0.79). Conclusion: Patients with Primary Open Angle Glaucoma had longer Axial length (AL) and deeper Anterior chamber depth (ACD) as compared to normal individuals.

Anatomical and Functional Success Analysis of Lacrimal Canalicular Lacerations Repaired with Bicanalicular Stents in a Tertiary Referral Teaching Center in Mexico

Introduction: Functional and anatomical success after canalicular laceration repair using only Crawford bicanalicular stents was evaluated in a ophthalmological teaching center. The objective of this study was to evaluate functional and anatomical success after canalicular laceration repair using Crawford bicanalicular stents. Materials and methods: Records of patients with canalicular laceration repair performed from 2010 to 2019 at Ophthalmology Institute Conde de Valenciana in Mexico City were reviewed. Demographic data, injury mechanism and complications were recorded. Anatomical success was assessed with canalicular irrigation and functional success was evaluated using Munk score. Phi correlation coefficient was used to compare the correlation between epiphora and lack of permeability of injured canaliculus and the presence of complications at 6th month postoperative visit. Results: Two-hundred eight patients with lacrimal canalicular injury reconstruction were documented during the study period. The most common age of presentation and etiology was from 21 to 30 years old and injury with a sharp object, respectively. 96 patients were included for the correlation analysis. At 6th month, anatomical success was found in 75% and functional success was found in 77.8%. A statistically significant and directly proportional linear was found between the presence of epiphora and lack of permeability of injured canaliculus, (rφ 0.76, p <0.05) and between the presence of epiphora and postoperative complications, (rφ 0.509, p <0.05). Conclusion: Crawford bicanalicular stents are a valid and accessible option for canalicular laceration repair. Our success rate of lacrimal canalicular lacerations repaired with bicanalicular stents in a Mexican teaching hospital matches worldwide literature. Factors involved in the functional and anatomical success of the reconstruction include presence of postoperative complications and permeability of canaliculus after surgery.

Barriers to Cataract Surgery in Peri-urban Regions of Eastern Nepal

Introduction: Despite cataract being a condition easily treated by surgery, it continues to be the leading cause of blindness worldwide (35.15%). In Nepal, the proportion of blindness due to cataract is much higher, with cataract accounting for 62.2% of all blindness. An effective method of decreasing this figure is by addressing the main barriers preventing people from accessing cataract surgery. Knowing that these barriers are dynamic and region-specific, our study aimed to determine the current barriers faced in Morang and Sunsari districts of Nepal. Materials and methods: Subjects were patients attending a cataract surgical camp, who had unilateral or bilateral blindness due to cataract. A survey was administered to determine the factors contributing to their delay in receiving treatment for cataract. Furthermore, the percentages of male and female subjects with bilateral blindness receiving treatment at the surgical camp were compared to the percentage of males and females with bilateral blindness due to cataract in Morang and Sunsari. Results: The main barriers for both subjects with unilateral and bilateral blindness were the inability to afford treatment and the lack of awareness that cataract is treatable. Additionally, although more women were bilaterally blind due to cataract compared to men in Morang and Sunsari, men were more likely to receive treatment compared to women. Conclusion: Policies targeted at reducing costs of surgery, increasing the awareness of cataract surgery, and specifically increasing women’s access to cataract surgery would be effective methods in decreasing the prevalence of avoidable blindness due to cataract in Morang and Sunsari.