ABSTRACT

Background: Myopia or near sightedness is a very common refractive error seen among children and adults. It is an eye disorder where the light focuses in front of the retina  ,causing distant objects to be blurred while the near objects appear normal. High myopia can be visually debilitating and affect one’s day to day activities. Aim: To analyse the efficacy and visual  outcome of using posterior chamber phakic intraocular lens- refractive implantable lens(RIL) for high myopic patients. Methods: A prospective study  was conducted in a tertiary care centre. The study included 50 eyes of 34 patients. The preoperative best corrected visual acuity was compared with their post operative uncorrected visual acuity along with the IOP changes, endothelial cell loss and associated complications. The whole database was recorded and statistically analysed. Results: Out of the 50 eyes that were taken for the study,94% of the eyes had uncorrected visual acuity equal to better than preoperative best corrected visual acuity and  34 %of the eyes had a visual acuity of 6/6. The intraocular pressure was less than 20mmHg postoperatively in all patients. No incidence of cataract was observed in this study. Conclusion: It is found that the visual outcome was favourable and satisfactory after RIL implantation.

Keywords: Myopia, phakic intraocular lens, refractive implantable lens

INTRODUCTION

Myopia is one of the most common refractive error worldwide. Its prevalence can vary with age , gender and ethnicity. However it has been seen that high myopia can be very debilitating visually and affect one’ s daily activities. There are multiple treatment options to correct high myopia like photorefractive keratectomy, laser assisted subepithelial keratectomy, laser in situ keratomileuis(LASIK) and epi- LASIK. However the recent modality of treatment is with phakic intraocular lens.(PIOL)

PIOL has become very popular recently. It was first introduced by Strampelli and later modified by Fyodorov. In the beginning anterior chamber (AC) PIOLs were used, later iris fixated lens were developed2. But recently posterior chamber PIOLs were introduced and it showed great efficacy, safety and most importantly patient satisfaction.  

The PIOL is placed between the iris and the natural crystalline lens in the ciliary sulcus. Compared to LASIK, PIOL implantation  causes lesser higher order aberrations and the contrast sensitivity and visual performance  appears to be superior than LASIK. They can also be used in the patients who are not fit for LASIK and those with mild keratoconus1.

Various PIOL s are available in the market but for our study we have used Refractive implantable lens (RIL) which is introduced by an Indian company, in order to study its efficacy and visual outcome in high myopic patients.

METHODS AND MATERIALS

Patients were selected from the OPD department of Ophthalmology, Chinmaya Mission Hopsital,Bangalore. Verbal consent was taken from the subjects. Prior to the study ,ethical clearance was obtained from the Institutional Ethics Committee.

Sample Size: The study material consisted of 50 eyes of 34 patients.

Inclusion Criteria:

1.Age >18 years

2.Stable refraction for one year

3.Patients having myopia >-6.00D

4.Iridocorneal angle >30°

5.AC depth>2.7 mm

6.Endothelial cell count >2500 cells/mm 2

7.Central corneal thickness > 0.400 mm

Exclusion Criteria:  Patients withcataract, glaucoma, recurrent uveitis, previous ocular surgeries, anterior segment diseases, macular/ retinal pathology, and  connective tissue diseases were contraindicated for the study.

Type of study: A cross sectional descriptive study for a period of 12 months

PROCEDURE:

A detailed history of the selected patients, their best corrected visual acuity(BCVA) using Snellen ‘s  chart, slit lamp examination, retinoscopy, gonioscopy, endothelial cell count with specular microscopy, central cornel thickness with pachymetry, iris diameter-horizontal and vertical with pentacam, white- white distance with a digital calliper, ,A san and B scan ultrasound and anterior segment optical coherence tomography were done.

Under local anaesthesia, a main incision of size 2.8 -3.2mm and two side port incisions are made. The cartridge is loaded with the lens and inserted through the main incision with the bevel down. The injector is placed superficially and the PIOL is injected into the AC which is filled with visco. The leading hole of the lens should be on the right. The lens is then rotated horizontally  with the blunt tip of the manipulator,taking care not to damage the anterior capsule of lens or the iris. The pupil is then contricted with intracameral pilocarpine and a peripheral iridectomy is done superiorly. The visco is then removed and the AC is hydrated.

During the follow up period the distance between the PIOL and endothelium is measured using the AS –OCT, which ranges between 350 to 600 mm.

Statistical analysis was done using the Statistical Package for Social Sciences (SPSS version 12.0). Chi square test and t- student test was used to compare the variables. Significance was considered if P<0.05

RESULTS

The study was conducted on 50 eyes of 34 patients, the average age being 25.56 years. 52% were male and 48% were female patients.

Figure 1 shows the preoperative best corrected visual acuity(BCVA) of the patients that were taken for our study. Preoperatively 4% eyes had  Best Corrected Visual acuity(BCVA)  of 6/36, 6% eyes had 6/24, 32% eyes had 6/18, 18% eyes had 6/12, 24% eyes had 6/9 and 16% eyes had 6/6

Figure 2 shows the uncorrected visual acuity(UCVA) of the patients after the PIOL implantatation. Post op34% had UCVA of 6/6, 36% had 6/9, 14% had 6/12, 10% had 6/18  and 6% had 6/24. In the 1st week- post op UCVA was less then pre op BCVA in 5% of eyes, whereas 95% of the eyes had equal or better UCVA than preop BCVA. At the end of 3rd month all eyes 100% showed equal or better UCVA then preoperative BCVA.

Figure 3 shows the spherical equivalence preoperatively. Preoperatively spherical equivalence for 16% of eyes was between -6.00D to -10.00 D, 51%  had between -10.25D—15.00D, 33% between -15.25D to – 20.00 D.

Figure 4 shows the residual spherical refraction after the lens implanataion. 3 months postoperatively, 84% had   zero spherical error , 14% had -0.50 D and 2% had between -0.50D to -0.75D

Preoperatively 86% of eyes had an AC depth between 2.5mm to 3.2 mm and 14 % had above 3.2 mm. Post op- 95% of eyes had AC depth between 2.4mm to 2.8 mm and 5 % had above 2.8 mm.AC depth showed a statistically significant reduction , but not below 2.4 mm(P<0.01).

Preoperatively 62% of eyes had IOP between 10-15 mm Hg and 34% between 16 to 20 mmHg . Post operatively in the 1 st week 46 % had  IOP between  10-15 mm Hg , 54% between 16-20mm Hg. However during the  3rd week and 3 rd month  postoperatively  all eyes had IOP <20 mmHg.

Postoperatively 96% of eyes had a reduction in  endothelial cell count  of<100 cells/mm2- which was  insignificant. In the 1st week,3 rd week and 3 rd month post operatively all patients had a vaulting ranging between 300 to 750 µ

Figure 1 shows the preoperative best corrected visual acuity(BCVA) of patients taken for the study.

Figure 2 shows the post operative uncorrected visual acuity(UCVA) of patients after lens implantation.

Figure 3 shows the spherical equivalence of the eyes preoperatively.

Figure 4 shows the residual spherical equivalence after lens implantation

.

DISCUSSION

RIL is an Indian PIOL made of hydrophilic acrylic material. They have 4 peripheral holes that help in the aqueous flow. They have a leading hole on the right and a trailing hole on the left which helps during implantation. The optic diameter ranges between 4.50 mm to 5.80 mm and the overall size ranges between 11.50mm to 13.25mm. It has a refractive index of 1.460.

In our study 50 eyes of 34 patients were taken having a mean age of 25.56 yrs. Perzcamtrodi et al in his study had a mean postoperative spherical equivalent of -1.00D ± 0.50 D, whereas our study showed a mean postoperative SE power of -0.50D ± 1.00D.

 In this study it was seen that the postoperative UCVA of 94% eyes were better than preoperative BCVA and 6% eyes were same as preoperative BCVA. In Uusitalo et al study, 71.5% had equal or better than preoperative BCVA4 and  Ju et al  study showed 96% had equal or better than preoperative BCVA.

 There was no incidence of cataract in our study.But in Lee et al study it was seen that 2% and in Uusitalo et al 2.6%  and in Perzcamtrodi et al  12% of eyes had cataract3.

In this study there was no rise in IOP, whereas in Ju et al study  it showed an increase in 8% of eyes and Le et al observed in 2% of eyes6.

 In our study it showed that there was  3.5% decrease in the endothelial cell count but in Lee et al study there was an 8% decrease in the endothelial cells. Our study showed that the mean preoperative AC depth was 3.06 mm and postoperative depth was 2.57 mm. There was a significant decrease in the AC depth but it was not <2.4 mm. Ju et al also noted a decrease in AC depth from 3.5 mm to 2.6mm.

Pupillary block was one of the complications noted in Uusitalo et al study whereas pigment dispersion was observed in 5 % of eyes in Ju et al study5. Other complications observed were iritis and retinal detachment which was not seen in our study7.

CONCLUSION

It can be concluded that posterior chamber PIOLs (RIL) are a safe , effective and  reliable option for the treatment of high refractive error in myopic patients. The complications like cataract development, AC depth and IOP changes were not significant. It is important that these patients are regularly monitored on  a long term basis.

CONFLICTS OF INTEREST

There are no conflicts of interest.

BIBLIOGRAPHY

1. JuY,GaoXw,RenB. Posterior chamber phakic intraocular lens implanatation for high myopia. Int J ophthalmology. 2013;vol(6): 831-835

2.Pinenda- Fernandez A,JaramilloJ,Vargas J. Phakic posterior chamber intraocular lens for high myopia. J cataract refract surg .2004;vol(20): 2277-2283

3. Kamiya K, Igarashi A ,Shimizu K. Visual performance after posterior chamber phakic intraocular lens. Am J ophthalmol. 2012;vol( 153): 1178-1860

4.Usitalo RJ, Aine E, Sen NH. Implantable contact lens for high myopia. J cataract refract surg. 2002;vol( 28) 29-35.

5.Hassaballa Ma, Mackay T. Phakic intraocular lens outcomes and complications. Artisan vs. Visian ICL 2011;vol( 25): 1365-1370

6.Lee J, Kim Y. Long term clinical results of posterior chamber phakic intraocular lens implantation to correct myopia. Clin Exp Ophthalmol.2016;vol( 44): 481-487

7. Alfonso JF,Baamonde B. Posterior chamber collagen copolymer phakic intraocular lenses to correct myopia. J cataract Refract Surg. 2011;vol( 37): 873-880

ABSTRACT

Nowadays intraoral local anaesthesia has been widely used to perform various dental procedures. The complications associated with it are very minimal though some of the commonly seen ocular complications include meiosis, nystagmus, diplopia, ptosis, amaurosis. In our case study a 30 year old female came to eye OPD with complaints of reduced vision. She had undergone a dental procedure which was done under intra oral local anaesthesia one week prior, following which her vision started deteriorating. Though various mechanisms have been suggested for the cause of diminution of vision post intra oral local anaesthesia, the exact aetiology still remains unknown. In our study intravascular injection of epinephrine which led to a cilioretinal artery occlusion could be the possible cause. The patient was followed up regularly and four weeks later she had recovered complete vision successfully.

Keywords: intraoral local anaesthesia, arterial occlusion.

INTRODUCTION

In order to perform painless dental procedures intraoral local anaesthesia was very widely used. Rarely the administration of a local anaesthesia intra orally can cause ocular complications. It is noted that complications like ptosis, meiosis, amaurosis , diplopia have occurred following therapeutic injections  given around the nose, lips and eye.

 The first case of blindness following intranasal injection of warm paraffin was noted in the early 90’s and reported by Sir Von Bahr. Many cases of decreased vision have been reported following a maxillary nerve block. However in most of the cases the symptoms developed immediately after the administration of the drug and lasted for a few hours. A case of complete blindness following the injection is extremely rare. Though various theories have been proposed to better understand the cause of ocular complications post intraoral local anaesthesia,the  exact aetiology still remains unclear.

CASE REPORT

A 30 year old female came to eye OPD with complaints of reduced vision the left eye since 1 week. On further investigation it was found that she underwent a dental procedure of the left upper maxillary canine exactly one week ago. She was given intraoral local anaesthesia of lignocaine hydrochloride and epinephrine( 1:100,000 )prior to the procedure.  Immediately after the procedure the patient started developing a headache and a gradual loss of vision. She also complained of seeing flashes of light occasionally. There was no history of nausea or photophobia and phonophobia. No significant medical history or surgical history or any previous ocular surgeries or trauma in the past.

On examination the patient’s vision  was 20/25(OS) and 20/20 (OD). The intraocular pressure was measured with applanation tonometer and was 12 mmHg in both eyes. Colour vision was slightly abnormal in the left eye. A relative afferent pupillary defect was noted in the left eye. The extra ocular movements were full in all directions with no evidence of internuclear ophthalmolegia. There were no signs of inflammation, no cells in the anterior chamber or vitreous.

 The visual field test was done and it showed a relative paracentral scotoma in the left eye and  normal field  in the right eye. A dilated fundus examination was done and it showed swelling of the optic disc along with cotton wool spots, hard exudates near the papillomacular bundle. The right eye fundus was normal. Optical coherence tomography was done (OCT) and it showed hypo perfusion in the superficial and deep retinal capillary plexus in the affected areas.

Figure  a: Fundus picture of the left eye showing a swollen optic disc with blurred disc margins along with cotton wool spots near the macular region. 

Figure b: optical coherence angiogram showing capillary dropout along the superficial and deep retinal plexus in the macular region.

A complete blood examination was then done and it normal. The C reactive protein, glucose, liver function test, renal function test, cholesterol, ESR was well within the normal limits. No past history of any cardiovascular diseases.

 A probable diagnosis of cilioretinal artery occlusion was made. The patient was started on 100 Mg of aspirin as a prophylactic measure and was asked to come for a follow up after 4 weeks. The patient showed a significant improvement and the vision improved to 20/20. Fundus examination showed a normal optic disc with very few hard exudates. OCT was also done and was normal except for a thinning of the outer retinal layer near the papillomacular bundle.

DISCUSSION

The cilioretinal artery arises from the short posterior ciliary artery. It is reported to be present in 50% of the eyes and can vary in size, number, distribution and point of origin. Isolated cilioretinal artery occlusion can occur but has a very good prognosis with 90% of the eyes returning to a 6/12 vision and over 60% returning to 6/6. In cases of retinal vascular occlusion, the presence of a cilioretinal artery can play a vital role as they supply the papillomacular bundle and macular region of the retina.

 Epinephrine is very commonly used in dental procedures. Epinephrine causes vasoconstriction and provides a bloodless field for the procedure and also prolongs the duration of the anaesthetic effect. Epinephrine when it reaches the orbit can cause vasoconstriction of the ophthalmic and ciliary arteries. But the cilioretinal arteries are more vulnerable due to their small diameters.

The presence of hard exudates led us to a differential diagnosis of malignant hypertensive retinopathy. The clinical presentation of hypertensive retinopathy is usually bilateral and unilateral cases are very rare. However vessel changes such as arteriovenous nipping, silver wiring typical of hypertensive retinopathy were absent. Clinically the blood pressure was well within the normal limits.

Presence of emboli was another differential. In such cases permanent visual loss can occur after an arterial occlusion due to emboli. In our case the patient started developing the symptoms around 5 to 7 minutes after the injection but she started improving gradually with 20/20 at the end of 4 weeks. A complete cardiovascular evaluation was also done and nothing significant was detected.

There was no history of previous attacks of migraine in the past or a similar family history. During migraine the vasospasm can also lead to a permanent retinal artery occlusion.

A number of theories were put forward to understand the mechanism by which the anaesthetic agent reaches the orbit. Some of them being diffusion, inadvertent needle penetration of the orbit, venous injection and retrograde arterial injection. One of the studies showed that retrograde flow of the epinephrine through the maxillary artery was one of the causes for reduced vision.  

In our study it is considered that the inadvertent administration of epinephrine led to vasospasm and insufficient blood flow to the cilioretinal artery causing a transient loss of vision. The onset of action of epinephrine is between 1 to 3 minutes  and our patient started developing the symptoms within 5 to 7 minutes. 

CONCLUSION.

Vasoconstriction of the cilioretinal artery following the injection of epinephrine is a very dreadful complication. In order to avoid such complication, it is important to aspirate before injection, or inject small quantities of the drug along with moving the needle while injecting to avoid accumulation of large quantities of epinephrine at one particular site. Hence it is important hat clinicians should be aware of this complication and take the necessary precautions.

BIBLIOGRAPHY

  1. Steenen SA, Dubois L .Ophthalmologic complications after intra oral local anaesthesia : a case report and review of literature . Oral Surg. 2012;vol( 113): 1-5
  2. Von Bahr. Multiple embolisms in the fundus of an eye after injection in the scalp. Acta Ophthalmol. 1963;vol( 41): 85-91
  3. Boynes SG, Echeverria Z. Ocular complications  associated with local anaesthesia administration in dentistry. Dent Clin North. 2010;vol(54): 677-686
  4. Von Arx, Lozanoff S. Ophthalmic complications and local anaesthesia. Swiss Dent J. 2014;vol( 124): 1189-1203
  5. Hayreh S S. The cilio retinal arteries. Br J Ophthalmol. 1963;vol( 47): 71-89
  6. Said Yekta- Michael S, Stein MJ. Evaluation of the anaesthetic effect of epinephrine. Head Face Med. 2015;vol(11): 2
  7. Sott Db, Jebson PJ. Factors affecting plasma levels of lignocaine and prilocaine .Br J Anaesth. 1972;vol( 44 ):1040-1049

Abstract

Transient loss of vision after using a smart phone is a temporary phenomenon where in a person has loss of vision in one eye for a short duration after prolonged exposure to the smart phone in the dark. This phenomenon is attributed to the bleaching of the retinal pigments. It is important to be aware of this condition and careful history needs to be taken from the patient before the patient is started on lifelong treatment.

KEYWORDS.  Smart phone, loss of vision

CASE 1:

 A 30 year old male patient had come to our OPD with complaints of transient loss of vision in his right eye. When asked in detail he revealed that he was lying on his left side and was looking at his smart phone at night for more than one hour. When the lights went off he was unable to see anything through his right eye. But however after a period of 20 minutes it stated improving and he was slowly able to see with his right eye.

CASE 2

A 40 year old lady said that she had loss of vision in her right eye at night which lasted for close to 30 minutes. During this period she could  see various shapes floating around. Prior to that, she was using her phone for close to 45 minutes. Since she was clueless and worried, she immediately closed her eyes and went to sleep and was happy to regain her vision the next day.

Both these individuals when consulted a physician diagnosed it as a possible cause of transient ischemic attack and was advised to start on aspirin and statins.

Another lady aged 60 years had a similar episode of transient unilateral loss of vision twice and she failed to report the usage of phone prior to the episode as she considered it as irrelevant. Later she was diagnosed as a case of multiple sclerosis and was started on medications.

All these patients had visual symptoms during the night after looking at their smart phones for a very long duration. Transient smart phone blindness was first discovered in the year 2016. There was temporary loss of vision which occurred at night after prolonged usage of smart phones which was due to the differential bleaching of the photopigment . However the symptoms resolved after a couple of minutes and this was due to the scotopic recovery after the bleach.

A study done showed that viewing the smart phone monocularly  at an arm’s length for several hours did lead to blurring of vision which recovered  after several minutes. Hence it shows that it is very important to assess the history if they have had exposure to smart phones in the dark for a long period. If not assessed ,it can be misdiagnosed as a case of a TIA or MS. This can help the patients from being started on unwanted medications and just a simple word of reassurance would be enough.

 Since smart phones have become an essential commodity in one’s life this unique phenomenon should always be kept in mind. Some of the other complications due to the use of smart phones is traffic accidents caused by the typical smart phone zombies and nomophobia or a sort of anxiety disorder of being out of cellular phone contact. It seems to have a very large population as shown by certain studies.

Other dangerous consequences due to improper use of smart phones include traffic accidents caused by “smartphone zombies” and selfie‑related injuries and deaths. Half of selfie‑related deaths in 2015 happened in India. Some countries have traffic lights on the road at pedestrian crossings and have dedicated pavements for smartphone zombies .

Bibliography

References 1. Alim‑Marvasti A, Bi W, Mahroo OA, Barbur JL, Plant GT. Transient smartphone “Blindness”. N Engl J Med 2016;374:2502‑4. 2. Irshad F, Adhiyaman V. Transient smartphone blindness. Can J Ophthalmol 2017;52:e107‑8. 3. Sathiamoorthi S, Wingerchuk DM. Transient smartphone blindness: Relevance to misdiagnosis in neurologic practice. Neurology 2017;88:809‑10.

MRIDULA V AMARNATH

Chinmaya Mission Hospital,Bangalore,Karnataka

*Corresponding author email: [email protected]

ABSTRACT

A 10 year old female child came to the OPD with complaints of decreased vision. She is a known case of lupus nephritis. Though her vision could be improved after refraction in both eyes, more shocking revelation was the deposition of   a dense yellow brown deposit of Kayser Fleischer(KF) ring and a sunflower cataract. She was further carried out various diagnostic tests for Wilson’s disease and was immediately treated for the same. Unfortunately the child died within two months due to hepatic encephalopathy and sepsis. Hence it is important to understand the significance of early detection of KF ring which is a definite and a long standing indicator of neurological Wilson disease.

Keywords: Kayser Fleischer ring, Wilson disease


INTRODUCTION

Wilson’s disease also known as hepatic degeneration and progressive lenticular degeneration is a medical condition having a wide clinical spectrum. It tends to affect 1 in 30,000 people worldwide. It is a very rare genetic disorder where the liver fails to remove the excess copper, which eventually tends to build up in organs like the brain, liver and eye and cause various abnormalities. Kayser Fleischer ring is one of the earliest manifestations of Wilson s disease. Early and prompt clinical diagnose of the KF ring is extremely crucial and life saving for the patient.

CASE REPORT

A 10 year old female child came to the eye OPD with complaints of decreased vision since 15 days. She was diagnosed as a case of lupus nephritis when she developed symptoms of hematuria, facial puffiness and pedal edema on and off. After blood investigations, urine routine examination and ultrasound of the kidney, ureter and bladder it was confirmed to be a case lupus nephritis with positive ANA.

Her uncorrected vision in her right and left eye were 6/36 and 6/60 respectively and she improved after refraction to 6/9 and 6 / 12 respectively in the right and left eye. On examination of the anterior segment, the cornea showed a very dense yellow brown KF ring in all the quadrants. After dilating the pupil ,a central disc of golden brown deposits with spokes appearance over the anterior lens capsule suggested that of a sunflower cataract which could be the  reason for her decrease in vision in both eyes. Fundus examination was done and it appeared normal in both the eyes.

Based on the above findings the child was assessed further for Wilson’s disease and it showed a low ceruloplasmin level and a high urinary copper level. She was immediately treated with steroids, mycophenolate mofetil , penicillamine and calcium

 Though initially in the first month the child responded well to the treatment ,but gradually during the follow up there were alterations in the blood parameters. The child started developing hypertension, behavioral changes , dystonia, dysphagia. She soon developed focal seizures which suggested significant hepatic encephalopathy  and it eventually led to the death of the child.

DISCUSSION

Wilson’s disease is a rare inherited autosomal recessive disorder. It occurs due to mutation in the ATP7B gene that mainly encodes for copper transporting P type adenosine triphosphate expressed in the liver and kidney2. Copper which gets absorbed from food through albumin in the small intestine reaches the liver cells with the help of membrane transporters. The gene ATP7B helps in the binding of copper to ceruloplasmin and the excess of copper gets eliminated into the bile. Impairment in the biliary excretion leads to an improper accumulation of copper into the extra hepatic sites like the brain, kidney, cornea and heart which lead to further manifestations. Most people are diagnosed between the age group of 5 to 35 years.

Clinical features of Wilson‘s disease don’t appear until the copper builds up in the brain liver and other organs. The features vary depending on the body part it is affected with.  Neurological manifestations like dystonia, tremors, dysarthria are common4. They may also have fatigue, lack of appetite, abdominal pain, accumulation of fluid in the legs and abdomen. Uncontrolled movements and stiffness of the muscles , yellowish discoloration of the skin and the conjunctiva of the eye are also seen . Deposition of yellowish brown pigment around the cornea called the Kayser Fleischer ring along with sunflower cataract is a very common finding. Hemolytic anemia, thrombocytopenia, renal tubular dysfunction, hypercalciuria, hyperphosphaturia, hypokalemia, cardiovascular dysfunction are also seen.

Figure 1:KF ring

http://www.tnoajosr.com/articles/2017/55/4/images/TNOAJOphthalmicSciRes_2017_55_4_307_231127_f1.jpg

Figure 2 : Sunflower Cataract

The diagnostic tests used for the diagnosis of Wilson disease include

  • low serum ceruloplasmin levels(<0.20 g/l, normal is 0.20 -0.40 g/l)
  • 24 hour urinary copper excretion (>100µ g/day or1.0mol/day)
  • 24 hour urinary copper excretion after D penicillamnie(>25mol/day)
  • Hepatic copper level on liver biopsy(>250µg/g dry weight, norml is <50 µg/g dry weight).


It is important for the early recognition of Wilson disease either by clinical ,biochemical or genetic examinations in order to prevent the progression of disease .

Kayser Fleischer ring is a characteristic feature in Wilson disease. It is seen that KF rings are seen in 100 percent of the neurological involvement, 85% in hepatic involvements and about 54% in pre -symptomatic patients. KF ring was first described by a German ophthalmologist by name Bernhard Kayser in the year 1902 and Bruno Fleischer in the year 19031. The ring occurs due to deposition of copper in the descemets membrane of the cornea and limbus. The free copper which is loosely bound to the albumin enters the aqueous humor and then the descemets membrane3.  It starts from the Schwalbe’s line and extends 5 mm on the corneal surface. It initially starts at the superior pole in the form of an arc from the 10 to 2 o clock position followed a similar inferior pole before it finally encircles the cornea.

 A study was done by Inne Et al reported a case of unilateral KF ring in a patient with WD. The patient had a reduced intraocular pressure with decreased aqueous production in the scarred eye. And hence the KF  ring was not manifested. Thus it was postulated that copper deposition is though the aqueous rather than the limbal circulation which was well maintained in the scarred eye. Both passive diffusion and a cellular activity may be responsible for the copper granule deposition.

The KF ring tends to evolve either partially or completely once the patient is started on penicillamine treatment or following a liver transplant. Other disorders where KF ring can be seen are cholestasis, primary biliary cirrhosis5 .Anterior segment optical coherence tomography(AS-OCT) can be used to visualize the KF ring. It appears as an intense hyperreflectivity of the decement membrane in the peripheral cornea. This is a very useful indicator, as if the KF cannot be captured using a slit lamp then a  AS-OCT comes in handy .

Compared to the KF ring, sunflower cataracts are comparatively more rare. They are seen in nearly only 17 % of the patients with Wilson disease. It was first described by Siemerlingg and Oloff in the year 1922. It is mainly seen due to the deposition of copper on the anterior capsule. Posterior capsule tends to be more uniform. Cataract consists of a central disc with folds radiating at the periphery. As reported by Duke Elder the radiating folds are due to the impression of the posterior surface of the iris on the anterior capsule of the lens.

CONCLUSION

This case was reported to understand the importance of KF rings and its significance. A young girl who was a case of lupus nephritis had undergone an ophthalmological examination as she complained of reduced vision during which the KF ring and sunflower cataract was diagnosed. It was a coincidental finding. Prompt referral by the pediatrician and early identification by the ophthalmologist is very crucial and life saving in a case of Wilson s disease. Though KF rings can occur in other conditions but it is most commonly seen in Wilson s disease and the necessary investigations and treatment should be started without any delay. In case of subclinical occurrence of KF ring, an AS -OCT should be done to confirm the above.

BIBLIOGRAPHY

  1. Ramya Silpa,Chidvila V. Wilson disase.Int J Pharma. 2013 ;(2): 18-23
  2. Pfeiffer Rf. Wilson disease.Neurophthal .2007 ;(27): 123-132
  3. Meenkshi Sundaram,Sinha S .Wilson disease- description of 300 patients evaluated over 3 decades. 2007;(86): 112-121
  4. Masud H, Bashir T. Kayser Fleischer ring in Wilson disease. Pak J ophthalmol. 2014;( 30): 112-116
  5. Lin KJ,TSai RT .Ocular manifestations as the initial presentation of Wilson Disease. Tiawan J ophthalmol. 2013 ;(3 )173-175

MRIDULA V AMARNATH

Chinmaya Mission Hospital,Bangalore,Karnataka

*Corresponding author email: [email protected]

Abstract

Encephalocraniocutaneous lipomatosis is a very rare neurocutaneous disorder. A 30 year old lady came to OPD presenting withsmall periocular papules, epibulbarchoriostomasalong with a lipomatous swelling in the frontotemporal area and a patchy alopecia on the scalp1. On imaging of the brain it showed dilatation of the ventricle along with cerebral atrophy of the right side. It was finally diagnosed as a case of encephalocraniocutanouslipomatosis based on the Moog’s criteria.

Keywords: encephalocraniocutaneous lipomatosis, neurocutaneous disorder

INTRODUCTION

Encephalocraniocutaneous lipomatosis is a very rare neurocutaneous disorder. It was first reported by Haberland and Perou in the year 1970 and hence it is also called as the” Haberland syndrome” and “Fishman’s syndrome”. It is very sporadic in nature with ocular manifestations like choriostoma and subcutaneous papules, dermatological features like subcutaneous lipomas and auricular tags and neurological abnormalities like intracranial lipomas.Thesymptom of ECCL very closely resemblesthat of Goldenhar syndrome and Oculocutaneous syndrome and hence its diagnosis can be challenging.

Case report

A 30 year lady came to the eye OPD with complaints of a small growth seen on her right eye. It has been theresince 2 years, asymptomatic and not increasing in size. On further assessment the visual acuity was found to be 6/6 in both the eyes. Examination of the anterior segment showed a diffuse yellow growth both on the nasal and temporal side of the bulbar conjunctiva more in favour of a lipodermoid. There were small papular lesions seen in the periocular area, near the canthus and along the upper lid margin. Fundus examination was done and it revealed a slightlyenlarged disc with a peripapillarystippling. The left eye appeared to be normal.

A diffuse swelling was noticed in the rightfrontotemporal region. It was subcutaneous in nature, measuring 8*6cm ,soft in consistency with well defined margins. The skin over the swelling appeared normal. It resembled a typical lipomatous subcutaneous swelling.

A skin tag was noticed behind the rightear. More importantly the lady developed a tongue shaped patch of alopecia extending from the forehead near the right frontotemporal region.

A C T scan of the brain was done and it showed dilatation of the right lateral ventricle along with increased CSF fluid.

Acomplete cardiac and neurological evaluation was done and it was normal. The lady had a normal birth history, with normal developmental milestones. No history of seizures in the past

Figure 1 : small papular lesions in the periocular area along with diffuse yellow  growth on the nasal and bulbar conjunctiva .

Figure 2: diffuse swelling in the right fronto temporal region along witha tongue shaped patch of alopecia.

MODIFIED MOOG’S CRITERIA FOR DIAGNOSING ENCEPHALOCRANIOCUTANEOUS LIPOMATOSIS.

SYSTEMMAJOR CRITERIAMINOR CRITERIA
EyeChoriostoma with or withour associated abnormalities1.corneal or anterior chamber anomalies 2. ocular or eyelid coloboma 3. calcification of the globe.
SkinProven nevus psiloliparius(NP)2.Probable NP and ≥one of the minor criteria2-5≥ two of the minor criteria 2- 51.possible NP 2. patchy non scarring alopecia 3.subcutaneous lipomas 4.Focal skin aplasia/hypoplasia 5.skin tags on eyelids
Central nervous systemIntracranial lipomasIntraspinallipomasTwo of the minor criteria1.abnormal intracranial vessels 2.arachnoid cyst /abnormality of meninges 3.completet /partial atrophy of hemisphere 4.a porencephalic cyst 5.dilated ventricles 6.calcification
Others1 .Jaw tumours 2.Coarctation of aorta 3.Multiple bone cysts 

APPLICATION OF DIAGNOSTIC CRITERIA

Definite caseInvolvement of three systems with major criteria >2Involvement of three systems,proven NP or possible NP and >1 minor skin criteria 2-5Involvement of two systems with major criteria >2,one of which is proven NP or possible NP along with  >1 minor skin criteria 2-5  
Probable caseInvolvement of two systems, major criteria in bothTwo systems involved, proven or possible NP.

Based on Moog’s modified criteria4 our patient had one major eye criteria(epibulbarchoriostoma), one major skin criteria(three minor criteria- alopecia, lipomatous swelling in the fronto temporal  region, auricular tags)and one major CNS  criteria( two minor criteria- dilatation of the lateral ventricle, cerebral hemi atrophy).

The lady was followed up again after one year and then after 3 years .The vision still remained 6/6 in both eyes. The anterior and posterior segment findings were thesame as the initial presentation. Eye pressure was measured and as foundto be 15 mm Hg and 12 mm Hg in theright and left eye respectively. Dermatological findings were similar. Thepatientdid not have any systemic abnormalities andwas leading a normal life.

DISCUSSION

ECCL is a very rareneurocutaneous  disorder with varied ocular , dermatological and neurological abnormalities. Though the exact aetiology still remains unknown,studies have suggested that a mosaic rat sarcoma gene (RAS)opathy could be considered3. A group of developmental disorders caused by mutation in the RAS subfamily- mitogen activated protein kinase pathway was responsible. It has also been reported that mutation in thegene encoding for the fibroblast growth factor receptor 1is also a possibility.

It has ocular, dermatological and neurological manifestations of which ocular abnormalities are most common. It includes epibulbarchoriostomas and small periocular skin tags2. Apart from these other findings includeeye lid coloboma, high myopia, pallor of the optic nerve, hypertelorism, epicanthus inversus, , cicatricialectropion of the  eye lid, proptosis due to fatty infiltration of the orbit.

Skin manifestations include subcutaneous lipomas, an area of non scarring alopecia,lipomas in the neck,lumbar,axillaryregion. Periocular papules have also been noted. CNS abnormalities include intracranial lipomas, intraspinallipomas, intracranial cysts, hydrocephalous, atrophy of the cerebral hemispheres.

There have been reports where ECCL have been diagnosed as Goldenhar syndrome until the neurological manifestations were to be seen. If this condition is diagnosed early it will help us to rule out co exiting systemic abnormalities and also start genetic counselling at the earliest5.

In our case the patient was diagnosed to have ECCL based on Moogs’s criteria.  Shewas able to lead  a normal life and do her day to day life activities. Hence it is important for physicians to consider and keep in mind a case of ECCL ,which is very rare though , in patients having mainly alopecia and epibulbardermoids.

BIBLIOGRAPHY

  1. Bieser S ,Reis M et al. Pilocytic astrocytoma in a 3 month old patient with ECCL-  a case study. Am J med. 2015 ;(167 A) : 878-881
  2. Moog U .Encephalocraniocutaneous lipomatosis. J med Genet. 2009;( 46 ):721-729
  3. Boppudi S, HoveHB, Percin EF. Specific mosaic KRAS mutation in ECCL. Clin Genet. 2016;( 90):334-342
  4. Parazzini C ,Tiriulzi F. ECCL – a complete neuroradiologic evaluation .Am J Neuroradiol.1999;(20 ):173-176
  5. Almer Z, Vishnevskia-Dai. Encephalocraniocutaneous lipomatosis. Indian J ophthalmol.2003;( 22 ):389-390

MRIDULA V AMARNATH

Chinmaya Mission Hospital,Bangalore,Karnataka

*Corresponding author email: [email protected]

ABSTRACT

Peribulbar anaesthesia is the most commonly used anaesthetic technique in most of the intraocular surgeries especially in glaucoma and vitreoretinal surgeries. This is a case study of  a 70 year old man who underwent a combined glaucoma and cataract surgery under Peribulbar anaesthesia and developed loss of consciousness and untoward complications of brainstem anaesthesia. Though the complications are very rare with Peribulbar anaesthesia, one need to be extremely careful and should be equipped with the necessary facilities to tackle the life threatening implications’ if any occurs in the operation theatre.

KEYWORDS: Peribulbar anaesthesia, ocular surgeries

INTRODUCTION

Surgeries in ophthalmology are performed under a wide range of anaesthesia techniques. In 1884 it was Sir Carl Koller who used cocaine as a topical anaesthetic agent for the ocular surgery. Later Knapp introduced retro bulbar anaesthesia. However in the late 1980s Sir Davis and Mandel discovered the Peribulbar anaesthesia technique. Since then it has been the most popular and successful mode of anaesthesia for a wide variety of ocular surgeries1. Peribulbar anaesthesia has several advantage when compared to retro bulbar  as it is less painful, less rise in the intraocular pressure, avoidance of a facial block  and most importantly there is minimum sight and life threatening complications like retro bulbar haemorrhage, damage to optic nerve which can cause loss of vision, oculocardiac reflex and brain stem anaesthesia3.In a prospective study done by Davis Mandel in 1994, he reported that though Peribulbar anaesthesia is safe it can still have life threatening complications. The incidence of brain stem anaesthesia was found to be 0.02% after Peribulbar block.

CASE STUDY

A 70 year old male patient came to the eye OPD with complaints of reduced vision. He was not a diabetic and hypertensive and his systemic examination and blood parameters were well within the normal limits.  After a thorough evaluation of the eye, the patient was advised to undergo a phacotrabeculectomy  surgery of the right eye. It was recommended to perform the surgery under the Peribulbar block.

  A 24 gauze  disposable needle was taken for the block. The anaesthetic agent was a mixture of 1 % of Lignocaine and 0.5% Bupivacaine in equal proportion in 50 ml hyaluronidase. The area which had to be injected was cleaned with Povidone iodine. The patient was placed on the OT table in a primary gaze position. The needle was introduced through the skin of the lower lid sulcus in the inferotemporal region. The needle was then inserted in a vertically downward direction along the orbital wall 2.5cm deep. Aspiration was done and the volume of 8 ml of the anaesthetic agent was injected.

It was noted that after close to 5 minutes, the patient’s speech started becoming incoherent and nystagmus was noted in both the eyes. The BP rose to 190/120 mmHg and tachycardia was seen (150 beats/min). The patient was immediately put on an oxygen mask. Since no spontaneous respiration was seen, the anaesthetist intubated the patient and put him on a mechanical ventilator. Simultaneously intravenous injection of Emolol (80mg) was given. In few minutes, the patients BP started to normalise but later it further started dipping down. Injection atropine (1mg) was given to control the hypotension.  After 15 minutes the patient had an episode of a grandmal seizure. Intravenous Midazolam 2mg was given to control the seizure. The patient was monitored extensively and slowly the parameters started to stabilise. After an hour the patient was extubated and was kept under observation. The patient was discharged the following day. The surgery was performed 2 weeks later but this time it was uneventful and the outcome was a great success.

DISCUSSION

When compared to retro bulbar anaesthesia, Peribulbar anaesthesia is a safer technique with fewer complications. Care has to be taken to maintain the ocular positioning of the patients while giving the block. The technique which was followed in our patient was the standard technique according to the literatures.

The doctor was at the head end of the patient while giving the block and the patient was asked to maintain the primary gaze position. However in some cases despite requesting the patients to maintain the primary gaze2, some of them tend to look towards the doctor. As a result the eyeball rolls up and thereby exposing the optic nerve. This makes the nerve more susceptible to the approaching needle. However if the doctor approaches the patient from the side position and patients attempts to look towards the doctor, then in that case there would be rolling down of the eyeball and minimal damage of the optic nerve.

 There are multiple ways and mechanisms as to how local anaesthetic toxicity can occur. In conditions were large volumes of the anaesthetic agent is given , it can lead to light headedness, auditory and visual disturbances, twitching of the facial muscles, seizures followed by respiratory depression and then respiratory arrest. But in our case the volume of the drug taken was very minimal to cause a systemic toxicity. Moreover in our case the symptoms of respiratory failure came ahead of central nervous system excitement or seizures.

In scenarios where  the anaesthetic agent4 is directly  injected into the meningeal coverings of the optic nerve and gains access to the subarachnoid space it can lead to respiratory depression prior to CNS manifestations but then the initial cardiovascular events cannot be explained. But however accidental intra-arterial injection can lead to a rise in the level of the anaesthetic agent in the brain via retrograde flow through the internal carotid artery. And this can cause the cardiovascular manifestations like rise in pulse and BP. This is very temporary as observed in our case. But once the drug starts redistributing out of the brain, the symptoms tends to wane off.

Hence in our case the initial rise in BP and pulse could indicate an inadvertent intra arterial injection of the LA while the respiratory arrest and seizure could be due to injection of LA into the meningeal coverings. In cases of brain stem anaesthesia5 the signs and symptoms will start within 5 to 10 minutes after the block and complete recovery is gained within an hour. In our case study the patient had respiratory complications occurred in less than 5 minutes with altered consciousness. However the patient regained consciousness and was stabilised within an hour.

CONCLUSION

Complications with Peribulbar anaesthesia are quite rare. But it shows that one needs to be handy and keep the operation theatre well equipped along with trained personnel to handle the complications and emergencies.

BIBLIOGRAPHY

  1. Davis DB,Mandel. Posterior Peribulbar anaesthesia: an alternative to retro bulbar anaesthesia. Indian J ophthalmol .1989;(37):59-61
  2. Eke T,Thompson JR. Complications for local anaesthesia for cataract surgery. Br J Ophthalmol. 2007;( 91): 470-475
  3. Hessemer V. Peribulbar anaesthesia vs retrobulbar anaesthesia. J Catact Refract Surg. 1994 ;(20): 327-337
  4. Berde CB, Strichatz. Local anaesthetics. Indian J OPhthalmol.2015;(24): 1047-1052
  5. Gomez RS,Andrade LO. Brainstm anaesthesia. Can J Anaesth.1997;( 44): 732-745.

MRIDULA V AMARNATH

Chinmaya Mission Hospital,Bangalore,Karnataka

*Corresponding author email: [email protected]

ABSTRACT

Aim: To study the association between the incidence, risk factors and treatment outcomes in retinopathy of prematurity.

Methodology: A longitudinal observational study was done among 70 babies who fulfilled the criteria for ROP screening at a tertiary care center.

Results: Out of the 70 babies that were screened at our hospital, 25 babies developed some stage of ROP with 10 babies developing Type 1 ROP. It was noted that the mean birth weight, mean gestational age and the duration of oxygen therapy was significantly associated with the development of ROP (P= 0.045,P<0.001 and P<0.001 respectively). Of the 25 babies with ROP, zone 3 was involved in 14 babies and zone 2 was involved in 11 babies.7 babies had stage 1,10 had stage 2 and 8 babies had stage 3. Of the 25 babies with ROP , 12 babies required treatment with laser photocoagulation and all the babies showed regression of ROP following treatment.

Conclusion: Birth weight less than 1.70 kg, gestational age <32 weeks and oxygen therapy were associated with the development of ROP and ROP regressed with laser treatment,

Keywords: laser photocoagulation, retinopathy of prematurity, laser.

INTRODUCTION:

In a developing country like India, the incidence of ROP is between 38% to 52.3 % among low birth weight babies.  And it is estimated that out of 27 million annual births in India, nearly 2 million babies are less than 2000 grams in weight and are more prone to develop retinopathy of prematurity (ROP). However with the recent advances in the neonatal care, the survival rates have increased significantly.1

ROP is one of the most common causes of blindness in preterm babies. Initially it was considered that oxygen supplementation is an important risk factor for the development of ROP. However ROP can develop without oxygen supplementation and babies who have received oxygen need not necessarily develop ROP2.  This suggested that there are other risk factors that can lead to ROP such as an early gestational age, low birth weight, apnea, hyperoxia , intraventricular haemorrhage, blood transfusions and maternal bleeding. 

Following a severe ROP it can lead to an impaired vision, large refractive error mainly myopia, strabismus and in some cases it can even lead to potential blindness3. Treatment for ROP mainly includes cryotherapy, laser photocoagulation and intravitreal injection of anti VGEF.Though  each one has its own merits and demerits, they have been found to be effective in the regression of ROP4.

AIM: to assess and study the incidence, risk factors and treatment outcomes in ROP.

OBJECTIVES:

1. To assess the incidence of ROP

2. To find out the various factors that influence ROP.

3. To assess the outcome after the treatment of ROP.

METHODOLOGY– A  prospective longitudinal study was done on preterm babies  in the neonatal intensive care unit of our hospital. The study was approved by the ethical committee. Informed consent was taken prior to the study.

Inclusion criteria

Babies with a birth weight less than 1700 g, gestational age <34 weeks at birth, exposure to oxygen, multiple gestations, respiratory distress syndrome , sepsis, intraventricular hemorrhage ,maternal complications like gestational diabetes mellitus, gestational hypertension, ante partum hemorrhage was identified and taken into consideration.

A detailed obstetric history and postnatal course was noted. For fundus evaluation, the pupils were dilated using half strength tropicamide 0.8 % with phenylephrine 5 % eye drops by diluting commercially available drops (AUROMIDE PLUS) with tear substitutes.  The fundus examination was done using indirect ophthalmoscope and with+28 D lens by a vitreoretinal specialist.

High risk babies and babies with features of ROP were monitored at weekly intervals. Those babies who required treatment were subjected to laser photocoagulation with an 810 nm diode laser. The follow up of those babies who underwent treatment were done at weekly interval until the ROP regressed or the retina matured.

The statistical analysis was done using the SPSS version 2.0 .The continuous variables were expressed in terms of percentage, mean, standard deviation and analyzed with the chi square test. Pearson’s correlation was used to compare the risk factors and its effects on the treatment outcome.

RESULTS:

Of the 70 preterm babies that were screened,25(35.7%) babies  develop ROP and 45(64.2%)babies did not develop ROP. The mean birth of the babies with ROP was 1.64±0.53 kg and in babies without ROP was 1.93±0.47 kg The mean gestational age in babies with ROP was  30.87±2.53 weeks and in babies without ROP it was 34.21± 1.79 weeks. The mean duration of oxygen therapy in babies with ROP was 12 days and in babies without ROP was 3.45 days.

It was noted that there was a significant relationship between the occurrence of ROP and birth weight(0.047), GA (<0.001), duration of oxygen therapy(<0.001), post conceptional age(0.002) and respiratory distress syndrome. However in this study it was seen that the relationship between ROP and the maternal risk factors such as antepartum haemorrhage, GDM,GHTN and multiple pregnancies was not significant. Out of the 70 babies screened,25(35.7%)developed ROP 4 babies(16%) had stage zone 2 stage 1,2 (8%) had zone 2 stage 2 and 5(24%) had zone 2 stage 3 .3 babies(12%) had zone 3 stage 1,8(32%) had zone 3 stage 3 and 3(12%) babies had zone 3 stage 3 .12 babies  had plus disease. There was no case of stage 4 or stage 5 of ROP.

Table 1 – relationship between retinopathy of prematurity and the risk factors.

parametersWith ROPWithout ROPP
Birth weight1.64 ±0.53 kg1.93±0.47kg0.047
GA30.87±2.53 weeks34.21±1.79 weeks<0.001
Oxygen therapy12 days3.45 days<0.001
Post conceptional age35.33± 3.54 weeks39.27±5.66 weeks0.002

Table 2 – Other risk factors associated with retinopathy of prematurity.

 With ROP (n=25)Without ROP (n=45)
Intraventricular hemorrhage1(4%)0
Gestational diabetes mellitus2(8%)1(2%)
Gestational hypertension2(8%)7(15.5%)
Ante partum hemorrhage2(8%)2(4.4%)
Twin pregnancy03(6.6%)
No maternal risk factors16(64%)27(60%)
Respiratory distress syndrome.15(62.5%)11(24.4%)

  Table 3 -Stages of retinopathy of prematurity

ROP STAGEN=25
Zone 2 stage 14(16%)
Zone 2 stage 22(8%)
Zone 2 stage 35(24%)
Zone 3 stage13(12%)
Zone 3 stage 28(32%)
Zone 3 sage 33(!2%)

Table 4 – Treatment of retinopathy of prematurity with laser photocoagulation.

With ROP(n=25)Treatment (n=12) With Plus diseaseNo treatment(n=13)
Zone 2 stage 130
Zone 2 stage 220
Zone 2 stage 360
Zone 3 stage111
Zone 3 stage 208
Zone 3 sage 304

 Out of the 25 babies with ROP , 12 babies required intervention with laser photocoagulation. 3  babies in zone 2 stage 1, 2 babies in zone 2 stage 2 and 6 babies in zone 2 stage 3 while 1 baby in zone 3 stage 3. All these 12 babies had plus disease and they showed improvement on follow up. The other 13 babies regressed spontaneously without any intervention.

DISCUSSION:

In our study it was found out that among the various risk factors that are responsible for ROP, low birth weight was the most common followed by duration of oxygen therapy and low GA. Our study was in correlation with various other studies done previously. Although multiple gestations, GDM , GHTN and interventicular hemorrhage were considered as risk factors for the development of ROP, it was not significant. In a study conducted by Ameen et al, it showed that multiple gestation as an independent risk factor for the development of ROP5. In our study it was seen that zone 3 stage 2(32%) was the most common followed by zone 2 stage 3 (24%).This could be attributed to the meticulous screening protocols and our cohort mainly had older babies. In our study it was noticed that zone 2 was the most commonly involved area. Stage 4 or 5 of ROP was not seen as all the cases were screened regularly in a timely fashion.

In our study, out of the 25 babies with ROP,12 required intervention with laser photocoagulation. It was seen that laser photocoagulated eyes showed a regression of the disease and the results were excellent. Other studies have also shown that laser therapy has a better outcome7.  A study done by Erick Dan compared the efficacy of laser with anti vascular growth factor as it has been used in severe forms of ROP6. It was concluded that Bevacizumab gives good results in stage 3 + ROP in zone 1 but not in zone 2. However in our study we have not compared the treatment outcomes with Bevacizumab as there were no babies with zone 1 ROP8.

Sine ROP is essentially asymptomatic is the early stages, it is very crucial to do a timely evaluation of the retina in infants that are at a risk of developing ROP to prevent any unseen complications9.

Limitation of our study was that a small sample size was taken and a single center study

CONCLUSION

The incidence of ROP among preterm babies was 37%. The prominent risk factors for the development of ROP were low birth weight, prematurity, duration of oxygen therapy and respiratory distress syndrome. Among the treatment choice, laser photocoagulation was found to be effective.

No financial support and sponsorship.

BIBLIOGRAPHY

1. Sen p, Rao G. Retinopathy of prematurity. Sci J Med.2018;vol(23):112-345

2.Jalala S,Anand R. Screening strategy in ROP. Indian J Ophthalmol. 2008;vol(2):76-90

3.Terry T.Eye changes in premature babies. Trans am ophthalmol. 2012,vol(14):556-667

4.Zubun D’sa, Bansal H.Risk factors for retinopathy of prematurity. Med Arch 2015; vol(20):77-90

5.Owen T,Lawrence J. Current concepts of oxygen management in ROP. J OphthalmicVis Res .2017;vol(20):45-78

6.Vijayalakshmi P, Kara T. Ocular morbidity associated with ROP. Indian Pediatric 2016,vol(11):34-45

7.Murthy KR,Shah DA.Screening of retinopathy of prematurity. Indian J Ophthalmol. 2017;vol(2):176-190.

8.Mutlu TR. Frequency, risk outcomes in retinopathy of prematurity. Trans am ophthalmol. 2015,vol(24):56-67.

9. Ram J. retinopathy of prematurity and its effects. Indian Pediatric 2019,vol(21):43-54

MRIDULA V AMARNATH

Chinmaya Mission Hospital,Bangalore,Karnataka

*Corresponding author email: [email protected]

ABSTRACT

Aim: To evaluate and analyze the outcome of preoperative subconjunctival Mitomycin C to conjunctival auto grafting using fibrin glue with respect to the recurrence rate and complications.

Methodology:  A prospective randomized hospital based study was conducted. 60 eyes were taken into consideration with primary progressive pterygium and were randomly divided into 2 groups of 30 each. In group A subconjunctival injection of Mitomycin C (MMC) 0.1 ml of 0.1 mg/ml was given 1 month before bare sclera technique and in group B pterygium excision with conjunctival auto graft using fibrin glue was performed. They were regularly followed up for 18 months.

Results: The mean age of the patients in this study was a 39.6±12.3 year with females outnumbering the males. The mean follow up period of group A was 10.6 ±5.44 months while in group B it was 11.2 ±4.49 months. The average surgery time was more in group B than compared to Group A. Both the techniques were not associated with any vision threatening complications.

Conclusion: Administration of subconjunctival injection of MMC 1 month before the bare sclera technique is considered to be safer, economical, less time consuming, technically less demanding and as effective as conjunctival autograft with fibrin glue.

Keywords: pterygium, bare sclera, MMC, auto graft.

INTRODUCTION

Pterygium is an elastotic subconjunctival degenerative fibro- vascular tissue proliferation. It is more commonly seen among those who are exposed to dry hot climatic conditions and ultra violet radiation exposure. Surgical intervention is indicated only if the individual has severe irritation, recurrent inflammation, obstruction to the visual axis, induced astigmatism, restriction in the motility and cosmetic blemish1.

Due to its high recurrence rates (30-70%), adjuvant modalities are required such as radiation, antimetabolites, conjunctival grafts and limbal grafts to reduce its recurrence. Among them it is observed that the best available option to prevent recurrence after pterygium excision is conjunctival autograft, where in after the excision of the pterygium a graft is fixed with the help of sutures or fibrin glue and autologous blood2.

Usage of Mitomycin as an adjunctive was first described in the year 1963 in Japan by Kunitomo and Mori. Since then various modifications have been made to use them either preoperatively or intra operatively. However the long term usage of Mitomycin C eye drops can lead to various complications such as secondary glaucoma, corneal edema,scleral necrosis, sudden onset of mature cataract thereby limiting its usage to a single intraoperative  application3. In a study done by Donnenfeld et al he reported a success rate of 94% with subconjunctival injection of MMC 1 month before the pterygium excision with bare sclera technique. It was observed that it allows the exact titration of MMC delivery to the activated fibroblasts and minimizes the epithelial toxicity.

The purpose of this study was to analyze if a simple and easy technique like subconjunctival MMC before pterygium excision by bare sclera technique can give  results comparable to conjunctival autograft with regards to its recurrence rates. To observe if subconjunctival injection of MMC is associated with complications such as ocular toxicity that is seen with intra operative application of MMC.

Materials and methods:

A prospective randomized hospital based study was conducted for a period of 12 months. In this study 60 eyes were taken who had primary progressive pterygium. In this study 12 patients had bilateral pterygium of which 5 were wiling to get both their eyes operated and hence one eye was allocated in group A and the other in group B. In the remaining 7 patients only one eye was included for the study. Approval to conduct the study was obtained from the ethical committee and a prior consent was taken from all the patients.

 A detailed preoperative eye examination was done for all the patients. Following the procedure the patients were regularly followed up from 6 to 18 months.

Inclusion criteria

All patients less than 50 years of age having primary progressive pterygium and willing to undergo the procedure were taken into consideration.

Exclusion criteria

Patients having atrophic pterygium, recurrent pterygium, dry eye syndrome, collagen vascular diseases, co existent conjunctival diseases like previous alkali  burns, Mooren’s ulcer which can predispose to pseudo pterygium, history of uveitis, scleritis, glaucoma and those who could not come for a regular follow up were excluded from the study

The patients were divided into 2 groups, Group A and Group B

In group A subconjunctival injection of MMC 0.1 ml of 0.1 mg/ml was given 1 month before the bare sclera technique. And in group B pterygium excision with conjunctival auto grating using fibrin glue was done. In order to reduce the cost in Group B, a group of 5 to 6 patients were made and each group was operated with fibrin glue on the same day.

Under aseptic precautions 0.5% proparacaine was instilled and with a30G needle on a tuberculin syringe0.1ml of 0.1 mg/ml of MMC  was injected into the body of the pterygium approximately 1.5 mm away from the limbus under an operating microscope. A sterile cotton bud was placed on the injection site for a few seconds to prevent the regress of MMC. After the injection, the conjunctival sac was washed with normal saline to wash out the excess MMC. The patient was advised to administer Ofloxacin 0.3% eye drops one drop 4 times a day for the next 4 days. The patient was reviewed on day 1 , after 1 week and after 1 month .  During the follow up period a complete ophthalmic examination was done including fluorescein staining. One month after the MMC injection, the patients were subjected to removal of the pterygium by the bare sclera technique. The eye was prepared  and draped in a sterile manner. A Peribulbar block was given using 5 cc of 2% xylocaine and 1:200000 adrenaline. The eye speculum was applied. The neck of the pterygium was grasped with the help of Saint Marin’s forceps and the head was dissected from the cornea with the help of conjunctival scissors following which the sclera portion of the pterygium was excised. A thorough removal of the subconjunctival fibrous tissue was done. The scleral bed and the cornea was polished with the help of a 15 surgical blade.  Antibiotic steroid combination ointment (polymyxin B sulfate 10000 units+ chloramphenicol 10 mg + dexamethasone sodium phosphate 1 mg/g ointment ) was instilled  and a sterile eye pad was applied. The time taken for the entire procedure was noted. 

In group B, the initial steps till the polishing of the corneal and scleral bed are the same, as in group A. The vertical and horizontal extents of the bare sclera was measured with Castroviejo’ s measuring caliper. And a free conjunctiva limbal graft of the same size was taken from the superotemporal conjunctiva. In cases where the exposure of the donor site was poor, a superior rectus bridle suture was applied  to fix the eye in the down gaze to get a better exposure of the donor site. The dissection was started from the forniceal end and brought towards the limbus. During this process extreme care had to be taken to avoid button holing of the graft and involvement of the tenon capsule. Once the graft reached the limbus , it was flipped on to the cornea and the teno’n s attachment at the cornea was meticulously dissected, the graft was then cut at the limbus  and once again flipped over the cornea  so that its tenon’ s surface faces the cornea. With the help of a duploject, fibrin glue was applied over the bare sclera and the conjunctival autograft was immediately flipped over the conjuctival defect. Proper care was taken to not disturb the orientation and the sides of the graft were opposed to the edges of the receipt conjunctiva. After a period of 3 minutes which was given for drying ,the lid speculum was removed, antibiotic steroid eye drops (oflocacin +dexamethasone) was instilled and a sterile eye pad was applied. The duration of the procedure was noted. The eye patch was removed after 6 hours followed by instillation of the antibiotic steroid eye drops 4 times a day for 15 days. Follow up of  both the groups were done at 1 week, 1 month, 3 months, 6 months,12 months and 18 moths post operatively.

Statistical analysis was done using SPSS version 2.0.The age of the patients , surgical time, follow up time of patients in group A and B were compared. Simple Z test was used to compare the recurrence and complications between group A and group B and p value < 0.05 was considered statistically significant.

RESULTS:

8 (13.33%) patients were in the age group of 21-30 years, 25 (41.6%) were in the age group 31-40 years and 27(45%) patients were in the age group 41 to 50 years. The average age of the patients in this study was 39.6±12.3 years. Out of the 60 patients in the study group, 22 (36.66 %) were males and 38 (63.33%) patients were females. Among the patients included for the study 26 (43.33%) patients had an indoor occupation while the remaining 43 (56.66%) of the patients had an outdoor occupation. The average surgical time taken for bare sclera with preoperative subconjunctival MMC was 16.77±1.73 minutes   while in group B where conjunctival autografting with fibrin glue was done, the average time taken was 23.36± 1.53 minutes.

Table 1 : Shows the recurrence rates of the two techniques used in this study

GroupSurgical TechniqueNumber of eyes operatedNumber of eyes with recurrence
ABare sclera with preoperative MMC301(3.4%)
BConjunctival autograft with fibrin glue302(6.7%)

Table 2: To compare the complications in group A and group B

ComplicationsGroup AGroup BP value
Conjunctival congestion30(100%)30(100%) 
Subconjunctival hemorrhage4(13.33%)1(3.3%)>0.05
Conjunctival granuloma2(6.7%)1(3.3%)>0.05
Graft edema 2(6.7%)>0.05
Graft hemorrhage 2(6.7%)>0.05
Graft loss 1(3.3%)>0.05

DISCUSSION:

Though pterygium excision is a very simple procedure but the only drawback and main concern is its recurrence rate. It is assumed that the surgical trauma and post operative inflammation activate the subconjunctival fibroblast which causes proliferation of the fibroblasts and deposition of extracellular matrix which causes the recurrence of the pterygium4.

However conjunctival autograft helps to reduce the recurrence rate by the presence of limbal stem cells which helps to restore the limbal barrier.But the drawback of conjunctival autografting is that it can adversely affect the outcome of future glaucoma filtration surgeries if ever required and it is of limited use with a large double headed pterygium and scarred conjunctiva as enough donor conjunctiva tissue might not be available.

The usage of fibrin bioadhesive in conjunctival limbal autograft surgery simplifies the surgical technique, shortens the duration and has lesser postoperative complications5. Though cost is a concern the average cost decreases with increasing number of patients scheduled for the surgery on the same day. But for this we need to get an adequate number of patients on the same day which might increase the waiting period for the patients which is not a practical and feasible solution.

Recurrence of pterygium is common among younger patients6. In our study the youngest patient was 23 year old and the oldest was 48 years old. The average age of the study was 39.6 ±12.3 In a study done by Gazzard et al, the prevalence rates of pterygium in subjects over the age of 51 years were 6 times than that  between 21-30 years of age. A study conducted by the Kim et al showed that 39.3 % were males and 66.5% were female which was similar to our study where the females outnumbered the males. In a study done in Meiktila it was found that the rates of pterygium and pingucuela in rural residents were more than five times as high as in urban residents and it was primarly as a result of ocular sun exposure.

The average surgical time taken for bare sclera with preoperative subconjunctival MMC was 16.77±1.73minutes. The average surgical time for conjunctival autografting with fibrin glue was 23.36±1.53 minutes. It was observed that the time taken for conjunctival autografting using fibrin glue was significantly more than that of bare sclera with preoperative MMC. . In our study the recurrence rate was 3.4% in group A at the end of mean follow up of 10.6±5.44 months.  And in group B it was 6.7 % at the end of the mean follow up of 11.2±4.49 months. Recurrence rates after conjunctival autografting with fibrin glue in various studies ranges from 4 to 12 %.

All patients had conjunctival congestion postoperatively due to surgical trauma which subsided with topical antibiotics- steroid eye drops,  4 patients in Group A had sub conjunctival hemorrhage after injection of MMC which cleared in 5 days. No patient had any sign of conjunctival or corneal staining after injection of MMC. 2 patients had conjunctival granuloma at 1 week and at 1 month post operatively after the bare sclera technique. No patient had vision threatening complications s during the study period like glaucoma, corneal edema, corneal perforation, scleral melting  and cataract which are usually associated with intraoperative application of MMC. In group B it was observed that after conjunctival autografting  using fibrin glue 2 patients had graft edema and 1 patient had hemorrhage under the graft after the first post operative day which cleared up with topical steroid drops. One patient had donor site granuloma on the 1 st week post operatively which resolved with topical steroids and lubricating eye drops.

CONCLUSION:

It was found out that the recurrence rate with subconjunctival MMC before bare sclera technique was 3.4 %while the recurrence rate with conjunctival autograft using fibrin glue was6.7%. Subconjunctival MMC 1 month before the bare sclera technique is simple, safe, economical, less time consuming, technically easy and as effective as various other techniques7. It is useful in patients with recurrent pterygium, large double headed pterygium, patients with glaucoma who require filtration surgery or combined cataract and pterygium operation.

It can be concluded that subconjunctival MMC 1 month before the bare sclera excision has a potential to replace other methods of management. However a longer follow up period along with a larger sample size are needed to further establish the safety and efficacy of preoperative MMC in pterygium surgery.

BIBLIOGRAPHY:

  1. Durkin SR,Abhay S. the prevalence and severity of pterygium. Br J Ophthalmol.2008; vol(12):112-134
  2. Karahan N,Baspinar T. recurrence of pterygium after excision. Indian J Opthalmol.2017;vol(23):36-45
  3. Youngson RM. Bare slerea techniques. BrJ Opthalmol .2017;vol(15):18-30
  4. Allan BD,Short P. pterygium excision with conjunctival autograft. Acta ophthalmol(Copenh)2008;vol(54):119-143
  5. Crawford GJ,Barret IJ. An effective and safe technique for pretygium exczion. BrJ Opthalmol .2018;vol(18):118-230
  6. Kunitomo N,Morisss . studies on pterygium . Indian J Opthalmol.2018;vol(33):236-245
  7. Richard TT,Maxwell . reurrenc after preygium excision. BrJ Opthalmol .2017;vol(38):128-238

Abstract

In our routine ophthalmology practice it is very common to come across lacrimal sac infections. Lacrimal sac infections most commonly presents with watering from the eye either associated with or without discharge, which can be assessed by applying pressure over the lacrimal sac.1 It is important to analyse the microbial spectrum in cases of lacrimal duct obstruction along with sac infection. It was noted that gram positive organisms are the most common source of infection. Among the gram positive organisms it is the Staphylococcal species mainly the Staphylococcus aureus which is responsible. Other gram positive organisms include Staphylococcus epidermis and Streptococcus pneumonia. Among the gram negative organisms the most common ones are the Pseudomonas aeruginosa, Hemophillus influenza, and Klebsiella. Anaerobic organism like Propionibacterium and fungi like Candida are very rare. It is equally important to assess the sensitivity of the organism to various drugs. A better understanding of the drug sensitivity is important in the management of lacrimal sac infections. It was found out that gram positive organisms are sensitive to vancomycin,ofloxacin, gatifloxacin and chloramphenicol while gram negative organisms showed sensitivity to mainly tobramycin.

INTRODUCTION
It is very common to come across lacrimal sac infections in one’s day to day practice as an ophthalmologist. Among the entire lacrimal system , infection of the lacrimal sac is the most common and is known as dacryocystitis. It is of two typesacute and chronic. Acute dacryocystitis often presents with pain, fever, and periocular swelling and shows signs of inflammation. Whereas in chronic dacryocystitis the patient complains of constant watering from the eye associated with or without regurgitation of mucoid or mucopureulent discharge. The patency of the lacrimal duct can be tested by applying pressure over the lacrimal sac area or by irrigating the lacrimal drainage system. The discharge that we obtain from the lacrimal puncta is then taken for microbial analysis. Multiple studies have been done in various parts of the world to get a better understanding of the bacteriological spectrum after taking swab culture from the conjunctiva and the lacrimal sac.

MATERIALS AND METHODS
A meta analysis and review of literature on various studies which were previously done regarding the microbial analysis and the drug sensitivity and resistance was performed. Various search engines and thesis were also evaluated in detail to get a better understanding of the current status.

ANATOMY LACRIMAL SAC
The lacrimal sac is situated in the lacrimal fossa. The lacrimal fossa is bonded in front by the frontal process of the maxillary bone and behind by the lacrimal bone. The thickness of the lacrimal bone can vary from one individual to another but in most cases the lacrimal bone is thinner than the maxillary 2 bone. The lacrimal bone can be visualized intranasally as it lies anterior to the uncinate process of the ethmoid bone. The lacrimal sac is lined by a double layered epithelium and it is divided into two parts –a fundus superiorly and a body inferiorly. The fundus starts 3 to 5 mm above the superior part of the medial canthal tendon while the body starts around 8 – 10 mm below the fundus to the osseous opening of the nasolacrimal canal. Near the posterior lacrimal crest ,the orbital periostum splits and encloses the lacrimal sac and forms the lacrimal fascia. The larimal fascia is surrounded by the fibres of the orbicularis oculi muscle. Between the lacrimal sac and the lacrimal fascia lies a rich venous plexus. The mucosa which lines the lacrimal sac helps to prevent colonization of microorganisms and thereby infections. The epithelial cells bind tightly to one and another and protect the
underlying tissues from the invading organisms .These epithelial cells also protect the sac by secreting immunoglobulin A, anti-infection peptides and mucins. Apart from these primary defense mechanism ,the lacrimal 3 drainage associated lymphoid tissue (LDALT) also protects the sac and forms the second line of defense.

NASOLACRIMAL DUCT.
The lacrimal sac continues downwards into a duct called the nasoclarimal duct. The NLD has a intraosseous part which lies superiorly and is about 12 mm and an inferiors 5 mm membranous portion. The diameter of the bony canal is 1 mm. The bony part travels posterolaterally within the maxillary bone while the membranous part runs through the nasal mucosa. The nasolacrimal duct finally opens into the inferior meatus under the inferior nasal turbinate. At the opening of the NLD lies the valve called the valve of Hasner. Similar to the double layer epithelium of the lacrimal sac, the NLD also has two layer lining. The mucin of the epithelial lining influences the tear fluid seceretion and also acts as an antimicrobial protective agent apart from helping in the transport of the tear fluid.

MICROBIOLOGY
A study of the patients having chronic dacryocystitis among adults was done to understand the bacterial growth. It was seen that gram positive organism were the most common ones. Among the gram positive organisms, Staphylococcus aureus (42%) was most common followed by Staphylococcus epidermis (10%) and then Staphylococcus pneumoniea(10%). With regards to gram negative organisms Pseudomonas aeruginosa( 18%) was very common. It was seen that chronic dacryocystitis was more prevalent among females compared to males and it was more common in the left eye. It was also more commonly seen among lower socioeconomic strata with poor hygienic conditions. Nasal pathologies like hypertrophied inferior turbinates, deviated nasal septum, nasal polyp and allergic rhinitis were also attributing factors. In a study done by Das et al, among the 500 samples that he took 93% were positive for bacteria and most of them were gram positive organisms(77%) with a predominance of staphylococcus species and a 23% showing gram negative species with predominance of pseudomonas aeruginosa. Another study conducted in Southern India showed that coagulase negative staphylococci and staphylococcus aureus to be most common isolates(73% and 12% respectively) . A study done by Bharathi Et al in Tamil Nadu showed that coagulase negative staphylococci (44%%), S aureus (11.2%) and S pneumonia(7%%) as the most common causative organism for chronic dacryocystitis. In a study done
among the population in Nepal having chronic dacryocystitis, it was seen that there was an equal proportion among both gram positive and negative organisms. However a study done by Badhu et al from Northern India showed that S pneumonia was the most frequently isolated organism. An Egyptian study showed that Coagulase negative staphylococci (53%%) and Klebsiella pneumonia (18%5) were the common isolates. Sun et al study which was done in China reported that staphylococcus species contributed majorly to the bacterial profile in chronic dacryocystitis (76%). An Iranian study showed that the prevalence of gram positive, gram negative and culture negative samples were 77%, 19.2% and 3.5 % respectively and staphylococcus epidermis was the most common one. In the lacrimal duct the oxygen supply was mainly consumed for the growth of aerobic and facultative bacteria. This in fact led to an anaerobic condition for the anaerobic bacteria like Propionibacterium. In the previous studies it was seen that anaerobic bacteria accounted for 8 % of the entire growth. A multicentered prospective study was done in the US in order to assess the microbial growth and it was performed in 17 centers and the acute and chronic groups of dacryocystitis were compared. There was a total of 90 culture isolates with 67% gram positive isolates,27% gram negative isolates and 3% mycobacterium isolates. In the acute group, 77% were gram positive, 22% were gram negative whereas in the chronic group 66% were gram positive and 32% were gram negative and 3% were mycobacterium isolates. The proportions between gram positive and negative among the groups revealed no statistically significant difference. In a study done by Kuchar et al in congenital NLD obstruction, the spectrum of microorganisms mainly included S pneumonia having a 36% of the isolates followed by Haemophillus influenza with 21%. In a study done by Usgha et al 250 samples were evaluated with congenital NLD obstruction among which 83% had a gram positive culture with S pneumonia being the most prevalent and Haemphilus influenza being the most frequent among gram negative organism. They also reported a single case of fungal isolate of candid species. Congenital NLD obstruction usually starts in the neonatal period and is more common among female. The clinical manifestation ranges from pediatric acute dacryocystitis to 4 meningitis . It is seen that S aureus is the most common isolate. Some of the rare organisms that are seen Pantoea species, Epstein barr virus and sporothrix. For the microbiological analysis the samples are usually taken from the conjunctival sac, lacrimal sac and in some cases from the intraoperative lacrimal sac fluid. The discharge can be obtained by either applying pressure over the lacrimal sac and allowing the purulent discharge to regurgitate through the lacrimal puncta or it can also be collected by irrigating the lacrimal drainage system with sterile saline and collecting the sample from the reflux material. The samples are collected with the help of a sterile cotton swab ensuring that the lid margins or the conjunctiva are not touched. The specimen which is collected is then inoculated on a solid media like sheep’s blood agar, chocolate agar, sabouraud’s dextrose agar or liquid media like brain heart infusion agar or thioglycolate media. The sample which is collected is also smeared onto a clean sterile glass slide for 10% potassium hydroxide wet mount, gram stain, zeihlneelson acid fast stain. All the inoculated media are incubated aerobically.

The sabouraud’ s dextrose agar is incubated at 27 C, and is examined on a day to day basis and is finally discarded after 3 weeks if no growth is noticed. Similarly the blood agar, chocolate agar, thioglycolate broth, brain heart infusion agar 0 is incubated at 37 C, examined daily and then is discarded if no growth is noticed after a period of 7 days. The cultures that 5 have been inoculated should be considered significant if


1) The growth of the same particular organism is seen on more than one solid phase medium.
2) If there is a presence of confluent growth at the site of inoculation on one solid medium
3) The growth on one of the medium is consistent with the microscopic findings like appropriate staining and morphology with gram stain.
4) If the same organism is seen in more than one specimen. The identification of the species should be made based on the microscopic morphological findings, staining properties and the biochemical properties according to the standard laboratory criteria.

For each inoculation the susceptibility testing has to be done according to the standardized methods. As in case for blood agar, the susceptibility is measured by measuring the area of where hemolysis had not occurred. For each antimicrobial agent the zone diameter is measured and it is then converted into the sensitivity and resistant categories by referring an interpretation chart according to the National committees for clinical laboratory standards, USA. In a study done by Mandal et al, it was seen that
chloramphenicol is effective against most of the gram positive organisms while for S epidermis drugs like aminoglycosides and tobramycin were effective. For P aeriginosa and klebsiella pneumonia, fluoroquinolones mainly the ciprofloxacin and ofloxacin are found to be beneficial. A study conducted by Chaudhary et al reported that a very high rate of microorganisms were seen in the lacrimal sac and hence it is mandatory to treat them before any intraocular surgery is conducted to rule the potential risk of postoperative infection. A study conducted by Amin et al to evaluate the sensitivity and resistance of the microorganism to the various drugs showed that majority of the bacterial isolates were susceptible to vancomycin (96%), gatifloxacin(92%) cefotaxime(89%) amikacin (93%) tobramycin(89%) and ofloxacin(83%). And they were mainly resistant to macrolides (43%) and amoxicillin (38%).It was seen that among all the drugs gatifloxacin and ofloxacin showed the least resistance to the bacterial isolates in both acute and chronic infections of the Lacrimal sac (8% and 11.3 % respectively). A study done by Ponpanich et al showed that ciprooxacin was the most effective drug against all gram positive and gram negative organisms. Mills et al showed that the frequency of Methicilin resistant S aureus in the acute group was certainly more when compared to the chronic group and they also revealed that ofloxacin and tetracycline is the most effective drug as monotherapy. They also proved that when acitracin and neomycin was used as the initial mode of therapy, it was successful in curing dacryocystitis in nearly 85 % of the patients. When compared to other developing countries, India is labeled as one of those counties that has a rampant usage of antibiotics. Inappropriate use of topical drugs can increase the resistance to the bacterial flora and eventually be less effective in the further management. The usage of broad spectrum antibiotics is also considered as a risk factor for developing resistance and hence it needs to be used with at most care and 6 concern . The diagnosis of dacryocystitis is further confirmed with the laboratory findings. Unlike previously where S pnemoniae was more common currently S aureus has become the prominent organism in lacrimal sac infections. The emergence of new rare species, resistant microbes may also be seen in the future causing lacrimal sac infections.

CONCLUSION
Obstruction of the NLD leads to colonization of the bacteria and thereby leading to infection in majority of the patients. Gram positive organisms are more commonly seen compared to gram negative organisms. The infections needs to be treated based on the sensitivity of the organism. It is very crucial for the early diagnosis and immediate treatment of the infection as sometimes it can be a threaten to the vision due to its untoward complications and sequel. However in the past few decades, accurate diagnosis along with medical management and surgical management if required has provided a good outcome in the management of lacrimal sac infections.

REFERENCES

  1. Perra M, Serra A. An immunochemical study of the defense mechanism in the human Lacrimal sac. Arch Histo Cytol. 1995;(58): 517-526
  2. Mauriello J,De Luca J. Clinico- pathological study of the lacrimal sac with nasolacrimal duct obstruction. Ophthal Plast Reconstr Surg. 2002;(8): 13-21
  3. KnopE. Lacrimal drainage associated lymphoid tissue. Invest ophthalmol Vis Sci. 2001;( 42): 566-574
  4. Paulsen F, Corfield A .Impact of mucins and TFF peptides. Ophthalmologe. 2006;( 101): 12-20
  5. Mandal AR, Banerjee TT.Clinicobacteriological study of chronic dacryocystitis in adults. J Indian Med Assoc .2008;(106):296-312
  6. Das JK,Deka AC.Bacteriology of chronic dacryocystitis .India J Clin Diagn Res. 2014 ;(24) 322-345