May 3, 2018 - Calculating graft size and position in rotational corneal autografting: A ... Transconjunctival orbital emphysema caused by compressed air ...
[Downloaded free from http://www.ijo.in on Thursday, April 5, 2018, IP: 188.231.136.199]
INDIAN JOURNAL OF OPHTHALMOLOGY Contents Vol. 56
No. 3
May-June 2008
Editorial Marching ahead with clinical trial registration
175
Barun Kumar Nayak
Editorial Policy Statement Statement on publishing clinical trials in Indian biomedical journals
177
K Satyanarayana, Anju Sharma, Purvish Parikh, VK Vijayan, DK Sahu, Barun K Nayak, RK Gulati, Mahendra N Parikh, Prati Pal Singh, SB Bavdekar, U Sreehari, Peush Sahni
Review Article Diabetic retinopathy: An update
179
Ramandeep Singh, Kim Ramasamy, Chandran Abraham, Vishali Gupta, Amod Gupta
Original Articles An observational study of the proceedings of the All India Ophthalmological Conference, 2000 and subsequent publication in indexed journals
189
Upreet Dhaliwal, Rajeev Kumar
Transconjunctival penetration of mitomycin C
197
T Velpandian, Ramanjit Sihota, Ankur Sinha, Viney Gupta
Symposium Distinguishing infectious versus noninfectious keratitis
203
M Srinivasan, Jeena Mascarenhas, CN Prashanth
Investigative modalities in infectious keratitis
209
Noopur Gupta, Radhika Tandon
Medical management approach to infectious keratitis
215
Nikhil S Gokhale
First aid for complications of infectious keratitis
221
Vinaykumar Agrawal
Ophthalmology Practice Practical approach to medical management of glaucoma
223
Rajul S Parikh, Shefali R Parikh, Shoba Navin, Ellen Arun, Ravi Thomas
Brief Communications Periocular necrotizing fasciitis associated with kerato-conjunctivitis and treated with medical management: A case report 231 Debraj Shome, Vandana Jain, Chaitra Jayadev, Kiran Shah, Sundaram Natarajan
Calculating graft size and position in rotational corneal autografting: A simplified approach 233 Srinivas K Rao, Dennis SC Lam
CMYK
15
[Downloaded free from http://www.ijo.in on Thursday, April 5, 2018, IP: 188.231.136.199]
Sudoriferous cyst of the orbit of adult origin after trauma
235
Anjali Mehta, Aparna Rao, Apoorva Khanna
Recurrent neovascularization of the disc in sympathetic ophthalmia
237
Raju Sampangi, Pradeep Venkatesh, Subrata Mandal, Sat Paul Garg
Giant hanging melanoma of the eyelid skin
239
Radha R Pai, Hema Kini, Sai Giridhar Kamath, Suneet Kumar
Descemet’s membrane detachment caused by inadvertent vancomycin injection
241
Harsha Bhattacharjee, Kasturi Bhattacharjee, Jnanankar Medhi, Abu Altaf
Voriconazole for the treatment of refractory Aspergillus fumigatus keratitis
243
Hijab Mehta, Hitendra B Mehta, Prashant Garg, Harish Kodial
Acute orbital abscess complicating deep posterior subtenon triamcinolone injection
246
Jaspreet Sukhija, Mangat R Dogra, Jagat Ram, Parul Ichhpujani, Amod Gupta
Transconjunctival orbital emphysema caused by compressed air injury: A case report
247
Mathew Sunu, Vasu Usha, Francis Febson, Nazareth Colin
Isolated and silent spinal neurocysticercosis associated with pseudotumor cerebri
249
Rabindra N Mohapatra, Jaya K Pattanaik, Sanjoy K Satpathy, Sonia Joshi
Letters to the Editor Sterilization of phacoemulsification handpieces
253
Ravi Thomas
Right traumatic carotico-cavernous fistula with bilateral eye signs and post-treatment right pseudo Argyll Robertson pupil
253
Mary Santhosh, Santhosh Joseph, Priyanka Doctor
Debate on the various anti-vascular endothelial growth factor drugs
255
Mohammad Reza Khalili, Hamid Hosseini
Authors’ reply
256
Manish Nagpal, Kamal Nagpal, PN Nagpal
Primary 25-guage transconjunctival sutureless vitrectomy in pseudophakic retinal detachment
256
Arvind K Dubey, Benu Dubey
Authors’ reply
257
Fatih Horozoglu, Ates Yanyalı, Erkan Celık, Banu Aytug, Ahmet F Nohutcu
Intra-cameral injection of bevacizumab (Avastin) to treat anterior chamber neovascular membrane in a painful blind eye
258
Manisha Agarwal, Suneeta Dubey
Intravitreal bevacizumab (Avastin) for the treatment of proliferative sickle retinopathy
259
Saad Shaikh
16
CMYK
Journal Abstracts
261
Training Program
264
Continuing Medical Education
265
[Downloaded free from http://www.ijo.in on Thursday, April 5, 2018, IP: 188.231.136.199]
Brief Communications Periocular necrotizing fasciitis associated with kerato-conjunctivitis and treated with medical management: A case report Debraj Shome, DNB, FRCS; Vandana Jain, MS; Chaitra Jayadev, DO; Kiran Shah, Dip Diabetology; Sundaram Natarajan, DO We report a 25-year-old systemically healthy male who presented with periocular necrotizing fasciitis (NF) in the left eyelid. This was associated with the presence of immunologically mediated marginal kerato-conjunctivitis, in the same eye. This potentially dangerous lid infection and the associated ocular surface infection resolved successfully, with medical management. We report this case to highlight the successful conservative management of periocular NF and the hitherto unreported anterior segment involvement. Key words: Kerato-conjunctivitis, medical management, necrotizing fasciitis, periocular infection. Indian J Ophthalmol 2008;56:231-2
Necrotizing fasciitis (NF) is the anatomical description used to describe the extensive necrosis of the subcutaneous tissues that is most commonly caused by a rapidly spreading infection of Streptococcus pyogenes in the subcutaneous plane.1 Necrotizing fasciitis is a serious life-threatening condition, with reported mortality of more than 20%. The limbs, perineum and abdomen are frequently involved with facial involvement being rare. The organisms most closely linked to NF are Group A beta-hemolytic streptococci (NF Type II), though these bacteria are isolated in only a minority of the cases.1 The rarer NF Type I is caused due to polymicrobial infections and the usual pathogens are obligate and facultative anerobes.1 Periocular NF is reported to have a better prognosis.2 Though reports of resolution of periocular NF post surgical debridement are common, a detailed Medline and Embase search revealed only one case series reporting resolution with conservative management.3 In addition, to the best of
Department of Retina (SN,CJ), Department of Cornea and Anterior Segment (VJ), Department of Internal Medicine (KS), Department of Ophthalmic and Facial Plastic Surgery orbital Diseases and Ocular Oncology (DS), Aditya Jyot Eye Hospital Pvt Ltd, Mumbai, India and from the Department of Ocular Oncology (DS), Tata Memorial Centre, Mumbai, India Correspondence to Dr. Debraj Shome, Department of Ophthalmic and Facial Plastic Surgery, Orbital Diseases and Ocular Oncology, Aditya Jyot Eye Hospital Pvt Ltd, Plot No 153, Road No 9, Major Parmeshwaran Road, Wadala, Mumbai - 400 031, India. E-mail: debraj_shome@ yahoo.com Manuscript received: 26.03.07; Revision accepted: 17.07.07
our knowledge, there are no published reports of anterior segment ocular involvement in periocular NF. We report this case to highlight the successful conservative management of periocular NF and the hitherto unreported ocular involvement.
Case Report A 25-year-old systemically healthy male patient presented with complaints of severe photophobia, redness, discharge, pain and severe swelling of the lids in the left eye, since two days. Past history was significant for a boil on the lower eyelid, two days ago. On examination, the best-corrected visual acuity was 20/20 and 20/30, in the right and left eyes respectively. Right eye examination was unremarkable. The left eye showed severe lid edema with scales on the skin and associated kerato-conjunctivitis [Fig. 1A]. The cornea showed multiple marginal inÞltrates. Photographic documentation of the anterior segment condition was impossible because of the severe photophobia. Extraocular movements were full. A conjunctival swab and a periorbital skin swab were sent for culture and sensitivity. The corneal inÞltrates were also cultured on blood agar and Sabouraud’s dextrose agar. The patient was seen by our infectious diseases expert and started on intravenous co-amoxiclav (Augmentin, GlaxoSmithKline) 1 g twice daily, intravenous ceftriaxone (ceftriaxone sodium, Sandoz, Novartis) 1 g twice daily and oral metronidazole (Flagyl, Searle) 500 mg three times daily, pending sensitivity reports. Topical loteprednol etabonate (0.5%) (Alrex eye drops, Bausch and Lomb Incorporated) every three hourly and ciproßoxacin (0.3%) (Ciplox eye drops, Cipla) six times a day were started, in the left eye. On follow-up two days later, the patient was symptomatically much better. The skin scabs had fallen off, revealing violaceous, sub-epidermal necrosis. The conjunctival inßammation had reduced and the corneal marginal infiltrates had almost disappeared [Fig. 1B]. Culture and sensitivity results showed Staphylococcus aureus, sensitive to the administered medications. The culture plates for corneal inÞltrates showed negative growth and were discarded after three weeks. The patient was sero-negative for HIV. Five days later, the skin lesions had healed and the conjunctivitis had resolved. Intravenous antibiotics were stopped and the patient was started on oral co-amoxiclav (Augmentin, GlaxoSmithKline), 625 mg thrice a day, for a week. On Þnal follow-up a month later, periocular skin discoloration was the only sequalae noted [Fig. 2].
Discussion Infections in the periocular region occur post surgical procedures, post trauma, furunculosis or even without any antecedent cause.2 Ideally, a combination of intensive parenteral antimicrobial therapy and prompt surgical debridement of necrotic tissue should be done. Intravenous pooled immunoglobulin and
[Downloaded free from http://www.ijo.in on Thursday, April 5, 2018, IP: 188.231.136.199]
232
Indian Journal of Ophthalmology
Vol. 56 No. 3
Figure 1: (A) External photograph of patient at presentation, showing left-sided severe lid edema, erythema and necrotic tissue with overlying skin scabs. (B) Slit-lamp photograph of the left eye, in diffuse illumination (with upper eyelid retracted), showing periocular skin erythema and kerato-conjunctivitis
zone of tissue surrounding the infected area has better local blood supply and hence a higher chance of avoiding necrosis.3
Figure 2: External photograph of patient, a month post presentation, showing healed skin lesions, with symmetrical palpebral apertures
We report the case of a 25-year-old male patient who presented with periocular NF associated with kerato-conjunctivitis. Associated kerato-conjunctivitis is commonly reported following lid infection of staphylococcal etiology. The paucity of literature regarding this entity, in association with staphylococcus-induced periocular NF probably stems from an under-reporting bias. These inÞltrates are usually the result of an immunological reaction with staphylococcal antigens but in cases with severe infection as in our patient, the inÞltrates need to be cultured for an infectious etiology. The patient responded to conservative medical management with systemic antibiotics, topical antibiotics and topical steroids. We report this case to highlight the successful conservative management of periocular NF and the hitherto unreported anterior segment involvement.
References heparinization may also have beneÞcial roles by neutralizing super-antigen activity and aiding antibiotic perfusion.4
1.
Urschel JD. Necrotizing soft tissue infections. Postgrad Med J 1999;75:645-9.
Necrotizing fasciitis is a clinical diagnosis. Necrotizing fasciitis limited to the eyelids looks and behaves differently from NF affecting other parts of the body, due to the excellent blood supply in the eyelid area.3 Mild cases, especially those restricted to the eyelids alone may respond to medical therapy. The increased blood supply allows for delayed debridement, because the local vasculature allows for better access of the systemic antibiotics to the infected area. The marginal
2.
Kronish JW, McLeish WM. Eyelid necrosis and periorbital necrotizing fasciitis: Report of a case and review of the literature. Ophthalmology 1991;98:92-8.
3.
Luksich JA, Holds JB, Hartstein ME. Conservative management of necrotizing fasciitis of the eyelids. Ophthalmology 2002;109:2118-22.
4.
Seal DV. Necrotizing fasciitis. Curr Opin Infect Dis 2001;14:127-32.