indian journal of ophthalmology

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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

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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

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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

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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.