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


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

atrophy or allergic reaction.2 Bakri et al. injected posterior subtenon triamcinolone in patients at least 3 months after laser treatment with minimal side-effects.3 Transient rise in intraocular pressure was observed in three eyes and ptosis in two eyes. In another study by Javadzadeh et al., a similar protocol for treating recalcitrant diabetic macular edema was followed.1 Only two cases in their series developed focal conjunctival necrosis over the site of injection. Orbital cellulitis has been seen after anterior subtenon injection of local anesthetic agent for cataract surgery.4 Recently, Oh et al. reported a case of periocular abscess which presented 1 month following posterior subtenon injection of triamcinolone and panretinal photocoagulation.5 Asymptomatic orbital abscess presenting 3 weeks following posterior subtenon injection of triamcinolone has been reported.6 However, acute orbital abscess is a previously unrecognized complication of this procedure. Our case highlights the fact that posterior subtenon triamcinolone injection should preferably be avoided at the same time as laser photocoagulation. Coupling solution used during focal laser treatment may have contaminated the conjunctival sac causing localized infection. Uncontrolled diabetes may have also contributed. It is well known that after posterior subtenon injection of anesthetic solution, nearly 50% of the solute resides in the orbital tissues anterior to the globe equator.7 In such a situation injection of deep posterior subtenon corticosteroid

247

may have created a similar tract for the infection to present as an orbital abscess.

References 1.

Javadzadeh A. The effect of posterior subtenon methyllprednisolone acetate in refractory diabetic macular oedema: A prospective non randomized interventional case series. BMC Ophthalmol 2006;6:15-29.

2.

Dafflon ML, Tran VT, Guex-Crosier Y, Herbort CP. Posterior subtenon’s steroid injections for the treatment of posterior ocular inßammation: Indications, efficacy and side effects. Graefes Arch Clin Exp Ophthamol 1999;237:289-95.

3.

Bakri SJ, Kaiser PK. Posterior subtenon triamcinolone acetonide for refractory diabetic macular edema. Am J Ophthalmol 2005;139:290-4.

4.

Dahlmann AH, Appaswamy S, Headon MP. Orbital cellulitis following sub-tenon’s anaesthesia. Eye 2002;16:200-1.

5.

Oh IK, Baek S, Huh K, Oh J. Periocular abscess caused by Pseudallescheria boydii after a posterior subtenon injection of triamcinolone acetonide. Graefes Arch Clin Exp Ophthalmol 2007;245:164-6.

6.

Engelman CG, Palmer JD, Jose S. Orbital abscess following subtenon triamcinolone injection. Arch Ophthalmol 2004;122:654-5.

7.

Niemi-Murola L, Krootila K, Kivisaari R, Kangasmaki A, Kivisaari L, Maunuksela EL. Localization of local anesthetic solution by magnetic resonance imaging. Ophthalmology 2004;111:342-7.

Transconjunctival orbital emphysema caused by compressed air injury: A case report

Key words: Compressed air, conjunctival tear, crepitus, narrow palpebral Þssure, orbital emphysema

Mathew Sunu, DNB; Vasu Usha, MS; Francis Febson, MS; Nazareth Colin, MS

Orbital emphysema following trauma is usually associated with fracture of the orbital bones.1 It is unusual for orbital emphysema to occur without orbital fracture but cases have been reported as a result of compressed air injury in the absence of orbital wall fracture.2-9 In trauma with a high pressure air gun, the air under pressure is pushed through the subconjunctival space into the subcutaneous and retro-orbital spaces. We report such a case, which highlights the need for the use of protective eye wear while working with air under pressure.

Orbital emphysema following conjunctival tear in the absence of orbital wall fracture, caused by air under pressure is rare. Usually orbital emphysema is seen in facial trauma associated with damage to the adjacent paranasal sinuses or facial bones. To the best of our knowledge, there have been only eight reports of orbital emphysema following use of compressed air during industrial work. The air under pressure is pushed through the subconjunctival space into the subcutaneous and retrobulbar spaces. We present here a rare cause of orbital emphysema in a young man working with compressed air gun. Although the emphysema was severe, there were no orbital bone fracture and the visual recovery of the patient was complete without attendant complications.

Department of Ophthalmology, St. Johns Medical College Hospital, Bangalore, Karnataka, India Correspondence to Dr. Sunu Mathew, Department of Ophthalmology, St. Johns Medical College Hospital, Bangalore - 560 034, Karnataka, India. E-mail: [email protected] Manuscript received: 05.06.07; Revision accepted: 12.09.07

Indian J Ophthalmol 2008;56:247-9

Case Report A 23-year-old healthy man was cleaning some tools with a compressed air gun, when the tubing of the air gun exploded close to his face. His left eyelid got swollen up due to this injury. The patient was not wearing protective eyewear at the time of cleaning. The patient reported to the emergency medicine department of our institute 2 h after the injury. Ophthalmological examination revealed a best corrected visual acuity of 20/20 in the right eye and 20/30 in the left eye. Rest of ocular examination in the right eye was normal. There was periorbital edema with marked lid swelling on the left side with palpable crepitus [Fig. 1]. There was 360° chemosis and minimal restriction of


248

Indian Journal of Ophthalmology

ocular movements in all directions. On retraction of the lids, a 4-mm tear of the conjunctiva was seen in the superior fornix and a 3-mm tear of conjunctiva in the inferior fornix. Adjacent to the tear, air could be seen under the conjunctiva both superiorly and inferiorly. Minimal bleeding was noticed in the region of the conjunctival tear superiorly. Subconjunctival hemorrhage was present nasally. The left eye cornea was clear, pupillary reactions - both direct and consensual were brisk. Fundus examination in the left eye done with a fully dilated pupil revealed an area of commotio retinae superotemporal to the optic disc. Intraocular pressure (IOP) measured with Goldman applanation tonometer was normal. Computed tomography of both orbits done without contrast showed radiolucent shadows [Fig. 2 (A, B)] consistent with air in the preseptal tissues, periorbital and intraorbital regions of the left eye suggestive of orbital emphysema. There were no fractures noted on the 1.5 mm sections of the orbit. Paranasal sinuses did not show any air ßuid level. Patient was put on oral ampicillin and ibuprofen along with topical ciproßoxacin eye ointment 3 times daily and ßurbiprofen eye drops 4 times daily. After 2 days, his visual acuity had improved to 20/20, but crepitus was still present

Vol. 56 No. 3

and the commotio retinae persisted. The patient was reviewed 1 week later. The crepitus had disappeared, IOP was normal but fundus examination still showed commotio retinae. The retina appeared normal when the patient was seen 1 month after the injury. There were no complications seen during the last follow-up visit at 1 month.

Discussion Orbital emphysema following a conjunctival tear in the absence of orbital wall fracture caused by the use of air under pressure is rare. Proptosis from orbital emphysema is usually associated with tense lids due to increased intraorbital tension and the characteristic stretching and narrowing of the palpebral Þssure, whereas there is often widening of the palpebral Þssure in proptosis due to other causes. The narrow palpebral Þssure makes it difficult to visualize conjunctival lacerations near the fornix in compressed air injuries. Stroh and Finger3 reported a case of ocular injury with an air gun. An 8-mm conjunctival laceration resulted in transconjunctival migration of air into the subcutaneous, subconjunctival and retrobulbar spaces. The only other injury was a corneal abrasion. Complete resolution was noted one month after the injury Li et al.4 and Hitchings and McGill5 each reported a case of air under pressure causing orbital emphysema. There was no entry wound in the conjunctiva or any fracture of the orbital bones. Ocular movements were restricted, which recovered and the emphysema had resolved completely 4 weeks after the injury. In this case, the compressed air blast was sufficient to lacerate the conjunctiva and orbital septum leading to orbitopalpebral emphysema. Complications that can occur following orbital emphysema include glaucoma, uveitis, central retinal artery occlusion, optic atrophy, blowout fracture of the orbit and tearing of the ophthalmic veins with fatal air embolism.2,3,6

Conclusion Figure 1: Orbital emphysema of the left orbit

This case was unique as orbital emphysema occurred without fracture of orbital walls and in spite of the severe and slowly

Figure 2A and B: CT scan of the orbit-axial and coronal images showing air seen as hypodensities (white arrows) within the left orbit

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Brief Communications

resolving emphysema, there were no attendant complications. Although complete resolution was seen in all cases reported till date, the possibility of occurrence of vision-threatening complications makes the use of protective eyewear a useful precaution.

References

249

4.

Li T, Mafee MF, Edward DP. Bilateral orbital emphysema from compressed air injury. Am J Ophthalmol 1999;128:103-4.

5.

Hitchings R, McGill JI. Compressed air injury of the eye. Br J Ophthalmol 1970;54:634-5.

6.

King YY. Ocular changes following air blast injury. Arch Ophthalmol 1971;86:125-6.

7.

Yuksel M, Yuksel KZ, Ozdemir G, Ugur T. Bilateral orbital emphysema and pneumocephalus as a result of accidental compressed air exposure. Emerg Radiol 2007;13:195-8.

1.

Carter KD, Nerad JA. Fluctuating visual loss secondary to orbital emphysema. Am J Ophthalmol 1987;104:664-5.

2.

Walsh MA. Orbito palpebral emphysema and traumatic uveitis from compressed air. Arch Ophthalmol 1972;87:228-9.

8.

Caesar R, Gajus M, Davies R. Compressed air injury of the orbit in the absence of external trauma. Eye 2003;17:661-2.

3.

Stroh EM, Finger PT. Traumatic transconjunctival orbital emphysema. Br J Ophthalmol 1990;74:380-1.

9.

Kaiserman I. Large subconjunctival emphysema causing diplopia and lagophthalmos. Eur J Ophthalmol 2003;13:86-7.

Isolated and silent spinal neurocysticercosis associated with pseudotumor cerebri Rabindra N Mohapatra, MCh; Jaya K Pattanaik, MD; Sanjoy K Satpathy, MD; Sonia Joshi, MS

by neurocysticercosis (NCC) may give rise to features of PTC, requiring LP shunt, for relief,3 isolated spinal NCC is not known to be associated with it. We report, for the Þrst time, a case of PTC associated with isolated spinal NCC. Incidentally, the cysticercous larva was also recovered through the Touhey’s needle injury, which is also being reported for the Þrst time.

Case Report Incidence of spinal neurocysticercosis (NCC) is rare. Isolated spinal NCC is still rarer. We present here a case report where a young lady presented with all the clinical features of pseudotumor cerebri (PTC), where medical treatment for PTC failed and the presence of cysticercous in spinal canal was detected only on the operation table, while doing a lumboperitoneal shunt (LP shunt) to save her vision. Diagnosis could be conÞrmed only after the histopathology report was received. She did not have any direct evidence of spinal involvement, thereby eluding correct diagnosis. In English literature, we could not Þnd any report of isolated and silent spinal NCC associated with PTC. In addition, we could not Þnd any report of recovery of cysticercous larva through the Touhey’s needle injury, although this was an incidental Þnding. In endemic areas, isolated spinal NCC should be suspected in patients presenting with PTC. Key words: Isolated, neurocysticercosis, pseudotumor cerebri, silent, spinal Indian J Ophthalmol 2008;56:249-51

Pseudotumor cerebri (PTC) is characterized by features of raised intracranial pressure, papilledema, normal imaging of brain and normal composition of cerebrospinal ßuid (CSF).1,2 Therapy of PTC is directed towards its etiology, when it is known.1,2 While diffuse involvement of brain parenchyma Departments of Neurosurgery (RNM), Pathology (JKP), Internal Medicine (SKS) and Ophthalmology (SJ), ISPAT General Hospital, Rourkela, Orissa, India Correspondence to Dr. RN Mohapatra, Qr. No. C/91, Sector - 19, Rourkela - 769 005, Orissa, India. E-mail: rkl_neororabi@dataone. in/drrnmohapatra@rediffmail.in Manuscript received: 18.03.07; Revision accepted: 19.09.07

A 35-year-old married lady was referred to us for headache and progressive blurring of vision since 6 months. Most of the time, her headache was accompanied by vomiting. Her menstrual cycle was normal. Her height was 150 cm and weight 71 kg. Her pulse was 80/min, blood pressure 140/90 mm of Hg. Her pupils were equal and reacting to light; visual acuity was Þnger counting in both eyes with secondary optic atrophy. Rest of the nervous system and all other systems were clinically normal. Her hemogram, biochemical parameters and thyroid proÞle were within normal range. Magnetic resonance imaging (MRI) of her brain done earlier and contrast enhanced computerized tomographic (CT) scan of brain done on admission were also normal. Opening pressure of CSF, during lumbar puncture, was 300 mm of water and it was clear; CSF sugar was 50 mg/dl, protein 32 mg/dl and cell count 1; culture was sterile. She had received acetazolamide and advised surgery 3 months back by our ophthalmologist, which she refused at that time. Perimetry done during her previous visit showed inferior altitudinal and nasal Þeld defect encroaching central Þxation in the left eye [Fig. 1] and inferior altitudinal and nasal Þeld defect in the right eye [Fig. 2]. With the diagnosis of PTC with impending blindness, lumbo-peritoneal (LP) shunt was undertaken under general anesthesia. Attempts to put Touhey’s needle initially at L4/L5 interspace and then at L3/L4 interspace resulted in CSF coming out under pressure, but outßow of CSF ended abruptly, for which it was decided to put the shunt into lumbar subarachnoid space under vision by open method. An elongated structure resembling a torn nerve root or Þlum terminale [Fig. 3] came out at the suction tip, when attempt was being made to dissect the interspinous space. Shunt procedure was completed. We could not ascertain the mother tissue of the 5-cm long specimen [Fig. 3]. The specimen was sent for tissue diagnosis. On the 8th postoperative day histopathology report revealed