Limbal stem cell transplantation

The past two decades have witnessed remarkable progress in limbal stem cell transplantation. In addition to harvesting stem cells from a cadaver or a live related donor, it is now possible to cultivate limbal stem cells in vitro and then transplant them onto the recipient bed. A clear understanding of the basic disease pathology and a correct assessment of the extent of stem cell deficiency are essential. A holistic approach towards management of limbal stem cell deficiency is needed. This also includes management of the underlying systemic disease, ocular adnexal pathology and dry eye. Conjunctival limbal autografts from the healthy contralateral eye are performed for unilateral cases. In bilateral cases, tissue may be harvested from a cadaver or a living related donor; prolonged immunosuppression is needed to avoid allograft rejection in such cases. This review describes the surgical techniques, postoperative treatment regimes (including immunosuppression for allografts), the complications and their management. The short and long-term outcomes of the various modalities reported in the literature are also described.     

Frequency, distribution, and outcome of keratoplasty for corneal dystrophies at a tertiary eye care center in South India

PURPOSE: To report the frequency, outcome, and atypical histology in corneal dystrophies. METHODS: Corneal buttons of patients diagnosed with corneal dystrophy as noted in the records of the ophthalmic pathology register over a period of 6 years were included in this study. The sections from formalin-fixed, paraffin-embedded tissues were reviewed specifically for the type of deposits, associated degenerations such as amyloid and spheroidal deposits, inflammation, and vascularization. Special stains including Masson trichrome, Congo red, and Alcian blue staining were used whenever required. The medical records were evaluated for demographics, clinical presentation, history of consanguinity, family medical history, and clinical outcome of keratoplasty, which was recorded as clear, recurrence of dystrophy, or graft failure. A clinicopathologic correlation was attempted. RESULTS: A total of 144 patients contributed 181 buttons, accounting for 8.1% of keratoplasties performed during the study period. The mean age of the patients was 34 +/- 19 years (range 3-72 years) with a male:female ratio of 1.6 (89):1 (55). Consanguineous parentage was noted in 26% of cases. History of a similar problem in siblings and other family members was elicited in 33 (22%) and 14 (9.7%), respectively. Dystrophies included macular (29.3%), congenital hereditary endothelial dystrophy (34.8%), Fuchs (16.6%), and lattice (15%); the remaining 11% included granular, gelatinous drop-like, Reis-Bucklers, and posterior polymorphous dystrophy. Associated histologic changes were degenerations (15%), vascularization (4%), and inflammation (2%). At a mean follow-up of 42 months, the graft remained clear in 148 eyes (81.7%), failed in 33 eyes (18.2%), and recurred in 5 eyes (2.8%). Graft survival for all dystrophies at the end of 1 year was 94.3 +/- 1.7%, and at the end of 5 years was 74.4 +/- 4.5%. Atypical histologic features did not affect graft survival. CONCLUSION: Consanguineous marriages possibly contributed to the increase in macular dystrophy and CHED in South India. The degenerative changes seen could possibly be related to late presentation or unknown environmental factors and do not have an effect on the ultimate graft outcome.     

Effectiveness of three models for comprehensive cardiovascular disease risk reduction

Cost and accessibility contribute to low participation rates in phase 2 cardiac rehabilitation programs in the United States. In this study, we compared the clinical effectiveness of 2 less costly and potentially more accessible approaches to cardiovascular risk reduction with that of a contemporary phase 2 cardiac rehabilitation program. Low- or moderate-risk patients (n = 155) with coronary artery disease (CAD) were randomly assigned to 12 weeks of participation in a contemporary phase 2 cardiac rehabilitation program (n = 52), a physician supervised, nurse-case-managed cardiovascular risk reduction program (n = 54), or a community-based cardiovascular risk reduction program administered by exercise physiologists guided by a computerized participant management system based on national clinical guidelines (n = 49). In all, 142 patients (91.6%) completed testing at baseline and after 12 weeks of intervention. For patients with abnormal (i.e., not at the goal level) baseline values, statistically significant (p < or =0.05) improvements were observed with all 3 interventions for multiple CAD risk factors. No statistically significant risk factor differences were observed among the 3 programs. For patients with a baseline maximal oxygen uptake < 7 metabolic equivalents, cardiorespiratory fitness increased to a greater degree in patients in the cardiac rehabilitation program and the community-based program versus the physician-supervised, nurse- case-managed program. These data have important implications for cost containment and increasing accessibility to clinically effective comprehensive cardiovascular risk reduction services in low- or moderate-risk patients with CAD.     

Ophthalmic complications and management of Stevens-Johnson syndrome at a tertiary eye care centre in south India

PURPOSE: To review the possible aetiological factors, ocular complications and their management in patients of Stevens-Johnson syndrome with ocular involvement, seen at a tertiary eye care centre. METHODS: We retrospectively reviewed the medical records of patients with Stevens-Johnson syndrome seen between 1987-1998 at L V Prasad Eye Institute. The demographic and possible aetiological factors data causing Stevens-Johnson syndrome were collected. The details of the ocular examination and treatment were collected and examined to determine the pattern of presentation, complications, treatment response and outcome. RESULTS: A total of 95 patients, 40 males (42.10%) and 55 females (57.89%), were identified during the 11-year period. A majority of the patients (n = 53; 55.78%) were between 20 and 40 years of age. All patients had bilateral involvement and most (n = 93; 97.89%) had bilateral symmetrical presentation. The duration from the onset of symptoms to the time of presentation at the institute varied from 6 days to 18 years with most patients presenting after one year (n = 39; 41.05%). The most commonly identified possible causative factor was drugs (n = 55; 51.89%). No definitive cause was identified in 37 (38.94%) patients, and 3 (3.15%) patients had a history of viral fever preceding the onset of Stevens-Johnson syndrome. The best corrected visual acuity at initial presentation was 6/12 or better in 32 (33.68%) patients. Lid abnormalities were observed in 87 (91.51%) patients, conjunctival abnormalities in 92 (96.84%) and corneal complications in 93 (97.89%). All patients were managed medically and 26 (27.36%) patients underwent surgery. CONCLUSION: Stevens-Johnson syndrome remains an important cause of severe visual loss and ocular morbidity, both of which significantly affect the quality of life. Not many medical or surgical options are available even in tertiary eye-care centres. Future advances in immune modulation techniques may prevent many of the sequelae that continue to occur despite the best possible medical care.     

Outcomes of early versus deferred laser after intravitreal ranibizumab in aggressive posterior retinopathy of prematurity

Purpose:The aim of this study was to report the treatment outcomes of early and deferred laser in infants of aggressive posterior retinopathy of prematurity (APROP) after initial treatment with intravitreal Ranibizumab (IVR).Methods:In a prospective, randomized, interventional study, infants with APROP received IVR (0.25 mg) and were randomized into two groups prior to laser. Laser was done at 1 week (group 1) or at 6 weeks or earlier if there was a recurrence of plus disease (group 2). The structural outcome, number of laser spots, duration of laser procedure and refractive error at 6 months were compared. Favorable structural outcome was defined as, complete regression of disease at 6 weeks after laser.Results:63 eyes of 32 infants with APROP were enrolled. Mean gestational age (GA) and birth weight (BW) were 30.2 ± 2.3 weeks and 1294 ± 372.8 grams respectively. GA, BW, and disease severity were comparable at baseline. 27 (90%) eyes in group 1 and 29 (93.5%) eyes in group 2 had favorable structural outcome (P = 0.61) at 6 weeks after laser. Eyes in group 2 (2149.8 ± 688.7) required lesser number of laser spots than group 1 (2570.8 ± 615) (P = 0.01). At six months, more eyes in group 1 had myopic refractive error (Mean spherical equivalent: –1.0D ± 1.3) than those in group 2 (Mean spherical equivalent: 0.5D ± 1.9) (P = 0.002).Conclusion:Infants with APROP receiving IVR have comparable structural outcomes after an early or deferred laser. Moreover, eyes undergoing deferred laser require less number of laser spots and have a less myopia at 6 months after laser.     

Patellar Clunk Syndrome in a Current High Flexion Total Knee Design

This retrospective study of 208 (204 patients) total knee arthroplasties evaluated the incidence of patellar clunk syndrome for two high-flex posterior stabilized knee prostheses; a high-flex fixed bearing prosthesis and a high-flex mobile bearing prosthesis. Patients were followed for up to two years and were evaluated for patellar clunk and component position. Knees receiving the mobile bearing had a significantly higher (p < 0.001) incidence of patellar clunk (15%) than knees receiving the fixed bearing (0%). There was a significantly higher incidence of patellar clunk in males (34.1%; p < 0.01) compared to females (8.6%). Fibrous nodules were treated surgically in 11 of the knees with patellar clunk. The design of this particular mobile bearing knee seems to contribute to patellar clunk syndrome.     

Widespread systemic embolization with isolated tricuspid valve endocarditis

Concurrent systemic and pulmonary septic emboli from isolated right-sided infective endocarditis are rare. One mechanism described is that of intrapulmonary shunting. We describe a case of widespread pulmonary and systemic septic embolization with sequelae in an intravenous drug user with concomitant chronic hepatitis C infection and discuss possible mechanisms involved in the pathogenesis.