IJCMR september issue, 2016

Original Research

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Analysis of Shallow Anterior Chamber Following Trabeculectomy Surgery: A Prospective Study of 32 Eyes Anjali Khairnar1, Anamika Agrawal2, Vaishali Jadhav3, Eesha Gokhale4, Vidhya Khobragade5, Anjali D. Nicholson6 ABSTRACT Introduction: IOP is the commonest risk factor that is modified either medically or surgically in the management of Glaucoma. Surgical options have an edge over the medical line of management in lowering IOP more effectively and trabeculectomy is the commonest surgery performed. In our study, we have aimed to study the predisposing factors and aetiology leading to shallow anterior chamber following trabeculectomy surgery; different management modalities; outcomes in terms of IOP control and bleb formation and complications due to persistent shallow anterior chamber. Material and Methods: It is prospective, consecutive case series study. 32 eyes that developed shallow anterior chamber following trabeculectomy surgery combined with cataract surgery and Mitomycin C application wherever indicated were included in the study. Complete success was considered when IOP was controlled without any medications. Results: 30 patients (32 eyes, Average age 55 years, females 33.33%) were included. The mean duration of follow up was 6 months. Bleb leak (31.25 %) was the commonest cause and its incidence was more (82.35 %) when Mitomycin C was used. 31.25 % eyes required surgical intervention and conjunctival suturing (70 %) was commonly performed surgery. 87.5 % achieved IOP control without any medications and in 6.25 % it was not controlled even with maximum medications. Visual acuity remained same in 56.25%, improved in 28.12 % and worsened in 15.62% with corneal decompensation occurring in 2 of these patients. Conclusion: It is crucial to detect the aetiology of persistent shallow ac earlier and to manage it accordingly to avoid further complications. Keywords: trabeculectomy, Mitomycin C

shallow

anterior

chamber,

Introduction Glaucoma is a chronic progressive optic neuropathy caused by a group of ocular conditions which lead to damage of the optic nerve with loss of visual function.1 Research over the last two decades has identified intraocular pressure (IOP) as the most common risk factor which can be easily modified. The irreversible damage caused by this progressive disorder can only be slowed or halted by appropriate IOP control using medical, laser or surgical modalities. Surgical options have an edge over the medical line of management in lowering IOP more effectively and consistently.2 In India, the situation is compounded due to lack of awareness, delayed presentation, financial constraints and non compliance in terms of treatment and follow-up. So very frequently, ophthalmologists have to prefer surgical line of management. A good surgical technique is one which effectively lowers the IOP, preserves the visual function, relieves pain, and is

safe, long lasting and one which can be easily repeated and adjusted. It should be cost effective with minimal side effects and complications. Achieving proper levels of post-operative IOP should be comprehensive goal, and extreme efforts with remarkable skills are required to accomplish this most challenging goal.3,4 As per the current status of anti glaucoma surgery, the aim is to produce a gap at the sclerocorneal junction so as to communicate the anterior chamber with the subconjunctival space for drainage of aqueous humor out of the anterior chamber. Trabeculectomy, the most commonly performed anti glaucoma surgery involves the creation of a lamellar scleral flap with excision of short length of the Schlemm’s canal, thus producing a filtering channel through the subconjunctival space.5 Following trabeculectomy surgery; IOP, anterior chamber depth and bleb morphology are important parameters during assessment of the post-operative status of the patient. A shallow or flat anterior chamber may occur in the early, intermediate or late postoperative period6-8 A persistent shallow or flat anterior chamber can lead to lenticulo corneal touch, corneal oedema, cataract, hypotony and its related complications like maculopathy and choroidal detachmen.9,10 Study aimed to aimed to find the predisposing factors and aetiology leading to shallow anterior chamber following trabeculectomy surgery; different management modalities; outcomes in terms of IOP control and bleb formation and complications due to persistent shallow anterior chamber.

Material and methods This study was performed in the ophthalmology department of a tertiary care hospital in Mumbai during 2011-2013.The study was approved by the Institutional ethics committee. The study design was prospective. An informed consent was obtained from every study patient. A sample size of 30 was chosen based upon power of the study, level of significance as also upon the prevailing rates of shallow Anterior chamber in large Randomised control trials. Thus having determined the underlying population event rate, we 1 Assistant Professor, 2Associate Professor, 6Professor and Head, Department of Ophthalmology, T.N.M.C and B.Y.L Nair Charitable Hospital, 3Glaucoma Consultant, Bombay City Eye Institute, 4Speciality Medical Officer, B.M.C Eye Hospital, 5Speciality Medical Officer, Seth G.S Medical College and K.E.M.H

Corresponding author: Dr. Eesha Gokhale, Speciality Medical Officer, B.M.C Eye Hospital How to cite this article: Anjali Khairnar, Anamika Agrawal, Vaishali Jadhav, Eesha Gokhale, Vidhya Khobragade, Anjali D. Nicholson. Analysis of shallow anterior chamber following trabeculectomy surgery: a prospective study of 32 eyes. International Journal of Contemporary Medical Research 2016;3(9):2503-2506.

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were able to calculate the estimated sample size for the study. Thirty patients diagnosed with either primary open angle or angle closure glaucoma were included in the study. Patients with advanced cataract underwent cataract extraction combined with trabeculectomy surgery. Mitomycin C (MMC) was used as adjunct in patients with advanced glaucomatous damage, or those undergoing combined surgery and one- eyed patient. Patients with aniridia, congenital or secondary glaucoma, and history of previous intraocular surgery were excluded from the study. Surgical technique In all cases, an 8 mm fornix based conjunctival flap was dissected and10-15 mm side pocketing was done. Wherever indicated 0.2mg/ml of Mitomycin C was applied with polyvinyl sponges under the conjunctival flap for 2 minutes, taking care to avoid contact with the edges of the conjunctival flap or cornea followed by wash with 100 ml of Ringer lactate solution. A 3×3 mm triangular scleral flap was incised and deepened to 1/3rd thickness of sclera. The dissection was done beyond bluish grey zone till clear cornea was reached. Paracentesis was done at this stage to avoid any sudden decompression of the eyeball. A block of 1×1mm deep scleral tissue was marked and excised. Peripheral iridectomy was done. Anterior chamber was formed with balanced salt solution. Scleral flap was sutured with 10-0 nylon with one suture at the apex of the triangle and 1 each on either sides of the triangle. IOP titration was done to adjust the tightness of the scleral sutures. Meticulous conjunctival closure was done with 10-0 nylon suture. Interrupted tight sutures were taken each at the two ends of the conjunctival incision. Subconjunctival injection of antibiotic and steroid was given and eye was patched with antibiotic and atropine drop. In combined procedure, cases of phacoemulsification were done through a temporal incision after sclera flap dissection. In cases with extracapsular cataract extraction, after dissecting the scleral flap, the incision was extended temporally through which cataract extraction was done. Postoperative treatment included steroid antibiotics, atropine and lubricating agents. Patients were followed up on day 1, day 3, day 7, then weekly for 1 month and monthly for 6 months. Laser suture lysis was done with Hoskins gonioscopy lens using frequency doubled Nd: YAG laser at 2-4 weeks post operatively in eyes with high IOP and flat bleb. The patients were followed up closely to watch for shallow AC. Depending on the etiology, different modalities were used to manage the shallow AC. In eyes with shallow AC, low IOP and low bleb, bleb leak was suspected and was confirmed with Seidel’s test. In such cases topical steroids were reduced. Pressure patching was done after putting antibiotic and atropine drops with eye pad folded and placed over the closed eyelid. Patient was observed the next day. Eye drops were restarted if the leak subsided. However, if the leak persisted, then patching was done again. A large diameter (17-21mm) bandage contact lens (BCL) was used if the patient was unable or unwilling to follow up daily. If the bleb leak persisted for more than 4-5 days, conjunctival resuturing was considered. For patients with shallow AC, low IOP and high bleb, over filtration was the cause. In these patients, a trial of conservative treatment was given. Topical steroids were reduced and aqueous suppressants were added when required. Trial of pressure patch or bandage contact lens was also given. In patients where over

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filtration persisted despite the conservative management, extra flap sutures were taken. In patients with shallow AC, high IOP and flat bleb, aqueous misdirection was suspected and the diagnosis was confirmed on UBM. Both eyes of one patient had aqueous misdirection. One eye underwent lensectomy with pars plana vitrectomy. Other eye with advanced glaucomatous damage was treated with topical medications. In the eyes with choroidal effusions i.e., shallow AC, low IOP and low bleb and light brown elevation on the indirect ophthalmoscopy, frequency of topical steroids was increased and oral steroids were added. In one patient with choroidal detachment who presented with lenticulocorneal touch at 2 month follow up, cataract extraction with PCIOL implantation was done on emergency basis. In patients who underwent surgical intervention for post trabeculectomy shallow anterior chamber, topical steroids, antibiotics and atropine were continued till 4-6 weeks post operatively. In the patients where the IOP was not controlled, antiglaucoma medications were added. Conjunctival sutures were removed at 3-4 weeks post operatively. Post-operative refraction was done after 6 weeks

statistical analysis Statistical analysis was done using SPSS software. Regression analysis was done to evaluate the influence of individual variable on outcomes. Unpaired t test and chi square test was used as required.

Results In our study, postoperative shallow AC occurred more in the older age group. Out of 32 eyes, 11 eyes had primary open angle glaucoma and 21 eyes had primary angle closure glaucoma. Females contributed more to the PACG group, i.e.17 out of 21 eyes. Of the 32 eyes, 27 eyes were with cataractous lens and 5 eyes were with clear lens. 10 eyes underwent trabeculectomy, 13 eyes underwent trabeculectomy with mitomycin C and 9 eyes underwent cataract extraction with PCIOL implantation with trabeculectomy with MMC (Table-2). 10 eyes (31.25%) had bleb leak, 3 eyes (9.375%) had choroidal detachment (CD), 7 eyes (21.87%) had bleb leak and CD,3 eyes (9.375%) had over filtration, 2 eyes (6.25%) had aqueous misdirection and 7 eyes (21.87%) had low scleral rigidity as the cause of shallow AC.17 eyes had bleb leak and MMC was used in 14 (82.35%) of them. Surgical intervention was needed in 10 eyes out of which conjunctival resuturing was done in 7 eyes, scleral flap resuturing was done in 1 eye, cataract extraction with PCIOL implantation was done in 1 eye and lensectomy with pars plana vitrectomy was done in 1 eye (Table-2). 6 months follow up visit revealed corneal decompensation in 2 eyes and cataract progression occurred in 4 eyes. Visual acuity improved in 9 eyes (28.12%), remained same in 18 eyes (56.25%) and worsened in 5 eyes (15.62%) (Figure-1). When IOP below 21 mm Hg was achieved without medications with good bleb, it was considered as complete success; if with medications then as qualified success and if uncontrolled then as failure. Out of the 32 eyes, complete success was achieved in 28 eyes (87.5%), qualified success in 2 eyes (6.25%) and failure in 2 eyes (6.25%) (Table-3).

Discussion In our study, the incidence of shallow Anterior Chamber was

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Khairnar, et al.

maximum in 17 eyes (53.13%) where the baseline IOP was in the range between 31 to 40 mm Hg. According to Suzhen Nie, occurrence of shallow anterior chamber after filtration surgery is related to prolonged ocular hypertension and abrupt drop in IOP during surgery.11,12 Out of the 32 eyes, 24 eyes (i.e.75%) eyes were myopic, and remaining 8 eyes (25%) were hypermetropic. Low scleral rigidity can be the contributing factor for the occurrence of shallow anterior chamber in myopia. According to Castren J A et al, the scleral rigidity of the myopic eye is lower as compared to hypermetropic or emmetropic eyes.13 in our study, 8 eyes (25%) had primary open angle glaucoma and 24 eyes (75%) had primary angle closure glaucoma. In primary angle closure glaucoma, anteroposterior lens thickness and age related laxity of the zonules causing forward movement of the lens cause pupillary block. In later stages, the forward movement of the lens iris diaphragm causes angle closure.14 In our study, all the eyes underwent trabeculectomy with fornix based conjunctival flap. A flat anterior chamber following surgery has been reported to be more common following trabeculectomy with a fornix based flap than a limbus based flap.15 Out of the 17 eyes in which bleb leak occurred, MMC was used in 13 eyes (82.35%). Thus, the incidence of leak was found to be more when mitomycin C was used.16-19 this is also observed in the study conducted by Anand N et al which shows that MMC application over the area of scleral flap dissection during glaucoma surgery is associated with a high incidence of bleb leaks.20 The incidence of bleb leaks probably is higher Etiology

No.of eyes % of eyes (of 22) Bleb leak 8 36.37 Choroidal detatchment (CD) 3 13.64 Bleb leak+CD 1 4.54 Overfiltration 2 9.09 Low scleral rigidity 7 31.82 Aqueous misdirection 1 4.54 Total 22 100 Table-1: Etiology of shallow AC in the cases who were managed conservatively

No.of eyes % of eyes (of 10) Conjunctival resuturing 7 70 Scleral flap resuturing 1 10 Cataract extraction +PCIOL 1 10 Lensectomy+pars plana vitrectomy 1 10 Total 10 100 Table-2: Surgical management of shallow AC.

Analysis of Shallow Anterior Chamber

in trabeculectomies supplemented with antimetabolites than nonsupplemented surgeries. This can be prevented by taking care to avoid the contact of antimetabolite with the edges of the conjunctival flap, use of polyvinyl sponges for its application, and tight meticulous conjunctival suturing. Also it is better to avoid the use of antimetabolite even if planned when there is slightest doubt about the conjunctival integrity due to surgical trauma. In our study, shallow anterior chamber occurred in both eyes of one patient due to aqueous misdirection that was confirmed on ultrasound biomicroscopy.21 This is a condition in which if one eye is affected then there are high chances that the other eye would also get affected.22-23 This was also seen in a case studied by Stan C where a patient with angle closure glaucoma underwent trabeculectomy in both eyes.24 In the right eye, six months after surgery, the patient presented with intraocular hypertension, shallow anterior chamber and cataract. The left eye (operated six months after the right eye) showed same signs two weeks after surgery. Diagnosis was malignant glaucoma in both eyes. In our study, 22 eyes (68.75%) were managed conservatively.25-30 Surgical intervention was required in 10 eyes (31.25% %) and it included conjunctival resuturing in 7 eyes (21.87%), scleral flap resuturing in 1 eye (0.31%) in which over filtration was the etiology, lensectomy with pars plana vitrectomy in 1 eye (0.31%) which had aqueous misdirection and cataract extraction with PCIOL implantation in 1 eye (10%) in which lenticulocorneal touch had occurred due to choroidal detachment. At the end of 6 months, 2 eyes (6.25%) had corneal decompensation and 4 eyes (12.5%) developed cataract. According to the study conducted by Husain R et al,5 trabeculectomy is associated with progression of lens opacity predominantly in the posterior sub capsular region. Modification of risk factors such as postoperative steroid use may delay progression. Our study also gives similar results. Another study Visual outcome at 6 months VA↑

VA no change

VA↓

25% 21.87%

21.87%

Surgery done

9.375%

9.375% 6.25%

6.25%

0

0

TRAB

TRAB+MMC

Figure-1: Visual Outcome at 6 months

TRAB+MMC +PE+PCIOL

Etiological factor

Complete success Qualified success Failure No.of eyes % of eyes No.of eyes %of eyes No.of eyes % of eyes Leak 10 31.25 0 0 0 0 CD 3 9.375 0 0 0 0 Leak+CD 7 25 0 0 0 0 Overfiltration 3 9.375 0 0 0 0 Aqueous misdirection 0 0 0 0 2 6.25 Low scleral rigidity 5 15.625 2 6.25 0 0 Total 28 87.5 2 6.25 2 6.25 Table-3: Etiological factor for post op shallow AC and their impact on success of the surgery.

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by the AGIS (Advanced Glaucoma Intervention Study) shows that the nuclear and cortical regions of the lens also get affected after filtration surgery.Globally, the reported incidence of cataract progression after filtering surgery varies greatly, from 2% to 53%. Use of MMC was associated with more chances of progression of cataract in our study. At the end of 6 months, the visual acuity improved in 9 eyes (28.12%), remained same in 18 eyes (56.25%) and worsened in 5 eyes (15.62%), out of which 3 eyes had undergone trabeculectomy and 2 had undergone trabeculectomy with MMC. Out of the 3 eyes which had undergone trabeculectomy, visual acuity worsened because of aqueous misdirection in one patient (with advanced glaucoma), lenticulocorneal touch with corneal decompensation in one patient and over filtration with subsequent cataract development in one patient. In the 2 eyes where trabeculectomy with MMC was performed, visual acuity was reduced due to cataract progression in one eye and due to decompensated cornea in other eye. 30 eyes (93.75 %) were having diffuse, moderately vascularized and elevated bleb. Bleb failure i.e. flat, vascularized bleb occurred in two eyes with malignant glaucoma.

Conclusion Shallow anterior chamber occurs commonly following trabeculectomy surgery. Most of them respond to conservative management. However; in cases with persistent shallow anterior chamber, detecting the etiology immediately and prompt management if required surgically should be considered to prevent complications.

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Foster PJ, Buhrmann R, Quigley HA, Johnson GJ. The definition and classification of glaucoma in prevalence surveys. The British Journal of Ophthalmology. 2002; 86:238-242. The Advanced Glaucoma Intervention Study (AGIS): 7. the relationship between control of intraocular pressure and visual field deterioration. The AGIS Investigators. Am J Ophthalmol. 2000;130:429–440. South East Asia Glaucoma Interest Group. Asia Pacific Glaucoma Guidelines. 2008;12 Available at:http://www. seagig.org/toc/APGG2_fullversionNMview.pdf.2009. Quigley HA, Broman A. The number of persons with glaucoma worldwide in 2010 and 2020. Br J Ophthalmol. 2006;90:262-67. Edmunds B, Thompson JR, Salmon JF, Wormald RP. The National Survey of Trabeculectomy. II. Variations in operative technique and outcome. Eye (Lond). 2001;15:441-8. Liebmann JM, Ritch B: Complications of glaucoma filtering surgery. Glaucomas, St Louis: Mosby. 1996:17031736. Alwitry A, Rotchford A, Patel V, Abedin A, Moodie J, King AJ. Early bleb leak after trabeculectomy and prognosis for bleb failure. Eye (Lond). 2009;23:858-63. Jampel HD, et al: Perioperative complications of trabeculectomy in the Collaborative Initial Glaucoma Treatment Study (CIGTS), Am J Ophthalmol. 2005; 140:16-18. Henderson H W A,Ezra E,Murdoch I E. Early postoperative trabeculectomy leakage: incidence, time course, severity, and impact on surgical outcome.Br J Ophthalmol.

2004;88:626-29. 10. Stewart WC, Shields MB. Management of anterior chamber depth after trabeculectomy. Am J Ophthalmol. 1988;106:41–44. 11. Suzhen Nie.Analysis on reasons and treatment approaches for shallow anterior chamber following glaucoma surgery. Eye Science. 2011;26:100-102. 12. Castren J A,Pohjola S.Myopia and scleral rigidity. Acta ophthalmologica. 1962;40:33-36. 13. Quigley H, Friedman D, Congdon N. Possible mechanisms of primary angle-closure and malignant glaucoma. J Glaucoma. 2003;12:167–180. 14. Al-Haddad C, Abdulaal M, Al-Moujahed A, Ervin AM. Fornix-based versus limbal-based conjunctival trabeculectomy flaps for glaucoma. Cochrane Database Syst Rev. 2015;11:CD009380. 15. Costa VP, Wilson RP, Moster MR et al. Hypotony maculopathy following the use of topical mitomycin C in glaucoma filtration surgery. Ophthalmic Surg. 1993; 24:389–394. 16. Kee C, Kaufman PL. Profound long-term hypotony without maculopathy after trabeculectomy with antimetabolite. Acta Ophthalmol (Copenh). 1994;72:388–390. 17. Bardak Y, Cuypers MH, Tilanus MA, Eggink CA. Ocular hypotony after laser suture lysis following trabeculectomy with mitomycin C. Int Ophthalmol. 1997;21:325–330. 18. Hong C, Hyung SM, Song KY et al. Effects of topical mitomycin C on glaucoma filtration surgery. Korean J Ophthalmol. 1993;7:1–10. 19. Anand N. Deep sclerectomy with mitomycin C for glaucoma secondary to uveitis. Eur J Ophthalmol. 2011;21:708-14. 20. Schroeder W, Fischer K, Erdmann I, Guthoff R. Ultrasound biomicroscopy and therapy of malignant glaucoma. Klin Monatsbl Augenheilkd. 1999;215:19–27. 21. Chandler PA, Grant WM. Mydriatic-cycloplegic treatment in malignant glaucoma. Arch Ophthalmol. 1962;68:353– 59. 22. Chandler PA, Simmons RJ, Grant WM. Malignant glaucoma. Medical and surgical treatment. Am J Ophthalmol. 1968;66:495–502. 23. Stan C. [Bilateral malignant glaucoma--case report]. Oftalmologia. 2005;49:33-4. Romanian. 24. Diane A, Schultz, Schuman, Singh. Managing a shallow anterior chamber after glaucoma filtering surgery.eyeworld (glaucoma); June 2000. 25. Blok MD, Kok JH, van Mil C, et al. Use of the Megasoft Bandage Lens for treatment of complications after trabeculectomy. Am J Ophthalmol. 1990;110:264. 26. Shoham A, Tessler Z, Finkelman Y, et al. Large soft contact lenses in the management of leaking blebs. CLAO J. 2000; 26:37. 27. Porges Y, Ophir A. Hollow bandage contact lens. Ophthalmic Surg Lasers. 2001;32:124. 28. Simmons RJ, Kimbrough RL. Shell tamponade in filtering surgery for glaucoma. Ophthalmic Surg. 1979;10:17. 29. Zalta AH, Wieder RH. Closure of leaking filtering blebs with cyanoacrylate tissue adhesive. Br J Ophthalmol. 1991;75:170.

Source of Support: Nil; Conflict of Interest: None Submitted: 05-07-2016; Published online: 20-08-2016

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ISSN (Online): 2393-915X; (Print): 2454-7379

Original Research

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A Comparative Study of Brachial Plexus Block using Infraclavicular (Coracoid) and Axillary Approaches in Forearm Surgery Chandrasekaran Ayyavu1, Geethanjali Rajamani2, Kundhavi Devi3, Heber Anandan4 ABSTRACT Introduction: Regional anaesthesia is more preferred over general anaesthesia considering easy techniques and the advantage of an awake patient. The Brachial plexus can be blocked by various approaches namely interscalene, supraclavicular, infraclavicular and axillary. Aim of this study was to compare two approaches of brachial plexus block (Infraclavicular block using coracoid approach and axillary block). Material and methods: A prospective, randomized comparative study comprising of 60 patients, divided randomly into two group. Group A received Infraclavicular block using lateral coracoid approach. Group B received Axillary block. Duration of surgery, Time taken to perform block, Time taken for the onset of sensory blockade, motor blockade, the degree of motor blockade, Discomfort during blockade, positioning or insertion of the needle, tourniquet tolerance and complications were observed. Results: Time taken to perform block, successful blockade, tourniquet tolerance was better in coracoid approach group when compared to axillary group. Onsets of both sensory and motor blockade were similar in both the groups. Complication like vascular puncture was found to be more with axillary block than with infraclavicular block. Conclusion: Brachial plexus blockade with infraclavicular technique by the coracoid approach was found to be better than Axillary approach. Keywords: Infraclavicular block, Axillary block, Brachial plexus block, vascular puncture and Nerve Stimulator

Introduction The merits of regional anaesthesia compared to general anaesthesia are many and have been well documented. The pain relief during the perioperative period can be maintained in the postoperative period, reducing the occurrence of side-effects caused by opioids1,2 (especially pruritus, nausea, vomiting and sedation). There are various approaches to the brachial plexus block such as Supraclavicular, Interscalene, Infraclavicular and Axillary approaches.3 The infraclavicular approach of brachial plexus has its own merits like decreased incidence of discomfort during patient positioning and also reduction in the chances of pneumothorax.4 The various modalities widely in practice to identify a nerve to facilitate the block are elicitation of paresthesia (blind techniques), stimulation of peripheral nerves (nerve locator) and ultrasound guided technique which is gaining importance in the recent years. The chances of successful nerve blockade seem to be high with the use of nerve locator than with blind techniques.5 Aim of this study was to compare two different approaches of brachial plexus block using the Infraclavicular technique by the coracoid approach and Axillary approach using the nerve stimulator in Forearm surgeries.

Material and Methods A prospective, randomized comparative study was done in

Department of Anesthesiology, Government Kilpauk Medical College Hospital and Government Royapettah Hospital. Institutional Ethics committee approval and written Informed consent were obtained. Patients of ASA 1 and 2 of both genders, age 18 to 45 years, weighing between 45 to 70 kg posted for forearm surgeries were selected for the study. Patients with hypersensitivity to the drug, chest wall deformities, any distortion of local anatomy, neck contractures, local infection, coagulopathy, pneumothorax, patient’s refusal and pregnant patients were excluded. Patients were all evaluated preoperatively and clinically examined. Investigations including biochemical, electrocardiogram, CXR were done prior to the assessment. Procedures were explained in detail and written consent was obtained. Patients were divided randomly into two groups. GROUP A: 30 patients receiving infraclavicular block of brachial plexus using lateral coracoid approach. GROUP B: 30 patients receiving brachial plexus block using axillary approach. All the patients selected for the study were kept in nil per oral state of about 8 hours before taking up for the procedure. Local anaesthetic test dose was carried out using 0.1 ml of Injection. Lignocaine 2%. Intravenous access was obtained with 18G IV cannula. Antacid prophylaxis with Injection Ranitidine 50 mg and Injection Ondansetron 0.1 mg/kg were given intravenously. Injection Midazolam (0.02 – 0.05 mg/kg) was given as premedication intravenously 10 minutes before the procedure. The procedure was performed in the theatre. Boyle machine, suctioning equipment, emergency intubation cart, Manual resuscitation bag with mask and reservoir were kept ready. Routine monitoring with ECG, Pulse Oximetry, NIBP was done. In patients belonging to group A, infraclavicular block of brachial plexus was carried out using lateral coracoid approach. Under strict aseptic precautions, identification of the coracoid process was done and a point about 2 cm inferior and 2 cm medial to coracoid process was infiltrated with 1-2 ml of 1% lignocaine. Insulated stimulating needle was then inserted at right angles to 1 Professor, 3Professor, Department of Anaesthesiology, Department of Anaesthesiology, Government Kilpauk Medical College,

The Tamilnadu Dr. M.G.R. Medical University, Chennai, Senior Resident, Department of Anaesthesiology of Government Kilpauk Medical College, Kilpauk, 4Senior Clinical Scientist, Department of Clinical Research of Dr.Agarwal’s Health care Limited, Tamilnadu, India 2

Corresponding author: Dr.Chandrasekaran Ayyavu, Department of Anaesthesiology, Kilpauk Medical College Hospital, Chennai – 600010, Tamilnadu, India How to cite this article: Chandrasekaran Ayyavu, Geethanjali Rajamani, Kundhavi Devi, Heber Anandan. A comparative study of brachial plexus block using infraclavicular (coracoid) and axillary approaches in forearm surgery. International Journal of Contemporary Medical Research 2016;3(9):2507-2510.

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the skin. The infraclavicular block was given with the guidance of a nerve stimulator which was attached to the proximal point of 50mm, 22 G insulated stimulator needle until the distal motor response (contraction of the middle and ring finger) was elicited with 0.5 mA current. Then Injection of 25ml – 30 ml of 0.5% bupivacaine was done with intermittent aspiration. In patients belonging to group B, Axillary block was performed using multiple Injection technique. All four main branches of brachial plexus (ulnar, radial, median and musculocutaneous nerves) were located based on the specific twitches elicited by stimulation. Arm flexion for Musculocutaneous nerve; Arm and finger extension, supination for Radial nerve; Wrist, second and third finger flexion, pronation for Median nerve; Fourth and fifth finger flexion, thumb adduction for Ulnar nerve. 5ml of 0.5% bupivacaine was injected for each nerve. Duration of surgery (in minutes), time taken to perform block (in minutes), time taken for the onset of sensory blockade (in minutes), time taken for the onset of motor blockade (in minutes), degree of motor blockade, discomfort during blockade, discomfort during positioning or insertion of the needle, tourniquet tolerance and complications were observed. Success rate – sufficiency of the block to perform surgery was observed. Block was termed as successful when it does not need any supplementation. Patients in whom the block was insufficient, were supplemented with either Injection Fentanyl (2 µ/kg) or local infiltration at the surgical site. Those converted to general anaesthesia were excluded from the study.

Statistical analysis Data obtained were subjected to statistical analysis. Continuous variables were analysed using Independent sample t test and chi- square test was used to analyse categorical variables. P value less than 0.05 was taken as statistically significant.

Results 60 patients were included in the study, distribution of demographic profile like age, sex, weight seems to be equal and comparable among the two study groups. Time taken to perform block ranges from 3 to8 minutes in group A with mean of 5.13 and standard deviation of 1.279 whereas in group B, it ranges from 6 to 11 minutes with mean 8.53 and standard deviation 1.137. The ‘p’ value was found to be 200. These results are consistent with a previous study by Gopinath et al who found mean CD4 count in patients with mycobacteremia to be 173.63 ± 49.2, which was significantly lower than the CD4 count in patients not having mycobacteremia (274.1 ± 32.8) with a P-value of 0.043.39 This association could be explained by the fact that lower CD4 counts are associated with an impairment of CMI due to decreased production of IFN-γ and other effector molecules.10,11 There are also certain limitations of the study. The small sample size may be inadequate to draw definite conclusions. No control population of patients without the diagnosis of tuberculosis was enrolled, so exact sensitivity of the test could not be calculated. However, it can reasonably be suggested that blood culture for mycobacteria may be used for diagnosis of tuberculosis in HIV positive patients who are likely to have a disseminated disease.

8.

9. 10. 11.

12.

13.

14.

15.

16.

Conclusion Mycobacteremia is not an infrequent occurrence in current clinical practice Mycobacteremia is common in HIV positive patients and can also be seen in HIV negative patients. It is strongly associated with HIV infection, low CD4 counts in HIV positive patients, negative Mantoux test and presence of disseminated tuberculosis. Detection of mycobacteremia provides with an additional armamentarium in the diagnostic tools for tuberculosis especially in the setting of disseminated TB or in patients with HIV-TB coinfection

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of patients with HIV infection and tuberculosis caused by multiple drug resistant bacilli. Ann Intern Med. 1992;117:184-90. Ruf B, Schurmann D, Brehmer W, Mauch H, Pohle HD. Mycobacteremia in AIDS patients. Klin Wochenschr. 1989; 67:717-722. Nightingale SD, Byrd LT, Southern PM, Wynne DA. Incidence of Mycobacterium avium-intracellulare complex bacteremia in human immunodeficiency virus-positive patients. J Infect Dis. 1992;165:1082-5. Salzman BR, Motyl MR, Friedland GH, McKitrick JC, Klein RS. Mycobacterium tuberculosis bacteremia in acquired immunodeficiency syndrome. JAMA. 1986;256: 390-1. Ramachandran R et al. Mycobacteremia in tuberculosis patients with HIV infection. Int J Tub. 2002;50:29-31. Carmen et al. Detection of mycobacteremia in bloodstream of patients with AIDS in a university hospital in Brazil. The Brazilian J Inf Disease. 2001;5:252-259. Barnes PF, Arevalo C. Six cases of Mycobacterium tuberculosis bacteremia. J Infect Dis. 1987;156:377-9. Bouza E, Martin-Scapa C, Bernaldo de Quiros JC, Martinez-Hernandez D, Menarguez J, Gomez Rodrigo J, et al. High prevalence of tuberculosis in AIDS patients in Spain. Eur J Clin Microbiol Infect. 1988;7:785-8. Grinsztejn B, Fandinho FC, Veloso VG, Joao EC, Lourenco MC, Nogueira SA, Fonseca LS, WerneckBarroso E. Mycobacteremia in patients with the acquired immunodeficiency syndrome. Arch Intern Med. 1997; 57:359-63. Bacha et al. Prevalence of Mycobacteremia in Patients with AIDS and Persistant Fever. The Brazilian J Inf Disease. 2004;8:290-97. Shafer RW, Goldberg R, Sieera M, Glatt AE, Frequency of mycobacterium tuberculosis bacteremia in patients with tuberculosis in an area endemic for AIDS. Am Rev Respir Dis. 1989;140:1611-13. Fandinho FC, Grinsztejn B, Veloso VG, Lourenco MC, Werneck-Barroso E, Joao E, Nogueira SA, Fonseca LS. Diagnosis of disseminated mycobacterial infection: testing a simple and inexpensive method for use in developing countries Bull World Health Organ. 1997;75:361-6. Bouza E, Diaz-Lopez MD, Moreno S, Bernaldo de Quiros JC, Vicente T, Berenguer 1. Mycobacterium tuberculosis bacteremia in patients with and without human immunodeficiency virus infection. Arch Intern Med. 1993; 153:496-500. Sungkanuparph S, Pracharktam R. The Yield of Mycobacterial Blood Culture in the Diagnosis of Disseminated Mycobacterial Infection in Patients with and without HIV Infection. J Infect Dis Antimicrob Agents. 2002;19:1-5. David S. T, Mukundan U, Brahmadathan K.N., John T. J. Detecting mycobacteremia for diagnosing tuberculosis. Indian J Med Res. 2004;119:259-266. Gopinath K., Kumar S., Singh S. Prevalence of mycobacteremia in Indian HIV-infected patients detected by the MB/BacT automated culture system. Eur J Clin Microbiol Infect Dis. 2008;27:423–431. Stone BL, Cohn DL, Kane S, Hildred MV, Wilson ML, Reves RR. Utility of paired blood cultures and smears in diagnosis of disseminated mycobacterium avium complex infections in aids Patients J Clin. Microbiol. 1994;32:841842.

41. Swaminathan S, Nagendran G. HIV and tuberculosis in India. J Biosci. 2008;33:527-37. 42. Maniar JK, Kamath RR, Mandalia S, Shah K, Maniar A. HIV and tuberculosis: partners in crime. Indian J Dermatol Venereol Leprol. 2006;72:276-82.

Source of Support: Nil; Conflict of Interest: None Submitted: 12-05-2016; Published online: 27-08-2016

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Prevalence of Mycotic Flora with Pulmonary Tuberculosis Patient in a Tertiary Care Hospital Babita1, Sanjeev Suman1, Prabhat Kumar2 ABSTRACT Introduction: Tuberculosis is one of the oldest infectious diseases known to mankind. Pulmonary mycosis superimposed on tuberculosis infection influences treatment and has high mortality. This study was done in order to study the prevalence of fungal infection in diagnosed pulmonary tuberculosis patients. Material and Methods: The study was conducted in Patna Medical College Hospital, Bihar from February 2011 to January 2012. 75 sputum samples were collected in the Department of Tuberculosis and Chest Disease. Result: Out of 75 samples 24% showed positive culture growth and 20% showed fungal elements in direct examination. Candida albicans was the most dominant pathogens (44.4%). Conclusion: The coexistence of fungal with tuberculosis adds complication to patient’s condition by adding more damaging and fatal dimensions to it. Keywords: Pulmonary tuberculosis, opportunistic fungal.

Introduction Tuberculosis is one of the oldest infectious diseases. About 1.7 million people die annually around the world from tuberculosis. Each year nearly 2 million people in India develop TB and also annually around 330,000 Indians die due to TB.1,2 Reports shows that India accounts for one fifth of global incidence of TB and it is on the top of list of 22 high TB burden coleus.3 Tuberculosis patents are immunocompromised and this is most important reason to explain that these patients may have superadded fungal infections.4 The incidence of life-threatening fungal infection has been increasing in recent years and the increasing incidence has been correlated with increasing number of immunocompromised patients.5-7 Pulmonary mycosis superimposed on tuberculosis infection influences treatment and has high mortality.8 As we know that Candida albicans has emerged as pathogenic fungus in patients with broncho – pulmonary disease. May be because of increased use of broad spectrum antibiotics and immunosuppressive drugs.9,10 The present study was conducted to find the fungal infection in patients with pulmonary tuberculosis. Most of the times these fungal infections are not diagnosed and often mistaken for recurrence of tuberculosis. These opportunistic infections if diagnosed early can be treated effectively to prevent the prognosis of disease.

Material and Methods The present study was conducted to isolate fungus which caused infection in patients with pulmonary tuberculosis. This study was conducted in a tertiary care hospital, Patna Medical college Hospital, Bihar from February 2011 to January 2012. Randomly collected 75 diagnosed pulmonary tuberculosis patients sputum samples were included in this study. Treated and cured cases were excluded. Sputum samples were collected in Department

of Tuberculosis and Chest Disease and brought to Microbiology department. Further process was done such as direct examination and culture. Direct examination of specimens were done by I. Direct KOH Mount (10% Potassium Hydroxide) II. Gram’s Stain Then samples were inoculated onto sabouraud’s dextrose agar with chloramphenical and incubated at 250 C for 6 weeks. Identification was done by gross examination of the colony and confirmed microscopically by emulsifying a portion of colony in LPCB. Germ tube test was done for identification of different species of Candida. This study was done after institutional ethical clearance.

Result Sputum of 75 diagnosed pulmonary tuberculosis patients were taken and subjected to direct examination and then cultured in SDA. In direct examination, 19 samples (20%) showed presence of fungal elements while 46 (61.3%) were negative. 18(24%) culture showed fungal growth. Candida albicans was isolated in 8 cases (44.4%) Aspergillus niger was isolated in 6 cases (33.3%), Aspergillus fumigatus in 3 cases (16.5%) and Aspergillus flavus in only 1 case (5.5%).

Discussion The relationship of fungus and tuberculosis infection has been reported in past. We have reported 24% cases of opportunistic fungal infections in tuberculosis patients. This was strongly proved by study of Shome et al8 and Bansod et al11 who reported 18% and 40%. In the present study majority of the isolates were candida albicans 44.4% which correlates with the study of Khanna et. al12 and Jain et.al.13 where they isolated Candida albicans in 22.73% cases and 18.57% cases respectively. Aspergillus niger was isolated in 33.3% cases which was very close to other study.14 Mathavi15 et al showed 4.6%. Aspergillus fumigatus was isolated in 16.5% cases.12 Aspergillus flavus was isolated in 5.5%.15,16 Candida albicans proved to be the most common fungal agent.17 Candida species are emerging as a pathogenic fungus in patients with broncho – pulmonary diseases. Association of Candida and Mycobacterium tuberculosis patients has increased concern for studying the various Candida spp. and its significance in pulmonary tuberculosis patients during current years.18

Assistant Professor, 2Professor and HOD, Department of Microbiology, Nalanda Medical College Hospital, India 1

Corresponding author: Dr. Babita, Nalanda Scan Centre, 0/63, Doctor’s Colony, Kankarbagh, Patna. Bihar, Pin – 800020, India How to cite this article: Babita1, Sanjeev Suman, Prabhat Kumar. Prevalence of mycotic flora with pulmonary tuberculosis patient in a tertiary care hospital. International Journal of Contemporary Medical Research 2016;3(9):2563-2564.

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Conclusion Fungal infections of lungs are important infective processes. Diseases like opportunistic infections if it is diagnosed early can be treated and thus can prevent progression to fibrotic stage. Taking this account the present study tries to assess some of aspects of pulmonary mycosis.

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Mamkiericz E. Mycobacterium tuberculosis and Candida albicans: a study of growth promoting factors. Can J Microbiol. 2010;2:85-9. Inside Indian March 24, 2009, special TB Issue http//www. uasaid.gov/in/pdfs/ii March 20.09.pdf. Central TB Division. Managing the Revised National Tuberculosis Control Programme in your area: A Training course.Modules. 2005;23:1-4. Solov’eva TN, Karaen ZO, Ignativa SM, Mizonov N. The diagnosis of mycotic infections in patients with respiratory Tuberculosis. 1991;7:37-40. Bodey GP, Bueltmann B, Duguid W, Gibbs D, Hanak H, Hotchi M et al. Fungal infections in cancer patients, an international autopsy survey. Eur. J.Clim. Microbial Infect Dis. 1992:11;99-109. Beck-Sague C, Jarvis WR. Secular trends in epidemiology of nosocomial fungal infection in the United States, 19801990. J Infect. Dis. 1993:167;1247-1251. Denning Dul. Invasive aspergillosis. Clin Infect. Dis. 1998:26;781-803. Shome SK, Upreti HB, Singh MM, Pamra SP. Mycosis associated with Pulmonary Tuberculosis. Ind J Tub. 1976;23:64-68. Latha R, Sasikala R, Muruganandam N, Venkatesh Babu R. Studying on the shifting paterns of Non Condido albicans Candida in lower respiratory tract infections and evaluation of the CHROM agar in identification of the Candida species. J Microbiol Biotech Res. 2011;1:4-9. Ochieng W,Wanzala P, Oishi, Ichimura H, Lihana R, Mpoke S, Mwaniki D, Okoth FA. Tuberculosis and oral Candida species surveillance in HIV infected individuals in Northern Kenya, and the implications on tuberculin skin test screening for DOPT-P. East Afr Med J. 2005:82:60913. Bansods, Rai M. Emerging of mycotic infection in patients infected with mycobacterium tuberculosis world. Journal of Med. Sciences. 2008;3:74-80. Khanna BK, Nath P, Ansari AH. A study of mycotic flora of respiratory tract in pulmonary mycotic flora of respiratory tract in pulmonary tuberculosis. Indian Journal of Tuberculosis. 1977;24:159-162. Jain SK, Agarwal RL, Sharma DA, Agarwal M. Candida in Pulmonary Tuberculosis. Journal of Post Graduated Medicine. 1982;28:24-29. Shahid M, Malik A, Bhargava R. Prevalence of Aspergillosis in Chronic Lung Disease. Indian Journal of Med Microbio. 2001;19:201-205. Mathavi S, Shankar R, Sashikala G, Kavitha A. A study on mycotic infections among sputum positive pulmonary tuberculosis patients in Salem district. Paripex- Indian Journal of Research. 2015;4:299-302. Sanchez MS, Lloyd-Smith JO, Getz WM. Monitoring linked epidemics: The case of tuberculosis and HIV. PLo S One. 2010;5:8796. Kali A, Charles MVP, Joseph NM, Umadevi S, Kumar S,

Easow JM, Prevalence of Candida co-infection in patients with pulmonary tuberculosis. AMJ. 2013;6,8:387-391. 18. Naz SA, Tariq P. A study of the trend in prevalence of opportunistic Candida co- infections among patients of pulmonary tuberculosis. Pak J Bot. 2004;36:857.

Source of Support: Nil; Conflict of Interest: None Submitted: 07-07-2016; Published online: 27-08-2016

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A Study Evaluating Xanthelasma Palpebrarum Clinically and Biochemically Rohit Aggarwal1, Praveen Kumar Rathore2 ABSTRACT Introduction: Xanthelasma palpebrarum refers to lipid deposition that occurs on eyelids and inner canthi. It may be associated with certain systemic conditions. Present study was done to know / understand about the relationship between xanthelasma and lipid profile. Material and Methods: In this type of Case control study, 30 cases with Xanthelasma palpebrarum and 30 healthy individuals of similar age group were selected. All cases and controls underwent clinical examination and fasting lipid profile study with written consent. A detailed history was taken from the patients about the lesions, with respect to age of onset, duration of lesion, progression of lesion etc. All cases underwent lipid profile study in empty stomach. Result: Total cholesterol levels were increased in 53.34% (16cases) as compared to 10 controls (30%), making it highly significant, triglycerides levels were increased in 19cases (63.34%) as compared to 8 controls (26.67%) . No significant relationship was observed with respect to other cholesterol parameters. Conclusion: This study showed that there is a significant elevation in total cholesterol and triglycerides in Xanthelasma palpebrarum patients as compared to controls, thus making lipid profile compulsory for all patients with Xanthelasma. Keywords: Xanthelasma palpebrarum (XP), Lipid profile

INTRODUCTION Xanthelasma palpebrarum (XP) refers to xanthoma that occurs on eyelids and inner canthi. The term ‘Xanthoma’ means ‘yellow tumour’ i.e. deposition of fat or lipid over the eyelids and around the eye.1 It was Erasmus Wilson2 who first coined the term xanthelasma nearly more than 100 years ago. Xanthelasma is derived from two Greek terms “xanthos” (yellow) and “elasma” (beaten metal plate). The commonest type of cutaneous xanthoma, is Xanthelasma palpebrarum. It’s symmetrical, bilateral and permanent. XP is highly associated with atherosclerosis, cardiovascular disease, diabetes, obesity and pancreatitis.1 Xanthelasma usually is seen in the 3rd – 5th decade, more commonly seen in women than in men. These xanthomas are yellowish in colour and are soft, velvety lesions on the eyelids.1 The exact cause is not known however any disturbance in the lipid metabolism contributes to its etiopathogenesis.3 Type V Hypolipoproteinemia often result in deposition of cholesterol in the skin. The risk of Coronary Artery Disease is more commonly associated with individuals presenting with XP than without XP.4 The LDL accumulated in the blood, lines along the wall of capillary blood vessels. When biochemical lipid profiles are considered for patients presenting with XP, it is noticed that there is a higher level of LDL and VLDL cholesterol and lower level of HDL cholesterol which is an important predictor for Coronary Artery Disease (CAD).5

Present study aimed to understand the relationship between xanthelasma and lipid profile.

MATERIAL AND METHODS Study design: A descriptive case control study was conducted from Sept 2015 to Feb 2016 in the department of Dermatology, Rohilkhand Medical College and Hospital, Bareilly. Sample was selected based on the inclusion and exclusion criteria. Prior to the study an informed consent was obtained from the patients. Inclusion Criteria: Patients attending Dermatology O.P.D. with xanthelasma palpebrarum. Patients of the age group 25-70 years of both sexes willing to undergo lipid profile test were included in the study. Similarly the age matched and disease free subjects taken as control group. Exclusion criteria: Patients not willing for lipid test. Grouping: Group A consisted of age and sex matched 30 Controls without Xanthelasma Palpebrarum and Group B consisted of 30 Cases with Xanthelasma Palpebrarum. All were subjected to undergo lipid profile test after which the study was carried. Methodology: A detailed history was taken from all the 30 patients regarding the skin lesion, in respect to appearance and duration of lesion. Past history regarding any systemic conditions like hypertension, diabetes mellitus, hyperlipidemia and their respective form of treatment were taken into account. Family history of xanthomas was also noted. General and systemic examination was also done for all cases. All subjects underwent a detailed cutaneous examination and morphology of the lesion in the eyelids was noted. All cases (subjects and controls) underwent lipid profile study (Total cholesterol, LDL cholesterol, HDL cholesterol, VLDL) in empty stomach. From each patient (Control and Case) 2ml of blood was collected aseptically and serum was separated by centrifugation. Within 24 hours, the sample was analyzed for lipid profile and the data was entered.

Statistical analysis Collected data was analyzed by t test and chi-square test with the help of SPSS version 21.

1 P.G. 3rd year, 2Professor, Department of Dermatology, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India

Corresponding author: Room no. 24, PG/ Interns hostel, Pilibhit bypass road, Rohilkhand medical college and hospital campus, Bareilly (U.P.) 243001, India How to cite this article: Rohit Aggarwal, Praveen Kumar Rathore. A study evaluating xanthelasma palpebrarum clinically and biochemically. International Journal of Contemporary Medical Research 2016;3(9):2565-2567.

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Result Total cholesterol levels were increased in 53.34% (16cases) as compared to 10 controls (30%) making it highly significant. Triglycerides levels were increased in 19 cases (63.34%) as compared to 8 controls (26.67%) . No significant relationship was observed with respect to other cholesterol parameters. Table-1 shows that total of 8 patients reported with diabetes mellitus, 7 with hypertension and 15 had no illness. Figure-1 shows that there were 16.67% of males and rest were females in the sample.

Males (16.67%)

Females (83.34%)

DISCUSSION Our study showed a female preponderance with 25 females (80.95%) and 5 males (19.04%) among the 30 cases. Female to male ratio of 5:1 was observed. This was in accordance with the study done by Jain et al6, Gangopadadhya et al7, Epstein et al8 and Pedace et al.9 Reddy et al found a peak incidence in the age group of 31-40 years. Gangopadadhya et al7 noted that highest number of cases (30%) were in the age group of 31- 40 years. Jain et al6 also observed that majority of the patients were in the age group of 31- 50 years (37.9%). Chhetri et al.10 observed a peak in the age group of 40- 50 majority of the cases i.e. 40% came in the age group of 30- 40 years Gangopadadhya et al reported Diabetes Mellitus (DM) in 20% of patients, Hypertension (HTN) in 32.5% and xanthoma in 2.5% of patients.7 In study by Jain et al 42.4% of patients had associated systemic diseases like HTN and DM. Epstein et al reported a history of HTN in 28.6% cases. Incidence of DM associated with XP was reported to be 6% by Ribera et al and 34.2% by Vacca et al . In our study Hypertension was seen in 8 cases (26.7%) and Diabetes Mellitus was seen in 7 cases (23.34%) and 11 of the 30 cases had no illness. Jain et al reported 72.7% had both eyelids involvement.6 Chhetri et al reported bilateral lesions in 39% cases, two eyelids involvement in 53.2% cases. Ribera et al reported 42.6% in both the eyelids.11 Examination in our study showed that 19 cases (63.34%) had bilateral lesions and that majority of xanthelasma were found near the medial canthus of the eyelids, 11 cases (36.67%). Tursen et al12 reported that clinically xanthelasma are usually plaque like yellow lesions. Chhetri et al observed that the lesion was yellowish in colour, flat topped and slightly raised from the surface. Whereas in our study, we have noticed that plaque like lesions were more commonly seen than the papular type of lesions. Comparison of total cholesterol and XP showed 16 cases (53.34%),making it highly significant. Gangopadadhya et al showed 40% patients (significant) and Pedace et al9 showed 59.8% patients as significant. Comparison of triglycerides and XP in our study showed increased triglycerides levels in 14cases (63.34%) which was statistically significant. Our study showed a decrease in HDL cholesterol in 6 cases (20%) which is non-significant. This was in accordance with the study done by Ribera et al13 with 31.3% (significant) values. Jain et al6 observed a significant increase in VLDL levels in patients with XP as compared to controls. In our study VLDL cholesterol were increased in 5 cases (16.67%). This shows that in our study along with the concordance of other articles that total cholesterol levels and triglycerides levels were not only high but were highly statistically significant. This proves that 2566

Figure-1: Sex distribution in cases Comorbid condition No. of patients Diabetes mellitus 8 Hypertension 7 No illness 15 Table-1: Comorbid conditions

Percentage 26.67 23.34 50

there is a correlation between the total cholesterol levels and LDL levels with individuals presenting with XP in the OPD with or without systemic involvement. The HDL levels are lower and there is an increase in the VLDL levels, but there seems to be no statistically significant making these lipid values insignificant in relationship with XP. Therefore in this current study there was a correlation of XP with total cholesterol and triglycerides values and this by itself can be a potential risk and an indicator for atherosclerosis and CAD.

CONCLUSION This study shows that there is a significant elevation in total cholesterol and triglycerides cholesterol in Xanthelasma palpebrarum patients as compared to controls, thus making lipid profile compulsory for all patients with Xanthelasma. Females were most commonly affected than males. Most of the cases were in the age group of 30-40 years. Hypertension and diabetes mellitus are the two commonly associated Comorbid illnesses.

ACKNOWLEDGEMENT It is with the sense of accomplishment and deep gratitude that we dedicate our work to all those who have been instrumental in its completion. We are thankful to the cooperative patients who have helped us in this study, our faculty and staff of RMC and H, Bareilly- for their timely help, support and constant in our work. We would like to thank our family members for their blessings and guidance.

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Source of Support: Nil; Conflict of Interest: None Submitted: 08-07-2016; Published online: 27-08-2016

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Non-Alcoholic Fatty Liver Disease, Hyperuricemia and Carotid Intima-Medial Thickness: A Case Control Study Malik Mohd Azharuddin1, Nasar Abdali2, Masihur-Rehman Ajmal3, Ibne Ahmad4, Athar Kamal5 ABSTRACT Introduction: Presence of Non-Alcoholic Fatty Liver Disease (NAFLD) portends increased cardiovascular risk. A large part of this association may be due the common risk factors for both the diseases including the various components of the metabolic syndrome. Hyperuricemia is also now considered to be an established cardiovascular risk marker. The present study was designed to study the association of NAFLD and Hyperuricemia as well as its influence on the development of Carotid atherosclerosis as detected by carotid intima-medial thickness (CIMT). Materia and Methods: The case controlled study compared 144 subjects with NAFLD (cases) with 98 control subjects. Serum uric acid (SUA), CIMT, all components of metabolic syndrome were estimated in all patients and were compared. Binary logistic regression on the whole data was also performed to assess independent predictors of development of carotid atherosclerosis. Results: Mean SUA were significantly higher in patients with NAFLD (5.96 ± 1.19 vs.5.20 ± 0.82; P-Value 20 g/day) and other causes of secondary steatosis like drugs or toxins, autoimmune diseases, hereditary disease (wilson’s disease), rapid weight loss etc., history of gout or any hypo/hyperuricemic drug intake. For establishing the diagnosis of NAFLD and to rule out other possible diseases, all patients underwent a detailed clinical and laboratory evaluation including liver enzymes, hepatitis markers, autoantibodies, ferritin, and ceruloplasmin. Body mass index (BMI), waist circumference, hip circumference, waist hip ratio were measured and Blood pressure was recorded of all subjects enrolled in the study. After overnight fasting, samples were taken for blood sugar and lipid profile. Glucose dehydrogenase method was used for measuring blood glucose while enzymatic procedures were used for determination of lipid profile. Serum uric acid level was done using uricase – peroxidase method. Metabolic syndrome was defined using ATP III criteria. Assistant Professor, 3Professor, Department of Medicine, 4Professor, Department of Radiodiagnosis, A.M.U., Aligarh, 2Senior Resident, L.P.S. Institute of Cardiology, G.S.V.M. Medical College, Kanpur, 5 Senior Resident, Dr RML Hospital and PGIMER, India 1

Corresponding author: Dr Malik Mohd Azharuddin, Assistant Professor, Department of Medicine, A.M.U., Aligarh, India How to cite this article: Malik Mohd Azharuddin, Nasar Abdali, Masihur-Rehman Ajmal, Ibne Ahmad, Athar Kamal. Non-alcoholic fatty liver disease, hyperuricemia and carotid intima-medial thickness: a case control study. International Journal of Contemporary Medical Research 2016;3(9):2568-2571.

International Journal of Contemporary Medical Research Volume 3 | Issue 9 | September 2016 | ICV: 50.43 |

ISSN (Online): 2393-915X; (Print): 2454-7379

Azharuddin, et al.

Non-Alcoholic Fatty Liver Disease, Hyperuricemia and Carotid Intima-Medial Thickness

Ultrasonography of abdomen of all the patients was done by a single experienced radiologist who was blinded to other clinical details of the patient. Patient was kept nil orally for 12 hours prior to ultrasound examination. Examination was performed in supine and semi-lateral positions, required for better visualization. Fatty liver was graded as follows according to routinely used criteria13: Grade I: The basic characteristics were clear/normal visualization of the diaphragm as well as intrahepatic vessel borders, slight/mild diffuse increase in fine echoes in liver parenchyma Grade II: Slight impairment in visualization of the intrahepatic vessels and diaphragm, along with moderate diffuse increase in fine echoes in liver parenchyma Grade III: There was no visualization of intrahepatic vessel borders and diaphragm. The posterior portion of the right lobe of the liver was not visible. Fine echoes in hepatic parenchyma were markedly increased. The intima-media thickness of the carotid arteries was determined using a high resolution B-mode Ultrasonography system (Logic 500 Proseries; Wipro GE) having an electrical linear transducer (multi-frequency probe of 5 to 9 MHz) by a single experienced radiologist blinded for the presence or absence of NAFLD. Imaging of the right and left common carotid artery was performed in multiple planes around the carotid bifurcation-bulb with images being obtained from the far wall of the distal 10 mm of left and right common carotid arteries at a site free from any discrete plaque. Mean of 3 readings of both right and left was taken to obtain the CIMT.

Statistical Analysis All statistical data were analysed by using SPSS software version 15.0 statistical package for windows (Chicago. Inc.). Statistical significance was set at two-sided p-value≤0.05. Results are reported as the mean ± standard deviation (SD) for continuous variables and as frequencies and number (%) for categorical variable. Independent samples t tests or the Mann–Whitney U test, when appropriate, were used to compare cases and control for continuous variables. Fischer’s exact test or the χ 2 test was Age (years) Sex (Females) Waist circumference(cm) Waist hip ratio BMI Total cholesterol (mg/dl) HDL (mg/dl) LDL (mg/dl) Triglyceride (mg/dl) Blood Sugar(F) (mg/dl) HbA1C Systolic BP(mm Hg) Diastolic BP(mm Hg) AST (I.U/L) ALT (I.U/L) SUA (mg/dL) CIMT (mm)

used for categorical variables. Pearson correlation coefficient was used to compare continuous variables. The independence of the association of variables with the presence of NAFLD or atherosclerosis was assessed by multivariate logistic regression and expressed as odds ratios. Comparison of IMT values and serum uric acid level between different groups of NAFLD were done using ANOVA.

Results Patients in both of the groups with or without NAFLD were comparable with respect to age and sex distribution (Table-1). Various components of metabolic syndrome like dyslipidemia, hypertension and diabetes were significantly more common in patients with NAFLD compared to patients without NAFLD as shown in Table-1. There also was association of increasing severity of NAFLD with various components of metabolic syndrome as well (Table-2). Serum Uric acid was also higher in patients with more severe NAFLD as was CIMT. After considering CIMT>0.8 mm as a marker for atherosclerosis the data was analyzed with binary logistic regression to find out independent predictors of carotid atherosclerosis which showed SUA to be independently associated with CIMT (p-Value