Guru Nanak Eye Centre

To the Editor, The term porcelain aorta, defined as an extensive calcification of the aorta, increases the complexity of cardiac surgery. Although usually seen in the elderly population, we report a rare and unprecedented finding of a porcelain aorta incidentally discovered in a patient in his twenties. A 29-year-old male patient with prior Bentall surgery in 2014 for ascending aorta aneurysm and aortic regurgitation (AR) presented with suprasternal swelling [Figure 1] and fever, revealing calcification of bilateral common carotid artery and arch of the aorta in chest X-ray (CXR) posterior-anterior (PA) view [Figure 2]. Contrast-enhanced computed tomography (CECT) thorax revealed dense peripheral wall calcification of bilateral common carotid artery, arch of the aorta, and descending thoracic aorta; also, aneurysmal dilation of the aortic arch and right subclavian artery; and narrowing of descending thoracic aorta. The patient was taken for emergency exploration because the swelling was increasing with an associated drop in hemoglobin. Intraoperatively, the patient was found to have a mediastinal abscess draining into subcutaneous space and drained under femoral bypass. The patient was shifted to the intensive care unit on vasopressor support and was extubated on postoperative day one, but later, he succumbed to sepsis.Figure 1: Suprasternal swellingFigure 2: CXR PA view showing bilateral carotid artery, aortic arch calcification and intercoastal drain in situ (for hydropneumothorax)Porcelain aorta is challenging because it precludes aortic cannulation and cross-clamping due to the risk of injury and release of thromboembolic material, causing stroke. Peripheral arterial cannulation, intraluminal balloon occlusion of the aorta, hypothermic circulatory arrest to avoid cross-clamping, and slow aortic clamping with flushing through the open aorta can minimize this risk.[1] Vascular calcification has been reported in younger patients with chronic kidney disease (due to altered mineral metabolism), systemic lupus erythematosus (SLE), and Takayasu arteritis due to systemic inflammation and immune mechanisms.[2] Our patient had a normal renal function test and no history of claudication, joint pain, or skin rashes. Tests for SLE were not performed. He fulfilled one major criterion (fever) and three minor criteria (previous history of AR, descending thoracic aorta narrowing, and high ESR, 40 mm/hr in our case) of the Sharma criteria for diagnosis of Takayasu arteritis, but using fever as a major criterion is dubious in the background of mediastinal abscess.[3] Boudagh et al.[3] had reported a similar case of Takayasu arteritis in a young patient with severe AR and atypical presentation. Unfortunately, the focus was on determining the reason for suprasternal swelling, and other findings on CECT were not thoroughly investigated. CT angiography, which depicts luminal changes and is a reliable tool in the diagnosis of Takayasu arteritis, was not performed, and rheumatology consultation was also not sought. Genetic predilection and chronic inflammation post-cardiac surgery might have led to accelerated vascular fibrosis and calcification in this patient, or he might have some underlying vasculitis that remained undiagnosed and Takayasu arteritis should also be kept in mind as a cause of AR and aortic aneurysm in young patients. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

ABSTRACT Purpose: Monocular Elevation Deficiency (MED) is characterized by limited ability to elevate the affected eye in any gaze position, while maintaining normal duction in all other gazes. The type of surgeries described in MED include Knapp’s surgery, vertical muscle recession and resection, contralateral superior rectus recession. Recently, the Nishida’s procedure has also been explored as a treatment for isolated cases of MED. Hence, we conducted this study to evaluate the surgical outcome of Modified Nishida’s procedure in cases of MED in a series of 15 patients. Methods: This prospective interventional study was performed on 15 patients with MED attending the Strabismus Clinic and outpatient department of our tertiary care centre over a period of 1 year from October 2023 to October 2024. In this study, 15 patients of age more than 13 years with Type 2 Congenital MED with negative forced duction test for inferior rectus, hypotropia more than 10 prism diopters and no horizontal deviation were included. Patients with previous history of strabismus surgery or with bleeding diathesis were excluded. Preoperatively, ocular deviation was measured using vertical prisms in terms of prism diopters (PD). Elevation deficit was noted in all the patients on a scale of 0 to -4 with 0 indicating full rotation and -4 indicating severe limitation (not crossing midline). All patients underwent Modified Nishida’s procedure following forced duction test for inferior rectus. Postoperatively, all the measurements were recorded at the end of first week, first month and the final follow up was done at the end of third month. Primary outcome included correction of vertical deviation at 3 months post Modified Nishida’s procedure. Secondary outcome included assessment of elevation deficit. Results: The mean age of the patients was 23.33 ± 15.73 years. There was statistically significant improvement in mean hypotropia from preoperative measurement of vertical deviation of 28.67 ± 9.904 PD to 7.60 ± 10.176 PD (p < 0.001) at the final follow up. There was statistically significant improvement in elevation deficit ranging from mean value of -3.47 ± 0.74 at baseline to -2.73 ± 0.70 postoperatively at final follow up (p < 0.01). Conclusion: The study demonstrated that the Modified Nishida’s procedure is effective in managing MED in terms of improvement of vertical deviation and elevation deficit.

To compare conventional and inverse occlusion in the treatment of amblyopia with eccentric fixation. This prospective randomized interventional study was conducted at a tertiary care center over a period of 1 year. Sixty patients with amblyopia (refractive or strabismic) with eccentric fixation who were older than 12 years were divided into two groups with systematic randomization: conventional occlusion (occlusion of sound eye for 6 hours/day) and inverse occlusion (occlusion of amblyopic eye for 6 hours/day). Patients with a systemic illness or neurological disorder were excluded. Follow-up data for corrected distance visual acuity (CDVA), stereopsis, and fixation pattern were taken at baseline and 1, 3, and 6 months postoperatively. At the final follow-up visit, there was significant improvement in CDVA in the amblyopic eye in both the conventional occlusion (P = .007) and inverse occlusion (P < .001) groups. The mean ± standard deviation of CDVA improved from 1.32 ± 0.3 and 1.32 ± 0.32 logMAR at baseline to 1.17 ± 0.15 and 1.10 ± 0.27 logMAR in the conventional occlusion and inverse occlusion groups, respectively. Stereoacuity improved significantly in both groups (P = .013 and .016 in the conventional and inverse occlusion groups, respectively). Improvement in fixation function was statistically significant only in the inverse occlusion group I (P = .002). Both conventional and inverse occlusion therapy are effective in treating amblyopia with eccentric fixation in terms of improvement of visual acuity and stereopsis. However, for improvement in anomalous fixation pattern, inverse occlusion is preferred with no issues of compliance and functional limitation.

[This corrects the article DOI: 10.7759/cureus.70749.].

The integration of cloud computing with Internet of Things (IoT) devices offers vast opportunities for scalable data storage and real-time services. However, it also introduces critical security and privacy challenges, particularly in ensuring fine-grained access control and secure data retrieval. This paper proposes a context-aware secure search framework using Attribute-Based Encryption (ABE) tailored for IoT-cloud platforms. The system enables encrypted data to be searched efficiently without revealing sensitive content or search patterns, leveraging context-aware policies to enhance access control flexibility. Additionally, the scheme supports forward security, ensuring past data remains protected even if current keys are compromised. Experimental analysis demonstrates the framework’s effectiveness in maintaining data confidentiality, reducing computational overhead, and ensuring practical usability in resource-constrained IoT environments

BCIs enable direct brain-to-device communication by decoding brain signals, with applications in assistive technologies, neurorehabilitation, and human-computer interaction. This study explores deep learning models, including CNNs, RNNs, and hybrid architectures, for BCI signal decoding. A synthetic EEG dataset was used to benchmark these models against traditional classifiers like SVM and LDA, focusing on accuracy, latency, and generalization. Preprocessing techniques such as noise reduction, signal normalization, and feature extraction were applied to enhance signal quality. Results showed CNNs and hybrid CNN-RNN models outperformed traditional classifiers with greater accuracy and robustness. Deep learning effectively addressed challenges like low signal-to-noise ratio, subject variability, and class imbalance. The study also demonstrated practical applications in assistive device control and cognitive monitoring, emphasizing deep learning's potential to advance BCI technology while underscoring the need for validation on larger datasets.

ABSTRACT Introduction: Acute acquired comitant esotropia (AACE) is a rare type of esotropia for which until now the main treatment modalities prescribed are prism glasses, botulinum toxin injection and surgery. The purpose of our study is to compare the surgical outcomes in patients with AACE managed with and without pre-operative prism adaptation test (PAT). Methods: We have done a prospective, interventional study for the duration of one year. Forty patients with AACE were randomly divided into two groups by computerized randomization – those undergoing surgery after pre- operative PAT and those undergoing surgery without it. In control group (Group C), patients underwent surgery based on the angle of deviation at distance measured by prism bar cover test (PBCT) and wearing full cycloplegic correction, while in test group (Group T), patients underwent surgery based on the preoperative prism-adapted angle at distance wearing prism power determined by PBCT and wearing full cycloplegic correction. The primary outcome was post-operative deviation and secondary outcome was stereopsis. Post-operatively, patients were followed up at week 1, week 4 and final follow-up was done at week 12. Results: The mean age of the 40 patients was 13.95 ± 5.36 years. The age of the youngest and the oldest patients enrolled were 8 years and 35 years, respectively. The mean SD (standard deviation) of the PBCT for distance (measured in prism diopters – PD), PBCT for near (measured in prism diopters – PD) and stereopsis for near (measured in seconds of arc using Titmus Fly Test) at last follow-up visit (week 12) in the test versus control group were as follows: 1.70 ± 1.42 PD versus 4.75 ± 3.39 PD, 2.55 ± 1.82 PD versus 6.95 ± 3.35 PD and 74.90 ± 53.47 sec of arc versus 48.60 ± 31.97 sec of arc, respectively, which were statistically significant (p = <0.01, p = <0.01 and p = .03, respectively). The change in visual acuity and spherical equivalent in each group was insignificant. Discussion: Surgical outcomes in patients of AACE are better when surgical planning is done after performing pre-operative PAT as opposed to when surgery is planned without PAT. Better motor alignment (less under correction and over correction) and better sensory results in terms of improvement in stereopsis were observed. We recommend the use of pre-operative PAT in surgical planning in patients of AACE.

A girl in her second decade of life presented with a painful, progressively increasing S-shaped swelling of the right upper lid, suggestive of acute dacryoadenitis. She had a history of close contact with a tuberculosis (TB) patient. Despite improvement in preseptal cellulitis with broad-spectrum (non-tubercular) systemic antibiotics, a fluctuant swelling persisted. After resolution of preseptal cellulitis, a CT scan revealed possible tubercular osteomyelitis of the lateral orbital wall and a cold abscess in the right orbit. Ultrasonography-guided drainage of the abscess was performed, and the sample tested positive for Cartridge-based Nucleic Acid Amplification Test, confirming TB. The patient was started on antituberculosis treatment, leading to complete resolution of the swelling with no recurrence during a 2-year follow-up. This case emphasises the importance of maintaining a high index of suspicion for TB in cases of dacryoadenitis unresponsive to antibiotics, especially in endemic regions like India.