In resource-constrained settings, the most frequently cited barrier to optimal antiretroviral therapy (ART) adherence among HIV-infected patients has been the cost of medications. In recent years many subsidized medication programs have been developed to improve ART affordability. A Graduated Cost Recovery program at the largest care center in South India has enrolled 839 eligible patients into four tiers based on an evaluation of their financial information and willingness to pay, of these patients 635 consented to participate in this study. Patients in Tier 1 receive first-line ART at no cost, whereas patients in Tiers 2, 3, and 4 pay 50, 75, and 100%, respectively of the cost of first-line medications based on an assessment of their means. Adherence rates of 95% or greater on 3-day recall were achieved by 84.6% of Tier 1 (n = 156), 71.6% of Tier 2 (n = 141), 72.3% of Tier 3 (n = 242), and 79.2% of Tier 4 (n = 96). These findings suggest patients are highly motivated and that the provision of no-cost ART can promote higher rates of optimal adherence.

Purpose. The purpose of this study was to report a case of bilateral vitreopapillary traction, previously misdiagnosed as papilledema. Methods. A case report is presented of a 47-year-old woman with a prior diagnosis of papilledema, who is shown to have bilateral vitreopapillary traction rather than true optic disc swelling, confirmed by optical coherence tomography (OCT). Results. OCT showed vitreous traction surrounding the optic discs of both eyes. Fluorescein angiography demonstrated focal leakage of both discs. Conclusion. Bilateral disc elevation caused by vitreous traction can be confused with papilledema. In such cases, OCT can be used to arrive at the correct diagnosis. Although the phenomenon of vitreopapillary traction is well reported, this case indicates that not all ophthalmologists recognize the condition.

We report an aggressive fungal keratitis caused by a putatively novel species of Lophotrichus in a patient with traumatic injury to the cornea from a dog paw. The organism was isolated from the patient's necrotic cornea, which perforated despite coverage with hourly fortified broad-spectrum topical antibiotic therapy. This report represents the first case of human infection caused by this species. CASE REPORTA 50-year-old woman from rural Maryland, USA, presented to the Johns Hopkins Emergency Department in April 2011 5 days after her dog stepped on her right eye during sleep. She experienced foreign body sensation and blurry vision at the time but experienced a rapid decrease in vision on day 4. When she presented on day 5, she could see only light and dark in the right eye. She had no known history of contact lens use. She had undergone cataract surgery in both eyes 1 year prior to presentation and did not wear glasses except for reading.The physical examination conducted 5 days after the injury revealed uncorrected visual acuity of light perception in the right eye and 20/25 at distance in the left eye. There was no afferent pupillary defect present. Slit-lamp examination of the right eye revealed upper and lower eyelid erythema and edema. The conjunctiva was 3ϩ injected, and the cornea demonstrated a large central ulceration measuring 6 mm in diameter with yellow-green discharge (Fig. 1A). The anterior chamber demonstrated a robust fibrinous reaction, with no view of the lens or posterior segment. The patient immediately started treatment with a fortified topical 25-mg/ml vancomycin and 14-mg/ml tobramycin ophthalmic solution hourly to the right eye. Corneal scrapings were obtained and inoculated onto three culture media: blood agar containing 5% sheep blood, chocolate agar, and Sabouraud dextrose agar with gentamicin.On day 6 after the injury, the patient added oral doxycycline at 100 mg twice daily and ciprofloxacin ointment nightly to her regimen. Ultrasonography revealed no choroidal or retinal detachment. When the patient returned on day 10, she complained of severe pain. Despite frequent drop use, the infiltrate and ulceration persisted, with formation of significant corneal neovascularization and inferior thinning. The eye was soft to palpation, and 360-degree shallow choroidal detachments were noted, consistent with microperforation of the cornea.At this point, 4 days after corneal scrapings and cultures, preliminary results demonstrated the presence of a filamentous fungus (on the chocolate agar) and very light growth (on the first quadrant of the culture plate) of Corynebacterium macginleyi. Topical voriconazole at 1% was started hourly in the right eye, in addition to continuing fortified vancomycin and tobramycin. She was taken to the operating room, where a corneal biopsy was conducted and an Ambio5 (IOP Ophthalmics, Costa Mesa, CA, USA) amniotic membrane patch was grafted onto the ocular surface.On day 17 after the initial injury, the infiltrate began to clear superiorly and the cornea had part...