A comparative analysis of topical corticosteroids and non-steroidal anti-inflammatory drugs to control inflammation and macular edema following uneventful phacoemulsification.

PURPOSE: To compare the efficacy of topical nonsteroidal anti-inflammatory drugs (NSAIDs) and prednisolone acetate in controlling inflammation and preventing cystoid macular edema (CME) after uneventful phacoemulsification. METHODS: All patients who underwent uneventful phacoemulsification from December 2020 to Feb 2021 were included in the study. These were randomly assigned to receive any one anti-inflammatory agent among topical nepafenac (0.1%) [96 eyes], bromfenac (0.07%) [93 eyes], preservative-free ketorolac (0.4%) [94 eyes], nepafenac (0.3%) [96 eyes], or prednisolone acetate (1%) [91 eyes]. The efficacy of the drugs was evaluated by comparing the grade of anterior chamber (AC) cells, conjunctival hyperemia, pain score, visual acuity, intraocular pressure (IOP), and central macular thickness (CMT) at 1 and 6 weeks after surgery. RESULTS: At 1 and 6 weeks, there was no significant difference in pain score, conjunctival hyperemia, AC cells, change in IOP, and visual acuity between the prednisolone and the NSAIDs groups, though nepafenac 0.3% was most effective. At 6 weeks, there was no significant difference in the number of patients developing subclinical CME in the prednisolone versus NSAID group. The mean increase in CMT was significantly lower in nepafenac 0.3% than prednisolone at 1 and 6 weeks (P = 0.003 and 0.004, respectively). CONCLUSION: NSAIDs used in isolation are comparable to prednisolone in preventing inflammation and pain after uneventful phacoemulsification. However, nepafenac 0.3% is most comparable to prednisolone and more efficacious in reducing the incidence of CME. We recommend that nepafenac 0.3% can be used as a sole anti-inflammatory agent in patients with uneventful phacoemulsification.

Intraoperative optical coherence tomography-guided release of lenticulo-corneal adhesion and lens aspiration in anterior dislocation of lens with corneal edema.

Purpose: To describe the outcome of microscope integrated optical coherence tomography (MiOCT) guided removal of lenticulo-corneal adhesion and intralenticular lens aspiration (ILLA) in cases with anterior dislocation of the crystalline lens and corneal edema. Methods: MiOCT-guided ILLA was performed in three eyes of two cases of homocystinuria with spontaneous anterior dislocation of lens and corneal edema. Lenticulo-corneal adhesion was noted intraoperatively, which was not apparent pre-operatively. The lenticulo-corneal adhesion could be successfully peeled using intravitreal forceps and viscodissection with visco-dispersive viscoelastic under the guidance of MiOCT. Results: In all cases, the lenticulo-corneal adhesion could be successfully removed without any complication such as Descemet tear or worsening in corneal edema. Improvement in visual acuity was noted in all cases with resolution in corneal edema by 1 week. Conclusion: MiOCT-guided ILLA can be extremely useful in cases of lenticulo-corneal adhesion especially in cases with corneal edema.

Descemet membrane detachment.

Descemet membrane detachment (DMD) is a potential vision-threatening complication that occurs most commonly after cataract surgery. DMD has also been reported to occur in various other surgeries such as keratoplasty, iridectomy, vitrectomy, trabeculectomy, holmium laser sclerostomy, alkali burn, and viscocanalostomy. Major risk factors include advanced age, preexisting endothelial diseases like Fuchs dystrophy or abnormality in the Descemet membrane and stromal interface, hard cataract, prolonged surgical time, ragged clear corneal incisions, and inadvertent trauma with blunt instruments or phacoemulsification probe. Most DMDs are peripheral and resolve spontaneously. Large, central DMDs if not managed appropriately may lead to corneal decompensation and opacification. Several authors have classified DMD depending on its configuration, height, extent, length, and position with respect to pupil. Anterior segment optical coherence tomography has been used to confirm and classify DMD and can also aid in deciding the management plan. Spontaneous reattachment of the DM with conservative management may occur in cases with small, peripheral, planar DMD with nonscrolled edges. Cases with nonplanar, central DMD, scrolled edges, and length >2 mm, however, have to be managed surgically. Descemetopexy is the gold standard for the management of DMD. Other management options include mechanical tamponade, suture fixation, descemetotomy, interface drainage, and keratoplasty. Prompt diagnosis and timely management often leads to a good visual outcome.

Tuck-In Tenon Patch Graft in Corneal Perforation.

PURPOSE: To describe the outcomes of tuck-in tenon patch graft (TPG) in the management of corneal perforation up to 5-mm size. METHODS: Thirty-one cases of sterile corneal perforation (3-5 mm) underwent autologous TPG. The technique included, freshening of the edges, measuring the size of defect, creating a 360-degree stromal pocket around the perforation margin, harvesting the tenon graft followed by tucking into the stromal pocket, and application of cyanoacrylate glue or suturing the graft using 10-0 monofilament nylon suture. The main outcome measure was rate of healing (percentage of cases healed). RESULTS: The mean age was 52.3 ± 8.9 years with 22 male and 9 female patients. The various etiologies of corneal perforation included trauma (n = 10), neurotrophic keratitis (n = 11), and peripheral ulcerative keratitis (n = 10). The mean size of corneal perforation was 4.2 ± 0.6 mm (range 3-5 mm). The mean duration of epithelial healing was 25.7 ± 6.7 days. Best-corrected visual acuity improved from 1.8 ± 0.4 to 1.2 ± 0.4 logarithm of the minimum angle of resolution units at 4 weeks after surgery (P ≤ 0.01). Twenty-seven (87.1%) cases healed with formation of a leucomatous scar at 16.9 ± 2.7 weeks, whereas 4 cases had a flat anterior chamber. In three-fourths of the cases, a corneal graft was performed. In one case, graft resuturing was performed for post-op aqueous leak, which healed with the formation of a corneo-iridic scar. CONCLUSIONS: TPG is a safe, simple, inexpensive, and an effective technique for the management of corneal perforations. The advantages include the autologous nature of the graft, cost effectiveness, and easy availability.

Optimal near and distance stereoacuity after binocular implantation of extended range of vision intraocular lenses.

PURPOSE: To evaluate stereopsis and visual quality after bilateral implantation of extended range of vision intraocular lenses (ERV IOLs). SETTING: R.P. Centre for Ophthalmic Sciences, AIIMS, New Delhi, India. DESIGN: Prospective interventional study. METHODS: Patients underwent phacoemulsification with bilateral implantation of ERV IOLs. The primary outcome measures were stereopsis (distance and near Randot) and visual quality (ray-tracing aberrometry). The secondary outcome measures were visual acuity and patient satisfaction. Follow-up was performed on day 1 and at 1, 3, 6, and 12 months postoperatively. RESULTS: The study comprised 50 patients (100 eyes). The mean age of the patients was 58.9 years ± 8.9 (SD). At 1 year, the mean distance stereopsis was 103.6 ± 49.1 seconds of arc (arcsec) and near stereopsis was 21.1 ± 2.3 arcsec. Perfect near stereopsis of 20 arcsec was present in 80% of cases, and 82% had good distance stereopsis of 100 arcsec or better. Stereopsis correlated well with the patient satisfaction score (P < .001) and average internal modulation transfer function (MTF) (P < .015). The mean Strehl ratio was 0.029 ± 0.021, MTF was 0.24 ± 0.08, total higher-order aberrations were 0.62 ± 0.41 µm, and coma was 0.25 ± 0.18 µm. The mean binocular uncorrected decimal visual acuities were 0.98 ± 0.07 (distance), 0.82 ± 0.09 (intermediate) and 0.64 ± 0.08 (near). The mean patient satisfaction score was 9.08 ± 1.1, and no case required IOL explantation because of visually disturbing phenomena or patient dissatisfaction. CONCLUSION: Excellent stereoacuity was observed after bilateral implantation of ERV IOLs, which correlated well with patient satisfaction and quality of vision.

Clinical presentation and management of corneal fistula.

PURPOSE: To describe the clinical features and management of corneal fistula in patients of healed keratitis. METHODS: Medical records of all patients of healed keratitis presenting to the cornea clinic from November 2016 to September 2017 were reviewed. Eightcases of corneal fistula (six true fistulas, two closed fistulas) were identified. Six patients were managed with autologous tenon patch graft while two patients were managed medically. Various risk factors and treatment outcomes of corneal fistulisation were evaluated. RESULTS: The patients included two patients of failed therapeutic keratoplasty (with resolved graft infection) and six patients of healed keratitis. The age of the patients ranged between 10 and 60 years. Five of the patients were male while three were female. The size of the fistula measured between 1 and 2 mm. A surrounding cystic area of diameter ranging between 1 and 4.5 mm was seen in all the patients. In all of the patients, the treating physician missed the diagnosis. Complete healing was noted at 6-8 weeks in all the patients who underwent tenon graft. One patient refused to undergo any surgery and was lost to follow-up. In another case, surgery was deferred due to uncontrolled hypertension and he developed anterior staphyloma subsequently. CONCLUSION: Corneal fistula can often be missed in an apparently healed perforated corneal ulcer. Tenon patch graft is an effective technique for the management of corneal fistula.

Phacoemulsification with coexisting corneal opacities.

The treatment of choice for cases of corneal opacity with significant cataract is often a triple procedure. However, in certain situations the chances of graft survival are poor, for example in cases with deep vascularization, secondary glaucoma, and healed viral keratitis. Under these circumstances, performing cataract surgery only might improve the visual acuity enough to maintain the patient's day-to-day activities. Performing cataract surgery, especially phacoemulsification, in these cases is challenging. Proper case selection, choosing the right technique, and a thorough idea about the difficulties and methods of tackling such cases is paramount to achieving optimum visual outcomes. In this review, we discuss the case selection and surgical modifications of performing phacoemulsification in cases with coexisting corneal opacities.

Vernal Keratoconjunctivitis.

Vernal keratoconjunctivitis, a chronic bilateral seasonal allergic inflammatory disease of the eye, is an important cause of visual debilitation and impairment of quality of life in children and young adults in certain parts of the world such as the Mediterranean areas, Central and West Africa, the Middle East, Japan, the Indian subcontinent, and South America. It usually has a self-limiting course; however, in a few cases, the disease is recurrent and leads to long-term visual disabling complications such as keratoconus and limbal stem cell deficiency. The main pathogenic mechanism is immunoglobulin E mediated; however, there may be non-immunoglobulin E and certain nonspecific hypersensitivity mechanisms. The predominant cell types involved are CD4 T cells and eosinophils. The management of vernal keratoconjunctivitis is challenging. Although an acute episode can be well managed with the help of currently available topical agents, the major challenge lies in preventing recurrences and their consequences. Steroids are highly effective in controlling both an acute episode and chronic disease; however, the long-term complications of steroid use often prevent their continued use. Immunomodulators such as tacrolimus and cyclosporine may be used as steroid-sparing agents; however, the dosing and duration of use still need to be clearly defined. Surgery is required for the management of complications such as shield ulcer and corneal ectasia or opacity; however, the disease process and management are largely well defined, and genetic predisposition factors responsible for chronicity and an effective albeit safe treatment modality for the chronic form of the disease need further research.

Continuous intraoperative optical coherence tomography-guided shield ulcer debridement with tuck in multilayered amniotic membrane transplantation.

Purpose: The aim of this study is to describe a modified surgical technique of continuous intraoperative optical coherence tomography (iOCT)-guided shield ulcer debridement with tuck-in multilayered Amniotic membrane transplantation (ML AMT) in vernal keratoconjunctivitis (VKC) with shield ulcer with plaque. Methods: Seven eyes of seven patients presenting with VKC with shield ulcer with plaque were enrolled in this prospective case series and planned for shield ulcer debridement with ML AMT. Debridement of the ulcer base with double-layered AMT was done under the continuous guidance of iOCT. The main outcome measure was the time for complete reepithelialization. Statistical analysis was performed using the Stata-14.0 program for Windows. Data were presented as mean ± standard deviation/median (minimum-maximum) and frequency percentage as applicable. Results: The surgery could be completed successfully in all cases and iOCT could provide real-time assessment of the depth of dissection during the entire procedure. The duration of complete healing and disintegration of amniotic membrane varied from 7 to 12 days. Recurrence was not seen in any case till 2 months follow-up. Conclusion: iOCT provides continuous monitoring of the depth of dissection and allows for a safe and complete debridement of the shield ulcer with plaque.

Corneal edema after phacoemulsification.

Phacoemulsification is the most commonly performed cataract surgery in this era. With all the recent advances in investigations and management of cataract through phacoemulsification, most of the patients are able to achieve excellent visual outcome. Corneal edema after phacoemulsification in the immediate postoperative period often leads to patient dissatisfaction and worsening of outcome. Delayed onset corneal edema often warrants endothelial keratoplasty. This review highlights the etiopathogenesis, risk factors, and management of corneal edema in the acute phase including descemet's membrane detachment (DMD) and toxic anterior segment syndrome. Various investigative modalities such as pachymetry, specular microscopy, anterior segment optical coherence tomography, and confocal microscopy have been discussed briefly.

Tenon patch graft for corneal fistula: a rare entity treated by a simple technique.

A 50-year-old patient presented with dull aching pain with some discomfort in his right eye for the past 2 weeks. History revealed the patient had a past episode of infective keratitis managed medically in a local hospital. The last follow-up record suggested a diagnosis of healed keratitis with corneoiridic scar. On examination, the patient had visual acuity of hand movement and a corneoiridic scar of 7×7 mm with an inferotemporal translucent cystic area measuring 3×4 mm in size with underlying uveal tissue visible. Seidel test was found to be positive confirming leakage. For this, a tenon patch over the area of defect along with anterior chamber formation was done. On postoperative day 1, the graft was well attached and anterior chamber was formed with no leak on Seidel test. Intraocular pressure was 16 mm Hg.

Component corneal surgery: An update.

Several decades ago, penetrating keratoplasty was a challenge to corneal surgeons. Constant effort by the corneal surgeon to improve the outcomes as well as utilization of the available resources has led to a revolutionary change in the field of keratoplasty. All these efforts have led to the evolution of techniques that allow a corneal surgeon to disease-specific transplant of individual layers of corneal "so-called component corneal surgery" depending on the layer of cornea affected. This has led to an improvement in corneal graft survival as well as a better utilization of corneal tissues. This article reviews the currently available literature on component corneal surgeries and provides an update on the available techniques.