Effect of intraoperative optical coherence tomography on anatomic and cosmetic results of intrastromal tattooing.

PURPOSE: The aim of the study was to evaluate the effect of intraoperative optical coherence tomography (i-OCT) on anatomic and cosmetic outcomes of intrastromal keratopigmentation (i-KTP) performed by novice lamellar corneal surgeons. METHODS: Thirty patients presenting with unilaterally disfiguring corneal scar and nil visual prognosis were subjected to i-OCT-guided intrastromal tattooing with rotring ink, by ophthalmology residents undergoing training in corneal surgeries at our center, who were later asked for a subjective feedback and mean stromal depth dissected was measured objectively. All patients were followed up for 9 months after surgery, and the subjective satisfaction of the patient, an independent observer, and surgeon was graded as poor, good, and excellent. RESULTS: The mean age of the patients was 29.53 ± 13.82 years (8-56 years). The most common cause of corneal opacity was healed keratitis with (6/30) or without (3/30) adherent leukoma, trauma-induced ocular disfigurement (7/30), and bullous keratopathy (6/30). All residents reported that feed-back images on i-OCT were "helpful" in all eyes and "very helpful" in eyes with corneal thinning, stromal scarring, adherent leukoma, bullous keratopathy, and hypotony. The mean depth of lamellar dissection was 51.16% ±4.62% of preoperative corneal thickness. The cosmetic results as perceived by the patient, an independent observer, and the surgeon were excellent and good in 23 and 7, 26 and 4, and 20 and 10 patients, respectively. CONCLUSION: I-KTP may be employed as a primary method of cosmetic correction of unsightly corneal scars. Centers equipped with i-OCT may employ this tool for teaching i-KTP to their ophthalmology residents for better surgical results with minimal complications.

Intralenticular changes in eyes with mature senile cataract on modified posterior segment optical coherence tomography.

PURPOSE: To study the morphological changes within mature senile cataracts on modified posterior segment optical coherence tomography (OCT). METHODS: A cross-sectional observational study recruiting patients of mature cataracts admitted for elective cataract surgery in tertiary eye care. A modified OCT imaging of the lens was done and lenticular findings were noted by a single observer. Corresponding slit-lamp biomicroscopic findings and intraoperative experiences were also noted by a second observer and respective surgeons. RESULTS: Forty-four eyes of 44 patients were included. The mean age of patients was 65 ± 5.7 years. The intralenticular findings were uniform in groups of eyes, and they were characterized into three stages. First was a stage of early lamellar separation where small intralenticular clefts were noted superficially. Second was the stage of established lamellar separation where crescentic fluid clefts appeared interspersed between the lens fibers, and the depth increased as a function of severity. Both these stages did not show any distinct slit-lamp or intraoperative findings. A third stage of liquefaction identified as extensive lamellar separation with subcapsular fluid pockets. This was also reflected in slit-lamp biomicroscopy, showing the hydrated cortex with intraoperative challenges. Two cases showed peculiar changes, one of a hyperreflective subcapsular sheath and another of superficial nuclear lamellar separation. CONCLUSION: Mature cataracts may also show graded progression, which could be delineated on lenticular OCT. This could be of immense help in pre-operative planning and optimal management of these high-risk cases.

Preoperative assessment of posterior capsular integrity using a posterior segment OCT with a +20 D lens: The 'conical sign' to suggest capsular deficiency in posterior polar cataracts.

PURPOSE: To study the morphology of posterior polar cataracts and posterior lens capsules using modified posterior segment optical coherence tomography (m-OCT). SETTING: Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India. DESIGN: A prospective observational case series. METHODS: Patients with clinically diagnosed posterior polar cataracts were included. The routine posterior segment OCT was modified by placing an aspheric +20.00 diopter lens along its aperture, enabling it to visualize the anterior segment structures. Cases of posterior polar cataract were assessed preoperatively using this method to study the morphology of posterior lens cortex and the posterior capsule. All m-OCT observations were performed by 2 observers, and findings were recorded. RESULTS: A total of 26 eyes of 17 patients were included. The mean age of patients was 53 years. The morphology of the cataract appeared as hyperreflective opacity just anterior to the posterior capsule, subsequently involving it, and with variable hyporeflective spaces. An intact posterior capsule showed a regularly convex contour, whereas a loss in the tracing of posterior capsule at the paracentral region and disturbance in contour with a localized protrusion of lens matter (the conical sign) depicted a possible posterior capsule dehiscence. Four (15.38%) of 26 eyes showed the conical sign, and this posterior capsule defect was confirmed intraoperatively in all cases. CONCLUSIONS: In posterior polar cataracts, the conical sign could be a valuable clue to predict preexisting posterior capsule dehiscence and could be identified on a m-OCT.

Optimal refinement of residents' surgical skills by training on induced goat's eye corneoscleral perforation.

Surgical skill enhancement for the residents under training can be performed through various efforts. Here in this report, the authors describe a technique of corneoscleral perforation repair on goat's eye, as the tissue resemblance and the reality of experience while performing crucial steps are similar to human eyes. Beginning from tissue handling, optimal suture placement was taught with an intention to impart quality techniques of traumatic globe injury repair. Therefore, rather than training on expensive artificial eye model, training budding surgeons on goat's eye gives much more realistic tissue handling experiences in the presence of constant challenges almost similar to human eyes.

Long-term Functional and Anatomic Outcomes of Repeat Graft After Optically Failed Therapeutic Keratoplasty.

PURPOSE: To evaluate the functional and anatomic outcomes of repeat penetrating keratoplasty (PK) in optically failed therapeutic grafts. DESIGN: Prospective interventional case series. METHODS: All cases admitted at the apex tertiary care center for repeat keratoplasty following optically failed therapeutic PK were enrolled over a period of 1 year. Repeat optical PK was performed in all eyes. Primary outcome measures were postoperative graft clarity and visual acuity. Secondary outcome measures were complications including graft rejection, infections, failure, and secondary glaucoma. Follow-up examinations were undertaken on day 1; on day 7; at 1, 3, 6, and 12 months; and yearly thereafter. RESULTS: Thirty-two eyes underwent repeat PK with mean follow-up of 18.4 ± 8.9 months. Clear grafts were observed in 63.14% of cases 1 year after regraft, and graft survival further decreased to 50% at last follow-up. Visual acuity ≥ 20/200 was achieved in 43.8% of cases, and no case had a visual acuity of ≥ 20/40. Multivariate Cox regression analysis analyzed risk factors for regraft survival, and observed a hazard ratio of 3.56 with size of initial therapeutic graft ≥ 8.75 mm, and 10.99 with deep vascularization in 1 or more quadrants. Graft survival (P = .004), visual acuity (P = .039), and rejection rates (P = .036) were significantly better in cases with initial therapeutic graft size < 8.75 mm. Secondary glaucoma was present in 59.4% (19/32) after regrafts. CONCLUSION: Regraft after therapeutic PK is associated with suboptimal visual outcomes and long-term graft survival. Large size of initial therapeutic graft and deep vascularization adversely affect graft survival.

Surgical removal of a giant iris stromal cyst: an intraoperative optical coherence tomography-guided approach.

An 11-year-old girl was brought with the chief complaint of progressive diminution of vision in her right eye for the past 3 months. There was no history of ocular trauma or any ocular surgery. Systemic and family history was insignificant. Visual acuity was 20/20 in her left eye and counting finger close to face with projection of rays being accurate in her right eye. Slit lamp examination of her right eye showed large cystic lesion filling almost entire anterior chamber. With the help of various imaging modalities like anterior segment optical coherence tomography (OCT) and ultrasound biomicroscopy diagnosis of iris stromal cyst was confirmed. Right eye surgical removal of the iris stromal cyst was done under real-time imaging of intraoperative OCT (iOCT). Best-corrected visual acuity at 6 months follow-up was 20/20 without any recurrence. iOCT-guided approach for complete removal of the iris cyst seems more promising.

Intraoperative Optical Coherence Tomography-Guided Management of Cap-Lenticule Adhesion During SMILE.

PURPOSE: To report successful lenticule extraction using intraoperative optical coherence tomography (OCT) in a case of cap-lenticule adhesion during small incision lenticule extraction (SMILE). METHODS: Case report. RESULTS: A 22-year-old patient with a refractive error of -5.00 -0.50 × 120° and -5.00 -0.75 × 60° in the right and left eyes, respectively, was scheduled for SMILE. The lenticule was created using the VisuMax femtosecond laser system (Carl Zeiss Meditec, Jena, Germany). The surgeon experienced difficulty while extracting the lenticule in the right eye. The patient was immediately shifted under the surgical microscope integrated with intraoperative OCT. The lenticule was found to be adherent to the anterior stromal cap, which was seen as hyperreflective spikes in the posterior plane, in contrast to the anterior plane, which showed minimal reflectivity, suggesting an inadvertent posterior plane entry. The peripheral edge of the lenticule was lifted from the anterior stromal cap under direct visualization of intraoperative feedback images provided by intraoperative OCT. The edge of the lenticule, which was freed, was then grasped with microforceps and extracted in toto using the continuous curvilinear lenticulerrhexis technique. At the end of surgery, the intrastromal pocket was screened under intraoperative OCT for any lenticule remnants. One week after surgery, the uncorrected distance visual acuity was 20/20 with smooth, regular interface on anterior segment optical coherence tomography. CONCLUSIONS: Intraoperative OCT is useful in cases of difficult lenticule extraction during SMILE because it provides real-time visualization of the lenticule and helps in discerning its relation with the anterior stromal cap and the underlying stromal bed. By using intraoperative OCT and the continuous curvilinear lenticulerrhexis technique, satisfactory anatomical and visual outcomes were obtained. [J Refract Surg. 2017;33(11):783-786.].

Microscope-integrated intraoperative optical coherence tomography-guided small-incision lenticule extraction: New surgical technique.

We describe the surgical technique of microscope-integrated intraoperative optical coherence tomography (OCT)-guided small-incision lenticule extraction. The technique enables manual tracking of surgical instruments and identification of the desired dissection plane. It also helps discern the relation between the dissector and the intrastromal lenticule. The dissection plane becomes hyperreflective on dissection, ensuring complete separation of the intrastromal lenticule from the overlying and underlying stroma. Inadvertent posterior plane entry, cap-lenticule adhesion, incomplete separation of the lenticule, creation of a false plane, and lenticule remnants may be recognized intraoperatively so corrective steps can be taken immediately. In cases with a hazy overlying cap, microscope-integrated intraoperative OCT enables localization and extraction of the lenticule. The technique is helpful for inexperienced surgeons, especially in cases with low amplitudes of refractive errors, ie, thin lenticules.

Bilateral fungal keratitis with ring infiltrates: a rare scenario.

A 12-year-old boy presented to the emergency department with chief complaints of pain, redness, discharge and diminution of vision in both eyes over the previous 20 days. There was no history of preceding trauma, contact lens use, any eye drop usage or ocular surgery. Systemic history was not significant. Presenting uncorrected visual acuity in his right eye was counting fingers at 1 m and 20/200 in the left eye, with accurate projection of rays in both eyes. Slit lamp biomicroscopy showed the presence of bilateral diffuse conjunctival congestion, corneal ring infiltrates and epithelial defect with corneal oedema. Potassium hydroxide wet mount showed the presence of septate fungal hyphae. The patient was treated with topical 5% natamycin and 1% voriconazole over a period of 6 weeks. Best-corrected visual acuity was 20/600 in the right eye and 20/20 in the left eye at 6-month follow-up.