Shave Excision With Keratopigmentation for Limbal Dermoid.

OBJECTIVES: To describe a modified technique of corneal tattooing for concomitant cosmetic rehabilitation in eyes with limbal dermoid. STUDY: Case series. METHODS: Three patients between 12 and 20 years of age with grade I limbal dermoid underwent shave excision with corneal tattooing. All patients had dark brown irides. Chemical keratopigmentation was performed over the bed using 2% gold chloride with 1% hydrazine hydrate as reducing agent to yield a dark brown color. Bandage contact lens was applied. RESULTS: Epithelium over the operated area healed by day 10. Visual acuity was maintained in all eyes with minimal change in keratometry. The dye was well retained in the tattooed area at 1 year. No complications such as infection, pseudopterygium, or local limbal stem-cell deficiency were observed. CONCLUSION: Corneal tattooing along with simple shave excision provides good cosmetic results in cases of limbal dermoids.

Evaluation of the Role of Umbilical Cord Serum and Autologous Serum Therapy in Reepithelialization After Keratoplasty: A Randomized Controlled Clinical Trial.

PURPOSE: To evaluate the role of umbilical cord serum (UCS) and autologous serum (AS) therapy in reepithelialization of corneal graft after keratoplasty in a randomized controlled trial. METHODS: A total of 105 eyes with epithelial defect (ED) after keratoplasty (penetrating keratoplasty-67 and anterior lamellar keratoplasty-38) on the first postoperative day were included in the study. The eyes were randomized into three groups: UCS (n=35), AS (n=35), and artificial tears (AT) (n=35). All patients received standard postoperative medical therapy. The primary outcome measure was time to epithelialization, and secondary outcome measures were best-corrected visual acuity and graft clarity. RESULTS: The ED healed completely in 103 eyes. The mean time for complete reepithelialization was 2.5±2.1, 3.1±2.2, and 4.5±1.4 days in UCS, AS, and AT groups, respectively. The mean percentage decrease in the size of the ED was significantly better in the UCS and AS groups as compared with the AT group (P=0.001). The rate of reepithelialization was comparable between the AS and UCS groups (P=0.3). On bivariate analysis, significant correlation was found between the mean size of postoperative ED, grade of the donor cornea (P=0.001), and the presence of preoperative ED (P=0.001). No complications were associated with the use of serum therapy. CONCLUSION: Most of the cases of postkeratoplasty corneal ED can be managed with AT only. The serum therapy (AS/UCS) helps in the faster reepithelialization of postkeratoplasty ED as compared with AT and may be considered as a treatment option for early epithelial healing.

Intraoperative Suprachoroidal Hemorrhage After Penetrating Keratoplasty: Case Series and Review of Literature.

OBJECTIVE: To describe four cases of intraoperative suprachoroidal hemorrhage (SCH) during penetrating keratoplasty and to review the literature. METHODS: Cases with intraoperative SCH during penetrating keratoplasty over 3-year period were reviewed. The parameters evaluated were ocular and systemic risk factors, intraoperative details, and postoperative outcomes. A review of literature of intraoperative SCH during penetrating keratoplasty was also conducted. RESULTS: Of the 543 cases that underwent penetrating keratoplasty for optical indications during the study period, four cases developed intraoperative SCH, which is an incidence of 0.73%. Suprachoroidal hemorrhage occurred in the following cases: failed pediatric graft, donor eye in a case of contralateral autokeratoplasty, Marfan syndrome with aphakic bullous keratopathy who had undergone multiple ocular surgeries, and a case of healed keratitis with corneoiridic scar. The mean age, axial length, and intraocular pressure were 32.75±22.17 years (range, 4-57 years), 23.29±2.12 mm (range, 20.38-25.2 mm), and 16.25±3.86 mm Hg (range, 16-20 mm Hg), respectively. Postoperatively, two eyes had a best-corrected visual acuity (BCVA) of counting fingers. The third case had BCVA of light perception (LP), and fourth eye had no LP. CONCLUSION: The visual outcomes in cases of open-sky penetrating keratoplasty with SCH continue to be abysmally poor. The importance of thoroughly informing the patient about this complication cannot be underrated.

Incision-Site Descemet Membrane Detachment During and After Phacoemulsification: Risk Factors and Management.

OBJECTIVE: To evaluate the occurrence of localized incision-site Descemet membrane detachment (DMD) during and after phacoemulsification and to study its relationship with phacoemulsification parameters. METHODS: Forty-three, consecutive uneventful cases of phacoemulsification through 2.8-mm clear corneal incision were included in this prospective study. Preoperatively, the grade of cataract was assessed. The phacoemulsification parameters noted were phacoemulsification time, aspiration time, cumulative dissipated energy (CDE), ultrasound time, and total fluid volume. Anterior segment optical coherence tomography (AS-OCT) was performed on postoperative days 1 and 7 to study the course of the incision-site DMD. RESULTS: Fourteen of 43 cases (32%) showed localized incision-site DMD either intraoperatively or on AS-OCT on the first postoperative day. Of these, nine cases were detected intraoperatively, and six cases were detected on AS-OCT on the first postoperative day. All cases were of planar type and resolved spontaneously. A single case showed a concurrent DMD involving central cornea, which resolved without any surgical intervention. The occurrence of DMD was significantly higher in those with the total ultrasound time greater than 60 sec (P=0.038) (odds ratio: 7.639). The CDE was higher in cases with DMD; however, the result was not statistically significant (P=0.062). Torsional equivalent in level-3, total torsional time, equivalent torsional time, aspiration time, and the total fluid volume were comparable (P>0.05) between cases with and without incision-site DMD. CONCLUSION: Postphacoemulsification incision-site DMD may occur in up to one third of cases and is associated with increase in the total ultrasound time.

Acute hydrops with secondary bacterial keratitis: sequelae of paediatric refractive surgery.

A 24-year-old male patient with bilateral high myopia presented to our outpatient department with sudden onset of pain and diminution of vision in his right eye. He had sequentially undergone bilateral trabeculectomy and photorefractive keratectomy at the age of 6 years in both eyes. This was followed by radial keratotomy in right eye at the age of 8 years. The slit lamp examination demonstrated the presence of infiltrates in central cornea with an underlying fluid cleft, along with 14 radial keratotomy scars. Anterior segment optical coherence tomography confirmed the presence of intrastromal cleft in communication with anterior chamber. Bacterial culture revealed coagulase-negative Staphylococcus. The patient was successfully treated with fortified antibiotics in conjunction with the sensitivity report. This case underlines the need for a cautious approach towards refractive surgery in paediatric age group and highlights the long-term sequelae of retreatments in these cases.

Management Algorithm for Fungal Keratitis: The TST (Topical, Systemic, and Targeted Therapy) Protocol.

PURPOSE: To evaluate the efficacy of the topical, systemic and targeted therapy (TST) protocol in management of fungal keratitis. METHOD: All cases of treatment-naive smear- or culture-proven fungal keratitis presenting between June 2013 and May 2017 were recruited. The TST protocol included initial treatment with topical natamycin 5% with addition of oral ketoconazole or voriconazole in ulcers with size >5 mm, depth >50%, or impending perforation. Topical voriconazole 1% was included in case of poor response at 7 to 10 days. Intrastromal or intracameral antifungal injections were administered in case of poor response to combination therapy. Penetrating keratoplasty was performed in case of poor response to any of the regimen. RESULTS: The study included 223 cases of fungal keratitis with a mean age of 43.6 ± 15.3 years and a male-to-female ratio of 1.8:1. The mean area of the ulcer and infiltrate at presentation was 25.52 ± 19 and 25.7 ± 14.4 mm, respectively. Corrected distance visual acuity at presentation was 2.05 ± 0.43 logMAR that improved to 1.6 ± 0.4 logMAR at 3 months. Fusarium (42.2%) was the most common microorganism isolated, followed by Aspergillus (32.8%). The mean healing time was 41.5 ± 22.2 days, with a final scar size of 14.6 ± 8.2 mm. The treatment success rate with the TST protocol was 79.8%. Corneal perforation developed in 7% of cases (n = 15), and keratoplasty was performed for 20.2% of cases (n = 45). CONCLUSIONS: The TST protocol provides a stepwise treatment algorithm for management of cases of fungal keratitis with varying severity.

Evaluation of a low-cost design keratoprosthesis in end-stage corneal disease: a preliminary study.

PURPOSE: To evaluate the indications, outcomes and complications of Auro keratoprosthesis (a low-cost design based on type I Boston Keratoprosthesis) in the end-stage corneal disease in a preliminary study. METHODS: In this prospective interventional study, 10 eyes of 10 patients with an end-stage corneal disease underwent implantation of Auro keratoprosthesis with the mean follow-up of 14.5±2.1 months. The indications included multiple failed grafts (n=7), aphakic bullous keratopathy (n=2) and chemical injury (n=1). The additional intraoperative procedures performed were synechiolysis (n=9), cataractous lens extraction (n=2), Ahmed glaucoma valve implantation (n=1) and vitreoretinal surgery (n=1). Antibiotic prophylaxis was administered postoperatively, and patients were followed up at 1 week, 2 weeks, 1 month and thereafter at monthly intervals. The main outcome measures were best corrected visual acuity (BCVA), retention of prosthesis, complications and need for secondary surgical interventions. RESULTS: The most common indication for keratoprosthesis implantation was graft failure (7/10, 70%). The postoperative BCVA improved to ≥20/200 in six patients. Nine out of 10 patients had retained keratoprosthesis. The complications seen were inflammatory debris behind keratoprosthesis (n=4), retroprosthetic membrane (n=2), glaucoma (n=4), small (<2 mm) sterile stromal necrosis or erosions at the graft edge (n=3) and microbial keratitis (n=1). Explantation of the keratoprosthesis was performed in one eye due to fungal keratitis. CONCLUSIONS: Auro keratoprosthesis, a low-cost keratoprosthesis, is a viable option in the end-stage corneal disease in this preliminary study. Multicentre studies with long-term follow-up are required to conclusively prove its safety and efficacy.

Genotyping of Acanthamoeba spp. and characterization of the prevalent T4 type along with T10 and unassigned genotypes from amoebic keratitis patients in India.

Free-living amoebae of the genus Acanthamoeba are the causative agents of severe sight-threatening infection of the cornea. This study was designed to characterize the genotype of 20 Acanthamoeba spp. isolates obtained from corneal scrapings of 183 suspected Acanthamoeba keratitis patients reporting to the Outpatient Department/Casualty Services of Dr R. P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India during the period 2011-2015. Corneal scrapings were inoculated onto 2 % non-nutrient agar plates overlaid with Escherichia coli and incubated at 30 °C for 15 days. Amongst 183 suspected Acanthamoeba keratitis patients, 29 were found culture-positive for Acanthamoeba spp. out of which 20 samples were established in axenic culture for molecular analysis. DNA was isolated and PCR assay was performed for the amplification of the diagnostic fragment 3 (DF3) (∼280 bp) region of the 18S rRNA gene from axenic culture of 20 Acanthamoeba spp. isolates. Rns genotyping was performed on the basis of variation in nucleotide sequences of the DF3 region of the 18S rRNA gene. In the phylogenetic analysis, 16 of the 20 isolates were found to be of prevalent genotype T4, two were of genotype T10 and the remaining two isolates were of unassigned genotypes. Hence, it was concluded that genotype T4 was found as the most predominant genotype involved in Acanthamoeba keratitis infections. Genotype T10, which had not been reported from India, was detected for the first time in two patients. Two isolates were found to be unique, which shared < 95 % homology with all the known genotypes (T1-T20) of Acanthamoeba spp.

Sutureless anterior lamellar keratoplasty with phacoemulsification.

PURPOSE: To compare the results of microkeratome-assisted sutureless anterior lamellar keratoplasty (SALK) with and without phacoemulsification. METHODS: In this retrospective comparative interventional case series, patients with superficial anterior corneal opacity were divided into 2 groups. Eyes in group 1 (n = 6) had associated cataract and underwent SALK with phacoemulsification surgery (SALK triple). Eyes in group 2 (n = 6) did not have cataract and underwent only anterior lamellar keratoplasty. A 200-µm microkeratome head was used for host and donor cut. Fibrin glue was applied at the graft-host junction. Visual acuity, refractive error, topographic changes, and pachymetry were noted. RESULTS: Mean follow-up was 9 ± 2.7 months. The best spectacle-corrected visual acuity (BSCVA) improved significantly over the preoperative value in both the groups at 1 month, 6 months, and the last follow-up (P = 0.028). The mean gain in BSCVA was 8.8 ± 3.4 lines and 6.8 ± 5.2 lines, respectively, for groups 1 and 2 at the last follow-up, with no statistically significant difference in the BSCVA of both groups at the last follow-up (P = 0.80). There was no statistical difference at the last follow-up between the 2 groups with respect to spherical equivalent (P = 0.6), cylinder (P = 0.81), topographic astigmatism (P = 0.75), and graft thickness (P = 0.81). One patient in group 1 underwent graft rejection, which completely reversed with treatment. No cases of graft dislocation, infection, epithelial ingrowth, vascularization, or recurrence of primary pathology were noted in either group. CONCLUSIONS: SALK triple is an effective surgery for early visual rehabilitation of patients with superficial anterior corneal opacity and concomitant cataract.

Detection of fungal hyphae using smartphone and pocket magnifier: going cellular.

PURPOSE: The aim of this study was to detect fungal hyphae in a corneal scraping sample using a cost-effective assembly of smartphone and pocket magnifier. METHODS: In this case report, a tissue sample was obtained by conventional corneal scraping from a clinically suspicious case of mycotic keratitis. The smear was stained with Gram stain, and a 10% potassium hydroxide mount was prepared. It was imaged using a smartphone coupled with a compact pocket magnifier and integrated light-emitting diode assembly at point-of-care. Photographs of multiple sections of slides were viewed using smartphone screen and pinch-to-zoom function. The same slides were subsequently screened under a light microscope by an experienced microbiologist. The scraping from the ulcer was also inoculated on blood agar and Sabouraud dextrose agar. RESULTS: Smartphone-based digital imaging revealed the presence of gram-positive organism with hyphae. Examination under a light microscope also yielded similar findings. Fusarium was cultured from the corneal scraping, confirming the diagnosis of mycotic keratitis. The patient responded to topical 5% natamycin therapy, with resolution of the ulcer after 4 weeks. CONCLUSIONS: Smartphones can be successfully used as novel point-of-care, cost-effective, reliable microscopic screening tools.