Paediatric cornea crosslinking current strategies: A review.

Background: In the general population, 1 in 2000 people has keratoconus. Indians and other people from Southeast Asia have a higher incidence of keratoconus. Children with keratoconus typically present earlier in life and with a more severe disease. Rubbing the eyes has been identified as a risk factor. Children have a higher incidence and a faster rate of keratoconus progression. Visual rehabilitation in children with keratoconus is challenging. They have a low compliance with contact lens use. Many of these children require penetrating keratoplasty at an early age. Therefore, stopping the progression of keratoconus in children is of paramount importance. Main text: Compared to treatment, keratoconus progression prophylaxis is not only preferable, but also easier. Corneal collagen cross-linking has been shown to be safe and effective in stopping its progression in children. The Dresden protocol, which involves central corneal deepithelization (7-9 â€‹mm), saturation of the stroma with riboflavin (0.25%), and 30 â€‹min UV-A exposure, has proven to be the most successful. Two significant disadvantages of the typical Dresden regimen are the prolonged operating time and the significant post-operative pain. Accelerated-CXL (9 â€‹mW/cm2 x 10 â€‹min) has been studied to reduce operative time and has been shown to be equally effective in some studies. Compared to accelerated CXL or traditional CXL, epi-off procedures, transepithelial treatment without the need for de-epithelialization and without postoperative discomfort, have been shown to be safer but less effective. Corneal crosslinking should only be performed after treating children with active vernal keratoconjunctivitis. Corneal opacity, chronic corneal edema, sterile infiltrates, and microbial keratitis have been reported after cross-linking of corneal collagen. Conclusions: The "Dresden protocol", also known as the conventional corneal cross-linking approach, should be used to halt the progression of keratoconus in young patients. However, if the procedure needs to be completed more rapidly, accelerated corneal crosslinking may be considered. Transepithelial corneal cross-linking has been proven to be less effective at stabilizing keratoconus, although being more safer.

Manual schism and intracameral air injection for impacted Descemet's membrane detachment.

A woman in her 60s was referred to us for management of poor vision following cataract surgery in the right eye. She had undergone manual small incision cataract surgery 12 weeks earlier. Slit-lamp biomicroscopy revealed corneal oedema, a horizontal line at the upper border and the adhered inferior border of detached Descemet's membrane (DM). Clinical diagnosis of impacted Descemet's membrane detachment (DMD) was considered.Surgical intervention with manual schisis and intracameral injection of air was planned. Using the 'push technique,' we tried to place the tip of the 27 gauge cannula between the back of the cornea and detached DM. The tip of the 27 gauge cannula was behind the impacted DM, and air injection was unsuccessful. Using the back-up the 'pull technique,' bent tip of the 27 gauge cannula was used to pull the impacted DMD. This manoeuvre, disimpacted the inferior border and the air bubble, was injected using the 27 gauge cannula. The air bubble unfolded and reattached the DM successfully.

In vitro antimicrobial efficacy of riboflavin, ultraviolet-A radiation, and combined riboflavin/ultraviolet-A radiation on ocular pathogens.

PURPOSE: There is a lack of studies evaluating the antimicrobial effect of riboflavin and ultraviolet-A (UVA) radiation using an epithelium-off cross-linking technique (Dresden protocol) in the literature. This study aimed to demonstrate the antimicrobial properties of riboflavin and UVA radiation and combined riboflavin/UVA radiation on various ocular pathogens Dresden protocol. MATERIALS AND METHODS: This was a prospective and comparative study. This study included four groups: Staphylococcus aureus, Pseudomonas aeruginosa, Candida albicans, and Acanthamoeba. All the groups were tested 12 different times with riboflavin alone, UVA light alone, and combined riboflavin with UVA. The growth inhibition zones were measured. Descriptive statistics were expressed as mean and standard deviation. The main outcome was measurement and analysis of growth inhibition zones. RESULTS: The mean growth inhibition zones following riboflavin and UVA exposure were 9.70 ± 1.63 mm for P. aeruginosa and 7.70 ± 1.08 mm for S. aureus. The mean growth inhibition zones for P. aeruginosa were greater than for S. aureus (t = 2.395, P = 0.038). The mean growth inhibition zones for C. albicans and Acanthamoeba were 0. The mean growth inhibition zones following UVA exposure alone and riboflavin alone for all organisms were also 0. CONCLUSION: Combined riboflavin and UVA in the clinical dose was effective against P. aeruginosa and S. aureus but ineffective against C. albicans and Acanthamoeba. Our study shows the potential of combined riboflavin and UVA in the treatment of bacterial keratitis.

Double bubble pneumo-descemetopexy for the management of Descemet membrane detachment: An innovative technique.

A 62-year-old woman was referred with poor vision following manual small incision cataract surgery. On presentation, the uncorrected distance visual acuity in the involved eye was 3/60, whereas slit-lamp examination revealed a central corneal edema with the peripheral cornea relatively clear. Direct focal examination with a narrow slit upper border and lower margin of detached rolled up Descemet's membrane (DM) could be visualized. We performed a novel surgical approach, "double-bubble pneumo-descemetopexy." The surgical procedure included unrolling of DM with "small air bubble" and descemetopexy with "big bubble." No postoperative complications were observed, and best corrected distance visual acuity improved to 6/9 at 6 weeks. The patient had a clear cornea and maintained BCVA 6/9 during 18 months at follow-up. Double-bubble pneumo-descemetopexy, a more controlled technique, provides a satisfactory anatomical and visual outcome in DMD without the need for endothelial keratoplasty (Descemet's stripping endothelial keratoplasty or DMEK) or penetrating keratoplasty.

Retrocorneal Scleral Patch Supported Glue: A Technique for Management of Corneal Perforation and Corneoscleral Melt following Pterygium Surgery.

Purpose: To describe a new method of treatment of corneal perforation with extensive corneoscleral melt. Case Report: A 42-year-old man presented with moderate-sized (3.5 mm) corneal perforation with extensive corneo-limbo-scleral ulceration following bare sclera excision of pterygium. No prior use of antimetabolites or postoperative beta radiation noted. We considered retrocorneal sclera patch supported cyanoacrylate application. The sclera was thinned to one-third thickness and a patch (4.5 × 4.5 mm) was punched. The sclera patch was placed on the iris, behind the corneal perforation, adequately covering it from inside. A minimal amount of adhesive was applied on the retrocorneal sclera patch and margin of corneal perforation. The ulcerating sclera was covered with double layered amniotic membrane. Topical antibiotic, steroid, and cycloplegic drops were instilled thrice daily. Corneal perforation healed and no recurrence occurred during the 18 months' follow-up. Conclusion: Retrocorneal scleral patch supported cyanoacrylate is effective for corneal perforation with corneo-scleral melt.

Tissue Adhesives for the Management of Corneal Perforations and Challenging Corneal Conditions.

Corneal perforations are ophthalmological emergencies which can have serious and detrimental consequences, if not managed timely and appropriately. These are a significant cause of ocular morbidity and can result in decreased vision, blindness, and even loss of the eye. Corneal perforations can be managed using a range of treatment approaches, including temporary solutions such as the application of corneal glue and bandage contact lens, as well as definitive treatment such as corneal transplantation. Tissue glues/adhesives were developed as substitutes for sutures in ophthalmic surgery. Unlike sutures, these glues are associated with shorter overall surgical times and reduced inflammation, thus improving postoperative comfort without compromising wound strength. The available tissue adhesives can be broadly classified into two types: synthetic (eg, cyanoacrylate derivatives) and biological (eg, fibrin glue). Cyanoacrylate glue is chiefly used as a corneal patch to manage acute corneal perforations and improve visual outcomes. Fibrin glue can be used instead of cyanoacrylate glue in many conditions with the benefits of reduced conjunctival and corneal inflammation and reaction. Apart from this, each type of adhesive is distinct in terms of its benefits as well as limitations and is accordingly used for different indications. The present review focuses on the two main types of tissue adhesives, their applications in the management of corneal perforations, the associated complications, safety and efficacy data related to their use available in the literature and the need for newer adhesives in this field.

Congenital corneal anesthesia: A case series.

Congenital corneal anesthesia (CCA) is an extremely rare condition where the cornea is affected in isolation or as a part of congenital syndrome, or can be associated with systemic anomalies. This case series of 12 eyes provides an overview of various clinical presentations and their final treatment outcomes. The average age of presentation was 3.2 years with a female preponderance (75%). Fifty percent of the patients had bilateral involvement and 50% had corneal ulcers at presentation. Two eyes required therapeutic keratoplasty for corneal perforation. All patients had isolated CCA except for one who had an associated hereditary and sensory autonomic neuropathy.

Voriconazole-impregnated multilayered AMT and intracorneal plus intracameral injection in recalcitrant fungal corneal ulcer.

We describe the management of a referred man in his 50s with corneal ulcer in the left eye. Slit-lamp biomicroscopy revealed an infiltrate (4.5×3.5 mm), involving full corneal thickness, corneal melt less than one-third corneal thickness and hypopyon (3.0 mm). Branched septate hypha on direct microscopy and Aspergillus flavus in Sabaraud's dextrose agar confirmed the clinical diagnosis of fungal corneal ulcer. We used natamycin 5% suspension 1 hourly, voriconazole 1% 1 hourly, gatifloxacin 0.5% three times and atropine 1% three times per day, for 2 weeks. However, there was no improvement and the corneal melt increased. We used intracameral plus intracorneal voriconazole injection with voriconazole-impregnated amniotic membrane transplant. We observed a significant decrease in conjunctival congestion, size/depth of infiltrate and hypopyon at the first week of antifungal therapy. Subsequently, at 6 weeks, corneal infiltrate had decreased and superficial corneal vascularisation appeared. Later, at 12 weeks, the patient developed corneal opacity.

Intracorneal scleral patch supported cyanoacrylate application for corneal perforations secondary to rheumatoid arthritis.

Purpose: To describe a new technique of intracorneal scleral patch (ICSP) supported cyanoacrylate tissue adhesive (CTA) application in corneal perforations, greater than 3.0 mm secondary to rheumatoid arthritis (RA). Methods: This Prospective, non-randomized, non-comparative, interventional series included 14 eyes (14 patients). All patients had corneal perforations sized 3.5 to 4.5 mm due to RA, which were treated with ICSP supported CTA application. A partial thickness scleral patch 1.0 mm larger than diameter of corneal perforation was prepared. A lamellar corneal pocket 0.5 mm all around the corneal perforation was created. The partial thickness scleral patch was placed in the corneal perforation site and the edge was fitted into the lamellar intracorneal pocket. A minimum quantity of CTA was applied on the scleral patch to seal the perforation. Results: The corneal perforations healed in 14 eyes (100%) in a mean 7.71 ± 1.14 (range, 6-9) weeks. One eye (7.14%) had inadvertent extrusion of ICSP due to premature removal of CTA but, Seidel's test was negative, and the corneal epithelial defect healed with BCL alone. One eye each (7.14%) developed steroid induced cataract and glaucoma. None of eyes developed infective keratitis, re-opening of corneal perforation (necessitating repeat procedure) or enlargement of corneal perforation requiring penetrating keratoplasty (PKP). Conclusion: ICSP supported CTA application is a successful alternative option to emergency PKP in treating corneal perforations sized 3.5 to 4.5 mm with associated RA.

Effect of Graft Attachment Status and Intraocular Pressure on Descemet Stripping Automated Endothelial Keratoplasty Outcomes in the Cornea Preservation Time Study.

PURPOSE: To examine the association of donor, recipient, and operative factors on graft dislocation after Descemet stripping automated endothelial keratoplasty (DSAEK) in the Cornea Preservation Time Study (CPTS) as well as the effects of graft dislocation and elevated IOP on graft success and endothelial cell density (ECD) 3 years postoperatively. DESIGN: Cohort study within a multi-center, double-masked, randomized clinical trial. METHODS: 1090 individuals (1330 study eyes), median age 70 years, undergoing DSAEK for Fuchs endothelial corneal dystrophy (94% of eyes) or pseudophakic or aphakic corneal edema (6% of eyes). Recipient eyes receiving donor corneal tissue randomized by preservation time (PT) of 0-7 days (N = 675) or 8-14 days (N = 655) were monitored for early or late graft failure through 3 years. Donor, recipient, operative, and postoperative parameters were recorded including graft dislocation (GD), partial detachment, and pre- and post-operative IOP. Pre- and postoperative central donor ECD were determined by a central image analysis reading center. Proportional hazards, mixed effects, and logistic regression models estimated risk ratios and (99% confidence intervals). RESULTS: Three independent predictive factors for GD were identified: a history of donor diabetes (odds ratio [OR]: 2.29 [1.30, 4.02]), increased pre-lamellar dissection central corneal thickness (OR: 1.13 [1.01, 1.27] per 25µ increase), and operative complications (OR: 2.97 [1.24, 7.11]). Among 104 (8%) eyes with GD, 30 (28.9%) developed primary donor or early failure and 5 (4.8%) developed late failure vs. 15 (1.2%; P < .001) and 29 (2.4%; P = .04), respectively, of 1226 eyes without GD. 24 (2%) of 1330 study eyes had early acutely elevated postoperative IOP that was associated with a higher risk of graft failure through 3 years (hazard ratio: 3.42 [1.01, 11.53]), but not with a lower mean 3-year ECD (mean difference 61 (-479, 601) cells/mm2, P = .77). History of elevated postoperative IOP beyond 1 month was not significantly associated with 3-year graft success or ECD. CONCLUSIONS: Donor diabetes, increased donor corneal thickness, and intraoperative complications were associated with an increased risk of GD. Early acutely elevated postoperative IOP and GD significantly increased the risk for graft failure following DSAEK.

Alopecia following oral acyclovir for the treatment of herpes simplex keratitis.

The authors report acyclovir-induced alopecia in a patient treated for herpetic keratouveitis. A 32-years-old female was diagnosed with herpetic keratouveitis. She was placed on prednisolone acetate (1%) suspension four times a day, atropine sulfate (1%) thrice a day, and oral acyclovir 400 mg twice-daily. Three weeks following oral acylovir, keratouveitis improved, but she developed alopecia without any drug eruptions. Oral acyclovir was discontinued. Three months later, alopecia completely resolved. Alopecia may be considered a possible complication following oral acyclovir.

Repositioning of pedicle conjunctival flap performed for refractory corneal ulcer.

A 50-year-old male was referred with a previous history of conjunctival flap (CF) for a nonhealing fungal corneal ulcer with extreme corneal thinning in the right eye. The peritomy for the CF extended from 6:30 to 9:30 clock h on the cornea. The CF was disengaged, peritomy area deepithelialized, and CF was repositioned. He later underwent penetrating keratoplasty and achieved 20/40 best corrected visual acuity. The authors present a new concept for surgically repositioning CF s to the original site immediately after healing of the corneal ulcer.

Scleral Patch Graft Augmented Cyanoacrylate Tissue Adhesive for Treatment of Moderate-Sized Noninfectious Corneal Perforations (3.5-4.5 mm).

PURPOSES: To describe a new technique of scleral tissue augmented cyanoacrylate tissue adhesive (CTA) application and to evaluate its efficacy in noninfectious corneal perforations that measure between 3.5 and 4.5 mm. METHODS: Retrospective noncomparative case series included 16 consecutive patients diagnosed with moderate-sized corneal perforations measuring 3.5 to 4.5 mm who were treated with scleral patch graft augmented glue application. A partial-thickness scleral patch equal to the size of corneal perforation was placed in the corneal perforation site. After the area was sufficiently dried, CTA was applied on the interface of the host cornea and scleral patch. The ability of the scleral patch graft with CTA to seal the perforation and allow complete wound healing was considered a successful outcome. RESULTS: The corneal perforation healed in 14 eyes (87.5%), with a mean of 5.65 weeks (range, 5-9 weeks). One eye (6.25%) developed microperforation that required additional CTA to seal the wound. Three eyes (18.75%) required reapplication of the scleral patch graft and CTA. The 2 eyes (12.50%) that failed scleral patch with CTA were successfully treated with tectonic penetrating keratoplasties. In all 5 eyes (100%), the corneal perforations as a result of Mooren ulcer healed in a mean 5.80 weeks (range, 5-7 weeks). One patient developed retinal detachment with proliferative vitreoretinopathy and cataract after trauma. CONCLUSIONS: Scleral patch graft augmented CTA technique is a successful alternative treatment method to emergent penetrating keratoplasty for corneal perforations that measure 3.5 to 4.5 mm.

Cocaine-assisted epithelial debridement for the treatment of anterior basement membrane dystrophy.

PURPOSE: To describe a method of epithelial debridement with the adjunctive use of topical cocaine for the treatment of symptomatic anterior basement membrane dystrophy (ABMD). METHODS: Retrospective consecutive chart review. Symptomatic patients with ABMD were treated with 4% topical cocaine followed by epithelial debridement. Preoperative and postoperative best-corrected visual acuities (BCVA), topography, subjective symptoms, complications, and evidence of disease recurrence were recorded. RESULTS: Thirty-three eyes of 27 patients were included. The average follow-up duration was 5 years (range, 1.3 months to 8 years). Fourteen patients (17 eyes) presented with recurrent erosion symptoms (group 1) and 13 patients (16 eyes) presented with reduced visual acuity from irregular astigmatism (group 2). Only 1 patient from group 1 experienced symptomatic recurrence of the corneal erosion. In this group, BCVA improved from a mean of 20/45 preoperatively to 20/38 at the last follow-up visit. In group 2, BCVA improved from a mean of 20/63 preoperatively to 20/32 at the last follow-up visit. No major recurrences were noted at the last follow-up visit in this group. No residual effect from the application of cocaine was noted in any of the eyes. Significant postoperative corneal haze occurred in 1 eye. CONCLUSIONS: Topical cocaine-assisted epithelial debridement offers a simple and inexpensive method for treating patients with ABMD who experience recurrent corneal erosions and/or irregular astigmatism resulting in decreased visual acuity.

Persistent corneal edema after collagen cross-linking for keratoconus.

PURPOSE: To present a new complication of persistent corneal edema after collagen cross-linking (CXL) in keratoconus patients. DESIGN: Retrospective case series of postoperative corneal edema after CXL. METHODS: study population: All patients who underwent CXL treatment with subsequent corneal edema. Patients with stromal haze were excluded. intervention: The CXL treatments used the Dresden protocol with corneal thickness of more than 400 µm after epithelium was removed. main outcome measure: The resolution of corneal edema after surgery. RESULTS: Postoperative corneal edema was identified in 10 (2.9%) of 350 patients who were followed up for a mean of 14 ± 4 months. The edema started on postoperative day 1 (10/10) and increased for 3 weeks. Additional findings included: deep vascularization (2 eyes; 20%), iris atrophy (6 eyes; 60%), pigment dispersion (5 eyes; 50%), persistent epithelial defect (3 eyes; 30%), and infectious keratitis (1 eye; 10%). Specular microscopy was unsuccessful, but the fellow untreated eyes had normal endothelial counts. Intraocular pressure and lenticular evaluations were normal. Corneal edema improved in 4 patients and resolved in 1 patient. In these 5 patients, the logarithm of the minimal angle of resolution best-corrected visual acuity was 0.5 ± 0.18. Penetrating keratoplasty was offered to 5 patients when improvement plateaued at 3 months, but only 2 patients underwent penetrating keratoplasty. CONCLUSIONS: CXL is a safe and effective procedure with few known side effects. This case series reports the possibility of corneal endothelial damage with visually significant corneal edema after CXL treatment. Based on the extent of endothelial damage, patients may require penetrating keratoplasty.

Endothelial keratoplasty without Descemet's stripping in eyes with previous penetrating corneal transplants.

AIMS: To evaluate techniques, outcomes and complications of endothelial keratoplasty (EK) without Descemet's stripping in eyes with previous penetrating keratoplasty (PK). METHODS: A retrospective, consecutive analysis of patients who underwent EK in eyes with previous PK. RESULTS: 33 eyes of 31 consecutive patients underwent EK without Descemet's stripping in eyes with previous PK. All 33 eyes were followed for an average of 14.2 ± 4.4 months. The reason for EK was either graft rejection (n=9) or endothelial failure (n=24). 32/33 (97.0%) eyes remained clear at the last follow-up visit. Visual acuity improved in 28/33 (84.8%) patients with 19/28 (67.9%) of these patients having more than three lines of visual acuity improvement. The average postoperative vision in this group was 20/60 (range 20/25-20/100). Pre-cut donor tissue was used for all cases with an average thickness of 127 µm. Endothelial cell density declined by 35% at 3 months and was stable at 1 year. 2/33 (6%) eyes had graft dislocations. One eye was successfully treated by a re-bubble. The other case failed EK revision and required a repeat PK. No patients developed EK or PK graft failure/rejection. CONCLUSION: EK without Descemet's membrane stripping in eyes with previous PK graft failure/rejection is a valuable alternative to a repeat full thickness PK.