Keratectasia After Presbyopia Treatment With INTRACOR.

PURPOSE: To report a case of keratectasis of a patient underwent INTRACOR presbyopic treatment 5 years ago. METHODS: Case Report. RESULTS: Fifty-eight-year-old gentleman had presented with deteriorating vision in his left eye. He reported undergoing INTRACOR presbyopic treatment in that eye 5 years ago. At presentation, his best-corrected visual acuity was 20/40. Slit-lamp examination of the left eye showed an ectatic cornea with concentric corneal scars. Corneal topography revealed marked keratectasia, with significant anterior and posterior elevations. The area of maximal corneal thinning coincided with the site of maximal elevation. Patient was fitted with hybrid contact lenses as a temporary treatment option and his best-corrected visual acuity improved to 20/30. CONCLUSIONS: INTRACOR is one of the newer modalilities to correct presbyopia. One must be aware of the complication such as corneal ectasia after this presbyopic treatment.

Microbial characteristics of post-traumatic infective keratitis.

PURPOSE: To determine the demographics, risk factors, clinical and microbiological characteristics, and treatment outcome of post-traumatic infective keratitis. METHODS: Consecutive patients with post-traumatic infective keratitis presenting to the Ophthalmology Department of a tertiary referral hospital in Singapore between March 2012 and March 2016 were prospectively identified. A standardized data collection form was used to document patient demographics, microbiological diagnosis, antibiotic sensitivity, and pretreatment and posttreatment ocular characteristics. Any contact lens-induced keratitis was excluded from the study. RESULTS: In total, 26 patients were included for analysis. The mean age was 40.0 years (SD ± 19.4) and 84.6% of the patients were male. The majority of the patients (69.2%, n = 18) had sustained work-related injury in their eyes. Gram-negative organisms were predominant isolates (75.0%, n = 12) in culture-positive corneal scrapings (n = 16). Pan-sensitive Pseudomonas aeruginosa was the commonest organism isolated among the culture-positive cases (56.2%, n = 9). Three patients (18.7%) had developed fungal keratitis and Acanthamoeba was isolated in 1 patient (6.2%) with polymicrobial keratitis. Infections resolved with medical treatment in 22 eyes (84.6%) and 4 eyes (15.3%) required therapeutic corneal transplantation. CONCLUSIONS: A shift of practice in post-traumatic infective keratitis should be considered in tropical countries to include Gram-negative cover. Work safety practices with vigilance in initiating treatment and education by front-line physicians such as ophthalmology and general practitioners should be reinforced.

Optical and Tectonic Corneal Transplant Outcomes in a Tertiary Hospital in Singapore within the Singapore Corneal Transplant Registry

<p><b>INTRODUCTION</b>This study aimed to describe and compare corneal graft survival and optical outcomes following deep anterior lamellar keratoplasty (DALK) and Descemet's stripping automated endothelial keratoplasty (DSAEK) with penetrating keratoplasty (PK), and to document tectonic success of patch grafts.</p><p><b>MATERIALS AND METHODS</b>This was a retrospective, non-randomised, comparative and descriptive cohort study. A total of 139 eyes that underwent primary keratoplasty between 2000 and 2016 were included, and the following data was extracted: demographics, clinical diagnosis and primary indication, pre- and intraoperative risk factors, postkeratoplasty outcomes, and complications. Optical success was defined as good graft clarity and best corrected visual acuity (BCVA) of 6/12 or better. Graft failure was defined as irreversible corneal oedema and loss of clarity. Tectonic success in patch grafts was defined as tectonic integrity with no repeat tectonic surgical procedure required in the postoperative period.</p><p><b>RESULTS</b>The mean follow-up duration was 3.24 ± 3.47 years in the PK group (n = 16), 1.89 ± 0.86 years in the DALK group (n = 37), 2.36 ± 1.24 years in the DSAEK group (n = 53), and 2.17 ± 1.09 years in the patch graft group (n = 33). The 3-year probabilties of survival for PK, DALK, DSAEK and patch graft were 60.9%, 94.1%, 89.9%, and 67.1%, respectively. The overall percentage of complications was significantly higher for PK (81.3%), compared to DALK (48.6%), DSAEK (49.1%), and patch graft (21.2%). In the PK and DALK groups, 100% achieved DSAEK (49.1%), and patch graft (21.2%). In the PK and DALK groups, 100% achieved BCVA of 6/12 or better, while in the DSAEK group, 96.43% achieved BCVA of 6/12 or better.</p><p><b>CONCLUSION</b>From a similar study cohort of Asian eyes, graft survival was superior and complications were reduced for DALK and DSAEK compared to PK, but optical outcomes were comparable. Graft survival for patch graft was expectedly lower, but the incidence of complications was low.</p>

Surgical treatment outcome of medically refractory huge giant papillary conjunctivitis.

PURPOSE: To compare the surgical outcome of excision of giant papillae with and without amniotic membrane in a patient with bilateral medically refractory giant papillary conjunctivitis (GPC). OBSERVATIONS: 27-year-old Chinese lady presented with bilateral itchy eyes, discomfort and fullness of upper lids for past two years. She was a long-term contact lens user but stopped completely 2 years ago. Not a known atopic, she had unusually large giant papillae involving both upper tarsal conjunctiva. She had used topical olopatadine(0.1%), intermittent dexamethasone(0.1%) and also underwent intralesional injection of Triamcinolone (40mg/ml) twice on each side without any improvement in past two years. We decided to excise the papillae with amniotic membrane transplantation (AMT) in left eye and only excision in the right eye. The results were compared after 2 years. Giant papillae were excised in both eyes under regional anesthesia on separate occasions. The left eye received AMT in addition to excision. A symblepharon ring was applied and left in place for two weeks in both eyes. She was treated with topical Prednisolone acetate (1%) and Levofloxacin 4 times a day for a month. Postoperative period was unremarkable and she recovered well. In 2 years follow-up, the upper tarsal conjunctiva was smooth in both eyes and there was no evidence of any recurrences. CONCLUSION AND IMPORTANCE: Excision of giant papillae is a treatment option for cases with refractory GPC. Additional AMT after excision may not be necessary as there was no difference in surgical outcome.

Bilateral simultaneous infective keratitis.

AIM: To analyze the demographics, risk factors, clinical and microbiological characteristics of cases of bilateral simultaneous infective keratitis. METHODS: In this retrospective case series, patients with clinical evidence of bilateral simultaneous infective keratitis were identified from January 1, 2011 to August 31, 2016. Demographics, risk factors, clinical and microbiological characteristics, and treatment outcomes were analyzed. RESULTS: Five patients (ten eyes) with bilateral simultaneous infective keratitis were identified. The mean age was 32.8 years (SD,±8.8; range, 24-44). All the patients were disposable soft contact lens wearers before presentation. The average size of the infiltrate was 4.76mm2 (SD±9.0; range, 0.2-31.34). A total of 4 types of bacteria were isolated, with Pseudomonas aeruginosa being the most frequently isolated bacteria involving 5 eyes of four patients. Infection resolved with medical treatment in 9 eyes, 1 patient required therapeutic corneal transplantation for impending corneal perforation. The average time taken for infection to resolve was 6.7days (SD±4.5; range, 2-16). CONCLUSIONS: In this case series, the most common risk factor of bilateral simultaneous microbial keratitis was use of soft disposable contact lens and the most commonly isolated bacteria was Pseudomonas aeruginosa. Bilateral simultaneous infective keratitis is uncommon and is a serious complication of contact lens use in immunocompetent adult patients.

Triple infection keratitis.

OBJECTIVE: To analyze the demographics, risk factors, and clinical and microbiological characteristics of triple infection keratitis. DESIGN: Retrospective case series. PARTICIPANTS: Five patients (five eyes) with triple infection keratitis were identified. METHODS: Eyes with polymicrobial keratitis were identified from January 2002 to December 2010. Only culture-positive cases and eyes infected by three different organisms were included. Demographics, risk factors, clinical and microbiological characteristics, and treatment outcomes were analyzed. MAIN OUTCOME MEASURES: The size of the corneal infiltrate, presence of hypopyon, pre- and post-treatment best-corrected visual acuity, antibiotic regimen and sensitivity, types of isolated pathogens, duration of infection, and treatment outcomes. RESULTS: The mean age was 39 years (SD, ±23.4; range, 21-74). Use of topical steroids was the commonest risk factor (80%). Multiple risk factors were identified in four eyes. The average size of corneal infiltrate was 23.5 mm (SD, ±35.2; range, 2.08-85.5), and all eyes developed hypopyon. A total of 15 organisms belonging to 10 species (bacteria=7, fungi=3) were isolated. Pseudomonas aeruginosa and Candida albicans were the most frequently isolated bacteria (n=3) and fungi (n=3), respectively. All patients had at least one type of fungal isolate. Infection resolved with medical treatment in four eyes and one eye had to be eviscerated as the patient developed panophthalmitis. The average time taken for infection to resolve was 30 days (SD, ±19.3; range, 13-61). CONCLUSIONS: A high index of suspicion of polymicrobial keratitis should be made in patients with multiple and systemic risk factors. Use of topical steroid was the most common risk factor. Prolonged course of disease, relatively large infiltrate, and presence of hypopyon and fungal isolates are typical features of triple infection keratitis.

Polymicrobial versus monomicrobial keratitis: a retrospective comparative study.

OBJECTIVES: To compare the risk factors, clinical characteristics, microbiological profile, and treatment outcomes of polymicrobial versus monomicrobial keratitis. METHODS: In this retrospective comparative case series, eyes with polymicrobial and monomicrobial keratitis were identified from microbiological records at a tertiary academic referral center, from January 2002 to December 2010. Only culture positive cases were included. Eyes with infectious keratitis involving two or more pathogens were included in the polymicrobial group, whereas eyes infected solely by Pseudomonas aeruginosa were included in the monomicrobial group. Various parameters including demographics, risk factors, clinical and microbiological characteristics, and treatment outcomes were analyzed. RESULTS: Twenty-one eyes each with polymicrobial and monomicrobial keratitis were included in this study. The mean age of polymicrobial patients was significantly higher than monomicrobials. Use of contact lens was the commonest predisposing factor in both groups. Systemic (23.8%) and multiple (33.3%) risk factors were involved in eyes with polymicrobial keratitis only. The mean size of corneal infiltrates and mean duration for resolvement of infection were significantly greater in the polymicrobial group. Medical treatment was successful only in 80.9% eyes with polymicrobial keratitis, whereas all monomicrobial keratitis patients responded to it. A total of 44 organisms belonging to 18 species (bacteria = 13, fungi = 5) were isolated from the polymicrobial group. P. aeruginosa and Candida albicans were the most frequently isolated bacteria (n = 12) and fungi (n = 5), respectively. In the polymicrobial group, gram-negative organisms were most sensitive to gentamicin (87.8%), followed by ciprofloxacin (78.7%), whereas gram-positive organisms were 100% sensitive to ciprofloxacin and cefazolin. CONCLUSIONS: A high index of suspicion of polymicrobial keratitis should be made in patients with multiple and systemic risk factors. Contact lens usage was the most common risk factor in both groups. Size of corneal infiltrate is a fairly reliable indicator for suspecting polymicrobial keratitis. Prolonged course of the disease and decreased antibiotic sensitivity were the other notable features of polymicrobial keratitis.

A rare polymicrobial keratitis involving Chryseobacterium meningosepticum and Delftia acidovorans in a cosmetic contact lens wearer.

OBJECTIVE: To report an unusual case of keratitis in a cosmetic contact lens wearer caused by two rare organisms. METHOD: Case report. RESULTS: A 14-year-old cosmetic contact lens user presented with a paracentral corneal ulcer in her right eye. The cosmetic lenses were bought online. The cultures from corneal scrapings and contact lenses demonstrated heavy growth of Chryseobacterium meningosepticum and Delftia acidovorans. The treatment with topical ciprofloxacin and fortified gentamicin was effective, and the infection resolved with corneal scar after 5 weeks. CONCLUSION: Use of cosmetic contact lenses and buying them online is a fairly common practice among teenagers. This can lead to serious eye infection as in this case. To our knowledge, this is the first report of contact lens-related keratitis simultaneously involving these two rare organisms.

Results of laser in situ keratomileusis for myopia of -10 to -19 diopters with a Technolas 217 laser.

PURPOSE: To evaluate the effectiveness, predictability, and safety of laser in situ keratomileusis (LASIK) for correcting myopia greater than -10.00 D. METHODS: Sixty-five eyes of 37 patients with myopia greater than -10.00 D underwent LASIK. Patients were evaluated on day 1, 1 week, 1, 3, and 6 months after surgery. Parameters evaluated were uncorrected visual acuity (UCVA) and best spectacle-corrected visual acuity (BSCVA), residual refractive error, regression of correction, and presence of any complication. RESULTS: Mean preoperative BSCVA was 0.745 +/- 0.234, which improved to 0.8070 +/- 0.237 postoperatively. The average preoperative UCVA was 0.022 +/- 0.02; postoperative UCVA at 6 months was 0.536 +/- 0.255. UCVA of 20/40 or better was achieved in 58% (38 eyes) and 20/20 or better in 26% (17 eyes). The average refractive error before LASIK was -12.64 +/- 2.16 D (range -10.00 to -19.00 D). Mean residual refractive error 1 week following LASIK was -0.63 +/- 1.36 D, which regressed to a mean -1.78 +/- 2.08 D at the end of 6 months. Nineteen eyes (29%) were within +/-0.50 D of intended refractive correction. CONCLUSION: LASIK was partially effective in the correction of high myopia. An initial overcorrection may be programmed to offset the effect of refractive regression.

Intraoperative arcuate transverse keratotomy with phacoemulsification.

PURPOSE: To evaluate the efficacy of paired intraoperative arcuate transverse keratotomy at a 7-mm-diameter zone along with a 3.5-mm clear corneal phaco tunnel in the steeper axis to correct pre-existing astigmatism. METHODS: A prospective randomized case-control study was conducted on 34 eyes of 28 patients with immature senile cataract. They were divided into two groups; in one group (17 eyes) intraoperative arcuate keratotomy was coupled with phacoemulsification in the steeper meridian (arcuate keratotomy group; mean preoperative astigmatism 2.28 +/- 0.89 D) and the other group (17 eyes) phacoemulsification was performed in the steeper meridian without arcuate keratotomy (control group; mean preoperative astigmatism 2.04 +/- 0.50 D). The patients were examined at 1 day, and 1, 4, and 8 weeks postoperatively. Correction of keratometric astigmatism, surgically induced refractive changes, magnitude and axis of cylinder, spherical equivalent refraction, with and against the wound change, and coupling ratio were evaluated. RESULTS: Mean reduction in keratometric astigmatism in the keratotomy group was 1.26 +/- 0.54 D (P = .0067) and in the control group was 0.48 +/- 0.60 D (P = .0423). The difference in reduction of keratometric astigmatism between the two groups was statistically significant (P = .0296). Surgically induced refractive change at 8 weeks follow-up was 2.15 +/- 1.13 D in the keratotomy group and 1.50 +/- 1.32 D in the control group (P = .046). Coupling ratio was -1.10 +/- 0.43 in the keratotomy group at 8 weeks after surgery while the control group was -0.82 +/- 0.38. CONCLUSION: A combination of intraoperative arcuate keratotomy with steep axis phacoemulsification incision is more effective than steep axis phacoemulsification incision alone in reducing pre-existing astigmatism.

Presumed epithelial inclusion cyst of the iris seven years after radial keratotomy.

PURPOSE: To report a case of presumed epithelial inclusion cyst of the iris 7 years after radial keratotomy (RK) that was treated with double-frequency Nd:YAG laser (532 nm). METHODS: A young adult woman underwent bilateral RK for the correction of myopia of -4.50 Diopters 7 years prior to the development of a white mass in the anterior chamber of her left eye. There was no evidence of any other surgery or trauma to the eye during this period. An epithelial inclusion cyst of the iris was diagnosed, and double-frequency Nd:YAG laser (532 nm) was used to coagulate the cyst under topical anesthesia. RESULTS: The size of the cyst reduced significantly immediately following laser treatment, and the prelaser visual acuity of 6/12 was maintained at 6 months' follow-up without any recurrence. CONCLUSIONS: In the absence of evidence of any other surgery or trauma, the most likely cause of the epithelial inclusion cyst of the iris following RK is epithelial seeding from the original surgery, which is amenable to coagulation with double-frequency Nd:YAG laser.

Subconjunctival dislocation of an anterior chamber intraocular lens.

Post-traumatic dislocation of an intraocular lens (IOL) is a serious complication, especially after a blunt trauma because the posterior chamber lenses can potentially dislocate subconjunctively. We report a case of subconjunctival dislocation of a Kelman multiflex AC IOL. Such cases require immediate wound repair with IOL explantation to prevent endophthalmitis.

Therapeutic keratoplasty for infectious keratitis: a review of the literature.

PURPOSE: This article provides a review of the literature on various aspects of therapeutic keratoplasty, including indications, techniques, complications and outcome, and its application in cases of infectious keratitis. METHODS: Various articles on therapeutic keratoplasty (including English- and non-English-language publications) were analyzed. Selection of the articles was based on a Medline search for articles using the key words therapeutic keratoplasty, penetrating keratoplasty, therapeutic keratoplasty for infectious keratitis, non-healing corneal ulcer, microbial keratitis, and perforated corneal ulcer. Abstracts in English were used for non-English articles. RESULTS: Therapeutic keratoplasty has a definitive role in the management of progressive bacterial, fungal, Acanthamoeba, and viral keratitis refractory to medical treatment. Management of bacterial keratitis has higher functional success and anatomic cure rate compared with fungal, viral and Acanthamoeba keratitis. Therapeutic keratoplasty offers a cure rate of up to 100% in bacterial and fungal keratitis, whereas the recurrence of infection after Acanthamoeba keratitis is frequent. Visual outcome depends on various factors such as the causative agent, timing of surgery, degree of inflammation, type of donor material used, and size of the graft used. For example, larger grafts have a higher incidence of graft rejection and failure compared to smaller grafts. The primary aim of the procedure is to reestablish the integrity of the globe and to eliminate the infectious disease process. Visual rehabilitation is a secondary outcome. CONCLUSIONS: This review helps to elucidate the various aspects of therapeutic keratoplasty, including indications, preoperative assessment, surgical techniques, postoperative management, complications, and anatomic and functional outcome.

Intralamellar autopatch with lamellar keratoplasty for paracentral corneal perforations.

PURPOSE: To report a new technique of tectonic intralamellar autopatch with lamellar keratoplasty (LK) for paracentral corneal perforations. METHODS: A partial thickness lamellar dissection of the host was undertaken to remove the superficial epithelium and the anterior stroma. A second lamellar dissection began at the periphery to approximately 1 mm away from the perforation to fashion a hinge. The hinged autolamellar flap was reflected over the perforation and sutured to the host with interrupted sutures. Finally, the autolamellar patch graft was supported by a lamellar graft, which was secured in place with 16 interrupted sutures. This technique was undertaken in 4 eyes with paracentral perforation after trauma (2 eyes), after pterygium (1 eye), and inadvertent perforation during host bed dissection of large LK (1 eye). RESULTS: All eyes achieved a stable ocular surface and a postoperative visual acuity of more than 6/60. CONCLUSIONS: Intralamellar autopatch with lamellar keratoplasty provides adequate tectonic support in cases of paracentral corneal perforation and thereby maintaining the integrity of the globe. It also provides ambulatory visual acuity.

Microbial keratitis after laser in situ keratomileusis.

PURPOSE AND METHOD: To review the literature on microbial keratitis reported after laser in situ keratomileusis (LASIK). RESULTS: Forty-one eyes have been reported to have microbial keratitis after LASIK. The causative organisms vary from gram positive bacteria to atypical mycobacteria, fungal, and viral pathogens. The infection is usually acquired intraoperatively, but may also be caused by postoperative contamination. A majority of the patients present within 72 hours of the surgery with an acute onset of symptoms. Management of microbial keratitis after LASIK includes aggressive topical fortified antibiotic therapy, irrigation of stromal bed with antibiotic solution after lifting the flap, and sending the scraping of the infiltrate for microbiological evaluation. The keratitis heals with scarring and a best spectacle-corrected visual acuity of 20/40 or better can be obtained in the majority of the patients. CONCLUSION: Microbial keratitis is a sight-threatening complication of LASIK.