Microbial keratitis following vegetative matter injury.

The purpose of the present study was to analyze the microbiological profile of cases of keratitis following trauma with vegetative matter in a tertiary care center. A retrospective review of the medical records of 49 patients with keratitis following vegetative matter injury over a 3-month period was performed. All patients underwent corneal scraping for smears and inoculation onto various culture media. The microbiological profile was based on the smear and culture reports. For patients who were culture-negative, outcome after standard empirical antibacterial therapy as per hospital protocol was analyzed. Thirteen patients with corneal ulcers had fungal etiology, eight had bacterial etiology, and two had protozoal etiology, while 13 patients were polymicrobial and 13 were culture-negative. Polymicrobial infections were mainly bacterial (eight cases), and the remaining five cases had coexistent fungal and bacterial etiology. The treatment was directed to the specific organism and patients improved with medical or surgical therapy. Only a third of culture-negative cases showed fungal etiology on biopsy or histopathology after keratoplasty while a third showed improvement with therapy. Corneal infections following vegetative matter trauma show a varied etiological profile; however, bacterial and polymicrobial infections are more prevalent. Empirical anti-fungal therapy, as commonly practiced, must be avoided in cases with vegetative matter injury.

Descemet's stripping endothelial keratoplasty (DSEK) for children with congenital hereditary endothelial dystrophy: surgical challenges and 1-year outcomes.

PURPOSE: To evaluate the outcomes of Descemet's stripping endothelial keratoplasty (DSEK) in patients with congenital hereditary endothelial dystrophy (CHED). METHODS: Retrospective, interventional case series of five eyes of five patients with congenital hereditary endothelial dystrophy (CHED) undergoing Descemet's stripping endothelial keratoplasty (DSEK) from June 2009 to June 2010 by a single surgeon. Patients were evaluated during the postoperative period for visual acuity, refraction, corneal clarity, lenticule status, and intraocular pressure. Anterior segment ocular coherence tomography (OCT) and confocal microscopy were performed when possible. RESULTS: Three male and two female children with an average age of 7.8 years (range 5-12 years) with CHED underwent DSEK. Surgery was uneventful in all patients and the lenticules stayed attached during the postoperative period. All the patients had 1-year follow-up. Corneal clarity improved in all the patients over the period of follow-up. Anterior segment OCT showed a gradual reduction in the thickness of the central corneal thickness and the graft over a period of time. CONCLUSIONS: DSEK is a viable alternative to penetrating keratoplasty in patients with CHED with distinct advantages of reduced postoperative astigmatism and potential reduction of postoperative complications.

Endothelial keratoplasty without Descemet's stripping in congenital hereditary endothelial dystrophy.

PURPOSE: To compare outcomes of non-Descemet's stripping endothelial keratoplasty (nDSEK) with Descemet's stripping endothelial keratoplasty (DSEK) for the surgical management of congenital hereditary endothelial dystrophy (CHED). METHODS: Patients with CHED who were treated with DSEK or nDSEK were analyzed and compared with respect to graft adhesion, graft clarity, visual acuity, refraction, and complications. RESULTS: A total of 6 patients were included in the series. Of these, 3 (mean age, 5.6 ± 1.52 years; 1 male) underwent DSEK and 3 (mean age, 5.6 ± 0.57 years; 2 males) nDSEK. Preoperative best-corrected visual acuity of patients who underwent DSEK was 1.3 logMAR units compared with 1.13 logMAR units for nDSEK patients. There were no intraoperative complications. During the early postoperative period, 1 patient who had n DSEK had lenticule detachment and was successfully managed by repeat air injection. The average time for resolution of graft edema was 30 days. The postoperative best-corrected visual acuity was 0.13 ± 0 .10 in DSEK patients and 0.13 ± 0 .10 in nDSEK patients (P = 1). Mean refraction was comparable in both groups of patients. CONCLUSIONS: The outcomes of nDSEK were similar to DSEK in CHED in this small series. The specific advantage of nDSEK is the decreased surgical time and intraocular tissue manipulation.

Immunosuppression for Mooren's ulcer: evaluation of the stepladder approach--topical, oral and intravenous immunosuppressive agents.

AIM: To evaluate a step ladder approach for immunosuppressive regimen for Mooren's ulcer. MATERIAL AND METHODS: We retrospectively analysed patients of Mooren's ulcer presenting to a tertiary care centre in south India from 1987 to 2010. Patients were analysed for the age, disease severity at time of presentation in terms of the quadrants of peripheral corneal involvement and amount of peripheral corneal thinning. According to the disease severity, patients were instituted either topical steroids (prednisolone acetate 1%) single agent or in combination with oral steroids (prednisolone 1-1.5 mg/kg/day), oral immunomodulators (methotrexate 7.5-12.5 mg/week), intravenous pulsed methyl prednisolone 1 g or pulsed cyclophosphamide 1 g. The main outcome measure was control of disease activity. RESULTS: Topical steroids as a single therapy had a disease resolution rate in 76% of the cases. Cases that required oral steroids, oral methotrexate, intravenous pulsed methyl prednisolone and combination of pulsed methyl prednisolone and cyclophosphamide had a resolution rate of 86%, 78.5%, 71.4% and 73.3%, respectively. The most common complication was secondary infection. Most of the cases that failed therapy had perforation of the cornea and required corneal transplantation. CONCLUSIONS: An aggressive immunosuppressive regimen that is tailor made based on disease severity as a first line of therapy improves the chances of disease control even in cases of aggressive Mooren's ulcer.

Paired-eye comparison of Descemet's stripping endothelial keratoplasty and penetrating keratoplasty in children with congenital hereditary endothelial dystrophy.

PURPOSE: To report the surgical outcomes of Descemet's stripping endothelial keratoplasty (DSEK) in cases of congenital hereditary endothelial dystrophy (CHED) cohort and compare it with penetrating keratoplasty (PK) in a paired-eye setting. METHODS: Ours is a retrospective, comparative, consecutive and interventional clinical case series. All patients less than 14 years of age who underwent PK in one eye and DSEK in the contralateral eye at a single centre from January 2006 and February 2011 were analysed. Main outcome measures were graft clarity, visual outcome and complications. RESULTS: The mean age of the patients was 6.6±2.19 years at the time of presentation. The outcomes of two surgeries were compared with 1 year of follow-up at the corresponding follow time. At 1 year, all grafts were clear. There was no significant difference in the spherical component of the refraction; the astigmatism was significantly lower after EK. The refraction stabilised in patients with EK as early as 3 months, while it continued to change up to 1 year after PK. Complications included graft dislocation in two cases of DSEK, which were managed by rebubbling, and a graft dehiscence in one case of PK, which was managed by resuturing. The final visual acuity improved in all the patients. CONCLUSIONS: Endothelial keratoplasty is a viable option to conventional PK in cases of CHED. It offers an advantage of early visual stabilisation compared with PK.

Deep anterior lamellar keratoplasty in children.

PURPOSE: To evaluate the outcomes of deep anterior lamellar keratoplasty (DALK) in children. DESIGN: Retrospective interventional case series. METHODS: setting: Institutional, L.V. Prasad Eye Institute, a tertiary care center in south India. study population and intervention: All children less than 16 years of age undergoing DALK from January 2003 to January 2011. main outcome measure: Visual outcome and complications. RESULTS: Twenty-six eyes of 26 children (13 male and 13 female) with a mean age of 7.82 ± 4.64 years underwent DALK for keratoconus (8), microbial keratitis (6), corneal scar (6), corneal keloid (3), chemical injury with limbal stem cell deficiency (2), and dermoid (1). Big bubble was achieved in 5 eyes, while manual dissection was done in 21. Follow-up ranged from 1 week to 7.3 years. Seventeen patients with a minimal follow-up of 6 months were evaluated for visual outcomes. Final vision varied from counting fingers to 20/20 (mean sphere 2.32 diopters, mean cylinder -2.5 diopters). Complications encountered were suture-related graft infiltrate (3), graft dehiscence (3), and Descemet membrane detachment (2). CONCLUSIONS: DALK is a feasible option in children with stromal corneal pathology. It offers advantages in the form of lower risk of graft rejection. However, the risk of complications such as suture-related infections and graft dehiscence persists even in these cases.

Measure of keratoconus progression in patients with vernal keratoconjunctivitis using scanning slit topography.

PURPOSE: To document topographic changes using Orbscan in patients with keratoconus and vernal keratoconjunctivitis over 1 year. MATERIAL AND METHODS: Retrospective analysis of clinical and Orbscan data of 22 eyes of 11 patients with keratoconus and VKC with follow up over 1 year period was done. The parameters studied included patients demographics, clinical features, visual acuity, refraction and Orbscan IIz. The changes in various Orbscan parameters were studied over the 1-year period. RESULTS: Mean age was 14±4.1 years. 20 eyes had clinical keratoconus, while 2 had forme fruste keratoconus. 8 eyes of 22 showed evident progression (>1 diopter change in mean simulated (sim) K over 12 months). There was no significant difference in the visual acuity or clinical features over follow up. In patients with progression, statistically significant change (p<0.05) was found in posterior float curvature, sim K astigmatism and maximum astigmatism. Rest of the parameters did not show significant change. Among the patients without evident progression, none of the parameters showed significant change. On comparing the patients with clinical signs of keratoconus with those with only topographic signs of keratoconus, there was no difference between the two groups with respect to the rate of progression of keratoconus. Patients with both mixed type and pure palpebral type of VKC had comparable Orbscan parameters at baseline and 1 year follow up and similar progression rate of keratoconus. CONCLUSION: Serial topographic analysis provides numerical information about various corneal parameters in patients with vernal keratoconjunctivitis and keratoconus.

Phototherapeutic keratectomy versus alcohol epitheliectomy with mechanical debridement for superficial variant of granular dystrophy: a paired eye comparison.

PURPOSE: To compare outcome of phototherapeutic keratectomy (PTK) and alcohol epitheliectomy with mechanical debridement for superficial variant of granular dystrophy. METHOD: Case report. A 7 year old girl with superficial variant of granular dystrophy with an visual acuity of 20/70 both eyes, underwent a simultaneous PTK in right eye (OD) and alcohol epitheliectomy with mechanical debridement in left eye (OS). Post operatively the visual acuity, refraction and corneal clarity were assessed. RESULTS: On the first post-operative day uncorrected visual acuity was 20/50 in both eyes. At 2 weeks, vision improved to 20/40 with +2.50 -2.00×180 in OD and +1.50 -1.50×180 in OS. At 2 years, vision and refraction were 20/25 with +2.50 -2.00×180 in OD and 20/25 with +1.25 -1.50×170 OS respectively. There was early recurrence of the granular dystrophy. CONCLUSION: The visual outcomes of both PTK and alcohol epitheliectomy are similar for superficial variant of granular dystrophy. The hyperopic shift with PTK is a matter of concern. Alcohol epitheliectomy can be used in treatment of superficial corneal dystrophies where PTK is unavailable.