Femtosecond laser-assisted successful management of subluxated cataractous lens with vitreous in anterior chamber.

Femtosecond laser-assisted cataract surgery was performed in a case of posttraumatic cataract with six clock hours subluxation and vitreous in the anterior chamber (AC). Femtosecond laser pretreatment allowed a closed-chamber creation of corneal incisions, capsulotomy, and lens fragmentation with minimal sudden lens-diaphragm movements and zonular stress. Integrated imaging systems allowed customization of the size and position of capsulotomy and nuclear fragmentation, based on the extent and site of subluxation. Presence of vitreous in AC did not hamper femtosecond laser application. Triamcinolone-assisted vitrectomy was performed before phacoemulsification and after implanting the intraocular lens (IOL). Postoperative uncorrected visual acuity was 20/20 with a stable IOL.

Efficacy and Safety of Topical Chloroquine in Mild to Moderate Dry Eye Disease.

Purpose: To evaluate the role of topical chloroquine (CHQ) as an adjunct to topical lubricants in the management of mild-moderate dry eye disease (DED)Methods: Prospective comparative pilot study allocated 150 patients with symptoms of mild to moderate DED to receive topical CMC 0.5% three times a day (group I, n = 75) or topical CHQ 0.03% twice a day with carboxymethylcellulose (CMC) 0.5% three times a day (group II, n = 75), for three months. Primary outcome measures were ocular surface disease index (OSDI) score and conjunctival impression cytology at 3 months. Secondary outcome measures were TBUT, Schirmer's test, ocular surface staining and any adverse effects at 3 months. Follow up was performed at 1 and 3 months.Results: At three months, the OSDI score was significantly better in the CHQ group as compared with the CMC group (CMC-18.36 ± 4.03 (SD), CHQ group- 15.9 ± 5.18 (SD); p = .002). Nelson's score was 0.92 ± 0.69 (SD) in the CHQ group as compared with 1.60 ± 0.77 (SD) in the CMC group (p < .001). Abnormal impression cytology was observed in 20% cases in the CHQ group as compared with 61.3% cases in CMC group (p < .001). A significant correlation was observed between Nelson's score and OSDI (Spearman's rho correlation coefficient 0.414, p < .001). TBUT, Schirmer test and ocular surface staining were significantly better in the CHQ group (p < .001). No adverse effects were observed in any group.Conclusion: Topical chloroquine is a useful adjunct to topical lubricants in the management of DED as it decreases the underlying chronic inflammation and helps maintain ocular surface stability.

Management of late-onset flocculent after-cataract with capsular bag lavage and posterior continuous curvilinear capsulorhexis.

We describe our technique for the management of late-onset liquefied after-cataract (LAC) to ensure long-term visual axis clarity. The densely adherent anterior capsular rim over the intraocular lens (IOL) optic was released with the help of microvitreoretinal blade, and multiple relaxing radial incisions were made on the capsular rim to facilitate easy access to the capsular bag. A thorough capsular bag lavage was performed with the help of bimanual irrigation-aspiration. Posterior continuous curvilinear capsulorhexis (PCCC) was performed after complete aspiration of fluid after-cataract to prevent recurrence. This technique was successfully performed in 14 cases. Postoperatively, IOL was stable and an uncorrected distance visual acuity of >20/32 was achieved in all cases. No recurrence was observed in any case over a follow-up of 1 year. Our technique of capsular bag lavage with PCCC is safe and effective for the management of LAC with optimal visual and anatomical outcomes.

'Double Bubble' Technique for Successful Reattachment of Total Descemet Membrane Detachment after Deep Anterior Lamellar Keratoplasty.

BACKGROUND: A double anterior chamber may be observed after deep anterior lamellar keratoplasty (DALK) and the management may be difficult especially in cases with a total descemet membrane detachment (DMD). Case Observations: We describe a novel "reverse double bubble" surgical technique for safe and effective reattachment of total DMD following DALK. Total DMD with air bubble in the interface was noted on the first postoperative day following DALK for healed keratitis. Intracameral air was injected via a 30-gauge needle inserted through a partial thickness MVR entry made at the posterior limbus, without disturbing the interface air-bubble. During this maneuver, the interface bubble did not change in size and moved towards the centre. The two distinct air bubbles, one in interface and other in anterior chamber indicated that air injection was in the anterior chamber, as per the reverse double bubble technique. The interface air bubble was removed by gently milking with an iris repositor towards the end of surgery. Thus, successful reattachment of DM was achieved despite difficult assessment of the plane of injection with the DM lying fl at on the surface of the iris. CONCLUSION: The reverse double bubble technique aids in the safe and successful reattachment of total DMD following intraocular surgeries.

Prevalence and risk factors of dry eye disease in North India: Ocular surface disease index-based cross-sectional hospital study.

PURPOSE: This study aims to study the prevalence of DED and analyze risk factors in North Indian population. METHODS: This was a cross-section hospital-based, observational study. Cases enrolled over 2 years (systematic random sampling) were administered ocular surface disease index questionnaire to evaluate the prevalence and risk factors of DED. Schirmer's test and tear break-up time were performed only in the subset of patients giving consent. Categorical data were assessed with Chi-square/Fisher's Exact test, and odds ratio was analyzed using bivariate and multivariate logistic regression. P < 0.05 was statistically significant. RESULTS: A total of 15,625 patients were screened. The prevalence of DED was 32% (5000/15625); 9.9% (496/5000) had mild DED; 61.2% (3060/5000) had moderate DED; and 28.9% (1444/5000) had severe DED. Age group of 21-40 years, male sex, urban region, and desk job were associated with increased risk of DED. Hours of visual display terminal (VDT) usage significantly correlated with DED (P < 0.001), and 89.98% of patients with 4 h or more of VDT use had severe dry eye. Cigarette smoking and contact lens usage had increased odds of developing severe DED (P < 0.001). Objective tests were undertaken in 552 patients; of these, 81.3% (449/552) had severe DED. CONCLUSIONS: The prevalence of DED in North India is 32%, with the age group of 21-40 years affected most commonly. VDT use, smoking, and contact lens use were associated with increased odds of developing DED.

"Meniscus Sign" to Identify the Lenticule Edge in Small-Incision Lenticule Extraction.

PURPOSE: To describe our technique of lenticule edge identification in small-incision lenticule extraction using the "meniscus sign" to prevent lenticule misdissection. METHODS: Femtosecond laser application for small-incision lenticule extraction was performed. A "double ring" was visible, signifying the edge of the cap cut (outer ring) and lenticule cut (inner ring). The anterior and posterior lamellar planes were delineated in 2 different directions. During creation of the posterior lamellar channel, the lenticule edge was slightly pushed away from the surgeon to create a gap between the inner ring (diameter of the lenticule cut) and the lenticule edge. The lenticule edge assumed a frilled wavy appearance, and the meniscus sign was observed as a gap between the lenticule edge and the inner ring. The meniscus-shaped gap served as a landmark to identify the lenticule edge, and the relationship between the frilled lenticule edge and surgical instruments further acted as a guide to identify the correct plane of dissection. RESULTS: This technique was successfully undertaken in 50 eyes of 25 patients. The meniscus sign was observed in all cases, and no case had cap lenticular adhesions. CONCLUSIONS: The meniscus sign helps to identify the lenticule edge and correct dissection planes and provides a visual landmark during the entire surgical procedure.

Effect of Lens Fragmentation Patterns on Phacoemulsification Parameters and Postoperative Inflammation in Femtosecond Laser-Assisted Cataract Surgery.

PURPOSE: To evaluate intraoperative and postoperative outcomes with "chop" or "matrix" lens fragmentation patterns in femtosecond laser-assisted cataract surgery. METHODS: Prospective comparative study of 66 eyes with grade III-IV nuclear sclerosis was conducted at an apex tertiary care ophthalmic center. Cases were randomly allocated to undergo femtosecond laser pretreatment using matrix pattern (group I; n = 33) or chop pattern (group II; n = 33) of lens fragmentation (LenSx laser platform), followed by phacoemulsification. The primary outcome measures were intraoperative phacoemulsification parameters and postoperative anterior chamber (AC) flare. Secondary outcome measures were intraoperative complications, postoperative central macular thickness, visual acuity, and endothelial cell counts. Follow-up was performed on postoperative day (POD) 1 and 30. RESULTS: Phacoemulsification parameters including cumulative dissipated energy (p = 0.008), ultrasonic time (p = 0.001), aspiration time (p < 0.001), and total duration (p = 0.001) were significantly less in group I. The AC flare was 9.8 ± 4.6 in group I and 15.4 ± 6.0 in group II (p < 0.001) on POD 1, and the difference persisted at 1 month. A highly significant positive correlation was observed between the total duration of phacoemulsification and AC flare (p < 0.001). No case developed cystoid macular edema. The postoperative specular counts were significantly less in group II on POD 1 (p = 0.036) and POD 30 (p = 0.02). There was no difference in visual acuity between the two groups, and intraoperative complications were not observed in any case. CONCLUSION: A decrease in phacoemulsification time and energy is observed after femtosecond laser pretreatment with the matrix pattern of lens fragmentation as compared to the chop pattern. The endothelial cell loss and postoperative inflammation is significantly less with the matrix pattern, and the inflammation correlates with the duration of phacoemulsification.

Impact of Clear Corneal Incision Morphology on Incision-Site Descemet Membrane Detachment in Conventional and Femtosecond Laser-Assisted Phacoemulsification.

PURPOSE: To assess intraoperative morphology of clear corneal incisions (CCI) and its impact on incision-site descemet membrane detachment (DMD) in conventional phacoemulsification and femtosecond laser-assisted cataract surgery (FLACS). METHODS: Prospective comparative study of 129 eyes that underwent either conventional phacoemulsification (Group I, n = 77) or FLACS (Group II, n = 52) was undertaken at an apex tertiary care ophthalmic setup. In group I, a 2.2-mm metal keratome was used to create a biplanar CCI. In group II, femtosecond laser-assisted biplanar CCI was created with 2.2 mm diameter. Incision architecture and incision-site DMD were assessed using microscope-integrated intraoperative OCT (iOCT) and anterior segment OCT on postoperative day (POD) 1 and 30. Visual acuity was assessed on POD 1 and 30. RESULTS: Smooth slit (SS) or ragged slit (RS) morphology of the proximal opening of CCI was observed immediately after creation [Group I: 68.8% SS, 31.2% RS; Group II: 86.5% SS, 13.5% RS]. DMD was observed in 87.1% cases with RS and 16.3% cases with SS morphology (p < 0.001). DMD was more frequent in group I (Group I = 38/77, Group II = 5/52; p < 0.001) and most commonly observed during the step of stromal hydration (83.7%). DMD was self-resolving and did not persist in any group at 1 month. Visual acuity was comparable in both groups on POD 1 and 30. CONCLUSION: Ragged morphology of proximal opening of CCI is the most important predictive factor for incision-site DMD. Femtosecond-laser CCIs have less incision-site DMD as compared to keratome-assisted CCIs. iOCT provides real-time assessment of CCI morphology and DMD.

Comparative evaluation of toric intraocular lens alignment and visual quality with image-guided surgery and conventional three-step manual marking.

PURPOSE: To compare toric intraocular lens (IOL) alignment assisted by image-guided surgery or manual marking methods and its impact on visual quality. PATIENTS AND METHODS: This prospective comparative study enrolled 80 eyes with cataract and astigmatism ≥1.5 D to undergo phacoemulsification with toric IOL alignment by manual marking method using bubble marker (group I, n=40) or Callisto eye and Z align (group II, n=40). Postoperatively, accuracy of alignment and visual quality was assessed with a ray tracing aberrometer. Primary outcome measure was deviation from the target axis of implantation. Secondary outcome measures were visual quality and acuity. Follow-up was performed on postoperative days (PODs) 1 and 30. RESULTS: Deviation from the target axis of implantation was significantly less in group II on PODs 1 and 30 (group I: 5.5°±3.3°, group II: 3.6°±2.6°; p=0.005). Postoperative refractive cylinder was -0.89±0.35 D in group I and -0.64±0.36 D in group II (p=0.003). Visual acuity was comparable between both the groups. Visual quality measured in terms of Strehl ratio (p<0.05) and modulation transfer function (MTF) (p<0.05) was significantly better in the image-guided surgery group. Significant negative correlation was observed between deviation from target axis and visual quality parameters (Strehl ratio and MTF) (p<0.05). CONCLUSION: Image-guided surgery allows precise alignment of toric IOL without need for reference marking. It is associated with superior visual quality which correlates with the precision of IOL alignment.

Intraoperative optical coherence tomography in anterior segment surgeries.

Intraoperative optical coherence tomography (iOCT) is a noninvasive imaging modality that provides a real-time dynamic feedback of the various surgical steps. Comprehensive literature search was performed in MEDLINE using "intraoperative optical coherence tomography" and "iOCT" as keywords. The use of iOCT as an aid to decision-making has been successfully reported in cases undergoing keratoplasty, implantable Collamer lens (ICL) implantation as well as cataract surgery. iOCT helps to assess the graft-host relationship in penetrating keratoplasty. It helps confirm the presence of a big bubble, detect subclinical big bubbles and guide layer by layer stromal dissection in cases of deep anterior lamellar keratoplasty. It acts as a guide during crucial surgical steps in endothelial keratoplasty, right from scoring of the Descemet membrane to ensuring graft apposition at the end of surgery. The morphological features of the corneal incision in phacoemulsification may be assessed. iOCT is a useful tool in assessing the status of the posterior capsule and may help identify preexisting posterior capsular defects during cataract surgery in various clinical scenarios such as posterior polar cataract, traumatic cataract, and vitrectomized eyes. It allows on-table assessment of the ICL vault and potentially facilitates exchange of ICL in the same sitting in extremes of vault. Ocular surface disorders such as ocular surface squamous neoplasia, pterygium, and dermoid may find an application for iOCT, wherein an iOCT-guided stromal dissection will ensure adequate depth of dissection. Further technological advancements may allow for automatic centration and tracking and address the present limitation of instrument-induced shadowing.

Optimizing outcomes with toric intraocular lenses.

Toric intraocular lenses (IOLs) are the procedure of choice to correct corneal astigmatism of 1 D or more in cases undergoing cataract surgery. Comprehensive literature search was performed in MEDLINE using "toric intraocular lenses," "astigmatism," and "cataract surgery" as keywords. The outcomes after toric IOL implantation are influenced by numerous factors, right from the preoperative case selection and investigations to accurate intraoperative alignment and postoperative care. Enhanced accuracy of keratometry estimation may be achieved by taking multiple measurements and employing at least two separate devices based on different principles. The importance of posterior corneal curvature is increasingly being recognized in various studies, and newer investigative modalities that account for both the anterior and posterior corneal power are becoming the standard of care. An ideal IOL power calculation formula should take into account the surgically induced astigmatism, the posterior corneal curvature as well as the effective lens position. Conventional manual marking has given way to image-guided systems and intraoperative aberrometry, which provide a mark-less IOL alignment and also aid in planning the incisions, capsulorhexis size, and optimal IOL centration. Postoperative toric IOL misalignment is the major factor responsible for suboptimal visual outcomes after toric IOL implantation. Realignment of the toric IOL is needed in 0.65%-3.3% cases, with more than 10° of rotation from the target axis. Newer toric IOLs have enhanced rotational stability and provide precise visual outcomes with minimal higher order aberrations.

AS-OCT as a Rescue Tool During Difficult Lenticule Extraction in SMILE.

PURPOSE: To report a case of lenticule adherent to the anterior cap during small incision lenticule extraction (SMILE) and its subsequent management aided by anterior segment optical coherence tomography (AS-OCT). METHODS: Case report. RESULTS: A 24-year-old woman presented with high myopia of -8.00 -0.50 @ 180° in the right eye and -8.00 -0.25 @ 180° in the left eye and underwent SMILE. In the right eye, difficulty was experienced in separating the lenticule from adjacent stroma. AS-OCT examination confirmed the presence of the lenticule adherent to the anterior stromal cap with the plane of dissection visible posterior to the lenticule. A Sinskey hook was used to lift off the peripheral edge of the lenticule from the anterior cap and the stripping of the lenticule was continued in a centripetal fashion until a small edge of the lenticule was rolled over. The lenticule was then completely separated from the overlying stromal cap and extracted through the side cut using forceps. Postoperative AS-OCT confirmed complete removal of the lenticule. Postoperative uncorrected distance visual acuity was 20/40 on day 1 and 20/20 on day 30 with a clear interface. CONCLUSIONS: AS-OCT-guided identification of the retained lenticule followed by Sinskey hook-assisted lenticule extraction aids in completion of the surgical procedure in the same sitting with optimal visual and anatomical outcomes. [J Refract Surg. 2017;33(5):352-354.].

Outcomes of Descemet Stripping Automated Endothelial Keratoplasty in Toxic Anterior Segment Syndrome After Phacoemulsification.

PURPOSE: To evaluate the visual and anatomical outcomes of Descemet stripping automated endothelial keratoplasty (DSAEK) in patients with toxic anterior segment syndrome (TASS). METHODS: Fourteen eyes of 14 patients who underwent clear corneal DSAEK for endothelial decompensation secondary to TASS after phacoemulsification were included in this prospective study. Intraoperative surgical difficulties were noted. Preoperative and postoperative evaluation of visual acuity, slit-lamp examination, intraocular pressure, central corneal thickness, and endothelial count was performed in all cases. RESULTS: The interval between onset of TASS and DSAEK was 9 ± 3.8 months (range: 2-15 months). Intraoperative difficulties were encountered during Descemet membrane scoring, and a floppy iris with extensive pigment release was observed. The postoperative inflammatory response was more intense with the formation of a characteristic pigment ring at the host-graft junction. Secondary glaucoma developed in 57.1% (8/14) cases. All grafts were attached postoperatively. In 2 patients, DSAEK was undertaken within 3 months of occurrence of TASS. Both cases required a regraft with eventual graft failure. In the subsequent 12 cases, DSAEK was performed more than 3 months after TASS. All 12 grafts were clear with no episode of graft rejection, and the corrected visual acuity ranged from 6/18 to 6/9. CONCLUSIONS: Successful visual and anatomical outcomes are achieved with DSAEK in cases of chronic TASS. The time interval between TASS and DSAEK is a critical factor determining long-term success, and a minimum 3- to 6-month waiting period after TASS is essential for optimal outcomes. Preoperative and postoperative control of inflammation and intraocular pressure is necessary to enhance graft survival.

Learning Curve of Small Incision Lenticule Extraction: Challenges and Complications.

PURPOSE: To describe the intraoperative complications observed during the initial learning curve of small incision lenticule extraction (SMILE) and their management. METHODS: Prospective evaluation of 100 consecutive eyes (50 patients) undergoing SMILE was performed at an apex tertiary care ophthalmic center. Patients older than 18 years with a stable refractive error ranging from -1.0 to -10.0 D myopia and up to 3.0 D astigmatism were included. Any intraoperative complications and their management were noted. Postoperative examination including visual acuity was performed on day 1, 1 week, and 1 month. RESULTS: Intraoperative difficulties observed in the initial 100 eyes included suction loss (2%), black spots (11%), opaque bubble layer (19%), epithelial defect (2%), and difficult lenticule extraction (9%). Difficult lenticule dissection and extraction was the most surgically challenging step and resulted in posterior stromal damage, anterior cap tear (1%), side-cut tears (4%), partially retained lenticule (1%), and completely retained lenticule (2%). Its incidence decreased from 16% (8/50) in the initial 50 cases to 2% (1/50) in the next 50 cases. Two eyes with completely retained lenticule were re-treated with flap-based excimer laser ablation after 3 months. Optimal visual and anatomical outcomes could be achieved, and no sight-threatening complication was observed in any case. CONCLUSIONS: The learning curve of SMILE is surgically challenging. Lenticule dissection and extraction is the most difficult step and leads to a multitude of complications. Most complications that result in delayed visual recovery are observed in the initial 50 cases.

Evaluation of Time to Donor Lenticule Apposition Using Intraoperative Optical Coherence Tomography in Descemet Stripping Automated Endothelial Keratoplasty.

PURPOSE: To evaluate the time to donor lenticule apposition in cases of Descemet stripping automated endothelial keratoplasty (DSAEK) using microscope-integrated intraoperative optical coherence tomography (iOCT). METHODS: Thirty eyes of 27 patients planned to undergo Descemet stripping automated endothelial keratoplasty were enrolled in this prospective study. In group I (n = 10), continuous intracameral positive pressure was maintained for 8 minutes. In group II (n = 10) and group III (n = 10), external corneal massage was initiated simultaneously with positive intracameral air pressure. The external corneal massage was continued till complete resolution of interface fluid; the positive intracameral pressure was maintained for 8 minutes in group II and for 5 minutes in group III. The host-donor relationship was continuously monitored with the iOCT. The main outcome measure was time to complete donor lenticule apposition. RESULTS: In group I, the interface fluid persisted after 8 minutes of positive intracameral pressure in all eyes (10/10); hence an external corneal massage was required to achieve optimal donor adherence. In groups II and III, all eyes (20/20) had complete resolution of the interface fluid at the end of 3 minutes. In 100% of the eyes (30/30), the grafts were attached after anterior chamber decompression as seen on the iOCT. In all cases, the donor lenticules were adhered in the postoperative period. CONCLUSIONS: iOCT helps in understanding that the donor lenticule is well apposed within 1 to 3 minutes with the technique of simultaneous positive intracameral pressure and external corneal massage. This knowledge minimizes the waiting time for graft apposition and prevents prolonged intraocular pressure elevation.

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.