Aashish K. Bansal

The Epidemiology of Dry Eye in Melbourne, Australia

OBJECTIVE To describe the epidemiology of dry eye in the adult population of Melbourne, Australia. DESIGN A cross-sectional prevalence study. PARTICIPANTS Participants were recruited by a household census from two of nine clusters of the Melbourne Visual Impairment Project, a population-based study of age-related eye disease in the 40 and older age group of Melbourne, Australia. Nine hundred and twenty-six (82.3% of eligible) people participated; 433 (46.8%) were male. They ranged in age from 40 to 97 years, with a mean of 59.2 years. MAIN OUTCOME MEASURES Self-reported symptoms of dry eye were elicited by an interviewer-administered questionnaire. Four objective assessments of dry eye were made: Schirmers test, tear film breakup time, rose bengal staining, and fluorescein corneal staining. A standardized clinical slit-lamp examination was performed on all participants. Dry eye for the individual signs or symptoms was defined as: rose bengal > 3, Schirmers < 8, tear film breakup time < 8, > 1/3 fluorescein staining, and severe symptoms (3 on a scale of 0 to 3). RESULTS Dry eye was diagnosed as follows: 10.8% by rose bengal, 16.3% by Schirmers test, 8.6% by tear film breakup time, 1.5% by fluorescein staining, 7.4% with two or more signs, and 5.5% with any severe symptom not attributed to hay fever. Women were more likely to report severe symptoms of dry eye (odds ratio [OR] = 1.85; 95% confidence limits [CL] = 1.01, 3.41). Risk factors for two or more signs of dry eye include age (OR = 1.04; 95% CL = 1.01, 1.06), and self-report of arthritis (OR = 3.27; 95% CL = 1.74, 6.17). These results were not changed after excluding the 21 people (2.27%) who wore contact lenses. CONCLUSIONS These are the first reported population-based data of dry eye in Australia. The prevalence of dry eye varies by sign and symptom.

Amniotic membrane transplantation for ocular surface reconstruction in stevens-johnson syndrome

PURPOSE To evaluate amniotic membrane transplantation (AMT) for ocular surface reconstruction in Stevens-Johnson syndrome (SJS). DESIGN Prospective interventional case series. PARTICIPANTS Ten consecutive patients (10 eyes) with SJS that underwent AMT as the first step in staged ocular surface reconstruction were included. METHODS Amniotic membrane was processed under sterile conditions from a fresh placenta obtained from cesarean section in a seronegative pregnant woman and stored at -700 degrees C. Symblepharon release, excision of epibulbar fibrous tissue, and clearing of the fibrovascular membrane over the cornea was performed in all cases. Amniotic membrane covered the entire bulbar surface up to the fornices in five eyes; cornea and the perilimbal area in two eyes; cornea, the inferior bulbar surface, and the lower fornix in two eyes; and cornea and the superior bulbar surface in one eye. Obliterated fornices were deepened by use of fornix-formation sutures in all eyes. Symblepharon ring was placed postoperatively for 3 weeks to 2 months. Mean postoperative follow-up was 13.5 months (SD, +3.8 months; range, 9-30 months). MAIN OUTCOME MEASURES Restoration of adequate bulbar surface free of symblepharon and good fornix depth were the main outcome measures. RESULTS Complete corneal reepithelization occurred in all eyes between 1 and 6 weeks. Adequate bulbar surface and fornix depth were achieved in nine eyes, all of which were free of symblepharon at the final follow-up visit. Cicatricial entropion resolved in four of five lower eyelids and one of two upper eyelids after AMT. One patient had a central corneal melt that required or necessitated a penetrating keratoplasty. CONCLUSIONS AMT restores adequate bulbar surface and fornix depth and prevents recurrence of symblepharon in severe cases of SJS.

Bilateral infectious keratitis after laser in situ keratomileusis: A case report and review of the literature

OBJECTIVE To report a case of bilateral infectious keratitis after simultaneous bilateral laser in situ keratomileusis (LASIK) and to explore appropriate preventive, diagnostic, and therapeutic measures. DESIGN Interventional case report and literature review. INTERVENTION A 22-year-old woman had bilateral corneal infiltrates after simultaneous bilateral LASIK. The same set of instruments was used for surgery on both eyes. Corneal scrapings from the edge of the infiltrate and underneath the flap were taken for microscopic examination and inoculation on culture media. Treatment consisted of irrigation of stromal bed with amikacin sulphate (2.5%) solution along with half hourly instillation of amikacin (2.5%) and cefazolin (5%) eye drops. MAIN OUTCOME MEASURES Causative organism and response to medical treatment. RESULTS Culture revealed a significant growth of Mycobacterium chelonae from the corneal scrapings of both eyes. There was progressive thinning of corneal stroma in the right eye requiring cyanoacrylate tissue adhesive application. The left eye showed progressive worsening after initial response and required penetrating keratoplasty. CONCLUSIONS The risk of bilateral sight-threatening complications must be kept in mind when contemplating bilateral simultaneous LASIK. Nontuberculous mycobacteria should be considered as an etiologic agent in cases of infectious keratitis occurring after LASIK. Microbiology work-up of a specimen collected directly from the site of lesion can help in early diagnosis and institution of appropriate therapy.

Amniotic membrane transplantation in acute chemical and thermal injury

PURPOSE To present a case of chemical injury and a case of thermal injury treated by amniotic membrane transplantation in acute phase. METHODS Case reports. An eye with sodium hydroxide injury, opaque cornea, and limbal ischemia of more than 180 degrees and an eye with hot tea injury, opaque cornea, stromal edema, and scarring were treated by amniotic membrane transplantation within the first few weeks of injury. RESULTS In the eye with sodium hydroxide injury, 4 months after amniotic membrane transplantation, the ocular surface is stable, superficial corneal scarring with vascularization is present, and visual acuity is 20/25. In the eye with thermal injury, 6 months after amniotic membrane transplantation, the ocular surface is stable, but there is superficial scarring and vascularization, and visual acuity is 20/20. CONCLUSIONS Amniotic membrane transplantation can be considered in chemical injury with severe limbal ischemia and in severe thermal injury in acute phase. Long-term studies are warranted to evaluate further the efficacy of amniotic membrane transplantation in these clinical situations.

Use of Autologous Cultured Limbal and Conjunctival Epithelium in a Patient with Severe Bilateral Ocular Surface Disease Induced by Acid Injury: A Case Report of Unique Application

Purpose. Reconstruction of the ocular surface in a case of severe bilateral partial limbal stem cell deficiency (LSCD) with extensive symblephara using autologous cultured conjunctival and limbal epithelium. Case report. A 31-year-old woman presented with severe bilateral ocular surface disease with partial limbal stem cell deficiency, symblephara, lid and facial scarring, with a vision of 20/400 and counting fingers at 1 m in both eyes. Limbal and conjunctival tissue was harvested from the healthy-appearing left eye and used to generate two sheets of composite epithelium consisting of central limbal and peripheral conjunctival cells. The limbal tissues were explanted in the central region while the conjunctival tissues were explanted on the periphery of the deepithelialized human amniotic membrane (HAM) and nurtured using human corneal epithelial cell medium. After successful generation of a monolayer from both tissues had been confirmed, the composite of cultivated limbal and conjunctival epithelium with HAM was transplanted in each eye after excision of fibrous tissue and release of symblephara. One year postoperatively, the patient had a best spectacle-corrected visual acuity of 20/40 in the right eye (preoperative acuity 20/400) and counting fingers at 1 m in the left eye (same as preoperative) with a stable ocular surface. Conclusions. Autologous cultured epithelial transplantation is as an excellent option in selected patients with bilateral partial LSCD with small area(s) of healthy limbus in either eye and avoids the attendant risk of rejection and cost and potential toxicity of immunosuppression in allogeneic tissue transplantation. This case also highlights the feasibility of generating a composite culture of limbal and conjunctival epithelium using a single amniotic membrane.

Fungal keratitis after laser in situ keratomileusis.

&NA; A 22‐year‐old woman presented with pain, redness, watering, and decrease in vision in her left eye 15 days after laser in situ keratomileusis for myopia. Slitlamp examination showed a central full‐thickness infiltrate with hyphate edges. Microscopic examination of corneal scrapings from the edge and underneath the flap showed fungal filaments, and the growth on culture media was identified as Scedosporium apiospermum.

Cultivated corneal epithelial transplantation for severe ocular surface disease in vernal keratoconjunctivitis

Purpose: To report cultivated epithelial transplantation in 2 patients with vernal keratoconjunctivitis (VKC) with severe ocular surface disease. Methods: Two patients initially diagnosed with burnt-out VKC presented with bilateral photophobia, decreased vision, and corneal neovascularization. The first patient underwent living-related conjunctival-limbal allograft in the left eye and cultivated limbal epithelial cell allotransplant in the right. The second patient underwent unsuccessful amniotic membrane transplantation (AMT) followed by autologous cultivated limbal epithelial cell transplantation in the worse eye. Results: Both patients had onset of VKC in the first decade. Surgical intervention in both led to marked amelioration in symptoms and improvement in vision. In patient 1, vision improved from 20/800 (both eyes) to 20/30 in the right and 20/100 in the left eye at a follow-up of 34 months. In patient 2, it improved from 20/400 to 20/50 after the second procedure, 25 months postoperatively. Histopathology of the excised pannus revealed fibrosis and mononuclear cell infiltrates in all 3 eyes. Conclusions: Severe ocular surface disease may occur in persistent VKC, leading to marked visual loss. AMT alone may be insufficient to restore the ocular surface, and limbal epithelial cell transplantation is warranted.

Outcome of pterygium surgery: analysis over 14 years

AimTo report the outcome of pterygium surgery performed at a tertiary eye care centre in South India.MethodsRetrospective analysis of medical records of 920 patients (989 eyes) with primary and recurrent pterygia operated between January 1988 and December 2001. The demographic variables, surgical technique (bare sclera, primary closure, amniotic membrane transplantation (AMT), conjunctival autograft (CAG), conjunctival–limbal autograft (CLAG), or surgical adjuvants), recurrences and postoperative complications were analysed.ResultsA total of 496 (53.9%) were male and 69 (7.5%) had bilateral pterygia. Bare sclera technique was performed in 267 (27.0%) eyes, primary conjunctival closure in 32 (3.2%), AMG in 123 (12.4%), CAG in 429 (43.4%), and CLAG in 70 (7.1%). Adjuvant mitomycin C was used in 44 (4.4%) cases. The mean duration of follow-up was 8.9±17.0 and 5.9±8.8 months for unilateral primary and recurrent pterygia, respectively. The overall recurrence rate was 178 (18.0%). Following primary and recurrent unilateral pterygium excision respectively, recurrences were noted in 46 (19.4%) and 1 (33.3%) eyes after bare sclera technique, five (16.7%) and 0 after primary closure, 28 (26.7%) and 0 with AMG, 42 (12.2%) and five (31.3%) with CAG, and nine (17.3%) and two (40%) with CLAG. Recurrences were significantly more in males with primary (23.3 vs10.7%, P<0.0001) and recurrent (26.7 vs0%, P=0.034) pterygia, and in those below 40 years (25.2 vs14.8%, P=0.003).ConclusionCAG appears to be an effective modality for primary and recurrent pterygia. Males and patients below 40 years face greater risk of recurrence. Bare sclera technique has an unacceptably high recurrence. Prospective studies comparing CAG, CLAG, and AMG for primary and recurrent pterygia are needed.

Aspergillus flavus keratitis after laser in situ keratomileusis

PURPOSE To report a case of fungal keratitis caused by Aspergillus flavus after laser in situ keratomileusis surgery. METHODS Case report. A 24-year-old woman developed pain, redness, decreased vision, and an infiltrate posterior to the corneal flap in her right eye 3 days after laser in situ keratomileusis. On referral, approximately 3 weeks after laser in situ keratomileusis, examination of the right eye revealed light perception vision, a large full-thickness corneal infiltrate, and hypopyon. Corneal scrapings were taken for direct microscopic examination and culture. RESULTS Corneal scraping revealed the presence of fungal filaments in smears and in culture. The fungus was identified as A. flavus. Intensive topical natamycin and systemic ketoconazole therapy was initiated. Despite intensive medical treatment, the infiltrate progressed and the patient was subjected to a therapeutic penetrating keratoplasty. There was no recurrence of infection after surgery. At last follow-up 4 months after surgery, the eye was quiet with graft edema. CONCLUSION Fungal keratitis is a rare complication of laser in situ keratomileusis surgery. In a case that does not respond to medical treatment, early surgical intervention must be considered.

Amniotic membrane transplantation in the management of shield ulcers of vernal keratoconjunctivitis

PURPOSE To report our experience with amniotic membrane transplantation in the management of severe shield ulcers. DESIGN Retrospective, interventional, noncomparative case series. PARTICIPANTS Four patients (seven eyes) with grade 2 (ulcer with opaque base) and grade 3 (plaquelike lesions) shield ulcers not responding to steroid therapy with or without surgical debridement. INTERVENTION Amniotic membrane transplantation with stromal side down was performed after meticulous debridement of the ulcer. MAIN OUTCOME MEASURES Healing of the ulcer with no epithelial defect. RESULTS The ulcers healed with disintegration or retraction of the membrane in all patients within 2 weeks. CONCLUSIONS Amniotic membrane transplantation in combination with debridement is an effective surgical modality in the management of severe shield ulcers. Further studies are warranted to confirm the efficacy of amniotic membrane transplantation in the management of shield ulcer and its correct position in the treatment algorithm.