Anubha Rathi

Clinical outcomes of clear lens extraction in eyes with primary angle closure.

Purpose To evaluate the effect of clear lens extraction (CLE) on intraocular pressure (IOP) and the anterior chamber angle in primary angle closure after laser peripheral iridotomy (LPI). Setting Tertiary eyecare center at a university hospital, New Delhi, India. Design Prospective case series. Methods The study included eyes with primary angle closure and an IOP over 25.0 mm Hg more than 8 weeks after LPI. All eyes had CLE by phacoemulsification. Absolute success was defined as an IOP less than 18.0 mm Hg without medications at 12 months. Results In 44 eyes (24 women, 20 men; mean age 57.2 years ± 4.2 [SD]), the mean preoperative IOP of 27.1 ± 1.55 mm Hg decreased to 13.2 ± 1.12 mm Hg at 12 months (P < .0001). The angle opening distance at 500 &mgr;m increased from baseline values at 0 degrees (from 0.104 ± 0.015 mm to 0.31 ± 0.013 mm) and 180 degrees (from 0.202 ± 0.008 mm to 0.412 ± 0.012 mm). The trabecular iris angle also increased at 0 degrees (from 9.3 ± 3.2 degrees to 32.7 ± 5.6 degrees) and 180 degrees (from 9.12 ± 3.2 degrees to 31.7 ± 5.6 degrees) (all P < .0001). In multivariate analysis, the preoperative IOP was the strongest determinant of IOP change (R2 = 0.69, P < .0001). Absolute success was achieved in 38 eyes (86.3%). Conclusion Clear lens extraction led to a significant reduction in IOP, a widening of the anterior chamber angle, and a reduced need for ocular hypotensive medications in eyes with primary angle closure and persistently raised IOP after LPI. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

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.].

Microbial Keratitis After Accelerated Corneal Collagen Cross-Linking in Keratoconus

Purpose: To assess the pattern of microbial keratitis after accelerated corneal collagen cross-linkage (aCXL) in patients with keratoconus. Method: The medical records of cases of keratoconus that underwent aCXL from June 2014 to May 2017 were reviewed. Cases that developed microbial keratitis after aCXL were included in the study. The clinical, microbiological profile and the treatment outcomes were evaluated. Results: Of 532 eyes that underwent aCXL, 7 cases developed microbial keratitis during the study period. Median age at presentation was 11 years (range 8–17). Association with vernal keratoconjunctivitis was noted in 57.1% of cases (n = 4/7). The median time at the onset of infection was 3 days after aCXL (range 1–4). Microbiological reports revealed mixed infection in 3 cases [coagulase-negative Staphylococcus (CoNS) + Aspergillus fumigatus, Staphylococcus aureus and Mucor spp., Staph. aureus and Acanthamoeba], Staph. aureus in 2 cases, and CoNS and Alternaria spp. in 1 case each. Resistance to fourth-generation fluoroquinolones was noted in 83.3% of cases of bacterial keratitis (n = 5/6). All cases were initially managed with empirical antibiotic treatment that was later tailored based on microbiological reports. One case eventually required therapeutic penetrating keratoplasty for corneal perforation. At 6 months, the corrected distance visual acuity was >6/60 in 3 cases while 4 cases had corrected distance visual acuity <6/60. Conclusions: Microbial keratitis after aCXL is rare; however, the infection tends to be severe with high preponderance of mixed infection and resistance to fourth-generation fluoroquinolones.

Dual intravitreal foreign body: Intravitreal cilia in penetrating injury

Intraocular cilia, though a rare condition, has been previously reported in cases of open globe injury. We discuss a unique case of intravitreal cilia, found incidentally during vitrectomy for intravitreal foreign body removal.

Autoimmune thyroiditis and central serous chorioretinopathy may have a relation

Autoimmune thyroiditis (AT) is an important cause of hypothyroidism, and central serous chorioretinopathy (CSCR) is an independent disease of the choroid and retina that leads to accumulation of fluid beneath the retina. While AT has been associated with multiple antibodies, CSCR is still regarded as idiopathic despite extensive research. We hypothesize a causative association between these 2 conditions on the basis of our experience of a case where both CSCR and AT presented simultaneously and depicted a parallel course. CSCR was documented with retinal imaging while AT was documented with serum antibody titers. Further, we discuss the possible mechanisms that may be involved in this intriguing association.

Small incision lenticule extraction (SMILE) techniques: patient selection and perspectives

Refractive lenticule extraction is becoming the procedure of choice for the management of myopia and myopic astigmatism owing to its precision, biomechanical stability, and better ocular surface. It has similar safety, efficacy, and predictability as femtosecond laser-assisted in situ keratomileusis (FS-LASIK) and is associated with better patient satisfaction. The conventional technique of small incision lenticule extraction (SMILE) involves docking, femtosecond laser application, lenticule dissection from the surrounding stroma, and extraction. It has a steep learning curve compared to conventional flap-based corneal ablative procedures, and the surgical technique may be challenging especially for a novice surgeon. As SMILE is gaining worldwide acceptance among refractive surgeons, different modifications of the surgical technique have been described to ease the process of lenticule extraction and minimize complications. Good patient selection is essential to ensure optimal patient satisfaction, and novice surgeons should avoid cases with low myopia (thin refractive lenticules), difficult orbital anatomy, high astigmatism, or uncooperative, anxious patients to minimize complications. A comprehensive MEDLINE search was performed using “small incision lenticule extraction,” “SMILE,” and “refractive lenticule extraction” as keywords, and we herein review the patient selection for SMILE and various surgical techniques of SMILE with their pros and cons. With increasing surgeon experience, a standard technique is expected to evolve that may be performed in all types of cases with optimal outcomes and minimal adverse effects.

Generalised nevus flammeus, episcleral capillary malformation and glaucoma

A 35-year-old woman presented with no vision, redness, pain and photophobia in the left eye (LE) since 4 months. This was associated with left-sided headache and vomiting too. She had history of poor vision in LE since 2–3 years, and had been treated with topical antiglaucoma medication. There was no significant family history. On examination, visual acuity was 6/6 in right eye (RE) and no perception of light in LE. Intraocular pressure (IOP) was measured as 14 mm Hg in RE and >60 mm Hg in LE. Slit lamp evaluation revealed conjunctival congestion, corneal oedema, fully dilated pupil and white cataract in LE (figure 1). Gonioscopy was within normal limits. RE ocular examination did not reveal any significant anomaly. RE pupil did not show any consensual response, while LE pupil was fixed. Systemic workup revealed nevus flammeus (NF) over the face …

Peripheral optical coherence tomography montage guided successful management of retinal detachment with sub retinal bands

Sub Retinal Bands (SRB) often complicate old Rhegmatogenous Retinal Detachments (RRD). We discuss the utility of Optical Coherence Tomography (OCT) montage in such a case of a 23 year old female who presented with BCVA of 20/40 in OS with a complicated cataract. She was found to have a shallow subtotal RRD in left eye extending till temporal ora serrata with macula off and a SRB extending across the temporal vascular arcades with superotemporal lattice with holes. The RD appeared to be self-settling peripherally due to pigmentary changes. OD was normal. RRD was imaged with OCT montage. The Neuro Sensory Retinal Detachment (NSD) started from the fovea and involved the immediate periphery with attached extreme periphery (Fig. 1). At the maximal height (583u) of the NSD, a round highly reflective structure was observed below the neuro sensory retina corresponding to the SRB. The holes were treated with cryotherapy and at first month follow-up the height of RD had decreased to 515u being centered at the SRB. 3 months later, the retina had completely attached, and foveal contour attained with a fold over the SRB (Fig. 2). As compared to images at presentation, there was focal pigment deposition in the area of the SRB (Fig. 3).

Ultrasonographic evaluation of transition from normal to ectatic area: A comparison between myopic staphylomata and coloboma

Choroidal coloboma and posterior staphyloma are two clinically distinct entities, with choroidal excavation being a unifying feature. They are associated with early onset cataract which can make ophthalmoscopy difficult. This report studies the transition between the normal and ectatic area in these cases with ultrasound. We evaluate “posterior hump” as a sign of differentiation between these two conditions.

Sclerokeratouveitis and lens dislocation in a patient with genital ulcer: was the great imitator imitated?

Uveitis is the most common ocular manifestation of syphilis, while scleritis is rare. A case of nodular scleritis, peripheral keratitis and uveitis in a patient with genital ulcer is presented in this report. This patient had a clinical profile suggestive of syphilis, though the serology was negative for treponemal antibodies. Other possible differential diagnosis imitating syphilis are discussed.