Arun K. Jain

Human amniotic membrane transplantation with fibrin glue in management of primary pterygia: a new tuck-in technique.

Purpose: To report the use of fibrin glue for attaching the human amniotic membrane graft with a tuck-in technique after primary pterygium excision. Methods: Twelve patients with primary pterygium (grade 2 or 3) underwent pterygium excision. The bare sclera was covered with an oversized human amniotic membrane graft by using fibrin glue for graft adherence. The edges of the graft were tucked underneath the adjacent free margin of conjunctiva on 3 sides. Various parameters such as operative time, patients postoperative comfort, graft adherence, time of graft epithelialization, and recurrence of pterygium were assessed. Results: The amniotic membrane graft adhered successfully in 11 patients. Average surgical time was 15.5 minutes (range, 13-21 minutes). The postoperative period was generally comfortable. Epithelialization of the graft was rapid, occurring within 7 days in 11 eyes. In 1 patient, the graft was found dislodged partially on the first postoperative day. Eleven eyes showed no recurrence at the end of 1-year follow-up. Conclusions: Use of fibrin glue for attaching human amniotic membrane graft in primary pterygium surgery is effective. It not only reduces the surgical time but also minimizes postoperative discomfort and complications.

Intracorneal epithelial ingrowth after descemet stripping endothelial keratoplasty and stromal puncture.

Purpose: To report a case of intracorneal epithelial ingrowth after Descemet stripping endothelial keratoplasty (DSEK) with stromal puncture for phakic bullous keratopathy. Methods: A 35-year-old man underwent DSEK for phakic bullous keratopathy in his right eye after an episode of trauma some years ago. Intraoperative drainage of interlamellar fluid was assisted by stromal punctures. Postoperatively, the patient had a best-corrected visual acuity of 20/40 in his right eye. A small area of epithelial ingrowth appeared in the corneal intrastromal interface inferiorly as an irregular flat haze about a month after surgery. It was in continuity with the inferior stromal puncture incision made intraoperatively. By 10 months, the epithelial pearls became confluent and homogenously white with a sharp demarcation. Results: Because the epithelial ingrowth remained stationary till the last follow-up (13 months), no surgical intervention was planned. The central visual axis was clear and the best-corrected visual acuity was 20/40. Conclusions: Epithelial ingrowth into the cornea may occur after an uncomplicated DSEK with stromal puncture. Patients undergoing DSEK should be closely monitored for development and progression of intracorneal epithelial ingrowth, especially when stromal punctures have been made to drain interface fluid.

Rose-K contact lens for keratoconus

AIM To report clinical experience and the comparative value of axial and instantaneous topography data in fitting Rose-K design contact lenses in moderate and severe keratoconus. MATERIALS AND METHODS Thirty-eight eyes (of 23 patients) with keratoconus were fitted with Rose-K design contact lenses and followed up for at least six months or more. Visual acuity with habitual vision correction available was measured. Axial and instantaneous topography maps for each eye were recorded. Contact lens wear comfort was graded on a ten point rating scale every three months. RESULTS Fourteen (100%) moderate keratoconus eyes (average Sim K 48.61 +/- 1.24D) and 23 of 24 (96%) of severe keratoconus eyes (average Sim K 60.88 +/- 5.31D) were successfully fitted with the Rose-K lenses. Final fit contact lenses in severe keratoconus had statistically significant steeper base curves compared to average axial corneal curvature than in moderate keratoconus eyes. Average simulated corneal curvature on axial maps predicted final fit contact lens base curves significantly better than on instantaneous maps. Thirty-three of the 37 eyes fitted with contact lenses maintained wear comfort over average follow up period of 13 +/- 3.5 months. CONCLUSIONS Rose-K design rigid contact lenses are successful in visually rehabilitating 100% of moderate and 96% of severe keratoconus eyes. Most patients (90%) maintained contact lens wear comfort. Corneal curvature on axial maps is a better predictive of base curve of final fit contact lens.

Evaluation of impression smear in the diagnosis of fungal keratitis

PURPOSE To evaluate and compare impression smear with the conventional mechanical corneal scraping by potassium hydroxide (KOH) method in the diagnosis of fungal keratitis. MATERIALS AND METHODS Fifty consecutive cases of clinically suspected fungal keratitis were included. Under topical anesthesia, impression smear was obtained from the lesion, followed by the conventional mechanical scraping and both were transferred to sterile glass slides. The slides were examined under direct microscopy with KOH 10% wet mount. Impression smear KOH was compared with the scraping KOH and culture. RESULTS The KOH smear was positive in 36 (72%) patients with impression smear technique and positive in 35 (70%) patients from corneal scrapings. Sensitivity of impression smear technique as compared to scraping was 97.14%, specificity 92.86%, positive predictive value 94.4%, negative predictive value 92.86%, false positive rate 5.56%, false negative rate 7.14% and accuracy was 94%. As compared to culture, the sensitivity was 100%, specificity 46.67%, positive predictive value 55.56%, negative predictive value 100%, false positive rate 53.33%, false negative rate 0% and accuracy was 68%. CONCLUSION Impression smear KOH examination is comparable to conventional mechanical corneal scraping KOH examination in making a tentative diagnosis of fungal keratitis and can be accurately relied upon for initiating anti-fungal therapy.

Effect of oral omega-3 Fatty Acid supplementation on contrast sensitivity in patients with moderate meibomian gland dysfunction: a prospective placebo-controlled study.

Purpose: To evaluate the effect of oral supplementation with omega-3 (&ohgr;-3) fatty acids (FAs) in improving contrast sensitivity (CS) of patients with moderate meibomian gland dysfunction (MGD). Methods: In this prospective study, 60 patients with moderate MGD were allocated alternately to treatment and control groups. Both groups received warm compresses, lid massage, and artificial tear substitutes. The treatment group also received oral supplements of 1.2 g &ohgr;-3 FAs per day. All parameters were recorded at baseline and at 12 weeks and included Ocular Surface Disease Index scores, CS testing at 3, 6, 12, and 18 cycles per degree (cpd), tear break-up time, Schirmer test I without anesthesia, corneal and conjunctival staining scores, and meibum quality and expressibility. Results: At the end of 12 weeks, significant improvement in CS was seen in the treatment group in 7 of the 8 testing conditions (3, 6, 12, and 18 cpd photopic and 6, 12, and 18 cpd mesopic), whereas in the placebo group, significant improvement was seen only in 3 of the 8 testing conditions (3 cpd photopic, 6 and 18 cpd mesopic). Ocular Surface Disease Index, tear break-up time, ocular surface staining, and meibum quality and expressibility improved significantly in both groups, but more so in the treatment group. Schirmer scores showed no significant improvement in either group. Conclusions: Oral supplementation with &ohgr;-3 FAs significantly improved CS under both photopic and mesopic testing conditions in patients with moderate MGD. Tear film stability also improved significantly, whereas no effect was seen on aqueous tear production.

Characteristics of Pre-Descemet Membrane Corneal Dystrophy by Three Different Imaging Modalities-In Vivo Confocal Microscopy, Anterior Segment Optical Coherence Tomography, and Scheimpflug Corneal Densitometry Analysis.

Purpose: To evaluate the characteristics of pre-Descemet membrane corneal dystrophy by 3 different imaging modalities: in vivo confocal microscopy (IVCM), anterior segment optical coherence tomography (ASOCT), and Scheimpflug corneal densitometry analysis. Methods: A 32-year-old male patient with pre-Descemet membrane corneal dystrophy was subjected to imaging by IVCM, ASOCT, and Scheimpflug tomography. Results: Slit-lamp biomicroscopy showed the presence of tiny pleomorphic opacities in the posterior stroma, immediately anterior to Descemet membrane bilaterally. On IVCM, pleomorphic, hyperreflective punctate particles were seen both intracellularly and extracellularly in the anterior and mid stroma with increased reflectivity of some keratocytes that, however, were of normal size. These changes increased in severity from the anterior to mid stroma. The posterior stroma had grossly enlarged hyperreflective keratocytes with prominent processes. The hyperreflective particles were also seen scattered on the endothelium. ASOCT revealed a well-delineated homogenous band of increased reflectivity of approximately 70 &mgr;m width in the posterior stroma of both eyes with a normal-appearing anterior and mid stroma. Corneal densitometry measured by Scheimpflug optical analysis revealed a higher amount of backscattered light from the posterior stroma with a posterior to anterior ratio of 0.8. Conclusions: In pre-Descemet membrane corneal dystrophy, although the structural changes seem to be limited to the posterior stroma as seen clinically and on ASOCT, IVCM demonstrates that the pathology is more extensive involving the entire corneal stroma and endothelium.

Pupillary Dilatation During Cataract Surgery-Relative Efficacy of Indomethacin and Flurbiprofen

In a prospective, randomized, double-blind trial, we evaluated the relative efficacy of indomethacin and flurbiprofen when used as adjuvants to routinely used mydriatics for maintenance of pupillary dilatation in patients with heavily pigmented iris undergoing extracapsular cataract extraction. The drugs were administered orally as well as topically according to a fixed regimen. The pupillary diameters, measured with calipers at various surgical steps, were significantly larger at every step in the study groups in which either of the adjuvants had been used than they were in the control group (P less than .001). Flurbiprofen tended to help maintain a larger pupillary diameter in the later stages of surgery than indomethacin, but this difference was not statistically significant. We conclude that it is important to use prostaglandin synthetase inhibitors as adjuvants to routine mydriatics, and that flurbiprofen may be somewhat more effective than indomethacin in this capacity.

Glued intrascleral fixation of posterior chamber intraocular lens in children.

WE READ WITH GREAT INTEREST THE ARTICLE ENTITLED ‘‘Glued intrascleral fixation of posterior chamber intraocular lens in children,’’ by Kumar and associates. The authors reported the short-term results of glued intrascleral fixation of posterior chamber intraocular lens (glued IOL) in children without adequate capsular support. It is indeed a good alternative in children without adequate capsular support. We are especially interested in the 9 eyes with ectopia lentis in this study. The authors reported excellent result with this technique, with none of the eyes developing retinal detachment, IOL dislocation, endophthalmitis, or glaucoma on follow-up. We would like to share our small study, which we abandoned in between because of serious complications in 1 group. We prospectively randomized the eyes of 5 Marfan syndrome children with bilateral ectopia lentis into 2 groups. Group A eyes underwent 23-gauge pars plana lensectomy (PPL) with anterior vitrectomy and transscleral fixation of polymethyl methacrylate (PMMA) IOL using 10-0 polypropylene suture employing ab externo technique. Group B eyes underwent 23-gauge PPL with anterior vitrectomy and glued intrascleral fixation of foldable 3-piece acrylic IOL (technique described by the authors). Intraoperative peripheral fundus examination of all these eyes was done after PPL, before inserting the implant, in both groups. The aim of the study was to compare the postoperative outcome and complications between the 2 groups. There were 5 eyes in group A and 4 eyes in group B at the time of termination of the study. Out of 4 eyes in group B, 2 developed retinal detachment (RD). One eye developed RD at 3 months and the other at 5 months. None of the eyes in group A developed RD. There was no other complication in either group during the followup period. Both of these eyes with RD were managed by pars plana vitrectomy and silicone oil tamponade. An important intraoperative finding was the presence of vitreous incarceration at the site of externalization of haptics. Both eyes required iris hooks for better visualization of the posterior segment. We offer different points of view regarding the use of this technique in these eyes. These eyes are already predisposed to retinal detachment for various reasons, with reported incidence of 8% to 25.6%. This rate further increases with surgical techniques that result in vitreous

Epithelial ingrowth within the interface following traumatic corneal lamellar laceration.

A 45-year-old patient with a traumatic corneal lamellar laceration who was treated conservatively initially developed an epithelial ingrowth within the flap-stroma interface, causing diminished vision. Confocal microscopy revealed highly refractive bodies without cellular elements at the flap-stroma interface. Treatment comprised surgical debridement of the epithelial sheet from the interface with a thorough irrigation of the stromal bed followed by careful realignment of the flap. The diagnosis was confirmed by histologic examination of the scraped specimen. At the last follow-up examination, vision had improved and there was no recurrence of epithelial ingrowth. Proper primary management of a traumatic corneal lamellar laceration can provide good visual outcome and prevent rare complications such as epithelial ingrowth.

Phenotypic heterogeneity of corneal endothelium in iridocorneal endothelial syndrome by in vivo confocal microscopy.

Purpose: To present a case of iridocorneal endothelial (ICE) syndrome showing phenotypic heterogeneity of endothelial morphology between the 2 eyes of a patient as visualized by in vivo confocal microscopy (IVCM). Methods: Confocal microscopy using the Heidelberg Retina Tomograph (HRT)-3 with Rostock Cornea Module was performed bilaterally during routine follow-up on a 60-year-old lady being managed as a case of ICE syndrome with secondary glaucoma in the right eye. Results: IVCM revealed endothelial changes in both eyes, which however varied in morphology. Endothelium of the right eye showed a “total ICE” pattern with “ICE-type of cells,” that is, diffuse involvement with enlarged, pleomorphic “epithelioid” cells having hyper-reflective nuclei and no intervening areas of the normal endothelium. The left endothelium had broad areas of normal hexagonal endothelial mosaic interspersed with different types of ICE cells showing nipple-shaped evaginations, light dark reversal and central craters with hyper-reflective rims. Conclusions: This report with the help of IVCM demonstrates that though ICE syndrome is a clinical entity which classically has been considered predominantly unilateral, the endothelial changes can be bilateral and heterogeneous. The apparent heterogeneity in the present case may represent 2 different stages of the disease process at the level of the corneal endothelium-advanced disease OD and presymptomatic disease OS.