Bhupesh Bagga

Endothelial failure after collagen cross-linking with riboflavin and UV-A: case report with literature review.

Purpose: To report a case of endothelial decompensation after a collagen cross-linking (CXL) procedure for keratoconus. Methods: An 18-year-old boy had CXL for keratoconus in the right eye. He developed keratouveitis with generalized corneal edema seen 3 weeks after the procedure. Polymerase chain reaction for aqueous humor Herpes simplex virus was negative. The patient was treated with topical steroids. Specular microscopy revealed mildly reduced density of endothelial cells. On follow-up to 6 months, corneal edema increased with the formation of epithelial bullae. Penetrating keratoplasty was performed. Possible causes for this complication are discussed. Results: Clinical and histopathological analyses revealed generalized loss of endothelial cells along with signs of inflammation. Conclusions: Although it is considered very safe, collagen CXL can cause severe keratouveitis and endothelial failure.

Decreased susceptibility to quinolones in methicillin-resistant Staphylococcus aureus isolated from ocular infections at a tertiary eye care centre

Methicillin-resistant Staphylococcus aureus (MRSA) is a serious cause of morbidity and mortality worldwide because of its multiple-drug resistance.1 In the past, MRSA infections were considered as hospital acquired; however, in the 1990s, serious MRSA infections were reported in patients with no previous contact with the healthcare system.2 Aggressive infections due to MRSA were observed in the eye and orbit in patients with no hospital exposure.3 There are very few reports on ocular MRSA infections, and to the best of our knowledge, there are no reports on MRSA in ocular infections from India. The present study was carried out to study the changing trends of methicillin susceptibility in S aureus isolated from different ocular infections and to analyse the susceptibility of MRSA to quinolones and vancomycin. …

One-stage femtolaser-assisted lamellar keratoplasty and foreign body removal.

Purpose To report the use of femtosecond laser platform to remove a glass foreign body (FB) and remove scar by performing sutureless lamellar keratoplasty. Case Report A 34-year-old man presented with a posttraumatic anterior stromal scar and retained corneal glass FB after injury to his left eye, sustained in a prior vehicular accident. Right eye examination was essentially normal. Best-corrected visual acuity of the left eye was 20/320. He underwent femtosecond laser–assisted sutureless anterior lamellar keratoplasty using the 500-kHz femtosecond laser machine. The host bed and donor lenticule diameters were 7.9 and 7.8 mm and the thickness of the lenticule was 125 and 150 &mgr;m, respectively. The recipient lenticule was obtained by placing the lamellar incision that encompassed the FB. When the recipient lenticule was lifted, partially embedded FB present in the stroma was removed after dislodging it with a 26-gauge needle. The femtosecond-dissected donor button was placed onto the stromal bed with a snug fit. No sutures were taken. Postoperatively, best-corrected visual acuity improved to 20/50 at 1 month and 20/30 at 7 months of follow-up. Conclusions Femtosecond laser–assisted sutureless anterior lamellar keratoplasty is a promising modality for lamellar keratoplasty, and as the depth of the incision can be obtained with precision, impacted stromal FBs can be removed in a single procedure along with scars.

Leap forward in the treatment of Pythium insidiosum keratitis

Background Pythium insidiosum is a parafungus that causes keratitis resembling fungal keratitis. This study compares outcome in a large cohort of patients with P insidiosum keratitis treated with antifungal drugs, to a pilot group treated with antibacterial antibiotics. Methods Between January 2014 and December 2016, 114 patients with culture positive P insidiosum keratitis were included in the study. A subset of culture isolates was tested in vitro for response to nine antibacterial antibiotics by disc diffusion and E test. Patients were treated with topical natamycin in 2014, 2015 and up until mid 2016. Thereafter, the patients received a combination of topical linezolid and topical and oral azithromycin. Therapeutic penetrating keratoplasty (TPK) was done for patients not responding to medical therapy. Results In vitro disc diffusion assay showed linezolid to be most effective. The rate of TPK was significantly higher in 2015 compared with 2016 (43/45, 95.6% vs 22/32, 68.8%; p=0.002). Eighteen patients were treated with antibacterial and 14 were treated with antifungal antibiotic in 2016. One patient was lost to follow-up in each group. The rate of TPK was higher and proportion of healed ulcers was lower (p=0.21, Fisher’s exact test) in the group on antifungal therapy (TPK—11/13, 84.6%; Healed—2/13, 15.3%) compared with the group on antibacterial therapy (TPK—11/17, 64.7%; Healed—6/17, 35.2%). Conclusions We report favourable but not statistically significant response of P insidiosum keratitis to antibacterial agents in a pilot series of patients. Further evaluation of this strategy in larger number of patients is recommended.

Phototherapeutic keratectomy for recurrent granular dystrophy in postpenetrating keratoplasty eyes

Purpose: The purpose is to assess the clinical and visual outcome after phototherapeutic keratectomy (PTK) procedure in eyes with prior penetrating keratoplasty (PKP) for granular corneal dystrophy (GCD) and the time of performance of repeat PTK for recurrence. Methods: PTK was performed for visually significant recurrence: A reduction in best-corrected visual acuity (BCVA) by >2 lines over BCVA before recurrence was considered as visually significant recurrence. Three eyes had amniotic membrane patch performed with PTK. The main outcome measures were a recurrence of GCD, clinical course, and visual outcome. Intervals between repeat PTK procedures were noted. Results: Six patients (n = 10 eyes; males: 4, mean age 39 ± 13.97 years) underwent PTK. The mean pachymetry before first PTK was 527.1 ± 34 microns. The mean duration between PKP and first PTK was 85.1 months (range: 37–108 months). Two and three PTK procedures were done for seven and five eyes, respectively. Mean duration between first and second and second and third PTK was 62.12 ± 34.41 and 42.8 ± 13.54 months respectively. The average cut depth was 43.66 ± 19.57, 75 ± 43.30 and 39 ± 19.79 microns after the first, second and third PTK procedures, respectively. All eyes had a corneal haze. Pre first PTK mean BCVA was 20/200 and improved significantly after the first two PTK procedures to 20/40 and after the third PTK procedure to 20/32 (P < 0.001). Five eyes had hyperopia. One acute graft rejection was managed successfully at 5 months with medical therapy. Conclusion: Multiple PTK procedures can be performed safely with improved visual acuity in grafts without compromising graft survival.

Femtosecond Laser-Assisted Anterior Lamellar Keratoplasty for Recurrence of Granular Corneal Dystrophy in Postkeratoplasty Eyes.

Purpose: To report the clinical and visual outcome of sutureless femtosecond laser-assisted anterior lamellar keratoplasty (FALK) for recurrent granular corneal dystrophy (GCD) in patients who had previously undergone penetrating keratoplasty and phototherapeutic keratectomy (PTK) performed for recurrent dystrophy in the grafted eyes. Methods: Four eyes of 4 patients who underwent FALK for recurrence of GCD in previously grafted eyes and underwent PTK performed for initial recurrence in the grafts were included. Patients who had undergone FALK for other indications were excluded. The patients were evaluated for preoperative and postoperative best-corrected visual acuities (BCVA), and intraoperative and postoperative complications. Visual outcomes and complications, if any, were noted. Results: FALK was uneventful in all 4 eyes. At last follow-up, BCVA improved by >2 lines in all eyes. Myopic shift in the refractive error was noted in 2 eyes. None of the eyes had any intraoperative or postoperative complications. One case had dissection margins cross the graft–host junction; however, no dehiscence occurred in this case. The grafts were clear at the last follow-up examinations. Conclusions: FALK is a safe and effective technique for the management of recurrence of GCD in post-penetrating keratoplasty and post-PTK eyes. BCVA improved by >2 lines after the FALK procedure. None of the patients in this series had any intraoperative or postoperative complications, which was indicative of the safety of the procedure.

Keratoglobus: An experience at a tertiary eye care center in India.

Context: This study was carried out as a part of an internal audit and is the largest series of patients having keratoglobus, published in the literature. Poor visual acuity of the patients indicates the blinding nature of the disease. Aims: We report our experience with patients having keratoglobus at a tertiary eye care center in India. Settings and Design: Retrospective study. Materials and Methods: We analyzed adults and pediatric patients (<16 years) with keratoglobus, seen during 2008–2012. The age, gender, consanguinity, presenting ocular signs, ocular and systemic associations, visual acuity, corneal topography, and surgeries were documented. Results: Forty-eight patients (mean age 22 ± 15 years, 31 males) having keratoglobus were analyzed. 21 patients (42 eyes) were <16 years. Twelve eyes (16 events) had positive history of trauma. The presenting clinical signs were corneal scars/scars of tear repair (15 eyes), hydrops, healed and acute (14 eyes) and corneal or globe rupture (9 eyes). Best-corrected visual acuity was >20/40 in 6/42 (14.3%) pediatric eyes and 15/53 (28.30%) adults. Visual acuity ranging from counting of fingers to no light perception was noted in 20/53 (37.74%) adults and 21/42 (50%) pediatric patients; 13/20 (65%) with blue sclera and 8/22 eyes (36.37%) without blue sclera. Vernal keratoconjunctivitis was present in one pediatric patient. Choroidal osteoma, retinitis pigmentosa, and retinal detachment were present in adults. Surgeries performed were corneal tear repair (5 eyes), tissue adhesive application (2 eyes), descematopexy (4 eyes) and penetrating keratoplasty (PK - 8 eyes: Three had post-PK glaucoma, graft failure-one eye, 4 patients wore scleral lens - prosthetic replacement of the ocular surface ecosystem). Conclusions: About 50% of pediatric eyes (65% having blue sclera) had no functional vision. Trivial trauma was responsible for corneal rupture indicating need for protective glasses. About 50% patients had post-PK glaucoma though grafts were clear.

Microbial keratitis in Stevens-Johnson syndrome: Clinical and microbiological profile

PURPOSE To study the clinical and microbiological profile of microbial keratitis in Stevens-Johnson syndrome (SJS). STUDY DESIGN Case series. PARTICIPANTS Patients with SJS who developed microbial keratitis. METHODS Medical records and microbiological data of patients with SJS who developed microbial keratitis from January 1991 to December 2012 were reviewed. We analysed the type of causative organisms and their antibiotic susceptibility along with the clinical pattern and responses to medications in this group of patients. MAIN OUTCOME MEASURE Clinical and microbiological profile of microbial keratitis. RESULTS We reviewed 65 eyes of 60 patients seen between January 1991 and December 2012. Positive microbiological culture results were obtained in 45 eyes (69.2%). Isolated bacterial infections were noted in 27 eyes (60%) while isolated fungal growth was seen in 1/45 eyes (2.2%). Polymicrobial infections were noted in 17/45 eyes (37.8%). The most common bacteria isolated were Staphylococcus species (35%). The median duration of SJS before presentation was 5 months (IQR, 2 months to 7 years) with 50% presenting within four months of the onset of SJS. Twenty-eight eyes (43%) needed treatment in addition to antibiotics for resolution of tarsorraphy, epilation, tissue adhesive application, and amniotic membrane grafting or punctal cautery. The average time for resolution was 25 days. CONCLUSION Microbial keratitis in SJS patients is different from patients without SJS in presentation and the response to medications. It requires a multi-disciplinary approach for healing.

LVP keratoprosthesis: anatomical and functional outcomes in bilateral end-stage corneal blindness

Purpose To describe the anatomical and functional outcomes of the novel LVP keratoprosthesis (Kpro), developed as an alternative to the modified osteo-odonto keratoprosthesis (MOOKP), in eyes with end-stage corneal blindness where conventional corneal surgeries are contraindicated. Methods This prospective case series included 58 eyes of 56 patients (12 children and 44 adults) with severe bilateral keratopathy and completely dry, dermalised ocular surfaces who underwent unilateral LVP Kpro implantation from 2012 to 2016. In this two-stage procedure, an ocular surface labial mucous membrane grafting was performed, followed for 3 months by the implantation of the device under the engrafted mucosal flap. The primary outcome measures were anatomical retention rate and improvement in best corrected visual acuity (BCVA). The secondary outcome measure was rate of occurrence of complications. Results Mean postoperative follow-up was 2.5±1.1 years. Kaplan-Meier survival analysis showed an anatomical retention rate of 90.8%±3.9% at 1 year, 80%±5.7% at 2 years and 76.6%±6.5% at 3–5 years. The survival rates were comparable in children and adults (91% vs 72% at 5 years, p=0.258). About 61.5% of eyes maintained 20/400 or better vision and median BCVA improved from perception of light to 20/70 at 1 year postoperatively (p<0.0001). Complications like retroprosthetic membrane formation, glaucoma, vitritis, endophthalmitis and panophthalmitis occurred in 43%, 26%, 22%, 12% and 3% of the eyes, respectively. Conclusion The LVP Kpro is an effective procedure for the treatment of end-stage corneal blindness in completely dry eyes. The LVP Kpro can be particularly useful in situations where the MOOKP is contraindicated or difficult to perform.