Deepali Singhal

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.

Tenon patch graft for corneal fistula: a rare entity treated by a simple technique

A 50-year-old patient presented with dull aching pain with some discomfort in his right eye for the past 2 weeks. History revealed the patient had a past episode of infective keratitis managed medically in a local hospital. The last follow-up record suggested a diagnosis of healed keratitis with corneoiridic scar. On examination, the patient had visual acuity of hand movement and a corneoiridic scar of 7×7u2009mm with an inferotemporal translucent cystic area measuring 3×4u2009mm in size with underlying uveal tissue visible. Seidel test was found to be positive confirming leakage. For this, a tenon patch over the area of defect along with anterior chamber formation was done. On postoperative day 1, the graft was well attached and anterior chamber was formed with no leak on Seidel test. Intraocular pressure was 16u2009mm Hg.

Floating iris cyst mimicking intravitreal cysticercosis.

A 12-year-old girl presented with a history of repeated headaches (with no ocular symptoms) for 3u2005years. There was no history of ocular trauma or surgery. On ocular examination elsewhere, she was diagnosed as having intravitreal cysticercosis after observing a cyst in the left eye and was referred for vitrectomy to a tertiary eye care centre.nnHer vision was 20/20 in both eyes, with no signs of ocular inflammation. Biomicroscopic examination of the left eye showed a …

Continuous intraoperative optical coherence tomography-guided shield ulcer debridement with tuck in multilayered amniotic membrane transplantation

Purpose: The aim of this study is to describe a modified surgical technique of continuous intraoperative optical coherence tomography (iOCT)-guided shield ulcer debridement with tuck-in multilayered Amniotic membrane transplantation (ML AMT) in vernal keratoconjunctivitis (VKC) with shield ulcer with plaque. Methods: Seven eyes of seven patients presenting with VKC with shield ulcer with plaque were enrolled in this prospective case series and planned for shield ulcer debridement with ML AMT. Debridement of the ulcer base with double-layered AMT was done under the continuous guidance of iOCT. The main outcome measure was the time for complete reepithelialization. Statistical analysis was performed using the Stata-14.0 program for Windows. Data were presented as mean ± standard deviation/median (minimum-maximum) and frequency percentage as applicable. Results: The surgery could be completed successfully in all cases and iOCT could provide real-time assessment of the depth of dissection during the entire procedure. The duration of complete healing and disintegration of amniotic membrane varied from 7 to 12 days. Recurrence was not seen in any case till 2 months follow-up. Conclusion: iOCT provides continuous monitoring of the depth of dissection and allows for a safe and complete debridement of the shield ulcer with plaque.

Immune stromal keratitis: a rare ocular presentation of tuberculosis

An 11-year-old female patient presented with diminution of vision in both the eyes for the last 4u2009days. She had redness, watering and photophobia for the past 11u2009days. Slit lamp examination revealed multiple disc-shaped corneal stromal infiltrates with an overlying epithelial defect and hypopyon in both the eyes. A provisional diagnosis of infective keratitis was made. The patient was started on empirical antimicrobial therapy. However, no improvement was noted over the next 72u2009hours. Microbiological examination of the corneal scraping from both the eyes was negative. Considering the above, provisional diagnosis was changed to immune stromal keratouveitis and the patient was started on topical steroids. Further evaluation revealed a positive Mantoux test (30×20u2009mm) and contrast enhanced CT chest showing pulmonary nodules, suggestive of tuberculosis. The patient was subsequently started on antitubercular treatment. The infiltrates along with the ulcer and anterior uveitis responded dramatically to the revised treatment and resolved completely within 7u2009days of therapy.

Clinical presentation and management of corneal fistula

Purpose To describe the clinical features and management of corneal fistula in patients of healed keratitis. Methods Medical records of all patients of healed keratitis presenting to the cornea clinic from November 2016 to September 2017 were reviewed. Eightcases of corneal fistula (six true fistulas, two closed fistulas) were identified. Six patients were managed with autologous tenon patch graft while two patients were managed medically. Various risk factors and treatment outcomes of corneal fistulisation were evaluated. Results The patients included two patients of failed therapeutic keratoplasty (with resolved graft infection) and six patients of healed keratitis. The age of the patients ranged between 10 and 60 years. Five of the patients were male while three were female. The size of the fistula measured between 1 and 2u2009mm. A surrounding cystic area of diameter ranging between 1 and 4.5u2009mm was seen in all the patients. In all of the patients, the treating physician missed the diagnosis. Complete healing was noted at 6–8 weeks in all the patients who underwent tenon graft. One patient refused to undergo any surgery and was lost to follow-up. In another case, surgery was deferred due to uncontrolled hypertension and he developed anterior staphyloma subsequently. Conclusion Corneal fistula can often be missed in an apparently healed perforated corneal ulcer. Tenon patch graft is an effective technique for the management of corneal fistula.

Component corneal surgery: An update

Several decades ago, penetrating keratoplasty was a challenge to corneal surgeons. Constant effort by the corneal surgeon to improve the outcomes as well as utilization of the available resources has led to a revolutionary change in the field of keratoplasty. All these efforts have led to the evolution of techniques that allow a corneal surgeon to disease-specific transplant of individual layers of corneal “so-called component corneal surgery” depending on the layer of cornea affected. This has led to an improvement in corneal graft survival as well as a better utilization of corneal tissues. This article reviews the currently available literature on component corneal surgeries and provides an update on the available techniques.

Corneal edema after phacoemulsification

Phacoemulsification is the most commonly performed cataract surgery in this era. With all the recent advances in investigations and management of cataract through phacoemulsification, most of the patients are able to achieve excellent visual outcome. Corneal edema after phacoemulsification in the immediate postoperative period often leads to patient dissatisfaction and worsening of outcome. Delayed onset corneal edema often warrants endothelial keratoplasty. This review highlights the etiopathogenesis, risk factors, and management of corneal edema in the acute phase including descemets membrane detachment (DMD) and toxic anterior segment syndrome. Various investigative modalities such as pachymetry, specular microscopy, anterior segment optical coherence tomography, and confocal microscopy have been discussed briefly.

Comparison of Oral Voriconazole Versus Oral Ketoconazole as an Adjunct to Topical Natamycin in Severe Fungal Keratitis: A Randomized Controlled Trial

Purpose: To compare the efficacy of oral voriconazole (VCZ) with oral ketoconazole (KCZ) as an adjunct to topical natamycin in severe fungal keratitis. Methods: Fifty eyes of 50 patients with proven severe fungal keratitis, (>5 mm size, involving >4 mm central cornea and >50% stromal depth), smear, and/or culture positive were randomized to receive either oral VCZ (n = 25) or oral KCZ (n = 25) 200 mg twice a day. Both groups received topical natamycin along with oral medication. The primary outcome measure was best spectacle-corrected visual acuity (BSCVA) at 3 months of follow-up. Secondary outcomes were the percentage of healed cases and scar size. Results: The mean BSCVA after treatment was 1.3 ± 0.35 logarithm of minimum angle of resolution units in the VCZ group and 1.6 ± 0.39 logarithm of minimum angle of resolution units in the KCZ group [P = 0.004, 95% confidence interval (CI), −0.10 to 0.54]. The final mean scar size was smaller for oral VCZ than for oral KCZ (P = 0.04, 95% CI, −0.01 to 0.93 mm). The percentage of cases healed were 80% and 72% in VCZ and KCZ groups, respectively (P = 0.51, 95% CI, −0.15 to 0.31). The ratio of tear film to serum concentration of oral VCZ was better than oral KCZ at days 14 (P = 0.002) and 21 (P = 0.006). Conclusions: Although the duration and percentage of healing was similar in both groups, oral VCZ attained a significantly better tear film concentration with a smaller scar size and better BSCVA compared with oral KCZ. Thus, oral VCZ may be preferred over oral KCZ in severe fungal keratitis.