Harathy Selvan

Holi colors and chemical contact keratitis

Having originated in India and celebrated across the world, ‘Holi’ marks the onset of spring.1 It symbolises the surrender of lust, forgiving the past mishaps and embracing each other, by immersing them in vibrant colors. Throwing of colours on each other is the hallmark of this festival. However, the enthusiasm of this festival may be marred by its alarming health consequences. Traditionally, holi colors were derived from natural sources and are either particulate powders or liquid splashes, applied by hand, toy guns, or pounding balloons. But off-late, these hues have been contaminated with hazardous compounds such as malachite green, rhodamine, gentian violet and auramine O, proven by High performance liquid chromatography.2,3 Other common adulterants include lead oxide, copper sulphate, mercury sulphite, chromium iodide, silica, mica dust etc. to impart attractive colours to carrier substances. Even fungal contamination of such powders has been proven.4 These powders, through contact with skin (dermatosis), respiratory tract or eyes may provoke unsought complications.5,6 Being poorly biodegradable and resistant to the conventional waste water purification processes, they are harmful to the environment too.7 With respect to the eye, the chemicals, their constituent endotoxins and fungal contamination produce ocular surface toxicity by induction of oxidative bursts in granulocytes.4 The ocular manifestations may vary from a mild chemical conjunctivitis to a secondarily infected corneal ulcer, all falling under the spectrum of ocular alkaline injury.5 However little is known about the specific clinical characteristics induced by these colours. We studied 13 consecutive patients soon after the holi festival, who presented with ocular complaints to our out-patient or casualty services. The mean age of the sample population was 33± 10.49 years. All of them complained of foreign body sensation, 11/13 had ocular pain, 6/13 showed signs of redness and excessive watering. Their presenting vision ranged from 20/40 to 20/125 (ETDRS). On fluorescein staining, 10/13 eyes demonstrated punctate keratopathy and 3/13 had a frank epithelial defect (Figure 1a). In cases of keratopathy, heaped up epithelium in a linear meandering fashion was observed, similar to a ‘wave-like epitheliopathy’, in the paracentral area, best appreciated under cobalt blue filter after fluorescein staining (Figure 1b). They were managed with copious saline irrigation followed by prophylactic topical antibiotics, lubricants and low potency steroids. The epitheliopathy took 3 weeks on an average to resolve; and also delayed epithelial healing was seen in patients with epithelial defects. Cases of similar epitheliopathy have been described in literature due to topical glaucoma medications, contact lens usage and their solutions, previous ocular surgeries and systemic inflammatory disorders,8 either arising from the limbus or from the site of corneal incisions. Confocal microscopy revealed abnormal basal epithelial cells in the former and basal nerve plexus damage in the latter.9,10 In our series, the epitheliopathy might have been due to the direct toxic effect of the chemicals or local inflammatory cytokines induced by the holi powder constituents.4 On confocal microscopy (Confoscan 4, Nidek technologies, Tokyo, Japan), we found abnormal extraneous deposits in the layers involving the corneal epithelium and stroma. The amount of deposition decreased from epithelium to the deep stroma, corresponding with the depth of diffusion of the toxins, with the maximum being in epithelium (Figures 1c–e). It was accompanied with keratocyte loss (Figure 1f) and an increase in inflammatory reaction with generalised haze depicting stromal edema. We observed that the chemical injury caused by holi colors did not fit into the conventional Roper Hall classification and that, a separate system of classification is C O M M E N T Eye (2018) 32, 1–3

Single-point pivot for combined repair of concurrent iridodialysis and cyclodialysis

Iridodialysis and cyclodialysis can occur simultaneously in patients with blunt trauma to the eye, and both might necessitate surgical correction when symptoms emerge. Numerous techniques are used to repair each dialysis individually; thus, the patient will have to return to the operating room for each additional surgery. To our knowledge, the literature lacks techniques to manage both conditions simultaneously. We developed a new approach in which both dialyses can be repaired using a single suture, pivoting both at the same point. The suture that passes through the eyelet of the capsular tension ring placed in the sulcus (for internal cyclopexy) is further passed through the detached iris root and retracted via the ciliary cleft to be tied over the scleral bed, facilitating closure of both dialyses at the same time. This is an effective approach for the repair of concurrent iridodialysis and cyclodialysis.

Hook and flip technique: for phacoemulsification in non-rotating nuclei and posterior polar cataracts

PurposeWe put forward a physical levitation method to hook and flip the chopped nuclear fragments that could not be solely drawn by vacuum during phacoemulsification, due to various reasons such as a non-rotating nuclei or posterior polar cataracts where hydrodissection was unsuccessful or contra-indicated, respectively.MethodA Sinskey hook is insinuated through the crack of the divided nuclei into a plane behind the nuclear pie to ‘hook and flip’ the chopped piece, heading it towards the phacoemulsification probe. This simple step disassembles the nuclear chunk, thereby creating space to facilitate the dismantling of the rest of the fragments. The remnant epinuclear cushion guards the posterior capsule, mitigating the chances of serious intra-operative complications.ResultWe have employed this technique in 17 eyes during similar situations. No specific intra-operative complications were observed; all surgeries were uneventful. A Sinskey hook utilised for this step ensures safety and familiarity, none encountered posterior capsular rent. This technique not only eases the surgery, but also decreases the anticipated intra-operative and post-operative complications.Conclusion‘Hook and flip technique’ thus proves useful whenever dismantling difficulties are encountered during phacoemulsification.

Deep blue dot corneal degeneration: confocal characteristics

PurposeTo discuss the clinical features, differential diagnosis and the novel confocal microscopic findings noted in the rare ‘deep blue dot corneal degeneration’.MethodsObservational case report.ResultsSlit-lamp biomicroscopic examination revealed bilateral, numerous, circular to oval discrete blue opacities at the level of deep stroma and fine grey linear opacities at the level of mid to deep stroma. Confocal microscopy demonstrated two types of corresponding hyper-reflective extracellular lesions: oval deposit-like, most concentrated at a depth of 430–480 µ and needle-like at the depth 330–370 µ.ConclusionsDeep blue dot corneal degeneration is a rare entity where blue deposits of amyloid are seen in the deep corneal stroma. It should be considered as a differential diagnosis when an old-aged person presents with good vision and the above mentioned findings.

Big double bubble trouble: in vivo real time demonstration of ‘mixed-type bubble’ and its consequent effects during deep anterior lamellar keratoplasty

The ‘big-bubble’ deep anterior lamellar keratoplasty (DALK) technique paved the way to redefine corneal anatomy by discovery of a new ‘pre-Descemet/Dua’s layer’. The study of evolution and morphology of these bubbles led them to be classified into three types [1]. Type-1 bubble is a dome-shaped elevation that forms centrally, spreading centrifugally between the stroma and pre-Descemet layer, while the type-2 is a larger, clear-edged thin-walled bubble, forming peripherally and expanding centripetally between the pre-Descemet layer and the Descemet membrane (DM). The third uncommon type is the ‘mixed bubble’ where usually there is a primary type-1 bubble along with a secondary type-2 bubble, which may even be hidden under the semi-opaque former one [1, 2]. This identification is important to foresee the specific complications such as the higher tendency of bursting of the type-2 component. Though studied extensively, yet they have been rarely documented in vivo [1–3]. We demonstrate a mixed bubble during DALK, by in vivo intra-operative video photography, clearly displaying the inception of both the bubbles (Supplemental Video file and Fig. 1a). Microscope-integrated optical coherence tomography (MiOCT) was used to capture this rare scenario, where it revealed two taut layers beneath the stroma, the pre-Descemet layer and DM, respectively, separated by tense intra-compartmental air (Fig. 1b). The type-1 bubble was then deflated and host stromal dissection continued to bare the pre-Descemet layer (Fig. 2a). Despite leaving the type-2 bubble intact, extensive DM detachment (DMD) was visible under the MiOCT system during the course of surgery (Fig. 2b). Intracameral air injection at the end led to successful apposition of the DM to the preDescemet layer. The most common and preferred type of big-bubble for DALK is the type-1, owing to the additional strength provided by the retained host pre-Descemet layer. A mixed bubble also confers the same advantage, but additionally provides the risk of DMD. To circumvent this, AlTaan et al. [3] suggested an intentional puncture of the pre-Descemet layer to release the type-2 air pocket off the mixed bubble. However, post-operative DMD was still noticeable when a patient incurred accidental intra-operative perforation during a mixed-bubble DALK [4]. Spontaneous resorption of the type-2 air pocket in the post-operative period has also been shown [5]. However, both these practices could not evade post-operative DMD because the mixed-type bubble intra-operatively creates an additional deeper enclosed space between the pre-Descemet layer and DM, and as both these layers are left intact, this space may potentially enlarge or be prevented from spontaneous resolution by the persistence of air or seepage of fluid. On the contrary, in pure type-1 or type-2 bubbles, when formed singly, the space created is deroofed during dissection. Considering this high propensity of DMD and lack of consensus on the management of the deeper type-2 component of a mixed bubble, the surgeon should be alert and aware to the clinical signs of mixed bubble forming and the possible need for intracameral air injection at the end of surgery to reverse the DMD by the strategy of internal tamponade, evading unnecessary post-operative patient morbidity. MiOCT provides an upper hand in the identification and management of such situations. * Radhika Tandon radhika_tan@yahoo.com

Transconjunctival rectus muscle bridle: an adjunct in surgical exposure

In addition to optimised body posturing, an ideal eye position is imperative for ophthalmic surgeries for a smooth intraoperative course. In situations of long-term eso/exotropia with subsequent muscle contractures, centring the patient’s eye becomes tedious. Such instances are unswerving to retro/peribulbar blocks (Fig. 1a). The usual norm resorted to in such situations is to grasp and pull the opposite limbal conjunctiva with a toothed forceps, with each surgical step, increasing the risk of conjunctival tearing and bleeding (Fig. 1b, c) due to the resistance mounted by the contracted rectus and tight conjunctiva. It also compromises the surgeon’s dexterity in addition. An attempt to centre the eye with in-situ intracameral/intravitreal instruments can be tried, but may not always succeed (Fig. 1d). All these result in surgeon discomfiture, laborious manipulations, compromised glow and visibility. To the rescue of the above, the contracted horizontal rectus muscle can be bridled with long cotton/silk sutures and clamped to the opposite territory of the sterile drape, giving a tight traction, centring the eye. After rotating the eye to the opposite gaze, the interested tendon can be grasped with superior rectus holding forceps (Fig. 2a), and bridled using Arruga’s needle holder. The mean distance from the anterior limbus to the mid-point of insertions of the medial rectus and lateral rectus is 5.3 ± 0.7 and 6.9 ± 0.7 mm, respectively [1]. Hence, the respective tendons can be grasped 6 mm from the nasal and 7.6 mm from the temporal limbus. The motility of the eye corresponding to the movement of the grasped tendon confirms that the muscle has been rightly picked up. This manoeuvre not just centres the eye, but also frees the surgeon’s hand and provides unrestricted room for manipulation. It maybe of undue help in lenticular and vireo-retinal surgeries, where a coaxial view is vital. In the former, by fetching maximum possible illumination and a worthy red glow, it aids in a confident capsulorhexis, phaco-aspiration of lens matter and assessment of the posterior capsular status [2], while in the latter it offers the view of posterior pole. In simple cases, a peribulbar or retrobulbar block may avert this, however, in cases of long-term strabismus where the root cause is a muscle contracture, an extra mile is deemed necessary. Bridling the superior rectus is a time tested technique used for cataract and glaucoma surgeries [3, 4], which is even now resorted in difficult situations. Similarly, bridling the horizontal rectus may be adopted to centre the eyeball in cases with contractured horizontal recti (Fig. 2b). The possible complications of this technique include bleeding, subconjunctival haemorrhage, soft tissue bridling, muscle haematoma, muscle damage and scleral perforation. However, given the familiarity and ease of this age-old technique, their chances are meagre. Also, being a one-time transconjunctival technique, the risk of overt bleeding is minimal. In conclusion, bridling the vertical recti for cataract surgeries is well known. We extend this idea to the horizontal recti, to manage cases of long-term horizontal strabismus with tight forced duction test providing a simple solution to centre the eye and combat surgical complexity.

One-step management of post-traumatic triple dialysis using two rings

Purpose: To report a case that presented with post blunt trauma cataract, zonular dialysis, cyclodialysis and iridodialysis and its successful single-sitting management. Methods: After lens aspiration, a capsular tension ring and multipiece intraocular lens were placed in the bag to support the zonules, a single eyelet Cionni ring was fixed in the sulcus to provide endocyclotamponade, and iridodialysis repair was done using the ‘stroke and dock technique’. Result: Successful centration of the intraocular lens, closure of the cleft and apposition of the iris root to its base were achieved at the end of the surgery. Conclusion: A single-sitting surgery correcting all the three dialysis can curtail the burden of repeated surgeries and their complications, providing early visual recovery and cost-effectivity.

Cyclodialysis cleft repair: a multi-centered, retrospective case series - comment

We read with interest, the study by Popovic et al, presenting the outcomes of a large multi-centric series on repair of cyclodialysis clefts and would like to congratulate them for the same. Given the rarity of this condition, we understand that a pooled retrospective data (2003-2017) across different nations (Canada, United States, Chile, Spain, Iran and United Kingdom) is a helpful means to understand the surgical outcomes, and applaud the authors for presenting this data in a systematic manner. However, we notice that there has been substantial variation in the nomenclature used for reporting the surgical techniques by different surgeons (as given in table 2). While most of them have used direct cyclopexy, case no-10 mentions the term “external suture cyclopexy” which could have been specified as direct or indirect cyclopexy for better understanding. While sulcus capsular tension ring (CTR) primarily acts by direct endotamponade on the detached ciliary body, the term “indirect cyclopexy with sulcus positioned CTR” in case no-17 appears confusing. Some cases such as no-29, 31, 32 and 34 just mention the term “cyclopexy” with no further information on the technique adopted, which creates ambiguity among the readers. Cataract frequently co-exists with cyclodialysis postblunt trauma, and both may be operated upon in the same sitting. In this series, 25% of eyes (9/36) had presented with co-existing cataract. Five of them underwent phacoemulsification with endotamponade, three of them underwent direct cyclopexy and one eye had undergone laser therapy followed by phacoemulsification and CTR. While the former technique acts as a means to correct both cataract and cyclodialysis simultaneously, in the three eyes that had undergone direct cyclopexy, information regarding the management of cataract is unaddressed. In addition, none of the eyes that had undergone endotamponade required a repeat surgery, reflecting the differential surgical outcomes between the two types of techniques followed, the cyclopexies vs endotamponade. When few patients required additional phacoemulsification (as given in table 2), and CTRs/scleral sutured modified Cionni rings were used, details on whether the ring was placed in sulcus as a mode of cyclotamponade for failed cyclopexy, or in-the-bag for capsule-intraocular lens complex stabilization could have been more informative. The outcomes of those who underwent only cryopexy have not been detailed. The treatment methods used for the sample seems heterogenous with variable number of laser sessions, some receiving additional cryopexy and a few eyes having undergone multiple and varying types of surgical attempts. However, this study quotes an overall favourable success of 96.4% for cleft repair surgeries. On the contrary, Ioannidis et al clearly reported 50% cleft closure rate after one intervention. It will be useful if the success rate after one intervention be given. Also, patients with no outcome data (four eyes) could have better been avoided to minimize numerical confusions. Thus, usage of consistent nomenclature and adding little more information would be more beneficial to the readers.

Dynamic gonioscopy and ultrasound biomicroscopy for diagnosis of latent or low-lying cyclodialysis clefts: Letter to the Editor

Cyclodialysis is the detachment of the longitudinal ciliary body muscle from the scleral spur. Bypassing the angle, it directs the aqueous into the suprachoroidal space causing hypotony. Hence it is important that the cleft be identified and treated, especially when associated with complications such as hypotonic maculopathy.1 Small clefts may resolve spontaneously, however, most of them need some form of treatment, primarily decided based on the number, height and extent of the clefts.2 Hence, accurate estimation of the cleft dimensions is important.

Spontaneous suprachoroidal haemorrhage with exudative retinal detachment in pregnancy-induced hypertension

A 35-year-old woman at 26 weeks’ gestation presented with vision loss in the right eye (RE) and abdominal pain for 10 days. There was no fever. RE had conjunctival congestion and chemosis with a visual acuity of finger counting close to face. The RE showed an exudative retinal detachment, disc oedema and choroidal detachment (figure 1). The left eye visual acuity was 6/12 and on examination there was disc oedema, cotton wool spots, subfoveal fluid and Elschnig’s spots (figure 2).1 Ultrasonogram showed echoes beneath the choroidal detachment suggestive of suprachoroidal haemorrhage (figure 3). Intraocular pressure and anterior chamber depth were normal in either eye. The blood pressure (BP) was 200/120 mm Hg. The laboratory …