Harinder Singh Sethi

Anterior capsule staining for capsulorhexis in cases of white cataract: Comparative clinical study

Purpose: To compare the safety and efficacy of trypan blue 0.1%, gentian violet 0.001%, indocyanine green 0.5% (ICG), fluorescein 2%, and the patients autologous blood for anterior capsule staining in cases of white cataract. Setting: Rajendra Prasad Center for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India. Methods: Fifty eyes of 50 patients with age‐related white cataract had anterior capsule staining with trypan blue, ICG, or gentian violet under an air bubble or subcapsularly with fluorescein or autologous blood followed by phacoemulsification with foldable intraocular lens implantation. Each stain was used in 10 eyes. The ease of creating a continuous curvilinear capsulorhexis (CCC) and the complications during the surgery were noted. Postoperative examinations at 6 hours, 1 day, 1 week, and 1 month included slitlamp microscopy, uncorrected visual acuity, and best corrected visual acuity (BCVA). The staining patterns on the anterior capsule, side port, corneal tunnel, and anterior cortex were assessed intraoperatively and within 6 hours and at 1 day. The intraocular pressure (IOP) was assessed at 1 day; pachymetry, at 1 day and 1 month; and the endothelial cell count, at 1 month. Results: The surgeon had best visualization during the anterior capsulorhexis with trypan blue, ICG, and gentian violet, and a complete CCC was achieved in all eyes in the 3 groups. Two eyes each in the fluorescein and autologous blood groups had extension of the CCC so that the capsulorhexis was complete but not curvilinear. Anterior capsule fibrosis was detected with trypan blue (1 eye) and ICG (2 eyes). The anterior vitreous was stained with fluorescein in 2 eyes. All eyes achieved a BCVA of 20/30 or better from 1 week postoperatively to the last follow‐up. The side port and corneal tunnel were stained most intensely with gentian violet followed by trypan blue and ICG and less intensely with fluorescein and autologous blood. The IOP, pachymetry, and endothelial cell loss were comparable between the stains. Conclusion: Although trypan blue, ICG, gentian violet, fluorescein, and autologous blood were safely used to stain the anterior capsule for phacoemulsification in eyes with white cataract, trypan blue, ICG, and gentian violet were more effective in staining the capsule.

Laboratory Diagnosis in Ulcerative Keratitis

Aims: To identify the common bacterial and fungal isolates from corneal ulcers and to determine the antimicrobial susceptibility patterns of bacterial isolates to commonly used antibiotics at B.P. Koirala Institute of Health Sciences (BPKIHS), eastern Nepal. Culture and direct microscopic correlation and reliability were also compared. Methods: All patients with suspected corneal ulceration presenting to the Ophthalmology Department of BPKIHS from 1st August 1998 to 31st July 2001 were evaluated. Corneal scraping was performed and processed for direct microscopy and culture for bacterial and fungal isolates. Bacterial isolates were subjected to antimicrobial susceptibility testing. Results: Of 447 specimens examined direct microscopy was positive in 216 (48%) specimens. Culture positivity could be correlated with direct microscopy in 179 (83%) of specimens. Growth of etiologic agents was found in 303 (67.8%) samples. Of these 145 (47.8%) had pure fungal growth, 103 (34%) had pure bacterial growth and 55 (18.2%) had mixed fungal and bacterial infection. The commonest fungal pathogen was Aspergillus spp.in 78 (38.4%) followed by Fusarium spp. in 45 (22%). Aureobasidium sp. was isolated in 25 (12.3%) samples. Staphylococcus aureus (93, 56.7%) dominated the scene as the commonest bacterial agent. Streptococcus pneumoniae (33, 20%) was second in the list. Most of the bacterial isolates were sensitive to commonly used antibiotics. Conclusion: This study emphasizes the importance and need of the continued surveillance of the agents and their antimicrobial susceptibility for the prevention and management of corneal ulcers and their complications.

Painting technique for staining the anterior lens capsule.

&NA; We describe a technique of capsule staining called capsule painting. Using a Khokhar capsule painting cannula, the dye is spread directly over the anterior capsule but to no other part of the anterior chamber. There is minimal turbulence in the anterior chamber as there is no need to replace the injected viscoelastic material. The use of minimal dye and viscoelastic material reduces the cost of surgery.

Results of laser in situ keratomileusis for myopia of -10 to -19 diopters with a technolas 217 laser

PURPOSE To evaluate the effectiveness, predictability, and safety of laser in situ keratomileusis (LASIK) for correcting myopia greater than -10.00 D. METHODS Sixty-five eyes of 37 patients with myopia greater than -10.00 D underwent LASIK. Patients were evaluated on day 1, 1 week, 1, 3, and 6 months after surgery. Parameters evaluated were uncorrected visual acuity (UCVA) and best spectacle-corrected visual acuity (BSCVA), residual refractive error, regression of correction, and presence of any complication. RESULTS Mean preoperative BSCVA was 0.745 +/- 0.234, which improved to 0.8070 +/- 0.237 postoperatively. The average preoperative UCVA was 0.022 +/- 0.02; postoperative UCVA at 6 months was 0.536 +/- 0.255. UCVA of 20/40 or better was achieved in 58% (38 eyes) and 20/20 or better in 26% (17 eyes). The average refractive error before LASIK was -12.64 +/- 2.16 D (range -10.00 to -19.00 D). Mean residual refractive error 1 week following LASIK was -0.63 +/- 1.36 D, which regressed to a mean -1.78 +/- 2.08 D at the end of 6 months. Nineteen eyes (29%) were within +/-0.50 D of intended refractive correction. CONCLUSION LASIK was partially effective in the correction of high myopia. An initial overcorrection may be programmed to offset the effect of refractive regression.

Pseudophakic pupillary block caused by pupillary capture after phacoemulsification and in-the-bag AcrySof lens implantation

We describe a 50-year-old patient who developed pupillary block caused by pupillary capture 1 week after uneventful phacoemulsification and implantation of an AcrySof foldable intraocular lens (IOL). The patient had a large but intact capsulorhexis with the haptics lying in the bag; the optic lay in the pupillary area anterior to the capsulorhexis. This case was successfully managed by a neodymium: YAG laser iridotomy, IOL explantation, and subsequent implantation of a poly(methyl methacrylate) posterior chamber IOL. To prevent this complication, we suggest the optic be larger than the capsulorhexis and advocate correct, gentle insertion of the foldable IOL.

Visual outcome after intravenous dexamethasone therapy for idiopathic optic neuritis in an Indian population: A clinical case series

PURPOSE To evaluate the clinical profile, response to dexamethasone treatment and visual function outcome in Indian patients with acute optic neuritis. MATERIALS AND METHODS We conducted an observational study of patients with acute optic neuritis who were treated with intravenous dexamethasone (100 mg in 250 ml of 5% dextrose over 1-2 hours daily, for three consecutive days) and had completed at least two years of follow-up. Parameters assessed included visual acuity, contrast sensitivity, color vision, visual fields, relative afferent pupillary defect (RAPD) and visually evoked potentials. Out of 40 patients studied, 26 patients (33 eyes) had all visual function parameters assessed. Twenty three patients (28 eyes) had completed two years of follow-up and were included for statistical analysis. RESULTS Improvement in visual acuity was statistically significant for distance after 24 hours of the first dose (P = < 0.001) and for near vision after 24 hours of the second dose (P = 0.006); improvement in color and contrast sensitivity was statistically significant 24 hours after the third dose (P = < 0.001 for color vision and P = 0.013 for contrast sensitivity). Significant improvement in RAPD and visual fields were seen by 1 month (P = 0.005). Recurrence was seen in 4 eyes of 4 patients. No serious side effects were observed. At two years, 82.14% (23 out of 28) eyes had visual acuity > 20/40. CONCLUSION Treatment with intravenous pulsed dexamethasone led to rapid recovery of vision in acute optic neuritis, without any serious side effects.

Precaruncular Periosteal Anchor of Medial Rectus, a New Technique in the Management of Complete External Third Nerve Palsy

Management of complete external third nerve palsy is a challenge to a strabismologist; as four of six extra-ocular muscles are affected, it leaves eye in fixed hypotropic and exotropic position (). Although numerous surgical procedures have been described, none has been found to be ideal for all cases. Horizontal supramaximal recession-resection procedure may work in cases having some function of medial rectus (). In cases of complete external palsy, anchoring of globe to periosteum of medial orbital wall using different structures has been described (; ; ), as recession-resection may result in large residual deviation and/or eye drifts back to abducted position due to unopposed lateral rectus action (). These anchoring procedures are with associated problems of skin incision, thigh surgery or loss of superior oblique function (; ; ). We describe a new and safe technique for management of complete external third nerve palsy by anchoring insertion of medial rectus to medial wall periosteum, posterior to posterior lacrimal crest, along with supra maximal recession of lateral rectus.

Survival of Pseudomonas aeruginosa in M-K preserved corneas

Aim: To present seven eyes of suspected donor to host transmitted Pseudomonas sp corneal graft infection after corneal and scleral graft leading to corneal melting within 24 hours, in a span of 10 months. Methods: Case series. Seven eyes, operated for either penetrating or lamellar keratoplasty or scleral patch graft for different indications and which developed massive corneal/corneoscleral infection within 24 hours, were studied prospectively. Results: Pseudomonas aeruginosa, resistant to almost all antibiotics except polymyxin B in all and vancomycin in two, was identified as the causative organism from all the specimens obtained from the infected graft. Conclusion: Post-keratoplasty infection is a disaster. The source of early infection is invariably iatrogenic. Use of empirical antibiotics in the media is not always sufficient to prevent such infection. Thus, measures must be taken in the form of strict maintenance of asepsis and revision of antibiotics added to the storage medium. Further, early recognition and energetic therapy for such infection could reduce the ophthalmic morbidity.

Deep anterior lamellar keratoplasty with phacoemulsification.

PURPOSE: To evaluate the technique and outcomes of deep anterior lamellar keratoplasty (DALK) combined with phacoemulsification for corneal opacity with coexisting cataract. SETTING: Cornea Service, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India. DESIGN: Cohort study. METHODS: Eyes with cataract of varied nucleus grade and with different corneal pathologies were selected. Modified triple procedures were performed in all eyes. RESULTS: Twenty eyes were evaluated. The corrected distance visual acuity (CDVA) after 3 months was 20/60 or better in 18 eyes. One eye had 20/80 CDVA as a result of perioperative and postoperative complications. One graft became opaque after postoperative infection. CONCLUSION: Simultaneous DALK with phacoemulsification was feasible in eyes with coexisting corneal and lenticular pathology, and the outcomes were encouraging. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Hyeropic shift after LASIK induced Diffuse lamellar keratitis

BackgroundDiffuse lamellar keratitis (DLK) is a relatively new syndrome that is increasingly being reported after LASIK. We have observed that a hyperopic shift may be associated with the occurrence of this diffuse lamellar keratitis.Case presentationA 26 year old man developed bilateral diffuse lamellar keratitis (DLK) following myopic LASIK. The residual refractive error was +0.5D OD and +0.25D OS at the end of the first week. The sterile infiltrates resolved over a period of 4–6 weeks on topical steroid therapy. A progressive hyperopic shift was noted in the right eye with an error +4.25Dsph/+0.25Dcyl 20 at the final follow up 6 months post surgery.ConclusionDiffuse lamellar keratitis after LASIK may be associated with a significant hyperopic shift.