Jagadesh C. Reddy

Long-term outcomes of penetrating keratoplasty for keratoconus with resolved corneal hydrops.

Purpose: To address the controversial issue of whether the occurrence of corneal hydrops adversely affects the fate of subsequent penetrating keratoplasty (PK), this study compared the long-term outcomes of PK in keratoconic eyes with resolved corneal hydrops with those without prior corneal hydrops. Methods: This was a retrospective chart review of 102 eyes of 102 patients with keratoconus who underwent PK. The primary outcome measure was endothelial rejection–free allograft survival and the secondary outcomes were vision, postoperative complications, and histopathologic findings of corneal buttons obtained during PK. Results: The mean follow-up after PK was 5.5 ± 3.3 years. The Kaplan–Meier endothelial rejection–free allograft survival at 1 and 5 years post-PK were 93.7% ± 4% and 82.6% ± 7%, respectively, in 32 eyes with hydrops and 100% and 98% ± 2%, respectively, in 70 eyes without hydrops (P = 0.04). Multivariate analysis showed that the risk of endothelial rejection episodes was greater in eyes with longer duration of corneal hydrops (P = 0.019) and coexistent ocular allergy (P = 0.012). All rejection episodes were reversed medically and only 1 allograft failed because of postoperative endophthalmitis. More than 90% of eyes achieved a visual acuity of better than 20/40. Common postoperative complications were cataract and graft infiltrate. Histopathology in cases of resolved hydrops after intracameral gas showed unique compression artifacts like folding and burial of the broken ends of Descemet membrane in the stroma. Conclusions: Although endothelial rejection episodes are more common in eyes with resolved corneal hydrops, long-term allograft survival and visual results after PK in eyes with keratoconus are excellent, irrespective of prior corneal hydrops.

Demographic and clinical profile of vernal keratoconjunctivitis at a tertiary eye care center in India.

Purpose: To study the demographic and clinical profile of patients with vernal keratoconjunctivitis (VKC) at a tertiary eye care center in India. Materials and Methods: Retrospective chart analysis of 468 patients of VKC seen from January 2006 to December 2006. Results: Mean age at presentation was 12 years. Majority of the patients had mixed pattern disease (72%). Chronic perennial disease was seen in 36% patients. Personal or family history of allergies was noted in 5% patients. Severe disease based on clinical grading was present in 37% patients. Moderate to severe vision loss was seen in 12% of total population. Persistent disease beyond 20 years of age was found in 12% patients. VKC-related complications such as corneal scarring (11%), shield ulcer (3%), keratoconus (6%), and limbal stem cell deficiency (1.2%) were seen. Treatment-related complications like corticosteroid-induced cataract and glaucoma were seen in 6% and 4% of patients, respectively. Conclusion: Clinical pattern of VKC seen in the tropical climate of India is essentially similar to that seen in other tropical countries. Few distinct features that we noted represent chronic perennial disease, low association with atopy, and higher propensity for disease and treatment-related complications.

Management, Clinical Outcomes, and Complications of Shield Ulcers in Vernal Keratoconjunctivitis

PURPOSEnTo assess the clinical outcomes and complications of shield ulcers by various treatment methods.nnnDESIGNnRetrospective, interventional case series.nnnMETHODSnsetting: Cornea and anterior segment service of L.V. Prasad Eye Institute, India. study population: One hundred ninety-three eyes of 163 patients clinically diagnosed with vernal keratoconjunctivitis and shield ulcers. intervention: The treatment algorithm was based on the Cameron clinical grading of shield ulcers. Grade 1 ulcers received medical therapy alone. Grade 2 and grade 3 ulcers received either medical therapy alone or medical therapy combined with debridement, amniotic membrane transplantation (AMT), or both. main outcome measures: Re-epithelialization time and best-corrected visual acuity.nnnRESULTSnGrade 1 ulcers were seen in 71 (37%) eyes, grade 2 ulcers were seen in 79 (41%) eyes, and grade 3 ulcers were seen in 43 (22%) eyes. In the grade 1 group, re-epithelialization was seen in 67 (94%) eyes. In the grade 2 group, re-epithelialization was seen in 36 (88%) eyes that received medical treatment, in 20 (95%) eyes that underwent debridement, and in 17 (100%) eyes that underwent AMT. In the grade 3 group, re-epithelialization was seen in only 1 (1.7%) eye that received medical treatment, whereas it was seen in all eyes that underwent debridement and AMT. The mean best-corrected visual acuity after re-epithelialization of the shield ulcer was 20/30, 20/30, and 20/40 in the grade 1, grade 2, and grade 3 groups, respectively. Recurrence and secondary bacterial keratitis were seen in 28 (14.5%) and 20 (10%) eyes, respectively.nnnCONCLUSIONSnGrade 1 shield ulcers respond well to medical therapy alone, whereas grade 2 ulcers occasionally may require additional debridement or AMT. Grade 3 ulcers, however, largely are refractory to medical therapy and require debridement and AMT for rapid re-epithelialization.

Outcomes of Repeat Keratoplasty for Failed Therapeutic Keratoplasty

PURPOSEnTo analyze clinical outcomes of repeat optical penetrating (PK) or endothelial keratoplasty (EK) after failed therapeutic keratoplasty (TPK).nnnDESIGNnRetrospective consecutive, comparative, interventional case series.nnnMETHODSnsetting: LV Prasad Eye Institute, Hyderabad, India.nnnSTUDY POPULATIONnPatients aged >18 years who underwent a repeat PK or EK following a failed TPK with a follow-up of at least 1 year were included. Patients with culture-negative ulcers, viral etiology, coexistent ocular surface disease, and multiple grafts were excluded from the study.nnnINTERVENTIONnPK or EK for failed TPK.nnnMAIN OUTCOME MEASUREnCorrected distance visual acuity at 1 year follow-up. secondary outcome measure: Graft clarity.nnnRESULTSnOne hundred twelve eyes (67 PK, 45 EK) were included in the study. The PK group had a significantly higher number of cases with high-risk features prior to regraft. Improvement in visual acuity in each ofxa0the types of grafts was statistically significant (Pxa0<xa0.01), but there was no difference between the 2 groups at 1 year postoperatively. A statistically significant proportion of grafts regained graft clarity after regrafting in the PK group (P < .01) but not in the EK group (Pxa0=xa0.205) at 1 year postoperatively. Endothelial rejection rates were higher in the PK group. Subgroup analysis showed that eyes that had PK or EK for failed TPK conducted for Aspergillus keratitis showed better outcomes in terms of graft clarity. Kaplan-Maier (KM) survival analysis for graft clarity showed cumulative survival of 50% at 5 years. The survival using the KM curve was not statistically different between the 2 groups (Pxa0= .33).nnnCONCLUSIONnThis study shows that visual rehabilitation with relatively good functional outcomes can be achieved by performing repeat PK or EK in patients after failed TPK.

Risk factors and clinical outcomes of bacterial and fungal scleritis at a tertiary eye care hospital.

Purpose: The aim was to analyze demographics, risk factors, pathogenic organisms, and clinical outcome in cases with microbiologically proven bacterial or fungal scleritis. Materials and Methods: Retrospective review of all the medical records of patients with microbiologically proven infectious scleritis examined from March 2005 to December 2009 in the cornea services of L. V. Prasad Eye Institute, Hyderabad, India was done. Results: Forty-two eyes of 42 patients were included in this study. The mean age at presentation was 48.52 u0381 14.10 years (range: 12-70). Surgery was the major risk factor seen in 24 eyes (58.5%). Scleral infection was noted after vitreoretinal surgery (with scleral buckle) in 15 eyes, cataract surgery in 3 eyes, pterygium surgery in 3 eyes, corneoscleral tear repair and scleral buckle surgery in 3 eyes. Sixteen eyes (39%) were on systemic or topical steroids at the time of presentation. History of injury was noted in 9 eyes (22%) and diabetes mellitus in 7 patients (17%). Associated keratitis was noted in 9 eyes (21.4%). The scleral abscess was unifocal in 33 eyes (78.5%), multifocal in 6 eyes (14.2%) and diffuse in 3 eyes (7.14%). The final follow-up ranged from 24 days to 37 months. The final visual acuity was better in 18 eyes (42.8%), stable in 13 (30.9%), and deteriorated in 7 eyes (16.6%). Recurrence was seen in 4 eyes (9.5%). Conclusions: Surgery is a major risk factor for infectious scleritis in our series. Fungus was the most common organism isolated. Thorough debridement and intensive use of medications have improved the outcome.

Clinical outcomes and risk factors for graft failure after deep anterior lamellar keratoplasty and penetrating keratoplasty for macular corneal dystrophy.

Purpose: The aim of this study was to compare visual acuity, clinical outcomes, complications, and risk factors for graft failure after deep anterior lamellar keratoplasty (DALK) and penetrating keratoplasty (PK) for macular corneal dystrophy. Methods: Retrospective comparative case series. Results: The PK group consisted of 109 eyes of 84 patients and the DALK group consisted of 21 eyes of 20 patients. The mean logarithm of the minimum angle of resolution best-corrected visual acuity at 3 and 12 months was 0.5 versus 0.5 (P = 0.285) and 0.4 versus 0.4 (P = 0.67) in the DALK and PK groups, respectively. There was no significant statistical difference in astigmatism and spherical equivalent between the 2 groups at 12 months. In the PK group, graft rejection that was the most common cause of graft failure was seen in 27 eyes (25%), of which 55% occurred within 1 year. In the DALK group, Descemet membrane microperforation occurred in 5 eyes (24%) intraoperatively, and early postoperative Descemet membrane detachment with double anterior chamber occurred in 9 eyes (43%). Kaplan–Meier estimate of graft survival in PK versus DALK groups were 93% versus 80% at 1 year and 78% versus 70% at 4 years, respectively. Conclusions: Visual and refractive outcomes are comparable between DALK and PK groups. DALK was superior to PK in its safety against postoperative complications such as endothelial rejection and secondary glaucoma. Graft failure in DALK was mostly associated with either intraoperative or early postoperative complications. DALK is a viable surgical option in cases with macular corneal dystrophy.

The role of penetrating keratoplasty in the era of selective lamellar keratoplasty.

Over the past several decades corneal transplantation has been the most successful form of tissue transplantation and the most frequently transplanted human tissue. The first successful human corneal transplant was performed in 1905 by Dr Eduard Zirm. Initially full-thickness keratoplasty [penetrating keratoplasty (PK)] was the treatment of choice for all corneal diseases but with better understanding of corneal anatomy and physiology, improved surgical techniques combined with the known shortcomings of PK, there has been increased impetus for selective lamellar keratoplasty (LK). However, PK still retains a major role in corneal transplantation despite these advances. The rationale for selective LK is when the pathology only involves a focal area or specific layer of the cornea, the patient may be best served by transplanting only the diseased layer instead of the entire cornea. For example, if only the endothelium has decompensated, selective replacement of diseased recipient Descemet’s membrane (DM) and the endothelium with a healthy donor DM and the endothelium with or without a thin layer of corneal stroma [endothelial keratoplasty (EK)] leaving the normal healthy stroma results in a more normal and stable corneal curvature and tectonically stronger eye than a PK. Conversely, when the pathology is superficial, the central corneal stroma can be replaced partially [anterior lamellar keratoplasty (ALK)] or completely [deep anterior lamellar keratoplasty (DALK)] leaving host corneal endothelium and DM intact, eliminating the risk of endothelial rejection, the most severe type of corneal graft rejection. Although the concept

Late-onset necrotizing scleritis due to pigmented mycetoma (dematiaceous fungi) in 2 cases.

Purpose: To describe the atypical presentation of fungal infection and necrotizing scleritis, the potential role of histopathology in the diagnosis, and surgical excision in the management. Methods: Retrospective interventional case series. Results: Two patients presented with a pigmented conjunctival mass, one resembling necrotizing scleritis with uveal prolapse and the other resembling a pigmented ocular surface tumor, both after excision of nasal pterygium, 12 and 50 years previously, respectively. The pigmented lesion was 2 × 1.5 mm in each case, both situated on the bulbar surface 2 mm from the nasal limbus. After surgical excision, each lesion histopathologically displayed fungal filaments (pigmented dematiaceous fungi). Conclusions: Pigmented mycetoma (dematiaceous fungi) can simulate uveal tissue prolapse, pigmented foreign body, or pigmented epibulbar tumors, particularly melanoma. Surgical excision of the entire lesion is effective for management.

Etiology and Management of Raised Intraocular Pressure following Posterior Chamber Phakic Intraocular Lens Implantation in Myopic Eyes.

Aim To evaluate the etiology and management of elevated intraocular pressure (IOP) following posterior chamber phakic implantable collamer lens (ICL) surgery. Methods Between 2009 and 2015, 638 eyes of 359 subjects with refractive myopia, underwent V4b and V4c (CentraFLOW) model ICL implantation. Ocular hypertension (OHT) was defined as IOP of ≥ 22 mm Hg on two separate occasions and elevated IOP with corresponding optic disc or visual field damage was defined as glaucoma. Results Elevated IOP ≥ 22 mm Hg was noted in 33 eyes of 30 subjects (33/638; 5.17%). Median age of subjects with raised IOP was 26 years (Inter quartile range (IQR):22, 29) and median refarctive error was -16 diopters (-19.5, -13). The median follow up was 7.8 months (IQR:0.3, 17.6) and median time for postoperative IOP rise was 12 days, (IQR:2, 24). The various etiologies for elevated IOP were steroid response in 21 eyes (64%; 10 eyes with V4b, 11 eyes with V4c), retained viscoelastic in 5 eyes (15%) (3 with V4b, 2 with V4c), pupillary block in four eyes (12%; 3 with V4b, 1 with V4c), malignant glaucoma in one eye (3%, V4b), and missed pre-existing Juvenile open angle glaucoma (JOAG) in two eyes (6% with V4b). Elevated IOP in 31 eyes resolved with conservative management. One eye (centraFLOW design) with central aquaport block by viscoelastic, needed AC wash and one eye with malignant glaucoma needed parsplana vitrectomy and hyaloidotomy. Ten eyes required longterm (>2 months) antiglaucoma medications (AGM) for IOP control. Except the two eyes with JOAG, none had disc and field damage. Conclusion In our series, OHT was seen in 4.85% and glaucoma in 0.3% eyes that underwent V4b and V4c model ICL implantation. Multiple etiologies were noted and steroid induced ocular hypertension was the most common cause of elevated IOP followed by retained viscoelastic and pupillary block. One third of these eyes required longterm AGM for IOP control.

Topography and tomography in the diagnosis of corneal ectasia

For the modern day refractive surgeon, tomography has become an invaluable tool for selection of patients for refractive surgery; in addition it is essential for the diagnosis and treatment planning of ectatic disorders of the cornea. This review article attempts to compare the Scheimpflug with the Placido disc systems, stresses the value of elevation-based topography and the importance of posterior float. Finally, this article provides a comprehensive literature review of the most widely used tomographers, the Orbscan IIz, anterior segment optical coherence tomography, Pentacam, and Galilei Scheimpflug systems. Comparisons of the above tomographers provided in the available literature with respect to corneal elevation, corneal curvature (power) and pachymetry and calculation of intraocular lens power post-refractive surgery have also been discussed.