Jatin N. Ashar

Deep anterior lamellar keratoplasty in children.

PURPOSE To evaluate the outcomes of deep anterior lamellar keratoplasty (DALK) in children. DESIGN Retrospective interventional case series. METHODS setting: Institutional, L.V. Prasad Eye Institute, a tertiary care center in south India. study population and intervention: All children less than 16 years of age undergoing DALK from January 2003 to January 2011. main outcome measure: Visual outcome and complications. RESULTS Twenty-six eyes of 26 children (13 male and 13 female) with a mean age of 7.82 ± 4.64 years underwent DALK for keratoconus (8), microbial keratitis (6), corneal scar (6), corneal keloid (3), chemical injury with limbal stem cell deficiency (2), and dermoid (1). Big bubble was achieved in 5 eyes, while manual dissection was done in 21. Follow-up ranged from 1 week to 7.3 years. Seventeen patients with a minimal follow-up of 6 months were evaluated for visual outcomes. Final vision varied from counting fingers to 20/20 (mean sphere 2.32 diopters, mean cylinder -2.5 diopters). Complications encountered were suture-related graft infiltrate (3), graft dehiscence (3), and Descemet membrane detachment (2). CONCLUSIONS DALK is a feasible option in children with stromal corneal pathology. It offers advantages in the form of lower risk of graft rejection. However, the risk of complications such as suture-related infections and graft dehiscence persists even in these cases.

Immunosuppression for Mooren's ulcer: evaluation of the stepladder approach--topical, oral and intravenous immunosuppressive agents.

Aim To evaluate a step ladder approach for immunosuppressive regimen for Moorens ulcer. Material and methods We retrospectively analysed patients of Moorens ulcer presenting to a tertiary care centre in south India from 1987 to 2010. Patients were analysed for the age, disease severity at time of presentation in terms of the quadrants of peripheral corneal involvement and amount of peripheral corneal thinning. According to the disease severity, patients were instituted either topical steroids (prednisolone acetate 1%) single agent or in combination with oral steroids (prednisolone 1–1.5 mg/kg/day), oral immunomodulators (methotrexate 7.5–12.5 mg/week), intravenous pulsed methyl prednisolone 1 g or pulsed cyclophosphamide 1 g. The main outcome measure was control of disease activity. Results Topical steroids as a single therapy had a disease resolution rate in 76% of the cases. Cases that required oral steroids, oral methotrexate, intravenous pulsed methyl prednisolone and combination of pulsed methyl prednisolone and cyclophosphamide had a resolution rate of 86%, 78.5%, 71.4% and 73.3%, respectively. The most common complication was secondary infection. Most of the cases that failed therapy had perforation of the cornea and required corneal transplantation. Conclusions An aggressive immunosuppressive regimen that is tailor made based on disease severity as a first line of therapy improves the chances of disease control even in cases of aggressive Moorens ulcer.

Paired-eye comparison of Descemet's stripping endothelial keratoplasty and penetrating keratoplasty in children with congenital hereditary endothelial dystrophy

Purpose To report the surgical outcomes of Descemets stripping endothelial keratoplasty (DSEK) in cases of congenital hereditary endothelial dystrophy (CHED) cohort and compare it with penetrating keratoplasty (PK) in a paired-eye setting. Methods Ours is a retrospective, comparative, consecutive and interventional clinical case series. All patients less than 14 years of age who underwent PK in one eye and DSEK in the contralateral eye at a single centre from January 2006 and February 2011 were analysed. Main outcome measures were graft clarity, visual outcome and complications. Results The mean age of the patients was 6.6±2.19 years at the time of presentation. The outcomes of two surgeries were compared with 1 year of follow-up at the corresponding follow time. At 1 year, all grafts were clear. There was no significant difference in the spherical component of the refraction; the astigmatism was significantly lower after EK. The refraction stabilised in patients with EK as early as 3 months, while it continued to change up to 1 year after PK. Complications included graft dislocation in two cases of DSEK, which were managed by rebubbling, and a graft dehiscence in one case of PK, which was managed by resuturing. The final visual acuity improved in all the patients. Conclusions Endothelial keratoplasty is a viable option to conventional PK in cases of CHED. It offers an advantage of early visual stabilisation compared with PK.

Endothelial keratoplasty in children: surgical challenges and early outcomes

A significant proportion of paediatric keratoplasties are performed for endothelial dysfunction due to failed graft, congenital hereditary endothelial dystrophy1 and pseudophakic corneal oedema. Descemets stripping endothelial keratoplasty (DSEK) is an evolving procedure for isolated endothelial dysfunction with encouraging results in adults. The application and outcome of this procedure in the paediatric population has not been well studied with few reports being published so far.2–5 This study reports the indications, surgical technique and early outcomes of DSEK in children <14 years of age. All children who underwent DSEK at our centre between January 2008 and January 2010 were included. Under general anaesthesia, an appropriate sized superior or temporal fornix based conjunctival flap was reflected and a 4–5 mm long, self-sealing scleral tunnel was made. The Descemets membrane was scored using a reverse …

Microbial keratitis following vegetative matter injury

The purpose of the present study was to analyze the microbiological profile of cases of keratitis following trauma with vegetative matter in a tertiary care center. A retrospective review of the medical records of 49 patients with keratitis following vegetative matter injury over a 3-month period was performed. All patients underwent corneal scraping for smears and inoculation onto various culture media. The microbiological profile was based on the smear and culture reports. For patients who were culture-negative, outcome after standard empirical antibacterial therapy as per hospital protocol was analyzed. Thirteen patients with corneal ulcers had fungal etiology, eight had bacterial etiology, and two had protozoal etiology, while 13 patients were polymicrobial and 13 were culture-negative. Polymicrobial infections were mainly bacterial (eight cases), and the remaining five cases had coexistent fungal and bacterial etiology. The treatment was directed to the specific organism and patients improved with medical or surgical therapy. Only a third of culture-negative cases showed fungal etiology on biopsy or histopathology after keratoplasty while a third showed improvement with therapy. Corneal infections following vegetative matter trauma show a varied etiological profile; however, bacterial and polymicrobial infections are more prevalent. Empirical anti-fungal therapy, as commonly practiced, must be avoided in cases with vegetative matter injury.

Mooren's ulcer in children

Purpose To describe the epidemiology, clinical features, management and outcomes of paediatric Moorens peripheral ulcerative keratitis. Methods All patients with Moorens ulcer aged <18 years presenting at a single centre from 1987 to 2010 were enrolled. Epidemiological features, symptomatology, clinical signs, disease severity, investigations, treatment, outcomes and complications were studied. Main outcome measures were anatomical and functional outcomes, disease activity and complications. Results 14 eyes of 11 children (seven males and four females with an average age of 12.45±2.25 years at presentation) with Moorens ulcer were included. Eight cases were unilateral and three bilateral. Symptoms at presentation were more severe than in adults. Trauma was the commonest predisposing factor. Eight eyes had severe corneal involvement. Medical management included intensive topical steroid therapy, oral steroid therapy and immunosuppressant agents. Surgical therapy included tissue adhesive and bandage contact lens application, amniotic membrane transplantation, optical penetrating keratoplasty and limbal stem cell transplantation and was performed in most eyes as part of primary management or later during the disease course. Patients were followed up for a mean of 69.1 weeks. Ten eyes healed successfully and one developed descemetocele. Three eyes developed secondary infections, one of which ultimately became phthisical. In most eyes, final vision either remained stable or was better than at presentation. Conclusions Our data suggest demographic and clinical features of Moorens ulcer in children differ from those in adults. Good anatomical results and stable visual results can be achieved with appropriate medical and surgical therapies. Systemic steroids and immunosuppression should be used judiciously with close monitoring.

Neonatal infectious keratitis.

Purpose: The aim of this study was to determine predisposing factors, clinico-microbiological profile, and outcomes of neonatal infectious keratitis. Methods: The retrospective study included 39 eyes of 34 neonates treated for microbial keratitis at the L. V. Prasad Eye Institute, India, between January 2006 and December 2011. Etiologic microorganisms, predisposing factors, and management outcomes were evaluated. Results: The Mean age at presentation was 16.9 + 7.7 days, male:female = 16:18. The potential risk factors and coexisting conditions identified were prematurity and prolonged Neonatal Intensive Care Unit (NICU) care, route of delivery, maternal infections, systemic associations, and ocular malformations. Microbiology workup yielded positive results in 29 eyes. Ten eyes were smear and culture negative, with results of immunofluorescent assay and polymerase chain reaction for herpes simplex virus being negative. Bacteria were the commonest (23/39 eyes, 59%) cause of infections, and Pseudomonas aeruginosa was the commonest (12/23 eyes, 52%) bacterial isolate. Multidrug-resistant Pseudomonas keratitis was identified in 8/12 (67%) eyes. Keratitis resolved on medical treatment in 34 eyes. Two of these eyes with scars underwent penetrating keratoplasty later. Of the 8 eyes with multidrug-resistant P. aeruginosa keratitis, 3 eyes had near-total corneal infiltrates, 2 eyes developed anterior staphyloma, 1 eye autoeviscerated, and 1 eye required a therapeutic tectonic graft. One of the 2 eyes with fungal keratitis underwent therapeutic penetrating keratoplasty. Conclusions: Identification of the appropriate predisposing factors, etiologic microbial organisms, and treatment outcome from this study may aid in early recognition and treatment of microbial keratitis in neonates.

Measure of keratoconus progression in patients with vernal keratoconjunctivitis using scanning slit topography.

PURPOSE To document topographic changes using Orbscan in patients with keratoconus and vernal keratoconjunctivitis over 1 year. MATERIAL AND METHODS Retrospective analysis of clinical and Orbscan data of 22 eyes of 11 patients with keratoconus and VKC with follow up over 1 year period was done. The parameters studied included patients demographics, clinical features, visual acuity, refraction and Orbscan IIz. The changes in various Orbscan parameters were studied over the 1-year period. RESULTS Mean age was 14±4.1 years. 20 eyes had clinical keratoconus, while 2 had forme fruste keratoconus. 8 eyes of 22 showed evident progression (>1 diopter change in mean simulated (sim) K over 12 months). There was no significant difference in the visual acuity or clinical features over follow up. In patients with progression, statistically significant change (p<0.05) was found in posterior float curvature, sim K astigmatism and maximum astigmatism. Rest of the parameters did not show significant change. Among the patients without evident progression, none of the parameters showed significant change. On comparing the patients with clinical signs of keratoconus with those with only topographic signs of keratoconus, there was no difference between the two groups with respect to the rate of progression of keratoconus. Patients with both mixed type and pure palpebral type of VKC had comparable Orbscan parameters at baseline and 1 year follow up and similar progression rate of keratoconus. CONCLUSION Serial topographic analysis provides numerical information about various corneal parameters in patients with vernal keratoconjunctivitis and keratoconus.

Long-term change in corneal astigmatism after sutureless cataract surgery.

1. Dong Z, Zhou X. Collagen cross-linking with riboflavin in a femtosecond laser–created pocket in rabbit corneas: 6-month results. Am J Ophthalmol 2011;152(1):22–27. 2. Prasad A, Fry K, Hersh PS. Relationship of age and refraction to central corneal thickness. Cornea 2011;30(5):553–555. 3. Greenstein SA, Shah VP, Fry KL, Hersh PS. Corneal thickness changes after corneal collagen crosslinking for keratoconus and corneal ectasia: one-year results. J Cataract Refract Surg 2011;37(4):691–700.

Phototherapeutic keratectomy versus alcohol epitheliectomy with mechanical debridement for superficial variant of granular dystrophy: a paired eye comparison.

PURPOSE To compare outcome of phototherapeutic keratectomy (PTK) and alcohol epitheliectomy with mechanical debridement for superficial variant of granular dystrophy. METHOD Case report. A 7 year old girl with superficial variant of granular dystrophy with an visual acuity of 20/70 both eyes, underwent a simultaneous PTK in right eye (OD) and alcohol epitheliectomy with mechanical debridement in left eye (OS). Post operatively the visual acuity, refraction and corneal clarity were assessed. RESULTS On the first post-operative day uncorrected visual acuity was 20/50 in both eyes. At 2 weeks, vision improved to 20/40 with +2.50 -2.00×180 in OD and +1.50 -1.50×180 in OS. At 2 years, vision and refraction were 20/25 with +2.50 -2.00×180 in OD and 20/25 with +1.25 -1.50×170 OS respectively. There was early recurrence of the granular dystrophy. CONCLUSION The visual outcomes of both PTK and alcohol epitheliectomy are similar for superficial variant of granular dystrophy. The hyperopic shift with PTK is a matter of concern. Alcohol epitheliectomy can be used in treatment of superficial corneal dystrophies where PTK is unavailable.