Javed Hussain Farooqui

Results of simple limbal epithelial transplantation in unilateral ocular surface burn

Purpose: This study aimed to report the long-term outcomes of autologous Simple Limbal Epithelial Transplantation (SLET) performed for unilateral limbal stem cell deficiency (LSCD) following chemical burn at a tertiary eye center in North India. Methods: This was a single-center prospective interventional case series of patients who developed unilateral LSCD after suffering from ocular surface burns and who underwent SLET between October 2012 and May 2016 with a follow-up period of at least 6 months. The primary outcome measure was restoration of a completely epithelized, stable, and avascular corneal surface. The secondary outcome measure was percentage of eyes, which reported visual gain. Results: The study included 30 eyes of 30 patients, 18 adults and 12 children, at a median follow-up of 1.1 years (range: 6 months to 3.5 years), 21 of 30 eyes (70%; 95% confidence interval, 53.6%–86.2%) maintained successful outcome. Visual acuity gain was seen in 71.4% of successful cases. The clinical factors associated with failure were identified as acid injury, severe symblepharon at the time of presentation, and SLET combined with penetrating keratoplasty (PK). Conclusion: Autologous SLET is an effective limbal cell transplantation technique for the treatment of unilateral LSCD. It is especially beneficial for centers where cell cultivation laboratory is unavailable. Presence of severe symblepharon, which requires PK peroperatively , has poor outcome.

Isolated Bilateral Complete Cryptophthalmos

Cryptophthalmos is a rare congenital anomaly, characterized by extension of the skin continuously from forehead onto the cheeks and covering eyeballs. Although cryptophthalmos, as a part of Fraser syndrome, has been reported many times, isolated cryptophthalmos without systemic associations is very rare. We present a 6-month- old child with isolated bilateral complete cryptophthalmos, which to the best of our knowledge, is the first case of cryptophthalmos being reported from Vietnam.

Use of modified international council of ophthalmology- ophthalmology surgical competency assessment rubric (ICO- OSCAR) for phacoemulsification- wet lab training in residency program

I am writing this letter to discuss a very important issue that we face in Ophthalmology training in the current day scenario in our country. India is home to a quarter of the blind population of the world, but unfortunately, the number of trained ophthalmologists is lagging behind the current need.[1,2] Our country needs 25,000–30,000 ophthalmologists till 2020, which means adding 300 training slots per year.[1] This needs a major revamp of our residency system as the existing system is found to be inadequate in its current form.[3]

Corneal surgery in the flying eye hospital: characteristics and visual outcome

OBJECTIVE The Flying Eye Hospital (FEH) of ORBIS International is a capacity-building platform that trains ophthalmologists throughout the developing world on-board a fully functional eye hospital based in an airplane and in the local hospitals of developing countries. Corneal blindness (CB) is the second leading cause of blindness in most developing countries. Treatment of existing global CB requires effective eye banking and surgeons trained in corneal transplant. ORBIS International has programs that addressed both those needs. This study reports the clinical outcome of all keratoplasty training programs of the FEH from January 2010 to December 2014. METHODS Surveys were sent to all local ophthalmologists trained on FEH to perform keratoplasty in the relevant time period. The survey included patient demographics, procedure performed, indications for surgery, postoperative steroid regiment, and visual acuity (VA). RESULTS Keratoplasty was undertaken in 87 eyes as follows: penetrating keratoplasty (PK) in 66 (75.9% of our population), deep anterior lamellar keratoplasty (DALK) in 6 (6.9%), Descemets stripping endothelial keratoplasty (DSEK) in 14 (16.1%), and Boston keratoprosthesis (KP) in 1 (1.1%). Corneal clouding was the indication in 83 (95.4%) of patients. Forty-seven (54%) patients returned for long-term care with the mean follow-up (FU) of 32.0 months (range 6-60 months). Thirteen (27.7%) were not using any steroids at last the FU. Eleven (23.4%) patients had signs of graft rejection. Best-corrected VA in meters and feet, respectively, was 6/6 to 6/18 (20/20 to 20/60) in 12 (25.5%) patients, 6/18 to 6/60 (20/60 to 20/200) in 19 (40.4%) patients, 6/60 to 3/60 (20/200 to 20/400) in 4 (8.5%) patients, and less than 3/60 (20/400) in 12 (25.5%) patients. CONCLUSION Clinical outcomes delivered by FEH keratoplasty training are acceptable compared to results in the developing world and to some reports of training programs in the developed world, though our study is limited by its retrospective nature and the poor rate of FU.

Management of Heavy Eyeball Syndrome--our experience.

Sir, We read with great interest the case report by Jethani and Amin[1] and the subsequent discussion on management and the need to operate on Inferior rectus by Bhambhwani et al.[2] We would like to congratulate the authors on successful management of this rare and interesting clinical entity and would like to share our experience in the management of a similar case. A 56-year-old Vietnamese lady presented to the Orbis Flying Eye Hospital program held in Hanoi, Vietnam in May 2015. The patient complained of deviation of the right eye started 10 years ago, gradually increasing in severity. She had a history of wearing eyeglasses since a young age and complained of difficulty in doing daily work without her glasses. There was no history of face turn. In 2012, the patient underwent phacoemulsification with posterior chamber intraocular lens in the bag for both eyes. The uncorrected visual acuity on presentation was 20/63 in the right eye, and 20/50 in the left eye. There was no family history of similar problems in the family members. Extraocular movements were restricted in abduction (−4 in the right eye, −2 in the left eye) and elevation (−3 in the right eye, −1 in the left eye). Cover test and prism bar test showed that this patient had 90-prism diopters (PD) bilateral esotropia and 10 PD hypotropia in the right eye [Fig. 1a]. Posterior segment examination revealed tessellated tigroid fundus, myopic macular degeneration with posterior staphyloma in both eyes. Figure 1 (a) Preoperative photo shows extraocular movements showing restriction in abduction (−4 in the right eye, −2 in the left eye) and elevation (−3 in the right eye, −1 in the left eye). (b) Postoperative photo shows improved ... Orbital magnetic resonance imaging showed nasally shifted superior rectus (SR) and inferiorly shifted lateral rectus (LR) [Fig. 2]. Axial length measured with the A Scan was 31.47 mm and 31.95 mm in the right and left eye, respectively. Figure 2 Coronal scan of magnetic resonance imaging showing (a) nasally displaced superior rectus and (b) inferiorly displaced lateral rectus We performed loop myopexy between SR and LR of both eyes 12 mm from the limbus and bilateral medial rectus recession of 5 mm under general anesthesia with adjustable sutures in the left eye. Postoperatively, the patient had residual 10 PD exotropia and no hypotropia 1 day postoperatively. Abduction was improved in both eyes but remained slightly restricted (−1). After 5 mm left medial rectus advancement of the adjustable suture, exotropia decreased to 6 PD [Fig. 1b]. Surgical management of such cases is complex and has evolved over years. It ranges from conventional maneuvers of resection recession procedures that mainly affect muscle forces[3,4] to modified procedures that include transposition techniques that alter the muscle paths.[5,6] We believe that loop myopexy of the SR and LR muscles with MR recession (in the case of tight muscles) is sufficient to restore the dislocated globe back into the muscle cone and to achieve improvement of esotropia, hypotropia, abduction, and supraduction in patients with large angle strabismus and displaced SR and LR. Using adjustable suturing improves the predictability and final outcome in such complex cases. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Mobilizing slit lamp to the field: A new affordable solution.

We are describing a simple and affordable design to pack and carry the slit lamp to the field. Orbis staff working on the Flying Eye Hospital (FEH) developed this design to facilitate mobilization of the slit lamp to the field during various FEH programs. The solution involves using a big toolbox, a central plywood apparatus, and foam. These supplies were cut to measure and used to support the slit lamp after being fitted snuggly in the box. This design allows easy and safe mobilization of the slit lamp to remote places. It was developed with the efficient use of space in mind and it can be easily reproduced in developing countries using same or similar supplies. Mobilizing slit lamp will be of great help for staff and institutes doing regular outreach clinical work.

Determination of post-operative toric IOL alignment - Analyzed by two different methods: Slit-lamp versus Adobe Photoshop

Purpose: To compare two different methods of determining the post-operative position of the toric IOL and to calculate the alignment error with each method. Setting/Venue: Cataract and Intraocular Lens Implantation Service, Shroff Eye Center, New Delhi, India. Design: Case series Materials and Methods: Eighty-nine eyes of 61 patients with cataract and co-existing corneal astigmatism ranging from 1 to 4 diopters planned for toric IOL implantation were included. All eyes underwent pre-operative automated keratometry and biometry. Toric IOL cylindrical power, axis of implantation, and anticipated residual astigmatism were calculated using the web-based Acrysof Toric calculator. All eyes underwent pre-operative reference marking to denote the 0° and the 180° positions (using bubble marker) followed by digital slit-lamp photography. All eyes were operated by the same surgeon, at the same incision location. At 3 months, the achieved IOL alignment was analyzed by aligning the slit-beam of the slit-lamp with the pair of marks denoting the axis of the IOL after pupillary dilation. Additionally, the IOL position was determined after capturing a digital retro-illuminated slit-lamp photograph, which was superimposed on the pre-operative photograph using single prominent major episcleral vessel around the limbus as landmark. The axis of orientation of the toric IOL was determined using tools in Adobe Photoshop (version 7.0) by aligning a line through the marks denoting the IOL axis. The amount of alignment error (in degrees) by both methods induced with respect to the desired axis of alignment was calculated and statistically analyzed. Results: The mean pre-operative keratometry was 44.19 ± 1.51 D, and the mean corneal cylinder was 2.54 ± 0.90 D. The mean post-operative absolute cylinder was 0.57 ± 0.28 D. Toric IOL models used were T3(1.03 D): 28 eyes (31.5%), T4(1.55 D): 21 eyes (23.6%), T5(2.06 D): 18 eyes (20.2%), T6(2.57 D): 11 eyes (12.4%), T7(3.08 D): 4 eyes (4.5%), T8(3.60 D): 4 eyes (4.5%), and T9(4.11 D): 3 eyes (3.4%). Mean post-operative alignment error was 3.44 ± 2.60 D by the slit-lamp method and 3.89 ± 2.86 D by the Photoshop method with no significant difference seen between the two methods (P = 0.384). Fifty-six eyes (62.9%) by the slit-lamp method and 52 eyes (58.4%) by the Photoshop method had rotation error ≤ 5 degrees (P = 0.526), and 78 eyes (87.6%) by the slit-lamp method and 75 eyes (84.3%) by the Photoshop method had rotation error ≤ 10 degrees (P = 0.422). Conclusions: Both Adobe Photoshop method and slit-lamp observation were reliable and predictable methods of assessing IOL alignment. Although the sensitivity is more with the Photoshop method, the slit-lamp method is more accessible in an outpatient setup. The clinical outcome following toric IOL implantation can be refined by reducing the alignment error, which is dependent on an accurate keratometry and biometry, surgeon-specific SIA, reference and intra-operative marking, and finally, placement of IOL in the bag.