Jawahar Lal Goyal

Results of Corneal Collagen Cross-linking in Pediatric Patients

PURPOSE To evaluate the safety and efficacy of corneal collagen cross-linking (CXL) in the treatment of keratoconus in pediatric patients. METHODS Epithelium-off CXL using the standard protocol was performed in 15 eyes from 15 patients (age range: 10 to 15 years) with moderate keratoconus in 1 eye and advanced disease in the fellow eye. Principal outcomes included uncorrected and corrected distance visual acuity (CDVA), refraction, and topography-derived outcomes of maximum and average keratometry (K). RESULTS Mean uncorrected distance visual acuity improved significantly from 1.00 ± 0.30 (20/200) to 0.72 ± 0.29 (20/100) logMAR (P=.035) and mean CDVA from 0.56 ± 0.21 (20/70) to 0.30 ± 0.15 (20/40) logMAR (P=.003) at the end of 12 months. Mean change in apical K (1.01 ± 2.40 diopters) was also significant (P=.004). No significant complications were noted. CONCLUSIONS Corneal collagen CXL was found to be safe and effective in the first 12 months for keratoconus in children with similar initial efficacy as in adults in terms of improvement in visual and topographic outcomes.

Bilateral orbital tumor formation and isolated facial palsy in Waldenstrom’s macroglobulinemia

A 32-year-old lady presented with bilateral painful proptosis and left infranuclear facial palsy. She was mildly anemic. Ocular examination revealed a firm non-tender mass in the super lateral quadrant of both orbits. Fine-needle aspiration cytology from the orbital mass showed the presence of lymphoplasmacytoid cells. Bone marrow aspiration also showed the presence of similar cells. An IgM monoclonal gammopathy was seen on serum protein electrophoresis. A diagnosis of Waldenstrom’s macroglobulinemia was made on the basis of these findings. Hyperviscosity retinopathy is the most commonly reported ocular abnormality in Waldenstrom’s macroglobulinemia. Orbital tumor formation and cranial nerve palsies are rarely reported in this condition. We describe the first case of Waldenstrom’s macroglobulinemia presenting as an isolated orbital mass and facial nerve palsy.

Comparative evaluation of higher-order aberrations and corneal asphericity between wavefront-guided and aspheric LASIK for myopia.

PURPOSE To compare visual outcome, higher-order aberrations, and corneal asphericity (Q value) between wavefront-guided and aspheric LASIK for myopia and myopic astigmatism. METHODS Forty patients were randomly selected to receive wavefront-guided LASIK (wavefront-guided group) or aspheric LASIK (aspheric group) (40 eyes of 20 patients in each group) using the Technolas 217z excimer laser platform (Bausch & Lomb, Rochester, NY). Flaps were created using the Zyoptix XP microkeratome (Bausch & Lomb). Preoperative and postoperative evaluation included uncorrected distance visual acuity (UDVA), corneal topography, wavefront aberrometry, and contrast sensitivity. Minimum follow-up period was 6 months. RESULTS At 6 months postoperatively, the aspheric group had significantly better UDVA (logMAR 0.04 ± 0.04 [Snellen 20/16] [range: -0.079 to 0.000]) and lower mean residual spherical error (+0.10 ± 0.52 diopters [D] [range: -1.12 to 1.25 D]) than the wavefront-guided group (logMAR UDVA 0.00 ± 0.07 [range: -0.079 to 0.176]; MRSE -0.35 ± 0.47 D [range: -1.5 to 0.62 D]) (P = .003 and < .001, respectively). Mean change in higher-order aberration root mean square at 6 months postoperatively (6-mm pupil) was 0.16 ± 0.17 µm after aspheric LASIK and 0.27 ± 0.28 µm after wavefront-guided LASIK (P = .02). Aspheric LASIK induced minimal change in spherical aberrations postoperatively (0.03 ± 0.12 µm, P = .09), unlike wavefront-guided LASIK (0.23 ± 0.17 µm, P < .01). Change in Q value was significantly less in the aspheric group (0.53 ± 0.31) than the wavefront-guided group (0.91 ± 0.30) (P < .01). The aspheric group had significant improvement in contrast sensitivity at all spatial frequencies (P < .01), whereas the wavefront-guided group showed a slight decrease at higher spatial frequency (18 cycles per degree). CONCLUSIONS Aspheric LASIK induced significantly less change in higher-order aberrations and maintained corneal asphericity better than wavefront-guided LASIK. The visual outcome and contrast sensitivity was better in the aspheric group at 6 months postoperatively.

Primary localised nodular amyloidosis of the eyelid and conjunctiva: a case report

Sir, Amyloidosis is characterised by the deposition of abnormal fibrillar protein in the extracellular spaces of the body causing alterations of the tissue architecture and function. It may present as systemic amyloidosis, or it may be restricted to a single site as in localised amyloidosis with a variable clinical picture. We report an unusual case of a nodular amyloid eyelid tumour involving the conjunctiva without systemic amyloid involvement or myeloma. A 65-year-female presented to the ophthalmology outpatient department with a 1-year history of progressive painless thickening of the lower left eyelid. Physical examination revealed a healthy appearing woman. The patient’s visual acuity was 20/20 in OS with normal anterior segment. The lower lid was thickened with a firm, painless, nodular tumour extending onto and involving the conjunctiva (Fig. 1). There was no evidence of healed trachoma or any other chronic inflammatory process in either eye. There was no previous history of medical or surgical treatment or drug therapy or chemical burns. CT scan showed uniform thickening of the lower eyelid with no infiltration into the orbit. With a clinical differential diagnosis of chronic tarsitis, squamous cell carcinoma, or meibomian cell carcinoma, an incisional wedge biopsy was taken. Histologically, large nodular deposits of amorphous, eosinophilic, hyaline-like material was seen filling the entire papillary and reticular dermis and focally within the walls of deep dermal blood vessels and eccrine sweat gland coils. It involved both the eyelid and conjunctiva (Fig. 2). The overlying epidermis was thinned out with loss of rete pegs. At the periphery of the deposits many mature plasma cells were found admixed with a few lymphocytes and occasional giant cell. These deposits were congophilic with an apple green birefringence on polaroscopy and showed metachromasia with methyl violet. Immunohistochemical studies showed staining for kappa immunoglobulin light chains only, indicating that the amyloid deposits were derived from a monoclonal population of plasma cells or B cells. The scattered plasma cells within the deposits did not show monoclonality by kappa (k) or lambda (l) light chain immunohistochemical staining, which excluded a focal plasmacytoma. A work-up was negative for systemic amyloidosis including complete blood count, comprehensive metabolic panel, serum electrophoresis, sedimentation rate and liver function tests. Ultrasonography of the abdomen was unremarkable. Multiple myeloma was ruled out by the absence of Bence Jones proteins in urine, normal serum electrophoresis and unremarkable bone marrow examination. Chest radiography, echocardiogram and renal ultrasound were normal. Biopsy of buccal and rectal mucosa was negative for amyloid. Owing to the localised nature of the lesion, the patient opted for conservative management and is on continued follow-up. Cutaneous amyloid deposits may occur in systemic forms or may be localised to skin in the absence of other organ involvement. Systemic forms of amyloidosis that may exhibit cutaneous involvement include primary systemic amyloidosis, myeloma with systemic amyloidosis and certain hereditary syndromes such as familial amyloid polyneuropathy, familial Mediterranean fever and Muckle– Wells syndrome. Primary localised cutaneous amyloidosis (PLCA) includes macular amyloidosis, lichen amyloidosis and nodular amyloidosis. Amyloid deposits in nodular amyloidosis originate from immunoglobulin light chain (AL type). Both l and k light chain amino acid homologies have been found, with l chains being more common. However, our patient showed a k derivation. Fig. 1 Nodular amyloid tumour causing thickening of left lower eyelid. Inset shows involvement of conjunctiva also.

Preliminary results from the comparison of simple limbal epithelial transplantation with conjunctival limbal autologous transplantation in severe unilateral chronic ocular burns

Purpose: To compare the safety, efficacy, and clinical outcomes of simple limbal epithelial transplantation (SLET) with conjunctival-limbal autologous transplantation (CLAU) in severe unilateral ocular chemical burns. Materials and Methods: Twenty patients of unilateral chronic ocular burns with more than 270° limbal stem cell deficiency and a healthy fellow eye were divided into two groups – ten patients of Group A underwent SLET while ten patients of Group B were operated for CLAU. Patients were followed up for 6 months and assessed for a stable epithelialized ocular surface, extent of reduction in vascularization and forniceal reconstruction, improvement in corneal clarity and visual acuity. Results: A stable epithelialized corneal surface was obtained in all patients, with a significant reduction in the mean clock hours of vascularization in both the groups (P < 0.001). The mean symblepharon score showed a statistically significant reduction from 1.80 ± 1.14 to 0.30 ± 0.63 in Group A and 1.70 ± 1.06 to 0.15 ± 0.24 in Group B at 6 months. Corneal clarity, as well as best-corrected visual acuity, showed a statistically significant improvement in both the groups. Conclusion: Both the procedures, SLET and CLAU, were equally effective in achieving a stable ocular surface, forniceal reconstruction, and regression of corneal vascularization. The requirement of minimal donor tissue in SLET makes it a preferred option over CLAU in cases of uniocular chronic ocular burns.

Congenital accessory palpebral aperture – An addition to the spectrum of Delleman syndrome

Delleman syndrome (oculocerebrocutaneous syndrome, MIM 164180) is characterized by orbital cysts, microphthalmia/anophthalmia, focal skin defects, skin appendages and multiple cerebral malformations. We herein describe a case of an 8-month-old male child with features suggestive of Delleman syndrome along with a rare congenital lid anomaly – an accessory palpebral aperture, not reported so far to the best of our knowledge.

Pigment dispersion syndrome associated with spontaneous subluxation of crystalline lens

Pigment dispersion syndrome (PDS) is an ocular condition characterized by a dispersion of iris pigment throughout the eye. This pigment is deposited in a characteristic manner on the corneal endothelium as Krukenbergs spindle, anterior surface of the iris, in the trabecular meshwork, on the lens and zonule and occasionally on the anterior hyaloid face. Even with deposition of pigment on zonular fibers, no zonular weakness, or zonular dehiscence has been reported in these cases. We report a unique case of PDS with bilateral spontaneous subluxation of crystalline lens. With characteristic findings of pigment distribution in both his eyes, the patient had concave iris configuration with heavily pigmented trabecular meshwork confirming the diagnosis of PDS. The patient had bilateral 180° temporal subluxation of crystalline lens in both his eyes. The usual cause of lens subluxation such as Marfans Syndrome and Ehlers Danlos Syndrome was ruled out. The patient underwent right eye followed by left eye intracapsular cataract extraction with ab-interno technique with postoperative best-corrected visual acuity (BCVA) of 6/9 in both eyes. Spontaneous subluxation of crystalline lens in isolated PDS is not known to occur and has been reported by means of this case. We recommend a thorough assessment of zonular status in all cases of PDS.

Diagnosis of reverse Implantable Collamer Lens (ICL) orientation on Anterior Segment Optical Coherence Tomography (ASOCT)

⇑ Corresponding author at: G-30, First Floor, Preet Vihar, Opposite Metro Pillar No. 102, New Delhi 110092, India. Tel.: +91 9654822172. e-mail address: aditi.manudhane13@rediffmail.com (A. Manudhane). Figure 1. (a) ASOCT showing low central vault with ICL almost touching the anterior lens surface. (b) Scan for peripheral vault showing anteroposterior orientation of ICL (note the concave surface of ICL facing up). Jawahar Lal Goyal; Ritu Arora; Aditi Manudhane ⇑; Gaurav Goyal

Refractive outcome of wavefront guided laser in situ keratomileusis and wavefront guided photorefractive keratectomy in high pre-existing higher order aberration

PURPOSE To compare visual outcome and higher order aberrations (HOA) between wavefront-guided LASIK (WF-LASIK) and wavefront guided PRK (WF-PRK) in patients with high preoperative HOA. METHODS Randomized prospective interventional study. Conducted at Guru Nanak Eye Centre, Maulana Azad Medical College, Delhi, India. Eighty myopic eyes of forty patients were included. INCLUSION CRITERIA age more than 21 years, best corrected visual acuity of 20/20 or better, a stable refraction, to be off soft contact lens for minimum 14 days prior to preoperative examination, preoperative RMS HOA more than 0.35 μ, preoperative central corneal thickness at least 500 μm, estimated residual stromal bed thickness of at least 275 μm in patients undergoing WF-LASIK and 350 μm in patients undergoing WF-PRK. Exclusion criteria were severe dry eye, blepharitis, corneal disease and warpage, uveitis, posterior segment abnormalities involving the macula or optic nerve and systemic diseases. Patients were randomly divided into two groups. They underwent either WF-LASIK (group A) or WF-PRK (group B) over 2 years (40 eyes each). Patients were followed up for 6 months. Main outcome measures were efficacy, safety, stability, predictability and HOA. RESULTS At 6 months mean uncorrected visual acuity (logMAR) in group A was -0.01 ± 0.04 and group B was 0.00 ± 0.07 (P = 0.23). HOA RMS (6mm pupil) in group A was 0.61 ± 0.24 μm and group B was 0.55 ± 0.25 μm. The increase was statistically significant in both the groups (P < 0.05). Both the groups showed similar efficacy, predictability and safety. CONCLUSION WF-LASIK and WF-PRK have similar efficacy, safety and predictability, though WF-PRK induces less HOA.

Evaluation of pattern ERG as a visual prognosticator in chiasmatic tumours

Tumours compressing the optic pathway may lead to irreversible loss of vision that can be detected by pattern electroretinogram owing to its relation to ganglion cell function. This study aims to assess whether pattern electroretinogram is a useful tool to predict visual outcome following decompressive surgery for sellar and parasellar tumours.