Jayanand Urkude

Intraoperative Optical Coherence Tomography–Guided Management of Cap–Lenticule Adhesion During SMILE

PURPOSE To report successful lenticule extraction using intraoperative optical coherence tomography (OCT) in a case of cap-lenticule adhesion during small incision lenticule extraction (SMILE). METHODS Case report. RESULTS A 22-year-old patient with a refractive error of -5.00 -0.50 × 120° and -5.00 -0.75 × 60° in the right and left eyes, respectively, was scheduled for SMILE. The lenticule was created using the VisuMax femtosecond laser system (Carl Zeiss Meditec, Jena, Germany). The surgeon experienced difficulty while extracting the lenticule in the right eye. The patient was immediately shifted under the surgical microscope integrated with intraoperative OCT. The lenticule was found to be adherent to the anterior stromal cap, which was seen as hyperreflective spikes in the posterior plane, in contrast to the anterior plane, which showed minimal reflectivity, suggesting an inadvertent posterior plane entry. The peripheral edge of the lenticule was lifted from the anterior stromal cap under direct visualization of intraoperative feedback images provided by intraoperative OCT. The edge of the lenticule, which was freed, was then grasped with microforceps and extracted in toto using the continuous curvilinear lenticulerrhexis technique. At the end of surgery, the intrastromal pocket was screened under intraoperative OCT for any lenticule remnants. One week after surgery, the uncorrected distance visual acuity was 20/20 with smooth, regular interface on anterior segment optical coherence tomography. CONCLUSIONS Intraoperative OCT is useful in cases of difficult lenticule extraction during SMILE because it provides real-time visualization of the lenticule and helps in discerning its relation with the anterior stromal cap and the underlying stromal bed. By using intraoperative OCT and the continuous curvilinear lenticulerrhexis technique, satisfactory anatomical and visual outcomes were obtained. [J Refract Surg. 2017;33(11):783-786.].

Rescuing the host Descemet’s membrane in full-thickness traumatic wound dehiscence in deep anterior lamellar keratoplasty: intraoperative optical coherence tomography (iOCT)-guided technique

Optimal visual recovery following full-thickness traumatic wound dehiscence in a case of operated deep anterior lamellar keratoplasty (DALK) is rarely seen. Here we report a case of 22-year-old male patient presented to our casualty department with complaint of sudden-onset diminution of vision in his right eye following blunt trauma of 1 day duration. DALK had been performed 11 months ago for advanced keratoconus in the same eye. Best-corrected visual acuity (BCVA) in the right eye was hand movement close to face with accurate projection of rays and in the left eye was 20/20. Slit-lamp examination showed the presence of inferior 180° graft dehiscence with broken sutures and shallow anterior chamber with corneal oedema. Repair of the dehiscence with descemetopexy was done under the guidance of intraoperative optical coherence tomography with the successful rescuing of the host Descemet’s membrane. BCVA at 6 months follow-up was 20/40.

Discerning the optic nerve and retinochoroidal pathology using B-scan ultrasound in cases with anterior segment opacity

Case 1: A posterior segment B-scan ultrasonography in a patient with typical iris coloboma and total cataract, showed well-defined excavated area in the inferior part just below the optic disc (red arrow) with the absence of retinochoroidal layer, suggestive of fundal coloboma (yellow arrow) (figure 1A). Involvement of macula and types of fundal coloboma can be ascertained quite fairly based on ultrasonography which might provide a clue or prediction about postoperative visual gain or visual prognosis.1 Figure 1 (A) Axial scan depicting a well-defined posterior ocular coat excavation below the optic nerve head (red arrow) is suggestive of fundal coloboma (yellow arrow). (B) Axial scan showing a well-defined excavated area over the optic nerve head (red arrow) suggests an optic disc coloboma (yellow arrow) along with thinned out inferior neuroretinal rim (purple arrow)

Surgical removal of a giant iris stromal cyst: an intraoperative optical coherence tomography-guided approach

An 11-year-old girl was brought with the chief complaint of progressive diminution of vision in her right eye for the past 3 months. There was no history of ocular trauma or any ocular surgery. Systemic and family history was insignificant. Visual acuity was 20/20 in her left eye and counting finger close to face with projection of rays being accurate in her right eye. Slit lamp examination of her right eye showed large cystic lesion filling almost entire anterior chamber. With the help of various imaging modalities like anterior segment optical coherence tomography (OCT) and ultrasound biomicroscopy diagnosis of iris stromal cyst was confirmed. Right eye surgical removal of the iris stromal cyst was done under real-time imaging of intraoperative OCT (iOCT). Best-corrected visual acuity at 6 months follow-up was 20/20 without any recurrence. iOCT-guided approach for complete removal of the iris cyst seems more promising.

Bilateral fungal keratitis with ring infiltrates: a rare scenario

A 12-year-old boy presented to the emergency department with chief complaints of pain, redness, discharge and diminution of vision in both eyes over the previous 20 days. There was no history of preceding trauma, contact lens use, any eye drop usage or ocular surgery. Systemic history was not significant. Presenting uncorrected visual acuity in his right eye was counting fingers at 1 m and 20/200 in the left eye, with accurate projection of rays in both eyes. Slit lamp biomicroscopy showed the presence of bilateral diffuse conjunctival congestion, corneal ring infiltrates and epithelial defect with corneal oedema. Potassium hydroxide wet mount showed the presence of septate fungal hyphae. The patient was treated with topical 5% natamycin and 1% voriconazole over a period of 6 weeks. Best-corrected visual acuity was 20/600 in the right eye and 20/20 in the left eye at 6-month follow-up.