Jeewan S. Titiyal

Ocular parameters in the subgroups of angle closure glaucoma.

Purpose: This study was conducted to compare anatomical parameters, thought to be responsible for causing angle closure glaucoma (ACG), among eyes having acute, subacute or chronic ACG.

Pseudomonas keratitis after collagen crosslinking for keratoconus: case report and review of literature.

A 19-year-old woman presented with a 3-day history of pain, redness, and diminution of vision occurring one day after collagen crosslinking (CXL) with riboflavin and ultraviolet-A had been performed for keratoconus in the right eye. On presentation, severe keratitis with a 7.0mm x 6.0mm central infiltrate was present. Culture results from the patients contact lens and corneal scrapings were positive for Pseudomonas aeruginosa. Keratitis can occur following CXL because of the presence of an epithelial defect, use of a soft bandage contact lens, and topical corticosteroids in the immediate postoperative period, and patients should be counseled about it.

Causes and temporal trends of blindness and severe visual impairment in children in schools for the blind in North India

Aims: To describe the causes of severe visual impairment and blindness (SVI/BL) in children in schools for the blind in north India, and explore temporal trends in the major causes. Methods: A total of 703 children were examined in 13 blind schools in Delhi. A modified WHO/PBL eye examination record for children with blindness and low vision which included sections on visual acuity, additional non-ocular disabilities, onset of visual loss, the most affected anatomical part of the eye concerning visual impairment, and the aetiological category of the child’s disorder based on the timing of insult leading to visual loss was administered in all children. Results: With best correction, 22 (3.1%) were severely visually impaired (visual acuity in the better eye of <6/60) and 628 (89.3%) children were blind (visual acuity in the better eye of <3/60). Anatomical sites of SVI/BL were whole globe in 27.4% children, cornea 21.7%, retina 15.1%, and lens 10.9%. The underlying cause of visual loss was undetermined in 56.5% children (mainly abnormality since birth 42.3% and cataract 8.3%), childhood disorders were responsible in 28.0% (mainly vitamin A deficiency/measles 20.5%), and hereditary factors were identified in 13.4%. Study of temporal trends of SVI/BL by comparing causes in children in three different age groups—5–8 years, 9–12 years, and 13–16 years—suggests that retinal disorders have become more important while childhood onset disorders (particularly vitamin A deficiency) have declined. Conclusions: Almost half of the children suffered from potentially preventable and/or treatable conditions, with vitamin A deficiency/measles and cataract the leading causes. Retinal disorders seem to be increasing in importance while childhood disorders have declined over a period of 10 years.

Evaluation of Intrastromal Injection of Voriconazole as a Therapeutic Adjunctive for the Management of Deep Recalcitrant Fungal Keratitis

PURPOSE To evaluate the role of intrastromal injection of voriconazole in the management of deep recalcitrant fungal keratitis. DESIGN Interventional case series. METHODS SETTING Cornea services at a tertiary care teaching hospital. PATIENTS Three eyes of three patients with deep stromal recalcitrant fungal keratitis not responding to topical antifungal medications. Intervention Procedure: Voriconazole 50 micrograms/0.1 ml was injected circumferentially around the fungal abscess in the corneal stroma as an adjunctive to the topical antifungal therapy. MAIN OUTCOME MEASURE Main outcome measure was a reduction in size of the abscess and resolution of the infection. RESULTS Before the intracorneal injection, all three eyes had gradually worsening lesions on topical medications. After the intervention, a faster reduction in the size of corneal infiltration was documented and a complete resolution of the ulcers was seen within three weeks in all cases. CONCLUSION Targeted delivery of voriconazole by intracorneal injection may be a safe and effective way to treat cases of deep-seated recalcitrant fungal keratitis responding poorly to conventional treatment modalities.

Tectonic grafts for corneal thinning and perforations.

Purpose. To evaluate the success of tectonic grafts in cases of corneal thinning and perforations. Methods. We performed 42 tectonic grafts in 41 eyes of 40 patients. Three types of tectonic grafts were used in our treatment protocol. These were (a) full-thickness grafts, (b) mushroom grafts, and (c) lamellar grafts. The parameters evaluated were indications, visual acuity, location, size and type of graft, postoperative outcome, and complications, if any. Results. The most common indication for tectonic grafts was corneal thinning and perforation subsequent to infection (12 eyes) followed by those due to immunologic causes (six eyes) and trauma (six eyes). Twenty-four full-thickness tectonic grafts, nine mushroom grafts, and nine lamellar patch grafts were performed. Anatomical success was achieved in 35 of 41 (85.4%) eyes. Visual acuity of 6/24 or better was obtained in 29 of 41 (70.73%) eyes. The mean of best-corrected visual acuity (expressed in decimal) improved from 0.2 ± 0.26 to 0.34 ± 0.26 at an average follow-up of 10.83 ± 6.27 months. The major complications were peripheral anterior synechiae in four eyes (9.76%) and graft melting in five eyes (12.2%). Conclusions. Tectonic graft is a useful therapeutic option in selected cases of corneal thinning and perforations because it effectively restores the integrity of the eye and allows acceptable visual rehabilitation.

Evaluation of Umbilical Cord Serum Therapy in Acute Ocular Chemical Burns

PURPOSE To evaluate the role of umbilical cord serum therapy in cases of acute ocular chemical burns. METHODS In a double-blind prospective randomized controlled clinical study, 33 eyes of 32 patients with acute ocular chemical burns of grade III, IV, and V severity were randomized into three groups: umbilical cord serum (n = 12), autologous serum (n = 11), and artificial tears (0.5% HPMC+0.3% glycerin; n = 10). In addition, all eyes received standard medical therapy. The parameters evaluated were pain score, size, and area of epithelial defect, extent of limbal ischemia, corneal clarity, and symblepharon formation. The patients were followed up at day 1, 3, 7, 14, and 21 and at the end of months 1, 2, and 3. RESULTS Mean time to complete epithelialization was 21.16 ± 26.81, 56.6 ± 35.5, and 40.13 ± 35.79 days in cord serum, autologous serum, and artificial tears groups respectively (P = 0.02). By day 21, the mean percentage decrease in epithelial defect diameter was 94.63 ± 11.99 with cord serum compared with 53.17 ± 34.81 and 64.22 ± 42.43 with autologous serum and artificial tears, respectively (P = 0.01). By month 3, the extent of limbal ischemia with cord serum showed a mean percentage decrease of 73.43 ± 25.51 compared with 35.64 ± 25.60 and 43.71 ± 28.71 with autologous serum and artificial tears, respectively (P = 0.008). More patients had clear corneas with cord serum compared with autologous serum and artificial tears (P = 0.048). No significant difference was seen between the groups with regard to symblepharon formation (P = 0.07). CONCLUSIONS Umbilical cord serum therapy is more effective than autologous serum eye drops or artificial tears in ocular surface restoration after acute chemical injuries. (www.controlled-trials.com number, ISRCTN08131903.).

Comparative Evaluation of Topical versus Intrastromal Voriconazole as an Adjunct to Natamycin in Recalcitrant Fungal Keratitis

OBJECTIVE To compare the efficacy of topical voriconazole and topical natamycin with that of intrastromal voriconazole and topical natamycin in patients with recalcitrant fungal keratitis. DESIGN Randomized clinical trial. PARTICIPANTS Forty eyes of 40 patients with fungal keratitis (positive smear or culture results or both) larger than 2 mm, involving up to two thirds of the stromal depth, and not responding to topical natamycin therapy for 2 weeks were recruited. INTERVENTION The patients were randomized to receive either topical 1% voriconazole therapy (n = 20) or intrastromal injections of voriconazole 50 μg/0.1 ml (n = 20). The patients in both groups continued topical natamycin 5% every 4 hours until the ulcer healed. MAIN OUTCOME MEASURES Primary outcome measure was best spectacle-corrected visual acuity (BSCVA) 3 months after intervention, and secondary outcome measures were time to healing and the size of the scar. RESULTS The patients in both groups had comparable baseline parameters. The mean BSCVA after treatment was 1.295 ± 0.5 logarithm of the minimum angle of resolution (logMAR) units in the topical group and 1.692 ± 0.29 logMAR units in the intrastromal group. The visual acuity after treatment was significantly better in the topical voriconazole group (P = 0.008). Nineteen patients receiving topical voriconazole and 16 patients who were given intrastromal voriconazole healed with therapy. CONCLUSIONS Topical voriconazole seems to be a useful adjunct to natamycin in fungal keratitis not responding to topical natamycin. Intrastromal injections did not offer any beneficial effect over topical therapy.

Ultrasound Biomicroscopy-Guided Assessment of Acute Corneal Hydrops

OBJECTIVE To analyze the morphologic features of acute hydrops and treatment success using ultrasound biomicroscopy (UBM). DESIGN Prospective interventional case series. PARTICIPANTS Fourteen patients (14 eyes) affected by keratoconus with acute corneal hydrops. INTERVENTION Patients with acute hydrops were treated with intracameral injection of 0.15 ml of 14% perfluoropropane (C₃F₈) gas. MAIN OUTCOME MEASURES The parameters evaluated on UBM included the location and length of the Descemets membrane (DM) tear and corneal thickness at the central corneal thickness at the area overlying the DM tear (CT₀), corneal thickness 2.5 mm from the central point (CT₂.₅), and peripheral corneal thickness 2.0 mm from the scleral spur toward the corneal side (CT(P)). The ratio of CT₂.₅ to CT₀ was calculated to obtain the hydrops resolving index (HyRI). RESULTS The DM tear was visualized with UBM in all cases and slit-lamp microscopy in 9 of 14 eyes. The mean length of DM tears at presentation was 1.74 ± 0.77 μm. Patients with zone 3 corneal edema had a longer DM tear compared with patients with zone 2 corneal edema (1.27 ± 0.55 vs 2.02 ± 0.79 μm, respectively, P = 0.09). Significant positive correlations were seen between DM tear length and CT₂.₅ and CT(p) (r = 0.790, P = 0.020 and r = 0.766, P = 0.027, respectively). An intracameral gas bubble was seen abutting the edges of the tear in all cases. At the 6-week follow-up, the apposition of the DM and the overlying stroma occurred in all eyes, and resolution of epithelial edema and intrastromal cysts were seen in 11 of 13 cases (84.6%) and 12 of 13 cases (92.3%). The mean values of CT₀, CT₂.₅, and CT(p) at presentation were 2359.69 ± 582.26 μm, 1911.15 ± 502.60 μm, and 1156.46 ± 275.77 μm, respectively, which decreased to 398.15 ± 31.65 μm (P = 0.0), 453.46 ± 68.45 μm (P = 0.0), and 638.00 ± 62.17 μm (P = 0.0), respectively. The mean HyRI showed a significant increase from 0.80 ± 0.05 at the time of presentation to 1.13 ± 0.12 (P = 0.03) at 3 months follow-up. CONCLUSIONS Ultrasound biomicroscopy is a useful tool for quantitative and qualitative study of the morphologic features of acute hydrops. FINANCIAL DISCLOSURE(S) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Randomized clinical study for comparative evaluation of fourth-generation fluoroquinolones with the combination of fortified antibiotics in the treatment of bacterial corneal ulcers.

Purpose: Comparative evaluation of efficacy of monotherapy with moxifloxacin (0.5%) or gatifloxacin (0.3%) with combination therapy of cefazolin (5%) and tobramycin (1.3%) in treatment of bacterial corneal ulcers. Methods: Patients diagnosed with bacterial keratitis (ulcer diameter 2-8 mm) were randomized to 1 of the 3 treatment groups (tobramycin 1.3% and cefazolin 5%, gatifloxacin 0.3%, or moxifloxacin 0.5%). After obtaining corneal scrapings, assigned study medication was instilled hourly for 48 hours and tapered as per clinical response. Healing of ulcer, duration to cure, adverse reactions, antibiogram profile, treatment failures, final visual acuity, and corneal opacity size were evaluated. Results: A total of 61 patients were enrolled [cefazolin and tobramycin (n = 20), gatifloxacin (n = 21), and moxifloxacin (n = 20)]. Overall, 57 patients (93%) healed on treatment. On comparison of the mean time taken to heal, no statistically significant difference was found among all the 3 treatment groups (P = 0.98). Positive bacterial culture was obtained in only 38 patients (62%). There was no significant difference in the bacterial isolates in each treatment group. There were 4 (7%) treatment failures (perforation or nonhealing ulcer): 1 (5%) each in moxifloxacin and gatifloxacin group and 2 (10%) in fortified antibiotics group. All regimens were well tolerated. Conclusion: The study failed to find a difference in the efficacy of monotherapy with fourth-generation fluoroquinolones in the treatment of bacterial corneal ulcers of 2-8 mm size when compared with combination therapy of fortified antibiotics.

Amniotic membrane transplantation as an adjunct to medical therapy in acute ocular burns

Aims To evaluate the role of amniotic membrane transplantation in patients with acute ocular burns. Methods In a prospective, randomised, controlled clinical trial, 100 patients with grade II to IV acute ocular burns (Roper Hall Classification) were recruited. 50 patients with grade II–III burns were graded as moderate burns, and 50 patients with grade IV burns were graded as severe burns. Both groups were individually randomised into control group (n=25) and study group (n=25). The corresponding grade of ocular surface burn by Dua classification was noted. The eyes in the study group underwent amniotic membrane transplantation in addition to conventional medical therapy. In the control group, conventional medical therapy along with mechanical release of early adhesions as and when necessary was instituted. Rate of healing of corneal epithelial defect, visual acuity, extent of corneal vascularisation, corneal clarity and formation of symblepharon were compared in both groups. Results In patients with moderate ocular burns treated with amniotic membrane transplantation, the rate of epithelial healing was significantly better than the group treated with standard medical therapy alone (p=0.0004). There was no overall difference in the final visual outcome, symblepharon formation, corneal clarity and vascularisation with or without amniotic membrane transplantation. Conclusions Amniotic membrane transplantation in eyes with acute ocular burns promotes faster healing of epithelial defect in patients with moderate grade burns. There seems to be no definite long-term advantage of amniotic membrane transplantation over medical therapy and mechanical release of adhesions in terms of final visual outcome, appearance of symblepharon and corneal vascularisation when compared in a controlled clinical setting.