Jitender Jinagal

Outcome of various Hydrophobic Acrylic Intraocular Lens Implantations in Children with Congenital Cataract

Purpose To evaluate performance of different intraocular lenses (IOLs) after cataract surgery in children aged less than 2 years with regards to rates of visual axis opacification (VAO). Methods This was a retrospective chart review of children <2 years of age undergoing cataract surgery with primary posterior capsulotomy, anterior vitrectomy, and IOL over a period of 5 years with minimum follow-up of 1 year at a tertiary care institute. Children with microphthalmos, persistent fetal vasculature, traumatic cataract, aphakia, secondary IOLs, or any other coexisting ocular disease were excluded. Results A total of 257 eyes of 159 children were included in the study. The mean age at the time of surgery was 11.63 ± 7.916 months (range 6-23 months). A total of 29 eyes of 16 children underwent phacoaspiration with implantation of SA60 AT (AcrySof, Alcon, Fort Worth, TX); 75 eyes of 45 children received Hoya IOL (Hoya-PS AF-1 Series, Model PC-60AD, Hoya, Japan), 70 eyes of 46 patients received Sensar (Abbott Medical Optics Inc., Santa Ana, CA, USA), and 83 eyes of 52 children received MA60AC (AcrySof). At mean follow-up of 18.31 ± 15.04 months, 22.46% of the patients required resurgery for visual axis obscuration. By multiple regression analysis, the rate of visual axis obscuration was affected by the rate of perioperative complications (p = 0.001) and not affected by age (p = 0.98), type of IOL (p = 0.104), or site of IOL implantation (p = 0.603). Conclusion Our findings suggest comparable rates of VAO for children less than 2 years of age receiving different types of hydrophobic acrylic IOLs.

Bitot’s Spots

Bitot’s Spots A 4-year-old boy presented to the ophthalmology clinic with poor night vision and enlarging white deposits in both eyes. A diagnosis of Bitot’s spots due to vitamin A deficiency was made.

Compound nevus simulating a conjunctival melanoma

A 50‐year‐old woman presented with a brownish‐black inferior limbal mass for many years with rapidly increasing in size and encroaching on the cornea of the right eye over the past year. The clinical examination revealed a dark brown, elevated and irregular mass adhering to the underlying sclera and cornea with four feeder vessels [Figure 1a]. The mass had a maximum basal diameter of 8.0 mm and thickness of approximately 0.6 mm. Ultrasound biomicroscopy revealed no involvement of the angles [Figure 2a]. The patient was scheduled for an excisional biopsy. Intraoperatively, alcohol‐assisted corneal epitheliectomy and excision using the “no‐touch technique” with lamellar sclerectomy were performed. The margins of the conjunctiva were treated with double freeze–thaw cryotherapy, and amniotic membrane was transplanted [Figures 1b‐d]. On histopathological analysis performed in our patient [Figures 2b and 3], the section examined under hematoxylin and eosin staining showed stratified squamous lining epithelium, which had a lesion with nests and sheets of nevus cells containing melanin. The cells were of three types: upper layer with abundant cytoplasm, lymphoid‐like and melanin containing middle layer, and spindle shaped lower layer. The nevus cells appeared to drop off from the epithelium into the Compound Nevus Simulating a Conjunctival Melanoma

Outcomes of cataract surgery in children with persistent hyperplastic primary vitreous

Purpose: To evaluate postoperative outcomes of cataract surgery in children with persistent hyperplastic primary vitreous (PHPV) and factors affecting outcomes. Methods: We analyzed 29 eyes of 28 children with PHPV presenting at a tertiary care center in northern India. All eyes underwent phacoaspiration followed by primary posterior capsulotomy with or without cauterization of persistent fetal vasculature under general anesthesia. Hydrophobic intraocular lens was implanted in selective cases. Postoperative outcomes such as clarity of visual axis, need for secondary surgical procedures, and complications were noted. Results: Out of a total of 28 children (16 male and 12 female), 27 were unilateral while 1 patient had bilateral involvement. Mean age at surgery was 25.14 months, ranging from 2 months to 144 months. Mean axial length of the globe at surgery was 19.66 ± 2.28 mm. Cataract surgery with intraocular lens implantation was done in 22 eyes whereas 7 were left aphakic. The most common intraoperative complication noted was intraoperative bleed in 11 eyes (37.9%) resulting in postoperative hyphema in 9 eyes (31%) and vitreous hemorrhage in 8 eyes (27.5%). Visual axis opacification was seen in 12 eyes and all required membranectomy. Three eyes developed glaucoma while retinal detachment was noted in 2 eyes and 1 of them became phthisical. Conclusions: Favorable outcome was more often achieved in anterior PHPV. Surgical outcomes in eyes with PHPV undergoing cataract surgery are limited by intraoperative and postoperative complications such as hyphema, vitreous hemorrhage, recurrent visual axis opacification, glaucoma, and retinal detachment.

Intraocular lens implantation in children with unilateral congenital cataract in the first 4 years of life

Purpose: To describe the outcome of phacoaspiration with intraocular lens implantation in children with unilateral congenital cataract in the first 4 years of life. Methods: A retrospective chart review of children with visually significant unilateral congenital cataract presenting in the first 4 years of life was done. Children with a minimum postsurgical follow-up of 1 year were included. Outcome measures were mean spherical equivalent, visual axis clarity, visual acuity and complications till the last follow-up. Results: Ninety-three children met the inclusion criteria. The mean age of surgery was 13.23 ± 11.89 months and the mean follow-up period was 24.37 ± 17.35 months. Nearly 40% of children presented during their first year of life. No difference was noted between the subgroups in terms of age (p = 0.310), sex (p = 0.475) or laterality (p = 0.349). Surgical membranectomy was performed in 22 eyes (23.6%) after an average period of 4.85 ± 2.58 months after surgery. One eye underwent piggy back intraocular lens and four eyes underwent intraocular lens exchange after a mean duration of 50 months (range 40–60 months). The mean visual acuity was 0.79 ± 0.11 (log MAR chart). A total of 60.7% of these children (n = 31) achieved best corrected visual acuity or 20/80 or better. Conclusion: The results of our study suggest that primary intraocular lens implantation in children with unilateral congenital cataract gives good structural and functional results. Besides a meticulous surgery, visual outcome is affected by the time of presentation and postoperative compliance to amblyopia therapy.

Visual outcomes of pediatric traumatic cataracts

Introduction: To report visual outcomes and risk factors of pediatric traumatic cataracts in a tertiary care referral center in northern India. Methods: We analyzed medical records of traumatic cataracts in the pediatric age group (1–15 years) operated for cataract surgery with or without posterior chamber intraocular lens implantation with or without primary posterior capsulotomy with anterior vitrectomy between 2004 and 2012. Causative agents, types of trauma, demographic factors, surgical interventions, complications, and visual acuity were recorded and compared among different groups. Results: A total of 147 children were documented to have undergone cataract surgery for traumatic cataract in the study period, male-to-female ratio being approximately 5:1. Mean age was 7.67 ± 3.30 years (range, 1–15 years). Type of primary insult was penetrating injury in 100 (68%) patients and blunt trauma in 47 (32%) patients. Mean interval between injury and cataract surgery in penetrating injury cases was 3.84 ± 7.05 months and in the blunt injury cases was 6.28 ± 11.13 months. Preoperatively, only 110 patients were cooperative for visual acuity. Out of them, none had vision better than 6/18 and only 21 patients (19.9%) had vision of ≥6/60. Visual acuity of 6/18 or better (was considered good visual outcome) was achieved by 87.9%, 97.3%, and 97.9% at 1, 6, and 36 months, postoperatively. Eyes which underwent primary posterior capsulotomy and anterior vitrectomy during cataract surgery showed statistically better visual outcome than those without it. Conclusion: Phacoaspiration with posterior chamber intraocular lens implantation along with primary posterior capsulotomy and anterior vitrectomy and timely introduction of amblyopia therapy helped in gaining good visual outcome in pediatric traumatic cataract patients irrespective of the age of presentation and the type of injury.

Immune keratitis: An unusual primary presentation of neuro-Behçet’s disease

A 19-year-old Nepalese male presented with complaints of bilateral ocular discomfort, photophobia, watering, and redness for 1 week. Visual acuity was 6/12 and 6/60 in the right and left eye, respectively. On biomicroscopic examination, presence of peripheral stromal infiltrates with conjunctival follicles was noted; infiltrates progressed to involve central cornea with further decrease in vision over next few days. After ruling out infectious keratitis, detailed systemic examination and laboratory investigations were diagnostic of neuro-Behçet’s disease. Patient responded to systemic steroidal and immunosuppressive therapy characterized by corneal healing and visual acuity improvement to 6/6 and 6/9. Although rare, but neuro-Behçet’s disease can primarily present as bilateral immune keratitis and every case of bilateral keratitis needs early systemic evaluation after ruling out infective etiologies.

A Rare Case of Bilateral Circumscribed Posterior Keratoconus in Microcornea Associated with Unilateral Irido-Fundal Coloboma

Purpose: To report a rare case of bilateral circumscribed posterior keratoconus in microcornea associated with unilateral irido-fundal coloboma. Method: A case of bilateral circumscribed posterior keratoconus associated with unilateral irido-fundal coloboma presented to us with complaints of diminution of vision in both eyes since birth. The patient had undergone renal transplant for end stage renal disease secondary to chronic glomerulonephritis. Anterior segment examination including anterior segment optical coherence tomography, fundus evaluation and Scheimpflug imaging was done to confirm and document the findings of bilateral posterior keratoconus and irido-fundal coloboma. Results: The diagnosis of bilateral posterior keratoconus was made by typical clinical findings and anterior segment optical coherence tomography. Thinning of posterior curvature of cornea was found on slit lamp examination and was confirmed on anterior segment optical coherence tomography (A/S OCT). Since the thinning was localised, diagnosis of bilateral circumscribed posterior keratoconus was made. Unilateral irido-fundal coloboma was documented on anterior segment and fundus photography. Conclusions: This is the first case report documenting bilateral circumscribed posterior keratoconus along with unilateral irido-fundal coloboma. Further studies are required to look for any association between these two diseases and of these diseases with other ocular as well as systemic anomalies.