Manotosh Ray

DEEP LAMELLAR KERATOPLASTY VERSUS PENETRATING KERATOPLASTY FOR CORNEAL LESIONS

PURPOSE To compare the effectiveness of deep lamellar keratoplasty (DLK) with that of penetrating keratoplasty (PKP) in cases of corneal lesions not involving the endothelium. METHODS Forty-eight eyes with leukomatous corneal opacity (n = 33), keratoconus with apical scarring (n = 6), granular corneal dystrophy (n = 5), lattice corneal dystrophy (n = 2), and multiple corneal foreign bodies (n = 2) in an age group varying from 16 to 53 years underwent DLK (n = 24) and PKP (n = 24) by utilizing B and (B+ and A) grade M-K preserved donor tissue, respectively. The patients were followed up closely, and the graft clarity, visual achievement, astigmatism and endothelial cell count were evaluated at repeated occasions up to 1 year. RESULTS Astigmatism of <3 diopters (D) and > or = 5D was obtained in 19 eyes and one eye, respectively, after DLK at 6 months, whereas six eyes of the PKP group had astigmatism <3D, and 12 eyes had > or = 5D at the end of 6 months. The same at 1 year was observed in 20 and one eye in the DLK and eight and five eyes of the PKP group. Astigmatism of > or = 5D at the end of 6 months in both the groups showed highly significant changes (p < 0.001). Best corrected visual acuity of 6/18 or more was achieved in 18 and 12 eyes at 6 months after DLK and PKP, respectively, which were statistically highly significant (p < 0.001), whereas at 1 year, it was seen in 17 and 15 eyes of the DLK and PKP groups, respectively, which was nonsignificant. The mean endothelial cell count was 2,233.3+/-64.453 cells/mm2 and 2,219.6+/-102.48 cells/mm2 at 6 months and I year, respectively, after DLK, which was nonsignificant. The mean cell count of the donor eyes used for PKP was 2,191+/-52.164 cells/mm2, 1,902.8+/-70.346 cells/mm2 at 6 months, and 1,579.0+/-80.24 cells/mm2 at 1 year. All the values showed highly significant changes (p < 0.001). Further, the graft clarity of > or = 3+ was achieved in 20 and 18 eyes at 6 months postoperatively in the DLK and PKP groups, whereas the same was observed in 19 and 13 eyes of both the groups, respectively, at 1-year follow-up. CONCLUSION DLK is a promising procedure and should be practiced more frequently for corneal pathology not involving the endothelium.

Microbial keratitis after laser in situ keratomileusis.

PURPOSE AND METHOD To review the literature on microbial keratitis reported after laser in situ keratomileusis (LASIK). RESULTS Forty-one eyes have been reported to have microbial keratitis after LASIK. The causative organisms vary from gram positive bacteria to atypical mycobacteria, fungal, and viral pathogens. The infection is usually acquired intraoperatively, but may also be caused by postoperative contamination. A majority of the patients present within 72 hours of the surgery with an acute onset of symptoms. Management of microbial keratitis after LASIK includes aggressive topical fortified antibiotic therapy, irrigation of stromal bed with antibiotic solution after lifting the flap, and sending the scraping of the infiltrate for microbiological evaluation. The keratitis heals with scarring and a best spectacle-corrected visual acuity of 20/40 or better can be obtained in the majority of the patients. CONCLUSION Microbial keratitis is a sight-threatening complication of LASIK.

Risk factors for pediatric presumed microbial keratitis: a case-control study.

PURPOSE To evaluate risk factors for pediatric presumed microbial keratitis and to describe the clinical picture, microbiologic spectrum, treatment modalities, posttreatment sequelae, and visual outcome in cases of pediatric presumed microbial keratitis. METHODS A case-control study design was used to identify the risk factors associated with pediatric presumed microbial keratitis. Fifty cases of fresh corneal ulceration aged 12 years or younger were compared with 50 controls. The study variables included were age, gender, immunization status, nutritional status (weight for height), and socioeconomic status. The clinical presentation of the cases with corneal ulceration, microbiologic spectrum, and treatment modalities also were evaluated. All the cases were followed up for a minimum of 3 months, and the posttreatment sequelae and visual outcome were analyzed. RESULTS The mean (+/- standard deviation) age of children with corneal ulceration and controls was 4.8 (+/-3.8) years and 5.1 (+/-2.8) years, respectively. Incomplete immunization status (AOR [95% confidence interval (CI)], 1.34 [0.62-2.9]) and poor nutritional status [AOR (95% CI) 1.06 (0.68-1.6)] were not found to be the predictors of corneal ulceration. Lower socioeconomic status was significantly associated with the occurrence of corneal ulceration [AOR (95% CI) 1.52 (1.1-2.3)]. Corneal trauma (38%) and systemic illness (24%) were the most often associated predisposing factors. Seventy percent of the cases were culture positive. Staphylococcus (70%) species was the most frequently isolated, followed by Pseudomonas aeruginosa (10%). Fungi were isolated in five eyes. Postresolution visual acuity at 3 months could be recorded only in 31 eyes and a visual acuity of 6/18 or better was achieved in 22% of these cases. CONCLUSION Corneal ulceration in pediatric age group in India is associated with poverty.

Results of laser in situ keratomileusis for myopia of -10 to -19 diopters with a technolas 217 laser

PURPOSE To evaluate the effectiveness, predictability, and safety of laser in situ keratomileusis (LASIK) for correcting myopia greater than -10.00 D. METHODS Sixty-five eyes of 37 patients with myopia greater than -10.00 D underwent LASIK. Patients were evaluated on day 1, 1 week, 1, 3, and 6 months after surgery. Parameters evaluated were uncorrected visual acuity (UCVA) and best spectacle-corrected visual acuity (BSCVA), residual refractive error, regression of correction, and presence of any complication. RESULTS Mean preoperative BSCVA was 0.745 +/- 0.234, which improved to 0.8070 +/- 0.237 postoperatively. The average preoperative UCVA was 0.022 +/- 0.02; postoperative UCVA at 6 months was 0.536 +/- 0.255. UCVA of 20/40 or better was achieved in 58% (38 eyes) and 20/20 or better in 26% (17 eyes). The average refractive error before LASIK was -12.64 +/- 2.16 D (range -10.00 to -19.00 D). Mean residual refractive error 1 week following LASIK was -0.63 +/- 1.36 D, which regressed to a mean -1.78 +/- 2.08 D at the end of 6 months. Nineteen eyes (29%) were within +/-0.50 D of intended refractive correction. CONCLUSION LASIK was partially effective in the correction of high myopia. An initial overcorrection may be programmed to offset the effect of refractive regression.

A study of the indications and changing trends of evisceration in north India

Aim: To study the demographic pattern and indications for evisceration in north India and to evaluate the changing trends over the last decade.

Intralamellar autopatch with lamellar keratoplasty for paracentral corneal perforations

Purpose. To report a new technique of tectonic intralamellar autopatch with lamellar keratoplasty (LK) for paracentral corneal perforations. Methods. A partial thickness lamellar dissection of the host was undertaken to remove the superficial epithelium and the anterior stroma. A second lamellar dissection began at the periphery to approximately 1 mm away from the perforation to fashion a hinge. The hinged autolamellar flap was reflected over the perforation and sutured to the host with interrupted sutures. Finally, the autolamellar patch graft was supported by a lamellar graft, which was secured in place with 16 interrupted sutures. This technique was undertaken in 4 eyes with paracentral perforation after trauma (2 eyes), after pterygium (1 eye), and inadvertent perforation during host bed dissection of large LK (1 eye). Results. All eyes achieved a stable ocular surface and a postoperative visual acuity of more than 6/60. Conclusions. Intralamellar autopatch with lamellar keratoplasty provides adequate tectonic support in cases of paracentral corneal perforation and thereby maintaining the integrity of the globe. It also provides ambulatory visual acuity.

Oversized corneal grafts for corneal opacities with iridocorneal adhesions

OBJECTIVE To evaluate the efficacy of 1-mm oversized corneal grafts in patients with acquired corneal opacities and extensive peripheral iridocorneal adhesions. DESIGN Prospective noncomparative case series. PARTICIPANTS Twenty patients (20 eyes) aged 15 years or older with unilateral or bilateral corneal opacification and a shallow anterior chamber. INTERVENTION Penetrating keratoplasty was performed with donor corneal buttons oversized by 1 mm. MAIN OUTCOME MEASURES The various parameters evaluated were visual acuity, graft clarity, keratometry, anterior chamber depth, intraocular pressure, and spherical equivalent refraction 12 months after surgery. RESULTS The keratoplasties were performed in 15 eyes with a corneo-iridic scar after infectious keratitis (75%) and 5 eyes with failed graft (25%). At the final follow-up, a clear graft was achieved in 17 eyes (85%), and 14 eyes (70%) achieved a best-corrected visual acuity of 6/12 or better. Three of the grafts failed because of rejection. The average keratometry was 44.1 +/- 1.0 diopters (D), and the mean spherical equivalent was -3.23 +/- 2.86 D. The oversized grafts provided a mean anterior chamber depth of 2.36 +/- 0.42 mm, and the mean intraocular pressure at the 12 month follow-up was 16.38 +/- 2.09 mmHg. CONCLUSIONS Corneal grafts oversized by 1 mm provide adequate anterior chamber depth and reduce the risk of peripheral anterior synechiae and secondary glaucoma in patients with corneal opacities and extensive peripheral iridocorneal adhesions.

Intraoperative arcuate transverse keratotomy with phacoemulsification.

PURPOSE To evaluate the efficacy of paired intraoperative arcuate transverse keratotomy at a 7-mm-diameter zone along with a 3.5-mm clear corneal phaco tunnel in the steeper axis to correct pre-existing astigmatism. METHODS A prospective randomized case-control study was conducted on 34 eyes of 28 patients with immature senile cataract. They were divided into two groups; in one group (17 eyes) intraoperative arcuate keratotomy was coupled with phacoemulsification in the steeper meridian (arcuate keratotomy group; mean preoperative astigmatism 2.28 +/- 0.89 D) and the other group (17 eyes) phacoemulsification was performed in the steeper meridian without arcuate keratotomy (control group; mean preoperative astigmatism 2.04 +/- 0.50 D). The patients were examined at 1 day, and 1, 4, and 8 weeks postoperatively. Correction of keratometric astigmatism, surgically induced refractive changes, magnitude and axis of cylinder, spherical equivalent refraction, with and against the wound change, and coupling ratio were evaluated. RESULTS Mean reduction in keratometric astigmatism in the keratotomy group was 1.26 +/- 0.54 D (P = .0067) and in the control group was 0.48 +/- 0.60 D (P = .0423). The difference in reduction of keratometric astigmatism between the two groups was statistically significant (P = .0296). Surgically induced refractive change at 8 weeks follow-up was 2.15 +/- 1.13 D in the keratotomy group and 1.50 +/- 1.32 D in the control group (P = .046). Coupling ratio was -1.10 +/- 0.43 in the keratotomy group at 8 weeks after surgery while the control group was -0.82 +/- 0.38. CONCLUSION A combination of intraoperative arcuate keratotomy with steep axis phacoemulsification incision is more effective than steep axis phacoemulsification incision alone in reducing pre-existing astigmatism.

Subconjunctival Dislocation of an Anterior Chamber Intraocular Lens

Post-traumatic dislocation of an intraocular lens (IOL) is a serious complication, especially after a blunt trauma because the posterior chamber lenses can potentially dislocate subconjunctively. We report a case of subconjunctival dislocation of a Kelman multiflex AC IOL. Such cases require immediate wound repair with IOL explantation to prevent endophthalmitis.