Mayank S Pangtey

Anterior capsule staining for capsulorhexis in cases of white cataract: Comparative clinical study

Purpose: To compare the safety and efficacy of trypan blue 0.1%, gentian violet 0.001%, indocyanine green 0.5% (ICG), fluorescein 2%, and the patients autologous blood for anterior capsule staining in cases of white cataract. Setting: Rajendra Prasad Center for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India. Methods: Fifty eyes of 50 patients with age‐related white cataract had anterior capsule staining with trypan blue, ICG, or gentian violet under an air bubble or subcapsularly with fluorescein or autologous blood followed by phacoemulsification with foldable intraocular lens implantation. Each stain was used in 10 eyes. The ease of creating a continuous curvilinear capsulorhexis (CCC) and the complications during the surgery were noted. Postoperative examinations at 6 hours, 1 day, 1 week, and 1 month included slitlamp microscopy, uncorrected visual acuity, and best corrected visual acuity (BCVA). The staining patterns on the anterior capsule, side port, corneal tunnel, and anterior cortex were assessed intraoperatively and within 6 hours and at 1 day. The intraocular pressure (IOP) was assessed at 1 day; pachymetry, at 1 day and 1 month; and the endothelial cell count, at 1 month. Results: The surgeon had best visualization during the anterior capsulorhexis with trypan blue, ICG, and gentian violet, and a complete CCC was achieved in all eyes in the 3 groups. Two eyes each in the fluorescein and autologous blood groups had extension of the CCC so that the capsulorhexis was complete but not curvilinear. Anterior capsule fibrosis was detected with trypan blue (1 eye) and ICG (2 eyes). The anterior vitreous was stained with fluorescein in 2 eyes. All eyes achieved a BCVA of 20/30 or better from 1 week postoperatively to the last follow‐up. The side port and corneal tunnel were stained most intensely with gentian violet followed by trypan blue and ICG and less intensely with fluorescein and autologous blood. The IOP, pachymetry, and endothelial cell loss were comparable between the stains. Conclusion: Although trypan blue, ICG, gentian violet, fluorescein, and autologous blood were safely used to stain the anterior capsule for phacoemulsification in eyes with white cataract, trypan blue, ICG, and gentian violet were more effective in staining the capsule.

Combined surgery, cryotherapy, and mitomycin-C for recurrent ocular surface squamous neoplasia.

Purpose. To report the outcome of combined excision, cryotherapy, and antimetabolite treatment of recurrent ocular surface squamous neoplasia. Methods. The patients with recurrent ocular surface squamous neoplasia were treated by excision of lesion, cryotherapy of limbus, and conjunctival margin followed by 0.02% Mitomycin C application at the time of surgery. Patients have been followed up for at least 1 year. Results. A total of five eyes of five patients with recurrent ocular surface squamous neoplasia were treated by combined excision, cryotherapy, and Mitomycin C. Histopathologic diagnosis included invasive squamous cell carcinoma in four cases and squamous dysplasia in one case. No recurrences have been noted for a follow-up period of more than 1 year now. Conclusion. Combining excision with cryotherapy and Mitomycin C application at the time of surgery is a very effective therapy for recurrent ocular surface squamous neoplasia. It is relevant for cases in large, poor countries where patients present late and are less likely to come for follow-up care.

Painting technique for staining the anterior lens capsule.

&NA; We describe a technique of capsule staining called capsule painting. Using a Khokhar capsule painting cannula, the dye is spread directly over the anterior capsule but to no other part of the anterior chamber. There is minimal turbulence in the anterior chamber as there is no need to replace the injected viscoelastic material. The use of minimal dye and viscoelastic material reduces the cost of surgery.

Surgically induced astigmatism after laser in situ keratomileusis for spherical myopia.

PURPOSE To study risk factors for surgically induced astigmatism (SIA) after laser in situ keratomileusis (LASIK). METHODS In a retrospective case control study of 104 eyes (52 patients) that underwent LASIK for myopia (spherical ablation alone), two groups were studied: 42/104 eyes with SIA, and controls (62/104 eyes). The main variables studied were preoperative refraction, corneal thickness, preoperative keratometric power, amount of ablation, ablation zone diameter, flap thickness, flap size, and the presence of complications. The effect of SIA on visual performance was also evaluated. RESULTS The mean myopia for which LASIK was undertaken was -4.50 +/- 2.04 D. Mean scalar astigmatism induced was 0.35 +/- 0.50 D at 1 month, 0.33 +/- 0.40 D at 3 months, and 0.16 +/- 0.60 D at 6 months. SIA based on refractive cylinder was 0.66 +/- 0.29 D at 1 month, 0.54 +/- 0.32 D at 3 months, and 0.49 +/- 0.34 D at 6 months. Mean axis of vector induced astigmatism was 82.5 degrees +/- 57 degrees at 1 month, 98.86 degrees +/- 52.4 degrees at 3 months, and 113.9 degrees +/- 62.6 degrees at 6 months. Risk factors associated with the occurrence of SIA were preoperative keratometric power of >44 D [OR (95% CI); 1.97 (0.62 to 6.26)], ablation zone diameter of <6 mm [OR (95 % CI) 2.76; (0.6 to 12.6)], and suction ring diameter of 8.5 mm [OR (95% CI) 12.46; (2.0 to 77.38)]. The occurrence of SIA had no significant effect on uncorrected Snellen high contrast visual acuity, contrast sensitivity, and glare in comparison with controls. CONCLUSION Surgically induced astigmatism was more likely to occur with the use of smaller suction rings of 8.5 mm and in ablation zones less than 6 mm. Parameters for visual performance were not affected by the presence of surgically induced astigmatism.

Phacoemulsification in filtered chronic angle closure glaucoma eyes

Purpose: To report the results of phacoemulsification in eyes with chronic angle closure glaucoma having a functional filtering bleb.

Phacoemulsification in a case of microspherophakia

Phacoemulsification with implantation of an acrylic foldable intraocular lens in a 14-year-old girl with microspherophakia is described. The associated lenticular myopia was disabling in terms of quality of life. With the help of nylon iris hooks, the procedure was uneventful and the outcome successful

Hyeropic shift after LASIK induced Diffuse lamellar keratitis

BackgroundDiffuse lamellar keratitis (DLK) is a relatively new syndrome that is increasingly being reported after LASIK. We have observed that a hyperopic shift may be associated with the occurrence of this diffuse lamellar keratitis.Case presentationA 26 year old man developed bilateral diffuse lamellar keratitis (DLK) following myopic LASIK. The residual refractive error was +0.5D OD and +0.25D OS at the end of the first week. The sterile infiltrates resolved over a period of 4–6 weeks on topical steroid therapy. A progressive hyperopic shift was noted in the right eye with an error +4.25Dsph/+0.25Dcyl 20 at the final follow up 6 months post surgery.ConclusionDiffuse lamellar keratitis after LASIK may be associated with a significant hyperopic shift.

Iris retraction and retroflexion after transscleral contact diode laser photocoagulation

A 9-year-old girl with refractory glaucoma with an anterior chamber intraocular lens underwent transscleral contact diode laser cyclophotocoagulation. Slit-lamp examination and ultrasound biomicroscopy revealed iris retraction and retroflexion at 2 weeks of follow-up. The probable cause of this complication is discussed.

Risk Factors for and Management of Dropped Nucleus After Phacoemulsification

The article by Aasuri and coauthors is an excellent summation of causes of an unfortunate incidence during phacoemulsification. We are working at a tertiary eye-care hospital involved in a residency program that also includes teaching phacoemulsification. We would like to share our experience regarding causes of dropped nucleus and their management. We have noted an increased incidence of dropped nucleus in myopic eyes in both experienced and inexperienced hands. The reasons include compromised zonules; deceptively soft nucleus; deep anterior chamber and large corneas, leading to optical aberrations and making manipulations difficult; vitreous liquefaction leading to quick sinking of the nucleus, in the event of a posterior capsule tear, without affording a chance for urgent nucleus retrieval. We also have noted a relatively increased incidence of posterior dislocation in small and deep-set eyes due to difficulty in manipulations, pooling of irrigation fluid leading to less than optimum visualization, and shallow anterior chambers leading to increased chances of the phaco probe hitting the posterior capsule, especially true with trainee surgeons. We advise a temporal-section approach in such cases when astigmatically permissible. In extreme cases, we would not hesitate to perform elective extracapsular cataract extraction (ECCE). Constriction of the pupil during surgery, coupled with the use of iris hooks, has been another rare factor. Although iris hooks work well with a small pupil, we have had 3 cases in which use of an iris hook led to disruption of the capsulorhexis and nucleus dislocation. We surmise that the capsulorhexis was inadvertently chopped because of difficult maneuvering as a consequence of poor pupillary dilation and it extended by getting caught in the iris hooks, which were introduced at this stage. We advise trainee surgeons to use iris hooks with discretion if the capsulorhexis has been extended. We agree with the authors that experienced surgeons may have numerically more posterior dislocations as they handle more cases and more difficult cases with hard nuclei. We would like to add hypermature cataract and pseudoexfoliation syndrome to the aforementioned category as they have more chances of zonular dehiscence, extra hard nucleus, and compromised corneas, along with advanced age. We would advise judicious selection of patients, with a propensity toward quick conversion to ECCE while doing phacoemulsification in these difficult cases. SUDARSHAN KHOKHAR, MD AMBARISH SONI, MD MAYANK S. PANGTEY, MD New Delhi, India

Indications for lamellar keratoplasty in India.

Purpose. To study the indications for lamellar keratoplasty (LK) in a tertiary eye care hospital in northern India. Methods. A retrospective analysis of 71 eyes that had undergone LK between January 1995 and December 1999 was performed. The parameters evaluated included demographic data, the diagnosis at admission, the laterality of involvement, and the graft size. Results. The mean age of the patients was 31 ± 21.8 years (range, 1–73 years). Forty-one male patients and 30 female patients underwent LK. Thirty-three patients (47%) lived in rural areas, and 38 patients (53%) were urban dwellers. LK was performed for optical indications in 63 eyes (88.7%), for tectonic purposes in six eyes (8.4%), and for therapeutic purposes in two eyes (2.8%). Chemical injuries (18%) were the most common indication for LK and were followed by trachomatous keratopathy (14%) and dermoids (14%). Conclusion. Chemical injuries, trachomatous keratopathy, and dermoids constitute the major indications for LK in India.