Murali K. Aasuri

Penetrating keratoplasty in children.

Purpose. To determine the success of penetrating keratoplasty in the presence of various pediatric corneal abnormalities. Methods. We performed a retrospective study of pediatric corneal grafts at L.V. Prasad Eye Institute, Hyderabad, India. Outcome of pediatric corneal transplantation was evaluated in terms of anatomic and optical success and factors contributing to poor graft survival. On the basis of the corneal pathology, patients were divided into three categories: congenital, acquired nontraumatic, and acquired traumatic. Results. A retrospective analysis of 154 penetrating keratoplasties performed in 140 children, aged 14 years or younger, was done. The average follow-up was 1.3 years (range, 1 week–5 years). Grafts remained clear in 102 (66.2%) of 154 eyes. Clear grafts were achieved in 30 (63.8%) of 47 eyes with congenital opacities, 12 (54.5%) of 22 eyes with opacities from trauma, and 60 (70.6%) of 85 eyes with acquired nontraumatic opacities. Most (26 of 52) of the graft failures occurred during the first 26 weeks after surgery. Survival analysis revealed the probability of a graft remaining clear at the end of 26 weeks as 80% (SE, 3.39%). Poor graft survival could be correlated with those younger than 5 years (p = 0.0341) and performance of anterior vitrectomy (p = 0.0002). Most grafts failed because of allograft rejection (42.3%), infectious keratitis (26.9%), or secondary glaucoma (13.4%). Postoperatively, 53 eyes had ≥20/400 vision, 29 of which had ≥20/50. Vision could not be assessed in 33 eyes because of the young age. Conclusion. Whereas anatomic success of pediatric keratoplasty is increasing, optical success continues to remain less than satisfactory. Early surgical intervention and intensive amblyopia therapy may promote visual recovery.

Outcome of pterygium surgery: analysis over 14 years

AimTo report the outcome of pterygium surgery performed at a tertiary eye care centre in South India.MethodsRetrospective analysis of medical records of 920 patients (989 eyes) with primary and recurrent pterygia operated between January 1988 and December 2001. The demographic variables, surgical technique (bare sclera, primary closure, amniotic membrane transplantation (AMT), conjunctival autograft (CAG), conjunctival–limbal autograft (CLAG), or surgical adjuvants), recurrences and postoperative complications were analysed.ResultsA total of 496 (53.9%) were male and 69 (7.5%) had bilateral pterygia. Bare sclera technique was performed in 267 (27.0%) eyes, primary conjunctival closure in 32 (3.2%), AMG in 123 (12.4%), CAG in 429 (43.4%), and CLAG in 70 (7.1%). Adjuvant mitomycin C was used in 44 (4.4%) cases. The mean duration of follow-up was 8.9±17.0 and 5.9±8.8 months for unilateral primary and recurrent pterygia, respectively. The overall recurrence rate was 178 (18.0%). Following primary and recurrent unilateral pterygium excision respectively, recurrences were noted in 46 (19.4%) and 1 (33.3%) eyes after bare sclera technique, five (16.7%) and 0 after primary closure, 28 (26.7%) and 0 with AMG, 42 (12.2%) and five (31.3%) with CAG, and nine (17.3%) and two (40%) with CLAG. Recurrences were significantly more in males with primary (23.3 vs10.7%, P<0.0001) and recurrent (26.7 vs0%, P=0.034) pterygia, and in those below 40 years (25.2 vs14.8%, P=0.003).ConclusionCAG appears to be an effective modality for primary and recurrent pterygia. Males and patients below 40 years face greater risk of recurrence. Bare sclera technique has an unacceptably high recurrence. Prospective studies comparing CAG, CLAG, and AMG for primary and recurrent pterygia are needed.

Trends in contact lens–associated microbial keratitis in Southern India

OBJECTIVE To review the microbiologic profile, clinical course, treatment, and outcome in patients with contact lens-associated microbial keratitis in the setting of a tertiary eye care center in a developing country in the Tropics. DESIGN Retrospective noncomparative case series selected from an ongoing prospective series. PARTICIPANTS Twenty-eight subjects examined in the contact lens clinic of L. V. Prasad Eye Institute, Hyderabad, south India, between February 1991 and September 2000, who presented with corneal stromal infiltrate on slit-lamp examination, were included in the study. INTERVENTION All patients underwent standard diagnostic microbiologic evaluation and smear and culture-guided topical antimicrobial therapy. Penetrating keratoplasty was performed in some patients. MAIN OUTCOME MEASURES Culture results and clinical response to antimicrobial therapy. RESULTS Twenty eight (0.11%) of 23,889 contact lens-wearing patients presented with laboratory-proven infectious keratitis; this constituted 0.56% of 4967 corneal ulcer patients seen during the same period. Most (15/28) of the patients wore soft contact lenses on a daily basis. Rigid gas-permeable lenses were worn by six patients, therapeutic bandage contact lenses by four, and Silsoft lenses by four. Laboratory results showed bacterial infections in 25 patients (89.2%); Pseudomonas was the most common organism (13/25; 52%). Acanthamoeba, herpes simplex virus, and Aspergillus niger were isolated in one case each. Laboratory-based medical therapy led to the healing of ulcers in 24 (85.7%) of 28 patients, whereas 4 patients required penetrating keratoplasty. Most of the organisms were sensitive to antibiotics. CONCLUSIONS Contact lens-associated microbial keratitis is rare in southern India. Soft contact lens wear is the most common risk factor; Pseudomonas keratitis is the predominant causative agent. Fungal, viral, and Acanthamoeba keratitis are rare. The offending bacteria are usually sensitive to antibiotics, and the treatment outcome with medical therapy is good.

Risk factors for and management of dropped nucleus during phacoemulsification

Purpose: To study the risk factors and management of posteriorly dislocated crystalline lenses during phacoemulsification at a teaching institution. Setting: L.V. Prasad Eye Institute, Hyderabad, India. Methods: This retrospective analysis included all phacoemulsification procedures performed by experienced and inexperienced surgeons over 7 years. The incidence, risk factors for, role of surgical experience, mode of management, and the final outcome of posteriorly dislocated lens nuclei were evaluated. Results: Of a total 11 343 phacoemulsification procedures performed between 1993 and 1999, the nucleus was dropped in 38 eyes (0.3%). Two patients with a dropped nucleus were referred from an outside practice. The incidence of dropped nucleus with experienced surgeons (22/8671; 0.2%) was significantly less than that with inexperienced surgeons (16/2672; 0.6%) (P = .007). Sixteen of the 22 cases of dropped nucleus (72.7%) in the experienced group and 1 of 16 (6.3%) in the inexperienced group had risk factors (P = .0005). Nucleus removal was performed using vitreoretinal procedures in 39 eyes; 1 eye with a dropped epinucleus was managed conservatively. The final best corrected visual acuity was 20/40 or better in 21 eyes (53.8%). Conclusions: The incidence of dropped nucleus was more frequent with inexperienced surgeons, even though experienced surgeons had more cases with predisposing risk factors. Modern vitreoretinal procedures reduce morbidity and improve the visual outcome.

Prospective evaluation of corneal endothelial cell loss after pediatric cataract surgery

Purpose: To study the alterations in endothelial cell count and morphology after pediatric cataract surgery using currently practiced techniques. Setting: L.V. Prasad Eye Institute, Hyderabad, India. Methods: In a prospective nonrandomized series comprising 20 eyes of 14 children with congenital or developmental cataract, endothelial cell loss from cataract surgery was evaluated. Mean patient age was 9.3 years (range 5 to 15 years). Extracapsular cataract extraction (ECCE) with intraocular lens QOL) implantation was performed in 11 eyes (Group 1). Primary posterior’capsulotomy and anterior vitrectomy were performed with ECCE and IOL implantation in 9 eyes (Group 2). Noncontact specular microscopy was done: preoperatively and‐6 to 8 and 24, to, 36 weeks postoperatively. Endothelial cell loss, alteration in the, coefficient of variation, and the change in the number of hexagonal cells were determined by semiautomated analysis of endothelial pictures. Results: Mean endothelial cell loss was 198.39 cells/mm2 (5.28%) in Group 1 and 295.17 cells/mm2 (7.50%) in Group 2 at 24 to 36 weeks. There was no statistically significant difference in alteration in endothelial cell count and morphology between the 2 groups. Conclusions: The results suggest that endothelial cell loss with currently practiced techniques of pediatric cataract surgery is within acceptable limits.

Differential diagnosis of microbial keratitis and contact lens-induced peripheral ulcer.

Differentiating a contact lens-induced peripheral ulcer (CLPU) from early stage microbial keratitis (MK) is primarily based on clinical judgment rather than on microbiologic or histopathologic investigations. For this reason, tests do not provide valuable information at the early stages in the clinical course of MK. Whereas in gross terms, the clinical picture of MK is more acute and severe than CLPU, clinical features of the two can overlap, sometimes resulting in errors of judgment and mismanagement. This article provides clinical clues that help distinguish the two conditions. In addition, a scoring system has been devised for MK and CLPU.

Heparin-surface-modified intraocular lenses in pediatric cataract surgery: Prospective randomized study

PURPOSE To evaluate the performance of heparin-surface-modified (HSM) intraocular lenses (IOLs) in pediatric eyes after cataract surgery. SETTING L.V. Prasad Eye Institute, Hyderabad, India. METHODS This prospective, randomized, double-masked, controlled clinical trial comprised 90 children aged 2 to 14 years with cataract. The patients were consecutively randomized to receive an HSM (Group 1) or an unmodified (Group 2) poly(methyl methacrylate) (PMMA) IOL. Extracapsular cataract extraction (ECCE) with IOL implantation was performed in children 8 years and older and ECCE with primary posterior capsulotomy, anterior vitrectomy, and IOL implantation in children younger than 8 years. Outcome parameters were inflammatory cell deposits on the IOL surface, posterior synechias, and anterior chamber reaction. RESULTS Follow-up data were available for 73, 70, 60, and 68 patients at 1 week, 1 month, 3 months, and 6 months, respectively. Significantly fewer cell deposits were noted in Group 1 at 1, 3, and 6 months (P < .001). Synechia formation and anterior chamber reaction were comparable in the 2 groups. CONCLUSION The lower incidence of inflammatory cell deposit formation in eyes with HSM PMMA IOLs indicates that these IOLs have greater bicompatibility than unmodified IOLs in pediatric cataract surgery.

Comparison of acrylic and polymethyl methacrylate lenses in a pediatric population

PURPOSE To compare the intra-patient incidence of posterior capsular opacification (PCO) and their post operative course, in children with bilateral cataract, following implantation of acrylic (Group 1) and polymethyl methacrylate (PMMA) (Group 2) intraocular lenses (IOLs). MATERIALS AND METHODS This was a prospective, interventional intra-patient case series. Twenty-five children with bilateral cataract, 5 years and older, underwent cataract surgery and implantation of an acrylic (AcrySof MA30BA, Alcon, Fortworth, TX) in one eye and PMMA (Indo Am IAB 203, Ocular Vision, Inc.) IOL in the other eye of each patient. They were followed up for an average of 11.1 +/- 9.5 months to assess the incidence of clinically significant PCO and occurrence of postoperative complications. RESULTS Twenty-three children (46 eyes), were included in this study. Post-operatively, 22(95.6%) patients with acrylic IOLs and 20 (86.9%) patients with PMMA IOLs, either maintained or improved their vision. In the acrylic and PMMA IOL groups respectively, the incidence of clinically significant PCO was 21% (4) and 75% (12) ( P =0.002), with a median onset at 2.9 months and 0.7 months. Other complications included pupillary capture in 2 (8.7%) eyes and uveal prolapse in 1 (4.3%) eye in the acrylic group and increased uveal inflammation in 6 (26.1%) eyes and presumed noninfectious endophthalmitis in 2 (8.7%) eyes in the PMMA group. CONCLUSION Incidence of PCO and post operative uveal inflammation is significantly less with acrylic lenses and were safe to use in pediatric eyes.

Co-occurrence of pneumococcal keratitis and dacryocystitis.

PURPOSE To evaluate the specific risk factors responsible for the development of pneumococcal keratitis. METHODS In a retrospective analysis of 383 patients of culture-proven bacterial keratitis, seen between 1991 and 1995, 139 had monobacterial isolates on culture. We analyzed the various predisposing factors in these patients, with special emphasis on the patency of nasolacrimal drainage system. RESULTS Of the 139 patients with monobacterial keratitis, 48 (group 1) grew Streptococcus pneumoniae in culture. In the remaining 91 patients (group 2), Pseudomonas (18), coagulase-negative Staphylococci (15), Staphylococcus epidermidis (23), Staphylococcus aureus (16), Corynebacterium species (12), and others (seven) were isolated. Trauma was found to be a predisposing factor in 12 patients of group 1 and 27 patients of group 2 (p = 0.5601). Twelve (25%) patients of group 1 revealed chronic dacryocystitis, and nine of them underwent sac excision. On the contrary, only three patients of group 2 demonstrated dacryocystitis (p = 0.0003). CONCLUSION These results underscore the importance of assessing the patency of lacrimal drainage system in patients with infectious keratitis, especially of pneumococcal origin.

Laser cataract surgery.

Lasers have been investigated for cataract removal for nearly two decades. The technology has now reached a stage at which cataract can indeed be removed entirely with laser alone. Neodymium:yttrium-aluminum-garnet and erbium:yttrium-aluminum-garnet are the laser sources being utilized at the present time by manufacturers of laser cataract surgery systems. Initial clinical experience reported in the literature has served to highlight both the lasers capabilities and areas that need further refinement. Despite the thrill associated with the availability of this alluring new technology for cataract removal, laser systems with higher efficiency and innovative surgical techniques to optimally utilize their capabilities are necessary if laser cataract surgery is to be an improvement over current techniques.