Muralidhar Ramappa

Cultivated Limbal Epithelial Transplantation in Children With Ocular Surface Burns

IMPORTANCE Although several reports are available on the use of conventional and cultured limbal epithelium using various substrates in the treatment of limbal stem cell deficiency (LSCD), the patient populations studied have been largely adults. Thus, to our knowledge, the outcomes of this procedure exclusively in a pediatric population have not been reported previously. OBJECTIVE To report the outcomes of autologous ex vivo cultivated limbal epithelial transplantation (CLET) in pediatric patients with LSCD after ocular burns. DESIGN AND SETTING A retrospective, interventional case series of patients treated at the L. V. Prasad Eye Institute, Hyderabad, India. PARTICIPANTS Children up to 15 years with LSCD secondary to chemical or thermal injury who underwent CLET from April 1, 2001, through June 31, 2010, with a follow-up of at least 1 year, were included in the study. INTERVENTION After a limbal biopsy specimen obtained from a healthy area of the limbus, the limbal epithelial cells were cultured on a denuded human amniotic membrane substrate using a xeno-free explant culture technique. A monolayer of cultivated epithelial cells along with the amniotic membrane was transplanted on the patients affected eye after pannus excision. In cases of failure, the same procedure was repeated. MAIN OUTCOMES AND MEASURES Ocular surface stability and visual improvement were the primary and secondary outcome measures, respectively. Success was defined as a stable corneal epithelium without conjunctivalization. Eyes with conjunctivalization and persistent epithelial defects were classified as failures. RESULTS Of the 107 eyes of 107 patients included in this study, 73 eyes (68.2%) underwent 1 and 34 eyes (31.8%) underwent 2 autologous CLET procedures. At a mean follow-up of 3.4 years, 50 eyes (46.7%) achieved completely epithelialized, avascular, and stable ocular surfaces. At the final visit, 58 eyes (54.2%) had improvement in visual acuity of 0.2 or more logMAR units. CONCLUSIONS Autologous CLET was successful in restoring the ocular surface and improving vision in almost half of the children blinded by ocular burns.

Intracameral Perfluoropropane Gas in the Treatment of Acute Corneal Hydrops

PURPOSE This study is aimed to evaluate the role of 14% nonexpansile concentration of perfluoropropane (C(3)F(8)) gas in the management of acute hydrops in corneal ectasias. DESIGN Retrospective, nonrandomized, comparative, interventional case series. PARTICIPANTS AND CONTROLS The study group consisted of 62 eyes of 57 patients and the control group included 90 eyes of 82 patients with acute corneal hydrops who presented within 30 days of onset of symptoms. INTERVENTION Patients in the control group underwent a single intracameral injection of 0.1 mL of nonexpansile concentration (14%) of C(3)F(8) gas. Patients in the control group were treated conservatively. Patients in both groups were followed regularly for 12.6±7.7 and 13.4±8.3 months in the study and control groups, respectively, and assessed clinically for complete disappearance of epithelial and stromal edema on slit-lamp biomicroscopy. MAIN OUTCOME MEASURES The primary outcome measure was mean time to resolution of corneal edema, which was calculated both from the date of onset of hydrops and the date of initiation of therapy to the date of resolution in days. RESULTS The overall time to resolution both from the date of onset of symptoms (90.5±55.8 vs 125±68.9 days; P = 0.0005) and from the date of initiation of therapy (78.7±53.2 vs 117.9±68.2 days; P = 0.0001) was significantly lower in the study group compared with the control group. However, on subgroup analysis a significant difference in the resolution time was found only in eyes with keratoconus (P<0.0001). No difference in the resolution time was seen in eyes with pellucid marginal corneal degeneration (PMCD) or keratoglobus. The main complication of this procedure was reversible pupillary block (16%; P<0.0001). There was no difference in the final visual acuity or endothelial cell counts between the 2 groups. CONCLUSIONS Intracameral C(3)F(8) gas in a nonexpansile concentration is a useful modality for faster resolution of corneal edema in patients with acute corneal hydrops and keratoconus, and its role in the treatment of PMCD and keratoglobus needs further evaluation.

Deep anterior lamellar keratoplasty in children.

PURPOSE To evaluate the outcomes of deep anterior lamellar keratoplasty (DALK) in children. DESIGN Retrospective interventional case series. METHODS setting: Institutional, L.V. Prasad Eye Institute, a tertiary care center in south India. study population and intervention: All children less than 16 years of age undergoing DALK from January 2003 to January 2011. main outcome measure: Visual outcome and complications. RESULTS Twenty-six eyes of 26 children (13 male and 13 female) with a mean age of 7.82 ± 4.64 years underwent DALK for keratoconus (8), microbial keratitis (6), corneal scar (6), corneal keloid (3), chemical injury with limbal stem cell deficiency (2), and dermoid (1). Big bubble was achieved in 5 eyes, while manual dissection was done in 21. Follow-up ranged from 1 week to 7.3 years. Seventeen patients with a minimal follow-up of 6 months were evaluated for visual outcomes. Final vision varied from counting fingers to 20/20 (mean sphere 2.32 diopters, mean cylinder -2.5 diopters). Complications encountered were suture-related graft infiltrate (3), graft dehiscence (3), and Descemet membrane detachment (2). CONCLUSIONS DALK is a feasible option in children with stromal corneal pathology. It offers advantages in the form of lower risk of graft rejection. However, the risk of complications such as suture-related infections and graft dehiscence persists even in these cases.

An outbreak of acute post-cataract surgery Pseudomonas sp. endophthalmitis caused by contaminated hydrophilic intraocular lens solution

OBJECTIVE To report the investigation for the source of infection and the clinical course and treatment response of 11 cases of acute post-cataract surgery endophthalmitis that developed during an outbreak. DESIGN Retrospective, consecutive, interventional case series. PARTICIPANTS Eleven patients who developed acute postoperative endophthalmitis after an uneventful cataract surgery with intraocular lens implantation from September 6 to 29, 2010, at a tertiary eye care center in South India. METHODS Aqueous aspirates, vitreous aspirates, and environmental surveillance specimens were sampled. All specimens were subjected to smear and culture. Positive cultures were subjected to antibiotic susceptibility. Genotypic diversity was determined by polymerase chain reaction (PCR) with enterobacterial repetitive intergenic consensus (ERIC) primers of each strain and was used to establish the clonal relationship between clinical and environmental isolates. The clinical patterns were analyzed. MAIN OUTCOME MEASURES Positive microbiology, molecular diagnostic similarity among the culture positive endophthalmitis cases, and surveillance specimens. RESULTS Aqueous and vitreous samples showed gram-negative bacilli in the smears of 8 of 11 eyes, and cultures grew Pseudomonas aeruginosa in 5 of 11 eyes. Among the samples from various surveillance specimens cultured, only the hydrophilic acrylic intraocular lenses and their solution grew P. aeruginosa, with antibiotic susceptibility pattern identical to the clinical isolates. The isolates from the patients and the intraocular lens solution revealed matching patterns similar to an American Type Culture Collection (ATCC) strain of P. aeruginosa on ERIC-PCR. The intraocular lenses of the same make were discontinued at our hospital, and the endophthalmitis did not recur. The final visual acuity improved to ≥ 20/50 in 8 of 11 patients (72.7%). One patient developed retinal detachment, but was treated successfully, and 2 other patients progressed to phthisis bulbi. CONCLUSIONS Positive microbiology and the ERIC-PCR results proved that contamination of hydrophilic intraocular lenses and the preservative solution was the source of infection in this outbreak. Early detection and a planned approach during the outbreak helped us to achieve good visual and anatomic outcomes, even though the offending organism was identified as P. aeruginosa.

Clinical manifestations of congenital aniridia.

PURPOSE To study the various clinical manifestations associated with congenital aniridia in an Indian population. METHODS In this retrospective, consecutive, observational case series, all patients with the diagnosis of congenital aniridia seen at the institute from January 2005 to December 2010 were reviewed. In all patients, the demographic profile, visual acuity, and associated systemic and ocular manifestations were studied. RESULTS The study included 262 eyes of 131 patients with congenital aniridia. Median patient age at the time of initial visit was 8 years (range: 1 day to 73 years). Most cases were sporadic and none of the patients had parents afflicted with aniridia. The most common anterior segment abnormality identified was lenticular changes. Cataract was the predominant lens finding, observed in 93 of 231 (40.3%) phakic eyes. Other lens abnormalities were subluxation, coloboma, posterior lenticonus, and microspherophakia. Corneal involvement of varying degrees was seen in 157 of 262 (59.9%) eyes, glaucoma was identified in 95 of 262 (36.3%) eyes, and foveal hypoplasia could be assessed in 230 of 262 (87.7%) eyes. Median age when glaucoma and cataract were noted was 7 and 14 years, respectively. None of the patients had Wilms tumor. CONCLUSIONS Congenital aniridia was commonly associated with classically described ocular features. However, systemic associations were characteristically absent in this population. Notably, cataract and glaucoma were seen at an early age. This warrants a careful evaluation and periodic follow-up in these patients for timely identification and appropriate management.

Safety profile of primary intraocular lens implantation in children below 2 years of age

Aim To study the safety profile of primary intraocular lens (IOL) implantation in children below 2 years of age Methods Retrospective, non-comparative, consecutive and interventional clinical case series of all patients who underwent surgery between January 2006 and December 2007. Results The data were collected for 120 eyes of 80 children with congenital/developmental cataract with a mean follow-up of 8.85±7.73 months (median 6, range 3–40). The age ranged from 1 to 23 months (mean 11.21±5.90 months, median 10 months). 31 eyes were operated on before the age of 6 months, and 89 were operated on after 6 months of age. The axial length of children ranged from 16.27 mm to 25.65 mm (mean 19.84±1.71, median 19.65). The IOL power implanted in these children ranged from 11 D to 30 D (mean 24.51±4.06 D, median 25.00). 30 eyes were implanted with rigid polymethylmethacrylate lenses, and the remaining 90 received acrylic hydrophobic foldable lenses. 8 eyes (6.7%) developed opacification of the visual axis, decentration of IOL was noticed in 2 (1.7%), increased anterior chamber inflammation was observed in five eyes (4.2%) in the early postoperative period, pigment dispersion on IOL was seen in four eyes (3.3%), and posterior synechiae were noticed in five eyes (4.2%). None of the children developed glaucoma; nor were there any endophthalmitis and retinal detachment at the last follow-up. There was no difference in terms of complications in children younger than 6 months and older than 6 months. Conclusion The results suggest that implantation of IOL in children below 2 years of age is safe and can be considered as a viable option for their visual rehabilitation.

Outcomes of Descemet's stripping endothelial keratoplasty in eyes with failed therapeutic penetrating keratoplasty.

Purpose:  To report the results of Descemet’s stripping endothelial keratoplasty (DSEK) for failed therapeutic penetrating keratoplasty (PK).

Paired-eye comparison of Descemet's stripping endothelial keratoplasty and penetrating keratoplasty in children with congenital hereditary endothelial dystrophy

Purpose To report the surgical outcomes of Descemets stripping endothelial keratoplasty (DSEK) in cases of congenital hereditary endothelial dystrophy (CHED) cohort and compare it with penetrating keratoplasty (PK) in a paired-eye setting. Methods Ours is a retrospective, comparative, consecutive and interventional clinical case series. All patients less than 14 years of age who underwent PK in one eye and DSEK in the contralateral eye at a single centre from January 2006 and February 2011 were analysed. Main outcome measures were graft clarity, visual outcome and complications. Results The mean age of the patients was 6.6±2.19 years at the time of presentation. The outcomes of two surgeries were compared with 1 year of follow-up at the corresponding follow time. At 1 year, all grafts were clear. There was no significant difference in the spherical component of the refraction; the astigmatism was significantly lower after EK. The refraction stabilised in patients with EK as early as 3 months, while it continued to change up to 1 year after PK. Complications included graft dislocation in two cases of DSEK, which were managed by rebubbling, and a graft dehiscence in one case of PK, which was managed by resuturing. The final visual acuity improved in all the patients. Conclusions Endothelial keratoplasty is a viable option to conventional PK in cases of CHED. It offers an advantage of early visual stabilisation compared with PK.

Endothelial keratoplasty in children: surgical challenges and early outcomes

A significant proportion of paediatric keratoplasties are performed for endothelial dysfunction due to failed graft, congenital hereditary endothelial dystrophy1 and pseudophakic corneal oedema. Descemets stripping endothelial keratoplasty (DSEK) is an evolving procedure for isolated endothelial dysfunction with encouraging results in adults. The application and outcome of this procedure in the paediatric population has not been well studied with few reports being published so far.2–5 This study reports the indications, surgical technique and early outcomes of DSEK in children <14 years of age. All children who underwent DSEK at our centre between January 2008 and January 2010 were included. Under general anaesthesia, an appropriate sized superior or temporal fornix based conjunctival flap was reflected and a 4–5 mm long, self-sealing scleral tunnel was made. The Descemets membrane was scored using a reverse …

Clinical profile of graft detachment and outcomes of rebubbling after Descemet stripping endothelial keratoplasty

Purpose To review the clinical profile of graft detachment following Descemets stripping endothelial keratoplasty (DSEK) and analyse the outcomes of rebubbling for graft detachment. Methods Retrospective review. Results 27 of a total of 309 eyes that underwent DSEK (8.7%) underwent rebubbling with air injection between January 2009 and February 2010. Eighteen (66.6%) of these eyes had complete and 9 (33.3%) had partial detachment of the transplanted lenticule. Successful attachment was observed in 20/27 (74%) eyes (12/18 with total and 8/9 with partial detachments), and clear grafts were achieved in 13 (65%) of these 20 eyes, while 7 (35%) eyes had primary graft failure. Visual acuity was 20/60 or better in 6 of these 20 eyes (35%), between 20/100 and 20/60 in 4 eyes (25%), and <20/200 in 10 eyes. Three of the 10 lenticules that failed to attach with the first rebubbling procedure underwent a second attempt of rebubbling, four underwent a repeat DSEK with good outcomes, and three underwent PK. Univariate analysis showed additional vitrectomy at the time of DSEK to be a statistically significant risk factor for persistent graft detachment following rebubbling (p<0.04). Conclusion Rebubbling following detachment of the donor lenticule was successful in achieving graft adhesion in the majority of patients (74%), but 35% had a primary graft failure. The second attempt at rebubbling (in three patients) led to successful attachment, but the oedema failed to recover. Those who underwent repeat DSEK for unsuccessful rebubbling did well with no complications.