Murugesan Vanathi

Post-penetrating keratoplasty glaucoma

To study the risk factors in the development of glaucoma following penetrating keratoplasty, we retrospectively analysed 190 eyes of 185 consecutive patients who had undergone surgery during 1990. The donor button was larger by 0.2 mm and 0.5 mm in phakia and aphakia/pseudophakia patients, respectively. Over a mean follow-up period of 14.5 months, 52 of the 190 eyes (27.4%) either developed glaucoma de novo or had worsening of preexisting glaucoma. Of these 52 eyes, 38 were managed medically and 14 required surgery. From our study, aphakia (37%), pseudophakia (24%), preexisting glaucoma (81.8%), and regrafting (43.18%) were found to be the significant risk factors in the development of glaucoma following penetrating keratoplasty.

Tectonic grafts for corneal thinning and perforations.

Purpose. To evaluate the success of tectonic grafts in cases of corneal thinning and perforations. Methods. We performed 42 tectonic grafts in 41 eyes of 40 patients. Three types of tectonic grafts were used in our treatment protocol. These were (a) full-thickness grafts, (b) mushroom grafts, and (c) lamellar grafts. The parameters evaluated were indications, visual acuity, location, size and type of graft, postoperative outcome, and complications, if any. Results. The most common indication for tectonic grafts was corneal thinning and perforation subsequent to infection (12 eyes) followed by those due to immunologic causes (six eyes) and trauma (six eyes). Twenty-four full-thickness tectonic grafts, nine mushroom grafts, and nine lamellar patch grafts were performed. Anatomical success was achieved in 35 of 41 (85.4%) eyes. Visual acuity of 6/24 or better was obtained in 29 of 41 (70.73%) eyes. The mean of best-corrected visual acuity (expressed in decimal) improved from 0.2 ± 0.26 to 0.34 ± 0.26 at an average follow-up of 10.83 ± 6.27 months. The major complications were peripheral anterior synechiae in four eyes (9.76%) and graft melting in five eyes (12.2%). Conclusions. Tectonic graft is a useful therapeutic option in selected cases of corneal thinning and perforations because it effectively restores the integrity of the eye and allows acceptable visual rehabilitation.

Factors affecting eye donation from postmortem cases in a tertiary care hospital

Purpose: To evaluate the responses to requests for eye donation from relatives of postmortem cases in a tertiary care hospital in India. Methods: In a prospective study, the cases brought for postmortem to the Forensic Medicine Department were screened as potential donors by our team. The next of kin of potential donors were approached and counseled in a systematic manner following a standard interview pattern. Responses were noted in a predesigned performa. The religion, level of literacy, socioeconomic status, relationship with the deceased, prior knowledge of eye donation, willingness for eye donation, and reasons for not donating eyes of the deceased were recorded. Results: One hundred fifty-nine potential donors were identified from a total of 721 postmortem cases. There were 119 (74.8%) men and 40 (25.2%) women. None of the deceased had previously pledged their eyes for eye donation. Eighty-eight (55.4%) next of kin were already aware of the concept of eye donation, but 71 (44.7%) families had not heard of it before. Willingness for eye donation was seen in 66 (41.5%), whereas 93 (58.5%) families refused eye donation. Of those already aware of eye donation, 39 (44.3%) gave consent for donation. Prior knowledge of eye donation had no influence on willingness for eye donation (P = 0.424). Similarly, literacy (P = 0.338) and socioeconomic status as estimated by a composite socioeconomic scale based on literacy and family income did not have any influence on willingness for eye donation (P = 0.338). Major reasons for not donating eyes included refusal to discuss the issue and dissuasion by distant relatives, legal problems, and religious beliefs. Conclusions: In our experience, literacy, socioeconomic status, and prior knowledge of eye donation of next kin had no correlation with donor corneal tissue procurement. Active counseling by a motivated team can be effective even in families with no prior knowledge and low socioeconomic status.

Indications and outcome of repeat penetrating keratoplasty in India

BackgroundRepeat penetrating keratoplasty is quite often required as there is high chance of failure of the primary graft particularly in the developing world. We planned a study to analyze the indications and outcome of repeat penetrating keratoplasty in a tertiary care centre in India.MethodsA retrospective analysis of all the patients who underwent repeat penetrating keratoplasty, between January 1999 and December 2001 was performed. The parameters evaluated were indication for the primary penetrating keratoplasty, causes of failure of the previous graft, and final visual outcome and clarity of the repeat corneal grafts.ResultsOf fifty-three eyes of 50 patients with repeat penetrating keratoplasty (three patients underwent bilateral corneal regrafts), 37 eyes had undergone one regraft each, 14 eyes two regrafts and two eyes had three regrafts. The follow-up of the patients ranged from one to three years. The most common primary etiologic diagnosis was vascularized corneal scars (66%), of which the scars related to infection were most common (68.5%). Twenty-eight regrafts (52.8%) remained clear at a mean follow-up of 1.54 ± 0.68 years, of which 25 were single regrafts (89.3%). The commonest cause of failure of regraft was infection to the corneal graft (recurrence of herpetic infection in 9 eyes and perforated graft ulcers in 3 eyes). Three (18.6%) of the 16 eyes with multiple corneal regrafts achieved a BCVA of 6/60. Overall, only five eyes (all with single regraft) achieved a BCVA of 6/18 or better at the end of follow-up.ConclusionGraft infection is the leading cause of failure of repeat keratoplasty in this part of the world. Prognosis for visual recovery and graft survival is worse in eyes undergoing multiple regrafts.

Topical autologous platelet-rich plasma eyedrops for acute corneal chemical injury.

Purpose: Evaluation of efficacy of autologous platelet-rich plasma eyedrops as an adjunct to standard medical treatment as compared with standard medical treatment with artificial tears in acute ocular chemical injury. Methods: Twenty eyes with grade III to grade V chemical injury were randomly assigned to 2 groups. Group I (10 eyes) received autologous platelet-rich plasma eyedrops along with standard medical treatment, and group II (10 eyes) received standard medical treatment alone. Follow-up was on days 3, 7, 14, 21, 30, 60, and 90. Chi-square test for categorical variables and Mann–Whitney test for quantitative variables were applied for statistical analysis. Results: The mean time between exposure and presentation was 2.15 ± 0.93 days (group I, 2.2 ± 0.73 days; group II, 2.1 ± 0.98 days; P = 0.81). Complete epithelialization was achieved in all the eyes. The mean ± SD and median (range) time to complete epithelialization were 40 ± 31.57 days and 25.5 (7–90) days in group I and 47 ± 26.15 days and 30.0 (21–90) days in group II (P = 0.29). For grade III injuries, mean ± SD and median (range) time to complete epithelialization were 14 ± 7 days and 14 (7–21) days in group I and 28.5 ± 3.67 days and 28.5 (21–30) days in group II (P = 0.006) [Wilcoxon rank sum (Mann–Whitney) test]. At 3 months, corneal clarity showed significant improvement in grade I compared with grade II (P = 0.048). Similarly, the percentage improvement in best-corrected visual acuity was 63.64 ± 55.75 and 37.74 ± 9.66 for grades I and II, respectively (P = 0.082). Conclusions: Topical autologous platelet-rich plasma therapy is safe and effective, and it promotes rapid reepithelialization of ocular surface and can be administered along with standard medical therapy.

Ultrasound biomicroscopy in opaque grafts with post-penetrating keratoplasty glaucoma.

Purpose: To evaluate the anterior segment in opaque grafts with post-penetrating keratoplasty glaucoma (PPKG) by using ultrasound biomicroscopy (UBM). Methods: An observational clinical case series of patients with opaque corneal grafts with PPKG who underwent UBM examination of the anterior chamber is reported. Indication for keratoplasty, lens status, intraocular pressure at the time of presentation, and the time of diagnosis of glaucoma were noted. Examination included slit-lamp biomicroscopy, posterior-segment ultrasound evaluation, and UBM evaluation of the anterior segment. Results: Thirty-one eyes of 31 patients with PPKG were recruited into the study. The mean intraocular pressure was 35.5 ± 5.8 mm Hg (range, 26-52 mm Hg). The mean time of follow-up after penetrating keratoplasty was 6.97 ± 2.98 months (range, 2-16 months). Of the 31 patients, 11 had undergone penetrating keratoplasty for therapeutic purposes (infectious keratitis), whereas the remaining 20 had undergone keratoplasty for optical reasons. Fourteen (45.1%) patients were pseudophakic, 13 (41.9%) were aphakic, and 4 (12.9%) were phakic. The types of synechiae noted on the UBM included peripheral anterior synechiae in 30/31 (96.7%) eyes, synechiae at the graft-host junction in 13/31 (41.93%) eyes, both peripheral anterior synechiae and graft-host junction synechiae in 12/31 (38.7%) eyes, central iridocorneal synechiae in 6/31 (19.3%) eyes, and intraocular lens iris synechiae in 3/31 (9.6%) eyes. Conclusions: Secondary angle closure caused by anterior synechiae formation is one of the important causes of PPKG in eyes with opaque grafts. UBM serves as a useful tool for anterior-segment evaluation in such cases and can help in planning the site for glaucoma filtering surgeries and drainage devices.

Anterior segment OCT-based diagnosis and management of retained Descemet's membrane following penetrating keratoplasty.

PURPOSE To report a case of retained Descemets membrane after penetrating keratoplasty for congenital hereditary endothelial dystrophy (CHED) documented by anterior segment optical coherence tomography and review of literature. METHODS Case report and review of literature. RESULTS A 14-year-old boy underwent penetrating keratoplasty for CHED. A retained host Descemets membrane was detected with a supernumerary anterior chamber on the first postoperative day. The retained Descemets membrane was documented using slit lamp adapted anterior segment optical coherence tomography (SLOCT). Surgical intervention for the Descemets membrane removal was done in the third postoperative week. The complete removal of the membrane was confirmed on SLOCT. CONCLUSION Inadvertent retention of the host Descemets membrane is a rare but possible complication in penetrating keratoplasty for CHED. Proper anticipation, early detection and removal will help in preventing any undue risk of graft failure.

Keratoplasty for keratomalacia in preschool children

Aim: To study the results of surgical management of keratomalacia in children. Methods: A clinical case series of all children with keratomalacia, admitted to an Indian centre during the period from June 2000 to June 2001 is presented. The parameters evaluated were demographic data, systemic associations, and results of medical and surgical intervention. Results: 29 children with keratomalacia ranging from 2 months to 5 years of age (mean 1.8 (SD 1.4) years) were included in the study. All children belonged to families of lower socioeconomic status. 27 patients (93.1%) had not been immunised at all. The systemic diseases precipitating the onset of keratomalacia included measles (41.37%), pneumonia (31.03%), and acute diarrhoea (37.93%). 36 eyes (66.7%) had total corneal melting and 11 (20.3%) eyes had paracentral corneal melting. In 15 eyes (27.8%) an emergency tectonic penetrating keratoplasty was performed of which only five grafts (33.3%) remained clear at a mean follow up of 7.3 (6.8) months (range 3–24 months). Seven eyes underwent optical penetrating keratoplasty, of which four grafts (57.14%) remained clear at a mean follow up of 6.4 (3.6) months (range 3–12 months). None of these could achieve a visual acuity better than 6/60. Conclusions: Corneal grafting surgery in keratomalacia is associated with poor visual outcome.

Intracameral SF6 injection and anterior segment OCT-based documentation for acute hydrops management in pellucid marginal corneal degeneration.

PURPOSE To report a case of acute hydrops in pellucid marginal corneal degeneration (PMCD) documented with anterior segment optical segment tomography and successfully treated with sulphur hexafluoride (SF6) intracameral injection. METHODS A 47-year-old female patient presented with spontaneous onset of pain, redness and decreased vision in her left eye. Clinical evaluation revealed bilateral PMCD with evidence of acute hydrops in the left eye. Anterior segment Slit lamp Adapted Optical Coherence Tomography (SL-OCT) examination revealed intrastromal clefts with Descemets membrane detachment in the left eye. She was managed with descemetopexy with 0.2ml injection of iso-expansile SF6 (18%) intracameral. RESULTS The patient showed excellent early resolution of the stromal edema with reattachment of the Descemets membrane. CONCLUSION Prompt intervention in acute hydrops in PMCD cases helps in achieving early good visual results and prevents potentially serious complications such as perforation. Newer imaging modalities like SL-OCT helps in better visualisation and also in monitoring the response to treatment.

Clinical outcomes of clear lens extraction in eyes with primary angle closure.

Purpose To evaluate the effect of clear lens extraction (CLE) on intraocular pressure (IOP) and the anterior chamber angle in primary angle closure after laser peripheral iridotomy (LPI). Setting Tertiary eyecare center at a university hospital, New Delhi, India. Design Prospective case series. Methods The study included eyes with primary angle closure and an IOP over 25.0 mm Hg more than 8 weeks after LPI. All eyes had CLE by phacoemulsification. Absolute success was defined as an IOP less than 18.0 mm Hg without medications at 12 months. Results In 44 eyes (24 women, 20 men; mean age 57.2 years ± 4.2 [SD]), the mean preoperative IOP of 27.1 ± 1.55 mm Hg decreased to 13.2 ± 1.12 mm Hg at 12 months (P < .0001). The angle opening distance at 500 &mgr;m increased from baseline values at 0 degrees (from 0.104 ± 0.015 mm to 0.31 ± 0.013 mm) and 180 degrees (from 0.202 ± 0.008 mm to 0.412 ± 0.012 mm). The trabecular iris angle also increased at 0 degrees (from 9.3 ± 3.2 degrees to 32.7 ± 5.6 degrees) and 180 degrees (from 9.12 ± 3.2 degrees to 31.7 ± 5.6 degrees) (all P < .0001). In multivariate analysis, the preoperative IOP was the strongest determinant of IOP change (R2 = 0.69, P < .0001). Absolute success was achieved in 38 eyes (86.3%). Conclusion Clear lens extraction led to a significant reduction in IOP, a widening of the anterior chamber angle, and a reduced need for ocular hypotensive medications in eyes with primary angle closure and persistently raised IOP after LPI. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.