Namrata Sharma

Management of keratoconus: current scenario

Keratoconus is an ectatic corneal dystrophy and is a leading indication for corneal transplantation surgery worldwide. The disease was first described in detail more than 150 years ago by Dr John Nottingham, but the understanding of the disease and its management have undergone significant changes over the last few decades. Corneal specialists have adopted new techniques and technologies for the effective management of keratoconus, while adhering to the age-old concepts of contact lens fitting and penetrating keratoplasty. Lamellar keratoplasty has been revived with improved outcomes and devices such as intracorneal ring segments are being used to treat cases of early keratoconus effectively. This review article discusses the current scenario on the surgical as well as non-surgical management of keratoconus with a focus on the established, novel and emerging treatment modalities.

Pseudomonas keratitis after collagen crosslinking for keratoconus: case report and review of literature.

A 19-year-old woman presented with a 3-day history of pain, redness, and diminution of vision occurring one day after collagen crosslinking (CXL) with riboflavin and ultraviolet-A had been performed for keratoconus in the right eye. On presentation, severe keratitis with a 7.0mm x 6.0mm central infiltrate was present. Culture results from the patients contact lens and corneal scrapings were positive for Pseudomonas aeruginosa. Keratitis can occur following CXL because of the presence of an epithelial defect, use of a soft bandage contact lens, and topical corticosteroids in the immediate postoperative period, and patients should be counseled about it.

MYCOTIC KERATITIS IN CHILDREN : EPIDEMIOLOGIC AND MICROBIOLOGIC EVALUATION

Purpose To evaluate the demographic features, clinical profile, and laboratory diagnosis in cases of mycotic keratitis in children. Methods We retrospectively analyzed 211 cases of mycotic keratitis in children younger than 16 years over a 5-year period in a tertiary eye center. Culture-proven cases of fungal keratitis were reviewed. Results Trauma was the most common predisposing factor (55.3%), followed by associated systemic illness (11.2%), previous ocular surgery (9.8%), and others. Corneal injury contaminated with vegetable matter was responsible for 60.5% of traumatic cases. Aspergillus species were the most frequent isolates (39.5%). Others included Fusarium (10.7%), Alter-naria (10.2%), Curvularia (7.4%), and Penicillium (7%). A seasonal variation in the incidence of mycotic keratitis revealed a peak incidence in the months of September and October. One hundred sixty-two children (76.7%) cooperated for examination and scraping under topical anesthesia with or without sedation. General anesthesia for scraping was required in 49 (23%) of 211 children for corneal scraping. Gram stains of corneal scraping were positive for hyphal elements in 54.5% of cases, and potassium hydroxide wet-mount preparation was positive in 90.2% of cases. Conclusions This study highlights important risk factors and organisms responsible for mycotic keratitis in children.

Amniotic membrane transplantation in refractory neurotrophic corneal ulcers: a randomized, controlled clinical trial.

Purpose: This study was designed to compare and evaluate the efficacy of amniotic membrane transplantation with the conventional management (tarsorrhaphy and bandage contact lens) in eyes with refractory neurotrophic corneal ulcers. Methods: Thirty eyes of 30 patients (14 females and 16 males) with neurotrophic corneal ulcers refractory to medical management were included and divided randomly into group 1 (n = 15), who received conventional management with a tarsorrhaphy (n = 11) or bandage contact lens (n = 4), and group 2 (n = 15), who underwent Amniotic Membrane Transplantation. The outcome parameters evaluated were epithelialization time, duration of healing of corneal ulcers, and improvement in best corrected visual acuity. Results: The mean age in our study was 37 ± 14.71 years. At the end of 3 months follow-up, 10 of 15 patients (66.67%) in group 1 showed complete epithelialization and subsequent healing and 11 of 15 patients (73.33%) in group 2 showed complete epithelialization and healing (P > 0.05). The median time for complete epithelialization was 21 days in both groups. Both groups showed an improvement in the best-corrected visual acuity. Conclusions: Both amniotic membrane transplantation and conventional management (tarsorrhaphy or bandage contact lens) are effective treatment modalities for refractory neurotrophic corneal ulcers.

Evaluation of Intrastromal Injection of Voriconazole as a Therapeutic Adjunctive for the Management of Deep Recalcitrant Fungal Keratitis

PURPOSE To evaluate the role of intrastromal injection of voriconazole in the management of deep recalcitrant fungal keratitis. DESIGN Interventional case series. METHODS SETTING Cornea services at a tertiary care teaching hospital. PATIENTS Three eyes of three patients with deep stromal recalcitrant fungal keratitis not responding to topical antifungal medications. Intervention Procedure: Voriconazole 50 micrograms/0.1 ml was injected circumferentially around the fungal abscess in the corneal stroma as an adjunctive to the topical antifungal therapy. MAIN OUTCOME MEASURE Main outcome measure was a reduction in size of the abscess and resolution of the infection. RESULTS Before the intracorneal injection, all three eyes had gradually worsening lesions on topical medications. After the intervention, a faster reduction in the size of corneal infiltration was documented and a complete resolution of the ulcers was seen within three weeks in all cases. CONCLUSION Targeted delivery of voriconazole by intracorneal injection may be a safe and effective way to treat cases of deep-seated recalcitrant fungal keratitis responding poorly to conventional treatment modalities.

Complications of pediatric cataract surgery and intraocular lens implantation

PURPOSE To study the pattern of postoperative complications following extracapsular cataract extraction (ECCE) with intraocular lens (IOL) implantation in pediatric eyes. SETTING Tertiary eye care center, New Delhi, India. METHODS A retrospective analysis of 39 eyes of 28 children referred for complications after ECCE with IOL implantation was performed. The results evaluated were visual acuity, iridocapsular problems, and IOL-related complications. Additional interventions such as neodymium:YAG (Nd:YAG) capsulotomy, surgical membranectomy, and penetrating keratoplasty (PKP) were done when necessary. Visual acuity was measured 1 week following intervention and at the last follow-up. RESULTS Congenital (17 eyes, 43.6%), developmental (11 eyes, 28.2%), and traumatic (11 eyes, 28.2%) cataract were the indications for surgery. Posterior capsule opacification (34 eyes, 87.2%), updrawn pupil (15 eyes, 38.5%), decentered IOL (13 eyes, 33.3%), and pupillary capture (12 eyes, 30.8%) were the major complications. An Nd:YAG capsulotomy was attempted in 19 eyes (48.7%). Surgical membranectomy was performed in 10 eyes (25.6%); PKP was performed in 2 eyes (5.1%) to treat pseudophakic bullous keratopathy. One eye had to be eviscerated because of uncontrolled endophthalmitis. In 31 eyes in which visual acuity could be measured, 27 had an acuity of 6/60 or worse at the time of presentation. Following intervention and amblyopia therapy, 19 eyes achieved a visual acuity of 6/18 or better. CONCLUSION Routine ECCE with IOL implantation in pediatric eyes is associated with various problems and may lead to permanent visual disability.

Management of Corneal Perforation

Corneal perforation may be associated with prolapse of ocular tissue and requires prompt diagnosis and treatment. Although infectious keratitis is an important cause, corneal xerosis and collagen vascular diseases should be considered in the differential diagnosis, especially in cases that do not respond to conventional medical therapy. Although medical therapy is a useful adjunct, a surgical approach is required for most corneal perforations. Depending on the size and location of the corneal perforation, treatment options include gluing, amniotic membrane transplantation, and corneal transplantation.

Management of Posterior Capsule Tears

Any breach in the continuity of the posterior capsule is defined as a posterior capsule tear. Posterior capsule tears can be preexisting (congenital or traumatic), spontaneous, or intrasurgical. Preexisting/congenital posterior capsule tears have been related to an intrauterine insult. Posterior capsule tears due to trauma may occur as a consequence of direct mechanical impact due to perforation or blunt injury. Depending on the duration of time between the posterior capsular trauma and the cataract surgery, these posterior capsule tears can have different features. Intrasurgical posterior capsule tears are the most common and can occur during any stage of cataract surgery. Also, they may be planned in the form of primary posterior capsulorhexis. The conventional management consists of prevention of mixture of cortical matter with vitreous, dry aspiration, and anterior vitrectomy, if required. In addition, during phacoemulsification low flow rate, high vacuum, and low ultrasound are advocated if a posterior capsule tear occurs. Dislocated nucleus or nuclear fragments require vitrectomy and the use of perfluorocarbon liquids. In the presence of a posterior capsule tear, the IOL can be placed in the sulcus, if the capsular rim is available, or in the bag, if the tear is small. Scleral fixated posterior chamber lenses and anterior chamber IOLs can be implanted when the posterior capsule tear is large.

STUDY OF THE FIRST CONTACT MANAGEMENT PROFILE OF CASES OF INFECTIOUS KERATITIS A HOSPITAL BASED STUDY

Purpose. To study the management pattern and examine the role of cultures and antibiotic sensitivity testing in infectious keratitis. Methods. A retrospective analysis of the demographic, clinical, and microbiological data was performed in 100 consecutive patients with infectious keratitis. The main parameters evaluated were nature of first contact with the health care services, investigations undertaken, treatment initiated, and the time interval between presentation to the first medical contact and to our center. Finally, the reports of culture and antibiotic sensitivity testing undertaken at our center were evaluated. Results. In 70% of cases, ophthalmologists in independent practice were the first medical contact. Direct microscopy of the corneal scraping was undertaken in only 6% of cases, whereas culture and sensitivity studies had not been performed in any of the patients. Forty-six percent of the patients were prescribed 0.3% ciprofloxacin eyedrops in an inadequate dosage. Broad-spectrum fortified antibiotics eye drops had not been prescribed in any of the cases. At our center, positive cultures were obtained in 73.86% of cases and the most common organism isolated was coagulase-negative Staphylococcus (33.84%), followed by Pseudomonas aeruginosa (15.38%). A large number of the isolates demonstrated resistance to the recommended antibiotic therapy. Conclusions. Failure to implement standard management protocol for infectious keratitis at first contact is a major factor contributing to ocular morbidity in India.

Indications of penetrating keratoplasty in northern India.

Purpose: To identify the indications for penetrating keratoplasty in northern India. Methods: All the eye bank records of penetrating keratoplasties performed during the period from June 1997 to November 2003 at Rajendra Prasad Center for Ophthalmic Sciences were reviewed. Results: During this period, 2022 penetrating keratoplasties were performed. The leading indications for penetrating keratoplasty were corneal scarring (38.03%) followed by acute infectious keratitis (28.38%), regrafting (11.5%), aphakic bullous keratopathy (7.27%), pseudophakic bullous keratopathy (6.18%), and corneal dystrophy (3.85%). Healed infectious keratitis (19.83%) was the most common subcategory among the eyes with corneal scarring followed by traumatic corneal scars (16.71%). Healed (19.83%) and active keratitis (28.38%) together accounted for the majority of keratoplasties (48.21%). In cataract-related corneal edema (13.45%), aphakic bullous keratopathy (7.27%) was almost as frequent as compared with pseudophakic bullous keratopathy (6.18%). Conclusions: Corneal infections either active or healed are the most common indication for keratoplasty in northern India.