Neelam Pushker

Microbial keratitis after laser in situ keratomileusis.

PURPOSE AND METHOD To review the literature on microbial keratitis reported after laser in situ keratomileusis (LASIK). RESULTS Forty-one eyes have been reported to have microbial keratitis after LASIK. The causative organisms vary from gram positive bacteria to atypical mycobacteria, fungal, and viral pathogens. The infection is usually acquired intraoperatively, but may also be caused by postoperative contamination. A majority of the patients present within 72 hours of the surgery with an acute onset of symptoms. Management of microbial keratitis after LASIK includes aggressive topical fortified antibiotic therapy, irrigation of stromal bed with antibiotic solution after lifting the flap, and sending the scraping of the infiltrate for microbiological evaluation. The keratitis heals with scarring and a best spectacle-corrected visual acuity of 20/40 or better can be obtained in the majority of the patients. CONCLUSION Microbial keratitis is a sight-threatening complication of LASIK.

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.

Invasive Aspergillosis of Orbit in Immunocompetent Patients: Treatment and Outcome

OBJECTIVE Invasive sino-orbital aspergillosis in immunocompetent patients is a rare clinical entity and often misdiagnosed. Invasive sino-orbital aspergillosis is potentially fatal; however, mortality may be avoided with timely treatment. Presently, there are no universal guidelines for its treatment. We present the clinical features, treatment, and outcome in 15 cases of invasive sino-orbital/orbital aspergillosis in healthy individuals. DESIGN Retrospective case series. PARTICIPANTS Fifteen cases of invasive sino-orbital/orbital aspergillosis in immunocompetent individuals. METHODS We retrospectively analyzed all patients with sino-orbital/orbital aspergillosis who were treated at the Dr. Rajendra Prasad Center for Ophthalmic Sciences between June 1999 and September 2009. Diagnosis was based on histopathologic documentation of tissue invasion by septate fungal hyphae with acute angle branching and presence of granulomatous inflammation. MAIN OUTCOME MEASURES Treatment outcome in terms of patient survival, resolution of symptoms, and resolution of orbital mass on imaging. RESULTS Fifteen patients (11 male and 4 female) were studied. Mean age of patients was 35 years. One patient declined treatment. Surgery was performed for orbital disease in 6 patients. Medical therapy consisted of intravenous amphotericin B followed by itraconazole in 10 patients, itraconazole alone in 2 patients, and voriconazole followed by itraconazole in 2 patients. Eleven patients are alive without recurrence at a median follow-up of 20 months. Of these patients, 5 had residual mass on imaging at last follow-up. One patient died of progressive disease. CONCLUSIONS This is a large case series of orbital aspergillosis reported in healthy individuals. The role of orbital surgery is not clear in treatment of this entity and requires further evaluation. Newer antifungal agents alone seem to be effective in controlling the infection.

Evaluation of polytetrafluoroethylene suture for frontalis suspension as compared to polybutylate-coated braided polyester

Purpose: To evaluate the efficacy of polytetrafluoroethylene (Gore‐Tex) suture as compared to polybutylate‐coated braided polyester (Ethibond) suture as sling materials for frontalis suspension in bilateral congenital ptosis.

Clinical predictors of high risk histopathology in retinoblastoma.

Previous studies show that clinical features at presentation, in retinoblastoma patients, like glaucoma and neovascularization of iris are associated with a higher incidence of high risk histopathology findings (HRF) in enucleated eyes. Herein, we analyze association between clinical features at time of enucleation and occurrence of HRF including invasion of anterior chamber, iris, ciliary body, choroid (massive), sclera, extrascleral tissue, optic nerve beyond lamina cribrosa, and optic nerve cut end, in a large series of eyes enucleated for retinoblastoma.

Atypical presentations of retinoblastoma

PURPOSE To study the atypical presentations of retinoblastoma in our institution. METHOD Retrospective, clinical study. RESULTS A total of 392 cases of retinoblastoma were reviewed; 72.2% of the patients had leukocoria, 13% had proptosis, 10% had strabismus, 1.5% were asymptomatic (detected on screening), and 3.3% had atypical presentations. Fourteen different atypical findings were observed including endophthalmitis (0.76%), secondary glaucoma (0.76%), uveitis (0.5%), corneal edema (0.5%), phthisis bulbi (0.5%), orbital cellulitis (0.5%), cataract (0.25%), pseudohypopyon (0.25%), iris nodules (0.25%), hyphema (0.25%), iris neovascularization (0.25%), microphthalmos (0.25%), exposure keratopathy (0.25%), and corneal blood staining (0.25%). All of the patients had Reese-Ellsworth grade V disease. On histopathology, invasion of neighboring structures was seen in 10 patients. All patients underwent enucleation with adjuvant radiotherapy, chemotherapy, or both. CONCLUSIONS Retinoblastoma can mimic any orbital or ocular pathology. Atypical presentations of retinoblastomas are usually associated with advanced disease. The possibility of ocular tumor should be entertained whenever there is an unusual presentation that is unresponsive to the usual therapy. Ultrasonography and computed tomography should be performed in all such patients, especially if the posterior segment is not visible.

Orbital and adnexal cysticercosis

Orbital and adnexal cysticercosis is emerging as a far commoner disease than previously considered, both in endemic and nonendemic areas of cysticercosis. A review of the literature on orbital and adnexal cysticercosis found that it has a predilection for children and young adults with no definite sex predilection. The extraocular muscle form is the commonest type of orbital and adnexal cysticercosis. Lodgement of cysts in the subconjunctival space is another common site, followed by the eyelid, optic nerve, retro‐orbital space and lacrimal gland. Association of orbital cysticercosis with systemic cysticercosis is quite rare. The clinical manifestations of orbital or adnexal cysticercosis are entirely different and depend on the location, size, relation to adjacent structures and stage of evolution of the cyst. Diagnosis of cysticercosis is based mainly on orbital imaging because of its highly specific appearance. Tissue diagnosis is not essential for initiating treatment. Medical therapy is the recommended treatment for the extraocular muscle form and retro‐orbital cysticer‐cosis. Surgical removal is advocated for subconjunctival and eyelid cysticercosis. Because of the limited number of cases of optic nerve and lacrimal gland cysticercosis, their treatment is controversial.

Correlation between Clinical Features, Magnetic Resonance Imaging, and Histopathologic Findings in Retinoblastoma: A Prospective Study

OBJECTIVE To correlate clinical features with histopathology findings in advanced intraocular retinoblastoma and to determine the diagnostic accuracy of magnetic resonance imaging (MRI) in detecting tumor invasion. DESIGN Prospective, nonrandomized case series. PARTICIPANTS We included 75 patients with group E retinoblastoma. METHODS Demographic and clinical features were recorded at presentation. Contrast-enhanced MRI was performed to study tumor characteristics and extent of invasion. Primary enucleation was performed and histopathologic features noted. Statistical analysis was done using the Kruskal-Wallis test to determine correlation between clinical features and histopathology. Sensitivity, specificity, and accuracy of MRI in detecting tumor invasion were determined. MAIN OUTCOME MEASURES Significant associations between clinical findings at presentation and high-risk histopathology, and correlation between MRI results and histopathologic evidence of tumor invasion. RESULTS A significant association was found between iris neovascularization and choroidal invasion (P = 0.032), intraocular pressure and optic nerve invasion (P = 0.034), and shallow anterior chamber and iris invasion (P = 0.021). Corneal diameter did not show any significant correlation with high-risk histopathology. On MRI, tumor volume showed a significant association with optic nerve invasion (P = 0.023). The accuracy of MRI in detecting choroidal invasion was 68% (sensitivity, 60%; specificity, 80%). Prelaminar invasion was correctly identified in 9 out of 15 eyes (accuracy, 84%; sensitivity, 60%; specificity, 90%), whereas the accuracy of MRI in detecting postlaminar invasion was 76% (sensitivity, 61.9%; specificity, 81.5%). Ciliary body invasion was correctly identified in 5 out of 7 eyes (accuracy, 93.3%; specificity, 95.6%) and scleral invasion in 5 out of 6 eyes (accuracy, 98.7%; specificity, 100%). CONCLUSIONS As far as we are aware, this is the first prospective study on the correlation of clinical features and MRI findings with histopathologic risk factors in eyes primarily enucleated for retinoblastoma. Neovascularization of iris, intraocular pressure, shallow anterior chamber, and tumor volume correlated well with high-risk histopathology. Because MRI has limitations in reliably predicting microscopic infiltration of the choroid and optic nerve, decision in favor of neoadjuvant chemotherapy on the basis of suspected postlaminar invasion on MRI is not justified in the absence of histopathologic evidence of disease.

Adjuvant Role of Amniotic Membrane Transplantation in Acute Ocular Stevens-Johnson Syndrome: A Randomized Control Trial.

PURPOSE To evaluate the adjuvant role of amniotic membrane transplantation (AMT) in cases of acute ocular Stevens-Johnson syndrome (SJS). DESIGN Prospective randomized controlled clinical trial. PARTICIPANTS Twenty-five patients (50 eyes) with acute ocular SJS who presented within 4 weeks of onset of symptoms were recruited. METHODS The eyes were randomized into 2 groups that underwent either AMT with medical therapy (MT; n = 25) or standard MT alone (n = 25). The patients were evaluated at presentation and during follow-up at 1 week and 1, 3, and 6 months. The parameters evaluated were the best-corrected visual acuity (BCVA), Schirmer test, tear film breakup time (TBUT), conjunctival congestion, corneal haze, vascularization, conjunctivalization, and limbal stem cell involvement. Lid edema, symblepharon, ankyloblepharon, ectropion, entropion, trichiasis, and metaplastic lashes also were analyzed. MAIN OUTCOME MEASURES Maintenance of BCVA and stable ocular surface. RESULTS At the end of 6 months, the mean BCVA was significantly better in the AMT group (0.068±0.10 logMAR units) compared with the MT group (0.522±0.52 logMAR units; P = 0.042). The mean TBUT in the AMT and MT groups was 9.92±4.1 and 6.96±4.5 seconds, respectively (P = 0.015). The mean Schirmer test results in the AMT and MT groups were 15.4±6.3 and 8.64±5.4 mm, respectively (P < 0.001). Conjunctival congestion persisted in 44% (11/25) in the MT group compared with 4% (1/25) in the AMT group (P = 0.03) at the end of the 6-month follow-up. No case in the AMT group demonstrated corneal haze, limbal stem cell deficiency, symblepharon, ankyloblepharon, or lid-related complications. Among eyes in the MT group, corneal haze occurred in 44% (11/25; P = 0.001), corneal vascularization and conjunctivalization in 24% (6/25; P = 0.03), symblepharon in 16% (4/25; P = 0.12), ankyloblepharon in 4% (1/25; P = 1.00), ectropion and entropion in 8% (2/25; P = 0.47), and trichiasis and metaplastic lashes in 24% (6/25; P = 0.03) eyes. CONCLUSIONS Amniotic membrane transplantation is a useful adjunct to conventional MT in maintaining BCVA and a stable ocular surface in cases of acute ocular SJS. Furthermore, the adjunctive use of AMT also helps to prevent intermediate-term ocular cicatricial sequelae.

LATERAL TARSORRHAPHY : IS IT PREFERABLE TO PATCHING?

PURPOSE To evaluate the effectiveness of lateral tarsorrhaphy for the management of postkeratoplasty epithelial defects. METHOD Thirty-six patients with persistent postkeratoplasty epithelial defects that did not heal despite topical medical therapy for a period of 96 hours were treated with either a lateral tarsorrhaphy (18 patients) or with tight patching (18 patients). All patients were evaluated daily by slit-lamp examination until complete reepithelialization occurred. RESULTS The epithelial healing was significantly faster (7.61+/-0.91 days vs. 12.6+/-1.61 days, p<0.5) in the lateral tarsorrhaphy group. Further, the patients with lateral tarsorrhaphies were significantly more comfortable when compared with those of the patching group (p<0.05). CONCLUSION Lateral tarsorrhaphy provides quick symptomatic relief and faster corneal epithelial defect healing. Therefore, it may be of benefit in cases of postkeratoplasty persistent epithelial defects.