Pranita Sahay

Microbial Keratitis After Accelerated Corneal Collagen Cross-Linking in Keratoconus

Purpose: To assess the pattern of microbial keratitis after accelerated corneal collagen cross-linkage (aCXL) in patients with keratoconus. Method: The medical records of cases of keratoconus that underwent aCXL from June 2014 to May 2017 were reviewed. Cases that developed microbial keratitis after aCXL were included in the study. The clinical, microbiological profile and the treatment outcomes were evaluated. Results: Of 532 eyes that underwent aCXL, 7 cases developed microbial keratitis during the study period. Median age at presentation was 11 years (range 8–17). Association with vernal keratoconjunctivitis was noted in 57.1% of cases (n = 4/7). The median time at the onset of infection was 3 days after aCXL (range 1–4). Microbiological reports revealed mixed infection in 3 cases [coagulase-negative Staphylococcus (CoNS) + Aspergillus fumigatus, Staphylococcus aureus and Mucor spp., Staph. aureus and Acanthamoeba], Staph. aureus in 2 cases, and CoNS and Alternaria spp. in 1 case each. Resistance to fourth-generation fluoroquinolones was noted in 83.3% of cases of bacterial keratitis (n = 5/6). All cases were initially managed with empirical antibiotic treatment that was later tailored based on microbiological reports. One case eventually required therapeutic penetrating keratoplasty for corneal perforation. At 6 months, the corrected distance visual acuity was >6/60 in 3 cases while 4 cases had corrected distance visual acuity <6/60. Conclusions: Microbial keratitis after aCXL is rare; however, the infection tends to be severe with high preponderance of mixed infection and resistance to fourth-generation fluoroquinolones.

Tenon patch graft for corneal fistula: a rare entity treated by a simple technique

A 50-year-old patient presented with dull aching pain with some discomfort in his right eye for the past 2 weeks. History revealed the patient had a past episode of infective keratitis managed medically in a local hospital. The last follow-up record suggested a diagnosis of healed keratitis with corneoiridic scar. On examination, the patient had visual acuity of hand movement and a corneoiridic scar of 7×7 mm with an inferotemporal translucent cystic area measuring 3×4 mm in size with underlying uveal tissue visible. Seidel test was found to be positive confirming leakage. For this, a tenon patch over the area of defect along with anterior chamber formation was done. On postoperative day 1, the graft was well attached and anterior chamber was formed with no leak on Seidel test. Intraocular pressure was 16 mm Hg.

Temporal Macular Pulsation During Retinopathy of Prematurity Screening

To the Editors: A 32-week infant with a birth weight of 1,200 g presented at 36 weeks’ post-conceptional age for retinopathy of prematurity (ROP) screening. Screening with indirect ophthalmoscopy revealed zone II stage 1 ROP with pre-plus disease in both eyes. In addition, pulsations were noted in both eyes in the temporal macular area. Fundus photography was performed with the RetCam 3 imaging system (Clarity Medical Systems, Inc., Pleasonton, CA) to document the findings. An abnormal temporal macular reflex in the form of a horizontal band was noted in both eyes, but was better appreciated in the left eye (Figure 1). This area seemed hypopigmented compared to the surrounding retina. Pulsations were confirmed in both eyes at this area (Video 1, available in the online version of this article), which decreased in amplitude with reduction of pressure on the globe with the RetCam handheld camera. These were in phase with induced arterial pulsations at the disc. These findings were again confirmed by indirect ophthalmoscopy with scleral indentation. The temporal macular pulsations observed in our case may be a result of a superficial lateral long posterior ciliary artery (PCA). The lateral long PCA is known to supply a sector of the choroid temporal to the macular region, with its apex oriented posteriorly.1 PCAs have numerous interarterial and arteriovenous anastamoses in the choroid.2 In addition, we believe that hyperdynamic ocular circulation could also have existed due to the associated plus component of the disease. All of these factors may be responsible for the easily visible PCA pulsations. Behera et al.3 previously demonstrated a case with satellite fovea-like light reflex in the temporal macula in zone I ROP previously treated with intravitreal bevacizumab injection. They also proposed this area to correspond to the site of entry of a lateral long PCA. However, they noted induced pulsation with pressure from the RetCam console rather than spontaneous transmitted pulsation. These were also noted in the avascular region of the retina. Such findings (transmitted pulsation from long PCA) are benign but rare to visualize. These can perplex a young ophthalmologist regarding the etiology and lead to unnecessary further ocular and orbital imaging. This case highlights the importance of in-depth knowledge of the vascular pattern and branches of PCA circulation.

Granular corneal dystrophy: an enigma resolved

PurposeTo report the intra-familial phenotypic variation of granular corneal dystrophy (GCD) across different age groups.MethodTwo cases of GCD belonging to the same family (mother and daughter) were assessed and clinical findings were noted.ResultAn 18-year-old female with complaint of glare, on examination showed brownish granules involving bowman’s layer and superficial corneal stroma suggesting a diagnosis of Bowman layer dystrophy. Screening of her mother revealed multiple diffuse white granular opacities with snowflake appearance involving the central cornea. The intervening cornea was clear and limbus was not involved. Focal illumination showed deep stromal involvement. All these findings were typical of GCD. Genetic analysis revealed mutation of TGF beta-1 located on 5q31 which was consistent with our clinical diagnosis of GCD.ConclusionVariable clinical presentation of GCD in different age groups can lead to diagnostic dilemma. Screening of family members can be helpful especially when dealing with early cases of GCD.

Continuous intraoperative optical coherence tomography-guided shield ulcer debridement with tuck in multilayered amniotic membrane transplantation

Purpose: The aim of this study is to describe a modified surgical technique of continuous intraoperative optical coherence tomography (iOCT)-guided shield ulcer debridement with tuck-in multilayered Amniotic membrane transplantation (ML AMT) in vernal keratoconjunctivitis (VKC) with shield ulcer with plaque. Methods: Seven eyes of seven patients presenting with VKC with shield ulcer with plaque were enrolled in this prospective case series and planned for shield ulcer debridement with ML AMT. Debridement of the ulcer base with double-layered AMT was done under the continuous guidance of iOCT. The main outcome measure was the time for complete reepithelialization. Statistical analysis was performed using the Stata-14.0 program for Windows. Data were presented as mean ± standard deviation/median (minimum-maximum) and frequency percentage as applicable. Results: The surgery could be completed successfully in all cases and iOCT could provide real-time assessment of the depth of dissection during the entire procedure. The duration of complete healing and disintegration of amniotic membrane varied from 7 to 12 days. Recurrence was not seen in any case till 2 months follow-up. Conclusion: iOCT provides continuous monitoring of the depth of dissection and allows for a safe and complete debridement of the shield ulcer with plaque.

Bilateral proliferative retinopathy in B-cell acute lymphoblastic leukemia

A 4-year-old child with B-cell acute lymphoblastic leukemia presented with vitreous hemorrhage due to proliferative retinopathy in both eyes. Pars plana vitrectomy was performed in both eyes to clear nonresolving vitreous hemorrhage after systemic stabilization. Visual recovery was limited by the disc drag in the right eye and subfoveal exudation in the left eye. Etiopathogenesis and management of proliferative retinopathy in acute leukemias are discussed.

Periocular contact dermatitis with use of topical voriconazole 1% in mycotic keratitis

We present two cases of culture-proven fungal keratitis on natamycin treatment which developed periocular erythema, oedema, burning sensation and pruritus within 48 hours of the addition of topical voriconazole. On clinical examination, periocular erythema with induration was noted. A diagnosis of orbital cellulitis was suspected, but the absence of pain and tenderness refuted the diagnosis on clinical grounds. A dermatology consultation was sought, and a diagnosis of periocular contact dermatitis with voriconazole was made. A skin patch test was performed with the same medication; however, it was negative. Topical voriconazole therapy was withdrawn, and the patient was prescribed cold compresses and oral antihistamine medication, to which they responded well.

Corneal epithelial toxicity with intravitreal methotrexate in a case of B-cell lymphoma with ocular involvement

A 49-year-old woman, known case of diffuse large B-cell lymphoma, presented with complaints of floater in both eyes since 3 days. On examination, visual acuity was 0.18 logMAR in both eyes. Indirect ophthalmoscopy revealed presence of vitreous clumps. Vitreous biopsy was done and the histopathological report suggested a diagnosis of ocular lymphoma. The patient was treated with weekly injections of intravitreal methotrexate in both eyes. The patient developed severe photophobia, watering, redness and diminution of vision in the both eyes 2 days following the fifth dose of intravitreal methotrexate. Severe limbitis with annular corneal epitheliopathy and corneal haze was noted on slit-lamp examination. The patient was started on topical lubricants, antibiotic, ciclosporin, loteprednol, folinic acid and oral folic acid. Complete resolution was noted at 2-week follow-up. The patient, however, refused further injections and was kept on close follow-up to look for recurrence of the disease.

Cloudy Cornea with Arcus Juvenilis in a Case of Dense Deposit Disease

A 25-year-old male patient presented with complaints of blurred vision in both eyes since 2 years. The patient was a known case of nephrotic syndrome with dyslipidaemia for which he was on diuretics and lipid-lowering agents for 3 years. On examination, his visual acuity was 6/9 in both eyes with cloudy cornea and arcus juvenilis. Fundus examination was within normal limits. On systemic work-up, his lipid profile was deranged with increased serum total cholesterol, very low density lipoprotein, low density lipoprotein and triglyceride. The serum high density lipoprotein was decreased. Renal function test revealed elevated serum creatinine with significant proteinuria. Renal biopsy was suggestive of dense deposit disease on immunofluorescence and transmission electron microscopy. Ocular manifestation of dense deposit disease is characterised by retinal drusen, pigmentary atrophy, choroidal neovascular membrane and atypical serous retinopathy. To the best of our knowledge, anterior segment changes in dense deposit disease has not been reported. This is the first case reporting cloudy cornea with arcus juvenilis in a case of dense deposit disease.

Clinical presentation and management of corneal fistula

Purpose To describe the clinical features and management of corneal fistula in patients of healed keratitis. Methods Medical records of all patients of healed keratitis presenting to the cornea clinic from November 2016 to September 2017 were reviewed. Eightcases of corneal fistula (six true fistulas, two closed fistulas) were identified. Six patients were managed with autologous tenon patch graft while two patients were managed medically. Various risk factors and treatment outcomes of corneal fistulisation were evaluated. Results The patients included two patients of failed therapeutic keratoplasty (with resolved graft infection) and six patients of healed keratitis. The age of the patients ranged between 10 and 60 years. Five of the patients were male while three were female. The size of the fistula measured between 1 and 2 mm. A surrounding cystic area of diameter ranging between 1 and 4.5 mm was seen in all the patients. In all of the patients, the treating physician missed the diagnosis. Complete healing was noted at 6–8 weeks in all the patients who underwent tenon graft. One patient refused to undergo any surgery and was lost to follow-up. In another case, surgery was deferred due to uncontrolled hypertension and he developed anterior staphyloma subsequently. Conclusion Corneal fistula can often be missed in an apparently healed perforated corneal ulcer. Tenon patch graft is an effective technique for the management of corneal fistula.