Purvasha Narang

Successful management of severe unilateral chemical burns in children using simple limbal epithelial transplantation (SLET)

Aim To study the outcomes of simple limbal epithelial transplantation (SLET) for unilateral total limbal stem cell deficiency (LSCD) secondary to severe ocular surface burns in children. Methods Retrospective interventional case series was performed at a private referral tertiary care centre. Children less than 15 years of age who underwent autologous SLET for total LSCD and had a minimum follow-up of 6 months were included in the study. Demographic and clinical data were recorded in a predesigned form. All patients underwent SLET with a standardised technique. The outcome was defined as complete success (completely epithelialised, avascular corneal surface), partial success (focal recurrence of symblepharon not involving the visual axis) and failure (unstable ocular surface with persistent epithelial defects/symblepharon recurrence involving the visual axis). Results The mean age was 5.75 years (range 2–12). The male to female ratio was 3:1. All eyes (four) presented in the acute phase, had grade 6 chemical injury (Dua classification) and underwent amniotic membrane transplantation at presentation. The mean interval between initial injury and SLET was 6 months (range 4.5–8). The outcome was complete success and partial success in one-fourth and three-fourths of cases, respectively. The overall follow-up was 12–60 months. Pre-SLET visual acuities were hand motions (one eye) and perception of light (three eyes). Post-SLET visual acuities were counting fingers close to face (one eye), 6/36 (two eyes) and 6/18 (one eye) at final follow-up. Cases with partial success underwent repeat SLET with conjunctival autograft, after which the outcome was complete success in all cases at varied follow-up intervals (13–36 months). Conclusions SLET appears to be a promising technique for treatment of LSCD secondary to ocular surface burns in children.

Primary Simple Limbal Epithelial Transplantation Along With Excisional Biopsy in the Management of Extensive Ocular Surface Squamous Neoplasia.

Purpose: To describe the utility of simple limbal epithelial transplantation (SLET) along with tumor excision in the management of extensive ocular surface squamous neoplasia (OSSN) to avoid limbal stem cell deficiency (LSCD). Methods: This case report describes the management of a 75-year-old man clinically diagnosed with OSSN involving more than 3 quadrants of limbus. The excisional biopsy of tumor along with 4-mm healthy margin led to a complete loss of the limbus, which was restored by limbal epithelial cell transplantation using the SLET technique in the same setting. Results: The tumor was found adherent to the episclera in the superotemporal quadrant and required episcleral and superficial lamellar scleral dissection. The entire tumor could be excised, and complete reepithelialization of the cornea was seen within 2 weeks. Histopathology showed tumor cells infiltrating the stroma and base of the excision biopsy, suggesting invasive squamous cell carcinoma. The excised margins were tumor free. To prevent recurrence, the patient underwent radiotherapy (plaque brachytherapy). After a follow-up period of 2 years, a successful outcome in the form of a stable ocular surface, no tumor recurrence, and no signs of LSCD was achieved in our patient. Conclusions: Restoration of limbal stem cells using SLET technique in an extensive OSSN in the primary setting may be pertinent to a good outcome.

Cataract surgery in chronic Stevens–Johnson syndrome: aspects and outcomes

Aim To assess the outcome of cataract surgery in patients with chronic sequelae of Stevens–Johnson syndrome (SJS). Methods Setting: Tertiary eye care centre in South India. Design: Retrospective, non-comparative, consecutive, interventional case series. Study period: March 2003 to May 2014. Of the 1662 consecutive patients with SJS, 32 patients (40 eyes) with chronic sequelae of SJS who underwent cataract surgery were included. The main outcome measures were best-corrected visual acuity (BCVA) and ocular surface stabilisation. The visual acuity was expressed with reference to the logMAR. Results The study included 12 men (37.5%) and 20 women (62.5%). 8 patients (25%) had bilateral cataract surgeries. The median preoperative BCVA was 1.61 (IQR, 0.80 to 2.78) (only perception of light in three eyes). The median BCVA in the immediate postoperative period was 0.60 (IQR, 0.30 to 1.48) (perception of light in an eye) which was significantly different from the preoperative BCVA (p<0.0001). The median BCVA achieved was 0.30 (IQR, 0.00 to 0.80), suggesting further improvement. Median time taken to achieve this postoperatively was 1.5 months (IQR, 8 days to 3 months). The median BCVA during the last follow-up was 0.48 (IQR, 0.18 to 1.00). The preferred type of cataract surgery was phacoemulsification. Ocular surface condition remained stable in 35 eyes (87.5%). Ocular surface breakdown in four eyes (10%) was managed appropriately. Conclusion Cataract surgery outcome can be visually rewarding in chronic sequelae of SJS provided ocular surface integrity is adequately maintained preoperatively and postoperatively.

Ocular surface squamous neoplasia in a setting of fungal keratitis: a rare co-occurrence

AbstractPurposeTo describe a rare co-occurrence of ocular surface squamous neoplasia (OSSN) in a patient with microbial keratitis.MethodsCase report.ResultsWe describe a 68-years female who developed ocular surface squamous neoplasia (OSSN) in an eye with culture proven severe fungal keratitis of 5 months duration, which progressed to endophthalmitis. She was managed with extended enucleation for left eye. Histopathology examination was consistent with squamous cell carcinoma of ocular surface with no corneal stromal/scleral/anterior chamber involvement. She received adjuvant chemotherapy with topical Interferon alpha2b (3 cycles) for positive margins. Six months after treatment, she is completely tumor free.ConclusionCo-occurrence of OSSN and chronic fungal keratitis is rare. We recommend that patients with chronic ocular infections should be examined and followed closely for abnormally thickened limbal areas.

Bilateral herpes simplex keratitis reactivation after lacrimal gland botulinum toxin injection

Botulinum toxin A (BTA) injections into lacrimal gland are being used for refractory epiphora due to intractable lacrimal disorders with success rates reported from 18% to 86%. Most common side effects are transient ptosis and diplopia. We report a case of a 59-year-old female injected with 2.5 units of BTA injection in each lacrimal gland for functional epiphora. The patient had a history of herpes simplex viral keratitis that was quiescent for more than 2 years. After 3 weeks, she developed reactivation of viral keratitis bilaterally, which was successfully managed with antivirals and topical steroids. Reactivation of quiescent herpes simplex keratitis is a possibility after lacrimal gland BTA and caution should be exercised in such cases.

Utility of intraocular endoscope for lacrimal canaliculi and sac examination

PurposeIntraocular endoscope was used as a dacryoendoscope, and its observations and performance in lacrimal drainage system (LDS) are reported.MethodsThe Endo Optiks (Little Silver, New Jersey, USA), an intraocular endoscope (modified with customized sheath), was used for LDS visualization in ten normal adults and five patients with lacrimal disorders.ResultsWe were able to capture high-definition images of lacrimal canaliculi and sac in all normal adults. Smooth whitish canalicular mucosa with lumen could be appreciated in all normal individuals. Common canaliculus showed variable folds among individuals and reddish lacrimal sac mucosa could be appreciated with great details. In patients with canalicular obstruction, site of obstruction was presented as whitish gray area with no visible lumen, which could be opened up precisely with trephination. No false passage was formed in any of the cases. One of the cases had membranous canalicular obstruction, which was opened with probe itself. Nasolacrimal duct could not be examined due to the shorter length of the probe.ConclusionIntraocular endoscope can be used as high-resolution dacryoendoscope for visualization of lacrimal canaliculi and sac.

Getting hooked: Eyelash in lacrimal punctum

a Ophthalmic Plastic Services, Sanjivni Eye Care, Ambala, India b Cornea and Anterior Segment Services, Sanjivni Eye Care, Ambala, India ⇑ Corresponding author at: Ophthalmic Plastic surgery, Dacryology and Ocular, Oncology services, Sanjivni Eye Care, Ambala, India. e-mail address: dr.swati888@yahoo.com (S. Singh). Fig. 1. A, Slit lamp image showing right nasal bulbar conjunctival congestion with a localized elevated nodule medially. B, Root of lash follicle im into upper lacrimal punctum. C, Slit lamp image (16 ) under cobalt blue filter showing an area of fluorescein uptake (borders marked) correspon lash-surface contact in closed eyelid. D, Removed lash follicle (held in forceps) with thin mucoid strand over its surface. Swati Singh a,⇑; Purvasha Narang ; Vikas Mittal b

Ocular surface burn secondary to smart phone battery blast

Sir, Indiscriminate usage of cellphones makes us vulnerable to the associated risks including accidental burns and blast injuries.[1] Low‐quality products and user negligence increase the risks.[2] A 37‐year‐old male admitted in emergency services of Sanjivni Eye Care, Ambala with pain, burning sensation and watering from both the eyes, following a smartphone battery blast. Immediately, after disconnecting the phone from the charger (after overnight charging), he tried to make a call. Since it was hot, it accidentally fell from his hand, its battery exploded and the phone blew apart. This led to sudden emission of smoke, flames, and soot particles, affecting his eyes, as he was facing it. His presenting visual acuity was 20/120 and 20/600 in right eye and left eye (LE), respectively. Examination revealed charred lashes, circumciliary congestion and multiple soot particles embedded over the cornea, conjunctiva, and the lid margins [Fig. 1a and b]. There was no limbal ischemia and it was diagnosed as Grade 1 ocular surface burn.[3] The eyes were washed with copious ringer lactate and the debris was carefully removed under operating microscope and eyes were re‐examined. Fluorescein staining showed corneal epithelial defects [Fig. 1c and d]. Posterior segments and intraocular pressures were normal, with no intraocular foreign bodies. Topical preservative free lubricants, corticosteroids (in tapering doses), broad‐spectrum antibacterial agent, and cycloplegic agent, were prescribed along with systemic nonsteroidal anti‐inflammatory drug for pain relief. The healing of epithelial defects started next day and was complete by the 3rd day. Inflammation subsided in 1 month with good final outcome in both eyes (unaided visual acuity 20/20; clear corneas except a faint peripheral scar in LE) [Supplementary File 1].

Oral mucosal grafting combined with tenonplasty for ocular surface and lid margin reconstruction in an atypical sectorial chemical burn

A 46-year-old woman presented with chemical injury in both eyes after the instillation of undefined eye-drops prescribed by quack. She had an atypical presentation in the form of bilateral severe necrosis of both lids and whole palpebral conjunctiva. Extensive debridement with conjunctival epitheliectomy, tenonplasty and amniotic membrane transplantation (AMT) was performed. Characteristic differences from typical chemical injuries were a sectorial involvement of ocular surface and keratinisation over distorted lid margins. Lid margin needed replacement by labial mucous membrane for the restoration of ocular surface. Ocular surface reconstruction with AMT in acute phase and mucous membrane grafting for involved lid margins in late phase achieves vision salvage and avoids late complications in drug-induced chemical injury.