Rajesh Fogla

Interface fluid after laser in situ keratomileusis

We report a case in which raised intraocular pressure (IOP) was associated with interface fluid after uneventful bilateral laser in situ keratomileusis (LASIK). The patient presented with diffuse lamellar keratitis in both eyes 3 weeks postoperatively that was treated aggressively with topical corticosteroids. A steroid-induced rise in IOP resulted in interface fluid accumulation and microcystic edema. Measurements with the Goldmann tonometer revealed an IOP of 3.0 mm Hg in both eyes. However, Schiotz tonometry recorded a pressure of 54.7 mm Hg in both eyes. Reduction in the dosage of topical corticosteroid and medical treatment of the raised IOP resulted in resolution of the microcystic edema and interface fluid accumulation. This case highlights the inaccuracies of IOP measurement after LASIK and the resulting complications.

Keratectasia in 2 cases with pellucid marginal corneal degeneration after laser in situ keratomileusis

&NA; We report 2 patients who experienced progressive blurring of vision following myopic laser in situ keratomileusis (LASIK) in 1 eye (Case 1) and bilaterally (Case 2). High against‐the‐rule astigmatism, associated with perilimbal thinning inferiorly, was seen on refraction in all eyes. Regional corneal pachymetry confirmed the peripheral corneal thinning inferiorly. Corneal topography revealed the typical features of pellucid marginal corneal degeneration (PMCD) in the untreated eye of Case 1. Advanced changes were noted in the fellow eye. The corneal topography findings in Case 2 were similar to those seen in PMCD. Patients with early PMCD may present to the refractive surgeon with a stable refraction, normal corrected visual acuity, and adequate central corneal thickness. Corneal topography data along with regional corneal pachymetry must be interpreted carefully to detect these cases. Laser in situ keratomileusis can lead to a rapid progression of PMCD.

Diffuse lamellar keratitis: are meibomian secretions responsible?

drawn in the irrigation mode, with the aspiration port facing anteriorly since the capsular bag becomes loose and inadvertent posterior capsule capture may occur at this juncture. If the I/A probe is in the aspiration mode during withdrawal of the probe, an inadvertent posterior capsule tear may occur. We would like to highlight additional clues for complete removal of an OVD during phacoemulsification.

Deep anterior lamellar keratoplasty combined with autologous limbal stem cell transplantation in unilateral severe chemical injury.

Purpose: To evaluate the efficacy of deep anterior lamellar keratoplasty combined with autologous limbal stem cell transplantation for ocular surface reconstruction and visual rehabilitation in eyes with unilateral, late-stage, severe chemical injury. Methods: This was a retrospective, noncomparative, interventional case series that included 7 eyes of 7 patients, with severe unilateral late stage chemical injury, exhibiting corneal vascularization, conjunctivalization, and extensive corneal scarring were treated at the C. J. Shah Cornea Service, Sankara Nethralaya, a tertiary care center. Surgical procedures included releasing symblepharon adhesions, excising epibulbar fibrous tissue, superficial keratectomy to remove fibrovascular tissues over cornea, deep anterior lamellar dissection, grafting a lamellar corneal button, and transplanting autologous limbal graft, with or without amniotic membrane transplantation. The main outcome measures were relief of patient symptoms, postoperative recovery of the ocular surface, corneal clarity, corneal epithelial stability, and best corrected visual acuity. Results: The mean duration between the injury and surgery was 24.4 ± 21.8 months. No intraoperative complications were noted. Successful epithelialization was achieved in all eyes. The reconstructed corneal surface remained stable during the entire follow-up period (mean follow-up, 16.57 ± 5.12 months). All patients had resolution of ocular symptoms. Remarkable improvement in vision was noted in all (85.7%) except 1 eye in which recovery was limited due to amblyopia. The average best corrected visual acuity at last follow-up was 20/50. No complications were noted in the donor fellow eye. Conclusions: DALK combined with autologous limbal transplantation can restore a healthy, stable ocular surface, besides providing a clear cornea that remarkably improves the visual acuity, in patients with unilateral, late stage, severe chemical injury.

Corneoscleral epithelial cysts: evidence of developmental etiology.

PURPOSE To describe the clinical features, histopathology, surgical management and possible etiopathogenesis of corneoscleral epithelial cysts. METHODS Three patients with corneoscleral epithelial cysts underwent surgical ablation of the cysts. Material obtained during surgery was subjected to histopathologic analysis. RESULTS At last follow-up (mean, 6.3 months), none of the cysts had recurred. All patients had improved visual acuity. Histopathology revealed the occurrence of glandular elements suggestive of lacrimal tissue in one of the cysts. CONCLUSION The presence of ectopic lacrimal tissue suggests a developmental etiology for such cysts. Marsupialization of the scleral portion of the cyst and chemical ablation of the lining epithelium of the corneal cyst with 20% trichloroacetic acid appears to be a safe and effective technique in the surgical management of corneoscleral epithelial cysts.

Bilateral corneal infiltrates after excimer laser photorefractive keratectomy

A 26-year-old man developed painless inferior subepithelial infiltrates away from the site of ablation in both eyes after excimer laser photorefractive keratectomy (PRK) for myopia. Clinical characteristics of the corneal infiltrates resembled staphylococcal-immune infiltrates. The condition responded to treatment with topical diluted steroids and antibiotics. There was no residual corneal scarring. The infiltrates did not affect the refractive outcome of the surgery. Recognition of this rare entity will help clinicians avoid aggressive investigative and treatment modalities that can affect the results of PRK.

CORNEAL TOPOGRAPHY IN ATYPICAL PELLUCID MARGINAL DEGENERATION

PURPOSE Pellucid marginal degeneration (PMD) is commonly described as a noninflammatory corneal ectasia typically involving the inferior cornea. Although reports of superior corneal changes in PMD exist, the topographic patterns of these PMD variants are not well characterized. We describe corneal topographic alterations seen in eyes with atypical PMD. METHODS Computer-assisted videokeratography was performed in 10 eyes of five patients with PMD. RESULTS Eight of the eyes studied had changes involving the superior cornea, with or without changes in the inferior cornea. Atypical presentations of PMD included extension of inferior peripheral thinning above the horizontal meridian and occurrence of superior corneal thinning and ectasia with or without typical inferior changes. Atypical PMD reveals topographic patterns similar to classic PMD, but corneal changes also involve the nasal, temporal, or superior quadrants or a combination of these. The topographic maps reflect the location of peripheral corneal thinning and extent of corneal protrusion. CONCLUSIONS Corneal topographic changes in atypical PMD are similar to those seen in typical PMD but can involve the superior cornea.

Chronic microsporidial stromal keratitis in an immunocompetent, non-contact lens wearer.

An 82-year-old healthy man with unilateral chronic stromal keratitis, initially diagnosed to have viral keratitis and refractory to medical therapy, showed numerous oval, microsporidial organisms, measuring 4-5 m in length in the corneal biopsy. Penetrating keratoplasty, followed by treatment with systemic albendazole and topical propamidine isethionate resulted in resolution of the infection. Electron microscopy of the keratoplasty specimen demonstrated sporoblasts with diplokaryotic nuclei and multiple coils of the filament. The light and electron microscopic features were consistent with microsporidial keratitis.

Bilateral penetrating keratoplasty--indications, results and review of literature.

Purpose: To analyze the indications, functional results, and rates of graft rejection and failure after bilateral penetrating keratoplasty (PK) in a major eye care hospital and research center in India. Methods: Retrospective review of the case records of 38 patients who underwent bilateral PK and had at least 6 months follow-up after cornealtransplantation in the second eye. Results: The mean age of the 38 patients (20 M, 18 F) was 35 ± 25 years (range, 0.5 to 79 years). Mean follow-up was 49 ± 23 months (range, 13.4 to 116.4 months) after surgery in the first eye and 31 ± 22 months (range, 6.6 to 103.6 months) after surgery in the second eye. The average time interval between surgery in the first and second eye was 18 ± 10 months (range, 0 to 38 months). The commonest indications for surgery were corneal dystrophies (50%),aphakic bullous keratopathy (21%), and keratoconus (11%). Postoperatively, secondary glaucoma occurred in 2 first and 3 second eyes. Best-corrected visual acuity at last follow-up was > 6/12 in 34% of first eyes and 50% of second eyes, and was > 6/60 in 26% and 18% of first and second eyes respectively. Allograft rejection occurred in 4 of the first eyes and 3 of the second eyes. The two-year graft survival rate in first eyes was 70% and in second eyes was 83%. Worse outcomes were noted in grafts performed for secondary endothelial failure. Earlier graft failure occurred in first eyes (54 ± 5 months) compared to second eyes (79 ± 10 months) (Logrank Test p = 0.2311).Conclusions: Bilateral penetrating keratoplasty has reasonable success in selected patients. Corneal transplantation in the second eye does not seem to increase the risk of graft rejection in either eye.

Sympathetic Ophthalmia Following Cyclocryotherapy With Histopathologic Correlation

Sympathetic ophthalmia following cyclocryotherapy is extremely rare. The authors report a case of sympathetic ophthalmia after cyclocryotherapy for neovascular glaucoma due to central retinal vein occlusion. Histopathologic examination of the exciting eye showed features of significant sympathetic ophthalmia along with migration of uveal pigments to the limbal conjunctiva with lymphocytic infiltration around it, thereby indicating probable etiopathogenesis.