Samrat Chatterjee

Tacrolimus in Corticosteroid-Refractory Vernal Keratoconjunctivitis.

Purpose: To evaluate the efficacy of 0.03% tacrolimus in the treatment of corticosteroid-refractory vernal keratoconjunctivitis (VKC). Methods: This open-label study enrolled 30 patients with VKC who were not responding to topical corticosteroid treatment for at least 4 weeks. All patients were treated with 0.03% tacrolimus eye ointment 3 times daily, 0.05% ketotifen eye drops twice daily, and preservative-free artificial tears. Symptoms (itching, redness, watering, discharge, burning, and photophobia) and signs (conjunctival injection, papillae, cobblestone papillae, limbal inflammation, or hypertrophy and corneal epithelial staining) were graded on a 4-point scale at enrolment, after 4 weeks, and at the end of treatment period, which was at 12 weeks. Composite scores for symptoms and signs were computed by summing individual scores. Treatment failure was denoted if additional treatment with corticosteroids were required. Results: The composite scores for symptoms (10.8, 3.8, 3.4) and signs (8.7, 4.7, 4.0) in 23 patients showed a statistically significant (P < 0.05) improvement from baseline to the 4- and 12-week visits. Among the signs, upper tarsal papilla showed improvement only at 12 weeks, but the scores for giant cobblestone papillae did not reach statistically significant reduction even at 12 weeks. There was improvement in visual acuity at 12 weeks, although it was not statistically significant (P = 0.05). Treatment failure was recorded in 17% patients. The only adverse effect reported was transient stinging sensation lasting for a few days. Conclusions: Tacrolimus 0.03% was apparently safe and effective in treating patients with steroid-refractory VKC. A small subset of patients may still require supplemental topical corticosteroids for resolution of their symptoms.

Fungal keratitis in lattice dystrophy.

We report a case of fungal keratitis occurring in a patient with lattice dystrophy. A 57-year-old farmer presented with a corneal ulcer following probable entry of paddy husk in the right eye, of one month duration. Corneal scraping revealed pigmented fungal filaments while culture grew Alternaria alternata. Treatment with 5% natamycin eye drops and 1% atropine healed the infection in four weeks. We would like to draw attention to the fact that the cornea in lattice dystrophy is prone to frequent erosions and is a compromised epithelial barrier to invasion by microorganisms. Patients must be made aware of this fact and should seek attention at the earliest following any trivial trauma. Management of minor corneal abrasions in them should be directed at healing the epithelium with adequate lubricants and preventing infection with topical antibiotic prophylaxis.

Multi-drug resistant Pseudomonas aeruginosa keratitis and its effective treatment with topical colistimethate

The purpose was to evaluate the clinical outcome in multi-drug resistant Pseudomonas aeruginosa (MDR-PA) bacterial keratitis and report the successful use of an alternative antibiotic, topical colistimethate in some of them. The medical records of 12 culture-proven MDR-PA keratitis patients, all exhibiting in vitro resistance by Kirby–Bauer disc diffusion method to ≥ three classes of routinely used topical antibiotics were reviewed. Eight patients were treated with 0.3% ciprofloxacin or ofloxacin, 1 patient with 5% imipenem/cilastatin and 3 patients with 1.6% colistimethate. The outcomes in 8 eyes treated with only fluoroquinolones were evisceration in 4 eyes, therapeutic corneal graft in 1 eye, phthisis bulbi in 1 eye, and no improvement in 2 eyes. The eye treated with imipenem/cilastin required a therapeutic corneal graft. All the three eyes treated with 1.6% colistimethate healed. Colistimethate may prove to be an effective alternative antibiotic in the treatment of MDR-PA keratitis.

Granulomatous inflammation in Acanthamoeba sclerokeratitis

This report describes the histopathological findings in a patient with Acanthamoeba sclerokeratitis (ASK). A 58-year-old patient with ASK underwent enucleation and sections of the cornea and sclera were subjected to histopathology and immunohistochemistry with monoclonal mouse antihuman antibodies against T cell CD3 and B cell CD20 antigens. Hematoxylin and Eosin stained sections of the cornea revealed epithelial ulceration, Bowmans membrane destruction, stromal vascularization, infiltration with lymphocytes, plasma cells, and granulomatous inflammation with multinucleated giant cells (MNGC). The areas of scleritis showed complete disruption of sclera collagen, necrosis and infiltration with neutrophils, macrophages, lymphocytes, and granulomatous inflammation with MNGC. No cyst or trophozoites of Acanthamoeba were seen in the cornea or sclera. Immunophenotyping revealed that the population of lymphocytes was predominantly of T cells. Granulomatous inflammation in ASK is probably responsible for the continuance and progression of the scleritis and management protocols should include immunosuppressive agents alongside amoebicidal drugs.

Trans-scleral explantation of posteriorly dislocated IOL-CTR complex in a case of anterior megalophthalmos with an unusually thin cornea

Anterior megalophthalmos and keratoglobus are characterised by corneal thinning and deep anterior chamber. They are clinically distinguished on the basis of normal to slightly decreased corneal thickness with a large corneal diameter (>13 mm) in case of anterior megalophthalmos, and marked limbus-to-limbus corneal thinning with globular protrusion in keratoglobus. To achieve and maintain a centred and stable intraocular lens (IOL) position in the bag is often difficult in cases of anterior megalophthalmos due to a too large diameter of the capsular bag and ciliary ring. We report a case of a 40-year-old man with features of anterior megalophthalmos with extremely thin cornea. He had spontaneous posterior dislocation of IOL and capsular tension ring (CTR) within the bag after initial successful cataract surgery. The dislocated complex could neither have been repositioned with scleral fixation due to large diameter of ciliary ring nor could it have been explanted through a clear corneal incision due to associated very thin cornea. We performed pars plana vitrectomy and separated the IOL-CTR complex inside the eye and explanted them separately through the sclerotomy, as is done for removal of intraocular foreign body. This avoided incision on the thin cornea. We conclude that this method can be very useful in a similar clinical situation but is complex enough to justify its use in routine cases.

Primary prevention of ocular injury in agricultural workers with safety eyewear

Purpose: The purpose of this study was to determine the effectiveness of preventing eye injury with the use of safety eyewear in agriculture workers. Methods: A sample group of 575 agricultural workers (Group A) engaged in harvesting paddy were provided with goggles with side covers. Following harvesting, a questionnaire-based survey was carried out to determine the frequency of their eye injuries. Workers with goggles were asked about the duration for which they used the goggles and also list barriers or difficulties with the same. The frequency of eye injuries in this group was compared with another group of agriculture workers (Group B) who did not use any safety eyewear. Results: The frequency of eye injuries in Group A was 4 (0.7%) and Group B was 61 (11.3%) which was highly significant (P = 0.0001). The relative risk calculated was 0.06 (95% confidence interval: 0.02–0.2). Agricultural workers in Group A had 94% less risk of ocular trauma compared to those in Group B. Injuries in both groups were caused by parts of the paddy plant. A significant number (76.2%) of workers used the goggles all or most of the time during work. Impaired vision when wearing goggles was the most frequent barrier reported by the workers. Other barriers were discomfort, shyness, forgetfulness, apathy, slowing of work pace, awkward appearance, and breakages. Conclusion: Safety eyewear conferred significant protection against work-related eye injuries in agriculture. Although safety eyewear was widely adopted by the workers, barriers reported by them will need to be addressed to make such programs more effective.

Silodosin-associated intraoperative floppy iris syndrome

A 75‐year‐old male presented to us for cataract surgery. He had been suffering from BPH for the past 8 years and was being treated with oral silodosin 8 mg daily for 4 years. The patient had not been informed of any potential ocular side effects of silodosin. He was neither diabetic nor hypertensive. His vision in the right eye and left eye was 20/80, N18 and 20/200, N36, respectively. Anterior segment examination was unremarkable but for nuclear sclerosis 2+ and 3+ in the right and left eye, respectively. Intraocular pressure was 10 mmHg in both the eyes. Fundus was normal. He was advised phacoemulsification with intra‐ocular lens implantation in the left eye which he underwent 3 days later. Preoperatively, the pupil was dilated with tropicamide 0.8% and phenylephrine 5% to a diameter of 6.0 mm. After a standard peribulbar block, routine phacoemulsification was performed with Alcon Infinity phaco machine using Ozil® technology and stop and chop technique through a 3.5 mm superior sclerocorneal tunnel. After hydrodissection, the pupil constricted to 4.0 mm diameter, and during subsequent steps, there was iris undulation and billowing. The anterior chamber was frequently formed with Viscoat® (Alcon Laboratories, Puurs, Belgium) to maintain pupillary dilatation. There was no iris prolapse at any time during surgery although the iris tended to be drawn toward the side port. An acrylic intra‐ocular lens (Acrysof IQ, Alcon Laboratories, Cork, Ireland) was implanted and the surgery was completed safely. The postoperative period was uneventful. His vision was 20/20 and N6 with correction.

Results of Ahmed glaucoma valve implantation in primary congenital glaucoma

To the Editor: We read with interest the article by Razeghinejad and colleagues on the results of Ahmed glaucoma valve implantation in primary congenital glaucoma. The study provides valuable data regarding a rarely encountered but potentially blinding childhood disease, considering the homogeneous population and inclusion of only primary congenital glaucoma. The aim of the study and the methods used for patient recruitment and detailed examination are appropriate. However, several pertinent questions remain unanswered. Although visual outcome was not the primary aim of the study, loss of light perception was considered a major complication, which occurred in 1 eye. It is difficult to have confirmatory qualitative evaluation by subjective methods in younger patients, and we would like to know how light perception was assessed. Chen and colleauges reported promising results after Ahmed glaucoma valve implantation and quantitative improvement in Snellen visual acuity. Morad and colleagues reported effective intraocular pressure control but severe visual loss. Therefore reporting of quantitative visual acuity assessment is warranted for the limited number of patients capable of assessment. Success or failure of the treatment in glaucoma is considered over 5 years. Survivor function at the far right of a Kaplan-Meier survival curve must be interpreted cautiously, because there are fewer patients remaining in the study group and the survival rates are not as accurate. In Razeghinejad and colleagues only 50% and 20% of patients are available for analysis at the third and fifth years of follow-up, respectively.

Retained releasable suture causing infectious keratitis following trabeculectomy

posed of elements such as sodium, chlorine, phosphorous, sulfur and calcium. Such FBs are thought to be chemically altered fragments of ophthalmic viscosurgical device and appear opaque white. In contrast, the Ti fragments from a phacoemulsification tip are made of Ti 6AL-4V ELI (grade 5) alloy, which is considered to be inert. Future magnetic resonance imaging compatibility is another key clinical issue, especially in light of the current 3–4 Tesla magnets being used for imaging. The Ti 6AL-4V ELI (grade 5) has no known magnetic properties and is commonly used in orthopedic and dental implants. A recent report recommended that a larger (2 mm) steel/titanium alloy Rosen chopper tip fragment FB be removed surgically because of its dislocation from the ciliary sulcus into the anterior chamber. However, our case demonstrates that conservative management of small phacoemulsification tip metallic FBs is a viable option because of their inert nature and compatibility with any need for future neuroimaging. Ultimately, the clinical decision to remove a FB associated with phacoemulsification should involve consideration of the FB source, size and location.