Senthil Maharajan

Outcomes of deep anterior lamellar keratoplasty following successful and failed ‘big bubble’

Aim The most popular technique for deep anterior lamellar keratoplasty (DALK) is the ‘big bubble’ (BB) technique wherein air is injected in the cornea to create a bubble that separates Descemets membrane (DM) from the stroma. An attempt to create a BB often results in the cornea being filled with numerous small bubbles without the formation of a BB. Manual dissection is then required to complete the procedure. The aim of the study is to compare these two groups, successful BB versus failed bubble (FB) dissection to determine whether the clinical outcomes were different. Methods In this retrospective comparative study, 46 patients out of 52 who underwent DALK for various corneal stromal diseases such as keratoconus, stromal dystrophy or corneal scarring (caused by different conditions) were included in the analysis. BB was achieved in 25 patients and in the remaining 21 patients a BB separation of the DM was not possible necessitating manual lamellar dissection of stroma to get as close to the DM as possible. Results The authors compared best-corrected visual acuity, contrast sensitivity, astigmatism, interface densitometry and Scheimpflug pachymetry in the two groups. Postoperative corneal thickness was higher in the ‘small bubbles’ group (mean 628.9 vs 564.1 μm; p<0.0005), but there was no significant difference in best-corrected visual acuity, astigmatism, contrast sensitivity and densitometry between the groups. Conclusions In DALK, manual lamellar dissection is a reasonable alternative when BB separation of the DM is not achieved.

Profile of sight-threatening infectious keratitis: a prospective study.

Purpose:  To prospectively study patients presenting with sight‐threatening corneal ulcers with a view to identify the predisposing factors, causative organisms, clinical signs and treatment outcomes.

Intra-lesional 5 fluorouracil for the management of recurrent pterygium

AimRecurrence is the most common complication arising from pterygium surgery. The aim of this study was to investigate the effectiveness of 5 fluorouracil (5FU) in halting the recurrence of pterygium after surgical excision.MethodsA retrospective review of patients treated for pterygium recurrence was carried out. Patients with recurrent (secondary) pterygium were treated with multiple weekly intra-lesional injections of 0.1–0.2 ml (2.5–5 mg) 5FU post-operatively depending on the size of the recurrence. The treatment was started within 1 month from the date of recurrence. The time from surgery to start of recurrence, previous treatment modalities, and number of recurrences were documented. The number of injections required to induce arrest of progression and/or regression of vascularity and fleshiness of the pterygium and any complications related to 5FU treatment were examined.ResultsFifteen eyes from 14 patients with recurrent pterygium treated with intra-lesional 5FU injections were analysed. Three of the 15 eyes had undergone a secondary excision and 12 had undergone a primary excision. In all, 93.3% of patients showed regression of the fibrovascular tissue (thickness and vascularity) and arrest of progression following a dose of 0.1–0.2 ml (2.5–5 mg) 5FU. Twelve eyes required three injections or fewer, whereas one patient required eight injections. This beneficial effect was maintained over an average follow-up period of 17 months. No complications from 5FU were observed.ConclusionThe use of weekly intra-lesional 5FU injections for the treatment of recurrent pterygium is safe and effective in limiting the progression and inducing the regression of recurrent pterygium. The number of injections can be tailored according to clinical need.

In vivo confocal microscopy in the diagnosis and management of acanthamoeba keratitis showing new cystic forms

Acanthamoeba keratitis (AK) is a painful potentially blinding corneal infection that has been increasingly reported in association with soft contact lens wear. Pain out of proportion to signs is noted when there is associated nerve involvement but epithelial AK might not present with severe pain. We present two cases in whom the decision to treat for AK was based on in vivo confocal microscopy (IVCM) findings, with favourable outcomes. Novel IVCM presentations of cysts as ‘signet rings’ and ‘bright spots’ in addition to the classical ‘double wall’ images, were noted. In both cases, acanthamoeba were confirmed on culture as well. IVCM can provide early evidence of acanthameba infection. Treatment, when initiated while the organism is largely confined to the epithelium as was carried out in these two patients, can result in healing with minimal scarring. A 24-year-old female contact lens wearer presented with a 1-mm diameter paracentral stromal infiltrate (Fig. 1a) with no overlying ulcer, in her left eye. Her vision was 20/20. Routine IVCM examination with HRT II Rostock Cornea Module (Heidelberg Engineering,

Choroidal detachment in perforated corneal ulcers: frequency and management

Aims: To determine the frequency of choroidal detachment (CD) in eyes with non-traumatic corneal ulcer perforation and, also, to assess the efficacy and safety of cyanoacrylate glue in sealing corneal perforations. Methods: 18 eyes of 17 patients were studied. Inclusion criterion was any patient with a non-traumatic perforated corneal ulcer. All patients had a thorough history taken and complete ophthalmic examination including B-scan ultrasonography. Patient demographics, presence of CD, and efficacy of corneal gluing were assessed. Results: Eight of the 18 eyes (44%) were documented to have a CD. Among perforations of >2 mm2, six eyes (75%) were documented to have CD compared with two eyes (20%) with perforations of ⩽2 mm2 (p = 0.054). No correlation could be determined between perforation duration and incidence of CD. Of the 15 eyes that underwent gluing, there were 13 successes (87%) and two failures (13%). Within the successes four patients (27%) required re-gluing because of infection (one patient) or progression of melt and glue loosening (three patients). Failure was the result of severe progression of melting (one patient) and a very large perforation (one patient). Conclusion: Choroidal detachment following corneal ulcer perforation is common and is more likely in larger corneal perforations. Preoperative B-scan should be considered in cases of large corneal perforations requiring therapeutic keratoplasty to document choroidal detachment, which if large may require drainage. Cyanoacrylate glue is an effective and safe method for sealing small corneal perforations. A vigil must be maintained for infection while the glue and bandage contact lens are in situ.

Atypical hydrops in keratoconus

To report the clinical presentation, progress and management of atypical acute hydrops. A retrospective case study of three patients with keratoconus, two of whom had previously undergone penetrating keratoplasty. The patients underwent full ophthalmological examination and digital slit-lamp imaging of the cornea throughout the course of the condition. The two patients who had previously undergone keratoplasty had spontaneous hydrops primarily affecting the host bed but in one case extended to the graft inferiorly; however, in the third patient it was traumatic in origin. The Descemet’s tear affected the host rim in only one patient, which resolved spontaneously. In another patient, the hydrops was related to an internal dehiscence of the graft–host junction and had to be managed by an endothelial transplant covering the dehisced graft–host junction. In the third patient, hydrops secondary to trauma was also associated with acute haemops. Progression of keratoconus post keratoplasty can occur exclusively in the recipient bed leading to acute hydrops in the host sparing the transplanted cornea. The progressive thinning and ectasia of the recipient bed can also result in internal graft–host dehiscence leading to chronic oedema. Rapid entry of aqueous or blood cells into the corneal stroma following acute rupture of the Descemet’s membrane suggests that the abnormal stroma of the eye with keratoconus may have an important role to play in the pathogenesis of acute hydrops/haemops.

Health tourism and the need for occasional strong paternalism: complications and management of cosmetic anterior chamber iris implantation

Health tourism involves intentional travel abroad to obtain private medical care. Motivations are numerous, ranging from financial (affordable treatment) to accessing care unavailable at home [1]. Evidence regarding risk is often limited, sometimes speculative, with little information to guide decisions. It can be biased, based on sensationalist reports, often produced by people with inadequate expertise in such procedures [2]. Most reports reflect individual cases or small case series of problems. Limited studies publishing complication rates for health tourism exist [3], making risk hard to assess. Complications may be underreported where surgery is associated with financial gain and where patients travel from abroad with poor follow up. A survey by the British Association of Plastic, Reconstructive and Aesthetic Surgery found 37% of members had seen complications of health tourism [4], raising concerns for an individual’s risk but the burden within public healthcare facilities treating complications. Several publications exist on the dangers of cosmetic iris implants [5], the risks of which have been known for years. We report a case of devastating complications following the procedure. A 45-year old phakic male had bilateral BrightOcular implantation in 2013 in Jordan (Fig. 1a). Upon return he periodically developed red, painful, photophobic eyes. Intraocular pressures were elevated during those episodes with associated anterior chamber inflammation. Gonioscopy showed peripheral iris entrapment into the iridocorneal angle (Fig. 1b). Uveitis, glaucoma, hypheama syndrome was diagnosed. He was asked to return promptly to Jordon for implant removal. After a period of delay, he went as advised. On return, subsequent examination revealed bilateral corectopia, extensive iris atrophy, stretch holes, peripheral anterior synechiae and cataract formation (Fig. 1c, d). Intraocular pressures were elevated and cyclodiode was performed. Despite implant removal, progressive endothelial cell loss with corneal decompensation ensued (Fig. 1e). The patient was listed for Descemets stripping automated endothelial keratoplasty (DSAEK). While awaiting a graft he developed bacterial keratitis (Fig. 1f), resulting in right eye corneal scarring, and the need for penetrating keratoplasty (PK) bilaterally. The right eye did well (Fig. 1g), with the graft remaining clear and Snellen best corrected visual acuity (BCVA) of 6/6. The left eye vision recovered, but developed a suture abscess with subsequent graft failure (Fig. 1h). The patient is awaiting a second PK (with BCVA of hand movements). Despite previous reports of significant complications, cosmetic iris implants are still advertised across multiple websites and social media platforms in various countries. Some testify the procedure as safe with no patient going blind. We highlight the dangers, reporting potential for bilateral pain, severe sight loss and morbidity. We emphasise visual rehabilitation is not always simple following implant extraction. Cataracts, glaucoma surgery, iris deformation and endothelial cell loss constitute multiple challenges. We join colleagues in calling for international eye surgery communities to increase awareness of this potentially sight threatening issue and informing patients of risks prior to undertaking surgery. Professional governing bodies should encourage reporting of complications from such cosmetic surgery and consider closer monitoring. Better international legislation restricting dangerous surgical practice could be explored. * Senthil Maharajan senthil.maharajan@nuh.nhs.uk

Reply to Abu-Ain and Webber

Comment The AM can be held on the eye by various methods: glue, suturing, or, as recently described, with a conformer. We have found all these methods to have disadvantages. Sutures can cut out, cause haemorrhage, and irritate, and we have found conformers to be uncomfortable for the patient. We believe the method described here has several advantages; it is cheap and can be easily performed, and is well tolerated by the patient. Examination of the eye is possible through the amnion (Figure 1d), and the BBCL can be removed and replaced whenever necessary with negligible trauma to the eye.