Sunita Chaurasia

Clinical Outcomes of Penetrating Keratoplasty After Autologous Cultivated Limbal Epithelial Transplantation for Ocular Surface Burns

PURPOSE To report the clinical outcomes of penetrating keratoplasty (PK) after autologous cultivated limbal epithelial transplantation in eyes with limbal stem cell deficiency (LSCD) after ocular surface burns. DESIGN Retrospective case series. METHODS This study included 47 patients with unilateral LSCD treated by autologous cultivated limbal epithelial transplantation and PK between 2001 and 2010. PK was performed either along with (single-stage; n = 12) or at least 6 weeks after (2-stage; n = 35) limbal transplantation. The primary outcome measure was corneal allograft survival, and failure was defined clinically as loss of central graft clarity. Secondary outcomes were postoperative Snellen visual acuity and complications. RESULTS Most patients were young (mean age, 18 ± 11.4 years) males (76.6%) with LSCD resulting from alkali burns (78.7%) and with visual acuity less than 20/200 (91.5%). The mean follow-up was 4.2 ± 1.9 years. Kaplan-Meier corneal allograft survival rate at 1 year was significantly greater in eyes undergoing 2-stage limbal and corneal transplantation (80 ± 6%; median survival, 4 years) compared with single-stage limbal and corneal transplantation (25 ± 13%; median survival, 6 months; P = .0003). Visual acuity of 20/40 or better was attained by 71.4% of eyes with clear corneal grafts. Allograft failure occurred in 26 (60.5%) eyes as a result of graft rejection (57.7%), graft infiltrate (26.9%), or persistent epithelial defects (15.4%). Recurrence of LSCD was more common after single-stage (58.3%) than 2-stage (14.3%) surgery (P = .008). CONCLUSIONS The 2-stage approach of autologous cultivated limbal epithelial transplantation followed by PK successfully restores ocular surface stability and vision in eyes with chronic ocular burns. The single-stage approach is associated with poorer clinical outcomes and should be avoided.

Microbial keratitis after LASIK.

PURPOSE To report cases of microbial keratitis after LASIK from a tropical climatic zone. METHODS This retrospective case series included 17 eyes of 15 patients managed at our center from January 1999 to December 2007. All patients had a detailed clinical evaluation followed by corneal scrapings. The material obtained on scraping was subjected to detailed microbiology evaluation. Initial medical treatment was based on microbiology results and included irrigation of the interface with appropriate antimicrobial solutions. The flap was amputated in patients who developed flap necrosis. N-butyl cyanoacrylate tissue adhesive was applied for gross thinning and penetrating keratoplasty (PK) was performed for advanced cases of keratitis. RESULTS Mean patient age was 25.8 years (range: 18 to 44 years). Two patients had undergone unilateral surgery. Thirteen patients presented with infection in 1 eye and 2 patients had bilateral infection. The microorganisms isolated were filamentous fungi (4 eyes), Nocardia asteroides (5 eyes), atypical mycobacteria (4 eyes), Acanthamoeba (2 eyes), Corynebacterium (1 eye), and Staphylococcus epidermidis (1 eye). The infection resolved with medical treatment in 6 eyes, medical treatment and flap amputation in 4 eyes, and PK in 4 eyes. Two patients were lost to follow-up. Five eyes of 4 patients referred to us within 10 days of symptom onset resolved on medical treatment with final visual acuity ranging from 20/20 to 20/80. CONCLUSIONS In a tropical region, it is important to consider uncommon organisms such as fungi, Nocardia, and Acanthamoeba as possible etiological agents in keratitis after LASIK. A detailed microbiology work-up will help in definitive diagnosis and appropriate treatment.

Deep anterior lamellar keratoplasty in children.

PURPOSE To evaluate the outcomes of deep anterior lamellar keratoplasty (DALK) in children. DESIGN Retrospective interventional case series. METHODS setting: Institutional, L.V. Prasad Eye Institute, a tertiary care center in south India. study population and intervention: All children less than 16 years of age undergoing DALK from January 2003 to January 2011. main outcome measure: Visual outcome and complications. RESULTS Twenty-six eyes of 26 children (13 male and 13 female) with a mean age of 7.82 ± 4.64 years underwent DALK for keratoconus (8), microbial keratitis (6), corneal scar (6), corneal keloid (3), chemical injury with limbal stem cell deficiency (2), and dermoid (1). Big bubble was achieved in 5 eyes, while manual dissection was done in 21. Follow-up ranged from 1 week to 7.3 years. Seventeen patients with a minimal follow-up of 6 months were evaluated for visual outcomes. Final vision varied from counting fingers to 20/20 (mean sphere 2.32 diopters, mean cylinder -2.5 diopters). Complications encountered were suture-related graft infiltrate (3), graft dehiscence (3), and Descemet membrane detachment (2). CONCLUSIONS DALK is a feasible option in children with stromal corneal pathology. It offers advantages in the form of lower risk of graft rejection. However, the risk of complications such as suture-related infections and graft dehiscence persists even in these cases.

Clinical manifestations of congenital aniridia.

PURPOSE To study the various clinical manifestations associated with congenital aniridia in an Indian population. METHODS In this retrospective, consecutive, observational case series, all patients with the diagnosis of congenital aniridia seen at the institute from January 2005 to December 2010 were reviewed. In all patients, the demographic profile, visual acuity, and associated systemic and ocular manifestations were studied. RESULTS The study included 262 eyes of 131 patients with congenital aniridia. Median patient age at the time of initial visit was 8 years (range: 1 day to 73 years). Most cases were sporadic and none of the patients had parents afflicted with aniridia. The most common anterior segment abnormality identified was lenticular changes. Cataract was the predominant lens finding, observed in 93 of 231 (40.3%) phakic eyes. Other lens abnormalities were subluxation, coloboma, posterior lenticonus, and microspherophakia. Corneal involvement of varying degrees was seen in 157 of 262 (59.9%) eyes, glaucoma was identified in 95 of 262 (36.3%) eyes, and foveal hypoplasia could be assessed in 230 of 262 (87.7%) eyes. Median age when glaucoma and cataract were noted was 7 and 14 years, respectively. None of the patients had Wilms tumor. CONCLUSIONS Congenital aniridia was commonly associated with classically described ocular features. However, systemic associations were characteristically absent in this population. Notably, cataract and glaucoma were seen at an early age. This warrants a careful evaluation and periodic follow-up in these patients for timely identification and appropriate management.

Descemet membrane endothelial keratoplasty combined with epithelial debridement and mitomycin-C application for fuchs dystrophy with preoperative subepithelial fibrosis or anterior basement membrane dystrophy.

Purpose: The aim of this study was to evaluate the anterior corneal surface regularity and light scattering before and after Descemet membrane endothelial keratoplasty (DMEK) with epithelial debridement and application of mitomycin C in Fuchs dystrophy–affected eyes with preoperative subepithelial fibrosis or anterior basement membrane dystrophy. Methods: In this case–control study, a chart review identified 37 eyes with Fuchs dystrophy and anterior corneal changes evident on preoperative slit lamp examination and that underwent DMEK combined with epithelial removal plus mitomycin-C application. These cases were compared with 83 contemporaneous DMEK procedures performed in eyes with Fuchs dystrophy without clinically evident anterior surface problems (controls). The outcome measures were corrected distance visual acuity (CDVA), corneal surface regularity assessed by topography, anterior corneal light scattering by densitometry, endothelial cell loss, and complications. Results: Cases and controls had comparable demographics. Preoperatively, the cases had significantly poorer corneal surface regularity and transparency than did controls (P < 0.0001). Six months postoperatively, the cases achieved comparable CDVA, corneal surface regularity, and transparency as did controls (all P > 0.05), and 77% had a CDVA ≥ 20/25, excluding 2 eyes with preexisting retinal problems. The median 6-month endothelial cell loss was 25% and did not differ significantly between cases and controls (P = 0.31). In 1 case, there was delayed epithelial healing. Conclusions: Even patients with endothelial dysfunction with anterior stromal changes can realize a significant improvement in corneal surface topography and transparency by undergoing combined epithelial removal with DMEK, and this can preclude the need for a subsequent procedure to address residual corneal surface problems or the need for a penetrating keratoplasty.

Outcomes of Descemet's stripping endothelial keratoplasty in eyes with failed therapeutic penetrating keratoplasty.

Purpose:  To report the results of Descemet’s stripping endothelial keratoplasty (DSEK) for failed therapeutic penetrating keratoplasty (PK).

Endothelial keratoplasty in children: surgical challenges and early outcomes

A significant proportion of paediatric keratoplasties are performed for endothelial dysfunction due to failed graft, congenital hereditary endothelial dystrophy1 and pseudophakic corneal oedema. Descemets stripping endothelial keratoplasty (DSEK) is an evolving procedure for isolated endothelial dysfunction with encouraging results in adults. The application and outcome of this procedure in the paediatric population has not been well studied with few reports being published so far.2–5 This study reports the indications, surgical technique and early outcomes of DSEK in children <14 years of age. All children who underwent DSEK at our centre between January 2008 and January 2010 were included. Under general anaesthesia, an appropriate sized superior or temporal fornix based conjunctival flap was reflected and a 4–5 mm long, self-sealing scleral tunnel was made. The Descemets membrane was scored using a reverse …

Clinical profile of graft detachment and outcomes of rebubbling after Descemet stripping endothelial keratoplasty

Purpose To review the clinical profile of graft detachment following Descemets stripping endothelial keratoplasty (DSEK) and analyse the outcomes of rebubbling for graft detachment. Methods Retrospective review. Results 27 of a total of 309 eyes that underwent DSEK (8.7%) underwent rebubbling with air injection between January 2009 and February 2010. Eighteen (66.6%) of these eyes had complete and 9 (33.3%) had partial detachment of the transplanted lenticule. Successful attachment was observed in 20/27 (74%) eyes (12/18 with total and 8/9 with partial detachments), and clear grafts were achieved in 13 (65%) of these 20 eyes, while 7 (35%) eyes had primary graft failure. Visual acuity was 20/60 or better in 6 of these 20 eyes (35%), between 20/100 and 20/60 in 4 eyes (25%), and <20/200 in 10 eyes. Three of the 10 lenticules that failed to attach with the first rebubbling procedure underwent a second attempt of rebubbling, four underwent a repeat DSEK with good outcomes, and three underwent PK. Univariate analysis showed additional vitrectomy at the time of DSEK to be a statistically significant risk factor for persistent graft detachment following rebubbling (p<0.04). Conclusion Rebubbling following detachment of the donor lenticule was successful in achieving graft adhesion in the majority of patients (74%), but 35% had a primary graft failure. The second attempt at rebubbling (in three patients) led to successful attachment, but the oedema failed to recover. Those who underwent repeat DSEK for unsuccessful rebubbling did well with no complications.

Outcomes of air descemetopexy for Descemet membrane detachment after cataract surgery.

PURPOSE: To analyze the outcomes of post‐cataract surgery descemetopexy for Descemet membrane detachment using intracameral air injection. SETTING: Cornea Department, LV Prasad Eye Institute, Hyderabad, India. DESIGN: Interventional case series. METHODS: The clinical data of patients who had descemetopexy from August 2010 to February 2011 for Descemet membrane detachment after cataract surgery using intracameral (100%) air injection were reviewed after institutional review board and ethics committee approval was obtained. RESULTS: Of the 14 patients, 9 had manual small‐incision cataract surgery using the Blumenthal and Moisseiev technique, 4 had phacoemulsification, and 1 had combined phacoemulsification with trabeculectomy. The mean duration between cataract surgery and descemetopexy was 19.5 days (range 2 to 49 days). Successful reattachment of Descemet membrane and resolution of corneal edema occurred in all except 1 patient. Two patients had elevated intraocular pressure 1 day postoperatively due to appositional angle closure in 1 and pupillary block in the other. Of the 13 patients with successful Descemet membrane reattachment, the corrected distance visual acuity was 20/40 or better in 11 cases, 20/80 in 1 case, and 20/160 in 1 case. Three of the 13 patients had comorbidity factors affecting vision. CONCLUSION: Air descemetopexy was a safe option in the management of Descemet detachment after cataract surgery. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Lens-preserving excision of congenital hyperplastic pupillary membranes with clinicopathological correlation

Persistent pupillary membrane is a congenital, incomplete involution of the tunica vasculosa lentis. These membranes are usually tenacious, with fine fibrils attached to the iris collarette on one side, with the other end either free floating or attached to the lens or iris focally on the opposite side. This condition is thought to represent ectopic iris tissue on the lens with abnormal iris stroma caused by aberrant involutional changes in the primitive embryological vascular system of anterior segment. Dense and thick membranes, particularly within the pupil, may result in deprivation amblyopia. We report clinical and histopathological findings in a case of a 12-year-old boy with bilateral extensive hyperplastic persistent pupillary membrane that was surgically removed without injury to the crystalline lens.