Surendra Basti

Results of a Prospective Evaluation of Three Methods of Management of Pediatric Cataracts

BACKGROUND Although a variety of approaches to manage cataracts in children have been studied, no consensus exists on the optimum approach. The authors, therefore, conducted a prospective, nonrandomized, consecutive study to evaluate three most commonly adopted methods of management of pediatric cataracts. METHODS Lensectomy anterior vitrectomy (LAV), extracapsular cataract extraction with intraocular lens implantation (ECCE + IOL) and ECCE, primary posterior capsulotomy, anterior vitrectomy with IOL (ECCE + PPC + AV + IOL) were the surgical procedures performed. Aphakia in the LAV group was corrected with spectacles or contact lenses. Intraoperative and postoperative results were analyzed. Discrete variables among the three groups were compared using chi square test. RESULTS One hundred ninety-two eyes were included in the study. There was no statistically significant difference in the intraoperative complications in the three groups. During a mean follow-up period of 11.3 months, postoperative obscuration of the visual axis was seen in 43.7% of eyes in the ECCE + IOL group and in 3.65% of eyes in the ECCE + PC + AV + IOL (p < 0.001). Two of the seven patients in the LAV group in whom contact lenses were prescribed developed corneal infiltrates. Severe postoperative anterior uveitis occurred in 15.9% and 13.8% of eyes in the ECCE + PPC + AV + IOL and ECCE + IOL groups, respectively. None of the eyes that underwent LAV developed this complication (P < 0.001). There was no statistically significant difference in the incidence of retinal detachment, endophthalmitis, or glaucoma in the three groups. CONCLUSION Of the three approaches, ECCE + PPC + AV + IOL was conducive to at least short-term maintenance of a clear visual axis, provided optimum refractive correction, and was not associated with increased risk of short-term complications. Continued follow-up of these eyes is necessary to conclude on the long term results of this technique.

Ocular surface squamous neoplasia: a review.

Even though ocular surface squamous neoplasia (OSSN) has been recognized for well over a century, the past decade has witnessed advances that have helped rewrite many of the paradigms for the diagnosis and management of these lesions. OSSN occurs predominantly in the elderly for whom they are the third most common oculoorbital tumors after melanoma and lymphoma. In addition to advanced age and male sex, other major risk factors linked to its pathogenesis are ultraviolet light, cigarette smoking, and the human papilloma virus. Although the latter has been linked to OSSN for nearly 4 decades, its identification and role in the pathogenesis of these tumors has been elucidated recently and is addressed in detail in this review. Newer techniques of impression cytology represent a noninvasive and reliable method of diagnosing OSSN and monitoring treated cases. The efficacy of chemotherapeutic agents such as mitomycin C and 5-fluorouracil have been proven in the recent past, making them a clear alternative to the time-tested treatment of surgical excision and cryotherapy. Early reports on the efficacy of topical Iterferon alpha 2b indicate significant promise in providing another alternative for the treatment of some of these neoplasms. These advances thus represent a minimally invasive and highly successful approach to the diagnosis and treatment of OSSN.

Experience during the learning curve of laser in situ keratomileusis

Purpose: To identify pitfalls and offer hints on achieving a successful outcome during the early laser in situ keratomileusis (LASIK) learning process. Setting: Gimbel Eye Centre, Calgary, Alberta, Canada. Methods: This was a retrospective review of the preoperative planning, surgical procedure, intraoperative and postoperative problems, and early postoperative anatomic and refractive results in the first 73 eyes that had LASIK. Results: Intraoperative complications included failure of the keratome to make a cut, excessively thin cap, repositioning difficulty, and inadequate intraocular pressure elevation. Early postoperative complications included excessive central and peripheral wrinkling of the cap, peripheral lipid deposits, and central edema of the cap. One month postoperatively, mean spherical equivalent refraction was ‐0.90 diopters (D) (range +1.75 to ‐6.00 D), and 45 eyes had a best corrected visual acuity between 20/15 and 20/40. Conclusion: Our retrospective review of the problems experienced during the early LASIK learning process should help novice lamellar refractive surgeons avoid such problems and shorten the learning curve.

Results of Bilateral Cataract Extraction with Posterior Chamber Intraocular Lens Implantation in Children

OBJECTIVE A retrospective study was undertaken to evaluate long-term anatomic and visual outcomes in eyes of children who underwent bilateral intraocular lens implantation. DESIGN The study design was a review of medical records of 24 children operated on for bilateral cataracts and posterior chamber-intraocular lenses. PARTICIPANTS Twenty-four children operated on for bilateral cataracts by 1 surgeon between February 1980 and February 1995 were studied. INTERVENTION Cataract extraction with bilateral posterior chamber-intraocular lens implantation was performed. MAIN OUTCOME MEASURES Best-corrected visual acuity, visual acuity without correction, intraocular pressure, manifest refraction, and any intraoperative or postoperative complications were measured. RESULTS At last follow-up (mean follow-up, 50.8 months; range, 10-149 months), the intraocular lens was in good position and the intraocular pressure was normal without medication in all eyes. Four years after surgery, 79.2% (19 of 24) of first eyes achieved a best-corrected visual acuity of 20/40 or better compared to 66.7% (16 of 24) of second eyes. No eye had any loss in best-corrected visual acuity. In first eyes of 3- to 8-year olds at the time of surgery, 73.3% (11 of 15) achieved a spherical equivalent within 2 diopters of the intended at 4 years after surgery compared to 80% of second eyes. In the 9- to 18-year-old group, 88.9% (8 of 9) of first eyes and 100% of second eyes achieved a spherical equivalent within 2 diopters of the intended at 4 years after surgery. Intraoperative and postoperative complications were minimal. CONCLUSIONS Long-term anatomic and visual results have been gratifying in this series of patients with bilateral implants.

Silicone oil adhesion to intraocular lenses: An experimental study comparing various biomaterials

Purpose: To perform an in vitro experimental study comparing the degree of adherence of silicone oil to various rigid and foldable intraocular lens (IOL) designs and to the human lens capsule. Setting: Center for Research on Ocular Therapeutics and Biodevices, Department of Ophthalmology, Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, USA. Methods: Seven IOL styles comprising various biomaterials were studied: fluorinetreated (FIuoriens™), heparin‐surface‐modified (HSM™), hydrogel, Memory‐Lens™, poly(methyl methacrylate) (PMMA), soft acrylic, and silicone lenses; the human crystalline lens was also studied. Each lens was immersed in silicone oil for 12 hours, then photographed, studied by scanning electron microscopy (except the crystalline lens), and subjected to computer‐generated image analysis to determine the silicone oil coverage. Results: Silicone oil coverage of dry silicone lenses was 100% and of lenses immersed in normal saline, 82.5%. The least coverage was on the heparin‐surfacemodified lens (mean score 9.4%). Coverage of the other four lenses ranged from approximately 15.1% to 33.7%. Mean coverage of the human lens capsule was 10.9%. Conclusion: Although a silicone IOL shows maximal adherence to silicone oil, other lens biomaterials are not immune to this complication. Silicone oil coverage was related to the dispersive energy component of the surface charge of the IOL biomaterial. Low dispersive energy materials had less silicone oil coverage, while those with higher dispersive energy had more oil coverage.

When may the posterior capsule be preserved in pediatric intraocular lens surgery

PURPOSE To refine indications for primary posterior capsulotomy (PPC) in conjunction with posterior chamber intraocular lens (PCIOL) implantation for cataract in childhood. DESIGN Noncomparative case series. PARTICIPANTS Patients 1 to 13 years old who underwent cataract extraction with intent to preserve the posterior lens capsule and PCIOL implantation between January 1992 and December 1998 at a pediatric hospital. METHODS Medical records were reviewed to determine the frequency and timing of posterior capsule opacification (PCO) after PCIOL surgery with preservation of an intact posterior capsule. Comparison of pseudophakic PCO rates for groups defined by age and several possible risk factors. Assessment of safety and efficacy for PPC with anterior vitrectomy performed through a limbal incision in cases where the posterior capsule could not be preserved. MAIN OUTCOME MEASURES Need for neodymium:yttrium-aluminum-garnet laser capsulotomy or surgical membranectomy to treat PCO. RESULTS PCO occurred in 40% of 30 eyes with intact posterior capsule. Mean follow-up duration was 22 months for eyes that had PCO develop and 24 months for those in which the posterior capsule remained clear. Laser capsulotomy was required for 64% of 14 eyes in the 1- to 6-year-old age range but for only 19% of 16 in the 6- to 13-year-old range (P < 0.05). Mean time from surgery to PCO was 7 months for the younger group and 13 months for the older group. A need for repeated capsulotomy (one eye) or membranectomy with anterior vitrectomy (two eyes) was found only in the younger age group. There was no association of PCO with trauma history, cataract type, residual lens cortex, IOL position, or postoperative fibrin clot. Final vision was possibly compromised as a result of PCO in one eye with amblyopia. None of 24 eyes in which PPC with anterior vitrectomy was performed out of intraoperative necessity before primary PCIOL implantation had secondary opacification develop. No reduction in postoperative vision was attributable to PPC. CONCLUSIONS PPC seems to be advisable for children less than 6 years old when cataract extraction with PCIOL implantation is performed. Preservation of the posterior capsule remains appropriate for older children with pseudophakia.

Current status of limbal conjunctival autograft.

The past decade has witnessed several major advances in the field of ocular surface reconstruction. It is now established that the limbal and corneal epithelia belong to the same clonogenic lineage and that conjunctival transdifferentiation does not occur. These facts have engendered the increasing use of limbal transplantation in several ocular conditions involving limbal compromise. Many reports on this procedure have been published in the past year. They add to the growing body of evidence that limbal transplantation is efficacious in replenishing the stem cell pool, promoting improved vision and enhancing ocular comfort. Recent clinical studies on limbal autograft transplantation also underscore the importance of preoperative impression cytology in donor eyes, highlight the fact that transplantation in inflamed eyes is to be avoided, and indicate that the procedure is likely to provide better outcomes if performed several months after ocular surface burns. The appreciation of the utility of amniotic membrane transplantation in ocular surface reconstruction has provided a surgical tool to use in tandem with limbal transplantation. Questions such as why limbal autografts fail, the long-term results of LAT, and whether limbal inclusion is mandatory during conjunctival transplantation after pterygium excision have not been answered fully. Studies on long-term outcomes with limbal allograft transplantation and those reporting on experience with newer techniques such as epithelial transplantation using tissue culture-cultivated epithelium are likely to provide better perspectives on the best way to reconstruct the ocular surface in stem cell-deficient eyes.

Eye findings of diffuse unilateral subacute neuroretinitis and multiple choroidal infiltrates associated with neural larva migrans due to Baylisascaris procyonis

PURPOSE To report childhood infection with Baylisascaris procyonis (raccoon round worm) manifesting as diffuse unilateral subacute neuroretinitis (DUSN) and choroidal infiltrates in association with neurologic disease (neural larva migrans). METHOD Observational case series, one with eye manifestations of DUSN, the other with choroidal infiltrates, both with severe neurologic degeneration. RESULTS Indirect immunofluorescence assays on serum and cerebrospinal fluid were positive for B. procyonis in one and serially positive and increasing in the other. Both children had a history of pica and raccoon exposure. CONCLUSIONS Baylisascaris procyonis infection is associated with two cases of severe neurologic degeneration with ocular lesions: DUSN and choroidal infiltrates. Although B. procyonis is known to cause DUSN, these cases indicate that concomitant ocular migration may accompany neural larva migrans. These are the third and forth cases in the US literature of neural larva migrans due to B. procyonis with eye findings.

Prospective evaluation of corneal endothelial cell loss after pediatric cataract surgery

Purpose: To study the alterations in endothelial cell count and morphology after pediatric cataract surgery using currently practiced techniques. Setting: L.V. Prasad Eye Institute, Hyderabad, India. Methods: In a prospective nonrandomized series comprising 20 eyes of 14 children with congenital or developmental cataract, endothelial cell loss from cataract surgery was evaluated. Mean patient age was 9.3 years (range 5 to 15 years). Extracapsular cataract extraction (ECCE) with intraocular lens QOL) implantation was performed in 11 eyes (Group 1). Primary posterior’capsulotomy and anterior vitrectomy were performed with ECCE and IOL implantation in 9 eyes (Group 2). Noncontact specular microscopy was done: preoperatively and‐6 to 8 and 24, to, 36 weeks postoperatively. Endothelial cell loss, alteration in the, coefficient of variation, and the change in the number of hexagonal cells were determined by semiautomated analysis of endothelial pictures. Results: Mean endothelial cell loss was 198.39 cells/mm2 (5.28%) in Group 1 and 295.17 cells/mm2 (7.50%) in Group 2 at 24 to 36 weeks. There was no statistically significant difference in alteration in endothelial cell count and morphology between the 2 groups. Conclusions: The results suggest that endothelial cell loss with currently practiced techniques of pediatric cataract surgery is within acceptable limits.

Acquired trichomegaly and symptomatic external ocular changes in patients receiving epidermal growth factor receptor inhibitors: Case reports and a review of literature

Purpose: To report the external ocular changes in 2 patients receiving epidermal growth factor receptor (EGFR) inhibitors. Methods: Retrospective observational case series. Two patients receiving epidermal growth factor inhibitors for metastatic non-small-cell lung carcinoma were followed clinically and with external photographs. Results: Findings included acneiform facial changes, telangiectasia of eyelid margins, meibomitis, tear film dysfunction, and unusual, hyperpigmented, tortuous eyelashes. Conclusions: EGFR inhibitors used in the treatment of certain malignancies can lead to symptomatic adnexal and ocular surface changes. Ophthalmologists should be aware of these to appropriately manage them.