Varsha M. Rathi

Management of traumatic cataract in children

Purpose: To evaluate the presentation, mode of management, and clinical outcome of traumatic cataract in children. Setting: L.V. Prasad Eye Institute, Hyderabad, India. Methods: One hundred thirty‐seven children (<16 years) who developed traumatic cataract, seen between January 1988 and December 1993, were retrospectively analyzed. Nature of injury, type of cataract, management, and outcome were evaluated. Results: The study group comprised 110 boys and 27 girls. Average follow‐up was 11.7 months (range 1 week to 60 months). Most injuries (54.7%) were caused by a stick or a bow and arrow. Most (53.2%) of the cataracts were total. Corneal scarring (60.5%) and iris‐related problems (49.6%) were the most common associated findings. Extracapsular cataract extraction with intraocular lens (IOL) implantation was performed in 65.67% of patients. Visual acuity improved from 20/200 or worse in 97.7% of patients preoperatively to 20/60 or better in 74.1 % of patients postoperatively. Seventeen patients had associated posterior segment insult; most failed to recover satisfactory vision. Posterior capsule opacification (PCO) was noted in 42.9% of patients. Conclusions: Extracapsular cataract extraction with IOL implantation provides satisfactory results in children with traumatic cataract. Associated posterior segment complications and development of PCO are the major obstacles to visual rehabilitation.

Boston ocular surface prosthesis: An Indian experience

Context: Boston ocular surface prosthesis (BOSP) is a scleral contact lens used in the management of patients who are rigid gas permeable (RGP) failures as with corneal ectasias such as keratoconus and in those patients who have ocular surface disease such as Stevens–Johnson syndrome (SJS). Aim: To report utilization of BOSP in a tertiary eye care center in India. Materials and Methods: We retrospectively reviewed charts of 32 patients who received BOSP from July 2008 to May 2009. Indications for fitting these lenses, improvement in visual acuity (VA) before and after lens fitting and relief of symptoms of pain and photophobia were noted. Paired t-test was used for statistical analysis using SPSS version 16.0 for Windows. Results: Thirty-two patients (43 eyes) received these lenses. These consisted of 23 eyes of 17 patients who failed RGP trials for irregular astigmatism and corneal ectasia such as keratoconus and post radial keratotomy and scar and 20 eyes of 15 patients with SJS. Mean age of RGP failures was 27.94 years. Pre- and post-BOSP wear mean LogMAR VA was 1.13 and 0.29, respectively, in RGP failures. The P value was statistically significant (P < 0.001). In patients with SJS, LogMAR VA was 0.84 ± 0.92 before and 0.56 ± 0.89 after lens wear. The P value was statistically significant (P < 0.001). VA improved by >2 lines in 7/20 eyes (35%) with SJS, with improvement in symptoms. Conclusion: BOSP improves VA in patients who have irregular astigmatism as in ectasias and RGP failures and improves vision and symptoms in patients with SJS.

Fluid filled scleral contact lens in pediatric patients: challenges and outcome.

PURPOSE To study the indications and the challenges while fitting scleral contact lens (ScCL) filled with fluid prior to lens insertion in pediatric patients. METHODS We retrospectively reviewed charts of patients of 16 years or less who received ScCL (PROSE - Prosthetic Replacement of the Ocular Surface Ecosystem, Boston Foundation for Sight, Needham Heights, MA, USA) that were filled with fluid (Normal saline) before lens insertion during July 2006 to April 2010. The main goal of ScCL fitting was to improve vision in patients having keratoconus (KC) and improve the ocular microenvironment in ocular surface disease (OSD). Visual acuity before and after lens wear was noted. RESULTS Fluid-filled ScCL were dispensed to 15 patients (20 eyes). The indications for ScCL fitting were KC (n = 3 eyes), Stevens Johnson syndrome (SJS, n = 13 eyes), radiation keratopathy (n = 1 eye), combined KC and SJS (n = 1 eye) and KC and vernal keratoconjunctivitis (VKC, n = 2 eyes). Mean age of the patients was 12.85 years. The average daily lens wear was 9 h. The vision improved by 2 lines or more in 85% and dropped by 2 lines or more in 45% eyes after 4 h of lens wear due to tear debris collection. None of the patients had any complications. Patients were self sufficient inserting and removing ScCL. Two patients had broken lenses during the follow-up. CONCLUSIONS ScCL are useful for pediatric patients who have OSD, irregular astigmatism or the two coexisting; KC combined with VKC or SJS, helping to maintain the health of the ocular surface and improves vision in these patients.

IKZF1, a new susceptibility gene for cold medicine–related Stevens-Johnson syndrome/toxic epidermal necrolysis with severe mucosal involvement

BACKGROUND Stevens-Johnson syndrome (SJS) and its severe form, toxic epidermal necrolysis (TEN), are acute inflammatory vesiculobullous reactions of the skin and mucous membranes, including the ocular surface, oral cavity, and genitals. These reactions are very rare but are often associated with inciting drugs, infectious agents, or both. OBJECTIVE We sought to identify susceptibility loci for cold medicine-related SJS/TEN (CM-SJS/TEN) with severe mucosal involvement (SMI). METHODS A genome-wide association study was performed in 808 Japanese subjects (117 patients with CM-SJS/TEN with SMI and 691 healthy control subjects), and subsequent replication studies were performed in 204 other Japanese subjects (16 cases and 188 control subjects), 117 Korean subjects (27 cases and 90 control subjects), 76 Indian subjects (20 cases and 56 control subjects), and 174 Brazilian subjects (39 cases and 135 control subjects). RESULTS In addition to the most significant susceptibility region, HLA-A, we identified IKZF1, which encodes Ikaros, as a novel susceptibility gene (meta-analysis, rs4917014 [G vs. T]; odds ratio, 0.5; P = 8.5 × 10(-11)). Furthermore, quantitative ratios of the IKZF1 alternative splicing isoforms Ik1 and Ik2 were significantly associated with rs4917014 genotypes. CONCLUSION We identified IKZF1 as a susceptibility gene for CM-SJS/TEN with SMI not only in Japanese subjects but also in Korean and Indian subjects and showed that the Ik2/Ik1 ratio might be influenced by IKZF1 single nucleotide polymorphisms, which were significantly associated with susceptibility to CM-SJS/TEN with SMI.

Contact lens in keratoconus.

Contact lenses are required for the visual improvement in patients with keratoconus. Various contact lens options, such as rigid gas permeable (RGP) lenses, soft and soft toric lenses, piggy back contact lenses (PBCL), hybrid lenses and scleral lenses are availble. This article discusses about selection of a lens depending on the type of keratoconus and the fitting philosophies of various contact lenses including the starting trial lens. A Medline search was carried out for articles in the English language with the keywords keratoconus and various contact lenses such as Rose k lens, RGP lens, hybrid lens, scleral lens and PBCL.

Trans-ethnic study confirmed independent associations of HLA-A*02:06 and HLA-B*44:03 with cold medicine-related Stevens-Johnson syndrome with severe ocular surface complications

Stevens-Johnson syndrome (SJS) and its severe variant, toxic epidermal necrolysis (TEN), are acute inflammatory vesiculobullous reactions of the skin and mucous membranes. Cold medicines including non-steroidal anti-inflammatory drugs and multi-ingredient cold medications are reported to be important inciting drugs. Recently, we reported that cold medicine related SJS/TEN (CM-SJS/TEN) with severe mucosal involvement including severe ocular surface complications (SOC) is associated with HLA-A*02:06 and HLA-B*44:03 in the Japanese. In this study, to determine whether HLA-B*44:03 is a common risk factor for CM-SJS/TEN with SOC in different ethnic groups we used samples from Indian, Brazilian, and Korean patients with CM-SJS/TEN with SOC, and investigated the association between CM-SJS/TEN with SOC and HLA-B*44:03 and/or HLA-A*02:06. We found that HLA-B*44:03 was significantly associated with CM-SJS/TEN with SOC in the Indian and Brazilian but not the Korean population, and that HLA-A*02:06 might be weakly associated in the Korean- but not the Indian and Brazilian population.

Fluid-filled scleral contact lenses in vernal keratoconjunctivitis.

Objectives: The purpose of this study is to report on the use of fluid-filled scleral contact lenses (F-ScCL) in patients with vernal keratoconjunctivitis (VKC). Methods: We retrospectively reviewed charts of four patients who had worn F-ScCL (PROSE, Boston Foundation for Sight, Needham Heights, MA) from July 2006 for VKC with two associated conditions; keratoconus and limbal stem-cell deficiency (LSCD). Any previous refractive correction or complications were noted. The main goal of fitting F-ScCL was to improve visual acuity in keratoconus and to improve the ocular microenvironment in LSCD. Visual acuity before and during lens wear and the average wearing time in hours per day was noted. Results: Four patients (7 eyes) with VKC wore F-ScCL for associated keratoconus (n=5 eyes), LSCD (n=2 eyes). The mean age of the patients was 17. 5 years. The LogMAR visual acuity was 0.4 and 0.18 before and during lens wear, respectively, at a mean follow-up of 14.8 months. The average lens wear was 8.30 hrs per day. Two patients developed acute hydrops at 2 and 12 months of lens wear and underwent descematopexy. Visual acuity with F-ScCL reduced by more than two lines because of the scar of healed hydrops. Of the 3 patients with keratoconus, 1 patient had used a piggy back lens system for 2.5 years before F-ScCL wear, and 2 patients had failed with rigid gas-permeable lens trial lenses. Conclusions: With coexisting keratoconus and VKC, F-ScCL improves vision and helps to maintain the health of the ocular surface.

Cataract formation after penetrating keratoplasty

Purpose: To assess the incidence and risk factors for developing cataract after penetrating keratoplasty (PKP). Setting: L.V. Prasad Eye Institute, Hyderabad, India. Methods: This retrospective analysis of 251 phakic patients who had PKP between 1987 and 1994 assessed the incidence of and risk factors for cataract formation. Patients were assigned to one of two groups: Group 1 (n = 96), patients with keratoconus and corneal dystrophy; Group 2 (n = 88), patients with corneal scar and adherent leucoma. Preoperative, intraoperative, and postoperative lens details were noted. Data on intraoperative iris procedures (excess manipulation, pupilloplasty, synechiolysis, peripheral iridectomy) and postoperative topical steroid usage were assessed. Results: Sixty‐seven patients were excluded because of incomplete lens status data. Of the remaining 184 patients, 45 (24.45%) developed cataract. Most cataracts (n = 31) developed within the first year of surgery. The incidence of cataract was significantly higher in Group 2 (n = 29) than in Group 1 (n = 16) (P = .0102). There was no significant between‐group difference in mean steroid dose (P = .7064); however, the mean dose was significantly higher in eyes with cataracts (563 ± 234 units) than in those without (479 ± 127 units) (P = .0352). In Group 2, 9 of 20 patients who had synechiolysis, 1 of 3 who had pupilloplasty, and 2 of 5 who had peripheral iridectomy developed cataract. In Group 1, no patient had irisrelated procedures. Conclusion: Excessive steroid use and intraoperative iris manipulations are major risk factors for cataract formation after PKP.

Prevalence of contact lens related complications in a tertiary eye centre in India

AIM To determine the prevalence of contact lens related complications in a tertiary eye care centre in India. METHODS A retrospective review of the charts of 1255 patients who visited our contact lens clinic during 2001-2004 was conducted. The inclusion criteria included patients of at least 18 years of age, having refractive errors and keratoconus. Exclusion criteria included previous corneal surgeries and pediatric patients. 190 subjects with lens related complications were identified from among 923 patients who were using lenses. RESULTS The prevalence of contact lens complications was 20.58%. Females with complications were more common (59.47%). The complications were more common in students. The most common complications were contact lens induced papillary conjunctivitis (CLPC) (6.39%), corneal vascularisation (4%), and superficial punctate keratitis (SPK) (3.5%). The total complications were less prevalent in patients wearing rigid gas permeable (RGP) lenses as compared to soft contact lenses. Infectious keratitis was noted in 8 eyes. Pseudomonas aeuroginosa was the most common organism isolated. The average daily wear with RGP lenses was 11.04±3.7h and 10.96±3h with soft contact lens. The highest number of complications was noted in 47.89% patients who were wearing lenses for excess of 11h. The number of patients with complications arising due to sleeping with the lenses was 74 (38.95%). CONCLUSION Prevalence of contact lens complications was more in soft contact lens wearers compared to RGP wearers. CLPC was the most common complication followed by vascularisation and SPK.

Misleading Goldmann applanation tonometry in a post-LASIK eye with interface fluid syndrome

A 21-year-old myope presented with decreased vision and corneal edema following vitreoretinal surgery for retinal detachment. While intraocular pressure (IOP) measurement with Goldmann applanation tonometer (GAT) was low, the digital tonometry indicated raised pressures. An interface fluid syndrome (IFS) was suspected and confirmed by clinical exam and optical coherence tomography. A tonopen used to measure IOP through the peripheral cornea revealed elevated IOP which was the cause of the interface fluid. Treatment with IOP-lowering agents resulted in complete resolution of the interface fluid. This case is being reported to highlight the fact that IFS should be suspected when there is LASIK flap edema and IOP readings using GAT are low and that GAT is not an optimal method to measure IOP in this condition. Alternative methods like tonopen or Schiotz tonometry can be used.