Complications and management in Descemet's stripping endothelial keratoplasty: Analysis of consecutive 430 cases.

Purpose: To analyze the complications and their managements in Descemet’s stripping endothelial keratoplasty (DSEK) in consecutive 430 cases by single surgeon in a tertiary eye hospital. Materials and Methods: 430 eyes of 366 patients with endothelial dysfunctions scheduled for DSEK, were analyzed retrospectively. In all cases donor dissection was performed manually, and ‘Taco’ insertion and unfolding technique was used. Intra-operative and postoperative complications with their managements and outcomes were reviewed retrospectively. Periodic endothelial cell density was analyzed for each patient till the last visit. Follow-up period was between 3 to 60 months (mean 18.7 months). Results: 13 (3.0%) eyes had operative complications during donor dissection and 16 (3.7%) had during recipient procedure. In 7 (1.6%) eyes, donor lenticule was replaced with a new one during the surgery. In early postoperative period, 21 (4.9%) eyes had donor dislocation and 12 (2.8%) eyes had air-induced pupillary block; and they were managed immediately. 2 cases had primary graft failure and in 1 case had postoperative bacterial endophthalmitis requiring evisceration. In late postoperative period, 48 (11.3%) eyes had secondary glaucoma and 14 (3.3%) eyes had late secondary graft failure. Endothelial rejection occurred in 5 (1.2%) cases. Mean endothelial cell loss was 19.7% after 3 months and 54.2% after 5 years. Total graft failure in this series was 31 (7.2%) and in 17 cases re-DSEK was performed successfully. Conclusions: Both operative and postoperative complications do occur in DSEK. Most of these complications can be managed by medical or appropriate surgical means. Some of the complications can be avoided and reduced with experience.

Keratouveitis caused by Euphorbia plant sap.

The milky sap or latex of Euphorbia plant is highly toxic and an irritant to the skin and eye. This report illustrates the spectrum of ocular inflammation caused by accidental inoculation of latex of Euphorbia plant. Three patients presented with accidental ocular exposure to the milky sap of Euphorbia species of recent onset. The initial symptoms in all cases were severe burning sensation with blurring of vision. Visual acuity reduced from 20/60 to counting fingers. Clinical findings varied from kerato-conjunctivitis, mild to severe corneal edema, epithelial defects, anterior uveitis and secondary elevated intraocular pressure. All symptoms and signs had resolved by 10-14 days with active supportive medication. People who handle Euphorbia plants should wear eye protection. It is always advisable to ask the patient to bring a sample of the plant for identification.

Ocular toxicity by latex of Calotropis procera (Sodom apple).

We report the spectrum of ocular toxicity following accidental inoculation of latex of Calotropis procera (Sodom apple) in 29 eyes between January 2003 and December 2006. All patients presented with sudden painless dimness of vision with photophobia. Twenty-five (86%) patients had initial visual acuity of less than 20/60. All eyes had conjunctival congestion and mild to severe corneal edema with Descemet's folds. Three (10%) eyes had an epithelial defect, nine (31%) had iridocyclitis, and seven (24%) had associated secondary glaucoma. After treatment with topical corticosteroids, antiglaucoma agents, cycloplegics, hypertonic saline and tears supplements, 27 (93%) eyes recovered completely within 3-14 days. After three months, 17 (74%) out of 23 eyes showed a significant low endothelial cell count compared to the normal fellow eye ( P 0.001). The latex of Calotropis procera causes significant ocular morbidity which may be preventable by simple health education. The long-term effect on corneal endothelium has to be studied further.

Descemet stripping and endothelial keratoplasty in endothelial dysfunctions: three-month results in 75 eyes.

PURPOSE: To analyze the results of Descemet stripping and endothelial keratoplasty (DSEK) in the first consecutive 75 cases. MATERIALS AND METHODS: Prospective, non-randomized, non-comparative interventional case series. Seventy-five eyes of 75 patients with endothelial dysfunctions of different etiology, scheduled for DSEK, were included in this study. Healthy donor cornea with a cell count of> 2000 cells/sq mm was considered for transplantation in each case. Indications, operative problems and postoperative complications were noted. Best corrected visual acuity (BCVA), refractive and keratometric astigmatism, central corneal thickness (CCT) and endothelial cell density (ECD) were analyzed for each patient after a minimum follow-up of three months. RESULTS: Main indication was pseudophakic corneal edema and bullous keratopathy in 53 (70.7%) eyes. Seventeen (22.7%) cases had moderate to severe Fuchs' dystrophy with various grades of cataract; and DSEK was combined with manual small-incision cataract surgery (MSICS) with posterior chamber intraocular lens (PCIOL) in those cases. After three months, BCVA was 20/60 or better in 62 (82.7%) cases. Mean refractive and keratometric astigmatism were 1.10 +/- 0.55 diopter cylinder (DCyl) and 1.24 +/- 0.92 DCyl. The CCT and ECD were 670.8 +/- 0.32 microm and 1485.6 +/- 168.6/sq mm respectively. The mean endothelial cell loss after three months was 26.8 +/- 4.24% (range: 13.3-38.4%). Dislocation of donor lenticule occurred in six (8.0%) eyes. Graft failure occurred in one case. CONCLUSIONS: Descemet stripping and endothelial keratoplasty is a safe and effective procedure in patients with endothelial dysfunctions with encouraging surgical and visual outcomes. It can be safely combined with MSICS with PCIOL in patients with moderate to severe Fuchs' dystrophy with cataract.

Persistent corneal edema secondary to presumed dead adult filarial worm in the anterior chamber.

We present three cases of persistent corneal edema secondary to presumed dead adult filarial worms lying in the anterior chamber with their attachment to the endothelium. Two of them were initially diagnosed as descemet's fold with corneal edema. Two patients underwent penetrating keratoplasty and in one case, surgical removal was partly possible with clearing of cornea.

Epidemiological and microbiological diagnosis of suppurative keratitis in Gangetic West Bengal, eastern India.

PURPOSE: To determine the epidemiological pattern and risk factors involved in suppurative corneal ulceration in Gangetic West Bengal, eastern India, and to identify the specific microbial agents responsible for corneal infections. METHODS: All patients with suspected microbial keratitis presenting to the corneal clinic at Disha Eye Hospital, Barrackpore, West Bengal, India, from January 2001 to December 2003 were evaluated. Sociodemographic data and information pertaining to the risk factors were recorded. After diagnosing infective corneal ulcer clinically, corneal scraping and cultures were performed. RESULTS: Over a three-year period, 1198 patients with suppurative keratitis were evaluated. Ocular trauma was the most common predisposing factor in 994 (82.9%) patients (P< 0.0001), followed by use of topical corticosteroids in 231 (19.28%) patients. Cultures were positive in 811 (67.7%) patients. Among these culture positive cases, 509 (62.7%) patients had pure fungal infections (P< 0.001), 184 (22.7%) patients had pure bacterial infections and 114 (14.1%) had mixed fungal with bacterial infections. Acanthamoeba was detected in 4 (0.49%) patients. The most common fungal pathogen was Aspergillus spp representing 373 (59.8%) of all positive fungal cultures (P< 0.0001), followed by Fusarium spp in 132 (21.2%) instances. Most common bacterial isolate was Staphylococcus aureus, representing 127 (42.6%) of all the bacterial culture (P< 0.0001) followed by Pseudomonas spp 63 (21.1%). CONCLUSION: Suppurative keratitis in Gangetic West Bengal, most often occurs after a superficial corneal trauma with vegetative or organic materials. Fungal ulcers are more common than bacterial ulcers. Aspergillus spp and Staphylococcus aureus were the most common fungus and bacteria respectively. These "regional" findings have important public health implications for the treatment and prevention of suppurative corneal ulceration in this region of India.

Low endothelial cell count and clear corneal grafts.

Specular microscopic study on clear corneal grafts indicates that at times surprisingly low endothelial cell density can maintain the grafted cornea in a relatively dehydrated state. The critical limit of the endothelial cell count for corneal decompensation is thought to be 700 cells/mm2. This communication reports 13 cases of clear corneal graft with endothelial cell count below 700 cells/mm2.

Intravitreal live Gnathostoma spinigerum.

Intraocular infestation by live Gnathostoma spinigerum is a rare occurrence in humans. Most of the published reports are from South-East Asia. We report a case of intravitreal gnathostomiasis, where the worm was removed live and intact by pars plana vitrectomy.