Outcome of pterygium surgery: analysis over 14 years.

AIM: To report the outcome of pterygium surgery performed at a tertiary eye care centre in South India. METHODS: Retrospective analysis of medical records of 920 patients (989 eyes) with primary and recurrent pterygia operated between January 1988 and December 2001. The demographic variables, surgical technique (bare sclera, primary closure, amniotic membrane transplantation (AMT), conjunctival autograft (CAG), conjunctival-limbal autograft (CLAG), or surgical adjuvants), recurrences and postoperative complications were analysed. RESULTS: A total of 496 (53.9%) were male and 69 (7.5%) had bilateral pterygia. Bare sclera technique was performed in 267 (27.0%) eyes, primary conjunctival closure in 32 (3.2%), AMG in 123 (12.4%), CAG in 429 (43.4%), and CLAG in 70 (7.1%). Adjuvant mitomycin C was used in 44 (4.4%) cases. The mean duration of follow-up was 8.9+/-17.0 and 5.9+/-8.8 months for unilateral primary and recurrent pterygia, respectively. The overall recurrence rate was 178 (18.0%). Following primary and recurrent unilateral pterygium excision respectively, recurrences were noted in 46 (19.4%) and 1 (33.3%) eyes after bare sclera technique, five (16.7%) and 0 after primary closure, 28 (26.7%) and 0 with AMG, 42 (12.2%) and five (31.3%) with CAG, and nine (17.3%) and two (40%) with CLAG. Recurrences were significantly more in males with primary (23.3 vs 10.7%, P<0.0001) and recurrent (26.7 vs 0%, P=0.034) pterygia, and in those below 40 years (25.2 vs 14.8%, P=0.003). CONCLUSION: CAG appears to be an effective modality for primary and recurrent pterygia. Males and patients below 40 years face greater risk of recurrence. Bare sclera technique has an unacceptably high recurrence. Prospective studies comparing CAG, CLAG, and AMG for primary and recurrent pterygia are needed.

Risk factors for and management of dropped nucleus during phacoemulsification.

PURPOSE: To study the risk factors and management of posteriorly dislocated crystalline lenses during phacoemulsification at a teaching institution. SETTING: L.V. Prasad Eye Institute, Hyderabad, India. METHODS: This retrospective analysis included all phacoemulsification procedures performed by experienced and inexperienced surgeons over 7 years. The incidence, risk factors for, role of surgical experience, mode of management, and the final outcome of posteriorly dislocated lens nuclei were evaluated. RESULTS: Of a total 11 343 phacoemulsification procedures performed between 1993 and 1999, the nucleus was dropped in 38 eyes (0.3%). Two patients with a dropped nucleus were referred from an outside practice. The incidence of dropped nucleus with experienced surgeons (22/8671; 0.2%) was significantly less than that with inexperienced surgeons (16/2672; 0.6%) (P =.007). Sixteen of the 22 cases of dropped nucleus (72.7%) in the experienced group and 1 of 16 (6.3%) in the inexperienced group had risk factors (P =.0005). Nucleus removal was performed using vitreoretinal procedures in 39 eyes; 1 eye with a dropped epinucleus was managed conservatively. The final best corrected visual acuity was 20/40 or better in 21 eyes (53.8%). CONCLUSIONS: The incidence of dropped nucleus was more frequent with inexperienced surgeons, even though experienced surgeons had more cases with predisposing risk factors. Modern vitreoretinal procedures reduce morbidity and improve the visual outcome.

Penetrating keratoplasty in children.

PURPOSE: To determine the success of penetrating keratoplasty in the presence of various pediatric corneal abnormalities. METHODS: We performed a retrospective study of pediatric corneal grafts at L.V. Prasad Eye Institute, Hyderabad, India. Outcome of pediatric corneal transplantation was evaluated in terms of anatomic and optical success and factors contributing to poor graft survival. On the basis of the corneal pathology, patients were divided into three categories: congenital, acquired nontraumatic, and acquired traumatic. RESULTS: A retrospective analysis of 154 penetrating keratoplasties performed in 140 children, aged 14 years or younger, was done. The average follow-up was 1.3 years (range, 1 week-5 years). Grafts remained clear in 102 (66.2%) of 154 eyes. Clear grafts were achieved in 30 (63.8%) of 47 eyes with congenital opacities, 12 (54.5%) of 22 eyes with opacities from trauma, and 60 (70.6%) of 85 eyes with acquired nontraumatic opacities. Most (26 of 52) of the graft failures occurred during the first 26 weeks after surgery. Survival analysis revealed the probability of a graft remaining clear at the end of 26 weeks as 80% (SE, 3.39%). Poor graft survival could be correlated with those younger than 5 years (p = 0.0341) and performance of anterior vitrectomy (p = 0.0002). Most grafts failed because of allograft rejection (42.3%), infectious keratitis (26.9%), or secondary glaucoma (13.4%). Postoperatively, 53 eyes had > or =20/400 vision, 29 of which had > or =20/50. Vision could not be assessed in 33 eyes because of the young age. CONCLUSION: Whereas anatomic success of pediatric keratoplasty is increasing, optical success continues to remain less than satisfactory. Early surgical intervention and intensive amblyopia therapy may promote visual recovery.

Management of pediatric aphakia with silsoft contact lenses.

PURPOSE: To evaluate the performance of silicone elastomer lenses in pediatric eyes with aphakia. METHODS: We retrospectively studied pediatric aphakic eyes fit with Silsoft lenses (elastofilcon A, Bausch & Lomb) at the L.V. Prasad Eye Institute, India. RESULTS: Seventy-four children (106 eyes) with a median age of 9.0 months (range: 1 month to 12 years) were included in the study. Congenital cataract was the pre-existing pathology in 84 eyes. Lenses were fit between 1 week and 5 years following surgical intervention (median: 25 days). The most frequently used base curves were 7.5 mm (n=46 eyes) and 7.7 mm (n=39 eyes); lens diameter was 11.3 mm (n=103 eyes). Satisfactory fit was achieved in 86 eyes (81.1%). One-week extended wear was the most commonly recommended mode of wear (n=95 eyes). Lenses (n=118) were replaced for change of power, lens loss, and deposits or damage. Lenses were worn for > or =6 months in 68 eyes (64.2%). Twenty-three contact lens related adverse events occurred, all of which resolved uneventfully. On survival analysis, the probability of not having a lens related complication was 75.5% (95% CI; 61.5-89.5) at 24 months. CONCLUSIONS: In the management of pediatric aphakia, Silsoft lenses are safe, provide satisfactory optical correction, and are easy to handle. Limited availability and the financial costs associated with frequent lens replacement are limitations in our socioeconomic circumstances.

Laser cataract surgery.

Lasers have been investigated for cataract removal for nearly two decades. The technology has now reached a stage at which cataract can indeed be removed entirely with laser alone. Neodymium:yttrium-aluminum-garnet and erbium:yttrium-aluminum-garnet are the laser sources being utilized at the present time by manufacturers of laser cataract surgery systems. Initial clinical experience reported in the literature has served to highlight both the laser's capabilities and areas that need further refinement. Despite the thrill associated with the availability of this alluring new technology for cataract removal, laser systems with higher efficiency and innovative surgical techniques to optimally utilize their capabilities are necessary if laser cataract surgery is to be an improvement over current techniques.

Heparin-surface-modified intraocular lenses in pediatric cataract surgery: prospective randomized study.

PURPOSE: To evaluate the performance of heparin-surface-modified (HSM) intraocular lenses (IOLs) in pediatric eyes after cataract surgery. SETTING: L.V. Prasad Eye Institute, Hyderabad, India. METHODS: This prospective, randomized, double-masked, controlled clinical trial comprised 90 children aged 2 to 14 years with cataract. The patients were consecutively randomized to receive an HSM (Group 1) or an unmodified (Group 2) poly(methyl methacrylate) (PMMA) IOL. Extracapsular cataract extraction (ECCE) with IOL implantation was performed in children 8 years and older and ECCE with primary posterior capsulotomy, anterior vitrectomy, and IOL implantation in children younger than 8 years. Outcome parameters were inflammatory cell deposits on the IOL surface, posterior synechias, and anterior chamber reaction. RESULTS: Follow-up data were available for 73, 70, 60, and 68 patients at 1 week, 1 month, 3 months, and 6 months, respectively. Significantly fewer cell deposits were noted in Group 1 at 1, 3, and 6 months (P < .001). Synechia formation and anterior chamber reaction were comparable in the 2 groups. CONCLUSION: The lower incidence of inflammatory cell deposit formation in eyes with HSM PMMA IOLs indicates that these IOLs have greater bicompatibility than unmodified IOLs in pediatric cataract surgery.

Co-occurrence of pneumococcal keratitis and dacryocystitis.

PURPOSE: To evaluate the specific risk factors responsible for the development of pneumococcal keratitis. METHODS: In a retrospective analysis of 383 patients of culture-proven bacterial keratitis, seen between 1991 and 1995, 139 had monobacterial isolates on culture. We analyzed the various predisposing factors in these patients, with special emphasis on the patency of nasolacrimal drainage system. RESULTS: Of the 139 patients with monobacterial keratitis, 48 (group 1) grew Streptococcus pneumoniae in culture. In the remaining 91 patients (group 2), Pseudomonas (18), coagulase-negative Staphylococci (15), Staphylococcus epidermidis (23), Staphylococcus aureus (16), Corynebacterium species (12), and others (seven) were isolated. Trauma was found to be a predisposing factor in 12 patients of group 1 and 27 patients of group 2 (p = 0.5601). Twelve (25%) patients of group 1 revealed chronic dacryocystitis, and nine of them underwent sac excision. On the contrary, only three patients of group 2 demonstrated dacryocystitis (p = 0.0003). CONCLUSION: These results underscore the importance of assessing the patency of lacrimal drainage system in patients with infectious keratitis, especially of pneumococcal origin.

Laser-assisted cataract surgery and other emerging technologies for cataract removal.

As we near the end of this century, refractive cataract surgery has become a reality through concerted contributions from ultrasonic phacoemulsification, foldable intraocular lens (IOL) implantation technology and keratorefractive surgery. As we enter the new millennium, our sights are set on realizing another dream: accommodative IOL surgery. Towards achieving this goal, many advances have been made in both techniques and technology of cataract removal. Lasers in particular have been under investigation for cataract removal for nearly two decades. The technology has now reached a stage where cataract can indeed be removed entirely with laser alone. Neodymium:YAG and erbium:YAG are the laser sources currently utilized by manufacturers of laser phaco systems. Initial clinical experience reported in the literature has served to highlight the capabilities of lasers and the need for further refinement. Despite the excitement associated with the availability of this alluring new technology for cataract removal, it is necessary to develop more effective laser systems and innovative surgical techniques that optimize its capabilities if laser phaco surgery is to be a genuine improvement over current techniques.

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 (IOL) 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.