Outcome of Optical Keratoplasty for Corneal Scar due to Infective Keratitis.

INTRODUCTION: Corneal opacity is an important cause of blindness in developing countries. OBJECTIVES: This study analyzes optical keratoplasty performed for corneal opacity due to infective keratitis. MATERIALS AND METHODS: This is a retrospective study of all consecutive cases of optical keratoplasty performed between 2011 and 2014 (four-year period) for healed infective keratitis. Cases with less than two months' followup were excluded during outcome evaluation. Comparison was made between keratoplasty for Microbial and Viral (herpetic) Scar. RESULTS: Ninety-three eyes of 93 patients were enrolled. Fifty-nine (63.4%) were male. Average age of patients was 38.9±19.5 years. Average donor endothelial cell count was 2713±434.5 cells/mm2. Fifty-four (58%) corneal scars were due to microbial keratitis and others were herpetic. Eighty-five (91.4%) had undergone penetrating keratoplasty. Eighty-eight (94.6%) cases were included for outcome analysis. Average follow-up duration was 37±27.5 months. Fifty-two (59%) had clear graft at their last visit. Twenty-three (26.1%) grafts had endothelial failure and 13 (14.7%) grafts failed due to late onset keratitis. Twenty-five (28.4%) had vision of ≥6/18. Rejection occurred in 24(27.2%) and glaucoma in 11(12.5%). Post-operatively viral keratitis in the graft occurred significantly more inViral Scar Group (38.6%, n=15) than in Microbial Scar Group (5.5%, n=3). But there was no significant difference in graft clarity, rejection, vision and secondary glaucoma between the two Groups. CONCLUSION: Outcome of keratoplasty for post-infectious scars was found fairly satisfactory. Although occurrence of viral keratitis was higher in case of keratoplasty done for Viral Scars, the final result was similar to that of microbial scar.

Indications and Outcomes of Repeat Keratoplasty for Graft Failure at a Tertiary Eye Care Center in Nepal.

INTRODUCTION: Graft failure is a common complication following keratoplasty requiring repeat keratoplasty (re-KP). OBJECTIVES: To determine the indications and outcome of repeat keratoplasty at a tertiary eye care centre in Nepal. MATERIALS AND METHODS: This was a retrospective study of 78 patients who underwent re-KP for graft failure in Tilganga Institute of Ophthalmology from Jan 2015 to Dec 2020. Indications for the primary keratoplasty, causes of graft failure and outcomes of re-KP in terms of vision acuity, graft clarity and secondary glaucoma were evaluated. Cases of regraft with less than one-year follow-up period were excluded. RESULTS: A total of 78 re-KPs had been performed in 78 patients during the study period. Seventy eyes had undergone single corneal regraft and 8 eyes had undergone multiple (second or third) regraft surgery. Most common indication of primary keratoplasty was infectious keratitis (n=36; 46.2%). On follow up, 36 eyes (46.2%) were clear at the last visit, of which 31 eyes were single regraft cases and 5 were of multiple regraft cases. Most common cause of graft failure was graft infection (n=34; 43.6%) followed by corneal scarring (n=12; 15.4%). Of 42 eyes with failed regrafts, recurrence of the preoperative infection was commonest cause (n=15, 35.7%) followed by secondary glaucoma (n=11; 26.2%). Of 36 eyes with clear regraft, only 4 eyes (11.11%) achieved best corrected vision of ≥6/18 and remaining 32 eyes had BCVA <6/18 due to associated cataract, secondary glaucoma and high astigmatism. CONCLUSION: The most common cause for re-KP includes graft infection followed by secondary glaucoma. Outcomes of corneal regrafts in the form of graft clarity and visual acuity are suboptimal.

Indication and Outcome of Paediatric Keratoplasty at a Tertiary Referral Eye Hospital in Nepal.

INTRODUCTION: Paediatric keratoplasty is rarely performed surgery with high risk of graft failure. Developing countries have not benefited due to lack of sufficient facilities and trained surgeons. OBJECTIVES: The objectives of the study were to analyze the indications and its outcome in terms of vision and graft survival. MATERIALS AND METHODS: This retrospective chart review used electronic medical records from January 2017 to December 2019 of all consecutive patients aged upto18 years or below that underwent paediatric keratoplasty after ethical approval at Tilganga Institute of Ophthalmology. Outcome was defined as anatomical or visual success and graft clarity. Different demographic and surgical parameters were studied among 59 eyes of 48 patients. RESULTS: Mean age of recipient was 12.23± 3.81 years. Majority 37 (52.5%) had unilateral grafts with keratoconus being the most common 24 (40.6%) acquired non-traumatic indication. Mean post-operative best corrected visual acuity 0.6 Logmar was significantly (p <0.001) low as compared to preoperative 1.3 Logmar. Overall graft survival rate was 47 (78%) at one-year follow-up; keratoconus accounting for 24 (100%). Major factors in contributing for graft failure were rejection, infection, and glaucoma. CONCLUSION: A good outcome in terms of anatomical and visual success was achieved in our study. Keratoconus has an excellent graft survival. Visual rehabilitation by cycloplegic refraction should be done to prevent amblyopia. Enhancing the training of surgeons and addressing challenges faced in a paediatric population will help decrease corneal blindness among paediatric patients in the future.

An Unusual Presentation of Corneal Intraepithelial Neoplasia: A Case Report.

INTRODUCTION: Corneal squamous neoplasia is less common than that of conjunctiva and can cause diagnostic confusion. CASE: A 40-year-old male presented with gradual onset blurring of vision in left eye for 8 weeks. He had received treatment for dry eyes, then for herpetic dendritic keratitis, but without improvement. On slit-lamp examination with diffuse light, apparently the cornea looked clear with some dilated conjunctival vessels nasally. But in the retro-illumination, on the corneal surface, there was a translucent inverted "V" shaped lesion with irregular fimbricated margin. He underwent excisional biopsy of the corneal lesion and the adjacent conjunctiva. Cryotherapy of the conjunctival margin and the adjoining limbus was done. Corneal and conjunctival specimens reported intraepithelial neoplasia grade II and I respectively.There had not been any recurrence till 4 year post-operatively. CONCLUSION: Corneal examination by retro-illumination aids to diagnose and demarcate corneal intraepithelial neoplasia clinically. Timely management results in good prognosis.

Macular Corneal Dystrophy in an Adolescent Managed with Deep Anterior Lamellar Keratoplasty.

INTRODUCTION: Macular corneal dystrophy (MCD) is a rare autosomal recessive stromal dystrophy. The prevalence of inherited diseases varies in different communities. It is not commonly observed in Nepal. CASE: A 14-year male presented with bilateral gradual and painless blurred vision with photophobia of three years duration. Cornea of both eyes showed focal grayish opacities in anterior and mid stroma with intervening stromal haze. There was no history of consanguinity in the family. Anterior segment ocular coherence tomography showed thinning of cornea and deposits in corneal stroma. Macular corneal dystrophy was the clinical diagnosis and the patient underwent deep anterior lamellar keratoplasty in the right eye. Histopathological examination and histochemical staining with Alcian Blue supported the diagnosis. CONCLUSION: Significant improvement in vision was observed in the operated eye. MCD may be present in communities without evidence of consanguinity. It can cause visual impairment at an early age. Timely intervention improves vision and quality of life.

Demography, indications and outcome of descemet stripping automated endothelial keratoplasty in Nepal.

BACKGROUND: Descemet stripping automated endothelial keratoplasty (DSAEK) is performed for corneal endothelial pathology. It had gained popularity over penetrating keratoplasty (PK) because of better outcome. METHODS: Retrospective data was collected from records of patients who underwent DSAEK from 2005 to 2019. Demography, indications and post-operative complications of DSAEK were analyzed. Outcome was measured in terms of graft clarity and vision. RESULTS: 93 eyes of 86 patients had undergone DSAEK in the study period of 15 years. Average age of the patients was 61.0 years. 55.9% were female. The common indications for DSAEK were cataract surgery related bullous keratopathy (n=47, 50.5%), Fuchs dystrophy (n=22, 23.6%) and failed graft (n=11, 11.8%). 8.6% of surgeries had graft detachment and 5.3% had pupillary block in the early post-operative period. Outcome analysis was done for cases (n=80) which had follow-up duration of at least 2 months (range: 2 months to 11 years; average: 28.5 months).Endothelial rejection occurred in 8 cases (10.0%), 5 of which regained graft clarity after treatment. At the last follow-up visit, 23.8% (n=19) of grafts had failed, which was mostly due to endothelial failure (n=16); 3 grafts failed due to infective keratitis. 42.5% (n=34) acquired best corrected vision of 6/18 or better. The average astigmatic error was 1.6 Diopter Cylinder by refraction. CONCLUSION: DSAEK showed good outcome with our results comparable to other studies. It had replaced traditional PK in our institute for endothelial dysfunction. Surgeons in the country should be encouraged and trained to do the procedure.

Bilateral Moraxella Keratitis in a Healthy Person after an Episode of Conjunctivitis: A Case Report.

Moraxella species are gram-negative diplobacilli and are rare cause of bacterial keratitis. We report a case of a 55-year-old woman presented with pain, redness and profound decrease in vision in both eyes for 2 weeks. One month back she had been treated as acute follicular conjunctivitis elsewhere. She had been treated with ofloxacin drops. On examination, she had central oval full-thickness infiltrate with thinning of cornea and hypopyon in both eyes. She had pseudomembrane in the tarsal conjunctiva. Corneal culture, done separately, showed isolation of Moraxella species, which was resistant to fluoroquinolones. She responded to fortified amikacin and ulcer healed with best-corrected vision of 6/24 and 6/18 in right and left eye respectively. Moraxella keratitis can cause severe keratitis. Conjunctivitis may be complicated by keratitis. Antibiotic resistance can cause problem. Bilateral keratitis should be referred promptly to higher centers if not responding well to treatment.

Recurrence of Avellino Corneal Dystrophy Following Penetrating Keratoplasty: A Case Report.

Granular - lattice (Avellino) corneal dystrophy is inherited in an autosomal dominant fashion which affects stroma of the cornea with recurrent erosions and decreased vision due to clouding of cornea in later stage. We reported a case of 53-year old woman presented with pain and blurring of vision of left eye for 10 days with history of right eye deep anterior lamellar dystrophy and Left eye penetrating keratoplasty 5years back for Avellino dystrophy. On examination right eye graft was clear and left eye showed circular edges of irregular epithelium with patchy stains and epithelial defect suggestive of recurrence of dystrophy. A patient with recurrent corneal erosions and opacity in cornea has to be examined carefully so as not to overlook Avellino corneal dystrophy. Being a rare disorder this case has been reported to draw the attention of ophthalmologists about its recurrence following keratoplasty.

Tectonic Graft for Persistent Leakage and Visual Outcome After Corneal Perforation Repair: A Case Series.

Keratoplasty is a modality of treatment for large and leaking corneal perforation in a tertiary center. We report cases of 20and 30-years old men presented in an emergency with history of road traffic accident 1 and 3 days back. Best corrected visual acuity was hand movement in both injured eye. Slit lamp examination of both cases revealed full thickness corneal laceration with Siedel test positive. Both cases underwent corneal laceration repair with resuturing and corneal glue on consecutive days but couldn't seal the leaking wound. Then ultimately both were undergone for tectonic keratoplasty. The final best corrected visual activity of involved eye was 6/36 in case 1 and 6/24 in case 2. Most cases of traumatic corneal perforation undergone urgent corneal repair but sometimes very difficult to seal the wound. In such cases donor cornea tissue may have to be used to maintain integrity of globe and better visual potential. Keywords: corneal perforation; laceration; siedel test; tectonic keratoplasty.

Demography, Risk Factors, and Clinical and Microbiological Features of Microbial Keratitis at a Tertiary Eye Hospital in Nepal.

BACKGROUND: Infective keratitis is the most common corneal pathology in developing countries. Updated knowledge is needed for its control and proper management. METHODOLOGY: All cases of presumed microbial keratitis that presented in an 18-month period from October 2013 to March 2015 were enrolled. Data collected were demographic profile, risk factors, clinical features, and organisms isolated and their sensitivities. RESULTS: A total of 602 cases of microbial keratitis were enrolled. Mean age of subjects (598 patients) was 47.9 years with 53.8% male. 64.1% worked in agriculture. 38.3% gave history of trauma followed by history of herpetic eye diseases (17.9%) and topical steroid use (14.2%). A total of 473 who were referred came at an average of 21.5 days of symptoms. 14.9% (n=90) of cases were either perforated or impending to perforate at presentation. 69.6% had infiltrate in the visual axis. A total of 516 (85.7%) underwent diagnostic corneal culture. A total of 256 (49.6%) yielded a positive result. Pure bacterial growth was seen in 111 (43.4%), pure fungal growth in 138 (53.9%), and mixed microbial growth was present in 7 (2.7%) cases. Out of 121 bacterial isolates, 95.0% were Gram positive. Streptococcus pneumoniae (45.5%, n=55) was the most common bacterial isolate followed by Staphylococcus aureus (20.6%, n=25). Out of 145 fungal isolates, Aspergillus and Fusarium species were found in equal numbers (n=41, 28.3% each). Over 85% of Gram-positive organisms isolated in the study were sensitive to vancomycin, cefazolin, moxifloxacin, and gatifloxacin. Over 80% of Gram-negative organisms were sensitive to gentamicin, tobramycin, and amikacin. CONCLUSION: Microbial keratitis and associated risk factors occurring in farmers implies a lack of awareness and prevention programs. Delay in reaching tertiary care is resulting in complicated cases. Training of local health workers for prophylaxis, updated guidelines for treating keratitis, and timely referral to higher centers are all important in a chain to decrease the incidence of microbial keratitis.

A Teenager with Vernal Keratoconjunctivitis and Pellucid Marginal Degeneration, Presenting with Exotropia.

BACKGROUND: Vernal keratoconjunctivitis (VKC), an allergic disease, has a known association with ectatic disorders of the cornea. Pellucid marginal degeneration (PMD) is a bilateral, asymmetrical, ectatic disorder of the cornea characterized by inferior corneal thinning. We report a case of sensory exotropia due to PMD in association with VKC. CASE DETAILS: A 19-year old boy with a history of VKC presented with exotropia of the right eye of 3 years' duration. His unaided vision in his right eye was 1/60 and in his left eye it was 6/36. On examination, both eyes had high against the rule astigmatism, which was more in the right eye. There was exotropia of 15º (40 prism diopter base in) in the right eye with suppression (Worth four dot test). Corneal examination in both eyes showed inferior band thinning, 2 mm above the inferior limbus, extending from 4 to 8 clock hours, with bulging of the cornea just above the thinning. The clinical features were suggestive of PMD, which was supported by his corneal scans - Atlas, Pentacam, and Optovue. Although he was undergoing treatment for VKC, the onset of PMD and decrease in vision went unnoticed. The asymmetric error which was not corrected during the sensitive period of visual development led to sensory exotropia. CONCLUSION: A child with VKC should undergo regular refraction so as not to miss any ectatic changes occurring in the cornea. A delay in diagnosing corneal ectasia may negate the possibility of collagen cross-linking which prevents progression of ectasia. If visual rehabilitation is delayed beyond the age of visual maturation, it can lead to strabismus, suppression, and loss of binocular function.

Lightning Injury to Eye: Brief Review of the Literature and Case Series.

PURPOSE: In ophthalmology, injuries due to lightning strikes have been documented as various entities ranging from keratitis, cataracts, uveitis in the anterior segments to retinal detachments, papillitis, and macular hole formation in the posterior segment. We report the largest case series so far with a total of seven cases of lightning injuries with ocular involvement and its management and a brief review of the literature on this topic. PATIENTS AND METHODS: All of the patients were evaluated for ocular injuries due to a lightning strike and each of the cases has been individually described as case series with their findings and management in this report. RESULTS: Ocular injuries caused by lightning are very rare, but when they occur, they can present with various ocular tissue pathology-ranging from anterior to the posterior segment structures. Most of the cases presented with maculopathy and foveschitic lesions, which resolved over time with the use of steroids. CONCLUSION: Lightning injuries to the eyes, if detected early and managed appropriately, have a very good prognosis. The recovery is usually good with minimal functional loss if there is a quick referral. The macular region seems to be particularly involved in most cases and OCT can be a valuable diagnostic tool to detect and monitor the pathology.

Donor Profile, Tissue Evaluation and Comparison of Voluntary and Motivated Corneal Donation in Nepal Eye Bank.

PURPOSE: Corneal problems is one of the major causes of blindness in developing countries like Nepal. This study intended to analyze donor and tissue profile of Nepal Eye Bank (NEB). MATERIAL AND METHODS: This was a cross-sectional descriptive type study. Data of corneal tissues collected by NEB from January 2015 to December 2016 were used in the study. Data collected were demographic profile, cause of death, type of corneal donation (whether voluntary or motivated), quality and utilization of tissues. A comparison was made between voluntary and motivated donors. RESULTS: 1244 corneal tissues were retrieved from 639 donors. Mean age of donors was 49.4 years. 57.7% of the donors were male. There were almost equal number of donor deaths due to cardiovascular disease, 27.2%, and respiratory disease, 26.7%, followed by hanging, 17.8%. Majority of donors were motivated (n = 561, 87.7%). Mean death to preservation time was 5.79 hours (hrs). Of the harvested corneas, 1040 (83.6.%) were suitable for transplant with a mean endothelial cell count of 2850 ± 520 cells/mm2; 16.4% were of poor tissue quality and 2.7% were seropositive. 76.2% of total tissues were of optical quality. Utilization rate of transplantable tissues was 97%. Tissues from motivated donors were significantly "younger" (p=0.0001), had better endothelial count (p=0.0001), and were of better quality (p=0.026) than those from voluntary donors. CONCLUSION: Motivated eye donation is a major and effective source of cornea collection in the eye bank under study with "younger" and better quality corneas compared to voluntary donors.

Clinical Profile on Keratoconus Presenting at A Tertiary Eye Care Centre- Tilganga Institute of Ophthalmology.

INTRODUCTION: Keratoconus (KC), is a bilateral, noninflammatory degenerative disease of the cornea which is characterized by progressive corneal ectasia and loss of visual function. The onset of KC is commonly seen at puberty and affects approximately 1 in 2000 in the general population. OBJECTIVE: The aim of this study was to assess the clinical profile of keratoconus in the tertiary eye centre in Nepal. MATERIAL AND METHODS: It is a retrospective, hospital based, consecutive study from June 2017 to May 2018. A total of 66 patients (114 eyes) were diagnosed cases of Keratoconus presented in Cornea clinic of Tilganga institute of Ophthalmology. Parameters investigated included patients' demography, keratometric readings, visualacuity and manifest refraction. Classification of keratoconus was based on Amslern-Krumeich grading system (modified). RESULTS: The mean age of subjects was 18.73 (range: 10-65). Male/female distribution was 48 (72.7%) and 18 (27.3%) respectively. 48 (72.7%) had bilateral keratoconus and 18 (27.3%) were unilateral. Mean Uncorrected visual acuity (UCVA) was 0.80 (range: 0.01-1.00), mean visual acuity ( VA) with spectacle correction was 0.47 (range: 0.01-1.00). Mean spherical amount of refractive was -2.17 (range: -0.50 to -17.00D) and mean cylindrical amount of refraction was -2.85 (range: 0.00 to -6.00). Mean spherical equivalent (SE) of refraction was -4.26 (range: -0.50 to -22.50D). Mean flattest keratometric reading (K1) was 49.63 (range: 40.63-76.70D) and mean steepest keratometric reading (K2) was 53.14 (range: 41.63-73.21D). Mean average keratometric reading was 51.43 (range: 41.63-72.10D). Regarding disease severity, 35.68% of subjects were classified as mild keratoconus, 29.73% as moderate keratoconus, 9.73% as advance keratoconus, while 24.86% were found with the severestage of keratoconus. 78.9% of total eyes presented with minimum pachymetry of 401 to 500 mm. CONCLUSION: Clinical profile of Nepalese keratoconus patients looks similar to that reported earlier worldwide. The condition was found to manifest at a younger age and was more common in males.

A Patient with Keratoconus, Axial Hyperopia and Pigmentary Retinopathy.

INTRODUCTION: Keratoconus has been known to be associated with various ocular conditions. OBJECTIVE: To describe a case of high hyperopia, keratoconus and pigmentary retinopathy. CASE: An eight year old boy, whose initial refractive error was high hyperopia with short axial length of 20mm, presented as bilateral advanced keratoconus with acute hydrops in one eye. Subsequently his other eye also developed hydrops. He had nystagmus and pigmentary retinopathy from his infancy. He was managed conservatively and the hydrops resolved in both the eyes leaving paracentral scar in the cornea. CONCLUSION: The triad of keratoconus, high hyperopia and pigmentary retinopathy has been quite rare. There could be syndromic association between the three simultaneous ocular findings.

Outcome of therapeutic penetrating keratoplasty in a tertiary eye care center in Nepal.

BACKGROUND: Corneal ulcer is an important cause of blindness in developing countries. Therapeutic keratoplasty for infective keratitis is a frequently performed surgery in these countries. OBJECTIVE: To find out the outcome of therapeutic keratoplasty for infective keratitis. METHODS: Records of 5 years were reviewed of patients who underwent therapeutic keratoplasty from 2006 to 2010. Data collected included demographic parameters, indications for surgery, microbiology of the ulcers, type of surgery performed, and donor tissue details. In the follow-up period, ocular status was evaluated in terms of eradication of disease, anatomic success, graft clarity, visual acuity, and development of glaucoma and cataract. RESULTS: In all, 180 eyes of 180 patients were enrolled in the study; 59.4% of the patients were male. Average age was 44.4±16.7 years. Overall, 71% of infective keratitis was perforated. A total of 101 (56%) eyes were positive for organisms of which 49 showed pure fungus and 49 showed pure bacteria. The commonest fungus and bacteria isolated were Aspergillus and Streptococcus, respectively. Average follow-up period was 29±23 months. Overall cure rate of infection was 88.8%, anatomical success rate was 89.5%, and graft clarity was 37.2%. Overall, 43.4% had secondary glaucoma. In the postoperative course, 65.8% of phakic eyes had developed cataract. In all, 38.6% of graft had endothelial failure and 24% of the graft failed due to late infective keratitis. Overall functional success with a visual acuity above 6/60 was 25.4%. Bacterial keratitis had a significantly higher cure rate, anatomical success, and graft clarity compared to fungal keratitis. CONCLUSION: Therapeutic keratoplasty is an important procedure to save the eye and preserve vision in severe infective keratitis. There is a high incidence of postoperative glaucoma, cataract, and graft failure in such a surgery. Bacterial keratitis has a better outcome than fungal keratitis.

A case of acute postoperative keratitis after deep anterior lamellar keratoplasty by multidrug resistant Klebsiella.

A healthy lady of 42 years underwent deep anterior lamellar keratoplasty for granular dystrophy. The very next day, it was complicated by development of infectious keratitis. The organism was identified as multidrug resistant Klebsiella pneumoniae. Donor corneal button may be implicated in the transmission of infection in an otherwise uneventful surgery and follow-up. Nosocomial infections are usually severe, rapidly progressive and difficult to treat. Finally, the lady had to undergo therapeutic penetrating keratoplasty for complete resolution of infection.

A prospective randomized clinical trial of phacoemulsification vs manual sutureless small-incision extracapsular cataract surgery in Nepal.

PURPOSE: To compare the efficacy and visual results of phacoemulsification vs manual sutureless small-incision extracapsular cataract surgery (SICS) for the treatment of cataracts in Nepal. DESIGN: Prospective, randomized comparison of 108 consecutive patients with visually significant cataracts. METHODS: settings: Outreach microsurgical eye clinic. patients: One hundred eight consecutive patients with cataracts were assigned randomly to receive either phacoemulsification or SICS. intervention Cataract surgery with implantation of intraocular lens. main outcome measures: Operative time, surgical complications, uncorrected and best-corrected visual acuity (BCVA), astigmatism, and central corneal thickness (CCT). RESULTS: Both surgical techniques achieved excellent surgical outcomes with low complication rates. On postoperative day 1, the groups had comparable uncorrected visual acuity (UCVA) (P = 0.185) and the SICS group had less corneal edema (P = 0.0039). At six months, 89% of the SICS patients had UCVA of 20/60 or better and 98% had a best-corrected visual acuity (BCVA) of 20/60 or better vs 85% of patients with UCVA of 20/60 or better and 98% of patients with BCVA of 20/60 or better at six months in the phaco group (P = 0.30). Surgical time for SICS was much shorter than that for phacoemulsification (P < .0001). CONCLUSION: Both phacoemulsification and SICS achieved excellent visual outcomes with low complication rates. SICS is significantly faster, less expensive, and less technology dependent than phacoemulsification. SICS may be the more appropriate surgical procedure for the treatment of advanced cataracts in the developing world.