Limited pars-plana vitrectomy for optimizing surgical outcome in subluxated cataracts undergoing femtosecond laser-assisted cataract surgery.

We propose a technique for combined femto laser-assisted cataract surgery (FLACS) and limited vitrectomy from the pars-plana site for optimization of surgical results in subluxated cataracts. FLACS creates a free-floating, customised capsulotomy, minimizes stress on compromised zonules, and prechops the nucleus, effectively reducing the ultrasonic power as well as the forces required to chop the nucleus. The area of zonular dehiscence creates a direct communication between the irrigation fluid and the anterior vitreous, leading to its hydration. Trans-limbal vitrectomy creates a continuum between the liquefied vitreous and the main wound, leading to further vitreous loss, and exaggeration of the zonular weakness, while pars-plana vitrectomy avoids this by cutting the liquefied vitreous, near its attachment, thereby preventing further hydration and causing lesser stress to the zonules. A combination of these procedures, along with a capsule support device, gives favorable surgical outcomes in moderate to severe subluxations.

Intra corneal ring segment implantation with lenticule assisted stromal augmentation for crosslinking in thin corneas.

PURPOSE: To evaluate the safety and efficacy of intra corneal ring segment (ICRS) implantation combined with crosslinking (CXL) using a Small Incision Lenticule Extraction (SMILE) lenticule for intraoperative stromal augmentation in thin corneas. OBSERVATIONS: The procedure was performed in three eyes of progressive keratoconus or post refractive surgery corneal ectasia, with a preoperative mean thinnest pachymetry of 389.34 ± 5.5 µm. Keratometry flattening (preoperative mean maximum keratometry of 63.17 ± 9.31D to postoperative mean maximum keratometry of 54.77 ± 9.47D) and improvement in spectacle corrected distance visual acuity (mean preoperative LogMAR 0.43 ± 0.19 to mean postoperative LogMAR 0.71 ± 0.26) was noted at three months, with stability at one-year postoperative visit. Demarcation line was demonstrated at a depth of 220.67 ± 8.32 µm. No significant endothelial cell loss was noted. CONCLUSIONS AND IMPORTANCE: Intraoperative stromal thickness augmentation using a lenticule obtained from SMILE allows safe and effective CXL in combination with ICRS in ultrathin corneas. This allows an alternative to lamellar keratoplasty for visual rehabilitation in such eyes.

Femtosecond laser-integrated anterior segment optical coherence tomography to detect preexisting posterior capsular dehiscence and increase safety in posterior polar cataracts.

PURPOSE: To determine the efficacy of the femtosecond laser with integrated anterior segment optical coherence tomography (AS-OCT) for the detection of posterior capsular dehiscence in posterior polar cataracts (PPCs). To evaluate the safety of phacoemulsification in these eyes undergoing femtosecond laser-assisted cataract surgery (FLACS). SETTING: Centre For Sight Group of Eye Hospitals, a chain of tertiary eyecare hospitals in India. DESIGN: Prospective interventional case series. METHODS: The study included eyes with PPCs undergoing FLACS using the CATALYS femtosecond platform. Real-time OCT guidance was used to image the posterior capsule (PC), which was then classified as intact or dehiscent. The femtosecond laser was used for the creation of capsulotomy, nuclear fragmentation, and corneal incisions. In all eyes, the posterior offset (distance between the posterior extent of nucleotomy and the PC) was increased to enable a thick epinuclear cushion. Intraoperative status of the PC was noted, and the specificity and the sensitivity of AS-OCT to detect a preexisting posterior capsular defect was determined. RESULTS: The cohort included 50 eyes (40 patients), in which a posterior capsular discontinuity on AS-OCT was observed in 7 eyes (14%). Five (10%) of these 7 eyes developed an intraoperative posterior capsular rent (PCR) A sensitivity and negative predictive value of 100% was noted. No case of nucleus drop was noted. CONCLUSIONS: Femtosecond laser with integrated AS-OCT is a relevant and helpful tool to detect and increase the safety in preexisting posterior capsular dehiscence, alerting the surgeon ahead of phacoemulsification.

Limited vitrectomy in phacomorphic glaucoma.

One of the challenging situations for a cataract surgeon is phacoemulsification in the shallow anterior chamber like cases of phacomorphic glaucoma. Some of the main concerns of operating in a narrow space include endothelial decompensation, descemet's detachment, and posterior capsular rents. High vitreous pressure predisposes to posterior capsular rents owing to a reduced concavity of the posterior capsule and increasing the proximity of phaco-tip to the posterior capsule. We describe a technique of limited vitrectomy in such cases. A small gauge 23-G/25-G trocar cannula is passed transconjunctivally, and the liquefied vitreous is allowed to egress. Vitrectomy is done extraocularly till the vitreous pressure lowers down. This technique helps to debulk the vitreous and decompress the globe in a controlled manner. The resultant posterior displacement of iris-lens diaphragm causes a deepening of the anterior chamber to facilitate phacoemulsification.

Unilateral corneal ectasia following small-incision lenticule extraction.

UNLABELLED: We describe a case of unilateral corneal ectasia in a 26-year-old man following small-incision lenticule extraction. The preoperative corneal topography was normal, with a minimum corneal thickness of 511 µm and 513 µm in the right eye and left eye, respectively. Lenticules of 85 µm and 82 µm were fashioned to offer a refractive correction of -3.75 -1.50 × 180 and -3.50 -1.50 × 165 in the right eye and left eye, respectively. Twelve months after small-incision lenticule extraction, the patient presented with early signs of ectasia in the left eye on corneal topography, which had worsened at the 18-month examination. Intrastromal corneal ring segment implantation with corneal collagen crosslinking was performed to arrest further progression and to improve uncorrected distance visual acuity. On the last examination, the corrected distance visual acuity was 20/20(-2). FINANCIAL DISCLOSURE: Dr. Mahipal S. Sachdev receives travel grants from Carl Zeiss Meditec AG. No author has a financial or proprietary interest in any material or method mentioned.

Tailored stromal expansion with a refractive lenticule for crosslinking the ultrathin cornea.

We describe a technique for stromal expansion of thin and ultrathin corneas in keratoconus patients that uses refractive stromal lenticules of patients having small-incision lenticule extraction for myopic correction. The stromal lenticule is placed and spread over the host cornea following epithelial debridement so the thickest area of the 6.2 mm diameter lenticule corresponds to the thinnest area of the cone. The remaining collagen crosslinking (CXL) procedure is carried out in a routine manner. We believe tailored stromal expansion is a safe and effective technique for performing CXL in patients with thin corneas.

Management of trachomatous keratopathy by automated lamellar therapeutic keratoplasty.

PURPOSE: To evaluate the efficacy of automated lamellar therapeutic keratoplasty (ALTK) for the management of anterior corneal stromal scarring caused by trachoma. METHODS: Seventeen cases of trachomatous keratopathy that were treated by ALTK were retrospectively evaluated. The main outcome measures were uncorrected visual acuity, best-corrected visual acuity (BCVA), keratometry, pachymetry, time to epithelialization, graft clarity, and complications, if any. RESULTS: The mean age of the patients was 50.3 ± 14.1 years. Five of the 17 cases had Salzmann nodular degeneration. The mean decimal BCVA was 0.06 ± 0.05 preoperatively, which improved to 0.41 ± 0.16 at 12 months, and 12 eyes (70.6%) had a postoperative BCVA of 6/18 or better. The median epithelialization time was 6 days (range, 1-38 days). Persistent epithelial defect developed in 6 eyes, and 1 eye developed graft infection. CONCLUSIONS: Anterior stromal corneal scarring caused by trachoma can be effectively treated with ALTK. However, occurrence of persistent epithelial defects may complicate the success of this surgery.

Study of factors for unsuitability of DSAEK in cases of corneal decompensation following cataract surgery.

To evaluate suitability of Descemet's stripping automated endothelial keratoplasty (DSAEK) in cases of corneal decompensation following cataract surgery. In this cross-sectional case series, 90 eyes of 90 patients were evaluated at a tertiary eye care centre. Cases with central corneal scarring or vascularisation, complicated aphakia with significant iris tissue defects and extensive synechaie or posterior segment pathology precluding visual recovery were classified as unsuitable for DSAEK. Of 90 eyes, 42 (46.67%) were unsuitable for DSAEK. Multivariate logistic regression analysis, revealed that patients presenting more than a year after cataract surgery had 7.5-fold odds of being unsuitable for DSAEK as compared with those who presented earlier(OR 7.5; CI 2.0-29.1). Patients with BCVA poorer than 0.06 at initial presentation had 5.0 times odds of being unsuitable for DSAEK (OR 5.0; CI 1.0-24.2). Patients who had prior non-phacoemulsification cataract surgery were 5.5 times less likely to be candidates for DSAEK as compared to those who had prior phacoemulsification (OR 5.5; CI 1.5-19.9) and those with anterior chamber IOL or aphakia were 5.0 times less likely suitable for DSAEK, in contrast to posterior chamber intraocular lenses (OR 5.0; CI 1.3-18.7). The type of cataract surgery, time to presentation and initial visual acuity play a role in determining the suitability of performing DSAEK in patients with corneal decompensation after cataract surgery.

Penetrating autokeratoplasty for unilateral corneal opacification.

OBJECTIVE: The aim was to evaluate the efficacy of autokeratoplasty as an alternative to conventional allograft transplantation for the management of corneal blindness in patients with a healthy cornea in the fellow blind eye. METHODS: A retrospective analysis of all consecutive cases of corneal blindness that were treated with autokeratoplasty was undertaken. We describe nine cases in which the healthy, transparent cornea from a blind eye was transplanted onto the fellow eye with a favorable visual potential but an opaque cornea. The parameters evaluated were uncorrected visual acuity, best-corrected visual acuity (BCVA), endothelial cell loss, graft clarity, and complications if any. RESULTS: The median age of the patients was 63 years (range 37-83 years). Intraoperative complications encountered included expulsive hemorrhage (n=1), retrieval of a corneal button unsuitable for transplantation onto the donor defect (n=1), and problems concerning sizing of the corneal graft (n=1). Glycerine-preserved cornea was used in two eyes. All the patients achieved BCVA >20/60 by 3 months postoperatively, and 8 of the 9 patients (88.9%) maintained a clear graft till the last follow-up (12 months-78 months). Endothelial cell loss of 31.4%± 6.3%, 33.2%±5.9%, 34.7%±8.2% was noted at 1, 6, and 12 months, respectively. Accelerated endothelial cell loss after three episodes of traumatic wound dehiscence was responsible for nonimmunological graft failure in one case. CONCLUSIONS: Autokeratoplasty is a viable option in selected cases of corneal blindness as an alternative to conventional allograft transplantation. In the event of adverse events, a backup tissue should be available.

Modified surgical technique for improving donor adherence in DSAEK in the aphakic vitrectomized eye.

We describe a modified technique for performing Descemet stripping automated endothelial keratoplasty (DSAEK) in a patient with aphakia and vitrectomized eye. A 72-year-old woman presented with corneal decompensation after a complicated cataract surgery and a subsequent vitreoretinal procedure. Before commencing DSAEK, a pars plana infusion cannula was inserted 3 mm from the limbus. The infusion fluid in the vitrectomized posterior segment helped circumvent potential complications, such as recurrent globe collapse, posterior dislocation of the donor disc, and loss of air tamponade. Increasing the infusion pressure allowed the surgeon to levitate the air bubble, effectively vaulting the donor disc against the recipient host bed. This modified approach helps overcome the possible complications of DSAEK in aphakic vitrectomized eyes and enhances donor adherence.

Bilateral microbial keratitis in highly active antiretroviral therapy-induced Stevens-Johnson syndrome and toxic epidermal necrolysis: a case series.

PURPOSE: To report three cases of bilateral microbial keratitis in eyes with Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) induced by highly active antiretroviral therapy (HAART) in patients of acquired immune deficiency syndrome (AIDS). METHODS: A case series. RESULTS: A detailed clinical examination and systemic review of all the three patients on HAART was performed. While one manifested with the more severe variant of TEN, two of these patients presented with SJS with ocular involvement. Despite withdrawal of nevirapine, the ocular surface disorder persisted. The entailing chronic epitheliopathy along with the compromised immune status led to the development of secondary microbial keratitis in all these cases. CONCLUSIONS: The immune reconstitution occurring as a response to the antiretroviral therapy may potentially increase immunologically mediated diseases like SJS and TEN, which in turn may predispose the eye to develop corneal ulcer.

Herpes zoster ophthalmicus: disease spectrum in young adults.

PURPOSE: To establish the clinical profile of herpes zoster ophthalmicus (HZO) in adults younger than 40 years and correlate the clinical manifestation with their immune status. MATERIALS AND METHODS: A retrospective chart review was performed of patients younger than 40 years who presented with HZO. Data were collected on demographics, medical history, clinical presentation, results of serological investigations, and visual outcome. RESULTS: The study cohort comprised 18 subjects with a mean age of 29.7 ± 6.2 years. Ophthalmic features included lid edema, ptosis, cicatricial lid deformities, sclerokeratitis, peripheral ulcerative keratitis, neuroparalytic keratitis, keratouveitis with concomitant glaucoma, secondary bacterial keratitis and superficial punctate keratitis with dry eye, optic neuritis, and trochlear nerve palsy. Eight of 18 (44.4%) subjects were found to be positive for Human Immunodeficiency Virus (HIV). Disseminated herpetic lesions were seen present in 5 (63%) of these 8 subjects. Postherpetic neuralgia was noted in 6 (75%) of 8 HIV-positive subjects and in 1 HIV-negative patient. Final visual acuity was 20/40 or better in 90% of the immunocompetent subjects and 20/200 or worse in 100% of the HIV-positive subjects. CONCLUSIONS: Immunocompetent young adults do present with features of HZO. However, the disease spectrum in HIV-negative patients is localized, less severe, and more amenable to therapy as compared with young adults with HIV.

Ocular surface squamous neoplasia in xeroderma pigmentosum: clinical spectrum and outcome.

BACKGROUND: To study the clinical spectrum and therapeutic outcome of ocular surface squamous neoplasia (OSSN) in patients with xeroderma pigmentosa (XP). METHODS: The authors performed a retrospective review of records of patients with xeroderma pigmentosa referred to Cornea Services for management of OSSN. Presenting symptoms, clinical features, tumour morphology and location, treatment modalities, recurrence rates and visual outcome were noted. RESULTS: Seven patients of XP (six males; one female) with bilateral OSSN were included in the study. All patients were less than 15 years of age at presentation, with 13 of 14 lesions of OSSN (93%) occurring at the limbus. Associated ocular features were limbal stem cell deficiency in nine eyes (64.3%), dry eye in all 14 eyes (100%), conjunctival melanosis in seven eyes (50%), pseudopterygium in two eyes (14.3%), anterior symblepharon in three eyes (21.4%) and conjunctival inflammatory granuloma in one eye (7.1%). Unaided visual acuity in the 14 eyes ranged from 6/6 to 6/36 at presentation. Six of the 14 eyes (42.9%) had histopathological features of invasive squamous cell carcinoma, and eight eyes (57.1%) demonstrated features consistent with conjunctival intraepithelial neoplasia. Recurrence was seen in nine of 14 eyes (64.3%). CONCLUSIONS: OSSN occurs predominantly in the elderly, but in patients of XP it tends to occur at a younger age (6-22 years). The disease appeared to be more aggressive (recurrence rate = 64.3%) than usual. Awareness and prompt management with close follow up is warranted in these patients.

Therapeutic keratoplasty for microbial keratitis.

PURPOSE OF REVIEW: The purpose of this review is to provide an update of peer-reviewed literature published over the previous 2 years on various aspects of therapeutic keratoplasty. RECENT FINDINGS: Therapeutic keratoplasty has a definitive role in the management of progressive microbial keratitis refractory to medical therapy. The primary aim of the procedure is to eliminate the infectious disease process and establish the integrity of the globe. This procedure offers a microbiological cure rate of up to 100% in bacterial keratitis; recurrence of infection remains a concern following fungal infections and Acanthamoeba keratitis. Newer techniques like corneal debulking allow maximal preservation of the iris tissue in cases of perforated corneal ulcers. Lamellar procedures are emerging as promising alternatives to the full thickness graft in cases of infectious keratitis sparing the Descemet's membrane. In addition to adept intraoperative skills, intensive postoperative treatment and meticulous follow-up are pivotal to ensure success of a therapeutic graft. SUMMARY: Therapeutic keratoplasty is a challenging procedure and is associated with a poor prognosis for graft survival as compared with the optical grafts. The recent advances in lamellar keratoplasty and antimicrobial therapy contribute to the success in terms of microbiological cure and improved visual outcomes.

Sutureless patch graft for sterile corneal melts.

An innovative technique to seal large paracentral corneal melts is being presented. Two patients with sterile corneal melts sized 3-5 mm in diameter were treated with a full-thickness patch graft punched using a dermatological trephine and secured with the fibrin-aprotinin biological tissue adhesive, supplanting the need for sutures. The defect was adequately sealed, and successful tectonic support with postoperative best-corrected visual acuity of 6/24 was achieved in both cases, circumventing the need for an emergency full-thickness penetrating keratoplasty.

Acute hydrops in keratectasia after radial keratotomy.

A 28-year-old male who underwent uneventful radial keratotomy for myopic correction 8 years earlier presented with sudden decrease in vision in the right eye. Slitlamp examination revealed 16 healed radial corneal scars in both eyes along with marked corneal edema and conjunctival congestion in the right eye. The Scheimpflug cross-sectional image of the right cornea displayed an intrastromal aqueous cleft in communication with the anterior chamber, consistent with the diagnosis of acute hydrops. The topographic and pachymetric analysis of the left eye revealed increased paracentral elevation of the anterior and posterior corneal surfaces along with inferotemporal thinning, consistent with the presence of keratectasia in the fellow eye. The hydrops resolved with subsequent corneal scarring 2 weeks after medical therapy with topical steroids, hypertonic saline, cycloplegics, and lubricants. This case emphasizes the importance of a comprehensive preoperative topographic assessment to rule out subclinical keratoconus to minimize complications such as keratectasia and hydrops.