Frequency, distribution, and outcome of keratoplasty for corneal dystrophies at a tertiary eye care center in South India

Purpose: To report the frequency, outcome, and atypical histology in corneal dystrophies. Methods: Corneal buttons of patients diagnosed with corneal dystrophy as noted in the records of the ophthalmic pathology register over a period of 6 years were included in this study. The sections from formalin-fixed, paraffin-embedded tissues were reviewed specifically for the type of deposits, associated degenerations such as amyloid and spheroidal deposits, inflammation, and vascularization. Special stains including Masson trichrome, Congo red, and Alcian blue staining were used whenever required. The medical records were evaluated for demographics, clinical presentation, history of consanguinity, family medical history, and clinical outcome of keratoplasty, which was recorded as clear, recurrence of dystrophy, or graft failure. A clinicopathologic correlation was attempted. Results: A total of 144 patients contributed 181 buttons, accounting for 8.1% of keratoplasties performed during the study period. The mean age of the patients was 34 ± 19 years (range 3-72 years) with a male:female ratio of 1.6 (89):1 (55). Consanguineous parentage was noted in 26% of cases. History of a similar problem in siblings and other family members was elicited in 33 (22%) and 14 (9.7%), respectively. Dystrophies included macular (29.3%), congenital hereditary endothelial dystrophy (34.8%), Fuchs (16.6%), and lattice (15%); the remaining 11% included granular, gelatinous drop-like, Reis-Bucklers, and posterior polymorphous dystrophy. Associated histologic changes were degenerations (15%), vascularization (4%), and inflammation (2%). At a mean follow-up of 42 months, the graft remained clear in 148 eyes (81.7%), failed in 33 eyes (18.2%), and recurred in 5 eyes (2.8%). Graft survival for all dystrophies at the end of 1 year was 94.3 ± 1.7%, and at the end of 5 years was 74.4 ± 4.5%. Atypical histologic features did not affect graft survival. Conclusion: Consanguineous marriages possibly contributed to the increase in macular dystrophy and CHED in South India. The degenerative changes seen could possibly be related to late presentation or unknown environmental factors and do not have an effect on the ultimate graft outcome

Corneal triple procedure: indications, complications, and outcomes: a developing country scenario

Purpose: We report the indications, complications, and outcomes of 104 corneal triple procedures in our institute. Methods: Patient records of 104 consecutive cases of corneal triple procedure (penetrating keratoplasty with extracapsular cataract extraction and intraocular lens implantation) performed by experienced corneal surgeons between January 1992 and December 1997 were retrospectively reviewed. Relevant preoperative, operative, and postoperative data were collected. The outcome was assessed by the graft clarity and visual acuity at the last visit. Survival analysis of these grafts was determined by Kaplan-Meier method. Results: Of 104 patients, 70 were men and 34 were women. Mean age of these patients was 48.5 ± 17.1 years (range, 1-75 years). Corneal scarring with cataract was the reason for surgery in 69 (66.4%) cases. The intraoperative complications included vitreous upthrust in seven (6.9%) cases and posterior capsular dehiscence in three (2.9%) cases. The most common early postoperative complications were increased intraocular pressure in 19 (18.3%) and increased anterior chamber reaction in 25 (24%) cases. Posterior capsular opacification was seen in 26 (25%), graft reaction in 15 (14.4%), and secondary glaucoma in 15 (14.4%) cases. These formed the important late postoperative complications. The average postoperative follow-up was 23.7 ± 17.6 months (range, 1.6-79.4 months); at which time 72% of the grafts remained clear. At last follow-up, 40% of patients had a visual acuity of ≥20/40. Conclusions: Corneal scarring with cataract is the most common reason for triple procedure in this part of the world. This is a safe surgical procedure with good graft clarity and reasonable visual recovery

Amniotic membrane transplantation in the management of shield ulcers of vernal keratoconjunctivitis

Purpose: To report our experience with amniotic membrane transplantation in the management of severe shield ulcers. Design: Retrospective, interventional, noncomparative case series. Participants Four patients (seven eyes) with grade 2 (ulcer with opaque base) and grade 3 (plaquelike lesions) shield ulcers not responding to steroid therapy with or without surgical debridement. Intervention: Amniotic membrane transplantation with stromal side down was performed after meticulous debridement of the ulcer. Main outcome measures: Healing of the ulcer with no epithelial defect. Results: The ulcers healed with disintegration or retraction of the membrane in all patients within 2 weeks. Conclusions: Amniotic membrane transplantation in combination with debridement is an effective surgical modality in the management of severe shield ulcers. Further studies are warranted to confirm the efficacy of amniotic membrane transplantation in the management of shield ulcer and its correct position in the treatment algorithm

Fungal infection of sutureless self-sealing incision for cataract surgery

Purpose: To report the clinical picture and outcome of fungal infection of self-sealing wounds in cataract surgery. Design: Retrospective noncomparative case series. Participants: Seven postoperative cataract patients. Methods: Seven consecutive patients who underwent cataract surgery in different locations in India and developed microbiologically proven fungal infection of the surgical wound were included. All were managed at a tertiary eye care center in India between May 2001 and April 2002. Main outcome measures: The data reviewed included patient age, gender, onset of symptoms after surgery, examination findings at the time of onset of symptoms and referral, laboratory workup, treatment, and outcome. The cataract surgeons involved were contacted to determine their cataract practice and to determine any possible breach in the sterile technique. Results: The median interval to onset of symptoms after cataract surgery was 5.0 days (mean, 5.8 days; range, 3-9 days). The initial diagnoses at the time of onset of symptoms were keratitis (n = 3), scleritis (n = 1), and excessive anterior chamber reaction (n = 3). The last 4 patients were treated with topical and/or systemic corticosteroid therapy before referral. All cases subsequently developed deep keratitis. Specimens for microbiology workup were obtained by scrapings (n = 6), corneoscleral biopsy (n = 4), and anterior chamber paracentesis (n = 4). Organisms identified were Aspergillus flavus (n = 2), Aspergillus terreus (n = 2), Aspergillus spp. (n = 2), and Candida albicans (n = 1). The infection resolved with medical therapy in 2 cases; the final visual acuity was 20/125 in one case and 20/20 in the other case. The infection progressed to endophthalmitis in 5 eyes, resulting in complete loss of vision. The source of infection could not be identified in any case. Conclusions: Infection of self-sealing tunnel incision for cataract surgery is a diagnostic and therapeutic challenge

Amniotic membrane transplantation for ocular surface reconstruction in Stevens-Johnson syndrome

Purpose: To evaluate amniotic membrane transplantation (AMT) for ocular surface reconstruction in Stevens-Johnson syndrome (SJS). Design: Prospective interventional case series. Participants: Ten consecutive patients (10 eyes) with SJS that underwent AMT as the first step in staged ocular surface reconstruction were included. Methods: Amniotic membrane was processed under sterile conditions from a fresh placenta obtained from cesarean section in a seronegative pregnant woman and stored at -70°C. Symblepharon release, excision of epibulbar fibrous tissue, and clearing of the fibrovascular membrane over the cornea was performed in all cases. Amniotic membrane covered the entire bulbar surface up to the fornices in five eyes; cornea and the perilimbal area in two eyes; cornea, the inferior bulbar surface, and the lower fornix in two eyes; and cornea and the superior bulbar surface in one eye. Obliterated fornices were deepened by use of fornix-formation sutures in all eyes. Symblepharon ring was placed postoperatively for 3 weeks to 2 months. Mean postoperative follow-up was 13.5 months (SD, ±3.8 months; range, 9-30 months). Main outcome measures: Restoration of adequate bulbar surface free of symblepharon and good fornix depth were the main outcome measures. Results: Complete corneal reepithelization occurred in all eyes between 1 and 6 weeks. Adequate bulbar surface and fornix depth were achieved in nine eyes, all of which were free of symblepharon at the final follow-up visit. Cicatricial entropion resolved in four of five lower eyelids and one of two upper eyelids after AMT. One patient had a central corneal melt that required or necessitated a penetrating keratoplasty. Conclusions: AMT restores adequate bulbar surface and fornix depth and prevents recurrence of symblepharon in severe cases of SJS

Surgical treatment of chronically recurring pterygium

Purpose: To report the result of a combined surgical procedure of pterygium excision with simultaneous amniotic membrane transplant, conjunctival limbal autograft, and mitomycin C application in the management of two cases of chronically recurring pterygium. Methods: Report of two cases. Results: The two male patients, ages 24 and 42 years, had undergone six previous surgeries for pterygium, with and without adjunct procedures. In the follow-up period of 26 months for the first case and 25 months for the second case, no recurrence or complications were encountered. Conclusion: A combined procedure seems to be beneficial in cases of chronically recurring pterygia in younger patients. This approach may be considered when all other types of surgery have failed