Drug induced cicatrizing conjunctivitis: A case series with review of etiopathogenesis, diagnosis and management

Drug induced cicatrizing conjunctivitis (DICC) is defined as a disease in which conjunctival cicatrization develops as a response to the chronic use of inciting topical and, rarely, systemic medications. DICC accounts for up to one third of cases of pseudopemphigoid, a large group of cicatrizing conjunctival diseases sharing similar clinical features to those of mucous membrane pemphigoid (MMP) but generally without the morbidity of progressive scarring or the need for systemic immunosuppression. The preservatives in topical anti-glaucoma medications (AGM) are the most frequently implicated inciting causes of DICC although topical antivirals, vasoconstrictors and mydriatics and some systemic drugs have been implicated. The literature review summarizes the classification, epidemiology, etiopathogenesis, histopathology, clinical presentation, diagnosis, management, and treatment outcomes of DICC in the context of a case series of 23 patients (42 eyes) with AGM induced DICC, from India and the UK. In this series all subjects reacted to preserved AGM with one exception, who also reacted to non-preserved AGM. At diagnosis >70% of eyes showed punctal scarring, inflammation, and forniceal shortening. Pemphigoid studies were negative in the 19/23 patients in whom they were carried out. DICC can be classified as non-progressive, progressive with positive pemphigoid immunopathology or progressive with negative pemphigoid immunopathology. It is unclear whether progressive DICC is a stand-alone disease, or concurrent (or drug induced) ocular MMP. Progressive cases should currently be treated as ocular MMP. The diagnosis can be made clinically when there is rapid resolution of symptoms and inflammation, usually within 1–16 weeks, after withdrawal of suspected inciting medications, ideally by temporary substitution of oral carbonic anhydrase inhibitors. If the response to withdrawal is uncertain, or the progression of inflammation and scarring continues then patients must be evaluated to exclude concurrent (or drug induced) MMP, and other potential causes of CC, for which the treatment and prognosis is different. Management, in addition to withdrawing inciting medications, may require short-term treatment of conjunctival inflammation with steroids, treatment of associated corneal disease with contact lenses or surface reconstructive surgery, control of intra-ocular pressure with non-preserved AGM and, in some, surgery for glaucoma or for trichiasis and entropion

Bilateral normal tension glaucoma: Can this be nutritional?

Normal tension glaucoma (NTG) also known as low tension glaucoma, presents with optic nerve head and visual field damage in the absence of high intraocular pressure (<21 mmHg). There are several patients of NTG seen in our clinics who have repeatable visual field defects, which may or may not correlate with the disc appearance, but are labeled as glaucoma. Ruling out ischemic, nutritional, and other causes of one-time damage are important before diagnosing an NTG. We report 3 such cases that were misdiagnosed and referred as NTG. All three cases were not glaucomatous and had typical features of nutritional optic neuropathy. The typical clinical features, visual field and imaging abnormalities seen in these two conditions and their management is highlighted in this article. Misdiagnosis leads to inappropriate investigations and treatment, but more importantly would lead to worsening of undiagnosed underlying disease

Conjunctival inclusion cyst following repair of tube erosion in a child with aphakic glaucoma, leading to endophthalmitis

Introduction: Glaucoma in aphakia is a major long term complication following congenital cataract surgery. Implantation of glaucoma drainage device provides an effective approach to manage refractory paediatric glaucoma. However implant surgery in young individuals is not free of complications. The prompt detection and management of tube erosion is of utmost importance to prevent devastating sequel of endophthalmitis. Implantation cyst following repair of tube erosion has not been reported so far. This case illustrates the rare occurrence of inclusion cyst following repair of tube erosion, the possible causes and its consequences. Case description: A 2-year-old child with aphakia developed intractable glaucoma. Following a failed glaucoma filtering surgery he underwent sequential Ahmed Glaucoma Valve implantation in both the eyes. Six weeks following right eye surgery, the child presented with conjunctival erosion overlying the tube, which was treated with scleral patch graft and conjunctival advancement. One month after the repair of tube erosion, the child presented with implantation cyst under the scleral patch graft, which was treated by drainage with a 29G needle. The child presented with endophthalmitis of his right eye following an episode of bilateral conjunctivitis. This was managed by an emergency pars plana vitrectomy, intraocular antibiotics and tube excision. At the last follow up visit, the IOP was 20 mmHg with 2 topical antiglaucoma medications in the right eye following a trans scleral photocoagulation.Discussion: Lifelong careful follow-up of paediatric eyes with implant surgery is mandatory to look for complication such as tube erosion. It is important to place additional sutures to secure the patch graft during implantation of glaucoma drainage devices in children to prevent graft displacement and consequent tube erosion. During repair of tube erosion, it is crucial to remove all the conjunctival epithelium around the tube, thus not to incorporate epithelial tissue within the surgical wound

Management of implant plate exposure of silicone Ahmed glaucoma valve: a review of six cases

Objective: To describe the management options for exposed silicone Ahmed glaucoma valve (AGV) implant.Methods: This was carried out as a retrospective chart review at a tertiary care eye hospital in Southern India. Medical records of six subjects managed for AGV exposure from 2006 to 2013 were reviewed.Results: All six eyes had explantation of the AGV and 3 of them had reimplantation in a different quadrant at a later date and the other 3 eyes were managed medically. All eyes had well controlled IOP at the last follow-up. The possible predisposing factors for exposure were improper conjunctival coverage, higher number of pre shunt surgeries and diabetes mellitus. Reimplantation was a challenge with scarred conjunctiva and the techniques used were conjunctival advancement, conjunctival relaxing incisions and contralateral conjunctival autograft. None had re-exposure but one eye had conjunctival erosion close to the limbus and was managed with scleral patch graft and conjunctival advancement.Conclusions: Implant exposure is a serious vision threatening complication following glaucoma drainage device implantation. Explantation and timely repair can save these eyes from serious sequel. Reimplantation is a good option, however warrants close follow-up for complications like erosion or re-exposure

Misleading Goldmann applanation tonometry in a post-LASIK eye with interface fluid syndrome

A 21-year-old myope presented with decreased vision and corneal edema following vitreoretinal surgery for retinal detachment. While intraocular pressure (IOP) measurement with Goldmann applanation tonometer (GAT) was low, the digital tonometry indicated raised pressures. An interface fluid syndrome (IFS) was suspected and confirmed by clinical exam and optical coherence tomography. A tonopen used to measure IOP through the peripheral cornea revealed elevated IOP which was the cause of the interface fluid. Treatment with IOP-lowering agents resulted in complete resolution of the interface fluid. This case is being reported to highlight the fact that IFS should be suspected when there is LASIK flap edema and IOP readings using GAT are low and that GAT is not an optimal method to measure IOP in this condition. Alternative methods like tonopen or Schiotz tonometry can be used

A retrospective analysis of the first Indian experience on Artisan phakic intraocular lens

<b>Purpose: </b> To evaluate the efficacy, safety, predictability and stability of implanting a polymethylmethacrylate phakic intraocular lens (PIOL) in high myopia. <b> Materials and Methods:</b> A retrospective analysis of the data of patients who underwent Artisan phakic IOL implantation between 2002 and 2003 with a follow-up of at least 24 months. <b> Results: </b> An Artisan myopia lens was implanted in 60 eyes of 36 patients with preoperative myopia ranging from -5.0 to -24.0 D. Mean patient age was 22.6 years. Mean spherical equivalent of manifest refraction stabilized by the first postoperative week. At three months follow-up, 54 eyes (90&#x0025;) had a postoperative refraction within &#x00B1; 1D emmetropia and 45 eyes (75&#x0025;) had uncorrected visual acuity of 20/40 or better. Seven eyes (11.6&#x0025;) had loss of one Snellen line and none had loss of two Snellen lines or more at three months. The mean endothelial cell loss was 3.8&#x0025; at three months, 5.2&#x0025; at six months, 5.25&#x0025; at 12 months and 6.38&#x0025; at two years, which was not significant. Postoperative complications included anterior chamber reaction in two eyes (3.3&#x0025;), rise in intraocular pressure in six eyes (10&#x0025;) and dislocation of PIOL in two eyes (3.3&#x0025;). <b> Conclusion:</b> Implantation of Artisan myopia lens to correct high myopia resulted in a stable and fairly predictable refractive outcome with few complications. Significant endothelial damage was not detected in two years of follow-up

Trabeculectomy with an implantable biodegradable collagen matrix (Ologen) for the management of glaucoma associated with cavernous sinus arteriovenous fistula

A 58-year-old gentleman presented with open angle glaucoma secondary in the right eye secondary to a cavernous sinus arteriovenous fistula.  Since the intraocular pressure control was refractory to medical management, an augmented filtration surgery was planned.  Trabeculectomy in eyes with raised episcleral venous pressure is associated with a substantially greater risk of intraoperative or post-operative choroidal effusion and suprachoroidal haemorrhage.  This patient was successfully managed by performing trabeculectomy with an implantable biodegradable collagen, type 1 atelocollagen, matrix (Ologen), without any sight threatening complications