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 8.917.0 and 5.98.8 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 vs10.7%, P<0.0001) and recurrent (26.7 vs0%, P=0.034) pterygia, and in those below 40 years (25.2 vs14.8%, 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

Fungal keratitis associated with vernal keratoconjunctivitis

Purpose: To report a case of fungal keratitis associated with vernal keratoconjunctivitis. Case Report: A 22-year-old man with a history of vernal keratoconjunctivitis since October 1999 developed a shield ulcer in the left eye in June 2000, which resolved with intensive topical steroid therapy. He presented in August 2001 with onset of acute pain, redness, and decreased vision. The tarsal conjunctiva in the left eye showed large papillae. The cornea showed a white plaque-like lesion with an underlying stromal infiltrate involving the upper half of the cornea. The overlying epithelial defect measured 4.5 × 2.5 mm. The anterior chamber showed 1+ flare and cells and hypopyon measuring about 1 mm. Results: Corneal scrapings were performed for microbiologic investigations. Smears of corneal scrapings revealed septate fungal filaments, and the culture showed a significant growth of Aspergillus flavus. Conclusions: Fungal keratitis may be associated with vernal keratoconjunctivitis. Though rare, fungal keratitis should be considered in the differential diagnosis of infections associated with vernal keratoconjunctivitis

Treatment and outcome of Nocardia keratitis

Objective: To report our experience in treatment and outcome of Nocardia keratitis. Methods: Medical and microbiology records of seven cases of culture-proven Nocardia keratitis seen between January 1997 and March 1999 were reviewed retrospectively. In all patients, corneal scrapings were obtained for direct microscopic evaluation and culture. Drug sensitivity was determined by the Kirby-Bauer disk-diffusion method. The minimum inhibitory concentration of ciprofloxacin and amikacin for these isolates was determined by agar dilution method. Response to medical therapy and the end result were analyzed. Results; By the in vitro Kirby-Bauer disk-diffusion techniques, all isolates were sensitive to amikacin; six of these isolates were sensitive to gentamicin and four were sensitive to ciprofloxacin. The minimum inhibitory concentration (MIC) of amikacin for all isolates by the agar-dilution technique was well below the MIC breakpoint for Nocardia resistance, whereas the MIC of ciprofloxacin was above the MIC breakpoint for Nocardia resistance. All patients responded to medical therapy. The corneal infection resolved in three patients after treatment with ciprofloxacin, in one patient after fortified gentamicin, and in three patients after fortified amikacin. Outcome details were available for six patients. There was good visual recovery in four patients, with visual acuity of 20/25 or better in three. The cornea of two patients developed nonvascularized scars, and in four patients in whom the infiltrates were peripheral, vascularization was seen. Conclusions; Although patients of Nocardia keratitis may respond to other antibiotics, amikacin appears to be a drug of choice. In this small series, when appropriate therapy was initiated, Nocardia keratitis resolved promptly with good visual recovery

Anterior chamber tap: diagnostic and therapeutic indications in the management of ocular infections

Purpose: To report three cases in which an anterior chamber tap was useful in the management of infection of the eye confined to the anterior segment. Methods: In the first case, the patient presented with diffuse conjunctival congestion and thick anterior chamber exudates adhering to the back of the cornea. The second case involved fungal keratitis, and the patient was not responding to topical natamycin and systemic ketoconazole. In this patient, infiltrate and thick hypopyon persisted despite medical therapy. The patient in the third case had a persistent thick endothelial exudate, and a retained intracameral foreign body, fungal infection, and a cataract were suspected. In all three cases, an anterior chamber tap was performed. In case 1, the exudate was removed and sent for microbiologic investigation. In case 2, the hypopyon was evacuated and intracameral amphotericin B (5 μg) was injected. In case 3, the exudate contained a wooden foreign body that was sent for culture. Intracameral amphotericin B (5 μg) was injected. Results: In the first case, the culture of the exudate grew Staphylococcus aureus. The eye quieted, and the exudate resolved following treatment with topical fortified cefazolin, fortified gentamicin, and systemic cefazolin. In the second case, smears of corneal scrapings revealed fungal filaments and the culture grew Aspergillus species. The infection resolved following an anterior chamber tap, but the patient developed a cataract. After cataract surgery, visual recovery was limited because of the corneal scar. In the third case, the culture of the foreign body grew an unidentified hyaline fungus. Following an anterior chamber tap, the infection resolved, but the cataract progressed. The patient did well after cataract surgery. Conclusions: An anterior chamber tap is an extremely useful procedure in the management of ocular infections confined to the anterior segment. The procedure should be performed under strict aseptic conditions. If the infection involves the anterior capsule of the lens, care should be taken to avoid injury to the lens, and the possibility of progression of the cataract should be explained to the patient

Aspergillus fumigatus keratitis with wreath pattern infiltrates

Purpose: To report a case of Aspergillus fumigatus keratitis with clinical features simulating Nocardia keratitis and to highlight the utility of microbiologic investigation in the successful management of infectious keratitis. Method: Case report. Results: A 62-year-old man presented with complaints of pain, redness, and watering of 10 days' duration in his right eye. Direct microscopic observation of smears of corneal scrapings revealed a fungal etiology. The patient was treated with 5% natamycin eye drops and 1% atropine sulphate eye drops and was advised to visit the hospital for observation. During his visit to the hospital on day 10 after medication, the eye demonstrated a wreath pattern corneal infiltrate that simulated Nocardia keratitis. The fungus grown from culture of corneal scraping was identified as A. fumigatus. Conclusion: This report highlights the significance of subjecting corneal scrapings from suspected cases of infectious keratitis to microbiologic evaluation and emphasizes the fact that a complete microbiologic work-up helps in establishing a definitive etiologic diagnosis and initiating specific antimicrobial therapy

Epithelial infectious crystalline keratopathy

Purpose: To report 2 cases of epithelial infectious crystalline keratopathy. Methods: Two patients (2 eyes) with significant meibomitis presented with minimal inflammation and plaque-like lesions on the corneal surface made of fine crystalline structures. Corneal scrapings of these lesions were performed for microbiological evaluation. The patients were treated with topical ciprofloxacin and artificial tears. Results: Smear examination of the corneal scrapings revealed numerous bacteria and keratinized epithelial cells with no inflammatory cells. Culture showed a significant growth of Staphylococcus epidermidis and Corynebacterium species in the first case and Pseudomonas aeroginosa in the second case. The response to treatment was poor, with recurrence of the crystalline lesion. Conclusion: Infectious crystalline keratopathy lesions may involve the epithelium and occur on the corneal surface

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

Conjunctival intraepithelial neoplasia presenting as corneal ulcer

Purpose: To report a case of conjunctival intraepithelial neoplasia presenting as corneal ulcer. Method: Case report of a 28-year-old man who presented with sudden onset of pain, redness, and watering in the right eye. Examination of right cornea revealed deep stromal infiltrate inferonasally. Adjacent to the infiltrate and straddling the inferonasal limbus, a reddish well-defined sessible lesion with prominent blood vessels was seen. After corneal scraping for microbiological evaluation, the patient was treated with frequent instillation of ciprofloxacin hydrochloride 0.3% eyedrops. Results: Corneal scraping revealed no microorganisms. Infiltrate resolved promptly after excision of the lesion. Histopathologic evaluation of the excised lesion revealed conjunctival intraepithelial neoplasia. Conclusions: This case highlights the fact that conjunctival intraepithelial neoplasia at the limbus may present as corneal ulcer. This ulcer could have occurred secondary to a dellen formation and epithelial breakdown predisposing to a corneal ulcer