Clinical and Optical Coherence Tomography Correlation of Recurrence Patterns After Femtosecond Laser-Assisted Anterior Lamellar Keratoplasty in Reis-Bucklers Corneal Dystrophy

PURPOSE

The aim of this study was to report the clinical profile and patterns of recurrence after femtosecond laser-assisted anterior lamellar keratoplasty (FALK) in Reis-Bucklers corneal dystrophy.

METHODS

This is a case series of 5 eyes of 4 patients with Reis-Bucklers corneal dystrophy. Clinical images of recurrence were correlated with the high-resolution optical coherence tomography. Histopathologic examination of excised corneal samples was performed when possible.

RESULTS

The median time to recurrence was 2 (1-5) years after FALK. Of the 5 eyes, 1 eye had primary FALK, whereas 4 eyes had secondary interventions, which included previous phototherapeutic keratectomy (once in 1 eye and twice in 2 eyes), and previous penetrating keratoplasty, followed by phototherapeutic keratectomy (1 eye). Recurrence was noted at the level of the subepithelium. In addition, 1 eye showed interface deposits along with epithelial downgrowth at the graft-host bed.

CONCLUSIONS

The 2 distinct patterns of recurrence noted were at the subepithelial region and the interface. The clinical patterns of recurrence favor an epithelial origin of recurrent deposits.

Clinical and demographic profile of herpes zoster ophthalmicus: A hospital-based study of 1752 Indian patients

PURPOSE

To describe the clinical and demographic profile of herpes zoster ophthalmicus (HZO) in patients presenting to a multitier ophthalmology hospital network in India.

METHODS

Cross-sectional hospital-based study included 3,004,470 new patients between August 2010 and October 2021. Patients with a clinical diagnosis of HZO in at least one eye were included. Data were collected using an electronic medical record system.

RESULTS

In total, 1,752 (0.058%) patients were diagnosed with HZO. Nearly two-thirds were male (63.76%) in the seventh decade of life (339;19.35% patients) with unilateral (98.34%) affliction. Higher prevalence was seen in patients from higher socioeconomic status (0.059%) and metropolitan geography (0.062%). Most common ocular signs included eyelid edema (44.19%), conjunctival congestion (65.69%), punctate keratopathy (23.36%), and anterior uveitis (21.22%). Of the 1,781 eyes, mild/no visual impairment was seen in 952 (53.45%) eyes, moderate in 258 (14.49%) eyes, and severe to blindness in 363 (20.39%) eyes. Oral antivirals were started within 72 h (Group A) in 361 (20.61%) patients and after 72 h in 1391 (79.39%) patients (Group B). Significantly lesser severity of ocular involvement was noted in Group A (P < 0.00001). Surgical intervention was required in 211 (11.85%) eyes.

CONCLUSION

HZO more commonly affects males in the seventh decade of life and is predominantly unilateral. It more commonly affects those from higher socioeconomic strata and metropolitan regions. Half of the eyes have mild or no visual impairment, while others have moderate to severe impairment. Institution of antivirals within 72 h is associated with less severe involvement. Surgical intervention is warranted in a tenth of the eyes.

Strategies and Application of Compression Sutures With a Modified Technique for Rapid Resolution of Large (Grade III) Hydrops: A Prospective Interventional Study

PURPOSE

The aim of this study was to describe the strategies and outcomes, with a modified technique, of compression sutures in large acute hydrops.

METHODS

This was a prospective interventional study in 29 eyes of 28 patients who underwent compression sutures using a modified technique. The degree of resolution after surgical intervention was quantified by 3 masked observers, using the slit-lamp photographic documentation and optical coherence tomography. The degree of resolution, best-corrected visual acuity, and complications were analyzed.

RESULTS

The mean age was 20.89 (7-46) years. Five patients had pellucid marginal degeneration (pellucid marginal corneal degeneration), 23 had keratoconus, and 1 had posttrauma hydrops. The preoperative visual acuity was hand motions in all eyes. The reduction in edema was 76% on day 1, 91.6% on 6 ± 2 days, 98.6% on 18 ± 3 days from surgical intervention. The baseline pachymetry assessed on optical coherence tomography was beyond measurement in 26 eyes. The mean pachymetry at day 1 was 704 μm (range 480-950) which reduced to 607 (range 422-850) microns at 6 ± 2 days and 518 (range 415-718) microns at 18 ± 3 days postintervention ( P < 0.0001). The mean duration between the surgery and complete suture removal was 48 (35-68) days. No suture-related complications were noted. Twenty eyes could attain good visual rehabilitation with glasses/contact lenses (vision could not be assessed in 5 eyes). Penetrating keratoplasty was performed on 1 patient.

CONCLUSIONS

Compression sutures using the modified technique was safe and effective in the rapid resolution of acute hydrops in keratoconus and pellucid marginal corneal degeneration. No complications were noted, and visual restoration with spectacles and contact lenses was satisfactory.

Band-shaped keratopathy in HNF4A-related Fanconi syndrome: a case report and review of the literature

BACKGROUND

Fanconi's syndrome (FS) is characterized by type-2 renal tubular acidosis, short stature, and renal rickets, along with glycosuria, aminoaciduria, hypophosphaturia, and urinary bicarbonate wasting. The genetic form of FS has been linked to HNF4A variants. Although additional clinical features such as hearing impairment have recently been associated with HNF4A-linked FS, its ocular manifestation has not been described.

MATERIAL AND METHODS

Presenting a case of a 5-year-old male child with bilateral progressive corneal opacification and the presence of bilateral greyish-white deposits in the interpalpebral region since infancy. A next-generation sequencing (NGS)-based genetic testing was performed for the child followed by parental genetic testing for the identified variant. Furthermore, relevant works of literature were reviewed related to this condition.

RESULTS

Detailed corneal findings showed a bilateral band-shaped keratopathy (BSK) in the patient. Physical and systemic findings showed signs consistent with FS. Sequencing analysis revealed a novel heterozygous c.635C>T, (p.Pro212Leu) variant in the HNF4A gene in the proband and mother, while the father had a normal genotype.

CONCLUSIONS

Our case highlights the occurrence of BSK in an exceptionally rare manifestation of hereditary FS linked to HNF4A gene variant. The variant exists both in proband and asymptomatic mother. Therefore, the variable penetrance which is known to exist in HNF4A is acknowledged in this context. This report suggests the first documented instance establishing a plausible connection between BSK and HNF4A-associated FS, characterized by the variable penetrance attributed to the HNF4A gene.

Axenfeld-Rieger syndrome in the pediatric population: A review

Axenfeld-Rieger syndrome (ARS) is a rare autosomal-dominant neurocristopathy that presents with a variety of classical ocular and systemic findings. The pathophysiology of the disease involves anterior segment dysgenesis, and patients may present with ophthalmic complications early in life, including secondary glaucoma, high refractive errors, amblyopia, and permanent visual damage. There are a limited number of studies in the literature that focus primarily on pediatric patients with ARS. The purpose of this article was to review the current literature on clinical presentation, genetic associations, diagnosis, secondary complications, and treatment of ARS in pediatric patients. Evaluating the essential clinical aspects of the disease in children may allow for earlier diagnosis and treatment and prevent visual morbidity from amblyopia and secondary glaucoma that may result in permanent visual damage.

Characteristics of Corneal Endothelium in Axenfeld Rieger Spectrum

PURPOSE

The purpose of this study was to compare the corneal endothelial characteristics in Axenfeld anomaly (AXA), Rieger anomaly (RGA), and Axenfeld-Rieger anomaly/syndrome with age-matched healthy controls.

METHODS

This is a retrospective, comparative case-control study of 52 eyes of 30 patients with AXA/RGA and AXA/S and 36 controls.

RESULTS

Median age at endothelial imaging was 21.5 years (interquartile range, 13.8-33.3 years). In the study group, the mean endothelial cell density (ECD) was 2112.4 ± 78.5 cells/mm 2 , the mean cell area (MCA) was 526.9 ± 28.5 μm 2 , and the coefficient of variation of cell size was 41.2 ± 1.8%. The ECD was significantly (all, P < 0.0001) lower than controls, while MCA ( P < 0.0001), SD of cell size ( P < 0.0001), and maximum cell area ( P = 0.0007) were significantly higher than controls. Four eyes of 3 patients had guttae on slitlamp evaluation and endothelial imaging. There were no differences in the corneal endothelial characteristics among the clinical subtypes.

CONCLUSIONS

Patients with AXA, RGA, and Axenfeld-Rieger anomaly/syndrome have lower ECD and increased MCA compared with normal eyes. The reduced ECD associated with inherent anterior segment alterations can predispose to the risk of postcataract surgery endothelial decompensation in these eyes. The association of guttae in some eyes needs further investigational studies.

Updates on congenital hereditary endothelial dystrophy

Congenital hereditary endothelial dystrophy (CHED) is a rare genetic corneal disorder causing progressive cornea clouding and significant visual impairment. CHED remains a leading indication for pediatric corneal transplantation despite its infrequency, particularly in regions with high consanguinity rates like Southeast Asia. Identifying the Solute Carrier Family 4 Member 11 (SLC4A11) gene as the genetic basis of CHED has led to the discovery of it's various genetic variations. However, a comprehensive understanding of its clinical-genetic correlation, pathophysiology, and optimal management is ongoing. This review aims to consolidate current knowledge about CHED, covering its genetic origins, pathophysiological mechanisms, clinical presentation, and management strategies. Surgical intervention, such as penetrating keratoplasty (PK), Descemet stripping automated endothelial keratoplasty (DSAEK), and Descemet membrane endothelial keratoplasty (DMEK), remains the primary treatment. DSAEK and DMEK offer advantages over PK, including quicker visual recovery, reduced complications, and longer graft survival, especially in the pediatric age group. The timing of surgical interventions depends on disease severity, age at presentation, comorbidities, and visual potential. Elevated oxidative stress in CHED corneal tissue suggests potential benefits from anti-inflammatory drugs to rescue mutated endothelial cells. Considering the limitations of corneal graft surgeries, exploring novel gene-based molecular therapies are essential for future management. Early diagnosis, appropriate surgical interventions, amblyopia control, and genetic counseling for predictive analysis are pivotal for optimizing CHED management. A multidisciplinary approach involving ophthalmologists, researchers, and genetic counselors is essential for precise diagnosis and optimal care for CHED patients.

Novel Proposed Algorithm in Congenital Hereditary Endothelial Dystrophy

PURPOSE

Congenital hereditary endothelial dystrophy (CHED) is a rare, autosomal recessive, monogenic corneal condition with variable expressivity. Often presents in bilateral symmetrical progressive corneal cloudiness that starts in the early infancy. It is characterized by increased corneal thickness, profound corneal edema, and thickening of the Descemet membrane due to endothelial dysfunction. The published literature lacks uniform guidelines for grading corneal cloudiness and management algorithm for CHED cases. This article focuses on applying newer investigational modalities to fine-tune surgical outcomes and more recent CHED management strategies.

METHODS

This comprehensive literature review was performed based on a search on the PubMed database of relevant CHED articles focusing on those published in the last 7 years. A total of around 70 articles were reviewed, and 17 of them were included in this review. These include systemic reviews, randomized controlled clinical trials, cohort studies, case-controlled studies, and case series.

RESULTS

Corneal cloudiness grading in CHED using subjective and objective methods using Anterior Segment Optical Coherence Tomography (AS-OCT) and densitometry using Scheimpflug imaging can help select appropriate management plan for CHED cases. DSAEK outscores penetrating keratoplasty with much fewer complications and expedites visual recovery, which helps mitigate amblyopia.

CONCLUSION

Managing cases of CHED has been a challenge due to the dilemma in timing and appropriate surgical method selection and lack of definitive medical or other conservative approaches. Currently, DSAEK has shown favorable results in cases of CHED. However, appropriate staging of CHED and selecting the appropriate management approach appears to play a critical role in managing such cases. Besides these, novel treatment modalities such as nonsteroidal anti-inflammatory agents (NSAIDS) that target restoring water-flux activity in subtype of CHED and gene editing using CRISPR-Cas9 are promising paradigm treatment modalities.

Objectively measuring anterior segment alterations in the eyes of mucopolysaccharidoses: Its utility in early diagnosis of glaucoma

Purpose

Our study aimed to evaluate the utility of the anterior segment morphometry for objectively assessing anterior segment architectural changes of corneal clouding in the mucopolysaccharidoses (MPS) cohort and to investigate whether these measurements correlate with the slit-lamp findings on the cornea and early diagnosis of glaucoma.

Methods

This retrospective study involved 70 eyes of 35 children with cloudy cornea due to MPS variants. Anterior segment architectural alterations were measured using anterior segment imaging and biometry in MPS children and compared with controls.

Results

Mean age of the cohort at the time of assessment was 7.9 ± 4.5 years. Males constituted two-thirds of the cohort. Variants of MPS with cloudy cornea were as follows: Type I (62%), Type IV (11%), and Type VI (22%). Morphometric measurements were available in 22 eyes of 11 MPS children and an age-matched healthy control group. There were significant differences between MPS cohort and controls in refraction in Diopters (5.03 ± 0.39 and 0.01 ± 0.04; P < 0.0001), axial length (AXL) in mm (21.39 ± 0.28 and 23.04 ± 0.28; P = 0.0002), average keratometry in Diopters (40.67 ± 0.44 and 42.83 ± 0.44; P < 0.0001), anterior chamber depth (ACD) in mm (2.92 ± 0.07 and 3.65 ± 0.07; P < 0.0001), and intraocular pressure (IOP) in mmHg (25.2 ± 2.0 and 14.1 ± 2.3; P = 0.0003). Secondary glaucoma was observed in 28% of the MPS cohort.

Conclusion

The anterior segment morphometry in the cloudy cornea due to MPS provides an objective measurement of anterior segment architectural changes, thus diagnosing early-onset secondary glaucoma. These findings highlight that cloudy cornea due to MPS variants merits close monitoring throughout life.

Selective Endothelialectomy in Peters Anomaly: A Novel Surgical Technique and Its Clinical Outcomes in Children

PURPOSE

This study describes the surgical outcomes of selective endothelialectomy in Peters anomaly (SEPA), a relatively new technique to manage Peters anomaly (PA).

METHODS

This study included 34 eyes of 28 children who had a visually significant posterior corneal defect due to PA and underwent SEPA between 2012 and 2019. A selective endothelialectomy from the posterior corneal defect was performed while preserving Descemet membrane. The primary outcome measure was the resolution of corneal opacification. The secondary outcome measures were functional vision, complications, and risk factors for failure.

RESULTS

At a mean postoperative follow-up of 0.96 ± 0.20 years, 29 eyes (85.3%) maintained a successful outcome. Mean preoperative and postoperative best-corrected visual acuities were 2.55 ± 0.13 and 1.78 ± 0.13 ( P < 0.0001), respectively. Ambulatory functional visual improvement was seen in 97%, and 23% attained vision ranging between 20/190 and 20/50. Corneal opacification failed to clear in 5 eyes (15%). Risk factors associated with surgical failure were female sex ( P = 0.006), disease severity ( P < 0.0001), glaucoma ( P = 0.001), and additional interventions after SEPA ( P = 0.002). In multivariate analysis, only disease severity (ie, a type 2 PA) was a significant risk factor for the failure of SEPA. There were no sight-threatening complications.

CONCLUSIONS

SEPA is a safe and effective technique in select cases of posterior corneal defect due to PA. SEPA could be a potential surgical alternative to pediatric keratoplasty or optical iridectomy in children with central corneal opacification smaller than 7 mm due to PA.

Identification and in silico analysis of a spectrum of SLC4A11 variations in Indian familial and sporadic cases of congenital hereditary endothelial dystrophy

Background

Congenital hereditary endothelial dystrophy (CHED) is a rare form of corneal dystrophy caused by SLC4A11 gene variations. This study aims to find the genetic alterations in SLC4A11, in two Indian familial CHED cases with affected members n = 3 and n = 2 respectively and five sporadic CHED cases using direct sequencing, followed by in silico analysis and characterization of the identified variants.

Results

All three affected members of the first CHED family were identified with a novel homozygous c.1514C > G (p.Ser489Trp) variation while second family showed presence of a compound heterozygous variation c.529A > C (p.Arg161Arg) + c.2461insT (p.Val805fs). Among five sporadic cases, two showed novel changes, homozygous c.1487G > T (p.Ser480Ile) and c.620-2A > G, while the other one had previously reported homozygous c.2653C > T (p.Arg869Cys) variation. The remaining two cases did not reveal the presence of SLC4A11-related pathogenic variations. The identified variations were excluded from the Indian control (n = 80). In silico analysis using homology-based protein modeling and pathogenicity prediction tools, which revealed these alterations as pathogenic, changing their protein stability, local flexibility, residue contact clashes, and the hydrogen bond interactions.

Conclusions

This study contributed to the CHED mutational spectrum, adding four novel variations and confirming a previously reported one. It demonstrates different type of variations in CHED cases, including coding, non-coding, homozygous, synonymous, and compound heterozygous variations. The identified variations revealed different degrees of pathogenic effects in silico. Moreover, two sporadic cases could not be identified with pathogenic variation emphasizing the involvement of other genes or genetic mechanisms.

New Frontier in the Management of Corneal Dystrophies: Basics, Development, and Challenges in Corneal Gene Therapy and Gene Editing

ABSTRACT

Corneal dystrophies represent a group of heterogeneous hereditary disorders causing progressive corneal opacification and blindness. Current corneal transplant management for corneal dystrophies faces the challenges of repeated treatments, complex surgical procedures, shortage of appropriate donor cornea, and, more importantly, graft rejection. Genetic medicine could be an alternative treatment regime to overcome such challenges. Cornea carries promising scope for a gene-based therapy involving gene supplementation, gene silencing, and gene editing in both ex vivo and in vivo platforms. In the cornea, ex vivo gene therapeutic strategies were attempted for corneal graft survival, and in vivo gene augmentation therapies aimed to prevent herpes stromal keratitis, neovascularization, corneal clouding, and wound healing. However, none of these studies followed a clinical trial-based successful outcome. CRISPR/Cas system offers a broad scope of gene editing and engineering to correct underlying genetic causes in corneal dystrophies. Corneal tissue--specific gene correction in vitro with minimal off-target effects and optimal gene correction efficiency followed by their successful surgical implantation, or in vivo CRISPR administration targeting pathogenic genes finds a way to explore therapeutic intervention for corneal dystrophies. However, there are many limitations associated with such CRISPR-based corneal treatment management. This review will look into the development of corneal gene therapy and CRISPR-based study in corneal dystrophies, associated challenges, potential approaches, and future directions.

Clinical and visual electrophysiological characteristics of vitelliform macular dystrophies in the first decade of life

Purpose:

To evaluate patterns of pediatric vitelliform macular dystrophy (PVMD).

Methods:

This is a retrospective analysis of Indian children with vitelliform macular dystrophy (VMD) presenting within the first decade of life. Records were evaluated for clinical findings, family screening, and investigative findings including optical coherence tomography (OCT), fundus autofluorescence (FAF), full-field electroretinogram (ERG) and electrooculogram (EOG). Electrophysiology was scrutinized and audited for acquisition and interpretation errors. Findings on follow-up were also recorded.

Results:

46 eyes of 24 patients were included. Mean age at presentation was 7.17 ± 2.17 years. Mean follow-up duration was 1.55 ± 1.69 years. Best disease was the commonest type of VMD detected (21 patients), while autosomal recessive bestrophinopathy was seen in three cases. Mean logMAR BCVA was 0.364 which decreased to 0.402 on follow-up. Hyperopia was noted in 29 out of 46 eyes (mean being +3.87 D, range ebing +0.75 to +8.75 D). Four eyes of four children had choroidal neovascular membrane at presentation, while another child developed while in follow-up. Solid type subretinal deposit was the commonest OCT finding (n = 29/38) and central hyper FAF was the commonest pattern (n = 18/32). EOG was available for review in 32 eyes, but was unreliable in 11 eyes. Seven eyes demonstrated complete absence of light rise on EOG.

Conclusion:

PVMD can present in advanced forms. Progression to complications with loss of visual acuity can happen within the first decade of life. EOG shows grossly suppressed waveforms in the light phase in a large number of such children.

Update on the genetics of corneal endothelial dystrophies

Corneal endothelial dystrophies are a heterogeneous group of diseases with different modes of inheritance and genetic basis for each dystrophy. The genes associated with these diseases encode transcription factors, structural components of the stroma and Descemet membrane, cell transport proteins, and others. Congenital hereditary endothelial dystrophy (CHED) is associated with mutations in two genes, OVOL2 and SLC4A11, for dominant and recessive forms of CHED, respectively. Mutations in three genes are known to cause posterior polymorphous corneal dystrophy (PPCD). They are OVOL2 (PPCD1), ZEB1 (PPCD3), and GRHL1 (PPCD4). The PPCD2 locus involving the collagen gene COL8A2 on chromosome 1 is disputed due to insufficient evidence. Mutations in the COL8A2 gene are associated with early-onset Fuchs’ endothelial corneal dystrophy (FECD). Several genes have been associated with the more common, late-onset FECD. Alterations in each of these genes occur in a fraction of patients, and the most prevalent genetic alteration in FECD patients across the world is a triplet repeat expansion in the TCF4 gene. Knowledge of the genetics of corneal endothelial dystrophies has considerably advanced within the last decade and has contributed to better diagnosis of these dystrophies as well as opened up the possibility of novel therapeutic approaches based on the molecular mechanisms involved. The functions of genes identified to date provide insights into the pathogenic mechanisms involved in each disorder.

Neurotization of the human cornea - A comprehensive review and an interim report

We present a comprehensive review of existing literature on surgical corneal neurotization (SCN) as a treatment modality for neurotrophic keratopathy (NK) with an interim report of seven cases where SCN was performed using the indirect approach and followed up till 18 months postoperatively to look for improvement in ocular surface, corneal sensations, and nerve regeneration by using in vivo confocal microscopy (IVCM). A literature search was performed for publications with keywords “corneal nerves,” “neurotization,” “esthesiometry,” “corneal anesthesia,” and “neurotrophic keratopathy.” All literature available till December 31, 2020 was reviewed and included to describe NK and its management options, particularly SCN. NK is associated with absent or reduced corneal sensations and is managed using a step-ladder algorithm ranging from medical management for symptomatic relief to surgical corneal neurotization. Both direct and indirect approaches of SCN have a favorable outcome with reduced surgical morbidity in the indirect approach using sural nerve graft. Post neurotization, corneal sensation recovery may take up to 3–6 months, while nerve regeneration on confocal microscopy can take as long as 6 months–1 year.

Secondary developmental glaucoma in eyes with congenital aphakia

PURPOSE

To describe the clinical spectrum and management of glaucoma in congenital aphakia.

METHODS

The demographics and clinical spectrum of eyes with congenital aphakia with and without glaucoma were compared, and management outcomes of congenital aphakia cases with glaucoma were studied retrospectively between April 2000 and June 2020.

RESULTS

There were a total of 168 eyes (84 subjects) with a diagnosis of congenital aphakia, of which 29 eyes of 18 subjects were diagnosed with glaucoma. Corneal opacity was the presenting complaint in 26/29 eyes with glaucoma and 139/139 eyes without glaucoma. The (interquartile range (IQR)) horizontal corneal diameterwas 10.5mm (IQR, 9.0-12.5) and 8mm (IQR, 5-10) in eyes with and without glaucoma (P = 0.01), respectively. The median (IQR) axial length was 17.5mm (IQR, 13.5-19.5) and 15mm (IQR, 14-16) mm in eyes with and without glaucoma (P = 0.03), respectively. Nineteen eyes with glaucoma had adequate intraocular pressure (IOP) control with one medication. Three eyes underwent transscleral diode cyclophotocoagulation and maintained IOP without medications. Three eyes underwent trabeculectomy and trabeculotomy, trabeculectomy followed by penetrating keratoplasty, and trabeculectomy, respectively, of which two eyes became phthisical. At the last follow-up, the median (IQR) IOP was 14 mm Hg (IQR, 14-17) Hg. The median(IQR) follow-up duration was 4.53 months (IQR, 2.03- 48.06).

CONCLUSION

One-fifth of the eyes with congenital aphakia had secondary developmental glaucoma. The corneal diameter and axial lengths were higher in the eyes with glaucoma compared to eyes without glaucoma. Medical management is the preferred short-term mode of IOP control. Transscleral cyclophotocoagulation may be preferred over surgical intervention.

Toric intraocular lenses: Expanding indications and preoperative and surgical considerations to improve outcomes

Since the introduction of the first toric intraocular lens (IOLs) in the early 1990s, these lenses have become the preferred choice for surgeons across the globe to correct corneal astigmatism during cataract surgery. These lenses allow patients to enjoy distortion-free distance vision with excellent outcomes. They also have their own set of challenges. Inappropriate keratometry measurement, underestimating the posterior corneal astigmatism, intraoperative IOL misalignment, postoperative rotation of these lenses, and IOL decentration after YAG-laser capsulotomy may result in residual cylindrical errors and poor uncorrected visual acuity resulting in patient dissatisfaction. This review provides a broad overview of a few important considerations, which include appropriate patient selection, precise biometry, understanding the design and science behind these lenses, knowledge of intraoperative surgical technique with emphasis on how to achieve proper alignment manually and with image-recognition devices, and successful management of postoperative complications.

Descemet Stripping Automated Endothelial Keratoplasty in Pediatric Age Group: A Decade of Our Experience

PURPOSE

This study was to report the outcomes of Descemet stripping automated endothelial keratoplasty (DSAEK) in managing corneal endothelial disorders in children less than 14 years of age.

METHODS

Medical records of 180 DSAEK performed, between 2008 and 2020, on 167 eyes of 111 children who had a visually significant endothelial dysfunction were retrospectively reviewed for the primary etiology of corneal decompensation, time of the onset and duration of cloudiness, preoperative visual acuity, the technique of endothelial keratoplasty, surgical modifications, and reintervention.

RESULTS

Median age at surgical intervention was 7.9 years (interquartile range, 5.2-11.2 years). At a median postinterventional follow-up of 2.5 years (interquartile range, 0.9-3.4 years), 86.2% (144 of 167 eyes, 95% confidence interval 79.9%-90.1%) maintained a clear graft. Median best-corrected visual acuity (logarithm of the minimum angle of resolution) improved from 1.45 ± 0.70 preoperatively to 0.90 ± 0.06 at the last follow-up visit (P < 0.0001). The cumulative overall long-term graft survival was 92.7%, 86.5%, and 77.7% at 1, 3, and 7 years, respectively. Cox proportional hazards regression analysis showed that the indication for DSAEK (P = 0.007; hazards ratio: 2.17 ± 0.62), age at surgery (P = 0.02; hazards ratio: 0.87 ± 0.05), and any subsequent intervention after DSAEK (P = 0.003; hazards ratio: 0.11 ± 0.08) were significant risk factors for DSAEK failure. The endothelial cell loss was 40.1% at 6 months, 45.4% at 1 year, 55.2% at 5 years, and 61.9% at 7 years.

CONCLUSIONS

DSAEK is a safe and effective surgical strategy in managing endothelial disorders among the pediatric age group.

Outcomes of Ahmed Glaucoma Valve Implantation in Eyes with Pediatric Keratoplasty

PURPOSE

This study aimed to assess the efficacy and safety of Ahmed glaucoma valve (AGV) (New World Medical Inc.) implantation in eyes with pediatric keratoplasty and glaucoma.

DESIGN

Retrospective, noncomparative, interventional case series.

PARTICIPANTS

Twenty-eight eyes of 25 children who underwent AGV after penetrating keratoplasty (PK) in 22 eyes and Descemet's stripping endothelial keratoplasty (DSEK) in 6 eyes were included.

METHODS

Children (age ≤ 16 years) treated with AGV implant after keratoplasty from 2008 to 2019 with documented 6 months follow-up operated by a single surgeon were included.

MAIN OUTCOME MEASURES

The primary outcome measure was AGV survival (intraocular pressure [IOP] between 6 and 21 mmHg with or without topical anti-glaucoma medications [AGMs]), and the secondary outcome measure was corneal graft survival.

RESULTS

The mean age (± standard deviation) of patients at AGV surgery was 4.8 ± 0.7 years. The mean follow-up after AGV was 3.4 ± 0.5 years. The mean IOP decreased significantly from 31.5 ± 2.0 mmHg to 21.1 ± 2.3 mmHg at 6 months postsurgery (P < 0.001). The mean number of AGM decreased significantly (P < 0.001), and there was no change in mean visual acuity (P > 0.04 with Bonferroni correction). The cumulative survival probability of AGV was 92.9% ± 4.9% at 1 year and 81.3% ± 11.7% at 5 years. The AGV success was comparable between PK and DSEK eyes (P = 0.73). The cumulative probability of graft survival was 96.2% ± 3.8% at 1 year and 77.8% ± 9.1% at 5 years. The graft survival was also comparable between PK and DSEK eyes (P = 0.18). One eye needed tube trimming; none had tube or implant exposure. The major complication noted was corneal graft infection in 8 eyes (28.5%).

CONCLUSIONS

In this cohort, the long-term AGV success and graft survival outcomes are satisfactory considering that AGV was performed in complex eyes with keratoplasty.

Outcomes after surgical removal of anterior epi-capsular plaque associated with persistent pupillary membranes in children

INTRODUCTION

Anteriorepi-capsular plaque (ACP) is usually eccentric and is associated with persistent iris strands arising from the collarette. Outcomes of lens preserving ACP peeling along with removal of persistent pupillary membrane (PPM) strands have seldom been reported with only a few cases within some case series appearing in the literature. Herein we aim to report outcome after surgical removal of ACP associated with PPM in children.

METHODS

Research was done in three different Institutes. Charts were reviewed for all children who had undergone ACP removal surgery from 2010. Age at surgery, gender, preoperative best corrected visual acuity (BCVA), preoperative refraction, morphologic details of ACP, intraoperative complications, ophthalmic viscosurgical device use, age at last follow-up, postoperative complications, and postoperative BCVA were reviewed.

RESULTS

A total of 16 patients, 10 male and 6 female, were included in study. Age at surgery ranged from 2 to 86 months old. Age at last follow up visit ranged from 2 to 14 years old. Postoperative complications were not observed in any of the 16 patients. Specifically, in all patients the crystalline lens remained clear at the last follow up visit.

CONCLUSIONS

Congenital ACP of the lens associated with PPM and clear lens can be safely surgically removed with a very low risk of iatrogenic cataract in the early period after surgery.

Outcomes of keratoplasty in a cohort of Indian patients with xeroderma pigmentosum

Purpose:

To evaluate the outcomes of keratoplasty for xeroderma pigmentosum (XP) performed at a tertiary eye care center.

Methods:

A retrospective review of medical records of those patients who were clinically diagnosed to have XP (54 eyes of 36 patients) and underwent keratoplasty; either deep anterior lamellar keratoplasty (DALK, four eyes), endothelial keratoplasty (EK, eight eyes), or penetrating keratoplasty (PK, 42 eyes) from 1994 to 2018.

Results:

The median age at surgery was 20.6 years (interquartile range [IQR], 14.6–27.6 years) and 20 (55.6%) were males. Graft failure occurred in 15 eyes (35.7%) in the PK group and two eyes (50%) in the DALK group; none failed in the EK group. The probability of graft survival in the PK group was 97.2% ± 2.7% at 1 year, 74.0% ± 8.0% at 2 years, and 54.8% ± 11.7% at 5 years. In the PK group, 13 eyes needed antiglaucoma medications, 11 eyes developed graft infiltrate, and 13 eyes needed secondary interventions (cataract surgery, excision biopsy, and tarsorrhaphy). In the EK group, three eyes needed secondary interventions (excision biopsy). Median postoperative endothelial cell density at the last follow-up in the PK group was 1214 cells/mm² (IQR, 623–2277 cells/mm²).

Conclusion:

Despite the complexities of the ocular surface and adnexal issues in XP, keratoplasty had reasonably good outcomes. More than half of the PK grafts survived 5 years with no failures in the EK group. Regular follow-up and timely management of suture-related infections raised intraocular pressure, and suspicious ocular surface lesions, in addition to solar protection, are important for the success of keratoplasty in these eyes.

Quantitative corneal neural imaging using in vivo confocal microscopy in cases of congenital corneal anesthesia: A prospective analysis and clinical correlation

Purpose:

Congenital corneal anesthesia (CCA) is a rare clinical entity that poses a diagnostic dilemma, particularly in the pediatric age group with very little literature on this. Accurate initial diagnosis, evaluation, early identification of risk factors, aggressive systemic workup, and appropriate therapy are paramount to prevent visual loss due to long-term complications of corneal anesthesia. The purpose of the study was to estimate and compare the corneal neural architecture using real time, in vivo confocal microscopy (IVCM) in patients with CCA as against a control population.

Methods:

This was a retrospective nonconsecutive, comparative clinical case series in a tertiary hospital in South India from June 2015 to December 2018.

Methods:

IVCM was accomplished in cooperative children in whom central cornea was relatively clear. The clearest three to five images from each eye were selected, and the nerves were analyzed for length, thickness, density, dichotomous pattern, and beading. Statistical analysis was done using Origin v7.0 (Origin Lab Corporation, Northampton, MA, USA).

Results:

In total, 15 eyes of 11 cases and 20 eyes of 10 controls were imaged. Measurements on corneal nerve density showed a significant difference (P = 0.0005), cases having a lower mean (3.85 ± 1.38 mm per mm²) compared to the controls (6.74 ± 1.75 mm per mm²). Measurements on corneal nerve length (P = 0.28), thickness (P = 0.45), and presence of beading (P = 0.97) and dichotomous pattern (P = 0.07) did not reveal a significant difference between cases and controls.

Conclusion:

There is a strong relationship between the functional loss (absent corneal sensation) and anatomical decrease (reduced subbasal nerve density) of corneal nerves in congenital corneal anaesthesia.

Anterior segment alterations in congenital primary aphakia-a clinicopathologic report of five cases

Purpose:

To report the clinicopathological features of corneal buttons in patients with congenital primary aphakia.

Methods:

Five corneal specimens of five patients with congenital primary aphakia who underwent penetrating keratoplasty (PKP) were studied by light microscopy, and immunohistochemistry with anti-smooth muscle (SMA) antibody.

Results:

All patients were born from consanguineous parents. Of the five, two patients were identical twins. All eyes were microphthalmic. In four patients, congenital primary aphakia was bilateral and in one patient (Patient 3), it was unilateral. PKP failed in all eyes due to hypotony. Histologically, Bowman's layer was absent in all specimens. The corneal stroma was thin; however, the stromal collagen showed thick and irregularly arranged fibers with neovascularization in all eyes. Descemet's membrane and the corneal endothelium were absent in all specimens. In three specimens, atrophic iris tissue without dilator muscle was adherent to the posterior corneal surface. In addition, anteriorly displaced hypoplastic ciliary body and/or pigmented and non-pigmented ciliary epithelium were attached to the posterior corneal surface in three of the five specimens. SMA staining demonstrated disorganized ciliary muscle in one case. SMA-positive stromal keratocytes demonstrated their myofibroblast nature.

Conclusion:

The corneal findings in congenital primary aphakia are similar to that seen in other causes of congenital corneal opacification. The anteriorly displaced hypoplastic ciliary body that was partially excised during keratoplasty explains the ocular hypotony in these eyes.

Acute endophthalmitis after penetrating and endothelial keratoplasty at a tertiary eye care center over a 13-year period

Purpose:

To evaluate the clinico-microbiological profile, donor cornea risk factors, and outcomes of postkeratoplasty endophthalmitis at a tertiary care center.

Methods:

Retrospective analysis of charts of 28 consecutive patients (28 eyes) of acute endophthalmitis following either an endothelial keratoplasty (EK) or an optical penetrating keratoplasty (PK) surgery, performed between 2006 and 2018 (13-year period). Positive microbiology, identification and classification of predisposing factors, surveillance of utilized paired donors, treatment outcomes, and differences in the rate and severity of the event between optical penetrating and endothelial keratoplasty.

Results:

The estimated incidence of endophthalmitis was 0.23% in the entire cohort; it was 0.34% and 0.15%, after EK and PK, respectively (P = 0.049). The median time of endophthalmitis was 4.5 days postsurgery. Donor-related endophthalmitis was recognized in 7/28 (25%) eyes. Culture positivity was 68% (n = 19 of 28). Bacteria was isolated in 84% (n = 16 of 19) instances; Gram-negative bacilli were more common (87.5%; 14 of 16), and Pseudomonas species (50%; 7 of 14) was the most common Gram-negative bacterium. Majority (>75%) of the Gram-negative bacteria were resistant to all fluoroquinolones, aminoglycosides, 3^rd generation cephalosporins, and meropenam; 1/3^rd were resistant to imipenem; and 90% were sensitive to colistin. Treatment included intraocular antibiotic injections (96.4%), vitrectomy (42.9%), and therapeutic keratoplasty (50%). In 85.7% (24 of 28), globe was salvaged. The final vision was 20/200 or better in 39.1% (9 of 23) eyes.

Conclusion:

EK carried a higher risk of endophthalmitis than PK in this cohort. Bacterial infection was more common in this series, with Gram negative bacilli being the commonest organisms. Multidrug resistance was common (~75%) in Gram negative isolates.

Bilateral retinal detachment in Goldenhar syndrome

The ocular features of Goldenhar syndrome (GS) are typically external, like surface dermoids and lid coloboma. Retinal detachment (RD) is rare and has not been reported in absence of other concomitant predisposing congenital ocular disorders. We present a unique case of bilateral rhegmatogenous retinal detachment (RRD) with GS. To the best of our knowledge, this association of GS with RRD is novel and has not been reported earlier in ophthalmic and systemic literature on RRD.

Clinical diversity in macular corneal dystrophy: an optical coherence tomography study

PURPOSE

To characterise the corneal deposits of macular corneal dystrophy and correlate with high-resolution optical coherence tomography (OCT).

METHODS

A total of 23 eyes of 15 patients were evaluated for clinical features on slit lamp biomicroscopy, and high-resolution OCT was performed to correlate the clinical findings. The deposits were characterised based upon their location and level in the corneal layers.

RESULTS

Mean age was 31.5 (Range 20-67) years. The stromal deposits were restricted to central 8 mm in 9 eyes; in the rest of the 14 eyes, the deposits were seen in both central and peripheral cornea. In one patient, no such distinction could be made due to diffuse nature of the deposits throughout the cornea with sparing of 1-2 mm of the cornea internal to the limbus. The central deposits were in the anterior stromal layers, while the peripheral deposits were in the deep stromal corneal layers and non-contiguous with the anterior stromal deposits. In one patient aged 67 years, the peripheral deposits in deep corneal layers were more prominent than the central anterior stromal deposits and were associated with a significant thickening of Descemet membrane.

CONCLUSIONS

MCD exhibits a clinically diverse presentation as revealed on the clinical and optical coherence tomography study. Immunophenotype and genotype-phenotype correlation may further help in understanding various clinical presentations of MCD.

Ligneous conjunctivitis in a Dandy-Walker syndrome: A rare case report

Ligneous conjunctivitis (LC) is a rare form of pseudomembranous conjunctivitis seen in children, perhaps due to plasminogen deficiency, which manifest as a chronic refractory pseudomembranous conjunctivitis. LC cases are incapable in maintaining their fibrinolytic activity due to plasminogen deficiency; consequently, transudates of plasma assume as a thick, gelatinous, woody membranes over the mucosal surfaces. This is a short case report on a child with a LC, who presented with recurrent pseudomembranous conjunctivitis in conjunction with progressive congenital hydrocephalus due to aqueductal stenosis (Dandy-Walker syndrome). This rare association was clinically confirmed and prompt corrective surgical measures were instituted.

Surgical management of acquired implantation iris cysts: indications, surgical challenges and outcomes

Purpose

To describe the clinical spectrum, clinicopathological correlation and outcomes of different surgical strategies in the management of acquired implantation iris cysts.

Methods

From 1 January 1989 to 31 December 2015, 27 patients (27 eyes) with acquired implantation iris cysts underwent surgery. The charts were reviewed for demographics, preoperative characteristics, surgical approach, histopathological records of excised cyst and postoperative outcomes.

Results

The median age at presentation was 5 years (IQR: 1.3–14 years). Out of 27 patients, 21 (78%) were aged≤18 years. Almost two-third (17/27, 63%) patients had history of penetrating ocular trauma prior to surgery. All patients underwent cyst aspiration combined with complete cyst excision with additional surgical procedures when necessary. Along with complete cyst excision, sector iridectomy was performed in 20/27 (74%) eyes. At a median postoperative follow-up period of 8 months (range: 1–72 months), recurrence was noted in 3/27 (11%) cases at a mean follow-up period of 2.3±1.5 months postsurgery. Eyes in which sector iridectomy was performed had lower incidence of recurrence, and this was statistically significant (p=0.03). However, the improvement in best-corrected visual acuity postoperatively was not statistically significant (p=0.15).

Conclusion

Acquired implantation iris cysts are associated with significant ocular morbidity. Complete excision of the cyst with sector iridectomy is an effective treatment option if other less invasive surgical approaches fail. Visual acuity can be significantly improved but is typically limited due to associated comorbidities.

Primary graft failure after big bubble deep anterior lamellar keratoplasty in macular corneal dystrophy

Macular corneal dystrophy is autosomal recessive dystrophy characterized by deposits of abnormal glycosaminoglycans in stromal lamellae and within endothelial cells. Deep anterior lamellar keratoplasty is successful in the management of this dystrophy. We herein describe three cases of primary graft failure after uneventful big bubble deep anterior lamellar keratoplasty for macular corneal dystrophy.

Outcomes of keratoplasty in lattice corneal dystrophy in a large cohort of Indian eyes

Purpose:

The purpose of this study is to evaluate the outcomes of keratoplasty for lattice corneal dystrophy (LCD) performed at a tertiary eye care center.

Methods:

A retrospective review of medical records of those patients who were clinically diagnosed to have LCD (72 eyes of 57 patients) and underwent either penetrating keratoplasty (PK, 58 eyes of 46 patients) or deep anterior lamellar keratoplasty (DALK, 14 eyes of 13 patients) between the years 1987 and 2014 was performed. The main outcome measures included demographics, clinical features, and outcomes of keratoplasty.

Results:

The median follow-up after keratoplasty was 3.1 years (interquartile range [IQR], 9 months to 9 years). The median best-corrected visual acuity (BCVA) was 0.18 (IQR, 0.10–0.48) (Snellen equivalent 20/30 [IQR, 20/25–20/60]) at 4 years postoperatively and 0.65 (IQR, 0.18-0.95) (Snellen equivalent 20/89 [IQR, 20/30–20/178]) at 10 years following surgery. DALK eyes had a significantly better BCVA than PK eyes at 2 years following keratoplasty. The median overall survival of grafts was 15.8 years. Late complications included recurrence of LCD (14 eyes), graft infiltrate (23 eyes), graft rejection (15 eyes), graft failure (16 eyes), and glaucoma (14 eyes).

Conclusion:

The outcomes of graft are similar following PK and deep anterior lamellar keratoplasty; however, the latter appears to provide slightly better visual outcome. Recurrence of dystrophy in the graft and graft infiltrates limit the overall graft survival in both the groups.

Management of Candida glabrata infectious crystalline keratopathy with endophthalmitis following penetrating keratoplasty

A 33-year-old male underwent an optical keratoplasty elsewhere in the right eye following which he developed endophthalmitis and subsequently underwent a pars plana vitrectomy and lensectomy. At presentation, he had a deep stromal crystalline infiltration along the graft–host junction. A large therapeutic keratoplasty was performed, and the excised corneal button was evaluated. Histopathology revealed gram-positive round-to-oval budding structures and microbiology identified the organism as Candida glabrata. He was treated with antifungals in the postoperative period. At 4 months after therapeutic keratoplasty, the patient developed recurrent endophthalmitis, following stoppage of antifungals. The treatment was reinstituted for another year, and the patient did well with a clear graft at 18-month-follow-up period after the recurrence episode. Management of infectious crystalline keratopathy with endophthalmitis is a challenging situation and requires long-term treatment.

High-resolution optical coherence tomography in a case of descemetocele managed with amniotic membrane transplantation

Amniotic membrane transplantation is a useful in the management of corneal melts and descemetocele. We describe high-resolution anterior segment optical coherence tomography (OCT) (Optovue) in a patient with descemetocele who was managed surgically with amniotic membrane transplantation. A 60-year-old female presented with a corneal melt in the right eye. She was a case of rheumatoid arthritis and was on systemic treatment with immunomodulators. Slit lamp examination revealed a severe thinning paracentrally. High-resolution OCT was performed at the site of descemetocele. She underwent amniotic membrane transplantation using fibrin glue and bandage contact lens application. At 6 weeks postoperative, the bandage contact lens was removed. The area of thinning healed with scarring. OCT at the healed site revealed stable surface and an increase in stromal thickness to 281 μ this case describes the utility of amniotic membrane in the healing of sterile corneal melts by providing tectonic support and its integration in the stroma. The stromal healing and increased thickness at the site of descemetocele could be delineated on high-resolution OCT imaging.

Reactivation of herpes simplex viral keratitis following the botulinum toxin injection

We describe a case of 55-year-old male farmer presented with recurrent corneal abrasions with a spastic entropion in the left eye. Superior cornea showed typical nummular opacities suggestive resolved herpetic eye diseases. On further enquiry, he had similar episodes in the past. Contralateral eye was essentially normal. Following the botulinum toxin injection for the management of spastic entropion, subject developed reactivation of herpetic necrotizing stromal keratitis. Diagnostic corneal scrapings were negative for herpes simplex virus-1 antigen by immunofluorescence assay and for DNA by molecular techniques. The case was successfully managed with topical steroids and antiviral medications.

In vitro study of air bubble dynamics following pneumodissection of donor corneas and relationship of air bubble pattern with a peripheral paracentesis incision

AIMS

To study various types of morphological patterns of the air bubble and their relation to a peripheral paracentesis after air injection in corneal stroma in vitro experiment.

METHODS

Air was injected into the donor corneas from the endothelial side and pattern was noted. Four different scenarios were created, namely (a) air injection into the deep stroma (n=11), (b) air injection into the superficial stroma (n=3), (c) air injection into the deep stroma after making a peripheral incision internal to the trabecular meshwork region that simulated an anteriorly placed paracentesis incision, with the site of air injection within a clock hour of the peripheral incision (n=7) and (d) air injection into the deep stroma after making a peripheral incision, the site of air injection being 180° away from the peripheral incision site (n=3).

RESULTS

Air injection at deep posterior stroma resulted in the formation of type-1 and type-2 bubbles, type 2 began from the periphery and followed the type-1 bubble pattern in majority of the donor corneas. The type-1 pattern was noted as a bubble in the central part of the donor disc that did not reach the peripheral extent of the cornea. The type-2 pattern was a bubble that started at the peripheral cornea and expanded but was limited by the limbus circumferentially. With a full-thickness peripheral incision and air injection in the same clock hour of the incision, only a type-1 bubble pattern was noted with air leakage from the site of the incision.

CONCLUSIONS

The results of the study corroborate with the clinical observations made during deep lamellar keratoplasty (DLK). The placement of the paracentesis has a bearing on the pattern of the air bubble and can be used to an advantage during DLK surgery.

Long-term outcome after superficial keratectomy in an infant with epidermolysis bullosa

A 5-month-old boy presented with a congenital whitish raised lesion in the central cornea of the left eye. The child had a tendency to develop bullous eruptions on the skin with trivial trauma. The patient's father had a similar history of skin lesions. Because the lesion was in the central visual axis, a superficial anterior keratectomy with an amniotic membrane grafting was performed. The lesion healed well, restoring the corneal transparency and resulting in good visual acuity. When the boy was 4 years of age, his cornea was clear, and best-corrected visual acuity in the left eye was 20/60. There was no recurrence of the lesion.

Outcomes of endothelial keratoplasty in pseudophakic corneal oedema: with or without Descemet's membrane stripping

AIMS

To evaluate and compare outcomes of Descemet's stripping endothelial keratoplasty (DSEK) with non-DSEK (nDSEK) in pseudophakic corneal oedema (PCE).

METHODS

The study was a prospective, non-consecutive, comparative, interventional case series. Twenty-six patients with PCE were randomised into two groups. Group 1 comprised of those cases that had undergone conventional DSEK, and group 2 consisted of those that had nDSEK for PCE between 2010 and 2012. The data on demographics and clinical characteristics were collected from all patients. Any intraoperative and early and late postoperative complications were also noted. The primary outcome measure was postoperative functional success. Graft survival and complications were analysed as secondary outcomes.

RESULTS

The median best-corrected visual acuities at 6 months postoperatively in groups 1 and 2 were 0.18 (IQR 0.10-0.30) and 0.44 (IQR 0.18-0.51), respectively (p=0.11). Corneal oedema cleared in all patients. During the early postoperative period, a patient in group 2 had lenticule detachment managed by rebubbling.

CONCLUSIONS

nDSEK has outcomes similar to DSEK in PCE with advantages of decreased surgical time and avoidance of inadvertent pull on the posterior stromal fibres that may occur during Descemet's stripping.