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   2014| January-March  | Volume 21 | Issue 1  
    Online since January 1, 2014

 
 
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REFRACTIVE SURGERY UPDATE
Intrastromal corneal ring segments: How successful is the surgical treatment of keratoconus?
Jorge L Alio, Alfredo Vega-Estrada, Santiago Esperanza, Rafael I Barraquer, Miguel A Teus, Joaquim Murta
January-March 2014, 21(1):3-9
DOI:10.4103/0974-9233.124076  PMID:24669139
This review evaluates the outcomes of intrastromal corneal ring segment (ICRS) implantation for the treatment of keratoconus considering a new grading system based on the preoperative visual impairment of the patient. Additionally, a five-year follow-up analysis of patients with stable and progressive keratoconus is performed in order to assess the long term stability of the surgical procedure. Corrected distance visual acuity decreased statistically significantly in patients with mild keratoconus (P < 0.01) but statistically significantly increased in all other grades (P < 0.05). The improvement in visual acuity and the decrease of keratometric and aberrometric values were stable throughout a long period of time in patients with stable keratoconus. In patients with progressive form keratoconus, a significant improvement was found immediately after the procedure, however clinically relevant regression greater than 3 D was observed at the end of the follow up period.
  4 3,892 463
ORIGINAL ARTICLES
Pigmented hypopyon in association with Listeria monocytogenes endopthalmitis: An interesting case report following refractive surgery procedure with literature review
Hind M Alkatan, Hassan A Al-Dhibi, Deepak P Edward, Ali A Al-Rajhi
January-March 2014, 21(1):40-43
DOI:10.4103/0974-9233.124090  PMID:24669144
Purpose: Listeria monocytogenes is an aerobic, motile, gram positive bacillus recognized as an intercellular pathogen in human where it most frequently affects neonates, pregnant women, elderly patients, and immunosuppressed individuals as well as healthy persons. Ocular listeriosis is rare, most frequently in the form of conjunctivitis, but has been also shown to cause rarely endophthalmitis with pigmented hypopyon and elevated intraocular pressure such as in our case. Materials and Methods: We are reporting one immunocompetent patient presenting with dark hypopyon following laser refractive procedure. His clinical findings, investigations, and further management are all described with relevant literature review of similar cases. Results: Diagnosis of ocular listeriosis was confirmed by positive culture of anterior chamber (AC) aspirate with identification of the above organism. His visual outcome was satisfactory with good preserved vision. Conclusion: We believe that his ocular infection was exogenous and that ophthalmologists should be aware of the causative organisms of colored hypopyon to avoid delayed diagnosis.
  2 1,902 119
Primary and secondary implantation of scleral-fixated posterior chamber intraocular lenses in adult patients
Zuleyha Yalniz-Akkaya, Ayse Burcu, Guner O Uney, Iskan Abay, Umit Eksioglu, Mehmet Akif Acar, Firdevs Ornek
January-March 2014, 21(1):44-49
DOI:10.4103/0974-9233.124093  PMID:24669145
Purpose: The purpose of this study is to evaluate and to compare the results of primary and secondary scleral-fixated posterior chamber intraocular lens (PCIOL) implantations in adult patients. Materials and Methods: A retrospective analysis of scleral-fixated PCIOLs-implanted during (primary group) or after (secondary group) cataract surgery was performed. The median follow-up time of 96 patients was 6 months (minimum: 6; maximum: 35 months). Outcome measures were indications, corrected distance visual acuity (CDVA), change in visual acuity and complications. Results: A total of 37 patients (38.5%) had primary implantations and 59 (61.5%) had secondary implantations. Penetrating keratoplasty was combined with secondary implantation in 13 cases. The median post-operative CDVA was 0.5 in decimal notation in both groups (P = 0.576). The CDVA improved by at least one Snellen line or remained unchanged in 35 eyes (94.6%) in the primary group and in 52 eyes (88.1%) in the secondary group (P = 0.263). Eyes with CDVA of 0.5 or higher were 62.2% (n = 23) in the primary group and 67.8% (n = 40) in the secondary group post-operatively (P = 0.066). The difference in early and late complications were not statistically significant between groups (P = 0.637, P = 0.154, respectively). Regarding late complications, 30 eyes (81%) in the primary group and 40 eyes (67.9%) in the secondary group had no complications (P = 0.154). Conclusion: Both primary and secondary scleral-fixated PCIOL implantations can provide favorable visual outcomes with lower complication rates. An important consideration is the appropriate timing for scleral fixation, taking into account the patient's characteristics and the course of the operation.
  2 2,390 207
Rose-K versus soper contact lens in keratoconus: A randomized comparative trial
Raghav Gupta, Rajesh Sinha, Pooja Singh, Namrata Sharma, Radhika Tandon, Jeewan S Titiyal
January-March 2014, 21(1):50-55
DOI:10.4103/0974-9233.124095  PMID:24669146
Purpose: To perform a comparative evaluation of the efficacy and acceptability of Rose-K and Soper contact lenses in Keratoconus. Setting: Dr. Rajendra Prasad Center for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi. Materials and Methods: A randomized comparative clinical trial was performed in keratoconic eyes fitted with Rose-K (Rose-K group) and Soper (Soper group) contact lenses. Patients data were evaluated for best spectacle corrected visual acuity, best contact lens corrected visual acuity (BCLCVA), corneal topography, glare acuity, contrast sensitivity, tear function tests and specular microscopy. Patients were also asked to complete a self-reported comfort questionnaire at each visit. Results: Sixty eyes were randomized to the Rose-K and Soper groups. The two groups were comparable in all the baseline parameters. There was a statistically significant improvement in BCLCVA in both groups at 3 months (P < 0.01, both groups). The difference between in BCLCVA in both groups was not statistically significant. In both groups, there was a significant improvement in the comfort score at 3 months compared to baseline (P < 0.05, both group). The Rose-K group had statistically significantly better scores at 1 and 3 months compared with the Soper group (P = 0.006 and P < 0.001 respectively). Both groups were associated with a significant (P < 0.01), but comparable improvement in glare acuity at 3 months. There was a significant improvement in contrast sensitivity at 3 months in both groups (P < 0.01); the Rose-K group was significantly better than the Soper group at 1 and 3 months (P = 0.001 and 0.002 respectively). The mean number of trial lenses required for fitting Rose-K lens (2.00 ± 0.59) was significantly lower than the Soper lens (3.43 ± 0.82; P < 0.001). Conclusion: Both the contact lens designs provide an equal improvement in visual acuity in patients with Keratoconus. However, Rose-K contact lens provides greater comfort, better quality of vision and requires less chair time compared with the Soper lens and hence may possibly have a greater acceptability.
  2 2,481 185
Comparison of morphological and functional endothelial cell changes after cataract surgery: Phacoemulsification versus manual small-incision cataract surgery
Sunil Ganekal, Ashwini Nagarajappa
January-March 2014, 21(1):56-60
DOI:10.4103/0974-9233.124098  PMID:24669147
Purpose: To compare the morphological (cell density, coefficient of variation and standard deviation) and functional (central corneal thickness) endothelial changes after phacoemulsification versus manual small-incision cataract surgery (MSICS). Design: Prospective randomized control study. Materials and Methods: In this prospective randomized control study, patients were randomly allocated to undergo phacoemulsification (Group 1, n = 100) or MSICS (Group 2, n = 100) using a random number Table. The patients underwent complete ophthalmic evaluation and specular microscopy preoperatively and at 1and 6 weeks postoperatively. Functional and morphological endothelial evaluation was Noncon ROBO PACHY SP-9000 specular microscope. Phacoemulsification was performed, the chop technique and MSICS, by the viscoexpression technique. Results: The mean difference in central corneal thickness at baseline and 1 week between Group 1 and Group 2 was statistically significant (P = 0.027). However, this difference at baseline when compared to 6 week and 1 week, 6 weeks was not statistically significant (P > 0.05). The difference in mean endothelial cell density between groups at 1 week and 6 weeks was statistically significant (P = 0.016). The mean coefficient of variation and mean standard deviation between groups were not statistically significant (P > 0.05, both comparisons). Conclusion: The central corneal thickness, coefficient of variation, and standard deviation were maintained in both groups indicating that the function and morphology of endothelial cells was not affected despite an initial reduction in endothelial cell number in MSICS. Thus, MSICS remains a safe option in the developing world.
  2 2,756 344
CASE REPORTS
Intraoperative fracture of phacoemulsification tip
Dewang Angmo, Sudarshan K Khokhar, Anasua Ganguly
January-March 2014, 21(1):86-88
DOI:10.4103/0974-9233.124116  PMID:24669153
Phacoemulsification (phaco) is an established procedure for cataract extraction and has undergone a significant advances in techniques, machines and phaco tips. The Aspiration Bypass System (ABS) phaco tip was introduced for phacoemulsification in 1998. The ABS tip allows fluid to be drawn through the opening when the phaco tip is occluded by nuclear material. The ABS tip allowed the safe use of high vacuum and flow rates and improved chamber stability by decreasing surge and therefore reducing intraoperative complications. To date, no disadvantages of ABS tips have been reported. We report a unique case of an intraoperative break of an ABS phaco tip during routine cataract surgery.
  1 1,480 89
Alternaria keratitis after deep anterior lamellar keratoplasty
Mekhla Naik, Mohd. Shahbaaz , Jay Sheth, SK Sunderamoorthy
January-March 2014, 21(1):92-94
DOI:10.4103/0974-9233.124121  PMID:24669155
To describe a case of Alternaria keratitis in a 30-year-old male patient who presented with bilateral vascularised central corneal opacity and underwent deep anterior lamellar keratoplasty (DALK) in the left eye. Patient was treated for recurrent epithelial defect with a bandage contact lens in the follow-up visits after DALK. Subsequently, patient presented with pigmented fungal keratitis, which on culture examination of the corneal scrapping demonstrated Alternaria species. Patient had to undergo a repeat DALK as the keratitis did not resolve with medical therapy alone. Patient did not have a recurrence for 11 months following the regraft. This case report highlights the importance of considering the Alternaria species as a possibile cause of non-resolving fungal keratitis after DALK.
  1 1,590 106
Alopecia following oral acyclovir for the treatment of herpes simplex keratitis
Ashok Sharma, Kanwar Mohan, Rajan Sharma, Verinder S Nirankari
January-March 2014, 21(1):95-97
DOI:10.4103/0974-9233.124131  PMID:24669156
The authors report acyclovir-induced alopecia in a patient treated for herpetic keratouveitis. A 32-years-old female was diagnosed with herpetic keratouveitis. She was placed on prednisolone acetate (1%) suspension four times a day, atropine sulfate (1%) thrice a day, and oral acyclovir 400 mg twice-daily. Three weeks following oral acylovir, keratouveitis improved, but she developed alopecia without any drug eruptions. Oral acyclovir was discontinued. Three months later, alopecia completely resolved. Alopecia may be considered a possible complication following oral acyclovir.
  1 2,729 129
REFRACTIVE SURGERY UPDATE
Current management of presbyopia
Pandelis A Papadopoulos, Alexandros P Papadopoulos
January-March 2014, 21(1):10-17
DOI:10.4103/0974-9233.124080  PMID:24669140
Presbyopia is a physiologic inevitability that causes gradual loss of accommodation during the fifth decade of life. The correction of presbyopia and the restoration of accommodation are considered the final frontier of refractive surgery. Different approaches on the cornea, the crystalline lens and the sclera are being pursued to achieve surgical correction of this disability. There are however, a number of limitations and considerations that have prevented widespread acceptance of surgical correction for presbyopia. The quality of vision, optical and visual distortions, regression of effect, complications such as corneal ectasia and haze, anisometropia after monovision correction, impaired distance vision and the invasive nature of the currently techniques have limited the utilization of presbyopia surgery. The purpose of this paper is to provide an update of current procedures available for presbyopia correction and their limitations.
  1 3,740 424
Refractive surgery in systemic and autoimmune disease
Majed AlKharashi, Kraig S Bower, Walter J Stark, Yassine J Daoud
January-March 2014, 21(1):18-24
DOI:10.4103/0974-9233.124082  PMID:24669141
Patients with underlying systemic disease represent challenging treatment dilemma to the refractive surgeon. The refractive error in this patient population is accompanied by a systemic disease that may have an ocular or even a corneal component. The literature is rather sparse about the use of laser refractive surgery (LRS) and such procedure is not approved by the United States Food and Drug Administration (FDA) in this patient population. Patients with collagen vascular disease, diabetes mellitus (DM), allergic and atopic disease, or human immunodeficiency virus (HIV) are never ideal for LRS. Patients with uncontrolled systemic disease or ocular involvement of the disease should not undergo LRS. However, a patient with well-controlled and mild disease, no ocular involvement, and not on multidrug regimen may be a suitable candidate if they meet stringent criteria. There is a need for a large, multicenter, controlled trial to address the safety and efficacy of LRS in patients with systemic disease before such technology can be widely adopted by the refractive surgery community.
  1 3,210 164
CASE REPORTS
Repositioning of pedicle conjunctival flap performed for refractory corneal ulcer
Ashok Sharma, Kanwar Mohan, Rajan Sharma, Verinder S Nirankari
January-March 2014, 21(1):89-91
DOI:10.4103/0974-9233.124118  PMID:24669154
A 50-year-old male was referred with a previous history of conjunctival flap (CF) for a nonhealing fungal corneal ulcer with extreme corneal thinning in the right eye. The peritomy for the CF extended from 6:30 to 9:30 clock h on the cornea. The CF was disengaged, peritomy area deepithelialized, and CF was repositioned. He later underwent penetrating keratoplasty and achieved 20/40 best corrected visual acuity. The authors present a new concept for surgically repositioning CF s to the original site immediately after healing of the corneal ulcer.
  - 2,151 113
Severe bilateral paralimbal sterile infiltrates after photorefractive keratectomy
Mohammed A Al-Amry
January-March 2014, 21(1):83-85
DOI:10.4103/0974-9233.124114  PMID:24669152
This study presents a case report of the clinical presentation and management of a 47-year-old male myope who underwent photorefractive keratectomy (PRK) and developed bilateral sterile corneal infiltrates at 1 day post-operatively. The patient was successfully treated with aggressive topical antibiotic and topical steroid therapy. The final corrected distance visual acuity (CDVA) was 20/25 with faint corneal scarring. Peripheral sterile corneal infiltrate can occur after PRK with excellent prognosis. Infectious causes should be suspected in all cases of corneal infiltrate. The most likely cause of peripheral sterile corneal infiltrate in this case was pooling of the tear film containing antigens under the bandage contact lens.
  - 2,027 109
EDITORIAL
Refractive surgery: The never-ending task of improving vision correction
Samar A Al-Swailem
January-March 2014, 21(1):1-2
DOI:10.4103/0974-9233.124075  PMID:24669138
  - 1,447 145
ORIGINAL ARTICLES
Gradient refractive index optics IOL: Theoretical background and clinical results
Boris Malyugin, Tatiana Morozova, Valentin Cherednik
January-March 2014, 21(1):32-39
DOI:10.4103/0974-9233.124086  PMID:24669143
Purpose: To present the theoretical optical background and clinical results of a new multifocal intraocular lens (MIOL) concept-gradient refractive index optics (Gradiol). Patients and Methods: Original mathematical modeling software was used to calculate optimal construction of the MIOL optic constructed from two polymer materials with different refractive indices. Gradiol lenses were manufactured from hydrophobic acrylic utilizing original step-by-step polymerization technology with the final power difference of of 3.5 D between optic components. Non-comparative prospective clinical study included 26 patients (29 eyes) who were candidates for MIOL implantation. All surgeries were performed at the S. Fyodorov Eye Microsurgery Complex State Institution, Moscow, Russia. After implantation of the Gradiol lenses, the postoperative evaluations included distance (best corrected visual acuity (BCVA)) and near visual acuity (NVA), contrast sensitivity (CS), and amplitude of pseudoaccommodation. Subjective patient's satisfaction was assessed using a questionnaire (VF-14). Results: The mean age of the patients was 62.5 ± 5.7 years (range 27-82 years). All surgical procedures were uneventful. At 6 months postoperatively, the mean uncorrected distance VA was 0.73 ± 0.18, mean uncorrected near VA was 0.57 ± 0.19, mean corrected distance VA was 0.89 ± 0.15, mean corrected near VA was 0.84 ± 0.07, and amplitude of pseudoaccommodation was 4.75 ± 0.5 D. Eighty-six percent of patients were spectacle independent for daily activities and reading. Optical disturbances that were functionally significant were reported by 10.7% of patients postoperatively. Conclusion: The clinical outcomes of this study confirmed the theoretical calculations of constructing MIOL optics from materials with different refractive indices.
  - 2,629 106
Prickly pear spine keratoconjunctivitis
Thabit Ali Mustafa Odat, Mohammad Jebreel Al-Tawara, Eman Hussein Hammouri
January-March 2014, 21(1):61-65
DOI:10.4103/0974-9233.124100  PMID:24669148
Objectives: To study the ocular and extra-ocular features, clinical presentation, and treatment of prickly pear glochids. Materials and Methods: This retrospective study included 23 eyes of 21 patients with ocular prickly pear spines who were seen between August and October 2011 in the outpatient ophthalmic clinic at Prince Rashid Bin Al Hassan military hospital in Jordan. Medical records of patients including age, gender, history of exposure to prickly pear plants, and ocular examination were reviewed. All glochids were localized and removed with forceps under topical anesthesia with the patient at the slit lamp. Patients were followed up after one week. Results: The mean age of patients was 37.1 years with a male to female ratio of 1.6: 1. Involvement of the right eye was seen in 61.9% patients, left eye in 28.6% patients, and bilateral involvement in 9.5% patients. Glochids were most commonly found in the upper subtarsal conjunctival space (47.6%) followed by inferior palpebral conjunctiva in 23.8% eyes. The most common complaint was eye irritation in 95.2% patients. Pain was a complaint in 57.1% patients. Superior corneal epithelial erosions or ulcer were found in 33.3% patients, inferior corneal epithelial erosions in 19.1% patients, and diffuse epithelial erosions in 9.5% patients. Glochids were found in other parts of the body in 38.1% patients. Conclusion: Although prickly pear glochid ocular surface injury is not uncommon in the region during summer, it should be considered in patient with eye pain during that period. Farmers who are in close contact with prickly pears should use protective eyeglasses and gloves.
  - 2,073 94
Modulatory effect of different riboflavin compositions on the central corneal thickness of African keratoconus corneas during collagen crosslinking
Timo Mark, Faustin Ngounou, James Tamon, Susanne Marx-Gross, Paul-Rolf Preussner
January-March 2014, 21(1):66-71
DOI:10.4103/0974-9233.124103  PMID:24669149
Purpose: A pilot investigation to transfer the established corneal collagen crosslinking (CXL) procedure in European eyes into clinically affected African eyes and to optimize the treatment by adapting the riboflavin composition. Materials and Methods: CXL was performed in 15 eyes (11 patients) with advanced stages of keratoconus in the Eye Clinic of Bafoussam in the West Region of Cameroon. The following six riboflavin compositions with different portions of active swelling additives were applied: Solution 1 (0.5% methylhydroxypropylcellulose [MHPC]), solution 2 (1.0% MHPC), solution 3 (1.7% MHPC), solution 4 (5% dextran), solution 5 (10% dextran) and solution 6 (no active swelling ingredient). The central corneal thickness (CCT) was measured by ultrasound pachymetry before and after de-epithelialization and at least every 10 min during CXL. Results: The application of the riboflavin solutions resulted in the following mean final CCT values: 172 ± 15% using solution 1 (60 min/n = 5); 183 ± 8% using solution 2 (60 min/n = 5); 170% using solution 3 (60 min/n = 1); 80% using solution 4 (45 min/n = 1); 99% using solution 5 (45 min/n = 1) and 150 ± 13% using solution 6 (50 min/n = 2). Conclusions: The combination of riboflavin compositions with swelling and stabilizing effects on the corneal stroma seems necessary in African eyes with advanced keratoconus. Further studies are required to confirm these primary results.
  - 1,786 134
Corneal topography patterns in the Tehran eye study: Warning about the high prevalence of patterns with a skewed radial axis
Hassan Hashemi, Asghar Beiranvand, Mehdi Khabazkhoob, Akbar Fotouhi
January-March 2014, 21(1):72-76
DOI:10.4103/0974-9233.124107  PMID:24669150
Purpose: The purpose of this study is to determine the distribution of corneal topography patterns in Tehran. Materials and Methods: In this population-based study, a total of 442 individuals were randomly selected by cluster sampling for complete ophthalmologic examination. A total of 404 (788 eyes) met the inclusion criteria and were enrolled in this study. Orbscan II (Bausch and Lomb Surgical, Salt Lake City, USA) was used to determine the anterior segment indices and axial power maps for each eye. Results: On the basis of the axial power maps, the symmetric bowtie (SB) (29.0%) and asymmetric bowtie with inferior steepening (16.7%) patterns were the most prevalent and the irregular (3.3%) and superior steepening (1.5%) patterns the least prevalent. Asymmetric bowtie pattern with a skewed radial axis (AB-SRAX) was seen in 7.6% of eyes. These cases had both thinner and steeper corneas compared with round and SB ones (P < 0.014 and P < 0.006). Maximum anterior elevation in 5 mm zone, of AB-SRAX corneas were higher than other patterns (P < 0.01) except for superior steepened and inferior steepened ones. Conclusions: The distribution of corneal topographic patterns in Iranians seems like other Asian population on the whole. The 7.6% prevalence of AB-SRAX patterns may be a warning on keratoconus prevalence in our population. This is in line with recent regional reports.
  - 3,754 171
Manual suture less small incision cataract surgery in patients with uveitic cataract
Rahul Bhargava, Prachi Kumar, Hafsa Bashir, Shiv Kumar Sharma, Anurag Mishra
January-March 2014, 21(1):77-82
DOI:10.4103/0974-9233.124110  PMID:24669151
Purpose: The purpose of this study is to evaluate the outcome of manual small incision cataract surgery (SICS) in eyes with uveitic cataract. Setting: Medical college hospital of the subcontinent. Design: Retrospective case series. Materials and Methods: In this retrospective study, patients who underwent SICS with posterior chamber intraocular lens implantation for uveitic cataract from 2006 to 2009 were evaluated. Patients with less than 3 months follow-up were excluded. Post-operative vision and complications were analyzed. Results: A total of 54 patients completed the study. The mean age was 52.3 ± 9.3 years. The mean follow-up was 11.53 ± 5.05 months. The mean surgical time was (10.2 ± 3.8 min). Etiological diagnosis was possible in 31.41% (17/54) of patients. There was a statistically significant improvement in vision after surgery (P < 0.001). When uveitis was well-controlled, pre-operative corticosteroids did not change post-operative inflammation (P = 0.796). However, pre-operative corticosteroids were statistically significantly associated to final best corrected visual acuity (BCVA) (P = 0.010). Conclusion: SICS with posterior chamber intraocular lens implantation is safe in most cataracts due to uveitis and improves BCVA at 6 months. Inflammation should be well-controlled pre-operatively for at least 3 months. Posterior capsule opacification, macular edema and persistent uveitis were the main factors affecting visual outcome. SICS requires minimal instrumentation, surgical time is short and can also be performed in rural clinics and eye-camps, where phacoemulsification machines are unavailable. SICS may be a more practical and cost-effective technique for uveitic cataract, in such circumstances.
  - 3,184 174
REFRACTIVE SURGERY UPDATE
Clear corneal incision in cataract surgery
Ammar M Al Mahmood, Samar A Al-Swailem, Ashley Behrens
January-March 2014, 21(1):25-31
DOI:10.4103/0974-9233.124084  PMID:24669142
Since the introduction of sutureless clear corneal cataract incisions, the procedure has gained increasing popularity worldwide because it offers several advantages over the traditional sutured scleral tunnels and limbal incisions. Some of these benefits include lack of conjunctival trauma, less discomfort and bleeding, absence of suture-induced astigmatism, and faster visual rehabilitation. However, an increasing incidence of postoperative endophthalmitis after clear corneal cataract surgery has been reported. Different authors have shown a significant increase up to 15-fold in the incidence of endophthalmitis following clear corneal incision compared to scleral tunnels. The aim of this report is to review the advantages and disadvantages of clear corneal incisions in cataract surgery, emphasizing on wound construction recommendations based on published literature.
  - 3,137 278
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