Laser-assisted in situ Keratomileusis (LASIK) is the most commonly performed refractive surgical procedure. The amount of tissue ablated in LASIK affects the safety and long-term outcome. The objective of this study was to compare the percent tissue altered (PTA) in topography guided (TG) and wavefront optimized (WFO) LASIK using Zeiss MEL 80 excimer laser.This retrospective observational study was conducted at a tertiary eye center. Patients with moderate myopia who underwent LASIK between June 2016 and January 2019 were divided into two groups (Group I: TG LASIK, 69 eyes; Group II: WFO LASIK, 70 eyes). The groups were compared for preoperative parameters [spherical equivalent (SE), keratometry and pachymetry], intraoperative parameters [ablation depth (AD), PTA and residual stromal bed thickness (RSBT)] and postoperative parameters (vision, SE).Among preoperative parameters, SE and keratometry were similar while thinnest pachymetry was significantly less in group I. Among the intraoperative parameters, PTA (P < 0.01) and AD (P < 0.01) were significantly less in group I while RSBT (P = 0.54) was not significantly different. Postoperatively at 6 months, 92.75% (64) eyes in group I and 90% (63) eyes in group II had visual acuity of 6/6 or better (P = 0.57). 98.55% (68) and 97.14% (68) eyes in group I and group II respectively had SE refraction within ± 0.5 dioptres.TG LASIK induces less tissue alteration for given refractive error with similar visual outcome as compared to WFO LASIK which makes TG apparently safer and is the preferred technique for borderline thin corneas.
Injuries to the eye causing ocular surface damage may develop symblepharon as a complication in which palpebral conjunctiva got adhered to the bulbar conjunctiva or cornea. Removal of adhesions is must for ocular surface reconstruction but chances of recurrence are more in simple removal. A study was done among 10 eyes of 10 patients to see the efficacy, safety and outcome of symblepharon excision with amniotic membrane transplantation. All the patients were operated by a single surgeon with standard technique and all of them were followed up for 6 months. All eyes exhibit a stable, intact corneal epithelial surface and healthy conjunctival growth without developing recurrent erosion or persistent epithelial defect. Visual improvement was seen in 60% of cases. Eighty per cent patients showed symptomatic relief. All eyes exhibited decreased vascularisation and inflammation at final follow-up. Thus, amniotic membrane transplantation is very effective in ocular surface reconstruction in cases of symblepharon and limbal stem cell deficiency.
Hereditary sensory and autonomic neuropathies (HSANs) are a group of an extremely rare inherited disorder of the peripheral nervous system with heterogeneous clinical presentations and genetic causes.[1] They are classified into types I–V based on the age at onset, inheritance pattern, clinical presentation, and genetic background.[1] HSAN II is a very rare autosomal recessive disease with unknown prevalence. It presents with usual onset in infancy—widespread sensory loss, mutilations in the hands and feet, acro-osteolysis, and mild or minimal autonomic dysfunction.[12] HSAN II is distinguished by normal mental health from HSAN III and IV.[2] The reported ocular manifestations in HSANs are optic neuropathy, recurrent corneal ulcers, and neurotrophic keratitis.[345] To the best of our knowledge, this is the first longitudinal report of keratoconus associated with HSAN II, describing the progression of keratoconus during a follow-up of 1.5 years. A 16-year-old girl presented to our ophthalmology clinic with complaint of decreased vision in both eyes for the past 3 months. Her medical history included HSAN II diagnosis since childhood. She had a history of multiple injuries and unnoticed trauma. Her parents gave a strong history of lack of response to any painful stimuli and insensitivity to extreme temperature stimuli which were observed at the age of 1. Family history revealed that her younger brother had similar complaints. History of consanguinity with parents being first cousins was noted. The neurological medical reports showed the presence of wasting, normal muscle power and limbs reflex, absences of plantar reflex, impaired joint position sense, and reduced crude touch sensation in all the four limbs which were greater distally than proximally. Her IQ was within normal limits. The external examination revealed the presence of ulcers and severe acro-mutilations in the fingers and toes. Multiple, well-defined, discrete, erythematous-based ulcers with sloping edges were present over the bilateral elbows, thighs, and abdomen. Also, multiple superficial healed skin ulcers were present over the whole body [Fig. 1a-c].Figure 1: (a) Clinical photograph of the patient with hereditary sensory, and autonomic neuropathy II, severe mutilations and ulcers in the (b) fingers and (c) toesAt the baseline examination, her distance best-corrected distance visual acuity (BCVA) was 20/80 OD and 20/60 OS with a refractive error of −8.00/−2.00 × 80 OD and −6.00/−2.50 × 110 OS. The slit-lamp bio-microscopy of the right eye showed Vogt's striae while protrusion, Fleischer ring, and prominent corneal nerves were present in both eyes [Fig. 2a and b]. Munson's sign was visible in OU [Fig. 2c]. Her intraocular pressures were normal. Sirius corneal topographer combined with Scheimpflug tomographer showed bilateral central steepening in OU [Fig. 3]. The corneal apex power and thinnest pachymetry were 68.3 D and 406 μm in OD and 61.4 D and 479 μm in OS, respectively.Figure 2: Photograph of the (a) right eye and (b) left eye slit-lamp bio-microscopy showed Vogt's striae in the right eye while protrusion in both the eyes, (c) presence of Munson's sign in both the eyesFigure 3: Corneal topography combined with the tomography of both the eyes showed central corneal steepening, reduced corneal thickness, and abnormal anterior and posterior elevation indices at the first visit of the patientHer fundus examination showed mild temporal disk pallor in both eyes. Schirmer's 1 test was found to be within the normal range. A wisp of the cotton-tipped applicator was used for the qualitative assessment of the corneal sensations, which were found to be absent. The laboratory investigations were within normal limits. The MRI of the brain and spinal cord was normal. The nerve biopsy report was not available. The patient was called for a follow-up visit of the contact lens trial after 3 days. A pedigree charting was done [Fig. 4]. The examination of the patient's parents and sibling was undertaken. The ocular examination did not show any similar or significant findings.Figure 4: Pedigree chart of the family of the patient with hereditary sensory and autonomic neuropathyThe patient did not come for the follow-up as per advice. The patient visited us after approximately 1.5 years. On examination, her distance BCVA was reduced to 20/120 OD and 20/60 − 2 OS with a refractive error of −8.00/−3.00 × 90 OD and with −7.00/−2.50 × 100 OS. The corneal tomography showed that the corneal apex power had increased to 81.1 D OD and 63.3 D OS whereas the thinnest corneal thickness was decreased to 351 μm OD and 421 μm OS, respectively [Fig. 5]. The patient was given a trial of semi-scleral contact lenses, and with them, her distance visual acuity improved to 20/40-2 OD and 20/30 OS. The epithelium-on corneal collagen cross-linking (CXL) was offered with explained prognosis.Figure 5: Corneal topography combined with the tomography of both the eyes showed increased central corneal steepening, reduced corneal thickness, and abnormal anterior and posterior elevation indices on the follow-up visit of the patientDiscussion This case report describes a rare association of keratoconus with HSAN II. Keratoconus is usually an isolated sporadic condition, although multiple reports have described its association with other systemic or ocular disorders or in combination with rare genetic diseases.[6] The previous studies have reported that keratoconus in the pediatric age group with some genetic associations tends to progress rapidly.[7] In our case too, the keratoconus progressed drastically in 1.5 years which demonstrates that pediatric keratoconus progresses more aggressively. Rapidly progressive keratoconus is an indication of CXL.[8] In this case, corneal sensations have been lost due to HSAN II. Considering the neurotrophic status of the cornea, epithelium-on CXL was advised. Any corneal surgery on the neurotrophic cornea can lead to poor wound healing and epithelial changes such as punctate epithelial keratopathy, persistent epithelial defects, corneal ulcer, and perforation.[9] Owing to the possibility of corneal erosions, the corneal lenses were also not recommended. The patient was managed with scleral contact lenses, which are both safe and effective because they rest on the sclera. However, due to finger mutilations in both hands, the patient will be reliant on her parents for lens insertion and removal. The reported genes associated with HSAN II are HSN2/WNK1, FAM134B, and K1F1A,[1] although no mutations were directly linked with keratoconus. Nerve biopsy and chromosomal analysis might have provided more information about the case. However, those could not be done and account for a limitation of our study. Our case provides further evidence that HSANs are commonly associated with ocular problems, highlighting the significance of a detailed ophthalmic evaluation in these diseases. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
AIM: To find out ocular symptoms in Visual Display Terminals (VDTs) users, among undergraduate students who adopted new education system in this COVID-19 era. Methods: A cross-sectional, observational survey carried out in the month of September 2020, which included undergraduate students from Ahmedabad, who were using Visual Display Terminals (VDTs) for educational activities for more than 6 to 8 months. A total of fourteen validated questionnaires were selected, webpage survey form was created and the link was sent via various social media platform. Responses were assessed in the scale of 0 to 4 (0= never, 1=infrequently, 2=sometimes, 3= often, 4=always). The percentage of symptoms was calculated in terms of subjects, also in the scale of 0 to 4.Results: A total of 103 undergraduate students responded with mean age of 19±1.5 years. Highest number (40: 4-6 hours, 36: 7-9 hours) of students had a screen time of 4 to 9 hours per day. The burning sensation (69.8%), redness (51.4%), itching (47.6%) were the most common symptoms, followed by irritation (34.6%), and scratchiness (25.5%) related to dry eyes. However, majority of the patients had those symptoms on infrequent duration. A loss of the concentration (73.8%), tired eyes (69.6%), discomfort (61.2%), headache (60.7%), reduced reading speed (56.3%), fluctuation in vision (44.7%), blurring (43.7%), were the most common symptoms related to the near work. Majority of participants felt these complain for the duration of infrequent to often basis. The double vision (25.2%) and floating of objects (11.7%) were the least common symptoms related to near work. Conclusion: The VDTs related symptoms are increasing in the students in this COVID-19 era. Increasing awareness, proper counselling regarding algorithm of VDTs, taking regular breaks, avoiding unnecessary web searching and social media can help to relieve or minizine symptoms related to VDTs work in this COVID-19 era.
Purpose: To identify the microbiological profile and evaluate the clinical course and outcomes in patients who developed severe infectious keratitis after colored cosmetic contact lens wear. Methods: This case series includes 13 patients who developed severe infectious keratitis after colored cosmetic contact lens wear. A detailed history regarding contact lens availability and storage and handling techniques was taken. All patients underwent standard diagnostic microbiological evaluation followed by culture-guided topical antimicrobial therapy. Results: Of 13 patients, 8 were male and 5 were female, with mean age at presentation of 19 ± 3.8 years. All patients were emmetropic, and lenses were worn solely for cosmetic purposes. Seven lenses were dispensed without prescription or fitting from an unlicensed optical shop, 5 patients had shared lenses with friends/relatives, and 1 patient obtained the lens from the garbage. None of the patients followed the recommended contact lens handling and storage techniques. The causative microorganisms included Pseudomonas aeruginosa (54%), Staphylococcus aureus (25%), and Staphylococcus epidermidis (17%), with 1 case of viral keratitis. In 62% of cases, ulcer size was ≥5 × 5 mm and posttreatment corrected visual acuity was 6/24 or less. All patients responded well to topical antimicrobials, and none required surgical intervention. Conclusions: Over-the-counter use of decorative lenses as a cosmetic aid is rapidly increasing. Easy and unmonitored availability of these cosmetic lenses is followed by severe sight-threatening complications in young emmetropic individuals.
To report a case of keratoconus with early-onset Fuchs’ endothelial corneal dystrophy (FECD) changes in identical twins. A case report. A 22-year-old female had ocular findings of corneal protrusion, Fleischer’s ring, and corneal endothelium pigment dusting in both eyes. Corneal tomography showed increased corneal power and reduced thickness, and specular microscopy revealed loss of endothelial cells, the presence of a few non-confluent guttata, pleomorphism, and polymegathism in both eyes. Based on these findings, she was diagnosed as keratoconus with early grade FECD changes. Her family history revealed that she has an identical twin sister. Examination of her twin sister showed similar findings suggesting keratoconus with early grade FECD. This case report provides further evidence for the role of genetics in the development of keratoconus. Furthermore, it shows the diagnostic, monitoring, and treatment challenges due to the combination of two different diseases.
The endothelial changes in keratoconus are of interest because these can affect the surgical plan in management. Previously, many studies have evaluated the endothelium in eyes with keratoconus, but there is no common consensus on change in endothelial cell density (ECD) with studies showing variable results.This study aimed to compare and correlate endothelial cell parameters in different stages of keratoconus using specular microscope.This cross-sectional, cohort, comparative study included 162 eyes of 96 patients with keratoconus in one or both eyes. Corneal endothelial cell parameters were assessed with SP-1P specular microscope (Topcon Co., Tokyo, Japan). Corneal topography and thickness data were obtained from Sirius tomographer (Costruzione Strumenti Oftalmici, Florence, Italy). Eyes were divided into keratoconus stage 0 to 4 according to ABCD classification. Comparison and correlation of endothelial cell parameters in different stages were done.There were 21.6% eyes (35) in stage 0, 29.6% eyes (48) in stage 1, 29.0% eyes (47) in stage 2, and 19.8% eyes (32) in stage 3 of keratoconus. Measurement was not possible in stage 4 keratoconus. Among the stages 0, 1, 2, and 3, the ECD was 3024, 3051, 3025, and 3043 cells/mm2; coefficient of variation was 27.2, 27.6, 26.8, and 27.4; and frequency of hexagon cells was 61.5, 63.7, 63.3, and 62.3, respectively (P > .05). The number of analyzed cells was 232, 209, 185, and 169 in stages 0, 1, 2, and 3, respectively (P < .001). No significant difference was found in minimum, maximum, and average cell area between the stages (P > .05). A weak Spearman rank correlation of ECD, coefficient of variation, and frequency of hexagon cells was found between eyes with keratoconus stages 0 and 1 and stages 2 and 3 (r = -0.05, P = .65; r = -0.11, P = .37; r = 0.05, P = .67, respectively). No significant correlation was found in the number of cells analyzed and minimum, maximum, and average cell area between the stages (P > .05).Endothelial cell parameters do not show any significant changes and correlation up to stage 3 of keratoconus in non-contact lens wearers.
Mooren's ulcer is a rare disorder of unknown etiology that is refractory to treatment. It can affect not just the cornea but also the scleral tissue and can involve both eyes. We report a case of a 25-year-old young male with a history of bilateral and malignant Mooren's ulcer. The patient had lost left eye to perforation of mooren’s ulcer before 3 years. The perforated Mooren's corneal ulcer also presented in the right eye and involved the adjacent scleral tissue. A crescent shaped corneal-scleral patch graft was performed to preserve the anatomical integrity of the eye as well as vision along with local as well as systemic immunosuppression. This report highlights how a corneal-scleral patch graft followed by systemic and local immunosuppressive treatment can be considered in monocular patients with malignant Mooren's ulcer which can prove to be globe saving as well as vision saving.
The article highlights various topographic patterns and their prevalence in a large spectrum of ectatic corneal diseases (ECDs). Knowledge of these patterns can help clinicians for quicker diagnosis and selection of appropriate contact lens design.This study aimed to determine various corneal topography patterns and their prevalence in patients with ECDs who visited a tertiary eye hospital in western India.Keratoconus, pellucid marginal degeneration, keratoglobus, and post-refractive surgery progressive corneal ectasia are considered under ECDs. This cross-sectional retrospective study reviewed records of 632 consecutive patients with clinical ECDs at their first presentation. The right eye was considered for pattern analysis. In cases with suspected or forme fruste ectasia in the right eye, the fellow eye was considered. A sagittal map with standard scale of Atlas 9000 topographer (Carl Zeiss Meditec AG, Jena, Germany) was used for pattern analysis. They were classified into 18 categories and grouped under five groups. The prevalence of these patterns was calculated and assessed with 95% confidence interval (CI).The mean ± SD age of patients was 23.6 ± 8.2 years. The highest prevalence was of asymmetric patterns (39.6% [95% CI, 35.7 to 43.5%]; asymmetric bowtie [AB] with steepest radial axis index [SRAX], 18.8%; AB with inferior steep, 16.0%; AB with superior steep [SS], 3.2%; symmetric bowtie with SRAX, 1.6%) and of central or paracentral patterns (28.6% [95% CI, 25.1 to 32.3%]; inferior steep, 12.2%; heart, 7.4%; oval, 4.1%; symmetric bowtie, 2.4%; round, 1.6%; irregular, 0.9%) followed by advanced patterns (17.3% [95% CI, 14.4 to 20.4%; nonmeasurable, 5.4%; globus, 4.9%; indiscriminate, 7.0%). The peripheral patterns were 11.7% (95% CI, 9.3 to 14.4%) (claw, 6.3%; junctional, 3.2%; butterfly, 1.9%; SS, 0.3%). Rare patterns were 2.8% (95% CI, 1.7 to 4.5%) (superior [junctional, claw, and heart], AB with SS with SRAX, and AB with SRAX located temporally).Asymmetric and central or paracentral are the most common patterns in our study. The higher prevalence of advanced patterns indicates the need for earlier diagnosis of ECDs in our population. The peripheral patterns also have significant prevalence.
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