"No Cornea" Corneal Transplantation

This week I am sharing a scientific video. It shows various techniques for restoring vision in cases with partial corneal opacification without the use of allograft corneal tissue. These techniques avoid the use of donor corneas and the complications associated with use of allograft corneal tissue.

Further Reading:
Alternatives to Allograft Corneal Transplantation. Current Opinion in Ophthalmology, July, 2010


I will be taking a break from the blog for Diwali and would be resuming posts from 9th November.
Happy Diwali and see you then.

A Case of a Perpetually Large Pupil

Continuing with the theme of iris repair techniques from the last post, this week I share a case of traumatic mydriasis.

A 52 year old man, sustained blunt trauma to his left eye. He was diagnosed with traumatic cataract and mydriasis. Subsequently, he underwent phacoemulsification along with PC IOL implantation (5.25mm PMMA IOL). He had 6/6 BCVA following surgery , but complained of debilitating glare. At this point he was referred for management of traumatic mydriasis.

On examination (Fig. 1), it was found that the pupil size was 8.0×7.8 mm along with exposed optic
edges. Further, a superior decentration of 1.5 mm of the IOL exposed the inferior optic–haptic junction (Fig. 2). These two factors( exposed optic edge and inferior optic-haptic junction) appeared to be the contributing causes of glare. Hence, a pupil-size reduction surgery was planned in the inferior area to cover the exposed edge of the IOL.

Surgical Technique

A 2.75-mm clear corneal tunnel incision was made superiorly, followed by 2 opposing stab incisions at 4 and 8 o’clock made with a 15-degree blade. The anterior chamber (AC) was filled with high-viscosity viscoelastic: Healon GV. Sinskey hook was used to mobilize the iris prior to suturing to ensure there were no posterior synechia. A 10-0 polypropylene suture  with straight needles was used. A 20-G pick forceps was used to provide countertraction to the iris for the passage of straight needles. After taking bites of iris at 8 and 4 o’clock, the needle was exited out of the AC with the help of 26-G guide needle through the second side port at 4 o’clock position . Several centimeters of suture were pulled through the AC. A Sinskey hook was used to engage the suture between the distal iris and the site
where it exits the cornea. It was then withdrawn, retrieving a loop of suture through the incision. The externalized suture loop was oriented adjacent to the original strand, untwisting any polypropylene within the incision neck so as to achieve a parallel orientation of the sutures . The trailing end of the suture was passed down through the loop twice, always directing the passes back toward the cornea and then over itself. Each free end of the polypropylene suture was cinched, gently drawing the 2 iris surfaces together with the initial slipknot. The distal suture loop was again retrieved and externalized. The trailing end was passed up through the similarly oriented loop and under itself. The free suture ends were cinched gently,completing the locking knot. The ends of the suture were
trimmed and removed with a 20-G horizontal scissors.

Postoperatively, there was a reduction of pupil size from 8.0×7.8 mm to 5.5 mm (Fig 3). The patient’s complaint of glare was relieved and the glare acuity was 20/40 at 6 months follow-up.

What I learnt from This Case

Achieving 6/6 BCVA following cataract surgery may enthuse the cataract surgeon but the patient may still be miserable.
All cases with traumatic mydriasis may not need repair. Such a repair may be considered if the visual symptoms of the patient can be correlated with the physical findings.


Further Reading: Single pass, single suture technique for repair of traumatic mydriasis. European Journal of Ophthalmology, 2013

A Case of Twice Subluxated Lens

This week I am pulling out a case from about 7 years back.
An 18 year old man presented with traumatic iridodialysis and underlying zonular dialysis with cataract (Fig. 1).

The patient was planned for iridodialysis repair along with phacoemulsification and IOL implantation. The cataract was removed without much difficulty. Subsequently, iris was repaired using prolene suture as shown in the video. A 3-piece foldable IOL was placed in the sulcus, without any bag fixation (remember, this is circa 2006). The IOL appeared quite stable on the table, and even sustained the pressure of viscoelastic removal without getting decentered.

Post operatively, the iris repair showed good outcome with only a mild distortion of the pupil. However, the IOL subluxated soon after.This was then treated with IOL explanation and scleral fixation of a PMMA IOL. Finally, the patient had a good overall outcome with a well centered IOL, adequately covered iris defect and BCVA improving to 6/6 (-0.5 DS) (Fig. 2) .

What I learnt from this Case

In cases with zonular dialysis >90 degrees, sulcus placement of IOL might appear stable on the table, but may not hold during the post operative period. These cases require some type of capsular bag/IOL fixation.

A Case of Pediatric Cataract

This week I am taking up a case of pediatric cataract. There are no diagnostic dilemmas in this case!
A 4-year old boy with developmental cataract managed with the current gold standard treatment- lens aspiration, posterior capsulorhexis, anterior vitrectomy and PC IOL implantation. The accompanying video shows all the steps of the surgery in detail.
The key to a successful surgery in such cases is that the surgeon should adhere to the standard protocol during all surgical steps. Each step, as highlighted in the video, is important on it's own. Unlike adult cataract surgery, there is very little margin of error in these cases.

However, one should remember, a successful surgery is only the beginning of the treatment of developmental cataract. Final visual outcome is dependent on meticulous follow up including timely refractive corrections, amblyopia therapy and intraocular pressure monitoring.
I am looking forward to your comments!

A Strange Growth 'in' the Cornea

A 4-year-old boy presented with complaint of progressive diminution of vision (Visual Acuity: 3/60) in left eye for the last 2 months. He gave history of trauma to right eye sustained with a broom stick 3 months back. Slit lamp examination showed a cystic structure in cornea with normal epithelium and corneal stroma (Fig. 1).

AS-OCT (Visante) showed a cyst of homogenous moderate reflectivity originating from inferior angle with a clear separation from iris, pupil, and lens, and attached to endothelium (Fig. 2).

Corneal epithelium and stroma appeared uninvolved by cyst. The patient underwent cyst aspiration and excision of mouth of the cyst.
On follow-up, although some corneal haze still persisted (Fig. 3), a significant improvement in vision (6/12) was noted. AS-OCT showed no residual cyst at 1 year of follow-up (Fig. 4).

Take Home Message

• Corneal cysts are a rare entity.
• Documenting complete extent of lesion is very important, especially in phakic patients for a sound surgical plan.
• AS-OCT can be a useful investigative modality that can help to clearly delineate extent of the cyst and can also be used as a monitoring tool postoperatively to ensure complete removal.

A Phony Case of Corneal Ulcer Following RK

A 38-year-old man presented with complaint of sudden onset of whiteness in right eye. The patient was being treated elsewhere as a case of corneal ulcer with no improvement in symptoms since 15 days.
PAst history was significant for the fact that he had undergone Radial Keratotomy (RK) in both
eyes 15 years back.
Slit lamp examination showed a white edematous appearance of cornea with minimal congestion
(Fig. 1) . There were multiple RK scars in both eyes.

Anterior-segment optical coherence tomography (AS-OCT) (Visante) demonstrated an edematous cornea in the center with a localized descemet’s membrane detachment allowing aqueous  into the corneal stroma
(Fig. 2).

Based on clinical examination and AS-OCT findings, a diagnosis of acute corneal hydrops in the right eye was made.
The patient was started on a course of Prednisolone 1%, Homatropine 2%, and oral Acetazolamide for a period of 3 weeks. On follow-up, corneal edema disappeared with improvement of visual acuity to 6/36 on Snellen’s chart at 3 weeks.

Takeaway Message

• The absence of cilliary congestion, pain, anterior chamber reaction and epithelial defect made the diagnosis of corneal ulcer unlikely in this case.
• Although Radial Keratotomy is no longer practiced, older patients who have undergone RK can still present with complications.
• Hydrops, though a rare complication, can be seen in such cases. AS-OCT can be a helpful modality to clearly delineate Descemet’s membrane rupture in such cases

A Curious Case of Late Onset Vision Loss after Cataract Surgery

A 70-year old man presented with gradual diminution of vision in left eye since 2 years and was referred for YAG laser for Posterior capsular opacification in left eye from elsewhere. He had previously undergone cataract surgery in both eye 10 years back with good visual recovery. On examination, vision in right eye was 6/12 and in the left eye, 3/60.
Slit lamp examination of left eye showed a dense white opacity behind the IOL along with suspected distension of the capsular bag (Figure 1).

AS-OCT confirmed the clinical findings in the left eye showing a hyperintense signal between the posterior capsule and the IOL (Figure 2).

Diagnosis of Left eye Capsular Distension Syndrome was made.
The patient subsequently underwent surgical decompression of the capsular bag along with enlargement of the capsulorhexis to prevent future recurrence of the condition (Video).

Postoperatively, BCVA improved to 6/18 (+1DS -2DC X90) in left eye. The visual axis was clear, with disappearance of the opacity and the eye was quiet (Figure 3).

Postoperative ASOCT also showed absence of hyper intense shadows between the capsule and the IOL (Figure 4).

Take Home Message

• Not all cases of visual axis opacification following cataract surgery are due to posterior capsular opacification.
• In cases where the capsulorhexis is much smaller than the IOL optic, conditions like anterior capsular phimosis and capsular distension syndrome can cause late onset loss of vision.

A Case of Corneal Ulcer following CXL

A 36-year-old man presented with a 3-day history of pain, redness and diminution of vision in his left eye. He had received corneal collagen cross-linking (CXL) treatment for keratoconus in the left eye 6 days prior to presentation, elsewhere. A bandage contact lens was inserted at the end of the surgery. On day 4 after the surgery, the patient presented to his surgeon with complaints of pain, redness, marked light sensitivity, and diminution of vision in the operated eye. The surgeon noticed multiple small corneal infiltrates. A presumptive diagnosis of infectious keratitis was made and empirical treatment was started in the form of hourly 0.5% moxifloxacin hydrochloride, hourly 1.3% tobramycin, hourly 5% natamycin. However, clinical deterioration was noted over the next 48 h and the patient was referred to our center.
At the time of presentation to us, the best-corrected visual acuity (BCVA) was 20/25 OD and counting fingers OS. Slit-lamp examination of the left eye showed marked conjunctival injection. A central, large epithelial defect measuring 7.5 X6.0mm was noted on the corneal surface along with multiple coarse, pinhead-size anterior stromal infiltrates (Figure 1A).

The intervening cornea was edematous. and hazy. There was mild anterior chamber reaction.Corneal scrapings staining with Gram and Giemsa staining showed spores characteristic of microsporidia (Figure 1B).

 Hourly 0.5% moxifloxacin hydrochloride eyedrops, 2% homatropine eyedrops 4 times a day, 0.5% moxifloxcain eye ointment nocte, and oral albendazole 400mg twice daily were commenced. Corneal debridement was performed twice during the first week of admission. Oral albendazole was continued for 6 weeks. The corneal infiltrates decreased in size and number and eventually disappeared at the end of 6 weeks, leaving a midstromal corneal scar (Figure 2D). At the end of 6 weeks, the BCVA was 20/60 in the left eye.

Reference: . Microsporidial Keratitis after Collagen Cross-linking. Ocul Immunol Inflamm. Gautam,V Jhanji, G Satpathy ,S Khokhar ,Tushar Agarwal . 2013 PubMed PMID: 23978264
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Welcome to Eye Case of the Week

Welcome to my Clinical Blog.
The idea is simple: to share an interesting Ophthalmology case every week, both to learn and to teach. Most of the cases shall pertain to Cornea, Lens, Refractive Surgery and Iris.
I hope to hear from you!
Good Luck!!