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 Table of Contents  
CURRENT OPINION
Year : 2018  |  Volume : 56  |  Issue : 4  |  Page : 268-272

Expert corner: Cornea consultation


1 Department of Cornea and Refractive Surgery, Aravind Eye Hospital, Madurai, Tamil Nadu, India
2 Department of Cornea and Refractive Surgery, Aravind Eye Hospital, Coimbatore, Tamil Nadu, India
3 Rajan Eye Care, Chennai, Tamil Nadu, India
4 Department of Cornea and Refractive Surgery, Sankara Netralaya, Chennai, Tamil Nadu, India
5 Department of Cornea, RIO GOH, Chennai, Tamil Nadu, India

Date of Web Publication19-Feb-2019

Correspondence Address:
Dr. Sharmila Devi Vadivelu
Department of Cornea, RIO GOH, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjosr.tjosr_103_18

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How to cite this article:
Prajna N V, Revathi R, Mohan S, Srinivasan B, Vadivelu SD. Expert corner: Cornea consultation. TNOA J Ophthalmic Sci Res 2018;56:268-72

How to cite this URL:
Prajna N V, Revathi R, Mohan S, Srinivasan B, Vadivelu SD. Expert corner: Cornea consultation. TNOA J Ophthalmic Sci Res [serial online] 2018 [cited 2019 Aug 18];56:268-72. Available from: http://www.tnoajosr.com/text.asp?2018/56/4/268/252485




  Q1. Enumerate the Pearls for Management of an Acute Case of Stevens–Johnson Syndrome? Top


Dr. Venkatesh Prajna

Stevens–Johnson syndrome is a life-threatening disease, and as an ophthalmologist, prompt referral to a facility experienced in the management of such patients is crucial. All patients should have a thorough examination of conjunctiva, cornea, lid margins, and fornices.

Fluorescein staining is important in determining the extent of the corneal and conjunctival epithelial defect. Regular periodical examination is essential to reassess the extent of involvement.

Acute stage management is focused on the prevention of infection and symblepharon formation and control of inflammation. Milder cases with nonmembranous conjunctivitis without corneal and lid margin involvement can be managed with topical antibiotics and anti-inflammatory agents such as steroids or cyclosporine. In patients with severe corneal and conjunctival epithelial defect, amniotic membrane transplant with symblepharon ring can be placed to prevent further cicatrizing ocular sequelae. Recent studies show a considerable benefit in treating this condition in the acute stage with amniotic membrane grafting.

In addition to local therapy, patients need systemic antibiotic prophylaxis and close monitoring of fluid state as they are highly prone to sepsis and electrolyte imbalance.

Dr. Revathi

Large area of ocular surface epithelial sloughing will be seen in the acute phase of the disease. These areas have to be covered to prevent infection and symblepharon formation. Topical antibiotic ointment and preferably a cohesive lubricant will help in coating the inflamed surface. Total amniotic membrane grafting to cover lid margin to lid margin with fornix coverage will be helpful. However, due to the severe active inflammation, Amniotic Membrane Graft (AMG) can get dissolved and need to be repeated. Topical steroids need to be used diligently.

Dr. Bhaskar Srinivasan

Prompt and appropriate management of the ocular surface in the acute phase goes a long way in reducing the severity of ocular sequelae.

Examination of the ocular surface with staining to assess areas of epithelial defect and prompt amniotic membrane (within 1 week of the onset) in the theater or in the intensive care unit sitting as the case may be, seems to offer the best outcome. Beyond a week, in case of an epithelial defect, amniotic membrane transplantation can be attempted, but the benefit in preventing long-term sequelae is questionable. The ocular surface inflammation will need course of steroids and lubricants. Regular ocular hygiene with cleaning of the crust and discharge and a protecting topical antibiotic ointment might reduce the risk of secondary infection.

Dr. Sujatha Mohan

Acute stage management is done with lubricants, steroid drops, and antibiotic ointment. I would also give intravenous methyl prednisolone 1000 mg for 3 days.

Breaking or preventing symblepharon formation can be done by sweeping a cotton bud under the lid, and along the fornices, symblepharon ring can be given if required. Amniotic membrane transplant covering the ocular surface is done in severe cases.


  Q2. How Will You Manage the Different Types of Descemet's Membrane Detachment? Top


Dr. Venkatesh Prajna

Management of Descemet's membrane detachment (DMD) depends on its location, whether it is shallow or deep, with or without scrolled edges. Small peripheral shallow DMD can be observed and conservatively managed with topical steroids and hyperosmotic agents. Surgical management is frequently needed for large DMDs. For large DMD without scrolling of edges, internal tamponade with intracameral air is performed. Extensive DMD or DMD with scrolled edges needs transcorneal suturing of Descemet's membrane (DM) along with internal air tamponade. If the DMD is not resolving with the aforementioned interventions, endothelial keratoplasty (Descemet's stripping automated endothelial keratoplasty [DSAEK] or DME keratoplasty [DMEK]) may be required.

Dr. Revathi

Management of DMD depends on its location, area and depth of detachment, whether torn edges are scrolled, its effect on visual acuity, and associated structural and physiological changes in the anterior segment.

A shallow localized detachment sparing the visual axis adjacent to the wound of entry, can be observed.

A large deep detachment, compromising vision with torn edges need to be repositioned. ASOCT can help in assessing the extent and whether edges are torn and scrolled or entangled with other structures. It is better to treat the severe fibrinous inflammatory reaction in the anterior segment before surgical intervention. The presence of vitreous, anterior capsular tags, lenticular remnants in the anterior chamber need to be identified before planning any intervention.

Appling autoclaved glycerol over cornea will clear the corneal edema and give better visibility. Preexisting entries can be used if the detachment did not extend up to them. Otherwise, a new limbal stab incision can be made. Gentle irrigation will help in assessing the floating transparent membrane, torn edges, and other entanglements. If it is a clear detachment, it can be repositioned with first air injection, done through a cannula kept close to the iris surface. Once the reattachment is confirmed, a peripheral iridectomy needs to be done. The wound should be sutured.

If the detachment is subtotal, temporal or inferior non expansile gas may be needed for pneumopexy. Scrolled edges need to be gently manipulated either with irrigating fluid or air. It needs to be unfurled before repositioning. Anterior chamber has to be cleared off other entangled structures such as vitreous or anterior capsular tags.

Dr. Bhaskar Srinivasan

It is important to know the configuration of the detachment, the presence of a tear, whether there is a loss of DM in any area or if DM is scrolled. Assess areas of attached DM since that will be the site for entry for air injection to reduce the risk of inadvertently increasing the size of detachment by injecting air between the DM and stroma. Superior detachment/temporal or nasal detachment without any tear is easy to manage with air injection. Attempt a full fill, and in an hour's time, the air can be burped similar to the strategy used for Descemet's stripping endothelial keratoplasty (DSEK). Inferior detachments might need a longer air fill. In case of an intraoperative detachment during phaco, one could suture fixate the DM to complete the surgery else it will keep flapping and can increase in size. If the DM is scarred option of relaxing descemetopexy as advocated by Soosan Jacob is an option, but in general, the visual outcome in these case will be suboptimal and they would ultimately need DSEK/DMEK. Preoperative assessment of the configuration of detachment in slit lamp is very crucial for success in the procedure. Intraoperatively, one can use Chandelier illumination and switch off the microscope light to visualize the DM better.

Dr. Sujatha Mohan

Localized DMD not involving visual axis can be managed with hypertonic saline drops. Air injection should be done in large and visual axis involving DMD. Nonexpansile C3F8 can be done if there is a recurrence of DMD. If there is no response DSEK can be done.


  Q3. Which Drug Would You Prefer in the Management of Ocular Surface Squamous Neoplasia? Mitomycin C or Interferon Alpha? Kindly Elaborate on the Schedule Top


Dr. Venkatesh Prajna

Our preferred choice of drug in ocular surface squamous neoplasia (OSSN) is mitomycin c (MMC), as we have long-term experience with the usage of this drug. We have limited experience with interferon. Our schedule is topical MMC 0.04% 4 times a day for 7 days followed by lubricating drops for 7 days. This is repeated for 4–6 cycles depending on the response. We have adapted this 7 days on and 7 days off schedule to improve the patient compliance to the drug, and in our experience, toxicity due to MMC is very minimal with this schedule. However, we prefer excision biopsy of the lesion than medical therapy in patients with poor compliance.

Dr. Revathi

In all cases of OSSN undergoing excision biopsy, we use intraoperative MMC 0.02% for 4 min with vigorous irrigation afterward. The indications for topical MMC are biopsy-proven invasive OSSN, recurrence of proved OSSN, and large lesions for chemoreduction.

Our preferred dosage is 0.04% for 4 times a day after temporary punctal occlusion and along with lubricants. If the inflammatory signs are significant after starting MMC, low-dose topical steroid also will be added. The cycles are 1 week on and 1 week off up to 4 cycles. One should keep in mind the side effects of the drug. Interferon is less toxic but expensive and needs to be given for a long time.

Dosage is as follows: Subconjunctival/intralesional –0.5 ml 3 million IU/0.5 ml. Repeated 1–3 injections per week until clinical resolution. Topical – QID 1 million IU/ml tapered over months or stopped at least 1 month after clinical resolution.

Dr. Bhaskar Srinivasan

Given a choice and the patient not having monetary consideration, interferon alpha would be better since ocular surface toxicity is much less. However, it involves longer duration of medication and the result is a higher cost to the patient. The benefit is there only in terms of the less side effects on the ocular surface, efficacy of MMC is also almost the same as interferon, and no study has conclusively proved interferon to be superior to MMC.

Dr. Sujatha Mohan

Interferon alpha would be my choice.


  Q4. What Would Be Your Preferred Choice for Crosslinking? Would You Go for Conventional C3R or Accelerated C3R? Top


Dr. Venkatesh Prajna

We prefer conventional C3R over accelerated C3R due to the relatively long-term experience with conventional C3R worldwide, with various trials proving its efficacy and safety. Although accelerated C3R is proven to be equally efficacious when compared to conventional C3R in many studies, some studies show decrease in biomechanical effects of C3R with higher irradiance and shorter duration time.

Dr. Revathi

In our practice, we found accelerated C3R using 9 mW/cm2 for 10 min is also effective and time-saving.

Dr. Bhaskar Srinivasan

Accelerated corneal crosslinking (CXL) (9 mV for 10 min) has been using it for the last 6 years and has compared our results between conventional 3 mV for 30 min and 9 mv for 10 min and they do not seem to show any difference. Hence, given the shorter duration of the procedure with the same success rate, I would prefer Accelerated CXL.

Dr. Sujatha Mohan

I prefer doing an accelerated C3R 9 mW for 10 min.


  Q5. What is the Type of Transplant That You Would Go for in Case of Aphakic Bullous Keratopathy and Which Type of Intraocular Lens Would You Prefer? Top


Dr. Venkatesh Prajna

In patients with absent stromal scarring, DSAEK is preferred. Cases with extensive scarring with vascularization would benefit from a full-thickness penetrating keratoplasty (PKP). Scleral fixation of intraocular lens (SFIOL) along with the keratoplasty (DSAEK/PKP) is our preferred choice in such cases.

Dr. Revathi

First, the need for corneal transplant should be assessed based on other co morbidities such as secondary glaucoma and posterior segment pathologies. If the visual prognosis is poor, it should be discussed with the patient clearly, before going for a surgery such as corneal transplantation, which demands a life-long commitment from the patient.

Type of transplant depends on structural integrity of the anterior segment. If the iridocapsular diaphragm is intact, endothelial keratoplasty can be planned. Otherwise, PKP would be a better choice. This also depends on the stromal clarity and surgeon's expertise.

If the capsular support is adequate, posterior chamber sulcus-fixated intraocular lens can be implanted. If not, an iris-fixated or scleral-fixated intraocular lens (IOL) can be planned.

Dr. Bhaskar Srinivasan

If iris structure is reasonably intact and air bubble can be maintained in the anterior chamber, I would prefer DSEK/DSAEK with SFIOL. If large iris defect is present, I would prefer a suture pull through of the tissue with suture fixation.

Dr. Sujatha Mohan

Glued IOL with DSEK.


  Q6. Would You Go for a Repeat Penetrating Keratoplasty (PK) or Endothelial Keratoplasty in Case You Are Regrafting the Failed PK? Top


Dr. Venkatesh Prajna

Endothelial keratoplasty is preferred in failed grafts associated with minimal stromal scarring as chances of rejection are less when compared to full-thickness keratoplasty. However, in patients with significant anterior stromal scarring, we would like to perform full-thickness PKP.

Dr. Revathi

The following four factors are important to decide the type of regraft:

  1. Stromal clarity
  2. Centration of the previous graft
  3. Preexisting astigmatism
  4. Anterior chamber structural integrity.


If the previous graft is well centered, adequately sized, with reasonable regular astigmatism and if anterior chamber is anatomically maintained, endothelial keratoplasty can be planned. Otherwise, a PKP is preferred to address these issues also simultaneously.

Dr. Bhaskar Srinivasan

My choice would depend on the astigmatism in the failed graft (K value/refraction when graft was clear), anterior chamber details, and IOL situations. If there is not much astigmatism and if anterior chamber is reasonably well formed without too much peripheral anterior synechiae I would prefer DSEK.

Dr Sujatha Mohan

I would prefer to do a DSEK.


  Q7. When Would You Time a Simple Limbal Epithelial Transplantation Procedure and What Are the Indications for Simple Limbal Epithelial Transplant in a Case of Chemical Injury? Top


Dr. Venkatesh Prajna

We perform simple limbal epithelial transplantation (SLET) procedure in cases of unilateral chemical injury which has resulted in 360° limbal stem cell deficiency or more than 6 clock hours of partial limbal stem cell deficiency. Associated conditions such as severe dry eye, infection, and lid margin abnormalities such as entropion, ectropion, and trichiasis should be treated before performing SLET. The basic requirement for SLET is a healthy contralateral ocular surface. After 3 months of chemical injury (and after effective control of inflammation), we plan for SLET procedure.

Dr. Revathi

SLET is not the procedure for the acute stage of the chemical injury. In the acute phase, restoring limbal and perilimbal vascularity with Tenon's mobilization, addressing the ocular surface inflammation, are the primary goals. SLET or conjuctivolimbal autografts can be tried roughly after 6–8 weeks once the inflammation is under control. In severe inflammation, it is better to get some epithelial cover, and ocular surface reconstruction can be planned later.

Dr. Bhaskar Srinivasan

Allo-SLET can be used in the acute phase of chemical injury in Dua's classification Grade 4 or worse. Auto SLET preferably needs to be done 6 months postacute chemical injury once the ocular surface has been reasonably stabilized and lid and fornix are stabilized.

Dr. Sujatha Mohan

We can plan for surgical intervention after the eye becomes reasonably quiet with medical management. Indications would be uniocular chemical injury involving the visual axis and more than 180° involved.


  Q8. What Would Be Your Line of Management in a Case of Superficial Punctate Keratitis Following Adenoviral Conjunctivitis? Top


Dr. Venkatesh Prajna

If the subepithelial infiltrates are extensive causing diminution of vision, we would like to start topical steroids preferably dexamethasone 0.1% 4 times a day for 1 week followed by tapering every week. If the subepithelial infiltrates are peripheral not affecting visual acuity and optical clarity, we would like to observe the patient.

Dr. Revathi

Superficial punctate keratitis (SPK) is a part of adenoviral keratoconjunctivitis, during its infective phase. Since no known antiviral therapy is proven to be effective in the acute phase of adenoviral keratoconjunctivitis, SPKs can be managed by symptomatic treatment.

Since SEK is an immune-mediated response, topical steroids or other immunomodulators such as cyclosporine A (CSA) or tacrolimus will be of use. This is a self-limiting condition. If the lesions are not coalescent and involving visual axis, they can be observed. If the patient is very symptomatic, with confluent lesions, I would prefer either CSA or tacrolimus than steroids.

Dr. Bhaskar Srinivasan

SPK following adenoviral conjunctivitis normally occurs around a weeks' time postacute infection. Normally it is more worse in the first affected eye as compared to the second eye. Treatment would be in the form of topical steroids (soft steroids loteprednol/fluorometholone) t apered weekly. In case of steroid dependence, tacrolimus seems to work well started at bid dose for a few weeks and then reduce to OD dose and stop.

Dr. Sujatha Mohan

Lubricants and soft steroids such as fluorometholone are given.

Cyclosporine eye drops are given in case of nummular subepithelial infiltrates.


  Q9. How Many Times Can Intrastromal Voriconazole Be Repeated? Top


Dr. Venkatesh Prajna

In our institute, we give intrastromal voriconazole for patients with culture-proven deep fungal keratitis not responding to appropriate medical therapy, without signs of perforation or limbal involvement. After the first injection, if there is inadequate clinical response, we repeat intrastomal voriconazole, 4–5 days post first injection. In patients with persistent worsening in terms of thinning or perforation or extension toward limbus, we prefer therapeutic keratoplasty over repeated intrastromal voriconazole injections. Hence, from our experience, we recommend that intrastromal injection can be repeated once as a measure to buy time till the availability of donor cornea.

Dr. Revathi

There is no clear literature evidence proving effectiveness of intrastromal voriconazole injections in the management of fungal keratitis. An analysis of our experience showed that it may be useful in the early stages of the infection before full-thickness tissue necrosis sets in. If a healing response is not appreciated after 1 or 2 injections, other treatment modalities have to be planned.

Dr. Bhaskar Srinivasan

I am not sure if there is any specific cutoff, but if the patient seems to respond to the injection, it can be repeated as many times till it scars; if after a few injection, there is very minimal or no change, I would prefer a Therapeutic Penetrating Keratoplasty (TPK).

Dr. Sujatha Mohan

Up to 3 times. If there is no response, then TPK is to be considered.


  Q10. How Often Do You Start Immunosuppressants in a Case of Sterile Corneal Melt? Top


Dr. Venkatesh Prajna

We start immunosuppressants in patients with sterile corneal melt associated with systemic collagen vascular disorders, bilateral aggressive Mooren's ulcer, and recurrent Mooren's ulcer. It is essential to start them early, especially in aggressive cases.

Dr. Revathi

If the etiology is a systemic collagen vascular disease, then systemic immunosuppressant therapy needs to be started with a rheumatologist comanagement.

Dr. Bhaskar Srinivasan

Sterile corneal melt would require topical and systemic steroids and a review with the internist to add or hike up or change the immunosuppression. Corneal melts is a sign of poor disease control and indicates a need for closer follow-up with the internist.

Dr. Sujatha Mohan

Sterile melts would require topical and systemic steroid therapy along with collagenase inhibitors like doxycycline.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.






 

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