Corneal Cross Linking with Riboflavin for Progressive Keratoconus in Paediatric Eyes

Purpose: To report visual, refractive and topographic outcomes after corneal collagen crosslinking (CXL) for progressive keratoconus in paediatric eyes. Methods: In this prospective interventional study, twenty eyes of eighteen patients with progressive keratoconus were included. All eyes underwent CXL with riboflavin after documented progression of the disease. Informed, written consent was taken from the parents of the patients. The patients were followed up for 6 months. Complete ophthalmic examination and Scheimpflug imaging were performed at each visit. Reduction of the mean refractive cylinder, and corneal flattening were the main outcome measures. Results: The mean age of the patients was 13.55 years, (range: 9 - 16 yrs). The mean refractive cylinder reduced from a preoperative value of -5.26D to -4.66D (p = 0.10), -4.31D (p = 0.009), and, -4.10D (p = 0.003) at one, three and six months (postoperative) respectively. The mean average K value increased from 51.88D to 52.18D (p = 0.64) at one month postoperatively and reduced thereafter to 51.28D (p = 0.32) and 51.54D (p = 0.02) at three and six months respectively. Thinnest pachymetry reduced very significantly from a mean preoperative value of 459.15 μm to 400.8 μm (p < 0.001), 405.9 μm (p < 0.001) and 413.6 μm (p < 0.001) postoperatively at one, three and six months respectively. Best corrected visual acuity (decimal units) improved insignificantly from a preoperative value of 0.43 to 0.49 (p = 0.42) at six months postoperatively. Conclusion: Short term results of corneal collagen crosslinking with riboflavin for progressive keratoconus in children are promising in terms of reduction in the mean refractive cylinder and flattening of the cornea, and appears effective in halting the progression of the disease in the paediatric age group. Long term follow up is required to assess the lasting effect of CXL in this age group.

Human amniotic membrane transplantation: Different modalities of its use in ophthalmology

The amniotic membrane(AM) is the inner layer of the fetal membranes and consist of 3 different layers: the epithelium, basement membrane and stroma which further consists of three contiguous but distinct layers: the inner compact layer, middle fibroblast layer and the outermost spongy layer. The AM has been shown to have anti-inflammatory, anti-fibrotic, anti-angiogenic as well as anti-microbial properties. Also because of its transparent structure, lack of immunogenicity and the ability to provide an excellent substrate for growth, migration and adhesion of epithelial corneal and conjunctival cells, it is being used increasingly for ocular surface reconstruction in a variety of ocular pathologies including corneal disorders associated with limbal stem cell deficiency, surgeries for conjunctival reconstruction, as a carrier for ex vivo expansion of limbal epithelial cells, glaucoma surgeries and sceral melts and perforations. However indiscriminate use of human AM needs to be discouraged as complications though infrequent can occur. These include risk of transmission of bacterial, viral or fungal infections to the recipient if the donors are not adequately screened for communicable diseases, if the membrane is not processed under sterile condi-tions or if storage is improper. Optimal outcomes can be achieved only with meticulous case selection. This review explores the ever expanding ophthalmological indications for the use of human AM.

Phacoemulsification in a rare case of keratoconus with Fuch's endothelial corneal dystrophy

Dear Sir,Iam Dr.Jaya Kaushik from the Department of Ophthalmology of the Post Graduate Institute of Medical Education and Research,Chandigarh,India.I write to present a case report of phacoemulsification in a rare case of cataract associated with keratoconus and Fuch’s endothelial corneal

Understanding practice patterns of glaucoma sub-specialists in India

AIM：To obtain information on the prevailing practice patterns of glaucoma specialists in India.METHODS：Glaucoma specialists attending the Annual Conference of the Glaucoma Society of India（GSI）were surveyed.This survey,conducted in 2013,was based on an interactive audience response system.RESULTS：The information was obtained from 146 glaucoma specialists.Approximately half（n=83;57%）had≥10y of experience in managing glaucoma and were in institutional practice（n=74,51%）.Goldmann applanation tonometry was preferred by 103（72%）specialists whilst n=25（17.4%）used non-contact tonometer.Indentation gonioscopy was favoured by two-thirds（n=90,66%）whereas stereoscopic optic disc examination and visual fields using Humphrey perimeter was performed by a majority of the specialists surveyed（n=115,86%and n=114;83%respectively）.Nearly three quarter specialists（n=96;72%）preferred optical coherence tomography for imaging.The primary choice for treatment of angle closure disease and primary open angle glaucoma was laser（iridotomy,n=117;93%）and medical management（prostaglandin analogue,n=104;78%）,respectively.Approximately only a third of the specialists surveyed（n=37;28%）were performing both trabeculectomy and implantation of a glaucoma drainage device and about half（n=64;47%）were not operating on congenital glaucoma at all.CONCLUSION：This survey has found conformance with preferred practice patterns in several areas of diagnosisand management of glaucoma,but there was diversity in a few areas.The information is a significant step towards improvement of glaucoma care in India,including planning for future strategies.

Nature nurtures:lens regeneration,a breakthrough in ophthalmology

Pediatric cataract is a major cause of treatable blindness worldwide(1,2).The prevalence of cataract in children has been estimated between 1-15/10,000 children(3).There are 200,000 children blind from cataract worldwide,and 20,000 to 40,000 children with developmental bilateral cataract are born each year(3).Pediatric cataracts are responsible for more than 1 million childhood blindness in Asia alone(3).Pediatric cataract blindness presents an enormous problem in terms of human morbidity,economic loss,and social burden.Despite the availability of meticulous surgery,cataract is still the leading cause of blindness worldwide in children(4).

The Indian retinopathy of prematurity society:a baby step towards tackling the retinopathy of prematurity epidemic in India

Background:India leads all nations in the number of preterms born annually.With over 3.5 million infants,a reducing infant mortality rate and an expanding base of rural neonatal intensive care units,the number of infants requiring retinopathy of prematurity(ROP)screening has dramatically increased.The number of ROP specialists in the country is currently inadequate.Leading ROP specialists of the country initiated the Indian ROP(IROP)society to address these challenges.Methods:In 2016,the IROP society was conceived and registered as a professional body with a mission to prevent needless blindness from ROP by promoting standards of excellence.A national online membership drive was carried out.The data collected in this survey was analyzed to collate information on past training,practice patterns,ease of screening and treatment,use of wide-field imaging and willingness to be certified.Results:Of the 113 members at the time of submission,67.3%were male.88.5%were formally trained for ROP and 85.8%were vitreo-retinal specialists.Of the practicing members,96%were“comfortable”with screening and 86%with ROP treatment and this correlated with training(P=0.001 and P=0.002 respectively).Only 25.7%performed vitreous surgery for ROP.Wide field imaging was used by 33%of members in their practice and 52%of those who did not,wanted to use it in the future.Members who used imaging performed more number of laser treatments than those who did not(P=0.008).Laser was the preferred modality of treatment for 98%of members.A majority of the members(92.5%)were willing to be audited.Conclusions:The IROP society is a novel platform for ROP specialists to collaborate.The society has setup short,mid and long-term goals to make ROP care more accessible and affordable with appropriate use of technology.

Clinical features and characteristics of retinopathy of prematurity in developing countries

Retinopathy of prematurity(ROP)is an emerging cause of childhood blindness in the developing countries.The low and middle-income countries are facing common challenges in the midst of the‘third epidemic’of ROP.Improvement in neonatal care facilities has increased survival of preterm babies.Lack of awareness and non-uniform standards of care in the ever-increasing number of neonatal intensive care units(NICUs)and special newborn care units(SNCUs)has resulted in this surge of ROP.Apart from low birth weight and the degree of prematurity,use of unblended supplemental oxygen,sepsis,anemia and blood transfusion are important risk factors associated with ROP in developing countries.Atypical forms of aggressive posterior ROP(APROP)are seen in heavier birth weight babies in the developing countries.Prevention of ROP by good quality neonatal care,timely diagnosis by mandatory ROP screening in NICUs and training manpower for laser treatment of ROP requires close collaboration between the neonatologists,ophthalmologists and the policy makers.Team approach and inter-disciplinary co-ordination are keys in a nation’s drive to fight this preventable cause of blindness.

Patch graft for pterygium surgery:stitch it or stick it?

Pterygia are an extremely common ocular condition believed to be occurring due to proliferation and overgrowth of abnormal epithelial and fibrovascular tissue onto the cornea.They are characterized by cellular proliferation,neovascularization and inflammation.Indications for treatment vary from minor cosmetic concerns to significant visual loss.Management options include an array of surgical techniques including simple resection(leaving the sclera bare),or resection followed by covering the sclera with primary conjunctival closure,a conjunctival or conjunctivolimbal autograft(CAG and CLAG respectively)from another site on the bulbar conjunctiva of the same eye,or with human amniotic membrane(HAM).