Publications by authors named "Rajesh Fogla"

33 Publications

Corneal Folds After Descemet Membrane Endothelial Keratoplasty in Congenital Hereditary Endotheial Dystrophy.

Cornea 2021 Jun;40(6):715-719

Cornea Services, Sankara Nethralaya, Chennai, India.

Purpose: To report a new clinical sign of corneal folds after Descemet membrane endothelial keratoplasty (DMEK) in the eyes with congenital hereditary endothelial dystrophy (CHED).

Methods: Retrospective review of cases of CHED who presented with unusual folds in recipient cornea after the DMEK procedure for CHED. Clinical outcomes including visual acuity, pachymetry, specular microscopy, anterior segment optical coherence tomography, and corneal clarity, besides postoperative complications were analyzed.

Results: Fifteen eyes of 11 cases of CHED successfully underwent DMEK. Five eyes of 4 patients, mean age 17.2 ± 5.8 years (range 10-23 years), developed unusual folds in the anterior cornea after resolution of stromal edema. Mean follow-up was 7.8 ± 2.5 months (range 6-12 months). Mean best spectacle-corrected visual acuity improved from 0.8 ± 0.3 LogMAR preoperatively to 0.3 ± 0.2 LogMAR postoperatively. Corneal thickness improved from 991 ± 65 μm (range 924-1088 μm) preoperatively to 595 ± 78 μm postoperatively (range 525-730 μm). Average endothelial cell counts were 1708 ± 271 cell/mm2 at the last follow-up. No intraoperative or postoperative complications were reported. The corneal folds remained unchanged during the follow-up. Comparative analysis with remaining 10 eyes did not show any significant differences.

Conclusions: Cornea can present with unusual folds in the anterior stroma after successful DMEK in CHED. These folds may possibly be due to difference in collagen structure between anterior and posterior corneal stroma and needs to be studied further.
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http://dx.doi.org/10.1097/ICO.0000000000002471DOI Listing
June 2021

Role of Anterior Segment OCT for Descemet Membrane Stripping During Descemet Membrane Endothelial Keratoplasty in Eyes With Congenital Hereditary Endothelial Dystrophy.

Authors:
Rajesh Fogla

Cornea 2021 Apr;40(4):458-461

Cornea Clinic, Eye Department, Apollo Hospitals, Jubilee Hills, Hyderabad, India.

Purpose: To report the utility of preoperative anterior segment optical coherence tomography (ASOCT) in decision-making for stripping of the Descemet membrane (DM) during Descemet membrane endothelial keratoplasty (DMEK) in eyes with congenital hereditary endothelial dystrophy (CHED).

Methods: ASOCT was performed in eyes with CHED undergoing DMEK. Host DM was retained if the DM appearance was normal on ASOCT. Outcomes of DMEK with or without DM stripping (non DM stripping [DMEK]) were analyzed and compared regarding graft adhesion, graft clarity, visual acuity, and complications.

Results: Twelve eyes of 8 patients were included in the series. Of these, 6 eyes (mean age, 6 ± 2.6 years, range 3-8 years) underwent nDMEK and 6 eyes (mean age, 23.6 ± 10.2 years, range 13-39 years) underwent standard DMEK. There were no intraoperative complications in either group. During the early postoperative period, one eye in the nDMEK group had donor detachment that was successfully managed by repeat air injection. The mean preoperative and postoperative corrected visual acuities were 1.15 and 0.37 logarithm of the minimum angle of resolution (LogMAR) in the nDMEK group, and 0.95 and 0.25 LogMAR in the DMEK group (P 0.39 and 0.06). Average endothelial cell counts were 1826 ± 318 cell/mm in the nDMEK group (32.3% loss), and 1708 ± 271 cells/mm in the DMEK group (33.6% loss) at the last follow-up.

Conclusions: Preoperative anterior segment OCT is useful in decision-making regarding stripping of host DM during DMEK in eyes with CHED. The outcomes of nDMEK were similar to DMEK in this small series.
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http://dx.doi.org/10.1097/ICO.0000000000002428DOI Listing
April 2021

A Novel Technique for Donor Insertion and Unfolding in Descemet Membrane Endothelial Keratoplasty.

Cornea 2021 Apr 1. Epub 2021 Apr 1.

Cornea Clinic, Apollo Hospitals, Hyderabad, India.

Purpose: To describe a novel technique for insertion and unfolding of donor Descemet membrane (DM) scroll during DM endothelial keratoplasty (DMEK).

Methods: DMEK was performed in 20 eyes. The donor DM scroll was loaded into a glass injector, and the fluid column was manipulated to achieve a double scroll configuration. After performing DM stripping and inferior iridectomy, an anterior chamber (AC) maintainer was placed in position. The glass injector was inserted into the AC and the tip rotated to ensure correct orientation of the DM scroll. After disconnecting the IV tubing from the AC maintainer, the donor DM scroll was delivered into the AC. Donor unfolding was performed using surface tapping techniques. An air bubble was injected under the graft to obtain a complete AC air fill. The outcomes of this surgical technique were analyzed.

Results: Donor DM insertion and unfolding were performed without any complications in all eyes. Double scroll configuration of donor DM in the injector could be achieved in 17 of 20 eyes (85%). A controlled delivery, maintaining correct scroll orientation, was possible in all eyes. Intraoperative duration from insertion to unfolding was 252.7 ± 45.4 seconds. A clear cornea was achieved in all eyes, with 75% of eyes (15/20) achieving corrected distance visual acuity of 20/20 or better, at average follow-up duration of 13.3 ± 1.3 months. Endothelial cell loss at 6 months follow-up was noted to be 16.7%. Partial donor detachment was noted in 2 eyes (10%), which resolved spontaneously.

Conclusions: Our novel technique of donor DM insertion allows easy donor insertion and unfolding, thereby simplifying the DMEK procedure.
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http://dx.doi.org/10.1097/ICO.0000000000002698DOI Listing
April 2021

Outcomes of Descemet's membrane endothelial keratoplasty for congenital hereditary endothelial dystrophy.

J AAPOS 2020 12 27;24(6):358.e1-358.e6. Epub 2020 Nov 27.

Apollo Hospitals, Jubilee Hills, Hyderabad, India. Electronic address:

Purpose: To report outcomes of Descemet's membrane endothelial keratoplasty (DMEK) in eyes with congenital hereditary endothelial dystrophy (CHED).

Methods: The medical records of patients with CHED who underwent DMEK were retrospectively reviewed. Pre- and postoperative visual acuity, corneal thickness, corneal clarity, and graft survival, were analyzed, and intra- and postoperative complications were assessed.

Results: A total of 14 eyes of 8 patients were included. Surgery was performed at a mean age of 10 ± 7 years (range, 2-23). DMEK was successfully performed in all eyes, with 13 of 14 eyes (93%) maintaining a clear cornea at final follow-up (mean, 16.9 ± 8.1 months). Following surgery, corrected distance visual acuity improved from 0.9 ± 0.3 logMAR (Snellen 20/158) to 0.4 ± 0.2 (20/50), and pachymetry improved from 932 ± 57 μm to 642 ± 93 μm. Endothelial cell loss was 33%, and average cell counts were 1767 ± 281 cells/mm at final follow-up. Intraoperative aqueous misdirection occurred in both eyes of a 2-year-old child, requiring pars plana vitrectomy. Postoperative donor Descemet's membrane detachment occurred in 4 eyes. Rebubbling was performed in 3 eyes (21%); 1 eye had spontaneous reattachment. One eye (8%) had possible graft failure during follow-up, requiring repeat DMEK surgery.

Conclusions: In our study cohort of eyes with CHED, DMEK was performed with good visual outcome. Rebubbling was necessary for donor reattachment in the early postoperative period in some cases.
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http://dx.doi.org/10.1016/j.jaapos.2020.07.018DOI Listing
December 2020

Preferred practice patterns for photorefractive keratectomy surgery.

Indian J Ophthalmol 2020 Dec;68(12):2847-2855

Department of Cataract and Refractive Surgery, Narayana Nethralaya, Bangalore, Karnataka, India.

Over the past two decades, excimer laser-based refractive surgery procedures have been successfully established for their safety and satisfactory visual outcomes. Surface ablation procedures or photorefractive keratectomy (PRK) are practised commonly for the correction of refractive errors including myopia, astigmatism and hyperopia. Satisfactory visual outcomes are achieved in majority of cases, although a very small percentage have issues related to corneal haze, regression, and its associated visual disturbances. To ensure optimal outcomes and to minimize complications, certain keys to success have been designed on the basis of the current review of literature on surface ablation procedures.
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http://dx.doi.org/10.4103/ijo.IJO_2178_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7856967PMC
December 2020

Gundersen Flap Removal to Restore Eyesight Without Limbal Transplantation-A Case Report.

Cornea 2021 Jun;40(6):783-785

Eye Department, Apollo Hospitals, Hyderabad, India.

Purpose: To report a case of Gundersen flap removal where the ocular surface was restored without the need for additional limbal stem cell transplantation.

Methods: We describe a case of 57-year-old man who underwent Gundersen flap for a nonhealing corneal ulcer in right eye 17 years ago. He recently lost eyesight in left eye after blunt trauma. Gundersen flap removal was performed in right eye along with amniotic membrane transplantation.

Results: The ocular surface recovered completely after surgery without any evidence of limbal stem cell deficiency. His corrected distance visual acuity improved to 20/60 along with a stable ocular surface, which was maintained till last follow-up of 12 months.

Conclusions: A normal ocular surface can be restored after Gundersen flap surgery if removal of limbal epithelium is not performed during the primary procedure. Additional corneal surgery might be required depending on corneal clarity.
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http://dx.doi.org/10.1097/ICO.0000000000002530DOI Listing
June 2021

Modified big bubble technique of deep anterior lamellar keratoplasty.

J Cataract Refract Surg 2020 Nov 2. Epub 2020 Nov 2.

From the Eye Department, Apollo Hospitals, Jubilee Hills, Hyderabad, India (Fogla, Indumathy); Ophthalmology Unit, Azienda USL-IRCCS di Reggio, Emilia, Italy (Fontana).

A new technique of air injection is described for bigbubble deep anterior lamellar keratoplasty (DALK) in eyes with keratoconus, along with a comparative analysis of the original technique. 50 eyes were analyzed in each group. Average steep keratometry and anterior chamber depth distribution were comparable between the 2 groups. The average size of type 1 bubble achieved with single air injection (Group 1) was 7.8 + 0.4 mm (range 6.5 - 8.5mm), and with sequential air injection (Group 2) was 8.5 + 0.3 (range 8 - 9mm). (P < 0.001) Intraoperative complications of spontaneous bursting of bubble in 1 eye (2%), and peripheral microperforation in 3 eyes (6%) occurred only in group 1. The modified technique of big-bubble DALK using sequential air injection aided by paracentesis to lower intraocular pressure allowed enlargement of a type 1 bubble in a safe and controlled manner with minimal risk for complications.
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http://dx.doi.org/10.1097/j.jcrs.0000000000000469DOI Listing
November 2020

Customized toric intraocular lens implantation in cornea plana.

J Cataract Refract Surg 2020 12;46(12):e11-e14

From the Eye Department, Apollo Hospitals, Hyderabad, India.

A 50-year-old woman with cornea plana had reduced visual acuity due to development of lenticular changes. Flat keratometry with high astigmatism, shallow anterior chamber depth, and short axial length made it challenging both for intraocular lens (IOL) power calculation and cataract surgery. Surgery was planned for the right eye because the left eye was densely amblyopic. IOL power required was beyond the commercially available lenses; hence, a customized toric IOL was obtained. Phacoemulsification was successfully performed along with in-the-bag implantation of the toric IOL, which resulted in improved visual acuity with satisfactory refractive outcome. Cataract surgery with a customized IOL improved visual acuity in an eye with cornea plana.
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http://dx.doi.org/10.1097/j.jcrs.0000000000000350DOI Listing
December 2020

All India Ophthalmological Society - Eye Bank Association of India consensus statement on guidelines for cornea and eyebanking during COVID-19 era.

Indian J Ophthalmol 2020 Jul;68(7):1258-1262

President, All India Ophthalmological Society, Chairman, Centre for Sight, New Delhi, India.

The COVID-19 pandemic has brought with it the huge burden of mortality and morbidity across the world and the added effects of the mandatory lockdown measures to try and control the spread. A number of aspects of healthcare including eye donation and eye collection require adequate safety precautions in place to keep both the involved healthcare workers and patients safe. This paper highlights the consensus-based guidelines by an expert panel on how to restart eye banking and eye collection services and carry out emergency corneal surgeries during this COVID-19 time. These guidelines will be applicable to all eye banks across the country and should help ophthalmologists and eye banking staff to restart eye banking while safeguarding themselves and their patients.
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http://dx.doi.org/10.4103/ijo.IJO_1554_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7574107PMC
July 2020

Long-term clinical outcomes of keratoplasty using gamma-irradiated corneal lenticules.

BMJ Open Ophthalmol 2019 10;4(1):e000396. Epub 2019 Nov 10.

Cornea and External Diseases, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.

Objective: To report long-term clinical outcomes of gamma-irradiated corneal lenticules in partial and full-thickness keratoplasty.

Methods And Analysis: This multicentre, retrospective case series includes 23 patients who underwent surgery at three centres (India, Guatemala, and USA) between May 2009 and March 2018. The main outcome measures were epithelialization and retention for therapeutic keratoplasty and best spectacle-corrected visual acuity (BSCVA) for optical keratoplasty.

Results: Patients were categorised according to primary aetiology requiring corneal transplantation: non-inflammatory conditions, infectious keratitis and sterile keratolysis. Nine patients with non-inflammatory conditions underwent anterior lamellar keratoplasty (n=7) and Boston type 1 keratoprosthesis (n=2). All nine grafts remained intact and epithelialized during follow-up (median 24 months). In the seven patients who underwent anterior keratoplasty, the graft stayed optically clear during follow-up (median 12 months), with BSCVA between 20/20 and 20/40 in all but one patient who developed cataract. Nine patients with severe infectious keratitis had emergency patch grafting. Six of those grafts epithelialized and remained intact over a median of 30 months, providing tectonic support until optical keratoplasty with fresh tissue could be performed. Three grafts had recurrent infectious keratitis 1-3 months postoperatively, two of which underwent tectonic keratoplasty with fresh tissue which also eventually became infected during follow-up. In five additional patients with sterile keratolysis who underwent lamellar patch graft, two grafts remained intact during follow-up (median 36 months). Two patients had recurrent corneal melt within 1 month, and both had subsequent corneal surgery with fresh tissue which also failed. There were no donor-related complications.

Conclusion: Gamma-irradiated sterile corneal stromal lenticules can be considered as a viable alternative to fresh tissue in various clinical settings.
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http://dx.doi.org/10.1136/bmjophth-2019-000396DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6861079PMC
November 2019

Comparison of Two Modified Sutureless Techniques of Scleral Fixation of Intraocular Lens.

Ophthalmic Surg Lasers Imaging Retina 2018 10;49(10):e129-e134

Background And Objective: To compare the visual outcome and complications of two different sutureless scleral-fixated intraocular lens (IOL) implantation techniques, that is, intrascleral IOL fixation technique and modified Yamane's technique of scleral fixation of IOL.

Patients And Methods: Patients who underwent scleral fixation of IOL (SFIOL) from June 2015 to February 2017 with more than 6 months of follow-up were examined retrospectively. Improvement in visual acuity (VA), intraocular pressure (IOP) measurements, endothelial cell count, central macular thickness (CMT), and intraoperative/postoperative complications were compared at 6 months follow-up.

Results: Seventy eyes were analyzed. The mean follow-up was 10.5 months ± 1.5 months. The final visual outcomes in both groups, modified intrascleral IOL fixation technique (Group A, n = 30) and modified Yamane's technique (Group B, n = 40), were comparable. The indications for surgery were aphakia (n = 15), subluxated/dislocated cataract (n = 31), and dislocated/subluxated IOL (n = 24). The majority of the eyes (92%) improved to VA 0.3 logMAR units or better. The uncorrected distance visual acuity (UDVA), endothelial cell density, and CMT at the 6-month follow-up were comparable in both groups. Postoperatively, transient IOP rise occurred in 18 eyes, retinal detachment in one eye, vitreous hemorrhage in one eye, cystoid macular edema in two eyes, and mild IOL decentration in two eyes.

Conclusion: Both techniques have favorable visual outcomes; however, modified 27-gauge needle-assisted Yamane's technique is technically superior because of its transconjunctival approach and less surgical time, and its needle-assisted approach for haptic externalization prevents haptic damage during externalization. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:e129-e134.].
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http://dx.doi.org/10.3928/23258160-20181002-15DOI Listing
October 2018

Sutureless 27-gauge needle-assisted transconjunctival intrascleral intraocular lens fixation: Initial experience.

Indian J Ophthalmol 2017 Dec;65(12):1450-1453

Department of Ophthalmology, University of Nottingham, Nottingham, UK.

Purpose: The purpose of the study was to report our initial experience with the transconjunctival Intrascleral Intraocular Lens (SFIOL) fixation with modified Yamane's double-needle technique and flanged haptics.

Methods: This was a prospective interventional study that enrolled 31 consecutive patients undergoing SFIOL with the modified Yamane's technique. All patients underwent comprehensive evaluation including uncorrected and best-corrected vision, intraocular pressure, ultrasound biomicroscopy, endothelial cell density, and macular thickness using optical coherence tomography (OCT). We excluded patients with visually significant coexistent pathology such as corneal scars, macular pathology, and glaucoma.

Results: The mean age of subjects was 57 ± 16.9 years and 23 were men (74%). Surgery was performed for aphakia following complicated cataract surgery in 10 eyes (32%), with lensectomy for subluxated/dislocated cataract in 6 eyes (19%), and with IOL explantation for subluxated/dislocated IOL in 15 eyes (48%). There were no intraoperative complications. Uncorrected visual acuity improved from median of 1.48 logarithm of minimum angle of resolution (logMAR) units (interquartile range [IQR] = 1.3-2 logMAR) at baseline to 0.3 logMAR (IQR = 0.2-0.4 logMAR) at 6 weeks (P < 0.001) which was maintained at 6 months. There were no significant changes in endothelial cell density (P = 0.34) and OCT-based macular thickness (P = 0.31) at 6 months. Two eyes had slight IOL decentration.

Conclusion: Our initial experience suggests that the Yamane's technique for SFIOL is a simple procedure with a short-learning curve and is independent of scleral flaps, tunnels, sutures, and fibrin glue. Using widely available 27-gauge needle instead of 30-gauge thin wall needle as originally described by Yamane makes it possible for the use of various three-piece IOLs available globally. Further studies are required for widespread acceptance of this technique.
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http://dx.doi.org/10.4103/ijo.IJO_659_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5742981PMC
December 2017

Artificial Anterior Chamber Model Using Human Donor Corneas for DMEK Surgical Training.

Cornea 2018 04;37(4):e17-e18

Cornea Clinic, Eye Department, Apollo Hospitals, Jubilee Hills, Hyderabad, Telangana, India.

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http://dx.doi.org/10.1097/ICO.0000000000001446DOI Listing
April 2018

April consultation #4.

Authors:
Rajesh Fogla

J Cataract Refract Surg 2016 Apr;42(4):639-640

Hyderabad, India.

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http://dx.doi.org/10.1016/j.jcrs.2016.03.017DOI Listing
April 2016

Microkeratome-assisted two-stage technique of superficial anterior lamellar keratoplasty for Reis-Bücklers corneal dystrophy.

Cornea 2014 Oct;33(10):1118-22

*Department of Ophthalmology, Apollo Hospitals, Andhra Pradesh, Hyderabad, India; and †Faculty of Health Sciences, Department of Ophthalmology, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel.

Purpose: The aim of this study was to describe a microkeratome-assisted 2-stage technique of superficial anterior lamellar keratoplasty (SALK) to manage Reis-Bucklers corneal dystrophy (RBCD).

Methods: A microkeratome was used to create a 9-mm, 140-μm-thick corneal flap in the first stage. Four weeks later, in the second stage, a Hessberg-Baron suction trephine was used to perform a 7.0-mm central trephination up to a depth of 150 μm, within the corneal flap. Donor lamellar tissue was prepared using a microkeratome system, after which a vacuum punch was used to trephine a 7.0-mm lamellar button. This donor button was used to replace the central corneal flap in the recipient cornea without using any sutures. A bandage contact lens was applied for 2 weeks.

Results: This modified technique of staged sutureless SALK was used in 4 eyes of 2 patients with RBCD. Postoperatively, all eyes experienced an improvement in both uncorrected and best spectacle-corrected visual acuities. The average best spectacle-corrected visual acuity was 20/30 at the last follow-up (19 months, range 16-22 months). The cornea remained clear in all eyes until the last follow-up without any evidence of recurrence of RBCD.

Conclusions: The staged technique of microkeratome-assisted SALK allows the replacement of superficial corneal stroma without the necessity for any sutures and seems to be a safe and effective method for the treatment of RBCD.
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http://dx.doi.org/10.1097/ICO.0000000000000189DOI Listing
October 2014

Deep anterior lamellar keratoplasty in the management of keratoconus.

Authors:
Rajesh Fogla

Indian J Ophthalmol 2013 Aug;61(8):465-8

Department of Ophthalmology, Apollo Hospitals, Jubilee Hills, Hyderabad, Andhra Pradesh, India.

Advanced cases of keratoconus often require surgical intervention to restore corneal anatomy and improve eyesight. Penetrating keratoplasty (PK) although commonly performed has potential risk of immunological rejection and is now no longer automatically the first choice of surgery. DALK procedures have evolved, which allows surgical replacement of recipient's corneal stroma, leaving behind healthy descemet membrane (DM) and endothelium. This reduces the risk of allograft endothelial rejection and late graft failure. In recent times, DALK techniques have led to significant improvements in visual outcome and current results are comparable to PK. Big bubble technique of DALK has become the most popular among the various surgical techniques described. Manual near DM DALK also gives good outcome although the visual recovery is often delayed. Future integration of femtosecond laser technology along with diagnostic imaging technology is likely to further improve outcomes of DALK in keratoconus.
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http://dx.doi.org/10.4103/0301-4738.116061DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3775089PMC
August 2013

Microkeratome-assisted corneal tattooing: a case report.

Cornea 2010 Apr;29(4):446-8

Cornea Clinic, Apollo Hospitals, Jubilee Hills, Hyderabad, India.

Purpose: The purpose of this study was to report a new technique of microkeratome-assisted corneal tattooing for cosmetic improvement in a young female patient with adherent leucoma.

Methods: The para-axial adherent leucoma had resulted from penetrating corneal injury sustained at the age of 2 years. A nasal hinged partial corneal flap of 140 μm thickness was raised using the microkeratome. The flap extended to just beyond the medial margin of the leucoma. Organic dye powder was spread on the stromal bed over the leucomatous scar as well as on the undersurface of the corneal flap corresponding to the area of opacity. The flap was then repositioned and a bandage contact lens placed.

Results: The staining dye powder completely concealed the leucomatous opacity with good cosmesis and patient satisfaction. Corneal topography and best-corrected visual acuity remained unchanged at last follow up of 9 months.

Conclusions: Microkeratome-assisted corneal tattooing appears to be a safe, effective, and precise method of corneal tattooing.
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http://dx.doi.org/10.1097/ICO.0b013e3181ae2560DOI Listing
April 2010

Initial results of small incision deep lamellar endothelial keratoplasty (DLEK).

Am J Ophthalmol 2006 Feb;141(2):346-351

Sankara Nethralaya, Medical and Vision Research Foundations, Chennai, Tamil Nadu, India.

Purpose: To evaluate the results of replacing the posterior stroma and endothelium, using small incision deep lamellar endothelial keratoplasty (DLEK) surgical technique, in patients with corneal endothelial dysfunction.

Design: Noncomparative case series.

Methods: Fifteen eyes of 15 patients (six males and nine females) with endothelial dysfunction were included in this study. Through a 5-mm scleral incision, a deep lamellar pocket was created across the cornea, followed by excision of an 8.0-mm disk of posterior lamellar corneal tissue. Same size lamellar donor disk was prepared and placed in position without the need of suture fixation. Best spectacle-corrected visual acuity (BSCVA), refraction, endothelial cell density, corneal topography, and corneal thickness were analyzed.

Results: Average BSCVA preoperative was 20/200 (range 20/40 to hand movements (HM)), improving to 20/50 (range 20/20 to 20/120) at a mean follow-up of 7.2 months. Average refractive astigmatism at last follow-up was 1.46+/-1.21 diopters (range, 0 to 4 diopters). Preoperative average donor endothelial cell density was 2047+/-311 cells/mm2, and that at last follow-up was 1732+/-514 cells/mm2. Preoperative average pachymetry was 801.4+/-211.3 microm, improving to 553+/-90.4 microm at last follow-up.

Conclusions: Initial results with small incision DLEK procedure indicate that it is a safe procedure that provides healthy donor endothelial cell count and function postoperatively, with encouraging visual results.
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http://dx.doi.org/10.1016/j.ajo.2005.10.010DOI Listing
February 2006

Results of deep lamellar keratoplasty using the big-bubble technique in patients with keratoconus.

Am J Ophthalmol 2006 Feb;141(2):254-259

Cornea Services, Sankara Nethralaya, Medical and Vision Research Foundations, Chennai, Tamil Nadu, India.

Purpose: To evaluate the efficacy of deep lamellar keratoplasty using the big-bubble technique in patients with keratoconus.

Design: Interventional case series.

Methods: Thirteen eyes of 12 patients (eight male and four female subjects) with moderate to advanced keratoconus and intolerance to contact lens wear were included in this study. Deep lamellar keratoplasty was performed by the intrastromal air injection technique. Full-thickness donor tissue devoid of Descemet membrane and endothelium was then sutured into place. Best-corrected visual acuity, refractive results, surgical technique, and complication rates were analyzed.

Results: Big bubble was successfully achieved in nine eyes (69.2%). Average postoperative best-corrected visual acuity was 20/25 (range 20/50 to 20/20) at a mean follow-up of 5 months. Intraoperative microperforation of Descemet membrane occurred in two eyes (15.3%). Three eyes (23%) developed a steroid-induced increase in intraocular pressure, which responded to medical therapy.

Conclusions: Deep lamellar keratoplasty that uses the big-bubble technique is safe and effective in patients with keratoconus. Visual outcome is comparable to standard penetrating keratoplasty, without the risk of endothelial rejection.
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http://dx.doi.org/10.1016/j.ajo.2005.08.064DOI Listing
February 2006

Chronic microsporidial stromal keratitis in an immunocompetent, non-contact lens wearer.

Indian J Ophthalmol 2005 Jun;53(2):123-5

Cornea Services, Sankara Nethralaya, Chennai, India.

An 82-year-old healthy man with unilateral chronic stromal keratitis, initially diagnosed to have viral keratitis and refractory to medical therapy, showed numerous oval, microsporidial organisms, measuring 4-5 m in length in the corneal biopsy. Penetrating keratoplasty, followed by treatment with systemic albendazole and topical propamidine isethionate resulted in resolution of the infection. Electron microscopy of the keratoplasty specimen demonstrated sporoblasts with diplokaryotic nuclei and multiple coils of the filament. The light and electron microscopic features were consistent with microsporidial keratitis.
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http://dx.doi.org/10.4103/0301-4738.16177DOI Listing
June 2005

Deep anterior lamellar keratoplasty combined with autologous limbal stem cell transplantation in unilateral severe chemical injury.

Cornea 2005 May;24(4):421-5

Sankara Nethralaya, Medical and Vision Research Foundations, Chennai, Tamil Nadu, India.

Purpose: To evaluate the efficacy of deep anterior lamellar keratoplasty combined with autologous limbal stem cell transplantation for ocular surface reconstruction and visual rehabilitation in eyes with unilateral, late-stage, severe chemical injury.

Methods: This was a retrospective, noncomparative, interventional case series that included 7 eyes of 7 patients, with severe unilateral late stage chemical injury, exhibiting corneal vascularization, conjunctivalization, and extensive corneal scarring were treated at the C. J. Shah Cornea Service, Sankara Nethralaya, a tertiary care center. Surgical procedures included releasing symblepharon adhesions, excising epibulbar fibrous tissue, superficial keratectomy to remove fibrovascular tissues over cornea, deep anterior lamellar dissection, grafting a lamellar corneal button, and transplanting autologous limbal graft, with or without amniotic membrane transplantation. The main outcome measures were relief of patient symptoms, postoperative recovery of the ocular surface, corneal clarity, corneal epithelial stability, and best corrected visual acuity.

Results: The mean duration between the injury and surgery was 24.4 +/- 21.8 months. No intraoperative complications were noted. Successful epithelialization was achieved in all eyes. The reconstructed corneal surface remained stable during the entire follow-up period (mean follow-up, 16.57 +/- 5.12 months). All patients had resolution of ocular symptoms. Remarkable improvement in vision was noted in all (85.7%) except 1 eye in which recovery was limited due to amblyopia. The average best corrected visual acuity at last follow-up was 20/50. No complications were noted in the donor fellow eye.

Conclusions: DALK combined with autologous limbal transplantation can restore a healthy, stable ocular surface, besides providing a clear cornea that remarkably improves the visual acuity, in patients with unilateral, late stage, severe chemical injury.
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http://dx.doi.org/10.1097/01.ico.0000151550.51556.2dDOI Listing
May 2005

Bilateral epithelial defects after laser in situ keratomileusis. Clinical features, management and outcome.

Indian J Ophthalmol 2005 Mar;53(1):37-42

Medical and Vision Research Foundations, Chennai, Tamil Nadu, India.

Purpose: To describe the preoperative characteristics, intraoperative details, management, and postoperative in patients with bilateral epithelial defects after laser in situ keratomileusis (LASIK).

Methods: Retrospective non-comparative case series.

Results: Six patients with bilateral epithelial defects after LASIK were part of a cohort of 605 patients undergoing bilateral LASIK at our center from December 2001 to April 2003. The mean age of the patients (5M:1F) was 28.5 +/- 7.9 years, and the average pretreatment myopic spherical equivalent (SE) refraction was 7.3 +/- 0.7 D (-4, -12.25D). An epithelial flap was present in 6 eyes and an epithelial defect with a mean diameter of 3 mm (2mm, 6mm) was seen in 6 eyes. In four patients the epithelial disturbance was bilaterally similar. All defects occurred in the inferior cornea and the epithelial flaps had the hinge positioned superiorly. None of the patients had ocular or systemic risk factors that could have resulted in this complication. A bandage contact lens was used in 6 eyes. At last follow-up of 5.5 +/- 9.5 months (0.25, 21 months), unaided visual acuity was 6/9 or better in 10 eyes. Best spectacle-corrected visual acuity (BSCVA) was maintained in 8 eyes, while 4 eyes lost one line of BSCVA. Recurrent corneal erosions were not reported in the follow-up period.

Conclusions: These patients represent a hitherto unrecognised group of individuals who appear to have a subclinical weakness of adhesion of the corneal epithelium to the underlying structures, which is not evident on clinical examination. This results in bilateral epithelial disturbances after LASIK. Appropriate management results in satisfactory clinical outcomes. Other options for treatment of the fellow eye of such patients include the use of a different microkeratome, release of suction during the reverse pass of the Hansatome microkeratome, and photorefractive keratectomy if the refractive error is low.
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http://dx.doi.org/10.4103/0301-4738.15283DOI Listing
March 2005

Interrupted sutures at the hinge site to manage a free flap during laser in situ keratomileusis.

J Cataract Refract Surg 2004 Oct;30(10):2235-8

Sankara Nethralaya, Medical and Vision Research Foundations, Chennai, India.

Two patients developed free flaps intraoperatively during laser in situ keratomileusis. After excimer laser treatment was performed, the free flap was replaced, maintaining proper alignment. Interrupted sutures were placed superiorly at the intended hinge site to secure the free flap. The uncorrected visual acuity was 20/30 in the affected eyes of both patients after treatment. At the 6-month follow-up, there were no flap-related complications and there was no loss of best corrected visual acuity.
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http://dx.doi.org/10.1016/j.jcrs.2004.02.084DOI Listing
October 2004

Ophthalmic photography using a digital camera.

Indian J Ophthalmol 2003 Sep;51(3):269-72

Sankara Nethralaya, Medical and Vision Research Foundation, Chennai, Tamil Nadu, India.

Purpose: To report the application of a digital camera for ophthalmic photography in routine clinical use.

Methods: A digital camera (Nikon Coolpix 995) was used both for external macrophotography of the eye and ocular adnexa, and slitlamp photography of the anterior segment of the eye.

Results: We were able to take external macrophotographs under high magnification of the eye and ocular adnexa. Slitlamp photography could be performed under diffuse, slit beam, and retroillumination. The structures of the angle, the optic disc and surrounding retina could be photographed using appropriate lenses. The attachment to the operating microscope allowed intraoperative photography. It could also be attached to the laboratory microscope to capture images of various histopathology and microbiology slides.

Conclusions: A digital camera is a versatile instrument for ophthalmic photography. It is easy to use in routine clinical practice and provides good quality photographs.
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September 2003

Interface keratitis due to Mycobacterium fortuitum following laser in situ keratomileusis.

Indian J Ophthalmol 2003 Sep;51(3):263-5

Sankara Nethralaya, Medical Research Foundation, Chennai, India.

A case of unilateral interface keratitis due to Mycobacterium fortuitum following simultaneous bilateral LASIK procedure for low myopia is reported. Excimer phototherapeutic keratectomy was performed to the stromal bed to reduce the infective load. Intensive topical therapy with topical amikacin and ciprofloxacin resulted in resolution of the keratitis.
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September 2003

Partial flap during laser in situ keratomileusis: role of smaller diameter corneal flap of original thickness.

J Refract Surg 2003 Mar-Apr;19(2):165-8

Cornea Services, Sankara Nethralaya, Medical and Vision Research Foundations, Chennai, Tamil Nadu, India.

Purpose: To report results of smaller diameter corneal flap of original thickness in the management of partial flap during laser in situ keratomileusis (LASIK).

Methods: Retrospective review of the case records of three patients (3 eyes) who had a partial corneal flap during LASIK.

Results: Retreatment was performed using an 8.5-mm-diameter corneal flap, which was smaller than the original partial flap of 9.5-mm diameter. The recut depth was maintained as the original cut depth of 160 microm. No intraoperative or postoperative complications were noted. At follow-up 4 weeks later, two patients had an uncorrected visual acuity of 20/20. One patient had uncorrected visual acuity of 20/40 that improved to preoperative best spectacle-corrected visual acuity of 20/30 with a correction of +0.50 -1.25 x 170 degrees.

Conclusion: A smaller diameter corneal flap of original thickness can be used for retreatment of partial flap during LASIK. A thicker posterior stromal bed after laser ablation may be retained with this technique, compared to retreatment using a corneal flap of greater thickness.
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June 2003

Keratectasia in 2 cases with pellucid marginal corneal degeneration after laser in situ keratomileusis.

J Cataract Refract Surg 2003 Apr;29(4):788-91

Sankara Nethralaya, Medical and Vision Research Foundations, Chennai, India.

We report 2 patients who experienced progressive blurring of vision following myopic laser in situ keratomileusis (LASIK) in 1 eye (Case 1) and bilaterally (Case 2). High against-the-rule astigmatism, associated with perilimbal thinning inferiorly, was seen on refraction in all eyes. Regional corneal pachymetry confirmed the peripheral corneal thinning inferiorly. Corneal topography revealed the typical features of pellucid marginal corneal degeneration (PMCD) in the untreated eye of Case 1. Advanced changes were noted in the fellow eye. The corneal topography findings in Case 2 were similar to those seen in PMCD. Patients with early PMCD may present to the refractive surgeon with a stable refraction, normal corrected visual acuity, and adequate central corneal thickness. Corneal topography data along with regional corneal pachymetry must be interpreted carefully to detect these cases. Laser in situ keratomileusis can lead to a rapid progression of PMCD.
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http://dx.doi.org/10.1016/s0886-3350(03)00047-6DOI Listing
April 2003

Current approaches to diagnosis and management of ocular lesions in human immunodeficiency virus positive patients.

Indian J Ophthalmol 2002 Jun;50(2):83-96

Medical and Vision Research Foundations, Sankara Nethralaya, 18, College Road, Chennai-600 006, India.

Human immunovirus infection in India is rapidly increasing. Ocular lesions due to highly active antiretroviral therapy have been well recognized. Acquired immunodeficiency syndrome can affect all parts of the eye. However, posterior segment lesions are the most common and of these, Human immunodeficiency virus retinopathy and cytomegalovirus retinitis predominate. Often clinical examination can establish the diagnosis of many ocular lesions in acquired immunodeficiency syndrome; therefore, ophthalmologists need to be aware of the more common ones. Various drugs in different routes can used to treat cytomegalovirus retinitis. Highly active antiretroviral therapy has remarkably reduced systemic and ocular morbidity among acquired immunodeficiency syndrome patients. To facilitate care of these patients aseptic precautions for ophthalmic care personnel are now well established and therefore ophthalmologist should not hesitate to provide ophthalmic care to acquired immunodeficiency syndrome patients.
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June 2002