Corneal Perforation after Nd:YAG Capsulotomy: A Case Report and Literature Review

Objectives: To find out the visual acuity outcome after Nd: YAG laser capsulotomy in posterior capsular opacification in pseudophakic patients after cataract surgery. Study Design: Analytical study. Setting: Department of Ophthalmology Khyber Medical University Institute of Medical Sciences / K.D.A Teaching Hospital Kohat. Period: January 2016 to June 2017. Materials and methods: Special proforma was designed for record of patients. PreNd:YAG laser posterior capsulotomy best corrected visual acuity was checked and noted. Anterior and posterior segments examination was done with slit lamp and indirect slit lamp bimicroscopy. Pupils were dilated with tropicamide eye drops. Nd:YAG laser capsulotomy was done. All these procedure were conducted as out door. Patients were put on topical steroid and antiglaucoma drops for ten days to control inflammation and rise in IOP. Post laser best corrected visual acuity was recorded after one month of laser. Results: Total 92 patients were selected with age range from 21 to 83 years. Out of these patients 43(46.74%) were male and 49(53.26%) were female. Post surgical laser period was from 7 months to 13 years. Prelaser best corrected visual acuity of 6/24-6/36 was present in 59(64.13%) patients, 6/60 in 24(26.08%) patients while 9(9.78%) patients had visual acuity of counting finger (CF). Post laser best corrected visual acuity after one month of 6/6-6/9 was recorded in 43(46.39%) patients ,6/12-6/18 in 27(29.34%), 6/24-6/36 in 13(14.13%)and 6/60 & below in 9(9.71%) patients. Conclusion: Post laser best corrected visual acuity is highly improved with Nd:YAG laser capsulotomy in posterior capsular opacification.

BACKGROUND Posterior capsule opacification (PCO) is the most common delayed complication of cataract surgery. Nd:YAG (Neodymium yttrium aluminium garnet) laser posterior capsulotomy presents the advantages of a non-invasive, effective, relatively safe technique to manage intact posterior capsule that opacifies postoperatively. With this background we want to study the visual outcome and complications following Nd-YAG laser posterior capsulotomy in posterior capsular opacification following small incision cataract surgery (SICS). METHODS The study includes 64 patients attending outpatient department of a tertiary eye care hospital at Latur from June 2018 to May 2019 who have undergone SICS with PMMA PC IOL (polymethyl methacrylate posterior chamber intraocular lens) implantation and clinically diagnosed with posterior capsular opacification. 64 eyes with PCO were subjected to Nd:YAG laser posterior capsulotomy after detailed slit lamp bio microscopic examination pre- and post-capsulotomy. Follow-up was done at 1 hour, 1 week, 2 weeks and 4 weeks and patients were examined for visual outcome and any complications at each visit. RESULTS There were 16 males (25 %) and 48 females (75 %) with a mean age of 65 years. Posterior capsule opacification occurs within 3 years accounting for 46.9 % of the cases. Elschnig pearls type of PCO was more common when compared to fibrous type of PCO. Best corrected visual acuity (BCVA) before Nd:YAG laser capsulotomy was less than 6 / 60 in 35 patients (54.7 %) and within 6 / 60 to 6 / 24 in 23 patients (35. 9 %) with 6 patients (9.4 %) accounting for visual acuity between 6 / 24 to 6 / 18. After Nd - YAG Laser Capsulotomy, 46.9 % gained best corrected visual acuity of 6 / 18 or better, 39.1 % cases improved 6 / 12 and better and BCVA of 6 / 9, 6 / 6 was observed in 11 cases and 1 case respectively. Only 12 out of 64 patients had complications. Raised intraocular pressure (IOP) was found in 4 patients. Intraocular lens (IOL) pitting was found in 8 patients. CONCLUSIONS Nd:YAG laser capsulotomy is a safe, effective and a non-invasive procedure which avoids all the complications of surgical capsulotomy in patients of posterior capsule opacification. KEYWORDS Posterior capsule opacification (PCO), Nd:Yag Laser Capsulotomy, Best Corrected Visual Acuity (BCVA), Central Subfield Macular Thickness (CSMT)

Purpose: To describe a case of keratouveitis caused by Euphorbia grandicornis sap, that resolved with topic steroids. Methods: We report a case presentation of a patient with keratouveitis. Results: A 70-year-old woman suffered from accidental ocular contact with E. grandicornis sap in her left eye. Two hours after the contact, she attended the clinic due to conjunctival hyperemia and pain. Best-corrected visual acuity (BCVA) was 20/25. The toxic conjunctivitis was treated with topical lubricant and steroid. After 24 h, she presented blurred vision. BCVA was 20/80. Toxic keratouveitis was diagnosed. Topical treatment with 1% cyclopentolate t.i.d., 5% sodium chloride, 1.14% dexamethasone phosphate each hour, and 4% sodium hyaluronate each hour was continued. Complete resolution was obtained 1 week later. Euphorbia sap content analysis was performed using dissolvent extraction spectrophotometry. Its contents included flavonoids, alkaloids, phenols and sesquiterpene lactones. Conclusion: Corneal exposure to E. grandicornis sap is a cause of nonvisually threatening keratouveitis when adequately treated with corticosteroids.

Abstract Background: Trichilemmal carcinoma (TLC) is a rare malignant adnexal tumor predominantly affecting the scalp, eyelids, neck and face of the elderly. Here, we firstly report a rare case of corneal perforation caused by TLC grown in eyelid margin. Case presentation: A 68-year-old female presented with two months history of unprovoked redness, pain and blurred vision in the left eye. On slit-lamp examination, a 1×2mm aseptic corneal perforation embedded by iris prolapsed was noted. After excluding other causes through examinations and case history inquiry, we speculated that the severe MGD and subsequent BKC might be the cause. In order to prevent the ulcer enlargement and intraocular infection, the patient was treated with penetrating keratoplasty immediately. However, a terrible phenomenon has aroused our concern that several small nodules gradually developed on the eyelid margin, accompanied with bleeding, burst and madarosis postoperatiely. The biopsy revealed the eyelid was involved by TLC and then the lesionectomy was performed immediately. There was no evidence of local recurrence and metastasis during 1 year follow-up. Conclusions: The involvement of eyelid margin by TLC, and subsequent BKC and corneal perforation were very rare and it has not been reported yet. The concomitant BKC can be gradually healed after rectifying eyelid margin by total excision of TLC. It is very important to offer careful follow-up to all patients.

Aim. To evaluate the efficacy of individualized corneal patching using a minimal graft for corneal trauma combined with tissue defects. Methods. Fifteen eyes (15 patients) were enrolled in this study, including 8 eyes with corneal perforation induced by removal of metal foreign bodies, 5 eyes with corneal laceration resulting from metal trauma, and 2 eyes with pencil injuries to the cornea. The size, shape, and depth of the tissue defects were assessed. For corneal perforation or irregular tissue defects, if the diameter or length was ≥3.0 mm, traditional penetrating keratoplasty (PK) or lamellar keratoplasty (LK) was adopted; if the diameter or length was ＜3.0 mm, a conical or irregular patch consistent with the defects was used. The visual acuity, corneal status, and postoperative complications were observed during the follow-up. Results. The diameter of corneal perforations was 1.0 mm in 2 eyes, 1.5 mm in 1 eye, 2.0 mm in 4 eyes, and 3.5 mm in 1 eye. During their PK procedures, a conical corneal graft was used in 7 eyes, while a traditional cylindrical graft was used in 1 eye. The other 7 eyes had corneal trauma combined with irregular tissue defects, which were full-thickness corneal defects in 5 eyes and lamellar defects in 2 eyes, all less than 3.0 mm in length. Thus, five eyes received PK, and 2 eyes received LK using an irregular wedge-shaped patch. The visual acuity increased greatly postoperatively, with mild corneal astigmatism. None of the patients developed immune rejection. Conclusion. Individualized corneal patching with a minimal graft can save corneal materials, relieve corneal scars, gain a good visual prognosis, and avoid immune rejection in the treatment of corneal trauma combined with tissue defects.

A longitudinal study was carried out in the laser unit of the Combined Military Hospital (CMH), Dhaka on 500 eyes of 500 patients who were treated with Neodymium-yttrium-aluminium-garnet (Nd:YAG) laser capsulotomy over a period of two and a half years. The aim of this study was to evaluate the visual acuity following Nd:YAG laser capsulotomy. The main entry criteria for this study were posterior capsular opacification (PCO) following Extracapsular Cataract Extraction (ECCE). The patients with corneal opacity, glaucoma, vitreous opacity, macular diseases, optic nerve diseases and any other retinopathies causing visual impairment were excluded from this study. Thirty six percent patients had pre-capsulotomy visual acuity 6/36 to 6/60, 32% patients had 6/18 to 6/24, 18% patients had <6/60 and 14% patients had 6/12. After seven days of capsulotomy 76% patients gained 6/12 or better vision. Eighty percent patients gained visual acuity of 6/12 with optical correction after thirty days. On the other hand, 64% patients had pre-capsulotomy near vision < N10 and 16% patients had N8. After capsulotomy near vision improved considerably. Four percent of the patients failed to improve vision following laser capsulotomy. It can be concluded that Nd:YAG laser capsulotomy in PCO can improve both distant and near vision, which can be augmented with optical correction after one month of laser surgery. Key words: Laser capsulotomy, Nd:YAG laser, visual acuity. DOI: 10.3329/jafmc.v5i2.4580 JAFMC Bangladesh Vol.5(2) (December) 2009, pp.29-31

Introduction. Gyrate atrophy is a rare genetical metabolic disorder affecting vision. Here, we report a 9-year-old boy with gyrate atrophy associated with bilateral macular edema at the time of diagnosis and the effect of long term metabolic control on macular edema.Case Presentation. A 9-year-old boy presented with a complaint of low visual acuity (best corrected visual acuity: 20/80 in both eyes, refractive error: −12.00 D). Dilated fundus examination revealed multiple bilateral, sharply defined, and scalloped chorioretinal atrophy areas in the midperipheral and peripheral zone. Spectral-domain optical coherence tomography revealed bilateral cystoid macular edema in both eyes. Serum ornithine level was high (622 μmol/L). An arginine-restricted diet reduced serum ornithine level (55 μmol/L). However, visual findings including macular edema remained unchanged in 2 years of follow-up.Conclusion. Arginine-restricted diet did not improve macular edema in our patient with gyrate atrophy. A more comprehensive understanding of the underlying factors for macular edema will lead to the development of effective therapies.

Purpose: To report a case of corneoscleral melt that occurred 50 years after resection of pterygium with postoperative administration of mitomycin C (MMC). Results: A 93-year-old woman developed acute corneal perforation and scleral melt in her left eye at 50 years after pterygium surgery with postoperative topical MMC. She underwent limbal transplantation. The anterior chamber reformed postoperatively and her intraocular pressure was normal. At 12 months after transplantation, best-corrected visual acuity was 20/500 and the graft-host junction was well apposed. Conclusion: This case shows that corneoscleral melt can occur even 50 years after resection of pterygium combined with postoperative topical MMC.

Purpose: To present a case of corneal toxicity following exposure to milky plant latex from Asclepias tuberosa. Methods: A 70-year-old female presented with blurred vision and pain in her left eye after handling an Ascepias tuberosa. Clinical examination revealed a corneal stromal oedema with small epithelial defects. The corneal endothelium was intact and folds in Descemets membrane were observed. The oedema was treated with chloramphenicol, dexamethasone and scopolamine. Results: The corneal oedema had appeared after corneal exposure to the plant, Asclepias tuberosa, whose latex contains cardenolides that inhibit the Na+/ K+-ATPase in the corneal endothelium. The oedema resolved after 96 hours. After nine months the best corrected visual acuity was 20/20. Conclusion: Corneal toxicity has previously been reported for plants of the Asclepias family. This is a rare case describing severe corneal toxicity caused by exposure to latex from Asclepias tuberosa. Handling of plants of the Asclepias family should be kept as a differential diagnosis in cases of acute corneal toxicity.

Ocriplasmin is a protease which has been approved for the treatment of symptomatic vitreomacular adhesion (VMA). A 63-year-old presented with blurred vision in the left eye and a best corrected visual acuity of 6/18. Optical coherence tomography revealed VMA with an underlying macular hole and she subsequently underwent a left intravitreal ocriplasmin injection. One week after the injection, VMA had been released but with enlargement of the macular hole and a drop in her BCVA to 6/60. This persisted at 1 month after the injection. It is important to warn patients that ocriplasmin may lead to an enlargement of their macular hole with resultant loss in visual acuity.