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PHOTO ESSAY
Year : 2021  |  Volume : 1  |  Issue : 1  |  Page : 41-42

A rare case of early neurotrophic keratitis following micropulse transscleral cyclophotocoagulation combined with phacoemulsification


Glaucoma Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India

Date of Submission20-Apr-2020
Date of Acceptance15-Jul-2020
Date of Web Publication31-Dec-2020

Correspondence Address:
Dr. Karthikeyan Mahalingam
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, Ansari Nagar, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_1040_20

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  Abstract 


Keywords: Combined surgery, micropulse, neurotrophic keratitis, phacoemulsification


How to cite this article:
Bafna RK, Sharma N, Balaji A, Mahalingam K, Shanmugam C, Mahalingam K. A rare case of early neurotrophic keratitis following micropulse transscleral cyclophotocoagulation combined with phacoemulsification. Indian J Ophthalmol Case Rep 2021;1:41-2

How to cite this URL:
Bafna RK, Sharma N, Balaji A, Mahalingam K, Shanmugam C, Mahalingam K. A rare case of early neurotrophic keratitis following micropulse transscleral cyclophotocoagulation combined with phacoemulsification. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Feb 25];1:41-2. Available from: https://www.ijoreports.in/text.asp?2021/1/1/41/305470



A 36-year-old male presented with Right eye (RE) healed anterior uveitis with complicated cataract and intractable glaucoma; left eye was normal with no other systemic illness. RE vision was perception of light with accurate projection of rays, intraocular pressure (IOP) was 28 mmHg on maximum topical and systemic glaucoma medications. Qualitative corneal sensation test showed comparable corneal sensation in both the eyes. Ultrasonography was anechoic. After giving intravenous mannitol, micropulse transcleral-cyclophotocoagulation (TSCP) was done using Iridex-CycloG6 glaucoma laser system (MountainView, CA) and micropulse P3 probe (curved-tip). Settings: Duration-160 s over 360°; 31.3% duty cycle; power: 2000 mW. It was followed by phacoemulsification (iris-hooks used for non-dialating pupil, [Figure 1]) with placement of foldable intraocular lens. On the 5th post-operative day, patient presented with painless epithelial defect (7*5 mm) and IOP was 8 mmHg. Corneal sensation was absent pointing towards neurotrophic keratitis. Bandage contact lens was placed and we switched to preservative free antibiotics, lubricants and oral steroids. 10-days later, there was no improvement with heaped up ulcer margin [Figure 2], so we planned for amniotic membrane graft.
Figure 1: Intraoperative image showing that iris hooks were used during surgery

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Figure 2: Post-operative image of RE showing epithelial defect before (a) and after staining (b)

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  Discussion Top


Although we spared the 3 & 9'o clock position during micropulse TSCP, thermal damage to perilimbal nerve plexus could lead to development of neurotrophic keratitis.[1] Past studies showed neurotrophic keratitis developing 22 days (R = 10-35) after TSCP.[1],[2],[3] In our case we diagnosed at 5th post-operative day. The combination of factors like chronic topical medication use (timolol), combined micropulse TSCP (360°) with phacoemulsification has led to early development of neurotrophic keratitis [Figure 3].[4],[5] This is the first case with early presentation of neurotrophic keratitis.
Figure 3: Schematic diagram showing the possible cause of early neurotrophic keratitis

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We recommend staged surgeries (adequate gap between TSCP and phacoemulsification); avoiding 3 and 9'o clock positions; too anterior positioning of probe during TSCP and 180° treatment with lesser power to prevent neurotrophic keratitis in high-risk cases. Adequate lubricants and switching to preservative free medications in advance may also be considered.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Perez CI, Han Y, Rose-Nussbaumer J, Ou Y, Hsia YC. Neurotrophic keratitis after micropulse transscleral diode laser cyclophotocoagulation. Am J Ophthalmol Case Rep 2019;15:100469. doi: 10.1016/j.ajoc. 2019.100469.  Back to cited text no. 1
    
2.
illiams AL, Moster MR, Rahmatnejad K, Resende AF, Horan T, Reynolds M, et al. Clinical efficacy and safety profile of micropulse transscleral cyclophotocoagulation in refractory glaucoma. J Glaucoma 2018;27:445-9.  Back to cited text no. 2
    
3.
Fernández-Vega González Á, Barraquer Compte RI, Cárcamo Martínez AL, Torrico Delgadillo M, de la Paz MF. Neurotrophic keratitis after transscleral diode laser cyclophotocoagulation. Arch Soc Espanola Oftalmol 2016;91:320-6.  Back to cited text no. 3
    
4.
Holden BA, Polse KA, Fonn D, Mertz GW. Effects of cataract surgery on corneal function. Invest Ophthalmol Vis Sci 1982;22:343-50.  Back to cited text no. 4
    
5.
Sacchetti M, Lambiase A. Diagnosis and management of neurotrophic keratitis. Clin Ophthalmol Auckl NZ 2014;8:571-9.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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