Search

Purpose: To describe the clinical course and treatment outcomes of Vogt-Koyanagi-Harada (VKH) disease during pregnancy., Methods: This retrospective study compares the clinical course and outcomes in pregnant and nonpregnant women with VKH. All VKH patients who were pregnant at presentation or on follow up and age-matched nonpregnant female controls during the study period (2013-2022) were included. Their best-corrected visual acuity (BCVA), clinical presentations, and treatment outcomes were analyzed., Results: Among the 532 female VKH patients, nine (1.7%) were included. Thirty nonpregnant patients were included as control. At presentation, the mean age in the study group was 26 years ± 6.48 standard deviation (SD) compared to the control group (mean 25.1 years ± 3.04). The mean BCVA was comparable between the two groups at presentation (study group 1.35 logarithm of the minimum angle of resolution [logMAR] vs. control group 0.76 logMAR; P = 0.05) and the final follow-up (study group 0.65 logMAR vs. control group 0.35 logMAR; P = 0.15). Participants with anterior segment inflammation (study group 77.7% vs. control group 70%; P = 0.65), the disease stage (early-stage VKH: study group 88.8% vs. control group 73.3%; P = 0.33), and disease exacerbation (study group 33.3% vs. control group 26.6%; P = 0.69) were all comparable between the study and control groups. Following treatment, 66.6% and 46.6% of the study and control groups, respectively, had sunset glow fundus (P = 0.29). At the last follow-up, 44.4% and 26.6% of the study and control groups, respectively, had subretinal fibrosis (P = 0.31)., Conclusion: Though pregnancy is an immunomodulatory state, the clinical course of VKH in pregnant patients can be similar to that of nonpregnant women and needs close monitoring and follow-up., (Copyright © 2024 Copyright: © 2024 Indian Journal of Ophthalmology.)

Introduction and Purpose: We report a case of extensively drug-resistant (XDR) Pseudomonas aeruginosa (PA) scleritis after pterygium surgery., Methods: Case report., Results: A 58-year-old farmer presented with a 40-day history of severe pain, swelling, and blurred vision after a pterygium excision was performed at another institute. The patient was on multiple medications with no relief. The examination showed a nasally located scleral thinning in his right eye, with ulceration and infiltrates. Microbiology revealed Pseudomonas aeruginosa , which showed intermediate sensitivity to colistin only. The patient was administered topical (0.19%) and intravenous colistin and dexamethasone. There was a rapid reduction in symptoms, and the lesions healed over the next 2 months., Conclusions: To the best of our knowledge, this is the first case report of XDR-PA scleritis. We suggest the possibility of evolving drug resistance caused by the iatrogenic use of antibiotics during the early stages of the disease course.

Purpose: To study the demographic, clinical, and microbiological profile of Demodex-related blepharokeratoconjunctivitis (BKC) at a tertiary eye care hospital., Methods: This retrospective observational study was conducted from January 2016 to September 2022. It included 83 patients with microbiologically proven Demodex BKC who presented to the cornea department of our tertiary care eye center. The clinical, microbiological, and demographic data of the 83 cases were analyzed., Results: Of the 83 cases, 57 (68.67%) were younger than 40 years, and 25 (30.12%) were below 20. Most patients presented with a good visual acuity of 20/40 or better (93 eyes; 84.55%). The disease was unilateral in 55 patients and bilateral in 28. Cylindrical dandruff was the predominant presentation noted in 61 eyes (54.95%), followed by corneal scarring in 47 eyes (42.34%) and corneal vascularization in 40 eyes (36.04%). On light microscopy, 87.95% of the positive samples were identified as Demodex folliculorum , 7.23% as Demodex brevis , and 6.02% remained unidentified. Tea tree oil and lid scrubs eradicated the disease in most patients clinically (75/83, 90.36%)., Conclusion: The spectrum of BKC includes both lid signs and corneal involvement. It can be a cause of recurrent BKC and detection of the mite by microscopic evaluation of the lashes can confirm the diagnosis. In most cases, the tea tree oil can effectively manage this condition. However, low doses of topical steroids are needed to control the inflammation in patients with corneal involvement., (Copyright © 2024 Copyright: © 2024 Indian Journal of Ophthalmology.)

The authors describe a case of reverse pupillary block with pigment dispersion following sequential phakic intraocular lens (pIOL) implantation for high myopia, in a young female patient. The intraocular pressure (IOP) elevation began 3 weeks postoperatively, for which Nd-YAG laser peripheral iridotomies (PIs) were attempted elsewhere. Despite maximum medical therapy, the IOP was uncontrolled. She was referred to our institute for further management. Examination showed anteriorly displaced iris-pIOL diaphragm, iris pigment dispersion and raised IOP. The PIs were incomplete. Based on clinical evaluation and investigations, we concluded that the excess area of contact of the posterior iris over the pIOL caused a reverse pupillary block and pigment dispersion. The IOPs were controlled by repeating laser iridotomies and with medical therapy. Subsequently, the patient developed a low lens vault leading to bilateral cataract. Sequential explantation of the pIOL along with cataract extraction was performed and her vision was restored., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: Microbial keratitis is a sight-threatening condition with a higher incidence in agrarian populations. In countries with a high indigent population, due to financial and other constraints, patients prefer to seek therapy locally rather than travel to advanced centres. The aim of this study is to describe the epidemiology, clinical characteristics, and outcomes of 60 consecutive patients with microbial keratitis managed at a rural centre., Methods: Descriptive case series. All patients clinically diagnosed with infectious keratitis were included. Corneal scrapings were obtained and microbiological identification was done by Gram stain. Anti-microbial therapy was commenced based on smear findings and the patients were followed up till disease resolution., Results: Sixty eyes of 60 patients were diagnosed with microbial keratitis in the study period. The mean age was 47.43 ± 18.69 years. Male:female ratio was 47:53. Risk factors included ocular trauma in the majority of patients (46/60; 76.7%). Microorganisms were identified on 75.6% of smears, with fungal filaments (65.4%) being the most common. Ulcers were central in over half (32/60; 53.3%), and > 3 mm in diameter in over three-fourths (81.6%) of patients. Forty-four patients (73.3%) achieved treatment success whereas 16/60 (26.6%) required referral to our tertiary-eye care facility for management. The median time to resolution was 14 days (IQR 10-26 days)., Conclusion: Our series demonstrates the feasibility of microbiology-guided therapy in microbial keratitis by ophthalmologists at the secondary rural eye-care level. Two-thirds of the patients could be successfully managed at the rural centre and only severe cases needed a referral to tertiary centres., (© 2024. The Author(s), under exclusive licence to Springer Nature B.V.)

To evaluate the surgical and visual outcomes of flap repositioning for various post-laser-assisted in-situ keratomileusis (LASIK) flap pathologies. Retrospective review of consecutive cases between April 1, 2017 and February 28, 2022, where surgical flap repositioning was performed following LASIK for various flap-related complications. Of the 6018 eyes, 31 needed flap repositioning (0.51%). Indications were flap displacement and folds in 20 eyes (64%), flap subluxation in five eyes (16%), epithelial ingrowth and interface debris in two each, and one eye each of diffuse lamellar keratitis and incomplete flap. Final best spectacle-corrected visual acuity of ≥ 20/25 was obtained in 25/31 (80%) eyes. The efficacy index pre to post repositioning showed significant improvement (0.86 ± 0.39 vs. 0.63 ± 0.29 preop, P = 0.011). Flap repositioning incidence was significantly higher (7/602 (1.16%)) during the COVID lockdown phases compared to the non-COVID lockdown phase (24/5416 (0.44%, P = 0.019)). The COVID group had lower efficacy (0.72 ± 0.36 vs. 0.90 ± 0.39, P = 0.300) and safety indices (0.85 ± 0.24 vs. 1.06 ± 0.35, P = 0.144) compared to the non-COVID group; however, the results were not statistically significant. The flap displacement rate was statistically higher in nasal hinged (microkeratome) flaps (18/2013, 0.89%) compared to superior hinged (Femto) flaps (13/4005, 0.32%) (0.32%, P = 0.003). Our study shows that flap repositioning has a low incidence in LASIK, with the most common indication being flap displacement/folds. The outcome post flap repositioning was poorer during the lockdown period, perhaps due to the inability to follow up early. Early identification and surgical repositioning are successful in both anatomical and visual restoration., (Copyright © 2023 Copyright: © 2023 Indian Journal of Ophthalmology.)

Purpose: This study aimed to report the strategies that evolved in managing Mooren's ulcer (MU) at a resource-limited center in rural India during the coronavirus disease 2019 (COVID-19) pandemic., Methods: This study includes a retrospective analysis of clinically diagnosed MU cases from January 2021 to August 2021 wherein strategies for management were developed. The demographic profile, ulcer clinical features, treatment algorithms (medical and surgical), complications encountered, referral to a higher center, and compliance with medication and follow-up were studied., Results: The mean age of presentation was 68.1 years (range, 62-73 years), and 90% were men. The median best-corrected visual acuity (BCVA) was 1.26 logarithm of the Minimum Angle of Resolution (LogMAR) (interquartile range (IQR), 0.00-5 logMAR) in the affected eye on presentation, which improved to 0.69 logMAR (IQR, 0.00-3 logMAR) at resolution ( P = 0.442). The first-line management was conjunctival resection and tissue adhesive application (90%). 70% of cases were unilateral, 50% of cases had less than 2 clock hours of involvement, and 50% had less than 50% stromal involvement. Confounding factors included infectious keratitis (2) and corneal perforation (3). The mean duration of follow-up was 96 (1-240) days. The average follow-up visits per patient were 8.8 (1-22). 90% of cases could be managed successfully at the secondary center level with two cases needing a tertiary care referral., Conclusion: MU can be managed effectively by following a systemic strategy of early diagnosis, surgical therapy, and rapid institution of systemic immunosuppression in a remote location-based secondary center. The strategies developed can be a guide for ophthalmologists at remote centers managing patients or who are unable to travel to tertiary institutes., (Copyright © 2023 Copyright: © 2023 Indian Journal of Ophthalmology.)

Atypical mycobacteria or non-tuberculous mycobacteria (NTM) are a group of acid-fast bacteria that are pathogenic to different parts of the eye. The organisms can cause a spectrum of ocular infections including keratitis, scleritis, uveitis, endophthalmitis and orbital cellulitis. Trauma, whether surgical or nonsurgical, has the highest correlation with development of this infection. Common surgeries after which these infections have been reported include laser in situ keratomileusis (LASIK) and scleral buckle surgery. The organism is noted to form biofilms with sequestration of the microbe at different inaccessible locations leading to high virulence. Collection of infective ocular material (corneal scraping/necrotic scleral tissue/abscess material/vitreous aspirate, etc.) and laboratory identification of the organism through microbiologic testing are vital for confirming presence of the infection and initiating treatment. In cluster infections, tracing the source of infection in the hospital setting via testing of different in-house samples is equally important to prevent further occurrences. Although the incidence of these infections is low, their presence can cause prolonged disease that may often be resistant to medical therapy alone. In this review, we describe the various types of NTM-ocular infections, their clinical presentation, laboratory diagnosis, management, and outcomes., (Copyright © 2023 Copyright: © 2023 Indian Journal of Ophthalmology.)

Purpose: This paper aims to describe the clinical presentation and demographic distribution of keratoconus (KCN) in India by analyzing the electronic medical records (EMR) of patients presenting at a multitier ophthalmology hospital network., Methods: This cross-sectional hospital-based study included the data of 2,384,523 patients presenting between January 2012 and March 2020. Data were collected from an EMR system. Patients with a clinical diagnosis of KCN in at least one eye were included in this study. Univariate analysis was performed to identify the prevalence of KCN. A multiple logistic regression analysis was performed using R software (version 3.5.1), and the odds ratios are reported., Results: Data were obtained for 14,749 (0.62%) patients with 27,703 eyes diagnosed with KCN and used for the analysis. The median age of the patients was 22 (inter-quartile range (IQR): 17-27). In total, 76.64% of adults (odds ratio = 8.77; P = <0.001) were affected the most. The majority of patients were male (61.25%), and bilateral (87.83%) affliction was the most common presentation. A significant proportion of the patients were students (63.98%). Most eyes had mild or no visual impairment (<20/70; 61.42%). Corneal signs included ectasia (41.35%), Fleischer ring (44.52%), prominent corneal nerves (45.75%), corneal scarring (13.60%), Vogts striae (18.97%), and hydrops (0.71%). Only 7.85% showed an association with allergic conjunctivitis. A contact lens clinic assessment was administered to 47.87% of patients. Overall, 10.23% of the eyes affected with KCN underwent a surgical procedure. the most common surgery was collagen cross-linking (8.05%), followed by deep anterior lamellar keratoplasty (1.13%) and penetrating keratoplasty (0.88%)., Conclusion: KCN is usually bilateral and predominantly affects males. It commonly presents in the second and third decade of life, and only a tenth of the affected eyes require surgical treatment., (Copyright © 2023 Copyright: © 2023 Indian Journal of Ophthalmology.)

The crystalline lens is an important structure in the eye that starts to develop as early as the 22 nd day of gestation, with further differentiation that continues after the induction. Congenital anomalies of the lens may involve the size, shape, and position of the lens. They may sometimes be associated with anterior segment dysgenesis or persistence of the tunica vasculosa lentis and hyperplastic vitreous and hyaloid system. Manifestations of anomalies of the lens shape are usually seen in early or late childhood however may sometimes be delayed into adulthood based on the level of visual impairment or the presence or absence of any syndromic associations. While lens coloboma has more often been reported in isolation, the more commonly implicated genes include the PAX6 gene, lenticonus in particular anterior is often part of Alport syndrome with extra-ocular manifestations in the kidneys and hearing abnormalities due to mutations in the alpha 5 chain of the Type IV collagen gene. Recognition of these manifestations and obtaining a genetic diagnosis is an important step in the management. The level of visual impairment and amblyopia dictates the outcomes in patients managed either conservatively with optical correction as well as surgically where deemed necessary. This review discusses the various anomalies of the lens shape with its related genetics and the management involved in these conditions., Competing Interests: The authors declare that there are no conflicts of interests of this paper., (Copyright: © 2023 Taiwan J Ophthalmol.)

A female patient in her 60s presented with an 8-month history of decreased vision in her right eye. She was diagnosed with pseudophakic bullous keratopathy (PBK), and Descemet stripping automated endothelial keratoplasty (DSAEK) surgery was planned. Intraoperative Descemet membrane detachment (DMD) occurred while inserting the lenticule using the Sheets glide technique. The detachment of the Descemet membrane was detected immediately, and air descemetopexy was performed intraoperatively. Postoperatively, the donor lenticule was attached properly to the stromal bed, except for a focal DMD approximately 3 mm in the inferior part of the lenticule. A second descemetopexy was performed 5 days later, resulting in a complete attachment. A DMD in DSAEK lenticule is an extremely rare complication. Early detection and timely intervention with descemetopexy helped achieve a good anatomical and functional outcome., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared.

Purpose: Peripheral ulcerative keratitis (PUK) is a sight threatening disease, often immune mediated and can rapidly progress to corneal perforation. Here we report the successful management of simultaneous bilateral peripheral ulcerative keratitis presenting with corneal perforation with surgical intervention and systemic immunosuppression., Case Description: A 41-year-old female presented with similarly located super-nasal peripheral ulcerative keratitis (PUK) in both eyes and focal area of adjoining scleritis in the left eye. Serological investigations for systemic immune-mediated conditions showed positive rheumatoid factor test. She underwent cyanoacrylate glue application in both eyes, and was started on topical and oral corticosteroids and oral immunomodulators, and the right eye stabilized. The left eye required a second surgical intervention with a corneal patch graft following which the condition stabilized., Conclusion and Importance: This case highlights the importance of investigating for an underlying systemic etiology in PUK and the role of systemic immunosuppression prior to and after surgical intervention in order to arrest the disease and prevent recurrences., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: The aim of this study was to evaluate the risk factors, microbiology, and treatment outcomes of polymicrobial keratitis (PMK)., Methods: We retrospectively analyzed 65 patients diagnosed with PMK between 2016 and 2019. The clinical and microbiological characteristics and outcomes were evaluated. The primary outcome measure was clinical resolution of keratitis. Absolute success (group A) was defined as resolution of infection with medical treatment, qualified success (group B) was resolution with medical therapy and additional minor procedures, and failure (group C) was defined as worsening of infection and presence of corneal melting or perforation requiring therapeutic penetrating keratoplasty or evisceration., Results: Of 4764 cases of microbial keratitis, PMK was identified in 65 eyes of 65 patients (1.36%). Infiltrate was central in 60% (39 eyes). Predisposing factors were higher in group C and included uncontrolled diabetes mellitus in 25% (7/28), history of trauma/foreign body in 57.1% (16/28), and poor presenting visual acuity (0.9 for group A vs. 1.79 for group B vs. 3.00 logarithm of the minimum angle of resolution for group C; P = 0.02). Microbiological profiling revealed that a majority (95%: 62/65) had bacterial with fungal keratitis. High fluoroquinolone resistance was noted (57%; 34/59). Absolute success was achieved in 28.3% (17/60), qualified success in 16.6% (10/60), and treatment failure was noted in 55% (33/60). The final best corrected visual acuity in group A was significantly better than that in group B and C (0.44 vs. 3.00 vs. 2.78; P < 0.001)., Conclusions: PMK is extremely rare but responds poorly to medical therapy. Bacterial with fungal etiology is predominant. Early surgical intervention to improve overall outcome is advocated., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To report bilateral Herpes Simplex virus (HSV) keratitis in a patient on latanoprost for primi]k=8ary open angle glaucoma (POAG)., Methods: Case report., Results: A 76-year-old healthy male on latanoprost monotherapy for POAG polresented with sudden bilateral decreased vision. Examination showed bilateral dense corneal edema with loose epithelium. Aqueous fluid was positive for HSV-1 DNA on polymerase chain reaction (PCR). Latanoprost was discontinued, topical prednisolone acetate 1% eye, acyclovir 400 mg 5 times a day and combination of dorzolamide hydrochloride 2% and timolol maleate 0.5% twice daily were prescribed. The vision rapidly improved to 20/25 along with complete resolution of corneal edema within four weeks, with no recurrences over the next one year., Conclusion: Bilateral simultaneous HSV endotheliitis is a rare condition and positive PCR test can help rule in the diagnosis. HSV keratitis is a known adverse event with Latanoprost use and can present atypically.

Competing Interests: None

The authors describe two cases of corneal ocular surface squamous neoplasia (OSSN), presenting at our rural eyecare centre, which were initially misdiagnosed as viral epithelial keratitis and corneal pannus with focal limbal stem cell deficiency. Both the cases were refractory to initial treatment and corneal OSSN was suspected. Anterior segment-optical coherence tomography (AS-OCT) revealed a thickened, hyper-reflective epithelium with abrupt transition and an underlying cleavage plane, features typical of OSSN. Topical 1% 5-fluorouracil (5-FU) therapy was initiated and in two cycles (first case) to three cycles (second case), complete resolution was noted both clinically and on AS-OCT, with no significant side effects. Both patients are currently free of tumour at the 2-month follow-up period. The authors report the rare, atypical presentations of corneal OSSN, discuss the masquerades and highlight the role of primary topical 5-FU in managing corneal OSSN in limited resource settings., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To report a challenging case of relapsing polychondritis with bilateral diffuse scleritis, with 17-year follow-up., Methods: Case report., Results: A 36-year-old female presented 17 years ago with bilateral diffuse scleritis and peripheral corneal infiltrates. Detailed systemic work-up was negative. Fourteen months later, she developed saddle nose deformity, debilitating myalgias, and severe recurrence of scleritis clinching the diagnosis of relapsing polychondritis. Despite high-dose oral corticosteroids, oral immunosuppressants, and cyclophosphamide infusions and adalimumab infusions, the condition showed waxing and waning over the next decade. In 2017, she was started on Tocilizumab injections after which both the systemic and ocular conditions stabilised and has been remained stable for the past 4 years., Conclusion: Relapsing polychondritis has a well-known association with scleritis. The ocular disease may precede systemic symptoms in some cases. Newer agent such as tocilizumab appears to be effective in controlling this relentless and recurrent disease.

Purpose: To establish normative data on anterior scleral thickness using the spectral domain anterior segment optical coherence tomography (AS-OCT)., Methods: In total, 200 eyes of 100 healthy subjects underwent AS-OCT scans in the temporal and nasal quadrants. The scleral + conjunctival complex thickness (SCT) was measured by a single examiner. Mean SCT was analyzed for differences across age groups, gender, and location (nasal versus temporal)., Results: Mean age was 46.4 ± 18.3 (21-84) years; male to female ratio was 54:46. Mean SCT (nasal + temporal) of the right eye (RE) was 682.3 ± 64.2 μm in males and 660.6 ± 57.1 μm in females. In the left eye (LE), it was 684.6 ± 64.9 μm in males and 661.8 ± 49.3 μm in females. These differences between male and female for both eyes were statistically significant (P = 0.006 and P = 0.002). The mean SCT of temporal and nasal quadrants in the RE was 678.54 ± 57.50 and 666 ± 66.2 μm, respectively. In the LE, the temporal mean SCT quadrant was 679.6 ± 55.8 μm, and the nasal was 668.6 ± 63.6 μm. Age had a negative correlation with SCT (-0.62 μm/year; P = 0.03), and males had a higher temporal SCT than females (22 μm higher; P = 0.03). After adjusting for age and gender in a multivariate analysis, temporal SCT was significantly (P < 0.001) higher than nasal SCT., Conclusion: In our study, mean SCT decreased with age and males had a higher temporal SCT. This is the first study to evaluate scleral thickness in the Indian population, and the data can be used as a baseline for comparing variations in scleral thickness in disease., Competing Interests: None

Background: Scleritis and episcleritis are an overlapping spectrum of diseases and accurate diagnosis is of utmost importance as the treatment and prognosis are vastly different. Predominantly a clinical diagnosis, the challenge lies in those cases with equivocal clinical features. Furthermore, clinical grading of scleritis is subjective and hence is neither very reliable nor reproducible. Existing modalities such as slit lamp examination and clinical photographs in scleritis describe macroanatomy but do not provide details on the microanatomy of the sclera. A recent adjusted algorithm for anterior segment optical coherence tomography (AS-OCT) imaging has improved the ability of this device to aid in the diagnosis of all the major forms of scleritis., Purpose: To highlight the role of AS-OCT in delineating various anatomical forms of episcleritis and scleritis and explore this tool in monitoring disease course and response to therapy., Methods: A comprehensive literature search was carried out in various medical databases using keywords AS-OCT and scleritis; AS-OCT and episcleritis; anterior segment imaging in scleritis; scleritis and episcleritis; Recent advances in anterior segment imaging. Original articles and novel reports describing the potential role of AS-OCT in the diagnosis and management of scleritis and episcleritis were included., Results: After a thorough assessment, it was clear that published literature lacks guidelines for uniform interpretation and also for classification and follow-up in scleritis. We describe a uniform protocol for AS-OCT image acquisition, interpretation of images and list the advantages and limitations., Conclusions: AS-OCT can be used to localize the level of scleral inflammation thus helping in the diagnosis of scleral inflammatory disease. It can be a valuable tool in studying progression.

Among the various indications for keratoplasty, failed graft is one of the commonest indications in many published series. It is well known that the major cause of graft failure is endothelial rejection. In the last two decades, there has been a major paradigm shift in the surgical management of corneal diseases, and component keratoplasty has emerged from the concept of replacing the layer that is actually diseased, rather than replacing the full-thickness cornea with the traditional penetrating keratoplasty. This has resulted in improved outcomes and the risk of endothelial rejection has reduced drastically, thus expanding the survival time of the graft. In recent years, reports of graft rejection in component keratoplasty have emerged, with each having a different presentation and responding to a different line of treatment. This review aims to summarize the presentation, diagnosis, and management of graft rejections in component keratoplasty., Competing Interests: None

A female patient in her 20s presented with a bulbar conjunctival mass lesion that was diagnosed as nodular scleritis. It was treated with topical and oral steroids in another hospital. Imaging was done using anterior segment optical coherence tomography and ultrasound biomicroscopy, which helped to rule out scleritis and subconjunctival cysticercosis. Histopathology of the excision biopsy specimen revealed fungal filaments. Topical antifungals were started, and the condition resolved without recurrence after therapy. Although rare, infections should be considered in the differential diagnosis of conjunctival mass lesions. Imaging can help to rule out other entities and guide towards appropriate management., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Peripheral ulcerative keratitis (PUK) is an inflammatory, necrotic condition in the peripheral cornea which may end in corneal perforation and visual morbidity if not treated adequately. PUK can occur due to infectious or non-infectious causes. Early cases need medical therapy, both locally and systemically (for some cases). However, advanced PUK may necessitate surgical removal of inciting cause of the pathology and maintaining tectonic stability. Such surgical treatment, including corneal transplantations, may be used in an emergency setting or for visual rehabilitation following preliminary stabilization of the affected cornea. The outcome of these surgeries need to be analyzed to understand the long-term visual prognosis of such eyes. This is an attempt to analyze surgical modalities in the management of PUK and their outcomes., Competing Interests: The authors report no conflicts of interest in this work., (© 2022 Sabhapandit et al.)

Purpose: To report a rare ocular presentation of unilateral anterior uveitis with hypopyon in a 5-year-old child, suspected as masquerade., Methods: Retrospective report., Results: A 5-year-old boy presented with hypopyon-uveitis. Detailed systemic work-up was negative for masquerade and uveitis entities. He was started on oral and topical steroids but had reactivation on taper. Real-time polymerase chain reaction (PCR) test of aqueous fluid was positive for herpes simplex virus (HSV)-1 DNA. The inflammation resolved completely on oral acyclovir and topical corticosteroids. He subsequently underwent pars plana lensectomy, primary posterior capsulotomy and vitrectomy for complicated cataract. Post-operatively, vision improved to 20/400 with aphakic correction. Maintenance oral acyclovir was stopped after 3 months with no reactivation and amblyopia therapy was continued., Conclusion: This is a rare presentation of hypopyon uveitis due to HSV-1 in a child. The role of real-time PCR in establishing the diagnosis is crucial in such cases of diagnostic dilemma.

Purpose: To report the pattern of noninfectious scleritis across a tertiary eye-care network., Methods: A three-year retrospective review of patients diagnosed with noninfectious scleritis was performed. Data were retrieved using diagnostic terms assigned to scleritis through the in-house eyeSmart-electronic medical record system., Results: 1103 patients, with a mean age of 44.33 ± 14.38 years and a median follow-up of 199.5 days (range 32-685) were enrolled. Unilateral disease was noted in 85%. Diffuse anterior scleritis (n = 542, 42.51%) and nodular scleritis (n = 482, 38.12%) were the commonest subtypes. Systemic immune disease association was present in 65 (5.89%). Treatment at onset was topical corticosteroids (n = 372, 36.54%) followed by oral non-steroidal anti-inflammatory drugs (n = 351, 34.45%), oral corticosteroids in 184 (19.04%), and immunomodulators in 32 patients (3.54%)., Conclusions: This study depicts the pattern of various noninfectious scleritis in a large cohort of patients. The present study helped to further customize the electronic medical records to minimize several data capture limitations.

Competing Interests: Competing interests: None declared.

The authors report two cases of unusually large deposits on their therapeutic bandage contact lens (BCL) following uneventful surgery for congenital ptosis. The first case presented at 6 weeks with decreased vision, large jelly-bump deposits over the contact lens and sterile corneal infiltrates. The infiltrates rapidly resolved with restoration of vision following contact lens removal and topical antibiotics. The second case presented 2 weeks after surgery with visual loss and similar deposits but with no corneal involvement. Following replacement of BCL and topical lubricants, her vision improved to 20/20. Studies on the role of BCL in ptosis surgery are scarce with literature supporting its use for ocular surface protection and minimising postoperative discomfort. The authors hypothesise impaired blink mechanism as the accelerating factor for this unusual occurrence in the early postoperative period and recommend frequent replacement of the contact lens and a closer follow-up in all these cases., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Flap displacement is a rare but vision-threatening complication of laser-assisted in situ keratomileusis (LASIK). A young male patient underwent uneventful microkeratome-assisted LASIK. One-week postoperatively, flap displacement was noted in his right eye with its lower edge folded inwards, macrostria at the superior edge and the epithelium covering the bare stroma and into the interface. Anterior segment optical coherence tomography (AS-OCT) delineated the morphology of the displaced flap and the extent of epithelial ingrowth. The flap was repositioned by unrolling the fold and all the exposed surfaces were debrided to remove the epithelial ingrowth. Two months later, his corrected distance visual acuity improved to 20/30, and a smooth surface could be achieved. Infolded LASIK flap is a rare complication, which requires timely surgical intervention to achieve successful anatomical and functional outcomes. AS-OCT can be pivotal in determining the extent of infolding as well to delineate the extent of epithelial ingrowth within the interface., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: Dengue fever is a severe mosquito-borne disease which can present with various severe ocular manifestations. We aim to report a case of infectious scleritis in dengue fever, occurring due to Methicillin-resistant Staphylococcus aureus (MRSA), managed with intravenous Teicoplanin., Methods: Case report., Results: A 23-year-old woman with recent hospitalization for dengue fever presented with severe pain and a nodular scleral lesion. She was initially diagnosed with immune-mediated scleritis, but as the condition worsened, she underwent scleral scraping which subsequently grew MRSA. She was initially started on topical vancomycin eye drops and topical linezolid but there was further worsening. Therapy was switched to intravenous Teicoplanin which resulted in rapid resolution of the condition., Conclusion: To the best of our knowledge, this is the first reported case of infectious scleritis in association with dengue fever due to MRSA.

A male in his 50s, who had undergone Descemet's stripping automated endothelial keratoplasty (DSAEK) for corneal oedema following irido-corneal-endothelial syndrome and glaucoma drainage device surgery for secondary glaucoma presented with gradual decreased vision. The patient was on ripasudil 0.4% for the past 4 months prior to the presentation. Honeycomb epithelial oedema was seen with vesicles and intraepithelial microcyst formation which were also noted on anterior segment optical coherence tomography (OCT) and histopathology, that co-related with the slit-lamp findings. The patient underwent repeat DSAEK and had a good outcome. While the clinical features and OCT findings have been reported earlier, the histopathological features have not been reported., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Financial disclosures/conflicts of interest: For S. I. Murthy: Funding Supported by Hyderabad Eye Research Foundation. The remaining authors have no funding or conflicts of interest to disclose.

We present a comprehensive review of existing literature on surgical corneal neurotization (SCN) as a treatment modality for neurotrophic keratopathy (NK) with an interim report of seven cases where SCN was performed using the indirect approach and followed up till 18 months postoperatively to look for improvement in ocular surface, corneal sensations, and nerve regeneration by using in vivo confocal microscopy (IVCM). A literature search was performed for publications with keywords "corneal nerves," "neurotization," "esthesiometry," "corneal anesthesia," and "neurotrophic keratopathy." All literature available till December 31, 2020 was reviewed and included to describe NK and its management options, particularly SCN. NK is associated with absent or reduced corneal sensations and is managed using a step-ladder algorithm ranging from medical management for symptomatic relief to surgical corneal neurotization. Both direct and indirect approaches of SCN have a favorable outcome with reduced surgical morbidity in the indirect approach using sural nerve graft. Post neurotization, corneal sensation recovery may take up to 3-6 months, while nerve regeneration on confocal microscopy can take as long as 6 months-1 year., Competing Interests: None

Inflammation of the cornea is known as keratitis, and bacteria, fungi, protozoans, and viruses are the etiological agents of this disease. Delayed treatment of keratitis could result in loss of vision and, under certain severity conditions, the removal of an eye and its associated structures. In the current study, the ocular surface (conjunctiva and cornea) mycobiomes of individuals with bacterial keratitis were compared with the ocular mycobiome (conjunctiva) of healthy individuals, free of any ocular morbidity. Mycobiomes were generated through NGS approach using conjunctival swabs and corneal scrapings as the source of DNA from which ITS2 was amplified and sequenced, as a proxy to identify fungi. The results indicated significant changes in the alpha-diversity indices and in the abundance at the phylum and genera level. Hierarchical clustering using a heatmap showed that the mycobiomes were different. Furthermore, NMDS plots also differentiated the mycobiomes in the three cohorts, implying dysbiosis in the mycobiomes of the conjunctivae and corneal scrapings of bacterial keratitis individuals compared to control individuals. A preponderance of negative interactions in the hub genera in the conjunctival swabs of bacterial keratitis individuals compared to healthy controls further re-emphasized the differences in the mycobiomes. The dysbiotic changes at the genera level in conjunctivae and corneal scrapings of bacterial keratitis individuals are discussed with respect to their possible role in causing or exacerbating ocular surface inflammation. These results demonstrate dysbiosis in the ocular mycobiome in bacterial keratitis patients compared to healthy controls for the first time., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Jayasudha, Chakravarthy, Prashanthi, Sharma, Garg, Murthy and Shivaji.)

Purpose: To report a retrospective series of three cases of infectious panophthalmitis post-dengue fever with ex vivo confirmation of dengue virusribonucleic acid (RNA) in the tissues of the eye., Methods: Four eyes of three patients, who were diagnosed with panophthalmitis following dengue fever and who underwent evisceration, were included. All demographic and clinical data were recorded. The eviscerated samples were subjected to direct microscopy, culture for bacteria, fungi, and parasites, and molecular virology (dengue virus [DENV] NS1-specific reverse transcription loop-mediated isothermal amplification (RT-LAMP) assay)., Results: The time from the development of dengue fever to the occurrence of ocular symptoms was 4.33 ± 1.15 (median 5) days. DENV NS1 RNA, suggestive of the presence of the dengue virus, was confirmed in all evisceration specimens (uveal tissue, cornea). All the patients recovered completely from dengue fever and on follow-up had healthy eviscerated sockets., Conclusion: Demonstration of the DENV RNA in the eviscerated specimens of panophthalmitis following dengue fever implicates the DENV in the pathophysiology of the ocular infection., Competing Interests: None

Purpose: The aim of this study was to report on the feasibility of setting up a system of corneal transplants at rural outreach centers and report the outcomes of the first 111 cases., Methods: Retrospective analysis of the outcomes of corneal transplantation performed on patients with optical indications between March 2016 and September 2019 at 4 secondary (rural) centers. The centers are a part of a network in the pyramidal model developed by L V Prasad Eye Institute. The graft clarity and best-corrected visual acuity (BCVA) at 1-year follow-up were analyzed., Results: Of the 111 patients, 34.23% underwent penetrating keratoplasty and 65.77% endothelial keratoplasty. The mean age was 59.4 ± 15.0 (range-17-86 years); 47.75% were men and 52.25% were women. The indications for surgery were bullous keratopathy (54.05%), corneal scar/adherent leukoma (23.42%), and repeat grafts (13.51%). At the end of 1 year, 69.37% grafts remained clear. Factors associated with graft failure included poor socioeconomic status and graft infiltrate in both univariate and multivariate analyses. Surgical technique of endothelial keratoplasty was associated with failure on multivariate analysis only. Of the 77 eyes with clear corneal grafts at 1 year, the preoperative mean logMAR BCVA was 1.91 ± 0.06, which improved to 0.90 ± 0.08 postoperatively. Overall, 84.4% had preoperative BCVA of <3/60. Postoperatively, 40% had BCVA of 6/18 or better., Conclusions: Our study showed that close to 70% grafts remained clear at 1 year. Graft failure was associated with poor socioeconomic status and graft infiltrates. This study established a viable model for delivery of corneal transplant surgery and care in a rural setup., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Since the introduction of the first toric intraocular lens (IOLs) in the early 1990s, these lenses have become the preferred choice for surgeons across the globe to correct corneal astigmatism during cataract surgery. These lenses allow patients to enjoy distortion-free distance vision with excellent outcomes. They also have their own set of challenges. Inappropriate keratometry measurement, underestimating the posterior corneal astigmatism, intraoperative IOL misalignment, postoperative rotation of these lenses, and IOL decentration after YAG-laser capsulotomy may result in residual cylindrical errors and poor uncorrected visual acuity resulting in patient dissatisfaction. This review provides a broad overview of a few important considerations, which include appropriate patient selection, precise biometry, understanding the design and science behind these lenses, knowledge of intraoperative surgical technique with emphasis on how to achieve proper alignment manually and with image-recognition devices, and successful management of postoperative complications., Competing Interests: None

Purpose: The purpose of this study was to report 3 cases of microbial keratitis, wherein trypan blue staining was used to aid the microbiological diagnosis of fungal keratitis and Pythium keratitis in a rural setup., Methods: Three consecutive patients who presented with a diagnosis of infectious keratitis underwent corneal scraping, and the smears were assessed using trypan blue stain and potassium hydroxide (KOH) mount., Results: Of the 3 cases, the first 2 cases showed septate fungal filaments in trypan blue-stained preparation and KOH mount. Case 3 showed the presence of broad aseptate filaments with ribbon-like folds on both KOH mount and trypan blue stain, consistent with the diagnosis of Pythium keratitis. The first 2 cases improved with topical and systemic antifungals. Case 1 healed with scarring at 7 weeks with improvement in best-corrected visual acuity (BCVA) to 20/60. Case 2 healed within 2 weeks, and BCVA improved to 20/40. Case 3 received topical linezolid (0.2%), azithromycin eye ointment, and oral azithromycin. At 5 weeks the infection decreased but thinning was noted, which necessitated tissue adhesive and bandage contact lens application. Scarring was noted at 10 weeks, and BCVA improved to 20/40., Conclusions: In this case series, trypan blue staining showed promising results in the easy identification of aseptate and septate fungal elements. This is the first case series showing the utility of this stain in the management of microbial keratitis., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To report the intermediate outcomes of therapeutic penetrating keratoplasty (TPK) performed for severe microbial keratitis using glycerol-preserved corneas during the Corona virus diseases of 2019 (COVID-19)., Methods: Retrospective non-comparative case series from April to August 2020 in a network of tertiary eye care centers. Glycerol-preserved tissues were used for therapeutic keratoplasty (TPK). We reviewed the demographics, microbiology, surgical outcomes such as wound integrity, recurrence, graft melt, epithelialization, and complications., Results: A total of 49 eyes that underwent TPK with glycerol-preserved corneal tissues were analyzed. The primary indication was severe microbial keratitis in 47 eyes. The majority was a fungal infection in 33 eyes (67.3%). The mean age was 53.8 ± 12.2 years, with male predominance (3:1). The corneas were stored for an average of 85.5 ± 53 days prior to transplant. The median donor age was 65 years. The grafts were tectonically stable in 32/36 eyes (88.9%) at 1 month and 20/24 eyes (83.3%) at 3 months. The graft melt was noted in three eyes at 1 and 3 months. The recurrence of the infection was noted in four eyes and all were of fungal etiology. The graft epithelialization was delayed with a mean duration of 48.9 ± 25 days after surgery. Post-TPK, raised intra-ocular pressure (>21 mm Hg) was noted in 51.2% at 1 week, 17.4% at 1 month, and 11.8% at 3 months., Conclusion: Glycerol preservation is a reliable alternative with good therapeutic outcomes in the short and interim postoperative period. Delayed epithelialization and secondary glaucoma were the commonest postoperative complications., Competing Interests: None

Purpose: : To report the frequency of periorbital aesthetic abnormalities in patients undergoing refractive surgery and to report the ability of the patient and the refractive surgeon in picking up these findings compared to the oculoplastic surgeon., Methods: Single-center, prospective observational case series. All patients underwent standard pre-operative work-up for refractive surgery, answered a study questionnaire, and underwent face photographs (with and without glasses). The patient, the refractive, and the oculoplastic surgeons evaluated the photographs to categorize the concerns as none, presence of ptosis, tear trough deformity, scleral show, and others. The findings of the oculoplastic surgeon were taken as the standard of reference., Results: The photographs of 121 patients were analyzed. The mean age was 25.76 ± 3.75 years and 72% were males. The main indication for surgery was to eliminate dependency on glasses in a majority (76%) followed by cosmesis in 23%. The oculoplastic surgeon noted tear trough deformity in 14 (11.5%) cases, scleral show in 51 (42.1%), ptosis in 35 (28.9%), and other findings in 45 (37.1%). When the symmetrical scleral show was excluded, the patient picked up aesthetic concerns in only 8.26%, the refractive surgeon in 14% as compared to 39% by the oculoplastic surgeon (P < 0.01)., Conclusion: Periorbital aesthetic significant findings were noted in 39% of the patients undergoing corneal refractive surgery when assessed by an oculoplastic surgeon. The refractive surgeon was able to pick up less than 50% of these. We recommend a basic aesthetic initial evaluation prior to refractive surgery and photographic documentation, especially in cosmetically aware patients., Competing Interests: None

Competing Interests: None

Purpose: The aim of the study was to assess the effect of mitomycin-C (MMC) 0.02% application on corneal endothelium in patients undergoing photorefractive keratectomy (PRK) for the correction of myopia and compound myopic astigmatism., Methods: A prospective observational study including patients with myopia who underwent PRK plus intraoperative application of MMC 0.02%. All patients underwent noncontact specular microscopy preoperatively and 6 months postoperatively. The following parameters were analyzed: mean cell area (MCA), central corneal endothelial cell density (ECD), and coefficient of variation (CV) in cell size., Results: One hundred and thirty-nine eyes of 73 patients with a mean age of 24.95 ± 3.23 years were included in the study. Mean baseline preoperative pachymetry was 519.54 ± 28.62 μm. The mean preoperative spherical equivalent was -4.6 ± 2.3D (range from -1D to -10D) which decreased to mean postoperative spherical equivalent of -0.125 ± 0.32D. Mean baseline ECD was 2829.3 ± 188.8 cells/mm 2 , MCA was 354.6 ± 24.9 μm 2 /cell, CV was 0.35 ± 0.06, and hexagonality was 50.1 ± 6.64. The mean ECD decreased by 43 ± 1.6 cells/mm 2 which was not statistically significant ( P = 0.07). The MCA increased by 5 ± 1.3 μm 2 /cell, but this was not statistically significant ( P = 0.07). However, both the CV and percentage of hexagonal cells showed statistically significant differences in the median values as compared to preoperatively ( P < 0.001)., Conclusion: In our study, MMC had no significant effect on corneal endothelial cell counts or MCA. While there were statistically reduced CV and percentage of hexagonal cells, these did not appear to be clinically significant. MMC is safe to use routinely to prevent haze formation in PRK., Competing Interests: There are no conflicts of interest., (Copyright: © 2021 Middle East African Journal of Ophthalmology.)

Purpose: To evaluate the efficacy of trypan blue in direct microscopic examination of corneal scrapings in the diagnosis of non-viral microbial keratitis., Methods: In a prospective, interventional, masked study, 82 consecutive patients were investigated. Direct microscopic examination of the corneal scrapings involved three smears stained with potassium hydroxide with calcofluor white (KOH + CFW), Gram stain (not analyzed), and trypan blue stain and culture for bacteria, fungus, and Acanthamoeba. While KOH + CFW stained slides were examined under a fluorescence microscope, trypan blue-stained slides were examined by two microbiologists (masked to KOH + CFW and culture results) under normal light microscopy. Thirty samples were reexamined for interobserver and intraobserver variability., Results: Out of 82 samples, fungal/fungus-like elements were seen in 48 (58.5%) in KOH + CFW and 38 (46.3%) in trypan blue stain. One microsporidial case, detected in KOH + CFW was negative in trypan blue stain (culture not done). Fungal growth was positive in 23 out of 81 (28.3%) cases cultured, single bacterial species in 18 (22.2%), Pythium insidiosum in three, mixed bacteria and fungus/Pythium in 7 (8.6%), Acanthamoeba in none and 30 (37.0%) samples were sterile. With culture as gold standard, the respective sensitivity (84.9%, 75.7%) and specificity (90.9%, 68.2%) of KOH + CFW stain and trypan blue stain were comparable (p = 0.16, P = 0.06). The interobserver linear weighted kappa score between the two microbiologists was 1.00 while it was 0.86 for intraobserver agreement., Conclusion: Trypan blue stain, an easily available dye to ophthalmologists, is highly efficacious in the diagnosis of fungal keratitis., Competing Interests: None