Giant facial congenital melanocytic nevus associated with conjunctival melanoma.

Giant congenital melanocytic nevi involving the face are benign lesions and malignant transformation to cutaneous melanoma involving the eyelid has been rarely reported. This report highlights the rare association of a giant facial melanocytic nevus and conjunctival primary acquired melanoses and melanoma.

Primary orbital yolk sac tumor presenting as fungating mass.

Primary yolk sac tumor of the orbit is a rare entity. Orbital involvement is usually seen in young children and proptosis is the commonest presentation. Aggressive orbital involvement and presentation as a fungating mass is rarely seen. We report a case of primary orbital yolk sac tumor with an aggressive presentation that responded well to systemic chemotherapy.

Fusarium Causing Recalcitrant Post-operative endophthalmitis-Report of a Case with Review of Literature.

PURPOSE: To study the clinical profile and management of a case of fungal postoperative endophthalmitis caused by fusarium solani. CASE REPORT: A 40-year-old male underwent an uneventful cataract surgery developed postoperative endophthalmitis. The infection was fulminant and was treated aggressively with pars plana vitrectomy with intravitreal and oral antifungals. The microbiology culture of vitreous sample showed fusarium solani. There was a late recurrence in the form of a fungal ball behind the iris after 6 months of the initial episode. This fungal ball was then managed by transscleral cryotherapy. The eye became hypotonus due to chronic inflammation and silicone oil was instilled to salvage the eye. CONCLUSION: Fusarium endophthalmitis needs an aggressive management. Due to late recurrence regular follow-up is mandatory. Early vitrectomy with oral and intravitreal voriconazole is the treatment of choice. Transscleral cryotherapy is a useful option to treat fungal balls behind the iris tissue.

Retinal Hemangioblastoma with Extraocular Extension: Report of Three Cases.

Retinal hemangioblastoma (RH) is the earliest and most common clinical manifestation in Von Hippel-Lindau (VHL) disease. RH can also present in isolation without any evidence of VHL. Clinical course of RH can be stationary or progress to exudation and chronic retinal detachment requiring surgical intervention. We report 3 cases of aggressive RH with extraocular extension in young males causing painful blind eye requiring enucleation. Two of our cases were bilateral involvement and had systemic manifestations of VHL. The third patient had unilateral involvement with no systemic evidence of VHL. This manifestation of RH is rarely reported. Two of our patients with VHL had early manifestations of RH and had undergone multiple cryotherapy sessions as well as retinal detachment surgery for exudative retinal detachment. This differential should be considered in vascular lesion arising from intraocular structures especially in diagnosed patients of VHL. The cases also highlight the aggressive behaviour and long-term progression of RH in some patients despite early treatment.

Microbiological and Antibiotic Sensitivity Profile of Postoperative Endophthalmitis in a Tertiary Eye Care Hospital of North India.

INTRODUCTION: We describe the microbiological profile of postoperative endophthalmitis from northern India and analyse the pattern of antibiotic sensitivity which may have changed due to development of resistance secondary to overuse of antimicrobial drugs. MATERIALS AND METHODS: This is a retrospective study of postoperative endophthalmitis from January 2011 to December 2017 in a tertiary eye hospital of northern India. Any patient developing endophthalmitis within one year of any intraocular procedure was included in the study. According to severity, treatment with a trial of intravitreal antibiotic injections or core vitrectomy was decided. Ocular samples were collected which were either anterior chamber tap or vitreous biopsy and sent for microbiological examination. The samples were stained with Gram's and KOH stain and cultured on chocolate agar, blood agar, brain heart infusion broth and Sabouraud dextrose agar. RESULTS: A total of 545 patients of postoperative endophthalmitis were analysed which showed a male predilection (60.5%) with maximum patients between the age group 50-69 years. 292 patients (53.5%) were culture negative and 253 patients (46.4%) were culture positive. Most common organism identified was Staphylococcus in 73 patients followed by Pseudomonas in 48 patients. Staphylococcus species was most sensitive to vancomycin (97%) followed by amikacin (91%) followed by gentamicin and moxifloxacin (88% each). Pseudomonas was the second most common isolate which showed maximum sensitivity to imipenem (82%) followed by ciprofloxacin(60%). Polymicrobial infection was noted in 23 patients. The most common fungal isolate was aspergillus in 11 patients, followed by fusarium in 10 patients. CONCLUSION: Our study shows that gram positive bacteria are the most common organisms in postoperative endophthalmitis and are most sensitive to vancomycin, followed by gram negative bacteria which show increased sensitivity with imipenem than commonly used antibiotic - ceftazidime.

Isolated noncaseating granulomatous inflammation of the lacrimal sac masquerading as a malignancy.

Idiopathic orbital granulomatous inflammation has been reported before, but isolated involvement of the lacrimal sac is extremely rare. The authors report the case of granulomatous inflammation in a 47-year-old-female limited to the lacrimal sac, nasolacrimal duct (NLD), and adjacent inferior meatal mucosa without any identifiable cause. She presented with rapidly progressive swelling involving the left medial canthal region and a palpable, nontender, nonregurgitant firm mass lesion extending above the medial canthus. The lacrimal irrigation was patent, and imaging showed a heterogeneous mass lesion involving the lacrimal fossa and extending into the NLD. The clinical presentation was suggestive of malignancy arising from the lacrimal sac, but histopathological findings of noncaseating granulomas, multinucleated giant cells, and scattered lymphoplasmacytic infiltrate involving the lacrimal sac and inferior meatal mucosa were suggestive of granulomatous inflammation. Her immunological workup was negative. She responded to oral steroids with complete clinical resolution maintained till 9 months of follow-up.

"Doughnut" Amniotic Membrane Transplantation With Penetrating Keratoplasty for Vernal Keratoconjunctivitis With Limbal Stem Cell Disease.

PURPOSE: Severe vernal keratoconjunctivitis (VKC) can cause ocular surface disease including partial or complete limbal stem cell deficiency (LSCD), especially in early-onset and severe limbal form of VKC. We report a novel technique of doughnut amniotic membrane transplantation (AMT) along with penetrating keratoplasty (PK) for management of partial LSCD and corneal scarring in a case of severe VKC. METHODS: Case report. RESULTS: A 17-year-old boy, with onset of disease at 8 years of age, and development of partial LSCD and corneal scarring over a period of 9 years despite therapy, presented with profound visual loss due to dense bilateral corneal scarring. After the active allergy subsided, he underwent modified AMT (doughnut AMT) with simultaneous PK in his left eye. Histopathology of the excised button revealed conjunctival phenotype and dense corneal scarring up to the posterior stroma. At 1-year follow up, his best spectacle-corrected visual acuity was maintained at 20/30 in the operated eye, the graft was clear, and the ocular surface was stable. CONCLUSIONS: Severe VKC can cause ocular surface disease including LSCD with corneal scarring, especially in early-onset limbal form of VKC. The modified technique of AMT (doughnut AMT) along with PK can successfully visually rehabilitate and address partial LSCD in such patients.

Delhi Infectious Keratitis Study: Update on Clinico-Microbiological Profile and Outcomes of Infectious Keratitis.

PURPOSE: To study the clinico-microbiological profile and outcomes of infectious keratitis (IK) at a tertiary eye care center in North India. METHODS: This is a retrospective, hospital-based, cross-sectional study. One thousand seven hundred and eighty-six corneal microbiological reports were identified from January 2017 to December 2018, out of which 625 patients of IK fulfilled the inclusion criteria. They underwent microbiological examination which included corneal scrapings, culture, and antibiotic sensitivity. Demographic features, signs and symptoms, risk factors such as associated trauma, previous ocular surgery, and use of corticosteroids were also recorded. RESULTS: Of the 625 patients, 68.2% were male and 31.8% were female. The age group affected most was the sixth decade; 21.9% (137 cases). Trauma was the most common associated risk factor in 151 cases (24.2%) followed by previous ocular surgery in 111 (17.8%). Out of the 625 corneal scrapings, 393 (62.9%) were culture-positive. Bacterial culture accounted for 60.6% (238/393) and fungal cultures were 143 (36.4%). More than 50% of the bacterial keratitis cases and more than 60% of the fungal cases had a favorable outcome. Staphylococcus sp. and Fusarium sp. were the most common bacteria and fungus isolated, respectively. Only one-third of the cases required surgical intervention, and the remaining two-thirds were managed medically. CONCLUSIONS: In the current study, cultures were positive in 63% of cases, and the majority of cases had bacterial growth. Surgical intervention was needed in one-third of the cases. Management of corneal infections is incomplete without a good microbiological workup. Ophthalmologists should be encouraged to learn and practice basic staining procedures, and this should start early in the training years.

Ocular oncology practice guidelines during COVID-19 pandemic-An expert consensus.

The outbreak of rapidly spreading COVID-19 pandemic in December 2019 has witnessed a major transformation in the health care system worldwide. This has led to the re-organization of the specialty services for the effective utilization of available resources and ensuring the safety of patients and healthcare workers. Suspension of oncology services will have major implications on cancer care due to delayed diagnosis and treatment leading to irreversible adverse consequences. Therefore various oncology organizations have called for a continuation of cancer care during this crisis with diligence. The COVID-19 pandemic has forced the clinicians to transform the components of care from screening to outpatient care and primary management. The purpose of this article is to establish guidelines and recommendations for ocular oncology in the management of ocular tumors set by a multidisciplinary team of experts including ocular, medical and radiation oncologists, and pathologists. As the pandemic is evolving fast, it will require constant updates and reformation of health strategies and guidelines for safe and quality health care.

Are high-efficiency particulate air (HEPA) filters and laminar air flow necessary in operating rooms to control acute post-operative endophthalmitis?

Purpose: To compare the five-year incidence of acute post-operative endophthalmitis following cataract surgery, between centers with and without laminar air flow and high-efficiency particulate air (HEPA) filters in operating rooms. Methods: Retrospective analysis of medical records of patients operated in a single network of a tertiary and four secondary hospitals across north India. Cases of endophthalmitis were identified from the records between January 2013 and June 2018. Protocols and consumables were standardized across all hospitals. The only infrastructural difference being the presence of laminar air flow and high energy particulate air filters in operating rooms of the tertiary center. The type of surgery, along with the demographic and socio-economic details, were captured and analyzed, using z-test for proportions and logistic regression. Results: Out of 88,297 cataract surgeries conducted, 36 cases of endophthalmitis were reported. The incidence of endophthalmitis across the network was estimated to be 0.041%, (95% CI: 0.027 to 0.054). There was no statistically significant difference between the incidence of POE at the tertiary (0.042%) and secondary centers (0.039%). Certain risk factors for high endophthalmitis incidence were identified, namely patients undergoing small incision cataract surgery and belonging to lower socio-economic status. However, for both factors the difference was not statistically significant. Conclusion: The five-year incidence of acute post-operative endophthalmitis in our network was found comparable to the best reported in literature. Incidence at secondary centers, without laminar air flow and high energy particulate air filters was found comparable to that in the tertiary center having these facilities.

Acute stromal keratitis in clinics - are we missing microsporidia?

Purpose: To report 3 cases of microsporidial stromal keratitis presenting as a diagnostic dilemma to a tertiary eye care center in north India. Methods: Three eyes of 3 patients underwent therapeutic keratoplasty for microsporidial stromal keratitis. A decision for early surgery was taken as the patients were not responding to conventional medical management and were worsening clinically. The diagnosis of microsporidia was made by corneal scraping and confirmed on histopathological evaluation of the corneal button. Results: Out of the 3 patients, one maintained a clear graft, one had a recurrence and one had graft rejection, 6 months postoperatively. The patients were not started on steroids in the postoperative period and were given topical antibiotics and polyhexamethylene biguanide (PHMD). Oral Albendazole 400 mg was also given twice a day for a month. Conclusion: Many questions remained unanswered about the management protocol of stromal keratitis caused by microsporidia. The role of topical steroids, antifungal agents, oral Albendazole needs to be discussed. Clinicians should be aware of recurrences which may mimic as rejections. There needs to be more awareness regarding microsporidia as a cause of acute stromal keratitis, so that its not overlooked or underdiagnosed.

Curvularia infection of corneoscleral tunnel.

Corneoscleral tunnel infection is a potentially sight threatening complication of cataract surgery. Microbiological investigations are mandatory and early surgical intervention helps in achieving favourable outcomes. Fungal infection of tunnel incisions can pose a diagnostic and therapeutic challenge. We report a case of post-operative tunnel infection with curvularia. Prompt surgical intervention and intensive topical therapy helped attain a good tectonic as well as visual recovery.

Ipsilateral presentation of ocular surface squamous neoplasia and conjunctival melanoma in xeroderma pigmentosum: A rare occurrence.

A case of a 16-year-old male with xeroderma pigmentosum (XP) who presented with multiple pigmented and nonpigmented conjunctival lesions in both eyes is reported. He had a keratinized lesion at the limbus and a pigmented lesion in bulbar conjunctiva in the left eye and multiple pigmented bulbar conjunctival lesions and a keratinized limbal nodule in the right eye. Excision biopsy confirmed the diagnosis of ocular surface squamous neoplasia (OSSN) and conjunctival intraepithelial melanocytic neoplasia-2 (CIMN-2) in the right eye and OSSN and conjunctival melanoma in situ (CIMN-5) in the left eye. Two malignant conjunctival lesions occurring simultaneously in the same eye of a patient with XP have not been reported earlier.

18S rDNA sequencing aided diagnosis of Acanthamoeba jacobsi keratitis -A case report.

Identification of Acanthamoeba cysts and trophozoites in cases of keratitis is traditionally done with microbiological techniques such as smear examination with 10% potassium hydroxide (KOH) and culture. Double walled cyst with hexagonal inner wall is characteristic of Acanthamoeba. We report a unique case of a 9 year old boy who presented with dense anterior corneal stromal infltration, which on smear examination showed atypical double walled spherical cysts, leading to a diagnostic dilemma. An 18S rRNA gene-based PCR done on the growth on culture, subsequently identifed a rarely reported species of Acanthamoeba. The patient was advised combination therapy with polyhexamethylene biguanide (PHMB 0.02%) and chlorhexidine (0.02%) eye drops. Three weeks post treatment, the keratitis resolved with scarring and vascularisation and visual acuity improved to 20/60. At 8 weeks follow up Best corrected visual acuity further improved to 20/30 with contact lens.

Panophthalmitis associated with scleral necrosis in dengue hemorrhagic fever.

Dengue is a mosquito-borne flavivirus disease affecting humans. The Aedes aegypti mosquito spreads it. Ophthalmic manifestations of dengue range from subconjunctival hemorrhage to optic neuropathy. Panophthalmitis in dengue fever is a rare finding. We report a case of a 22-year-old male having dengue fever, who presented with pain, redness, swelling and loss of vision in his right eye. He was diagnosed as panophthalmitis with subretinal hemorrhage and required right eye evisceration.

Microbiological profile and antibiotic susceptibility of scleral buckle infections in North India.

Purpose: The aim of this article to study causative organisms for scleral buckle (SB) infections in North India. Methods: A retrospective review of records was done for all patients who have undergone SB removal at our institute between January 2009 and December 2017. The records were analyzed for etiological agent of the infected buckle and its antibiotic sensitivity. Results: A total of 43 samples were analyzed and a positive culture was noted in 35 (81.40%) cases. The buckle infection rate at our institute was noted to be 2.53%. The commonest organism causing SB infections was Staphylococcus - 15 (42.6%) cases, followed by Pseudomonas - 6 (17.14%) cases and Fungi - 6 (17.14%) cases. The median interval between retinal detachment surgery and buckle explantation was 3 years. Conclusion: A large variety of organisms may cause SB infections. The commonest organism found to cause buckle infections in our study was Staphylococcus sp.

Increased postoperative anterior chamber inflammation secondary to heat-resistant endotoxins.

PURPOSE: To evaluate the cause of clusters of increased postoperative anterior chamber inflammation after uneventful cataract surgery, and to examine its relation to the presence of endotoxins in sterile consumables. SETTING: Tertiary eye center in north India. DESIGN: Single-center retrospective case series. METHODS: All cataract surgeries performed at the tertiary eye center over 12 weeks (October 1, 2017 to December 31, 2017) were noted. Any patient with a "severe reaction" postoperatively was monitored closely and the postoperative drug regimen was altered accordingly. "Severe reaction" was defined as any patient with more than 4+ cells and/or fibrin with or without hypopyon. The Hospital Infection Control committee was informed, and a root cause analysis was performed to determine the cause. All the consumables were recalled and replaced. The samples were sent for microbiological evaluations. RESULTS: Of the 781 cataract surgeries performed, 81 patients had a severe reaction. Most patients were men (71%) and the mean age of the patients was 63 years. Twelve patients had fibrin, 3 of whom presented with hypopyon. Because all samples were negative of any growth, endotoxin tests were performed. All the samples were found to be negative, except for the ophthalmic viscosurgical device (OVD), which showed positive endotoxin levels. The OVD was changed and the anterior chamber reactions ceased to occur. CONCLUSION: A careful, stepwise approach is necessary when investigating clusters of increased postoperative anterior chamber reactions after uneventful surgery. A high degree of suspicion is important to rule out all possible reasons and in the absence of any identifiable cause, sterile consumables should be checked for endotoxins.

A rare case of scleral buckle infection with Curvularia species.

BACKGROUND: Scleral buckling is an established modality of treating retinal detachment. Being an external implant the buckle may be prone to infections. We report such a case with a delayed presentation and a rare etiology. CASE PRESENTATION: A 45 year old male presented with redness, foreign body sensation and discharge for one month in his right eye. The patient had undergone a retinal detachment surgery elsewhere 14 years back without any visual gain. Right eye demonstrated no perception of light and the best corrected visual acuity in the left eye was 6/6, N6. On downgaze an exposed and anteriorly displaced scleral buckle was identified with black deposits and mucopurulent material overlying the buckle. Scleral buckle removal was done. On microbiological examination Curvularia species was identified. Successful treatment with antifungals was done. CONCLUSIONS: Scleral buckle infection with dematiaceous fungi is a rare occurrence. To the best of our knowledge this is the first case report describing a buckle infection caused by the curvularia species.

Capillary Dropout: A Novel Fluorescein Angiography Finding in Primary Vitreoretinal Lymphoma.

Tissue diagnosis with vitreous and/or retinal biopsy usually confirms the diagnosis of primary vitreoretinal lymphoma. Multiple imaging modalities like fundus fluorescein angiography, fundus autofluorescence, and optical coherence tomography have been used to support the diagnosis of vitreoretinal lymphoma. We report a case of a 74-year-old lady diagnosed with primary vitreoretinal lymphoma showing a novel fluorescein angiographic finding of capillary dropout. We hypothesize that this clinical finding on the fluorescein angiogram may be due to the occlusion of the retinal vasculature by the malignant tumor cells. This finding also suggests the possible intraocular invasion of the malignant lymphomatous cells into the inner retinal layers.