Midperipheral mini-capsulorhexis as an additional step for safe phacoemulsification in white intumescent cataracts.

ABSTRACT: The present article describes a novel surgical technique of a primary mini-capsulorhexis in midperiphery to minimize surgical complications in white intumescent cataracts. Patients with white mature cataracts with a convex anterior capsule or swollen lens fibers were selected. An initial puncture was made 3-4 mm away from the center, in the midperipheral anterior capsule, with a conventional cystitome. A mini-capsulorhexis (2-2.5 mm) was created. Loose cortical matter and fluidic contents were aspirated to reduce the intralenticular pressure. Two cuts were made at the margin of the mini-capsulorhexis, and an adequately sized secondary rhexis was completed, after which phacoemulsification was done. A circular curvilinear capsulorhexis was successfully achieved in all cases, including those with a small pupil. Rhexis could be completed in a patient where an initial extension occurred due to head movement. This refined technique aims to enhance the safety and precision of capsulorhexis in intumescent cataracts, thereby reducing the risk of complications such as the Argentinian flag sign. Further exploration and validation of this approach through clinical trials are warranted to establish its efficacy and safety profile.

Outcomes of Simple Limbal Epithelial Transplantation Without Amniotic Membrane Grafting in Unilateral Limbal Stem Cell Deficiency: A Case Series of 6 Patients.

PURPOSE: This study describes the technique of simple limbal epithelial transplantation (SLET) without amniotic membrane grafting (AMG) in limbal stem cell deficiency (LSCD). METHODS: Retrospective, interventional case series of 6 patients who underwent SLET without AMG were included. The procedure followed the standard technique, involving limbal biopsy from the healthy eye, resection of symblephera, and pannus dissection in the affected eye. Following host bed preparation, limbal explants were placed on the bare cornea and secured with fibrin glue. A large-diameter bandage contact lens was applied post surgery. No amniotic membrane was used. Preoperative data, including age, gender, cause of LSCD, best-corrected visual acuity, and previous ocular surgeries, were recorded. Postoperative clinical information, such as the duration of follow-up and recurrence of LSCD, best-corrected visual acuity, and other ocular examination findings, was recorded in an excel sheet. RESULTS: Preoperatively, 2 patients had total LSCD (secondary to a firecracker injury and excision biopsy for ocular surface squamous neoplasia). 4 patients had partial LSCD (3 chemical injuries, 1 firecracker injury). The mean age of participants was 30.67 ± 15.91 years, with a mean follow-up duration of 9.33 ± 8.04 months. Intraoperatively, all patients exhibited a smooth corneal surface after pannus removal. Postoperatively, all limbal explants remained securely attached, with complete corneal epithelialization achieved within 2 to 3 weeks. The ocular surface remained stable throughout, and no recurrence of LSCD was observed in any patient. No loss of explants was seen. CONCLUSIONS: The present series suggests that AMG may not be a necessary step for performing SLET.

An intuitionistic approach for the predictability of anti-angiogenic inhibitors in cancer diagnosis.

Malignant cancer angiogenesis has historically attracted enormous scientific attention. Although angiogenesis is requisite for a child's development and conducive to tissue homeostasis, it is deleterious when cancer lurks. Today, anti-angiogenic biomolecular receptor tyrosine kinase inhibitors (RTKIs) to target angiogenesis have been prolific in treating various carcinomas. Angiogenesis is a pivotal component in malignant transformation, oncogenesis, and metastasis that can be activated by a multiplicity of factors (e.g., VEGF (Vascular endothelial growth factor), (FGF) Fibroblast growth factor, (PDGF) Platelet-derived growth factor and others). The advent of RTKIs, which primarily target members of the VEGFR (VEGF Receptor) family of angiogenic receptors has greatly ameliorated the outlook for some cancer forms, including hepatocellular carcinoma, malignant tumors, and gastrointestinal carcinoma. Cancer therapeutics have evolved steadily with active metabolites and strong multi-targeted RTK inhibitors such as E7080, CHIR-258, SU 5402, etc. This research intends to determine the efficacious anti-angiogenesis inhibitors and rank them by using the Preference Ranking Organization Method for Enrichment Evaluation (PROMETHEE- II) decision-making algorithm. The PROMETHEE-II approach assesses the influence of growth factors (GFs) in relation to the anti-angiogenesis inhibitors. Due to their capacity to cope with the frequently present vagueness while ranking alternatives, fuzzy models constitute the most suitable tools for producing results for analyzing qualitative information. This research's quantitative methodology focuses on ranking the inhibitors according to their significance concerning criteria. The evaluation findings indicate the most efficacious and idle alternative for inhibiting angiogenesis in cancer.

Surgical application of Ong speculum in simple limbal epithelial transplantation and pterygium surgery.

Ong speculum is used in glaucoma surgeries such as trabeculectomy to expose the superior part of the globe. The large inferior blade pushes the inferior conjunctival fornix, due to which the eyeball rotates downwards. It has not been used in other anterior segment surgeries before. We used this speculum in simple limbal epithelial transplantation (SLET) and pterygium surgery to expose superior bulbar conjunctiva for harvesting limbal and conjunctival grafts, respectively. As the superior conjunctiva and sclera become exposed, it facilitates the steps of harvesting limbal biopsy and conjunctival graft in SLET and pterygium surgery. This eliminated the need for a superior rectus suture or an assistant who would keep the globe rotated downwards. Its position could also be maneuvered to adjust the site of exposure when dissecting the area of pannus in SLET. Thus, it makes the superior conjunctiva more accessible.

Customized Bowman-Stromal Inlay: An Attempt to Change the Topography of the Keratoconus Cornea.

PURPOSE: The objective of this report is to describe a modification of a previously reported technique with an aim of improving the corneal topography and visual outcomes in progressive keratoconus along with stabilization of ectasia. METHOD: In a 26-year-old man with progressive keratoconus, corneal collagen cross-linking was performed in one eye. The other eye had a keratometry of 69.6 D and thinnest pachymetry of 397 µm for which a customized Bowman-stromal inlay surgery was performed. The technique involved the harvesting of Bowman-stromal inlay (anterior 180-µm human donor cornea having the Bowman's layer and anterior stroma) using the femtosecond laser and central ablation of this inlay was done on the stromal side using an excimer laser. This customized inlay was placed in the anterior stromal pocket of the patient's cornea using a regular intraocular lens injector. RESULTS: Stabilization of keratoconus could be achieved in the present case along with improvement in the corrected distance visual acuity and pachymetry. Maximum keratometry decreased from 69.6 D to 57.3 D. CONCLUSIONS: Customized Bowman-stromal inlay technique appears to be a step towards creating an ideal inlay for the keratoconus cornea.

Multimodal analysis of the COVID-19-associated mucormycosis outbreak in Delhi, India indicates the convergence of clinical and environmental risk factors.

BACKGROUND: The aetiology of the major outbreak of COVID-19-associated mucormycosis (CAM) in India in spring 2021 remains incompletely understood. Herein, we provide a multifaceted and multi-institutional analysis of clinical, pathogen-related, environmental and healthcare-related factors during CAM outbreak in the metropolitan New Delhi area. METHODS: We reviewed medical records of all patients diagnosed with biopsy-proven CAM (n = 50) at 7 hospitals in the New Delhi, and NCR area in April-June 2021. Two multivariate logistic regression models were used to compare clinical characteristics of CAM cases with COVID-19-hospitalised contemporary patients as controls (n = 69). Additionally, meteorological parameters and mould spore concentrations in outdoor air were analysed. Selected hospital fomites were cultured. Mucorales isolates from CAM patients were analysed by ITS sequencing and whole-genome sequencing (WGS). RESULTS: Independent risk factors for CAM identified by multivariate analysis were previously or newly diagnosed diabetes mellitus, active cancer and severe COVID-19 infection. Supplemental oxygen, remdesivir therapy and ICU admission for COVID-19 were associated with reduced CAM risk. The CAM incidence peak was preceded by an uptick in environmental spore concentrations in the preceding 3-4 weeks that correlated with increasing temperature, high evaporation and decreasing relative humidity. Rhizopus was the most common genus isolated, but we also identified two cases of the uncommon Mucorales, Lichtheimia ornata. WGS found no clonal population of patient isolates. No Mucorales were cultured from hospital fomites. CONCLUSIONS: An intersection of host and environmental factors contributed to the emergence of CAM. Surrogates of access to advanced COVID-19 treatment were associated with lower CAM risk.

Partial-thickness compression sutures without descemetopexy for management of acute hydrops in keratoconus: A novel surgical technique.

This article reports a novel surgical technique of partial-thickness compression sutures without descemetopexy with air or gas for the management of acute hydrops in keratoconus. Two patients presented with localized corneal edema with a Descemet membrane (DM) tear in the left eye. Tomography of the right eye revealed localized steepening with increased maximum keratometry and decreased central pachymetry. They were diagnosed with keratoconus in the right eye and acute corneal hydrops (ACH) in the left eye. Compression sutures were passed through the stroma without touching the DM. The anterior chamber was not entered at all at any point during the surgery. Resolution of edema was noted intraoperatively itself. Further resolution of edema was noted from the first postoperative day which markedly reduced within the first week. A corneal scar with no edema was seen at six weeks. In both the patients, vision at presentation was counting fingers close to face which improved to 20/60 and 20/50, respectively, at the last visit.

Novel Application of Predictive Modeling: A Tailored Approach to Promoting HCC Surveillance in Patients With Cirrhosis.

OBJECTIVE: There has been increased interest in interventions to promote hepatocellular carcinoma (HCC) surveillance given low utilization and high proportions of late stage detection. Accurate prediction of patients likely versus unlikely to respond to interventions could allow a cost-effective approach to outreach and facilitate targeting more intensive interventions to likely non-responders. DESIGN: We conducted a secondary analysis of a randomized clinical trial evaluating a mailed outreach strategy to promote HCC surveillance among 1200 cirrhosis patients at a safety-net health system between December 2014 and March 2017. We developed regularized logistic regression (RLR) and gradient boosting machine (GBM) algorithm models to predict surveillance completion during each of the 3 screening rounds in a training set (n = 960). Model performance was assessed using multiple performance metrics in an independent test set (n = 240). RESULTS: Among 1200 patients, surveillance was completed in 41-47% of patients over the three rounds. The RLR and GBM models demonstrated good discriminatory accuracy, with area under receiver operating characteristic (AUROC) curves of 0.67 and 0.66 respectively in the first surveillance round and improved to 0.77 by the third surveillance round after incorporating prior screening behavior as a feature. Additional performance characteristics including the Brier score, Hosmer-Lemeshow test and reliability diagrams were also evaluated. The most important variables for the predictive model were prior screening completion status and past primary care contact. CONCLUSIONS: Predictive models can help stratify patients' likelihood to respond to surveillance outreach invitations, facilitating tailored strategies to maximize effectiveness and cost-effectiveness of HCC surveillance population health programs.

Bowman-stromal inlay using an intraocular lens injector for management of keratoconus.

A simple approach for transplanting Bowman layer and anterior stroma Bowman-stromal inlay (BSI) in keratoconic patients as an intervention to cease progression of ectasia and increase the overall thickness is described. A femtosecond laser was used to create BSI from human eye bank donor corneas and form an intrastromal pocket in the host cornea. The inlay was placed in the intrastromal space using an intraocular lens injector. This technique was performed successfully in 10 eyes of patients with progressive corneal ectasia. Postoperatively, the increased host pachymetry was as per BSI thickness. The tomography parameters remained stable, suggesting stabilization of keratoconus over a mean 15.9 months of follow-up. The BSI may offer a technically easy and safe technique of stromal augmentation to arrest keratoconus progression. It also opens up the possibility of surface ablation in the future for visual rehabilitation.

Effect of date fruit waste extract as an antioxidant additive on the properties of active gelatin films.

In this work, date-fruit syrup waste extract (DSWE) was used as an antioxidant additive to develop active gelatin films with enhanced food preservation properties. The effect of DSWE content (5, 10, 15, and 25 wt%) on the mechanical, physical, and antioxidant properties of the gelatin films were analyzed. Total phenolic content and antioxidant assay analysis revealed that the active compounds in blend films are highly migrated to the aqueous phase than the fatty medium. In the canola oil stability studies, gelatin/25 wt% DSWE film immersed oil sample exhibited low peroxide (POV) and p-anisidine (PV) values of 28.6 and 7.1, respectively, compared to the control oil (POV = 41.7 and PV = 13.1) in the air atmosphere and 45 °C for 30 days. Totox values of canola oil samples were decreased as a function of DSWE content in the films, indicating that polyphenols in DSWE are significantly resistant to oil's lipid oxidation.

Descemet Membrane Endothelial Keratoplasty in Congenital Hereditary Endothelial Dystrophy: Initial Experiences.

PURPOSE: To report our early experiences with Descemet membrane endothelial keratoplasty (DMEK) in congenital hereditary endothelial dystrophy (CHED). METHODS: Retrospective analysis of medical records of eyes with CHED that underwent DMEK between January 1, 2018, and April 30, 2019, and had a minimum of 1-year follow-up. RESULTS: Three eyes of 2 CHED patients (a 10-year-old girl and a 22-year-old man) were included. Both had decreased vision and hazy corneas from birth and underwent DMEK during the study period. Surgery was performed by a single surgeon and was uneventful in all 3 eyes. Within 1 month of surgery, the corneal edema cleared, and vision improved significantly. The mean decimal visual acuity improved from 0.15 ± 0.08 (baseline) to 0.33 ± 0.19 at 3 months. The mean central corneal thickness improved from 928 ± 2.3 µm (baseline) to 555.3 ± 25.8 µm at 3 months. The final visual outcome was less in 1 eye because of dense amblyopia. In all 3 eyes, a subtle stromal haze persisted even after resolution of edema. One eye had graft rejection 7 months after surgery because of discontinuation of medications, effectively managed by increasing the frequency of topical steroids. CONCLUSIONS: DMEK may be a viable option in phakic eyes with CHED.

Lacrimal drainage anomalies in Tessier cleft 3 with unilateral anophthalmos.

Bilateral Tessier cleft types 3 and 4 are rare and commonly involve the lacrimal drainage system owing to their anatomical location. Such clefts commonly present with associated ocular anomalies and include colobomatous eyelids, hypertelorism, microphthalmia, punctal or canalicular agenesis, and nasolacrimal duct obstruction or exstrophy. The current report presents an 18-month-old baby with bilateral Tessier cleft 3 with a unilateral anophthalmos, symmetrical eyelid colobomas, and lacrimal drainage anomalies. The lacrimal anomalies noted include small lacrimal sac with inferior canaliculus on the right side and upper and lower punctal and canalicular agenesis on the left side. Computed tomographic dacryocystography demonstrated unilateral lacrimal sac and bilateral maldevelopment of the bony nasolacrimal duct.

Labial mucosa grafting for lid margin, anterior lamellar, and posterior lamellar correction in recurrent cicatricial entropion.

PURPOSE: To report a novel modified technique for severe recurrent cicatricial entropion correction based on anterior lamellar recession (ALR) and grafting. METHODS: Six eyelids of five patients (9-48 years; three females) with severe cicatricial entropion (three upper and three lower eyelids) had surgical correction using ALR and labial mucosal grafting for spacing the ciliary margin away from the lid margin and reconstruction of the lid margin and posterior lamella. The modified technique included using mucous membrane as a single unit for anterior lamella, lid margin, and posterior lamella reconstruction employing a different suturing technique. RESULTS: The indications for surgery included Stevens-Johnson syndrome (3), chemical injury (2), and post-surgical scarring in congenital distichiasis with lymphedema (1). Entropion resolved in all patients with restoration of eyelid margin and reduction in ocular discomfort. Trichiasis was present in all six eyelids (100%) preoperatively and resolved completely in all but one case (83% success rate) with three residual focal trichiatic lashes in the temporal area, which was successfully managed with radiofrequency ablation. There were no recurrences of trichiatic or distichiatic lashes at a median follow-up duration of 16 months (range, 12-18 months). CONCLUSION: Successful resolution of the recurrent cicatricial entropion can be achieved with the use of labial mucosa as one solution for spacing the anterior lamella and reconstruction of the lid margin and posterior lamella with minimal recurrence rate.

UV Aging Behavior of Functionalized Mullite Nanofiber-Reinforced Polypropylene.

In this study, the effect of accelerated ultraviolet (UV) aging on the properties of polypropylene (PP) as well as its blend with PP-graft-maleic anhydride (PP-g-MA) and composite with amine-functionalized mullite nanofibers (AMNF) was compared. Solid-state NMR exhibited some changes in the macromolecular chain structure after aging, whereas the formation of degradation products was confirmed through Fourier transform infrared (FTIR) spectroscopy. The aged composite was observed to exhibit the least increment in the crystallinity from X-ray and differential scanning calorimetry (DSC) analyses (0.3 and 0.5%, compared to 9.7 and 10.4%, respectively, for PP) owing to the stability of its amorphous phase against degradation. Similar resistance toward degradation was also confirmed by thermogravimetric analysis (TGA). The surface morphology of the materials also exhibited the lowest extent of surface embrittlement as well as a small number of shallow cracks in the case of a-PP/PP-g-MA/AMNF composite. The aged composite had a much higher impact strength of 14.9 kJ m-2 compared to 2.5 kJ m-2 for aged PP, thus exhibiting its stability against degradation owing to a synergistic combination of the filler and compatibilizer. The optimal performance of the composite was further confirmed through the least extent of reduction in the tensile strength and elongation at break. These findings demonstrate the superior performance of AMNF-reinforced PP composite over PP for outdoor applications.

Ocular surface squamous neoplasia in a setting of fungal keratitis: a rare co-occurrence.

PURPOSE: To describe a rare co-occurrence of ocular surface squamous neoplasia (OSSN) in a patient with microbial keratitis. METHODS: Case report. RESULTS: We describe a 68-years female who developed ocular surface squamous neoplasia (OSSN) in an eye with culture proven severe fungal keratitis of 5 months duration, which progressed to endophthalmitis. She was managed with extended enucleation for left eye. Histopathology examination was consistent with squamous cell carcinoma of ocular surface with no corneal stromal/scleral/anterior chamber involvement. She received adjuvant chemotherapy with topical Interferon alpha2b (3 cycles) for positive margins. Six months after treatment, she is completely tumor free. CONCLUSION: Co-occurrence of OSSN and chronic fungal keratitis is rare. We recommend that patients with chronic ocular infections should be examined and followed closely for abnormally thickened limbal areas.

Primary limbal stem cell transplantation in the surgical management of extensive ocular surface squamous neoplasia involving the limbus.

PURPOSE: To determine the role of primary limbal stem cell transplantation (LSCT) in managing extensive ocular surface squamous neoplasia (OSSN) with more than 3 quadrants of limbal involvement to prevent manifestations of limbal stem cell deficiency. METHODS: A multi-center, comparative, and interventional clinical study of cases and historical controls was done. Patients with a limbal mass suggestive of OSSN involving more than 3 quadrants of limbus (> 9 clock hours) and no local, regional or systemic metastasis, who underwent primary surgical excision with or without adjuvant chemotherapy and had a minimum follow-up of 12 months were included in this study. Two historical controls underwent tumor excision with only amniotic membrane grafting. Three cases underwent tumor excision along with LSCT in the form of conjunctival limbal autograft (CLAG) or simple limbal epithelial transplant (SLET). RESULTS: None of the eyes had any recurrences of OSSN during the follow-up period. Cases with primary LSCT with tumor excision showed better ocular surface stability in the long term. CONCLUSION: Concomitant LSCT either in the form of CLAG or SLET appears to provide better long-term outcomes and is advocated while excision of extensive OSSN involving the limbus.

Ethylene-co-Vinyl Acetate/MWCNTs/Hectorite Elastomeric Nanocomposites: Characterization and Electrical Properties.

MWCNTs/hectorite 3D hybrid filler was prepared from the 1:1 combination by weight of constituent MWCNTs (1D) and hectorite (2D) through simple dry grinding method. The resulting hybrid filler was subsequently utilized for the preparation of Ethylene-co-vinyl acetate (EVA)/MWCNTs/hectorite nanocomposites by solution intercalation method. Transmission electron microscopy and X-ray diffraction studies of the nanocomposites confirm homogeneous dispersion of the fillers in the polymer matrix. Mechanical, thermal and dielectric properties of neat EVA are significantly enhanced with increase in filler content. The improvement in tensile properties observed at 4 wt.% filler content are: 243% in tensile strength (1.78 MPa to 6.11 MPa), 105% in elongation at break (366% to 750%) and 426% in toughness (3.36 MPa to 17.67 MPa) without significant change (1.12 MPa to 1.31 MPa) in Young's modulus. Differential scanning calorimetry confirms significant increase in crystallinity, crystallisation temperature (Tc) and crystallite melting temperature (Tm) of the nanocomposites vis-a-vis neat EVA. Observed shift in Tc by more than 10 °C (~87 to ~98 °C) and Tm by more than 30 °C (~118 to ~151 °C) are really significant confirming the improved thermal stability of the nanocomposites. Maximum improvements in dielectric constant and AC conductivity observed at 5 wt.% hybrid filler content are ~25% and ~50% respectively. Superior mechanical properties of the nanocomposites combined with enhanced thermal stability and dielectric properties make it a prospective material for flexible dielectric applications. Properties attained can be attributed to improved polymer-filler interaction on account of homogeneous dispersion.