Nasal loop myopexy for management of exotropia-hypotropia complex associated with high myopia.

INTRODUCTION: Exotropia-hypotropia complex is an uncommon phenomenon associated with high myopia. However, some literature reports cases of the exotropia-hypotropia complex where residual hypotropia is managed through a secondary surgery following the conventional recession-resection of the lateral rectus (LR) and medial rectus (MR). Nasal Loop myopexy as a primary surgical procedure for the management of exotropia-hypotropia complex has been rarely reported in the literature. METHODS: A 24-year-old male with unilateral high myopia presented with a large angle exotropia-hypotropia complex with limitation of elevation in abduction in his left eye. His ocular deviation was successfully managed through a nasal loop myopexy of the superior rectus (SR) and MR using a non-absorbable suture, combined with large LR recession and MR resection. RESULTS: Postoperatively, the patient had satisfactory ocular alignment with improved hypotropia and normal elevation in abduction, contributing to enhanced binocular vision and better cosmesis. DISCUSSION: Managing the exotropia-hypotropia complex in the context of high myopia demands a comprehensive approach that addresses both vertical and horizontal deviations. The surgical strategy employed in this case, which included loop myopexy of SR and MR along with LR recession and MR resection, achieved positive outcomes regarding alignment, elevation, and binocular vision. The case supports variations in muscle path and the potential benefits of tailored surgical strategies for complex strabismus cases associated with high myopia.

Reasons for declining corneal refractive laser correction for refractive candidates in Southern India.

PURPOSE: To analyze the reasons for declining corneal refractive laser correction procedures in patients presenting to tertiary eye care centers in Tamil Nadu, Southern India, and review the literature. METHODS: Retrospective case records of subjects presenting from January 2019 to December 2021 for refractive surgery workup were analyzed. Demographic details and refractive parameters of patients rejected for corneal refractive laser corrections (CRLC) were documented and reviewed. RESULTS: A total of 2358 patients presented for refractive surgery evaluation during the study period, and out of them, 395 patients (16.8%) were not considered ideal candidates for undergoing CRLC. The common reasons for rejecting the patients were unfit topography (n = 110, 27.8%), unstable refraction over a one-year duration (n = 9, 2.27%), low corneal thickness (n = 85, 21.5%), keratoconus (n = 5, 12.9%), and other ocular and systemic disorders (n = 48, 12.1%). CONCLUSION: There was a marked change in magnitude and rationalization for not performing either laser-assisted in situ keratomileusis (LASIK) or photorefractive keratectomy in our study. The reasons are unfit topography, keratoconus, and systemic disorders, which were diagnosed during pre-LASIK screening workup, being the most common cause for rejecting patients for corneal refractive corrections.

Epithelial ingrowth under LASIK flaps: tips and tricks for preventing recurrence!

Background: LASIK for refractive error correction has become a universal surgery. Despite its popularity, the estimated prevalence of traumatic flap dislocations in post-LASIK patients is 3.9%, and it is sometimes associated with epithelial ingrowth. The prognosis in such cases depends on the rapid surgical revision of the flap with the removal of the EI and perioperative steps to prevent Epithelial ingrowth (EI) recurrence in the future. Purpose: The video aims to display the steps involved in revising the flap, removing EI, and tips to prevent its recurrence. Synopsis: A 33-year-old post-LASIK patient presented with decreased vision, photophobia, and glare during the COVID pandemic in the right eye for 2 months. The best-corrected visual acuity was reduced to 6/60. The anterior segment revealed traumatic flap dislocation along with macro fold temporally and epithelial ingrowth. She underwent a successful flap revision surgery with no recurrence of epithelial ingrowth postoperatively. Highlights: A successful revision of a 2-month-old traumatic folded flap was performed along with the complete removal of EI. It explains the step-by-step approach to avoid the recurrence of EI in each step of the surgical revision of the flap. The video is self-explanatory and guides novice surgeons too. Video link: https://youtu.be/JuOSjhrfw0g.

A novel transconjunctival, intrascleral, ab-externo, knotless, and double-flanged technique with 6-0 Prolene for iridodialysis repair.

Small traumatic iridodialysis (ID) may be asymptomatic, but large ones usually cause polycoria and corectopia, leading to symptoms like diplopia, glare, and photophobia. The management of ID, including medical and surgical methods, depends upon the patient's symptoms. Mild glare and diplopia can be treated either with atropine, antiglaucoma medications, tinted spectacles, colored contact lens, or corneal tattooing, but extensive IDs require surgical options. The surgical techniques are challenging due to the iris texture and the damage encountered during the primary surgery, the narrow anatomical workspace for repair, and the associated surgical complications. Numerous techniques have been described by several authors in the literature; each has its advantages and disadvantages. All the procedures described previously involve conjunctival peritomy, scleral incisions, and suture knots and are time consuming. Here, we report a novel transconjunctival, intrascleral, knotless, and ab-externo, double-flanged technique for repair of large ID with a 1-year follow-up.

Management of pediatric subluxated cataract and different methods to face the challenges.

Background: Traumatic cataracts present in multiple and different forms. Based on the nature of injury, it necessitates a customized approach for individual case. Capsulorhexis and in the bag intraocular lens (IOL) placement are vital for long term centration of pediatric IOLs. Paediatric lenses having elastic capsule provide more challenges to perform optimum rhexis and the surgery becomes further complicated, when it is subluxated or fibrosed. Here is a pediatric case with such challenges managed using capsular tension ring (CTR) and capsular tension segment (CTS). Purpose: To demonstrate the making of optimum rhexis in a fibrosed capsule in subluxated lens and placing the IOL along with fixation of bag using CTR and CTS. Synopsis: A 13-year-old boy sustained an injury in the right eye from an air pistol, underwent lid tear repair in a local hospital, and presented to us one month post trauma with visual acuity of 6/60 in the right eye and 6/6 in the left eye. On examination, there was more than 180° temporal zonular dialysis with fibrosis of the anterior capsule. In this situation, creating an intact capsulorhexis was a challenge which was solved using micro-scissors and micro-vitreo-retinal forceps, in addition to routine instruments. After removing the lens material, CTS was placed initially in the bag to stabilize it while introducing CTR. The CTS was then fixated to the sclera. Foldable IOL was placed in the bag. Technique and tips to make intact rhexis and easy passage of suture are demonstrated. Highlights: This video shows tips and different methods adopted in each step of the surgery for successful placement of IOL in bag along with fixation of bag using CTR and CTS in a case of traumatic subluxated cataract with shrunken anterior lens capsule. Video link: https://youtu.be/Vwp1qUh1Mrc.

Gore-tex a magic sheet for symblepharon prevention!

Background: Symblepharon occurs as chronic sequelae of severe chemical injuries. The risk of recurrence is high due to unpredictable wound healing of conjunctiva and tenons following excision in young patients. Gore-tex aids in prevention of the recurrence of pterygium 1. Purpose: To present a surgical video on role of Gore-tex in grade 4 Symblepharon lysis. Synopsis: A 28-year-old male with a previous history of Grade 4 chemical injury presented with symblepharon and total obliteration of both upper and lower fornices after one year in the right eye. He underwent symblepharon lysis, Living related conjunctival allograft, Amniotic membrane graft and Gore-tex. The video explains the surgical steps in detail. A 360-degree complete peritomy was done, Symblepharon was released from the corneal surface, and the fibrotic tissue was extensively dissected away from the corneal surface and released into the fornix. Further, cryopreserved AMG was placed over the entire raw ocular surface and sutured to the episclera with glue. Prepared Gore-tex was placed on the superior and inferior fornix and sutured with 10-0 nylon suture. Again, AMG was placed over the Gore-tex in the fornices and covered with glue. A small 2x2mm biopsy of limbal stem cells from the superior limbus was already excised from the fellow eye (CLAG) and then Lr-CLAL was prepared from the patient's mother. These two grafts were placed on the nasal and temporal bulbar surface over the AMG and sutured to the underlying AMG and the episclera with glue. The entire surface was then covered with the AMG to promote epithelisation. At one month postoperative period, patient had stable ocular surface with intact Limbal conjunctival graft with mild conjunctival recurrence of fibrosis superiorly. Highlights: The video clearly explains the surgical steps of Symblepharon and the benefits of using Gore-tex. Online Video Link: https://youtu.be/aFfq2x9QBwA.

Preferred practice of cataract surgery in brown cataract: A questionnaire-based survey among Indian ophthalmic surgeons.

Purpose: To determine the most preferred method of operating brown cataracts among ophthalmologists in India. Methods: A cross-sectional, questionnaire-based study was conducted among ophthalmologists all over India through electronic and social media from May 1 to June 15, 2022. All single, voluntary entries within the stipulated time period were accepted for analysis. Results: A total of 230 ophthalmologists participated in the study among which 198 (86%) preferred Manual small-incision cataract surgery (mSICS) as the first option. This was preferred due to the high risk of complications associated (40, 33.6%) as well as endothelial damage due to increased Phaco power (53, 47.9%). The majority of the surgeons (162, 70.4%) preferred a superior tunnel for SICS, and 51.7% (119) performed continuous curvilinear capsulorhexis in 100% of their cases. The most common complication encountered was posterior capsular rupture (PCR) (66%), followed by zonular dialysis (ZD) (18.7%), whole bag removal (8.3%), and Descemet's membrane detachment (7%). Conclusion: Despite diverse recent new modalities of Femto Laser assisted cataract surgery (FLACS). Phakonit, and Smart Intraocular Lens (IOLs), the majority of ophthalmologists still find the manual small-incision cataract surgery (mSICS) procedure a safe surgery for mature brown cataracts.

Side port incision in manual small-incision cataract surgery - A teaching video for postgraduates.

Background: Manual Small Incision Cataract Surgery (MSICS) is the basic of cataract surgery with a short learning curve, less time-consuming, and can be performed in high-volume setups at low cost. Hence, it is imperative for every surgeon to know in detail the perfect way of wound construction and nucleus delivery methods. Purpose: A teaching video prepared for the postgraduates to understand the importance of creating a proper side port wound construction in MSICS. Synopsis: In MSICS, the side port is made for the intraocular manipulation, to fill the anterior chamber (AC) with viscoelastic and Balanced salt solutions, for easier rhexis in fluid tight maintained AC, for easy aspiration of cortex with deep AC, for cutting the extended rhexis margin with the vannas and for dialling the IOL into the bag complex (Video clip 1). In this video, a limbal stab incision for the side port is created with the 15 degree side port blade made of polycarbonate handle with maximum width of a 20G needle (1.5mm) made parallel to the iris plane of 1.5mm and the 90-110 degree distance from the superior main scleral incision to avoid astigmatic change in axis and power (Video clip 2). It is constructed with the pushing force applied along the cutting edge of the blade through the cornea to create an internal and external ostium, 0.5mm to 1mm thickness into the corneal stroma. The incision produced this way is considered astigmatically neutral (Video clip 3&4). Apart from the astigmatism, the side port is very important to avoid intra and postoperative wound leakage, iris prolapse, and DM detachment. The wound leakage favours bacterial contamination and endophthalmitis (Video clip 5). Ensure good quality of blade while entering the AC (Video clip 6). Hence, albeit small, the side port incision is as important as the main incision. Highlights: The video explains the importance of creating a proper sideport, the benefits and the complications involved were clearly explained. Video link: https://youtu.be/nljn8c6XaHY.

"Outcomes of optical penetrating keratoplasty with the large sized donor for failed therapeutic grafts for infectious keratitis from the tertiary eye care center, South India".

PURPOSE: To evaluate the preoperative risk factors, complications, and postoperative outcomes following regraft with the large-sized donor for failed therapeutic grafts. METHODS: In this retrospective interventional case series, patients who underwent optical penetrating keratoplasty for failed therapeutic keratoplasty (TPK) from 2010 till 2019 were studied at the Cornea clinic, Tertiary eye care center, with a maximum follow-up period of 3 years within the study period. Demographic patterns, preoperative risk factors, graft survival, visual outcomes, and complications were reviewed from the electronic medical records. RESULTS: A total of 77 eyes of 77 patients underwent optical penetrating keratoplasty, with the mean age of 46.18 ± 12.56 years. The median interval between the two procedures was 10.29 months (IQR: 9.0-15.5) and a mean follow-up of 31.27 months. Non-healing fungal keratitis (n = 48) was the most common indication for TPK. The mean size of the donor used was 10 mm (IOR: 9.5-11 mm). The presence of Peripheral anterior synechiae (p < 0.001) and deep limbal vessels (p = 0.011) showed a significant association with the graft outcomes. Four eyes (5%) developed graft reinfection, one patient (1.2%) underwent evisceration, 28 eyes (39%) had graft rejection; among them, 11 eyes (14.28%) resolved with treatment, and in 17 eyes (22.07%), graft failed. Forty-seven eyes (61%) had secondary glaucoma, of which in 32 eyes (68.08%), intraocular pressure was controlled with anti-glaucoma medications; fifteen eyes (31.19%) needed surgery. The graft's cumulative success rate was 83.1% at six months, 58.4% at one year, and 35.1% at three years. CONCLUSION: We conclude that despite the high complication rate following optical penetrating keratoplasty for failed therapeutic grafts, the visual and clinical outcomes are satisfactory for such high-risk grafts. Hence, it is imperative to venture surgical intervention to salvage these eyes.

Descemet Membrane Endothelial Transfer (DMET) in Pseudophakic Bullous Keratopathy After DSEK-A Case Report and Review of Literature.

PURPOSE: The purpose of this study was to report a Descemet membrane endothelial transfer (DMET) in a patient with pseudophakic bullous keratopathy (PBK) who developed graft dislocation after manual Descemet stripping endothelial keratoplasty. METHODS: A 60-year-old man presented with defective vision in the left eye; after Descemet stripping endothelial keratoplasty, graft dislocation was noted 1 month after surgery. RESULTS: Corneal clarity was improving slowly over 3 months without any secondary surgical intervention. The mechanism of DMET and the review of literature were enunciated. CONCLUSIONS: DMET occurs commonly in eyes with Fuch endothelial dystrophy and rarely in patients with PBK. The mechanism of DMET in PBK probably occurs because of migration of the donor endothelial cells from partially attached Descemet stripping endothelial keratoplasty grafts to the host stroma, in contrast to Fuch endothelial dystrophy, where the endothelial cells from the periphery migrate to the center. Hence, waiting for spontaneous corneal clarity is pivotal because of DMET even in patients with PBK for at least 3 months.

Impact of teleophthalmology during COVID-19 lockdown in a tertiary care center in South India.

PURPOSE: The aim of this study was to describe the experience of teleconsultations addressed at our hospital in India during the ongoing coronavirus (COVID-19) lockdown. METHODS: This cross-sectional hospital-based study included 977 teleconsultations presenting between April 1st and May 31, 2020. A two-level protocol was implemented to triage the calls. RESULTS: Overall, 977 teleconsultation were addressed. Of the 621 teleconsultation addressed the most common queries were related to redness/pain/ watering/blurred vision/itching/irritation (52.49%), followed by queries related to medications (28.01%), appointments (18.84%) & 0.64% cited an emergency need to visit the hospital due to sudden loss of vision. The majority of the queries were directed to the department of cornea (58.93%) followed by retina (16.26%), cataract (13.04%), glaucoma (10.14%) & pediatric ophthalmology (1.61%). The most common advice given to the patient was related to medications (47.66%) followed by appointment-related queries (31.72%) & fixing of surgical appointment (20.61%). Among the 356 preterm babies that were screened, 57 (16.01%) were diagnosed with retinopathy of prematurity (ROP). Of them 3 required laser and 3 were given injection. CONCLUSION: Teleconsultation is here to stay beyond the pandemic. WhatsApp was the preferred modality of communication for us. Teleophthalmology has given us insights to use this evolving technology to reach out to the population at large to provide eye care services. We believe that this mode of teleophthalmology has helped us in providing feasible eye care to the patients.

Acute comitant esotropia in a very young child due to combined mechanism: A case report.

We report a case of esotropia with high hyperopia in a 3-year-old female child. She was initially treated with hyperopic correction and noted to have residual esotropia, which was diagnosed as partial accommodative esotropia. Later when she presented with headache, she was diagnosed to have an intracranial tumour. To our surprise, after neurosurgical excision of tumour, her non-accommodative component of the esotropia resolved over 1 year implying that the intracranial lesion was an additional causative factor for this acute onset Accommodative esotropia. The child attained Orthophoria with the same hyperopic correction.

Optic disk contractility in morning glory disk anomaly.

Morning glory disk anomaly is a nonhereditary, congenital optic disk dysplasia characterized by conical excavation of the posterior fundus with a central glial tuft and radial retinal vessels. We report the case of a 4-year-old girl who presented with esotropia, enophthalmos, no light perception, and afferent pupillary defect in her left eye; fundus examination revealed morning glory disk anomaly. Ultrasound B-scan showed axial length increasing in the left eye on consensual light exposure. Magnetic resonance imaging/angiogram of the brain and orbits were within normal limits except for globe elongation posteriorly in the left eye. On examination under anesthesia with video indirect ophthalmoscopy, the left optic disk showed contraction and expansion when stimulated by strong light to the fellow eye and no spontaneous contraction on direct light stimulation. Morning glory disk contractility with increasing axial length on consensual light exposure in a child has not been reported previously.

Glaucoma following childhood cataract surgery: the South India experience.

PURPOSE: To determine the characteristics and risk factors for the development of glaucoma after cataract surgery in children seen at a major referral tertiary eye centre in South India. METHODS: This is a retrospective review of the medical records of consecutive patients seen at the glaucoma/paediatric eye clinic of the centre, with a diagnosis of glaucoma secondary to aphakia/pseudophakia over a 5-year period. RESULTS: There were 21 eyes of 14 children that developed glaucoma and 23 eyes of 12 children were selected as control. The mean age (standard deviation SD) at the time of cataract surgery for the glaucoma group was 7.4 (± 10.1) months and 39.13 (± 41.2) months for the control. The mean follow-up (SD) period was 114.29 (± 61.9) months and 97.61 (± 43.5) months for the glaucoma and control, respectively. The mean duration from cataract surgery to onset of glaucoma was 81.19 (± 52.4) months (median 66 months, range 21-172 months). Multivariate analysis detected age at surgery younger than 12 months (OR 10.45, 95%CI 1.76-62.03, p = 0.010) and ocular anomalies mainly microcornea (OR 7.11, 95%CI 1.14-44.46, p = 0.036) as risk factors for development of glaucoma after paediatric cataract surgery. CONCLUSION: Glaucoma can develop several years after childhood cataract surgery. Surgery in the first year of life and microcornea are risk factors for the development of glaucoma post-surgery. Signs of glaucoma should specifically be looked for during follow-up visits.

OCT-documented optic atrophy in nonsyndromic craniosynostosis and lacunar skull.

We report the case of 6-year-old boy who presented with mild redness in the left eye. On fundus examination, disk pallor was noted in both eyes. He did not complain of headache, vomiting, or blurred vision. Three-dimensional computed tomography (CT) imaging was suggestive of craniosynostosis and lacunar skull (lückenschädel). Magnetic resonance imaging findings were suggestive of intracranial hypertension. HD-OCT imaging revealed optic neuropathy in both eyes. The patient underwent sutural release and expansion cranioplasty surgery.

Scedosporium Keratitis: An Experience From a Tertiary Eye Hospital in South India.

PURPOSE: To determine the clinical profile and prognosis of Scedosporium keratitis. METHODS: All culture-proven cases were retrospectively analyzed for demographics, clinical characteristics, treatment offered, and resolution time with sequel. RESULTS: Among the 1792 culture-proven fungal keratitis cases in the study period, 10 (0.6%) were the result of Scedosporium. The mean age of patients was 44.2 years. Eight patients were male. A history of trauma was present in 8 patients. The infiltrate involved the center of the cornea in 5 patients, whereas 4 patients had paracentral involvement and 1 patient had limbal involvement. The mean maximum diameter of infiltrate was 3.4 mm. Five cases were prescribed topical natamycin alone: 4 patients were successfully treated with this monotherapy, whereas 1 patient was lost to follow-up, but the records of the last visit revealed healing. Three patients were treated with a combination therapy of topical natamycin and 1% voriconazole: 2 patients showed complete healing of the ulcer, and 1 patient progressed to corneal perforation necessitating penetrating keratoplasty. CONCLUSIONS: To our knowledge, this is the largest case series on Scedosporium keratitis to date. This is the first study to report successful treatment of this infection with topical natamycin monotherapy. The outcome may improve if appropriate medical therapy is started early.

Outcomes After Auro Keratoprosthesis Implantation: A Low-Cost Design Based on the Boston Keratoprosthesis.

PURPOSE: To evaluate outcomes after Auro keratoprosthesis (kpro) implantation. METHODS: Retrospective observational case series. The records of all patients who were implanted with Auro kpro from December 2012 to August 2015 at a single institute were retrospectively analyzed to evaluate preoperative characteristics, postoperative outcomes, and complications. RESULTS: Fifteen cases were included in the study. Failed graft was the most common indication for the surgery (n = 14; 93.3%). The mean BCVA (Log MAR) improved from 2.20 ± 0.43 in the preoperative period to 1.46 ± 1.12 (P = 0.0247) at the mean final follow-up of 13.5 months. The best corrected visual acuity (BCVA) improved to 20/200 or better in 9 patients (60%) at the final follow-up. Postoperative complications included retroprosthetic membrane formation (n = 7; 46.7 %), graft infection (n = 4; 26.7%), sterile corneal melt (n = 3; 20%), and spontaneous optic extrusion (n = 1; 6.7%). Eleven patients retained prosthesis at the final follow-up (retention rate = 73.3%). CONCLUSIONS: Auro kpro seems to be effective in treating end-stage corneal diseases. The outcomes are comparable to Boston kpro in terms of visual acuity, postoperative complications, and retention rates.

Iron deficiency anemia presenting with macular star.

We report the case of 16-year-old girl who presented with sudden painless decreased vision in her right eye of 5 days' duration. Anterior segment examination in both eyes showed conjunctival pallor. Results of ophthalmoscopic examination and optical coherence tomography were consistent with macular preretinal hemorrhage in both eyes with macular star in the left eye. Hematologic investigation disclosed severe iron deficiency anaemia. After 2 months, with oral substitution therapy with ferrous ascorbate and improved iron levels, the patient's visual acuity improved and macular preretinal hemorrhage resolved in both eyes.

Prevalence of eye signs in congenital rubella syndrome in South India: a role for population screening.

PURPOSE: Congenital rubella syndrome (CRS) resulting from maternal rubella infection, especially in the first trimester, affects an estimated 100 000 infants each year worldwide. Immunisation has reduced its occurrence in the developed world, though it remains a problem in countries with poor immunisation coverage. This population-based study was aimed at screening children below 5 years of age for ocular signs suspicious of CRS. METHODS: Suspected CRS cases were recruited from hospital and outreach services of the Aravind Eye Care System over a 24-month period. Clinical confirmation was based on the fulfilment of the World Health Organization (WHO) definition, and laboratory confirmation was based on a positive test for IgM antibody. RESULTS: Children under 5 years of age (n = 51 548) with ocular complaints were screened for eye signs suspicious of CRS; CRS compatible signs were detected in 1.92% (1090) children. Of these suspects (299), 27.42% were subsequently confirmed clinically according to WHO definition, and (46) 4.2% were serologically (Laboratory) confirmed. Of all the eye signs evaluated for screening, cataracts were the most sensitive (80.43%). CONCLUSIONS: Cataracts among children have a high sensitivity for detecting CRS in India. It is the only clinical eye finding that has a high enough sensitivity and specificity to be useful as a screening tool for CRS.