Evolution of eye banking in India - A review.

Corneal blindness ranks third among the causes of blindness worldwide, after cataract and glaucoma. Corneal transplantation offers us a means to address this, and is currently the most commonly performed transplantation procedure worldwide - restoring the gift of sight to many an eye. Eye banks play a very important role in these procedures. India was quick to develop its own eye bank in 1945 soon after the launch of world's first eye bank in 1944. The evolution over the past six decades has been tremendous, placing India on the top, with one of the largest eye-banking system in the world. As of 2023, around 740 members are registered under the Eye Bank Association of India. The highest-ever collection of 71,700 donor eyes was achieved in 2017-2018. The overall tissue utilisation rate ranged between 22 - 28 % for voluntary donations and 50% for hospital-based corneal retrieval programs. Though India has an excellent infrastructure and readiness for corneal transplantation surgery, the need of the hour is to create a strong and independent nodal system. It shall take care of the logistics and factor in technological advances - surgical and otherwise. Public awareness, a national corneal grid, and reducing the red-tape barriers, shall improve availability of grafts nationwide. This review aims to detail the evolution of eye banking in India, to provide a comprehensive understanding, and help the stakeholders focus on the road ahead to attain our targets faster.

Relationship Between Cooking Fuel and Lens Opacities in South India: A 15-Year Prospective Cohort Study.

PURPOSE: To determine whether exposure to unclean cooking fuels was associated with subsequent cataract progression as reported in previous cross-sectional studies. DESIGN: Prospective cohort study. METHODS: This is a secondary observational analysis of the community-based Antioxidants in Prevention of Cataracts trial (ClinicalTrials.gov ID NCT01664819). The exposure of interest was cooking fuel type, measured at baseline. Main outcome measures were baseline cataract severity and self-reported cataract surgery at a 15-year visit. RESULTS: Baseline and 15-year follow-up data were available for 798 and 579 participants, respectively. Wood or kerosene was used by 711 of 798 (89.1%) baseline participants, including 539 of 579 (93.1%) participants with complete follow-up. Cooking fuel type was not associated with cataract severity at baseline (P = .443). Of 8334 person-years of follow-up, 90 cataract surgeries were observed over 15 years (1.08 surgeries per 100 person-years; 95% CI = 0.87-1.32). Use of wood or kerosene was not associated with 15-year incidence of cataract surgery relative to use of propane (adjusted P = .154). Cataract surgery was more common in older individuals (HR = 1.1 per year, 95% CI = 1.1-1.2, P < .001), those with baseline myopia (HR = 2.1, 95% CI = 1.2-3.5, P = .009), and women (HR = 3.5, 95% CI = 1.2-10.1, P = .019). CONCLUSIONS: This study found no association between unclean cooking fuels and cataract progression over a 15-year period. No other modifiable risk factors were associated with incident self-reported cataract surgery.

To Evaluate the Role of H. pylori in Patients with Chronic Recurrent Tonsillitis.

The usual indication for surgical resection of tonsils is chronic recurrent tonsillitis. Literature also does not indicate the reason behind the fact that only part of the population suffers from recurrent chronic tonsillitis in spite being exposed to similar conditions. This was a prospective study, in which 50 tonsil biopsy samples obtained from chronic tonsillitis patients. Specimens were analysed with rapid urease broth test, HelicotecUT PLUS assay and Toluidine blue staining for presence of Helicobacter pylori. The age ranged from 4 to 34 years. The median age for patients with chronic recurrent tonsillitis was 9.5, 23 (46%) patients were male while 27 (54%) were female, presence of H. pylori by rapid urease broth test, HelicotecUT PLUS assay and Histopathology was 4%. Our analysis revealed that H. pylori did not significantly colonize the tonsils and does not play a role in the pathogenesis or development of chronic tonsillitis. The heterogeneity in study population and methodology may have contributed to the non significant results.

Natural History and Predictors of Progression to Sjögren's Syndrome Among Participants of the Sjögren's International Collaborative Clinical Alliance Registry.

OBJECTIVE: To explore changes in the phenotypic features of Sjögren's syndrome (SS), and in SS status among participants in the Sjögren's International Collaborative Clinical Alliance (SICCA) registry over a 2-3-year interval. METHODS: All participants in the SICCA registry who were found to have any objective measures of salivary hypofunction, dry eye, focal lymphocytic sialadenitis in minor salivary gland biopsy, or anti-SSA/SSB antibodies were recalled over a window of 2 to 3 years after their baseline examinations to repeat all clinical examinations and specimen collections to determine whether there was any change in phenotypic features and in SS status. RESULTS: As of September 15, 2013, a total of 3,514 participants had enrolled in SICCA, and among 3,310 eligible, 771 presented for a followup visit. Among participants found to have SS using the 2012 American College of Rheumatology (ACR) classification criteria, 93% again met the criteria after 2 to 3 years, and this proportion was 89% when using the 2016 ACR/European League Against Rheumatism (EULAR) criteria. Among those who did not meet ACR or ACR/EULAR criteria at baseline, 9% and 8%, respectively, had progressed and met them at followup. Those with hypergammaglobulinemia and hypocomplementemia at study entry were, respectively, 4 and 6 times more likely to progress to SS by ACR criteria than those without these characteristics (95% confidence interval 1.5-10.1 and 1.8-20.4, respectively). CONCLUSION: While there was stability over a 2-3-year period of both individual phenotypic features of SS and of SS status, hypergammaglobulinemia and hypocomplementemia at study entry were predictive of progression to SS.

Clinical and demographic study of microsporidial keratoconjunctivitis in South India: a 3-year study (2013-2015).

AIM: To study the demographic profile, clinical features, treatment outcome and ocular morbidity of smear-positive microsporidial keratoconjunctivitis. METHODS: Retrospective case series of all patients with clinical features of microsporidial keratoconjunctivitis and who were smear positive for the same on Gram stain from January 2013 to December 2015. Demographic data, predisposing factors, microbiological investigations, clinical course and visual outcome were analysed. RESULTS: Of the 10 655 patients with conjunctivitis, 550 (5.2%) patients were positive for microsporidia on Gram stain during this time period. The disease was prevalent throughout the year with an increased incidence from July to December. Bilateral involvement was seen in 27 (4.9%) patients. There was no predisposing risk factor in 428 (77.8%) patients. 384 (69.1%) patients had received prior treatment before presentation to us with the most common drug being antibiotic in 285 (49.4%) patients. All the patients underwent diagnostic corneal debridement and received topical 0.3% fluconazole eye drops four times a day. Of the 296 patients who followed-up, 187 (63.1%) patients had complete resolution without sequelae. 68 (22.9%) had persistent superficial punctate keratopathy, 30 (10.1%) developed subepithelial nummular keratitis. No significant change in visual acuity was seen in 255 (80.7%) eyes, two or more line improvement was seen in 48 (15.2%) eyes, while two or more line worsening was seen in 13 (4.1%) eyes. CONCLUSIONS: Microsporidial keratoconjunctivitis is prevalent in South India throughout the year. The characteristic clinical signs and simple microbiological investigation help us to differentiate it from adenoviral keratoconjunctivitis. The visual prognosis is good.

Trends in bacterial and fungal keratitis in South India, 2002-2012.

OBJECTIVE: To assess the trends in microbiological organisms identified from corneal scrapings from patients with infectious keratitis at a tertiary care medical centre in South India. METHODS: We reviewed the records of the microbiology laboratory at Aravind Eye Hospital in Madurai, India, from 2002 until 2012. We identified the microbiological causes of all corneal ulcers from the culture and smear results, and assessed for trends in bacterial and fungal keratitis over time. RESULTS: Of 23 897 corneal patients with ulcer with a corneal smear from 2002 to 2012 a fungal organism was identified in 34.3%, a bacterial organism in 24.7% and no organism in 38.3%. During this period, the annual number of keratitis cases due to bacteria decreased from 677 to 412, and the annual number due to fungus increased from 609 to 863. In analyses accounting for the total number of outpatients seen each year, the decline in number of smears positive for bacteria was statistically significant (p<0.001) but the increase in the number positive for fungus was not (p=0.73). The relative frequency of individual bacterial or fungal organisms remained relatively stable over this time. CONCLUSIONS: At a tertiary eye care centre in South India, there has been a reduction in the numbers of smear-positive bacterial keratitis over the past 11 years. This decline likely reflects economic development in India and increased access to antibiotics.

A subset of human limbal epithelial cells with greater nucleus-to-cytoplasm ratio expressing high levels of p63 possesses slow-cycling property.

PURPOSE: The purpose of this study was to evaluate the subset of limbal epithelial cells with greater nucleus-to-cytoplasm (N/C) ratio expressing high levels of p63 for their slow-cycling property, a characteristic feature of stem cells (SCs). METHODS: Limbal and peripheral corneal explant cultures were pulse labeled with 5-5-bromo-2'-deoxyuridine (BrdU) for 5 days, followed by a period of 3-week chase. Cultured explants were cryosectioned and stained for BrdU. The epithelial cells in the outgrowth and those remaining on the explant were isolated and subjected to cytospin and double immunostaining for BrdU and p63, followed by identification of label-retaining cells (LRCs) and quantification of p63 expression using confocal microscopy. RESULTS: A distinct population of small cells with large N/C ratio expressing high levels of p63 retained the BrdU label after 21-day chase. Further, this population of LRCs, negative for the differentiation marker K3, was observed in the epithelial outgrowth of limbal but not in that of peripheral cornea. LRCs were seen to migrate along the cut edge of limbal explants in culture and were also observed as clusters of small cells in the outgrowth, which contained cells with the ability to form holoclone colonies. CONCLUSIONS: These results demonstrate that the small cells with large N/C ratio and high levels of p63 have BrdU label retaining slow-cycling property, thus confirming that these 2 parameters in combination may serve as a precise marker for identification and quantification of ex vivo-expanded limbal SCs. This method would be useful to standardize the optimal culture conditions that can maintain and expand SCs for therapeutic applications.

A method to isolate human limbal basal cells enriched for a subset of epithelial cells with a large nucleus/cytoplasm ratio expressing high levels of p63.

The objectives were to develop method of isolating viable human limbal basal cells in order to enrich a subset of small cells with a large Nucleus/Cytoplasm (N/C) ratio expressing high levels of p63, nuclear protein. Limbal tissues were treated with trypsin for 50 min at 37 degrees C in an orbital shaker at 100 rpm with epithelial side down followed by additional 5 min with epithelial side up and then with Dispase II to obtain various epithelial fractions. Isolated cell fractions were assessed for colony forming efficiency and DeltaNp63alpha, connexin (Cx43) mRNA levels. Cytospin smears were double-immunostained for p63 and any one of the stem cell (SC) related markers and analyzed using a laser scanning confocal microscope and advanced image analysis software (Leica Confocal software, 2.61 build 1537 version) for quantification of fluorescence intensity. The isolated limbal basal cells were highly positive for DeltaNp63alpha mRNA but expressing low Cx43 mRNA. They gave rise to higher number of large colonies with compact morphology in contrast to the limbal suprabasal/superficial (LS/S) colonies. Furthermore, a subset with a large N/C ratio expressing high levels of p63 was observed, as much as 25% among the limbal basal cell fraction, in contrast to only about 4% in the total limbal epithelial cells. Such cells were positive for K5 and negative for Ki67, Cx43, and 14-3-3s and were absent in the LS/S fraction. These results collectively substantiate our method of isolation of limbal basal layer cells containing an enriched population of cells with SC phenotype.

Antioxidants in prevention of cataracts in South India: methodology and baseline data*.

PURPOSE: To describe the methodology and baseline data for the Antioxidants in Prevention of Cataracts (APC) study in South India. METHODS: The APC study is a prospective, 5-year, randomized, triple-masked, placebo-controlled, field-based clinical trial to examine the effect of antioxidants (combination tablet of vitamins A, C, and E) on progression of cataract. The primary outcome variable is cataract progression (nuclear opalescence), evaluated with the slit-lamp biomicroscope by the Lens Opacification Classification System III method. Secondary outcome variables are progression in cortical and posterior subcapsular opacity and nuclear color, change in best corrected visual acuity, myopic shift, and treatment failure (progression to cataract surgery or best corrected vision worse than 20/400 in an eye). Inclusion criteria are age between 35 and 50 years and best-corrected visual acuity of 20/40 or better. Exclusion criteria are a diagnosis of diabetes mellitus or nonfasting blood glucose level>7.8 mmol/L, history or presence of various ocular conditions or treatment forms, or current use of vitamin supplements. Baseline ophthalmic, demographic, and potential cataract risk factor data (such as smoking, sunlight, or alcohol exposure) were compared between groups on an intent-to-treat basis. RESULTS: Of 954 people screened, 798 were enrolled, a sample size which exceeded the required estimate. More than 80% of subjects had 20/20 or better vision in at least one eye, and baseline prevalence of significant cataract according to the LOCS III grading scale was high. The two treatment groups were comparable for all baseline measures except alcohol intake. CONCLUSION: The sample size and group baseline characteristics will provide sufficient power to detect a change in cataract progression within 5 years.

High expression of p63 combined with a large N/C ratio defines a subset of human limbal epithelial cells: implications on epithelial stem cells.

PURPOSE: To characterize human limbal epithelial cells based on the expression levels of nuclear protein p63 and the nucleus-to-cytoplasm (N/C) ratio. METHODS: Limbal, peripheral, and central corneal epithelia were separated from the stroma by Dispase II and subsequently were treated with trypsin to obtain single-cell suspensions. Cytospin smears of the cell suspensions were double immunostained for p63 and then stained for any one of the markers (acidic cytokeratins [AE1], K5, K3, or connexin 43 [Cx43]). They were counterstained with propidium iodide. More than 100 cells from each zone were analyzed for p63 expression levels and nuclear/cellular area using quantitative confocal microscopy. RESULTS: A gradient of p63-positive cells was observed in corneal and limbal epithelial cells. The percentage of p63-positive cells and the level of p63 expression were significantly higher in the limbal than in the peripheral or central corneal epithelium. Two-parameter (p63 levels and N/C ratio) analysis revealed the presence of a distinct population of small cells with higher levels of p63 and a large N/C ratio in the limbal epithelium. Such limbal epithelial cells were positive for AE1 and K5 but negative for K3 and Cx43. CONCLUSIONS: These results suggest that this distinct group of small cells in the limbal epithelium with greater N/C ratio, expressing high levels of nuclear protein p63, probably represent corneal epithelial stem cells.

Nocardia endophthalmitis after cataract surgery: clinicomicrobiological study.

PURPOSE: To analyze the clinical presentation, microbiological profile, and treatment outcome in cases of nocardial endophthalmitis after cataract surgery. DESIGN: Retrospective, observational case series. METHODS: setting: Tertiary referral hospital. patients: Retrospective analysis of 24 cases of culture-proven exogenous nocardial endophthalmitis following cataract surgery between January 2000 and December 2003. main outcome measures: Visual acuity and anatomic outcome. RESULTS: Visual outcome was poor in most patients, with 79% (19/24) of patients obtaining a final visual acuity of hand motions or worse and 46% (11/24) of patients with no light perception. Initial presenting visual acuity was strongly associated with final visual outcome (P = .0026). There was a statistically significant trend favoring better visual outcome in patients who presented early after the onset of symptoms (P = .01). The majority of the eyes (23/24) had an early onset with predominantly anterior segment involvement. Wound infection was noted in 46% (11/24) of the patients at presentation. Clinical features included scleral abscess, cotton ball exudates in the anterior chamber, fluffy exudates on the corneal endothelium, nodular exudates on the iris, and hypopyon. Among the specimens cultured, the highest positivity was seen with the anterior chamber aspirate (15/16 = 93.75%), which was significantly higher than the vitreous aspirate cultured (1/22 = 4.54%) (P = .001). CONCLUSION: Nocardia endophthalmitis after cataract surgery is an aggressive disease with poor visual prognosis. Early diagnosis and treatment with good visual acuity at presentation may be associated with better visual outcome.