Clinical Profile and Treatment Outcomes of Patients With Acremonium Species Positive Keratitis Managed in a Tertiary Eye Care Center.

PURPOSE: To report the clinical profile and treatment outcomes of patients with culture-positive Acremonium keratitis. METHODS: This is a retrospective observational study. Medical records of all patients treated in a tertiary eye hospital for culture positive infective keratitis from March 2016 to February 2021 were screened, of which those positive for Acremonium species on fungal culture were reviewed. Demographic details, clinical presentation, clinical course, treatment given, total follow-up duration, time taken for ulcer to heal, scar size, and final visual acuity in the last follow-up were recorded. RESULTS: Fifty three cases of fungal keratitis caused by Acremonium species were identified, 22 females and 31 males, with average age of 46.39±18.64 years. The mean duration of symptoms being 54.47±50 days. Only five patients had a history of trauma with vegetative matter. Clinical presentation of patients showed a large number of variations, with 2 patients presenting as peripheral ulcerative keratitis and 1 with epithelial plaque. The mean visual acuity of patients at presentation was 2.43±0.46 logMAR units. Thirty-three of 53 patients presented with perforated corneal ulcer and underwent penetrating keratoplasty; 20 patients were medically managed on topical voriconazole 1%, natamycin 5%, and oral voriconazole. The mean duration of healing of epithelial defect was 95±60.62 days (range 60-165 days). CONCLUSION: Acremonium keratitis has a long and indolent course. A prolonged combination therapy of natamycin and voriconazole seems to be effective in the management. A delay in the diagnosis of Acremonium keratitis often leads to clinical worsening requiring keratoplasty.

Evaluation of Visual Outcome of 2 Phakic Posterior Chamber Implantable Lenses in High Myopia: A Comparative Study.

PURPOSE: To evaluate and compare the visual outcomes of two phakic intraocular lenses in high myopia. METHODS: A prospective comparative study was undertaken on 50 eyes of 26 patients {age ≥21 years and divided into two groups (implantable collamer lens [ICL] V4c, n=25 eyes and refractive implantable lens [RIL], n=25 eyes)}. Patients were evaluated for uncorrected distance visual acuity (UCVA), best-corrected distance visual acuity, manifest refractive spherical equivalent (MRSE), contrast sensitivity, intraocular pressure, dilated fundus examination, trabecular-iris angle (TIA), anterior chamber depth, horizontal white-to-white diameter, wavefront aberrometry, and endothelial cell (EC) count. All patients were followed up until 6 months and additionally evaluated for anterior chamber inflammation, cataract, and lens vault. RESULTS: The baseline parameters (UCVA, MRSE, and EC count) and postoperative improvement in UCVA, contrast sensitivity, MRSE, EC loss, safety index, and efficacy index were comparable between both the lenses. The improvement in aberrometric profile was significantly better in the ICL group. The mean postoperative vault was higher in RIL group (434.88±162.48 µm vs. 547.24±159.83 µm, P=0.0173); however, the vault was within normal range in both the groups. The decrease in mean TIA was significantly higher in RIL group (8.58 vs. 13.45 µm, P=0.0073). CONCLUSION: Acrylic phakic lens can be considered as a suitable alternative to collamer lens for refractive correction of high myopia. The collamer lenses showed slight superiority in some qualitative visual parameters; however, collamer lenses do not present with subjective complaints in the patients.

Granular corneal dystrophy: an enigma resolved.

PURPOSE: To report the intra-familial phenotypic variation of granular corneal dystrophy (GCD) across different age groups. METHOD: Two cases of GCD belonging to the same family (mother and daughter) were assessed and clinical findings were noted. RESULT: An 18-year-old female with complaint of glare, on examination showed brownish granules involving bowman's layer and superficial corneal stroma suggesting a diagnosis of Bowman layer dystrophy. Screening of her mother revealed multiple diffuse white granular opacities with snowflake appearance involving the central cornea. The intervening cornea was clear and limbus was not involved. Focal illumination showed deep stromal involvement. All these findings were typical of GCD. Genetic analysis revealed mutation of TGF beta-1 located on 5q31 which was consistent with our clinical diagnosis of GCD. CONCLUSION: Variable clinical presentation of GCD in different age groups can lead to diagnostic dilemma. Screening of family members can be helpful especially when dealing with early cases of GCD.

Comparison of Hospital Cornea Retrieval and Voluntary Eye Donation Program in Eye Banking.

OBJECTIVES: Comparison of demographic, clinical, microbiological, and utility profile of the corneas obtained through hospital corneal retrieval program (HCRP) and voluntary eye donation (VED) program. METHODS: Donor corneas retrieved during a 14 months period at National eye bank, India were included in the study. The donor cornea grading was done according to the cornea donor study. The corneal swabs were taken from the donor eyes and were sent for microbiological evaluation. The quality of the donor corneas and their utility was assessed. RESULTS: Out of 1,014 donor corneas collected (700 through HCRP, 314 through VED), 455 were of optical grade (91.2% [415/455] through the HCRP and 8.7% [40/455] through the VED). HCRP had a higher proportion of donors in younger age (81.6% vs. 21%, P<0.0001), clear lens (78.6% vs. 66.2%, P<0.0001), and endothelial cell counts of more than2,000 cells per squared millimeter (64.9% vs. 28%, P<0.0001). Higher proportions of corneas in HCRP were used for optical indications (Penetrating keratoplasty, 24.5% vs. 13.3%, P<0.0001 and endothelial keratoplasty, 18.14% vs. 4.14%, P<0.0001). VED had a greater number of corneas found unsuitable for keratoplasty (37.4% vs. 6.4%, P<0.001). Most of the donors in the HCRP belonged to lower socioeconomic status (59.4% vs. 17.9%, P<0.0001). No significant difference was found in the microbial contamination between the two groups. CONCLUSIONS: Most corneas retrieved through HCRP were of optical grade quality and efforts should be focused on HCRP to reduce the demand-supply deficit in cornea transplantation.

Comparative Evaluation of Use of 400-µm and 350-µm Microkeratome Head to Prepare Donor Tissue in Cases of Descemet Stripping Automated Endothelial Keratoplasty.

PURPOSE: To compare the outcomes of 400-µm microkeratome head with 350-µm microkeratome head Descemet stripping automated endothelial keratoplasty (DSAEK) in a prospective comparative study. METHODS: Twenty cases of pseudophakic bullous keratopathy were randomly allocated into two groups. Group 1 underwent slow, single-pass 400-µm microkeratome head, whereas group 2 underwent the standard technique of DSAEK using a 350-µm microkeratome head. The primary outcome measures were best-corrected visual acuity (BCVA) at 6 months. RESULTS: Groups were comparable in baseline characteristics. The mean central graft thickness (GT) at 6 months in group 1 was significantly thinner than group 2 (90.44±28.67 vs. 165.60±62.74 µm; P=0.003). The BCVA and contrast sensitivity were significantly better in group 1 than in group 2 (BCVA: 0.34±0.15 vs. 0.53±0.19 logMAR units, P=0.02; contrast sensitivity: 1.48±0.13 vs. 1.06±0.22, P=0.001). A significant correlation was found between both postoperative BCVA and contrast sensitivity, with the postoperative GT using Spearman rho correlation analysis (R=0.534, P=0.01 for BCVA and R=-0.522, P=0.02 for contrast sensitivity). The percentage endothelial cell loss was comparable between the 2 groups at the last follow-up (P=0.3). No major complications were observed during the study period. CONCLUSIONS: The use of a 400-µm microkeratome head instead of 350-µm head can improve the visual outcomes in DSAEK without increasing the risk of complications. The thickness of the DSAEK graft can affect the visual acuity and contrast sensitivity.

Evaluation of the Role of Umbilical Cord Serum and Autologous Serum Therapy in Reepithelialization After Keratoplasty: A Randomized Controlled Clinical Trial.

PURPOSE: To evaluate the role of umbilical cord serum (UCS) and autologous serum (AS) therapy in reepithelialization of corneal graft after keratoplasty in a randomized controlled trial. METHODS: A total of 105 eyes with epithelial defect (ED) after keratoplasty (penetrating keratoplasty-67 and anterior lamellar keratoplasty-38) on the first postoperative day were included in the study. The eyes were randomized into three groups: UCS (n=35), AS (n=35), and artificial tears (AT) (n=35). All patients received standard postoperative medical therapy. The primary outcome measure was time to epithelialization, and secondary outcome measures were best-corrected visual acuity and graft clarity. RESULTS: The ED healed completely in 103 eyes. The mean time for complete reepithelialization was 2.5±2.1, 3.1±2.2, and 4.5±1.4 days in UCS, AS, and AT groups, respectively. The mean percentage decrease in the size of the ED was significantly better in the UCS and AS groups as compared with the AT group (P=0.001). The rate of reepithelialization was comparable between the AS and UCS groups (P=0.3). On bivariate analysis, significant correlation was found between the mean size of postoperative ED, grade of the donor cornea (P=0.001), and the presence of preoperative ED (P=0.001). No complications were associated with the use of serum therapy. CONCLUSION: Most of the cases of postkeratoplasty corneal ED can be managed with AT only. The serum therapy (AS/UCS) helps in the faster reepithelialization of postkeratoplasty ED as compared with AT and may be considered as a treatment option for early epithelial healing.

Evaluation of corneal collagen cross-linking as an additional therapy in mycotic keratitis.

BACKGROUND: To report the treatment outcomes of mycotic keratitis with collagen cross-linking. DESIGN: Retrospective study. PARTICIPANTS: Patients with smear-positive moderate mycotic keratitis. METHODS: A retrospective case-file analysis was performed to identify cases of moderate mycotic keratitis treated with and without additional collagen cross-linking, in addition to intensive topical antifungal therapy. Patients in which collagen cross-linking was performed on the day of presentation (group 1) were compared with patients who received medical treatment alone in the form of 5% natamycin eye drops (group 2). MAIN OUTCOME MEASURES: The primary outcome measure was the time taken for resolution of infection. RESULTS: Overall, 41 cases were included for analysis (group 1, 20 cases; group 2, 21 cases). Mean age of the patients was comparable in both groups (46.5 ± 17.01 vs. 41.2 ± 20.7 years; P = 0.36). Average infiltrate size was 16.35 ± 6.8 mm(2) in group 1 and 17.09 ± 7.4 mm(2) in group 2 (P = 0.83). Overall, Aspergillus was the most commonly isolated organism (n = 4 group 1; n = 6 group 2). Resolution of infection was observed in 18 cases (90%) in group 1 and 18 (85.71%) cases in group 2. The average healing time was 30.85 ± 26.6 days in group 1, while it was 31.28 ± 19.97 days in group 2 (P = 0.94). Final best-corrected visual acuity in group 1 was 1.13 ± 0.55 and 1.25 ± 0.46 in group 2 (P = 0.46). A tectonic keratoplasty was performed in two cases in group 1 and three cases in group 2 (P = 1.00). CONCLUSIONS: In our study, additional collagen cross-linking treatment did not have any advantage over medical management in cases with moderate mycotic keratitis.

Thin lenticule Descemet's stripping automated endothelial keratoplasty: single, slow pass technique.

BACKGROUND: To evaluate the outcomes of single pass thin lenticule sutureless Descemet's stripping automated endothelial keratoplasty with donor lenticules prepared using a 400 µm microkeratome head. DESIGN: Interventional case series. PARTICIPANTS: Cases with corneal endothelial dysfunction. METHODS: Fifteen cases with corneal endothelial dysfunction (eight pseudophakic bullous keratopathy, three Fuchs' endothelial dystrophy, three congenital hereditary endothelial dystrophy and one failed graft) underwent thin lenticule Descemet's stripping automated endothelial keratoplasty at a tertiary care hospital. Donor lenticule was prepared with a single pass 400 µm Carriazo Barraquer microkeratome (Moria, Antony, France) head. Sutureless Descemet's stripping automated endothelial keratoplasty was performed in all the cases through a 3.5 mm corneoscleral tunnel using a Busin glide for graft insertion. MAIN OUTCOME MEASURES: Main parameters evaluated were postoperative donor lenticule thickness and best-corrected visual acuity. RESULTS: Donor lenticules were harvested successfully for all 15 cases without any complications. At 6-months follow up, the mean logMAR best-corrected visual acuity improved from 1.87 ± 0.52 to 0.109 ± 0.11 (P = < 0.0001). The mean donor lenticule thickness was 111 ± 17.62 µm (range 70-134 µm) at the last follow up. The mean endothelial cell loss was 26.33 ± 1.34%. CONCLUSIONS AND RELEVANCE: Thin donor lenticules for Descemet's stripping automated endothelial keratoplasty can be safely harvested using a single pass technique with 400 µm microkeratome head and can be used for a successful Descemet's stripping automated endothelial keratoplasty surgery.

Deep anterior lamellar keratoplasty for keratoconus: a review.

Deep anterior lamellar keratoplasty (DALK) is a surgical technique that involves the removal of pathological corneal stroma down to Descemet membrane and replacing it with a donor cornea. Over the last decade, there has been a paradigm shift in the surgical techniques of DALK, which has made it safer with visual outcomes comparable with penetrating keratoplasty. This review aims to discuss the existing popular techniques of DALK, their advantages and limitations. We will also describe techniques of DALK that are useful in special situations.

Hybrid technique of tuck-in Tenon's patch graft and tissue adhesives and bandage contact lens (TABCL) for large corneal perforation in microbial keratitis.

ABSTRACT: We describe the hybrid technique of tuck-in Tenon's patch graft (TPG) and tissue adhesive bandaged contact lens (TABCL) for large corneal perforations (>5 mm) with intact surrounding stroma. Management of large corneal perforation is often challenging, and urgent availability of donor cornea might be difficult; Tenon patch alone does not provide tectonic support; hence, this hybrid technique can be used safely in large perforations. This involves freshening the perforation edges, creating a 3600 stromal pocket, harvesting a Tenon's graft 1 mm oversized, tucking into the pocket, and suturing. Then areas of leakage were noted, and only those areas were supplemented with minimal cyanoacrylate glue (CG) at the graft edges. This technique was used in two eyes, one with a large corneal perforation and intact surrounding stroma and the other with 4 mm corneal fistula post healed keratitis with a failed primary TPG alone, and led to epithelialization and a smooth corneal surface at 6 weeks. The advantages include autologous tissue, cost-effective, easily available, minimal post-operative inflammation, vascularization, and surface irregularity.

Toxic anterior segment syndrome (TASS): A review and update.

Toxic anterior segment syndrome (TASS) is an acute, sterile, postoperative inflammatory reaction of the anterior segment without vitreous involvement, following an uncomplicated and uneventful ocular surgery, having broad and multiple etiologies. The symptoms of decreased visual acuity and ocular discomfort generally occur within the first 12-48 h after intraocular surgery. The clinical signs include prominent limbus-to-limbus corneal edema, anterior chamber cells, aqueous flare, fibrinous inflammation, and/or keratic precipitates. There can be sight-threatening complications of TASS, such as permanent corneal decompensation, intractable glaucoma, and cystoid macular edema. The causes of TASS are emerging and being reported, so are the newer treatment options for managing the inflammation and its complications. Prevention guidelines for TASS are being updated, and a traceability system for surgical instruments and intraocular fluids used during the surgery is being perpetually developed. It is important to recognize TASS and start treatment on an immediate effect. Hereby, we review the literature on TASS, emphasizing its etiology, pathophysiology, management, prognosis, complications, and the importance of prevention as well as prompt recognition.

Management of acute corneal hydrops - Current perspectives.

Acute corneal hydrops (ACH) is a rare but sight-threatening complication of corneal ectasias. We aim to review the current literature on etiopathogenesis, histology, role of ancillary investigations, management, and outcomes of ACH by classifying the various management strategies based on their site of action and the underlying mechanism. A review of the literature was conducted by searching the following databases: PubMed (United States National Library of Medicine), Embase (Reed Elsevier Properties SA), Web of Science (Thomson Reuters), and Scopus (Elsevier BV) till April 2023. The literature search used various combinations of the following keywords: acute corneal hydrops, keratoconus, ectasia, management, keratoplasty. Nine hundred eighty-three articles were identified based on the above searches. Case reports which did not add any new modality of treatment to the existing literature, articles unrelated to management, those with no full text available, and foreign-language articles with no translation available were excluded. Eventually, 75 relevant articles that pertained to the management of ACH were shortlisted and reviewed. Recent studies have described newer surgical interventions like full-thickness or pre-Descemetic sutures, thermokeratoplasty, and plasma injection that aim to close the posterior stromal break. Posterior lamellar keratoplasties act by replacing the posterior torn Descemet's membrane (DM), and early deep anterior lamellar keratoplasty (DALK) has been attempted to combine the correction of the anatomical defect and visual rehabilitation in a single surgery. These surgical interventions may help by reducing the scarring and increasing the number of patients who can be visually rehabilitated with contact lenses rather than keratoplasty.

Management and prevention of corneal graft rejection.

The management of an episode of corneal graft rejection (CGR) is primarily by corticosteroids. Immunomodulators are useful for long-term immunosuppression and in dealing with cases of high-risk (HR) corneal grafts. The classical signs of CGR following penetrating keratoplasty (PKP) include rejection line, anterior chamber (AC) reaction, and graft edema. However, these signs may be absent or subtle in cases of endothelial keratoplasty (EK). Prevention of an episode of graft rejection is of utmost importance as it can reduce the need for donor cornea significantly. In our previous article (IJO_2866_22), we had discussed about the immunopathogenesis of CGR. In this review article, we aim to discuss the various clinical aspects and management of CGR.

Cataract surgery outcomes in pediatric patients with systemic comorbidities.

Purpose: The aim of the study was to evaluate the outcomes of cataract surgery in patients of the pediatric age group with systemic comorbidities. Methods: Medical records of 54 eyes (30 patients) of the pediatric age group with systemic comorbidities who had undergone cataract surgery in a tertiary-care center were reviewed. The following parameters were recorded: systemic comorbidity; toxoplasmosis, rubella, cytomegalovirus, herpes simplex, HIV (TORCH) profile, best spectacle-corrected visual acuity (BSCVA), strabismus, nystagmus, and cataract morphology. Results: Thirty patients with a mean age of 55 months (9 months-14 years) were included. On average, every child was seen by three physicians, and the mean duration between the first visit to a physician and presentation to our center was 2.23 ± 0.67 years. The various causes for delay in referral include multiple referrals due to a lack of general anesthesia services in 78% of cases, a long waiting list at the referral hospital in 35% of cases, and a lack of awareness at the primary-care physician level in 50% of cases. The mean BSCVA at presentation was 1.4 logMAR (0.3 to 3 logMAR). The most common cataract morphology was that of zonular cataract (31.48%; 17/54). Strabismus and abnormal eye movements were observed in 27.7% (15/54) and 33.3% (18/54) of eyes, respectively. Various systemic associations were periventricular leukomalacia (12/30), Down's syndrome (6/30), seizure disorder (6/30), cardiac valvular anomalies (6/30), Marfan's syndrome (4/30), hypothyroidism (4/30), rubella (3/20), cytomegalovirus (3/20), cerebral palsy (2/30), nephrotic syndrome (2/30), Type 1 diabetes mellitus (1/30), microcephaly (1/30), cryptogenic West syndrome (1/30), congenital rubella syndrome (1/30), and Tourette syndrome (1/30). The mean postoperative corrected distance visual acuity (CDVA) at 2-year follow-up improved to 1.0 logMAR (0 to 3 logMAR). No postoperative complications were reported at the final follow-up. Around 70% of the parents reported improvement in their child's psychomotor skills. Conclusion: Intellectually impaired pediatric patients with cataract should be operated upon whenever there is a presence of infrastructure, and unnecessary delay in surgery should be avoided by referring the patient to higher centers. Even though objective improvement in visual acuity was suboptimal, there was definitely an improvement in the psychomotor skills of the patients.

Management of acute corneal hydrops in ectatic corneal disorders.

PURPOSE OF REVIEW: The purpose of this review is to outline the risk factors, clinical features, diagnosis, and management of acute corneal hydrops in corneal ectatic disorders. RECENT FINDINGS: The advent of newer investigative modalities aids in diagnosis and planning of treatment in cases of acute hydrops. Although visual outcome does not differ with intervention such as intracameral air/gas injection the duration of symptoms and the risk of complications decrease in comparison with medical therapy alone. SUMMARY: The intent of this article is to highlight the various risk factors and the newer diagnostic modalities such as ultra biomicroscopy, anterior segment optical coherence tomography and confocal microscopy in cases of acute corneal hydrops. Further, the conventional as well as the newer treatment modalities are also described. Although newer diagnostic and treatment modalities are found to be useful, the available information in literature is limited. This article will encourage future prospective studies and randomized controlled trials, which may help in finding novel diagnostic and effective therapeutic techniques.

Ocular manifestations in Kindler syndrome.

We aimed describe the chronic ocular sequelae of Kindler syndrome. All cases of Kindler syndrome with ocular involvement that presented to a tertiary eye care center were included. Three cases of Kindler syndrome with ocular changes were reviewed. Case 1 (10 years, female) had recurrent epithelial breakdown with severe dry eye and corneal opacity secondary to keratitis. Case 2 (28 years, male) had symblepharon , ocular surface keratinization , and severe dry eye. Case 3 (16 years , female ) had partial limbal stem cell deficiency with dry eye. All cases were treated with topical lubricants, short course of low-potency steroids and immuno-modulators. Attention must be paid to the eye in addition to the oro-an-genital mucosa to avoid longterm ocular sequelae.

Fungal keratitis: A review of clinical presentations, treatment strategies and outcomes.

Infectious keratitis is a significant cause of corneal blindness worldwide. Although less prevalent in the developed world, cases of fungal keratitis account for almost half of all keratitis cases, occurring in the developing countries. These cases are one of the most refractory types of infectious keratitis and present various challenges to the treating physician such as delayed presentation, long waiting time for culture positivity, limited availability effective antifungal drugs, prolonged duration for response to therapy, a highly variable spectrum of anti-fungal drug sensitivity and a high recurrence rate following keratoplasty. The advent of rapid diagnostic tools, molecular methods, in vitro anti-fungal drug sensitivity testing, alternatives to natamycin, targeted drug delivery and most importantly the results of large randomized controlled trials have significantly improved our understanding and approach towards the diagnosis and management of cases with fungal keratitis. Overall, Aspergillus and Fusarium species are the most common causes ones of fungal keratitis. History of antecedent trauma is a significant predisposing factor. Corneal scrapings for microscopic evaluation and culture preparation, is the standard of care for establishing the diagnosis of fungal keratitis. Molecular identification of cultures offers accurate identification of fungal pathogens, especially the rare species. Natamycin is an approved first-line drug. Voriconazole is the best alternative, especially for non-fusarium cases. Management involves administration of drugs usually by a combination of various routes, the treatment regimen being individualized depending upon the response to therapy. Photodynamic therapy is a newer treatment modality, being tried for non-responsive cases, before resorting to a therapeutic graft.