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.

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.

Utility of intraocular endoscope for lacrimal canaliculi and sac examination.

PURPOSE: Intraocular endoscope was used as a dacryoendoscope, and its observations and performance in lacrimal drainage system (LDS) are reported. METHODS: The Endo Optiks (Little Silver, New Jersey, USA), an intraocular endoscope (modified with customized sheath), was used for LDS visualization in ten normal adults and five patients with lacrimal disorders. RESULTS: We were able to capture high-definition images of lacrimal canaliculi and sac in all normal adults. Smooth whitish canalicular mucosa with lumen could be appreciated in all normal individuals. Common canaliculus showed variable folds among individuals and reddish lacrimal sac mucosa could be appreciated with great details. In patients with canalicular obstruction, site of obstruction was presented as whitish gray area with no visible lumen, which could be opened up precisely with trephination. No false passage was formed in any of the cases. One of the cases had membranous canalicular obstruction, which was opened with probe itself. Nasolacrimal duct could not be examined due to the shorter length of the probe. CONCLUSION: Intraocular endoscope can be used as high-resolution dacryoendoscope for visualization of lacrimal canaliculi and sac.

Descemet membrane endothelial keratoplasty (DMEK) aquarium: Diving in to learn DMEK surgical concepts.

A novel simulation model (without using human corneas) has been described for understanding the surgical concepts and developing tactile reflexes of Descemet membrane (DM) endothelium scroll manipulation and orientation in the anterior chamber, which are necessary for performing Descemet membrane endothelial keratoplasty (DMEK). Termed the "DMEK aquarium," this model helps facilitate the understanding of different maneuvers of the DM graft needed inside the fluid-filled anterior chamber, like unrolling or unfolding, flipping or inversion, and checking orientation and centration in the host cornea. A stepwise plan for surgeons starting to learn DMEK utilizing various available resources is also suggested.

Evaporative dry eye disease due to meibomian gland dysfunction: Preferred practice pattern guidelines for diagnosis and treatment.

Evaporative dry eye (EDE) due to meibomian gland dysfunction (MGD) is one of the common clinical problems encountered in ophthalmology. It is a major cause of dry eye disease (DED) and of ocular morbidity. In EDE, inadequate quantity or quality of lipids produced by the meibomian glands leads to faster evaporation of the preocular tear film and symptoms and signs of DED. Although the diagnosis is made using a combination of clinical features and special diagnostic test results, the management of the disease might be challenging as it is often difficult to distinguish EDE from other subtypes of DED. This is critical because the approach to the treatment of DED is guided by identifying the underlying subtype and cause. The traditional treatment of MGD consists of warm compresses, lid massage, and improving lid hygiene, all measures aimed at relieving glandular obstruction and facilitating meibum outflow. In recent years, newer diagnostic imaging modalities and therapies for EDE like vectored thermal pulsation and intense pulsed light therapy have emerged. However, the multitude of management options may confuse the treating ophthalmologist, and a customized rather than a generalized approach is necessary for these patients. This review aims to provide a simplified approach to diagnose EDE due to MGD and to individualize treatment for each patient. The review also emphasizes the role of lifestyle modifications and appropriate counseling so that patients can have realistic expectations and enjoy a better quality of life.

A review on drug-induced dry eye disease.

Dry eye disease encompasses a broad range of etiologies and disease subtypes which have similar clinical manifestations. Medications can cause dry eye disease or symptoms of dryness as a side effect by either interfering with the lacrimal gland or meibomian gland function, or both, and by other mechanisms that affect the ocular surface homeostasis. This is important to know and recognize as eliminating the offending medication can reverse the symptoms and, in many cases, prevent further deterioration of the ocular surface inflammation. This review focuses on drugs like systemic isotretinoin and taxanes, which cause meibomian gland dysfunction; immune checkpoint inhibitors that cause lacrimal gland dysfunction; gliptins and topical antiglaucoma medications that cause cicatrizing conjunctivitis; and epidermal growth factor receptor inhibitors, fibroblast growth factor receptor inhibitors, and belantamab mafodotin, which cause mucosal epitheliopathy. Many of these medications, particularly the newer anticancer agents, have only recently been introduced for clinical use, and knowledge and awareness of their ocular side effects are still evolving. This review aims to update ophthalmologists on the drug-induced causes of dry eye disease or symptoms of dryness, which is avoidable by discontinuation of the incriminating agent or can be mitigated by reducing the dose or frequency of usage.

TFOS Lifestyle: Impact of cosmetics on the ocular surface.

In this report the use of eye cosmetic products and procedures and how this represents a lifestyle challenge that may exacerbate or promote the development of ocular surface and adnexal disease is discussed. Multiple aspects of eye cosmetics are addressed, including their history and market value, psychological and social impacts, possible problems associated with cosmetic ingredients, products, and procedures, and regulations for eye cosmetic use. In addition, a systematic review that critically appraises randomized controlled trial evidence concerning the ocular effects of eyelash growth products is included. The findings of this systematic review highlight the evidence gaps and indicate future directions for research to focus on ocular surface outcomes associated with eyelash growth products.

Chronic cicatrizing conjunctivitis: A review of the differential diagnosis and an algorithmic approach to management.

Cicatrizing conjunctivitis constitutes a group of chronic local and systemic disorders that cause conjunctival scarring. A systematic approach is required to sift through the clinical history, examination, and laboratory investigations of patients to arrive at the correct diagnosis of the underlying cause. Establishing the etiology is critical, as the therapeutic approach changes based on the cause of conjunctival inflammation. Effective management of patients with the condition requires knowledge of multiple modalities such as systemic immunosuppressive therapy, use of scleral contact lenses, and surgery for ocular surface and vision improvement. We review the clinical features of this condition and present diagnostic and treatment algorithms to help simplify the complexities in its management. This review attempts to place all the relevant information on chronic cicatrizing conjunctivitis together in one place for the benefit of cornea and ocular surface specialists, general ophthalmologists, and ophthalmology residents.

Bilateral herpes simplex keratitis reactivation after lacrimal gland botulinum toxin injection.

Botulinum toxin A (BTA) injections into lacrimal gland are being used for refractory epiphora due to intractable lacrimal disorders with success rates reported from 18% to 86%. Most common side effects are transient ptosis and diplopia. We report a case of a 59-year-old female injected with 2.5 units of BTA injection in each lacrimal gland for functional epiphora. The patient had a history of herpes simplex viral keratitis that was quiescent for more than 2 years. After 3 weeks, she developed reactivation of viral keratitis bilaterally, which was successfully managed with antivirals and topical steroids. Reactivation of quiescent herpes simplex keratitis is a possibility after lacrimal gland BTA and caution should be exercised in such cases.

Simulation Model for DMEK Donor Preparation.

PURPOSE: To demonstrate a simulation model for donor preparation in Descemet membrane endothelial keratoplasty (DMEK). METHODS: The inner transparent membrane of the onion (Allium cepa) was used as a simulation model for human Descemet membrane (DM). Surgical video (see Video, Supplemental Digital Content 1, http://links.lww.com/ICO/A663) demonstrating all the steps was recorded. RESULTS: This model closely simulates human DM and helps DMEK surgeons learn the nuances of DM donor preparation steps with ease. The technique is repeatable, and the model is cost-effective. CONCLUSIONS: The described simulation model can assist surgeons and eye bank technicians to learn steps in donor preparation in DMEK.

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.

Oral mucosal grafting combined with tenonplasty for ocular surface and lid margin reconstruction in an atypical sectorial chemical burn.

A 46-year-old woman presented with chemical injury in both eyes after the instillation of undefined eye-drops prescribed by quack. She had an atypical presentation in the form of bilateral severe necrosis of both lids and whole palpebral conjunctiva. Extensive debridement with conjunctival epitheliectomy, tenonplasty and amniotic membrane transplantation (AMT) was performed. Characteristic differences from typical chemical injuries were a sectorial involvement of ocular surface and keratinisation over distorted lid margins. Lid margin needed replacement by labial mucous membrane for the restoration of ocular surface. Ocular surface reconstruction with AMT in acute phase and mucous membrane grafting for involved lid margins in late phase achieves vision salvage and avoids late complications in drug-induced chemical injury.

Cataract surgery in chronic Stevens-Johnson syndrome: aspects and outcomes.

AIM: To assess the outcome of cataract surgery in patients with chronic sequelae of Stevens-Johnson syndrome (SJS). METHODS: Setting: Tertiary eye care centre in South India. DESIGN: Retrospective, non-comparative, consecutive, interventional case series. Study period: March 2003 to May 2014. Of the 1662 consecutive patients with SJS, 32 patients (40 eyes) with chronic sequelae of SJS who underwent cataract surgery were included. The main outcome measures were best-corrected visual acuity (BCVA) and ocular surface stabilisation. The visual acuity was expressed with reference to the logMAR. RESULTS: The study included 12 men (37.5%) and 20 women (62.5%). 8 patients (25%) had bilateral cataract surgeries. The median preoperative BCVA was 1.61 (IQR, 0.80 to 2.78) (only perception of light in three eyes). The median BCVA in the immediate postoperative period was 0.60 (IQR, 0.30 to 1.48) (perception of light in an eye) which was significantly different from the preoperative BCVA (p<0.0001). The median BCVA achieved was 0.30 (IQR, 0.00 to 0.80), suggesting further improvement. Median time taken to achieve this postoperatively was 1.5 months (IQR, 8 days to 3 months). The median BCVA during the last follow-up was 0.48 (IQR, 0.18 to 1.00). The preferred type of cataract surgery was phacoemulsification. Ocular surface condition remained stable in 35 eyes (87.5%). Ocular surface breakdown in four eyes (10%) was managed appropriately. CONCLUSION: Cataract surgery outcome can be visually rewarding in chronic sequelae of SJS provided ocular surface integrity is adequately maintained preoperatively and postoperatively.

Primary Simple Limbal Epithelial Transplantation Along With Excisional Biopsy in the Management of Extensive Ocular Surface Squamous Neoplasia.

PURPOSE: To describe the utility of simple limbal epithelial transplantation (SLET) along with tumor excision in the management of extensive ocular surface squamous neoplasia (OSSN) to avoid limbal stem cell deficiency (LSCD). METHODS: This case report describes the management of a 75-year-old man clinically diagnosed with OSSN involving more than 3 quadrants of limbus. The excisional biopsy of tumor along with 4-mm healthy margin led to a complete loss of the limbus, which was restored by limbal epithelial cell transplantation using the SLET technique in the same setting. RESULTS: The tumor was found adherent to the episclera in the superotemporal quadrant and required episcleral and superficial lamellar scleral dissection. The entire tumor could be excised, and complete reepithelialization of the cornea was seen within 2 weeks. Histopathology showed tumor cells infiltrating the stroma and base of the excision biopsy, suggesting invasive squamous cell carcinoma. The excised margins were tumor free. To prevent recurrence, the patient underwent radiotherapy (plaque brachytherapy). After a follow-up period of 2 years, a successful outcome in the form of a stable ocular surface, no tumor recurrence, and no signs of LSCD was achieved in our patient. CONCLUSIONS: Restoration of limbal stem cells using SLET technique in an extensive OSSN in the primary setting may be pertinent to a good outcome.

Successful management of severe unilateral chemical burns in children using simple limbal epithelial transplantation (SLET).

AIM: To study the outcomes of simple limbal epithelial transplantation (SLET) for unilateral total limbal stem cell deficiency (LSCD) secondary to severe ocular surface burns in children. METHODS: Retrospective interventional case series was performed at a private referral tertiary care centre. Children less than 15 years of age who underwent autologous SLET for total LSCD and had a minimum follow-up of 6 months were included in the study. Demographic and clinical data were recorded in a predesigned form. All patients underwent SLET with a standardised technique. The outcome was defined as complete success (completely epithelialised, avascular corneal surface), partial success (focal recurrence of symblepharon not involving the visual axis) and failure (unstable ocular surface with persistent epithelial defects/symblepharon recurrence involving the visual axis). RESULTS: The mean age was 5.75 years (range 2-12). The male to female ratio was 3:1. All eyes (four) presented in the acute phase, had grade 6 chemical injury (Dua classification) and underwent amniotic membrane transplantation at presentation. The mean interval between initial injury and SLET was 6 months (range 4.5-8). The outcome was complete success and partial success in one-fourth and three-fourths of cases, respectively. The overall follow-up was 12-60 months. Pre-SLET visual acuities were hand motions (one eye) and perception of light (three eyes). Post-SLET visual acuities were counting fingers close to face (one eye), 6/36 (two eyes) and 6/18 (one eye) at final follow-up. Cases with partial success underwent repeat SLET with conjunctival autograft, after which the outcome was complete success in all cases at varied follow-up intervals (13-36 months). CONCLUSIONS: SLET appears to be a promising technique for treatment of LSCD secondary to ocular surface burns in children.