Distribution of TGFBI variants in patients with early onset glaucoma.

Purpose: To describe a novel association of TGFBI variants with congenital glaucoma in a family with GAPO (growth retardation, alopecia, pseudoanodontia, and progressive optic atrophy) syndrome, as well as among other unrelated cases of juvenile onset open-angle glaucoma (JOAG) and primary congenital glaucoma (PCG). Methods: This study of one family of GAPO with congenital glaucoma and three unrelated patients with JOAG analyzed a common link to glaucoma pathogenesis. Three girls with GAPO syndrome born to consanguineous parents in a multi-generation consanguineous family were identified. Two of the girls had congenital glaucoma in both eyes, while the elder sibling (a 10-year-old female) had features of GAPO syndrome without glaucoma. Results: A genetic evaluation using whole exome sequencing revealed a novel homozygous ANTXR1 mutation in all three affected siblings with GAPO. No other mutations were detected in the genes associated with glaucoma. A rare missense variant in the TGFBI gene was shared in the two siblings with congenital glaucoma and GAPO syndrome. We found three other unrelated patients with JOAG and one patient with primary congenital glaucoma with no known glaucoma causing gene mutations, but having four different missense variants in the TGFBI gene. One of these patients with JOAG had familial granular corneal dystrophy. Molecular dynamic simulations of TGFBI and 3-D structural models of three of its variants showed significant alterations that could influence TGFBI protein function. Conclusions: The possibility that variations in the TGFBI gene could have a possible role in the pathogenesis of congenital and juvenile onset open-angle glaucomas needs further evaluation.

Artificial liver support systems.

Artificial liver systems are used to bridge between transplantation or to allow a patient's liver to recover. They are used in patients with acute liver failure (ALF) and acute-on-chronic liver failure. There are five artificial systems currently in use: molecular adsorbent recirculating system (MARS), single-pass albumin dialysis (SPAD), Prometheus, selective plasma filtration therapy, and hemodiafiltration. The aim is to compare existing data on the efficiency of these devices. A literature search was conducted using online libraries. Inclusion criteria included randomized control trials or comparative human studies published after the year 2000. A systematic review was conducted for the five individual devices with a more detailed comparison of the biochemistry for the SPAD and MARS systems. Eighty-nine patients were involved in the review comparing SPAD and MARS. Results showed that there was an average reduction in bilirubin (-53 µmol/L in MARS and -50 µmol/L in SPAD), creatinine (-19.5 µmol/L in MARS and -7.5 µmol/L in SPAD), urea (-0.9 mmol/L in MARS and -0.75 mmol/L in SPAD), and gamma-glutamyl transferase (-0.215 µmol/L·s in MARS and -0.295 µmol/L·s in SPAD) in both SPAD and MARS. However, there was no significant difference between the changes in the two systems. This review demonstrated that both MARS and SPAD aid recovery of ALF. There is no difference between the efficiency of MARS and SPAD. Because of the limited data, there is a need for more randomized control trials. Evaluating cost and patient preference would aid in differentiating the systems.

Outcomes of surgical interventions for the treatment of limbal stem cell deficiency.

Background & objectives: In the current scenario, with availability of different surgical procedures for limbal stem cell deficiency (LSCD), there exists no common consensus as to the standardization of the management protocol for the same. In addition, there also exists diversity in the views about the clinical diagnosis, ancillary investigations and clinical parameters. The objective of the present study was to evaluate the reported outcomes of surgical interventions for the management of LSCD. Methods: A systematic review of published literature on limbal stem cell transplantation (LSCT) was performed using Ovid Medline, Embase and PubMed for a duration of 2009 to 2019. Original studies including prospective, retrospective case series and randomized controlled trials, articles in English language, articles with access to full text and studies with more than or at least 10 patients were included in this review. Data related to clinical and visual outcomes were evaluated, and pool estimates of different surgeries were calculated using random-effects model and individually using Pearson's Chi-square test. Results: A total of 1133 abstracts were evaluated. Finally, 17 studies were included for the analysis. Among these 17 studies, direct limbal lenticule transplantation was performed in five studies, of which autologous tissue from the fellow eye [conjunctival limbal autograft (CLAU)], allograft from a cadaver/live donor [keratolimbal allograft (KLAL)/conjunctival limbal allograft (CLAL)] and combination of CLAU plus KLAL were done in one, three and one studies, respectively. The ex vivo expanded cultivated limbal epithelial transplantation (CLET) was reported in six studies and simple limbal epithelial transplantation (SLET) in four studies. Two were comparative studies comparing CLET and CLAL (living-related CLAL) with cadaveric KLAL, respectively. Outcome analysis of the included studies showed significant heterogeneity. Calculated pool rate for various types of surgeries was calculated. The pool estimate for CLAL was 67.56 per cent [95% confidence interval (CI), 41.75-93.36; I2=83.5%, P=0.002]. For KLAL, this value was 63.65 per cent (95% CI, 31.38-95.91; I2=92.4%, P=0.000). Pool estimate for CLET was 78.90 per cent (95% CI, 70.51-87.28; I2=73.6%, P=0.001). Corresponding values for SLET were 79.08 per cent (95% CI, 74.10-84.07; I2=0.0%, P=0.619). CLAU and combination of CLAU plus KLAL were done in one study each; hence, statistical analysis could not be done. The functional outcome in terms of gain in visual acuity post-operatively was better in KLAL (P<0.005) and SLET group as compared to CLET group. Interpretation & conclusions: The present analysis suggests that though the anatomical success rates were almost identical between SLET, CLET, CLAL, and KLAL procedures, the functional success rates were better following KLAL and SLET procedures as compared to CLET. Decision for LSCT for cases of ocular burns based on either clinical judgement of the surgeon or individual diagnosis remains a suitable option.

Species identification, antifungal susceptibility profiles and biofilm formation attributes of Rhodotorula isolates from ocular infections.

BACKGROUND: Members of genus Rhodotorula are widely distributed in nature and have been traditionally considered non-pathogenic. Last few decades have seen the yeast as an emerging pathogen. We observed increase in numbers of Rhodotorula isolates from ocular infections in last few years, thus this prospective study was planned. OBJECTIVES: To identify the species of Rhodotorula isolates from ocular infections. To know the antifungal susceptibilities and study the biofilm formation attributes of the isolates. MATERIALS AND METHODS: Rhodotorula isolates were speciated using conventional methods, Matrix Assisted Laser Desorption and Ionisation - Time of Flight (MALDI- TOF) and sequencing of ITS region of ribosomal DNA. Antifungal susceptibility testing (AFST) was done using disc diffusion and E-test. Biofilm formation was studied using XTT [2,3-bis (2-methoxy-4-nitro-5-sulfo-phenyl)-2H-tetra-zolium-5-carboxanilide] assay. RESULTS: Twenty four isolates (92.3%) were identified as R. mucilaginosa and two as R. Minuta. AFST showed high MICs against Fluconazole, Amphotericin-B, Caspofungin, Micafungin and Flucytosine; MIC distribution from low to very high against Voriconazole, Itraconazole and Natamycin; and very low MICs against Posaconazole 57.7% of isolates were strong biofilm producers, 23.1% were moderate, and 19.2% were non producers. CONCLUSIONS: This is the first prospective study on species distribution, antifungal susceptibility and biofilm production attributes of Rhodotorula isolates from ocular infections; also first time demonstrating the utility of proteomics based MALDI-TOF in diagnosing Rhodotorula up to species level. The study has shown high MICs against the conventional azoles, Amphotericin-B and Flucytosine. However, low MICs against Posaconazole and Natamycin give a hope for their possible therapeutic use.

An unusual presentation of conjunctival aspergillosis as a polyp in an immunocompetent child.

Fungi are a part of normal ocular flora and usually do not cause clinical infection in the absence of predisposing factors. We report a 7-year-old healthy boy from a rural area of India, who presented with a gradually increasing mass in the left eye. Excisional biopsy of the mass was performed, and pathological examination revealed multiseptate hyphae with acute-angle branching consistent with aspergillosis.

Ophthalmic genetics practice and research in India: Vision in 2020.

Ophthalmic genetics is a much needed and growing area in India. Ethnic diversity, with a high degree of consanguinity, has led to a high prevalence of genetic disorders in the country. As the second most populous country in the world, this naturally results in a significant number of affected people overall. Practice involves coherent association between ophthalmologists, genetic counselor and pediatricians. Eye genetics in India in recent times has witnessed advanced research using cutting edge diagnostics, next generation sequencing (NGS) approaches, stem cell therapies, gene therapy and genomic editing. This article will highlight the studies reporting genetic variations in the country, challenges in practice, and the latest advances in ophthalmic genetic research in India.

Corneal transplantation in the modern era.

Corneal blindness is one of the major causes of reversible blindness, which can be managed with transplantation of a healthy donor cornea. It is the most successful organ transplantation in the human body as cornea is devoid of vasculature, minimizing the risk of graft rejection. The first successful transplant was performed by Zirm, and since then, corneal transplantation has seen significant evolution. It has been possible because of the relentless efforts by researchers and the increase in knowledge about corneal anatomy, improvement in instruments and advancements in technology. Keratoplasty has come a long way since the initial surgeries wherein the whole cornea was replaced to the present day where only the selective diseased layer can be replaced. These newer procedures maintain structural integrity and avoid catastrophic complications associated with open globe surgery. Corneal transplantation procedures are broadly classified as full-thickness penetrating keratoplasty and partial lamellar corneal surgeries which include anterior lamellar keratoplasty [sperficial anterior lamellar keratoplasty (SALK), automated lamellar therapeutic keratoplasty (ALTK) and deep anterior lamellar keratoplasty (DALK)] and posterior lamellar keratoplasty [Descemet stripping automated endothelial keratoplasty (DSAEK) and Descemet membrane endothelial keratoplasty (DMEK)] broadly.

Spectacle Coverage among Urban Schoolchildren with Refractive Error Provided Subsidized Spectacles in North India.

SIGNIFICANCE: Provision of subsidized spectacles to schoolchildren with refractive error in Delhi was associated with increased spectacle coverage. PURPOSE: Studies involving free spectacle distribution and self-purchase of spectacles often report poor compliance. We assessed 1-year spectacle coverage among schoolchildren with refractive error who were provided subsidized spectacles. METHODS: This was a study of a prospective cohort of 10,114 students from 20 randomly selected schools of Delhi. Children were presumed to have refractive error when unaided visual acuity was worse than or equal to 6/12 in either eye and a best-corrected visual acuity better than or equal to 6/9.5 in both eyes (n = 1503). Children with unmet need of spectacles (presenting with a visual acuity worse than 6/9.5 in the worse eye) were provided subsidized spectacles (n = 1191). Coverage was established by direct observation at baseline and after 1 year through unannounced visits. RESULTS: Mean age of cohort was 12.0 ± 2.0 years, and 566 (37.7%) were girls. Baseline spectacle coverage was 29.3% (95% confidence interval [CI], 27.1 to 31.7%), which improved to 65.9% (95% CI, 56.0 to 61.6%) among all children (n = 1470) and 58.8% (95% CI, 56.0 to 61.6%) among children with unmet need (n = 1163) at 1 year. Uptake of the subsidized spectacles was 98.6%. On multivariate regression, the odds of spectacle use were greatest when unaided vision was poor: 55.5% when visual acuity was better than or equal to 6/9.5, 74.8% when visual acuity was 6/19 to 6/60 (adjusted odds ratio, 2.5; 95% CI, 1.7 to 3.5), and 91.5% when visual acuity was worse than 6/60 (adjusted odds ratio, 3.1; 95% CI, 1.0 to 9.5). Sex (boys, 66.3%; girls, 65.3%) and socioeconomic status (lower, 58.6%; middle, 61.8%; upper middle, 70.7%) were not associated with coverage. Increasing maternal education and baseline spectacle use were associated with coverage. However, 38.0% were wearing spectacles prescribed by the project, and 61.9% of the spectacles being used at 1 year were purchased in the open market. CONCLUSIONS: Spectacle coverage after 1 year increased through a subsidized spectacle scheme, particularly for children with poor uncorrected vision.

Knowledge and attitude towards eye donation among health professionals of northern India.

Background: We aimed to assess the knowledge and attitude of health professionals towards eye donation at an apex tertiary care centre of northern India. Methods: We interviewed 600 health professionals, comprising doctors, nurses, medical as well as nursing students, social workers and allied paramedical staff. A structured questionnaire (12 questions for assessing knowledge and 5 questions for assessing attitude) was used to estimate the awareness of eye donation and willingness to pledge eyes for donation. The responses pertaining to knowledge were graded as 'excellent', 'good' and 'poor' and those pertaining to attitude were grouped into 'positive' and 'negative'. Results: Of the 600 participants, 138 participants (23%) had 'excellent' knowledge and 234 participants (39%) had 'good' knowledge about eye donation. Awareness of eye donation was positively related to the level of literacy (odds ratio [OR] 8.5 [2.30-31.2]; p<0.001). Medical social workers and health supervisors had better knowledge about eye donation (OR 2.01 [1.08-3.72]; p=0.026) than other professional groups. Knowledge of eye donation had no significant association with age, gender, religion, family type and marital status of the respondent. Willingness to pledge eyes for donation was observed in only 6% of the participating health professionals. Pledging of eyes for donation was higher among older participants (OR 7.8 [2.67-22.77]; p<0.001). Conclusion: Our study shows that there is sufficient knowledge about eye donation, but an alarmingly low willingness to pledge eyes for donation among health professionals. Concerted efforts are required to alter their attitude to strengthen the Hospital Cornea Retrieval Programme.

Treatment Decision-making of Cracked Teeth: Survey of American Endodontists.

AIM: The aim of this study is to survey the opinion of endodontists in the United States regarding their approach to treatment of cracked teeth. MATERIALS AND METHODS: A survey assessing the opinions of 3,500 endodontists in the United States was administered over a 4-week period. It consisted of a hypothetical clinical case and eight different treatment scenarios. Participants were asked to select one of the two treatment options: (A) informing the patient of the presence of a crack, reinforcing the tooth, and continuing with endodontic treatment; and (B) extraction of the tooth followed by replacement with an implant supported crown or fixed partial denture. RESULTS: When the crack extended across the distal marginal ridge with no associated probing depths, 92.65% endodontists preferred to continue with endodontic treatment and reenforcing the tooth. When the crack extended across the distal marginal ridge and was associated with a probing depth of 6 mm, 80% preferred extraction of the tooth. When the crack extended across the mesial marginal ridge up to the orifice of the mesiolingual canal with no associated probing depth, 82.78% preferred to continue with the treatment. When the crack was associated with a 6-mm probing depth, 83.79% preferred tooth extraction. When the crack extended across the mesial marginal ridge and down into the mesiolingual canal with/without associated probing depth, 91.13% and 63.54% preferred tooth extraction, respectively. When the crack involved both mesial and distal marginal ridges and extended across the pulp chamber, 79.74% preferred tooth extraction. When a split tooth was presented, 98.48% preferred tooth extraction. CONCLUSION: It appears that the presence of a 6-mm periodontal pocket is considered an important factor by most American endodontists when deciding whether to preserve the cracked tooth or extract it. CLINICAL SIGNIFICANCE: There is no consensus among dentists regarding the best approach to treat cracked teeth. Conclusive studies evaluating clinical approaches of endodontists regarding treatment of cracked teeth are lacking. Therefore, surveyed opinion of endodontists in the United States regarding their approach to treatment of cracked teeth was done to try to reach the best clinical decision regarding this dilemma.

Deep blue dot corneal degeneration: confocal characteristics.

PURPOSE: To discuss the clinical features, differential diagnosis and the novel confocal microscopic findings noted in the rare 'deep blue dot corneal degeneration'. METHODS: Observational case report. RESULTS: Slit-lamp biomicroscopic examination revealed bilateral, numerous, circular to oval discrete blue opacities at the level of deep stroma and fine grey linear opacities at the level of mid to deep stroma. Confocal microscopy demonstrated two types of corresponding hyper-reflective extracellular lesions: oval deposit-like, most concentrated at a depth of 430-480 µ and needle-like at the depth 330-370 µ. CONCLUSIONS: Deep blue dot corneal degeneration is a rare entity where blue deposits of amyloid are seen in the deep corneal stroma. It should be considered as a differential diagnosis when an old-aged person presents with good vision and the above mentioned findings.

Eye donation and eye banking in India.

Corneal blindness is a priority condition under the National Programme for Control of Blindness and an important cause of avoidable blindness in India. A multipronged approach is needed to eliminate corneal blindness. Curable or treatable blindness requires a spectrum of care including medication, optical rehabilitation and corneal transplantation. Corneal transplantation is dependent on the availability of safe, donor eyes; however, there is scarcity of donor corneal tissues in India. To improve the eye banking system, the Government of India supports eye banks through recurring grants for operational costs and non-recurring grants for infrastructure costs. Strategic interventions by the government and non-governmental organizations include awareness by health promotion and education, community participation, sustainable source of donor cornea, quality medical standards, accreditation and endeavours to strengthen eye banking systems and procedures through training and research. A model eye banking system in India can be achieved only when it is linked with the targeted infrastructure proposed under 'Vision 2020: Right to Sight- India'. Considering these targets, there is a requirement of at least 20 eye bank training centres, 200 eye banks with corneal transplant facility (collection of nearly 500 corneas per year) and 2000 eye donation centres in the country. This would become a reality if the Hospital Cornea Retrieval Programme is strengthened at all private and government hospitals, uniform medical standards are made mandatory for all eye banks and eye donation centres and the process of registration and eye donation is simplified to enhance community participation.

Triple chamber: a clinical rarity after deep anterior lamellar keratoplasty and role of optical coherence tomography in management.

PURPOSE: To report a case demonstrating triple chamber following deep anterior lamellar keratoplasty (DALK) and its successful intra-operative optical coherence tomography-guided management. METHOD: Case report of a young male with macular corneal dystrophy, who underwent DALK in his left eye by Big-Bubble technique. The surgery was uneventful. On the first post-operative day, triple chamber was observed and followed-up with serial clinical photography and anterior segment optical coherence tomography. Due to decrease in graft clarity and increase in volume of the two extra chambers, interface drainage along with descemetopexy was undertaken 4 days later. RESULT: The compartments constituting the triple chamber were those in-between the donor tissue and host pre-Descemet layer (Dua's layer), the latter and host Descemet membrane and the true anterior chamber. Presence of viscoelastic in the interface was identified as the cause. Microscope integrated optical coherence tomography (MiOCT) guided drainage followed by intracameral air tamponade ensured near total disappearance of the two extra chambers at the end of surgery. Examination on the next day confirmed complete apposition of the graft and host. CONCLUSION: To the best of our knowledge, this is a unique demonstration of Dua's layer in vivo by slit lamp biomicroscopy and description of MiOCT guided management of triple chamber.

Long-term outcome of cataract surgery in patients with idiopathic hypoparathyroidism and its relationship with their calcemic status.

Cataract is a cardinal manifestation of hypoparathyroidism. Although patients with hypoparathyroidism require cataract surgery at a younger age than individuals without hypoparathyroidism, there is limited information on the outcome of this surgery. We assessed long-term complications of cataract surgery in patients with idiopathic hypoparathyroidism (IH) and its relationship with their clinical and biochemical parameters. Twenty-seven patients with IH and 25 nonhypoparathyroid controls with a minimum follow-up of 2 years after cataract surgery were assessed for visual acuity, intraocular pressure, lens centricity, Nd:YAG laser capsulotomy, and the severity of posterior capsular opacification (PCO) and anterior capsular opacification. High-resolution optical slit-lamp images were analyzed by an ophthalmologist. Patients with IH had cataract surgery at a younger age than controls (34.0 ± 16.4 years vs 58.0 ± 11.2 years, P < 0.001). A higher proportion of IH patients had dense white PCO (75.0 % vs 39.4 %, P = 0.004), Nd:YAG laser capsulotomy (44.2 % vs 10.0 %, P = 0.001), anterior capsular opacification (97.7 % vs 84.2 %, P = 0.03), and a decentric lens (28.3% vs 2.6 %, P = 0.001) at a comparable time after surgery (8.6 ± 6.1 years vs 8.7 ± 6.8 years, P = 0.85). On regression analysis, the severity of PCO in IH correlated only with male sex and not with other factors, including serum total calcium and inorganic phosphorus levels at the baseline and during follow-up. To conclude, patients with IH are likelier than individuals without IH to develop PCO and to require Nd:YAG laser capsulotomy after cataract surgery. Proper precautions should be taken during surgery to minimize this complication in IH.

Transscleral Suture-Fixated Versus Intrascleral Haptic-Fixated Intraocular Lens: A Comparative Study.

PURPOSE: To compare the clinical outcomes between sutured transscleral-fixated and intrascleral haptic-fixated posterior chamber intraocular lens (IOL). SETTING: Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi. DESIGN: A comparative case series. METHODS: Forty eyes of 40 patients were included; 20 in each group. Patients in group 1 underwent sutured transscleral-fixated IOL and those in group 2 underwent intrascleral haptic-fixated IOL augmented by fibrin glue. Parameters evaluated were uncorrected visual acuity (UCVA), best corrected visual acuity (BCVA), intraocular pressure (IOP), central macular thickness (CMT), IOL tilt on ultrasound biomicroscopy (UBM), and pseudophakodonesis on slitlamp and UBM. RESULTS: The most common cause of aphakia was complicated cataract surgery (50%). The mean preoperative UCVA in logarithm of minimum angle of resolution (logMAR) was 1.59±0.24 and 1.63±0.26 in group 1 and 2, respectively (P=0.45). There was significant improvement in UCVA in both groups (P=0.001) at 6 months (group 1: 0.33±0.17; group 2: 0.22±0.10); the improvement being greater in group 2 (P<0.05). Mean percentage endothelial cell loss and IOP change were comparable. Mean CMT (µm) was 250.95±23.98 and 225.85±21.13 in group 1 and 2, respectively (P=0.009). Pseudophakodonesis was more in group 1 as assessed on slitlamp (P=0.037) and as assessed on UBM (P=0.046). Macular edema was the most common complication seen more in group 1. CONCLUSIONS: Intrascleral haptic-fixated IOL provides more stable fixation, better visual outcome, and lesser complication in comparison with sutured transscleral-fixated IOL.

Invasive Ocular Surface Squamous Neoplasia Masquerading as Nodular Scleritis.

The authors report a rare case of ocular surface squamous neoplasia with intraocular involvement that had an initial masquerade presentation of recurrent anterior nodular scleritis. A 35-year-old male patient presented with right eye recurrent anterior nodular scleritis for which a lamellar patch graft was done. Two months later, the patient presented with recurrence of symptoms. Histopathology review revealed the presence of well-differentiated squamous cell malignancy. A high index of suspicion for malignancy is required in such cases when they do not respond to conventional therapy.

Association of ZEB1 and TCF4 rs613872 changes with late onset Fuchs endothelial corneal dystrophy in patients from northern India.

PURPOSE: Fuchs endothelial corneal dystrophy (FECD) results in loss of vision associated with progressive corneal edema and loss of corneal transparency. The aim of the study was to evaluate changes in ZEB1, COL8A2, SLC4A11, and TCF4 rs613872 and correlate them with clinical findings. METHODS: Eighty-two patients with clinically diagnosed FECD and 143 controls were recruited during the period 2007-2012. Clinical details, pedigree information up to three generations, and 5 ml of blood samples were collected. Histopathological and transmission electron microscopy studies were performed on host corneal buttons from patients who underwent keratoplasty. Genomic DNA from blood was processed for PCR amplification followed by direct sequencing to screen genetic changes in the candidate genes. The pathogenic nature of the genetic variants was assessed using Sorting Intolerant From Tolerant (SIFT) and MutationTaster. RESULTS: The mean age at the onset of symptoms was 59.14±1.41years, the male to female ratio was 1:1.5, and the mean specular count (endothelial cell density) was 1629±93.62 cells/mm(2) with a mean central corneal thickness (CCT) of 617.30±15.73 µm. ZEB1 showed a novel variant IVS2+276 C/T in 14% of the cases, a novel nonsense p.Leu947stop mutation in one patient, two novel missense mutations (p.Glu733Lys, p.Ala818Val) in one patient each, and one novel synonymous variation (p.Ser234Ser) in two patients. Reported mutation p.Gln840Pro and five polymorphisms were also identified. The TCF4 single nucleotide polymorphism (SNP) rs613872 was significantly higher in patients with FECD. CONCLUSIONS: This is the first report of genetic variations in ZEB1 and TCF4 SNP rs613872 in patients with FECD from northern India that suggests a possible role in disease pathogenesis and the regulation of endothelial cell density.

Corneal changes in childhood glaucoma.

OBJECTIVE: To study the clinical features and topography of the cornea in eyes with childhood glaucoma. DESIGN: Cross-sectional, observational study. PARTICIPANTS: Fifty-eight eyes with childhood glaucoma and 28 eyes of age-matched controls. METHODS: Clinical and topographic corneal changes were evaluated. MAIN OUTCOME MEASURES: Corneal topographic changes were evaluated on Orbscan (Orbscan Topography System II; Bausch & Lomb, Salt Lake City, UT) in eyes with childhood glaucoma and those changes were compared with the control eyes. RESULTS: Fifty-eight eyes with childhood glaucoma and 28 eyes of age-matched controls were evaluated. Thirty-six eyes (62.1%) were classified as having primary childhood glaucoma and 22 eyes (37.94%) as having childhood glaucoma with associated ocular anomalies. The corneas in 18 of 58 eyes (31.0%) with childhood glaucoma were clear, whereas 24.1% of eyes (14/58 eyes) had some corneal opacification. Haab's striae were noted in 44.8% of eyes (26/58 eyes) and were most frequently present between 3 and 5 mm from the optical axis. The mean posterior elevation recorded in eyes with childhood glaucoma controlled with medication or surgery was significantly higher than that in control eyes: 0.043 ± 0.027, 0.042 ± 0.017, and 0.018 ± 0.058 µm, respectively (P < 0.0001). The presence of Haab's striae was correlated significantly with a higher posterior elevation (P = 0.0396) and poor vision. The mean anterior elevation in eyes with childhood glaucoma (0.022 ± 0.015 µm) and in control eyes (0.015 ± 0.078 µm) was comparable (P = 0.08). Corneal astigmatism in eyes with childhood glaucoma was significantly higher and irregular compared with that in control eyes: 2.09 ± 1.40 versus 0.93 ± 0.60 diopter cylinder (P = 0.0001); the irregularity index was 2.8 (range, 1-18.1) and 2.3 (range, 0.6-2.3) at 3 mm (P = 0.0005) and 3.2 (range, 1.4-21.3) and 1.8 (range, 0.5-2.9) at 5 mm, respectively (P = 0.0003). Best-corrected visual acuity correlated significantly with cup-to-disc ratio, axial length, refractive error, astigmatism, and posterior corneal elevation. Multivariate analysis showed a significant correlation only with cup-to-disc ratio and axial length. CONCLUSIONS: Childhood glaucoma causes a significant increase in posterior corneal elevation and irregular astigmatism, which contribute to visual disability in such eyes.

Ocular graft versus host disease in allogenic haematopoetic stem cell transplantation in a tertiary care centre in India.

BACKGROUND & OBJECTIVES: This study was aimed to report the occurrence of ocular graft versus host disease (oGVHD) in allogeneic haematopoietic stem cell transplantation (allo-HSCT) patients in a tertiary care hospital setting. METHODS: A cross-sectional study of ocular surface of allo-HSCT patients was done. Slit lamp biomicroscopy, symptom score, tear meniscus height, fluorescein tear break-up time, Schirmer's test I, ocular surface staining, dry eye severity, ocular surface disease index score were done. Indications for allo-HSCT, human leukocyte antigen (HLA) matching, GVHD risk factor, systemic manifestation and treatment were also noted. RESULTS: GVHD occurred in 44.4 per cent of 54 allo-HSCT patients (mean age 26.7 ± 12 yr) included in the study. GVHD risk factors identified included female gender, relapse, older age of donor, cytomagelo virus (CMV) reactivation, and multiparous female donors. oGVHD was noted in 31.5 per cent with mean time to occurrence being 17.8 ± 21.9 months after the allo-HSCT and was observed in 89.5 per cent of chronic GVHD cases. Acute GVHD (oral and dermatological) involvement showed a significant association with GVHD in our patients (P< 0.001, 0R 23.0, CI 6.4-82.1). Chronic GVHD was observed to be associated with the occurrence of oGVHD (dry eye) (P<0.001, OR = 24.0, CI 0.02 - 0.29). Of the 34 eyes with oGHVD, dry eye of level 3 severity was seen in 16, level 2 in six, level 1 in 12 eyes. INTERPRETATION & CONCLUSIONS: GVHD occurred in 44.4 per cent of the patients studied in the present study. Acute and chronic GVHD showed a strong association with oGVHD. Dry eye disease due to chronic oGVHD was observed in 17 (31.5%) of 54 allo-HSCT patient with chronic oGVHD occurring in 17 (89.4%) of chronic GVHD cases in allo-HSCT patients. Our study on oGVHD in post allo-HSCT patients in tertiary care centre points towards the fact that ocular morbidity due to dry eye disease as a result of oGVHD is a cause for concern in these patients.

Collagen cross-linking in keratoconus in Asian eyes: visual, refractive and confocal microscopy outcomes in a prospective randomized controlled trial.

To evaluate the safety and efficacy of collagen cross-linking (CXL) in the treatment of keratoconus. A prospective randomized sham-controlled clinical trial was undertaken and 43 eyes with moderate to severe keratoconus were randomized into two groups that is the treatment (n = 23) and the sham (n = 20) group. CXL was performed with riboflavin (0.1 in 20 % dextran) followed by UVA radiation (365 nm, 3 mW/cm(2), 30 min). In the sham group, only riboflavin was administered without UVA radiation. Uncorrected distance visual acuity (UDVA), corrected distance visual acuity, intraocular pressure, corneal thickness, keratometry, endothelial count, confocal microscopy were evaluated at baseline and at 1 week, 1, 3, and 6 months. In cases where CXL was done, UDVA improved by mean 0.11 ± 0.06 logMAR units at 6 months (P = 0.01). The refractive cylinder and spherical equivalent decreased by mean of 0.62 D (P = 0.01) and 0.5 D (P = 0.19), respectively. Ultrasonic central corneal thickness decreased by mean 22.7 ± 10.3 µm (P = 0.01). The maximum and minimum keratometry decreased by mean of 1.2 ± 0.8 D (P = 0.01) and 0.83 ± 1.2 D (P = 0.39), respectively. The specular count and intraocular pressure did not show any significant change. In the sham group, no significant change was observed in any parameter. Confocal analysis showed that the epithelial healing was complete at 1 week after crosslinking. The sub-epithelial plexus showed loss of nerve plexus at 1 month, regeneration of nerve fibers which started at 3 months and was complete at 6 months. The anterior stroma showed loss of keratocytes with honeycomb oedema and apoptotic bodies till 3 months. The regeneration of keratocytes started at 3 months and was complete at 6 months of follow-up. Collagen cross-linking is an effective procedure to halt progression in keratoconus. The confocal microscopic changes correlate with the outcomes in the treatment and the sham groups.