Evaluation of Meibomian Gland Structure and Function in Patients with Vernal Keratoconjunctivitis Using Non Contact Meibography and Lipid Layer Interferometry.

PURPOSE: This study evaluated the structural and functional impact of vernal keratoconjunctivitis (VKC) on meibomian glands (MGs) using a combination of noncontact meibography and lipid layer interferometry. METHODS: In this observational study 50 patients with moderate persistent or severe VKC and 50 age-matched controls underwent MG imaging and lipid layer thickness (LLT) measurements with Lipiview II. Image J software was used to assess MG loss (meibograde) in both lids. All patients underwent dry eye evaluation comprising tear break-up time (TBUT), ocular surface staining (OSS), Schirmer I scoring, and meiboscoring (expressibility and quality of meibum secreted). RESULTS: Meibograde, OSS score, and meiboscore was higher in cases (2.68 ± 0.96, 0.580 ± 1.07, and 0.56 ± 0.95 respectively) than controls (1.80 ± 0.67, 0.00 ± 0.00, 0.22 ± 0.47 respectively) (p < 0.001, 0.001, 0.025 respectively). LLT and TBUT was lower in cases (54.58 ± 9.43 nm and 4.92 ± 3.09 sec respectively) than controls (70.14 ± 22.50 nm and 12.02 ± 2.73 sec respectively) (both p's = 0.001). Both groups had comparable Schirmer I scores. CONCLUSION: Children with VKC have significant MG dropouts, deterioration in meibum quality and a thinner and less stable tear film. VKC patients are thus prone to a vicious cycle of inflammation attributable both to the allergic component and to deterioration in MG structure and function. Co-management of MG dysfunction warrants as much attention as the allergic component itself.

Ocular Cicatricial Pemphigoid in Young Patients.

PURPOSE: The purpose of this study is to report ocular cicatricial pemphigoid (OCP) occurring in young patients. Relevant literature is also reviewed. METHODS: Medical records of patients aged 30 years or younger who were treated for OCP between August 2021 and May 2023 at a tertiary care eye institute were reviewed. The most common differential diagnoses of cicatrizing conjunctivitis, such as Stevens-Johnson syndrome sequelae, chemical injury, chronic topical/systemic drug use, autoimmune connective tissue disorders, or allergic eye diseases, were ruled out based on clinical history, examination, and the Cicatrizing Conjunctivitis Score described by Shanbhag et al. The diagnosis of OCP was confirmed by positive direct immunofluorescence of oral mucosal and/or conjunctival biopsy in a majority of the patients. RESULTS: Seven patients fulfilled the criteria for a diagnosis of OCP. The mean age at presentation was 21.86 ± 5.25 years (13-28 years). Some of the patients presented with relatively atypical features for OCP such as corneal immune ring infiltrate and bilateral corneal perforation. Six patients exhibited systemic mucosal lesions, and the direct immunofluorescence yield was 85.71%. All patients required aggressive immunosuppressive treatment. CONCLUSIONS: OCP is classically described as a rare disease that occurs in old age. This case series highlights the importance of a higher index of suspicion for diagnosing OCP at a younger age. Early administration of immunosuppressive agents can potentially control severe ocular surface inflammation and its sequelae.

Correlation of anterior segment optical coherence tomography and ultrasound biomicroscopy in congenital corneal opacity.

PURPOSE: To investigate the correlation between swept-source anterior segment optical coherence tomography (AS-OCT) and ultrasound biomicroscopy (UBM) in congenital corneal opacity (CCO). METHODS: All children with unilateral or bilateral congenital corneal opacities who underwent examination under anesthesia (EUA) and anterior segment optical coherence tomography (AS-OCT) imaging from January 1, 2022, to December 31, 2022, were included. Main outcome measures were corneal and anterior segment evaluation and correlation of UBM and AS-OCT findings. RESULTS: A total of 22 eyes of 15 patients were imaged using both technologies. The age at first EUA ranged from 11 days to 4 years. Different phenotypes were classified based on the clinical examination, UBM, and AS-OCT findings. Fourteen eyes were diagnosed with Peters anomaly, congenital corneal staphyloma was observed in 4 eyes, 2 eyes had coloboma, 1 eye had peripheral sclerocornea, and 1 eye was diagnosed with congenital primary aphakia. AS-OCT and UBM findings were closely correlated in 18 of 22 eyes (82%) but AS-OCT failed to provide detailed information in 4 eyes (18%) where UBM revealed more details. CONCLUSIONS: Although AS-OCT offers valuable preliminary data for initial assessment and counseling, it may not consistently provide precise assessments in all cases. Therefore, UBM should be considered for definitive evaluation.

Effect of decentration on the quality of vision in two aspheric posterior chamber intraocular lenses: A contralateral eye study.

PURPOSE: To perform an intraindividual comparison of the quality of vision and the effect of decentration between two aspheric intraocular lenses: aspheric balanced curve (ABC) design Vivinex iSert XY1 (Hoya Surgical Optics, Singapore) and anterior aspheric design Tecnis ZCB00 (Abbott Medical Optics, CA). SETTING: Tertiary Eye Care Centre. DESIGN: Prospective, randomized comparative study using a random number table. METHODS: Thirty patients were randomized to the implantation of Vivinex iSert XY1 in one eye and Tecnis ZCB00 in the contralateral eye. Then, 12 weeks postoperatively, a laser ray-tracing aberrometer was used to evaluate the visual Strehl ratio, higher-order aberrations (HOA), decentration of IOL from the visual axis and geometric axis, angle alpha, and angle kappa. Contrast sensitivity was measured using the functional visual analyzer. RESULTS: The visual internal Strehl ratio was higher ( P < 0.05) at all pupil sizes and the spherical aberrations values were lower ( P < 0.05) at larger pupil sizes (5 mm and 6 mm) in the Vivinex group. The mean decentration from the visual axis in the Vivinex group was significantly more than that in the Tecnis group ( P < 0.01). With an increase in angle alpha, there was a greater decline in the visual Strehl ratio for Tecnis; however, there was a statistically significant decline at 3 mm pupil size for Tecnis ZCB00 ( P = 0.028). The contrast sensitivity was similar for both IOLs. CONCLUSION: In comparison to an anterior aspheric design IOL, the ABC design IOL yielded better quality of vision, neutralized spherical aberrations to a larger extent, and provided a relatively superior quality of vision with decentration.

Clinical outcomes of corneal neurotization using sural nerve graft in neurotrophic keratopathy.

OBJECTIVE: To evaluate the efficacy of corneal neurotisation using sural nerve graft coaptation of the contralateral supratrochlear nerve in unilateral neurotrophic keratopathy and corneal anesthesia. Corneal neuralization has emerged as a potential option in the treatment of neurotropic keratopathy, however not free from the predicament. We evaluated the long-term outcome of corneal neurotisation in the treatment of unresponsive unilateral neurotropic keratopathy using surgical variations to mimic and expedient the surgical procedure. METHODS: A Prospective interventional study involving patients with unilateral neurotrophic keratopathy (NK) who did not respond to medical measures was conducted. The study parameters evaluated were best-corrected visual acuity improvement, ocular surface evaluation parameters [tear break-up time (TBUT), Schirmer's 1, and ocular surface staining scores (corneal and conjunctival staining)], central corneal sensation (Cochet Bonnet esthesiometer), sub-basal nerve fiber length (SBNFL), and sub-basal nerve fiber density (SBNFD) determined by central confocal microscopy at recruitment and during follow-up at 1-month, 3-month, 6-month, 9-month and 12-month respectively, following corneal neurotization. RESULTS: Eleven eyes of 11 patients with unilateral neurotrophic keratopathy (NK) who underwent corneal neurotisation were studied. The mean follow-up was 10.09±2.31months (range, 6-12). Mean best corrected visual acuity in log MAR at baseline, 1.35±0.52 improved significantly to 1.06±0.76 (P = 0.012) at 3 months and continued to 0.55±0.60 (P = 0.027) at 12 months. There was a significant reduction in NK grade severity and improvement in the ocular surface as early as 1 month, and central corneal sensations (P = 0.024) as soon as 3 months. Mean corneal SBNF improved from 3.12±1.84 mm/mm2 to 4.49±1.88 at 1 month (P = 0.008), 13.31±3.61 mm/mm2 (P = 0.028) at 12 months. Mean central corneal SBNFD evident at 6 months was 1.83±2.54no/mm2 (P = 0.018) and 4.90±3.12no/mm2 (P = 0.028) at 12 months. CONCLUSION: This study substantiates the routine practice of corneal neurotisation by simplifying the intricacies observed during the procedure.

Dead bag syndrome-in the capsular bag subluxated intraocular lens centration and refixation: A new technique.

We describe a technique of scleral IOL fixation and optic centration of in the capsular bag subluxated IOL in a patient of "dead bag syndrome." A 29-year-old male diagnosed case of thalassemia presented with painless progressive diminution of vision in the left eye following uncomplicated sequential phacoemulsification in both eyes 15 years back. The right eye revealed completely centered IOL with significant amount of anterior capsular opacification (ACO), while the left eye revealed inferior subluxation of the IOL within capsular bag. The capsular bag was dilated, diaphanous with clear anterior and posterior capsule without any evidence of capsular fibrosis or opacification. Thus, a diagnosis of "dead bag syndrome" was made. The haptics were sutured to sclera (Hoffman's pockets) using two loops of 9-0 polypropylene, passed anterior and posterior to IOL haptics within the capsular bag. Postoperatively, the patient had a vision of 20/40 with a centered intraocular lens.

Intraoperative aberrometry versus preoperative biometry for intraocular lens power selection in patients with axial hyperopia.

Purpose: This study was conducted to evaluate the accuracy of intraoperative aberrometry (IA) in intraocular lens (IOL) power calculation and compare it with conventional IOL formulas. Methods: This was a prospective case series. Eyes with visually significant cataract and axial hyperopia (AL <22.0 mm) underwent IA-assisted phacoemulsification with posterior chamber IOL (Alcon AcrySof IQ). Postoperative spherical equivalent (SE) was compared with predicted SE to calculate the outcomes with different formulas (SRK/T, Hoffer Q, Haigis, Holladay 2, Barrett Universal Ⅱ and Hill-RBF). Accuracy of intraoperative aberrometer was compared with other formulas in terms of mean absolute prediction error (MAE), percentage of patients within 0.5 D and 1 D of their target, and percentage of patients going into hyperopic shift. Results: Sixty-five eyes (57 patients) were included. In terms of MAE, both Hoffer Q (MAE = 0.30) and IA (MAE = 0.32) were significantly better than Haigis, SRK/T, and Barrett Universal Ⅱ (P < 0.05). Outcomes within ±0.5 D of the target were maximum with Hoffer Q (80%), superior to IA (Hoffer Q > IA > Holladay 2 > Hill-RBF > Haigis > SRK/T > Barrett Universal Ⅱ). Hoffer Q resulted in minimum hyperopic shift (30.76%) followed by Hill-RBF (38.46%), Holladay 2 (38.46%), Haigis (43.07%), and then IA (46.15%), SRK/T (50.76%) and Barrett Universal Ⅱ (53.84%). Conclusion: IA was more effective (statistically significant) in predicting IOL power than Haigis, SRK/T, and Barrett Universal Ⅱ although it was equivalent to Hoffer Q. Hoffer Q was superior to all formulas in terms of percentage of patients within 0.5 D of their target refractions and percentage of patients going into hyperopic shift.

Corneal and corneal epithelial thickness distribution characteristics in healthy North Indian eyes using spectral domain optical coherence tomography.

Purpose: To determine the pattern of corneal thickness and epithelial thickness distribution in healthy North Indian eyes by using spectral domain optical coherence tomography (SD-OCT). Methods: The observational study measured total corneal and epithelial thickness in the central 2 mm zone and eight sectors each in paracentral 2-5 mm (ring 1) and midperipheral 5-7 mm (ring 2) zones on SD-OCT. Results: The study included 67 eyes of 67 subjects with a male:female ratio of 32:35 and mean age of 25.04 ± 4.54 years. The mean central corneal and epithelial thicknesses were 505.97 ± 30.12 µm and 60.48 ± 8.37 µm, respectively. The epithelium of inferior and infero-nasal sectors in ring 1 and inferior sector in ring 2 was significantly thicker than the radially opposite sectors of the respective rings (P = 0.001; P = 0.01 and P = 0.02, respectively). Sector-wise analysis did not reveal any significant correlation between the total corneal thickness and epithelial thickness (all P > 0.05) except in the outer superior sector where there was a weak positive correlation (r = 0.28, P = 0.02). Central epithelial thickness in males (60.59 ± 9.28 µm) and females (60.37 ± 7.58 µm) was comparable (P = 0.91). Pachymetry was thinnest in the inferior, inferonasal, and inferotemporal sectors in 44.79% of eyes (n = 30), while thinnest epithelium was seen in the superior, superonasal, and superotemporal quadrants in 50.75% of eyes (n = 34). Conclusion: The epithelial thickness distribution in this sample of topographically normal healthy North Indian eyes was nonuniform and independent of the underlying corneal thickness. Epithelium was thinner in the superior cornea, whereas total corneal thickness was minimum in the inferior part.

Comparison of contact lens-assisted and transepithelial corneal crosslinking with standard epithelium-off crosslinking for progressive keratoconus: 24-month clinical results.

PURPOSE: To compare the outcomes of contact lens-assisted corneal crosslinking (CACXL) and transepithelial CXL (TECXL) with standard epithelium-off (epi-off) CXL for progressive keratoconus. SETTING: Advanced Eye Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India. DESIGN: Retrospective, comparative study. METHODS: Patients with progressive keratoconus undergoing CXL with a minimum follow-up of 24 months were included. CACXL and TECXL were performed in patients with epithelium-on minimal pachymetry between 350 µm and 450 µm. The main outcome measures included change in maximum keratometry (Kmax), corrected distance visual acuity (CDVA), and efficacy in halting progression (increase in Kmax ≥1 diopter [D]). RESULTS: Standard epi-off CXL, CACXL, and TECXL were performed in 34, 14, and 10 eyes, respectively. Baseline Kmax and CDVA were comparable for all groups. Kmax reduced significantly by -2.83 ± 3.35 D, -3.18 ± 2.74 D, and -2.02 ± 1.66 D in the standard epi-off CXL (P < .01), CACXL (P = .001), and TECXL (P = .004) groups, respectively; the reduction was comparable for all groups (P = .63). CDVA improved by -0.14 ± 0.24, -0.04 ± 0.19, and -0.12 ± 0.17 logMAR in the standard epi-off CXL (P = .006), CACXL (P = .42), and TECXL (P = .05) groups, respectively; the reduction was comparable for all groups (P = .46). Progression was documented in 2 eyes (6%) in the standard epi-off CXL group and in 0 eyes of the CACXL and TECXL groups (P = .61). CONCLUSIONS: CACXL and TECXL were comparable with the standard epi-off CXL for progressive keratoconus.

Efficacy of 2% Rebamipide Suspension for Vernal Keratoconjunctivitis: A Clinical Comparison with Topical Immune Modulators Cyclosporine and Tacrolimus.

PURPOSE: To compare the efficacy of 2% rebamipide suspension with topical cyclosporine and tacrolimus for managing vernal keratoconjunctivitis (VKC). METHODS: In this prospective, interventional study, 38 patients with moderate to severe VKC were allocated to receive either 2% rebamipide in one eye and 0.03% tacrolimus ointment in the contralateral eye (n = 19) or 2% rebamipide in one eye and 0.05% cyclosporine in the contralateral eye (n = 19) for 12 weeks. Ten ocular signs and 7 symptoms were graded on a scale of 0-3 each for each eye at every visit. RESULTS: Total sign and symptom scores reduced significantly in all 4 subgroups (all p's <0.05) at 12 weeks. Reduction of mean sign scores between rebamipide and tacrolimus (- 4.67 ± 4.63 and - 2.80 ± 3.18 respectively) and between rebamipide and cyclosporine (-6.00 ± 3.74 and -5.42 ± 3.68 respectively) was comparable. Reduction in symptom scores was also comparable between subgroups. CONCLUSION: Our findings suggest that efficacy of topical rebamipide is comparable to topical cyclosporine and tacrolimus for managing moderate to severe VKC and it merits further evaluation as a novel steroid sparing alternative for this disorder.

Effect of decentration on the quality of vision: comparison between aspheric balance curve design and posterior aspheric design intraocular lenses.

PURPOSE: To study the effect of decentration on the quality of vision in 2 aspheric intraocular lenses (IOLs): aspheric balance curve (ABC) design Vivinex iSert XY1 (Hoya Surgical Opticals, Inc.) and posterior aspheric design AcrySof IQ SN60WF (Alcon Laboratories, Inc.). SETTING: Advanced Eye Centre, PGIMER, Chandigarh, India. DESIGN: Randomized prospective trial using a random number table. METHODS: 85 eyes were randomized to group 1 (Vivinex XY1) and group 2 (AcrySof IQ) with 40 and 45 eyes, respectively. The higher-order aberration (HOA) profile, Strehl ratio, decentration of the IOL from the visual axis (decentration from the visual axis [DVA]) and the geometric axis (decentration from the geometric axis [DGA]), angle α, and κ were recorded on the iTrace aberrometer, and contrast sensitivity was measured using the Functional Acuity Contrast Test at 12 weeks postsurgery. RESULTS: A total of 85 eyes in 60 patients were evaluated in this study. The mean values of the Strehl ratio (P = .48) and the HOAs (P = .12) of both IOLs were comparable. The HOAs gradually increased with increasing DVA for both lenses at 3.0 mm, 4.0 mm, and 5.0 mm pupil sizes. On comparing the HOAs with the DGA, a statistically insignificant positive correlation was observed. The Strehl ratio did not deteriorate with an increasing angle α in the Vivinex XY1 group; however, it worsened in the AcrySof IQ group. Contrast sensitivity was comparable in both the IOLs except at 1.5 cycles per degree under photopic conditions where the AcrySof IQ was better. CONCLUSIONS: Decentration of the lens was best measured with respect to the visual axis. In eyes with a large α, the ABC design induced lesser HOAs and maintained a better Strehl ratio.

Elliptical versus circular flap configuration in myopic eyes undergoing femtosecond laser in situ keratomileusis surgery: A contralateral eye study.

PURPOSE: To study whether a customized elliptical flap configuration offers any visual, refractive, or biomechanical advantage over the "conventional" circular flaps in patients undergoing myopic laser in situ keratomileusis (LASIK). METHODS: A prospective interventional contralateral eye study was undertaken enrolling 290 eyes of 145 myopic patients (≤-6.0D) undergoing LASIK, wherein the corneal flap was created in one eye using a customized elliptical flap configuration versus a conventional circular flap configuration in the other eye. Postoperatively, we compared the visual outcome, change in higher-order aberrations, corneal asphericity, and corneal biomechanics. RESULTS: The visual outcomes, including higher-order aberrations, were comparable between the two groups. Changes in spherical aberration (mean: 0.234-0.331 versus 0.234-0.42; P = 0.644), corneal asphericity (-0.32-0.34 versus - 0.34-0.45; P = 0.42), corneal hysteresis (9.35-7.33 versus 9.4-6.71, P = 0.489), corneal resistance factor (9.71-7.40 versus 10.38-6.9, P = 0.181) were comparable between the elliptical and circular groups, respectively. CONCLUSION: We evaluated the usefulness of a customized elliptical flap configuration for performing LASIK surgery. Our data suggests that elliptical flaps may be associated with superior visual and biomechanical performance compared to circular flaps. This is certainly relevant in eyes with "borderline" pre-LASIK profile to improve patient satisfaction and safety after surgery.

Achieving successful capsulorhexis in intumescent white mature cataracts to prevent Argentinian flag sign - A new multifaceted approach to meet the challenge.

Purpose: To present a case series of intumescent white cataract cases managed by a new surgical technique to attain a single stage Continuous Curvilinear Capsulorhexis (CCC). Methods: The series included 60 eyes of 60 patients with white cataract which underwent preoperative anterior chamber depth, lens thickness and ultrasonographic A-scan for intralenticular spikes. A partial size main port (~1.8mm) is created as the first entry into the anterior chamber (AC). A 30-gauge needle of insulin syringe entered through a limbal stab incision is used to decompress the anterior and posterior intralenticular compartments. Following which a standard size, one stage capsulorhexis was performed in a trypan blue stained capsule using microcapsulorhexis forceps entered through the partial sized trapezoidal main port. The main port was secondarily enlarged for phacoemulsification. Results: Based on the intraoperative findings, 43 eyes were categorized as Intumescent type-1 cataracts i.e., with presence of actual liquefied cortex aspirated using 30-gauge needle and 17 eyes as Intumescent type-2 cataracts, i.e., presence of swollen lens without any obvious liquefied cortex. Standard size, circular and centred CCC was achieved in 100% of the cases and no Argentinean flag sign was noted. Surgeon perceived raised intralenticular pressure in 41% of the cases in type-1 subset and 61% cases in type-2 subset (P-0.06). Posterior capsular plaque was observed in 22% of the cases, adherent cortex in 25% and anterior capsular plaque in 5% of the cases. At 6weeks follow up 92% patients had best corrected visual acuity of 20/40 or better. Conclusion: A multi-layered approach can help in attaining successful CCC in cases of white mature cataract with high intralenticular pressure.

Phacoemulsification in posterior polar cataract: Experience from a tertiary eye care Centre in North India.

Purpose: To determine the rate of posterior capsular rupture (PCR) and assess the postoperative outcomes in patients of posterior polar cataract (PPC) undergoing phacoemulsification using a combination of "V" or "λ" nucleofractis and viscodissection. Methods: It was a retrospective study of 80 eyes of 64 patients undergoing surgery for PPC. All surgeries were performed by a single surgeon. After completion of the continuous curvilinear capsulorrhexis (CCC), controlled hydrodelineation was used to separate the endonucleus from the epinuclear shell with limited viscodissection. Phacoemulsification was then carried out by making a "V" or lambda-shaped nucleofractis with the phaco tip followed by multiple chopping of the nucleus, ensuring the integrity of the epinuclear part of the lens. The epinuclear plate was removed after viscodissection. Results: The overall rate of PCR was 7.5% (6 out of 80 eyes). Of the 6 eyes, 4 eyes had been documented to have a pre-existing posterior capsular defect on slit-lamp examination. The rate of "on table" PCR, that is, PCR occurring intraoperatively was only 2.6% (2 of 76 eyes). Nucleus drop was not encountered in any case. Overall 87.5% eyes achieved a final visual acuity of 20/40 or better with 68.75% being 20/20 or better. Of the eyes developing PCR, two-third achieved a visual acuity of 20/30 or better. Conclusion: Using a combination of surgical techniques of V groove or lambda technique for nucleofractis and removal of epinucleus by viscodissection can result in a low rate of PCR and extremely good postoperative outcomes in cases of PPC.

Combination of capsular tension ring and capsular tension segment for the management of lens coloboma >4 clock hours.

Lens colobomas extending more than 4 clock hours and causing visual impairment require lens extraction along with capsular support devices with scleral fixation for adequate centration of the capsular bag and for prevention of capsular fornix aspiration with inadvertent extension of zonular dialysis intraoperatively. In this case series, we describe a technique for the management of isolated lens colobomas involving 4-5 clock hours by clear lens extraction and intraocular lens implantation using a combination of a capsular tension ring with a capsular tension segment (CTS) for the centration and stability of the capsular bag. Hoffman's corneoscleral pocket and half-bow sliding knot technique were used for scleral fixation of the CTS.