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.

Connective tissue disorders and eye: A review and recent updates.

Collagen vascular disorders (CVDs), also known as connective tissue diseases (CTDs), are a heterogeneous group of entities that affect the connective tissues and are capable of causing end-organ damage to multiple systems, primarily cardiopulmonary and musculoskeletal. However, the occurrence and severity are highly variable among patients. Ocular involvement occurs in a significant number of these disorders and may precede the onset of other extraocular features, thereby serving as an important marker in the diagnosis of these diseases. A timely and accurate diagnosis enables the management of complications. CTDs are primarily immune-mediated inflammatory diseases; however, classifications have encompassed heritable disorders affecting collagen-containing structures and disorders of vascular development. A review of literature published until 25 January 2022 and collected from various databases using the relevant keywords was conducted. All publications (original articles, review articles, as well as case reports) describing the ocular features in CTDs were studied in detail. The objective of this review is to recognize the common ophthalmic presentations of various autoimmune and heritable CTDs, distinguish them from overlapping diseases, elaborate on the prognosis and management of these varied eye presentations, and deliberate on their impact on other ophthalmic surgeries.

Premium intraocular lenses in children.

Multifocal and toric intraocular lenses (IOLs) or the so-called premium IOLs are currently widely used in adult patients as a one-step refractive solution following cataract surgery. However, the decision to implant a premium IOL in a pediatric patient involves multiple factors affecting the child's visual development and is associated with several dilemmas and surgical challenges. The purpose of this review is to summarize these factors and analyse the influence of each of them on the visual outcomes following premium IOL implantation. A review of literature was conducted using the relevant keywords from various databases until 31st January 2022. All pertinent studies with multifocal or toric IOL implantation in children were reviewed, and relevant articles were studied in detail for age, IOL power calculation, visual outcomes (refractive outcomes, contrast sensitivity and stereopsis) and complications such as dysphotic phenomena and others. A total of 17 relevant studies (10 case series/interventional studies and 7 case reports) on the subject were included. All studies showed a favourable refractive outcome; however, the data available was significantly less. Studies with earlier models of multifocal IOLs showed a higher incidence of IOL decentration and posterior capsule opacification; however, more recent studies with newer IOL models showed much better safety profiles. Toric IOLs showed promising results in all the studies evaluated. Premium IOLs have shown promising results in the pediatric age group. However, their long-term outcomes specifically concerning refractive shift, capsular contraction and role in the management of amblyopia needs to be explored further.

A novel low-cost indigenous goggle design for oxygen delivery in oxygen supplemented accelerated corneal collagen cross-linking.

PURPOSE: Our study aims to describe a novel low-cost indigenous design of goggles for delivery of oxygen during oxygen supplemented accelerated corneal collagen cross-linking (CXL). METHODS: The goggles were prepared by modifying the safety goggles available in personal protective equipment (PPE) kit. The goggle has two side openings covered with plugs. One plug was removed to insert a tubing for oxygen delivery at a rate of 5 litres/minute. A 20-gauge intravenous cannula was introduced from superior aspect of the goggle for measuring oxygen saturation in periocular environment. RESULTS: The procedure could be successfully performed without any intraoperative difficulty with an oxygen concentration between 80-90% throughout procedure. The time to achieve maximum concentration after switching on oxygen supply was between 30-60 s. None of our patients complained of any discomfort due to goggles. There was no mechanical interference of the goggles with the UV delivery system and a focused UV light could be delivered. The opening in goggles allowed for uninterrupted alignment and centration of UV light at the corneal level. The effective cost of the goggles, canula and tubing amounted to 400INR (5.50USD). There was no distortion, kinking or slippage of the tubing allowing for uninterrupted oxygen flow. These goggles could be sterilized multiple times using plasma sterilization. CONCLUSION: The current modified cost-effective goggle design could be an effective alternative to the currently available oxygen delivery goggles, especially in a low resource setting.

Portable femtosecond laser assisted cataract surgery in a child with bilateral ectopia lentis with microspherophakia.

Purpose: The purpose of this case report is to describe the utility of portable femtosecond laser platform in a child with bilateral isolated microspherophakia and ectopia lentis performed under general anesthesia. Observation: An appropriately sized and well centered capsulotomy with well centered PCIOL could be achieved in both eyes of the patient. Conclusion & Importance: The advent of mobile femtosecond laser assisted cataract surgery might prove a useful and convenient platform for surgeries in pediatric patients with subluxated cataracts even under general anesthesia. It may circumvent the need for an additional laser suite and reduce surgical time by eliminating the need for patient movement.

Hitch suture assisted tuck in Tenon's Patch Graft for management of Corneal Perforations.

PURPOSE: To describe a novel modification of tuck-in Tenon's patch graft (TPG) using temporary horizontal mattress sutures and fibrin glue to hitch the graft in the management of corneal perforations. DESIGN: Ambispective interventional case series. METHODS: Modified technique of autologous TPG was used to seal corneal perforations measuring 3-5 mm, using horizontal mattress sutures to hitch the graft in a lamellar pocket, followed by application of fibrin glue. The horizontal mattress sutures were removed after the reformation of the anterior chamber. The primary outcome measure was a well formed anterior chamber in the post-operative period and the secondary outcome was epithelization time. RESULTS: The surgery was performed in 22 eyes. The mean age was 43.86 ± 16.02 (26-66) years, with 14 males and eight females. The etiologies of corneal perforation included dry eye (n = 10), neurotrophic keratitis (n = 6), trauma (n = 2), chemical injury (n = 2) and exposure (n = 2). The mean size of the perforation with the thinned-out area was 4.3 mm (range 3-5 mm). The mean duration of epithelialization was 14.31 ± 2.63 days (7-21 days). No intraoperative complications were observed. All eyes had a well-formed anterior chamber in the immediate postoperative period. Postoperatively, two eyes had graft pseudoectasia due to a thick graft and supra tenon haemorrhage each; one eye each had graft thinning with the formation of pseudopterygium and graft melting. CONCLUSION: Tenon's patch graft, along with the use of temporary horizontal mattress sutures and fibrin glue, is an effective modification of the technique for managing corneal perforations measuring 3-5 mm.

Rotational stability of Toric intraocular lenses.

BACKGROUND: A prospective study to evaluate the rotational stability of toric intraocular lenses (IOLs). METHODS: A prospective study of 30 eyes in 29 patients. All patients with regular astigmatism of range 0.75-4 D were included in the study. Exclusion criteria included irregular corneal astigmatism, post-refractive surgery and corneal dystrophies. All patients underwent uncomplicated phacoemulsification cataract surgery by the same surgeon. Three eyes with corneal astigmatism of 0.75-1.5 D were implanted with the AcrySof SA60T3 IOL, eight eyes with astigmatism between 1.5 and 2.0 D received the SA60T4 IOL and eight eyes with astigmatism between 2.0 and 2.50 D received the SA60T5 and rest with astigmatism of 2.5 D and higher received SA60T6 and above models. Main outcome measure was the post-operative position of the lens, assessed at day 1, 1 week, 1 month and 6 months, using toric marker and the slit lamp. RESULTS: There was no significant rotation of IOL observed during a follow-up period of 6 months. Overall, the post-operative rotation was within 5° in 95% of cases. There was no trend for either clockwise or anti-clockwise rotation. However, IOL rotation happens mostly within the first month of surgery, and if it is significant, it requires early repositioning. CONCLUSION: Toric IOLs are very effective and consistent in correcting astigmatism during the cataract surgery. Once placed to its position, toric IOLs demonstrate rotational stability in the capsular bag.

Long-term Outcomes of Fibrin Glue-Assisted Intrascleral Haptic Fixation of Posterior Chamber Intraocular Lenses in Children.

OBJECTIVES: To evaluate the long-term outcomes of intrascleral haptic fixation of posterior chamber intraocular lens (PCIOL) with fibrin glue in children. METHODS: This is a retrospective case study conducted in a tertiary eye institute in North India. A total of 118 eyes of 82 children who underwent glued intrascleral haptic fixation of PCIOLs were retrospectively analyzed. Detailed analysis of the indication for surgery and ocular and systemic associations was performed. The outcome measures included intraoperative complications, final visual and refractive outcomes, and postoperative complications. RESULTS: The mean age of the patients was 10.16±3.94 years. Fifty-one patients (62.2%) were male and 31 (37.8%) were female. The mean follow-up period was 31.28±13.22 months. The mean preoperative corrected distance visual acuity was 1.18±0.63 Logarithm of Mean angle of resolution (logMAR) which improved to 0.60±0.58 logMAR postoperatively at 6 weeks (P<0.001). The mean preoperative and 6 weeks postoperative endothelial cell density were 3,176.08±318.6 and 2,936±289.9 cells/mm2, respectively (P=0.23). In the immediate postoperative period, corneal edema (19 eyes; 16.1%), decentered IOL/tilt (3 eyes; 2.54%), vitreous hemorrhage (3 eyes; 2.54%), optic capture (4 eyes; 3.38%), and hypotony (2 eyes; 1.69%) were seen. In the late postoperative period (>6 weeks), retinal detachment was observed in two eyes that had associated Marfan syndrome. Cystoid macular edema was seen in four eyes (3.38%), and glaucoma was seen in five eyes (4.23%). CONCLUSIONS: Fibrin glue-assisted intrascleral haptic fixation of a PCIOL is a safe and effective method to manage aphakia with inadequate capsular support in children.

Demographic and clinical profile, surgical outcome, and quality of life in patients who underwent bilateral lamellar corneal grafts.

Purpose: Lamellar corneal grafts have revolutionized the management of corneal blindness by replacing only the disease specific corneal layers. To the best of our knowledge, there is no study in literature describing the outcomes of bilateral lamellar keratoplasty in the Indian population. The aim of this work was to study the demographic profile, surgical outcomes, and quality of life in patients who underwent bilateral lamellar keratoplasty and to assess the correlation between these three. Methods: An observational cross-sectional study was conducted on 47 patients who underwent bilateral deep anterior lamellar keratoplasty (DALK) (n = 31) or descemet stripping automated endothelial keratoplasty (DSAEK) (n = 16) with a minimum follow-up of 6 months after the second surgery. Demographic parameters were collected by interview, surgical outcomes by clinical examination, and quality of life by a questionnaire. Results: A total of 47 patients were evaluated, women 42.56%, (n = 20) and men 57.44% (n = 27) with 38.3% being in 18-30 years age group and 23.4% above 60 years; 17.02% patients had a good socioeconomic status (score >60) and 61.70% had poorer socioeconomic status (score <50). Quality of life score (VR-QoL) was ≥50 in 82.9% patients and ≥70 in 14.89%. No significant association existed between VR-QoL scores and demographic factors. However, statistically significant association existed between VR-QoL and age of patient (P < 0.05), postoperative vision (P ≤ 0.05), and contrast sensitivity (P ≤ 0.01). Conclusion: Bilateral lamellar corneal grafts provide satisfactory visual outcomes compatible with day-to-day functioning. VR-QoL has a direct correlation to the age, visual acuity, contrast sensitivity, and inverse correlation with lenticule thickness in DSAEK and residual bed thickness in DALK.

Posterior Chamber Phakic Intraocular Lens Implantation for Refractive Correction in Corneal Ectatic Disorders: A Review.

PURPOSE: To summarize the indications and outcomes of posterior chamber phakic intraocular lens (PIOL) implantation in corneal ectasias including keratoconus, pellucid marginal degeneration (PMD), post-refractive surgery, and post-keratoplasty ectasias. METHODS: A review of the literature was conducted using the relevant keywords from various databases up to August 15, 2020. All pertinent studies were reviewed, and the relevant articles were studied in detail for efficacy, stability, predictability, and safety outcomes. In addition, visual quality, corneal biomechanical outcomes, complications, the role of posterior chamber PIOL in combination treatment, and comparison of posterior chamber PIOL with other PIOLs for ectasias were also evaluated. RESULTS: A total of 30 relevant studies (13 prospective, 13 retrospective, 4 case reports) on the subject were studied and summarized. All studies showed a favorable refractive outcome. Quality of vision remained unaffected and no significant complications were reported in any of the studies. CONCLUSIONS: Posterior chamber PIOLs represent a viable option in the treatment of mild to moderate and stable corneal ectasia in patients with contact lens intolerance who have low irregular astigmatism, a clear central cornea, and good preoperative corrected distance visual acuity. [J Refract Surg. 2021;37(5):351-359.].

Novel technique of tetra trephination for elliptical-shaped tectonic patch grafts in peripheral sterile keratolysis.

PURPOSE: To describe a novel technique of tectonic patch grafts for elliptical-shaped peripheral sterile keratolysis with iris prolapse. METHODS: We performed a full thickness corneo-scleral patch graft in five eyes of five patients with elliptical-shaped peripheral sterile keratolysis with perforation and iris tissue prolapse. In this technique, four disposable trephines with predetermined diameter were employed to fashion both the host and the donor without any free-hand dissection. An intact anatomical integrity of the globe without the need for any repeat tectonic measures was considered as a successful outcome. RESULTS: The mean age was 34.2 ± 10.2 years (18-45). The mean total surgical time and donor preparation time was 94.4 ± 7.12 min and 7.6 ± 1.14 min, respectively. The intraoperative course was uneventful in all cases and all eyes had a well-maintained corneal integrity till 6 months follow up. CONCLUSION: We describe a simple, reproducible, and time-saving technique of performing elliptical shaped corneoscleral patch grafts for peripheral corneal perforations with iris prolapse.

Modified Contact Lens Sandwich Technique of Glue for Management of Medium to Large Corneal Perforations in the COVID Era.

ABSTRACT: The aim of this article is to describe a novel technique of gluing as an interim measure to provide tectonic support in cases of medium-sized to large-sized (3-6 mm) corneal perforations. Five eyes of five patients in which conventional cyanoacrylate glue application was not feasible, and therapeutic keratoplasty could not be performed in view of the unavailability of corneal tissues were included. Surgery to maintain integrity of the globe was performed, and a therapeutic keratoplasty was performed on tissue availability (mean interval of 7.4 days). On follow-up, all patients had a well-formed anterior chamber, and none of them had progression. The contact lens sandwich technique of glue was a feasible, reproducible, and economical technique during times of tissue unavailability such as the present COVID pandemic, in patients with medium to large perforated corneal ulcers.

The enigma of subnormal vision in persistent pupillary membrane.

Persistent pupillary membrane (PPM) is a common congenital anomaly of the eye, representing the remnants of tunica vasculosa lentis. It is often detected as an incidental finding upon examination. The presentation may vary from being an insignificant strand of iris to a hyperplastic dense membrane, with or without adhesions to the surrounding structures, which notably obscures the visual axis. When present as an isolated pathology, these patients are often asymptomatic. However, some patients with isolated PPM do present with poor visual acuity or subnormal quality of vision. The severity of their disability does not always correlate to the extent of the anomaly present in the eye. The rationale as to why only some patients with significant PPM experience this visual handicap while others don't is one of the baffling conundrums in ophthalmology at present. Hence, we attempt to elaborate on the possible mechanisms that explain the unpredictable and variable clinical manifestation of persistent pupillary membranes.

Modified head inversion technique for pterygium and pseudopterygium surgery combined with keratopigmentation.

PURPOSE: We describe a single sitting modified technique of pterygium surgery along with corneal tattooing for combined cosmetic rehabilitation in eyes with corneal opacity and pterygium or pseudopterygium. METHOD: Five patients with corneal opacity due to healed keratitis/optically failed therapeutic grafts along with pterygium or pseudopterygium underwent combined pterygium surgery by head inversion technique and corneal tattooing in the same sitting. All patients had no visual prognosis in that eye and surgery was indicated for cosmetic reasons only. RESULTS: At 6 months follow up no complications of pterygium surgery like recurrence, thinning, dellen, infections were noted in any patient. The dye was retained in the cornea and the cosmetic rehabilitation was excellent in all patients. DISCUSSION: Corneal tattooing combined with pterygium/pseudopterygium surgery can be performed in a single sitting with this novel technique in eyes with no visual potential. This is particularly suitable for eyes with limbal stem cell deficiency or large pterygia/pseudopterygia where conjunctival autograft is not advisable. These patients are often apprehensive for an allograft from their only seeing other eye.

Suturing large therapeutic corneal grafts based on donor size: A simplified technique for the novice corneal surgeon.

PURPOSE: We describe a simple technique for achieving radial and equally spaced sutures by novice corneal surgeon in cases of large penetrating keratoplasties. METHOD: A simple mathematical equation was derived for precise calculation of spacing between interrupted sutures in large grafts (n = 50). The ubiquitous and easily available Castroviejo calipers were used to mark the donor cornea according to the derived formula. Interrupted sutures were passed over the pre-marked points and tied. Radiality was assessed in the post-operative period. RESULTS: A total of 50 eyes undergoing therapeutic keratoplasty with graft size between 9 and 12 mm were enrolled. Equally spaced and radially aligned sutures were achieved in all cases postoperatively with watertight apposition of the graft host junction using our simple technique. CONCLUSION: The Castroviejo caliper can be effectively used for equidistant spacing of interrupted sutures in large therapeutic grafts by a novice surgeon thereby simplifying the procedure and reducing the surgical time.

Visual outcomes of binocular implantation of a new extended depth of focus intraocular lens.

PURPOSE: To evaluate the visual outcomes of bilateral implantation of a new hydrophobic foldable extended depth of focus (EDOF) IOL. METHODS: All cases undergoing phacoemulsification with bilateral implantation of Supraphob Infocus IOL between December 2017 and July 2018 at a tertiary eye care center were recruited in this prospective interventional study. The primary outcome measures were uncorrected distance visual acuity (UDVA), uncorrected intermediate visual acuity (UIVA), and uncorrected near visual acuity (UNVA). Postoperative follow-up was done on day 1, 1 week, 1 month, and 3 months. RESULTS: One hundred and four eyes of 52 patients with a mean age of 58.4 ± 9.3 years were included. The mean UDVA improved from 0.84 ± 0.32 logMAR preoperatively to 0.11 ± 0.08 logMAR at 3 months following surgery. At the final follow-up, the binocular UDVA, UIVA, and UNVA was 0.03 ± 0.07, 0.14 ± 0.06, and 0.36 ± 0.05 logMAR, respectively. The mean CS was 1.47 ± 0.06 logCS. The distance and near stereopsis was 90.2 ± 24.8 s of arc (arcsec) and 62.5 ± 19.4 arcsec, respectively. The mean total higher-order aberration (HOA), point spread function, and modulation transfer function were 0.30 ± 0.13, 0.07 ± 0.08, and 0.26 ± 0.07, respectively. CONCLUSION: The Supraphob Infocus EDOF IOL provides good unaided visual acuity for distance, intermediate, and near along with a high quality of vision as assessed by contrast sensitivity, HOAs, and stereoacuity. It may be a potential alternative to the currently available EDOF IOLs in providing good visual acuity at variable distances.

Use of 'U-shaped tool for follow up of corneal ulcer cases in the COVID-19 pandemic.

To describe a smartphone-based telemedicine tool for monitoring of corneal ulcer size during the corona pandemic, a simple "U"-shaped tool was constructed using three Schirmer's strips that were provided to the patients with small to medium-sized corneal ulcers. The patient and the attendant were trained to use this simple U-shaped tool at home and send digital images to the treating ophthalmologist, to monitor the course of the ulcer. The tool was used in five eyes of five patients with active microbial keratitis. Patients were followed up regularly with the use of telemedicine facility every 48 h for an average duration of 7.6 days (range 6-9 days). In all the five eyes, assessment of the serial images with U-shaped tool showed decrease in size of corneal ulcer, which corroborated with subjective improvement in symptoms. Hence, the novel "'U'-shaped tool" may provide an effective measure in following-up of corneal ulcer patients in times of the COVID-19 pandemic, obviating frequent hospital visits and risk of contracting COVID.

Change in subfoveal choroidal thickness in diabetes and in various grades of diabetic retinopathy.

BACKGROUND: To evaluate subfoveal choroidal thickness (SFCT) change in diabetes and in various grades of diabetic retinopathy (DR) in comparison to age-matched healthy subjects. METHODS: This prospective observational study included 100 eyes of diabetic patients without DR (group D), 100 eyes with DR (group R), and 100 eyes of healthy subjects (group N). The assessment included demographics, duration of diabetes, comprehensive ocular examination, fundus photography with/without fundus fluorescein angiography, spectral domain optical coherence tomography with enhanced depth imaging to assess SFCT. RESULTS: The SFCT was comparable between groups N (310.65 ± 37.34 µm) and D (308.48 ± 30.06 µm; P = 0.60), but was significantly lower in R (296.52 ± 21.41 µm; P < 0.01). The SFCT was significantly lower in proliferative DR (n = 36; SFCT = 284.56 ± 21.09 µm) as compared to non-proliferative DR (n = 64; SFCT = 303.25 ± 18.59 µm; P < 0.001). The SFCT had moderately negative correlation with severity of DR (R = - 0.50; P < 0.01). The difference in SFCT when compared with normal subjects was significant only in severe/very severe non-proliferative DR (294.47 ± 15.65 µm; P < 0.01) and in proliferative DR (284.56 ± 21.09 µm; P < 0.01). There was a negative correlation of SFCT with the duration of diabetes (R = - 0.41; P < 0.01). CONCLUSION: SFCT decreases with increasing duration of diabetes. The decrease is significant after the onset of severe DR, and is proportionate to the severity of DR.