Chemical (Alkali) Burn-Induced Neurotrophic Keratitis Model in New Zealand Rabbit Investigated Using Medical Clinical Readouts and In Vivo Confocal Microscopy (IVCM).

PURPOSE: Chemical eye injury is an acute emergency that can result in vision loss. Neurotrophic keratitis (NK) is the most common long-term manifestation of chemical injury. NK due to alkali burn affects ocular surface health and is one of its most common causes. Here, we established a rabbit model of corneal alkali burns to evaluate the severity of NK-associated changes. MATERIAL METHODS: Alkali burns were induced in NZ rabbits by treating the cornea with (i) a 5 mm circular filter paper soaked in 0.75 N NaOH for 10 s (Mild NK) and (ii) trephination using a guarded trephine (5 mm diameter and 150-micron depth), followed by alkali burn, with a 5 mm circular filter paper soaked in 0.75 N NaOH for 10 s (a severe form of NK). Immediately after, the cornea was rinsed with 10 mL of normal saline to remove traces of NaOH. Clinical features were evaluated on Day 0, Day 1, Day 7, Day 15, and Day 21 post-alkali burn using a slit lamp, Pentacam, and anterior segment optical coherence tomography (AS-OCT). NK-like changes in epithelium, sub-basal nerve plexus, and stroma were observed using in vivo confocal microscopy (IVCM), and corneal sensation were measured using an aesthesiometer post alkali injury. After 21 days, pro-inflammatory cytokines were evaluated for inflammation through ELISA. RESULTS: Trephination followed by alkali burn resulted in the loss of epithelial layers (manifested using fluorescein stain), extensive edema, and increased corneal thickness (550 µm compared to 380 µm thickness of control) evaluated through AS-OCT and increased opacity score in alkali-treated rabbit (80 compared to 16 controls). IVCM images showed complete loss of nerve fibers, which failed to regenerate over 30 days, and loss of corneal sensation-conditions associated with NK. Cytokines evaluation of IL6, VEGF, and MMP9 indicated an increased angiogenic and pro-inflammatory milieu compared to the milder form of NK and the control. DISCUSSION: Using clinical parameters, we demonstrated that the alkali-treated rabbit model depicts features of NK. Using IVCM in the NaOH burn animal model, we demonstrated a complete loss of nerve fibers with poor self-healing capability associated with sub-basal nerve degeneration and compromised corneal sensation. This pre-clinical rabbit model has implications for future pre-clinical research in neurotrophic keratitis.

Krupple-like factor 4 (KLF4) methylation signature in host cell in active viral keratitis with epithelial manifestation.

HSV1 presents as epithelial or stromal keratitis or keratouveitis and can lead to sight-threatening complications. KLF4, a critical transcription factor, and regulator of cell growth and differentiation, is essential in corneal epithelium stratification and homeostasis. Here, we want to understand the epigenetic modification specifically the methylation status of KLF4 in epithelium samples of HSV1 keratitis patients. After obtaining consent, epithelial scrapes were collected from 7 patients with clinically diagnosed HSV1 keratitis and 7 control samples (patients undergoing photorefractive keratectomy). Genomic DNA was isolated from the collected samples using the Qiagen DNeasy Kit. Subsequently, bisulfite modification was performed. The bisulphite-modified DNA was then subjected to PCR amplification using specific primers designed to target the KLF4, ACTB gene region, allowing for the amplification of methylated and unmethylated DNA sequences. The amplified DNA products were separated and visualized on a 3% agarose gel. KLF4 hypermethylation was found in 6 out of 7 (85.71%) eyes with viral keratitis, while 1 eye showed hypomethylation compared to PRK samples. Out of these 6, there were 2 each of epithelial dendritic keratitis, epithelial geographical keratitis, and neurotrophic keratitis. The patient with hypomethylated KLF4 had a recurrent case of HSV1 keratitis with multiple dendrites and associated vesicular lesions of the lip along with a history of fever. KLF4 hypermethylation in most viral keratitis cases indicated the under functioning of KLF4 and could indicate a potential association between KLF4 hypermethylation and the development or progression of HSV1 keratitis.

Three Consecutive Cases of Ocular Polyhexamethylene Biguanide (PHMB) Toxicity Due to Compounding Error.

Acanthamoeba keratitis is treated with long-term biguanide therapy, and the treatment itself can lead to ocular side effects. Knowledge of possible toxic complications can help in the better titration of the treatment regimen. Here, we describe the toxic side effects of polyhexamethylene biguanide (PHMB), which occurred in three consecutive patients treated with in-house compounded PHMB. There was an error in compounding the solution, with the resultant concentration of PHMB being around 0.2%. Patients developed ocular toxicity like conjunctival inflammation, persistent epithelial defect, and large pigment clumps on endothelium within six weeks of initiation of therapy. All of them developed rapidly progressive cataract and mydriatic pupil within three months. PHMB has the potential to cause irreversible damage to ocular structures, and the toxicity is time and concentration-dependent.

Prolonged Inflammation and Infectious Changes in the Corneal Epithelium Are Associated with Persistent Epithelial Defect (PED).

Purpose: Failure of rapid re-epithelialization within 10-14 days after corneal injury, even with standard supportive treatment, is referred to as persistent corneal epithelial (CE) defect (PED). Though an array of genes regulates reepithelization, their mechanisms are poorly understood. We sought to understand the network of genes driving the re-epithelialization in PED. Method: After obtaining informed consent, patients underwent an ophthalmic examination. Epithelial scrapes and tears samples of six PED patients and six individuals (control) undergoing photorefractive keratectomy (PRK) were collected. RNA isolation and quantification were performed using either the epithelial scrape taken from PED patients or from HCLE cells treated with control tears or tears of PED patients. Quantitative real-time polymerase chain reaction (qRT-PCR) was performed to detect the expression of a few important genes in CE homeostasis, inflammation, and cell-cell communication, viz., Kruppel-like factor 4 (KLF4), GPX4, IL6, TNFα, STING, IL8, desmoglein, and E-cadherin, among others. Their expressions were normalized with their respective housekeeping genes and fold changes were recorded. KLF4 localization and MMPs activity was carried out via immunofluorescence and zymography, respectively. Results: KLF4, a transcription factor important for CE homeostasis, was upregulated in tears-treated HCLE cells and downregulated in PED patients compared to the healthy PRK group. Cell-cell communication genes were also upregulated in tears-treated cells, whereas they were downregulated in the PED tissue group. Genes involved in proinflammation (IL6, 282-fold; TNFα, 43-fold; IL8, 4.2-fold) were highly upregulated in both conditions. MMP9 activity increased upon tears treatment. Conclusions: This study suggests that tears create an acute proinflammatory milieu driving the PED disease pathology, whereas the PED patients scrapes are an indicator of the chronic stage of the disease. Interferons, pro-inflammatory genes, and their pathways are involved in PED, which can be a potential target for inducing epithelialization of the cornea.

Twelve-Months Follow-Up Postmarket Study of a Hydrophobic Intraocular Lens Using a Preloaded Automated Injector in an Indian Population.

Purpose: To assess real-world clinical outcomes and safety of the Clareon® intraocular lens (IOL) and AutonoMe® automated preloaded delivery system in an Indian population. Patients and methods: This was a prospective, single-arm, multicenter, 12-month clinical study in patients aged ≥20 years with unilateral or bilateral cataracts. Surgery was performed by phacoemulsification followed by implantation of the Clareon monofocal IOL (CNA0T0). Monocular best-corrected distance visual acuity (BCDVA) and uncorrected distance visual acuity (UCDVA) were assessed at 1 week and 1, 6, and 12 months after implantation. Posterior capsular opacification (PCO), surface haze, and glistenings were evaluated at all visits. Surgeons' satisfaction with automated injector system was also evaluated using a questionnaire. Safety was assessed by monitoring adverse events (AEs). Results: A total of 151 eyes received the CNA0T0 IOL. Mean ± SD monocular BCDVA improved from 0.53±0.44 logMAR preoperatively to 0.00±0.08 logMAR at week 1 and -0.03±0.08 logMAR at 12 months after implantation. At 12 months, 137/137 (100%) of eyes achieved BCDVA of 0.3 logMAR or better. Mean ± SD monocular UCDVA was 0.78±0.40 logMAR preoperatively, 0.11±0.15 logMAR at week 1, and 0.08±0.13 logMAR at 12 months after implantation. At 12 months, 132/137 (96%) eyes achieved UCDVA of 0.3 logMAR or better. Serious intraoperative AEs were posterior capsule rupture (n=1) and ciliary zonular dehiscence (n=1). Surgeons reported that the automated preloaded device was more intuitive compared with other push- or screw-style preloaded injector systems. None of the eyes in this study presented surface haze; all were graded as 0 glistenings at all visits. No clinically significant PCO or neodymium-doped yttrium aluminum garnet (Nd:YAG) capsulotomies were reported. Conclusion: The hydrophobic IOL preloaded in an automated injector system provided good visual and refractive outcomes, as well as no surface haze and grade 0 glistenings. None of the patients required Nd:YAG capsulotomy.

Incidence of vitreous loss and visual outcome following cataract surgery by surgeons with various levels of experience at a tertiary eye care center in North India.

Purpose: To determine the incidence of vitreous loss and visual outcome after a vitreous loss during cataract surgery performed by surgeons with various levels of experience in adults >40 years of age at a tertiary eye care center in North India. Methods: The study was conducted at a tertiary eye care center in North India. This was an observational, retrospective, cross-sectional study of patients who underwent cataract surgery from August 1, 2011 to July 31, 2014. All adult cataract cases who were operated on from August 1, 2011 to July 31, 2014 and who experienced vitreous loss during their surgery were included in the study. The visual outcomes of these patients who experienced vitreous loss during cataract surgery in uncomplicated cataract and were managed using standard automated vitrectomy techniques were assessed for different cataract surgical techniques (extracapsular, small-incision, and phacoemulsification) as well as at different levels of skill of the operative surgeon (consultant, short term fellow, and long-term fellow). Details of the postoperative period and best-corrected visual acuity (BCVA) were collected from patient records by the principal investigator on day 1, 1 week, 4 weeks, 6 weeks, and 3 months post cataract surgery. Results: Vitreous loss occurred in 374 out of 18,430 patients who underwent cataract surgery from August 1, 2011 to July 31, 2014. The overall incidence of vitreous loss in our study was found to be 2.03% with consultants having a rate of 1.66%, short-term fellows at 5.19%, and long-term fellows at 2.02%. Two hundred eighty-eight patients of the 374 cases followed up for 3 months at the hospital and 75.69% of these patients had a final visual acuity of ≥6/18. Conclusion: In an institute with a structured training program for residents/trainees, the vitreous loss rate is low during cataract surgery. Early intervention and proper management with the standard microsurgical technique by experienced hands can improve the final visual outcome in eyes with vitreous loss. Cystoid macular edema and corneal edema were the most common causes of poor postoperative vision.

Role of AS-OCT in Managing Corneal Disorders.

Optical coherence tomography (OCT) is analogous to ultrasound biometry in the cross sectional imaging of ocular tissues. Development of current devices with deeper penetration and higher resolution has made it popular tool in clinics for visualization of anterior segment structures. In this review, the authors discussed the application of AS-OCT for diagnosis and management of various corneal and ocular surface disorders. Further, recent developments in the application of the device for pediatric corneal disorders and extending the application of OCT angiography for anterior segment are introduced.

Incidence and risk factors for post-penetrating keratoplasty glaucoma.

Purpose: To carry out a prospective study to analyze the incidence and various preoperative, intraoperative, and postoperative risk factors for the development of PPKG. Methods: A total of 207 patients were analyzed prospectively, who were operated for penetrating keratoplasty (PK) in a tertiary eye care hospital between the time period of August 1, 2017 and February 28, 2018 and were followed up till the sixth month. Each patient was analyzed at every visit to determine the factors responsible for post-keratoplasty glaucoma. Results: Out of 207 eyes, post-PK glaucoma developed in 84 cases, which yielded an incidence of 41%. Incidence of PPKG (Post PK glaucoma) in various conditions was as follows: in repeat PK 62%, in perforated corneal ulcer 33%, in nonperforated corneal ulcer 29%, in corneal scar including adherent leukoma 37.2%, and in pseudophakic bullous keratopathy and aphakic bullous keratopathy, 14% and 80%, respectively. In age- and sex-adjusted multivariate analysis, the significant risk factors were age (P-value- 0.006), presence of PAS (P-value 0.001), and fellow eye glaucoma (P-value 0.04). Aphakia and combined surgery were not found to be significant. Conclusion: Our study recommends a meticulous examination of the fellow eye to assess the presence of glaucoma as it can increase the suspicion of glaucoma in the eye to be operated. The presence of PAS and age are important risk factors for developing PPKG. The risk of developing PPKG increases exponentially as the number of risk factors increases, but the presence of more than three risk factors does not add to the development of PPKG.

Post penetrating keratoplasty infectious keratitis: Clinico-microbiological profile and predictors of outcome.

PURPOSE: To study the clinico-microbiological profile, outcomes and prognostic factors of post penetrating keratoplasty (PKP) infectious keratitis. METHODS: Retrospective review of medical records of 78 patients with post PKP infectious keratitis presenting between January 2014 and December 2018. Demographic, clinical and microbiological profile was documented and predictors of treatment and graft success were evaluated using univariate and subsequent multivariate logistic regression analysis. RESULTS: Mean age of patients was 52.17 ± 15.51 years and mean infiltrate size was 19.39 ± 19.68 mm2. Mean duration of presentation with infection post PKP was 11.66 ± 10.65 months. Culture positivity was seen in 64 eyes (82.05%). Bacterial growth was observed in 47 eyes (60.25%), fungal growth in 17 (21.79%) and no microbiological growth in 14 eyes (17.94%). At 3 months the visual acuity (VA) improved in 37 eyes (47.44%), did not change in 27 (34.62%) and deteriorated in 14 (17.95%). Graft failure was noted in 53 eyes (73.08%). Surgical intervention was needed in 47 (60.25%) eyes of which most common was therapeutic PKP in 32 eyes (41.02%). Treatment failure was noted with fungal infection (p = 0.05), poorer vision at presentation (p = 0.02), larger infiltrate area (p = 0.002) and graft infection developing before 1 year (p = 0.02). Graft failure was noted with associated endophthalmitis (p = 0.02), poorer VA at presentation (p = 0.01) and larger infiltrate area (p = 0.02). CONCLUSION: Post PKP infectious keratitis is a sight threatening ocular condition. It is associated with high incidence of graft failure and frequently requires surgical intervention. Fungal etiology, larger infiltrate size, poorer vision at presentation and associated endophthalmitis carries a poorer prognosis.

Training Indian ophthalmologists in phacoemulsification surgery: Nine-year results of a unique two-week multicentric training program.

Purpose: To assess the outcome of 2 weeks phacoemulsification training program that is a unique collaboration between premier ophthalmic training institutes of India and Alcon Inc. initiated 10 years ago. Methods: Cataract surgeons eager to adopt phacoemulsification surgery as the primary treatment modality were enrolled in an intensive 2 weeks training program across seven premier ophthalmic institutes in India. These surgeons performed supervised phacoemulsification surgery under the guidance of expert faculty. Simultaneously didactic lectures, postoperative video discussions, and wet laboratory training were conducted. To assess improvement in the surgical skills each surgery was scored using the International Council of Ophthalmology-Ophthalmology Surgical Competency Assessment Rubrics (ICO-OSCAR). Phaco Development Specialist supported these surgeons for minimum duration of 1 year and maximum of 9 years and 2 months. In this multicentric study, surgical data of the participants enrolled between June 2010 to August 2018 was retrospectively analyzed. Results: Nine hundred 89 ophthalmologists across 27 Indian states and 4 Union Territories were trained between June 2010 and August 2018. The mean age of participants was 40.6 (+ 8.2 years) and 64.8% were males. After completing their training they performed 1,022,508 phacoemulsification surgeries in 9 years and 2 months. At follow-up, 92.11% and 88.77% of the surgeons were performing phacoemulsification at the end of 1 year and final follow-up, respectively. Conclusion: This program highlights how partnership model between industry and ophthalmologists can go hand in hand for training and skill development of doctors contributing to much-needed improvement in patient care across societies.

Risk of SARS-CoV-2 virus transmission from donor corneal tissue: A review.

Since the outbreak of respiratory coronavirus disease (COVID-19) caused by the coronavirus SARS-CoV-2, there is an ongoing discussion about whether the virus could be transmitted through corneal transplantation from donor to recipient. The purpose of this review was to summarize the current knowledge in the scientific community to provide aid in risk evaluation for potential virus transfer by corneal transplants. Literature was searched in PubMed.gov for relevant articles on coronavirus in conjunction with cornea processing, cornea transplantation and eye banking. Further, guidelines of health authorities and eye banking associations were reviewed. Studies have shown that SARS-CoV-2 RNA can be detected in ocular swabs and/or fluid of patients with COVID-19. However, the risk of SARS-CoV-2 virus transmission through these ocular tissues or fluid of patients is judged differently. To date, per literature and official guidelines, no evidence of viable virus in ocular tissue and no cases of transmission of SARS-CoV-2 via tissue preparations have been reported.

Acute graft rejection in a COVID-19 patient: Co-incidence or causal association?

A 32-year-old man with a clear and compact graft following a penetrating keratoplasty 6 years back, developed an episode of acute graft rejection, coinciding with the COVID-19 disease. Subsequent to the infection with the novel coronavirus, he developed symptoms of acute graft rejection concurrent with the development of respiratory distress and peak systemic symptoms. This was the phase of cytokine storm as evidenced by the raised inflammatory markers in his blood tests. Such a case of acute corneal graft rejection coinciding with SARS-CoV-2 infection has been reported only once in the literature and this unique association needs to be researched further.

Resuming eye bank services during the COVID-19 pandemic: Experience and inferences.

PURPOSE: The aim of this study was to formulate a methodological approach for resuming eye bank services during COVID-19 pandemic. METHODS: Eye bank operations were temporarily halted in March after the government-mandated "Lockdown" in response to COVID-19 pandemic. Before restarting eye bank operations in May, we studied sources of exposure, performed risk assessment, instituted additional process validations and redefined the Standard Operating Procedures (SOPs) in consultation with the guidelines published by the Eye bank Association of India and All India Ophthalmological Society. The eye bank staff were rigorously trained before and after operations were restarted. We conducted a survey at the end of July to gauge staff attitude and reaction. RESULTS: Eye banks services resumed on 20th May 2020. Since reopening till the end of July total 41 keratoplasties have been done. 91.75% of all keratoplasties done were therapeutic surgeries and 17% of the surgeries were done using glycerine preserved tissues. No staff had COVID-19 symptoms when the operations restarted and none developed symptoms up to the end of July. All eye bank staff were aware of COVID-19 pandemic and 86% said they felt safe working at the eye bank. 86% of the staff said that they received adequate training and 66% of the staff expressed that they always received proper PPE and kits. Overall, 93% of the staff expressed that the measures taken by the eye bank ensured their safety. CONCLUSION: Based on our experience we suggest the following activities for planned resumption of eye bank services during the pandemic: Exposure Risk Analysis, Personal Protective Equipment usage training, SOP Revision and staff training on modified SOPs. Criteria based selection of donor sources, participatory planning involving the staff and double-checking at critical process junctions helped us in managing a smooth transition.

Effect of timolol maleate (0.5%) in the management of myopic regression post laser-assisted in-situ keratomileusis: Clinical and topographical outcomes.

PURPOSE: The aim of this study was to analyze the effect of timolol maleate (0.5%) eye drops in the treatment of myopic regression after laser-assisted in-situ keratomileusis (LASIK). METHODS: The study was conducted at a tertiary care eye hospital in north India between April 2017 & March 2018 as a prospective interventional study. Patients who underwent uneventful myopic LASIK with hansatome mechanical keratome and presented with regression were included in the study. Baseline demographic characteristics, time to presentation with regression best-corrected visual acuity (BCVA), refraction, intraocular pressure, central corneal thickness and keratometry were recorded at baseline and at each follow-up visit. The enrolled patients were prescribed timolol maleate (0.5%) eyedrops twice daily. They were followed up every month till 3 months on timolol maleate (0.5%) eyedrops and at 6 months post stopping the treatment. RESULTS: Twenty-nine eyes of 15 patients were enrolled in the study. Mean pre LASIK spherical equivalent (SE) was - 7.48 ± 2.9 Diopters (Range-3.125 to -11.75 Diopters) and mean regression spherical equivalent was -1.02 ± 1.1 Diopters. There was a decrease in mean SE from presentation (intervention start point) up to 6 months follow-up (-1.34 ± 0.89 to -0.30 ± 0.29 Diopters). While posterior corneal curvature (K1 and K2 Back) changed significantly over treatment period (P = 0.0029, P = 0.0024 respectively), changes in anterior corneal curvature (K1 and K2 Front) were not significant (P = 0.05, P = 0.06 respectively). Central corneal thickness (CCT) and intraocular pressure (IOP) did not change significantly over treatment course. CONCLUSION: Timolol maleate (0.5%) eyedrop is an effective modality for the treatment of refractive regression post LASIK circumventing the need for laser re-treatment in such patients. The most probable mechanism is reversal of the anterior bowing of the cornea in response to intraocular pressure changes.

Generic and vision related quality of life associated with different types of cataract surgeries and different types of intraocular lens implantation.

OBJECTIVES: To assess the effects of different types of cataract surgeries and intraocular lenses on generic as well as vision related quality of life of cataract patients, using EQ-5D and IND-VFQ 33 instruments respectively. METHODS: An observational, longitudinal study of patients undergoing cataract surgery was carried out at three ophthalmology centres. Patients were prospectively admitted for surgery for age-related cataract. Generic quality of life was assessed by using Euroqol's EQ5D-5L questionnaire and vision related quality of life was assessed by the IND-VFQ-33 questionnaire. Data pertaining to vision function and quality of life were collected pre surgery and 4 weeks after the surgery. RESULTS: Out of total patients (n = 814) recruited for the study, 517 patients were interviewed for both pre-surgery and post-surgery for EQ5D and 519 patients were interviewed for both pre-surgery and post-surgery for IND VFQ 33 tool. The combined data from all three centres showed that Quality Adjusted Life Year (QALY) gains observed in patients undergoing phacoemulsification with foldable lens implantation (2.25 QALY) were significantly higher (0.57 QALY) as compared to Small Incision Cataract Surgery (SICS) with PMMA lens implantation (1.68 QALY). Highest improvement however, in all three subscales of IND-VFQ-33 tool were clearly observed for SICS with PMMA lens implantation. CONCLUSIONS: The study has elicited the Health related and vision related Quality of Life scores for cataract surgeries and subsequent lens implantation. This study also offers Health State Utility Values along with visual outcomes for different surgical procedures, lenses and for the combination of surgery with lens implantation for cataract procedures providing a useful resource for future economic evaluation studies.

Delhi Infectious Keratitis Study: Update on Clinico-Microbiological Profile and Outcomes of Infectious Keratitis.

PURPOSE: To study the clinico-microbiological profile and outcomes of infectious keratitis (IK) at a tertiary eye care center in North India. METHODS: This is a retrospective, hospital-based, cross-sectional study. One thousand seven hundred and eighty-six corneal microbiological reports were identified from January 2017 to December 2018, out of which 625 patients of IK fulfilled the inclusion criteria. They underwent microbiological examination which included corneal scrapings, culture, and antibiotic sensitivity. Demographic features, signs and symptoms, risk factors such as associated trauma, previous ocular surgery, and use of corticosteroids were also recorded. RESULTS: Of the 625 patients, 68.2% were male and 31.8% were female. The age group affected most was the sixth decade; 21.9% (137 cases). Trauma was the most common associated risk factor in 151 cases (24.2%) followed by previous ocular surgery in 111 (17.8%). Out of the 625 corneal scrapings, 393 (62.9%) were culture-positive. Bacterial culture accounted for 60.6% (238/393) and fungal cultures were 143 (36.4%). More than 50% of the bacterial keratitis cases and more than 60% of the fungal cases had a favorable outcome. Staphylococcus sp. and Fusarium sp. were the most common bacteria and fungus isolated, respectively. Only one-third of the cases required surgical intervention, and the remaining two-thirds were managed medically. CONCLUSIONS: In the current study, cultures were positive in 63% of cases, and the majority of cases had bacterial growth. Surgical intervention was needed in one-third of the cases. Management of corneal infections is incomplete without a good microbiological workup. Ophthalmologists should be encouraged to learn and practice basic staining procedures, and this should start early in the training years.

Necrotizing scleritis after strabismus surgery in Treacher Collins syndrome.

Objective: To describe a case of surgically induced scleral necrosis in Treacher Collins syndrome after strabismus surgery. Methods: A 19-year-old girl underwent bilateral squint surgery. Two weeks postoperatively, she presented with subconjunctival abscess in the left eye. The surrounding conjunctiva was markedly inflamed with raised edges. Surgical debridement, microbiological evaluation and medical management were started immediately. Screening for autoimmune and vasculitic conditions did not provide any positive results. Results: On subsequent follow-up, conjunctival retraction and an area of scleral necrosis with thinning was noted. Significant healing with antibiotics and steroids was noted within one week. The integrity of the globe was well maintained and no further procedure for tectonic support was performed. Conclusion: Surgically induced scleral necrosis can be immune-mediated or following surgical site infection. Pre-existing scleral thinning due to neuroectodermal apoptosis in Treacher Collins syndrome remains a possible explanation for the accelerated necrotising scleritis in our case.