The role of corneal biopsy in the management of microbial keratitis.

PURPOSE: Corneal biopsy helps in diagnosing deep-seated or recalcitrant lesions of microbial keratitis (MK). We aim to analyze its role in managing these challenging cases. METHODS: This is a retrospective review of 22 cases of corneal biopsy at our institute from January 2010 to December 2021. Data were retrospectively collected using the electronic medical record (EMR) system. Those cases of indolent, progressive MK or deep-seated lesions where cornea scraping was not possible were considered for corneal biopsy to establish the microbiological diagnosis. The primary aims of our study were to analyze the indications, success rates, and outcomes for biopsy patients in our series. Additional outcomes that were analyzed included the average time from presentation to biopsy, the type of causative organism isolated from the biopsy by either histopathological or microbiological method, and the frequency and outcome of surgical interventions performed. Descriptive statistics using mean (±standard deviation) and median (±range) were used to interpret the demographic data. RESULTS: Overall, 15 of 22 patients (68%) had a positive corneal biopsy after microbiological or histopathological examinations. The most identified organism was microsporidia (n = 4,30.7%), followed by mycobacteria (n = 2,15.4%), gram-negative bacilli (n = 2,15.4%), acid-fast bacilli (n = 1,7.6%), fungus (n = 2,15.4%), gram-positive cocci (n = 1,7.6%), and mixed bacterial infection (n = 1,7.6%). CONCLUSION: Corneal biopsy should be considered a diagnostic modality for patients with deep-seated or unresponsive MK. It can improve the treatment for MK, ensuring targeted therapy.

Indications and types of keratoplasties: Trends in the past 10 years (2011-2020) in Eastern India.

Purpose: To observe the trends of various types of keratoplasties in different etiologies over a period of 10 years (2011-2020) in a tertiary eye care center of eastern India. Methods: A retrospective review of patients undergoing keratoplasties from 2011 to 2020 was performed in a tertiary eye care hospital situated in eastern part of India. Apart from demographic data, primary indication for each surgery and type of procedure carried out was recorded. For comparison, data were divided into two time periods: Group I: Jan 2011 to Dec 2015 and Group II: Jan 2016 to Dec 2020. Results: Over a period of 10 years, a total of 2365 (Group I: 902, Group II: 1463) keratoplasties were performed. The average age of patients was 45.8 ± 19.9 and 46.9 ± 20.9 years in Group I and Group II, respectively. Among all the corneal grafts, 1747 (74%) surgeries were full-thickness. Although optical penetrating keratoplasty (OPK) was most the common indication for full-thickness keratoplasties, Descemet's stripping endothelial keratoplasty (DSEK) remained most performed lamellar keratoplasty. Keratitis, corneal scars, and bullous keratopathies remain to be most common indications in both groups. Number of lamellar keratoplasties increased significantly from Group I to Group II for corneal scars (P = 0.02), bullous keratopathies (P = 0.01), and endothelial dystrophies (P = 0.00). Conclusion: With change in time, the indication and technique of keratoplasty has witnessed a changing trend from full-thickness keratoplasty to lamellar keratoplasty. There is rise in trend of lamellar keratoplasties over the period.

Sequelae of carbide-related thermo-chemical injury: A retrospective analysis.

Purpose: To describe the outcomes of eyes with calcium carbide (CaC2)-related thermo-chemical injury. Methods: This study included 28 eyes of 23 patients who presented with calcium carbide-related ocular burns. Only patients with more than three months of follow-up were included. Group A included 16 eyes with Dua's Grade I-III burns, while Group B included 12 eyes with Grade IV-VI burns. Electronic medical records were reviewed to provide data on the etiology of burn, presenting clinical signs and visual acuity, sequelae, and surgical interventions performed, both in the acute and chronic phases. Results: The overall mean age was 28.48 ± 11.8 years. Fifteen patients were injured while using carbide to create an explosion to scare away animals on farms. The median presenting BCVA (best-corrected visual acuity) in Group A (20/160) was significantly better than in Group B [(20/2000) (P = 0.002)]. Five eyes in Group A and one eye in Group B underwent medical management. There was no difference in the duration of follow-up for both groups (P = 0.24). The median final BCVA in Group A (20/32) was significantly better than in Group B [(20/200) (P = 0.02)]. Two eyes in Group A and nine eyes in Group B developed LSCD. Two eyes in Group B were phthisical at the last visit. Conclusion: Calcium carbide-related ocular injuries can result in significant visual morbidity in young adults. Early presentation and management may improve outcomes. Prevention of these injuries by increasing awareness and increasing advocacy efforts is necessary.

Demographic profile and clinical characteristics of Fuchs' endothelial corneal dystrophy in a tertiary eye care center.

Purpose: This study was performed to determine the demographic profile and clinical characteristics in patients with Fuchs' endothelial corneal dystrophy (FECD) reporting to a tertiary eye care center in India. It is a retrospective, single-center, observational study. Methods: The study included 280 patients (559 eyes) diagnosed with FECD presenting between January 2013 and December 2020. The data was collected from the electronic medical record system of the institute. Patient data included demographic features, clinical characteristics, investigations, and surgical interventions. Results: The mean age of the patients was 62 years. Late-onset FECD (95.7%) was more common than early-onset FECD (4.3%). Male: female ratio for late-onset FECD and early-onset FECD was 1:1.65 and 3:1, respectively. More than one-third of the patients had associated systemic history. Preexisting ocular diseases were seen in 5.9% of eyes. Blurring of vision was seen in 383 eyes (68.5%), 13 eyes (2.1%) had glare, and 163 eyes (29.2%) were asymptomatic. A total of 113 surgical interventions were done in 108 eyes (including repeat transplants). Only cataract surgery was done in 40 (7.2%) eyes, whereas penetrating keratoplasty, Descemet stripping endothelial keratoplasty, and Descemet membrane endothelial keratoplasty without or with cataract surgery (sequential or triple procedure) were done in 12 (2.1%), 47 (8.4%), and 14 (2.5%) eyes, respectively. Conclusion: Patients with FECD present mostly during the sixth decade. Posterior lamellar keratoplasty is the most common transplant procedure being performed on FECD patients.

Microsporidia-Associated Anterior Uveitis After Keratoconjunctivitis.

OBJECTIVE: The aim of this study was to describe the clinical features and management of uveitis associated with microsporidial keratoconjunctivitis (MKC). METHODS: The medical records of clinically diagnosed or microbiologically proven patients with MKC between July 2016 and August 2021 were reviewed. Patients with documented evidence of keratic precipitates (KPs) or anterior chamber cells were analyzed for their demography, clinical features, and treatment. Patients with microsporidial stromal keratitis and herpes simplex virus keratouveitis were excluded from the study. RESULTS: Of the 2212 patients reviewed within the study period 171 of 172 eyes (7.7%) had documented evidence of KPs and/or anterior chamber cells. The patients' mean age was 43.8 ± 13.8 years, and there were more men (n = 120). The mean duration of appearance of KPs was 6.9 ± 5.5 days, and 28% (n = 48 of 171) appeared on the day of presentation. Superficial punctate keratitis was central and diffuse in 48 and 49 patients, respectively. The treatment was either lubricant alone (45.3%; 78 eyes) or combined with topical steroids (54.7%; 94 eyes). The mean duration of the resolution was longer in the "corticosteroid" than "no corticosteroid" group: KPs: 15.3 ± 6.5 days versus 12.3 ± 5.8 days ( P = 0.007) and superficial punctate keratitises: 15.4 ± 9.4 days versus 11.7 ± 6.2 days ( P = 0.01). The presenting visual acuity with a pinhole was 0.26 ± 0.26 (logMAR) and it improved to 0.03 ± 0.07 on resolution ( P < 0.0001, paired t test). CONCLUSIONS: Uveitis after MKC is a self-limiting entity that often resolves without corticosteroid. One must exercise caution in using steroids in the presence of active corneal lesions.

Assessment of SARS-CoV-2 virus in the tear secretion of conjunctivitis patients during COVID-19 pandemic.

Purpose: : To determine the presence of SARS-CoV-2 virus in the tear secretion of conjunctivitis patients during the COVID-19 pandemic. Methods: This observational, cross-sectional study was conducted in clinically diagnosed patients with conjunctivitis attending the outpatient services of our institute from July 2021 to December 2021. The tear samples were collected from patients using Schirmer's strips or capillary tubes to detect the presence of SARS-CoV-2 by real-time PCR assay. COVID-19 vaccination and infection status, visual acuity, and clinical features were documented in all cases. Results: A total of 111 patients with symptoms of conjunctivitis were included during the study period. The mean age was 41.1 ± 13.1 years, and the mean duration of symptoms was 7.1 ± 4.4 days, with 74% males. Conjunctival congestion was mild in 69 (62.1%) patients, moderate in 30 (27%) patients, and severe in 12 (10.8%) patients. All except four had superficial punctate keratitis (SPK). Five (4.3%) patients were positive for SARS-CoV-2 RNA in their tear samples. All had mild-moderate conjunctival congestions with variable papiliofollicular reaction and SPKs, superficial hemorrhages were seen in three and pseudomembrane in one patient. They were followed up with telemedicine and three of them developed mild COVID-19-related symptoms and recovered after in-home quarantine. None of them had a previous history of COVID-19 infection and all had received COVID-19 vaccination within 2 weeks to 2 months. Conclusion: SARS-CoV-2 transmission through ocular secretion of conjunctivitis patients cannot be ignored and appropriate COVID-19-preventive behavior should be followed in ocular settings.

Factors affecting the epithelial integrity of human donor corneas.

Purpose: To evaluate various factors affecting the integrity of human donor corneal epithelium. Methods: Donor corneal buttons were evaluated for epithelial defect (ED) and exposure. The slit-lamp photographs were taken on day 01, and the data such as age and gender of the donor, cause of death, refrigeration of cadavers, death-to-preservation time (DPT), experience of technician, and distance from site of collection to eye bank were collected. Results: A total of 100 consecutive corneal buttons belonging to 56 donors were evaluated. The median age of donors was 50 years. Males constituted 45 (80.4%). The mean DPT was 9.7 ± 5.3 hours. After death, 34 donors (60.7%) were refrigerated before the collection/retrieval. Most of the corneas (80%) were recovered by technicians having an experience of 0-5 years. Thirty-one donors (55.3%) were located at 1-50 km from the eye bank. The mean area of exposure was 15 ± 4.3 mm2. The mean area of ED was 28.7 ± 5.9 mm2. ED was significantly associated with refrigeration of cadavers and longer DPT. On multivariate analysis, only DPT was found to be significantly associated (P = 0.006; odds ratio [OR] = 1.54 ± 0.24) with the presence of ED. After transplantation, only two corneas had persistent epithelial defects and were treated successfully using various interventions. Conclusion: Integrity of donor corneal epithelium is mainly influenced by the refrigeration of cadavers and DPT.

Carbide Gun-Related Ocular Injuries: A Case Series.

PURPOSE: The purpose of this study was to report a case series of sight-threatening ocular injuries caused by calcium carbide guns used as fire crackers. METHODS: Medical records of 15 eyes of 14 patients with ocular injuries caused while using carbide guns, visiting the Institute, from January 2021 to January 2022, were retrospectively reviewed. The collected data included patients' demography (age, sex), presenting ophthalmic features, management, and outcome. Grade I and II ocular injuries were managed medically. All grade III-V injuries were managed using Amniotic Membrane Transplantation. RESULTS: All patients were male. The mean age of the patients was 23.57 ± 11.76 years. According to the Dua classification, 5 eyes (33.3%) had Grade I-II ocular surface burns, 3 eyes (20%) had grade III burns, and 7 eyes (46.6%) had grade IV-VI burns. Presenting visual acuity ranged between hand movements to 20/50, and in 6 eyes (40%), the visual acuity was ≤20/200. Five eyes were managed medically alone, and 10 (66.6%) eyes needed surgical intervention (Amniotic Membrane Transplantation). After a mean follow-up of 14.23 ± 11.92 weeks, complete epithelization was seen in 10 eyes (66.6%). Partial limbal stem cell deficiency and its sequelae such as conjunctivalization of the cornea were noted in 7 eyes (46.6%). CONCLUSIONS: Calcium carbide-related ocular injuries can result in corneal blindness secondary to limbal stem cell deficiency in young individuals. Loss of vision in this age group can lead to loss of economic productivity and cosmetic disfigurement. More advocacy efforts are thus needed to prevent these injuries.

Multidrug-resistant keratitis: challenging yet manageable.

PURPOSE: To study the incidence, clinical features and outcomes of multidrug-resistant (MDR) bacterial keratitis. METHODS: All cases of MDR-bacterial keratitis presenting to our institute over a period of 2 years were retrospectively analysed. Details of risk factors, size and depth of infiltrate, treatment, and outcome were noted. Antibiotic susceptibility tests were done on the ocular isolates from the culture of samples obtained from ocular infections, and resistance or sensitivity of the organisms to the commonly used antibiotics was studied. RESULTS: Forty patients were diagnosed with MDR-bacterial keratitis in the study period. The mean age of patients was 50.9±25.4 years. Most common risk factors were vegetative trauma (n=12, 30.0%), followed by corneal transplantation (n=7, 17.5%) and systemic comorbidities (n=7, 17.5%). Infiltrate was small (<6 mm) in 22 (55%) and large (>6 mm) in 18 (45%) patients. It involved the superficial, mid and deep stroma in 11 (27.5%), 9 (22.5%) and 15 (37.5%) cases, respectively. Gram-negative bacilli (n=18, 45%) were the maximum, among which Pseudomonas aeruginosa (15%) was the most common. Resistance to 3 (n=17, 42.5%) and 4 (n=17, 42.5%) classes of antibiotics was the most commonly observed. One (2.5%) patient showed resistance to all seven classes of drugs tested. Complete resolution of infection was seen in 15 (37.5%) MDR patients on medical management alone. Five (12.5%) patients underwent therapeutic penetrating keratoplasty. Size of the infiltrate was found to have a significant correlation with the outcome (p=0.002). CONCLUSION: MDR keratitis, despite being a challenge to treat, can be successfully managed by medical therapy alone, if appropriate therapy is started early in the clinical course.

Microsporidia-induced stromal keratitis: a new cause of presumed immune stromal (interstitial) keratitis.

BACKGROUND AND OBJECTIVE: To describe the clinical features, diagnosis and management of immune stromal keratitis/interstitial keratitis (IK) associated with microsporidial epithelial keratitis. METHODS: Between October 2020 and January 2021, medical records of IK patients microbiologically proven as microsporidia from samples collected from corneal epithelium on smear examination, and/ or molecular analysis were reviewed. Demography, clinical profile and treatment were analysed. Real-time PCR (RT-PCR) for adenovirus (ADV), Epstein-Barr virus (EBV), herpes simplex virus (HSV) and varicella-zoster virus (VZV) was done. RESULTS: Twenty of 152 (13%) microbiologically proven cases of microsporidial keratitis were diagnosed as IK during the study period, the mean age and duration of symptoms were 35.7±11.4 years and 46.3±27.7 days, respectively. Half had predisposing risk factors, like trauma; and 30% had prior recurrences. One-fourth of patients were using antivirals on presentation. Characteristic presentations included disciform keratitis(n=12), incomplete/complete ring(n=5), and combination(n=3), along with variable subepithelial infiltrates (n=14). All cases had stromal oedema, with an intact epithelium and fine pigment dusting on endothelium. Corneal epithelial scrapings had scanty microsporidia spores in smears of 17/20 (85%), and pan-microsporidial DNA was identified in 14/20 (70%), with Vittaforma corneae by sequencing in 11/20 (55%). Other viruses detected were ADV (14,70%), VZV (2,10%), EBV (1,5%) and HSV (1,5%). Rapid resolution of inflammation and oedema within 2 weeks of starting steroids was seen in all cases. CONCLUSION: Microsporidia epithelial keratitis induced stromal inflammatory keratitis; is distinguished from microsporidial keratoconjunctivitis and stromal keratitis, by characteristic clinical features, and response to topical steroids.

Past, present, and prospects in microsporidial keratoconjunctivitis- A review.

Ocular microsporidiosis comprises two entirely different spectra of disease as keratoconjunctivitis and stromal keratitis. Microsporidial keratoconjunctivitis (MKC) has been increasingly reported in the past two decades, probably due to raised awareness, simpler diagnostic procedures, and a better understanding of the clinical presentation. It is characterized by the presence of raised, coarse, punctate, multifocal, round to oval, greyish-white corneal epithelial lesions which usually evolve into nummular scars before resolution. Conjunctivitis seen is non-purulent and of mild-moderate intensity, with mixed papillary-follicular reaction. The mode of transmission and pathogenesis is poorly understood. Despite lack of inflammatory response, uncommon associations reported were- endotheliitis, corneal edema, limbitis, uveitis, and sub-epithelial infiltrates. There has been no consensus on the management of MKC. It varies from the use of multiple antimicrobial agents to simple lubricants. The majority of the disease goes underdiagnosed or misdiagnosed and treated as adenoviral keratoconjunctivitis, with topical steroids or anti-virals empirically. Changing trends have been noticed in the pattern of infection, possibly with increasing evidence of Vittaforma corneae as causative organisms, previously reported to cause stromal keratitis. An elaborate review of the past and present literature on MKC is provided in this review article, along with gaps in knowledge, and future directions of research.

Acremonium keratitis: Risk factors, clinical characteristics, management, and outcome in 65 cases.

Purpose: To study the risk factors, clinical presentation, management options, and outcomes in cases of culture-proven Acremonium keratitis. Methods: Medical and microbiology records of culture-proven Acremonium keratitis from Jan 2007 to Dec 2019 at a tertiary eye care center were reviewed. Details of clinical findings on each visit and operating notes were reviewed from the medical records. All cases were subjected to corneal scraping at the first visit for microbiological investigation consisting of direct smear examination and culture. Topical natamycin 5% was the mainstay of medical treatment. Surgical treatment was considered for nonresponding patients. Results: During the 13-year study period, 65 cases of culture-proven Acremonium keratitis were identified out of 1605 cases of fungal keratitis. Trauma was the most common predisposing factor in 32 cases (49.2%). The average area of the corneal stromal infiltrate was 24.8 mm2 at the initial presentation. Hypopyon at the time of presentation was evident in 28 (43.1%) cases. Staphylococcus spp. was the most common (n = 22, 33.8%) organism coexistent with Acremonium. Direct microscopy of corneal scraping was positive for fungal filaments in 57/65 (87.6%) cases. Medical management alone was given in 44 patients (67.6%). Age (>50 years) and treatment delay (>15 days) were found to be independent risk factors for the poor final visual outcome (VA <20/60). Conclusion: When treated early, Acremonium keratitis responds well to medical therapy with currently available topical antifungals. However, advanced and nonresponding cases require surgical intervention for resolution of the infection.

Preservation of donor corneal epithelium in McCarey-Kaufman medium.

Purpose: To evaluate the role of McCarey-Kaufman (MK) medium in maintaining the integrity of donor corneal epithelium. Methods: Nineteen corneal buttons were harvested and stored in MK media at 2°C-8°C for four days. Serial photographs were done every day till the 3rd day, and images were then analyzed with ImageJ software (LOCI, University of Wisconsin, USA). The area of exposure and epithelial defect (ED) was calculated every day for each corneal button. Results: The average age of the donors was 56.5 ± 22.7 years and mean time from death to preservation of the corneal buttons was 7.7 ± 3.1 hours. The average corneal area was 145.6 ± 18.8 mm2. The total mean area of exposure was 3.6 ± 4.8, 7.2 ± 9.2, and 9.0 ± 11.9 mm2, and ED was 1.7 ± 4.6, 2.8 ± 5.3, and 3.3 ± 5.9 mm2 on days 1, 2, and 3, respectively. The percentage of increase in the area of exposure and ED in MK media was 3.71% and 1.1% from day 1 to day 3, respectively. Six out of 19 corneal buttons (31.57%) were utilized for keratoplasties, of which two were utilized in house and four were distributed outside. Of the two utilized corneas, none had epithelial defect on postoperative day 1. Rest 13 corneas were either used for training and research purposes, stored in glycerol media, or discarded. Conclusion: Since the percentage change in area of exposure/ED is not much at the end of day 3, corneas stored in MK media can be safely used even after three days of storage. Hence, MK medium serves as an excellent medium in maintaining the integrity of donor corneal epithelium.

Are there disparities in access to robot-assisted laparoscopic surgery among pediatric urology patients? US institutional experience.

OBJECTIVE: Literature suggests access to robotic surgery varies by race and payer status. We seek to investigate whether disparities exist in robot-assisted laparoscopic surgery among the pediatric urology population at our tertiary academic medical center and, if so, to find plausible reasons why. METHODS: Retrospective analysis identified patients who underwent open or robot-assisted laparoscopic surgery by a single surgeon at a tertiary care center between 2008 and 2019. Univariate and multivariate analyses determined the relationship of patient demographic and socioeconomic factors to procedure approach. RESULTS: Among 356 patients, race, age, American Society of Anesthesiologists status, and year of surgery were significant by univariate analysis. Insurance status was not significant (P = 0.066). Multivariate analysis indicated that age, American Society of Anesthesiologists status, and year of surgery were statistically significant (P < 0.001, P = 0.005, P < 0.001). By multivariate logistic regression, Black and Hispanic patient race were not significant with an odds ratio of 0.60 (0.35-1.02) (P = 0.061). In 60.2% of open cases, open approach selection was attributable to complex pathology, limitations of robotic approach, and surgeon's robot-assisted laparoscopic learning curve. CONCLUSIONS: Optimal procedure approach was determined by case complexity and surgeon's robot-assisted laparoscopic learning curve and was independent of patient race and payer status. This study did not find racial or socioeconomic disparities in robotic surgery within pediatric urology at our tertiary medical center, inconsistent with previous literature.

Systematic Review and Meta-Analysis of Pediatric Robot-Assisted Laparoscopic Pyeloplasty.

Introduction: To perform a systematic review (SR) and meta-analysis (MA) of outcomes of robot-assisted laparoscopic pyeloplasty (RALP) for ureteropelvic junction (UPJ) obstruction in children. Evidence Acquisition: A SR of the English-language literature on surgical techniques and perioperative outcomes of RALP for UPJ obstruction in children was performed without time filters using the MEDLINE (through PubMed), EMBASE, and Cochrane databases in July 2020 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement recommendations. Evidence Synthesis: Overall, 58 studies were selected for qualitative analysis, 46 of which were included in the MA. Nearly all studies included were observational and retrospective, either cohort or case-control. The quality of evidence was assessed using Modified Newcastle-Ottawa Scoring, with the majority of studies scoring medium or high quality. The mean success rate was 95.4% (confidence interval 91.0%-99.3%), over a wide age range. There was a noticeable heterogeneity in reported follow-up length and definitions of success rate. The majority of studies reported length of stay of ∼1 day. The mean overall complication rate was 12%. For studies that reported complication rate by grade, the mean low Clavien grade (Grade 2 or less) complication rate was 9.3% and the mean high Clavien grade (Grade 3 or more) complication rate was 6.5%. Conclusions: Robot-assisted surgery is technically feasible and has been shown to achieve very favorable outcomes for pyeloplasty in children. The evidence, however, is mostly retrospective and from single sites, which introduces potential biases. Further research is needed to further elucidate RALP benefits compared with the open and laparoscopic approach. As a randomized control trial may not be practical in this space, perhaps a prospective multi-institutional design with a uniform reporting system of pediatric RALP is the next step to define its benefits and limits.

Outcome of four-point fixated open loop polymethyl methacrylate anterior chamber intraocular lens.

PURPOSE: To study long-term visual and refractive outcomes and complications in eyes with anterior chamber intraocular lens (ACIOL) implantation. METHODS: Data of patients who underwent primary and secondary ACIOL implantation at L V Prasad Eye Institute, Bhubaneswar between 2011 and 2020 was collected, including details of post-operative visits. For analysis, sample was divided into: group Ia (primary ACIOL in cases without risk factors, n = 104); group Ib (primary ACIOL in cases with pre-existing risk factors, n = 49); and group II (secondary ACIOL, n = 40). RESULTS: A total of 193 eyes of 192 patients were included. Mean post-operative follow-up in groups I and II were 8.6 and 11.51 months, respectively. Mean pre-operative and last visit corrected distance visual acuity were 1.73 ± 0.11 and 0.42 ± 0.05 logMAR units in group Ia (p < 0.001), and 1.53 ± 0.14 and 0.49 ± 0.10 logMAR units in group Ib (p < 0.001). The mean spherical equivalent (MSE) for last refraction was -0.37 ± 0.18 diopters (D) and -0.15 ± 0.51 D in groups I and II, respectively. Of 76 eyes in which addition of 2.5 D (over the near emmetropic posterior chamber intraocular lens power) was taken for ACIOL, 40 (52.6%) had MSE within ± 0.5 D. Most common complications were transient corneal edema and anterior chamber reaction. Eyes on anti-glaucoma medications at last visit were eight (7.7%), 15 (30.6%), and two (5.0%) in groups Ia, Ib, and II, respectively. CONCLUSION: We observed that ACIOLs have good visual and refractive outcomes. Raised IOP is a concern in eyes with pseudoexfoliation, but can be managed with close monitoring. Hence ACIOL can be a good option for managing aphakia after cataract surgery.

Efficacy of montelukast in preventing seasonal recurrence of vernal keratoconjunctivitis in children.

BACKGROUND: Vernal keratoconjunctivitis is a chronic, seasonally exacerbated, allergic inflammation of the eye. The study aims to evaluate the efficacy and safety of oral montelukast in treating vernal keratoconjunctivitis in pediatric patients. METHODS: This is a 26-week, prospective, randomized, open-label study. Fifty-eight patients were randomly assigned to two groups-the treatment (montelukast) and control groups. At the beginning of the study, both the groups received topical loteprednol etabonate (0.1%) in tapering doses for a month, and topical olopatadine (0.1%) for the first 3 months. Symptoms and signs observed before and after treatment and assigned scores were studied. The primary efficacy endpoint was change in the mean score on the visual analog scale (VAS) for each subjective symptom. The secondary efficacy endpoint was change in the total score of objective signs. RESULTS: The montelukast group showed clinically relevant improvements in the signs and symptoms of vernal keratoconjunctivitis, compared to the control group. There was considerable improvement in clinical signs. Individual symptoms such as redness, itching, foreign body sensation, and tearing showed significant improvement at 6 months follow-up. The gradual improvement in symptoms until the last visit was statistically more significant within montelukast group. Mean VAS score showed statistically significant improvement in itching (p < 0.001) and redness (p < 0.008) in montelukast group even at 3 months. No adverse events were reported in either group. CONCLUSIONS: Montelukast was found to be safe and effective as a long-term therapy to prevent relapse in moderate to severe vernal keratoconjunctivitis.

"A prospective study on the clinical course and proposed morphological classification scheme of microsporidial keratoconjunctivitis."

Background and objective: To describe the clinical course and propose a morphological classification scheme of microsporidial keratoconjunctivitis. Methods: This is a prospective study at L V Prasad Eye Institute, Odisha, between August-January (2017-19). Patients of any age or sex, microbiologically proven as microsporidial keratoconjunctivitis were included. Demographic parameters, history, clinical course, and visual outcome were analysed. All received artificial tear substitutes till resolution and topical immunosuppressants used in cases of persisting sub-epithelial infiltrates (SEI) beyond 2 weeks. Results: Fifty-three eyes of 47 cases were included with males, 72.3%. Corneal lesions were classified into 3 morphological types- coarse, ring, and flat-topped (Type1, 2 & 3). Depending upon the location, Type 1 was further sub-divided into peripheral, paracentral, central, and diffuse (Type 1a, b, c & d). The mean age was highest in Type 3(p = .026). Risk factors and prior steroid use were most common in Type 1d. The mean duration of symptom before presentation was longest in Type 3(11.6 ± 3.65) days. Severe conjunctival congestion at presentation in more than half of the eyes were seen in Type 1a, 1b and 1d, with moderate congestion at Day14 persisting in 66.7% and 40% of eyes belonging to Type 1c and 1d, respectively. Keratic precipitates were most common in Type 2. The mean duration of resolution was longest in Type 1d (38 ± 15.87) days and shortest in type 1b (7.88 ± 2.47) days (p = .022). Persistent SEIs beyond Day 90 were seen in total of 6 (11.3%) (Type 1c & 1d- 3 each) eyes and recurrent SEIs in 7(13.2%) (Type 1c-2 & 1d- 5) eyes. The mean duration of topical steroids use was longest in Type 1d (49.3 ± 22.3) days, followed by Type 1c (28 ± 0) days. Conclusion: Microsporidial keratoconjunctivitis can have a variable clinical presentation, the course of each being different depending on the host and ocular surface factors. Though considered as a self-limiting disease, central and diffuse coarse variety (Type1c&1d) required long-term topical immunosuppressants and follow-up.

Sequelae of microsporidial keratoconjunctivitis and its management.

Purpose: : To characterize the sequelae of microsporidia keratoconjunctivitis (MKC) and outline its management. Methods: Retrospective analysis of microbiologically proven MKC returned with persistent disease between January 2015 and December 2019 was done. Demographics, clinical features, management, and outcome were analyzed. Results: Sixteen patients (21 eyes) of 332 treated for MKC returned with the persisting disease. The mean age of 11 males (68.7%), and 5 females was 35.1 ± 12.2 years. Three-quarter of them did not have a known predisposing risk factor and one-quarter of them were referred for chronic conjunctivitis. Past medications included topical antivirals (n = 8) and topical corticosteroid (n = 6). Three predominant presentations were persistent (>3 weeks) superficial punctate keratitis (SPKs, n = 7), sub-epithelial infiltrates (SEIs, n = 13), and uveitis (n = 2). The lesions recurred in eight eyes (SPK and SEI 4 each) after a disease-free interval of 60.4 ± 40.6 days; there were 13 episodes of recurrence. Topical low potent corticosteroids (loteprednol/fluorometholone), and tacrolimus ointment 0.03% were used in 17 (80.9%) and 8 (38%) eyes, respectively, for a mean duration of 44.8 ± 31.6 and 226.8 ± 180.5 days, respectively. At follow-up, 172.3 ± 183.6 days, visual recovery was statistically significant in persistent eyes (BCVA 0.07 ± 0.07 logMAR; P < 0.00001) but, not in recurrent eyes (BCVA 0.16 ± 0.08 logMAR; P = 0.07). Five of 21 eyes were left with residual significant scar. Conclusion: The sequelae of microsporidial keratoconjunctivitis are not uncommon. Topical 0.03% tacrolimus ointment appeared to be an effective corticosteroid-sparing agent for the treatment of SEIs and prevention of recurrence.