Dematiaceous Fungal Keratitis With Tentacles Mimicking Pythium Keratitis.

This case report describes a diagnosis of Curvularia fungal keratitis in a man aged 60 years who presented with a paracentral corneal infiltrate in the right eye with tentacular projections.

Corneal blindness and eye banking: Current strategies and best practices.

Corneal blindness (CB) is one of the leading causes of blindness in India and globally, affecting around 8 million population worldwide. Many of these corneal blind patients may be visually rehabilitated by corneal transplantation (CT). Eye banking plays a crucial role in facilitating CT and ocular research. Many countries have adopted regulatory frameworks, quality assurance programs, and technological advancements to enhance the efficacy and safety of CT. Various infrastructural and organizational frameworks of eye banks (EBs) in India, according to the Eye Bank Association of India (EBAI), aid in establishing guidelines and standards for EB practices. Initiatives such as the National Programme for Control of Blindness (NPCB) have significantly contributed to eye donation rates and improved access to donor corneas. This review article discusses the established eye banking networks in countries such as India, the United States (USA), and Europe, where dedicated EB organizations work collaboratively to ensure efficient procurement, processing, and distribution of corneal tissue. It also highlights specific strategies employed in India and global countries to address EBs' challenges. These challenges include the shortage of donor corneas, improving donor screening and tissue processing techniques, ensuring timely distribution of corneal tissue, and maintaining high-quality standards. Interestingly, the comparative analysis between India and other developed countries highlights the similarities and differences in eye banking strategies. By understanding the strategies employed by different regions, EBs can learn from each other's experiences and work toward achieving optimal outcomes in CT and ocular research worldwide. It underscores the importance of knowledge sharing and collaborative efforts in addressing common challenges and implementing best practices in eye banking.

Association of Serious Adverse Effects With the Contamination of Ocular Medications-A Global Perspective.

This Viewpoint offers examples of the causes of infectious keratitis around the world and emphasizes the need for vigilance among ophthalmologists to reduce the risk of sight-threatening complications.

Heavy metal profile, mobility, and source characterization in size-fractionated bed-sediments of River Ganga, India.

Sediment quality assessment is vital while assessing the quality of rivers since sediments can alter the water quality depending on pH, redox conditions, and other physico-chemical characteristics. The present study aims to assess the heavy metal concentration in the size-fractionated sediments of River Ganga, and ascertain the sources of contamination in upper Himalayan stretch of around 300 km. The bed sediments of River Ganga were collected from Gomukh, Bhojwasa, Gangotri, Jhala Bridge, Chinyalisaur, Devaprayag, and Rishikesh; and these were size-fractionated in the range of 0-75, 75-150, 150-200, 200-250, 350-300, 300-450, 450-600 µm particle size to determine the concentration of heavy metals associated with each range of particle size using Atomic Absorption Spectrophotometer (AAS). The mean concentration of the metals in the sediments varied in the order Al (126 g/kg) > Fe (68 g/kg) > Cr (79 mg/kg) > Zn (67 mg/kg) > Pb (59 mg/kg) > Ni (38 mg/kg) > Cu (36 mg/kg) > Cd (2 mg/kg), and representing more affinity of metals with finer particle size of sediments. Contamination Factor and Metal Enrichment Factor indicated that sediments in the lower stretch were contaminated and enriched with many toxic metals. Geo-accumulation index, Sediment Pollution Index, and Pollution Load Index revealed that the sediments of Chinyalisaur, Devaprayag, and Rishikesh were moderately to strongly polluted and are progressively getting deteriorated by metals, thus, classifying these locations as hotspots of contamination. The major sources of Al and Fe were found to be natural; whereas Cr, Zn, Pb, Ni, Cu and Cd were mainly contributed by anthropogenic sources. The study stresses for immediate interventions to control further contamination by restricting addition of wastewater directly to River Ganga, or through other streams in Ganga basin.

Analysis on the completeness of case records of patients with penetrating ocular trauma following a multimodal intervention.

Purpose: To describe the process development of a multimodal intervention and the pre- and postintervention results on the completeness of case records of patients with penetrating ocular trauma in a high-volume tertiary eye care hospital in south India. Methods: A multimodal intervention including an objective-validated case sheet template, an education program, a physical template case record reminder, a continuous near-real time audit process, and a feedback system was developed. Analysis on the completeness of the case records of patients with ocular trauma from October 2020 to December 2020 (preintervention) and from January 2021 to March 2021 (postintervention) was performed. These case records and the personnel involved in the documentation, were given scores based on the scores assigned to the subsections of the validated template case sheet. The mean total score of the case records and of the personnel involved were analyzed. Results: One hundred and eleven case records of patients with ocular trauma who underwent primary wound repair were included in the study. Of these 111 case records, 46 belonged to preintervention group and 65 belonged to postintervention group. The mean total score for preintervention group during the study period was 57.93 ± 24 out of 100 and for postintervention group was 99.07 ± 4.49 out of 100. The temporal trend of postintervention group showed a consistent improvement every month (97.14, 100,100) during the 3-month study period. Postintervention improvement was noted in all the sections of case records completed by both fellows and consultants. Conclusion: A sustained improvement in ocular trauma case record documentation among all levels of medical professionals was noted following the five-component multimodal intervention.

Comparative study on costs incurred for treatment of patients with bacterial and fungal keratitis - A retrospective analysis.

Purpose: To compare the costs associated with medications and travel of patients with smear-proven bacterial keratitis and fungal keratitis in a tertiary care center in India. Methods: Retrospective analysis of case records of a cohort of patients who presented between April 2017 and March 2018 to a tertiary care center in India, with infectious keratitis who were smear-positive for bacteria or fungi, and whose costs of treatment and travel were supported by a philanthropic program. Results: In total, 672 case records of 177 smear-positive bacterial keratitis (BK) and 495 smear-positive fungal keratitis (FK) were included in the study. Further, 62% of BK and 75% of FK received more than one antimicrobial drug (P < 0.001). The mean total medication cost (INR) was significantly more in FK (959.1 ± 675.2) compared to BK (674.9 ± 463.7) (P < 0.0001). The mean medication cost (INR) per visit was also more for FK (201.1 ± 109.4) compared to BK (155.2 ± 84.1) (P < 0.0001). The mean total medication cost was significantly more for FK for both patients who healed with medical treatment (611.6 ± 395.6 for BK, 801.5 ± 599.9 for FK, P = 0.0005) and for patients who required TPK (953.7 ± 653.1 for BK, 1374.6 ± 701.5 for FK, P = 0.0023) compared to their respective counterparts in BK. Conclusion: Patients with fungal keratitis incurred significantly more on medications compared to patients with bacterial keratitis irrespective of whether they had healed with successful medical treatment or required therapeutic keratoplasty. Prolonged duration of treatment and the high costs of antifungal medications account for the significant economic burden of fungal keratitis.

Mediators of the Effect of Corneal Cross-Linking on Visual Acuity for Fungal Ulcers: A Prespecified Secondary Analysis From the Cross-Linking-Assisted Infection Reduction Trial.

PURPOSE: The purpose of this study was to determine whether astigmatism or corneal scarring is mediating the reduced visual acuity among patients with fungal keratitis randomized to corneal cross-linking (CXL). DESIGN: This was a prespecified exploratory outcome from an outcome-masked, 2 × 2 factorial design, randomized controlled clinical trial. STUDY PARTICIPANTS: Consecutive patients presented with moderate vision loss from a smear-positive fungal ulcer at Aravind Eye Hospital, Madurai, India. INTERVENTION: Study eyes were randomized to one of 4 treatment combinations using an adaptive randomization protocol. The treatment arms included (1) topical natamycin 5% alone, (2) topical natamycin 5% plus CXL, (3) topical amphotericin B 0.15% alone, and (4) topical amphotericin 0.15% plus CXL. Best spectacle-corrected visual acuity (BSCVA), contact lens over-refraction, and scar size and depth as measured by a masked study ophthalmologist using a standardized protocol were recorded at 3 months. Pentacam Scheimpflug imaging was also obtained at 3 months. MAIN OUTCOME MEASURES: BSCVA and contact lens over-refraction, infiltrate and/or scar size and depth, total astigmatism of the front and back of the cornea, total lower-order and higher-order aberrations of the anterior and posterior cornea, and total densitometry of the anterior, central, and posterior stroma were recorded. We performed a mediation analysis looking at the proportion of the effect of CXL on BSCVA that was mediated through scar size, scar depth, astigmatism and density. RESULTS: BSCVA at 3 months was available for 99 of 111 patients (89%) who had a mean of 0.82-LogMAR (SD 0.68). Three-month infiltrate and/or scar size ( P < 0.001), depth ( P < 0.001), and densitometry ( P = 0.001) were statistically significant predictors of 3-month BSCVA. Astigmatism seemed to mediate 23% of the effect of CXL on BSCVA, whereas scar size mediated 23%, scar depth 17%, and densitometry 7%. CONCLUSIONS: Corneal scarring and astigmatism are mediators of worse visual acuity after cross-linking in fungal keratitis. Corneal densitometry may be a helpful cornea-specific variable for clinicians and researchers in determining the effect of corneal scarring on visual acuity in specific patients and as an objective study outcome. TRIAL REGISTRATION: NCT02570321.

Outcomes of Pythium keratitis: a meta-analysis of individual patient data.

Background: Pythium keratitis is a difficult-to-treat corneal infection. Methods: A meta-analysis of individual patient data from observational studies of Pythium keratitis was performed. The outcomes of interest were therapeutic penetrating keratoplasty (TPK) and globe removal (evisceration, enucleation, or exenteration); the main exposures were linezolid and azithromycin use. Findings: Of 46 eligible articles, individual patient data were available for 306 eyes (34 studies). Pythium keratitis was associated with high rates of TPK (80%, 95%CI 70-87%) and globe removal (25%, 95%CI 13-43). In multivariable models adjusting for age and country, fewer TPKs were performed in patients treated with azithromycin (RR=0.80, 95%CI 0.67-0.96; P=0.04) and linezolid (RR=0.82, 95%CI 0.67-0.99; P=0.02). Conclusions: Studies of Pythium keratitis reported high rates of TPK and globe removal. Use of azithromycin and linezolid was associated with a lower rate of TPK. While promising, these results should be interpreted with caution given the biases inherent to observational studies.

In Vivo Confocal Microscopic Evaluation of the Limbus and Cornea in Vogt Koyanagi Haradas Syndrome.

AIM: To elucidate the microarchitecture of limbus and cornea in subjects with Vogt Koyanagi Haradas syndrome (VKH). METHODS: From January 2019 to December 2019 a total of 17 VKH subjects, 5 acute and 12 chronic, 18 non VKH uveitis controls, and 6 healthy controls were recruited for this study . In vivo confocal microscopic (IVCM) analysis of the limbal basal epithelium, scleral side of the limbus, limbal niche, corneal keratocytes, and corneal nerves was carried out . RESULTS: Absence of pigmented cells in the limbal basal epithelium, presence of inflammatory cells on the scleral side of the limbus, fibrotic niche, degenerated keratocytes, thinning, and beading of corneal nerves were noted in VKH eyes as compared to controls. CONCLUSION: Presence of inflammatory cells and depigmentation of limbus in chronic VHK points to disease progression.Keratocyte and corneal nerve changes in Vogt Koyanagi Haradas syndrom are novel findings.

Effectiveness of a Tele-Ophthalmology Vision Center in Treating Corneal Disorders and Its Associated Economic Benefits.

PURPOSE: The aim of this study was to study the clinical and economic impact of a teleophthalmology-based vision center (VC) in the management of corneal diseases in rural south India. METHODS: Data of patients with corneal disorders who visited the VC in the year 2019 were analyzed for the total number of outpatient visits, the proportion of corneal cases that were treated at the VC, those referred to the base hospital (BH), and the costs of treatment. RESULTS: In 2019, 1131 (10%) of 10,850 patients who visited the VC were diagnosed with corneal disorders. Of these, 950 (84%) patients were treated at the VC itself and did not require to be referred. The remaining 181 (16%) were referred to the BH. Of these 1131 patients, 836 (74%) patients presented with a painful acute corneal disorder. The most common painful acute corneal disorders included corneal foreign body (376, 33%), epithelial abrasions (205, 18%), and infectious keratitis (124, 11%). A patient can save approximately a minimum of INR 1200 (USD 16) by attending the VC rather than the BH. In 2019, by treating 950 patients, the VC saved approximately INR 114,0000 (USD 15,200) for the community. A similar calculation extrapolated to a 10-year period (2009-2019) revealed that by providing care for these corneal disorders at the community level, the VC saved approximately INR 705,8400 (USD 94,112) for the community. CONCLUSIONS: VC reduces the barriers to care by increasing the accessibility and affordability of treatment for patients with corneal disorders, resulting in a significant cost saving to the community.

Double-masked, sham and placebo-controlled trial of corneal cross-linking and topical difluprednate in the treatment of bacterial keratitis: Steroids and Cross-linking for Ulcer Treatment Trial (SCUT II) study protocol.

INTRODUCTION: Although antibiotics are successful at achieving microbiological cure in infectious keratitis, outcomes are often poor due to corneal scarring. Ideal treatment of corneal ulcers would address both the infection and the inflammation. Adjunctive topical steroid treatment may improve outcomes by reducing inflammation. Corneal cross-linking (CXL) is a novel prospective therapy that may simultaneously reduce both inflammatory cells and bacterial pathogens. The purpose of this study is to determine differences in 6-month visual acuity between standard medical therapy with antibiotics versus antibiotics with adjunctive early topical steroid therapy versus antibiotic treatment plus CXL and early topical steroids. METHODS AND ANALYSIS: This international, randomised, sham and placebo-controlled, three-arm clinical trial randomises patients with smear positive bacterial ulcers in a 1:1:1 fashion to one of three treatment arms: (1) topical 0.5% moxifloxacin plus topical placebo plus sham CXL; (2) topical 0.5% moxifloxacin plus difluprednate 0.05% plus sham CXL; or (3) the CXL group: topical 0.5% moxifloxacin plus difluprednate 0.05% plus CXL. ETHICS AND DISSEMINATION: We anticipate that both adjunctive topical steroids and CXL will improved best spectacle corrected visual acuity and also reduce complications such as corneal perforation and the need for therapeutic penetrating keratoplasty. This study will comply with the NIH Data Sharing Policy and Policy on the Dissemination of NIH-Funded Clinical Trial Information and the Clinical Trials Registration and Results Information Submission rule. Our results will be disseminated via ClinicalTrials.gov website, meetings and journal publications. Our data will also be available on reasonable request. TRIAL REGISTRATION NUMBER: NCT04097730.

Corneal Involvement in HIV-infected Individuals.

Corneal involvement in HIV-infected individuals may be broadly classified into two categories, namely, infectious and noninfectious with the vast majority of manifestations occurring in the former. In this article, we shall focus on these two categories and strive to highlight those presentations that should alert the clinician to suspect underlying HIV infection. Infectious group mainly consists of Herpitic group of viral infections. Bacterial causes may be due to Staphylococcus epidermidis, Staphylococcus aureus, Pseudomonas aeroginosa, alpha hemolytic Streptococcus, Micrococcus and Bacillus. Fungalf keratitis in HIV-infected individuals depends on the geographic locations from which patient comes. Microsporidia and Acanthamoeba are common Protozoal causes. Non-infective inflammatory causes include peripheral ulcerative keratitis, keratoconjunctivitis sicca, and squamous cell carcinoma of the conjunctiva. Severity which is abnormally severe or very minimally reactive makes the clinician suspect of immunosuppression.

Chemical Cross-Linking of Corneal Tissue to Reduce Progression of Loss of Sight in Patients With Keratoconus.

Purpose: We aimed to develop a novel chemical cross-linker treatment for keratoconus by reacting dicarboxylic acid spacer molecules and amine functional groups on protein structure of the tissue using carbodi-imide chemistry. We propose this as an alternative to conventional cross-linking treatment for keratoconus. Methods: The study involved optimization of the cross-linker formulation. Mechanical stiffness of ex vivo porcine and human corneas after application of the cross-linker was measured. Histochemical analysis was performed to record changes in gross morphology after cross-linker treatment on ex vivo porcine and human and in vivo rabbit corneas. Terminal deoxynucleotidyl transferase-mediated dUTP-X nick-end-labeling (TUNEL) staining was performed to study apoptotic effects of cross-linker. Cytotoxicity potential of cross-linker was evaluated by studying explant cultures for cellular outgrowth and immunostaining assays on porcine and human corneas after treatment. Results: We demonstrated a clinically relevant increase in stiffness in ex vivo experiments using porcine and human cornea without removal of corneal epithelium. Histological analysis showed no change in gross morphology of cornea and no evidence of apoptosis. In vivo treatment of rabbit eyes demonstrated initial thinning of corneal epithelium that recovered after seven days although with abnormal regularity of cells. Cellular outgrowth from corneal explant cultures after treatment further confirmed cell survival after treatment. Conclusions: This chemical cross-linking of corneal tissue has potential advantages over current therapeutic options including lower cytotoxicity to stromal cells than ultraviolet A treatment. Translational Relevance: The cross-linker has potential to become a treatment for keratoconus because it overcomes the need for procedures using specialized equipment and ensures accessibility to large populations.

Cross-Linking Assisted Infection Reduction (CLAIR): A Randomized Clinical Trial Evaluating the Effect of Adjuvant Cross-Linking on Bacterial Keratitis.

PURPOSE: To determine whether there is a benefit to adjuvant corneal cross-linking (CXL) for bacterial keratitis. METHODS: This is an outcome-masked, randomized controlled clinical trial. Consecutive patients presenting with a smear-positive bacterial ulcer at Aravind Eye Hospitals at Madurai, Pondicherry, and Coimbatore in India were enrolled. Study eyes were randomized to topical moxifloxacin 0.5% or topical moxifloxacin 0.5% plus CXL. The primary outcome of the trial was microbiological cure at 24 hours on repeat culture. Secondary outcomes included best spectacle corrected visual acuity at 3 weeks and 3 months, percentage of study participants with epithelial healing at 3 weeks and 3 months, infiltrate and/or scar size at 3 weeks and 3 months, 3-day smear and culture, and adverse events. RESULTS: Those randomized to CXL had 0.60 decreased odds of culture positivity at 24 hours (95% confidence interval [CI]: 0.10-3.50; P = 0.65), 0.9 logarithm of the minimum angle of resolution lines worse visual acuity (95% CI: -2.8 to 4.6; P = 0.63), and 0.41-mm larger scar size (95% CI: -0.48 to 1.30; P = 0.38) at 3 months. We note fewer corneal perforations or need for therapeutic penetrating keratoplasty in the CXL group. CONCLUSIONS: We were unable to confirm a benefit to adjuvant CXL in the primary treatment of moderate bacterial keratitis. However, CXL may reduce culture positivity and complication rates; therefore, a larger trial to fully evaluate this is warranted. TRIAL REGISTRATION: NCT02570321.