Microbial keratitis and its management at a rural centre: achieving success with limited resources.

PURPOSE: Microbial keratitis is a sight-threatening condition with a higher incidence in agrarian populations. In countries with a high indigent population, due to financial and other constraints, patients prefer to seek therapy locally rather than travel to advanced centres. The aim of this study is to describe the epidemiology, clinical characteristics, and outcomes of 60 consecutive patients with microbial keratitis managed at a rural centre. METHODS: Descriptive case series. All patients clinically diagnosed with infectious keratitis were included. Corneal scrapings were obtained and microbiological identification was done by Gram stain. Anti-microbial therapy was commenced based on smear findings and the patients were followed up till disease resolution. RESULTS: Sixty eyes of 60 patients were diagnosed with microbial keratitis in the study period. The mean age was 47.43 ± 18.69 years. Male:female ratio was 47:53. Risk factors included ocular trauma in the majority of patients (46/60; 76.7%). Microorganisms were identified on 75.6% of smears, with fungal filaments (65.4%) being the most common. Ulcers were central in over half (32/60; 53.3%), and > 3 mm in diameter in over three-fourths (81.6%) of patients. Forty-four patients (73.3%) achieved treatment success whereas 16/60 (26.6%) required referral to our tertiary-eye care facility for management. The median time to resolution was 14 days (IQR 10-26 days). CONCLUSION: Our series demonstrates the feasibility of microbiology-guided therapy in microbial keratitis by ophthalmologists at the secondary rural eye-care level. Two-thirds of the patients could be successfully managed at the rural centre and only severe cases needed a referral to tertiary centres.

Alterations in the conjunctival surface bacterial microbiome in bacterial keratitis patients.

Microbial keratitis is an infectious disease of the eye, in which the cornea is inflamed. Under severe conditions, keratitis can lead to significant loss of vision and enucleation of the eye. Ocular trauma is the major risk factor causing keratitis and microorganisms viz., bacteria, fungi, viruses are the causative agents. The current study characterized the conjunctival bacterial microbiomes of healthy individuals and individuals with bacterial keratitis (BK) and assessed whether ocular microbiome dysbiosis is prevalent in BK patients. Ocular bacterial microbiomes were generated from the conjunctival swabs of healthy controls (HC-SW) and conjunctival swabs (BK-SW) and corneal scrapings (BK-CR) of BK patients using V3-V4 amplicon sequencing and data analysed using QIIME and R software. The Alpha diversity indices, diversity and abundance of different phyla and genera, heat map analysis, NMDS plots and inferred functional pathway analysis clearly discriminated the bacterial microbiomes of conjunctival swabs of healthy controls from that of BK patients. Preponderance of negative interactions in the hub genera were observed in BK-CR and BK-SW compared to HC-SW. In addition, a consistent increase in the abundance of pathogenic bacteria, as inferred from published literature, was observed in the conjunctiva of BK patients compared to HC and this may be related to causing or exacerbating ocular surface inflammation. This is the first study demonstrating dysbiosis in the ocular bacterial microbiome of conjunctiva of bacterial keratitis patients compared to the eye of healthy controls. The bacterial microbiome associated with the corneal scrapings of keratitis individuals is also described for the first time.

Microbial Keratitis in Thyroid Eye Disease: Clinical Features, Microbiological Profile, and Treatment Outcome.

PURPOSE: To report the incidence, clinical features, microbiologic profile, and risk indicators in the development of microbial keratitis in Thyroid Eye Disease (TED). METHODS: All patients who were diagnosed to have TED and developed microbial keratitis between the years 2009 to 2017 at the Ophthalmic Plastic Surgery service, LV Prasad Eye Institute were included in this retrospective interventional study. The clinical features, microbiological profile, and treatment outcome of the infection were studied. Possible risk factors leading to the development of microbial keratitis were studied. RESULTS: A total of 1,000 patients of TED were evaluated in the 10-year period. Of the 1,000, 13 patients (14 eyes, 1.4%) were diagnosed with microbial keratitis. The average age at presentation was 44 years (range 1969 years). Of the 13 patients, 10 (77%) were men, 12 (92%) were hyperthyroid, and 12 (92%) were active (average clinical activity score 3) at presentation. Average exophthalmometry value in the involved eye was 24.75mm, and severe eyelid retraction (>2mm scleral show) was noted in 13 of 14 eyes. None of the patients had optic nerve compression. Moderate motility restriction (2 in all gazes) was noted in 6 eyes, and severe motility restriction (4 in all gazes) in 8 eyes. At presentation, 11 (85%) had visual acuity of counting fingers at 1 meter or less, The mean follow up from the time of presentation was 18.3 months (range 566 months). Majority of the eyes (8/14) presented with severe infection (panophthalmitis with microbial keratits = 1, total corneal infiltrate with/without melt = 4, severe thinning/perforation = 4). Microbiological work up of 14 eyes revealed presence of gram-negative bacteria in 5 eyes which included Escherichia coli, Pseudomonas sp., and Acinetobacter sp., and gram-positive bacteria in 4 eyes including Streptococcus pneumoniae, Corynebacterium sp., and Staphylococcus sp. Three eyes revealed a mixed infection of E. coli with Alternaria sp, and E. coli with Corynebacterioum amycolatum while 1 had Corynebacterium pseudodiptheriticum, and S. pneumoniae. Two eyes of the bilateral case showed no growth. Antibiotic susceptibility revealed 6 of the 7 gram-negative isolates were multidrug resistant, whereas the gram-positive isolates were susceptible to most drugs tested. Surgical procedures required were tarsorrhaphy in 7 eyes, tissue adhesive with bandage contact lens in 4, evisceration in 4, levator recession in 2, 3-wall orbital decompression in 2, and penetrating keratoplasty in 1 eye. The visual acuity at presentation was counting fingers or worse in 10/14 eyes. Posttreatment, 10 eyes achieved resolution of infiltrate (with visual improvement in 2), and 4 required evisceration. CONCLUSIONS: In the authors large series of TED, microbial keratitis was noted in 1.3% of patients presenting to a tertiary eye center. Majority presented with advanced diseases and ended with a poor outcome. Gram-negative isolates showed multidrug resistance. An association with early phase of active TED (CAS 3 or more), severe eyelid retraction, and moderate-severe motility restriction is suggested.Microbial Keratitis occurs in 1.3% cases of Thyroid Eye Disease. It is more common in men, and in active disease. The microbiological spectrum and possible clinical risk factors are presented.

Clinical characterization of posterior polymorphous corneal dystrophy in patients of Indian ethnicity.

PURPOSE: To characterize the clinical presentation of posterior polymorphous corneal dystrophy (PPCD) in eyes of Indian ethnicity. DESIGN: Retrospective cohort study from January 1995 to December 2015. PARTICIPANTS: Patients with the diagnosis of posterior polymorphous corneal dystrophy. METHODS: Medical records of the patients were reviewed for clinical presentation. Histology of corneal specimens of those that underwent keratoplasty was assessed. MAIN OUTCOME MEASURES: Descriptive analysis of clinical condition. RESULTS: Mean age at first evaluation was 32.5 years (range 1-73 years), male:female = 35:18. Majority (44/53; 83 %) of the patients had bilateral involvement. 5/9 (44 %) patients with unilateral presentation were amblyopic in the affected eye. The clinical features documented were vesicles in 94 eyes, band-like pattern in 32 eyes, edema of varying degree in 23 eyes (12 patients, 1 patient was one eyed), and anterior segment changes in 1 eye. 8/45 (17 %) eyes had a regular astigmatism with steep axis >47 D (range 47.2-56.2 D). 16 eyes of 12 patients who had clinically evident corneal edema underwent keratoplasty. Mean age at keratoplasty was 58 years (range 1-73 years). 8 patients had penetrating keratoplasty (PK) and 8 had Descemet stripping endothelial keratoplasty (DSEK). Mean follow-up after keratoplasty was 4.2 years (1 month to 13 years). Except one, all grafts remained clear till the last follow-up. In all specimens, the Descemet membrane was grossly thickened. CONCLUSIONS: In our study, 12/53 (22.6 %) patients required keratoplasty for visually significant corneal edema. Except one, all were older adults. The patients who needed keratoplasty were bilaterally afflicted and had visually significant cornea edema in both eyes. With a mean follow-up duration of 4.2 years after keratoplasty, no recurrences were noted.

Chronic conjunctivitis due to Mycobacterium tuberculosis.

To report the clinical characteristics and treatment outcome in six patients with chronic conjunctivitis due to Mycobacterium tuberculosis. In this retrospective observational case series, all patients with a diagnosis of conjunctival tuberculosis seen in our clinics between January 2000 and January 2010 were reviewed. The clinical presentation, diagnostic investigations and response to medical therapy and outcomes were analyzed. Six patients (age range 15-47 years) were diagnosed with conjunctival tuberculosis. The mean duration from onset of symptoms to diagnosis was 6.5 months (range 1-12 months). Of the six patients, two had ulceration, one had a nodulo-ulcerative lesion, one had bilateral nodular epibulbar masses, and one had a hypertrophied papillary lesion. Systemic signs of tuberculosis were noted in two patients--pleural effusion in one and preauricular and submandibular lymph node involvement in the other. All patients had resolution of symptoms after treatment with four-drug anti-tuberculosis therapy (ATT). None had ocular or systemic recurrences after completion of ATT. Tuberculosis of the conjunctiva can have varied clinical presentation. Although a rare entity, it should be suspected in non-responding chronic conjunctivitis. A high index of suspicion and clinical examination aided by appropriate microbiological and histopathological testing can help in early diagnosis and management.

Reverse pupillary block with pigment dispersion and elevated intraocular pressure following bilateral phakic intraocular lens implantation.

The authors describe a case of reverse pupillary block with pigment dispersion following sequential phakic intraocular lens (pIOL) implantation for high myopia, in a young female patient. The intraocular pressure (IOP) elevation began 3 weeks postoperatively, for which Nd-YAG laser peripheral iridotomies (PIs) were attempted elsewhere. Despite maximum medical therapy, the IOP was uncontrolled. She was referred to our institute for further management. Examination showed anteriorly displaced iris-pIOL diaphragm, iris pigment dispersion and raised IOP. The PIs were incomplete. Based on clinical evaluation and investigations, we concluded that the excess area of contact of the posterior iris over the pIOL caused a reverse pupillary block and pigment dispersion. The IOPs were controlled by repeating laser iridotomies and with medical therapy. Subsequently, the patient developed a low lens vault leading to bilateral cataract. Sequential explantation of the pIOL along with cataract extraction was performed and her vision was restored.

Surgical and visual outcomes of flap repositioning for various flap-related pathologies post laser in-situ keratomileusis (LASIK).

To evaluate the surgical and visual outcomes of flap repositioning for various post-laser-assisted in-situ keratomileusis (LASIK) flap pathologies. Retrospective review of consecutive cases between April 1, 2017 and February 28, 2022, where surgical flap repositioning was performed following LASIK for various flap-related complications. Of the 6018 eyes, 31 needed flap repositioning (0.51%). Indications were flap displacement and folds in 20 eyes (64%), flap subluxation in five eyes (16%), epithelial ingrowth and interface debris in two each, and one eye each of diffuse lamellar keratitis and incomplete flap. Final best spectacle-corrected visual acuity of ≥ 20/25 was obtained in 25/31 (80%) eyes. The efficacy index pre to post repositioning showed significant improvement (0.86 ± 0.39 vs. 0.63 ± 0.29 preop, P = 0.011). Flap repositioning incidence was significantly higher (7/602 (1.16%)) during the COVID lockdown phases compared to the non-COVID lockdown phase (24/5416 (0.44%, P = 0.019)). The COVID group had lower efficacy (0.72 ± 0.36 vs. 0.90 ± 0.39, P = 0.300) and safety indices (0.85 ± 0.24 vs. 1.06 ± 0.35, P = 0.144) compared to the non-COVID group; however, the results were not statistically significant. The flap displacement rate was statistically higher in nasal hinged (microkeratome) flaps (18/2013, 0.89%) compared to superior hinged (Femto) flaps (13/4005, 0.32%) (0.32%, P = 0.003). Our study shows that flap repositioning has a low incidence in LASIK, with the most common indication being flap displacement/folds. The outcome post flap repositioning was poorer during the lockdown period, perhaps due to the inability to follow up early. Early identification and surgical repositioning are successful in both anatomical and visual restoration.

Clinical spectrum in microbiologically proven Demodex blepharokeratoconjunctivitis: An observational study.

PURPOSE: To study the demographic, clinical, and microbiological profile of Demodex-related blepharokeratoconjunctivitis (BKC) at a tertiary eye care hospital. METHODS: This retrospective observational study was conducted from January 2016 to September 2022. It included 83 patients with microbiologically proven Demodex BKC who presented to the cornea department of our tertiary care eye center. The clinical, microbiological, and demographic data of the 83 cases were analyzed. RESULTS: Of the 83 cases, 57 (68.67%) were younger than 40 years, and 25 (30.12%) were below 20. Most patients presented with a good visual acuity of 20/40 or better (93 eyes; 84.55%). The disease was unilateral in 55 patients and bilateral in 28. Cylindrical dandruff was the predominant presentation noted in 61 eyes (54.95%), followed by corneal scarring in 47 eyes (42.34%) and corneal vascularization in 40 eyes (36.04%). On light microscopy, 87.95% of the positive samples were identified as Demodex folliculorum , 7.23% as Demodex brevis , and 6.02% remained unidentified. Tea tree oil and lid scrubs eradicated the disease in most patients clinically (75/83, 90.36%). CONCLUSION: The spectrum of BKC includes both lid signs and corneal involvement. It can be a cause of recurrent BKC and detection of the mite by microscopic evaluation of the lashes can confirm the diagnosis. In most cases, the tea tree oil can effectively manage this condition. However, low doses of topical steroids are needed to control the inflammation in patients with corneal involvement.

Strategies for successful management of moderate and severe Mooren's ulcer at a rural center during the COVID-19 pandemic: Lessons learnt.

PURPOSE: This study aimed to report the strategies that evolved in managing Mooren's ulcer (MU) at a resource-limited center in rural India during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: This study includes a retrospective analysis of clinically diagnosed MU cases from January 2021 to August 2021 wherein strategies for management were developed. The demographic profile, ulcer clinical features, treatment algorithms (medical and surgical), complications encountered, referral to a higher center, and compliance with medication and follow-up were studied. RESULTS: The mean age of presentation was 68.1 years (range, 62-73 years), and 90% were men. The median best-corrected visual acuity (BCVA) was 1.26 logarithm of the Minimum Angle of Resolution (LogMAR) (interquartile range (IQR), 0.00-5 logMAR) in the affected eye on presentation, which improved to 0.69 logMAR (IQR, 0.00-3 logMAR) at resolution ( P = 0.442). The first-line management was conjunctival resection and tissue adhesive application (90%). 70% of cases were unilateral, 50% of cases had less than 2 clock hours of involvement, and 50% had less than 50% stromal involvement. Confounding factors included infectious keratitis (2) and corneal perforation (3). The mean duration of follow-up was 96 (1-240) days. The average follow-up visits per patient were 8.8 (1-22). 90% of cases could be managed successfully at the secondary center level with two cases needing a tertiary care referral. CONCLUSION: MU can be managed effectively by following a systemic strategy of early diagnosis, surgical therapy, and rapid institution of systemic immunosuppression in a remote location-based secondary center. The strategies developed can be a guide for ophthalmologists at remote centers managing patients or who are unable to travel to tertiary institutes.

Ocular infections associated with atypical mycobacteria: A review.

Atypical mycobacteria or non-tuberculous mycobacteria (NTM) are a group of acid-fast bacteria that are pathogenic to different parts of the eye. The organisms can cause a spectrum of ocular infections including keratitis, scleritis, uveitis, endophthalmitis and orbital cellulitis. Trauma, whether surgical or nonsurgical, has the highest correlation with development of this infection. Common surgeries after which these infections have been reported include laser in situ keratomileusis (LASIK) and scleral buckle surgery. The organism is noted to form biofilms with sequestration of the microbe at different inaccessible locations leading to high virulence. Collection of infective ocular material (corneal scraping/necrotic scleral tissue/abscess material/vitreous aspirate, etc.) and laboratory identification of the organism through microbiologic testing are vital for confirming presence of the infection and initiating treatment. In cluster infections, tracing the source of infection in the hospital setting via testing of different in-house samples is equally important to prevent further occurrences. Although the incidence of these infections is low, their presence can cause prolonged disease that may often be resistant to medical therapy alone. In this review, we describe the various types of NTM-ocular infections, their clinical presentation, laboratory diagnosis, management, and outcomes.

Keratoconus in India: Clinical presentation and demographic distribution based on big data analytics.

PURPOSE: This paper aims to describe the clinical presentation and demographic distribution of keratoconus (KCN) in India by analyzing the electronic medical records (EMR) of patients presenting at a multitier ophthalmology hospital network. METHODS: This cross-sectional hospital-based study included the data of 2,384,523 patients presenting between January 2012 and March 2020. Data were collected from an EMR system. Patients with a clinical diagnosis of KCN in at least one eye were included in this study. Univariate analysis was performed to identify the prevalence of KCN. A multiple logistic regression analysis was performed using R software (version 3.5.1), and the odds ratios are reported. RESULTS: Data were obtained for 14,749 (0.62%) patients with 27,703 eyes diagnosed with KCN and used for the analysis. The median age of the patients was 22 (inter-quartile range (IQR): 17-27). In total, 76.64% of adults (odds ratio = 8.77; P = <0.001) were affected the most. The majority of patients were male (61.25%), and bilateral (87.83%) affliction was the most common presentation. A significant proportion of the patients were students (63.98%). Most eyes had mild or no visual impairment (<20/70; 61.42%). Corneal signs included ectasia (41.35%), Fleischer ring (44.52%), prominent corneal nerves (45.75%), corneal scarring (13.60%), Vogts striae (18.97%), and hydrops (0.71%). Only 7.85% showed an association with allergic conjunctivitis. A contact lens clinic assessment was administered to 47.87% of patients. Overall, 10.23% of the eyes affected with KCN underwent a surgical procedure. the most common surgery was collagen cross-linking (8.05%), followed by deep anterior lamellar keratoplasty (1.13%) and penetrating keratoplasty (0.88%). CONCLUSION: KCN is usually bilateral and predominantly affects males. It commonly presents in the second and third decade of life, and only a tenth of the affected eyes require surgical treatment.

Anatomic and visual outcomes of descemetopexy in post-cataract surgery descemet's membrane detachment.

OBJECTIVE: To study the anatomic and visual outcomes of descemetopexy in Descemet's membrane detachment (DMD) after cataract surgery. DESIGN: Retrospective case series. PARTICIPANTS: Clinical notes of 60 patients who underwent DMD after cataract surgery between 2007 and 2011. METHODS: Descemetopexy was performed with air or 14% isoexpansile perfluoropropane (C3F8). MAIN OUTCOME MEASURES: Anatomical (reattachment rates) and functional results (best-corrected visual acuity) were studied. Secondary outcome measures were assessment of surgical complications and association of various factors with final visual outcome. RESULTS: The mean age of the patients was 64.3 ± 8.3 years, and the male:female ratio was 21:39. At 1 month, the mean logarithm of the minimum angle of resolution (logMAR) interval visual acuity (IVA) improved from 1.27 ± 0.8 to 0.42 ± 0.49 (P < 0.001). Five patients (8.3%) obtained 20/20 vision, and 37 of 60 patients (61.6%) achieved IVA of ≥ 20/40. Ninety-five percent (57/60) of patients had successful reattachment of the Descemet's membrane (DM) after the intervention. Multiple linear regression analysis showed that patients with a cataract score of 5 (estimate = 0.38; P=0.014), with a cataract score of 4 with compromised visibility due to a corneal opacity (estimate = 0.45; P=0.039), and prolonged duration between cataract surgery and descemetopexy (estimate = 0.012; P=0.007) were associated with a significantly poorer final visual outcome. No association of final visual outcome was observed with age; sex; eye treated; cataract scores 2, 3, and 4; preoperative visual acuity; and involvement of the visual axis (P > 0.5). The eyes in which air was used for descemetopexy (estimate = -0.2; P=0.009) had statistically significantly better final visual outcomes. Three patients (5%) had treatment failures and required subsequent endothelial transplantation. Pupillary block was observed in the early postoperative period in 7 patients (11.66%) in whom C3F8 had been used and was not seen with air (P=0.02). CONCLUSIONS: This study suggests that DMD after cataract surgery can be treated effectively and good visual outcomes can be expected if the patient is treated in time with anterior chamber injection of gas. Air has advantages of better efficacy than C3F8 without the risk of pupillary block and thus should be preferred.

Role of anterior segment optical coherence tomography in scleral diseases: A review.

BACKGROUND: Scleritis and episcleritis are an overlapping spectrum of diseases and accurate diagnosis is of utmost importance as the treatment and prognosis are vastly different. Predominantly a clinical diagnosis, the challenge lies in those cases with equivocal clinical features. Furthermore, clinical grading of scleritis is subjective and hence is neither very reliable nor reproducible. Existing modalities such as slit lamp examination and clinical photographs in scleritis describe macroanatomy but do not provide details on the microanatomy of the sclera. A recent adjusted algorithm for anterior segment optical coherence tomography (AS-OCT) imaging has improved the ability of this device to aid in the diagnosis of all the major forms of scleritis. PURPOSE: To highlight the role of AS-OCT in delineating various anatomical forms of episcleritis and scleritis and explore this tool in monitoring disease course and response to therapy. METHODS: A comprehensive literature search was carried out in various medical databases using keywords AS-OCT and scleritis; AS-OCT and episcleritis; anterior segment imaging in scleritis; scleritis and episcleritis; Recent advances in anterior segment imaging. Original articles and novel reports describing the potential role of AS-OCT in the diagnosis and management of scleritis and episcleritis were included. RESULTS: After a thorough assessment, it was clear that published literature lacks guidelines for uniform interpretation and also for classification and follow-up in scleritis. We describe a uniform protocol for AS-OCT image acquisition, interpretation of images and list the advantages and limitations. CONCLUSIONS: AS-OCT can be used to localize the level of scleral inflammation thus helping in the diagnosis of scleral inflammatory disease. It can be a valuable tool in studying progression.

Iatrogenic Descemet membrane detachment in the donor lenticule during Descemet stripping automated endothelial keratoplasty.

A female patient in her 60s presented with an 8-month history of decreased vision in her right eye. She was diagnosed with pseudophakic bullous keratopathy (PBK), and Descemet stripping automated endothelial keratoplasty (DSAEK) surgery was planned. Intraoperative Descemet membrane detachment (DMD) occurred while inserting the lenticule using the Sheets glide technique. The detachment of the Descemet membrane was detected immediately, and air descemetopexy was performed intraoperatively. Postoperatively, the donor lenticule was attached properly to the stromal bed, except for a focal DMD approximately 3 mm in the inferior part of the lenticule. A second descemetopexy was performed 5 days later, resulting in a complete attachment. A DMD in DSAEK lenticule is an extremely rare complication. Early detection and timely intervention with descemetopexy helped achieve a good anatomical and functional outcome.

Tocilizumab in Recalcitrant Bilateral Scleritis in a Case of Relapsing Polychondritis: A 17-year Follow Up.

PURPOSE: To report a challenging case of relapsing polychondritis with bilateral diffuse scleritis, with 17-year follow-up. METHODS: Case report. RESULTS: A 36-year-old female presented 17 years ago with bilateral diffuse scleritis and peripheral corneal infiltrates. Detailed systemic work-up was negative. Fourteen months later, she developed saddle nose deformity, debilitating myalgias, and severe recurrence of scleritis clinching the diagnosis of relapsing polychondritis. Despite high-dose oral corticosteroids, oral immunosuppressants, and cyclophosphamide infusions and adalimumab infusions, the condition showed waxing and waning over the next decade. In 2017, she was started on Tocilizumab injections after which both the systemic and ocular conditions stabilised and has been remained stable for the past 4 years. CONCLUSION: Relapsing polychondritis has a well-known association with scleritis. The ocular disease may precede systemic symptoms in some cases. Newer agent such as tocilizumab appears to be effective in controlling this relentless and recurrent disease.

Management of simultaneous bilateral immune-mediated peripheral ulcerative keratitis.

PURPOSE: Peripheral ulcerative keratitis (PUK) is a sight threatening disease, often immune mediated and can rapidly progress to corneal perforation. Here we report the successful management of simultaneous bilateral peripheral ulcerative keratitis presenting with corneal perforation with surgical intervention and systemic immunosuppression. CASE DESCRIPTION: A 41-year-old female presented with similarly located super-nasal peripheral ulcerative keratitis (PUK) in both eyes and focal area of adjoining scleritis in the left eye. Serological investigations for systemic immune-mediated conditions showed positive rheumatoid factor test. She underwent cyanoacrylate glue application in both eyes, and was started on topical and oral corticosteroids and oral immunomodulators, and the right eye stabilized. The left eye required a second surgical intervention with a corneal patch graft following which the condition stabilized. CONCLUSION AND IMPORTANCE: This case highlights the importance of investigating for an underlying systemic etiology in PUK and the role of systemic immunosuppression prior to and after surgical intervention in order to arrest the disease and prevent recurrences.

Corneal squamous neoplasia: masquerades and management outcomes at a rural eyecare centre.

The authors describe two cases of corneal ocular surface squamous neoplasia (OSSN), presenting at our rural eyecare centre, which were initially misdiagnosed as viral epithelial keratitis and corneal pannus with focal limbal stem cell deficiency. Both the cases were refractory to initial treatment and corneal OSSN was suspected. Anterior segment-optical coherence tomography (AS-OCT) revealed a thickened, hyper-reflective epithelium with abrupt transition and an underlying cleavage plane, features typical of OSSN. Topical 1% 5-fluorouracil (5-FU) therapy was initiated and in two cycles (first case) to three cycles (second case), complete resolution was noted both clinically and on AS-OCT, with no significant side effects. Both patients are currently free of tumour at the 2-month follow-up period. The authors report the rare, atypical presentations of corneal OSSN, discuss the masquerades and highlight the role of primary topical 5-FU in managing corneal OSSN in limited resource settings.

Penetrating keratoplasty and glaucoma valve surgery in recurrent Mooren's disease: A multidisciplinary approach.

INTRODUCTION AND IMPORTANCE: The case report highlights the challenges in managing recurrent Mooren's ulcer, a rare and severe form of peripheral ulcerative keratitis. CASE PRESENTATION: A 49-year-old male, with bilateral Mooren's disease who underwent multiple surgical interventions for visual rehabilitation but developed disease recurrence in the left eye despite being on systemic and topical immunosuppression. The authors report successful long-term visual rehabilitation following a large-graft penetrating keratoplasty and Ahmed glaucoma valve implantation performed under immunosuppressive cover after adequate control of inflammation with intravenous Rituximab. CLINICAL DISCUSSION: We discuss the traditionally poor survival of penetrating keratoplasty in refractory Mooren's disease due to the recurrence of the disease in the graft. Occurrence of secondary glaucoma is commonly seen in these eyes, which often requires combined filtration surgery and medical management. The first and second line systemic immunosuppression may be insufficient in adequately controlling the disease, and that intravenous monoclonal antibodies, such as Rituximab, may be a promising treatment modality in refractory Mooren's disease prior to embarking on any surgical intervention. CONCLUSION: Overall, the case report highlights the importance of adequate control of inflammation and the use of immunosuppressive cover in achieving successful outcomes of PK and AGV surgery in Mooren's ulcer. The authors suggest that intravenous Rituximab may be a valuable addition to the management of refractory Mooren's disease, particularly prior to surgical intervention. However, as with any case report, the findings should be interpreted with caution and further research is needed to validate the efficacy of this treatment modality.

Congenital anomalies of lens shape.

The crystalline lens is an important structure in the eye that starts to develop as early as the 22nd day of gestation, with further differentiation that continues after the induction. Congenital anomalies of the lens may involve the size, shape, and position of the lens. They may sometimes be associated with anterior segment dysgenesis or persistence of the tunica vasculosa lentis and hyperplastic vitreous and hyaloid system. Manifestations of anomalies of the lens shape are usually seen in early or late childhood however may sometimes be delayed into adulthood based on the level of visual impairment or the presence or absence of any syndromic associations. While lens coloboma has more often been reported in isolation, the more commonly implicated genes include the PAX6 gene, lenticonus in particular anterior is often part of Alport syndrome with extra-ocular manifestations in the kidneys and hearing abnormalities due to mutations in the alpha 5 chain of the Type IV collagen gene. Recognition of these manifestations and obtaining a genetic diagnosis is an important step in the management. The level of visual impairment and amblyopia dictates the outcomes in patients managed either conservatively with optical correction as well as surgically where deemed necessary. This review discusses the various anomalies of the lens shape with its related genetics and the management involved in these conditions.

Bilateral Severe Herpes Simplex Endotheliitis with a Possible Association with Latanoprost.

PURPOSE: To report bilateral Herpes Simplex virus (HSV) keratitis in a patient on latanoprost for primi]k=8ary open angle glaucoma (POAG). METHODS: Case report. RESULTS: A 76-year-old healthy male on latanoprost monotherapy for POAG polresented with sudden bilateral decreased vision. Examination showed bilateral dense corneal edema with loose epithelium. Aqueous fluid was positive for HSV-1 DNA on polymerase chain reaction (PCR). Latanoprost was discontinued, topical prednisolone acetate 1% eye, acyclovir 400 mg 5 times a day and combination of dorzolamide hydrochloride 2% and timolol maleate 0.5% twice daily were prescribed. The vision rapidly improved to 20/25 along with complete resolution of corneal edema within four weeks, with no recurrences over the next one year. CONCLUSION: Bilateral simultaneous HSV endotheliitis is a rare condition and positive PCR test can help rule in the diagnosis. HSV keratitis is a known adverse event with Latanoprost use and can present atypically.