Pediatric corneal transplantation: techniques, challenges, and outcomes

Pediatric corneal transplant is a highly demanding and technically challenging procedure for the cornea surgeon in today's era. These cases pose unique challenges in clinical and surgical management. The indications of pediatric corneal transplant can be therapeutic, tectonic, optical, and cosmetic. Pediatric patients undergoing corneal transplants are at a high risk of graft infection, failure, rejection, dehiscence, and amblyopia due to young age, robust immune system, increased incidence of trauma, and compliance issues. The other factors contributing to graft failure can be allograft rejection, secondary glaucoma, corneal vascularization, multiple surgeries, vitreous prolapse, and lack of treatment compliance. A successful corneal transplant in children depends on meticulous preoperative evaluation, uneventful surgery, the expertise of a corneal surgeon, and regular and timely postoperative follow-up. Therapeutic and optical penetrating keratoplasty are the most commonly performed transplants in children. However, with the advancements in surgical technique and management protocol, the current focus has shifted toward lamellar keratoplasty. Lamellar keratoplasty offers early visual recovery and potentially fewer complications. Visual rehabilitation through corneal transplant in otherwise blind eyes can be a boon for the children. Recently, keratoprostheses have been promising in children with multiple graft failures. The current review gives insights into epidemiology, etiology, indications, clinical characteristics, investigations, management options, recent advances, and the future of pediatric corneal transplants. As surgical techniques continue to grow and comprehension of pediatric corneal transplants is improving, we can safeguard these eyes with the best possible anatomical and functional outcomes.

Molecular and epigenetic mechanisms governing ocular surface squamous neoplasia: opportunities for diagnostics

INTRODUCTION

Ocular surface squamous neoplasia (OSSN) is the most common ocular malignancy; the pathophysiology is influenced by molecular, genetic, and epigenetic mechanisms. The incidence of OSSN is associated with the anatomy and physiology of the ocular surface, limbal stem cell configuration, limbal vulnerability, cancer stem cells, dysplasia, neoplasia, angiogenesis, invasion, and metastasis. The key etiological factors involved are human papillomavirus (HPV), human immunodeficiency virus (HIV), immunosuppression, p53 tumor suppressor gene, hypovitaminosis A, and failure of Deoxyribonucleic acid (DNA) repair mechanisms.

AREAS COVERED

This special report is a focussed attempt to understand the molecular mechanism, genetic and epigenetic mechanism, and diagnostic modalities for OSSN.

EXPERT OPINION

While these mechanisms contribute to genome instability, promoter-specific hypermethylation might facilitate and promote tumor formation by silencing tumor suppressor genes. OSSN understanding has improved with increased literature available on various genetic, molecular, and epigenetic mechanisms, although the exact genetic and epigenetic mechanisms still need to be elucidated. It is important to note that the molecular mechanisms of OSSN can vary among individuals, and further research is required to elucidate the underlying processes fully. Understanding these mechanisms is crucial for the development of targeted therapies and improved management of OSSN.

Tofacitinib in acute severe ulcerative colitis (TACOS): A randomized controlled trial: Tofacitinib in ASUC

BACKGROUND

Intravenous corticosteroids are the mainstay of treatment of patients hospitalized with acute severe ulcerative colitis (ASUC). However, 30%-40% of the patients are refractory to corticosteroids. We investigated whether addition of tofacitinib to corticosteroids improved the treatment responsiveness in patients with ASUC.

METHODS

This single center, double blind, placebo controlled trial randomized adult patients with ASUC (defined by Truelove Witts severity criteria) to receive either tofacitinib (10 mg thrice daily) or a matching placebo for 7 days while continuing intravenous corticosteroids (hydrocortisone 100 mg q6h). The primary end point was response to treatment (decline in Lichtiger index by >3 points, and an absolute score <10 for 2 consecutive days without the need for rescue therapy) by day 7. The key secondary outcome was the cumulative probability of requiring initiation of infliximab or undergoing colectomy within 90 days following randomization. All analyses were done in the intention-to-treat population.

RESULTS

A total of 104 patients were randomly assigned to a treatment group (53 to tofacitinib and 51 to placebo). At day 7, response to treatment was achieved in 44/53 (83.01%) patients receiving tofacitinib versus 30/51 (58.82%) patients receiving placebo (OR 3.42, 95% CI 1.37-8.48, p=0.007). The need for rescue therapy by day 7 was lower in the tofacitinib arm (OR 0.27, 95% CI 0.09-0.78, p=0.01). The cumulative probability of need for rescue therapy at day 90 was 0.13 in patients who received tofacitinib vs 0.38 in patients receiving placebo (Log Rank p=0.003). The majority of the treatment related adverse effects were mild. One patient, receiving tofacitinib, developed dural venous sinus thrombosis.

CONCLUSION

In patients with ASUC, combination of tofacitinib and corticosteroids improved treatment responsiveness and decreased the need for rescue therapy. Trial registration number: ISRCTN42182437.

Effectiveness of Yoga Intervention in Reducing Felt Stigma in Adults With Epilepsy: A Randomized Controlled Trial

BACKGROUND AND OBJECTIVES

Persons with epilepsy are afflicted with comorbidities such as stigma, anxiety, and depression which have a significant impact on their quality of life. These comorbidities remain largely unaddressed in resource-limited countries. This randomized controlled trial (RCT) aimed to investigate whether yoga and psychoeducation were effective in reducing felt stigma (primary outcome), neuropsychiatric outcomes, and seizure frequency, as compared with sham yoga and psychoeducation in persons with epilepsy.

METHODS

This was an assessor-blinded, sham yoga-controlled RCT. Patients clinically diagnosed with epilepsy, aged 18-60 years, and scoring higher than the cutoff score for felt stigma as measured by the Kilifi Stigma Scale (KSS) in our population were randomly assigned to receive either yoga therapy plus psychoeducation (intervention) or sham yoga therapy plus psychoeducation (comparator) for a duration of 3 months. The primary outcome was a significant decrease in felt stigma as compared with the comparator arm as measured by the KSS. Primary and secondary outcomes (seizure frequency, quality of life, anxiety, depression, mindfulness, trait rumination, cognitive impairment, emotion regulation) were assessed at baseline, 3 months, and 6 months. Parametric/nonparametric analysis of covariance and the χ2 test were used to compare the 2 arms.

RESULTS

A total of 160 patients were enrolled in the trial. At the end of the follow-up period (6 months), the intervention arm reported significant reduction in felt stigma as compared with the control arm (Cohen's d = 0.23, 95% CI -0.08 to 0.55, p = 0.006). Significantly higher odds of >50% seizure reduction (odds ratio [OR] 4.11, 95% CI 1.34-14.69, p = 0.01) and complete seizure remission (OR 7.4, 95% CI 1.75-55.89, p = 0.005) were also observed in the intervention group. The intervention group showed significant improvement in symptoms of anxiety, cognitive impairment, mindfulness, and quality of life relative to the control group at the end of follow-up period (p < 0.05).

DISCUSSION

Yoga can alleviate the burden of epilepsy and improve the overall quality of life in epilepsy by reducing perceived stigma.

TRIAL REGISTRATION INFORMATION

Clinical Trials Registry of India (CTRI/2017/04/008385).

CLASSIFICATION OF EVIDENCE

This study provides Class I evidence that yoga reduces felt stigma in adult patients with epilepsy.

Propofol versus Desflurane in Moyamoya Disease Patients-A Pilot Study

Objectives  The choice of inhalational or intravenous anesthetic agents is debatable in neurosurgical patients. Desflurane, a cerebral vasodilator, may be advantageous in ischemic cerebral pathologies. Hence, we planned to compare desflurane and propofol in patients with moyamoya disease (MMD) with the objective of comparing neurological outcomes. Materials and Methods  This prospective pilot trial was initiated after institutional ethics committee approval. Patients with MMD undergoing revascularization surgery were randomized into two groups receiving either desflurane or propofol intraoperatively. Neurological outcomes were assessed using a modified Rankin score (mRS) at discharge and an extended Glasgow outcome score (GOS-E) at 1 month. Intraoperative parameters, including hemodynamic parameters, end-tidal carbon dioxide, entropy, intraoperative brain relaxation scores (BRS), and rescue measures for brain relaxation, were compared. Statistical Analysis  The normality of quantitative data was checked using Kolmogorov-Smirnov tests of normality. Normally distributed data were compared using unpaired t -tests, skewed data using Mann-Whitney U tests, and categorical variables using chi-squared tests. Results  A total of 17 patients were randomized, 10 in the desflurane and 7 in the propofol group. mRS (1.3 ± 0.6 and 1.14 ± 0.4, p  = 0.450) and GOS-E (6.7 ± 0.6 and 6.85 ± 0.5, p  = 0.45) were comparable between desflurane and propofol groups, respectively. BRS was significantly higher in the desflurane group (3.6 ± 0.5) compared to the propofol group (2.1 ± 0.3, p  = 0.001), with a significant number of patients requiring rescue measures in the desflurane group (70%, p  < 0.001). Other outcome parameters were comparable ( p  > 0.05). Conclusion  We conclude that postoperative neurological outcomes were comparable with using either an anesthetic agent, desflurane, or propofol in MMD patients undergoing revascularization surgery. Maintenance of anesthesia with propofol had significantly superior surgical field conditions.

Understanding barriers, recommended solutions, and future prospects for the diagnosis and management of Pythium insidiosum keratitis

Pythium insidiosum keratitis (PIK) is a devastating corneal infection resulting in blindness in a large number of cases. Clinically and morphologically, it closely mimics fungal keratitis, and hence is also labeled as "parafungus." Although many clinical studies have documented evidence regarding the virulence of microorganism, and anatomical and functional outcomes, it remains a clinical challenge and diagnostic dilemma for most clinicians. Till today, PIK is being diagnosed and treated with certainty at only limited centers across the globe. But the question is why this is so? Taking this as the research question, this section on current ophthalmology aims to highlight the understanding of barriers to diagnosing and treating PIK, the suggestions to improve diagnosis and treatment, and the future prospects.

Innovative lanthanide complexes: Shaping the future of cancer/ tumor chemotherapy

Developing new therapeutic and diagnostic metals and metal complexes is a stunning example of how inorganic chemistry is rapidly becoming an essential part of modern medicine. More study of bio-coordination chemistry is needed to improve the design of compounds with fewer harmful side effects. Metal-containing drugs are widely utilized in the treatment of cancer. Platinum complexes are effective against some cancers, but new coordination compounds are being created with improved pharmacological properties and a broader spectrum of anticancer action. The coordination complexes of the 15 lanthanides or rare earth elements in the periodic table are crucial for diagnosing and treating cancer. Understanding and treating cancer requires the detection of binding lanthanide (III) ions or complexes to DNA and breaking DNA by these complexes. Current advances in lanthanide-based coordination complexes as anticancer treatments over the past five years are discussed in this study.

Past, present and future of xanthine oxidase inhibitors: design strategies, structural and pharmacological insights, patents and clinical trials

Xanthine oxidase, a molybdo-flavoenzyme, and an isoform of xanthine dehydrogenase both exist as xanthine oxidoreductase and are responsible for purine catabolism. Xanthine oxidase is more involved in pathological conditions when extensively modulated. Elevation of xanthine oxidase is not only the prime cause of gout but is also responsible for various hyperuricemia associated pathological conditions like diabetes, chronic wounds, cardiovascular disorders, Alzheimer's disease, etc. Currently available xanthine oxidase inhibitors in clinical practice (allopurinol, febuxostat and topiroxostat) suffer from fatal side effects that pose a serious problem to the healthcare system, raising global emergency to develop novel, potent and safer xanthine oxidase inhibitors. This review will provide key and systematic information about: a. design strategies (inspired from both marketed drugs in clinical practice and natural products), structural insights and pharmacological output (xanthine oxidase inhibition and associated activities) of various pre-clinical candidates reported by various research groups across the globe in the past two decades; b. patented xanthine oxidase inhibitors published in the last three decades and c. clinical trials and their outcomes on approved drug candidates. Information generated in this review has suggested fragment-based drug design (FBDD) and molecular hybridization techniques to be most suitable for development of desired xanthine oxidase inhibitors as one provides high selectivity toward the enzyme and the other imparts multifunctional properties to the structure and both may possess capabilities to surpass the limitations of currently available clinical drugs. All in combination will exclusively update researchers working on xanthine oxidase inhibitors and allied areas and potentially help in designing rational, novel, potent and safer xanthine oxidase inhibitors that can effectively tackle xanthine oxidase related disease conditions and disorders.

Development of a novel green catalyzed nanostructured Cu(II) macrocyclic complex-based disposable electrochemical sensor for sensitive detection of bisphenol A in environmental samples

BPA is an endocrine disruptor and the leading environmental pollutant due to its use as raw material in industries. Therefore, the present work reports the sensitive, efficient, and disposable electrochemical paper-based SPE for determining the BPA sensor using an amide-based macrocyclic complex (nanostructured complex of copper acetate with macrocyclic ligand, i.e., CuL (CH3COO)2) synthesized using Citrus limon (lemon) extract via sonication for the first time. The structural, morphological, and electrochemical analyses have been characterized by mass spectroscopy, FTIR, UV-Vis, XRD, FESEM-EDX, elemental mapping and electrochemical techniques. The sensor platform for detecting BPA was fabricated by simple drop-casting on the disposable paper-based SPE using macrocyclic complex, i.e., CuL (CH3COO)2/SPE. After optimizing the conditions, CuL (CH3COO)2/SPE electrode was employed for determining BPA via CV with a wide linear range of 31 × 10-9 μM-0.205 μM, low LOD of 0.027 nM, and high sensitivity of 49.71 μA (log nM)-1 cm-2 having correlation coefficient (R2) of 0.976 which is quite better in compared to other reported SPE sensor for detection of BPA. Further, our sensor also showed good selectivity and reproducibility, in addition to detecting BPA in environmental samples (tube well water, river water and drain water) with acceptable recoveries and RSDs values. In this work, the combination of macrocyclic complex and paper-based SPE has turned out to be a cost-effective electrochemical sensor.

Non-insulinoma pancreatogenous hypoglycemia syndrome (NIPHS)/Nesidioblastosis as the underlying cause of recurrent hypoglycemia in a diabetic adult

Non-insulinoma pancreatogenous hypoglycemia syndrome (NIPHS), without previous bariatric surgery, is a rare form of hypoglycemia in adult patients and is associated with nesidioblastosis. Adult-onset nesidioblastosis in diabetic patients is rare and histologically identical to "non-insulinoma pancreatogenous hypoglycemia syndrome (NIPHS)". Nesidioblastosis is rare in adults and clinically and biochemically mimics Insulinoma. In the literature, there have only been four cases of adult nesidioblastosis that followed diabetes mellitus. We report a case of nesidioblastosis in a 36-year-old diabetic female presenting with dizziness, sweating, and palpitations for three years. Selective non-invasive techniques failed to detect a tumor. Based on the pursuit of an insulinoma, a distal pancreatectomy specimen was received at our laboratory, and a diagnosis of nesidioblastosis was made. She is currently on follow-up with a favorable outcome. The definitive diagnosis of nesidioblastosis is made on a histological basis. The preferred form of treatment is pancreatic surgical resection. Nesidioblastosis should be taken into consideration in cases where diabetes transforms into hyperinsulinemic hypoglycemia.

Characterization and regulation of salt upregulated cyclophilin from a halotolerant strain of Penicillium oxalicum

Penicillium species are an industrially important group of fungi. Cyclophilins are ubiquitous proteins and several members of this family exhibit peptidyl-prolyl cis-trans isomerase (PPIase) activity. We had earlier demonstrated that the salt-induced PPIase activity in a halotolerant strain of P. oxalicum was associated with enhanced expression of a cyclophilin gene, PoxCYP18. Cloning and characterization of PoxCYP18 revealed that its cDNA consists of 522 bp encoding a protein of 173 amino acid residues, with predicted molecular mass and pI values of 18.91 kDa and 8.87, respectively. The recombinant PoxCYP18 can catalyze cis-trans isomerization of peptidyl-prolyl bond with a catalytic efficiency of 1.46 × 107 M-1 s-1 and is inhibited specifically only by cyclosporin A, with an inhibition constant of 5.04 ± 1.13 nM. PoxCYP18 consists of two cysteine residues at positions - 45 and - 170, and loses its activity under oxidizing conditions. Substitution of these residues alone or together by site-directed mutagenesis revealed that the PPIase activity of PoxCYP18 is regulated through a redox mechanism involving the formation of disulfide linkages. Heterologous expression of PoxCYP18 conferred enhanced tolerance to salt stress in transgenic E. coli cells, implying that this protein imparts protection to cellular processes against salt-induced damage.

Impact of Covid-19 on Pediatric Ophthalmology Care: Lessons Learned

The COVID-19 pandemic came with many new challenges that forced personal and professional lifestyle modifications. Medical facilities were in scarcity against this new unknown enemy and were challenged with the overloaded patient flow, scarcity of healthcare staff, and evolving treatment modalities with a better understanding of the virus each day. Ophthalmology as a "branch of medicine" suffered challenges initially because of a lack of guidelines for patient management, close working distance during routine examinations, and halt of major surgeries, including cataracts. Pediatric ophthalmology had major implications, as reduced outpatient visits would mean deeper amblyopia, and changed lifestyles, including online classes and home refinement, predisposing children to myopia, digital eye strain, and worsening of strabismus. COVID-19 also unveiled underlying accommodation and convergence anomalies that predisposed pediatric and adolescent patients to an increased prevalence of headache and acute onset esotropia. Teleophthalmology and other innovative solutions, including the use of prism glasses, safe slit-lamp shields, alternative ways of school screening with the use of photoscreeners, performing retinoscopy only when needed, and using autorefractors were among the few guidelines or modifications adopted which helped in the efficient and safe management of pediatric patients. Many pediatric ophthalmologists also suffered in terms of financial constraints due to loss of salary or even closure of private practices. School screening and retinopathy of prematurity screening suffered a great setback and costed a lot of vision years, data of which remains under-reported. Important implications and learnings from the pandemic to mitigate future similar situations include using teleophthalmology and virtual platforms for the triage of patients, managing non-emergency conditions without physical consultations, and utilizing home-based vision assessment techniques customized for different age groups. Though this pandemic had a lot of negative implications, the innovations, modifications, and other important learnings helped pediatric ophthalmologists in navigating safely.

Antimicrobial and antibiofilm effects of shikonin with tea tree oil nanoemulsion against Candida albicans and Staphylococcus aureus

The current work aims to develop a shikonin and tea tree oil loaded nanoemulsion system stabilized by a mixture of GRAS grade surfactants (Tween 20 and monoolein) and a cosurfactant (Transcutol P). This system was designed to address the poor aqueous solubility and photostability issues of shikonin. The authenticity of shikonin employed in this study was confirmed using nuclear magnetic resonance (NMR) spectroscopy. The optimized nanoemulsion exhibited highly favorable characteristics in terms of zeta potential (-23.8 mV), polydispersity index (0.216) and particle size (22.97 nm). These findings were corroborated by transmission electron microscopy (TEM) micrographs which confirmed the spherical and uniform nature of the nanoemulsion globules. Moreover, attenuated total reflectance (ATR) and X-ray diffraction analysis (XRD) analysis affirmed improved chemical stability and amorphization, respectively. Photodegradation studies were performed by exposing pure shikonin and the developed nanoemulsion to ultraviolet light for 1 h using a UV lamp, followed by high performance liquid chromatography (HPLC) analysis. The results confirmed that the developed nanoemulsion system imparts photoprotection to pure shikonin in the encapsulated system. Furthermore, the research investigated the effect of the nanoemulsion on biofilms formed by Candida albicans and methicillin resistant Staphylococcus aureus (MRSA). Scanning electron microscopy, florescence microscopy and phase contrast microscopy unveiled a remarkable reduction in biofilm area, accompanied by disruptions in the cell wall and abnormalities on the cell surface of the tested microorganisms. In conclusion, the nanoencapsulation of shikonin with tea tree oil as the lipid phase showcased significantly enhanced antimicrobial and antibiofilm potential compared to pure shikonin against resistant strains of Candida albicans and Staphylococcus aureus.

Bilateral acute vision loss as the initial presentation of chronic myeloid leukemia in a young female

Chronic myeloid leukemia (CML) is a hematological malignancy characterized by structural/functional changes and increased neutrophils. Rarely, ophthalmic manifestations are the first clue toward underlying pathology. We report a case of a 34-year-old woman who presented with sudden-onset diminution of vision in both eyes. On examination, she was diagnosed with panuveitis in the right eye and choroiditis in the left eye. Further investigations revealed an underlying CML in the accelerated phase. The patient was managed with systemic immunomodulators along with topical and periocular steroids. Prompt diagnosis and management in collaboration with an oncologist and hematologist helped us achieve a good outcome.

Assessment of anti-psoriatic activity of bakuchiol-loaded solid lipid nanoparticles-based gel: design, characterization, and mechanistic insight via NF-kB signaling pathway

The aim of the current study is to evaluate the anti-psoriatic potential of bakuchiol (Bak) loaded solid lipid nanoparticles (SLNs) via modulating inflammatory and oxidative pathways. Bak-loaded SLNs were prepared using hot homogenization method and characterized by various spectroscopic techniques. Bak-SLNs suspension was formulated into gel using Carbopol. Different in vivo assays were executed to explore the role of inflammatory markers and oxidative enzymes in psoriasis. DLS (dynamic light scattering) analysis showed suitable particle size, zeta potential, and polydispersity index (PDI) of developed formulation. TEM (transmission electron microscopy) reveal the spherical shape of Bak-SLNs particles. The release studies confirmed the sustained release of Bak-SLNs-based gel. UV-B-induced psoriatic Wistar rat model showed significant anti-psoriatic effect of Bak via regulating inflammatory markers (NF-kB, IL-6, IL-4, and IL-10) and levels of anti-oxidant enzymes, superoxide dismutase (SOD), catalase (CAT), glutathione (GSH), and glutathione-S-transferase (GST). Furthermore, RT-qPCR analysis confirms that Bak downregulates the expression of inflammatory markers, while histology and immunohistology results also confirm the anti-psoriatic effect of Bak. The study indicates that Bak-loaded SLNs-based gel significantly downregulates the level of cytokines and interleukins involve in NF-kB signaling cascade; hence, it can prove to be a novel therapeutic approach to cure psoriasis.

First clinical case series of frosted branch angiitis: A diagnostic algorithm is suggested

Key Clinical Message

FBA is a clinical diagnosis of a diverse spectrum, which needs a high index of suspicion to identify the possible specific etiologies. The zones of retinal involvement can help in predicting the final visual outcome. The proposed diagnostic algorithm facilitates meticulous evaluation and targeted treatment to improve the final visual outcome.

Abstract

Frosted branch angiitis is a clinical diagnosis of a diverse spectrum, which needs a high index of suspicion to identify the possible specific etiologies. We present a series of three cases of FBA with an attempt to formulate a diagnostic algorithm and refine the definition of FBA.