Intricate insights into immune response in dry eye disease

Dry eye disease (DED) is a complex disorder of the ocular surface with a loss of tear film homeostasis, causing an imbalance in the tear-air interface and leading to ocular discomfort, pain, and vision issues. Immune control issues are a primary factor in dry eye disorder's origin, progression, and management. The aim of managing DED is to reduce symptoms and improve the life quality of those affected. Despite the diagnosis, up to half of the patients do not get proper care. The scarcity of successful treatments for DED is worrisome, and it is of increasing importance to comprehend the root causes and create more effective therapies to alleviate the distress of those afflicted with the disorder. Therefore, the role of the immune system in the initiation and progression of DED has become the research focus. This paper reviews the current insight into the immune response in DED, the existing treatment methods, and ongoing research to search for better treatments.

A clinical trial on phakic intraocular lens for the treatment of refractive amblyopia in children and adolescents

Purpose

To analyze the demographics and clinical outcomes of posterior chamber phakic intraocular (IOL) implantation for refractive amblyopia in children and adolescents.

Methods

A prospective interventional study was performed on children and adolescents with amblyopia at a tertiary eye care center from January 2021 to August 2022. Twenty-three eyes of 21 anisomyopic and isomyopic amblyopia patients operated for posterior chamber phakic IOL (Eyecryl phakic IOL) as a treatment for amblyopia were included in the study. Patient demographics, pre- and postoperative visual acuity, cycloplegic refraction, anterior and posterior segment examination, intraocular pressure, pachymetry, contrast sensitivity, endothelial count, and patient satisfaction scores were evaluated. Patients were followed up at day 1, 6 weeks, 3 months, and 1 year after surgery, and visual outcomes and complications were documented.

Results

The mean age of patients was 14.16 ± 3.49 years (range: 10-19 years). The mean intraocular lens power was - 12.20 diopter spherical (DS) in 23 eyes and - 2.25 diopter cylindrical (DC) in four patients. The mean unaided distant visual acuity (UDVA) and best-corrected visual acuity (BCVA) were 1.39 ± 0.25 and 0.40 ± 0.21 preoperatively on the log of minimum angle of resolution (logMAR) chart. Postoperatively, the visual acuity improved by 2.6 lines in 3 months period and maintained till 1 year. Postsurgery, contrast sensitivity in the amblyopic eyes significantly improved, and the average endothelial loss recorded was 5.78% at 1 year, which was statistically insignificant. Patient satisfaction score was statistically significant, with 4.736/5 recorded on the Likert scale.

Conclusion

Posterior chamber phakic IOL is a safe, effective, and alternative method for treating amblyopia patients who are noncompliant with glasses, contact lenses, and keratorefractive procedures.

Adoption, implementation, definitions, and future of blockchain technology in ophthalmology

In this era of cutting-edge research and digitalization, artificial intelligence (AI) has rapidly penetrated all subspecialties, including ophthalmology. Managing AI data and analytics is cumbersome, and implementing blockchain technology has made this task less challenging. Blockchain technology is an advanced mechanism with a robust database that allows the unambiguous sharing of widespread information within a business model or network. The data is stored in blocks that are linked together in chains. Since its inception in 2008, blockchain technology has grown over the years, and its novel use in ophthalmology has been less well documented. This section on current ophthalmology discusses the novel use and future of blockchain technology for intraocular lens power calculation and refractive surgery workup, ophthalmic genetics, payment methods, international data documentation, retinal images, global myopia pandemic, virtual pharmacy, and drug compliance and treatment. The authors have also provided valuable insights into various terminologies and definitions used in blockchain technology.

Novel nucleus management technique in hypermature morgagnian cataracts with liquified cortex during phacoemulsification

PURPOSE

To describe a novel nucleus management technique of variable size mobile nucleus in Hypermature Morgagnian cataracts.

METHODS

In this technique, under topical anesthesia, temporal tunnel incision and capsulorhexis were performed, and the capsular bag was inflated with 2% w/v hydroxypropylmethylcellulose. A chopper and phacoemulsification probe were used to consciously nudge the nucleus towards the capsular periphery (fornix) to immobilize the floating nucleus against the capsular bag recess. Firm nuclear impaling was achieved using longitudinal power in linear mode (range 0-70%), 650 mmHg vacuum, and aspiration flow rate of 42 ml/min. The nucleus was chopped by direct chop technique, total separation achieved, and fragments emulsified. Primary outcome measures included ease of nuclear holding, iatrogenic zonular stress/damage, posterior capsule tear, and endothelial cell loss.

RESULTS

This technique was performed in 29 consecutive cases from June 2019 - December 2021, and no intraoperative or postoperative complications were noted. The average phacoemulsification time and cumulative dissipated energy (CDE) were nearly similar in all cases.

CONCLUSION

This technique would make phacoemulsification much safer in eyes with hypermature cataract and liquified cortex with lower complication rates and maintenance of better endothelial integrity.

Successful Management of Pythium insidiosum Keratitis Masquerading as Dematiaceous Fungal Keratitis in an Immunosuppressed Asian Male

PURPOSE

To describe the first case of Pythium insidiosum keratitis masquerading as dematiaceous fungal keratitis in a seropositive male.

CASE SUMMARY

A 44-year-old seropositive male previously treated for acute retinal necrosis presented with pain and defective vision in the right eye following a mud injury 5 days back. Presenting visual acuity was hand movements close to the face. Ocular examination revealed a 7 × 7 mm dense, greyish-white mid stromal infiltrate with pigmentation and few tentacles. The clinical diagnosis suggested fungal keratitis. Corneal scraping on 10% KOH and Gram stain revealed slender, aseptate hyaline hyphae. Before culture results, the patient was treated with topical 5% natamycin and 1% voriconazole, but the infiltrate progressed. Culture on 5% sheep blood agar revealed white fluffy, submerged, shiny, and appressed colonies, and Pythium insidiosum was confirmed by zoospore formation. The patient was further managed with topical linezolid 0.2% hourly, azithromycin 1% hourly, and adjuvant drugs.

CONCLUSION

This is an uncommon presentation of Pythium keratitis masquerading as dematiaceous fungal keratitis in an immunocompromised male.

Risk Factors for Descemet Membrane Endothelial Keratoplasty Rejection: Current Perspectives- Systematic Review

Descemet membrane endothelial keratoplasty (DMEK) is a corneal endothelial transplantation procedure with selective removal of a patient's defective Descemet membrane and endothelium. It is replaced with a healthy donor Descemet membrane and endothelium without a stromal component. Corneal graft rejection can be at the level of epithelium, stroma as well endothelium. DMEK graft rejection is relatively less common than rejection with DSAEK or penetrating keratoplasty, and a good outcome may be achieved with prompt management. The clinical picture of DMEK rejection is usually similar to endothelial rejection in Descemet Stripping Endothelial Keratoplasty (DSEK/DSAEK), which generally manifests as pain, redness, reduction in visual acuity, stromal edema, endothelial rejection line, keratic precipitates at the back of the cornea and corneal neovascularization. However, more subtle forms of rejection or immune reactions are more common in DMEK compared to DSAEK eyes. Early clinical diagnosis, prompt intervention, and meticulous management safeguard visual acuity and graft survival in these cases. Intensive topical steroids form the mainstay in the management of DMEK rejection. Sometimes, oral or intravenous steroids or other systemic immunomodulators may be required. DMEK graft failure can be primary or secondary, and failure usually requires a second procedure in the form of repeat DMEK or DSEK or penetrating keratoplasty (PKP). A detailed literature search was performed using search engines such as Google Scholar, PubMed, and Google books, and a comprehensive review on DMEK rejection was found to be lacking. This review is a comprehensive update on the risk factors, pathophysiology, primary and secondary graft failure, recent advances in diagnosis, prevention of rejection, and updates in the management of DMEK rejection. The review also discusses the differential diagnosis of DMEK failure and rejection, prognosis, and future perspectives considering DMEK failure and rejection.

Retrospective multifactorial analysis of ocular firecracker injuries and review of literature

Purpose

To analyse demographics, risk factors, clinical features, functional, anatomical outcomes, and prevalence of blindness in firecracker injury patients presenting to a tertiary eye care centre.

Methodology

A retrospective analysis of ocular firecracker injuries patients who presented to our hospital from April 2018 to March 2019 was performed. A total of 114 patients with a minimum follow-up of 3 months were included. The parameters recorded were demographics, mode of injury, type of cracker, baseline and last follow up best-corrected visual acuity (BCVA), anterior and posterior segment findings, seidel's test, intraocular pressure, gonioscopy, treatment, functional and anatomical outcomes. Investigations in form of B Scan, X-ray, or CT scan were undertaken whenever indicated.

Results

A total of 132 eyes of 114 patients were analysed. The mean (SD) age was 18.96 +/−15.4 years (range 3–71 years). Seventy-four (64.91%) patients were ≤ 18 years of age. The male-to-female ratio was 4:1. The ratio of right: left eye involvement was 1:1. Eighteen patients (15.79%) had bilateral involvement. A total of 125 eyes had closed globe injury, 7 eyes had open globe injury and 17 patients needed hospital admission for management. The mean (SD) baseline BCVA was 0.54(+/−0.75). The mean (SD) final BCVA improved to 0.23(+/−0.62) till the last follow-up. The final outcome was good in most patients, except 5 eyes (3.78%) which resulted in near/total blindness.

Conclusion

Firecracker injuries are a major cause of irreversible blindness, especially among the younger age group. Prompt diagnosis with meticulous management can prevent devastating sequelae.

Retrospective analysis of low vision assistive products – A 6-year review

PURPOSE

The purpose of the study was to analyze the demographics, visual acuity (VA), etiologies, recommended low vision assistive products (LVAP), and the acceptance rates of LVAP in various age groups.

METHODS

This was a long-term retrospective review of all the patients presenting to the low vision clinic of our tertiary eye care hospital from January 2011 to December 2016. Data obtained included age, gender, VA, visual fields, ocular pathology causing the low vision, and types of LVAP advised. The primary outcome was to analyze the type of LVAP prescribed in different age groups, and the secondary outcome was the acceptance rate of LVAP.

RESULTS

We analyzed the results of 8309 patients, out of which 2844 (34%. 2) were <15 years of age, 2425 (29.5%) were between 16-40 years, and 3013 (36.3%) were above 40 years. A total of 5522 (66.4%) had best-corrected visual acuity (BCVA) ranging from 6/18-3/60, and 2796 (33.6%) had BCVA from 3/60-No PL. Approximately 38% improved with LVAPs. The most common etiology was retinitis pigmentosa in 1545 (18.6%) patients, followed by congenital nystagmus in 1482 (17.8%), and the least was albinism 383 (4.6%). Maximum prescribed and accepted LVAP were hand and stand magnifiers among 1017 (44.3%) and 512 (52.6%) patients, respectively.

CONCLUSION

Products that are easy to use, require lesser adaptability, are cheap, and require lower maintenance have maximum acceptance rates. We suggest that great emphasis should be laid on training, education, and guidance for low vision rehabilitation centers.

Corneal ectasia, cerulean (blue dot) cataract with acute hydrops in a child with Down's syndrome and hypothyroidism - a rare presentation

Down's syndrome or trisomy 21 is a genetic disorder caused by presence of all or a part of a third copy of chromosome 21. Keratoconus occurs in up to 15% of the adult population with Down's syndrome. There is a close consortium between trisomy 21 and keratoconus (a conical ectatic protrusion of the cornea), and children with Down's syndrome are also susceptible to developing thyroid disease, including hypothyroidism and thyrotoxicosis with exophthalmos. The authors describe a case report on acute corneal hydrops with congenital cerulean cataract in a patient with Down's syndrome with hypothyroidism having bilateral advanced keratoconus. As per the detailed literature review, this is the first case of Down's syndrome with hypothyroidism presenting with acute corneal hydrops.

Successful management of delayed hyaluronidase hypersensitivity after subtenon's anesthesia during the COVID-19 pandemic: A rare case report

Subtenon's block is commonly used to achieve akinesia, analgesia, and anesthesia for ophthalmic surgeries. This case study detailed a rare hypersensitivity report in a 65-year-old female who had underwent manual small incision cataract surgery under subtenon's anesthesia (STA) in the left eye. On postoperative day 1, she presented with acute onset proptosis, periorbital edema, conjunctival chemosis, and restriction of extraocular movements. The pupillary reaction and dilated fundus examination were normal. A differential diagnosis of orbital cellulitis, Mucormycosis, and hyaluronidase hypersensitivity (HH) was considered. Since the patient was afebrile, and pupillary reactions, ENT, neurological, and fundus examination were normal, the diagnosis was narrowed down to delayed HH. The patient was managed with a 1 cc IV injection of dexamethasone once a day for 3 days, along with routine postoperative drugs. As per detailed literature review, this is probably a second case report of delayed HH post-STA.

Do motivational cards really benefit sibling screening of primary open-angle glaucoma probands?

Purpose

To compare the impact of Sibling Motivational Card (SMC) and oral counseling in screening siblings of primary open-angle glaucoma (POAG) probands.

Methods

Two hundred and thirty-four newly diagnosed POAG probands were randomized to receive either oral counseling or SMC to motivate their siblings for a glaucoma screening at a tertiary eye care hospital in South India from July 2015 and June 2017. A total of 116 probands were orally counseled with a standard template of dialogs about the importance of family screening to motivate their siblings for a screening. One hundred and eighteen probands were randomized to receive SMC, bearing the details of the proband, sibling, and a message stressing the importance of family screening, in addition to oral counseling. We assessed the response rate in each group. Additionally, we evaluated the prevalence of POAG in the siblings.

Results

A total of 95 siblings of 234 POAG probands were screened. The mean age distribution was 53.33 ± 10.9 years (range 28-79 years). The male to female ratio was 3:4. The percentage of siblings screened was more in the oral counseling group (63.2%) than in the SMC group (36.8). About 43 (45%) siblings had some form of glaucoma, and 13.6% had POAG. An additional 22.1% were disk suspects, and 5.2% had ocular hypertension.

Conclusion

SMC did not have an additional benefit over the standard oral counseling in promoting sibling screening. Our study stresses the importance of sibling screening in POAG probands. Targeting siblings of POAG probands with oral counseling may offer a relatively inexpensive way of detecting glaucoma.

Assessment of optic disk by disk damage likelihood scale staging using slit-lamp biomicroscopy and optical coherence tomography in diagnosing primary open-angle glaucoma

Purpose

The current study was aimed at assessment of optic disk by disk damage likelihood scale (DDLS) staging using slit-lamp biomicroscopy and optical coherence tomography (OCT) in diagnosing primary open-angle glaucoma (POAG) patients.

Methods

This was a cross-sectional observational study of 106 POAG patients, which was conducted from April 2017 to April 2018. All patients underwent slit-lamp fundoscopy with a +78 D lens and high-definition (HD)-OCT, and the vertical cup disk ratios (VCDRs) were recorded. Disk size and neuroretinal rim assessment were done, and the disk was then staged using the recent version, which stages the optic nerve head (ONH) from 1 to 10 as read from the DDLS nomogram table. DDLS scores >5 indicate glaucomatous damage. Pearson coefficient was used to correlate the DDLS staging by slit-lamp biomicroscopy with best-corrected visual acuity (BCVA), intraocular pressure (IOP), disk size, and VCDR and VCDR, mean deviation, and DDLS staging by HD-OCT.

Results

The mean age of the patients was 59.54 ± 6.61 years. The male: female ratio was 2:1. The mean IOP was 16.04 ± 1.97 mmHg, and BCVA was 0.72 ± 0.13 LogMAR units. The mean VCDR on 78 D slit-lamp biomicroscopy was 0.76 ± 0.09 (standard deviation [SD]) (range 0.1-0.77), whereas on HD-OCT, the mean VCDR was 0.81 ± 0.09 (SD) (range 0.07-0.81). The mean deviation on visual field testing in decibels was -14.43 ± 3.31 (SD). The correlation coefficient between DDLS staging by slit-lamp biomicroscopy and DDLS staging by HD-OCT parameters was r = 0.96.

Conclusion

There is a positive correlation between the DDLS system of optic disk evaluation on slit-lamp biomicroscopy and most of the HD-OCT evaluation parameters.

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.

Bilateral Morgagnian Cataract Post Neoadjuvant Chemotherapy for Oral Carcinoma- A Potentially Blinding Sequelae

Cataract is one of the most common causes of defective vision globally, and one if the rare potential complication arising out of chemotherapy. This report highlights a rare case of bilateral Morgagnian cataract following neoadjuvant chemotherapy given for an oral cavity malignancy. A 65-year-old female presented with bilateral reduced visual acuity secondary to Morgagnian cataract with normal fundus. The patient underwent a successful cataract surgery in right eye preventing the eye from developing devastating sequelae like phacomorphic glaucoma, lens subluxation, or aphakia post-cataract surgery. The oncosurgeon, oncologist, and ophthalmologist should have a close liaison to prevent, diagnose, and treat these rare sequelae which could be potentially blinding.