Repeat deep anterior lamellar keratoplasty (DALK) for failed primary DALK

Purpose: To evaluate the effectiveness of repeat deep anterior lamellar keratoplasty (DALK) in patients of previous failed DALK. Methods: A retrospective analysis of records of seven patients who had undergone repeat DALK following the failure of the primary DALK was done. The indications for repeat surgery, time elapsed since the first surgery, and pre? & postoperative best?corrected visual acuity (BCVA) were noted for all the patients. Results: The follow?up period ranged between one? to four?year post repeat DALK. The indication of primary DALK was keratoconus with vernal keratoconjunctivitis (VKC) (n = 3), corneal amyloidosis (n = 2), Salzman nodular keratopathy (n = 1), and healed keratitis (n = 1). The need for repeat surgery arose when the BSCVA dropped to less than 20/200. The time interval elapsed since the first surgery ranged from two months to four years. Postoperatively, the BSCVA improved from 20/120 to 20/30 at the end of one?year post repeat DALK in all except one patient. All regrafts were clear at the most recent examination, performed after a mean period of 18 months after the secondary graft. No complication was encountered during the resurgery. The dissection of the host bed was easier in the second surgery owing to weaker adhesions. Conclusion: The prognosis for repeat DALK for failed DALK is excellent, and the outcomes of secondary grafts were comparable to those of primary DALK grafts. Re DALK offers the advantage of an easier dissection and lower chances of graft rejection compared to penetrating keratoplasty.

Ocular sequelae in severe COVID-19 recovered patients of second wave

Purpose: To evaluate the retinal microvascular changes in patients, recovered from severe COVID?19 during the second wave of the pandemic in North India. Methods: In this observational cross?sectional study, 70 eyes of 35 patients who recovered from severe COVID?19 during the second wave underwent detailed ophthalmic evaluation 4–6 weeks after discharge. Twelve controls were also enrolled, and the difference in the findings between the case and control groups on optical coherence tomography (OCTA) were studied. Result: The ages of study participants ranged from 27 to 60 years with the male:female ratio being 1.05:1. The fundus changes suggestive of ischemia in the form of cotton wool spots and vascular tortuosity were seen in 25 eyes (35.71%). Increased venous tortuosity was the most common finding seen in 23 eyes (32.85%), of which 10 eyes (28.57%) had concurrent hypertensive retinopathy (HTR) changes. There was a significant reduction in the mean vascular density (VD) and perfusion density (PD) for both the superficial capillary plexus (SCP) and deep capillary plexus (DCP) at inner, outer ring, and whole (P < 0.05). Foveal avascular zone was significantly enlarged in both the SCP (P = 0.01) and the DCP (P = 0.03). The mean ganglion cell?inner plexiform layer (GC?IPL) was significantly reduced in comparison to controls (P < 0.001). Conclusion: Severe COVID?19 can result in microvascular changes at the macula in the form of reduction in vascular and perfusion density, which can be evaluated using OCTA. As structural changes precede functional changes, a close watch is recommended in patients showing compromise in retinal microvasculature

Bilateral sequential non-arteritic optic neuropathy post-COVID-19

Corona virus disease 2019 (COVID?19) has been documented to have a spectrum of neuro?ophthalmic manifestations. However, bilateral non?arteritic anterior ischemic optic neuropathy (NAION) post?COVID?19 has not been reported in the literature. We studied the case of a 45?year?old male who presented to our outpatient department (OPD) with bilateral blurring of vision following an episode of COVID?19, 1 month back. Examination and investigations were conclusive of a bilateral NAION. The patient was given a trial of oral steroids. However, the vision loss could not be recovered. Thus, through this case report, we would like to highlight the importance of a close follow?up of patients following COVID?19 infection to detect any sequelae

Risk factors and outcome of placenta previa: accrete in a tertiary health care center of Punjab, India

Background: The aim of this study was to identify and evaluate risk factors associated with placenta accrete (PA) and its clinical outcome.Methods: A descriptive, case control study was conducted in department of obstetrics and gynecology, GMC Amritsar in which authors retrospectively reviewed data of 180 patients of placenta previa (PP) over 5 years, categorized as PA (cases; n=23) or no PA (control; n=157). Furthermore, these groups were compared as to maternal demographics, intrapartum and postpartum complications and neonatal outcomes. Stepwise logistic regression analysis was done to evaluate the extent to which exposure variable contributed to the incidence of PA including advanced maternal age (AMA), parity, location of placenta and previous caesarian section (CS).  Primary aim was to identify and quantify the various risk factors of PA and secondary aim measured incidences of PP, PA and fetomaternal outcome.Results: The cumulative incidence of PA over 5 years was 2.98 per 1000 deliveries. Accrete rate increased with number of CSs at 4.76% in patients with no previous CS versus 45.94% in ≥1 CS (p < 0.003). Anterior PP (AOR 10.128  CI 2.406 -42.632; p <0.001) and number of previous CSs (AOR 36.405, 95% CI 2.743 -483.24, p =0.006) were significant risk factors for PA. AMA (OR >30 years: 4.326 95% CI 0.724 -25.856; p =0.108), parity (AOR 1 vs 0: 2.526 95% CI 0.242-26.41; p=0.439), prior uterine curettage (AOR ≥1 vs 0: 11.143 95% CI 0.522-9.726; p=0.278) although had association with PA but was not statistical significant. Caesarian hysterectomy was done in 95.65% patients of PA while only 1 patient of PP required hysterectomy (p<0.001). Neonatal outcome was similar in both groups.Conclusions: Prior caesarian and anterior PP emerged out as significant predictors of PA. Other risk factors like AMA, multiparous, history of prior uterine curettage, central PP have incremental risk of having PA and such patients should be managed diligently to lower feto-maternal morbidities and mortalities.

Short Syndrome-An Expanding Phenotype.

The phenotypic description of SHORT syndrome (OMIM- 269880) is expanding since its initial description in 1975. There have been 26 case reports till date but the genetic locus of this syndrome is elusive. Involvement of PITX2 gene initially envisaged is probably is not the only gene involved but has an important role to play in ocular development. Our case did not demonstrate mutation in PITX2 gene. Here, we report a case of SHORT syndrome with two new unreported features – deviated nasal septum and cryptorchidism and stress on lipodystrophy, a cardinal feature but not a part of the pneumonic SHORT.

Dysmyelination of the Cerebral White matter with Microdeletion at 6p25.

A 6-year old boy presented with mental retardation, hypotonia, abnormal facies, impaired hearing, protuberant eyes, visual impairment, short stature, Axenfeld- Rieger anomaly, a bicuspid aortic valve, and bilateral sensorineural deafness. CT scan of head suggested dysmyelination of the subcortical and periventricular white matter. FISH revealed a subtelomeric microdeletion encompassing both FOXC1 and FOXF2 loci within 6p25. Dysmyelination of the central nervous system has been infrequently described earlier in patients with 6p25 deletion.

Peters plus syndrome.

A 10-year-old boy, issue of unrelated parents presented with visual impairment, short stature and mental retardation. The presence of a Peters' anomaly, mental retardation, disproportionate short stature, skeletal abnormalities and distinctive facial features (broad forehead, telecanthus, cupid bow shaped upper lip) established the diagnosis of Peters' plus syndrome. Analysis of his genomic DNA revealed a homozygous deletion in the beta1,3-galactosyltransferase-like gene (B3GALTL), a recently identified gene.

Bilateral periorbital necrotizing fasciitis following exposure to Holi colors: a case report.

Holi festival is celebrated in India traditionally by applying colors on one another. Various ocular adverse effects of these colors have been reported including conjunctivitis and corneal abrasion. We report a case of bilateral periorbital necrotizing fasciitis, following exposure to Holi colors. General physicians might encounter more such cases after exposure to Holi colors. In India, these colors are prepared on a small scale and lack any quality checks. Use of such toxic colors should be discouraged, and all doctors should caution people against using synthetic dyes. This case report highlights the need to put manufacturing of Holi colors under guidelines of the Food and Drug Cosmetic Act and the Bureau of Indian Standards.

Familial calcific band-shaped keratopathy: report of two new cases with early recurrence.

We report two siblings with the rare entity of familial calcific band-shaped keratopathy (BSK). Detailed ophthalmic and systemic investigations failed to reveal any underlying causative pathology. Topical disodium ethylenediamine-tetraacetate (EDTA) was applied for 30 min to all four eyes. In addition the right eye of the younger sibling required a superficial keratectomy. An improvement in corneal clarity was seen in the immediate postoperative period in both siblings. Histopathology of the keratectomy specimen revealed linear extracellular sub-epithelial granular calcium deposits. However, an early recurrence was noted in all four eyes at four weeks postoperatively. We report the second instance in the English literature of this entity. Band-shaped keratopathy presenting without an obvious etiology merits a complete systemic and ophthalmic workup. Patients with familial idiopathic BSK could be cases with poor prognosis for treatment with EDTA due to an early recurrence of the disease.

Phacoemulsification after penetrating keratoplasty with autologous limbal transplant and amniotic membrane transplant in chemical burns.

We report a patient who had earlier penetrating keratoplasty with amniotic membrane transplant and autologous limbal cell transplant for chemical injury who underwent cataract surgery by phacoaspiration. A posterior limbal incision with corneal valve was made superotemporally with extreme caution to avoid damage to the limbal graft. Aspiration flow rates and vacuum were kept low to avoid any turbulence during surgery. A 6.0 mm optic diameter acrylic foldable intraocular lens was inserted in the bag. The patient achieved a best-corrected visual acuity of 6/12 at 10 months' follow-up with a clear corneal graft. We conclude that caution during wound construction and phacoaspiration can help preserve corneal and limbal graft integrity in patients undergoing cataract surgery after corneal graft and limbal transplantation.

Penicillium keratitis in vernal Keratoconjunctivitis.

We report a case of penicillium keratitis in vernal shield ulcer in the absence of corticosteroid use. This report illustrates super-added infection in vernal shield ulcer by an organism which is otherwise innocuous and forms a part of the normal ocular flora.

Significance of mucin secretion in carcinoma of uterine cervix.

Biopsies from 300 cases with clinical diagnosis of carcinoma cervix were subjected to H&E staining, PAS with diastase and alcian blue at pH 2.5. Interpretation of cases on basis of H&E staining alone and on basis of H&E and mucin stains was done and results compared with each other. Categorization into squamous cell carcinoma (well, moderately & poorly differentiated), adenocarcinoma and mixed carcinoma was done. Morphologic assessment of cases of H&E stain revealed 282 (94%) cases of squamous cell carcinoma, 8 (2.66%) cases of adeno carcinoma and 10 (3.38%) cases of mixed carcinoma respectively. While on the basis of H&E and mucin stains, squamous cell carcinoma case turned out to be 266 (88.66%) in number; mixed carcinomas which included adenosquamous carcinoma and squamous cell carcinoma with mucin secretion accounted for 26 (8.66%) of cases, number of adenocarcinoma was unchanged i.e. 8 (2.66%). 16 of 282 cases (5.6%) diagnosed as squamous cell carcinoma on H&E stain alone were reclassified as mixed carcinoma on inclusion of mucin stains. Thus mucin stains are very helpful in deciding the types of carcinoma cervix and should be done in all cases of carcinoma cervix in order to avoid errors in diagnosis and to detect poorly differentiated mixed carcinomas, which may escape detection by H&E staining.