Systematic approach to managing vernal keratoconjunctivitis in clinical practice: Severity grading system and a treatment algorithm.

Vernal keratoconjunctivitis is an ocular allergy that is common in the pediatric age group. It is often chronic, severe, and nonresponsive to the available treatment options. Management of these children is difficult and often a dilemma for the practitioner. There is a need to simplify and standardize its management. To achieve this goal, we require a grading system to judge the severity of inflammation and an algorithm to select the appropriate medications. This article provides a simple and practically useful grading system and a stepladder algorithm for systematic treatment of these patients. Use of appropriate treatment modalities can reduce treatment and disease‑related complications.

Epidemiology of keratoconus.

Prevalence of keratoconus is variable in different parts of the world. Environmental and ethnic factors and the cohort of patients selected for such studies may explain the wide variation in the reported rates. Family history, gender differences, asymmetry in the two eyes, association with ocular rubbing, and natural history of disease are discussed.

Oral cyclosporine therapy for refractory severe vernal keratoconjunctivitis.

We report the success of oral cyclosporine therapy in a patient with severe vision-threatening vernal keratoconjunctivitis. A child presented with severe allergy which was not controlled with topical steroids, cyclosporine and mast cell stabilizers. Oral steroids were required repeatedly to suppress inflammation. Child showed a dramatic improvement and stabilization with oral cyclosporine therapy. Oral cyclosporine therapy can be tried in severe vision-threatening allergy refractory to conventional therapy.

Scleral ulceration after vitreoretinal surgery.

Scleral ulceration after ocular surgery is a rare but serious complication. Determination of the underlying systemic and local causes is critical for treatment. An unusual case of ischemic scleral ulceration after vitreoretinal surgery in a diabetic patient is reported. Patient was successfully treated with a pedicle conjunctival graft.

Late corneal edema due to retained foldable lens fragment.

Late onset of corneal edema after cataract surgery is an unusual complication. We report a case of corneal edema presenting one month after cataract surgery. During implantation of the foldable lens, one haptic of the intraocular lens fractured at the optic haptic junction. This caused lens decentration, necessitating an intraocular lens exchange ten days later. The patient was recovering well but presented again two weeks later with a drop in vision due to corneal edema. A retained haptic of the intraocular lens was seen in the inferior anterior chamber angle. After surgical removal of the retained haptic the corneal edema fully resolved. Retained intraocular lens fragments can cause corneal endothelial damage, which may be reversible with an early diagnosis and intervention.

Viscoexpression technique in manual small incision cataract surgery.

Viscoexpression method of nucleus delivery in manual small incision cataract surgery is described in this article. The practical modifications to the conventional technique in special situations are presented. Intraoperative and postoperative problems likely to be encountered and the steps to avoid them and tackle them effectively are discussed.

Medical management approach to infectious keratitis.

This section provides guidelines on medical therapy of patients with infectious keratitis. In addition to initial empirical therapy, preferred medications, once the organisms responsible are isolated, are discussed. Atypical mycobacterial keratitis following lasik is described. General guidelines for supportive therapy and follow-up, of these patients are presented. Clinical response to treatment and indications for intervention are discussed. Possible causes and approach to cases refractory to medical therapy are discussed.

Surgically induced necrotizing scleritis after pterygium surgery.

We report a case of surgically induced necrotizing scleritis following pterygium surgery with the bare sclera technique, without the use of adjunctive irradiation or mitomycin C. The patient was successfully treated with systemic immunosuppression.

Nocardia infection following phacoemulsification.

Infection of a self-sealing tunnel incision is a rare but vision-threatening complication of cataract surgery. We describe two cases of side port infection following an uneventful phacoemulsification. Nocardia was isolated in one case. Both the cases were worsening on medical treatment and were successfully treated by therapeutic keratoplasty.

Unusual dendritic keratitis.

Bilateral pseudo-dendritic keratitis in infancy can be due to tyrosinemia, a rare metabolic disorder. Ocular involvement may be the earliest presenting manifestation of this disease. Early diagnosis is essential because dietary modifications can result in complete reversal of the manifestations of this disorder. This disease must be suspected in all cases of non-responsive dendritic keratitis in the pediatric age group, especially if it is associated with cutaneous lesions such as patmoplantar keratosis. Serum tyrosine levels must be done in these cases.

Reduction in astigmatism in manual small incision cataract surgery through change of incision site.

To compare the astigmatism induced by a superior, supero-temporal and temporal incision in manual small incision cataract surgery. Induced astigmatism was analysed by Cartesian coordinates based analysis, using Holladay's system. Mean astigmatism induced by surgery was 1.28 Dx2.9 degrees for superior incision, 0.20 Dx23.7 degrees for supero-temporal incision and 0.37 Dx90 degrees for temporal incision. The study found that induced astigmatism was lower in the temporal and superotemporal groups compared to that in the superior group.