Clinical profile and management of ocular superglue injuries: Case series and review of literature.

PURPOSE: To describe the clinical profile and management of patients with ocular superglue injury (OSI). METHODS: This retrospective study included all patients with OSI who presented at a tertiary eye care institute between 2016 and 2020. Data regarding demographics, clinical profile, and management were collected. RESULTS: A total of 66 eyes of 58 patients (24 children, 34 adults) with a median age of 22.5 years [interquartile range (IQR): 11.3-31] were included. All cases sustained accidental injuries, with domestic injury at home being the most common location of injury among children (79%) and adults (53%) ( P = 0.39). The median visual acuity at presentation was worse in children [0.3 logMAR (IQR: 0.2-0.4)] as compared to adults [0.1 logMAR (IQR: 0.1-0.3)] ( P = 0.03)]. The most common clinical sign at presentation was conjunctival congestion in 77% of eyes (51/66) followed by polymerized glue stuck to the eyelashes and eyelids in 52% of eyes (34/66). The median duration from the time of injury to presentation was 2 hours in both groups. All eyes resolved with medical management. Examination under anesthesia was required in three children (13%) to evaluate the extent of OSI. None of the patients had long-term ocular complications. CONCLUSION: Improper and careless handling of superglue in the domestic setting may cause accidental ocular injuries that require immediate medical attention. OSI represents less severe ocular injuries that respond to medical therapy alone and is not associated with long-term visual morbidity. Modifications in the packaging of superglue containers and awareness about their deleterious effects could prevent these injuries.

Impact of Symblepharon Management With Ocular Surface Reconstruction on Scleral Lens Fitting in Eyes With Chronic Cicatrizing Conjunctivitis and Keratopathy.

PURPOSE: The aim of this study was to describe the importance of symblepharon release with ocular surface reconstruction (OSR) for optimal fitting of scleral contact lenses (SCLs) in eyes with chronic cicatrizing conjunctivitis (CCC) and keratopathy. METHODS: This retrospective study included 32 eyes with CCC and keratopathy with symblepharon which underwent symblepharon release with OSR and were fitted with SCLs. The primary outcome measure was the improvement in best-corrected visual acuity with SCL wear. RESULTS: A total of 32 eyes of 29 patients (66% men) with a median age of 30.5 years were included. The common causes of CCC were Stevens-Johnson syndrome (66%) and ocular burns (16%). The most common location of symblepharon was superior (59%) with limbal involvement in most eyes (94%). Symblepharon release was combined with mucous membrane grafting (63%), amniotic membrane grafting (31%), or conjunctival autografting (6%). The median interval between symblepharon release with OSR and SCL trial was 15 weeks [interquartile range (IQR): 6-24]. The median best-corrected visual acuity improved from logMAR 1.5 (IQR: 1.2-1.8) to logMAR 1.2 (IQR: 0.6-1.4) with SCLs after symblepharon release with OSR (P < 0.001). The median diameter of the SCL used was 15 mm (IQR: 15-16), with a median base curve of 7.9 mm (IQR: 7.9-8). Symblepharon recurrence was noted in 70% of eyes that underwent amniotic membrane grafting; no recurrence was seen with mucous membrane grafting or conjunctival autografting. CONCLUSIONS: In eyes with CCC with keratopathy and symblepharon, visual rehabilitation is possible with SCLs after symblepharon release with OSR without having to resort to a penetrating corneal procedure.

Demographic profile and clinical characteristics of patients presenting with acute ocular burns.

Purpose: To study and compare the demographic and clinical profile of acute ocular burns (AOB) in children and adults. Methods: This retrospective case series included 271 children (338 eyes) and 1300 adults (1809 eyes) who presented to two tertiary eye care centers within one month of sustaining AOB. Data regarding demographics, causative agents, severity of injury, visual acuity (VA), and treatment were collected and analyzed. Results: Males were more commonly affected particularly among adults (81% versus 64%, P < 0.00001). Among children, 79% sustained domestic injuries, whereas 59% of adults had work-place injuries (P < 0.0001). Most cases were due to alkali (38%) and acids (22%). Edible lime (chuna, 32%), superglue (14%), and firecrackers (12%) in children, and chuna (7%), insecticides, lye, superglue (6% each), toilet cleaner (4%) and battery acid (3%) in adults, were the main causative agents. The percentage of cases with Dua grade IV-VI was greater in children (16% versus 9%; P = 0.0001). Amniotic membrane grafting and/or tarsorrhaphy were needed in 36% and 14% of affected eyes in children and adults, respectively (P < 0.00001). The median presenting VA was logMAR 0.5 in children and logMAR 0.3 in adults (P = 0.0001), which improved significantly with treatment in both groups (P < 0.0001), but the final VA in eyes with Dua grade IV-VI burns was poorer in children (logMAR 1.3 versus logMAR 0.8, P = 0.04). Conclusion: The findings clearly delineate the at-risk groups, causative agents, clinical severity, and treatment outcomes of AOB. Increased awareness and data-driven targeted preventive strategies are needed to reduce the avoidable ocular morbidity in AOB.

Outcomes of therapeutic penetrating keratoplasty in Pythium insidiosum keratitis managed with a combination of antibiotics.

Purpose: To describe the clinical outcomes of therapeutic penetrating keratoplasty (TPK) in patients with Pythium insidiosum keratitis following treatment with anti-pythium therapy (APT) consisting of linezolid and azithromycin. Methods: A retrospective review of medical records from May 2016 to December 2019 of patients with P. insidiosum keratitis was carried out. Patients who were treated with APT for a minimum of 2 weeks and then subsequently underwent TPK were included in the study. Data on demographic characteristics, clinical features, microbiology characteristics, and intraoperative details, postoperative outcomes were documented. Results: A total of 238 cases of Pythium keratitis were seen during the study period and 50 cases that satisfied the inclusion criteria were included. The median of the geometric mean of the infiltrate was 5.6 mm (IQR 4.0-7.2 mm). The patients received topical APT for a median of 35 days (IQR 25-56) prior to surgery. The most common indication of TPK was worsening keratitis (41/50, 82%). No recurrence of infection was observed. An anatomically stable globe was noted in 49/50 eyes (98%). The median graft survival rate was 2.4 months. A clear graft was present in 10 eyes (20%) with a final median visual acuity of 20/125 after a median follow-up period of 18.4 months (IQR 11-26 months). Graft size of less than 10 mm [OR: 5.824 (CI:1.292-41.6), P = 0.02] was found to be significantly associated with a clear graft. Conclusion: Performing TPK following the administration of APT has good anatomical outcomes. A smaller graft of <10 mm was associated with a higher chance of graft survival.

Role of topical and systemic immunosuppression in aqueous-deficient dry eye disease.

Immunosuppression in aqueous-deficient dry eye disease (ADDE) is required not only to improve the symptoms and signs but also to prevent further progression of the disease and its sight-threatening sequelae. This immunomodulation can be achieved through topical and/or systemic medications, and the choice of one drug over the other is determined by the underlying systemic disease. These immunosuppressive agents require a minimum of 6-8 weeks to achieve their beneficial effect, and during this time, the patient is usually placed on topical corticosteroids. Antimetabolites such as methotrexate, azathioprine, and mycophenolate mofetil, along with calcineurin inhibitors, are commonly used as first-line medications. The latter have a pivotal role in immunomodulation since T cells contribute significantly to the pathogenesis of ocular surface inflammation in dry eye disease. Alkylating agents are largely limited to controlling acute exacerbations with pulse doses of cyclophosphamide. Biologic agents, such as rituximab, are particularly useful in patients with refractory disease. Each group of drugs has its own side-effect profiles and requires a stringent monitoring schedule that must be followed to prevent systemic morbidity. A customized combination of topical and systemic medications is usually required to achieve adequate control, and this review aims to help the clinician choose the most appropriate modality and monitoring regimen for a given case of ADDE.

Management of corneal perforations in dry eye disease: Preferred practice pattern guidelines.

Corneal perforations in eyes with dry eye disease (DED) are difficult to manage due to the interplay of several factors such as the unstable tear film, surface inflammation, and the underlying systemic disease affecting the wound healing process, and the eventual outcome. A careful preoperative examination is required to identify the underlying pathology, and status of ocular surface and adnexa, rule out microbial keratitis, and order appropriate systemic workup in addition to assessing the perforation itself. Several surgical options are available, which include tissue adhesives, multilayered amniotic membrane grafting (AMT), tenon patch graft (TPG), corneal patch graft (CPG), and penetrating keratoplasty (PK). The choice of procedure depends upon the size, location, and configuration of the perforation. In eyes with smaller perforations, tissue adhesives are effective treatment modalities, whereas AMT, TPG, and CPG are viable options in moderate-sized perforations. AMT and TPG are also preferable in cases where the placement of a bandage contact lens may be a challenge. Large perforations require a PK, with additional procedures such as tarsorrhaphy to protect the eyes from the associated epithelial healing issues. Conjunctival flaps are considered in eyes with poor visual potential. The management of the acute condition is carried out in conjunction with measures to improve the tear volume bearing in mind the chances of delayed epithelialization and re-perforation in these cases. Administration of topical and systemic immunosuppression, when indicated, helps improve the outcome. This review aims to facilitate clinicians in instituting a synchronized multifaceted therapy for the successful management of corneal perforations in the setting of DED.

Aqueous-deficient dry eye disease: Preferred practice pattern guidelines on clinical approach, diagnosis, and management.

Dry eye disease (DED) is a broad term that includes a diverse group of clinical disorders. Aqueous-deficient dry eye (ADDE), a subtype of DED, is characterized by decreased tear production by the lacrimal gland. It can be seen in up to one-third of individuals with DED and can be comorbid with a systemic autoimmune process or occur secondary to an environmental insult. Since ADDE can be a source of long-term suffering and severe visual impairment, early identification and adequate treatment are imperative. Multiple etiologies can underlie ADDE, and it is critical to identify the underlying cause to not only improve the ocular health but also to improve the overall quality of life and well-being of affected individuals. This review discusses the various etiologies of ADDE, highlights a pathophysiology-based approach for evaluating underlying contributors, outlines various diagnostic tests, and reviews treatment options. We present the current standards and discuss ongoing research in this field. Through this review, we propose a treatment algorithm that would be useful for an ophthalmologist in diagnosing and managing individuals with ADDE.

Dry eye disease and risk factors for corneal complications in chronic ocular graft-versus-host disease.

Purpose: The current study was carried out to evaluate the clinical features and management outcomes of dry eye disease (DED) in chronic ocular GvHD following allogenic hematopoietic stem cell transplantation (HSCT). Methods: A retrospective review of consecutive patients diagnosed with chronic ocular GvHD between 2011 and 2020 was performed at a tertiary eye care network. Multi-variate regression analysis was carried out for identifying risk factors associated with progressive disease. Results: A total of 34 patients (68 eyes) with a median age of 33 years [inter-quartile range (IQR) 23-40.5] were studied. The most common indication for HSCT was acute lymphocytic leukemia (26%). Ocular GvHD developed at a median of 2 years (IQR 1-5.5 years) after HSCT. Aqueous tear deficiency was present in 71% of the eyes, of which 84% had a Schirmer value of <5 mm. The median visual acuity at presentation and that after a median follow-up of 6.9 months were comparable at 0.1 log minimum angle of resolution (logMAR) (P = 0.97). Topical immunosuppression was required in 88% of cases, and with this, improvement in corneal (53%, P = 0.003) and conjunctival staining scores (45%, P = 0.43) was noted. A progressive disease was present in 32% with persistent epithelial defects being the most common complication. Grade 2 conjunctival hyperemia [odds ratio (OR): 2.6; P = 0.01] and Schirmer's value <5 mm (OR: 2.7; P = 0.03) were found to be associated with progressive disease. Conclusion: Aqueous deficient DED is the most common ocular manifestation of chronic ocular GvHD, and the risk of the disease progression is greater in eyes with conjunctival hyperemia and severe aqueous deficiency. Awareness among ophthalmologists of this entity is essential for its timely detection and optimal management.

Randomized Double-Masked Placebo-Controlled Trial for the Management of Pythium Keratitis: Combination of Antibiotics Versus Monotherapy.

PURPOSE: The aim of this study was to compare the efficacy of monotherapy (topical linezolid 0.2%) versus a combination of antibiotics (topical linezolid 0.2% and topical azithromycin 1%) for the treatment of Pythium insidiosum keratitis. METHODS: Cases of P. insidiosum keratitis were prospectively randomized into group A on topical 0.2% linezolid along with topical placebo (sodium carboxymethyl cellulose [CMC] 0.5%) and group B on a combination of topical 0.2% linezolid and topical 1% azithromycin. Both groups were compared by proportion of both clinical resolution and worsening of keratitis along with the number of therapeutic penetrating keratoplasty (TPK) performed at 3 months. RESULTS: We initially planned N = 66 patients but later limited to 20 (N = 10 in each group) patients owing to one interim analysis. The average size of the infiltrate in group A and B was 5.6 ± 1.5 mm and 4.8 ± 2.0 mm, respectively, with a mean Logarithm of the Minimum Angle of Resolution (logMAR) visual acuity of 2.74 ± 0.55 and 1.79 ± 1.19. At 3 months, from group A, 7 (70%) patients needed TPK and 2 patients had signs of resolution, whereas from group B, 6 (60%) patients achieved complete resolution ( P = 0.0003) and 2 were improving while only 1 needed TPK ( P = 0.02). The median duration of treatment in group A and B, with the study drugs, was 31 days (17.8-47.8) and 101.5 days (80-123.3), P value = 0.003, respectively. Final visual acuity at 3 months was 2.50 ± 0.81 and 0.75 ± 0.87, P = 0.02, respectively. CONCLUSIONS: A combination of topical linezolid and topical azithromycin was found to have superior efficacy than the monotherapy with topical linezolid for the management of Pythium keratitis.

Safety and Efficacy of Contact Lenses in Eyes After Simple Limbal Epithelial Transplantation.

PURPOSE: The aim of this study was to evaluate the safety and efficacy of contact lenses (CLs) in eyes after simple limbal epithelial transplantation (SLET) for limbal stem cell deficiency (LSCD). METHODS: This retrospective study included 61 eyes with partial or total LSCD which underwent SLET and were fitted with corneal or scleral rigid gas-permeable CLs. The primary outcome measure was best-corrected visual acuity (BCVA) with CLs. RESULTS: The median age at presentation was 22 years. The most common cause of LSCD was chemical injury [47/61 eyes (77%)]. Twenty-seven eyes (44%) were fitted with corneal rigid gas-permeable lenses, while 34 eyes (56%) were prescribed scleral lenses. The median duration of interval between SLET and CL trial was 10 months (interquartile range: 4-17). The median preoperative BCVA was logarithm of minimal angle of resolution (logMAR) 1.8. This improved to logMAR 1 ( P < 0.001) after SLET and to logMAR 0.6 ( P < 0.001) with CLs. Eyes with chemical injury (logMAR 1 vs. 0.6, P = 0.0001), grade 1 (logMAR 0.8 vs. 0.4, P < 0.0001), and grade 2 (logMAR 0.9 vs. 0.6, P = 0.004) corneal scarring had better improvement in BCVA with CLs. No complications were noted until the last follow-up visit. CONCLUSIONS: CLs, both corneal and scleral lenses, provide significant visual improvement in eyes after SLET with residual corneal scarring. These can be safely prescribed in such eyes without any adverse effects. This option can be considered before offering keratoplasty in these eyes.

Clinico-microbiological Features and Treatment Outcomes of Serratia Keratitis and Comparison with Pseudomonas aeruginosa Keratitis.

PURPOSE: To describe clinico-microbiological features and outcomes of Serratia keratitis and to compare them with Pseudomonas aeruginosa keratitis. METHODS: Cases of microbiologically proven Serratia keratitis and P. aeruginosa keratitis were reviewed. Data regarding demographic and clinical characteristics, and outcomes were recorded. RESULTS: 39 patients with pure Serratia keratitis were included. Median presenting vision was 1.8 logMAR (IQR, 0.8-2.4) and median infiltrate size was 5 mm (IQR 3-7.8 mm). An ocular risk factor was present in 35 (89.7%) cases. S. marcescens was the most common species (31/39, 79.5%). Medical resolution was observed in 36/39 (92.3%) cases, while three (7.7%) eyes needed penetrating keratoplasty. On comparing with P. aeruginosa keratitis (58 eyes), no difference in outcomes (p = .14) was noted. CONCLUSION: Serratia keratitis usually occurs in eyes with a compromised surface and has good resolution with medical therapy. Both Serratia and P. aeruginosa keratitis have similar outcomes.

Corneal blindness in the developing world: The role of prevention strategies.

Corneal blindness is an important contributor to the burden of global blindness and has a greater prevalence in low-income countries of the developing world where resources and infrastructure are limited. The causes of corneal blindness too are different from high-income countries and include infectious keratitis, ocular trauma, and xerophthalmia. Persons with these indications tend to have unfavourable outcomes after corneal transplantation, limiting their chances of benefitting from this sight-saving procedure. However, most causes of corneal blindness in the developing world are preventable. This highlights the importance of understanding the unique challenges in these regions and the need for targeted interventions. This article discusses various prevention strategies, including primordial, primary, and secondary prevention, aimed at reducing the burden of corneal blindness in low-income countries. These include capacity building, training, and awareness campaigns to reduce the risk factors of ocular trauma, infectious keratitis, and to improve access to first aid. It is also important to promote safe eye practices and tackle nutritional deficiencies through public health interventions and policy changes. Providing the required training to general ophthalmologists in the management of basic corneal surgeries and diseases and enhancing the accessibility of eye care services in rural areas will ensure early treatment and prevent sequelae. Current treatment modalities belong to the tertiary level of prevention and are largely limited to corneal transplantation. In developing nations, there is a scarcity of donor corneal tissue necessitating an urgent expansion of eye banking services. Alternative approaches to corneal transplantation such as 3D printed corneas, cultured stem cells, and biomaterials should also be explored to meet this demand. Thus, there is a need for collaborative efforts between healthcare professionals, policymakers, and communities to implement effective prevention strategies and reduce the prevalence of corneal blindness in the developing world.

The role of Tenonplasty in the management of limbal and scleral ischemia due to acute ocular chemical burns.

Of the various manifestations of ocular chemical burns (OCBs), ischemia of the limbus and the peri-limbal sclera indicates poor prognosis and in severe cases threaten the integrity of the globe. Tenonplasty is a surgical procedure which involves advancing the Tenon's capsule over the ischemic areas to provide a vascular supply and to enable migration of the conjunctival epithelium. This review aims to provide an overview of the diagnosis of limbal ischemia and its management with Tenonplasty. A literature review was conducted using the keywords "Tenonplasty," "Tenon's capsule," "ocular chemical injury," "ocular thermal injury," "Tenon advancement," "scleral ischemia," and "limbal ischemia," and outcomes were studied from seven selected articles. In addition to clinical evaluation, in vivo imaging techniques such as anterior segment optical coherence tomography angiography can provide an objective method of measuring and monitoring the ischemia and re-perfusion of the peri-limbal vasculature. Tenonplasty can be performed in eyes with acute OCBs with scleral or limbal ischemia by dissecting the Tenon's layer from the orbit and securing it to the limbus. The indications, mechanism of action, peri-operative considerations, surgical technique, and post-operative care of Tenonplasty are discussed in detail. The average time for post-operative re-epithelization ranges from 1 to 6 months with the formation of a symblepharon being the most common complication. In conclusion, Tenonplasty is a globe-salvaging procedure in cases with severe limbal and scleral ischemia because of OCBs and has good anatomical outcomes priming the globe for subsequent re-constructive and vision-restoring surgeries.

Deep anterior lamellar limbo-keratoplasty for bilateral limbal stem cell deficiency with corneal scarring in chemical injury sequelae: Two case reports.

INTRODUCTION AND IMPORTANCE: This report describes a new technique of deep anterior lamellar limbo-keratoplasty for the management of bilateral limbal stem cell deficiency (LSCD) with corneal scarring. PRESENTATION OF CASES: A 45-year-old male presented with chronic sequelae of ocular chemical injury and had bilateral total LSCD with corneal scarring. The visual acuity (VA) in the right eye was counting fingers. A large diameter deep anterior lamellar limbo-keratoplasty (DAL-LK) was carried out and the donor cornea and limbus were sourced from a single tissue. The VA at the last visit, 2.5 years after the surgery was 20/80. A similar presentation was seen in a 31-year-old male with a VA of 20/320 in the right eye. He underwent a DAL-LK and 3 years after the procedure, the VA was 20/60. Both grafts remained clear with no episodes of rejection until the last follow up visit. DISCUSSION: Limbal stem cell transplantation with keratoplasty or a keratoprosthesis is required to manage bilateral LSCD with stromal scarring. The former necessitates multiple interventions while the latter is associated with several globe threatening complications. DAL-LK was devised to overcome these disadvantages and offers a simple, single staged technique of simultaneously transplanting the corneal stroma with the limbal stem cells. As the host endothelium is preserved, there is no risk of rejection episodes. CONCLUSION: DAL-LK can successfully restore stability of the ocular surface and visually rehabilitate cases with bilateral LSCD and stromal scarring. The procedure has stable long-term outcomes with a good safety profile.

A Review of the Diagnosis and Treatment of Limbal Stem Cell Deficiency.

Limbal stem cell deficiency (LSCD) can cause significant corneal vascularization and scarring and often results in serious visual morbidity. An early and accurate diagnosis can help prevent the same with a timely and appropriate intervention. This review aims to provide an understanding of the different diagnostic tools and presents an algorithmic approach to the management based on a comprehensive clinical examination. Although the diagnosis of LSCD usually relies on the clinical findings, they can be subjective and non-specific. In such cases, using an investigative modality offers an objective method of confirming the diagnosis. Several diagnostic tools have been described in literature, each having its own advantages and limitations. Impression cytology and in vivo confocal microscopy (IVCM) aid in the diagnosis of LSCD by detecting the presence of goblet cells. With immunohistochemistry, impression cytology can help in confirming the corneal or conjunctival source of epithelium. Both IVCM and anterior segment optical coherence tomography can help supplement the diagnosis of LSCD by characterizing the corneal and limbal epithelial changes. Once the diagnosis is established, one of various surgical techniques can be adopted for the treatment of LSCD. These surgeries aim to provide a new source of corneal epithelial stem cells and help in restoring the stability of the ocular surface. The choice of procedure depends on several factors including the involvement of the ocular adnexa, presence of systemic co-morbidities, status of the fellow eye and the comfort level of the surgeon. In LSCD with wet ocular surfaces, autologous and allogeneic limbal stem cell transplantation is preferred in unilateral and bilateral cases, respectively. Another approach in bilateral LSCD with wet ocular surfaces is the use of an autologous stem cell source of a different epithelial lineage, like oral or nasal mucosa. In eyes with bilateral LSCD with significant adnexal issues, a keratoprosthesis is the only viable option. This review provides an overview on the diagnosis and treatment of LSCD, which will help the clinician choose the best option amongst all the therapeutic modalities currently available and gives a clinical perspective on customizing the treatment for each individual case.

Management of Symblepharon Prior to Keratoprosthesis in Chronic Ocular Burns: A Sequential Approach.

This report describes two cases with stepwise management of chronic ocular burn sequelae with concurrent total limbal stem cell deficiency (LSCD) and advanced symblepharon. Both were mono-ocular patients with the other eye being phthisical. In both cases, a sequential approach was planned, and at the first stage, the symblepharon was released to stabilize the ocular surface and form the fornices. This was followed by a type 1 keratoprosthesis (KPro) after four months of symblepharon release in the first case, and after nine months in the second case. In the first case, after symblepharon release, the resultant bare sclera was addressed with an oral mucous membrane graft (MMG). Over two years of follow-up, there was no evidence of recurrence of the symblepharon. No further surgical interventions were required. In the second case, after symblepharon release, the resultant bare sclera was addressed with a cryopreserved amniotic membrane (AM). Over eight years of follow-up, six episodes of recurrence of the symblepharon were noted over the optic of the KPro, necessitating trimming of the conjunctiva from over the optic. Thus, with these two cases, we would like to emphasize that addressing adnexal pathologies such as a symblepharon with an oral MMG before implanting a KPro, may help prevent further recurrences of symblephara and the need for multiple surgical interventions. The oral mucosa is a better alternative to the conjunctiva as compared to the AM in a mono-ocular patient where conjunctiva cannot be harvested from the contralateral eye.

Conjunctival Autograft for Bilateral Tarsal Keratinization in a Case of Chronic Vernal Keratoconjunctivitis.

This report describes the clinical features and management in a case of vernal keratoconjunctivitis (VKC) with bilateral tarsal conjunctival keratinization. A 32-year-old male presented with VKC since childhood that had exacerbated in the eight years prior to presentation. Examination revealed partial limbal stem cell deficiency in both eyes, with keratinization of the superior tarsal conjunctiva. The corresponding areas of the cornea exhibited punctate keratopathy in both eyes. To address this, the patient underwent excision of the conjunctival keratinization in both eyes. The resultant bare areas were covered with conjunctival autografts (CAGs). Postoperatively, the grafts were well apposed, and there was no recurrence of keratinization observed during the period of follow-up of four years. Resolution of corneal epitheliopathy was also noted. Although keratinization can occur in eyes with VKC, it is usually limited to the bulbar conjunctival areas. This is the first report of tarsal conjunctival keratinization in such cases. Milder cases may be observed or managed with scleral contact lenses. In more severe forms, there is associated corneal epitheliopathy, which may progress to corneal vascularization and scarring. Surgical excision of the lesion is recommended in these eyes. Following excision, several options exist to cover the bare area, which include a CAG, an amniotic membrane, or an oral mucous membrane. Of these, a CAG is an autologous tissue that can be harvested with a simple surgical technique and yields stable long-term results. Thus, tarsal conjunctival keratinization is a rare complication of chronic VKC. Excision of the lesion followed by a CAG is a viable approach for treatment, which reestablishes and maintains a stable ocular surface.

Role of AS-OCT in Managing Corneal Disorders.

Optical coherence tomography (OCT) is analogous to ultrasound biometry in the cross sectional imaging of ocular tissues. Development of current devices with deeper penetration and higher resolution has made it popular tool in clinics for visualization of anterior segment structures. In this review, the authors discussed the application of AS-OCT for diagnosis and management of various corneal and ocular surface disorders. Further, recent developments in the application of the device for pediatric corneal disorders and extending the application of OCT angiography for anterior segment are introduced.

Allogeneic simple limbal epithelial transplantation for bilateral limbal stem cell deficiency in chronic vernal keratoconjunctivitis: A case report.

INTRODUCTION AND IMPORTANCE: This report describes the management of bilateral limbal stem cell deficiency (LSCD) in vernal keratoconjunctivitis (VKC) with allogeneic simple limbal epithelial transplantation (allo-SLET). PRESENTATION OF CASE: A 22-year-old female presented with bilateral VKC with total LSCD. A thick fibrotic pannus was present in both eyes, with visual axis involvement in the right eye. The central cornea in the left eye was clear. The patient underwent a cadaveric allo-SLET in the right eye to restore the ocular surface. Systemic immunosuppression with oral cyclosporine was administered following the surgery. The corrected visual acuity with scleral contact lenses (SCL) was 20/20 in both eyes which was maintained until the last follow-up visit, one year after the surgery. No recurrence of LSCD was observed in the right eye and the ocular surface was well epithelialized. DISCUSSION: Allo-SLET is a simple and efficacious surgical technique for bilateral LSCD. Eyes with VKC have a wet ocular surface, relatively clear corneal stroma, and minimal adnexal involvement. Thus, allo-SLET is the ideal procedure to address LSCD in such cases. The systemic immunosuppression that is given for ensuring graft survival can also help control the underlying allergy. Scleral contact lenses improve the visual acuity and their long-term usage does not affect the functioning of the SLET transplants. CONCLUSION: VKC with bilateral LSCD can be successfully managed with allogeneic SLET. Post-operative systemic immunosuppressants are essential to maintain viable grafts. The use of SCL can improve vision and they do not pose any risk to the SLET transplants.