Dry eye module - An application intelligence platform for diagnosing and monitoring dry eye disease.

Dry Eye Module (DEM), a software application, was developed to facilitate the streamlining of dry eye evaluation and documentation, to unify diagnostic jargon, and to analyze data input to generate a dry eye diagnostic report. This diagnostic report generated is based on the current understanding of dry eye diagnostic algorithms (Dry Eye Workshop 2 [DEWS2]/Asia Dry Eye Society [ADES]). Apart from its plausible role in aiding unprecedented multicentric dry eye demographic data collection, the application software can generate a customized referral letter to the rheumatologist, highlighting the salient ophthalmic features to be shared. DEM uses schematic illustrations to depict eyelid, conjunctival, and corneal parameters that impact the ocular surface in dry eyes that can be captured and compared during serial visits. Furthermore, DEM displays a symptom sign trend chart that graphically represents improvement/stability or worsening of the subjective and objective dry eye status. DEM can generate a curated prescription using preloaded advice templates. DEM includes facility for state-of-the-art advanced dry eye diagnostic reporting for super specialty use. The addition of DEM to the dry eye diagnostic armamentarium would help bridge the current unmet needs of dry eye evaluation. These are lack of uniform reporting, lack of multicentric data on a unified platform, the inability to ensure complete evaluation, inability to avoid lacunae during follow-up visits, and the lack of a simple patient-ophthalmologist and an ophthalmologist-rheumatologist interface.

DALK rejection following vaccination against SARS-CoV-2: 2 case reports.

PURPOSE: To report two cases of deep anterior lamellar keratoplasty (DALK) rejection occurring in association with SARS-CoV-2 vaccination. METHODS: Two patients with prior history of DALK developed immunologic rejection after SARS-CoV-2 vaccination. The first patient, a 15-year-old girl, had a stromal and sub-epithelial rejection nine days after receiving the first dose of the SARS-CoV-2 vaccine BBV152(COVAXINTM, Bharat Biotech, India). The second patient, an 18-year-old male, had a stromal rejection 13 days after receiving the second dose of the ChAdOx1 SARS-CoV-2 vaccine (COVISHIELDTM, Serum Institute of India, India). RESULTS: Both patients received frequent topical corticosteroids. The first patient recovered within four weeks and the second patient recovered within two weeks of initiating therapy. Both patients experienced complete resolution of corneal edema and had improvement in their visual acuity. CONCLUSIONS: DALK rejection is a rare but distinct possibility in patients following SARS-CoV-2 immunization. Further studies are required before establishing clear guidelines regarding risk, follow-up and treatment strategies in such a scenario.

Selective Endothelialectomy in Peters Anomaly: A Novel Surgical Technique and Its Clinical Outcomes in Children.

PURPOSE: This study describes the surgical outcomes of selective endothelialectomy in Peters anomaly (SEPA), a relatively new technique to manage Peters anomaly (PA). METHODS: This study included 34 eyes of 28 children who had a visually significant posterior corneal defect due to PA and underwent SEPA between 2012 and 2019. A selective endothelialectomy from the posterior corneal defect was performed while preserving Descemet membrane. The primary outcome measure was the resolution of corneal opacification. The secondary outcome measures were functional vision, complications, and risk factors for failure. RESULTS: At a mean postoperative follow-up of 0.96 ± 0.20 years, 29 eyes (85.3%) maintained a successful outcome. Mean preoperative and postoperative best-corrected visual acuities were 2.55 ± 0.13 and 1.78 ± 0.13 ( P < 0.0001), respectively. Ambulatory functional visual improvement was seen in 97%, and 23% attained vision ranging between 20/190 and 20/50. Corneal opacification failed to clear in 5 eyes (15%). Risk factors associated with surgical failure were female sex ( P = 0.006), disease severity ( P < 0.0001), glaucoma ( P = 0.001), and additional interventions after SEPA ( P = 0.002). In multivariate analysis, only disease severity (ie, a type 2 PA) was a significant risk factor for the failure of SEPA. There were no sight-threatening complications. CONCLUSIONS: SEPA is a safe and effective technique in select cases of posterior corneal defect due to PA. SEPA could be a potential surgical alternative to pediatric keratoplasty or optical iridectomy in children with central corneal opacification smaller than 7 mm due to PA.

Descemet Membrane Endothelial Transfer (DMET) in Pseudophakic Bullous Keratopathy After DSEK-A Case Report and Review of Literature.

PURPOSE: The purpose of this study was to report a Descemet membrane endothelial transfer (DMET) in a patient with pseudophakic bullous keratopathy (PBK) who developed graft dislocation after manual Descemet stripping endothelial keratoplasty. METHODS: A 60-year-old man presented with defective vision in the left eye; after Descemet stripping endothelial keratoplasty, graft dislocation was noted 1 month after surgery. RESULTS: Corneal clarity was improving slowly over 3 months without any secondary surgical intervention. The mechanism of DMET and the review of literature were enunciated. CONCLUSIONS: DMET occurs commonly in eyes with Fuch endothelial dystrophy and rarely in patients with PBK. The mechanism of DMET in PBK probably occurs because of migration of the donor endothelial cells from partially attached Descemet stripping endothelial keratoplasty grafts to the host stroma, in contrast to Fuch endothelial dystrophy, where the endothelial cells from the periphery migrate to the center. Hence, waiting for spontaneous corneal clarity is pivotal because of DMET even in patients with PBK for at least 3 months.

Algorithmic approach to diagnosis and management of post-refractive surgery dry eye disease.

Dry eye disease (DED) is a condition that is fast reaching epidemic proportions around the world. Dry eye post-refractive surgery is the leading cause of iatrogenically induced DED. The wide variety of presentations and the disparity between signs and symptoms in many patients make this a very challenging aspect of our clinical practice. There has been a paradigm shift in the way we approach and treat this condition. The International Dry eye workshop has added new knowledge and focus to our management of dry eye. A wide range of newer diagnostic modalities are available for the diagnosis of DED. Dry eye is one of the most common side effects of refractive surgery and can have a bearing the patient's perception of surgical outcomes as well. A thorough understanding of the possible underlying etiopathologies of this disease and the difference in etiopathogenesis of postrefractive dry eye is essential for optimal outcomes. It is important to approach each case in a unique fashion and customize the therapy to the patient presentation. This review article compiles all these aspects of management of dry eye in general, and postrefractive surgery dry eye in particular; from the ones commonly practiced in the clinic to the newer modalities of therapy with insights into the disease from a more practical point of view.

Bowman's topography for improved detection of early ectasia.

The aim of this study was to evaluate whether OCT topography of the Bowman's layer and artificial intelligence (AI) can result in better diagnosis of forme fruste (FFKC) and clinical keratoconus (KC). Normal (n = 221), FFKC (n = 72) and KC (n = 116) corneas were included. Some of the FFKC and KC patients had the fellow eye (VAE-NT) with normal topography (n = 30). The Scheimpflug and OCT scans of the cornea were analyzed. The curvature and surface aberrations (ray tracing) of the anterior corneal surface [air-epithelium (A-E) interface in OCT] and epithelium-Bowman's layer (E-B) interface (in OCT only) were calculated. Four random forest models were constructed: (1) Scheimpflug only; (2) OCT A-E only; (3) OCT E-B only; (4) OCT A-E and E-B combined. For normal eyes, both Scheimpflug and OCT (A-E and E-B combined) performed equally in identifying these eyes (P = .23). However, OCT A-E and E-B showed that most VAE-NT eyes were topographically similar to normal eyes and did not warrant a separate classification based on topography alone. For identifying FFKC eyes, OCT A-E and E-B combined performed significantly better than Scheimpflug (P = .006). For KC eyes, both Scheimpflug and OCT performed equally (P = 1.0). Thus, OCT Topography of Bowman's layer significantly improved the detection of FFKC eyes.

Recurrent non-tuberculous mycobacterial keratitis after deep anterior lamellar keratoplasty for keratoconus.

A 26-year-old farmer underwent deep anterior lamellar keratoplasty (DALK) for keratoconus. After 3 months, he presented with interface keratitis. Medical treatment failed and he underwent a repeat DALK. Microbiological scrapings from the interface revealed an infection caused by non-tuberculous mycobacteria. Despite the use of intensive antibiotic therapy and a repeat lamellar keratoplasty, the infiltrates recurred. The patient underwent therapeutic penetrating keratoplasty. Microbiology of the corneal tissue revealed growth of Mycobacterium chelonae, and on histopathology, the acid-fast bacilli were noted to be located deep at the pre-Descemet level. There was complete resolution of the infection with no episodes of recurrence and final best-corrected visual acuity was 20/40 at 1 year of follow-up. Medical therapy is unlikely to succeed in post-DALK interface keratitis and penetrating rather than lamellar keratoplasty may be considered the surgery of choice.

Imaging modalities in keratoconus.

Diagnosis of keratoconus has greatly improved from simple clinical diagnosis with the advent of better diagnostic devices like corneal topographers based on placido disc, elevation based topographers and lately optical coherence tomography (OCT). These instruments are quite sensitive to pick up early keratoconus, which could help refractive surgeons to avoid serious complications like ectasia following keratorefractive surgeries. Each of these instruments has their advantages and disadvantages; in spite of that each one of them has its own place in the clinical practice. Currently, placido disc based topographers are the most commonly used topographers all over the world. There are many different companies making such devices, which follow the different techniques and color for the display. Due to these differences they are not directly comparable to each other. Various quantitative indices based on these topographers have been suggested and validated by different authors to aid in the diagnosis and quantification of keratoconus. OCT with its higher resolution and deeper penetration has created its place in the diagnostic armamentarium for keratoconus.

Management of intra-Descemet membrane air bubble in big-bubble deep anterior lamellar keratoplasty.

PURPOSE: To report the recognition and management of intra-Descemet membrane air bubble (IDMA) as a complication of big-bubble deep anterior lamellar keratoplasty (DALK). METHODS: IDMA was present intraoperatively in 8 eyes after DALK. Indications for surgery were healed keratitis (n = 4), macular dystrophy (n = 2), and keratoconus (n = 2). The IDMA was present between the anterior banded layer and posterior nonbanded layer of Descemet membrane (DM). They were slid and displaced toward the peripheral cornea using 27-gauge cannula and punctured taking care that underlying DM was not ruptured. RESULTS: DM was bared in all eyes, and DALK was completed in 7 cases. One patient required conversion to penetrating keratoplasty because of macroperforation. No case had double anterior chamber. Mean follow-up was 13.9 ± 4.1 months. A DM fold was noted in 1 eye. Seven cases had postoperative best-corrected visual acuity of 20/60 or better. CONCLUSIONS: Prompt recognition of the IDMA intraoperatively is required, which can be managed successfully.

Is blood agar an alternative to sabouraud dextrose agar for the isolation of fungi in patients with mycotic keratitis.

To compare the blood agar (BA), sabouraud dextrose agar (SDA) and chocolate agar (CA) for the isolation of fungi in patients with mycotic keratitis. Corneal Scrapings of 229 patients with clinically diagnosed microbial keratitis were inoculated on BA, SDA, CA. The culture media were evaluated for the rate and time taken for the fungal growth. Seventy six of 229 patients had fungal keratitis. Fungus grew on BA in 60/76(78.9 %), on SDA in 76/76 (100 %), on CA in 40/76(52.6 %) patients. The fungi which grew on BA (60/76) also grown on SDA at the same time. The colony morphologies of different fungi were better on SDA than BA/CA. Among the different culture media, SDA is essential for the isolation fungi in patients with mycotic keratitis.