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.

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.

Contact lenses in dry eye disease and associated ocular surface disorders.

Dry eye disease (DED) is prevalent in all age groups and is known to cause chronic ocular discomfort and pain, and greatly affects the quality of life. Patients with ocular surface disease (OSD) may also have reduced tear secretion due to lacrimal gland damage, thus leading to aqueous deficient DED. Even with conventional management modalities such as lubricating eyedrops, topical corticosteroids, autologous serum eyedrops, or punctal plugs, many patients continue to suffer from debilitating symptoms. Contact lenses are increasingly being used in OSD providing surface hydration, protection from environmental insults, mechanical damage from abnormal lids, and as a modality for constant drug delivery to the ocular surface. This review describes the role of soft lenses and rigid gas-permeable scleral lenses in the management of DED associated with OSD. The efficacy of contact lenses, lens selection, and optimal lens fit are reviewed for specific indications.

Presentation, aetiology and outcomes of corneal ulceration in Sjogren's Syndrome.

PURPOSE: To report the clinical course of corneal ulceration/perforation in patients with Sjogren's syndrome. METHODS: Retrospective descriptive study of patients diagnosed with Sjogren's syndrome (primary and secondary) and corneal ulceration over past 8 years at tertiary eye care network. Assessed parameters were demographics, clinical details, microbiological profile, types of intervention and their outcomes. RESULTS: Forty-six eyes of 44 patients (11 males; mean age, 50 years) had corneal ulceration (28 eyes) or perforation (18 eyes) at the time of presentation. Of 46 eyes, 38 had sterile ulceration/perforation and rest 8 showed microorganism on microscopy or culture. The location was peripheral in 63% of eyes and it was the first presenting sign of Sjogren's syndrome in 26% of patients. All 43 eyes (3 lost to follow-up after intervention) had successful management of corneal ulceration/perforation. Twenty-eight eyes with ulceration required medical management alone in 15 eyes, soft contact lens and isobutylcyanoacrylate in 12 eyes, and amniotic membrane grafting in one eye. Four eyes with ulceration worsened and required penetrating keratoplasty (n = 2), and amniotic membrane grafting (n = 2). Corneal perforations were successfully managed with isobutylcyanoacrylate patch and BCL (n = 15), corneal patch graft (n = 2) and multilayered amniotic membrane grafting (n = 1). The average time taken for ulcers to heal was 49 days over a mean follow-up duration of 10 months. CONCLUSION: Corneal ulceration or perforation in Sjogren's syndrome is often sterile and can be a presenting sign of undiagnosed SS. These patients usually respond to intensive medical therapy and bandage contact lens and isobutylcyanoacrylate patch application.

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.

Management of an unresponsive case of HSV keratouveitis with trabeculectomy and DSAEK: A case report.

INTRODUCTION AND IMPORTANCE: This case demonstrates an unusual presentation of Herpes simplex virus (HSV) ocular infection and the challenges faced during the management of its complications. PRESENTATION OF THE CASE: A thirty year-old lady, a steroid responder with HSV keratouveitis, was referred for non-response to treatment with the prophylactic dose of oral acyclovir and acetazolamide. She presented with large epithelial bullae, anterior chamber reaction, and raised intraocular pressure in her right eye. Initially, she responded to the therapeutic dose of oral acyclovir, but on follow-up visits, she developed high intraocular pressures of up to 45 mmHg on maximum medical therapy. Hence, trabeculectomy with mitomycin-C was performed. One year later, she developed corneal endothelial decompensation, for which a Descemet's stripping automated endothelial keratoplasty (DSAEK) was done. Eight months post-operatively, she had a best corrected visual acuity of 20/20, clear corneal graft, quiet anterior chamber, and well-controlled intraocular pressures. DISCUSSION: HSV trabeculitis is associated with inflammation of the anterior chamber, endothelitis and raised intra-ocular pressure. A combination of anti-viral, anti-inflammatory, and anti-glaucoma medications helps in the management. However, glaucoma filtration surgery is often needed to the control intra-ocular pressure. Chronic recurrent episodes eventually lead to endothelial failure and demand endothelial keratoplasty (EK). It is prudent to adopt certain measures to perform EK in these phakic eyes without causing any iatrogenic damage to the filtration bleb as well as to the clear crystalline lens. CONCLUSION: This case highlights the difficulties of treating HSV-related keratouveitis with uncontrolled glaucoma, problems of associated steroid response, and complexities in performing corneal endothelial procedures in young phakic patients especially post-trabeculectomy.

Scleral contact lenses for optimal visual recovery in a case of severe acid burn with total lagophthalmos.

Chemical injuries can severely damage the ocular surface. We present the case of a man in his 40s with severe periocular chemical injury with total lid loss and severe exposure keratopathy. He sustained burns to 45% of his body surface area and needed tracheostomy and multiple full-thickness skin grafts. Both eyes required surgery, Boston type 1 keratoprosthesis and penetrating keratoplasty for the right and left eye, respectively. There was melting in the right eye and a persistent epithelial defect in the left eye. Eventually, we suggested 18 mm diameter scleral contact lenses for both eyes to aid in ocular surface stabilisation. His best corrected visual acuity improved significantly with the scleral lenses to 20/100 and 20/320 in the right and left eyes, respectively. This case demonstrates that scleral lenses can treat the complications of exposure keratopathy and can improve vision. Therefore, they may be considered for rehabilitation of the ocular surface in eyes with severe chemical periocular injuries.

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.

A multi-parameter grading system for optimal fitting of scleral contact lenses.

Background: While scleral lens practise has improved over the years due to factors such as availability of lenses with better materials and designs as well as experience of practitioners, a lack of objectivity appears to remain in terms of assessment of scleral lens fitting. This prospective observational work aimed to achieve standardization on this front through proposing a grading system for scleral lens fitting. Methods: After application of prosthetic replacement of ocular surface ecosystem (PROSE) devices on the participants' eyes, four fundamental components for understanding scleral lens fitting such as central and limbal corneal clearance, mid-haptic compression, and alignment of lens edge over anterior sclera were assessed through a series of slit-lamp biomicroscopy imaging as well as with anterior segment optical coherence tomography. FitConnect® was used to modify the device parameters to simulate different grading patterns on the proposed scale. Serial imaging was done for all the different lenses to compose the grading scale. Results: A clinically relevant grading scale was constructed that pictorially demonstrated grades for the different aspect of scleral lens fitting. The grades were conveniently scaled within three categories: "optimal", "acceptable" and "not acceptable". Conclusion: The gradation of scleral lens fitting parameters would take a step towards objectifying the assessment patterns in practise. This will also help reducing the gap between a novice and an experienced practitioner in terms of understanding of scleral lens fitting.

Predictive Factors for Resolution of Dematiaceous Fungal Keratitis.

PURPOSE: To ascertain the clinicomicrobiological correlation and evaluate the prognostic factors associated with medical resolution in cases of Curvularia, Alternaria, and Scedosporium keratitis. METHODS: A retrospective review of clinical and microbiological records of culture-proven cases of Curvularia, Alternaria, and Scedosporium keratitis from 2017 to 2019 was performed. Multivariate logistic regression analyses were performed to assess the predictive factors for medical resolution. RESULTS: There were a total of 79 eyes of 79 patients. Among these, there were 56 (70.8%), 15 (18.9%), and 8 (10.1%) patients with Curvularia, Scedosporium, and Alternaria keratitis, respectively. Clinical resolution with medical treatment was achieved in 46 of 56 (82.1%) patients with Curvularia keratitis, 8 of 15 (53.3%) patients with Scedosporium, and 7 of 8 (87.5%) patients with Alternaria keratitis. In comparison between Curvularia and Scedosporium, macroscopic pigmentation [18/56 (32.1%)] of anterior stromal plaque-like infiltrate [20/56 (35.7%)] was clinically more in cases with Curvularia, whereas larger diameter of the infiltrate, P = 0.002, posterior stromal infiltrate (40%), P = 0.03, and hypopyon, P = 0.009, were more common with Scedosporium. Multivariate logistic regression analysis, by backward elimination, showed that maximum dimension of the infiltrate (P = 0.01; odds ratio = 0.52, 95% confidence interval, 0.31-0.86) and presence of a hypopyon (P = 0.02; odds ratio = 0.12, 95% confidence interval, 0.02-0.71) were significant factors that were not favoring medical resolution. CONCLUSIONS: Larger size of the infiltrate, posterior stromal involvement, and presence of a hypopyon are poor prognostic indicators among all 3 species. Variation in species is not a predictor of clinical resolution.

Long term outcome of Tenon's patch graft in corneal perforation secondary to neurotrophic keratitis: A case report on a 4-year anatomical functional outcome.

INTRODUCTION: This report describes the long-term outcomes of Tenon's patch graft (TPG) in a corneal perforation secondary to neurotrophic keratitis and outcome of subsequent successful cataract surgery. PRESENTATION OF THE CASE: A 60-year gentleman presented with a corneal perforation secondary to Herpes Zoster ophthalmicus (HZO). After multiple unsuccessful attempts of cyanoacrylate tissue adhesive application over the perforation, he was referred for a corneal patch graft. Following TPG, he had a tectonically stable cornea that was managed with topical steroids and prophylactic oral Acyclovir. Sequential imaging of the cornea using high-resolution anterior segment- optical coherence tomography (HR-ASOCT) was done to monitor wound healing. Fifteen months later, he underwent uneventful cataract surgery with best-corrected visual acuity improving to 20/30 at 1-month. DISCUSSION: Serial imaging of the site of perforation with HR-ASOCT revealed that a fluffy, oedematous TPG in the early postoperative period transitioned into a hyper-reflective, thin, and compact graft over 3-4 months. Despite the corneal thickness at the site of perforation being only 142 µm, the wound had adequate tensile strength to withstand the altered anterior chamber dynamics during phacoemulsification. The resultant translucent nature of the scar provided superior media clarity and better visual outcomes. CONCLUSION: This case demonstrates the efficacy of TPG in acute phase management of corneal perforation following HZO thereby restoring the tensile strength of the cornea, enabling it to withstand the stress of future surgeries like phacoemulsification.

A Rare Presentation of Orbital Castleman's Disease.

Castleman's disease (CD) is an uncommon group of atypical lymphoproliferative disorders. Extranodal involvement such as the orbit is extremely rare. We aim to report a case of a 62-year-old male who presented with left painless proptosis for the past three years. Examination revealed a firm, lobulated mass in the left superotemporal orbit, displacing the globe inferomedially. A well-defined extraconal orbital lesion encasing the left lateral rectus muscle with intraconal extension was seen on Magnetic Resonance Imaging (MRI) that led to the provisional diagnosis of left solitary encapsulated venous malformation. Excision of the mass via lateral orbitotomy was performed. However, on histopathology, the features were consistent with a mixed-cell variant of Castleman's disease. A detailed systemic workup was unremarkable. Proptosis resolved after surgery and no recurrence was noted in the three-year follow-up. To the best of our knowledge, this is the first case report of a mixed-cell variant of unicentric orbital CD without any systemic features. This case highlights the importance of including CD in the differential diagnosis of well-defined orbital lesions so as to enable its early detection and timely management.