Successful management of recalcitrant fungal keratitis with topical caspofungin.

Objective: To report a case of recalcitrant fungal keratitis successfully managed with topical caspofungin acetate in North India. Methods: Case report and literature review. Results: An 18-year-old male patient presented with complaints of redness, watering, pain and diminution of vision in the right eye and was referred to our centre as a case of corneal ulcer. The patient was examined and found to have a near total epithelial defect, with corneal infiltrates approximately 8x8 mm. A provisional diagnosis of polymicrobial keratitis was made based on corneal scraping suggestive of S tap h ylococcus aureus and confocal scan revealing fungal hyphae. The patient failed to respond to topical voriconazole 1%, natamycin 5% and moxifloxacin hydrochloride 0.5% with oral voriconazole. In view of the poor response to these drugs, the patient was subsequently administered topical caspofungin 0.5% in place of natamycin and continued on topical and oral voriconazole, in addition to topical moxifloxacin and cycloplegics, which finally led to healing with minimal scarring. The patient attained a best corrected visual acuity (BCVA) of 6/12. Conclusion: Topical caspofungin may be used as a useful and effective alternative in cases of recalcitrant fungal keratitis. It may result in healing with minimal scarring.

Outcomes of surgical intervention in cases of ectopia lentis.

Purpose: To evaluate the outcomes of surgical intervention in cases of ectopia lentis. Methods: This retrospective study included all cases of ectopia lentis that presented between June 2015 and March 2019 in a tertiary care center. They were reviewed retrospectively. The corrected distance visual acuity (CDVA), severity of lens subluxation, type of surgery, intra-operative and post-operative complication, and specular count were recorded. Results: Seventy-eight eyes of 57 cases with a mean age at surgery of 14.73 years were analyzed. Intra-lenticular lens aspiration was the most common (n-62/78; 79.5%) surgical procedure followed by lens aspiration, intra-capsular cataract extraction, phaco-aspiration, and pars-plana lensectomy. Simultaneous intra-ocular lens (IOL) implantation was performed in 46.2% (n-32/78) of the eyes. The mean CDVA improved from 0.85 ± 0.55 logMAR to 0.44 ± 0.29 logMAR at 6 weeks follow-up. The post-operative CDVA was significantly better in the pseudo-phakic group compared to the aphakic group (p-0.02). The patient's age at the time of surgery and the degree of subluxation did not impact the final visual outcome. Intra-operative complication included vitreous hemorrhage (n-1) and lens matter drop (n-1). Post-operative complications were noted in 26.9% of the eyes (n-21/78) with a higher complication rate in the pseudo-phakic group (p-0.00). A second intervention was required in 7.7% of the eyes (n-6/78). Conclusion: Age and degree of subluxation at the time of surgery do not influence the final visual outcome in cases of ectopia lentis undergoing lens extraction surgery. IOL implantation results in better visual outcomes but is associated with a high complication rate.

Management of descemetocele: Our experience and a simplified treatment algorithm.

Purpose: To formulate a treatment algorithm for the management of descemetocele. Methods: This was a prospective interventional study that was conducted at a tertiary eye-care center. All consecutive cases of descemetocele during the study period (April 1, 2017-March 31, 2018) were evaluated for the following parameters: age, sex, previous medical or surgical therapy, risk factors, preexisting ocular diseases, location, site and size of descemetocele, interventions undertaken, visual acuity, and the fellow eye status. The surgical modalities and fellow eye status were correlated individually with therapeutic and functional outcomes, based on which a treatment algorithm was formulated. Results: The study included 24 eyes of 24 patients (19M, 5F) with a median age of presentation of 45 years. The mean follow-up duration was 6.79 ± 3.97 months (3-12 months). The most common cause of descemetocele was microbial keratitis (66.66%), and most cases were central (50%), small (58.33%), and non-perforated (79.16%). The surgical interventions undertaken were cyanoacrylate glue (CG, 37.5%), penetrating keratoplasty (PKP, 33.33%), patch graft (16.66%), and deep anterior lamellar keratoplasty (DALK, 12.5%). Therapeutic success was noted in 13/24 eyes (54.16%). Final visual acuity > 3/60 was seen in 25% cases. Suboptimal therapeutic (P = 0.07) and visual (P = 0.34) outcomes were noted in subjects with non-functional fellow eye. Conclusion: PKP was preferred for descemetoceles with active microbial keratitis and extensive infiltrates, while CG and DALK were undertaken for healed microbial keratitis, neurotrophic keratitis, and ocular surface disorders with partial limbal stem cell deficiency (LSCD). For total LSCD, amniotic membrane graft was preferred.

Rapid spontaneous resolution of corneal hydrops in post-CXL keratitis.

An 11-year-old boy presented with right eye post-Corneal Collagen Cross-Linking (CXL) keratitis, which was complicated by acute corneal hydrops (CH). Keratitis was managed by topical antibiotics, and CH was managed conservatively. Cornea was monitored with serial anterior segment optical coherence tomography (ASOCT) scans. Spontaneous resolution of CH usually takes 8-12 weeks, but in this case it completely resolved in 3 weeks. Rapid resolution of CH after post-CXL keratitis could be attributed to a thinner cornea, increased interlamellar cohesive strength between collagen fibrils of corneal stroma coupled with normal functioning endothelial pump.

Bilateral nodular sclerokeratitis secondary to syphilis - A case report.

A 30-year-old female patient presented with bilateral anterior nodular sclerokeratitis and multiple erythematous skin lesions involving the face, trunk, arms, and legs. The patient had a history of temporary relief with steroids, however the lesions recurred. A dermatology consultation was sought and the patient was diagnosed to have syphilis, consequent to which she was started on benzathine penicillin and showed a dramatic improvement in both skin and ocular lesions. A high index of suspicion for syphilis should be kept in mind for patients presenting with nodular scleritis to initiate timely and appropriate management with penicillin.

Real-time intraoperative dynamics of white cataract-intraoperative optical coherence tomography-guided classification and management.

PURPOSE: To evaluate morphological characteristics and intraoperative dynamics of different types of white cataract using intraoperative optical coherence tomography (iOCT). SETTING: Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India. DESIGN: Prospective interventional study. METHODS: Fifty eyes with white cataract undergoing phacoemulsification were evaluated. The primary outcome measure was the classification of white cataract based on morphology and intraoperative dynamics on iOCT. The secondary outcome measure was rhexis-related complications. RESULTS: Four types of white cataract were identified based on iOCT-type I (9 eyes), type II (3 eyes), type III (24 eyes), and type IV (14 eyes). Type I had regularly arranged lamellar cortical fibers, type II had continuous hyperreflective bands of cortical fibers with intralenticular clefts, type III had intralenticular clefts combined with areas of homogenous ground-glass appearance, and type IV had homogenous ground-glass appearance of the anterior lens cortex. Capsulorhexis in type I cataract was uneventful. In type II cataract, cortical bulge was observed in the anterior chamber on creating the initial nick, indicating raised intralenticular pressure (ILP) with an imminent risk of rhexis extension. A bimanual irrigation/aspiration was performed until lowering of ILP was observed on iOCT. In types III and IV, fluid release was observed on initiation of rhexis leading to partial (type III) or complete (type IV) lowering of ILP, with a mild-moderate risk of capsulorhexis extension. A continuous curvilinear capsulorhexis was achieved in all cases, with no case of posterior capsular tear or vitreous loss. CONCLUSIONS: Intraoperative OCT helped elucidate intraoperative dynamics of the spectrum of white cataracts and facilitates completion of capsulorhexis.

Intraoperative optical coherence tomography-guided release of lenticulo-corneal adhesion and lens aspiration in anterior dislocation of lens with corneal edema.

Purpose: To describe the outcome of microscope integrated optical coherence tomography (MiOCT) guided removal of lenticulo-corneal adhesion and intralenticular lens aspiration (ILLA) in cases with anterior dislocation of the crystalline lens and corneal edema. Methods: MiOCT-guided ILLA was performed in three eyes of two cases of homocystinuria with spontaneous anterior dislocation of lens and corneal edema. Lenticulo-corneal adhesion was noted intraoperatively, which was not apparent pre-operatively. The lenticulo-corneal adhesion could be successfully peeled using intravitreal forceps and viscodissection with visco-dispersive viscoelastic under the guidance of MiOCT. Results: In all cases, the lenticulo-corneal adhesion could be successfully removed without any complication such as Descemet tear or worsening in corneal edema. Improvement in visual acuity was noted in all cases with resolution in corneal edema by 1 week. Conclusion: MiOCT-guided ILLA can be extremely useful in cases of lenticulo-corneal adhesion especially in cases with corneal edema.

Descemet membrane detachment.

Descemet membrane detachment (DMD) is a potential vision-threatening complication that occurs most commonly after cataract surgery. DMD has also been reported to occur in various other surgeries such as keratoplasty, iridectomy, vitrectomy, trabeculectomy, holmium laser sclerostomy, alkali burn, and viscocanalostomy. Major risk factors include advanced age, preexisting endothelial diseases like Fuchs dystrophy or abnormality in the Descemet membrane and stromal interface, hard cataract, prolonged surgical time, ragged clear corneal incisions, and inadvertent trauma with blunt instruments or phacoemulsification probe. Most DMDs are peripheral and resolve spontaneously. Large, central DMDs if not managed appropriately may lead to corneal decompensation and opacification. Several authors have classified DMD depending on its configuration, height, extent, length, and position with respect to pupil. Anterior segment optical coherence tomography has been used to confirm and classify DMD and can also aid in deciding the management plan. Spontaneous reattachment of the DM with conservative management may occur in cases with small, peripheral, planar DMD with nonscrolled edges. Cases with nonplanar, central DMD, scrolled edges, and length >2 mm, however, have to be managed surgically. Descemetopexy is the gold standard for the management of DMD. Other management options include mechanical tamponade, suture fixation, descemetotomy, interface drainage, and keratoplasty. Prompt diagnosis and timely management often leads to a good visual outcome.

Infectious Keratitis Caused by Rare and Emerging Micro-Organisms.

PURPOSE: To provide a comprehensive review of rare and emerging micro-organisms causing infectious keratitis. MATERIAL AND METHODS: A literature search was performed using PubMed Medline, Cochrane Library Database, EMBASE and Scopus (1960 onwards), using the terms: keratitis caused by rare pathogens; mycotic keratitis; fungal keratitis; bacterial keratitis; infectious keratitis; infective keratitis; atypical fungal keratitis; fungal keratitis caused by rare organisms; fungal keratitis caused by rare ocular pathogen; atypical bacterial keratitis; bacterial keratitis caused by rare organisms; bacterial keratitis caused by rare ocular pathogen. All relevant articles were included in this review. RESULTS: A total of 1232 articles matched our search strategy of which 124 articles were included in this mini-review. The rare and emerging bacteria causing keratitis include atypical mycobacteria, Nocardia spp., Chrysebacterium spp., Delftia acidovorans, Kocuria spp., Enterococcus spp., Bartonella henslae, Achromobacter spp. and others. The rare and emerging fungi causing keratitis include Pythium spp., Alternaria spp., Acremonium spp., Cladosporium spp., Curvularia spp., Bipolaris spp., Microsporidia spp., Pseudallescheria spp., Colletotrichum spp., and others. The clinical presentation of these cases is variable. While a few organisms produce characteristic clinical features, rest present similar to bacterial or fungal keratitis with variable response to routine treatment. A strong degree of suspicion is therefore essential for its diagnosis. Special investigations like polymerase chain reaction, gene sequencing, mass spectroscopy and enzyme-linked immunosorbent assay are required for accurate identification of these organisms. Culture-sensitivity is extremely useful as drug resistance to routinely used anti-microbial drugs is common. Prognosis is usually poor for keratitis with Pythium spp., Pseudallescheria spp., Arthrographis spp., Purpureocillium spp., Kociria spp. and Achromobacter spp. CONCLUSION: Keratitis caused by rare and emerging micro-organisms must be suspected in cases where the infection runs an unusual course or shows a poor response to standard anti-microbial drugs. Early diagnosis and timely treatment hold the key for a good outcome.

Comparison of ranibizumab alone versus ranibizumab with targeted retinal laser for branch retinal vein occlusion with macular edema.

Purpose: To determine the effect of ultra-widefield fluorescein angiography (UWFFA)-guided targeted retinal photocoagulation (TRP) in branch retinal vein occlusion (BRVO) with macular edema after intravitreal Ranibizumab (RBZ). Methods: 33 eyes of 32 treatment naïve patients diagnosed as BRVO with macular edema were prospectively randomized to 0.5 mg Ranibizumab only (RBZ group) (n = 17) or Ranibizumab with UWFFA-guided laser (RBZ + TRP group) (n = 16). Both groups received three injections at monthly intervals and PRN henceforth. RBZ + TRP group additionally underwent UWFFA-guided TRP of peripheral capillary nonperfusion areas 1 week post injection. Outcome measures included improvement in visual acuity, central subfoveal thickness (CST), and the number of injections required with a minimum follow-up of 9 months. Results: Both groups showed significant improvement in mean BCVA (25.7 ± 8.19 letters, P < 0.001 vs. 23.38 ± 7.56 letters, P < 0.001; in RBZ and RBZ + TRP group, respectively) and reduction in mean central subfoveal thickness (379.12 ± 242.7 µm, P < 0.001 vs. 253.75 ± 137.9 µm, P < 0.001 in RBZ and RBZ + TRP group, respectively) at 9 months. The number of injections in the RBZ group (5.76 ± 1.3) was significantly greater than RBZ + TRP (4.06 ± 0.99) (P < 0.001). Both groups had significant improvement in contrast sensitivity and mean deviation on visual fields; however, the difference between the groups was not significant (P = 0.62 and P = 0.79, respectively). Conclusion: UWFFA-guided TRP reduced the number of injections of Ranibizumab in patients having BRVO with macular edema, while maintaining similar benefits in the improvement of BCVA, central subfoveal thickness without deleterious effect on the visual field, and contrast sensitivity.

Direct Smartphone Disc Video Documentation for Pediatric Glaucomas During Evaluation Under Anesthesia.

The newer version of iPhone, that is iPhone Xs max camera application is opened and a video mode is selected with a with continuous light source on. This device is now slowly advanced towards the patient's eye (pharmacologically dilated while evaluating under anesthesia) and the optic disc and peripapillary area findings can be documented with great ease. This video graphic and/or standstill images obtained from the video can be stored in the smartphones or on the cloud memory for future assessment/comparison.

Intra-lenticular lens aspiration in paediatric cases with anterior dislocation of lens.

PURPOSE: To assess the outcomes of intra-lenticular lens aspiration (ILLA) in paediatric cases with anterior dislocation of lens. METHODS: A retrospective review of medical records of cases with anterior dislocation of the lens in children (age < 16 years) that underwent ILLA between June 2017 and May 2018 was performed. Corrected distance visual acuity (CDVA), intraocular pressure (IOP), and anterior segment findings were noted at presentation and follow-up. Surgical notes were reviewed for all cases. Post-operative central corneal thickness (CCT) and central macular thickness (CMT) were recorded. RESULTS: Eleven eyes of eight patients with a median age of ten years underwent ILLA. There were four males and four females. The median duration of symptoms was 2 months, CDVA was 1.77 logMAR, and IOP was 16 mm of Hg. Ten eyes had corneo-lenticular touch with corneal oedema, and two had raised IOP at presentation. Homocystinuria (n = 2/8), Microspherophakia (n = 2/8), Marfan syndrome (n = 1/8), Buphthalmos (n = 1/8) and Ectopia lentis et pupillae (n = 1/8) were the identifiable causes for anterior dislocation. There were no intra-operative complications in any case. Immediate post-operative corneal oedema and raised IOP was observed in nine and three cases respectively and was treated with medical therapy. The median post-operative CDVA and IOP at 6-months was 1 logMAR and 15 mm of Hg respectively. The median CCT and CMT were 516 and 248 µm respectively. Five eyes developed a central corneal descemet scar. CONCLUSIONS: ILLA is a safe and effective technique for surgical removal of an anteriorly dislocated lens in paediatric cases.

Smartphone Disc Photography Versus Standard Stereoscopic Disc Photography as a Teaching Tool.

Optic disc photographic assessment was performed using an unmodified iPhone Xs Max. A video recording of the disc and peripapillary area was obtained in 5 patients. Good quality screenshots were acquired from the video, and, from them, a single best quality image was selected. This was compared with their respective standard optic disc stereo photograph. A glaucomatologist blinded to the type of image acquisition studied these images and concluded that both images could help well in the identification of glaucomatous optic disc features; however, the stereo photograph had better clarity than the iPhone static image. Nevertheless, the iPhone offered the advantage of real-time video assessment of the disc and peripapillary area and could serve as a practical and handy tool for telemedicine and teaching purposes.