Case Report: Simultaneous penetrating keratoplasty with autologous simple limbal epithelial transplantation as an alternative to keratoprosthesis [version 3; peer review: 2 approved]

Introduction and importance: This case report highlights the multidisciplinary approach required to achieve successful anatomical and functional outcomes, in an eye with total limbal stem cell deficiency (LSCD) associated with underlying corneal scarring and thinning. Presentation of case: A 59-year-old gentleman had poor visual recovery in the right eye (RE) following accidental carbide blast, 1-year before presenting to us. The visual acuity was counting fingers and clinical examination revealed cicatricial entropion involving the upper eyelid, total LSCD, corneal scarring with a central descemetocele and cataract in the RE. Prior to ocular surface reconstruction, entropion correction was performed. Three months later, penetrating keratoplasty combined with cataract surgery and intraocular lens implantation (penetrating keratoplasty (PK) triple), with autologous simple limbal epithelial transplantation (SLET) was performed. The visual acuity was 20/100, 18 months after the surgery, with a clear well-epithelized corneal graft and stable ocular surface. Discussion: LSCD is caused by a decrease in the population and /or function of the limbal epithelial stem cells. Limbal stem cell transplantation (LSCT) is warranted in eyes with total LSCD. In eyes with coexisting corneal scarring, LSCT alone may be inadequate to restore the vision. These eyes require simultaneous or sequential lamellar or full-thickness corneal transplantation for visual rehabilitation. Though, the existing literature favors a sequential approach, where LSCT is performed first followed by corneal transplantation, under certain circumstances such as a thin underlying cornea like in our case, corneal transplantation may have to be combined with LSCT to achieve optimal outcomes. Conclusion: Combining autologous SLET with PK can be performed for visual rehabilitation in eyes with unilateral total LSCD and underlying corneal thinning. Corneal and limbal graft survival is prolonged if existing adnexal comorbidities are addressed before any surgical intervention is planned and adequate time interval is allowed for the surface inflammation to subside

Drug induced cicatrizing conjunctivitis: A case series with review of etiopathogenesis, diagnosis and management

Drug induced cicatrizing conjunctivitis (DICC) is defined as a disease in which conjunctival cicatrization develops as a response to the chronic use of inciting topical and, rarely, systemic medications. DICC accounts for up to one third of cases of pseudopemphigoid, a large group of cicatrizing conjunctival diseases sharing similar clinical features to those of mucous membrane pemphigoid (MMP) but generally without the morbidity of progressive scarring or the need for systemic immunosuppression. The preservatives in topical anti-glaucoma medications (AGM) are the most frequently implicated inciting causes of DICC although topical antivirals, vasoconstrictors and mydriatics and some systemic drugs have been implicated. The literature review summarizes the classification, epidemiology, etiopathogenesis, histopathology, clinical presentation, diagnosis, management, and treatment outcomes of DICC in the context of a case series of 23 patients (42 eyes) with AGM induced DICC, from India and the UK. In this series all subjects reacted to preserved AGM with one exception, who also reacted to non-preserved AGM. At diagnosis >70% of eyes showed punctal scarring, inflammation, and forniceal shortening. Pemphigoid studies were negative in the 19/23 patients in whom they were carried out. DICC can be classified as non-progressive, progressive with positive pemphigoid immunopathology or progressive with negative pemphigoid immunopathology. It is unclear whether progressive DICC is a stand-alone disease, or concurrent (or drug induced) ocular MMP. Progressive cases should currently be treated as ocular MMP. The diagnosis can be made clinically when there is rapid resolution of symptoms and inflammation, usually within 1–16 weeks, after withdrawal of suspected inciting medications, ideally by temporary substitution of oral carbonic anhydrase inhibitors. If the response to withdrawal is uncertain, or the progression of inflammation and scarring continues then patients must be evaluated to exclude concurrent (or drug induced) MMP, and other potential causes of CC, for which the treatment and prognosis is different. Management, in addition to withdrawing inciting medications, may require short-term treatment of conjunctival inflammation with steroids, treatment of associated corneal disease with contact lenses or surface reconstructive surgery, control of intra-ocular pressure with non-preserved AGM and, in some, surgery for glaucoma or for trichiasis and entropion

Society of Dermatology Hospitalists supportive care guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis in adults

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening conditions with high morbidity and mortality. Supportive care management of SJS/TEN is highly variable. A systematic review of the literature was performed by dermatologists, ophthalmologists, intensivists, and gynecologists with expertise in SJS/TEN to generate statements for supportive care guideline development. Members of the Society of Dermatology Hospitalists with expertise in SJS/TEN were invited to participate in a modified, online Delphi-consensus. Participants were administered 9-point Likert scale questionnaires regarding 135 statements. The RAND/UCLA Appropriateness Method was used to evaluate and select proposed statements for guideline inclusion; statements with median ratings of 6.5 to 9 and a disagreement index of ≤1 were included in the guideline. For the final round, the guidelines were appraised by all of the participants. Included are an evidence-based discussion and recommendations for hospital setting and care team, wound care, ocular care, oral care, urogenital care, pain management, infection surveillance, fluid and electrolyte management, nutrition and stress ulcer prophylaxis, airway management, and anticoagulation in adult patients with SJS/TEN

An Evidence-Based Strategic Approach to Prevention and Treatment of Dry Eye Disease, a Modern Global Epidemic

Dry eye disease (DED) is an emerging health concern causing significant visual, psychological, social, and economic impact globally. In contrast to visual rehabilitation undertaken at late stages of DED, measures instituted to prevent its onset, establishment, or progression can alter its natural course and effectively bring down the associated morbidity. This review attempts to present the available literature on preventive strategies of DED at one place, including strategies for risk assessment and mitigation, targeting a wide range of population. A literature search was conducted using PubMed and an extensive literature review on preventive strategies for DED was compiled to put forth a holistic and strategic approach for preventing DED. This can be undertaken at various stages or severity of DED directed at different tiers of the health care system. Conclusion: This review intends to put emphasis on preventive strategies being adopted as an integral part of routine clinical practice by general ophthalmologists and specialists to tackle the burden of DED and improve the quality of the lives of the patients suffering from it

The grave necessity to make eye bank specular microscopy mandatory in all eye banks in the subcontinent to improve utilization of scarce donor corneas

Context: Donor tissue scarcity, Eye Bank Specular Microscopy as yet not made mandatory and tissue utilization often based on clinical judgment only. Aims: Prospectively analyze alteration in clinical grading of donor corneas and hence utilization, based on Eye Bank Specular Microscopy (EBSM) and to infer if EBSM should be mandatory in all eye banks. Materials and Methods: 200 consecutive otherwise ′suitable for surgery′ donor eyes were graded clinically. On quantitative and qualitative analysis of endothelial cells by EBSM, final grading was adjusted. Impact on subsequent utilization for various surgeries was analyzed with regard to Age of Donor, Death to Enucleation Time, Death to Preservation Time and Lens Status of Donor Eye. Results: 76 eyes (38%) (P 60 years showed CD >= 2500. From donor >=81 years, 2/13 (15.3%) eyes showed CD between 2501-3000 and 1 (7.6%) eye showed CD > 3000. Owing to better grading after EBSM, 13/14 (92.85%) tissues with DTET >6 hours and 5/5 (100%) tissues with DTPT > 16 hours were transplanted. Out of 45 (22.5%) pseudo-phakic tissues, 21 (46.67%) tissues were used for Therapeutic/Tectonic Penetrating Keratoplasty (PKP) while 24 (53.33%) tissues were used for Optical PKP. Conclusions: EBSM significantly alters final grading of tissues and its subsequent utilization. Acquiring huge importance in areas where adequate supply of corneas is lacking, EBSM becomes an indispensable tool for optimizing availability of qualified tissues for surgery. EBSM should be made a mandatory analysis

Orbital Chondroma: A rare mesenchymal tumor of orbit

While relatively common in the skeletal system, cartilaginous tumors are rarely seen originating from the orbit. Here, we report a rare case of an orbital chondroma. A 27-year-old male patient presented with a painless hard mass in the superonasal quadrant (SNQ) of left orbit since 3 months. On examination, best-corrected visual acuity of both eyes was 20/20, with normal anterior and posterior segment with full movements of eyeballs and normal intraocular pressure. Computerized tomography scan revealed well defined soft tissue density lesion in SNQ of left orbit. Patient was operated for anteromedial orbitotomy under general anesthesia. Mass was excised intact and sent for histopathological examination (HPE). HPE report showed lobular aggregates of benign cartilaginous cells with mild atypia suggesting of benign cartilaginous tumor - chondroma. Very few cases of orbital chondroma have been reported in literature so far

High-Resolution Optical Coherence Tomography Angiography Characteristics of Limbal Stem Cell Deficiency

This study aimed to identify the anterior segment high-resolution optical coherence tomography (HR-OCT) and HR-OCT angiography (HR-OCTA) features suggestive of limbal stem cell deficiency (LSCD) as confirmed by both impression cytology (IC) and in vivo confocal microscopy (IVCM). This was a single-centre prospective cross-sectional study including 24 eyes of 22 patients with clinical suspicion of LSCD based on peripheral superficial corneal vascularisation and scarring. On IC and IVCM, performed and interpreted by blinded observers, 12 eyes each were diagnosed with and without LSCD. Additionally, 10 eyes of 5 healthy volunteers with no ocular pathology were also imaged. The 136 HR-OCT/A images of these 34 eyes were analysed with respect to 12 imaging parameters; the parameters most suggestive of LSCD were identified and the sensitivity and specificity were calculated. In the LSCD group, the most common aetiology was ocular chemical burns (83%), whereas in the non-LSCD group, the most common aetiology was viral keratitis (67%). Multiple logistic regression analysis revealed that mean epithelial reflectivity, mean stromal reflectivity, and mean superficial vascular density were the parameters that were diagnostic of LSCD on HR-OCT/A (p < 0.0001). A ratio of the mean epithelial reflectivity to stromal reflectivity of >1.29 corresponded with a high sensitivity (91.7%) and specificity (98.75%); while a mean superficial vascular density score of >0.38 corresponded with a sensitivity of 97.9% and specificity of 73.8%. In conclusion, HR-OCT/A as a non-invasive imaging modality could prove to be a useful tool for confirming the diagnosis of LSCD, with potential clinical and research applications

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

Current state of artificial intelligence applications in ophthalmology and their potential to influence clinical practice

Artificial intelligence (AI) has emerged as a major frontier in healthcare and finds broad range of applications. It has the potential to revolutionize current procedures of disease diagnosis and treatment, thus influencing the clinical practice. Artificial intelligence (AI) in ophthalmology, primarily concentrates on diagnostic and treatment pathways for eye conditions such as cataract, glaucoma, age-related macular degeneration (MDA) and diabetic retinopathy (DR). The purpose of this article is to systematically review the existing state of literature on the various AI techniques and its applications in the diagnosis and treatment of eye diseases and conduct an in-depth enquiry to identify the challenges in accurate detection, pre-processing of data, monitoring and assessment through various AI algorithms. The results suggest that all AI models proposed reduce the detection time considerably. The potential limitations and challenges in the development and application play a significant role in clinical practice. There is a need for the development of AI-assisted technologies that shall consider the clinical implications based on experience and guided by patient-centred healthcare principles. The diagnostic models should assist ophthalmologists on making quick and accurate decisions in determining the progression of various ocular diseases