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Filamentary keratitis (FK) is a clinical sign of underlying ocular and systemic conditions. FK can cause significant irritation, tearing, and photophobia in the eye. It is a refractory debilitating condition caused by dry eye that affects the day-to-day activities of patients. The etiopathogenesis of FK is not well known; there are numerous predisposing causes. The condition starts as a sub-epithelial or Bowman's membrane dysfunction and leads to the shedding of epithelial cells that take a strand-like form and attach to the cornea. These strands are surrounded by mucin and continue to elongate to become filaments. The filament formation is further aided by the shearing action caused by eyelid movements. Several management approaches, such as addressing the underlying causes of filamentary keratitis, administering copious lubricants, topical corticosteroids, mucolytic agents, bandage contact lenses, punctal plugs, and mechanical removal of filaments are available. The prognosis is fair, and most cases resolve with occasional recurrences. Traditionally FK has been treated with lubricants, mechanical removal, and bandage contact lenses. The newer treatments are topical immunomodulators especially that treat filamentary keratitis associated with aqueous deficient dry eye. The review describes the treatment as well as pathogenesis., Competing Interests: Declaration of competing interest The authors do not have any financial or conflicting interests to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: Although blink rate is considered important for digital eye strain and dry eye conditions, its assessment has been mostly manual. This study aimed at quantifying blink rate automatically using the Eyelink 1000 Plus eye tracker and comparing it with manual counting. Additionally, blink rate was correlated with reading eye movements and reading speed., Methods: Thirty participants (mean age 26.8 ± 3.5 years; 19 females) were enrolled. An on-screen reading task for 3 min duration, was repeated 3 times with a 2-min break between the repetitions. During this task, eye movements and blinks were measured through the Eyelink 1000 Plus eye tracker. The blink was also counted manually by the examiner in real time from a video feed., Results: The blink rate obtained by the eye tracker (median [Q1, Q3]:11.7 [6.8,15.5] blinks/min) and manual counting (11.6 [7.1, 15.4] blinks/min) were comparable (p > 0.5). No significant correlations were observed between the blink rate and any of the reading eye movement parameters except saccadic amplitude (Spearman's rho, r s  = 0.506). No statistically significant correlation was found between the blink rate and reading speed., Conclusion: The Eyelink 1000 Plus eye tracker gives a comparable blink rate compared to that obtained through manual counting. A positive correlation between the blink rate and saccade amplitude could indicate a coupled interaction between the two mechanisms to minimize visual loss during reading. The option of using this tracker to investigate blinks in dry eye and binocular vision disorders can be further explored., Competing Interests: Declaration of competing interest None for all authors., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Brittle cornea syndrome type 2 is associated with corneal thinning, joint hypermobility, dental and skeletal issues, osteal fragility, and deafness. We present a rare association of congenital glaucoma with brittle cornea syndrome type 2 and keratoglobus in a patient with a novel PRDM5 gene mutation. Our case underscores the importance of genetic testing for early clinical diagnosis and tailored surgical approaches., (Copyright © 2024 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: To investigate the dysmorphic facial features in congenital rubella syndrome (CRS) and describe their associations with ocular and systemic features., Methods: The medical records of children diagnosed with CRS between 2016 and 2021 were retrospectively reviewed for ocular and systemic features. CRS was diagnosed either on the basis of positive serology for rubella antibodies or with the classic triad of congenital cataract, sensorineural hearing loss, and congenital heart defect. Children with photographic documentation of the face were analyzed independently by three experienced investigators for facial dysmorphic features (triangular face, microcephaly, broad forehead, low anterior hairline, whorl on the anterior hairline, prominent nose, micrognathia). The dysmorphic feature was recorded as present only when at least two of the three examiners confirmed its existence., Results: CRS was diagnosed in 237 children: mean age at presentation, 5.45 ± 4.5 years; 126 males (53%); bilateral cataract, 176 (75%). Positive serology for rubella antibodies was noted in 153 children (65%). Photographic record of facial features was documented in 127 (54%). The most common dysmorphic facial feature was wide forehead (82 [65%]), followed by low anterior hairline with whorl (41 [32%]). However, microcornea (P = 0.9801), cataract (P = 0.8342), pupillary sphincter atrophy (P = 0.7421), and salt and pepper retinopathy (P = 0.8803) were not significantly associated with the presence of facial dysmorphism. Congenital heart disease was significantly associated with facial dysmorphism (P = 0.0308). Sensorineural hearing loss was not associated with the presence of facial dysmorphism (P = 0.8463)., Conclusions: Facial dysmorphism is common in children with CRS, but it was not predictive of the presence of ocular manifestations of CRS in this cohort., (Copyright © 2023 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Objective: To report the profile of newly diagnosed childhood glaucoma using the Childhood Glaucoma Research Network (CGRN) classification, presenting over 1 year from across centers in India., Design: Prospective observational multicentric study., Subjects: Newly diagnosed children aged < 18 years diagnosed with childhood glaucoma according to CGRN criteria presenting between January and December 2019 to 13 centers across India., Methods: All children underwent a comprehensive ocular examination, including examination under anesthesia for younger children, and were diagnosed with childhood glaucoma as per CGRN. Data were entered in a standard Excel chart. Refraction and visual acuity assessments were done when feasible., Main Outcome Measures: The profile of newly diagnosed childhood glaucoma in different parts of India and the severity of glaucoma at presentation., Results: A total of 1743 eyes of 1155 children fulfilled the definition of glaucoma and were analyzed. Primary congenital glaucoma (PCG) comprised the single largest group (34.4%), most of which were infantile onset (19%). Neonatal-onset PCG comprised 6.2% of all glaucoma. Secondary glaucoma constituted 53.4% of all glaucoma, one-half of which were acquired conditions (28%), followed by isolated ocular anomalies (14.7%), glaucoma after cataract surgery (6.7%), and glaucoma with nonacquired systemic diseases (4.5%). Of the 1743 eyes with glaucoma, all 3 parameters for severity grading were available in 842 eyes, of which 501 (59.5%) eyes presented with mild, 320 (38%) with moderate, and 21 (2.5%) with severe glaucoma. Nearly one-third of the children (28.5%) were not brought back for follow-up after the initial treatment given., Conclusions: Our study has one of the largest numbers of consecutive children with glaucoma classified according to the CGRN classification. Despite a widely diverse population, the profile of childhood glaucoma was relatively uniform across India. Childhood glaucoma is a significant problem in India, primarily treated in tertiary care hospitals. The data presented may be the tip of the iceberg because we have only reported the children who reached the hospitals offering treatment for this challenging disease., Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article., (Copyright © 2023 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To assess the real-time changes in the tear film and ocular surface of symptomatic video display terminal (VDT) versus asymptomatic users., Methods: A total of 35 symptomatic (29 ± 5.6 years; Group 1, mild dry eye disease) and 35 asymptomatic (24.1 ± 4.6 years; Group 2) VDT users with a mean OSDI of 28 ± 11 and 0.86 ± 2.1, respectively, had tear film examination (Oculus Keratograph 5 M and Tearlab Osmolarity System) at baseline and after 1 h of watching a movie on the laptop inside a controlled environment chamber along with blink rate calculation., Results: The mean VDT use was 11.4 ± 3.2 h/day in Group 1 and 2.3 ± 2.3 h/day in Group 2. In Group 1, the mean pre- and post-VDT task values for NIBUT and bulbar congestion were 10.7 ± 3.7s and 6.7 ± 3.1s (P = 0.007), and 0.8 ± 0.4 and 1.1 ± 0.5 (P = 0.01), respectively. There were no significant changes in tear meniscus height (P = 0.77), Schirmer I (P =0.14), corneal staining score (P = 1.0), and tear osmolarity (P > 0.05). Group 2 showed insignificant change in all parameters. Only 16.2% individuals in Group 1 met modified TFOS-DEWS II diagnostic criteria at baseline that increased to 67.6% following VDT task. The blink rate reduced significantly during the last 15 min (6.8 ± 3.4 vs. 9.3 ± 4.5; P = 0.006) compared to the first 15 min of the task in Group 1, whereas no significant change occurred in Group 2., Conclusion: Tear film instability and increased bulbar congestion are observed in symptomatic VDT users after computer work despite baseline stable tear film. The changes are significantly altered in symptomatic VDT users compared to asymptomatic users., Competing Interests: Declaration of competing interest None for any of the authors., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: To compare the corneal endothelial cell morphology using specular microscopy imaging between primary congenital glaucoma (PCG) and age-matched healthy controls, and to determine if the endothelial cell parameters vary among different subtypes of PCG., Design: Retrospective case-control study., Participants: One hundred forty-five eyes of 145 patients operated for PCG between 1991 and 2018 and who returned for a follow-up visit between June 2021 and May 2022. Three hundred and nineteen age-matched healthy individuals constituted the control group., Methods: Corneal endothelial cell layer analysis was performed with EM-3000 (Tomey) noncontact specular microscope. Patients were categorized according to the clinical subtypes of PCG (neonatal, infantile, and late-onset) based on the Childhood Glaucoma Research Network classification., Main Outcome Measures: Specular microscopic parameters, including endothelial cell density (ECD), average cell size, coefficient of variation (CV), and maximum and minimum cell size, were compared with that of the control group., Results: Mean ± standard deviation (SD) age of patients at endothelial imaging was 13.5 ± 6.54 years, and there was a male preponderance (n = 88, 61%). The majority of the patients had infantile-onset PCG (n = 67, 46%). Eyes with PCG demonstrated a significantly lower ECD compared with controls (2158.7 ± 636.5 vs. 2840.9 ± 232.5 cells/mm 2 ; P < 0.0001). Other endothelial cell parameters were also significantly worse in PCG compared with controls. The mean ± SD ECD was 2344.3 ± 544.3, 2131.9 ± 626.4, and 2054.2 ± 714.0 cells/mm 2 in neonatal onset, infantile, and late-onset PCG groups, respectively. Although the ECD was lowest in the late-onset PCG group, there was no significant difference in the ECD between the 3 subgroups. Except for CV, all the endothelial cell parameters were significantly worse in eyes with Haab striae than in eyes without., Conclusions: Patients with PCG have significantly lower ECD compared with healthy controls. Furthermore, other endothelial cell parameters were also significantly worse in the PCG group. These changes in the corneal endothelium in patients with PCG should be considered in long-term medical and surgical management., Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article., (Copyright © 2023 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To report the ophthalmic findings and ocular complications in a large cohort of pediatric patients with facial nerve palsy (FNP)., Methods: Ocular data of children (≤16 years of age) diagnosed with FNP presenting to an eye care network from 2012 to 2021 were analyzed. Study parameters were etiology of FNP, ocular and imaging findings, degree of lagophthalmos, and degree of vision loss. Clinical characteristics were compared between those with and without moderate-to-severe vision impairment (best-corrected visual acuity <20/50) and those with and without exposure keratopathy at presentation., Results: A total of 112 patients were included. Mean age at presentation was 8.3 ± 5.0 years. The most common etiology was idiopathic (57%) followed by congenital (22.3%) and traumatic (13.4%). There was bilateral involvement in 8% of children, multiple cranial nerve involvement in 15.2%, and exposure keratopathy at presentation in 38.4%. One-fifth (20.5%) of children (29.6% of affected eyes with known visual acuity) had moderate-to-severe visual impairment. Multiple cranial nerve involvement was present in 31% of eyes with visual impairment compared with 14% of those without. Corneal scarring and strabismic amblyopia were both frequent causes of visual impairment. Most children with exposure keratopathy had lagophthalmos (76.6%), whereas it was less common in those without keratopathy (49.2%)., Conclusions: Pediatric FNP was most commonly idiopathic, secondarily congenital. Strabismic amblyopia and corneal scarring were the most common causes of visual impairment in our cohort., (Copyright © 2023 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Ocular microsporidiosis comprises two entirely different spectra of disease as keratoconjunctivitis and stromal keratitis. Microsporidial keratoconjunctivitis (MKC) has been increasingly reported in the past two decades, probably due to raised awareness, simpler diagnostic procedures, and a better understanding of the clinical presentation. It is characterized by the presence of raised, coarse, punctate, multifocal, round to oval, greyish-white corneal epithelial lesions which usually evolve into nummular scars before resolution. Conjunctivitis seen is non-purulent and of mild-moderate intensity, with mixed papillary-follicular reaction. The mode of transmission and pathogenesis is poorly understood. Despite lack of inflammatory response, uncommon associations reported were- endotheliitis, corneal edema, limbitis, uveitis, and sub-epithelial infiltrates. There has been no consensus on the management of MKC. It varies from the use of multiple antimicrobial agents to simple lubricants. The majority of the disease goes underdiagnosed or misdiagnosed and treated as adenoviral keratoconjunctivitis, with topical steroids or anti-virals empirically. Changing trends have been noticed in the pattern of infection, possibly with increasing evidence of Vittaforma corneae as causative organisms, previously reported to cause stromal keratitis. An elaborate review of the past and present literature on MKC is provided in this review article, along with gaps in knowledge, and future directions of research., Competing Interests: Declaration of competing interest None., (Copyright © 2021 Elsevier Inc. All rights reserved.)

The transplantation of salivary glands to the eye serves as a substitute for restoring tear volume in patients with severe dry eye disease. The lacrimal gland and salivary glands share similar acinar-ductal organization with some differences in the nature of secretions. This review summarizes the comparative anatomy of salivary and lacrimal glands, various salivary gland transplantation techniques, their indications, outcomes and complications along with future perspectives. Autologous microvascular submandibular gland transplantation (SMGT) into the temporal fossa with duct placement into the conjunctival fornix improves tear volume considerably but provides a hyposmolar tear film, which can induce corneal edema (in 3.5-40% of eyes). The transplanted submandibular graft improves tear volume and stability but visual acuity and conjunctival inflammation remain unchanged. The transplanted submandibular gland maintains stable function in the long-term and can have hypersecretion in 24-60% secondary to persistent autonomic innervation. Partial SMGT, gland reduction surgery, topical atropine gel or Botulinum Toxin A injection are options for treatment of postoperative epiphora. Minor salivary gland transplantation (MSGT) into the upper and/or lower conjunctival fornix results in an average improvement of 2-4 mm in Schirmer values compared to 16 to > 30 mm observed in eyes after SMGT. Reflex epiphora is rarely a problem in MSGT. Both MSGT or SMGT can improve the ocular surface and quality of life of patients with severe, debilitating dry eye disease. However, postoperative visual acuity and outcomes of corneal transplantation are still inconsistent. More studies and additional technical improvements are needed to further improve the results of these procedures., Competing Interests: Declaration of competing interest None of the authors have any conflicts of interest., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Purpose: To demonstrate the feasibility of identifying a germline RB1 pathogenic variant in retinoblastoma (RB) from an aqueous humor (AH) sample., Methods: In this pilot case series, peripheral blood, fresh tumor tissue, and AH were obtained from 3 eyes of 3 RB patients who underwent enucleation at a tertiary eye care institute. After isolation of the cell-free DNA (cfDNA), sequence analysis of the RB1 core promoter and of exons 1 through 27, including nearby flanking intronic regions, was performed using a custom targeted hybridization protocol, followed by high-throughput sequencing., Results: The study cohort included 3 enucleated eyes with advanced RB (group E [n = 2], group D [n = 1]). In case 1, deletion of the RB1 promoter to exon 23 (delP->23) on both alleles was identified from tumor as well as AH samples and absent in the blood sample, indicative of absence of a germline RB1 pathogenic variant. In case 2, two heterozygous RB1 nonsense variants, c.610G>T p.(Glu204Ter) and c.751C>T p.(Arg251Ter), were identified in tumor and AH samples (allele frequency of 49% and 45%, resp.) and were absent in the blood sample, indicative of absence of a germline RB1 pathogenic variant. In case 3, a heterozygous c.2326-14T>A substitution on allele 1 and loss of heterozygosity on allele 2 were identified in the tumor and AH (allele frequency of 97%), with the same heterozygous mutation in the blood sample, indicating presence of a germline RB1 pathogenic variant., Conclusions: The pathogenic RB1 variant results from AH in all 3 eyes were concordant with direct tumor DNA sampling, suggesting that AH can serve as a surrogate for tumor tissue. Because the AH can be accessed during treatment, specific testing can be performed even in the absence of enucleation., (Copyright © 2022 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: To demonstrate the usefulness of ultrawide-field fundus (UWF) photography for documentation in retinopathy of prematurity (ROP)., Methods: The medical records of infants with ROP who underwent at least one sitting of UWF fundus photography in addition to binocular indirect ophthalmoscopy (BIO) from April 2018 to September 2020 were analyzed retrospectively. BIO was conducted by a trained ROP specialist, and final diagnosis and treatment were based solely on BIO findings. All fundus photographs were captured on Optos UWF camera (Dunfermline, UK) in a flying baby position. Demographic details and fundus findings on BIO and fundus photographs were analyzed., Results: Of the 187 infants who met inclusion criteria for successful imaging, 22 (11.7%) had findings that were discordant with BIO. Although no posterior disease was missed, 4 infants who received treatment would not have been treated based solely on UWF photography findings. Of the 60 babies whose images did not meet the inclusion criteria for successful imaging, 41 had ROP that required intervention., Conclusions: In our patient cohort, UWF photography proved useful in documenting the initial and follow-up findings of preterm babies with ROP., (Copyright © 2022 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Purpose: This study aimed to examine the ultrastructural features of the lacrimal glands of patients with severe dry eye due to Stevens-Johnson syndrome (SJS)., Methods: Biopsies form orbital lobes of six lacrimal glands obtained from fresh body donors (n=3) and patients with SJS (n=3; absolute tear deficiency; 2-6 months of disease duration) were examined using transmission electron microscopy (TEM)., Results: On TEM, normal lacrimal glandular tissue shows columnar acinar epithelial cells containing basally located rounded or oval euchromatic nuclei with cytoplasmic electron dense and -moderately electron-dense secretory granules. Histologically, the lacrimal gland biopsies showed varied degree of acinar atrophy with lymphocytic infiltration in SJS patients. While on TEM, the lacrimal glands in SJS patients showed homogenous appearance of the nuclear chromatin of acinar cells with no differentiation into hetero-or euchromatin and loss of nucleoli. The cytoplasm lacked any electron dense material and showed significant loss of endoplasmic reticulum, mitochondria and Golgi bodies. The myoepithelial cells shared similar characteristics as in acinar epithelial cells along with loss of spindle shaped processes., Conclusion: Transmission electron microscopy revealed ultrastructural changes in terms of nuclear composition, secretory vesicles, lysosomal vacuolation and myoepithelial cell distribution in the lacrimal glands of SJS patients., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Infectious keratitis (IK) represents the leading cause of corneal blindness worldwide, particularly in developing countries. A good outcome of IK is contingent upon timely and accurate diagnosis followed by appropriate interventions. Currently, IK is primarily diagnosed on clinical grounds supplemented by microbiological investigations such as microscopic examination with stains, and culture and sensitivity testing. Although this is the most widely accepted practice adopted in most regions, such an approach is challenged by several factors, including indistinguishable clinical features shared among different causative organisms, polymicrobial infection, long diagnostic turnaround time, and variably low culture positivity rate. In this review, we aim to provide a comprehensive overview of the current diagnostic armamentarium of IK, encompassing conventional microbiological investigations, molecular diagnostics (including polymerase chain reaction and mass spectrometry), and imaging modalities (including anterior segment optical coherence tomography and in vivo confocal microscopy). We also highlight the potential roles of emerging technologies such as next-generation sequencing, artificial intelligence-assisted platforms. and tele-medicine in shaping the future diagnostic landscape of IK., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Purpose: This study aimed to assess the efficacy and safety of Ahmed glaucoma valve (AGV) (New World Medical Inc.) implantation in eyes with pediatric keratoplasty and glaucoma., Design: Retrospective, noncomparative, interventional case series., Participants: Twenty-eight eyes of 25 children who underwent AGV after penetrating keratoplasty (PK) in 22 eyes and Descemet's stripping endothelial keratoplasty (DSEK) in 6 eyes were included., Methods: Children (age ≤ 16 years) treated with AGV implant after keratoplasty from 2008 to 2019 with documented 6 months follow-up operated by a single surgeon were included., Main Outcome Measures: The primary outcome measure was AGV survival (intraocular pressure [IOP] between 6 and 21 mmHg with or without topical anti-glaucoma medications [AGMs]), and the secondary outcome measure was corneal graft survival., Results: The mean age (± standard deviation) of patients at AGV surgery was 4.8 ± 0.7 years. The mean follow-up after AGV was 3.4 ± 0.5 years. The mean IOP decreased significantly from 31.5 ± 2.0 mmHg to 21.1 ± 2.3 mmHg at 6 months postsurgery (P < 0.001). The mean number of AGM decreased significantly (P < 0.001), and there was no change in mean visual acuity (P > 0.04 with Bonferroni correction). The cumulative survival probability of AGV was 92.9% ± 4.9% at 1 year and 81.3% ± 11.7% at 5 years. The AGV success was comparable between PK and DSEK eyes (P = 0.73). The cumulative probability of graft survival was 96.2% ± 3.8% at 1 year and 77.8% ± 9.1% at 5 years. The graft survival was also comparable between PK and DSEK eyes (P = 0.18). One eye needed tube trimming; none had tube or implant exposure. The major complication noted was corneal graft infection in 8 eyes (28.5%)., Conclusions: In this cohort, the long-term AGV success and graft survival outcomes are satisfactory considering that AGV was performed in complex eyes with keratoplasty., (Copyright © 2021 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To report the clinical outcomes of glaucoma management in patients with phacomatosis pigmentovascularis (PPV) treated over a period of 3 decades., Design: Retrospective cohort study., Participants: Fifty-five eyes of 38 patients (21 unilateral and 17 bilateral) with glaucoma in PPV managed at one institution between January 1990 and December 2019 with a minimum follow-up of 1 year., Methods: Medical records of children with glaucoma in PPV were reviewed, and demographic and clinical data were collected. Surgical interventions included primary combined trabeculotomy-trabeculectomy (CTT), trabeculectomy with mitomycin C (MMC), and transscleral cyclophotocoagulation (TSCPC). Complete success was defined as intraocular pressure (IOP) ≥ 6 and ≤ 16 mmHg without medications and qualified success as IOP ≤ 16 mmHg with the use of up to 2 medications., Main Outcome Measures: Intraocular pressure, best-corrected visual acuity (BCVA), corneal clarity, antiglaucoma medications at preoperative and postoperative visits (last visit), and complications., Results: Median age was 4 months (range, 0.2-252 months) at the time of glaucoma surgery. Thirty-nine eyes (74%) had primary CTT, 10 eyes (19%) had trabeculectomy with MMC, and 4 eyes (7%) with advanced glaucoma had TSCPC. Two eyes (3.6%) received medical treatment. Preoperative IOP reduced from a mean of 25.7 ± 8.4 mmHg on 0.8 ± 0.6 medications to 14.6 ± 5.2 mmHg on 0.4 ± 0.5 medications (P < 0.0001) at last follow-up after surgery (77.7 ± 56.5 months). Thirty-seven eyes (67.3%) required medications preoperatively, and 22 eyes (40%) required medications at the last follow-up. Of 25 patients with available BCVA at last follow-up, 9 (36%) had ≥ 20/60; of these, 6 had > 20/40. Four of 10 eyes that underwent trabeculectomy with MMC developed retinal detachment and were managed surgically; however, all of these eyes had poor visual outcomes. There was no incidence of bleb leakage, bleb-related infection, or endophthalmitis., Conclusions: Combined trabeculotomy-trabeculectomy is safe and effective as a primary procedure for management of glaucoma in PPV. Trabeculectomy augmented with MMC as a second procedure was associated with a higher rate of complications., (Copyright © 2021 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Lid margin keratinization (LMK) is a chronic ocular sequela of Stevens-Johnson syndrome (SJS), which causes lid wiper epitheliopathy and progressive ocular surface damage. The exact etiopathogenesis of LMK, however, remains elusive. This review summarizes the potential pathophysiological mechanisms of LMK and describes its histopathological features. A literature search of articles discussing the pathophysiology of LMK in SJS was performed. The possible pathophysiologic mechanisms contributing to LMK, as identified on the literature review, included loss of the muco-cutaneous junction barrier leading to epidermalization, dyskeratosis involving the meibomian gland orifices, altered lid margin microbiome, and de novo squamous metaplasia of the marginal conjunctival epithelium. Based on these mechanisms, the possible sources of keratinized epithelium at the posterior lid margin in SJS could be the adjacent anterior eyelid skin, hyperkeratinized epithelium from the meibomian gland ductal orifices, or the inflamed marginal conjunctiva. The epithelial, sub-epithelial, and stromal changes seen in keratinized posterior lid margins in SJS patients undergoing mucous membrane grafting were also investigated. The findings revealed keratinizing squamous metaplasia of the posterior lid margin accompanied by subepithelial infiltration of helper T cells predominantly on the conjunctival side. The visible meibomian gland orifices had ductal hyperkeratinization and plugging. These findings support a role for inflammation in the pathogenesis of LMK in SJS. Future research can be directed at delineating the pathways that lead to LMK by studying the changes in the lid margin microbiome, and the molecular mechanisms regulating keratinization in the conjunctiva and the meibomian gland orifices in eyes affected by SJS., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Purpose: To report a consolidated management protocol for patients with spasm of near reflex (SNR), including classification of cases as mild, moderate, and severe based on treatment outcomes., Methods: Patients with SNR treated at a single institution between August 2016 and November 2018 were included. Management of SNR included modified optical fogging, vision therapy, and pharmacological intervention (cyclopentolate eye drops and, if required, atropine eye drops). Outcome measures were visual acuity (20/25 or better) and refractive error (reduction of excessive myopia)., Results: Of 1,306 patients examined during the study period, 66 were diagnosed with SNR, yielding a prevalence of 5% among first-time patients visiting our binocular vision and orthoptics clinic. Of the 45 patients recruited for this study (mean age, 14 ± 5 years; 24 males), all three near-triad components were involved in 11 patients (24%), only the accommodation component in 32 (71%), and only the convergence component in 2 (4%). SNR was relieved in the first post-cyclopentolate refraction visit or with the modified optical fogging technique in 29 patients (66%; mild SNR) and with one-time usage of atropine eyedrops in 10 patients (22%; moderate SNR). In 6 patients (13%), atropine was continued long-term (severe SNR). Of 15 patients with long-term follow-up (1 year), 11 (73%) had persistent relief of SNR., Conclusions: In our study cohort, SNR with accommodation component was the most common and could be largely relaxed through a one-time use of cycloplegic eye drops and optical intervention. Only severe forms of SNR may require extended use of strong cycloplegics., (Copyright © 2021 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: Little is known about quality of life (QoL) and life satisfaction (LS) of treated primary congenital glaucoma (PCG) patients in adulthood. The purpose of this study was to assess the QoL and LS and their predictors among young adults treated for PCG during early childhood., Design: Cross-sectional study., Participants: Eighty-two participants with PCG (mean age, 22.5 years; standard deviation [SD], 4.6); 52% were male; 94% bilateral) recruited at L V Prasad Eye Institute., Methods: Participants were asked to complete the 26-item World Health Organization Quality of Life-BREF (WHOQOL-BREF) questionnaire (items related to satisfaction with general health, physical, psychological, social relations, and environmental aspects) and the 5-item Satisfaction with Life Scale (SWLS) in the clinic visit. Clinical data including visual acuity (VA) and visual fields (VFs) were collated from medical records. Rasch analysis was used to optimize the psychometric properties, with higher scores indicating a higher degree of QoL and LS, for both the questionnaires. Linear regression models were used to examine associations between overall QoL and LS (in separate models), and sociodemographic and clinical variables., Main Outcome Measures: The QoL and LS were measured using Rasch-transformed scores from the WHOQOL-BREF questionnaire and SWLS, respectively., Results: Response rate was 93%. The overall mean (SD) Rasch-scaled scores for QoL were 0.93 (1.11) and 0.87 (1.32) for environment domain and 0.41 (1.56) logits for LS. Better QoL was significantly related to rural residence and higher education in both univariable and multivariable analyses and explained 13% variance. Higher LS was significantly related to marital status, unilateral affliction, and higher education in univariable analyses. However, multivariable regression analysis showed that only marital status was independently associated with higher LS and explained 8.8% of variance. Clinical and treatment variables (VF, surgical interventions, medications) were not independent predictors of QoL/LS., Conclusions: Our results suggest that QoL and LS of treated patients with PCG during adult life are generally good and appear to be driven by factors other than clinical indices. Educational achievement appears to be linked to better QoL and LS, and clinicians should emphasize the importance and need for education in the continued care of these patients., (Copyright © 2020 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To report clinical features and treatment outcomes of primary combined trabeculotomy with trabeculectomy (CTT) in congenital aniridia with glaucoma in children 3 years of age or younger., Design: Retrospective study., Participants: Sixty-six eyes of 35 children with congenital aniridia and early-onset glaucoma who underwent CTT between May 1997 and June 2015 were included., Methods: Success was defined as complete when intraocular pressure (IOP) was more than 5 mmHg and less than or equal to 21 or 16 mmHg without antiglaucoma medications (AGMs), and qualified when AGMs were required. Eyes needing repeat surgery for IOP control were considered as failures., Main Outcome Measures: IOP control and number of AGMs., Results: The median age at presentation of 35 children was 26 days (interquartile range [IQR], 7-106 days). There were 22 males (62.9%) and 13 females (37.1%). Parental consanguinity was noted in 11 children (31.4%). Aniridia was total in 52 eyes and partial in 14 eyes. At presentation, there was corneal edema in 30 eyes (45.4%), enlarged corneal diameter in 32 eyes (48.5%), nystagmus in 15 children (23%), limbal stem cell deficiency in 1 eye, cataract in 9 eyes (13.6%), and foveal hypoplasia in 4 eyes. After CTT, median IOP was reduced significantly (P < 0.0001). Corneal edema cleared in 12/30 eyes and cleared with scar in 18/30 eyes. Median follow-up was 5.33 (IQR, 3.05-7.59) years. At latest follow-up, median number of AGMs was 1 (IQR, 0-2) and median visual acuity in logarithm of minimum angle of resolutions (n = 34 eyes) was 1.35 (IQR, 0.80-2.78). The probability of complete success for IOP ≤ 21 mmHg was 79.9% at 1 year and 62.3% between 2 and 10 years; for IOP ≤ 16 mmHg, it was 78.6% at 1 year and decreased to 51.9% at 10 years. Qualified success for IOP ≤ 21 mmHg at 1 year was 82.6% and 81% over 10 years; for IOP ≤ 16 mmHg, it was 81.4% at 1 year and decreased to 63.1% at 10 years. Seven eyes (10.6%) required repeat intervention for IOP control with median time of 3.17 years (IQR, 0.92-6.56) from first surgery., Conclusions: CTT showed good success in children with congenital aniridia with early-onset glaucoma., (Copyright © 2020 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To study the agreement between the Icare ic200 (ICare Finland Oy, Helsinki, Finland) and the Goldmann Applanation Tonometer (GAT) in the measurement of intraocular pressure (IOP) in adult eyes., Design: Noninterventional, cross-sectional study., Participants: A total of 156 eyes of 156 adult participants with clear corneas were included., Methods: The IOP measurements were obtained with the Icare ic200 by 1 observer followed by GAT readings by a second masked observer. The central corneal thickness (CCT) and biometry of all subjects were recorded., Main Outcome Measures: The agreement between Icare ic200 and GAT was measured using the Bland-Altman plot., Results: The mean age ± standard deviation of subjects was 55.3 ± 13.7 years. The GAT IOP ranged from 6 to 50 mmHg with a mean IOP of 19.5 ± 8.8 mmHg. The Icare ic200 IOP ranged from 7.4 to 50 mmHg with a mean IOP of 20.8 ± 9.3 mmHg. The mean difference between the IOP measurement of GAT and Icare ic200 was -1.27 mmHg with the 95% limits of agreement (LoA) ranging from -3.4 to 0.9 mmHg for all ranges of IOP. The mean difference (95% LoA) between the IOP measurement of GAT and Icare ic200 was -1 mmHg (-3 to 1 mmHg) and -1.8 mmHg (-4 to 0.2 mmHg) for a GAT IOP ≤21 mmHg and >21 mmHg, respectively. The CCT, axial length, age, and gender did not significantly affect the difference in measurement of IOP between the 2 tonometers. However, for every 1-mmHg increase in GAT IOP, the difference between the 2 tonometers increased by 0.04 mmHg (P < 0.001)., Conclusions: In our study, the Icare ic200 overestimated the IOP. The overestimation increased as the baseline IOP increased. The agreement between the IOP measurement by GAT and Icare ic200 was <2 mmHg at all ranges of IOP. The narrow LoA between the tonometers for an IOP <21 mmHg makes it a useful alternative to GAT in this pressure range., (Copyright © 2020 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Superior rectus transposition with medial rectus recession is commonly performed for unilateral esotropic Duane syndrome. For bilateral esotropic Duane syndrome, bilateral medial rectus recession is the most frequently performed surgery and usually provides satisfactory alignment in primary position; however, there is limited improvement in abduction. We report the outcomes of bilateral augmented superior rectus transposition and medial rectus recession in 4 patients with bilateral esotropic Duane syndrome. Postoperatively, abduction was improved in all patients; 3 were orthotropic in the primary position, and 1 had residual esotropia., (Copyright © 2021 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Background: The Delphi process has been widely used to delineate guidelines for the treatment of disorders for which there is little or no evidence in the published literature. The purpose of this study was to use the Delphi process to identify areas of consensus and disagreement on the definition of success after surgery for each type of strabismus., Methods: Two rounds of electronic questionnaires were sent to 28 members of the Strabismus Success Definition Delphi Study Group. For the first round, responses to 70 questions were captured as agree (= 1) and disagree (= 2). For round 2, a total of 89 questions were captured on a Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). Consensus was determined a priori at 85%., Results: In both the first and second rounds, inter-rater agreement of 85% consensus was reached for only 20% of questions. Intra-rater agreement per question was low, with κ values ranging from -0.11 to 0.62. Intra-rater agreement was also low among themes, ranging from poor to fair agreement: κ = 0.25 for motor, κ = 0.28 for sensory, and κ = 0.35 for follow-up., Conclusions: This study highlights consensus areas that could be considered by researchers in designing studies and identifies areas where lack of consensus indicates that further research is needed., (Copyright © 2021 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: To study the agreement between the Icare ic200 (ICare Finland Oy, Helsinki, Finland) and the Goldmann Applanation Tonometer (GAT) in the measurement of intraocular pressure (IOP) in adult eyes., Design: Noninterventional, cross-sectional study., Participants: A total of 156 eyes of 156 adult participants with clear corneas were included., Methods: The IOP measurements were obtained with the Icare ic200 by 1 observer followed by GAT readings by a second masked observer. The central corneal thickness (CCT) and biometry of all subjects were recorded., Main Outcome Measures: The agreement between Icare ic200 and GAT was measured using the Bland-Altman plot., Results: The mean age ± standard deviation of subjects was 55.3 ± 13.7 years. The GAT IOP ranged from 6 to 50 mmHg with a mean IOP of 19.5 ± 8.8 mmHg. The Icare ic200 IOP ranged from 7.4 to 50 mmHg with a mean IOP of 20.8 ± 9.3 mmHg. The mean difference between the IOP measurement of GAT and Icare ic200 was -1.27 mmHg with the 95% limits of agreement (LoA) ranging from -3.4 to 0.9 mmHg for all ranges of IOP. The mean difference (95% LoA) between the IOP measurement of GAT and Icare ic200 was -1 mmHg (-3 to 1 mmHg) and -1.8 mmHg (-4 to 0.2 mmHg) for a GAT IOP ≤21 mmHg and >21 mmHg, respectively. The CCT, axial length, age, and gender did not significantly affect the difference in measurement of IOP between the 2 tonometers. However, for every 1-mmHg increase in GAT IOP, the difference between the 2 tonometers increased by 0.04 mmHg (P < 0.001)., Conclusions: In our study, the Icare ic200 overestimated the IOP. The overestimation increased as the baseline IOP increased. The agreement between the IOP measurement by GAT and Icare ic200 was <2 mmHg at all ranges of IOP. The narrow LoA between the tonometers for an IOP <21 mmHg makes it a useful alternative to GAT in this pressure range., (Copyright © 2020 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Exudative retinal detachment as the initial presentation of retinopathy of prematurity is extremely rare. We present 2 such cases with extensive subretinal exudation, ischemia and exudative retinal detachment. Both were managed successfully with a combination of intravitreal anti- vascular endothelial growth factor injection and laser photocoagulation., (Copyright © 2020 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: To investigate the efficacy and safety of endocycloplasty (ECPL) versus trabeculectomy when it is combined with phacotrabeculectomy in medically controlled or uncontrolled primary angle-closure (PAC) or primary angle-closure glaucoma (PACG) after laser peripheral iridotomy (LPI)., Design: Prospective, interventional, randomized control trial., Participants: Subjects with PAC/PACG aged 30 years or more after LPI with visually significant cataract., Methods: Subjects underwent computer-generated randomized sequence of either procedure, phaco-ECPL or phacotrabeculectomy, for standard indications of combined glaucoma and cataract surgery., Main Outcome Measures: Primary outcome measure was intraocular pressure (IOP). Secondary outcome measures were best-corrected visual acuity (BCVA), number of antiglaucoma medications (AGMs), complications, and failure., Results: A total of 45 eyes of 39 subjects were included. A total of 25 eyes underwent phaco-ECPL, and 20 eyes underwent phacotrabeculectomy. Five eyes in the phaco-ECPL group were excluded; 2 were excluded because laser was not delivered per protocol, and the rest had less than 3 months of follow-up. Mean follow-up was 16.25±8.1 months in the phaco-ECPL group and 18.9±9.5 months in the phacotrabeculectomy group. Mean preoperative and postoperative IOP, AGM, and BCVA did not differ between the groups. However, the rate of complications (P = 0.011) and interventions (P = 0.047) was greater in the phacotrabeculectomy group., Conclusions: Both procedures are efficacious in lowering IOP in PACG, but the rate of complication and interventions for these were more in the phacotrabeculectomy group. Longer follow-up is indicated to probe the feasibility of phaco-ECPL, a minimally invasive procedure, as first-step management in PAC disease, for which combined cataract and glaucoma surgery is indicated., (Copyright © 2020 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Background and Objective: To describe four cases of recurrent, fleeting corneal epithelial lesion, migratory serpiginous corneal epitheliopathy (MSCE)., Method: Description of cases, histopathology and discussion of treatment outcome., Results: The study included 4 consecutive male patients; mean age was 21.25 years. Only one eye was affected. The common symptoms were irritation and tearing. Typical interpalpebral corneal lesion was a superficial greyish-white elevated corneal epithelium with stippled fluorescein staining in various geographic patterns. Corneal scrapings did not show any microorganisms and culture was negative; histopathology did not show corneal dysplasia. The lesions recurred within 1-3 weeks despite repeated scraping, application of a bandage contact lens, and a combination of topical antibiotics and lubricants. The recurrent lesion was of a different shape and eventually healed within 3-6 months without scarring., Conclusion: We describe a possibly new entity, unilateral migratory serpiginous corneal epitheliopathy (MSCE) affecting young males, with inconspicuous inflammation. Etiology is not known and usually takes several months to heal after repeated epithelial debridement., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: To describe the etiological causes and clinical profile of dry eye disease (DED) among children and adolescents seeking eye care in India., Methods: This was a cross-sectional study of 1023 new patients (≤21 years of age) diagnosed with DED presenting between 2010 and 2018 to a multi-tier ophthalmology hospital network. Children and adolescents with both symptoms and signs of dry eyes were considered as subjects. The data entry and retrieval were done using an electronic medical record system and analyzed using appropriate statistical tests., Results: The mean age of the patients was 15.2 ± 5.6 years and 76% were in their early and late adolescence. Overall, the main etiologies responsible for DED in children and adolescents were Meibomian gland dysfunction (MGD) in 49% of cases, Stevens-Johnson Syndrome (SJS) in 33% and Vitamin A deficiency (VAD) in 9%. Aqueous deficiency dry eye (ADDE) because of SJS and VAD accounted for most of the cases in infancy (92%), toddlerhood (96%), early childhood (76%) and middle childhood (68%). While Meibomian gland dysfunction (MGD) related evaporative dry eye (EDE) was the leading cause of DED in early (51%) and late adolescence (66%). Severe visual impairment and blindness was significantly greater in eyes with ADDE as compared to those with EDE (p < 0.0001), 81% of which were affected by SJS., Conclusion: The causes of and visual morbidity due to DED varied significantly in different age-groups. Most of the visual morbidity in children and adolescents was limited to eyes with ADDE due to SJS., (Copyright © 2020 Elsevier Inc. All rights reserved.)

The purpose of this review was to identify areas of consensus and disagreement among experts for the definition of success following strabismus surgery using the Delphi process. Three rounds of electronic questionnaires were sent to a panel of 28 strabismus experts. Throughout the process, members of the panel were masked to one another's identities to minimize the possibility of influence among members. Prior to data collection, we defined consensus as an 85% agreement on the answer to each question. Questions for which there was no consensus were reworded, and the resultant new questions were used in each subsequent round of questioning. We arrived at consensus for 23 of the 36 questions (64%). Consensus was obtained for recommending unique criteria for the definition of success for certain specific strabismus conditions. In addition, it was considered important that stereopsis and the range of single binocular vision be included in the definition of success for certain types of strabismus., (Copyright © 2019 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: Corneal injuries are associated with significant impairment in vision. Mesenchymal stem cells (MSCs) have been shown to limit inflammation and promote tissue repair at the ocular surface. Here, we evaluate the efficacies of different modes of MSC delivery (topical, subconjunctival, intraperitoneal [IP] and intravenous [IV]) to promote tissue repair and restore corneal transparency in a murine model of corneal injury., Methods: MSCs were purified from the bone marrow of C57BL/6  mice and expanded using plastic adherence in vitro. Corneal injury was created using an Algerbrush, and 0.5 × 10 6 MSCs/mouse were administered via topical, subconjunctival, IP or IV routes. Qdot-labeled MSCs were employed to determine the effect of route of administration on corneal and conjunctival MSC frequencies. Corneal opacity scores were calculated using ImageJ. Expression of inflammatory cytokines was quantified by qPCR, and infiltration of CD45 + cells was evaluated by flow cytometry., Results: Subconjunctival or IV administration results in increased frequencies of MSCs in ocular surface tissues following corneal injury, relative to topical or intraperitoneal delivery. Subconjunctival or IV administration reduces: (i) corneal opacity, (ii) tissue fibrosis as quantified by α-Sma expression, (iii) the expression of inflammatory cytokines (Il-1β and Tnf-α) and (iv) CD45 + inflammatory cell infiltration relative to untreated injured control animals. Administration via subconjunctival or IV routes was observed to accelerate corneal repair by restoring tissue architecture and epithelial integrity., Conclusions: Our data suggest that subconjunctival or IV delivery of MSCs has superior therapeutic efficacy compared to topical or IP delivery following corneal injury., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: To describe the demographics, clinical presentation and risk-factors of allergic eye disease (AED) in children and adolescents presenting to a multi-tier ophthalmology hospital network in India., Methods: This was a hospital-based cross-sectional study of 259,969 new patients (≤21 years of age) presenting between 2010 and 2018. Patients with a clinical diagnosis of AED were considered as cases. Data were collected using an electronic medical record system. Multiple logistic regression with odds ratios (OR) was performed to identify the high risk-factors of AED., Results: Overall, 26,309 (10.1%) children and adolescents were diagnosed with AED. The prevalence of AED was 0.3%, 6.6%, 18.3%, 15.8%, 8.1%, and 4.9% in infancy (<1 years), toddlerhood (1-2 years), early childhood (3-5 years), middle childhood (6-11 years), early adolescence (12-18 years) and late adolescence (18-21 years), respectively. Most patients with AED presented in spring and summer. Palpebral vernal keratoconjunctivitis was the commonest clinical form, seen in 42.8% of eyes. Corneal scarring, keratoconus, limbal stem cell deficiency and shield ulcers were seen in 2.4%, 1.4%, 0.4% and 0.3% of eyes, respectively. Male sex (OR 2.05); early and middle childhood age groups (OR 66.6; 59.1); higher socio-economic class (OR 1.46) and history of systemic allergy (OR 3.74) were identified as high-risk factors of AED., Conclusion: About a tenth of the children and adolescents seeking eye care in India are affected by AED, which commonly affects boys with atopy, from middle to higher income families during their early to middle childhood and shows a self-limiting trend by late adolescence., (Copyright © 2019. Published by Elsevier Inc.)

Adult strabismus is often characterized by surgical complexity. In recent years, several innovative techniques for the management of complex strabismus have been developed. Strabismus surgeons should understand the indications for various strabismus surgical techniques in the management of these difficult cases. This workshop describes several new surgical techniques to manage complex strabismus, including small-angle incomitant and very large-angle strabismus, torsional diplopia, and restrictive, paralytic, and secondary strabismus. Because strabismus surgery is an ever-evolving field, it is important to continue to refine our surgical armamentarium. Strabismus surgeons may wish to add these techniques to their surgical repertoire for select cases., (Copyright © 2019 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: To describe the incidence, demographics, types and risk-factors of dry eye disease (DED) in patients presenting to a multi-tier ophthalmology hospital network in India., Methods: This was an observational hospital-based study of 1,458,830 new patients presenting between 2010 and 2018. Patients with recent onset of both symptoms and signs, as defined by the tear film and ocular surface society dry eye work shop (TFOS DEWS) II guidelines, were considered as DED subjects. The data was prospectively collected using an electronic medical record system. Multiple logistic regression with odds ratio (OR) estimation was performed to identify the high risk-factors of DED., Results: Overall, 21,290 (1.46%) patients were diagnosed with recent-onset DED. The incidence of DED was 2688 and 16,482 per million population in children and adults, respectively (p < 0.0001). While incidence was significantly greater in males in 3rd, 4th, 9th and 10th decade (p < 0.03), it was greater in females in 5th and 6th decade (p < 0.0001) of life. Classified etiologically 35.5%, 20.6% and 39.9% of patients had evaporative, aqueous deficient and mixed type of DED, respectively. Age (OR 3.7-13.5), urban residence (OR 1.6), professional work (OR 1.5); homemaking (OR 1.42), retirement/unemployment (OR 1.24) and socio-economic affluence (OR 1.6-3.2) were identified as high risk-factors for developing DED., Conclusion: The study results indicate that age, sex, residence, occupation, and socio-economic status have significant impact on development of DED. Since India is an emerging economy with a growing middle-class, increasing urban-migration and large aging population, the country is on the brink of a DED epidemic., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Aqueous drainage devices play an important role in the treatment of refractory glaucomas; however, they can be associated with early and late postoperative complications, including conjunctival dehiscence, which must be repaired surgically. Recurrent dehiscence despite surgical repair is uncommon and can be sight threatening. We discuss possible causes and management options of recurrent conjunctival dehiscence in a 2-year-old and the role of oral doxycycline and azithromycin in its management., (Copyright © 2018 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: To compare outcomes of a nonvalved glaucoma drainage device (the Aurolab aqueous drainage device [AADI] with a valved glaucoma drainage device (the Ahmed glaucoma valve [AGV]) in refractory pediatric glaucoma., Design: Retrospective interventional case series., Participants: One hundred sixteen eyes of 97 children with refractory pediatric glaucoma., Methods: Children (≤16 years) treated with drainage implants from January 2007 through December 2016 with a minimum follow-up of 6 months (operated by a single surgeon) were included. Success was defined as intraocular pressure (IOP) ≥6 mmHg or ≤21 mmHg (complete without antiglaucoma medications [AGMs] and qualified with AGM); repeat glaucoma surgery or loss of light perception was failure., Main Outcome Measures: Comparison of success rates and complications with AADI (350 mm 2 ) and silicone AGV (models FP7 [182-mm 2 surface area] and FP8 [102-mm 2 surface area]) implantation., Results: Outcomes of 116 eyes of 97 children (AADI, 36 eyes; AGV, 85 eyes; FP7, n = 14; FP8, n = 72) were analyzed. Median follow-up for AADI was 16.8 months (interquartile range [IQR], 11.7-24.5 months) and for AGV was 27 months (IQR, 15.3-52.3 months). Preoperative parameters (age, IOP, number of AGMs) were similar in both groups except number of previous nonglaucoma surgeries, which were significantly more in AADI (P = 0.05). Qualified success was similar (P = 0.81) in both groups, 91% and 88% at 1 year and 81% and 84% at 3 years with AADI and AGV, respectively. With AADI, the complete success was significantly more (41.8% vs.13.7%; P < 0.005). The postoperative mean IOP (12.6±5.5 mmHg vs. 17.6±6.8 mmHg; P = 0.001), median number of AGMs (1 [IQR, 0-2] vs. 2 [IQR, 1-3]; P < 0.001), and hypertensive phase (16.5% [n = 7] vs. 40% [n = 34]; P = 0.02) were significantly less in AADI compared with AGV. Transient complications (AADI, 30.5% [n = 11/36] vs. AGV, 21.1% [n = 18/85]; P = 0.26), sight-threatening complications (AADI, 13.9% [n = 5/36) vs. AGV, 7% [n = 6/85]; P = 0.22), and complications needing intervention (AADI, 19.4% [n = 7/36] vs. AGV, 14.1% [n = 12/85]; P = 0.46) were similar in both groups., Conclusions: In refractory pediatric glaucoma, both AGV and AADI showed similar qualified success and complication rates at 1 and 3 years. However, the AADI showed greater complete success, better IOP control, less need for AGM, and lesser incidence of an hypertensive phase., (Copyright © 2018 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To study the clinical and microbiological profile of microbial keratitis in Stevens-Johnson syndrome (SJS)., Study Design: Case series., Participants: Patients with SJS who developed microbial keratitis., Methods: Medical records and microbiological data of patients with SJS who developed microbial keratitis from January 1991 to December 2012 were reviewed. We analysed the type of causative organisms and their antibiotic susceptibility along with the clinical pattern and responses to medications in this group of patients., Main Outcome Measure: Clinical and microbiological profile of microbial keratitis., Results: We reviewed 65 eyes of 60 patients seen between January 1991 and December 2012. Positive microbiological culture results were obtained in 45 eyes (69.2%). Isolated bacterial infections were noted in 27 eyes (60%) while isolated fungal growth was seen in 1/45 eyes (2.2%). Polymicrobial infections were noted in 17/45 eyes (37.8%). The most common bacteria isolated were Staphylococcus species (35%). The median duration of SJS before presentation was 5 months (IQR, 2 months to 7 years) with 50% presenting within four months of the onset of SJS. Twenty-eight eyes (43%) needed treatment in addition to antibiotics for resolution of tarsorraphy, epilation, tissue adhesive application, and amniotic membrane grafting or punctal cautery. The average time for resolution was 25 days., Conclusion: Microbial keratitis in SJS patients is different from patients without SJS in presentation and the response to medications. It requires a multi-disciplinary approach for healing., (Copyright © 2018. Published by Elsevier Inc.)

Dry eye disease (DED) is a complex condition with a multifactorial etiology that can be difficult to manage successfully. While external factors are modifiable, treatment success is limited if genetic factors contribute to the disease. The purpose of this review is to compile research describing normal and abnormal ocular surface function on a molecular level, appraise genetic studies involving DED or DED-associated diseases, and introduce the basic methods used for conducting genetic epidemiology studies., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose: To estimate the prevalence and causes of visual impairment and other ocular comorbidities among tribal children in an urban school population in eastern India., Method: In this cross-sectional study, vision screening tests were administered to tribal school children. Demographic data, including name, age, sex, home district, height, and weight of each child, and examination data, including unaided and pinhole visual acuity, external eye examination with a flashlight, slit-lamp examination, intraocular pressure (IOP) measurement, and undilated fundus photography, were collected. Children with visual acuity of less than 20/20, abnormal anterior or posterior segment findings, and IOP of >21 mm Hg were referred for further evaluation., Results: Of 10,038 children (5,840 males [58.2%]) screened, 335 (median age, 9 years; range, 6-17 years) were referred. Refractive error was the most common cause of visual impairment (59.52%; 95% CI, 51.97-66.65) followed by amblyopia (17.2%; 95% CI, 12.3-23.6) and posterior segment anomaly (14.88%; 95% CI, 10.2-21.0). The prevalence of best-corrected visual acuity of 20/40 was 0.13%. The prevalence of blindness was 0.03%., Conclusions: Visual impairment among tribal children in this residential school is an uncommon but important disability., (Copyright © 2018 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Dry eye can be caused by a variety of iatrogenic interventions. The increasing number of patients looking for eye care or cosmetic procedures involving the eyes, together with a better understanding of the pathophysiological mechanisms of dry eye disease (DED), have led to the need for a specific report about iatrogenic dry eye within the TFOS DEWS II. Topical medications can cause DED due to their allergic, toxic and immuno-inflammatory effects on the ocular surface. Preservatives, such as benzalkonium chloride, may further aggravate DED. A variety of systemic drugs can also induce DED secondary to multiple mechanisms. Moreover, the use of contact lens induces or is associated with DED. However, one of the most emblematic situations is DED caused by surgical procedures such as corneal refractive surgery as in laser-assisted in situ keratomileusis (LASIK) and keratoplasty due to mechanisms intrinsic to the procedure (i.e. corneal nerve cutting) or even by the use of postoperative topical drugs. Cataract surgery, lid surgeries, botulinum toxin application and cosmetic procedures are also considered risk factors to iatrogenic DED, which can cause patient dissatisfaction, visual disturbance and poor surgical outcomes. This report also presents future directions to address iatrogenic DED, including the need for more in-depth epidemiological studies about the risk factors, development of less toxic medications and preservatives, as well as new techniques for less invasive eye surgeries. Novel research into detection of early dry eye prior to surgeries, efforts to establish appropriate therapeutics and a greater attempt to regulate and oversee medications, preservatives and procedures should be considered., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: To evaluate the surgical outcome of augmented superior rectus transposition (SRT) and medial rectus recession (MRc) in patients with abducens nerve palsy., Methods: The medical records of consecutive patients with abducens nerve palsy who underwent unilateral or bilateral simultaneous SRT with MRc from January 2012 to December 2014 were analyzed. Patients with previous strabismus surgery or botulinum toxin injection were excluded. Primary outcome measures were esotropia in primary position and abduction deficit. Data collected included age, sex, etiology, pre- and postoperative deviation, pre- and postoperative abduction deficit, anomalous head posture, induced vertical or torsional deviations postoperatively, reoperations, and details of other complications. Success was defined as postoperative alignment within 10 Δ of orthotropia; failure, as residual esotropia of ≥20 Δ ., Results: A total of 15 eyes of 13 patients were included. The most common cause of abducens nerve palsy was trauma (10 patients). The mean preoperative esotropia was 55.4 Δ ± 24 Δ , which improved postoperatively to 9.9 Δ ±10 Δ (P = 0.0000). The mean preoperative abduction deficit was -5 units, decreasing postoperatively to -3.1 (P = 0.000). Nine patients (69%) achieved success; 2 were classified as failures. One patient each developed postoperative hypotropia and intorsion; however, these were transient and did not require additional procedures. No patients developed anterior segment ischemia., Conclusions: Augmented SRT with MRc is effective in the management of abducens nerve palsy; however, its success in large deviations remains variable. Long-term follow-up is essential to determine the incidence of vertical and torsional deviations., (Copyright © 2016 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Limbal stem cell deficiency (LSCD) is now established as a distinct entity with a spectrum of clinical manifestations. Bilateral LSCD presents a unique set of challenges to the clinician dealing with ocular surface disease, due to the underlying causes, clinical presentation, and adnexal status, as well as lack of a source of autologous limbal stem cells. Various surgical modalities have been described to achieve visual rehabilitation in patients with bilateral LSCD. These can primarily be divided into cell-based therapies and implantation of keratoprostheses. In this review, the surgical options for management of bilateral LSCD, including autologous and allogeneic cell-based therapies and different types of keratoprostheses are described and classified. The indications, prerequisites, technique, results and complications of each modality are discussed. Based on the status of the ocular surface, an algorithm for choosing appropriate surgical management for vision restoration in bilateral LSCD has been proposed., (Copyright © 2016 Elsevier Inc. All rights reserved.)

A 37-year-old woman presented with progressive large-angle esotropia (>140(Δ)) since childhood. Her best-corrected visual acuity was 20/80 in right eye and unrecordable in the left eye because of severe esotropia and limitation of abduction. Computed tomography of the orbits showed presence of nasal displacement of the superior rectus muscle and inferior displacement of the lateral rectus muscle in the left eye, which was confirmed intraoperatively. Intraoperatively, axial length was 23 mm in the right eye and 24.6 mm in the left eye. Diagnosed with convergent strabismus fixus without high myopia, she underwent medial rectus recession of 8.0 mm and superior rectus-lateral rectus loop myopexy. Postoperatively, she had an exotropia of about 8(Δ). This case highlights the possibility of progressive esotropia similar to "heavy eye syndrome" in the absence of high myopia., (Copyright © 2016 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Salzmann's nodular degeneration (SND) is a rare, noninflammatory, slowly progressive degenerative disease of the cornea that is characterized by the appearance of nodular bluish gray opacities that vary in number and size. It is usually bilateral; most commonly occurring in people aged 50-60 years old, with a female preponderance; and often associated with a history of prior corneal inflammation. The clinical features usually depend on the location of the nodules. Generally, the nodules of SND are bluish white to gray in color, 1-2 mm in size, and round, conical or prismatic in shape. The overlying Bowman's layer is usually absent from the nodular areas and is partially replaced by granular Periodic Acid Schiff-positive eosinophilic material resembling the basement membrane. Diagnostic investigations include ultrasonic pachymetry, anterior segment optical coherence tomography, ultrasound biomicroscopy, and confocal microscopy. The majority of patients respond well to conservative management with topical lubricants; severe cases may require surgical intervention. The various surgical modalities described include superficial keratectomy, which may be combined with phototherapeutic keratectomy and keratoplasty. Various modifications of these procedures include the use of alcohol-assisted epithelial delamination, intraoperative mitomycin-C or amniotic membrane transplantation to make the procedure easy, reduce the risk of recurrence and improve postoperative comfort. Recurrences are rarely reported; overall, the visual prognosis following treatment is optimal., (Copyright © 2016 Elsevier Inc. All rights reserved.)