Search

Corneal injuries often lead to epithelial damage, apoptosis, and inflammation which impact visual function. Effective epithelial healing is critical for optimal vision and functioning of the cornea. Mesenchymal stem/stromal cells (MSCs)-derived extracellular vesicles (EVs) present promising avenues for cell-free therapy, however, evaluation of their specific roles in corneal epithelial injury requires further investigations with due consideration to the endogenous human corneal epithelial cell-derived EVs (HCEC-EVs). This study aims to isolate and characterize the EVs from a commonly available human corneal epithelial cell line (HCE-2 [50. B1], ATCC) and evaluate their corneal epithelial repair, anti-apoptotic, and immunomodulatory potential in comparison with human bone marrow mesenchymal stem cell-derived EVs (BM-MSC-EVs) in vitro. Both the BM-MSC- and HCEC-EVs exhibited similar morphology with a diameter <150 nm. However, the yield of EVs from HCECs was higher than that of BM-MSCs. Nanoparticle tracking analysis revealed an average EV size of ∼120 nm, while western blotting confirmed the presence of CD63, CD81, and TSG101, whereas Calnexin could not be detected in the BM-MSC- and HCEC-EVs. The corneal epithelial repair was monitored through in vitro wound healing assay, whereas apoptosis was studied through flow cytometry-based Propidium iodide staining in H 2 O 2 -treated cells. IL-1β-stimulated HCECs were treated with BM-MSC- and HCEC-EVs for 24 h and expression of pro- (IL-6 and TNF-α) and anti-inflammatory (IL-10 and TGF-β) cytokines was evaluated through ELISA. Our results, limited to in vitro investigations, suggest that compared with HCEC-EVs, BM-MSC-EVs showed: i) accelerated corneal epithelial healing, ii) enhanced anti-apoptotic potential, and iii) improved anti-inflammatory properties, in cultured HCECs., (Copyright © 2024 Elsevier Ltd. 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.)

Background/objectives: To assess the relationship between macular vessel density metrics and foveal avascular zone (FAZ) characteristics on optical coherence tomography angiography (OCTA) and lesion distribution in eyes with diabetic retinopathy (DR)., Subjects/methods: Patients with DR who underwent both Optos ultrawidefield (UWF) pseudocolor imaging and macular OCTA (Cirrus Angioplex, 6 × 6 mm) were included in this cross-sectional observational study. The distribution of DR lesions was assessed by comparing each of the peripheral ETDRS extended fields (3-7) against their corresponding ETDRS field, hence eyes were defined as either having predominantly peripheral lesions (PPL) or predominantly central lesions (PCL). En face OCTA images from the superficial and deep capillary plexuses (SCP and DCP) were then analysed using Image J software. Perfusion density (PD), vessel length density (VLD), and fractal dimensions (FD) were calculated following binarization and skeletonization of the images., Results: Out of 344 eyes, 116 (33.72%) eyes had PPL and 228 (66.28%) eyes had PCL. For all DRSS levels, VLD, PD, and FD were not significantly different between eyes with PPL and PCL. The FAZ in eyes with PPL, however, was found to be more circular in shape compared to eyes with PCL (p = 0.037)., Conclusion: Although the presence of PPL has been associated with a higher risk for diabetic retinopathy progression, the macular perfusion is similar in eyes with PPL and PCL. The FAZ is more circular in eyes with PPL, but the clinical relevance of this difference remains to be defined., (© 2024. The Author(s).)

Intraocular fungal infection poses a significant clinical challenge characterized by chronic inflammation along with vision impairment. Understanding the host defense pathways involved in fungal endophthalmitis will play a pivotal role in identifying adjuvant immunotherapy. Clinical isolates of Candida albicans (15,000 CFU/μL) were intravitreally injected in C57BL/6 mice followed by enucleation at 24 and 72 h postinfection. Histopathological analysis was performed to evaluate the retinal changes and the disease severity. RNA-seq analysis was conducted on homogenized eyeballs to assess the relevant gene profiles and their differentially expressed genes (DEGs). Pathway enrichment analysis was performed to further annotate the functions of the DEGs. Histopathological analysis demonstrated a higher disease severity with increased inflammatory cells at 72 hpi and transcriptome analysis revealed 27,717 DEGs, of which 1493 were significant (adj p value ≤0.05, FC ≥ 1.5). Among these, 924 were upregulated, and 569 were downregulated. Majority of the upregulated genes were associated with the inflammatory/host immune response and signal transduction and enriched in the T-cell signaling pathway, natural killer cell-mediated cytotoxicity, C-type receptor signaling pathway, and NOD-like receptor signaling pathway. Furthermore, inflammation-associated genes such as T-cell surface glycoprotein CD3, cathelicidin antimicrobial peptide, and lymphocyte cell-specific protein tyrosine kinase were enriched, while pathways such as MAPK, cAMP, and metabolic pathways were downregulated. Regulating the T-cell influx could be a potential strategy to modulate excessive inflammation in the retina and could potentially aid in better vision recovery in fungal endophthalmitis., Competing Interests: The authors declare no competing financial interest., (© 2024 The Authors. Published by American Chemical Society.)

We measured the average group refractive index (RI) of 120 isolated lenses from 120 human donors (age: 0.03 to 61 years). The average group RI was calculated from a measurement of the optical thickness of the lens using optical coherence tomography and the apparent window shift of the test chamber caused by the lens. The estimated measurement uncertainty was ±0.004. The group RI at 880 nm was converted to phase RI at 589 nm using the dispersion equation of water and protein. From 2 to 61 years, the mean value of the RI was 1.415 ± 0.002 (group index at 880 nm) and 1.406 ± 0.002 (phase index at 589 nm) independent of age (p = 0.774). Two lenses from donors of age 0.33 and 3 months had significantly lower RI (group index: 1.405 and 1.403; phase index: 1.396 and 1.394). From age 2 to 61, the average lens RI is constant with age within the measurement uncertainty (±0.004)., Competing Interests: There are no financial interests to disclose., (© 2024 Optica Publishing Group.)

Fungal endophthalmitis is a chronic inflammatory condition of the eye's posterior segment that can lead to irreversible vision loss. While relatively rare in western countries, its incidence is notably higher in Asia, particularly India. The condition's prevalence is exacerbated by factors such as intravenous drug use, antibiotics, and ocular surgeries. Fungal endophthalmitis can be categorized as endogenous, arising from systemic infection, or exogenous, linked to external sources such as trauma or surgery. The fungal agents responsible vary by region, with Candida species common in the West and Aspergillus and Fusarium species more prevalent in India. Management typically involves vitrectomy and intravitreal antifungal drugs such as amphotericin B and voriconazole, though treatment is often complicated by multidrug resistance and culture-negative cases. Recent proteomic and transcriptomic analyses have highlighted the early and sustained activation of the host immune response during infection involving key inflammatory and oxidative stress-related proteins. Given the potential for excessive inflammation to cause retinal damage, targeted immunotherapies are crucial. Immunomodulation, which aims to balance the immune response, shows promise in preserving vision while effectively combating the infection. Key targets for immunomodulation include pro-inflammatory cytokines (TNF-α, IL-1β, IL-6, IL-17), chemokines (CCL2, CXCL8), Toll-like receptors (TLR2, TLR4), and the complement system. Additionally, modulating the activity of macrophages, neutrophils, regulatory T cells, and Th17 cells, as well as targeting inflammasomes, can help control inflammation. Biologic agents and small molecule inhibitors offer further avenues for precise immune response modulation. This review underscores the importance of a comprehensive understanding of host-pathogen interactions in the development of effective therapies for fungal endophthalmitis.

Retinoblastoma (Rb) is a pediatric eye cancer which if diagnosed at later stages can lead to Rb invasion into the choroid, optic nerve, sclera, or beyond, with the potential of undergoing metastasis. Cancer cells, including Rb cells, reprogram their metabolic circuits for their own survival and progression, which provides a great opportunity to monitor the extent of Rb progression based on metabolic differences. Henceforth, the present study aims to map the metabolic variations in patients with invasive (primarily enucleated eyes with high-risk histopathological features) and noninvasive (eyes salvaged with treatment) unilateral retinoblastoma (Rb) using nuclear magnetic resonance (NMR) based serum metabolomics. Quantification of differential metabolites in the serum obtained from 9 patients with invasive and 4 with noninvasive unilateral Rb along with 6 controls (no retinal pathology) was carried out using 1 H NMR spectroscopy. A total of 71 metabolites, such as organic acids, amino acids, carbohydrates, and others, were identified in the serum obtained from 9 patients with invasive and 4 with noninvasive unilateral Rb. Partial least-squares discriminant analysis (PLS-DA) models depicted distinct grouping of invasive and noninvasive Rb patients and controls. Differential metabolic fingerprints were observed for invasive and noninvasive Rb patients based on their biostatistical analyses with respect to controls. Remarkable perturbation was observed among various metabolites such as 4-aminobutyrate, 2-phosphoglycerate, O -phosphocholine, proline, Sn-glycero-3-phosphocholine (Sn-GPC), and O -phosphoethanolamine in noninvasive and invasive Rb patients with most of the effects being heightened in the latter group. Metabolic changes unique to invasive and noninvasive Rb patients were also observed. Multivariate receiver operating characteristics (ROC) analysis unveiled the highest accuracy and potency of ROC models 2 and 5 to distinguish the noninvasive and invasive Rb from controls, respectively. Metabolites identified in the serum of patients with invasive and noninvasive Rb may aid in advancing our knowledge about Rb tumor biology. Differential aberrant metabolic variations in patients with invasive Rb compared to those with noninvasive Rb may guide the decision of enucleation versus globe salvage., Competing Interests: The authors declare no competing financial interest., (© 2024 The Authors. Published by American Chemical Society.)

Purpose: To describe the construction and diagnostic accuracy of a modularized, virtual reality (VR)-based, pupillometer for detecting relative afferent pupillary defect (RAPD) in unilateral optic neuropathies, vis-à-vis, clinical grading by experienced neuro-ophthalmologists., Methods: Protocols for the swinging flashlight test and pupillary light response analysis used in a previous stand-alone pupillometer was integrated into the hardware of a Pico Neo 2 Eye ® VR headset with built-in eye tracker. Each eye of 77 cases (mean ± 1SD age: 39.1 ± 14.9yrs) and 77 age-similar controls were stimulated independently thrice for 1sec at 125lux light intensity, followed by 3sec of darkness. RAPD was quantified as the ratio of the direct reflex of the stronger to the weaker eye. Device performance was evaluated using standard ROC analysis., Results: The median (25th - 75th quartiles) pupil constriction of the affected eye of cases was 38% (17 - 23%) smaller than their fellow eye (p<0.001), compared to an interocular difference of +/-6% (3 - 15%) in controls. The sensitivity of RAPD detection was 78.5% for the entire dataset and it improved to 85.1% when the physiological asymmetries in the bilateral pupillary miosis were accounted for. Specificity and the area under ROC curve remained between 81 - 96.3% across all analyses., Conclusions: RAPD may be successfully quantified in unilateral neuro-ophthalmic pathology using a VR-technology-based modularized pupillometer. Such an objective estimation of RAPD provides immunity against biases and variability in the clinical grading, overall enhancing its value for clinical decision making., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision., (Copyright © 2024 Negi, Kalivemula, Bisht, Bhate, Sachdeva and Bharadwaj.)

Introduction: Genetic aetiology is suspected in the development of early-onset high myopia (spherical equivalent refractive error [SER] ≤-6.00 D at ≤6 years of age), considering that the role of environmental factors in inducing high myopia is improbable at an early age. Therefore, we aimed to understand if early-onset high myopia is associated with parental myopia in a clinical setting., Methods: A retrospective study was conducted in which information about demographics, age of apparent onset of myopia, refractive error, axial length, number of myopic parents, time spent outdoors and time spent on near-work was obtained from electronic medical records (EMR). It included 195 myopic individuals categorised into (1) Early-onset high myopes (EOHM): SER ≤ -6.00 D with age of presentation ≤6 years, (2) Early-onset low myopes (EOLM): SER > -6.00 D with age of apparent onset ≤6 years, (3) Late-onset high myopes (LOHM): SER ≤ -6.00 D with age of presentation and age of apparent onset >6 years and (4) Late-onset low myopes (LOLM): SER > -6.00 D with age of apparent onset >6 years., Results: Overall, 63% of individuals were found to have parental myopia. The proportion of individuals with EOHM, EOLM, LOHM and LOLM with parental myopia was 57%, 74%, 53% and 64%, respectively. After adjustment for age, gender and environmental factors, the odds of development of EOHM (Odds ratio: 0.78, 95% confidence interval: 0.25-2.48), EOLM (1.54, 0.65-3.67) or LOHM (0.70, 0.30-1.65) were similar in the presence of myopic parents, when compared with LOLM. The SER and axial length did not differ based on the number of myopic parents in any of these categories., Conclusion: This retrospective analysis reveals that the presence of parental myopia, which was self-reported, did not induce additional risk for early-onset high myopia., (© 2024 College of Optometrists.)

Retinoblastoma (RB) is an intraocular malignancy initiated by loss of RB1 function and/or dysregulation of MYCN oncogene. RB is primarily treated with chemotherapy; however, systemic toxicity and long-term adverse effects remain a significant challenge necessitating the identification of specific molecular targets. Aurora kinase A (AURKA), a critical cell cycle regulator, contributes to cancer pathogenesis, especially in RB1-deficient and MYCN-dysregulated tumors. The current immunohistochemistry study in patient specimens (n = 67) indicated that AURKA is overexpressed in RB, and this elevated expression correlates with one or more histopathologic high-risk factors, such as tumor involvement of the optic nerve, choroid, sclera, and/or anterior segment. More specifically, AURKA is ubiquitously expressed in most advanced-stage RB tumors that show a suboptimal response to chemotherapy. shRNA-mediated depletion/pharmacologic inhibition studies in cell lines, patient-derived cells, in vivo xenografts, and enucleated patient specimens confirmed that RB cells are highly sensitive to a lack of functional AURKA. In addition, AURKA and N-myc proto-oncogene protein (MYCN) associate with each other to regulate their levels in RB cells. Overall, these results demonstrate a previously unknown up-regulation of AURKA in RB, facilitated by its crosstalk with MYCN. The elevated levels of this kinase may indicate unfavorable prognosis in tumors refractory to chemotherapy. This study provides a rationale and confirms that therapeutic targeting of elevated AURKA in RB could be a potential treatment approach., Competing Interests: Disclosure Statement None declared., (Copyright © 2024 American Society for Investigative Pathology. Published by Elsevier Inc. All rights reserved.)

Purpose: Fishing stands out as a widely enjoyed leisure pursuit. While ocular fishing injuries are infrequent, they carry the potential for severe ocular trauma, and safe extraction of a fish hook can pose challenges. We here in report a series of 21 cases of penetrating injury to the cornea by fish hook, detailing successful surgical interventions employed for their management. The report not only outlines different techniques for the removal of fish hooks but also provides clarification on terminologies associated with various components of a fish hook., Methods: This was a retrospective study conducted at tertiary eye care centers in South India. Our hospitals cater to the states of Telangana, Andhra Pradesh, and Odisha. All medical records of patients who attended the emergency department from the period of 2003 to 2023 were evaluated and all patients with fish hook injury were included in the study. This is the longest and largest study in India., Results: Twenty-one cases of ocular fish-hook injuries were presented to the emergency room between 2003 and 2023. Patients were between the ages of 9 and 59 years (mean, 29.4 years), and 90.4 % (19 out of 21) were males. Patient demographics, injury characteristics, surgical interventions, and visual outcomes were meticulously documented. Out of 21 cases, three cases (14.3 %) had blunt trauma, 17 cases (80.9 %) had penetrating injury and one case had lid laceration. Patients had better visual outcomes after the second surgery. Out of 21 cases, 7 (33.3 %) had post-operative visual acuity (VA) between 20/20 and 20/40. Three (14.3 %) had post-operative VA between 20/60 and 20/125. Five (23.8 %) had post-operative VA between 20/200 and 20/600. Six cases (28.6 %) had poor visual outcomes of which two had no perception of light (NPL), two had Hand movements and the other two had the perception of light present and projection of rays inaccurate CONCLUSION: This extensive case series underscores the complexity of ocular injuries caused by fish hooks and emphasizes significance of tailored surgical approaches for optimal visual outcomes. The hook can be successfully removed with minimal trauma to ocular structures by understanding structure of fish hook and by employing appropriate method of extraction., Competing Interests: Declaration of competing interest No conflicting relationship exists for any author, (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Introduction and Purpose: We report a case of extensively drug-resistant (XDR) Pseudomonas aeruginosa (PA) scleritis after pterygium surgery., Methods: Case report., Results: A 58-year-old farmer presented with a 40-day history of severe pain, swelling, and blurred vision after a pterygium excision was performed at another institute. The patient was on multiple medications with no relief. The examination showed a nasally located scleral thinning in his right eye, with ulceration and infiltrates. Microbiology revealed Pseudomonas aeruginosa , which showed intermediate sensitivity to colistin only. The patient was administered topical (0.19%) and intravenous colistin and dexamethasone. There was a rapid reduction in symptoms, and the lesions healed over the next 2 months., Conclusions: To the best of our knowledge, this is the first case report of XDR-PA scleritis. We suggest the possibility of evolving drug resistance caused by the iatrogenic use of antibiotics during the early stages of the disease course.

Introduction: Physicians need an accurate understanding of diabetic retinopathy (DR) severity to optimally manage patients. The aim of this prospective study is to correlate the severity of macular and peripheral retinal vascular abnormalities seen on widefield (WF) optical coherence tomography angiography (OCTA) with DR grading based on WF fundus photography., Methods: The study included 150 eyes from 82 patients with treatment-naïve DR. All patients were imaged with WF fundus photography and swept-source WF OCTA. Quantitative and qualitative analyses of the foveal avascular zone (FAZ) size and shape, and measurement of capillary nonperfusion (CNP) areas, were performed from the OCTA images. The mixed-effects model was used to compare the DR grading from WF photography with the vascular changes seen on WF-OCTA, and Bonferroni correction was applied to the gradings., Results: The mean [± standard deviation (SD)] age of patients was 55.5 (± 9.4) years. The WF-OCTA showed that an increasing size of the FAZ (from 0.442 (± 0.059) µm to 0.933 (± 0.086) µm) correlated with increasing severity of the DR (as determined with WF photography). The deep capillary plexus, FAZ size, and CNP areas in eyes with proliferative diabetic retinopathy (PDR) differed from those with mild nonproliferative diabetic retinopathy (NPDR) (p < 0.001). Most eyes with severe nonproliferative DR were found to have CNP in four quadrants [superficial capillary plexus (SCP) 60%, deep capillary plexus (DCP) 50%]. The WF-OCTA detected subtle neovascularization of the disc (NVD) in 7 eyes (10%) and neovascularization elsewhere (NVE) in 13 eyes (18%) that had been diagnosed with only moderate NPDR on WF photography., Conclusions: FAZ and CNP areas as measured by WF-OCTA correlate with DR severity. WF-OCTA can also detect subtle NVE and NVD that cannot be seen with fundus photography., (© 2024. The Author(s).)

Chromosomal abnormalities that involve the MYCN gene are rare; however, it is one of the most commonly mutated genes in retinoblastoma (RB) after the RB1 gene. MYCN is amplified in approximately 1-9 % of all RB tumors. It plays a role in RB oncogenesis via many mechanisms, including synergism with RB1 deletion, positive feedback with MDM2, upregulation of cell cycle regulating genes, upregulation of miRNA, and upregulation of glucose metabolism. MYCN amplifications are not mutually exclusive and can occur even in the presence of RB1 gene mutations. Clinically, RB1 +/+ MYCN A tumors present as sporadic, unilateral, advanced tumors in very young children and tend to follow an aggressive course. Magnetic resonance imaging features include peripheral tumor location, placoid configuration, retinal folding, tumor-associated hemorrhage, and anterior chamber enhancement. Genetic testing for MYCN A is especially recommended in patients with unilateral RB where genetic blood testing and tumor tissue show a lack of RB1 mutation. MYCN-targeted therapies are evolving and hold promise for the future., Competing Interests: Declaration of Competing Interest No conflicting relationship exists for any author., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: To report the clinical profile and donor characteristics of post-optical keratoplasty adverse events notified at an eye bank., Methods: Between January 2013 and December 2022, 37,041 donor corneas were utilized for keratoplasty, of which 16,531 were used for penetrating keratoplasty (PK), 12,171 for endothelial keratoplasty (EK), and 1356 for anterior lamellar keratoplasty (ALK). EK included 10,956 Descemet stripping automated endothelial keratoplasty (DSAEK) and 1215 Descemet membrane endothelial keratoplasty (DMEK). The adverse events reported within the first 6 weeks of optical keratoplasty were analyzed for donor-related parameters., Results: A total of 41 (0.11%) recipients had post-keratoplasty infections. Of these, 33 occurred after EK (29 after DSAEK, and four after DMEK), two after ALK, and six after PK. The clinical presentation was keratitis alone in 16 eyes and associated with endophthalmitis in 25 eyes. The organisms isolated were gram-negative bacteria in 26 eyes, fungus in eight eyes, gram-positive bacteria in four eyes, mixed infection in five eyes, and microbiology inconclusive in seven eyes. The majority (78%) of the gram-negative infections were due to multidrug-resistant organisms. Most (88%) donor corneas were harvested from hospital premises. The most common cause of donor mortality was trauma. The median duration of presentation from surgery was 4.46 (range: 1-30) days. The death to preservation time was 4.18 (1.5-7.65) hours. The death to utilization time was 3 (2-4.7) days., Conclusion: The overall risk of infectious adverse events after keratoplasty was 0.11%, ranging from 0.08% to 0.36%. Most (80.4%) of the adverse events occurred after EK. The majority (78.9%) of the adverse events were of bacterial etiology, of which gram-negative infections (68.4%) were the most common. The trends and microbiological spectrum of organisms associated with infections should be thoroughly documented in eye banks to gain insights and formulate guidelines on the management of adverse events., (Copyright © 2024 Copyright: © 2024 Indian Journal of Ophthalmology.)

Gonioscopy-assisted transluminal trabeculotomy (GATT) is a promising cost-effective minimally invasive glaucoma surgery (MIGS). The main advantage is safety with regards to low risk for hypotony and its related complications. However, the Schlemm's canal (SC) based procedures have a different set of complications, the most common being hyphema and transient intraocular pressure spike. The other rare complications being, the false passage of the suture by traversing the external wall of the SC into the suprachoroidal space or posterior chamber or breaching the internal wall of the SC into the anterior chamber. Although these complications are rare, knowledge about them is important not only for early identification but for prevention and management if they occur. Through this case report, we describe a rare complication where the suture had traversed through a dilated episcleral vein during GATT. To our knowledge, there has been no prior report of such a complication., Competing Interests: Disclosure: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To analyse baseline imaging characteristics and factors affecting poor visual acuity in diabetic papillopathy., Methods: This was a retrospective, observational study conducted at a tertiary eye care centre in eyes with a diagnosis of diabetic papillopathy. Demographic data including age, gender, duration of diabetes, type of diabetes, HbA1c values and other systemic co-morbidities were recorded. Baseline best corrected visual acuity (BCVA), and various imaging characteristics were noted., Results: 37 eyes of 22 patients with diagnosis of diabetic papillopathy were included [mean age of 46.6 ± 13.5 years, five (22.7%) females and 17 (77.3%) males]. Bilateral involvement was seen in 15 (68.2%) patients. The mean baseline BCVA was 0.51 ± 0.49 logMAR (Snellen equivalent 20/60). Two eyes (5.4%) had features of concurrent mild NPDR, 9 eyes (24.3%) had moderate NPDR, 10 eyes (27.03%) had severe NPDR while 16 (43.2%) other had PDR. All eyes had optic disc edema while 4 had disc pallor at presentation. Telangiectatic vessels/ neovascularisation of disc was present in 17 eyes (45.9%) detected either clinically or on optical coherence tomography (OCT) angiography. 11 (29.7%) eyes had a peripapillary cuff of subretinal fluid accompanying the disc edema. Sixteen eyes (43.2%) had centre involving macular edema seen on OCT. In eyes with a macular edema, the mean central macular thickness was 407.4 ± 71.42 microns at baseline. On assessing the baseline factors that contribute to the final visual acuity, presenting visual acuity was the only variable found to be statistically significant., Conclusion: Although described to have good visual outcome, eyes presenting with poor visual acuity tend to have worse vision on follow up. This may aid in prognosticating and guiding management plan., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

This review summarizes the impact of systemic and ocular inflammatory disorders on diabetes mellitus (DM) and diabetic retinopathy (DR). Local inflammation is a key pathology in diabetic retinopathy (DR) and is also an evolving target for clinical therapy. The legacy effects of local inflammation at the intracellular level make DR a persistent self-driven vicious process. Ocular inflammation is accompanied as well as incited by systemic inflammation due to diabetes mellitus (DM) itself. Over the years, a multitude of studies have evaluated the impact of systemic inflammatory disorders (SIDs, like rheumatoid arthritis, lupus, psoriasis, etc.) and anti-inflammatory drugs prescribed for managing them on manifestations of DM. Recent studies have indicated increased insulin resistance to be a result of chronic inflammation, and the anti-inflammatory drugs to have a protective effect towards DM. Very few studies have evaluated the impact of SIDs on DR. Furthermore, the evidence from these studies is conflicting, and while local anti-inflammatory therapy has shown a lot of clinical potential for use in DR, the results of systemic anti-inflammatory therapies have been inconsistent. The impact of local ocular inflammation due to uveitis on DR is a crucial aspect that has not been evaluated well at present. Initial pre-clinical studies and small-sized clinical reports have shown a strong and positive relationship between the presence of uveitis and the severity of DR as well as its progression, while larger cross-sectional patient surveys have refuted the same. The long term impact of ocular inflammation due to uveitis on DR needs to be studied while adjusting for confounders.

Neovascularization of the macula, a common complication of many chorioretinal diseases such as neovascular age-related macular degeneration, polypoidal choroidal vasculopathy, and pathologic myopia, results from increased synthesis of vascular endothelial growth factor (VEGF) by the retinal pigment epithelium and/or Müller cells because of localized ischemia and inflammation. The Consensus on Neovascular AMD Nomenclature (CONAN) study group acknowledged that these vessels may originate from either the choriocapillaris or the retinal microvasculature, prompting them to propose the term 'macular neovascularization' (MNV) to include intraretinal, subretinal, and sub-pigment epithelial neovascularization localized to the macula. MNV frequently appears as a grey-green macular lesion with overlying intraretinal thickening and/or subretinal exudation, causing metamorphopsia, reduced central vision, relative central scotoma, decreased reading speed, and problems with color recognition. Multimodal imaging with optical coherence tomography (OCT), OCT angiography, dye-based angiographies, fundus autofluorescence, and multiwavelength photography help establish the diagnosis and aid in selecting an appropriate treatment. The standard of care for MNV is usually intravitreal anti-vascular endothelial growth factor injections, though thermal laser photocoagulation, verteporfin photodynamic therapy, and vitreoretinal surgery are occasionally used. We discuss the etiology and clinical features of MNV, the role of multimodal imaging in establishing the diagnosis, and the available therapeutic options., Competing Interests: Declaration of Competing Interest JUS: None. M.W.S.: Consultant: Bayer, Biogen, Alkahest, Revana; Institutional Research Support: Alexion. R.N.:None.G.A.: None. K.C.: None. T.L: Honorarium for consultant and/or lecture fees from Allergan, Alcon, Astellas, Bayer, Boehringer Ingelheim, Chengdu Kanghong Biotech, Genentech, Iveric Bio, Novartis, Oculis and Roche. U.C.:Consultant: Aviceda, Annexon, Apellis, Eyepoint, Genentech Roche, Iveric Bio, OcuTx, Unity Biotechnologies. T.D.: None., (Copyright © 2025 Elsevier Inc. All rights reserved.)

Purpose: The aim of this series was to report recurrent pterygium as a presenting feature of ocular mucous membrane pemphigoid (oMMP)., Methods: A retrospective review was performed, and patients with biopsy positive oMMP who presented with recurrent pterygia were included. Data on the demographic profile, clinical characteristics, and details of the surgical intervention were collected., Results: A total of 5 patients with recurrent pterygium were included. All the patients were men. The median age was 63 years. History of pterygium surgery was present in 8/10 eyes (80%), of which 6 eyes (60%) developed a recurrent pterygium. A symblepharon was present in 4/6 eyes (67%). Forniceal shortening was present in 10/10 (100%) eyes. All eyes were subjected to a conjunctival biopsy for direct immunofluorescence, of which 9 eyes (90%) had positive results consistent with oMMP. Systemic immunomodulatory therapy (IMT) with either methotrexate or azathioprine was initiated in all 5 patients., Conclusions: Recurrent pterygium can be a presenting feature of oMMP. The presence of symblepharon formation or forniceal shortening, especially in the fellow eye, warrants a conjunctival biopsy and prompt initiation of IMT to prevent disease progression., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Children with special education needs (SEN) are at high risk of developing vision problems. In India, there is no data available on the awareness level of eye health needs of children with SEN among special school managers (SSM) and on the barriers to providing eye care for these children in schools. This study aimed to identify the awareness level among SSM and the barriers to organizing School Eye Health (SEH) programmes in special schools, as reported by the eye health program organizers., Methods: A mixed-method study was conducted between July and August 2020 among SSM and eye health programme organizers from a local eye care provider in Hyderabad, India. SSM participants completed an online questionnaire assessing their knowledge, attitude, and practice concerning the eye health needs of children with SEN. Quantitative responses were described with summary statistics. Qualitative interviews with eye health programme organizers were conducted via telephone, and transcripts were thematically analysed. Results: In total, 13/67 (19.4%) invited SSM participated and 2/4 invited eye health programme organizers (50%) were interviewed. Among the SSM participants, 92.3% were aware of vision impaired (VI) children in their schools. Awareness of potential causes of VI ranged from 53.9%-92.3%, common eye conditions ranged from 7.7%-69.2%, and difficulties experienced by children with SEN in classroom activities ranged from 46.2%-76.9%. Only 30.8% of the special schools organized SEH programmes at least once a year. Eye health programme organizers reported barriers, such as a lack of interest from SSM, unavailability of qualified screening staff, and a lack of provision for spectacles and low-vision devices., Conclusion: This study identified varied levels of knowledge, attitudes, and practices of SSM related to the eye health needs of children with SEN. Key barriers to conducting SEH programmes included a lack of demand, inadequate human resource availability, and limited access to government-funded resources. As the study was negatively impacted by the Covid pandemic, further research with wider representation is needed to plan comprehensive eye health programmes for children with SEN., Competing Interests: The authors have declared no competing interest exists., (Copyright: © 2024 Prakash et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: In the past few decades, the primary management for uveal melanoma has evolved from enucleation to eye-preserving treatments. However, despite achieving a high rate of local tumour control, complications following eye-preserving treatments still occur and are partly responsible for functional loss and secondary enucleation., Methods: A literature review by a broad international panel., Results: We summarised the current literature on utilizing vitreoretinal (VR) surgery for managing the complications of uveal melanoma. We also provided insights from the authors' personal experience and practical recommendations for clinical care., Conclusions: With the advancement of VR instruments and surgical techniques and the combination of VR and ocular oncology knowledge ("Onco-VR"), it is now possible to manage or even prevent complications such as vitreous haemorrhage, retinal detachment, and toxic tumour syndrome.

Objectives: To report the surgical outcomes of sterile dehydrated human umbilical cord allograft over the Ahmed glaucoma valve (AGV) plate for refractory glaucoma., Methods: Thirty-four eyes of 34 patients with refractory glaucoma who underwent AGV with umbilical cord allograft (AmnioPlast THICK™; Life Cell International Private Limited, Mumbai, India) placed over the AGV plate between September 2021 and 2022 at a tertiary eye care centre were included (group1) and compared with 30 eyes of 30 patients undergoing AGV without amnioblasts (group 2). The intraocular pressure (IOP) at day one, one month, six months, and final IOP; the necessity for medications; or additional surgeries for IOP control were extracted from the hospital database. Success was defined as achieving an IOP below 22 mm Hg with or without glaucoma medications. IOP spikes after surgery were identified as a rise in pressure beyond 22 mm Hg at any point beyond six weeks post-surgery following an initial reduction of pressure exceeding 30% from the baseline pre-surgical IOP., Results: A notable reduction in intraocular pressure (37 ± 7.9 mm Hg preoperative versus 14 ± 3.7 mm Hg at the final follow-up and 28 ± 3.6 mm Hg versus 18 ± 6.7 mm Hg in group 1 and 2, respectively) was observed in all eyes, with successful outcomes observed in 23 out of 34 eyes (67%). Ten eyes experienced a pressure spike, occurring at a median time of 12 months (range: 6-18 months), predominantly beyond six months post-surgery in group 1, while group 2 had similar pressure spikes in 21 of 30 eyes at a median time of two months (range: 1-5 months). No eyes necessitated supplementary glaucoma procedures, concluding with a final IOP of 14 ± 3.7 mm Hg at 1.9 ± 0.8 years. Vision loss occurred in only one of the 11 eyes that failed owing to non-glaucoma-related causes in group 1., Conclusions: The human umbilical cord allograft plate over the AGV plate may help in postponing the onset of intraocular pressure spikes beyond traditionally defined timelines. This helps in reducing and delaying the hypertensive phase occurring due to fibrosis., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. LV Prasad Eye institute issued approval (IEC-16-IM-3). This study approval is extended until March 2024. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Rao et al.)

Purpose: To determine the efficacy of extended depth of focus (EDOF) contact lenses for controlling myopia progression in children through a 1-year randomised clinical trial., Methods: A total of 104 children aged 7-15 years, with spherical equivalent refraction ≤-0.50 D, were randomly assigned to wear SEED 1 dayPure EDOF Mid contact lenses (n=48) or single vision spectacle lenses (n=56). Cycloplegic refraction with Shin-Nippon open field autorefractor and axial length with Lenstar LS 900 was determined at the baseline and 12-month visits. The compliance, visual discomfort and dryness questionnaires were administered during the final visit., Results: Sixty-nine children (control: n=38; treatment: 31) completed the 12-month follow-up visit, with no difference in baseline characteristics between the groups. Mean (SEM) myopia progression in the 12th month was -0.48±0.07D in the control group and -0.20±0.08D in the treatment group. Mean axial elongation was 0.22±0.03 mm and 0.11±0.03 mm in the control and treatment groups, respectively. SEED 1 dayPure EDOF Mid contact lenses slowed myopia progression by 59% (-0.28D; p=0.01) based on spherical equivalent refraction and controlled axial length by 49% (0.11 mm; p=0.007) in comparison to single vision spectacle lenses. None of the participants reported any adverse effects. While most of the participants (82%) were comfortable with the contact lenses, 11% reported occasional dryness and 14% experienced mild fluctuations in visual acuity after immediate lens wear., Conclusion: Daily wear of SEED 1 dayPure EDOF Mid contact lenses in Indian children showed a significant effect in controlling myopia progression and axial elongation., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Aim: To describe the gonioscopic profile and intraocular pressure (IOP) in primary angle-closure (PAC) disease in patients presenting to a tertiary eye care network in India., Methods: A cross-sectional hospital-based study that included 31 484 new patients presenting between 2011 and 2021. Patients with a clinical diagnosis of PAC/suspect/glaucoma were included. The data was collected from an electronic medical record system., Results: PAC glaucoma (PACG) (47.55%) was the most common diagnosis followed by PAC (39.49%) and PAC suspect (PACS; 12.96%). Female preponderance (54.6%) was noted with higher mean age at presentation among males ( P <0.0001). PACS and PAC showed the highest prevalence in 6 th decade but PACG was higher at 7 th decade. The probability of angle opening was 95.93%, 90.32% and 63.36% in PACS, PAC and PACG eyes respectively post peripheral iridotomy (PI). Plateau iris syndrome (PIS) was noted in 252 eyes and all showed post dilated rise of IOP. A post dilated IOP rise was also noted with 8.86%, 33.95% and 57.19% eyes with PACS, PAC and PACG respectively with IOP rise between 6-8 mm Hg across the disease spectrum., Conclusion: The superior quadrant is the narrowest angle and difficult to open with indentation and post PI. The probability of angle opening is less in PIS especially the complete variety along with post dilated IOP rise. The post dilated IOP rise in angle closure eyes warrants a careful dilatation, especially with PIS., Competing Interests: Conflicts of Interest: Ramyashri S, None; Das AV, None; Senthil S, None., (International Journal of Ophthalmology Press.)

Background: This study aims to assess systemic risk factors in diabetes mellitus (DM) patients and predict diabetic retinopathy (DR) using a Random Forest (RF) classification model., Methods: We included DM patients presenting to the retina clinic for first-time DR screening. Data on age, gender, diabetes type, treatment history, DM control status, family history, pregnancy history, and systemic comorbidities were collected. DR and sight-threatening DR (STDR) were diagnosed via a dilated fundus examination. The dataset was split 80:20 into training and testing sets. The RF model was trained to detect DR and STDR separately, and its performance was evaluated using misclassification rates, sensitivity, and specificity., Results: Data from 1416 DM patients were analyzed. The RF model was trained on 1132 (80%) patients. The misclassification rates were 0% for DR and ~20% for STDR in the training set. External testing on 284 (20%) patients showed 100% accuracy, sensitivity, and specificity for DR detection. For STDR, the model achieved 76% (95% CI-70.7%-80.7%) accuracy, 53% (95% CI-39.2%-66.6%) sensitivity, and 80% (95% CI-74.6%-84.7%) specificity., Conclusions: The RF model effectively predicts DR in DM patients using systemic risk factors, potentially reducing unnecessary referrals for DR screening. However, further validation with diverse datasets is necessary to establish its reliability for clinical use.

Purpose: Mitigating unwanted refractive errors is crucial for surgeons to ensure quality vision after penetrating keratoplasty (PK). The primary objective of the present study is to highlight the importance of microstructural matching of the host and the donor cornea during PK on the distribution of the corneal tissue while suturing., Methods: For this purpose, the present study undertakes an in-vitro PK model to analyse the effect of suturing and host-donor misalignment on corneal birefringence. Five groups of experiments were performed using five corneoscleral buttons. In each group, N = 16 data points (corresponding to 16 simple interrupted sutures) were assessed before and after PK with five degrees of misalignments, 0°, 30°, 45°, 60° and 90° to detect the variations in corneal birefringence post-PK. The technique of digital photoelasticity is utilized to capture the corneal birefringence experimentally., Results: The local and global features of corneal birefringence provided interesting insights into the nuances of corneal birefringence in PK. Statistical analysis was performed to study the effects of suturing on the birefringence around the suture bites. It was observed that the interaction of the suture tension and structural misalignment between the host and the donor cornea influences the corneal birefringence in PK. Conclusions The zero-degree structural misalignment of the host and the donor tissue is preferable to minimize the topographical irregularities and related astigmatism post-PK. The findings of the present study envisage an additional step of structurally aligning the donor tissue with the host before suturing to minimize topographical irregularities in PK., Competing Interests: NO authors have competing interests, (Copyright: © 2024 Gururani et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Purpose: To describe the clinical features, management, and long-term outcome of Infectious crystalline keratopathy (ICK)., Methods: The medical records of clinically diagnosed and microbiologically proven cases of ICK were reviewed from January 2011 to December 2022. Clinical characteristics include the presence of whitish needle-like projections with branching, limited to anterior-mid stroma. Keratoplasty being the most common risk factor, graft-related microbial keratitis during the same period was also studied. The demography, clinical profile, microbiology, treatment, and outcome were analyzed, and compared with secondary graft infiltrate(GI)., Results: Medical records of 24 cases with ICK were reviewed. The mean age was 49.3 ± 20.1 years, with 15(62.5%) males. Prior keratoplasty was done in 18 (75%) cases, with a mean graft size of 10.1 ± 1.5 mm, and mean interval between the last graft and presentation was 9.7 ± 6.2 (3-90) months. In comparison to GI (n = 24), ICK patients (n = 18,75%) were less symptomatic, presented late (7.3 ± 6.5 days vs 16.3 ± 19.4, p = 0.003), using frequent topical steroids (> 3 times/day, p =  0.006), smaller infiltrate size < 4 mm (p =  0.008), central (p =  0.02), less associated with epithelial defect (p =  0.0001), hypopyon (p =  of 0.0002), corneal perforation (p =  0.0006), and surgical management (p =  0.03). On microbiology, 22 (91.6%) ICK cases were culture positive, 14 (63.6%) gram-positive, 3 (13.6%) gram-negative, 2 (9%) mixed bacteria, and 3 (13.6%) fungus, comparable with GI., Conclusion: ICK affects poor ocular surfaces usually following keratoplasty with larger graft size, the use of steroids being the most common association, and it responds to medical management as compared to GI., (© 2024. The Author(s), under exclusive licence to Springer Nature B.V.)

We explore the interaction between corneal immunity and mesenchymal stem/stromal cells (MSCs) and their potential in treating corneal and ocular surface disorders. We outline the cornea's immune privilege mechanisms and the immunomodulatory substances involved. In this realm, MSCs are characterized by their immunomodulatory properties and regenerative potential, making them promising for therapeutic application. Therefore, we focus on the role of MSCs in immune-mediated corneal diseases such as dry eye disease, corneal transplantation rejection, limbal stem cell deficiency, and ocular graft-versus-host disease. Preclinical and clinical studies demonstrate MSCs' efficacy in promoting corneal healing and reducing inflammation in these conditions. Overall, we emphasize the potential of MSCs as innovative therapies in ophthalmology, offering promising solutions for managing various ocular surface pathologies., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to disclose., (Copyright © 2025 The Authors. Published by Elsevier Inc. All rights reserved.)

Non-infectious uveitis (NIU) encompasses a range of conditions marked by inflammation within various layers of the eye. NIU is a significant contributor to irreversible vision loss among the working-age population in developed countries. The aim of treating uveitis is to manage inflammation, prevent its recurrences and to restore or salvage vision. Presently, the standard treatment protocol for NIU involves initiating corticosteroids as the primary therapeutic agents, although more aggressive approaches and steroid sparing agent may be necessary in certain cases. These advanced treatments option include synthetic immunosuppressants like antimetabolites, calcineurin inhibitors and alkylating agents. For patients who exhibit an intolerance or resistance to corticosteroids and conventional immunosuppressive therapies, biologic agents have emerged as a promising alternative. Notably, among the biologic treatments evaluated, TNF-α inhibitors, anti-CD20 therapy and alkylating agents have shown considerable efficacy. In this review, we delve into the latest evidence surrounding the effectiveness of biologic therapy and introduce novel therapeutic strategies targeting immune components as potential avenues for advancing treatment of NIU., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Chauhan and Tyagi.)

Purpose: Benzalkonium chloride (BAK) is a common preservative in ophthalmic formulations that causes cytotoxic damage to the corneal epithelial cells. This study aims to explore the role of mesenchymal stem cell (MSC)-derived conditioned medium in modulating the BAK-induced cytotoxic effects in cultured human corneal epithelial cells (HCECs) as a cell-free therapeutic agent., Methods: The in vitro cultured HCECs derived from a HCE cell line were treated with BAK (0.001% and 0.005%, diluted in DMEM/F12, v/v) for 15 min, washed with 1xPBS, and allowed to recover for 24 h in human bone marrow MSC-derived conditioned medium (MSC-CM: undiluted (100%) and diluted (50%, v/v)). On the other hand, HCECs were co-incubated with BAK (0.005%, v/v) and MSC-CM (100% and 50%, v/v) for 24 h. The HCEC-derived conditioned medium (HCE-CM) was used as an optimal control for MSC-CM, whereas HCECs cultured in DMEM/F12 were used as a control. The DMEM/F12 was used as the base medium for the culture of HCECs and preparation of HCE- and MSC-CM. The role of MSC-CM in modulating the metabolic activity, cell death, epithelial repair, and proliferation, in BAK-treated HCECs was evaluated using MTT assay, Propidium iodide staining, scratch assay, and Ki-67 staining, respectively., Results: Compared to the control, recovery of BAK-treated (0.001% and 0.005%, for 15 min) HCECs in MSC-CM showed significantly reduced cell death with enhanced metabolic activity, epithelial repair, and proliferation. However, in comparison with HCE-CM, the beneficial effects of MSC-CM were predominantly observed at lower BAK concentration (0.001%, for 15 min). Whereas the co-incubation of BAK (0.005%) and MSC-CM for a longer duration (24 h) was marginally beneficial., Conclusions: Our results suggest that the MSC-CM is effective in modulating the BAK-induced cell death, retardation of metabolic activity and proliferation in cultured HCECs, particularly at lower concentration (0.001%) and shorter exposure (15 min) of BAK.

Purpose: To describe a potential biomarker termed as inner choroidal fibrosis in cases of chronic central serous chorioretinopathy (CSCR) presenting to a tertiary referral center., Design: Observational case series., Methods: Five eyes of 4 patients with CSCR were noted to have a gray-white subretinal lesion in the macula, which was analyzed with multimodal imaging., Results: The lesions were hypofluorescent on autofluorescence, fundus fluorescein angiography, and indocyanine angiography. In all cases, a characteristic heterogeneous, hyperreflective lesion in the inner choroid was seen on optical coherence tomography (OCT), corresponding to the white subretinal lesions. The lesion was distinct from the adjacent choroid, with greater reflectivity and greater thickness than the adjacent compressed choroidal vasculature. The dilated outer pachyvessels were pushed outward or sideways in all cases. On OCT-angiography, the corresponding lesion showed flow void areas. We have termed this zone of inner choroidal hyperreflectivity "inner choroidal fibrosis." Upon analyzing the clinical course, 3 of the patients had a history of choroidal neovascularization. The contralateral eye in 2 of these 3 patients also developed choroidal neovascularization. Three of the eyes had an overlying focal choroidal excavation., Conclusions: We report a potential biomarker of CSCR termed "inner choroidal fibrosis" in 4 cases of chronic CSCR. It can best be identified on enhanced depth or swept source OCT as a region of heterogeneous hyperreflectivity in the inner choroid. This fibrosis could be regarded as a degenerative process secondary to more severe disease in the past., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: To study the inner and outer retinal functions using a full-field electroretinogram (ERG) before and after intravenous chemotherapy (IVC) in children with retinoblastoma (RB)., Methods: Of the 11 eyes, seven had RB and four were normal. All children were examined under anesthesia using a handheld ERG machine with a standard protocol - light-adapted single-flash ERG (fERG), photopic single-flash 3.0- and 30-Hz flickers, and photopic negative response (PhNR) amplitudes at 72 ms (P72). The amplitudes and peak times were compared before and after IVC., Results: Post-chemotherapy tumor regressed in all seven eyes. Of the seven eyes, the fERG peak time (a-wave) was delayed in two eyes (29%), whereas the b-wave was delayed in six eyes (86%). The fERG amplitude height for a- and b-waves decreased in five eyes (71%) and six eyes (86%), respectively. In addition, photopic flicker 30-Hz b-wave peak time delayed in five eyes (71%), whereas the b-wave amplitude height decreased in six eyes (86%). Simultaneously, the P72 amplitude height decreased in six eyes (86%), whereas the P-ratio increased in all seven eyes (100%). In comparison, the ERG responses improved in three of the four contralateral normal eyes. Overall, the cone function improved in two eyes (29%), whereas cone bipolar cell and retinal ganglion cell (RGC) function improved in one eye (14%) each., Conclusion: Comparison of light-adapted ERG changes before and after IVC showed reduced amplitudes and delayed peak times for both a and b waveforms, as well as reduced PhNR amplitude attributable to bipolar and RGC injury., (Copyright © 2024 Copyright: © 2024 Indian Journal of Ophthalmology.)

Purpose: To review the etiology and antibiotic susceptibility patterns of infectious endophthalmitis over 11 years in different age groups., Methods: Microbiology records of culture-positive endophthalmitis cases from January 2011 and December 2021 were reviewed for the age groups 0-30, 31-60, and >60 years. Additionally, data was also analysed for trends in antibiotic susceptibility between different age groups., Results: A total of 5590 patients were clinically diagnosed with endophthalmitis. Of these, 1316 (23.5%) patients were culture positive comprising of 1097 bacteria (83.3%) and 219 fungal (16.6%). Gram-positive bacteria predominated the culture-proven bacterial endophthalmitis group with 709 cases (62.6%). Streptococcus pneumoniae (9.3%) was the most prevalent organism in the age group between 0 and 30 years, while Staphylococcus epidermidis (6%) was the most prevalent organism in the age group of 31-60 years. In comparison, Pseudomonas aeruginosa (4.1%) was the most abundant organism in the age group >60 years. Interestingly, Aspergillus flavus (13.24%) was the predominant fungal pathogen in all age groups. There was an increasing trend in antibiotic resistance from younger to older age groups and this pattern was observed for almost all drugs tested except vancomycin and amikacin., Conclusion: While infection can occur at any age, the etiology also seems to vary. This study helps us understand the demography of endophthalmitis along with choice of empirical antibiotics that would influence treatment outcomes. Although vancomycin currently holds good for the treatment for gram-positive infections, gram-negative infections calls for an immediate need for newer drugs or advanced treatment options.

Objective: To evaluate the environmental and economic impact of teleophthalmological services provided by a primary (rural) and tertiary (urban) eyecare network in India., Methods: This prospective study utilised a random sampling method, and administered an environmental and economic impact assessment questionnaire. The study included 324 (primary: 173; tertiary: 151) patients who received teleconsultations from July to September 2022. The primary network (rural) used a colour-coded triage system (Green: eye conditions managed by teleconsult alone; yellow: semi-urgent referral within 1 week to a month, red: urgent referral within a day to a week). The tertiary network (urban) included new and follow-up patients. The environmental impact was assessed by estimating the potential CO 2 emissions saved by avoiding travel for various transport modes. Economic impact measured by the potential cost savings from direct (travel) and indirect (food and wages lost) expenses spent by yellow and red referrals (primary) and the first-visit expenses of follow-up (tertiary) patients., Results: The primary rural network saved 2.89 kg CO 2 /person and 80 km/person. The tertiary urban network saved 176.6 kg CO 2 /person and 1666 km/person. The potential cost savings on travel expenses were INR 19,970 (USD 250) for the primary (average: INR 370 (USD 4.6) per patient) and INR 758,870 (USD 9486) for the tertiary network (average: INR 8339 (USD 104) per patient). Indirect cost savings (food and wages) were of INR 29,100 (USD 364) for the primary and INR 347,800 (USD 4347) for the tertiary network., Conclusion: Teleophthalmology offers substantial environmental and economic benefits in rural and urban eyecare systems., (© 2024. The Author(s), under exclusive licence to The Royal College of Ophthalmologists.)

Purpose: To study the clinical presentation and treatment outcomes of indocyanine green-enhanced transpupillary thermotherapy (ICG-TTT) for treatment-naïve juxtapapillary retinal capillary hemangioblastoma (JRCH)., Methods: A prospective interventional case series. The technique involved ICG dye infusion 45 seconds prior to application of TTT. The main study outcomes were local tumor control, resolution of subretinal fluid (SRF), and improvement in best-corrected visual acuity (BCVA)., Results: Eight eyes of seven patients (5 males and 2 females) were included. The mean age was 26 years (range: 5-56 years). Systemic evaluation revealed von-Hippel Lindau (VHL) disease in five patients. The most common location was the temporal aspect of the optic disc (5 eyes). The mean basal diameter was 2.9 mm (range: 1-8 mm), and tumor thickness was 1.4 mm (range: 1-4 mm). All eight eyes were treated with multiple sessions of ICG-TTT (mean: 3 sessions). Six eyes received adjuvant intravitreal injection of dexamethasone implant (4 eyes) and/or bevacizumab (4 eyes). Post treatment, six eyes (75%) had tumor regression with reduction of SRF. One eye had a partial response with persisting SRF, and one eye showed poor response to TTT for which external beam radiotherapy was performed. At the last follow-up (median: 11 months; range: 6-29 months), the BCVA remained stable in seven eyes and improved in one eye (hand motion to 20/40)., Conclusion: Multiple ICG-TTT sessions can be considered as an alternative treatment option for JRCH with effective local tumor control and SRF resolution., (Copyright © 2024 Copyright: © 2024 Indian Journal of Ophthalmology.)

Purpose: Glaucoma is a leading public health concern globally and its detection and management are way more complex and challenging in the developing world. This review article discusses barriers to glaucoma screening in developing countries from the perspective of different key stakeholders and proposes solutions., Methods/results: A literature search was carried out in the electronic catalogs of PubMed, Medline, and Cochrane database of systematic reviews to find studies that focused on barriers and enablers to glaucoma screening. The authors' interpretations were tabulated as descriptive and qualitative data and presented concisely from the point of view of key stakeholders such as the patients and their relatives, care providers, and system/governing bodies. Key barriers to glaucoma care identified are lack of awareness, poor accessibility to ophthalmic centers, inadequately trained human resources, unsatisfactory infrastructure, and nonavailability of financially viable screening programs. Educating care providers, as well as the public, providing care closer to where people live, and developing cost-effective screening strategies are needed to ensure proper identification of glaucoma patients in developing countries., Conclusions: The logistics of glaucoma detection and management are complex. Hence, glaucoma detection programs should be implemented only when facilities for glaucoma management are in place. Understanding the importance of glaucoma screening and its future implications, addressing the various roadblocks, empowering and efficiently implementing the existing strategies, and incorporating novel ones using Artificial Intelligence (AI) and deep learning (DL) will help in establishing a robust glaucoma screening program in developing countries., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: This prospective cohort study aimed to investigate the ocular outcomes of universal eye screening in newborns and assess the relationship between different perinatal risk factors and various ocular abnormalities in infants who do not meet the criteria for retinopathy of prematurity (ROP) screening., Methods: An universal eye screening questionnaire was utilised to screen newborn babies who did not meet the ROP screening criteria within 72 h of birth at a public and private hospital between June 2016 and April 2018. The questionnaire covered demographic characteristics, neonatal history, and eye examination findings. A trained retina specialist conducted comprehensive anterior and posterior segment examinations utilising a binocular indirect ophthalmoscope., Results: Out of the 1795 newborns screened, 55.2% were male, and 44.8% were female. The most prevalent ocular abnormality observed was retinal haemorrhage (RH), with a prevalence of 10.64% (95% CI: 9.25-12.16%). The prevalence of non-RH abnormality was 7.5% (95% CI: 6.34-8.84%). The retinal haemorrhages were associated with normal vaginal deliveries (OR: 9.91; 95% CI: 6.71-14.64, p-value < 0.001), while non-RH abnormalities were associated with pre-term babies (OR: 4.87; 95% CI: 3.03-7.83, p < 0.001), consanguinity (OR: 2.20; 95% CI: 1.28-3.8, p < 0.001), low birth weight (OR: 0.22; 95% CI: 0.14-0.34, p < 0.001) and systemic abnormalities (OR: 3.08; 95% CI: 1.94-4.91, p < 0.001)., Conclusions: Sight-threatening ocular pathology in newborns may be linked to perinatal risk factors such as preterm birth, low birth weight, consanguinity, and systemic abnormalities. Accordingly, it may be prudent to consider specialized ocular screening protocols for neonates within this high-risk cohort in future prospective studies., (© 2024. The Author(s), under exclusive licence to The Royal College of Ophthalmologists.)

Prcis: This study concludes that GATT can be an effective and safe surgical alternative for managing IOP in eyes with prior failed glaucoma surgeries, associated with minimal complications., Purpose: To report outcomes of gonioscopy-assisted transluminal trabeculotomy (GATT) in eyes with prior failed glaucoma surgery., Patients and Methods: A retrospective study involving 30 eyes of 30 patients, all of whom had open angles on gonioscopy, experienced prior glaucoma surgery failures, and subsequently underwent GATT. The primary outcome measure was success defined as complete when the intraocular pressure (IOP) was >5 and ≤21/16 mm Hg without glaucoma medications and qualified with medications., Results: The mean age was 51.8±16.1 years. Twenty-one eyes underwent GATT and 9 eyes underwent phaco-GATT. Twenty-seven eyes had failed trabeculectomy and 3 eyes had failed glaucoma drainage device. Post-GATT, the IOP decreased from 27.1±7 to 16.9±6 mm Hg (P<0.001) at the end of 15 months, with a mean drop in AGM from 4.9±1.0 to 2±1.6. At postoperative 1 year, the probability of complete success was 20% (95% CI: 9-43) for an IOP criterion of both 21 and 16 mm Hg. The qualified success probability at 1 year was 82% (67-100) for an IOP criterion of 21 mm Hg and 57% (38-84) for an IOP criterion of 16 mm Hg. Risk factor for failure was older age [hazard ratio (HR): 1.03, 95% CI: 1.01-1.06]. The complications noted were hyphema in 14 eyes (46%), majority resolved within 1 week and all by 2 weeks. None needed any intervention., Conclusions: This study concludes that GATT can be an effective and safe surgical alternative for managing IOP in eyes with prior failed glaucoma surgeries, associated with minimal complications., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Diabetic eye disease is a highly prevalent and sight-threatening disorder. It is a disease of neuro-vascular unit of the retina, if left untreated can cause blindness. Therapeutic approaches followed for its treatment can only restrict the progression of the disease with highly variable results. There is no known biomarker for an early diagonsis of this disease, therefore by the time it is detected it goes beyond repair. This creates a massive demand for development of such biomarkers that help detect disease in its earlier stages., Methods: PUBMED (https://pubmed.ncbi.nlm.nih.gov/) was searched for articles relevant to the topic published till November 2023. The search was made using keywords such as Diabetic Retinopathy, inflammation, tear, biomarker, proteomics etc. The studies providing relevant information to prove the importance of biomarker discovery were chosen. After compiling the data, the manuscript writing was planned under relevant headings and sub-headings., Results: The review provides a comprehensive overview of all the tear protein biomarker studies in the field of DR and DME. Briefly, their potential in other diseases is also elucidated. While there are many studies pertaining to DR biomarkers, the identified markers lack validations which has restricted their usage in clinics. In case of DME, there was no such study towards biomarker discovery for its diagnosis and prognosis., Conclusions: The review highlights major studies and their lacunae in the field of biomarkers discovery for DR and DME.

Purpose: This study aims to elucidate the tear proteome and understand the underlying molecular mechanisms involved in the ocular complications following Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN)., Methods: Mass spectrometry (MS) was performed to quantify the tear fluid proteins from chronic SJS/TEN patients (n = 22 eyes) and age- and gender-matched controls (n = 22 eyes). The candidate proteins were validated using ELISA (n = 80 eyes) in tear samples and immunohistochemistry (IHC; n = 12) in eyelid margin specimens. These proteins were compared for significant differences based on age, gender, disease duration, and ocular severity., Results: A total of 1692 tear fluid proteins were identified, of which 470 were significantly differentially regulated in chronic SJS/TEN. The top 10 significantly upregulated proteins were neutrophil secretions including neutrophil elastase (p < .0001), defensin (p < .0001), and matrix metalloproteinase 8 (p < .0001). The presence of neutrophils was confirmed by the upregulation of IL-8 (p < .001) in tears, a key cytokine known for recruiting neutrophils. Additionally, positive expression of myeloperoxidase was observed in the keratinized eyelid margins of SJS/TEN to validate the presence of neutrophils. Among 41 unique proteins identified by MS, IL-36γ (p < .01) was expressed in three SJS/TEN patients and was confirmed in SJS/TEN tears and eyelid margins by ELISA and IHC, respectively. IL-36γ was specifically expressed in the superficial layers of eyelid margin keratinized conjunctiva. The majority of the significantly downregulated proteins were lacrimal gland secretions such as lacritin (p < .0001) and opiorphin (p < .002). Neutrophil elastase (p < .02) was significantly elevated in patients with severe eyelid margin keratinization., Conclusion: Our observations indicate a clear correlation between eyelid margin keratinization and the expression of IL-36γ, potentially mediated by neutrophils recruited via IL-8. Future experimental studies are needed to test the role of therapies targeting IL-8 and/or IL-36γ in reducing eyelid margin keratinization and its associated ocular complications in SJS/TEN., (© 2024 The Authors. Allergy published by European Academy of Allergy and Clinical Immunology and John Wiley & Sons Ltd.)

Purpose: The aim of this study was to describe the importance of symblepharon release with ocular surface reconstruction (OSR) for optimal fitting of scleral contact lenses (SCLs) in eyes with chronic cicatrizing conjunctivitis (CCC) and keratopathy., Methods: This retrospective study included 32 eyes with CCC and keratopathy with symblepharon which underwent symblepharon release with OSR and were fitted with SCLs. The primary outcome measure was the improvement in best-corrected visual acuity with SCL wear., Results: A total of 32 eyes of 29 patients (66% men) with a median age of 30.5 years were included. The common causes of CCC were Stevens-Johnson syndrome (66%) and ocular burns (16%). The most common location of symblepharon was superior (59%) with limbal involvement in most eyes (94%). Symblepharon release was combined with mucous membrane grafting (63%), amniotic membrane grafting (31%), or conjunctival autografting (6%). The median interval between symblepharon release with OSR and SCL trial was 15 weeks [interquartile range (IQR): 6-24]. The median best-corrected visual acuity improved from logMAR 1.5 (IQR: 1.2-1.8) to logMAR 1.2 (IQR: 0.6-1.4) with SCLs after symblepharon release with OSR ( P < 0.001). The median diameter of the SCL used was 15 mm (IQR: 15-16), with a median base curve of 7.9 mm (IQR: 7.9-8). Symblepharon recurrence was noted in 70% of eyes that underwent amniotic membrane grafting; no recurrence was seen with mucous membrane grafting or conjunctival autografting., Conclusions: In eyes with CCC with keratopathy and symblepharon, visual rehabilitation is possible with SCLs after symblepharon release with OSR without having to resort to a penetrating corneal procedure., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: To report 15-year incidence rate of primary open angle glaucoma (POAG) in the Andhra Pradesh Eye Disease Study (APEDS)., Methods: A population-based longitudinal study was carried out at three rural study sites. Phakic participants aged ≥40 years who participated at baseline (APEDS I) and the mean 15-year follow-up visit (APEDS III) were included. A comprehensive ophthalmic examination was performed on all participants. Mean intraocular pressure (IOP) was average of IOPs of right and left eyes. The definition of glaucoma was based on the International Society of Geographical and Epidemiological Ophthalmology (ISGEO) classification. The main outcome measure was incidence of POAG during the follow-up period in participants without glaucoma or suspicion of glaucoma at baseline., Results: Data from the available and eligible participants from the original cohort (1241/2790; 44.4%) were analysed. The mean age (standard deviation) of participants at baseline was 50.2 (8.1) years; 580 (46.7%) were men. Thirty-six participants developed POAG [bilateral in 17 (47.2%)] over 15 years. The incidence rate of POAG per 100-person years (95% confidence interval) was 2.83 (2.6, 3.08). Compared to baseline, the reduction in mean IOP [median (range) mm Hg] was -0.75 (-7.5, 9) in participants with incident POAG and -2.5 (-14.5, 14.5) in those without. The inter-visit difference in mean IOP was a significant risk factor on logistic regression analysis., Conclusion: We report the long-term incidence of POAG in rural India. A longitudinal change in IOP, specifically a less pronounced reduction in IOP with increasing age, was a novel risk factor., (© 2023. The Author(s), under exclusive licence to The Royal College of Ophthalmologists.)

Purpose: To assess the changing trends in barriers towards accessing eye care in a rural population cohort from Southern India., Methods: This is a population-based longitudinal cohort of participants (the Andhra Pradesh Eye Disease study [APEDS]) from three rural regions of Telangana and Andhra Pradesh who were evaluated at baseline (APEDS I; 1996-2000), along with follow-ups at 10 years (APEDS II; 2009-10) and 15 years (APEDS III; 2012-2016). At follow-up, all participants 30 years and above were administered a structured questionnaire on barriers to uptake of eye care services., Results: Of 3810 participants, 1449 had visual impairment (VI). Among them, 1302 noticed a reduction in vision over last five years and 722 sought treatment, a significant improvement from baseline (P < 0.001). Participants were more likely to seek treatment if they were educated (OR = 1.43, 95%CI: 1.07-1.89), had hypertension (OR = 1.36, 95%CI: 1.04-1.77), had VI from causes other than cataract and refractive error (OR = 2.49, 95%CI: 1.56-3.99) and were residents of Adilabad (OR = 2.21; 95%CI: 1.58-3.08) and Mahbubnagar (OR = 3.55; 95%CI: 2.48-5.08) districts. Those with moderate or worse VI were less likely to seek treatment (moderate VI: OR = 0.56; 95%CI: 0.42-0.75, severe VI: OR = 0.34; 95%CI: 0.19-0.57, blindness: OR = 0.38; 95%CI: 0.2-0.73). The most important barriers to uptake of services were, not perceiving loss of vision as a serious problem (25.9%), accepting it an aging process (21.4%) or due to economic reasons (16.0%)., Conclusion: Personal and economic elements accounted for considerable amounts of barriers for utilization of eye care services. The uptake of services could be improved by addressing these specific barriers and risk factors for non-compliance., (© 2024. The Author(s), under exclusive licence to The Royal College of Ophthalmologists.)

Background: Uncorrected refractive error (URE) is one of the leading causes of childhood vision impairment. Increasing effective refractive error coverage (e-REC) is one of the main indicators of WHO's 2030 global eye health targets. The aim of this study is to estimate the e-REC and spectacle coverage among school children in Telangana, South India., Methods: School children aged 4-15 years in the study locations underwent vision screening using 6/12 tumbling E optotype by trained community eye health workers in the schools. Those failing the initial vision screening and/or found to be having eye conditions were referred to a nearby referral centre appropriately, where they underwent detailed eye examination., Results: A total of 774,184 children were screened in schools of which 51.49% were boys. The mean age was 9.40 ± 3.27 years. The prevalence of URE was 1.44% (95%CI:1.41-1.46) of which myopia was 1.38% (95%CI: 1.35-1.41). In multivariate analysis, the risk of myopia was higher among older children (Adj.OR: 17.04; 95%CI: 14.64-19.85), those residing in urban areas (Adj.OR:3.05, 95%CI:2.60-3.57), those with disabilities (Adj.OR:2.61, 95%CI:2.00-3.39) and among girls (Adj.OR:1.30, 95%CI:1.25-1.35) (P < 0.001). The overall e-REC was 56.97% and the spectacle coverage was 62.83%., Conclusion: The need for interventions to improve e-REC to achieve 2030 global eye health target is eminent among children in this region. Improving refractive services through school eye health programs could aid in accelerating this process to achieve the target. Myopia being the most common type of RE, the risk factors included increasing age, urban location, and presence of disability., (© 2024. The Author(s), under exclusive licence to The Royal College of Ophthalmologists.)

Background/objective: To determine the prevalence of visual impairment (VI), uncorrected refractive errors (URE), and effective refractive error coverage among individuals aged 15-50 years in Koshi Province, Nepal., Methods: A population-based cross-sectional study was conducted in Koshi Province in which 4800 participants were selected from 80 clusters. The study teams visited the selected households and conducted eye examinations. This included monocular unaided (and aided) visual acuity assessment using a Snellen chart with tumbling E optotypes at a distance of 6 meters. Near vision was assessed binocularly using the N notation chart at a fixed distance of 40 cm for each individual. Torchlight examination and distance direct ophthalmoscopy was done. VI was defined as presenting visual acuity worse than 6/12 in the better eye. URE was defined as presenting visual acuity worse than 6/12 and improving to 6/12 or better on using a pinhole. Near Vision Impairment was defined as binocular presenting near vision worse than N8 among those age 35 years and older., Results: In total, 4057 were examined (84.5% response rate). The prevalence of VI was 3.52% (95% CI:2.89-4.13; n = 143). The prevalence of URE in the better eye was 1.95% (95% CI:1.54-2.42; n = 79). The Refractive Error Coverage and Effective Refractive Error Coverage were 34.8% and 31.3% respectively. The prevalence of NVI was 34.24% (95% CI: 32.1-36.40; n = 666)., Conclusion: The prevalence of VI and  URE was low, attributed to the availability and uptake of services in Koshi province in Nepal., (© 2023. The Author(s), under exclusive licence to The Royal College of Ophthalmologists.)