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To characterise the corneal deposits of macular corneal dystrophy and correlate with high-resolution optical coherence tomography (OCT). A total of 23 eyes of 15 patients were evaluated for clinical features on slit lamp biomicroscopy, and high-resolution OCT was performed to correlate the clinical findings. The deposits were characterised based upon their location and level in the corneal layers. Mean age was 31.5 (Range 20–67) years. The stromal deposits were restricted to central 8 mm in 9 eyes; in the rest of the 14 eyes, the deposits were seen in both central and peripheral cornea. In one patient, no such distinction could be made due to diffuse nature of the deposits throughout the cornea with sparing of 1–2 mm of the cornea internal to the limbus. The central deposits were in the anterior stromal layers, while the peripheral deposits were in the deep stromal corneal layers and non-contiguous with the anterior stromal deposits. In one patient aged 67 years, the peripheral deposits in deep corneal layers were more prominent than the central anterior stromal deposits and were associated with a significant thickening of Descemet membrane. MCD exhibits a clinically diverse presentation as revealed on the clinical and optical coherence tomography study. Immunophenotype and genotype–phenotype correlation may further help in understanding various clinical presentations of MCD.

PURPOSE To report the outcomes of corneal transplantation using donor corneas retrieved from snakebite victims. METHODS This study was a retrospective analysis of 30 corneal transplants performed from 2014 to 2016 using donor corneas retrieved from snakebite victims. The details of the donor corneal characteristics and the transplant recipients were collected from the eye bank and the medical records department. RESULTS The mean age of the donors was 30.4 ± 17.5 years. The median death-to-preservation time was 3.3 hours [interquartile range: 1.3-5.6 hours]. Ninety percent (27/30) of the corneas were evaluated as optical grade, and 10% (3/30) of the corneas were deemed as therapeutic grade. The mean endothelial cell density on specular microscopy of the donor corneas was 2943 ± 615 cells/mm, and median corneal thickness was 514 μm (interquartile range: 506-520). Seventy-five percent of the corneas transplanted had cleared, with a mean follow-up duration of 1.5 ± 1.0 years (range: 0.4-3.7) years and mean logarithm of the minimum angle of resolution (LogMAR) visual acuity of 0.51 ± 0.27 (range: 0-1.2) at the last follow-up. CONCLUSIONS The donor corneas retrieved from snakebite victims are apparently safe and suitable for transplantation, and screening for such donor corneas should include a thorough examination of ocular adnexa to rule out local envenomation before corneal retrieval in addition to the routine evaluation protocol.

Corneal dystrophies represent a group of heterogeneous hereditary disorders causing progressive corneal opacification and blindness. Current corneal transplant management for corneal dystrophies faces the challenges of repeated treatments, complex surgical procedures, shortage of appropriate donor cornea, and, more importantly, graft rejection. Genetic medicine could be an alternative treatment regime to overcome such challenges. Cornea carries promising scope for a gene-based therapy involving gene supplementation, gene silencing, and gene editing in both ex vivo and in vivo platforms. In the cornea, ex vivo gene therapeutic strategies were attempted for corneal graft survival, and in vivo gene augmentation therapies aimed to prevent herpes stromal keratitis, neovascularization, corneal clouding, and wound healing. However, none of these studies followed a clinical trial-based successful outcome. CRISPR/Cas system offers a broad scope of gene editing and engineering to correct underlying genetic causes in corneal dystrophies. Corneal tissue--specific gene correction in vitro with minimal off-target effects and optimal gene correction efficiency followed by their successful surgical implantation, or in vivo CRISPR administration targeting pathogenic genes finds a way to explore therapeutic intervention for corneal dystrophies. However, there are many limitations associated with such CRISPR-based corneal treatment management. This review will look into the development of corneal gene therapy and CRISPR-based study in corneal dystrophies, associated challenges, potential approaches, and future directions.

To investigate endothelial imaging patterns in ICE syndrome and correlate these with the observed clinical features in the affected eye.Of the 70 patients of ICE syndrome referred from the glaucoma clinic between 2017 and 18, 17 patients had a clear cornea for reliable endothelial imaging were included in the study.Mean age was 47(range 29-63) years; 9 males and 8 females. The right eye was involved in 10 and left eye in 7 patients. Mean best corrected visual acuity was 20/30 (20/20-20/80) in the affected eye. All 17 patients had clear and compact central cornea and reasonably good vision at the time of specular microscopy. Those with best corrected visual acuity20/20 had cataract as a co-morbidity. Endothelial abnormalities were noted in all patients and were documented using Hirst and modified Sherrard's classification system. As per the modified Sherrard's classification system, 9 eyes were categorised into total ICE, 5 eyes into subtotal ICE, in 3 eyes grading could not be applied. Of the 4 subtotal ICE, 1 was subtotal ICE (+) and 3 were subtotal ICE (-). 12/17 patients had glaucomatous disc.Specular microscopy provides information on the various morphological pattern of endothelial abnormalities and helps in mapping out the areas with abnormal/diseased endothelium. These have implications in the management of ICE syndrome.

PURPOSE To study the causes of non-utilization of donor corneas and assess whether non-utilized tissues differ from utilized tissues with regard to age and endothelial cell density (ECD). METHODS Aretrospective, cross-sectional analyses of all donor corneas collected from a network of 4 eye banks of a tertiary eye care institute in India during a 1-year period (January to December 2019) was conducted. All donor corneas were assessed for tissue quality by slit lamp evaluation, donor age, and specular microscopy. The causes of non-utilization and effect of donor age and ECD on tissue utilization were studied. RESULTS A total of 10,969 corneas were harvested during the study period; 4618 (42.1%) tissues were discarded. The main causes of non-utilization were poor tissue quality accounting for 86.16% (n = 3979) of all discarded corneas. The mean donor age was 50.7 ± 2.9 years and 63.3 ± 2.3 years for used and discarded corneas, respectively (P < 0.0001). The mean ECD of donor tissues was significantly (P < 0.0001) higher in the utilization group (2787.3 ± 77.4 cells/mm2) than that in the non-utilization group (2394.4 ± 82.5 cells/mm2). Donor age and ECD and their interaction were significant (P < 0.001) predictors of tissue utilization rate. CONCLUSIONS Donor age and ECD and their interaction were significantly associated with the rate of utilization of donor corneal tissues.

To report the outcomes of endothelial keratoplasty (EK) combined with near total iridectomy in the management of iridocorneal endothelial (ICE) syndrome with severely disorganised anterior segment. Three patients with ICE syndrome, who had a severely disorganised anterior segment underwent near total iridectomy, with/without cataract surgery, followed by EK at the same time. Mean age was 35 years. Prior to EK, the intraocular pressure (IOP) was in the range of 12–15 mm Hg. One patient (patient 2) had advanced disc damage prior to EK. Two eyes (patients 1 and 2) had a glaucoma drainage device, and in one, the IOP was controlled with two antiglaucoma medications. All grafts were clear, and IOP was well controlled till the last mean follow-up of 53 (range 30–72) months. The outcomes of EK with this surgical approach are favourable and should be considered in selective cases of ICE syndrome.

Blindness and visual impairment affect the quality of life of the affected individual and their family; it also impacts the socio-economic order of the country in many ways. A prevalence study in 2015 showed that of the 4.2 million blind people, 2.6 million people lived in East-, South-, and South-East Asian countries [1]. Corneal diseases are significant causes of blindness worldwide, second only to cataract [1, 2]. Many times, corneal blindness is treated by corneal grafting. Hence, corneal transplantation statistics are a proxy by which a country’s ability to address corneal blindness can be measured. This chapter discusses the important causes of corneal blindness in the South-East Asia region and the available infrastructure to deal with these.

Purpose To evaluate the long-term outcomes of Descemet-stripping endothelial keratoplasty (DSEK) in 52 eyes with iridocorneal endothelial (ICE) syndrome. Methods Retrospective study of 52 eyes of 52 patients who were diagnosed with ICE syndrome and underwent DSEK between January 2010 and December 2019 with a follow-up of at least 6 months. Results The mean age was 48.8 +/- 10.8 years. Female patients (n = 33) constituted 63.5%. The median duration of follow-up was 2.4 years (range, 0.5-9.1 yrs). The mean best-corrected visual acuity improved significantly after surgery and remained stable (~20/50) through 5 years. The mean endothelial cell loss was 28%, 37.9%, 43.6%, and 56.9% at 6 months and at 1, 2, and 3 years, respectively. Graft rejection was noted in 5 eyes (9.6%). Postoperatively, increased intraocular pressure (IOP) was seen in 17 eyes (32.7%), and 10 eyes (19.2%) underwent glaucoma surgeries. Fourteen eyes (26.9%) had secondary graft failures. The estimates of graft success were 93.6% +/- 3.6% at 1 year, 85.6% +/- 5.5% at 2 years, 79.3% +/- 6.7% at 3 years, 69.0% +/- 8.9% at 4 years, and 59.1% +/- 11.9% at 5 years. Postoperative increased IOP was found to be the only significant (P = 0.05) risk factor (hazard ratio 8.92) associated with graft failure. The clinical variant of ICE syndrome did not seem to influence the graft survival (P = 0.68). Conclusions In this study, DSEK had a success rate of ~60% at 5 years. Increased IOP post-DSEK is a significant risk factor for graft failure. Graft survival is not affected by the clinical variant of ICE syndrome.

To describe the patient demographics and recent clinical indications of endothelial keratoplasty (EK) in patients presenting to a tertiary eye care center in India. This cross-sectional hospital-based study included 2,182 patients who underwent EK between Jan 2016 and Dec 2019 (4 years period). The data were collected using an electronic medical record system. Overall, 2,632 eyes of 2,182 patients underwent EK during the study period. Median age was 62 (IQR: 48–70) years and adults (94.45%) comprised most of the cohort. More commonly, the patients were male (55.59%) and from the higher socioeconomic strata (67.51%). The corneal signs included corneal edema (70.93%), corneal scarring (29.60%), corneal vascularization (16%) and guttae (12.88%). The major indications of EK were post-cataract surgery corneal edema in 1331 (50.57%) patients, endothelial dystrophy in 537 (20.4%) patients, failed graft in 535 (20.33%) patients causing a vision impairment of > 20/400–20/1200 in about a half (45.55%) of the patients. Descemet stripping endothelial keratoplasty (DSEK) and Descemet membrane endothelial keratoplasty (DMEK) were performed in 2075 (78.84%) and 557(21.16%) patients, respectively. EK is commonly performed during the sixth decade of life and in males. The most performed procedure is DSEK. The commonest indication was post-cataract surgery corneal edema.

PURPOSE The aim of this study is to determine the presence of oxidative stress markers in the aqueous humor (AH) and corneal tissues of patients with congenital hereditary endothelial dystrophy (CHED). METHODS Interventional prospective study was undertaken to quantify levels of ascorbic acid and glutathione in the AH of patients with CHED. AH was collected from patients undergoing keratoplasty and levels of ascorbic acid and glutathione were determined using biochemical assays and measured spectrophotometrically. AH collected from pediatric patients with cataract were used as control. Corneal sections of patients who underwent penetrating keratoplasty were obtained, and presence of glutathione peroxidase 1, catalase, and superoxide dismutase was determined by immunohistochemistry. Tissue sections obtained from cadaveric corneas unsuitable for clinical transplant were used as control. RESULTS Significantly increased ascorbic acid levels were determined in patients with CHED (605.6 ± 158.9 μM) compared with those in controls (190.5 ± 74.72 μM). However, a trend toward reduced level of glutathione was detected in patients with CHED compared with that in the controls. Increased glutathione peroxidase 1 staining and reduced expression of catalase was detected in corneal tissues of patients with CHED compared with those in control corneal tissues. There was no apparent changes observed in the expression of superoxide dismutase in the corneal sections obtained from patients with CHED. CONCLUSIONS To the best of our knowledge, this is the first study to determine the levels of ascorbic acid and glutathione in AH of patients with CHED. Our data suggest the presence of oxidative stress in CHED that might be responsible for the pathological changes in patients with CHED.

Purpose: The purpose of this study was to discuss the guidelines and modification of practices with respect to corneal transplantation and eye banking during the COVID-19 pandemic lockdown period and beyond, at a network of tertiary care centers in India. Methods: Descriptive study of the challenges faced in eye banking during the lockdown, and practices adopted to overcome the critical aspects in the clinical care of patients who presented with emergency corneal diseases requiring keratoplasty. Results: Complete lockdown orders from the Indian government, as a strategy to control the Coronavirus pandemic, resulted in drastic reduction of all types of elective corneal transplants and eye banking activities from March 24, 2020 to May 31, 2020. The sudden cessation of eye banking resulted in an acute demand and supply imbalance of fresh donor corneas for transplants during this time. Our network of eye banks addressed this issue by adopting glycerol preservation of donor corneas, which were subsequently utilized for tectonic penetrating keratoplasty. The donor cornea retrieval was resumed in a strategized manner 3 weeks prior to the date of exit of the lockdown, with modified guidelines on donor suitability, screening, retrieval, processing, and harvesting from various sources. A triage of keratoplasty priority was formulated to tide over the post lockdown shortage of corneas. We performed 31 therapeutic keratoplasties during the nationwide lockdown among our network of tertiary eye care centers. Conclusion: The study highlights the approach and strategies to manage and tide over an unprecedented crisis situation faced by corneal surgeons in general and, specifically, the eye banking community.

Purpose: To report the clinical outcomes and histopathological and immunohistochemistry (IHC) features in eyes with the sequelae stage of vernal keratoconjunctivitis (VKC). Methods: Investigative study of corneal samples obtained following surgical intervention for vision restoration in four eyes of three patients with VKC. Patient 1 (an 11-year-old boy) had deep anterior lamellar keratoplasty in both eyes, Patient 2 (a 24-year-old male) underwent superficial keratectomy followed by penetrating keratoplasty, and Patient 3 (a 22-year-old male) underwent penetrating keratoplasty. The corneal samples retrieved after surgical intervention were assessed for histology features and immunohistochemistry (IHC) studies. Results: The grafts were clear till the follow-up of 2–18 months. Histopathology of all four corneal samples showed epithelial hyperplasia, absent Bowman layer, thick hyalinized stromal lamellae, vascularization, and chronic inflammatory cells such as lymphocytes and plasma cells. IHC showed strong expression of CK 3 in both eyes of Patient 1 and no expression in Patients 2 and 3. The marker for limbal stem cells, ABCG2, was absent in all four samples; however, p63α was expressed strongly in Patients 2 and 3, moderately in the right eye of Patient 1, and marginally expressed in the left eye of Patient 1. Conclusion: The eyes in the sequelae stage of VKC (having corneal scarring and 360° hypertrophied limbus) can be managed favorably with keratoplasty and amniotic membrane transplantation without allogenic/cadaveric stem cell transplantation. The expression of transient progenitor cells in the scarred corneas of VKC patients in the sequelae stage suggests that the limbal stem cell dysfunction is more likely partial and self-renewal of limbal stem cells is a plausibility in these eyes.

Descemet membrane endothelial keratoplasty (DMEK) is the closest to the physiological replacement of endothelial cells. In the initial years, the technique was surgically challenging. Over the years, with better understanding and modifications in the surgical steps, the technique has evolved as an alternative to more popular procedure Descemet stripping endothelial keratoplasty. The article highlights the various preoperative, intraoperative, and postoperative nuances of DMEK. Additionally, it summarizes the various comparative and noncomparative studies on DMEK outcomes.

We report two cases of corneal coinfection with Acanthamoeba and Fusarium sp. along with the review of published literature. A 35-year-old woman and 65-year-old man presented to the institute with corneal ulcer refractory for treatment with topical antibiotics. Microbiological examination revealed the presence of Acanthamoeba cysts along with septate, hyaline fungal filaments. After emergency therapeutic penetrating keratoplasty (TPK) in both, the corneal tissue was sent for histopathologic examination, which confirmed the presence of Acanthamoeba and fungal coinfection. One patient had a recurrence of fungal infection after TPK. In subjects with a rapid progression of mycotic ulcer, coinfection with other microorganisms including Acanthamoeba should be suspected. The two cases presented here emphasize the importance of microbiology in making prompt diagnosis and appropriate management of these cases at an early stage.

To report the intricacies of managing complications that arose out of cosmetic iris implants (BrightOcular) placement. Interventional case report. A thirty-year-old gentleman presented with complaint of progressive loss of vision after having cosmetic iris implant surgery to change his eye colour. He then developed raised intraocular pressures and had a right eye trabeculectomy conducted with the implants in situ. Subsequently, he had implant removal surgery because of persistent implant-associated complications. The vision was impaired due to progressive corneal oedema and glaucoma. Various considerations were taken while planning for surgical intervention because of the extensive structural damage to the anterior segment of the eye. This case report highlights that cosmetic iris implants are dangerous intraocular devices and management of the associated complications is also challenging. As these devices cause irreversible structural and functional damage, their use should be discouraged in normal eyes.

Introduction: Corneal opacities constitute one of the major causes of paediatric corneal blindness. Keratoplasty may be the treatment of choice for most of these disorders. Paediatric corneal transplantation poses various challenges.Areas covered: Success of paediatric keratoplasty needs dedicated team work. In recent past, there has been significant changes in the field of keratoplasty.Expert opinion: With newer lamellar techniques, graft survival has improved significantly. A team approach involving ophthalmologist, paediatrician, anaesthesiologist, and the patient’s family, is necessary to achieve optimal visual potential. Although paediatric penetrating keratoplasty is challenging, successful transplantation with good graft survival can be obtained. A better understanding of prognostic factors can possibly improve graft survival in the future.

Ligneous conjunctivitis (LC) is a rare form of pseudomembranous conjunctivitis seen in children, perhaps due to plasminogen deficiency, which manifest as a chronic refractory pseudomembranous conjunctivitis. LC cases are incapable in maintaining their fibrinolytic activity due to plasminogen deficiency; consequently, transudates of plasma assume as a thick, gelatinous, woody membranes over the mucosal surfaces. This is a short case report on a child with a LC, who presented with recurrent pseudomembranous conjunctivitis in conjunction with progressive congenital hydrocephalus due to aqueductal stenosis (Dandy–Walker syndrome). This rare association was clinically confirmed and prompt corrective surgical measures were instituted.

PURPOSE: To evaluate the relationship between central corneal thickness (CCT) and horizontal corneal diameter (HCD) in eyes with uveal coloboma and microcornea. PATIENTS AND METHODS: All adult patients with uveal coloboma having microcornea in at least one eye and seen between May 2014 and July 2016 at the cataract clinic of our tertiary eye care center were evaluated. The study group comprised 26 colobomatous eyes of 15 patients who had associated microcornea. The control group comprised eyes with uveal coloboma and normal-sized cornea (n=12 eyes of 9 patients). The main outcome measure included the relationship between CCT and HCD in eyes with uveal coloboma and microcornea. RESULTS: The mean HCD of the study and control groups was 6.97±1.28 and 11.39±0.67 mm, respectively. The mean central pachymetry of the study group was 668.4±40.2 μm compared with 555.3±41.8 μm in the control group. In both the groups, CCT was negatively correlated with HCD (R=−0.62 in the study group and R=−0.72 in the control group). CONCLUSIONS: Uveal colobomatous eyes with microcornea have thicker corneas compared with uveal colobomatous eyes with normal diameter corneas that have normal central corneal thickness. In all the eyes with uveal coloboma, there is a negative correlation between horizontal corneal diameter and central corneal thickness.

We describe a case of 55-year-old male farmer presented with recurrent corneal abrasions with a spastic entropion in the left eye. Superior cornea showed typical nummular opacities suggestive resolved herpetic eye diseases. On further enquiry, he had similar episodes in the past. Contralateral eye was essentially normal. Following the botulinum toxin injection for the management of spastic entropion, subject developed reactivation of herpetic necrotizing stromal keratitis. Diagnostic corneal scrapings were negative for herpes simplex virus-1 antigen by immunofluorescence assay and for DNA by molecular techniques. The case was successfully managed with topical steroids and antiviral medications.

Purpose To evaluate parents of probands affected with autosomal recessive congenital hereditary endothelial dystrophy (CHED) for clinical signs of Fuchs endothelial corneal dystrophy (FECD) and to determine the genotypes of the SLC4A11 gene in the probands and their parents. Methods This study involved 9 patients affected with CHED from 8 families. The parents of such probands were examined to investigate for possible signs of FECD although they did not present with any visual complaints. Blood samples were collected after obtaining consent, from all 9 cases and the parents of each proband, for genetic analysis. Genomic DNA isolated from blood leukocytes was used for genetic analysis. Screening of the coding regions of the SLC4A11 gene for mutations was carried out by standard procedures using polymerase chain reaction (PCR) amplification and sequencing. Sequences were checked against the human SLC4A11 reference sequence to detect alterations and in normal control samples available in the laboratory. Results The probands had characteristic signs of CHED, whereas one of the parents of each of the probands showed early signs of FECD, characterized by the presence of guttae in the central cornea corroborative with the diagnosis of FECD, and were otherwise asymptomatic at that time. The CHED-affected probands were homozygous for various SLC4A11 mutations, and their parents were heterozygous for the same. The mutations included missense mutations in 6 probands and nonsense mutations in 2 cases. Conclusions Heterozygosity for SLC4A11 mutations in the parents of children with autosomal recessive CHED appears to be a risk factor for the development of FECD in these cases.

To report the clinical course and management of interface keratitis due to Enterococcus faecalis after Descemet membrane endothelial keratoplasty (DMEK). A 64-year-old man underwent DMEK, with unevenful immediate postoperative course, with a visual recovery of 20/30 at 2 weeks. At 3 months of clinical visit, interface keratitis was noted. DMEK graft removal with stromal bed scrapings was performed. A diagnosis of E. faecalis interface keratitis was made. The patient responded favourably to antibiotic susceptibility-guided intensive treatment with vancomycin 5% with complete resolution of infection. After 2 months of graft removal, Descemet stripping endothelial keratoplasty (DSEK) was performed. The corneal clarity was restored and the best corrected visual acuity was 20/40 at last follow-up of 1 year. E. faecalis should be kept as a differential in delayed onset interface keratitis after DMEK. After microbiological cure with antibiotic therapy, visual rehabilitation with DSEK restores corneal clarity and results in favourable visual outcome.

Purpose: Congenital corneal anesthesia (CCA) is a rare clinical entity that poses a diagnostic dilemma, particularly in the pediatric age group with very little literature on this. Accurate initial diagnosis, evaluation, early identification of risk factors, aggressive systemic workup, and appropriate therapy are paramount to prevent visual loss due to long-term complications of corneal anesthesia. The purpose of the study was to estimate and compare the corneal neural architecture using real time, in vivo confocal microscopy (IVCM) in patients with CCA as against a control population. Methods: This was a retrospective nonconsecutive, comparative clinical case series in a tertiary hospital in South India from June 2015 to December 2018. Methods: IVCM was accomplished in cooperative children in whom central cornea was relatively clear. The clearest three to five images from each eye were selected, and the nerves were analyzed for length, thickness, density, dichotomous pattern, and beading. Statistical analysis was done using Origin v7.0 (Origin Lab Corporation, Northampton, MA, USA). Results: In total, 15 eyes of 11 cases and 20 eyes of 10 controls were imaged. Measurements on corneal nerve density showed a significant difference (P = 0.0005), cases having a lower mean (3.85 ± 1.38 mm per mm2) compared to the controls (6.74 ± 1.75 mm per mm2). Measurements on corneal nerve length (P = 0.28), thickness (P = 0.45), and presence of beading (P = 0.97) and dichotomous pattern (P = 0.07) did not reveal a significant difference between cases and controls. Conclusion: There is a strong relationship between the functional loss (absent corneal sensation) and anatomical decrease (reduced subbasal nerve density) of corneal nerves in congenital corneal anaesthesia.

Purpose: The aim of this study was to describe the clinical profile and demographic distribution of pellucid marginal corneal degeneration (PMD) in patients presenting to a multitier ophthalmology hospital network in India. Methods: This cross-sectional hospital-based study included 2,470,793 new patients presenting between September 2012 and September 2020 (~8 years period). Patients with a clinical diagnosis of PMD in at least one eye were included as cases. The data were collected using an electronic medical record system. Results: Overall, 559 (0.02%) new patients were diagnosed with PMD. The prevalence rates were 0.004% in children (age

The aim of the study is to describe the experience with precut facility for endothelial keratoplasty at a single eye bank affiliated to a tertiary eye care center in India. Data on precut tissues from Nov 2012 to Dec 2014 were retrospectively reviewed from the electronic database of the eye bank of a tertiary eye care center in South India. Donor characteristic data including donor age, precut and postcut endothelial cell density (ECD), recipient age, and thickness of graft were collected. The number of precuts increased from 42 in 2012 (Nov and Dec) and 422 in 2013 to 584 in 2014. Of the total of 1048 precuts, seven (0.67 %) were miscut and could not be utilized for transplants. The donor age ranged from 2 to 89 years. A mean change of 43.6 ± 325.2 cells/mm2 in ECD was noted after cut, proportional increase in mean being 1.9 %. The change in ECD after cut was negatively correlated with ECD before cut. The recipient age ranged from 1 to 89 years. The median thickness of donor lenticule after cut was 148 µm (interquartile range 131-166 µm). Analysis of precut donor corneas from a single eye bank shows that the ECD of the processed tissues was excellent for transplantation. The tissue wastage in the hands of eye bank personal was minimal.

Purpose: In tropical countries, physicians are skeptic in using corneas with death-to-preservation time (DTPT) >6 h, concerns being endothelial cell viability and microbial contamination on prolonged DTPT. The objective of the study was to investigate these concerns by analyzing the outcomes of corneal transplants performed using donor corneas with DTPT >6 h. Materials and Methods: The study was a retrospective case series of 65 transplants performed in 2013 with donor corneas that had DTPT >6 h (range, 6.1–9.8 h). The information on donor cornea tissues and the recipient details were collected from the eye bank and the medical records department of our tertiary eye care center. The main outcome measures were slit lamp assessment of the donor corneas, primary graft failure, graft survival, and postoperative adverse reactions, especially infections, if any. Results: Median DTPT was 7 h. Forty-four (67.7%) corneas were evaluated as optical grade and 21 (32.3%) were deemed as therapeutic grade; 36 (55.4%) were used for optical indications. There was no relationship between DTPT and the tissue grading of corneas or endothelial cell density. Of the 23 keratoplasties for purely optical indications with a minimum follow-up of 3 months, 15 (65.2%) remained clear whereas 7 (30.4%) failed (mean follow-up 15.1 ± 6.7 months). The causes of failure were primary graft failure (n = 1) and secondary graft failure (n = 6). Conclusion : The donor corneas with DTPT 6 h to 10 h can be utilized for optical indications provided that they meet the criteria of tissue acceptance for optical use.

The growth of eye banking in India was showing positive trends until the nation was hit by unprecedented times as a result of the COVID-19 pandemic. The impact of this has led to a downward spiraling in eye banking activities globally. Several measures had to be implemented to tide over the crisis and strategies planned for future to prepare for the needs of corneal transplantation. While eye banks in India have been practicing short- term and intermediate storage preservation media, there is a definite need to evolve other methods of very long-term preservation. This review discusses various methods of long term corneal preservation, their relevance and applications in the present times. We reviewed relevant medical literature in English from PUBMED with the key words "Corneal preservation", "Cryopreservation", "Glycerol preservation", Gamma Irradiation", "Eye Banking" ,"COVID-19".

PURPOSE To evaluate the relationship between endothelial cell density (ECD) and mean corneal diameter (MCD) in eyes with uveal coloboma associated with microcornea. METHODS Corneal endothelial cell imaging was performed using specular microscopy on 22 eyes of 18 subjects diagnosed with uveal coloboma associated with microcornea. The MCD was noted as the average of horizontal and vertical corneal diameters, which were measured using the ruler tool of the slit-lamp biomicroscope and Castroviejo calipers. RESULTS Mean age of the study subjects was 29.7 ± 10.4 years (range, 14-46 years). The MCD was 7.3 ± 1.1 mm (range, 4.9-9 mm). Mean ECD (3436 ± 316.2 cells/mm) of the study subjects was significantly (P < 0.0001) higher than the mean ECD (2761.8 ± 140.9 cells/mm) of age-matched (range, 10-40 years) normal eyes with no ocular pathology. The pleomorphism and polymegathism were comparable between the 2 groups. Regression analysis showed that MCD had a significant negative (R = -0.55; P = 0.02) relationship with ECD. CONCLUSIONS Eyes with congenital uveal coloboma associated with microcornea have increased ECD. Increased ECD may be partly due to a reduced posterior corneal surface area in microcornea.

We report two cases of corneal coinfection with Acanthamoeba and Fusarium sp. along with the review of published literature. A 35-year-old woman and 65-year-old man presented to the institute with corneal ulcer refractory for treatment with topical antibiotics. Microbiological examination revealed the presence of Acanthamoeba cysts along with septate, hyaline fungal filaments. After emergency therapeutic penetrating keratoplasty (TPK) in both, the corneal tissue was sent for histopathologic examination, which confirmed the presence of Acanthamoeba and fungal coinfection. One patient had a recurrence of fungal infection after TPK. In subjects with a rapid progression of mycotic ulcer, coinfection with other microorganisms including Acanthamoeba should be suspected. The two cases presented here emphasize the importance of microbiology in making prompt diagnosis and appropriate management of these cases at an early stage.

PurposeTo describe the clinical spectrum, clinicopathological correlation and outcomes of different surgical strategies in the management of acquired implantation iris cysts.MethodsFrom 1 January 1989 to 31 December 2015, 27 patients (27 eyes) with acquired implantation iris cysts underwent surgery. The charts were reviewed for demographics, preoperative characteristics, surgical approach, histopathological records of excised cyst and postoperative outcomes.ResultsThe median age at presentation was 5 years (IQR: 1.3–14 years). Out of 27 patients, 21 (78%) were aged≤18 years. Almost two-third (17/27, 63%) patients had history of penetrating ocular trauma prior to surgery. All patients underwent cyst aspiration combined with complete cyst excision with additional surgical procedures when necessary. Along with complete cyst excision, sector iridectomy was performed in 20/27 (74%) eyes. At a median postoperative follow-up period of 8 months (range: 1–72 months), recurrence was noted in 3/27 (11%) cases at a mean follow-up period of 2.3±1.5 months postsurgery. Eyes in which sector iridectomy was performed had lower incidence of recurrence, and this was statistically significant (p=0.03). However, the improvement in best-corrected visual acuity postoperatively was not statistically significant (p=0.15).ConclusionAcquired implantation iris cysts are associated with significant ocular morbidity. Complete excision of the cyst with sector iridectomy is an effective treatment option if other less invasive surgical approaches fail. Visual acuity can be significantly improved but is typically limited due to associated comorbidities.

Cornea being constantly exposed to sunlight and atmospheric oxygen is readily prone to oxidative damages. The functional antioxidant signaling helps maintain the levels of reactive oxygen species in the cells and keeps the cornea healthy. Corneal endothelial dystrophies include a group of corneal diseases that are marked by progressive degeneration of corneal endothelium leading to loss of vision. The increased level of oxidative stress in several corneal endothelial dystrophies indicates that there might be disruption in proper functioning of these signaling pathways. Various strategies to improve antioxidant signaling pathways may help develop novel clinical interventions to combat degeneration of endothelial cells that leads to vision loss. This review gives an overview of oxidative stress in the pathogenesis of corneal diseases.

Xeroderma pigmentosum is a condition caused due to a defective DNA repair mechanism when exposed to ultraviolet radiation. Many of the patients with this disorder develop severely oedematous cornea with varying degrees of anterior corneal haze, which necessitates a full-thickness keratoplasty or selective endothelial keratoplasty. Presence of corneal oedema suggests that these patients have a dysfunctional endothelium. The purpose of this study is to evaluate the corneal endothelium in the patients with xeroderma pigmentosum when clinical specular microscopy was feasible.Thirteen patients with classic skin changes of xeroderma pigmentosum were included in the study conducted during January 2010-December 2012. An age-matched group of 13 volunteers were included as controls who were emmetropes without any history of ocular or systemic illness. Corneal endothelium was assessed using specular microscopy from the central clear area of cornea.The mean age of the patients with xeroderma pigmentosum was 16.6±7.2 years and that of the controls was 17.4±6.9 years (p=0.78). The number of analysed cells and endothelial cell density were significantly higher in controls (p0.001), whereas the average cell area, coefficient of variation of cell area and maximum cell area were significantly higher in xeroderma pigmentosum (p≤0.007).The specular microscopic findings in patients with xeroderma pigmentosum are suggestive of an accelerated endothelial cell loss. It is pertinent that the treating physicians must be involved in emphasising proper ocular protection from ultraviolet radiation to prevent avoidable blindness from xeroderma pigmentosum.

Bilateral corneal dystrophy includes a group of genetically determined, non-inflammatory corneal diseases, which result in loss of corneal transparency and visual impairment.1 Earlier, the classification of corneal dystrophy was solely anatomically based. However, the newer classification system based on recommendations of the International Committee for Classification of the Corneal Dystrophies (IC3D)2 has incorporated clinical findings, pathological characteristics and genetic basis, thereby giving a complete insight into each dystrophy, and has also enabled easy adaptation to advances in understanding from the continued discovery of new genes and mutations. Herein, we report two siblings who were clinically diagnosed with a rare variant of granular dystrophy i.e. superficial variety, confirmed histopathologically from debrided epithelia using an innovative procedure i.e. alcohol assisted phototherapeutic keratectomy (PTK). To the best our knowledge, such an innovative method to confirm the diagnosis has not been mentioned in literature. Genetic analysis was also done, thereby enabling a clinicopathogenetic correlation, considering the newer classification of corneal dystrophies.

Purpose The aim of this study was to compare visual acuity, clinical outcomes, complications, and risk factors for graft failure after deep anterior lamellar keratoplasty (DALK) and penetrating keratoplasty (PK) for macular corneal dystrophy. Methods Retrospective comparative case series. Results The PK group consisted of 109 eyes of 84 patients and the DALK group consisted of 21 eyes of 20 patients. The mean logarithm of the minimum angle of resolution best-corrected visual acuity at 3 and 12 months was 0.5 versus 0.5 (P = 0.285) and 0.4 versus 0.4 (P = 0.67) in the DALK and PK groups, respectively. There was no significant statistical difference in astigmatism and spherical equivalent between the 2 groups at 12 months. In the PK group, graft rejection that was the most common cause of graft failure was seen in 27 eyes (25%), of which 55% occurred within 1 year. In the DALK group, Descemet membrane microperforation occurred in 5 eyes (24%) intraoperatively, and early postoperative Descemet membrane detachment with double anterior chamber occurred in 9 eyes (43%). Kaplan-Meier estimate of graft survival in PK versus DALK groups were 93% versus 80% at 1 year and 78% versus 70% at 4 years, respectively. Conclusions Visual and refractive outcomes are comparable between DALK and PK groups. DALK was superior to PK in its safety against postoperative complications such as endothelial rejection and secondary glaucoma. Graft failure in DALK was mostly associated with either intraoperative or early postoperative complications. DALK is a viable surgical option in cases with macular corneal dystrophy.

Purpose To describe the previously unreported successful treatment of presumptive Pythium keratitis (PK) with medical therapy alone. Methods A 42-year-old female homemaker presented to us with a 15-day history of pain and redness in the right eye after a trivial injury. Her vision was 20/80 at presentation. Slit-lamp biomicroscopy revealed a central, dense and dry-looking, grayish-white infiltrate reaching mid stroma. The infiltrate had feathery margins and was surrounded by multiple tentacle-like lesions and peripherally expanding pinhead-sized subepithelial lesions. The contralateral eye was essentially normal. Diagnostic corneal scraping on smears revealed broad, aseptate, hyaline filaments with ribbon-like folds; very characteristic of Pythium species. Confocal imaging revealed fungal filaments. Based on corroborative evidence, a diagnosis of presumptive PK was made. She was administered a combination therapy consisting of eye drop linezolid 0.2% 1 hourly, azithromycin 1% 2 hourly, atropine sulfate 1% thrice daily, and oral azithromycin 500 mg once daily for 3 days in a week. Results After initial worsening in the form of stromal expansion, regression of pinhead-sized lesions was seen with onset of scarring by as early as day 4 of intense medical therapy. The tentacle-like lesions did not worsen. On day 8, significant resolution was noted with scarring, and by the end of 2 weeks, the entire stromal lesion had scarred and complete resolution of expanding tentacles was observed in 3 weeks. Conclusions Presumptive Pythium keratitis of the patient completely resolved with antibacterial treatment alone. It is pertinent for ophthalmologists to be aware of this new treatment regimen.

The aim of this study was to determine predisposing factors, clinico-microbiological profile, and outcomes of neonatal infectious keratitis.The retrospective study included 39 eyes of 34 neonates treated for microbial keratitis at the L. V. Prasad Eye Institute, India, between January 2006 and December 2011. Etiologic microorganisms, predisposing factors, and management outcomes were evaluated.The Mean age at presentation was 16.9 + 7.7 days, male:female = 16:18. The potential risk factors and coexisting conditions identified were prematurity and prolonged Neonatal Intensive Care Unit (NICU) care, route of delivery, maternal infections, systemic associations, and ocular malformations. Microbiology workup yielded positive results in 29 eyes. Ten eyes were smear and culture negative, with results of immunofluorescent assay and polymerase chain reaction for herpes simplex virus being negative. Bacteria were the commonest (23/39 eyes, 59%) cause of infections, and Pseudomonas aeruginosa was the commonest (12/23 eyes, 52%) bacterial isolate. Multidrug-resistant Pseudomonas keratitis was identified in 8/12 (67%) eyes. Keratitis resolved on medical treatment in 34 eyes. Two of these eyes with scars underwent penetrating keratoplasty later. Of the 8 eyes with multidrug-resistant P. aeruginosa keratitis, 3 eyes had near-total corneal infiltrates, 2 eyes developed anterior staphyloma, 1 eye autoeviscerated, and 1 eye required a therapeutic tectonic graft. One of the 2 eyes with fungal keratitis underwent therapeutic penetrating keratoplasty.Identification of the appropriate predisposing factors, etiologic microbial organisms, and treatment outcome from this study may aid in early recognition and treatment of microbial keratitis in neonates.

Purpose To compare the outcomes of triple Descemet's membrane endothelial keratoplasty (DMEK) versus DMEK alone in pseudophakic eyes. Design Retrospective, comparative, interventional case series. Participants Patients with Fuchs' endothelial dystrophy, secondary corneal edema, and prior failed endothelial keratoplasty with or without prior cataract extraction. Methods Outcomes of 492 DMEK procedures performed between April 2010 and August 2012 were reviewed; 292 pseudophakic eyes underwent DMEK (group 1) and 200 eyes had concurrent cataract surgery with DMEK (group 2). Main Outcome Measures Corrected distance visual acuity, endothelial cell loss, immediate and early postoperative complications. Results The mean age at the time of surgery was 70 years (range, 47–94 years) in group 1 and 64 years (range, 46–90 years) in group 2 ( P 0.0001). At 6 months, the median corrected distance visual acuity was 20/25 (range, 20/16–20/80; n = 164) in group 1 and 20/20 (range, 20/16–20/100; n = 121) in group 2 ( P 0.0001), excluding 21 eyes with retinal or optic nerve problems. The DMEK graft failed to clear in 9 eyes (3.1%) in group 1 and 7 eyes (3.5%) in group 2 ( P = 0.34); all were regrafted successfully with DMEK. No further graft failures occurred during the follow-up period. The air reinjection rate was 30% in group 1 and 29% in group 2 ( P = 0.69). The air reinjection rate dropped significantly in both groups, from 45% to 16%, after use of viscoelastic was eliminated during the tissue insertion step. The median endothelial cell loss at 3 to 6 months did not differ significantly between groups (26% in both). Conclusions Triple DMEK was not associated with any higher risk of complications than DMEK alone. Compared with sequential management of patients with concomitant cataract and endothelial dysfunction, triple DMEK is an effective strategy in rapid visual rehabilitation and offers the advantage of a 1-stage procedure, with reduced risks and costs.

Purpose The objective of this study was to review the indications for endothelial keratoplasty (EK) performed at a tertiary eye care center in South India between January 2007 and December 2011. Design This was a hospital-based, cross-sectional study. Methods A retrospective analysis of the indications of EK surgeries between January 2007 and December 2011 was done using the Corneal Tissue Utilization Register available with the Ramayamma International Eye Bank, L. V. Prasad Eye Institute, Hyderabad, India. Additional data such as age, sex, and socioeconomic status of the transplant recipients were obtained from the Medical Records Department, L. V. Prasad Eye Institute. Results Data were available for 1048 EK surgeries performed on 978 patients. The number of EK surgeries increased from 40 in 2007 to 232 in 2011. The median age of the patients was 58 years (range, 5 months to 92 years) with a male-female ratio of 1.5:1. The clinical indications for EK were pseudophakic corneal edema (47.9%), failed prior penetrating keratoplasty (20.0%), Fuchs endothelial corneal dystrophy (10.8%), aphakic corneal edema (6.0%), failed prior EK (4.3%), congenital hereditary endothelial dystrophy (1.8%), Descemet membrane detachment/tear (1.6%), iridocorneal endothelial syndrome (1.4%), and corneal edema due to other reasons (6.2%). Conclusions The most common indication for EK was pseudophakic corneal edema, followed by post-penetrating keratoplasty graft failure and Fuchs endothelial corneal dystrophy.

Purpose: To study the outcomes of therapeutic penetrating keratoplasty in fungal keratitis. Methods: This retrospective, observational, interventional case series involved an audit of 198 consecutive eyes that underwent therapeutic penetrating keratoplasty (ThPK) for fungal keratitis at L V Prasad Eye Institute between January 2008 and December 2010 was performed. The data on demographics, clinical characteristics, intraoperative, and late postoperative complications were noted. The primary outcome measure was eradication of infection and postoperative anatomical success. Secondary outcome measures were graft survival, risk factors, clinical features, and management of recurrent fungal keratitis post ThPK. Results: Mean follow-up after ThPK was 24 ± 17 months. A total of 178 (89.9%) eyes had complete eradication of fungal infection, whereas 20 (10.1%) eyes developed recurrence. Anatomical restoration was achieved in majority of cases (192 eyes; 97%). Larger infiltrate size was associated with a higher risk of recurrence of infection. The median graft survival rate was 5.9 months. The graft survival was better for grafts 8 mm (P = 0.026) and not found significantly related to the species of fungus. Twenty-seven eyes underwent re-grafting: penetrating keratoplasty in 14 eyes, and Descemet's stripping endothelial keratoplasty in 13 eyes. Conclusion: As larger infiltrate prior to therapeutic keratoplasty had much higher risk of recurrences; timely surgical intervention should be considered in cases not responding to medical therapy. Alternative strategies of management of postoperative inflammation need to be considered to prevent graft failures.

Aims To evaluate and compare outcomes of Descemet9s stripping endothelial keratoplasty (DSEK) with non-DSEK (nDSEK) in pseudophakic corneal oedema (PCE). Methods The study was a prospective, non-consecutive, comparative, interventional case series. Twenty-six patients with PCE were randomised into two groups. Group 1 comprised of those cases that had undergone conventional DSEK, and group 2 consisted of those that had nDSEK for PCE between 2010 and 2012. The data on demographics and clinical characteristics were collected from all patients. Any intraoperative and early and late postoperative complications were also noted. The primary outcome measure was postoperative functional success. Graft survival and complications were analysed as secondary outcomes. Results The median best-corrected visual acuities at 6 months postoperatively in groups 1 and 2 were 0.18 (IQR 0.10–0.30) and 0.44 (IQR 0.18–0.51), respectively (p=0.11). Corneal oedema cleared in all patients. During the early postoperative period, a patient in group 2 had lenticule detachment managed by rebubbling. Conclusions nDSEK has outcomes similar to DSEK in PCE with advantages of decreased surgical time and avoidance of inadvertent pull on the posterior stromal fibres that may occur during Descemet9s stripping.

Selective anterior lamellar corneal replacement procedures have resulted in fewer allograft rejections compared with penetrating keratoplasty. Deep anterior lamellar keratoplasty offers several advantages over conventional penetrating keratoplasty, significantly reducing the lifetime endothelial rejection. We report the case of a child with a presumed immune-mediated stromal rejection after deep anterior lamellar keratoplasty who presented with interface fluid, confirmed by optical coherence tomography, that subsequently resolved after prompt topical steroid treatment.

To report the clinical characteristics and treatment outcome in six patients with chronic conjunctivitis due to Mycobacterium tuberculosis. In this retrospective observational case series, all patients with a diagnosis of conjunctival tuberculosis seen in our clinics between January 2000 and January 2010 were reviewed. The clinical presentation, diagnostic investigations and response to medical therapy and outcomes were analyzed. Six patients (age range 15-47 years) were diagnosed with conjunctival tuberculosis. The mean duration from onset of symptoms to diagnosis was 6.5 months (range 1-12 months). Of the six patients, two had ulceration, one had a nodulo-ulcerative lesion, one had bilateral nodular epibulbar masses, and one had a hypertrophied papillary lesion. Systemic signs of tuberculosis were noted in two patients--pleural effusion in one and preauricular and submandibular lymph node involvement in the other. All patients had resolution of symptoms after treatment with four-drug anti-tuberculosis therapy (ATT). None had ocular or systemic recurrences after completion of ATT. Tuberculosis of the conjunctiva can have varied clinical presentation. Although a rare entity, it should be suspected in non-responding chronic conjunctivitis. A high index of suspicion and clinical examination aided by appropriate microbiological and histopathological testing can help in early diagnosis and management.