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With the surging demand for versatile products with eclectic fabric construction, weaving industries often qualify the standardized denting order with a view to utilize the reeds that are at their disposal. In the weaving cycle, beat-up operation is performed by reed which also controls the denting order. The appearance and quality of woven fabric vary due to various parameters. Among them denting order is one of the most overlooked parameters. The present study is uniquely designed to determine the ramifications of the denting order changing on plain woven fabric quality and appearance while keeping the loom parameters, yarn parameters and fabric construction constant. A total of five plain fabrics were manufactured and six performance properties including tear resistance, tensile strength, seam slippage resistance, fabric weight, abrasion and pilling resistance of the samples were analyzed and statistically evaluated with ANOVA. The appearance was assessed visually. What appeared was that tensile, tear, and appearance had undergone perpetual change for all the samples but change of seam slippage, fabric weight, abrasion, and pilling resistance remained inconsistent. Statistical evaluation also revealed that the difference among the fabric properties due to variation of denting order were significant especially for tearing and tensile strength.

PURPOSE: To describe the preoperative characteristics, intraoperative details, management, and postoperative in patients with bilateral epithelial defects after laser in situ keratomileusis (LASIK). METHODS: Retrospective non-comparative case series. RESULTS: Six patients with bilateral epithelial defects after LAISK were part of a cohort of 605 patients undergoing bilateral LASIK at our center from December 2001 to April 2003. The mean age of the patients (5M:1F) was 28.5 7.9 years, and the average pretreatment myopic spherical equivalent (SE) refraction was 7.3 0.7 D (-4, -12.25D). An epithelial flap was present in 6 eyes and an epithelial defect with a mean diameter of 3 mm (2mm, 6mm) was seen in 6 eyes. In four patients the epithelial disturbance was bilaterally similar. All defects occurred in the inferior cornea and the epithelial flaps had the hinge positioned superiorly. None of the patients had ocular or systemic risk factors that could have resulted in this complication. A bandage contact lens was used in 6 eyes. At last follow-up of 5.5 9.5 months (0.25, 21 months), unaided visual acuity was 6/9 or better in 10 eyes. Best spectacle-corrected visual acuity (BSCVA) was maintained in 8 eyes, while 4 eyes lost one line of BSCVA. Recurrent corneal erosions were not reported in the follow-up period. CONCLUSIONS: These patients represent a hitherto unrecognised group of individuals who appear to have a subclinical weakness of adhesion of the corneal epithelium to the underlying structures, which is not evident on clinical examination. This results in bilateral epithelial disturbances after LASIK. Appropriate management results in satisfactory clinical outcomes. Other options for treatment of the fellow eye of such patients include the use of a different microkeratome, release of suction during the reverse pass of the Hansatome microkeratome, and photorefractive keratectomy if the refractive error is low.

Purpose: To report the application of a digital camera for ophthalmic photography in routine clinical use. Methods: A digital camera (Nikon Coolpix 995) was used both for external macrophotography of the eye and ocular adnexa, and slitlamp photography of the anterior segment of the eye. Results: We were able to take external macrophotographs under high magnification of the eye and ocular adnexa. Slitlamp photography could be performed under diffuse, slit beam, and retroillumination. The structures of the angle, the optic disc and surrounding retina could be photographed using appropriate lenses. The attachment to the operating microscope allowed intra-operative photography. It could also be attached to the laboratory microscope to capture images of various histopathology and microbiology slides. Conclusions: A digital camera is a versatile instrument for ophthalmic photography. It is easy to use in routine clinical practice and provides good quality photographs.

Human immunovirus infection in India is rapidly increasing. Ocular lesions due to highly active antiretroviral therapy have been well recognized. Acquired immunodeficiency syndrome can affect all parts of the eye. However, posterior segment lesions are the most common and of these, Human immunodeficiency virus retinopathy and cytomegalovirus retinitis predominate. Often clinical examination can establish the diagnosis of many ocular lesions in acquired immunodeficiency syndrome; therefore, ophthalmologists need to be aware of the more common ones. Various drugs in different routes can used to treat cytomegalovirus retinitis. Highly active antiretroviral therapy has remarkably reduced systemic and ocular morbidity among acquired immunodeficiency syndrome patients. To facilitate care of these patients aseptic precautions for ophthalmic care personnel are now well established and therefore ophthalmologist should not hesitate to provide ophthalmic care to acquired immunodeficiency syndrome patients.

PURPOSE: To report indications, technique, and results of excimer phototherapeutic keratectomy (PTK), and describe possible reasons for the small numbers of such procedures performed in a referral institute in India. METHODS: Retrospective review of case records of 10 patients (11 eyes) who underwent excimer PTK at our institute between February 1994 and September 1997. RESULTS: Corneal scars were the most common indication for treatment. Best-corrected visual acuity (BCVA) improved in 6 eyes (mean: 2 lines of Snellen acuity). All eyes had BCVA > or = 6/12 after treatment. None of the patients experienced loss of BCVA after treatment. Unaided visual acuity improved in 3 eyes and decreased in 2 eyes. Change in spherical equivalent refraction > or = 1 diopter occurred in 77.8% of eyes after treatment. Treating central corneal scars resulted in a significant hyperopic shift in refraction. CONCLUSIONS: Excimer PTK is a safe and effective procedure for the treatment of superficial corneal opacities. Post-treatment ametropia may require further correction with optical aids. Inappropriate referrals, deep corneal scars, and cost of the procedure could have contributed to the small numbers of PTK performed at our institute. Improved understanding of procedural strengths and limitations could lead to increased use of this procedure, with satisfying results in selected patients.

An 82-year-old healthy man with unilateral chronic stromal keratitis, initially diagnosed to have viral keratitis and refractory to medical therapy, showed numerous oval, microsporidial organisms, measuring 4-5 m in length in the corneal biopsy. Penetrating keratoplasty, followed by treatment with systemic albendazole and topical propamidine isethionate resulted in resolution of the infection. Electron microscopy of the keratoplasty specimen demonstrated sporoblasts with diplokaryotic nuclei and multiple coils of the filament. The light and electron microscopic features were consistent with microsporidial keratitis.

A case of unilateral interface keratitis due to Mycobacterium fortuitum following simultaneous bilateral LASIK procedure for low myopia is reported. Excimer phototherapeutic keratectomy was performed to the stromal bed to reduce the infective load. Intensive topical therapy with topical amikacin and ciprofloxacin resulted in resolution of the keratitis.

Descemet membrane endothelial keratoplasty (DMEK) is a partial-thickness corneal transplantation procedure that involves selective transplantation of the Descemet membrane and endothelium. DMEK offers significant advantages over other keratoplasty techniques, such as faster visual rehabilitation, better final visual acuity due to minimal optical interface effects, lower risk of allograft rejection, and less long-term dependence on topical steroids. Despite all its advantages, DMEK has been found to be more challenging than other corneal transplantation techniques, and its steep learning curve appears to be an obstacle to its widespread use and adoption by corneal surgeons worldwide. DMEK surgical training laboratories (wet labs) provide a window of opportunity for surgeons to learn, prepare, manipulate, and deliver these grafts in a risk-free environment. Wet labs are a significant learning tool, especially for those institutions that have limited tissue availability in their local centers. We provide a step-by-step guide for preparing DMEK grafts using different techniques on human and nonhuman models with instructional videos. This article should eventually help the trainees and the educators understand the requirements for performing DMEK and conducting a DMEK wet lab and develop their skills and interests from a wide variety of available techniques., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

An enhanced online and manual grading system, based on the I's and E's, for acute ocular chemical injuries is being proposed. E-PIX is designed to be an online/manual grading system that includes all the parameters that adversely affect the outcome of acute chemical injuries. The importance of addressing the I's and E's in chemical burns cannot be underestimated. These include the need for the documentation and management of epithelial defect (E), intraocular pressure (P) (IOP), ischemia (scleral) (I), and exposure (X) (acronym - E-PIX). Epithelial defect includes that involving the limbus (L), along with conjunctival (C), corneal (K), and tarsal (T). These additional parameters are graded and represented as an annotation along with the limbal grade providing a comprehensive grading for the injury. A manual entry sheet and a freely accessible online grade generator are a part of the system. The proposed enhanced grading offers a final annotation that provides a clear understanding of all factors that can lead to vision-threatening complications ensuring their assessment and hence subsequently their addressal to improve outcomes, if abnormal. The prognostication continues to be based on the grade of limbal involvement. The additional annotations impact prognosis and outcome if not addressed. Including the laterality of injury provides, in addition, a futuristic understanding of available options. The grade generator retains the flexibility to be dynamic with changes reflecting upon the healing process in the acute stage. The proposed system aims to provide primary and tertiary caregivers alike with a uniform grading system., Competing Interests: None

Ocular surface disorders (OSDs) constitute a varied spectrum of conditions that could be associated with dryness, compromised limbal status, varying grades of forniceal obliteration, corneal scars, and a possible underlying immune etiology. These associations adversely impact surgical outcomes in the eye. One of the treatable causes of decreased vision in these eyes is cataracts which could be secondary to the disease, its treatment, or age-related. The compromised ocular surface status can interfere with decision-making regarding the technique of cataract surgery, preoperative biometry for intraocular lens (IOL) power calculation, and intraoperative visibility, increasing the possibility of complications and compromising the final visual outcome. The postoperative course can be affected by complications, including melt and infection. Stabilization of the ocular surface by medical or surgical means, and appropriate management of underlying immune etiology, if any, helps improve and maintain a healthy ocular surface, optimizing cataract outcomes. With the help of pre, intra, and postoperative tools and means, such as punctal occlusion, ocular surface reconstruction, systemic immunosuppression, illuminators, capsule staining dyes, optical iridectomy, prosthetic replacement of the ocular surface ecosystem (PROSE) lenses, and others, the visual outcome post-cataract surgery in these eyes can be maximized. This article highlights the nuances of performing cataract surgery in various OSDs and the need to have a comprehensive stepwise approach is emphasized., Competing Interests: None

Purpose: This study aims to assess the preferred surgical technique of Descemet membrane endothelial keratoplasty (DMEK) among corneal surgeons in India, and barriers in performing DMEK surgeries amongst the non-DMEK surgeons., Methods: An online, questionnaire-based, cross-sectional survey was conducted among members of the Cornea Society of India (CSI) (n = 500). Responses on their surgical experience, preferred technique, complications, and outcome of DMEK were collected and analyzed. Barriers in performing DMEK surgeries were assessed amongst the non-DMEK surgeons., Results: A total of 100 responses were obtained and response rate for the survey was 20%. DMEK was performed by 55% of the participants of whom only 40% had formal training in this technique. Surgical video-based learning was the most often used self-training method for others. Lack of training was the most common reason for not performing DMEK by the non-DMEK surgeons. Descemet stripping endothelial keratoplasty (DSEK) was the most common endothelial keratoplasty (EK) performed by both DMEK and non-DMEK surgeons. High volume (>50 cases) DMEK surgeries were reported by limited surgeons (n = 6). Nearly all the DMEK surgeons prepared the donor tissue by themselves on the day of the surgery, and majority felt that unrolling the graft in the anterior chamber was the most difficult surgical step. Nearly 80% of the DMEK surgeons were more comfortable with DSEK or Descemet stripping automated endothelial keratoplasty (DSAEK) when compared to DMEK., Conclusion: DMEK practice in India needs improvement with increased accessibility to DMEK training programs, wet lab facilities, and better support from eye banks., Competing Interests: None

The aim of this systematic review and meta-analysis was to summarize and compare the available evidence on the level of vitamin D and antioxidant trace elements between the keratoconus (KC) patients and healthy controls. Seven case-control studies with 830 subjects were found eligible with a systematic search using PubMed, SCOPUS, Web of Science, and EMBASE till November 21, 2021. Data were synthesized with a DerSimonian and Laird random-effects method of meta-analysis. The mean serum vitamin D level was significantly lower in the patients with KC [standardized mean difference (SMD): -0.71; P < 0.001] as compared with the control group. The mean serum vitamin D level decreased more in the progressive patients (SMD: -0.80; P = 0.016) than in the stable patients (SMD: -0.66; P < 0.001) when compared with the control group. The mean serum zinc level was found significantly lower in the patients with KC compared with the control group (SMD: -1.98; P = 0.005). Pooled analysis based on the two studies showed significantly lower mean selenium levels in the KC patients (SMD: -0.34; P = 0.003). Regular evaluation of serum vitamin D, zinc, and selenium levels among the patients with KC at disease onset and future follow-ups could be promising in predicting the progressive disease and disease severity., Competing Interests: None

The COVID-19 pandemic has brought a radical change in safety measures in outpatient clinics. The use of face masks by patients and healthcare workers has become a mandatory norm. Exhaled air with a face mask often follows an upward route. The warm exhaled air leads to fogging of 90/78D lens during fundus examination, hampering visualization. This can be prevented by the use of a simple yet innovative DIY adapter for a 90/78D lens, which can be made using simple household items such as PVC pipes or water hose pipes., Competing Interests: None

Purpose: To report a new complication of spontaneous deflation of type 1 big bubble (BB) in deep anterior lamellar keratoplasty (DALK)., Methods: This is a retrospective review of the surgical videos of BB DALK in 2 cases of advanced keratoconus, wherein spontaneous deflation of type 1 big bubble was noted after removal of air injection cannula. Surgical management and visual outcomes were noted., Results: After spontaneous deflation of the BB, the first case was managed using a layer-by-layer dissection of the residual posterior stroma to expose pre-Descemet layer. In the second case, a paracentesis was performed to lower intraocular pressure along with reinflation of the type 1 BB, which was followed by standard surgical steps of BB DALK. Both cases accomplished good visual outcome in the postoperative period. Retrospective analysis of the surgical videos revealed possible mechanism of spontaneous deflation., Conclusions: Spontaneous deflation of type 1 BB can occur after removal of the air injection cannula during DALK, especially in eyes with advanced keratoconus and thin corneas. This complication can be successfully managed without compromising the final visual outcome., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

A new technique of air injection is described for big-bubble deep anterior lamellar keratoplasty (DALK) in eyes with keratoconus, along with a comparative analysis of the original technique. Fifty eyes were analyzed in each group. The mean steep keratometry and anterior chamber depth distribution were comparable between the 2 groups. The mean size of type 1 bubble achieved with single air injection (Group 1) was 7.8 ± 0.4 mm (range 6.5 to 8.5 mm), and with sequential air injection (Group 2) was 8.5 ± 0.3 (range 8 to 9 mm) (P < .001). Intraoperative complications of spontaneous bursting of bubble in 1 eye (2%) and peripheral microperforation in 3 eyes (6%) occurred only in Group 1. The modified technique of big-bubble DALK using sequential air injection aided by paracentesis to lower intraocular pressure allowed enlargement of a type 1 bubble in a safe and controlled manner with minimal risk for complications., (Copyright © 2021 Published by Wolters Kluwer on behalf of ASCRS and ESCRS.)

Purpose: To describe a novel technique for insertion and unfolding of donor Descemet membrane (DM) scroll during DM endothelial keratoplasty (DMEK)., Methods: DMEK was performed in 20 eyes. The donor DM scroll was loaded into a glass injector, and the fluid column was manipulated to achieve a double scroll configuration. After performing DM stripping and inferior iridectomy, an anterior chamber (AC) maintainer was placed in position. The glass injector was inserted into the AC and the tip rotated to ensure correct orientation of the DM scroll. After disconnecting the IV tubing from the AC maintainer, the donor DM scroll was delivered into the AC. Donor unfolding was performed using surface tapping techniques. An air bubble was injected under the graft to obtain a complete AC air fill. The outcomes of this surgical technique were analyzed., Results: Donor DM insertion and unfolding were performed without any complications in all eyes. Double scroll configuration of donor DM in the injector could be achieved in 17 of 20 eyes (85%). A controlled delivery, maintaining correct scroll orientation, was possible in all eyes. Intraoperative duration from insertion to unfolding was 252.7 ± 45.4 seconds. A clear cornea was achieved in all eyes, with 75% of eyes (15/20) achieving corrected distance visual acuity of 20/20 or better, at average follow-up duration of 13.3 ± 1.3 months. Endothelial cell loss at 6 months follow-up was noted to be 16.7%. Partial donor detachment was noted in 2 eyes (10%), which resolved spontaneously., Conclusions: Our novel technique of donor DM insertion allows easy donor insertion and unfolding, thereby simplifying the DMEK procedure., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To report a new clinical sign of corneal folds after Descemet membrane endothelial keratoplasty (DMEK) in the eyes with congenital hereditary endothelial dystrophy (CHED)., Methods: Retrospective review of cases of CHED who presented with unusual folds in recipient cornea after the DMEK procedure for CHED. Clinical outcomes including visual acuity, pachymetry, specular microscopy, anterior segment optical coherence tomography, and corneal clarity, besides postoperative complications were analyzed., Results: Fifteen eyes of 11 cases of CHED successfully underwent DMEK. Five eyes of 4 patients, mean age 17.2 ± 5.8 years (range 10-23 years), developed unusual folds in the anterior cornea after resolution of stromal edema. Mean follow-up was 7.8 ± 2.5 months (range 6-12 months). Mean best spectacle-corrected visual acuity improved from 0.8 ± 0.3 LogMAR preoperatively to 0.3 ± 0.2 LogMAR postoperatively. Corneal thickness improved from 991 ± 65 μm (range 924-1088 μm) preoperatively to 595 ± 78 μm postoperatively (range 525-730 μm). Average endothelial cell counts were 1708 ± 271 cell/mm2 at the last follow-up. No intraoperative or postoperative complications were reported. The corneal folds remained unchanged during the follow-up. Comparative analysis with remaining 10 eyes did not show any significant differences., Conclusions: Cornea can present with unusual folds in the anterior stroma after successful DMEK in CHED. These folds may possibly be due to difference in collagen structure between anterior and posterior corneal stroma and needs to be studied further., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

The aim of this study was to describe a novel device for improved visualization of descemet membrane (DM) during donor preparation for descemet membrane endothelial keratoplasty (DMEK). Comparative analysis was performed using this device (group 1) versus conventional technique (group 2) between an experienced and a trainee surgeon. A total of 20 eyes were analyzed in each group. Average time for DM peeling by experienced surgeon was 238.8 + 17.2 s in group 1 and 382.8 + 36.3 s in group 2 (P < 0.0001), and for trainee surgeon it was 519 + 30.8 s and 686.8 + 31.9 s (P < 0.0001). Retro-illumination made it easier to identify the peripheral cut edge of DM and abnormal adhesions to the underlying stroma during peeling. In group 2, DM tear occurred in 2/10 eyes with an experienced surgeon and 4/10 eyes with a trainee surgeon. Our novel device with retro-illumination allows DM peeling for donor preparation in DMEK to be performed safely with reduced risk of tissue damage., Competing Interests: None

Purpose: Collection of family cancer histories (FCHs) can identify individuals at risk for familial cancer syndromes. The aim of this study is to evaluate the literature on existing strategies whereby providers use information technology to assemble FCH., Methods: A systematic search of online databases (Ovid MEDLINE, Cochrane, and Embase) between 1980 and 2020 was performed. Statistical heterogeneity was assessed through the chi-square test (ie, Cochrane Q test) and the inconsistency statistic (I 2 ). A random-effects analysis was used to calculate the pooled proportions and means., Results: The comprehensive search produced 4,005 publications. Twenty-eight studies met inclusion criteria. Twenty-seven information technology tools were evaluated. Eighteen out of 28 studies were electronic surveys administered before visits (18, 64.3%). Five studies administered tablet surveys in offices (5, 17.8%). Four studies collected electronic survey via kiosk before visits (4, 14.3%), and one study used animated virtual counselor during visits (1, 3.6%). Among the studies that use an FCH tool, the pooled estimate of the overall completion rate was 86% (CI, 72% to 96%), 84% (CI, 65% to 97%) for electronic surveys before visits, 89% (CI, 0.74 to 0.98) for tablet surveys, and 85% (CI, 0.66 to 0.98) for surveys via kiosk. Mean time required for completion was 31.0 minutes (CI, 26.1 to 35.9), and the pooled estimate of proportions of participants referred to genetic testing was 12% (CI, 4% to 23%)., Conclusion: Our review found that electronic FCH collection can be completed successfully by patients in a time-efficient manner with high rates of satisfaction., Competing Interests: Charlene ThomasTravel, Accommodations, Expenses: Inovio Pharmaceuticals, Nektar, Pfizer Kevin HolcombResearch Funding: Fujirebio DiagnosticsExpert Testimony: Johnson and Johnson Inc Melissa K. FreyResearch Funding: InvitaeNo other potential conflicts of interest were reported.

Purpose: This study aimed to assess the preferred surgical technique and outcome of deep anterior lamellar keratoplasty (DALK) among corneal surgeons in India., Methods: An online questionnaire-based cross-sectional survey was conducted among members of the Cornea Society of India (CSI) with experience of performing >10 DALK procedure. The responses pertaining to their surgical experience, preferred technique, complications, and outcome of DALK were collected and analyzed., Results: A total of 156 responses were received. In total, 35.9% of participants reported annual keratoplasty of >50, and DALK constituted >25% surgeries for 25% of participants. Ectatic corneal disorder was reported as the most common indication for DALK by 71.6% of the respondents. Big-bubble (BB) DALK (W A -1.82) was the most preferred technique, along with suction trephine (50%) for partial trephination and bottom port cannula (45.5%) for BB formation. On statistical analysis, no difference was observed in the surgeon reported success rate of BB formation with or without anterior lamellar keratectomy (ALK) (χ2 (1,156) = 3.1498, P = 0.08) or paracentesis (χ2 (1,156) = 0.2737, P = 0.60) before stromal air injection, and method of stromal air injection (χ2 (1,156) = 4.7325, P = 0.09). Conversion to penetrating keratoplasty was reported by 16% of participants in >25% cases, while 66.7% reported in <10% cases. Cataract and double anterior chamber were the most common complications. 50% of participants suggested that >20 procedures are required to overcome the learning curve., Conclusion: BB DALK is the most commonly practiced DALK technique, and its success is independent of ALK and paracentesis being performed prior to air injection and method of air injection (cannula/needle)., Competing Interests: None

Purpose: To report a case of Gundersen flap removal where the ocular surface was restored without the need for additional limbal stem cell transplantation., Methods: We describe a case of 57-year-old man who underwent Gundersen flap for a nonhealing corneal ulcer in right eye 17 years ago. He recently lost eyesight in left eye after blunt trauma. Gundersen flap removal was performed in right eye along with amniotic membrane transplantation., Results: The ocular surface recovered completely after surgery without any evidence of limbal stem cell deficiency. His corrected distance visual acuity improved to 20/60 along with a stable ocular surface, which was maintained till last follow-up of 12 months., Conclusions: A normal ocular surface can be restored after Gundersen flap surgery if removal of limbal epithelium is not performed during the primary procedure. Additional corneal surgery might be required depending on corneal clarity., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To report the utility of preoperative anterior segment optical coherence tomography (ASOCT) in decision-making for stripping of the Descemet membrane (DM) during Descemet membrane endothelial keratoplasty (DMEK) in eyes with congenital hereditary endothelial dystrophy (CHED)., Methods: ASOCT was performed in eyes with CHED undergoing DMEK. Host DM was retained if the DM appearance was normal on ASOCT. Outcomes of DMEK with or without DM stripping (non DM stripping [DMEK]) were analyzed and compared regarding graft adhesion, graft clarity, visual acuity, and complications., Results: Twelve eyes of 8 patients were included in the series. Of these, 6 eyes (mean age, 6 ± 2.6 years, range 3-8 years) underwent nDMEK and 6 eyes (mean age, 23.6 ± 10.2 years, range 13-39 years) underwent standard DMEK. There were no intraoperative complications in either group. During the early postoperative period, one eye in the nDMEK group had donor detachment that was successfully managed by repeat air injection. The mean preoperative and postoperative corrected visual acuities were 1.15 and 0.37 logarithm of the minimum angle of resolution (LogMAR) in the nDMEK group, and 0.95 and 0.25 LogMAR in the DMEK group (P 0.39 and 0.06). Average endothelial cell counts were 1826 ± 318 cell/mm in the nDMEK group (32.3% loss), and 1708 ± 271 cells/mm in the DMEK group (33.6% loss) at the last follow-up., Conclusions: Preoperative anterior segment OCT is useful in decision-making regarding stripping of host DM during DMEK in eyes with CHED. The outcomes of nDMEK were similar to DMEK in this small series.

Over the past two decades, excimer laser-based refractive surgery procedures have been successfully established for their safety and satisfactory visual outcomes. Surface ablation procedures or photorefractive keratectomy (PRK) are practised commonly for the correction of refractive errors including myopia, astigmatism and hyperopia. Satisfactory visual outcomes are achieved in majority of cases, although a very small percentage have issues related to corneal haze, regression, and its associated visual disturbances. To ensure optimal outcomes and to minimize complications, certain keys to success have been designed on the basis of the current review of literature on surface ablation procedures., Competing Interests: None

Purpose: To report outcomes of Descemet's membrane endothelial keratoplasty (DMEK) in eyes with congenital hereditary endothelial dystrophy (CHED)., Methods: The medical records of patients with CHED who underwent DMEK were retrospectively reviewed. Pre- and postoperative visual acuity, corneal thickness, corneal clarity, and graft survival, were analyzed, and intra- and postoperative complications were assessed., Results: A total of 14 eyes of 8 patients were included. Surgery was performed at a mean age of 10 ± 7 years (range, 2-23). DMEK was successfully performed in all eyes, with 13 of 14 eyes (93%) maintaining a clear cornea at final follow-up (mean, 16.9 ± 8.1 months). Following surgery, corrected distance visual acuity improved from 0.9 ± 0.3 logMAR (Snellen 20/158) to 0.4 ± 0.2 (20/50), and pachymetry improved from 932 ± 57 μm to 642 ± 93 μm. Endothelial cell loss was 33%, and average cell counts were 1767 ± 281 cells/mm 2 at final follow-up. Intraoperative aqueous misdirection occurred in both eyes of a 2-year-old child, requiring pars plana vitrectomy. Postoperative donor Descemet's membrane detachment occurred in 4 eyes. Rebubbling was performed in 3 eyes (21%); 1 eye had spontaneous reattachment. One eye (8%) had possible graft failure during follow-up, requiring repeat DMEK surgery., Conclusions: In our study cohort of eyes with CHED, DMEK was performed with good visual outcome. Rebubbling was necessary for donor reattachment in the early postoperative period in some cases., (Copyright © 2020 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

A 50-year-old woman with cornea plana had reduced visual acuity due to development of lenticular changes. Flat keratometry with high astigmatism, shallow anterior chamber depth, and short axial length made it challenging both for intraocular lens (IOL) power calculation and cataract surgery. Surgery was planned for the right eye because the left eye was densely amblyopic. IOL power required was beyond the commercially available lenses; hence, a customized toric IOL was obtained. Phacoemulsification was successfully performed along with in-the-bag implantation of the toric IOL, which resulted in improved visual acuity with satisfactory refractive outcome. Cataract surgery with a customized IOL improved visual acuity in an eye with cornea plana.

The COVID-19 pandemic has brought with it the huge burden of mortality and morbidity across the world and the added effects of the mandatory lockdown measures to try and control the spread. A number of aspects of healthcare including eye donation and eye collection require adequate safety precautions in place to keep both the involved healthcare workers and patients safe. This paper highlights the consensus-based guidelines by an expert panel on how to restart eye banking and eye collection services and carry out emergency corneal surgeries during this COVID-19 time. These guidelines will be applicable to all eye banks across the country and should help ophthalmologists and eye banking staff to restart eye banking while safeguarding themselves and their patients., Competing Interests: None

Objective: To report long-term clinical outcomes of gamma-irradiated corneal lenticules in partial and full-thickness keratoplasty., Methods and Analysis: This multicentre, retrospective case series includes 23 patients who underwent surgery at three centres (India, Guatemala, and USA) between May 2009 and March 2018. The main outcome measures were epithelialization and retention for therapeutic keratoplasty and best spectacle-corrected visual acuity (BSCVA) for optical keratoplasty., Results: Patients were categorised according to primary aetiology requiring corneal transplantation: non-inflammatory conditions, infectious keratitis and sterile keratolysis. Nine patients with non-inflammatory conditions underwent anterior lamellar keratoplasty (n=7) and Boston type 1 keratoprosthesis (n=2). All nine grafts remained intact and epithelialized during follow-up (median 24 months). In the seven patients who underwent anterior keratoplasty, the graft stayed optically clear during follow-up (median 12 months), with BSCVA between 20/20 and 20/40 in all but one patient who developed cataract. Nine patients with severe infectious keratitis had emergency patch grafting. Six of those grafts epithelialized and remained intact over a median of 30 months, providing tectonic support until optical keratoplasty with fresh tissue could be performed. Three grafts had recurrent infectious keratitis 1-3 months postoperatively, two of which underwent tectonic keratoplasty with fresh tissue which also eventually became infected during follow-up. In five additional patients with sterile keratolysis who underwent lamellar patch graft, two grafts remained intact during follow-up (median 36 months). Two patients had recurrent corneal melt within 1 month, and both had subsequent corneal surgery with fresh tissue which also failed. There were no donor-related complications., Conclusion: Gamma-irradiated sterile corneal stromal lenticules can be considered as a viable alternative to fresh tissue in various clinical settings., Competing Interests: Competing interests: PMM: WL Gore & Associates: consultant/advisor. EKA: Allergan, WL Gore & Associates: institutional grant support; CorneaGen and KeraLink: medical director; Novaliq, Clementia, Novartis Pharma AG, Shire, EpiTech, Takeda: consultant/advisor; Dompe: ad board; Sjogren's Syndrome Foundation: unpaid member of the Board of Directors; Up-To-Date: royalty., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and Objective: To compare the visual outcome and complications of two different sutureless scleral-fixated intraocular lens (IOL) implantation techniques, that is, intrascleral IOL fixation technique and modified Yamane's technique of scleral fixation of IOL., Patients and Methods: Patients who underwent scleral fixation of IOL (SFIOL) from June 2015 to February 2017 with more than 6 months of follow-up were examined retrospectively. Improvement in visual acuity (VA), intraocular pressure (IOP) measurements, endothelial cell count, central macular thickness (CMT), and intraoperative/postoperative complications were compared at 6 months follow-up., Results: Seventy eyes were analyzed. The mean follow-up was 10.5 months ± 1.5 months. The final visual outcomes in both groups, modified intrascleral IOL fixation technique (Group A, n = 30) and modified Yamane's technique (Group B, n = 40), were comparable. The indications for surgery were aphakia (n = 15), subluxated/dislocated cataract (n = 31), and dislocated/subluxated IOL (n = 24). The majority of the eyes (92%) improved to VA 0.3 logMAR units or better. The uncorrected distance visual acuity (UDVA), endothelial cell density, and CMT at the 6-month follow-up were comparable in both groups. Postoperatively, transient IOP rise occurred in 18 eyes, retinal detachment in one eye, vitreous hemorrhage in one eye, cystoid macular edema in two eyes, and mild IOL decentration in two eyes., Conclusion: Both techniques have favorable visual outcomes; however, modified 27-gauge needle-assisted Yamane's technique is technically superior because of its transconjunctival approach and less surgical time, and its needle-assisted approach for haptic externalization prevents haptic damage during externalization. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:e129-e134.]., (Copyright 2018, SLACK Incorporated.)

Purpose: The purpose of the study was to report our initial experience with the transconjunctival Intrascleral Intraocular Lens (SFIOL) fixation with modified Yamane's double-needle technique and flanged haptics., Methods: This was a prospective interventional study that enrolled 31 consecutive patients undergoing SFIOL with the modified Yamane's technique. All patients underwent comprehensive evaluation including uncorrected and best-corrected vision, intraocular pressure, ultrasound biomicroscopy, endothelial cell density, and macular thickness using optical coherence tomography (OCT). We excluded patients with visually significant coexistent pathology such as corneal scars, macular pathology, and glaucoma., Results: The mean age of subjects was 57 ± 16.9 years and 23 were men (74%). Surgery was performed for aphakia following complicated cataract surgery in 10 eyes (32%), with lensectomy for subluxated/dislocated cataract in 6 eyes (19%), and with IOL explantation for subluxated/dislocated IOL in 15 eyes (48%). There were no intraoperative complications. Uncorrected visual acuity improved from median of 1.48 logarithm of minimum angle of resolution (logMAR) units (interquartile range [IQR] = 1.3-2 logMAR) at baseline to 0.3 logMAR (IQR = 0.2-0.4 logMAR) at 6 weeks (P < 0.001) which was maintained at 6 months. There were no significant changes in endothelial cell density (P = 0.34) and OCT-based macular thickness (P = 0.31) at 6 months. Two eyes had slight IOL decentration., Conclusion: Our initial experience suggests that the Yamane's technique for SFIOL is a simple procedure with a short-learning curve and is independent of scleral flaps, tunnels, sutures, and fibrin glue. Using widely available 27-gauge needle instead of 30-gauge thin wall needle as originally described by Yamane makes it possible for the use of various three-piece IOLs available globally. Further studies are required for widespread acceptance of this technique.

Purpose: The aim of this study was to describe a microkeratome-assisted 2-stage technique of superficial anterior lamellar keratoplasty (SALK) to manage Reis-Bucklers corneal dystrophy (RBCD)., Methods: A microkeratome was used to create a 9-mm, 140-μm-thick corneal flap in the first stage. Four weeks later, in the second stage, a Hessberg-Baron suction trephine was used to perform a 7.0-mm central trephination up to a depth of 150 μm, within the corneal flap. Donor lamellar tissue was prepared using a microkeratome system, after which a vacuum punch was used to trephine a 7.0-mm lamellar button. This donor button was used to replace the central corneal flap in the recipient cornea without using any sutures. A bandage contact lens was applied for 2 weeks., Results: This modified technique of staged sutureless SALK was used in 4 eyes of 2 patients with RBCD. Postoperatively, all eyes experienced an improvement in both uncorrected and best spectacle-corrected visual acuities. The average best spectacle-corrected visual acuity was 20/30 at the last follow-up (19 months, range 16-22 months). The cornea remained clear in all eyes until the last follow-up without any evidence of recurrence of RBCD., Conclusions: The staged technique of microkeratome-assisted SALK allows the replacement of superficial corneal stroma without the necessity for any sutures and seems to be a safe and effective method for the treatment of RBCD.

Advanced cases of keratoconus often require surgical intervention to restore corneal anatomy and improve eyesight. Penetrating keratoplasty (PK) although commonly performed has potential risk of immunological rejection and is now no longer automatically the first choice of surgery. DALK procedures have evolved, which allows surgical replacement of recipient's corneal stroma, leaving behind healthy descemet membrane (DM) and endothelium. This reduces the risk of allograft endothelial rejection and late graft failure. In recent times, DALK techniques have led to significant improvements in visual outcome and current results are comparable to PK. Big bubble technique of DALK has become the most popular among the various surgical techniques described. Manual near DM DALK also gives good outcome although the visual recovery is often delayed. Future integration of femtosecond laser technology along with diagnostic imaging technology is likely to further improve outcomes of DALK in keratoconus.

Purpose: The purpose of this study was to report a new technique of microkeratome-assisted corneal tattooing for cosmetic improvement in a young female patient with adherent leucoma., Methods: The para-axial adherent leucoma had resulted from penetrating corneal injury sustained at the age of 2 years. A nasal hinged partial corneal flap of 140 μm thickness was raised using the microkeratome. The flap extended to just beyond the medial margin of the leucoma. Organic dye powder was spread on the stromal bed over the leucomatous scar as well as on the undersurface of the corneal flap corresponding to the area of opacity. The flap was then repositioned and a bandage contact lens placed., Results: The staining dye powder completely concealed the leucomatous opacity with good cosmesis and patient satisfaction. Corneal topography and best-corrected visual acuity remained unchanged at last follow up of 9 months., Conclusions: Microkeratome-assisted corneal tattooing appears to be a safe, effective, and precise method of corneal tattooing.

Purpose: To evaluate the results of replacing the posterior stroma and endothelium, using small incision deep lamellar endothelial keratoplasty (DLEK) surgical technique, in patients with corneal endothelial dysfunction., Design: Noncomparative case series., Methods: Fifteen eyes of 15 patients (six males and nine females) with endothelial dysfunction were included in this study. Through a 5-mm scleral incision, a deep lamellar pocket was created across the cornea, followed by excision of an 8.0-mm disk of posterior lamellar corneal tissue. Same size lamellar donor disk was prepared and placed in position without the need of suture fixation. Best spectacle-corrected visual acuity (BSCVA), refraction, endothelial cell density, corneal topography, and corneal thickness were analyzed., Results: Average BSCVA preoperative was 20/200 (range 20/40 to hand movements (HM)), improving to 20/50 (range 20/20 to 20/120) at a mean follow-up of 7.2 months. Average refractive astigmatism at last follow-up was 1.46+/-1.21 diopters (range, 0 to 4 diopters). Preoperative average donor endothelial cell density was 2047+/-311 cells/mm2, and that at last follow-up was 1732+/-514 cells/mm2. Preoperative average pachymetry was 801.4+/-211.3 microm, improving to 553+/-90.4 microm at last follow-up., Conclusions: Initial results with small incision DLEK procedure indicate that it is a safe procedure that provides healthy donor endothelial cell count and function postoperatively, with encouraging visual results.

Purpose: To evaluate the efficacy of deep lamellar keratoplasty using the big-bubble technique in patients with keratoconus., Design: Interventional case series., Methods: Thirteen eyes of 12 patients (eight male and four female subjects) with moderate to advanced keratoconus and intolerance to contact lens wear were included in this study. Deep lamellar keratoplasty was performed by the intrastromal air injection technique. Full-thickness donor tissue devoid of Descemet membrane and endothelium was then sutured into place. Best-corrected visual acuity, refractive results, surgical technique, and complication rates were analyzed., Results: Big bubble was successfully achieved in nine eyes (69.2%). Average postoperative best-corrected visual acuity was 20/25 (range 20/50 to 20/20) at a mean follow-up of 5 months. Intraoperative microperforation of Descemet membrane occurred in two eyes (15.3%). Three eyes (23%) developed a steroid-induced increase in intraocular pressure, which responded to medical therapy., Conclusions: Deep lamellar keratoplasty that uses the big-bubble technique is safe and effective in patients with keratoconus. Visual outcome is comparable to standard penetrating keratoplasty, without the risk of endothelial rejection.