Purpose: The purpose of this study was to report the incidence and outcomes of infectious keratitis after corneal collagen cross-linking (CXL) over 10 years in South India. Methods: Patients who underwent CXL for progressive keratoconus between January 2011 and December 2020 and those with infectious keratitis were identified from an electronic database system. The clinical and microbiological profiles of those affected were extracted from the case files and included in the analysis, whereas viral keratitis was excluded. Results: Eleven eyes with post-CXL infectious keratitis were identified, with 3842 CXL procedures (0.21%) occurring in-house, while 3 were referred from outside. The mean age of the patients was 21.8 +/- 7.8 years, and 7 (64%) were male. Six eyes (54%) had conventional isotonic CXL, whereas 5 had hypotonic CXL when pachymetry was <400 mu m. Six eyes (54%) presented with hypopyon at a median of 3 days after CXL. Culture of the corneal scrapings grew methicillin-sensitive Staphylococcus aureus in 4 patients, methicillin-sensitive Staphylococcus epidermidis in 2, Aspergillus fumigatus in 1, Aspergillus flavus in 1, Haemophilus parainfluenzae in 1, and no organisms in 2 patients. Almost all the isolates were resistant to ciprofloxacin and other fluoroquinolones. The majority of eyes responded well to intensive topical antibiotics guided by antibiograms and regained 6/18 vision (median). Therapeutic keratoplasty was needed in 2 eyes while cyanoacrylate glue was needed in another 2 eyes. Conclusions: Post-CXL infections are rare, most frequently caused by antibiotic-resistant commensals, and resemble the clinical spectrum and outcomes of non-CXL-related infectious keratitis in most cases.

We successfully utilized one donor cornea for three patients: firstly, a crescentic lamellar keratoplasty for Terrien’s marginal degeneration; secondly, Descemet’s membrane endothelial keratoplasty for Fuchs endothelial dystrophy; and finally, deep anterior lamellar keratoplasty for an advanced keratoconus patient. All three grafts were prepared during the first surgery, and the other two grafts were preserved and used on another day. Patients were followed up for 1 year, and all have good visual outcomes with stable grafts. Our first patient underwent a novel combined surgery of tight sutures for ectasia reduction that is usually performed at an earlier stage, with tissue augmentation using a lamellar graft meant for the later stage of the disease. With a successful outcome of up to 1-year follow-up, this technique can be considered in other suitable peripheral ectasias in the future. By sharing our experience, we hope that corneal surgeons and their patients at large will benefit.

A young diabetic male patient presented with a ring infiltrate and hypopyon of 1-day onset in the left eye. Though we suspected acanthamoeba keratitis, the initial smear report showed fungal filaments. So, we started dual topical with systemic antifungals. On day 3, the ring was filled with a reddish-brown infiltrate, and the culture grew pale-gray fungal colonies. A clinical diagnosis of dematiaceous fungi was made, commonly observed at our clinic is Curvularia , which responds to the chosen treatment combination. Due to clinical worsening, we considered therapeutic penetrating keratoplasty that got delayed until diabetic control. With further worsening, we re-scraped with a day off medication and performed confocal microscopy and polymerase chain reaction (PCR). The organism was identified as Cladorrhinum bulbillosum from the DNA extract from colonies grown in blood agar when subjected to PCR-based sequencing carried out in the ABI 3130 genetic analyzer. The patient underwent therapeutic penetrating keratoplasty on day 11.

We report six eyes of five patients with keratoglobus who underwent limbal-sparing lamellar keratoplasty (LSLK) with 7 years of follow-up. In two patients' three eyes, it was congenital and the rest had acquired keratoglobus from pellucid marginal degeneration combined with keratoconus. In LSLK, the peripheral corneal epithelium is dissected to include the stem cells and reflected along with conjunctival peritomy. The host cornea is de-epithelialized, stromal irregularities dissected, and then a corneoscleral graft denuded of Descemet's membrane is anchored to a scleral ledge fashioned. Postoperatively, all received adequate tectonic support, and except for one posttrauma eye, the rest improved visually.

Purpose: To analyze retrospectively the outcomes of Hoffmann pocket scleral fixated intraocular lens implantation combined with penetrating keratoplasty at a tertiary institute by a single corneal surgeon. Methods: Forty-two eyes of 42 patients, aged between 11 and 84 years, had a mean follow-up of 2 ± 2.216 years. Overall, five (11.9%) had congenital and 37 had acquired pathology, 15 were pseudophakic, 23 were aphakic, and four were phakic. The commonest indication was trauma in 19 (45.2%), and 21 had previous multiple surgeries including five retinal procedures. Results: The grafts were clear in 20 (47.6%), they failed in 20, three had acute rejection, three were ectatic, two had infection, one had persistent edema, and one had endophthalmitis. The mean log of minimum angle of resolution (logMAR) best corrected visual acuity was 1.902 pre-op, 1.802 at the final follow-up, and 0.52 after excluding preexisting retinal pathologies. At the last follow-up, the vision improved in 18 (42.9%), maintained in 6, and worsened in 18, and three needed more than −5.00 D and seven needed more than −3.00 D cylinder correction. Five had glaucoma preoperatively, 10 developed the condition postoperatively, six needed cyclodestructive procedure, and three had valve surgery. Conclusion: Advantages of this surgery are avoidance of additional sections to insert the lens, direct positioning of the lens in the posterior chamber, rotational stability of the lens from four-point fixation, and untouched conjunctiva over the scleral pockets. The fact that 20 had clear grafts and 18 visually improved, though two needed lens removal and one developed retinal detachment postsurgery is encouraging. More cases with longer follow-ups will help understand the technique better.

Corneal vascularization is a nonspecific response to insult that creates an imbalance between angiogenic factors and leads to corneal vascular endothelial cell migration and proliferation.[1] Unstopped vascularization not only causes stromal edema, protein or lipid deposition, persistent inflammation, scaring, and eventually visual deprivation, but also triggers lymphangiogenesis. Direct vessel occlusion is achieved by cautery, laser,[2] fine needle diathermy, or photodynamic therapy, while indirect methods focus on treating the triggers. We used frequency-doubled Nd YAG (532 nm) laser to occlude (frost) the main vessels that arborize in the stroma causing deposits like snowflakes (Fig 1a-b).Figure 1: (a) Slit-lamp sclerotic scatter showing vascularized corneal scar with snowflake-like deposits, (b) Slit-lamp slit view showing frosted branch-like peripheral vessels after Nd YAG laser occlusionFinancial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Eye banking difficulties in pandemic times lead to interrupted availability of donor corneas.[1] Glycerol-preserved corneal tissue (GCT) has become a valuable resource for tectonic and therapeutic corneal transplants in these situations.[2] Being acellular, GCT is nonimmunogenic and also provides excellent tensile support [Fig. 1]. However, postoperative reepithelization is slow and optical clarity poor in full-thickness transplants.[3]Figure 1: (a) Preoperative picture of one of the cases with total corneal abscess. (b) DMD in glycerol-preserved corneal tissue used for therapeutic penetrating keratoplasty (yellow arrows). (c) Cloudy appearance of the acellular GCTWe report three cases of Descemet’s Membrane detachment (DMD) following uneventful therapeutic penetrating keratoplasty (TPK) with GCT, performed by experienced surgeons. The indications were two nonresolving fungal corneal ulcers and one perforated corneal ulcer. GCT was washed with balanced salt solution prior to the TPKs and a small lateral tarsorrhaphy was done to facilitate epithelialization. Over a follow-up of 2 months, there was no recurrence of infective keratitis in any of the patients. Discussion DMDs were noted in all cases in the second postoperative week [Fig. 2], which were confirmed on anterior segment optical coherence tomography (AS-OCT). The DM in all cases redetached after initial success with gas descemetopexy. Also, reverse sutures taken from limbal side to graft side through the detachment in one case were able to hold up the DM only temporarily. Full thickness cardinal suture bites taken intraoperatively during TPK with GCT may help prevent DMD. Alteration of tissue texture due to acellularity and loss of endothelial pump function in these grafts were reasons for nonattachment of DM. Also, the hazy view offered by GCT predisposes to small DMD during surgery which then progresses with aqueous seepage into the cleft.Figure 2: Panel of AS-OCT pictures in three meridians showing near-total DMD in the second postoperative weekDMD occurs commonly with usage of GCT due to tissue alteration and visibility issues. As GCT grafts are very cloudy, AS-OCT done postoperatively helped in the confirmation of this complication in our cases. As the acellular GCT has nonviable endothelium, observation alone, followed by future optical transplant, is a definite option. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

To overcome tissue shortage during pandemic, we switched to 100% glycerol preservation of the donor cornea, which is economical and provides longer duration of storage than the short and intermediate storage mediums we normally use like McCAREY Kaufman (MK) or cornisol. During our initial few cases of therapeutic penetrating keratoplasty using glycerol preserved donor cornea, we faced spontaneous Descemet's detachments resistant to air tamponade. We tried reverse graft suturing and successfully reinforced Descemet's attachment along with air tamponade, in one of the cases after multiple failed air injections. In the subsequent two cases of infective keratitis needing therapeutic penetrating Keratoplasty, we took eight reverse sutures in between the eight cardinals, to anchor the Descemet's membrane of the graft. Both the grafts showed attached Descemet's and maintained good graft clarity. The reverse corneal suturing technique has not been described to the best of our knowledge and hope this helps our corneal fraternity.

During pandemic, eye banks worldwide faced drastic reduction of corneal retrieval. Since precut tissues are uncommon in India, the onus is on corneal surgeons to maximize the donor corneal usage. The stumbling block making the stromal part unusable in the graft preparation of the Descemet membrane endothelial Keratoplasty is the stromal window creation to place the orientation mark on the stromal side of the folded graft. To overcome this, we simply marked directly on the folded Descemet graft, after partly stripping it from the donor cornea. Then, we unfolded, punched, and created two grafts after completely stripping it, retaining the Descemet part for the endothelial Keratoplasty and the stromal part for lamellar Keratoplasty. Initially, we used a special F marker, and later we marked an L using just a spatula. This simple technique needing no extra donor tissue or instrumentation maximizes the tissue utility with proper patient selection.

Purpose:To assess the long-term outcome of graft insertion by taco technique through a 2.8-mm clear corneal incision in patients undergoing Descemet's stripping automated endothelial keratoplasty (DSAEK).Methods:This is a retrospective interventional case series of 77 eyes of 75 patients who underwent DSAEK in a tertiary eye hospital. The DSAEK donor grafts were folded to an uneven 70/30 taco and held at a single point using Utrata forceps. All insertions were through a 2.8-mm clear corneal incision except the two aphakic patients requiring combined SFIOL implantation. All patients underwent a comprehensive eye examination preoperatively and were followed up to 6 years postoperatively. Visual outcomes, graft clarity, and complications of all and endothelial cell loss in 22 patients with available postop specular microscopy were analyzed.Results:Overall, 59 (76.6%) had clear grafts until the final follow-up. Visual acuity improved in 48 (62.3%) from an average of 1.3 to 0.8 logMAR (P = 0.0001). Vision was maintained in seven and worsened in four eyes. Grafts failed in 18 (23.3%) eyes: seven (9%) were primary failures, two post rejection, four done for failed PK did not clear, four due to worsening of preexisting glaucoma, and one noncompliant failed eventually. Average endothelial cell density reduction was 26.3% (mean preop donor 2419 to postop 1779 cells/mm2; P = 0.000).Conclusion:Our study shows good long-term clinical outcome of DSAEK using Taco technique through a 2.8-mm clear corneal incision in a tertiary hospital.

Infectious keratitis with large perforations requires therapeutic penetrating keratoplasty (TPK) to eliminate infection and restore the tectonic integrity of the globe [1,2].Donor corneal tissue of fair to good quality is usually used for this surgery for good anatomical outcome [3].

Purpose To evaluate the efficacy of CXL in treating fungal keratitis as an adjuvant therapy. Methods Detailed clinical examination microbiological investigation was performed. Twenty fungal keratitis patients were recruited and randomized into two groups: group 1 (n= 11, standard antifungal), group 2 (n=9, corneal collagen crosslinking with standard antifungal). Corneal scraping and tear samples collected were subjected to real-time PCR targeting ITS, TLR analysis and cytokine analysis. Results The mean time for complete resolution of ulcer for group 2 was significantly shorter compared to group 1 and the final mean BCVA was better for group 2. Expression of IL-1 beta, IL-8, IFN-gamma significantly decreased immediately post CXL in group 2 patients. Significant downregulation of TLR 6, TLR-3, TLR-4 was observed 3-days post CXL compared to group 1 patients. Conclusion Adjuvant effect of CXL was significant in treating fungal keratitis compared to standalone antifungal treatment.

Purpose To report clinical profile and compare management options for Pythium keratitis. Method Retrospective interventional study of 46 patients diagnosed as Pythium keratitis by PCR DNA sequencing from January 2014 to July 2017. Interventions were categorised into medical management (MM) (topical azithromycin and linezolid with oral azithromycin at presentation), surgery (S) (therapeutic penetrating keratoplasty, TPK), surgical adjunct (SA) (cryotherapy±alcohol with TPK) and medical adjunct (MA) (MM after TPK). Results Primary treatment included MM (1 eye), SA (3 eyes) and S (42 eyes). Recurrence occurred in 27/43 eyes (MM+S group). Second surgery (S) was required in 11 eyes (TPK-2), with additional procedures (SA) in 10 eyes and evisceration in five eyes. 8/43 eyes received MA after TPK-1. One eye required TPK-3. Recurrence occured in all eyes that received MA (100%) and in 28 of 54 TPKs (51.8%) (TPK 1+2+3) in 42 eyes. Recurrence was noted in 1/14 (7.1%) that underwent SA. Conclusion The currently available and recommended treatment for Pythium keratitis is surgical by means of a TPK and in worse cases evisceration. In our study, MM/MA measures showed no benefit with recurrence or worsening of infection requiring resurgery. Almost 50% of TPKs had a recurrence requiring resurgery. However, adjunctive procedures during TPK appear to have additional benefit with low risk of recurrence and could be included as routine care.

The purpose of the study was to report a case of ulcerative keratitis caused by an unusual algae Prototheca wickerhamii in a diabetic patient. This study design was a case report. A 46-year-old male, who was a known diabetic for 3 years, had an injury to the left cornea with the sparks of fire from wielding at work that developed into an ulcerative keratitis over a period of next 3 months as the patient was not on any medication. Corneal scraping culture report and Vitek 2 system investigation result confirmed it to be a P. wickerhamii infection. The patient was started on intensive topical 1% voriconazole and 5% natamycin for 1 month and with no improvement subsequently underwent penetrating keratoplasty. No recurrence of infection postoperatively was noted. This opportunistic algae rarely known to cause human eye infections is so far reported in either patients with severe systemic immunosuppression causing posterior segment eye involvement or as postcorneal surgery infections. We report an ulcerative keratitis by P. wickerhamii in a diabetic patient post corneal trauma with no prior ocular surgery.

PURPOSETo report the long-term outcome of corneal collagen cross-linking (CXL) for progressive keratoconus in pediatric patients.METHODS"Epithelium-off" CXL was performed in pediatric eyes with progressive keratoconus. Spectacle-corrected distance visual acuity (CDVA), retinoscopy, topography, and tomography were documented preoperatively and postoperatively at 3 months, 6 months, 1 year, and annually thereafter.RESULTSA total of 377 eyes of 336 pediatric patients aged 8 to 18 years with progressive keratoconus underwent CXL. Of these, 194 eyes had a follow-up beyond 2 years and up to 6.7 years. At last follow-up, there was significant improvement in mean CDVA from 0.33 ± 0.22 to 0.27 ± 0.19 logMAR (P ≤ 0.0001), reduction in mean topographic astigmatism from 7.22 ± 3.55 to 6.13 ± 3.28 D (P = 0.0001), mean flattening of 1.20 ± 3.55 diopters in maximum keratometry (Kmax) (P = 0.0002), and mean corneal thinning of 31.1 ± 36.0 μm (P < 0.0001) after CXL. The mean change in Kmax was most significant in moderately advanced keratoconus (average keratometry 48-53 diopters). Central cones showed more corneal flattening than peripheral cones. Stabilization or flattening of Kmax was seen in 85% of eyes at 2 years and in 76% after 4 years. Stabilization or improvement of CDVA was seen in 80.1% of eyes at 2 years and in 69.1% after 4 years.CONCLUSIONSCXL remains effective in stabilizing keratoconus for longer than 2 years in a majority of pediatric eyes. Flattening of Kmax was greater in moderately advanced keratoconus and central cones. Long-term follow-up beyond 4 years, however, revealed that a few eyes showed features suggestive of reversal of the effect of CXL.