Publications by authors named "Varsha M Rathi"

53 Publications

Masked comparison of trypan blue stain and potassium hydroxide with calcofluor white stain in the microscopic examination of corneal scrapings for the diagnosis of microbial keratitis.

Indian J Ophthalmol 2021 Sep;69(9):2457-2460

L V Prasad Eye Institute, Banjara Hills, Hyderabad, Telangana, India.

Purpose: To evaluate the efficacy of trypan blue in direct microscopic examination of corneal scrapings in the diagnosis of non-viral microbial keratitis.

Methods: In a prospective, interventional, masked study, 82 consecutive patients were investigated. Direct microscopic examination of the corneal scrapings involved three smears stained with potassium hydroxide with calcofluor white (KOH + CFW), Gram stain (not analyzed), and trypan blue stain and culture for bacteria, fungus, and Acanthamoeba. While KOH + CFW stained slides were examined under a fluorescence microscope, trypan blue-stained slides were examined by two microbiologists (masked to KOH + CFW and culture results) under normal light microscopy. Thirty samples were reexamined for interobserver and intraobserver variability.

Results: Out of 82 samples, fungal/fungus-like elements were seen in 48 (58.5%) in KOH + CFW and 38 (46.3%) in trypan blue stain. One microsporidial case, detected in KOH + CFW was negative in trypan blue stain (culture not done). Fungal growth was positive in 23 out of 81 (28.3%) cases cultured, single bacterial species in 18 (22.2%), Pythium insidiosum in three, mixed bacteria and fungus/Pythium in 7 (8.6%), Acanthamoeba in none and 30 (37.0%) samples were sterile. With culture as gold standard, the respective sensitivity (84.9%, 75.7%) and specificity (90.9%, 68.2%) of KOH + CFW stain and trypan blue stain were comparable (p = 0.16, P = 0.06). The interobserver linear weighted kappa score between the two microbiologists was 1.00 while it was 0.86 for intraobserver agreement.

Conclusion: Trypan blue stain, an easily available dye to ophthalmologists, is highly efficacious in the diagnosis of fungal keratitis.
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http://dx.doi.org/10.4103/ijo.IJO_3685_20DOI Listing
September 2021

Demographics and clinical profile of patients with ocular poisoning in India.

Indian J Ophthalmol 2021 Sep;69(9):2417-2420

Allen Foster Community Eye Health Research Centre, Gullapalli Pratibha Rao International Centre for Advancement of Rural Eye Care (GPRICARE); Indian Health Outcomes, Public Health and Economics Research Center; Brien Holden Eye Research Centre, LVPEI, Banjara Hills, Hyderabad, Telangana, India; School of Optometry and Vision Science, University of New South Wales, Sydney, Australia.

Purpose: To describe the clinical profile of patients with ocular Calotropis poisoning presenting to a multitier ophthalmology hospital network in India.

Methods: This cross-sectional hospital-based study included 2,047,360 new patients presenting between August 2010 and March 2020. Patients with a clinical diagnosis of Calotropis poisoning in at least one eye were included. The data were collected using an electronic medical record system. Descriptive statistics using mean ± standard deviation and median with inter-quartile range (IQR) were used to elucidate the demographic data. Chi-square test was done for univariate analysis.

Results: Overall, 362 (0.018%) new patients were diagnosed with ocular Calotropis poisoning during the study period. The mean age of the patients was 44.10 ± 18.61 years. The incidence rates were 0.013% in children and 0.018% in adults. Males were 57.46% and 87.29% had unilateral affliction. A significant number of patients presented from the rural geography (59.67%) and were from the higher socioeconomic class (72.65%). About a fourth of the patients were homemakers (23.48%) followed by agriculture workers (18.23%). Of the 408 affected eyes, 49.26% had mild visual impairment (<20/70) followed by moderate visual impairment (>20/70 to ≤ 20/200) in 23.28%. The most common clinical signs were conjunctival congestion (61.03%), descemet membrane folds (57.35%), stromal edema (30.39%), and corneal epithelial defect (24.51%).

Conclusion: Calotropis poisoning in individuals seeking eye care in India is very rare. It is commonly unilateral and occurs more in the rural geography. It is common in middle-aged males and may affect vision due to involvement of the cornea.
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http://dx.doi.org/10.4103/ijo.IJO_3434_20DOI Listing
September 2021

Feasibility and Outcomes of Corneal Transplantation Performed at Rural Centers: An Extension of the Pyramidal Model of Enhanced Eye Care at Rural Outreach.

Cornea 2021 Jul 28. Epub 2021 Jul 28.

Allen Foster Community Eye Health Research Centre, Gullapalli Pratibha Rao International Centre for Advancement of Rural Eye Care, LV Prasad Eye Institute, Hyderabad, India; Indian Health Outcomes, Public Health and Economics (IHOPE) Research Centre, LVPEI, Hyderabad, Telangana, India; Cornea Service, The Cornea Institute, L V Prasad Eye Institute, Hyderabad, Telangana, India; Brien Holden Eye Research Centre, LV Prasad Eye Institute, Hyderabad, India; and School of Optometry and Vision Science, University of New South Wales, Sydney, Australia.

Purpose: The aim of this study was to report on the feasibility of setting up a system of corneal transplants at rural outreach centers and report the outcomes of the first 111 cases.

Methods: Retrospective analysis of the outcomes of corneal transplantation performed on patients with optical indications between March 2016 and September 2019 at 4 secondary (rural) centers. The centers are a part of a network in the pyramidal model developed by L V Prasad Eye Institute. The graft clarity and best-corrected visual acuity (BCVA) at 1-year follow-up were analyzed.

Results: Of the 111 patients, 34.23% underwent penetrating keratoplasty and 65.77% endothelial keratoplasty. The mean age was 59.4 ± 15.0 (range-17-86 years); 47.75% were men and 52.25% were women. The indications for surgery were bullous keratopathy (54.05%), corneal scar/adherent leukoma (23.42%), and repeat grafts (13.51%). At the end of 1 year, 69.37% grafts remained clear. Factors associated with graft failure included poor socioeconomic status and graft infiltrate in both univariate and multivariate analyses. Surgical technique of endothelial keratoplasty was associated with failure on multivariate analysis only. Of the 77 eyes with clear corneal grafts at 1 year, the preoperative mean logMAR BCVA was 1.91 ± 0.06, which improved to 0.90 ± 0.08 postoperatively. Overall, 84.4% had preoperative BCVA of <3/60. Postoperatively, 40% had BCVA of 6/18 or better.

Conclusions: Our study showed that close to 70% grafts remained clear at 1 year. Graft failure was associated with poor socioeconomic status and graft infiltrates. This study established a viable model for delivery of corneal transplant surgery and care in a rural setup.
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http://dx.doi.org/10.1097/ICO.0000000000002839DOI Listing
July 2021

Patterns of Non-Infectious Scleritis across a Tertiary Eye Care Network Using the Indigenously Developed Electronic Medical Record System-eyeSmart.

Ocul Immunol Inflamm 2021 Jul 13:1-7. Epub 2021 Jul 13.

Uveitis Service and Smt Kannuri Santhamma Vitreo-retinal Service, L. V. Prasad Eye Institute, Hyderabad, India.

Purpose: To report the pattern of noninfectious scleritis across a tertiary eye-care network.

Methods: A three-year retrospective review of patients diagnosed with noninfectious scleritis was performed. Data were retrieved using diagnostic terms assigned to scleritis through the in-house eyeSmart-electronic medical record system.

Results: 1103 patients, with a mean age of 44.33 ± 14.38 years and a median follow-up of 199.5 days (range 32-685) were enrolled. Unilateral disease was noted in 85%. Diffuse anterior scleritis (n = 542, 42.51%) and nodular scleritis (n = 482, 38.12%) were the commonest subtypes. Systemic immune disease association was present in 65 (5.89%). Treatment at onset was topical corticosteroids (n = 372, 36.54%) followed by oral non-steroidal anti-inflammatory drugs (n = 351, 34.45%), oral corticosteroids in 184 (19.04%), and immunomodulators in 32 patients (3.54%).

Conclusions: This study depicts the pattern of various noninfectious scleritis in a large cohort of patients. The present study helped to further customize the electronic medical records to minimize several data capture limitations.
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http://dx.doi.org/10.1080/09273948.2021.1942497DOI Listing
July 2021

Tribal Odisha Eye Disease Study (TOES) Report # 9. Eye diseases and retinal disorders in an adult and elderly tribal community in Odisha, India - A community hospital-based study.

Indian J Ophthalmol 2021 07;69(7):1846-1849

Srimati Kanuri Santhamma Center for Vitreoretinal Diseases, LV Prasad Eye Institute, Kallam Anji Reddy Campus, Hyderabad, Telangana, India.

Purpose: To measure the proportion of people with major ophthalmic and retinal disorders in the tribal and non-tribal people presenting to a community eye hospital in an Indian state with a sizeable tribal population.

Methods: Hospital-based cross-sectional retrospective study of all new adult patients, examined between September 2015 and June 2020. A tribal was defined as per the Indian ethnic classification. Blindness and visual impairment were defined as per the WHO standards. Diabetes and hypertension were defined as per Indian standards. The proportion of common ophthalmic and retinal disorders between the tribal and non-tribal community were compared.

Results: This cohort consisted of 76,166 people (45.8%; n = 34,869, tribal); 39.4% (n = 29,989; non-tribal 23.6% and tribal 15.8%) people had ophthalmic disorders. In the examined people 2.3% were blind (higher in tribal community 4.7% versus 0.8%; P < 0.001) and 8.4% had moderate-to-severe visual impairment (higher in tribal community 14.4% versus 4.4%; P < 0.001). Refractive error (64.4%; higher in non-tribal community, 77.3% versus 44.6%, P < 0.001) and operable cataract (23.9%; higher in tribal community, 40.9% versus 11.8%, P < 0.001) were the principal ophthalmic disorders. Retinal disorders were higher in non-tribal people (5.9% vs. 2.9%; P < 0.001), but the tribal group had higher proportion of retinitis pigmentosa (20% vs. 6.4%; P < 0.001) and lower proportion of diabetic retinopathy (8% vs. 40.7%; P < 0.001).

Conclusion: : The health-seeking behavior of the tribal community in India is low. A tribal person in India apparently visits the hospital when vision is grossly affected. It calls for greater advocacy, increased access to healthcare, and a larger population-based study.
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http://dx.doi.org/10.4103/ijo.IJO_3420_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8374820PMC
July 2021

Application of Trypan Blue Stain in the Microbiological Diagnosis of Infectious Keratitis-A Case Series.

Cornea 2021 Apr 21. Epub 2021 Apr 21.

Gullapalli Pratibha Rao International Centre for Advancement of Rural Eye Care, LV Prasad Eye Institute (LVPEI), LV Prasad Marg, Hyderabad, India; The Cornea Institute, LV Prasad Eye Institute, LV Prasad Marg, Hyderabad, India; and Jhaveri Microbiology Centre, LV Prasad Eye Institute, Kallam Anji Reddy Campus, LV Prasad Marg, Hyderabad, India.

Purpose: The purpose of this study was to report 3 cases of microbial keratitis, wherein trypan blue staining was used to aid the microbiological diagnosis of fungal keratitis and Pythium keratitis in a rural setup.

Methods: Three consecutive patients who presented with a diagnosis of infectious keratitis underwent corneal scraping, and the smears were assessed using trypan blue stain and potassium hydroxide (KOH) mount.

Results: Of the 3 cases, the first 2 cases showed septate fungal filaments in trypan blue-stained preparation and KOH mount. Case 3 showed the presence of broad aseptate filaments with ribbon-like folds on both KOH mount and trypan blue stain, consistent with the diagnosis of Pythium keratitis. The first 2 cases improved with topical and systemic antifungals. Case 1 healed with scarring at 7 weeks with improvement in best-corrected visual acuity (BCVA) to 20/60. Case 2 healed within 2 weeks, and BCVA improved to 20/40. Case 3 received topical linezolid (0.2%), azithromycin eye ointment, and oral azithromycin. At 5 weeks the infection decreased but thinning was noted, which necessitated tissue adhesive and bandage contact lens application. Scarring was noted at 10 weeks, and BCVA improved to 20/40.

Conclusions: In this case series, trypan blue staining showed promising results in the easy identification of aseptate and septate fungal elements. This is the first case series showing the utility of this stain in the management of microbial keratitis.
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http://dx.doi.org/10.1097/ICO.0000000000002725DOI Listing
April 2021

Economic, clinical and social impact of simple limbal epithelial transplantation for limbal stem cell deficiency.

Br J Ophthalmol 2021 Mar 9. Epub 2021 Mar 9.

Innovation Department, Dr Shroff's Charity Eye Hospital Delhi, New Delhi, Delhi, India

Aims: To report the global uptake of simple limbal epithelial transplantation (SLET) and compare the economic, clinical and social outcomes of SLET with those of cultured limbal epithelial transplantation (CLET).

Methods: A comprehensive literature review and an online survey of eye surgeons were conducted to understand the efficacy and current uptake of SLET surgery. A de novo economic model was developed to estimate the cost savings with SLET compared with CLET. Our economic analysis is conducted from an Indian perspective, as this is where the technique originated. A scenario analysis using the UK cost data and a user-friendly Excel model is included to allow users to input the costs from their setting to estimate the cost savings with using SLET compared with using CLET RESULTS: The anatomical success with SLET in adults (72.6% (range 62%-80%)) was the same as CLET (70.4% (range 68%-80.9%)). For children, the outcome for SLET (77.8% (range 73%-83%)) was better than with CLET (44.5% (range 43%-45%)). In response to our informal questionnaire, 99 surgeons reported to have performed SLET on 1174 patients in total. They appreciated that SLET negates the requirement for costly tissue engineering facilities. Results of economic analysis suggested that SLET provided an estimated cost-savings of US$6470.88 for adults and US$6673.10 for children. In broad terms, the cost of SLET is approximately 10% of the cost of CLET for adults and 8% for children.

Conclusion: SLET offers a more accessible and financially attractive alternative to CLET to treat limbal stem cell deficiency.
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http://dx.doi.org/10.1136/bjophthalmol-2020-318642DOI Listing
March 2021

The impact of COVID-19 "Unlock-I" on L V Prasad Eye Institute Network in Southern India.

Indian J Ophthalmol 2021 Mar;69(3):695-700

Allen Foster Community Eye Health Research Centre, Gullapalli Pratibha Rao International Centre for Advancement of Rural Eyecare; Brien Holden Eye Research Centre, L V Prasad Eye Institute, Hyderabad, India; School of Optometry and Vision Science, University of New South Wales, Sydney, Australia.

Purpose: The aim of this study was to report on the impact of COVID-19 "Unlock-I" on Network of Eye Centers in Southern India.

Methods: Our eye health pyramid model has a network of eye care centers in four Indian states. The network constitutes a center of excellence (CoE) at the apex followed by tertiary care centers (TC) located in urban areas, secondary care centers (SC), and primary care vision centers (VC) at the base located in rural areas. We collected data on patients seen between June 2019 and June 2020, which included age, gender, total patients seen (new or follow-up), and socioeconomic status (paying and nonpaying). A comparative study was done between the data for outpatients and surgeries performed pre-COVID-19 and during Unlock-I in COVID-19 period.

Results: There was a 36.71% reduction in the overall outpatients seen in June 2020 (n = 83,161) compared to June 2019 (n = 131,395). The reduction was variable across different levels of the pyramid with the highest reduction in CoE (54.18%), followed by TCs (40.37%), SCs (30.49%) and VCs (18.85%). Similar pattern was seen for new paying patients with the highest reduction in CoE (54.22%), followed by TCs (25.86%) and SCs (4.9%). A 43.67% reduction was noted in the surgeries performed in June 2020 (n = 6,168), compared to June 2019 (n = 10,950). Reduction in paying services was highest in CoE (47.52%), followed by TCs (15.17%) and SCs (4.87%). There was no significant change in the uptake of services by gender in the network.

Conclusion: Highest reduction in patient footfalls during "Unlock-1" was noted in urban centers. Going forward, there is a need to develop strategies to provide eye care closer to the doorsteps.
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http://dx.doi.org/10.4103/ijo.IJO_3143_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7942085PMC
March 2021

Pregnancy-induced keractesia - A case series with a review of the literature.

Indian J Ophthalmol 2020 Dec;68(12):3077-3081

Cornea Institute, L V Prasad Eye Institute, KAR Campus, Hyderabad, Telangana, India.

We report a case series of patients who developed post-laser-assisted in situ keratomileusis (LASIK) ectasia or had a progression of keractesia during pregnancy. We reviewed the medical records of 12 patients (20 eyes) who had reported deterioration of vision during their pregnancy and were diagnosed with keractesia. All 12 patients had experienced symptoms of deterioration of vision between 2 months to 1 year of onset of their pregnancies. A total of 17 eyes of 10 patients had developed post-refractive surgery keractesia. Sixteen of these had undergone LASIK and one had undergone femtosecond lenticule extraction (FLEX). Three eyes of two patients had an exacerbation of keratoconus during pregnancy while one patient had associated hypothyroidism. The results indicate that the hormonal changes that take place in pregnant women can affect the biomechanical stability of the cornea and may trigger the onset of keractesia.
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http://dx.doi.org/10.4103/ijo.IJO_1508_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7856952PMC
December 2020

Endophthalmitis Prophylaxis Study, Report 2: Intracameral antibiotic prophylaxis with or without postoperative topical antibiotic in cataract surgery.

Indian J Ophthalmol 2020 11;68(11):2451-2455

Allen Foster Research Centre for Community Eye Health, Gullapalli Pratibha Rao International Centre for Advancement of Rural Eye Care, L V Prasad Eye Institute (LVPEI), Banjara Hills, Hyderabad, India.

Purpose: Intracameral antibiotic in cataract surgery has shown level I evidence as prophylaxis for postoperative endophthalmitis. Not much is known if one should also use topical antibiotics after intracameral injection. The purpose of the study was to determine efficacy of intracameral antibiotic with and without postoperative topical antibiotic in reducing the incidence of acute endophthalmitis after cataract surgery in rural India.

Methods: A.

prospective comparative, non-randomized interventional study was designed in 15 rural centres in India. The study recruited 40,006 patients (n = 42,466 eyes), who underwent cataract surgery (phacoemulsification/small incision cataract surgery), and received intracameral antibiotic (cefuroxime/moxifloxacin). Postoperative topical antibiotic prescription was left to the choice of the treating physician, but they were encouraged not to use it in uneventful surgeries. Primary outcome measure was occurrence of acute clinical endophthalmitis within 6 weeks of surgery. Statistical analysis was done using STATA software v13.1 (StataCorp, Texas); P value of <0.05 was considered statistically significant.

Results: In the study, 17,932 (42%) eyes received intracameral cefuroxime (ICC) and 24,534 (58%) eyes received intracameral moxifloxacin (ICM). Topical antibiotic was not prescribed to 17,855 (42%) eyes - 5723 (32%) eyes in ICC group and 12,132 (68%) eyes in ICM group. Acute clinical endophthalmitis occurred in 15 (0.035%) eyes - 1 / 3515 (0.028%) eyes and 1 / 2231 (0.045%) eyes that received and did not receive topical antibiotic, respectively. The difference in occurrence of endophthalmitis with/without topical antibiotics in each group (ICC: 0.016% and 0.017%; P = 0.958; ICM: 0.040% and 0.058%; P = 0.538) was not significant (P = 0.376).

Conclusion: Supplementing intracameral antibiotic with topical antibiotic postoperatively did not impact the occurrence of acute post cataract surgery endophthalmitis in rural India.
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http://dx.doi.org/10.4103/ijo.IJO_1738_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7774195PMC
November 2020

Impact of COVID-19-related lockdown-I on a network of rural eye centres in Southern India.

Indian J Ophthalmol 2020 Nov;68(11):2396-2398

Allen Foster Community Eye Health Research Centre, Gullapalli Pratibha Rao International Centre for Advancement of Rural, Eyecare L V Prasad Eye Institute; Brien Holden Eye Research Centre; School of Optometry and Vision Science, University of New South Wales, Sydney, Australia; School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA.

Purpose: With the outbreak of coronavirus disease 2019 (COVID-19), India went for lockdown-I on March 23, 2020. In this article, we report on the demographic profile and ocular disorders from our 20 rural eye centres during lockdown-I and its comparison with the pre-lockdown period.

Methods: A retrospective analysis was conducted for all patients who visited or had teleconsultations at the 20 rural centres in our network between March 23 and April 19, 2020. Demographic and clinical details were collected from electronic medical records (EMR). Subspecialty was decided based on the diagnosis. Patients who needed advanced care were referred to the higher tertiary centres. We report the profile of patients seen and managed at the rural centres and the reasons for referrals. We also compare the data with the pre-lockdown period.

Results: During the lockdown-I period, a total of 263 patients were treated including 48 teleconsultations (18.25%). The mean age was 48.16 years (SD: 19.53 years). There were 118 females (44.87%). As compared to pre-lockdown, during the lockdown, the patient visits were highest in the cornea and anterior segment specialty with 114 patients (43.35%), including conjunctivitis (n = 25; 22.32%). Of the 263 patients, 24 patients (9.12%) were referred to tertiary centres. This includes 6/27 (22.22%) patients of microbial keratitis. As compared to this, during pre-lockdown, 28,545 patients were seen. The mean age was 49.03 years (SD: 19.24 years). There were 14,927 (52.29%) females. The referral was 1525 (5.34%), including 34/249 (13.65%) of those with keratitis.

Conclusion: Lockdown-I had significantly impacted patient care in rural areas. As compared to the pre-lockdown period, during the lockdown, there was an issue with access to services by females. Despite a higher number of specialty patients (including emergencies) visiting during the lockdown, 91% of the patients who visited rural centres could be managed locally, avoiding long-distance travel.
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http://dx.doi.org/10.4103/ijo.IJO_2303_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7774145PMC
November 2020

A randomized masked pilot clinical trial to compare the efficacy of topical 1% voriconazole ophthalmic solution as monotherapy with combination therapy of topical 0.02% polyhexamethylene biguanide and 0.02% chlorhexidine in the treatment of Acanthamoeba keratitis.

Eye (Lond) 2021 May 27;35(5):1326-1333. Epub 2020 Jul 27.

The Cornea Institute, L V Prasad Eye Institute, Hyderabad, India.

Purpose: To compare the efficacy of topical voriconazole 1% and the combination therapy of 0.02% polyhexamethylene biguanide (PHMB) and 0.02% chlorhexidine for the treatment of Acanthamoeba keratitis (AK).

Methods: This is a prospective, pilot, double-masked randomized comparative study. Twenty-three eyes of 23 patients with microbiologically (smear and/or growth on culture) confirmed AK were randomized to group BG (PHMB 0.02% and chlorhexidine 0.02%) or group VZ (voriconazole 1%). Primary outcome measure was change in geometric mean (GM) of the corneal ulcer size at final visit. Secondary outcome measures were change in visual acuity.

Results: Out of 71 patients with confirmed AK seen during study period, 23 patients were recruited and 18 patients completed minimum 2 weeks of treatment and further analyzed. Ten patients received BG, whereas eight received VZ. Median ulcer size measured as GM of infiltrate decreased from 5.7 mm (IQR, 5.3-6.5 mm) (p = 0.02) to 1 mm (IQR, 0-4.3 mm) in group BG and from 4.5 mm (IQR, 1.8-5.1 mm) (p < 0.05) to 0.7 mm (IQR, 0-1.6 mm) in VZ group. Median visual acuity improved from 1.79 (IQR, 1.48-2.78) to 1.10 (IQR, 0.48-1.79) in BG group (p = 0.02) and from 1.60 (IQR, 1.00-2.78) to 0.80 (IQR, 0.48-1.30) in VZ group (p = 0.18).

Conclusion: These outcomes suggest that topical VZ as a monotherapy in AK treatment is effective and comparable to BG combination therapy but needs trials with larger sample size and longer follow-up to provide conclusive evidence.
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http://dx.doi.org/10.1038/s41433-020-1109-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8182824PMC
May 2021

Commentary: Preferred practice pattern for primary eye care in the context of COVID-19 in L V Prasad Eye Institute network in India.

Indian J Ophthalmol 2020 07;68(7):1311-1315

Allen Foster Community Eye Health Research Centre, Gullapalli Pratibha Rao International Centre for Advancement of Rural Eyecare; Brien Holden Eye Research Centre, Hyderabad, Telangana, India; School of Optometry and Vision Science, University of New South Wales, Sydney, Australia; School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA.

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http://dx.doi.org/10.4103/ijo.IJO_1417_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7574086PMC
July 2020

Factors associated with visual outcomes after cataract surgery: A cross-sectional or retrospective study in Liberia.

PLoS One 2020 18;15(5):e0233118. Epub 2020 May 18.

Allen Foster Community Eye Health Research Centre, Gullapalli Pratibha Rao International Centre for Advancement of Rural Eyecare, LV Prasad Eye Institute, Hyderabad, India.

Objective: To report the initial outcomes and associated risk factors for poor outcome of cataract surgery performed in Liberia.

Methods And Analysis: LV Prasad Eye Institute (LVPEI), Hyderabad, started providing eye care in Liberia since July 2017. Electronic Medical Records of 573 patients operated for age-related cataract from July 2017 to January 2019 were reviewed. One eye per patient was included for analysis. All patients underwent either phacoemulsification or manual small incision cataract surgery (MSICS). Pre and postoperative uncorrected visual acuity (UCVA) and best-corrected visual acuity (BCVA) were recorded at one day, 1-3 weeks and 4-11 weeks. Main outcome measure was BCVA at 4-11 weeks; Intraoperative complications and preoperative ocular comorbidities (POC) were noted. BCVA less than 6/12 was classified as visual impairment (VI). Risk factor for VI was analysed using the logistic regression model.

Results: Of the 573 patients, 288 were males and 285 were females (49.7%). Mean age was 65.9±10.9 years; 14.3% had POC. The surgical technique was mainly MSICS (94.59%, n = 542). At 4-11 weeks, good outcome of 6/12 or better was noted in 38.55% (UCVA) and 82.54% (BCVA). Visual acuity (VA) of 6/18 or better as UCVA and BCVA was noted in 63.5% and 88% eyes respectively. Poor outcome of less than 6/60 was noted as UCVA (11.11%) and BCVA (5.22%). Multivariable analysis showed poor visual outcomes significantly higher in patients with POC (odds ratio 3.28; 95% CI: 1.70, 6.34).

Conclusion: The cataract surgical outcomes in Liberia were good; with ocular comorbidities as the only risk factor.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0233118PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7233528PMC
August 2020

Endophthalmitis prophylaxis study. Report 1: Intracameral cefuroxime and moxifloxacin prophylaxis for the prevention of postcataract endophthalmitis in rural India.

Indian J Ophthalmol 2020 05;68(5):819-824

Allen Foster Research Centre for Community Eye Health, Gullapalli Pratibha Rao International Centre for Advancement of Rural Eye Care, L V Prasad Eye Institute (LVPEI), Banjara Hills, Hyderabad, India.

Purpose: Intracameral antibiotics are known to reduce the incidence of acute endophthalmitis. Various drugs are available for intracameral use. This prospective study was carried out to compare the efficacies of intracameral cefuroxime and moxifloxacin prophylaxis in reducing the incidence of acute endophthalmitis after cataract surgery in rural India.

Methods: This was a prospective, nonrandomized, comparative, interventional study. Between October 2016 and March 2018, 15 eye care facilities spread over four Indian states were preselected to use either of the intracameral antibiotics, cefuroxime or moxifloxacin, following cataract surgery (phacoemulsification or manual small incision cataract surgery, SICS). The main outcome measure was the occurrence of acute clinical endophthalmitis within six weeks of the surgery. This was compared with the earlier rate of endophthalmitis in the same locations.

Results: The study was done in 42,466 eyes. Of the total, 42.2% received intracameral cefuroxime and 57.8% received intracameral moxifloxacin. SICS was performed more often. Clinical acute endophthalmitis occurred in 15 eyes. This accounted to a 72.22% reduction, from the earlier 0.126% to 0.035%, of postcataract surgery acute endophthalmitis. The reduction in the incidence of endophthalmitis after intracameral cefuroxime was 0.017% and that after intracameral moxifloxacin was 0.049%. With either intracameral antibiotics, the reduction in incidence was statistically significant (P < 0.001), but not between the molecules. Intracameral cefuroxime showed 66.67% reduction and intracameral moxifloxacin showed 74.74% reduction.

Conclusion: A 3.6-fold decrease in postcataract surgery endophthalmitis was observed upon the use of intracameral antibiotics in rural India. Both intracameral cefuroxime and moxifloxacin proved efficacious.
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http://dx.doi.org/10.4103/ijo.IJO_1400_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7350447PMC
May 2020

Role of teleophthalmology to manage anterior segment conditions in vision centres of south India: EyeSmart study-I.

Indian J Ophthalmol 2020 02;68(2):362-367

Department of EyeSmart EMR and AEye, L V Prasad Eye Institute, Hyderabad, Telangana, India.

Purpose: To study the role of teleophthalmology (TO) in the diagnosis and treatment of anterior segment conditions (including adnexal conditions) in rural areas.

Methods: This is a pilot study of 5,604 patients, who visited primary vision centres (VCs) for 1 week from 1-7 September 2018. The patients were examined by a vision technician (VT) to identify those who may need teleconsultation. The centres were located in 16 districts of four Indian states of Andhra Pradesh, Telangana, Odisha, and Karnataka. The demographic profile, along with the role of teleconsultation was reviewed.

Results: Teleconsultation was advised in 6.9% of the patients, out of which 59.6% were referred to a higher level of care, and 40.4% were treated directly at the VC. Teleconsultations were higher among males (7.0% as compared to 6.6% in females), though not statistically significant (P = 0.55). Teleconsultation was higher in the older population, that is, 60 years and above (14.5%); those with severe visual impairment (VI) (21%) and blindness (31.1%); and in the states of Telangana (11%) and Andhra Pradesh (6.3%). It was noted that 45% of the patients who underwent teleconsultation had pathologies related to ocular surface, cornea and lid, and adnexa-related conditions.

Conclusion: Teleconsultation has a significant role in the management of anterior segment conditions in bridging the gap between the patients and ophthalmologists in rural India. TO can also play an important role in the diagnosis and management of anterior segment, lid, and adnexa-related pathologies.
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http://dx.doi.org/10.4103/ijo.IJO_991_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7003575PMC
February 2020

Presumed Intraocular Tuberculosis Manifesting as Unilateral Iris Granuloma.

Ocul Immunol Inflamm 2020 Oct 16;28(7):1056-1059. Epub 2020 Jan 16.

Smt Kannuri Santhamma Vitreoretinal Services, KallamAnji Reddy Campus, L.V. Prasad Eye Institute , Hyderabad, India.

Ocular tuberculosis can manifest in a wide variety of clinical presentations. The prevalence is higher in endemic areas as a cause of granulomatous uveitis. While posterior segment manifestations are well known, anterior segment granulomas alone are relatively rare. We report two cases of unilateral iris granulomata in two young patients who presented with decreased vision and redness and were found to have well-circumscribed iris granulomas. Both underwent systemic evaluation and had a negative Mantoux test. Biopsy pathology of the lesions revealed granulomatous inflammation but were negative for PCR, staining, and culture for TB. One patient turned out to have multiple pulmonary lesions. The ocular condition initially worsened with steroid therapy alone and improved and resolved completely after starting a 9 months course of anti-tubercular therapy (ATT).
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http://dx.doi.org/10.1080/09273948.2019.1699578DOI Listing
October 2020

keratitis following microkeratome-assisted laser keratomileusis.

Oman J Ophthalmol 2019 Sep-Dec;12(3):203-205. Epub 2019 Oct 11.

Tej Kohli Cornea Institute, L V Prasad Eye Institute, Hyderabad, Telangana, India.

We hereby report a case of infectious keratitis after laser keratomileusis (LASIK) caused by , a commensal, managed successfully in a nonimmunocompromised individual. A 25-year-old healthy male underwent uneventful bilateral simultaneous LASIK for myopia using disposable blades. Postoperatively, topical antibiotic and steroids were advised; he discontinued antibiotic on his own after using for a day. On the 5 postoperative day, he had pain, redness, decreased vision, and white spot in the left eye (LE) for 1-day duration. Uncorrected visual acuity (UCVA) of LE reduced to 20/80 from postoperative 20/20. Slit-lamp biomicroscopy revealed tiny infiltrate in the interface with reticular haze in the flap and stroma. Gram-positive cocci in pairs and tetrads were found on corneal smears that were collected after lifting the flap from infiltrate, stromal bed, and undersurface of the flap. was isolated on culture. The infiltrate resolved with scarring with intensive topical antibiotics. UCVA was 20/25. To the best of our knowledge, this is a first case report of post-LASIK infectious keratitis caused by .
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http://dx.doi.org/10.4103/ojo.OJO_54_2017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6826603PMC
October 2019

Contact lens fitting after corneal collagen cross-linking.

Oman J Ophthalmol 2019 Sep-Dec;12(3):177-180. Epub 2019 Oct 11.

Bausch and Lomb Contact Lens Clinic, L V Prasad Eye Institute, Hyderabad, Telangana, India.

Background: Contact lenses (CLs) remain the mainstay in improving vision in patients having keratoconus. With corneal collagen cross-linking (CXL) performed worldwide, whether the same CLs can be used or needs replacement needed to be assessed and considered.

Aims: The aim of this study was to evaluate the changes in CL fitting following CXL.

Settings And Design: This is a retrospective study conducted at a tertiary center.

Subjects And Methods: We analyzed the medical records of patients who underwent CXL and used CL. Data collected included demographics, pre- and post-CXL refraction, corneal topography, anterior-segment examination, and CL [rigid gas permeable(RGP)] fitting details and duration between CXL and RGP fitting.

Statistical Analysis: Descriptive analysis and paired -test were used to compare the pre- and post-CXL data on refraction, visual acuity, and CL parameters. The statistical significance was kept at < 0.05.

Results: Thirty-four eyes (keratoconus = 32, pellucid marginal degeneration = 1, and post-LASIK ectasia = 1) of 27 patients who used CL before and after undergoing CXL were analyzed. Mean duration between CXL and RGP lens use was 2.53 months. Mean sphere and cylinder post-CXL was -4.11 ± 4.32 D and -3.54 ± 2.51 D, respectively. A mean change of 0.75 ± 3.72 D sphere and 0.71 ± 3.39 D cylinder was noted post-CXL. The post-CXL best spectacle-corrected visual acuity (CVA) was 0.52 ± 0.36 and with RGP lens it was 0.09 ± 0.18. There was no significant difference in pre- and post-CXL RGP lens CVA (0.07 ± 0.09 and 0.09 ± 0.18, respectively; = 0.556). Pre-CXL, 3-point-touch fitting was in 24 eyes (70.59%) and central fluorescein pooling was in 10 eyes (29.41%). Post-CXL, 30 eyes (88.24%) had 3-point-touch and central fluorescein pooling was found in four eyes (11.76%). One patient had CL intolerance after CXL. Of the 32 keratoconus eyes, 62.5% ( = 20 eyes) were prescribed new lenses; 37.5% ( = 12 eyes) continued using own lenses.

Conclusions: There was no significant difference in refraction, topography indices, and RGP lens parameters pre- and post-CXL. However, changes in RGP lens fitting characteristics suggest a possible change in shape or apex location of the cornea after CXL. RGP lenses remain the best option to improve visual acuity after CXL in corneal ectasia.
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http://dx.doi.org/10.4103/ojo.OJO_43_2018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6826600PMC
October 2019

Innovative bulls eye drop applicator for self-instillation of eye drops.

Cont Lens Anterior Eye 2020 06 5;43(3):256-260. Epub 2019 Dec 5.

TejKohli Cornea Institute, L V Prasad Eye Institute, Hyderabad, India; Gullapalli Pratibha Rao International Centre for Advancement of Rural Eye care, L V Prasad Eye Institute, Banjara Hills, Hyderabad, India. Electronic address:

Purpose: To report the role of Bulls eye drop applicator device in self-instillation of eye drops and in prevention of wastage of medicine.

Methods: A small pocket sized device "Bulls eye drop applicator" was developed, which is a simple, handy, mirror-based attachment which can be attached to any eye drop bottle to help in accurate self-instillation of the drops in the eye. The prototype of this device was tried in ten volunteer subjects (Group 1) and 15 patients (Group 2); they were asked to use lubricating eye drops (5 ml bottle) in one eye without the device (N) and in the other eye with the device (M). The numbers of attempts for the application of eye drops were noted and the residual eye drops in the returned bottles were measured for quantitative assessment.

Results: Ten volunteers and 11/15 patients completed the study. At the completion of the study, there were a total of 232 applications of eye drops in the Group 1 N (without device) and 1 M (with device). To achieve these 232 applications, there were 330 attempts without the device and 266 attempts of instillation were needed with the device (P < 0.0001). In Group 2, there were a total of 544 applications of eye drops; to achieve this, there were 879 attempts in Group 2 N and 685 attempts of instillation in Group 2 M (p < 0.0001). The cumulative quantity of residual drops in the returned bottles collected from Group 2 N was 5.1 ml and it was 19.7 ml in Group 2 M (p = 0.001).

Conclusions: The number of attempts of instillation reduced significantly with the use of the eye drop applicator device. The use of eye drops applicator device reduced the wastage of drops from 42.2% to 14.6% in Group 1 N Vs Group 1 M and saving of about 35.7 % in Group 2 M compared to Group 2 N.
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http://dx.doi.org/10.1016/j.clae.2019.11.010DOI Listing
June 2020

Anterior megalophthalmos: Is visual restoration possible?

Oman J Ophthalmol 2018 May-Aug;11(2):184-186

L V Prasad Eye Institute, Hyderabad, Telangana, India.

We report two cases of anterior megalophthalmos with cataract. Both cases have megalocornea, cavernous anterior chamber, enlarged iris-lens diaphragm, and normal axial length. The vision was less due to cataract. To restore vision, phacoemulsification was performed in each eye in both cases. Intraoperatively, to overcome anatomical challenges, we made scleral tunnel incision, stained anterior capsule, and fixated intraocular lens (IOL) by different techniques. In thefirst case, IOL was fixated through the sclera, whereas in the second case, IOL stabilization was achieved by capturing the optic in anterior capsulorhexis margin and placing the haptics in sulcus. Successful vision was restored in both cases without pseudophacodonesis.
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http://dx.doi.org/10.4103/ojo.OJO_165_2015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5991068PMC
June 2018

Scleral lens after intracorneal ring segments in patients with keratoconus.

Cont Lens Anterior Eye 2018 04 1;41(2):234-237. Epub 2017 Nov 1.

Tej Kohli Cornea Institute, L V Prasad Eye Institute, Hyderabad, TS, India.

Background: To report the use of scleral lens (ScCL) to improve vision in patients having keratoconus who had intracorneal ring segment (ICRS) surgery.

Methods: Two eyes of two keratoconus patients fitted with ScCL (PROSE - prosthetic replacement of the ocular surface ecosystem, USA) after having undergone ICRS surgery are reported as noncomparative interventional case series. The ICRS implanted were INTACs and kerarings. Indications, visual acuity with ScCL, complications and follow-up are reported.

Results: Case 1 underwent ScCL trial as he was referred for keratoplasty for being contact lens intolerant after ICRS surgery. Case 2 was intolerant to both corneal rigid gas permeable (RGP) lens and soft contact lens (SCL). 18.5 and 18mm diameter ScCLs were dispensed to Case 1 and 2 respectively. The ScCLs had adequate corneal clearance with no corneal touch. There was no staining of the cornea or vascularization with the lens use. Case 1 complained of double images during trial with different Front surface eccentricity (FSE). A ScCL that did not cause diplopia was ordered. At four months of lens wear, the patient had diplopia with ScCL, which cleared when second lens with changed FSE was dispensed. Case 2 used SCL for five years before ScCL was fitted. He used the same ScCLs for five years. ScCL use resulted in improved comfort and visual acuity of 20/20. No complications were noted.

Conclusions: ScCL may be tried in patients who have ICRS and are intolerant to corneal RGP or SCL and before subjecting such patients to keratoplasty.
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http://dx.doi.org/10.1016/j.clae.2017.10.013DOI Listing
April 2018

Role of Scleral Contact Lenses in Management of Coexisting Keratoconus and Stevens-Johnson Syndrome.

Cornea 2017 Oct;36(10):1267-1269

*Tej Kohli Cornea Institute, L V Prasad Eye Institute, Hyderabad, India; and †Bausch & Lomb Contact Lens Centre, L V Prasad Eye Institute, Hyderabad, India.

Purpose: To report the rare coexistence of keratoconus and Stevens-Johnson syndrome (SJS) managed with scleral contact lenses (ScCLs).

Methods: This is a retrospective case series. Five patients (9 eyes) who had coexisting SJS and corneal ectasia were identified from the database during the 2-year period. Diagnosis of SJS was based on a positive history of drug reactions, signs of ocular surface disease, and the presence of keratinization of lid margins. Keratoconus was diagnosed by slit-lamp biomicroscopy.

Results: Five eyes of 3 patients had coexisting SJS and keratoconus and were dispensed with ScCLs (PROSE, prosthetic replacement of the ocular surface ecosystem; Boston Foundation for Sight, Needham Heights, MA). All these patients had photophobia. Visual acuity improved in all these patients with ScCL wear. Two patients (4 eyes) were excluded from this study because they had SJS with generalized corneal thinning from limbus to limbus, corneal opacification, and pannus. One patient developed deep vessels in the cornea on prolonged ScCL wear. Reduction in the ScCL wear schedule and change of material with a higher Dk resulted in regression of vascularization. Case 3 developed conjunctival congestion and was uncomfortable wearing ScCLs, although visual acuity was 20/40. He discontinued using ScCL wear.

Conclusions: Keratoconus, a noninflammatory condition of the cornea coexisted with inflammatory SJS. Managing such patients with ScCLs may improve vision and comfort.
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http://dx.doi.org/10.1097/ICO.0000000000001310DOI Listing
October 2017

KOH mount as an aid in the management of infectious keratitis at secondary eye care centre.

Br J Ophthalmol 2017 11 24;101(11):1447-1450. Epub 2017 Jul 24.

Tej Kohli Cornea Institute, L V Prasad Eye Institute, Hyderabad, India.

Aims: To report the clinical outcome of infectious keratitis managed after doing 10% KOH mount of corneal smears and reporting done by an ophthalmologist in the secondary eye care centre in South India.

Methods: 103 consecutive cases of microbial keratitis were studied. Inclusion criteria were presence of corneal infiltrate on slit lamp biomicroscopy. An ophthalmologist carried out microbiological evaluation of 10% KOH mount of corneal scrapings. No cultures were done at secondary centres. Antifungal therapy with 5% Natamycin was initiated when 10% KOH mount was positive for fungal filaments. Else, the patients were started on combined topical ciprofloxacin (0.3%) and fortified cefazolin (5%).

Results: 41/103 (39.8%) smears were positive for fungus and 62 (60.2%) were negative. 89 out of 103 patients (86.40%) healed with scarring at an average of 2.95±1.58 weeks. Healing was noted in 39/41 (95.12%) of patients at an average of 3.06±1.19 weeks in patients with KOH smear positive keratitis. 80.64% (50/62) healed with scarring at an average period of 2.86±1.86 weeks in KOH mount negative keratitis.

Conclusions: Initial smear examination of KOH mount by an ophthalmologist helped in diagnosis of infectious keratitis caused by fungi and its management and 95.12% of KOH positive patients healed with scarring. Reading of KOH mount by an ophthalmologist helped in initiation of specific therapy with improved clinical outcome.
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http://dx.doi.org/10.1136/bjophthalmol-2017-310241DOI Listing
November 2017

Change in vault during scleral lens trials assessed with anterior segment optical coherence tomography.

Cont Lens Anterior Eye 2017 Jun 31;40(3):157-161. Epub 2017 Mar 31.

Tej Kohli Cornea Institute, L V Prasad Eye Institute, Hyderabad, India.

Purpose: To assess the change in vault during scleral lens fitting with anterior segment optical coherence tomography (AS-OCT).

Methods: This study comprised of patients who had AS-OCT performed after 1h and 4h of scleral lens wear (PROSE, prosthetic replacement of the ocular surface ecosystem, Boston Foundation for Sight, Needham Heights, MA, USA). Vault was measured on AS-OCT as the distance between the front surface of the cornea in the center and the back surface of the scleral lens.

Results: Fifty eyes of 41 patients were analyzed. The main indications for scleral lens trial were ectasia (keratoconus, post surgery) (n=20 eyes) and ocular surface disease (OSD - Stevens - Johnson syndrome, dry eyes and limbal stem cell deficiency) (n=30 eyes). Mean age of the patients was 31.4 years. Twenty were males. The diameter of the scleral lens ranged from 16mm to 18.5mm. Vault measurements reduced in 45/50 eyes (90%), remained same (n=2) or increased (n=3). Overall mean vault decreased from 680±421μm at 1h to 589±355μm (p=<0.001) at 4h of lens wear. Mean vault in ectasia was 759±574μm and 634±455μm (p=0.02) at 1h and 4h of lens wear respectively. In OSD group, mean vault was 626±276μm and 558±273μm (p<0.01) at 1h and 4h of lens wear respectively. Average reduction in the vault was 125μm in ectasia and 68μm in OSD group.

Conclusion: Vault reduced significantly after 4h of lens wear during scleral lens trial indicating that the final assessment of the scleral lens may be done after 4h of lens wear.
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http://dx.doi.org/10.1016/j.clae.2017.03.008DOI Listing
June 2017

Allergic conjunctivitis.

Community Eye Health 2017 ;30(99):S7-S10

Faculty, Tej Kohli Cornea Institute, L.V. Prasad Eye Institute, Kallam Anji Reddy Campus, Hyderabad, India.

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5968423PMC
January 2017

Prevention, diagnosis & management of dry eye in South Asia.

Community Eye Health 2017 ;30(99):S3-S4

Faculty, Tej Kohli Cornea Institute, Kallam Anji Reddy Campus, L V Prasad Eye Institute (LVPEI), Hyderabad, India.

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5968421PMC
January 2017

Femtosecond Laser-Assisted Anterior Lamellar Keratoplasty for Recurrence of Granular Corneal Dystrophy in Postkeratoplasty Eyes.

Cornea 2017 Mar;36(3):300-303

Tej Kohli Cornea Institute, L V Prasad Eye Institute, L V Prasad Marg, Kallam Anji Reddy Campus, Hyderabad, India.

Purpose: To report the clinical and visual outcome of sutureless femtosecond laser-assisted anterior lamellar keratoplasty (FALK) for recurrent granular corneal dystrophy (GCD) in patients who had previously undergone penetrating keratoplasty and phototherapeutic keratectomy (PTK) performed for recurrent dystrophy in the grafted eyes.

Methods: Four eyes of 4 patients who underwent FALK for recurrence of GCD in previously grafted eyes and underwent PTK performed for initial recurrence in the grafts were included. Patients who had undergone FALK for other indications were excluded. The patients were evaluated for preoperative and postoperative best-corrected visual acuities (BCVA), and intraoperative and postoperative complications. Visual outcomes and complications, if any, were noted.

Results: FALK was uneventful in all 4 eyes. At last follow-up, BCVA improved by >2 lines in all eyes. Myopic shift in the refractive error was noted in 2 eyes. None of the eyes had any intraoperative or postoperative complications. One case had dissection margins cross the graft-host junction; however, no dehiscence occurred in this case. The grafts were clear at the last follow-up examinations.

Conclusions: FALK is a safe and effective technique for the management of recurrence of GCD in post-penetrating keratoplasty and post-PTK eyes. BCVA improved by >2 lines after the FALK procedure. None of the patients in this series had any intraoperative or postoperative complications, which was indicative of the safety of the procedure.
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http://dx.doi.org/10.1097/ICO.0000000000001068DOI Listing
March 2017

Reply: amniotic membrane transplantation in Stevens-Johnson syndrome.

Surv Ophthalmol 2017 Mar - Apr;62(2):249-250. Epub 2016 Oct 15.

Center for Ocular Regeneration (CORE), Srujana-Center for Innovation, L V Prasad Eye Institute, Hyderabad, India. Electronic address:

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http://dx.doi.org/10.1016/j.survophthal.2016.10.005DOI Listing
March 2018
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