Journal of Current Ophthalmology
Volume:31 Issue: 2, Jun 2019

A comprehensive review in congenital cataract management can guide general ophthalmologists in managing such a difficult situation which remains a significant cause of preventable childhood blindness. This review will focus on surgical management, postoperative complications, and intraocular lens (IOL)-related controversies. Electrical records of PubMed, Medline, Google Scholar, and Web of Science from January 1980 to August 2017 were explored using a combination of keywords: "Congenital", "Pediatric", "Childhood", "Cataract", "Lens opacity", "Management", "Surgery", "Complication", "Visual rehabilitation”, and "Lensectomy". A total number of 109 articles were selected for the review process. This review article suggests that lens opacity obscuring the red reflex in preverbal children and visual acuity of less than 20/40 is an absolute indication for lens aspiration. For significant lens opacity that leads to a considerable risk of amblyopia, cataract surgery is recommended at 6 weeks of age for unilateral cataract and between 6 and 8 weeks of age for bilateral cases. The recommended approach in operation is lens aspiration via vitrector and posterior capsulotomy and anterior vitrectomy in children younger than six years, and IOL implantation could be considered in patients older than one year. Most articles suggested hydrophobic foldable acrylic posterior chamber intraocular lens (PCIOL) for pediatrics because of lower postoperative inflammation. Regarding the continuous ocular growth and biometric changes in pediatric patients, under correction of IOL power based on the child's age is an acceptable approach. Considering the effects of early and late postoperative complications on the visual outcome, timely detection, and management are of a pivotal importance. In the end, the main parts of post-operation visual rehabilitation are a refractive correction, treatment of concomitant amblyopia, and bifocal correction for children in school age. The management of congenital cataracts stands to challenge for most surgeons because of visual development and ocular growth. Children undergoing cataract surgery must be followed lifelong for proper management of early and late postoperative complications. IOL implantation for infants less than 1 year is not recommended, and IOL insertion for children older than 2 years with sufficient capsular support is advised.

To review the published literature regarding cataract surgery in keratoconus (KCN) patients with emphasis on challenges encountered during intraocular lens (IOL) power calculation and their solutions. A literature review was performed to investigate all the relevant articles on the advancements of IOL calculations in KCN patients. Cataract surgery in keratoconic eyes can improve patients' refraction, and proper patient selection and IOL calculation methods are necessary to get the best results. The main problem in KCN patients is unreliable biometric measurements. It is more difficult to make conclusions in more advanced keratoconic corneas, as the steep keratometric values in these eyes will result in the selection of a low-power IOL. Presence of a low-power IOL will yield in extreme postoperative hyperopia, and IOL exchange might be mandatory. In cases in which keratoplasty may be needed in the future, contact lens fitting can help surgeons make a better decision preoperatively. Axial length (AL) measurements may have better repeatability and reproducibility than keratometry (K) readings in keratoconic eyes. SRK II formula may provide the most accurate IOL power in mild KCN. There is still not a comprehensive consensus of which formula is the best one in moderate and severe KCN, as the literature is limited in this subject. Various methods of IOL power calculation optimization and recommendations may hold the key to improve surgical outcomes in keratoconic eyes. There are multiple sources of biometric error in KCN patients, hence IOL calculation methods may not be as efficient as expected in these eyes.

To compare clinical outcomes between mechanical debridement photorefractive keratectomy (m-PRK) and trans-epithelial photorefractive keratectomy (t-PRK) in myopic patients. Eighty eyes of 40 myopic patients with age between 18 and 55 years were included in this study. In each patient, one eye was randomly assigned for t-PRK, using the Amaris laser's ORK-CAM software and the other eye for m-PRK, using a spatula. Stromal ablation was done by Schwind Amaris 750S. Uncorrected and best corrected visual acuity (BCVA), refractive outcomes, epithelial healing, pain, and discomfort were compared between the groups on day 1, 3, 7 and month 1, 3, and 6. Preoperative spherical equivalent (SE) were
3.97 ± 2.08 diopter (D) and
3.98 ± 2.06 D in m-PRK and t-PRK eyes, respectively (P ¼ 0.981). Operation time was significantly shorter in the t-PRK group than m-PRK (P < 0.001). Postoperative pain was experienced significantly higher in the t-PRK group measured by 11-point numeric scale of pain questionnaire on the first postoperative day (P < 0.001). Photophobia, tearing, and vision fluctuation were also significantly higher in the t-PRK group postoperatively. However epithelial defect size and re-epithelialization time were lower in the t-PRK group (P ¼ 0.012 and P < 0.001, respectively). Postoperative parameters including SE, uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), and contrast acuity did not show any significant difference between the two groups during all intervals. Although epithelial defect size and epithelial healing time were lower in t-PRK, postoperative pain, photophobia, and vision fluctuation were significantly less in the m-PRK group in the first postoperative days. There was no statistically significant difference between the groups after one week, and both mechanical and trans-epithelial techniques were shown to be safe and effective.

To evaluate the effects of air bubbles on clear corneal incision (CCI) in patients who had phacoemulsification surgery, and to compare this type of CCI architecture with patients who had no air bubbles after phacoemulsification surgery, using anterior segment optical coherence tomography (AS-OCT). Eyes which had undergone uneventful phacoemulsification cataract surgery with implantation of a posterior chamber intraocular lens (IOL) were equally randomized into two groups. Group 1 comprised patients with anterior chamber air bubble injection after phacoemulsification, and Group 2 comprised patients who had undergone phacoemulsification surgery without anterior chamber air bubble. Postoperative evaluation included AS-OCT (Heidelberg Engineering, Germany) and pneumatic tonometry (Nidek NT-1000 Pneumatic Tonometer, Japan) in the 2nd hour, then at 1 week, and 1 month. Astigmatic changes assessed with corneal topography after phacoemulsification cataract surgeries were noted. Evaluation was made of 40 eyes of 28 patients (10 female, 18 male) as 20 eyes in Group 1 and 20 eyes in Group 2. On the first postoperative day, the endothelial gap rate was 13.3% in Group 1 and 57.1% in Group 2 (P ¼ 0.02), and this continued until the 1-month followup examination. The Descemet's membrane detachment (DMD) rate was 0% in Group 1 and 42.8% in Group 2 on postoperative day 1 (P ¼ 0.006), and this continued at the 1-month follow-up examination. At 1 month postoperatively, the rates of optical coherence tomography (OCT) parameters were similar. There were no significant differences between preoperative astigmatism and postoperative astigmatism in the group analyses. In this study, air bubbles decreased the rate of DMD and of endothelial and epithelial gap during the early postoperative period.

To determine the central corneal thickness (CCT), apex, and paracentral thicknesses and their determinants in children aged 6e12 years. The present study was part of the phase 1 of Shahroud School Children Eye Cohort Study in 2015. Cluster sampling was done in urban areas while all children were invited to participate in the study in rural areas. The Pentacam HR was used for measurements. CCT was measured within the central 3 mm zone of the cornea, and corneal thickness 3 mm further from the center was considered paracentral thickness. Of 6624 students who were selected, 5620 (84.8%) participated in the study. Among 4956 students, studied in this report, 52.2% were boys, and the mean age of the study participants was 9.75 ± 1.71 years (6e12). The mean CCT and apical thickness was 556.29 ± 34.04 and 557.43 ± 34.03 mm, respectively. The mean paracentral thickness was 657.62 ± 39.11 mm in the superior, 632.65 ± 37.63 mm in the inferior, 648.64 ± 38.75 mm in the nasal, and 617.36 ± 37.19 mm in the temporal region. A multiple regression model showed that CCT decreased by 4.70 mm with every 1 diopter increase in the mean keratometry and increased by 20.06 mmwith every 1mmincrease in the anterior chamber depth (ACD) (Both P-Value < 0.001). Age, sex, ethnicity and residence place were also found to be associated with CCT. This study is the first to describe the distribution of corneal thickness in Iranian children with a large sample size. This study showed that corneal thickness was significantly correlated with younger age, female gender, urban residence, and a number of biometric variables.

To evaluate the effects of subthreshold diode micropulse laser photocoagulation on treating patients with refractory diabetic macular edema (DME). This randomized clinical trial recruited patients with DME in both eyes that were resistant to treatment with intravitreal bevacizumab (IVB). The eyes were randomly divided into two groups who received laser therapy and IVB, or IVB alone. Subthreshold diode micropulse laser photocoagulation and IVB injection were administered in one eye, and an IVB injection was administered in the second eye. IVB injections were repeated in both eyes within one month and two months after the first injection. Best corrected visual acuity (BCVA) logarithm of the minimum angle of resolution (logMAR) and central macular thickness (CMT) were measured before, within a month, and three months after start of intervention. In this study, 42 eyes of 21 patients were evaluated. The mean age of patients was 60.86 ± 8.57 years. Ten patients (47.6%) were male. Within-group analysis showed a significant decreased in BCVA logMAR in the laser þ IVB group reflecting improvement in visual acuity (VA) (P < 0.001); it increased in the control group during study reflecting more vision loss (P ¼ 0.01). In the laser þ IVB group, a significant decrease in mean ± standard deviation (SD) CMT at 3 months compared to baseline was observed (baseline: 513 ± 126.29 vs. three months: 408.1 ± 95.28; P < 0.001). The mean ± SD CMTwas significantly lower in the laser þ IVB group of eyes than in the control group three months after intervention (P ¼ 0.02). Using subthreshold diode micropulse laser photocoagulation in combination with IVB can significantly reduce CMT and improve BCVA in patients with refractory DME.

To compare optical coherence tomography angiography (OCT-A) image quality gradings performed by readers of varying retinal expertise levels in different retinal diseases. Central 3
3 mm2 OCT-A images (AngioVue, Optovue) of 57 healthy controls (50.9 ± 22.4 years) and 148 patients (66.5 ± 14.1 years) affected by various chorioretinal diseases were retrospectively analyzed including early age-related macular degeneration (AMD, n ¼ 26), neovascular AMD (nAMD, n ¼ 22), and geographic atrophy due to AMD (GA, n ¼ 6), glaucoma (n ¼ 28), central serous chorioretinopathy (CSC, n ¼ 14), epiretinal membrane (EM, n ¼ 26), retinitis pigmentosa (RP, n ¼ 16), and retinal venous occlusion (RVO, n ¼ 10). A senior expert in medical retina (SE), an ophthalmology resident (OR), and a non-ophthalmologic medical doctor (MD) independently assessed OCT-A image quality using the motion artifact score (MAS) and the segmentation accuracy score (SAS). Regarding MAS, inter-reader agreement between SE and OR was 93.7% (Cohen's kappa ¼ 0.907) and 85.4% (Cohen's kappa ¼ 0.786) between SE and MD. Regarding SAS, inter-reader agreement between SE and OR was 95.1% (Cohen's kappa ¼ 0.92) and 92.2% (Cohen's kappa ¼ 0.874) between SE and MD. In the SAS analysis, signal strength index (SSI) and presence of retinal pathology had a significant influence on the overall agreement (P ¼ 0.046; P < 0.001). OCT-A image quality assessment can be performed most reliably by an ophthalmologist with knowledge in retinal image analysis. Yet, well-instructed non-ophthalmologic assessors show only slightly inferior results and, thus, may be integrated in routine OCT-A image quality assessment as well.

To assess the efficacy of adjuvant topical timololedorzolamide with intravitreal bevacizumab (IVB) injection on anatomic and functional results in eyes affected with diabetic macular edema (DME). In an interventional prospective contralateral pilot eye study at a third level referral academic facility, patients with bilateral DME who were treatment-naive were enrolled. Enrolled patients received a treatment plan of topical timololedorzolamide twice daily in the right eye. Three monthly bilateral IVB injections 1.25 mg/0.05 mL were also planned. Baseline central macular thickness (CMT) was measured by spectral-domain optical coherence tomography (SD-OCT), and clinical information such as best corrected visual acuity (BCVA) and intraocular pressure (IOP) were collected at enrollment and one month after the third injection. Eleven patients (seven females) with DME were included. BCVA and CMT improved in both eyes and IOP decreased in the right eye but did not change in the left eye. In repeated measures ANOVA analysis, the decrease in CMTand improvement in BCVAwere significant in the right eye. Our study suggested that adjuvant topical timololedorzolamide in combination with IVB may further reduce central macular thickness in eyes with DME.

To report the genetic analysis of an Iranian Bietti crystalline dystrophy (BCD)-affected family, and to review previously reported mutations in the gene and assess the distribution of affected amino acids in the encoded protein. The eleven exons of CYP4V2 were sequenced in the DNA of the proband of the Iranian BCD family. The putative disease-causing variation was screened in all affected and non-affected members. BCD causing CYP4V2 mutations previously reported in the literature were compiled, and positions of amino acids affected by nonsense and missense mutations were mapped onto the primary structure of the CYP4V2 protein. C.1219G > T in CYP4V2 that causes p.Glu407* was identified as cause of BCD in the Iranian family. The mutation segregated with disease status. Clinical presentations were similar among affected members, except that one patient presented with retinal macular hole. Twelve nonsense and 47 missense mutations in CYP4V2 were compiled. Inspection of distribution of amino acids affected by the mutations suggested non-random distribution and clustering of affected amino acids in nine regions of the protein, including regions that contain the heme binding site, the metal binding site, and a region between these binding sites. The most C-terminus proximal nonsense mutation affected position 482. This study presents results of the genetic analysis of an Iranian BCD family. Protein regions affected by mutations within the nine mutation clusters include regions well conserved among orthologous proteins and human CYP4 proteins, some of which are associated with known functions. The findings may serve to identify reasonable candidate gene region targets for gene editing therapy approaches.

To investigate indocyanine green angiography (ICGA), fluorescein angiography (FA), and enhanced depth imaging optical coherence tomography measured choroidal thickness (EDI-OCT-CT) in the follow-up of inflammatory activity in stromal choroiditis [Vogt-Koyanagi-Harada disease (VKH) and birdshot retinochoroiditis (BRC)] under treatment in order to monitor tapering of therapy or readjustment of therapy in case of subclinical disease recurrence. Patients with initial onset disease and/or treatment-naive stromal choroiditis (VKH & BRC) at entry, quiet under therapy, and having had a follow-up of at least four years monitored with dual FA and ICGA and EDI-OCT-CT measurements were analyzed retrospectively. ICGA and FA scores and EDI-OCT-CT values were correlated with therapy, and significant changes of each modality were correlated with disease evolution. Of the 31 VKH and 29 BRC patients seen from 1995 to 2017 in our center, four patients (2 VKH and 2 BRC patients) fulfilled the inclusion criteria. During tapering, two patients (both VKH) showed no significant ICGA, FA, and EDI-OCT-CT changes (mean follow-up time 5.6 years) and allowed for safe tapering. In the other two (BRC) patients (mean follow-up time 6.25 years), a total of seven significant subclinical changes were demonstrated by ICGA alone after therapy modifications due to side-effects or during attempted tapering of therapy, while FA and EDI-OCT-CT remained unchanged. ICGA was the most sensitive monitoring modality of stromal choroiditis, able to identify subclinical recurrences following change of therapy and inversely treatment responses after readjusted therapy, events otherwise missed by FA and EDI-OCT. ICGA proved efficient for safe therapy tapering or for timely adjustment of therapy in stromal choroiditis when necessary.

To measure Horizontal Inequity Index (HI) of unmet refractive error and its changes between 2009 and 2014 in Iran. The data used in this study was taken from population-based study, Shahroud Eye Cohort Study. The number of participants analyzed in first (2009) and second phases of study (2014) were 5190 and 4737, respectively, and individuals between 40 and 64 years were included. The HI was determined by using the Concentration Index (C) based on the nonlinear (Probit) model, and C was decomposed to identify and quantify the contribution of each factor. After adjusting for need variables, the results demonstrated that the HI in unmet refractive need decreased from
0.288 (95% CI: 0.370,
0.206) in the 2009 to
0.132 (95%CI: 0.290,
0.028) in 2014.Decomposition of the C showed that level of education and economic statuswere the greatest contributors with shares of 26.2% and 17.9%, respectively, in reducing the amount of HI in unmet refractive error between 2009 and 2014. The current study demonstrated that unmet refractive error did not have an equal distribution among economic quintiles, despite the same need for correcting refractive errors. Reducing the amount of HI in unmet refractive error between 2009 and 2014 indicated an improvement in the unmet need in the five years period between two phases of study.

To evaluate ocular movement disorders after scleral buckling surgery (SBS) for retinal detachment. In this prospective, observational, case series, 206 patients (206 eyes) with rhegmatogenous retinal detachment who underwent SBS and investigated at the strabismus ward of Farabi Eye Hospital in Iran between November 2011 and November 2014 were assessed. Patients were followed from 6 to 36 months after SBS to evaluate for strabismus. Logistic regression analysis test and SPSS software version 20 were used for statistical analysis. From 206 patients, 56.8% were male, and 33.2% were female. For scleral buckle in 44.7% of patients, silicone band and tire (SBT) was used, and in 55.3%, a sponge. Among all patients, seven (3.39%) exhibited ocular movement disorder. There was no significant relation between type of buckle (P ¼ 0.65) or the location of buckle (P ¼ 0.56) and movement disorder. Ocular movement disorder is one of the main complications after SBS without specific association between the type and location of exoplanet.

To evaluate the effect of full-time and part-time occlusion therapy on axial length (AL) of non-amblyopic eyes in anisohyperopic patients. Sixty-five patients who were treated for anisohyperopic amblyopia were recruited for this prospective cross-sectional study. Treatment was provided as patching of the non-amblyopic for 4 h or less (part-time occlusion therapy, n = 42), patching of the non-amblyopic for 8 h or more (full-time occlusion therapy, n = 13) and refractive correction (spectacles, non-patched group, n = 10). AL measurements were calculated by a Lenstar LS 900 at the last session of amblyopia therapy. The mean age of patients treated for anisohyperopic amblyopia was 4.90 ± 0.80 years, and the mean follow-up period was 1.50 ± 0.80 years. The mean of spherical equivalent in amblyopic and non-amblyopic eyes were +3.58 ± 2.26 and +1.84 ± 0.97 diopter (D) before treatment, and +3.21 ± 2.28 and +1.49 ± 0.99 D after treatment, respectively. The mean of spherical equivalent in non-amblyopic eyes before (F = 0.452, df = 2, P = 0.639) and after (F = 0.190, df = 2, P = 0.828) treatment did not have any significant difference between the three groups. The mean AL of amblyopic and non-amblyopic eyes were 22.11 ± 93.0 and 22.68 ± 1.07 mm, respectively. The mean AL of the non-amblyopic eye was significantly higher in the full-time occlusion therapy group when compared to the part-time patch and the non-patched groups (P < 0.001). The mean AL of amblyopic eyes showed no difference across the three treatment groups (P = 0.840). The results show that a longer AL in the non-amblyopic eye, but not the amblyopic eye, can be expected with longer daily hours of patching in anisohyperopic patients. Future studies are needed to evaluate the effect of patching on AL in children with anisohyperopic amblyopia.

To determine 4-year changes of ocular biometric and dioptric components in Iranian children aged 7e11 years following the first phase. 468 children were evaluated in the first phase of the study in 2012 and again in 2016e2017. Multi-stage stratified cluster sampling was applied to select the participants. The Topcon autorefractometer and the LENSTAR/BioGraph biometer (WaveLight AG, Erlangen, Germany) were used for cycloplegic refraction and biometry, respectively. All measurements were repeated at 4 years as the baseline assessments. Of 468 children, 251 (53.6%) were boys. Spherical equivalent (SE) showed a marked myopic shift (P ¼ 0.000) in the second phase which was significantly higher in boys (0.24 vs. 0.18 D) (P < 0.001). Axial length (AL) and anterior chamber depth (ACD) increased by 0.49 ± 0.05 and 0.12 ± 0.02 mm, while lens thickness (LT) and lens power (LP) decreased by 0.08 ± 0.01 mm and 1.59 ± 0.12 D, respectively (P < 0.05). The mean corneal curvature and thickness did not change significantly during 4 years. All biometric component changes were greater in boys. Biometric changes in different age groups showed a decreased LP, increased AL, and increased ACD in most age groups (P < 0.05), while LT and SE did not change significantly in the age groups 9 and 11 years and 8 and 9 years, respectively. Changes in the corneal thickness, diameter, curvature, and refractive astigmatism were not significant in any of the age groups (P > 0.05). Statistical and clinical changes were seen in AL, ACD, LP, and LT. The changes observed in biometric components (AL, ACD, and LT) had a sinus rhythm.

To assess the efficacy of sclerotherapy with sodium tetradecyl sulfate (STS; Fibrovein 1%) in superficial periocular venous and lymphatic malformations. Eleven patients with low-flow venous and lymphatic malformations with extension predominantly to the eyelids, conjunctiva, and anterior orbit were selected. Sclerotherapy with STS was undertaken as an office-based procedure without any radiological guidance. Injections were repeated every 4 weeks until desired response occurred. Therapeutic effect was assessed objectively by change in the size of the lesions in serial photography. The lesions completely resolved in 4 cases with small eyelid and fornix lesions. In other 7 cases there was partial resolution to less than half of primary size. We did not have any significant complications. Sclerotherapy with STS is an easy and effective modality for treatment of venous-lymphatic malformations and can be undertaken as an office-based procedure in lesions which are limited to eyelids and anterior orbit.

Dear Editor,
We read with great interest the article by Lal et al.1 regarding awareness and knowledge about eye donation among students in Goa. Even though several studies2, 3 have been reported from south India in regards to eye donation, there is paucity of literature from central and north India. Lal and associates1 update us about the current status of eye donation trends in central India, and we would like to share our experience from north India.
From March 2017 till February 2018, we interviewed 407 people in Delhi (north India) to understand the trends, awareness, knowledge, influences, and barriers to eye donation in Indian society.
In our cohort, we found that the majority of people willing for eye donations were in the 32–52 years age group, and age did not have any correlation to willingness for eye donation (P = 0.64). Prior wish to donate eyes also had no effect on the family's decision for eye donation (P = 0.09). The socioeconomic status of the participants in terms of urban and national quintile also did not have any impact on the consent for eye donation. Socioeconomic status was evaluated using KoBoToolbox, a Harvard Humanitarian Initiative, which is an open source suite of tools for data collection and analysis in humanitarian emergencies and other challenging environments and was built to address this gap (https://www.kobotoolbox.org/). This equity tool was designed using the source data of Demographic and Health Survey (DHS) of 2005–06.4 Statistical analysis was performed using SPSS statistical software (SPSS version 21. Inc., Chicago, IL, USA). Chi-square test was used to compare categorical variables, and independent sample t-test was used to compare continuous variables. Statistical significance was defined at a level of 5% (P < 0.05). There was no significant difference in willingness for eye donation between various religious groups (P = 0.194). When parents were approached, they consented 50% of the time for eye donation of their child, followed by siblings (42.9%), relatives (41.6%), spouse (36.5%), and children (34.5%). The decision for eye donation was mainly self-driven (36.97%), followed by consultations with relatives (33.52%) and parents (15.59%).
Our eye bank over the years has tried to standardize eye donation practices5, 6 and like many other eye banks in India, has adopted the concept of Eye Donation Counselors (EDC) to approach families and proactively counsel them for eye donation. One of the highlights of our study was the positive impact of EDCs on families in deciding for eye donation (P = 0.05).
We found that three hundred and sixty (88.45%) participants had heard about eye donation; however, there was no statistical correlation between willingness to donate eyes and prior awareness of eye donation (P = 0.13).
Lastly, we noted that the foremost concern before decision-making was transparency in how the cornea would be used (32.25%). The concern with regards to whether the body would remain intact after eye donation (P < 0.05) significantly decreased the probability of consent for eye donation. Similarly, family becoming upset (P < 0.05), concerns on whether body would be treated properly (P < 0.05), and religious reasons (P < 0.05) also significantly impacted (negatively) the chance of getting consent for eye donation.
Our observations, along with Lal et al.1 and other studies, form a platform for government and non-government agencies to work on eye donation models on a national level. These models could shape up and streamline the eye donation process in the country. Departments should be formed in the government to overlook organ donation, and satellite centers should be opened in smaller towns and cities to make tissues available to local ophthalmologists. Annual meeting should be held to discuss the performance and to share ideas and experiences. Dedicated funds should be set aside for these activities and both short and long-term goals should be determined. We wish to highlight that the barriers to eye donation are mostly due to misinformation and apprehensions about proper utilization of the donated tissue. There is a need to correct these misconceptions, which can be done by actionable nationwide strategies when devising information, education, and communication tools to boost up the eye banking movement in India. We recommend incorporating special lectures in schools and colleges on eye donation, educating the next generation, and making eye donation a culture. These can be used to target all misconceptions surrounding eye donation and addressing donor apprehensions. Radios and televisions should be used as advocacy tools, and frequent advertisements should be shared with the public. Events like ‘eye donation fortnight’ and ‘honoring family members of donors’ should be organized at national and local levels. We would also want to emphasize the pivotal role of EDCs in facilitating the eye donation movement. Training courses for EDCs should be made available at designated training sites and youth should be encouraged to take up this as a career path. Collaborations with general hospitals should be encouraged so that any hospital or mortuary death can be traced and potential donors identified. Integrated software could be developed and incorporated in the hospitals Electronic Medical Records (EMR) tracking the functioning of the eye banks. We would also like to encourage other eye banks to share their ‘on-field’ experiences in dealing with a sensitive topic like this eye donation and ways to improve awareness, knowledge, and donation rates.

To report a novel finding of peripheral retinal avascularity (PRA) and peripheral capillary leakage (PCL) on wide-field fluorescein angiography (WFA) in non-dependent quadrants, in eyes with bilateral chronic central serous chorioretinopathy (CSCR). Forty six patients with bilateral CSCR were studied. Four patients had PRA and PCL, and 42 patients did not. The demographic profile, clinical findings, and imaging characteristics of the two groups were compared. There was no significant difference between those patients with and without PRA and PCL with respect to the demographic profile, clinical findings, and imaging characteristics. Laser photocoagulation to extrafoveal points of leakage seen on fluorescein angiography (FA) was sufficient to cause complete resolution of CSCR in these 4 patients. PRA areas were not treated. The PRA and PCL in CSCR are novel findings, which have not been previously described.

To describe three individuals with severe keratitis and a substantial delay before floppy associated eyelid syndrome (FES) was identified, and to estimate the prevalence of severe corneal disease in individuals with FES. We defined severe keratitis as corneal ulceration, vascularization or scar that affected vision. We recorded the clinical characteristics, the duration of symptoms before the diagnosis of FES, subsequent management and outcome. Then, to determine the proportion of individuals with FES who had severe corneal disease, we interrogated the Moorfields Eye Hospital electronic patient record (EPR) for the diagnosis of FES made in the ten-year interval from 2008. Three individuals presented with severe progressive keratitis (median duration of symptoms 19 months, range 2e48 months). All were male and with a high body mass index (BMI, range 38.9e41.2). In each the etiology of the keratitis was unclear before FES was identified. All had very lax lids and were aware they had periods of lid malposition during sleep. None mentioned symptoms of obstructive sleep apnoea (OSA) until they or their partner were directly questioned. The management of keratitis included both medical and surgical corneal treatments, with tarsorrhaphy and lid shortening surgery. We identified an additional 104 cases of FES from the EPR, of which 4 (3.8%) had severe keratitis. FES can be missed unless signs of lid laxity are directly elicited. A delay in diagnosis can result in clinical deterioration, with unnecessary investigations and treatments. An assessment for FES should be included as part of the evaluation of individuals with severe or chronic keratitis.

To report the successful management of a case of tuberculosis (TB) related multifocal serpiginous-like choroiditis with anti-TB medications alone. A case report with multimodal imaging. A 28-year-old man presented with progressive loss of vision in his left eye. He mentioned a similar history for his right eye about 2 years earlier. Fundus examination showed multiple discrete greyish irregularly bordered lesions in both eyes. Based on a highly positive skin tuberculin test and exclusion of other possible causes, a diagnosis of presumed TB associated multifocal serpiginous-like choroiditis was made, and quadruple classic anti-TB therapy was initiated. One year after introduction of anti-TB treatment, active lesions turned into scars, with significant improvement of vision. Anti-TB therapy may be enough as the only necessary treatment for TB-related serpiginous-like choroiditis.

To present a rare anaplastic form of retinal pleomorphic xanthoastrocytoma (PXA) unassociated with phakomatosis. A 9-year-old girl, presented with a rapidly growing unilateral intraocular white mass unresponsive to intra-arterial chemotherapy, underwent enucleation with the clinical suspicion of retinoblastoma versus malignant astrocytoma. Histopathology revealed pleomorphic cells with rosenthal fibers, mitosis, and necrosis. Immunohistochemistry confirmed the diagnosis of anaplastic pleomorphic xanthoastrocytoma (aPXA). The patient had no signs of phakomatosis. Retinal PXA may occur in patients without phakomatosis and rarely progress toward malignant transformation.

To present our experience in Osteo-odonto-keratoprosthesis (OOKP) as the only option to restore vision after severe ocular dog bite injuries. We describe our results in OOKP performed in two patients with previous severe dog bite facial injuries that required exenteration of one eye and facial reconstruction. Both cases achieved initially successful anatomical and visual outcome; however, one case suffered retinal detachment after one year. Buccal mucosa (BM) ulcerations and tilted lamina were present as a result of extraocular muscles loss, and both were difficult to treat. OOKP has the capability to restore vision in the most challenging cases of ocular trauma; however, refractory BM ulcerations and tilted lamina could be expected as a result of an ischemic ocular surface and orbital pulleys loss.

To present a patient with bilateral choroidal hemangioma in Sturge-Weber syndrome (SWS) and highlight multimodal imaging techniques for early detection and management of ocular alterations. A 37-year-old woman with diagnosis of SWS presented to our unit. The patient had been treated with pulsed dye laser for bilateral nevus flammeus and had right leptomeningeal angiomatosis. She had glaucoma, but ultrasound biomicroscopy did not show anterior chamber or ciliary body alterations. Enhanced depth imaging (EDI) spectral domain optical coherence tomography (SD-OCT) showed bilateral diffuse choroidal hemangiomas in both eyes with choroidal thickness above 1000 mm. B-scan ultrasound examination showed diffuse choroidal hemangioma in both eyes, with a choroidal thickness of 1.53 mm and 1.94 mm in the right and left eye (RE, LE), respectively. Peripapillary retinal nerve fiber evaluation showed thinning of the retinal nerve fiber layer in both eyes. This report highlights multimodal imaging techniques for the critical assessment of patients with SWS, especially in rare cases with bilateral choroidal hemangioma of the choroid. Novel imaging modalities enable optimal management and follow-up of rare conditions, and our case adds further evidence to the existing literature.