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Dry eye disease (DED) is a broad term that includes a diverse group of clinical disorders. Aqueous-deficient dry eye (ADDE), a subtype of DED, is characterized by decreased tear production by the lacrimal gland. It can be seen in up to one-third of individuals with DED and can be comorbid with a systemic autoimmune process or occur secondary to an environmental insult. Since ADDE can be a source of long-term suffering and severe visual impairment, early identification and adequate treatment are imperative. Multiple etiologies can underlie ADDE, and it is critical to identify the underlying cause to not only improve the ocular health but also to improve the overall quality of life and well-being of affected individuals. This review discusses the various etiologies of ADDE, highlights a pathophysiology-based approach for evaluating underlying contributors, outlines various diagnostic tests, and reviews treatment options. We present the current standards and discuss ongoing research in this field. Through this review, we propose a treatment algorithm that would be useful for an ophthalmologist in diagnosing and managing individuals with ADDE.

Background: Expulsive suprachoroidal hemorrhage is a rare but dreadful complication of any ophthalmic surgery. Hence an ophthalmologist should know about the various risk factors, methods for preventing such a situation, and be aware of the various options for timely management to tackle the situation. Purpose: To discuss the risk factors, intraoperative signs, and ways of managing expulsive choroidal hemorrhage. Synopsis: We discuss two cases having multiple risk factors, where the patients underwent tectonic penetrating keratoplasty. In view of extensive involvement of ocular structures, the patients were clearly explained about the guarded visual prognosis and the risk of auto-evisceration. Following trephination of host cornea, rise in intraocular pressure was identified by the increasing size of the vitreous seen prolapsing through the wound and markedly visible pulsations, along with subconjunctival bleeding. Suprachoroidal hemorrhage was suspected and immediate tamponade was given. However, bleeding was not controlled, and eventually, expulsion of all the intraocular contents occurred. Highlights: A surgeon must be aware of the risk factors, be prompt to identify the signs, and must take immediate actions for the management of expulsive choroidal hemorrhage, a rare but dreadful complication of intraocular procedures. Online Video Link: https://youtu.be/UnCH-lWGzwU Key words: Expulsive suprachoroidal hemorrhage

Purpose: To describe the clinical presentation and demographic distribution of retinitis pigmentosa (RP) in Laurence-Moon-Bardet-Biedl (LMBB) syndrome patients. Methods: This is a cross-sectional observational hospital-based study wherein 244 patients with RP in LMBB syndrome presenting to our hospital network between March 2012 and October 2020 were included. An electronic medical record database was used for data retrieval. Results: There were 244 patients in total, with a hospital-based prevalence rate of 0.010% or 1000/100,000 population. The mean and median age of patients was 15.22 ± 7.56 and 14 (IQR: 10-18.5) years, respectively, with the majority being in the age group of 11-20 years (133/244 patients; 54.50%). Males were more commonly affected (164 patients; 67.21%), and the majority (182 patients; 74.59%) were students. All 244 patients (100%) complained of defective central vision at presentation. More than one-fourth of the patients had severe visual impairment to blindness at presentation. Prominent retinal feature at presentation was diffuse or widespread retinal pigment epithelial degeneration in all patients. Conclusion: Patients with RP in LMBB syndrome present mainly in the first to second decade of life with severe visual acuity impairment to blindness early in life. It is important to rule out LMBB syndrome in early-onset RP with central visual acuity impairment. On the contrary, all patients diagnosed or suspected with LMBB syndrome systemic features at physician clinic should also be referred for ophthalmic evaluation, low vision assessment, rehabilitation, and vice versa.

This report describes two cases with stepwise management of chronic ocular burn sequelae with concurrent total limbal stem cell deficiency (LSCD) and advanced symblepharon. Both were mono-ocular patients with the other eye being phthisical. In both cases, a sequential approach was planned, and at the first stage, the symblepharon was released to stabilize the ocular surface and form the fornices. This was followed by a type 1 keratoprosthesis (KPro) after four months of symblepharon release in the first case, and after nine months in the second case. In the first case, after symblepharon release, the resultant bare sclera was addressed with an oral mucous membrane graft (MMG). Over two years of follow-up, there was no evidence of recurrence of the symblepharon. No further surgical interventions were required. In the second case, after symblepharon release, the resultant bare sclera was addressed with a cryopreserved amniotic membrane (AM). Over eight years of follow-up, six episodes of recurrence of the symblepharon were noted over the optic of the KPro, necessitating trimming of the conjunctiva from over the optic. Thus, with these two cases, we would like to emphasize that addressing adnexal pathologies such as a symblepharon with an oral MMG before implanting a KPro, may help prevent further recurrences of symblephara and the need for multiple surgical interventions. The oral mucosa is a better alternative to the conjunctiva as compared to the AM in a mono-ocular patient where conjunctiva cannot be harvested from the contralateral eye.

Background: Research and awareness on refractive solutions for presbyopia, commonly known as the \"Curse of the 40's,\" is essential as a large population in the world suffer from vision impairments. Population-based surveys have shown that one billion people in the world are in presbyopic age. Purpose: Many structural and physiological changes occur in the eye with the onset of presbyopia, including the decrease in amplitude of accommodation. At present, various static and dynamic techniques have been attempted to give presbyopes good vision at near-, intermediate-, and far-viewing distances. The aim of the video is to familiarize the modern-day ophthalmologists to these modalities. Synopsis: In this video, we tried to summarize the indications and contraindications of presbyopic laser. Preoperative investigations like dominance testing and micro monovision testing are described. The role of neuroadaptation and patient counselling is emphasized. Static techniques described in the video include spectacles, contact lenses, surgical options like corneal inlays and onlays, corneal laser ablation, conductive keratoplasty, corneal implant lenses, INTRACOR and IOLs. Dynamic presbyopia correction (accommodative) is always surgical. This is split into lenticular (accommodating IOLs, piggyback, lens refilling, lentotomy) and scleral treatment (laser-assisted presbyopia reversal and scleral expansion bands). Highlights: The types of corneal laser ablation, which is otherwise very confusing, is elaborated in a step-wise manner here. The difference in approach of PresbyLasik (Nidek), Presbyond (Zeiss) - Laser Blended Vision, PresbyMax (Schwind), INTRACOR (Technolas) are explained with examples. Each approach has its pros and cons. Our challenge as a surgeon is to identify the best combination for the patient. This video illustrates the treatment options which can help break the curse of presbyopia. Online Video Link: https://youtu.be/rTxMIqMrgaw