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Laser-assisted in situ keratomileusis (LASIK) is one of the most commonly performed kerato-refractive surgery globally. Since its introduction in 1990, there has been a constant evolution in its technology to improve the visual outcome. The safety, efficacy, and predictability of LASIK are well known, but complications with this procedure, although rare, are not unknown. Literature review suggests that intraoperative complications include suction loss, free cap, flap tear, buttonhole flap, decentered ablation, central island, interface debris, femtosecond laser-related complications, and others. The postoperative complications include flap striae, flap dislocation, residual refractive error, diffuse lamellar keratitis, microbial keratitis, epithelial ingrowth, refractive regression, corneal ectasia, and others. This review aims to provide a comprehensive knowledge of risk factors, clinical features, and management protocol of all the reported complications of LASIK. This knowledge will help in prevention as well as early identification and timely intervention with the appropriate strategy for achieving optimal visual outcome even in the face of complications.

Purpose: This study aims to assess the preferred surgical technique of Descemet membrane endothelial keratoplasty (DMEK) among corneal surgeons in India, and barriers in performing DMEK surgeries amongst the non-DMEK surgeons. Methods: An online, questionnaire-based, cross-sectional survey was conducted among members of the Cornea Society of India (CSI) (n = 500). Responses on their surgical experience, preferred technique, complications, and outcome of DMEK were collected and analyzed. Barriers in performing DMEK surgeries were assessed amongst the non-DMEK surgeons. Results: A total of 100 responses were obtained and response rate for the survey was 20%. DMEK was performed by 55% of the participants of whom only 40% had formal training in this technique. Surgical video-based learning was the most often used self-training method for others. Lack of training was the most common reason for not performing DMEK by the non-DMEK surgeons. Descemet stripping endothelial keratoplasty (DSEK) was the most common endothelial keratoplasty (EK) performed by both DMEK and non-DMEK surgeons. High volume (>50 cases) DMEK surgeries were reported by limited surgeons (n = 6). Nearly all the DMEK surgeons prepared the donor tissue by themselves on the day of the surgery, and majority felt that unrolling the graft in the anterior chamber was the most difficult surgical step. Nearly 80% of the DMEK surgeons were more comfortable with DSEK or Descemet stripping automated endothelial keratoplasty (DSAEK) when compared to DMEK. Conclusion: DMEK practice in India needs improvement with increased accessibility to DMEK training programs, wet lab facilities, and better support from eye banks.

Purpose: This study aimed to assess the preferred surgical technique and outcome of deep anterior lamellar keratoplasty (DALK) among corneal surgeons in India. Methods: An online questionnaire-based cross-sectional survey was conducted among members of the Cornea Society of India (CSI) with experience of performing >10 DALK procedure. The responses pertaining to their surgical experience, preferred technique, complications, and outcome of DALK were collected and analyzed. Results: A total of 156 responses were received. In total, 35.9% of participants reported annual keratoplasty of >50, and DALK constituted >25% surgeries for 25% of participants. Ectatic corneal disorder was reported as the most common indication for DALK by 71.6% of the respondents. Big-bubble (BB) DALK (WA-1.82) was the most preferred technique, along with suction trephine (50%) for partial trephination and bottom port cannula (45.5%) for BB formation. On statistical analysis, no difference was observed in the surgeon reported success rate of BB formation with or without anterior lamellar keratectomy (ALK) (Χ2 (1,156) = 3.1498, P = 0.08) or paracentesis (Χ2 (1,156) = 0.2737, P = 0.60) before stromal air injection, and method of stromal air injection (Χ2 (1,156) = 4.7325, P = 0.09). Conversion to penetrating keratoplasty was reported by 16% of participants in >25% cases, while 66.7% reported in <10% cases. Cataract and double anterior chamber were the most common complications. 50% of participants suggested that >20 procedures are required to overcome the learning curve. Conclusion: BB DALK is the most commonly practiced DALK technique, and its success is independent of ALK and paracentesis being performed prior to air injection and method of air injection (cannula/needle).

The most common cause of corneal graft failure is corneal graft rejection (CGR). Although cornea is one of the immune-privileged sites, it can still get a rejection episode due to a breach in its natural protective mechanism. Both anatomical and structural properties of cornea and anterior chamber contribute toward its immune tolerance. Clinically, every layer of the transplanted cornea can get a rejection episode. A proper understanding of immunopathogenesis will help in understanding the various mechanism of CGR and the development of newer strategies for the prevention and management of such cases.

A female patient in her sixth decade of life presented with a 7-day history of progressive diminution of vision and restricted ocular motility associated with fever, headache and vomiting. On general examination, she was febrile (temperature 100.4°F) and had enlarged submandibular lymph nodes, along with multiple nodules on the scalp and upper back. At baseline, ocular examination revealed visual acuity of 20/30 in the right eye and hand movements close to the face in the left eye. A relative afferent pupillary defect was noted in the left eye. The Hirschberg test revealed left esotropia (15°°) with an abduction deficit, suggestive of left sixth cranial nerve paresis. Fundus examination was unremarkable. A provisional diagnosis of left orbital apex syndrome (OAS) was made. A comprehensive work-up in neurology and dermatology was performed. Contrast-enhanced MRI of the brain and orbit suggested an asymmetrically enhancing lesion of the cavernous sinus, soft tissue involvement of the left orbital apex and a nodule involving the white matter of the left parietal lobe. Hormone analysis suggested a decreased level of thyroid-stimulating hormone, follicular-stimulating hormone and luteinising hormone. Fine needle aspiration cytology of a submandibular lymph node and nodules of the scalp and upper back was suggestive of metastatic mucin-secreting adenocarcinoma. Tumour marker analysis revealed raised CEA and CA 125. Further, a positron emission tomography scan revealed active lesions in the lungs with multiorgan spread, supporting the diagnosis of primary lung carcinoma with disseminated metastases manifesting as OAS. In view of the poor prognosis, the patient refused further treatment and succumbed to her condition 1 month following her diagnosis.This case highlights the importance of recognising subtle ocular signs, as they can be indicative of underlying life-threatening conditions. Early detection and thorough investigation of such symptoms are crucial, as they can lead to the identification of serious systemic diseases, such as metastatic cancer, that may otherwise be overlooked.

Purpose: To assess the ophthalmic practice pattern among ophthalmologists in India amidst the COVID-19 pandemic. Methods: An online questionnaire-based analysis was performed among members of the All India Ophthalmological Society (AIOS) and results were analyzed using SPSS software version 20. Results: A total of 2253 responses were received. The majority of the participants (72.6%) were between 30 and 60 years of age and were into private practice (64.7%). During the lockdown, over one-third of participant ophthalmologists reported not attending any OPD patients, whereas a majority (64%) provided only emergency ophthalmic services. During the COVID-19 pandemic, <15% surgeries were performed compared to the pre-COVID-19 era by 81% of participants, whereas elective surgeries were performed by only 4.3%. The proportion of participants utilizing telemedicine in ophthalmology showed a two-fold rise from the pre-COVID-19 era (21.9%) to the COVID-19 pandemic (46%). Over half of the participants reported following the AIOS guidelines, reducing clinic hours, use of screening questionnaires, minimizing staff, and use of breath shield on a slit lamp as precautionary measures to reduce the exposure. Over 95% of ophthalmologists were satisfied (score > 5/10) by the AIOS guidelines for ophthalmic practice during COVID-19. Conclusion: COVID-19 pandemic has adversely affected the ophthalmic care services across India with telemedicine emerging as a major rescue. The majority of practicing ophthalmologists are satisfied with guidelines provided by AIOS for ophthalmic care during the COVID-19 pandemic and have implemented the same in their setup.

BackgroundAlthough full-field electroretinogram (ffERG) is the gold standard test to detect physiological dysfunction in siderosis, it measures overall retinal function. This study aims to determine if multifocal electroretinogram (mfERG) can detect subclinical siderosis in eyes with an iron intraocular foreign body (IOFB).MethodsTwenty eyes of 20 patients with retained iron IOFB, clear ocular media and good visual acuity (≥20/120) were enroled in this prospective case-control study. The fellow eyes served as control. These were evaluated with ffERG and mfERG at baseline. Serial mfERG was done till six months after pars plana vitrectomy with IOFB removal. Primary outcomes measures were amplitude and peak time of P1 and N1 wave of mfERG.ResultsThe median age was 25 years (range 18–55). Most patients (n = 14/20) presented within a month of trauma. Baseline ffERG showed no difference in either ‘a’ or ‘b’ wave amplitude or peak time between cases and controls. However, on mfERG, there was a significant decrease in P1 and N1 wave amplitude and delay in P1 wave peak time in <2° retinal ring in cases as compared to controls (p = 0.001, 0.001 and 0.02 respectively) despite variability in results. At 6 months, P1 amplitude showed significant improvement from baseline in cases (p = 0.010). However, P1 peak time did not show significant recovery (p = 0.65).ConclusionsmfERG may reveal subclinical electrophysiological retinal dysfunction in eyes with iron IOFB in cases with normal ffERG. P1 peak time may serve as an electrophysiological marker for past retinal damage.

Phacoemulsification is the most commonly performed cataract surgery in this era. With all the recent advances in investigations and management of cataract through phacoemulsification, most of the patients are able to achieve excellent visual outcome. Corneal edema after phacoemulsification in the immediate postoperative period often leads to patient dissatisfaction and worsening of outcome. Delayed onset corneal edema often warrants endothelial keratoplasty. This review highlights the etiopathogenesis, risk factors, and management of corneal edema in the acute phase including descemet's membrane detachment (DMD) and toxic anterior segment syndrome. Various investigative modalities such as pachymetry, specular microscopy, anterior segment optical coherence tomography, and confocal microscopy have been discussed briefly.