Custard apple seeds have been used in native medicine from time immemorial for the management of head lice and skin exfoliation. We report six consecutive patients who developed toxic keratoconjunctivitis within 6-12 h of ocular exposure to custard apple seeds. The use of topical steroid worsens the toxicity and predisposes to the development of microbial keratitis in such cases. Patients showed a good response to primary treatment with topical fortified antibiotics and lubricants. This case series highlights the need to educate the patients regarding the potential toxic effects of the custard seeds and the treating physicians about possible deleterious effects on using topical steroid.

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Introduction: Repair of large defects of the lower eyelid can be difficult. A common procedure performed to address these defects is a Hughes flap. This procedure has a number of disadvantages: The eye is closed postoperatively, a second stage is required, and the edge of the flap is often erythematous. The purpose of this paper is to describe a one-stage procedure for the repair of large full-thickness defects of the lower lid as an alternative to a Hughes flap. Materials and Methods: This is a retrospective study of patients who underwent the described procedure. The procedure employs lateral stabilization of the posterior lamella with a periosteal strip, medial transposition of the lateral posterior lamella for central and medial defects, and a myocutaneous advancement flap to stabilize the anterior lamella. Results: A total of 38 patients underwent the procedure to reconstruct full-thickness defects of the lower lid ranging from 50% to 75%. All patients underwent previous Mohs excision of a skin cancer. The average follow-up was 5.6 months. Eleven patients (29%) had postoperative sequelae, but only two patients (5%) required additional treatment. Conclusion: Lateral stabilization with a periosteal strip and myocutaneous advancement flap is an excellent one-step procedure that avoids many of the complications seen with the Hughes procedure and is comparable to other techniques used for the reconstruction of subtotal, full-thickness lower lid defects.

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Purpose: The purpose of this study is to evaluate the effectiveness of chronic suppurative lacrimal canaliculitis treatment using chalazion forceps. Patients and Methods: A prospective study was performed on consecutive patients who accepted the aid of chalazion forceps to treat chronic suppurative lacrimal canaliculitis. Two different treatment methods using chalazion forceps were performed according to the degree of lacrimal canaliculitis. Postoperatively, the patients received 0.5% levofloxacin eye drops four times per day and 0.5 g oral levofloxacin tablets once per day for 4 days. The follow-up period was more than 3 months. Lacrimal irrigation, the condition of the lacrimal punctum, and patients' symptoms were carefully evaluated. Results: In total, 32 patients met the criteria for chronic suppurative lacrimal canaliculitis. Included were 6 males and 26 females. Their average age was 51.7 ± 14.9 years (range; 19-80 years), and all had unilateral canaliculitis. The mean duration of the symptoms was 18.9 ± 9.8 months (range; 3-48 months). The mean follow-up time was 14.7 ± 7.8 months. The signs and symptoms resolved completely in all patients within 15 days, and no recurrence was observed. No patients reported epiphora after the treatment. Conclusions: The use of chalazion forceps is effective in treating chronic suppurative lacrimal canaliculitis. The forceps may offer an alternative treatment technology in the management of suppurative lacrimal canaliculitis.

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Context: Glaucoma is the leading cause of global irreversible blindness. No recent study with adequate sample size has been carried out to estimate glaucoma prevalence in Eastern India. Aims: The aim of this study was to assess and compare the prevalence and types of glaucoma in a rural and urban East Indian population. Settings and Design: The Hooghly River Glaucoma Study (HRGS) is a population-based cross-sectional study from West Bengal. A tertiary hospital in Kolkata was our urban study center. Our rural study area included 28 contiguous villages from the district of Hooghly surrounding the rural base hospital located at Dhobapara in village Bakulia. Individuals aged 40 years and above were included in this study. Subjects and Methods: All subjects underwent a detailed ophthalmic examination at our base hospitals including applanation tonometry, ultrasound pachymetry, gonioscopy, and frequency doubling technology perimetry. Glaucoma was defined using modified International Society of Geographical and Epidemiological Ophthalmology criteria. Statistical Analysis Used: Analysis was performed using Chi-square test and multiple logistic regression using SPSS. Results: Totally, 14,092 individuals participated; 2.7% were detected to have glaucoma in rural arm and 3.23% in urban arm (P < 0.001). In urban population, 2.10% had primary open angle glaucoma (POAG), 0.97% had primary angle closure glaucoma (PACG), and 0.15% had secondary glaucoma. In rural population, 1.45% had POAG, 1.15% had ACG, and 0.10% had secondary glaucoma. Conclusions: HRGS is the largest population-based glaucoma study in India to date with glaucoma prevalence comparable to other landmark Indian studies. POAG was the most common form of glaucoma in our study population as well. PACG was more common in this region than previously thought.

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Context: Caregivers who assist persons with visual impairment often neglect their needs, resulting in burden and depression. Rehabilitation efforts, directed to the disabled, seldom target the caregiver. Aim: To assess burden and depression in persons caring for blind individuals. Settings and Design: This was a cross-sectional study carried out in the outpatient department of a tertiary-level teaching hospital in New Delhi. Materials and Methods : Institutional Ethical Board approval was obtained and written informed consent too was obtained from the participants involved in this study. Persons with best-corrected vision <20/200 in the better eye, and their primary caregivers, were recruited. We recorded demography, other illness/disability, household income, relationship with disabled person, and caregiver burden (Caregiver Burden Scale) and depression (Centre for Epidemiologic Studies Depression Scale). Statistical Analysis: Statistical analysis was carried out using SPSS version 20 (Released 2011. Armonk, NY: IBM Corp.); range, average, and standard deviation were determined for age, burden, and depression. The association between burden and depression was determined using Pearson's correlation; the relationship between degree of disability and caregiver burden and depression was determined using unpaired t-test; using multiple linear regression, factors were found to be statistically significant; significance was taken at P < 0.05. Results: Twenty-seven (53.0%) men and 24 (47.0%) women had visual impairment. Most caregivers (n = 40; 81.6%) were first-degree relatives or a spouse; 32 (65%) had schooling <5 years; and 29 (59%) were unemployed. Depression ranged from 21 to 52 (average 43.2 ± 5.71); it correlated with degree of disability (P = 0.012), household income (r = −0.320; P = 0.025), and burden (r = 0.616; P < 0.001). Burden ranged from 30 to 73 (average 54.5 ± 6.73) and correlated with degree of disability (P = 0.006). On multiple linear regression, burden predicted depression (r = 0.557; P < 0.001). Conclusions: Caregivers merit community support, financial benefit, interventions to diagnose and treat depression, and training in coping. Centers that provide disability certification could offer counseling.

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Introduction: Toric intraocular lenses (IOLs) are an effective way of compensating preexisting corneal astigmatism during cataract surgery. To achieve success, it is imperative to align the toric IOLs in desired position and preoperative reference marking is one among the three important steps for accurate alignment. To make the marking procedure simpler and effective, we have modified the conventional three-step slit lamp-based technique. Materials and Methods: Patient is seated in front of the slit lamp and asked to keep the chin over chin rest. A 26-gauge bent needle with tip stained by sterile blue ink marker is used to make anterior stromal puncture (ASP) at the edges of horizontal 180° axis near the limbus. Results: A total of 58 eyes were retrospectively evaluated. Mean (+/-SD) IOL deviation on day 1 and day 30 was 5.7 ± 6.5° and 4.7 ± 5.6°, respectively. Median IOL misalignment on day 1 and day 30 was 3°. Redialing of IOL was required in 2 (3.4%) eyes only, all of which were performed within 1 week of surgery. In total, 2 (3.7%) eyes had a residual astigmatism of − 0.5 Dcyl and − 1.0 Dcyl, respectively. Conclusion: ASP is an effective technique for reference marking, technically simpler and can be practiced by most of the surgeons. It avoids the necessity of high-end sophisticated machinery and gives a better platform for the reference corneal marking along with the benefit of reproducibility and simplicity.

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Aim : The aim of this study is to describe the clinical features and diagnostic criteria of Fuchs' uveitis (FU) and to determine whether it has an association with virus and toxoplasma in the aqueous humor during cataract surgery. Setting and Design : This is a prospective, case-control study. Materials and Methods : Patients with FU (n = 25), anterior uveitis (n = 15), and no uveitis (normal) (n = 50) were included based on predefined inclusion and exclusion criteria for all three groups. Polymerase chain reaction (PCR) of aqueous humor and serum for rubella, herpes simplex virus (HSV), cytomegalovirus (CMV), varicella-zoster virus (VZV), and toxoplasma was done using conventional uniplex PCR. Statistical Analysis : It was done using SPSS software using Chi-square test for categorical variables, and P < 0.05 was considered statistically significant. Results : Ninety patients were enrolled in the study in three groups, comparable for age, gender, and laterality of ocular involvement. All patients had diffuse keratic precipitates in FU group (P = 0001) with none having posterior synechiae (P = 0.046) which was statistically significant when compared to anterior uveitis patients. Iris nodules were noted in one case in both groups. Serum and aqueous PCR was negative for detection of VZV, CMV, toxoplasma, and rubella in all groups. PCR for HSV was positive in one patient in "normal" group but was not statistically significant. Conclusion: Our study shows that diagnosis of FU is mainly clinical. There appears to be no role of aqueous humor testing for viruses by PCR to aid in etiological diagnosis.

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Immunoglobulin G4 (IgG4-related diseases) affects various tissues and organs of the human body. Orbital, adnexal, and scleral inflammations were already reported in the medical literature. To the best of our knowledge, we report the first case of intraocular IgG4-associated inflammatory mass in the ciliary body mimicking as a melanoma in a 23-year-old female from Northeast India. Characteristic histopathology, immunohistochemistry in the tissue, protein chemistry, and raised serum IgG4 were supportive for the diagnosis. As this newly diagnosed disease has multi-organ affection and little is known about its pathogenesis particularly in eye and adnexa, the present case will open many challenges in clinico-pathological diagnosis and research in the future.

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Orbital cellulitis is an infection of soft tissue behind the orbital septum. Common pathogens isolated include Staphylococcus aureus, Staphylococcus epidermidis, and Streptococcus pneumoniae. It is a straightforward diagnosis and usually responds to empirical treatment without any sequela. We report a case of orbital cellulitis caused by Enterococcus faecalis, which was complicated by myositis of levator palpebrae superioris. To the best of our knowledge, only one case report exists dating way back to 1986.

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Background: The aim of this study was to assess the surgical outcomes of combined femtosecond laser-assisted cataract surgery (FLACS) with 25-gauge vitrectomy surgery. Materials and Methods: A retrospective analysis of 45 patients who underwent combined FLACS with 25-gauge vitrectomy surgery. Results: A total number of 45 eyes of 45 patients were treated with a mean age of 63.27 years (range 45-75). The mean follow-up was 3 months (range 3-12 months). The mean preoperative best-corrected visual acuity was 1.47 ± 0.86. The mean postoperative vision was 0.36 ± 0.36 and 0.275 ± 0.184 at a paired t-test revealed a statistically significant improvement in visual acuity at 1 month (P < 0.001) and 3 months (P < 0.001). The most common indication for surgery was full-thickness macular hole (51.1%), vitreous hemorrhage (24.4%), followed by epiretinal membrane (17.7%) and rhegmatogenous retinal detachment (4.4%). Conclusion: Combining FLACS with vitrectomy may be a step toward achieving better outcomes when combined CS and vitrectomy is performed.

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A 34-year-old female presented with firecracker injury with curved metallic foreign body embedded in the left orbit and protruding out through the upper eyelid. The report highlights notable aspects in diagnosis, decision-making, and successful removal of this unusual case of retro-orbital foreign body.

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Purpose: To compare the results of conventional 1064 nm neodymium-doped yttrium-aluminum garnet laser goniopuncture (Nd:YAG-GP) and selective 532 nm Nd:YAG laser (selective laser trabeculoplasty [SLT])  gonioreconditioning (GR) on trabeculo-Descemet's membrane in eyes resistant to viscocanalostomy surgery. Methods: Thirty-eight eyes of 35 patients who underwent laser procedure after successful viscocanalostomy surgery were included in the study. When postoperative intraocular pressure (IOP) was above the individual target, the eyes were scheduled for laser procedure. Nineteen eyes underwent 532 nm SLT-GR (Group 1), and the remaining 19 eyes underwent conventional 1064 nm Nd:YAG-GP (Group 2). IOPs before and after laser (1 week, 1 month, 3 months, 6 months, 1 year, and last visit), follow-up periods, number of glaucoma medications, and complications were recorded for both groups. Results: Mean times from surgery to laser procedures were 17.3 ± 9.6 months in Group 1 and 13.0 ± 11.4 months in Group 2. Mean IOPs before laser procedures were 21.2 ± 1.7 mmHg in Group 1 and 22.8 ± 1.9 mmHg in Group 2 (P = 0.454). Postlaser IOP measurements of Group 1 were 12.1 ± 3.4 mmHg and 13.8 ± 1.7 mmHg in the 1 ^st week and last visit, respectively; in Group 2, these measurements were 13.6 ± 3.7 mmHg and 14.9 ± 4.8 mmHg, respectively. There were statistically significant differences (P < 0.001) in IOP reduction at all visits in both groups; the results of the two groups were similar (P > 0.05). Mean follow-up was 16.6 ± 6.4 months after SLT-GR and 18.9 ± 11.2 months after Nd:YAG-GP. Conclusions: While conventional Nd:YAG-GP and SLT-GR, a novel procedure, are both effective choices in eyes resistant to viscocanalostomy, there are fewer complications with SLT-GR. SLT-GR can be an alternative to conventional Nd:YAG-GP.

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A 32-year-old female patient underwent deep anterior lamellar keratoplasty (DALK) in both eyes for advanced keratoconus. She developed an infiltrate in the nasal paracentral interface of the left eye. In view of the paracentral location, localized epithelial removal/stromal scraping was done and the infiltrate was removed using forceps and sent for microbiological assay, which revealed fungal filaments. The patient successfully responded to intensive topical antifungal therapy with the maintenance of visual acuity. Interface keratitis following DALK frequently needs graft lift/interface wash due to deep location, rapid spread and poor penetration and efficacy of topical medications. In view of a paracentral location, modified debulking with topical therapy resulted in a satisfactory outcome in our case thereby avoiding the need for more invasive treatments.

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Association of choroidal neovascular (CNV) membrane with circumscribed choroidal hemangioma is rare, and the CNV development after photodynamic therapy (PDT) is also rare. Etiopathogenesis of these associations is poorly understood. We noted the development of CNV over choroidal hemangioma after PDT therapy in a young female patient in our hospital. Temporal association of CNV development after PDT treatment points toward the possible side effects of PDT. Repeat injections of antivascular endothelial growth factor (ranibizumab) regressed the CNV resulting in a favorable visual outcome.

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Vision loss following sclerotherapy for facial vascular malformations (VMs) is a rare but detrimental complication. Here, we report a case of an 11-year-old boy with acute onset blepharoptosis, ophthalmoplegia, and blindness in his right eye after the 14 ^th sclerotherapy session (percutaneous intralesional injection of sodium tetradecyl sulfate) for a right facial low-flow VM without orbital involvement. Computed tomography angiography revealed no contrast enhancement in the right ophthalmic artery, superior ophthalmic vein, or extraocular muscles. He presented with the hallmarks of orbital infarction syndrome: Clear signs of anterior and posterior segment ischemia and disrupted arterial flow to the extraocular muscles. His blepharoptosis and eye movement improved 4 months later; however, he remained blind, and phthisis bulbi developed eventually. Thus, sclerotherapy for facial VM-even without orbital involvement--may result in severe ocular and orbital complications.

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