Aravind Eye Hospital

Purpose: To describe the progressive morphologic changes of macular hole (MH)-associated epiretinal proliferation over long-term follow-up and to explore potential pathologic mechanisms. Methods: A single case was retrospectively reviewed. Results: A patient with a history of open-angle glaucoma and proliferative diabetic retinopathy maintained stable visual acuity (VA) of 6/9 OD and 6/18 OS over 2 years. On examination, MH-associated epiretinal proliferation was noted in the left eye, demonstrating increased thickness and cystic changes compared with the previous visit, for which topical nepafenac eye drops were advised. A follow-up visit 1 year later showed a marked increase in the volume of epiretinal proliferation with associated intraretinal fluid, despite no change in VA. Conclusions: This report documents progressive structural changes in this infrequently encountered entity and explores the possible pathologic mechanisms through a review of relevant literature. Cystic changes with epiretinal proliferation may represent a benign process attributable to chronicity and often may not require intervention.

Diagnosing fungal keratitis (FK) in patients with negative smear and culture results remains clinically challenging, highlighting the need for alternative diagnostic approaches. To determine the diagnostic accuracy of the clustered regularly interspaced short palindromic repeats (CRISPR)-based Rapid Identification of Mycoses using CRISPR (RID-MyC) assay for detecting FK in patients with negative smear and culture results using in vivo confocal microscopy (IVCM) as the reference standard. This prospective diagnostic accuracy study was conducted from December 2024 to March 2025 at Aravind Eye Hospital, a tertiary ophthalmology referral hospital in Coimbatore, India. Consecutive patients clinically suspected to have microbial keratitis with negative smear and culture results were eligible for inclusion. Data were analyzed from March 2025 to June 2025. All included participants underwent corneal scraping for RID-MyC assay and imaging by IVCM. The primary outcomes were sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic concordance of the RID-MyC assay compared with IVCM results. Of 245 consecutive patients clinically suspected to have microbial keratitis, 82 were smear negative. After exclusions due to contraindications or positive subsequent cultures, 41 patients with smear- and culture-negative results were ultimately included in the final analysis. Of these 41 patients (mean [SD] age, 51.0 [14.6] years; 21 [51.2%] women), RID-MyC demonstrated sensitivity of 82.1% (95% CI, 63%-94%) and specificity of 76.9% (95% CI, 46%-95%). Positive predictive value was 88.5% (95% CI, 74%-95%) and negative predictive value was 66.7% (95% CI, 46%-82%). Concordance between RID-MyC and IVCM was observed in 33 cases (80.5%). Notably, prior antifungal treatment was most frequent (4 of 5 [80%]) among patients with positive IVCM but negative RID-MyC results. Conversely, all patients (3 of 3 [100%]) with negative IVCM but positive RID-MyC findings had smaller, peripheral, or paracentral lesions. In this diagnostic study, in patients with smear- and culture-negative FK, the RID-MyC assay showed good diagnostic accuracy comparable with IVCM and was feasible in all cases, including those in whom imaging was not possible. With its rapid turnaround and minimal equipment needs, RID-MyC may serve as a practical adjunct to conventional diagnostics, particularly in high-burden, resource-limited settings where IVCM is unavailable or contraindicated.

Micropulse transscleral cyclophotocoagulation (MP TSCPC) has emerged as a significant innovation in the surgical management of glaucoma, challenging the traditional perception of cyclodestructive procedures as interventions of last resort. By delivering diode laser energy in a micropulsed, duty-cycled manner, MP TSCPC aims to achieve intraocular pressure (IOP) reduction while minimizing collateral thermal damage to the ciliary body and adjacent tissues. This technological refinement has broadened the potential indications of cyclophotocoagulation and prompted reconsideration of its place in contemporary glaucoma care. It employs infrared diode laser radiation of 810 nm targeting the melanin present in pigmented ciliary epithelium. The key feature differentiating it from continuous wave trans-scleral diode cyclophotocoagulation (CW TSCPC) is the energy, which is delivered in short pulses in an on-and-off cycle fashion. The longer “off phase” allows energy dissipation and minimizes collateral tissue damage by allowing them to thaw which has been proven histologically. In MP TSCPC, the probe is directed to pars plicata unlike the CW TSCPC, where laser is delivered at the level of pars plana. The possible mechanisms of action include: (i) targeted action in the form of subthreshold cellular damage on the pigmented epithelium and indirect effect on nonpigmentary epithelium of ciliary body causing reduced aqueous production, (ii) improving uveoscleral outflow by mediating extracellular matrix remodeling, and (iii) a possible pilocarpine-like effect where micropulse causes the longitudinal fibers of the ciliary muscles to contract, thereby displacing the scleral spur posteriorly, which results in improving the conventional outflow pathway by opening the trabecular beams. Although both continuous-wave and micropulse CPC use infrared radiation to target aqueous humor production, their outcomes differ, largely due to the on–off laser delivery cycles employed in micropulse TSCPC. A randomized trial demonstrated that IOP reduction was better in MP TSCPC group at 6-month and 1-year follow-up, but it was similar at 18 months in both the groups.[1] However, the IOP lowering effect was found to have more predictable pattern and there was a significant decrease in incidence of post-op inflammation in MP TSCPC as compared to CW TSCPC.[1] The major advantage was in the incidence of post-laser complications like prolonged hypotony, phthisis bulbi, and persistent anterior chamber inflammation, which was found to be significantly higher in CW TSCPC group as compared to MP TSCPC. The drop in visual acuity which is attributed to the mydriasis was also found to be higher in the CW TSCPC group. Another prospective interventional study analyzing the applicability of MP TSCPC as primary versus additional mode of intervention found that there was no statistical difference in complications and additional interventions between the two groups.[2] This indicates that MP TSCPC can be an effective tool for IOP control in eyes having high risk of vision-threatening complications with invasive surgery. When it comes to energy parameters, no definitive settings have been defined. The duty-on cycle which defines the duration for which the laser is actively emitted is kept at 31.3% for glaucoma treatment. The energy settings range from 62 to 225 J, and there are varied published data on outcomes of low, mid, and high energy settings. The current role of MP TSCPC in the management of various types of glaucoma based on the available evidence is highlighted in Table 1.[1–8]Table 1: Role of micropulse transscleral cyclophotocoagulation in various types of glaucomaIn management of refractory glaucoma in the pediatric age group, MP TSCPC has reported good safety but mixed results in terms of efficacy.[7,8] In comparison with CW TSCPC, the IOP lowering effect was comparable; the rate of complications, pain, and inflammation seemed to be lower in the first group, but this difference was not statistically significant. When it comes to applicability of MP TSCPC, race has to be kept in mind and use of shorter treatment times in heavily pigmented eyes (African-Americans) reduces the incidence of severe postprocedure inflammation. In conclusion, MP TSCPC has transformed the conceptual framework of cyclophotocoagulation in glaucoma management. While it does not replace trabeculectomy, tube shunt surgery, or minimally invasive glaucoma surgery, it fills an important therapeutic gap between maximal medical therapy and incisional surgery with a favorable balance of efficacy, safety, and flexibility. As clinical experience grows and treatment protocols become more refined, MP TSCPC is likely to secure a well-defined and enduring role in the modern glaucoma treatment algorithm. However, there is still a need to fully understand its mechanism of action, long term outcomes, and ideal treatment dose with duration. Furthermore, concrete evidence on its repeatability needs to be explored.

Background:Over the past few decades, children from the south eastern regions of India presented with anterior chamber angle granulomas and/or subconjunctival granulomas or a retro corneal membrane with nodules at the advancing edge. These lesions were initially considered as tuberculous in origin and were referred as “conglomerate tubercles” for several years. Subsequent investigations identified the true etiology as trematode eye disease.Purpose:To analyze the epidemiological, geographical, and clinical characteristics of pediatric patients diagnosed with ocular granuloma caused by trematode infection.Methods:A retrospective review was conducted on medical records of pediatric patients with the diagnosis of anterior chamber granuloma or subconjunctival granuloma seen between 1997 and 2017. Data were compiled and analyzed descriptively.Results:A total of 269 children were diagnosed with trematode granuloma. Among them, 216 were boys and 53 were girls, with the age ranging from 3 to 16 years and a mean age of 10.13 years ± (3.01) years. The majority of cases were reported from Tamil Nadu. Of 269 children, 171 received medical treatment, and 98 children underwent surgical removal of the granuloma. Visual prognosis was generally favorable, when the visual axis was spared.Conclusion:Trematode-induced ocular granuloma is a distinct parasitic condition predominantly affecting children in specific geographical areas, especially in those living near trematode larva contaminated water bodies. Accurate identification of the etiology is essential to ensure effective management and to prevent vision loss.

Abstract Aim: To evaluate the concordance between diagnoses provided by trained vision center(VC) technician and neuro-ophthalmologists for patients referred from VC to the Neuro-Ophthalmology Clinic. Methodology: This retrospective observational study analyzed electronic medical records (EMR) from the neuro-ophthalmology outpatient department for 1 year. The investigation involved a comprehensive review and comparison of findings between trained VC technicians and neuro-ophthalmologist. Collected data included patient age, sex, clinical history, time from referral to hospital arrival, and the final diagnosis. Results: The study incorporated data from 17 VC facilities, encompassing 331 referrals, with a mean age of 45 years (range: 7–83 years). The overall agreement between diagnoses made by trained VC technicians and neuro-ophthalmologist was 66%. This agreement was sustained in 66% of cases (195 out of 297) for afferent pathway disorders and in 67% of cases (24 out of 36) for efferent pathway disorders. Specific clinical findings showed varying levels of alignment between the VC and neuro-ophthalmologist assessments: lid abnormalities achieved the highest agreement at 89% (κ = 0.75), while pupil abnormalities had the lowest at 48% (κ = 0.40). The overall kappa coefficient was 0.66 (95% confidence interval: 0.60–0.72), indicating substantial agreement ( P < 0.001), with specialist evaluations. Conclusion: The findings underscore the diagnostic capabilities of trained VC technicians, with substantial diagnostic concordance between trained VC technician and neuro-ophthalmology specialist.

Objective: To evaluate the accuracy of nurse-led triage using a three-level institutional protocol in a tertiary care emergency department (ED) and identify predictors of triage discordance. Methods: This cross-sectional study included 1,249 adult ED patients. Nurse-assigned triage levels were compared with emergency physician (EP) triage, considered the gold standard. Accuracy, under-triage, and over-triage rates were calculated. Cohen's Kappa (κ) assessed agreement. Univariate chi-square (χ²) analysis was performed to identify associations between variables and triage inaccuracy, with odds ratios (OR) and 95% confidence intervals (CI) calculated from cross-tabulations. Results: Triage accuracy was 94.6%, with 4.88% over-triage and 0.48% under-triage. Agreement between nurse and EP triage was κ = 0.91 (95% CI: 0.89–0.93), indicating excellent concordance. Univariate analysis identified significant associations between over-triage and elevated respiratory rate (≥25/min; p=0.002) and elevated systolic blood pressure (≥160 mmHg; p=0.039). Under-triage was rare (n=6, 0.48%). No variables significantly predicted under-triage. Conclusion: Nurse-led triage demonstrated high accuracy and excellent agreement with emergency physicians. Over-triage occurred more often than under-triage and was strongly associated with abnormal physiological parameters. Reinforcement of vital-sign interpretation, structured training, and periodic audits may improve further accuracy in resource-limited settings. Keywords: Triage accuracy; Under-triage; Over-triage; Emergency department; Physiological predictors; Kerala

Purpose: The aim of this study was to describe the surgical management and postoperative outcome of a visually significant limbal dermoid involving the central cornea in a 5-month-old infant, complicated by intraoperative Descemet membrane (DM) perforation and successfully managed with a modified rescue technique. Case Report: A 5-month-old male infant presented with a whitish mass over the left cornea that had been present since birth. Ocular examination revealed a vascularized, elevated limbal dermoid extending into the visual axis, measuring 8 × 8.5 mm. Considering the risk of amblyopia, surgical excision was planned under General Anesthesia. During lamellar keratectomy, an unintentional DM perforation of size 1.5 mm occurred. The perforation was immediately sealed with a same-sized stromal lamellar graft and an air bubble in the anterior chamber. The postoperative nonresolving corneal edema and DM detachment were managed with a “suture barricade” technique. Results: The postoperative period was uneventful, with a clear cornea, attached DM, and a satisfactory cosmetic outcome. Suture removal was performed after 3 months. Conclusions: The suture barricade technique for DM perforation presented here can enable successful lamellar keratectomy even in the context of deep limbal dermoid. The suture barricade technique may provide a viable option for managing small DM perforations in other contexts (eg, corneal hydrops or optical Deep Anterior Lamellar Keratoplasty) as well, without compromising corneal clarity or cosmesis.