Topical Lubricants Research Articles

Ocular Manifestations in Paediatric Erythema Multiforme: A Case Report

Erythema multiforme (EM) is a type IV cytotoxic hypersensitivity reaction characterized by classic target lesions on the skin and mucosa, typically affecting the oral, genital, and rarely, ocular mucosa. We describe a 9-year-old girl with widespread rashes, blisters and target lesions on her trunkfor three days. She had eye redness, discomfort, a week-long fever, and a dry cough, without any medication. Ophthalmological examination revealed localized conjunctival injection in her right eye, with no visual impairment or corneal lesions. The diagnosis of EM major (EMM) was based on prior infection, characteristic skin lesions, and mucosal involvement, including ocular manifestation of conjunctival injection. Treatment requires addressing the underlying cause and ophthalmologic consultation for systemic or topical corticosteroids, antibiotics, lubricants, and antihistamines. This case highlights the diagnostic challenges of atypical EM presentations, emphasizing the need for comprehensive evaluation, early recognition, and interdisciplinary collaboration to prevent severe ocular complications and preserve vision.

Evaluation of adjuvant role of topical cyclosporine 1% in acute Stevens-Johnson syndrome: a randomised control trial

PurposeTo evaluate the role of topical cyclosporine A 1% (CsA) as an adjuvant therapy in patients with acute Stevens-Johnson syndrome (SJS).MethodsThis is a randomised controlled trial in which 44 patients...

Changes in corneal epithelial irregularity following treatment with artificial tears.

Dry eye sufferers have a highly irregular corneal epithelial surface compared with those without dry eye. This study demonstrated that corneal epithelial thickness irregularity can be significantly reduced after as little as 48 hours following treatment with regular use of topical ocular lubricants. This study aimed to compare changes in corneal epithelial thickness irregularity factor (EIF) and ocular symptoms in a population with symptoms of dry eye before and up to 4 weeks after treatment with two commercially available lubricating eye drops versus saline. We conducted a prospective single-center, investigator-masked, randomized, parallel-group dispensing study. Participants with moderate to severe symptoms of dry eye (Ocular Surface Disease Index score >23 at baseline) were enrolled and randomly assigned to receive either 0.15% hyaluronic acid + hydroxypropyl guar, 0.2% hyaluronic acid, or saline (16 in each group). Corneal epithelial thickness measurements were obtained along vertical and horizontal CASIA SS-1000 Optical Coherence Tomography scans at baseline and after 48 hours, 2 weeks, and 4 weeks. The Ocular Surface Disease Index questionnaire was administered at baseline, 2 weeks, and 4 weeks. Forty-eight participants (male-to-female ratio, 17:31) completed the study. Horizontal EIF was significantly lower at all follow-up visits compared with baseline (p=0.001), but there were no significant differences between study eye drops (p=0.34). No significant difference in vertical EIF was observed over time (p=0.32) or between eye drops (p=0.08). Ocular symptoms significantly improved after 2 and 4 weeks of treatment compared with baseline (p<0.001), but no differences were observed between eye drops (p=0.46). All treatments were effective for reducing EIF along the horizontal meridian 48 hours after initiation of treatment, and improvements were maintained for 4 weeks. Improvements in ocular symptoms were observed with all study treatments.

Prevalence of Corneal Lesions in Dogs After Non-Ocular Surgery: Impact of Preoperative Topical Lubrication and Duration of Anaesthesia

Corneal lesions are the most common ophthalmologic complication that occurs during general anesthesia (GA) for non-ocular surgery (Di Pietro et al., 2021). The aim of this study was to identify the prevalence of corneal lesions in dogs that were administered preoperative ocular lubrication and those that did not and how the duration of anesthesia influences the occurrence of them. A fluorescein test was performed before and after anesthesia in 18 dogs undergoing non-ophthalmic procedures. Subjects were randomly divided into two groups of 9 subjects each, group A which received preoperative ocular lubrication and group B that did not. Subsequently, the subjects were divided into three groups according to the duration of anesthesia in order to highlight the correlation between its duration and the occurrence of corneal lesions: group 1 (under 90 minutes) with 4 subjects, group 2 (between 90 and 180 minutes) with 9 subjects and group 3 (over 180 minutes) with 5 subjects. Only 11% (1 subject) of group A showed postoperative corneal lesion, while no subjects in the group B showed a positive fluorescein test result. 20% of subjects (1 subject) from group 3 had postoperative corneal lesions and a positive fluorescein test result, while no subjects from group 1 and 2 showed a postoperative positive fluorescein test result. The results of the study could not highlight the protective role of preoperative ocular lubrication. Further studies on a larger number of subjects and homogeneous groups are needed for more relevant results.

Incidence of Ophthalmological Complications in NF-1 Patients Treated with MEK Inhibitors.

MEK inhibitors (MEKi) represent innovative and promising treatments for managing manifestations of neurofibromatosis type 1 (NF1). To mitigate potential ophthalmic side effects, such as MEKi-associated retinopathy (MEKAR), patients undergoing MEKi therapy routinely receive ophthalmology evaluations. Our study aims to assess the necessity of this regular screening within a predominantly pediatric NF1 population by examining the occurrence of ocular adverse events (OAE). A retrospective study evaluated 45 NF1 patients receiving MEKi. Inclusion criteria included baseline and follow-up examinations following the initiation of MEKi therapy. At each assessment, a comprehensive eye evaluation was performed, comprising a dilated fundus examination, ocular coherence tomography of the macula and nerve fiber layer, and Humphrey visual field testing. Twenty-six patients, with an average age of 13 years (range 2-23 years) and an average follow-up duration of 413 days were included in the analysis. Three different MEKi were used: selumetinib (77%), trametinib (23%), and mirdametinib (4%). None of the patients experienced retinopathy at any point during the study. Some patients had pre-existing optic neuropathies (27%), but no instances of nerve changes occurred after commencing MEKi therapy. Four patients (15%) exhibited symptoms of dry eye, all of which were effectively managed with topical lubrication.

Blast Eye Injury After Mobile Phone Battery Explosion: A Case Report

Introduction : Injuries from mobile phone blasts have been on the rise in recent years. Mobile phone blasts cause serious ocular morbidity. We report a rare case of blast eye injury after mobile phone battery explosion.&#x0D; Case Illustration : A 16 years old woman presented with burning sensation on both the eyes, following a smartphone battery blast. Immediately, after disconnecting the phone from the charger, the battery exploded and the phone blew apart. Her presenting visual acuity was 1/300 and 1.0 in right eye and left eye. Examination revealed broad corneal haziness on right eye, charred lashes, circumciliary congestion, and multiple soot particles embedded over the cornea, conjunctiva, and the lid margins. The eyes were washed with copious ringer lactate and the debris was carefully removed. Topical preservative free lubricants, broad-spectrum antibacterial agent, corticosteroid, and cycloplegic agent were prescribed along with systemic nonsteroidal anti-inflammatory drug. The healing of epithelial defects started on the next day and was complete by the 14th day.&#x0D; Discussion : We describe an ocular blast injury due to mobile phone explosion. The mechanism of injury from battery blast could be a combination of mechanical (battery pieces), thermal, and chemical injuries. The vision can be saved if the ocular surface burns are treated promptly and properly.&#x0D; Conclusion : Mobile blast injury is emerging as a new mode of ocular trauma. Knowing proper management is very important to achieve the best result.

Neurotrophic Keratopathy after wide retinal endolaser and postoperative Ketorolac eye drops: A case series.

We report a series of 5 cases, happened in a period of 5 months, who developed neurotrophic keratopathy (NK) following pars plana vitrectomy (PPV) and retinal endolaser for rhegmatogenous retinal detachment (RRD). In our several decennary experience of surgical center predominantly based on vitreoretinal surgery, we had rare cases of postoperative NK. These recent cases of post-surgical NK happened contextually to our change of postoperative non-steroidal anti-inflammatory drugs (NSAIDs) drops, based on Ketorolac Tromethamine 0.5% eye drops. Five patients with a mean age of 61 ± 7.3 years were treated with one or more PPV with intraoperative peripheral endolaser for RRD. Nobody had previous herpetic keratitis, systemic disease like diabetes mellitus or other predisposing factors for NK. In the postoperative period, all patients received Ketorolac Tromethamine 0.5% eye drops for a mean period of 54 ± 25 days. During follow-up visits they developed NK and they were successfully treated with suspension of Ketorolac eye drops, application of therapeutic contact lens or amniotic membrane patch and topical lubricant therapy. Postoperative Ketorolac eye drops, in patients who underwent PPV with endolaser, may reduce the corneal sensitivity, predispose to epithelial disruption and NK development. Studies are needed to explore the effect of NSAIDs on corneal sensitivity reduction in patient who will undergo PPV and extensive endolaser.

Evaluation of the effect of Muller muscle-conjunctival resection on meibomian glands by meibography.

To evaluate the effect of upper eyelid ptosis repairwith Muller muscle-conjunctival resection on meibomian gland function and ocular surface parameters. Thirty-eight patients who underwent ptosis repair with Muller muscle-conjunctival resection were retrospectively reviewed. Meibomian gland loss, Ocular Surface Disease Index OXFORD score, meiboscore, and noninvasive keratograph break-up time were measured preoperatively and at 1st, 3rd, and 6th months postoperatively. Noninvasive keratograph break-up time values decreased significantly at 1st and 3rd months postoperatively compared to the preoperative level, but were similar to the preoperative level at 6th months postoperatively (p<0.001 and p=0.628, respectively). Ocular surface disease index, OXFORD score, meibomian gland loss, and meiboscore values increased significantly in the 1st and 3rd postoperative months compared to the preoperative period, but these values decreased to preoperative levels in the 6th postoperative month (p<0.001 and p>0.05, respectively). There is a transient deterioration in meibography findings and OSDI score in the early postoperative period afterMuller muscle-conjunctival resection. Patients undergoing Muller muscle-conjunctival resection may require topical lubricants, especially in the first 3 postoperative months.

Comparison of Two Topical Lubricants on the Corneal Surface Recovery and Patient Discomfort After Photorefractive Keratectomy.

This study aimed to compare the effect of two preservative-free (PF) artificial tears, one containing carboxymethylcellulose (CMC) (control group) vs another containing hyaluronic acid and hydroxypropyl guar (HA + HP-guar) (study group), on the healing of the corneal epithelium and the ocular discomfort after bilateral photorefractive keratectomy (PRK) surgery. A total of 68 patients that were scheduled to have PRK to correct myopia were randomized into two groups: 34 patients (68 eyes) in the study group and 34 patients (68 eyes) in the control group. Ocular examinations were performed on postoperative days1, 4, 7, 30, and 90, evaluating the diameter of the de-epithelized cornea, the fluorescein staining using the Oxford scale, the tear film osmolarity and stability (tear breakup time), and the pain using visual analog scale (VAS). On postoperative day4, 97% of the study eyes vs 84.4% of the control eyes were completely re-epithelized (p = 0.01). Less ocular pain was observed on postoperative day3 in the study group (5.0(3.0-6.0) vs 6.0 (3.5-7.0), p = 0.03). No differences were observed beyond postoperative day7 in the healing of the corneal epithelium, non-invasive Keratograph breakup time (NIKBUT), and the self-perceived ocular discomfort between the two groups. The current study shows faster healing of the corneal epithelium and less ocular pain and discomfort in the first days after PRK with the use of topical lubricants containing HA + HP-guar compared to conventional CMC artificial tears, probably due to the different trophic effect of the aforementioned tears on the corneal epithelial cells. EudraCT No. 2020-003488-25.

THU444 A Case Of Zoledronic-Acid Induced Acute Anterior Uveitis, Episcleritis, And Synovitis

Abstract Disclosure: X. Au: None. R.I. Dorin: None. L.E. Aguirre: None. Introduction: IV zoledronic acid infusion (ZAI) may result in acute phase reaction associated with self-limited symptoms of pyrexia, myalgia, headache, arthralgia, and pain in extremities. Eye inflammation and joint swelling are less common manifestations of post-ZAI acute phase reaction, but are important to recognize and treat owing to the potential for long-term sequelae. Clinical Case: A 66-year-old female was diagnosed with osteoporosis by DXA. She received her first ZAI (5 mg) and within 24 hours noted onset of moderate-to-severe diffuse musculoskeletal pain and fever up to 102°F. Two days later, the patient noted swelling of her left wrist and bilateral knee and ankle joints. Clinical assessment led to a diagnosis of post-ZAI synovitis, which improved somewhat with IV ketorolac followed and outpatient po acetaminophen and ibuprofen. Six days after ZAI she developed left eye (OS) redness. Ophthalmologic evaluation identified acute episcleritis and acute anterior uveitis with normal visual acuity and intraocular pressures. The patient was managed with a transient (5 day) course of prednisone (40 mg daily) and a 14-day course of topical prednisone, cyclosporine, and lubrication. Posterior synechiae of OS resolved on follow-up exam and topical medications were successfully tapered over three weeks with resolution of visual complaints. Discussion: Acute phase reaction is a common side effect of ZAI, with an incidence of fever (17.2%) and diffuse musculoskeletal pain (15.7%) reported in one study [1]. Eye inflammation and joint swelling have also been reported after ZAI, but at a lower incidence (0.4% each) [1]. Patients with acute episcleritis and uveitis may require systemic steroids. While the prognosis of appropriately treated acute anterior uveitis is good, it may be associated with concomitant orbital inflammation that could lead to permanent vision loss. Risk factors for development of severe acute-phase reactions after ZA infusion have not been identified, though acute phase reactions are more commonly observed after the first dose of ZAI [2]. Conclusion: Physicians should be aware of rare ophthalmic complications of ZAI, as their prompt recognition and treatment may be important in prevention of long-term ocular sequelae.

Acute exacerbation of ocular graft-versus-host disease and anterior uveitis after COVID-19 vaccination

BackgroundTo report a case of simultaneous occurrence of acute exacerbation of ocular graft-versus-host disease (GVHD) and anterior uveitis following coronavirus disease 2019 (COVID-19) vaccination.Case presentationA 60-year-old man with primary myelofibrosis and GVHD after receiving allogeneic hematopoietic stem cell transplantation (HSCT), developed acute exacerbation of ocular GVHD and anterior uveitis after receiving first dose of COVID-19 vaccine. The patient developed erythema of the eyelids, conjunctival hyperemia, superficial punctate keratopathy, and prominent anterior chamber inflammation in both eyes. The ocular GVHD and anterior uveitis were managed with mainly topical corticosteroids, antibiotics, lubricants, and systemic corticosteroids, but were difficult to control. Intravitreal injection of dexamethasone was administered, and the inflammation gradually subsided 6 months after the onset of initial symptoms.ConclusionsClinicians should be aware of rare refractory anterior uveitis and acute exacerbation of ocular GVHD after COVID-19 vaccination in patients undergoing HSCT. Early diagnosis and aggressive treatment should be considered to reduce the likelihood of severe complications.

Flammability of Ocular Surface Lubricants.

Surgical fires pose a substantial risk to patients and can cause significant injury, especially in oculofacial surgery. Ocular surface lubricants can potentially act as fuel for an operating room fire. We present an experimental analysis of the flammability of 9 commonly used ophthalmic lubricants under 4 ignition sources used in oculofacial surgery with and without supplemental oxygen. The flammability of 9 ophthalmic lubricants were tested under various operating room conditions. Each lubricant was exposed to 4 different ignition sources: an open flame lighter, monopolar cautery, bipolar cautery, and hand-held high temperature cautery, and the response of the lubricant was recorded. The testing was conducted both in room air and with 6 L/minute of 100% oxygen directed at the lubricant through a nasal cannula. Any reaction in which there was ignition, sparking, smoking, or a transient or permanent change in appearance of the lubricant was deemed notable. Of the 9 lubricants tested, 4 displayed a reaction to the ignition source. Without supplemental oxygen, 100% petrolatum and neomycin-polysporin-bacitracin-hydrocortisone ointment produced some smoke when applied with the high temperature cautery. Notably, under both the conditions of no supplemental oxygen and with the addition of 6 L/minute of 100% oxygen, the carboxymethylcellulose drops and lidocaine jelly both conducted and sparked with the monopolar cautery leaving visible burn marks on the paper. The overall fire hazard posed by ocular surface lubricants is low. Some topical lubricants can conduct electricity from monopolar cautery, which could increase the risk of inadvertent electrical burns. Certain lubricants could potentially become a fuel source when used in combination with hand-held high temperature battery cautery. Bipolar cautery was not associated with either increased conductivity or flammability with any of the lubricants tested.

Vesicular contact dermatitis following sulfacetamide eye drop instillation raising the specter of vesiculobullous mucocutaneous syndrome – Case presentation

Allergic reactions to ocular drops are a well-known side effect and usually present as eczematous dermatitis localized to periocular skin. However, rarely, the reactions can be severe and present with systemic involvement leading to vision or even life-threatening consequences. We report a case of vesicular allergic contact dermatitis following instillation of an over-the-counter sulfacetamide eye drop in right eye with involvement of oral mucosa, raising a threat of mucocutaneous vesiculobullous disorders. Prompt discontinuation of ocular drops followed by treatment with systemic and topical steroids, topical lubrication, and fornix glass rod sweeping prevented vision- and life-threatening sequalae.

Pediatric Conjunctivitis: A Review of Clinical Manifestations, Diagnosis, and Management.

Conjunctivitis is a common pediatric problem and is broadly divided into infectious and non-infectious etiologies. Bacterial conjunctivitis makes up the majority of cases in children and often presents with purulent discharge and mattering of the eyelids. Treatment is supportive with an individual approach to antibiotic use in uncomplicated cases since it may shorten symptom duration, but is not without risks. Viral conjunctivitis is the other infectious cause and is primarily caused by adenovirus, with a burning, gritty feeling and watery discharge. Treatment is supportive. Allergic conjunctivitis is largely seasonal and presents with bilateral itching and watery discharge. Treatment can include topical lubricants, topical antihistamine agents, or systemic antihistamines. Other causes of conjunctivitis include foreign bodies and non-allergic environmental causes. Contact lens wearers should always be treated for bacterial conjunctivitis and referred to evaluate for corneal ulcers. Neonatal conjunctivitis requires special care with unique pathogens and considerations. This review covers essential information for the primary care pediatric provider as they assess cases of conjunctivitis.

The Whitnall Barrier: A Technique for the Management of Lacrimal Gland Prolapse.

The Whitnall barrier procedure, a modified Beer and Kompatscher surgical technique to reposition the lacrimal gland, is presented alongside a case series of patients demonstrating excellent aesthetic and functional outcomes. The Whitnall barrier procedure is illustrated procedurally and accompanied by a case series of 20 consecutive patients treated in a single institution by a single surgical team between December of 2016 and February of 2020. Lid contour and function were assessed postoperatively, as was patient satisfaction. Thirty-seven eyes of 20 patients were included. All patients were women, with an average age of 50 years. Fourteen patients underwent surgery for cosmesis, four had inactive thyroid eye disease, and two had lacrimal gland enlargement secondary to dacryoadenitis. The degree of lacrimal gland prolapse was described as mild in two eyes and moderate in 35 eyes. All patients had one or more additional surgical procedures. Mean follow-up duration was 11 months, with complete resolution of lacrimal gland prolapse in 34 eyes. The patient who did not have complete resolution had dacryoadenitis and required ongoing immunosuppressive therapy. Two patients were discharged on topical lubricants: one with thyroid eye disease and one cosmetic patient who underwent upper and lower lid blepharoplasties at the same time. There were no intraoperative complications and no incidences of infection, dehiscence, or damage to the lacrimal gland ductules. The Whitnall barrier technique is a safe and effective surgical procedure to restore the anatomic location of the lacrimal gland. It provides excellent aesthetic and functional outcomes.

Limbal stem cell deficiency secondary to systemic daptopotamab deruxtecan (Dato-DXd): A case report and literature review.

Limbal stem cell deficiency (LSCD) secondary to drug toxicity has been reported in topical and systemic chemotherapy. We report the first case of LSCD arising from a novel antibody-drug conjugate (ADC), Daptopotamab deruxtecan (Dato-DXd), in a patient with breast cancer. A 66-year-old female with treatment-naïve breast cancer was enrolled in a clinical trial with regimen of Dato-DXd in combination with Durvalumab. She suffered from blurred vision, photophobia and ocular pain of both eyes after administration of the regimen for 5 months. Slit-lamp biomicroscopy with fluorescein staining revealed irregular epithelium at the upper 1/3 cornea. There was limited effect of topical steroid and lubricants, yet significant improvement after the cessation of Dato-DXd. The cornea resumed clear, and the best-corrected visual acuity were 20/20 in both eyes 6 months after discontinuation of Dato-DXd. Early detection of the ocular adverse reaction and cessation of the causative drug can avoid permanent ocular morbidity and visual impairment.

Silent tears and the loud mimic.

A 57-year-old gentleman presented with a bilateral (OU) upper eyelid swelling since a month along with gritty sensation in the eyes. There was no history of systemic manifestations or similar family history. On examination, best corrected visual acuity (BCVA) in OU was 20/20 and N6 with Schirmer’s of 5 mm in the right eye (OD) and 3 mm in the left eye (OS), and ocular surface staining OU indicating aqueous deficiency dry eyes. Bilaterally, upper eyelid fullness was seen temporally along with S-shaped drooping of the eyelids [Fig. 1]. The superior orbital margin was palpable in OU along with mild tenderness. The palpebral lobe of the lacrimal gland was prolapsed and congested with surrounding chemosis. There was mild restriction of ocular motility on abduction. There was no evidence of proptosis. Intraocular pressure was 16 mmHg in OU. Posterior segment examination was within normal limits.Figure 1: (a) Shows bilateral upper eyelid fullness laterally and S-shaped lateral droop; (b) shows bilaterally prolapsed and congested palpebral lobes of the lacrimal gland, Figure 1c shows axial cut of the CT orbit showing a diffusely enlarged isodense lacrimal gland bilaterally, with no additional bony changesWhat is the next step? Radiological investigations Multilevel incisional biopsy with histopathologic confirmation Collagen vascular profile All of the above Correct Answer D. All of the above Diagnosis and Management Table 1 shows the clinical characteristics of common lacrimal gland disorders. Considering the possibility of subacute dacryoadenitis involving the orbital and palpebral lobes of the lacrimal gland, radiological investigation was done in the form of computed tomography (CT), which showed bilaterally bulky lacrimal glands abutting the lateral rectus on both the sides along with slightly bulky appearance of the lateral recti. A multilevel incisional biopsy was performed for the patient, and histopathology and immunohistochemistry confirmed the diagnosis of IgG4-related dacryoadenitis. A detailed collagen vascular profile was done to evaluate all underlying collagen vascular diseases. Out of the panel, serum IgG4 was found to be raised, therefore correlating with the histopathology. The patient was treated with intravenous methyl prednisolone 500 mg pulse therapy for six pulses along with topical lubricants. He started responding by the fourth cycle and at the latest follow-up of 2 years and 8 months, he is doing extremely well with normalized serum IgG4 levels and resolution of ocular symptoms with Schirmer’s improved to 10 mm in OU.Table 1: Clinical characteristics of lacrimal gland disordersDiagnosis OU IgG4-related dacryoadenitis with severe dry eyes. Discussion Over the last two decades, the unidentified zone of IgG4-related disease has been duly explored. The disease mimics a broad spectrum of clinical entities, ranging from neoplastic to inflammatory and even infectious conditions, which makes it mandatory for the clinicians to understand the clinical presentation, possible differentials, management, and prognosis of IgG4-related disease. Ophthalmologically, the patients present with diplopia, ptosis, visual acuity, disturbance, ocular motility restriction, dry eyes, corneal ulcer, or epiphora.[1] Baseline radiological imaging followed by surgical biopsy would be appropriate.[2] Systemic correlation rules out its presentation as sialadenitis, pancreatitis, and lymphadenopathy as well.[1] Serum IgG4 levels are confirmatory as well as prognostic. The disease responds well to treatment with steroids, but has follows a chronic course with systemic morbidity if left undiagnosed and untreated as it causes end-stage organ failure.[3] Therefore, this possible differential diagnoses and the low remission rate of 23.8% must be kept in mind in a patient with dacryoadenitis presenting with dry eyes.[4] Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his names and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Keratomalacia in a young diabetic

A 38-year-old male presented with complaints of gradual and painless diminution of vision in both the eyes for 1 month. He also had a history of on and off diarrhea for the past 4 months. He was a known case of latent auto-immune diabetes mellitus. Ophthalmic examination showed bilateral conjunctival xerosis and inferior corneal ulceration with stromal edema and Descemet's folds. With the suspicion of vitamin A deficiency-induced keratomalacia, a complete workup was performed. He turned out to be a case of chronic calcific pancreatitis, and stool test was also positive for steatorrhea. The patient was started on oral vitamin A supplementation. Topical lubricants and prophylactic antibiotics were also started in both the eyes with the application of bandage contact lens. Visual acuity improved within a period of 2–3 weeks of treatment and is now on regular follow-up.

Unilateral conjunctival concretions associated with chronic inflammation and tear instability.

Conjunctival concretions are small yellow-white subconjunctival spots that can be asymptomatic for years and are an incidental finding on routine ophthalmic examination.[1,2] The etiologies are chronic vernal conjunctivitis, severe atopic keratoconjunctivitis, and post-trachomatous changes.[1–5] The concretions are located within the conjunctival recesses layered by epithelium and are made up of cell debris and phospholipids.[3,4] Case Report A 24-year-old-female presented with chronic irritation and redness in the right eye for 1 year. Systemic evaluation was unremarkable with no immunosuppressive disorders. Her symptoms were intermittently associated with discharge. Her vision was 20/20 in both eyes. Everted upper and lower eyelids of the right eye showed multiple concretions scattered beneath the tarsal conjunctiva, more in the upper eyelid, protruding through the conjunctiva at two focal points [Fig. 1]. There was diffuse congestion in the tarsal conjunctiva with a normal lid margin appearance. The left eyelid had neither congestion nor concretions. There was no ocular surface staining with fluorescein dye, but the exposed concretions showed fluorescein uptake. Dry eye workup revealed a tear break-up time of 7.8 s with normal tear secretion in the right eye, whereas tear breakup and secretion was normal in the left eye. She gave an antecedent history of a vegetative object falling into her right eye while driving a bike. The ocular symptoms developed 1 month after that trauma. She was using topical lubricants and antibiotic ointment over the eyelid margin for the meibomitis. Because of unilateral presentation and young age, two concretions were removed on slit lamp using a sterile 26-gauge needle under topical anesthesia and sent for tissue processing.Figure 1: (a) Everted right upper eyelid of the 24-year-old female shows scattered numerous concretions in the tarsal conjunctiva, fewer in the lower eyelid (d). (b) Gomori methenamine silver stain (100×) shows presence of fungal elements within the concretions (higher magnification in inset), which are also seen on gram stain (e, 400×) as empty round and vertical spaces. (c and f) Left upper and lower eyelids show normal tarsal conjunctivaThe histopathologic examination of concretions revealed eosinophilic homogenous amorphous material containing fungal elements, which were Gomori methenamine silver stain positive [Fig. 2]. The deepest sections (till the last tissue section) also contained numerous fungal hyphae, which ruled out contamination. Due to atypical histopathologic findings of concretions, a superficial conjunctival incision biopsy containing tarsal conjunctiva, concretions, and a thin sliver of tarsus was taken at 4 mm from the upper eyelid margin. The incision biopsy showed scattered amorphous, acellular eosinophilic hyaline-like material and diffuse lymphocytic infiltration in the substantia propria. The amorphous material had a rim of conjunctival epithelium suggestive of concretions embedded within the pseudoglands of Henle. The periphery of the concretions had a slight basophilic appearance. The concretions were negative for von Kossa stain, Alcian blue, and Congo red but were red on Masson trichrome stain, suggesting cell debris and keratin to be one of the constituents. Alcian blue was focally positive in the conjunctival epithelium at the location of goblet cells. She was started on tablet fluconazole 150 mg once a week for 3 weeks along with 1% itraconazole eye ointment into the eye twice a day. Her symptoms resolved with a reduction in the conjunctival concretions’ number and conjunctival congestion.Figure 2: (a) Everted right upper eyelid with highlighted biopsied part. (b and c) Incisional biopsy from the upper tarsal conjunctiva shows diffuse subepithelial lymphocytic infiltration along with eosinophilic hyaline-like material deposits (c, at 200×). Masson trichrome (d), Congo red (e), and Alcian blue (f) were negative for amyloid and mucopolysaccharide depositsTear film instability and reduced tear production have been reported in patients with conjunctival concretions, where 51% of asymptomatic patients with conjunctival concretions have reduced tear break-up time.[3] The current case had reduced tear break-up time in the eye with concretions. An interesting finding in the current case was the presence of fungal elements, which can be explained by the possible entrapment of organic body containing fungus 1 year back. The organic material dissolved away, but the fungal elements caused persistent chronic inflammation, which resulted in the formation of concretions. This case reports the possibility of having unilateral concretions secondary to chronic inflammation with degenerative changes. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Hyderabad Eye Research Foundation, Hyderabad. Conflicts of interest There are no conflicts of interest.

An unusual case of herpes simplex keratitis presenting as persistent epithelial defect after pterygium surgery

Pterygium is a common conjunctival degeneration and surgical excision is the mainstay of treatment. HSV keratitis after ocular surgery has been attributed to various factors including reactivation of latent infection secondary to surgical trauma to the corneal subepithelial nerve plexus and the modulation of the ocular immune response in the postoperative period caused by steroids. In the current case, the patient had persistent epithelial defect which was non responsive to routine topical lubricant therapy and showed a classical dendritic ulcer pattern upon staining with fluorescein dye. Upon initiation of conventional anti-viral therapy, the patient improved and the epithelial defect was gradually healed. HSV keratitis can rarely present as a non-healing epithelial defect after pterygium surgery and a close follow-up in the post-operative period, timely diagnosis and prompt antiviral therapy plays an important role in achieving a favourable clinical outcome in such cases.