Category: Clinical Challenges

Conjunctival Melanosis Clinical Challenges Pigmented lesions of the conjunctiva are a common finding during an ophthalmic examination. They can pose a significant diagnostic challenge since they can stem from a wide variety of causes. Although malignant melanomas of the conjunctiva are rare, and account for less than 5% of ocular melanoma (majority are from the uveal tract), they can have significant morbidity and mortality and hence, early diagnosis is important. When evaluating these lesions, the clinical appearance, age at presentation, location, bilaterally and when in doubt, histopathology can help. In a 10-year-old boy, with dark skin, brown irides, the appearance of light brown, dispersed flat lesions seen symmetrically in both eyes, with no change since detection, the diagnosis is Complexion associated Melanosis (formerly called racial melanosis). Documentation and periodic observation for change in size, color, thickness and vascularity are necessary.

  Clinical Challenges   Deep Anterior Lamellar Keratoplasty (DALK) Deep Anterior Lamellar Keratoplasty (DALK) retains the patients endothelium and hence is considered superior to a Penetrating Corneal transplant (PK) from the immunology point of view. However, patients undergoing DALK must also be advised to report early when symptoms of Redness, Sensitivity to light, Vision change or Pain (RSVP) occur. This patient who was 1 year post DALK, reported with redness for one month. Multiple loose and broken sutures are noted, with ocular surface epithelial changes. There is no infection, but early vascularization is noted in the deep stroma in the superior quadrant. Early suture removal, antibiotics to avoid infection, and steroids to reduce the inflammation and vascularization are required.

Clinical Challenges Riboflavin staining of the Ocular Surface A new option is now available The ocular surface can be affected by a variety of problems. These can cause significant discomfort to the patient. One of the important ways in which the health of the ocular surface is assessed is by staining with dyes. Traditionally, fluorescein dye is used to assess the health of the cornea, while lissamine green and rose Bengal are used to study the health of the conjunctiva. In India, the dyes are available as strips, and sometimes, the latter two dyes do not elute from the strip well. All slit lamps have a blue filter and this is used to study the effects of fluorescein staining on the cornea. If fluorescein staining of the conjunctiva is to be assessed, an additional yellow filter must be used to enhance the staining. Recently, riboflavin has been used for staining of the ocular surface. Unlike fluorescein, it is available as a solution, which can be used from a bottle – with a shelf life of a month. With the blue and yellow filters, it can also be used to assess conjunctival staining.

  Clinical Challenges   Fungal keratitis Fungal keratitis is not uncommon in India, and this is probably due to a combination of the hot tropical climate and a largely agrarian economy. Injury with vegetative matter is an important cause for fungal keratitis. Recognizing the fungal cause of the corneal infection is extremely important, as it does not respond to the commonly used first-line fourth generation fluoroquinolone antibiotic drops, unlike bacterial keratitis. A delay in recognizing the fungal cause of the keratitis, and instituting the appropriate antifungal agents, can result in significant corneal morbidity and vision loss. A study from Aravind Eye Care system, has shown that much of the fungal infections in South India, are due to filamentous organisms, and they respond better to natamycin eye drops, rather than voriconazole eye drops. These infections typically have a dry stromal infiltrate, with hyphate edges, and satellite lesions, and the signs can exceed symptoms at the start of the infection. Yeast infections, usually by candida, are rare and are seen in immunocompromised patients. These infections can be multiple, have fluffy stromal infiltrates and do not respond to natamycin eye drops. They respond better to fluconazole, amphotericin B and voriconazole eye drops. Hence, determining the fungal cause of infectious keratitis, and the type of fungal organism at an early stage helps institute appropriate therapy and promotes corneal healing. This will require corneal scrapings and cultures. Darshan Google Reviews

Clinical Challenges Acute Conjuctivitis (Pink/madras Eye) With The Onset Of Monsoon Season In Different Parts Of India, The Prevalence Of Acute Viral Conjuctivitis Is On The Rise. The Disease May Vary Between Mild Forms Which Settle Without Medications, To Severe Variants, Which May Require Treatment For Upto 3 Weeks Or More. It Can Affect Patients Of All Age Groups. Patients With Symptoms Of Red Eye, Itchiness And Discharge Are Advised To Visit The Hospital For A Consult And Are Advised Against The Use Of Over The Counter Eye Drops (Especially Those Containing Steroids) And Native Remedies, As The May Inadvertently Cause The Disease To Become Severe,thereby Prolonging Recovery.