The 9th Asia Cornea Society in conjunction with The 7th INASCRS Biennial Scientific Meeting 2024

Abstract Title
Using AI to Understand the Role of Vitamin D, IgE, and Its Association with Tear Cytokines in Viral Conjunctivitis

Introduction & Objectives
To determine the association between systemic vitamin D and IgE levels with severity and ocular surface inflammatory profile in patients with epidemic keratoconjunctivitis (EKC) and stratify risk factors using Artificial intelligence(AI).

Methods
335 eyes of patients who were clinically diagnosed with EKC were included in the study and their demographic data was noted. Patients were clinically classified as mild-moderate or severe conjunctivitis .The levels of serum vitamin D (VD) and serum immunoglobulinE (IgE) were measured. Artificial intelligence(AI) model was built to assess these factors. Schirmer’s strip-based tear fluid (TF) was used to determine levels of IL-1β, IL-6, IL-10, IL-17A, TNFα, MMP9, sICAM1, and VEGF-A in a subset of patients.

Results
Levels of VD were significantly (P<;0.05) lower and IgE was significantly higher in patients with severe form of conjunctivitis compared to those with non-severe forms. A negative correlation (r =–0.682; P<;0.0001)was observed between VD and IgE levels. TF levels of IL-1β, IL- 6, TNFα, and sICAM1 were significantly higher in eyes with severe form of conjunctivitis compared to those with non-severe forms and controls.These factors showed a positive correlation (P<;0.05) with IgE levels and a negative correlation (P<;0.05) with VD levels.AI model successfully detected systemic allergy,IgE and VitD as factors which were related to severity with an area under curve(AUC) of 0.970.

Conclusion
Patients with severe forms of EKC exhibited VD deficiency and higher levels of IgE. Increased TF inflammatory factors demonstrated a disease causal relationship with VD and IgE and this can be pivotal in the prevention and management of severe conjunctivitis.

Keyword
Vitamin D,IgE,Tear cytokines

Abstract Title
The Battle Against Inflammation: Sub-Tenon Triamcinolone Acetonide 40 mg Versus 0.1% Dexamethasone Eye Drops in Complicated Cataract After Phacoemulsification

Introduction & Objectives
To compare the efficacy of sub-tenon corticosteroid triamcinolone acetonide (TCA) 40mg injections with corticosteroid dexamethasone 0.1% eye drops in Interleukin-6 (IL-6) levels in tears and ocular clinical parameters after performing phacoemulsification in complicated cataracts

Methods
This study was a randomized double blinded-controlled trial with total of 36 patients (36 eyes) who had complicated cataracts and underwent uneventful phacoemulsification were divided equally into a control group (18 patients) who received topical dexamethasone 0.1% eye drops and an intervention group (18 patients) who received a sub-tenon injection of Triamcinolone acetonide 40 mg. IL-6 levels in tears, Macular OCT, BCVA, and IOP were measured one day prior to surgery and 28 days postoperatively

Results
The mean IL-6 levels 28 days post-operation was 23.82±18.12 pg/ml in the control group and 7.88±3.07 pg/ml in the intervention group. The mean CST, CV, and CAT was 259.20±54.63 µm, 10.16±1.56 mm3, and 296.27±57.32 µm in the control group. The mean CST, CV, and CAT was 264.20±42.33 µm, 10.32±1.43 mm3, 275.77±50.78 µm. The mean BCVA 28 days post-operation was 1.01 LogMar in the control group and 1.02 LogMar in the intervention group. The mean IOP 28 days post-operation was 17.72 mmHg in the control group and 15.05 mmHg in the intervention group. There was no statistical difference between both groups in the IL-6 tear levels, OCT macular thickness (CST, CV, CAT), BCVA, and IOP

Conclusion
The option of choosing anti-inflammatory drugs after phacoemulsification in complicated cataracts is based on surgeon preference. Sub-tenon Triamcinolone Acetonide had advantages in cost savings

Keyword
Complicated cataract, phacoemulsification, anti-inflammation

Abstract Title
Evaluation of Contact Lenses Wearing in Children with Congenital Cataract Underwent Surgery

Introduction & Objectives
Congenital cataract is one of the leading causes of childhood vision loss. Controversy surrounds primary intraocular lenses (IOL) implantation in the first 2 years of life due to rapid and unpredictable eye growth, which presents potential adverse events. Contact lenses (CL) are considered a well-tolerated optical treatment in pediatric aphakia. This study aimed to evaluate the visual acuity and complications in congenital cataract patients who utilized CL postoperatively before the age of 2 years.

Methods
We conducted a systematic review following the PRISMA guidelines. Our search encompassed several databases such as the Cochrane Library, EBSCO, Proquest, PubMed, and Scopus, supplemented by manual searches, from 2009 to 2024. Three authors independently evaluated the selected studies using The Joanna Briggs Institute (JBI) Critical Appraisal Tool for Randomized Controlled Trials.

Results
Six randomized controlled trials (RCT), comprising 561 participants, were included. Four studies compared CL and IOL, while two studies compared between CL types. There was consistent evidence regarding an insignificant difference in visual acuity between treatment groups (p>0.05). Fewer adverse events were observed following CL wear compared to children received IOL implantation. Different types of CL, silicone elastomer (SE) and rigid gas permeable (RGP), did not show superiority over each other.

Conclusion
CL emerged as a safe and effective treatment for correcting vision in children who underwent congenital cataract surgery, notably those under 2 years old, demonstrating comparable visual outcomes to primary IOL.

Keyword
aphakia, children, congenital cataract, contact lenses, visual outcome

Abstract Title
The Role of Amniotic Membrane Transplantation for Management of Bullous Keratopathy in Axenfeld-Rieger Syndrome: A Case Report

Introduction & Objectives
Axenfeld-Rieger syndrome is a rare developmental anomaly involving both ocular and extraocular structures, which could cause corneal edoema and bullous keratopathy. Bullous keratopathy can cause blurred vision, glare, and pain. Amniotic membrane transplantation (AMT) has been proven to reduce pain, so it can be used as a treatment option for bullous keratopathy. In this case, we report the management of bullous keratopathy in a rare case of Axenfeld-Rieger syndrome with AMT.

Methods
A 33-year-old male came with complaints of blurred vision, glare, and pain in his left eye since 2 years ago. These complaints worsened in 2 months. Visual acuity was 0.32 on the right eye and close-to-face finger counting on the left eye. The ophthalmology examination showed an edoematous cornea on the temporal side with microbullae on the right eye and corneal edoema with keratopathy, microbullae, and ciliary injection on the left eye. There was correctopia on both eyes and polycoria on the left eye. A trabeculectomy of the left eye was done four years ago. The patient was diagnosed with bullous keratopathy on both eyes, secondary glaucoma on both eyes, and Axenfeld-Rieger syndrome. A superficial keratectomy and AMT were then performed on this patient to reduce complaints in the left eye.

Results
Visual acuity one week after surgery was 1/60 with a smoother corneal surface. The pain was reduced, and the patient felt comfort.

Conclusion
Amnion membrane transplantation have benefits in reducing pain for bullous keratopathy.

Keyword
Amnion membrane transplantation, bullous keratopathy, Axenfeld-Rieger syndrome

Abstract Title
Peripheral Ulcerative Keratitis with Necrotizing Scleritis in A Case of Rheumatoid Arthritis

Introduction & Objectives
To report a case of managing peripheral ulcerative keratitis with necrotizing scleritis secondary to rheumatoid arthritis and multiple comorbidities

Methods
A 53-year-old male with a history of rheumatoid arthritis was admitted due to bilateral blurred vision. Ocular examination revealed corneal melting involving nearly 360 degree. The patient also had stage IV chronic kidney disease, pulmonary tuberculosis, and idiopathic thrombocytopenic purpura. Optimal immunosuppressive therapy was not feasible; hence, a regimen of oral methylprednisolone was initiated. The right eye underwent amniotic membrane transplantation and temporary tarsorrhaphy.

Results
After a 2-month follow-up, both corneal ulcers had healed, and the patient's visual acuity improved.

Conclusion
Peripheral ulcerative keratitis is often associated with systemic autoimmune diseases. Multidisciplinary collaboration in diagnosis and treatment is crucial to reduce the risk of visual loss and mortality in these patients.

Keyword
Peripheral ulcerative keratitis, necrotizing scleritis, rheumatoid arthritis.

Abstract Title
Atypical Keratitis due to Co-Infection with Herpes Simplex Virus and Trichomonascus ciferrii

Introduction & Objectives
To report the atypical keratitis caused from co-infection with herpes simplex virus (HSV) and Trichomonascus ciferrii in an immunocompromised Thai male.

Methods
A case report

Results
A Co-infection of HSV type 1 and Trichomonascus (Stephanoascus) ciferri was identified in a 37 year-old Thai male with well-controlled type 1 diabetes mellitus. The patient had a history of recurrent herpes necrotizing keratitis and initially presented with stromal infiltration and a geographic epithelial defect. Despite adequate antiviral therapy, his condition detoriorated presenting with endothelial plaque and pigmented keratic precipitates, suggesting a possible fungal co-infection. Corneal tissue was sent for PCR testing confirmed the presence of both HSV type 1 and Trichomonascus ciferrii. This fungus is rarely reported in human infections and there are no known prior reports of keratitis caused by this organism. Although the PCR was positive, the fungal culture was negative, likely due to antifungal treatment before specimen collection, resulting in no antifungal susceptibility profile. The patient was treated with intravenous acyclovir, and topical voriconazole and topical amphotericin-B, however the infection did not resolve. Eventually, a therapeutic penetrating keratoplasty was performed with no recurrence of infection.

Conclusion
Co-infection of herpes necrotizing keratitis and fungi is possible. The clinical presentations of these infections can be difficult to differentiate, leading to delayed diagnosis and treatment. PCR is useful for identifying causative organisms especially atypical fungal infection which might not be detected by standard corneal culture.

Keyword
herpes simplex virus, Trichomonascus ciferrrii, PCR

Abstract Title
Improving Eye Donation Counselling Through Competency Assessment: Introducing the Eye Donation Counsellor Skill Evaluation Tool (EDC-SET)

Introduction & Objectives
The study aims to evaluate the competency levels of Eye Donation Counsellors (EDCs) using a newly developed tool, the Eye Donation Counsellor Skill Evaluation Tool (EDC-SET). This tool is designed to standardize the assessment of EDC skills, identify areas for improvement, and ultimately enhance their performance in the Hospital Corneal Retrieval Programme (HCRP). By improving EDC competencies, the study seeks to increase the availability of donor corneas for transplantation and reduce corneal blindness in India.

Methods
The study employed a prospective design, focusing on the development and pilot testing of EDC-SET at a tertiary eye hospital. A competency framework was established, encompassing key parameters like "Initiation of the Case," "Empathy and Emotional Support," "Body Language," "Cultural Awareness," and "Attentiveness to Family Dynamics." Independent assessors were trained to use EDC-SET and evaluated seven EDCs through role-plays based on pre-designed scripts. EDCs were briefed on the EDC-SET framework but not the specific scripts used during evaluations. Assessments were conducted independently by two assessors per EDC to ensure reliability. Data collection involved conformity, kappa, and intraclass correlation coefficient (ICC) calculations to determine parameter-wise reliability.

Results
The pilot study demonstrated that EDC-SET reliably captured EDC competency levels, with scores from both assessors showing moderate agreement across most parameters. Conformity, kappa, and ICC values indicated that EDC-SET is an effective evaluation tool. "Initiation of the Case" and "Empathy and Emotional Support" were identified as the most challenging parameters for EDCs, while "Body Language," "Cultural Awareness," and "Attentiveness to Family Dynamics" were perceived as easier.

Conclusion

Keyword
Eye Donation, Skill development , Standardised Competency Tool

Abstract Title
Does Combined Phaco-Trabeculectomy Affect Corneal Density? A Prospective Study

Introduction & Objectives
The endothelium plays a crucial role in maintaining corneal transparency and proper hydration. Currently, cataract surgery is the most common cause of corneal edema. It can still lead to significant cell loss, particularly when combined with trabeculectomy surgery. However, very few studies have been conducted on this topic. The aim of this research was to evaluate the outcomes of surgical treatment focusing on its impact on corneal endothelial cell density (CECD)

Methods
A prospective observational study was carried out on 10 eyes from 10 patients. The eyes were divided into a two groups: one where combined surgery of phacoemulsification and trabeculectomy was done (group 1; n=5), versus two separate surgeries of trabeculectomy and phacoemulsification within one month (group 2; n=5). We evaluated the impact of the surgeries on various clinical variables, particularly focusing on CECD

Results
In the combined phaco-trabeculectomy group, the mean corneal endothelial cell density loss (±SD) was 30.03% ±12.23, compared to 13.18%±5.42 in the two-step groups. The cell densities in the combined surgery group were higher than those in the two-step surgery groups. The coefficient of variation for endothelial cell area (±SD) was 13.80%±5.42 in the combined surgery group and 11.20%±5.63 in the two-step groups, with no statistically significant differences. The mean change in central corneal thickness (±SD) was 20.6μm±15.99 in the combined group and 12.20μm±10.47 in the two-step groups, with no significant differences between them

Conclusion
The combination of trabeculectomy, phacoemulsification, and intraocular lens implantation results in greater endothelial cell damage compared to two-step combined procedure.

Keyword
Corneal Endothelium, Phacoemulsification, Trabeculectomy

Abstract Title
Shewanella Keratitis: An Emerging Cause of Gram-Negative Bacterial Keratitis

Introduction & Objectives
Shewanella algae is facultative anaerobic, Gram-negative, motile rods found in marine water and deep sea sediments. Human infections by Shewanella are usually associated with trauma while fishing in the sea. This case highlights infection with Shewanella algae not associated with marine environment and is the first reported case in Southeast Asia.

Methods
Case report and review of related literature

Results
A man in his 50s consulted for blurring of vision associated with whitish opacity on the right eye twelve hours after a piece of cement hit his right eye while he was chiselling a dry cement in a pool of water. He then washed his right eye with running tap water. No medication was applied. On examination, the right eye was best-corrected to 20/50 and a 2 x 1.5 mm inferior paracentral anterior stromal infiltrate with brush-like border with positive fluorescein uptake associated with <1 millimeter hypopyon. The Gram stain of the corneal scraping showed multiple Gram-negative bacilli. The patient was given levofloxacin 1.5% and tobramycin 0.3% eyedrops every 2 hours. On follow-up after 1-week, the visual acuity was best corrected to 20/30. Examination showed a clear cornea with resolution of the stromal infiltrates and fluorescein uptake. The culture showed growth of Shewanella algae sensitive to ciprofloxacin and gentamicin. The medications were then discontinued.

Conclusion
Shewanella algae keratitis is an emerging cause of Gram-negative bacterial keratitis presenting similarly to Pseudomonas aeruginosa. Despite the virulent nature of Shewanella algae, the infection in this case was diagnosed early and was treated timely, thus preventing visual complications.

Keyword
Shewanella algae, keratitis, emerging cause

Abstract Title
Systemic Valganciclovir Treatment in Cytomegalovirus Corneal Endothelitis: Experience from Ho Chi Minh City Eye Hospital

Introduction & Objectives
Cytomegalovirus (CMV) corneal endotheliitis is an inflammation of the corneal endothelial cells caused by CMV. To report the demographic profiles and clinical characteristics of three cases diagnosed as CMV endotheliitis. Additionally, it sought to evaluate the therapeutic efficacy of oral valganciclovir and topical corticosteroid in these patients.

Methods
Retrospectively reported the findings of three immunocompetent patients diagnosed with CMV endotheliitis, confirmed through clinical features and positive real-time polymerase chain reaction (RT-PCR) from anterior chamber tap samples.

Results
The initial visual acuity and IOP of these patients were count finger, 17mmHg; 5/10, 16mmHg; and 6/10, 20mmHg; respectively. Their clinical characteristics were conjunctival hyperemia, varying degrees of corneal stromal edema, coin-shaped keratic precipitates (KPs), and mild anterior chamber (AC) inflammation. Microbiological analysis confirmed positive CMV RT-PCR results from AC tap samples. All three patients received a three-week course of oral valganciclovir 900mg twice daily and topical 1% prednisolone acetate 4-6 hours daily. The clinical features were improved significantly with completed conjunctival congestion, decreased corneal stromal edema, absented of new KPs, resolved AC inflammation and visual acuity enhanced to 1/10, 5/10, and 7/10, respectively. Three patients had been managed with maintenance of oral 900mg valganciclovir daily for 2 to 3 months before discontinuation. All cases were followed up for a 3-month period, during which no recurrence was observed.

Conclusion
The administration of a three-week course of oral valganciclovir alongside with topical 1% prednisolone acetate demonstrated efficacy in treating CMV corneal endotheliitis. This regimen proves particularly beneficial in regions where topical ganciclovir may not be available.

Keyword
Cytomegalovirus, endotheliitis, valganciclovir

Abstract Title
Incidence, Causative Pathogens, Risk Factors, Geographical Variations, and Outcomes of Post-Keratoplasty Infectious Keratitis Over the Last 15 Years: A Systematic Review and Meta-Analysis

Introduction & Objectives
Cornea with prior keratoplasty has been associated with an increased risk of infectious keratitis (IK). Over the last 15 years, the trend in keratoplasty surgery has shifted from penetrating keratoplasty to endothelial keratoplasty, which might considerably affect the occurrence of post-keratoplasty infectious keratitis (PKIK). We aim to assess the incidence, risk factors, causative microorganisms, and outcomes of PKIK, considering the differences in the type of keratoplasty and potential geographical variations.

Methods
Electronic searches were conducted in four databases (PubMed/MEDLINE, Cochrane, Scopus, and Wiley) for studies reporting PKIK from 2009 to 2024. This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines.

Results
Eight studies were eligible for final analysis. The incidence of PKIK ranged from 1.80% to 18.77%. Compared to penetrating keratoplasty endothelial keratoplasty showed a trend towards a lower risk of PKIK (log odds ratio -1.33, 95% CI: -2.96 – 0.30, p = 0.108). While gram-positive bacteria were the most common pathogens found to cause PKIK, it was estimated that 21% (95% CI: 9-33%) of cases were attributed to fungal infections. The influence of the geographical study site on thefungal proportion was not significant in meta-regression analysis (p > 0.05). Several risk factors for PKIK were also identified. Severe visual impairment was commonly observed following treatment of PKIK. Topical quinolone can be used as first-line therapy despite the increasing antibiotic resistance rate of pathogens.

Conclusion
Endothelial keratoplasty showed a trend towards a lower incidence of PKIK compared to penetrating keratoplasty. PKIK remains a devastating complication after keratoplasty.

Keyword
Corneal transplant, penetrating keratoplasty, endothelial keratoplasty, infection, keratitis, incidence

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