By Dr Ashvira Moodley A classic example of herpes simplex virus (HSV) epithelial keratitis presenting as a dendritic corneal ulcer. What to look for: • A branching, dendritic epithelial defect • Characteristic terminal bulbs at the ends of the branches • Reduced corneal sensation may be present • Typically unilateral, although bilateral disease can occur, particularly in immunocompromised patients • Fluorescein staining highlights the epithelial defect and helps demonstrate the classic dendritic pattern A little more about HSV: HSV is a double-stranded DNA virus that remains latent in the trigeminal ganglion after primary infection. Reactivation can occur with triggers such as illness, stress, ultraviolet exposure, fever, trauma, or immunosuppression. Ocular HSV may involve the eyelids, conjunctiva, corneal epithelium, corneal stroma, uvea, or retina. Epithelial keratitis typically results from active viral replication within the corneal epithelium and may begin as punctate epithelial lesions before progressing to a branching dendritic ulcer. Image 1 — Pretreatment: Classic dendritic epithelial keratitis consistent with HSV. Image 2 — Post-treatment: Marked epithelial healing following appropriate antiviral therapy by Dr Ashvira Moodley. Management considerations: Antiviral treatment is used to limit viral replication and promote epithelial healing. Treatment options may include topical or oral antivirals. Avoid topical corticosteroids in active untreated epithelial HSV keratitis, as they may worsen viral replication and lead to progression of the epithelial defect. Steroids may have a role in selected cases of stromal or intraocular inflammation, but only with appropriate antiviral cover and ophthalmic supervision. If there is diagnostic uncertainty, stromal involvement, significant anterior chamber inflammation, reduced vision, marked pain, recurrent disease, or deterioration despite treatment, ophthalmology referral is warranted. Take-home message: - Recognising the classic dendritic pattern early can make a significant difference to management and visual outcome.

By Dr Kashmira Rawjee Mrs SN is a 65 year old Caucasian female who was referred to me with a non-healing “cyst” of her eyelid for the past few months. She reported spending a lot of time in the sun while playing bowls in recent years. The position of the lesion on the lower eyelid and ulcerative appearance prompted a wedge excision of the lid. The specimen was sent for histopathological examination and confirmed Basal Cell Carcinoma. Importantly, the pathology demonstrated clear surgical margins, indicating that no tumour was identified at the examined margins. The patient will continue to be observed closely for recurrence. The routine examination of the eyelids and periocular skin can provide an important opportunity to identify malignancy at an early stage. BCC is the most common malignant eyelid tumour, accounting for more than 90% of malignant eyelid neoplasms. It is usually a slow-growing, locally invasive tumour associated predominantly with cumulative ultraviolet exposure. What should you look out for? - A suspicious eyelid lesion may demonstrate: • A non-healing lesion or persistent crust • Recurrent ulceration or bleeding • Loss of eyelashes (madarosis) • Fine telangiectatic vessels • Nodularity or a pearly appearance • Distortion of the normal eyelid margin • Progressive change in size or appearance • Skin ulceration • Paresthesia or reduced sensation BCC commonly occurs on the lower eyelid, followed by the medial canthus. Medial canthal lesions deserve particular attention because of their potential for deeper/orbital extension. Although BCC can occur in any skin type, risk is increased with: • Chronic UV exposure, particularly UVB • Lightly pigmented skin • Previous radiation exposure • Immunosuppression, including solid-organ transplantation • Previous scars or chronic skin damage • Genetic syndromes such as xeroderma pigmentosum Histological confirmation is required. Depending on size of the lesion, this may involve an incisional or excisional biopsy.

By Dr Sachin Bawa This week's case is a good reminder that sometimes those seemingly common symptoms of flashes and floaters can be a warning sign of something more serious. Our patient presented with a recent history of flashes and floaters. She was found to be myopic, with the following visual findings: Unaided Visual Acuity R)0.3 L) 0.6 Refraction R) -2.00/-0.75x48 L) -2.00/-0.00 Given her symptoms, a careful retinal examination was performed. The Findings: Examination of the retina revealed a horseshoe retinal tear. A horseshoe tear occurs when the vitreous pulls on the retina strongly enough to create a tear. The danger is that fluid can then pass through the tear and underneath the retina, potentially resulting in a retinal detachment. Treating the Tear Before It Becomes a Detachment: Fortunately, the tear was identified before a retinal detachment had developed. The patient underwent prophylactic retinal laser treatment around the retinal tear. The aim of the laser is to create a strong adhesion between the retina and the underlying tissue, effectively creating a barrier around the tear and reducing the risk of fluid tracking underneath the retina. A Quick but Important Procedure Retinal laser treatment is usually: ⚡ Quick — often taking less than 10 minutes 🙂 Generally painless 👁️ Performed as an outpatient procedure 🛡️ Highly effective at reducing the risk of retinal detachment from an appropriately treated retinal tear The Take-Home Message Flashes and floaters are common, particularly as we get older and the vitreous naturally changes. However, a sudden onset of flashes and floaters should always prompt a thorough retinal examination. In patients who are myopic, the importance of carefully examining the peripheral retina is even greater. In this case, identifying the retinal tear early meant that it could be treated with a relatively simple laser procedure — before it progressed to a potentially sight-threatening retinal detachment. 👁️ Before and After

By Dr Ashvira Moodley This patient developed significant redness, irritation and ocular surface inflammation while using topical glaucoma medication. At first glance, this may seem like a common ocular surface issue. However, persistent redness and irritation should prompt us to consider allergy or intolerance to the glaucoma drops themselves. In this case, the eyes cleared significantly after all topical glaucoma drops were stopped. No topical anti-inflammatory treatment was required. During this period, the IOP was managed with oral Diamox (acetazolamide) while the ocular surface recovered. Once the suspected medication-related reaction was identified, treatment options could be reassessed. Topical drops can be reintroduced cautiously, one at a time, to identify the offending agent, or SLT can be considered to reduce the need for topical medication. The patient was managed by Dr Ashvira Moodley and has also undergone selective laser trabeculoplasty (SLT). Key takeaway: When a glaucoma patient develops persistent ocular surface inflammation, consider whether the treatment itself may be contributing to the problem. Stopping the offending drops, maintaining IOP control and then individualising further treatment can help protect both ocular surface health and long-term glaucoma control.

By Dr Kashmira Rawjee Modern cataract surgery is refractive surgery. A refractive surprise refers to an unexpected residual refractive error after cataract surgery, where the achieved postoperative refraction differs from the planned target. Although uncommon with modern biometry and IOL calculation formulas, refractive surprises can still occur and may significantly impact patient satisfaction. Fortunately, when surprises occur, we have excellent solutions available. The main types of refractive surprise after cataract surgery are classified according to the residual refractive error, it can be myopic, hyperopia or parent as residual astigmatism. A refractive surprise may result from: • Unusual ocular anatomy (short or long eyes) • Prior corneal refractive surgery • Ocular surface disease affecting keratometry • Errors in biometry or lens selection • Effective lens position variability • Less commonly, postoperative IOL displacement In this weeks case, this patient experienced an unexpected hyperopic refractive surprise following routine cataract surgery with a visual acuity of 0.7. Although the surgery itself was uncomplicated, the postoperative refraction left the patient dissatisfied with their visual outcome. Rather than performing an intraocular lens exchange—which can be technically more challenging and carries additional risks once capsular fibrosis has developed—I elected to implant a supplementary (add-on) intraocular lens in the ciliary sulcus. What is an add-on IOL? A supplementary IOL is specifically designed to sit safely in the ciliary sulcus, in front of the original capsular bag IOL. It works by adding the required refractive power to correct the residual error while leaving the primary lens undisturbed. Advantages include: Precise correction of residual refractive error Preservation of the original capsular bag IOL Lower risk than late IOL exchange Reversible if future intervention is required Excellent visual outcomes in appropriately selected patients