This week’s case highlights an important complication of keratoconus — corneal hydrops. A young lady (30 years old), known with keratoconus, presented with sudden reduced vision in the right eye. She was initially referred with a possible corneal ulcer. Her background included scleral contact lens wear, with decent visual acuity. Clinical findings showed an oedematous right cornea, with the anterior segment OCT showing oedema in the stroma. A diagnosis of hydrops was made. UVAR) 0.05 ph 0.2 AVAL)0.7 Pachymetry R)244um Her corneas were noted to be very thin, making her unsuitable for corneal cross-linking. She had been managing well with scleral lenses prior to this event. Treatment of the hydrops included the injecting of sulfur hexafluoride (SF6) gas into the anterior chamber. The gas acts as a tamponade, helping to seal the break in Descemet’s membrane. Picture 3 shows her 1 day post op. Historically, hydrops were managed with sodium chloride eyedrops and antibiotic eyedrops. These cases often progressed to corneal scarring, with many patients ultimately requiring a full-thickness corneal transplant. In this case, intervention with SF6 gas injection saved the patient from a corneal transplant. SF6 gas is known to expand and can remain in the eye for approximately 7–14 days, and can assist in expelling the fluid from the cornea and promote healing. A great reminder that timely intervention can completely change the trajectory of these patients Picture 1: Cornea pre-op Picture 2: Cornea post-op picture 3: Slit lamp photo of right eye 1 day post op showing gas bubble.

By Dr Ashvira Moodley. Today’s patient presented with a sectoral red eye associated with mild discomfort and irritation, but notably without significant discharge, photophobia, or visual disturbance. On slit lamp examination, the inflamed vessels blanched with topical phenylephrine — a positive phenyl test — supporting a diagnosis of episcleritis rather than scleritis. Episcleritis is a relatively common, benign, and often self-limiting inflammation of the episcleral tissue. Patients typically present with: • Sectoral or diffuse redness • Mild tenderness or irritation • Little to no pain • Normal visual acuity One of the most useful clinical pearls in differentiating episcleritis from scleritis is the phenylephrine blanching test: - Superficial episcleral vessels blanch with phenylephrine - ⁠Deeper scleral vessels remain injected in scleritis This distinction is important because while episcleritis is usually benign and manageable with supportive treatment or topical anti-inflammatory therapy, scleritis can be vision-threatening and may be associated with underlying systemic autoimmune disease. A good reminder that careful examination of the “simple red eye” can make all the difference.

By Dr Kashmira Rawjee Today’s case is a 41 year old female presenting with reduced visual acuity of 0.5 in the right eye. A diagnosis of immune stromal keratitis was made and the patient was treated with oral acyclovir and topical cortisone. Visual acuity improved to 0.9 in 2 weeks on the above treatment. Disciform keratitis is also known as immune stromal keratitis. The pathophysiology is an immune mediated reaction to Herpes Simplex Virus rather than viral replication and the findings therefore differ from classic dendritic keratitis. Clinically it presents as central stromal oedema with an intact corneal epithelium. There is reduced corneal sensitivity and only mild discomfort in comparison to disproportionate drop in visual acuity. Keratic precipitates are usually absent and the anterior chamber is quiet. Although the most common presentation is as a disciform keratitis, other forms include linear, diffuse and sectoral. Management consists of systemic antiviral agents in therapeutic doses for 10-14 days and judicious use of topical corticosteroid drops . Intraocular pressure needs to be monitored and close follow up is required to taper the medication depending on the response to treatment. Timely recognition is imperative and prevents mismanagement. Topical steroids can be vision saving but only when paired with appropriate antiviral cover to prevent reactivation.

Mr JM, a 63-year-old patient, presented to our practice with bilateral blindness from dense cataracts. His visual acuity was hand movements in both eyes, leaving him unable to mobilize independently or work to support his family. After waiting two years for surgery at a local hospital, he sought help at our practice—and we were privileged to assist. During surgery we encountered a classic intraoperative sign seen in intumescent white cataracts: the Argentinian Flag Sign. To perform cataract surgery safely, the anterior capsule is often stained with trypan blue to improve visualisation while creating a continuous curvilinear capsulorrhexis—a circular opening in the capsule that allows access to the lens material. In intumescent cataracts, the lens becomes pressurised by liquefied cortex trapped beneath the capsule. When the capsulorrhexis is initiated, the sudden decompression can cause the tear to extend rapidly toward the lens periphery on either side. The resulting pattern—a central white cataract bordered by two blue-stained capsular flaps—resembles the blue-white-blue stripes of the Argentinian flag . Recognizing this sign is critical because uncontrolled capsular extension can lead to: • Extension of the tear to the lens equator or posterior capsule • Risk of lens material dropping into the vitreous cavity requiring retinal surgery • The need to modify surgical technique or convert to a different surgical approach In this case, Dr Kashmira Rawjee used specialised techniques to safely decompress and remove the cataract without vitreous loss or capsular complications. An intraocular lens was successfully implanted in the capsular bag, and the capsulorrhexis was completed. The most rewarding moment came two days after surgery, when Mr JM was able to perform a simple but life-changing task again—walking independently. We look forward to his upcoming postoperative review to see the full visual and functional impact that cataract surgery will have on his life.

Cyst removal performed by Dr Ashvira Moodley from iSurgeon. Optometrists often spot subtle eyelid lesions during routine eye exams. One that occasionally appears is a hydrocystoma — a benign cyst arising from the sweat glands of the eyelid. In this case: The first image shows a translucent cystic lesion on the lower eyelid. The second image shows the post-removal result, restoring a smooth lid contour. Hydrocystomas are typically fluid-filled, dome-shaped lesions that may appear clear or slightly bluish. They are usually painless but can slowly enlarge and sometimes become cosmetically bothersome for patients. Clinical clues at the slit lamp • Smooth, cystic appearance • Translucent or shiny surface • Often located along the lower eyelid margin or periocular skin • May fluctuate in size with heat or humidity When to refer? If the lesion is growing, atypical, symptomatic, or the diagnosis is uncertain, referral to an ophthalmologist is helpful for confirmation and management. Management: Hydrocystomas are benign and treatment is often straightforward, with simple removal providing both functional and cosmetic improvement. A great reminder of how optometrists and ophthalmologists work together to keep patients seeing — and feeling — their best.