Curated article summaries

1. OUTCOMES OF ANTERIOR CHAMBER WASH WITH ADJUVANT INTRACAMERAL AND INTRASTROMAL VORICONAZOLE IN DEEP STROMAL FUNGAL KERATITIS WITH ENDOEXUDATES—A RETROSPECTIVE STUDY Muraleedharan P, Christy JS, Radhakrishnan N. Outcomes of anterior chamber wash with adjuvant intracameral and intrastromal voriconazole in deep stromal fungal keratitis with endoexudates—A retrospective study. Indian J Ophthalmol 2025;731482-5. Filamentous fungal keratitis often shows poor response to topical antifungals because natamycin has limited stromal penetration and topical voriconazole, though achieving adequate AC levels, is ineffective as monotherapy. Deep stromal infections with anterior chamber exudates frequently progress to therapeutic keratoplasty, which usually results in suboptimal visual recovery. Intrastromal and intracameral voriconazole have been used as adjuncts with variable outcomes. However, a systematic evaluation of their combined role in managing deep stromal keratitis with endoexudates has not been conducted before. In this retrospective observational study done in a tertiary care center in South India from January 2022 to December 2022, records of patients with microbiologically proven deep stromal fungal keratitis were analyzed. Patients unresponsive to or worsening on topical natamycin and voriconazole dual therapy, were subjected to AC wash with intracameral and intrastromal voriconazole (50 mcg/0.1 mL), repeated up to a maximum number of three times within a 24–48-hour interval. In patients with rapid progression of ulcer or impending perforation or perforation during or even after three AC washes with intracameral and intrastromal voriconazole, therapeutic keratoplasty was done. Out of the 40 patients who underwent AC wash with intrastromal and intracameral voriconazole, Only 7 (17.5%) achieved complete resolution with scarring; the remaining 33 eyes (82.5%) required therapeutic penetrating keratoplasty (TPK), of which 10 (≈30.3%) experienced reinfection despite the intervention. WHY THIS ARTICLE? This article directly addresses a practical, high-stakes clinical question. Deep fungal keratitis with intraocular involvement is sight-threatening and there’s little high-quality evidence guiding escalation beyond topical/systemic therapy. Many have tried intrastromal/intracameral voriconazole, but the results were inconsistent. Although the outcome is negative, this study offers crucial information that should temper enthusiasm for routine use of these adjuvants and may push toward earlier surgical intervention or alternative strategies. 2. EFFICACY AND SAFETY OF PILOCARPINE HYDROCHLORIDE OPHTHALMIC SOLUTION USP 1.25% W/V VERSUS PLACEBO OPHTHALMIC SOLUTION FOR THE TREATMENT OF PRESBYOPIA—A MULTICENTRIC CLINICAL TRIAL Singh P, Garasiya T, Ajila V, Sengupta S, Datta A, Nivean M. Efficacy, and safety of pilocarpine hydrochloride ophthalmic solution USP 1.25% w/v versus placebo ophthalmic solution for the treatment of presbyopia—A multicentric clinical trial. Indian J Ophthalmol 2025;73:1251-7. Pilocarpine is a cholinergic muscarinic receptor agonist that enhances accommodation by inducing miosis and stimulating the ciliary muscle. The GEMINI 1 and 2 trials (2021, Allergan)) have led to FDA approval of pilocarpine 1.25% (Vuity) in the US for pharmacological treatment of presbyopia. Indian eyes have smaller pupils and increased iris pigmentation, which may alter pilocarpine’s efficacy and pharmacodynamics. Despite global evidence supporting pilocarpine, there is a lack of studies and local availability in India, limiting applicability to the Indian population. This multicenter, randomized, double-masked, parallel-assignment clinical trial evaluated the efficacy and safety of 1.25% pilocarpine for the treatment of presbyopia, comparing it to a placebo, with 1:1 randomization of Indian men and women aged 45–55 years with a clinical diagnosis of presbyopia. Participants instilled one drop of the study drug or placebo in each eye once daily in the morning and were evaluated on day 0,3, 7, 14, and 30 50% of participants gained at least two lines of near visual acuity, while 31% gained three lines by day 30, which was almost identical to the GEMINI1 clinical trial, despite several racial anatomical differences in eyes. No adverse drug reactions or ophthalmic side effects were reported during the study. WHY THIS ARTICLE? Although pilocarpine 1.25% was found to be effective in treatment of presbyopia, almost all the studies were conducted in Western populations, under industry sponsorship and used stringent inclusion criteria (healthy emmetropic presbyopes, no refractive error, no lens changes). So, while we know the drug can work in ideal eyes, real-world data in diverse populations were lacking. This study was Conducted in Indian eyes, which often have smaller pupils, darker irides, and higher baseline accommodative tone than Western counterparts—all of which affect miotic-based near vision improvement. Done in different light environments and in non-ideal eyes (mild cataract, ametropia), which is closer to real life situation Multicentric, which increases its external validity Non-industry, investigator-initiated work which provides a neutral safety and tolerability profile The results of the trial support the findings from previous trials, and validates the use of pilocarpine 1.25% as a viable pharmacotherapy in Indian presbyopes, although further studies are required before we include it in the armamentarium Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.