Surgical outcomes in aggressive retinopathy of prematurity (AROP)-related retinal detachments

Introduction

Aggressive retinopathy of prematurity (AROP) is a severe and progressive variant of retinopathy of prematurity (ROP) rapidly forming fibrous tissue extending from the disc toward the posterior lens surface progressing to Stage 5 disease without traversing the classical course that includes Stages 1 to 3. Since AROP behaves differently from type 1 ROP, this study was undertaken to evaluate the surgical outcome of AROP-related detachments.

Methods

Retrospective analysis of data from electronic medical records of babies diagnosed with AROP-related detachments who underwent micro-incision vitrectomy surgery (MIVS) was included. The demographic data, details of primary intervention (laser and/or intravitreal bevacizumab), and surgery were noted. In a subset of patients, surgical intervention was planned early at the onset of fibrovascular tissue.

Results

43 eyes of 26 babies with median birth weight 1175 g and median gestational age of 29 weeks were analyzed. 42/43 eyes underwent primary intervention in form of laser and/or anti-VEGF injection before surgery. 41.8%, 25.5%, and 32.5% eyes progressed to stages 4A, 4B, and 5, respectively, requiring surgical intervention. 66% eyes underwent lensectomy and vitrectomy (LV), and 44% eyes underwent lens sparring vitrectomy (LSV). 58% eyes had attached macula. 44% eyes that had a relatively less vascular diseases had better anatomical outcome (P = 0.019). At final follow-up, 53.4% eyes followed or at least had light fixation, and 77.7% eyes undergoing LSV fixated and/or followed light compared to 33% for LV (P = 0.04).

Conclusion

Challenges in AROP include rapid progression to advanced stages of ROP requiring close monitoring and multiple interventions. Surgeries for AROP have a favorable anatomical and functional outcome in 58% and 53%, respectively. Eyes undergoing lens sparing vitrectomy had better visual outcomes.

Next-generation sequencing--based genetic testing and phenotype correlation in retinitis pigmentosa patients from India

Purpose

Inherited retinal dystrophies (IRD) are a heterogeneous group of retinal diseases leading to progressive loss of photoreceptors through apoptosis. Retinitis pigmentosa (RP) is considered the most common form of IRD. Panel-based testing in RP has proven effective in identifying the causative genetic mutations in 70% and 80% of the patients. This is a retrospective, observational, single-center study of 107 RP patients who had undergone next-generation sequencing-based targeted gene panel testing for IRD genes. These patients were inspected for common phenotypic features to arrive at meaningful genotype-phenotype correlation.

Methods

Patients underwent complete ophthalmic examination, and blood was collected from the proband for DNA extraction after documenting the pedigree. Targeted Next Generation Sequencing (NGS) was done by panel-based testing for IRD genes followed by co-segregation analysis wherever applicable.

Results

Of the 107 patients, 72 patients had pathogenic mutations. The mean age of onset of symptoms was 14 ± 12 years (range: 5-55). Mean (Best Corrected Visual Acuity) BCVA was 6/48 (0.9 logMAR) (range 0.0-3.0). At presentation, over one-third of eyes had BCVA worse than 6/60 (<1 logMAR). Phenotype analysis with the gene defects showed overlapping features, such as peripheral well-defined chorioretinal atrophic patches in patients with CERKL, PROM1, and RPE65 gene mutations and large macular lesions in patients with RDH12 and CRX gene mutations, respectively. Nummular or clump-like pigmentation was noted in CRB1, TTC8, PDE6A, and PDE6B.

Conclusion

NGS-based genetic testing can help clinicians to diagnose RP more accurately, and phenotypic correlations can also help in better patient counselling with respect to prognosis and guidance regarding ongoing newer gene-based therapies.

Anatomical and surgical considerations and outcomes in infantile Terson syndrome

Purpose

To study the presentation and outcomes of infantile Terson syndrome (TS).

Methods

This was a retrospective analysis of 18 eyes of nine infants diagnosed to have TS-related intraocular hemorrhage (IOH).

Results

Nine infants (seven males) were diagnosed to have IOH secondary to TS, of which eight infants had imaging features suggestive of intracranial bleed meeting our definite criteria. Median age at presentation was 5 months. In 11 eyes of six infants with suspected birth trauma, the median age of presentation was 4.5 months (range 1-5 months) of which one baby had a history of suction cup-aided delivery and four babies had a history of seizures. Vitreous hemorrhage (VH) was noted in 15 eyes (extensive in 11 eyes). Ten of these eyes showed membranous vitreous echoes, or triangular hyperechoic space with apex at the optic nerve head (ONH) posteriorly and base at the posterior lens capsule anteriorly, with or without dot echoes in the rest of the vitreous cavity, with a configuration of "tornado-like hemorrhage" suggestive of Cloquet's canal hemorrhage (CCH). Eight eyes underwent lens-sparing vitrectomy (LSV) and one eye underwent lensectomy with vitrectomy (LV). On follow-up, disc pallor and retinal atrophy were noted in 11 and 10 eyes, respectively. The mean follow-up was 62 months (1.5 month-16 years). Visual acuity/behavior improved in all cases at the final follow-up. Developmental delay was noted in four children.

Conclusion

Unexplained and altered vitreous hemorrhage with typical ultrasonography (USG) features should raise the suspicion of CCH in TS. Despite early intervention to clear visual axis, anatomical and visual behavior may remain subnormal.

Surgical management of complicated retinal detachment in a case of retinal hemangioblastoma

Background:

A 40-year-old male presented with a complaint of sudden onset diminution of vision in the left eye for 2 weeks. He was a follow-up case with retinal hemangioblastoma in both eyes. He underwent two sittings of fundus fluorescein angiography-guided trans-pupillary thermotherapy 2 years back. Since then, he was regularly followed up for 2 years with stable vision and stable retinal findings. At present, the best-corrected visual acuity (BCVA) in the right eye is 6/6, and in the left eye, it is counting fingers 2 meters. On fundus examination, he had one active hemangioblastoma in the right eye and total retinal detachment in the left eye with multiple active lesions. The right eye was treated with a single sitting of thermotherapy, and the left eye underwent pars plana vitrectomy and angioma excision, followed by silicone oil tamponade. The immediate and late post-operative periods were uneventful, with successful anatomical and functional outcomes. The left eye BCVA on late follow-up was 6/36, no further treatment was advised, and the patient was kept under follow-up and observed closely.

Purpose:

To educate regarding the systemic workup, diagnosis, and surgical management of complicated retinal detachment in retinal hemangioblastoma.

Synopsis:

Systemic workup, diagnosis, and surgical steps in the management of complicated retinal detachment in retinal hemangioblastoma were performed.

Highlights:

Close follow-up, keen observation, and prompt treatment in the early stages of the disease are indispensable to prevent untoward sequelae of retinal hemangioblastoma. A thorough systemic workup is necessary to diagnose the systemic involvements early. Surgery, if indicated for the retinal hemangioblastoma or its associated sequelae, should be performed diligently and with careful handling of blood vessels and anomalous tissues.

Online Video Link:

https://youtu.be/CkoqWEnaPB8

Preferred practice patterns in aphakia management in adults in India: A survey

Purpose:

To assess different approaches in the management of aphakia in adults in Indian ophthalmologists via an online survey.

Methods:

A survey-monkey based online questionnaire was fielded to Indian ophthalmologists in accordance with the CHERRIES guidelines. We recorded participants’ demographics, practice settings, and preferred surgical options including the type of intraocular lens (IOL) preferred when encountering a case of aphakia in adults with and without adequate capsular support. Differences between anterior segment (AS) surgeons and vitreoretinal (VR) surgeons as well as differences between surgeons with more or less than 10 years of surgical experience were evaluated using analytic statistics.

Results:

Of the 481 surgeons who responded to the survey, 369 (77%) were AS surgeons and the remaining 112 (23%) were VR surgeons and represented all regions of India. When encountering posterior capsular rent during cataract surgery, a three-piece IOL in the ciliary sulcus was the most preferred (n = 275, 57%) when there was adequate capsular support, while a retrofixated iris-claw IOL (n = 91, 19%) was the commonest choice in eyes without adequate capsular support. With associated nucleus drop, 85% of surgeons preferred to refer the patient to a VR surgeon and left the eye aphakic. Multivariable logistic regression showed that VR surgeons were more than six times likely to prefer a scleral fixated intraocular lens (SFIOLs) [odds ratio (OR) = 6.5, 95% confidence interval (CI) = 3.4–12.5, P < 0.001] and surgeons with >10 years of experience were also twice more likely to prefer an SFIOL (OR = 2.4, 95% CI = 1.2–4.9, P = 0.02).

Conclusion:

The choice of IOL in absence of capsular support in adult eyes differs between AS and VR surgeons and is also influenced by the surgeon’s experience.

Genetic testing in four Indian families with suspected Stickler syndrome

Purpose:

Stickler syndrome is associated with the development of rhegmatogenous retinal detachment (RRD), and often presents with ocular, auditory, skeletal, and orofacial abnormalities. Molecular analysis has proven effective in diagnosis, confirmation and classification of the disease. We aimed to describe the utility of next-generation sequencing (NGS) in genetic analysis of four Indian families with suspected Stickler syndrome.

Methods:

The index cases presented with retinal detachment with family history. Genetic analysis in the index case was performed by next-generation sequencing of inherited retinal degeneration genes, and validated by Sanger sequencing followed by co-segregation analysis in the other family members.

Results:

Twenty patients were included for the genetic analysis (15 males and 5 females from four families). Clinical details were available for 15 patients (30 eyes). Fourteen eyes (11 patients) developed RRD. In the 16 eyes without RRD, 8 underwent barrage laser to lattice degeneration and 8 were under observation. Disease segregating heterozygous mutations with pathogenic/likely pathogenic effect was identified in COL2A1 (c.4318-1G>A, c.141G>A, c.1221+1G>A for 3 families) and COL11A1 (c.1737+1 G>A for 1 family) gene. In addition to the mutation in the COL2A1 gene, a pathogenic heterozygous variant associated with risk for arrhythmogenic right ventricular cardiomyopathy (ARVC) was identified in one member.

Conclusion:

NGS testing confirmed the presence of the causative gene for Stickler syndrome in the index case followed by evaluation of family members and confirmation of genetic and ocular findings. We believe that this may be the first such report of families with RRD from India.

Preferred practice guidelines for retinopathy of prematurity screening during the COVID-19 pandemic

Retinopathy of prematurity (ROP) is the leading cause of preventable infant blindness in the world and predominantly affects babies who are born low birth weight and premature. India has the largest number of surviving preterm births born annually. ROP blindness can be largely prevented if there is a robust screening program which detects treatment requiring disease in time. ROP treatment must be provided within 48 h of reaching this threshold of treatment making it a relative emergency. During the severe acute respiratory syndrome-coronavirus disease 2019 pandemic in 2020 ROP screening was disrupted throughout the world due to lockdowns and restriction of movement of these infants, their families, specialists and healthcare workers. The Indian ROP Society issued guidelines for ROP screening and treatment in March 2020, which was aimed at preserving the chain-of-care despite the potential limitations and hazards during the (ongoing) pandemic. This preferred practice guideline is summarized in this manuscript.

All India Ophthalmological Society (AIOS) Task Force guidelines to prevent intraocular infections and cluster outbreaks after cataract surgery

Infectious endophthalmitis is a serious and vision-threatening complication of commonly performed intraocular surgeries such as cataract surgery. The occurrence of endophthalmitis can result in severe damage to the uveal and other ocular tissues even among patients undergoing an uncomplicated surgical procedure. If the infections result from common factors such as surgical supplies, operative or operation theater-related risks, there can be a cluster outbreak of toxic anterior segment syndrome (TASS) or infectious endophthalmitis, leading to several patients having an undesirable outcome. Since prevention of intraocular infections is of paramount importance to ophthalmic surgeons, the All India Ophthalmological Society (AIOS) has taken the lead in the formation of a National Task Force to help ophthalmic surgeons apply certain universal precautions in their clinical practice. The Task Force has prepared a handy checklist and evidence-based guidelines to minimize the risk of infectious endophthalmitis following cataract surgery.

Outcomes of macular buckling with a T-shaped buckle for myopic tractional maculopathies associated with posterior staphyloma: An Indian experience

Purpose:

To report the anatomic and visual outcomes following macular buckling in patients affected by pathological myopia-associated foveoschisis (FS) and macular detachment with or without macular hole (MH).

Methods:

A retrospective interventional consecutive case series wherein 25 highly myopic eyes (mean axial length 28.46 mm; range, 25–33.8 mm) of 24 patients (16 females and 8 males; mean age 54.1 years; range, 35–74 years) presenting with macular detachment associated with a posterior staphyloma (PS), who underwent macular buckling, were evaluated. Patients with absence or reduction in subretinal fluid by more than 90% during the final follow-up along with inversion of contour of staphyloma were considered to have a successful anatomical outcome and those with improvement or maintenance in visual acuity were considered to have a successful functional outcome. The mean duration of follow-up was 11.2 months.

Results:

At the time of initial presentation, the mean age of the 24 patients was 54.1 ± 10.28 years. Macular detachment along with FS was present in all cases, whereas full-thickness macular hole-related retinal detachment was present in nine cases. Swept-source optical coherence tomography parameters showed reduction of FS with foveal reattachment in all eyes except one at last visit. Mean axial length decreased from 28.5 mm preoperatively (range 26–33.8 mm) to 26.2 mm (range 24–29.3 mm). The mean best-corrected visual acuity changed from 1.16 log MAR to 1.096 Log MAR (P = 0.165). Visual acuity improved in 10 eyes (40%), remained stable in 11 eyes (44%) and decreased in 4 eyes (16%).

Conclusion:

Macular buckling is a good surgical technique with encouraging anatomic and visual outcomes in patients with myopic macular detachment associated with PS. Highly selective cases of myopic traction maculopathy can have a viable option of macular buckle surgery in stabilizing the retinal tractional changes, and thereby, vision loss.

A Delphi method based consensus statement for surgical management of proliferative diabetic retinopathy in India

Purpose

To derive consensus statements for surgical management of proliferative diabetic retinopathy (PDR) for vitreoretinal (VR) surgeons.

Methods

Thirteen prolific VR surgeons representing all regions of India were invited to participate in a 42-point questionnaire based on the Delphi methodology describing various surgical scenarios commonly encountered in PDR. Consensus was derived using predefined robust analytics. Scenarios that returned a moderate consensus in round 1 were taken to round 2 as per the Delphi methodology. After considering all inputs, the final consensus criteria were developed.

Results

A strong consensus was derived about waiting for 4 weeks before considering vitrectomy. In treatment-naïve eyes with fresh vitreous hemorrhage (VH), the wait time was slightly shorter for extramacular tractional retinal detachment (2-4 weeks) and longer (4-6 weeks) for eyes treated previously with laser or anti-VEGF agents. The expert panel recommended using preoperative anti-VEGF only in eyes with large membranes requiring extensive dissection. For post vitrectomy VH, while a conservative approach was recommended for the first episode of VH, experts recommended immediate vitreous lavage for recurrent episodes of VH. In eyes with iris neovascularization, the panel recommended immediate anti-VEGF injection followed by early vitreous lavage in nonresponsive eyes. A strong consensus was derived for stopping antiplatelet agents before surgery, while there was only a moderate consensus for performing vitrectomy for recalcitrant macular edema unresponsive to anti-VEGF injections in the absence of traction.

Conclusion

This study provides valuable consensus on managing the different scenarios encountered during surgical management of PDR and should help guide the VR surgeons in clinical decision-making.

Outcomes of vitreoretinal surgery in retinal detachment associated with morning glory disc anomaly

Purpose:

Morning glory disc anomaly (MGDA) is associated with a high prevalence of retinal detachment (RD), sometimes requiring multiple surgeries. The study aimed to establish the outcomes of RD surgery in such eyes and predict factors influencing the outcome, if any.

Methods:

It was a retrospective observational study of 9 eyes that underwent pars plana vitrectomy (PPV) for RD associated with MGDA. Clinical and surgical details were correlated with outcomes of surgery as noted at the final follow-up.

Results:

PPV was performed in 9 eyes. Lensectomy was done in 5 of 9 eyes (55.5%) during PPV. Laser photocoagulation around the disc was performed in 55.5% (5/9) of the eyes. Silicone oil tamponade was used in 77.7% (7/9) of eyes and gas tamponade (14% C3F8) was used in 22.3% (2/9) of eyes. Attached retina at final visit was observed in 66% of the eyes (6/9). Two out of 3 eyes that were seen to have preoperative glial tissue at the disc had poor outcome (odds ratio 10, P = 0.16). Five out of 7 (71%) eyes that had silicone oil tamponade, had an attached retina. No identifiable breaks were noted preoperatively in 5 eyes, of which 4 (80%) had an attached retina postoperatively. Vision improved by 1 line in 67% of the eyes that underwent surgery.

Conclusion:

MGDA related RD presents a unique set of challenges; meticulous PPV with or without lensectomy can help in achieving a successful anatomical and functional outcome in about two-thirds of patients.

Surgical Management of Advanced Coats Disease in 32 Eyes: A 20-Year Study

Purpose:

This work studies outcomes of external subretinal fluid (SRF) drainage in management of eyes with advanced Coats disease.

Methods:

Patients with advanced-stage Coats disease (≥stage 3B), who were younger than 12 years and underwent external SRF drainage from 1996 to 2016, were included in this retrospective study. Surgical intervention involved external drainage of SRF and cryotherapy. SRF drainage was performed by lamellar scleral dissection or by external needle drainage. Favorable anatomical outcome was defined as retinal reattachment with normal intraocular pressure (IOP). IOP greater than 24 mm Hg was considered raised. Univariate and multivariate analyses were performed to measure the association between preoperative or intraoperative factors and retinal status at final follow-up. Outcome measures evaluated included visual acuity, IOP, retinal status, globe status, and complications of surgery. Kaplan-Meier analysis was performed for globe salvage without pain.

Results:

Thirty-two eyes of 32 patients were included in the study. Mean age at surgery was 3.8 ± 3 years. The mean duration of follow-up was 7 years (range, 6 months-15.7 years). Improvement in visual acuity was seen in 5 eyes. Retina was attached at final visit in 6 eyes. IOP in the range of 8 to 24 mm Hg was noted in 16 eyes. Favorable anatomical outcome was achieved in 3 (9%) eyes. Globe salvage was achieved in 84% of eyes. Complications included intraoperative vitreous hemorrhage (n = 1) and postoperative inflammation (n = 1). Kaplan-Meier ocular survival rate without pain at 10 years was 76%.

Conclusions:

SRF drainage and cryotherapy in eyes with advanced Coats disease favorably alter the natural history of the disease and prevent end-stage complications. Visual outcomes remain poor.

Evolving consensus on managing vitreo-retina and uvea practice in post-COVID-19 pandemic era

The COVID-19 pandemic has brought new challenges to the health care community. Many of the super-speciality practices are planning to re-open after the lockdown is lifted. However there is lot of apprehension in everyone's mind about conforming practices that would safeguard the patients, ophthalmologists, healthcare workers as well as taking adequate care of the equipment to minimize the damage. The aim of this article is to develop preferred practice patterns, by developing a consensus amongst the lead experts, that would help the institutes as well as individual vitreo-retina and uveitis experts to restart their practices with confidence. As the situation remains volatile, we would like to mention that these suggestions are evolving and likely to change as our understanding and experience gets better. Further, the suggestions are for routine patients as COVID-19 positive patients may be managed in designated hospitals as per local protocols. Also these suggestions have to be implemented keeping in compliance with local rules and regulations.

Retinopathy of prematurity treatment: Asian perspectives

Retinopathy of prematurity (ROP) is a vasoproliferative disease of developing retinal vessels that affects premature infants and can lead to severe and irreversible visual loss if left untreated. India and some other Asian countries are in the middle of a 'third ROP epidemic'. Blindness due to ROP is largely preventable if appropriate, adequate and accessible screening programmes are available. Screening of the premature babies is the first step in ROP management. With the increase in use of tele-screening techniques, more premature babies have been brought under the screening network both from urban and rural regions. Laser photocoagulation to the avascular retina using indirect ophthalmoscopy delivery system is the gold standard for ROP treatment and is usually done under topical anaesthesia in the Asian region in contrast to the western world. Use of intravitreal anti-vascular endothelial growth factors (VEGF) although controversial in management of ROP has been found to be effective in various Asian studies as well. ROP surgery in India and other middle-income Asian countries is largely performed only in few tertiary eye care centres. Poor visual prognosis, late presentation with advanced retinal detachments, lack of adequate number of trained paediatric retinal surgeons and paediatric anaesthetists also contribute to this problem. This current paper summarizes the Asian experience of ROP management.

Treatment outcomes of zone 1 retinopathy of prematurity: A study from a tertiary eye care center in South India

PURPOSE:

The main purpose is to study the treatment outcomes of zone 1 retinopathy of prematurity (ROP).

MATERIALS AND METHODS:

A retrospective analysis was done of infants diagnosed with zone 1 ROP with any stage with or without plus disease who were treated with either laser photocoagulation and/or intravitreal injection of antivascular endothelial growth factor (anti-VEGF) agents and/or underwent surgery according to their stage at presentation. The retinal outcome at the final visit was analyzed. A favorable outcome was characterized by an attached retina at the posterior pole with regression of ROP (regression of plus disease as well as new vessels) while an unfavorable outcome was detached retina at posterior pole in spite of treatment.

RESULTS:

Seventy-eight eyes of 39 infants presented with zone 1 ROP in various stages with plus disease in 50% cases. About 60 eyes underwent treatment. Forty eyes (66.6%) had an attached retina at the final follow-up. Thirty-three eyes (55%) underwent monotherapy with 14 eyes (23.3%) showing regression of ROP with laser alone. Nineteen (31.6%) eyes were treated only by surgery. Of these, a favorable outcome was seen in four eyes (44.4%) with Stage 4 disease and three eyes (30%) with Stage 5 disease. None of the eyes received anti-VEGF as monotherapy. A combination of two or more modalities was required in the remaining 27 eyes (45%). Six eyes (10%) needed anti-VEGF injections in addition to laser and six eyes needed surgery in addition to laser to achieve a favorable outcome. Six eyes (10%) required surgery in addition to both laser and anti-VEGF therapy, and one eye (1.6%) required surgery in addition to anti-VEGF therapy for a favorable final outcome. Among the eyes undergoing treatment, 66.6% had a favorable outcome with 92.9% of eyes in Stage 3, 59% in Stage 4, and 33% in Stage 5 showing regression of disease and attached retina.

CONCLUSION:

In spite of the aggressive nature of zone 1 ROP, favorable outcome is possible as was seen in 66.6% of our cases. A multipronged approach using a combination of laser, intravitreal anti-VEGF agents with or without surgery may be necessary for the management of these eyes.

Outcomes of surgery in eyes with familial exudative vitreoretinopathyassociated retinal detachment

OBJECTIVE

The aim of this study was to evaluate various techniques of surgical treatment of retinal detachment associated with familial exudative vitreoretinopathy (FEVR) and the factors affecting the anatomical and visual outcome.

DESIGN

Retrospective case series.

PARTICIPANTS

Patients diagnosed with FEVR associated retinal detachment and operated for the same between January 2004 and September 2017.

METHODS

A retrospective chart review was conducted of all patients diagnosed with FEVR between January 2004 and September 2017. Patients with rhegmatogenous retinal detachment (RRD) and tractional retinal detachment (TRD) were included for analysis. Statistical analysis was performed using the t test for mean visual acuities, Fisher's exact test for categorical data, and the one-way analysis of variance for visual outcomes among surgical management options.

RESULTS

A total of 44 eyes of 38 patients diagnosed with FEVR-associated retinal detachment and operated for the same were evaluated. At the time of initial presentation, the mean age of the 38 patients was 14.6 ± 10.9 years and 57.8% were males. Out of 44 eyes that underwent surgical intervention, 79.5% cases were of RRD (n = 35), and TRD was seen in 20.5% cases (n = 9). Primary management in the form of scleral buckle was done in 14 (31.8%) eyes, with 11 eyes (78.6%) having an attached retina after a single surgery and 85.7% after multiple surgeries. Primary pars plana vitrectomy (PPV) was done in 30 (68.2%) eyes, of which 73.3% had attached retina after single surgery and 83.8% after multiple surgeries. Poor pre-operative best-corrected visual acuity, presence of TRD, and presence of falciform folds were associated with poor anatomical outcome.

CONCLUSIONS

Favourable outcomes can be achieved, though multiple surgical interventions may, however, be necessary for the ultimate success in some cases.

Endogenous endophthalmitis in children and adolescents: Case series and literature review

Purpose:

To study the clinical and microbiological profile, treatment modalities, and anatomical and functional outcomes among children and adolescents with endogenous endophthalmitis (EE) at a tertiary eye care centre in India.

Methods:

Medical records of subjects <18 years, presenting with EE from 1997 to 2007 were reviewed. Cases where the causative organism was identified were included. Treatment regimen included systemic antibiotics, vitrectomy, intravitreal antibiotics, and enucleation. Systemic evaluation to identify the source of infection was done by an internist. Microbiological analysis of blood, urine, and ocular specimens was done. The favorable anatomical outcome was defined as the attached retina, with controlled intraocular pressure and clear media at the last follow up. The favorable functional outcome was defined as vision >3/60 on the final follow up. Univariate regression analysis was done to identify factors predicting functional outcome.

Results:

Thirty eyes of 30 subjects (23 (77%) males) were studied. The mean age at presentation was 6.8 years (range=1–16 years). Fever was evident in four (13%) and blood culture was negative in all cases. Gram-positive organisms were identified in 11 (37%) eyes, fungi in 3 (10%), and toxocara in 8 (27%) eyes. Twenty-three (77%) eyes underwent vitrectomy. Favorable functional and anatomical outcomes were achieved in 9 (30%) and 12 (40%) eyes, respectively. Eyes undergoing vitrectomy showed significant correlation with good functional outcome (P = 0.05).

Conclusion:

EE is under-reported and not well studied in children. The absence of systemic features may be evident in a developing country with over the counter availability of antibiotics. Gram-positive infections are common and vitrectomy is a beneficial modality of treatment.

Surgical outcomes of vitreoretinal surgery for rhegmatogenous retinal detachment in eyes with regressed retinopathy of prematurity

Purpose:

To report the anatomical and functional outcomes of vitreoretinal surgery in eyes with “regressed ROP” presenting with rhegmatogenous retinal detachment (RRD).

Methods:

In this retrospective interventional case series, twenty-two eyes (of 22 patients) with regressed ROP, who underwent surgery for RD. Primary outcome measures were final anatomical and visual outcome for scleral buckling and pars plana vitrectomy (PPV). Visual outcomes were categorized into three groups: improved, remained stable, and deteriorated. Univariate binary logistic regression analysis was used to determine the risk factors for RD.

Results:

Of 22 eyes in the study, overall anatomic success was achieved in 16 of 22 eyes (72.7%). The macula was attached in 17 of 22 eyes (77.3%) at final visit. In the scleral buckle (SB) group, overall anatomical success was achieved in six of seven eyes (85.7%). Overall, in the PPV group, anatomical success was seen in 10 of 15 eyes (66.7%) at final visit. At final follow-up, significant improvement in best-corrected visual acuity from baseline was seen in 11 cases (50%, P = 0.02), stable in 5 cases (22.7%), and significant visual deterioration was seen in 6 cases (27.3%, P = 0.02). The total mean follow-up duration of the patients was 45.5 months (range: 2.1 months to 11.2 years).

Conclusion:

Early recognition and surgical intervention in such cases can lead to a high rate of anatomical success and can prevent the development of profound visual impairment in some patients.

To remove the buckle or watch?

Scleral buckling is one of the most effective modality for treatment of rhegmatogenous retinal detachment and in selected cases of retinopathy of prematurity. Although quite safe, it has its own set of associated morbidities. This report presents an interesting case, where the scleral buckle migrated posteriorly reaching up to the optic nerve.

Surgical outcomes of microincision vitrectomy surgery in eyes with retinal detachment secondary to retinopathy of prematurity in Indian population

Purpose:

To analyze and report outcomes of microincision vitrectomy surgery (MIVS) for Stage 4 and 5 retinopathy of prematurity (ROP).

Methods:

Medical records of 202 eyes of 129 premature children undergoing MIVS for Stage 4/Stage 5 ROP between January 2012 and April 2015 were evaluated. The primary outcome measure was the proportion of eyes with anatomical success (defined as attached retina at the posterior pole at last follow-up). Complications associated with MIVS were noted and analysis of risk factors associated with poor anatomical outcome was also done using logistic regression.

Results:

Mean age of presentation of babies with Stage 4 ROP (2.9 ± 1.75 months) was lower than those with stage 5 disease (5.62 ± 2.55 months) (P < 0.005). One hundred seventeen eyes (56% or 58%) had Stage 5, 38 (19%) had Stage 4a, and 47 (23%) Stage 4b. Ninety-four eyes (47%) had received prior treatment (laser and/or anti-vascular endothelial growth factors [VEGF]). Lens-sparing vitrectomy (LSV) was performed in 58 (29%) eyes while lensectomy with vitrectomy (LV) was performed in 144 (71%) eyes. At a mean follow-up of 32.5 weeks, 102 (50.5%) eyes achieved anatomical success, including 74% eyes in Stage 4a and 4b and 33% in Stage 5. Complications included intraoperative break formation (19%), postoperative vitreous hemorrhage (28%), raised intraocular pressure (12.7%), and cataract progression (2.4%). Factors significantly associated with favorable anatomical outcome were Stage 4 disease (vs. Stage 5) (odds ratio [OR] 5.8; confidence interval [CI] =2.6–13.8, P < 0.005), prior treatment (laser ± anti-VEGF) (OR 2.5; CI 1.4–4.7, P < 0.005) surgery with 25G MIVS (vs. 23G) (OR: 1.7; CI = 0.98–3.00, P = 0.05) and LSV (vs. LV) (OR 7; CI = 3.4–14.6, P < 0.005). Retinal break was significantly associated with poor anatomical outcome (OR 0.21; CI = 0.09–0.5, P < 0.005).

Conclusion:

MIVS along with wide angle viewing systems allow surgeons to effectively manage ROP surgeries while at the same time reducing complication rate in these eyes which have complex pathoanatomy and otherwise grim prognosis.

Risk factors and outcomes of management of delayed suprachoroidal haemorrhage following Ahmed glaucoma valve implantation in children

Aims

To assess the incidence, risk factors and outcomes of management of delayed suprachoroidal haemorrhage (DSCH) in children who had undergone Ahmed glaucoma valve implantation.

Methods

A retrospective case-control study of eyes which developed DSCH in children <18 years of age who underwent surgery between January 2009 and December 2017 with a follow-up of at least 2 months was performed. Nine cases were compared with 27 age, gender and surgeon matched controls who had undergone surgery during this period.

Results

The incidence of DSCH was 4.7% (95% CL 1.5% to 7.7%, 9 eyes of 191 children). There were no significant differences between cases and controls in baseline details except for the number of intraocular pressure (IOP) lowering medications (p=0.01) and follow-up period (p=0.001). Risk factors identified on univariate analysis (p≤0.1) were axial length (p=0.02), diagnosis of primary congenital glaucoma (p=0.05), postoperative hypotony (p=0.07) and aphakia (p=0.1). None of them were found to be significant on multivariate analysis. Five eyes, three with retinal apposition and two with retinal detachment, underwent surgical drainage. There were no significant differences in the outcomes of eyes which underwent drainage compared with those which did not. Failures, defined as IOP>18 mm Hg despite use of medications, loss of light perception, phthisis or removal of the implant were more frequent in cases (three eyes, 33.3%) compared with controls (four eyes, 14.8%) (p=0.002).

Conclusions

None of the risk factors analysed in our series proved to be significant. Failures were more common in eyes with choroidal haemorrhage, despite surgical intervention.

Outcome of vitreoretinal surgery for rhegmatogenous retinal detachment in X-linked juvenile retinoschisis

Purpose

Rhegmatogenous retinal detachment (RRD) is a vision-threatening complication of X-linked juvenile retinoschisis (XLRS). The aim of this study is to report the anatomical and functional outcomes of vitreoretinal surgery for the treatment of RRD in X-linked juvenile retinoschisis (XLRS).

Methods

This is a retrospective, interventional, consecutive case series in which case records of 34 eyes of 28 XLRS patients, who underwent surgery for RRD, were reviewed. Statistical analysis used is as follows: visual outcomes were categorized into three groups: improved, remained stable or deteriorated. Wilcoxon signed-rank test was used to determine the difference in visual acuity at baseline and at final visit. Univariate binary logistic regression analysis was used to determine the risk factors for retinal detachment. Any P value < 0.05 was considered as statistical significant.

Results

Mean age of the boys at presentation was 9.2 ± 3.5 years. Indication for surgery was RRD in all eyes. Concurrent vitreous haemorrhage was present in four eyes (11.8%). The primary surgical intervention was scleral buckle in 12 eyes and pars plana vitrectomy in 22 eyes. Persistence of subretinal fluid/redetachment was seen in 15 eyes of which 11 eyes underwent additional surgeries. At final follow up, 27 eyes (79.4%) were noted to have an attached retina. Of the total eyes, in 20, 6 and 8 eyes the visual acuity improved, stabilized and deteriorated, respectively.

Conclusion

Favourable outcomes are seen in a majority of eyes after vitreoretinal surgery for RRD in XLRS; however, multiple surgical interventions may be necessary.

Outcomes of rhegmatogenous retinal detachment surgery in eyes with pre-existing glaucoma drainage devices

Purpose:

To evaluate the outcome of rhegmatogenous retinal detachment (RRD) surgery in eyes with preplaced glaucoma drainage device (GDD) with respect to intraocular pressure (IOP) control as well as success of retinal detachment (RD) surgery.

Methods:

It is a retrospective case series. The case records of patients who underwent RD surgery after GDD implantation from 2000 to 2014 were screened. The demographic data, ocular examination findings at all visits, details pertaining to retinal detachment and its repair, and the postoperative course was documented.

Results:

Twelve patients were included in study. The mean age of patients was 24.3 years (median 11 years; range 3-72 years). Male: Female ratio was 3:1. Mean duration between GDD and RD was 24 months (4 days-91 months). Of the ten eyes that underwent surgery, nine eyes underwent pars plana vitrectomy, and in one eye scleral buckling was done. GDD was removed only in one eye. At final follow-up, retina was attached with controlled IOP in 6 (60%) eyes, of which 5 (50%) had improvement in best corrected visual acuity.

Conclusion:

Pars plana vitrectomy was required in almost all cases for the management of RD in eyes with preplaced GDD. Retinal reattachment with good IOP control could be achieved in 60% of eyes. Removal of the drainage device was not essential for the effective management of the RRD in most cases. With multidisciplinary approach, close follow-up and timely intervention, vision can be preserved along with glaucoma control and successful retinal reattachment.

Outcome of Sutured Scleral-Fixated Intraocular Lens in Blunt and Penetrating Trauma in Children

BACKGROUND AND OBJECTIVE

To determine the anatomical and functional outcomes of sutured scleral-fixated intraocular lens (SSFIOL) implantation in children with blunt and penetrating injuries to the eye.

PATIENTS AND METHODS

This is a retrospective, interventional case series study. Case records of children who underwent SSFIOL implantation in a tertiary eye care facility for traumatic aphakia, cataract, or subluxation were screened. Relevant data on demographics, visual acuity (VA) outcomes, and complications and their management were collected. Results for blunt and penetrating trauma were compared.

RESULTS

There was stability or improvement of vision in 88.9% of eyes during the follow-up period. Young age at time of trauma (P = .031) and SSFIOL implantation (P = .002), history of retinal detachment (RD) before SSFIOL implantation (P = .019), poor preoperative best-corrected VA (BCVA) (P = .004), and development of RD in the follow-up period (P = .046) were independent risk factors for low final BCVA on univariate regression analysis. RD rate was 6.53% and was comparable in open and closed globe injuries. Intraocular lens (IOL) dislocation rate was 3.9%, and probability of survival was higher for open globe (0.78) as compared to closed globe (0.64) injuries (P = .042).

CONCLUSIONS

SSFIOL implantation results in good VA improvement in both open and closed globe injuries. RD remains an important vision-threatening complication. IOL dislocation is more likely to occur in closed globe injuries. A prospective study evaluating the outcomes would better elucidate the role of these IOLs. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:757-764.].

Stage 5 retinopathy of prematurity: An update

Retinopathy of prematurity (ROP) is one of the most common causes of preventable blindness in children. In spite of the availability of various treatment options, and favorable results with timely intervention, many infants present to the ophthalmologists in the advanced end stage of the disease due to lack of awareness especially in the developing nations. This blinding or Stage 5 of ROP presents with total retinal detachment and has to be managed surgically. The surgical techniques for Stage 5 ROP are unique and demanding. The successful anatomical results after surgery are only seen in 20%–50% of cases. In spite of a successful anatomical result, the visual outcome may be slow and limited. The use of newer pharmacological adjuncts has shown promising results. Because of heterogeneity of presentation of the disease severity, a genetic predisposition has also been proposed. A concerted effort from the pediatricians, ophthalmologists, and healthcare workers is required to establish effective screening and treatment guidelines to prevent blindness due to ROP. Till then surgical management has to be done. Parents must be educated regarding the limited visual benefits of surgery and the need for prolonged follow-up. This review gives a comprehensive overview of the pathogenesis, clinical aspects, surgical interventions, and their outcomes and future prospects of Stage 5 ROP.

Incidence, outcomes, and risk factors for hemorrhagic complications in eyes with polypoidal choroidal vasculopathy following photodynamic therapy in Indian subjects

PURPOSE

To evaluate the incidence, outcomes, and risk factors for hemorrhagic complications in eyes with polypoidal choroidal vasculopathy (PCV) following photodynamic therapy (PDT).

METHODS

Medical records of 94 eyes of 86 consecutive patients with PCV who underwent PDT between January 2007 and December 2014 were retrospectively reviewed. The diagnosis of PCV was based on clinical features and indocyanine green angiography. Eyes were treated with PDT monotherapy or a combination of PDT plus anti-vascular endothelial growth factor. PDT was performed at (standard [SFPDT] or reduced fluence RFPDT).

RESULTS

Ninety-four eyes had 119 PDT treatment sessions (mean: 1.3 sessions). Mean presenting vision was 0.46 ± 0.44 logarithm of the minimum angle of resolution (logMAR). Following PDT, ten eyes (11%) of nine patients had hemorrhagic complications such as subretinal hemorrhage (SRH; n = 5), subretinal pigment epithelium (RPE) hemorrhage (n = 1), breakthrough vitreous hemorrhage (BVH; n = 3), and SRH with sub-RPE hemorrhage and BVH (n = 1). Median interval to hemorrhage following PDT was 2 months. Age (P = 0.842), duration of symptoms (P = 0.352), number of laser spots (P = 0.219), and laser spot size (LSS) (P = 0.096) were not significantly associated with increased risk of hemorrhagic complications. Female gender was associated with reduced risk of hemorrhage (P = 0.045). SFPDT was significantly associated with increased risk of hemorrhage (P = 0.026). The probability of developing hemorrhagic complications in SFPDT group was 0.24 compared to 0.07 in RFPDT group (P = 0.039). Multivariate logistic regression analysis showed SFPDT as the only significant risk factor for hemorrhage following PDT (odds ratio 5.3, 95% confidence interval 1.1-24.8, P = 0.03). Mean final vision was 0.61 ± 0.53 logMAR at mean follow-up of 33 months (median = 22 months; range = 2-157 months).

CONCLUSION

Age, LSS, number of laser spots, preexisting hemorrhages, or use of anticoagulants were not associated with increased risk of hemorrhagic complications. SFPDT was significantly associated with increased risk of hemorrhagic complications in such eyes.

Enterococcus faecalis Endophthalmitis in Children - A 21 Year Study

PURPOSE

To report Enterococcus faecalis endophthalmitis (EFE) in children and its comparison with adults.

METHODS

Retrospective study of 19 children up to 18 years age, undergoing vitrectomy for EFE at a referral eye center from January 1995 to December 2015. The results were compared to 18 adults with EFE.

RESULTS

The mean age was 7.4 ± 3.06 years. Post-traumatic EFE was seen in 17 (89.4%) children (p < 0.05) versus postoperative EFE seen in 12 (66%) adults. Broomstick 9 (52.9%) and hypodermic needle injury 6 (35.2%) were common associations. "Optimum functional outcome" was achieved in 12 (63.1%) eyes of children and 5 (27.7%) eyes of adults (p = 0.03). Sealed and Zone II wounds, lens, and needle injuries had good outcome whereas intervention after 3 days and retinal detachment had poor outcomes (p < 0.05). The was no correlation with the Ocular Trauma Score.

CONCLUSION

EFE in children is rare; seen with broom stick and needle injuries, if managed early recovers optimum vision.

Influence of laser versus lens-sparing vitrectomy on myopia in children with retinopathy of prematurity

Purpose:

The purpose of this study is to compare the refractive error outcomes in the eyes of premature babies with retinopathy of prematurity (ROP) who underwent laser plus lens-sparing vitrectomy (LSV) in one eye and laser alone in the fellow eye.

Methods:

This is a retrospective study. Fourteen babies with Stage 4A of ROP or worse who underwent laser plus LSV in one eye (Group 1) and laser alone in the fellow eye (Group 2) were followed at 2 months, 6 months, 1 year, one and a half year, and 2 years. The main outcome variable studied was cycloplegic refraction at the baseline and follow-up visits. The change in spherical and cylindrical power at each visit was compared in Groups 1 and 2. The changes in spherical equivalent in subgroups were analyzed.

Results:

Mean gestational age at birth was 29.43 ± 2.10 weeks (range 26–32 weeks). Mean chronological age at the time of surgery was 4.11 ± 3.00 months (range 2–10 months). Mean postmenstrual age was 45.86 ± 12.13 weeks (range 39–75 weeks). Mean birth weight was 1340.71 ± 361.59 g (range 860–1980 g). All the babies in both groups had progressive myopia till 2 years follow-up; laser group had less myopia than LSV group till 1 year, thereafter, there was no difference in median till 2-year follow-up. The mean ± standard deviation of spherical equivalent in LSV versus laser group was: −4.36 ± 5.52 versus −3.21 ± 4.59 at 2 months; −5.09 ± 5.82 versus −4.04 ± 4.68 at 6 months; −7.14 ± 5.36 versus −5.36 ± 5.09 at 1 year; and −7.47 ± 1.38 versus −6.41 ± 1.91 at 2 years. Spherical equivalent difference across the visits did not differ significantly between Groups 1 and Group 2 in children whose birth weight was <1500 g (P = 0.247) and those who had more than 1500 g (P = 0.748), in those with gestational age between 20 and 30 weeks (P = 0.215) compared to those >30 weeks (P = 0.602).

Conclusion:

No difference in the progression of myopia was noted in eyes that underwent additional LSV following laser photocoagulation in one eye and laser alone in the fellow eye.

Aflibercept for recurrent or recalcitrant polypoidal choroidal vasculopathy in Indian eyes: Early experience

Treatment guidelines for symptomatic polypoidal choroidal vasculopathy (PCV) have been described, but the management of recurrent or recalcitrant PCV is a challenge. The newer anti-vascular endothelial growth factor: aflibercept has shown promise in the treatment of both treatment naive and recalcitrant PCV in studies outside India. We present the minimum 6 months results of intravitreal aflibercept in recurrent and recalcitrant PCV in Indian eyes after multiple injections of bevacizumab/ranibizumab with or without photodynamic therapy. Of 10 eyes, 7 resolved of which 4 recurred needing continued aflibercept. Three of the ten eyes did not show a response. To the best of our knowledge, this is the first report from India in this challenging situation.

Proteomic profiling of human intraschisis cavity fluid

Background

X-linked retinoschisis (XLRS) is a vitreoretinal degenerative disorder causing vision deterioration, due to structural defects in retina. The hallmark of this disease includes radial streaks arising from the fovea and splitting of inner retinal layers (schisis). Although these retinal changes are attributed to mutations in the retinoschisin gene, schisis is also observed in patients who do not carry mutations. In addition, the origin of intraschisis fluid, the triggering point of schisis formation and its progression are largely unknown still. So far, there is no report on the complete proteomic analysis of this fluid. Schisis fluid proteome could reflect biochemical changes in the disease condition, helping in better understanding and management of retinoschisis. Therefore it was of interest to investigate the intraschisis fluid proteome using high-resolution mass spectrometry.

Methods

Two male XLRS patients (aged 4 and 40 years) underwent clinical and genetic evaluation followed by surgical extraction of intraschisis fluids. The two fluid samples were resolved on a SDS-PAGE and the processed peptides were analyzed by Q-Exactive plus hybrid quadrupole-Orbitrap mass spectrometry. Functional annotation of the identified proteins was performed using Ingenuity pathway analysis software.

Results

Mass spectrometry analysis detected 770 nonredundant proteins in the intraschisis fluid. Retinol dehydrogenase 14 was found to be abundant in the schisis fluid. Gene ontology based analysis indicated that 19% of the intraschisis fluid proteins were localized to the extracellular matrix and 15% of the proteins were involved in signal transduction. Functional annotation identified three primary canonical pathways to be associated with the schisis fluid proteome viz., LXR/RXR activation, complement system and acute phase response signalling, which are involved in immune and inflammatory responses. Collectively, our results show that intraschisis fluid comprises specific inflammatory proteins which highly reflect the disease environment.

Conclusion

Based on our study, it is suggested that inflammation might play a key role in the pathogenesis of XLRS. To our knowledge, this is the first report describing the complete proteome of intraschisis fluid, which could serve as a template for future research and facilitate the development of therapeutic modalities for XLRS.

Electronic supplementary material

The online version of this article (doi:10.1186/s12014-017-9148-y) contains supplementary material, which is available to authorized users.

Culture and Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) Proven Mycobacterium Tuberculosis Endophthalmitis: A Case Series

PURPOSE

To report early confirmation of Mycobacterium tuberculosis (MTB) endophthalmitis by detection of 85B mRNA in vitreous by a reverse transcriptase polymerase chain reaction (RT-PCR) technique.

METHODS

Retrospective, interventional case series of 5 patients with MTB endogenous endophthalmitis. Vitreous aspirate was subjected to Ziehl-Neelsen (ZN) staining, BACTEC MicroMGIT culture, RT-PCR targeting the 85B gene, real-time PCR targeting the IS6110 region, and nested PCR targeting the MPB64 gene and IS6110 region. Correlation between detection of MTB RNA, culture positivity, and ZN staining was studied.

RESULTS

Five patients with endophthalmitis with no history of tuberculosis revealed acid-fast bacilli on ZN staining of vitreous. RT-PCR detected 85B RNA within 24 h. Culture for MTB was positive in 3/5 patients after 1 month. None of the eyes recovered any useful vision.

CONCLUSIONS

RT-PCR can detect viable MTB RNA and provide evidence of active infection much earlier than culture.

Indications and outcomes of scleral buckle removal in a tertiary eye care center in South India

Purpose:

To study the clinical profile of patients undergoing scleral buckle removal (SBR) surgery.

Materials and Methods:

All consecutive patients undergoing SBR surgery following scleral buckle for retinal detachment repair between January 2002 and December 2011 with a minimum postSBR follow-up of 6 months were included in this study. A record based on analysis of indications, methods, complications, and outcomes of the eyes was performed.

Results:

One hundred and two eyes of 101 patients (men = 77; 76.24% and women = 24; 23.76%) belonging to the age group of 15–78 years (mean 50 ± 15 years) were included in this study. Time gap between scleral buckle and SBR ranged from 2 to 216 months (mean 61 ± 51 months). Buckle exposure with clinical infection (81; 79.41%) was the most common indication. Of 90 (88.2%) eyes with positive culture, 75 (83.3%) revealed single and 15 (16.6%) revealed multiple microorganisms. Staphylococcus epidermidis (42; 41.2%), was the most common isolate. Fungus was isolated in 3 (2.94%) eyes. Globe perforation (14; 13.7%) and recurrent retinal detachment (7; 6.9%) were the commonest complications. Time gap between SBR and recurrent retinal detachment ranged from 15 days to 50 months (mean 12.2 ± 18.3 months).

Conclusions:

Most of the exposed scleral buckles developed clinical infection few months to years after surgery, ultimately requiring SBR. Recurrent retinal detachment after SBR may appear from few days to years later warranting a long-term follow-up.

Comparison of photodynamic therapy, ranibizumab/bevacizumab or combination in the treatment of myopic choroidal neovascularisation: a 9-year-study from a single centre

AIM

To compare treatment outcomes for myopic choroidal neovascularisation (CNV) managed with verteporfin photodynamic therapy (vPDT), intravitreal antivascular endothelial growth factor (anti-VEGF, bevacizumab/ranibizumab) agents or combination thereof.

METHODS

Clinical data of 79 eyes with myopic CNV examined from March 2004 to July 2013 was retrospectively reviewed. Patients were managed with vPDT, intravitreal bevacizumab (1.25 mg/0.05 mL)/ranibizumab (0.5 mg/0.05 mL) or a combination of vPDT and anti-VEGF. Outcome measures included complete regression (scarring) of CNV and best-corrected visual acuity (BCVA).

RESULTS

Treatments provided were vPDT (n=23), anti-VEGF (n=25) (ranibizumab, n=12; bevacizumab, n=13), vPDT+anti-VEGF (n=31). Mean logMAR BCVA changed from 0.59±0.44 to 0.49±0.40 at mean follow-up of 54.63±39.46 months. Mean logMAR vision changed from 0.68±0.57, 0.54±0.48 and 0.59±0.39 at presentation to 0.59±0.53, 0.38±0.44 and 0.37±0.37 at last follow-up in PDT (p=0.4), anti-VEGF (p=0.1) and vPDT+anti-VEGF groups (p=0.0002), respectively. CNV was scarred in 64 eyes (81%) at mean 11.03±13.56 months. Most common complication was macular scar (n=64), associated with reduced (n=17) or preserved (n=47) vision. Chorioretinal atrophy attributable to vPDT was seen in five eyes (vPDT, n=3; vPDT+anti-VEGF, n=2).

CONCLUSION

Combination of vPDT and intravitreal anti-VEGF (ranibizumab/bevacizumab) was associated with better visual outcomes and higher rates of regression in eyes with myopic CNV as compared with monotherapy with PDT or anti-VEGF. Larger size of CNV, and high refractive error were independent risk factors for poor visual outcomes.

Endogenous Endophthalmitis: A 10-Year Retrospective Study at a Tertiary Hospital in South India

PURPOSE

The aim of this study was to review the clinical profile including predisposing systemic conditions, microorganisms responsible, clinical presentation, and outcomes of endogenous endophthalmitis (EE) in South India.

DESIGN

This study is a retrospective, noncomparative case series.

METHODS

This study presents a retrospective analysis of records of patients with EE in a 10-year period.

RESULTS

A total of 61 eyes of 58 patients were included in the study. Preceding systemic illness or surgery was noted in 31 patients (53.4%). No predisposing condition was found in 27 patients (46.5%). All eyes had severe diffuse EE. Culture positivity was seen in 34 of 58 patients (58.6%). Gram-positive organisms were isolated in 9 cases (15.5%), and Gram-negative organisms were isolated in 20 cases (34.5%). Pseudomonas aeruginosa (13.8%) was the most common isolate. Eleven eyes (18%) were managed medically with intravenous and intravitreal antibiotics, and 38 eyes (62.3%) also underwent vitrectomy. Eight eyes (13.1%) required repeat vitrectomy, and 12 eyes (19.7%) were eviscerated. The mean follow-up was 16.2 ± 13.9 months. Final visual acuity of 20/200 or better was seen in 29.5% eyes. A favorable outcome was noted in culture-positive patients (P = 0.03) and in patients with no predisposing causes.

CONCLUSIONS

This study provides information about the clinical and microbiologic profile of EE. Aggressive medical and surgical treatment can result in favorable outcomes.

Brachytherapy of intra ocular tumors using 'BARC I-125 Ocu-Prosta seeds': an Indian experience

Aim:

To report our experience of brachytherapy using ‘BARC I-125 Ocu-Prosta seeds’ for the management of intraocular tumors with regard to tumor control, globe preservation visual outcome, and patient survival at Sankara Nethralaya, Chennai, India between September 2003 and May 2011.

Materials and Methods:

We reviewed records of 35 eyes of 35 patients who underwent ophthalmic brachytherapy between September 2003 and May 2011. Twenty-one cases had choroidal melanoma, nine had childhood retinoblastoma, two had adult-onset retinoblastoma, and there were one case each of vasoproliferative tumor, retinal angioma, and ciliary body melanoma. Brachytherapy was administered using a 15- or 20-mm gold plaque with or without a notch. Brachytherapy was the primary treatment modality in all tumors other than retinoblastoma, wherein brachytherapy was done post chemoreduction for residual tumor.

Results:

For choroidal melanomas, the mean radiation dose was 68.69 ± 15.07 (range, 47.72-94.2) Gy. The eye salvage rate was 13/20 (65%) and tumor control rate was 16/20 (80%) at an average follow-up of 24.43 ± 24.75 (range, 1.5-87.98) months. For retinoblastoma, the mean dose was 45.85 ± 3.90 (range, 39.51-50.92) Gy. The eye salvage rate and tumor control rate was 5/6 (83.3%) at an average follow-up of 38.36 ± 31.33 (range, 4.14-97.78) months. All eyes with retinoblastoma needed additional focal therapy for tumor control and eye salvage.

Conclusion:

The results of this retrospective study confirms that the use of ‘BARC I-125 Ocu-Prosta seeds’ in episcleral plaques to treat intraocular tumors offers a viable option for the management of intraocular cancers.

Coats' disease: an Indian perspective

Aim:

To describe the clinical features, treatment and outcome patterns in 307 eyes with Coats' disease.

Materials and Methods:

Retrospective chart review of patients diagnosed with Coats' disease between January 1996 and January 2006 from a single referral center in southern India.

Results:

Two hundred and eighty patients (307 eyes) with mean age of 15.67 years (range: Four months-80 years) were included. Decreased vision (77%), unilateral affection (90%) and male preponderance (83.4%) were chief presenting features. Anterior segment involvement was seen in 67 (21.8%) eyes. Retinal telangiectasia were seen in 302 (99%) eyes, exudation in 274 (89%) eyes and retinal detachment in 158 (51.5%) eyes. Four-quadrant disease was seen in 207 (67.2 %) eyes. Visual acuity was < 20/200 in 249 (80.9%) eyes. One hundred and nine of 176 treated eyes (61.93%) had favorable anatomical outcome; 207 of 280 eyes (74%) had an optimal structural outcome. Seventeen (5.3%) eyes were enucleated. Complications following treatment included phthisis bulbi (7%), neovascular glaucoma (5%), epiretinal membrane (4.4%) and rubeosis iridis (4.4%).

Conclusion:

Indian patients with Coats' disease have a high male predominance, the majority of whom present with severe visual impairment and extensive four-quadrant exudation. Unusual presentations such as pain, vitreous hemorrhage and a high incidence of anterior segment involvement are distinctive to Indian eyes.

Functional and anatomical outcomes after primary lens-sparing pars plana vitrectomy for Stage 4 retinopathy of prematurity

Background:

While lens-sacrificing vitrectomy is the standard approach to manage Stage 5 retinopathy of prematurity (ROP), scleral buckling has been used to manage some cases of Stage 4. Lens-sparing vitrectomy was popularized by Maguire and Trese in selected cases of Stage 4 disease.

Purpose:

To assess the functional and visual outcomes after primary lens-sparing pars plana vitrectomy for Stage 4 ROP.

Materials and Methods:

In a retrospective, interventional, consecutive case series, the records of 39 eyes of 31 patients presenting with Stage 4 retinal detachment secondary to ROP who underwent primary two or three-port lens-sparing vitrectomy from January 2000 to October 2006 were evaluated. The outcomes studied at the final follow-up visit were the retinal status, lens and medial clarity and visual acuity. Favorable anatomical outcome was defined as the retinal reattachment of the posterior pole at two months after the surgery; and favorable functional outcome was defined as a central, steady and maintained fixation, with the child following light.

Results:

At mean follow-up of 15 months, 74% of the eyes had a favorable anatomical outcome with single procedure. The visual status was favorable in 63%. The lens remained clear in all the eyes at the last follow-up, and the media clarity was maintained in 87%. Intraoperative complications included vitreous hemorrhage, pre-retinal hemorrhage and retinal break formation.

Conclusions:

Lens-sparing vitrectomy helps to achieve a favorable anatomical and functional outcome in selected cases of Stage 4 ROP.

Visual outcome after discontinuation of corticosteroids in atypical severe central serous chorioretinopathy

PURPOSE

To elucidate the effect of discontinuation of corticosteroids in patients with atypical severe central serous chorioretinopathy (CSC) on retinal reattachment, resolution of retinal pigment epithelium (RPE) leaks, and improvement in visual acuity (VA).

DESIGN

Prospective, noncomparative, observational case series.

PARTICIPANTS

Twenty-four eyes of 17 patients who were being treated with corticosteroids for atypical severe CSC. Of these 17 patients, 16 were treated inappropriately with corticosteroids for their ocular condition; presumably, these patients' conditions were misdiagnosed, and they were thought to have choroiditis, Harada's syndrome, or similar entities, and not central serous chorioretinopathy.

INTERVENTION

Observation or laser photocoagulation.

MAIN OUTCOME MEASURES

Reattachment of the retina, obliteration of RPE leaks on fundus fluorescein angiography, and improvement in Snellen VA.

RESULTS

Discontinuation of corticosteroids resulted in reattachment of the retina in 21 eyes (87.5%), with median time to reattachment of 49 days (range, 32-400); only 3 eyes required laser photocoagulation. Fundus fluorescein angiography showed obliteration of RPE leaks at a median period of 75 days (range, 32-400) in the observed eyes; the median VA improved from 20/80 to 20/30. The mean follow-up was 16.5 months.

CONCLUSIONS

Discontinuation of corticosteroids in atypical CSC helped in obliteration of RPE leaks and retinal reattachment in 87.5% of the eyes without laser treatment, and improvement in VA was observed.

Solitary retinal astrocytoma in an infant

A 5-month-old infant presented with a solitary retinal astrocytoma that clinically and ultrasonographically mimicked retinoblastoma. The diagnosis was established on histopathologic examination. There was no systemic evidence of tuberous sclerosis or neurofibromatosis. Thus, solitary, large, retinal astrocytomas can occur in the absence of any systemic manifestations.

Indocyanine green dye-enhanced transpupillary thermotherapy of classic subfoveal choroidal neovascularization

BACKGROUND AND OBJECTIVE

To evaluate the efficacy of indocyanine green dye-enhanced transpupillary thermotherapy for the treatment of classic subfoveal choroidal neovascular membrane (CNVM) with differing etiologies.

PATIENTS AND METHODS

Nine eyes of 9 patients with classic subfoveal CNVM with different etiologies that was treated with indocyanine green dye-enhanced transpupillary thermotherapy were prospectively studied. All patients underwent pretreatment fluorescein angiography. Three minutes after dye injection (25 mg of indocyanine green), transpupillary thermotherapy was delivered using a modified diode laser at 810 nm, with a variable spot size of 0.8 to 2 mm depending on the size of the CNVM. A power range between 100 and 800 mW was used and treatment was initiated in one spot for 60 seconds; the end point was a barely detectable light gray appearance of the lesion. The outcome measures were assessed by Snellen visual acuity chart and obliteration of the CNVM by fluorescein angiography. Mean follow-up was 16 months.

RESULTS

Obliteration of the CNVM was seen in all patients during the last visit. Visual acuity improved in one eye and remained stable (+/-2 line change on Snellen chart) in three eyes. Three eyes revealed a moderate visual loss of 3 to 4 lines and two eyes had a severe decline (> 5 lines) in vision. None of the eyes exhibited recurrence of the CNVM during follow-up.

CONCLUSIONS

Indocyanine green dye-enhanced transpupillary thermotherapy was highly effective in closing classic CNVM in all cases without any recurrence. Visual acuity was either stabilized or improved in 4 of 9 eyes (44.5%).