Air bubble guide for adequacy of ophthalmic viscosurgical device during phacoemulsification

ABSTRACT

Phacoemulsification in hard cataracts is a challenge. The use of dispersive ophthalmic viscosurgical devices (OVDs) to protect the endothelium is a routine step in such scenarios. However, as OVD is transparent, it is difficult to spot within the anterior chamber. Therefore, surgeons may not be aware when the OVD coating of the endothelium disappears during surgery. Consequently, there may be too frequent OVD injections, resulting in a waste of resources. On the contrary, the surgeon may fail to inject OVD at an appropriate time, leading to greater endothelial damage. We propose a novel technique of using an air bubble as a guide that helps in identifying the time when OVD disappears from the anterior chamber, thereby suggesting the surgeon to reinject before proceeding further.

Distribution of TGFBI variants in patients with early onset glaucoma

Purpose

To describe a novel association of TGFBI variants with congenital glaucoma in a family with GAPO (growth retardation, alopecia, pseudoanodontia, and progressive optic atrophy) syndrome, as well as among other unrelated cases of juvenile onset open-angle glaucoma (JOAG) and primary congenital glaucoma (PCG).

Methods

This study of one family of GAPO with congenital glaucoma and three unrelated patients with JOAG analyzed a common link to glaucoma pathogenesis. Three girls with GAPO syndrome born to consanguineous parents in a multi-generation consanguineous family were identified. Two of the girls had congenital glaucoma in both eyes, while the elder sibling (a 10-year-old female) had features of GAPO syndrome without glaucoma.

Results

A genetic evaluation using whole exome sequencing revealed a novel homozygous ANTXR1 mutation in all three affected siblings with GAPO. No other mutations were detected in the genes associated with glaucoma. A rare missense variant in the TGFBI gene was shared in the two siblings with congenital glaucoma and GAPO syndrome. We found three other unrelated patients with JOAG and one patient with primary congenital glaucoma with no known glaucoma causing gene mutations, but having four different missense variants in the TGFBI gene. One of these patients with JOAG had familial granular corneal dystrophy. Molecular dynamic simulations of TGFBI and 3-D structural models of three of its variants showed significant alterations that could influence TGFBI protein function.

Conclusions

The possibility that variations in the TGFBI gene could have a possible role in the pathogenesis of congenital and juvenile onset open-angle glaucomas needs further evaluation.

Knowledge, attitude, and practice patterns of Indian ophthalmologists regarding medicolegal issues

PURPOSE

To assess the knowledge, attitude, and practice patterns (KAPP) of Indian ophthalmologists regarding medicolegal issues using an initial survey.

METHODS

An online form was circulated among Indian ophthalmologists of all ages over social media and email by the Young Ophthalmologists Society of India (YOSI) and its medicolegal working group. Anonymous responses were obtained and analyzed for each question. The questionnaire comprised questions about demographic details, KAPP of medicolegal issues including how to deal with medicolegal issues (if faced), medical indemnity insurance, deviation from the recommended minimum sum assured (Rs. 1 crore for Indian ophthalmologists), and legal service providers.

RESULTS

A total of 109 responses were obtained. The majority of the respondents were male (60, 55%). More than 50% of respondents (58, 53.2%) were younger than 35 years. More than one-fourth of the respondents were private practitioners (29, 27%), and the majority were of senior consultant designation (45, 41%). Around 80% of respondents (89, 81.6%) were aware of professional indemnity insurance; however, only 54% (n = 59) bought the insurance cover. A majority of the respondents (38, 64.4%) had an indemnity cover of a maximum of Rs. 50 lacs. Only 20% of respondents were aware of the expert body at the state/national level that deals with medicolegal cases. Thirty percent of respondents recommended the ideal cover amount to be more than Rs. 1 crore.

CONCLUSION

The current survey highlights the dismally low rate of awareness of medicolegal issues among ophthalmologists. Specifically, a majority of Indian ophthalmologists surveyed did not have recommended minimum insured cover for professional indemnity insurance. Larger studies are needed to further explore KAPP of Indian ophthalmologists in various medicolegal issues.

Recovery course of persistent posterior subretinal fluid after successful repair of rhegmatogenous retinal detachment

PURPOSE

To investigate best corrected visual acuity (BCVA), subretinal fluid (SRF) absorption time or ellipsoid zone (EZ) restoration time and various variables in patients with persistent SRF after successful primary repair of rhegmatogenous retinal detachment (RRD).

METHODS

This retrospective multicenter study allowed independent analysis of the healing pattern by two observers based on composite of serial cross-sectional macular optical coherence tomography (OCT) scans. Univariate and multivariate analyses were implemented.

RESULTS

One hundred and three cases had persistent SRF after pars plana vitrectomy, scleral buckling, or pneumatic retinopexy. By univariate analysis, SRF resolution time correlated positively with the number of retinal breaks (p < 0.001) and with increased myopia (p = 0.011). Using multivariate analysis, final BCVA (log MAR) correlated positively with age, duration of RRD, initial BCVA (OR = 3.28; [95%CI = 1.44-7.47]; p = 0.015), and SRF resolution time (OR = 0.46 [95%CI 0.21-1.05]; p = 0.049). EZ restoration time was longer with increasing number of retinal tears (OR = 0.67; [95%CI 0.29-1.52]; p = 0.030), worse final BCVA, and presence of macula-off RRD (OR = 0.26; [95%CI 0.08-0.88]; p = 0.056). SRF resolution time correlated marginally with prone position.

CONCLUSIONS

Residual posterior SRF is more common in eyes with multiple breaks or in myopic eyes. Final BCVA is better in younger subjects and in eyes with shorter duration of RRD. Persistent SRF is a self-limited disorder with a mean resolution of 11.2 months with good visual prognosis improving from a mean baseline logMAR of 1.08 to 0.25 at one year.

Idiopathic Macular Hole: Algorithm for Nonsurgical Closure Based on Literature Review

Our purpose is to review the closure time and optical coherence tomography (OCT) biomarkers that result in the non-surgical repair of idiopathic full-thickness macular holes (IFTMH). Our methodology consisted of a comprehensive literature review of the nonsurgical resolution of IFTMH followed by the calculation of the estimated closure time using the structural equation model. Forty-nine studies were found eligible yielding 181 eyes with IFTMH: 81.1% being small holes (< 250 µm) with a median diameter of 166 µm. Final vision (mean 20/41) was related to initial vision (mean 20/65) and mean age (67 years). The hole diameter was correlated with initial vision and closure time (mean 3.9 months). Closure time was related to hole diameter and initial vision in the following algorithm: Closure time (month)= - 0.057 + 0.008 diameter (µm) + 0.021 age (year) + 2.153 initial vision (logMAR). Biomarkers by OCT for self-closure included in decreasing frequency: pointed edge, de-turgescence of cystic macular edema (CME) with reversal of bascule bridge, and vitreomacular traction (VMT) release. The crucial function of Muller cell bridging in sealing the hole attests to its exceptional capacity for regeneration. After the hole has begun to close; however in less than 5%, a delayed restoration of the ellipsoid layer or a persistent outer foveal defect may prevent visual recovery and reopening of the hole is possible. In conclusion, eyes with small-size IFTMH and good baseline vision can have the additional option of close OCT monitoring for biomarkers of self-sealing biomarkers. When rehabilitative activity seems to be lacking, surgery is therefore mandatory.

Analysis of choroidal thickness on optical coherence tomography in a patient with sudden-onset bilateral myopia, macular striae, and shallow anterior chamber after topiramate use

This patient presented with sudden onset myopia, shallow anterior chamber, and radial macular folds in both eyes after using topiramate. Ocular parameters including increased choroidal thickness normalized after cessation of topiramate.

Risk Factors for Descemet Membrane Endothelial Keratoplasty Rejection: Current Perspectives- Systematic Review

Descemet membrane endothelial keratoplasty (DMEK) is a corneal endothelial transplantation procedure with selective removal of a patient's defective Descemet membrane and endothelium. It is replaced with a healthy donor Descemet membrane and endothelium without a stromal component. Corneal graft rejection can be at the level of epithelium, stroma as well endothelium. DMEK graft rejection is relatively less common than rejection with DSAEK or penetrating keratoplasty, and a good outcome may be achieved with prompt management. The clinical picture of DMEK rejection is usually similar to endothelial rejection in Descemet Stripping Endothelial Keratoplasty (DSEK/DSAEK), which generally manifests as pain, redness, reduction in visual acuity, stromal edema, endothelial rejection line, keratic precipitates at the back of the cornea and corneal neovascularization. However, more subtle forms of rejection or immune reactions are more common in DMEK compared to DSAEK eyes. Early clinical diagnosis, prompt intervention, and meticulous management safeguard visual acuity and graft survival in these cases. Intensive topical steroids form the mainstay in the management of DMEK rejection. Sometimes, oral or intravenous steroids or other systemic immunomodulators may be required. DMEK graft failure can be primary or secondary, and failure usually requires a second procedure in the form of repeat DMEK or DSEK or penetrating keratoplasty (PKP). A detailed literature search was performed using search engines such as Google Scholar, PubMed, and Google books, and a comprehensive review on DMEK rejection was found to be lacking. This review is a comprehensive update on the risk factors, pathophysiology, primary and secondary graft failure, recent advances in diagnosis, prevention of rejection, and updates in the management of DMEK rejection. The review also discusses the differential diagnosis of DMEK failure and rejection, prognosis, and future perspectives considering DMEK failure and rejection.

A hypothetical therapeutic effect of light peripheral panretinal photocoagulation in neovascular age-related macular degeneration

Background

Vascular endothelial growth factor (VEGF) is a significant modulator of ocular angiogenesis, including that of neovascular age-related macular degeneration (nAMD). Intravitreal injection of anti-VEGF is the benchmark treatment for most retinal vascular diseases, including nAMD, diabetic maculopathy, and macular edema secondary to retinal venous occlusion. Anti-VEGF treatment is a high-frequency, time-consuming, non-cost-effective therapy, especially in countries and regions with limited resources. This treatment is easily restricted, and in practice, maintaining long-term periodic care is challenging for patients.

Hypothesis

Light peripheral panretinal photocoagulation (PPRP) is applied in a mild form (barely visible mild light gray mark) anterior to the equator so as not to jeopardize the visual field. PPRP lessens the ischemia that causes neovascularization and decreases the metabolic demand in the peripheral retina. PPRP reduces serum angiopoietin-2 and VEGF levels in patients with type 2 diabetes mellitus with proliferative diabetic retinopathy. We propose using light PPRP to suppress VEGF secretion, aiming to attenuate the VEGF drive and halt choroidal neovascular growth in eyes with nAMD. Our regimen is based on two concepts: first, nAMD is a diffuse or generalized disease that affects the posterior segment; and second, PPRP is very effective in regressing diabetic retinopathy. PPRP has reportedly been successful in cases of macular edema (diabetic or following venous occlusion) resistant to VEGF antagonists. Light PPRP may be used as prophylaxis, adjunctive treatment, or monotherapy in nAMD when intravitreal injections of VEGF antagonists are not feasible.

Conclusions

The established light PPRP therapy could be promising as a one-time, cost-effective therapy or prophylaxis in patients with nAMD or at high risk. This proposed modality could be suitable for patients who have injection phobia or prefer a one-time affordable therapy to the long-term monthly visits to retinologists. Future trials are necessary to verify the safety and efficacy of this proposed treatment modality in selected patients with nAMD.

Pythium insidiosum Keratitis: Past, Present, and Future

Pythium insidiosum (PI) is an oomycete, a protist belonging to the clade Stramenopila. PI causes vision-threatening keratitis closely mimicking fungal keratitis (FK), hence it is also labeled as "parafungus". PI keratitis was initially confined to Thailand, USA, China, and Australia, but with growing clinical awareness and improvement in diagnostic modalities, the last decade saw a massive upsurge in numbers with the majority of reports coming from India. In the early 1990s, pythiosis was classified as vascular, cutaneous, gastrointestinal, systemic, and ocular. Clinically, morphologically, and microbiologically, PI keratitis closely resembles severe FK and requires a high index of clinical suspicion for diagnosis. The clinical features such as reticular dot infiltrate, tentacular projections, peripheral thinning with guttering, and rapid limbal spread distinguish it from other microorganisms. Routine smearing with Gram and KOH stain reveals perpendicular septate/aseptate hyphae, which closely mimic fungi and make the diagnosis cumbersome. The definitive diagnosis is the presence of dull grey/brown refractile colonies along with zoospore formation upon culture by leaf induction method. However, culture is time-consuming, and currently polymerase chain reaction (PCR) method is the gold standard. The value of other diagnostic modalities such as confocal microscopy and immunohistopathological assays is limited due to cost, non-availability, and limited diagnostic accuracy. PI keratitis is a relatively rare disease without established treatment protocols. Because of its resemblance to fungus, it was earlier treated with antifungals but with an improved understanding of its cell wall structure and absence of ergosterol, this is no longer recommended. Currently, antibacterials have shown promising results. Therapeutic keratoplasty with good margin (1 mm) is mandated for non-resolving cases and corneal perforation. In this review, we have deliberated on the evolution of PI keratitis, covered all the recently available literature, described our current understanding of the diagnosis and treatment, and the potential future diagnostic and management options for PI keratitis.

Orbital magnetic resonance imaging profile and clinicoradiological correlation in COVID-19-associated rhino-orbital-cerebral mucormycosis: A single-center study of 270 patients from North India

Purpose:

To study the clinical profile and magnetic resonance imaging (MRI) features in patients of COVID-19-associated rhino-orbital-cerebral mucormycosis (CA-ROCM) with orbital involvement and perform a clinicoradiological correlation.

Methods:

A cross-sectional study was performed at a tertiary care center in north India from May 2021 to June 2021. Consecutive patients with clinical, nasal endoscopic, and/or microbiological evidence of CA-ROCM underwent MRI of paranasal sinuses, orbit, and brain as per the study protocol. Orbital MRI findings were studied in detail and were correlated with clinical signs.

Results:

Two hundred and seventy patients were studied. The mean age was 48.4 (± 16.82) years. A male predilection was noted (male:female = 1.77). Orbital involvement was seen in 146 (54%) patients on clinical evaluation and in 184 (68%) patients on MRI. Unilateral orbital involvement was more common (134; 92%). The most common presenting symptom was periorbital and/or facial pain (141; 52.2%) and the most common clinical sign was periorbital edema (116; 43%). The most common MRI finding was suggestive of orbital cellulitis (160; 59%). Orbital compartment syndrome was found in 17 (6.3%) patients. The inter-rater agreement between clinical and radiological assessments to detect the involvement of infraorbital nerve and frontal nerve was found to be 85.56%, (κ 0.621) and 93.70% (κ 0.776), respectively. The diagnostic accuracy, sensitivity, and specificity of MRI to detect medial orbital wall defect were found to be 87.9%, 65%, and 97%, respectively.

Conclusion:

Orbital imaging features of a cohort of ROCM patients have been presented with clinicoradiological correlation.

Sympathetic Ophthalmia: Where Do We Currently Stand on Treatment Strategies?

Sympathetic ophthalmia is a rare bilateral diffuse granulomatous panuveitis that usually results from surgical or penetrating trauma to one eye. The symptoms range from impaired near vision to pain, photophobia, and loss of visual acuity. Anterior segment manifestations include bilateral acute uveitis with mutton-fat keratic precipitates and posterior segment findings include vitritis, multifocal neurosensory retinal detachment, choroiditis, optic nerve edema, and Dalen-Fuchs nodules. The diagnosis is clinical. Ancillary investigations include fundus fluorescein angiography, indocyanine green angiography, optical coherence tomography (OCT), ultrasound B scan, and autofluorescence imaging. The management options include corticosteroids (topical and systemic) as the first line along with immunomodulatory therapy started at the presentation of the disease. Recent advances include imaging with OCT-angiography, enhanced depth imaging-OCT (EDI-OCT, choroidal vascular index/CVI), targeting IL-23/IL-17 pathway, and use of biologics for the management of this rare entity. Recent advances in early diagnosis and prompt treatment has led to improved final visual outcomes in both the sympathizing and exciting eye. This review is aimed at giving a comprehensive overview of sympathetic ophthalmia along with a special emphasis on current treatment strategies and recent advances.

Is there a genetic link between Keratoconus and Fuch's endothelial corneal dystrophy?

Keratoconus (KC) is a noninflammatory, bilateral, progressive corneal stromal thinning disorder that leads to corneal ectasia, central anterior corneal stromal scarring, irregular myopic astigmatism, and reduced visual acuity. Fuchs endothelial corneal dystrophy (FECD) is bilateral, sporadic, or autosomal dominant, non-inflammatory, dystrophy involving the corneal endothelium. As the dystrophy evolves, the major complaints include glare, halos, and reduced visual acuity. Very rarely, both the pathologies can co-exist in the same patient. After the initial report of KC with FECD, there have been nearly 70 cases of coexistence reported in the literature till now. The reported number of cases varies from region to region and the majority of cases have no documented family history, hence it is difficult to approximate the incidence and prevalence based on the available literature. Hence, we hypothesize that both pathologies have probably the same genetic link. Available literature supporting the hypothesis has been discussed. We have also discussed various probable mechanisms of coexistence and proposed a management algorithm while assessing and attempting surgery in these patients. We also propose that all these patients must undergo genetic screening and counselling to prevent the spread of these pathologies in future generations.

Evaluating the presence of SARS-CoV-2 in the intraocular fluid of COVID-19 patients

PURPOSE

To detect the presence of SARS-CoV-2 in aqueous and vitreous humor of COVID-19 patients in a pilot study.

METHODS

: Consecutive patients planned for emergency ophthalmic surgeries after ocular trauma were subjected to naso-oropharyngeal RT-PCR test for SARS-CoV-2. Laboratory-confirmed cases were enrolled for the study. During surgery, 0.1 mL aqueous and vitreous each was aspirated. The vitreous tap was collected on clinical suspicion of endophthalmitis. RT-PCR test was used to detect SARS-COV-2 nucleotide in the samples. Cycle threshold (Ct) for E gene of ≤35 along with confirmatory results on one of the two target genes (RdRp or ORF1b) was considered as positive.

RESULTS

: One hundred and thirty two patients were found positive on naso-oropharyngeal RT-PCR test for SARS-CoV-2 preoperatively. Seven patients with ocular trauma were studied. The mean age was 31.8 years. There were six male and one female patient. Two patients had symptoms of mild COVID-19 disease and the rest were asymptomatic. The mean Ct value of the E gene on naso-oropharyngeal RT-PCR was 23.14 ± 4.7. Corneal and corneoscleral laceration repair was done in five patients, intracorneal wooden foreign body was removed in one patient, and injection of intravitreal antibiotics was done in one patient. Aqueous and vitreous tap was collected in 7 and 5 patients, respectively. None of the aqueous or vitreous samples was found positive for SARS-CoV-2.

CONCLUSION

: SARS-CoV-2 was not detected by RT-PCR in aqueous or vitreous humor in this pilot study. Future studies with a larger sample size are needed to further explore the presence of SARS-CoV-2 in intraocular fluids.

Ultrawide field imaging to document the progression of gyrate atrophy of the choroid and retina over 5 years

A family of three siblings affected with gyrate atrophy of the choroid and retina is presented. Ultrawide field fundus imaging was used to monitor the progression of the disease objectively over 5 years.

Widefield Fundus Fluorescein Angiography Features of Uveitis Associated with Juvenile Idiopathic Arthritis

PURPOSE

To evaluate the wide-field fundus fluorescein angiography (WFA) characteristics of uveitis associated with juvenile idiopathic arthritis (JIA-uveitis).

METHODS

Retrospective review of records. WFA with Spectralis (Heidelberg) of JIA-uveitis patients were analyzed using the scoring system by Angiography Scoring for Uveitis Nomenclature.

RESULTS

Thirty-seven eyes of 20 patients were studied. A total score of at least 1 was noted in 27 eyes (72.97%). WFA features included optic disc hyperfluorescence (51.35%), macular leakage (27.03%), retinal vascular staining/leakage at posterior pole (27.03%) and peripheral retina (64.86%), capillary leakage at the posterior pole (37.84%), and peripheral retina (59.46%). A decision to change the management plan was made in 8 of 9 patients with bilateral quiet anterior chambers after WFA results.

CONCLUSION

More than 70% of JIA-uveitis eyes showed some WFA-evidence of posterior segment inflammation, which changed the course of therapy for a major proportion of patients with no clinically active anterior chamber inflammation.

Repeated phototherapeutic keratectomy (PTK) followed by PTK with photorefractive keratectomy for anterior granular corneal dystrophy

Two preteen siblings with the anterior-stromal variant of granular corneal dystrophy type 1 underwent multiple phototherapeutic keratectomies (PTK) (due to recurrences of the dystrophy) with progressively increasing hyperopia after each procedure. The last procedure performed was an additional photorefractive keratectomy along with the PTK which led to a decrease in the hyperopia with better refractive outcomes. The addition of mitomycin C may have led to a delay in the recurrence of the dystrophy.

Outer retinal tubulation and inner retinal pseudocysts in a patient with maternally inherited diabetes and deafness evaluated with optical coherence tomography angiogram

A 47-year-old lady (index case) with diabetes and deafness showed multiple oval circumferential areas of perifoveal atrophy in both eyes. Autofluorescence revealed areas of hypoautofluorescence. Optical coherence tomography (OCT) showed depression of inner retinal surface, inner retinal hyporeflective spaces (pseudocysts), disorganization/thinning of outer retina, outer retinal tubulation, loss of external limiting membrane, ellipsoid and interdigitation zone, and thinning of the retinal pigment epithelium and choriocapillaris. The patient was evaluated using OCT angiogram. Retinal lesions of her mother (68-year-old) were very obvious on autofluorescence imaging. The result of A3243G mutation in MTTL1 gene was positive in the index case confirming the diagnosis of maternally inherited diabetes and deafness (MIDD).

Analysis of optical coherence angiography in cystoid macular oedema associated with gyrate atrophy

BACKGROUND

To evaluate the relationship between superficial, deep foveal avascular zone (FAZ) and foveal cyst areas in eyes with cystoid macular oedema (CMO) associated with gyrate atrophy of the choroid and retina (GA).

METHODS

This is a retrospective collaborative multicenter study of optical coherence tomography-angiography (OCTA) images in GA. Superficial and deep FAZ and foveal cyst were measured using Image J by two independent experts. Values were corrected for myopia magnification. These values were compared with age-matched controls from normative data.

RESULTS

Twenty-three eyes from 12 patients with GA and CMO were included in the study. The mean ± standard deviation age was 22 ± 19.7 years, mean Snellen spectacle-corrected visual acuity of 20/70 with mean myopia of 5.7 ± 4.1 dioptres. Qualitatively, no focal occlusion of superficial and deep capillary plexus was noted. Mean superficial FAZ area (0.484 ± 0.317 mm²), deep FAZ area (0.626 ± 0.452 mm²), and foveal cyst area (0.630 ± 0.503 mm²) were significantly larger than superficial and deep FAZ areas in controls of same age range (p < 0.001). Macular cyst area correlated with superficial FAZ area (R = 0.59; p = 0.0057) and more strongly with deep FAZ area (R = 0.69; p < 0.001).

CONCLUSIONS

The superficial and deep FAZ area in GA-associated CMO were noted to be significantly larger than in controls. It seems that RPE dysfunction leads to foveal cyst enlargement displacing the capillary plexus with resultant enlarged superficial and deep FAZ area.

Optical coherence tomography of racemose angioma

Wyburn-Mason syndrome is associated with racemose angioma of the retina and arteriovenous malformation of the brain. Optical coherence tomography and MRI angiography may be used to document the vascular lesion of the retina and brain, respectively.