Outcome of real-time telescreening for retinopathy of prematurity using videoconferencing in a community setting in Eastern India

PURPOSE

To evaluate the feasibility and outcome of a real-time retinopathy of prematurity (ROP) telescreening strategy using videoconferencing in a community setting in India.

METHOD

In a prospective study, trained allied ophthalmic personnel obtained the fundus images in the presence of the parents and local childcare providers. Analysis of images and parental counseling were done in real time by an ROP specialist located at a tertiary center using videoconferencing software. A subset of babies was also examined using bedside indirect ophthalmoscopy by an ROP care-trained ophthalmologist. The data were analyzed using descriptive statistics, sensitivity, specificity, positive and negative predictive values, and correlation coefficient.

RESULTS

Over 9 months, we examined 576 babies (1152 eyes) in six rural districts of India. The parents accepted the model as they recognized that a remotely located specialist was evaluating all images in real time. The strategy saved the travel time for ROP specialists by 477 h (47.7 working days) and for parents (47,406 h or 1975.25 days), along with the associated travel cost. In a subgroup analysis (100 babies, 200 eyes), the technology had a high sensitivity (97.2%) and negative predictivity value (92.7%). It showed substantial agreement (k = 0.708) with the bedside indirect ophthalmoscopy by ROP specialists with respect to the detection of treatment warranting ROP. Also, the strategy helped train the participants.

CONCLUSION

Real-time ROP telescreening using videoconferencing is sensitive enough to detect treatment warranting ROPs and saves skilled workforce and time. The real-time audiovisual connection allows optimal supervision of imaging, provides excellent training opportunities, and connects ophthalmologists directly with the parents.

Tear Protein Markers for Diabetic Retinopathy and Diabetic Macular Edema - Towards an Early Diagnosis and Better Prognosis

BACKGROUND

Diabetic eye disease is a highly prevalent and sight-threatening disorder. It is a disease of neuro-vascular unit of the retina, if left untreated can cause blindness. Therapeutic approaches followed for its treatment can only restrict the progression of the disease with highly variable results. There is no known biomarker for an early diagonsis of this disease, therefore by the time it is detected it goes beyond repair. This creates a massive demand for development of such biomarkers that help detect disease in its earlier stages.

METHODS

PUBMED (https://pubmed.ncbi.nlm.nih.gov/) was searched for articles relevant to the topic published till November 2023. The search was made using keywords such as Diabetic Retinopathy, inflammation, tear, biomarker, proteomics etc. The studies providing relevant information to prove the importance of biomarker discovery were chosen. After compiling the data, the manuscript writing was planned under relevant headings and sub-headings.

RESULTS

The review provides a comprehensive overview of all the tear protein biomarker studies in the field of DR and DME. Briefly, their potential in other diseases is also elucidated. While there are many studies pertaining to DR biomarkers, the identified markers lack validations which has restricted their usage in clinics. In case of DME, there was no such study towards biomarker discovery for its diagnosis and prognosis.

CONCLUSIONS

The review highlights major studies and their lacunae in the field of biomarkers discovery for DR and DME.

Retinopathy of prematurity in triplets - Indian twin city ROP study report number 12

PURPOSE

To evaluate the incidence and severity of retinopathy of prematurity (ROP) amongst surviving triplets.

METHODS

Records of preterm babies born to mothers with triplet pregnancies were retrieved from our Indian twin city ROP study database between 1 Jan 2000 and 31 Dec 2020 and analyzed.

RESULTS

253 surviving triplet babies born to 108 mothers were evaluated. 48 out of 108 (44%) mothers received treatment for infertility. Data was available and analyzed for 242 babies (484 eyes). Mean gestational age was 31.76 ± 3.74 weeks (26- 38 weeks). The mean birth weight was 1.44 ± 0.37 kg (0.57-2.76 kg). At the first screening, incomplete vascularization was noted in 67% (131 babies;322 eyes) of which ROP was diagnosed in 14% (28 babies; 56 eyes). Among them, only 18 babies (53%) were the smallest birth weight babies in each of the triplet sets. Treatment with laser or bevacizumab was performed in 14 babies (5.8%), one eye of one baby additionally needed vitreoretinal surgical intervention. Good anatomical outcomes in terms of regression of ROP without sequelae were achieved in all babies.

CONCLUSION

The present study reveals low incidence and favorable outcomes of ROP in triplet pregnancies in a large cohort of babies from a middle-income country. Our cohort did not show any difference in the treatment-requiring ROP among the larger or smaller birth weight babies of the same gestational age. In multiple pregnancies, gestational age remains a critical factor for ROP development; however, this does not necessitate modifying screening or treatment criteria in such triplet pregnancies.

Management of diabetic ocular complications: from cellular insights to community strategies

The editorial outlines an integrated approach to managing diabetic ocular complications, combining advanced scientific research with practical public health strategies to improve the prevention, diagnosis, and treatment of diabetic retinopathy and macular edema globally.

Population-based assessment of awareness of diabetes and diabetes related eye diseases in rural areas in Telangana, India - implications for eye health promotion

CLINICAL RELEVANCE

Understanding the awareness level of diabetes and diabetes-related eye diseases will help in developing better eye health education programmes and improve health-seeking behaviour in the community.

BACKGROUND

Diabetes and diabetes related eye diseases are increasing in numbers both in urban and rural areas in India. There are limited data on awareness of diabetes and diabetes-related eye disease in rural communities of India. This study reports on awareness of diabetes and diabetes-related eye diseases in people aged ≥40 years from two rural districts of Telangana, India.

METHODS

A structured questionnaire was used to determine the awareness of diabetes and diabetes-related eye diseases among participants aged ≥40 years in the Khammam and Warangal districts of Telangana, India. Social investigators visited the participant's households and conducted the interviews. A positive response to a question on having heard about diabetes was considered as 'awareness'. For those aware, follow-up questions were asked about the effect of diabetes on vision, frequency of eye examination and source of information. A positive response on a question that diabetes could cause loss of vision was considered as awareness of diabetic eye disease.

RESULTS

A total of 3273 participants were interviewed. Among them, 56.2% (n = 1840) were women, 60.6% (n = 1985) had no formal education, and 50.2% (n = 1645) were from the Khammam district. The mean age of the participants was 55.3 years (standard deviation: 11.7 years). Awareness of diabetes was 52.5% (n = 1719). Among them, 1056 participants (61.4%) were aware that diabetes could affect vision.

CONCLUSION

Only half of the participants were aware of diabetes and of this substantial proportion of individuals was unaware of potential vision loss due to diabetes. Improving awareness about diabetes and its impact on vision is recommended to prevent potential vision loss in this population.

Recommendations for diabetic macular edema management by retina specialists and large language model-based artificial intelligence platforms

PURPOSE

To study the role of artificial intelligence (AI) in developing diabetic macular edema (DME) management recommendations by creating and comparing responses to clinicians in hypothetical AI-generated case scenarios. The study also examined whether its joint recommendations followed national DME management guidelines.

METHODS

The AI hypothetically generated 50 ocular case scenarios from 25 patients using keywords like age, gender, type, duration and control of diabetes, visual acuity, lens status, retinopathy stage, coexisting ocular and systemic co-morbidities, and DME-related retinal imaging findings. For DME and ocular co-morbidity management, we calculated inter-rater agreements (kappa analysis) separately for clinician responses, AI-platforms, and the "majority clinician response" (the maximum number of identical clinician responses) and "majority AI-platform" (the maximum number of identical AI responses). Treatment recommendations for various situations were compared to the Indian national guidelines.

RESULTS

For DME management, clinicians (ĸ=0.6), AI platforms (ĸ=0.58), and the 'majority clinician response' and 'majority AI response' (ĸ=0.69) had moderate to substantial inter-rate agreement. The study showed fair to substantial agreement for ocular co-morbidity management between clinicians (ĸ=0.8), AI platforms (ĸ=0.36), and the 'majority clinician response' and 'majority AI response' (ĸ=0.49). Many of the current study's recommendations and national clinical guidelines agreed and disagreed. When treating center-involving DME with very good visual acuity, lattice degeneration, renal disease, anaemia, and a recent history of cardiovascular disease, there were clear disagreements.

CONCLUSION

For the first time, this study recommends DME management using large language model-based generative AI. The study's findings could guide in revising the global DME management guidelines.

Recommendations for initial diabetic retinopathy screening of diabetic patients using large language model-based artificial intelligence in real-life case scenarios

PURPOSE

To study the role of artificial intelligence (AI) to identify key risk factors for diabetic retinopathy (DR) screening and develop recommendations based on clinician and large language model (LLM) based AI platform opinions for newly detected diabetes mellitus (DM) cases.

METHODS

Five clinicians and three AI applications were given 20 AI-generated hypothetical case scenarios to assess DR screening timing. We calculated inter-rater agreements between clinicians, AI-platforms, and the "majority clinician response" (defined as the maximum number of identical responses provided by the clinicians) and "majority AI-platform" (defined as the maximum number of identical responses among the 3 distinct AI). Scoring was used to identify risk factors of different severity. Three, two, and one points were given to risk factors requiring screening immediately, within a year, and within five years, respectively. After calculating a cumulative screening score, categories were assigned.

RESULTS

Clinicians, AI platforms, and the "majority clinician response" and "majority AI response" had fair inter-rater reliability (k value: 0.21-0.40). Uncontrolled DM and systemic co-morbidities required immediate screening, while family history of DM and a co-existing pregnancy required screening within a year. The absence of these risk factors required screening within 5 years of DM diagnosis. Screening scores in this study were between 0 and 10. Cases with screening scores of 0-2 needed screening within 5 years, 3-5 within 1 year, and 6-12 immediately.

CONCLUSION

Based on the findings of this study, AI could play a critical role in DR screening of newly diagnosed DM patients by developing a novel DR screening score. Future studies would be required to validate the DR screening score before it could be used as a reference in real-life clinical situations.

CLINICAL TRIAL REGISTRATION

Not applicable.

Teleophthalmology at a primary and tertiary eye care network from India: environmental and economic impact

OBJECTIVE

To evaluate the environmental and economic impact of teleophthalmological services provided by a primary (rural) and tertiary (urban) eyecare network in India.

METHODS

This prospective study utilised a random sampling method, and administered an environmental and economic impact assessment questionnaire. The study included 324 (primary: 173; tertiary: 151) patients who received teleconsultations from July to September 2022. The primary network (rural) used a colour-coded triage system (Green: eye conditions managed by teleconsult alone; yellow: semi-urgent referral within 1 week to a month, red: urgent referral within a day to a week). The tertiary network (urban) included new and follow-up patients. The environmental impact was assessed by estimating the potential CO2 emissions saved by avoiding travel for various transport modes. Economic impact measured by the potential cost savings from direct (travel) and indirect (food and wages lost) expenses spent by yellow and red referrals (primary) and the first-visit expenses of follow-up (tertiary) patients.

RESULTS

The primary rural network saved 2.89 kg CO2/person and 80 km/person. The tertiary urban network saved 176.6 kg CO2/person and 1666 km/person. The potential cost savings on travel expenses were INR 19,970 (USD 250) for the primary (average: INR 370 (USD 4.6) per patient) and INR 758,870 (USD 9486) for the tertiary network (average: INR 8339 (USD 104) per patient). Indirect cost savings (food and wages) were of INR 29,100 (USD 364) for the primary and INR 347,800 (USD 4347) for the tertiary network.

CONCLUSION

Teleophthalmology offers substantial environmental and economic benefits in rural and urban eyecare systems.

Optical coherence tomography characteristics and factors affecting visual acuity in diabetic papillopathy

PURPOSE

To analyse baseline imaging characteristics and factors affecting poor visual acuity in diabetic papillopathy.

METHODS

This was a retrospective, observational study conducted at a tertiary eye care centre in eyes with a diagnosis of diabetic papillopathy. Demographic data including age, gender, duration of diabetes, type of diabetes, HbA1c values and other systemic co-morbidities were recorded. Baseline best corrected visual acuity (BCVA), and various imaging characteristics were noted.

RESULTS

37 eyes of 22 patients with diagnosis of diabetic papillopathy were included [mean age of 46.6 ± 13.5 years, five (22.7%) females and 17 (77.3%) males]. Bilateral involvement was seen in 15 (68.2%) patients. The mean baseline BCVA was 0.51 ± 0.49 logMAR (Snellen equivalent 20/60). Two eyes (5.4%) had features of concurrent mild NPDR, 9 eyes (24.3%) had moderate NPDR, 10 eyes (27.03%) had severe NPDR while 16 (43.2%) other had PDR. All eyes had optic disc edema while 4 had disc pallor at presentation. Telangiectatic vessels/ neovascularisation of disc was present in 17 eyes (45.9%) detected either clinically or on optical coherence tomography (OCT) angiography. 11 (29.7%) eyes had a peripapillary cuff of subretinal fluid accompanying the disc edema. Sixteen eyes (43.2%) had centre involving macular edema seen on OCT. In eyes with a macular edema, the mean central macular thickness was 407.4 ± 71.42 microns at baseline. On assessing the baseline factors that contribute to the final visual acuity, presenting visual acuity was the only variable found to be statistically significant.

CONCLUSION

Although described to have good visual outcome, eyes presenting with poor visual acuity tend to have worse vision on follow up. This may aid in prognosticating and guiding management plan.

Refractive outcomes following silicone oil tamponade in vitreoretinal surgery

PURPOSE

To evaluate the factors influencing the refractive outcomes following silicone oil tamponade (SOT) and silicone oil removal (SOR) in different lens statuses post-vitreoretinal surgery.

DESIGN

Retrospective analysis of three different lens statuses.

MATERIALS AND METHODS

This was a descriptive study that included 150 eyes of 147 patients who had undergone pars plana vitrectomy with SOT and SOR between January 2017 and June 2021. Demographic profile, spherical equivalent refraction (SER), and its association with clinical features were evaluated with SOT and post-SOR.

RESULTS

The mean (±standard deviation [SD]) age was 47 ± 17.8 years, including all three groups. SER was represented in diopters (D). The mean ± SD refraction with SOT in phakic, pseudophakic, and aphakic was 4.28 ± 2.59 D, 2.94 ± 2.58 D, and 3.98 ± 4.82 D. The mean SER post-SOR in phakic, pseudophakic, and aphakic was -2.72 ± 2.03 D, -1.12 ± 1.41 D, and 8.22 ± 3.70 D. The diagnosis of rhegmatogenous retinal detachment (RRD) among 96 eyes (64%) is the common indicator to perform vitreoretinal (VR) surgery. A minority of subjects were managed with retinal lasers before VR surgery (14%). The macula was attached in 100 eyes (67.6%), the belt buckle was done in 37 eyes (24.7%), and the silicone oil viscosity with 1000 centistoke was chosen in 129 eyes (86%).

CONCLUSION

SOT was used as a tamponade in VR surgeries irrespective of lens status. The significant predictor for post-SOR refraction in phakic and aphakic is post-SOT refraction. In pseudophakic, gender and diagnosis of RRD are the predictors of SOR refraction.

Impact of macular buckle removal on the functional and anatomical outcomes of myopic macular hole associated retinal detachment

A man in his 70s presented with a 1-month history of vision loss in the right eye. His best-corrected visual acuity (BCVA) in the affected eye was limited to counting fingers at close range. The examination revealed a macular hole with associated retinal detachment in the right eye and features of pathological myopia in both eyes. A macular buckling surgery was performed and resulted in a successful anatomical and functional outcome. Postoperatively, at week 10, the patient developed diplopia and buckle exposure. Therefore, the buckle was removed. However, the patient maintained a BCVA of 20/250 with an attached retina and closed macular hole after 6 months of follow-up.

Prevalence of age-related macular degeneration and associated factors in Indian cohort in a tertiary care setting

Purpose

To report a big data analysis of risk and protective factors in patients with AMD, as well as report on the age-adjusted prevalence in a geriatric Indian cohort in a hospital setting.

Methods

This retrospective, observational study of all patients older than 60 years of age. Multiple logistic regression was performed for the binary outcome and the presence of AMD. Variables analyzed include age, gender, socioeconomic status, occupation, urban-rural-metropolitan distribution, self-reported history of diabetes mellitus (DM), hypertension (HTN), or coronary artery disease (CAD), ocular comorbidities, history of cataract surgery, and presenting VA. Odds ratios (OR) and 99% confidence intervals were calculated.

Results

Of the 608,171 patients over the age of 60 years who attended our clinics, 1.68% of subjects had a diagnosis of AMD (N = 10,217). Less than half (4,621 of 10,217 with AMD) of them were diagnosed to have dry AMD. Cataract, glaucoma, and diabetic retinopathy were associated with lower risk of AMD. Cataract surgery was associated with the higher risk of AMD (OR = 1.20; 99% CI 1.13-1.29). Smoking was not associated with AMD.

Conclusion

Big data analysis from a hospital setting shows that the prevalence of AMD above the age of 60 years is low. More patients with wet AMD present for treatment compared to dry AMD. Smoking was not associated with AMD in the Indian population. Cataract surgery was associated with higher prevalence of AMD.

Clinical presentation and treatment outcomes of an algorithmic approach to uveal effusion syndrome

Purpose

To describe the clinical features and treatment outcomes in spontaneous uveal effusion syndrome (UES).

Methods

A 10-year retrospective chart review of UES patients from a tertiary eye center was carried out. Optical coherence tomography (OCT), fundus fluorescein angiography, and ultrasound biomicroscopy (UBM) scans were performed. UES was managed based on presenting best-corrected visual acuity (BCVA), symptoms, and fundus findings. Patients with secondary causes of uveal effusion were excluded.

Results

Twenty-five eyes of 16 patients were included. Of the 16 patients, 14 (88%) were male and 9 (56%) had bilateral disease. Fifteen of 25 affected eyes had nanophthalmos (axial length (AL) <20.5 mm) and 6 had hyperopia with AL >20.5 mm. The presenting mean distance BCVA was 0.74 ± 0.64 logMAR (mean Snellen: 20/100). Eleven eyes had exudative retinal detachment, and 4 also had exudative choroidal detachment (CD). Choroidal thickness (CT) was increased in 11 eyes on B-scan ultrasonography, and the mean CT was 1.74 ± 0.38 mm. Sub-retinal fluid (SRF) and retinal folds were the most common OCT findings. UBM findings included shallow angles, peripheral CD, and supra-ciliary effusion. A combination of local and systemic corticosteroids was used to successfully treat 12 eyes, 6 needed surgery, and 7 were observed. Partial sclerectomy with anterior chamber maintainer-assisted SRF drainage was the favored surgery. The median period of follow-up was 6.5 months (0.1-76 months), and the mean distance BCVA at the last follow-up was 0.58 ± 0.42 logMAR (mean Snellen: 20/80).

Conclusion

UES can be suitably managed both medically and surgically based on clinical presentation.

Spontaneous resolution of subretinal fluid postvitreoretinal surgery for tractional retinal detachment in proliferative diabetic retinopathy

A man in his 60s with proliferative diabetic retinopathy presented with vision loss in both eyes in the past 1 month. On presentation, the best corrected visual acuity was 20/60 and 20/125 for the right and left eyes, respectively. On examination, he had total tractional retinal detachment (TRD) in the left eye and macula threatening TRD in the right eye. In both eyes, the patient had pars plana vitrectomy, membrane peeling, endolaser and silicone oil injection. Though the left eye's postoperative recovery was uneventful, the subretinal fluid (SRF) in the right eye macula persisted. There was no open retinal break noted in the postoperative period, and no surgical intervention was done for the persistent SRF. The fluid was eventually absorbed over 4 months, with the recovery of vision to 20/40.

Guidelines in establishing telerehabilitation services for people with vision impairment

Telerehabilitation is a viable option to provide continuum of rehabilitation intervention in situations like the ongoing pandemic. Presently, there is no policy guidelines to the minimum standard of telerehabilitation. This paper describes procedures for telerehabilitation for people with blindness and low vision from the evidence-based practices from a premier eye institute in South India. The suggested guidelines can help develop and replicate similar models of telerehabilitation to reach people in need in difficult situations like COVID 19 pandemic.

Feasibility study for measuring patients' visual acuity at home by their caregivers

Purpose

To assess the feasibility of measuring patients' visual acuity (VA) in their homes by their caregivers.

Methods

Patients consulting in a tertiary eye care institute were prospectively enrolled with informed consent. All underwent standard COMPlog distance VA testing. Patients and caregivers were oriented to test distance VA using the Peek Acuity app. The app was installed on the caregiver's or patient's smartphone. The patient's VA was measured by the caregiver in the clinic (baseline value) under supervision. After 1 week, the caregivers recorded the patient's VA with the Peek Acuity app at their home and reported the value in a telephone consultation. A questionnaire to assess the ease of using the app was administered at both the baseline visit and 1 week later.

Results

A total of 100 patients (age group: 13 to 76 years) and 100 caregivers (age group: 17 to 65 years) participated. VA measurements with the Peek Acuity app were comparable with COMPlog (P > 0.1) both during the baseline and after 1-week measurement, regardless of the underlying ocular condition or educational level of the caregivers/patients. Most caregivers (95%) felt the app was easy to use.

Conclusion

Though the Peek Acuity app was originally developed for health care workers to be used in field visits, we found that with proper orientation, the layperson can also use it. Such orientation can enable caregivers to effectively measure VA at home. Such a tool would enhance teleophthalmology consultations and can minimize the need for short follow-up visits.

Clinical characteristics of comorbid retinal dystrophies and primary angle closure disease

PURPOSE

To assess the clinical characteristics of comorbid retinal dystrophies and primary angle closure disease.

DESIGN

Retrospective study from January 1992 to June 2020.

METHODS

This descriptive study included 92 eyes of 46 patients with comorbid retinal dystrophies and primary angle closure disease (PACD) that included eyes with primary angle closure suspect, primary angle closure and primary angle closure glaucoma. Demographic profile, clinical characteristics of PACD and its association with retinal dystrophies are described.

RESULTS

The study included 46 patients (92 eyes). Males were majority, 63%. Mean (± standard deviation) age when retinal dystrophy was diagnosed was 29.6 ± 9.4 years and PACD was diagnosed at 32.23 ± 7.92 years. Mean BCVA at presentation was 1.07 ± 0.87 log MAR [95% confidence interval (CI) 0.87, 1.26]. Mean Intraocular pressure at diagnosis of glaucoma was 27 ± 16 mmHg (95% CI 23.5, 31.5 mmHg). The most common retinal dystrophy associated with PACD was retinitis pigmentosa (RP) followed by RP with retinoschisis. The hospital-based prevalence of PACD among all patients with RP and retinoschisis was 0.19% and 0.15% respectively. Laser peripheral iridotomy was performed in 74 eyes (80.5%). Glaucoma was managed medically in majority of the eyes (58 eyes, 63.04%) and minority required surgical management with trabeculectomy (11, 11.9%).

CONCLUSION

Retinitis pigmentosa is the most common retinal dystrophy associated with PACD. Comorbid PACD in eyes with retinal dystrophies was observed in second to third decade of life. This calls for screening for angle closure in eyes with retinal dystrophies from second decade onwards to identify the comorbid PACD and treat or refer them appropriately.

Cryptococcus laurentii endogenous endophthalmitis post COVID-19 infection

A man in mid-50s presented with progressive blurred vision in his left eye for over 6 weeks. He was a known diabetic with history of COVID-19 pneumonia treated with steroids and remdesivir. He had pyelonephritis and urinary culture grown Klebsiella. He was referred as a case of non-resolving vitreous haemorrhage. Visual acuity (VA) was hand movements with fundus showing dense vitritis. He underwent pars plana vitrectomy, vitreous biopsy with intraocular antibiotics (imipenem) suspecting as a case of endogenous bacterial endophthalmitis. Vitreous biopsy did not yield organisms on the smear/culture. The patient’s condition worsened with perception of light and fundus showing dense vitritis with discrete yellowish white deposits on the surface of the retina. A repeat vitreous biopsy done along with intravitreal injection of voriconazole (suspecting fungal aetiology) grown fungal colonies and the organism was identified as Cryptococcus laurentii. At 4-month follow-up, the VA improved to 6/24.

Suprasellar paraganglioma in a clinical setting of von Hippel-Lindau syndrome

A man in his 20s presented to the neurosurgery department 2 years ago with headache and blurred vision. He was diagnosed to have a suprasellar mass on neuroimaging. Best-corrected visual acuity in the right eye was 6/36 and that in the left eye was 6/60. Automated visual fields showed a temporal hemianopia in the right eye and an advanced field defect in the left eye. His hormonal profile was normal, and he underwent partial excision of suprasellar tumour, which was a histopathologically proven paraganglioma (PGL). Subsequently, the patient underwent radiotherapy and his vision and visual fields showed improvement. Follow-up examination 3 years later showed a left retinal capillary hemangioblastoma (RCH), which was treated with green laser photocoagulation, resulting in complete sclerosis. This case is unique because of the extremely rare coexistence of a sellar PGL and RCH, which to our knowledge has not been reported so far.

Sight-threatening intraocular infection in patients with COVID-19 in India

Purpose

Intraocular infection in patients with COVID-19 could be different in the presence of treatment with systemic corticosteroid and immunosuppressive agents. We describe the epidemiology and microbiological profile of intraocular infection in COVID-19 patients after their release from the hospital.

Methods

We analyzed the clinical and microbiological data of laboratory-confirmed COVID-19 patients from April 2020 to January 2021 presenting with features of endogenous endophthalmitis within 12 weeks of their discharge from the hospital in two neighboring states in South India. The data included demography, systemic comorbidities, COVID-19 treatment details, time interval to visual symptoms, the microbiology of systemic and ocular findings, ophthalmic management, and outcomes.

Results

The mean age of 24 patients (33 eyes) was 53.6 ± 13.5 (range: 5-72) years; 17 (70.83%) patients were male. Twenty-two (91.6%) patients had systemic comorbidities, and the median period of hospitalization for COVID-19 treatment was 14.5 ± 0.7 (range: 7-63) days. Infection was bilateral in nine patients. COVID-19 treatment included broad-spectrum systemic antibiotics (all), antiviral drugs (22, 91.66% of patients), systemic corticosteroid (21, 87.5% of patients), supplemental oxygen (18, 75% of patients), low molecular weight heparin (17, 70.8% of patients), admission in intensive care units (16, 66.6% of patients), and interleukin-6 inhibitor (tocilizumab) (14, 58.3% of patients). Five (20.8%) patients died of COVID-19-related complications during treatment for endophthalmitis; one eye progressed to pan ophthalmitis and orbital cellulitis; eight eyes regained vision >20/400. Fourteen of 19 (73.7%) vitreous biopsies were microbiologically positive (culture, PCR, and microscopy), and the majority (11 patients, 78.5%) were fungi.

Conclusion

Intraocular infection in COVID-19 patients is predominantly caused by fungi. We suggest a routine eye examination be included as a standard of care of COVID-19.

Clinical profile and magnitude of diabetic retinopathy: An electronic medical record-driven big data analytics from an eye care network in India

Purpose:

This study aimed to describe the clinical profile and magnitude of diabetic retinopathy (DR) in patients presenting to a multitier eye hospital network in India.

Methods:

This cross-sectional hospital-based study included 263,419 individuals with diabetes mellitus (DM) presenting between February 2012 and February 2021 (9-year period). The data were collected using an electronic medical record (EMR). Patients with a clinical diagnosis of DR in at least one eye were included in the analysis. Severe nonproliferative DR/proliferative DR/diabetic macular edema (DME) were considered sight-threatening DR (STDR).

Results:

In the study period, 25% (n = 66,913) were new patients diagnosed with DR. The majority of patients were males (70%). The mean age of the patients was 57 ± 10 years. The risk factors for DR were increased age: 30 to 50 years (odds ratio [OR] = 2.42), and 51 to 70 years (OR = 3.02), increased duration of DM: 6 to 10 years (OR = 2.88) and >10 years (OR = 6.52), blindness (OR = 2.42), male gender (OR = 1.36), lower socioeconomic status (OR = 1.43), and rural habitation (OR = 1.09). STDR was seen in 58% (n = 38,538) of examined patients. Risk factors for STDR were increased age 31 to 50 years (OR = 3.51), increased duration of DM: 6 to 10 years (OR = 1.23) and >10 years (OR = 1.68), blindness (OR = 3.68), male gender (OR = 1.12), and higher socioeconomic status (OR = 1.09).

Conclusion:

Every fourth person with DM was found to have DR, and every second person with DR had STDR in this study cohort. These real-world big data might provide greater insight into the current status of DR. Additional big data from similar EMR-based sources will help in planning and resource allocation.

The ORNATE India project: Building research capacity and capability to tackle the burden of diabetic retinopathy-related blindness in India

The ORNATE India project is an interdisciplinary, multifaceted United Kingdom (UK)–India collaborative study aimed to build research capacity and capability in India and the UK to tackle the burden of diabetes-related visual impairment. For 51 months (October 2017–December 2021), this project built collaboration between six institutions in the UK and seven in India, including the Government of Kerala. Diabetic retinopathy (DR) screening models were evaluated in the public system in Kerala. An epidemiological study of diabetes and its complications was conducted through 20 centers across India covering 10 states and one union territory. The statistical analysis is not yet complete. In the UK, risk models for diabetes and its complications and artificial intelligence-aided tools are being developed. These were complemented by joint studies on various aspects of diabetes between collaborators in the UK and India. This interdisciplinary team enabled increased capability in several workstreams, resulting in an increased number of publications, development of cost-effective risk models, algorithms for risk-based screening, and policy for state-wide implementation of sustainable DR screening and treatment programs in primary care in Kerala. The increase in research capacity included multiple disciplines from field workers, administrators, project managers, project leads, screeners, graders, optometrists, nurses, general practitioners, and research associates in various disciplines. Cross-fertilization of these disciplines enabled the development of several collaborations external to this project. This collaborative project has made a significant impact on research capacity development in both India and the UK.

Various models for diabetic retinopathy screening that can be applied to India

The increased burden of diabetes in India has resulted in an increase in the complications of diabetes including sight-threatening diabetic retinopathy (DR). Visual impairment and blindness due to DR can be prevented by early detection and management of sight-threatening DR. Life-long evaluation by repetitive retinal screening of people with diabetes is an essential strategy as DR has an asymptomatic presentation. Fundus examination by trained ophthalmologists and fundus photography are established modes of screening. Various modes of opportunistic screening have been followed in India. Hospital-based screening (diabetes care/eye care) and community-based screening are the common modes. Tele-ophthalmology programs based on retinal imaging, remote interpretation, and grading of DR by trained graders/ophthalmologists have facilitated greater coverage of DR screening and enabled timely referral of those with sight-threatening DR. DR screening programs use nonmydriatic or mydriatic fundus cameras for retinal photography. Hand-held/smartphone-based fundus cameras that are portable, less expensive, and easy to use in remote places are gaining popularity. Good retinal image quality and accurate diagnosis play an important role in reducing unnecessary referrals. Recent advances like nonmydriatic ultrawide field fundus photography can be used for DR screening, though likely to be more expensive. The advent of artificial intelligence and deep learning has raised the possibility of automated detection of DR. Efforts to increase the awareness regarding DR is essential to ensure compliance to regular follow-up. Cost-effective sustainable models will ensure systematic nation-wide DR screening in the country.

Severity of diabetic retinopathy and its relationship with age at onset of diabetes mellitus in India: A multicentric study

Purpose:

To present clinical profile and risk factors of sight-threatening diabetic retinopathy (STDR) among people with age of onset of diabetes (AOD) <25 versus ≥25 years.

Methods:

A retrospective chart analysis of consecutive patients with diabetic retinopathy (DR) n = 654) treated at 14 eye care centers across India between 2018 and 2019 was performed. Patients were divided into two groups, Group 1: AOD <25 years and Group 2: AOD ≥25 years. DR and diabetic macular edema (DME) were classified using the International Clinical Classification of DR severity scale. STDR included severe nonproliferative DR (NPDR), proliferative DR (PDR), and moderate to severe DME. A multilevel mixed-effects model was used for comparison between two groups: 1) Patients with DR and AOD <25 years and 2) Patients with DR and AOD ≥25 years. Bivariate and multivariate regression analyses were used to evaluate risk factors between the two groups.

Results:

A total of 654 patients were included, 161 (307 eyes) in AOD <25 and 493 (927 eyes) in AOD >25 group. There was a higher prevalence of PDR with high-risk characteristics in AOD <25 group (24% vs. 12%) at baseline and 12-month follow-up (25% vs. 6%); P < 0.001. Systolic hypertension and poor glycemic control were risk factors in both groups, with no difference in these modifiable risk factors between groups.

Conclusion:

People with youth-onset DM are likely to present with severer form of STDR despite similar modifiable risk factors. Therefore, strict control of systolic blood pressure, glycemic status, and regular screening for DR are recommended to reduce the risk of STDR irrespective of the age of onset of diabetes.

Does myopia decrease the risk of diabetic retinopathy in both type-1 and type-2 diabetes mellitus?

Purpose

To study the relationship between the severity of myopia and the severity of diabetic retinopathy (DR) in individuals with type 1 or type 2 diabetes mellitus (DM).

Methods

This retrospective study was conducted using data from electronic medical records from a multicentric eyecare network located in various geographic regions of India. Individuals with type 1 or type 2 DM were classified according to their refractive status. Severe nonproliferative DR (NPDR), PDR, or presence of clinically significant macular edema (CSME) with any type of DR was considered as vision-threatening diabetic retinopathy (VTDR).

Results

A total of 472 individuals with type-1 DM (mean age 41 ± 10 years) and 9341 individuals with type-2 DM (52 ± 9 years) were enrolled. Individuals with a hyperopic refractive error had a significant positive association with the diagnosis of VTDR (odds ratio (OR) 1.26; 95%CI 1.04-1.51, P = 0.01) and moderate nonproliferative DR (OR 1.27; 95%CI 1.02-1.59, P = 0.03) in type-2 DM; however, no significant association was found in type-1 DM. After adjusting for age, gender, anisometropia, and duration of diabetes, the presence of high myopia (< - 6 D) reduced the risk of VTDR in type 2 DM (OR 0.18; 95% CI 0.04-0.77, P = 0.02), but no association was found in type 1 DM. Mild and moderate myopia had no significant association with any forms of DR in both type-1 and type-2 DM.

Conclusion

Hyperopic refractive error was found to increase the risk of VTDR in persons with type 2 DM. High-myopic refractive error is protective for VTDR in type 2 DM, but not in type-1 DM.

Recently updated global diabetic retinopathy screening guidelines: commonalities, differences, and future possibilities

Diabetic retinopathy (DR) is a global health burden. Screening for sight-threatening DR (STDR) is the first cost-effective step to decrease this burden. We analyzed the similarities and variations between the recent country-specific and the International Council of Ophthalmology (ICO) DR guideline to identify gaps and suggest possible solutions for future universal screening. We selected six representative national DR guidelines, one from each World Health Organization region, including Canada (North America), England (Europe), India (South- East Asia), Kenya (Africa), New Zealand (Western Pacific), and American Academy of Ophthalmology Preferred Practice Pattern (used in Latin America and East Mediterranean). We weighed the newer camera and artificial intelligence (AI) technology against the traditional screening methodologies. All guidelines agree that screening for DR and STDR in people with diabetes is currently led by an ophthalmologist; few engage non-ophthalmologists. Significant variations exist in the screening location and referral timelines. Screening with digital fundus photography has largely replaced traditional slit-lamp examination and ophthalmoscopy. The use of mydriatic digital 2-or 4-field fundus photography is the current norm; there is increasing interest in using non-mydriatic fundus cameras. The use of automated DR grading and tele-screening is currently sparse. Country-specific guidelines are necessary to align with national priorities and human resources. International guidelines such as the ICO DR guidelines remain useful in countries where no guidelines exist. Validation studies on AI and tele-screening call for urgent policy decisions to integrate DR screening into universal health coverage to reduce this global public health burden.

Medical management of silicone oil associated acute postoperative ocular inflammation

We report a case of a 57-year-old man, who underwent right eye silicone oil injection as a part of his surgical treatment for rhegmatogenous retinal detachment. Following this, on the first postoperative day, he developed acute postoperative intraocular inflammation. There was circumciliary congestion, diffuse corneal oedema, anterior chamber (AC) reaction, hypopyon and a pupillary membrane. The AC had not been entered during the surgery. No patients, who had been operated on the same day, or with the materials having the same batch number, developed similar reactions. We started the patient on hourly topical steroids and cycloplegics after which the patient's condition showed gradual improvement. At the 2 weeks follow-up appointment, his pupillary membrane had completely contracted and the AC was quiet. This case highlights a clinical picture of acute postoperative silicone oil-induced ocular inflammation, which was resolved through medical management.

Impact of treatment of diabetic macular edema on visual impairment in people with diabetes mellitus in India

Purpose:

The aim of this study was to report visual and anatomical outcomes following treatment for diabetic macular edema (DME) in clinical practice in India.

Methods:

Retrospective chart review of patients with DME who were initiated on treatment and followed up for at least 1 year at 9 tertiary eye care centers during 2016–2017 was performed. Data on demographics, systemic illnesses, visual acuity and anatomical characteristics of DME, treatment history were collated and analyzed for change in visual acuity level and central macular thickness at 1 year.

Results:

A total 1853 patients were diagnosed with treatable DME during study period, 1315 patients were treated and 556 patients (1019 eyes) followed up at one year. Although patients achieved significantly better anatomical outcome (central macular thickness of <300μ in 32.3% at baseline compared to 60.7% at 1 year, P < 0.001), visual impairment due to DME did not differ from baseline (mild visual impairment in 53.2% at baseline compared to 56% at 1 year, P = 0.7). Cystoid type of DME was the most common phenotype (432/1019, 42.4%) followed by spongy type (325, 31.9%) and cystoid plus spongy type (138, 13.5%). Bevacizumab monotherapy was the most common (388/1019, 38.1%) treatment followed by combination therapy (359, 35.2%). Mean number of anti-VEGF injections received per eye in a year was 2.1 (SD ± 0.9).

Conclusion:

Only about a third of treated DME patients complete one year follow up in India. Most patients receive suboptimal number of treatments. Treated DME cases largely show better anatomical outcome but not a better functional outcome.

Neovascular glaucoma - A review

Neovascular glaucoma (NVG) is a sight-threatening secondary glaucoma characterized by appearance of new vessels over the iris and proliferation of fibrovascular tissue in the anterior chamber angle. Retinal ischemia is the common driving factor and common causes are central retinal vein occlusion, proliferative diabetic retinopathy, and ocular ischemic syndrome. The current rise in the prevalence of NVG is partly related to increase in people with diabetes. A high index of suspicion and a thorough anterior segment evaluation to identify the early new vessels on the iris surface or angle are essential for early diagnosis of NVG. With newer imaging modalities such as the optical coherence tomography angiography and newer treatment options such as the anti-vascular endothelial growth factor, it is possible to detect retinal ischemia early, tailor appropriate treatment, monitor disease progression, and treatment response. The management strategies are aimed at reducing the posterior segment ischemia, reduce the neovascular drive, and control the elevated intraocular pressure. This review summarizes the causes, pathogenesis, and differential diagnoses of NVG, and the management guidelines. We also propose a treatment algorithm of neovascular glaucoma.

Capacity building for diabetic retinopathy screening by optometrists in India: Model description and pilot results

Purpose:

The present study's objectives are 1) to describe a novel model of Diabetic Retinopathy Capacity Building (DRCB) for optometrists in the detection of diabetes-related retinal pathology in India and 2) to assess the outcomes of this model by comparing the ability of optometrists to detect these diseases using retinal photographs, vis-à-vis, a specialist ophthalmologist.

Methods:

The DRCB model for optometrists conducted between August 2016 and August 2018 included training, certification in the screening, and referral guidelines for Diabetic Retinopathy (DR) and hospital-and community-based service delivery. Training included a 7-month long fellowship in DR and mentored participation as cofacilitators in 1-day orientation workshops on DR screening guidelines across India. The sensitivity and specificity of study optometrists in screening for DR by fundus photography were compared to a retina specialist before certification.

Results:

A total of eight optometrists successfully completed their DR fellowship in the project duration of 24 months. The sensitivity and specificity of detection of any DR were 95 and 79%, any Diabetic macular edema (DME) was 80 and 86%. The sensitivity and specificity of detection of sight threatening DR were 88 and 90% and DME was 72% and 92% respectively. Seven workshops were cofacilitated by study optometrists training 870 optometrists in DR screening guidelines across India.

Conclusion:

The present DRCB model results advocate for an optometry coordinated DR screening in India. Lessons learnt from this model can be useful in designing community-based task sharing initiatives for optometrists in DR screening.

Subfoveal retinal pigment epithelium inflammatory lesion presenting as a sign of reactivation of tubercular multifocal choroiditis

Multifocal choroiditis (MFC) can be associated with ocular tuberculosis (TB). Inflammatory peripapillary choroidal neovascular membrane (PPCNVM) is uncommon in TB MFC. Subretinal pigment epithelial inflammatory lesions are suggestive of acute inflammation or reactivation of inflammation in the setting of MFC. We present a case of MFC, of tubercular aetiology, during course of treatment of PPCNVM developed a subfoveal retinal pigment epithelial lesion. Clinical examination suggested a recurrence of PPCNVM, with the new macular lesions posing a dilemma of new onset inflammatory choroidal neovascular membrane (CNVM) at the macula versus reactivation of choroiditis at the posterior pole. Multimodal imaging helped differentiate the lesion from CNVM and give the appropriate antitubercular treatment to prevent future recurrences.

Outcomes of neovascular glaucoma in eyes presenting with moderate to good visual potential

PURPOSE

To compare the disease characteristics and treatment outcomes of patients with neovascular glaucoma (NVG) presenting with visual acuity (VA) 6/60 or better in two different health systems.

METHODS

Retrospective chart review of consecutive patients with NVG who presented between January 2016 to January 2018 in 5 tertiary-centres in India and one eye-specialist centre in London (UK) was performed. The baseline characteristics, treatment provisions, and visual outcomes in the India and UK cohorts were compared.

RESULTS

At presentation, 18% (83 of 451) and 22% (59 of 270) of patients with NVG had VA 6/60 or better in India and the UK cohorts, respectively. The aetiologies of NVG were similar with proliferative diabetic retinopathy being the most common cause (60.9%, India; 64.4%, UK; p = 0.38). Previous panretinal photocoagulation was more prevalent in the UK cohort compared to the India cohort (94.9% versus 66.3%, respectively; p < 0.001). The mean number of intravitreal anti-VEGF injections per eye was higher in the Indian cohort (1.65 ± 0.97 versus 1.14 ± 1.02 injections; p < 0.001). The number of eyes with closed angles (36.9% India versus 30.5% UK; p = 0.45) and the number of eyes needing glaucoma interventions (52.1% India; 62.7% UK; p = 0.82) were similar in two cohorts. Among glaucoma surgeries, trabeculectomies were more commonly performed in the Indian cohort (23 vs 4; p < 0.001),while glaucoma drainage device surgeries were more prevalent in the UK cohort (18 vs 4 p < 0.001). After a median follow-up of 21 months (IQR 8.4-34.8 India; 24-36 months UK), favourable visual outcomes (vision stable or improved) were similar in both health systems (52.5% in the Indian cohort vs 43.4% in the UK cohort; p = 0.28). On multivariate regression analysis, the need for trans-scleral cyclophotocoagulation was associated with worse visual outcomes in both cohorts.

CONCLUSIONS

The causes and clinical profile of neovascular glaucoma with presenting visual acuity 6/60 or better in India and the UK were similar. Only up to 50% of eyes achieved favourable visual outcomes with current management protocols in both health systems.

Posterior pole retinal breaks causing posterior pole retinal detachment in a middle-aged man with retinal vasculitis and moderate myopia

A 38-year-old man presented with sudden decreased vision in the right eye 3 years ago due to vitreous haemorrhage. During follow-up, right eye fundus showed evidence of vasculitis, non-perfusion areas and neovascularisation elsewhere. Systemic evaluation findings of positive Mantoux test, QuantiFERON Gold test and right apical pleuroparenchymal fibrosis observed on high-resolution CT of the chest were suggestive of postinfection probable tubercular aetiology. He was treated with oral steroids, antitubercular therapy, intravitreal bevacizumab and anterior retinal cryopexy, leading to resolution of vasculitis and vitreous haemorrhage. Later he developed peripheral retinal flap and posterior retinal breaks at 8-month and 11-month follow-up, respectively, which were managed by barrage laser. He maintained a stable visual acuity of 20/20, N6 for the next 2 years. He then presented with sudden decreased vision in the right eye (20/50, N10). Right eye fundus showed posterior pole retinal detachment with lifting of previously barraged posterior retinal breaks. He underwent vitreoretinal surgery with gas tamponade. Recent 1-month postoperative visit showed successful retinal reattachment and visual recovery of 20/20, N6.

Utility of pattern recognition and multimodal imaging in the diagnosis and management of doyne honeycomb retinal dystrophy complicated with type one choroidal neovascular membrane

A 44-year-old woman presented with decreased vision in both eyes. The retina in both eyes had drusen distributed along vascular arcades, central macula and in peripapillary region. Macula had pigmented scarring and exudation. Fundus autofluorescence showed drusen. Optical coherence tomography showed drusen, subretinal and intraretinal fluid. Fundus fluorescein and indocyanine green angiography showed drusen, retinal pigment epithelial atrophy and vascular network. Younger age at presentation, bilateral symmetry, typical distribution of drusen along the arcades in a radiating pattern, peripapillary involvement, scarring and atrophy at macula were suggestive of doyne honeycomb retinal dystrophy. The reduced vision was due to macular atrophy and an active choroidal neovascular membrane. The patient was treated with antivascular endothelial growth factor injections for choroidal neovascular membrane. Our case highlights the importance of pattern recognition and multimodal imaging for diagnosing the type of macular dystrophy as doyne honeycomb retinal dystrophy, while simultaneously managing choroidal neovascular membrane.

Validation of visual acuity applications for teleophthalmology during COVID-19

PURPOSE

The objective of this study was to identify and validate smartphone-based visual acuity (VA) apps that can be used in a teleophthalmology portal.

METHODS

The study was conducted in three phases: A survey to investigate if the SmartOptometry App was easy to download, understand and test (phase I), an in-clinic comparison of VA measured in a random testing order with four tools namely COMPlog, Reduced Snellen near vision, Peek Acuity (Distance VA) and SmartOptometry (Near VA) (phase II) and a repeatability study on these 4 tools by measuring VA again (phase III). The study recruited the employees of our institute and adhered to the strict COVID-19 protocols of testing.

RESULTS

Phase I Survey (n = 40) showed 90% of participants used android phones, 60% reported that instructions were clear, and all users were able to self-assess their near VA with SmartOptometry App. Phase II (n = 68) revealed that Peek Acuity was comparable to COMPlog VA (P = 0.31), however SmartOptometry was statistically significantly different (within 2 log MAR lines) from Reduced Snellen near vision test, particularly for young (n = 44, P = 0.004) and emmetropic (n = 16, P = 0.04) participants. All the 4 tests were found to be repeatable in phase III (n = 10) with a coefficient of repeatability ≤0.14.

CONCLUSION

Smartphone-based apps were easy to download and can be used for checking patient's distance and near visual acuity. An effect of age and refractive error should be considered when interpreting the results. Further studies with real-time patients are required to identify potential benefits and challenges to solve.

Need for Vitreous Surgeries in Proliferative Diabetic Retinopathy in 10-Year Follow-Up: India Retinal Disease Study Group Report No. 2

INTRODUCTION

To report the 10-year rate of vitrectomies and the associated factors in people with proliferative diabetic retinopathy (PDR) from a multicentric cohort of people with diabetes mellitus.

METHODS

Ten centres in India with established vitreoretinal (VR) services for over 10 years were invited to provide long-term data on PDR. People with Type 1 or 2 diabetes with a clinical diagnosis of active PDR in 1 or both eyes were included. Baseline data collected included age, sex, duration of diabetes, source of referral and best-corrected visual acuity, and diabetic retinopathy status in both eyes. Available follow-up data included the numbers of panretinal photocoagulation (PRP) sessions, cataract surgery, treatment of diabetic macular oedema, use of anti-vascular endothelial growth factor (VEGF) therapy, vitrectomy with or without retinal surgeries over 10 years.

RESULTS

Over 10 years, 89% needed supplemental PRP after initial complete PRP. One-third required retinal surgery, 16% needed intravitreal injection. Men (74.5%) had significant higher risk for vitreous (VR) surgery. Of the group with low-risk PDR, 56.8% did not require VR surgery, p < 0.001. Of the patients who underwent cataract surgery and had intravitreal anti-VEGF injections, 78.5 and 28.2% needed subsequent vitreous (VR) surgery, p = 0.006 and <0.0001, respectively. Independent predictors of need for vitreoretinal surgery included those who underwent cataract surgery and those with poor baseline visual acuity (logMAR). Eyes at lower risk for VR surgery included the eyes previously treated with PRP and low-risk PDR at baseline.

CONCLUSION

Despite initial "complete" PRP, one-third of our study cohort needed vitrectomies over 10 years, highlighting that these patients require regular follow-up for a long period of time.

Reversal of diabetic tractional retinal detachment attributed to keto diet

A 40-year-old woman, known type 2 diabetes mellitus, obese (100 kg), on insulin (80 units), was under treatment for unstable proliferative diabetic retinopathy with extramacular tractional retinal detachment (TRD) in the left eye. At 1-year follow-up, she developed progression of TRD involving the macula in the left eye for which she was advised surgery. She did not follow-up for 6 months during which time she had adopted a coconut oil-rich ketogenic diet. She reported losing 25 kg body weight along with reversal of diabetes (Glycosylated Haemglobin (HbA1C) of 5.3% without insulin) in the interim. During this 2-year follow-up visit, it was found that there was complete resolution of macular detachment due to TRD in the left eye with stable vision. This was attributed to the impactful ketogenic diet.

Bullous central serous chorioretinopathy and retinal pigment epithelium sequelae postblunt trauma

A 68-year-old man presented with diminution of distance and near vision in the right eye for a duration of 1 month postblunt trauma with a stick. On examination, his visual acuity in the right eye was 20/320 and near vision was <N36. Right eye fundus showed bullous neurosensory retinal detachment at posterior pole and retinal pigment epithelium (RPE) atrophic area temporal to fovea. Optical coherence tomography showed subretinal fluid with pigment epithelial detachment and an area of RPE and photoreceptor loss temporal to fovea. Fundus fluorescein angiography and indocyanine green angiography showed focal leaks and transmitted hyperfluorescence corresponding to the area of RPE loss. Left eye examination was unremarkable except for senile cataract of nuclear opalescence grade 3. A diagnosis of right eye bullous central serous chorioretinopathy (CSCR) and RPE sequelae postblunt trauma was made. Our patient was managed conservatively with no specific treatment for CSCR. One month later, there was improvement in vision with decrease in neurosensory detachment. The area of RPE loss remained the same with photoreceptor loss. Since this area of RPE and photoreceptor loss were temporal to fovea, our patient's visual acuity was not affected significantly.

Management outcomes of secondary glaucoma due to retinopathy of prematurity: A 19-year prospective study at a tertiary eye care Institute. The Indian Twin cities ROP Screening (ITCROPS) database report number 8

PURPOSE

To report the clinical presentation and management outcomes of glaucoma in the "Indian Twin cities retinopathy of prematurity (ROP) Screening database."

METHODS

All children with diagnosis of ROP and glaucoma between 1997 and 2016 from a prospective database were included. Glaucoma was classified as open when anterior chamber (AC) was deep, closed when AC was shallow or flat and neovascular when there was extensive iris neovascularization. ROP was classified based on International classification of ROP.

RESULTS

The prevalence of secondary glaucoma in our cohort was 1.36% (82 eyes of 6000 children). Eighty-two eyes of 54 children with secondary glaucoma due to ROP where included in this study. The distribution of glaucoma among the ROP stages included, stage V (58.5%), stage 1V (24.3%), stage III (2.4%) and stage II (1.2%) eyes. Median (interquartile range) duration from birth to glaucoma diagnosis was 7.8 (4.2, 24.9) months. Type of glaucoma was angle closure in 39 (47.6%), open angle in 35 (42.7%) and neovascular in 8 (9.8%) eyes. Retinal interventions included vitreoretinal surgery in 59 (72%), retinal laser in 14 (17%) and intravitreal bevacizumab injection in 19 (23.1%) eyes. The mean (±standard deviation) IOP at presentation was 22.6 ±11.8 mm Hg. Glaucoma was managed medically in 66 (76%) and surgically in 16 (19.5%) eyes. The mean follow up for the entire cohort was 1.14±2.24 years. At final visit, 37% eyes with ROP and glaucoma had ambulatory vision with mean IOP of 16.0±8.1 mm Hg and 56 eyes (68.2%) needed glaucoma medications.

CONCLUSION

In this large ROP cohort, 1.36% eyes developed secondary glaucoma. Majority of them had stage V or IV ROP and 1/5 of them needed glaucoma surgery. Around 1/3rd of the ROP eyes with glaucoma had ambulatory vision.

Multimodal imaging in retinal pigment epithelium rip with exudative bullous retinal detachment

A middle-aged man presented with exudative retinal detachment in the left eye. He was previously diagnosed as a case of large pigment epithelial detachment in the same eye, for which he was asked to follow-up closely, citing the risk of an retinal pigment epithelium (RPE) rip. Multimodal imaging confirmed the presence of a large RPE rip with exudative retinal detachment. He is a known retrovirus patient on anti-retroviral therapy with stable CD4 counts. He was diagnosed as a possible case of bullous variant of central serous chorioretinopathy and underwent external subretinal fluid drainage. We highlight the multimodal imaging findings of RPE rip with exudative retinal detachment and its impact on the patients visual acuity.

A rare case of bilateral sequential posterior scleritis in an elderly woman

A 63-year-old woman came with complaints of decreased vision and minimal pain on extraocular movements in the left eye and, after investigations, was diagnosed with posterior scleritis. Systemic steroid treatment helped resolve the symptoms and signs. One year later, she presented with right eye involvement. She was evaluated for systemic illness and, based on clinical and investigational findings, it was deduced that probably a sarcoidosis was predisposing her to the eye problem. She was provisionally diagnosed with bilateral sequential posterior scleritis secondary to sarcoidosis. She was prescribed oral steroids, which helped resolve her eye problem. She was next referred to a rheumatologist and a pulmonologist for further evaluation and treatment.