OUTCOME OF EYES TREATED FOR RETINOPATHY OF PREMATURITY IN POSTERIOR ZONE I: An Eastern India Study

PURPOSE

To analyze the outcomes of eyes treated for retinopathy of prematurity in posterior Zone I.

METHODS

In a part retrospective (9 years) and part prospective (1 year) interventional study, we analyzed eyes treated for retinopathy of prematurity in posterior Zone I with a minimum follow-up for 6 months.

RESULTS

This study included 109 eyes of 56 infants; mean gestational age and birth weights were 29.3 (±2.1) weeks and 1112.5 (±381.9) g, respectively. The treatment included intravitreal anti-vascular endothelial growth factor as the initial treatment modality in 101 eyes (92.6%), either alone (27 eyes) or combined with laser or vitreous surgery (73 eyes). Laser was the initial treatment modality in eight eyes, either alone (n = 3) or in combination with surgery (n = 5). With anti-vascular endothelial growth factor alone, 30.68% (n = 27) eyes responded favorably, and the remaining 69.32% (n = 59) eyes needed retreatment (laser in the majority). At the final follow-up, 89.9% (out of 109) of eyes did well anatomically. Good outcome was significantly linked to no detachment at presentation ( P < 0.0001) and the presence of well-defined central vascular trunks ( P = 0.001).

CONCLUSION

Treating the eyes before retinal detachment with bevacizumab followed by laser (and surgery, if needed) results in a favorable outcome in babies with posterior Zone I retinopathy of prematurity.

Clinico-Microbiological Correlation in Salmonella Endophthalmitis: Case Series and Review of Literature

PURPOSE

To report two rare cases of Salmonella endogenous endophthalmitis in an immunocompromised premature baby and an immunocompetent adult and do a brief literature review of related cases. Diagnosis in both cases was confirmed only after the pathogen grew from ocular samples, in the absence of clear signs of enteric fever.

METHODS

Retrospective analysis of medical and microbiology records.

RESULTS

Both of our cases of Salmonella endophthalmitis had poor visual outcome, despite timely and aggressive management and irrespective of immune status of the patient. Salmonella infection being a rare cause of endophthalmitis was not initially suspected as the adult had minimal systemic symptoms 2 weeks before presentation, while the preterm baby was still on milk feeds. These were just two microbiologically confirmed cases of Salmonella endophthalmitis at our institute over the past 10 years, though enteric fever due to Salmonella species is endemic in Asian countries.

CONCLUSIONS

Salmonella endophthalmitis, though rare, leads to poor visual outcomes despite early recognition and aggressive management and may be confused with other infections or non-infectious entities such as necrotizing retinoblastoma in babies, in the absence of clear systemic signs of the disease.

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.

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.

Understanding the relationship between pachychoroid spectrum disorders and retinitis pigmentosa: A review of the evidence

This study aims to investigate the relationship between pachychoroid spectrum disorders and retinitis pigmentosa (RP) or rod-cone dystrophy through a comprehensive literature review. The purpose is to explore the association between these disorders, understand their underlying mechanisms, and summarize the existing hypotheses and opinions. A thorough review of the literature was conducted using PubMed, focusing on articles related to central serous chorioretinopathy (CSC), RP, pachychoroid pigment epitheliopathy, pachychoroid neovasculopathy, polypoidal choroidal vasculopathy, focal choroidal excavation, peripapillary pachychoroid neovasculopathy, and peripheral exudative hemorrhagic chorioretinopathy. Relevant studies were selected for a detailed narrative review and analysis. Several studies have reported the coexistence of CSC and RP, indicating a potential association between the two conditions. The dysfunction of the retinal pigment epithelium is proposed as a common factor. Choroidal thinning is observed in RP, but conflicting results exist regarding choroidal thickness (CT). While some studies support choroidal thinning in RP, others suggest preserved or increased thickness. Additionally, cases of pachychoroid neovasculopathy and polypoidal choroidal vasculopathy in RP have been reported, suggesting an overlap between these conditions. The literature suggests conflicting reports on CT changes in RP. Future research should focus on large-scale studies using comprehensive imaging techniques, genetic analysis, and long-term follow-up to uncover the underlying mechanisms and determine the prevalence of pachychoroid spectrum disorders in RP patients.

Generation of two induced pluripotent stem cell lines (LVPEIi004-A and LVPEIi005-A) from probands with Leber Congenital Amaurosis 2 (LCA2) and harboring mutations in RPE65

Leber Congenital Amaurosis 2 is an early onset retinal dystrophy that occurs due to mutation in RPE65 gene. Here, we report the generation of two patient specific induced pluripotent stem cell lines harboring nonsense mutations in exon 7 (c.646A > T) and exon 9 (c.992G > A) of RPE65 gene, respectively, which leads to premature translational termination and formation of defective protein. These lines were generated by the reprogramming of human dermal fibroblast cells using integration-free, episomal constructs expressing stemness genes. The stable lines maintained a normal karyotype, expressed the key stemness factors, underwent trilineage differentiation, and maintained their genetic identity and genomic integrity.

Generation of two induced pluripotent stem cell lines (LVPEIi007-B, LVPEIi008-B) from patients harboring homozygous mutation in ABCA4 (c.6088C>T) using non-integrative Sendai virus-based approach

Mutations in ABCA4 gene leads to the most common form of an inherited retinal disease namely, the Stargardt disease, type 1. Here, we report the generation of two different patient-specific induced pluripotent stem cell lines (LVPEIi007-B and LVPEIi008-B), carrying an identical homozygous mutation, (c.6088C>T) within the exon 44 of ABCA4 gene. These lines were generated by the reprogramming of patient-specific dermal fibroblasts, using the integration-free, Sendai viral vectors. Both lines were stably expanded and expressed the stemness and pluripotency markers, differentiated into cell types of all three germ layers, and maintained a normal karyotype.

Evaluation of optical coherence tomography biomarkers to differentiate favourable and unfavourable responders to intravitreal anti-vascular endothelial growth factor treatment in retinopathy of prematurity

OBJECTIVE

Evaluation of optical coherence tomography biomarkers in predicting treatment response to intravitreal injection of anti-vascular endothelial growth factor (anti-VEGF) Bevacizumab, in aggressive retinopathy of prematurity (A-ROP).

METHODS

Non-contact ultra-widefield (NC-UWF) fundus imaging with integrated UWF guided swept source Optical coherence tomography (SS-OCT) was performed prospectively in preterm babies before and after intravitreal anti-VEGF (Bevacizumab) monotherapy. OCT biomarkers were analysed in eyes that reached complete vascularization versus others.

RESULTS

Eyes with retinal vessels reaching near ora serrata were labelled as regressed ROP and vascularised retina (Group1). Eyes with reactivation of ROP needing laser or vitreoretinal surgery or eyes with peripheral avascular retina (PAR) at 16th week post-injection were considered as Group 2. Pre-injection baseline OCT showed a hyperreflectivity of inner retinal layers in 12 out of 46 eyes in Group 1 versus 30 out of 34 eyes in Group 2 (p value 0.002). None of the eyes in Group 1 showed choroidal thinning at posterior pole as compared to 14 out of 34 eyes in Group 2 (p value 0.001). Intraretinal hypo reflective Cystic changes at fovea were seen in 16 out of 46 eyes in Group 1 and 2 out of 34 eyes in Group 2 (p value 0.012).

CONCLUSION

Pre-injection swept source OCT biomarkers could predict the treatment outcomes of anti-VEGF (Bevacizumab) monotherapy in A-ROP eyes. Hyperreflectivity of inner retinal layers and choroidal thinning had poorer and unpredictable response to anti-VEGF injection whereas, cystic changes at fovea predicted favourable response.

Generation of Leber congenital amaurosis, type 12 patient-specific induced pluripotent stem cell line (LVPEIi006-A), harboring a homozygous mutation in RD3

Leber congenital amaurosis (LCA) is a congenital, early onset, autosomal recessive inherited retinal disease (IRD). This report describes an LCA12 patient-specific iPSC line (LVPEIi006-A), generated by the reprogramming of dermal fibroblasts using integration-free episomal plasmids.This disease-specific iPSC model carries a homozygous point mutation in RD3, within the donor splice site at the end of exon 2 (c.296 + 1G > A). The stable line at passage 15 has displayed a normal colony morphology, expressed multiple stemness and pluripotency markers, lost all transgenes, differentiated into cell types of all three germ layers, and maintained a normal karyotype.

RPE65 mutations in Leber congenital amaurosis, early-onset severe retinal dystrophy, and retinitis pigmentosa from a tertiary eye care center in India

INTRODUCTION

Mutations in the retinal pigment epithelial 65 kilodalton protein (RPE65) gene are associated with various inherited retinal diseases (IRDs), including Leber congenital amaurosis (LCA), early-onset severe retinal dystrophy (EOSRD), and retinitis pigmentosa (RP). We screened for mutations in RPE65 in a series of Indian patients with these IRDs to determine the frequency/types of mutations and to describe the associated phenotypes.

MATERIALS AND METHODS

Diagnosis of LCA, EOSRD, and RP was made by standard and pre-defined criteria. Patients were evaluated by clinical, retinal imaging, and electrophysiological parameters. Genomic DNA from patients and available family members were used for identifying mutations by direct Sanger sequencing of the RPE65 gene or targeted NGS gene panel for IRDs covering 260+ genes. Variations detected were tested in healthy control populations and for co-segregation with the disease in available family members.

RESULTS

Mutations were found in eight patients, out of 220 total cases screened, all homozygous for the respective mutant alleles. Seven patients had mutations leading to premature termination codons and one patient had a missense change. The onset of visual loss ranged from birth to <2 years of life. At presentation, RPE mottling in the background retina was present in all cases with macular involvement in five cases with or without vascular attenuation and optic disc pallor.

CONCLUSION

RPE65 mutations in this series were found in 3.6% of cases associated with severe, early-onset disease, with consistent RPE mottling and variable manifestations with regard to the extent of disc pallor, arteriolar attenuation, and appearance of the macula.

Outcomes of vitreoretinal surgery in eyes with retinitis pigmentosa without retinal detachment

PURPOSE

Outcomes of retinal detachment (RD) have been discussed in detail in many reports of patients with retinitis pigmentosa (RP). This study tries to understand the outcomes of vitreoretinal (VR) surgery for indications other than RD in the eyes with RP.

METHODS

This is a retrospective study that includes clinical data from January 2013 to December 2021. Patients with RP who were treated with a VR surgical intervention were included in the study. The primary outcome of the study was to assess the changes in best-corrected visual acuity.

RESULTS

Forty-four eyes of 40 patients with RP were included in the study. Nearly half of the eyes (43%, 19/44) presented from 1 month to 1 year after the onset of diminished vision, with or without floaters. The mean ± standard deviation (SD) best-corrected visual acuity (BCVA) at presentation was 1.30 ± 0.79 logMAR (20/400 ± 20/125). The major surgical indications were vitreous opacities (43.2%, 19/44) and subluxated/dislocated cataractous lenses (25%, 11/44). The median follow-up duration was 8 months (interquartile range (IQR): 1.5-27). Approximately 77% (34/44) of the eyes had improvement in vision. The mean postoperative BCVA at the last follow-up was 0.95 ± 0.73 logMAR (p-value: 0.03).

CONCLUSIONS

Most eyes with RP recovered well after VR surgical interventions, with short-term improvements in visual acuity. It may be crucial to address the vitreous opacities and membranes as they hinder the residual central island of vision in RP. However, appropriate counselling is required regarding the progressive nature of retinal neuronal degeneration.

Gene Therapy for Inherited Retinal Diseases: From Laboratory Bench to Patient Bedside and Beyond

This comprehensive review provides a thorough examination of inherited retinal diseases (IRDs), encompassing their classification, genetic underpinnings, and the promising landscape of gene therapy trials. IRDs, a diverse group of genetic conditions causing vision loss through photoreceptor cell death, are explored through various angles, including inheritance patterns, gene involvement, and associated systemic disorders. The focal point is gene therapy, which offers hope for halting or even reversing the progression of IRDs. The review highlights ongoing clinical trials spanning retinal cell replacement, neuroprotection, pharmacological interventions, and optogenetics. While these therapies hold tremendous potential, they face challenges like timing optimization, standardized assessment criteria, inflammation management, vector refinement, and raising awareness among vision scientists. Additionally, translating gene therapy success into widespread adoption and addressing cost-effectiveness are crucial challenges to address. Continued research and clinical trials are essential to fully harness gene therapy's potential in treating IRDs and enhancing the lives of affected individuals.

Characteristics of posterior zone I retinopathy of prematurity

OBJECTIVE

To report the demographic profile and clinical characteristics of retinopathy of prematurity (ROP) in posterior Zone I.

METHODS

In a partly retrospective (ten years) and partly prospective (one year) study, we analysed the demographic profile and clinical characteristics of babies with ROP in posterior Zone I.

RESULTS

The study included 130 eyes of 67 infants with a mean gestational age and birth weight of 29.3 (±2.2) weeks and 1217.3 (±381.9) grams, respectively. All babies had received unblended oxygen. In 47 of 51 (91.1%) babies, the weekly weight gain was <100 g (details were not available in 16 babies). The ROP subtypes included aggressive, threshold, hybrid, stage 4, and atypical types in 78 (60%), 20 (15.4%), 11 (8.5%), 15 (11.5%), and 6 (4.6%) eyes, respectively. Fibrovascular proliferation, when present, was prominent nasally, occasionally overriding the disc margin. Extensive arteriovenous tortuosity was more prominent than vascular dilatation. Atypical observations included bleb-like detachment (6 eyes; 4.6%) and candle wax-like preretinal deposits (23 eyes; 17.7%).

CONCLUSIONS

Retinopathy of Prematurity in posterior Zone I in this cohort was strongly associated with 100% unblended oxygen supplementation, poor weight gain, and multiple systemic co-morbidities. ROP in posterior zone 1 has a distinct profile with several atypical characteristics different from ROP in other zones.

Electronic medical records driven big data analytics in retinal diseases, report number 1: non-oncological retinal diseases in children and adolescents in India

PURPOSE

To describe the spectrum and demographic distribution of non-oncological retinal diseases in children and adolescents presenting to a multi-tier ophthalmic hospital network in India.

METHODS

This is a cross-sectional hospital-based retrospective study over nine years (March 2011-March 2020) from a pyramidal eye care network in India. The analysis included 477,954 new patients (0-21 years), collected from an International Classification of Diseases (ICD) coded electronic medical record (EMR) system. Patients with a clinical diagnosis of retinal disease (non-oncological) in at least one eye were included. Age-wise distribution of these diseases in children and adolescents was analysed.

RESULTS

In the study, 8.44% (n = 40,341) of new patients were diagnosed with non-oncological retinal pathology in at least one eye. The age group-specific distribution of retinal diseases was 47.4%, 11. 8%, 5.9%, 5.9%, 6.4%, 7.6% in infants (< 1 year), toddlers (1-2 years), early childhood (3-5 years), middle childhood (6-11 years), early adolescents (12-18 years) and late adolescents (18-21 years), respectively. 60% were male, and 70% had bilateral disease. The mean age was 9.46 ± 7.52 years. The common retinal disorders were retinopathy of prematurity (ROP, 30.5%), retinal dystrophy (19.5%; most commonly, retinitis pigmentosa), and retinal detachment (16.4%). Four-fifth of the eyes had moderate to severe visual impairment. Nearly one-sixth of patients needed low vision and rehabilitative services, and about 1 in 10 patients required surgical intervention (n = 5960, 8.6%).

CONCLUSION AND RELEVANCE

About 1 in 10 children and adolescents seeking eye care in our cohort had non-oncological retinal diseases; the common ones were ROP (in infants) and retinitis pigmentosa (in adolescents). This information would help future strategic planning of eye health care in the institution in pediatric and adolescent age groups.

Color fundus imaging in retinopathy of prematurity screening: Present and future

Advent of pediatric handheld fundus cameras like RetCam, 3netra Forus, and Phoenix ICON pediatric retinal camera has aided in effective screening of retinopathy of prematurity (ROP), especially in countries with limited number of trained specialists. Recent advent of various smartphone-based cameras has made pediatric fundus photography furthermore affordable and portable. Future advances like ultra-wide field fundus cameras, trans-pars-planar illumination pediatric fundus camera, artificial intelligence, deep learning algorithm, and handheld SS-OCTA can help in more accurate imaging and documentation. This article summarizes the features of existing and upcoming imaging modalities in detail, including their features, advantages, challenges, and effectiveness, which can help in implementation of telescreening as a standard screening protocol for ROP across developing as well as developed countries.

Tablet-based 'ON/OFF' pathway test can distinguish between rod- and cone-dominated diseases

INTRODUCTION

The photopic ON pathway defect is associated with nocturnal vision loss. However, the measurement of ON function to detect a rod-dominated disease (rods affected more than cones) has not been explored. We evaluated whether the psychophysical evaluation of ON/OFF pathways can be used to distinguish cone-dominated from rod-dominated diseases.

METHODS

Thirty-seven patients with inherited retinal diseases were tested using the 'EyeSpeed' [iOS application] on an iPad. The test displayed a random number (1-3) of light or dark targets on a black-and-white noise background. Participants responded on a touch screen indicating the correct number of targets displayed. The outcome variables-reaction time, accuracy and performance index (speed [1/reaction time] * accuracy) to both light and dark targets were assessed for diagnostic ability using standard receiver-operating characteristic (ROC) analysis.

RESULTS

Mean ± standard deviation age and visual acuity for the cone- and rod-dominated groups were 25.15 ± 11.74 years, 0.80 ± 0.25 logMAR and 28.3 ± 14.29 years, 0.48 ± 0.26 logMAR, respectively. The median reaction time to light targets in rod-dominated disease [interquartile range] was 5.28 s [3.17], significantly greater than for patients with cone-dominated disease (2.07 s [0.93]; Mann-Whitney U test, p < 0.001). Amongst all of the outcome variables evaluated, the reaction time to light targets (criterion of ≥2.98 s) exhibited the highest area under the ROC curve (area = 0.89 ± 0.11; p < 0.001), with a sensitivity and specificity of 82.4% and 85% respectively.

CONCLUSIONS

Reaction time to light targets using the ON/OFF pathway paradigm is a valid marker to differentiate between rod- and cone-dominated retinal dystrophies. ON pathway function measured using a tablet-based test could act as a supplemental test in the diagnosis of challenging photoreceptor-specific inherited retinal diseases.

Visual impairment and blindness due to retinitis pigmentosa in India: 15-year follow-up of the Andhra Pradesh Eye Disease Study cohort

Purpose

To assess the incidence, visual impairment, and blindness due to retinitis pigmentosa (RP) in a rural southern Indian cohort.

Methods

This is a population-based longitudinal cohort study of participants with RP from the Andhra Pradesh Eye Disease Study (APEDS) cohorts I and III, respectively. The study included participants with RP of APEDS I who were followed until APEDS III. Their demographic data along with ocular features, fundus photographs, and visual fields (Humphrey) were collected. Descriptive statistics using mean ± standard deviation with interquartile range (IQR) were calculated. The main outcome measures were RP incidence, visual impairment, and blindness as per the World Health Organization (WHO) definitions.

Results

At baseline (APEDS I), 7771 participants residing in three rural areas were examined. There were nine participants with RP with a mean age at baseline of 47.33 ± 10.89 years (IQR: 39-55). There was a male preponderance (6:3), and the mean best-corrected visual acuity (BCVA) of 18 eyes from nine participants with RP was 1.2 ± 0.72 logarithm of minimum angle of resolution (logMAR; IQR: 0.7-1.6). Over a mean follow-up duration of 15 years, 5395/7771 (69.4%) were re-examined, which included seven RP participants from APEDS 1. Additionally, two new participants with RP were identified; so, the overall incidence was 370/ million in 15 years (24.7/million per year). The mean BCVA of 14 eyes of seven participants with RP who were re-examined in APEDS III was 2.17 ± 0.56 logMAR (IQR: 1.8-2.6), and five of these seven participants with RP developed incident blindness during the follow-up period.

Conclusion

RP is a prevalent disease in southern India that warrants appropriate strategies to prevent this condition.

Avascular Peripheral Retina in Infants

Avascular peripheral retina in an infant is a common characteristic of numerous pediatric retinal vascular disorders and often presents a diagnostic challenge to the clinician. In this review, key features of each disease in the differential diagnosis, from retinopathy of prematurity, familial exudative vitreoretinopathy, Coats disease, incontinentia pigmenti, Norrie disease, and persistent fetal vasculature, to other rare hematologic conditions and telomere disorders, will be discussed by expert ophthalmologists in the field.

Combined rhegmatogenous and tractional retinal detachment in a child with incontinentia pigmenti managed by scleral imbrication with scleral buckle

We report for the first time a child with incontinentia pigmenti presenting with acute-onset rhegmatogenous retinal detachment in association with pre-existing tractional retinal detachment. Due to the combined nature of this detachment, complex vector forces acting on the retina makes this a difficult to treat situation. A single surgery of modified scleral imbrication with scleral buckle was effective in reattaching the retina by providing a very high buckle indent to accommodate all the complex vector forces. Commonly used procedure of vitrectomy and silicone oil usage was avoided as that often requires multiple surgeries and may result in variable and unpredictable response.

Intravitreal Clindamycin as an Adjuvant Therapy in Congenital Toxoplasma Retinochoroiditis in a Neonate - A Case Report

PURPOSE

To report a case of active retinochoroiditis in a neonate treated with intravitreal clindamycin as an adjuvant therapy.

CASE REPORT

A 10-day-old infant presented with active retinochoroiditis lesions in both eyes along with hepatosplenomegaly, abdominal distension, and thrombocytopenia. The mother had a history of fever in the third trimester for which she received symptomatic treatment. The infant was treated with systemic anti-toxoplasma therapy along with intravitreal clindamycin in the severely affected eye. There was a significant faster resolution in the retinochoroiditis lesions, which eventually lead to better anatomical and visual outcomes.

CONCLUSION AND IMPORTANCE

Active screening and timely intervention of the neonates who are born to mothers with fever during pregnancy can go a long way in preventing unlikely outcomes due to congenital toxoplasma retinochoroiditis. Intravitreal clindamycin can be considered as an adjuvant therapy in selected cases.

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.

Non-contact widefield neonatal retinal imaging for retinopathy of prematurity using the Clarus 700 high resolution true colour reflectance imaging

OBJECTIVE

To illustrate the role of non-contact widefield retinal imaging (NC-WFI) of retinopathy of prematurity (ROP) using the Clarus 700 high resolution true colour reflectance imaging.

METHODS

All babies were examined by the vitreoretinal faculty in a tertiary eye care centre from a period of March 2021 to November 2021 using the indirect ophthalmoscope after pupillary dilatation. ROP grading was done according to the revised ICROP (2005) classification. NC-WFI was then performed using the Clarus 700 high resolution true colour reflectance imaging (Carl Zeiss Meditec, Dublin, CA) in the retina diagnostic set up of a tertiary eye care centre.

RESULTS

A total of 22 babies (44 eyes) underwent NC-WFI from March 2021 to November 2021. 13 unique cases of retinopathy of prematurity with images captured on Clarus 700 and the clinical summary is described.

CONCLUSION

Clarus is a non-contact wide field imaging (NC-WFI) system that can capture high resolution and true colour images (images of the fundus appear similar colour to direct observation by ophthalmoscopy) helping in more accurate diagnosis and grading of the severity of ROP.

Effectiveness and future implications of COVID-19-related risk stratification for managing retinopathy of prematurity: The Indian twin cities retinopathy of prematurity study report number 10

Purpose

To evaluate the effectiveness and future implications of COVID-related risk stratification for managing retinopathy of prematurity (ROP).

Methods

A prospective study was conducted at a tertiary eye care center from the beginning of the lockdown in India from 23 March 2020 till the end of the first phase of lockdown on 29 May 2020. We evaluated 200 prematurely born infants (< 34 weeks of gestational age) using the new safety guideline protocols for low-risk babies developed in conjunction with the Indian ROP Society for care during the COVID-19 pandemic. Low risk included babies born at more than 30 weeks of gestational age, post menstrual age 34 weeks or above at presentation, more than 1000 grams of birth weight, and stable systemically with good weight gain.

Results

New guidelines were implemented in 106 (53%) infants who were low risk while 94 (47%) infants with high risk were followed up as per the old guidelines. Out of the 106 infants (212 eyes) managed by the new guidelines, good outcome (group 1) was seen in 102 (96.2%) infants. Twenty-seven of the 102 infants had some form of ROP and 5 of these infants needed treatment. None of the low-risk babies with no detachment at presentation managed by new guidelines required surgery later (group 2). Two (1.9%) infants came with retinal detachment at presentation and underwent successful surgery (group 3) and two infants (1.9%) were lost to follow up.

Conclusion

New risk stratification during the COVID-19 pandemic was an efficient and safe strategy in managing low-risk ROP babies.

Retinitis pigmentosa in Laurence-Moon-Bardet-Biedl syndrome in India: Electronic medical records driven big data analytics: Report II

Purpose:

To describe the clinical presentation and demographic distribution of retinitis pigmentosa (RP) in Laurence–Moon–Bardet–Biedl (LMBB) syndrome patients.

Methods:

This is a cross-sectional observational hospital-based study wherein 244 patients with RP in LMBB syndrome presenting to our hospital network between March 2012 and October 2020 were included. An electronic medical record database was used for data retrieval.

Results:

There were 244 patients in total, with a hospital-based prevalence rate of 0.010% or 1000/100,000 population. The mean and median age of patients was 15.22 ± 7.56 and 14 (IQR: 10–18.5) years, respectively, with the majority being in the age group of 11–20 years (133/244 patients; 54.50%). Males were more commonly affected (164 patients; 67.21%), and the majority (182 patients; 74.59%) were students. All 244 patients (100%) complained of defective central vision at presentation. More than one-fourth of the patients had severe visual impairment to blindness at presentation. Prominent retinal feature at presentation was diffuse or widespread retinal pigment epithelial degeneration in all patients.

Conclusion:

Patients with RP in LMBB syndrome present mainly in the first to second decade of life with severe visual acuity impairment to blindness early in life. It is important to rule out LMBB syndrome in early-onset RP with central visual acuity impairment. On the contrary, all patients diagnosed or suspected with LMBB syndrome systemic features at physician clinic should also be referred for ophthalmic evaluation, low vision assessment, rehabilitation, and vice versa.

Retinitis pigmentosa in Usher syndrome in India: Electronic medical records driven big data analytics: Report III

Purpose:

To describe the clinical presentation and demographic distribution of retinitis pigmentosa (RP) in patients with Usher syndrome (USH).

Methods:

This is a cross-sectional observational hospital-based study including patients presenting between March 2012 and October 2020. In total, 401 patients with a clinical diagnosis of USH and RP in at least one eye were included as cases. The data were retrieved from the electronic medical record database. For better analysis, all 401 patients were reclassified into three subtypes (type 1, type 2, and type 3) based on the USH criteria.

Results:

In total, there were 401 patients with USH and RP, with a hospital-based prevalence rate of 0.02% or 2/10,000 population. Further, 353/401 patients were subclassified, with 121 patients in type 1, 146 patients in type 2, and 86 patients in the type 3 USH group. The median age at presentation was 27 years (IQR: 17.5–38) years. There were 246 (61.35%) males and 155 (38.65%) females. Males were more commonly affected in all three subtypes. Defective night vision was the predominant presenting feature in all types of USH (type 1: 43 (35.54%), type 2: 68 (46.58%), and type 3: 40 (46.51%) followed by defective peripheral vision. Patients with type 2 USH had more eyes with severe visual impairment.

Conclusion:

RP in USH is commonly bilateral and predominantly affects males in all subtypes. Patients with USH and RP will have more affection of peripheral vision than central vision. The key message of our study is early visual and hearing rehabilitation in USH patients with prompt referral to otolaryngologists from ophthalmologists and vice versa.

Evaluation of a revised care plan for babies with retinopathy of prematurity during SARS-CoV-2 pandemic in India

Purpose:

To analyze the impact of a revised care plan for retinopathy of prematurity (ROP) during SARS-CoV-2 pandemic in a tertiary eye care facility in eastern India.

Methods:

In a retrospective study, we analyzed the medical records of babies managed for ROP during the peak of the SARS-CoV-2 pandemic, with particular reference to the challenges, and the revised strategies addressing travel restrictions for five months, from April to August 2020. The strategy included selective referral (babies with higher treatment probability), longer follow-up intervals (babies with non-alarming findings), use of locally available workforce, and teleconsultation whenever feasible.

Results:

In the given period, 222 babies were examined versus 624 in the preceding year (P = 0.001). The average gestational age, birth weight, and postmenstrual age at presentation were 30.4 weeks, 1.31 kg, and 37.7 weeks, respectively. The first examination was on time in 40.1% of babies but was delayed by a median of 23 days in the remaining babies. In the cohort, 56.7% of babies had any ROP, and 27.9% required treatment (versus 8.8% in the previous year; P < 0.001). The intravitreal anti–vascular growth factor (anti-VEGF) injection was more often used than in the previous year (n = 72 vs 36; P < 0.0001). The treatment outcome was comparable before and after the SARS-CoV-2 lockdown period. There was no report of health issues among the care providers attributable to ROP care.

Conclusion:

The revised strategy resulted in a smaller pool of babies screened but a larger proportion of babies treated for ROP. This strategy could be used more profitably in future ROP care.

Exudative retinal detachment as an initial presentation of retinopathy of prematurity: Clinical profile and outcomes of a rare presentation

Purpose

To describe the clinical profile and treatment outcomes of infants with retinopathy of prematurity (ROP) presenting with isolated exudative retinal detachment (ERD).

Methods

Retrospective interventional case series. Preterm infants diagnosed with ROP with ERD at presentation were included. All demographic details, clinical findings, and treatment given were documented. The anatomical outcome was categorized as good, fair, and poor. Refractive outcome was classified into mild, moderate, and severe according to spherical equivalent at the last visit.

Results

Fifteen eyes (8 patients) were included. Mean gestational age was 31.3 weeks, and birth weight was 1462.6 g. All eyes presented with aggressive ROP. Patches of retinal edema in avascular retina were seen in all eyes. A total of 86.6% of eyes had vascular sclerosis while 86.6% of eyes had subretinal exudates. The anatomical outcome was good in all eyes. In addition, 40% of eyes had a mild refractive error.

Conclusion

Exudative retinal detachment in ROP is rare. The use of unregulated oxygen can be a contributory factor. Vascular sclerosis is consistent with hyperoxia-induced retinopathy models. Retinal edema and subretinal exudates indicate disrupted inner and outer blood-retinal barrier. Treatment outcomes are good when diagnosed and treated in time.

Clinical and visual electrophysiological characteristics of vitelliform macular dystrophies in the first decade of life

Purpose:

To evaluate patterns of pediatric vitelliform macular dystrophy (PVMD).

Methods:

This is a retrospective analysis of Indian children with vitelliform macular dystrophy (VMD) presenting within the first decade of life. Records were evaluated for clinical findings, family screening, and investigative findings including optical coherence tomography (OCT), fundus autofluorescence (FAF), full-field electroretinogram (ERG) and electrooculogram (EOG). Electrophysiology was scrutinized and audited for acquisition and interpretation errors. Findings on follow-up were also recorded.

Results:

46 eyes of 24 patients were included. Mean age at presentation was 7.17 ± 2.17 years. Mean follow-up duration was 1.55 ± 1.69 years. Best disease was the commonest type of VMD detected (21 patients), while autosomal recessive bestrophinopathy was seen in three cases. Mean logMAR BCVA was 0.364 which decreased to 0.402 on follow-up. Hyperopia was noted in 29 out of 46 eyes (mean being +3.87 D, range ebing +0.75 to +8.75 D). Four eyes of four children had choroidal neovascular membrane at presentation, while another child developed while in follow-up. Solid type subretinal deposit was the commonest OCT finding (n = 29/38) and central hyper FAF was the commonest pattern (n = 18/32). EOG was available for review in 32 eyes, but was unreliable in 11 eyes. Seven eyes demonstrated complete absence of light rise on EOG.

Conclusion:

PVMD can present in advanced forms. Progression to complications with loss of visual acuity can happen within the first decade of life. EOG shows grossly suppressed waveforms in the light phase in a large number of such children.

Ophthalmological Manifestations of Oculocutaneous and Ocular Albinism: Current Perspectives

Albinism describes a heterogeneous group of genetically determined disorders characterized by disrupted synthesis of melanin and a range of developmental ocular abnormalities. The main ocular features common to both oculocutaneous albinism (OCA), and ocular albinism (OA) include reduced visual acuity, refractive errors, foveal hypoplasia, congenital nystagmus, iris and fundus hypopigmentation and visual pathway misrouting, but clinical signs vary and there is phenotypic overlap with other pathologies. This study reviews the prevalence, genetics and ocular manifestations of OCA and OA, including abnormal development of the optic chiasm. The role of visual electrophysiology in the detection of chiasmal dysfunction and visual pathway misrouting is emphasized, highlighting how age-associated changes in visual evoked potential (VEP) test results must be considered to enable accurate diagnosis, and illustrated further by the inclusion of novel VEP data in genetically confirmed cases. Differential diagnosis is considered in the context of suspected retinal and other disorders, including rare syndromes that may masquerade as albinism.

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.

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.

The retinal vascular growth rate in babies with retinopathy of prematurity could indicate treatment need

Purpose

To analyze the weekly rate of retinal vascular growth in treatment-naïve babies with various stages of retinopathy of prematurity (ROP) and validate if this could be a predictor of treatment need.

Methods

Retrospective review of medical charts and retinal images of babies with various stages of ROP. The images were enhanced using red-green image enhancement software. Using the length of the horizontal disc diameter (DD) of each eye, the vessel growth was measured from the disc margin up to the vessel tip in fixed quadrants. The rate of vessel growth was the ratio of vessel length to the number of weeks it took to reach this length. The babies were divided into treatment warranting ROP (group 1), low-risk pre-threshold (type II) ROP (group 2,), and no-ROP (group 3) for analysis. The "no-ROP" group acted as normal control. Group 1 was further subdivided into 1A (threshold ROP), IB (aggressive posterior ROP), 1C (hybrid ROP), and ID (high-risk pre-threshold ROP).

Results

Out of 436 eyes, groups 1, 2, and 3 had 238, 108, and 90 eyes, respectively. The mean rate of vascular outgrowth along with 95% confidence interval (CI) was 0.490 [0.487,0.520], 0.612 [0.599, 0.638], and 0.719 [0.703, 0.740] DD/week, respectively, for babies with "treatment warranting," "low risk pre-threshold" and "no ROP" groups, respectively. In our estimate, more than 80% of eyes with a vessel growth rate of 0.54 DD/week or less required treatment.

Conclusion

A rate of retinal vascular growth less than 0.54 DD/week can be used to determine treatment requirements in babies with ROP.

A retrospective analysis of ultra-widefield photograph (Optos) documentation of retinopathy of prematurity at a tertiary eye care outpatient setup: the Indian Twin Cities ROP Study, report number 11

PURPOSE

To demonstrate the usefulness of ultrawide-field fundus (UWF) photography for documentation in retinopathy of prematurity (ROP).

METHODS

The medical records of infants with ROP who underwent at least one sitting of UWF fundus photography in addition to binocular indirect ophthalmoscopy (BIO) from April 2018 to September 2020 were analyzed retrospectively. BIO was conducted by a trained ROP specialist, and final diagnosis and treatment were based solely on BIO findings. All fundus photographs were captured on Optos UWF camera (Dunfermline, UK) in a flying baby position. Demographic details and fundus findings on BIO and fundus photographs were analyzed.

RESULTS

Of the 187 infants who met inclusion criteria for successful imaging, 22 (11.7%) had findings that were discordant with BIO. Although no posterior disease was missed, 4 infants who received treatment would not have been treated based solely on UWF photography findings. Of the 60 babies whose images did not meet the inclusion criteria for successful imaging, 41 had ROP that required intervention.

CONCLUSIONS

In our patient cohort, UWF photography proved useful in documenting the initial and follow-up findings of preterm babies with ROP.

Age-related decline in function of ON and OFF visual pathways

Purpose

A simple psychophysical paradigm is available as a digital application in iOS devices such as iPad to measure the function of ON and OFF visual pathways. However, an age-matched normative database is not readily available. The purpose of the study is to evaluate the response of ON and OFF visual pathways as a function of age.

Methods

158 normal healthy adults (84 males and 74 females) whose age ranged 18–80 years participated in the study. None of them had any ocular disease (except cataract of grade II or less) and visual acuity of ≤ 20/25. Monocular testing (only one eye) was performed on the ‘EyeSpeed’ application on an iPad at 40cm distance. The targets ranged between 1 to 3 light or dark squares presented randomly in a noise background and participants responded by indicating the number of squares by touching the screen as fast as possible. The main outcome variables are reaction time, accuracy and performance index (1 / speed * accuracy).

Results

The median reaction time was shorter (Median (IQR): 1.53s (0.49) [dark] Vs 1.76s (0.58) [light], p < 0.001) and accuracy was higher (97.21% (3.30) [dark] Vs 95.15% (5.10) [light], p < 0.001) for dark targets than the light targets. Performance index and reaction time for both target types significantly correlated with age (ρ = -0.41 to -0.43; p < 0.001).

Conclusions

This normative database will be useful to quantify disease-specific defects. More importantly, the ON pathway function can potentially serve as a surrogate for rod photoreceptor function.

Genetics of Inherited Retinal Diseases in Understudied Populations

Retinitis pigmentosa is one of the major forms of inherited retinal dystrophy transmitted in all Mendelian and non-Mendelian forms of inheritance. It involves the loss of retinal photoreceptor cells with severe loss of vision or blindness within the first 2 decades of life. RP occurs at a relatively high prevalence in India and is often associated with consanguinity in certain South Asian communities where this practice is customary. This review describes the studies that have been published with regard to genetics of retinitis pigmentosa in India and neighboring South Asian countries. These populations have been understudied in these aspects although to a variable degree from one country to another. Genetic studies on RP in India have been carried out with a range of methods aimed at detecting specific mutations, to screening of candidate genes or selected genomic regions, homozygosity mapping to whole genome sequencing. These efforts have led to a molecular genetic characterization of RP in Indian families. Similar studies on large extended families from Pakistan have provided insight into several novel genes underlying the pathogenesis of these diseases. The extreme degree of clinical and genetic heterogeneity of RP renders it challenging to identify the associated genes in these populations, and to translate the research output towards better management of the disease, as there are no unifying genetic features that are characteristic of any population so far.

A207 COMMON BILE DUCT OBSTRUCTION FROM RADIOGRAPHICALLY OCCULT LITHIASIS: A CASE REPORT AND CAUTIONARY TALE

Background

Biliary obstruction from choledocholithiasis (CDL) can lead to many serious complications, such as cholangitis and pancreatitis. Among noninvasive diagnostic tests for CDL, MRCP is superior to US and CT with a sensitivity of 89–95%. Despite this, MRCP may not always identify the cause of obstruction, leading to diagnostic dilemmas.

Aims

We aim to review the various ways that CDL can hide on imaging, specifically MRCP.

Methods

A 22-year-old male with pyruvate kinase deficiency was admitted to General Surgery for acute cholecystitis, for which he had a laparoscopic cholecystectomy. Preoperative MRCP showed a 3 mm common bile duct (CBD) with no stones; however, gross inspection of the gallbladder showed multiple green stones. Around one month later, he was readmitted to General Surgery for symptomatic biliary obstruction, with total bilirubin 923, ALP 457 and ALT 559. He was not febrile and did not require antibiotics. An MRCP showed a CBD of 10 mm with intra- and extrahepatic biliary dilation, but no obstructing focus was seen. Gastroenterology was consulted for undifferentiated hyperbilirubinemia. After further discussion, an ERCP with sphincterotomy was done the next day which also did not show obstruction. An abdominal US done the day after ERCP showed improvement in biliary dilation. After ERCP, the patient’s symptoms improved. Total bilirubin, ALP, and ALT one month later decreased to 121, 134, and 139 respectively. The hypothesis was that he had an obstructing gallstone that camouflaged within bile on imaging.

Consent was obtained from the patient to present this case report.

Results

Although MRCP is one of the best noninvasive diagnostic tests for CDL, some stones may not appear on imaging. On MRCP, stones usually appear as hypointense spots surrounded by hyperintense bile on T2-weighted imaging. However, sludge can be isointense compared to bile. Additionally, stones impacted at the ampulla of Vater typically are not surrounded by bile and thus may evade detection on MRCP. Small stones <4 mm can be missed as well. CBD dilation greater than 10 mm is also associated with reduced sensitivity of MRCP for CDL. Even with ERCP, small stones may be missed unless seen on direct optical visualization after a blind balloon sweep.

Even if no obstructing lesion is seen on imaging, other clinical features can still suggest CDL requiring ERCP. The ASGE 2019 Guidelines on CDL recommend prompt ERCP for patients with total bilirubin >68.4 µmol/L and CBD dilation on imaging. Other radiographic signs suggesting CDL include CBD dilation, papillitis, and pericholecystic fat infiltration on CT, and MRCP findings of CDL-associated inflammation such as biliary wall thickening and periductal edema.

Conclusions

Even if MRCP does not show obvious obstruction, ERCP should still be considered if the likelihood of CDL remains high.

Funding Agencies

None

Association of follistatin and cytochrome p450 side-chain cleavage enzyme with polycystic ovarian syndrome

Objectives

Polycystic ovarian syndrome is a complex disorder commonly found in women in their reproductive age around the globe. Due to its higher clinical implications and communicability, this research article describes epidemiological studies and the association of known microsatellite markers with PCOS in the Pakistani population.

Methods

Data were collected from 62 Pakistani women. The study involved pedigree analysis which revealed recessive mode of inheritance in all of them. The mendelian ratio in marriages between non-PCOS (male) and PCOS (female) individuals remained 1:1 while between non-PCOS (male) and non-PCOS (female) remained 3:1, respectively.

Results

The result showed that there was an association of marker D15S519 (CYP11A, 10q24.3) with family 5 with an X2 value of 7.78 (P < 0.01) while a strong association of marker D5S822 (FS, 5p14) with an X2 value of 4.89 (P < 0.05) was observed in family 2. In the case of family 1, a weak association of allele 1 with marker D19S212 (INSL3, 19p13.1) was observed with an X2 value of 2.25 (P > 0.10), While family 6 also presented a very weak association of homozygosity with marker D19S391 (INS receptor, 19p13.2) with X2 value of 3.45 (P ≥ 0.05).

Conclusion

Findings indicated a higher prevalence of PCOS and highlights the emergence of more interventions to minimize the level of complications in women. Our intrusions intended to describe the genetic basis of PCOS in Pakistani population with special emphasis on large families in current study. Moreover, association of known loci for PCOS with our families.

Compassionate and standard operating procedure-based counseling and practice are essential in high-risk infantile anesthesia and managing death in eye surgery

Physicians have to play the role of a team leader and counselor and take written informed consent for high-risk surgeries in many cases. This is the first step toward initiating a mutually trustworthy relationship with the patient and family. The situation is more sensitive when vulnerable patients like small premature babies or the elderly are under consideration. In the event of a death, leadership and processes in place become extremely critical. We share our experience and practice pattern during this process, especially suited to India, but the broad principles would apply to most human situations. Hopefully, some of these can be incorporated into the existing training curriculum for team building and the art of effective physician-patient communication that should be intricately woven into the curriculum for the Science of Ophthalmic care.

Coats' disease: trends and long-term treatment outcomes in a tertiary referral centre

Background:

The long-term treatment outcomes in Coat’s disease – particularly in the era of newer pharmacotherapies such as anti-vascular endothelial growth factor (VEGF) agents and depot steroids – are poorly understood.

Aim:

To describe the clinical features and treatment outcomes of 148 eyes with Coats’ disease assessed in a referral centre over 30 years.

Materials and methods:

We conducted a retrospective chart review of patients diagnosed with Coats’ disease between 1 June 1987 and 31 July 2017. The demographic, clinical and treatment data were collected and long-term functional and anatomical outcomes were analysed based on the treatment either with conventional therapy (cryo/laser) or along with adjuvants like intravitreal steroids or anti-VEGFs.

Results:

The mean age at presentation was 15.22 years (median 11). Familial exudative vitreoretinopathy was the most common referral diagnosis, 76/148 (51.5%), followed by Coats’ disease, 37/148 (25%), and retinoblastoma, 35/148 (23.6%). Stage 3B was most common at presentation (31.8%), followed by 2B (22.3%) and 2A (16.9%). A total of 107 patients were treated either with conventional therapy or in combination with adjuvants. The mean follow-up period was 24.95 months. The visual acuity improved from baseline logMAR 2.17 (Snellen-20/2958) to logMAR 1.88 (Snellen-20/1517) at final follow-up (p = 0.004). The improvement in visual acuity was better when the presenting BCVA was <1 logMAR (Snellen 20/200), p = 0.004. No statistically significant change in BCVA was noted between conventional and adjuvant groups, p = 0.5. However, the final anatomical outcome was good in 78/99 (78.8%) in the conventional group and 45/49 (91.8%) in the adjuvant group, respectively (p = 0.046).

Conclusion:

In this series of patients with Coats’ disease over three decades, the use of intravitreal steroids or anti-VEGFs as adjuvants resulted in better anatomical outcomes. A better baseline visual acuity, lower stage of the disease, and older age at presentation were found to be the factors leading to favourable visual outcomes.

Summary

In the current series of 148 eyes with Coats’ disease, adjuvant treatment with intravitreal steroids or anti-VEGFs resulted in better outcomes as compared with conventional cryotherapy or laser photocoagulation alone. Patients with Coats’ disease who had presented with better visual acuity at baseline, lower stage of the disease and older age had better final visual outcomes.

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.

OCT Imaging in Infants

Optical coherence tomography (OCT) is widely applied in diagnosis and management of retina diseases particularly macular diseases in adult retina practices. However, it has been under-utilized in pediatric retinal diseases especially in neonates and infants. Utilization of OCT in primary macular diseases in this age group is also uncommon and is less reported. Challenges involved in image acquisition and limitations with available devices technique can explain the limited research and accurate data availability in the literature in this field. Purpose of this review article is to summarize the use of OCT and its importance in various infantile retinal pathologies such as vascular diseases, tumors, retinal dystrophies, and optic nerve pathologies with primary focus on neonates and infants, along with infant choroid. In addition, we also discuss about future directions including OCT angiography for infants.

Clinical Presentation and Demographic Distribution of Retinitis Pigmentosa in India and Implications for Potential Treatments: Electronic Medical Records Driven Big Data Analytics: Report I

AimTo describe the clinical presentation and demographic distribution of retinitis pigmentosa in patients presenting to a multi-tier ophthalmology hospital network in India and implications for potential treatments.DesignCross-sectional hospital-based study.MethodsThis study included 2,541,810 patients presenting between March 2012 and October 2020. Patients with a clinical diagnosis of retinitis pigmentosa in at least one eye were included as cases. The data were collected using an electronic medical record system.ResultsOverall, 15,062 (0.59%) new patients were diagnosed with retinitis pigmentosa and were included for analysis. The median age was 35 (IQR: 21-49) years and adult age (84.56%) presented more often. The most common presenting age group was between 21 and 30 years (20%). Majority of patients were male (61.68%) and had bilateral (96.39%) affliction. There was a family history in a tenth of the patients (10.46%) and a history of consanguinity in a minority (5.53%). The majority of the eyes had mild or no central visual acuity impairment of <20/70 (34.25%) followed by blindness <20/400 to 20/1200 (21.26%). The predominant retinal signs included disc pallor (76.43%), attenuated arterioles (82.61%) and bony spicule pigmentation (90.15%), and almost all had retinal pigmentary changes. A minority of the eyes underwent a surgical procedure (4.96%).ConclusionRetinitis pigmentosa is commonly bilateral and predominantly affects males. Most patients present in the third decade of life with severe visual acuity impairment. More than half of the eyes from our study are potential candidates for newer therapies. These results have implications for upcoming treatment choices and planning.

Imaging the pediatric retina: An overview

Recent decade has seen a shift in the causes of childhood blinding diseases from anterior segment to retinal disease in both developed and developing countries. The common retinal disorders are retinopathy of prematurity and vitreoretinal infections in neonates, congenital anomalies in infants, and vascular retinopathies including type 1 diabetes, tumors, and inherited retinal diseases in children (up to 12 years). Retinal imaging helps in diagnosis, management, follow up and prognostication in all these disorders. These imaging modalities include fundus photography, fluorescein angiography, ultrasonography, retinal vascular and structural studies, and electrodiagnosis. Over the decades there has been tremendous advances both in design (compact, multifunctional, tele-consult capable) and technology (wide- and ultra-wide field and noninvasive retinal angiography). These new advances have application in most of the pediatric retinal diseases though at most times the designs of new devices have remained confined to use in adults. Poor patient cooperation and insufficient attention span in children demand careful crafting of the devices. The newer attempts of hand-held retinal diagnostic devices are welcome additions in this direction. While much has been done, there is still much to do in the coming years. One of the compelling and immediate needs is the pediatric version of optical coherence tomography angiography. These needs and demands would increase many folds in future. A sound policy could be the simultaneous development of adult and pediatric version of all ophthalmic diagnostic devices, coupled with capacity building of trained medical personnel.

Rare case of Terson's syndrome and viral retinitis due to dengue haemorrhagic fever in an infant

Dengue haemorrhagic fever with consequent thrombocytopaenia can lead to intracranial haemorrhage and Terson's syndrome that can lead to visual problems. Simultaneously, the dengue virus can cause typical viral retinitis like picture in the eye. Early funduscopy and vision assessment is desirable in all dengue patients. In our case, an infant with dengue haemorrhagic fever and intracranial haemorrhage developed not only simultaneous bilateral vitreous and subinternal limiting membrane haemorrhage due to Terson's syndrome from the indirect effect of thrombocytopaenia but also typical chorioretinitis possibly due to the direct effect of the virus on the retina. The vitreoretinal surgical outcome was satisfactory in this case.

Clinical presentations, microbiology and management outcomes of culture-proven endogenous endophthalmitis in India

Purpose:

To report the clinical presentation, microbiology, and management outcome of endogenous endophthalmitis in Indian patients.

Methods:

Retrospective chart review of culture-positive (vitreous/urine/blood) endogenous endophthalmitis cases treated in tertiary eye care facility in India was done.

Results:

The study included 173 eyes of 117 patients. Mean patient age was 25.41 ± 20.46 years (median 24 years). Pre-disposing systemic illness could not be elicited in 79 (67.63%) patients. Commonest predisposing systemic condition in patients where it could be detected (n = 79) was pyrexia of unknown origin (25/79 = 32.0%). Following treatment, 45 out of 173 (26.0%) eyes regained vision of ≥20/400. Commonest isolated organism from vitreous was Streptococcus pneumoniae (36 eyes, 20.8%) and fungi were isolated in 24 (13.8%) eyes, the commonest being Candida spp. (8/24, 33.33%). Favorable functional outcome was seen in 26% eyes and favorable anatomic outcome in 43% eyes. Those with an underlying systemic illness were older (P = 0.02), had greater urine culture positivity (P = 0.003), lesser vitreous culture positivity (0.001), greater gram negative etiology (P = 0.0006), and greater fungal etiology (P = 0.01) as compared to those cases without underlying systemic illness.

Conclusion:

Endogenous endophthalmitis in India often presents in young immunocompetent individuals without any underlying systemic illness and with negative blood or urine microbiologic work up. Underlying systemic illness leads to greater gram-negative and fungal etiology. Overall visual outcome is poor inspite of prompt management.