Incidence of post vitrectomy endophthalmitis in India - A multicentric study by VRSI study Group.

INTRODUCTION: The incidence of post vitrectomy endophthalmitis (PVE) is reported to be between 0.02 and 0.84%. Resterilization of single use instruments is a common practice amidst developing countries to make it more affordable to the patients by reducing the cost of the surgery and also reduce the environmental hazard. The aim of our study is to evaluate the incidence of PVE amidst existing sterilization practices of reused instruments in multiple vitreoretinal centres in India. METHODOLOGY: Centres with an endophthalmitis tracking system were invited to participate in a survey. Twenty-five centres were sent a questionnaire via email. The questionnaire included details about the institution, number of vitrectomies performed in a year, sterilization practices followed pre-operatively, intraoperatively and postoperatively, incidence of endophthalmitis and instrument reuse policies. RESULTS: A total of 29 cases of endophthalmitis were reported out of the 47,612 vitrectomies performed across various centres. The mean incidence of endophthalmitis was 0.06%. There was no difference in the rates of endophthalmitis based on various pre-operative, intraoperative or postoperative prophylactic measures. Nearly 80% of the centres change most of the instruments after every case, while the rest reused. The mean number of times a cutter was being reused until discarded was 4.7. Nearly 76% followed a performance-based protocol, and the remaining 24% had a fixed protocol for the number of times an instrument can be reused before discarding it. CONCLUSION: PVE rates are not significantly different in India despite the multiuse of single use instruments. The purpose of this paper is not to suggest an alternate protocol but to creating one in the future with these results in mind, to rationalise the use of single use instruments, make VR surgery more affordable and also have a positive impact on the carbon footprint of consumables in surgery.

A Rare Case of Acute Hemorrhagic Retinopathy Following Intravitreal Melphalan Injection for Persistent Vitreous Seeds in Retinoblastoma.

Purpose: This report describes a case of acute occlusive hemorrhagic complication after intravitreal melphalan for vitreous seeds in retinoblastoma. Methods: A case report is presented. Results: Intravitreal melphalan has been used extensively for vitreous seeds in retinoblastoma. Although melphalan is relatively safe at optimal doses, it can sometimes cause inadvertent complications like hemorrhagic events if the drug is administered close to the retina or in more pigmented eyes. We report a case of a 5-month-old patient with bilateral retinoblastoma who underwent enucleation of the right eye and 2 intravitreal melphalan injections in the left eye (20 µg/0.02 mL) at a 1-month interval for persistent vitreous seeds. After the second injection, there was a sudden decrease in the child's visual acuity in the left eye, and the retina showed multiple intraretinal hemorrhages and diffuse chorioretinal atrophy. Conclusion: Intravitreal melphalan may cause acute hemorrhagic complications after intravitreal use for retinoblastoma seeds, especially in pigmented eyes.

Serpentine retinal pigment epithelial tear.

We report a case of retinal pigment epithelial tear in a patient with peripheral exudative hemorrhagic chorioretinopathy (PEHCR). A 60-year-old diabetic female presented with left eye metamorphopsia. Fundus examination showed bilateral peripheral retinal pigment epithelium (RPE) degeneration, and a large serpentine-shaped RPE degeneration tract extending from the superotemporal arcade to the inferior periphery with associated subretinal hemorrhages in her left eye. This tract curved around the fovea, just sparing it. Fundus fluorescein and indocyanine green angiographies showed bilateral polyps in the superotemporal periphery. Optical coherence tomography through the tract showed scrolled up RPE at its edges with bare underlying Bruch's membrane and choroid in the region of the rip. There was no sign of an underlying pigment epithelial detachment. The patients with PEHCR should be prognosticated about such a rare vision-threatening macular complication.

Subthreshold Micro-Pulse Yellow Laser and Eplerenone Drug Therapy in Chronic Central Serous Chorio-Retinopathy Patients: A Comparative Study.

PURPOSE: To study the outcomes of subthreshold micropulse yellow laser (SML) and eplerenone (EP) therapy in central serous chorio-retinopathy (cCSCR). METHODS: Retrospective study of 28 eyes of 27 patients undergoing SML and 20 eyes of 19 patients undergoing EP therapy. RESULTS: Median duration of follow-up was 8 months for SML and 4.5 months for EP group. Complete SRF resolution was seen in 12/28 (42.8%) eyes in SML and 4/20 (20%) in EP group. Six eyes in SML group and two eyes in EP group needed additional SML. No EP patients demonstrated hyperkalemia warranting stopping of therapy. Baseline visual acuity (VA) was correlated positively with final VA in both groups. Presence/absence of focal leaks had differing outcomes in both treatment groups in terms of anatomical resolution. CONCLUSION: Both treatment modalities were effective in the management of cCSCR showing comparable favorable anatomical outcomes, but visual outcomes were not significant, probably due to chronicity of the pathology.

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

Purpose: To study the clinical and microbiological profile, treatment modalities, and anatomical and functional outcomes among children and adolescents with endogenous endophthalmitis (EE) at a tertiary eye care centre in India. Methods: Medical records of subjects <18 years, presenting with EE from 1997 to 2007 were reviewed. Cases where the causative organism was identified were included. Treatment regimen included systemic antibiotics, vitrectomy, intravitreal antibiotics, and enucleation. Systemic evaluation to identify the source of infection was done by an internist. Microbiological analysis of blood, urine, and ocular specimens was done. The favorable anatomical outcome was defined as the attached retina, with controlled intraocular pressure and clear media at the last follow up. The favorable functional outcome was defined as vision >3/60 on the final follow up. Univariate regression analysis was done to identify factors predicting functional outcome. Results: Thirty eyes of 30 subjects (23 (77%) males) were studied. The mean age at presentation was 6.8 years (range=1-16 years). Fever was evident in four (13%) and blood culture was negative in all cases. Gram-positive organisms were identified in 11 (37%) eyes, fungi in 3 (10%), and toxocara in 8 (27%) eyes. Twenty-three (77%) eyes underwent vitrectomy. Favorable functional and anatomical outcomes were achieved in 9 (30%) and 12 (40%) eyes, respectively. Eyes undergoing vitrectomy showed significant correlation with good functional outcome (P = 0.05). Conclusion: EE is under-reported and not well studied in children. The absence of systemic features may be evident in a developing country with over the counter availability of antibiotics. Gram-positive infections are common and vitrectomy is a beneficial modality of treatment.

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

Purpose: To analyze and report outcomes of microincision vitrectomy surgery (MIVS) for Stage 4 and 5 retinopathy of prematurity (ROP). Methods: Medical records of 202 eyes of 129 premature children undergoing MIVS for Stage 4/Stage 5 ROP between January 2012 and April 2015 were evaluated. The primary outcome measure was the proportion of eyes with anatomical success (defined as attached retina at the posterior pole at last follow-up). Complications associated with MIVS were noted and analysis of risk factors associated with poor anatomical outcome was also done using logistic regression. Results: Mean age of presentation of babies with Stage 4 ROP (2.9 ± 1.75 months) was lower than those with stage 5 disease (5.62 ± 2.55 months) (P < 0.005). One hundred seventeen eyes (56% or 58%) had Stage 5, 38 (19%) had Stage 4a, and 47 (23%) Stage 4b. Ninety-four eyes (47%) had received prior treatment (laser and/or anti-vascular endothelial growth factors [VEGF]). Lens-sparing vitrectomy (LSV) was performed in 58 (29%) eyes while lensectomy with vitrectomy (LV) was performed in 144 (71%) eyes. At a mean follow-up of 32.5 weeks, 102 (50.5%) eyes achieved anatomical success, including 74% eyes in Stage 4a and 4b and 33% in Stage 5. Complications included intraoperative break formation (19%), postoperative vitreous hemorrhage (28%), raised intraocular pressure (12.7%), and cataract progression (2.4%). Factors significantly associated with favorable anatomical outcome were Stage 4 disease (vs. Stage 5) (odds ratio [OR] 5.8; confidence interval [CI] =2.6-13.8, P < 0.005), prior treatment (laser ± anti-VEGF) (OR 2.5; CI 1.4-4.7, P < 0.005) surgery with 25G MIVS (vs. 23G) (OR: 1.7; CI = 0.98-3.00, P = 0.05) and LSV (vs. LV) (OR 7; CI = 3.4-14.6, P < 0.005). Retinal break was significantly associated with poor anatomical outcome (OR 0.21; CI = 0.09-0.5, P < 0.005). Conclusion: MIVS along with wide angle viewing systems allow surgeons to effectively manage ROP surgeries while at the same time reducing complication rate in these eyes which have complex pathoanatomy and otherwise grim prognosis.

Retinal Detachment in 31 Eyes with Retinitis Pigmentosa.

OBJECTIVE: To describe clinical features and treatment outcomes of retinal detachment (RD) in eyes with retinitis pigmentosa (RP). DESIGN: Single-center, retrospective, interventional case series. SUBJECTS: All RP patients with RD examined between April 2003 and December 2013 and minimum 2 months of follow-up. METHODS: Medical records of RP patients were screened and 31 eyes with RD were included. Family history of RP, duration of symptoms, age at presentation, associated ocular and systemic findings, and detailed ophthalmic evaluation including presenting visual acuity, type and amount of refractive error, fundus findings, electroretinogram details, surgical details, and postoperative complications and outcomes were evaluated. Univariate analysis was done to determine risk factors associated with RD in eyes with RP and risk factors associated with poor visual outcomes after treatment. Subset analysis was also done for comparing the functional and anatomical outcomes between patients undergoing scleral buckling or vitrectomy. OUTCOME MEASURES: Final surgical reattachment rate, best-corrected visual acuity. RESULTS: Mean age at presentation was 22 years (median, 17; range, 4-63). Mean duration of symptoms was 12 months (median, 3 months: range, 3 days-60 months). Associated ocular findings included nyctalopia (n = 23), myopia (n = 21), and hyperopia (n = 10). Systemic associations included hearing loss (n = 5), deaf-mutism (n = 1), and Bardet-Biedel syndrome (n = 1). No association between degree of myopia and RD was noted (P = 0.63). Observed retinal breaks included horse-shoe-shaped tear (n = 15), lattice with hole (n = 7), atrophic retinal hole (n = 3), retinal dialysis (n = 3), and macular hole (n = 3). The most common location of breaks was superotemporal quadrant (n = 15). Younger age, male gender, and presence of posterior vitreous detachment were strongly associated with RD with odds ratio of 1.3 (P = 0.001), 8.3 (P = 0.010), and 6 (P = 0.003), respectively. Retinal reattachment was achieved in 13 of 13 eyes (100%) with scleral buckle and 9 of 10 eyes (90%) with vitrectomy. Vision improved from 1.63±0.52 to 0.87±0.25 logarithm of the minimum angle of resolution (P < 0.001) at a mean follow-up of 33 months (median, 24, range; 1-145). CONCLUSION: Rhegmatogenous RD in eyes with RP is rare. Precocious vitreous degeneration and sparse pigmentation in younger male patients has a role in etiopathogenesis. Visual prognosis remains poor despite satisfactory surgical outcomes.

Hospital anxiety and depression scale assessment of 100 patients before and after using low vision care: A prospective study in a tertiary eye-care setting.

PURPOSE: Assessment of anxiety and depression in patients attending low vision care (LVC) using Hospital Anxiety and Depression Scale (HADS). METHODS: In this prospective, observational study, 100 patients with best-corrected visual acuity (BCVA) worse than 6/18 in the better eye or limitation of field of vision to <10° from center of fixation were assessed on the depression and anxiety subscales of HADS questionnaire before and after LVC. HADS is a 14-item scale with seven items each for anxiety and depression subscales. Scoring for each item ranges from zero to three. A subscale score >8 denotes anxiety or depression. RESULTS: Mean age at presentation was 38.2 years. Mean duration of symptoms was 9.6 years. Underlying etiology of visual impairment included retinal dystrophy/degeneration (n = 35), disorders of the optic nerve (n = 17), glaucoma (n = 10), diabetic retinopathy (n = 9), age-related macular degeneration (n = 5), uncorrected refractive errors (n = 5), and miscellaneous diseases (n = 19). Mean presenting BCVA in the better eye was 0.83 (±0.64) which improved significantly to 0.78 (±0.63) after LVC (P < 0.001). The HADS-Depression subscale score was comparable for severity of visual impairment for both distance (P = 0.57) and near vision (P = 0.61). Similarly, HADS-Anxiety scores were also comparable for severity of distance (P = 0.34) and near-visual impairment (NVI; P = 0.50). At baseline, mean HADS-Depression and HADS-Anxiety scores were 8.4 (±3.7) and 9.6 (±4.3) points, which improved significantly to 6.0 (±3.4) and 6.7 (±3.7), respectively, after low-vision correction (P < 0.001). CONCLUSION: Low vision correction can significantly improve anxiety and depression indicators in visually impaired patients.

Methoxsalen-induced macular toxicity.

Psoralen compounds such as methoxsalen are photosensitizer agents used in conjunction with ultraviolet A (UVA) radiation exposure as photochemotherapy (Psoralens and ultraviolet-A therapy [PUVA therapy]) for certain epidermal skin disorders such as psoriasis and vitiligo. Methoxsalen has been shown to be associated with premature cataract formation by forming adducts with lens proteins following oral administration and subsequent UVA exposure. Hence, the use of UV-filtering glasses is recommended during PUVA therapy sessions. Ocular tissues can be exposed to its photosensitizing effect with subsequent UV radiation exposure through sunlight if the patient was to be without protective eye glasses, potentially causing macular toxicity. Till date, there have been no reports in the literature of any posterior segment ocular toxicity arising from methoxsalen use. Here, we describe a case of a bilateral macular toxicity in a middle-aged male treated with methoxsalen for vitiligo.

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

PURPOSE: To evaluate the incidence, outcomes, and risk factors for hemorrhagic complications in eyes with polypoidal choroidal vasculopathy (PCV) following photodynamic therapy (PDT). METHODS: Medical records of 94 eyes of 86 consecutive patients with PCV who underwent PDT between January 2007 and December 2014 were retrospectively reviewed. The diagnosis of PCV was based on clinical features and indocyanine green angiography. Eyes were treated with PDT monotherapy or a combination of PDT plus anti-vascular endothelial growth factor. PDT was performed at (standard [SFPDT] or reduced fluence RFPDT). RESULTS: Ninety-four eyes had 119 PDT treatment sessions (mean: 1.3 sessions). Mean presenting vision was 0.46 ± 0.44 logarithm of the minimum angle of resolution (logMAR). Following PDT, ten eyes (11%) of nine patients had hemorrhagic complications such as subretinal hemorrhage (SRH; n = 5), subretinal pigment epithelium (RPE) hemorrhage (n = 1), breakthrough vitreous hemorrhage (BVH; n = 3), and SRH with sub-RPE hemorrhage and BVH (n = 1). Median interval to hemorrhage following PDT was 2 months. Age (P = 0.842), duration of symptoms (P = 0.352), number of laser spots (P = 0.219), and laser spot size (LSS) (P = 0.096) were not significantly associated with increased risk of hemorrhagic complications. Female gender was associated with reduced risk of hemorrhage (P = 0.045). SFPDT was significantly associated with increased risk of hemorrhage (P = 0.026). The probability of developing hemorrhagic complications in SFPDT group was 0.24 compared to 0.07 in RFPDT group (P = 0.039). Multivariate logistic regression analysis showed SFPDT as the only significant risk factor for hemorrhage following PDT (odds ratio 5.3, 95% confidence interval 1.1-24.8, P = 0.03). Mean final vision was 0.61 ± 0.53 logMAR at mean follow-up of 33 months (median = 22 months; range = 2-157 months). CONCLUSION: Age, LSS, number of laser spots, preexisting hemorrhages, or use of anticoagulants were not associated with increased risk of hemorrhagic complications. SFPDT was significantly associated with increased risk of hemorrhagic complications in such eyes.

Surgical refixation of posteriorly dislocated intraocular lens with scleral-tuck technique.

PURPOSE: To report the outcomes of surgical refixation of posteriorly dislocated intraocular lens (IOL) using scleral-tuck method, and to compare the "scleral groove" and the "scleral flap" techniques used. STUDY DESIGN: Single-center, retrospective, interventional, comparative study. METHODS: Medical records of patients undergoing closed globe scleral refixation of posteriorly dislocated posterior chamber IOL (PCIOLs) by scleral-tuck method using two different techniques ("scleral groove" vs. "scleral flap" technique) were reviewed. This approach involved retrieving the dislocated PCIOL, externalizing the haptics through 2 sclerotomies created in paralimbal lamellar scleral grooves, or under lamellar scleral flaps and tucking the haptics into limbus-parallel scleral tunnels. No specific haptic architecture, haptic suturing, or large incisions were needed. Main outcome measures included best-corrected visual acuity (BCVA), final mean refractive error, and intra- and post-operative complications. RESULTS: Thirteen eyes of 13 patients (scleral groove, n = 6; scleral flap, n = 7 eyes) with a mean follow-up of 20.6 months were included. BCVA in all eyes was maintained or improved postoperatively, with three eyes (23%) showing ≥2 line improvement. Median astigmatic error at 6-week follow-up was -1.25 D cylinder (range: -0.5 D--2.0 D) which remained stable till final follow-up. All IOLs remained stable and well centered. None of the eyes had a recurrent dislocation, retinal detachment, endophthalmitis, or glaucoma. Both techniques were comparable in terms of postoperative BCVA, and refraction. CONCLUSION: Intrascleral haptic fixation by scleral-tuck method is reliable and effective for secure IOL refixation of posteriorly dislocated IOLs, providing good IOL centration and stability with minimal surgically-induced astigmatism. Both techniques (scleral groove and scleral flap) appear to have similar outcomes in the short term.

Intra-arterial chemotherapy for retinoblastoma: Two-year results from tertiary eye-care center in India.

AIM: The aim of this study is to describe treatment outcomes and complications of selective intra-arterial chemotherapy (IAC) for intraocular retinoblastoma (RB). MATERIALS AND METHODS: A retrospective, interventional series of 10 eyes with RB which underwent IAC using melphalan (5 mg/7.5 mg) and topotecan (1 mg), or melphalan (5 mg/7.5 mg) alone. Treatment outcomes were evaluated in terms of tumor control, vitreous seeds (VS) and subretinal seeds (SRS) control, and globe salvage rates. RESULTS: Ten eyes of 10 patients underwent 38 IAC sessions (mean = 3.8; median = 4; range = 3-5 sessions). Following IAC, complete regression of main tumor was seen in 9 eyes (90%) and partial regression in 1 (10%). All four eyes with SRS showed complete regression (100%). Of 5 eyes with VS, 3 eyes (60%) showed complete regression, 1 eye (20%) showed relapse, while 1 eye (20%) showed no response. Globe salvage was achieved in 8 of 10 eyes (80%). Complications included transient ophthalmic artery narrowing (n = 2), branched retinal vein occlusion (n = 1), forehead skin pigmentation (n = 1), and vitreous hemorrhage (n = 2). There was no case of stroke, hemiplegia, metastasis, or death. Transient hematological changes included relative pancytopenia (n = 4), relative leukopenia (n = 5), and relative thrombocytopenia (n = 4). Mean follow-up was 26 months (median = 28, range = 13-36) from the initiation of first IAC. CONCLUSIONS: IAC is an effective therapy for globe preservation in eyes with intraocular RB, in the setting of a developing country like India. Larger studies with longer follow-up are required to validate these results.