A novel Y-shaper and chopper for small pupil management in cataract surgery: The initial experience.

Small pupil is a well-known risk factor for causing cataract surgery complications such as vitreous loss, anterior capsular tear, increased inflammation, and an irregular pupil shape. Because all currently available pharmacological approaches of dilating the pupil before or during cataract surgery cannot guarantee the result, the surgeon sometimes resorts to the use of mechanical pupil-expanding devices. However, these devices can increase the overall surgical cost and operative time. Very frequently, a combination of the two is needed; thus, we present the Y-shaped chopper designed by the authors, which serves the purpose of managing the intra-operative miosis and allows simultaneous nuclear emulsification.

Comparison of patient satisfaction with red-free (green) versus yellow light using binocular indirect ophthalmoscope for retinal examination.

Purpose: Comparison of patient satisfaction with red-free (green) versus yellow light using binocular indirect ophthalmoscope for retinal examination. Methods: This is an observational questionnaire-based study of 100 myopes in the age group of 18-40 years coming for a routine check-up or for refractive surgery workup. The examination was done using an indirect ophthalmoscope and a 20D lens with green or yellow light and was assigned in two groups randomly using the coin toss method, following which, a questionnaire was used to assess the following parameters: a) level of comfort, b) any complaints of discomfort during examination, d) preference of the used light source in future, e) grading of discomfort on a linear scale, and f) patient cooperation and duration of examination. Results: Patients were randomized for observation with IDO using either green light (n = 55) or yellow light (n = 45) filter. In the study, 46 patients (83.6%) were very comfortable and only 9 patients (16.4%) experienced mild discomfort when using red-free (green) light, while only 3 patients (6.7%) were very comfortable and 31 (68.9%) had mild discomfort when using yellow light. The complaints of watering with yellow and green light were noted in 36 patients (80.0%) and 15 patients (27.3%), pain in 13 patients (28.9%) and 3 patients (5.5%), light sensitivity in 29 patients (64.4%) and 4 patients (7.3%), respectively, all being significantly more in yellow light category (P < 0.001). The time of examination was significantly more in yellow light category with 83 ± 10.75 seconds (P < 0.001). Conclusion: Retinal examination using the green filter of indirect ophthalmoscope is more comfortable in examining the patients as compared to routine yellow light with decreased number of complaints, lesser examination time, and better patient cooperation.

To evaluate the functional and anatomical outcomes for autologous retinal autograft with Finesse™ Flex Loop for failed macular holes.

Purpose: To evaluate the functional and anatomical outcomes for autologous retinal autograft with Finesse™ Flex Loop for failed macular holes. Methods: This is a retrospective study analyzing medical records of consecutive patients with refractory macular hole (at least 1 prior surgery) and eyes with retinal detachment with coexisting macular holes (MH). Optical coherence tomography (OCT) of the macula was performed before and after surgery. The primary study outcome evaluated were the functional and anatomic macular hole closure, and secondary outcomes were improvement in visual acuity and restoration of the outer retinal bands, external limiting membrane, and ellipsoid zone in eyes with acquisition of autologous retinal transplant using Finesse Loop. Results: The study included eight eyes of eight patients; retinal autograft was performed in six (75.0%) and autologous retinal transplantation (ART) with rhegmatogenous retinal detachment (RRD) was performed in two (25.0%) eyes. The average MH basal diameter in the study was 1310.88 ± 138.63 µm. The successful hole closure rate was observed to be 75% (6 eyes) and 100% retinal reattachment was observed in ART with RRD. Statistically significant (P = 0.001) improvement was noted for preop and postop visual acuity gain for ART acquisition and postop macular hole closure. The restoration of the external limiting membrane (ELM) and ellipsoid zone (EZ) was observed in 37.5% (3 eyes) of patients. Conclusion: Finesse™ Flex Loop can be used to harvest retinal tissue and it provides good anatomical and functional outcomes for failed macular hole.

Comparison of three techniques of harvesting full-thickness retinal tissue for large or persistent macular holes.

Purpose: To evaluate the success rate of autologous retinal graft (ARG) for the closure of full-thickness macular holes (MHs) and compare the outcomes of three different techniques of harvesting the graft. Methods: Clinic files of all patients who had undergone ARG for MH using intraocular scissors, membrane loop, or retinal punch to harvest retinal tissue were retrospectively reviewed. All patients were evaluated for MH closure, retinal reattachment, and visual improvement. Results: Twenty-two eyes of 22 patients were included. ARG was done for 16 eyes (72.7%) with failed, large persistent MH, and six eyes (27.3%) also underwent simultaneous repair of retinal detachment. The basal diameter of MH was 1103.67 ± 310.09 (range 650-1529) µm. Intraocular scissors were used in 10 eyes (45.5%), a membrane loop in five eyes (22.7%), and a retinal punch in seven eyes (31.8%). Silicone oil tamponade was used in seven (31.8%) eyes and gas in 15 (68.1%) eyes. The follow-up ranged from 6 to 18 months. The hole closure rate was 72.7% (16/22). Visual improvement was noted in 18 eyes (81.8%). Retinal reattachment was seen in all eyes. Good graft integration with the surrounding area was seen in 17 eyes (77.3%). Graft retraction was seen in four eyes (18.18%) and graft loss in one eye (4.55%). No significant differences were noted among the three groups. Conclusion: ARG is successful in closing large, failed MH with and without retinal detachment. A membrane loop and retinal punch are equally useful in harvesting the graft, but scissors are preferable in case the retina is detached. With all three techniques, integration of the graft with the surrounding tissue can be achieved.

Anterior uveitis after transepithelial photorefractive keratectomy: Demographics and clinical characteristics - a one-year analysis.

PURPOSE: To report a case series of anterior uveitis after Transepithelial Photorefractive Keratectomy (TransPRK) and determine its incidence, demographics and associated clinical features over a study period of 1 year. METHODS: This retrospective case series comprised of 200 eyes (100 patients) which underwent elective TransPRK surgery for ametropia correction at a tertiary eye care center by two refractive surgeons over 1 year. TransPRK was performed on Streamlight software (EX500, Alcon Wavelight, Inc.). Postoperatively, all patients received topical antibiotic and steroid eye drops and tapered over 4 weeks. RESULTS: The mean age of study patients was 25.76 ± 4.29 years with a pre-operative mean refractive spherical equivalent (MRSE) of -3.49 ± 2.12 diopter (D); 11.76% eyes had simple myopia and 88.23% had compound myopic astigmatism, mean ablation depth of 61.99 ± 24.27 um. Four patients (seven eyes) developed anterior uveitis with mean age of 25 ± 3.53 years, mean MRSE -2.91 ± 0.32 D, ablation depth 44.75 ± 5.29 um with a mean onset at 33.28 days postoperatively after surgery and 5.28 days after the routine postoperative topical steroid withdrawal. Laboratory and immunological tests were negative in all four patients. The incidence of TransPRK-related anterior uveitis was 3.5% over 1 year. CONCLUSION: Anterior uveitis after TransPRK is infrequent. It could be due to intraocular transmittance of high frequency excimer laser beams used for longer durations to provide continuous, single step ablation in this novel type of PRK surgery. Further studies are needed to investigate the mechanisms of this association.

Analysis of the parental satisfaction for retinopathy of prematurity screening using binocular indirect ophthalmoscopy versus wide field retinal imaging.

Purpose: Analysis of the parental satisfaction for retinopathy of prematurity screening using binocular indirect ophthalmoscopy versus wide field retinal imaging. Methods: This was an observational, questionnaire survey-based study. The study cohort comprised of parents/legal guardians of consecutive Asian Indian premature infants enrolled for retinopathy of prematurity screening (for infants less than 2000 gms and/or 34-weeks gestational age) using binocular indirect ophthalmoscopy (BIO) with scleral depression and b) wide field retinal imaging using the 3Nethra Neo Camera (Forus Health, India). We evaluated the retina for the presence or absence of stages of ROP and plus disease. The survey analysis used closed-ended (multiple-choice) and open-ended questions for assessing 1) parents' experience/preference among the two screening modalities namely, BIO and wide field imaging used in the study, 2) knowledge prior to ROP screening, 3) knowledge gained post ROP screening, in the outpatient ophthalmologic care unit in our hospital. Results: Parents/legal guardians of 90 infants were included in the study. Among the 90 parents who filled in the questionnaire, 62.3% were referred by their pediatrician, 23.3% came for self check-up and 14.4% incidentally came to the hospital for complaints like ocular discharge and were screened. 93.3% parents were satisfied with either ROP screening modality in our study, with 54.4% stated a preference for retinal imaging. In the study 20% of the parents felt that retinal imaging was painful for the infant and 31.1% felt that BIO was painful for the infant. Conclusion: Wide field imaging is increasingly becoming an effective tool and screening tool in ROP screening and helps in better understanding of the disease amongst parents.

MANAGEMENT OF RETINOBLASTOMA WITH HIV SEROPOSITIVITY.

PURPOSE: To report a case of retinoblastoma with concomitant association with HIV seropositivity and its management. METHODS: A retrospective case report of a 3-year-old male child presenting with right eye Group B and left eye Group E retinoblastoma with simultaneous positivity for HIV1 antibody. The parents were also tested positive for HIV and were referred for initiating antiretroviral therapy. RESULTS: The child was managed with focal laser therapy for the right eye and six cycles of systemic chemotherapy, and the left eye was planned for enucleation with ball implant. CONCLUSION: This case poses an outlook into a dilemma as to whether or not systemic chemotherapy should be started along with antiretroviral therapy for treating retinoblastoma, as there are no cited case reports in the literature of retinoblastoma coexisting with HIV and its related management regime and future considerations to be taken for management.

Clinical and electrophysiological characteristics of Efavirenz-induced macular toxicity.

Efavirenz (EFV), a non-nucleoside reverse transcriptase inhibitor, is commonly used to treat HIV-infected individuals. We report a case of painless, progressive and bilateral blurring of vision in an HIV-positive 54-year-old lady within months of treatment with anti-retro viral therapy including Efavirenz. On presentation, her visual acuity was 6/18; N24 and 6/9; N10 in both eyes with mottling of the retinal pigment epithelial at the macula with corresponding scotomas on HVF 30-2 and loss of ellipsoid layer on spectral domain optical coherence topography (OCT). Though full field ERG was normal, multifocal ERG revealed reduced foveal and parafoveal amplitudes. Our case emphasizes the need of periodic ocular examination of these patients on long-term EFV.

Real-world experience with pro re nata dosing of intravitreal dexamethasone implant for eyes with refractory diabetic macular edema.

Aims: To evaluate treatment outcomes of pro re nata dosing of intravitreal dexamethasone implant in eyes with refractory diabetic macular edema (DME) amongst Indian subjects. Methods and material: Retrospective, interventional case series. Medical records of 28 eyes of 23 patients with refractory DME who underwent intravitreal dexamethasone (700 µ) implant were reviewed. Paired t-test was carried out to measure mean change in the parameters evaluated. Mann-Whitney U test and Fisher's exact t-test were done to explore differences between groups receiving single or multiple injections. Results: Best corrected visual acuity (BCVA) and central macular thickness (CMT) at baseline were 0.85 (±0.44) and 612 µm (±123), respectively. Mean CMT over 6 months (measured monthly) following injection was 340±119 µm (p=0.001), 346±150 µm (p=0.02), 368±169 µm (p=0.02), 304±174 µm (p=0.001), 525±216 µm (p=0.94) and 532±201 µm (p=0.46), respectively. Mean BCVA at each month following injection was 0.68±0.36 (p=0.02), 0.75±0.45 (p=0.42), 0.55±0.40 (p=0.11), 0.63±0.40 (p=0.12), 0.78±0.30 (p=0.90) and 0.60±0.47 (p=0.92), respectively. Mean follow-up was 12 months (range: 6-33 months). Mean BCVA and CMT at mean 12 months were 0.72±0.46 (p=0.10) and 358 µm±189 (p=0.0001), respectively. Seven eyes had raised IOP; five eyes required cataract extraction. Conclusions: Intravitreal dexamethasone implant is effective in treatment of refractory DME. However, its therapeutic effect lasts for about 4 months.

Intravitreal Ziv-Aflibercept : Safety Analysis in Eyes Receiving More Than Ten Intravitreal Injections.

Purpose: To report the ocular and systemic adverse events in eyes receiving ≥10 intravitreal ziv-aflibercept (IVZ) injections.Methods: Medical records of patients who received ≥10 IVZ for various chorioretinal conditions with minimum follow up period of 12 months were retrospectively analysed. These eyes received standard dose of IVZ (1.25 mg/0.05 ml) on pro-re-nata (PRN) or treat and extend (T&E) protocol. The primary study outcome was ocular and systemic adverse events related to IVZ injections whereas secondary outcomes were change in best corrected visual acuity (BCVA) and central macular thickness (CMT) on optical coherence tomography (OCT) at last visit compared to baseline. Comparison of BCVA and CMT at baseline and final visit was done using paired t-test.Results: A total of 94 eyes which received a mean ± standard deviation (mean±SD = 14.4 ± 4.6) IVZ injections were studied. A total of 41 eyes were treatment naïve whereas 53 eyes received intravitreal injections in the past with last injection at least 3 months prior. Mean (±SD) follow up period was 26.7 ± 8.7 months. Ocular adverse events were limited with a case each of acute iridocyclitis, endophthalmitis, cataract progression and early epiretinal membrane formation. No systemic events were recorded within a month of IVZ injection. There was a significant improvement in BCVA (p = 0.001) and change in CMT (p = 0.001) at last visit.Conclusion: Ocular use of ziv-aflibercept is safe with limited ocular and systemic side effects. Multiple injections of IVZ can be used in various chorioretinal diseases over the long term.

Macular edema secondary to malignant Hypertension managed with Intravitreal Bevacizumab.

INTRODUCTION: Intravitreal anti VEGF agents are used in a variety of retinal pathologies to decrease the VEGF levels resulting due to breakdown of the blood retinal barrier hence decrease the exudation from vessels which causes macular edema (ME). CASE: A 61year old patient presented with sudden decrease in vision in both eyes with a history of systemic malignant hypertension leading to macular edema as documented on optical Coherence Tomography (OCT) in both eyes. The foveal thickness (FT)of 536 and 328 microns (µ) were observed in the right and left eye each. He was advised intravitreal anti vascular endothelial growth factor (VEGF) in both eyes and advised complete systemic evaluation with the physician. Following one month postintravitreal bevacizumab ( IVB) injection in right eye, marked visual improvement was noted with concomitant significant reduction in macular edema in both eyes. OBSERVATION: Single Bevacizumab injection with control of hypertension in our patient resulted in rapid resolution of the macular edema and early visual recovery. Intravitreal anti VEGF is an effective treatment option in eyes due to hypertensivemaculopathy especially to gain speedy visual recovery. CONCLUSION: The case gives a unique outlook to the course of ME in the single patient with malignant HTN with or without IVB injection. We believe that anti VEGF injections may result in rapid recovery in vision and minimize the risk of permanent vision loss in eyes with malignant hypertension.

Role of anterior segment optical coherence tomography for safer management of mature white cataracts.

PURPOSE: Role of anterior segment optical coherence tomography (AS-OCT) for safer management of mature white cataracts. SETTING: Patients with mature white cataracts attending the outpatient department of a tertiary eye care hospital, aspiring to have cataract surgery performed, were scheduled for elective phacoemulsification and intraocular lens implantation by two surgeons during the period of October 2017 to March 2018. DESIGN: A prospective interventional study of 30 patients. METHODS: All patients with mature cataracts and absence of any retinal pathology had AS-OCT to assess the presence or absence of intralenticular subcapsular fluid pockets. The patients with the presence of subcapsular fluid pockets (Group 1) underwent 30-gauge needle aspiration fluid aspiration followed by capsulorhexis and phacoemulsification and those without any fluid (Group 2) underwent Utrata forceps-assisted capsulorhexis. RESULTS: The study comprised 30 eyes of 30 patients, of which 15 eyes (50%) had subcapsular fluid and 15 eyes (50%) had no fluid on AS-OCT. Of the 15 eyes in Group 1, 13 eyes (86.7%) underwent complete circular curvilinear capsulorhexis (P = .001), with a surgical success rate of 87%, whereas 2 eyes (13.3%) had capsular runaway complications. Of the 15 eyes with no subcapsular fluid, 13 eyes (86.7%) underwent complete circular curvilinear capsulorhexis (P = .001), whereas 2 eyes (13.3%) had posterior capsule rupture. Thus, 87% of the cases had uneventful capsular outcomes in each group. CONCLUSION: The detection of subcapsular fluid on AS-OCT allows better planning and management with 30-gauge assisted-needle drainage of fluid, thus decreasing the chances for capsular runaway complications with better surgical outcomes.

Quantitative polymerase chain reaction analysis of serpiginous choroiditis with biopsy-proven testicular tuberculosis.

We report a case of a 47-year-old male patient presenting with diminution of vision in the left eye. The left eye fundus showed yellowish lesions with indistinct geographical margin extending over the posterior pole just abutting the macula, suggestive of diffuse choroiditis. The patient gave a history of testicular swelling for the past 2 years. Aqueous tap for polymerase chain reaction analysis was positive for IS6110 mycobacterial tuberculosis (TB) genome, and a biopsy of testicular sac was suggestive of tubercular epididymitis. A diagnosis of TB-multifocal serpiginoid choroiditis was established and was managed with anti-tubercular therapy and systemic steroids.

Pneumatic retinopexy outcomes as primary or secondary surgical option for treating rhegmatogenous retinal detachment.

PURPOSE: To report the outcomes of pneumatic retinopexy (PR) performed as a primary surgical procedure for rhegmatogenous retinal detachment (RRD) or as a secondary procedure for recurrent RRD. METHODS: We retrospectively analyzed case records of 54 patients (54 eyes) who underwent PR for RRD by injecting 0.3 ml of perfluoropropane (C3F8) in the vitreous cavity and cryopexy to break in the same sitting, followed by positioning. RESULTS: A total 54 eyes of 54 patients aged between 17 and 84 years (mean - 51.3, median - 53 years) were included in the study. Except five eyes, all had breaks in the superior quadrants. The RRD ranged from 1 quadrant to 4 quadrants. Twenty-eight eyes (51.8%) were phakic and 26 (48.1%) were pseudophakic. The follow-up ranged from 6 to 144 months. In 25 eyes (46.2%), PR was the primary intervention and was successful in 15 (60%) eyes with a significant visual improvement (P = 0.023). Twenty-nine eyes (52.7%) with failed scleral buckle or failed pars plana vitrectomy underwent PR with a success rate of 65.5% and significant visual improvement (P = 0.0017). Progression of proliferative vitreoretinopathy changes (40%) was the most common cause of failure. The success rate was higher in phakic eyes, eyes with attached macula, superior breaks, superior RRD, and RRD limited to 3 quadrants or less. CONCLUSION: PR remains a minimally invasive procedure which can be used primarily or as a salvage procedure in failed surgery with moderately good success rate and minimal complications. One-step procedure reduces patient visits and ensures adequate treatment of the break.

Retinoblastoma: An overview of modern management.

Retinoblastoma (RB) is an embryonic tumor originating from the retinal cells. RB is the most common intraocular cancer of childhood and accounts for 4% of all pediatric malignancies.

Needle stick injuries in a tertiary eye-care hospital: Incidence, management, outcomes, and recommendations.

PURPOSE: The purpose of this study is to assess the incidence, management, and outcomes for needle stick injuries (NSIs) in a tertiary eye-care hospital and provide appropriate recommendations for its prevention. METHODS: This was a retrospective database review of NSI recorded between 2010 and 2015 at a tertiary eye care center. All staff members who had NSI were managed with standard treatment protocol. The mode, location, health-care workers affected and/or at risk for NSI were analyzed. RESULTS: One hundred and forty NSI were reported between 2010 and 2015, with ophthalmic fellows under training encountering maximum needle pricks (n = 33; 24%), followed by nursing staff (n = 32; 23%), and consultants (n = 30; 21%). Location wise, the highest incidence of NSI was found in the operating room (n = 94; 67%), followed by the laboratory (n = 17; 12%), and patients' ward (n = 14; 10%). Maximum pricks (n = 10; 20%) occurred while passing sharp instruments, anterior segment surgeons (n = 23; 79%) being affected more than posterior segment surgeons (n = 6; 21%). None of the NSI incidents was attributed to anti-VEGF injections. None of the subjects with NSI had seroconversion to hepatitis B surface antigen, human immunodeficiency virus, or hepatitis C virus in the 5-year study period. CONCLUSIONS: NSI is the most commonly encountered in the operating room among training personnel while passing sharp instruments, especially anterior segment surgeons. A proper needle/sharp disposal mechanism, documentation of adverse event, on-going staff training, and prompt prophylactic treatment are essential components of the protocol for NSI management.

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.

Biopsy techniques for intraocular tumors.

Biopsy involves the surgical removal of a tissue specimen for histopathologic evaluation. Most intraocular tumors are reliably diagnosed based on the clinical evaluation or with noninvasive diagnostic techniques. However, accurately diagnosing a small percentage of tumors can be challenging. A tissue biopsy is thus needed to establish a definitive diagnosis and plan the requisite treatment. From fine-needle aspiration biopsy (FNAB) to surgical excision, all tissue collection techniques have been studied in the literature. Each technique has its indications and limitations. FNAB has been reported to provide for 88-95% reliable and safe ophthalmic tumor diagnosis and has gained popularity for prognostic purposes and providing eye conserving treatment surgeries. The technique and instrumentation for biopsy vary depending upon the tissue involved (retina, choroid, subretinal space, vitreous, and aqueous), suspected diagnosis, size, location, associated retinal detachment, and clarity of the media. The cytopathologist confers a very important role in diagnosis and their assistance plays a key role in managing and planning the treatment for malignancies.