The Slitscope.

Slit lamp biomicroscope is the right hand of an Ophthalmologist. Even though precise, its bulky design and complex working process are limiting constraints, making it difficult for screening at outreach camps, which are an integral part of this field for the purpose of eliminating needless blindness. The torchlight is the main tool used for screening. Recently, the integration of smartphones with instruments and the digitization of slit lamp has been explored, to provide simple and easy hacks. By bringing the slit of the slit lamp to traditional torchlight, we have created "The Slitscope". It combines the best of both worlds as a simple innovative do-it-yourself novel technique for precise cataract screening. It is especially useful in peripheral centers, vision centers, and outreach camps. We present two prototypes which can also be 3D printed.

Neonatal intensive care practices and the influence on skin condition.

BACKGROUND: Premature skin has a thinner epidermis with a poorly formed stratum corneum (SC) barrier compared to full term skin. Poor skin integrity increases the risk of exposure to irritants and infectious agents. Interventions that facilitate skin maturation are essential. OBJECTIVE: The objective was to examine the effects of prematurity and time from birth on SC maturation and to identify factors that impact skin condition. METHODS: A retrospective review was conducted among 130 NICU patients. Skin regions were evaluated for erythema, rash, integrity and function. The effects of gestational age, time from birth, stool exposure, nutrition and diagnosis were examined. RESULTS: Three groups emerged: (i) premature and <38 weeks adjusted age; (ii) premature and >38 weeks adjusted age; and (iii) full term. Surprisingly, the premature infants exhibited lower perineal irritation and greater SC integrity (lower transepidermal water loss) than full terms (P < 0.05). Group 2 had a longer time before the first skin-stool contact. Chest skin pH showed maturational changes for Group 1 (P < 0.05) but did not change for premature Group 2 who was older at enrollment. Erythema was lower for infants using elemental formulas or total parenteral nutrition. CONCLUSIONS: Premature infants with early stool contact and high exposure, full term infants, and patients with congenital diaphragmatic hernia or trisomy 21 are at high risk for skin compromise and may benefit from prophylactic interventions to minimize compromise. Low stool exposure and greater time before the first stool contact appear to be protective against skin compromise.

Aicardi syndrome: the importance of an ophthalmologist in its diagnosis.

Aicardi syndrome is a rare genetic disorder. The salient features of this syndrome include agenesis of corpus callosum, chorioretinal lacunae and infantile spasms. Of these three, chorioretinal lacunae is the most constant feature present. This case highlights the importance of fundus findings by an ophthalmologist in making the diagnosis of this rare syndrome.

A rare case of focal choroidal excavation associated choroidal neovascularization in angioid streaks.

The purpose is to report a case of focal choroidal excavation (FCE) in a patient with angioid streaks (ASs) associated with secondary choroidal neovascularization (CNV). A 26-year-old man was referred for the treatment of CNV. On further evaluation, he was found to have ASs and optical coherence tomography revealed the presence of the choroidal neovascular complex associated with FCE. The patient was treated with a single dose of intravitreal bevacizumab (1.25 µg/0.05 ml). There was resolution of the lesion, and on further follow-up over 6 months, there were no recurrences. CNV in patients with ASs may also be associated with FCE. These patients have a good response to intravitreal antivascular endothelial growth factor injection.

Intracameral injection of bevacizumab (Avastin) to treat anterior chamber neovascular membrane in a painful blind eye.

Intracameral injection of bevacizumab (Avastin) helped in the successful regression of an anterior chamber neovascular membrane in a painful blind eye. The effect was persistent even after six months of follow-up. This is the first report on intracameral administration of bevacizumab with six months of follow-up.

Intravitreal bevacizumab (Avastin) for post laser anterior segment ischemia in aggressive posterior retinopathy of prematurity.

Aggressive posterior retinopathy of prematurity (formerly known as fulminate/type II/rush disease) occurs in zone 1 or posterior zone 2. Treatment involves extensive near confluent laser ablation of a large area of avascular retina. Anterior segment ischemia is a rare complication that can occur due to injury to the long posterior ciliary arteries in the horizontal meridians during aggressive posterior laser treatment. The outcome of this rare complication is very poor. This case describes a favorable outcome of intravitreal injection of bevacizumab (Avastin) in a case of anterior segment ischemia.

"Worm in the eye": the rationale for treatment of DUSN in south India.

AIM: To discuss the rationale for different techniques of treatment for DUSN (diffuse unilateral subacute neuroretinitis) and their effectiveness in two patients from south India. METHODS: Two rare cases of live worms in DUSN from India are reported, where filarial Brugia malayi is endemic. Both cases presented with progressive unilateral loss of vision with no history of animal contact. They were 40 year old, apparently healthy men. In case 1, the worm (1500-2000 microm) was easy to identify with wriggling movements among crisscrossing diffuse subretinal tracks. The worm was destroyed by a single shot of laser to its advancing end, which was followed by oral steroid to control the inflammation caused by the dead worm. In case 2, the worm was small and difficult to identify. Initially diffuse neuroretinitis was diagnosed and treated with intravenous methylprednisolone and oral corticosteroid. A week later, a small live worm (400-600 microm) was found and subsequently destroyed by laser photocoagulation followed by a combination of anthelminthics. RESULTS: The patients' vision had improved to 6/60-6/36 from counting fingers after a few weeks. CONCLUSION: The role of a combination of laser treatment, systemic steroid, and anthelminthics is discussed.

Screening for retinopathy of prematurity--a comparison between binocular indirect ophthalmoscopy and RetCam 120.

AIM: To compare the photographic screening for retinopathy of prematurity (ROP) using RetCam 120 with binocular indirect ophthalmoscope (BIO), which is the current gold standard. SETTING AND DESIGN: Prospective, comparative study. MATERIALS AND METHODS: A total of 87 RetCam examinations were performed on 27 premature babies. They were stored in a separate file after deleting the identifying information. At the same visit using the BIO with scleral depression, an experienced vitreoretinal surgeon evaluated the fundus in detail. A masked examiner then evaluated the RetCam photographs for presence or absence of ROP, the stage and zone of the disease and the presence or absence of plus disease. These data were then compared with the BIO findings to determine the sensitivity, specificity and the positive and negative predictive values of the method. RESULTS: ROP was detected in 63 of 87 examinations by BIO and in 56 of 87 RetCam examinations. Nine RetCam examinations were false-negative and two were false-positive. Sensitivity of RetCam was 85.71% (54/63) and specificity was 91.66% (22/24). The positive and negative predictive values were 96.43% and 70.97% respectively. CONCLUSION: Nine cases having ROP were missed by the RetCam. All these cases were either in zone 3 or the outer part of zone 2, which later regressed. These were missed mostly because of the restricted mobility of the camera head caused by its size and the barrier caused by the lid speculum arms. No case of threshold ROP was missed. RetCam may replace BIO for screening of ROP.

Prenatal genetic diagnosis of retinoblastoma and report of RB1 gene mutation from India.

BACKGROUND: Retinoblastoma is the most common intraocular malignancy of childhood. There is a paucity of genetic testing and prenatal genetic diagnosis from India, which has the highest incidence worldwide. MATERIALS AND METHODS: RB1 gene screening of an 8-month-old female child with bilateral retinoblastoma was accomplished using next generation sequencing. The results were used for prenatal testing in this family. RESULTS: A heterozygous germline mutation (chr13: 48951119delA; c.1281delA) was detected, which resulted in premature termination of a protein product (p.Glu428Argfs*29). Prenatal testing in maternal DNA revealed carrier status of the mother. Further clinical examination in the family members revealed retinocytomas in both eyes of the mother and maternal grandmother. Prenatal genetic testing of the developing fetus showed positivity for the mutation. As the family preferred to continue the pregnancy, serial 3-D ultrasounds were carried out every 2 weeks in the third trimester. Ten days after delivery, small extrafoveal tumors developed in both eyes, which were then treated successfully with transpupillary thermotherapy. CONCLUSION: We report the significance of genetic testing in the early detection and management of retinoblastoma from India.

Risk of Tractional Retinal Detachment Following Intravitreal Bevacizumab Along with Subretinal Fluid Drainage and Cryotherapy for Stage 3B Coats' Disease.

PURPOSE: To review the surgical outcomes of intravitreal bevacizumab (IVB) along with subretinal fluid drainage with cryotherapy in patients with stage 3B Coats' disease. MATERIALS AND METHODS: A retrospective study of seven cases of stage 3B Coats' disease, who underwent subretinal fluid drainage with cryopexy, from May 2011 to March 2014. Five eyes received additional IVB at the end of surgery. Green laser therapy was performed on telangiectatic vessels postoperatively. RESULTS: The mean age was 34 months (range, 10-84 months). Mean follow-up was 19 months. Six patients (85.7%) had an attached retina at final follow-up. Three out of four patients (75%) that received IVB developed tractional retinal detachments (TRDs). Two eyes that did not receive bevacizumab did not develop any traction. None progressed to neovascular glaucoma or phthisis bulbi. CONCLUSION: Simultaneous injection of bevacizumab along with subretinal drainage and cryotherapy for advanced Coats' disease could not avoid TRD.

Racial disparities in cord blood vitamin D levels and its association with small-for-gestational-age infants.

OBJECTIVE: To examine the relationship of race and maternal characteristics and their association with cord blood vitamin D levels and small-for-gestational-age (SGA) status. STUDY DESIGN: Cord blood vitamin D levels were measured in 438 infants (276 black and 162 white). Multivariable logistic regression models were used to evaluate associations between maternal characteristics, vitamin D status and SGA. RESULTS: Black race, Medicaid status, mean body mass index at delivery and lack of prenatal vitamin use were associated with vitamin D deficiency. Black infants had 3.6 greater adjusted odds (95% confidence interval (CI): 2.4, 5.6) of vitamin D deficiency when compared with white infants. Black infants with vitamin D deficiency had 2.4 greater adjusted odds (95% CI: 1.0, 5.8) of SGA. Vitamin D deficiency was not significantly associated with SGA in white infants. CONCLUSION: Identification of risk factors (black race, Medicaid status, obesity and lack of prenatal vitamin use) can lead to opportunities for targeted prenatal vitamin supplementation to reduce the risk of neonatal vitamin D deficiency and SGA status.

Speciation of coagulase negative staphylococcus causing bacterial keratitis.

Thirty-five coagulase negative Staphylococcus (CoNS) cultured from corneal ulcer were speciated and antibiotic sensitivity tested. S epidermidis was the commonest isolate and it was sensitive to ampicillin and vancomycin.

Fulminate retinopathy of prematurity - clinical characteristics and laser outcome.

PURPOSE: To analyse the clinical characteristics and treatment outcome of zone 1 Fulminate type of Retinopathy of Prematurity (ROP) and compare it to Conventional ROP. METHODS: Preterm infants from two neonatal intensive care units (NICU) born between July 2002 and November 2003 were screened for ROP. Cases with Conventional ROP were classified according to the International Classification of Retinopathy of Prematurity (ICROP) while that of Fulminate ROP according to Shapiro's classification. Threshold disease was kept the cut off for treatment for Conventional ROP and stage 3A for Fulminate ROP. RESULTS: Of the 54 cases that had treatable ROP, 36 (66.67%) had Fulminate type. The mean gestational age and birth weight was higher in Fulminate ROP compared to Conventional disease (31.75 weeks and 1554 gms vs 31 weeks 1387 gms) whereas the mean postnatal age at laser was lower (4.62 weeks vs 6.3 weeks). The average number of laser spots given was 3036.6 for Fulminate disease. CONCLUSION: Fulminate ROP had an atypical morphology which was difficult to classify according to ICROP classification and we would like to lay stress upon the importance of screening of premature infants from the age of 4 weeks and to start treatment immediately once Fulminate ROP has been diagnosed.

Safety and efficacy of simultaneous bilateral 25-gauge lens-sparing vitrectomy for vascularly active stage 4 retinopathy of prematurity.

PURPOSE: To report the safety and efficacy of simultaneous bilateral 25-gauge lens-sparing vitrectomy for vascularly active stage 4 retinopathy of prematurity (ROP). METHODS: Retrospective, noncomparative, consecutive case series. Twenty eyes of 10 babies who presented with vascularly active stage 4 ROP in both the eyes underwent simultaneous bilateral 25-gauge lens-sparing vitrectomy. After completing surgery for one eye, the other eye was re-prepped as performed before starting any new case of a different patient and an entire new set of disposable 25-gauge instruments were used. During the post-operative period parents were advised to keep separate eye drops for each eye and to wash their hands in between switching the eyes to put the drops. RESULTS: The mean follow-up was 8.7 months (range 4-17 months). None of the cases developed any signs of infection. The anatomic success rate for stage 4a was 100% (11/11 eyes) and for stage 4b was 8/9 eyes (89%). CONCLUSION: These results show that simultaneous bilateral 25-gauge lens-sparing vitrectomy for stage 4 ROP is a safe and effective procedure with a good outcome provided both eyes of the baby are treated as eyes of two different patients.

In vitro susceptibility of filamentous fungi from mycotic keratitis to azole drugs.

OBJECTIVE: The in vitro antifungal activities of azole drugs viz., itraconazole, voriconazole, ketoconazole, econazole and clotrimazole were investigated in order to evaluate their efficacy against filamentous fungi isolated from mycotic keratitis. METHODS: The specimen collection was carried out from fungal keratitis patients attending Aravind eye hospital and Post-graduate institute of ophthalmology, Coimbatore, India and was subsequently processed for the isolation of fungi. The dilutions of antifungal drugs were prepared in RPMI 1640 medium. Minimum inhibitory concentrations (MICs) were determined and MIC50 and MIC90 were calculated for each drug tested. RESULTS: A total of 60 fungal isolates were identified as Fusarium spp. (n=30), non-sporulating moulds (n=9), Aspergillus flavus (n=6), Bipolaris spp. (n=6), Exserohilum spp. (n=4), Curvularia spp. (n=3), Alternaria spp. (n=1) and Exophiala spp. (n=1). The MICs of ketoconazole, clotrimazole, voriconazole, econazole and itraconazole for all the fungal isolates ranged between 16 µg/mL and 0.03 µg/mL, 4 µg/mL and 0.015 µg/mL, 8 µg/mL and 0.015 µg/mL, 8 µg/mL and 0.015 µg/mL and 32 µg/mL and 0.06 µg/mL respectively. From the MIC50 and MIC90 values, it could be deciphered that in the present study, clotrimazole was more active against the test isolates at lower concentrations (0.12-5 µg/mL) when compared to other drugs tested. CONCLUSION: The results suggest that amongst the tested azole drugs, clotrimazole followed by voriconazole and econazole had lower MICs against moulds isolated from mycotic keratitis.