Comparative analysis of outcomes of two (popular) techniques of haptic exteriorization in scleral fixation intra-ocular lens surgery - A retrospective study.

PURPOSE: To compare the visual outcomes and complication rates between the extra-ocular needle-guided haptic insertion technique (XNIT) and the conventional handshake (HS) technique of scleral fixation intra-ocular lens (SFIOL). METHODS: In this retrospective study, we retrieved data of those patients who had undergone SFIOL surgery from January 2018 to May 2022 at our institute for aphakia following either a complicated cataract surgery or an ocular trauma and had a minimum follow-up of 3 months. RESULTS: Of the 156 eyes, the HS technique was done in 80 eyes and the remaining 76 eyes with XNIT. At 3 months follow-up visit, there was no significant difference in the median best corrected visual acuity (BCVA) ( P = 0.988) and uncorrected visual acuity (UCVA) ( P = 0.765) between the two techniques. There was no statistically significant difference between pre-operative median BCVA and post-operative UCVA in XNIT ( P = 0.961) and the HS technique ( P = 0.831) at 3 months follow-up visit. The complication rates between the two techniques were minimal and comparable. The most common post-operative complication was corneal edema. The incidence of cystoid macular edema was slightly more in the XNIT group but not statistically significant ( P = 0.05). Two patients in the HS group developed retinal detachment, which settled after repeat surgery. CONCLUSION: The newer XNIT technique was found to be as safe and effective as compared to the conventional HS technique.

S-FIX: A sutured way of doing sutureless SFIOL surgeries beyond X-NIT!

BACKGROUND: The video describes a technique in scleral fixation intraocular lens (SFIOL) surgery that is very simple and easily reproducible by any novice surgeon. PURPOSE: This technique may serve as a simple option for tucking the haptic of a multipiece IOL into the sclera without the need for the scleral flap, scleral pocket, forceps, glue, or flange. SYNOPSIS: The two most crucial steps in scleral fixation intraocular lens (SFIOL) surgery are 1) the exteriorization of the haptic, and 2) the fixation of the exteriorized haptic. The first half of the video describes the steps of our previously published technique of extraocular needle-guided haptic insertion technique (X-NIT), which simplifies the exteriorization step by shifting the intraocular hand-shake maneuver to an extraocular site. The second half describes a novel suture-guided haptic fixation (S-FIX) device, which simplifies the fixation step. S-FIX has three components: 1) a 380-micron spatulated needle, 2) a 5-o nylon suture thread, and 3) a polyimide tube. There are four steps involved in S-FIX: 1) docking of the exteriorized haptic into the polyimide tube, 2) pushing the docked polyimide tube into the eye, 3) suture bite starting from the point of sclerotomy, and 4) pulling the suture thread. As the suture thread is being pulled, the haptic along with the polyimide tube comes out and the haptic gets fixed into the narrow suture track. HIGHLIGHTS: The technique enhances the overall safety in SFIOL surgeries by avoiding haptic slips during exteriorization and fixation steps. Most anterior segment and novice surgeons do not perform SFIOL surgeries due to fear of fall of IOL. VIDEO LINK: https://youtu.be/ZoJBiw2SNaU.

Closure rate and recovery of subfoveal microstructures following conventional internal limiting membrane peeling versus per fluoro octane-assisted inverted flap for large macular holes - A randomized controlled trial (InFlap Study).

PURPOSE: To analyze the outcomes following conventional internal limiting membrane (ILM) peeling versus perfluoro octane-assisted inverted flap technique for large macular holes (MH). METHODS: A consecutive 99 eyes of 99 patients were enrolled {45 - conventional group and 54 - inverted flap (InFlap) group}. The primary outcome was a difference in closure rate. Secondary outcomes were differences in best-corrected visual acuity (BCVA), restoration of external limiting membrane (ELM) and ellipsoid zone (EZ) between groups at 3 (primary endpoint), 6 and 12 (secondary endpoints) months. Additionally, the effect of different gas tamponades on closure rates, ILM flap disintegration in InFlap group, and subfoveal thickness (SFT) between groups in closed. RESULTS: At 3 months, there was no difference in the closure rate and BCVA between groups. At six months, closure rate was significantly better in the InFlap group. However, this difference was not maintained at 12 months. There was no difference in BCVA between groups at any visit. The ELM recovery was significantly higher in the conventional group at three months; however, there was no difference in ELM/EZ recovery between groups at other visits. The closure rate in the InFlap group was the same irrespective of gas tamponade. The ILM flap was identifiable in one-third of patients at 12 months. In closed MH, SFT was significantly more in InFlap group. CONCLUSION: The closure rate and visual outcomes remained similar in both groups in the immediate and long term. Conventional ILM peeling technique seems to have early ELM recovery when compared to inverted flap technique.

Suprachoroidal hemorrhage following sutureless scleral-fixated intraocular lens - A case series.

Suprachoroidal hemorrhage (SH) is a rare complication of scleral-fixated intraocular lens (SFIOL). In this series, we report three cases of sutureless SFIOL who developed SH postoperatively. Details of surgery, treatment, and outcome were analyzed. Two cases had limited SH which resolved with conservative treatment and had optimum visual recovery. One case developed massive SH needing surgical drainage, with final best-corrected visual acuity of 6/18 due to a persistent retinal fold. SH can be a potential complication while creating scleral grooves for haptic fixation. The use of a bent needle instead of a straight microvitreoretinal knife while creating scleral grooves might reduce the risk of SH in sutureless SFIOL surgeries.

Bilateral Occlusive Vasculitis Associated with Retinitis Pigmentosa - A Case Report.

PURPOSE: To report a case of bilateral occlusive vasculitis associated with retinitis pigmentosa (RP). METHOD: Case report. CASE REPORT: A 34-year male presented with blurred vision in left eye (OS) for two weeks and right eye (OD) for one day. He had night blindness for five years. His best corrected visual acuity (BCVA) was OD 20/63 and OS 20/200. Ophthalmoscopy revealed bilateral RP with OD inflammatory central retinal vein occlusion (CRVO) and OS occlusive vasculitis with bilateral macular edema. Presumed intraocular tuberculosis (IOTB) was suspected based on clinical features, positive Mantoux and high-resolution computed tomography chest findings. Oral steroids and antitubercular therapy (ATT) were started. OD received six intravitreal ranibizumab injections. At his 7-month follow-up, BCVA improved, OD 20/40 and OS 20/80. CONCLUSION: RP rarely can be associated with presumed IOTB. Oral steroids with ATT are helpful; however, in inflammatory CRVO, intravitreal ranibizumab can give good results.

Towards a Device Agnostic AI for Diabetic Retinopathy Screening: An External Validation Study.

Purpose: To evaluate the performance of a validated Artificial Intelligence (AI) algorithm developed for a smartphone-based camera on images captured using a standard desktop fundus camera to screen for diabetic retinopathy (DR). Participants: Subjects with established diabetes mellitus. Methods: Images captured on a desktop fundus camera (Topcon TRC-50DX, Japan) for a previous study with 135 consecutive patients (233 eyes) with established diabetes mellitus, with or without DR were analysed by the AI algorithm. The performance of the AI algorithm to detect any DR, referable DR (RDR Ie, worse than mild non proliferative diabetic retinopathy (NPDR) and/or diabetic macular edema (DME)) and sight-threatening DR (STDR Ie, severe NPDR or worse and/or DME) were assessed based on comparisons against both image-based consensus grades by two fellowship trained vitreo-retina specialists and clinical examination. Results: The sensitivity was 98.3% (95% CI 96%, 100%) and the specificity 83.7% (95% CI 73%, 94%) for RDR against image grading. The specificity for RDR decreased to 65.2% (95% CI 53.7%, 76.6%) and the sensitivity marginally increased to 100% (95% CI 100%, 100%) when compared against clinical examination. The sensitivity for detection of any DR when compared against image-based consensus grading and clinical exam were both 97.6% (95% CI 95%, 100%). The specificity for any DR detection was 90.9% (95% CI 82.3%, 99.4%) as compared against image grading and 88.9% (95% CI 79.7%, 98.1%) on clinical exam. The sensitivity for STDR was 99.0% (95% CI 96%, 100%) against image grading and 100% (95% CI 100%, 100%) as compared against clinical exam. Conclusion: The AI algorithm could screen for RDR and any DR with robust performance on images captured on a desktop fundus camera when compared to image grading, despite being previously optimized for a smartphone-based camera.

Development and validation of an offline deep learning algorithm to detect vitreoretinal abnormalities on ocular ultrasound.

Purpose: We describe our offline deep learning algorithm (DLA) and validation of its diagnostic ability to identify vitreoretinal abnormalities (VRA) on ocular ultrasound (OUS). Methods: Enrolled participants underwent OUS. All images were classified as normal or abnormal by two masked vitreoretinal specialists (AS, AM). A data set of 4902 OUS images was collected, and 4740 images of satisfactory quality were used. Of this, 4319 were processed for further training and development of DLA, and 421 images were graded by vitreoretinal specialists (AS and AM) to obtain ground truth. The main outcome measures were sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and area under receiver operating characteristic (AUROC). Results: Our algorithm demonstrated high sensitivity and specificity in identifying VRA on OUS ([90.8%; 95% confidence interval (CI): 86.1-94.3%] and [97.1% (95% CI: 93.7-98.9%], respectively). PPV and NPV of the algorithm were also high ([97.0%; 95% CI: 93.7-98.9%] and [90.8%; 95% CI: 86.2-94.3%], respectively). The AUROC was high at 0.939, and the intergrader agreement was nearly perfect with Cohen's kappa of 0.938. The model demonstrated high sensitivity in predicting vitreous hemorrhage (100%), retinal detachment (97.4%), and choroidal detachment (100%). Conclusion: Our offline DLA software demonstrated reliable performance (high sensitivity, specificity, AUROC, PPV, NPV, and intergrader agreement) for predicting VRA on OUS. This might serve as an important tool for the ophthalmic technicians who are involved in community eye screening at rural settings where trained ophthalmologists are not available.

Vogt Koyanagi Harada disease following a recent COVID-19 infection.

A 23-year-old female presented with a 3-day history of bilateral (OU) diminution of vision 3 weeks after COVID-19 infection. Best corrected visual acuity (BCVA) was 20/30 in right eye and 20/40 in left eye. Anterior segment showed OU 1+ cells in anterior chamber and anterior vitreous face. Fundus OU showed disc hyperemia and multiple pockets of subretinal fluid (SRF), confirmed on optical coherence tomography. Fundus fluorescein angiography showed multiple pin point leaks suggestive of Vogt Koyanagi Harada disease. Oral corticosteroids 1 mg/kg/day were started. At 2-months' follow-up, her BCVA improved to 20/25 OU with complete resolution of SRF.

A novel device for safe exteriorization of haptic in scleral fixation intraocular lens surgery.

The aim of this study was to describe a novel device that has been designed to facilitate anterior segment and novice surgeons to perform extraocular needle-guided haptic insertion technique (X-NIT) for scleral fixation intraocular lens surgery (SFIOL). We performed SFIOL surgery using X-NIT device in 21 eyes of 21 patients. The mean preoperative best-corrected visual acuity (BCVA) was 0.5 ± 0.2 logarithm of minimum angle of resolution (log MAR), which improved by one or more lines postoperatively in all eyes. There were no intraoperative complications. Postoperatively, we noted minimal corneal edema in one patient and dispersed vitreous hemorrhage in one patient. The sharpness and angulation of the needle and the haptic holding ability of silicone stopper were found to be satisfactory. The X-NIT device may potentially improve the safety of SFIOL procedures by minimizing intraocular maneuvers.

A modified air-assisted silicone oil removal from the anterior chamber.

Silicone oil (SO) is a commonly used tamponading agent in retinal detachment surgeries. Inadvertent anterior migration of SO and complete anterior chamber (AC) oil fill in an aphakic or pseudophakic eye is occasionally encountered. This can cause secondary glaucoma with very high intraocular pressure and pain. In this scenario, an urgent silicone oil removal (SOR) is warranted. Since SO is buoyant, in the supine position, it tends to rise anteriorly. Hence, removal of SO trapped in the AC will invariably lead to further migration of oil from the posterior segment into the AC to replace the volume removed. Simultaneous replacement of AC volume is necessary to prevent this. We describe a modified technique of partial SOR that employs air to prevent recurrent migration of SO into AC.

Peripheral retinal avascularity and capillary leakage in central serous chorioretinopathy.

PURPOSE: To report a novel finding of peripheral retinal avascularity (PRA) and peripheral capillary leakage (PCL) on wide-field fluorescein angiography (WFA) in non-dependent quadrants, in eyes with bilateral chronic central serous chorioretinopathy (CSCR). METHODS: Forty six patients with bilateral CSCR were studied. Four patients had PRA and PCL, and 42 patients did not. The demographic profile, clinical findings, and imaging characteristics of the two groups were compared. RESULTS: There was no significant difference between those patients with and without PRA and PCL with respect to the demographic profile, clinical findings, and imaging characteristics. Laser photocoagulation to extrafoveal points of leakage seen on fluorescein angiography (FA) was sufficient to cause complete resolution of CSCR in these 4 patients. PRA areas were not treated. CONCLUSION: The PRA and PCL in CSCR are novel findings, which have not been previously described.

Sensitivity and Specificity of Smartphone-Based Retinal Imaging for Diabetic Retinopathy: A Comparative Study.

PURPOSE: To determine the sensitivity and specificity of a smartphone-based fundus camera, the Remidio Fundus on Phone (FOP; Remidio Innovative Solutions Pvt. Ltd., Bengaluru, India) in detecting diabetic retinopathy (DR) compared with a conventional tabletop fundus camera and clinical examination. DESIGN: Cross-sectional, single-site, instrument validation study. PARTICIPANTS: Consecutive patients with diabetes who had no DR (n = 55 eyes), mild to moderate nonproliferative diabetic retinopathy (NPDR; n = 70 eyes), severe NPDR (n = 46 eyes), proliferative diabetic retinopathy (PDR; n = 62 eyes), and diabetic macular edema (DME; n = 44 eyes). METHODS: All participants underwent a dilated examination to determine the grade of DR. Then all participants had mydriatic 45° fundus photographs obtained from three fields of view with the Remidio FOP and a Topcon tabletop fundus camera (Topcon Medical Systems, Inc., Oakland, NJ). Two masked retina specialists graded images for DR and DME, using National Health Service guidelines as well as for image quality using predefined criteria. MAIN OUTCOME MEASURE: Sensitivity and specificity of the Remidio FOP for the detection of any DR compared to clinical examination. RESULTS: One hundred thirty-five subjects (233 eyes) were recruited for the study. Compared with the reference clinical examination, using images from the Remidio FOP, graders 1 and 2 reported a sensitivity of 93.1% (95% confidence interval [CI] = 88.3-96.4) and 94.3% (95% CI = 89.7-97.2) and a specificity of 89.1% (95% CI = 68.2-92.2) and 94.5% (95% CI = 84.9-98.9), respectively, in identifying any DR (κ = 0.55; 95% CI = 0.50-0.57). With images from the Topcon camera, graders reported similar sensitivities and specificities with marginally better agreement (κ = 0.68; 95% CI = 0.67-0.73). The sensitivity of detecting DR gradually increased from R1 to R3 disease using both cameras. Both graders classified significantly fewer images as "ungradable" (2.6%-4.3% for Topcon vs. 1.7%-2.1% for Remidio FOP) and more images as excellent from the Remidio FOP (59%-74%) than the Topcon device (52%-61%). CONCLUSIONS: The Remidio FOP device was found to have high sensitivity and specificity for the detection of any grade of DR with good agreement between graders. The rate of ungradable images was acceptably low and image quality was marginally better with the Remidio FOP.