Intermediate Uveitis with Cystoid Macular Edema as Presentation of Retained Caterpillar Hair in the Vitreous Cavity.

PURPOSE: To report an unusual case of retained caterpillar hair in the vitreous cavity presenting as recurrent Intermediate Uveitis with cystoid macular edema. METHOD: Case Report. RESULTS: A 40-year-old male presented to our uveitis clinic with recurrent episodes of redness and diminution of vision in his left eye for 3 years. He was diagnosed and treated elsewhere as a case of recurrent intermediate uveitis and was referred to our center for a second opinion to initiate immunosuppressive therapy. A detailed history revealed that a caterpillar had fallen into his left eye 3 years back, followed by severe irritation, pain, and redness. He received topical antibiotics and corticosteroids, and retained caterpillar hair was removed from the ocular surface. During the last 3 years, the patient had multiple episodes of inflammation despite being treated with oral and topical corticosteroids. At the current visit, a meticulous clinical examination at our centre revealed multiple, migrated, retained caterpillar hair in the vitreous cavity. The patient was diagnosed with Ophthalmia Nodosa (Type V) and managed with surgical intervention (vitreous surgery). The case highlights an unusual presentation of ON and the role of pars plana vitrectomy in its successful management. CONCLUSION: We highlight a rare and unusual presentation of ophthalmia nodosa and its successful management.

Outcomes after giant peripheral retinotomy and anterior flap retinectomy for rhegmatogenous retinal detachments with advanced proliferative vitreoretinopathy using small gauge vitrectomy.

PURPOSE: To analyze the visual and anatomical outcomes for eyes with rhegmatogenous retinal detachment (RRD) and advanced proliferative vitreoretinopathy (PVR) undergoing giant peripheral retinotomy (GPR) using 25-gauge pars plana vitrectomy (PPV). METHODS: In this retrospective multi-center study, patients with RRD with either anteroposterior or circumferential retinal shortening and advanced PVR requiring more than 90-degree GPR with/without relaxing retinotomy were included. Subjects of either gender, any age group, and with complete surgical notes were included. Outcome measures of the study included anatomical success (i.e. complete retinal re-attachment) at 6 months using survival analysis, visual outcomes, and post-operative complications. RESULTS: Forty-one eyes of 41 patients (33 males) with a mean age of 44.9 ± 21.4 years were included. At 6 months follow-up, anatomical success was seen in 29 eyes (70.7%) with a cumulative re-attachment rate of 66% (95% confidence interval = 48 = 79%). All re-detachments occurred at ≤6 months with a peak at 4-6 months (n = 9). Twenty-three eyes (56%) achieved ambulatory vision (5/200) or better. Direct perfluorocarbon liquid-silicone oil exchange was performed in 20 eyes. Intra-operative complications included persistent retinal folds (2 eyes), subretinal air (1 eye), and subretinal bleed (1 eye). Eleven eyes (26.8%) developed secondary glaucoma (2 eyes required a drainage device), and hypotony of ≤6 mmHg was noted in 3 eyes (7.3%). Corneal decompensation was noted in 8 eyes (19.5%), and 3 eyes (7.3%) underwent re-surgery for re-RRD. CONCLUSION: After GPR using small gauge PPV, two-thirds achieve anatomical success, and over half have ambulatory vision, but overall post-operative complications can occur in more than half of the eyes.

Microscope integrated OCT (Mi-OCT) guided retrieval of intrastromal corneal foreign body.

Introduction: To describe the role of microscope integrated optical tomography (Mi-OCT) in removal of intrastromal corneal foreign body. Methodology: A young male presented with trauma to the right eye with sugarcane stick. Ocular examination revealed two sugarcane particles, approximately 3.5 mm in greatest dimension, embedded in the corneal stroma. For removal of foreign body, Mi-OCT was switched on and the area of interest was focused. Sugarcane particles appeared as hyperreflective structures embedded in the corneal stroma with everted edges of the overlying corneal epithelium and anterior stroma. Results: Both the sugarcane particles were removed successfully under real time images provided by Mi-OCT without causing any inadvertent damage to the corneal stroma. Conclusion: Mi-OCT can be used as an adjunct in emergency surgical procedures like removal of intrastromal corneal foreign bodies with accurate precision.

Endogenous Endophthalmitis in COVID-19 Patients: A Case Series and Literature Review.

PURPOSE: To report outcomes in cases of endogenous endophthalmitis (EE) following COVID-19 infection. MATERIAL AND METHODS: In a retrospective study, patients with EE, who had a recent history of COVID-19 infection requiring hospital admission were recruited. Necessary demographic details, details of ocular examination, and microbiological details were collected. RESULTS: Six patients (10 eyes), with a mean age of 48 + 19.80 years were included. The mean duration of onset of ocular symptoms from the time of diagnosis of COVID was 28.16 + 16.15 days. 8 eyes required surgical intervention, whereas 2 eyes were managed conservatively. Three patients were positive for Candida albicans, two patients were positive for Aspergillus fumigatus, and one patient was a presumed bacterial EE. The majority of the eyes had favorable functional and anatomical outcomes during the post-operative period. CONCLUSION: High-dose corticosteroid therapy in the management of moderate and severe COVID-19 infection may be associated with EE, predominantly fungal.

Tacrolimus Induced Thrombotic Microangiopathy (TMA) Presenting as Acute Macular Neuroretinopathy.

This report highlights the association of tacrolimus use with acute macular neuroretinopathy (AMN). A 27-year-old woman, a known case of diffuse proliferative membranous glomerulonephritis, developed abnormal body movements, loss of consciousness, and blurring of vision in the left eye, after 3 months of starting tacrolimus. Blood investigations revealed anemia, thrombocytopenia, raised urea and creatinine levels, and raised LDH levels. A diagnosis of tacrolimus induced hemolytic uremic syndrome (HUS) with posterior reversible encephalopathy syndrome (PRES) was made. Ocular examination revealed a reddish-brown petaloid retinal lesion, which was better appreciated on red-free imaging as dark grey area pointing towards the fovea. OCT-A and SD-OCT revealed flow voids in deep retinal plexus, and disruption of ellipsoid and interdigitation zone, respectively, findings consistent with AMN. To the best of our knowledge, it is the first report of association of tacrolimus with AMN.

Demographic profile of patients seeking teleophthalmology consultations through e-Sanjeevani: Retrospective analysis of 5138 patients from North India.

Purpose: To report the demographic profile of patients registered through e-Sanjeevani OPD seeking teleophthalmology services. Methods: This was a cross-sectional data analysis of patients with ocular complaints registered through the e-Sanjeevani platform at a tertiary care center. It was a doctor-to-doctor consultation, where teleophthalmology consultants provided teleconsultation services at subcenters (SCs), primary health centers (PHCs), and community health centers (CHCs). Data regarding the patient's age, gender, residential address, provisional diagnosis, and treatment prescribed were recorded from May 2021 to February 2022 (9 months). Results: In total, 5138 patients were teleconsulted from the mean age of the patients was 37.64 ± 19.34 years. Among these patients, 44% were males and 56% were females. Most of the teleconsultation calls were made from Palwal district (19.8%), followed by Hisar (14.5%) and Sonipat. The most common provisional diagnosis was dry eyes (21%), followed by allergic conjunctivitis (18%), refractive error (15%), and cataract (14%). These constituted approximately 70% of the diagnosis made through teleconsultations. The rest of the eye problems were diagnosed as stye, blepharitis, nasolacrimal duct obstruction, pterygium, subconjunctival hemorrhage, etc., The majority of the patients were managed medically (56.6%) and approximately 11.6% of the patients were referred for surgical intervention. Conclusion: e-Sanjeevani is an effective way to provide teleconsultations to patients in remote locations. The majority of the patients seeking ophthalmology consultations can be managed conservatively. Patients requiring surgical intervention can be referred timely, thus avoiding any delay in treatment.

A hybrid 26G needle drainage technique in scleral buckling: A mini scleral cut-down.

Purpose: To evaluate the efficacy and safety of hybrid 26-gauge needle drainage in scleral buckling for rhegmatogenous retinal detachment (RRD). Methods: In this retrospective study, we included patients who underwent scleral buckling surgery along with subretinal fluid (SRF) drainage using the 'Hybrid 26G needle drainage technique'. Pre-operative assessment included the best corrected visual acuity (BCVA), lens status, and extent of retinal detachment. Intra-operative surgical details such as the height of retinal detachment, number of attempts required to drain the fluid, amount of fluid drained, adequacy of break buckle relationship, and any intra-operative or post-operative complications were noted. Post-operatively, the final visual outcome and retina status were assessed at 3 months of follow-up. Results: A total of 10 eyes with primary RRD and proliferative vitreoretinopathy C1 or less were included. Pre-operatively, the mean BCVA was 2.43 ± 1.01 logMAR units, which improved significantly to 0.679 ± 0.45 logMAR units (p value < 0.05) at 3 months of follow-up. Regarding the extent of RRD, five eyes (50%) had a total detachment, two eyes (20%) had a sub-total detachment, and three eyes (30%) had an inferior detachment. Four eyes had shallow detachment, four had a moderate detachment, and two eyes had bullous detachment. Complete drainage of SRF (>75%) was achieved in five patients, and a partial but adequate drainage (50-75%) was achieved in the rest of the five patients. In none of the patients, inadequate or dry tap was encountered. No intra-operative complications were encountered. The retina was attached in eight out of ten eyes at 1 week and at a 1-month follow-up period. Two patients required pars plana vitrectomy for persistent SRF. The retina was attached in all the patients at 3 months of follow-up. Conclusion: The 'Hybrid needle drainage' technique is a safe and effective technique for SRF drainage in scleral buckling surgery.

Oral valganciclovir in human immunodeficiency virus-positive patients suffering from cytomegalovirus retinitis at a tertiary care hospital in North India.

Purpose: To study clinical efficacy of valganciclovir in cytomegalovirus retinitis (CMVR) in human immunodeficiency virus (HIV)-positive-positive patients in a tertiary care clinic in a developing nation. Methods: In a retrospective study, systemic and ocular records of HIV patients suffering from CMVR and treated with valganciclovir, were analyzed. Primary outcome measures were involvement of the other eye, incidence of retinal detachment, systemic involvement, and mortality encountered. Secondary outcome measures included change in BCVA. Results: Out of nine patients who were included, two patients developed CMVR in the other eye and only one patient (11.11%) developed retinal detachment during the course of the study. No patient developed any systemic manifestations or had mortality during the course of the study. The change in BCVA was not statistically significant. Conclusion: Use of oral valganciclovir showed good outcome and was found to be a better alternative compared to the use of intravitreal ganciclovir in the literature. Introduction of valganciclovir at an affordable price in developing nations can decrease disease burden.

Intraoperative optical coherence tomography (I-OCT) assisted passage of the encircling element during retinal detachment surgery.

Objective: To describe the role of microscope integrated optical tomography (Mi-OCT) in passage of the encircling element during retinal detachment surgery. Materials and methods: Mi-OCT was switched on while passing scleral anchoring sutures to secure the encircling element. The depth of the suture tract was seen in real time while the needle was passed through the sclera. The amount of scleral intend achieved was assessed using Mi-OCT at the end of the surgery. Results: The depth of needle tract through the sclera and the amount of scleral indentation achieved while tying the sutures could be successfully analyzed using Mi-OCT. Conclusion: Mi-OCT can be used as an adjunct while training vitreoretinal fellows and trainees in surgical procedures like passage of scleral sutures for anchoring the encircling element.

Intraoperative haemorrhagic choroidal detachment during MicroIncision Vitrectomy Surgery (MIVS): a unique mechanism.

Haemorrhagic choroidal detachment (HCD) is a dreaded intraoperative complication of ophthalmic surgery, despite being rare. Multiple systemic and ocular risk factors of HCD have been reported. Acute hypotony during surgery is considered one of the most important precipitating factors. We herein describe a series of events during pars plana vitrectomy surgery for management of rhegmatogeneous retinal detachment which lead to localised HCD. We believe that the pathogenesis of localised HCD is related to compressive decompressive forces during the final tie of the encircling element after fluid air exchange.

Subretinal Hemorrhage Complicating Retinal Angiomatous Proliferation in Tubercular Retinal Vasculitis.

PURPOSE: To report a patient with submacular hemorrhage due to retinal angiomatous proliferation (RAP) in tubercular retinal vasculitis (TRV). METHODS: Case report. RESULTS: We report a 33-year-old Asian Indian patient of TRV presenting with capillary non-perfusion areas, submacular hemorrhage and venous loops. The patient presented with sudden onset decrease in vision in the right eye. Multimodal imaging revealed presence of retinal vascular anastomosis and stage 2 RAP. Systemic examination was within normal limits. Laboratory evaluation revealed positive Mantoux and interferon gamma release assay. He underwent right eye intravitreal injection of recombinant tissue plasminogen activator (12.5µg/0.1ml) with 100% sulphur hexafluoride (SF6) tamponade. The patient had successful displacement of the submacular hemorrhage with some improvement in visual acuity. CONCLUSION: This case highlights that rare vascular alterations such as RAP can develop in subjects with ocular tuberculosis.

Retinal Involvement in COVID-19: Results From a Prospective Retina Screening Program in the Acute and Convalescent Phase.

Objective: To detect retinal involvement in coronavirus disease 2019 (COVID-19) patients in acute and convalescent phase by their fundus screening. Methods: In a prospective, cross-sectional, observational study (July-November 2020), 235 patients (142 acute and 93 convalescent phase) underwent fundus screening in a tertiary care center in North India. For convalescent phase, "hospitalized" patients (73) were screened at least 2 weeks after hospital discharge, and "home-isolated" patients (20) were screened 17 days after symptom onset/COVID-19 testing. Results: None in acute phase showed any retinal lesion that could be attributed exclusively to COVID-19. Five patients (5.38%) in convalescent phase had cotton wool spots (CWSs) with/without retinal hemorrhage, with no other retinal finding, and no visual symptoms, seen at a median of 30 days from COVID-19 diagnosis. Conclusions: CWSs (and retinal hemorrhages) were an incidental finding in COVID-19, detected only in the convalescent phase. These patients were much older (median age = 69 years) than the average age of our sample and had systemic comorbidities (diabetes mellitus, hypertension, etc.). We propose the term "COVID-19 retinopathy" to denote the presence of CWSs at the posterior pole, occasionally associated with intraretinal hemorrhages, in the absence of ocular inflammation in patients with a history of COVID-19 disease.

Reversibility of retinochoroidal vascular alteration in patients with obstructive sleep apnea after continuous positive air pressure and surgical intervention.

Purpose: The aim of this work was to study various retinochoroidal parameters in patients with obstructive sleep apnea syndrome (OSAS) and the effect of interventions on these parameters at 6 months follow-up. Methods: A total of 36 patients were recruited prospectively from the otorhinolaryngology clinics of a large tertiary center between September 2018 to March 2020. The subjects were divided into three groups depending upon intervention chosen for OSAS: Group A (surgery, i.e., uvulopalatopharyngoplasty), group B (medical therapy, i.e., continuous positive air pressure) and group C (no intervention). Various retinochoroidal parameters which were studied included retinal thickness (RT), choroidal thickness (CT), choroidal vascularity index (CVI), arteriovenous ratio (AVR), capillary density index (CDI) in superficial and deep retina, at baseline and 6 months of follow-up after the intervention. Results: In group A, CT increased significantly at 6 months (332.76 ± 86.41 um) compared to baseline (306.28 ± 78.19) (P = 0.0004). Similarly, CDI at both superficial and deep capillary plexus increased significantly at 6 months (superficial CDI: 0.65 ± 0.04, deep CDI: 0.38 ± 0.01) compared to baseline (superficial CDI: 0.62 ± 0.03, deep CDI: 0.36 ± 0.02) (P = 0.004 and 0.002 respectively). In group B, CT increased significantly at 6 months (361.38 ± 78.63 um) compared to baseline (324.21 ± 76.97 um) (P = 0.008). Also, CVI showed a significant decrease at 6 months (65.74 ± 1.84%) compared to baseline (67.36 ± 1.57%) (P = 0.019). In group C, all except CDI in deep capillary plexus showed a significant decrease at 6 months (0.35 ± 0.01) compared to baseline (0.36 ± 0.02) (P = 0.003). Conclusion: OSAS alters various retinochoroidal parameters and timely intervention in patients with OSAS can prevent these alterations. Also, these retinochoroidal parameters could serve as one of the markers to monitor the disease progression.