LncRNA VEAL2 regulates PRKCB2 to modulate endothelial permeability in diabetic retinopathy.

Long non-coding RNAs (lncRNAs) are emerging as key regulators of endothelial cell function. Here, we investigated the role of a novel vascular endothelial-associated lncRNA (VEAL2) in regulating endothelial permeability. Precise editing of veal2 loci in zebrafish (veal2gib005Δ8/+ ) induced cranial hemorrhage. In vitro and in vivo studies revealed that veal2 competes with diacylglycerol for interaction with protein kinase C beta-b (Prkcbb) and regulates its kinase activity. Using PRKCB2 as bait, we identified functional ortholog of veal2 in humans from HUVECs and named it as VEAL2. Overexpression and knockdown of VEAL2 affected tubulogenesis and permeability in HUVECs. VEAL2 was differentially expressed in choroid tissue in eye and blood from patients with diabetic retinopathy, a disease where PRKCB2 is known to be hyperactivated. Further, VEAL2 could rescue the effects of PRKCB2-mediated turnover of endothelial junctional proteins thus reducing hyperpermeability in hyperglycemic HUVEC model of diabetic retinopathy. Based on evidence from zebrafish and hyperglycemic HUVEC models and diabetic retinopathy patients, we report a hitherto unknown VEAL2 lncRNA-mediated regulation of PRKCB2, for modulating junctional dynamics and maintenance of endothelial permeability.

Topiramate induced bilateral hypopyon uveitis and choroidal detachment: a report of two cases and review of literature.

BACKGROUND: Topiramate (TPM) is a drug commonly used by neurophysicians and psychiatrists for a plethora of indications. Topiramate has been reported to induce acute angle closure glaucoma as an adverse effect. However, there is limited literature on Topiramate causing hypopyon uveitis and intense ocular inflammation. It is imperative for ophthalmologists as well as physicians to be aware of the potential sight threatening ocular adverse effects of Topiramate. We report 2 rare consecutive cases of severe hypopyon uveitis and choroidal detachments after using Topiramate. CASE PRESENTATION: Two patients presented with sudden onset of angle closure, bilateral hypopyon uveitis and choroidal detachments. On reassessing a detailed treatment history, it was found that both patient were taking oral Topiramate which had been started 2 weeks before the onset of ocular symptoms. The bilateral hypopyon and angle closure were considered to be induced by Topiramate and the drug was discontinued. The patients were started on oral and topical steroids which led to resolution of hypopyon uveitis and choroidal detachments. The visual acuity improved and the intraocular pressure also got normalised in both the cases. CONCLUSIONS: Topiramate can lead to a bilateral hypopyon uveitis and severe ocular inflammation. An urgent cessation of topiramate along with topical and systemic steroids is required to prevent serious complications.

Distribution of peripheral lesions identified by mydriatic ultra-wide field fundus imaging in diabetic retinopathy.

PURPOSE: To analyze the distribution of diabetic retinopathy (DR) lesions in an Indian population using ultra-wide field (UWF) fundus imaging. METHODS: Seven hundred fifteen subjects (1406 eyes) with diabetic retinopathy in India were enrolled in this multicenter, prospective, observational study using UWF pseudocolor imaging with Optos Daytona Plus (Optos plc, Dunfermline, Scotland, UK). Images were transmitted to Doheny Image Reading Center, Los Angeles, CA, for grading. The ETDRS grid was overlaid on stereographic projections of UWF images, and images were graded independently by 2 masked graders. Lesion distribution was graded as predominantly central (PCL) or predominantly peripheral (PPL) according to previous criteria, considering both lesion number and area. An image was graded as PPL if > 50% of the lesion area was seen in at least one peripheral field as compared with the corresponding ETDRS field. Diabetic retinopathy severity was also assessed based on the International Classification of Diabetic Retinopathy (ICDR) grading scale. The main outcome measures were lesion distribution (PPL versus PCL): overall and within specific fields in eyes with various grades of DR. RESULTS: Lesion distribution was rated to be PPL in 37% of eyes and PCL in 63% of eyes (P < 0.003). The frequency of a PPL distribution varied significantly across all ICDR severity levels, with frequencies of mild non-proliferative DR (NPDR) (30.9%), moderate NPDR (40.3%), severe NPDR (38.5%) and PDR (34.9%), P = 0.005. When assessing which individual fields were rated to show a PPL distribution, the frequency was greatest in field 4 and least in field 7. For any grade of DR, temporal fields showed the greatest PPL frequency, followed in order by the superior, inferior, and nasal fields (P < 0.001). Only 3.5% of eyes showed PPL distribution in all five peripheral fields. CONCLUSIONS: One-third of the UWF images showed a PPL distribution in this cohort with the temporal quadrant having the widest distribution of PPL. As the PPL distribution varied significantly between various grades of DR, UWF imaging may prove to be important for screening of referral warranted retinopathy.

CLINICAL PRESENTATIONS, DIAGNOSIS, AND MANAGEMENT OUTCOMES OF CURVULARIA ENDOPHTHALMITIS AND A REVIEW OF LITERATURE.

PURPOSE: To describe the clinical presentation and management of Curvularia endophthalmitis and compare with previous published literature. METHODS: Retrospective interventional comparative case series and literature review. Eight cases with culture-proven Curvularia endophthalmitis from January 2000 to March 2018 underwent vitrectomy/vitreous biopsy, intravitreal antibiotic with or without additional procedures as appropriate. The undiluted vitreous biopsy was subjected to microbiologic evaluation. Pre-existing literature was reviewed, and the current outcomes were compared with them. The mean age at presentation, etiology, number of interventions, interval between inciting event and presentation, type of intravitreal antifungal used, anatomical, and the functional outcomes were reported and compared with pre-existing literature. A favorable anatomical outcome was defined as preservation of the globe, absence of hypotony, attached retina, and absence of active inflammation at the last visit. RESULTS: In the current series, there were 4 men and 4 women. Mean age at presentation was 34.5 ± 13.51 years (median 30 years). Inciting event was open-globe injury in five cases and cataract surgery, trabeculectomy, and endogenous cause in one case each. Presenting visual acuity was ≥20/400 in 3 cases at presentation and 5 cases at the last visit. One case with staphyloma and endophthalmitis underwent evisceration for a painful blind eye. The patients in the current series were much younger than those described previously. CONCLUSION: Presentation and diagnosis of Curvularia can be delayed especially in postoperative cases. Early and appropriate management with multiple interventions can result in an acceptable visual and anatomical outcome.

SURGICAL OUTCOMES AFTER INVERTED INTERNAL LIMITING MEMBRANE FLAP VERSUS CONVENTIONAL PEELING FOR VERY LARGE MACULAR HOLES.

PURPOSE: To evaluate the anatomical and visual outcomes of inverted flap technique of peeling of internal limiting membrane (ILM) versus standard peeling of ILM for macular holes of basal diameter more than 800 µm. METHODS: Patients with very large idiopathic macular holes more than 800 µm in basal diameter (ranging from 243 µm to 840 µm in minimum diameter) were retrospectively included in the study. In Group A, 18 eyes of 18 patients underwent ILM peeling using the inverted flap technique. In Group B, 18 eyes of 18 patients underwent conventional ILM peeling. The primary endpoint was the rate of hole closure at 6 months after surgery. The secondary outcome measure was the change in best-corrected visual acuity at 6 months after surgery. RESULTS: There were no significant differences in ocular characteristics of the study groups at baseline except for the age distribution. Mean macular hole diameter was 1,162.8 ± 206.0 µm and 1,229.6 ± 228.1 µm in Group A and Group B, respectively. The hole closure rate was 88.9% (16/18) in Group A and 77.8% (14/18) in Group B (P = 0.66). The mean gain in best-corrected visual acuity was higher in Group A than in Group B (P = 0.12) at 6 months, but this was not statistically significant. There were no severe ocular adverse events in either group. CONCLUSION: In this multicenter series, inverted ILM flap technique did not lead to significantly higher anatomical closure rates than conventional ILM peeling in large macular holes more than 800 µm in diameter.

CLINICAL PRESENTATION, MICROBIOLOGIC PROFILE AND FACTORS PREDICTING OUTCOMES IN BACILLUS ENDOPHTHALMITIS.

PURPOSE: To describe the clinical presentation, microbiologic profile, and factors predicting outcomes in Bacillus endophthalmitis. METHODS: Retrospective interventional case series. Eighty-six patients with culture-proven Bacillus endophthalmitis, from January 2001 to December 2015, underwent vitrectomy/vitreous biopsy and intravitreal antibiotic with or without steroid as appropriate. The undiluted vitreous biopsy was subjected to microbiologic evaluation. The duration of symptoms, presenting visual acuity, organisms isolated, influence of intravitreal dexamethasone with intravitreal antibiotics, and type of initial intervention were examined for any clinical and statistical correlation in terms of odds ratio with the final visual outcome. RESULTS: Trauma was the commonest etiology (n = 75; 87.2%). Mixed infection with other bacteria was seen in 11 patients. All Bacillus species were sensitive to gentamicin followed by ciprofloxacin (n = 85; 98.83%) and vancomycin (n = 81; 94.18%). Odds in favor of a favorable visual outcome were seen with clinical treatment within 48 hours of the symptoms (OR 25.47, 95% CI 2.45-254.16, P = 0.006), better presenting vision (OR 31.21, 95% CI 2.96-323.64, P = 0.004), and absence of polymicrobial infection (OR 18.03, 95% CI 0.9-344.4, P = 0.05). Only 20% of all treated patients regained ambulatory vision, and one fifth of all of them developed phthisis. CONCLUSION: Patients diagnosed with Bacillus endophthalmitis merit aggressive vitreous intervention guided by the culture-sensitivity report. Despite early and appropriate treat ment, the outcomes are generally poor.

Clinical presentations, risk factors and outcomes of ceftazidime-resistant Gram-negative endophthalmitis.

BACKGROUND: To describe the clinical features and outcomes of patients diagnosed with ceftazidime-resistant Gram-negative endophthalmitis and the role of intravitreal imipenem in these cases. DESIGN: Retrospective consecutive interventional case series at a tertiary eye care centre in South India. PARTICIPANTS: Consecutive cases of ceftazidime-resistant Gram-negative endophthalmitis from April 2010 to December 2014. Fifty-six cases diagnosed during this time period were included. METHODS: All cases were managed with vitreous biopsy/vitrectomy, microscopy and undiluted vitreous culture, antimicrobial susceptibility of bacterial isolates and received intravitreal antibiotics. MAIN OUTCOME MEASURES: Anatomic and visual outcome of these cases, antimicrobial susceptibility pattern of intravitreal imipenem and outcome of cases injected with it. RESULTS: Commonest presentation was acute endophthalmitis following cataract surgery (27 eyes, 48.21%). Pseudomonas aeruginosa was isolated in 33 eyes (58.93%; 95% CI 46.05-71.81%). Nineteen eyes (34%; 95% CI 21.59-46.41%) developed phthisis; 14 eyes (25%; 95% CI 13.66-36.34%) had vision <20/200; 17 eyes (30.35%; 95% CI 18.31-42.39%) eyes had an ambulatory vision >20/200 (logMAR 1); 6 eyes (10.71%; 95% CI 2.61-18.81%) had a reading vision >20/40 (logMAR 0.3). Trend was towards better anatomic (72.73% vs. 40%) (P = 0.05) and visual improvement in the imipenem group (logMAR 3.94 + 0.21 to 2.43 + 1.4; P = 0.002), as compared with non-imipenem group (logMAR 2.99 + 1.3 to 2.55 + 1.4; P = 0.13). CONCLUSIONS: Outcome of ceftazidime-resistant Gram-negative endophthalmitis is poor. P. aeruginosa is the commonest isolated organism. All cases were sensitive to imipenem. There was a trend towards better anatomic outcome in imipenem-treated eyes.

CLINICAL PRESENTATIONS AND OUTCOMES OF RHEGMATOGENOUS RETINAL DETACHMENT IN RETINITIS PIGMENTOSA.

PURPOSE: To describe the clinical presentations and outcomes of rhegmatogenous retinal detachments (RRD) in eyes with retinitis pigmentosa. METHODS: A retrospective review of all patients of retinitis pigmentosa with RRD from January 1990 to December 2013 at a tertiary eye care institute. RESULTS: Of total 28,622 patients of retinitis pigmentosa over a 23-year period, 17 eyes of 17 patients had RRD. Mean age at presentation was 34.53 ± 16.42 years (median 32 years). Median duration of decreased vision attributed to RRD was 6 months. Ten eyes (59%) had cataract and 3 eyes (18%) had history of cataract surgery. Thirteen eyes (76%) had inferior retinal detachment; 9 eyes (53%) had lattice with retinal holes; and 8 eyes (47%) had atrophic retinal holes. There were no horse-shoe tears, giant retinal tears, dialysis, and macular holes related RRD. Majority (82%) of retinal breaks were in the inferotemporal quadrant. Only 3 eyes (18%) had proliferative vitreoretinopathy at presentation. Twelve eyes at presentation had best-corrected visual acuity <20/200 and 6 eyes had only light perception. The macula was involved by the detachment in all cases. Mean preoperative visual acuity was 1.4 ± 0.88 logarithm of the minimum angle of resolution (median 1.3, range 3-0.1; 20/502). Surgery was not advised in 6 eyes (35% patients); 5 eyes (30%) underwent scleral buckling and 6 eyes (35%) underwent vitrectomy. Median follow-up was 5 months. Reattachment rate at last follow-up was 91% (15 eyes). Mean postoperative best-corrected visual acuity recorded was 1.06 ± 0.8 (median 1, range 3-0.1; 20/229) (P = 0.15). Eight eyes at last visit had best-corrected visual acuity <20/200. Of the 11 eyes operated, 4 improved in vision and 7 retained the preoperative vision. CONCLUSION: The incidence of RRD in retinitis pigmentosa is very low. Presentation, although delayed, is at a younger age. Horse-shoe tears and proliferative vitreoretinopathy are uncommon; cataract is a common coexisting pathology. Surgical reattachment rates appear high and recurrent RRD is uncommon. However, visual gain is limited by the underlying retinal degenerative condition.

VKH disease in the elderly: Variations in clinical course as compared to VKH disease in adults.

PURPOSE: To describe disease characteristics and outcomes of Vogt-Koyanagi-Harada (VKH) disease in elderly patients. METHODS: Retrospective analysis of patients older than 50 years with VKH disease at two referral centers in India. Demographics, extraocular and ocular involvement, treatment, complications, and visual acuity outcomes were noted. RESULTS: In total, 69 patients (mean age at presentation: 56.4 ± 4.7 years) were analyzed; 6/69 patients had diabetes mellitus at presentation, and 10/69 had hypertension. Clinical signs included anterior chamber cells >2+ (29%), granulomatous keratic precipitates (23%), disc hyperemia (26%), neurosensory retinal detachment (34.7%), and "sunset-glow" fundus (52.1%). Patients were classified as probable (n = 50, 72.4%), incomplete (n = 18, 26%), and complete VKH (n = 1, 1.4%). The mean follow-up period was 20.2 ± 19.4 months. Improvement in mean BCVA of (0.63 LogMAR, 6 Snellen lines) was noted on the last follow-up. Patients receiving systemic steroids with immunosuppressants ( P < 0.0001) had better visual outcomes at final follow-up compared to steroids alone ( P = 0.103). Eight patients (11.6%) had complications due to systemic immunosuppressants, and 17 patients (24.6%) developed diabetes mellitus or had worsening of diabetes while on systemic corticosteroids. CONCLUSION: Few patients presented with systemic manifestations in our cohort. Those treated with steroids and concurrent immunosuppressants had better outcomes. However, therapy with immunosuppressants was encountered with major dose-limiting complications in a significant number of elderly patients with VKH syndrome.

Relationship between macular perfusion and lesion distribution in diabetic retinopathy.

BACKGROUND/OBJECTIVES: To assess the relationship between macular vessel density metrics and foveal avascular zone (FAZ) characteristics on optical coherence tomography angiography (OCTA) and lesion distribution in eyes with diabetic retinopathy (DR). SUBJECTS/METHODS: Patients with DR who underwent both Optos ultrawidefield (UWF) pseudocolor imaging and macular OCTA (Cirrus Angioplex, 6 × 6 mm) were included in this cross-sectional observational study. The distribution of DR lesions was assessed by comparing each of the peripheral ETDRS extended fields (3-7) against their corresponding ETDRS field, hence eyes were defined as either having predominantly peripheral lesions (PPL) or predominantly central lesions (PCL). En face OCTA images from the superficial and deep capillary plexuses (SCP and DCP) were then analysed using Image J software. Perfusion density (PD), vessel length density (VLD), and fractal dimensions (FD) were calculated following binarization and skeletonization of the images. RESULTS: Out of 344 eyes, 116 (33.72%) eyes had PPL and 228 (66.28%) eyes had PCL. For all DRSS levels, VLD, PD, and FD were not significantly different between eyes with PPL and PCL. The FAZ in eyes with PPL, however, was found to be more circular in shape compared to eyes with PCL (p = 0.037). CONCLUSION: Although the presence of PPL has been associated with a higher risk for diabetic retinopathy progression, the macular perfusion is similar in eyes with PPL and PCL. The FAZ is more circular in eyes with PPL, but the clinical relevance of this difference remains to be defined.

Association of the del443ins54 at the ARMS2 locus in Indian and Australian cohorts with age-related macular degeneration.

PURPOSE: The ARMS2/HTRA1 genes at the 10q26 locus have been associated with risk of age-related macular degeneration (AMD), with the most significantly associated variants being A69S (rs10490924), del443ins54 (EU427539) and rs11200638. We wished to explore the association of the del443ins54 in two ethnically different populations from India and Australia. METHODS: The del443ins54 was screened in a large cohort of ~1500 subjects from these two populations by a combination of PCR-based agarose gel electrophoresis and validated by resequencing. Statistical analysis comprised the calculations of allele, genotype and haplotype frequencies along with their p values and corresponding odds ratios (OR), and 95% confidence intervals (95% CI) and measures of linkage disequilibrium (LD). RESULTS: The del443ins54 was significantly associated with AMD in both the Indian (p=1.74 × 10(-13); OR = 2.80, 95%CI, 2.12-3.70) and Australian cohorts (p = 2.78 × 10(-30); OR = 3.15, 95%CI, 2.58-3.86). These associations were similar to those previously identified for the A69S and the rs11200638 variant in these populations that also exhibited high degrees of LD (D' of 0.87-0.99). A major risk haplotype of "T-indel-A" (p = 5.7 × 10(-16); OR = 3.16, 95%CI, 2.34-4.19 and p=6.33 × 10(-30); OR = 3.15, 95%CI, 2.57-3.85) and a protective haplotype of "G-wild type-G" (p=2.35 × 10(-11); OR = 0.39, 95%CI, 0.29-0.52 and p=1.02 × 10(-30); OR = 0.31, 95%CI, 0.25-0.38) were identified in the Indian and Australian cohorts, respectively. CONCLUSIONS: These data provide an independent replication of the association of del443ins54 variant in two different ethnicities, despite differences in allele and haplotype frequencies between them. High levels of LD in both populations limit further genetic dissection of this region in AMD.

Vascular changes in eyes treated with dexamethasone intravitreal implant for macular edema after retinal vein occlusion.

OBJECTIVE: To evaluate the angiographic findings in eyes from 2 clinical trials of the dexamethasone intravitreal implant (DEX implant) 0.7 mg in the treatment of macular edema (ME) after branch retinal vein occlusion (BRVO) or central retinal vein occlusion (CRVO). DESIGN: Post hoc analysis of pooled data from 2 identical phase 3 clinical trials. PARTICIPANTS: Patients with vision loss as a result of ME (≥ 6 weeks' duration) after BRVO or CRVO for whom angiographic data were available (n = 329 eyes). METHODS: Fluorescein angiography (FA) results assessed by masked, certified graders using standardized grading protocols. MAIN OUTCOME MEASURES: The primary outcome measure in the parent studies was change from baseline in best-corrected visual acuity. Prospectively defined secondary outcomes included FA measurements (to assess macular capillary leakage, neovascularization, and nonperfusion) and optical coherence tomography results (to assess central retinal thickness [CRT]). RESULTS: At baseline, 42% of eyes in the DEX implant group and 38% of eyes in the sham group had unreadable assessments because of hemorrhage. At day 180, significantly fewer DEX implant-treated eyes (2%) than sham-treated eyes (9%) had unreadable assessments because of hemorrhage (P = 0.029). Among eyes with gradable assessments, the incidence of nonperfusion remained fairly steady from baseline to day 180. The proportion of eyes with active neovascularization increased from baseline to day 180 in the sham group, but stayed relatively constant in the DEX implant group (P = 0.026 for DEX vs. sham). The mean area of overall nonperfusion and the mean area of macular capillary nonperfusion increased from baseline to day 180 in both treatment groups (no statistically significant between-group difference). There was a statistically significant positive correlation between changes in macular leakage and changes in CRT in both the DEX implant group (r = 0.22; 95% confidence interval, 0.03-0.40; P = 0.023) and the sham group (r = 0.29; 95% confidence interval, 0.10-0.46; P = 0.003). CONCLUSIONS: This study demonstrated that the clinical improvements observed with the DEX implant were accompanied by significant improvements in vascular parameters and suggests that treatment with the DEX implant may be associated with some clinically significant improvements in angiographic findings, specifically active neovascularization.

Multifocal electroretinography in type 2 idiopathic macular telangiectasia.

BACKGROUND: To characterize the electroretinographic response of the macula by multifocal electroretinography (mfERG) in patients with type 2 idiopathic macular telangiectasia (MacTel). METHODS: A prospective study of mfERG in patients with type 2 MacTel was conducted from April 2009 to November 2009. mfERGs were recorded using a visual evoked response imaging system (MonElec2, Metrovision, Perenchies, France). The International Society for Clinical Electrophysiology of Vision (ISCEV) guidelines were followed. Patients with type 2 MacTel confirmed by fundus fluorescein angiography without subretinal neovascularisation were included. For recording purposes, 61 stimulus hexagonal elements were used. The first-order kernel mfERG responses were analyzed. Individual mfERG responses for the hexagons were grouped into concentric rings centered on the fovea for analysis (< 2, 5-10, 10-15 and >15°). Student's t-test and Mann-Whitney U test and linear regression analysis was performed with STATA ver 11.1 (StataCorp, College Station , TX, USA). RESULTS: Twenty eight eyes of 14 patients and 20 eyes of ten normal controls were included in the study. The mean logMAR visual acuity of the patients was 0.51 (Snellen equivalent 20/63). The mean N1 amplitude (nv/deg(2)) of patients were significantly reduced compared to controls and were as follows: 8.91 ± 14.00 vs 43.44 ± 9.55 (p < 0.0001) in less than 2°, 9.24 ± 10.47 vs 22.00 ± 3.87 (p < 0.0001) in 5-10°, 8.57 ± 10.02 vs 15.24 ± 1.89 (p < 0.0001) in 10-15°, and 7.03 ± 6.52 vs 12.47 ± 2.62 in > 15° (p < 0.001). The mean P1 amplitude (nv/deg(2)) was also significantly reduced in patients compared to controls and was as follows: 27.66 ± 37.44 vs 96.20 ± 12.41 (p < 0.0001) in less than 2°, 22.61 ± 19.38 vs 53.78 ± 9.79 (p < 0.0001) in 5-10°, 18.75 ± 20.21 vs 35.22 ± 4.16 (p < 0.001) in 10-15°, and 17.10 ± 12.54 vs 25.71 ± 3.93 (p < 0.001). The implicit time of N1 and P1 were also delayed significantly in all the rings. The mean central foveal thickness assessed by optical coherence tomography (OCT) scan was 84.78 ± 45.12 µm. There was poor correlation between mfERG amplitudes or implicit times with either the visual acuity or OCT central thickness. CONCLUSION: mfERG showed significant reduction in amplitudes and implicit times of the waveforms in patients with type 2 MacTel in all the rings, suggesting a more generalized affection of the macula. The maximum reductions were seen in the <2(o) rings. Although there was poor correlation between the visual acuity and the amplitudes a of the waveforms, mfERG is a useful investigative modality for functional assessment of macula in type 2 MacTel patients.

Efficacy of anti-vascular endothelial growth factor therapy in subretinal neovascularization secondary to macular telangiectasia type 2.

PURPOSE: To evaluate the efficacy of intravitreal anti-vascular endothelial growth factor monotherapy in the treatment of naive subretinal neovascular membrane (SRNVM) secondary to macular telangiectasia (Mactel) Type 2. METHODS: A retrospective chart review of consecutive patients with naive SRNVM secondary to Mactel who were examined between January 2007 and April 2011 was performed. Eyes with diabetic retinopathy, age-related macular degeneration, or any other macular pathology were excluded. Demographic data, medical history, and ocular history were recorded. The mean change in best-corrected visual acuity at the final visit was the primary outcome measure. The mean number of intravitreal injections, retinal thickness on optical coherence tomography, and intraocular pressure were the secondary outcomes. RESULTS: A total of 16 eyes of 16 patients were included in the study. Of 16 eyes, 4 were treated with intravitreal ranibizumab monotherapy and 12 with intravitreal bevacizumab monotherapy. The average follow-up duration was 12 months (range, 3-43 months). The mean baseline visual acuity was 0.17 ± 0.16 (Snellen equivalent 20/120) (range, 0.001-0.5), and the mean final visual acuity was 0.27 ± 0.14 (Snellen equivalent 20/70) (range, 0.05-0.66), and this difference was statistically significant (P = 0.02). The mean number of intravitreal injections was 1.9 (range, 1-3), and there were no injection-related complications. CONCLUSION: Intravitreal anti-vascular endothelial growth factor monotherapy appears to be effective and safe in treatment-naive SRNVM secondary to Mactel.

Acute macular neuroretinopathy: long-term insights revealed by multimodal imaging.

PURPOSE: To report the structural and functional changes in acute macular neuroretinopathy (AMN) and their long-term evolution. Multimodal retinal imaging was acquired, including Fourier domain optical coherence tomography (OCT), infrared (IR) reflectance, and near IR autofluorescence (NIA). METHODS: In this retrospective observational case series, detailed clinical history and multimodal imaging are reported in eight patients with AMN. Manual segmentation of the Fourier domain OCT volume scans was done in one patient with the largest AMN lesion to yield retinal sublayer topographic maps. RESULTS: Two patients were seen within the first 1 to 2 days of symptoms, and both showed outer nuclear and outer plexiform layer hyperreflectivity. Both patients developed enlargement of the lesion over the first week on IR reflectance imaging with a corresponding lateral extension of the outer retinal disruption on Fourier domain OCT. Thinning of the outer nuclear layer persisted in all patients with lesions >100 µm width, and in one patient this thinning worsened over the course of follow-up, as noted on the sublayer maps. This structural abnormality correlated with long-term functional deficits, persisting up to 14 months after the initial episode. Infrared reflectance highlights the lesion best, and abnormalities on near IR autofluorescence may be present. CONCLUSION: Acute macular neuroretinopathy acutely affects the outer nuclear and plexiform layers manifesting as OCT hyperreflectivity. The hallmark long-term changes are outer nuclear thinning on Fourier domain OCT and a fading dark lesion on IR reflectance imaging. These changes correspond to focal disruption of the outer segment/retinal pigment epithelium junction on OCT, and not the inner segment/outer segment junction, as previously reported. Optical coherence tomography and near IR autofluorescence abnormalities suggest previously unrecognized melanin and retinal pigment epithelium derangements in this condition.

Endoscopy-assisted pars plana lensectomy for brunescent cataracts in eyes with microcornea with microphthalmos.

PURPOSE: Conventional cataract surgeries can be a challenge in eyes with microcorneas due to difficult manipulation in a crowded anterior chamber (AC) and can lead to a high occurrence of corneal edema and an increased rate of complications. Similarly, in cases of dense brunescent cataracts even a lensectomy through posterior approach may prove to be difficult because of inadequate visualization. An endoscopyassisted pars plana lensectomy can help in obviating these difficulties. This study aims to describe the surgical technique of endoscopy-assisted pars plana lensectomy in eyes with brunescent cataract, microcornea, and microphthalmos. METHODS: Retrospective review of two cases where endoscopy-assisted pars plana vitrectomy and lensectomy was performed for patients with dense cataract and microcornea and microphthalmos. RESULT: Complete clearance of the cataract was achieved without having to resort to a sclerocorneal incision. Postoperatively the cornea was clear and there was no postoperative corneal edema. CONCLUSION: Endoscopy-assisted pars plana lensectomy can help in overcoming the challenges of conventional anterior and posterior approaches of cataract extraction in cases of microcornea with reduced intraoperative and postoperative complications.

CLOSTRIDIAL ENDOPHTHALMITIS: CLINICAL PRESENTATIONS, MANAGEMENT OUTCOMES, AND REVIEW OF LITERATURE.

PURPOSE: To describe the clinical presentations, diagnosis and management outcomes of clostridial endophthalmitis, and a review of the previous literature. DESIGN: Retrospective, interventional case series from January 2005 to March 2018 and a literature review. METHODS: The study included seven eyes of seven patients with culture-proven Clostridium sp. endophthalmitis. Identification of Clostridium sp. was confirmed by the VITEK 2 system using the ANC card. When VITEK failed to identify the organism, MALDI-TOF was used. Data regarding demography, clinical presentations, interventions received, and final visual and anatomical outcomes were noted. RESULTSTHE: mean age of the patients was 28.28 ± 22.35 years (median 21 years). By the etiology of infection, 5 (75%) eyes were post-open-globe injury, 1 (12.5%) was post-trabeculectomy, and 1 (12.5%) was postintravitreal injection. The mean follow-up was 9.71 ± 12.03 months, median 6 months. Two samples were positive for Clostridium perfringens, one each for C. subterminale, C. difficile, and C. tertium, and two were unidentified clostridial species. Favorable anatomical outcome was seen in 3/7 eyes (42.85%). Favorable functional outcome was seen in 2/7 eyes (28.57%). These were comparable with the outcomes of the pooled pre-existing literature. There was a trend toward better functional and anatomical outcomes and lesser evisceration/enucleation rates with vitrectomy instead of a vitreous tap, although not statistically significant. All cases showed susceptibility to empirically used intravitreal antibiotic vancomycin. CONCLUSION: Commonest setting of clostridial endophthalmitis is post-open-globe injury. Despite treatment with appropriate antibiotics, the visual and anatomical outcome is unsatisfactory because of high organism virulence. Early vitrectomy may allow for globe salvage and potential vision.

Evidence of dengue virus in eviscerated specimens of panophthalmitis secondary to dengue fever: A possible cause-effect phenomenon.

PURPOSE: To report a retrospective series of three cases of infectious panophthalmitis post-dengue fever with ex vivo confirmation of dengue virusribonucleic acid (RNA) in the tissues of the eye. METHODS: Four eyes of three patients, who were diagnosed with panophthalmitis following dengue fever and who underwent evisceration, were included. All demographic and clinical data were recorded. The eviscerated samples were subjected to direct microscopy, culture for bacteria, fungi, and parasites, and molecular virology (dengue virus [DENV] NS1-specific reverse transcription loop-mediated isothermal amplification (RT-LAMP) assay). RESULTS: The time from the development of dengue fever to the occurrence of ocular symptoms was 4.33 ± 1.15 (median 5) days. DENV NS1 RNA, suggestive of the presence of the dengue virus, was confirmed in all evisceration specimens (uveal tissue, cornea). All the patients recovered completely from dengue fever and on follow-up had healthy eviscerated sockets. CONCLUSION: Demonstration of the DENV RNA in the eviscerated specimens of panophthalmitis following dengue fever implicates the DENV in the pathophysiology of the ocular infection.

Vogt Koyanagi Harada Disease In Paediatric Age Group: Clinical Characteristics, Remission, Recurrences and Complications in Asian Indian Population.

PURPOSE: To describe disease characteristics and outcomes of Vogt-Koyanagi-Harada (VKH) syndrome in paediatric patients. STUDY DESIGN: Retrospective chart analysis. METHODS: A RETROSPECTIVE: Analysis of all patients ≤16 years with VKH syndrome was done. Clinical presentations, complications, recurrences and outcomes in cases of paediatric VKH were reviewed. RESULTS: 72 eyes of 36 patients with a mean age at presentation of 13.7 ± 2.34 years were assessed. Mean duration of symptoms and follow up were 9.88 ± 17.3 weeks and 55 months respectively. Clinical signs at presentation included anterior chamber cells >2+(34/72eyes, 47.2%), granulomatous keratic precipitates (6 eyes, 8.3%), posterior synechiae (35 eyes,48.6%), disc edema (46 eyes, 63.8%), neurosensory retinal detachments (44 eyes, 61.1%) and 'sunset-glow' fundus (9 eyes, 12.5%). Best corrected visual acuity (BCVA) at the time of presentation was 1.3logMAR or a Snellens equivalent of 20/400 which improved to 0.51logMAR (Snellens equivalent of 20/63) at last follow up. Remission was achieved in 61.1% cases. More than half of our patients developed one or more complications. CONCLUSION: VKH in paediatric patients poses a challenge due to a delayed presentation and paediatric VKH patients have a worse visual acuity at the time of presentation as compared to adult age groups. Rates of remission may be low along with high risk of complications and hence there is a need for prolonged immunosuppression.