Surgical management of a case of giant retinal tear with closed funnel retinal detachment in a pediatric patient.

BACKGROUND: A 7-year-old male child was brought by his parents with a complaint of low vision in both eyes for 2 months. The child had low vision in both the eyes for 1.5 years, but the parents noticed when it worsened further 2 months back, leading to profound vision loss. On ophthalmic evaluation, the child did not perceive light in the right eye. Furthermore, anterior segment examination showed complicated cataract and open funnel retinal detachment with intra-retinal cysts in ultrasound (USG) B scan. In the left eye, he could appreciate light but with poor fixation. Fundus evaluation of the left eye showed total retinal detachment on indirect ophthalmoscopy, which was confirmed on USG B scan. Since the right eye had poor visual potential, no intervention was done. The left eye underwent pars plana vitrectomy with silicone oil tamponade, which led to successful anatomical outcomes. The immediate and late postoperative periods were uneventful, and the child was kept under follow-up and was observed closely. PURPOSE: To educate regarding the surgical management of giant retinal tears in a pediatric patient. SYNOPSIS: To inform regarding the surgical challenges faced and steps adopted to manage such cases. HIGHLIGHTS: Through this case, we want to highlight the challenges faced, such as delayed presentation, difficult preoperative evaluation, intraoperative difficulties such as mobile retina, absence of posterior vitreous detachment, and tenacious vitreous gel. We also want to emphasize on the steps taken to overcome the challenges. CONCLUSION: In such challenging situations, effective planning, careful manipulation, and persistence are essential for success. VIDEO LINK: https://youtu.be/T0Gy6Wj13zI.

Distance and near vision changes after intravitreal anti-vascular endothelial growth factor injection in eyes with center-involving diabetic macular edema.

Purpose: To elucidate distance and near vision changes after intravitreal injections in center-involving diabetic macular edema (CIDME) in phakic and pseudophakic groups. Methods: A retrospective study was done on 148 eyes (72 phakic and 76 pseudophakic) with center-involving DME. All eyes were treated with intravitreal anti-vascular endothelial growth factor (VEGF) injection. All patients underwent distance best-corrected visual acuity (BCVA) testing, near BCVA testing, dilated fundus examination, and optical coherence tomography (OCT) at baseline and follow-up visits. Eyes that could not improve after the first injection were given 2nd, 3rd, and more injections in the subsequent visits. Results: On follow-up, post injections in the phakic group (n = 72), there were 65 eyes (90.3%) with stable/improved near vision and 59 eyes (81.9%) with stable/improved distance vision, whereas in the pseudophakic group (n = 76), 63 eyes (82.9%) and 60 eyes (78.9%), respectively. Both in phakic and pseudophakic eyes, 7.7%-13% of the cohort showed only near vision improvement. Conclusion: In DME, besides the changes in distance vision, there are also changes in near vision. These changes should be taken into account while determining the response to anti-VEGF in DME treatment.

Retinal Displacement after Scleral Buckle versus Combined Buckle and Vitrectomy for Rhegmatogenous Retinal Detachment: ALIGN Scleral Buckle versus Pars Plana Vitrectomy with Scleral Buckle.

PURPOSE: To assess the risk of retinal displacement after scleral buckle (SB) versus pars plana vitrectomy with SB (PPV-SB). DESIGN: Multicenter prospective nonrandomized clinical trial. METHODS: The study took place at VitreoRetinal Surgery in Minneapolis, Minnesota, Sankara Nethralaya in Chennai, India, and St. Michael's Hospital in Toronto, Canada from July 2019 to February 2022. Patients who underwent successful SB or PPV-SB for fovea-involving rhegmatogenous retinal detachment with gradable postoperative fundus autofluorescence (FAF) imaging were included in the final analysis. Two masked graders assessed FAF images 3 months postoperatively. Metamorphopsia and aniseikonia were assessed with M-CHARTs and the New Aniseikonia Test, respectively. The primary outcome was the proportion of patients with retinal displacement detected with retinal vessel printings on FAF in SB versus PPV-SB. RESULTS: Ninety-one eyes were included in this study, of which 46.2% (42 of 91) had SB and 53.8% (49 of 91) underwent PPV-SB. Three months postoperatively, 16.7% (7 of 42) in the SB group and 38.8% (19 of 49) in the PPV-SB group had evidence of retinal displacement (difference = 22.1%; odds ratio = 3.2; 95% confidence interval [CI], 1.2-8.6; P = 0.02) on FAF. The statistical significance of this association increased after adjustment for extent of retinal detachment, baseline logarithm of the minimum angle of resolution, lens status, and sex in a multivariate regression analysis (P = 0.01). Retinal displacement was detected in 22.5% (6 of 27) of patients in the SB group with external subretinal fluid drainage and 6.7% (1 of 15) of patients without external drainage (difference = 15.8%; odds ratio = 4.0; 95% CI, 0.4-36.9; P = 0.19). Mean vertical metamorphopsia, horizontal metamorphopsia (MH), and aniseikonia were similar between patients in the SB and PPV-SB groups. There was a trend to worse MH in patients with retinal displacement versus those without retinal displacement (P = 0.067). CONCLUSIONS: Scleral buckle is associated with less retinal displacement compared with PPV-SB, indicating that traditional PPV techniques cause retinal displacement. There is a trend toward increased risk of retinal displacement in SB eyes that underwent external drainage compared with SB eyes without drainage, which is consistent with our understanding that the iatrogenic movement of subretinal fluid, such as that which occurs intraoperatively during external drainage with SB, may induce retinal stretch and displacement if the retina is then fixed in the stretched position. There was a trend to worse MH at 3 months in patients with retinal displacement. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Scleral cut-down technique of subretinal fluid drainage in scleral buckle surgery for rhegmatogenous retinal detachment.

Background: The art of scleral buckle (SB) surgery is being largely forgotten. However, it still remains a good option for selected cases of rhegmatogenous retinal detachment. Drainage of subretinal fluid (SRF) is one of the most crucial steps of the surgery. When performed correctly, it gives the advantage of immediate retinal reattachment, and it hastens recovery. However, it has its own set of complications. Purpose: To demonstrate, step by step, the scleral cut-down technique of SRF drainage in SB surgery for rhegmatogenous retinal detachment (RRD) and to discuss its indications, contraindications, and complications. Synopsis: Longstanding RRDs with bullous detachments, old age, inferior breaks, or multiple breaks are indications of SRF drainage. In shallow RDs or young patients, a non-drainage procedure may be preferred. It is safer to drain at the bed of the buckle. After the sclera is cut and dissected, it is essential to inspect the choroid for the presence of large vessels. Choroidal vessels are avoided from getting injured while perforating. The release of pigments indicates the end of the drainage. Various possible complications can be prevented by being careful in the surgical technique. Highlights: Diagrammatic illustrations explain the steps of the surgical technique. Intraoperative complications have been explained in an easy-to-understand manner with tips to manage such conditions and their prevention. The video highlights the correct way of performing SRF drainage. Online Video Link: https://youtu.be/L0TrdkCwk20.

Surgical management of complicated retinal detachment in a case of retinal hemangioblastoma.

Background: A 40-year-old male presented with a complaint of sudden onset diminution of vision in the left eye for 2 weeks. He was a follow-up case with retinal hemangioblastoma in both eyes. He underwent two sittings of fundus fluorescein angiography-guided trans-pupillary thermotherapy 2 years back. Since then, he was regularly followed up for 2 years with stable vision and stable retinal findings. At present, the best-corrected visual acuity (BCVA) in the right eye is 6/6, and in the left eye, it is counting fingers 2 meters. On fundus examination, he had one active hemangioblastoma in the right eye and total retinal detachment in the left eye with multiple active lesions. The right eye was treated with a single sitting of thermotherapy, and the left eye underwent pars plana vitrectomy and angioma excision, followed by silicone oil tamponade. The immediate and late post-operative periods were uneventful, with successful anatomical and functional outcomes. The left eye BCVA on late follow-up was 6/36, no further treatment was advised, and the patient was kept under follow-up and observed closely. Purpose: : To educate regarding the systemic workup, diagnosis, and surgical management of complicated retinal detachment in retinal hemangioblastoma. Synopsis: : Systemic workup, diagnosis, and surgical steps in the management of complicated retinal detachment in retinal hemangioblastoma were performed. Highlights: : Close follow-up, keen observation, and prompt treatment in the early stages of the disease are indispensable to prevent untoward sequelae of retinal hemangioblastoma. A thorough systemic workup is necessary to diagnose the systemic involvements early. Surgery, if indicated for the retinal hemangioblastoma or its associated sequelae, should be performed diligently and with careful handling of blood vessels and anomalous tissues. Online Video Link: https://youtu.be/CkoqWEnaPB8.

Mitigation of traumatic blepharoptosis with "central levator tuck": A novel approach in upper eyelid repair.

PURPOSE: Complex upper eyelid lacerations can present to the emergency department after a myriad of trauma. The goal of the surgical repair is anatomical and functional recovery along with symmetrical cosmesis. Despite meticulous surgery, post traumatic blepharoptosis may develop. We describe an additional step during upper eyelid laceration repair to help mitigate the development of traumatic blepharoptosis. METHODS: Patients with traumatic eyelid laceration without head injury, globe injury or associated orbital fractures, who were planned for a primary upper eyelid repair were included. Intraoperatively, wound margins and tissues were identified to establish anatomical continuity. After the LPS muscle was reinserted onto the tarsus, a single, central suture LPS plication - the "central levator tuck" was performed. This helped in improving the muscle action as well as strengthening its reattachment onto tarsus. RESULTS: Four cases underwent laceration repair with this modified technique. The nature of eyelid injury, surgical technique, and the outcome at 6 months is described. Three patients had a successful outcome, whereas one patient developed early scarring which reduced with scar therapy over time. CONCLUSION: We describe a simple and effective "central levator tuck" technique for traumatic eyelid laceration repair with optimal functional and cosmetic outcome while reducing the development of blepharoptosis in four patients.