A study for evaluating clinical relevance of circulating cell-free DNA in cervical cancer.

Introduction: Recent techniques available for the detection of cervical cancer (CC) are highly invasive and costly, which makes it a rate-limiting step toward early diagnosis of this fatal disease. Evaluation of circulating cell-free DNA (ccfDNA) through liquid biopsy is a minimally invasive and cost-effective method that may serve as a unique tumor marker for early detection, treatment monitoring, the status of residual disease, and distant tumor metastasis in CC patients. Materials and Methods: In this study, initially, ccfDNA was measured in serum samples from 11 histopathologically proven cervix carcinoma patients and 8 controls. On successful screening, it was further extended to 2 more patients with a series of serum samples extracted at 3 different phases of the concurrent chemoradiotherapy (i.e., before, during, and after 6 months of follow-up). Results: Agarose gel electrophoresis profile for ccfDNA of CC patients showed that of 11 patients, 4 patients had a comparatively higher tumor burden (ccfDNA) than the other 7 patients. Notably, during concurrent chemoradiotherapy, ccfDNA load disappeared and, after 6 months of follow-up, appeared back due to distant metastasis. Conclusion: Hence, we propose that this method could be an affordable and reliable way to diagnose/screen CC.

Internal limiting membrane peeling in macular hole surgery.

Since the era when macular hole was considered untreatable, macular hole surgery has come a long way to being one of the most successful surgeries. Internal limiting membrane (ILM) peeling has been an essential step of macular hole surgery since the establishment of the role of ILM in the aetiopathogenesis and progression of macular hole. However, the novel technique was not all virtuous. It had some vices which were not evident immediately. With the advent of spectral domain optical coherence tomography, short- and long-term effects of ILM peeling on macular structures were known; and with microperimetry, its effect on the function of macula could be evaluated. The technique has evolved with time from total peeling to inverted flap to just temporal peeling and temporal flap in an attempt to mitigate its adverse effects and to improve its surgical outcome. ILM abrasion technique and Ocriplasmin may eliminate the need of ILM peeling in selected cases, but they have their own limitations. We here discuss the role of ILM in the pathogenesis of macular hole, the benefits and adverse effects of ILM peeling, and the various modifications of the procedure, to then explore the alternatives.

Outcome of Non-drainage Scleral Buckling in Primary Rhegmatogenous Retinal Detachment.

INTRODUCTION: Scleral buckling (SB) was the principal surgical intervention for patients with rhegmatogenous retinal detachment (RRD) until the development of pars plana vitrectomy. The study aims to evaluate the outcome of SB without subretinal fluid (SRF) drainage in RRD. MATERIALS AND METHODS: A retrospective observational study was conducted at a tertiary eye care center. Charts of patients operated with SB without SRF drainage for RRD between January 2014 and December 2015 were evaluated. The main outcome measure was the primary reattachment rate at 1 month after single SB surgery. Other outcome measures were final reattachment rate after further intervention, visual improvement and relation of various parameters with retinal reattachment. RESULTS: One hundred and seventeen patients were included of which 90 (76.9%) were men. Mean age was 26.68±12.6 years (Range 9-60). All eyes were phakic. Only 1 patient had a macula on RD. The primary reattachment rate was 84.6% (n=99). Mean LogMAR (±SD) visual acuity (VA) improved from 1.92(±0.46) to 1.02(±0.42). Extent of RD, number of breaks, and type of break was found to have no association with retinal reattachment. Association between type of PVR and status of retina post buckling was found to be significant (p=0.026) with retinal reattachment seen in 100% in PVR-A and only 60% in PVR-C2. Final reattachment rate was 98.2%. Complications encountered were postoperative diplopia (n=1), suture granuloma (n=1) and buckle infection (n=2). CONCLUSION: Scleral buckling without SRF drainage, an exclusively extra ocular procedure, is an effective and safe treatment modality for non-complicated RRD.

Intra-operative scleral rupture during 23 gauge pars plana vitrectomy: a case report.

BACKGROUND: Use of perfluorocarbon liquid (PFCL) has been increasingly growing as an adjuvant in vitreo-retina surgeries. Some commonly encountered complications with its use include subretinal migration, formation of sticky silicone oil or retained PFCL in vitreous cavity and anterior chamber. Scleral rupture during PFCL injection has a rare occurrence. We report an unexpected event of scleral rupture during PFCL injection and discuss the management challenges faced by the surgeon. CASE PRESENTATION: A 66 year indo-aryan male was undergoing pars-plana vitrectomy (PPV) with diagnosis of subtotal rhegmatogenous retinal detachment (RD) with Proliferative Vitreo-retonipathy (PVR)-B. After near total vitrectomy PFCL was being injected and then there was sudden poor visualization of fundus with development of bullous RD and globe hypotony. The surgeon was not able to figure out the cause of hypotony and air was switched on in the infusion cannula. This further complicated the situation resulting in migration of air in the anterior chamber, posterior dislocation of intraocular lens complex, 180° inferior retinal dialysis and ballooning of the conjunctiva which gave a clue of probable scleral rupture. Conjunctival peritomy was performed superiorly and scleral defect was noted. Intraocular tissue incarceration and air leak was visible from the wound. This confirmed scleral rupture during PFCL injection. Repositioning of incarcerated retina was not possible and retinectomy was performed followed by repair of scleral rupture with lots of difficulty in a vitrectomised eye. CONCLUSION: PFCL injection, a crucial step of vitreoretina surgery, should be performed slowly with extreme caution maintaining an optimal intraocular pressure to prevent devastating complications like scleral rupture.

A novel way of Subfoveal Perfluorocarbon liquid Removal using 26 gauge spinal anesthesia needle.

INTRODUCTION: Perfurocarbon Liquid (PFCL) is an essential adjunct of retinal detachment surgery. Subfoveal migration of PFCL is a rare and vision threatening complication of its use. Various techniques have been described for its removal. However, no consensus on ideal technique of its removal has been established. We present a novel, relatively atraumatic and cost effective way of PFCL removal using a widely available 26Ga spinal anesthesia needle. CASE: An 18 years old myopic patient who had undergone left eye pars plana vitrectomy (PPV) for myopic Rhegmatogenous Retinal Detatchment (RRD) in the past presented after 1 month with retained subfoveal PFCL. Its subretinal location was confirmed by Optical Coherence Tomography (OCT). He was taken up for early Silicone Oil Removal (SOR) along with removal of retained subfoveal PFCL under high magnification by using a surgical disposable contact macula lens. A 26G spinal anesthesia needle tip was used to dissect a small separation parallel to the nerve fibers at the temporal edge of tense cystic PFCL bleb. Silicone tipped flute cannula was used to passively aspirate the sub retinal PFCL under fluid with no additional intervention. No barrage LASER was done. OBSERVATION: Anatomical restoration of the retina was noted both intraoperatively and post-operatively. SD-OCT showed complete restoration of anatomical layers with no presence of intraretinal cystic cleft both at day 1 and 30 days postoperatively. CONCLUSION: Safe removal of subfoveal PFCL can be done with 26Ga spinal anesthesia needle which is atraumatic, inexpensive and readily available. However, long term validity of this process needs to be established in a case series.

Variable presentation of diabetic papillopathy and treatment dilemma- A case series.

INTRODUCTION: Diabetic papillopathy (DP) is a diagnosis of exclusion in type 1 and type 2 diabetics with transient disc edema. It was initially described in young patients with type1 diabetes mellitus (DM) as a bilateral disease with minimal visual symptoms which resolved spontaneously. Lately, DP has been a focus of controversy because of its wide clinical spectrum. CASES: We describe three variable cases of DP. These are unilateral DP with Proliferative Diabetic Retinopathy (PDR) with macular edema (ME), unilateral DP with severe Non Proliferative Diabetic Retinopathy (NPDR) with ischemic maculopathy and a case of bilateral DP with Moderate NPDR with ME. We also discuss viable treatment for the variable presentation. DP has been reported in this case series in moderate NPDR, severe NPDR as well as PDR. Macular involvement in the form of macular edema as well as ischemia has been demonstrated to result in diminution of vision. It shows both unilateral and bilateral presentation. Remarkable visual loss seen, in these cases, call for intervention. CONCLUSIONS: DP has a wide spectrum of presentation and its knowledge is eminent to make a complete diagnosis. Individualisation of treatment has to be done for variable presentation and realistic outcomes should be explained to the patients.

Intraoperative Ocular Decompression Retinopathy During 23 Gauge Transconjunctival Vitrectomy: A Case Report.

PURPOSE: To report an uncommon case of intraoperative ocular decompression retinopathy (ODR). CASE REPORT: A 48-year-old man presented with decreased vision and pain in the left eye (LE) for 10 days following trauma with a bamboo stick. He had visual acuity of counting finger close to face in the same eye, along with corneal edema, dilated pupil and posteriorly dislocated lens. Intraocular pressure (IOP) was 42 mm of mercury (Hg). He underwent 23-gauge pars plana vitrectomy with removal of the dislocated lens. Towards the end of otherwise uneventful surgery, blot hemorrhages appeared over the posterior pole and equator. The following day, his vision was counting finger close to face and IOP was 16 mm of Hg. Fundus examination revealed large blotches of hemorrhages at different levels of the retina, later confirmed by optical coherence tomography. Disc hyperfluorescence and blocked fluorescence corresponding to blot hemorrhages were seen on fundus fluorescein angiography. Blood investigations to rule out blood dyscrasias were within normal limits. CONCLUSION: Ocular decompression retinopathy, though not common, has been reported to occur following various types of surgeries, especially if associated with preoperatively raised IOP. The event can also occur intraoperatively and the preoperative control of IOP is of paramount importance in the prevention of ODR.

Underdosing of the maxillary sinus for small fields used in newer radiotherapy techniques: Comparison of thermoluminescent dosimeter and Monte Carlo data.

AIMS: To evaluate the underdosing of the maxillary sinus at its distal end produced by air cavity in the path of the 6 MV photon beam. MATERIALS AND METHODS: A cubic solid water slab phantom of dimensions 18 cm × 18 cm × 18 cm with 4 cm × 4 cm × 4 cm air cavity 3 cm away from its anterior surface was used in this study. The percentage depth dose (PDD) for 6 MV X-rays along the central axis of the cubical air cavity was measured using thermoluminescent dosimeter-100 chips. The EGSnrc/DOSXYZnrc Monte Carlo (MC) code was used to estimate the PDD values in both homogeneous and inhomogeneous conditions. The dose data were generated for 1 cm × 1 cm, 2 cm × 2 cm, 3 cm × 3 cm, and 5 cm × 5 cm field sizes. RESULTS: Average percentage dose reductions at 1 mm beyond the distal surface of the maxillary sinus for the field sizes 1 × 1, 2 × 2, and 3 × 3 cm2 are 42.4%, 39.5%, and 29.4%, respectively. However, for 5 cm × 5 cm field size, there is a dose enhancement (i.e., overdosing) at 1 mm from the distal surface of the maxillary sinus and the average percentage dose enhancement is 5.9%. Also, beyond 1 cm from the air-water interface, there is dose enhancement for all the field sizes. CONCLUSION: This study showed that the significant dose reduction occurs near the air-water interface for the treatment techniques using small photon fields such as intensity-modulated radiotherapy or other newer techniques. MC-based treatment planning calculation predicts realistic dose distribution while using small photon fields in the treatment of maxillary sinus.

Visual outcome and early complications of sutureless and glueless scleral fixated intraocular lens.

INTRODUCTION: In the absence of capsular support, anterior chamber intraocular lens (IOL), iris fixated IOL and sutured scleral fixated intraocular lens (SFIOL) implantation have been performed for many years. Recently sutureless glued SFIOL have been used as a primary or secondary procedure to correct aphakia. In this study we have used sutureless and glueless technique of SFIOL implantation. METHODOLOGY: An interventional case series was conducted. Aphakic patients without capsular support, sub-luxated lens (>180°), dislocated lens and dislocated IOL were the inclusion criteria. The patients with hazy cornea, non-dilating pupil, macular scar and glaucoma were not enrolled in the study. RESULTS: Of 62 eyes who completed 1 month follow- up, 48 were men and 14 women. There was a significant improvement in uncorrected distance visual acuity after surgery (p less than 0.001). One month postoperative best corrected distance visual acuity was 6/18 or better in 45 eyes (72.6%). The common early postoperative complications were hypotony, corneal edema. No serious complications such as endophthalmitis and retinal detachment were seen. CONCLUSION: Our technique of sutureless and glueless SFIOL implantation showed good visual outcome in the absence of serious complications. SFIOL will be the only choice in eyes that have anatomic contraindications like non constricting pupil, large sectoral iridectomy and peripheral anterior synechia in which other types of lens are not suitable.

Carcinoma Gall Bladder with Bouveret's Syndrome: A Rare Cause of Gastric Outlet Obstruction.

We describe a case of bouveret's syndrome associated with carcinoma gall bladder. This is probably the second reported case of such an association. Computed tomography detected the calculus in the duodenum but endoscopy could not retrieve it. Open gastrojejunostomy and stone retrieval was done.