Prevalence of age-related macular degeneration and associated factors in Indian cohort in a tertiary care setting.

Purpose: To report a big data analysis of risk and protective factors in patients with AMD, as well as report on the age-adjusted prevalence in a geriatric Indian cohort in a hospital setting. Methods: This retrospective, observational study of all patients older than 60 years of age. Multiple logistic regression was performed for the binary outcome and the presence of AMD. Variables analyzed include age, gender, socioeconomic status, occupation, urban-rural-metropolitan distribution, self-reported history of diabetes mellitus (DM), hypertension (HTN), or coronary artery disease (CAD), ocular comorbidities, history of cataract surgery, and presenting VA. Odds ratios (OR) and 99% confidence intervals were calculated. Results: Of the 608,171 patients over the age of 60 years who attended our clinics, 1.68% of subjects had a diagnosis of AMD (N = 10,217). Less than half (4,621 of 10,217 with AMD) of them were diagnosed to have dry AMD. Cataract, glaucoma, and diabetic retinopathy were associated with lower risk of AMD. Cataract surgery was associated with the higher risk of AMD (OR = 1.20; 99% CI 1.13-1.29). Smoking was not associated with AMD. Conclusion: Big data analysis from a hospital setting shows that the prevalence of AMD above the age of 60 years is low. More patients with wet AMD present for treatment compared to dry AMD. Smoking was not associated with AMD in the Indian population. Cataract surgery was associated with higher prevalence of AMD.

Radiation chorioretinopathy: unusual occurrence of intervortex venous anastomosis.

A woman in her 60s presented with vision blur in both eyes, a year post-radiotherapy for oral cancer. The best corrected visual acuity was 20/40 in both eyes. Posterior segment examination was remarkable for a unilateral intervortex venous anastomosis in choroid in her right eye, on the side of her face that had received radiation. Ultra-wide field indocyanine green angiography complimented the clinical findings. We discuss the ramifications of detection of this entity and suggest non-invasive methods of detection.

Correlating the patterns of diabetic macular edema, optical coherence tomography biomarkers and grade of diabetic retinopathy with stage of renal disease.

PURPOSE: To correlate optical coherence tomography (OCT)-based morphological patterns of diabetic macular edema (DME), biomarkers and grade of diabetic retinopathy (DR) in patients with various stages of chronic kidney disease (CKD) secondary to diabetes. DESIGN: Multicentric retrospective cross-sectional study was conducted at seven centers across India. METHODS: Data from medical records of patients with DME and CKD were entered in a common excel sheet across all seven centers. Staging of CKD was based on estimated glomerular filtration rate (eGFR). RESULTS: The most common morphological pattern of DME was cystoid pattern (42%) followed by the mixed pattern (31%). The proportion of different morphological patterns did not significantly vary across various CKD stages (p = 0.836). The presence of external limiting membrane-ellipsoid zone (ELM-EZ) defects (p < 0.001) and foveal sub-field thickness (p = 0.024) showed a direct correlation with the stage of CKD which was statistically significant. The presence of hyperreflective dots (HRD) and disorganization of inner retinal layers (DRIL) showed no significant correlation with the stage of CKD. Sight threatening DR was found to increase from 70% in CKD stage 3 to 82% in stages 4 and 5 of CKD, and this was statistically significant (p = 0.03). CONCLUSION: Cystoid morphological pattern followed by mixed type was the most common pattern of DME on OCT found in patients suffering from stage 3 to 5 of CKD. However, the morphological patterns of DME did not significantly vary across various CKD stages. ELM-EZ defects may be considered as an important OCT biomarker for advanced stage of CKD.

Scleral Fixation of Intraocular Lens in Aphakic Eyes without Capsular Support: Description of a New Technique.

PURPOSE: To study the efficacy and safety of a modified trans-scleral intraocular lens (IOL) fixation technique in aphakic eyes when performed by ophthalmologists in training. METHODS: The study was conducted in an institutional setting that included 43 surgeries performed by surgeons training in small incision cataract surgeries. The data were analyzed for stability and position of IOL, refractive changes, best-corrected vision, and associated complications. RESULTS: Mean age of the subjects was 53.8 ± 18.5yrs (range 6-81yrs). Surgical aphakia (58.14%) was the most common cause. The corrected distance visual acuity improved significantly at six weeks (p = 0.0003). The mean residual spectacle correction was +0.74 ± 1.2D spherical equivalent (cylinder -1.6±1.5D at 84 ± 50°) at the 6th-month follow-up (24.35 ± 6.71wks). Lens tilt on ultrasound biomicroscopy (kappa 0.762; p < 0.001) and the IOL centration (kappa 0.411; p = 0.001), assessed by two independent masked observers, were satisfactory at the 6th-month visit. Transient postoperative vitreous hemorrhage was the most common complication (46.5%). Cellular deposits on the IOL surface (18.6%), cystoid macular edema (11.6%), subconjunctival haptic exposure (4.66%), and haptic slippage (2.33%) were the other complications. CONCLUSION: This method of trans-scleral IOL fixation is an effective rescue procedure for eyes with deficient capsular support when ophthalmologists perform in training.

Is immediate treatment necessary for diabetic macular edema after pars plana vitrectomy for tractional complications of proliferative diabetic retinopathy?

PURPOSE: To assess the treatment benefit of eyes with diabetic macular edema (DME) in vitrectomized eyes for tractional complications of proliferative diabetic retinopathy (PDR). METHODS: In a retrospective multicentre observational study in India, the clinical outcomes of eyes with center-involving DME in vitrectomized eyes for tractional complications of PDR in people with type 2 diabetes with at least 12 months follow-up data were assessed. The DME status and visual acuity outcomes were compared between those who received treatment versus those observed. RESULTS: In the 10-year study period, 45 eyes of 44 patients from 5 tertiary centers in India met the inclusion criteria. Center-involving DME was documented after a mean of 7 ± 7 months following pars plan vitrectomy (PPV) for tractional complications of PDR. More than half of the (n = 25) eyes were immediately treated for DME, and treatment was deferred for the rest. At one year, there was a statistically significant reduction in mean central subfield thickness in treated (467.9 ± 124.8 µm to 367.8 ± 143.7 µm; p < 0.001) as well as observed (405.2 ± 132.6 µm to 325.6 ± 149 µm; p < 0.001) eyes, and the change was comparable (p = 0.574). The change in vision was also comparable (0.12 ± 0.31 and 0.22 ± 0.54 Log MAR in the treated and observed group, respectively; p = 0.443). CONCLUSION: Treatment for pre-existing or new-onset DME after PPV for tractional complications of PDR may be deferred for up to one year because the DME may resolve spontaneously with time.

Outcomes of neovascular glaucoma in eyes presenting with moderate to good visual potential.

PURPOSE: To compare the disease characteristics and treatment outcomes of patients with neovascular glaucoma (NVG) presenting with visual acuity (VA) 6/60 or better in two different health systems. METHODS: Retrospective chart review of consecutive patients with NVG who presented between January 2016 to January 2018 in 5 tertiary-centres in India and one eye-specialist centre in London (UK) was performed. The baseline characteristics, treatment provisions, and visual outcomes in the India and UK cohorts were compared. RESULTS: At presentation, 18% (83 of 451) and 22% (59 of 270) of patients with NVG had VA 6/60 or better in India and the UK cohorts, respectively. The aetiologies of NVG were similar with proliferative diabetic retinopathy being the most common cause (60.9%, India; 64.4%, UK; p = 0.38). Previous panretinal photocoagulation was more prevalent in the UK cohort compared to the India cohort (94.9% versus 66.3%, respectively; p < 0.001). The mean number of intravitreal anti-VEGF injections per eye was higher in the Indian cohort (1.65 ± 0.97 versus 1.14 ± 1.02 injections; p < 0.001). The number of eyes with closed angles (36.9% India versus 30.5% UK; p = 0.45) and the number of eyes needing glaucoma interventions (52.1% India; 62.7% UK; p = 0.82) were similar in two cohorts. Among glaucoma surgeries, trabeculectomies were more commonly performed in the Indian cohort (23 vs 4; p < 0.001),while glaucoma drainage device surgeries were more prevalent in the UK cohort (18 vs 4 p < 0.001). After a median follow-up of 21 months (IQR 8.4-34.8 India; 24-36 months UK), favourable visual outcomes (vision stable or improved) were similar in both health systems (52.5% in the Indian cohort vs 43.4% in the UK cohort; p = 0.28). On multivariate regression analysis, the need for trans-scleral cyclophotocoagulation was associated with worse visual outcomes in both cohorts. CONCLUSIONS: The causes and clinical profile of neovascular glaucoma with presenting visual acuity 6/60 or better in India and the UK were similar. Only up to 50% of eyes achieved favourable visual outcomes with current management protocols in both health systems.

Pneumoretinopexy versus scleral buckling in retinal detachments with superior breaks: A comparative analysis of outcome and cost.

Purpose: The purpose of this study is to study single surgery reattachment rate, refractive shift, surgical time, cost, and complications of pneumoretinopexy (PR) compared to scleral buckling (SB) in rhegmatogenous retinal detachments (RRDs) with superior breaks. Methods: Data of RRD with superior breaks, from 2013 through 2016, treated either with PR or SB surgery at a tertiary eye-care center were retrospectively reviewed. Treatment outcomes, procedural costs, refractive shift, surgical time, and complications, namely, cataract and glaucoma, were analyzed. Results: Thirty-two cases treated by PR (n = 15) and SB surgery (n = 17) fulfilled the selection criteria. Macula off RRD (91%) was the commonest presentation. Baseline parameters like duration of vision loss, presenting vision, and ocular characteristics were comparable. Single surgery retinal reattachment (66.7% PR vs. 76.5% SB) was analogous (P = 0.698). Retinal reattachment with secondary intervention was achieved in all cases at the last follow-up. Average vision gain in logMAR of 0.8 in PR and 0.6 in SB was not significantly different (P = 0.645) between the two groups, with SB group having a 1.9 Dioptre myopic shift and PR group none. Surgical time was shorter in PR versus SB at 15 versus 85 min and surgical cost (including additional surgery) was 50% less in PR. Complications like cataract progression (P > 0.99) and glaucoma (P = 0.71) were analogous among the groups. Horse-shoe tears were associated with failed primary surgery in 60% of PR and 75% of SB procedures. Conclusion: In RRDs secondary to superior breaks, PR proved to be faster, more economical, and less tissue manipulative than scleral buckle surgery, with equivalent efficacy and safety profile.

Intra-lenticular caterpillar seta in ophthalmia nodosa.

PURPOSE: To report the clinical course of ophthalmia nodosa with a retained lenticular seta misdiagnosed and treated as non-infectious posterior uveitis for 7 consecutive years. METHODS: Meticulous clinical examination led to discovery of the caterpillar seta embedded in the crystalline lens and the intravitreal setae. RESULTS: Lens-sparing pars plana vitrectomy and removal of free-floating vitreal seta resulted in complete resolution of vitritis and uveitis. CONCLUSION: Embedded seta within a clear lens may remain sequestered, and may be left untouched under close observation, precluding a clear lens extraction in such patients.

Need for Vitreous Surgeries in Proliferative Diabetic Retinopathy in 10-Year Follow-Up: India Retinal Disease Study Group Report No. 2.

INTRODUCTION: To report the 10-year rate of vitrectomies and the associated factors in people with proliferative diabetic retinopathy (PDR) from a multicentric cohort of people with diabetes mellitus. METHODS: Ten centres in India with established vitreoretinal (VR) services for over 10 years were invited to provide long-term data on PDR. People with Type 1 or 2 diabetes with a clinical diagnosis of active PDR in 1 or both eyes were included. Baseline data collected included age, sex, duration of diabetes, source of referral and best-corrected visual acuity, and diabetic retinopathy status in both eyes. Available follow-up data included the numbers of panretinal photocoagulation (PRP) sessions, cataract surgery, treatment of diabetic macular oedema, use of anti-vascular endothelial growth factor (VEGF) therapy, vitrectomy with or without retinal surgeries over 10 years. RESULTS: Over 10 years, 89% needed supplemental PRP after initial complete PRP. One-third required retinal surgery, 16% needed intravitreal injection. Men (74.5%) had significant higher risk for vitreous (VR) surgery. Of the group with low-risk PDR, 56.8% did not require VR surgery, p < 0.001. Of the patients who underwent cataract surgery and had intravitreal anti-VEGF injections, 78.5 and 28.2% needed subsequent vitreous (VR) surgery, p = 0.006 and <0.0001, respectively. Independent predictors of need for vitreoretinal surgery included those who underwent cataract surgery and those with poor baseline visual acuity (logMAR). Eyes at lower risk for VR surgery included the eyes previously treated with PRP and low-risk PDR at baseline. CONCLUSION: Despite initial "complete" PRP, one-third of our study cohort needed vitrectomies over 10 years, highlighting that these patients require regular follow-up for a long period of time.

Serial Swept-Source Optical Coherence Tomography Features of Gentamicin Macular Toxicity: A Glimpse Into the Injury Cascade.

The early clinical manifestations of macular infarction secondary to subconjunctival gentamicin (Gentak; Akorn, Lake Forest, IL) use in an aphakic eye were documented sequentially on swept-source optical coherence tomography (OCT) and fundus fluorescein angiography. The first recorded event after drug toxicity was macular detachment, along with disorganization of outer retinal layers in about 12 hours. The changes in inner retinal layers occurred after 36 hours had elapsed. OCT-documented initial damage to outer retinal layers could be due to the susceptibility of first order retinal neurons, followed by subsequent inner retinal layer involvement and ischemia. This helps in understanding pathogenesis of a catastrophic complication of subconjunctival gentamicin injection commonly used for endophthalmitis prophylaxis. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:456-459.].

Bilateral macular infarction after gemcitabine and carboplatin chemotherapy.

PURPOSE: To report a case of macular infarction after doublet chemotherapy with gemcitabine and carboplatin. METHODS: A middle-aged lady presenting with bilateral macular infarction post-chemotherapy for metastatic cervical malignancy was investigated for thromboembolic risks and treated. RESULTS: The macular perfusion and edema improved with control of hypertension and treatment with pentoxifylline. Visual improvement was satisfactory, and the possible associated risk such as hypertension was noted. CONCLUSION: This case underscores the need for active screening of patients on chemotherapy with gemcitabine and carboplatin for retinal vascular occlusive changes when hypertension is associated.

ROLE OF EARLY VITRECTOMY IN THE TREATMENT OF FUNGAL ENDOPHTHALMITIS.

PURPOSE: To study whether immediate pars plana vitrectomy at the time of sampling vitreous for culture alter the visual and structural outcomes in fungal endophthalmitis. METHODS: Surgical results of 66 consecutive patients with culture-positive fungal endophthalmitis attending a tertiary eye care hospital in eastern India were analyzed. Based on the timing of vitrectomy, they were divided into 2 groups: Group 1-immediate vitrectomy (n = 31) and Group 2-diagnostic vitrectomy alone (n = 35) as the first-line intervention. The demographics, clinical features, and visual and structural outcomes were compared between the groups. RESULTS: The proportion of postoperative (54.83 vs. 51.42%), traumatic (29.03 vs. 34.28%), and endogenous (16.12 vs. 14.28%) endophthalmitis and clinical signs such as pain (54.83 vs. 60%), lid edema (48.38 vs. 48.57%), conjunctival congestion (87.09 vs. 94.28%), and corneal involvement (87.09 vs. 80%) in Groups 1 and 2, respectively, were comparable. Logarithm of the minimum angle of resolution vision improvement in Group 1 was significant (P = 0.0278) though there was no statistically significant difference in posttreatment vision between the groups (P = 0.322). Phthisis was seen in 25.8% in Group 1 and 25.7% in Group 2 (P = 0.993). Aspergillus species was the most common fungal pathogen isolated. Early vitrectomy plus intravitreal antifungals in a subset of clinically suspected fungal endophthalmitis resulted in statistically significant visual improvement over diagnostic vitrectomy plus intravitreal antifungals (P = 0.013). CONCLUSION: A strong clinical suspicion that translates into early vitrectomy plus intravitreal antifungal antibiotics leads to favorable visual and structural outcomes. A long wait till microbiological confirmation to institute antifungal therapy may result in poorer outcome.

Real-time polymerase chain reaction in the diagnosis of acute postoperative endophthalmitis.

PURPOSE: To evaluate the efficacy of quantitative real-time polymerase chain reaction (qPCR) in the diagnosis of postoperative bacterial endophthalmitis among patients who underwent cataract surgery at a tertiary care center. DESIGN: Prospective experimental study. METHODS: This was a single-center study of 64 eyes of 64 patients presenting with clinical signs and symptoms of endophthalmitis within 1 year of cataract surgery. Patients with glaucoma filtering or cornea surgery in the past year, postoperative trauma, fungal endophthalmitis, or preoperative inflammatory conditions were excluded. Vitreous samples were obtained during vitreous tap or vitrectomy and sent for both culture and qPCR with sequencing. Vitreous samples obtained from 50 patients undergoing vitrectomy for noninflammatory indications served as controls. The main outcome measures were the sensitivity of qPCR compared to culture and concordance of results of pathogen identification with sequencing vs phenotypic speciation. RESULTS: qPCR detected 16s bacterial DNA in 37 patients (66%), compared to 19 (34%) with traditional culture. Only 1 patient had a positive result by culture (Nocardia species) but negative result by qPCR. For the 18 samples positive by both qPCR and culture, there was a 100% concordance in pathogen identification between sequencing and phenotypic speciation. CONCLUSION: In cases of suspected bacterial endophthalmitis, qPCR offers an improved diagnostic yield and may be a useful adjunct to traditional culture. Further large-scale clinical studies are needed to elucidate the full clinical utility of qPCR.

Serous macular detachment as a predictor of resolution of macular edema with intravitreal triamcinolone injection.

BACKGROUND AND OBJECTIVE: To evaluate serous macular detachment as a predictor for response of macular edema to intravitreal triamcinolone acetonide. PATIENTS AND METHODS: Sixteen eyes (16 patients) with macular edema and serous macular detachment secondary to diabetic retinopathy (n = 11) or branch vein occlusion (n = 5) were prospectively enrolled. After intravitreal triamcinolone acetonide injection (4 mg/0.1 mL), they were reevaluated at 1 week and 1 and 3 months. The main outcome measure was change in central macular thickness. RESULTS: The mean baseline central macular thickness was 651.13 +/- 245.96 microm. One month after intravitreal triamcinolone acetonide injection, central macular thickness decreased to 255.38 +/- 80.64 microm (P < .0001). After 3 months, central macular thickness increased marginally to 329.69 +/- 161.98 microm, still significantly less than baseline (P < .0001). There was a significant correlation between the height of serous macular detachment and reduction in central macular thickness at 1 (r = .827) and 3 (r = .835) months (P< .0001). CONCLUSION: When serous macular detachment coexists with vascular or microvascular macular edema, it responds to intravitreal triamcinolone acetonide in direct proportion to the height of the serous macular detachment. However, the response begins to fade by 3 months.