Aflibercept vs. dexamethasone implant for recalcitrant diabetic macular edema in pseudophakic eyes - 1-year outcomes from a quazi-randomized study in India.

PURPOSE: To assess the safety and efficacy of intravitreal Aflibercept (IVA) versus dexamethasone (DEX) implant for treating recalcitrant diabetic macular edema (DME) in pseudophakic eyes at 1-year follow-up. DESIGN: Retrospective comparative case series. PARTICIPANTS: Data of all patients diagnosed with DME between January 2019 and December 2021, who underwent 4-monthly doses of intravitreal ranibizumab but had persistent DME [central macular thickness (CMT) within 10% of baseline value] were extracted from a computerized database. Of these, only pseudophakic eyes that underwent either IVA or DEX implant and had at least 1-year follow-up were included for analysis. METHODS: DEX implant was preferred before December 2020 and IVA after this time point. In the IVA group, patients were followed up every month while DEX were followed at least every 3 months. Reinjections were considered when vision dropped by at least 1 Snellen's line or CMT increased by at least 10% from the previous visit in both groups. MAIN OUTCOME MEASURES: Comparison of change in vision and CMT at 1-year follow-up in DEX versus IVA groups. RESULTS: Eighty-four eyes of 84 patients aged 54.4 + 4.4 years were included, 39 (46%) received DEX and 45 (54%) received IVA. Groups were comparable for baseline vision and CMT. Vision improved equally in both groups from 0.83 + 0.15 logMAR to 0.52 + 0.10 logMAR at 3 months ( P < 0.01) and then stabilized till 1 year. However, eyes in the IVA group were 6.5 times more likely (Odds ratio = 6.45, 95% CI = 1.3 - 31.9) to achieve >3-line improvement in vision. The CMT reduction was also comparable between groups (-169 + 51 in DEX vs. -174 + 49 in IVA, P = 0.67). More eyes in the IVA group required >3 injections (91% vs. 69% in DEX, P = 0.01). The IOP was significantly higher at 6 and 9 months in the DEX group and 5 eyes (13%) required IOP lowering medications. CONCLUSION: In pseudophakic eyes with recalcitrant DME not responding to ranibizumab, switching to IVA or DEX implant results in equal visual improvement and CMT reduction. Though >3-line improvement occurs more frequently with IVA, this comes at the expense of a greater number of injections and follow-up visits.

Incidence, clinical features, risk factors, and outcomes of Intraocular inflammation following Brolucizumab in Indian eyes - A multicentric study.

Purpose: To report the incidence, clinical features, potential risk factors, and outcomes of intraocular inflammation (IOI) following brolucizumab in Indian eyes. Methods: All consecutive patients diagnosed with brolucizumab-induced IOI from 10 centers in eastern India between October 2020 and April 2022 were included. Results: Of 758 injections given during the study period across centers, 13 IOI events (1.7%) were recorded attributable to brolucizumab. The IOI occurred after the first dose in two eyes (15%) (median 45 days after brolucizumab), second dose in six eyes (46%) (median = 8.5 days), and third dose (39%) in the remaining five eyes (median 7 days). Reinjections of brolucizumab were administered at a median interval of 6 weeks (interquartile range = 4-10 weeks) in the 11 eyes, where IOI occurred after the second or third dose. Eyes that experienced IOI after the third dose had received a significantly greater number of previous antivascular endothelial growth factor injections (median = 8) compared to those who developed it after the first or second dose (median = 4) (P = 0.001). Anterior chamber cells were seen in almost all eyes (n = 11, 85%), while peripheral retinal hemorrhages were seen in two eyes, and one eye showed branch artery occlusion. Two-thirds of patients (n = 8, 62%) recovered with a combination of topical and oral steroids, while remaining recovered with topical steroids alone. Irreversible visual loss was not seen in any eye, and median vision recovered to pre-IOI levels by 3 months' time point. Conclusion: Brolucizumab-induced IOI was relatively rare, occurring in 1.7% of eyes, was more common after the second or third injection, especially in those who required frequent reinjections every 6 weeks, and occurred earlier with increasing number of previous brolucizumab injections. Continued surveillance is necessary even after repeated doses of brolucizumab.

Complete manuscript title: role of sub-silicone oil application of triamcinolone acetonide (TA) drops on outcomes after 360° relaxing retinectomy: a pilot study.

PURPOSE: To perform a pilot study to evaluate the role of sub-silicone oil Triamcinolone Acetonide (TA) crystal drops in complex Retinal Detachment (RD) with extreme proliferative vitreoretinopathy (PVR) requiring 360-degree relaxing retinectomy (RR). DESIGN: It was a retrospective pilot study. MATERIALS AND METHODS: It was a retrospective case-control pilot study. TA-assisted 23G or 25G vitrectomy was done in 24 complex RDs with extreme PVR where 360 degree RR had to be performed. Group A (n = 13) included cases where additional TA crystal drops were applied, after settling the detached retina, over the site of RR under silicone oil (SO 5000 CSt) tamponade. In the control arm, group B (n = 11), additional TA crystals were not applied. MAIN OUTCOMES MEASURED: Mean pre- and post-operative BCVA, ultra-widefield fundus photograph by Optos 200Tx, macular OCT and the propensity to remove silicone oil were measured. RESULTS: Mean pre-operative and post-operative BCVA at final follow-up were Log MAR 2.69 ± 0.41 and Log MAR 1.51 ± 0.90 (Mann-Whitney U test, p < 0.05), respectively, in Group A and Log MAR 2.9 and Log MAR 2.37 ± 0.86 (Mann-Whitney U test, p < 0.05), respectively, in group B. Visual improvement in group A was significantly better than group B (Wilcoxon W test, p < 0.025) with significantly less recurrence of RD (Fisher's Exact Test, p = 0.002). Silicone oil removal was done significantly more in group A (Fisher's Exact Test, p = 0.0017). CONCLUSION: Sub-silicone oil crystals application over sites of RR after 360-degree relaxing retinectomy leads to improved postoperative visual recovery as well as improved anatomical outcomes with fewer complications.

Initial experience in treating polypoidal choroidal vasculopathy with brolucizumab in Indian eyes - A multicenter retrospective study.

Purpose: To report the initial experience of managing treatment-resistant and treatment-naïve eyes with polypoidal choroidal vasculopathy (PCV) by using brolucizumab 6 mg. Methods: This was a retrospective multicentric series of all consecutive eyes with PCV treated with brolucizumab. Treatment resistance was defined as taking at least six prior anti-VEGF injections over the past 1 year and showing persistent disease activity in the form of intra (IRF) or subretinal fluid (SRF) or both. All patients were treated on a pro re nata (PRN) basis and followed up monthly. Retreatment was considered when either SRF or IRF were present at any time point during the study. Results: We included 21 eyes of 21 patients with PCV with a mean age of 65.1 ± 9.9 years, of which 16 eyes (76%) were treatment-resistant. The mean follow-up period from receiving the first brolucizumab was 27.3 ± 3.3 weeks. Of the 21 eyes, seven eyes (33%) received three injections during follow-up, 13 eyes (62%) received two injections, and one eye received one injection. The mean injection-free interval was 12 ± 1.2 weeks. The median pretreatment vision was 0.6 logMAR (IQR = 0.47-1 logMAR) and improved to 0.3 logMAR (IQR = 0.25-0.6 logMAR), whereas the mean macular thickness improved from 443 ± 60 µm at baseline to 289 ± 25 µm (P < 0.001) at the last follow-up period. None of the eyes experienced any intraocular inflammation across 48 injection sessions. Conclusion: Brolucizumab is safe and effective in controlling PCV disease in both treatment-resistant and treatment-naïve eyes.

Outcomes of preoperative bevacizumab in diabetics with nonclearing vitreous hemorrhage without tractional detachment - A quasi-randomized retrospective study.

PURPOSE: To assess whether preoperative bevacizumab (BVZ) in treatment-naïve eyes with proliferative diabetic retinopathy (PDR) and vitreous hemorrhage (VH) without tractional retinal detachment (TRD) leads to lesser macular edema and better visual outcome compared to eyes that do not receive BVZ. METHODS: This quasi-randomized retrospective study included 217 treatment-naïve eyes with nonclearing VH without TRD that had vitrectomy with or without BVZ and had a minimum 6-months follow-up. Postoperative variables, including visual acuity (BCVA), central macular thickness (CMT) at 1 month, and need for additional anti-VEGF injections till 6 months follow-up, were recorded for analysis. RESULTS: Of the 217 eyes, 107 eyes (49%) received preoperative BVZ and 110 (51%) did not. Groups were comparable in terms of preoperative characteristics. At 1 month, mean CMT was significantly higher in eyes without BVZ (310 ± 33 m vs. 246 ± 34m; P < 0.001). The likelihood of developing center-involving DME at 1 month after vitrectomy was 67% lower if the eye received preoperative BVZ (OR = 0.33, 95%CI = 0.18-2.54, P = 0.56). Though BCVA improved significantly in both groups at 1 month, it was 1/3rd of a line better in the BVZ group (b coefficient = -0.035 logMAR, 95%CI = -0.04 to -0.008 logMAR, P = 0.01). CONCLUSION: Preoperative BVZ in treatment-naïve eyes with PDR and VH but without TRD lead to better macular status and marginally improved vision at 1 month, which was maintained at 6 months. In view of these results, patients may be offered BVZ only when it is readily affordable to them.

A Delphi method based consensus statement for surgical management of proliferative diabetic retinopathy in India.

PURPOSE: To derive consensus statements for surgical management of proliferative diabetic retinopathy (PDR) for vitreoretinal (VR) surgeons. METHODS: Thirteen prolific VR surgeons representing all regions of India were invited to participate in a 42-point questionnaire based on the Delphi methodology describing various surgical scenarios commonly encountered in PDR. Consensus was derived using predefined robust analytics. Scenarios that returned a moderate consensus in round 1 were taken to round 2 as per the Delphi methodology. After considering all inputs, the final consensus criteria were developed. RESULTS: A strong consensus was derived about waiting for 4 weeks before considering vitrectomy. In treatment-naïve eyes with fresh vitreous hemorrhage (VH), the wait time was slightly shorter for extramacular tractional retinal detachment (2-4 weeks) and longer (4-6 weeks) for eyes treated previously with laser or anti-VEGF agents. The expert panel recommended using preoperative anti-VEGF only in eyes with large membranes requiring extensive dissection. For post vitrectomy VH, while a conservative approach was recommended for the first episode of VH, experts recommended immediate vitreous lavage for recurrent episodes of VH. In eyes with iris neovascularization, the panel recommended immediate anti-VEGF injection followed by early vitreous lavage in nonresponsive eyes. A strong consensus was derived for stopping antiplatelet agents before surgery, while there was only a moderate consensus for performing vitrectomy for recalcitrant macular edema unresponsive to anti-VEGF injections in the absence of traction. CONCLUSION: This study provides valuable consensus on managing the different scenarios encountered during surgical management of PDR and should help guide the VR surgeons in clinical decision-making.

Anatomical and functional outcomes one year after vitrectomy and retinal massage for large macular holes.

Purpose: The aim of this study was to report results of macular hole closure, visual benefit and longitudinal changes in foveal architecture over 1 year following macular hole surgery with retinal massage. Methods: Records of patients with full thickness macular hole (FTMH) with minimum basal diameter of 550 µ who underwent vitrectomy, internal limiting membrane (ILM) peeling and retinal massage were drawn up. Retinal massage was performed after dye assisted ILM peeling, using a 27G flute needle with a long and soft silicone tip under air in a centripetal direction around the FTMH. At the end, 10% C3F8 gas was used as tamponade. The foveal contour at 1 year follow up was recorded based on its cross sectional appearance on OCT and was classified into U, V and irregular types of closure as previously described. Results: Forty-one eyes of 41 patients with a mean age of 70.4 ± 6.9 years were included. The mean preoperative vision was 0.99 ± 0.07 logMAR and mean maximum basal diameter of the FTMH was 835 ± 208 µ. Macular hole closure was seen in all patients at 1-month follow up. The BCVA improved to 0.5 ± 0.1 log MAR at 6 months (P < 0.001) and then stabilized. The U shaped closure was the commonest pattern (n = 22, 54%), followed by V-shaped closure (n = 16, 39%) while irregular closure was seen in 3 eyes (7%). Conclusion: Retinal massage after ILM peeling is a very simple, and as yet under-utilized manoeuvre that may improve hole closure rates and lead to potentially greater improvement in vision compared to existing techniques for large holes.

B-HEX pupil expander in vitreoretinal surgery - A case series.

We describe the successful use of the B-HEX pupil expansion device in four cases of combined phacovitrectomy with significant cataract, non-dilating pupil, and surgical vitreoretinal pathologies including vitreous hemorrhage, inferior retinal detachment (RD) with proliferative vitreoretinopathy in an oil filled eye, recurrent rhegmatogenous RD, and macular hole with RD localized to the posterior pole in an eye with uveitic sequelae. The B-HEX remained well engaged and maintained excellent mydriasis throughout the surgery despite wide fluctuations in intraocular pressure and anterior chamber fluidics. This is the first series describing use of B-HEX for combined phacovitrectomy due to myriad causes.

Cut Throat Injury: Our Experience in Rural Set-Up.

Cut throat injuries are one of the emergency conditions managed by ENT specialists. If not treated in time, they may lead to death. Prevention of these complications depends on immediate resuscitation by securing the airway by tracheostomy or intubation, prompt control of hemorrhage and blood replacement. The present study was conducted to study the sociodemographic profile of patients of cut throat injury, motives behind cut throat injury, site and depth of the injury, treatment given at our hospital and outcome. A prospective study was done in the department of ENT in a tertiary care hospital of rural West Bengal between January 2014 and December 2015. Patients who were brought dead and minor neck injury were excluded from the study. Endotracheal intubation where possible, or emergency tracheostomy was done below the level of injury. Ryle's tube was inserted where necessary. Injured structures were repaired in layers. Among 22 patients there were 18 male and 4 female. The peak age of incidence was in the 4th decade of life. Suicidal cut throat injury was the most common mode of injury. Most of the injuries were in the zone II (72.73%). Three patients died due to severe haemorrhage and/or aspiration. Decannulation was possible in 9 out of 12 patients. Cut throat injuries have become a major cause of morbidity and mortality in our society. Patients with injury of larynx or upper trachea need preliminary tracheostomy. Post-operative endoscopy identifies nerve injuries and stenosis problems.

Neurofibroma of the external ear - a case report.

Neurofibromas are relatively common tumours of the nervous system, but only a few cases involving the external ear have been reported. We are reporting here a case of a 20-year-old female with neurofibroma of the external ear. The primary complaint was cosmetic deformity. There was partial occlusion of the external auditory canal. The swelling was excised by postauricular approach. Surgery resulted in an excellent functional and cosmetic outcome.

Cutaneous matastasis from sino-nasal malignant melanoma - a rare case report.

To report a case of disseminated cutaneous metastasis from malignant melanoma of sino-nasal region. A 53-year-old man from rural parts of West Bengal presented with progressive nasal obstruction. CT scanning was done to know the extent of the mass and punch biopsy from the mass was performed. Malignant melanoma of sino-nasal region was diagnosed and chemotherapy was started. The patient developed cutaneous deposits after two cycles of chemotherapy. The patient developed cutaneous deposits during the course of chemotherapy. Excision biopsy from cutaneous deposits revealed malignant melanoma. A rare case of diffuse cutaneous metastasis of malignant melanoma is presented here along with review of literature.

Sarcomas of head and neck - A 10 yrs experience.

38 cases of sarcoma of head and neck region were analysed in a retrospective way in relation to age, anatomic location, histological, clinical profile, and surgical approaches. Compared to other types of head and neck neoplasms, such as squamous cell carcinoma, soft tissue sarcomas have low rates of regional metastases. However the biological behaviour of soft tissue sarcoma is more aggressive specially in paediatric age group. In the present series, CT scan was considered as the primary modality of investigation. Surgery generally has been recommended as the primary method of treatment for achieving local control, except in those high-grade tumours arising in sites not amenable to resection. 3-year and 5-year survival rates in this present series 50% and 31.6% respectively.

Management of a posteriorly dislocated endocapsular tension ring and a foldable acrylic intraocular lens.

We report a rare case of late spontaneous extension of a posterior capsule tear from lateral traction of an endocapsular ring, resulting in dislocation of the capsular tension ring and acrylic intraocular lens (IOL) into the vitreous cavity. A 3-port pars plana vitrectomy was performed to explant the prostheses; the eye was made pseudophakic by placement of a scleral-fixated posterior chamber IOL. The combined triple procedure was safe and effective.

Cataract surgery and intraocular lens implantation in a retinoblastoma case treated by external-beam radiation therapy.

We report a case of extracapsular cataract extraction with posterior chamber intraocular lens implantation in a pediatric patient with a radiation-induced cataract that developed after combined external-beam radiation therapy and chemotherapy for retinoblastoma. A 12-year follow-up revealed effective tumor regression and sustained visual recovery.