Toxic posterior segment syndrome with retinal vasculitis likely caused by intraocular cotton fiber after vitreoretinal surgery - a case report.

BACKGROUND: Intraocular inflammation is common after anterior or posterior segment surgery. They typically manifest either as non-infectious inflammation of the anterior or posterior segment, known as toxic anterior or posterior segment syndrome (TPSS), or as sterile or infective endophthalmitis. In this report, we describe a rare case of TPSS following vitreoretinal surgery, presenting as hemorrhagic retinal vasculitis. CASE PRESENTATION: A 58-year-old male diagnosed with a left eye acute rhegmatogenous retinal detachment underwent an uneventful primary pars plana vitrectomy with silicone oil endotamponade on the same day of presentation. At presentation, there were no signs of intraocular inflammation, and his visual acuity in the affected eye was 20/200. RESULTS: The retina was well-attached with silicone oil in place on the first post-operative day. Along the inferior retinal periphery, a hemorrhagic occlusive vasculitis was observed. Clinical examination revealed retained intraocular cotton fiber along the inferotemporal quadrant over the retinal surface. In addition to the standard post-operative medications, a course of systemic steroids (40 mg per day of Prednisolone tablets) was started. At the end of the first post-operative week, clinical signs of hemorrhagic retinal vasculitis were beginning to resolve, and by the end of the fourth post-operative week, they had completely resolved. CONCLUSION: This report describes an unusual diagnosis of TPSS after vitreoretinal surgery, most likely due to the presence of an intraocular cotton fiber. This excessive inflammation of the posterior segment usually responds to a course of topical and systemic steroids.

Correlation between tear levels of vascular endothelial growth factor and vitamin D at retinopathy of prematurity stages in preterm infants.

Deregulation of vascular endothelial growth factor (VEGF) levels leads to retinopathy of prematurity (ROP). Vitamin D (VIT-D) is known to regulate VEGF in an oxygen dependent manner. The purpose of this study was to correlate tear levels of VEGF and VIT-D with different ROP stages in preterm infants. In this prospective cross-sectional study, we enrolled 104 pre-term infants. They were grouped into: Group-1 (Classical ROP) and Group-2 (Aggressive ROP), which were further subdivided into Group-1A (progressing), Group-1B (regressing), Group-2A (pre-treatment), and Group-2B (post-treatment). Tear VEGF and VIT-D levels and their association with different ROP stages were assessed. Stage 1 and stage 2 had higher whereas stage 3 had lower VEGF levels in Group-1B compared to Group-1A. Stage 1 and stage 3 showed higher levels of VIT-D with no difference in stage 2 in Group-1B compared to Group-1A., Group-2B showed higher VEGF and lower VIT-D levels compared to Group-2A. Presence of a positive correlation at an early stage (stage 1) of ROP and a negative correlation at a more advanced stage (stage 3) of ROP with VIT-D and VEGF implies stage-specific distinct signaling crosstalk. These findings suggest that VIT-D supplementation may have the potential to modify the course and outcome of ROP.

Human immunodeficiency virus retinopathy with presumed cytomegalovirus retinitis with macular oedema in a diabetic.

A man in his early 50s on regular follow-up for a stable non-proliferative diabetic retinopathy (NPDR) presented with decreased vision, worsening of retinal pathology and macular oedema in both eyes. His corrected distance visual acuity (CDVA) was 6/9 in the right eye and 6/15 in the left eye and fundus examination showed multiple intraretinal haemorrhages in all quadrants. His systemic workup revealed a severe thrombocytopaenia, which prompted a further detailed systemic evaluation revealing him to be positive for HIV with retinopathy complicating the pre-existing NPDR. Given the significant inflammation and macular oedema, a cocktail of intravitreal bevacizumab, ganciclovir and dexamethasone was administered. The retinopathy and macular oedema resolved and the CDVA improved to 6/6 in both eyes over a 6-month follow-up period. Any sudden worsening of fundus findings in a patient with diabetes necessitates immediate and detailed ocular and systemic evaluation, especially when the immune status is unknown.

Ocular surface changes following vitreoretinal procedures.

Dry eye disease (DED) can lead to ocular discomfort as well as visual disturbances. Older adults are more likely to develop DED. They are also more likely to develop retinal diseases such as diabetic retinopathy and age-related macular degeneration, which may require vitreoretinal surgeries, lasers, and intravitreal injections. Posterior segment surgery may cause or worsen existing dry eye symptoms, albeit temporarily. Despite good anatomic and functional outcomes, ocular surface dysfunction can have a significant impact on the quality of life, lowering a patient's satisfaction with the retinal treatment. Preexisting DED, intraoperative tissue handling, and postoperative treatment may all contribute to the severity of ocular surface dysfunction. In this article, we have reviewed all relevant studies on the development of ocular surface changes and DED, as well as the impact of vitreoretinal surgeries and procedures on the ocular surface.

Resveratrol for dry eye disease - Hope or Hype?

Dry eye disease (DED) is a multifactorial and common ophthalmic disease that has a tremendous effect on the quality of life. It is now becoming a public health concern because of our changing lifestyle and environment. The current treatment modalities, artificial tear substitutes, and anti-inflammatory therapy are directed at dry eye symptoms. One of the major drivers for DED is oxidative stress, and the polyphenol group of natural compounds has the potential to reduce the same. Resveratrol, widely found in the skin of grapes and nuts, has antioxidative and anti-inflammatory properties. It has been shown to have beneficial effects in glaucoma, age-related macular degeneration, retinopathy of prematurity, uveitis, and diabetic retinopathy. Studies have also explored the beneficial effects of resveratrol in DED, making it as a promising therapeutic molecule. Resveratrol has not yet reached clinical application because of difficulty in deliverability and low bioavailability. In this review, we explore the potential of resveratrol in DED treatment based on various in vitro and in vivo studies.

Recommendations for management of peripheral retinal degenerations.

Some degenerations involving the peripheral retina can result in a rhegmatogenous retinal detachment. Currently, there are no clear guidelines for retinal screening and/or management of these peripheral retinal degenerations in patients with or without recent onset posterior vitreous detachment or in those prior to refractive surgery or intraocular procedures. This article aims to provide a set of recommendations for the screening and management of peripheral retinal degenerations based on a common consensus obtained from an expert panel of retinal specialists.

Atypical Refractory Macular Edema: Are We Missing Something?

Purpose: To report a case of bilateral refractory macular edema in a diabetic macular edema in a diabetic with an underlying systemic illness. Case Report: A 65-year-old male presented with the symptom of blurred vision in both eyes for three months. He was a known diabetic patient and was also hypertensive for the last 10 years. The corrected distance visual acuity was 20/120 in the right eye and 20/80 in the left eye. Fundus examination revealed multiple deep and superficial retinal hemorrhages, cystoid macular edema, and serous macular detachment in both eyes. With a diagnosis of diabetic macular edema in both eyes, the patient was treated with multiple intravitreal injections of anti-vascular endothelial growth factor and steroids. Since he did not show a favorable response, the patient was further investigated and diagnosed with multiple myeloma. After undergoing treatment for the same, the patient was seen a year later and noted to have significant resolution of the macular edema and subretinal fluid in both eyes. Conclusion: In patients who suffer with atypical macular edema that is resistant to conventional treatment, it is imperative to look for underlying systemic illnesses such as immunoproliferative disorders and hematologic malignancies.

Diabetic Retinopathy and Diabetic Macular Edema in People With Early-Onset Diabetes.

This study examined the clinical profile, treatment profile, and vision outcomes of people ≤40 years of age with diabetes and diabetic macular edema (DME). Within this age-group, the prevalence of center-involving DME was 16%, with 74% of eyes showing cystoid edema, 37% showing spongiform edema, and 41% having neurosensory detachment. Longer diabetes duration (P = 0.001) and greater severity of diabetic retinopathy (P <0.001) were associated with DME prevalence. Thus, regular and more frequent follow-up, as well as early and aggressive treatment of diabetic eye disease, are required in people diagnosed early with diabetes.

Neovascular glaucoma following Nd:YAG laser capsulotomy: a rare complication in a postvitrectomised patient with diabetes.

To describe a case of acute-onset neovascular glaucoma (NVG) after a neodymium:yttrium-aluminium-garnet (Nd:YAG) capsulotomy in a diabetic vitrectomized eye of a patient with severe systemic and ocular comorbidities. A man in his 50s underwent a Nd:YAG capsulotomy for visually significant posterior capsular opacification with a previous history of vitrectomy with silicone oil in situ for diabetic retinopathy. He had systemic and ocular comorbidities implicating an advanced ischaemic status, both systemically and locally. Five days post Nd:YAG capsulotomy, extensive neovascularisation of the iris and angles was noted. Despite maximum antiglaucoma medication, an evisceration ensued due to intractable NVG. This case report highlights the importance of irreversible complications after a seemingly simple capsulotomy in eyes with advanced ocular conditions and systemic comorbidities necessitating extreme caution.

Trends in teleconsultations for uveitis during the COVID-19 lockdown.

Purpose: To study the use of teleophthalmology as a tool to manage patients with uveitis and to describe the experience of teleconsultation for uveitis at a tertiary eye care hospital in India during the two waves of the COVID-19 pandemic. Methods: A prospective observational case series of uveitis patients seeking teleconsultations during the first (March 25-May 2020) and second lockdown (April 27 to June 21, 2021) in a tertiary eye care center were analyzed. Results: There were 79 teleconsultations in the first and 89 teleconsultations in the second lockdown. A majority of the patients presented in the age group of 41-60 years in both the lockdowns. There were both new or primary consultations and follow-up patients (6% vs. 94%) in the first lockdown, and similarly in the second lockdown (8% new vs. 92% follow-up). The majority of patients resided in Bengaluru city (78% in the first and 76% in the second lockdown). After evaluation through video consultation, only 15% required a hospital referral in the first lockdown, whereas in the second lockdown, 21.3% were referred to the hospital. During the second lockdown, 20% presented with COVID-19 infection-related ailments. Conclusion: Based on our preliminary experience using a customized smartphone-based application for teleconsultation, we found it to be an alternative option to provide continuation of ophthalmic care to uveitis patients. Given the current COVID-19 situation, it can help avoid physical visits of uveitis patients to the hospital.

Risk Assessment of Aerosol Generation During Vitreoretinal Surgery Using High Speed Imaging Amidst the COVID-19 Pandemic.

Purpose: The purpose of this study was to discuss the propensity of aerosol and droplet generation during vitreoretinal surgery using high speed imaging amidst the coronavirus disease 2019 (COVID-19) pandemic. Methods: In an experimental set up, various steps of vitreoretinal surgery were performed on enucleated goat eyes. The main outcome measures were visualization, quantification of size, and calculation of aerosol spread. Results: During intravitreal injection, insertion of cannulas, lensectomy, and vitrectomy with both 23 and 25-gauge instruments, with either valved or nonvalved cannulas, aerosols were not visualized which was confirmed on imaging. Although there was no aerosol generation during active fluid air exchange (FAE), there was bubbling and aerosol generation at the exit port of the handle during passive FAE. Under higher air pressure, with reused valved and fresh nonvalved cannulas, aerosol generation showed a trajectory 0.4 to 0.67 m with droplet size of 200 microns. Whereas removing cannulas or suturing under active air infusion (35 mm Hg and above) aerosols were noted. Conclusions: Based on the above experiments, we can formulate guidelines for safe vitrectomy during COVID-19. Some recommendations include the use of valved cannulas, avoiding passive FAE or to direct the exit port away from the surgeon and assistant, and to maintain the air pressure less than or equal to 30 mm Hg. Translational Relevance: In the setting of the COVID-19 pandemic, the risk from virus laden aerosols, as determined using an experimental setup, appears to be low for commonly performed vitreoretinal surgical procedures.

Internal limiting membrane detachment in acute central retinal artery occlusion: a novel prognostic sign seen on OCT.

BACKGROUND: To present a series of acute central retinal artery occlusion (CRAO) cases showing internal limiting membrane detachment (ILMD) on optical coherence tomography (OCT) and to describe the possible etiopathogenesis and outcomes associated with it. METHODS: Demographic and OCT features of patients with acute CRAO were analysed retrospectively. OCT parameters noted were posterior vitreous opacities, ILMD, inner retinal layer stratification, hyperreflectivity and thickening, cystoid macular edema, neurosensory detachment. Eyes were grouped into Group (1) CRAO with ILMD; Group (2) CRAO with no ILMD. RESULTS: A total of 28 eyes of acute CRAO who had undergone OCT scans at the time of the acute episode were identified. Out of these, ILMD was noted in 5 eyes. The study findings suggested that cases of acute CRAO with ILMD are associated with poor presenting visual acuity and have more severe signs of retinal hypoperfusion on OCT, like inner retinal thickening, inner retinal hyperreflectivity and loss of inner retinal layer stratification. Patients with ILMD have poor final visual acuity and thinning and atrophy or necrosis of the inner retinal layers. CONCLUSION: ILMD can occur in acute CRAO due to total retinal artery occlusion and severe retinal hypoperfusion. The presence of ILMD on OCT can be considered a sign of poor prognosis in cases of acute CRAO. TRIAL REGISTRATION: Not applicable.

Post COVID-19 Ophthalmic Manifestations in an Asian Indian Male.

Introduction: The Ocular manifestations of coronavirus disease 2019 (COVID-19) reported include conjunctivitis, conjunctival hyperemia, chemosis, epiphora, episcleritis, retinal manifestations included cotton wool spots (CWS), micro-hemorrhages, papillophlebitis and neuro-ophthalmic manifestations.Purpose: To report post COVID-19 ophthalmic manifestations using multimodal imaging.Results: A 66-year-old Asian Indian male presented to us with bilateral blurring of vision, RE>LE, of 3 days following a diagnosis of COVID-19 disease. Corrected distance visual acuity were 20/2666 and 20/25 in the right (RE) and left (LE) eyes respectively. He had bilateral anterior chamber inflammation with a relative afferent pupillary defect in the RE. RE showed central retinal artery occlusion(CRAO) with CWS, few flame-shaped retinal hemorrhages and disc edema and hyperemia. LE had disc edema and hyperemia, few flame-shaped retinal hemorrhages, cystoid changes and CWS. A diagnosis of bilateral panuveitis and papillitis with CRAO in the RE was made.Conclusion: Our patient developed a vascular occlusion with panuveitis, which possibly represents an immune mediated event following COVID-19. Patients should be warned about possible ophthalmic sequelae even after recovery.

Morphological features of focal choroidal excavation and its association with macular pathology in Asian Indian eyes.

Purpose: To study the characteristics of focal choroidal excavation (FCE) in Indian eyes based on spectral-domain optical coherence tomography (SD-OCT) findings and their association with macular pathologies. Methods: Retrospective study of 26 patients diagnosed with FCE. All patients' clinical and imaging data were reviewed. Results: There were eight females and 18 males aged between 24 and 85 years. FCE was noted in 31 eyes of 26 patients - unilateral in 21 and bilateral in 5. The conforming type was noted in 13 and nonconforming in 19 eyes. The location was extrafoveal in 16 and subfoveal in 15 eyes. The morphology was bowl-shaped in 24, cone-shaped in six eyes, and mixed type in one eye. Associated pathologies were central serous chorioretinopathy in nine eyes, choroidal neovascular membrane in seven eyes, Stargardt's disease in three eyes, Best disease in four eyes, other retinal dystrophies in two eyes, polypoidal choroidal vasculopathy and moderate non-proliferative diabetic retinopathy, each in one eye. The mean FCE width was 1667.2 ± 817.7 µ, mean depth was 95.7 ± 46.4 µ, and the mean choroidal thickness under the FCE was 234.8 ± 85.9 µ. No abnormal choroidal tissue was found under any FCE. Conclusion: FCE is a relatively common entity and frequently associated with macular pathologies. The presence of an FCE did not alter the course or management of these conditions.

Stem cell therapy in coronavirus disease 2019: current evidence and future potential.

The end of 2019 saw the beginning of the coronavirus disease 2019 (COVID-19) pandemic that soared in 2020, affecting 215 countries worldwide, with no signs of abating. In an effort to contain the spread of the disease and treat the infected, researchers are racing against several odds to find an effective solution. The unavailability of timely and affordable or definitive treatment has caused significant morbidity and mortality. Acute respiratory distress syndrome (ARDS) caused by an unregulated host inflammatory response toward the viral infection, followed by multi-organ dysfunction or failure, is one of the primary causes of death in severe cases of COVID-19 infection. Currently, empirical management of respiratory and hematological manifestations along with anti-viral agents is being used to treat the infection. The quest is on for both a vaccine and a more definitive management protocol to curtail the spread. Researchers and clinicians are also exploring the possibility of using cell therapy for severe cases of COVID-19 with ARDS. Mesenchymal stromal cells are known to have immunomodulatory properties and have previously been used to treat viral infections. This review explores the potential of mesenchymal stromal cells as cell therapy for ARDS.