Multimodal imaging of eyes with metamorphopsia after vitrectomy for rhegmatogenous retinal detachment.

PURPOSE: To assess the retinal features in eyes with postoperative metamorphopsia (POM) following rhegmatogenous retinal detachment (RRD) repair using multimodal imaging (MMI). METHODS: In this cross-sectional; case-control study, patients after successful RRD repair following 25-gauge vitrectomy, clear vitreous cavity, and corrected distance visual acuity (CDVA)>20/200 were categorized using Amsler chart: cases with POM and controls without POM. MMI was performed on swept-source platform (Triton, Topcon Inc) and the confocal scanning laser ophthalmoscope system (Spectralis HRA, Heidelberg). The measures assessed were CDVA, morphological features on optical coherence tomography, autofluorescence, and multicolor imaging (MCI). RESULTS: Thirty-nine eyes were included in each group. Cases had greater number of eyes with total RRD (P = 0.029) preoperatively; abnormal foveal contour (P = 0.036), ellipsoid zone (EZ) disruption (P < 0.001) and poorer postoperative CDVA (P = 0.046) as compared to controls. Outer retinal folds and retinal shift (unintentional translocation of retina after reattachment surgery for RRD) did not differ significantly between the groups (P = 0.48 and 0.35, respectively). On MCI, the distribution of detected ERM was similar between the groups (P = 0.25). Postoperative CDVA was significantly worse in eyes with POM. CONCLUSION: POM is affected by extent of RRD, postoperative foveal contour, and EZ status but not by retinal shift.

Clinical and Multimodal Imaging Features of Subretinal Drusenoid Deposits.

PURPOSE: To describe the multimodal imaging (MMI) features of subretinal drusenoid deposits (SDD) in Indian population. METHODS: Patients diagnosed to have SDD from January 2016 to December 2018 at our tertiary care center were recruited. The diagnosis of SDD was made on the basis of MMI consisting of a combination of color fundus photography (CFP), optical coherence tomography (OCT), red-free (RF) imaging, blue autofluorescence (BAF), and near-infra red reflectance (NIR) imaging. The morphological type and distribution of SDD and the associated retinal lesions were reviewed. RESULTS: Twenty-three patients with SDD were included. The mean age of the patients was 68.1 ± 12.2 years. SDD were noted in 77.8% of eyes clinically (n = 35/45) and could be detected in 100% of these eyes with OCT. The morphology of SDD was nodular in 65.7% of eyes (n = 23/35), reticular in 5.7% (n = 2/35), and mixed pattern in the remaining cases. BAF and NIR showed hyporeflective nodular lesions often with a target configuration. The location was commonly in the perifoveal area, mostly involving the superotemporal quadrant (74.3%, n = 26/35). Associated retinal lesions were type-3 neovascularization or retinal angiomatous proliferation in 17.1% (n = 6/35), disciform scar in 11.4% (n = 4/35), type-1 neovascularization in 8.5% (n = 3/35), and geographic atrophy in 5.7% (n = 2/35) of eyes. The mean subfoveal choroidal thickness was 186.2 ± 57.8 µm. CONCLUSION: SDD commonly have a nodular morphology and their identification often requires confirmations with OCT. Advanced age-related macular degeneration features are frequently present in eyes with SDD and the fellow eyes.

Ultra-wide field retinal imaging: A wider clinical perspective.

The peripheral retina is affected in a variety of retinal disorders. Traditional fundus cameras capture only a part of the fundus even when montaging techniques are used. Ultra-wide field imaging enables us to delve into the retinal periphery in greater detail. It not only facilitates assessing color images of the fundus, but also fluorescein angiography, indocyanine green angiography, fundus autofluorescence, and red and green free images. In this review, a literature search using the keywords "ultra-widefield imaging", "widefield imaging", and "peripheral retinal imaging" in English and non-English languages was done and the relevant articles were included. Ultra-wide field imaging has made new observations in the normal population as well as in eyes with retinal disorders including vascular diseases, degenerative diseases, uveitis, age-related macular degeneration, retinal and choroidal tumors and hereditary retinal dystrophies. This review aims to describe the utility of ultra-wide field imaging in various retinal disorders.

Perception among ophthalmologists about webinars as a method of continued medical education during COVID-19 pandemic.

PURPOSE: To ascertain ophthalmologist's perceptions about webinars as a method of continued medical education during the COVID-19 pandemic. METHODS: In a cross-sectional study, a 21-question survey was circulated using digital media platform to approximately 1400 ophthalmologists in India between 16th August 2020 to 31st August 2020. The questionnaire focussed on the quality and usefulness of webinars based on the Bloom's taxonomy. The responses (on 4- or 5-point Likert scale) were analyzed among three professional groups- ophthalmologists in-training, consultants in public sector, and private practitioners. RESULTS: 393 ophthalmologists participated in the survey, with a response rate of 28%. The mean age was 34.6 ± 9.7 years, and males constituted 49.6% (199/393) of the respondents. Forty-seven percent of the respondents perceived the quality of webinars as good or excellent (185/393), 72.8% reported knowledge gain from webinars (286/393), and 63.9% felt that webinars are important in clinical practice and should continue post-COVID-19 pandemic (251/393), with distinct responses among the professional groups. The drawbacks perceived were overt number of webinars (371; 94.4%), confusion regarding which webinars to attend (313; 79.6%), repetition of the information (296; 75.3%), limited opportunity for participant interaction (146; 37.2%) and disparate weightage to the core disciplines of Ophthalmology. CONCLUSION: Most respondents had favorable perceptions of Ophthalmology webinars happening during the COVID-19 pandemic. However, there is need for improvisation in the volume of webinars, target-audience-based delivery, and participant interaction to add value to this new dimension of teaching-learning.

Management of a case of bilateral dengue maculopathy with intravitreal steroid therapy.

Bilateral sight threatening macular and optic nerve inflammation may occur with dengue fever, necessitating the use of systemic steroids. We report a case of bilateral dengue maculopathy in an elderly woman managed with targeted intravitreal steroid therapy. A 63-year-old woman presented with acute-onset painless diminution of vision in both eyes following a dengue fever episode. She had bilateral foveal inflammatory lesions, macular oedema, small vessel occlusions at the macula and scattered retinal haemorrhages and cotton-wool spots. Following systemic evaluation, intravitreal triamcinolone acetonide injection was performed in both eyes at an interval of 3 days. The foveal lesion and macular oedema resolved quickly in both eyes with a normal foveal architecture at the end of 6-week follow-up. The visual acuity improved considerably in both eyes. Inflammatory retinopathy in dengue fever may be managed with a targeted intravitreal steroid injection approach.

Aggressive posterior retinopathy of prematurity: a review on current understanding.

A review of literature was performed, focused on the etiopathogenesis of aggressive posterior retinopathy of prematurity (APROP), the characteristic and atypical clinical features, management strategies, anatomical and visual outcomes. Characteristically APROP has zone I/posterior zone II involvement with prominent plus disease, featureless junction, large vascular loops, flat extra-retinal fibrovascular proliferation, and a rapidly progressive course. The risk factors for APROP are extreme prematurity (birth weight ≤1000 gram and/or gestational age ≤28 weeks), dysregulated oxygen supplementation, intrauterine growth retardation, sepsis, and thrombocytopenia. The uncommon presentations include small zone I disease, a hybrid disease with additional ridge tissue, and APROP in bigger babies with birth weight greater than 1500 g. Laser photocoagulation role is limited by the resultant visual field loss and high refractive error. Although anti-vascular endothelial growth factor injection allows peripheral retinal vascularization; reactivation of disease, systemic absorption of the drug and long-term safety are the chief concerns. Early vitrectomy is required when tractional retinal detachment develops. The visual outcome depends upon the morphology and vascular development of the macula. With the limited yet emerging new understanding of the pathophysiology, a multifaceted rational and individualized treatment strategy is suggested for APROP. Best practices in neonatal intensive care may prevent the occurrence of APROP. Further studies need to be performed for the prevention and safe, effective management of APROP.

Chronic myeloid leukaemia accelerates proliferative retinopathy in patients with co-existent diabetes: A risk factor not to be ignored.

OBJECTIVE: To describe the retinal imaging characteristics, retinopathy management strategies and visual outcomes in cases of diabetes with chronic myeloid leukaemia. DESIGN: Retrospective observational study. PARTICIPANTS: Patients with diabetes and chronic myeloid leukaemia managed at our tertiary eye care centre from January 2015 to December 2017. METHODS: Detailed ophthalmic and systemic evaluation, treatment and follow-up records were reviewed. The main measures studied were visual acuity, intra-ocular pressure, retinopathy severity, and surgical indications and techniques. RESULTS: Of the six patients studied, three had diabetes and chronic myeloid leukaemia at presentation, while in three cases chronic myeloid leukaemia was diagnosed following evaluation for proliferative retinopathy. The visual acuity ranged from 20/20 to perception of light. All eyes had marked proliferative retinopathy out of proportion to the exudation. None of the eyes had significant macular oedema. Pan-retinal photocoagulation (10/12, 83.33%), intravitreal anti-vascular endothelial growth factor injection (8/12, 66.67%), vitrectomy (2/12, 16.67%), cataract surgery (2/12, 16.67%) and trabeculectomy followed by cryoablation (2/12, 16.67%) was performed for management of the ocular disease as indicated. Median follow-up was 16.5 months (range: 6-24 months). Final visual acuity ranged from PL to 20/20 with acuity ⩾ 20/100 in eight eyes. Four eyes had advanced optic neuropathy from neovascular glaucoma. CONCLUSION: Accelerated proliferative retinopathy can be seen in cases of diabetes with chronic myeloid leukaemia at the very initial ophthalmic evaluation. Thus, there is a need to alter screening guidelines for retinopathy in cases of diabetes with chronic myeloid leukaemia. Early detection and aggressive management may help preserve visual acuity in such cases.

Combined Vitrectomy and Anti-VEGF Treatment for Stage 4 Retinopathy of Prematurity With Extensive Neovascular Proliferation.

PURPOSE: To study the role of combined vitrectomy and intravitreal anti-vascular endothelial growth factor (VEGF) injection for stage 4 retinopathy of prematurity (ROP) with extensive neovascular proliferation. METHODS: In a retrospective interventional study at a tertiary eye care center, 15 eyes (9 infants) with advanced stage 4 ROP underwent 25-gauge vitrectomy combined with intravitreal 0.625 mg of bevacizumab (n = 12) or 0.25 mg of ranibizumab (n = 3) injection and were followed up until 65 weeks' postconceptional age (PCA). The perinatal history, tractional retinal detachment (TRD) characteristics (zone, stage, and presence of "plus" disease), treatment details, and anatomical outcomes were reviewed. The main outcome measures were fibrovascular tissue and TRD regression and final macular status. RESULTS: Mean gestational age and birth weight were 28.5 ± 1.2 weeks and 1,167 ± 185 g, respectively. Thirteen eyes had zone I disease and 2 eyes had zone II disease. Thirteen eyes were stage 4A and 2 eyes were stage 4B ROP. The morphology was aggressive posterior ROP in 10 eyes. The mean PCA at surgery was 37.8 ± 2.3 weeks. Lensectomy was also performed in 2 eyes. Rapid fibrovascular tissue regression was seen in 14 eyes within 2 weeks, followed by TRD regression and macular vascularization, although 2 eyes had macular pucker formation. Persistent vitreous bleeding was present in 1 eye, which needed lavage, and eventually the TRD regressed. Disease reactivation was noted in 1 eye at 5 weeks and was managed with repeat intravitreal anti-VEGF injection. CONCLUSIONS: Anti-VEGF treatment combined with vitrectomy leads to rapid disease regression in advanced stage 4 ROP with extensive neovascular proliferation. [J Pediatr Ophthalmol Strabismus. 2020;57(1):61-66.].

Multifocal electroretinogram in eyes with intravitreal silicone oil and changes following silicone oil removal.

PURPOSE: To determine the effect of intravitreal silicone oil (SO) on multifocal electroretinogram (mfERG) and the changes in mfERG following SO removal. METHODS: Twelve eyes of 12 patients with SO in vitreous cavity with corrected distance visual acuity (CDVA) > 20/200 were prospectively enrolled as cases over a period from July 2016 to June 2018. The fellow normal eyes served as control. The eyes were evaluated with P1 and N1 wave amplitude and implicit time on mfERG at baseline, 1 and 4 weeks after SO removal. RESULTS: The mean age was 44.9 ± 18.9 (range 18-74) years. The indication for SO injection was retinal detachment (n = 9, three macula-on eyes, six macula-off eyes) and endophthalmitis (n = 3). The median (range) LogMAR CDVA at baseline was 0.54 (0.18-0.78) in cases and did not change post-SO removal (p = 0.29). There was a significant decrease in average P1 and N1 wave amplitude (p = 0.0001 and 0.0001, respectively) and delay in average P1 and N1 wave implicit time (p = 0.0002 and 0.021, respectively) in cases as compared to controls. The macular status and duration of SO tamponade did not have a significant correlation with mfERG parameters. There was a significant increase in average P1 and N1 wave amplitude (p = 0.009 and 0.003, respectively) at 1 week following SO removal but no change in average P1 and N1 wave implicit time (p = 0.41 and 0.37, respectively). CONCLUSION: mfERG may be reliably performed for the assessment of macular function in SO-filled eyes. Intravitreal SO exerts an insulating effect on the density of the electric potentials.

Iatrogenic Crystalline Lens Injury in Pediatric Eyes Following Intravitreal Injection for Retinopathy of Prematurity.

PURPOSE: To report the occurrence of lens injury during intravitreal anti-vascular endothelial growth factor (anti-VEGF) injection in infants with retinopathy of prematurity (ROP). METHODS: ROP cases presenting to a tertiary care center with cataract following intravitreal injection were retrospectively studied from June 2017 to May 2018. The indication, setting, and method of injection were noted. Ultrasound biomicroscopy (UBM) details were recorded. The main measures were morphology of cataract, posterior capsular defect, and intraocular lens (IOL) placement. RESULTS: Three children (mean age: 14 ± 8.6 months, two male and one female) received injection elsewhere under topical anesthesia in the neonatal intensive care unit (NICU) for type 1 ROP (stage 3 in zone I or II with significant plus disease) 9 to 18 months earlier. All cases developed cataract caused by intravitreal needle damaging the posterior capsule. In one case, a dense zonular cataract was present and peripheral dehiscence of the posterior capsule became evident only during lens aspiration. The second and third cases had a central posterior subcapsular cataract. Preexisting central dehiscence of the posterior capsule was noted on UBM and confirmed during surgery. A multi-piece IOL was securely placed in all cases. At last follow-up (median: 6 months; range: 3 to 6 months), the IOL was stable and centered in all cases with a clear visual axis. CONCLUSIONS: The increasing occurrence of cataract in treatment-requiring ROP following intravitreal anti-VEGF injections being given by practitioners in the NICU setting under topical anesthesia that hinders optimal visualization and technique is a significant concern. [J Pediatr Ophthalmol Strabismus. 2019;56(3):162-167.].

Surgical outcomes of immediate sequential bilateral vitreoretinal surgery for advancing retinopathy of prematurity.

Purpose: Bilateral eye surgery in the same session may be required for advancing stage 4 retinopathy of prematurity (ROP). The purpose of this study was to evaluate the outcomes of immediate sequential bilateral vitreoretinal surgery (ISBVS) in stage 4 ROP. Methods: In a retrospective interventional study at a tertiary care center, 60 eyes of 30 infants who underwent ISBVS for stage 4 ROP between December 2015 and May 2017 were studied. In cases with clear retrolental access, 25G or 27G lens sparing vitrectomy (LSV) was performed and in the rest 25G lensectomy with vitrectomy (LV) was performed through clear corneal entries. The final anatomical outcome measures were the status of tractional retinal detachment (TRD) and macular status. Results: The mean gestational age was 28.4 ± 2.0 weeks and birth weight was 1214.5 ± 329.7gms. The mean postconceptional age at surgery was 40.8 ± 2.2 weeks. Stages 4a and 4b were present in 86.7% and 13.3% eyes respectively. LSV was performed in 95% eyes whereas LV was performed in the rest. None of the eyes developed lens touch, choroidal hemorrhage, postoperative hypotony, corneal decompensation, or endophthalmitis. At last follow-up (mean 45 weeks, range 20-68 weeks), macula was attached in 90% eyes with the TRD resolved completely in 61.7% eyes and significantly decreased in another 25% eyes. Sequalae included macular drag, epiretinal membrane, and progression to fibrotic stage 5 disease. Conclusion: ISBVS is safe and effective for bilateral stage 4 ROP and should be recommended in rapidly progressive cases.

Short-term incidence and management of glaucoma after successful surgery for stage 4 retinopathy of prematurity.

Purpose: The purpose of this study is to describe the short-term incidence, clinical features, and management of glaucoma in children after successful surgery for stage 4 retinopathy of prematurity (ROP). Methods: The retrospective study included all eyes undergoing successful surgery for stage 4 ROP with good outcomes at a tertiary eye care center between June 2014 and June 2016. Cases developing postoperative glaucoma underwent examination under anesthesia for measurement of intraocular pressures (IOP), corneal diameters, Retcam-assisted fundus imaging, and gonioscopy. Outcomes of glaucoma management were evaluated. Results: Hundred eyes of 70 babies underwent successful surgery for stage 4 ROP (with postoperative attached retina, and minimal sequelae) with minimum follow-up of 15 months. Six eyes (6%) developed postoperative glaucoma. Of these, four eyes had undergone lens-sparing vitrectomy and two were managed with lensectomy and vitrectomy (LV). Median time duration for development of glaucoma after primary vitreous surgery was 17.5 weeks. Two cases could be managed with topical IOP-lowering agents alone, whereas four required filtering surgeries (trabeculotomy with trabeculectomy and 0.04% mitomycin C [MMC] application). Average IOP decreased from 25 ± 2.36 to 12.2 ± 2.05 mmHg at 12 months from glaucoma diagnosis. Conclusion: Glaucoma is a potential adverse event following successful vitreous surgery for stage 4 ROP. A combined trabeculotomy-trabeculectomy along with MMC gives favorable outcome.

Hybrid clear corneal micro-incision surgical technique for stage 5 retinopathy of prematurity.

A safe technique for entry incisions and closure in stage 5 retinopathy of prematurity (ROP) surgery is being described. Three 23G clear corneal incisions are made which allow for safe and snug entry of 25G calibrated infusion and 25G instruments for performing lensectomy, membrane removal and vitrectomy. At the end of surgery, air is injected and corneal entries are hydrated for sutureless closure. The technique was performed in 50 eyes of 36 children with stage 5 ROP. The hybrid technique ensured safe entry and exit with stable anterior chamber during surgery. None of the cases developed retinal breaks during surgical entry nor had any complications such as hypotony, flat anterior chamber, hyphaema or corneal edema in post operative period. Clear corneal entry using 23G incisions for 25G instrument access is a safe and effective technique for performing lensectomy and vitrectomy with sutureless closure in cases with stage 5 ROP.

Post-Ranibizumab injection endophthalmitis in aggressive posterior retinopathy of prematurity.

A preterm infant with zone 1 aggressive posterior retinopathy of prematurity developed infectious endophthalmitis after intravitreal injection of ranibizumab. Urgent empirical intravitreal therapy with vancomycin, ceftazidime, and dexamethasone along with intravenous therapy with amikacin and meropenem helped in early resolution. Vascularization/activity of disease subsided on follow-up, media cleared, and laser photocoagulation was completed. Later the disease reactivated, developed vitreous membranes and central retinal traction, for which 25-gauge lens-sparing vitrectomy was performed. Emergent treatment helped in salvaging the eye from both aggressive ROP disease and devastating endophthalmitis. Rationale approach to such a case is being discussed.