Humphrey visual field made easy for residents.

BACKGROUND: Visual field testing is an indispensable part of the assessment of glaucoma. Of paramount importance to both the practitioner and the perimetrist is the guidance on how to conduct the test to get the best results and also the interpretation of test results. PURPOSE: To simplify the basics of understanding single-field analysis of visual field tests by using the Humphrey perimeter. SYNOPSIS: The general principle and a brief overview of how the Humphrey visual field is conducted and the approach to interpreting the results of single field analysis in an easy-to-understand manner are presented. HIGHLIGHTS: This educational video is an attempt to simplify the interpretation of Humphrey visual field single-field analysis with illustrations and video clips that would be useful to practicing ophthalmologists and optometrists and in training programs. VIDEO LINK: https://youtu.be/x8iZLDR4XdY.

Long and short of Ahmed glaucoma valve tube.

Background: The Ahmed Glaucoma Valve (AGV, New World Medical Inc., Rancho Cucamonga, CA, USA) is a glaucoma drainage device commonly used in the treatment of refractory glaucoma either as a primary surgical procedure or after the failure of conventional filtration procedures. During surgery, After the AGV plate is fixed to the sclera, at least 8 mm posterior to the corneoscleral limbus, the length of tube is trimmed to the desired length, based on decision to insert it in the anterior chamber (AC) or ciliary sulcus. Purpose: This video describes that the length of AGV silicone tube should be cut based on decision to place it in the AC or ciliary sulcus. The tube should not be cut too long or short as in either case it may cause postoperative complications. Synopsis: The video illustrates useful tips for AGV tube insertion into the AC, taking care that it does not cross pupillary margin and is of adequate length. The silicone AGV tube is cut using Westcott scissors to permit a length of 2- to 3-mm tube insertion in the AC, with its bevel facing up, and the tip is cut to an angle of 30°, to facilitate AC entering. In ciliary sulcus placement of the AGV tube, the tunnel is made longer when compared with the AC implantation, and the length of tube should be kept long enough for the tip to be just visible beyond the pupillary border. Highlights: This video highlights the importance of customization of the AGV tube length for individual patients based on its placement into AC or ciliary sulcus. Video link: https://youtu.be/jqS4SvCkSqs.

Qualitative ultrasound biomicroscopy in glaucoma.

Background: UBM is a high-resolution ultrasound technique which allows non-invasive, in vivo imaging of the anterior segment and iridocorneal angle. Purpose: This video is compilation of short video clips and images which gives description on identification of angle closure due to pupillary block, peripheral anterior synechiae, iris bombe, plateau iris, supra ciliary effusion, and malignant glaucoma. It also shows video demonstrating partially and fully patent iridotomy and features of trabeculectomy bleb. Synopsis: This video summarizes importance of UBM application in angle closure glaucoma to understand its pathophysiology by showing the relationship between the peripheral iris, trabecular meshwork and ciliary processes. Highlights: UBM provides two-dimensional, grayscale images of the angle structures and allows identification of non-pupillary block mechanism in angle closure glaucoma, which can be recorded for qualitative and quantitative analyses. Video Link: https://youtu.be/prsmGnR8jYc.

Incidence of Glaucoma after Combined Descemet's Stripping Endothelial Keratoplasty and Retropupillary Fixated Iris-Claw Lens.

Purpose: To assess the incidence of glaucoma after combined Descemet's stripping endothelial keratoplasty (DSEK) and retropupillary fixated iris-claw intraocular lens (IOL) implantation in the patients with bullous keratopathy (BK) who required secondary IOL or IOL exchange. Methods: In this retrospective case series, medical records of 22 patients who underwent combined DSEK and retropupillary fixated iris-claw IOL implantation were evaluated. Preoperative vision, intraocular pressure (IOP), postoperative IOP at different time periods, and intraoperative and postoperative complications were analyzed. Results: A total of 22 eyes of 22 patients (7 females and 15 males) were analyzed. The median age was 62 years, and the median duration of the postoperative follow-up was 106.5 days. The corrected distance visual acuity improved from a median of 1.85 logMAR to 1.68 logMAR. None of the patients had intraoperative complications. Three patients (13.6%) had dislocation of the donor tissue on the 1st postoperative day and were successfully rebubbled. Six eyes (27.3%) had graft failure and required penetrating keratoplasty. Eleven eyes (50%) had a sustained rise in the IOP, of which 2 (9.09%) had ocular hypertension and 9 eyes (40.9%) progressed to glaucoma. Conclusions: DSEK combined with retropupillary fixated iris-claw lens is a good surgical option for the management of aphakic/pseudophakic BK in patients who require secondary IOL or IOL exchange. Regular IOP monitoring after the surgery is an essential, as there is a risk of IOP rise and glaucoma in the postoperative period. Clinicians should be vigilant and control the IOP to prevent glaucoma progression.

Ocular hypertension and its predictor after a single Ozurdex implant: One-year follow-up in Asian Indian eyes.

BACKGROUND: To determine the incidence and risk factors for an increase in the intraocular pressure (IOP) after a single dexamethasone intravitreal implant (Ozurdex). MATERIALS AND METHODS: Medical records of 41 consecutive eyes who had received a single 0.7 mg Ozurdex implant for the various vitreoretinal pathology, between March 2015 and April 2016 were reviewed retrospectively. Ocular hypertension (OHT) was defined as IOP of >22 mmHg or an increase in the IOP of >6 mmHg from the baseline. Univariate regression analysis was used to measure the predictor of OHT after the implant. RESULTS: Among the 41 eyes, who received a single Ozurdex intravitreal implant, 6/41 (14.6%) of the injected eyes had OHT, with the peak of IOP at 1 month after the injection when compared with the baseline IOP. Eight eyes (19.5%) had preexisting glaucoma or OHT, and 4/8 (50%) of them developed sustained elevation of IOP after the injection. Two eyes had transient OHT, a day after the implant, which did not require any treatment. All the eyes were managed with topical antiglaucoma medications and none required surgery to control the IOP. Preexisting OHT or glaucoma was found to be a significant risk factor for OHT after the Ozurdex injection (P < 0.0001). CONCLUSION: Patients with preexisting OHT or glaucoma have an increased risk of OHT following the Ozurdex implant and hence needs to be informed of the possible risk. Follow-up at a regular interval is mandatory to monitor and recognize OHT early and treat it appropriately.

Simple and novel technique of using lampblack soot as a corneal tattoo for disfiguring corneal opacities.

The aim of this study was to report a series of corneal tattooing in three eyes of three patients with disfiguring corneal scar and no visual potential, which underwent the procedure using the lampblack prepared in the operating room (OR), and to describe the novel technique of lampblack preparation for the surgery. The depth of corneal opacity was carefully assessed and a superficial lamellar pocket was made by lamellar separation using corneal dissectors, following which the prepared lampblack soot using materials available in the OR was deposited in the pocket. At a mean follow-up of 6 months, all the eyes had a stable corneal surface with an acceptable cosmetic outcome. Corneal tattoo using lampblack gives a satisfactory cosmetic result with good patient satisfaction and improved quality of life in the eyes with disfiguring corneal scar.

Incidence and Risk Factors for Intraocular Pressure Rise after the Scleral Buckle Surgery for Retinal Detachment.

PURPOSE: To determine the incidence and risk factors for intraocular pressure (IOP) rise after the scleral buckle (SB) procedure for retinal detachment (RD). METHODS: A retrospective chart review of the medical records of patients, who underwent RD repair by SB performed by a single surgeon and had a minimum follow-up of 6 months was carried out. The outcome measures were the incidence of IOP rise in the operated eyes and the associated risk factors. RESULTS: Fifty-two eyes of 52 patients with a median postsurgical follow-up of 18 months (interquartile range: 6, 36, range: 6-60 months) were included. Seven eyes had encircling buckle, 23 eyes had encircling buckle and 1 quadrant segmental buckle, and 22 eyes had encircling buckle and 2 quadrant segmental buckle. IOP rise was seen in 15/52 eyes (28.85%), within 1 month of the SB surgery. Nine out of 15 eyes (60%) of patients <40 years of age had a rise in IOP as compared to 6/37 eyes (16.2%) of patients >40 years of age (P = 0.002). Patients <40 years had a significant increased risk of developing IOP rise, compared to those above 40 years of age (adjusted odds ratio: 7.246 with 95% confidence interval of 1.641-31.986, P = 0.009). None of the fellow eyes had a rise in IOP during the follow-up period. None of the operated eyes with raised IOP progressed to glaucoma. CONCLUSIONS: Elevated IOP is a common complication after the SB procedure, and age <40 years is associated with a greater risk of development of increase in the IOP. Hence, IOP monitoring after the SB surgery is of paramount importance to detect early rise during follow-up.

"Separate the Wheat from the Chaff" - Descemet's Stripping Endothelial Keratoplasty Graft Failure due to Accidental Implantation of Full-Thickness Precut Tissue.

We present an interesting case of failed Descemet's stripping endothelial keratoplasty (DSEK) graft, due to accidental implantation of a full-thickness precut tissue. A repeat DSEK was planned, and during the surgery along with the DSEK graft, an extra thick corneal tissue was also retrieved. Careful evaluation of both the explanted tissues revealed that the primary surgeon failed to separate a precut DSEK graft and implanted the entire full-thickness tissue. After the repeat DSEK, there was improvement in corneal edema and visual acuity.

A simplified ex vivo model to learn the correct orientation of Descemet membrane endothelial graft.

We describe a simple, endoilluminator-assisted technique, which enables an easy identification of the descemet membrane endothelial keratoplasty graft orientation, as well as provides its good visualization in the anterior chamber, during all the steps of surgery in the wet lab.

Zinsser-Engman-Cole Syndrome Presenting as Partial Limbal Stem Cell Deficiency.

PURPOSE: To report a case of partial limbal stem cell deficiency and characteristic mucocutaneous triad in an 11-year-old boy. METHODS: Systemic features along with ocular features are described in this case report. RESULTS: Ophthalmic evaluation showed bilateral partial limbal stem cell deficiency (LSCD) and systemic examination revealed characteristic mucocutaneous triad of oral leukoplakia, skin hypopigmentation, and nail dystrophy suggestive of the Zinsser-Engman-Cole syndrome or dyskeratosis congenita. CONCLUSIONS: Thorough ocular and systemic evaluation can help in clinching the diagnosis of this rare condition. Timely referral to a dermatologist and hemato-oncologist would help in the management of life-threatening complications like malignancy or progressive bone marrow failure.

Surgical Outcomes of Retropupillary-Fixated Iris-Claw Intraocular Lens.

PURPOSE: To assess the visual outcome and complications following retropupillary-fixated iris-claw intraocular lens (IOL) implantation. METHODS: For this retrospective, non-comparative study, chart review of patients who underwent retropupillary iris-claw IOL implantation for the correction of aphakia from July 2014 to October 2018 and had a minimum postoperative follow-up of 2 months was carried out. Postoperative corrected distance visual acuity (CDVA), intraocular pressure (IOP), and complications were noted. RESULTS: One hundred and twenty-two eyes of 122 patients (mean follow-up: 7.48 ± 5.2 months, range, 2 months-3.5 years) were enrolled in the study. The mean logMAR CDVA improved from 1.36 ± 0.52 preoperatively to 0.5 ± 0.42 postoperatively, at the last follow-up visit (P < 0.0001). The final CDVA improved in 110 eyes (90.2%), remained unchanged in 8 eyes (6.6%), and worsened in 4 eyes (3.3%). In cases of pre-existing cystoid macular edema (CME) or excessive intraoperative manipulations, 0.05 ml of 4 mg intravitreal triamcinolone acetonide (IVTA) was injected at the end of the surgery. Twenty eyes (16.4%) had transient ocular hypertension (OHT), 6 eyes (4.9%) had persistent OHT, and 2 eyes (1.6%) progressed to glaucoma. Choroidal detachment was noted in 2 eyes (1.6%), CME in 6 eyes (4.9%), 2 eyes (1.6%) had retinal detachment, 20 eyes (16.4%) had significant ovalization of pupil, 8 eyes (6.6%) had one haptic disenclavation, 1 eye (0.8%) had corneal decompensation, and 1 eye (0.8%) had endophthalmitis. CONCLUSIONS: Retropupillary iris-claw IOL provides good visual rehabilitation with a few complications. Its ease of insertion and short surgical time makes it a good option to correct aphakia in patients with an inadequate capsular support.

Comparison of the Surgical Outcomes of Single-Site, Mitomycin C-Augmented Trabeculectomy Combined with Phacoemulsification versus Manual Small-Incision Cataract Surgery.

PURPOSE: To compare the safety, efficacy, and outcome measures of a single-site, mitomycin C (MMC)-augmented trabeculectomy combined with phacoemulsification (PT) versus manual small-incision cataract surgery (MSICS) with the posterior chamber intraocular lens (PCIOL) implantation as a primary surgery in the patients with primary glaucoma coexistent with cataract. METHODS: From April 2015 to August 2017, medical records of all the patients who underwent combined cataract surgery with PCIOL and MMC augmented trabeculectomy were reviewed. One hundred and thirty-seven eyes met the inclusion criteria. Ninety-seven eyes which underwent PT with MMC were compared with forty eyes that underwent MSICS combined with trabeculectomy (MSICST) MMC. Outcome measures were best corrected visual acuity (BCVA), intraocular pressure (IOP), and number of anti-glaucoma medications (AGM). Complications, if any, were noted in both the groups. RESULTS: The mean follow-up period after surgery was 18.6 ± 7.7 months (range, 12-40 months). At the last follow-up visit, there was no statistically significant difference between the groups, in terms of mean logMAR BCVA (PT: 0.22 ± 0.31, MSICST: 0.21 ± 0.33, P = 0.8), mean IOP reduction (PT: 13.9 ± 2.98 mmHg, MSICST: 14.1 ± 4.12 mmHg, P = 0.8), and mean number of AGM (PT: 0.03 ± 0.8, MSICST: 0.025 ± 0.7, P = 0.8). Complications were few and transient. One eye in the PT group was considered as a failure and had to undergo needling, repeat trabeculectomy, and later, cyclodestructive procedure. None of the eyes in the MSICST group required an additional procedure for IOP reduction. CONCLUSION: There was no difference in the mean IOP reduction, BCVA, and mean number of AGM between the two procedures, and both appeared to be safe and effective techniques as a primary surgery in the patients with coexistent cataract and glaucoma.

Reversal of laser in situ keratomileusis interface fluid after Descemet stripping automated endothelial keratoplasty for pseudophakic bullous keratopathy.

To report a case of interface fluid syndrome (IFS) after laser-assisted in situ keratomileusis (LASIK) in a patient with Anterior chamber intraocular lens (ACIOL) induced corneal decompensation treated with Descemet's stripping automated endothelial keratoplasty (DSAEK). At 6 months follow-up, the cornea became clear with improvement in visual acuity and resolution of interface fluid.

Management of Nocardia Interface Keratitis After Descemet Membrane Endothelial Keratoplasty.

PURPOSE: To report the clinical course and management of graft-host interface Nocardia keratitis after Descemet membrane endothelial keratoplasty (DMEK). METHODS: A 70-year-old man presented with a corneal epithelial defect, stromal edema, graft infiltrate, and graft-host interface infection 5 months after an uneventful DMEK performed for bullous keratopathy in the left eye. Corneal scrapings from the margin of epithelial defect showed gram-positive bacillus, and the organism was identified as Nocardia asteroides. RESULTS: Intensive and appropriate topical and systemic antibiotic therapy resulted in complete resolution of infection. Three months later, the patient underwent a repeat DMEK, which resulted in clearing of corneal edema and improvement in visual acuity. CONCLUSIONS: Nocardia interface keratitis is a rare entity, which can occur after DMEK. Proper clinical evaluation and microbiological workup helped us in accurate diagnosis and management. Repeat DMEK after complete resolution of the infection resulted in good outcomes regarding corneal clarity and vision improvement.

Recurrent scleral patch graft shrinkage and Ahmed valve tube exposure.

AIM: To report a case of recurrent Ahmed glaucoma valve (AGV) tube exposure dueto scleral patch graft (SPG) melt Background: AGV is a useful modality in the management of medically refractory glaucoma. Human donor SPG has been employed to cover the external portion of the tube to prevent its exposure. CASE DESCRIPTION: A 23 year old male with Anterior chamber intraocular lens (ACIOL)had undergone retinal detachment (RD) surgery with silicone oil insertion (SOI)followed by SO removal (SOR), re- RD and SO re-injection, followed by implantation of Ahmed glaucoma valve (AGV) for uncontrolled glaucoma in the right eye. Three months after the AGV implantation, he presented with exposure of the subconjuctival portion of AGV tube with melted, displaced and shrunk donor sclera graft, which was managed by placing larger sized, full thickness, donor scleral patch graft (SPG) over the exposed tube. Six months later, he presented again with tube exposure and the donor SPG was found to be retracted nasally and shrunk to one fourth of its original size. The AC portion of the tube was blocked by the SO bubble and the emulsified SO could be seen inside the exposed tube. The patient underwent SOR with tube explanation and intraocular pressure was later controlled with transscleral cyclophotocoagulation and medical management. CONCLUSION: SPG thinning and the overlying conjunctival erosion can occur after the AGV implantation. This can cause AGV tube exposure and hence, long - term patient follow up is essential to ensure timely identification of this possible complication and prompt treatment.