Efficacy of an Automated Algorithm for Screening Diabetic Retinopathy in Gradable and Ungradable Images in Real-Time Conditions.

Background: To examine the effectiveness of a computer-assisted device (CAD) for diabetic retinopathy (DR) screening from retinal photographs at a vitreoretinal outpatient department (VR OPD), telecamps, and diabetes outpatient clinic by an ophthalmologist. In particular, the effectiveness of CAD in gradable and ungradable retinal images was examined. Methods: A total of 848 eyes of 485 patients underwent 45° retinal photographs at the VR OPD of a tertiary care hospital in southern India. A total of 939 eyes of 472 patients with diabetes were examined in the telecamps conducted in remote villages in Tamil Nadu, a state in southern India. A total of 2,526 eyes of 1,263 patients were examined in a diabetes clinic using 45° field retinal photographs. The algorithm was validated under physiological dilatation (without pharmacological dilatation) in all three arms. Results: Seventy-one percent of 848 eyes in VR OPD, 13% of 939 eyes in telecamps, and 7% of 2,526 eyes in diabetes clinic were diagnosed to have DR. The algorithm showed 78.3% sensitivity and 55.1% specificity for all images and 78.9% sensitivity and 56.8% specificity for gradable images in the VR OPD; 80.1% sensitivity and 79.2% specificity for all images and 84.8% sensitivity and 80.0% sensitivity for gradable images in telecamps; 63.0% sensitivity and 79.6% specificity for all images and 63.2% sensitivity and 78.1% specificity for gradable images in the diabetes clinic. The algorithm had an overall accuracy of 76.4%. The ungradable rate was variable. Conclusion: The algorithm performs equally well in identifying DR from gradable and ungradable photographs and may be used for DR screening in a rural setting with limited or no access to eye care.

The impact of the first peak of the COVID-19 pandemic on childhood myopia control practice patterns among ophthalmologists-an international pediatric ophthalmology and strabismus council global perspective.

BACKGROUND: The prevalence of myopia keeps increasing during the COVID-19 pandemic. We aimed to map the worldwide treatment preferences of ophthalmologists managing myopia control during the first wave of the pandemic. METHODS: An online questionnaire inquiring about pharmacological and optical treatment patterns during the first half of 2020 was sent to pediatric ophthalmology as well as general ophthalmology memberships worldwide. The results among pediatric ophthalmologists were compared to a previous study we performed before the pandemic. RESULTS: A total of 2269 respondents from 94 countries were included. Most respondents were pediatric ophthalmologists (64.6%), followed by ophthalmologists from other subspecialties (32.3%). The preferred modality for all geographical regions was a combination therapy of pharmacological and optical treatments. When evaluated independently, the pharmacological treatment was more popular than the optical treatment in most regions other than East Asia (P < 0.001). Compared to a pre-pandemic questionnaire, the participation of pediatric ophthalmologists affiliated with non-university hospitals increased. Additionally, the prevalence of respondents utilizing either any type of pharmacological treatment and those that using only evidence-based treatments increased globally. Although a decline in the use of optical treatment was evident worldwide, the use of evidence-based optical treatments increased. CONCLUSION: Ophthalmologists around the world preferred a combination therapy of pharmacological and optical treatments. More pediatric ophthalmologists treated myopia progression and preferred a better evidence-based approach to control myopia. These trends reflect a positive response and more awareness of the rising prevalence of myopia due to the increased burden of myopia imposed by the COVID-19 pandemic.

A series of 777 pellet gun ocular injuries over a 4-month period in Kashmir.

Purpose: To examine the incidence, clinical findings and management of pellet gun-related ocular injuries that occurred during protests in Kashmir region. Methods: This retrospective study included records from 777 patients diagnosed with pellet gun-related ocular injuries admitted to a tertiary hospital in Srinagar, India, between July and November 2016. By reviewing the clinical records, the following data were collected: demographics, clinical information pertaining to the injury, imaging reports including computer tomography and ultrasonography B-scan, management in the emergency setting, and follow-up treatment. Results: Mean age was 22.3 ± 7.2 years and majority patients were male (97.7%). In terms of laterality, 94.3% and 5.7% of the patients sustained monocular and binocular injuries, respectively. In terms of the nature of injury, 76.3% of the eyes had open globe injury while 23.7% of the eyes had closed eye injury. Emergency surgical exploration was performed in 67.7% of closed globe injuries while emergency primary repair was done in 91.1% of open globe injuries. The vast majority of patients (98.7%) who required surgery underwent surgical intervention on the day of admission or the next day. Final best-corrected visual acuity (BCVA) after treatment was counting fingers or worse in 82.4% of the eyes. Conclusion: Pellet gun-related ocular injuries resulted in significant ocular morbidity, mostly manifesting as open globe injuries. Treatment often required surgical interventions, but despite expeditious management, visual prognosis remained poor for most of the patients.

Embracing technology in cataract surgical training - The way forward.

While ophthalmology as a surgical branch itself has evolved technologically with newer instruments, techniques and procedures; ophthalmic surgical training appears to have stagnated in terms of how it is delivered and how trainees' learning and performance are assessed. This collaborative editorial attempts to identify the lacunae in ophthalmic residency training and highlight how technological tools such as surgical simulators can be incorporated into ophthalmic training even in limited-resource settings with good results.

Globe and Adnexal Trauma Terminology Survey.

Importance: Ocular trauma terminology should be periodically updated to enable comprehensive capturing and monitoring of ocular trauma in clinical and research settings. Objective: To update terminology for globe and adnexal trauma. Design, Setting, and Participants: A 2-round modified Delphi survey was conducted from January 1 to July 31, 2021, using an expert panel, including 69 ophthalmologists identified through their membership in ophthalmology (globe and adnexal trauma) societies. Consensus was defined as at least 67% expert agreement. A steering committee developed questions after identifying gaps in the current terminology via a targeted literature review. Round 1 sought consensus on existing and newly proposed terminology, and round 2 focused on unresolved questions from round 1. Experts included ophthalmologists who had managed, on average, 52 globe or adnexal trauma cases throughout their careers and/or published a total of 5 or more globe or adnexal trauma-related peer-reviewed articles. Main Outcomes and Measures: Expert consensus on ocular and adnexal terms. Results: A total of 69 experts participated in and completed round 1 of the survey. All 69 participants who completed round 1 were asked to complete round 2, and 58 responses were received. Consensus was reached for 18 of 25 questions (72%) in round 1 and 4 of 7 questions (57%) in round 2. Existing Birmingham Eye Trauma Terminology system terminology achieved consensus of 84% (58 of 69 experts) in round 1 and 97% (56 of 58 experts) in round 2. Experts agreed on the need for further refinement of the definition of zones of injury (55 of 69 [80%]), as the zone affected can have a substantial effect on visual and functional outcomes. There was consensus that the mechanism of injury (52 of 69 [75%]) and status of the lacrimal canaliculi (54 of 69 [78%]), nasolacrimal ducts (48 of 69 [69%]), lens (46 of 58 [80%]), retina (42 of 58 [73%]), and central and paracentral cornea (47 of 58 [81%]) be included in the revised terminology. Conclusions and Relevance: There was consensus (defined as at least 67% expert agreement) on continued use of the existing Birmingham Eye Trauma Terminology system definitions and that additional terms are required to update the current ocular trauma terminology.

Diabetic macular edema treatment guidelines in India: All India Ophthalmological Society Diabetic Retinopathy Task Force and Vitreoretinal Society of India consensus statement.

Diabetic macular edema (DME) is a common cause of moderate visual impairment among people with diabetes. Due to the rising number of people with diabetes in India, the absolute numbers of people with DME are significant. There are several treatment options for DME, and the choice of treatment is based on the availability of retinal specialists and infrastructure for the delivery of treatment. A major challenge is the out-of-pocket expenditure incurred by patients as most treatment options are costly. Treatment also varies based on the associated ocular and systemic conditions. The All India Ophthalmology Society (AIOS) and the Vitreo-Retinal Society of India (VRSI) have developed this consensus statement of the AIOS DR task force and VRSI on practice points of DME management in India. The objective is to describe the preferred practice patterns for the management of DME considering the different presentations of DME in different clinical scenarios.

Use of offline artificial intelligence in a smartphone-based fundus camera for community screening of diabetic retinopathy.

PURPOSE: The aim of the study was to analyse the reliability of an offline artificial intelligence (AI) algorithm for community screening of diabetic retinopathy. METHODS: A total of 1378 patients with diabetes visiting public dispensaries under the administration of the Municipal Corporation of Greater Mumbai between August 2018 and September 2019 were enrolled for the study. Fundus images were captured by non-specialist operators using a smartphone-based camera covering the posterior pole, including the disc and macula, and the nasal and temporal fields. The offline AI algorithm on the smartphone marked the images as referable diabetic retinopathy (RDR) or non-RDR, which were then compared against the grading by two vitreoretinal surgeons to derive upon the sensitivity and specificity of the algorithm. RESULTS: Out of 1378 patients, gradable fundus images were obtained and analysed for 1294 patients. The sensitivity and specificity of diagnosing RDR were 100% (95% CI: 94.72-100.00%) and 89.55% (95% CI: 87.76-91.16%), respectively; the same values for any diabetic retinopathy (DR) were 89.13% (95% CI: 82.71-93.79%) and 94.43% (95% CI: 91.89-94.74%), respectively, with no false-negative results. CONCLUSION: The robustness of the offline AI algorithm was established in this study making it a reliable tool for community-based DR screening.

New Classification for the Reporting of Complications in Retinal Detachment Surgical Trials.

IMPORTANCE: Quantifying severity of complications in rhegmatogenous retinal detachment (RRD) surgical trials is needed. A consensus classification system will help surgeons to more effectively compare harms of different surgical techniques. OBJECTIVE: To develop a new consensus-based classification to quantify severity of complications of RRD surgery. DESIGN, SETTING, AND PARTICIPANTS: A comprehensive list of complications was developed followed by a Delphi consensus survey of international vitreoretinal surgeons. The survey was conducted in 17 countries in mainland Europe, the United Kingdom, the United States, Asia, South Africa, and Australia. Seventy vitreoretinal surgeons were invited to take part in the Delphi survey; 45 agreed to participate. Participants were selected through boards/members lists of retinal societies. Data were analyzed between April 2019 and August 2019. MAIN OUTCOMES AND MEASURES: Consensus-derived classification of complications of RRD surgery, according to their severity. RESULTS: Forty-three of 45 vitreoretinal surgeons who agreed to participate in the Delphi survey completed round 1 (96%); all but 1 (98%) completed round 2. Consensus was reached for 96% of the 84 complications assessed. Examples of complications classified as least severe (graded 1) included subconjunctival hemorrhage and chemosis while those classified as most severe included endophthalmitis and sympathetic ophthalmia (graded 9) and phthisis (graded 10). CONCLUSIONS AND RELEVANCE: We propose a new classification for quantifying severity of surgical complications based on an international consensus of vitreoretinal surgeons to quantify harm and improve the reporting of complications of RRD surgery.

Reporting of Complications in Retinal Detachment Surgical Trials: A Systematic Review Using the CONSORT Extension for Harms.

IMPORTANCE: Knowledge on the frequency and severity of complications in surgical trials for rhegmatogenous retinal detachment (RRD) is essential to determine whether surgical procedures are developed and compared adequately, taking into account not only efficacy but also harms. OBJECTIVE: To review standards of reporting of complications in recent randomized clinical trials of RRD surgery. EVIDENCE REVIEW: This systematic review included randomized clinical trials on RRD surgery published between January 2008 and January 2021 in Embase, MEDLINE, and Web of Science Core Collection databases. Titles, abstracts, and full-text articles retrieved were reviewed for eligibility by 2 independent authors. Eligible studies were evaluated against checklist items from the Consolidated Standards of Reporting Trials Extension for Harms criteria by 2 independent authors, and discrepancies were resolved by discussion with a third author. FINDINGS: Fifty studies were included. The median number of checklist items fulfilled was 8 (range, 0-15), of a possible total of 18. Frequently reported items were discussions balanced with regard to efficacy and adverse events (42 studies [84%]) and inclusions of harm-associated timing of data collection (41 studies [82%]). The least frequently reported items were distinctions between expected and unexpected adverse events (1 study [2%]) and mentions of the use of a validated instrument to report adverse event severity (4 studies [8%]). Frequency of complications was commonly reported (29 studies [58%]) in contrast with complication severity (10 studies [20%]). CONCLUSIONS AND RELEVANCE: This review suggests that severity of complications of RRD surgery has been infrequently quantified and reported in randomized clinical trials and potentially represents an important area of improvement in future RRD surgical trials.

Ophthalmology residency trainers' perspective on standardization of residency training in India.

Purpose: The aim of this study was to study the perception of residency trainers about an optimum residency program. Methods: A survey, using a pre-validated questionnaire, was conducted by the Academic and Research Committee of the All India Ophthalmological Society, in 2019-20 with questions directed to teachers in medical colleges and national board of examination's ophthalmology residency programs on demography, teaching experience, imparting clinical and surgical skills, ideal academic schedule and dissertation in the post-graduate residency program. Results: The response rate in the survey was 47.6%. Valid responses were obtained from 309 residency trainers. Of these, 132 of 309 (42.7%) were females. The mean age was 45.3 ± 9.5 years, range 26-68 years. The trainers believed that on a scale of 0-10, clinical skills teaching should be taught, mean ± SD: slit lamp 9.8 ± 0.7; indirect ophthalmoscopy 9.3 ± 1.3; gonioscopy 9.2 ± 1.5; perimetry 8.9 ± 1.5; OCT 8.4 ± 1.9; applanation tonometry 9.5 ± 1.2 and orthoptic evaluation 8.1 (±1.9). A resident should ideally perform independently surgeries (median, inter-quartile range IQR): SICS 50 (IQR 40-100); phaco 50 (20-60); pterygium excision 20 (10-40); DCR 10 (5-20); chalazion 20 (10-50), trabeculectomy 7 (5-15); strabismus 5 (2-10), LASIK and retinal detachment 0. Ideally there should be four lectures, four seminars, four case presentations, five journal clubs and four wet labs every month. Conclusion: Teachers expected their wards to become competent professionals. There was near unanimity about the content of clinical skills training, non-medical skills and academics, but there was a significant variation on extent of surgical training that should be imparted to the residents.

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.

Central retinal vein occlusion with COVID-19 infection as the presumptive etiology.

Thromboembolic phenomenon related to Coronavirus disease 2019 (COVID-19) has been well documented in literature; however, reported ocular manifestations of COVID-19 are limited to vision sparing ocular conditions like conjunctivitis. We report a case of a 17-year-old female who presented to us with central retinal vein occlusion with proven recent past COVID-19 infection as presumed etiology which was not known to her at the time of presentation.

Topical timolol for the treatment of conjunctival pyogenic granulomas: Outcomes and effect on intraocular pressure.

PURPOSE: To report the clinical outcomes of 0.5% timolol maleate eye drops for the treatment of conjunctival pyogenic granuloma (PG) and its effect on intraocular pressure (IOP). METHODS: In this retrospective study, consecutive patients with conjunctival pyogenic granuloma between January 2019 and September 2019 were prescribed 0.5% timolol maleate eye drops twice a day and followed up for 8 weeks. IOPs were measured before treatment, while on treatment and 6 weeks after treatment. RESULTS: A total of 12 patients with conjunctival PGs were treated with 0.5% timolol maleate eye drops. Patients ranged from 7 to 72 years with a mean age of 31.1 years. Eleven (11/12; 91.6%) patients had complete resolution of pyogenic granulomas after a mean duration of treatment of 4.4 weeks (range: 3-6 weeks). One patient had a persistent PG, which showed sub-optimal resolution at 6 weeks of treatment and was surgically excised. The mean IOP of the affected eye at presentation was 15.1 mm Hg (range: 10 to 20 mm Hg; SD: ±2.9 mm Hg). One week after initiating therapy, the mean IOP was 12.1 mm Hg (range: 8-16 mm Hg; SD: ±2.4 mm Hg). The mean reduction IOP compared to the baseline IOP was statistically significant (p = 0.02). No adverse events were noted in any of the patients. CONCLUSION: Topical timolol is effective in the treatment of conjunctival pyogenic granulomas with no major side effects. There is a significant reduction in IOP while on treatment which is reversible and returns to baseline following completion of therapy.

An International Comparison of Baseline Characteristics of Patients Undergoing Initiation of Anti-VEGF Therapy for DME.

BACKGROUND AND OBJECTIVE: Diabetic macular edema (DME) is a leading cause of vision loss worldwide. The object of this study is to compare global differences of baseline characteristics of patients undergoing initiation of anti-vascular endothelial growth factor (VEGF) therapy for DME. PATIENTS AND METHODS: This multicenter, cross-sectional study included diabetic patients with foveal-involving retinal edema secondary to DME as documented by fundus exam and optical coherence tomography who were undergoing initiation of intravitreal anti-VEGF drugs. Variables were collected to find possible risk factors and to create an epidemiological profile of DME patients undergoing initiation of anti-VEGF agents. RESULTS: Nine hundred two patients were selected. Mean age was 62.4 (±11) years, 49.7% were Caucasians, 57.6% were male, and 96% had type two diabetes with an average disease duration of 181.7 months ± 113 months. Of the patients included, 74.7% suffered from hypertension, 26.6% from cardiovascular disease, 12.1% from cerebrovascular disease, 12.8% from peripheral vascular disease, and 12.8% from renal insufficiency. Best-corrected visual acuity (BCVA) was 65 (±20) Early Treatment Diabetic Retinopathy Study letters, central subfield thickness was 364 (±162) µm, cube volume 11.1 ± 3.1 mm3, cube average thickness 328.8 µm ± 61 µm, and 63.9% had nonproliferative diabetic retinopathy. Comparison between U.S. versus international patients, and patients with BCVA 70 letters or less versus more than 70 letters were performed, significant differences were acknowledged, and risk factors were recognized. CONCLUSION: There were key differences in the epidemiologic profile between patients presenting with DME in the U.S. and internationally. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:e300-e310.].

Ophthalmology residency training in India: Comparing feedback about how the training equips ophthalmologists to combat retinal diseases. READS report #6.

Purpose: To document whether the residency training in management of retinal diseases has improved in 2000s to meet the increasing demand of retina care in India. Methods: A survey, using a prevalidated questionnaire, was conducted by Academic and Research Committee (ARC) of the All India Ophthalmological Society (AIOS) in 2014-2016 among ophthalmologists to document teaching of retina-related clinical and surgical skills in the postgraduate residency program. Results: The 144-item questionnaire was mailed to 4512 practicing ophthalmologists with residency training in two different periods, between 1967 and 2000 (group 1; 20th-century trained) and between 2003 and 2012 (group 2; 21st-century trained). Response was received from 320 (19.1%) of group 1 ophthalmologists and 531 (18.7%) of group 2 ophthalmologists. The average age was 49.2 ± 8.7 and 32.6 ± 4 years, respectively. Group 2 residents had received superior training in indirect ophthalmoscopy, slit lamp biomicroscopy using + 78 and + 90D lens, optical coherence tomography, fundus photography, and fluorescein angiography (all P < 0.001), but there was large variation between the training institutions. The residents were not taught vitreous and retinal detachment surgeries in either period of training. Conclusion: Teaching of retina-related clinical skills have improved in Indian residency program, but there are variations across programs. This information might help redesign the ophthalmology residency programs to meet the demands of comprehensive eye care and universal health coverage of increasing retinal diseases in India.

Case report on two diabetic donor eyes with no retinopathy: Clinicopathological and molecular studies.

We were intrigued to analyze donor eyes of two individuals without retinopathy even after 40 years of type 2 diabetes mellitus. Targeted molecular factors associated with angiogenesis and the key antioxidant enzymes in retinal tissue were analyzed. Accordingly PEDF, Adiponectin and Paraoxonase 2 showed augmented mRNA expression in both the retina with no significant change in VEGF expression. Vitreous showed increased PEDF protein in donor 1 and Adiponectin in donor 2 with no change in VEGF protein. This study highlights the profile of specific molecular factors that contribute to the non-development of diabetic retinopathy changes in these individuals.