OUTCOME OF EYES TREATED FOR RETINOPATHY OF PREMATURITY IN POSTERIOR ZONE I: An Eastern India Study.

PURPOSE: To analyze the outcomes of eyes treated for retinopathy of prematurity in posterior Zone I. METHODS: In a part retrospective (9 years) and part prospective (1 year) interventional study, we analyzed eyes treated for retinopathy of prematurity in posterior Zone I with a minimum follow-up for 6 months. RESULTS: This study included 109 eyes of 56 infants; mean gestational age and birth weights were 29.3 (±2.1) weeks and 1112.5 (±381.9) g, respectively. The treatment included intravitreal anti-vascular endothelial growth factor as the initial treatment modality in 101 eyes (92.6%), either alone (27 eyes) or combined with laser or vitreous surgery (73 eyes). Laser was the initial treatment modality in eight eyes, either alone (n = 3) or in combination with surgery (n = 5). With anti-vascular endothelial growth factor alone, 30.68% (n = 27) eyes responded favorably, and the remaining 69.32% (n = 59) eyes needed retreatment (laser in the majority). At the final follow-up, 89.9% (out of 109) of eyes did well anatomically. Good outcome was significantly linked to no detachment at presentation ( P < 0.0001) and the presence of well-defined central vascular trunks ( P = 0.001). CONCLUSION: Treating the eyes before retinal detachment with bevacizumab followed by laser (and surgery, if needed) results in a favorable outcome in babies with posterior Zone I retinopathy of prematurity.

Post-vitrectomy secondary macular holes: Risk factors, clinical features, and multivariate analysis of outcome predictors.

Purpose: We report clinical characteristics, risk factors, treatment outcomes, and prognostic predictors of post-vitrectomy secondary macular holes (MHs). Methods: This was a retrospective observational case series from November 2014 to December 2020. Eyes that developed secondary MH, two weeks and beyond after primary vitrectomy for non-MH indications, were enrolled. Pre- and intraoperative records were screened to exclude pre-existence of MH. Eyes with multiple vitreoretinal surgeries prior to MH detection and tractional myopic maculopathy were excluded. Results: A total of 29 eyes of 29 patients with a mean age of 52 years developed secondary MH post-vitrectomy. The most common indications for primary vitrectomy were rhegmatogenous retinal detachment (RRD, 48.2%) and tractional retinal detachment (TRD, 24.1%). Time to MH detection after primary vitrectomy was 91.5 ± 117.6 days. The mean minimum hole diameter was 530 ± 298 microns. Epi-retinal membrane and cystoid degeneration was noted in 6 (20.7%) and 12 (41.3%) eyes, respectively (p = 0.088). The mean time from MH detection to MH repair was 34 ± 42 days. The surgical intervention included internal limiting membrane peeling with tamponade in 25 eyes. Overall, 80% showed anatomic hole closure, 90.9% versus 57.1% in the RRD and TRD (p = 0.092), respectively. The mean best-corrected visual acuity (BCVA) at the final visit was 0.71 logarithm of the minimum angle of resolution. Thirteen eyes (52%) had a BCVA of 20/100 or better. Minimal hole diameter (p = 0.029) only predicted final visual acuity. The interval between MH diagnosis and repair did not affect hole closure significantly (p = 0.064). Conclusion: Secondary MH post-vitrectomy closed successfully with limited visual improvement and trails behind idiopathic MH.

Effectiveness and future implications of COVID-19-related risk stratification for managing retinopathy of prematurity: The Indian twin cities retinopathy of prematurity study report number 10.

Purpose: To evaluate the effectiveness and future implications of COVID-related risk stratification for managing retinopathy of prematurity (ROP). Methods: A prospective study was conducted at a tertiary eye care center from the beginning of the lockdown in India from 23 March 2020 till the end of the first phase of lockdown on 29 May 2020. We evaluated 200 prematurely born infants (< 34 weeks of gestational age) using the new safety guideline protocols for low-risk babies developed in conjunction with the Indian ROP Society for care during the COVID-19 pandemic. Low risk included babies born at more than 30 weeks of gestational age, post menstrual age 34 weeks or above at presentation, more than 1000 grams of birth weight, and stable systemically with good weight gain. Results: New guidelines were implemented in 106 (53%) infants who were low risk while 94 (47%) infants with high risk were followed up as per the old guidelines. Out of the 106 infants (212 eyes) managed by the new guidelines, good outcome (group 1) was seen in 102 (96.2%) infants. Twenty-seven of the 102 infants had some form of ROP and 5 of these infants needed treatment. None of the low-risk babies with no detachment at presentation managed by new guidelines required surgery later (group 2). Two (1.9%) infants came with retinal detachment at presentation and underwent successful surgery (group 3) and two infants (1.9%) were lost to follow up. Conclusion: New risk stratification during the COVID-19 pandemic was an efficient and safe strategy in managing low-risk ROP babies.

Jet stream related iatrogenic retinal breaks during vitreo-retinal surgery.

PURPOSE: To evaluate the causes of jet stream injury (JSI)-related iatrogenic retinal breaks (IRBs) during vitreoretinal surgery (VRS). METHODS: The precise surgical environment, which includes the indication and type of surgical procedure, retina status, details of instrumentation and fluidic parameters, and characteristics of the jet responsible for the IRB, was noted from case records. The nature of IRB and its healing and impact on anatomical and visual outcomes were analyzed. RESULTS: Five eyes of five patients with complete documentation of both the JSI and the IRB were included. Two cases were operated for macular hole, and one each for vitreous hemorrhage, retinal detachment, and endophthalmitis. One case had infusion-fluid-related JSI, while four developed it because of injection of surgical adjuncts (drugs, PFCL, and dye). JSI developed in two cases when the vitreous cavity was filled with fluid, while it was air-filled in three cases. In four cases, the fluid migrated into subretinal space, necessitating further maneuvers following which the breaks healed, but were directly responsible for vision loss in two cases. CONCLUSION: JSI related IRBs are rare but may be directly responsible for vision loss if they impact the macula. The balance between jet stream velocity, its distance from the retinal surface, the intervening media (vitreous cavity), and retinal health play an important role. It can occur because of both infusion as well as injection jets. Precautions must be taken in cases vulnerable to complications with suggested modifications in the surgical technique.

Compassionate and standard operating procedure-based counseling and practice are essential in high-risk infantile anesthesia and managing death in eye surgery.

Physicians have to play the role of a team leader and counselor and take written informed consent for high-risk surgeries in many cases. This is the first step toward initiating a mutually trustworthy relationship with the patient and family. The situation is more sensitive when vulnerable patients like small premature babies or the elderly are under consideration. In the event of a death, leadership and processes in place become extremely critical. We share our experience and practice pattern during this process, especially suited to India, but the broad principles would apply to most human situations. Hopefully, some of these can be incorporated into the existing training curriculum for team building and the art of effective physician-patient communication that should be intricately woven into the curriculum for the Science of Ophthalmic care.

OCT Imaging in Infants.

Optical coherence tomography (OCT) is widely applied in diagnosis and management of retina diseases particularly macular diseases in adult retina practices. However, it has been under-utilized in pediatric retinal diseases especially in neonates and infants. Utilization of OCT in primary macular diseases in this age group is also uncommon and is less reported. Challenges involved in image acquisition and limitations with available devices technique can explain the limited research and accurate data availability in the literature in this field. Purpose of this review article is to summarize the use of OCT and its importance in various infantile retinal pathologies such as vascular diseases, tumors, retinal dystrophies, and optic nerve pathologies with primary focus on neonates and infants, along with infant choroid. In addition, we also discuss about future directions including OCT angiography for infants.

Immediate Sequential Bilateral Pediatric Vitreoretinal Surgery: An International Multicenter Study.

PURPOSE: To determine the feasibility and safety of bilateral simultaneous vitreoretinal surgery in pediatric patients. DESIGN: International, multicenter, interventional, retrospective case series. PARTICIPANTS: Patients 17 years of age or younger from 24 centers worldwide who underwent immediate sequential bilateral vitreoretinal surgery (ISBVS)-defined as vitrectomy, scleral buckle, or lensectomy using the vitreous cutter-performed in both eyes sequentially during the same anesthesia session. METHODS: Clinical history, surgical details and indications, time under anesthesia, and intraoperative and postoperative ophthalmic and systemic adverse events were reviewed. MAIN OUTCOME MEASURES: Ocular and systemic adverse events. RESULTS: A total of 344 surgeries from 172 ISBVS procedures in 167 patients were included in the study. The mean age of the cohort was 1.3±2.6 years. Nonexclusive indications for ISBVS were rapidly progressive disease (74.6%), systemic morbidity placing the child at high anesthesia risk (76.0%), and residence remote from surgery location (30.2%). The most common diagnoses were retinopathy of prematurity (ROP; 72.7% [P < 0.01]; stage 3, 4.8%; stage 4A, 44.4%; stage 4B, 22.4%; stage 5, 26.4%), familial exudative vitreoretinopathy (7.0%), abusive head trauma (4.1%), persistent fetal vasculature (3.5%), congenital cataract (1.7%), posterior capsular opacification (1.7%), rhegmatogenous retinal detachment (1.7%), congenital X-linked retinoschisis (1.2%), Norrie disease (2.3%), and viral retinitis (1.2%). Mean surgical time was 143±59 minutes for both eyes. Higher ROP stage correlated with longer surgical time (P = 0.02). There were no reported intraoperative ocular complications. During the immediate postoperative period, 2 eyes from different patients demonstrated unilateral vitreous hemorrhage (0.6%). No cases of endophthalmitis, choroidal hemorrhage, or hypotony occurred. Mean total anesthesia time was 203±87 minutes. There were no cases of anesthesia-related death, malignant hyperthermia, anaphylaxis, or cardiac event. There was 1 case of reintubation (0.6%) and 1 case of prolonged oxygen desaturation (0.6%). Mean follow-up after surgery was 103 weeks, and anatomic success and globe salvage rates were 89.8% and 98.0%, respectively. CONCLUSIONS: This study found ISBVS to be a feasible and safe treatment paradigm for pediatric patients with bilateral vitreoretinal pathologic features when repeated general anesthesia is undesirable or impractical.

Safety, sterility and stability of direct-from-vial multiple dosing intravitreal injection of bevacizumab.

BACKGROUND: This study aims to determine the stability, sterility and safety of bevacizumab multiple dosing from a single vial without prior aliquoting. METHODS: In-vitro and human study. Six bevacizumab vials, used in multiple patients on a single day by direct withdrawal from the vial, and stored in 4°C up to a variable period, were tested for stability (high-performance liquid chromatography; [HPLC]), sterility (culture), conformational stability by circular dichroism and fluorescence spectroscopy and the rubber cork structural integrity (electron microscopy [EM]). RESULTS: HPLC of all six samples of used bevacizumab and the control bevacizumab sample were similar; culture was negative; and the EM of rubber corks did not show an open communication. Spectroscopic studies indicated drug conformational stability. Further, there was no infection or inflammation in 221 consecutive patients (973 injections) when bevacizumab was stored at 4°C and used for one week. CONCLUSION: Bevacizumab does not lose stability when stored at 4°C. It may be used for a week by direct withdrawal from the vial without fear of infection or inflammation if all standard precautions related to intravitreal injection are adhered to.

Endophthalmitis patients seen in a tertiary eye care centre in Odisha: a clinico-microbiological analysis.

BACKGROUND & OBJECTIVES: Geographical variations are known to influence different aspects of endophthalmitis. We report the epidemiological, clinical and microbiological profile of patients with infectious endophthalmitis presented to a tertiary eye care centre in Odisha, India, and compare the results with published reports from other parts of India. METHODS: Retrospective review of medical records of 107 patients, seen between December 2006 and January 2009 was done. All patients had undergone parsplana vitrectomy with intraocular antibiotics and the management was based on microbiological analysis of the vitreous fluid. RESULTS: Forty six (43.0%) patients had post-operative (PO), 43 had post-traumatic (PT) and 18 (16.8%) had endogenous (EG) endophthalmitis. Males were predominant in all three types of endophthalmitis. Significantly younger individuals constituted PT group. While culture established microbial diagnosis in 45 patients (42%), direct microscopy was positive in 38 patients (35.5%). Fungal aetiology was found in 13 patients (PO-7, PT-4, EG-2) and bacteria accounted for 32. Similar to studies from north, central and south India, fungi and Gram-negative bacteria accounted for a large number of PO endophthalmitis cases. Two PT patients had polymicrobial infection. All Gram-positive bacteria were susceptible to vancomycin. Susceptibility to ceftazidime was variable among the Gram-negative bacteria. Best corrected visual acuity (BCVA) at presentation was less than 20/200 in majority (93%) of the patients. While the treatment outcome was variable in fungal and sterile endophthalmitis, the BCVA was either unchanged or improved in 100 per cent of bacterial endophthalmitis patients. INTERPRETATION & CONCLUSIONS: The spectrum of infection and outcome of infectious endophthalmitis in Odisha was similar to other parts of the country. Fungi and bacteria were involved in all three types of endophthalmitis. Empirical use of standard intravitreal therapy is recommended while emphasizing on vitreous biopsy for culture and sensitivity whenever possible.

Optical coherence tomography findings and retinal changes after vitrectomy for optic disc pit maculopathy.

PURPOSE: To study the optical coherence tomography (OCT) patterns in optic disc pit maculopathy and retinal changes after vitreous surgery. MATERIALS AND METHODS: Retrospective review of consecutive cases with optic disc pit maculopathy seen at two tertiary eye institutes from January 2005 to June 2009. RESULTS: Twenty-four eyes of 23 patients are included. The presenting visual acuity ranged from 20/400 to 20/20 (median:20/80). The median age at presentation was 24 years (range, 6-57 years). Optical coherence tomography demonstrated a combination of retinoschisis and outer layer detachment (OLD) in 19 (79.17%) eyes, OLD only in 3 (12.5%) eyes and retinoschisis only in 2 (8.33%) eyes. An obvious communication (outer layer hole) between the schisis and OLD was seen in 14 (73.68%) of the 19 eyes with both features. Of the 21 eyes with retinoschisis, schisis was present in multiple layers in 15 (71.43%) and single layer in 6 (28.57%) eyes. Eleven eyes underwent pars plana vitrectomy including creation of posterior vitreous detachment (PVD), fluid-air exchange, low intensity laser photocoagulation at the temporal edge of the optic disc pit and non-expansile perfluoropropane gas (14%) injection. Five (45.45%) of 11 eyes undergoing vitrectomy had complete resolution and 4 (36.36%) eyes had partial resolution of maculopathy. Visual acuity improved in 8 (72.72%) of 11 eyes. CONCLUSION: Optical coherence tomography demonstrates multiple layer schisis and outer layer detachment as main features of optic disc pit maculopathy. Vitrectomy with PVD induction, laser photocoagulation and gas tamponade results in anatomical and visual improvement in most cases with optic disc pit maculopathy.

Acute idiopathic frosted branch angiitis in an 11-month-old infant treated with intravitreal triamcinolone acetonide.

An 11-month-old boy presented with bilateral vision loss following upper respiratory tract infection. Extensive perivascular sheathing resembling frosted branch angiitis and severe macular edema was noted in both eyes. All tests for etiological diagnosis were negative. Treatment with systemic corticosteroids and antibiotics caused resolution of perivascular infiltrates. Macular edema resolved with improvement in visual acuity following consecutive bilateral intravitreal triamcinolone acetonide injections. To our knowledge, this is the youngest reported case of frosted branch angiitis.

Clinicomicrobiological characteristics and treatment outcome of sclerocorneal tunnel infection.

PURPOSE: To analyze the clinical presentation, microbiological evaluation, and management of post-cataract surgery sclerocorneal tunnel infection. METHODS: This is a retrospective chart review of 11 patients with sclerocorneal tunnel infection after cataract surgery, managed between November 2006 and October 2009. The clinical characteristics and treatment outcomes were analyzed. RESULTS: All patients presented within 1 to 10 weeks of primary surgery. The presenting visual acuity ranged from hand motions to 20/50. Ten of 11 patients had sclerocorneal involvement, and 4 patients had associated endophthalmitis. The causative organisms were fungus (n = 6), bacteria (n = 4), or both (n = 1). Deroofing of the tunnel and sclerocorneal patch graft was done in 4 patients. Intensive medication was administered to all patients. The final visual acuity ranged from light perception to 20/50 at a mean follow-up of 119 days (median, 66 days; range, 2-357 days). Five patients had ≥20/100 vision. The mean interval between presentation to resolution of infiltrate and formation of peripheral scarring was 20 days (median, 11 days; range, 2-66 days). CONCLUSIONS: Sclerocorneal tunnel infection must be microbiologically evaluated. Intensive medical management, wound revision and repair may lead to a favorable outcome.