Incidence of post vitrectomy endophthalmitis in India - A multicentric study by VRSI study Group.

INTRODUCTION: The incidence of post vitrectomy endophthalmitis (PVE) is reported to be between 0.02 and 0.84%. Resterilization of single use instruments is a common practice amidst developing countries to make it more affordable to the patients by reducing the cost of the surgery and also reduce the environmental hazard. The aim of our study is to evaluate the incidence of PVE amidst existing sterilization practices of reused instruments in multiple vitreoretinal centres in India. METHODOLOGY: Centres with an endophthalmitis tracking system were invited to participate in a survey. Twenty-five centres were sent a questionnaire via email. The questionnaire included details about the institution, number of vitrectomies performed in a year, sterilization practices followed pre-operatively, intraoperatively and postoperatively, incidence of endophthalmitis and instrument reuse policies. RESULTS: A total of 29 cases of endophthalmitis were reported out of the 47,612 vitrectomies performed across various centres. The mean incidence of endophthalmitis was 0.06%. There was no difference in the rates of endophthalmitis based on various pre-operative, intraoperative or postoperative prophylactic measures. Nearly 80% of the centres change most of the instruments after every case, while the rest reused. The mean number of times a cutter was being reused until discarded was 4.7. Nearly 76% followed a performance-based protocol, and the remaining 24% had a fixed protocol for the number of times an instrument can be reused before discarding it. CONCLUSION: PVE rates are not significantly different in India despite the multiuse of single use instruments. The purpose of this paper is not to suggest an alternate protocol but to creating one in the future with these results in mind, to rationalise the use of single use instruments, make VR surgery more affordable and also have a positive impact on the carbon footprint of consumables in surgery.

Sub-optimal gain in vision in retinal vein occlusion due to under-treatment in the real world: results from an open-label prospective study of Intravitreal Ranibizumab.

BACKGROUND: Macular edema secondary to retinal vein occlusion (RVO) is an important cause of loss of vision. Intravitreal injections (IVI) of anti-vascular endothelial growth factor (VEGF) are the standard of care in this disease, as shown in numerous randomized controlled trials. The purpose of this study was to study the efficacy and safety of ranibizumab, an anti-VEGF agent, in the real-world setting. METHODS: This was 48 weeks, open-label, prospective, multicentre, observational study. Patients diagnosed with ME secondary to RVO were treated with IVI of Ranibizumab 0.5 mg in real-world conditions. Efficacy was measured by improvement seen in best-corrected visual acuity (BCVA) in terms of Early Treatment of Diabetic Retinopathy Study (ETDRS) Letter Scores and change in central retinal thickness (CRT) measured by optical coherence tomography. RESULTS: One hundred eyes of 100 patients (79 with branch retinal vein occlusion and 21 with central retinal vein occlusion) were recruited in the study. The mean (standard deviation, SD) BCVA was 52.8 (21.99) letters at baseline and 62.3 (24.40) letters at week 48. From baseline, there was a significant improvement in BCVA by 7.7 letters (p = 0.001) at 48 weeks. The mean (SD) of CRT was 479.9 (216.25) µm at baseline and it decreased significantly to 284.9 (171.35) µm at week 48 (p < 0.001). During the study period, the average number of intravitreal injections was 3.5 per patient. There was no report of endophthalmitis in any eye. CONCLUSIONS: Ranibizumab is well tolerated and effective in treating macular edema secondary to RVO in real-world clinical settings. However, there is under-treatment compared to controlled clinical trials, and the gain in vision is sub-optimal with under-treatment. TRIAL REGISTRATION: Clinical Trials Registry - India: CTRI/2015/07/005985 .

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.

Clinical features and treatment outcomes of vasoproliferative tumors in Indian participants.

PURPOSE: The aim of the study was to describe the clinical features and treatment outcomes of vasoproliferative tumors (VPT) in Indian participants. METHODS: This study design was a retrospective case series in a tertiary eye care center. Case records of patients diagnosed with VPT from 2011 to 2015 were reviewed, and their demographic details, clinical presentation, and treatment outcomes were documented. Baseline and follow-up visual acuity and tumor dimensions were statistically compared by applying paired t-test. Statistical analysis used SPSS version 14. RESULTS: Twenty-two tumors from 19 eyes of 17 patients were included. Mean age at presentation was 43.5 years (range: 15-68 years). Mean presenting best-corrected visual acuity (BCVA) was + 1.10 logMAR. Sixty-eight percent eyes had secondary tumors. Most common association of secondary VPT was Coats disease followed by retinal vasculitis, polypoidal choroidal vasculopathy, familial exudative vitreoretinopathy, and traumatic chorioretinopathy. Ten tumors (45%) involved the inferior quadrant. Tumor-associated features were intra/subretinal exudates, vitritis, subretinal fluid, vitreous hemorrhage, preretinal fibrosis, epiretinal membrane, and subretinal blood. Treatment included cryotherapy, intravitreal or oral steroids, laser photocoagulation, cryotherapy with encirclage, cryotherapy with anti-vascular endothelial growth factor, and observation. Complications included tumor recurrence, retinal detachment, raised intraocular pressure, neovascularization of iris, and cataract. Ninety-five percent VPT regressed at mean 21 months (Median: 17 months; Range: 3-64 months). Mean final BCVA was + 1.21 logMAR. CONCLUSION: VPTs are commonly unilateral, unifocal, and located anterior to equator in inferior fundus. Secondary tumors are more common than primary tumors. Treatment achieves tumor regression in majority of cases.

Choroidal neovascular membrane in a treated choroidal hemangioma.

Association of choroidal neovascular (CNV) membrane with circumscribed choroidal hemangioma is rare, and the CNV development after photodynamic therapy (PDT) is also rare. Etiopathogenesis of these associations is poorly understood. We noted the development of CNV over choroidal hemangioma after PDT therapy in a young female patient in our hospital. Temporal association of CNV development after PDT treatment points toward the possible side effects of PDT. Repeat injections of antivascular endothelial growth factor (ranibizumab) regressed the CNV resulting in a favorable visual outcome.

Sympathetic ophthalmitis following vitreoretinal surgery: Does antecedent trauma make a difference?

BACKGROUND: Sympathetic ophthalmitis (SO) has been reported following vitrectomy; however, there is a lack of data on the role of antecedent penetrating ocular trauma impacting the disease manifestation in eyes developing SO following vitrectomy. AIM: To report differences in the presentation and outcomes of SO in eyes with or without a history of antecedent penetrating trauma; SO being diagnosed after vitreoretinal (VR) surgery. DESIGN: Comparative case series. METHODS: Seventeen consecutive patients presenting with SO following VR surgery, diagnosed between 1995 and 2011 were included. Eyes with and without prior penetrating injury were included in Group I (n = 7) and Group II (n = 10), respectively. All Group I patients had received systemic steroids prior to presentation. Demographic and clinical parameters were evaluated. RESULTS: Differences were observed between Group I and Group II mainly with regards to time interval between VR surgery and diagnosis of SO (1.5 months vs. 8 months, P = 0.10), presence of neurosensory detachments (100% vs. 30%, P = 0.01), and the inciting eye vision at presentation (nil light perception in 28.5% vs. 80%, P = 0.049). Other differences observed though not statistically significant were optic disc and retinal vessel involvement (42% vs. 70%, P = 0.28), Dalen-Fuchs nodules (localized vs. diffuse) and leaks on fundus fluorescein angiography (pin-head vs. pin-point leak). CONCLUSION: SO in patients with antecedent penetrating ocular trauma present early with the central serous chorioretinopathy-like picture. Prior use of systemic steroids might have a bearing on the differences in presentation and the visual acuities between the two groups.

Retinoblastoma presenting with orbital cellulitis.

PURPOSE: To study the effectiveness of pre-enucleation steroids in reducing inflammation in patients with retinoblastoma presenting as orbital cellulitis. METHODS: Medical records of consecutive retinoblastoma patients presenting at a single tertiary eye care center during a period of 3 years were retrospectively reviewed. For those who presented with orbital cellulitis, clinical, radiological, and histopathological variables were assessed. The effect of pre-enucleation steroids was noted in this group of patients. RESULTS: Of 260 retinoblastoma cases reviewed, 14 had retinoblastoma-associated cellulitis (5.39%). Of these 14 patients, 4 received neoadjuvant chemotherapy and were excluded from the series. Of the remaining 10 cases (mean age at presentation, 14.2 months; mean follow-up, 16.4 months), 9 presented with orbital cellulitis and were included in the study. Radiological imaging depicted intraocular tumors occupying 80% to 100% of the globe in each case. All patients underwent enucleation. Five children received pre-enucleation systemic steroids (mean, 5.4 days), which resulted in a prompt decrease in inflammation. Postenucleation chemotherapy was administered in 4 (6 cycles) and external beam radiation therapy in 1 patient with high-risk histopathological characteristics. CONCLUSIONS: Advanced necrotic retinoblastoma with anterior segment involvement may present as orbital cellulitis. Pre-enucleation systemic steroids can aid in the surgical management of these tumors.

Intravitreal anti-vascular endothelial growth factor agents as an adjunct in the management of Coats' disease in children.

We describe the role of intravitreal anti-vascular endothelial growth factor (VEGF) agents in Coats' disease in children. In a prospective, interventional, non-randomized case series, three patients (three eyes) aged 16, seven and two years were diagnosed to have Coats' disease. In Case 1 (16 yr/ male) with macular edema, previous laser photocoagulation being unsuccessful, intravitreal pegaptanib sodium (Macugen) was tried. Case 2 (seven yr/ male) and Case 3 (two yr/ female) were diagnosed to have Stage 4 Coats' and underwent external needle drainage, laser photocoagulation, SF6 gas injection and intravitreal injection of bevacizumab (Avastin). Reduction of exudation and attached posterior pole (Cases 2 and 3) was seen at a follow-up of six months and two months respectively. Intravitreal anti-VEGF agents may be successfully used as adjunct treatment in select cases of Coats' disease in childhood.