Successful anatomical closure of a photographically documented 30-year-old idiopathic full-thickness macular hole following surgery for concurrent repair of an acute macula-on rhematogenous retinal detachment.

A 62-year-old man with a 30-year-old photographically documented idiopathic full-thickness macular hole and visual acuity of 6/45 developed an acute macula-on rhegmatogenous retinal detachment in his left eye. A pars plana vitrectomy, internal limiting membrane peeling around the macular hole, fluid-air exchange, endolaser retinopexy around the peripheral retinal break and perfluoropropane (C3F8) internal tamponade were performed to repair the detached retina and macular hole. One month postoperatively, the patient developed a large peripheral circumferential retinal tear with shallow retinal detachment which necessitated scleral buckling, repeat vitrectomy, endolaser photocoagulation and C3F8 tamponade. The retina was successfully re-attached and the macula hole was closed. Three years post-vitrectomy, the repaired 30-year-old macular hole remained closed although the visual acuity remained unchanged at 6/45. In summary, we describe the successful anatomical closure of a 30-year-old idiopathic full-thickness macular hole which we believe to be the longest duration photographically documented macular hole closed following surgery.

Lacquer cracks in pathological myopia: a clinical review.

Lacquer cracks, described as breaks in the Bruch's membrane, are unique lesions in the spectrum of fundus changes associated with pathological myopia. Lacquer cracks are generally believed to be relatively innocuous lesions by themselves; however, progression to other features of myopic macular degeneration, such as patchy chorioretinal atrophy and choroidal neovascularization, may result in irreversible visual impairment. With the rising prevalence of pathological myopia to epidemic proportions, particularly in the Asian countries, ophthalmologists expect to encounter lacquer cracks more frequently in clinical practice. Therefore, it is crucial for the ophthalmic community to be aware of lacquer cracks and to actively look for these lesions in myopic patients so that early detection and close monitoring can help prevent blinding complications. This article provides a comprehensive review on lacquer cracks in eyes with pathological myopia from a clinical perspective.

Delayed-Onset Hypnopompic Visual Hallucinations 20 Years After Initiation of Propranolol Therapy for Systemic Hypertension: A Case Report.

BACKGROUND Visual hallucinations occur in a variety of clinical settings and may be extremely troubling to individuals experiencing them. We report a case of delayed-onset visual hallucinations 20 years after initiation of medical therapy to highlight the importance of considering iatrogenic causes when managing such patients. CASE REPORT An 88-year-old woman presented with recurring hypnopompic formed visual hallucinations for the past 20 years. These hallucinations began 20 years after she was started on propranolol to treat her systemic hypertension 40 years earlier. Her hallucinations began with plants and insects. They later progressed to vivid, detailed human figures of different races, ages, genders, and religious personnel such as monks, nuns, and priests. The hallucinations occurred almost daily and upon awakening from sleep. Each episode of visual hallucinations lasted for 10 to 20 seconds, occurring when she awoke after dozing off, multiple times each day. The patient became mentally distressed by her visual hallucinations and began to attribute them to supernatural causes. After substituting her propranolol with atenolol, the patient's hallucinations decreased dramatically and became rare and non-frightening. The dramatic improvement suggested a drug-induced etiology. CONCLUSIONS Our case illustrates the importance of considering iatrogenic causes in the diagnosis of visual hallucinations and having a high index of suspicion, even if the onset of symptoms is delayed for many years after initiation of therapy. This iatrogenic condition can easily be rectified to drastically improve the quality of life in affected patients.

Large corneal epithelial detachment as a complication of wound burping to release aqueous humor for elevated intraocular pressure following cataract surgery.

Wound burping is a technique used to treat intraocular pressure spikes in the immediate postoperative period after cataract surgery. A 55-year-old man with no history of glaucoma presented with painless blurring of vision in his left eye following cataract surgery 20 days earlier. Ophthalmic examination disclosed elevated intraocular pressure, mild conjunctival hyperemia, corneal microcystic epithelial edema, and mild anterior chamber reaction. In an attempt to lower the intraocular pressure quickly, the corneal wound was 'burped' at the slitlamp. Upon burping the wound, a large epithelial bulla formed instantly in the cornea. The patient's blinking caused the corneal epithelial bulla to burst and collapse. Examination the next day disclosed the detached epithelium had sloughed off completely. The epithelial defect healed gradually over 10 days. Wound burping to release aqueous humor after the corneal epithelium has healed over the surgical incision can result in corneal epithelial detachment and should be avoided.

Severe astigmatism secondary to large intraocular lens pantoscopic tilt because of a malpositioned haptic following cataract surgery.

An 80-year-old woman presented with painless blurring of vision and monocular diplopia in her left eye following routine phacoemulsification and monofocal intraocular lens (IOL) implantation 5 weeks earlier. Her uncorrected visual acuity (VA) was 6/60 correctable with pinhole to 6/21. Her best-corrected VA was 6/15 with a subjective refraction of -0.50DS/-5.25DCx37. Her corneal astigmatism was -1.25DCx74. Ophthalmic examination disclosed a severely tilted single-piece posterior chamber IOL in the capsular bag. The inferior portion of the optic was tilted posteriorly because of a twisted and malpositioned haptic. The patient underwent remedial surgery to untwist and reposition the IOL haptic which led to immediate improvement of the IOL position. Her uncorrected VA improved to 6/12-2 correctable with pinhole to 12+1 with an autorefraction of +0.25DS/-2.00DCx74 on the first postoperative day. One month postoperatively, her best-corrected VA was 6/12 with a refraction of +0.50DS/-2.50DCx82. Her final vision was limited by myopic macular degeneration.

Impact of the coronavirus disease 2019 pandemic on the progression, prevalence, and incidence of myopia: A systematic review.

We systematically reviewed the literature on the effects of the coronavirus disease 2019 (COVID-19) pandemic on the progression, prevalence, and incidence of myopia. A comprehensive literature search was performed on PubMed, Cochrane Central Register of Controlled Trials, and Scopus databases. Studies included in the review assessed myopia progression, prevalence, and/or incidence as the primary outcome. Of 523 articles yielded in the initial search, 23 studies (6 cross-sectional and 17 cohort) were eligible for inclusion. Sixteen of these were conducted in China and one each in Hong Kong, Turkey, Spain, Israel, India, Korea, and Tibet. Quality appraisals were conducted with the Joanna Briggs Institute Critical Appraisal Checklists. Of the included studies, a large majority reported a greater myopic shift and increase in myopia prevalence during the COVID-19 pandemic compared to the pre-COVID-19 years. All three studies on myopia incidence showed increased incidence during the COVID-19 pandemic. Myopia progression accelerated during the COVID-19 pandemic, even in individuals using low-concentration atropine eye drops in two studies but not in those using orthokeratology treatment in one study. Overall, the studies found that the COVID-19 pandemic and its associated home confinement measures generally increased myopia progression, prevalence, and incidence, even in individuals using low-concentration atropine eye drops.

Choroidal neovascularization following laser in situ keratomileusis for high myopia: a case series.

To report three patients who developed unilateral choroidal neovascularization (CNV) following laser in situ keratomileusis (LASIK) for high myopia. Retrospective chart reviews of three highly myopic patients who developed CNV following LASIK and who attended a tertiary care private practice were conducted. The clinical presentation of the patients was analyzed. All patients were treated with a combination of intravitreal ranibizumab and photodynamic therapy with verteporfin. Main outcome measures were clinical fundus appearance and best-corrected visual acuity (BCVA) after treatment. Two females and one male with a mean age of 34 ± 2.8 years underwent LASIK for high myopia in both eyes. The mean spherical equivalent was -11.42 diopters (D) (range -6.75 to -20.00). The mean time interval between LASIK and the appearance of symptoms was 9.3 ± 8.5 weeks. One patient developed an extrafoveal CNV at the edge of a laser photocoagulation scar, one developed a subfoveal CNV and the third patient developed a juxtafoveal CNV. The mean BCVA at the time of CNV presentation was 0.44 logMAR (range 0.10-0.70 logMAR). Following treatment, the mean BCVA improved to 0.17 logMAR with complete resolution of CNV in two patients. CNV is a rare but potentially blinding complication following LASIK. Short-term good visual outcome can be achieved with timely intervention with current treatment modalities.

Steroid-induced glaucoma: an avoidable cause of irreversible blindness.

A man in his 70s on regular follow-up with an ophthalmologist for 10 years presented with blurry vision in his right eye for 4 days. He was diagnosed with elevated intraocular pressure (IOP) bilaterally 18 months earlier and treated with antiglaucoma eye-drops. On direct questioning, he admitted to using fixed combination tobramycin 0.3%/dexamethasone 0.1% eye-drops frequently to relieve ocular redness and discomfort in both eyes for 3.5 years without his ophthalmologist's knowledge. Examination disclosed markedly elevated IOP, advanced optic disc cupping and tunnel vision due to steroid-induced glaucoma bilaterally. After cessation of the eye-drops and 2 weeks of antiglaucoma therapy, his IOP returned to normal and his visual field remained stable for 4 years.Our case highlights the danger of habitual self-treatment of prescription medications containing corticosteroids and the importance of taking a detailed medication history in the diagnosis and management of steroid-induced glaucoma.

Quantitative analysis of myopic chorioretinal degeneration using a novel computer software program.

To quantify the fundus color on digital color fundus photographs as a surrogate of myopic chorioretinal degeneration in myopic subjects using a novel computer software program. In this cross-sectional study, the following details were recorded in 152 eyes of 78 myopic subjects: Snellen visual acuity, refractive status, ocular biometric parameters, intraocular pressure, color fundus photography, and myopic chorioretinal degeneration index (MCDI) using an automated computer program. The mean age of the subjects was 32.58 ± 11.12 years (range, 21-62 years). Subjects with aged ≥40 years had a significantly higher MCDI when compared with subjects with aged <40 years (MCDI: age ≥ 40 = 0.519; age < 40 = 0.462, P = 0.000). The MCDI demonstrated a statistically significant and positive relationship with axial length (r = 0.47, P = 0.000) and lens thickness (r = 0.26, P = 0.023). A significant positive relationship was observed between the MCDI and visual acuity (r = 0.30, P = 0.007). The MCDI represents an objective technique for quantitative assessment of chorioretinal degenerative changes in myopic subjects. Older myopic subjects with a relatively higher MCDI and longer axial length may represent a high-risk population who have an increased likelihood of developing visually consequential complications of myopia.

Ophthalmic manifestations in seropositive dengue fever patients during epidemics caused by predominantly different dengue serotypes.

Purpose: Dengue fever (DF) epidemics in Singapore in 2005-2006 and 2007 were caused predominantly by dengue virus serotypes 1 (DENV-1) and 2 (DENV-2) respectively. We investigated the prevalence of ophthalmic manifestations during these consecutive epidemics. Methods: Seropositive DF patients admitted to the hospital during two separate dengue epidemics were enrolled from June 2005 to December 2007. Demographic, ophthalmic, and laboratory data were collected. The primary outcome measures were differences in ophthalmic and laboratory features across the two epidemics. Factors associated with increased risk of developing various DF-related ophthalmic manifestations were the secondary outcome measures. Results: Of the 115 patients enrolled, 109 (94.7%; 33 in 2005-2006 and 76 in 2007) completed the eye screening protocol. Majority of patients were Chinese (65, 59.6%) and males (81, 74.3%). The mean age was 40.8 years (range, 18-87). Colour vision impairment (12 vs 14 [36.4% vs 18.7%]; P â€‹= â€‹0.04), cotton wool spots (10 vs 3 [30.3% vs 3.9%]; P â€‹< â€‹0.001), bleeding diathesis (7 vs 3 [21.2% vs 3.9%]; P â€‹= â€‹0.004) and abnormal liver function (mean alanine amino-transferase [150.2 U/L vs 68.28 U/L; P â€‹= â€‹0.001], mean aspartate amino-transferase [196.86 U/L vs 99.53 U/L; P â€‹= â€‹0.002], total protein [68.43 â€‹g/L vs 72.27 â€‹g/L; P â€‹= â€‹0.016], serum albumin [36.86 â€‹g/L vs 40.5 â€‹g/L; P â€‹= â€‹0.001]) were noted more often in DF epidemics predominantly caused by DENV-1 compared to DENV-2. Conclusions: A higher prevalence of colour vision impairment, cotton wool spots, bleeding diathesis, and abnormal liver function was found in DF epidemics predominantly caused by DENV-1 compared to DENV-2.

Mucus fishing syndrome.

Mucus fishing syndrome is a chronic inflammatory ocular surface condition characterised by repetitive self-extraction of mucous strands from the eye.A man in his 30s presented with bilateral ocular redness, itch, irritation, tearing and sticky mucoid discharge for 3 months. Examination disclosed bilateral bulbar and tarsal conjunctival injection. Fluorescein staining disclosed a well-circumscribed area of tarsal conjunctival epithelial defect near the inferior lacrimal punctum in both eyes. The patient admitted to a habit of mechanically removing mucus from his eyes several times a day. Demonstration of the mucus extraction process disclosed direct contact of his fingers with the excoriated tarsal conjunctiva in each eye. He was diagnosed with mucus fishing syndrome and his condition resolved within a month after he stopped fishing mucus from his eyes and had a course of topical antibiotics and steroids.Mucus fishing syndrome is an important diagnostic consideration in patients with chronic conjunctivitis.

Global Ophthalmology Practice Patterns during COVID-19 Pandemic and Lockdown.

AIM: To assess the impact of practice patterns amongst global ophthalmologists during severe acute respiratory syndrome Coronavirus 2 (SARS Cov2) causing Corona virus disease (COVID-19) and understand the various modifications made to address emergency surgeries and practice needs. METHODS: An online survey was sent to practicing ophthalmologists around the world through email, Whatsapp™ ListServ17.0™ (for pediatric ophthalmologists), WeChat™ (China) and ophthalmology associations (Indonesia, Philippines, Ireland). All queries were collected and categorized. Responses to the queries were given according to the recommendations by the Ophthalmology association. Practices ability to deal with the COVID were also classified according to country and type of access to PPE. Statistical analyses of the association between these data and queries, where appropriate were carried out. RESULTS: One thousand nine hundred sixteen ophthalmologists were invited to participate in a survey between April 10th and April 30th, 2020 of which 1207 responded, which is a response rate of approximately 63%. The majority of respondents were from India, Indonesia, China, Singapore and the USA. Our study indicates a precipitous drop in surgical procedures with 46% (n = 538) ophthalmologists ceased to operate on their patients and almost 40% (n = 486) were doing less than 25% of their original number of surgeries. The intent to resume elective surgeries was a consideration in 41% (n = 495) after an evaluation of the situation and in consultation with professional bodies. More than 2/3 of the respondents (n = 703) made it a priority to use and mandate their patients to practice physical distancing, wearing masks, and hand dis-infection for protection to limit the spread of infection. CONCLUSION: This global survey provides a real-world assessment of diverse practices that were in various forms of "shut down mode" and circumstances with varying capabilities to deal with COVID. It is unprecedented that the collective wisdom for a curtailment of practice has had an enormous immediate and far reaching implications on the livelihoods of ophthalmologists, their staff, and their families. Nevertheless, ophthalmologists and their staff remain resilient and have adapted to these changes pragmatically.

Effect of intravenous sedation on patients' visual experience and vital signs during cataract surgery under topical anesthesia: A randomized controlled trial.

Purpose: Effect of intravenous sedation on patients' visual experience and vital signs during cataract surgery under topical anesthesia: a randomized controlled trial. Design: Prospective, double masked, randomized controlled trial. Methods: 150 eyes of 150 patients undergoing phacoemulsification and IOL implantation under topical anesthesia were randomized to receive either intravenous midazolam (0.015 â€‹mg/kg) or normal saline. The patients' experience was evaluated using a questionnaire. Vital signs including blood pressure and heart rate were measured before, during and after surgery. Mean arterial pressure (MAP) was calculated. Results: Both groups were comparable except that fewer patients in the control group were pseudophakic in the fellow eye (25.3% vs. 41.3%). More patients in the control group perceived hand movements (p â€‹< â€‹0.01), surgeon/medical staff (p â€‹= â€‹0.04) and sudden increase in vision during surgery (p â€‹< â€‹0.01) compared to midazolam group. More control group patients experienced fear (p â€‹< â€‹0.001), pain (p â€‹= â€‹0.06) and unpleasant surgical experience (20.3% vs. 1.3%, p â€‹< â€‹0.001). They also experienced greater fluctuation in MAP (16.9 â€‹± â€‹7.9 vs.7.2 â€‹± â€‹5.3, p â€‹< â€‹0.001) and this was accentuated in hypertensives. After adjusting for age, gender, hypertension status and other eye lens status, multivariable logistic regression analysis revealed that subjects in the control arm (OR â€‹= â€‹11.7, 95% [CI] â€‹= â€‹1.3-108, p â€‹= â€‹0.03), had a longer duration of surgery, experienced pain and more likely to report unpleasant experience. Adjusting for similar covariates, multivariable linear regression analysis showed that control group patients (ߠ​= â€‹8.5 â€‹mmHg, 95% CI â€‹= â€‹6.2-10.8, p â€‹= â€‹0.03) had hypertension, experienced fear during surgery and greater fluctuations in the MAP. Conclusions: A sedative dose of intravenous midazolam during phacoemulsification under topical anesthesia significantly reduces patients' visual experience, fear and fluctuations in MAP and improves overall surgical experience.

Fructus lycii: A Natural Dietary Supplement for Amelioration of Retinal Diseases.

Fructus lycii (F. lycii) is an exotic "berry-type" fruit of the plant Lycium barbarum that is characterized by a complex mixture of bioactive compounds distinguished by their high antioxidant potential. F. lycii is used in traditional Chinese home cooking and in the Chinese Pharmacopeia as an aid to vision and longevity as well as a remedy for diabetes to balance "yin" and "yang" in the body for about two centuries. Although a myriad of bioactive compounds have been isolated from F. lycii, polysaccharides, carotenoids, flavonoids, and phenolics represent the key functional components of F. lycii. F. lycii has been shown to exhibit a wide range of biological activities in experimental settings including antioxidant, anti-inflammatory, antiapoptotic, and neuroprotective effects. Despite its medicinal role dating back to the eighteenth century in the Far East and robust evidence of beneficial effects on ocular health and retinal diseases originating mainly from studies in animal models, the role of F. lycii in the clinical management of retinal diseases is yet to be established. This article comprehensively reviews the literature germane to F. lycii and retinal diseases with particular emphasis on age-related macular degeneration, diabetic retinopathy, and retinitis pigmentosa, which are commonly seen in clinical practice.

Visual experience during phacoemulsification-trabeculectomy under peribulbar anesthesia.

BACKGROUND AND OBJECTIVE: To investigate the subjective visual experience of patients with concurrent cataract and glaucoma during phacoemulsification-trabeculectomy under peribulbar anesthesia. PATIENTS AND METHODS: Consecutive patients with concurrent cataract and glaucoma who underwent phacoemulsification-trabeculectomy under peribulbar anesthesia for the first time were interviewed using a standardized questionnaire between 30 minutes and 4 hours after the surgery. They were asked about their intraoperative visual experiences and their reaction to their visual experience. There was no preoperative discussion with the patients on possible intraoperative visual sensations that they might experience. No preoperative or intraoperative sedation was used. RESULTS: Sixty patients with a mean age of 64.8 years (range: 41 to 86 years) were included in the study. Light perception was reported by 73.3% of patients and no light perception by 26.7% throughout the operation. Some patients reported they could also see movements (65%), flashes (53.3%), one or more colors (48.3%), a change in light brightness (38.3%), instruments (8.3%), and/or the surgeon/medical staff (1.7%). Of the 29 patients (48.3%) who saw one or more colors, 18 patients saw yellow, 12 blue, 4 green, 2 orange, and 1 red. One patient (1.7%) found the visual experience frightening and the rest (98.3%) found theirs pleasant. CONCLUSION: The majority of patients with concurrent cataract and glaucoma undergoing phacoemulsification-trabeculectomy using peribulbar anesthesia experience a variety of visual sensations, although only a minority was frightened by the visual experience.

Survey on the knowledge of age-related macular degeneration and its risk factors among Singapore residents.

PURPOSE: To assess the awareness of age-related macular degeneration (AMD) and its risk factors among Singapore residents. METHODS: A cross-sectional questionnaire-based telephone survey was conducted to ascertain the awareness of AMD with regards to knowledge of the disease entity and possible risk factors among Singapore residents. A Singapore residential telephone directory was used to identify potential households by choosing the first and last entries on randomly selected pages. Respondents included individuals from households with landline telephone connection who were willing to participate in the study after a brief introduction about the study. Verbal consent was sought before proceeding with the interview. Interpreters were used for respondents whose ability to converse in English was limited. Prior to commencement of the study, the protocol was reviewed and approved by Ethics committee of the Domain Specific Review Board. RESULTS: The interviewers contacted 796 subjects from different households, of which 520 participated (response rate, 65.3%). The age of the respondents ranged from 18 to 85 (median 41) years. Only 38 (7.3%) of them were aware of AMD, the majority of whom had completed secondary or higher education. Two hundred (38.5%) and 191 (36.7%) of the respondents considered age and smoking, respectively, to be risk factors for AMD. CONCLUSIONS: The awareness of AMD among Singapore residents is low. AMD awareness needs to be improved by educational programmes designed for this specific purpose.