Morphological characterization of subretinal hyper-reflective material in posterior uveitis using swept-source optical coherence tomography and optical coherence tomography angiography

Purpose: To analyze the structural features of subretinal hyper-reflective material (SHRM) in posterior uveitis using swept-source optical coherence tomography (SS-OCT) and optical coherence tomography angiography (SS-OCTA). Methods: In this observational study, subjects with quiescent posterior uveitis and the presence of SHRM on SS-OCT were subjected to SS-OCTA to identify the presence of an intrinsic choroidal neovascular (CNV) network. OCT features were compared for SHRM harboring CNV (vascular SHRM) with those without CNV network (avascular SHRM) to identify clinical signs pointing toward the presence of CNVM inside SHRM. Results: Forty-two eyes of 33 subjects (18 males; mean age: 29.52 ± 12.56 years) were evaluated. Two-thirds (28/42) of eyes having SHRM on SS-OCT harbored intrinsic neovascular network (vascular SHRM). Increased reflectivity of SHRM (P < 0.001) and increased transmission of OCT signal underlying SHRM (P = 0.03) were suggestive of the absence of CNVM. The presence of intra/subretinal fluid (P = 0.08) and pitchfork sign (P = 0.017) were important markers of vascular SHRM. Conclusion: SHRM is an important OCT finding in eyes with posterior uveitis. Meticulous assessment of SHRM characteristics on SS-OCT can aid in identifying the underlying intrinsic neovascular network.

Redrawing vitreoretinal surgical training program in the COVID-19 era: Experiences of a tertiary care institute in North India

Purpose: The COVID?19 pandemic has brought medical and surgical training to a standstill across the medical sub?specialties. Closure of outpatient services and postponement of elective surgical procedures have dried up opportunities for training vitreoretinal trainees across the country. This “loss” has adversely impacted trainees’ morale and mental health, leading to feelings of uncertainty and anxiety. Therefore, there is an urgent need to redraw the surgical training program. We aimed to describe a systematic stepwise approach to vitreoretinal surgical training. Methods: We introduced a three?pronged approach to vitreoretinal surgical training comprising learn from home, wet lab and simulator training, and hands?on transfer of surgical skills in the operating room in our institute. Results: Encouraging results were obtained as evaluated by feedback from the trainees about the usefulness of this three?pronged approach in developing surgical skills and building their confidence. Conclusion: The disruption caused by the COVID?19 global pandemic should be used as an opportunity to evolve and reformulate surgical training programs to produce competent vitreoretinal surgeons of the future.

Sensitivity and specificity of nonmydriatic digital imaging in screening diabetic retinopathy in Indian eyes.

Background: Nonmydriatic digital imaging (NMDI) is ideal for screening diabetic retinopathy (DR), but its use in Indian eyes has not been evaluated. Aim: The aim was to evaluate the sensitivity and specifi city of NMDI as a screening tool in detecting DR in Indian eyes. Design: A prospective, nonrandomized, noncomparative, noninterventional study. Materials and Methods: A total of 500 diabetic patients visiting the endocrinology clinic (September 2008-June 2010) underwent NMDI (Zeiss Procam), followed by routine dilated fundus photography (FP; Zeiss Visupac 450+) of 345° retinal fi elds (1) optic disc and macula, (2) superotemporal, and (3) nasal to optic disc. Two-masked retina specialists graded the images for quality and severity of DR, and compared between NMDI and dilated FP. Statistical Analysis: SPSS Windows 17 for version. Results: Mean age was 52.97 ± 13.46 years (306 males: 194 females). The rate of ungradable images was 30.6% and 31% by the two observers. By observer 1, the sensitivity and specifi city of detecting any DR was 58.8% and 69.1%, respectively, ( = 0.608) and sight-threatening DR (STDR) was 63.1% and 68.9%, respectively, ( = 0.641). By observer 2, the sensitivity and specifi city was 57.3% and 68.3%, respectively, for any DR ( = 0.593) and 62.8% and 68.3%, respectively, for STDR ( = 0.637). The level of agreement between two observers was high ( = 0.96). Conclusion: A high rate of poor quality photographs and low sensitivity limited the use of NMDI as a perfect screening system, particularly in dark iris population with diabetes as seen in Indian eyes.

Current approach in the diagnosis and management of panuveitis.

Panuveitis is a generalized inflammation of not only the whole of the uveal tract but also involves the retina and vitreous humor. It differs from other anatomical sites of inflammation in terms of causes as well as distribution. The common causes of panuveitis in our population are tuberculosis, Vogt-Koyanagi-Harada syndrome, sympathetic ophthalmia, Behcet's disease and sarcoidosis. A large number of cases still remain idiopathic. A stepwise approach is essential while evaluating these patients to be able to identify and treat the disease timely and correctly. Ancillary tests can be appropriately applied once the anatomic site of inflammation is identified. An exhaustive approach comprising a full battery of tests is obsolete. Only specific tailored investigations are ordered as suggested by the preliminary clinical and ocular examination. The mainstay of the treatment of uveitis is corticosteroids. Immunosuppressive agents are administered if the inflammation is not adequately controlled with corticosteroids. One of the recent breakthroughs in the treatment of refractory uveitis includes the introduction of immunomodulating drugs: Tumor necrosis factor-alpha antagonist and Interferon-alpha. Vitrectomy has been used in uveitis for over a few decades for diagnostic and therapeutic purposes. When compared to other anatomical sites of inflammation, panuveitis has poor visual outcome due to more widespread inflammation. The side-effects of the chronic treatment that these patients receive cannot be overlooked and should be specifically monitored under the supervision of an internist with special interest in inflammatory diseases.

Evaluation of impression smear in the diagnosis of fungal keratitis.

PURPOSE: To evaluate and compare impression smear with the conventional mechanical corneal scraping by potassium hydroxide (KOH) method in the diagnosis of fungal keratitis. MATERIALS AND METHODS: Fifty consecutive cases of clinically suspected fungal keratitis were included. Under topical anesthesia, impression smear was obtained from the lesion, followed by the conventional mechanical scraping and both were transferred to sterile glass slides. The slides were examined under direct microscopy with KOH 10% wet mount. Impression smear KOH was compared with the scraping KOH and culture. RESULTS: The KOH smear was positive in 36 (72%) patients with impression smear technique and positive in 35 (70%) patients from corneal scrapings. Sensitivity of impression smear technique as compared to scraping was 97.14%, specificity 92.86%, positive predictive value 94.4%, negative predictive value 92.86%, false positive rate 5.56%, false negative rate 7.14% and accuracy was 94%. As compared to culture, the sensitivity was 100%, specificity 46.67%, positive predictive value 55.56%, negative predictive value 100%, false positive rate 53.33%, false negative rate 0% and accuracy was 68%. CONCLUSION: Impression smear KOH examination is comparable to conventional mechanical corneal scraping KOH examination in making a tentative diagnosis of fungal keratitis and can be accurately relied upon for initiating anti-fungal therapy.