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.

Anterior staphyloma repair following trauma and surgery – A retrospective review of techniques and outcomes over 25 years

Purpose: To review surgical options, techniques, and outcomes of anterior staphyloma repair done following trauma and surgery. Methods: This was a retrospective case study of patients who underwent staphyloma repair with scleral or tibial periosteal patch grafts following trauma and surgery with a minimum follow-up of 3 months postoperatively. Preoperative risk factors, choice of graft materials, surgical details, and outcomes in terms of graft uptake and tectonic integrity were analyzed. Results: Seventeen eyes of 17 patients underwent successful staphyloma repair (scleral 15, tibial periosteal two). Mean follow-up was 47.1 months (3–159 months). Postoperative intraocular pressure rise noted in four eyes was controlled medically or surgically. Three patients underwent successful repeat patch grafting (graft melt one and recurrent ectasia two). Tectonic integrity of the eyeball was restored and maintained in all patients at the final follow-up. Conclusion: Comprehensive evaluation of the risk factors, control of ocular comorbid conditions, and early and meticulous surgery can optimize results.

Necrosis of uveal melanoma post-COVID-19 vaccination

A 49?year?old Indian male presented with rapidly progressive vision loss 1 day after receiving the second dose of BNT162b2 mRNA coronavirus disease 2019 (COVID?19) vaccine (Pfizer?BioNTech, NY, USA). The eye had secondary angle closure glaucoma, bullous retinal detachment, and massive intraocular hemorrhage. Ultrasound showed an ill?defined subretinal mass with moderate internal reflectivity. Magnetic resonance imaging (MRI) confirmed an enhancing heterogeneous subretinal mass. Histopathology showed a necrotic melanocytic lesion arising from the posterior edge of the ciliary body and choroid. Necrotic uveal melanoma was confirmed after expert histopathology opinion. Uveal melanomas can rarely present with tumor necrosis following mRNA COVID?19 vaccination.

Coats’ disease of adult‑onset in 48 eyes.

Background: Coats’ disease diagnosed in adulthood is an idiopathic, retinal exudative vascular disease without an inciting factor and has retinal features different from the childhood disease. Aim: To describe clinical features, treatment, and outcomes of eyes with Coats’ disease first diagnosed in patients 35 years or older. Materials and Methods: Retrospective chart review of patients first diagnosed with Coats’ disease at the age of 35 years or more at a tertiary eye care center between January 1995 and 2012. Eyes with retinal exudation or Coats’‑like response from secondary causes were excluded. Results: Forty‑five of 646 patients (7%) diagnosed with Coats’ disease had adult‑onset disease. Mean age at presentation was 47 years. Systemic hypertension was the most common (22%) systemic association and decreased vision the predominant presenting feature (83%). Localized (<6 clock h) presentation (74%) was unique to adults as against diffuse involvement (69%) in children (P < 0.001). Eyes were treated with laser photocoagulation 29 (60%), cryotherapy (4%), or both (2%) with surgical intervention in three (6%) eyes. Following treatment eight (35%) eyes improved, 11 (48%) eyes were stable while four (12%) eyes worsened due to complications. Conclusion: Adult‑onset Coats’ disease has less extensive involvement, more benign natural course, and a more favorable treatment outcome as against the childhood‑onset disease. The bilateral presentation emphasizes the need for regular follow‑up to detect possible future involvement of the fellow eye.

Eye wall resections for intraocular tumors: Our experience.

We conducted a retrospective review of 11 eyes undergoing eye wall resection between October 1998 and October 2009. The median age of 11 patients was 29 years. Decreased vision (eight) was the most common presenting symptom. Ciliary body medulloepithelioma was the most common clinical diagnosis (six). Medulloepithelioma was the most common histopathological diagnosis (four). The duration of follow-up ranged from 0.5 to 67 months (median 11 months). Three eyes needed to be enucleated in the postoperative period (margin involvement two eyes, recurrence one eye). Postoperative complications among others included retinal detachment (three), vitreous hemorrhage (three), cataract (two), and suprachoroidal hemorrhage (two). To conclude, prognosis of this procedure continues to be guarded needing close postoperative follow-up.

Brachytherapy of intra ocular tumors using ‘BARC I-125 Ocu-Prosta seeds’: An Indian experience.

Aim: To report our experience of brachytherapy using ‘BARC I‑125 Ocu‑Prosta seeds’ for the management of intraocular tumors with regard to tumor control, globe preservation visual outcome, and patient survival at Sankara Nethralaya, Chennai, India between September 2003 and May 2011. Materials and Methods: We reviewed records of 35 eyes of 35 patients who underwent ophthalmic brachytherapy between September 2003 and May 2011. Twenty‑one cases had choroidal melanoma, nine had childhood retinoblastoma, two had adult‑onset retinoblastoma, and there were one case each of vasoproliferative tumor, retinal angioma, and ciliary body melanoma. Brachytherapy was administered using a 15‑ or 20‑mm gold plaque with or without a notch. Brachytherapy was the primary treatment modality in all tumors other than retinoblastoma, wherein brachytherapy was done post chemoreduction for residual tumor. Results: For choroidal melanomas, the mean radiation dose was 68.69 ± 15.07 (range, 47.72-94.2) Gy. The eye salvage rate was 13/20 (65%) and tumor control rate was 16/20 (80%) at an average follow‑up of 24.43 ± 24.75 (range, 1.5-87.98) months. For retinoblastoma, the mean dose was 45.85 ± 3.90 (range, 39.51-50.92) Gy. The eye salvage rate and tumor control rate was 5/6 (83.3%) at an average follow‑up of 38.36 ± 31.33 (range, 4.14-97.78) months. All eyes with retinoblastoma needed additional focal therapy for tumor control and eye salvage. Conclusion: The results of this retrospective study confirms that the use of ‘BARC I‑125 Ocu‑Prosta seeds’ in episcleral plaques to treat intraocular tumors offers a viable option for the management of intraocular cancers.

Systemic medical management of diabetic retinopathy

Diabetes mellitus [DM] has assumed epidemic proportions and as a consequence, diabetic retinopathy is expected to be a major societal problem across the world. Diabetic retinopathy [DR] affects the vision by way of proliferative disease that results in vitreous hemorrhage and traction retinal detachment or by way of diabetic maculopathy [DME]. The present-day management of diabetic retinopathy revolves around screening the diabetics for evidence of retinopathy and treating the retinopathy with laser photocoagulation. DME is treated with laser photocoagulation and/or intra- vitreal injection of anti-vascular endothelial growth factor [VEGF] agents or steroids. Laser remains the mainstay of treatment and is potentially destructive. Systemic management aims at preventing or delaying the onset of retinopathy; reversing the early retinopathy; or delaying the progression of established retinopathy. Evidence from multiple studies has confirmed the protective role of rigid control of blood glucose and blood pressure. The evidence for lipid control versus maculopathy was less definitive. However, the use of fenofibrates [originally used for lowering serum lipids] has shown a benefit on both proliferative disease and maculopathy outside their lipid-lowering effect. Other drugs being tried are the Protein Kinase C [PKC] inhibitors, other peroxisome proliferator-activated receptors [PPAR] agonists, Forsoklin [which binds GLUT 1 receptor], minocycline [for its anti inflammatory effect], and Celecoxib [Cox-2 inhibitor]

Submacular hemorrhage: A study amongst Indian eyes.

Aim: To evaluate the management outcomes amongst various treatment modalities for submacular hemorrhage (SMH) in Indian subjects. Settings and Design: Retrospective, single-center study. Materials and Methods: Patients presenting with SMH between 1999 and 2006 were included. Treatment modalities included: vitrectomy with subretinal recombinant tissue plasminogen activator (r-tPA) assisted SMH evacuation (group 1, n = 14); pneumatic displacement with intravitreal r-tPA and gas (group 2, n = 25); and pneumatic displacement with intraocular gas (group 3, n = 7). Favorable anatomical outcome was defined as complete displacement of SMH from fovea and favorable functional outcome was defined as a gain of >2 Snellen lines from the baseline. Kruskal–Wallis, analysis of variance (ANOVA), and Chi-square tests were used to compare the three groups, while Mann–Whitney and independent t-test were used to evaluate the influence of duration and size of SMH on outcomes. Results: There was no difference amongst groups in terms of favorable anatomical (P = 0.121) or functional outcomes (P = 0.611). Eyes with median duration of SMH less than 7.5 days had a significantly higher probability of achieving favorable anatomical outcome compared to eyes with SMH >14.5 days (P = 0.042). However, duration of SMH did not influence functional outcome (P = 0.595). Similarly, size of SMH did not affect anatomical (P = 0.578) or functional (P = 0.381) outcome. Median follow-up was 31.5, 6.5, and 2.5 months in the three groups, respectively. Conclusions: Co- existing posterior segment conditions and duration of SMH may influence the choice of treatment modality and treatment outcomes. Pneumatic displacement with r-tPA and r-tPA assisted vitrectomy appear to be favorable options for the management of SMH.

Fifteen-year trends in indications for enucleation from a tertiary care center in South India.

Aim: To analyze the trends in clinicopathologic indications for enucleations over a 15-year period. Materials and Methods: Clinicopathologic details of all eyes that underwent enucleation from January 1996 to December 2010 were drawn up from a computerized database. The study was divided into three periods of 5 years each and comparison tables for each cause of enucleation during these periods were generated. Chi-square test was used to compare proportions. Results: Out of a total 1467 enucleations performed during the study period, 693 (46%) were attributable to retinoblastoma, 189 (12.5%) to uveal melanoma, 228 (15%) to trauma, and 149 (10%) to phthisis bulbi. Intraocular tumors accounted for more than 63% of all enucleations performed. Over the three time periods, proportion of enucleations secondary to retinoblastoma increased from 38% in the 1st period to 58% in the 3rd period (P < 0.001). Enucleations for trauma showed statistically significant reduction in trends over the three periods (24% in the 1st period vs. 4.4% in the 3rd period, P < 0.001). Similar trends were also seen in the proportion of enucleations due to intractable glaucoma and chronic uveitis. The absolute number of enucleations secondary to retinoblastoma out of the total cases seen during the study period did not change over the three periods (range 51–60%). Conclusion: Intraocular tumors were the commonest indications for enucleation in our patient population despite the availability of globe-conserving treatments such as chemotherapy and radioactive plaques. We observed increasing trends in the proportion of enucleations due to retinoblastoma and reduction of enucleations secondary to trauma, chronic uveitis, and glaucoma.

Photodynamic monotherapy or combination treatment with intravitreal triamcinolone acetonide, bevacizumab or ranibizumab for choroidal neovascularization associated with pathological myopia.

This retrospective, interventional case series analyses treatment outcomes in eyes with choroidal neovascularization (CNV) secondary to pathological myopia, managed with photodynamic therapy, (PDT), (Group 1, N = 11), PDT and intravitreal triamcinolone acetonide (4 mg/0.1ml) (Group 2, N = 3), PDT and intravitreal anti-vascular endothelial growth factor (anti-VEGF) bevacizumab 1.25 mg/0.05 ml, ranibizumab 0.5 mg/0.05 ml and reduced-fluence PDT and intravitreal ranibizumab 0.5 mg/0.05 ml (Group 3, N=12). All the patients underwent PDT. Intravitreal injections were repeated as required. SPSS 14 software was used to evaluate the data. Wilcoxon signed ranks test was used to evaluate pre- and post-treatment vision. The Kruskal-Wallis test was used for comparison between the groups. All the groups were statistically comparable. All the eyes showed complete regression of CNV, with a minimum follow-up of six months. All groups had visual improvement; significantly in Group 3 (P = 0.003). Combination PDT with anti-VEGF agents appeared to be efficacious in eyes with myopic CNV. However, a larger study with a longer follow-up is required to validate these results.

Technical aspects of laser treatment for acute retinopathy of prematurity under topical anesthesia.

Retinopathy of prematurity (ROP) is a significant cause of childhood blindness. The criteria for laser therapy have been revised from threshold ROP to include the earlier stage of high-risk prethreshold ROP. Laser photocoagulation is an established technique for the treatment of ROP. However, the detailed procedure and techniques for laser photocoagulation have not yet been published. Adequate and appropriate laser photocoagulation for ROP is different from the application of lasers in adult retinal vascular diseases, and many ophthalmologists need to be trained in this technique if the outreach of ROP treatment programs is to improve. Laser under topical anesthesia has been practiced in India as a preferred modality especially due to logistics and risks of general anesthesia in these pre-term babies. We discuss the details of the technique as practiced at tertiary care ophthalmic hospitals in India, so that the nuances in treatment parameters and clinical decision-making can be usefully applied to ophthalmic practice. This will ultimately lead to safe and effective treatment delivery in ROP.

Coats' disease: An Indian perspective.

Aim: To describe the clinical features, treatment and outcome patterns in 307 eyes with Coats' disease. Materials and Methods: Retrospective chart review of patients diagnosed with Coats' disease between January 1996 and January 2006 from a single referral center in southern India. Results: Two hundred and eighty patients (307 eyes) with mean age of 15.67 years (range: Four months-80 years) were included. Decreased vision (77%), unilateral affection (90%) and male preponderance (83.4%) were chief presenting features. Anterior segment involvement was seen in 67 (21.8%) eyes. Retinal telangiectasia were seen in 302 (99%) eyes, exudation in 274 (89%) eyes and retinal detachment in 158 (51.5%) eyes. Four-quadrant disease was seen in 207 (67.2 %) eyes. Visual acuity was < 20/200 in 249 (80.9%) eyes. One hundred and nine of 176 treated eyes (61.93%) had favorable anatomical outcome; 207 of 280 eyes (74%) had an optimal structural outcome. Seventeen (5.3%) eyes were enucleated. Complications following treatment included phthisis bulbi (7%), neovascular glaucoma (5%), epiretinal membrane (4.4%) and rubeosis iridis (4.4%). Conclusion: Indian patients with Coats' disease have a high male predominance, the majority of whom present with severe visual impairment and extensive four-quadrant exudation. Unusual presentations such as pain, vitreous hemorrhage and a high incidence of anterior segment involvement are distinctive to Indian eyes.

Functional and anatomical outcomes after primary lens-sparing pars plana vitrectomy for Stage 4 retinopathy of prematurity.

Background: While lens-sacrificing vitrectomy is the standard approach to manage Stage 5 retinopathy of prematurity (ROP), scleral buckling has been used to manage some cases of Stage 4. Lens-sparing vitrectomy was popularized by Maguire and Trese in selected cases of Stage 4 disease. Purpose: To assess the functional and visual outcomes after primary lens-sparing pars plana vitrectomy for Stage 4 ROP. Materials and Methods: In a retrospective, interventional, consecutive case series, the records of 39 eyes of 31 patients presenting with Stage 4 retinal detachment secondary to ROP who underwent primary two or three-port lens-sparing vitrectomy from January 2000 to October 2006 were evaluated. The outcomes studied at the final follow-up visit were the retinal status, lens and medial clarity and visual acuity. Favorable anatomical outcome was defined as the retinal reattachment of the posterior pole at two months after the surgery; and favorable functional outcome was defined as a central, steady and maintained fixation, with the child following light. Results: At mean follow-up of 15 months, 74% of the eyes had a favorable anatomical outcome with single procedure. The visual status was favorable in 63%. The lens remained clear in all the eyes at the last follow-up, and the media clarity was maintained in 87%. Intraoperative complications included vitreous hemorrhage, pre-retinal hemorrhage and retinal break formation. Conclusions: Lens-sparing vitrectomy helps to achieve a favorable anatomical and functional outcome in selected cases of Stage 4 ROP.

Uveal melanoma presenting as cataract and staphyloma.

Blind eyes can harbor a choroidal melanoma. We report a case of uveal melanoma presenting as staphyloma and complicated cataract in a 45-year-old female. The left eye was blind for six months. She underwent comprehensive ocular examination but fundus examination was precluded due to total cataract. The ultrasound of the eye showed a large mass filling the superior, nasal and inferonasal vitreous cavity with high surface reflectivity and low to moderate internal reflectivity. Magnetic resonance imaging (MRI) confirmed the diagnosis of choroidal melanoma. The patient underwent extended enucleation and histopathology was consistent with uveal melanoma.

Cystoid macular edema after bone marrow transplantation.

We report a case of cystoid macular edema in a patient who underwent bone marrow transplant for aplastic anemia. After having ruled out all the other causes of cystoid macular edema, we concluded that it was secondary to the bone marrow transplant. The patient had mild visual impairment and did not recover the lost vision. In this case report, we describe in detail the clinical presentation, follow-up, and course of medication that this patient had. It is an illustrated case report of cystoid macular edema after bone marrow transplant with mild visual impairment and no recovery.

Direct aspiration of capsular bag material in a case of sequestered endophthalmitis.

Chronic recurrent endophthalmitis can occur following uncomplicated cataract surgery with intraocular lens implantation secondary to organisms sequestered in the capsular bag. There is a need to identify these sequestered organisms to facilitate appropriate management. Frequently, specimens from the anterior chamber and vitreous cavity could be unyielding, especially in the early cases in which the vitreous is still uninvolved. This article highlights the technique of directly sampling the capsular bag material in the effective diagnosis of the organism, which facilitates the total cure by irrigation with appropriate antibiotics into the capsular bag.

Suprachoroidal collection of internal tamponading agents through a choroidal hole.

We report two cases of significantly large choroidal holes following penetrating trauma that led to suprachoroidal migration of internal tamponading agents during repair of retinal detachments with proliferative vitreoretinopathy secondary to penetrating trauma. In the first case, choroidal hole was a direct result of the injury and was identified immediately after vitreoretinal surgery which was done for traumatic retinal detachment with hemorrhagic choroidal detachment. In the second case, the hole occurred over a period of several months after the repair of traumatic retinal detachment with silicone oil tamponade. This was attributed to progressive fibrosis exerting traction on the bare choroid/retinal pigment epithelium. Choroidal hole significant enough to cause suprachoroidal migration of internal tamponading agents is a very rare complication seen in eyes with posttraumatic retinal detachment with proliferative vitreoretinopathy.

Serous macular detachment associated with dysplastic disc.

The article describes a case of abnormal looking optic disc (dysplastic) associated with serous macular detachment similar to what is described in cases of optic pit. However clinically as well as on fluorescein angiography, no optic pit or coloboma could be identified. Gas injection, prone positioning and laser along the temporal border of the disc could correct the macular detachment.

Anterior chamber exudative mass due to Scedosporium apiospermum in an immunocompetent individual.

Endogenous intraocular infection of fungal etiology is extremely rare in an immunocompetent individual. Usually, an antecedent history of trauma, surgery, intravenous drug abuse or an immunocompromized state can be elicited. Scedosporium apiospermum is a known cause of keratomycosis after traumatic implantation and can cause fatal disseminated infection in immunocompromized patients. However, cases of S. apiospermum intraocular infection in immunocompetent individuals have been very rarely reported in literature. We report here a case of an anterior chamber exudative mass due to S. apiospermum in an immunocompetent individual which was managed successfully with anterior chamber wash and intravitreal injection of voriconazole.