Impact of inverted internal limiting membrane-flap technique on functional outcome and structural restoration of small and medium size macular holes

Purpose: To evaluate the impact of the inverted internal limiting membrane (ILM)?flap technique on the visual outcome and anatomical recovery for small (<250 ?), medium (<400 ?), and large (>400 ?) macular holes (MHs). Methods: Retrospective study included consecutive idiopathic MH cases operated on using the inverted ILM?flap technique. Clinical data were retrieved from electronic medical records (EMRs), surgical videos, and optical coherence tomography (OCT) machines. Eyes with axial length >25 mm, coexisting macular diseases, and follow?up <6 weeks were excluded. Data included the presence or absence of ILM flap and restoration of External Limiting Membrane (ELM), Ellipsoid Zone (EZ) lines. Mean visual improvement and structural recovery were compared between eyes showing ILM flap and those showing no flap in three MH size groups. Results: Forty eyes of 38 patients with a mean age of 62.7 ± 10.1 years and a mean MH diameter of 348 ± 152 ?m were included. The mean follow?up was 527 ± 478 days with anatomical closure observed in all eyes. Mean best?corrected visual acuity (BCVA) improved significantly from 0.87 ± 0.38 to 0.35 ± 0.26. ILM flap was visible in 29 (72.5%) all MHs, 7 (53.8%) small MHs (n = 13), 8 (61.5%) medium MHs (n = 13), and 14 (100%) large MHs (n = 14). The mean BCVA change was 0.47 ± 0.34, 0.53 ± 0.48, and 0.56 ± 0.20 in large, medium, and small MHs, respectively, and the difference between eyes showing ILM flap versus no flap in each MH size group was not statistically significant (P > 0.05). However, for medium MHs, it was higher in the ILM flap (0.66 ± 0.52) group compared to the no flap (0.32 ± 0.37) group. One eye with small MH developed significant gliosis resulting in reduced BCVA. ELM was restored in all eyes with small and medium MHs. Conclusion: We observed that the ILM flap did not adversely affect anatomical and visual outcomes for MHs <400 ?m. Restoration of ELM suggests minimal interference in structural recovery by an ILM flap.

Clinical profile of medicolegal cases presenting to the eye casualty in a tertiary care center in India.

Purpose: The purpose of this study was to analyze the clinical profile of medicolegal cases (MLCs) presenting to the eye casualty in a tertiary care hospital. Materials and Methods: Retrospective review of records. The cases were grouped according to the Ocular Trauma Classification Group classification system. Results: Out of 188 MLCs, 164 (87.2%) were male. Mean age (±standard deviation) was 31.6 (±12.7) years. Age ranged from 7 to 75 years. Twenty‑six (13.8%) patients had bilateral involvement. The fist was the most common mode of injury, which was seen in 109 (58%) cases. A total of 27 (14.3%) patients had associated extraocular injury. No evidence of ocular or orbital trauma (malingering) could be found in 13 (7%) patients. Mechanical trauma was present in 169 (90%) patients with injury to globe in 129 (69%) patients and injury to lid or orbit without damage to the globe in 40 (21%) patients. Chemical injury was observed in 6 (3%) patients. Closed globe injury (CGI) was seen in 116 eyes and open globe injury (OGI) was noted in 29 eyes. The most common type of injury, zone, pupil, and grade of injury in CGI were Type A or contusion (79%), Zone I (72%), Pupil B (absence of relative afferent pupillary defect) in 95%, and Grade A [visual acuity (VA) ≥20/40] in 68% of the eyes, respectively. The most common type of injury, zone, pupil, and grade of injury in OGI were Type B or penetrating (48%), Zone II (38%), Pupil B (59%), and Grade D (VA 4/200‑light perception) (42%), respectively. Conclusions: The most common form and mode of ocular injury in MLC were closed globe injury and fist, respectively. The most common type of injury in CGI and OGI was contusion and penetrating injury, respectively.

A Pilot, Randomized Sham Control Trial of Autologous Bone Marrow Derived Mononuclear Cells in Acute Ischemic Central Retinal Vein Occlusion.

In this pilot, sham controlled randomized control trial (RCT) in patients with ischemic central retinal vein occlusion (CRVO), we studied the safety and efficacy of intravitreal injection of autologous bone marrow derived mononuclear cells and found that both patients who received stem cell injections did not develop anterior segment neovascularization at 1 year follow up. Except for some sterile inflammatory reaction in the initial follow up, no long term injection related serious adverse events (SAEs) were observed. Based on our observations we recommend a larger, multicentric study to further establish the safety and efficacy of this treatment in patients with ischemic CRVO. Purpose: To study the safety and efficacy of autologous bone marrow derived mononuclear cells injected intravitreally in patients with ischemic CRVO. Study Design: Randomized sham controlled trial. Methods: 4 cases with ischemic CRVO were recruited into the study. 2 cases were randomized into intervention group and 2 into control group. Baseline investigations included best corrected visual acuity (BCVA), intra ocular pressure (IOP), fundus fluorescein angiography (FFA), gonioscopy and optical coherence tomography (OCT). Patients in the intervention group received intravitreal injection of autologous bone marrow derived mononuclear cells (MNCs) and those in control group received sham injection. Patients were followed up over a 12-month period. Main Outcome Measures: Development of anterior segment neovascularization. Results: Both patients in the intervention group did not develop anterior segment neovascularization over a follow up period of 12 months. 1 patient in control group developed neovascularization of iris and elevated intra ocular pressure over a follow up period of 6 weeks and required trabeculectomy for control of IOP. The other patient in control group was lost follow up after 2 weeks. Conclusions: Our initial observations suggest that intravitreal injection of mononuclear cells may reduce the risk of developing anterior segment neovascularization in patients with ischemic central retinal vein occlusion. A larger, multicentric study would be valuable to gain further evidence to our preliminary observations.

Intravitreal anti-VEGF monotherapy for thick submacular hemorrhage of less than 1 week duration secondary to neovascular age-related macular degeneration.

Aim: To investigate the role of anti‑VEGF monotherapy in patients with thick submacular hemorrhage (SMH) of ≤1 week duration secondary to neovascular age‑related macular degeneration (N‑AMD). Materials and Methods: A retrospective chart review of 14 eyes of 14 patients presenting with acute decrease in central vision of ≤1 week duration secondary to a thick SMH measuring ≥ 2 MPS disk areas from N‑AMD was performed. Intravitreal injections of bevacizumab 1.25 mg (13 eyes) or ranibizumab 0.5 mg (1 eye) were given monthly until resolution of SMH and less frequently thereafter, based on treat-and-extend approach utilizing spectral domain optical coherence tomography (SDOCT). Patients with follow‑up of ≥6 months were included. Results: Patients presented after a median of 4 (range 1-7) days from the onset of SMH. Mean lesion size was 27.9 mm2 (range 5.47-100, median 15), with blood comprising 77-98% of the lesion. Presenting visual acuity (VA) ranged from 20/60 to hand motions (median 20/200). Patients received a mean of 11.4 (range 5-20) injections over 18.4 (range 7-50) months. SMH resolved in all eyes in a mean of 4.8 (range 2-8) months. At 6 months follow‑up, mean VA gain was −0.54 logMAR (range: −1.5 to +1, Snellen range 20/25‑20/400, median 20/100, P = 0.0037), with 11 gaining ≥0.2 logMAR. Mean change in VA from baseline at final follow‑up was −0.58 logMAR (range −1.6 to +1, Snellen range 20/30-20/400, median 20/60; P = 0.0022). Conclusion: A good anatomical and visual outcome can be accomplished in patients with thick SMH secondary to N‑AMD treated with anti‑VEGF monotherapy within 1 week.

Progressive atrophy of retinal pigment epithelium after trypan-blue-assisted ILM peeling for macular hole surgery.

We report a case of progressive atrophy of the retinal pigment epithelium (RPE) after trypan-blue-assisted peeling of internal limiting membrane (ILM) for macular hole surgery. A 68-year-old Caucasian female underwent a 20-g pars plana vitrectomy for a chronic stage-3 macular hole. The ILM was stained with 0.06% trypan blue (VisionBlue™, DORC Netherlands) for 2 min after fluid air exchange. Dye was reapplied for another 2 min due to poor staining. The ILM was completely removed around the macular hole with forceps. RPE atrophy was noticed at the edge of the hole 1 month after surgery. It progressively increased in intensity and enlarged over 2 years. Her final visual acuity was counting fingers, significantly worse compared to her presenting visual acuity of 20/200. Progressive atrophy of RPE in our patient was most likely due to the toxicity of trypan blue. Reapplication of the dye may increase the likelihood of toxicity.

Multifocal electroretinogram in normal emmetropic subjects: Correlation with optical coherence tomography.

Aim of the Study: To establish the normative database for multifocal electroretinogram (mfERG) parameters in a normal emmetropic population. To correlate the data so obtained with the central macular thickness obtained using the optical coherence tomography (OCT) scan. Materials and Methods: mfERG data were obtained from 222 eyes of 111 emmetropic subjects. The amplitude (nv/deg2) and implicit times (ms) of the first-order kernel mfERG responses (N1, P1, and N2 waves) were obtained and grouped into five rings (Ring 1: Central 2°, Ring 2: 2–5°, Ring 3: 5–10°, Ring 4: 10–15°, Ring 5: >15°). The central macular thickness (CMT) was obtained using the macular thickness scan protocol of the OCT. Results: The mfERG data obtained were used to create a normative database. The amplitudes of the mfERG waves were maximum in the fovea and progressively decreased with increasing eccentricity (P = 0.0001). The latencies of the P1 and N2 waves were longest in the central ring and progressively shortened with eccentricity (P = 0.0001). No statistically significant correlations were observed between central ring 1 parameters and the CMT. Conclusion: This study establishes normative database for mfERG parameters in an emmetropic population. No statistically significant correlation was noted between CMT and mfERG parameters.

Impact of early rise of intraocular pressure on visual outcome following diabetic vitrectomy.

Objective: The objective was to study the incidence and risk factors for an early rise in intraocular pressure (IOP) following pars plana vitrectomy (PPV) for proliferative diabetic retinopathy (PDR) and to correlate its impact on visual outcome. Materials and Methods: This was a longitudinal prospective study. IOP and best corrected visual acuity (BCVA) for 73 cases of PDR (52 males and 21 females) who underwent PPV were recorded at day 1, week 1, and months 1, 3, and 6. Risk factors for the early IOP rise, defined as IOP ≥ 30 mmHg at day 1, were evaluated using cross-tabulation and the t-test. Results: Mean IOP at day 1 was 21.8 ± 9.8 mmHg with 15 cases (20.5%) having an early rise in IOP. Risk factors for the early IOP rise included intraoperative fibrovascular frond removal (P = 0.003), lens removal (P = 0.043), and intraoperative vitreous bleed (P = 0.008). The early rise in IOP was also associated with consistently raised IOP (P = 0.02), defined as IOP > 21 mmHg during first three consecutive follow-up visits. Further, difference in BCVA at 6 months among the two groups, i.e., with and without an early IOP rise was statistically significant (3.11 ± 1.52 logMAR vs. 2.11 ± 1.49 logMAR; P = 0.025). Conclusion: An early rise in IOP is a significant risk factor which compromises the visual outcome of patients undergoing diabetic vitrectomy.

Interaction of Perfluoro-n-octane with extracted intraocular foreign bodies.

Perfluorocarbon liquid ( PFCL ) s have been known to facilitate foreign body (FB) removal. Their ability to float the frequently encountered FB in vitreoretinal practice is unknown. We preserved all intraocular foreign bodies (IOFB) removed by ars plana vitrectomy during 6 months period. All FBs were analyzed and tested with perfluoro-n-octane to assess its usefulness in FB removal. Out of total 25 FBs extracted during the period 20 (80%) were nonmagetic with size varying from 1.5 to 7.5mm. All FBs sank when placed at saline air interface and only 2(FBs both nonmagnetic ) floated when placed at the saline-PFCL interface. In second set of experiments we were unable to float any FB off the bottom of the test container. Higher specific gravity and larger size limit the usefulness of perfluoro-n-octane for floating and manipulating most commonly-encountered IOFBs. Further work utilizing heavier PFCLs and retinal impact measurements are needed to investigate the possible (cushion effect ) offered by PFCLs during foreign body removal.

Long-term anatomical and visual outcome of vitreous surgery for retinal detachment with choroidal coloboma.

CONTEXT: Vitreous surgery has been advocated as an alternative treatment of selected retinal detachments with choroidal colobomas. AIM: To study the long term anatomical and visual outcome of choroidal coloboma with retinal detachment managed by pars plana vitrectomy with silicone oil tamponade. SETTING AND DESIGN: Retrospective study conducted in a tertiary eye care hospital. MATERIALS AND METHODS: Fourty two eyes of 40 patients with retinal detachments related to coloboma of the choroid without any peripheral breaks were analyzed. All eyes underwent pars plana vitrectomy with internal tamponade using silicone oil. Endolaser was performed along the coloboma border. Silicone oil was removed in 50% of patients. The main outcome measures were retinal reattachment and visual recovery. SPSS (Statistical Package for the Social Science), version 10.0 was used for analysis. RESULTS: The retina in all cases (100%) undergoing vitrectomy were completely reattached intra-operatively. After a mean follow-up of 14 months, 37 (88.1%) eyes had attached retina. The best corrected visual acuity was 10/200 or better in 33 (78.4%) eyes. The best corrected visual acuity improved from a preoperative median of counting fingers (range 20/40 to perception of light) to median best corrected visual acuity of 20/200 (range 20/40 to perception of light) at the end of 6 months. Of the 50% (21) cases that underwent silicone oil removal, two eyes had re-detachment of retina. CONCLUSION: Pars plana vitrectomy along with silicone oil tamponade for retinal detachment related to choroidal coloboma improves the long-term anatomical and visual outcome.

Iris intraocular foreign bodies: safe and successful removal through limbus.

Metallic iris intra ocular foreign body (IOFBs) with minimal ocular damage pose an interventional challenge. We report safe removal of metallic intraocular foreign bodies embedded on the iris, in three cases by use of intraocular magnets. Two eyes had a clear lens with best corrected visual acuity (BCVA) of 20/20, while the third eye had a BCVA of 20/200 with siderotic cataract. Ultrasound biomicroscopy confirmed the superficial impaction of IOFB into the iris. Foreign bodies were successfully removed via the limbal route with a 20 g intravitreal magnet atraumatically in all 3 cases with preservation of their pre-operative BCVA. Case series highlights the usefulness and safety of intraocular magnet for removal of metallic iris foreign bodies in selected cases. Prior ultrasound biomicroscopy to know the actual depth of penetration of IOFB into the iris and preoperative confirmation of magnetic property of IOFB are essential.

Role of Antitubercular therapy in Eales' Disease

Eales’ disease is most frequently found linked with tuberculosis. Hence, the present prospective randomized study was conducted to evaluate the role of anti-tuberculosis therapy in Eales’disease, by carrying out physical, neurological, ophthalmological examination and laboratory tests. The results of present study reveals that there is no rationale for prescribing anti-tuberculosis treatment with active Eales’ disease with no systemic tuberculosis

Profile of Ocular Trauma at Tertiary Eye Centr

This prospective study reveals the epidemiological profile of ocular trauma referred to a tertiary eye centre over one year. All consecutive patients referred to Vitreo-retina service during 1 year period were examined.Out of total 523 eyes registered large proportion was <25years of age (67%), males (88%) and literate (77%). Forty-four percent belonged to rural area and 38% were students. Most of the open globe injuries were Zone 1(50.8%). 75% presented >1 week after injury. The incidence of intraocular foreign body and retinal detachment was 17.4, and 11.3% respectively. Diagnosis of post traumatic endophthalmitis was made in 20.5% of open globe injuries. Development of endophthalmitis correlated with younger age, rural setting, illiteracy, presence of foreign body and lens disruption. Ocular trauma requiring tertiary care commonly affects young students, labourers and factory workers. Younger, rural and illiterate patients are more likely to develop infection especially if they have lens injury or intraocular foreign body.

Modified needle drainage. A safe and efficient technique of subretinal fluid drainage in scleral buckling procedure.

PURPOSE: To compare modified needle drainage (MND) with conventional drainage (CD) of subretinal fluid (SRF) as described by Schepens in surgery for primary rhegmatogenous retinal detachment. METHODS: Prospective randomised clinical trial of 80 patients undergoing scleral buckling with subretinal fluid drainage for primary rhegmatogenous retinal detachment. In 40 patients modified needle drainage of subretinal fluid (SRF) was done using a perpendicular trans-scleral entry with a 26-gauge needle and the appearance of SRF in the hub of needle as end point. In 40 patients conventional drainage was done as described by Schepens using a diathermy needle. Adequacy of SRF drainage, intraoperative complications, anatomical and functional outcome were noted. RESULTS: 100% adequate drainage was achieved in all cases. The complication rate was 32.5% (n=13) in the CD group and 15% (n=6) in the MND group. In the CD group, 17.5% (n=7) patients had subretinal haemorrhage and in 2 eyes it was clinically significant. In the MND group 15% (n=6) of cases had subretinal haemorrhage and in one patient it was clinically significant. In the CD group, more serious SRF drainage complications were observed; these were absent in the MND group. CONCLUSION: Modified needle drainage is a safe and effective procedure for SRF drainage. In comparison with CD, MND is technically easy, less cumbersome and requires no special equipment.