Mean Ocular Perfusion Pressure Effect During Pars Plana Vitrectomy on the Foveal Avascular Zone: A Pilot Study.

Purpose: To evaluate the effect of mean ocular perfusion pressure on the foveal avascular zone (FAZ) area in eyes with successful retinal detachment (RD) surgery. Methods: This prospective pilot fellow eye-controlled study measured the intraoperative mean ocular perfusion pressure in eyes having surgery for rhegmatogenous RD (RRD). Postoperatively, the FAZ area was measured; the change was calculated as the difference in the FAZ area between the operated eye and the contralateral control eye. Results: The study comprised 8 patients with a mean age (±SD) of 53.38 ± 13.92 years. The mean superficial FAZ area was not different between operated eyes and control eyes, while the deep FAZ area was significantly larger in operated eyes. There was a strong negative correlation between the mean ocular perfusion pressure and the change in the deep FAZ area (Spearman ρ, -0.73; P = .04); the correlation between the mean ocular perfusion pressure and the change in the superficial FAZ area was not significant (Spearman ρ, -0.24; P = .57). A significant linear regression was found between the mean ocular perfusion pressure and the change in the deep FAZ area (R2 = 0.388). The predicted enlargement of the deep FAZ area was 0.03 mm with every 1 mm Hg decrease in the mean ocular perfusion pressure. Conclusions: Lower intraoperative mean ocular perfusion pressure is associated with enlargement of the deep FAZ area in eyes having successful RRD surgery.

Nodular Posterior Scleritis With Associated Choroiditis Masquerading As A Choroidal Tumour: A Case Report.

A case of nodular posterior scleritis in a 25-year-old male who presented with a 14-day history of unilateral decline in vision, pain, and redness in his right eye. Slit lamp examination of the right eye revealed dilated episcleral vessels present nasally as well as a choroidal mass at the nasal periphery of the fundus, associated with choroidal oedema. Systemic evaluation and imaging of the choroidal mass were performed to rule out choroidal tuberculoma and choroidal metastasis. Ultrasound B-scan of the right eye showed marked thickening of the nasalsclera resulting in sympathetic choroidal oedema without the characteristic T-sign. Nodular posterior scleritis with associated choroiditis, was diagnosed without any underlying systemic illness. The patient was immediately started on systemic steroids and later on subcutaneous Methotrexate as advised by the rheumatologist, to which he responded well and his vision significantly improved from 6/60 to 6/9, gradually during his treatment course.

Suprachoroidal silicone oil migration following 27 gauge 3 ports pars plana vitrectomy - a rare complication and its management.

Suprachoroidal silicone oil migration is an unusual complication of small gauge 3 ports Pars plana vitrectomy (3PPV) system. Our objective is to report a retrospective, observational case of an intra-operative suprachoroidal silicone oil (SO) migration during 27 gauge 3PPV and its successful surgical management. A 49 years old male patient with type 2 diabetes, presented to the ophthalmology outpatient department with reduced visual acuity in his right eye. He was diagnosed as having tractional retinal detachment involving macula. During combined phaco-vitrectomy following injection of SO, peripheral choroidal elevations were noted suggesting suprachoroidal SO migration. In an attempt to drain this intra-operatively nasal sclerotomy was enlarged. Post-operative B scan showed significant choroidal detachment for which patient was re-scheduled for surgery after 1 day. Three radial trans-scleral incisions (2 nasal and 1 temporal) for drainage were made at the site of maximum choroidal detachment. By massaging and widening these scleral incisions, suprachoroidal haemorrhage and SO was successfully drained with good post-operative visual improvement.

Frequency and Outcome of Retinopathy of Prematurity at Tertiary Care Hospital in Pakistan.

OBJECTIVE: To describe the frequency and outcome of Retinopathy of prematurity (ROP). STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: Ophthalmology Department, Shifa International Hospital (SIH) Islamabad from May 2014 to December 2019. METHODOLOGY: All preterm infants with gestational age ≤35 weeks and/or birth weight ≤2000g were included while those born at greater than 35 weeks of gestation and having a gestational weight more than 2000g were excluded from this study. Studied variables included gender, gestational age, birth weight, form and duration of supplemental oxygen, systemic diseases, presence or absence of ROP, ROP stage, treatment, and outcome. RESULTS: Six hundred and twenty-two met the inclusion criteria out of whom 316 were screened. The majority (n=202, 64%) of the screened infants were males. Supplemental oxygen was given to 244 (77.2%) infants. The mean gestational age was 31.94 ± 2.2 weeks. The mean birth weight was 1632 ± 446 g. ROP was diagnosed in 10 (3.2%) infants with stage 1 in 3 (0.9%) infants, stage 2 in 1 (0.3%), stage 3 in 5 (1.5%), and stage 4B in 1 (0.3%) infant. In the infants diagnosed with ROP, mean gestational age was 30.4 ± 2.9 weeks, and mean birth weight was 1393 ± 416 g. ROP regressed spontaneously in 3 infants with stage 1 and 1 infant with stage 2 disease. Infants with stage 3 disease also had disease regression after treatment with intravitreal Ranibizumab (n=3) or intravitreal Bevacizumab (n=2) injection along with concurrent laser photocoagulation (n=1). The infant with 4B ROP underwent bilateral vitrectomy with the complete attachment of retina on follow-up. CONCLUSION: There was a low frequency of 3.2 % of ROP reported in this study. The infants diagnosed with ROP had favorable outcomes following timely treatment of this dreadful disease. KEY WORDS: Retinopathy of prematurity, Eye, Retina, Supplemental oxygen, Screening.

The Clinical and Safety Outcomes of 27 Gauge Pars Plana Vitrectomy in Eyes With Macular Hole.

Objective To report the clinical, visual, and safety outcomes of 27 gauge pars plana vitrectomy (27G PPV) in eyes with full thickness and lamellar macular hole (MH).  Methodology This retrospective cross-sectional study, conducted at the ophthalmology department of Shifa International Hospital, Islamabad, was done on 89 eyes of 85 patients who underwent 27G PPV for full-thickness and lamellar MH with a postoperative follow-up period of six months.  Results The mean age was 61.9 ± 17.3 years with 57.3% being males. Most of the eyes had idiopathic stage III full-thickness MH (n=34, 38.2 %). The total mean operating time was 42.5 ± 19.8 minutes. During surgery, 48 (53.9%) eyes had concurrent phacoemulsification. Hexafluoroethane was the most commonly used tamponade agent (n=81, 91%). Postoperatively, the primary closure rate was 93.2% (n=83) while the final closure rate was 100% (n=6) either by prolonged posturing (n=3, 3.3%) or by an additional procedure involving autologous internal limiting membrane (ILM) transplant (n=3, 3.3%). The complication rate was 2.2% including iatrogenic retinal tear (n=1, 1.1%) and raised IOP (n=1, 1.1%). The overall best-corrected visual acuity (BCVA) improved significantly from 1.20 ± 0.67 to 0.31 ±0.17 (p=<0.001). Conclusion As per this study, 27G PPV is a practical and efficient surgical system with substantial anatomical success, minimal complication, and considerable visual recovery rates in eyes with full thickness and lamellar MH. We suggest 27G PPV with ILM peeling and medium-acting intraocular gas as the standard procedure for MH.

Efficacy and Safety Profile of 25-Gauge Pars Plana Vitrectomy in Rhegmatogenous Retinal Detachment in Pakistan: A Multicenter Retrospective Study.

Introduction This study aims to evaluate the primary anatomical success and visual outcomes of 25-gauge pars plana vitrectomy (25g PPV) in patients with rhegmatogenous retinal detachment (RRD) in Pakistan. Design This is a five-year retrospective, interventional cohort study conducted at tertiary care hospitals in Pakistan from October 2013 to October 2018. Methods This is a retrospective, interventional cohort study of 418 consecutive patients with RRD who underwent 25g PPV. All surgeries were performed by two experienced surgeons at tertiary care hospitals in Pakistan. Consecutive patients who underwent 25g PPV surgery as the treatment for RRD from October 2013 to October 2018 were included. We excluded patients who had a history of previous retinal surgery or did not complete the 4-8 weeks of primary outcome visit. We used the Statistical Package for the Social Sciences (SPSS) version 23.0 (IBM Corporation, Armonk, NY, USA) for statistical analysis. A p-value of <0.05 was considered significant. Results We identified 452 patients through the coding system of our hospitals who underwent 25g PPV surgery for RRD during the study period. A total of 441 patient files were reviewed for the study, of which 418 patients met the criteria for final analysis. The mean age was 49 ± 15.8 years. There was a higher number of males (n = 284, 67.9%). In our study, 186 (44.4%) patients were phakic at the time of presentation. The macula was detached in 361 (86.4%) patients. At the primary outcome visit (4-8 weeks of follow-up), the primary anatomical success rate was 89.47%. The most common cause of failure was proliferative vitreoretinopathy (PVR) (n = 20), followed by missed breaks (n = 5). Conclusions The surgical outcomes of RRD with 25g PPV surgery in our study were similar to the outcomes reported in the developed world. We propose a prospective multicenter national study to prospectively evaluate the risk factors for RRD surgical failure in the Pakistani population.

Comprehensive overview of IRVAN syndrome: a structured review of Case Reports and Case Series.

Idiopathic retinal vasculitis, aneurysms, and neuroretinitis (IRVAN) syndrome is a rare spectrum of retinal vasculitis, aneurysms, and neuroretinitis affecting young individuals in their third decade. Most of our current knowledge is based on case reports, case series, and a handful of collaborative studies. There is much diversity in treatment approaches and outcomes in the reported literature. We have aggregated published case reports and case series into quantitative and narrative synthesis to draw evidence-based conclusions toward clinical features, atypical and rare findings, systemic associations, disease course, and treatment outcomes. The analysis suggested the disease mostly affects young individuals with a female predilection. Anterior chamber and vitreous inflammation are common than previously believed. The most prevalent pattern of retinal vasculitis in IRVAN eyes is mixed vasculitis, followed by arteritis and phlebitis. Most eyes at the time of presentation have capillary nonperfusion and require treatment. Most eyes retain good visual acuity; however, treatment is required to maintain visual function. Intravitreal antivascular endothelial growth factors administered as an adjunct to retinal laser photocoagulation are more likely to improve visual outcomes. Besides, we have discussed the different hypotheses on the etiopathogenesis of the disease and stronger evidence suggests an inflammatory origin of the disease.

A Novel Method of Quantifying the Choriocapillaris in Normal and Post-inflammatory Eyes.

OBJECTIVE: To assess the reliability and validity of gray level co-occurrence matrices (GLCM) in the quantification of choriocapillaris and describe GLCM features in normal and eyes with resolved acute posterior multifocal placoid pigment epitheliopathy (APMPPE) and serpiginous choroiditis (SC). METHODS: In this, multicenter, reliability, validity and comparative study; OCTA was performed on eyes with resolved APMPPE and SC and normal individuals. CC texture classification, low flow area measurements and GLCM feature extraction were performed. RESULTS: A total of 13 normal, 8 APMPPE and 15 SC eyes were analyzed. All GLCM parameters demonstrated an excellent reliability. GLCM parameters were differently distributed across the three groups. Decision-tree based on the random forest predictive model provided an overall accuracy of 86% in classifying the three groups using GLCM features. CONCLUSION: These data demonstrated an excellent reliability and validity of GLCM features in quantifying the choriocapillaris in healthy and diseased eyes.

Impact of COVID-19 lockdown on Retinal Surgeries.

OBJECTIVES: To determine the frequency and severity of surgical Vitreo-Retinal diseases during COVID-19 lockdown period (LP) and compare it with same period last year. METHODS: Single hospital based retrospective Cohort Study. Data of the patients that underwent retinal surgeries during the COVID-19 LP i.e., 23-03-2020 till 23-06-2020 and same period last year i.e., 23-03-2019 till 23-06-2019 was analyzed. RESULTS: One hundred thirty-six eyes of 105 patients were included. Among these eyes, 48 (35.3%) were operated during the COVID-19 LP while 88 (64.7%) were operated during the same time last year. A decline of 45.5% (p=0.023) was observed in the frequency of surgeries during the LP. Mean age of patients during the LP was 43.2 ± 20.3 years compared to 48.4 ± 17.9 years last year. There was reduction in the surgeries for Diabetic Tractional Retinal Detachment (11.4% vs 4.2% during LP, p=0.166), Vitreous hemorrhage (10.2 % vs 8.3% during LP, p=0.04), Full thickness macular hole (3.4% vs 0% during LP) and Epiretinal membrane (12.5% vs 0% during LP). While Rhegmatogenous retinal detachment (27.3% vs 58.3% during LP, p<0.001) among other disorders had a higher proportion during the LP. CONCLUSION: The decline in the frequency of retinal surgeries during the LP is indicative of complex pathologies presenting later with more advanced disease. However, earlier presentation and an increase trend in surgeries for RRD during the LP shows the positive impact of free time on the health concerns of our population.

Outcomes of 27gauge pars plana vitrectomy for a variety of posterior segment diseases.

OBJECTIVE: To report outcomes of 27 gauge pars plana vitrectomy for the management of a variety of simple to complex posterior segment disorders. METHODS: This retrospective cohort study was conducted at the Shifa International Hospital, Islamabad, Pakistan, and comprised data of all patients who underwent 27 gauge pars plana vitrectomy between July 1, 2015, and June 30, 2019, for a variety of indications. Data noted included age, gender, laterality, diagnosis, pre-operative visual acuity, date of surgery and surgical details, including operating time and complications. Best corrected visual acuity at 3 months was also recorded. Data was analysed using SPSS 21. RESULTS: Of the 574 patients, 355(62%) were males and 219(38%) were females. The overall mean age was 55±16.9 years. There were total 665 eyes as 91(15.8%) patients underwent bilateral surgeries. The most common surgical indications were diabetic tractional retinal detachment 196(29.5%) and vitreous haemorrhage 191(28.7%). Mean operating time was 62± 37 minutes. With the exception of 0.34% cases where 20 gauge fragmatome was used, no case required conversion to 20 gauge system, while 25 gauge trocar was used for silicon oil injection. Per-operative complications included iatrogenic retinal tear 2(0.3%) eyes and supra choroidal silicon oil migration 1(0.15%) eye. Post-operative complications were raised intraocular pressure 7(1.05%), endophthalmitis 1(0.15%) eye, haemorrhagic occlusive retinal vasculitis 1(0.15%) eye and rhegmatogenous retinal detachment 2(0.3%) eyes. Mean best corrected visual acuity improved from 1.62± 0.68 to 0.4± 0.38 logarithm of minimum angle of resolution (p<0.001). CONCLUSIONS: The 27 gauge pars plana vitrectomy was found to be a safe and effective procedure for both simple and complex retinal pathologies requiring significant surgical manipulation.

Incidence of endophthalmitis following intravitreal anti VEGF injections at a tertiary care hospital in Pakistan.

OBJECTIVE: To assess the rate of infectious endophthalmitis with anti-vascular endothelial growth factor injection, and to evaluate institutional procedure protocol in this regard. METHODS: The retrospective consecutive case series was conducted at Shifa International Hospital, Islamabad, Pakistan, from August 2018 to January 2019, and comprised 5-year data from August 2014 to July 2019 related to patients who underwent intravitreal anti-vascular endothelial growth factor injections. Data was analysed using SPSS 21. RESULTS: Of the 7,542 injections administered to 2,734 patients, 5,976(79.2%) were bevacizumab, 1,081(14.3%) ranibizumab and 485(6.4%) aflibercept. There was 1(0.01%) case of infectious endophthalmitis which was treated with 25 gauge pars plana vitrectomy. CONCLUSIONS: The institutional procedure protocol was found to be effective as the rate of infectious endophthalmitis was lower than what is reported in literature.

Ophthalmological Aspects of von-Hippel-Lindau Syndrome.

Background: von Hippel-Lindau (VHL) syndrome is a multisystem neoplastic disorder involving eyes, central nervous system, kidneys, spine, and other tissues. A retinal capillary hemangioma (RCH) is the earliest manifestation of the VHL disease in most cases.Areas covered:This paper aims to provide an up-to-date review of the current literature about von Hippel-Lindau syndrome. Molecular background, systemic and ocular features of the diseases as well as the utility of newer imaging modalities in diagnosis and monitoring of ocular VHL disease have been described. Besides, we have discussed newer treatment modalities and therapeutic targets.Conclusion: Modern imaging technologies like optical coherence tomography and optical coherence tomography angiography are tools of the trade, in making an appropriate diagnosis and monitoring disease activity and response to treatment. Peripheral RCH may be treated using laser photocoagulation in tumors up to 3000 µm. Vascular endothelial growth factor suppression can help in reducing tumor activity and stabilize the tumor size; however, it does not regress the RCH.

Evaluation of practices of macular ganglion cell complex scan in early detection of glaucoma.

The purpose of this survey was to evaluate the level of awareness and practices regarding macular ganglion cell complex (GCC) scans for early detection of glaucoma. The study design was descriptive cross-sectional and the sampling technique was non-probability convenient method. Data was collected through an online survey, from 100 practicing ophthalmologists and optometrists of Pakistan in two weeks, from January 20 to February 03 2019. Data were analysed using Microsoft Excel 2016. From the results it is strongly evident that significant number of respondents recorded the retinal nerve fibre layer (RNFL) to be the first layer affected as glaucoma progresses, which depicts lack of knowledge among eye care practitioners. Furthermore, both the groups (ophthalmologists and optometrists), used macular GCC scan the least as compared to the RNFL (optic nerve head) scan and visual field tests for early diagnosis of glaucoma. It demonstrated lack of knowledge and practices of macular GCC scan for glaucoma among eye care practitioners.

Haemorrhagic occlusive retinal vasculitis caused by intravitreal vancomycin.

Intraocular Vancomycin is used as a treatment as well as prophylaxis of endophthalmitis, but in rare instances it can cause serious ischaemic vasculitis. The most salient features of the disease include painless visual loss after cataract surgery, mild to moderate inflammation in the anterior chamber and peripheral retinal involvement with patchy haemorrhages and ischaemic vasculitis. We present case reports of two such patients who were identified with ischaemic vasculitis when they were given intravitreal Vancomycin for treatment of suspected endophthalmitis after complicated phacoemulsification surgery. Both developed profound visual loss with typical signs of haemorrhagic occlusive retinal vasculitis (HORV). 25 gauge 3 ports parsplana (25G 3 PPV) vitrectomy was performed on both the patients and dropped lenticular matter were removed from the vitreous cavity. Topical antibiotics and steroids were given. There was no significant visual improvement in both the cases which illustrates the toxic potential of intraocular use of Vancomycin.

Long-term visual acuity and the duration of macular detachment: findings from a prospective population-based study.

AIM: To report the long-term visual outcome of a multicentre prospectively recruited cohort of macula-off rhegmatogenous retinal detachments (RRD) METHODS: The Scottish retinal detachment study was a prospectively recruited study that recruited all incident cases of primary RRD in Scotland over a 2-year period (2007-2009). All patients with a macula-off RRD from four participating sites were invited for clinical examination at 6 weeks, 3 months, 6 months and 1 year after the initial surgery. Using a joinpoint model we estimated the effect of duration of macular detachment on final visual outcome. RESULTS: In total, there were 291 patients with macula-off RRD without pre-existing retinal disease who had successful repair after one operation. 65.9% achieved a final visual acuity (VA) of 0.48 logMAR(6/18). Our model identified two time points (day 8 (95% CI 3 to 15 days) and (day 21 (95% CI 6 to 26 days)) after which there was a statistically significant worsening in final VA. CONCLUSIONS: Our study suggests that the majority of patients with macula-off RRD successfully repaired with one operation will achieve a VA of 6/18 or better at final follow-up. After 8 days of macular detachment, the final visual outcome may be adversely affected and, thus, operative repair within this period is desirable. Duration of macular detachment of ≤8 days demonstrated a continuing improvement in VA for up to 1 year, a finding which was not found in macula detachments of longer duration.

A novel technique of tangential, circumferential, scleral tunnel in 20-gauge transconjunctival sutureless vitrectomy: optical coherence tomography-aided analysis of wound integrity and clinical outcome.

AIM: To describe a novel technique of sclerotomy construction to facilitate 20-gauge transconjunctical sutureless vitrectomy (TSV) along with the evaluation of the wound integrity. METHODS: The surgical technique is described. One hundred consecutive patients who underwent TSV were evaluated for wound leaks, postoperative hypotony, endophthalmitis and any other complication related to surgery. The sclerotomies of eight patients (24 ports) were analysed by imaging with anterior segment optical coherence tomography immediately after surgery, and on the first postoperative day and after the first postoperative month. RESULTS: 104 eyes of 100 patients were evaluated with a mean follow-up of 9.6 months. All cases underwent surgery with standard 20-gauge instrumentation and vitrectomy techniques. Five sclerotomies were found to leak at the end of surgery, requiring a suture. Anterior segment optical coherence tomography images were obtained from eight eyes with good apposition of the tunnel noted in all the cases. Mean intraocular pressure was 18.7 mm Hg on the first postoperative day. One patient had hypotony without leak and this patient had pre-existing hypotony due to chronic panuveitis. There was no instance of postoperative endophthalmitis. CONCLUSIONS: This technique of 20-gauge TSV achieves good wound apposition with a low incidence of complications while using standard 20-gauge instrumentation and vitrectomy techniques.

Superior forniceal advancement conjunctival pedicle (SFACP) in the management of corneal perforations and impending perforations due to rheumatoid arthritis related autoimmune corneal melts.

Peripheral ulcerative keratitis (PUK) is a disorder consisting of a crescent-shaped destructive inflammation of the perilimbal corneal stroma. PUK may occur in variety of systemic diseases including collagen vascular disease. We describe the outcome of superior forniceal advancement conjunctival pedicle (SFACP) in two patients with corneal perforation and impending perforation due to rheumatoid arthritis (RA) related auto immune corneal melt that has not previously been reported. Both patients had good recovery with restoration of vision when SFACP was performed as an adjunct to systemic immunosuppressive agents. SFACP is a valuable surgical option which may have an important role in reducing progression of corneal melt and underlying disease when used along with adequate systemic immunosuppressive agents.

The effect of the first application of verteporfin photodynamic therapy on lesion growth in choroidal neovascularisation and its potential impact on combination therapy.

PURPOSE: To evaluate the impact of lesion size on the observed growth of the choroidal neovascularisation (CNV) following the first application of photodynamic therapy (PDT). METHODS: A retrospective study of consecutive patients with subfoveal classic CNV or predominantly classic CNV undergoing first verteporfin photodynamic therapy (VPDT) according to treatment of age-related macular degeneration with photodynamic therapy (TAP) protocol between June 2005 and September 2005. Patients were classified into two groups according to baseline greatest linear dimension (GLD) at the time of VPDT monotherapy. Group 1 comprised patients with lesion GLD less then 2000 microm and Group 2, patients with lesion GLD 2000 microm or larger. Difference between the mean GLD at baseline and at three months post-treatment were investigated for clinical significance using the paired t-test. RESULTS: Group 1 (n = 16) showed a mean change in GLD from 1380.25 microm to 2031.25 microm, while Group 2 (n = 26) showed a mean change of 2909.26 microm to 3023.07 microm. Data of mean percentage change in GLD for Group 1 showed a 51.97 per cent increase in the lesion size [95% CI, 22.93 - 81.01%] in comparison to Group 2, which showed only 5.8 per cent increase in the lesion [95% CI, -9.65 - 21.61%]. Comparison of the mean percentage change in GLD between the two groups showed a statistically significant difference (p = 0.003). CONCLUSIONS: Our study demonstrates that following the first application of VPDT, smaller lesions enlarge disproportionately more than larger lesions. As we have entered into the era of using angiostatic agents in combination with VPDT, it may be important to evaluate this effect with regards to the timing of VPDT commencement.