Outcomes of intravitreal anti-VEGF injections and panretinal photocoagulation in preretinal hemorrhage secondary to proliferative diabetic retinopathy involving the fovea.

PURPOSE: To evaluate the outcome of intravitreal anti-vascular endothelial growth factor (VEGF) injections and panretinal photocoagulation (PRP) in fovea involving preretinal hemorrhage (PRH) secondary to proliferative diabetic retinopathy (PDR). METHODS: Retrospective non-comparative cross-sectional series of patients diagnosed with fovea involving PRH secondary to PDR at our institute from March 2019 to October 2021 who were treated with combination treatments of intravitreal anti-VEGF and PRP and have completed a minimum 6-month follow-up. The primary outcome measure was serial changes in the visual acuity (VA) and PRH regression from the fovea. Secondary outcome measures were the quantitative assessment of the size of PRH, its association with VA improvement and time to regression, and the proportion of patients who underwent surgery for poor response. RESULTS: In total, 22 eyes of 21 patients showed regression of PRH from the foveal center at 33.6 days, and complete regression was seen at 140.7 days. The average number of anti-VEGF injections required for clearance of PRH from the fovea was 1.6. Mean LogMAR visual acuity improved from 0.54 at baseline to 0.32 at 4 weeks and 0.18 at 6 months ( P < 0.01). Three eyes (13.6%) required vitrectomy surgery during follow-up. The mean area of PRH as measured by Image J analysis was 14.78 mm 2 at baseline, 8.97 mm 2 at 4 weeks, and 1.25 mm 2 at 3 months ( P < 0.01). No statistically significant difference was seen between the size of PRH and PRH clearance time and VA improvement. No systemic side effects were observed following the intravitreal injections during follow-up. CONCLUSION: Intravitreal anti-VEGF injections and PRP were found to be effective and safe treatment methods for fovea involving PRH secondary to PDR. Long-term studies are warranted to assess the long-term efficacy.

Rapid regression of idiopathic multifocal choroiditis with intravitreal methotrexate-wide-field optical coherence tomography angiography-based study.

Wide-field optical coherence tomography angiography (OCTA) results in a patient of idiopathic multifocal choroiditis successfully treated with intravitreal methotrexate injections.

Impact of COVID-19-related lockdown on retinal disorders treated with intravitreal injections.

PURPOSE: To study functional changes in vision and morphological changes on optical coherence tomography (OCT) scans in patients where intravitreal therapy (IVT) with injections has been delayed due to COVID-19 pandemic lockdown. METHODS: Retrospective cross-sectional study included 77 eyes with the diagnosis of exudative age-related macular degeneration (eAMD), diabetic macular edema (DME), and retinal vein occlusion (RVO), regularly receiving IVT with anti-vascular endothelial growth factor (Anti-VEGF) injections or dexamethasone implant and were not able to receive the injections as intended due to lockdown. Best-corrected visual acuity (BCVA), central foveal thickness (CFT), and qualitative morphological features on OCT were analyzed pre- and post-therapy break off. RESULTS: The mean duration of IVT break-off was 57 days. Mean BCVA logarithm of minimum angle of resolution (logMAR) worsened from 0.33 (20/42) to 0.35 (40/44) (P = 0.02) and mean CFT increased from 297.90 µm to 402.16 µm (P < 0.01), from pretherapy break-off to return visit. Worsening of the visual acuity was seen across all the three disease cohorts, significantly more in the eyes with eAMD. CONCLUSION: Marginal decline in the visual acuity and worsening of the OCT features were observed as a result of delay in the IVT injections of DME, eAMD and RVO patients.

To compare intralesional and oral propranolol for treating periorbital and eyelid capillary hemangiomas.

Purpose: A pilot randomized control trial to compare the efficacy and side effects of intralesional and oral propranolol in periorbital and eyelid capillary hemangiomas. Methods: Twenty patients were prospectively randomized to two groups of ten each. Group 1 was initiated on oral propranolol 1 mg/kg/day titrated to final dose of 3 mg/kg/day over 1 week which was continued for 6 months and then tapered over 1 week; Group 2 received 3 doses of direct intralesional propranolol hydrochloride 1 mg/ml; 0.2 ml/cm 4-6 weeks apart. Hemangioma area and corneal astigmatism were measured. Results: Within each group at 6 months there was a significant reduction in area (group 1: 83.48 ± 11.67%,P= 0.0019; group 2: 67.78 ± 21.71%,P= 0.0019) and improvement in astigmatism (pre, post: group 1: 2.98D @ 179.8°, 1.13D @ 179.8°,P= 0.0045; group 2: 1.62D @ 90.16°, 0.75D @ 179.9°,P= 0.0001). There was no difference in area reduction (P = 0.056), change in appearance (P = 0.085), ptosis (P = 0.23) and side effects (lethargy, poor feeding;P= 0.171) between the two groups. Conclusion: Efficacy and side effects with intralesional propranolol are comparable to oral propranolol for periorbital and eyelid lesions.

Quantitative analysis of anterior chamber following peripheral laser iridotomy using Pentacam in eyes with primary angle closure.

Purpose. To quantify the effects of laser peripheral iridotomy (LPI) on peripheral anterior chamber depth (PACD), central internal anterior chamber depth (CACD), and anterior chamber volume (ACV) using Rotating Scheimpflug Imaging System, i.e., Pentacam, on Asian Indian eyes. Methods and Materials. This was an institutional, prospective, nonrandomized, interventional study. Sixty-eight eyes of 68 consecutive patients with primary angle closure were enrolled. Pentacam scanned the anterior ocular segment with the 25-image acquisition scan protocol and PACD, CACD, and ACV values were obtained. The PACD was measured in nasal, temporal, superior, and inferior meridian at 4 mm and 8 mm circles. Nd:YAG laser iridotomy was performed. Preiridotomy, immediate postiridotomy, 1 week and 1 month postiridotomy data for PACD, CACD, and ACV were acquired. The t test and repeated-measures analysis of variance (ANOVA) and one-way ANOVA were used for statistical significance. Results. Pre-LPI ACV increased immediately after iridotomy (28.4 mm3; p=0.001), at 1 week (15.9 mm3; p=0.001), and at 1 month post-LPI (19.8 mm3; p=0.00). There was no change in CACD (p>0.05). Significant PACD deepening was observed at 4 mm and 8 mm in all meridians (p<0.001) at all visits. Conclusions. Laser peripheral iridotomy significantly increased the PACD and ACV. Extent of the LPI-induced PACD increase was enhanced with increasing distance from the optical axis.

Clinical applications of Scheimpflug imaging in cataract surgery.

Since the Scheimpflug principle was first described over a century ago, there has been a great interest among ophthalmologists for the use of Scheimpflug camera in anterior segment imaging. Scheimpflug imaging has since advanced significantly and modern day instruments provide comprehensive imaging and topographic data of the anterior segment. In this article the clinical applications and limitations of Scheimpflug imaging in modern cataract surgery patients are discussed. This article reviews recent work on assessment of lens transparency for cataract grading and integrity, using preoperative lens density measurements to help predict phacoemulsification parameters, its utility in challenging situations like capsular bag distension syndrome and traumatic cataract and assessment of density of the posterior capsule for objectively quantifying posterior-capsule opacification.

Posterior corneal elevation after LASIK with three flap techniques as measured by Pentacam.

PURPOSE: To evaluate and compare posterior corneal changes using elevation data obtained from Pentacam (Oculus Optikgeräte GmbH) Scheimpflug imaging in eyes undergoing LASIK with three different modes of flap creation: IntraLase femtosecond laser FS60 (Abbott Medical Optics) (femtosecond group), Amadeus (Ziemer Group AG) mechanical microkeratome (keratome group), or flap formation using 20% alcohol laser epithelial keratomileusis (LASEK) (LASEK group). METHODS: Ninety myopic patients (90 eyes) undergoing refractive surgery were recruited. The change in posterior corneal elevation at 21 predetermined points in the central 5-mm area was measured using exported elevation data from the Pentacam before LASIK and 18 months postoperative and was compared among and within three modes of flap creation. RESULTS: Mean change in posterior elevation in the central 5-mm area was 5.13±4.16 µm for the femtosecond group, 5.78±4.42 µm for the keratome group, and 6.68±4.72 µm for the LASEK group and was similar among groups (P=.59). Change in posterior elevation before and after LASIK was not significant within any group (P=.342, P=.232, and P=.321 for the femtosecond, keratome, and LASEK groups, respectively). Preoperative spherical equivalent, central corneal thickness, ablation depth, and estimated residual bed thickness did not correlate with change in posterior corneal elevation for the femtosecond, keratome, or LASEK groups (P>.05). CONCLUSIONS: Using Pentacam elevation data, there were no significant changes in posterior corneal elevation following LASIK among or within the three methods of flap creation. At 18 months after LASIK, the posterior corneal surface is not displaced anteriorly significantly and is equally stable using these three surgical techniques.

Correlation of nuclear cataract lens density using Scheimpflug images with Lens Opacities Classification System III and visual function.

PURPOSE: To calculate the average lens density (ALD) and nuclear lens density (NLD) using Scheimpflug images and to determine their correlation with logarithmic minimal angle resolution (logMAR) best-corrected visual acuity (BCVA), contrast sensitivity (CS), and lens grading based on the Lens Opacities Classification System (LOCS) III. DESIGN: Cross-sectional observational study. PARTICIPANTS: One hundred ten patients with age-related nuclear cataract. METHODS: The logMAR BCVA was recorded using Early Treatment Diabetic Retinopathy Study charts and photopic contrast-sensitivity using CSV-1000LV (Vector Vision, Greeneville, OH). Fifty Scheimpflug images (Pentacam, Oculus, Germany) covering 360 degrees of the lens were obtained for 1 eye of each patient after dilation. All Scheimpflug images were exported to ImageJ software (NIH, Bethesda, MD) for analysis wherein the ALD and NLD (using a mask applied to the lens nuclear area) were calculated in pixel-intensity units. Repeatability was determined using coefficient of variation (CoV) and intraclass correlation coefficient (ICC). Lens opacity on slit-lamp images was graded using LOCS III for nuclear opalescence (NO) and nuclear color (NC). MAIN OUTCOME MEASURES: We evaluated ALD and NLD on Scheimpflug images and their correlation with NO and NC LOCS III grading, BCVA, and photopic CS. RESULTS: The ICC for ALD and NLD were 0.983 and 0.99, respectively; the CoV were 3.92+/-1.76% and 2.57+/-0.74%, respectively. The ALD correlated with NO (r = .774; P<0.001), NC (r = .732; P<0.001), BCVA (r = 0.696; P<0.001), and CS at 3 cycles per degree CPD (P = 0.011), 6, 12, and 18 CPD (P<0.001). The NLD correlated with NO (r = .859; P<0.001), NC (r = .81; P<0.001), BCVA (r = .760; P<0.001), CS at 3 CPD (P = 0.002), 6, 12, and 18 CPD (P<0.001). The NLD had a significantly stronger correlation with BCVA (P<0.05), NO (P<0.01), NC (P<0.01), and CS at 6 CPD (P<0.01) and 12 CPD (P<0.005) compared with ALD. CONCLUSIONS: Repeatable 360 degrees lens density measurements were obtained using Scheimpflug imaging. A stronger correlation was observed between NLD and LOCS III grading, BCVA, and photopic CS than with ALD. The NLD is an objective and repeatable method for assessment of lens density, which could be helpful in longitudinal studies monitoring nuclear cataracts.

Scheimpflug imaging of pediatric posterior capsule rupture.

We report a case of an 11-year-old boy who presented two days after blunt trauma to the left eye with a slingshot. On examination his best corrected visual acuity (BCVA) was 20/20 in the right eye and 20/400 in the left eye. Slit-lamp examination of the left eye revealed a Vossius ring, traumatic cataract, traumatic posterior capsule tear (PCT). The contour of the posterior capsule bulge corresponded to the edges of the PCT. Rotating Scheimpflug imaging (Pentacam 70700:Oculus, Wetzlar Germany) confirmed the traumatic cataract in the region of the PCT visualized as increased lens density at the cortex-vitreous interface. The extent of the PCT in the greatest and least dimensions was documented before and after intraocular lens (IOL) implantation. Intra-operatively, the PCT was evident and phaco-emulsification with an IOL implant was performed. Postoperatively, his BCVA improved to 20/20 in the left eye with a well-centered in-the-bag IOL as found on slit-lamp and Scheimpflug images.

Corneal collagen crosslinking using riboflavin and ultraviolet-A light for keratoconus: one-year analysis using Scheimpflug imaging.

PURPOSE: To evaluate changes in corneal curvature, corneal elevation, corneal thickness, lens density, and foveal thickness after corneal collagen crosslinking with riboflavin and ultraviolet-A (UVA) light in eyes with progressive keratoconus. SETTING: Grewal Eye Institute, Chandigarh, India. METHODS: Subjective refraction, best corrected visual acuity (BCVA), Scheimpflug imaging, and optical coherence tomography were performed preoperatively and 1 week, 1, 3, and 6 months, and 1 year after crosslinking. RESULTS: There were no significant differences (P > 0.05) in mean values between preoperatively and 1 year postoperatively, respectively, in BCVA (0.22 +/- 0.10 and 0.20 +/- 0.10), spherical equivalent (-6.30 +/- 4.50 diopters (D) and -4.90 +/- 3.50 D), or cylinder vector (1.58 x 7( degrees ) +/- 3.8 D and 1.41 x 24( degrees ) +/- 3.5 D). There was no significant difference in mean measurements between preoperatively and 1 year postoperatively, respectively, for central corneal thickness (458.9 +/- 40 microm and 455.2 +/- 48.6 microm), anterior corneal curvature (50.6 +/- 7.4 D and 51.5 +/- 3.6 D), posterior corneal curvature (-7.7 +/- 1.2 D and -7.4 +/- 1.1 D), apex anterior (P = .9), posterior corneal elevation (P = .7), lens density (P = .33), or foveal thickness (175.7 +/- 35.6 microm and 146.4 +/- 8.5 microm; P = .1). CONCLUSIONS: Stable BCVA, spherical equivalent, anterior and posterior corneal curvatures, and corneal elevation 1 year after crosslinking indicate that keratoconus did not progress. Unchanged lens density and foveal thickness suggest that the lens and macula were not affected after UVA exposure during crosslinking.

Evaluation of subconjunctival bevacizumab as an adjunct to trabeculectomy a pilot study.

PURPOSE: To determine whether bevacizumab can reduce bleb failure in patients undergoing first-time trabeculectomy for primary open-angle glaucoma (POAG) or chronic angle-closure glaucoma (CACG). DESIGN: Nonrandomized, open-label, prospective, interventional case series. PARTICIPANTS: Twelve individuals (7 males; 5 females) with a diagnosis of POAG or CACG, a recorded intraocular pressure (IOP) of more than 21 mmHg (between 10 am and 12 pm), glaucomatous damage on visual field or optic disc, and taking a maximum tolerated dose of IOP-lowering medication. INTERVENTION: Unilateral trabeculectomy with subconjunctival injection of bevacizumab (0.05 ml, 1.25 mg) adjacent to the bleb using a 30-gauge needle and tuberculin syringe administered immediately after trabeculectomy. MAIN OUTCOME MEASURES: Treatment success (unmedicated IOP of 6 to 16 mmHg inclusive) at 6 months; bleb characteristics according to the Moorfields bleb grading system on days 1, 7, 30, 90, and 180; incidence of postoperative intervention with 5-fluorouracil or mitomycin C; bleb needling; and incidence of and time to surgical failure. RESULTS: Mean age was 54.6+/-13.6 years. The mean preoperative IOP was 24.4+/-7.1 mmHg (range, 12-44 mmHg) and the patients were taking an average of 2.7+/-1.6 IOP-lowering medications (range, 1-4). The mean postoperative IOP was 8+/-3.1 mmHg (range, 4-13 mmHg) on day 1, 9.4+/-2.7 mmHg (range, 6-14 mmHg) on day 7, 10.9+/-2.8 mmHg (range, 8-16 mmHg) at 1 month, 10.3+/-2.5 mmHg (range, 7-14 mmHg) at 3 months, and 11.6+/-2.2 mmHg (range, 8-14 mmHg) at 6 months follow-up with no IOP-lowering medications. Preoperative best-corrected visual acuity was 0.70+/-0.3, whereas at 6 months after trabeculectomy, it was 0.66+/-0.3 (P = 0.39). After a mean follow-up of 182 days, of the 12 eyes, a successful trabeculectomy with respect to IOP control was observed in 11 eyes (92%), with an average IOP reduction of 52%. CONCLUSIONS: In this pilot study with a small number of subjects, 6-month outcomes suggest that subconjunctival bevacizumab is a potential adjunctive treatment for reducing the incidence of bleb failure after trabeculectomy. FINANCIAL DISCLOSURE(S): The authors have no proprietary or commercial interest in any materials discussed in this article.

Pentacam tomograms: a novel method for quantification of posterior capsule opacification.

PURPOSE: To develop and validate a method to quantify posterior capsule opacification (PCO) in eyes after cataract surgery and intraocular lens implantation using Scheimpflug Pentacam tomograms and compare its validity with slit lamp retroillumination image analysis. METHODS: One hundred twenty-four pseudophakic eyes of 124 patients were divided into two groups. Group 1 consisted of 40 eyes with visually significant PCO, and group 2 consisted of 84 eyes without visually significant PCO. Pentacam Imaging was performed after full mydriasis using the 50-scan acquisition protocol, and high-resolution tomograms were reconstructed and analyzed using ImageJ freeware. Retroillumination photographs were captured for group 1 eyes using the Topcon digital slit lamp, and these were analyzed using POCOman software to calculate an aggregate severity grade and percentage PCO value. Correlation coefficients were calculated for PCO values obtained using POCOman and ImageJ. RESULTS: Mean PCO percentage value obtained using POCOman software was 23.34 +/- 6.25 U, mean aggregate PCO severity grade was 0.46 +/- 0.28 U, and mean pixel-intensity value using ImageJ was 31.071 +/- 8.26 U. There was a significant positive correlation between the percentage PCO (P = 0.000; r = 0.864) and PCO severity grade (P = 0.001; r = 0.490) obtained for group 1 eyes using slit lamp retroillumination images and PCO pixel intensity obtained using Pentacam tomograms. CONCLUSIONS: Retroillumination photographs are the standard for quantifying PCO. Pentacam tomograms are easier to obtain and are free of flash reflections, and they allow for a more objective analysis. The correlation between the two methods demonstrates that ImageJ analysis of Pentacam tomograms is a viable tool for PCO analysis.

Repeatability of corneal parameters with Pentacam after laser in situ keratomileusis.

AIM: To investigate the coefficient of repeatability (CR) for corneal parameters evaluated with Pentacam after laser in situ keratomileusis (LASIK) in myopic eyes. DESIGN AND SETTING: Prospective, non-interventional, non-comparative study in an institutional setup. MATERIALS AND METHODS: Forty eyes of 40 consecutive subjects who had undergone LASIK for myopia were assessed with the Scheimpflug system (Pentacam 70700: Oculus, Wetzlar Germany). The mean of five consecutive measurements of all the corneal parameters was recorded and CR was calculated as standard deviation of the difference from the mean of these repeat measurements divided by the mean response. The statistical significance of the CR was calculated for these parameters at 5% significance level. RESULTS: The best CR was observed for the periphery of the anterior corneal curvature (0.18%) and the least for the horizontal meridian of the posterior corneal curvature (1.29%). Despite being significantly different ( P < 0.001), both the measurements were highly repeatable in post-LASIK eyes. The central, apical and minimal corneal thickness had a CR of 1%, 0.78% and 0.77% respectively. These were equally repeatable ( P> 0.323). The CR of the mean radius of curvature of the anterior cornea (0.29%) was significantly better ( P < 0.001) than the posterior corneal curvature (0.57%). CONCLUSION: The CR for the post-LASIK cornea with Pentacam was the best for the anterior corneal curvature. Significantly, Pentacam has a high degree of repeatability for the posterior corneal curvature, which has a potential for early detection of keratectasia in these eyes. Post-LASIK pachymetry with Pentacam also showed excellent repeatability.

Unilateral electric cataract: Scheimpflug imaging and review of the literature.

A 22-year-old man presented with diminution of vision in the left eye 1 month after sustaining an injury from a high-voltage electric current to the left side of his head. Slitlamp examination and Scheimpflug imaging confirmed the typical anterior subcapsular lenticular opacities in the left eye and also documented early anterior subcapsular vacuoles in the right eye. Based on history, the electric shock wound, and the typical appearance of the opacities, an electric cataract was diagnosed. The difference in lens density between the 2 eyes was also documented. The best corrected visual acuity (BCVA) was 20/20 in the right eye and counting fingers at 1 foot in the left eye. Phacoaspiration and posterior chamber intraocular lens implantation were performed in the left eye. Postoperatively, the BCVA improved to 20/20. The developmental mechanisms of these opacities after exposure to an electric current and the role of Scheimpflug imaging in assessing the earliest subclinical manifestations of electric cataract injuries are discussed.

In vivo fluorescein staining of SI-30NB silicone intraocular lens.

We report a case of a 48-year-old pseudophakic woman who presented 3 weeks after Heidelberg retinal angiography using intravenous sodium fluorescein 2%. Bilateral retinal vasculitis with severe retinal ischemia and extensive capillary dropouts had been diagnosed. Anterior segment examination revealed green staining on the silicone optic of the 3-piece SI-30NB intraocular lens (IOL) (AMO), with no cell or flare in the aqueous humor. The anterior and posterior capsules were not stained. The patient did not report dark vision, double vision, or altered color vision. The anterior and posterior IOL surfaces demonstrated an autofluorescence at the time of fundus photography, which persisted to the 6-week examination although there were no symptoms. This is suggestive of deposits of sodium fluorescein on the IOL surface following angiography.

Scheimpflug imaging in late Capsular Bag Distention syndrome after phacoemulsification.

PURPOSE: To describe two cases of late Capsular Bag Distention syndrome (CBDS) and posterior capsular opacification (PCO) as documented on Pentacam. DESIGN: Case series. METHODS: A 55-year-old male and a 72-year-old female presented three years after phacoemulsification and intraocular lens (IOL) implantation with a complaint of decreased vision. Scheimpflug imaging was done using Pentacam. Patients underwent Nd:YAG capsulotomy for PCO, and postcapsulotomy capsular bag dynamics were imaged on Pentacam. RESULTS: Three years after phacoemulsification, patients presented with blurred vision and posterior bowing of opacified posterior capsule. Anterior capsular opening was apparently sealed by lens optic, and space between IOL and opacified posterior capsule was filled with turbid fluid. Nd:YAG laser capsulotomy was done. All findings, including collapse of distended bag, were precisely documented on Scheimpflug images. CONCLUSIONS: Pentacam Scheimpflug imaging is a useful technique to diagnose and document the presence and progress of CBDS and PCO.

Role of scheimpflug imaging in traumatic intralenticular foreign body.

PURPOSE: The role of Pentacam Scheimpflug imaging in evaluation of penetrating eye injury and intralenticular foreign body (ILFB). DESIGN: Interventional case report. METHODS: A 35-year-old male presented to our clinical practice with penetrating eye injury and endophthalmitis. Scheimpflug imaging helped localize the intralenticular foreign body (ILFB). It confirmed the posterior capsule to be intact. He underwent phacoemulsification, foreign body removal, and intraocular lens (IOL) implant. Postoperatively, IOL was imaged with Pentacam Scheimpflug imaging. RESULTS: Scheimpflug imaging allowed us to confirm the presence and exact location of ILFB and its relation to the intact posterior capsule as well as the postoperative IOL positioning. This helped in better planning of management of traumatic cataract with ILFB. CONCLUSIONS: Pentacam is a potential tool for accurate localization of foreign bodies lodged in the lens and provides an objective basis for better patient counseling and surgical planning.