Iodine-125 brachytherapy for choroidal melanoma by using Ocuprosta seeds with indigenous non-collimated plaques: Our initial experience.

PURPOSE: Brachytherapy is the gold-standard treatment for choroidal melanoma. This study evaluated iodine-125 brachytherapy by using Ocuprosta seeds with indigenous non-collimated plaques in Asian patients. METHODS: Retrospective single-center study in a tertiary care hospital of 12 eyes with choroidal melanoma in 12 Asian patients who underwent brachytherapy with Ocuprosta seeds fixed on non-collimated plaques and had a follow-up of at least 32 months (mean: 42.4 ± 9.5 months; median: 40 months). Radiotherapy was planned after developing the digital 3D model of the tumor within the eye by using radiological images and clinical pictures. Ocuprosta iodine-125 seeds were used on indigenous non-collimated gold plaques to deliver the radiation for precalculated time. "Successful outcome" was taken as a decrease in the volume of the tumor, and "unsuccessful outcome" was defined as no change in the tumor volume or increase in the tumor volume at 24 months after brachytherapy. RESULTS: The mean decrease in tumor volume was 21% (914.5 ± 912.2 mm3 to 495.7 ± 633.6 mm3) after brachytherapy, which correlated with the baseline volume of the tumor. Ten eyes (83.3%) showed a reduction in tumor volume, whereas two eyes showed an increase in the volume of the tumor after brachytherapy. One of the cases with a reduction in tumor size developed neovascular glaucoma. Enucleation was done in three eyes. A globe salvage rate of 75% and tumor regression rate of 83% were seen in the present study using Ocuprosta seeds. CONCLUSIONS: Iodine-125 brachytherapy with uncollimated indigenous gold plaques is an effective treatment modality for choroidal melanomas in Asian patients.

Concomitant multiple subretinal cysticerci in neurocysticercosis.

We present a unique case of asymptomatic NCC that was accidently diagnosed on radiological investigations after a road traffic accident. An Ophthalmologic consult was sought to rule out intraocular or optic nerve cysticercosis. Fundoscopy showed multiple white-pale yellow lesions in the right eye which on ultrasonography confirmed cyst lined by a cyst wall consistent with subretinal cysticercosis. The patient was treated with diode laser photocoagulation. A high index of suspicion is required to diagnose NCCin endemic areas. In the right eye which on ultrasonography confirmed cyst lined by a cyst wall consistent with subretinal cysticercosis. The patient was treated with diode laser photocoagulation.

Systemic biomarkers of retinopathy of prematurity in preterm babies.

PURPOSE: Retinopathy of prematurity (ROP) progression is an inter-play of various perinatal and neonatal angiogenic and inflammatory cytokines. A small subset of ROP progresses to ROP requiring treatment. The present study was conducted with the aim to determine whether levels of IL-6, IL-8 and VEGF in serum and urine at the time of first ROP screening visit could be a biomarker for the prediction of development of treatable ROP. METHOD: Prospective single-center observational study of preterm babies screened for ROP. Blood and urine samples were collected as a part of routine sampling at initial ROP screening visit and stored at -80 °C for further processing. The babies were followed up and grouped into 'Group A' comprising of 35 babies who developed treatable ROP and 'Group B' comprising of 36 babies with regressed ROP or no ROP. The evaluation of blood and urine samples was done for IL6, IL8 and VEGF by solid-phase sandwich RayBio® Human ELISA kit. RESULTS: The median serum values for IL-6, IL-8 and VEGF in Group A and Group B were 5.8 pg/ml (IQR 1.5,128.5) and 8.7 pg/ml (IQR 1.5,30.5), 55.9 pg/ml (IQR 28.0, 392.9) and 27.0 pg/ml (IQR 20.5,444.9) and 26.6 pg/ml (IQR 6.3, 39.4) and 30.0 pg/ml (IQR9.2,70.3), respectively. Group A had significantly increased levels of IL-8 (p < 0.05). However, AUROC curve for serum IL-8 demonstrated suboptimal discriminating ability. CONCLUSION: Babies developing ROP requiring treatment had significantly increased levels of IL-8 in the serum at the time of initial screening. However, it could not serve as predictor for treatable ROP.

Fundus fluorescein angiography in retinopathy of prematurity.

BACKGROUND/OBJECTIVES: Retinopathy of prematurity (ROP) is a potentially blinding disease of immature retinal vasculature. ROP regresses in majority of the cases and very few go on to develop ROP needing treatment. Fundus fluorescein angiography (FFA) is the gold standard technique to study retinal vasculature. The present study was undertaken with the objective to identify the FFA findings associated with the progression of ROP. SUBJECT/METHODS: Prospective single centre study in a tertiary care hospital of 99 eyes of 50 preterm babies. Fundus fluorescein angiography (FFA) was performed in all babies using RetCam 3 at the first detection of ROP. The babies were followed up for the progression of ROP. The FFA predictors for the progression of ROP were evaluated using the Mann-Whitney U test and Fisher's test. RESULTS: Thirty-eight eyes were Type 1 ROP at initial presentation and were lasered. Amongst the rest, 24 eyes showed features of stage 3 ROP with intense leakage on FFA and were designated as FFA-treatable ROP and were also lasered. Amongst the rest of the 37 eyes, the disease progression was seen in 13 eyes and the disease regression was seen in 24 eyes. The baseline FFA findings associated with the progression of ROP were delayed retinal arterial perfusion (p = 0.037) and popcorn lesions (p = 0.042). The post hoc analysis was done using a validated FFA scoring system. CONCLUSIONS: FFA may be added in the classification of ROP and delayed retinal arterial perfusion and popcorn lesions on FFA may predict the progression of ROP.

Rhegmatogenous retinal detachment with giant retinal tear in a child with Marfan's syndrome: a rare ocular emergency.

A 7-year-old boy with Marfanoid habitus presented with sudden and painless decrease in the vision of the right eye. Ocular examination revealed rhegmatogenous retinal detachment with 360° giant retinal tear in the right eye and small peripheral retinal breaks with lattice degeneration in the left eye. The patient underwent a 23-gauge pars plana vitrectomy with scleral buckling in the right eye and laser around the breaks in the left eye. At 1-week follow-up visit, the child presented with similar complaints in the left eye as were seen in the right eye. This was later managed effectively with 23-gauge pars plana vitrectomy only. So, with our case report, we would like to highlight the need for aggressive screening in children who are diagnosed with Marfan's syndrome and the need for prophylactic treatment in the unaffected eye.

Metastatic endophthalmitis presenting as subretinal abscess following a forearm furuncle.

Metastatic endophthalmitis (ME) is rare form of secondary uveitis commonly prevalent in immunocompromised patients. A 55-year-old immunocompetent woman presented with painful decrease in left eye vision (referred to us as cytomegalovirus retinochoroiditis). Ocular examination revealed diffuse yellowish-white retinitis lesion (diagnosed as subretinal abscess on macular optical coherence tomography). Vitreous tap was unremarkable, but vitreous biopsy from the posterior vitreous overlying the subretinal abscess confirmed the growth of methicillin-sensitive Staphylococcus aureus (MSSA). Detailed systemic examination revealed a forearm furuncle, which yielded MSSA on culture. The infection followed relentless course despite aggressive treatment with pars plana vitrectomy and antibiotics (topical, systemic and intravitreal). This case is presented due to rarity of presentation of ME as subretinal abscess following skin infection, which became a management challenge. Due to its rapid progression and irreversible damage to ocular tissue, high index of suspicion and aggressive management is needed in such cases. The disease course, management and prognosis of such cases are dismal in majority of the patients.

Use of an online screening algorithm - Weight, Insulin-derived growth factor 1, Neonatal Retinopathy of Prematurity (WINROP) for predicting retinopathy of prematurity in Indian preterm babies.

Purpose: Inopathy of prematurity (WINROP) Weight, insulin-derived growth factor 1, neonatal ROP algorithm is an online tool that has been validated as a predictor of retinopathy of prematurity (ROP) in various countries. The current study was designed to evaluate the predictive ability of WINROP algorithm (http://winrop.com) using postnatal weight gain in detecting Type 1 ROP in Indian babies. Methods: Prospective single centre observational study of 153 consecutive preterm babies who were eligible for screening for ROP as per the standard guidelines. Sixteen babies were excluded from the study because of various reasons. Thirty-five babies had gestational age ≥32 weeks and were ineligible for WINROP algorithm. Online WINROP algorithm was used for 102 babies with gestation at birth less than 32 weeks. The alarms triggered by WINROP were documented. Results: Laser treatment was done in 30 babies who developed Type 1 ROP. Of these, WINROP alarm was signaled in 24 babies and 6 babies developed ROP without any WINROP alarm. These babies had associated comorbidities like respiratory distress syndrome, patent ductus arteriosus, bacterial sepsis, and ventilatory support. WINROP alarm was significantly associated with Type 1 ROP (P < 0.001). The sensitivity of WINROP was 80% and specificity was 80.6% with a positive predictive value of 63.2% and negative predictive value of 90.6% in detecting Type 1 ROP. In the present study, no baby who was ineligible for WINROP developed Type 1 ROP. Conclusion: WINROP provides a novel online monitoring screening tool for identifying babies at risk of developing Type 1 ROP. In our cohort, none of the babies whose period of gestation was more than or equal to 32 weeks developed sight threatening Type 1 ROP. WINROP algorithm may also be useful in Indian population.

Plaque brachytherapy for choroidal melanoma with vitreous haemorrhage: a therapeutic challenge.

A 47-year-old man presented with profound loss of vision in right eye and relative afferent pupillary defect. On fundus examination, posterior pole details were obscured due to dense vitreous haemorrhage. B-scan ultrasonography was performed that revealed a mushroom-shaped hyperechoic lesion with medium internal reflectivity on A-scan ultrasonography. After performing contrast-enhanced MRI of the orbit, a diagnosis of choroidal melanoma was established. Patient was managed using plaque brachytherapy based on multiplanar MRI. This was followed 10 months later by pars plana vitrectomy and cataract extraction. Vision postoperatively improved to 20/60. A systematic clinical assessment along with supportive ancillary investigations augments diagnostic accuracy and reduces delay in definitive management.

Avascular island in the vascularised retina in zone II ROP.

We describe an atypical form of avascular island demarcated by a ridge in the vascularised retina of retinopathy of prematurity. Fundus fluorescein angiography showed an unusual finding of an avascular island demarcated by shunt vessels in vascularised retina posterior to the ridge. There is a need to document this finding as this could throw some light on the aetiopathogenesis of the disease.

Unusual case of intraocular medulloepithelioma in an adult male.

Medulloepithelioma is a rare tumor of the eye, arising from the posterior segment. This embryonic tumor is mostly seen in children and is very rare in adult population. This case report presents the case of a 39-year-old Indian male, who had gradual vision loss over 4 years in his left eye with new onset of pain. He was referred to our center in view of secondary cataract and intraocular mass. Vision in right eye was 20/ 20 while left eye had no light perception at presentation. Ocular examination of the left eye revealed shallow anterior chamber, florid iris neovascularization, raised intraocular pressure and cataractous lens. B-scan ultrasonography showed a heterogenous mass filling the entire globe. MRI scan confirmed the finding, showing a mass hyper-intense to vitreous. No invasion of optic nerve or sclera was observed. Left eye enucleation with PMMA implant placement was performed and histopathology confirmed the diagnosis of benign teratoid medulloepithelioma. At the time of submission of this report, the patient was still under follow-up and had no detectable metastases at 15 months follow-up. This report highlights a very rare case of embryonic tumor in adult male, which could be managed successfully with a high index of suspicion and timely intervention.

Unusual presentation of Retinoblastoma.

Most cases of retinoblastoma are diagnosed before the age of 5 years. The cases in older age groups can have variable presentations leading to misdiagnosis and management challenges. We report a case of retinoblastoma in an 8-year-old female who was primarily referred as a case of sympathetic ophthalmia due to a co-incidental misleading history of penetrating eye injury to other eye 3 weeks prior. The patient complained of decreased vision in the left eye after 3 weeks of repair of the corneo-scleral laceration in the right eye. Visual acuity in the right and left eye was 3/60 and light perception respectively. The anterior segment examination showed moderate sized keratic precipitates, intense inflammatory cellular reaction with large fluffy cells, hypopyon and dense vitreous exudates. Ultrasonography showed abundant hyperechoic contents within the vitreous cavity in the left globe. The retino-choroid was thickened. The possibility of endophthalmitis and sympathetic ophthalmia was considered. Diagnostic vitrectomy was planned. Intraoperatively, after clearing the exudates, a yellowish white mass lesion was seen superiorly. Post- operatively contrast-enhanced MRI scan confirmed the presence of an enhancing mass lesion in the globe consistent with the diagnosis of intraocular retinoblastoma. Enucleation of left globe was done after chemotherapy. Thus, a high risk of suspicion has to be kept for this malignant tumour in children with unexplained visual loss.

Toll-like receptors in acute post-cataract surgery endophthalmitis.

OBJECTIVE: To evaluate the expression of toll-like receptor 2 (TLR2) and toll-like receptor 4 (TLR4) on CD14 + cells in vitreous and blood of post-cataract surgery acute endophthalmitis. DESIGN: This prospective case-control pilot study enrolled 16 patients of post-cataract surgery endophthalmitis. All the cases were subjected to 23 G pars plana vitrectomy (PPV). Ten patients undergoing 23 G PPV for non-infectious conditions were taken as controls. METHODS: 23 G PPV was performed, and three undiluted vitreous samples were collected in heparinized syringes from the cases and the controls. Simultaneous venous blood sample was taken, and flow cytometry was performed to detect the expression of TLR2 and TLR4 in vitreous and blood samples. The vitreous and blood samples were incubated with fluorescein isothicyanate (FITC) conjugated anti-TLR2 monoclonal antibody Alexafluor (AX) 647 and anti-TLR4 monoclonal antibody phycoerythrin. Data acquisition was done on a pre-calibrated flow cytometer. TLR analysis of the acquired flow cytometry data was then performed. Mean channel fluorescence intensity (MFI) derived from fluorescence histogram was used to study the level of cell surface TLR expression. MFI was calculated as a ratio and recorded as the MFI of the TLR2 or -4 antibody divided by the MFI of the isotype-matched negative control antibody. Core vitrectomy was done as per the comfort of the surgeon, and intravitreal antibiotics vancomycin (1 mg/0.1 ml) and ceftazidime (2.25 mg/0.1 ml) were injected. The cytological examination was done on vitreous and blood sample. STATISTICAL ANALYSIS: The median TLR 2 and TLR4 values between cases and controls were compared by Mann-Whitney U test. Spearman's rank correlation test was used to assess the correlation between TLR expression and disease activity. RESULTS: Vitreous cytology evaluation showed the presence of neutrophils (81.25%, n = 13), monocytes (68.75%, n = 11) and lymphocytes (62.50%, n = 10). The level of expression of TLR2 in vitreous showed a statistically significant correlation with an increase in the time interval of cataract surgery and intervention for endophthalmitis (p < 0.05), but the same was not observed for TLR4. A drift toward higher level of expression of TLR2 and TLR4 in vitreous was observed in patients with poor outcome. CONCLUSION: TLR2 levels increase with the delay in presentation; thus, TLR2 ligands in vitreous could serve as a good target for the treatment of endophthalmitis.

Choroidal osteoma: the varied response of subretinal fluid to anti-VEGF agents.

The present case shows a remarkable long-term response of the choroidal neovascular membrane and serous retinal detachment associated with choroidal osteoma to two injections of ranibizumab which is an anti-vascular endothelial growth factor (anti-VEGF) agent.

To study the impact of diabetic retinopathy on quality of life in Indian diabetic patients.

Purpose: To study the impact of diabetic retinopathy (DR) on the quality of life (QoL) of Indian patients with diabetes. Methods: This cross-sectional tertiary health care institution-based study involved 250 patients of DR. They were interviewed using four questionnaires, namely, the General Health Questionnaire (GHQ), Final Quality of Life Instrument for Indian Diabetic Patients (QoLID) questionnaire for diabetes and questionnaire modified for DR, retinopathy dependent quality of life (RetDQoL), and coping strategy checklist (CSCL). Results: The mean GHQ score was 1.12, indicating the absence of psychological morbidity. Mean QoLID score for financial worries and treatment satisfaction scores were 15 each for DR compared with 17 and 16, respectively, for diabetes mellitus (DM). The mean RetDQoL score was -27.94 (±2.14), showing the negative impact of DR on QoL. The mean CSCL score was 1.22 (±0.14), indicating infrequent use of coping strategies. Scores achieved by all four questionnaires correlated to each other. On subgroup analysis, proliferative DR (PDR) patients had a significantly higher GHQ score, lower treatment satisfaction, and more financial worries, with a poorer QoL than nonproliferative DR (NPDR). The severity of the disease had a negative impact on the QoL. The treatment satisfaction and psychological impact on the patients undergoing all types of eye treatments were comparable. Conclusion: DR has a significantly detrimental impact on the QoL, which increases with increasing severity of the disease.

Post-Traumatic Endophthalmitis Due to Acinetobacter radioresistens: Virulence Potential of Commensal Bacteria.

Acinetobacter species are widely distributed in soil, water and hospital environment. In addition to A. calcoaceticus-baumannii complex, the clinically most relevant species, there are other genomospecies which are less frequently identified, mostly due to lack of accurate methods for routine identification. We describe the first case of post-traumatic endophthalmitis caused by otherwise non-pathogenic A. radioresistens, in India. Gram-negative coccobacilli were observed on Gram stain and culture of vitreous fluid specimen, and identified biochemically as Acinetobacter spp. The species was identified by Matrix Assisted Laser Desorption Ionization- Time of Flight Mass Spectrometry (MALDI-TOF MS). The pathogenic potential of 'commensal' A. radioresistens and its role in dissemination of carbapenem resistance genes underlines the importance of species-level identification in Acinetobacter infections.