The Slitscope.

Slit lamp biomicroscope is the right hand of an Ophthalmologist. Even though precise, its bulky design and complex working process are limiting constraints, making it difficult for screening at outreach camps, which are an integral part of this field for the purpose of eliminating needless blindness. The torchlight is the main tool used for screening. Recently, the integration of smartphones with instruments and the digitization of slit lamp has been explored, to provide simple and easy hacks. By bringing the slit of the slit lamp to traditional torchlight, we have created "The Slitscope". It combines the best of both worlds as a simple innovative do-it-yourself novel technique for precise cataract screening. It is especially useful in peripheral centers, vision centers, and outreach camps. We present two prototypes which can also be 3D printed.

A rare case of focal choroidal excavation associated choroidal neovascularization in angioid streaks.

The purpose is to report a case of focal choroidal excavation (FCE) in a patient with angioid streaks (ASs) associated with secondary choroidal neovascularization (CNV). A 26-year-old man was referred for the treatment of CNV. On further evaluation, he was found to have ASs and optical coherence tomography revealed the presence of the choroidal neovascular complex associated with FCE. The patient was treated with a single dose of intravitreal bevacizumab (1.25 µg/0.05 ml). There was resolution of the lesion, and on further follow-up over 6 months, there were no recurrences. CNV in patients with ASs may also be associated with FCE. These patients have a good response to intravitreal antivascular endothelial growth factor injection.

Risk of Tractional Retinal Detachment Following Intravitreal Bevacizumab Along with Subretinal Fluid Drainage and Cryotherapy for Stage 3B Coats' Disease.

PURPOSE: To review the surgical outcomes of intravitreal bevacizumab (IVB) along with subretinal fluid drainage with cryotherapy in patients with stage 3B Coats' disease. MATERIALS AND METHODS: A retrospective study of seven cases of stage 3B Coats' disease, who underwent subretinal fluid drainage with cryopexy, from May 2011 to March 2014. Five eyes received additional IVB at the end of surgery. Green laser therapy was performed on telangiectatic vessels postoperatively. RESULTS: The mean age was 34 months (range, 10-84 months). Mean follow-up was 19 months. Six patients (85.7%) had an attached retina at final follow-up. Three out of four patients (75%) that received IVB developed tractional retinal detachments (TRDs). Two eyes that did not receive bevacizumab did not develop any traction. None progressed to neovascular glaucoma or phthisis bulbi. CONCLUSION: Simultaneous injection of bevacizumab along with subretinal drainage and cryotherapy for advanced Coats' disease could not avoid TRD.

Racial disparities in cord blood vitamin D levels and its association with small-for-gestational-age infants.

OBJECTIVE: To examine the relationship of race and maternal characteristics and their association with cord blood vitamin D levels and small-for-gestational-age (SGA) status. STUDY DESIGN: Cord blood vitamin D levels were measured in 438 infants (276 black and 162 white). Multivariable logistic regression models were used to evaluate associations between maternal characteristics, vitamin D status and SGA. RESULTS: Black race, Medicaid status, mean body mass index at delivery and lack of prenatal vitamin use were associated with vitamin D deficiency. Black infants had 3.6 greater adjusted odds (95% confidence interval (CI): 2.4, 5.6) of vitamin D deficiency when compared with white infants. Black infants with vitamin D deficiency had 2.4 greater adjusted odds (95% CI: 1.0, 5.8) of SGA. Vitamin D deficiency was not significantly associated with SGA in white infants. CONCLUSION: Identification of risk factors (black race, Medicaid status, obesity and lack of prenatal vitamin use) can lead to opportunities for targeted prenatal vitamin supplementation to reduce the risk of neonatal vitamin D deficiency and SGA status.

Prenatal genetic diagnosis of retinoblastoma and report of RB1 gene mutation from India.

BACKGROUND: Retinoblastoma is the most common intraocular malignancy of childhood. There is a paucity of genetic testing and prenatal genetic diagnosis from India, which has the highest incidence worldwide. MATERIALS AND METHODS: RB1 gene screening of an 8-month-old female child with bilateral retinoblastoma was accomplished using next generation sequencing. The results were used for prenatal testing in this family. RESULTS: A heterozygous germline mutation (chr13: 48951119delA; c.1281delA) was detected, which resulted in premature termination of a protein product (p.Glu428Argfs*29). Prenatal testing in maternal DNA revealed carrier status of the mother. Further clinical examination in the family members revealed retinocytomas in both eyes of the mother and maternal grandmother. Prenatal genetic testing of the developing fetus showed positivity for the mutation. As the family preferred to continue the pregnancy, serial 3-D ultrasounds were carried out every 2 weeks in the third trimester. Ten days after delivery, small extrafoveal tumors developed in both eyes, which were then treated successfully with transpupillary thermotherapy. CONCLUSION: We report the significance of genetic testing in the early detection and management of retinoblastoma from India.

Safety and efficacy of simultaneous bilateral 25-gauge lens-sparing vitrectomy for vascularly active stage 4 retinopathy of prematurity.

PURPOSE: To report the safety and efficacy of simultaneous bilateral 25-gauge lens-sparing vitrectomy for vascularly active stage 4 retinopathy of prematurity (ROP). METHODS: Retrospective, noncomparative, consecutive case series. Twenty eyes of 10 babies who presented with vascularly active stage 4 ROP in both the eyes underwent simultaneous bilateral 25-gauge lens-sparing vitrectomy. After completing surgery for one eye, the other eye was re-prepped as performed before starting any new case of a different patient and an entire new set of disposable 25-gauge instruments were used. During the post-operative period parents were advised to keep separate eye drops for each eye and to wash their hands in between switching the eyes to put the drops. RESULTS: The mean follow-up was 8.7 months (range 4-17 months). None of the cases developed any signs of infection. The anatomic success rate for stage 4a was 100% (11/11 eyes) and for stage 4b was 8/9 eyes (89%). CONCLUSION: These results show that simultaneous bilateral 25-gauge lens-sparing vitrectomy for stage 4 ROP is a safe and effective procedure with a good outcome provided both eyes of the baby are treated as eyes of two different patients.

In vitro susceptibility of filamentous fungi from mycotic keratitis to azole drugs.

OBJECTIVE: The in vitro antifungal activities of azole drugs viz., itraconazole, voriconazole, ketoconazole, econazole and clotrimazole were investigated in order to evaluate their efficacy against filamentous fungi isolated from mycotic keratitis. METHODS: The specimen collection was carried out from fungal keratitis patients attending Aravind eye hospital and Post-graduate institute of ophthalmology, Coimbatore, India and was subsequently processed for the isolation of fungi. The dilutions of antifungal drugs were prepared in RPMI 1640 medium. Minimum inhibitory concentrations (MICs) were determined and MIC50 and MIC90 were calculated for each drug tested. RESULTS: A total of 60 fungal isolates were identified as Fusarium spp. (n=30), non-sporulating moulds (n=9), Aspergillus flavus (n=6), Bipolaris spp. (n=6), Exserohilum spp. (n=4), Curvularia spp. (n=3), Alternaria spp. (n=1) and Exophiala spp. (n=1). The MICs of ketoconazole, clotrimazole, voriconazole, econazole and itraconazole for all the fungal isolates ranged between 16 µg/mL and 0.03 µg/mL, 4 µg/mL and 0.015 µg/mL, 8 µg/mL and 0.015 µg/mL, 8 µg/mL and 0.015 µg/mL and 32 µg/mL and 0.06 µg/mL respectively. From the MIC50 and MIC90 values, it could be deciphered that in the present study, clotrimazole was more active against the test isolates at lower concentrations (0.12-5 µg/mL) when compared to other drugs tested. CONCLUSION: The results suggest that amongst the tested azole drugs, clotrimazole followed by voriconazole and econazole had lower MICs against moulds isolated from mycotic keratitis.

Long term refractive and structural outcome following laser treatment for zone 1 aggressive posterior retinopathy of prematurity.

AIM: To report the long term refractive, visual and structural outcome post-laser for zone 1 aggressive posterior retinopathy of prematurity (AP-ROP). MATERIALS AND METHODS: A retrospective analysis was performed of refractive status of premature infants with zone 1 AP-ROP who underwent laser photocoagulation from 2002 to 2007 and followed up till 2013. Once the disease regressed, children were followed up six monthly with detailed examination regarding fixation pattern, ocular motility, nystagmus, detailed anterior segment and posterior segment examination, and refractive status including best corrected visual acuity. RESULTS: Forty-eight eyes of 25 infants were included in the study. Average follow-up was 6.91 years (range, 3.8-9.5years) after laser treatment. Astigmatism was noted in 43 out of 48 eyes (89.6%). Two eyes had simple myopia whereas three eyes had no refractive error. CONCLUSION: After successful laser treatment for zone 1 retinopathy of prematurity (ROP), 94% of our cases developed refractive error. Although most had a favorable anatomical and visual outcome, long-term follow-up even after a successful laser treatment in ROP was necessary.

Neonatal intensive care practices and the influence on skin condition.

BACKGROUND: Premature skin has a thinner epidermis with a poorly formed stratum corneum (SC) barrier compared to full term skin. Poor skin integrity increases the risk of exposure to irritants and infectious agents. Interventions that facilitate skin maturation are essential. OBJECTIVE: The objective was to examine the effects of prematurity and time from birth on SC maturation and to identify factors that impact skin condition. METHODS: A retrospective review was conducted among 130 NICU patients. Skin regions were evaluated for erythema, rash, integrity and function. The effects of gestational age, time from birth, stool exposure, nutrition and diagnosis were examined. RESULTS: Three groups emerged: (i) premature and <38 weeks adjusted age; (ii) premature and >38 weeks adjusted age; and (iii) full term. Surprisingly, the premature infants exhibited lower perineal irritation and greater SC integrity (lower transepidermal water loss) than full terms (P < 0.05). Group 2 had a longer time before the first skin-stool contact. Chest skin pH showed maturational changes for Group 1 (P < 0.05) but did not change for premature Group 2 who was older at enrollment. Erythema was lower for infants using elemental formulas or total parenteral nutrition. CONCLUSIONS: Premature infants with early stool contact and high exposure, full term infants, and patients with congenital diaphragmatic hernia or trisomy 21 are at high risk for skin compromise and may benefit from prophylactic interventions to minimize compromise. Low stool exposure and greater time before the first stool contact appear to be protective against skin compromise.

Episcleral plaque brachytherapy using 'BARC I-125 Ocu-Prosta seeds' in the treatment of intraocular tumors: a single-institution experience in India.

CONTEXT: To analyze the results of episcleral plaque brachytherapy using indigenous Bhabha Atomic Research Centre (BARC) Iodine-125 Ocu-Prosta seeds for the management of intraocular tumors from a single institute. AIM: To report our initial experience and learning curve on the use of 'BARC I-125 Ocu-Prosta seeds' for the management of intraocular tumors such as choroidal melanomas, retinoblastomas and vasoproliferative tumors (VPT). MATERIALS AND METHODS: We retrospectively reviewed 13 eyes of 13 patients who underwent ophthalmic brachytherapy between May 2008 to March 2012. Nine cases had choroidal melanomas; three had retinoblastomas while one case had VPT. RESULTS: For choroidal melanomas the average apical diameter before brachytherapy was 7.6 mm and average largest basal diameter was 12.1 mm, respectively, which reduced to 4.2 mm and 7.7 mm after the procedure at an average follow-up of 24 months (range 10-43 months). Retinoblastoma and VPT also showed good regression after brachytherapy. CONCLUSION: Plaque radiotherapy using 125 I seeds can be performed under peribulbar anesthesia and provides a viable option for the management of intraocular cancer with minimal invasiveness and surgical complications. Patients in our studies experienced excellent local tumor control. With the availability of indigenous 'BARC I-125 Ocu-Prosta seeds' locally, cost effective ophthalmic brachytherapy can be performed in India.

In vivo sectional imaging of the retinal periphery using conventional optical coherence tomography systems.

Optical coherence tomography (OCT) has transformed macular disease practices. This report describes the use of conventional OCT systems for peripheral retinal imaging. Thirty-six eyes with peripheral retinal pathology underwent imaging with conventional OCT systems. In vivo sectional imaging of lattice degeneration, snail-track degeneration, and paving-stone degeneration was performed. Differences were noted between phenotypes of lattice degeneration. Several findings previously unreported in histopathology studies were encountered. Certain anatomic features were seen that could conceivably explain clinical and intraoperative behavior of peripheral lesions. Peripheral OCT imaging helped elucidate clinically ambiguous situations such as retinal breaks, subclinical retinal detachment, retinoschisis, choroidal nevus, and metastasis. Limitations of such scanning included end-gaze nystagmus and far peripheral lesions. This first of its kind study demonstrates the feasibility of peripheral retinal OCT imaging and expands the spectrum of indications for which OCT scanning may be clinically useful.

The lost art of intubation: assessing opportunities for residents to perform neonatal intubation.

OBJECTIVE: The objective of this study is to assess the opportunities afforded to and competence of pediatric residents in performing neonatal endotracheal intubations. STUDY DESIGN: The records of all intubations performed on neonates over a 3-year period at a university-based birthing hospital were reviewed to assess the relationships between outcomes, types of providers and the setting of intubations. RESULT: A total of 785 attempts were made during 362 intubations. Pediatric residents were given the opportunity to intubate 38% of the cohort (n=137) and were successful on 21% of the attempts. Residents were more likely to perform intubation in the neonatal intensive care unit (vs delivery room; P<0.001), in non-emergency situations (P<0.001), and on older (P<0.001) and larger (P=0.07) infants. CONCLUSION: Opportunities for residents to intubate neonates were few and their success rate was low. In the current care paradigm, it is doubtful if trainees can be sufficiently skilled in endotracheal intubation during residency. Residents that plan to pursue procedure-intensive subspecialties may benefit from other models for training.

Hospital and neurodevelopmental outcomes of extremely low-birth-weight infants with necrotizing enterocolitis and spontaneous intestinal perforation.

OBJECTIVE: We sought to determine the incidence of necrotizing enterocolitis (NEC) and spontaneous intestinal perforation (SIP) in surviving extremely low-birth-weight (ELBW, <1000 g birth weight) infants and to establish the impact of NEC on outcomes by hospital discharge and at 18 to 22 months adjusted age in a large, contemporary, population-based practice. STUDY DESIGN: Hospital outcome data for all ELBW infants born in the greater Cincinnati region from 1998 to 2009 were extracted from the National Institute of Child Health Neonatal Research Network Database. Neurodevelopmental outcome at 18 to 22 months was assessed using Bayley Scales of Infant Development-II scores for Mental Developmental Index and Psychomotor Developmental Index. Multivariable logistic regression was used and adjusted odds ratios reported to control for confounders. RESULT: From 1998 to 2009, ELBW infants accounted for 0.5% of the 352 176 live-born infants in greater Cincinnati. The incidence of NEC was 12%, with a 50% case-fatality rate. Death before discharge, morbid complications of prematurity and neurodevelopmental impairment were all increased among infants diagnosed with NEC. Infants with surgical NEC and SIP had a higher incidence of death, but long-term neurodevelopmental outcomes were not different comparing surviving ELBW infants with medical NEC, surgical NEC and SIP. CONCLUSION: Although ELBW infants comprise a very small proportion of live-born infants, those who develop NEC and SIP are at an increased risk for death, morbid complications of prematurity and neurodevelopmental impairment. No significant differences in neurodevelopmental outcomes were observed between the medical and surgical NEC and SIP groups.

Awareness of retinopathy of prematurity among pediatricians in a tier two city of South India.

PURPOSE: To analyze the level of awareness and knowledge about retinopathy of prematurity (ROP) among pediatricians in Coimbatore, which is a tier two city in South India. MATERIALS AND METHODS: A questionnaire was framed on the knowledge attitude and practice (KAP) pattern. The questionnaire was given to 83 practicing pediatricians in government and private practice in Coimbatore and collected in person between November and December 2009. Answers were obtained on criteria like knowledge, prevention, screening, treatment and awareness of ROP. RESULTS: Only 54 (65.1%) pediatricians were aware of ROP, while 29 (34.9%) were not aware of the disease. Thirty-three (39.8%) answered that ROP is preventable, while 24 (28.9%) responded that ROP is not preventable. Thirty-four (41%) pediatricians had no idea as to which part of the eye is affected in ROP, while 38 (45.8%) did not know when ROP screening should be started. Only 43 (51.8%) pediatricians were sure that ROP is treatable. Pediatricians in private hospitals were more aware of ROP compared to their counterparts in government hospitals (P = 0.006). CONCLUSION: Awareness among pediatricians in Coimbatore about ROP is poor. Our study emphasizes the need to increase awareness of this avoidable cause of blindness.

Atypical retinocytoma with diffuse vitreous seeds: An insight.

Retinocytoma is a rare benign form of retinoblastoma. It is usually found on routine examinations and also while screening families of patients with retinoblastoma. Distinctive features are a translucent retinal mass with calcification, retinal pigment epithelial disturbance, chorioretinal atrophy and absence of growth. We report a case with all the above features along with diffuse vitreous seeds and optical coherence tomographic documentation of intralesional cavitary lesions.

Combination therapy of low-fluence photodynamic therapy and intravitreal ranibizumab for choroidal neovascular membrane in choroidal osteoma.

Choroidal osteoma is an unusual form of intraocular calcification seen in otherwise healthy eyes. It is a benign idiopathic osseous tumor of the choroid, typically seen in young females. Choroidal neovascular membrane (CNVM) is a complication seen in one-third of these patients and carries a poor visual outcome. We report a case of a 25-year-old hyperthyroid female with choroidal osteoma and subfoveal CNVM in her left eye which was successfully treated using low-fluence photodynamic therapy (PDT) with verteporfin followed by a single injection of intravitreal ranibizumab.