Glue-Assisted Retinopexy for Retinal Detachments Study Report 2: Fibrin Glue As a Surgical Adjunct in Complex Rhegmatogenous Retinal Detachment.

Purpose: To present the successful application of fibrin glue as a surgical adjunct in the management of complex rhegmatogenous retinal detachment (RRD). Methods: In this retrospective case series, fibrin glue was used as a surgical adjunct in 5 cases of complex RRD. In each case, standard pars plana vitrectomy and laser retinopexy were performed by the same surgeon. Fibrin glue was used intraoperatively as a tamponade to seal the breaks because the isolated use of conventional tamponade agents was not feasible given the variable nature of the complex RRDs, the anatomy of the eye, or an inability to maintain postoperative positioning. Results: In 1 patient previously treated for a large corneoscleral tear, fibrin glue was used to seal a large iatrogenic retinal break caused by a fragmatome-related surge that led to a quadrantic RD. In 2 patients treated for combined RRD, fibrin glue was used with silicone oil to manage recurrent RRD with incompletely drained thick subretinal fluid and blood. In 2 other cases, fibrin glue was applied to manage RRD in congenital aniridia with advanced glaucoma and aphakia. In all cases, retinal attachment without serious adverse effects was attained over a follow-up ranging from 4 to 6 months. Conclusions: Fibrin glue is an effective, safe surgical adjunct in complex RRD. It can be used to transiently seal a retinal break when use of a conventional tamponade agent is not possible or not sufficient alone.

Trends in infectious adverse events after elective optical keratoplasty (PK, EK, and ALK) - Ten years' analysis from an eye bank.

PURPOSE: To report the clinical profile and donor characteristics of post-optical keratoplasty adverse events notified at an eye bank. METHODS: Between January 2013 and December 2022, 37,041 donor corneas were utilized for keratoplasty, of which 16,531 were used for penetrating keratoplasty (PK), 12,171 for endothelial keratoplasty (EK), and 1356 for anterior lamellar keratoplasty (ALK). EK included 10,956 Descemet stripping automated endothelial keratoplasty (DSAEK) and 1215 Descemet membrane endothelial keratoplasty (DMEK). The adverse events reported within the first 6 weeks of optical keratoplasty were analyzed for donor-related parameters. RESULTS: A total of 41 (0.11%) recipients had post-keratoplasty infections. Of these, 33 occurred after EK (29 after DSAEK, and four after DMEK), two after ALK, and six after PK. The clinical presentation was keratitis alone in 16 eyes and associated with endophthalmitis in 25 eyes. The organisms isolated were gram-negative bacteria in 26 eyes, fungus in eight eyes, gram-positive bacteria in four eyes, mixed infection in five eyes, and microbiology inconclusive in seven eyes. The majority (78%) of the gram-negative infections were due to multidrug-resistant organisms. Most (88%) donor corneas were harvested from hospital premises. The most common cause of donor mortality was trauma. The median duration of presentation from surgery was 4.46 (range: 1-30) days. The death to preservation time was 4.18 (1.5-7.65) hours. The death to utilization time was 3 (2-4.7) days. CONCLUSION: The overall risk of infectious adverse events after keratoplasty was 0.11%, ranging from 0.08% to 0.36%. Most (80.4%) of the adverse events occurred after EK. The majority (78.9%) of the adverse events were of bacterial etiology, of which gram-negative infections (68.4%) were the most common. The trends and microbiological spectrum of organisms associated with infections should be thoroughly documented in eye banks to gain insights and formulate guidelines on the management of adverse events.

Update on non-infectious uveitis treatment: anti-TNF-alpha and beyond.

Non-infectious uveitis (NIU) encompasses a range of conditions marked by inflammation within various layers of the eye. NIU is a significant contributor to irreversible vision loss among the working-age population in developed countries. The aim of treating uveitis is to manage inflammation, prevent its recurrences and to restore or salvage vision. Presently, the standard treatment protocol for NIU involves initiating corticosteroids as the primary therapeutic agents, although more aggressive approaches and steroid sparing agent may be necessary in certain cases. These advanced treatments option include synthetic immunosuppressants like antimetabolites, calcineurin inhibitors and alkylating agents. For patients who exhibit an intolerance or resistance to corticosteroids and conventional immunosuppressive therapies, biologic agents have emerged as a promising alternative. Notably, among the biologic treatments evaluated, TNF-α inhibitors, anti-CD20 therapy and alkylating agents have shown considerable efficacy. In this review, we delve into the latest evidence surrounding the effectiveness of biologic therapy and introduce novel therapeutic strategies targeting immune components as potential avenues for advancing treatment of NIU.

Vitrectomy for cases of diabetic retinopathy.

ABSTRACT: Microvascular complications of diabetic retinopathy (DR) may require surgical intervention in the form of vitrectomy. Since its inception, diabetic vitrectomy has evolved with introduction of better instruments, newer techniques, and smaller port sizes. Common indications for diabetic vitrectomy include nonresolving vitreous hemorrhage, tractional retinal detachment, epiretinal membrane, progression of fibrovascular membranes despite laser therapy, recalcitrant diabetic macular edema, and neovascular glaucoma. Preoperative systemic stabilization is essential prior to planning surgery. Surgical techniques commonly used in diabetic vitrectomy are segmentation, delamination, and rarely en-bloc dissection. Modification in surgical techniques such as chandelier-assisted bimanual dissection and pharmacological adjuvants improve surgical outcomes in these patients. Prognosis in these patients could be improved with early intervention. Studies evaluating the outcome of vitrectomy in patients with early proliferative DR are required to understand the appropriate time of intervention in patients. Treatment aimed at arresting the progression of DR and gene therapy are avenues that need further evaluation. The following review will focus on covering the epidemiology of DR, indications of vitrectomy, preoperative considerations, surgical procedures of diabetic vitrectomy, methods of membrane dissection, pharmacological adjuvants to vitrectomy, outcomes of diabetic vitrectomy, and future directions of diabetic vitrectomy.

Systemic and ocular outcomes in TB-immunoreactive patients receiving immunomodulatory therapy for non-infectious uveitis: a case-control study.

BACKGROUND: Tuberculosis (TB)-immunoreactivity, measured in vivo (tuberculin skin test (TST)) or in vitro (interferon gamma release assay (IGRA)), can be found in latent, active or even following clearance of TB infection. In this case-control study, we compared the systemic and ocular outcomes between patients with or without TB-immunoreactivity, who received immunomodulatory therapy (IMT) for non-infectious uveitis. METHODS: We retrospectively reviewed charts of patients with (cases) or without (controls) TB-immunoreactivity (TST±IGRA), who received conventional IMT for ≥6 months, for the treatment of non-infectious uveitis. Patients who received prior or concomitant anti-TB therapy were excluded. Systemic and ocular outcomes were compared between both groups. RESULTS: 36 cases and 70 controls (gender-matched and age-matched) were included. New-onset pulmonary or extrapulmonary TB developed in one case and none of the controls. Based on this outcome, the absolute risk increase for systemic TB reactivation was noted to be 0.028 (95% CI 0.005 to 0.051) and the number needed to harm was 36. The incidence of persistent or recurrent (worsening ≥2 grades) intraocular inflammation during IMT was comparable between both groups (cases 18/36, controls 35/70, p=1.0). A change in anatomical site of presentation at recurrence was not seen in any case, but in six controls (p=0.15). No new focal chorio-retinal lesions were noted in either group. CONCLUSIONS: Conventional IMT has a very low risk of systemic TB reactivation, and no additional detrimental effect on ocular outcomes, in TB-immunoreactive patients with non-infectious uveitis.

Anterior Non-Necrotizing Scleritis with Active Uveitis in Cases of Ocular Syphilis.

PURPOSE: To study clinical characteristics and management outcomes of cases of ocular syphilis co-presenting with scleritis and active uveitis. METHODS: A retrospective analysis of cases diagnosed with ocular syphilis between January 2020 and December 2023 was conducted at a tertiary eye care centre. Clinical records, investigations, and outcomes were reviewed to identify cases with scleritis with active uveitis. Demographic data, clinical features, treatment modalities, and resolution patterns were analyzed. RESULTS: Among the 135 eyes of 95 cases of ocular syphilis studied, scleritis with uveitis was observed in 3.70% of eyes (five eyes). All cases with scleritis and uveitis were unilateral and male, with ages ranging from 32 to 61 years. Concurrent features included placoid chorioretinitis, retinal vasculitis, and anterior uveitis. Misdiagnosis with subsequent oral steroid therapy precipitated scleritis as an exacerbation in two cases. Three cases, which were previously undiagnosed, were found to be HIV-positive. Scleritis manifested as anterior, non-necrotizing inflammation, often accompanied by chemosis, and responded rapidly to antibiotic and non-steroidal anti-inflammatory therapy. Scleritis resolution preceded that of chorioretinitis and retinal vasculitis. CONCLUSIONS: Non-necrotizing anterior scleritis with chemosis can be a rare presentation of active syphilitic uveitis. Large placoid chorioretinitis lesions, preceding inadvertent oral steroid and/or undiagnosed HIV status were the possible risk factors for the development of concurrent scleritis.

Tear Protein Markers for Diabetic Retinopathy and Diabetic Macular Edema - Towards an Early Diagnosis and Better Prognosis.

BACKGROUND: Diabetic eye disease is a highly prevalent and sight-threatening disorder. It is a disease of neuro-vascular unit of the retina, if left untreated can cause blindness. Therapeutic approaches followed for its treatment can only restrict the progression of the disease with highly variable results. There is no known biomarker for an early diagonsis of this disease, therefore by the time it is detected it goes beyond repair. This creates a massive demand for development of such biomarkers that help detect disease in its earlier stages. METHODS: PUBMED (https://pubmed.ncbi.nlm.nih.gov/) was searched for articles relevant to the topic published till November 2023. The search was made using keywords such as Diabetic Retinopathy, inflammation, tear, biomarker, proteomics etc. The studies providing relevant information to prove the importance of biomarker discovery were chosen. After compiling the data, the manuscript writing was planned under relevant headings and sub-headings. RESULTS: The review provides a comprehensive overview of all the tear protein biomarker studies in the field of DR and DME. Briefly, their potential in other diseases is also elucidated. While there are many studies pertaining to DR biomarkers, the identified markers lack validations which has restricted their usage in clinics. In case of DME, there was no such study towards biomarker discovery for its diagnosis and prognosis. CONCLUSIONS: The review highlights major studies and their lacunae in the field of biomarkers discovery for DR and DME.

Paracentral acute middle maculopathy in a patient with Myelin Oligodendrocyte glycoprotein antibody associated optic neuritis.

Purpose: There is insufficient literature reporting the concurrent occurrence of retinal ischemic lesions with optic neuritis. In this case report, we present a distinctive instance of Optic Neuritis with a positive Myelin Oligodendrocyte glycoprotein (MOG) antibody, accompanied by retinal ischemia manifesting as paracentral acute middle maculopathy (PAMM) lesions. Observations: Our patient is a 25-year-old female who tested positive for MOG antibodies and exhibited retinal PAMM lesions without any apparent underlying ischemic cause. She received intravenous pulse steroid therapy, and her symptoms and signs completely resolved one month later. Conclusion: PAMM can serve as an initial manifestation of Myelin Oligodendrocyte glycoprotein Antibody Associated Disease (MOGAD). This case has the potential to contribute to the existing literature, facilitating a deeper exploration of the pathophysiology of retinal ischemia in MOG associated optic neuritis.

Intraocular Bioadhesives in Vitreoretinal Surgeries: A Systematic Review.

BACKGROUND: Bioadhesion is the ability of materials to adhere to biological surfaces. Bioadhesives are substances which induce or promote bioadhesion. The internal application of bioadhesives is gaining popularity in recent years and is being increasingly utilized in vitreoretinal surgeries. The aim of this review is to discuss the various bioadhesives and their applications in vitreoretinal surgeries. METHODS: PubMed, Google Scholar, ePub and Cochrane library database were used for literature selection. Keywords such as vitreoretinal surgery, bioadhesives, intraocular bioadhesives, glue, fibrin glue, cyanoacrylate glue and transforming growth factor were used individually and in differing combinations to perform a comprehensive systematic literature search. RESULTS: A total of 47 papers were retrieved and included in this review. Cyanoacrylate glue was the first bioadhesive to be utilized for vitreoretinal surgery in human eyes in 1976. The most common indications for the use of bioadhesives were in optic disc pit maculopathy, macular holes and rhegmatogenous retinal detachments. CONCLUSION: The use of intraocular bioadhesives in vitreoretinal surgery represents a significant and evolving area of interest within ophthalmic research. While the pioneering use of cyanoacrylate glue, fibrin glue and transforming growth factor beta demonstrated the possible use of intraocular adhesives, fibrin glue is the most widely used intraocular bioadhesive in vitreoretinal surgery.

Suspected Retinal Toxicity After Multiple Intravitreal Ganciclovir Injections in a Patient of CMV Retinitis.

PURPOSE: Intravitreal Ganciclovir has been one of the treatments of choice for cytomegalovirus (CMV) retinitis and has been used extensively for its treatment since 1987. It has not been shown to have any major adverse effects. There are no reports on any retinal toxicity even after multiple, repeated injections. Herein, we report a rare case of retinal toxicity after multiple intravitreal injections in a patient of CMV retinitis. CASE REPORT: A 69-year-old one eyed male, who was on oral corticosteroids and systemic immunosuppression for Granulomatosis with Polyangiitis, presented with CMV retinitis in both eyes. His visual acuity was 20/60 in his right eye and no perception of light in his left eye. He was treated with multiple injections of intravitreal Ganciclovir in his right eye. The left eye was not treated since it had no vision potential. The right eye of the patient which had received multiple injections went on to developed a progressive diffuse atrophy of Retinal Pigment Epithelium (RPE). No such changes were noted in the left eye of the patient. CONCLUSION AND IMPORTANCE: We present a case of progressive diffuse RPE atrophy as a result of toxicity of intravitreal ganciclovir injections. It is important to be aware of this rare potential toxicity of intravitreal Ganciclovir.

Macular Punctate Lesions Presenting as a Primary Manifestation of Ocular Toxoplasmosis.

PURPOSE: To study clinical features and outcomes of primary ocular Toxoplasmosis (OT) cases presenting as macular punctate lesions. METHODS: Retrospective review of three cases of OT with positive Toxoplasma serology. RESULTS: We describe three cases presenting as primary OT with no evidence of old retinochoroidal scar in either eye. All the cases had multiple foveal or extrafoveal, punctate, inner/outer, or combined lesions at macula with minimal vitreous reaction. During the first/primary episode, all the lesions resolved with 1. retinal atrophy, thinning (n = 1) or 2. Progressed to limited full-thickness retinitis lesions (n = 2). Recurrence as typical retinochoroiditis was seen in one eye. More than four-fold IgG positivity was seen in all cases while IgM positivity was seen in two cases. CONCLUSIONS: Macular punctate lesions (inner/outer/combination) can be the primary manifestation of ocular toxoplasmosis in the absence of old retinochoroiditis scars in either eye.

VKH disease in the elderly: Variations in clinical course as compared to VKH disease in adults.

PURPOSE: To describe disease characteristics and outcomes of Vogt-Koyanagi-Harada (VKH) disease in elderly patients. METHODS: Retrospective analysis of patients older than 50 years with VKH disease at two referral centers in India. Demographics, extraocular and ocular involvement, treatment, complications, and visual acuity outcomes were noted. RESULTS: In total, 69 patients (mean age at presentation: 56.4 ± 4.7 years) were analyzed; 6/69 patients had diabetes mellitus at presentation, and 10/69 had hypertension. Clinical signs included anterior chamber cells >2+ (29%), granulomatous keratic precipitates (23%), disc hyperemia (26%), neurosensory retinal detachment (34.7%), and "sunset-glow" fundus (52.1%). Patients were classified as probable (n = 50, 72.4%), incomplete (n = 18, 26%), and complete VKH (n = 1, 1.4%). The mean follow-up period was 20.2 ± 19.4 months. Improvement in mean BCVA of (0.63 LogMAR, 6 Snellen lines) was noted on the last follow-up. Patients receiving systemic steroids with immunosuppressants ( P < 0.0001) had better visual outcomes at final follow-up compared to steroids alone ( P = 0.103). Eight patients (11.6%) had complications due to systemic immunosuppressants, and 17 patients (24.6%) developed diabetes mellitus or had worsening of diabetes while on systemic corticosteroids. CONCLUSION: Few patients presented with systemic manifestations in our cohort. Those treated with steroids and concurrent immunosuppressants had better outcomes. However, therapy with immunosuppressants was encountered with major dose-limiting complications in a significant number of elderly patients with VKH syndrome.

Microbiological Landscape and Epidemiology of Endophthalmitis in Children and Adolescents in a Multi-Tier Ophthalmology Network in India: An Electronic Medical Record-Driven Analytics Report.

PURPOSE: To study the epidemiology and microbiological landscape in patients (≤21 yrs) diagnosed with endophthalmitis across a multi-tier ophthalmology network in India. METHODS: This cross-sectional hospital-based study included 1,041 patients (≤21 yrs) diagnosed with endophthalmitis, between April 2012 and May 2022. The data were collected using an electronic medical record system. RESULTS: Bacteria (24%) was the most common etiology followed by fungus (2%). The majority of the patients were male (66%) with a mean age of 8.37 ± 5.99 years. The most common age group was middle childhood (6-11 years) with 365 (35.06%) patients. The patients were more commonly from the lower socio-economic status (60.81%) and urban geography (49%). The common cause of endophthalmitis was trauma (59.33%) and amongst the 279 culture positive eyes, the predominant bacteria isolated was Streptococcus pneumoniae followed by Bacillus species and fungus included predominantly Aspergillus and Candida species. The most common surgical intervention performed was intraocular antibiotics (74%) followed by pars plana vitrectomy (52%). CONCLUSION: The most common etiology of endophthalmitis in children is bacterial and traumatic in nature and presented from the lower socio-economic status. A half of the eyes warranted a vitreo-retinal surgical intervention. .

A cross-sectional study on the microbiological landscape in pediatric endophthalmitis showed that the most common cause of endophthalmitis was trauma and the predominant bacteria isolated was Streptococcus spp. and Bacillus spp. Additionally, majority of the patients were from the lower socio-economic status and urban geography and the most common surgical intervention performed was injection of intraocular antibiotics.

Ten-year results of scleral-fixated intraocular lens implantation: outcomes of ab externo scleral fixation with 10-0 polypropylene suture.

PURPOSE: To describe long-term visual and anatomical outcomes of sutured scleral-fixated intraocular lens (SF IOL) implantation. SETTING: Tertiary eyecare hospital in India. DESIGN: Retrospective interventional noncomparative study. METHODS: Postoperative change in corrected distance visual acuity (CDVA) and occurrence of complications were assessed from the patient medical records. Long-term SF IOL survival rates and factors affecting the occurrence of postoperative IOL-related complications were assessed. Patients with postoperative follow-up less than 10 years or incomplete medical records were excluded. RESULTS: 64 eyes of 53 patients were included. Follow-up duration was 11.4 ± 1.2 years. Mean preoperative CDVA was 0.71 ± 0.43 logMAR (Snellen equivalent: 6/30), and mean CDVA at the final visit was 0.52 ± 0.49 logMAR (Snellen equivalent: 6/18) (P < .01). 48% cases had CDVA of 6/12 or better at the last follow-up. 58% cases had coexistent ocular pathology affecting the final visual outcome. IOL and suture-related complications were the commonest and included IOL decentration (17% cases), IOL drop (14%), and suture exposure (6%). The probability of IOL survival (postoperative period without IOL-related complications) was 90.6% at 8 years and 81.2% at 10 years (Kaplan-Meier analysis). Occurrence of postoperative IOL-related complications was unaffected by patient sex, age, indication for surgery (trauma or other), previous intraocular surgery, or technique of scleral fixation (2-point or 4-point) (multivariate regression analysis). CONCLUSIONS: Although sutured SF IOL implantation is viable with favorable long-term visual outcomes, there is a risk of postoperative IOL-related complications. Occurrence of postoperative IOL-related complications is unaffected by patient and ocular factors.

New Insights into HIV Life Cycle, Th1/Th2 Shift during HIV Infection and Preferential Virus Infection of Th2 Cells: Implications of Early HIV Treatment Initiation and Care.

The theory of immune regulation involves a homeostatic balance between T-helper 1 (Th1) and T-helper 2 (Th2) responses. The Th1 and Th2 theories were introduced in 1986 as a result of studies in mice, whereby T-helper cell subsets were found to direct different immune response pathways. Subsequently, this hypothesis was extended to human immunity, with Th1 cells mediating cellular immunity to fight intracellular pathogens, while Th2 cells mediated humoral immunity to fight extracellular pathogens. Several disease conditions were later found to tilt the balance between Th1 and Th2 immune response pathways, including HIV infection, but the exact mechanism for the shift from Th1 to Th2 cells was poorly understood. This review provides new insights into the molecular biology of HIV, wherein the HIV life cycle is discussed in detail. Insights into the possible mechanism for the Th1 to Th2 shift during HIV infection and the preferential infection of Th2 cells during the late symptomatic stage of HIV disease are also discussed.

Fibrin-Glue-Assisted Surgery for Idiopathic Macular Holes.

METHODS: This pilot clinical trial included 10 eyes of 10 patients with idiopathic MH, where PPV along with ILMP was done. Fibrin glue was used as a tamponade, and no postoperative positioning was given to any patient. The primary outcome measure was successful anatomical closure of the MH. The secondary outcome measures were postoperative improvement in best-corrected visual acuity (BCVA) and any complications of the procedure. RESULTS: The median age of patients was 62.5 years. Eight eyes were pseudophakic and two were phakic. The mean basal diameter of the MH was 1193 microns. The mean minimal linear diameter was 652 microns. Successful anatomic closure of MH was achieved in eight cases. The median BCVA improved from a Snellen equivalent of 20/100 preoperatively to 20/60 at 1 month postoperatively. The median follow-up period was 4 months. CONCLUSION: The findings of this study suggest that the use of fibrin glue can be useful in patients where postoperative positioning is difficult.

Bacillary layer detachment as an inflammatory biomarker in toxoplasmosis retinochoroiditis: serial evolution on optical coherence tomography.

We describe the clinical course and serial evolution of bacillary layer detachment (BALAD) on optical coherence tomography (OCT) in toxoplasmosis retinochoroiditis and its importance as an inflammatory biomarker. Colour fundus photography and swept-source OCT of the BALAD were done at the time of presentation and subsequently at 1 week, 2 weeks, 4 weeks and at 11 weeks. Treatment involved oral trimethoprim (160 mg) + sulphamethoxazole (800 mg) two times per day, started at presentation for 2 months. Oral prednisolone was started after 1 week at a dose of 50 mg a day and tapered weekly over the next 5 weeks. The BALAD initially increased after starting treatment with trimethoprim-sulphamethoxazole and regressed within 1 week after initiation of oral prednisolone. Best corrected visual acuity improved to 20/40 from 20/160 at presentation (Snellen equivalent). This suggests that BALAD is an indicator of an acute inflammatory event and the accumulated fluid is secondary to retinal and choroidal inflammation.

Effect of Age on the Etiology and Antibiotic Susceptibility Pattern of Infectious Endophthalmitis.

PURPOSE: To review the etiology and antibiotic susceptibility patterns of infectious endophthalmitis over 11 years in different age groups. METHODS: Microbiology records of culture-positive endophthalmitis cases from January 2011 and December 2021 were reviewed for the age groups 0-30, 31-60, and >60 years. Additionally, data was also analysed for trends in antibiotic susceptibility between different age groups. RESULTS: A total of 5590 patients were clinically diagnosed with endophthalmitis. Of these, 1316 (23.5%) patients were culture positive comprising of 1097 bacteria (83.3%) and 219 fungal (16.6%). Gram-positive bacteria predominated the culture-proven bacterial endophthalmitis group with 709 cases (62.6%). Streptococcus pneumoniae (9.3%) was the most prevalent organism in the age group between 0 and 30 years, while Staphylococcus epidermidis (6%) was the most prevalent organism in the age group of 31-60 years. In comparison, Pseudomonas aeruginosa (4.1%) was the most abundant organism in the age group >60 years. Interestingly, Aspergillus flavus (13.24%) was the predominant fungal pathogen in all age groups. There was an increasing trend in antibiotic resistance from younger to older age groups and this pattern was observed for almost all drugs tested except vancomycin and amikacin. CONCLUSION: While infection can occur at any age, the etiology also seems to vary. This study helps us understand the demography of endophthalmitis along with choice of empirical antibiotics that would influence treatment outcomes. Although vancomycin currently holds good for the treatment for gram-positive infections, gram-negative infections calls for an immediate need for newer drugs or advanced treatment options.