Intraocular pressure fluctuation following intravitreal dexamethasone implant and incidence of secondary ocular hypertension: a Zambian perspective.

INTRODUCTION: to evaluate the effect of dexamethasone biodegradable implant (DEX-I), on intraocular pressure (IOP), to determine the incidence of secondary ocular hypertension (OHT) and to analyze the IOP changes as per the treatment indication in Zambian cohort. METHODS: retrospective consecutive case series of patients receiving one DEX-I between January 2016 and September 2018 with a minimum follow-up of four months in a tertiary care centre in Zambia. The IOP was recorded before the injection and at 1st week, 1st, 2nd, 3rd and 4th month after the injection. Ocular hypertension was defined as IOP ≥ 21 mmHg or an increase of ≥ 10 mmHg from baseline. RESULTS: the effects of 122 injections given to ninety - nine patients (65 male: 65%; mean age 57.3) were included. The main indications for treatment were diabetic macular edema (DME, 52%), retinal vein occlusion (18%), post-surgical macular edema (18%) and non-infectious posterior uveitis (10%). Mean IOP before the injection was was 14.7mmHg and at 1st week, 1st, 2nd, 3rd and 4th months after the injection it was 14.4 (p=0.08), 16.1 (p=0.01), 17.5 (p<0.001), 15.7 (p=0.006) and 14.9 (p=0.06) mmHg, respectively. The incidence of secondary OHT was 30.32% in this cohort. Peak incidence of OHT was between 1 - 2 months, with majority of cases in DME group (75%) and 43% diabetic eyes followed by 23% non-infectious posterior uveitis cases developing OHT post injection. OHT was well managed with anti-glaucoma medications only. CONCLUSION: DEX-I showed a good pressure tolerance in this cohort. Secondary ocular hypertension developed in one-third of patients receiving injection which was transient and successfully managed with topical anti-glaucoma medications only. Diabetic eyes are more prone to develop ocular hypertension and therefore needs close monitoring following injection.

Incidence of Paradoxical Neurosensory Detachment in Diabetic Eyes Undergoing Hemodialysis for End-Stage Renal Disease.

Introduction Ocular fluid dynamics are known to improve during hemodialysis, and the improvement of uremia after dialysis may lead to osmotic pressure changes in the retina, which eventually affect retinal edema. Recent studies using optical coherence tomography (OCT) to assess the effect of hemodialysis on macular thickness have shown variable results with a majority of them finding a decrease in retinal thickness. Paradoxical neurosensory retinal detachment (NSD) may be defined as the accumulation of subretinal fluid under the macula in patients who are on continuous HD. The purpose of the study was to find out the incidence of paradoxical neurosensory detachment in diabetic eyes undergoing hemodialysis (HD) and its management. Methods This was a cross-sectional, prospective study involving end-stage renal disease (ESRD) patients secondary to diabetes. This study evaluated the changes in macular thickness in diabetic retinopathy patients with and without diabetic macular edema (DME) by spectral-domain optical coherence tomography (SD-OCT) 60 minutes before and after HD for ESRD. Results Sixty-three eyes (36 patients) were included, with a mean age of 58.2±9.8 years. Seven eyes had paradoxical NSD at presentation with an incidence of 11.11%. Eyes with DME (Group A) showed a significant reduction in central macular thickness (CMT) by 28±2µm post HD, compared to eyes without DME (Group B) where CMT decreased by 15±2µm (p=0.003). Massive subretinal fluid accumulation (paradoxical NSD) with mean CMT 675.57±69.41µm recovered to 250.71±46.79µm at the final follow-up. Five eyes underwent an intravitreal dexamethasone implant (DEX-I, Ozurdex; Allergan, Dublin, Ireland) to achieve the resolution of SRF, whereas two eyes improved spontaneously by nine months. Conclusion Hemodialysis results in a decrease of macular thickness in diabetic eyes with or without DME. Paradoxical neurosensory detachment can develop in eyes of patients undergoing HD chronically. Intravitreal dexamethasone implant (DEX-I, Ozurdex; Allergan, Dublin, Ireland) results in early amelioration of such a complication.

Intravitreal dexamethasone implant with retinal photocoagulation for adult-onset Coats' disease.

PURPOSE: To report a case of adult-onset Coats' disease with secondary retinal vasoproliferative tumor managed with dexamethasone intravitreal implant and retinal photocoagulation. METHODS: Case study. RESULTS: A 41-year-old female with counting finger vision was diagnosed with Coats' disease with secondary retinal vasoproliferative tumor in right eye. Fundus examination revealed exudative retinopathy involving posterior pole and a retinal tumor located in the inferotemporal quadrant. Optical coherence tomography scan confirmed massive exudative neurosensory detachment and fundus fluorescein angiography showed areas of telangiectatic vessels with capillary non-perfusion. Intravitreal injection of dexamethasone implant was done initially followed by laser photocoagulation when the detachment resolved. There was significant improvement in patient's visual acuity with no further recurrence of exudation. CONCLUSION: Intravitreal dexamethasone implant Ozurdex(®) (Allergan, Inc., Irvine, Calif., USA) may be an effective initial therapeutic approach for Coats' disease with massive exudation.

Retinal Neovascularisation in Susac Syndrome: A Rare Complication.

PURPOSE: To report a case of Susac syndrome with ocular complications in the chronic stage of the disease. METHODS: Case report. RESULTS: A 37-year-old male patient of Indian origin presented with painless blurring of vision in the right eye. Ophthalmoscopic examination revealed vitreous hemorrhage in the right eye and NVE in both eyes well-documented angiographically. Old medical records revealed a previous attack of bilateral BRAO as a complete triad of Susac syndrome 10 years before, with an uncomplicated clinical course. Panretinal photocoagulation helped in stabilization of the condition. CONCLUSION: Ocular neovascularisation like NVE with vitreous hemorrhage can be a late manifestation of occlusive arteriolitis in Susac syndrome.

Secondary Angle-Closure Glaucoma Due to Posterior Synechiae of Iris Following Combined Phacoemulsification and 23-Gauge Transconjunctival Vitrectomy.

PURPOSE: To describe the clinical characteristics of eyes with secondary angle-closure glaucoma following combined phacovitrectomy. METHODS: Retrospective case series. RESULTS: Nine eyes developed angle-closure glaucoma due to iris posterior synechiae with an incidence rate of 1.82% (95% CI: 0.64 - 3%) among 493 eyes following phacovitrectomy. PDR with TRD was the most common surgical indication. Single piece IOL insertion and silicone oil were present in all cases. Fibrin in the anterior chamber was found in six eyes postoperatively. Mean degree of iris bombe was 310±79.37° at 3.55±1.87 weeks with a mean IOP of 32.56±5.89 mm of Hg. Systemic diabetes and grade of cataract were the only significant risk factors (r2 =1; p= 0.016 and 0.049, respectively). Nd:YAG laser PI relieved the angle-closure attack in all cases. CONCLUSION: Systemic diabetes and advanced grade of cataract are significant risk factors for secondary angle-closure glaucoma following combined phacovitrectomy.

Clinical outcomes of double membrane peeling with or without simultaneous phacoemulsification/gas tamponade for vitreoretinal-interface-associated (VRI) disorders.

The purpose of this study is to evaluate the clinical outcomes of double membrane (ERM & ILM) peeling and the effect of combined cataract surgery and SF6 gas injection in vitreoretinal interface (VRI) disorders. This is a retrospective interventional study. Seventy-two eyes with idiopathic vitreoretinal interface abnormalities that underwent 23 gauge pars plana vitrectomy with "double stain and double peel" technique were reviewed. SD-OCT was used to classify VRI disorders into following 4 groups: 44 in ERM type, 17 in VMTS type, 7 in macular pseudohole (MPH) type, and 4 in lamellar macular hole (LMH) type. ERM was a common association in all types. Mean preoperative BCVA improved from 0.58 ± 0.14 logMAR to 0.27 ± 0.16 logMAR units (p = 0.001). Mean CFT reduced from 409.17 ± 122.31 µm preoperatively to 277.28 ± 0.16 µm postoperatively (p < 0.0001). Among the VRI subtypes, visual improvement was significant except in LMH variety (ERM type, p = 0.0029; VMTS type, p = 0.0281; MPH type, p = 0.05; and LMH type, p = 0.7926). Mean change in CFT from baseline was least in LMH cases (p = 0.0093). There was no significant difference in BCVA and CFT in the group who had combined phacovitrectomy versus pseudophakic group (p > 0.05). Use of intraocular SF6 gas tamponade did not show any added benefits among the groups (p > 0.05). Improvement in foveal contour was seen in all groups. Simultaneous removal of ILM along with ERM during surgery for VRI disorders helps in restoring normal foveal contour with a favorable visual outcome. Combined cataract extraction or use of intraocular SF6 gas injection does not affect the surgical results.

Ocular manifestations in hyperornithinemia-hyperammonemia-homocitrullinuria syndrome: a rare association.

PURPOSE: To report ophthalmic features in hyperornithinemia-hyperammonemia-homocitrullinuria syndrome, an uncommon presentation. METHODS: Case report. RESULTS: An 18-year-old Indian boy presented with progressive diminution of vision, night blindness, lenticular opacities, and midperipheral chorioretinal atrophy. Spectral domain optical coherence tomography revealed myopic foveoschisis, and Humphrey visual fields 30-2 showed peripheral field constriction. He had no neurocognitive disabilities. Serum biochemical analysis revealed hyperornithinemia, hyperglycinemia, and raised ornithine/citrulline ratio suggestive of hyperornithinemia-hyperammonemia-homocitrullinuria syndrome. CONCLUSION: Ocular findings of midperipheral chorioretinal degeneration with myopic foveoschisis can be the initial presenting manifesation of hyperornithinemia-hyperammonemia-homocitrullinuria syndrome.