Comparing Intraocular Pressure, Ocular Blood Flow, and Retinal Nerve Fiber Layer Thickness in Early and Chronic Hypertensives With Normotensives.

PURPOSE: To compare blood pressure (BP), intraocular pressure (IOP), ophthalmic artery flow (OAF) velocity, retinal nerve fiber layer (RNFL) thickness, and visual fields in newly diagnosed hypertension (HT) patients (before treatment), chronic HT (on antihypertensive medications >5 years) and normotensives. METHODS: A prospective, cross-sectional study at a tertiary care centre in India. Three groups of 45 patients each: group 1 - early HT, group 2 - chronic HT, and Group 3 - normotensives, underwent evaluation of BP, IOP by Goldmann applanation tonometry (GAT), OAF velocity by transcranial doppler (TCD), RNFL analysis by spectral-domain optical coherence tomography (SD-OCT), and visual fields. RESULTS: The BP was highest in early HT > chronic HT > normotensives (p < 0.001). The IOP of early HT, chronic HT, and normotensives were 15.87 ± 2.19 mmHg, 13.47 ± 1.92 mmHg, and 15.67 ± SD 1.75 mmHg (p < 0.001). The OAF velocity [peak systolic velocity (PSV), end-diastolic velocity (EDV) in cm/sec] was lowest in chronic HT (30.80 ± 7.05, 8.58 ± 1.58) < early HT (35.47 ± 5.34, 10.02 ± 1.74) < normotensives (36.29 ± 4.43, 10.44 ± 2.29), (p < 0.001). The average RNFL thickness was significantly lower in chronic HT (p = 0.022). The PSV, EDV, and MFV showed significant correlation with IOP (r = 0.247, p = 0.004; r = 0.206, p = 0.016; r = 0.266, p = 0.002) and average RNFL thickness (r = 0.309, p= <0.001; r = 0.277, p = 0.001; r = 0.341, p < 0.001). CONCLUSIONS: Patients with chronic HT demonstrated the lowest retrobulbar flows, IOP and lower RNFL measurements. Lower ocular perfusion may be associated with lower IOP and may be a risk factor for end-organ damage (RNFL) independent of IOP.

Herpetic Keratitis Following Treatment of Acute Antibody-Mediated Rejection in a Renal Transplantation Recipient.

We report an incident case of herpetic keratitis in a renal transplant recipient treated for acute renal allograft rejection. A lady in her forties, a renal transplant recipient on treatment for allograft rejection, was referred with mild ocular symptoms in the right eye for two days. On evaluation, she had mild conjunctival hyperemia and extensive herpetic epithelial keratitis involving the limbal and central corneas. The patient healed without sequelae from the antivirals and lubricants. Viral keratitis in immunosuppressed patients should be suspected, even in patients with mild symptoms, as early initiation of treatment can prevent rapid stromal involvement and scarring.

Comparing Peribulbar and Topical Anesthesia in Cataract Surgery among Patients with Cardiovascular Disease.

PURPOSE: To compare topical and peribulbar anesthesia in cataract surgery for hemodynamic changes, rate of complications and pain score in patients with cardiovascular disease. METHODS: A prospective comparative study at a tertiary care center in India. Patients >40 years old with treated/controlled hypertension and cardiovascular disease scheduled for cataract surgery under topical or peribulbar anesthesia were recruited. Heart rate, blood pressure, and ophthalmic and systemic complications were noted: preoperatively, immediately after block, intraoperatively, immediately postoperatively and 1 hour postoperatively. A visual analog scale was used to assess the pain score. RESULTS: A total of 150 patients (75 in each group) underwent cataract surgery. There was a significant rise in pulse rate and blood pressure after peribulbar injection and intraoperatively, which gradually reduced to baseline 1 hour after surgery in both groups (p < 0.001), with systolic blood pressure intraoperatively being significantly greater in the peribulbar group (155.49 ±18.14 mmHg vs. 147.95 ±17.71 mmHg, p = 0.01). The topical group had slightly lower visual analog scale scores (1.12 ± 0.99) than the peribulbar group (1.44 ± 0.90, p = 0.04). CONCLUSIONS: Cataract surgery appears safe in patients with adequately controlled cardiovascular disease, and topical anesthesia may be preferable due to noninvasiveness, adequate analgesia, and minimal effect on hemodynamic parameters. Therefore, hemodynamically stable patients of cardiovascular disease undergoing uncomplicated cataract surgery may be counselled for topical anesthesia.

Preparation and uses of amniotic membrane for ocular surface reconstruction.

Background: The use of human amniotic membrane transplantation is rapidly increasing for the management of various ocular surface disorders. Despite its numerous advantages, amniotic membrane is not widely available due to the lack of awareness among ophthalmologists regarding its preparation and preservation techniques. Purpose: To provide an instructional video demonstrating the technique of harvesting, preparation, preservation of human amniotic membrane, and its uses in the management of ocular surface diseases. Synopsis: The amniotic membrane is the innermost layer of the human placenta. Properties of the amniotic membrane, like the presence of various growth factors, anti-inflammatory and anti-angiogenic factors, and its low immunogenicity, contribute to its ability to promote epithelial growth and differentiation with the reduction in fibrosis during healing. To harvest amniotic membrane, informed consent is obtained from a patient undergoing an elective caesarian section, and the donor is screened to exclude the risk of infections. Under sterile precautions, the amniotic membrane is separated from the chorion and washed free of blood clots. With the epithelial surface up, the amniotic membrane is spread uniformly without folds or tears on individually sterilized 0.22 µm nitrocellulose filter papers of the required sizes. The prepared filter paper with the adherent amniotic membrane is placed in freshly prepared Dulbecco's Modified Eagle's Medium and stored at -80°C. The amniotic membrane can be used for surgical procedures like symblepharon release, pterygium or dermoid excision, perforated ulcers, nonhealing epithelial defects, etc. Highlights: Instructional videos demonstrating the preparation and preservation of amniotic membrane are very sparse. This video clearly explains how any ophthalmologist can learn to prepare and preserve the human amniotic membrane and gives a glimpse of its properties, advantages, and scope of use. Video Link: https://youtu.be/8HfSjXUKoiY.

Comparing Static Perimetry Protocols of Central Field Testing among Patients with Glaucoma.

SIGNIFICANCE: On comparing the Humphrey Field Analyzer (HFA) 24-2C Faster, which tests 10 additional points in the central field, with the 24-2 Swedish Interactive Thresholding Algorithm (SITA) Standard for detecting central field defects, we found that the HFA 24-2C Faster may be used for the initial field evaluation in glaucoma with the advantage of a shorter testing time. PURPOSE: This study aimed to compare the HFA 24-2C Faster with the 24-2 SITA Standard and 10-2 among patients with glaucoma for the number of defective central points, global indices, and testing time. METHODS: Sixty eyes of 60 patients with glaucoma and glaucomatous visual field defects on the 24-2 SITA Standard algorithm underwent the 24-2C Faster and 10-2 field tests. The number of central points detected, global indices, and reliability indices were compared between the 24-2C Faster and the 24-2 SITA Standard and 10-2 field tests. RESULTS: The 24-2C Faster, on average, detected 5.5 defective points more on the total deviation plot and 2 defective points more on the pattern deviation plot than the 24-2 SITA Standard in central 10°. The 10-2 algorithm detected 2.5 times more points on the total deviation plot than the 24-2C Faster. There was excellent consistency by an intraclass correlation coefficient of 0.95 for the mean deviation and 0.93 for the pattern standard deviation between the 24-2C Faster and the 24-2 SITA Standard. There was good consistency by an intraclass correlation coefficient of 0.80 for both mean deviation and pattern standard deviation between the 24-2C Faster and the 10-2. The testing time was significantly lower with the 24-2C Faster compared with the 24-2 SITA Standard and 10-2 test. CONCLUSIONS: Our study demonstrates that the HFA 24-2C Faster may be used for the initial evaluation of the visual field in glaucoma with the added advantage of a shorter testing time compared with the 24-2 SITA Standard program.

Evaluation of changes in anterior segment morphology using Sirius Scheimpflug-Placido disk topographer following laser peripheral iridotomy in primary angle-closure disease.

Purpose: To assess the morphological changes in the anterior segment following laser peripheral iridotomy (LPI) in primary angle-closure disease (PACD) using Sirius Scheimpflug-Placido disk corneal topographer. Methods: This was a prospective observational study. A total of 52 eyes of 27 patients with PACD who underwent LPI were analyzed for iridocorneal angle (ICA), anterior chamber depth (ACD), anterior chamber volume (ACV), horizontal visible iris diameter (HVID), corneal volume (CV), central corneal thickness (CCT), and horizontal anterior chamber diameter (HACD) 1 week following LPI, using Sirius Scheimpflug-Placido disk corneal topographer. Data analysis was done using Statistical Package for the Social Sciences (SPSS) software version 19.0, and paired t-test was used to assess the statistical significance. Results: Laser peripheral iridotomy was performed in 43 eyes with primary angle-closure suspect (PACS), six eyes with primary angle closure (PAC), and three eyes with primary angle-closure glaucoma (PACG). The analysis of the data showed statistically significant changes in anterior segment parameters of ICA, ACD, and ACV. Post-laser increase in ICA from 34.13° ± 2.64° to 34.75° ± 2.84° (P < 0.041), mean ACD increase from 2.21 ± 0.25 to 2.35 ± 0.27 mm (P = 0.01), and mean ACV increase from 98.19 ± 12.13 to 104.15 ± 11.16 mm3 (P = 0.001) were noted. Conclusion: Significantly quantifiable short-term changes in the anterior chamber parameters of ICA, ACD, and AC volume were seen after LPI in patients with PACD on Sirius Scheimpflug-Placido disc corneal topographer.

Comparison of the visual field test of Glaufield Lite with Humphrey Field Analyser.

PURPOSE: To compare visual field test results of Glaufield Lite AP901 CTS 133 (Appasamy Associates, Mannadipet Commune, Thirubhuvanai, Puducherry, India, hereafter Glaufield Lite) with Humphrey Field Analyser (HFA, Carl Zeiss Meditec, Dublin, California, USA, hereafter HFA). METHODS: A pilot study at a tertiary eye centre involving 23 normal and 24 glaucoma patients who underwent two consecutive visual field tests on (i) HFA 24-2 SITA Fast and (ii) Glaufield Lite Quick Central program. RESULTS: The mean testing time on HFA was significantly shorter than Glaufield Lite (normals: HFA: 2.75 ± 0.49 min, Glaufield Lite: 6.85 ± 0.86 min, p < 0.001; glaucoma patients: HFA: 3.45 ± 1.08 min, Glaufield Lite: 6.95 ± 0.54 min, p < 0.001). Reliability criteria were similar, but false-positivity was lower with Glaufield Lite. Bland-Altman analysis showed poor agreement for mean deviation (MD), [~ 2.69 units less for HFA], and acceptable agreement for pattern standard deviation (PSD) [~ 0.426 units more for HFA] between the two devices. CONCLUSION: Both perimetric techniques showed reliable test results though test duration was longer with Glaufield Lite perimetry. The MD showed poor agreement, likely due to different scales and principles used for perimetry. The PSD showed acceptable agreement, making it valid for use in glaucoma, though a direct comparison of fields from the two devices is not possible. We recommend using the same perimetry device for follow-up evaluation.

Spontaneous suprachoroidal haemorrhage in haemophilia coincident with ChAdOx1 nCoV-19 vaccine.

PURPOSE: To report a case of spontaneous suprachoroidal haemorrhage in a haemophilia patient immediately following ChAdOx1 nCoV-19 vaccination. CASE PRESENTATION: A 60-year-old man with haemophilia developed painful vision loss in his left eye a day following the ChAdOx1 nCoV-19 vaccination due to acute angle-closure glaucoma from a massive suprachoroidal haemorrhage. He had an extremely deranged coagulation profile; activated partial thromboplastin time (APTT): 89 s, normal range 29-35 s After factor VIII transfusion, ocular hypotensive therapy and systemic/topical steroids, the suprachoroidal haemorrhage and glaucoma resolved, but the vision remained poor. CONCLUSION: Spontaneous suprachoroidal haemorrhage may be seen in haemophiliacs with deranged coagulation profiles. In our case, it followed ChAdOx1 nCoV-19 vaccination, and we recommend caution and checking the coagulation profile in such patients apriori.

Safety and efficacy of Aurolab aqueous drainage implant in refractory glaucoma: A prospective study.

Purpose: This study was conducted to assess the intraocular pressure (IOP) control and postoperative complications following a non-valved glaucoma drainage device (GDD) surgery in refractory glaucoma. Methods: This was a prospective interventional study conducted on patients with glaucoma refractory to maximal medications or failed surgical treatment who underwent Aurolab aqueous drainage implant (AADI; Aurolabs, India) surgery. Primary outcome measures were IOP control, postoperative complications, and reduction in the number of antiglaucoma medications (AGM). Results: Thirty-four eyes were analyzed and the mean follow-up was 16.06 ± 5.63 months. The preoperative median (Q1, Q3) IOP was 31 mmHg (28, 36.5) which decreased to 12 mmHg (12, 14) at 6 months postoperatively. The median (Q1, Q3) number of AGMs decreased from 3 (3, 4) to 0 (0, 1). Significant complications like implant extrusion and tube exposure were noted in two eyes. The total success and failure rates at 6 months were 91.1% and 8.8%, respectively. Conclusion: AADI is effective in achieving target IOP and significantly reduces the use of AGMs with good safety in the short term. Long-term follow-up studies are needed to assess long-term IOP control and cost-effectiveness.

Bilateral Optic Neuritis and Facial Palsy Following COVID-19 Infection.

Cases of optic neuritis have been reported following the novel coronavirus disease 2019 (COVID-19), with most being unilateral and associated with demyelinating illness. We report a case of a 22-year-old woman who presented with sudden onset painless diminution of vision in both eyes six weeks following COVID-19 infection. She also had a history of left lower motor neuron (LMN) facial palsy immediately following COVID-19 disease that recovered fully on steroids. Ocular examination and ancillary and laboratory investigations pointed to bilateral atypical optic neuritis. The patient responded well to the standard optic neuritis treatment protocol. We diagnosed her as a case of left LMN facial palsy and parainfectious bilateral optic neuritis following COVID-19. Parainfectious bilateral optic neuritis and facial nerve palsy associated with COVID-19 can occur following COVID-19 disease. Ours is the first case to report the occurrence of both in a patient.

Study of anxiety in patients with glaucoma undergoing standard automated perimetry and optical coherence tomography - A prospective comparative study.

Purpose: To compare the anxiety levels related to visual field testing and optical coherence tomography (OCT) in patients with glaucoma. Methods: This prospective, comparative study was conducted on patients with glaucoma. The participants' anxiety traits were assessed using the State-Trait Anxiety Inventory [STAI]. Before visual field testing on Humphrey visual field analyzer (HVF) and retinal nerve fiber analysis on OCT, the participants completed Form Y1 to measure the current pretest level or 'State' anxiety [pretest anxiety]. Immediately after testing, participants were administered the Form Y1 questionnaire to assess the induced anxiety level during the testing [Intratest anxiety]. Results: A total of 228 patients were enrolled with 152 participants in the HVF group and 76 in the OCT group. The mean age of the participants in the HVF group was 57.2 ± 20.8 years and in the OCT group was 56.8 ± 20 years. There was no significant difference in trait and pretest anxiety between the HVF group and the OCT group (P = 0.971 and P = 0.716). Intratest test anxiety score was slightly higher in the HVF group (HVF: 42.13 ± 10.63, OCT: 40.71 ± 9.76; P = 0.33). The anxiety scores were higher when the experience of previous HVF tests was <2 and least when the number of tests exceeded five. Conclusion: Automated perimetry induces slightly more anxiety than OCT, which may affect test performance. The measured anxiety reduces as patients gain familiarity with the test with experience. This adds credence to the recommendation of more frequent visual field testing in newly diagnosed glaucoma patients.

Meta-herpetic ulcer following intravitreal bevacizumab.

PURPOSE: To report a case of meta-herpetic ulcer that developed after intravitreal bevacizumab injection. METHODS: A 55-year-old man with type 2 diabetes mellitus and nephropathy received intravitreal injection of bevacizumab in his right eye for proliferative diabetic retinopathy with macular edema. RESULTS: Two days after the injection, the patient presented with severe pain, redness, and photophobia, and decreased visual acuity in the right eye. The cornea showed a paracentral epithelial erosion with heaped margins with subepithelial haze and punctate keratopathy, and high intraocular pressure. He initially responded to topical antiviral and antiglaucoma medications. However, it rapidly progressed to a geographic ulcer on initiation of mild steroid and became resistant to conventional medical management. His nephropathy precluded treatment with full dose of systemic antivirals and antiglaucoma drugs. Subsequently, it healed after a paramedian tarsorrhaphy was performed. CONCLUSION: Herpetic epithelial keratitis following intravitreal bevacizumab is a rare occurence. However, this case is the first report of progression to a meta-herpetic ulcer.