Impact of Coronavirus Disease 2019 on Intravitreal Antivascular Endothelial Growth Factor Injection Rates in Nigerians.

Aim: To quantify the impact of coronavirus disease 2019 (COVID-19) on the rate of intravitreal antivascular endothelial growth factor (VEGF) injections (IVI) in eye hospitals in Nigeria. Materials and Methods: A retrospective, observational, comparative study. The IVIs given 12 months before (pre-COVID) and 12 months after the first announcement of the COVID-19 lockdown (COVID) in Nigeria in four hospitals were used as the sample for this study. All eyes were treatment naïve. We determined the total number of all anti-VEGF injections, the number given for each indication, and the number of each type of the three anti-VEGFs given. A comparison of the presenting vision in IVI eyes between the two eras and the visual outcome of the IVI treatment was made. Data were analyzed using the SPSS version 22 to determine statistical significance. Results: Male/female ratio, pre-COVID 63.4%/36.6% and COVID 58.6%/41.4% (P = 0.123). Age, pre-COVID 61.3 (SD 12.9) 9-95 years and COVID 57.5 (SD 16.4) 0.15-95 years. There was a 15.3% (81 eyes) reduction in the number of eyes between pre-COVID and COVID eras (528 and 447 eyes, respectively). Likewise, the number of IVIs reduced by 26% (221 IVIs) from 850 pre-COVID to 629 COVID, P = 0.005. A comparison of the proportion of eyes in the four clinic locations between the two eras was not statistically significant (P = 0.148). The commonest indication was proliferative diabetic retinopathy in both eras, 208 versus 178 eyes (323 versus 226 IVIs). Bevacizumab, Ranibizumab, and Aflibercept were given in the following proportions 60.2%, 22.3%, and 17.4% (pre-COVID) versus 60.2%, 31.5%, and 8.3% (COVID), P = 0.000. Presenting visual acuity was >6/60 in 67.4% of eyes (pre-COVID) versus 59.4% of eyes (COVID), P = 0.039. Vision improved in 51.3% of eyes (pre-COVID) versus 47.7% (COVID); there was no significant difference in visual outcome comparing both eras, P = 0.972. Conclusion: COVID-19 significantly reduced the number of eyes and IVIs. Eyes had worse presenting visual acuity during the COVID era; however, treatment outcome was comparable between COVID and pre-COVID eras.

Impact of COVID-19 on ophthalmic surgical procedures in sub-Saharan Africa: a multicentre study.

BACKGROUND: The COVID-19 pandemic had a profound impact on healthcare and ophthalmology services globally. Numerous studies amongst various medical and surgical specialties showed a reduction in patient attendance and surgical procedures performed. Prior published ophthalmic literature focused on specific types of procedures and were usually single centre. The current study attempts to quantify the impact on a larger scale, namely that of sub-Saharan Africa, and to include all ophthalmic subspecialties. METHODS: This is a retrospective analysis of the surgical records from 17 ophthalmology centres in seven countries located in East, Central, West and Southern Africa. The date of declaration of the first lockdown was used as the beginning of the pandemic and the pivot point to compare theatre records one year prior to the pandemic and the first year of the pandemic. We examined the total number of surgical procedures over the two year period and categorized them according to ophthalmic subspecialty and type of procedure performed. We then compared the pre-pandemic and pandemic surgical numbers over the two year period. RESULTS: There were 26,357 ophthalmic surgical procedures performed with a significant decrease in the first year of the pandemic (n = 8942) compared to the year prior to the pandemic (n = 17,415). The number of surgical procedures performed was lower in the first year of the pandemic compared to the year prior to the pandemic by 49% [Incidence rate ratio (IRR) 0.51, 95% CI 0.41-0.64), 27% (0.73, 0.55-0.99), 46% (0.54, 0.30-0.99), 40% (0.60, 0.39-0.92) and 59% (0.41, 0.29-0.57) in sub-Saharan Africa (4 regions combined), West, Central, East and Southern Africa, respectively]. The number of surgical procedures in the different sub-specialty categories in sub-Saharan Africa (4 regions combined) was significantly lower in the first year of the pandemic compared to the year prior to the pandemic, except for glaucoma (IRR 0.72, 95% CI 0.52-1.01), oncology (0.71, 0.48-1.05), trauma (0.90, 0.63-1.28) and vitreoretinal (0.67, 0.42-1.08) categories. CONCLUSION: This study provides insight into the impact of the COVID-19 pandemic in multiple regions and countries on the African continent. The identification of which surgical subspecialty was most affected by the COVID-19 pandemic in each region allows for better planning and resource allocation to address these backlogs.

Visual outcome of treating proliferative sickle cell retinopathy in 108 eyes.

AIM: To report treatment methods and visual outcome of treating proliferative sickle cell retinopathy (PSCR). DESIGN: Retrospective interventional. METHODS: Review of PSCR eyes treated between 2017 to 2022. Patient demographics, fundus findings at presentation, genotype, PSCR stage, treatment used, and visual outcome were assessed. RESULTS: 108 eyes of 88 consecutive patients were studied. Male: Female 48:40. Mean age: 38.91 (SD:12.52) years. Genotype: sickle cell haemoglobin C (SC) 83 eyes (76.9%), sickle cell haemoglobin S (SS) 19 eyes (17.6%), and sickle cell trait (AS) 6 eyes (5.5%). PSCR stages: 3: 15 eyes (11.0%), 4: 74 eyes (67.0%), and 5: 19 eyes (22.0%). Treatment methods: Intravitreal Injection (IVI) of anti-vascular endothelial growth factor (VEGF) only (27 eyes,25%), scatter retinal laser photocoagulation (SRLP) only (7 eyes, 6.5%), Vitrectomy + SRLP (29 eyes, 26.9%), IVI + SRLP (25 eyes, 23.1%), and Vitrectomy + IVI + SRLP (20 eyes, 18.5%). The treatment used correlated with PSCR stage (p = 0.000). IVI only was mostly used to treat stage 4 (81.4%), and SRLP only was used for stages 3 (42.9%) and 5 (57.1%). IVI + SRLP treated eyes had the best pre- and post-treatment vision. Vitrectomy + SRLP treated eyes had the most improved vision. SRLP only had least visual improvement. Fundus findings correlated with visual outcome (p = 0.003); but stage of PSCR, genotype and treatment used had no correlation (P > 0.05). CONCLUSION: Several options effectively treat PSCR. Visual outcome improved or remained same in 90.7% of treated eyes. Randomized controlled trials will determine the optimum treatment for each distinct presentation of PSCR. Treatment guidelines and a disease classification system of prognostic value are unmet needs.

Clinical presentation and macular morphology in retinitis pigmentosa patients.

Background: Optical coherence tomography (OCT) is a noninvasive, frequently used imaging technology that enables detailed viewing of retina anatomy. It is used to monitor disease progression in retinitis pigmentosa (RP) eyes, including detecting changes in retinal thickness. Purpose: The purpose of the study is to determine the clinical presentation and macular morphology in RP eyes using OCT imaging. Methods: A retrospective review of case records and OCT scans in eyes diagnosed with RP in two ophthalmic clinics in Nigeria. Biodata, Snellen best-corrected visual acuity (BCVA), intraocular pressure (IOP), vertical cup-to-disc ratio (VCDR), and presence of maculopathy were determined. Data were analyzed using IBM SPSS version 22.0 (IBM Corp. Armonk, NY, USA). Results: Fifty-five eyes of 28 patients (18 males and 10 females), with a mean age of 47.16 ± 15.56 years (22-77 years), were studied. 40-49 years was the most frequent age group, 28.6%. Severe visual impairment occurred in 22% of eyes and myopia in 32%. Twenty-nine percent had undergone cataract surgery or had a significant cataract. The mean IOP was 11 mmHg, and the mean VCDR was 0.46. On OCT examination, macular atrophy was the most common finding in 74.5% of eyes, epiretinal membrane in 16.3%, cystoid macular edema in 7.3%, vitreomacular adhesion in 5.4%, and vitreomacular traction in 1.8%. There was no association between macular morphology, macular thickness, and BCVA (P = 0.155, P = 0.424). Conclusion: OCT provides information on macula structure in RP eyes. About 14.5% of eyes had a normal macula, while 85.5% had a maculopathy, confirming that RP eyes have a higher rate of maculopathy than non RP eyes. OCT evaluation of an RP eye should be a standard workup for the early detection of such maculopathy and monitoring for disease progression.

Résumé Contexte: La tomographie par cohérence optique (OCT) est une technologie d'imagerie non invasive fréquemment utilisée qui permet une visualisation détaillée de l'anatomie de la rétine. Elle est utilisée pour surveiller la progression de la maladie dans les yeux de la rétinite pigmentaire (RP), y compris la détection des changements dans l'épaisseur de la rétine. Objectif: Le but de l'étude était de déterminer la présentation clinique et la morphologie maculaire des yeux présentant une RP à l'aide de l'imagerie OCT. Méthodes: Une revue rétrospective des dossiers de cas et des scans OCT dans les yeux diagnostiqués de RP a été réalisée dans deux cliniques ophtalmologiques au Nigeria. Les données biographiques, la meilleure acuité visuelle corrigée de Snellen (MAVC), la pression intraoculaire (PIO), le rapport cup-sur-disc vertical (RCDV) et la présence de maculopathie ont été déterminés. Les données ont été analysées à l'aide d'IBM SPSS version 22.0 (IBM Corp. Armonk, NY, USA). Résultats: Cinquante-cinq yeux de 28 patients (18 hommes et 10 femmes), âgés en moyenne de 47,16 ± 15,56 ans (22­77 ans) ont été étudiés. Les 40 à 49 ans étaient la tranche d'âge la plus fréquente à 28,6 %. Une déficience visuelle sévère est survenue dans 22 % des yeux et une myopie dans 32 %. Vingt-neuf pour cent avaient subi une chirurgie de la cataracte ou avaient une cataracte importante. La PIO moyenne était de 11 mmHg et le RCDV moyen était de 0,46. À l'examen OCT, on retrouvait l'atrophie maculaire prédominante dans 74,5 % des yeux, la membrane épirétinienne (16,3 %), l'œdème maculaire cystoïde (7,3 %), l'adhérence vitréomaculaire (5,4 %) et la traction vitréomaculaire (1,8 %). Il n'y avait aucune association entre la morphologie maculaire, l'épaisseur maculaire et la MAVC (P = 0,155, P = 0,424). Conclusion: l'OCT fournit des informations sur la structure de la macula dans la RP. Environ 14,5% des yeux avaient une macula normale contre 85,5% avec maculopathie, confirmant ainsi que les yeux avec RP ont un taux de maculopathie plus élevé que les yeux sans RP. L'évaluation OCT d'un œil avec RP devrait être un bilan standard pour la détection précoce de maculopathie et la surveillance de la progression de la maladie. Mots-clés: Membrane épirétinienne, dystrophie rétinienne héréditaire, atrophie maculaire, œdème maculaire, tomographie par cohérence optique, rétinite pigmentaire.

Choroidal thickness and effect of sex and age in Africans.

Purpose: The purpose of the study is to evaluate choroidal thickness (CT) and the effect of age and gender in healthy Africans using enhanced depth imaging spectral-domain optical coherence tomography. Materials and Methods: In 172 eyes of 88 volunteers, the CT in the central subfoveal (CSF) area and at 2.5 mm superior, inferior, nasal, and temporal quadrants was measured. Four eyes were excluded due to poor image quality and image decentration. Simple linear regression was used to measure the effect of age on CT, and statistical analysis was done using IBM SPSS Statistics version 22. Results: The were 88 male and 84 female eyes, aged 30-80 years. The mean CT was CSF 265.44 ± 6.2 µm; inferior 256.19 ± 70.6 µm; superior 249.92 ± 76.2 µm; temporal 235.51 ± 70.3 µm; and nasal 199.53 ± 69.8 µm. The choroid was thickest in the CSF > Inferior > Superior > Temporal, and the nasal quadrant was thinnest in all age groups. There was a considerable decrease in the CSF with increasing age (P < 0.001). CT in males and females was similar since the difference in mean CSF CT between the genders was 2.085 µm (P = 0.858). Menopausal females had thinner CSF CT compared to premenopausal females (P < 0.001), but this was due to the aging effect. Conclusion: CT decreases significantly with increasing age but shows no gender difference in Africans. A comparison of CT studies from other ethnic nationalities shows some similarity with CT in Africans, suggesting that CT findings from other ethnic groups can be extrapolated to Africans.

Résumé Objectif: Évaluer l'épaisseur choroïdienne (CT) et l'effet de l'âge et du sexe chez les Africains noirs en bonne santé à l'aide de la tomographie par cohérence optique dans le domaine spectral (SD-OCT) par imagerie en profondeur améliorée (EDI). Matériel et méthodes: Dans 172 yeux de 88 volontaires, la tomodensitométrie dans la zone sous-fovéale centrale (LCR) et à 2,5 mm quadrants supérieur, inférieur, nasal et temporal a été mesurée. Quatre yeux ont été exclus en raison de la mauvaise qualité de l'image et de la décentration de l'image. Une régression linéaire simple a été utilisée pour mesurer l'effet de l'âge sur la TDM, et l'analyse statistique a été effectuée à l'aide de la version 22 d'IBM SPSS Statistics. Résultats: Il y avait quatre-vingt-huit yeux masculins et 84 yeux féminins, âgés de 30 à 80 ans. La TDM moyenne était de 265,44 ± 6,2 µm ; inférieure 256,19±70,6 µm; supérieur 249,92 ±76,2 µm; temporal 235,51 ±70,3 µm; et nasale 199,53 ±69,8 µm. La choroïde était la plus épaisse dans le LCR > inférieure > supérieure > temporal, et le quadrant nasal était le plus mince dans tous les groupes d'âge. Il y a eu une diminution considérable du LCR avec l'âge (p < 0,001). La TDM chez les hommes et les femmes était similaire puisque la différence de TDM moyenne du LCR entre les sexes était de 2,085 µm (p = 0,858). Les femmes ménopausées avaient une TDM du LCR plus mince que les femmes préménopausées (p<0,001), mais cela était dû à l'effet du vieillissement. Conclusion: CT diminue significativement avec l'âge, mais ne montre aucune différence entre les sexes chez les Africains noirs. Une comparaison des études CT d'autres nationalités ethniques montre une certaine similitude avec CT chez les Africains, ce qui suggère que les résultats CT d'autres groupes ethniques peuvent être extrapolés aux Africains noirs. Mots-clés: Africains, vieillissement, choroïde, épaisseur choroïdienne, tomographie par cohérence optique, rétine.

Vitrectomy and manipulation of intraocular and arterial pressures for the treatment of nonarteritic central retinal artery occlusion.

The purpose of this study is to describe a surgical technique and report the functional outcome of treating nonarteritic central retinal artery occlusion (CRAO) in 2 eyes of two consecutive male patients. Two males (A) and (B) presented 6 days and few hours, respectively, after symptom onset with the clinical features typical of CRAO, including sudden severe deterioration of vision to counting fingers and a cherry-red spot in the left and right fovea, respectively. While A had been on recent treatment for hypertension and hyperlipidemia, B had no significant medical history. Both patients underwent surgery, A, 9 days, and B, <15 h after symptom onset. Surgery involved a vitrectomy, lowering of intraocular pressure (<3 mmHg), and gradual increase of arterial pressure to 165/100 mmHg (through the slow injection of intravenous adrenaline). Intraoperatively, this resulted in immediate perfusion and visible dilation of the blood-filled central retinal artery (CRA) and retinal arteriolar network and dilatation of the central retinal vein. The final vision settled to 6/60 in A and 6/36+1 in B. Although preoperative macular infarction persisted in both eyes as demonstrated by optical coherence tomography angiography, both patients claim a convincing subjective visual benefit. The procedure appeared to have positively changed the natural history of the disease in both eyes. Vitrectomy with the manipulation of intraocular and arterial pressures significantly increases ocular perfusion along the entire CRA, which can dislodge CRA thrombo-emboli and has the potential to restore retinal perfusion and improve visual outcome if undertaken before irreversible retina damage. This is a relatively straightforward technique and should join the list of surgical techniques for treating CRAO.

Autologous Neurosensory Retinal Transplantation: A Report of Three Cases.

PURPOSE: To present the anatomical and functional outcomes of autologous surgical transplantation of a free neurosensory retinal graft in three cases of recurrent and chronic full thickness macular hole (MH). METHODS: A retrospective case series, reporting the profile, preoperative presentation, surgical technique, and postoperative outcome of three consecutive eyes of three patients who had autologous retina transplantation (ART) surgery for recurrent and chronic MHs, and had a minimum of six months follow-up. The technique involved excision of a free neurosensory graft after laser demarcation of the harvest site. The graft was slid under perfluorocarbon liquid (PFCL) into the MH. A five-day tamponade with PFCL was used to secure the graft within the MH and then exchanged with air. RESULTS: The patients were one female and two males aged 60, 44, and 67 years, respectively. All eyes had successful surgery. Postoperative vision improved from 6/36 to 6/18 in patient 1 and remained same as preoperative vision in the other two eyes. No eye lost vision postoperatively. The main complication of surgery was occurrence of retinal and vitreous hemorrhage in one eye (this did not appear to jeopardize the outcome) and retraction of graft tissue in two eyes. CONCLUSION: ART appears to be a safe and effective treatment for difficult MHs. Our results are comparable to previous studies. Short-term use of PFCL can be useful to secure the graft within the MH. Methods of improving visual function should be the focus of further research in this promising area.

Post intravitreal bevacizumab recurrent Burkholderia cepacia endophthalmitis treated with clear lens extraction in an African.

PURPOSE: To report the successful treatment of post intravitreal bevacizumab recurrent Burkholderia cepacia endophthalmitis managed with a clear lens extraction and posterior capsulectomy. OBSERVATION: A 34-year-old female African, known SC hemoglobinopathy patient, presented with bilateral blur in vision and floaters of a week duration; worse in her right eye. Her visual acuity was right eye 6/9 (20/30) and left eye 6/6 (20/20). Her anterior segment examination was normal in both eyes. On fundus examination, she had a right eye vitreous hemorrhage and bilateral active Sea-fan neovascular proliferation in the retina periphery. Following the administration of bilateral simultaneous intravitreal bevacizumab, she presented 4 days later with a right eye infective endophthalmitis. She suffered multiple recurrences despite adequate treatment, including a vitrectomy with silicone oil injection. Multiple microbiological assessment of intraocular extracts confirmed persistent Burkholderia cepacia infection. A wide ring-shaped opaque plaque was noticed on the posterior capsule of her clear lens. A decision was taken to perform a lensectomy and posterior capsulectomy. This resulted in immediate resolution of hypopyon and all intraocular inflammation. Vision improved from Hand Motion to 6/18 (20/60). CONCLUSION AND IMPORTANCE: This report suggests than in some cases of recurrent, difficult to treat, Burkholderia cepacia endophthalmitis, since the organism may have colonized the posterior lens capsule, the eye and vision can be salvaged by timely removal of a clear lens and capsulectomy. Clear lens removal has not been previously reported for treating recurrent Burkholderia cepacia endophthalmitis.

Natural History of a Large Bubble of Migratory Submacular Perfluorocarbon.

PURPOSE: To report the natural history of a large bubble of perfluorocarbon liquid (PFCL) in a parafoveal subretinal position which was monitored using optical coherence tomography (OCT) and optical coherence tomography angiography (OCTA). The bubble of PFCL was removed when it migrated to the subfoveal position; outcome after removal is also reported. OBSERVATION: A 62-year-old male, after repair of a giant retinal tear (GRT) detachment, regained Snellen acuity of 6/18 from preoperative vision of CF at 1 meter. A large bubble of subretinal PFCL was in the superior parafoveal area. For 18 months, the PFCL bubble was monitored using OCT and OCTA until it migrated into the subfoveal position after 22 months, coinciding with a decrease in vision to 6/36. Surgical removal of subfoveal PFCL was performed. This involved detachment of the foveomacular, epiretinal membrane (ERM) peel (complicated by iatrogenic macular hole (MH) formation), intravitreal injection of PFCL to displace subretinal PFCL to the periphery, creation of an inverted internal limiting membrane (ILM) flap to repair the MH and air exchange. Postoperative vision remained 6/36. His postoperative OCT showed significant loss of subfoveal outer retina. On OCTA, the superficial and deep vascular plexi and choriocapillaris appeared to be intact after the removal of the subfoveal PFCL. CONCLUSION AND IMPORTANCE: This report suggests that a large superior parafoveal bubble of PFCL may take as much as 18 months to migrate to the subfoveal position. Before this time, vision does not appear to be affected, though macular edema is present. Therefore, removal of the PFCL can be delayed until a convenient time for surgeon and patient. A large bubble of parafoveal PFCL ought to be removed before migrating to a subfoveal position and vision loss, since its removal will reduce the risk of outer retina loss.

Outer retina reconstruction following inverted internal limiting membrane flap technique for large macular holes.

PURPOSE: The aim of this study is to investigate the outer retina reconstruction using postoperative spectral domain optical coherence tomography (SD OCT) in large diameter macular holes (MHs) treated with the inverted internal limiting membrane (ILM) flap technique. METHODS: A retrospective study of 14 consecutive eyes that had vitrectomy and inverted ILM flap technique for MHs with a base diameter of 400 µ or greater. Preoperative and postoperative SD OCT images were assessed for MH closure and for outer retina presence; represented by the external limiting membrane (ELM) and ellipsoid zone (EZ), in the subfoveal and parafoveal areas. RESULTS: The average MH base diameter was 963 µ. Postoperative SD-OCT revealed an absence of the outer retina in six eyes, a continuous (regular) presence of the outer retina in four eyes, and a discontinuous (interrupted) presence in four eyes. There was an inverse relationship between MH size and presence or absence of ELM and EZ. A larger MH base diameter size was associated with a higher probability of an absent ELM and EZ (P = 0.04). Eyes in which an outer retina was present postoperatively achieved 6/18 and better vision compared to eyes without (P = 0.08). CONCLUSION: The outer retina in some large MHs treated with ILM flap technique can undergo reconstitution and remodeling which improves over time. The average size for MHs with complete reconstitution was 652 µ, 855 µ for those with interrupted reconstitution, and 1242 µ for eyes with no outer retina reconstruction. This suggests that MHs having a size within the limit of the no outer retina reconstitution MH group may be candidates for other surgical techniques in which postoperative outer retina presence is expected.

Indications and outcomes of vitrectomy surgery in a series of 1000 black African eyes.

OBJECTIVE: To determine the common indications for, and outcomes of pars plana vitrectomy surgery among black Africans in a low-resource setting. METHODS AND ANALYSIS: A retrospective, non-comparative case review was undertaken. Data from 1000 consecutive eyes of 1000 patients in a single centre who underwent pars plana vitrectomy surgery between May 2005 and July 2013 were used for the study. Demographic data, primary indication for surgery, ocular status and outcomes were assessed. RESULTS: Rhegmatogenous retinal detachment was the most common primary indication occurring in 61.8% of eyes. Diabetic vitrectomy, trauma and proliferative sickle cell retinopathy were also common indications occurring in 10.1%, 6.1% and 4.5% of eyes, respectively. At presentation, 33% of patients with retinal detachment had some form of proliferative vitreoretinopathy, and half of those had the more advanced grades C and D. Patients presented on an average of 13.5 months after onset of symptoms. As a result, visual outcomes were less than other reported studies. CONCLUSION: Retinal detachment was the most common indication for vitrectomy, but even these cases presented late with an advanced presentation. This study highlights the need for affordable and accessible vitreoretinal services in Sub-Saharan Africa and increased awareness of general eye health, along with strategies to reduce trauma and identify early those at risk of chronic eye diseases, such as diabetic retinopathy and sickle cell retinopathy.

Removal of adult subconjunctival Loa loa amongst urban dwellers in Nigeria.

Loiasis is a neglected tropical disease caused by infection with the filarial parasite Loa loa. It is a disease considered by many to be benign. Several reports of trans border importation of the Loa loa worm amongst immigrants and visitors from endemic regions of the world exist. In most cases an adult subconjunctival worm is removed from the patient. An interventional case series is reported and examines the practice of removal of subconjunctival adult Loa loa worms amongst urban dwellers in Nigeria. Four cases of ocular loiasis seen amongst urban dwellers in Nigeria exemplify the different presentations and removal methods of the subconjunctival adult worm. There were 2 males and 2 females aged 35years, 23years, 25years and 30years respectively. Each patient gave a history of having been raised in a rural community in childhood years, during which they were exposed to streams and muddy farm land; and then migrated to the urban community in later years. They all present with the finding of a subconjunctival adult worm, which was successfully removed and identified to be Loa loa. There are more urban dwellers in Nigeria who present with symptoms of foreign body sensation that may be related to the manifestation of a subconjunctival worm and are not recognized. This is because the emphasis on this disease has erstwhile been on the rural, village dwellers and not on urban dwellers. Eye care practitioners working in urban centers need to be aware of the possibility of this presentation, and be ready to remove any subconjunctival worm when it presents.

Burkholderia cepacia, a cause of post pars plana vitrectomy silicone oil related endophthalmitis: clinico-pathological presentation and outcome of management.

AIM: To report the long-term outcome of the management of a series of culture proven post pars plana vitrectomy endophthalmitis in which the infective agent was in the silicone oil used as an endotamponade. The isolates were Burkholderia cepacia and Pseudomonas aeruginosa. METHOD: A retrospective interventional reporting of a series consisting of a cluster of five cases. CASES: Five consecutive patients received the same batch of 5000-centistoke silicone oil as endotamponade at the conclusion of vitreoretinal surgery and presented with features of acute intraocular inflammation, which was due to an infective cause. The infective organism isolated from the mixture of silicone oil and fluid was B. cepacia in three out of the initial cluster of four eyes and P. aeruginosa in the fifth eye. OUTCOME OF MANAGEMENT: The initial 4 eyes evolved into eyes with poor vision (hand motion, perception of light and no perception of light), advanced proliferative vitreoretinopathy, hypotony, phthisis bulbi and cornea opacity. The poor visual outcome was deemed to be consequent to delay in removal of the silicone oil, despite use of intravitreal, systemic and topical antibiotics. The fifth case, because of the heightened index of suspicion gained from the preceding four cases, had a prompt removal of the silicone oil, vitreal lavage with antibiotics, and intravitreal injection of antibiotics and steroid. He regained a 6/9 vision. CONCLUSION: Gram-negative bacilli can colonize silicone oil resulting in post pars plana vitrectomy endophthalmitis. The index of suspicion for this should be high and can be managed successfully with prompt removal of the silicone oil, microbial sensitive antibiotic lavage of the vitreous cavity, followed by a repeat tamponade.

Inverted Internal Limiting Membrane Technique Maintains Macular Hole Closure in Retinal Detachment Following Macular Hole Repair.

Recent advances in macular hole surgery have significantly improved the rates of anatomical success. One important advance is the dye-assisted peeling of the internal limiting membrane (ILM) around the hole. In large holes (<400 µ), sometimes, ILM peeling alone is not enough to achieve closure, and this may be improved by inverting part of the peeled membrane and using it to cover the macular hole or inverting and tucking the ILM flap into the hole. In this case report, a patient with large full-thickness macular hole underwent a hole repair with an inverted ILM flap technique. The eye developed a subsequent retinal detachment with large collection of subretinal fluid beneath the repaired hole, but the hole remained intact, suggesting that the adhesive forces binding an inverted flap to the edges of a repaired macular hole appear to be strong enough to maintain structural integrity of the closed hole even in the presence of a macula-involving retinal detachment with large subretinal fluid collection.