Comparative study of the three-dimensional perception of videos recorded on a "Do it yourself" three-dimensional recording assembly versus the conventional recording system.

PURPOSE: To develop an indigenous "Do it yourself" (DIY) three-dimensional (3D) ophthalmic surgery recording system and validate the perception of stereopsis using it. METHODS: A cross-sectional survey of practicing ophthalmologists with post-postgraduation experience of at least 5 years for perception of stereopsis for three different surgeries was performed; cataract, retinal detachment, and intravitreal drug injection were recorded on DIY assembly, viewed on VRBOX and using laptop videos and pseudo 3 d videos as control. RESULTS: The laptop videos and 3D VR Box videos received higher ratings for stereopsis than the pseudo 3D videos. The parameters that received significantly higher ratings on the 3D VR Box viewing were instrument's position relative to the ocular surface in cataract surgery, anterior chamber depth during capsular staining, ophthalmic visco-surgical device injection, capsulorhexis, phaco tunnel depth, movement of nuclear fragments in the anterior chamber, and intra-ocular lens tilt in the capsular bag during cataract surgery (P < 0.05). In scleral buckling surgery, the parameters that were significantly rated higher on VR Box were globe contour, separation of the scleral plane from muscle, and explant plane (P < 0.05). Furthermore, the depth of the needle in the vitreous cavity while administering intravitreal drug injection was also rated significantly higher on VR Box (P < 0.05). However, the ratings for the depth of corneal incision, depth of scleral incision, overall color, and overall quality were not different statistically when compared between laptop and VR Box viewing. CONCLUSION: DIY 3D recording assembly offers a superior means of appreciating depth at various stages of cataract surgery, scleral buckling, and intravitreal drug injection when compared to laptop viewing and can serve as an effective tool for skill transfer.

Implementing competency-based medical education in post-graduate ophthalmology training: Understanding key concepts and methodologies and overcoming challenges.

The National Medical Council (NMC) has mandated that all post-graduate training shall be competency-based, following the principles of Competency. Based Medical Education (CBME). This aims to serve the dual purpose of standardizing ophthalmology post-graduate training and to overcome the shortcomings of the traditional curriculum by employing innovative and interactive teaching-learning and assessment techniques to produce competent ophthalmologists well equipped with clinical, surgical, and professional skills relevant to current times. CBME marks a paradigm shift from traditional curriculum methodologies and involves the introduction of several new concepts. This article aims to highlight the key principles of CBME and the various teaching-learning and assessment technique methodologies which can be employed for post-graduate training. It also highlights the various challenges that are likely to be faced in its implementation and measures to overcome them.

Optical Coherence Tomography Features of Ocular Cysticercosis: A Review of Literature With Observer Variation.

Ocular cysticercosis is a sparsely reported condition, requiring urgent management. The gold standard for diagnosis is an in toto extraction of the cyst with subsequent histopathology. The procedure can be demanding in contrast to the frequently adopted practice of in vivo cyst lysis. The latter, however, obviates a conventional biopsy. We reviewed published optical coherence tomography (OCT) images of ocular cysticercosis for their suitability to surrogate a conventional biopsy and identified commonly reported features. We also used triple masking and ascertained the observer agreement on identification of these features. We found that the features of the parasite are much more clearly discernible as compared with features of the involved ocular tissue itself. The hyperreflective cyst wall and scolex and the hyporeflective cyst cavity had the highest frequency and observer agreement among all the analyzed features, suggesting their use for diagnosis. We could match many of the OCT features with the previously reported histopathological findings, supporting the role of OCT as a diagnostic adjunct and a substitute for conventional biopsy. Conversely, features of the ocular tissue could be judged poorly with low observer agreement, suggesting poor prognostic ability of OCT. [Ophthalmic Surg Lasers Imaging Retina 2022;53:446-454.].

Slit lamp examination during COVID-19: Where should the protective barrier be?

PURPOSE: The aim of this study was to describe a poly-vinyl chloride air condition (PVC AC) curtain shield placed at the intervening space between the chin rest and the illuminating and optical arm of the slit lamp microscope (distal barrier) instead of the present position at the oculars (proximal barrier) to guard against severe acute respiratory syndrome Coronavirus 2. This experimental study was done to validate and compare the protection offered by the conventional breath shields and the one described by us in a simulated environment. METHODS: In this experimental study, 12 puffs of fine mist were sprayed over a period of 1 minute using "magenta-colored dye" and "cyan-colored dye" for analyzing proximal barrier and distal barrier respectively. To access the amount of contamination of the slit lamp, caused by sprayed "magenta" and "cyan" colored dye, we covered the entire slit lamp with appropriately sized white-colored cotton sheet. The stained sheets were individually photographed and then the images were first cropped, then color threshold adjusted and then converted to binary and finally fraction of surface area stained was calculated using the ImageJ software. (Pn Surface Area magenta fraction (%) during analysis of "proximal barrier" and Pn Surface Area cyan fraction (%) during the analysis of "distal barrier", where Pn refers to various parts of slit lamp. RESULTS: The entire surface area of the cloth covering the slit lamp was 9912.45 cm2. The surface area of the cloth which was stained when using the "proximal barrier" was 567.50 cm2 whereas when using the "distal barrier" was 222.93 cm2. When using proximal barrier, 97.71% of the staining was present on the slit lamp base, viewing arm, illumination arm and the pivot of the slit lamp. While using the distal breath shield no parts of the viewing arm, illumination arm, the pivot or the mechanical base with joystick were stained. CONCLUSION: The novel PVC AC curtain shield provides better barrier against the simulated contaminated stream of patient's breath directed towards the working parts of the slit lamp as compared to conventional slit lamp oculars mounted breath shields.

Modified intraocular lens injector assisted rescue technique for failed viscoexpression in a case of intracameral cysticercosis.

Intracameral cysticercosis is a rare disease, and surgical management with viscoexpression is the preferred technique. We discuss a novel technique for removal of anterior chamber parasitic cysts and present it as an alternative to the conventional viscoexpression. Our technique uses a custom-made assembly combining an intraocular lens (IOL) cartridge with an aspiration cannula. We compare its utility with the preexisting surgical methods.

Post-transplant erythrocytosis-related maculopathy: successful management of hyperviscosity with phlebotomy.

PURPOSE: To report clinical features in a case of hyperviscosity retinopathy following post-renal transplant erythrocytosis (PTE) and its outcome after phlebotomy. METHODS: Fundus fluorescein angiography and optical coherence tomography (OCT) were carried out for a 29-year-old renal allograft recipient who presented with acute unilateral visual loss. RESULT: There was mild retinal vascular dilation in both eyes with retinal hemorrhages and retinal opaqueness in left eye. Cystoid macular edema was noted on OCT. Microvascular leaks and micro-occlusions were seen all around the foveal avascular zone on fluorescein angiogram. Investigations revealed hemoglobin to be 16.8 g%, and a PTE was diagnosed. The patient underwent phlebotomy following which there was near complete resolution of macular edema with improvement in vision. CONCLUSION: Hyperviscosity retinopathy can cause acute visual loss in cases of renal allograft recipients who develop PTE. Prompt management with phlebotomy can lead to reversal of macular edema in such cases.

Comparison of surgeon comfort assessment during phacoemulsification using bilateral topical anesthesia versus ipsilateral topical anesthesia: a randomized controlled study.

AIM: To evaluate the effectiveness of bilateral use of topical anesthetic eye drops during phacoemulsification procedure as compared to use in one eye only. METHODS: This is a prospective double-blind randomized case study of 180 cases undergoing phacoemulsification under topical anesthesia using 0.5% proparacaine: Group 1 consisting of patients who had topical anesthetic eye drop instilled into the operating eye only and Group 2 consisting of patients who had both their eyes anesthetized using topical anesthetic eye drops. Phacoemulsification was done using standard surgical technique. Main parameters evaluated included number of intra-operative patient counseling score (IPCS), surgical comfort score (SCS), total phacoemulsification procedure time (TPPT) and total operation time (TOPT). RESULTS: A comparison of mean value of various variables between Group 1 (60; 33.3% cases) and Group 2 (120; 66.7% cases) using "t" test revealed that there was a statistically significant difference for mean SCS (78.38 ± 10.31 vs. 85.05 ± 8.70; p = 0.00), mean IPCS (12.60 ± 3.11 vs. 6.63 ± 1.74; p = 0.00) and mean TOPT (418.88 ± 89.59 vs. 341.64 ± 79.51; p = 0.00), respectively. However, no statistically significant difference existed for mean TPPT (143.57 ± 87.96 vs. 152.96 ± 78.99; p = 0.48). CONCLUSION: Simultaneous instillation of topical anesthetic eye drops in both the eyes, i.e., operating eye and the fellow eye as against practice of instilling topical anesthetic eye drop in the operating eye only, helps in decreasing the total surgical time by primarily shortening the durations of pre- and post-ultrasonic periods of surgery where effective globe stabilization is wanted. This is achieved by better patient compliance, which in turn enhances surgeon's comfort during phacoemulsification surgery.

Evaluation of vitreoretinal interface changes in patients receiving intravitreal anti-VEGF therapy.

PURPOSE: To study the effects of repeated intravitreal injection of anti-VEGF drug bevacizumab on the vitreoretinal interface (VRI). METHODS: Patients undergoing intravitreal injection of bevacizumab were enrolled. Eyes with media haze, uveitis, high myopia, history of cataract surgery or laser capsulotomy in last 6 months and complicated pseudophakia were excluded. VRI evaluation was done monthly for a minimum of 6 months. The nature and timing of the change(s) event was recorded. RESULTS: A total of 100 eyes were evaluated. Thirty-seven eyes developed new vitreoretinal interface change event (VICE). Pseudophakia (OR = 5.23, 95% CI = 1.99-14.07, p = 0.001), pre-injection VRI abnormality (OR = 2.63, 95% CI = 1.13-6.14, p = 0.024) and older age at enrollment (62.6 ± 13.9 vs. 56.3 ± 14 years) were risk factors for development of VICE. Eighty percent of interface events occurred in the first 3 months of therapy. Eight needed surgical intervention for consequences of vitreoretinal separation. CONCLUSION: VICE is not infrequent in eyes receiving anti-VEGF therapy though rarely need surgical intervention. The first 3 months are the critical months to watch out for these events. The treating ophthalmologists must keep the risk factors for development of in mind and monitor and counsel patients accordingly.

Use and validation of mirrorless digital single light reflex camera for recording of vitreoretinal surgeries in high definition.

PURPOSE: The purpose of this study is to describe the use of commercial digital single light reflex (DSLR) for vitreoretinal surgery recording and compare it to standard 3-chip charged coupling device (CCD) camera. METHODS: Simultaneous recording was done using Sony A7s2 camera and Sony high-definition 3-chip camera attached to each side of the microscope. The videos recorded from both the camera systems were edited and sequences of similar time frames were selected. Three sequences that selected for evaluation were (a) anterior segment surgery, (b) surgery under direct viewing system, and (c) surgery under indirect wide-angle viewing system. The videos of each sequence were evaluated and rated on a scale of 0-10 for color, contrast, and overall quality Results: Most results were rated either 8/10 or 9/10 for both the cameras. A noninferiority analysis by comparing mean scores of DSLR camera versus CCD camera was performed and P values were obtained. The mean scores of the two cameras were comparable for each other on all parameters assessed in the different videos except of color and contrast in posterior pole view and color on wide-angle view, which were rated significantly higher (better) in DSLR camera. CONCLUSION: Commercial DSLRs are an affordable low-cost alternative for vitreoretinal surgery recording and may be used for documentation and teaching.

Cow Urine Keratopathy: A Case Report.

Injury to the ocular surface has been described to occur with a wide variety of chemicals. In most cases the cause is industrial injury with acids or alkalis. We are reporting a case of ocular surface injury due to "Cow urine" which to the best of our knowledge is been reported for the first time. Cow urine is a well-accepted medicinal ingredient in ancient Indian medicine. However, wrong formulation and inadvertent prescriptions by quacks can lead to severe ocular surface injury and morbidity. Here, with this case report we have discussed the possible culprit and possible mechanism of ocular injury due to instillation of a concoction containing cow urine as an active ingredient and also discuss legal aspects of quackery in India.

Recent trends: Medical management of infectious keratitis.

This review article highlights the newer diagnostic modalities and approaches in the medical management of infectious keratitis. A Medline literature search conducted to March 2014 has been included. Recent studies or publications were selected from international indexed journals using suitable key words. Development of specular microscopy and polymerase chain reaction (PCR) has a promising role as diagnostic modalities in infectious keratitis, especially in refractory cases. Previously fortified antibiotics have been the mainstay of treatment for bacterial keratitis. Recently, the advent of fourth-generation fluoroquinolones monotherapy has shown promising results in the management of bacterial keratitis. Corneal collagen cross-linking is being considered in the refractory cases. Topical natamycin and amphotericin B should be considered as the first choice anti-fungal agents in suspected filamentous or yeast infection respectively. Voriconazole and newer routes of administration such as intrastromal and intracameral injection of conventional anti-fungal agents have demonstrated a positive clinical response. Ganciclovir is a newer anti-viral agent with promising results in herpes simplex keratitis. Thus, introduction of newer diagnostic modalities and collagen cross-linking along with fourth-generation fluoroquinolones and newer azoles have a promising role in the management of infectious keratitis.

Therapeutic vitrectomy for vitreal recurrence of intraocular lymphoma resistant to intravitreal methotrexate post systemic chemotherapy.

A 49-year-old female with biopsy proven primary vitreoretinal lymphoma and primary central nervous system lymphoma (PCNSL) presented with asymmetric involvement of both eyes. Right eye had primarily retinal and optic nerve involvement with no light perception while the left eye had purely vitreal form of the disease with visual acuity of 6/18. She was treated with recommended DeAngelis protocol for PCNSL and achieved complete remission of CNS disease and in the right eye and responded only partially to the systemic chemotherapy in the left eye. She received multiple intravitreal methotrexate injections (400 µg/0.1 ml) for persisting disease in the left eye. However, she developed resistance to the same after repeated injections for which therapeutic vitrectomy was performed. She achieved final visual acuity of 6/12 in the right eye and 6/18 in the left eye and did not relapse until last follow-up of 2 years.

Evaluation of the effect of scleral buckling on the anterior chamber angle using ASOCT.

PURPOSE: To evaluate the change in anterior chamber angle parameters after scleral buckling surgery using anterior segment optical coherence tomography (ASOCT). METHODS: Fifty-five phakic eyes of 55 subjects undergoing scleral buckling with the placement of an encircling band for primary rhegmatogenous retinal detachment were included in this study. Anterior chamber angle assessment was performed using ASOCT. The trabecular iris angle (TIA), the angle-opening distance, and the trabecular iris space area were the parameters obtained preoperatively and 48 hours, 1 week, and 1 month after the surgery using ASOCT. The intraocular pressure (IOP) was measured using Goldmann applanation tonometry. RESULTS: The mean age of the patients was 43.2±11.3 years; there were 38 male and 17 female patients. There was a significant decrease in all the angle parameters (TIA, angle opening distance, and trabecular iris space area) at 48 hours, 1 week, and 1 month after surgery (P<0.0001). TIA 180 degree decreased from 41.93±14.27 degrees preoperatively to 31.09±10.52 degrees (P<0.0001) and TIA 0 degree from 42.7±14.04 degrees to 32.92±12.17 degrees (P<0.0001) at 48 hours postoperatively. The mean IOP at 48 hours (17.04±3.26 mm Hg) was significantly higher than the preoperative level (12.68±1.96 mm Hg; P<0.001). No significant difference was noted between the mean preoperative IOP and the IOP readings at 1 week (P=0.402) and 1 month (P=0.23) postoperatively. CONCLUSIONS: ASOCT imaging reveals that scleral buckling surgery for retinal detachment induces significant narrowing of the anterior chamber angle.