Single-port transconjunctival vitrectomy for malignant glaucoma.

The management of malignant glaucoma involves either anterior vitrectomy with zonulectomy and iridectomy or 3-port core pars plana vitrectomy (PPV) by retinal surgeons. The proposed modification can be performed with reasonable success rates. In this technique, synechiolysis and anterior chamber irrigation were performed through a limbal incision, and a single-port 23- or 25-gauge vitrector was introduced through PPV superotemporally to perform anterior vitrectomy and central posterior capsulotomy in pseudophakic eyes. The same procedure can be performed after cataract surgery in phakic eyes. Vitrectomy is continued until anterior chamber deepens, ensuring a conduit between anterior and posterior chambers through the posterior capsulotomy alone, bypassing the need for a posterior iridectomy/zonulectomy. In a series on 9 eyes, all achieved optimization of anterior chamber depth with intraocular pressure normalization in 8 of 9 eyes, without showing any signs of recurrence at a mean follow-up of 8.6 months.

Clinical validation of RIA-G, an automated optic nerve head analysis software.

Purpose: To clinically validate a new automated glaucoma diagnosis software RIA-G. Methods: A double-blinded study was conducted where 229 valid random fundus images were evaluated independently by RIA-G and three expert ophthalmologists. Optic nerve head parameters [vertical and horizontal cup-disc ratio (CDR) and neuroretinal rim (NRR) changes] were quantified. Disc damage likelihood scale (DDLS) staging and presence of glaucoma were noted. The software output was compared with consensus values of ophthalmologists. Results: Mean difference between the vertical CDR output by RIA-G and the ophthalmologists was - 0.004 ± 0.1. Good agreement and strong correlation existed between the two [interclass correlation coefficient (ICC) 0.79; r = 0.77, P < 0.005]. Mean difference for horizontal CDR was - 0.07 ± 0.13 with a moderate to strong agreement and correlation (ICC 0.48; r = 0.61, P < 0.05). Experts and RIA-G found a violation of the inferior-superior NRR in 47 and 54 images, respectively (Cohen's kappa = 0.56 ± 0.07). RIA-G accurately detected DDLS in 66.2% cases, while in 93.8% cases, output was within ± 1 stage (ICC 0.51). Sensitivity and specificity of RIA-G to diagnose glaucomatous neuropathy were 82.3% and 91.8%, respectively. Overall agreement between RIA-G and experts for glaucoma diagnosis was good (Cohen's kappa = 0.62 ± 0.07). Overall accuracy of RIA-G to detect glaucomatous neuropathy was 90.3%. A detection error rate of 5% was noted. Conclusion: RIA-G showed good agreement with the experts and proved to be a reliable software for detecting glaucomatous optic neuropathy. The ability to quantify optic nerve head parameters from simple fundus photographs will prove particularly useful in glaucoma screening, where no direct patient-doctor contact is established.

Patterns of uveitis in patients with proven systemic (pulmonary and extrapulmonary) tuberculosis.

PURPOSE: To report patterns of uveitis in patients with systemic tuberculosis. METHODS: Records of patients presenting at uvea clinic of a tertiary eye care centre were evaluated retrospectively, and 47 cases with proven systemic tuberculosis were analyzed for patterns of uveitis. Tuberculosis had been proven with a combination of radio imaging and detection of acid fast bacilli in body fluids. All patients had been reviewed by a specialist as applicable before diagnosing tuberculosis. These patients had undergone a thorough ocular workup. Pattern of uveitis was the primary outcome measure. RESULTS: Mean age was 35.34 ± 15.56 years. Lung was the commonest systemic focus, seen in nearly 75% of the cases. Anterior uveitis was the most common presentation (48.9%), followed by posterior (25.5%), panuveitis (10.6%) and intermediate uveitis (10.6%). Multifocal serpiginoid choroidopathy (MSC) was seen in only one patient, while granulomatous choroiditis was the commonest type of posterior uveitis. CONCLUSIONS: Anterior uveitis is the most frequent type of uveitis seen in patients with proven systemic tuberculosis. Rarity of MSC in such patients indicates possibility of etiologies other than tuberculosis in causing MSC.

Treatment before macular grid in patients of diabetic macular edema.

AIM: The aim of this study is to compare the efficacy of intravitreal bevacizumab and posterior subtenons triamcinolone acetate in the management of diffuse diabetic macular edema (DME) and to evaluate their efficacy as an adjunct to modified grid laser in management of DME. DESIGN: This was a prospective, randomized clinical trial of 30 patients. MATERIALS AND METHODS: A total of 30 patients attending the medical ophthalmology clinic at a tertiary care hospital were included in the study. These 30 patients were divided into two groups. Group I (15 eyes) received intravitreal bevacizumab followed by modified grid photocoagulation 2 weeks after injection. Group II (15 eyes) received posterior subtenons triamcinolone followed by modified grid photocoagulation 2 weeks after injection. Each patient in our study was followed up at 1 week, 2 weeks, 1 month, 2 months, 3 months, and 6 months after the initial injection to record the central macular thickness (CMT) and best-corrected visual acuity (BCVA). RESULTS: Both the combination therapies have efficacy to reduce the CMT (P = 0.001). The percentage fall in CMT was greater in bevacizumab + laser group, and there was a significant difference in the CMT values at the end of the study in the bevacizumab group (P = 0.013). The mean BCVA improved in both the groups and this difference was statistically significant compared to the baseline (P = 0.005). However, there was no statistically significant difference in BCVA between the two groups at the end of the study. CONCLUSION: Both intravitreal bevacizumab and posterior subtenons triamcinolone given as an adjuvant therapy along with modified grid laser are equally efficacious in the reduction of the CMT; however, the percentage fall in the CMT was greater in bevacizumab + laser group, and there was a significant difference in the fall in CMT at all the visits as compared to a plateau in the fall of CMT in posterior subtenons triamcinolone group.

Endoillumination (chandelier) and wide-angle viewing-assisted fine-needle aspiration biopsy of intraocular mass lesions.

Fine-needle aspiration biopsy (FNAB) of intraocular mass lesions is an important intervention in the presence of diagnostic difficulty. FNAB of intraocular mass lesions is also likely to become more commonly recommended for prognostication of tumors such as choroidal melanoma. The most commonly described approach for tumor localization and visualization during FNAB is transillumination and indirect ophthalmoscopic viewing. Herein, we report endoillumination (chandelier) and wide-angle viewing assisted, microscope-based approach for FNAB in two patients using two port minimally invasive vitreoretinal surgical approach. The submission is supported by a video demonstration. The entire procedure was completed under the microscope. Adequate sample was obtained. In the first patient, the inflammatory nature of the lesion was confirmed though magnetic resonance imaging had been reported as melanoma. In the second patient, a clinical diagnosis of amelanotic melanoma was confirmed. Endoillumination-assisted FNAB of intraocular mass lesions is easier to learn and more precise and hence carries lesser risks.

Short-term Intensive Immunosuppression: A Randomized, Three-arm Study of Intravenous Pulse Methylprednisolone and Cyclophosphamide in Macular Serpiginous Choroiditis.

PURPOSE: To compare the efficacy of pulse cyclophosphamide with pulse dexamethasone in acute macular serpiginous choroiditis (SC). METHODS: A total of 30 patients with macular SC were prospectively randomized into three treatment groups: group D (pulse dexamethasone); group C (pulse cyclophosphamide); and combination (pulse group DCP) administered for 3 days. Macular SC was defined as any active lesion involving/threatening macula. RESULTS: A total of 30 patients were enrolled, with 10 patients in each group. Lesions completely healed at median duration of 2 weeks in each group, with significant improvement in visual acuity compared with pretreatment levels (p<0.05). Pulse cyclophosphamide was most effective in faster healing of lesions compared with other groups. There was no difference in gain in visual acuity between any of the groups (p = 0.32). CONCLUSIONS: Cyclophosphamide may be an effective treatment modality for acute macular SC, though it may not have a long-term effect on disease relapse.

Evaluating role of bone marrow-derived stem cells in dry age-related macular degeneration using multifocal electroretinogram and fundus autofluorescence imaging.

AIM: To evaluate the role of bone marrow-derived stem cells in the treatment of advanced dry age-related macular degeneration (AMD) using multifocal electroretinogram (mf-ERG) and fundus autofluorescence imaging. METHODS: Thirty patients (60 eyes) with bilateral central geographic atrophy (GA) were recruited. Worse eye of each patient received autologous bone marrow-derived hematopoietic stem cells (BM-HSCs) (group 1) and the fellow eye with better visual acuity served as control (group 2). The effect of stem cell therapy was determined in terms of visual acuity, amplitude and implicit time in mf-ERG and size of GA on fundus autofluorescence imaging. These tests were performed at presentation and first, third and sixth month follow up. Adverse events (if any) were also monitored. RESULTS: At 6mo follow-up there was no statistically significant improvement in median logMAR best corrected visual acuity (BCVA) in either group. Mf-ERG revealed significant improvement in amplitude and implicit time in the intervention group. A significant decrease was also noted in greatest linear dimension (GLD) of GA in the eyes receiving stem cells [6.78±2.60 mm at baseline to 6.56±2.59 mm at 6mo (P=0.021)]. However, no such improvement was noted in the control group. CONCLUSION: Electrophysiological and anatomical improvement in the intervention group sheds light on the therapeutic role of BM-HSCs. Further studies are required to determine the stage of disease at which the maximal benefit can be achieved and to standardize the dose and frequency of stem cell injection.

Vitreous Amyloidosis: Ocular, Systemic, and Genetic Insights.

PURPOSE: To report the unique clinical and surgical characteristics encountered in eyes with vitreous amyloidosis. Systemic evaluation and visual outcome after vitrectomy are discussed. A novel mutation in the transthyretin gene (TTR) in Indian patients with familial amyloid polyneuropathy (FAP) is described. DESIGN: Retrospective, observational study. PARTICIPANTS: Ten eyes of 5 patients from 2 pedigrees with a diagnosis of vitreous amyloidosis. METHODS: Detailed history, pedigree charting, systemic and ocular examination of 10 eyes (5 patients from 2 pedigrees) were carried out. Tests were performed to rule out vitreitis, retinal vasculitis, vitreous hemorrhage, and systemic amyloidosis. Genetic analysis to identify the mutation was performed in 1 patient. Vitreous biopsy, followed by 25-gauge pars plana vitrectomy, was performed in the same sitting in all cases. Samples were sent for Congo red staining and polarized microscopy. Patients were followed up on days 1, 7, and 28 and then every 2 months. Visual acuity assessment, intraocular pressure measurement, and fundus examination were performed each time. MAIN OUTCOME MEASURES: Mutations in TTR and postoperative visual acuity. RESULTS: Mean age at presentation was 32 years, with a 3:2 male-to-female distribution. Family history was positive in all patients. Nine eyes had pseudopodia lentis, whereas all 10 had glass wool-like vitreous. Glaucoma developed in 1 patient (2 eyes). Waxy paper-like vitreous with firm vitreous adhesions beyond major arcades and along retinal vessels was noted during surgery in all eyes. Congo red staining and apple green birefringence demonstrated vitreous amyloidosis. The mean preoperative best-corrected visual acuity (BCVA) was 1.39±0.64 logarithm of the minimum angle of resolution (logMAR), whereas the postoperative BCVA improved to 0.17±0.07 logMAR (P = 0.004). Gene sequencing revealed a phenylalanine→isoleucine mutation in the 33rd position of exon 2 of TTR in 1 patient of 1 pedigree, confirming the diagnosis of FAP. Two patients subsequently were found to have sensorimotor autonomic neuropathy, whereas 2 others had subclinical autonomic dysfunction. CONCLUSIONS: The clinical clues, management strategy, surgical characteristics, vitrectomy outcomes, and significance of systemic evaluation in vitreous amyloidosis are highlighted. A novel single mutation (Phe33Ile) in a case of FAP with vitreous amyloidosis from India is reported.

Evaluation of fundus autofluorescence patterns in age-related macular degeneration.

AIM: To study the various morphological patterns of fundus autofluorescence (FAF) images in patients with age-related macular degeneration (AMD) in Indian population. METHODS: Totally 179 eyes of 104 patients with clinical diagnosis of AMD were recruited into the study. Autofluorescence images were captured using confocal scanning laser ophthalmoscope and the patterns of FAF were classified. RESULTS: Of 179 eyes, 27 (15.08%) were early AMD, 58 (32.41%) were intermediate AMD, 94 eyes (52.51%) were late AMD. Of 94 eyes with late AMD, 79 (84.04%) were neovascular AMD and 15 (15.96%) were central geographic atrophy. In eyes with early and intermediate AMD, 9 patterns of FAF were noted. Six patterns (normal, minimal change, focal increased, patchy increased, linear, reticular) were similar to that in the published classification. Two patterns (lacelike and speckled) described in the published classification were not found. Three new patterns (focal hypo-fluorescence, patchy hypo-fluorescence, mixed focal hypo-fluorescence and hyper-fluorescence) were detected. In eyes with neovascular AMD, 6 morphological patterns of FAF were noted. Two patterns (mixed hypo-fluorescence and hyper-fluorescence, central hypo-fluorescence with hyper-fluorescent rim) were similar to that in published classification. Two patterns (normal, near normal or normal background fluorescence in the centre of hypo-fluorescent area) described in the published classification were not found. Four new patterns (minimal change, hypo-fluorescent patch, central hypo-fluorescence with surrounding reticular, bull's eye) were recognized. In eye with central geographic atrophy 5 morphological patterns were noted and these were similar to that in published classification. CONCLUSION: Phenotypic differences in the pattern of FAF exist in the study population compared to existing classification systems.

Progressive outer retinal necrosis-like retinitis in immunocompetent hosts.

We describe two young immunocompetent women presenting with bilateral retinitis with outer retinal necrosis involving posterior pole with centrifugal spread and multifocal lesions simulating progressive outer retinal necrosis (PORN) like retinitis. Serology was negative for HIV and CD4 counts were normal; however, both women were on oral steroids at presentation for suspected autoimmune chorioretinitis. The retinitis in both eyes responded well to oral valaciclovir therapy. However, the eye with the more fulminant involvement developed retinal detachment with a loss of vision. Retinal atrophy was seen in the less involved eye with preservation of vision. Through these cases, we aim to describe a unique evolution of PORN-like retinitis in immunocompetent women, which was probably aggravated by a short-term immunosuppression secondary to oral steroids.

Ultrawide field fluorescein angiogram in a family with gyrate atrophy and foveoschisis.

Gyrate atrophy of choroid and retina is an autosomal recessive condition characterized by peripheral multiple sharp areas of chorioretinal atrophy which become confluent with age. Macula and central vision is typically involved late in the disease. Macular involvements such as cystoid macular edema, epimacular membrane, and choroidal neovascularization have been reported in gyrate atrophy. In this report, we present a family with diminished central vision presenting within 8 years of age. All of three siblings had typical peripheral chorioretinal atrophic lesions of gyrate atrophy and hyperornithinemia. On spectral domain optical coherence tomography, two of elder siblings showed macular edema. Hyporeflective spaces appeared to extend from outer nuclear layer to the inner nuclear layer level separated by multiple linear bridging elements in both eyes. Ultrawide field fluorescein angiogram (UWFI) even in late phase did not show any leak at macula suggesting foveoschisis. Foveoschisis in gyrate atrophy has not been reported before.

Scleral tunnel phacoemulsification: Approach for eyes with severe microcornea.

Cataract surgery in eyes with microcornea is associated with frequent complications such as corneal edema, posterior capsular rent, and risk of unplanned aphakia. We describe an improved surgical technique for the creation of surgical incisions during phacoemulsification in eyes with cataract associated with microcornea. A retrospective analysis of eight patients (8 eyes) operated at our center was undertaken. The mean age of the patients was 29.5 ± 10.9 years. All eyes were operated using the scleral pocket incision for phacoemulsification. This scleral pocket incision was tangential to the limbus and created approximately 2.5 mm behind limbus through which phacoemulsification probe was inserted. Because of the posterior placement of incision, the anterior chamber crowding was minimized. There was no incidence of port-site peripheral corneal edema. Fifty percent eyes developed transient central corneal edema, the intraocular lens in bag was implanted in 5/8 eyes, and none developed Descemet's membrane detachment. Mean best-corrected visual acuity improved from 1.85 ± 0.38 logarithm of minimum angle of resolution (LogMAR) to 1.26 ± 0.70 LogMAR postoperatively (P = 0.01; paired t-test). Posterior incision placement during phacoemulsification in microcornea helps achieve favorable postoperative outcomes in contrast to outcomes using clear corneal approach described in literature.

Capsular hook-assisted implantation of modified capsular tension ring.

A 16-year-old boy presented with decrease of vision over a period of 2 years. On examination, he was diagnosed to have microspherophakia with lenticular myopia with secondary glaucoma in both eyes. He was treated by lens aspiration and two-point capsular support using a modified capsular tension ring (M-CTR) and capsular tension segment (CTS) sutured to the sclera along with implantation of a foldable intraocular lens inside the bag. Lens aspiration was performed without artificial capsular hook support of the bag, as the lens was soft and vitreous was formed. However, M-CTR rotation into the bag was fraught with repeated adherence of the advancing end of the M-CTR into the loose bag causing simultaneous rotation of the bag with the rotation of the ring resulting in transient increase in bag subluxation. Capsular hooks provided appropriate countertraction to the unsupported bag, thus facilitating easy insertion and rotation of the ring into the bag.

Patterns of pseudophakic retinal detachment in a referral tertiary care center and the need for improving cataract surgical training.

PURPOSE: To determine the risk factors associated with development of rhegmatogenous retinal detachment (RRD) in patients undergoing different types of cataract surgery. METHODS: Records of 200 patients presenting with pseudophakic retinal detachment (PRD) between January 2012 and July 2013 at a tertiary care center were reviewed. Duration and type of cataract surgery (phacoemulsification, extracapsular cataract extraction [ECCE], and small-incision cataract surgery [SICS]) and history of YAG capsulotomy with risk factors were recorded. Presence or absence of these risk factors was analyzed and their association with type of cataract surgery was evaluated. RESULTS: Of these 200 patients, 137 were male and 63 were female. The mean age of the patients was 55.19 ± 12.60 years and mean duration of cataract surgery to diagnosis of RRD was 8.64 ± 5.15 months. Most patients underwent phacoemulsification (45%), followed by ECCE (31.5%) and SICS (23.5%). Most of the patients with PRD had complicated cataract surgery with intraocular lens (IOL) in sulcus in 63%, anterior chamber IOL in 3%, and aphakia in 0.5%. There was no difference among the 3 types of surgery performed in mean presenting visual acuity, duration between cataract surgery and YAG capsulotomy, or number of posterior chamber IOLs. Incidence of posterior capsular rent (p = 0.02) and presence of vitreous in anterior chamber (p = 0.01) were significantly higher for patients with retinal detachment (RD) who underwent SICS. CONCLUSIONS: Many risk factors are associated with RD development after cataract surgery. More stringent efforts at improving the quality of cataract surgical training are likely to help in reducing the risk of PRD.

Patterns of uveitis at the Apex Institute for Eye Care in India: Results from a prospectively enrolled patient data base (2011-2013).

The purpose of the study was to identify the clinical and etiological profile of uveitis at the apex institute for eye care in India. This is a prospective, prevalence study. 980 consecutive patients with uveitis referred to uvea clinic, Dr. RP Centre for Ophthalmic Sciences (Ophthalmology division, All India Institute of Medical Sciences). Demographic data of each patient were noted and a thorough ocular examination including slit lamp examination and dilated fundus evaluation was carried out. OCT and fluorescein angiography were undertaken whenever indicated. Uveitis was classified based on the anatomic location of inflammation (IUSG classification). Relevant serological and radiological investigations were obtained based on systemic symptomatology, and if the uveitis was recurrent (even in the absence of systemic symptoms). The presence of a systemic disease was confirmed by obtaining an internist consultation. The main outcome measures include pattern of uveitis according to anatomical classification and the etiology. Out of 980 patients with uveitis, 413 (42.14 %) patients had anterior uveitis, 131 (13.36 %) had intermediate uveitis, 165 (16.83 %) had posterior uveitis, 91 (9.2 %) had panuveitis, 47 (4.7 %) had retinal vasculitis, 22 (2.24 %) had scleritis, 17 (1.7 %) had masquerade syndromes, 8 (0.8 %) had keratouveitis, 22 (2.24 %) had sclerokeratouveitis, 19 (1.9 %) had endophthalmitis and 45 (4.5 %) had other causes of inflammation including trauma and intraocular surgery. Out of all uveitic patients definite etiological correlation could be made out in 225 (23 %) patients; thus 77 % were categorised as idiopathic. Only 9 % of all patients were found to have uveitis with an infectious etiology. Amongst infectious causes of uveitis tuberculosis was the leading cause, accounting for sixty percent of all infectious uveitis (approximately 5 % of overall uveitis). Non-infectious uveitis etiology accounted for more than 90 % of all cases with ankylosing spondylitis being the most common followed by sarcoidosis and juvenile rheumatoid arthritis. Amongst known uveitic syndromes serpiginous like choroidopathy was the most common and was followed by acute posterior placoid pigmented epitheliopathy and Fuch's heterochromic iridocyclitis. Infection, including tuberculosis, is an infrequent cause of uveitis in the study population. Multicentric, collaborative efforts are required to improve levels of clinical evidence and evolve consensus in establishing stringent guidelines for labelling uveitis as being of infectious etiology.

Dual Endotemponade for Extensive Long-standing Cyclodialysis Using Sulcus-fixated Cionni Ring and PCIOL.

A young patient presented with visual acuity of hand movements only, unrecordable intraocular pressure, and total cataract after trauma 12 months ago. She reported failure to improve with conservative therapy as well as a direct cycloplexy elsewhere. After cleft localization on preoperative gonioscopy, ultrasound biomicroscopy (UBM), and intraoperative gonioscopy, a partial-thickness scleral flap was fashioned at the site of maximum cleft height. Following phacoaspiration, a multipiece intraocular lens was implanted in the sulcus; its haptics aligned to the axis with maximum height of cyclodialysis. A Cionni ring placed in sulcus was sutured to sclera under the flap to provide additional tamponading effect. Postoperative UBM and gonioscopy confirmed cleft closure. Normalization of intraocular pressure was found on repeated follow-ups till 1 year (12 to 14 mm Hg). UBM showed increase in sulcus diameter, and "double indentation sign" on the ciliary body.