EVALUATION OF PRONE VERSUS SUPINE POSITIONING IN FRESH RHEGMATOGENOUS RETINAL DETACHMENT TREATED WITH PARS PLANA VITRECTOMY AND GAS.

PURPOSE: To compare Supine versus Prone positioning in fresh rhegmatogenous retinal detachments treated with vitrectomy and gas tamponade. METHODS: This was a prospective randomized controlled trial of 72 eyes with fresh rhegmatogenous retinal detachment that underwent 25-gauge vitrectomy: 37 eyes were allotted supine position and 35 were allotted prone position. Cases were evaluated for single-surgery reattachment rates, best-corrected visual acuity, intraocular pressure, cataract formation, and any complications. The patients were followed up for a period of 3 months. RESULTS: Both groups had similar demographics, and no significant difference was found between the two groups in terms of extent of retinal detachment, position, and number of breaks. The anatomical success after single surgery was 97.3% in the Supine group and 94.3% in the Prone group ( P = 0.609). The best-corrected visual acuity at the end of 3 months was 0.44 ± 0.27 in the Supine group and 0.35 ± 0.27 in the Prone group ( P = 0.119) with a significant increase in best-corrected visual acuity preoperatively from 0.11 ± 0.22 and 0.13 ± 0.22 in Supine and Prone groups, respectively ( P = <0.001). The intraocular pressure in the two groups was comparable at each follow-up. The rates of cataract formation were also similar in the two groups-60% and 53.8% in Supine and Prone groups, respectively ( P = 1.00). Complications such as spikes in intraocular pressure, epiretinal membrane formation, and cystoid macular edema were similar in both groups. CONCLUSION: Rates of retinal reattachment were comparable in both groups showing that supine position is equally safe and effective for adequate tamponade.

Simple Bimanual Technique of Internal Limiting Membrane Retrieval.

PURPOSE: To describe a novel technique of internal limiting membrane retrieval. METHODS: A 25-gauge vitrectomy was performed in all patients. After internal limiting membrane (ILM) peeling (after brilliant blue dye staining), the ILM was held with the forceps in the midvitreous cavity and a 25-gauge cannula mounted on a 2 mL of balanced salt solution-filled syringe was introduced. When the tip of the cannula made contact with the ILM, mild suction was applied, and the ILM was retrieved in the syringe. RESULTS: Internal limiting membrane retrieval was successful in the all the patients attempted. CONCLUSION: To conclude, bimanual technique of membranous tissue removal using a soft tip cannula under direct visualization is a safe and efficient technique that makes membrane retrieval a predictable process.

ASSESSMENT OF QUALITY AND ADEQUACY OF PANRETINAL PHOTOCOAGULATION IN PROLIFERATIVE DIABETIC RETINOPATHY USING ULTRA-WIDEFIELD IMAGING.

PURPOSE: To assess the characteristics of completed panretinal photocoagulation (PRP), using ultra-widefield imaging in proliferative diabetic retinopathy. METHODS: Quantitative assessment of ultra-widefield imaging images of 133 patients with proliferative diabetic retinopathy with completed PRP was made using ImageJ software. The parameters assessed included distance of laser spots from the optic disk, foveal center, superior and inferior arcades, and extent of the maximum width of laser. Areas assessed were total area of the image, area of the inner limit within which laser spots are restricted, minimum areas of unlasered patches, total area lasered, and ideal area to be covered by PRP. RESULTS: Two hundred one images were assessed for the final analysis. The mean distance of laser spots was 4.2 ± 2.4 mm from the optic disk (nasal) and 6.6 ± 2.5 mm from the foveal center (temporal). The mean distance of laser spots from the superior arcade vessel was 3.2 ± 1.9 mm and 6.2 ± 4.4 mm from the inferior arcade. The mean area of the retina that should have been ideally lasered was found to be 900 ± 267 mm 2 , and the actual area lasered was found to be 681 ± 254.4 mm 2 . CONCLUSION: Approximately one-quarter area of the retina continues to remain ischemic because of the lack of inadequate coverage of PRP. Further longitudinal studies are recommended, using ultra-widefield imaging to objectively assess the adequacy of PRP and its role in modulating the course of progression of the retinopathy.

PERIPAPILLARY PACHYCHOROID SYNDROME: New Insights.

PURPOSE: Available literature on peripapillary pachychoroid syndrome (PPS) is very limited. The purpose of this study is to evaluate features of PPS using multimodal imaging and shed further light on this entity. METHODS: This is a retrospective case series at a tertiary eye-care center. Patients with features of pachychoroid with preferential choroidal thickening in nasal macula along with pachyvessels were identified and included for analysis. The patients underwent fundus photography, fundus autofluorescence, optical coherence tomography, fundus fluorescein angiography, and indocyanine angiography. Images were separately analyzed by two different retina specialists. RESULTS: A total of 27 eyes of 14 patients with mean age of 52.2 years were included. Seven patients had bilateral PPS, whereas six had unilateral; one patient had only one seeing eye. A total of 21 eyes with PPS were studied. 52.4% of the eyes revealed retinal pigment epithelium gravitational tracks, outer retinal atrophy, and serous PEDs. None of the eyes showed choroidal folds. Fundus fluorescein angiography showed late leakage at macula in 33% eyes. Fundus autofluorescence showed features of PPS to be similar to central serous chorioretinopathy in most cases. CONCLUSION: Peripapillary pachychoroid syndrome shares common findings with central serous chorioretinopathy and seems to be a subset of central serous chorioretinopathy than a separate entity in pachychoroid disease spectrum.

PNEUMATIC VITREOLYSIS VERSUS PARS PLANA VITRECTOMY IN FOCAL SYMPTOMATIC VITREOMACULAR TRACTION SYNDROME: A Randomized Trial.

PURPOSE: To compare pneumatic vitreolysis and pars plana vitrectomy in the management of focal symptomatic vitreomacular traction (VMT). METHOD: Patients aged 18 years or older, with idiopathic focal symptomatic VMT and best-corrected visual acuity <20/40, without any other retinal pathology were randomized to undergo pneumatic vitreolysis (Group 1) or pars plana vitrectomy (Group 2). The primary outcome measure was resolution of traction confirmed with optical coherence tomography at 3 months. Secondary outcome measures were to compare changes in best-corrected visual acuity, central foveal thickness, and complications if any. RESULTS: A total of 30 eyes of 30 patients were included with 15 eyes in each group. Vitreomacular traction resolved successfully in 12 of 15 (80%) eyes in Group 1 and in all (100%) eyes in Group 2 (P = 0.224). The mean visual acuity improved from 0.80 ± 0.26 (20/126 Snellen's equivalent) to 0.70 ± 0.46 logMAR (20/100 Snellen's equivalent) in Group 1 (P = 0.71) and from 0.904 ± 0.44 (20/160 Snellen's equivalent) to 0.47 ± 0.26 logMAR (20/59 Snellen's equivalent) in Group 2 (P = 0.0016). Although 4 of 15 (26.66%) eyes in Group 1 had formation of full-thickness macular hole and 7 eyes required resurgery (4 for full-thickness macular hole and 3 for unresolved VMT), none in the pars plana vitrectomy group had any complications requiring resurgery (P = 0.0063). Two eyes in the pars plana vitrectomy group had intraoperative deroofing of the fovea leading to full-thickness macular hole. CONCLUSION: Pars plana vitrectomy is better than pneumatic vitreolysis as a single intervention in the management of focal symptomatic VMT.

COMPARATIVE EVALUATION OF OUTCOMES OF DRAINAGE TECHNIQUES IN VITRECTOMY FOR RHEGMATOGENOUS RETINAL DETACHMENT.

PURPOSE: To compare the anatomical and functional outcomes of drainage through posterior retinotomy versus perfluorocarbon liquid (PFCL)-assisted drainage in vitreoretinal surgery for rhegmatogenous retinal detachment and to study intraoperative and postoperative complications. METHODS: This was a prospective randomized study of 52 cases who underwent vitreoretinal surgery for rhegmatogenous retinal detachment. Group 1 underwent PFCL-assisted drainage through preexisting break, whereas Group 2 had posterior retinotomy to drain subretinal fluid. Cases were evaluated for retinal reattachment rates, visual outcomes, optical coherence tomography parameters, and postoperative metamorphopsia. The patients were followed up for minimum period of 3 months. RESULTS: Two groups were comparable in terms of demographic and preoperative parameters. Both groups had single surgery success rate of 100% by the end of follow-up. Final best-corrected visual acuity in Group 1 was 0.61 ± 0.33 and 0.61 ± 0.32 in Group 2 (P = 0.77). Optical coherence tomography parameters (foveal contour, retinal layers, central macular thickness, and epiretinal membrane formation) were similar between the two groups. Subjective metamorphopsia was present in 30.77% (8 of 26) patients in Group-1 and 69.23% (18 of 26) patients in Group-2 (P = 0.034). One eye had retained subretinal PFCL away from the macula in Group 1. CONCLUSION: Anatomical and functional outcomes were similar in vitrectomy using PFCL-assisted drainage versus posterior retinotomy drainage. Postoperative metamorphopsia was lesser in patients who underwent PFCL-assisted drainage through the pre-existing break.

Case Report: Pediatric Ocular Ischemia and Neovascular Glaucoma in Neurofibromatosis Type 1.

SIGNIFICANCE: Neovascular glaucoma is an important subset of secondary glaucoma in neurofibromatosis patients. Vasculopathy of the ophthalmic circulation needs to be borne in mind while evaluating their etiology. PURPOSE: This study aimed to report the presentation, diagnostic work-up and management of an unusual case of neovascular glaucoma in a child. CASE REPORT: A 7-year-old boy presented with uniocular ischemic fundus and secondary neovascular glaucoma. Detailed family history and evaluation led to a diagnosis of familial neurofibromatosis type 1. Fundus fluorescein angiography revealed compromised retinal and choroidal circulations in the affected eye. Ocular ultrasound B scan and neuroimaging did not show any contributory lesions. Cardiovascular evaluation was within normal limits. Ophthalmic Doppler imaging revealed normal proximal ophthalmic arteries in both eyes; however, the central retinal artery of the affected eye showed low flow in its proximal part and absent flow in the distal part, as compared with the fellow eye showing regular flow until the optic disc margin. Corroborating the clinical, fundus fluorescein angiography and Doppler findings, a diagnosis of neurofibromatosis type 1-related vasculopathy of the distal ophthalmic artery was made. Poor visual prognosis for the affected eye was explained, and anterior retinal cryopexy along with cyclocryotherapy was performed to treat the neovascular glaucoma. CONCLUSIONS: Vasculopathy of the ophthalmic circulation is an important cause of neovascular glaucoma in neurofibromatosis patients. The morphology of Lisch nodules may be altered in an ischemic eye, and therefore, careful examination of the other eye and systemic evaluation is vital in such unusual scenarios.

Ophthalmic genetics practice and research in India: Vision in 2020.

Ophthalmic genetics is a much needed and growing area in India. Ethnic diversity, with a high degree of consanguinity, has led to a high prevalence of genetic disorders in the country. As the second most populous country in the world, this naturally results in a significant number of affected people overall. Practice involves coherent association between ophthalmologists, genetic counselor and pediatricians. Eye genetics in India in recent times has witnessed advanced research using cutting edge diagnostics, next generation sequencing (NGS) approaches, stem cell therapies, gene therapy and genomic editing. This article will highlight the studies reporting genetic variations in the country, challenges in practice, and the latest advances in ophthalmic genetic research in India.

COMPARATIVE EVALUATION OF ANTERIOR SEGMENT OPTICAL COHERENCE TOMOGRAPHY, ULTRASOUND BIOMICROSCOPY, AND INTRAOCULAR PRESSURE CHANGES AFTER PANRETINAL PHOTOCOAGULATION BY PASCAL AND CONVENTIONAL LASER.

PURPOSE: To compare intraocular pressure, anterior segment optical coherence tomography, and ultrasound biomicroscopy parameters over 3 months after panretinal photocoagulation (PRP) for proliferative diabetic retinopathy after 1 of 2 sittings by conventional laser (half PRP) and a single sitting of Pattern Scan Laser (PASCAL) PRP. METHODS: This was a prospective, randomized, interventional study. All tests were performed at baseline, and at 1, 6, and 24 hours, and 1, 4, 8, and 12 weeks after PRP. RESULTS: The intraocular pressure at 1 hour and 6 hours after PRP was significantly raised in both groups. Mean intraocular pressure was 21.17 ± 4.01 mmHg after PASCAL and 17.48 ± 3 mmHg after conventional laser at 1 hour, P < 0.001. On anterior segment optical coherence tomography, conventional laser PRP caused a more significant narrowing of angle-opening distance (AOD750) and trabecular-iris space area (TISA 500), P = 0.03 and 0.04, respectively, on Day 1. Ultrasound biomicroscopy showed a significantly narrow angle in both groups on Day 1. A significant increase in ciliary body thickness was observed in both groups, with 57.1% of PASCAL and 100% of conventionally treated eyes showing ciliary effusion on Day 1 that decreased but persisted for the next 3 months. CONCLUSION: Performing PRP in sittings, prescribing previous glaucoma medications in patients at risk, and recording intraocular pressure an hour after the PRP could decrease complications.

Multifocal electroretinogram in eyes with intravitreal silicone oil and changes following silicone oil removal.

PURPOSE: To determine the effect of intravitreal silicone oil (SO) on multifocal electroretinogram (mfERG) and the changes in mfERG following SO removal. METHODS: Twelve eyes of 12 patients with SO in vitreous cavity with corrected distance visual acuity (CDVA) > 20/200 were prospectively enrolled as cases over a period from July 2016 to June 2018. The fellow normal eyes served as control. The eyes were evaluated with P1 and N1 wave amplitude and implicit time on mfERG at baseline, 1 and 4 weeks after SO removal. RESULTS: The mean age was 44.9 ± 18.9 (range 18-74) years. The indication for SO injection was retinal detachment (n = 9, three macula-on eyes, six macula-off eyes) and endophthalmitis (n = 3). The median (range) LogMAR CDVA at baseline was 0.54 (0.18-0.78) in cases and did not change post-SO removal (p = 0.29). There was a significant decrease in average P1 and N1 wave amplitude (p = 0.0001 and 0.0001, respectively) and delay in average P1 and N1 wave implicit time (p = 0.0002 and 0.021, respectively) in cases as compared to controls. The macular status and duration of SO tamponade did not have a significant correlation with mfERG parameters. There was a significant increase in average P1 and N1 wave amplitude (p = 0.009 and 0.003, respectively) at 1 week following SO removal but no change in average P1 and N1 wave implicit time (p = 0.41 and 0.37, respectively). CONCLUSION: mfERG may be reliably performed for the assessment of macular function in SO-filled eyes. Intravitreal SO exerts an insulating effect on the density of the electric potentials.

ATYPICAL MACULAR HOLES.

PURPOSE: To study the etiology, clinical features, management options, and visual prognosis in various types of atypical macular holes (MHs). METHODS: A review of the literature was performed, which focused on the etiopathogenesis of atypical or secondary MHs, their differentiating clinical features, management strategies, and varied clinical outcomes. Idiopathic or age-related, myopic, and traumatic MHs were excluded. RESULTS: Atypical or secondary MHs arise out of concurrent ocular pathologies (dystrophy, degeneration, or infections) and laser/surgery. The contributing factors may be similar to those responsible for idiopathic or typical MHs, i.e., tangential or anteroposterior vitreofoveal traction or cystoid degeneration. The management is either observation or treatment of the underlying cause. The prognosis depends on the background pathology, duration of disease, and baseline visual acuity governed by the size of MH and morphologic health of underlying RPE and photoreceptors. The closer the morphology of atypical MH is to that of an idiopathic MH, the better the surgical outcome is. CONCLUSION: With the advancements in retinal imaging, atypical MHs are now more frequently recognized. With increasing understanding of the underlying disease processes, and improvement in investigations and surgical treatment, management of atypical MHs may improve in the future.

Proposed Classification System for Retinal Capillary Angiomatosis.

Retinal angiomas are rare tumors that develop within the vascular bed of the retina. Their occurrence may be sporadic or as part of the multisystem disorder called von Hippel-Lindau disease. It is well established in literature that retinal angiomas have a natural history of evolving as small aneurysmal dilatations and progressing to vision-threatening retinal detachments. Several approaches to the management of these angiomas have been reported in the literature, but it is difficult to decipher which modality is best suited for which type of angioma. A classification of retinal angiomas is proposed herein. A classification system may help in developing future guidelines for the study, screening, treatment, and prognostication of patients with retinal angiomas.

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.

Selfie fundus imaging: Innovative approach to retinopathy screening.

The currently available methods of screening for diabetic retinopathy (DR) depend on the availability of healthcare professionals and technology. The high prevalence of diabetes in India, and the need to repeatedly screen such patients for DR and treat them, places an enormous economic and logistic burden. We introduce the concept of screening for DR with 'selfie retinal imaging' through this report of 3 patients. The patients can themselves capture retinal images and transfer to a grading centre for further deliberation. If incorporated into the current technological revolution of smartphones, this futuristic concept is likely to be of huge benefit in preventing loss of vision due to diabetes.

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.

Patterns of uveitis in children at the apex institute for eye care in India: analysis and review of literature.

AIM: To study patterns of uveitis in Indian children and compare with data sets published earlier in the literature. METHODS: Consecutive patients below 16 years of age presenting to the uvea clinic of a tertiary eye care center were included prospectively through the period of July 2009-August 2013. Children with retinal vasculitis, exogenous endophthalmitis and masquerade syndromes were excluded from analysis. Uveitis was classified as per the nomenclature system adopted by the International Uveitis Study Group. Hemogram, Mantoux test and chest X-ray were done for each patient, along with tailored investigations and pediatric review as per clinical profile. Clinical pattern and etiology were the main outcome measures. RESULTS: One hundred and thirty-four children were analyzed. Anterior uveitis (40%) was the commonest pattern followed by intermediate uveitis (25%), panuveitis (18%) and posterior uveitis (17%). Bilateral disease was present in 54%, 15% had infectious uveitis, 10% had granulomatous uveitis and 54% had idiopathic uveitis. Complications were present in half of the patients. Juvenile idiopathic arthritis (22), followed by toxoplasmosis (10) and tuberculosis (5), was the commonest etiology. Intermediate uveitis, non-granulomatous inflammation and older onset of disease had the high odds ratio of having idiopathic disease. CONCLUSION: Patterns of pediatric uveitis can vary between regions from even within the same geopolitical region. Anterior uveitis is commonest, and juvenile idiopathic arthritis and toxoplasmosis are the most frequent etiologies. Diagnosis of pediatric ocular tuberculosis is more difficult than in adults and needs better and well-defined criteria.

Biometric evaluation of myopic eyes without posterior staphyloma: disproportionate ocular growth.

PURPOSE: To evaluate changes in the anterior segment of myopic eyes and assess anterior biometry as a function of axial length (AL). DESIGN: Retrospective investigational study. PARTICIPANTS: Patients evaluated for phakic intraocular lens surgery at a tertiary eye care centre. METHODS: Patients with corrected visual acuity > 20/40 and AL > 24.5 mm were included in the study. Posterior staphyloma and maculopathy were ruled out in all the patients, and 176 eyes were included for analysis. AL was measured with partial coherence interferometry, while keratometry, central corneal thickness (CCT), anterior chamber depth (ACD), and horizontal white to white (WTW) were measured with slit-scanning topography. Group 1 included 55 eyes with AL < 26.5 mm, group 2 had 57 eyes with AL between 26.5 and 28.5 mm while group 3 had 64 eyes with AL > 28.5 mm. MAIN OUTCOME MEASURE: Correlation of AL with anterior biometry. RESULTS: The mean AL of the study eyes was 27.88 + 2.14 mm. The mean values of ACD (2.99 mm), CCT (0.52 mm), WTW (11.68 mm), and keratometry (43.62 D) were within the normal range. Overall, very weak correlations could be established between AL and CCT (R = 0.17, p = 0.02), AL and keratometry (R = - 0.28, p < 0.001), and AL and WTW (R = 0.22, p = 0.002), while ACD did not relate to AL significantly. The ACD and CCT did not relate significantly to AL in any of the three groups. Keratometry had a weak negative relation with AL in groups 1 and 2, while WTW had a weakly positive relation with AL in group 2 only. No variable had any significant relation with AL in group 3. CONCLUSION: There is disproportionate elongation of the eyeball in myopic patients with very weak or no correlation between anterior biometry and AL. This discord is more in longer eyes. Such a scenario can be challenging to a refractive surgeon treating highly myopic eyes and needs further evaluation.

Impact of estimated glomerular filtration rate on diabetic macular edema.

PURPOSE: Diabetic macular edema (DME) is a major cause of visual impairment in patients with diabetes and is influenced by various systemic factors. This study evaluates the effect of renal status on DME using estimated glomerular filtration rate (eGFR) as a study marker. METHODS: This was a prospective observational cross-sectional study. One hundred and ninety-five patients of diabetic retinopathy (DR) were included. Group 1 had patients of DR without DME (n = 100), and group 2 had patients of DR with DME (n = 95). All patients were evaluated for DR/DME-related risk factors. eGFR was calculated in all patients. Spectral domain optical coherence tomography (SDOCT) was done to identify the various patterns and severity of DME. RESULTS: Group 2 patients had significantly higher comorbidities than those in group 1 (p < 0.001). Hba1c, total cholesterol, triglycerides, LDL/HDL ratio, systolic and diastolic blood pressures were significantly higher in group II (p < 0.001 in each). There was no significant difference between the groups in terms of blood urea, serum creatinine or eGFR. eGFR did not show a significant association with a specific SDOCT pattern or severity of DME. CONCLUSION: Comorbidities are more common and more severe in patients with DME. However, eGFR as a marker was not useful in predicting either the severity or pattern of DME. eGFR, in its present form, may not be useful in the evaluation and management of patients with DME.