Clinical Profile and Treatment Outcomes of Patients With Acremonium Species Positive Keratitis Managed in a Tertiary Eye Care Center.

PURPOSE: To report the clinical profile and treatment outcomes of patients with culture-positive Acremonium keratitis. METHODS: This is a retrospective observational study. Medical records of all patients treated in a tertiary eye hospital for culture positive infective keratitis from March 2016 to February 2021 were screened, of which those positive for Acremonium species on fungal culture were reviewed. Demographic details, clinical presentation, clinical course, treatment given, total follow-up duration, time taken for ulcer to heal, scar size, and final visual acuity in the last follow-up were recorded. RESULTS: Fifty three cases of fungal keratitis caused by Acremonium species were identified, 22 females and 31 males, with average age of 46.39±18.64 years. The mean duration of symptoms being 54.47±50 days. Only five patients had a history of trauma with vegetative matter. Clinical presentation of patients showed a large number of variations, with 2 patients presenting as peripheral ulcerative keratitis and 1 with epithelial plaque. The mean visual acuity of patients at presentation was 2.43±0.46 logMAR units. Thirty-three of 53 patients presented with perforated corneal ulcer and underwent penetrating keratoplasty; 20 patients were medically managed on topical voriconazole 1%, natamycin 5%, and oral voriconazole. The mean duration of healing of epithelial defect was 95±60.62 days (range 60-165 days). CONCLUSION: Acremonium keratitis has a long and indolent course. A prolonged combination therapy of natamycin and voriconazole seems to be effective in the management. A delay in the diagnosis of Acremonium keratitis often leads to clinical worsening requiring keratoplasty.

Vitreoretinal Complications and Outcomes in 92 Eyes Undergoing Surgery for Modified Osteo-Odonto-Keratoprosthesis: A 10-Year Review.

PURPOSE: To analyze vitreoretinal (VR) complications and treatment outcomes in eyes undergoing modified osteo-odonto-keratoprosthesis (OOKP) surgery. DESIGN: Retrospective case series. PARTICIPANTS: All patients who underwent modified OOKP (mOOKP) surgery at a tertiary eye-care center from March 2003 to February 2013 were included. METHODS: Medical records were reviewed for relevant medical history, best-corrected visual acuity (BCVA), slit-lamp examination, ultrasound scan, oral examination findings, and VR complications. MAIN OUTCOME MEASURES: The BCVA at the last visit. Optimal anatomic outcome was attached retina with a normal intraocular pressure at the last visit. RESULTS: A total of 92 eyes of 90 patients were included. Indications for OOKP included Stevens-Johnson syndrome (n = 53), chemical injury (n = 36), and ocular cicatricial pemphigoid (n = 3). A total of 41 eyes of 39 patients developed VR complications, including vitritis (n = 21), retinal detachment (RD) (n = 12; primary RD = 5), retroprosthetic membrane (RPM) (n = 10; primary RPM = 2), endophthalmitis (n = 8), vitreous hemorrhage (VH) (n = 5; primary VH = 1), serous choroidal detachment (n = 5), hemorrhagic choroidal detachment (n = 2), and leak-related hypotony (n = 1). Mean interval from mOOKP surgery to occurrence of VR complication(s) was 43.8 months (median, 41.9 months; range, 0.2-95.5 months). After treatment of VR complication, visual improvement was seen in 17 eyes (42%) (mean improvement = 1.2 logarithm of the minimum angle of resolution [logMAR]; median, 0.8 logMAR; range, 0.1-2.5 logMAR), visual decline in 7 eyes (14%) (mean decline in BCVA = 0.6 logMAR; median, 0.4 logMAR; range, 0.3-1.8 logMAR), and no change in BCVA in 17 eyes (42%). However, BCVA ≥6/60 was retained in 19 eyes and ≥6/18 was retained in 9 eyes after final VR treatment. CONCLUSIONS: Vitreoretinal complications constitute a significant cause of visual morbidity in eyes undergoing mOOKP surgery and pose a challenging situation to manage. However, appropriate and timely intervention can achieve encouraging results.

Ocular graft versus host disease in allogenic haematopoetic stem cell transplantation in a tertiary care centre in India.

BACKGROUND & OBJECTIVES: This study was aimed to report the occurrence of ocular graft versus host disease (oGVHD) in allogeneic haematopoietic stem cell transplantation (allo-HSCT) patients in a tertiary care hospital setting. METHODS: A cross-sectional study of ocular surface of allo-HSCT patients was done. Slit lamp biomicroscopy, symptom score, tear meniscus height, fluorescein tear break-up time, Schirmer's test I, ocular surface staining, dry eye severity, ocular surface disease index score were done. Indications for allo-HSCT, human leukocyte antigen (HLA) matching, GVHD risk factor, systemic manifestation and treatment were also noted. RESULTS: GVHD occurred in 44.4 per cent of 54 allo-HSCT patients (mean age 26.7 ± 12 yr) included in the study. GVHD risk factors identified included female gender, relapse, older age of donor, cytomagelo virus (CMV) reactivation, and multiparous female donors. oGVHD was noted in 31.5 per cent with mean time to occurrence being 17.8 ± 21.9 months after the allo-HSCT and was observed in 89.5 per cent of chronic GVHD cases. Acute GVHD (oral and dermatological) involvement showed a significant association with GVHD in our patients (P< 0.001, 0R 23.0, CI 6.4-82.1). Chronic GVHD was observed to be associated with the occurrence of oGVHD (dry eye) (P<0.001, OR = 24.0, CI 0.02 - 0.29). Of the 34 eyes with oGHVD, dry eye of level 3 severity was seen in 16, level 2 in six, level 1 in 12 eyes. INTERPRETATION & CONCLUSIONS: GVHD occurred in 44.4 per cent of the patients studied in the present study. Acute and chronic GVHD showed a strong association with oGVHD. Dry eye disease due to chronic oGVHD was observed in 17 (31.5%) of 54 allo-HSCT patient with chronic oGVHD occurring in 17 (89.4%) of chronic GVHD cases in allo-HSCT patients. Our study on oGVHD in post allo-HSCT patients in tertiary care centre points towards the fact that ocular morbidity due to dry eye disease as a result of oGVHD is a cause for concern in these patients.

Chop and tumble nucleotomy - A technique for safe nuclear emulsification in posterior polar cataract.

A modified phaco chop technique for nuclear emulsification in posterior polar cataracts with nuclear sclerosis that avoids hydrodissection or nuclear rotation has been described. After performing a vertical chop maneuver to divide the nucleus, two pie-shaped nuclear fragments are removed from either side of the initial chop. The remaining nuclear fragments are then sequentially tumbled toward the center using the second instrument and emulsified while maintaining an intact epinuclear shell, which safeguards the fragile posterior capsule. The technique was successfully performed in 62 eyes of 54 patients with posterior polar cataract and grade II-IV nuclear sclerosis. The Chop and Tumble nucleotomy is a safe and effective technique for phacoemulsification in posterior polar cataracts with nuclear sclerosis, where hydrodissection and nuclear rotation are typically avoided.

Refractive surgery and dry eye - An update.

Dry eye disease is the most common complication and a frequent cause of patient dissatisfaction after corneal laser refractive surgery, which includes laser-assisted in situ keratomileusis (LASIK), small-incision lenticule extraction (SMILE), and photorefractive keratectomy (PRK). It has a complex, multifactorial etiology and is characterized by a highly variable clinical presentation. A detailed preoperative screening and optimization of the ocular surface prior to refractive surgery are the key to minimizing the incidence and severity of postoperative dry eye. Diagnosis of postrefractive surgery dry eye remains a challenge as no single symptom or clinical parameter is confirmative of the condition, and the symptoms and signs may not correlate well in many cases. A thorough understanding of the pathomechanism of the disease and its manifestations is essential to facilitate a treatment approach that is individualized for each patient. This article reviews various aspects of postrefractive surgery dry eye including its epidemiology, etiopathogenesis, risk factors, diagnosis, and management.

Flap amputation for long-standing post-LASIK flap dislocation with epithelial ingrowth.

A man aged 26 years presented with complaints of diminution of vision in his right eye for 1 year following a fist injury. He had a history of laser-assisted in situ keratomileusis in both eyes 5 years earlier. On examination, his uncorrected distance visual acuity (UDVA) in the right eye was 1.0 logMAR. Slit-lamp examination of the right eye revealed a superotemporal dislocation of the flap with coexisting epithelial ingrowth encroaching the pupillary area. Due to the presence of long-standing fixed flap folds, a flap amputation was performed along with removal of the epithelial ingrowth using 0.02% mitomycin C as adjunct. Postoperatively, the UDVA was 0.3 logMAR on day 1, which improved to 0.2 logMAR at 1 week. At 1 year, the UDVA was 0.2 logMAR improving to 0.1 logMAR with refraction, with minimal paracentral corneal haze and no signs of corneal ectasia.

Impact of Taping The Upper Mask Edge On Ocular Surface Stability and Dry Eye Symptoms.

PURPOSE: To evaluate the impact of taping the upper mask edge on ocular surface stability, dry eye symptomology, and tear osmolarity in N95 mask users. DESIGN: Prospective interventional before-and-after study. METHODS: Fifty eyes of 50 health care workers regularly using N95 masks were included. Preintervention, ocular surface parameters, subjective dry eye score, and visual acuity were assessed at the end of an 8-hour shift when the subjects used an N95 face mask without taping the upper edge. Next day, the upper edge of the N95 mask was taped to the nasal bridge in all subjects at the beginning of the 8-hour shift, and postintervention assessment was performed after the shift. The primary outcome measure was change in noninvasive tear break-up time (NIBUT). Secondary outcome measures were change in the symptom score, tear lipid layer thickness (LLT), tear break-up time (TBUT), Schirmer I test, tear meniscus height (TMH), osmolarity, and visual acuity. RESULTS: Mean age of the cohort was 26.7 ± 3.67 years. Post-taping, significantly better ocular surface stability was observed in terms of NIBUT (P < .001), TBUT (P < .001), LLT (P < .001), TMH (P = .01), corneal staining score (P = .001), and tear osmolarity (P = .04). There was no significant change in visual acuity, Schirmer I, and Ocular Surface Disease Index score (P > .05). Symptom improvement was reported by 68% patients (SANDE version 2), which correlated well with change in NIBUT (r = 0.38; P = .005), TMH (r = 0.37; P = .007), LLT (r = 0.35; P = .01), and TBUT (r = 0.28; P = .04). CONCLUSION: Taping of the upper mask edge resulted in significantly better ocular surface stability, which correlated well with decrease in dry eye symptoms.

Intraoperative optical coherence tomography-guided management of post-laser-assisted in situ keratomileusis epithelial ingrowth.

We describe a modified technique of intraoperative optical coherence tomography (iOCT)-guided removal of post-laser-assisted in situ keratomileusis (LASIK) epithelial ingrowth with interface ethyl alcohol and mitomycin C application to prevent a recurrence. Epithelial ingrowth was visualized as hyperreflective deposits in the interface on iOCT, and the location and extent were noted at the beginning of the procedure. A simple dimple-down maneuver was performed to help identify the circumference of the LASIK flap. iOCT helped to delineate the flap edge and ensure dissection in the correct plane with complete removal of epithelial cell nests. Real-time visualization of the interface helped in on-table decision making regarding the extent of lifting the flap to encompass the entire region of hyperreflective epithelial ingrowth, as well as the need for additional interventions to ensure complete flap apposition at the end of surgery. All patients gained an uncorrected visual acuity of 20/20-20/25 with no recurrence.

Graft detachments in endothelial keratoplasty.

Graft detachment is the most common complication of endothelial keratoplasty. With the ongoing advancements in the field of endothelial keratoplasty, our understanding of risk factors of graft detachments and its management has been evolving. Various prevention measures have been described in literature including presoaking the donor graft, anterior chamber tamponade, venting incisions, sutures to prevent dislocation of graft. Management of a detached graft involves secondary interventions such as rebubbling, suturing and regrafts. In this review, we discuss graft detachment in different types of endothelial keratoplasty techniques including Descemet stripping endothelial keratoplasty, Descemet stripping automated endothelial keratoplasty and Descemet's membrane endothelial keratoplasty; with emphasis on incidence, risk factors, preventive measures and their management.

Post-penetrating keratoplasty astigmatism.

Postoperative astigmatism is one of the common complications affecting visual outcomes after a penetrating keratoplasty. It can result from various factors related to host, donor and surgical technique, resulting in suboptimal visual outcome. While some of the measures taken during preoperative planning and during actual surgery can reduce the magnitude of postoperative astigmatism, postoperative correction of astigmatism is often required in cases with high degrees of astigmatism. When spectacles and contact lenses fail to provide optimal visual outcomes, various surgical techniques that include astigmatic keratotomy, compression sutures, toric intraocular lens placement, and laser refractive procedures can be considered. When none of these techniques are able to achieve a desired result with in the acceptable optical range, a repeat keratoplasty is considered a last option. We discuss the various causes and management of complication of postoperative astigmatism occurring after a full thickness corneal transplantation surgery.

Multicenter prospective validation study for international chronic ocular graft-versus-host disease consensus diagnostic criteria.

PURPOSE: To validate the international chronic ocular graft-versus-host disease (GVHD) diagnostic criteria (ICCGVHD) compared to the National Institute of Health diagnostic criteria 2014 (NIH2014) for chronic ocular GVHD. METHODS: Between 2013 and 2019, the study enrolled 233 patients with or without chronic ocular GVHD combined with the presence or absence of systemic chronic GVHD in an internationally prospective multicenter and observational cohort from 9 institutions. All patients were evaluated for four clinical parameters of ICCGVHD. RESULTS: The relation between the ICCGVHD score (0-11) and NIH2014 eye score (0-4) was relatively high (r = 0.708, 95% CI: 0.637-0.767, p < 0.001). The sensitivity and specificity of ICCGVHD for NIH 2014 for 233 patients were 94.3% (95% CI: 89.6%-98.1%) and 71.7% (95% CI: 63.0-79.5%), respectively (cutoff value of the ICCGVHD score = 6). The positive predictive value was 77.1% (95% CI: 71.1%-82.1%), and the negative predictive value was 87.0% (95% CI:81.6-92.5%). For the patients with systemic GVHD (n = 171), the sensitivity and specificity were 94.2% and 67.2%, respectively (ICCGVHD-score cutoff value = 6). By receiver operating characteristic (ROC) curve analysis, the area under the curve (AUC) was 0.903 (95% CI: 0.859-0.948). For patients without systemic GVHD (n = 62), the sensitivity and specificity were 100% and 76.7%, respectively (ICCGVHD-score cutoff value = 6). The AUC was 0.891 (95% CI 0.673-1.000). CONCLUSIONS: Good sensitivity, specificity, predictive value and correlation were found between ICCGVHD and NIH2014. ICCGVHD scores ≥6 can be useful to diagnose ocular GVHD with or without systemic GVHD for clinical research.

Mental Health in the Times of Corona: A model for Positive Mental Health During the Global Pandemic.

As the world comes to terms with the changes brought on by the appearance and spread of Covid-19, there is an increase in fear and anxiety levels. The World Health Organization has stressed on the need to focus on mental health, as the epidemic affects both young and old. One of the biggest challenges is that the situation has no precedent. This has led to the creation of uncertainty and doubt. The current study focusses on studying the positive mental health of the Indian population. For the study, the researchers have restricted the scope to include only Generation Y and Generation Z, as they form a majority of the working population and literature suggests that negative moods, stressors and apprehensions are far more prevalent among the younger sections of the society. The findings suggest that positive mental health is not dependent on gender or age. However, some of the dimensions do show significant variance. The researchers have also proposed a model of Positive Mental Health based on the dimensions of the Positive Mental Health Instrument.

Intraoperative optical coherence tomography in anterior segment surgery.

Intraoperative optical coherence tomography (iOCT) enables real-time visualization of ocular structures during surgery and enhances our understanding of intraoperative dynamics. iOCT aids in decision-making during various anterior segment surgeries, and its efficacy and feasibility in anterior lamellar keratoplasty and endothelial keratoplasty is well established. The landmark DISCOVER study observed that iOCT altered the surgeon decision in 38% of cases undergoing lamellar keratoplasty and provided guidance regarding the need for secondary surgical intervention. iOCT also finds an application in phacoemulsification wherein it helps to assess corneal incisions, intralenticular pressure, and posterior capsule integrity during nuclear emulsification. iOCT aids in the visualization of angle structures during placement of tubes and shunts in glaucoma surgeries and allows precise creation of partial thickness scleral flaps. In addition, iOCT helps in establishing a diagnosis, as well as provide intraoperative guidance, in pediatric patients who are not cooperative for examination. The role of iOCT in refractive surgeries and ocular surface disorders is increasingly being evaluated. The limitations of present-day iOCT systems are related to instrument compatibility, automated tracking of the surgical field, and on-table volumetric analysis of the real-time images. Technological advances may facilitate complete integration of OCT in the surgical microscopes for all surgical procedures.

Effect of intraoperative optical coherence tomography on anatomic and cosmetic results of intrastromal tattooing.

PURPOSE: The aim of the study was to evaluate the effect of intraoperative optical coherence tomography (i-OCT) on anatomic and cosmetic outcomes of intrastromal keratopigmentation (i-KTP) performed by novice lamellar corneal surgeons. METHODS: Thirty patients presenting with unilaterally disfiguring corneal scar and nil visual prognosis were subjected to i-OCT-guided intrastromal tattooing with rotring ink, by ophthalmology residents undergoing training in corneal surgeries at our center, who were later asked for a subjective feedback and mean stromal depth dissected was measured objectively. All patients were followed up for 9 months after surgery, and the subjective satisfaction of the patient, an independent observer, and surgeon was graded as poor, good, and excellent. RESULTS: The mean age of the patients was 29.53 ± 13.82 years (8-56 years). The most common cause of corneal opacity was healed keratitis with (6/30) or without (3/30) adherent leukoma, trauma-induced ocular disfigurement (7/30), and bullous keratopathy (6/30). All residents reported that feed-back images on i-OCT were "helpful" in all eyes and "very helpful" in eyes with corneal thinning, stromal scarring, adherent leukoma, bullous keratopathy, and hypotony. The mean depth of lamellar dissection was 51.16% ±4.62% of preoperative corneal thickness. The cosmetic results as perceived by the patient, an independent observer, and the surgeon were excellent and good in 23 and 7, 26 and 4, and 20 and 10 patients, respectively. CONCLUSION: I-KTP may be employed as a primary method of cosmetic correction of unsightly corneal scars. Centers equipped with i-OCT may employ this tool for teaching i-KTP to their ophthalmology residents for better surgical results with minimal complications.

Update on ocular graft-versus-host disease.

Ocular graft-versus-host disease (oGVHD) occurs as a complication following hematopoietic stem cell transplantation and is associated with significant ocular morbidity resulting in a marked reduction in the quality of life. With no current consensus on treatment protocols, management becomes challenging as recurrent oGVHD often refractory to conventional treatment. Most authors now diagnose and grade the disease based on criteria provided by the National Institutes of Health Consensus Conference (NIH CC) or the International Chronic oGVHD (ICCGVHD) consensus group. This article will provide an insight into the diagnostic criteria of oGVHD, its classification, and clinical severity grading scales. The inflammatory process in oGVHD can involve the entire ocular surface including the eyelids, meibomian gland, corneal, conjunctiva, and lacrimal system. The varied clinical presentations and treatment strategies employed to manage them have been discussed in the present study. The recent advances in ocular surface imaging in oGVHD patients such as the use of meibography and in vivo confocal microscopy may help in early diagnosis and prognostication of the disease. Researching tear proteomics and identification of novel potential tear biomarkers in oGVHD patients is an exciting field as they may help in objectively diagnosing the disease and monitoring the response to treatment.

Intraoperative posterior polar cortical disc defect: sign of intact posterior capsule.

PURPOSE: To describe the incidence and morphological characteristics of posterior polar cortical disc defect (PPCDD) sign observed during phacoemulsification in posterior polar cataract (PPC). SETTING: Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India. DESIGN: Prospective case series. METHODS: Sixty-seven eyes of 56 patients with PPC undergoing phacoemulsification were evaluated. Outcome measures were the incidence and characteristics of the intraoperative PPCDD sign, as well as its relation to the intraoperative surgical dynamics and posterior capsule (PC) dehiscence. RESULTS: Of the 67 eyes evaluated, the PPCDD sign was seen in 86.5% of eyes (58/67). Among these, 93.1% of eyes (54/58) showed a complete disc defect, whereas 6.9% of eyes (4/58) had a partial disc defect with incomplete margins. In the majority of cases (89.6%; 52/58), the PPCDD sign was seen after epinuclear plate and plaque aspiration. Among the 9 eyes that did not show the PPCDD sign, en bloc separation of the plaque and cortical matter from the PC was observed in 2 eyes, the plaque remained adherent to the PC till the end of cortical fiber aspiration in 3 eyes, and intraoperative PC rupture (PCR) was observed during the plaque separation in 4 eyes. The incidence of PCR in eyes without PPCDD sign was significantly higher (44.4% vs 0%; P < .001). CONCLUSIONS: The visualization of intraoperative PPCDD sign during phacoemulsification in PPC is suggestive of an intact PC and associated with a significantly lower rate of intraoperative PCR as compared with eyes without the PPCDD sign.

Descemet-stripping automated endothelial keratoplasty with intrascleral haptic-fixated intraocular lens in a sequential vs simultaneous approach.

PURPOSE: To compare the outcomes of Descemet-stripping automated endothelial keratoplasty (DSAEK) with intrascleral haptic-fixated intraocular lens (IOL) in a sequential and simultaneous approach. SETTING: Tertiary eyecare center. DESIGN: Prospective randomized comparative study. METHODS: Patients with aphakic or complicated pseudophakic bullous keratopathy visiting a tertiary eyecare center were included in the study. A total of 40 patients were randomized into 2 groups of 20 each. Group 1 had subjects who underwent scleral-fixated IOL (SF IOL) implantation by intrascleral haptic fixation technique, followed by DSAEK (sequential procedure) with an interval of at least 3 months. Group 2 (simultaneous) had subjects who underwent DSAEK with SF IOL as a combined procedure. Graft survival, endothelial cell loss (ECL), corrected distance visual acuity (CDVA), and need for any intervention such as rebubbling were evaluated for both the groups at the end of 6 months. RESULTS: At 6 months, the sequential group had significantly better CDVA of 0.62 ± 0.17 logMAR compared with 0.87 ± 0.19 logMAR in the simultaneous group (P = .002). Group 1 had significantly better overall cumulative graft survival (100% vs 60%, P = .002), significantly lower ECL (P = .006), lesser mean central corneal thickness (P = .03), and significantly thinner donor lenticule (P = .009). Rebubbling rate was significantly higher in Group 2 (P = .025). The mean hyperopic shift was significantly more in Group 2 (P = .02). CONCLUSION: The sequential procedure of SF IOL followed by DSAEK has better visual outcomes and graft survival when compared with simultaneous procedure in cases of aphakic or complicated pseudophakic bullous keratopathy.

Hey good lookin'! Popular culture, femininity, and lesbian representation in transnational regimes.

Currently, four big "Indian: names circulate within lesbian public culture within the United States: the biracial Indian-Dutch actress Janina Gavankar, the biracial model and actress Lisa Ray, Indian-American actress Sheetal Sheth, and Purva Bedi. These actresses have all represented a certain kind of close-to-Whiteness and a carefully constructed "feminine" aesthetic that has much to do with disciplining the racial body as it does the gendered body. In addition, they also position themselves in problematic ways with respect to their racial and sexual identities. What are the consequences of such representation for "real-life" "third-world" lesbians living in Western cultures like the United States in which racist and imperialist gestures constantly frame preemptive meanings about our bodies and our selves? If the only images of third-world lesbians we see are those that are carefully constructed along the same racist and heteronormative ideals of femininity, can racially marked lesbians find accurate models for our own invisible lives? How do these representations affect our perception of ourselves--as women who are lesbian and as women who are not White? How does our "femininity" get positioned within this? Are we the exoticized Other equally available for consumption by hetero and queer Whiteness? How might this only repeat rather than correct imperialist histories of race? How might they further divide communities of color from each other by their problematic selectivity of who gets to represent the racial and sexual Other?

Atypical Presentation of Bilateral Retinoblastoma with Floaters and Sub-Internal Limiting Membrane Seeds in an 11-Year-Old Asian Indian Male.

PURPOSE: To report bilateral retinoblastoma in an 11-year-old child presenting with floaters and sub-internal limiting membrane (sub-ILM) seeds. METHOD: An 11-year-old child presented with floaters of 4 months' duration. Examination revealed circumscribed, whitish, subhyaloid, floccular nodules in the juxtapapillary region of both eyes. No solid tumor was seen. Swept-source optical coherence tomography revealed moderately reflective echoes in the sub-ILM space. Vitreous aspiration of sub-ILM deposits and cytopathological examination revealed retinoblastoma. Intravitreal melphalan (20 µg/0.02 mL) was followed by 6 monthly cycles of high-dose systemic chemotherapy (vincristine, etoposide, carboplatin). Metastatic workup and genetic testing for RB1 mutational screening were negative. Ocular lesions resolved after 13 weeks of treatment. Brain metastases developed after 20 weeks and were treated with radiation. Bilateral vitreous seeds recurred at 44 weeks and were treated with intravitreal chemotherapy (melphalan 20 µg/0.02 mL and topotecan 20 µg/0.02 mL). There was no extra-ocular spread from sclerotomy sites. RESULTS: Retinoblastoma and brain metastases resolved with multimodal treatment without recurrence at 59 weeks of follow-up. CONCLUSION: Atypical manifestation of retinoblastoma can be seen in older children presenting with "floaters" and bilateral deposits of sub-ILM seeds, without solid tumor.