Removal of Intraocular Foreign Bodies Using a Modified Flute Needle.

PURPOSE: To describe the construction of a novel intraocular snare and evaluate its effectiveness in intraocular foreign body (IOFB) removal. METHOD: This is a retrospective consecutive case series. Five patients underwent pars plana vitrectomy and IOFB removal using the intraocular snare constructed from modified flute needle. RESULTS: All IOFBs were successfully engaged and removed with the snare on the first attempt. Three of the 5 cases (60%) enjoyed good visual outcome (0.4-1.0) postoperatively. No complication related to the use of the snare was encountered in this case series. CONCLUSION: Intraocular foreign body snare is simple, safe, and effective in IOFB removal.

Are we facing an increasing surgical demand for high myopic traction maculopathies? A 12-year study from Hong Kong.

PURPOSE: We aimed to investigate the longitudinal change in the number of surgically operated myopic traction maculopathies (MTM) cases at a tertiary eye centre. METHODS: A retrospective study of all consecutive cases of surgically operated MTM over 12 years (2009-2020) was conducted in a myopia prevalent region. We compared outcomes among three groups: (1) myopic macular hole (MH), (2) myopic macular hole with retinal detachment (MHRD), and (3) myopic foveoschisis with retinal detachment (MFRD). RESULTS: Fifty-one cases were included in the study (8 cases of MH, 33 cases of MHRD and 10 cases of MFRD). The overall mean age was 63.8 +/- 8.7 with a female preponderance (2:1). The mean age of the MH group (58.6) was significantly younger than the MHRD group (64.2) and MFRD group (66.6) (p = 0.02). Subgroup analysis using ATN classification did not show its correlation with both visual improvement and anatomical success. When comparing the first 6-year period (2009-2014) with the second 6-year period (2015-2020), there was a significant increase in the number of cases (p = 0.01). CONCLUSION: We observe an increase in the number of surgically operated MTM. This follows the trend of the global rise in the prevalence of myopia and baby boomers entering retirement.

Association between endoscopic cyclophotocoagulation and vitreous prolapse in trabeculectomy: a case report.

BACKGROUND: To propose that possible alteration or damage to the ciliary zonules during uncomplicated endoscopic cyclophotocoagulation (ECP) can cause complications in subsequent filtration surgery. CASE PRESENTATION: We present two cases with uncomplicated primary combined phacoemulsification and ECP that underwent subsequent trabeculectomy. Both cases were complicated with vitreous prolapse during the trabeculectomy procedure. We review the anatomy of the ciliary zonules and their spatial relationship with the ciliary processes targeted during ECP and propose an association between ECP, zonular damage and complications in subsequent trabeculectomy such as vitreous prolapse. CONCLUSIONS: Damage to ciliary zonules during ECP may not manifest until subsequent glaucoma filtration surgery. In patients who received prior ECP, we may consider taking preventative measures to avoid associated complications such as vitreous prolapse. Patients with known risk factors for weak zonules may consider choosing alternative intraocular pressure-lowering means.

The Implications of COVID-19 to Ophthalmology.

The coronavirus disease 2019 (COVID-19) pandemic has brought unprecedented challenges to ophthalmology. At least 16 ophthalmologists worldwide have succumbed to COVID-19. It reflects the susceptibility of ophthalmologists to COVID-19 infection as they are in close proximity to patients. This chapter provides an overview of the ocular manifestations of COVID-19, risks of COVID-19 to ophthalmologists and patients, clinical service adjustments due to COVID-19, and infection control measures to minimize the transmission of COVID-19 in ophthalmic practice.

The use of short message service (SMS) to reduce outpatient attendance in ophthalmic clinics during the coronavirus pandemic.

PURPOSE: In order to minimize the risk of transmission of coronavirus disease 2019 (COVID-19), many clinic appointments were postponed to lower patient attendance. Actively calling patients to postpone appointments is a labour-intensive process. We were the first ophthalmic clinics in Hong Kong to use short message service (SMS) to dispatch messages simultaneously to a large number of patients to offer postponement of appointments. The aim of this study is to evaluate whether SMS is an effective method to reduce outpatient attendance during the COVID-19 pandemic. METHODS: This is an observational study reviewing data on SMS messages sent to all patients attending ophthalmology clinics of a tertiary eye centre in Hong Kong. All SMS were sent at least 5 days before the scheduled appointments. The text message included an enquiry hotline for postponement of appointments and offered drug refill. The study included data from February to April 2020. Two hundred patients were invited to take part in a questionnaire on satisfaction level and reason(s) for appointment rescheduling. RESULTS: During the study period, a total of 17,028 SMS were sent. The overall response rate was 23.6%. 14.3% postponed their appointments. This led to an overall 13.9% reduction of clinic attendance. The overall satisfaction was high (96%). The main reason for postponing appointment was worries about infection risk (93.1%). CONCLUSION: SMS was an efficient and cost-effective flow-control method which was well accepted by patients and can reduce outpatient attendance. The time saved can potentially allow healthcare workers to conduct other infection control measures during the COVID-19 pandemic.

The use of personal protective equipment in clinical ophthalmology during corona virus disease-2019: a review of international guidelines and literature.

PURPOSE OF REVIEW: The use of nonpharmaceutical interventions can prevent viral spread in COVID-19 pandemic and PPE forms a crucial part of this strategy. However, there are discrepancies in existing guidelines and a lack of consensus among ophthalmic communities. This review aims to identify general consensus and provides recommendation of PPE for most common ophthalmological scenarios. With a global shortage of PPE, extended use and reuse strategies are also discussed. RECENT FINDINGS: In this review, guidelines and resources were selected, based on a three-tier process. The first-tier resources were from international infection control organizations. The second-tier resources were from ophthalmological professional associations and colleges. The third-tier resources involved a PubMed search using the keywords 'COVID-19; coronavirus; personal protective equipment' performed on 1 May 2020. Non-English guidelines and literatures were excluded. SUMMARY: On the basis of our methodology, we included a total of 30 documents, including 5 resources from tier 1, 14 resources from tier 2 and 15 from tier 3. Different levels of protection are necessary. Whenever performing an aerosol generating procedure, maximum protection should be ensured, this includes FFP3 respirator, fluid resistant gown, goggles or face-shield and disposable gloves. Similar protection should be used for handling COVID-19-positive/suspected case but the use of FFP2 respirator is acceptable. During routine outpatient clinic in cases of negative triage, it is recommended to use ASTM III surgical mask, plastic apron, disposable gloves and eye protection with goggles or face-shield. Lastly, patients should be encouraged to wear surgical masks whenever possible.

Stepping up infection control measures in ophthalmology during the novel coronavirus outbreak: an experience from Hong Kong.

PURPOSE: Coronavirus disease (COVID-19) has rapidly emerged as a global health threat. The purpose of this article is to share our local experience of stepping up infection control measures in ophthalmology to minimise COVID-19 infection of both healthcare workers and patients. METHODS: Infection control measures implemented in our ophthalmology clinic are discussed. The measures are based on detailed risk assessment by both local ophthalmologists and infection control experts. RESULTS: A three-level hierarchy of control measures was adopted. First, for administrative control, in order to lower patient attendance, text messages with an enquiry phone number were sent to patients to reschedule appointments or arrange drug refill. In order to minimise cross-infection of COVID-19, a triage system was set up to identify patients with fever, respiratory symptoms, acute conjunctivitis or recent travel to outbreak areas and to encourage these individuals to postpone their appointments for at least 14 days. Micro-aerosol generating procedures, such as non-contact tonometry and operations under general anaesthesia were avoided. Nasal endoscopy was avoided as it may provoke sneezing and cause generation of droplets. All elective clinical services were suspended. Infection control training was provided to all clinical staff. Second, for environmental control, to reduce droplet transmission of COVID-19, installation of protective shields on slit lamps, frequent disinfection of equipment, and provision of eye protection to staff were implemented. All staff were advised to measure their own body temperatures before work and promptly report any symptoms of upper respiratory tract infection, vomiting or diarrhoea. Third, universal masking, hand hygiene, and appropriate use of personal protective equipment (PPE) were promoted. CONCLUSION: We hope our initial experience in stepping up infection control measures for COVID-19 infection in ophthalmology can help ophthalmologists globally to prepare for the potential community outbreak or pandemic. In order to minimise transmission of COVID-19, ophthalmologists should work closely with local infection control teams to implement infection control measures that are appropriate for their own clinical settings.

Phacoemulsification cataract surgery in patients receiving novel oral anticoagulant medications.

INTRODUCTION: An increasing number of patients are taking novel oral anticoagulant (NOAC) medication, making perioperative management in phacoemulsification surgery an important issue. This study reports the haemorrhagic complications of NOAC in phacoemulsification surgery. DESIGN: Retrospective case study over a 4-year period. METHODS: Consecutive cases receiving NOAC during the time of phacoemulsification were reviewed. Patients were either advised to continue medications (continued group) or withhold medications before surgery (withheld group). MAIN OUTCOME MEASURES: Details including patient demographics, preoperative assessment, postoperative outcome and intraoperative, postoperative and systemic complications were recorded. RESULTS: A total of 20,100 cases of phacoemulsification were performed. Of which, 66 cases were found to be on NOAC (0.33%). This included 66 eyes of 53 patients, with 42 continued and 24 withheld medications before surgery. There was no statistically significant difference between the two groups in demographics, cataract risk factors, baseline renal function, clotting profile, type of NOAC, incision size, phacoemulsification energy, preoperative and postoperative visual acuity. There was also no significant difference in intraoperative, postoperative and systemic complications (p = 1.00 and 0.53, Fischer's exact test). None of the patients in the continued group had postoperative complications; two cases in the withheld group receiving retrobulbar anaesthesia had bruising and subconjunctival haemorrhage after resumption of NOAC (p = 0.13, Fischer's exact test). CONCLUSION: The present study found no difference in haemorrhagic complications between cases continuing and withholding NOAC during phacoemulsification. Nevertheless, the potential risks and benefits to continue or withhold NOAC perioperatively should be carefully considered via a multidisciplinary approach.

Retrospective review on the outcome and safety of transscleral diode laser cyclophotocoagulation in refractory glaucoma in Chinese patients.

PURPOSE: Transscleral cyclodiode laser cyclophotocoagulation (TSCP) is often reserved for treatment of refractory glaucoma. This retrospective study investigates the safety and efficacy of TSCP among the Chinese population. METHODS: A retrospective review was performed on electronic patient records of all patients receiving TSCP between years 2009 to year 2016. Patient demographics, indication for laser, success and response rate, change in intraocular pressure (IOP), number of treatment sessions, laser energy, glaucoma medication, visual acuity, pain symptoms and complication rate were documented. RESULTS: The study included 126 patients: 81 patients were male and 45 were female, and the mean age was 66.6 ± 14.3 years old and the mean follow-up was 22.7 ± 14.1 months. The mean number of treatment sessions was 1.5 ± 0.8. The success rate was 67.3%. The mean IOP before TSCP was 67 ± 38.6 mmHg and 22.8 ± 14.2 mmHg after TSCP, the mean IOP reduction was 38.4%, which was statistically significant (P value < 0.001, Wilcoxon signed rank test). The mean laser energy used per eye was 72.7 ± 56.6 and 49.2 ± 22.9 J per individual treatment session. The mean number of laser shots was 15.0 ± 6.1. 71% of patients were able to reduce their glaucoma medication after TSCP, (P value < 0.01, Wilcoxon signed rank test). 86.1% of patients had improvement in pain symptoms after TSCP. The overall complication rate was 7.1%. CONCLUSION: TSCP was found to be safe and effective among the Chinese population, with comparably low laser energy setting and complication rate. It was found to be most effective in treatment of glaucoma due to trauma, acute angle closure, uveitis and chronic angle closure.

Angiographic and Tomographic Prognostic Factors of Chronic Central Serous Chorioretinopathy Treated with Half-Dose Photodynamic Therapy.

AIMS: To identify the angiographic and tomographic prognostic factors of chronic central serous chorioretinopathy (CSC) treated with half-dose photodynamic therapy (PDT). METHODS: This is a consecutive series of 61 eyes with chronic CSC treated with half-dose PDT from January 1, 2009 to October 31, 2016. RESULTS: The mean logMAR best-corrected visual acuity (BCVA) improved from 0.47 to 0.31 at 3 months (p < 0.001). From multivariate regression, the final BCVA was significantly associated with the baseline BCVA (p = 0.003), a diffuse hyperfluorescence pattern on indocyanine green angiography (ICGA) (p = 0.024), posttreatment shallow irregular pigment epithelium detachment (PED) (p = 0.022), and disruption of the ellipsoid zone (p = 0.007). A diffuse hyperfluorescence pattern on ICGA was associated with a 77.4 times risk of subretinal fluid persistence after treatment (p = 0.009). CONCLUSION: A poor baseline BCVA, diffuse hyperfluorescence ICGA pattern, shallow irregular PED, and disruption of the ellipsoid zone indicate poor prognosis.

The efficacy of latent tuberculosis treatment for immunocompetent uveitis patients with a positive T-SPOT.TB test: 6-year experience in a tuberculosis endemic region.

PURPOSE: To assess the efficacy of latent tuberculosis (TB) treatment for immunocompetent uveitis patients with a positive T-SPOT.TB test. METHODS: This is a consecutive case series of all T-SPOT.TB positive latent TB patients with presumed tuberculous uveitis managed with anti-tuberculous therapy (ATT) from 1 January 2000 to 31 December 2015. Patients with active TB or other known causes of uveitis, immunocompromised states and those followed up < 12 months were excluded. Descriptive statistics and hypothesis testing were performed, with a significance level of p < 0.05 taken. RESULTS: Among the 75 T-SPOT.TB tests performed for uveitis, 14 cases were enrolled. Mycobacterium tuberculosis was isolated in none of the sputum and intraocular samples. Most cases had posterior uveitis (10/14 cases, 71.4%) and/or intermediate uveitis (9/14 cases, 64.3%). Vasculitis was predominantly occlusive. The mean presenting best-corrected visual acuity (BCVA) was 0.18, improving to 0.44 at 6 months (p = 0.03) and 0.40 at 12 months. (p = 0.03). At 1 year, remission of uveitis was achieved in 92.9%, in which none of them recurred at the last follow-up. High-dose systemic steroid was required in 50% of patients. Only 1 patient was steroid dependent at 18 months. The BCVA improvement in patients treated with or without steroid was comparable. CONCLUSION: In a TB-endemic region with wide Bacille Calmette-Guerin vaccination coverage, ATT for immunocompetent uveitis patients with latent TB identified from T-SPOT.TB test can improve vision, induce long-term steroid-free remission, and prevent recurrence and systemic reactivation of TB in those who require steroid.

Self-retaining magnetic implant: A novel design of orbital prosthesis for the exenterated orbit.

Orbital exenteration can lead to significant disfigurement causing considerable functional, cosmetic and psychological disturbances to the patient. Orbital prosthesis is important for the patient's cosmetic and psychological rehabilitation. A 49-year-old man received orbital exenteration and postoperative radiotherapy for malignant orbital carcinoma. In view of uncertain suitability and survival of osseointegrated implant in his case, a novel design of ocular implant consisting of a self-retaining magnetic spring retainer and a coupling silicone prosthesis was used. This novel design was shown to provide the patient with ease of use, good cosmetic outcome and better quality of life.

Epidemiology and clinical outcome of intraocular foreign bodies in Hong Kong: a 13-year review.

The purpose of this study was to describe the epidemiology, visual outcome and prognostic factors of intraocular foreign body (IOFB) injuries in a tertiary centre in Hong Kong. A retrospective review of 21 eyes in 21 patients with IOFB that presented to United Christian Hospital from January 2001 to July 2014 was performed. IOFB represented 16 % of all open-globe traumas. There was a high male predominance (90 %). The mean age was 42. Work-related injuries (86 %) were the main cause, where only 10.5 % had eye protection. Hammering was the commonest mechanism of injury (43 %). Most IOFBs were metallic (67 %). The IOFB was found in the anterior segment in 31 % and posterior segment in 69 %. 57 % presented with an initial visual acuity of ≥0.1, and up to 24 % of patients had an initial visual acuity of better than or equal to 0.5. Most cases (76 %) received prompt surgical intervention within 24 h, and there was a low (0 %) endophthalmitis rate. Forty-eight percent had an improvement in visual acuity, defined as final visual acuity more than or equal to 2 lines of improvement from initial visual acuity, and 48 % attained a final visual acuity of better than or equal to 0.5. One case underwent evisceration. A smaller IOFB size (<5 mm) was associated with a good final visual acuity of better than or equal to 0.5 (p = 0.048). It was also found that a posterior segment IOFB was more likely to give a final VA of less than 0.5 (p = 0.035). IOFB remains a significant complication of work-related injuries in Hong Kong. This is the first local study that explores the epidemiology of IOFB injuries in Hong Kong. The favourable visual outcome and low endophthalmitis rate may be related to early removal of IOFB. Despite legal ordinances for mandatory eye protection, the uptake of eye protection was low.

Eccrine Porocarcinoma of the Eyelid in a Non-Caucasian Patient.

A 60-year-old lady of Chinese origin presented with a right medial canthal mass. The lesion had been present for many years but progressively increased in size a few months prior to the consultation. Clinical examination revealed a medial canthal mass measuring 1.8 cm in diameter. It was firm with an irregular crusting surface. It was not attached to underlying deep lamella, and there were overlying telangiectatic vessels with contact bleeding. Excisional biopsy of the lesion confirmed a diagnosis of eccrine porocarcinoma. Eccrine porocarcinoma rarely occurs in the eyelid, and this is the first reported case of its occurrence in non-Caucasian patient. Given the significant risk of recurrence and metastasis, long-term surveillance is warranted. Although being rare, ophthalmologists should be vigilant of this potentially life-threatening lesion in the management of eyelid tumors.