Creatively tiding over the crisis

Background: A patient with a retained intraocular metallic foreign body post?trauma was taken up for vitrectomy and intraocular foreign body removal. Unfortunately, the intraocular magnet was not available at the moment on the table! How a little bit of creativity and innovative thought helped us tide over this crisis is the content of this video. Purpose: To demonstrate magnetization of a metallic surgical instrument for temporary use in the event of unavailability of the intraocular magnet for intraocular foreign body removal. Synopsis: A ferromagnetic substance can be magnetized temporarily using an existing magnet. We obtained a general?purpose magnet and wrapped it in sterile plastic, using which we magnetized normal intraocular forceps and a Micro Vitreo Retinal (MVR) blade by giving about 20–30 strokes over the magnet in a single direction. This aligned the magnetic domains in the metal in a parallel fashion. These Do It Yourself (DIY)? magnetic instruments were then effectively utilized to remove the metallic intraocular foreign body. Highlights: The video showcases effectively harnessing the available resources and tiding over the dearth of a necessary instrument, with the right use of an innovative idea and some creativity!.

Long-term real-world outcomes in retinal vein occlusions: How close are we to the trials?

Purpose: To assess and analyze the visual outcomes of patients with retinal vein occlusions in a real?world setting with a long?term follow?up of more than 5 years. Methods: Retrospective analysis of 56 patients having retinal vein occlusions from a tertiary eye center, with a mean follow?up of 7 years was performed. Primary outcome measures were mean change in best?corrected visual acuity (BCVA) from baseline at 6 months, 1 year, 2 years, 3 years, and final visit (?5 years), proportion of patients having BCVA better than 20/40 and worse than 20/200, and mean number of injections. Secondary outcome measures were change in central macular thickness (CMT), development of subsequent retinal vein occlusion (RVO) in same eye or the other eye, and development of neovascular complications. Results: The mean change in letter score was + 11.84 in branch RVO (BRVO), +7.14 in non?ischemic central RVO (CRVO), and ?9.5 in ischemic CRVO at 1 year, which changed to + 8.57, ?5 and ? 24, respectively, at the end of follow?up. CMT had improved from 506 ± 98.8 ?m, 576.44 ± 149 ?m, and 618 ± 178.27 ?m, respectively, at baseline to 267 ± 94 ?m, 345.20 ± 122.61 ?m, and 265.50 ± 107.75 ?m, respectively, in BRVO, non?ischemic, and ischemic hemi RVO (HRVO)/CRVO groups. The total mean number of injections given in BRVO, non?ischemic CRVO, and ischemic CRVO groups were 4.6, 6.6, and 4.1, respectively. None of the patients with BRVO developed neovascular glaucoma (NVG). Non?ischemic to ischemic HRVO/CRVO conversion was noted in 4/11 eyes at a mean duration of 12.6 months. NVG was noted in 7/9 eyes (77.8%) in initial ischemic CRVO/HRVO group and 3/4 (75%) converted eyes. Conclusion: Patients with BRVO have good visual outcomes with anti?VEGF, while in CRVO results may vary considerably owing to patient compliance and treatment burden on long?term follow?up in a real?world setting

Plug it, fill it and forget it!

Background: Management of posterior scleral perforation is commonly done with cryotherapy/laser or scleral patch graft depending on the size of perforation. However, for large perforations, the availability of donor sclera is always an issue. To overcome this problem, we tried using absorbable gelatin sponge to plug the perforation as an alternative. Purpose: To evaluate the efficacy of gelatin foam as an alternative to scleral patch graft in cases with perforation of posterior sclera. Synopsis: Here we report the case of a 27?year?old male, who sustained penetrating injury to right eye with two metallic intraocular foreign bodies with visual acuity of hand movement close to face. Primary wound repair was done, followed by retrieval of the first piece of metallic foreign body that measured 11X3mm in size. The second foreign body visualized at posterior pole adjascent to the disc was removed using Machemar forceps and it measured 10X3 mmin size. Leakage of PFCL at the site confirmed a posterior scleral perforation. Cryotherapy was avoided due to its proximity to optic nerve head, and donor sclera was not readily available at that moment. We managed the case by plugging the defect with absorbable gelatin foam, followed by silicone oil injection into the vitreous cavity. Post operative outcome was good with restoration of anatomical integrity of the globe along with improvement in visual acuity upto 6/18. Highlights: Gelatin foam being absorbable and inciting less reaction aids in sealing the perforation and maintenance of globe contour with the advantage being readily available, cost?effective and it can be left in situ without the need for additional surgery for its removal. This would be of use in situations where the donor sclera is not readily available, and thus can be a potential alternative. However, further studies with larger sample size need to be done to evaluate and compare its effectiveness over donor scleral grafts

Ocular occlusions in two cases of COVID-19

In late 2019, we saw the emergence of a new coronavirus, the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS?CoV?2), which rapidly evolved into a global pandemic. We report two cases of ocular vascular occlusion related to coronavirus disease 2019 (COVID?19) disease. The first case is of choroidal artery occlusion, while the second case is of combined central retinal artery and vein occlusion (CRAO and CRVO). We performed a thorough literature search and to the best of our knowledge, neither any of the above said has been reported in COVID?19–positive patients.

Acceptability of artificial intelligence-based retina screening in general population

Purpose: A deep learning system (DLS) using artificial intelligence (AI) is emerging as a very promising technology in the future of healthcare diagnostics. While the concept of telehealth is emerging in every field of medicine, AI assistance in diagnosis can become a great tool for successful screening in telemedicine and teleophthalmology. The aim of our study was to assess the acceptability of AI?based retina screening. Methods: This was a prospective non?randomized study performed in the outpatient department of a tertiary eye care hospital. Patients older than 18 years who came for a regular eye check?up or a routine retina screening were recruited in the study. Fundus images of the posterior pole were captured on fundus on a phone camera (REMIDIOTM, India) with a built?in AI software (Netra.AI) that can identify normal versus abnormal retina. The patients were then given an 8?point questionnaire to assess their acceptance and willingness toward AI?based screening. We recruited 104 participants. Results: We found that 90.4% were willing for an AI?based fundus screening; 96.2% were satisfied with AI?based screening. Patients with diabetes (P = 0.03) and the male population (P = 0.029) were more satisfied with the AI?based screening. The majority (i.e., 97.1%) felt that AI?based screening gave them a better understanding of their eye condition and 37.5% felt that AI?based retina screening prior to a doctor抯 visit can help in routine screening. Conclusion: Considering the current COVID?19 pandemic situation across the globe, this study highlights the importance of AI?based telescreening and positive patient approach toward this technology.

Not-so-minimal for minimally invasive surgery

Sub?macular hemorrhage poses a potential threat to vision if left untreated. The preferred surgical technique to clear sub?macular hemorrhage includes vitrectomy followed by retinotomy using a 41G needle with subsequent injection of recombinant tissue plasminogen activator (r?tPA) followed by air/SF6 injection into the sub?retinal space. A malleable nature, increased resistance, and the cost of the 41G needle limit its use. We evaluated the safety and efficacy of a 26G needle for retinotomy as a supplement for the 41G needle in a series of six subjects with sub?macular hemorrhage. A slight modification in the procedure was done by injecting air into the sub?retinal space prior to the r?tPA injection. We found that our technique of using the 26G needle for retinotomy is safe and effective due to its stable nature and self?sealing properties. An air injection prior to r?tPA allows for increased bioavailability of the drug by preventing efflux due to its tamponading effect.

Coats’ disease – Prognostic factors for globe and vision salvage in children, a long-term experience

Coats’ disease is associated with poor outcomes, and there are limited studies on long?term outcomes of Coats’ disease. The purpose of our study is to identify various predictive factors to help in prognosticating the treatment outcomes in advanced Coats’ disease in children. Methods: This is a retrospective case series from a single tertiary eye care center of children (<18 years) diagnosed with coat’s disease. Sixty?seven patients with Coat’s disease were identified from the medical records from 2009 to 2020. Patients’ demographic data, clinical presentation, stage, extent of involvement, detailed treatment history, clinical sequelae post?treatment (including complications and anatomical and functional outcomes) were noted. Binary logistic regression was performed to correlate the predictive factors for anatomical and functional improvement. Results: Of the 67 patients, 51 eyes of 51 patients were included in the study. The male to female proportion was 2.2. Mean age at presentation was 4.98 ± 3.55 years (range: 2 months–15 years). Mean duration of follow?up was 31.53 ± 26.38 months. Overall, our globe salvage rate was 92.2%. We found that vitreoretinal fibrosis (P < 0.001), subretinal gliosis (P < 0.001), vitreous hemorrhage (P = 0.02), tractional or combined retinal detachment (P < 0.001), foveal scar (P < 0.006), and cataract (P < 0.001) to be important factors to affect the outcome. Conclusion: Advanced stage of presentation (stage 3B and above), diffuse involvement, cataract, vitreoretinal fibrosis (preretinal and subretinal), vitreous hemorrhage, tractional or combined retinal detachment, and anterior hyaloid proliferation are poor prognostic factors for globe salvage in advanced disease. Subretinal gliotic nodule or scar and lack of visual rehabilitation suggest poor functional outcomes

Unconventional techniques of fundus imaging: A review.

The methods of fundus examination include direct and indirect ophthalmoscopy and imaging with a fundus camera are an essential part of ophthalmic practice. The usage of unconventional equipment such as a hand‑held video camera, smartphone, and a nasal endoscope allows one to image the fundus with advantages and some disadvantages. The advantages of these instruments are the cost‑effectiveness, ultra portability and ability to obtain images in a remote setting and share the same electronically. These instruments, however, are unlikely to replace the fundus camera but then would always be an additional arsenal in an ophthalmologist’s armamentarium.

Brachytherapy, A viable option of globe salvage in treatment of large ciliary body melanocytoma.

We report a case of large histopathologically proven melanocytoma of the ciliary body in a 15‑year‑old male, presented with rapid extraocular growth following incisional biopsy with scleral patch graft. We chose brachytherapy with Ruthenium 106 plaque over enucleation as the later was refused by the parents. The initial apical height of the tumor was 14.2 mm on ultrasonography. Two weeks after brachytherapy, the mass regressed to a size of 8.1 mm and 1 year later to 6.7 mm. This is the first case report showing the response of brachytherapy to ciliary body melanocytoma, which results in ocular and visual acuity salvation with considerable decreased in size of the tumor. The authors conclude that brachytherapy is an option in the management of non‑resectable melanocytoma of the ciliary body.

Brachytherapy, A viable option of globe salvage in treatment of large ciliary body melanocytoma.

We report a case of large histopathologically proven melanocytoma of the ciliary body in a 15‑year‑old male, presented with rapid extraocular growth following incisional biopsy with scleral patch graft. We chose brachytherapy with Ruthenium 106 plaque over enucleation as the later was refused by the parents. The initial apical height of the tumor was 14.2 mm on ultrasonography. Two weeks after brachytherapy, the mass regressed to a size of 8.1 mm and 1 year later to 6.7 mm. This is the first case report showing the response of brachytherapy to ciliary body melanocytoma, which results in ocular and visual acuity salvation with considerable decreased in size of the tumor. The authors conclude that brachytherapy is an option in the management of non‑resectable melanocytoma of the ciliary body.

Fundus imaging with a mobile phone: A review of techniques.

Fundus imaging with a fundus camera is an essential part of ophthalmic practice. A mobile phone with its in‑built camera and flash can be used to obtain fundus images of reasonable quality. The mobile phone can be used as an indirect ophthalmoscope when coupled with a condensing lens. It can be used as a direct ophthalmoscope after minimal modification, wherein the fundus can be viewed without an intervening lens in young patients with dilated pupils. Employing the ubiquitous mobile phone to obtain fundus images has the potential for mass screening, enables ophthalmologists without a fundus camera to document and share findings, is a tool for telemedicine and is rather inexpensive.

Brachytherapy of intra ocular tumors using ‘BARC I-125 Ocu-Prosta seeds’: An Indian experience.

Aim: To report our experience of brachytherapy using ‘BARC I‑125 Ocu‑Prosta seeds’ for the management of intraocular tumors with regard to tumor control, globe preservation visual outcome, and patient survival at Sankara Nethralaya, Chennai, India between September 2003 and May 2011. Materials and Methods: We reviewed records of 35 eyes of 35 patients who underwent ophthalmic brachytherapy between September 2003 and May 2011. Twenty‑one cases had choroidal melanoma, nine had childhood retinoblastoma, two had adult‑onset retinoblastoma, and there were one case each of vasoproliferative tumor, retinal angioma, and ciliary body melanoma. Brachytherapy was administered using a 15‑ or 20‑mm gold plaque with or without a notch. Brachytherapy was the primary treatment modality in all tumors other than retinoblastoma, wherein brachytherapy was done post chemoreduction for residual tumor. Results: For choroidal melanomas, the mean radiation dose was 68.69 ± 15.07 (range, 47.72-94.2) Gy. The eye salvage rate was 13/20 (65%) and tumor control rate was 16/20 (80%) at an average follow‑up of 24.43 ± 24.75 (range, 1.5-87.98) months. For retinoblastoma, the mean dose was 45.85 ± 3.90 (range, 39.51-50.92) Gy. The eye salvage rate and tumor control rate was 5/6 (83.3%) at an average follow‑up of 38.36 ± 31.33 (range, 4.14-97.78) months. All eyes with retinoblastoma needed additional focal therapy for tumor control and eye salvage. Conclusion: The results of this retrospective study confirms that the use of ‘BARC I‑125 Ocu‑Prosta seeds’ in episcleral plaques to treat intraocular tumors offers a viable option for the management of intraocular cancers.

Subretinal lipid exudation associated with untreated choroidal melanoma.

Subretinal lipid exudation in an untreated choroidal melanoma is very rare. It is seen following plaque radiotherapy in choroidal melanoma. There is only one case report of untreated choroidal melanoma with massive lipid exudation in a patient with metastatic hypernephroma. We report here a rare case of untreated choroidal melanoma with lipid exudation. Subretinal exudation that is rarely seen following plaque brachytherapy was noted at the borders of this untreated tumor. Lipid exudation partially resolved following brachytherapy.

Video indirect ophthalmoscopy using a hand-held video camera.

Fundus photography in adults and cooperative children is possible with a fundus camera or by using a slit lamp-mounted digital camera. Retcam™or a video indirect ophthalmoscope is necessary for fundus imaging in infants and young children under anesthesia. Herein, a technique of converting and using a digital video camera into a video indirect ophthalmoscope for fundus imaging is described. This device will allow anyone with a hand-held video camera to obtain fundus images. Limitations of this technique involve a learning curve and inability to perform scleral depression.

CGA codons multiplex PCR in rapid diagnosis of retinoblastoma.

Background: Multiplex polymerase chain reaction allows amplification of multiple target sequences of a genome under identical conditions in a single tube. This "one-shot" polymerase chain reaction detection is time and cost effective when large or multiple genes, with many target fragments are investigated. This is applicable for retinoblastoma susceptibility gene having 27 exons with recurrent mutations reported at most of the 12 CGA codons. Materials and Methods: Multiplex polymerase chain reaction assay for the amplification of 12 CGA codons, which constitutes about 50 % of retinoblastoma susceptibility gene mutations has been designed. The time and cost (includes only reagent cost) involved in both multiplex and uniplex polymerase chain reaction was also calculated. Results: Twelve CGA codons were multiplexed in 5 instead of 12 uniplex polymerase chain reactions, which took 36 hours and 9.78 US$ whereas multiplex polymerase chain reaction took 15 hours and 6.88 US$. Multiplex polymerase chain reaction method saved 58.3% of time and 29.6% of cost over uniplex polymerase chain reaction. Conclusion: Saving time by more than half and cost by nearly a third would help clinicians and geneticists while counseling retinoblastoma patients.