Reducing Waiting-time of Preterm Babies at a Retinopathy of Prematurity Clinic: A Quality Improvement Project

Objective: To decrease the waiting time for preterm babiesvisiting the Retinopathy of prematurity clinic in a tertiary eyehospital.Design: Interventional study.Setting: Tertiary eye care hospital.Patients: All preterm babies reporting for screening and follow upat Retinopathy of prematurity clinic.Intervention/Procedure: A quality improvement teamcomprising of a faculty (team leader), two senior residents, twojunior residents, one nursing officer, and a registration staff wasconstituted.Fish bone analysis was done to understand variousreasons for the high waiting time for preterm babies. Baseline datawas collected followed by multiple Plan-Do-Study- Act (PDSA)cycles.Main outcome measures: Average waiting-time, maximumwaiting-time, and last baby entry-time were measured.Results: The median average waiting-time, maximum waiting-time and last baby entry-time at baseline were 90.5 min (range74.1 to 118.8 min), 177.5 min (range 160 to 190 min) and 111 min(90 to 118 min), respectively. At the end of 3rd PDSA cycle, thesereduced to 77.6 min (range 55.2 to 94.3 min), 122 min (range 110to 135 min), and 60 min (range 45 to 80 min), respectively andwere sustained; the decrease from baseline being 14.3%, 31.2%,and 46%, respectively.Conclusion: The time spent in the waiting area at theRetinopathy of Prematurity clinic was significantly reduced bysimple changes in the process flow.

Reducing Preoperative Waiting-time in a Pediatric Eye Operation Theater by Optimizing Process Flow: A Pilot Quality Improvement Project

Objective: To decrease the preoperative area waiting-time forchildren posted for eye surgery.Methods: A pilot quality improvement project was conducted in asingle paediatric eye operation theatre in our tertiary-carehospital. Operation theatre process flow was analyzed, baselinedata was collected, and two Plan-Do-Study-Act cycles wereperformed on consecutive days. Average and maximal waiting-time were recorded across six operation theatre days.Results: The average and maximal waiting time at baseline were221 and 390 minutes, respectively. After two rapid Plan-Do-Study-Act cycles, these were reduced to 29 (87% reduction) and 52minutes (87% reduction) from baseline, respectively, and couldsubsequently be sustained.Conclusion: Preoperative waiting time in ophthalmic operationtheatre was significantly reduced by simple process flowoptimization, thereby improving quality of care.

Asymmetric Presentation of Retinopathy of Prematurity

Retinopathy of prematurity (ROP) usually has symmetricpresentation and progression between fellow eyes. In thisretrospective review of records, asymmetric presentation wasnoted in 16 (3.9%) out of 410 babies over a period of one year.Management and final outcome differed in 10 and 11 infantsrespectively. ROP need not always be symmetric and may requirevariable management.

An unusual case of protruding retro‑orbital metallic foreign body.

A 34‑year‑old female presented with firecracker injury with curved metallic foreign body embedded in the left orbit and protruding out through the upper eyelid. The report highlights notable aspects in diagnosis, decision‑making, and successful removal of this unusual case of retro‑orbital foreign body.

Ultra‑wide field angiography in the management of Eales disease.

Aims: This study aims to evaluate the use of ultra‑wide field (UWF) angiography in patients with Eales disease (ED). Settings and Design: Prospective observational case series in tertiary eye care center. Subjects and Methods: This study involved 17 patients diagnosed with ED, who underwent UWF fluorescein angiography. The angiograms were analyzed to look for additional information as compared to Early Treatment Diabetic Retinopathy Study seven standard field. The impact of this information in the management of patients was analyzed. Results: 24 eyes of 17 patients with mean age of 26.3 years were diagnosed with ED and underwent UWF angiography. UWF fluorescein angiography was helpful in the documentation of peripheral retinal changes (in 67% of eyes), exact localization of capillary nonperfusion (CNP) (in 54% of eyes), and in determination of vascular involvement (in 21% of eyes). In 33% of eyes, immediate treatment plan changed because of changes picked up on UWF angiography. Conclusions: UWF angiography helped in the better documentation, exact quantification, and location of CNP areas and better determination of disease activity. UWF imaging may play an important part in the management of patients with ED.

Comparative evaluation of RetCam vs. gonioscopy images in congenital glaucoma.

Purpose: To compare clarity, exposure and quality of anterior chamber angle visualization in congenital glaucoma patients, using RetCam and indirect gonioscopy images. Design: Cross‑sectional study Participants. Congenital glaucoma patients over age of 5 years. Materials and Methods: A prospective consecutive pilot study was done in congenital glaucoma patients who were older than 5 years. Methods used are indirect gonioscopy and RetCam imaging. Clarity of the image, extent of angle visible and details of angle structures seen were graded for both methods, on digitally recorded images, in each eye, by two masked observers. Outcome Measures: Image clarity, interobserver agreement. Results: 40 eyes of 25 congenital glaucoma patients were studied. RetCam image had excellent clarity in 77.5% of patients versus 47.5% by gonioscopy. The extent of angle seen was similar by both methods. Agreement between RetCam and gonioscopy images regarding details of angle structures was 72.50% by observer 1 and 65.00% by observer 2. Conclusions: There was good agreement between RetCam and indirect gonioscopy images in detecting angle structures of congenital glaucoma patients. However, RetCam provided greater clarity, with better quality, and higher magnification images. RetCam can be a useful alternative to gonioscopy in infants and small children without the need for general anesthesia.

Ranibizumab as an adjunct to laser for macular edema secondary to branch retinal vein occlusion.

To compare the safety, efficacy, and dosing regimen of intravitreal ranibizumab as an adjunct to laser therapy for the treatment of macular edema secondary to branch retinal vein occlusion (BRVO). Materials and Methods: Thirty eyes of 30 patients of BRVO of at least 6 weeks duration were randomized into three groups: Group 1 received grid laser treatment alone, Group 2 received a single dose of intravitreal injection of ranibizumab (0.5 mg / 0.05 ml) followed by grid laser treatment on 7th day following injection, while Group 3 received three loading doses of intravitreal ranibizumab at monthly interval (i.e. 0, 1, & 2 months) + standard laser treatment 7 days after the 1st injection. Outcome measure noted at 6 months follow-up were the improvement in best-corrected visual acuity (BCVA) and central macular thickness (CMT). Results: At 6 months follow-up, there was an average gain of 12 letters (P=0.05), 17.5 letters (P=0.05) and 19 letters (P=0.05) in groups 1, 2, and 3, respectively, with the decrease in CMT being 208.7 μm (P=0.05), 312.9 μm (P= 0.05) and 326.8 μm (P=0.05), respectively, in these groups. Gain in BCVA of more than 3 lines was noted in 1/10 patients in Group 1(10%) as compared to 3/10 (30%) and 4/10 (40%) patients in groups 2 and 3, respectively. Conclusion: The gain in BCVA and reduction in CMT were better with combination therapy (single- and triple- dose regimen) compared to grid laser alone. Single dose of intravitreal ranibizumab with grid laser seems to be an effective therapy.

Multifocal electroretinogram in normal emmetropic subjects: Correlation with optical coherence tomography.

Aim of the Study: To establish the normative database for multifocal electroretinogram (mfERG) parameters in a normal emmetropic population. To correlate the data so obtained with the central macular thickness obtained using the optical coherence tomography (OCT) scan. Materials and Methods: mfERG data were obtained from 222 eyes of 111 emmetropic subjects. The amplitude (nv/deg2) and implicit times (ms) of the first-order kernel mfERG responses (N1, P1, and N2 waves) were obtained and grouped into five rings (Ring 1: Central 2°, Ring 2: 2–5°, Ring 3: 5–10°, Ring 4: 10–15°, Ring 5: >15°). The central macular thickness (CMT) was obtained using the macular thickness scan protocol of the OCT. Results: The mfERG data obtained were used to create a normative database. The amplitudes of the mfERG waves were maximum in the fovea and progressively decreased with increasing eccentricity (P = 0.0001). The latencies of the P1 and N2 waves were longest in the central ring and progressively shortened with eccentricity (P = 0.0001). No statistically significant correlations were observed between central ring 1 parameters and the CMT. Conclusion: This study establishes normative database for mfERG parameters in an emmetropic population. No statistically significant correlation was noted between CMT and mfERG parameters.

Prevailing clinical practices regarding screening for retinopathy of prematurity among pediatricians in India: A pilot survey.

Aims: To evaluate the prevailing practices for proper screening and referral scheme among Indian pediatricians for retinopathy of prematurity (ROP). Materials and Methods: Pediatricians registered with Indian Academy of Pediatrics from six states of India were selected randomly and were telephonically interviewed in accordance with a preformed questionnaire which comprised of questions regarding demographic factors, number of premature children seen per month, awareness and referral scheme to ophthalmologist; responses thus obtained were analyzed. Results: Hundred percent knowledge about ROP and need for screening in premature babies was observed among the respondents. However, only 135 (58%) pediatricians always referred for ROP screening, 19 (8%) referred only sometimes and 80 (34%) did not refer at all. Consistent referral protocols taking into account all plausible risk factors for ROP were followed by only 25% of those who always referred. Major deterrent in ROP screening was perceived as non-availability of trained ophthalmologists. Conclusions: Only 14.5% of total pediatricians contacted were following international recommendations for ROP referral. Screening for ROP remains dismal as observed in this pilot survey as a consequence of non-availability of trained ophthalmologists as well as inconsistent screening guidelines.

Profile of asymmetrical retinopathy of prematurity in twins.

Background: In twin births, both babies have the same gestational age and pre-natal conditions. However, twins may develop a varied retinopathy of prematurity (ROP) course depending on birth weight and other systemic factors. Objective: To study the profile of asymmetric ROP in twins Design: Retrospective study Setting: Tertiary ROP referral eye hospital. Materials and Methods: The profile of 56 pairs of twins with ROP were studied and analyzed for differences in zone or need for treatment, while studying possible causes for the varied outcome. Results: In 45 pairs of twins (80%) the disease progressed identically in both eyes, while in 11 pairs (20%) the ROP showed differences in zone or need for treatment. Four of these pairs were discordant. In 3 of these 4 pairs, the heavier birth weight twin had a more severe ROP course. Conclusions: Twins can present with asymmetric ROP course, and it is therefore essential to examine both twins as per screening protocols.

The economic implications of the use of anti-vascular endothelial growth factor drugs in age-related macular degeneration.

Age-related macular degeneration (ARMD) is the most common cause for visual impairment in the elderly in western countries. Recently several anti-vascular endothelial growth factor (VEGF) drugs like pegaptanib sodium (Macugen), ranibizumab (Lucentis) and bevacizumab (Avastin) are available for use in the management of wet ARMD. A major limitation of these drugs is that they require multiple intravitreal injections, every 4 to 6 weeks interval for a period of 2 years. Moreover, most of these drugs are too expensive for the general masses to afford in developing nations. Avastin, though used "off-label", offers a comparable result at affordable cost, however, long term results are awaited. The drug industry should review the entire pricing policy of these drugs in developing countries like India, and develop affordable alternative compounds. The article reviews the economic burden and affordability issues of these Anti-VEGF drugs in ARMD.

Iris intraocular foreign bodies: safe and successful removal through limbus.

Metallic iris intra ocular foreign body (IOFBs) with minimal ocular damage pose an interventional challenge. We report safe removal of metallic intraocular foreign bodies embedded on the iris, in three cases by use of intraocular magnets. Two eyes had a clear lens with best corrected visual acuity (BCVA) of 20/20, while the third eye had a BCVA of 20/200 with siderotic cataract. Ultrasound biomicroscopy confirmed the superficial impaction of IOFB into the iris. Foreign bodies were successfully removed via the limbal route with a 20 g intravitreal magnet atraumatically in all 3 cases with preservation of their pre-operative BCVA. Case series highlights the usefulness and safety of intraocular magnet for removal of metallic iris foreign bodies in selected cases. Prior ultrasound biomicroscopy to know the actual depth of penetration of IOFB into the iris and preoperative confirmation of magnetic property of IOFB are essential.

Retinopathy of prematurity.

Retinopathy of prematurity (ROP) is a vasoproliferative disorder of the retina that occurs in premature and low birth weight babies. Stages of ROP are 1, 2, 3, 4A, 4B and 5. There are three zones I, II and III. Screening is essential to detect ROP. Whom, when and how to screen ROP has been narrated in a nutshell. Once threshold ROP is detected, it is essential to treat within 72 hours. Retinal ablation of the avascular retina is done using laser photocoagulation or cryotherapy. Rush disease is primarily a zone I ROP with extraretinal proliferation. It requires aggressive laser treatment with larger number of high intensity closely applied spots to stop the progression. Surgical management is advocated in stages IVA and IVB ROP by scleral buckling. Stage V requires complex vitreoretinal surgery. It is important to promote awareness about the disease and to ensure timely management to prevent blindness.

Retinopathy of prematurity--screening and management.

Retinopathy of prematurty (ROP) is a relentless disease of the retina in premature children that in advanced cases leads to blindness. A good screening programme ensures early detection and timely intervention. Surgical results in advanced stages of ROP are very poor. Creating awareness, training of specialists end development of viable ROP centres is an urgent need. New research insights have shown promise to prevent, detect and treat ROP.