Scleral tunnel phacoemulsification: Approach for eyes with severe microcornea.

Cataract surgery in eyes with microcornea is associated with frequent complications such as corneal edema, posterior capsular rent, and risk of unplanned aphakia. We describe an improved surgical technique for the creation of surgical incisions during phacoemulsification in eyes with cataract associated with microcornea. A retrospective analysis of eight patients (8 eyes) operated at our center was undertaken. The mean age of the patients was 29.5 ± 10.9 years. All eyes were operated using the scleral pocket incision for phacoemulsification. This scleral pocket incision was tangential to the limbus and created approximately 2.5 mm behind limbus through which phacoemulsification probe was inserted. Because of the posterior placement of incision, the anterior chamber crowding was minimized. There was no incidence of port‑site peripheral corneal edema. Fifty percent eyes developed transient central corneal edema, the intraocular lens in bag was implanted in 5/8 eyes, and none developed Descemet’s membrane detachment. Mean best‑corrected visual acuity improved from 1.85 ± 0.38 logarithm of minimum angle of resolution (LogMAR) to 1.26 ± 0.70 LogMAR postoperatively (P = 0.01; paired t‑test). Posterior incision placement during phacoemulsification in microcornea helps achieve favorable postoperative outcomes in contrast to outcomes using clear corneal approach described in literature.

A Pilot, Randomized Sham Control Trial of Autologous Bone Marrow Derived Mononuclear Cells in Acute Ischemic Central Retinal Vein Occlusion.

In this pilot, sham controlled randomized control trial (RCT) in patients with ischemic central retinal vein occlusion (CRVO), we studied the safety and efficacy of intravitreal injection of autologous bone marrow derived mononuclear cells and found that both patients who received stem cell injections did not develop anterior segment neovascularization at 1 year follow up. Except for some sterile inflammatory reaction in the initial follow up, no long term injection related serious adverse events (SAEs) were observed. Based on our observations we recommend a larger, multicentric study to further establish the safety and efficacy of this treatment in patients with ischemic CRVO. Purpose: To study the safety and efficacy of autologous bone marrow derived mononuclear cells injected intravitreally in patients with ischemic CRVO. Study Design: Randomized sham controlled trial. Methods: 4 cases with ischemic CRVO were recruited into the study. 2 cases were randomized into intervention group and 2 into control group. Baseline investigations included best corrected visual acuity (BCVA), intra ocular pressure (IOP), fundus fluorescein angiography (FFA), gonioscopy and optical coherence tomography (OCT). Patients in the intervention group received intravitreal injection of autologous bone marrow derived mononuclear cells (MNCs) and those in control group received sham injection. Patients were followed up over a 12-month period. Main Outcome Measures: Development of anterior segment neovascularization. Results: Both patients in the intervention group did not develop anterior segment neovascularization over a follow up period of 12 months. 1 patient in control group developed neovascularization of iris and elevated intra ocular pressure over a follow up period of 6 weeks and required trabeculectomy for control of IOP. The other patient in control group was lost follow up after 2 weeks. Conclusions: Our initial observations suggest that intravitreal injection of mononuclear cells may reduce the risk of developing anterior segment neovascularization in patients with ischemic central retinal vein occlusion. A larger, multicentric study would be valuable to gain further evidence to our preliminary observations.

Minimal gauge vitrectomy for optic disc pit maculopathy: Our results.

The purpose of the study was to describe the surgical technique and clinical outcomes of pars plana vitrectomy without laser or gas tamponade in cases with optic disc pit maculopathy at our centre. Six eyes of six consecutive patients presenting with unilateral optic disc pit maculopathy were enrolled. Preoperative optical coherence tomography (OCT) was performed to determine the presence and extent of schisis and macular detachment. All eyes underwent 23-gauge pars plana vitrectomy with induction of posterior vitreous detachment (PVD) and internal limiting membrane (ILM) peeling and eyes were closed under fluid. Patients were followed up for at least 12 months post-surgery. Median age of patients was 22.5 years. Five of six eyes had neurosensory detachment (NSD) at the presentation; whereas, inner layer schisis was present in all patients. None of the patients had any evidence of vitreomacular or vitreopapillary adhesion or PVD either clinically or on OCT. Inner and outer retinal schisis resolved in all eyes after follow-up of at least 6 months. Resolution of subretinal fluid in eyes with NSD was seen in 4 of 5 eyes. There was a significant visual acuity improvement from mean preoperative visual acuity of 0.79 logarithm of the minimum angle of resolution (logMAR) units to 0.36 logMAR units at 12 months (P = 0.001). Thus, vitrectomy with ILM peeling and PVD induction alone could achieve good functional outcomes in cases with optic disc pit maculopathy.

Changes in stereoacuity following implantable Collamer lens implantation in patients with myopia.

The study evaluated the impact of implantable Collamer lens (ICL) implantation on stereoacuity in myopes in a retrospective case series. Ninety‑five eyes of 48 patients were recruited. Distance and near stereoacuity were measured using distance Randot stereotest and TNO test, respectively, before surgery and at 4 weeks postoperatively. Mean age of the patients was 23.67 ± 3.7 years. Mean uncorrected distance visual acuity (UDVA) was 1.28 ± 0.37 logarithm of the minimum angle of resolution (logMAR) (median: 1.3; range: 0.3–1.8), and median best‑corrected distance visual acuity (BDVA) was 0.18 logMAR (range: 0–0.6). There was a significant improvement in both UDVA and BDVA postsurgery (P < 0.001; Wilcoxon signed rank test). The overall improvement in stereopsis was observed in 15/48 (31.25%) and 13/48 (27.10%) subjects for near and distance, respectively, with no significant difference between the two (P = 0.82; Fisher’s exact test). Among stereoblind individuals, the odd’s ratio for near stereoacuity to improve in comparison to distance stereoacuity was 8.85 (95% confidence interval: 1.68–46.70; P = 0.01). ICL implantation for refractive correction aided stereoacuity improvement in myopes more so for near.

Changing pattern of utilization of human donor cornea in India.

Purpose: To review the changing pattern of donor, corneal utilization in an eye bank at a Tertiary Care Center in Northern India by analyzing the trend in the years 2003, 2008, and 2011. Methods: A retrospective review of eye bank records for 3 years (2003, 2008, and 2011) was performed at the National Eye Bank. Details including a clinical grade of donor cornea, indication of corneal transplantation (therapeutic or optical), type of procedure (penetrating or lamellar keratoplasty [LK]), and clinical diagnosis of the graft recipients were recorded. Primary outcome measure was to observe any preference toward LK, judicious usage of donor corneal tissue, and impact of lamellar corneal transplant in the usage of donor corneas. Secondary outcomes included overall utilization rate and change in trend of indication for keratoplasty. Results: A total of 673, 745, and 864 corneas were retrieved in the years 2003, 2008, and 2011, respectively. The percentage of donor corneal utilization increased significantly over time with the rate being 65.08%, 70.06%, and 68.29%, respectively, in the years 2003, 2008, and 2011 (P = 0.014); however, this change was reflected only in the usage of nonoptical grade corneas and not for the optical grade corneas. There was an overall increase in lamellar corneal procedures for any clinical grade of cornea (P = 0.0019); number of Descemet’s stripping automated endothelial keratoplasty (DSAEK) procedures increased significantly (P < 0.001), particularly for pseudophakic corneal edema (PCE) (P = 0.0085) and failed graft (P = 0.002). Significant increase in the utilization of nonoptical grade corneas was observed over the years (P = 0.005), though the utilization did not increase significantly for optical purposes viz., LK (P = 0.08). Conclusions: Utilization rate of donor corneas increased over the years, primarily due to increase in usage of nonoptical grade corneas for therapeutic purposes. There was a procedural shift toward DSAEK for PCE and failed graft. However, an increase in usage of nonoptical grade corneas for LK, a single donor corneal tissue for two recipients, and retrieval or utilization of optical grade cornea was not observed.

Pulse cyclophosphamide therapy in the management of patients with macular serpiginous choroidopathy.

Purpose: To evaluate safety and efficacy of intravenous pulse cyclophosphamide (CyP) in acute macular serpiginous choroiditis (SC). Methods: Patients with acute macular SC with lesions threatening and/ or involving fovea were enrolled. All patients received CyP (1 g/m2) for 3 days followed by high‑dose oral steroids (1.5 mg/kg) tapered over 6 months and monitored for visual acuity, response to treatment and systemic side effects. Results: Eight patients (seven unilateral and one bilateral) with median age of 27 years (range: 13-40 years) were recruited. Mean visual acuity at presentation was 0.71 ± 0.35 logarithm of the minimum angle of resolution while postpulse visual acuity was 0.40 ± 0.32. Final mean visual acuity at 1‑year was 0.31 ± 0.23 (P ≤ 0.05). Three eyes had recurrence and 3 patients developed transient hair loss with no other adverse effect. Conclusion: Intravenous CyP provides rapid resolution of lesion activity and thereby helps in maintaining good functional acuity.

Evaluation of predictors for anatomical success in macular hole surgery in Indian population.

Purpose: The aim was to evaluate outcomes and predictors for anatomical success in macular hole (MH) surgery. Materials and Methods: This was a prospective cohort study of patients operated for idiopathic MH with stages II, III or IV. Patients underwent pars plana vitrectomy with internal limiting membrane (ILM) peeling, internal gas tamponade, and postoperative face down positioning. The primary outcome measure was anatomical closure of MH, while secondary outcome measure was postoperative external limiting membrane (ELM) continuity. Effect of MH size, duration of MH, size of ILM peel, type of gas tamponade (SF6 vs. C3F8) and macular hole index (MHI) on anatomical MH closure was also evaluated. Results: Of the 62 eyes operated, anatomical closure of MH was achieved in 55 eyes (88.7%). The median duration of follow‑up was 8 months (range: 6–15 months). Mean BVCA improved from 0.94 ± 0.26 at baseline to 0.40 ± 0.23 logMAR at last follow‑up (P = 0.01). There was a statistically significant association between size of ILM peel and anatomical closure of MH (P = 0.04). Duration of symptoms, size of MH, type of gas tamponade, MHI had no effect on anatomical closure (P = 0.22, 0.28, 0.40 respectively, Chi‑square test). Postoperative continuity of the ELM was significantly associated with a shorter symptom duration (<6 months) before surgery. Conclusion: Acceptable anatomical closure could be attained with the defined technique. Size of ILM peel is a new predictor of anatomical success while symptom duration affects postoperative ELM continuity.

Endoilluminator-assisted scleral buckling: Our results.

Aims: The aim was to evaluate the long-term surgical outcomes of endoillumination assisted scleral buckling (EASB) in primary rhegmatogenous retinal detachment (RRD). Methods: Twenty-fi ve eyes of 25 patients with primary RRD and proliferative vitreoretinopathy ≤C2 where any preoperative break could not be localised, were included. All patients underwent 25 gauge endoilluminator assisted rhegma localisation. Successful break determination was followed by cryopexy and standard scleral buckling under surgical microscope. Anatomical and functional outcomes were evaluated at the end of 2 years. Results: At least one intraoperative break could be localized in 23 of 25 (92%) eyes. Median age of these patients was 46 years (range: 17-72). Thirteen eyes (56.52%) were phakic, 8 (34.78%) were pseudophakic and 2 (8.6%) were aphakic. Anatomical success (attachment of retina) was achieved in 22 (95.63%) of 23 eyes with EASB. All eyes remained att ached at the end of 2 years. Signifi cant improvement in mean visual acuity (VA) was achieved at the end of follow-up (1.09 ± 0.46 log of the minimum angle of resolution [logMAR]) compared with preoperative VA (1.77 ± 0.28 logMAR) (P < 0.001). Conclusion: EASB can be considered an eff ective alternative to vitreoretinal surgery in simple retinal detachment cases with the added advantage of enhanced microscopic magnifi cation and wide fi eld illumination.

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.

Compliance in retinoblastoma.

Objective. To evaluate compliance to treatment in advanced retinoblastoma. Methods. This is a retrospective descriptive study of patients of retinoblastoma registered at our cancer center from June 2003-February 2007 to study compliance. Results. Sociodemographic data of 177 patients revealed rural:urban ratio of 2:1, median age 36 months (unilateral disease) and 24 months (bilateral disease); median symptom duration 7.2 months. Overall, 84/141 evalued cases took adequate therapy; follow-up could be achieved in 67/141 (47.5%) cases in comparison to 92.4% in Hodgkin’s lymphoma (p=0.001), 62.8% in acute myeloid leukemia (p=0.036) and 72.7% in non Hodgkin’s lymphoma (p=0.001). There was no significant impact of any sociodemographic factors on compliance. Amongst those offered enucleation upfront for intraocular disease, it was accepted in 86/93 (92.5%) eyes. Conclusions. This is one of the largest studies in relation to sociodemographic factors and clinical spectrum, and the only study from Asia evaluating compliance with recommended therapy in retinoblastoma. In order to improve ocular and patient salvage rates in Asian countries, exact causes for poor compliance in retinoblastoma need to be closely examined through a prospective study.