Epidemic retinitis during pregnancy

Purpose: To study the clinical presentation and treatment outcome of epidemic retinitis (ER) during pregnancy. Methods: This is a retrospective, observational chart review of pregnant patients diagnosed with ER from January 2014 to February 2023. Demographic details, month of pregnancy at the onset of ocular symptoms, history of present illness, clinical manifestations, and treatment outcomes were studied. Results: In 9 years, ER was seen in 86 females, of whom 12 (13.9%) were pregnant. Twenty?one eyes of those 12 patients were studied. Most of the patients presented in the sixth month of pregnancy (range: 5–9 months, mean: 6.3 months). Physicians diagnosed viral exanthematous fever in six, typhoid in three, and suspected rickettsia in one patient. Medical termination of pregnancy (MTP) was performed in two patients before presentation. Weil–Felix test was positive in five, Brucella in one, WIDAL in three, and coronavirus disease 2019 (COVID?19) IgG and dengue IgG in one patient each. Oral antibiotics were given in five patients (two post?medical termination of pregnancy [MTP]) for the retinitis. All except four received oral steroids. Mean presenting corrected distant visual acuity (n = 21) was 20/125 (range: 20/20–20/20,000), which improved to (n = 18) 20/30 (range: 20/20–20/240). Macular edema (n = 11) resolved in 33.18 days (range: 20–50 days), and retinitis (n = 13) resolved in 58 days (range: 30–110 days). Ocular and systemic examination of newborn was possible in two and the babies were normal. Conclusion: ER is seen commonly at the beginning of the third trimester. Lack of antibiotics may delay the resolution of retinitis. Ocular health needs to be assessed in larger series to conclude absence of retinal involvement in newborns.

Epidemic retinitis during the COVID-19 pandemic

Purpose: To study the impact of the novel coronavirus disease?2019 (COVID?19) pandemic on incidence, seasonal variation, clinical presentation, and disease outcome of epidemic retinitis (ER) and to compare clinical outcomes with positive and negative COVID?19 serology. Methods: This is a retrospective, observational study conducted at a tertiary eye care hospital from August 2020 to June 2022. A graph of ER cases against the month of presentation was compared with the graph of the COVID?19 pandemic in the same region. Cases presented before COVID?19 vaccination, with positive COVID?19 serology (Group 1) were compared with cases with negative serology (Group 2). Results: One hundred and thirty?two cases of ER were seen. The least number of cases were seen during and immediately after the peak of the pandemic (May 2021–August 2021). COVID?19 serology was positive in 13 (22 eyes)/60 (21.6%) unvaccinated cases. Along with COVID?19, positive serology for other ER etiologies was seen in 5/13 cases (38.4%). All patients received oral doxycycline with/without steroids. Groups 1 and 2 included 22 and 21 eyes of 13 cases each. Macular edema resolved in 43.6 and 32 days in groups 1 and 2, respectively. Retinitis resolved at 1 month in both groups. Corrected distant visual acuity was 20/50 and 20/70 at the presentation, which improved to 20/20 and 20/25 in groups 1 and 2, respectively. Mean and median follow?up was 6 months and 4.5 months, respectively, in both groups. No complications or recurrences were seen. Conclusion: No significant impact of the COVID?19 pandemic on ER was observed

Pole-to-pole involvement of varicella zoster virus reactivation following COVID-19 vaccination

The aim of this study is to report the clinical features, imaging findings including confocal imaging, corneal nerve fiber analysis, and management outcomes in a series of three cases of varicella zoster virus (VZV) reactivation following one dose of coronavirus disease 2019 (COVID-19) vaccination. This was a retrospective and observational study. All the patients who developed uveitis post-vaccination were pooled together. Patients who had VZV reactivation were included. Two cases had polymerase chain reaction positive for VZV from aqueous humor. At the time of presentation, IgG and IgM spike protein antibodies for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) were tested. Out of this pool, three patients with classical features to describe pole-to-pole manifestations were chosen. A 36-year-old lady with post-vaccination sclerokeratouveitis associated with reactivation of herpes zoster ophthalmicus, a 56-year-old lady with post-vaccination acute anterior uveitis associated with herpes zoster ophthalmicus, and a 43-year-old gentleman with post-vaccination acute retinal necrosis were included. We present a possible link between anti-SARS-CoV-2 virus vaccination and varicella zoster reactivation in these patients and also describe the clinical features, imaging findings including confocal imaging, corneal nerve fiber analysis, and management with detailed discussion.

Socioeconomic factors in childhood cataracts – A descriptive study from a tertiary eye care center in India

Purpose: While there are a few studies that show the prevalence of blindness and ocular morbidity in children, studies on socioeconomic factors in childhood cataracts are scarce. We aimed to study the socioeconomic status, education and occupation of the parents, consanguinity, and gender inequality among children presenting with cataracts. Methods: This was a hospital?based, prospective, descriptive study of 68 children with cataracts (aged 0–18 years). In addition to the data on clinical parameters and surgical management, we also collected data on age, gender, age at which the chief complaint was noticed, consanguinity of parents, socioeconomic class, and occupation and education of parents. All statistical analyses were performed using MedCalc statistical software (MedCalc Software 2019, Ostend, Belgium). Results: Sixty?eight children with pediatric cataract, out of which 36 were bilateral, were studied. Thirty children (44%) were in the age group of 1–5 years. Out of the 36 bilateral cataracts, 25 (69.44%) were males and 11 (30.56%) were females. Thirty (44.1%) had a delayed presentation. Also, 31% belonged to middle class and 28% belonged to lower middle class. Moreover, 65% of the mothers had an undergraduate education. Conclusion: There is a gender?based inequality and late presentation of childhood cataracts. To improve early detection, red reflex screening should be mandatorily done. Further studies are required to identify barriers to access of eye care specific to girls, in order to plan interventions to improve uptake of treatment. The lower socioeconomic status of the patients should be taken into account in the management of this disease.

Monitoring Weil–Felix test in epidemic retinitis

Purpose: The objective was to study the positivity of the Weil–Felix test (WFT) in epidemic retinitis (ER) during the course of the disease. Methods: This is a retrospective, observational case series of patients diagnosed with ER and presented to a tertiary eye care hospital in south India. Patients with positive WFT at the presentation, and who underwent a follow?up WFT during or after the resolution of ER were studied from September 2019 to March 2022. Patient’s demographics, timings of clinical presentation and resolution, and investigation details with a special focus on WFT positivity and its duration were noted. Results: Sixteen patients were studied. Patients presented after 5 weeks of the fever (range: 2?12 weeks, median: 4). After 1?2 months, WFT was still positive in eight patients (50%). Only in one patient titers increased after 1 month, while in others, the titers decreased (n = 11) or remained the same (n = 4). Repeated tests in those patients (n = 6) after 3?4 months turned negative. Resolution of ER was seen at 1.35 months (range: 1?3 months) after the presentation. The mean duration for WFT to turn negative was 2 months from the presentation (range: 1?4 months) or 3.2 months of the fever (range: 1.5?6 months). Conclusion: In contrast to the reported physician’s observation of increasing titers of WFT after rickettsial fever, ophthalmologists may observe decreasing WFT titers in ER. The clinical resolution of ER may precede the normalization of WFT. Follow?up WFT titers should be studied in larger series in confirmed cases of rickettsial?ER to validate the affordable and readily available WFT in India

Trends in teleconsultations for uveitis during the COVID-19 lockdown

Purpose: To study the use of teleophthalmology as a tool to manage patients with uveitis and to describe the experience of teleconsultation for uveitis at a tertiary eye care hospital in India during the two waves of the COVID?19 pandemic. Methods: A prospective observational case series of uveitis patients seeking teleconsultations during the first (March 25–May 2020) and second lockdown (April 27 to June 21, 2021) in a tertiary eye care center were analyzed. Results: There were 79 teleconsultations in the first and 89 teleconsultations in the second lockdown. A majority of the patients presented in the age group of 41– 60 years in both the lockdowns. There were both new or primary consultations and follow?up patients (6% vs. 94%) in the first lockdown, and similarly in the second lockdown (8% new vs. 92% follow?up). The majority of patients resided in Bengaluru city (78% in the first and 76% in the second lockdown). After evaluation through video consultation, only 15% required a hospital referral in the first lockdown, whereas in the second lockdown, 21.3% were referred to the hospital. During the second lockdown, 20% presented with COVID?19 infection?related ailments. Conclusion: Based on our preliminary experience using a customized smartphone?based application for teleconsultation, we found it to be an alternative option to provide continuation of ophthalmic care to uveitis patients. Given the current COVID?19 situation, it can help avoid physical visits of uveitis patients to the hospital

Jet stream related iatrogenic retinal breaks during vitreo-retinal surgery

Purpose: To evaluate the causes of jet stream injury (JSI)?related iatrogenic retinal breaks (IRBs) during vitreoretinal surgery (VRS). Methods: The precise surgical environment, which includes the indication and type of surgical procedure, retina status, details of instrumentation and fluidic parameters, and characteristics of the jet responsible for the IRB, was noted from case records. The nature of IRB and its healing and impact on anatomical and visual outcomes were analyzed. Results: Five eyes of five patients with complete documentation of both the JSI and the IRB were included. Two cases were operated for macular hole, and one each for vitreous hemorrhage, retinal detachment, and endophthalmitis. One case had infusion?fluid?related JSI, while four developed it because of injection of surgical adjuncts (drugs, PFCL, and dye). JSI developed in two cases when the vitreous cavity was filled with fluid, while it was air?filled in three cases. In four cases, the fluid migrated into subretinal space, necessitating further maneuvers following which the breaks healed, but were directly responsible for vision loss in two cases. Conclusion: JSI related IRBs are rare but may be directly responsible for vision loss if they impact the macula. The balance between jet stream velocity, its distance from the retinal surface, the intervening media (vitreous cavity), and retinal health play an important role. It can occur because of both infusion as well as injection jets. Precautions must be taken in cases vulnerable to complications with suggested modifications in the surgical technique.

Imaging the Intraoperative Macular Morphology Changes using a Handheld Spectral Domain Optical Coherence Tomography.

Purpose: To study the intraoperative retinal macular morphology during macular surgery using handheld spectral domain optical coherence tomography (SDOCT). Design: Prospective, observational case series. Methods: A handheld SDOCT device was used to characterize the preoperative and intraoperative OCT images in 10 eyes of 10 patients undergoing vitrectomy for macular hole (MH) and epiretinal membrane (ERM). I intraoperative imaging was repeated after removal of the internal limiting membrane or the ERM and the images were analyzed. Results: Intraoperative SDOCT images from patients undergoing surgery (5 for full thickness MH including 2 previously failed surgeries and 5 for ERM were reviewed and quantitatively analyzed. In the 5 eyes undergoing surgery for MH, the minimum diameter of the hole showed a significant decrease (P = 0.031; the mean reduction 15.18%; range 6.14- 34.88%). Basal diameter increased in 2 eyes (mean change 9.96%), reduced in 2 (mean reduction 3.28%) while it remained unchanged in 1 case. The MH height decreased in 2 eyes (mean reduction 5.43%) and increased in 3 (mean change 20.04%). Intraoperative imaging in 5 eyes undergoing surgery for ERM revealed immediate decrease in retinal thickness in 3 eyes (mean change 5.00%), and increase in 2 eyes (mean change 17.76%). Comparison of the preincisional and intraoperative handheld SDOCT images demonstrated distinct changes in retinal macular morphology. Conclusion: The intraoperative use of handheld SDOCT provides a novel method for visualizing and quantifying changes in retinal anatomy during macular surgery. Further study is warranted to determine whether intraoperative macular morphological changes could affect and prognosticate MH closure.

Effect of fluidics on corneal endothelial cell density, central corneal thickness, and central macular thickness after phacoemulsification with torsional ultrasound.

Aim: To study the relative effects of high and low fluidic parameters on endothelial cell density (ECD), central corneal thickness (CCT), and central macular thickness (CMT) after phacoemulsification with torsional ultrasound. Settings and Design: Prospective, randomized clinical trial based on a tertiary eye hospital. Subjects and Methods: The study included 65 patients in each group. Patients were randomized to either the high or the low flow group using a computerized random number table. The study was patient and examiner masked. All patients underwent phacoemulsification with torsional ultrasound. Visual acuity, ECD, CCT, and CMT were measured for all patients preoperatively at 2 weeks and 6 weeks postoperatively. Statistical Analysis Used: The Shapiro–Wilks test was used to assess the normality of the data. Mann–Whitney U‑test with the P value set at 0.05 was used to compare the two groups. Results: Cumulative dissipated energy was significantly higher in the low flow group (16.44 ± 9.07 vs. 11.74 ± 6.68; P = 0.002). No statistically significant difference was noted between the two groups in the ECD, CCT, CMT, or corrected distance visual acuity at the end of 6 weeks. Conclusions: No significant difference was noted in the postoperative outcome between high and low flow groups. Parameters can be modified to suit the surgeon’s preference, as both high and low flow parameters were found to have comparable postoperative outcomes.

Macular edema in Asian Indian premature infants with retinopathy of prematurity: Impact on visual acuity and refractive status after 1‑year.

Purpose: To report the impact of transient, self‑resolving, untreated “macular edema” detected on spectral domain optical coherence tomography in Asian Indian premature infants with retinopathy of prematurity (ROP) on visual acuity (VA) and refraction at 1‑year of corrected age. Materials and Methods: Visual acuity and refraction of 11 infants with bilateral macular edema (Group A) was compared with gestational age‑matched 16 infants with ROP without edema (Group B) and 17 preterms infants without ROP and without edema (Group C) at 3, 6, 9 and 12 months of corrected age using Teller Acuity Cards and cycloplegic retinoscopy. Sub‑group analysis of the previously described pattern A and B macular edema was performed. Results: Visual acuity was lower in infants with macular edema compared with the other two control groups throughout the study period, but statistically significant only at 3 months. Visual improvement in these infants was highest between the 3rd and 6th month and plateaued by the end of the 1st year with acuity comparable to the other two groups. The edema cohort was more hyperopic compared to the other two groups between 3 and 12 months of age. Pattern A edema had worse VA compared to pattern B, although not statistically significant. Conclusion: Macular edema, although transient, caused reduced VA as early as 3 months of corrected age in Asian Indian premature infants weighing <2000 g at birth. The higher hyperopia in these infants is possibly due to visual disturbances caused at a critical time of fovealization. We hypothesize a recovery and feedback mechanism based on the principles of active emmetropization to explain our findings.

Look what else we found - clinically significant abnormalities detected during routine ROP screening.

Purpose: The purpose of this study was to report the spectrum of anterior and posterior segment diagnoses in Asian Indian premature infants detected serendipitously during routine retinopathy of prematurity (ROP) screening during a 1 year period. Methods: A retrospective review of all Retcam (Clarity MSI, USA) imaging sessions during the year 2011 performed on infants born either <2001 g at birth and/ or <34.1 weeks of gestation recruited for ROP screening was performed. All infants had a minimum of seven images at each session, which included the dilated anterior segment, disc, and macula center and the four quadrants using the 130° lens. Results: Of the 8954 imaging sessions of 1450 new infants recruited in 2011, there were 111 (7.66%) with a diagnosis other than ROP. Anterior segment diagnoses seen in 31 (27.9%) cases included clinically significant cataract, lid abnormalities, anophthalmos, microphthalmos, and corneal diseases. Posterior segment diagnoses in 80 (72.1%) cases included retinal hemorrhages, cherry red spots, and neonatal uveitis of infective etiologies. Of the 111 cases, 15 (13.5%) underwent surgical procedures and 24 (21.6%) underwent medical procedures; importantly, two eyes with retinoblastoma were detected which were managed timely. Conclusions: This study emphasizes the importance of ocular digital imaging in premature infants. Visually significant, potentially life‑threatening, and even treatable conditions were detected serendipitously during routine ROP screening that may be missed or detected late otherwise. This pilot data may be used to advocate for a possible universal infant eye screening program using digital imaging.

Repeatability and Agreement of Four Biometers for Measuring Various Anterior Segment Parameters.

Purpose: To assess the repeatability and agreement of a new swept source optical coherence tomography (SS-OCT) biometer (IOL Master® 700, Carl Zeiss Meditec), an optical low coherence reflectometer (Lenstar LS 900®, Haag-Streit AG, Koeniz, Switzerland), a dual scheimpflug ray tracing biometer (Galilei G6®, Ziemer, Switzerland) and a partial coherence interferometer, AL scan® (Nidek Co. Ltd., Japan) to measure the keratometry (K), astigmatism (AST), axial length (AL), anterior chamber depth (ACD), central corneal thickness (CCT) and white-to-white (WTW) in cataractous eyes in a Cross-sectional study. Methods: 50 eyes of 50 consecutive patients scheduled for cataract surgery were included. Three consecutive scans were performed using the 4 biometers by a single operator. Within-subject standard deviation (Sw), test-retest repeatability and coefficient of variation for assessing repeatability were assessed. Bland-Altman plots for the agreement between the mean measurements of each machine were examined. Results: The mean age of patients was 60.2 ± 10.6 years. Dropouts for AL measurement were significantly higher in AL scan® and Galilei G6® compared to IOL Master® 700. There was good agreement between IOL Master® 700 and Lenstar LS 900® for AL and keratometry (P < 0.5). High variability was seen between the 4 machines for AST and WTW. Conclusion: The new SS-OCT biometer showed valid measurements, good repeatability and good agreement with the optical low coherence reflectometry biometer. The new long range SS-OCT biometer was better than the other three devices in acquiring AL measurements in denser cataracts due to better penetration.

Systematic Transition to Phaco-Chop.

Phaco surgeons initially train in a four quadrant divide and conquer technique. Subsequently, several surgeons transition to chopping techniques due to the perceived advantages of phaco-chop that include lower ultrasound energy and lesser zonular stress. Stop and chop has conventionally been the technique of choice for making this transition. However, the surgeon has to execute a full-fledged chop after the creation of two hemi-segments by the classical trenching and cracking skills already acquired in divide and conquer techniques. Here we describe a set of intermediate steps during four quadrant divide and conquer that breaks down the skills required for chopping and enables the surgeon to sequentially imbibe the required skill sets to make the transition to chop safer and smoother.

Sutureless femtosecond anterior lamellar keratoplasty: A 1-year follow-up study.

Aim: To study the safety and efficacy of sutureless femtosecond anterior lamellar keratoplasty (FALK) in patients with corneal stromal opacities. Materials and Methods: Eleven eyes of 11 consecutive patients with corneal stromal opacities involving <250 μ due to various pathologies were included in the study. Preoperatively, all underwent anterior segment imaging with spectral domain optical coherence tomography (SD‑OCT) (Bioptigen Inc., Durham, North Carolina, USA) to measure the depth of the stromal opacity. All patients underwent FALK, and bandage contact lens was placed for a period of 2 weeks. Postoperatively, uncorrected visual acuity, best corrected visual acuity (BCVA), and SD‑OCT evaluation were performed. Results: All patients showed significant improvement in BCVA. The mean postoperative BCVA (in decimals) improved from 0.11 ± 0.06 preoperatively to 0.59 ± 0.08. There were no intraoperative or significant postoperative complications that were noticed. Conclusion: FALK is a safe and effective alternative to deep anterior lamellar keratoplasty or penetrating keratoplasty in the treatment of anterior stromal opacities.

The KIDROP model of combining strategies for providing retinopathy of prematurity screening in underserved areas in India using wide-field imaging, tele-medicine, non-physician graders and smart phone reporting.

Aim: To report the Karnataka Internet Assisted Diagnosis of Retinopathy of Prematurity (KIDROP) program for retinopathy of prematurity (ROP) screening in underserved rural areas using an indigenously developed tele-ROP model. Materials and Methods: KIDROP currently provides ROP screening and treatment services in three zones and 81 neonatal units in Karnataka, India. Technicians were trained to use a portable Retcam Shutt le (Clarity, USA) and validated against ROP experts performing indirect ophthalmoscopy. An indigenously developed 20-point score (STAT score) graded their ability (Level I to III) to image and decide follow-up based on a three-way algorithm. Images were also uploaded on a secure tele-ROP platform and accessed and reported by remote experts on their smart phones (iPhone, Apple). Results: 6339 imaging sessions of 1601 infants were analyzed. A level III technician agreed with 94.3% of all expert decisions. The sensitivity, specifi city, positive predictive value and negative predictive value for treatment grade disease were 95.7, 93.2, 81.5 and 98.6 respectively. The kappa for technicians to decide discharge of babies was 0.94 (P < 0.001). Only 0.4% of infants needing treatment were missed.The kappa agreement of experts reporting on the iPhone vs Retcam for treatment requiring and mild ROP were 0.96 and 0.94 (P < 0.001) respectively. Conclusions: This is the fi rst and largest real-world program to employ accredited non-physicians to grade and report ROP. The KIDROP tele-ROP model demonstrates that ROP services can be delivered to the outreach despite lack of specialists and may be useful in other middle-income countries with similar demographics.

Toric implantable collamer lens for keratoconus.

Keratoconus is a progressive non-inflammatory thinning of the cornea that induces myopia and irregular astigmatism and decreases the quality of vision due to monocular diplopia, halos, or ghost images. Keratoconus patients unfit for corneal procedures and intolerant to refractive correction by spectacles or contact lenses have been implanted toric posterior chamber phakic intraocular lenses (PC pIOLs) alone or combined with other surgical procedures to correct the refractive errors associated with keratoconus as an off label procedure with special informed consent from the patients. Several reports attest to the safety and efficacy of the procedure, though the associated corneal higher order aberrations would have an impact on the final visual quality.

Endothelial cell study in a case of Werner's syndrome undergoing phacoemulsification and Yettrium-Aluminum-Garnet laser capsulotomy.

Werner's syndrome (WS) is a rare autosomal recessive disorder with multisystem manifestations of premature aging from the second decade of life. Cataract is one of the features of WS. Cataract surgery is complicated with postoperative wound dehiscence and bullous keratopathy when the surgery is done by intracapsular or conventional extracapsular method. We report the short-term result of phacoemulsification and Neodymimum Yettrium-Aluminum-Garnet laser (Nd YAG) capsulotomy in a case of WS with bilateral cataracts. Postoperatively and post capsulotomy, there was no change in the endothelial cell morphology. There was an 8.6% decrease in endothelial cell count at the end of 15 months postoperatively and 11 months post YAG capsulotomy. This decrease is within the acceptable range of cell loss after phacoemulsification and YAG capsulotomy. To the best of our knowledge, this is the first reported case of YAG laser capsulotomy in WS.

Safety and efficacy of Intacs in Indian eyes with keratoconus: an initial report.

CONTEXT: In contact lens-intolerant keratoconus patients, intrastromal placement of Intacs is becoming a promising new modality of treatment. AIMS: To study the safety and efficacy of implantation of microthin corneal inserts (Intacs) in Asian-Indian keratoconus patients. SETTINGS AND DESIGN: Retrospective interventional case series, in the cornea and refractive surgery service, at a tertiary care eye hospital in South India, between May 2006 and July 2007. MATERIALS AND METHODS: Intacs (Addition Technology, USA) were successfully implanted by mechanically creating tunnels, in 12 eyes of 12 keratoconus patients, who were contact lens-intolerant. The patients (mean age 25.58 years, nine male and three female) had a minimum follow-up of six months. Five patients had severe keratoconus (mean K > 53 D) and nine had central cones. RESULTS: All patients improved or retained visual acuity. The uncorrected visual acuity (UCVA) improved from a mean value of 0.06, (SD +/- 0.08) to 0.19 postoperatively (SD+/- 0.15) ( P = 0.01). The change in mean best corrected visual acuity (BCVA) was from 0.51, (SD +/- 0.24), to 0.69, (SD +/-0.00) ( P = 0.01) postoperatively. The average central keratometry reading was 52.55 D. The change in mean K from 52.84 to 49.16 and 49.15 at one and six months respectively, was statistically significant. We did not have any major intra- or early postoperative complications. Eight of 12 eyes became contact lens-tolerant post-surgery. CONCLUSION: The procedure of Intacs implantation appears to be safe and effective in a small group of Indian population at an intermediate follow-up.