The use of handheld spectral domain optical coherence tomography in pediatric ophthalmology practice: Our experience of 975 infants and children.

Purpose: Optical coherence tomography (OCT) is an important imaging tool assessing retinal architecture. In this article, we report a single centers experience of using handheld spectral domain (SD)‑OCT in a pediatric population using the Envisu 2300 (Bioptigen Inc., Research Triangle Park, NC, USA). Methods: We studied SD‑OCT images from 975 patients imaged from January 2011 to December 2014. The variety of cases that underwent an SD‑OCT was analyzed. Cases examples from different case scenarios were selected to showcase unique examples of many diseases. Results: Three hundred and sixty‑eight infants (37.7%) were imaged for retinopathy of prematurity, 362 children (37.1%) underwent the test for evaluation of suboptimal vision or an unexplained vision loss, 126 children (12.9%) for evaluation of nystagmus or night blindness, 54 children (5.5%) for an intraocular tumor or a mass lesion such as retinoblastoma, and 65 children (6.7%) for other diseases of the pediatric retina. The unique findings in the retinal morphology seen with some of these diseases are discussed. Conclusion: The handheld SD‑OCT is useful in the evaluation of the pediatric retinal diseases. The test is useful in the assessment of vision development in premature children, evaluation of unexplained vision loss and amblyopia, nystagmus and night blindness, and intraocular tumors (including retinoblastoma).

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.

Microscope‑integrated optical coherence tomography: A new surgical tool in vitreoretinal surgery.

Optical coherence tomography (OCT) has revolutionized imaging of ocular structures and various disease conditions. Though it has been used in the clinic for some decades, the OCT has only recently found its way into the operating theater. Early attempts at intraoperative OCT, hand‑held and microscope mounted, have already improved our understanding of the surgical pathology and the role it might play in surgical decision‑making. The microscope‑integrated OCT now allows seamless, high‑resolution, real‑time imaging of surgical maneuvers from the incision to wound closure. Visualization of instruments and intraoperative tissue manipulation are possible with this in vivo modality and, therefore, help improve the outcome of surgery. In this article, we describe the advantages it offers during various vitreoretinal procedures.

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.

Comparison of Tele Screening for Retinopathy of Prematurity Screening and Impact of Neonatal Team Support in Government and Private Centers in Rural Bijapur District of Southern India

Purpose: To compare the incidence of retinopathy of prematurity (ROP) with neonatal support provided during tele-ROP screening between government and private hospitals in rural Bijapur district of Karnataka. Methods: One government and four private hospitals under the ROP screening program between July 2011 and July 2012 were included. All infants born <2000 g at birth were imaged on a weekly basis. Centers were classified as “supportive” or “non-supportive” based on the support extended to the visiting team. Yield of enrollment and disease burden were compared between the centers. Results: Of the 145 infants analyzed, the mean incidence of any stage and treated ROP in the government center was 27.3% and 0% versus 36.6% and 9.7% in the private units, respectively. The proportion of infants enrolled in the government hospital was 40.7% versus 88.9% (mean) in the private hospitals. In the two “supportive” hospitals, the enrollment was 100% and 159.3% respectively, whereas it was 38.7% and 58.7% respectively in “non-supportive” units. Conclusions: The incidence of ROP in rural Bijapur is comparable to urban centers in India. Good pediatric and nursing support enhances infant enrollment into an ROP screening program. Private hospitals may have higher treatable ROP because of the sicker infants they admit. The report emphasizes the need to strengthen ROP screening programs in rural India.

Management of recurrent postoperative fungal endophthalmitis.

Aim: To report the management of recurrent postoperative fungal endophthalmitis  (POFE) after failed pars plana vitrectomy  (PPV) and antifungal therapy. Settings and Design: Tertiary Care Referral Centre in North India. Retrospective, single institution, interventional case‑series. Materials and Methods: Six patients with microbiologically proven recurrent post‑operative fungal endophthalmitis refractory to conventional management were included. The final recurrence was managed with intraocular lens  (IOL) explantation and re‑PPV. Main outcome measures included preserved globe anatomy, visual acuity and retinal status. ‘Anatomical success’ was defined as preserved anatomy of the globe, and absence of signs of inflammation. 'Functional success' was defined as an attached retina and a best corrected visual acuity of better than 20/400. Results: Of the six cases of POFE, five were culture positive  [Aspergillus flavus  (1), Aspergillus fumigatus  (2), Candida albicans  (1) and Candida glabrata  (1)] and one was smear positive for yeast. All recurred  (mean recurrences, 4) despite a mean of 2.17 PPVs and intravitreal amphotericin B. No recurrences were observed after IOL explantation with re  –   PPV  (median follow‑up, 37  months). Pre‑study defined criteria for successful ‘anatomical’ and ‘functional’ outcomes were achieved in 83.3% and 50% respectively. Conclusion: This report highlights the effective role of combined IOL explantation with PPV in managing recurrent POFE.

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.

Retinopathy of prematurity in Asian Indian babies weighing greater than 1250 grams at birth: ten year data from a tertiary care center in a developing country.

BACKGROUND: Retinopathy of prematurity (ROP) is an important cause of childhood blindness in developing countries. AIM: To report the spectrum of ROP and associated risk factors in babies weighing > 1250 g at birth in a developing country. SETTING AND DESIGN: Institutional, retrospective, non-randomized, observational clinical case series. MATERIALS AND METHODS : Retrospective analysis (10 years) of 275 eyes (138 babies) with ROP. STATISTICAL ANALYSIS: Qualitative data with the Chi-square test. Quantitative data using the unpaired t test or the ANOVA and further tested using multivariate logistic regression. RESULTS: The mean birth weight was 1533.9 g (range 1251 to 2750 g) and the mean period of gestation was 30.9 weeks (range 26 to 35). One hundred and twenty-four of 275 eyes (45.1%) had threshold or worse ROP. Risk factors for threshold or worse disease were, 'outborn babies' ( P P = 0.007) and exchange transfusion ( P = 0.003). The sensitivity of the American and British screening guidelines to pick up threshold or worse ROP in our study group was 82.4% and 77.4% respectively. CONCLUSIONS : Severe ROP is often encountered in babies weighing greater than 1250 g at birth in developing countries. Western screening guidelines may require modifications before application in developing countries.