23-gauge vitrectomy with intraocular foreign body removal via the limbus: An alternative approach for select cases.

Purpose: To study the outcome of removal of retained intraocular foreign bodies (RIOFBs) via limbus using 23‑gauge transconjunctival sutureless vitrectomy (TSV). Materials and Methods: In this prospective, non‑comparative interventional case series, fourteen eyes of 14 patients fulfilling the inclusion criteria were enrolled. They underwent 23‑gauge TSV for management of posterior segment RIOFB and reviewed at 1 day, 7 days, 6 weeks, 3, 6 and 12 months. Eyes with penetrating eye injury involving cornea or limbus (corneal injury not so severe to hinder vitrectomy), cataract associated with anterior and/or posterior capsular tear requiring cataract surgery and posterior segment RIOFB with minimal posterior segment involvement were included. Main outcome measures include success in removal of RIOFB without enlarging sclerotomy, ability to preserve capsular support, improvement in visual acuity and complications, if any. Results: All eyes underwent the successful RIOFB removal through limbal port without enlarging scleral ports. None of the eyes required suturing of the sclera, cornea or conjunctiva. Anterior capsular rim could be preserved in all eyes except one. Postoperatively follow up ranged from one year in 8, 6 months in 4 and 3 months in 2 eyes. The mean logMAR visual acuity at 3, 6, and 12 months showed significant improvement. There were no intraoperative complications. Postoperative complications include microscopic hyphema and loose blood in vitreous cavity in one eye. Conclusion: The advantages of 23‑gauge TSV for removal of RIOFB may be passed on to select cases. RIOFB removal through limbal route obviated the need for scleral port enlargement and preserved capsular support for early visual rehabilitation.

Ocular ischemic syndrome: A classical presentation of an uncommon condition.

We report a 47-year-old male who presented with acute monoocular vision loss, and had classical signs of global ocular ischemia in the right eye. Fundus fl uorescein angiography demonstrated delayed choroidal fi lling and no perfusion of retinal vasculature. Carotid Doppler and computed tomogram (CT) angiography studies revealed extensive bilateral atherosclerotic disease involving the carotid circulation. Ophthalmologists must be aware of the possibility of this potentially fatal condition, which is extremely rare. An astute clinical diagnosis, targeted workup for systemic associations and a prompt referral may turn out to be life-saving.

Optical coherence tomography findings and retinal changes after vitrectomy for optic disc pit maculopathy.

Purpose: To study the optical coherence tomography (OCT) patterns in optic disc pit maculopathy and retinal changes after vitreous surgery. Materials and Methods: Retrospective review of consecutive cases with optic disc pit maculopathy seen at two tertiary eye institutes from January 2005 to June 2009. Results: Twenty-four eyes of 23 patients are included. The presenting visual acuity ranged from 20/400 to 20/20 (median:20/80). The median age at presentation was 24 years (range, 6-57 years). Optical coherence tomography demonstrated a combination of retinoschisis and outer layer detachment (OLD) in 19 (79.17%) eyes, OLD only in 3 (12.5%) eyes and retinoschisis only in 2 (8.33%) eyes. An obvious communication (outer layer hole) between the schisis and OLD was seen in 14 (73.68%) of the 19 eyes with both features. Of the 21 eyes with retinoschisis, schisis was present in multiple layers in 15 (71.43%) and single layer in 6 (28.57%) eyes. Eleven eyes underwent pars plana vitrectomy including creation of posterior vitreous detachment (PVD), fluid-air exchange, low intensity laser photocoagulation at the temporal edge of the optic disc pit and non-expansile perfluoropropane gas (14%) injection. Five (45.45%) of 11 eyes undergoing vitrectomy had complete resolution and 4 (36.36%) eyes had partial resolution of maculopathy. Visual acuity improved in 8 (72.72%) of 11 eyes. Conclusion: Optical coherence tomography demonstrates multiple layer schisis and outer layer detachment as main features of optic disc pit maculopathy. Vitrectomy with PVD induction, laser photocoagulation and gas tamponade results in anatomical and visual improvement in most cases with optic disc pit maculopathy.

Aggressive posterior retinopathy of prematurity in infants ≥1500 g birth weight.

In this retrospective case series, we report the spectrum and outcomes of aggressive posterior retinopathy of prematurity (APROP) in infants ≥1500 g birth weight. Twenty‑nine eyes of 15 infants are included. All infants were referred from level I or II nurseries, received supplemental unmonitored oxygen for prolonged duration (>1 week) and had multiple systemic co‑morbidities. Of the 29 eyes, 10 (34.5%) had zone 1 and 19 (65.5%) had posterior zone 2 disease. Twenty‑five (86.2%) eyes had flat neovascularization and 4 (13.8%) eyes had brush like proliferation. We noticed large vascular loops in 10 (34.5%) eyes. After confluent laser photocoagulation, 22 (75.9%) eyes had a favorable outcome. The study concludes that APROP in heavier (≥1500 g birth weight) premature infants occurs mostly in posterior zone 2 with flat neovascularization and atypical features like large vascular loops. Supplemental unmonitored oxygen for prolonged duration and multiple systemic co‑morbidities could be a contributing factor.

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.

Outcome of surgery in post-cytomegalovirus retinal detachment: Experience before and in the era of highly active anti-retroviral therapy in Indian eyes.

Purpose: To evaluate the outcome of surgery for cytomegalovirus associated retinal detachment (CMVRD) in human immunodeficiency virus (HIV)‑infected patients in pre‑highly active antiretroviral therapy (HAART) and HAART era in Indian eyes. Materials and Methods: Retrospective, we reviewed medical records of all consecutive HIV patients, who underwent surgical repair for CMVRD from July 1998 to June 2011. We divided patients into two groups, i.e. group 1, pre HAART era and group 2, HAART era. We compared two groups for various parameters like visual outcome, surgical success, additional procedures, follow‑up, etc., Results: Twenty‑eight eyes of 26 patients were included; 12 eyes of the 11 patients in group 1 and 16 eyes of the 15 patients in group 2. Significant visual acuity improvement was seen in both groups. Complete anatomic success was seen in 11 eyes in group 1 and 15 eyes in group 2. One additional procedure in group 1 and 29 additional procedures were done in group 2. A mean follow‑up was 16 months in group 1 and 41 months in group 2. Conclusion: There was no difference in outcome in pre‑HAART and HAART group, except for longer follow‑up and additional surgical procedures in HAART group.

Structural sequelae and refractive outcome 1 year after laser treatment for type 1 prethreshold retinopathy of prematurity in Asian Indian eyes.

Aim: The aim was to study the structural sequelae and refractive outcome after laser treatment for Type 1 prethreshold retinopathy of prematurity (ROP) in Asian Indian eyes. Materials and Methods: A retrospective chart review of infants with Type 1 prethreshold ROP (defined according to the Early Treatment for Retinopathy of Prematurity study) undergoing laser treatment at a tertiary center between January 2004 and December 2008 was done. The 1-year outcome of infants was analyzed. Results: Sixty-nine eyes of 36 infants were included. The mean birth weight was 1121.69 ± 254.81 g and the gestational age was 28.99 ± 2.03 weeks. Sixty-five eyes (94.2%) had zone 2 and 4 (5.8%) had zone 1 disease. Forty-four (63.77%) eyes had stage 2 ROP with plus disease and 25 (36.23%) eyes had prethreshold (fewer than five contiguous or eight cumulative clock hours) stage 3 ROP with plus disease. None of the eyes developed retinal structural sequelae. On cycloplegic retinoscopy, 59.4% eyes had nonsignificant hyperopia [spherical equivalent (SE) ≤ 4 D], 14.5% eyes had no refractive error (SE 0 D), 24.7% eyes had low myopia (SE < 5 D), and 1.4% eyes had high myopia (SE > 5.0 D). Eyes developing myopia were associated with a greater number of clock hours of ROP, greater number of laser spots used, and a longer time to disease regression. Two infants (5.6%) had esotropia and one (2.8%) had exotropia. Conclusion: Asian Indian infants treated for Type 1 prethreshold ROP did not develop retinal structural sequelae. Myopia was seen in nearly one-fourth of the eyes.The risk factors for myopia were a greater number of clock hours of ROP, greater number of laser spots, and a longer time to regression of ROP.

Technical aspects of laser treatment for acute retinopathy of prematurity under topical anesthesia.

Retinopathy of prematurity (ROP) is a significant cause of childhood blindness. The criteria for laser therapy have been revised from threshold ROP to include the earlier stage of high-risk prethreshold ROP. Laser photocoagulation is an established technique for the treatment of ROP. However, the detailed procedure and techniques for laser photocoagulation have not yet been published. Adequate and appropriate laser photocoagulation for ROP is different from the application of lasers in adult retinal vascular diseases, and many ophthalmologists need to be trained in this technique if the outreach of ROP treatment programs is to improve. Laser under topical anesthesia has been practiced in India as a preferred modality especially due to logistics and risks of general anesthesia in these pre-term babies. We discuss the details of the technique as practiced at tertiary care ophthalmic hospitals in India, so that the nuances in treatment parameters and clinical decision-making can be usefully applied to ophthalmic practice. This will ultimately lead to safe and effective treatment delivery in ROP.

Results of intraocular lens implantation with capsular tension ring in subluxated crystalline or cataractous lenses in children.

Purpose: To evaluate the outcome of intraocular lens (IOL) implantation using capsular tension ring (CTR) in subluxated crystalline or cataractous lenses in children. Setting: Tertiary care setting Materials and Methods: We prospectively studied 18 eyes of 15 children with subluxation of crystalline or cataractous lenses between 90° up to 210° after phacoemulsification, CTR and IOL implantation. Each child was examined for IOL centration, zonular dehiscence and posterior capsular opacification (PCO). Results: Age of the patient ranged between five to 15 years. Out of 18 eyes, seven had traumatic and 11 had spontaneous subluxation of crystalline or cataractous lens. Phacoemulsification was successfully performed with CTR implantation in the capsular bag. Intraoperative zonular dialysis occurred in two eyes. Anterior vitrectomy was performed in six eyes to manage vitreous prolapse. IOL implanted was polymethyl methacrylate (PMMA) in eight eyes, hydrophobic acrylic in seven and hydrophilic acrylic in three. Follow-up ranged from 24 months to 72 months. Sixteen eyes had a best corrected visual acuity of 20/40 or better. Nine eyes developed significant PCO and were managed with Neodymium Yttrium Aluminum Garnet (Nd:YAG) laser posterior capsulotomy. One eye with acrylic IOL in the capsular bag had IOL dislocation after two years which was managed with vitrectomy and secondary trans-scleral fixation of IOL. Conclusions: Phacoaspiration with CTR implantation makes capsular bag IOL fixation possible in most of the eyes with subluxated crystalline or cataractous lenses. PCO still remains a challenge in children with successful phacoaspiration with CTR implantation

Acute orbital abscess complicating deep posterior subtenon triamcinolone injection.

A 54-year-old diabetic female presented with orbital abscess and corneal infiltrate 3 days after deep posterior subtenon triamcinolone acetonide injection in her right eye. This was administered immediately after focal laser photocoagulation for diabetic macular edema. The orbital abscess and corneal infiltrate responded to systemic and topical antibiotics.

An evaluation of medical college departments of ophthalmology in India and change following provision of modern instrumentation and training.

AIM: To evaluate teaching and practice in medical college ophthalmology departments in a representative Indian state and changes following provision of modern instrumentation and training. STUDY TYPE: Prospective qualitative study. MATERIALS AND METHODS: Teaching and practice in all medical colleges in the state assessed on two separate occasions by external evaluators. Preferred criteria for training and care were pre-specified. Methodology included site visits to document functioning and conduct interviews. Assessments included resident teaching, use of instrumentation provided specifically for training and standard of eye care. The first evaluation (1998) was followed by provision of modern instrumentation and training on two separate occasions, estimated at Rupees 34 crores. The follow-up evaluation in 2006 used the same methodology as the first. RESULTS: Eight departments were evaluated on the first occasion; there were 11 at the second. On the first assessment, none of the programs met the criteria for training or care. Following the provision of modern instrumentation and training, intraocular lens usage increased dramatically; but the overall situation remained essentially unchanged in the 8 departments evaluated 8 years later. Routine comprehensive eye examination was neither taught nor practiced. Individually supervised surgical training using beam splitters was not practiced in any program; neither was modern management of complications or its teaching. Phacoemulsification was not taught, and residents were not confident of setting up practice. Instruments provided specifically for training were not used for that purpose. Students reported that theoretical teaching was good. CONCLUSIONS: Drastic changes in training, patient care and accountability are needed in most medical college ophthalmology departments.

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.

Optical coherence tomography following successful management of endophthalmitis.

Optical coherence tomography (OCT) was done in 20 eyes to detect causes of poor visual outcome, at least three months after successful management of endophthalmitis, which obtained clear media and best corrected visual acuity of < 20/40. Only four (20%) eyes had normal foveal contour on OCT. Eleven (55%) eyes showed treatable lesions, including epiretinal membrane with macular thickening in five (25%), epiretinal membrane without macular thickening in three (15%), cystoid macular edema in two (10%) and subfoveal serous detachment in one (5%) eye. Five eyes (25%) had foveal atrophy. OCT was helpful in segregating treatable conditions like cystoid macular edema from nontreatable causes like neurosensory atrophy in the postendophthalmitis patients.

Risk factors of threshold retinopathy of prematurity.

OBJECTIVE: To determine the risk factors which predispose to the development of threshold retinopathy of prematurity among patients of retinopathy of prematurity. METHODS: The ROP clinic records of a 3 year period were retrospectively studied to identify babies with threshold ROP (T-ROP) and sub-threshold ROP (ST-ROP). Various antenatal and perinatal risk factors, neonatal morbidity and therapeutic interventions were compared between the 2 groups. RESULTS: Of the total of 108 babies, 55 had T-ROP and 53 had ST-ROP. On univariate analysis, packed cell transfusions for anemia, double volume exchange transfusions (DVET), number of DVET, ventilation, gestational age <or= 28 weeks and apneic episodes were significantly higher in the T-ROP group. On multivariate analysis, the administration of packed cells [OR 2.8, 95 PERCENT CI 1.2, 6.6; (p = 0.014)] and DVET [OR 2.7, 95 PERCENT CI 1.2, 6.5; (p = 0.022)] emerged as independent risk factors of T-ROP. CONCLUSION: Administration of blood products increases the risk of developing T-ROP among patients who have ROP. There is a need to exercise caution in the use of blood products in premature newborns.

Paediatric open globe injuries. Visual outcome and risk factors for endophthalmitis.

PURPOSE: To study the incidence of open globe injuries and the outcome in children, and to study the risk factors for post-traumatic endophthalmitis. METHODS: Paediatric patient population. Retrospective analysis of 72 consecutive cases of open globe injury over 3 years (January 1998 to December 2000). RESULTS: The cause of trauma was sports related (n = 18), home-made bow and arrow (n = 16), household kitchen injuries (n = 10), cracker injuries (n = 7) and other miscellaneous outdoor activities (n = 16). In 5 children the cause could not be ascertained. Visual acuity of > or = 3/60 in the injured eye at the last follow-up examination was recorded in 37 of 70 patients (52.86%) whose visual acuity could be tested. The final visual acuity was significantly poorer in eyes where primary repair was delayed beyond 24 hours of injury (P < 0.05). Post- traumatic endophthalmitis developed in 39 of 72 (54.16%) eyes. Bow and arrow and household injuries (P < 0.5) and eyes in which primary repair was delayed beyond 24 hours of injury (P < 0.01) had a higher risk of endophthalmitis in univariate analysis. In multivariate analysis delayed repair was the only significant risk factor for the occurrence of endophthalmitis (P = 0.014). CONCLUSION: Delayed repair, bow and arrow injuries and household injuries were associated with significantly higher risk of endophthalmitis. The incidence of endophthalmitis can be reduced by early referral of trauma cases and parental supervision.

Granulomatous keratitis following corneal tattooing.

We report a patient who developed granulomatous keratitis following corneal tattooing.

Spectrum and clinical profile of post cataract surgery endophthalmitis in north India.

PURPOSE: To determine the spectrum, clinical profile and risk factors for poor visual outcome in patients of post cataract surgery endophthalmitis. METHODS: Data from 124 eyes were analysed. Various clinical and microbiological parameters were evaluated and risk factors for unfavourable outcome identified. RESULTS: The mean age of the patients was 59.50 +/- 13.75 years; 60.5% were males. The median surgery-symptom interval was 7 days (mean 15.81 +/- 24.01) and the medium symptom-presentation interval 7.5 days (mean 14.19 +/- 19.13). Corneal infiltrates were seen in 29%, hypopyon in 62 (50%). Smear positivity was 52.5% and culture positivity 38%. Equivocal microbiological positivity was seen in 22 (18%), bacterial 12 (10%), fungal 27 (21.5%), polymicrobial 8 (6.5%) and negative 55 (44%). 20% eyes had total loss of vision at last follow-up. Poor visual acuity at presentation, presence of intraocular lens, shorter surgery-symptom interval, corneal and surgical wound infiltrates, loss of red reflex, microbiological positivity of the vitreous tap and systemic diabetes mellitus were significant risk factors for unfavourable outcome. CONCLUSION: Our data highlights a low culture positivity and a predominance of fungal pathogens as a cause of post cataract surgery endophthalmitis. The visual outcome in these patients is still dismal and better treatment strategies should be evolved keeping in mind the microbiological spectrum. The risk factors identified may be helpful in prognosticating the outcome in such patients.