Full thickness macular hole with subfoveal pigment epithelial detachment in chronic central serous chorioretinopathy: A therapeutic challenge.

We describe the diagnostic and therapeutic strategies employed in the management of a patient with subfoveal pigment epithelial detachments (PEDs) combined with full-thickness macular hole (FTMH) and discuss the possible pathophysiology of these diseases occurring concurrently. A 38-year-old patient with a history of central serous chorioretinopathy (CSC) presented with FTMH overlying a large subfoveal serous PED. Multimodal imaging confirmed the same and intravitreal anti-vascular endothelial growth factor (VEGF) injections and eplerenone failed to resolve the PED. Spontaneous resolution of the large PED was observed later and pars plana vitrectomy with internal limiting membrane peeling closed the macular hole successfully. However, the PED with fibrinous CSC recurred postoperatively and low fluence photodynamic therapy (PDT) was done to tackle the same. At 10 months' follow-up, the final vision was 6/9, the macular hole remained closed, and the PED had not recurred. Macular hole formation may be the result of choroidal hyperpermeability and leakage in the backdrop of CSC which gives rise to an exudative component causing mechanical stretching and disruption of the overlying sensory retina. Spontaneous uncomplicated resolution of large subfoveal PED in CSCR is rare. This case was managed with a combination of intravitreal anti-VEGF injections, surgery, and PDT. The therapeutic challenge here was the timing of surgery.

Demographic and clinical profile, surgical outcome, and quality of life in patients who underwent bilateral lamellar corneal grafts.

Purpose: Lamellar corneal grafts have revolutionized the management of corneal blindness by replacing only the disease specific corneal layers. To the best of our knowledge, there is no study in literature describing the outcomes of bilateral lamellar keratoplasty in the Indian population. The aim of this work was to study the demographic profile, surgical outcomes, and quality of life in patients who underwent bilateral lamellar keratoplasty and to assess the correlation between these three. Methods: An observational cross-sectional study was conducted on 47 patients who underwent bilateral deep anterior lamellar keratoplasty (DALK) (n = 31) or descemet stripping automated endothelial keratoplasty (DSAEK) (n = 16) with a minimum follow-up of 6 months after the second surgery. Demographic parameters were collected by interview, surgical outcomes by clinical examination, and quality of life by a questionnaire. Results: A total of 47 patients were evaluated, women 42.56%, (n = 20) and men 57.44% (n = 27) with 38.3% being in 18-30 years age group and 23.4% above 60 years; 17.02% patients had a good socioeconomic status (score >60) and 61.70% had poorer socioeconomic status (score <50). Quality of life score (VR-QoL) was ≥50 in 82.9% patients and ≥70 in 14.89%. No significant association existed between VR-QoL scores and demographic factors. However, statistically significant association existed between VR-QoL and age of patient (P < 0.05), postoperative vision (P ≤ 0.05), and contrast sensitivity (P ≤ 0.01). Conclusion: Bilateral lamellar corneal grafts provide satisfactory visual outcomes compatible with day-to-day functioning. VR-QoL has a direct correlation to the age, visual acuity, contrast sensitivity, and inverse correlation with lenticule thickness in DSAEK and residual bed thickness in DALK.

EARLY SPECTRAL-DOMAIN OPTICAL COHERENCE TOMOGRAPHY BIOMARKERS TO CONFIRM FELLOW EYE CHANGES IN ASYMMETRIC TYPE-2 MACULAR TELANGIECTASIA: A Case-Control Study (India Macular Telangiectasia Report 1).

PURPOSE: To evaluate the earliest spectral-domain optical coherence tomography markers in fellow eyes of asymmetric Type-2 macular telangiectasia (MacTel). METHODS: A multicentered case-control study of spectral-domain optical coherence tomography images captured on Spectralis Heidelberg Engineering, Germany, comparing features of fellow eyes of patients with asymmetric clinical presentation of MacTel with 50 age-matched control subjects. RESULTS: Of 649 patients, 28 (4.3%) with MacTel presented with asymmetric features. The mean age of the MacTel patients was 63.5 (12.4) years with female predilection (4:1). Mean best-corrected visual acuity of the unaffected eye was 0.2 logarithm of the minimum angle of resolution (20/32 Snellen equivalent). The mean central subfoveal thickness in the unaffected MacTel eyes was 194 (SD, 38) µm, and the temporal retinal thickness was 204 (SD, 43) µm. These parameters were significantly thinner than those of control subjects in whom mean central subfoveal thickness was 273 (SD, 26) µm (P = 0.001). Presence of hyperreflective outer retinal dots was found in 92.8% of the unaffected MacTel eyes. These hyperreflective dots were scattered, punctate, nonconfluent, and confined to the outer retinal layers of foveal and parafoveal region. CONCLUSION: Although these cases presented with advanced presentation of MacTel features in only one eye, temporal retinal thinning and presence of hyperreflective outer retinal dots in the fellow eye can be considered as the earliest signs of MacTel.

Perceived difficulties and complications in learners of phacoemulsification: A principal component analysis model.

PURPOSE: To evaluate the difficulty perceived of each step of phacoemulsification and analyze the factors affecting them. METHODS: Overall, 12 trainee residents were allotted 10 cases of phacoemulsification of eyes with senile cataract, under a single observer, and the steps of each surgery were rated from very easy to very difficult with a questionnaire. The completion rates of steps and complications of each surgery were noted. Principal component analysis of the responses to the difficulty level questionnaire was conducted to obtain factors resulting in the perceived difficulty. RESULTS: The lowest difficulty scores were for initial step of incision creation (1.63 ± 0.84), followed by intraocular lens insertion (2.51 ± 0.8). The most difficult step was divide/chop of the nucleus (3.74 ± 0.97) followed by phacoemulsification (3.32 ± 0.82). Highest completion rates were seen for the initial steps of the surgery and the lowest for divide/chop. We identified two major patterns of difficulty among the trainees - one for steps involving high amount of binocularity and the other, for steps involving high precision of hand control. The rate of complication of our study was within acceptable range. CONCLUSION: Although trainees have practiced phacoemulsification steps on simulation, real-life situation may bring in unprecedented level of difficulty and challenges, which may be documented and used for targeted improvement of surgical skills. Stereopsis and hand control training should form a major part of training modules of cataract surgery both on simulation and real-life scenarios.

Clinical presentation and management of corneal fistula.

PURPOSE: To describe the clinical features and management of corneal fistula in patients of healed keratitis. METHODS: Medical records of all patients of healed keratitis presenting to the cornea clinic from November 2016 to September 2017 were reviewed. Eightcases of corneal fistula (six true fistulas, two closed fistulas) were identified. Six patients were managed with autologous tenon patch graft while two patients were managed medically. Various risk factors and treatment outcomes of corneal fistulisation were evaluated. RESULTS: The patients included two patients of failed therapeutic keratoplasty (with resolved graft infection) and six patients of healed keratitis. The age of the patients ranged between 10 and 60 years. Five of the patients were male while three were female. The size of the fistula measured between 1 and 2 mm. A surrounding cystic area of diameter ranging between 1 and 4.5 mm was seen in all the patients. In all of the patients, the treating physician missed the diagnosis. Complete healing was noted at 6-8 weeks in all the patients who underwent tenon graft. One patient refused to undergo any surgery and was lost to follow-up. In another case, surgery was deferred due to uncontrolled hypertension and he developed anterior staphyloma subsequently. CONCLUSION: Corneal fistula can often be missed in an apparently healed perforated corneal ulcer. Tenon patch graft is an effective technique for the management of corneal fistula.