Outbreak of toxic anterior segment syndrome following vitreoretinal surgery - A retrospective analysis.

BACKGROUND: Toxic anterior segment syndrome (TASS) is an uncommon complication of vitreoretinal surgery and is characterized by severe anterior chamber reaction, hypopyon, and limbus-to-limbus corneal edema. METHODS: Twenty-nine vitreoretinal surgeries were performed, of which 14 developed TASS in the early postoperative period. The operative records were reviewed retrospectively. RESULTS: The median age of patients was 49.07 ± 16.75 years and 14.28% of them were female. Also, 71.42% were operated in the left eye and 42.8% were pseudophakic. Recurrent retinal detachment, secondary scleral-fixating intraocular lens (SFIOL), and silicone oil removal (SOR) were the most common procedures. Severe anterior chamber reaction was seen in 14 patients, circumcorneal congestion in eight, corneal edema in 11 (78.6%), hypopyon in 13 (92.8%), and severe fibrin membrane in two patients. CONCLUSION: We describe the largest series of TASS following uneventful vitreoretinal surgery. Balanced salt solution was the instigating agent in this series. A prompt and thorough investigation is critical in obviating recurrences.

Surgical management of glaucoma in microspherophakia using quadruple procedure.

Background: Microspherophakia is a rare developmental lens anomaly with increased anteroposterior and reduced equatorial diameter. It presents with refractive myopia, shallow anterior chamber, and angle closure glaucoma. It is associated with subluxated or dislocated lens, progressive myopia, defective accommodation, and glaucoma. Glaucoma is the most common vision-threatening complication and mostly requires surgical management that includes trabeculectomy, lensectomy, and drainage implant. A staged or combined procedure can be performed. The purpose of this video is to highlight the advantages of combining parsplana vitrectomy (PPV) with parsplana lensectomy (PPL), scleral fixated intraocular lens (SFIOL), and Aurolab aqueous drainage implant (AADI) in a young patient with advanced glaucoma and gross subluxation. Drainage implants are preferred over filtering surgeries in eyes undergoing vitreoretinal procedures due to the risk of bleb fibrosis and hypotony seen in the latter. The combined procedures should be tailored according to the lens status and severity of glaucoma in each patient. Purpose: The purpose of this video is to illustrate a combined quadruple procedure (PPL, PPV, SFIOL, and AADI) in microspherophakic patients with unstable glaucoma and video-based skill transfer to a novice surgeon. Synopsis: This video illustrates quadruple surgery in a microspherophakic patient with secondary angle closure glaucoma. The authors also emphasize the advantages of a combined quadruple procedure over staged procedure or combined PPL with filtering procedure. Highlights: Quadruple procedure can be performed in young microspherophakic patients with advanced glaucoma or at risk of progression and losing central vision along with gross subluxation of lens. It eliminates the need for multiple procedures, the risk of hypotony, and bleb-related complications. Video link: https://youtu.be/KdFjb7acXCI.

Profiling of idiopathic macular hole vitreous proteome identifies the role of extracellular matrix remodelling, epithelial-mesenchymal transformation and unfolded protein-response pathways.

Purpose: To analyze and describe the proteome of the vitreous humour in eyes with idiopathic macular holes. Methods: We performed mass spectrometry (MS)-based label-free quantitative analysis of the vitreous proteome of idiopathic macular hole (IMH) and control donor vitreous. Comparative quantification was performed using SCAFFOLD software which calculated fold changes of differential expression. Bioinformatics analysis was performed using DAVID and STRING software. Results: A total of 448 proteins were identified by LC-MS/MS in IMH and cadaveric eye vitreous samples, of which 199 proteins were common. IMH samples had 189 proteins that were unique and 60 proteins were present only in the control cadaveric vitreous. We found upregulation of several extracellular matrix (ECM) and cytoskeletal proteins, namely collagen alpha-1 (XVIII) chain, N-cadherin, EFEMP1/fibulin-3, basement membrane-specific heparan sulfate proteoglycan core protein, and target of Nesh-3. Several cytoskeleton proteins, namely tubulin, actin, and fibronectin levels, were significantly lower in IMH vitreous, probably reflecting increased ECM degradation. IMH vitreous also had a downregulation of unfolded protein response-mediated-mediated apoptosis proteins, possibly related to a state of increased cell survival and proliferation, along with a remodelling and aberrant production of ECM contents. Conclusion: The pathogenesis of macular holes may involve ECM remodelling, epithelial-mesenchymal transformation, downregulation of apoptosis, protein folding defects, and complement pathway. The vitreo-retinal milieu in macular holes contain molecules related to both ECM degradation and inhibition of the same, thereby maintaining a homeostasis.

Peripapillary and macular retinoschisis - A vision-threatening sequelae of advanced glaucomatous cupping.

PURPOSE: To present a selected case series of advanced glaucoma-associated peripapillary and macular retinoschisis and response to various treatment strategies with a comprehensive literature review. METHODS: Retrospective observational case series. Retrospective review of five selected cases of advanced glaucoma with peripapillary and macular retinoschisis. RESULTS: All five patients had advanced glaucomatous damage with macular and peripapillary retinoschisis, three (patients 2, 3, and 5) had a neurosensory detachment of the macula. Increased intraocular pressure was managed with maximal antiglaucoma medications and G6 micropulse diode laser treatment in the first patient, transscleral diode laser in the second patient, mitomycin-C augmented trabeculectomy in the third patient, maximal antiglaucoma medications alone in the fourth patient, pars plana vitrectomy followed by trabeculectomy in the fifth patient. CONCLUSION: We speculate that peripapillary and macular retinoschisis may indicate a vision-threatening sequelae of advanced glaucoma. The probable inciting factor for this vision-threatening pathology being elevated intraocular pressure, fluctuations in intraocular pressure, and chronic glaucoma with advanced cupping. We emphasize that meticulous examination of the macula in patients with advanced glaucoma is mandatory. It is imperative to do OCT macula in patients with advanced glaucoma to diagnose this distinct entity at an earlier stage and preserve the existing visual potential.

Telemedicine in diabetic retinopathy screening in India.

With ever-growing prevalence of diabetes mellitus and its most common microvascular complication diabetic retinopathy (DR) in Indian population, screening for DR early for prevention of development of vision-threatening stages of the disease is becoming increasingly important. Most of the programs in India for DR screening are opportunistic and a universal screening program does not exist. Globally, telemedicine programs have demonstrated accuracy in classification of DR into referable disease, as well as into stages, with accuracies reaching that of human graders, in a cost-effective manner and with sufficient patient satisfaction. In this major review, we have summarized the global experience of telemedicine in DR screening and the way ahead toward planning a national integrated DR screening program based on telemedicine.

Identification of risk factors for targeted diabetic retinopathy screening to urgently decrease the rate of blindness in people with diabetes in India.

PURPOSE: There is an exponential rise in the prevalence of diabetes mellitus (DM) in India. Ideally all people with DM should be periodically screening for diabetic retinopathy (DR) but is not practical with current infrastructure. An alternate strategy is to identify high-risk individuals with vision-threatening diabetic retinopathy (VTDR) for priority screening and treatment. METHODS: We reanalyzed four population-based studies, conducted in South India between 2001 and 2010, and reclassified individuals above 40 years into known and newly diagnosed diabetes. Multiple regression analysis was done to identify risk factors in people with known and new DM. RESULTS: The prevalence of DR in 44,599 subjects aged ≥40 years was 14.8% (18.4 and 4.7% in known and new DM, respectively), and the prevalence of VTDR was 5.1%. Higher risk factors of VTDR were older age >50 years, diabetes duration >5 years, and systolic blood pressure >140 mm Hg. Targeted screening of people with diabetes using high-risk criteria obtained from this study was able to detect 93.5% of all individuals with VTDR. CONCLUSION: In a limited resource country like India, a high-risk group-based targeted screening of individuals with DM could be prioritized while continuing the current opportunistic screening till India adopts universal screening of all people with DM.

Quantification of relative afferent pupillary defect by an automated pupillometer and its relationship with visual acuity and dimensions of macular lesions in age-related macular degeneration.

PURPOSE: The occurrence of relative afferent pupillary defect (RAPD) secondary to optic nerve diseases and widespread retinal disorders is well established. However, only very few reports of RAPD in macular disorders exist in the literature. In this study, we used automated pupillometer to evaluate RAPD in eyes with macular lesions. METHODS: It was a prospective cross-sectional study. A total of 82 patients with choroidal neovascular membrane (CNVM) - 65 unilateral and 17 bilateral macular lesions - were enrolled. RAPD was assessed with an automated pupillometer and macular lesions evaluated with optical coherence tomography (OCT). The length of the ellipsoid zone disruption was measured as the longest length of lesion on the horizontal raster scans and the area of macular lesion was measured manually, mapping the affected area of ellipsoid zone on the enface images. RESULTS: : RAPD scores showed good correlation with the intereye difference in length of maximum ellipsoid zone disruption (r-value = 0.84, P value <0.001) and macular lesion area as measured on OCT in all unilateral cases (r-value = 0.84, P value <0.001). Best-corrected visual acuity was also found to have a significant correlation with lesion size on the OCT as well as the length of ellipsoid zone disruption in unilateral cases. CONCLUSION: : RAPD evaluated with an automated binocular pupillometer is a noninvasive and objective method to assess macular lesions in CNVMs; it shows good correlation with structural lesion dimensions on OCT in unilateral cases. Further longitudinal studies are needed to assess the significance of these findings in disease progression as well as correlation with lesion response to treatment.

Clinical characteristics of morning glory disc anomaly in South India.

PURPOSE: Reports of morning glory disc anomaly (MGDA) in India have mostly been case reports. The aim of this study was to describe the demographic and clinical profile of patients with MGDA in South India. MATERIALS AND METHODS: A retrospective review of the medical records of patients with MGDA seen at a tertiary eye hospital in South India over a period of 8 years was carried out. The patients' demographic and clinical data were extracted from the case files and were entered into Epi Info reporting software version 7.2.3.0 and then analyzed. RESULTS: There were 51 eyes of 44 patients with MGDA comprised 25 (56.8%) males and 19 (43.2%) females. Seven (15.9%) patients had bilateral MGDA. The mean age for females was 5.8 years (standard deviation [SD]: 5.8) and for males, 11.2 years (SD: 12.1). This difference was not statistically significant with a P = 0.07. The most common ocular associations were strabismus, refractive error, and retinal detachment, whereas the most common systemic associations were cleft lip and cleft palate. Fifty-one percent of eyes were blind at presentation. CONCLUSION: Patients with MGDA in India tend to present late with poor visual prognosis. Early diagnosis and prompt treatment of blinding complications are crucial in reducing the risk of irreversible visual loss. Associated systemic abnormalities highlight the importance of a multidisciplinary approach in the management of patients with this condition.

Incidence and Outcomes of Suprachoroidal Hemorrhage Following Aurolab Aqueous Drainage Implant in Adult and Pediatric Glaucoma.

PRCIS: Postoperative suprachoroidal hemorrhage (PSCH) is an infrequent but devastating complication after nonvalved aqueous drainage implant surgery and demonstrated a bimodal distribution. The final outcomes of either conservative management or surgical drainage of the hemorrhage remained poor. PURPOSE: The aim was to report the incidence and outcomes of eyes developing PSCH after undergoing Aurolab aqueous drainage implant (AADI) surgery for adult and pediatric refractory glaucomas. MATERIALS AND METHODS: In this retrospective series, case files of all patients who underwent AADI between May 2012 and December 2019 were retrieved from an electronic database. A PSCH was defined as the presence of hemorrhagic choroidal detachment, confirmed by ultrasound B scan, occurring in a closed system in the postoperative period. RESULTS: Of the 986 eyes that underwent AADI during the study period, 7 (0.7%), developed PSCH (95% confidence interval=0.3-1.6%). There were no differences in the preoperative parameters between those with and without PSCH. Of these, 4 were seen in pediatric eyes (4/288, 1.4%) and 3 in adult eyes (3/698, 0.4%) (P<0.01). Four eyes (57%) had PSCH in the immediate postoperative period (ie, between 24 and 48 h of AADI surgery), while the remaining 3 had onset ranging from 6 to 7 weeks after surgery. Anatomic risk factors were present in all eyes including hypotony (n=4), myopia (n=3), microcornea (n=2), microphthalmos (n=1), postvitrectomy (n=1), and staphyloma (n=1). Visual acuity improved in only 1 (14%) eye while 3 (43%) eyes developed phthisis bulbi, all in the pediatric age group. CONCLUSIONS: PSCH is a rare complication following AADI and is seen in <1% eyes. The incidence is higher in the pediatric age group. Visual and anatomic outcomes are dismal following PSCH with globe salvage possible in only about half these eyes.

Imaging of Muller cell sheen dystrophy.

To report a rare case of Muller cell sheen dystrophy and to describe its clinical and diagnostic aspects. A 42-year-old woman presented with unilateral defective vision. Fundus evaluation revealed bilateral glistening retinal reflexes throughout the posterior pole with a wrinkled appearance in the right. Spectral Domain-OCT in the right showed abnormal internal limiting membrane, intraretinal schisis with serous detachment at macula. Angiography revealed staining along vessels. Electroretinogram in the affected eye was negative. At 4 months of follow up, vision dropped and intraretinal schisis increased. Family screening was negative.

Bullous Central Serous Chorioretinopathy Associated with Retinal Pigment Epithelial Tear.

Bullous retinal detachment (RD) is a rare manifestation of chronic central serous chorioretinopathy and may be associated with an underlying retinal pigment epithelial (RPE) tear. It may be confused with rhegmatogenous RD or serous RD from conditions such as Harada disease. Appropriate diagnosis is essential as this may prevent unnecessary surgery or treatment with medication that may worsen the condition. We present the case of a young male Indian patient with unilateral bullous RD and a tentative diagnosis of rhegmatogenous RD. He underwent RD surgery, however a large RPE tear was discovered intraoperatively.

A Rare Case Report of Frank Ter Haar Syndrome in a Sibling Pair Presenting With Congenital Glaucoma.

Frank Ter Haar syndrome (FTHS) is a rare autosomal recessive disorder with characteristic skeletal, cardiac, ocular, and craniofacial abnormalities. We report a sibling pair presenting with clinical features typical of FTHS, born to consanguineous parents, with a novel mutation in the SH3PXD2B gene on chromosome 5q35.1 that results in premature truncation of the protein encoded. The children presented with brachycephaly, multiple joint contractures, cardiac valvular defects, bilateral megalocornea, and congenital glaucoma. Trabeculotomy combined with trabeculectomy was performed in both siblings to control intraocular pressure. The characteristic clinical features with the underlying genetic defects confirmed the diagnosis of FTHS. Early diagnosis and treatment of congenital glaucoma preserved vision in the children.

Outcome of 2 cc pure sulfur hexafluoride gas tamponade for macular hole surgery.

BACKGROUND: Isoexpansile concentrations of intraocular gases are typically used as tamponading agent in macular hole surgery. Using a small volume of the pure form of these gases may achieve the same result without increasing the incidence of postoperative complications. The purpose of this study was to evaluate the anatomical and visual outcomes following macular hole surgery with 2 cc pure (100 %) sulfur hexafluoride (SF6) gas tamponade. METHODS: A retrospective study of eyes with idiopathic macular holes that underwent 23-gauge pars plana vitrectomy with 2 cc pure SF6 gas tamponade. Macular hole surgery was performed alone or in combination with phacoemulsification in eyes with cataract. Preoperative and postoperative data including best corrected visual acuity recorded in LogMAR units, slit-lamp biomicroscopy, and optical coherence tomography were analysed. Surgical complications were also recorded. RESULTS: Seventy six eyes of seventy five patients were analysed. A closure rate of 100 % was achieved with reoperation in 4 eyes. There was a significant improvement in best-corrected visual acuity from a mean of 0.65 LogMAR preoperatively to 0.36 at 6 months (p value 0.004). Forty five (59 %) eyes gained at least 2 lines on the Snellen visual acuity chart. Postoperative elevation in intraocular pressure (≥30 mmHg) was documented in 3 eyes (4 %). CONCLUSION: Macular hole surgery with 2 cc pure SF6 gas tamponade achieved a high success rate with a low incidence of complications. The smaller volume of gas required makes it a cheaper technique.

Management of Ocular Siderosis: Visual Outcome and Electroretinographic Changes.

Purpose. Ocular siderosis (OS) is a sight threatening complication of retained iron-containing Intraocular Foreign Body (IOFB). Successful localization of the IOFB and timely removal are crucial to its management. The purpose of this study was to review the presentation, management, and outcome of OS at our institution. Methods. A retrospective case series of eyes with OS that underwent IOFB removal from January 2009 to March 2015 at our institution. Results. OS was seen in 9 eyes of 9 patients during the study period. There were 8 males and 1 female with an age range of 31.6 years. An IOFB was in all the eyes. The most common features of siderosis were cataract and pigmentary retinopathy seen in 6 (67%) and 4 (44%) eyes, respectively. Electroretinogram (ERG) readings were reduced in the 9 eyes. The IOFB was removed by pars plana vitrectomy in all the cases with improvement in ERG amplitudes occurring postoperatively in 7 (78%) eyes. Conclusion. A retained iron-containing IOFB can manifest itself after several years with features of OS. A careful clinical and radiologic evaluation is imperative in patients with history suggestive of penetrating ocular injury to rule out retained or occult IOFB and thus prevent this catastrophic condition.

A preliminary study of Heavy Brilliant Blue G for internal limiting membrane staining in macular hole surgery.

CONTEXT: Surgical outcomes of vitrectomy for idiopathic macular hole using a "heavy" Brilliant Blue G (HBBG) solution for staining and removal of the internal limiting membrane (ILM). SETTINGS AND DESIGN: Prospective interventional case series conducted in a tertiary eye care hospital. MATERIALS AND METHODS: Nineteen patients (20 eyes) with idiopathic macular hole were enrolled to undergo vitrectomy with ILM peeling using HBBG. BBG dye was made heavy by mixing with 10% dextrose normal saline (DNS) solution in 2:1 ratio. The adequacy of ILM staining was noted intraoperatively. The closure rates of macular hole and visual improvement were recorded. Patients were followed up postoperatively on day 1, week 1, and subsequently at 1, 3, and 6 months, and every 6th month thereafter. STATISTICAL ANALYSIS: Wilcoxon signed-rank test was used; P < 0.05 was considered significant. RESULTS: Preoperative best-corrected visual acuity (BCVA) ranged from 20/1000 to 20/63 (median: 20/100). Intraoperatively, the ILM stained very well in all eyes, and was easily removed. All macular holes closed postoperatively. The mean follow-up was 6.15 ± 2 months (range: 4-10; median: 6 months). Final BCVA ranged from 20/20 to 20/80 (median: 20/40), amounting to a significant visual improvement (P = 0.0001). BCVA improved by 1-8 Snellen lines in 19 eyes (95%); 16 eyes (80%) improved by ≥2 lines; 13 eyes (65%) achieved a final BCVA of 20/40 or better. CONCLUSIONS: Addition of 10% DNS to BBG dye allowed good ILM staining with less dye during macular hole surgery, and provided excellent anatomic and visual outcomes.