AMNIOTIC MEMBRANE GRAFT FOR THE TREATMENT OF LARGE REFRACTORY MACULAR HOLE.

PURPOSE: Study off-label human amniotic membrane use outcomes for giant refractory macular hole closure. MATERIALS AND METHODS: The study was performed at Lahore General Hospital, Lahore, over 52 months on patients who had undergone standard macular hole surgical procedures for treatment, but the hole failed to close. Refractory macular hole dimensions ranged from 824 µ m to 1,568 µ m. Before surgery, patients underwent slit-lamp examination, fundus photography, and optical coherence tomography for macular scan. Amniotic membrane graft (AMG) used in surgery was harvested from a human placenta 24 hours before. Before AMG application, enough internal limiting membrane peeling was performed to ensure perfect fitting and recovery. All holes were plugged with AMG and SF6 gas tamponade. RESULTS: Twenty-nine patients, 20 men and nine women, were included in this study. Mean age of patients was 58 ± 6. Patients had refractory holes of average 1,237.48 ± 151.25 µ m. Post-op, 100% macular hole closure was achieved in all patients. Type 1 closure was found in patients (37.93%) who underwent AMG surgery within 3 months after primary surgical failure. Type 2 closure was found in patients (62.07%) who were operated on 3 months after primary surgical failure. CONCLUSION: Refractory macular holes treated by AMG with SF6 gas tamponade achieve anatomical Type 1 closure if performed within 3 months of primary surgical repair.

Less is more: new one-step intracameral chemotherapy technique.

Purpose: To describe the feasibility of a new one-step approach to aspirate the aqueous and apply melphalan in a single-go without repeated entries into the anterior chamber. Methods: This retrospective non-comparative study was conducted at a referral center and included 12 patients. The one-step approach is described in a step-wise manner. No complications were observed among the patients. Results: One single injection of intracameral melphalan proved to be a successful treatment in nine cases. Two patients required a second injection, which was administered two weeks after the first one following the same technique. Conclusions: This proved to be a reasonable technique for the smooth application of melphalan in the anterior chamber studded with retinoblastoma seeds. Our outcomes revealed that it is an effective, quick, and cost-effective technique. Longer-term data collection is underway, though initial findings are encouraging.

Plug the pit: a surgical technique for optic disc pit.

Purpose: To present a recently described surgical technique for the treatment of optic disc pit (ODP) and evaluate its outcomes. Methods: A patient presented with refractory serous macular detachment and secondary full thickness macular hole associated with ODP, for which he had already undergone pars-plana vitrectomy with internal limiting membrane peeling and autologous serum application over the optic disc pit. A recently described surgical technique was carried out to treat this case. In this procedure, a silicone punctal plug was used to close the ODP. The macular hole was closed with a human amniotic membrane graft. Endotamponade was carried out with 1000cs silicone oil. Results: Postoperatively, the serous macular detachment subsided and the punctal plug and amniotic membrane graft were in situ. Patient's visual acuity improved from counting fingers to 6/38 at one year postoperative. Conclusion: This technique appears to be safe and effective in resolving long standing serous macular detachment associated with ODP, which was refractory to the conventional intervention. However, more cases and longer follow-ups are needed to affirm the safety and efficacy of this recently described procedure.

Customized disposable kit versus a conventional stainless steel instrument for an intravitreal injection: A comparison.

Comparison of a customized disposable kit with a conventional stainless steel instrument was performed for an intravitreal injection. A total of 2700 eyes of 2250 patients were enrolled in two groups. Comfort level of the patients was assessed using a 'Pain Scale' and any post intravitreal injection complications were examined clinically by a slit lamp biomicroscopy. Surgeon's ease was assessed by a questionnaire. In group A, no pain was recorded in 1231(82.06%) eyes, mild pain was d escribed in 184(12.27%), moderate pain was documented in 78 (5.2%) while, severe pain was noticed in 7(0.47%). In group B, no pain was seen in 1014(84.5%), mild pain was present in 123(10.25%), moderate pain was perceived in 58 (4.83%) while, severe pain was recorded in 5 (0.42%). With respect to surgeon's ease, 6 out of the 7 surgeons found the kit to be more convenient and cost effective as compared to the conventional instruments. Disposable intravitreal kit is beneficial for both the patients as well as the surgeons.

Experience of selective intra-arterial chemotherapy for Retinoblastoma.

This study determined the outcomes of selective intraarterial chemotherapy (IAC) for the treatment of Retinoblastoma in Pakistan. Single centre, prospective, interventional case series of three consecutive eyes were diagnosed as unilateral Retinoblastoma. Patients underwent IAC with Melphalan (0.5mg/kg) at Lahore General Hospital from July 2017 to January 2018. Selective ophthalmic arterial infusion was carried out in all 3 cases. Patients were evaluated on 1st, 3rd and 10th postoperative day and then at 4 weeks interval, till date. Among three eyes, 2(66.6%) were of stage C and 1(33.3%) of stage D. After 3 cycles of intra-arterial chemotherapy, full regression of the lesion was observed in all the eyes (100%). Complete regression and calcification of tumour was seen in 1 (33.3%) eye at 1 month post-treatment and 2 eyes at 2 months post-treatment. Globe was preserved in all 3 (100%) cases. Notable complications included eyelid oedema, orbital congestion and skin hyperaemia. None of the patients had any systemic side effects. Intra-arterial chemotherapy (IAC) is an effective modality for the treatment of Retinoblastoma and it plays a cardinal role in preservation of integrity of the globe.

Frequency of post-operative hypotony after 23-gauge transconjunctival vitrectomy with locally made instruments.

The objective of this study was to discern the frequency of post-operative hypotony after 23-gauge vitrectomy with locally made instruments. This study was conducted at the Department of Ophthalmology, Lahore General Hospital, Lahore from July 2012 to June 2016. A total of 300 patients underwent 23-gauge pars-plana vitrectomy. Locally made 23-gauge trocar cannula system was used in all the patients. Post-operative Intraocular Pressure(IOP) was measured using Goldman Applanation Tonometer on the first post-operative day. IOP of less than 06mmHg was termed as hypotonic. In our study, mean post-operative intraocular pressure was recorded as 8.32±3.04mmHg and frequency of post-operative hypotony after 23-guage vitrectomy with locally made instruments reveals 10.67% (n=32) while 89.33% (n=268) had no findings of hypotony. We concluded that the frequency of post-operative hypotony after 23-gauge vitrectomy with locally made instruments is slightly higher when compared with other studies and this instrument can be used for further surgeries.

Comparison of Topical Versus Peribulbar Anesthesia for 23G Pars Plana Vitrectomy.

OBJECTIVE: To compare the safety and efficacy of topical anesthesia versus peribulbar anesthesia for 23-gauge pars plana vitrectomy. STUDY DESIGN: Randomized controlled trial. PLACE AND DURATION OF STUDY: Ophthalmology Department, Lahore General Hospital, Ameer-ud-Din Medical College, Postgraduate Medical Institute, Lahore from April 2013 to March 2016. METHODOLOGY: A total of 110 patients were equally divided (n=55) in group A (topical anesthesia) and group B (peribulbar anesthesia). In group A, pledget soaked with 0.5% proparacaine hydrochloride were placed in the superior and inferior fornices three minutes before surgery, and removed just before surgery. For group B patients, 3 ml of 0.5% bupivacaine was used for peribulbar anesthesia three minutes before surgery. Surgical time was noted from the placement of pledget in fornix till the eye pad placed in group A, and from the time of peribulbar anesthesia in group B till the eye pad placed at the end of surgery. All data was recorded in Excel sheet and p-values were calculated using online OpenEpi. RESULTS: The mean age of the patient was 56.28 ±13.76 years. Male patients were 78 (70.9%) and female patients were 32 (29.1%). Mean duration of surgery was 30.32 ±7.07 minutes and mean pain score was 2.30 ±0.98. There was a significant difference with respect to mean duration of surgery in patients who were given topical anesthesia (32.52 ±6.92 minutes) versus those given peribulbar anesthesia (28.12 ±6.57 minutes, p<0.001). Mean pain score in topical anesthesia group (3.11 ±0.89) was significantly higher as compared to peribulbar anesthesia group (2.67 ±0.91, p=0.011). CONCLUSION: Topical anesthesia is as effective as peribulbar anesthesia in terms of patient comfort and duration of surgery for 23-G pars plana vitrectomy in patients with vitreous hemorrhage.

Visual Outcomes of Macular Hole Surgery.

OBJECTIVE: To determine the mean visual improvement after internal limiting membrane (ILM) peeling assisted with brilliant blue staining of ILM in macular hole, and stratify the mean visual improvement in different stages of macular hole. STUDY DESIGN: Quasi-experimental study. PLACE AND DURATION OF STUDY: Eye outpatient department (OPD), Lahore General Hospital, Lahore from October 2013 to December 2014. METHODOLOGY: Patients with macular hole underwent measurement of best corrected visual acuity (BCVA) and fundus examination with indirect slit lamp biomicroscopy before surgery. The diagnosis of all patients was confirmed on optical coherence tomography. All patients had 23G trans-conjunctival three ports pars plana vitrectomy, ILM peeling, and endotamponade of SF6. The mean visual improvement of different stages of macular hole was noted. Paired t-test was applied. RESULTS: There were 30 patients, 15 males and 15 females (50%). The mean age was 62 ±10.95 years. They presented with low mean preoperative visual acuity (VA) of 0.96 ±0.11 logMar. The mean postoperative VAwas 0.63 ±0.24 logMar. The mean visual increase was 0.33 ±0.22 logMar (p < 0.001). In patients with stage 2 macular hole, mean visual increase was 0.35 ±0.20 logMar (p < 0.001). In patients with stage 3 macular hole, mean visual increase was 0.44 ±0.21 logMar (p < 0.001), and in patients with stage 4 macular hole it was 0.13 ± 0.1 logMar (p = 0.004). CONCLUSION: ILM peeling assisted with brilliant blue is a promising surgery for those patients who have decreased vision due to macular hole, in 2 - 4 stages of macular hole.