Long-term Visual and Anatomical Outcome after Surgical Management of Epiretinal Membrane.

OBJECTIVE: To assess the functional and surgical long-term outcomes following epiretinal membrane surgery. STUDY DESIGN: Case series. PLACE AND DURATION OF STUDY: Layton Rahmatulla Benevolent Trust Tertiary Care Eye Hospital, Karachi, from January 2016 to December 2020. METHODOLOGY: A medical record review was carried out of patients, who had undergone surgical management of ERM and had presented for follow-up for at least three years. Best corrected visual acuity (BCVA) and Optical Coherence Tomography (OCT) parameter [(integrity of ellipsoid zone (EZ)] was evaluated. BCVA, using Snellen's chart, is performed routinely on each visit, which was converted to logMAR chart for analysis in this study. OCT was also performed to evaluate the integrity of outer retinal layers using Heidelberg OCT. RESULTS: Sixty-five eyes of 54 patients were included in the study, including 41 eyes of 36 men (63%) and 24 eyes of 18 women (37%). Mean age was 46.2 ± 8.9 years. The mean BCVA significantly improved from 0.88 ± 0.28 logMAR (6/45 Snellen) preoperatively to 0.64 ± 0.21 (6/27) at the end of first year (p <0.001), which improved to 0.54 ± 0.19 (6/21) at the end of second year, and 0.53 ± 0.20 (6/20) after three years of follow-up. The post-op vision at three years was stratified according to the integrity of EZ on OCT performed at the same follow-up; and a significant difference was observed. EZ was intact in 52 eyes with a mean BCVA of 0.49 ± 0.16 logMAR (6/18 Snellen); while it was found disrupted in 13 eyes, where the BCVA was 0.68 ± 0.26 (6/29). CONCLUSION: Anatomically intact outer retinal layer significantly correlated with improved BCVA. Key Words: Epiretinal membrane, Optical coherence tomograghy, Best corrected visual acuity.

Treatment of Chronic Large and Persistent Macular Hole by a new technique in a Tertiary Care Hospital.

OBJECTIVE: To assess the anatomical and functional outcomes of treating chronic persistent large macular hole by macular hole hydrodissection technique in a tertiary eye care hospital. METHODS: This interventional case series study was conducted in the Vitreoretinal department of LRBT Tertiary Teaching Eye Hospital, Karachi, from October 2017 to March 2018, with follow-ups till February 2019. The study included eighteen cases of chronic (symptoms of loss of central vision ≥ 2years), persistent (previously failed macular hole surgery), large (aperture diameter of ≥ 400µm) macular hole. Out of the eighteen patients, eight (44.4%) were males and ten (55.6%) were females. All operated patients underwent macular hole hydrodissection by balanced salt solution using a silicone soft tip extrusion cannula. Patients were followed up post operatively to assess post-operative complications and surgical results. RESULTS: Among eighteen patients with a mean aperture diameter of 477.1±102.9 µm and basal diameter of 849.4± 92.6µm, complete anatomical closure was achieved in sixteen (88.8%). Five (27.7%) out of the eighteen patients achieved best corrected visual acuity improvement of 6/36, whereas seven (38.8%) patients reached up to a BCVA of 6/60, with maximum improvement of two lines. The mean post-operative follow-up was 332.3± 46.7 days. CONCLUSION: Macular hole hydrodissection is a relatively new emerging technique with promising results for the closure of chronic persistent large macular hole.

Role of Concomitant Internal Limiting Membrane (ILM) Peeling During Rhegmatogenous Retinal Detachment (RRD) Surgery in Preventing Postoperative Epiretinal Membrane (ERM) Formation.

OBJECTIVE: To investigate the role of concomitant Internal Limiting Membrane (ILM) peeling during surgery for macula off Rhegmatogenous Retinal Detachment (RRD) in preventing postoperative Epiretinal Membrane (ERM) formation; and its effect on the visual acuity. METHODS: This was a prospective, quasi-experimental study conducted from August 2018 to July 2019 at LRBT Tertiary Eye Care hospital, Karachi. Fifty-six patients with macula off RRD were divided into groups A (with ILM peeling) and B (without ILM peeling) via non-probability convenience sampling. All patients underwent standard 3 ports pars plana vitrectomy with silicon oil tamponade. In Group-A, ILM was stained using 0.5% ICG. Patients were evaluated clinically and by spectral domain optical coherence tomography (SD-OCT), pre- and post-operatively. Main outcomes recorded were best corrected visual acuity (BCVA) and occurrence of ERM on SD-OCT. RESULTS: There were 26 patients in Group-A and 30 patients in Group-B. At six months' follow-up, ERM had not developed in any case in Group-A compared to five patients (16.7%) in Group-B. There was no statistical difference in mean BCVA change from baseline. CONCLUSION: ILM peeling during vitrectomy for RRD prevents the formation of macular ERM post-operatively. This may reduce the need of a second vitrectomy. However, visual outcomes were comparable to the non-ILM peeling vitrectomy.

Comparison of Retinal Nerve Fibre Layer versus Bruch Membrane Opening-Minimum Rim Width as an Optical Coherence Tomography-based Marker for Glaucoma in Myopia.

OBJECTIVE: To compare the reliability of Bruch Membrane Opening-Minimum Rim Width (BMO-MRW) Optical Coherence Tomography (OCT) with Retinal Nerve Fibre Layer (RNFL) in myopic patients. STUDY DESIGN: Cross-sectional study. PLACE AND DURATION OF STUDY: LRBT Free Base Eye Hospital, Karachi, from May 2019 to July 2020. METHODOLOGY: Moderate myopes with refractive errors between -3 to -6 diopters were examined by 2 glaucoma consultants separately, who performed fundoscopy to evaluate the optic nerve head, checked IOP and assessed CCT and visual fields to stratify the eyes into myopic normal and myopic glaucomatous eyes. All eyes were imaged with SD OCT of Spectralis version 1.10.2.0 of Heidelberg Engineering. Two scanning patterns, one for BMO-MRW and the other for RNFL thickness analysis, were performed. RESULTS: Fifty eyes of 50 patients were diagnosed with glaucoma in 50% (25 out of 50 patients). OCT RNFL detected glaucoma in 72% (36 out of 50 patients). While OCT BMO-MRW detected glaucoma in 56% (28 out of 50 patients). There was strong agreement between the consultant's judgements and BMO-based test (κ = 0.800, p <0.001), but the association was comparatively weaker with RNFL-based prediction (κ = 0.480, p <0.001). Specificity was better with OCT BMO-MRW (85.7%) than RNFL (66.7%). There were lower false positive rates with BMO-MRW (14.3%) than RNFL (33.3%). CONCLUSION: OCT BMO-MRW is a better indicator of glaucomatous damage in moderately myopic eyes as compared to OCT RNFL analysis. Key Words: Glaucoma, Myopia, Optical Coherence Tomography (OCT), Bruch Membrane Opening-Minimum Rim Width (BMO-MRW), Retinal Nerve Fibre Layer (RNFL).

Anatomical Outcome Following Indocyanine Green Assisted Internal Limiting Membrane Peeling for Stage 3 and 4 Macular Hole Surgery.

OBJECTIVE: To evaluate the anatomical success of stage 3 and 4 macular hole surgery after removal of internal limiting membrane (ILM) with the help of Indocyanine green (ICG). STUDY DESIGN: An experimental study. PLACE AND DURATION OF STUDY: LRBTTertiary Care Eye Hospital, Karachi, October 2015 to August 2016. METHODOLOGY: Twenty patients with stage 3 and 4 macular hole (confirmed by spectral domain optical coherence tomography) underwent standard 3 ports pars plana vitrectomy. Staining of ILM was performed with the help of 0.5% ICG to aid in visualization. ILM was removed by using intraocular forceps in circular fashion. Finally, gas fluid exchange with internal tamponade of SF6 20% was performed. Postoperative face down posture was maintained for seven days. Patients were followed-up for 8 months and assessment of macular hole closure was done using SD-OCT. RESULTS: After a follow-up of 8 months, macular hole was closed in 17 eyes (85%) and vision had improved in 6 patients. Postoperative complications included cataract, hyphema and vitreous hemorrhage. CONCLUSION: Surgery for stage 3 and 4 macular hole with ILM peeling has high anatomical success rate. Final visual acuity is dependent on preoperative macular hole stage and visual acuity at presentation.

Outcomes of transconjunctival sutureless 27-gauge micro-incision vitrectomy surgery in diabetic vitreous haemorrhage.

OBJECTIVE: To evaluate the visual outcomes of 27-gauge transconjunctival sutureless vitrectomy surgery and its complications in patients with diabetic vitreous hemorrhage. METHODS: A quasi-experimental study was conducted where eighty seven eyes of 87 uncontrolled type II diabetes mellitus patients presenting with diabetic vitreous hemorrhage were selected to undergo 27-gauge transconjunctival sutureless micro-incision vitrectomy surgery. Main outcome measured was best corrected visual acuity (BCVA). Post-operative complications were also screened for at each visit. The follow ups were at post-operative day one, one month, three months and six months respectively. RESULTS: Out of 87 patients, 52 (59.8%) were males and 35 (40.2%) were females. The mean age of the patients was 52.32 ± 6.78 years (95% CI: 53.13 - 55.57). For most of the patients, the BCVA improved progressively with each subsequent follow up visit. Pre-operative BCVA was 1.01 ± 0.206 logMar, compared to BCVA at final follow up of 0.44 ± 0.231 (p-value < 0.001). Six (6.9%) patients developed recurrent vitreous hemorrhage during the study period, four (4.6%) developed cataract, one (1.1%) had increased intraocular pressure and sub conjunctival hemorrhage was present in two (2.3%). CONCLUSION: 27-gauge micro-incision vitrectomy surgery is an effective sutureless surgery with favorable outcomes, in terms of vision, in patients with diabetic vitreous hemorrhage. The associated complications are few which can be easily managed.

Role of bevacizumab in the prevention of early postoperative haemorrhage after 25-gauge microincision vitrectomy surgery.

OBJECTIVE: To evaluate the effect of preoperative intravitreal bevacizumab injection on the incidence of postoperative haemorrhage and visual prognosis, in patients undergoing 25-gauge micro incision vitrectomy surgery (MIVS) for diabetic vitreous haemorrhage. METHODS: One hundred and twenty two eyes of 122 patients of diabetic retinopathy of both genders and aged over 18 years, who presented with non-resolving vitreous haemorrhage were enrolled for this study. All patients received an intravitreal injection of 1.25 mg/0.05 mL bevacizumab (Avastin) which was followed one week later by 25-gauge sutureless micro incision vitrectomy surgery. Main outcomes measured were best corrected visual acuity (BCVA) assessed with logMAR and post-operative vitreous haemorrhage. Follow ups were up to six months post-operatively. IBM SPSS 21 was used for data analysis. RESULT: A total of 122 patients were included; 78 (63.9%) males and 44 (36.1%) females. Mean age at the time of surgery was 51.4 ± 13.66 years. The mean preoperative BCVA was 1.64 ± 0.427 logMAR which improved to 0.57 ± 0.253 logMAR at 12 months post-operatively (p-value < 0.001). Recurrent vitreous haemorrhage was seen in four patients (3.28%). one1 week before 25-gauge vitrectomy helps to reduce the incidence of early post-vitrectomy haemorrhage in diabetic patients.

Comparison of 1000-Centistoke versus 5000-Centistoke Silicone Oil in Complex Retinal Detachment Surgery.

OBJECTIVE: To compare the efficacy and complications of using 1000-centistoke versus 5000-centistoke silicone oil for complex retinal detachment repair. STUDY DESIGN: Case series. PLACE AND DURATION OF STUDY: LRBT Tertiary Eye Hospital, Karachi, from January 2007 to June 2013. METHODOLOGY: Eighty-five eyes (85 patients) presenting with superior rhegmatogenous retinal detachments associated with PVR grades B and C (involving not more than 3 clock hours) were randomized to either 1000 centistokes (n=44) or 5000 centistokes (n=41) silicone oil group. All patients underwent 23-gauge pars plana vitrectomy surgery with silicone oil intraocular tamponade. Patient data was analysed at 18 months post-operatively. IBM SPSS 21 was used for data analysis. RESULTS: There were 52 male and 33 female patients aged between 22 and 70 years (45.2 ±16.2). After the first surgery, successful reattachment of the retina was achieved in 67 eyes (78.8%); of which 35 eyes were in 1000-centistoke and 32 eyes in 5000-centistoke groups. Mean pre-operative Best Corrected Visual Acuity (BCVA) was 1.63 ±0.54 which was improved to a mean post-operative BCVAof 1.46 ±0.78 (1.42 ±0.74 in 1000-centistoke group; 1.49 ±0.78 in 5000 centistoke group). The 1000-centistoke group had a significantly higher frequency of oil emulsification which necessitated early removal of silicone oil. There were 66 eyes (77%) with at least one complication (34 eyes in 1000-centistoke group; 32 eyes in 5000-centistoke group) including cataract, corneal abnormalities, raised IOP, hypotony, vitreous haemorrhage and retinal redetachment. CONCLUSION: Although visual and anatomical outcomes were comparable between the two groups, the 1000-centistoke silicone oil group developed early oil emulsification necessitating its early removal.

Visual outcome of 25-gauge microincision vitrectomy surgery in diabetic vitreous haemorrhage.

OBJECTIVE: To assess the visual outcome and complications of 25-gauge micro incision vitrectomy surgery (MIVS) in diabetic vitreous haemorrhage. METHODS: This Quasi Experimental study was conducted at LRBT, Tertiary eye care hospital Karachi, from February 2012 to January 2013. Sixty eyes of sixty patients with uncontrolled type II diabetes mellitus (DM) were included. There were 43 (71.7%) males and 17 (28.3%) females. Age range was 40 - 60 years. All randomly selected patients underwent 25-gauge sutureless micro incision vitrectomy surgery for diabetic vitreous haemorrhage. Main outcomes measured were best corrected visual acuity (BCVA) assessed with logMAR and post-operative complications. Follow ups were at one day, one week, one month, three months and six months post-operatively. RESULT: Best corrected visual acuity (BCVA) gradually improved in majority of subjects in each subsequent follow up visit. Preoperative visual acuity was 1.023 ±0.226 logMAR, which was improved after final follow up to 0.457±0.256 and P-value was < 0.001. Five patients developed recurrent vitreous haemorrhage during study period, one patient developed cataract (1.7%), one (1.7%) had ocular hypotony defined as intraocular pressure < 5 mmHg and one (1.7%) developed endophthalmitis. CONCLUSION: 25-gauge micro incision vitrectomy surgery (MIVS) is an effective sutureless parsplana vitrectomy surgery which has good visual outcome in diabetic vitreous haemorrhage with minimum manageable complications.

Visual acuity after trans-scleral sutured posterior chamber intraocular lens.

OBJECTIVE: To determine the changes in visual acuity in patients undergoing Trans-Scleral Sutured Posterior Chamber Intra-Ocular Lens (TSSPCIOL) implantation at a tertiary care hospital in Karachi, Pakistan. STUDY DESIGN: Case series. PLACE AND DURATION OF STUDY: LRBT Tertiary Eye Hospital, Karachi, from January 2006 to December 2010. METHODOLOGY: Records of all patients undergoing implantation of TSSPCIOL were reviewed. Patients with diagnosed glaucoma, diabetic retinopathy, macular degeneration, history of recurrent uveitis, corneal haze or central corneal scars were excluded. For the final analysis, 70 eyes out of a total of 75 were selected. Main outcomes of interest were pre and postoperative visual acuities and surgical complications. SPSS 21 was used for data analysis. RESULTS: Pre-operatively, the average Best Spectacle-Corrected Visual Acuity (BSCVA) was 6/36 on the Snellen chart. This improved to 6/12 postoperatively. The mean improvement seen was 2.4 lines on the Snellen chart (p < 0.05). Complications include transient intraocular pressure elevation in 25 eyes (36%), IOL tilt in 4 eyes (7.1%), Cystoid Macular Edema (CME) in 4 eyes (5.7%), vitreous haemorrhage in 2 eyes (2.9%), hyphema in 2 eyes (2.9%), uveitis in 1 eye (1.4%), and retinal detachment 1 eye (1.4%). No IOL subluxation, suture erosion, iris capture, choroidal effusion or endophthalmitis was encountered and no re-operations were needed. CONCLUSION: TSSPCIOLs are a good management option for patients with aphakia in whom PC IOLs cannot be placed.