Single-triangle technique for congenital ptosis repair with a frontalis sling in blepharophimosis patients.

The purpose of this study was to describe the single-triangle technique for congenital ptosis repair with a frontalis sling in blepharophimosis patients. The single-triangle technique was used in 40 eyes of 20 patients of blepharophimosis syndrome. The center point of the lid is marked. The desired base length is calculated depending on the available horizontal fissure width. Two marks are inked 2 mm above the lid margin, equidistant from the central mark. A single brow mark is placed in such a way that it is directly above the center point of the lid. These are now joined to complete the triangle. In blepharophimosis patients, the mean preoperative margin reflex distance (MRD1) was 1.0 ± 1.1 mm which increased to 4.1 ± 1.6 mm after surgery. The MRD1 increased by 3.1 ± 1.7 mm. Cosmetic outcome was graded with a score of 0, 1, or 2 to indicate poor, good, and excellent results, respectively. Out of the 40 eyes that were operated, 33 eyes had a score of 2, 5 eyes had a score of 1, and 2 eyes were scored 0. The single-triangle technique has several advantages over both the Fox pentagon technique and modified Crawford technique in severe blepharophimosis patients. It is not only a much simpler procedure to perform but also has a better control over the curvature of the lid without any central focal notching, thus providing better cosmesis and esthetic results.

Future of anti-VEGF: biosimilars and biobetters.

The advent of Anti- VEGFs like Lucentis (Ranibizumab), Eylea (Aflibercept) and off-label Avastin (Bevacizumab) have radically improved visual outcomes in patients of neovascular Age Related Macular Degeneration (nARMD), Diabetic Macular Edema (DME) and Retinal Vein Occlusion (RVO). It is a matter of great concern that the US patents for Ranibizumab and Aflibercept expired in 2020 with European patents to expire in 2022 and 2025, respectively. With the expiry of these biologics, Biosimilars can prove to be saviours in the posterior segment pharmacotherapy owing to their cost effectiveness and availability of various options. Numerous biosimilars are expected to gain approval for clinical use from the US-FDA and EMA soon. Biobetters are better than the original biologic in one or more parameters but require more research and development resources. With the emergence of better manufacturing and purification processes it is imperative that the biologics and biosimilars become better. The Ophthalmologists need to have in depth knowledge about these Biosimilars and Biobetters before these molecules take over the mainstream market.

Preoperative COVID-19 Testing for Elective Ophthalmological Procedure in a Tertiary Health Care Centre: Our Experience During the Pandemic.

BACKGROUND: To study the prevalence of coronavirus infection among asymptomatic patients requiring eye surgery and the role of screening in prevention of spread of infection among the healthcare workers. DESIGN: The prospective observational study was conducted in the Ophthalmology department of a tertiary care center in Delhi from September 2020 to December 2020. SETTING: Patients requiring elective ophthalmological procedures in a tertiary care hospital were screened for coronavirus using the RT-PCR method. Testing methods and results were documented. RESULTS: Among the 218 asymptomatic patients posted for elective surgery in that period, 16 (7.3%) were found to be positive for COVID-19. Those who tested positive were advised home isolation and surgery was postponed for the next 14 days. No complications were reported in these patients. One health-care worker also tested positive for COVID-19 during our study period. CONCLUSION: In our study, 1 out of 14 asymptomatic patients were found to be carriers for the novel virus. Asymptomatic COVID-infected patients may lead to transmission of the virus inside the hospital among the visiting patients and hospital staff while they have no adverse effect on the surgery and its outcome.

Is Interferon α-2b 1 MillionIU/mL Truly Better Than Tacrolimus 0.03% for Steroid-Resistant VKC ?: Our 2-Year Experience at a Tertiary Health-Care Centre.

PURPOSE: To compare the efficacy of eye-drop interferon (IFN) α-2b 1 millionIU/mL with eye-ointment tacrolimus 0.03% in refractory vernal keratoconjunctivitis (VKC). MATERIALS AND METHODS: Fifty patients with VKC refractory to conventional treatment with topical corticosteroids and antihistamines after 4 weeks of regular use were selected retrospectively. Patients were divided into two groups depending on whether they received eye-ointment tacrolimus 0.03% three times a day or eye-drop IFN alpha-2b 1 millionIU/mL three times a day and were followed up for 24 months. The main outcome measures were total subjective symptom score (TSSS) and total objective ocular score (TOSS). RESULTS: Mean baseline TSSS was 7.24±1.98 in Group A (tacrolimus group) and 7.84±1.82 in Group B (IFN group), and it reduced to 1.12±0.83 in Group A and 0.62±0.41 in Group B at 6 months, which was statistically significant compared to the baseline score (p<0.05) as well as between the two groups. Mean baseline TOSS was 6.72±2.07 in Group A and 6.56±2.04 in Group B, and it improved to 1 month onwards to 1.52±0.87 in Group A and 1.0±0.71 in Group B at 6 months, which was statistically significant compared to the baseline score (p<0.05) as well as between the two groups. Side effects like stinging and burning sensations were seen in the tacrolimus group only. CONCLUSION: Our study suggests that while both eye-drop IFN α-2b 1 millionIU/mL and eye-ointment tacrolimus eye ointment 0.03% are both safe and effective steroid-sparing agents in steroid-resistant VKC. IFN α-2b results in greater improvement in subjective symptoms and objective signs, has fewer side effects in long term and is better tolerated as compared to tacrolimus.

Ripasudil Endgame: Role of Rho-Kinase Inhibitor as a Last-Ditch-Stand Towards Maximally Tolerated Medical Therapy to a Patient of Advanced Glaucoma.

PURPOSE: To elucidate the use of Ripasudil in patients of advanced glaucoma on maximally tolerated medical therapy who could not be offered the option of surgery due to the global pandemic lockdown. MATERIALS AND METHODS: Only patients with primary open angle glaucoma (POAG), who had a cup-disc ratio (CDR) of 0.9 or a near total cupping on maximum tolerated medical therapy for at least 4 weeks and yet could not meet the target IOP were included. Target IOP was defined as ≤12 mm Hg. A total of 30 patients were enrolled. All patients in study cohort were started on E/D Ripasudil BD. Patients were followed up at 1 week, 2 weeks, 4 weeks and then monthly for 6 months for their best corrected visual acuity (BCVA), intraocular pressure (IOP), disc changes (slit lamp biomicroscopy), perimetry, and retinal nerve fibre layer analysis using optical coherence tomography (OCT-RNFL). RESULTS: Mean pre-treatment IOP on five drugs was 18.3 ± 2.1 mm Hg (range 14 to 22mmHg) on maximally tolerated medical therapy. At 1 week follow-up, mean post-treatment IOP was 15.1 ± 1.7 mm Hg (range 12 to 18mmHg) and at 2 week follow-up, mean post-treatment IOP was 12.5 ± 1.9 mmHg (range 10 to 16mmHg). Thus, target IOP ≤12mmHg was attained in 28 patients at 2 weeks. This target IOP was maintained throughout the 6 months of follow-up period. Of the 2 patients who could not meet target IOP, 1 patient needed rearrangement of their fixed-drug-combinations to achieve target IOP at 4 weeks. The second patient required unfixing of all fixed-drug-combinations to achieve target IOP at maximally tolerated medical therapy at 6 weeks. CONCLUSION: Ripasudil not only provides a better IOP control but also has a high safety profile even when started as an add-on drug to already-existing yet inadequate maximally tolerated medical therapy.

Optic perineuritis.

Optic perineuritis (OPN) is a rare inflammatory disorder in which the inflammation is confined to optic nerve sheath. It can be idiopathic or secondary to underlying systemic autoimmune disorder. It usually presents with unilateral progressive diminution of vision with pain on eye movements and optic disc oedema. Hence, clinically OPN mimics optic neuritis resulting in delayed diagnosis and suboptimal treatment. In contrast to optic neuritis, patients with OPN are usually of older age group and more likely show sparing of central vision. MRI is an important tool for diagnosis of OPN apart from optic nerve sheath biopsy. Perineural enhancement on MRI is diagnostic of OPN. Oral corticosteroid therapy gives dramatic and rapid improvement in signs and symptoms. Rapid tapering of steroids increases the risk of relapse. Overall, prognosis of OPN is generally good if adequate treatment is given timely.

Capsular bag phimosis.

A 60year old male presented with insidious onset, gradually progressive, painless diminution of vision in the right eye since a year. He was operated for cataract about 7 years ago. However, details of surgery or intraocular lens (IOL) were unavailable. Fellow eye was unremarkable. Examination revealed a visual acuity of FC at 5 mts. Slit-lamp examination revealed a quiet anterior chamber without any cells-flare nor any posterior synechiae. Co-axial retro-illumination revealed an in-the-bag IOL, having both haptics folded on the optic with scarring and contraction of the capsular bag, most apparent in the centre. Fundus examination with indirect ophthamoloscopy was difficult owing to the media haze due to capsular scarring but retina was unremarkable as far as could be seen. A diagnosis of "Capsular Bag Phimosis"1,2,3,4 was made. An ASOCT demonstrated such severe moulding of the IOL that a simple YAG capsulotomy may have increased visual acuity but would have lead to severe image distortion, metamorphopsia and resultant aniseikonia. IOL was explanted alongwith the phimosed capsular bag and a Scleral-fixated IOL was placed to achieve a final BCVA 20/20P Snellen.

Can We Corroborate Peripapillary RNFL Analysis with Macular GCIPL Analysis? Our 2-Year Experience at a Single-Centre Tertiary Healthcare Hospital Using Two OCT Machines and a Review of Literature.

PURPOSE: To determine whether macular volume and macular GCA measurements in patients are comparable to their RNFL thickness parameters. MATERIALS AND METHODS: The cross-sectional, observational study was conducted on 1380 eyes with 460 each, into three groups. Group I: patients with healthy eyes. Group II: patients diagnosed as pre-perimetric glaucoma. Group III: patients with diagnosed perimetric glaucoma. After patients were selected on the basis of inclusion and exclusion criteria, baseline standard ophthalmic examination was done by the same operator under the same settings, including SD-OCT using both the Spectralis SD-OCT and the Cirrus SD-OCT as elaborated below. STATISTICAL ANALYSIS: Data were checked for normality before statistical analysis using Shapiro-Wilk test. Normally distributed continuous variables were compared using ANOVA. For all statistical tests, a p < 0.05 was taken to indicate a significant difference. Receiver operating characteristic (ROC) curves were used to define the ability RNFL and GCC parameters to distinguish perimetric and preperimetric glaucomatous eyes from control eyes. RESULTS: There was a statistically significant difference in the average, superior, inferior RNFL thickness and average, superior, inferior GCIPL thickness between Group I and Group II (p<0.001), between Group I and Group III (p<0.001) and also between Group II and Group III (p<0.001). The statistical significance was also reflected in their AUROCs. CONCLUSION: Mean, superior, inferior GCIPL thickness along with macular volume analysis can substantiate RNFL analysis for diagnosis, serial monitoring and follow-up of glaucoma patients and suspects.

Topical vs Peribulbar Anesthesia: Comparison of Anterior Chamber Depth and the Resultant Visual Outcome After Phacoemulsification.

PURPOSE: To compare anterior chamber depth and postoperative visual outcome in patients undergoing phacoemulsification under topical vs peribulbar anesthesia. MATERIALS AND METHODS: Prospective, randomized, comparative observational study.Sample size: 110 eyes with 55 eyes each. Group I: Patients undergoing phacoemulsification under topical anesthesia.Group II: Patients undergoing phacoemulsification under peribulbar anesthesia.Once patients were selected, baseline a standard ophthalmic examination was done including best-corrected visual acuity (BCVA), refraction, IOP by NCT, anterior segment evaluation with slit lamp biomicroscopy, keratometry, axial length, and ACD measurement by IOL master. Post-operatively, the patients were reviewed at day 1, week 1, week 6 for the same parameters.Statistics:Quantitative variables: Paired and unpaired t-test.Qualitative variables: Chi square test.A P-value of <0.05 was considered statistically significant. RESULTS: Inter-group comparisons of post-operative change in ACD at 1-week post-op (P-value<0.001) and 6-week post-op (P-value<0.001) were statistically significant when compared to the pre-op values. The mean spherical equivalent in group I was 0.27±0.26 d and that in group II was 1±0.32 d at 1-week post-op. The mean spherical equivalent in group I was 0.23±0.20 d, while that in group II was 0.85±0.64 d at 6-week post-op. This difference was statistically significant both at 1-week post-op (P-value=0.002) and 6-week post-op (P-value<0.001). CONCLUSION: Post-phacoemulsification, the ACD is more after peribulbar anesthesia as compared to topical anesthesia. Post-op refractive outcome is better with the use of topical anesthesia.

Does Frontalis Sling Surgery for Congenital Ptosis Change the Corneal Topography and Refractive Characteristics Postoperatively?

PURPOSE: To evaluate the effect of frontalis sling surgery for congenital ptosis on corneal curvature and refractive status. METHODS: Prospective study of 60 eyes of 48 patients with severe simple congenital ptosis who underwent surgical correction by frontalis sling surgery. Assessment was done pre-operatively and at 1 week, 1 month, 3 months post-operatively by computerized topographer (Shipp Nippon, CT 1000), IOL master (Carl Zeiss, 500), autorefractometer (Unicos URK-800) and AS-OCT (Cirrus HD-OCT). The results were statistically evaluated to analyze any change in visual acuity, refractive status, keratometry, astigmatism and central corneal thickness (CCT). RESULTS: Three months post-operatively, significant reduction of cylindrical power by -0.358 D was observed by refraction with corresponding improvement of mean BCVA by 0.24±0.04 logMAR. Corneal topography showed reduction in astigmatism by -0.47±0.95 D; however, the average keratometry did not undergo a significant change. The mean values of astigmatism by IOL master and topographer were comparable. There was significant steepening of the previously flatter meridian (horizontal meridian, in 63.3% patients) while the steeper meridian remained relatively unchanged. A greater reduction in astigmatism was noticed in children in the age group of 5-10 years. CONCLUSION: Ptosis surgery modifies the corneal curvature, restoring corneal symmetry and reducing astigmatism; thus changing the refractive status of the patient, which needs to be addressed post-operatively to improve the quality of vision. Children with severe ptosis may benefit from being operated at an early age to achieve better astigmatic reduction.

Forceps-assisted, 10-0 monofilament nylon, suture-guided capsular tension ring insertion in subluxated cataracts.

Capsular tension ring (CTR) and iris hooks have proved to be useful devices in cataract surgery in cases of zonular weakness and dialysis. We would like to describe the use of monofilament 10-0 nylon (MFN)- guided CTR insertion in a subluxated cataractous lens. Here, the MFN is passed through the distal trailing eyelet of the CTR (simple or Morcher's depending on the size of the defect and subluxation) for controlled insertion of the distal eyelet of the CTR beneath the anterior capsulorhexis margin and safe retrieval of CTR in case of an iatrogenic posterior capsular tear during CTR insertion or phacoemulsification.

Modified bandage-contact-lens used as a guide-marker for performing continuous-curvilinear-capsulorhexis by a first-year-post-graduate-ophthalmology-resident.

PURPOSE: To define the use of modified bandage-contact-lens as a guide-marker for performing continuous-curvilinear-capsulorhexis by a first-year-post-graduate-ophthalmology-resident. OBSERVATION: Phacoemulsification has now become the standard cataract surgery in which anterior capsulorhexis is the first and most crucial step. A perfect capsulorhexis is difficult to learn and even more difficult to master with a steep learning curve when performed free-hand especially by a first-year post-graduate ophthalmology-resident. There is paucity of simple, single-use, easily portable, cost-effective and affordable devices designed especially for performing CCCs in a safe and reproducible way.In our technique, the bandage contact lens (BCL) is trephined using a 6mm corneal trephine. After topical or peribulbar block (as the case may be), the 6mm-guide-marker (trephined BCL) is placed on the cornea. The CCC is then completed using the edge of the contact-lens as a guide for CCC. CONCLUSION: AND IMPORTANCE: CCC with contact-lens-guide-marker is expected to yield better results in carrying out the procedure more accurately being closer to the target in terms of size, circularity and centration as compared to contact-lens-unassisted conventional CCC. This would eventually facilitate better surgical outcomes and we recommend this to be applied as the standard protocol for first-year post-graduate ophthalmology-resident performing the surgery.

Congenital isolated idiopathic episcleral arteriovenous malformation.

PURPOSE: To report the occurrence of an episcleral AVM and to discuss the gravity as well as management of dilated tortuous episcleral vasculature. OBSERVATION: A 16-year-old Asian male presented with redness in the left eye since birth and a history of gradual painless progressive increase in size since the past two years, causing a cosmetic concern for the patient. There was no history of any diminution of vision, diplopia, headache, trauma or any similar lesions anywhere in the body.On examination, unaided visual acuity (UCVA) was 6/6 Snellen in both eyes. Hirschberg's reflex was central and extraocular movements were full and free in both the eyes.On slit-lamp examination, dilated tortuous episcleral vessels were found in the temporal aspect of the palpebral aperture, shaped like a single continuous vascular frond, vertically measuring 10-11mm in extent and horizontally commencing 6mm from the temporal limbus but the posterior limit could not be discernible. The episcleral plane was freely mobile from the overlying conjunctiva and underlying sclera. The dilated episcleral vasculature remained unchanged on Valsalava maneuver and on bending forward.Intraocular pressure was 14 mmHg by Goldmann's appalanation tonometer in both eyes. Iris was normal in configuration and gonioscopy revealed open angles without any evidence of any neovascularisation in both eyes. Fundus examination was unremarkable.USG B-scan was grossly normal. MR Angiography of head and orbit with using thin high-resolution cuts (1mm using 3T machine) was done and was later followed up with a Contrast Enhanced MRI. Both imaging studies revealed an isolated episcleral AVM with a possible feeder vessel from the anterior ciliary artery to the lateral rectus and without any intraorbital or intracranial lesion.A diagnosis of isolated episcleral AVM was made. The episcleral plane was dissected and dilated tortuous vessels were excised. After cautery, conjunctival autograft was obtained from the fellow-eye was used to cover the defect. Histopathological examination revealed both thick and thin walled vessels of varying calibre corresponding to arteries and veins confirming the diagnosis of isolated episcleral AVM. Ref. Fig. 2. No recurrence has been observed over a follow-up period of 1 year. CONCLUSION: AND IMPORTANCE: Isolated idiopathic episcleral AVM should be a diagnosis of exclusion. A thorough systemic and ophthalmological evaluation including a glaucoma workup is necessary for both diagnosis and management. UBM and MRI/MRA may be required in select cases to rule out any associations or complications. Management includes observation, embolization and excision.

Atypical optic neuritis as the presenting feature of testicular malignancy: Rare case report with review of literature.

A 23-year-old male presented with unilateral acute onset, painless, progressive diminution of vision. Initial clinical and radiological findings were consistent with optic neuritis. The patient was started on pulse steroids leading to visual recovery. However, the patient relapsed within one week. Repeat imaging revealed metastatic lesions near the orbital apex. Orbit is an unusual site of metastasis from testicular tumors and only 3 cases of testicular synovial sarcoma with orbital metastasis have been reported. A thorough systemic evaluation should be done in cases of atypical and relapsing optic neuritis to rule out the causes of optic neuritis (ON) masquerade syndrome.

Topical steroid alone vs a combination with a posterior segment NSAID after Nd-YAG capsulotomy: Is the posterior segment NSAID really necessary?

PURPOSE: To compare the effect of topical 1% prednisolone acetate and 0.09% bromfenac versus topical 1% prednisolone acetate alone on macular thickness following Nd: YAG laser capsulotomy. MATERIALS AND METHODS: About 150 eyes with posterior capsule opacification following were included. All patients were treated with Nd: YAG laser posterior capsulotomy. Patients were randomly divided into two groups of 75. Group 1-Patients received: Topical 1% prednisolone acetate and Topical 0.09% bromfenac. Group 2-Patients received: Topical 1% prednisolone acetate alone. Outcome measures by an independent observer were BCVA by Snellen chart, IOP by NCT, and Central Macular Thickness (CMT) by Macular OCT. All patients were examined before the procedure, 1 h after the procedure, at 1 week, and at 6 weeks. STATISTICS: 1. Quantitative variables: Mann-Whitney Test and Wilcoxon ranked sum test. 2. Qualitative variables: Chi-square test. A P value of < 0.05 was considered statistically significant. RESULTS: Mean IOP increase in both groups is statistically significant at 1 h and later decreases back to nonsignificant levels at 1 week and 6 weeks. No significant change in mean CMT was seen in the duration of 6 weeks neither in Group 1 nor Group 2. CONCLUSION: Prophylactic antiglaucoma medications are not recommended in patients undergoing Nd: YAG laser capsulotomy. No evidence of cystoid macular edema was recorded till the end of 6 weeks follow-up.

Retro-intraocular Lens Irrigation-aspiration to Prevent Capsular Block Syndrome at the Hands of Novice Surgeons.

Retro-intraocular lens (IOL) irrigation-aspiration is of paramount importance in order to remove the viscoelastic substance from the retro-IOL space and to prevent any early post-operative capsular block syndrome. However, manoeuvring the IOL to reach the retro-IOL space may be difficult at the hands of novice surgeons despite the use of coaxial or bimanual irrigation-aspiration probes. We describe a simpler and safer technique in order to facilitate the removal of this retro-IOL viscoelastic substance using a 26-Gauge bent-cannula mounted on a 2-ml syringe. The fluid is injected forcefully along with sideways movement of cannula in a single-plane to displace the viscoelastic substance.

Megaloblastic anemia and bilateral disc edema: An enigma Have we figured it out yet?

A 28-year-old male presented with insidious-onset, painless, progressive diminution of vision in both eyes. He denied any other ocular symptoms. On examination, visual acuity in both eyes was 6/60. Color vision and contrast sensitivity were maintained in both eyes. Direct ophthalmoscopy revealed that the optic discs were bilaterally hyperemic and congested, with blurring of all the disc margins and loss of spontaneous venous pulsations. Besides this bilateral disc edema, rest of the clinical examination was normal. Primary intensive search for any intracranial space-occupying lesions returned negative on computed tomography scan imaging. Blood investigations revealed a hemoglobin level of 9.2 g/dl, leukocyte count of 7000 cells/mm3, and serum Vitamin B12 level of 155 pg/ml (200-835 pg/ml). Serum homocysteine and methylmalonic acid levels were done and were found to be elevated. After 4 weeks, visual acuity improved to 6/6 in both the eyes, and laboratory investigations showed no signs of Vitamin B12 deficiency. Nonsurgical causes for papilledema should be considered in the differential diagnosis. Early diagnosis and prompt treatment is the key to a good prognosis in Vitamin B12-deficient optic neuropathy, which has shown to have a good prognosis if treatment is initiated in the first few months after the onset of symptoms.