Impact of inverted internal limiting membrane-flap technique on functional outcome and structural restoration of small and medium size macular holes.

Purpose: To evaluate the impact of the inverted internal limiting membrane (ILM)-flap technique on the visual outcome and anatomical recovery for small (<250 µ), medium (<400 µ), and large (>400 µ) macular holes (MHs). Methods: Retrospective study included consecutive idiopathic MH cases operated on using the inverted ILM-flap technique. Clinical data were retrieved from electronic medical records (EMRs), surgical videos, and optical coherence tomography (OCT) machines. Eyes with axial length >25 mm, coexisting macular diseases, and follow-up <6 weeks were excluded. Data included the presence or absence of ILM flap and restoration of External Limiting Membrane (ELM), Ellipsoid Zone (EZ) lines. Mean visual improvement and structural recovery were compared between eyes showing ILM flap and those showing no flap in three MH size groups. Results: Forty eyes of 38 patients with a mean age of 62.7 ± 10.1 years and a mean MH diameter of 348 ± 152 µm were included. The mean follow-up was 527 ± 478 days with anatomical closure observed in all eyes. Mean best-corrected visual acuity (BCVA) improved significantly from 0.87 ± 0.38 to 0.35 ± 0.26. ILM flap was visible in 29 (72.5%) all MHs, 7 (53.8%) small MHs (n = 13), 8 (61.5%) medium MHs (n = 13), and 14 (100%) large MHs (n = 14). The mean BCVA change was 0.47 ± 0.34, 0.53 ± 0.48, and 0.56 ± 0.20 in large, medium, and small MHs, respectively, and the difference between eyes showing ILM flap versus no flap in each MH size group was not statistically significant (P > 0.05). However, for medium MHs, it was higher in the ILM flap (0.66 ± 0.52) group compared to the no flap (0.32 ± 0.37) group. One eye with small MH developed significant gliosis resulting in reduced BCVA. ELM was restored in all eyes with small and medium MHs. Conclusion: We observed that the ILM flap did not adversely affect anatomical and visual outcomes for MHs <400 µm. Restoration of ELM suggests minimal interference in structural recovery by an ILM flap.

Virtual-reality headset mounted smartphone-based Indentation fundus videography.

To describe a simple and novel technique that overcomes the limitation of smartphone-based fundus photography and allows examiners to capture peripheral retinal images with indentation. Smartphone with video camera in flash-on mode was mounted on virtual-reality (VR) headset. This was combined with +28D lens and +20D lens and soft cotton bud to capture high-quality videos of peripheral fundus with indentation. Autofocus function of the camera and examiner's head movements to adjust the distance was used to obtain retinal video. The procedure is akin to indirect ophthalmoscopy. The feasibility of obtaining well-focused retinal images during indentation was checked. We could obtain good quality videos demonstrating indentation of the peripheral fundus in 10 eyes showing different pathologies such as laser marks, lattice degeneration, and pigmented lesions. VR headset-mounted smartphone-based indentation fundus videography is an innovative cost-effective technique to capture peripheral retinal images. The technique can be useful for documenting retinopathy of prematurity lesions and other situations where widefield photography is not possible.

Epiretinal Membrane from Uncontrolled Gliosis After Inverted ILM Flap Technique for Idiopathic Macular Hole.

We describe two cases with epiretinal membrane (ERM) from uncontrolled gliosis seen after multilayered inverted internal limiting membrane (ILM) flap technique for full thickness macular hole (FTMH). Two patients with FTMH who had undergone surgery with inverted ILM flap technique were examined by serial optical coherence tomography scans to evaluate the course of multilayered ILM flaps seen as foveal hyperreflective lesions postoperatively. We observed excessive uncontrolled gliosis over these hyperreflective ILM flaps with ERM formation, along with worsening metamorphopsia and best-corrected visual acuity. Case 1 underwent a repeat surgery for ERM. We report excessive uncontrolled gliosis as a rare complication of multilayered inverted ILM flap technique for FTMH. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:663-665.].

Comparison of the Safety and Efficacy of Intravitreal Ranibizumab with or without Laser Photocoagulation Versus Dexamethasone Intravitreal Implant with or without Laser Photocoagulation for Macular Edema Secondary to Branch Retinal Vein Occlusion.

BACKGROUND: There is an ambiguity regarding the therapy of choice for patients with macular edema following branch retinal vein occlusion (BRVO). AIM: The purpose of the study was to compare the efficacy and safety of ranibizumab (3 injections 0.5 mg) versus ranibizumab (1 injection 0.5 mg) with laser photocoagulation (LP) versus dexamethamethasone intravitreal (IVT) implant (0.7 mg) with or without LP in patients with macular edema following BRVO. MATERIALS AND METHODS: 60 eyes of 60 patients were divided into 4 groups. Group 1 received IVT ranibizumab (3 injections 0.5 mg), Group 2 received IVT ranibizumab (1 injection 0.5 mg) + LP, Group 3 received dexamethasone IVT implant (0.7 mg), and Group 4 received dexamethasone IVT implant (0.7 mg) + LP. The endpoints were the difference in mean changes in best corrected visual acuity (BCVA), central macular thickness (CMT), and inter-group differences in contrast sensitivity (CS), retinal sensitivity (RS), and intraocular pressure (IOP). RESULTS: BCVA gains in Group 1 (18.00±8.51) patients were significantly (p < 0.05) higher than patients in Groups 2 (10.00±10.26), 3 (9.50±9.60), and 4 (10.50±10.97), after 6 months of therapy. No significant inter-group variation was found in the CMT, CS, and RS. CONCLUSIONS: Ranibizumab (3 injections 0.5 mg) showed significantly higher BCVA gains at 6 months post-therapy. Improvements in the BCVA, CMT, CS, and RS were comparable initially in all the therapies.

Evaluation of rhegmatogenous retinal detachments using Optos ultrawide field fundus fluorescein angiography and comparison with ETDRS 7 field overlay.

PURPOSE: To evaluate the ultrawide field fundus fluorescein angiography (UWFA) characteristics of rhegmatogenous retinal detachments (RRDs) and compare the findings with an early treatment diabetic retinopathy study (ETDRS) 7 field (ETDRS7F) overlay. METHODS: UWFA (Optos, PLC, Dunfermline, UK) was performed in 10 eyes with macula-off RRDs in 9 patients. The findings of UWFA were compared with that of an overlay of standard ETDRS7F. RESULTS: Vascular dilation, tortuosity of vessels, and blockage of choroidal fluorescence were noted in all eyes in both UWFA and ETDRS7F overlay. Other findings in UWFA and ETDRS7F included peripheral perivascular staining (10 versus 4 eyes), peripheral capillary nonperfusion (CNP) (9 eyes compared to none), vascular loop formation (7 eyes versus none), optic disc hyperfluorescence (5 eyes in both), petaloid leak at macula (2 eyes in both), and neovascularization elsewhere (3 eyes versus none). CONCLUSIONS: Peripheral perivascular staining and leak, CNP, and vascular tortuosity are common UWFA features of RRDs. Standard ETDRS7F missed peripheral CNP, peripheral vascular loops, and peripheral retinal new vessels in all eyes compared to UWFA in the current study.

Intravitreal gas injection with prone positioning for giant retinal pigment epithelial tear.

We report a 78 year old male with acute RPE tear with sudden vision loss, who underwent intravitreal C3F8 injection for reattaching the RPE. The impact of gas on detached RPE was studied by serial OCTs and Fundus pictures.

Phthisis Bulbi-a Clinicopathological Perspective.

Phthisis bulbi denotes end-stage eye disease characterized by shrinkage and disorganization of the eye with the resultant functional loss. The major factors associated with the pathogenesis of phthisis are hypotony, deranged blood-ocular barriers, and inflammation. Common causes include trauma, surgery, infection, inflammation, malignancy, retinal detachment, and vascular lesions. A phthisical globe shows a small squared off shape, opaque and thickened cornea, thickened sclera, neovascularization of iris, cataract, cyclitic membrane, ciliochoroidal detachment, and retinal detachment. Microscopic features include internal disorganization, inflammatory reaction, a reactive proliferation of various cells, calcification, and ossification. Early treatment of the causative etiology is the best strategy available to avoid an eye from going into phthisis. A phthisical eye has no visual potential and cosmetic rehabilitation or symptomatic relief of pain remains the mainstay in the management. The authors present a comprehensive review of the etiopathogenesis, pathology, clinical features, and management of the end-stage ocular disease.

Excellent visual outcome after vitrectomy for traumatic macular hole associated with choroidal rupture across papillomacular bundle.

PURPOSE: To report the visual result of Surgery for traumatic macular hole with choroidal rupture running across papillomacular bundle. METHOD: Observation case report Patient 20 year old male patient presented with acute vison loss in OS with BCVA reduced to 20/80 following blunt trauma. Examination revealed full thickness macular hole with choroidal rupture between disc and macula, spanning across papillomacular bundle (PMB) in OS. Patient underwent 25G Vitreous Surgery with ILM peeling and SF6 injection for OS. RESULTS: Macular hole was successfully closed at 4 weeks follow up and BCVA improved to 20/20. There was no postoperative complication. CONCLUSION: We report that Traumatic macular holes with associated choroidal rupture running through PMB can be successfully repaired with Vitreous surgery and these eyes may achieve good visual outcome.

Intravitreal Bevacizumab for Choroidal Neovascular Membrane at the Edge of a Healed Choroidal Tuberculoma.

The authors present a 36-year-old female with pulmonary tuberculosis who developed a choroidal tuberculoma in the left eye. The choroidal tuberculoma successfully resolved with visual gain following oral anti-tubercular and oral steroid therapy leaving behind a chorioretinal scar. One year after the completion of anti-tubercular treatment, she developed visual loss due to the development of a secondary choroidal neovascular membrane at the fovea. This was treated successfully with one intravitreal injection of bevacizumab in the left eye. The fovea remained free of fluid until the last follow-up 10 months after the intravitreal injection. Intravitreal bevacizumab may be an effective modality for treating secondary choroidal neovascular membranes that may form at the edge of a healed choroidal tuberculoma.

Impact of estimated glomerular filtration rate on diabetic macular edema.

PURPOSE: Diabetic macular edema (DME) is a major cause of visual impairment in patients with diabetes and is influenced by various systemic factors. This study evaluates the effect of renal status on DME using estimated glomerular filtration rate (eGFR) as a study marker. METHODS: This was a prospective observational cross-sectional study. One hundred and ninety-five patients of diabetic retinopathy (DR) were included. Group 1 had patients of DR without DME (n = 100), and group 2 had patients of DR with DME (n = 95). All patients were evaluated for DR/DME-related risk factors. eGFR was calculated in all patients. Spectral domain optical coherence tomography (SDOCT) was done to identify the various patterns and severity of DME. RESULTS: Group 2 patients had significantly higher comorbidities than those in group 1 (p < 0.001). Hba1c, total cholesterol, triglycerides, LDL/HDL ratio, systolic and diastolic blood pressures were significantly higher in group II (p < 0.001 in each). There was no significant difference between the groups in terms of blood urea, serum creatinine or eGFR. eGFR did not show a significant association with a specific SDOCT pattern or severity of DME. CONCLUSION: Comorbidities are more common and more severe in patients with DME. However, eGFR as a marker was not useful in predicting either the severity or pattern of DME. eGFR, in its present form, may not be useful in the evaluation and management of patients with DME.

Central Retinal Vein Occlusion-like Appearance: A Precursor Stage in Evolution of Frosted Branch Angiitis.

PURPOSE: To report a young man with a central retinal vein occlusion (CRVO)-like appearance which later evolved to frosted branch angiitis (FBA). CASE REPORT: As 28-year-old Indian man presented with optic disc swelling, hyperemia, peripapillary hemorrhages, and dilated tortuous veins in the left eye, 6 months after being diagnosed with idiopathic FBA in the right eye. Within 3 days of presentation, the left eye developed FBA, which was promptly and successfully treated with oral steroids. CONCLUSION: A CRVO-like picture may be the first stage of FBA. Young patients with CRVO and intraocular inflammation should be followed closely for early detection of FBA. Early initiation of oral steroids may preserve visual acuity in such cases.

Triads in Ophthalmology: A Comprehensive Review.

Ophthalmology, like any other clinical science, is constantly evolving. As our knowledge in this field expands, we enumerate and describe classical triads of symptoms or signs with relevance to ophthalmology in this article. Characteristic clinical triads for certain systemic conditions with ocular implications are also discussed.

Periarterial Plaques (Kyrieleis' Arteriolitis) in a Case of Bilateral Acute Retinal Necrosis.

PURPOSE: To describe unilateral periarterial plaque in a case of bilateral acute retinal necrosis (BARN) due to varicella zoster virus (VZV). METHODS: Case report. RESULTS: A 43-year-old diabetic male presented to us with dimness of vision in the left eye for three months. He was already on oral steroids and anti-viral therapy. Best-corrected visual acuity was 6/6 OD and hand movements close to face OS. The right eye showed inferior and temporal retinal thinning and pigmentation and periarterial whitish focal Kyrieleis' plaques, specifically along arterioles. Left eye had mild vitritis, optic disc pallor, arteriolar attenuation, with retinal whitening and areas of pigmentation involving 360° of peripheral retina along with some involvement of the posterior pole. Serology for human immunodeficiency virus (HIV), herpes simplex virus (HSV), and cytomegalo virus (CMV) was negative. IgM for VZV was positive. Oral Valacyclovir 1 g thrice daily was continued and a slow taper of oral steroids was instituted. CONCLUSIONS: ARN should be considered as a differential diagnosis in cases with Kyrieleis' plaques and a peripheral retinal examination must be done to rule out patches of healed retinitis and vasculitis.

Evaluation of fundus autofluorescence patterns in age-related macular degeneration.

AIM: To study the various morphological patterns of fundus autofluorescence (FAF) images in patients with age-related macular degeneration (AMD) in Indian population. METHODS: Totally 179 eyes of 104 patients with clinical diagnosis of AMD were recruited into the study. Autofluorescence images were captured using confocal scanning laser ophthalmoscope and the patterns of FAF were classified. RESULTS: Of 179 eyes, 27 (15.08%) were early AMD, 58 (32.41%) were intermediate AMD, 94 eyes (52.51%) were late AMD. Of 94 eyes with late AMD, 79 (84.04%) were neovascular AMD and 15 (15.96%) were central geographic atrophy. In eyes with early and intermediate AMD, 9 patterns of FAF were noted. Six patterns (normal, minimal change, focal increased, patchy increased, linear, reticular) were similar to that in the published classification. Two patterns (lacelike and speckled) described in the published classification were not found. Three new patterns (focal hypo-fluorescence, patchy hypo-fluorescence, mixed focal hypo-fluorescence and hyper-fluorescence) were detected. In eyes with neovascular AMD, 6 morphological patterns of FAF were noted. Two patterns (mixed hypo-fluorescence and hyper-fluorescence, central hypo-fluorescence with hyper-fluorescent rim) were similar to that in published classification. Two patterns (normal, near normal or normal background fluorescence in the centre of hypo-fluorescent area) described in the published classification were not found. Four new patterns (minimal change, hypo-fluorescent patch, central hypo-fluorescence with surrounding reticular, bull's eye) were recognized. In eye with central geographic atrophy 5 morphological patterns were noted and these were similar to that in published classification. CONCLUSION: Phenotypic differences in the pattern of FAF exist in the study population compared to existing classification systems.