A quantitative evaluation of the effect of meals on macular thickness in diabetic patients with diabetic macular edema.

PURPOSE: Central subfoveal thickness measurement is used in a large number of clinical trials to monitor the progression and treatment response of diabetic macular edema (DME) in patients of diabetic retinopathy (DR). Several studies have been carried out to investigate various factors affecting the central subfoveal thickness in order to minimize errors in the testing. We planned a study to investigate the effect of meals on central macular thickness (CMT) in patients with DME and compare that with nondiabetic patients. METHODS: In this observational study, 50 patients of diabetes with DME and 50 normal controls were included. Macular thickness was measured after overnight fasting and 2 h postprandial for both the groups. Any changes in morphology and CMT were evaluated. RESULTS: Each group had 22 females and 28 males with a mean age of 60.6 ± 6.6 in the diabetic group and of 49.66 ± 11.13 in the control group. Reduction in the CMT was noticed after the meals (mean: -9.78 ± 12.77 µm; P < 0.001) in those with DME as compared to the control group. This was more prominent in those who had intraretinal cystic spaces (17.14 ± 10.33 µm) and neurosensory detachment (66 µ). Patients with high blood sugar levels had higher CMT and a greater reduction in thickness was noticed in them postprandially (r = 0.414; P = 0.0028). CONCLUSION: The CMT values in patients with DME are significantly affected by meals. Hence, an attempt should be made to measure CMT during the fasting state for more accurate results.

Anterior scleral thickness in patients of central serous chorioretinopathy: A Case-control study.

BACKGROUND: The aim of this study was to determine whether anterior scleral thickness (AST) varies significantly between patients with central serous chorioretinopathy (CSCR) versus normal individuals. To validate scleral thickness measurements by ultrasound biomicroscopy (UBM) vis a vis anterior segment optical coherence tomography (ASOCT). METHODS: This case-control study analyzed 50 eyes of 50 patients with CSCR (cases) and compared it with that of 50 eyes of 50 age- and gender-matched controls. In cases, AST was measured at 1 mm and 2 mm temporal to the temporal scleral spur by ASOCT and UBM. In controls, AST was measured only by ASOCT. In all participants, posterior choroidal thickness (CT) was measured subfoveally, 1 mm nasal and 1 mm temporal to fovea by enhanced depth imaging optical coherence tomography. RESULTS: The mean AST, as measured by ASOCT among cases and controls was 703.86 µm and 667.54 µm, respectively (P = 0.006). The mean AST by ASOCT and UBM in cases were 703.86 µm and 657.42 µm, respectively (P = 0.001). AST measurement by ASOCT and UBM showed a positive and statistically significant correlation (r = 0.431, P = 0.000). The mean CT among cases and controls was 443.56 µm and 373.88 µm, respectively (P = 0.000). We found a weak positive correlation (r = 0.11) in cases and weaker positive correlation in controls, between CT and AST measured by ASOCT. CONCLUSIONS: Our findings suggest that AST varies significantly between patients with CSCR versus normal individuals. We found poor agreement of AST when measured by ASOCT and UBM.

To Study the Role of Serum Homocysteine Levels and Ocular Involvement in Retinal Vasculitis.

Idiopathic retinal vasculitis is a chronic disease of unknown aetiology which results in ocular morbidity in patients of productive age group. Homocysteine has been implicated in various ocular conditions like age-related macular degeneration, retinal vein occlusions, diabetic retinopathy, and optic nerve diseases. We conducted a study to investigate the relation between serum homocysteine levels and retinal vasculitis at a tertiary care centre in North India. In this case-control study, 32 cases and 64 controls were included and the duration was from June 2017 to March 2019. Serum homocysteine of cases and controls was detected by reflectance photometry using VITROS Chemistry Products HCY 2 (Homocysteine) and the normal range of serum homocysteine as per this method was 6.60 to 14.80 micro mol per litre. Our study found that of the total 32 retinal vasculitis patients, serum homocysteine was raised in 65.62% (21 cases out of 32) and in 70.31% of control group (45 out of 64). Chi square test results showed that there was no significant association found between S. homocysteine levels and Reticular vasculitis (P: 0.64). The two groups were comparable in terms of the age with mean ± SD in cases being 33.47 ± 8.336 years and controls being 35.16 ± 8.568 years with a P value of 0.37 being statistically insignificant. The data collected was analysed using SSPS-16 (Statistical Package for Social Sciences Version 16) software and test of association was Odd's ratio. Power of study was 80% and P < 0.05 is considered statistically significant. We found that there is no significant association between raised serum homocysteine and retinal vasculitis (with P < 0.64). Odds ratio was 0.80(0.33-1.99) implying that the cases and controls were statistically significantly different with respect to homocysteine levels.

Changing patterns of posterior segment trauma during the COVID-19 pandemic: A regional analysis from the Bodhya Eye Consortium.

Purpose: To assess changes in the presentation patterns of posterior segment trauma during the COVID-19 pandemic from six tertiary eye care institutes of North and Central India. Methods: A multicenter, hospital-based, retrospective comparative analysis of patients presenting with posterior segment trauma was done during the COVID-19 (Group A) (March 25, 2020 - September 30, 2020) period and the pre-COVID-19 (Group B) (March 25, 2019 - September 30, 2019) period. Results: A total of 405 patients were diagnosed with posterior segment trauma (Group A: 206, Group B: 199). The time interval between onset of trauma and presentation was higher in Group A (16.59 ± 29.87 days) as compared to Group B (9.41 ± 19.19 days) (P = 0.004). A majority of patients in Group A had a history of prior consultation before presentation (P = 0.049). In Group A, 120 (58.2%) patients sustained ocular trauma at home as compared to 80 (40.2%) patients in Group B (P < 0.0001). Patients presenting with light perception were significantly more in Group A (43.7%) as compared to Group B (30.2%) (P = 0.004). In Group B, 37.6% patients had presenting visual acuity of counting finger or better as compared to 27.6% patients in Group A (P = 0.07). Patients in Group A had a significantly higher proportion of post-traumatic endophthalmitis with delayed presentation (P = 0.011) and retinal detachment (P = 0.041). Patients undergoing surgery for foreign-body removal were significantly fewer in Group A (P = 0.05). Conclusion: Although the number of patients presenting with posterior segment trauma was comparable in Groups A and B, a greater number of patients sustained home injuries during the COVID-19 pandemic. A majority of these patients had delayed presentation with poor presenting visual acuity and a higher tendency of retinal detachment.

Management of Post-DALK Recipient Posterior Stromal Scarring: A Novel Approach.

AIM: Management of recipient posterior stromal scarring following deep anterior lamellar keratoplasty (DALK) by a novel approach. METHODS: A side port knife bent at the tip is used to make a linear incision in the host posterior stroma. Plane between host posterior stroma and DALK tissue is separated using a reverse sinskey hook and multiple radial incisions are made using microvitroretinal scissors. The recipient posterior stromal wedges are removed using 20G vitrector with a cut rate of 800 cuts/min. A Descemet stripping endothelial keratoplasty lenticule is inserted into the anterior chamber and apposed to the posterior surface of DALK tissue using air tamponade. RESULT: This technique was used in 10 patients who showed clearing of the scarring after the surgery with good apposition of the donor graft to the previous DALK tissue. Conclusion: This is a sutureless, relatively simple, inexpensive, and effective novel surgical technique that avoids complications of open sky procedure and can be replicated in any ophthalmologic operation theatre setup.

Endogenous endophthalmitis secondary to Burkholderia cepacia: A rare presentation.

Burkholderia cepacia (previously known as Pseudomonas cepacia) is low virulent, gram negative bacilli, known to cause infections in immunocompromised hosts. There are reports about this organism causing keratitis, acute or delayed postoperative, or post traumatic endophthalmitis. Persistence of infection and poor visual outcome are well known complications of infection caused by this organism. Endogenous endophthalmitis due to Burkholderia cepacia is rare. There is no such case report available of endogenous endophthalmitis caused by these bacteria in the literature, where it is presented as retinal abscess and retinal vasculitis. Our aim is to report such a rare case from our hospital, which was treated with systemic and intravitreal antibiotics, with control of infection.

Endothelial corneal transplants: indications, clinical profile and surgical outcomes in a tertiary care hospital.

BACKGROUND: Endothelial keratoplasties have become the surgical procedure of choice over full thickness penetrating keratoplasty for corneal decompensation because of endothelial dysfunction. METHODS: A retrospective data review was performed from February 2016 to April 2017 for all the patients who underwent endothelial keratoplasty in a tertiary care center for Indian Armed Forces. RESULTS: A total of 161 corneal transplants were performed; endothelial keratoplasties accounted for 34 (21.1%) transplants. Most common indication was pseudophakic/aphakic bullous keratopathy followed by Ahmed glaucoma valve-related corneal decompensation and Fuchs' corneal dystrophy, respectively. Mean preoperative corneal thickness was 845.96 ± 106.9 microns. Mean lenticule thickness was 131.55 ± 42.47 microns with microkeratome for descemet stripping automated endothelial keratoplasty (DSAEK) and 174 ± 70.4 microns manually for descemet stripping endothelial keratoplasty (DSEK). Mean preoperative best-corrected visual acuity (BCVA) was 1.65 LogMAR (Snellen equivalent in meters 2/60 approx) which significantly improved to 0.82 LogMAR (Snellen equivalent in meters 6/36 approx) after surgery. In the DSAEK group, BCVA improved from 1.61 to 0.7 LogMAR, whereas in the DSEK group, the visual acuity improved from 1.7 to 0.94 LogMAR at one-month postoperative period. Postoperatively, two patients had graft detachment and had to undergo repeat DSAEK. CONCLUSION: Study results suggest the similar trends in our tertiary care hospital as in other most advanced ophthalmic centers around the world for adoption of newer techniques of lamellar corneal transplants and their outcomes.

Evolving consensus on managing vitreo-retina and uvea practice in post-COVID-19 pandemic era.

The COVID-19 pandemic has brought new challenges to the health care community. Many of the super-speciality practices are planning to re-open after the lockdown is lifted. However there is lot of apprehension in everyone's mind about conforming practices that would safeguard the patients, ophthalmologists, healthcare workers as well as taking adequate care of the equipment to minimize the damage. The aim of this article is to develop preferred practice patterns, by developing a consensus amongst the lead experts, that would help the institutes as well as individual vitreo-retina and uveitis experts to restart their practices with confidence. As the situation remains volatile, we would like to mention that these suggestions are evolving and likely to change as our understanding and experience gets better. Further, the suggestions are for routine patients as COVID-19 positive patients may be managed in designated hospitals as per local protocols. Also these suggestions have to be implemented keeping in compliance with local rules and regulations.

New use of a pupillary expansion ring to avoid intraoperative positive vitreous pressure during triple procedures.

Positive vitreous pressure can complicate cataract surgery during a triple procedure by inadvertently extending the capsulorhexis. This occurs because the procedure is open sky and positive vitreous pressure cannot be countered by injecting ophthalmic viscosurgical devices. We describe a new use of a pupillary expansion ring (Malyugin) to achieve a stable open anterior chamber under open sky during triple procedures. The scrolls are tucked under cut margins of the host cornea to create the capsulorhexis, the cataractous nucleus is removed, and an intraocular lens (IOL) is implanted in the bag. This technique is especially useful in cases of hypermature cataract and nondilating pupils with positive vitreous pressure in patients having triple procedures. The technique provides a stable open anterior chamber, increasing to the safety of the procedure and the chance of achieving a continuous curvilinear capsulorhexis and IOL implantation in the capsular bag.

A study on the contamination of injection bevacizumab on storage of multidose vials.

PURPOSE: The aim of this study is to establish the safety of storage and reuse of bevacizumab vials for 1 week with multiple vial punctures. METHODS: This was an experimental microbiological study conducted at tertiary care hospital. The study samples included bevacizumab vials that had been used for injecting patients by the pooling method. Vials were stored and sampled in a manner that replicated their proposed clinical use. Contamination of vials was evaluated on the basis of microbial culture and validated by positive and negative controls. The probability of obtaining such results purely by chance was calculated. RESULTS: A total of 210 samples from 30 vials were evaluated along with 210 positive and 210 negative controls. No growth was seen in any of the bevacizumab samples. The probability of obtaining 210 consecutive sterile samples just by chance is <5.547 × 10-6 (0.000005547). CONCLUSION: The vials showed no contamination on storage for 7 days in an ordinary refrigerator. Thus, we conclude that the rate of contamination of bevacizumab vials on storage for 7 days in a refrigerator is likely to be insignificant. The results need to be validated by other studies replicating this protocol.

Combined Ahmed valve and phacoemulsification with intraocular lens implantation under infliximab in refractory uveitic glaucoma.

PURPOSE: To evaluate the outcome of combined Ahmed glaucoma valve (AGV) and phacoemulsification with posterior chamber intraocular lens implantation under infliximab in refractory uveitic glaucoma (UG). METHODS: In this prospective interventional case series, 26 eyes of 26 patients with refractory UG underwent surgery under intravenous infliximab. The success rate was defined as intraocular pressure (IOP) 5 to 21 mm Hg with or without antiglaucoma medications (AGM), without additional glaucoma surgical intervention. RESULTS: The mean IOP (37.8 ± 11.86 to 12.2 ± 2.8 mm Hg; p<0.0001) and mean number of AGM (3.4 ± 1.2 to 0.4 ± 0.1; p<0.001) were significantly reduced after surgery at 2 years. Kaplan-Meier survival analysis showed a cumulative probability of success for IOP control of 92% at 2 years of follow-up. CONCLUSIONS: Combined AGV and phacoemulsification is an effective treatment for controlling refractory UG with complicated cataract under infliximab.

Endogenous Nocardial Endophthalmitis in an Immunosuppressed Patient: A Serious Warning of an Underlying Life Threatening and Blinding Disorder.

PURPOSE: To report a case of bilateral endogenous nocardial endophthalmitis with central nervous system involvement in an immunocompromised individual with an extremely poor outcome. CASE REPORT: A 35-year-old man with a history of long-term, prescribed oral steroid use for membranoproliferative glomerulonephritis presented with profound bilateral vision loss. Patient's diagnosis of bilateral endogenous nocardial endophthalmitis was delayed. Nocardia was finally isolated from a brain biopsy after a repeat magnetic resonance imaging revealed a brain abscess. With anti-nocardia therapy, patient improved systemically, but the visual outcome was poor, with no light perception in both eyes. CONCLUSION: Ocular nocardiosis is a serious vision and life threatening disorder, particularly in patients on immunosuppressive therapy. A high index of suspicion is required for successful treatment.

Orbital apex osteodural fistula--An unusual surgical access.

Dural arteriovenous fistulas (DAVFs) are fistulas connecting the branches of dural arteries to dural veins or a venous sinus. Osteodural fistulas are a rare subset of this group of diseases. We wish to report a rare case of an osteodural arteriovenous fistula at the foot of the superior ophthalmic vein (SOV), treatment of which required an unusual surgical approach via the orbit and SOV. Though access for endovascular treatment via the SOV for treatment of caroticocavernous fistulas is reported, the external approach is relatively infrequently performed, outside Europe and the Americas, with this being the first reported procedure from the Indian subcontinent. We wish to explain the steps of this unusual surgical access and highlight the salient precautions and pitfalls in the technique.

Enterobacter endophthalmitis: clinicomicrobiologic profile and outcomes.

PURPOSE: To report the clinical presentations, antibiotic sensitivities, management, and outcomes of Enterobacter endophthalmitis. METHODS: This is a retrospective, consecutive, noncomparative, interventional case series. The medical records of culture-proven Enterobacter endophthalmitis cases from the endophthalmitis registry between January 1995 and March 2006 were reviewed. RESULTS: Enterobacter was the causative agent in 36 culture-proven cases. The causative event was cataract surgery in 11 and trauma in 25 patients. The presenting visual acuity was light perception in 26 eyes (72.2%). Polymicrobial infection was detected in 7 patients (19.4%). Enterobacter organisms were most sensitive to ciprofloxacin (n = 34; 94%), followed by amikacin (n = 31; 86%) and ceftazidime (n = 28; 78%). In postoperative endophthalmitis, final visual outcome of ≥20/200 was achieved in 3 patients (27%) and of ≥5/200 in 5 patients (45%). The eyes became phthisical in 3 patients (27%) and evisceration was carried out in 1 patient. In posttraumatic endophthalmitis, final visual outcome of ≥20/200 was achieved in 5 patients (20%) and of ≥5/200 in 7 patients (28%). The eyes of 11 patients (44%) became phthisical and evisceration was carried out in 1 patient. CONCLUSION: Enterobacter organisms are mostly susceptible to ciprofloxacin, amikacin, and ceftazidime. Despite this coverage, the visual outcome is often poor.

Technical aspects of laser treatment for acute retinopathy of prematurity under topical anesthesia.

Retinopathy of prematurity (ROP) is a significant cause of childhood blindness. The criteria for laser therapy have been revised from threshold ROP to include the earlier stage of high-risk prethreshold ROP. Laser photocoagulation is an established technique for the treatment of ROP. However, the detailed procedure and techniques for laser photocoagulation have not yet been published. Adequate and appropriate laser photocoagulation for ROP is different from the application of lasers in adult retinal vascular diseases, and many ophthalmologists need to be trained in this technique if the outreach of ROP treatment programs is to improve. Laser under topical anesthesia has been practiced in India as a preferred modality especially due to logistics and risks of general anesthesia in these pre-term babies. We discuss the details of the technique as practiced at tertiary care ophthalmic hospitals in India, so that the nuances in treatment parameters and clinical decision-making can be usefully applied to ophthalmic practice. This will ultimately lead to safe and effective treatment delivery in ROP.