Predictive value of retinal nerve fibre layer thickness for postoperative visual improvement in patients with pituitary macroadenoma.

OBJECTIVE: To determine the usefulness of retinal nerve fibre layer (RNFL) thickness and a reliable cut-off value that can predict postoperative visual function improvement in patients with pituitary macroadenoma. METHODS AND ANALYSIS: This was a prospective observational study. Preoperative optical coherence tomography of the RNFL was performed in patients with pituitary macroadenoma. Postoperative visual function changes (acuity and visual fields) were identified using predefined criteria. Receiver operating characteristic curves were constructed for RNFL values to define the ideal cut-off value that predicted improvement. Other variables including preoperative visual acuity, mean deviation, visual field index and tumour volume were also analysed. RESULTS: Twenty-nine eligible subjects (58 eyes) were recruited. The mean (±SD) age was 43.9 (±12.85) years and 65.5% were male. The mean (±SE) follow-up duration was 20.8 (±6.42) months. RNFL thickness was significantly thinner in eyes with visual dysfunction and optic disc pallor. Better preoperative logarithmic minimum angle of resolution (logMAR) visual acuity, higher RNFL thickness and smaller tumour volume were associated with postoperative visual field improvement on univariate analysis; however, only mean RNFL thickness had significant association on multivariate analysis. None of the preoperative variables showed significant association with improvement in visual acuity. The best cut-off of mean RNFL thickness for visual field improvement was estimated at 81 µm with 73.1% sensitivity and 62.5% specificity. CONCLUSION: Preoperative RNFL thickness can be an objective predictor of visual field outcomes in patients undergoing surgery for pituitary macroadenomas, with moderate sensitivity and specificity. It is, however, not a good predictor of visual acuity outcome.

Conjunctival Relaxing Incisions with a Bare Bed: An Overlooked Privilege in Contracted Sockets.

INTRODUCTION: The aim of reconstruction of a contracted socket is to retain a satisfactory prosthesis. Simple procedures to modify the socket architecture as first line options could avoid multiple staged procedures, increased surgical time, harvesting tissues or use of allografts. The objective of this study was to evaluate the outcome of modifying the socket architecture by making conjunctival relaxing incisions leaving it bare to re-epithelialize and compare it to dermis-fat graft. MATERIALS AND METHODS: A retrospective review of all socket reconstruction surgeries in our hospital over a period of 10 years (July 2009 to June 2019) was done. The two procedures which were compared were dermis-fat graft (DFG) and conjunctival relaxing incisions (CRI) without a graft. In the latter, the split conjunctiva was left bare under a conformer and temporary tarsorrhaphy. The conjunctiva was allowed to re-epithelialize under cover of topical antibiotic and steroid. RESULTS: The patients included had a mean age of 24 years (n=8) in the DFG group and 36 years (n=10) in the CRI group. The most common cause of anophthalmic socket was enucleation for tumour and evisceration for trauma in the two groups, respectively. Six patients (75%) in the DFG group and six (60%) in the CRI group achieved good prosthesis retention (P = 0.51). None had post-operative infection. CONCLUSION: Transverse conjunctival relaxing incisions with tissue stretching can be a safe first line option to rehabilitate a contracted socket.

Understanding the pathogenesis of Graves' orbitopathy: A new age paradigm.

Graves' orbitopathy or thyroid associated orbitopathy (TAO) is a disquieting condition both for the patient and the clinician. While the mainstay of treatment of the orbitopathy is corticosteroids, its action is non-specific. The arguments against its use also include multiple side effects and recurrence on stopping it. While some clinicians are complacent with the drug due to our long term experience with it, many are in search for specific so called 'targeted' treatment. The autoimmune process in TAO is rather complex where multiple cytokines act at more than one level making it challenging to control the inflammation. Hence, in order to discover better treatment strategies, having a sound understanding of the pathogenesis of the disease is essential.

Recent advances in the management of thyroid associated orbitopathy: A promising roadmap.

Thyroid associated orbitopathy (or Graves' orbitopathy) is the most common extrathyroidal manifestation of Graves' disease; an auto-immune entity that has precarious visual consequences as well as psychological morbidity even in its milder stages. The treatment is largely based on the 'activity' and 'severity' of the disease; however, outcome can vary between patients depending on certain known and unknown risk factors. While there are certain guidelines on managing the orbitopathy, there are multiple lacunae in our knowledge of its pathophysiology. The current era is one where our mainstay of treatment of the active disease is still glucocorticoids, albeit a few good immunomodulatory drugs that have shown promising outcomes are in our armamentarium. In this article we present a compendium of the current consensus in the management of Graves' orbitopathy, its evidence based rationale and crucial constraints along with the details of emerging biological agents.

Screening for diabetic retinopathy in primary care: Future prospects in low-middle income countries.

Diabetic retinopathy (DR) is an urgent public health concern, and it is prudent to prevent DR than face the burden of blindness arising from it. This requires committed physicians, ophthalmologists, patients as well as policy makers. Blindness rate due to DR has shown a decline in developed countries which is not only due to advanced and accessible tertiary care, but also large-scale screening programmes. Currently, the most common method of screening in low- and middle-income countries is still an opportunistic model. A more practical, cost-effective and systematic screening model is needed, utilizing advances in telemedicine and artificial intelligence.