Inverse drainage Nd:YAG membranotomy for pre-macular hemorrhage.

AIM: To report the outcomes of the "inverse drainage Nd:YAG laser membranotomy" technique for the management of pre-macular hemorrhage (PMH), which has its inferior margin near the fovea. METHODS: This retrospective study included eyes with PMH, with its inferior margin located within 0.5 disc-diameter (DD) of the fovea. Laser membranotomy was performed near the superior margin of PMH followed by intravitreal injection of 0.3 mL undiluted sulphur hexafluoride (SF6) gas. The patients were advised to maintain a prone position for three days. RESULTS: Twenty patients (20 eyes) with a mean age of 46.1 ± 18.6 years were included in the study. The mean duration of symptoms was 6.9 ± 7.0 days. The mean size of PMH was 4.1 ± 1.2DD. The causes of PMH were Valsalva retinopathy (n = 11) and retinal artery macroaneurysm (RAM, n = 9). The mean maximum height of the blood collection, measured by optical coherence tomography (OCT), within 1 disc-diameter from the inferior and superior borders of the PMH was 738.9 ± 232.9µm and 1240.6 ± 338.1µm respectively (p = 0.001). The mean best-corrected visual acuity (BCVA) improved from logMAR 1.32 ± 0.44 (Snellen equivalent, 20/418) to logMAR 0.11 ± 0.20 (Snellen equivalent, 20/26) (p = 0.001). Vitrectomy was not required in any case. Persistent pre-macular cavity, macular hole, epiretinal membrane (ERM), intra-ocular pressure spike, or rhegmatogenous retinal detachment (RRD) was not noted in any patient. CONCLUSION: This technique can be safely used to treat eyes with PMH having its inferior margin near the fovea.

Is perioperative blood pressure monitoring during intravitreal injections important?

Background: Anti-vascular endothelial growth factor intravitreal injections (IVIs) have proved to be a boon for patients suffering from several retinal pathologies. They are one of the most commonly performed procedures in ophthalmology. A perioperative rise in blood pressure (BP) has been noted during cataract surgery. Objectives: To evaluate the perioperative BP changes during IVI, and the associated risk factors. Design: Cross-sectional observational study. Methods: The patients undergoing IVI from May 2019 to August 2019 were evaluated. All the patients underwent BP measurement before, during, and 1 h after the IVI. The correlation between the demographics and, the systemic comorbidities of the patients, and the ocular condition for which IVI was given was evaluated. Results: The study included 302 patients (mean age of 59.9 ± 10.7 years). The mean increase in systolic BP (SBP) and diastolic BP (DBP) at the time of injection was 25.7 ± 21.0 and 1.3 ± 13.4 mmHg, respectively. A ⩾ 10, ⩾ 20, ⩾ 30 mmHg increase in SBP at the time of injection was seen in 83.8% (n = 253), 69.5% (n = 210) and 49.0% (n = 148) patients, respectively. Forty-one (13.6%) patients developed intra-procedural hypertensive urgency, out of which six patients (14.6%) did not recover even after 1 h of the procedure. None of the patients experienced any cardiovascular events. The univariate and multivariate linear regression analyses showed that the change in intra-procedural SBP correlated positively with the age of the patient and negatively with the baseline SBP. Conclusion: There is a significant rise of SBP at the time of IVI, especially in patients with advanced age and high baseline SBP. Some of the patients can experience hypertensive urgency at the time of injection and may take more than 1 h to recover. The patients receiving IVI should undergo a detailed physician evaluation before the procedure.

Retinal detachment in eyes treated with Aurolab aqueous drainage implant for refractory glaucoma - Incidence and outcomes.

Purpose: To analyze the incidence of rhegmatogenous retinal detachment (RRD) in patients who have undergone prior Aurolab aqueous drainage implant (AADI) surgery and report outcomes in terms of anatomic, visual acuity, and intraocular pressure (IOP) findings. Methods: Case records of all patients who underwent RRD repair after AADI surgery from 2013 to 2019 were retrospectively analyzed. Data collected included patient demographics, ocular examination findings at all visits including IOP and best-corrected visual acuity (BCVA) and clinical findings related to RRD both at baseline and postoperatively. Results: Ten eyes of nine patients were included in study. The mean age of patients was 28.2 years (median: 15 years, range: 6-83 years). Mean duration between AADI and RRD was 14 months (median 2.5 months; range 2 days-72 months). All eyes underwent pars plana vitrectomy with silicon oil injection. The preoperative LogMAR BCVA (logarithm of the minimum angle of resolution) was 2.52 ± 0.15 which improved to 2.29 ± 0.58 at final follow-up; however, only one eye had vision ≥ 20/400 largely due to recurrent RRD and advanced glaucomatous disc damage. Postoperatively retina was attached in 6 eyes (60%) and IOP was ≤ 21 mmHg in 5 out of 6 eyes with anatomic success. Conclusion: The incidence of RRD following AADI was found to be 0.86% in our study. Pars plana vitrectomy (PPV) with silicon oil tamponade was the preferred approach in the management of these eyes with IOP being well controlled post PPV. However, visual acuity outcomes were largely unsatisfactory due to recurrent RRD and preexisting advanced glaucoma.

Clinical Presentation and Management of Eyes with Globe Perforation during Peribulbar and Retrobulbar Anesthesia: A Retrospective Case Series.

PURPOSE: To evaluate the clinical presentation, management, and outcome of eyes with an inadvertent globe perforation during peribulbar or retrobulbar block. METHODS: This retrospective study evaluated the eyes which had an accidental globe perforation during local ocular anesthesia from 2012 to 2020. The patients were divided into three groups: group 1, Clear media with no rhegmatogenous retinal detachment (RRD); group 2, significant vitreous hemorrhage (VH) precluding the retinal view without RRD; and group 3, RRD with/without VH. RESULTS: Twenty-five patients were included in the study. The mean axial length (AL) was 24.7 ± 2.7 mm (range, 20.9-31.2 mm). The most common presenting feature was VH (n = 14). The treatment included retinal laser barrage (n = 7) and vitrectomy (n = 17). Retinal breaks were identified in all the eyes (total breaks = 37). The mean presenting best-corrected visual acuity in groups 1, 2, and 3 were logarithm of the minimum angle of resolution 0.79 ± 0.73, 1.82 ± 0.78, and 2.13 ± 0.59 respectively. All the treated patients had an attached retina at the last follow-up. The mean final best-corrected visual acuity for each group was logarithm of the minimum angle of resolution 0.59 ± 0.79, 0.48 ± 0.26, and 1.25 ± 0.64, respectively (p = 0.006). The development of RRD was associated with a larger AL (p = 0.015); while the development of significant VH associated with the superior location of the perforation (p = 0.015), late recognition of the perforation (p = 0.004), and multiple perforations (p = 0.015). CONCLUSIONS: Early recognition and intervention in eyes with an inadvertent perforation can lead to a good outcome. Eyes with a longer AL, superior, and multiple perforations are at higher risk of developing complications like RRD and VH. Complications like RRD, macular injury, and vascular occlusion are risk factors for poor prognosis.

Frosted branch angiitis following corneal tear repair.

We report a patient who developed frosted branch angiitis (FBA) and was diagnosed 1 month after the penetrating eye injury (PEI) repair. A 31-year-old male with no systemic comorbidities presented with defective vision following trauma to his left eye while cutting wood. His best-corrected visual acuity (BCVA) was 20/200. Anterior segment examinations showed a zone I full-thickness corneal tear with iris tissue incarceration. There was no clinical evidence of intraocular foreign body (IOFB) or endophthalmitis. He underwent PEI repair with iris abscission on the same day with intracameral moxifloxacin injection. His BCVA on postoperative day 45 was 20/200. Examination showed a resolving vitreous hemorrhage, venous tortuosity, and retinal perivascular infiltration affecting the venules from the posterior pole up to the periphery. He was treated with oral and topical steroids. The clinical signs resolved completely and BCVA improved to 20/20 after 1 month of treatment. FBA can complicate the recovery of eyes after PEI repair, even in the absence of endophthalmitis or sympathetic ophthalmia. A thorough search for IOFB or its tell-tale signs should be done in such eyes.

Serpentine retinal pigment epithelial tear.

We report a case of retinal pigment epithelial tear in a patient with peripheral exudative hemorrhagic chorioretinopathy (PEHCR). A 60-year-old diabetic female presented with left eye metamorphopsia. Fundus examination showed bilateral peripheral retinal pigment epithelium (RPE) degeneration, and a large serpentine-shaped RPE degeneration tract extending from the superotemporal arcade to the inferior periphery with associated subretinal hemorrhages in her left eye. This tract curved around the fovea, just sparing it. Fundus fluorescein and indocyanine green angiographies showed bilateral polyps in the superotemporal periphery. Optical coherence tomography through the tract showed scrolled up RPE at its edges with bare underlying Bruch's membrane and choroid in the region of the rip. There was no sign of an underlying pigment epithelial detachment. The patients with PEHCR should be prognosticated about such a rare vision-threatening macular complication.

Clinical features and surgical outcomes of complications of proliferative diabetic retinopathy in young adults with type 1 diabetes mellitus versus type 2 diabetes mellitus - A comparative observational study.

PURPOSE: To evaluate the clinical profile, visual outcomes, and complications among young adult patients with type 1 diabetes mellitus (insulin-dependent DM-T1DM) in comparison with patients with type 2 diabetes mellitus (T2DM) undergoing vitrectomy for complications of proliferative diabetic retinopathy (PDR).. METHODS: A retrospective review of patients between 18 and 45 years with T1DM undergoing vitrectomy for complications of PDR between June 2017 and June 2019, with a minimum follow-up of 12 months. Consecutive patients between 30 and 45 years with type 2 diabetes (non-insulin-dependent DM-T2DM) who underwent vitrectomy for the same indications were retrospectively enrolled as the control group. RESULTS: There were 42 eyes (28 patients) in the T1DM group and 58 eyes (47 patients) in the T2DM group. The average age at operation was 35.9 ± 6.88 years and 39.8 ± 3.03 years, respectively (P < 0.001). At the end of follow-up, the mean logarithm of the minimum angle of resolution (logMAR) best-corrected visual acuity (BCVA) improved from 1.53 ± 0.55 to 1.30 ± 0.93 (P value 0.07) in the T1DM group and from 1.59 ± 0.46 to 1.00 ± 0.78 in the T2DM group (P = 0.0001). The rate of the primary and final reattachment was 76.2% and 88.1% in the T1DM group and 84.5% and 96.6% in the T2DM group. Preoperative macular tractional retinal detachment (MTRD) and neovascular glaucoma (NVG) in both the groups, chronic kidney disease (CKD) and lack of preoperative Pan retinal photocoagulation (PRP) in the T1DM group, hypertension (HTN) and, resurgery in the T2DM group, were risk factors for poor vision at the final follow-up. CONCLUSION: The visual and anatomic outcomes were poorer in the T1DM patients which could be due to the longer duration of diabetes with worse glycemic control, associated comorbidities like CKD, and a higher incidence of MTRD.

Surgical outcome of full-thickness macular hole secondary to tractional retinal detachment in proliferative diabetic retinopathy.

PURPOSE: To evaluate the surgical outcome of full-thickness macular hole (FTMH) secondary to active fibrovascular proliferation (FVP) and tractional retinal detachment (TRD) in eyes with proliferative diabetic retinopathy (PDR), and factors influencing the outcome. METHODS: This retrospective study included the patients who underwent vitrectomy for FTMH secondary to PDR TRD from 2016 to 2020. Anatomical and visual outcomes were analyzed after six months along with the factors predicting the final outcome and duration of subretinal fluid (SRF) resolution. RESULTS: Group A (macula-off combined RD, i.e., tractional and rhegmatogenous) included 10 eyes, while group B (macula-threatening TRD) included eight eyes. The mean best-corrected visual acuity improved from logMAR 1.21 (Snellen equivalent: 20/324) to logMAR 0.76 (Snellen equivalent: 20/115) (P = 0.008). Seventeen patients gained ≥1 line(s) of vision. Mean visual gain in groups A and B was 3.7 ± 1.9 and 1.9 ± 1.1 lines, respectively (P = 0.051). MH closed in 88.9% eyes. Type 1 anatomical closure was achieved in 88.9% of eyes. At 6 months, SRF and central macular thickness reduced from 479.6 ± 512.5 µm to 11.4 ± 23.5 µm (P = 0.002) and 874.3 ± 422.6 µm to 207.6 ± 81.7 µm (P = 0.0002), respectively. Finally, macular SRF resolved in all the patients. The mean duration for complete SRF resolution was 4.9 ± 3.2 months. Eyes with a shorter duration of diabetes mellitus (rho = -0.49, P = 0.040) and macula-off combined RD (P = 0.048) took a longer time for complete SRF resolution. CONCLUSION: Good anatomical and visual outcomes can be achieved in eyes with PDR TRD-associated FTMH. The residual macular SRF resolves slowly after the surgery and extra intervention is not required. Macula-off combined RD is associated with worse outcome and a slower SRF resolution rate.

Incidence of ocular and systemic diseases affecting visual function among state bus drivers.

PURPOSE: To evaluate the incidence of ocular and systemic disease affecting visual function among state transport corporation bus drivers in a south Indian district. METHODS: This retrospective study analysed the records of all the drivers who presented to a south Indian tertiary-care eye hospital in 2019 for their mandatory annual ocular check-up. Details reviewed included demographic details; refraction; presence of systemic and ocular diseases with vision-threatening potential; presence of ocular conditions responsible for visual loss and the treatment administered. RESULTS: 3042 drivers (mean age, 47.0 ± 5.7 years) were evaluated. Visual function-threatening systemic diseases were present in 25.0% drivers, out of which diabetes mellitus (18.7%) was the most common pathology. The most common ocular problem was refractive error (45.0%). Visual function-threatening ocular diseases were present in 9.5% drivers. Diabetic retinopathy, visually-significant cataract, glaucoma and central serous chorioretinopathy were noted in 4.0%, 1.9%, 1.7% and 0.8% drivers. Surgical intervention was required in 2.2% drivers. Thirteen drivers were temporarily deemed unfit for driving heavy-weight vehicles. CONCLUSION: Several bus drivers suffer from vision-threatening systemic and ocular diseases. Some of them require surgical intervention to retain fitness. A complete ocular and systemic evaluation of diseases with vision-threatening potential should be performed at the time of renewal of the driving license. The drivers should be educated about the systemic diseases which can affect their driving skills and must be encouraged to seek medical help at an early stage.