Learning Curve in Posterior Segment Ophthalmic Diagnostic Endoscopy: Implications for Budding Enthusiasts and Fellows-In-Training.

PURPOSE: To elucidate the learning curve for posterior segment diagnostic endoscopy (DE) based on the results of a self-trained (ST) and a supervised (SUP) vitreoretinal surgeon. METHODS: Retrospective review of medical records of DE performed between 2017 and 2023 by one ST and one SUP vitreoretinal surgeon at a tertiary eye care institute. Data were collected and the serial number of cases was plotted against the time taken for the procedure. A comparative regression plot was created for both the surgeons to know the slope of the learning curve. The start time was noted as that of attachment of the endoscope and the stop time was noted as the end of diagnostic evaluation. Procedures were divided into blocks of 10 cases each and the time taken for the procedures was calculated. RESULTS: Total of 106 eyes (58 by ST surgeon and 48 by SUP surgeon) were included. For ST surgeon, the time taken for the surgery correlated inversely (reduced sequentially) with the serial number of the case till the 20th case (correlation coefficient = -0.5, p = .01), for SUP surgeon, the time taken for the surgery correlated inversely with the serial number of the case till the 10th case (correlation coefficient = -0.9, p = <0.0001) and then stabilized. Neither of the groups had any adverse events. CONCLUSION: About 20 cases for a self-trained and about 10 cases for a supervised vitreoretinal surgeon are required to get stable with DE. These observations have implications in creating a training module for DE with appropriate number of training cases.

Surgical approach to endophthalmitis: an overview.

Endophthalmitis is one of the most severe ocular emergencies faced by ophthalmologists worldwide. Without prompt treatment significant visual loss is inevitable. With increased understanding of the science of endophthalmitis, recent studies have shown a clear role of early and more definitive surgery to achieve better visual and anatomic outcomes. Surgery in endophthalmitis encompasses a whole gamut of interventions. There are diagnostic procedures like anterior chamber tap and vitreous biopsy or therapeutic procedures like complete pars plana vitrectomy and retinal detachment repair. Current literature is deficient on a detailed description of the spectrum of surgical interventions in endophthalmitis. In the current communication, we summarize the studies based on various surgical interventions in endophthalmitis. We also elaborate in detail on each surgical maneuver, taking the reader through the nuances of each surgery via an exhaustive description and appropriate photos and surgical video clips.

Ten-year results of scleral-fixated intraocular lens implantation: outcomes of ab externo scleral fixation with 10-0 polypropylene suture.

PURPOSE: To describe long-term visual and anatomical outcomes of sutured scleral-fixated intraocular lens (SF IOL) implantation. SETTING: Tertiary eyecare hospital in India. DESIGN: Retrospective interventional noncomparative study. METHODS: Postoperative change in corrected distance visual acuity (CDVA) and occurrence of complications were assessed from the patient medical records. Long-term SF IOL survival rates and factors affecting the occurrence of postoperative IOL-related complications were assessed. Patients with postoperative follow-up less than 10 years or incomplete medical records were excluded. RESULTS: 64 eyes of 53 patients were included. Follow-up duration was 11.4 ± 1.2 years. Mean preoperative CDVA was 0.71 ± 0.43 logMAR (Snellen equivalent: 6/30), and mean CDVA at the final visit was 0.52 ± 0.49 logMAR (Snellen equivalent: 6/18) (P < .01). 48% cases had CDVA of 6/12 or better at the last follow-up. 58% cases had coexistent ocular pathology affecting the final visual outcome. IOL and suture-related complications were the commonest and included IOL decentration (17% cases), IOL drop (14%), and suture exposure (6%). The probability of IOL survival (postoperative period without IOL-related complications) was 90.6% at 8 years and 81.2% at 10 years (Kaplan-Meier analysis). Occurrence of postoperative IOL-related complications was unaffected by patient sex, age, indication for surgery (trauma or other), previous intraocular surgery, or technique of scleral fixation (2-point or 4-point) (multivariate regression analysis). CONCLUSIONS: Although sutured SF IOL implantation is viable with favorable long-term visual outcomes, there is a risk of postoperative IOL-related complications. Occurrence of postoperative IOL-related complications is unaffected by patient and ocular factors.

PRESENTATIONS AND FACTORS AFFECTING OUTCOME OF RHEGMATOGENOUS RETINAL DETACHMENT WITH CHOROIDAL DETACHMENT: An Indo-Taiwanese Study.

PURPOSE: To report the clinical settings, management, and factors associated with outcomes of rhegmatogenous retinal detachment with concurrent choroidal detachment. METHODS: Retrospective, consecutive, multicenter case series from January 2014 to January 2021 were included. Cases were from a tertiary eye care center in India and Taiwan. RESULTS: Overall 303 eyes were included. Mean age was 43.72 ± 20.64 years (median 46). Best-corrected presenting visual acuity was 1.79 ± 0.92 logMAR (median 2.10) (Snellen 20/1,233). Forty-four patients (17.91%) received preoperative steroids. Final visual acuity was 1.33 ± 0.94 logMAR (median 1.10) (Snellen 20/427). Favorable anatomic outcome was seen in 200/303 (66%), whereas favorable functional outcome was seen in 128/303 (42.20%). Factors predicting favorable anatomic outcome were absence of phakic lens status (odds ratio [OR] 2.76), absence of proliferative vitreoretinopathy worse than Grade A (OR 7.69), use of preoperative steroids (OR 4.50), and use of an encircling band (3.85). Factors predicting favorable functional outcome were better presenting visual acuity (OR 3.03), absence of phakic lens status (OR 4.93), absence of proliferative vitreoretinopathy worse than Grade A (OR 10.41), and use of preoperative steroids (OR 7.24). CONCLUSION: Administration of preoperative steroids, use of an encircling band during surgery, and pseudophakic status of the eye were found to have better outcomes in rhegmatogenous retinal detachment with concurrent choroidal detachment.

Retinotomies and retinectomies: A review of indications, techniques, results, and complications.

Retinotomy refers to "cutting" or "incising" the retina, whereas retinectomy denotes "excising" the retina. Retinotomies and retinectomies aid in tackling traction and retinal shortening that persist following membrane dissection and scleral buckling. We performed a literature search using Google Scholar and PubMed, followed by a review of the references procured. All relevant literature was studied in detail and summarized. We discuss the indications of retinotomies and retinectomies for relaxing retinal stiffness, accessing the subretinal space for choroidal neovascular membrane, hemorrhage and abscess clearance, drainage retinotomies to allow retinal flattening, radial retinotomies to release circumferential traction, harvesting free retinal grafts, and prophylactic chorioretinectomies in trauma.

Clinical presentation and treatment outcomes of an algorithmic approach to uveal effusion syndrome.

Purpose: To describe the clinical features and treatment outcomes in spontaneous uveal effusion syndrome (UES). Methods: A 10-year retrospective chart review of UES patients from a tertiary eye center was carried out. Optical coherence tomography (OCT), fundus fluorescein angiography, and ultrasound biomicroscopy (UBM) scans were performed. UES was managed based on presenting best-corrected visual acuity (BCVA), symptoms, and fundus findings. Patients with secondary causes of uveal effusion were excluded. Results: Twenty-five eyes of 16 patients were included. Of the 16 patients, 14 (88%) were male and 9 (56%) had bilateral disease. Fifteen of 25 affected eyes had nanophthalmos (axial length (AL) <20.5 mm) and 6 had hyperopia with AL >20.5 mm. The presenting mean distance BCVA was 0.74 ± 0.64 logMAR (mean Snellen: 20/100). Eleven eyes had exudative retinal detachment, and 4 also had exudative choroidal detachment (CD). Choroidal thickness (CT) was increased in 11 eyes on B-scan ultrasonography, and the mean CT was 1.74 ± 0.38 mm. Sub-retinal fluid (SRF) and retinal folds were the most common OCT findings. UBM findings included shallow angles, peripheral CD, and supra-ciliary effusion. A combination of local and systemic corticosteroids was used to successfully treat 12 eyes, 6 needed surgery, and 7 were observed. Partial sclerectomy with anterior chamber maintainer-assisted SRF drainage was the favored surgery. The median period of follow-up was 6.5 months (0.1-76 months), and the mean distance BCVA at the last follow-up was 0.58 ± 0.42 logMAR (mean Snellen: 20/80). Conclusion: UES can be suitably managed both medically and surgically based on clinical presentation.

Brilliant Blue G toxicity in macular hole surgeries: A report on combined phototoxicity and dye-induced macular damage.

PURPOSE: Vitrectomy with brilliant blue G (BBG) assisted internal limiting membrane (ILM) peeling is the standard operational technique in macular hole surgeries. However, BBG dye, though considered safe and nontoxic, can also occasionally lead to macular toxicity. This study aims to describe the clinical features and characteristics of four eyes who developed macular toxicity after following surgery for macular hole repair. METHODS: Retrospective review of four consecutive cases of macular toxicity after conventional BBG assisted ILM peeling. All the cases reviewed, their operative surgical notes were retrieved and analyzed. The ILM was stained twice during surgery with prolonged intraoperative surgical time. RESULTS: All four cases had a prolonged surgical time and the ILM was stained twice during surgery in all cases. The area of macular toxicity was corresponding to the area of ILM peeling which had been exposed to repeated staining by BBG dye. By the end of one month, all four cases had foveal thinning along with choriocapillary atrophy. The mean BCVA was 20/80 before surgery and the final mean visual acuity was <20/800. CONCLUSION: This report highlights the occurrence of macular and choriocapillary atrophy due to prolonged focal endoillumination and the increased risk of toxicity with repeated dye staining.

Sight-threatening intraocular infection in patients with COVID-19 in India.

PURPOSE: Intraocular infection in patients with COVID-19 could be different in the presence of treatment with systemic corticosteroid and immunosuppressive agents. We describe the epidemiology and microbiological profile of intraocular infection in COVID-19 patients after their release from the hospital. METHODS: We analyzed the clinical and microbiological data of laboratory-confirmed COVID-19 patients from April 2020 to January 2021 presenting with features of endogenous endophthalmitis within 12 weeks of their discharge from the hospital in two neighboring states in South India. The data included demography, systemic comorbidities, COVID-19 treatment details, time interval to visual symptoms, the microbiology of systemic and ocular findings, ophthalmic management, and outcomes. RESULTS: The mean age of 24 patients (33 eyes) was 53.6 ± 13.5 (range: 5-72) years; 17 (70.83%) patients were male. Twenty-two (91.6%) patients had systemic comorbidities, and the median period of hospitalization for COVID-19 treatment was 14.5 ± 0.7 (range: 7-63) days. Infection was bilateral in nine patients. COVID-19 treatment included broad-spectrum systemic antibiotics (all), antiviral drugs (22, 91.66% of patients), systemic corticosteroid (21, 87.5% of patients), supplemental oxygen (18, 75% of patients), low molecular weight heparin (17, 70.8% of patients), admission in intensive care units (16, 66.6% of patients), and interleukin-6 inhibitor (tocilizumab) (14, 58.3% of patients). Five (20.8%) patients died of COVID-19-related complications during treatment for endophthalmitis; one eye progressed to pan ophthalmitis and orbital cellulitis; eight eyes regained vision >20/400. Fourteen of 19 (73.7%) vitreous biopsies were microbiologically positive (culture, PCR, and microscopy), and the majority (11 patients, 78.5%) were fungi. CONCLUSION: Intraocular infection in COVID-19 patients is predominantly caused by fungi. We suggest a routine eye examination be included as a standard of care of COVID-19.

Comparing clinical outcomes of macular hole surgeries performed by trainee surgeons using a 3D heads-up display viewing system versus a standard operating microscope.

PURPOSE: To compare the surgical outcomes of macular hole (MH) surgery performed by trainee surgeons using a three-dimensional heads-up display (3D HUD) versus a standard operating microscope (SOM). MATERIALS AND METHODS: A retrospective review of all consecutive medical records patients operated on for MHs by a trainee surgeon between 2017 and 2020 using either 3D HUD or SOM was performed. Minimum hole diameter, maximum hole diameter, total surgical time, and MH closure rates were compared between the two groups. MH retinal detachments, traumatic MHs, and MHs for which inverted internal limiting membrane flaps were used were excluded from the study. RESULTS: Trainee surgeons operated on 51 patients using 3D HUD and 63 patients using SOM. Age at presentation, intraocular pressure (IOP) at diagnosis, maximum hole diameter, minimum hole diameter, surgical time, duration between diagnosis and surgery were comparable between both groups. MH closure rate was significantly (p < 0.004) higher in the 3D HUD group (n = 44, 86.3%) than that of the SOM group (n = 38, 60.3%). There were no postoperative adverse events such as glaucoma or retinal detachment in either group. Other than the viewing technique, there were no significant variables associated with MH closure in the two groups. CONCLUSION: Surgeries conducted by trainee surgeons using 3D HUD had higher MH closure rates than those using SOM.

Alterations in the gut bacterial microbiome in people with type 2 diabetes mellitus and diabetic retinopathy.

Gut bacterial microbiome dysbiosis in type 2 Diabetes Mellitus (T2DM) has been reported, but such an association with Diabetic Retinopathy (DR) is not known. We explored possible link between gut bacterial microbiome dysbiosis and DR. Using fecal samples of healthy controls (HC) and people with T2DM with/without DR, gut bacterial communities were analysed using 16S rRNA gene sequencing and data analysed using QIIME and R software. Dysbiosis in the gut microbiomes, at phyla and genera level, was observed in people with T2DM and DR compared to HC. People with DR exhibited greater discrimination from HC. Microbiomes of people with T2DM and DR were also significantly different. Both DM and DR microbiomes showed a decrease in anti-inflammatory, probiotic and other bacteria that could be pathogenic, compared to HC, and the observed change was more pronounced in people with DR. This is the first report demonstrating dysbiosis in the gut microbiome (alteration in the diversity and abundance at the phyla and genera level) in people with DR compared to HC. Such studies would help in developing novel and targeted therapies to improve treatment of DR.

Cytomegalovirus retinitis in a patient of granulomatosis with polyangiitis on long-term immunosuppressants.

A 69-year-old male patient presented to the retina clinic with a sudden decrease in vision in his right eye since 1 day. He was a known case of granulomatosis with polyangiitis and was on systemic immunosuppression for the past 3 years. The best-corrected visual acuity (BCVA) in his right eye was 20/60 and he has no perception of light in the left eye. Fundus examination revealed the presence of retinitis lesions in the right eye and total optic atrophy in the left eye. A vitreous biopsy was done and the PCR was found to be positive for cytomegalovirus (CMV). He was treated with intravitreal ganciclovir injections. Subsequently, the retinitis lesions regressed and BCVA in the right eye improved to 20/40.This case report elaborates on the risks of the development of opportunistic ocular infections in patients receiving long-term systemic immunosuppressants and the need for regular ocular examinations in such cases.

Severe ocular and adnexal complications in dengue hemorrhagic fever: A report of 29 eyes.

Purpose: To describe a series of sight-threatening ocular and adnexal involvement associated with dengue hemorrhagic fever and their treatment options. Methods: Retrospective, interventional, non-comparative case series. Medical records of patients who presented with ocular symptoms attributed to dengue hemorrhagic fever were reviewed. Demography, presenting features, and treatment outcomes were recorded. Outcome measures assessed included globe salvage, vision salvage, and visual improvement. The outcome was deemed as favorable if vision salvage was possible and unfavorable if the vision was lost. Results: Twenty-nine eyes of 23 patients were included. Bilateral ocular involvement was seen in 6 (26%) patients. The mean age was 37.62 ± 18.68 years (range: 14 to 81 years). Coexistent diabetes mellitus and enteric fever were present in three patients. History of blood transfusion was present in nine (40%) and thrombocytopenia in eight (35%) patients at the time of presentation with ocular complaints. Presenting features included endophthalmitis in 11 (38%), panophthalmitis in 10 (35%), orbital cellulitis with panophthalmitis in four (14%), isolated corneal or scleral melt in three (10%), and orbital hemorrhage with panophthalmitis in one (3%) patient. Globe salvage was achieved in 21/29 eyes (72.4%), vision salvage in 6/29 eyes (20.68%), and improvement in visual acuity was noted in 5/29 eyes (17.24%). Logistic regression analysis revealed no significant effect of any clinical-microbiological factors on globe salvage, vision salvage, and visual improvement. However, visual improvement and globe salvage were possible in eyes that underwent early endoscopic vitrectomy. Conclusion: Dengue fever can present with sight-threatening ocular and adnexal inflammation resulting in endophthalmitis and panophthalmitis, orbital cellulitis, corneal and scleral melt, and orbital hemorrhage. Early vitrectomy may improve vision and globe salvage in cases with significant vitritis.

Response of L V Prasad Eye Institute to COVID-19 outbreak in India: experience at its tertiary eye care centre and adoption to its Eye Health Pyramid.

AIM: To summarize the experience of response to COVID-19 outbreak at a tertiary eye care institute and its network of health facilities in India. METHODS: Our responses are based on the principles of social distancing, hand hygiene, respiratory etiquettes, surface disinfection protocol, and rational use of appropriate personal protective equipment (PPE). We describe our response in terms of administrative controls, clinical protocols, staff protection, environmental controls, and social distancing measures. We also discuss our communication strategies and monitoring systems, to ensure compliance to protocols. RESULTS: Administrative control is mainly related to formation of task force and its functions. Clinical protocols are related to patient triaging methods and clinical examination guidelines in Outpatient, Inpatient and Operating Room. Staff protection is focused on training staff on the protocols to be followed in hospital as well as at home, and use of PPE. Environmental protocol is focused on cleaning and disinfectant methods to be used in the hospital. In addition, there are systems for communication as well as monitoring compliance to protocols. CONCLUSION: We hope that these protocols and our experience would help the ophthalmic community globally and serve as a guide to protect ophthalmologists and ophthalmic care personnel, and their patients across the world.

Intraocular endoscopy: A review.

Optimal visualization is one of the most challenging aspects of performing vitreoretinal surgery. In situations where conventional microscopic techniques provide poor posterior visualization, the adjunctive skill set of endoscopic visualization may be needed. This allows for by-passing the opaque anterior segment media and getting access to the posterior segment pathology. Endoscopic vitrectomy is a useful and unique adjunct to microincision vitreoretinal surgery. The optical set-up of endoscopy allows for clinical approaches that are impossible with regular microscope viewing systems. These include the ability to observe across optically significant anterior segment opacities and directly visualize the posterior segment of the eye. It also allows for visualizing the difficult-to-access retroirideal, retrolental, and anterior retinal structures. Surgical access to anatomic spaces like the pars plana, pars plicata, ciliary sulcus, ciliary body, and peripheral lens is tedious. This is made simpler by endoscopy. In this review, we summarize and review the usage of the intraocular endoscope as a diagnostic and therapeutic armamentarium across a wide spectrum of ocular pathologies.

Miliary Retinal Lesions in Ocular Syphilis: Imaging Characteristics and Outcomes.

Purpose: To describe full thickness miliary retinal lesions in ocular syphilis.Methods: Retrospective chart review of patients with serologically confirmed ocular syphilis. Retinal miliary lesions in three cases of Syphilitic uveitis, in immunocompetent individuals are described. Case 1 and case 2 were positive for both VDRL (venereal disease research laboratory) and TPHA (Treponema pallidum hemagglutination), case 3 was VDRL negative but TPHA positive.Results: Miliary lesions were small round to oval, yellow retinal lesions, measuring less than » disc diameter size, with distinct margins, involving complete thickness of retina on OCT, in a pillar like manner, associated with ground glass retinitis, outer retinal placoid lesion or with retinal vasculitis. In cases 1 and 3, these healed with pigmentation.Conclusion: In contrast to similar lesions described, retinal miliary lesions seem to involve full thickness of the retina on OCT and may heal with pigmentation. These lesions may be characteristic of ocular syphilis.

CLINICAL PRESENTATIONS, DIAGNOSTIC DILEMMA, AND MANAGEMENT OUTCOMES OF CHRONIC POSTOPERATIVE ENDOPHTHALMITIS CAUSED BY STEPHANOASCUS CIFERRII.

PURPOSE: To report the diagnosis and management of a series of chronic postoperative endophthalmitis caused by Stephanoascus ciferrii. METHODS: This is a retrospective consecutive case series at a tertiary eye care institute. Case records of consecutive cases of chronic postoperative endophthalmitis caused by a novel fungus S. ciferrii were analyzed. The clinical presentations, microbiologic workup including microscopy, culture, antifungal susceptibility and polymerase chain reaction for fungal DNA of clinical samples, and the clinical management were noted. The cases underwent anterior chamber tap, vitreous biopsy, core vitrectomy, and intraocular lens explantation, and the management consisted of a combination of topical and systemic therapy and intravitreal injections of antimicrobial agents. RESULTS: The report includes four eyes of four patients. All patients were diagnosed as chronic postcataract surgery endophthalmitis, and they showed variable levels of persistent low-grade intraocular inflammation till the intraocular lens was explanted. S. ciferrii (identified by the Vitek 2 compact system) was grown in culture from one or more of the clinical samples such as vitreous, anterior chamber fluid, capular bag, and intraocular lens. Fungal DNA was detected from vitreous in one case. One isolate tested for antifungal susceptibility was resistant to amphotericin B; however, the patient responded to treatment with the drug. Good clinical outcome was achieved in all patients. CONCLUSION: We describe successful treatment of endophthalmitis caused by S. ciferrii. A good response is obtained after pars plana vitrectomy and intraocular lens explantation.

Foveal cone count reduction in resolved endophthalmitis: an adaptive optics scanning laser ophthalmoscopy (AO-SLO)-based prospective pilot study.

AIM: To report the foveal cone count in eyes with resolved endophthalmitis vis-à-vis normal fellow eyes using an indigenous adaptive optics scanning laser ophthalmoscopy (AO-SLO). METHODS: In a prospective cross-sectional comparative pilot study, we recruited patients with resolved endophthalmitis in one eye (study eye) and a normal fellow eye (control eye). Collected data included measurement of the best-corrected visual acuity (BCVA), spectral-domain optical coherence tomography (OCT) imaging and AO-SLO imaging and cone counting at the fovea in both eyes. RESULTS: The study included 12 eyes of 6 patients. The mean age was 51.66±11.97 years (median 56 years). BCVA in all control eyes was 20/20 (logarithm of the minimum angle of resolution (LogMAR) 0), and in the study, eyes was 0.21±0.13 (median 0.19, Snellen 20/30; p=0.001; 95% CI -0.39 to -0.09). The follow-up was 18.66±12.32 (median 20 months). The cone count at the fovea in the control eye was 4356.33±1993.93 (median 4498), and in the study eye, it was 2357.16±1541.17 (median 2187.5; p=0.03; 95% CI -3556 to -1082). CONCLUSIONS: Eyes with resolved endophthalmitis with near-normal vision have reduced number of foveal cones even in absence of OCT-detected gross structural changes. TRANSLATIONAL RELEVANCE: The current work describes the application of cellular-level imaging technique called adaptive optics scanning laser ophthalmoscopy (AO-SLO) to the clinical condition of resolved endophthalmitis. The study of retinal cell biology at the cellular level is possible using the emerging technology of AO-SLO. This new investigative modality that has the potential to image the retina at the cellular level until the photoreceptors is more likely to unravel the pathophysiology of a variety of retinal diseases.

Intraocular endoscopy in the management of ocular trauma: clinical settings and treatment outcomes at a tertiary eye care centre.

PURPOSE: To report the application of endoscopy in the management of ocular trauma, describe the clinical settings and the treatment outcomes. METHODS: Retrospective, consecutive, non-comparative case series at a tertiary eye care centre. Data recorded included aetiology of trauma, presenting vision, corneal condition at presentation, per-operative clinical findings during endoscopy, prognostication of the cases on table, final visual and anatomic outcome. Odds ratios for a favourable outcome were computed for various surgical indications. RESULTS: The study included 58 eyes of 58 patients. Males constituted 82% of all cases. Mean age at presentation was 35.55 ± 18.9 years, median 31.5 years. Commonest corneal condition causing opaque media was corneal oedema (44.8%) followed by corneal laceration in 25.8%, repaired corneal laceration in 13.7% and scarred cornea in 12%. Commonest indication for surgery was retinal detachment (36.2%) followed by vitreous haemorrhage (29.3%), retained foreign body (13.7%) and combined detachment with haemorrhage in 10.3%. Of the 58 eyes, 17 eyes were deemed inoperable on endoscopic examination and 11 eyes were deemed to have poor prognosis. Of the fair prognosis (n = 30), 60% had final vision of 20/400 (p = 0.0001) compared to 10% before surgery and 13.33% had final vision of 20/40 (p = 0.03) as compared to nil in the pre-operative period. Odds ratio for a favourable visual outcome was best for the indication of vitreous haemorrhage (OR = 9, p = 0.0006). CONCLUSION: Endoscopy in ocular trauma with opaque media provides adequate visualisation and allows for prognostication. In cases deemed to have prognosis, suitable intervention leads to globe and vision salvage.