Creatively tiding over the crisis.

Background: A patient with a retained intraocular metallic foreign body post-trauma was taken up for vitrectomy and intraocular foreign body removal. Unfortunately, the intraocular magnet was not available at the moment on the table! How a little bit of creativity and innovative thought helped us tide over this crisis is the content of this video. Purpose: To demonstrate magnetization of a metallic surgical instrument for temporary use in the event of unavailability of the intraocular magnet for intraocular foreign body removal. Synopsis: A ferromagnetic substance can be magnetized temporarily using an existing magnet. We obtained a general-purpose magnet and wrapped it in sterile plastic, using which we magnetized normal intraocular forceps and a Micro Vitreo Retinal (MVR) blade by giving about 20-30 strokes over the magnet in a single direction. This aligned the magnetic domains in the metal in a parallel fashion. These Do It Yourself (DIY)- magnetic instruments were then effectively utilized to remove the metallic intraocular foreign body. Highlights: The video showcases effectively harnessing the available resources and tiding over the dearth of a necessary instrument, with the right use of an innovative idea and some creativity!. Video link: https://youtu.be/QtRC-AK5FLU.

Incidence of post vitrectomy endophthalmitis in India - A multicentric study by VRSI study Group.

INTRODUCTION: The incidence of post vitrectomy endophthalmitis (PVE) is reported to be between 0.02 and 0.84%. Resterilization of single use instruments is a common practice amidst developing countries to make it more affordable to the patients by reducing the cost of the surgery and also reduce the environmental hazard. The aim of our study is to evaluate the incidence of PVE amidst existing sterilization practices of reused instruments in multiple vitreoretinal centres in India. METHODOLOGY: Centres with an endophthalmitis tracking system were invited to participate in a survey. Twenty-five centres were sent a questionnaire via email. The questionnaire included details about the institution, number of vitrectomies performed in a year, sterilization practices followed pre-operatively, intraoperatively and postoperatively, incidence of endophthalmitis and instrument reuse policies. RESULTS: A total of 29 cases of endophthalmitis were reported out of the 47,612 vitrectomies performed across various centres. The mean incidence of endophthalmitis was 0.06%. There was no difference in the rates of endophthalmitis based on various pre-operative, intraoperative or postoperative prophylactic measures. Nearly 80% of the centres change most of the instruments after every case, while the rest reused. The mean number of times a cutter was being reused until discarded was 4.7. Nearly 76% followed a performance-based protocol, and the remaining 24% had a fixed protocol for the number of times an instrument can be reused before discarding it. CONCLUSION: PVE rates are not significantly different in India despite the multiuse of single use instruments. The purpose of this paper is not to suggest an alternate protocol but to creating one in the future with these results in mind, to rationalise the use of single use instruments, make VR surgery more affordable and also have a positive impact on the carbon footprint of consumables in surgery.

Long-term real-world outcomes in retinal vein occlusions: How close are we to the trials?

Purpose: To assess and analyze the visual outcomes of patients with retinal vein occlusions in a real-world setting with a long-term follow-up of more than 5 years. Methods: Retrospective analysis of 56 patients having retinal vein occlusions from a tertiary eye center, with a mean follow-up of 7 years was performed. Primary outcome measures were mean change in best-corrected visual acuity (BCVA) from baseline at 6 months, 1 year, 2 years, 3 years, and final visit (≥5 years), proportion of patients having BCVA better than 20/40 and worse than 20/200, and mean number of injections. Secondary outcome measures were change in central macular thickness (CMT), development of subsequent retinal vein occlusion (RVO) in same eye or the other eye, and development of neovascular complications. Results: The mean change in letter score was + 11.84 in branch RVO (BRVO), +7.14 in non-ischemic central RVO (CRVO), and -9.5 in ischemic CRVO at 1 year, which changed to + 8.57, -5 and - 24, respectively, at the end of follow-up. CMT had improved from 506 ± 98.8 µm, 576.44 ± 149 µm, and 618 ± 178.27 µm, respectively, at baseline to 267 ± 94 µm, 345.20 ± 122.61 µm, and 265.50 ± 107.75 µm, respectively, in BRVO, non-ischemic, and ischemic hemi RVO (HRVO)/CRVO groups. The total mean number of injections given in BRVO, non-ischemic CRVO, and ischemic CRVO groups were 4.6, 6.6, and 4.1, respectively. None of the patients with BRVO developed neovascular glaucoma (NVG). Non-ischemic to ischemic HRVO/CRVO conversion was noted in 4/11 eyes at a mean duration of 12.6 months. NVG was noted in 7/9 eyes (77.8%) in initial ischemic CRVO/HRVO group and 3/4 (75%) converted eyes. Conclusion: Patients with BRVO have good visual outcomes with anti-VEGF, while in CRVO results may vary considerably owing to patient compliance and treatment burden on long-term follow-up in a real-world setting.

Plug it, fill it and forget it!

Background: Management of posterior scleral perforation is commonly done with cryotherapy/laser or scleral patch graft depending on the size of perforation. However, for large perforations, the availability of donor sclera is always an issue. To overcome this problem, we tried using absorbable gelatin sponge to plug the perforation as an alternative. Purpose: To evaluate the efficacy of gelatin foam as an alternative to scleral patch graft in cases with perforation of posterior sclera. Synopsis: Here we report the case of a 27-year-old male, who sustained penetrating injury to right eye with two metallic intraocular foreign bodies with visual acuity of hand movement close to face. Primary wound repair was done, followed by retrieval of the first piece of metallic foreign body that measured 11X3mm in size. The second foreign body visualized at posterior pole adjascent to the disc was removed using Machemar forceps and it measured 10X3 mmin size. Leakage of PFCL at the site confirmed a posterior scleral perforation. Cryotherapy was avoided due to its proximity to optic nerve head, and donor sclera was not readily available at that moment. We managed the case by plugging the defect with absorbable gelatin foam, followed by silicone oil injection into the vitreous cavity. Post operative outcome was good with restoration of anatomical integrity of the globe along with improvement in visual acuity upto 6/18. Highlights: Gelatin foam being absorbable and inciting less reaction aids in sealing the perforation and maintenance of globe contour with the advantage being readily available, cost-effective and it can be left in situ without the need for additional surgery for its removal. This would be of use in situations where the donor sclera is not readily available, and thus can be a potential alternative. However, further studies with larger sample size need to be done to evaluate and compare its effectiveness over donor scleral grafts. Online Video Link: https://youtu.be/fkardnkMQQo.

Ocular occlusions in two cases of COVID-19.

In late 2019, we saw the emergence of a new coronavirus, the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), which rapidly evolved into a global pandemic. We report two cases of ocular vascular occlusion related to coronavirus disease 2019 (COVID-19) disease. The first case is of choroidal artery occlusion, while the second case is of combined central retinal artery and vein occlusion (CRAO and CRVO). We performed a thorough literature search and to the best of our knowledge, neither any of the above said has been reported in COVID-19-positive patients.

Acceptability of artificial intelligence-based retina screening in general population.

Purpose: A deep learning system (DLS) using artificial intelligence (AI) is emerging as a very promising technology in the future of healthcare diagnostics. While the concept of telehealth is emerging in every field of medicine, AI assistance in diagnosis can become a great tool for successful screening in telemedicine and teleophthalmology. The aim of our study was to assess the acceptability of AI-based retina screening. Methods: This was a prospective non-randomized study performed in the outpatient department of a tertiary eye care hospital. Patients older than 18 years who came for a regular eye check-up or a routine retina screening were recruited in the study. Fundus images of the posterior pole were captured on fundus on a phone camera (REMIDIOTM, India) with a built-in AI software (Netra.AI) that can identify normal versus abnormal retina. The patients were then given an 8-point questionnaire to assess their acceptance and willingness toward AI-based screening. We recruited 104 participants. Results: We found that 90.4% were willing for an AI-based fundus screening; 96.2% were satisfied with AI-based screening. Patients with diabetes (P = 0.03) and the male population (P = 0.029) were more satisfied with the AI-based screening. The majority (i.e., 97.1%) felt that AI-based screening gave them a better understanding of their eye condition and 37.5% felt that AI-based retina screening prior to a doctor's visit can help in routine screening. Conclusion: Considering the current COVID-19 pandemic situation across the globe, this study highlights the importance of AI-based telescreening and positive patient approach toward this technology.

Coats' disease - Prognostic factors for globe and vision salvage in children, a long-term experience.

PURPOSE: Coats' disease is associated with poor outcomes, and there are limited studies on long-term outcomes of Coats' disease. The purpose of our study is to identify various predictive factors to help in prognosticating the treatment outcomes in advanced Coats' disease in children. METHODS: This is a retrospective case series from a single tertiary eye care center of children (<18 years) diagnosed with coat's disease. Sixty-seven patients with Coat's disease were identified from the medical records from 2009 to 2020. Patients' demographic data, clinical presentation, stage, extent of involvement, detailed treatment history, clinical sequelae post-treatment (including complications and anatomical and functional outcomes) were noted. Binary logistic regression was performed to correlate the predictive factors for anatomical and functional improvement. RESULTS: Of the 67 patients, 51 eyes of 51 patients were included in the study. The male to female proportion was 2.2. Mean age at presentation was 4.98 ± 3.55 years (range: 2 months-15 years). Mean duration of follow-up was 31.53 ± 26.38 months. Overall, our globe salvage rate was 92.2%. We found that vitreoretinal fibrosis (P < 0.001), subretinal gliosis (P < 0.001), vitreous hemorrhage (P = 0.02), tractional or combined retinal detachment (P < 0.001), foveal scar (P < 0.006), and cataract (P < 0.001) to be important factors to affect the outcome. CONCLUSION: Advanced stage of presentation (stage 3B and above), diffuse involvement, cataract, vitreoretinal fibrosis (preretinal and subretinal), vitreous hemorrhage, tractional or combined retinal detachment, and anterior hyaloid proliferation are poor prognostic factors for globe salvage in advanced disease. Subretinal gliotic nodule or scar and lack of visual rehabilitation suggest poor functional outcomes.

Not-so-minimal for minimally invasive surgery.

Sub-macular hemorrhage poses a potential threat to vision if left untreated. The preferred surgical technique to clear sub-macular hemorrhage includes vitrectomy followed by retinotomy using a 41G needle with subsequent injection of recombinant tissue plasminogen activator (r-tPA) followed by air/SF6 injection into the sub-retinal space. A malleable nature, increased resistance, and the cost of the 41G needle limit its use. We evaluated the safety and efficacy of a 26G needle for retinotomy as a supplement for the 41G needle in a series of six subjects with sub-macular hemorrhage. A slight modification in the procedure was done by injecting air into the sub-retinal space prior to the r-tPA injection. We found that our technique of using the 26G needle for retinotomy is safe and effective due to its stable nature and self-sealing properties. An air injection prior to r-tPA allows for increased bioavailability of the drug by preventing efflux due to its tamponading effect.

Ethambutol induced toxic optic neuropathy - A retrospective study in a tertiary eye care centre in Southern India.

INTRODUCTION: Ethambutol is an antibiotic used as a first line drug in the treatment of tuberculosis and a vision threatening side effect of EMB is ethambutol-induced optic neuropathy (EON). The aim of the study is to create awareness about the potentiality of ethambutol to cause ethambutol-induced optic neuropathy, careful monitoring of dose and patient education. MATERIALS AND METHODS: A retrospective observational study of 14 patients whose complete Anti- tubercular treatment records could be retrieved were included. Epidemiological data including age, sex, systemic illness were recorded. Duration between optic nerve toxicity , usage of ethambutol and the drug dosage were noted. Best corrected visual acuity, anterior segment examination including pupils, extraocular movements, colour vision, central fields and fundus examination were evaluated. The patients were followed up at one and three month intervals. RESULTS: Associated systemic illness was found to be a confounding factor for the development of ethambutol-induced optic neuropathy. 57% of patients had diabetes mellitus followed by hypertension (14.2%), renal disease (7.1%). The average daily dose of Ethambutol ingested was 1078.5 mg (21 mg/kg) and this high dose could have been the primary cause for development of ethambutol-induced optic neuropathy. Vision ranged from total blindness to mild visual impairment and poor recovery of vision was noted even after discontinuing ethambutol. CONCLUSION: Only a minority of patients showed improvement in visual function following discontinuation of ethambutol and the toxicity was found to be dose-dependent. Patients with comorbidities like renal impairment and diabetes mellitus appeared to be at greater risk. Ophthalmological examination before commencing treatment and periodic evaluation thereafter is mandatory.

Dexamethasone implant improves anatomic response to anti-VEGF therapy in treatment-resistant polypoidal choroidal vasculopathy.

BACKGROUND: A significant proportion of eyes with polypoidal choroidal vasculopathy (PCV) can be resistant to anti-vascular endothelial growth factor (VEGF) injections. We evaluated the efficacy of a combination of dexamethasone intravitreal implant (DXI) and anti-VEGF therapy in eyes resistant to anti-VEGF monotherapy. METHODS: In this retrospective study, patients with PCV resistant to anti-VEGF injections were additionally injected with a DXI along with an anti-VEGF agent. Best-corrected visual acuity (BCVA), slit-lamp examination, fundus evaluation, and optical coherence tomography (OCT) data were analyzed. Anatomical response on OCT was the primary outcome measure. Change in visual acuity and injection-free interval after DXI were evaluated as secondary outcome measures. RESULTS: Twelve eyes of 11 patients were included in the study. Mean age of patients at presentation was 64.7 ± 9.5 years (range, 49-78.8 years), and there were seven females (63.6%). Median number of anti-VEGF injections prior to DXI was 4 (interquartile range IQR, 3-7). Median follow-up duration after DXI was 32.2 months (IQR, 6.6-41.6 months). Median logMAR BCVA immediately prior to DXI was 0.41 (IQR, 0.30-0.88) and after injection was 0.40 (IQR, 0.30-1.05), which was not significantly different (p = 0.85). Median Central Retinal Thickness (CRT) after DXI was 305.5 µm (IQR, 249-409 µm), which was significantly (p = 0.003) lesser than pre-injection thickness of 547 µm (IQR, 431-771 µm). Median injection-free interval in these eyes after DXI was 5 months (IQR, 2.8-6.4 months). Kaplan-Meier estimates of first injection after DXI were 27.3% at 3 months, 67.3% at 6 months, and 89.1% at 12 months. CONCLUSIONS: Dexamethasone implant combined with anti-VEGF treatment can prolong the treatment-free interval in eyes with PCV resistant to anti-VEGF injection while maintaining visual acuity.

Intractable hiccups, nausea, and vomiting, an unnerving cause of vision loss.

Acute optic neuritis (ON) is caused by variety of complex disorders that can be differentiated with the help of history, radiology, and serology. Identification of nonneurological symptoms that occur before the demyelinating event aids in timely diagnosis and prevention of further neurological attacks. We describe a case of unilateral ON with a history of intractable hiccups, nausea, and vomiting, wherein the possibility of area postrema syndrome (APS) was overlooked until the development of visual symptoms. APS recently identified as a hallmark of neuromyelitis optica spectrum disorder is a rare neurologic cause of gastrointestinal symptoms. This atypical presentation of APS results from autoantibodies directed against the aquaporin-4 rich sites, such as area postrema. This case brings to light the importance of eliciting history of intractable hiccups, nausea, and vomiting in a patient with ON. Despite being a commonly encountered symptom, it may rarely raise a suspicion for neuromyelitis optica.

A questionnaire-based assessment of Safe Eye Examination (SEE) technique.

PURPOSE: This study aims to assess the novel and innovative method of Safe Eye Examination (SEE) technique using the model eye for the purpose of teaching, training, and resident examination. METHODS: A questionnaire-based study (Descriptive Data) with 53 participants, including ophthalmology residents, fellows in various subspecialties, and trainee optometrists was used. In our study, we used the Reti Eye model, but instead of the usual retina template sheet, we used prominent pathological fundus photographs loaded into the model eye. The study participants were asked to view prominent pathological fundus images printed on a matte finish paper. A circular image was cut and was placed in the Reti Eye model. The candidates were made to perform indirect ophthalmoscopy with a + 20D lens and to fill up a Google image assessment scale questionnaire with characteristics, including pixelation, sharpness, contrast, reflexes, blotchy appearance, and diagnostic confidence, which were then analyzed and depicted. Association between categorical variables was analyzed using Fisher exact test and Chi-square test. A P value of less than 0.05 was considered statistically significant. All data were analyzed with a statistical software package (SPSS, Version 16.0 for Windows). RESULTS: The number of positive responses (>90%) obtained for the pixelation, sharpness, contrast, reflexes, blotchy appearance, and diagnostic confidence of the image viewed were statistically more significant than the negative responses (P < 0.05). CONCLUSION: The SEE technique of using the model eye can be incorporated for teaching, training, and skill assessment in the examinations in these difficult times of COVID-19 (coronavirus disease 2019) pandemic.

Influence of segmental supply of Cilioretinal artery on morphology of diabetic macular edema.

BACKGROUND: The supply of Cilioretinal artery (CRA) to different layers of the retina influences retinal pathologies such as diabetic retinopathy (DR). Since the supply of CRA is segmental, our aim was to analyze the location of CRA with respect to non - center involving diabetic macular edema (DME) differentiated by various segments and center involving DME based on Early Treatment of Diabetic Retinopathy Study (ETDRS) scale using optical coherence tomography (OCT). METHODS: A retrospective study was conducted in which forty-three patients with various stages of DR and the presence of CRA were identified. Presence and location of CRA was recognized using fundus fluorescein angiography. Classification of DME was based on ETDRS subfields on OCT. RESULTS: Evaluation of 26 men and 17 women with varying degrees of severity involving DR revealed the presence of unilateral CRA in 40 subjects and bilateral CRA in 3 subjects. When CRA supplied the central area, maximum retinal thickness was noted at the temporal quadrant (271.67 ± 164.02 µm) along with non - center involving DME (194.87 ± 121.06 µm); when CRA supplied the lower area, maximum retinal thickness was noted at the superior quadrant (293.64 ± 159.36 µm) along with center involving DME (395 ± 285.75 µm) and when it supplied the upper area, maximum retinal thickness was noted at the nasal quadrant (293.49 ± 176.18 µm) along with center involving DME (292 ± 192.79 µm). CONCLUSION: The presence of CRA seems to influence the morphology of the retina amongst patients diagnosed with DR by altering the segments involved in DME based on its supply location. However, further studies with a larger sample size are warranted to strenghten this association.

Comparison of standard and "innovative wide-field" optical coherence tomography images in assessment of vitreoretinal interface in proliferative diabetic retinopathy: A pilot study.

Purpose: To compare the standard and "innovative wide-field" optical coherence tomography images in assessment of vitreoretinal interface in proliferative diabetic retinopathy. Methods: Fifty consecutive eyes of 25 patients with proliferative diabetic retinopathy underwent 12 × 12 mm radial swept source-optical coherence tomography (OCT) imaging using standard technique and innovative wide-field (+90D) technique. The image expansion ratio was calculated using Image J software. Results: Out of the 50 eyes, only in four eyes with +90 D were minimally misaligned or were having quality less than grade 2 as compared to standard OCT. The mean age group was 51 ± 4.5 years. The expansion ratio (scan length) increased by a factor of 1.65 ± 0.67 when obtained using +90 D technique. Conclusion: Innovative wide-field technique provides us with the widest of available OCT scans with the presently available machine and the software.

"HOURGLASS COLOBOMA": A CASE REPORT AND REVIEW OF ETIOPATHOGENESIS.

PURPOSE: To report a rare case of multiple fundal colobomata and to review the possible etiopathogenic factors involved in its genesis. METHOD: Case report. RESULT: A 21-year-old myopic lady was noted to have 2 fundal colobomata-one in the inferior and the other in superior hemisphere of globe in a mirror-image fashion resembling an "hourglass" in the right eye and a typical Type 3 coloboma in the left eye. The iris was normal in both the eye. Multiple fundal colobomata have not been described in the literature. The presence of "accessory embryonic fissure" in the developing eyeball is the only probable mechanism that can explain this presentation. This case is an evidence for the possibility of presence of accessory embryonic fissure in developing eyeball in human. The eponym "hourglass coloboma" or "mirror-image colobomata" best describes this condition. CONCLUSION: This report of multiple fundal colobomata is the first of its kind. This case is an evidence for possibility of presence of accessory embryonic fissure in developing eyeball in human.