Reducing the Impact of the COVID-19 Pandemic on Retinopathy of Prematurity Screening: Successful Strategies Learnt from a Multi-Center Tele-Medicine Program in India.

PURPOSE: Control of blindness due to retinopathy of prematurity (ROP) requires timely screening and treatment within 48-72 h. Anticipating that the coronavirus disease 2019 (COVID-19) pandemic would disrupt ROP services, we devised strategies ''on-the''-go"" to ameliorate this possiblity. We describe the successful outcomes of this approach in preventing infant blindness during the pandemic. METHODS: Data on the number of preemies recruited, screened and treated in the Karnataka Internet-assisted Diagnosis of Retinopathy of Prematurity (KIDROP) program were collected in a retrospective (2019, interval 1) - prospective (2020, interval 2) manner. We summarize 10 key strategies that were developed as we faced logistic, operational and implementation challenges. These included pragmatic methods of enhancing enrolment, transporting for screening and ensuring timely treatment in the outreach. RESULTS: The total number of ROP screening sessions was 20,598 (7,197 new) and 14,371 (5,773 new) during interval 1 and 2 respectively. Of these, 166 (2.3%) and 157 (2.7%) infants required treatment during interval 1 and 2 respectively. All infants needing treatment during the COVID period, were treated on time which was possible due to successful implementation of the 'on-the-go' strategies throughout the state of Karnataka. The fiscal equivalent of the blindness prevented during this period is USD 15.6 million. CONCLUSION: The greater decline in the number of ROP screening episodes in neonatal units in government hospitals was because several were converted to 'COVID only" hospitals. KIDROP's multi-zonal, decentralized strategy, which uses non-physician-based imaging in a telemedicine network, ensured that essential ROP services continued even during the lockdown.

Inherited retinal disorders: a genotype-phenotype correlation in an Indian cohort and the importance of genetic testing and genetic counselling.

PURPOSE: Recent advances in sequencing technologies have enabled radical and rapid progress in the genetic diagnosis of inherited retinal disorders (IRDs). Although the list of gene variations continues to grow, it lacks the genetic etiology of ethnic groups like South Asians. Differences in racial backgrounds and consanguinity add to genetic heterogeneity and phenotypic overlaps. METHODS: This retrospective study includes documented data from the Gen-Eye clinic from years 2014 to 2019. Medical records and pedigrees of 591 IRD patients of Indian origin and genetic reports of 117 probands were reviewed. Genotype-phenotype correlations were performed to classify as correlating, non-correlating and unsolved cases. RESULTS: Among the 591 patients, we observed a higher prevalence of clinically diagnosed retinitis pigmentosa (38.9%) followed by unspecified diagnoses (28.5%). Consanguinity was reported to be high (55.6%) in this cohort. Among the variants identified in 117 probands, 36.4% of variants were pathogenic, 19.2% were likely pathogenic, and 44.4% were of uncertain significance. Among the pathogenic and likely pathogenic variants, autosomal recessive inheritance showed higher prevalence. About 35% (41/117) of cases showed genotype-phenotype correlation. Within the correlating cases, retinitis pigmentosa and Stargardt disease were predominant. Novel variants identified in RP, Stargardt, and LCA are reported here. CONCLUSION: This first-of-a-kind report on an Indian cohort contributes to existing knowledge and expansion of variant databases, presenting relevant and plausible novel variants. Phenotypic overlap and variability lead to a differential diagnosis and hence a clear genotype-phenotype correlation helps in precise clinical confirmation. The study also emphasizes the importance of genetic counselling and testing for personalized vision care in a tertiary eye hospital.

Novel Method of Plugging the Hole: Anatomical and Functional Outcomes of Human Amniotic Membrane-Assisted Macular Hole Surgery.

PURPOSE: To describe the surgical outcomes of macular holes (MHs) by inserting a human amniotic membrane (hAM) plug. METHODS: In this retrospective, interventional, comparative case series, 10 patients who had undergone hAM plugging for a MH were included in the study. Seven patients had idiopathic full-thickness MHs, 1 patient had traumatic MH, and 1 patient each had a MH-induced retinal detachment and combined retinal detachment. The control group included 10 cases with similar configuration and duration of MHs treated with the inverted peeling of the internal limiting membrane technique. All patients underwent a standard 3-port, 25-gauge transconjunctival pars plana vitrectomy and hAM plug transplantation in the subretinal space under the MH. The anatomic and functional outcomes were assessed at 4 weeks postsurgery. RESULTS: At the 4-week follow-up visit, all the MHs in the hAM plug group achieved hole closure, whereas 80% of the eyes in the control group were able to achieve hole closure. Improvement of 0.1 logMAR vision was noted in 8 of the 10 patients. At the 4-week follow-up visit, the external limiting membrane and ellipsoid zone layer continuity over the hAM was defined only in one case. No significant difference was found between the hAM plug group and controls in visual and anatomical responses. No complications following hAM transplantation such as rejection, endophthalmitis, or hypotony were noted following surgery. CONCLUSION: Subretinal hAM graft transplantation can be a useful option in the repair of primary or refractory MHs not only for achieving anatomic closure but also for the accompanying visual improvement.

Surgical Outcome of Congenital Cataract in Eyes With Microcornea.

PURPOSE: To report the intraoperative and postoperative outcomes of congenital cataract surgery in eyes with microcornea. METHODS: In this retrospective, interventional, comparative case series, the authors reviewed 47 eyes of 26 children with microcornea and congenital cataract (21 bilateral and 5 unilateral) who underwent lens aspiration with primary posterior capsulectomy and anterior vitrectomy between 2008 and 2014 with a minimum follow-up period of 6 months. Demographic profiles and systemic and ocular features were documented. Intraoperative and postoperative complications were studied separately for bilateral and unilateral cases. Patients were also divided into two groups on the basis of their ages at surgery (early surgery group: 3 months or younger; late surgery group: older than 3 months) and postoperative complications were compared. Visual outcome was analyzed in those with a follow-up period of more than 1 year. RESULTS: Early surgery was performed in 24 eyes of 13 patients (11 bilateral and 2 unilateral) and late surgery in 23 eyes of 13 patients (10 bilateral and 3 unilateral). Intraoperatively, all eyes had poor pupillary dilatation and 6 (12.8%) eyes needed iris hooks. Postoperatively, the most common early complication was transient corneal edema observed in 22 (46.8%) eyes (13 and 8 eyes in the early and late surgery groups, respectively). Late complications included visual axis opacification in 6 (12.76%) eyes (3 in each group), and secondary glaucoma in 5 (10.64%) eyes (2 and 3 eyes in the early and late surgery groups, respectively). Vision was normal for age in 18 (60%) of the bilateral cases with a follow-up period of more than 1 year. CONCLUSIONS: Early surgical intervention for congenital cataract in eyes with microcornea can result in favorable outcomes with an acceptable rate of postoperative complications. [J Pediatr Ophthalmol Strabismus. 2018;55(1):30-36.].

A Prospective OCT Study of Rubella Retinopathy.

PURPOSE: To analyze rubella retinopathy qualitatively and quantitatively in children diagnosed with congenital rubella syndrome (CRS) using a handheld spectral-domain (SD) OCT device. DESIGN: Prospective, cross-sectional, nonrandomized, comparative observational study in a tertiary eye care center in south India. PARTICIPANTS: Cases comprised 24 eyes of 13 children diagnosed with CRS based on seropositivity with rubella retinopathy. Controls comprised 26 eyes of 13 age-matched healthy children with normal retina. METHODS: All participants underwent retinal imaging with RetCam fundus photography (Natus Medical Inc, Pleasanton, CA) and handheld SD OCT (Bioptigen, Inc., Durham, NC). The SD OCT images of both cases and controls were segmented. Retinal and choroid thickness parameters were computed. MAIN OUTCOME MEASURES: Qualitative and quantitative changes were observed in SD OCT images of rubella retinopathy compared with those from controls. RESULTS: Characteristic salt-and-pepper appearance was observed on fundus photography in children with rubella compared with the healthy children. The appearance of fovea and retinal features such as foveal dip, external limiting membrane, inner segment-outer segment boundary, outer segment-retinal pigment epithelium boundary, and retinal pigment epithelium were significantly different (P < 0.05) in eyes with rubella retinopathy compared with healthy eyes Furthermore, eyes with rubella retinopathy exhibited significantly reduced central foveal thickness (P = 0.025), subfoveal outer retinal thickness (P = 0.01), and subfoveal choroid thickness (P = 0.007) compared with healthy eyes. CONCLUSIONS: Distinct qualitative and quantitative differences were observed in the SD OCT images of eyes with rubella retinopathy compared with those from healthy eyes.

Anterior segment optical coherence tomography findings of iris granulomas in Hansen's disease: a case report.

BACKGROUND: A 50-year-old male was diagnosed to have a right eye sclerouveitis and left eye granulomatous anterior uveitis due to Hansen's disease. We are reporting the anterior segment optical coherence tomography (ASOCT) findings of iris granuloma in this case. FINDINGS: Skin biopsy revealed plenty of acid fast bacilli with a bacteriological index of 5 suggestive of multibacillary polar lepromatous leprosy. ASOCT revealed well-demarcated smooth-surfaced nodular lesion with internal hyporeflectivity corresponding to the areas of granuloma which decreased in size following treatment with antileprosy drugs and systemic and topical steroids. CONCLUSION: ASOCT is a non-invasive technique to assess the extent of involvement of anterior segment in Hansen's disease and is a useful tool in follow-up. This is also the first report on ASOCT findings of iris granuloma in Hansen's disease.

In vivo imaging of riboflavin penetration during collagen cross-linking with hand-held spectral domain optical coherence tomography.

PURPOSE: To compare the effect of complete versus grid-like epithelial removal on riboflavin penetration during collagen cross-linking (CXL) in vivo using hand-held spectral domain optical coherence tomography (OCT, Bioptigen Inc). METHODS: In this prospective, observational, comparative case series, patients with progressive keratoconus undergoing CXL with riboflavin and ultraviolet A (UVA) light were enrolled. Twenty eyes (20 patients) undergoing CXL using 0.1% riboflavin and UVA light (365 nm) were imaged intraoperatively at 30 and 60 minutes after starting the procedure, using hand-held spectral domain OCT. In 10 eyes, the epithelium was removed completely in the central 7-mm zone (complete removal group) whereas in the remaining 10 eyes, the epithelium was removed in a grid pattern, leaving behind intact islands of epithelium (grid-like removal group). The depth of hyperreflective band (representing penetration of riboflavin) in the anterior corneal stroma was measured. RESULTS: In the complete removal group, the hyper-reflective band was homogenous, extending to a mean depth of 54.2±5.2 µm and 72.4±7.1 µm at 30 and 60 minutes, respectively (P<.001). In the grid-like removal group, the mean depth of the hyperreflective band was uneven, being significantly more in the "epithelium off" areas (56.90±4.66 µm and 74.2±6.7 µm at 30 and 60 minutes, respectively) (P<.001) compared to the "epithelium on" areas (18.9±2.3 µm and 24.7±2.3 µm at 30 and 60 minutes, respectively) (P<.001). CONCLUSIONS: Epithelial removal appears to be an essential step prior to performing CXL, as an intact epithelium appears to block penetration of riboflavin in the anterior corneal stroma.

Do platelets have a role in the pathogenesis of aggressive posterior retinopathy of prematurity?

PURPOSE: The purpose of this study was to report the possible role of thrombocytopenia in the pathogenesis of aggressive posterior retinopathy of prematurity (APROP). METHODS: The index case described in this study showed spontaneous resolution of APROP with plus disease within 3 days of correcting thrombocytopenia and did not require laser treatment. The retrospective cohort of nine consecutive Asian Indian infants with APROP with similar stage and plus disease as the index case was studied. The mean platelet count of these infants before laser treatment was compared with 21 age- and birth weight-matched control subjects. Correlation of platelet count with APROP is discussed. RESULTS: The mean birth weight of the 10 cases with APROP was 1,030 g (+/-178 g), and the mean period of gestation was 29.4 weeks (+/-2.0 weeks). The mean platelet count of the cases was 82,870/mm3 (+/-58,702/mm3) and that of the control subjects was 178,285 +/- 57,051/mm3 (P = 0.0002). Five of the 10 cases (50%) and 1 of the 21 control subjects (4.8%) had a platelet count of <100,000/mm3 (P = 0.007). In all, 19.4% of infants had culture-proven sepsis. There was no correlation between sepsis and thrombocytopenia in our cohort (P = 0.567). CONCLUSION: The role of low platelets in the etiopathogenesis of APROP has not been previously elucidated. Our study shows that a platelet count of <100,000 was associated with severe disease. Recently, platelets have been reported to play a key role in angiogenic regulatory protein delivery. It is possible that premature infants who develop retinopathy of prematurity in the setting of low platelet counts may lack the function of either delivering the optimal level or incompletely scavenging the excess of vascular endothelial growth factor A present in APROP. The spontaneous resolution of disease in our index case with platelet correction alone needs additional studies to correlate the timing and magnitude of correction that may play a role.

Serpiginous choroiditis-like picture due to ocular toxoplasmosis.

PURPOSE: To report an atypical presentation of ocular toxoplasmosis in the form of serpiginous choroiditis-like picture in an immunocompetent individual. CASE REPORT: A 32-year-old man with blurred vision in the left eye showed serpiginous choroiditis-like appearance. Fundus fluorescein angiography and relevant laboratory tests including anti-toxoplasma serology and polymerase chain reaction (PCR) in aqueous humor were performed. RESULTS: The serology in blood and PCR in aqueous humor were positive for Toxoplasma gondii infection. The patient was treated with anti-toxoplasma antimicrobials and systemic steroids. At the end of six weeks of treatment the fundus lesions had healed well, with good visual recovery. CONCLUSIONS: Serpiginous choroiditis-like picture can be an atypical manifestation of ocular Toxoplasma gondii infection.