Impact of inverted internal limiting membrane-flap technique on functional outcome and structural restoration of small and medium size macular holes.

Purpose: To evaluate the impact of the inverted internal limiting membrane (ILM)-flap technique on the visual outcome and anatomical recovery for small (<250 µ), medium (<400 µ), and large (>400 µ) macular holes (MHs). Methods: Retrospective study included consecutive idiopathic MH cases operated on using the inverted ILM-flap technique. Clinical data were retrieved from electronic medical records (EMRs), surgical videos, and optical coherence tomography (OCT) machines. Eyes with axial length >25 mm, coexisting macular diseases, and follow-up <6 weeks were excluded. Data included the presence or absence of ILM flap and restoration of External Limiting Membrane (ELM), Ellipsoid Zone (EZ) lines. Mean visual improvement and structural recovery were compared between eyes showing ILM flap and those showing no flap in three MH size groups. Results: Forty eyes of 38 patients with a mean age of 62.7 ± 10.1 years and a mean MH diameter of 348 ± 152 µm were included. The mean follow-up was 527 ± 478 days with anatomical closure observed in all eyes. Mean best-corrected visual acuity (BCVA) improved significantly from 0.87 ± 0.38 to 0.35 ± 0.26. ILM flap was visible in 29 (72.5%) all MHs, 7 (53.8%) small MHs (n = 13), 8 (61.5%) medium MHs (n = 13), and 14 (100%) large MHs (n = 14). The mean BCVA change was 0.47 ± 0.34, 0.53 ± 0.48, and 0.56 ± 0.20 in large, medium, and small MHs, respectively, and the difference between eyes showing ILM flap versus no flap in each MH size group was not statistically significant (P > 0.05). However, for medium MHs, it was higher in the ILM flap (0.66 ± 0.52) group compared to the no flap (0.32 ± 0.37) group. One eye with small MH developed significant gliosis resulting in reduced BCVA. ELM was restored in all eyes with small and medium MHs. Conclusion: We observed that the ILM flap did not adversely affect anatomical and visual outcomes for MHs <400 µm. Restoration of ELM suggests minimal interference in structural recovery by an ILM flap.

COVID-19-related bilateral acute de-pigmentation of iris with ocular hypertension.

A 43-year-old male patient presented with acute blurring of vision in both eyes associated with photophobia, redness, and mild pain following coronavirus disease 2019 (Covid-19) infection. Clinical examination revealed extensive pigment dusting in the corneal endothelium and the trabecular meshwork with de-pigmentation bands in the iris periphery. The patient was managed empirically with topical anti-glaucoma medications for high intra-ocular pressure. The patient was prescribed systemic antibiotics including cephalosporins and amoxicillin for respiratory symptoms. A rare condition called bilateral acute de-pigmentation of iris (BADI) was suspected after ruling out common entities, for example, viral kerato-uveitis, pigment dispersion syndrome, and Fuchs iridocyclitis. Covid-19 infection and systemic antibiotics including cephalosporins have shown to cause BADI in the literature. The patient responded well with good outcome.

Aspergillus flavus endogenous endophthalmitis in an immunocompetent man: treatment outcomes and swept-source optical coherence tomography findings.

A non-diabetic man in his 40s presented with a 4-day history of sudden, painless, rapidly progressive severe vision loss in his right eye. Anterior segment was unremarkable. A dense, solitary vitreous abscess with feathery margins obscured the macula. Retinal haemorrhages, exudates and retinal vasculitis were noted. There was no history of ocular surgery, trauma, intravenous drug abuse or immunocompromise. He received intravenous fluids during a spinal procedure 5 days prior. Prompt diagnostic and therapeutic pars-plana vitrectomy was done and Aspergillus flavus was cultured. Postoperatively, he was treated with oral Voriconazole and four intravitreal Voriconazole injections, till the chorioretinitis lesions had completely healed and was objectively confirmed on follow-up swept-source optical coherence tomography (OCT). He achieved a best-corrected visual acuity of 6/36. A high index of suspicion, early vitrectomy and OCT-based treatment were key to favourable outcomes in this case. Intravenous fluid bottles must be checked for contamination prior to administration.

Bilateral neovascular age-related macular degeneration: unilateral regression following endophthalmitis with persistent activity in the fellow eye.

A woman in her 70s who was being followed up for neovascular age-related macular degeneration (nAMD) in both eyes for 2 years with recalcitrant choroidal neovascularisation (CNV) and had an episode of acute endophthalmitis in one eye was identified. After treatment of postinjection culture-negative right eye (RE) endophthalmitis with intravitreal vancomycin and tazobactam, the patient had complete regression of treatment-resistant CNV in RE to date with postinfection follow-up of 2 years. In contrast, the fellow eye continued showing activity in the choroidal neovascular membrane that required antivascular endothelial growth factor injections on a pro re nata basis to date. Prolonged regression of nAMD for 3 years in the affected eye and continued activity in the fellow eye support the hypothesis that inflammation accompanying endophthalmitis or the drugs used for the treatment can have a role in the regression of nAMD.

Virtual-reality headset mounted smartphone-based Indentation fundus videography.

To describe a simple and novel technique that overcomes the limitation of smartphone-based fundus photography and allows examiners to capture peripheral retinal images with indentation. Smartphone with video camera in flash-on mode was mounted on virtual-reality (VR) headset. This was combined with +28D lens and +20D lens and soft cotton bud to capture high-quality videos of peripheral fundus with indentation. Autofocus function of the camera and examiner's head movements to adjust the distance was used to obtain retinal video. The procedure is akin to indirect ophthalmoscopy. The feasibility of obtaining well-focused retinal images during indentation was checked. We could obtain good quality videos demonstrating indentation of the peripheral fundus in 10 eyes showing different pathologies such as laser marks, lattice degeneration, and pigmented lesions. VR headset-mounted smartphone-based indentation fundus videography is an innovative cost-effective technique to capture peripheral retinal images. The technique can be useful for documenting retinopathy of prematurity lesions and other situations where widefield photography is not possible.

Epiretinal Membrane from Uncontrolled Gliosis After Inverted ILM Flap Technique for Idiopathic Macular Hole.

We describe two cases with epiretinal membrane (ERM) from uncontrolled gliosis seen after multilayered inverted internal limiting membrane (ILM) flap technique for full thickness macular hole (FTMH). Two patients with FTMH who had undergone surgery with inverted ILM flap technique were examined by serial optical coherence tomography scans to evaluate the course of multilayered ILM flaps seen as foveal hyperreflective lesions postoperatively. We observed excessive uncontrolled gliosis over these hyperreflective ILM flaps with ERM formation, along with worsening metamorphopsia and best-corrected visual acuity. Case 1 underwent a repeat surgery for ERM. We report excessive uncontrolled gliosis as a rare complication of multilayered inverted ILM flap technique for FTMH. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:663-665.].

Arcuate Vitelliform detachment with morning glory disc maculopathy: OCT findings of evolution and resolution after early surgery.

Morning glory disc (MGD) is known to develop secondary maculopathy and vision loss. We followed a 7-year-old girl with MGD in right eye from 2010 to 2021. Her best-corrected Snellen visual acuity (BCVA) was 20/20 in both eyes till 2017. She presented with reduced vision in right eye with BCVA of 20/80 in 2018. Optical Coherence Tomography (OCT) revealed maculopathy related to MGD in right eye and arcuate Vitelliform neurosensory detachment (V-NSD) temporal to fovea. She underwent 25G vitrectomy with internal limiting membrane peeling. Resolution of retinoschisis and V-NSD was analysed by OCT and fundus autofluorescence (FAF) postoperatively. Arcuate V-NSD was hyperfluorescent on FAF and concentric to optic disc. It resolved slowly with BCVA improving to 20/20 at 18 and 30 months postoperatively. We report excellent outcome following early vitrectomy for MGD-related maculopathy and recommend serial follow-up and considering early vitrectomy whenever traction and BCVA worsens. We also describe arcuate V-NSD with MGD.

Decompression retinochoroidopathy: a unique presentation post-trabeculectomy.

PURPOSE: To present a unique case of decompression retinochoroidopathy presenting with intraretinal, subretinal and preretinal hemorrhages. METHODS: A 65-year-old hypertensive female presented with diminution of vision in right eye of 1-week duration. She had been a known case of primary open-angle glaucoma and had undergone trabeculectomy with mitomycin C in right eye 1 week back. Her day 1 postoperative intraocular pressure was 6 mmHg. Her left eye had undergone Ahmed glaucoma valve surgery for the same 2 years back. RESULT: Right eye vision at 1 week of presentation was 6/36, N36 and left eye hand movements. Both eyes were pseudophakic. Intraocular pressure in right eye was 35 mmHg with nonfunctional bleb and in left eye 15 mmHg. Right eye fundus shows multiple subretinal, intraretinal, preretinal and some white-centered blot hemorrhage in all the four quadrants including the posterior pole. Disk had glaucomatous cupping with no dilatation or tortuosity of retinal blood vessels. Left eye had total glaucomatous optic atrophy. CONCLUSION: Old hypertensive females may not tolerate hemodynamic changes in retinal and choroidal vasculature so well, and if the autoregulation of retinal capillaries and choriocapillaris fails because of IOP spikes or rise of IOP to high levels in a relatively short duration, sudden lowering of IOP after trabeculectomy may cause decompression retinopathy and choroidopathy.

Intravitreal gas injection with prone positioning for giant retinal pigment epithelial tear.

We report a 78 year old male with acute RPE tear with sudden vision loss, who underwent intravitreal C3F8 injection for reattaching the RPE. The impact of gas on detached RPE was studied by serial OCTs and Fundus pictures.

Excellent visual outcome after vitrectomy for traumatic macular hole associated with choroidal rupture across papillomacular bundle.

PURPOSE: To report the visual result of Surgery for traumatic macular hole with choroidal rupture running across papillomacular bundle. METHOD: Observation case report Patient 20 year old male patient presented with acute vison loss in OS with BCVA reduced to 20/80 following blunt trauma. Examination revealed full thickness macular hole with choroidal rupture between disc and macula, spanning across papillomacular bundle (PMB) in OS. Patient underwent 25G Vitreous Surgery with ILM peeling and SF6 injection for OS. RESULTS: Macular hole was successfully closed at 4 weeks follow up and BCVA improved to 20/20. There was no postoperative complication. CONCLUSION: We report that Traumatic macular holes with associated choroidal rupture running through PMB can be successfully repaired with Vitreous surgery and these eyes may achieve good visual outcome.

Familial ectopia lentis with Axenfeld-Rieger anomaly.

Three siblings with ectopia lentis were examined for associated abnormalities. Case 1 had Axenfeld-Rieger anomaly and retinal detachment. Case 2 had Axenfeld-Rieger anomaly, ciliary staphyloma, and glaucoma. Case 3 had no associated ocular abnormality. The parents had normal eyesight. This is the first report of ectopia lentis associated with Axenfeld-Rieger anomaly. The mode of inheritance is likely autosomal recessive.

Iris intraocular foreign bodies: safe and successful removal through limbus.

Metallic iris intra ocular foreign body (IOFBs) with minimal ocular damage pose an interventional challenge. We report safe removal of metallic intraocular foreign bodies embedded on the iris, in three cases by use of intraocular magnets. Two eyes had a clear lens with best corrected visual acuity (BCVA) of 20/20, while the third eye had a BCVA of 20/200 with siderotic cataract. Ultrasound biomicroscopy confirmed the superficial impaction of IOFB into the iris. Foreign bodies were successfully removed via the limbal route with a 20 g intravitreal magnet atraumatically in all 3 cases with preservation of their pre-operative BCVA. Case series highlights the usefulness and safety of intraocular magnet for removal of metallic iris foreign bodies in selected cases. Prior ultrasound biomicroscopy to know the actual depth of penetration of IOFB into the iris and preoperative confirmation of magnetic property of IOFB are essential.

Visual outcome after fireworks injuries.

BACKGROUND: The epidemiology and prognosis of fireworks-related injuries treated at a tertiary eye care center in less developed nations remain unknown. METHODS: We conducted a prospective observational study that enrolled all consecutive eyes with fireworks-related ocular injury visiting our trauma clinic during a 1-year period. Eyes were graded by ocular trauma classification and followed for 6 months at least. Best corrected visual acuity (BCVA) at 6 months was considered the final visual outcome. Data were analyzed. RESULTS: Twenty-five (96%) of a total of 26 patients enrolled during study period were male patients and 13 (50%) were younger than 15 years. The type of fireworks involved was a bottle rocket in 38.5%. Factors significantly associated with better final visual outcome were better BCVA at presentation (p = 0.041), absence of bottle rocket injury (p = 0.028), closed globe injury (p = 0.028), absence of relative afferent pupillary defect (p = 0.019), absence of intraocular foreign body (p = 0.026), and absence of endophthalmitis (p = 0.006). Besides poor visual outcome, bottle rocket injuries were more frequently associated with facial lacerations, intraocular foreign body, and endophthalmitis development. CONCLUSION: Fireworks-related ocular injuries commonly affect young male subjects of northern India. Visual outcome is better in eyes having better initial BCVA or closed globe injury and if relative afferent pupillary defect, bottle rocket injury, intraocular foreign body, and endophthalmitis are absent.