Scheimpflug imaging for evaluation of intraocular lens position in modified flanged scleral fixated intraocular lens

Background

Scleral fixation of intraocular lens (IOLs) is the most preferred technique for the management of aphakia and the techniques have evolved over the years. These methods have their advantages and disadvantages, however, the major concern being the position of the intraocular lens, its stability and complications. The final IOL position is the major determinant of the final visual acuity, and various imaging modalities have been used to quantify the IOL tilt.

Objectives

Use of Scheimpflug imaging to evaluate the IOL tilt in modified flanged scleral-fixated intraocular lens (MFSIOL).

Design

Retrospective chart review of 41 consecutive patients who underwent MFIOL.

Methods

We conducted a retrospective chart review of 41 consecutive patients who underwent MFIOL. The baseline and final best-corrected visual acuity (BCVA), refractive error, and clinical examination findings were recorded. The vertical and horizontal tilts of the IOLs were calculated using the Scheimpflug image. The IOL tilt (in degrees) in the vertical and horizontal axes was the primary outcome and the BCVA, residual refractive error, intraocular pressure, and surgical complications were secondary outcome measures.

Results

The mean baseline BCVA was logMAR 0.49, which improved to logMAR 0.356 (p < .005) after the surgery. The mean IOL tilt in the vertical axis was 3.40° (range of 0.0°-8.5°, interquartile range: 1.21-5.66) and in the horizontal axis was 1.35° (range of 0.60°-4.620°, interquartile range: 0.44-1.86), respectively. There was no correlation between angle of IOL tilt and UCVA (r = 0.089, p = 0.580), BCVA (r = 0.109, p = 0.498), final spherical error (r = 0.081, p = 0.615), cylindrical error (r = 0.207, p = 0.195), axial length (r = 0.105, p = 0.514), and IOL power (r = -0.139, p = 0.388).

Conclusion

Modified flanged IOL (MFIOL) is an alternative technique for intrascleral fixation of IOL resulting in good lens stability. The IOL tilt achieved by this technique is minimal and did not influence the final visual outcome or spectacle correction. Scheimpflug imaging is simple and non-invasive method to measure the IOL tilt.

Plain Language Summary Scheimpflug imaging for modified flanged scleral fixated lens position

This study on 41 eyes was aimed to analyze the lens tilt using Scheimpflug imaging in cases of modified flanged scleral fixation of intraocular lens (MFSFIOL), which is a novel technique to minimize the complications and simplify the procedure. The intraocular lens (IOL) remained stable with an acceptable range of vertical and horizontal tilt. There was no significant effect of IOL tilt on the final best-corrected visual acuity (BCVA) or spectacle correction. Scheimpflug imaging is an accurate and non-invasive technique for assessment of lens position in the patients with intrascleral fixation of IOL.

Coats' disease: trends and long-term treatment outcomes in a tertiary referral centre

Background:

The long-term treatment outcomes in Coat’s disease – particularly in the era of newer pharmacotherapies such as anti-vascular endothelial growth factor (VEGF) agents and depot steroids – are poorly understood.

Aim:

To describe the clinical features and treatment outcomes of 148 eyes with Coats’ disease assessed in a referral centre over 30 years.

Materials and methods:

We conducted a retrospective chart review of patients diagnosed with Coats’ disease between 1 June 1987 and 31 July 2017. The demographic, clinical and treatment data were collected and long-term functional and anatomical outcomes were analysed based on the treatment either with conventional therapy (cryo/laser) or along with adjuvants like intravitreal steroids or anti-VEGFs.

Results:

The mean age at presentation was 15.22 years (median 11). Familial exudative vitreoretinopathy was the most common referral diagnosis, 76/148 (51.5%), followed by Coats’ disease, 37/148 (25%), and retinoblastoma, 35/148 (23.6%). Stage 3B was most common at presentation (31.8%), followed by 2B (22.3%) and 2A (16.9%). A total of 107 patients were treated either with conventional therapy or in combination with adjuvants. The mean follow-up period was 24.95 months. The visual acuity improved from baseline logMAR 2.17 (Snellen-20/2958) to logMAR 1.88 (Snellen-20/1517) at final follow-up (p = 0.004). The improvement in visual acuity was better when the presenting BCVA was <1 logMAR (Snellen 20/200), p = 0.004. No statistically significant change in BCVA was noted between conventional and adjuvant groups, p = 0.5. However, the final anatomical outcome was good in 78/99 (78.8%) in the conventional group and 45/49 (91.8%) in the adjuvant group, respectively (p = 0.046).

Conclusion:

In this series of patients with Coats’ disease over three decades, the use of intravitreal steroids or anti-VEGFs as adjuvants resulted in better anatomical outcomes. A better baseline visual acuity, lower stage of the disease, and older age at presentation were found to be the factors leading to favourable visual outcomes.

Summary

In the current series of 148 eyes with Coats’ disease, adjuvant treatment with intravitreal steroids or anti-VEGFs resulted in better outcomes as compared with conventional cryotherapy or laser photocoagulation alone. Patients with Coats’ disease who had presented with better visual acuity at baseline, lower stage of the disease and older age had better final visual outcomes.

Optical Coherence Tomography and ImageJ Software for objective assessment of optical density of anterior chamber iris cyst

Aim: To report the optical characteristics of the fluid in an anterior chamber iris cyst.

Method: A 26-year-old male presented with blurring of vision in his right eye for two months, without any other associated ocular complaints. His visual acuity was 6/ 9 on Snellen’s chart. On slit lamp examination, a small translucent pigmented cyst was noted inferiorly in the anterior chamber, struck on to the cornea at 6 o’clock periphery, without any feeder vessel. Anterior segment optical coherence tomography (OCT) revealed a cystic lesion with hyperreflective walls and hypo reflective lumen attached to the cornea, compressing the endothelium.

Results: The optical density (OD) of the cyst fluid was determined using ImageJ, an open code Java-based image processing software. The OD of cyst fluid was found comparable to the anterior chamber fluid.

Conclusion: Ultrasound biomicroscopy (UBM) and OCT are useful tools for the diagnosis of cystic lesions of the anterior segment. The innovative use of an OCT image and the ImageJ software to determine the optical density of the iris cyst may aid in the diagnosis and follow-up of such cases.

Treatment outcomes of optic disc pit maculopathy over two decades

Aim

To study the long-term outcomes of optic disc pit maculopathy.

Methods

Electronic medical records of 154 patients with optic disc pit were reviewed and 50 patients with optic disc pit maculopathy who met the study criteria were included in the study. Demographic profile of patients, along with clinical characteristics, optical coherence tomography (OCT) features and change in best-corrected visual acuity (BCVA) was recorded. Patients were treated either by observation, barrage laser alone or pars plana vitrectomy (PPV) with optional additional surgical procedures. The primary outcome measures were the change in BCVA and resolution of fluid on OCT.

Results

The mean age of patients was 29.96 years (3-62 years) with a follow-up of 27.16 months. The mean baseline BCVA in observation, laser and vitrectomy group was log MAR 0.94, 0.76 and 0.87 and final BCVA was log MAR 0.9, 0.67 and 0.46, respectively. There was a statistically significant improvement in the final BCVA and reduction in subretinal fluid with resolution of the schisis cavity in vitrectomy group than in other groups. On regression analysis significant association was found between final BCVA with baseline BCVA (R ² = 0.815, p = 0.002), use of C3 F8 endotempanode (p = 0.004) ILM peeling (p = 0.012) and use of triamcinolone (TA; p = 0.003). No significant association was found with juxtapapillary endolaser (p = 0.062).

Conclusions

In patients with disc pit maculopathy, PPV lead to better functional and anatomical outcomes as compared to laser or observation alone. Use of surgical adjuvants like ILM peeling, TA and C3F8 tamponade improved the outcomes, unlike juxtapapillary endolaser treatment.

Modified inexpensive needle for suprachoroidal triamcinolone acetonide injections in pseudophakic cystoid macular edema

Pseudophakic cystoid macular edema (PCME) is one of the leading causes of reduced vision, after cataract surgery. Topical steroids and nonsteroidal anti-inflammatory drops are frequently used in the management; however, intravitreal injections may be required for chronic cases. Suprachoroidal injection of preservative free Triamcinolone acetonide is a recent addition to the therapeutic armamentarium of ophthalmologists for treatment of cystoid macular edema of varied etiology. Though the drug is commercially available at a reasonable cost, the microneedle is not commonly available. We modified a 26 G needle for safe and cost-effective delivery of preservative-free suprachoroidal triamcinolone acetonide (SCT). In the current series of three patients with non-resolving PCME, macular edema resolved and vision improved over 3 months.

Peripheral iridectomy for preventing iris-related complications in glued intraocular lens surgery in children

Purpose

To assess the role of surgical peripheral iridectomy (PI) in preventing iris-related complications associated with glued intraocular lens (GIOL) surgery in children with bilateral ectopia lentis.

Methods

Nonrandomized interventional case series of 34 eyes of 17 children (<15 years of age) who underwent pars plana lensectomy (PPL) and GIOL surgery between January 2013 and December 2016. Eyes with surgical PI (January 2013-June 2015) were compared with those without surgical PI (July 2015-December 2016). The primary outcome measure of the role of surgical PI in GIOL surgery was to account for complications such as optic capture, secondary glaucoma, intraocular lens (IOL) dislocation, or repeat surgery. The secondary outcomes were changes in the best-corrected visual acuity (BCVA).

Results

The mean age at surgery was 8.8 years (range: 3.5-15 years). Surgical PI was conducted in 15 eyes. Among the 19 eyes without PI, 9 eyes had complications (optic capture -6; rise in IOP -4; IOL subluxation -4; repeat surgery -5). The complications were significantly less in the PI group, P = 0.02. There was a statistically significant improvement in BCVA (P = 0.0001) in all the patients. The mean presenting BCVA was 0.99 (±0.79) logMAR (Snellen ≈ 20/200) and post BCVA was 0.40 (±0.50) (Snellen ≈ 20/50). The mean preoperative refraction was - 9 D (±8D) (range: -5 D to -23D) and postoperative was -1 (±1.15) D. The mean follow-up was 25.4 months.

Conclusion

Surgical PI along with GIOL surgery in children undergoing PPL is shown to reduce optic-capture-related complications.

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.

Autologous blood-assisted scleral fixation of intraocular lens

In this technique, the lamellar scleral tunnel is fashioned to cover IOL haptics and autologous blood is used to close the conjunctiva, which alleviates the need for fibrin glue. The cornea is marked at four and 10'O clock meridian, and 2 mm incision is made on the conjunctiva. A lamellar scleral tunnel is fashioned 2 mm superior on one side and 2 mm inferior on the other side of this mark. The IOL is inserted into the anterior chamber and the haptics are exteriorized using bent 26-gauge hypodermic needle, flanged, and buried in the tunnel. A visible conjunctival blood vessel is punctured, allowing the blood to pool underneath the conjunctiva. The conjunctiva is approximated with the help of blood coagulum and allowed to remain dry for 3 min. Lamellar scleral tunnels give adequate cover to haptics, and autologous blood can be used to glue the conjunctival flaps instead of fibrin glue.

Multimodal imaging and adaptive optics in internal limiting membrane dystrophy

An 18-year-old boy presented with a mild blurring of vision in both his eyes for the last 2 years. His best-corrected visual acuity was 20/60 in both the eyes with normal colour vision. Fundus evaluation showed exaggerated shiny reflex from the internal limiting membrane (ILM) with the wrinkled inner retinal surface at posterior pole. No vessel attenuation or retinal pigment epithelium changes were evident. Optical coherence tomography showed thickened ILM, which was appreciated in fundus photo also. The electrodiagnostic tests were normal, and the photoreceptors appeared normal in adaptive optics in the central macula at 2°-4° eccentricity. Among the very few reported cases of Muller cells sheen dystrophy, our patient was the probably the youngest and was picked up by a thoughtful ophthalmologist in detailed clinical examination. Adaptive optics in the case of ILM dystrophy is also not reported earlier.

Multimodal Imaging in a Case of Localized Suprachoroidal Hemorrhage

Purpose

To report a case of localized suprachoroidal hemorrhage presenting as a choroidal mass.

Case Report

A 66-year-old woman presented with sudden onset pain in the right eye, one week following uneventful cataract surgery. The best corrected visual acuity (BCVA) was 20/160 and fundus examination showed a brown elevated choroidal mass temporal to the fovea in the right eye with normal retina and retinal vessels over it. The differential diagnoses considered were choroidal granuloma, melanoma, choroidal hemangioma, posterior scleritis, and localized suprachoroidal hemorrhage (SCH). Fluorescein angiography (FA) and indocyanine green (ICG) angiography were unremarkable except for mild disc leakage; B-scan showed a choroidal mass with high surface reflectivity and low internal reflectivity, and optical coherence tomography (OCT) showed an elevation of retino-choroidal complex with hyporeflective mass in the outer choroid with choroidal folds suggestive of SCH. Her systemic evaluation showed raised erythrocyte sedimentation rate (ESR) and consolidation in the upper lobe of the right lung. The patient did not take any additional treatment for her eye and the lesion regressed and visual acuity improved to 20/30 in one month.

Conclusion

Delayed spontaneous suprachoroidal hemorrhage can present as a choroidal mass. Multimodal imaging helps to differentiate it from other sight-threatening and life-threatening ocular diseases.

The giant tear of retinal pigment epithelium following focal laser in central serous chorioretinopathy

A 35-year-old male smoker presented with reduced vision in OD for the previous two years. He reported a further drop in the vision for the previous two weeks after he underwent focal laser elsewhere. Clinical examination and multimodal imaging confirmed a giant tear of the retinal pigment epithelium (RPE) and a focal leak of CSCR. He was managed with the focal laser to the active leak and lifestyle modification. The ocular condition remained stable. RPE rips in CSCR have been reported to occur spontaneously or with an intervention like exogenous use of steroids, or photodynamic therapy (PDT). This case highlighted the fact that focal laser can precipitate RPE rip in a case of CSCR with tense bullous PED. The physician should keep this fact in mind while counselling the patient before a laser procedure and suspect an RPE rip in a patient with CSCR who presents with an acute onset of vision loss.

Surgical outcomes, complications and learning curve of glued intraocular lens of a vitreo retinal fellow in training

Purpose:

To evaluate surgical outcomes, complications and learning curve of glued intraocular lens surgery by a vitreoretinal (VR) fellow in training.

Methods:

Analysis of 50 eyes requiring glued intraocular lens (GIOL) surgery for various indications was done. Both the consultant VR surgeon (Group 1) and VR fellow in training (Group 2) operated 25 eyes each. The primary outcome measures were visual acuity at 3 months, and time taken for completion of surgery. Secondary outcome measures were refractive correction, intraocular pressure and intraoperative or postoperative complications.

Results:

The uncorrected visual acuity (UCVA) improved from log MAR 1.54±0.56 (Snellen 20/693) to 0.45±0.26 (Snellen 20/56) and from 1.64±0.53 (Snellen 20/873) to 0.56±0.45 (Snellen 20/72) in group 1 and 2, respectively. The best corrected visual acuity (BCVA) improved from log MAR 0.74±0.61 (Snellen 20/109) to 0.33±0.26 (Snellen 20/42) and from 1±0.68 (Snellen 20/200) to 0.40±0.50 (Snellen 20/50) in group 1 and 2, respectively (P > 0.05). The surgical time was significantly less in group 1 when compared to that of group 2 (64.26 vs 107.16 minutes) P value <0.05). The mean time taken for the initial 10 cases and later 15 cases in group 2 were 131.9 and 91.2 minutes, which was statistically significant. The complication rates in both groups were comparable. Transient hypotony (IOP < 11) was seen in 56% (14/25) of eyes in group 2 and 44% (11/25) in group 1 (P = 0.39).

Conclusion:

The study results are encouraging for a VR fellow with good short-term visual outcomes and comparable surgical complications. The procedure gives promising results and the learning curve is overcome by a desire to learn and with increasing number of procedures done under supervision.

Ziv-aflibercept combined with intravitreal steroid for management of peripheral exudative haemorrhagic chorioretinopathy

Peripheral exudative haemorrhagic chorioretinopathy (PEHCR) is considered a variant of polypoidal choroidal vasculopathy. It may have varried presentations and systemic associations. We present a case of PEHCR which dramatically responded to intravitreal steroid and ziv-aflibercept injection. This case not only highlights the promising role of combination therapy with intravitreal steroids and ziv-aflibercept but also the need to look for any associated systemic comorbidity.

Secondary pneumatic retinopexy for failed scleral buckle

Scleral buckle (SB) is a well-established modality to treat retinal detachment (RD). The surgery can fail because of various reasons. This case highlights the role of secondary pneumatic retinopexy (PR) for dealing with recurrent RD after SB surgery. This modality of treatment could be explored before taking up patients for vitrectomy, especially in cases of retinal break without proliferative vitreoretinopathy. In the case presented, secondary PR could save another major surgery and good outcome was achieved with less invasive option.

Pachydrusen in Indian population: A hospital-based study

Purpose:

To report the prevalence of pachydrusen in Indian population and their characteristics in relation to subfoveal choroidal thickness (SFCT), choroidal vascularity index (CVI) in comparison to eyes with soft drusen and subretinal drusenoid deposits (SDD) in age-related macular degeneration (AMD).

Methods:

The study was a retrospective, cross-sectional study involving patients with a diagnosis of dry AMD in at least one eye. The diagnosis of soft drusen, SDD, and pachydrusen was made on the basis of color fundus photograph and optical coherence tomography (OCT). SFCT and CVI was calculated and compared among the different subtypes of drusen.

Results:

A total of 169 eyes (143 dry and 26 wet AMD) of 85 patients with a mean age of 67.67 ± 9.57 years were included. In eyes with dry AMD, pachydrusen were seen in 12 eyes (8.4%) with a mean (±SD) SFCT of 289.66 ± 91.01 μ. The difference in SFCT was statistically significant (P = 0.001) using analysis of variance (ANOVA) test. The eyes with pachydrusen had significantly thickened choroid compared to the eyes with SDD (30 eyes; 21.0%) or combination of soft drusen and SDD (29 eyes; 20.3%) but not soft drusen (72 eyes; 50.3%). The difference of CVI in different subgroups was significant (P = 0.03). One eye in wet AMD group had concurrent pachydrusen. Comparison of SFCT and CVI in wet AMD and fellow dry AMD eyes were not significant.

Conclusion:

In Indian eyes with dry AMD, prevalence of pachydrusen (8.4%) is slightly lower compared to western literature (11.7%) and is associated with thicker choroid and higher CVI.

Efficacy of red contact lens in improving color vision test performance based on Ishihara, Farnsworth D15, and Martin Lantern Test

Background

The aim of this study was to evaluate the efficacy of red contact lens in improving color vision test performance based on Ishihara, Farnsworth D15, and Martin Lantern Test (MLT).

Methods

Thirty subjects with a known color vision defect were enrolled after consent. The color vision was assessed using Ishihara test, D15 test, and MLT. The error scores were recorded. The test was repeated after using a red contact lens.

Results

The mean error scores were 7.87 (±1.00), 3.33 (±3.15), and 5.67 (±2.52) on Ishihara, MLT, and D15 test, respectively. The error scores reduced to 3.93 (±3.78), 1.33 (±1.34), and 2.77 (±2.12) Ishihara, MLT, and D15 test, respectively (P value < 0.05, Wilcoxon rank test). None of the subjects were in color perception (CP) II at presentation but 47.5% became CP II with the lens on Ishihara test. Ninety percent could pass the MLT CP III standard.

Conclusion

This study shows that red lens reduced error scores and subjects could pass the color vision tests. Notwithstanding the improvement in performance on color vision tests, lens is not recommended for personnel on active combat duty. The recruiting medical officer needs to be aware of the fact that a subject with defective color vision can pass various tests with a red contact lens.

Serum vitamin D levels in Indian patients with retinal venous occlusions

Purpose

To estimate serum vitamin D (25 OH D) level in patients of retinal vein occlusion (RVO) and compare it with age-matched controls.

Methods and material

Forty patients above 18 years of age with retinal vein occlusion and forty age-matched controls underwent serum vitamin D (Vit D) level estimation using a standard protocol. Student’s t test was used to analyse differences between the mean of two groups.

Results

The mean age in RVO and control group was 60.25 and 60.73 years respectively. The mean (±SD) level of vitamin D in RVO patients was 13.68 (±4.58) ng/mL (range 5.5–24.8), and the 95% CI of mean was 12.21–15.14 with SD 4.58 while in control group it was 23.03 (±2.89) ng/ml (range 18.4–30.1) with 95% CI of mean being 22.11–23.96 with SD 2.89 (p value of <0.005). While comparing the level of Vitamin D based on type of occlusion the mean level of Vit D in CRVO patients was 15.36 (SD 5.30) and in BRVO it was 12.77 (SD 3.96) which was statistically not significant (p = 0.08). The odds ratio calculated for RVO cases versus controls was 133.33 which was statistically significant (P < 0.05).

Conclusions

There is a paucity of published literature on level of Vit D in RVO. This study shows significantly lower levels of serum vitamin D in Indian patients with retinal vein occlusion as compared to age matched controls. Establishment of this correlation has possible implications for prophylaxis or treatment of RVOs.

Can ganglion cell complex assessment on cirrus HD OCT aid in detection of early glaucoma?

Context

Ganglion cell complex is damaged early in glaucoma. Does this loss of GCC help in early diagnosis of glaucoma.

Aims

To compare the RNFL thickness and ganglion cell complex (GCC) in diagnosed patients of glaucoma, pre-perimetric glaucoma and normal controls.

Settings and design

Case controlled, observational study.

Methods and material

33 glaucoma patients, 45 pre-perimetric glaucoma, and 30 controls were enrolled in the study. ONH parameters on cirrus HD OCT like CD ratio, para papillary RNFL thickness and GCC were calculated for each case.

Statistical analysis used

ANOVA test to analyse differences between groups. ROC for ganglion cell layer.

Results

RNFL thickness was 71.6 μ and GCC was 69.19 μ in glaucoma patients. RNFL thickness was 77.31 μ and GCC was 71 μ in pre-perimetric glaucoma and 99.6 μ and 85.16 μ in controls respectively. The difference of mean for RNFL and GCC by ANOVA was statistically significant for controls, glaucoma patients and pre-perimetric glaucoma patients. RNFL (p < 0.001) and GCC (p < 0.001). Receiver operating characteristic curve for GCC was 0.83 (p < 0.000).

Conclusions

The RNFL analysis is increasingly being used as newer tool in diagnosis of glaucoma. In addition, GCC can be used as a supplementary tool in picking up cases of pre-perimetric glaucoma as loss is significant in pre-perimetric glaucoma also.