Congenital pterygium with anterior segment dysgenesis: rare ocular manifestation in Rubinstein-Taybi syndrome

Pterygium is a benign, wing-shaped fibrovascular overgrowth of subconjunctival tissue that can encroach over the cornea. This condition usually occurs in individuals aged 20-40 years but is rarely seen in children. We report a case of an infant with Rubenstein-Taybi syndrome presenting with nebulo-macular corneal opacity and congenital pterygium. On examination under anaesthesia, bilateral infero-nasal nebulo-macular corneal opacity (6 × 5 mm) with a whitish pink tissue originating from nasal bulbar conjunctiva was noticed. The probe test was negative for this tissue. To the best of our knowledge, only two other cases of congenital pterygium have been reported in the literature. The presence of this anomaly supports the hypothesis of genetic factors having a role in the development of pterygium.

Clinical applications of aqueous angiography in glaucoma

Aqueous humor outflow (AHO) pathways are the main site of resistance causing elevated intraocular pressure in glaucoma, especially primary open-angle glaucoma patients. With the recently introduced technique of aqueous angiography (AA); functional, real time assessment of AHO from proximal (trabecuar meshwork) to distal pathways under physiological conditions has been made possible. AHO pathways are segmental, and AA can identify high-flow region (increased angiographic signals) and low flow region (decreased angiographic signals) in an individual. With the introduction of canal-based minimally invasive glaucoma surgeries (MIGS), the assessment of AHO can help guide the placement of stents/incisions during MIGS procedures. This can allow individualized and targeted MIGS procedures in glaucoma patients for better results. Based on the density of AHO pathways visualized on AA, surgeons can decide whether to perform MIGS or conventional glaucoma surgery for improved outcomes for the patient. Immediate intraoperative assessment for functionality of the MIGS procedure performed is possible with AA, allowing for surgical adjustments of MIGS procedure in the same sitting, if needed. This review provides a summary of the studies performed with AA to date, with a special focus on Indian patients. It covers the basics and clinical applications of AA for improving surgical outcomes in glaucoma patients.

Early Drainage of Suprachoroidal Hemorrhage Combined with Surgical Correction of Hypotony after Trabeculectomy

Aims and background

Delayed suprachoroidal hemorrhage (DSCH) is a vision-threatening complication of intraocular surgeries with a higher prevalence in postglaucoma filtering surgeries. Through these case series of trabeculectomy complicated with DSCH, we aim to emphasize that correction of hypotony (inciting factor) is fundamental for complete resolution and prevention of recurrence.

Case description

All three glaucoma patients underwent trabeculectomy surgery followed by DSCH on postoperative day 1. Drainage of DSCH using a 23 gauge trocar cannula within 48 hours of onset was performed along with exploration for the cause of hypotony. All three patients had satisfactory visual and anatomical outcomes.

Conclusion

Early drainage using 23 gauge trocar cannulas gives good results in DSCH. The cause of hypotony must simultaneously be corrected during the drainage of DSCH. Preventive measures against hypotony should be taken while doing glaucoma filtering surgery.

Clinical significance

Surgical exploration for the cause of hypotony must simultaneously be performed during drainage of DSCH. Primary preventive measures against hypotony and bleeding during glaucoma filtering surgeries, like the use of releasable sutures, viscoelastic in the anterior chamber, and discontinuation of anticoagulants, can be done. Early drainage using trocar cannulas gives satisfactory results in DSCH postglaucoma surgeries.

How to cite this article

Beri N, Verma S, Bukke AN, et al. Early Drainage of Suprachoroidal Hemorrhage Combined with Surgical Correction of Hypotony after Trabeculectomy. J Curr Glaucoma Pract 2024;18(1):23-27.

Analyzing the Shortcomings of Trabecular Micro-bypass Stents for Surgical Management of Glaucoma

How to cite this article: Dada T, Beri N. Analyzing the Shortcomings of Trabecular Micro-bypass Stents for Surgical Management of Glaucoma. J Curr Glaucoma Pract 2024;18(1):1-3.

Viscodilation of Schlemm's Canal Combined with Goniectomy Using a 30 G Needle (Visco-Bent Ab Interno Needle Goniectomy)

Background and aim

Bent ab interno needle goniectomy (BANG) is a low-cost minimally invasive glaucoma surgery (MIGS) technique that has gained wide popularity in developing nations. However, the risk of injury to surrounding angle structures and especially the outer wall of Schlemm's canal (SC) is the main drawback of this technique. We describe a simple and easy-to-perform modification, "Visco-BANG," to improve the safety and efficacy of the BANG procedure.

Technique

A 30 gauge (G) needle attached to a syringe filled with cohesive viscoelastic is used. The needle is bent at the proximal junction of the bevel with bevel towards the operating surgeon. The needle is then inserted into the SC and viscoelastic injected to dilate the canal, creating a buffer between the inner and outer walls of SC, which is followed by cutting of a trabecular meshwork (TM) strip.

Conclusion

The current modification can prevent damage to adjoining angle structures, including the outer wall of SC, which is critical for aqueous outflow. It can potentially increase efficacy of the BANG procedure by incorporating viscodilation of the SC along with removal of the TM.

Clinical significance

Injury to surrounding structures causes a fibrotic response, which is the main cause of failure for the BANG procedure. Prevention of injury to adjoining structures and dilatation of the SC can potentially increase the long-term success rates of this procedure.

How to cite this article

Dada T, Beri N, Sethi A, et al. Viscodilation of Schlemm's Canal Combined with Goniectomy Using a 30 G Needle (Visco-Bent Ab Interno Needle Goniectomy). J Curr Glaucoma Pract 2023;17(4):210-213.

The Psychological Impact of Rhino-Orbital Mucormycosis During the Second Wave of COVID-19 Pandemic From South East Asian Country

AIM

The present study addressed overcoming the lacunae in the literature of psychiatric manifestations associated with rhino-orbital mucormycosis. The current study aimed to assess the symptoms of depression, anxiety, stress, coping measures, suicidal intent, and visual disability in patients of rhino-orbital mucormycosis (ROM) during the epidemic of the disease at the nodal tertiary care center in North India.

METHODS

Fifty-four inpatients of laboratory-proven rhino-orbital mucor-mycosis (ROM) were included for an observational, cross-sectional study at nodal, designated COVID-19, and mucormycosis treating tertiary care hospital. Patients with Hindi Mini-Mental State Examination score <24, prior psychiatric illness, and severely ill requiring ventilator support were excluded. The psychological variables were assessed using Depression, Anxiety, and Stress Scale 21 (DASS 21), Beck's Suicide intent Scale, Coping Scale Questionnaire, and Visual disability scale (IND-VFQ33). Their socioeconomic status was assessed using the Modified Kuppuswamy Scale.

RESULTS

Ninety percent of patients with ROM had diabetes mellitus. The majority (44%) of patients belonged to lower socioeconomic strata. Higher frequencies of severe depression (28%), extremely severe anxiety (26%), and mild stress (17%) were noted in the study participants. On the Tukey test, depression score was higher in patients of ROM compared to COVID (with ROM) (p-value= 0.016). On Tukey analysis, anxiety score was significantly higher in ROM patients compared to COVID (with ROM) patients (p-value = 0.018). Coping scores were significantly higher in COVID (with ROM) patients compared to ROM patients (p value = 0.035). Mild to moderate visual disability was noted in the study participants.  Conclusion: The current study reflects the association of higher depression and anxiety scores in cases with ROM that indicated higher mental health needs. Early assessment, early detection, and early intervention for psychological help, along with the multidisciplinary team, helped to improve the overall psychological outcome of the affected patients.

Demographic and Clinical Profile of Patients Presenting with COVID-19-Associated Rhino-orbito-cerebral Mucormycosis at a Tertiary Care Center

Objectives Individuals affected with rhino-orbito-cerebral mucormycosis (ROCM) associated with coronavirus disease 2019 (COVID-19) increased enormously in northern India during the second wave of the novel coronavirus disease. This study determined the demographic and clinical profile including the risk factors in patients presenting to a tertiary care hospital in northern India.

Materials and Methods This is a descriptive study involving patients admitted with COVID-19-associated ROCM and were managed from May 2021 to 20th July 2021.

Statistical Analysis The data was analyzed using SPSS (IBM SPSS Statistics 20, SPSS Inc., Chicago, Illinois, United States) software and Microsoft Excel (Version 16.49). The chi-squared and Fisher's exact tests were used to compare various outcomes. A p-value of less than or equal to 0.05 was considered to be statistically significant.

Results One hundred and seventeen (117) patients (males: 70 [59.8%], females:47 [40.2%]) with the average age of 51.85 ± 12.80 years presented with orbital involvement. Diabetes mellitus was noted in 100 (86.2%) patients. Of the available data from the records, oxygen supplementation for the management of COVID-19 was received by 37/108 (34.3%) patients for a median average duration of 11 days. Forty-eight patients of one-hundred-seventeen (60%) patients were treated with corticosteroids with a median duration of steroid administration being 10 days. The duration between onset of symptoms related to mucormycosis and diagnosis of COVID-19 was 0 to 75 days for 48 patients. Intravenous amphotericin B was administered in all cases. External sinonasal debridement was performed in 90 of 114 (78.9%) patients, retrobulbar amphotericin B injection was administered in 56 of 117 (47.9%), and orbital exenteration was performed in 17 of 117 (14.5%) of cases.

Conclusion Administration of corticosteroids and diabetes mellitus seem to be the major underlying causes for the development of COVID-19-associated ROCM. Prompt diagnosis and multidisciplinary management approach are essential for a reduction in mortality.

Comparative evaluation of outcomes of novel approach of subconjunctival Mitomycin C (MMC) injection at the end of trabeculectomy versus intraTenon injection of MMC prior to the initial conjunctival incision - A pilot study

Purpose

To describe a novel approach of subconjunctival injection of mitomycin C (MMC) at the end of trabeculectomy and compare it with intraTenon MMC injection.

Methods

This pilot study included 40 eyes of 40 patients with uncontrolled primary and secondary glaucoma. Patients below18 years and failed trabeculectomy were excluded. Patients were randomly allocated into groups A and B (20 patients each). Group A patients received subconjunctival MMC injection in the superonasal quadrant at the end of standard trabeculectomy. Group B received an intraTenon MMC injection before the initial conjunctival incision. Outcome measures included intra-ocular pressure (IOP) reduction, bleb morphology, and complication rates. The complete success was defined as an IOP of ≤21 mmHg without antiglaucoma drugs.

Results

The mean preoperative IOP of 46.00 ± 11.2 mmHg in group A and 43.05 ± 10.3 mmHg in group B reduced to 12.00 ± 2.41 mmHg (P ≤ 0.001) in group A and 13.65 ± 2.76 mmHg in group B (P ≤ 0.001) at last follow-up. Complete success was 95% and 75% in groups A and B, respectively, 19 months after surgery. Avascular microcystic blebs (70% of group A and 45% of group B) were more common than avascular white blebs (15% in group A and 35% in group B). No intraoperative complications were seen. Postoperative wound leak, hypotony, choroidal detachment, or endophthalmitis were not encountered in any group.

Conclusion

A novel approach of subconjunctival MMC application during trabeculectomy is reported. Both approaches appear to be highly effective in reducing IOP in primary and secondary glaucoma with similar safety profiles and bleb morphology. Subconjunctival MMC yielded a greater success rate (95%) compared to the intraTenon MMC group (75%).

Risk factors for severe rhino-orbital mucormycosis during its epidemic post-COVID-19 pandemic

Postsecond wave of COVID-19 pandemic in the year 2021, rhino-orbital mucormycosis (ROM) was seen as an epidemic in the Indian community. Severe ROM disease has poor prognosis and requires a multidisciplinary approach for treatment. Hence, its prevention is better than cure. Studies done during the epidemic assessed predisposing factors, but this was a novel study which focused on assessing risk factors for severe disease of ROM. Ninety-four consecutive patients of ROM admitted at our designated nodal tertiary hospital of North India were enrolled, and data were collected and analyzed. Facial edema was the most common presenting complaint. Subclinical and mild COVID-19 infection was associated with severe ROM. Uncontrolled diabetes mellitus and prophylactic zinc supplementation were other significant risk factors for severe ROM. Public awareness among the general population for the above risk factors can prevent a debilitating disease like severe ROM.