Bhaskar Gupta

Predicting visual success in macular hole surgery

Aim: Data on the outcome of surgery facilitate informed preoperative patient counselling. Most studies on the outcome of surgery for idiopathic full thickness macular hole surgery have concentrated on rates of anatomical closure. The aim of this study was to identify factors predicting visual success (better than 20/40; 6/12 Snellen) following macular hole surgery. Methods: A retrospective study of 133 patients undergoing standardised macular hole surgery with at least 3 months of postoperative follow-up. All patients underwent preoperative measurement of the maximum macular hole diameter using optical coherence tomography. Results: Multivariable regression analysis identified that age, preoperative visual acuity and macular hole size were significant predictors of visual success. The resulting model correctly classified the visual outcome of 80% of cases. Predicted rates of visual success varied from 93% in patients <60 years old with visual acuity better than 6/24 and a hole diameter of <350 μm, to 2% in patients those >79 years old with visual acuity of 6/60 or worse and hole diameter of >500 μm. Conclusion: The results provide a simple and clinically useful model to employ when counselling patients on macular hole surgery.

The role of anti-tubercular therapy in patients with presumed ocular tuberculosis.

Abstract Objective: To analyze the factors affecting the treatment outcome in patients with presumed ocular tuberculosis on anti-tubercular therapy (ATT). Methods: Retrospective chart review of patients with presumed ocular tuberculosis seen at a tertiary referral eye care center in the United Kingdom. Failure was defined as recurrence of inflammation within 6 months of completion of ATT. Results: There were a total of 175 patients with presumed ocular tuberculosis who had ATT. Patients with intermediate uveitis or panuveitis and those on immunosuppressive therapy had higher odds of treatment failure (pu2009<u20090.05) while those with more than 9 months of ATT (77, 79.38%) had less likelihood of failure. Conclusion: We present the largest case series of patients with presumed ocular tuberculosis in a low endemic area treated with ATT. Longer duration of treatment resulted in reduced risk of recurrence of inflammation, whereas immunosuppression adversely affected the final treatment outcome.

Predictive factors for treatment failure in patients with presumed ocular tuberculosis in an area of low endemic prevalence

Aim To assess the impact of antitubercular therapy (ATT), oral steroids and steroid sparing immunosuppressive treatment on treatment success in cases with presumed ocular tuberculosis in an area of low endemic prevalence. Methods A retrospective cross-sectional study was performed for 213 patients with presumed ocular tuberculosis from a database from a tertiary referral eye hospital in the UK. A logistic regression model was constructed incorporating demographics, baseline characteristics and different cut-offs of QuantiFERON-TB Gold In-Tube test (QFT-G) to identify significant factors accounting for the variability of the response variable (‘failure’) across the whole group. Treatment failure was defined as the recurrence of inflammation or inability to taper steroids within 6u2005months of completion of ATT or after at least 6u2005months of treatment in the non-ATT group. Results There were 126 patients who had at least 6u2005months of ATT. Patients with QFT-G values >1.50 (OR=0.20, 95% CI 0.09 to 0.48, p<0.001) had less risk of treatment failure as against those with QFT-G values between 0.35 and 1.50. Steroid sparing immunosuppressive agents reduced the chances of treatment success (OR=24.10, 95% CI 6.75 to 86.11, p<0.001). This effect persisted even after adjusting for potential confounding factors. Conclusions Patients with higher values of QFT-G (>1.5) are more likely to have treatment success with ATT. In our model, steroid sparing immunosuppressive agents reduced the chances of success in both ATT and non-ATT-treated patients. It is unclear whether this effect reflects the intrinsic underlying severity of disease (ie, study bias), or whether steroid sparing immunosuppressive agents mitigate against successful ATT.

Visual impairment certification due to diabetic retinopathy in North and Eastern Devon

To determine certifications of visual impairment (CVIs) due to diabetic retinopathy (DR) in a region that has operated diabetic screening since 1992.

Visual Morbidity and Ocular Complications in Presumed Intraocular Tuberculosis: An Analysis of 354 Cases from a Non-Endemic Population

ABSTRACT Purpose: To describe the visual morbidity associated with intraocular tuberculosis (TB) and to report ocular complications of intraocular TB. Methods: Retrospective cohort study of patients diagnosed with intraocular TB at a tertiary referral eye care hospital in central London. Data on baseline and final best-corrected visual acuity (BCVA) along with ocular complications were collected and analyzed. Results: In total, 354 patients with intraocular TB were included in this study. Mean age was 48.45 years (range 19–94) and follow-up was 22.56 ± 7.44 (range 6–30) months post cessation of therapy. Blindness as defined by the World Health Organization was reported in 11 (3.11%) patients at baseline and 13 (3.67%) patients at follow-up. The most common ocular complications were cystoid macular edema (n = 107, 30.5%) and glaucoma (n = 99, 28.12%). Conclusion: Intraocular TB can be associated with significant ocular morbidity. Early recognition, treatment, and regular follow-up of this complex disease may help to reduce visual morbidity and ocular complications.

The Collaborative Ocular Tuberculosis Study (COTS)-1 Report 3: Polymerase Chain Reaction in the Diagnosis and Management of Tubercular Uveitis: Global Trends

ABSTRACT Purpose: To analyze the role of polymerase chain reaction (PCR) of ocular fluids in management of tubercular (TB) anterior, intermediate, posterior, and panuveitis. Methods: In Collaborative Ocular Tuberculosis Study (COTS)-1 (25 centers, n = 962), patients with TB-related uveitis were included. 59 patients undergoing PCR of intraocular fluids (18 females; 53 Asian Indians) were included. Results: 59 (6.13%) of COTS-1 underwent PCR analysis. PCR was positive for Mycobacterium TB in 33 patients (23 males; all Asian Indians). 26 patients were PCR negative (18 males). Eight patients with negative PCR had systemic TB. Anti-TB therapy was given in 18 negative and 31 PCR cases. At 1-year follow-up, five patients with positive PCR (15.15%) and three with negative PCR (11.54%) had persistence/worsening of inflammation. Conclusions: Data from COTS-1 suggest that PCR is not commonly done for diagnosing intraocular TB and positive/negative results may not influence management or treatment outcomes in the real world scenario.

Intraoperative complications of patients undergoing small-gauge and 20-gauge vitrectomy: a database study of 4,274 procedures.

Purpose To compare the intraoperative complications between 23-G and 20-G instrumentation in patients undergoing pars plana vitrectomy (PPV). Methods This was a retrospective comparative study of 4,274 PPV procedures by the same surgical team between 1998 and 2016. A total of 2,648 operations were carried out with 20-G surgery and 1,626 operations with 23-G surgery. Main outcome measures were the incidence of choroidal haemorrhage, iatrogenic retinal break, and lens touch. Results The most frequent surgical indication in both 20-G and 23-G was rhegmatogenous retinal detachment (RRD), 38.7% (1,026/2,648) and 45.9% (746/1,626), respectively. The frequency of choroidal haemorrhage was 1.0% with 20-G surgery (26/2,648) vs 0.6% with 23-G (9/1,626, p = 0.16). Subgroup analysis showed the increased risk was present in RRD surgery, 1.6% (16/1,026) vs 0.1% (1/746, p = 0.002), but not in all other indications combined, 20-G with 0.6% (10/1,622) and 23-G 0.9% (8/88, p = 0.46). This increased risk was also true for RRD when excluding combined scleral buckle surgery. There was an increased risk of iatrogenic retinal break in RRD cases undergoing 20-G, 5.8% (60/1,026), compared to 23-G vitrectomy, 1.9% (14/746, p<0.0001). There was no difference in rates of lens touch between 20-G and 23-G. Conclusions 23-G microincisional PPV has a lower risk of choroidal haemorrhage and iatrogenic retinal tears than 20-G vitrectomy particularly for eyes with RRD.

Ocular manifestations of tuberculosis: an update

ABSTRACT Tuberculosis (TB) remains a major global health burden and has both pulmonary and extra-pulmonary manifestations. One well-recognised and complex extra-pulmonary form is ocular TB, with its diverse extra- and intra-ocular presentations and often without signs of systemic illness. These could be caused directly by Mycobacterium tuberculosis and inflammation or represent a delayed immune response. Epidemiological data on the true prevalence of ocular TB is scanty and varied in different parts of the world. This is due to lack of a uniform diagnostic criteria as well as difficulties in confirming the diagnosis with traditional laboratory methods. A variety of investigations including imaging, blood tests and biopsies can be used to predict and diagnose ocular involvement in tuberculosis. Our expert review seeks to identify key clinical and laboratorial features and provide a literature update that may facilitate diagnosis of intra-ocular tuberculosis.

Trends and emerging patterns of practice in vitreoretinal surgery

Editor, V itrectomy surgical techniques have rapidly developed over the last 15 years and continue to evolve with the introduction of perfluorocarbon liquids, multifunctional probes, improved endoillumination and sutureless microincision vitrectomy. In the context of rhegmatogenous retinal detachment (RRD)management, there is a decline in buckle surgery (El-Amir et al. 2009) and shift towards pars plana vitrectomy (PPV) as the procedure of choice. Other established indications for PPV include macular hole (MH), epiretinal membrane (ERM), non-clearing diabetic vitreous haemorrhage (NCVH), tractional retinal detachment (TRD) with variations in gases used, posturing regime and vital dyes. The surgical episodes for all patients having vitreoretinal procedures at three sites (St Thomas’ Hospital, London Eye Clinic, Queen Mary’s Hospital, United Kingdom) under a single surgeon were anonymized and prospectively recorded on an electronic medical record (Vitreor, AxSys Technologies, Glasgow, UK) between January 1997 and December 2013 and is being reported. Included in the study are data on baseline primary indication, details of surgical procedure, method of anaesthesia and intra-ocular agents. Two-sided t-tests and Pearson correlation were performed to test for slope, and all p values are presented with a Bonferroni correction. There were 7570 operations in 5591 patients (1.35 operation per patient), ratio of males to females (1.27:1), the mean age was 59.8 years (SD, 170.0 years), and 48.8% of operations were on left eyes and 51.2% on right eyes. The most common indication for surgery was RRD (42.8%) followed by intervention for vitreous haemorrhage (VH) (12.6%), TRD (6.1%), MH (10.4%) and ERM (7.7%). The relative frequency of vitreoretinal surgical intervention for most indications has remained similar over the past 16 years. In the management of RRD, 82.6% of the cases were pars plana vitrectomy procedures, and 16.6% were external buckle procedures with an increasing pattern towards PPV as the preferred choice (r = 0.229. R = 0.052, p < 0.001) (Fig. 1). The percentage of cases undergoing PPV, as compared to explant surgery, has increased from 60% in 1997 to over 90% in 2013. Macular hole surgery increased as a relative proportion of all cases (r = 0.95, p < 0.013) over the 16 years, and there was increasing use of hexafluoroethane (C2F6) as a tamponade agent following its introduction in 2009 rather than perfluoropropane (C3F8: r = 0.508, r = 0.252, p < 0.001). This trend in preferential use of C2F6 over C3F8 was also seen for other indications in later years. There was an increasing trend for combined lens and vitreous (CLV) extraction with PPV for the management of ERM andMH (Fig. 1). Brilliant blue is increasingly being used to stain internal limiting membrane in macular pathologies and was preferred over trypan blue. There was a general increasing preference for local anaesthesia across all surgical indications with time (p < 0.001). This study presents one of the largest series in the literature of patients who underwent vitreoretinal (VR) surgery over a prolonged period of 15 years. Overall, this study demonstrates that there is a move towards vitrectomy for both phakic and pseudophakic RRD. It is similar to increasing use of small

The Collaborative Ocular Tuberculosis Study (COTS)-1: A Multinational Description of the Spectrum of Choroidal Involvement in 245 Patients with Tubercular Uveitis

PURPOSEnTo contribute a global description of the spectrum of choroidal involvement in tubercular uveitis (TBU).nnnMETHODSnRetrospective cohort study of TBU patients with choroidal involvement from 25 centers between January 2004 and December 2014. Medical records of patients with a minimum follow-up of 1xa0year were reviewed.nnnRESULTSn245 patients were included. The phenotypic variations included serpiginous-like choroiditis (SLC) (46%), tuberculoma (13.5%), multifocal choroiditis (MFC) (9.4%), ampiginous choroiditis (9%), among others. 219 patients were treated with anti-tubercular therapy (ATT) (nxa0=xa0219/245, 89.38%), 229 patients with steroids (nxa0=xa0229/245, 93.47%) and 28 patients with immunosuppressive agents (nxa0=xa028/245, 11.42%). Treatment failure was noted in 38 patients (nxa0=xa038/245, 15.5%). Patients with SLC and ampiginous choroiditis appeared to have superior outcomes on survival analysis (pxa0=xa00.06).nnnCONCLUSIONnThis study provides a comprehensive description of choroidal involvement in TBU. Patients with SLC and ampiginous choroiditis may have better clinical outcomes.