Bhujang Shetty

Intacs in advanced keratoconus.

Purpose: To evaluate the surgical outcomes of microthin intracorneal ring segment (INTACS) implantation in advanced keratoconus. Methods: INTACS implantation was performed in eyes with advanced keratoconus. The main outcome measures were uncorrected visual acuity, best spectacle-corrected visual acuity, change in mean refractive spherical equivalent (MRSE), and keratometry. Results: Intacs were implanted in 14 eyes with advanced keratoconus. At 6 months, uncorrected visual acuity improved from 0.05 ± 0.08 to 0.16 ± 0.11 (P < 0.05), and best spectacle-corrected visual acuity improved from 0.50 ± 0.23 to 0.67 ± 0.00 (P = 0.01). The spherical refractive error improved from −6.68 D ± 6.44 to −3.11 D ± 3.08 (P = 0.03), whereas the cylindrical refractive error improved from −4.89 D ± 1.91 to −3.64 D ± 1.27 (P = 0.04). The MRSE reduced from −9.13 D ± 5.62 to −4.93 D ± 3.19 (P = 0.01), and the average keratometry decreased from 53.01 D ± 3.70 to 49.42 D ± 3.79 (P < 0.05). The results were stable from 6 months to 1 year. The procedure showed 100% safety, and more than 60% tolerated contact lenses. Younger age, male sex, and minimum central pachymetry of more than 400 μm seemed to be associated with better outcomes. Conclusions: In this series, Intacs provided good results with respect to visual acuity, corneal topography, and MRSE in eyes with advanced keratoconus without major complications or the need for segment explanation. INTACS is potentially a safe and efficacious treatment option in the management of advanced keratoconus.

The KIDROP model of combining strategies for providing retinopathy of prematurity screening in underserved areas in India using wide-field imaging, tele-medicine, non-physician graders and smart phone reporting

Aim: To report the Karnataka Internet Assisted Diagnosis of Retinopathy of Prematurity (KIDROP) program for retinopathy of prematurity (ROP) screening in underserved rural areas using an indigenously developed tele-ROP model. Materials and Methods: KIDROP currently provides ROP screening and treatment services in three zones and 81 neonatal units in Karnataka, India. Technicians were trained to use a portable Retcam Shuttle (Clarity, USA) and validated against ROP experts performing indirect ophthalmoscopy. An indigenously developed 20-point score (STAT score) graded their ability (Level I to III) to image and decide follow-up based on a three-way algorithm. Images were also uploaded on a secure tele-ROP platform and accessed and reported by remote experts on their smart phones (iPhone, Apple). Results: 6339 imaging sessions of 1601 infants were analyzed. A level III technician agreed with 94.3% of all expert decisions. The sensitivity, specificity, positive predictive value and negative predictive value for treatment grade disease were 95.7, 93.2, 81.5 and 98.6 respectively. The kappa for technicians to decide discharge of babies was 0.94 (P < 0.001). Only 0.4% of infants needing treatment were missed. The kappa agreement of experts reporting on the iPhone vs Retcam for treatment requiring and mild ROP were 0.96 and 0.94 (P < 0.001) respectively. Conclusions: This is the first and largest real-world program to employ accredited non-physicians to grade and report ROP. The KIDROP tele-ROP model demonstrates that ROP services can be delivered to the outreach despite lack of specialists and may be useful in other middle-income countries with similar demographics.

Visual quality after posterior chamber phakic intraocular lens implantation in keratoconus.

PURPOSE: To quantify image‐quality characteristics after correction of refractive error with a posterior chamber phakic intraocular lens (PC pIOL) in eyes with stable or stabilized keratoconus. SETTING: Narayana Nethralaya Postgraduate Institute of Ophthalmology, Bangalore, India. DESIGN: Case series. METHODS: Eyes with stable or stabilized keratoconus that had V4 Visian PC pIOL implantation for correction of refractive error were evaluated postoperatively for visual‐quality metrics. RESULTS: Ten eyes of 7 patients had PC pIOL implantation. The preoperative mean refractive spherical equivalent of −7.21 diopters (D) ± 2.25 (SD) decreased to −0.55 ± 1.53 D at 6 weeks and −0.44 ± 1.21 D at 6 months. The efficacy index was 0.72 and the safety index, 1.13. The mean modulation transfer function (MTF) was 18.96 ± 14.16 (≥30 cycles per degree = good), the Strehl ratio was 0.11 ± 0.07 (1 = perfect), and the objective scatter index (OSI) was 4.45 ± 3.29 (≥1.5 = significant scatter). The MTF correlated inversely with secondary coma (P=.026), negative vertical coma (P=.014), and the root mean square (RMS) of total aberrations (P=.010) and higher‐order aberrations (HOAs) (P=.015). The OSI was directly correlated with secondary coma (P=.021), secondary trefoil (P=.016), the RMS of total aberrations (P=.032), and HOAs (P=.050). CONCLUSION: In keratoconus, the refractive error could be corrected with the PC pIOL; however, the associated aberrations had an adverse impact on the ultimate visual quality and have to be addressed. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

In Vivo Confocal Microscopy of Keratic Precipitates in Infectious Versus Noninfectious Uveitis

PURPOSE To test the hypothesis that morphologic patterns of keratic precipitates (KPs) evaluated by in vivo confocal microscopy (IVCM) can differentiate infectious from noninfectious uveitis. DESIGN Cross-sectional, observational case series. PARTICIPANTS Sixty-eight eyes of 53 subjects with uveitis. METHODS A cross-sectional study was performed in patients with infectious and noninfectious uveitis presenting to a tertiary care eye hospital. Detailed ophthalmologic evaluation was performed in all the subjects. Keratic precipitates were studied by IVCM using the HRT II Rostock corneal module (Heidelberg Engineering GmbH, Heidelberg, Germany) and categorized on the basis of morphologic patterns. MAIN OUTCOME MEASURES Morphology of KPs by slit-lamp biomicroscopy and confocal microscopy. RESULTS The age of patients ranged from 15 to 87 years (median 40 years). Thirty-two patients were male (60.37%). Thirty-eight subjects had a unilateral presentation (71.69%) of uveitis. Infectious uveitis was seen in 38 cases (71.69%). The characteristics in KPs as seen in infectious uveitis were dendritic, central globular with dendritic, and infiltrative. In noninfectious uveitis (28.3%), stippled, globular, and multiple globular types of KPs were found. The sensitivity, specificity, and positive predictive value for specific combinations of KPs with an infectious cause were 84.21%, 93.33%, and 96.96%, respectively. CONCLUSIONS In vivo confocal microscopy can act as an adjunct tool for differentiating infectious from noninfectious uveitis. A central globular with dendritic form of KPs is strongly suggestive of infectious uveitis.

Microscope Integrated Intraoperative Spectral Domain Optical Coherence Tomography for Cataract Surgery: Uses and Applications

Abstract Aim: To demonstrate the uses and applications of a microscope integrated intraoperative Optical Coherence Tomography in Micro Incision Cataract Surgery (MICS) and Femtosecond Laser Assisted Cataract Surgery (FLACS). Methods: Intraoperative real time imaging using the RESCAN™ 700 (Carl Zeiss Meditec, Oberkochen, Germany) was done for patients undergoing MICS as well as FLACS. The OCT videos were reviewed at each step of the procedure and the findings were noted and analyzed. Results: Microscope Integrated Intraoperative Optical Coherence Tomography was found to be beneficial during all the critical steps of cataract surgery. We were able to qualitatively assess wound morphology in clear corneal incisions, in terms of subclinical Descemet’s detachments, tears in the inner or outer wound lips, wound gaping at the end of surgery and in identifying the adequacy of stromal hydration, for both FLACS as well as MICS. It also enabled us to segregate true posterior polar cataracts from suspected cases intraoperatively. Deciding the adequate depth of trenching was made simpler with direct visualization. The final position of the intraocular lens in the capsular bag and the lack of bioadhesivity of hydrophobic acrylic lenses were also observed. Conclusions: Even though Microscope Integrated Intraoperative Optical Coherence Tomography is in its early stages for its application in cataract surgery, this initial assessment does show a very promising role for this technology in the future for cataract surgery both in intraoperative decision making as well as for training purposes.

Universal ocular screening of 1021 term infants using wide‐field digital imaging in a single public hospital in India – a pilot study

Universal eye screening of neonates is currently not standard of care. Early detection of abnormalities could offer prompt management and a reduction in visual morbidity. We report a pilot study using wide‐field digital imaging to screen all infants at birth to explore its feasibility as a tool for universal screening.

A Novel, Low-Cost Method of Enrolling Infants at Risk for Retinopathy of Prematurity in Centers with No Screening Program: The REDROP Study

Purpose: To report the first-year results of the Red Card for Retinopathy of Prematurity (REDROP) study, a low-cost interim strategy to enroll infants into retinopathy of prematurity (ROP) screening where limited expertise exists, piloted at a multi-specialty general hospital. Methods: Red “warning” cards were placed alongside green “congratulations” cards above the weighing scale in the neonatal unit. Staff weighing the newborn were instructed to give either one of the cards to each mother depending on the weight of the child (≤ 2000 g, red, and > 2000 g, green). Red cards contained information (tri-lingual) about ROP and the venue of screening. Green cards contained general pediatric eye education and recipients were not called. A portion of the red card with the infant’s birth date and mother’s contact number was retained and collected weekly by volunteers. Mothers were reminded on the mobile phone to come for ROP screening. Screening and treatment were performed free. Results: During the study period, 224 of 805 (27.8%) infants were born ≤ 2000 g. Of these, 169 (75.4%) survived and were eligible for the red card; 91 (53.8%) received it. Of these, 43 (47.3%) infants completed ROP screening, 14 (32.6%) had some stage ROP, and three (6.9%) required laser treatment. The main reason for the lower turnout for screening was the inability to contact mothers on their provided phone numbers. Conclusions: REDROP demonstrates the feasibility of this low-cost method of enrolling unscreened infants into a ROP program. The cost of enrolling each infant was less than 5 rupees (US

COMPARING THE OUTCOME OF SINGLE VERSUS MULTIPLE SESSION LASER PHOTOABLATION OF FLAT NEOVASCULARIZATION IN ZONE 1 AGGRESSIVE POSTERIOR RETINOPATHY OF PREMATURITY: A Prospective Randomized Study.

0.10). Suggested strategies to improve use require multi-center validation.

Modified Technique for Epinucleus Removal in Posterior Polar Cataract

Purpose: To compare single versus 2-session laser photoablation for flat neovascularization in cases with Zone 1 aggressive posterior retinopathy of prematurity. Methods: Twenty-nine Asian Indian infants with aggressive posterior retinopathy of prematurity were randomized; each eye received 1 of 2 methods (29 each in Group A or B) proposed by the PHOTO-ROP group. Group A underwent single session laser to the avascular retina underlying the flat neovascularization by direct laser over the fronds. Group B underwent laser in 2 sessions; first, laser was delivered to the avascular periphery up to the flat neovascularization and 7 days later to the avascular bed exposed by the retraction of the fronds. Outcome and complications between the two groups were compared. Results: Mean birthweight and gestational ages were 1,276 g and 30.1 weeks, respectively. All eyes showed favorable outcome at a minimum 12-month follow-up. Hemorrhages after laser (41.4% vs. 17.2%, P < 0.001) were more common in the single laser group. Large hemorrhages (>1 disk diameter) seen in Group A took longer than 8 weeks to resolve and developed focal fibrosis. Conclusion: This study demonstrates that the two-staged laser procedure produces fewer and smaller hemorrhages and no fibrosis compared with a single session. Both methods have comparable favorable outcomes in Asian Indian infants.

Safety and efficacy of Intacs in Indian eyes with keratoconus: An initial report

The authors describe a novel technique for the removal of the sub-incisional epinucleus in cases of posterior polar cataracts. After the removal of the nucleus, the epinucleus is removed from the quadrant opposite to the section by aspiration using the phaco probe. Then hydrodissection is performed to dislodge the sub-incisional epinucleus, which is aspirated out. The rate of posterior capsular rupture decreased considerably with this technique because it reduced the manipulations required.