Devesh Kumawat

Insight into high myopia and the macula

The incidence of myopia is constantly on the rise. Patients of high myopia and pathological myopia are young and can lose vision due to a number of degenerative changes occurring at the macula. With the emergence of new technologies such as swept-source optical coherence tomography (OCT) and OCT angiography, our understanding of macular pathology in myopia has improved significantly. New conditions such as myopic traction maculopathy have been defined. Early, noninvasive detection of myopic choroidal neovascularization and its differentiation from lacquer cracks is possible with a greater degree of certainty. We discuss the impact of these new exciting and promising technologies and management of macular pathology in myopia. Incorporation of OCT in the microscope has also improved macular surgery. New concepts such as fovea-sparing internal limiting membrane peeling have emerged. A review of literature and our experience in managing all these conditions are discussed.

Multimodal imaging in a case of butterfly pattern dystrophy of retinal pigment epithelium

AimsTo report multi-modal imaging findings in a case of butterfly pattern dystrophy of retinal pigment epithelium.MethodsA middle-aged female with butterfly pattern dystrophy, who presented with progressive loss of vision, was examined using coloured fundus photographs, short wave autofluorescence, swept source optical coherence tomography (SS-OCT), fundus fluorescein angiography and enface optical coherence tomography.ResultsMulti-modal imaging was useful in the characterization of the various disease features. Autofluorescence pattern was opposite to that of fluorescein angiogram and SS-OCT showed disruption in the outer retinal layers. Enface OCT images depicted the pigment deposition prominently.ConclusionThe features of butterfly pattern dystrophy on these modalities correlated well with the histopathological findings described in the literature. Enface imaging highlights the deposition of pigment/lipofuscin and has never been described in BPD.

Reducing Waiting-time of Preterm Babies at a Retinopathy of Prematurity Clinic: A Quality Improvement Project

ObjectiveTo decrease the waiting time for preterm babies visiting the Retinopathy of prematurity clinic in a tertiary eye hospital.DesignInterventional study.SettingTertiary eye care hospital.PatientsAll preterm babies reporting for screening and follow up at Retinopathy of prematurity clinic.Intervention/ProcedureA quality improvement team comprising of a faculty (team leader), two senior residents, two junior residents, one nursing officer, and a registration staff was constituted. Fish bone analysis was done to understand various reasons for the high waiting time for preterm babies. Baseline data was collected followed by multiple Plan-Do-Study-Act (PDSA) cycles.Main outcome measuresAverage waiting-time, maximum waiting-time, and last baby entry-time were measured.ResultsThe median average waiting-time, maximum waiting-time and last baby entry-time at baseline were 90.5 min (range 74.1 to 118.8 min), 177.5 min (range 160 to 190 min) and 111 min (90 to 118 min), respectively. At the end of 3rd PDSA cycle, these reduced to 77.6 min (range 55.2 to 94.3 min), 122 min (range 110 to 135 min), and 60 min (range 45 to 80 min), respectively and were sustained; the decrease from baseline being 14.3%, 31.2%, and 46%, respectively.ConclusionThe time spent in the waiting area at the Retinopathy of Prematurity clinic was significantly reduced by simple changes in the process flow.

Reducing Preoperative Waiting-time in a Pediatric Eye Operation Theater by Optimizing Process Flow: A Pilot Quality Improvement Project

ObjectiveTo decrease the preoperative area waiting-time for children posted for eye surgery.MethodsA pilot quality improvement project was conducted in a single paediatric eye operation theatre in our tertiary-care hospital. Operation theatre process flow was analyzed, baseline data was collected, and two Plan-Do-Study-Act cycles were performed on consecutive days. Average and maximal waiting-time were recorded across six operation theatre days.ResultsThe average and maximal waiting time at baseline were 221 and 390 minutes, respectively. After two rapid Plan-Do-Study- Act cycles, these were reduced to 29 (87% reduction) and 52 minutes (87% reduction) from baseline, respectively, and could subsequently be sustained.ConclusionPreoperative waiting time in ophthalmic operation theatre was significantly reduced by simple process flow optimization, thereby improving quality of care.

Temporal Macular Pulsation During Retinopathy of Prematurity Screening

To the Editors: A 32-week infant with a birth weight of 1,200 g presented at 36 weeks’ post-conceptional age for retinopathy of prematurity (ROP) screening. Screening with indirect ophthalmoscopy revealed zone II stage 1 ROP with pre-plus disease in both eyes. In addition, pulsations were noted in both eyes in the temporal macular area. Fundus photography was performed with the RetCam 3 imaging system (Clarity Medical Systems, Inc., Pleasonton, CA) to document the findings. An abnormal temporal macular reflex in the form of a horizontal band was noted in both eyes, but was better appreciated in the left eye (Figure 1). This area seemed hypopigmented compared to the surrounding retina. Pulsations were confirmed in both eyes at this area (Video 1, available in the online version of this article), which decreased in amplitude with reduction of pressure on the globe with the RetCam handheld camera. These were in phase with induced arterial pulsations at the disc. These findings were again confirmed by indirect ophthalmoscopy with scleral indentation. The temporal macular pulsations observed in our case may be a result of a superficial lateral long posterior ciliary artery (PCA). The lateral long PCA is known to supply a sector of the choroid temporal to the macular region, with its apex oriented posteriorly.1 PCAs have numerous interarterial and arteriovenous anastamoses in the choroid.2 In addition, we believe that hyperdynamic ocular circulation could also have existed due to the associated plus component of the disease. All of these factors may be responsible for the easily visible PCA pulsations. Behera et al.3 previously demonstrated a case with satellite fovea-like light reflex in the temporal macula in zone I ROP previously treated with intravitreal bevacizumab injection. They also proposed this area to correspond to the site of entry of a lateral long PCA. However, they noted induced pulsation with pressure from the RetCam console rather than spontaneous transmitted pulsation. These were also noted in the avascular region of the retina. Such findings (transmitted pulsation from long PCA) are benign but rare to visualize. These can perplex a young ophthalmologist regarding the etiology and lead to unnecessary further ocular and orbital imaging. This case highlights the importance of in-depth knowledge of the vascular pattern and branches of PCA circulation.

Leukemic retinopathy and foveal infiltrates

The authors describe leukemic retinopathy with foveal leukemic infiltrates as the presenting feature of chronic myeloid leukemia. Spectral domain optical coherence tomography (SD-OCT) features of leukemic foveal infiltrates are presented. Though the retinopathy resolved with remission of disease, visual recovery was not complete due to loss of ellipsoid zone on SD-OCT.

Resolution of arterial aneurysms in idiopathic retinal vasculitis, aneurysms and neuroretinitis: a case report and review of literature

PurposeTo report a case of resolution of retinal arterial aneurysms in a patient of idiopathic retinal vasculitis, aneurysms and neuroretinitis (IRVAN) treated with oral steroids.MethodsThis study contains case report and review of literature.ResultsA 16-year-old girl with stage 2 IRVAN was treated with oral steroids alone. Fluorescein angiography confirmed the presence of aneurysms and absence of neovascularization in both eyes. The aneurysms resolved gradually over 4-month follow-up.ConclusionsThis case demonstrates previously unreported reversibility of arterial aneurysms with steroid therapy alone in early stages of IRVAN.

Bilateral proliferative retinopathy in B-cell acute lymphoblastic leukemia

A 4-year-old child with B-cell acute lymphoblastic leukemia presented with vitreous hemorrhage due to proliferative retinopathy in both eyes. Pars plana vitrectomy was performed in both eyes to clear nonresolving vitreous hemorrhage after systemic stabilization. Visual recovery was limited by the disc drag in the right eye and subfoveal exudation in the left eye. Etiopathogenesis and management of proliferative retinopathy in acute leukemias are discussed.

Ultra-wide field imaging of pigmented para-venous retino-choroidal atrophy

Objective: To describe the ultra-wide field imaging features of pigmented para-venous retino-choroidal atrophy. Design: Retrospective review at a tertiary care centre. Participants: Eight eyes of five patients with pigmented para-venous retino-choroidal atrophy who presented to our retina clinic over last 2 years. Methods: Retrospective review of ultra-wide field pseudo-colour and short wave autofluorescence imaging was performed. In vivo histology of the macula and areas of retino-choroidal atrophy was studied with swept source optical coherence tomography (SS-OCT). Results: The median age was 40 years (range: 22–67 years). Best corrected visual acuity ranged from perception of light to 20/20. The para-venous retino-choroidal atrophy and pigment clumping not only involved the major arcade vessels but also extended into the peripapillary area and retinal periphery. The affected areas demonstrated hypoautofluorescence with sharp hyperautofluorescent borders. Macular atrophy, epiretinal membrane and optic disc pallor were noted in two eyes each. In all cases, the affected pigmentary area had disorganization of inner retinal layers, disruption of outer retinal layers and retinal pigment epithelium and markedly thinned out choroid on swept source optical coherence tomography. Concurrent involvement with retinitis pigmentosa in the fellow eye was noted in two patients. Conclusion: Ultra-wide field imaging of pigmented para-venous retino-choroidal atrophy sheds light onto the widespread retino-choroidal abnormalities. Concurrent disc and macular involvement may jeopardize the visual function. Pigmented para-venous retino-choroidal atrophy may be considered as a self-limited form of retinitis pigmentosa.

Twenty-five–gauge Pars Plana Vitrectomy In Complex Retinal Detachments Associated With Giant Retinal Tear

Purpose: To study the structural and functional outcomes of 25-gauge pars plana vitrectomy in giant retinal tear–associated retinal detachments. Methods: Seventeen eyes of 17 patients with giant retinal tear, who underwent 25-gauge pars plana vitrectomy over a period of 15 months at a tertiary eye care center by a single surgeon, were recruited in this retrospective interventional study. Results: Giant retinal tears were mostly traumatic (35.3%) or associated with myopia (35.3%) and occurred in young (mean age 25.7 years) males (94.1%). Most eyes had best-corrected visual acuity ⩽20/1,200 (in 82.3%), foveal detachment (in 88.2%), and proliferative vitreoretinopathy ⩽Grade B (in 82.3%). The giant retinal tear extent was more than 180° in 29.4% and the fellow eye was involved in 35.2% of eyes. All eyes underwent 25-gauge pars plana vitrectomy with encircling band in 41.1%, perfluorocarbon liquid use in 82.3%, and endotamponade with sulphur hexafluoride (23.6%) or silicone oil (76.4%). At mean follow-up of 10.2 months, reattachment rate was 88.2%. Only 35.2% of eyes achieved final visual acuity ≥20/80 with a cause of poor vision being cataract, secondary glaucoma, macular pucker, and corneal edema. Conclusion: Twenty-five–gauge pars plana vitrectomy can achieve excellent attachment rates in eyes with giant retinal tear–associated retinal detachment. It can be as efficient as larger-gauge vitrectomy, at the same time retaining all advantages of smaller-gauge surgery.