Niranjan Pehere

Choroidal thickness profile in healthy Indian children

Purpose: The purpose was to study choroidal thickness and its profile based on location in healthy Indian children using enhanced depth spectral-domain-optical coherence tomography (SD-OCT). Methods: In this cross-sectional observational study 255 eyes of 136 children with no retinal or choroidal disease were consecutively scanned using enhanced depth SD-OCT. Eyes with any ocular disease or axial length (AXL) >25 mm or < 20 mm were excluded. A single observer measured choroidal thickness from the posterior edge of the retinal pigment epithelium to the choroid/sclera junction at 500-microns intervals up to 2500 microns temporal and nasal to the fovea. Generalized estimating equations were used to evaluate the correlation between choroidal thickness at various locations and age, AXL, gender and spherical equivalent (SEq). Results: Mean age of the subjects was 11.9 ± 3.4 years (range: 5–18 years). There were 62 Females and 74 males. The mean AXL was 23.55 ± 0.74 mm. Mean subfoveal choroidal thickness was 312.1 ± 45.40 μm. Choroid was found to be thickest subfoveally, then temporally. Age, AXL and SEq showed a significant correlation with choroidal thickness, whereas gender did not affect choroidal thickness. Conclusion: Our study provides a valid normative database of choroidal thickness in healthy Indian children. This database could be useful for further studies evaluating choroidal changes in various chorioretinal disorders. Age and AXL are critical factors, which negatively correlated with choroidal thickness.

Treatment outcomes and clinicomicrobiological characteristics of a protocol-based approach for neonatal endogenous endophthalmitis.

Purpose To describe the outcomes and clinicomicrobiological profile of 11 years of a protocol-based management in neonatal endogenous endophthalmitis. Methods This was a retrospective interventional study of endogenous endophthalmitis in 31 eyes of 26 neonates. The protocol for active infection included systemic antimicrobials, vitreous and/or aqueous tap, and intravitreal antimicrobials under topical or general anesthesia along with core vitrectomy in selected cases. Blood, urine, umbilicus, aqueous, and vitreous samples underwent microbiological evaluation. Retinopathy of prematurity screening and treatment were done when indicated. Primary outcome was anatomic status assessed by comprehensive eye examination and by fundus photography whenever possible. Results Twenty-one of 26 babies (81%) were preterm. Two types of presentations included those with a fulminant appearance (24 eyes) and those with focal retinitis detected during routine screening (7 eyes). Vitreous culture was positive in 12/20 eyes (60%). Pseudomonas aeruginosa (8) was the most common isolate. Incorrect initial diagnosis was common. Treatment included intravitreal injections in 26 eyes, 10 of which also underwent vitrectomy. Twenty-four of the 26 patients (92%) received parenteral antimicrobials and 17 had evidence of systemic infection. All eyes with a fulminant presentation developed phthisis, while all focal fungal cases were salvaged. Conclusions Neonatal endogenous endophthalmitis has 2 distinct presentations. Focal retinal infections have good visual and anatomical outcomes while fulminant nosocomial cases do poorly. Management under topical anesthesia can be an alternative strategy for sick babies that cannot undergo surgery under general anesthesia due to systemic morbidity. Awareness about early diagnostic signs may help early referral.

Opacification of Intraocular Lenses Implanted during Infancy: A Clinicopathologic Study of 4 Explanted Intraocular Lenses

OBJECTIVE To report the clinicopathologic features of 4 opacified, single-piece, hydrophilic, acrylic intraocular lenses (IOLs) explanted from children who had undergone IOL implantation during infancy. DESIGN Observational case series. PARTICIPANTS Four IOLs explanted from 4 eyes of 3 children for visually significant opacification were included in the study. METHODS The clinical details of each case were obtained to look for possible risk factors for IOL opacification. The explanted IOLs were subjected to gross examination, staining by alizarin red 1% for calcium, scanning electron microscopy, and energy-dispersive x-ray spectroscopy (EDS). Levels of calcium and phosphorous were analyzed in the serum of all cases and in the aqueous humor of 1 case. MAIN OUTCOME MEASURES Morphologic features and composition of deposits. RESULTS Two cases had congenital cataract while one case was after bilateral lens sparing vitrectomy for retinopathy of prematurity. All underwent surgery during infancy with implantation of an IOL. The IOLs were explanted 8 months after surgery from 4 eyes of 3 children at the age of 17, 25, and 26. All the children received a single-piece hydrophilic acrylic IOL. The IOLs were in situ for an average duration of 13.86 months. The deposits were in the shape of a bicycle wheel on 3 IOLs and looked like fish eggs on 1 IOL. All deposits stained bright orange with alizarin red. On EDS, the deposits were found to be composed of calcium, phosphate, and silicone. CONCLUSIONS The morphologic features and composition of IOL deposits in 2 cases were similar to those of earlier reports in adults. The hydrophilic nature of the IOL material, sulcus implantation, and postoperative inflammation may be possible risk factors for opacification. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found after the references.

Posterior microphthalmos pigmentary retinopathy syndrome

Posterior Microphthalmos Pigmentary Retinopathy Syndrome (PMPRS). Posterior microphthalmos (PM) is a relatively infrequent type of microphthalmos where posterior segment is predominantly affected with normal anterior segment measurements. Herein, we report two siblings with posterior microphthalmos retinopathy syndrome with postulated autosomal recessive mode of inheritance. A 13-year-old child had PM and retinitis pigmentosa (RP) and his 7-year-old sister had PM, RP, and foveoschisis. The genetics of this syndrome and variable phenotype is discussed. Importance of being aware of posterior microphthalmos and its posterior segment associations is highlighted.

Measuring Health-Related Quality of Life in Strabismus: A Modification of the Adult Strabismus-20 (AS-20) Questionnaire Using Rasch Analysis

Purpose To evaluate the psychometric properties of the Adult Strabismus-20 (AS-20)- a health-related quality of life (HRQoL) questionnaire in adults with strabismus, and if flawed, to revise the AS-20 and its subscales creating valid measurement scales. Methods 584 adults (meanage, 27.5 years) with strabismus were recruited from an outpatient clinic at a South Indian tertiary eye care centre and were administered the AS-20 questionnaire.The AS-20 was translated and back translated into two Indian languages. The AS-20 and its two 10-item subscales – ‘psychosocial’ and ‘function’were assessed separately for fit to the Rasch model, including an assessment of the rating scale, unidimensionality (by principal components analysis), measurement precision by person separation reliability, PSR, targeting, and differential item functioning (DIF; notable > 1.0 logits). Results Response categories were not used as intended, thereby, required re-organization and reducing their number from 5 to 3. The AS-20 had adequate measurement precision (PSR = 0.87) but lacked unidimensionality; however, deletion of the six multi-dimensionality causing items and an additional three misfitting items resulted in 11-item unidimensional questionnaire (AS-11). Two items failed to satisfy the model expectations in the ‘psychosocial’ subscale and were deleted – resulting in an 8-item unidimensional scale with adequate PSR (0.81) and targeting (0.23 logits). One item misfit in the ‘function’ subscale and was deleted—resulting in a 9 item Rasch-revised unidimensional subscale with acceptable PSR (0.80) and targeting (0.97 logits).None of the items displayed notable DIF by age, gender and level of education. Conclusions The AS-11 and its two Rasch-revised subscales – 8-item psychosocial and 9-item function subscale may be more appropriate than the original AS-20 and its two 10-item subscales for use as unidimensional measures of HRQoL in adults with strabismus in India. Further work is required to establish the validity of the revised rating scale.

Inadvertent Intraocular Injection of Botulinum Toxin A

This report describes an inadvertent perforation of the globe while injecting botulinum toxin A into the medial rectus muscle without electromyography guidance. Botulinum toxin A does not appear to have toxic effects on the human retina. Close observation and necessary measures to treat any retinal breaks and control increased intraocular pressure should be undertaken.

Rotational Autokeratoplasty in Pediatric Patients for Nonprogressive Paracentral Corneal Scars

OBJECTIVE To report the outcomes of ipsilateral rotational autokeratoplasty (RAK) for nonprogressive paracentral corneal opacities in children <16 years of age. DESIGN Retrospective, consecutive, interventional case series. PARTICIPANTS Thirty-three eyes of 33 children aged <16 years undergoing RAK for nonprogressive paracentral scars. METHODS Medical records were retrospectively reviewed for the primary etiology of corneal opacity, time of onset, duration of opacity, preoperative visual acuity, formula used for calculation of trephine size, size of the trephine used, and duration of follow-up. Any intraoperative and early and late postoperative complications were noted for all patients. Postoperative visual acuity and astigmatism were noted. Visual acuity was converted to logarithm of the minimum angle of resolution units for analysis. MAIN OUTCOME MEASURES Primary outcome was postoperative visual acuity. Graft clarity and complications were analyzed as secondary outcomes. RESULTS The mean age at surgery was 7.2 ± 3 .9 months. The mean follow-up duration was 27 ± 37 months. The commonest etiology of corneal opacity was trauma (62.5%), followed by resolved microbial keratitis (21.9%). Postoperative visual acuity (1.25 ± 0.84) was significantly better (P<0.001) than preoperative visual acuity (2.05 ± 0.96). The mean astigmatism at last visit was 4.04 ± 2.21 diopters. Postoperative visual acuity was better in older children (β = -0.01; P = 0.03) and had a shorter delay in presentation (β = 0.02; P = 0.05). At the last follow-up, the graft was clear in 27 cases (81.25%). The cumulative probability of graft survival was 85% at 2 years and 65% at 5 years. Complications included wound leak in 4 eyes, secondary glaucoma in 2 eyes, graft infiltrate and traumatic dehiscence in 1 eye each. CONCLUSIONS Rotational is a autokeratoplasty viable alternative surgical option to allogenic keratoplasty. Graft survival at 2 years seems to be better than allogenic keratoplasty. Younger age and delay in presentation contribute to poorer visual outcomes after surgery. FINANCIAL DISCLOSURE(S) The authors have no proprietary or commercial interest in any of the materials discussed in this article.

Cerebral visual impairment in children: Causes and associated ophthalmological problems

Purpose: The aim of this study is to identify common causes, associated ophthalmological abnormalities, and systemic comorbidities in children in Andhra Pradesh, India, with cerebral visual impairment (CVI). Methods: A retrospective review of case records of all children aged <16 years with diagnosis of CVI seen between January 2016 and December 2016 was carried out. Data were collected for their age, gender, cause of CVI, refraction, accommodation, anterior and posterior segment examination findings, and systemic problems. Results: A total of 124 patients were identified and studied (80 boys and 44 girls, mean age 5.23 years, 44.8% aged <2 years). The most common causes of CVI were hypoxic–ischemic encephalopathy (HIE) (34.4%), undetermined etiology (32.8%), neonatal seizures, and infantile spasms (16% each). The most common presenting complaints were poor vision (76%) and squint (11.2%). Profound visual impairment was seen in 88.8%, and 11.2% had high functioning CVI. Fifty-eight (46.4%) patients had significant refractive errors, 40 (32.25%) had strabismus, 4 (3.2%) had visually significant cataract, and 40 (32%) had optic atrophy. Motor delay was observed in 39.5%, speech delay was evident in 22.4%, and cognitive delay in 16%. Conclusion: HIE is the most common cause (one-third) of CVI in our population, and the majority of them presented at age <2 years (44.8%) with profound visual impairment (88.8%). A significant number of them have treatable ophthalmic conditions such as refractive errors (46.4%), accommodative insufficiency (12.1%), and cataract (3.2%), and more than one-third of them also have delay in other areas of development.

Inferior oblique transposition for large hypertropia after vertical rectus transposition

Consecutive vertical deviations occur in 13% to 30% of cases after full tendon vertical rectus transposition (VRT) surgery in adult patients with abducens nerve palsy. We report a 7-year-old boy with congenital abducens nerve palsy who developed a large hypertropia following VRT with posterior fixation sutures. During subsequent surgery, extensive scarring of the vertical rectus muscles was observed, and an inferior oblique nasal anterior transposition was performed. The patient was orthotropic in primary position through 18 months of follow-up. The causes and management options for vertical deviation following VRT are discussed.

Compressive Optic Neuropathy Caused by a Cholesterol Granuloma of the Sphenoidal Sinus

Cholesterol granuloma is a foreign body giant cell reaction to cholesterol deposits. The pathology is rarely seen in the paranasal sinuses. In this report we describe a case of compressive optic neuropathy caused by cholesterol granuloma arising from the sphenoidal sinus. A 46-year-old lady presented with painless progressive decrease in vision in her left eye over the past 7 years. Magnetic resonance imaging of the brain and orbit with gadolinium enhancement showed a homogenous T1 and T2 hyperintense lesion causing expansion of the sphenoidal sinus compressing the ethmoidal sinus and also the left optic nerve. An endoscopic marsupialisation of the lesion was performed. Histopathological examination showed multiple characteristic cholesterol clefts surrounded by numerous multinucleated giant cells, histiocytes, lymphocytes, haemosiderin-laden macrophages, and plasma cells. This case emphasises the importance of appropriate neuro-imaging in cases of progressive optic neuropathy: cholesterol granuloma of the paranasal sinuses is a rare cause of optic nerve compression.