Ramanath Bhandari

Reversal of paracentral occlusive retinopathy in a case of sickle cell disease using exchange transfusion.

Paracentral occlusive retinopathy is an uncommon manifestation of sickle cell disease. If macular ischemia is not reversed, permanent vision loss can result. The authors report the successful use of exchange transfusion to treat unilateral paracentral occlusive retinopathy secondary to sickle cell disease in a 23-year-old man with hemoglobin SS disease. Initial presentation demonstrated arteriolar occlusion, perivenous hemorrhages, vessel tortuosity, and areas of retinal ischemia. Visual acuity was count fingers, and the patient noted a paracentral scotoma. Following transfusion, there was restoration of arteriolar flow as documented with fluorescein angiogram, and visual acuity returned to 20/20.

23-Gauge Vitrectomy for Retained Lens Material

A technique for removal of retained lens material is described with a three-port 23-gauge vitrectomy system. Removal of the core vitreous is first performed, followed by removal of the cortical vitreous. All vitreous adhesions to the lens are cleared. The cut rate is then decreased to 1,500 cuts per minute, and vacuum increased to 600 mm Hg. The cortical lens material is cleared first, and then the nuclear material is taken with the same vitrectomy probe using the light pipe to assist in crushing the nuclear fragments. With this technique, even large dense nuclear and cortical retained lens material can be removed from the vitreous chamber without the need for a fragmatome.

A nanopore membrane regulator device for laser modulated flow after glaucoma surgery

Glaucoma, the second most common cause of blindness in the world, is a multifactorial disease with several risk factors, of which intraocular pressure (IOP) is a primary contributing factor. Filtration surgery is one of the most effective means to significantly lower IOP compared to medical or laser treatments, and it is typically reserved for advanced disease. However, there are high rates of postoperative complications associated with the procedure, often from over- or under-filtration. To address these problems, the glaucoma drainage device regulator (GDDR) implant was developed to allow post-operative control of aqueous flow and IOP. The device, a tube with a nanopore membrane, is placed beneath the scleral flap. Postoperatively, the membrane surface can be ruptured with a laser to augment flow through the system. This feature allows adjustable control of aqueous flow and diminishes the risk of hypotony in the early postoperative period.

Development of a laser controlled device to modulate intraocular pressure

ABSTRACT Introduction: The current standard of treatment for glaucoma is trabeculectomy. The use of glaucoma drainage devices has increased in recent years since its efficacy and safety was established as it provides an alternative surgical option. A downfall of these devices is the lack of proper flow rate control. Areas covered: In this paper we describe a glaucoma drainage device regulator that has already been protoyped and undergone initial testing. It consists of an implantable device with a semipermeable membrane that is used during glaucoma surgery and can be opened with either thermal or photodisruptive laser to adjust the amount of flow precisely and non-invasively, addressing the current difficulties of glaucoma surgeries. A literature search was conducted using MEDLINE and manuscript references for studies published in English between 2000 and 2015 using the terms glaucoma, trabeculectomy and glaucoma drainage devices. Expert commentary: The GDDR device can decrease surgical risk and allow surgeons to post-operatively adjust flow as clinically needed using a non-invasive method. Further testing is planned to substantiate these initial results and evaluate the device’s biocompatibility, tunability and efficacy.

Retina Evaluation With Nonmydriatic Ultrawide-Field Color Imaging After Cataract Extraction Surgeries in Asymptomatic Patients

BACKGROUND AND OBJECTIVE To evaluate the role of nonmydriatic ultrawide-field (UWF) color retinal imaging as a screening tool in the follow-up of asymptomatic patients after cataract extraction surgeries. PATIENTS AND METHODS A retrospective, observational case series. A review of electronic medical records identified patients after cataract extraction followed with UWF retinal imaging (Optos 200Tx; Optos, Dunfermline, Scotland). Images were graded and reviewed by a retina specialist. Outcome measures included image quality, the detection of peripheral lesions, and association with perioperative risk factors. RESULTS Seventy-six eyes of 58 consecutive patients were enrolled. A good visualization of the peripheral retina was accomplished in more than 90% of patients. Peripheral lesions were identified in 40 eyes (52.6%) with no surgery-related retinal breaks and/or detachments. Additional pathologies were found in 35 eyes (46.1%). CONCLUSION Nonmydriatic UWF color retinal imaging was found to be a useful screening tool in the follow-up of asymptomatic patients after cataract extraction in this series.

Vogt–Koyanagi–Harada disease masquerading as a lymphoproliferative process of the uvea

A 57-year-old man of Dutch-Indonesian ancestry presented with a 1-month history of bilateral iritis, optic nerve head swelling and decreased vision. He was initially seen by his local ophthalmologist and was treated with prednisolone acetate 1% drops with no improvement, and transferred to our tertiary care institution. On presentation, the patient had an acuity of 20/60 bilaterally with no evidence of anterior chamber inflammation and normal angle structures. On dilated exam, no vitritis was evident; however, optic nerve head swelling and a diffuse bilateral choroidal infiltrate with choroidal folds but without serous retinal detachment was present (figure 1A). Extra ocular symptoms included meningismus and tinitus. Serum testing was negative for cryptococcal antigen, rapid plasma reagin (RPR), human immunodeficiency virus (HIV), bartonella IgM/IgG, quantiferon gold tuberculosis and polymerase chain reaction (PCR) for herpes simplex (HSV), herpes zoster (HZV), and cytomegalovirus (CMV). Serum lysozyme and angiotensin converting enzyme (ACE) levels were normal. The lumbar puncture revealed elevated cerebrospinal fluid (CSF) protein (88 mg/dL), normal glucose and CSF lymphocytosis (253 nucleated cells with 94% lymphocytes) with normal flow cytometry. B-scan ultrasound revealed bilateral diffuse choroidal infiltrates most prominent near the ciliary body (figure 1B). The circumferential infiltrate, the choroidal folds and the lack of serous retinal detachment were suspicious for a lymphoproliferative process of the uvea. However, the infiltrate was bilateral and the human leukocyte antigen (HLA) typing revealed HLA-DRB104 which has been associated with Vogt–Koyanagi–Harada (VKH) disease. The patient was then treated with 1 g intravenous methylprednisolone q day for 3 days with a marked decrease in the circumferential infiltrate and diffuse choroidal thickening …