Ruchir Tewari

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.

Multimodal imaging questions etiology of idiopathic retinal vasculitis, aneurysms and neuroretinitis syndrome (IRVAN syndrome)

Idiopathic retinal vasculitis, aneurysms and neuroretinitis (IRVAN) syndrome is a rare entity of unknown etiology for which many hypotheses have been proposed with inflammation being the most commonly accepted hypothesis. We report cases of a 9 year old girl and a 22 year old male patient with diagnosis of IRVAN syndrome. The conclusions drawn from the clinical examination and multimodal imaging including optical coherence tomography angiography of the patients are discussed. Our conclusions and interpretation point towards IRVAN being a developmental vascular anomaly rather than a consequence of inflammation. It is thus proposed to be renamed as Idiopathic retinal arteriolar aneurysm syndrome (IRAA).

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.

Macular hole-associated retinal detachment in Best vitelliform dystrophy: Series of two cases and literature review

Two eyes of 2 patients with macular hole-associated retinal detachment in clinically diagnosed vitelliruptive stage of Best vitelliform dystrophy were surgically managed by 25-gauge sutureless pars plana vitrectomy, internal limiting membrane (ILM) peeling with inverted ILM flap, and short-acting (SF6) gas tamponade. The patients were assessed with respect to best-corrected visual acuity, color fundus photographs, shortwave fundus autofluorescence, and swept source optical coherence tomography. Surgical intervention led to Type 1 closure of macular hole, resolution of retinal detachment, and improvement in vision in both patients.

Optic nerve aplasia

Manuscript received: 19.07.17; Revision accepted: 21.09.17 A 10‐month‐old child was referred in view of convergent squint in the right eye. Antenatal period was uneventful, and family history was noncontributory. The child had otherwise normal developmental milestones. The left eye was normal. The child did not follow light with his right eye. The right eye had 60 prism diopters of esotropia on modified Krimsky test, and ocular motility was full. The corneal diameter (measured during sleep) in the right eye was 6 mm compared to 10 mm in the left eye [Fig. 1a]. Iris was hypoplastic in the right eye [Fig. 1b]. Fundus examination of the right eye showed the absence of optic nerve head and retinal vessels [Fig. 1c]. A large area of chorioretinal atrophy was seen at the posterior pole along with posterior staphyloma and scleral show. Axial length was 22.10 and 19.96 mm in the right and the left eye respectively. Visually evoked responses were absent in the right eye. Magnetic resonance imaging of brain and orbit revealed absent optic nerve with no other intracranial anomalies [Fig. 1d]. The patient was diagnosed with right isolated optic nerve aplasia (ONA), and parents were apprised of the situation.

Documentation of active bleed from retinal neovascularization during fluorescein angiography

Manuscript received: 13.08.17; Revision accepted: 16.11.17 A 54‐year‐old gentleman with type 2 diabetes mellitus for the past 15 years was diagnosed with bilateral proliferative diabetic retinopathy (PDR) and diabetic macular edema. Best‐corrected visual acuity was noted to be 6/18 (Snellen acuity) in both eyes. He was posted for a baseline fundus fluorescein angiography (FFA). Color fundus photographs of both eyes showed multiple microaneurysms as well as hard and soft exudates at the macula. The right eye also had few regions of retinal hemorrhages and a lacy branching network of fine blood vessels in the superotemporal region suggestive of a neovascularization elsewhere (NVE). The left eye also showed a similar NVE in the superotemporal region [Fig. 1]. FFA revealed leakage from the NVE in the left eye [Fig. 2].

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.

Ultra wide field imaging of coats like response in Leber’s congenital amaurosis

howing on and A 12-year-old boy presented with poor vision and abnormal eye movements in his both eyes since birth. There were no systemic complaints. The visual acuity was light perception only in both eyes. The cycloplegic refraction revealed a hypermetropia of 6 and 7 diopters in right and left eye respectively, but the correction did not improve his visual acuity. The child had pendular nystagmus; enophthalmos and oculo-digital sign were present. The pupil reacted sluggishly to light in both the eyes. A dilated fundus examination revealed bilateral optic disc pallor, pigment spicules all over the fundus and vascular attenuation. In addition the right eye (Fig. 1) showed well-defined excavated area of chorio-retinal atrophy in macula and sclerosed vessels with scattered retinal hemorrhages in the temporal fundus. The left eye showed thick glial tissue with exudation in macula (Fig. 2). An area of retinal vascular telangiectasias and subretinal exudation was noted inferiorly and temporally in left fundus. Electroretinography (ERG) showed extinguished scotopic and photopic responses. A diagnosis of Leber’s Congenital Amaurosis (LCA) with ‘‘Coats like’’ response was made. Patient was advised for regular follow-up.

Imaging Studies for Ocular Tuberculosis

Ocular tuberculosis has protean manifestations which can involve both the anterior and posterior segments of the eye. Ophthalmologists are fortunate as ophthalmic imaging today is quite advanced and most ocular pathologies can be seen and documented. Thus ocular imaging and investigations play an important role in assessing various ocular disorders. However, the various ocular manifestations of tubercular uveitis are not exclusive to tuberculosis. Though the ocular investigations may suggest a diagnosis of tuberculosis, it cannot be established beyond doubt. It is finally the ophthalmologist who has to correlate the history, ocular and systemic investigations and circumstances of the patient to make a diagnosis of ocular tuberculosis. Response to antitubercular therapy is generally taken as confirmatory evidence of tubercular aetiology. Due to a high prevalence of tuberculosis in India, it is all the more imperative and all the more challenging to correctly establish a diagnosis of ocular tuberculosis. Tuberculosis, time and again, has proven to be the great masquerader and, even today, does not fail to surprise.