Salil S Gadkari

Evaluation of 19 cases of inadvertent globe perforation due to periocular injections.

BACKGROUND Inadvertent globe perforation due to periocular injection is a serious iatrogenic complication. AIM To study risk factors, management and visual outcome of inadvertent globe perforation during periocular injection, in cases referred to a tertiary eye care center. DESIGN AND SETTING Retrospective study at a tertiary referral center with a single investigator. MATERIALS AND METHODS Nineteen consecutive cases with a clinical diagnosis of globe perforation were studied (1998-2004). Clinical setting, risk factors, clinical presentation, management and visual outcome were analyzed. RESULTS Retrobulbar injections 6 (32%), peribulbar injections 10 (53%) and subconjunctival injections 3 (16%) were responsible for inadvertent globe perforation. Anesthetists accounted for 6 (32%) injections and 13 (69%) were referred from high volume community settings. Anesthetists identified the mishap on the table in 17% (1 out of 6) of cases and the ophthalmologists in 69% (9 out of 13) myopia was present in 10 (53%). Breaks were located inferotemporally in nine eyes. Four underwent laser and cryopexy, 14 (74%) underwent vitreous surgery. Visual acuity greater than 20/200 was achieved in 12 patients. CONCLUSION Myopia was found to be a significant risk factor. Inferotemporal breaks were common. Anesthetists were more likely to miss this complication when it occurred. In this series, intervention salvaged vision in a significant number of eyes.

Vitreoretinal surgery for advanced retinopathy of prematurity: Presentation and outcomes from a developing country

OBJECTIVE To study the outcome of pars plana vitrectomy performed on patients with stage 4b and stage 5 retinopathy of prematurity and to examine differences in clinical presentation from developed countries. DESIGN Observational prospective case series. PARTICIPANTS Babies with stage 4b or 5 retinopathy of prematurity who underwent vitrectomy. METHODS The study was undertaken at a tertiary care ophthalmology centre in a developing country. Demographic variables, postnatal risk factors, and anatomic and visual status were noted preoperatively. Patients with stage 4b ROP underwent a 3-port lens-sparing vitrectomy. Those with stage 5 ROP additionally underwent lensectomy and retrolental membrane dissection. Patients were assessed on their last follow-up for anatomic, visual, and functional results. Statistical evaluation was performed using the nonparametric Wilcoxon rank sum test. RESULTS The results were evaluated by number of eyes treated, except for functional score. In 21 patients, 31 eyes underwent operation, of which 20 were stage 4b and 11 were stage 5. Anatomic success was achieved in 18 eyes (90%) with stage 4b. Mean vision in this anatomically successful group was 3.765, and the functional score was 5.36. In stage 5 eyes, anatomic success was achieved in 5 eyes (45.45%). Mean vision in this anatomically successful group was 1.833, and the functional score was 3. The visual results of stage 4b cases, compared with stage 5, were significantly better (p=0.0387). CONCLUSIONS Larger, older babies and previously unablated eyes presented with retinopathy of prematurity for surgery compared with developed countries. Anatomic, visual, and (notably) functional recovery was found in a good percentage of eyes.

Diabetic retinopathy screening: Telemedicine, the way to go!

India is considered to be the diabetes capital of the world with a diabetic population which is predicted to hit 69.9 million by 2025.[1] All professional eye‐care organizations advocate annual eye examinations for patients with diabetes.[2] Screening over 12% of India’s population, distributed over a subcontinent is not easy. A nationwide cross‐sectional study of diabetic patients by the AIOS for the first time in 2014 for diabetic retinopathy (DR), reiterated the findings of earlier regional studies, with a prevalence at 21.7% on a pan Indian scale.[3]

Variation in the vitreoretinal configuration of Stage 4 retinopathy of prematurity in photocoagulated and treatment naive eyes undergoing vitrectomy

Purpose: We sought to document the difference in the vitreoretinal configuration of Stage 4 retinopathy of prematurity (ROP) in photocoagulated and treatment naive eyes undergoing vitrectomy and to correlate it with surgical complexity. Methods: Consecutive eyes posted for vitrectomy with Stage 4 ROP were documented preoperatively using a RetCam for the presence of peripheral traction (PT), presence of central traction just outside the arcades, and presence of traction extending to the lens. A note was made of the following intraoperative events: lensectomy, intraoperative bleeding, and iatrogenic breaks. Wilcoxon rank-sum test was used for analysis. Results: From a total of 46 eyes, 16 and 30 eyes were from the treated and treatment naive group, respectively. More eyes in the treated group had central (P < 0.0001) and lenticular traction (P = 0.022). More eyes in the untreated group had PT (P < 0.0001). A significant number of eyes without photocoagulation needed lensectomy (P = 0.042), and no difference in intraoperative bleeding (P = 0.94) was demonstrable. Iatrogenic retinotomy occurred in three eyes, all naive. Notably, age at surgery was more in the untreated group (P = 0.00008). Conclusion: Vasoproliferative activity in all retinopathies occurs at the junction of the ischemic and nonischemic retina. In the natural course of ROP, this takes place peripherally, at the ridge. In photocoagulated eyes, this junction is displaced posteriorly due to peripheral ablation. Treated eyes manifested with posterior proliferative changes and were more amenable to lens-sparing vitrectomy. Naive eyes were older when they underwent surgery to relieve PT with greater chances of lensectomy and iatrogenic breaks.

The posterior iris-claw lens outcome study: 6-month follow-up

Purpose: The purpose of this study was to evaluate functional and anatomical outcomes of posterior iris-claw intraocular lens (IOL) implant for correction of aphakia in eyes with inadequate capsular support. Materials and Methods: Prospective case series of 108 aphakic eyes with inadequate capsular support which underwent posterior iris-claw IOL with a 6-month follow-up period was conducted. The cases belonged to two clinical settings: elective secondary implantation and those with intraoperative posterior dislocation of cataractous lens or IOL. Main outcome measures were visual acuity, anterior chamber reaction, stability of IOL, endothelial cell count, intraocular pressure (IOP), and cystoid macular edema (CME). Results: The mean best-corrected visual acuity was LogMAR 0.25. None had chronic anterior chamber inflammation. The mean difference in central endothelial counts before surgery and 1 month after surgery was 104.21 cell/mm2 (4.92%). There was no statistically significant difference in central endothelial cell count at 1 and 6 months (P = 0.91) and also in the central macular thickness at preoperative and after 6 months suggestive of CME (P = 0.078). Three eyes had raised IOP which were managed with neodymium-doped yttrium aluminum garnet laser peripheral iridotomy. There were no IOL dislocations or other adverse events in our series. Conclusion: Posterior chamber iris-claw lenses are a good option in eyes with inadequate posterior capsular support. Chronic inflammation, poor lens stability, or significant central endothelial cell loss was not observed during the 6-month follow-up period.

Minimally fibrotic stage 5 ROP: a clinical prognostic factor in eyes undergoing vitrectomy for stage 5 retinopathy of prematurity

TitleMinimally fibrotic Stage 5: A clinical prognostic factor in eyes undergoing vitrectomy for stage 5 retinopathy of prematurity (ROP).PurposeTo define minimally fibrotic stage 5 ROP and to demonstrate better surgical outcomes in this subgroup.MethodsA cohort of eligible eyes with stage 5 ROP undergoing vitrectomy were further divided into those with minimally fibrotic stage 5 and others. Minimally fibrotic stage 5 ROP was defined as those stage 5 eyes having a translucent retrolental membrane with visibility of the underlying retinal vessels and absence of anteriorly rotated ciliary processes. We reported on anatomic and visual outcomes in eyes with defined characteristics of this subgroup identified before surgery and then observing them post vitrectomy over a period of time as compared to others.ResultsMinimally fibrotic stage 5 eyes had better visual (p = .0068) and anatomical outcomes (p = .0001).ConclusionMinimally fibrotic stage 5 ROP shows ridge to ridge traction that has resulted in a traction retinal detachment with a retrolental membrane, but fibrotic change has just begun. This stage 5 ROP with limited fibrosis represents a subset of this stage 5 ROP with a positive anatomic and visual prognosis.

Innovative model for telemedicine-based screening for diabetic retinopathy in the developing world

A descriptive study was done by Genereau et al. on patients from the French Vasculitis Study to assess the frequency of temporal artery involvement in different types of systemic necrotizing vasculitis (SNV). From their cohort of 141 consecutive patients undergoing TAB for suspected GCA, they found 6 patients with SNV; they then accumulated 21 other patients with SNV identified on TAB retrospectively from collaborating institutions for a total of 27 patients diagnosed with SNV by support of TAB. Only 2 were known to have SVN before the TAB. They found that cephalic symptoms such as jaw claudication, clinically abnormal temporal arteries, and neuro-ophthalmologic symptoms were present in 81% of patients. In 70% (19 patients), the diagnosis of SNV was based on findings of the TAB. In the majority of these cases, temporal artery localization of the SNV was the first sign of vasculitis. Esteban et al. reviewed 28 patients in whom small vessel vasculitis in the soft tissue surrounding a spared temporal artery was the first histologic finding that led to the diagnosis of vasculitis. They identified 3 patients with SNV but did not further subclassify them. Finally, Hamidou et al. retrospectively identified 7 patients with SNV who underwent TAB for cephalic symptoms. They concluded that TAB is a simple tool to diagnose systemic vasculitis, but the histopathological findings need to be correlated with the clinical findings as it does not always discriminate between SNV and classic GCA. This case highlights the importance of including other SNV in the differential diagnosis of GCA. Non–giant cell temporal arteritis is rare but is a documented finding in SNV; therefore, TAB should be considered as a site for biopsy when cephalic symptoms are present in the context of systemic vasculitis. The key to the correct diagnosis of SNV in TAB is a good arterial specimen with surrounding soft tissue to include small vessels as well as proper communication with the pathologist.

Spontaneous resorption of sub-retinal cortical lens material.

We report a rare case of retained sub-retinal cortical material, which underwent spontaneous resorption. Patient presented with a left eye traumatic retinal detachment with a large retinal tear and posteriorly dislocated cataractous lens. Vitrectomy, lensectomy, silicone oil injection, and endolaser were performed. A good visual result was achieved. The report draws attention to this condition and highlights possible technique for minimizing risk of this complication in similar cases.