T H M Fung

Non-contact ultra-widefield imaging of retinopathy of prematurity using the Optos dual wavelength scanning laser ophthalmoscope

AimsThe purpose of this report is to demonstrate that a non-contact ultra-widefield dual wavelength laser camera (Optos) is able to capture high-quality images in retinopathy of prematurity (ROP).Materials and methodsWe conducted a retrospective review of patients attending the Oxford Eye Hospital with ROP between 1 August 2012 and 16 November 2012 that underwent standard clinical assessment. Anterior segment imaging, where relevant, was performed with Retcam. Retinal imaging was then performed with Optos, using a modified ‘flying baby position’.ResultsThe Optos scanning laser ophthalmoscope was able to acquire ultra-widefield fundal images in nine ROP subjects. The images obtained show clear views of the different stages of ROP features at the posterior pole and peripheral retina. Regression of ROP features were identified, following laser and intravitreal bevacizumab treatment. Additionally, ‘skip areas’ missed by initial laser treatment could be identified in the peripheral retina.ConclusionThe Optos ultra-widefield scanning laser ophthalmoscope is capable of acquiring clinically useful high-quality images of the fundus in ROP subjects. The imaging technique could potentially be used in monitoring ROP progression and documenting ROP regression following treatment.

Noncontact High-Resolution Ultra–Wide-Field Oral Fluorescein Angiography in Premature Infants With Retinopathy of Prematurity

IMPORTANCE We report for the first time, to our knowledge, the acquisition of noncontact ultra-wide-field oral fluorescein angiograms in premature infants with retinopathy of prematurity. OBSERVATIONS High-resolution oral fluorescein angiograms were successfully obtained in 3 consecutive premature infants with retinopathy of prematurity at the Oxford Eye Hospital, Oxford, England, using the Optos Panoramic 200MA imaging system (Optos PLC). CONCLUSIONS AND RELEVANCE Noncontact ultra-wide-field oral fluorescein angiograms captured using the Optos Panoramic 200MA fluorescein angiographic system provide a safe and alternative method for evaluating the retinal vasculature in premature infants with retinopathy of prematurity.

Non-contact ultra-widefield retinal imaging and fundus fluorescein angiography of an infant with incontinentia pigmenti without sedation in an ophthalmic office setting

When fluorescein angioscopy or angiography is required in an infant, it is usually performed in the operating theater or neonatal unit. We report a case of an infant with incontinentia pigmenti in whom we were able to acquire angiographic information in an office setting by using an ultra-widefield non-contact system with oral fluorescein.

Transient retinal artery occlusion during phacoemulsification cataract surgery.

PurposeTransient retinal artery occlusion (TRAO) is a potentially underdiagnosed cause of immediate ‘pad off’ visual loss following phacoemulsification cataract surgery under sub-Tenon’s anaesthesia.MethodsWe describe a series of three patients presenting with enigmatic ‘pad off’ visual loss following phacoemulsification surgery, each diagnosed with TRAO. We describe the variable clinical presentation, illustrate the value of optical coherence tomography (OCT) imaging in establishing the diagnosis, and present the final visual outcomes.ResultsClinical findings alone may be subtle and inadequate in localising the pathology in patients with TRAO. Cross-comparison of superior and inferior macula OCT profiles in branch-pattern arterial occlusion—and between healthy and affected eyes in central-pattern arteriolar occlusion—is critical in clinching the diagnosis. The typical evolution of OCT appearance is acute-phase inner retinal thickening/oedema and hyperreflectivity followed by progressive, late-phase inner retinal atrophy. Visual acuity may recover but central scotomas, and defects in colour perception may persist.ConclusionThe diagnosis of TRAO is challenging; delayed presentation may resolve fundal and retinal angiographic abnormalities. OCT may be the only imaging modality that can provide objective evidence of TRAO. Meticulous comparison/segmentation of OCT images is therefore mandatory in patients presenting with acute post-operative visual loss to exclude TRAO.

Ultra-widefield retinal imaging through a black intraocular lens.

Purpose To evaluate the feasibility of ultra‐widefield retinal imaging in patients with near infrared (IR)–transmitting black intraocular lenses (IOLs). Setting Oxford Eye Hospital, Oxford, United Kingdom. Design Laboratory evaluation of a diagnostic technology with interventional case report. Methods The field of retinal imaging through a Morcher poly(methyl methacrylate) (PMMA) black IOL was determined in a purpose‐built adult schematic model eye with the HRA2 Spectralis confocal scanning laser ophthalmoscope using standard imaging, Staurenghi retina lens–assisted imaging, and ultra‐widefield noncontact imaging. Retinal imaging using each modality was then performed on a patient implanted with another Morcher PMMA black IOL model. Results Ultra‐widefield noncontact imaging and lens‐assisted imaging captured up to 150 degrees of field (versus 40 degrees with a standard confocal scanning laser ophthalmoscope). Ultra‐widefield retinal images were successfully acquired in a patient eye with a black IOL. Conclusions This study has identified the first ultra‐widefield retinal imaging modalities for patients with near IR‐transmitting black IOLs. Should larger studies confirm this finding, noncontact ultra‐widefield confocal scanning laser ophthalmoscopy might be considered the gold standard imaging technique for retinal surveillance in patients with near IR‐transmitting black IOLs. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Primary black intraocular lens selection.

Sir, We read with interest the recent report by Shonibare and Lochhead1 describing a patient with visual confusion who suffered troublesome visual ghosting following primary implantation of a near-infrared (NIR)-transmitting black IOL. Secondary implantation of a NIR-blocking Artisan black IOL abolished the patients symptoms. Simultaneously—and independently—we reported an identical experience in a patient with intractable diplopia who required a secondary NIR-blocking Artisan IOL to suppress debilitating visual ghosting.2 NIR light is assumed imperceptible to humans, yet perception of light is almost universal in patients following NIR-transmitting black IOL implantation.3 In all, 91% of patients perceived light post-operatively, the remainder had acquired optic neuropathies with impaired long-wavelength spectral sensitivity and consequently could not perceive NIR light.3 Taken together, these observations suggest that careful and systematic evaluation of both patient factors and black IOL properties are necessary to identify the optimal primary black IOL implant pre-operatively in each patient to minimize the risk of treatment failure. First, patient factors should be considered including the necessity of posterior segment monitoring, need for absolute light occlusion, scotopic pupil size, lens status, and optic nerve pathology (Table 1). Second, the properties of each black IOL, including optimum surgical configuration, occlusive optic size, and utility in primary and secondary IOL implantation must then be considered (Table 2). Black intraocular lenses are variably occlusive to NIR light and may be usefully categorized by this property.4 Table 1 Summary of patient factors relevant to primary Black IOL selection in eligible patients Table 2 Technical details of all black intraocular lenses in clinical use High levels of post-operative satisfaction have been reported with NIR-transmitting black IOL implantation,5 although emerging reports of treatment failure do advise some caution.1, 2, 3 Predicting this risk pre-operatively is critical to the long-term efficacy of surgical intervention. Design of a NIR-transmitting black contact lens would permit a therapeutic trial to determine pre-operative NIR light sensitivity where uncertainty exists. Primary implantation of a NIR-blocking IOL would be advised if troublesome ghosting occurred. SLO/OCT posterior segment imaging remains a distinct clinical advantage in patients with NIR-transmitting black IOLs and may improve long-term safety. However, informed consent in this context must raise the possibility of treatment failure and need for secondary NIR-blocking IOL implantation in this patient group.

Non-contact ultra-widefield retinal imaging of infants with suspected abusive head trauma

PurposeThe purpose of the study was to audit the use of non-contact ultra-widefield retinal imaging in infants with suspected abusive head trauma (AHT) using the Optos P200MA Scanning Laser Ophthalmoscope.Patients and methodsA retrospective, observational case series. Ten eyes of five consecutive infants (aged 1–15 months) with suspected (or in 1 case, known) AHT referred for an ophthalmological opinion were included. Each infant underwent non-contact ultra-widefield retinal imaging using the Optos P200MA scanning laser ophthalmoscope. Optos fundus fluorescein angiography (FFA) was performed in one infant with oral sedation. The other four infants did not require sedation. The main outcome measure was the acquisition of a single, definitive ultra-widefield retinal image in each eye. Safety was audited by determining adverse changes in heart rate and oxygen saturations that required cessation of imaging.ResultsThe Optos P200MA ultra-widefield scanning laser ophthalmoscope acquired good quality retinal images in all infants. Documentation of acute, widespread retinal haemorrhages contributed to a diagnosis of AHT in three infants. Chronic pre-macular haemorrhage and macular schisis were documented by FFA in a fourth infant. The absence of retinal haemorrhages was documented in a fifth infant contributing to the exclusion of a diagnosis of AHT. There were no adverse safety signals in any infant in this series.ConclusionThe Optos P200MA ultra-widefield scanning laser ophthalmoscope appears safe to use in infants with suspected AHT, providing high-quality retinal images in a single frame without ocular contact. Optos P200MA may be used as alternative to RetCam to document retinal haemorrhages in stable infants with suspected AHT.

Multifocal Necrotizing Chorioretinitis Following Phacoemulsification Surgery

Abstract Introduction: Toxoplasma chorioretinitis is a leading cause of infectious posterior uveitis worldwide. Methods: We report an atypical presentation of Toxoplasma chorioretinitis presenting after uneventful cataract surgery in an 81-year-old male, with known hypernephroma and rheumatoid arthritis, treated with prednisolone and methotrexate. Results: He was treated for acute retinal necrosis and cytomegalovirus retinitis before Toxoplasma chorioretinitis was confirmed by vitreous biopsy 11 months after presentation. He developed a secondary rhegmatogenous retinal detachment, treated successfully with pars plana vitrectomy, silicone oil and endolaser. Visual acuity at discharge was 6/12 following silicone oil removal. Discussion: Necrotising chorioretinitis in immunosuppressed or elderly patients may present with an atypical phenotype. Clinical diagnosis in this context remains challenging. We discuss the clinical reasoning behind investigation and management of this patient group in whom viral and Toxoplasma retinitis may be clinically indistinguishable. The significance of vitreous PCR results in clinical decision making in the context of infectious posterior uveitis is discussed.

Integrating retinal simulation with a peer-assessed group OSCE format to teach direct ophthalmoscopy

OBJECTIVE To describe the conception and evaluation of a novel educational intervention to teach direct ophthalmoscopy with retinal simulators using a peer-assessed group objective structured clinical examination (OSCE) format. DESIGN Prospective, single-centre educational trial at Oxford University Medical School, Oxford, U.K. PARTICIPANTS A total of 160 consecutive undergraduate fifth-year medical students participated in the study. METHODS Students identified prior experience, teaching, examination, and feedback relevant to direct ophthalmoscopy. Students self-evaluated their perceived confidence across 6 domains of direct ophthalmoscopy examination before and after the educational intervention using a Likert-type psychometric scale. Wilcoxon matched pair testing was used to determine statistical significance for each domain. RESULTS The group OSCE intervention increased confidence in direct ophthalmoscopy overall from 2.5% to 63.8% (p < 0.001). Confidence improved in all 6 domains, most significantly in controls of ophthalmoscope (p < 0.001) and sequence of examination (p < 0.001) but also in the identification and interpretation of retinal signs (p < 0.001). Students rated the tutorial as very effective or effective across all 6 domains, and 96.29% rated the tutorial as effective overall. CONCLUSIONS Retinal simulation, integrated with a peer-assessed group OSCE format, is effective in increasing confidence in all aspects of direct ophthalmoscopy. It may be insufficient alone for training in the identification and interpretation of posterior segment clinical signs. Diminishing ophthalmology clerkships worldwide require ophthalmologists to identify innovative teaching methods, using modern technology and pedagogy to deliver high-quality, yet high-throughput, training in direct ophthalmoscopy. This novel teaching strategy may be considered by ophthalmologists responsible for direct ophthalmoscopy training in a teaching hospital context.

Silicone oil pupil block glaucoma in a pseudophakic eye

Intravitreal silicone oil achieves an effective endotamponade in patients with complex retinal detachments. Silicone oil displacement into the anterior chamber risks glaucoma and endothelial failure. We describe a 52-year-old patient with pseudophakia with silicone oil endotamponade presenting with visual loss and intraocular pressure of 60 mm Hg. Inferior YAG iridotomy was undertaken to repatriate silicone oil to the posterior segment. Despite normal intraocular pressure, acute corneal oedema occurred postiridotomy, resolving spontaneously over 2 weeks. Pupil block glaucoma secondary to silicone oil requires a management approach based on an understanding of silicone oil fluidics. Careful selection of inferior laser iridotomy site is critical to effectively reverse pupil block. Anterior migration of silicone oil in patients with pseudophakia is rare. We offer an hypothesis to explain unanticipated transient corneal oedema following silicone oil displacement from the anterior chamber. Clinicians must discuss the possibility of transient or permanent endothelial failure preoperatively in this patient group.