Indian Journal of Ophthalmology最新文献

Purpose: The management of idiopathic macular holes (iMH) has evolved over time with various modifications in surgical approach. The study aimed to survey the surgeons' preferences in the management of iMH in current times.

Design: Cross-sectional descriptive survey.

Methods: A 12-item questionnaire addressing the key aspects of iMH management was sent, between October 2022 to November 2022, by personal correspondence to 104 vitreoretinal specialists, actively practicing and performing iMH surgeries at various institutes in India. The responses were gathered till January 2023 and analyzed as per appropriate statistical methods.

Results: Ninety-one retina specialists responded to the survey (response rate of 87.5%) with a median annual surgical load of 30 cases (range: 5-150). Most respondents had similar views on patient selection, combined phaco-vitrectomy, internal limiting membrane (ILM) staining, ILM peel initiation and propagation, tamponade, postoperative positioning, and prognostic factors. The preferred approach for peel initiation was "pinch and peel," but "scrape and peel" was equally recommended for beginners. Most respondents considered iMH >600 microns in size as large and used additional surgical maneuvers for large and failed cases such as ILM flap, large flap, macular detachment, platelet-rich plasma application, and amniotic membrane graft. The three most important visual prognostic factors were duration, preoperative vision, and MH size.

Conclusions: The practice of surveyed surgeons performing iMH surgery was uniform in several aspects. There is a need to create consensus on the preferred ILM peel technique among trainee surgeons, revisit the iMH size classification, and standardize the surgical approach as per hole size and characteristics.

Purpose: To report the clinical features and management outcomes of rejection after deep anterior lamellar keratoplasty (DALK).

Methods: The clinical features, indications, predisposing risk factors, management, and outcome of six eyes of six patients with rejection after DALK were analyzed retrospectively.

Results: The median time of rejection from the day of surgery was 12 (range 3-36) months. Median duration of symptoms was 4 (range 2-28) days. The indication for DALK was keratoconus in all eyes. The clinical features at presentation included graft haze, vascularization, and melt at the graft-host junction. The risk factors noted were noncompliance to steroids in all eyes, vernal conjunctivitis (four eyes), and eccentric graft (one eye). The rejection episode reversed with topical steroids in all eyes and intravenous methylprednisolone in one eye. One eye developed secondary fungal keratitis after initial recovery and one eye had a second episode of rejection 3 months later, which resulted in progressive vessels and lipid keratopathy in the visual axis. The median best corrected visual acuity was 20/40 (range 20/30-20/200).

Conclusion: Severe stromal rejection can present with graft melt. Repeat episodes of rejection can occur on sudden cessation of topical steroids. Prompt recognition of clinical signs and symptoms with timely management helps in quick reversal of the rejection episode. Reversal of graft rejection results in good visual outcomes.

The use of small-gauge trocar cannulas during transconjunctival sutureless pars plana vitrectomy (PPV) facilitates the smooth transition of instruments into the posterior segment and reduces trauma. However, room lighting is routinely dimmed during PPV, thereby making cannula visualization difficult and hence compromising efficient instrument exchange. We report the use of a frugal, fluorescent "glow-in-the-dark" ring placed over vitrectomy cannulas to visualize the cannula entry, thereby providing a smooth and efficient instrument exchange. We 3D-printed phosphorescent rings of optimum inner diameter to comfortably fit around the trocar cannula (The Glowport). Two such rings are fitted into the two trocar cannulas prior to surgery initiation. The cannulas are then passed via sclerostomy as performed in routine PPV. The light from the fiberoptic endo-illuminator is focused over the rings for approximately 5 seconds to activate the photoluminescence. Under mesopic conditions, the fluorescence provides visualization of the cannula entry and helps in the facilitation of smooth entry and exchange of instruments into the globe for performing vitreoretinal surgical procedures, which helps in reducing ocular touch errors as well as surgical time. The Glowport is a frugal device retrofitted onto the trocar cannulas and helps in the smooth entry and exchange of instruments under darkroom conditions, which are required in vitreoretinal surgery.

Purpose: The primary objective was to evaluate the clinical response of refractory cases of fungal keratitis to topical 1% posaconazole therapy.

Methods: Prospective longitudinal non-randomized open label dual-cohort study of 70 eyes of refractory fungal keratitis, 35 were recruited as posaconazole treatment (PCZ) group for topical 1% posaconazole therapy and compared to 35 eyes on conventional antifungal therapy. Study parameters included demographic and treatment details, visual acuity, comprehensive slit-lamp biomicroscopy, clinical photography, ASOCT at recruitment and weekly (week 1, 2, 3 and 4 after treatment initiation). Clinical assessment included keratitis severity grade, time of healing, and healing response. Anti-fungal susceptibility testing was performed.

Results: The mean age of 35 patients recruited in the PCZ treatment group was 45 ± 17.32 years and that for the conventional treatment group was 43.22 ± 15.04 years. Culture isolation was possible in 25 eyes (71.4%) in the PCZ treatment group, with Fusarium and Aspergillus spp. being the most common cornea pathogenic mycotic organisms. The mean healing time in the PCZ group was 27.13 ± 5.8 days and in the conventional treatment group was 26.41 ± 4.81 days. Healing response in the PCZ treatment showed that 27 eyes (77.14%) had healed, 3 (8.5%) had delayed healing, and 5 (14.28%) required therapeutic keratoplasty, whereas in the conventional treatment group, 26 (74.28%) healed, 2 (5.7%) had delayed healing, and 7 (20%) needed keratoplasty (P = 0.65, 0.72, 0.54, respectively). Topical 1% PCZ therapy of chronic mycotic keratitis was helpful in resolution in 85.7% of cases (30 eyes) with five eyes needing surgical intervention, which was comparable to that of conventional antimycotic therapy cohorts. Fusarium isolates showed greater susceptibility to natamycin in our study per MIC50 values, with susceptibility to the common antimycotic agents varying between the Aspergillus spp. in both PCZ treatment and conventional treatment groups. All isolates showed minimal values of MIC-50 with PCZ. Antifungal susceptibility testing in our study recruits showed that about 90% of the Fusarium spp. isolates to be best responsive to natamycin and PCZ, whereas Aspergillus niger isolates were sensitive to voriconazole, itraconazole, amphotericin B, and PCZ, Aspergillus flavus to voriconazole and PCZ, Aspergillus fumigatus to both polyenes and triazoles. Cladosporium spp. were best sensitive to natamycin and PCZ, Penicillium spp. to natamycin and azoles. Alternaria keratitis isolates were sensitive to voriconazole and PCZ, whereas Rhizopus isolate was best sensitive to PCZ.

Conclusion: Topical 1% PCZ therapy in refractory fungal keratitis was comparable to that of conventional antimycotic agents, with lower MIC-50 against the common pathogenic fungi as compared to natamycin, amphotericin B, and voriconazole.

Scleral-fixated intraocular lens (SFIOL) is a widely used technique for IOL implantation in patients where capsular support is insufficient. Most surgeons have shifted away from sutured to sutureless SFIOL techniques where haptics of a multifocal IOL are inserted in scleral tunnels/flaps. Large-scale publications have shown wide variation in the refractive status of eyes post-SFIOL even in the best of the hands. This is because even slight variations in the site of scleral flap/tunnel formation and tension on haptics due to the variable length of haptics placed in scleral flaps/tunnels can alter the effective lens position and induce significant residual refractive error, especially cylindrical astigmatism due to IOL tilt. Our technique aims to reduce residual refractive error after SFIOL implantation. This is achieved by using intraoperative aberrometry and adjusting haptics accordingly to achieve minimal refractive error intraoperatively.

Purpose: To study the clinical profile of patients with microspherophakia and the factors associated with poor vision following lensectomy surgery.

Methods: A multicenter, retrospective, cross-sectional analysis was conducted from January 2010 to June 2022 on patients diagnosed with microspherophakia.

Results: A total of 102 eyes from 51 patients were enrolled, of whom 24 (47.1%) were male and 27 (52.9%) were female. All patients presented with bilateral involvement. The most common presenting complaint was defective vision, affecting 98 (96.1%) eyes. Patients exhibited varying degrees of lenticular myopia, with a mean refractive error of -13.54 ± 11.92 D. Glaucoma was present in 36 (35.3%) eyes at presentation. Subluxation of the crystalline lens was observed in 50 (49.1%) eyes, dislocation of the lens into the anterior chamber in 24 (23.5%) eyes, and dislocation into the vitreous cavity in 4 (3.9%) eyes. Limbal or pars plana lensectomy was performed in 54 (52.9%) eyes. The mean corrected visual acuity improved from 1.05 ± 0.82 logMAR units to 0.82 ± 0.79 logMAR units after lensectomy (P = 0.029). Poor postoperative visual acuity (less than 20/200) was associated with poor preoperative visual acuity (P = 0.005), presence of glaucoma at the first visit (P = 0.013), and intraocular pressure >30 mmHg (P < 0.001).

Conclusion: Microspherophakia is associated with high lenticular myopia, subluxation, and dislocation of the crystalline lens. Significant improvement in postoperative vision was observed after lensectomy. Factors associated with poor postoperative vision included poor preoperative corrected vision, presence of glaucoma, and high intraocular pressure.

Purpose: To study change in the contact of intraocular lens (IOL) with the posterior capsule with respect to the vertical versus horizontal orientation of the haptic-optic junction of the IOL using intraoperative spectral domain optical coherence tomography (SD-OCT).

Methods: Fifty eyes of 50 patients with senile immature cataract underwent topical phacoemulsification procedure with implantation of a monofocal IOL by a single experienced surgeon. The Rescan 700 SD-OCT system was used for intraoperative imaging. These patients were imaged using intraoperative SD-OCT after implantation of IOL, with the haptics oriented horizontally and then vertically.

Results: The vertical height between the posterior surface of the lens capsule and the posterior surface of IOL reduced significantly when the haptics were oriented vertically compared to horizontal orientation. This difference was found on analyzing both vertical as well as horizontal axis scans.

Conclusion: We found a greater contact between the posterior capsule and the posterior surface of IOL, with the haptic optic junction of the IOL oriented vertically. This study also suggests the need for newer toric IOL designs which allow vertical orientation of haptics, leading to better contact between IOL and the bag.

Purpose: This study aims to assess the effectiveness of atropine 0.05% for myopia control among children exhibiting (documented) rapid myopia progression (>0.75D/year).

Methods: This prospective interventional single-arm clinical trial included children aged between 6-12 years, spherical equivalent refractive (SER) error between - 2 and - 6D, and having documented myopia progression of >0.75D in the preceding year. All participants were administered atropine 0.05% in both eyes once at bedtime for 1 year. The primary outcome measure was a change in the rate of myopia progression (D/year) and change in SER and axial length (AL) at 1 year and documentation of any adverse effects related to therapy.

Results: Forty children were enrolled with a mean age of 8.5 ± 2.2 years. (45% male) The mean SER 1 year before starting atropine treatment was -3.53 ± 0.78D. At baseline, the mean SER was -4.58 ± 1.03D, which increased to -4.98 ± 0.97D after 1-year follow-up. The study reported a 62% reduction in the rate of myopia progression after 1 year of atropine 0.05% treatment (-1.05 ± 0.21D/year [baseline] to - 0.4 ± 0.14D/year[1-year follow-up] [P < 0.001]). The mean AL increased from 24.98 ± 2.43 mm (baseline) to 25.21 ± 2.32 mm (1 year). There was no significant correlation between changes in AL and SER (r: 0.57; P: 0.063). The study observed the response to treatment was independent of the age at baseline, baseline refractive error, baseline rate of progression, gender, and family history of myopia. No adverse effects from atropine 0.05% were reported.

Conclusions: Atropine 0.05% could be an effective treatment for children with rapidly progressing myopia with no significant side effects.