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Background Topiramate (TPM) is a drug commonly used by neurophysicians and psychiatrists for a plethora of indications. Topiramate has been reported to induce acute angle closure glaucoma as an adverse effect. However, there is limited literature on Topiramate causing hypopyon uveitis and intense ocular inflammation. It is imperative for ophthalmologists as well as physicians to be aware of the potential sight threatening ocular adverse effects of Topiramate. We report 2 rare consecutive cases of severe hypopyon uveitis and choroidal detachments after using Topiramate. Case presentation Two patients presented with sudden onset of angle closure, bilateral hypopyon uveitis and choroidal detachments. On reassessing a detailed treatment history, it was found that both patient were taking oral Topiramate which had been started 2 weeks before the onset of ocular symptoms. The bilateral hypopyon and angle closure were considered to be induced by Topiramate and the drug was discontinued. The patients were started on oral and topical steroids which led to resolution of hypopyon uveitis and choroidal detachments. The visual acuity improved and the intraocular pressure also got normalised in both the cases. Conclusions Topiramate can lead to a bilateral hypopyon uveitis and severe ocular inflammation. An urgent cessation of topiramate along with topical and systemic steroids is required to prevent serious complications.

Gut bacterial microbiome dysbiosis in type 2 Diabetes Mellitus (T2DM) has been reported, but such an association with Diabetic Retinopathy (DR) is not known. We explored possible link between gut bacterial microbiome dysbiosis and DR. Using fecal samples of healthy controls (HC) and people with T2DM with/without DR, gut bacterial communities were analysed using 16S rRNA gene sequencing and data analysed using QIIME and R software. Dysbiosis in the gut microbiomes, at phyla and genera level, was observed in people with T2DM and DR compared to HC. People with DR exhibited greater discrimination from HC. Microbiomes of people with T2DM and DR were also significantly different. Both DM and DR microbiomes showed a decrease in anti-inflammatory, probiotic and other bacteria that could be pathogenic, compared to HC, and the observed change was more pronounced in people with DR. This is the first report demonstrating dysbiosis in the gut microbiome (alteration in the diversity and abundance at the phyla and genera level) in people with DR compared to HC. Such studies would help in developing novel and targeted therapies to improve treatment of DR.

AIM: To summarize the experience of response to COVID-19 outbreak at a tertiary eye care institute and its network of health facilities in India. METHODS: Our responses are based on the principles of social distancing, hand hygiene, respiratory etiquettes, surface disinfection protocol, and rational use of appropriate personal protective equipment (PPE). We describe our response in terms of administrative controls, clinical protocols, staff protection, environmental controls, and social distancing measures. We also discuss our communication strategies and monitoring systems, to ensure compliance to protocols. RESULTS: Administrative control is mainly related to formation of task force and its functions. Clinical protocols are related to patient triaging methods and clinical examination guidelines in Outpatient, Inpatient and Operating Room. Staff protection is focused on training staff on the protocols to be followed in hospital as well as at home, and use of PPE. Environmental protocol is focused on cleaning and disinfectant methods to be used in the hospital. In addition, there are systems for communication as well as monitoring compliance to protocols. CONCLUSION: We hope that these protocols and our experience would help the ophthalmic community globally and serve as a guide to protect ophthalmologists and ophthalmic care personnel, and their patients across the world.

Purpose: To describe a series of sight-threatening ocular and adnexal involvement associated with dengue hemorrhagic fever and their treatment options. Methods: Retrospective, interventional, non-comparative case series. Medical records of patients who presented with ocular symptoms attributed to dengue hemorrhagic fever were reviewed. Demography, presenting features, and treatment outcomes were recorded. Outcome measures assessed included globe salvage, vision salvage, and visual improvement. The outcome was deemed as favorable if vision salvage was possible and unfavorable if the vision was lost. Results: Twenty-nine eyes of 23 patients were included. Bilateral ocular involvement was seen in 6 (26%) patients. The mean age was 37.62 ± 18.68 years (range: 14 to 81 years). Coexistent diabetes mellitus and enteric fever were present in three patients. History of blood transfusion was present in nine (40%) and thrombocytopenia in eight (35%) patients at the time of presentation with ocular complaints. Presenting features included endophthalmitis in 11 (38%), panophthalmitis in 10 (35%), orbital cellulitis with panophthalmitis in four (14%), isolated corneal or scleral melt in three (10%), and orbital hemorrhage with panophthalmitis in one (3%) patient. Globe salvage was achieved in 21/29 eyes (72.4%), vision salvage in 6/29 eyes (20.68%), and improvement in visual acuity was noted in 5/29 eyes (17.24%). Logistic regression analysis revealed no significant effect of any clinical-microbiological factors on globe salvage, vision salvage, and visual improvement. However, visual improvement and globe salvage were possible in eyes that underwent early endoscopic vitrectomy. Conclusion: Dengue fever can present with sight-threatening ocular and adnexal inflammation resulting in endophthalmitis and panophthalmitis, orbital cellulitis, corneal and scleral melt, and orbital hemorrhage. Early vitrectomy may improve vision and globe salvage in cases with significant vitritis.

Optimal visualization is one of the most challenging aspects of performing vitreoretinal surgery. In situations where conventional microscopic techniques provide poor posterior visualization, the adjunctive skill set of endoscopic visualization may be needed. This allows for by-passing the opaque anterior segment media and getting access to the posterior segment pathology. Endoscopic vitrectomy is a useful and unique adjunct to microincision vitreoretinal surgery. The optical set-up of endoscopy allows for clinical approaches that are impossible with regular microscope viewing systems. These include the ability to observe across optically significant anterior segment opacities and directly visualize the posterior segment of the eye. It also allows for visualizing the difficult-to-access retroirideal, retrolental, and anterior retinal structures. Surgical access to anatomic spaces like the pars plana, pars plicata, ciliary sulcus, ciliary body, and peripheral lens is tedious. This is made simpler by endoscopy. In this review, we summarize and review the usage of the intraocular endoscope as a diagnostic and therapeutic armamentarium across a wide spectrum of ocular pathologies.

Purpose: To document the clinical features, systemic association, and treatment outcome of patients with a combined retinal vein and artery occlusion (CRVAO) and review of literature. Methods: A retrospective chart review of patients diagnosed with CRVAO at a tertiary eye care center. Patient's demographic details and associated ocular and systemic factors were recorded. Treatment included laser photocoagulation, anti-vascular endothelial growth factor (VEGF) intravitreal injection or transscleral cyclophotocoagulation (TSCPC), alone or in combination. At last, follow- up treatment response was measured in visual acuity status, regression of neovascularization, and control of intraocular pressure (IOP). All cases reported in the current decade were analyzed and compared with this study. Results: Seventeen eyes with CRVAO accounted for 0.3% of total vascular occlusion (total 5151 patients were seen in this period). The mean age was 48.12 ± 17.5 years (range: 12-87 years) and there were 9 females. Nine eyes had CRVO + CRAO; 6 eyes had BRVO + BRAO, and one patient each had CRVO + BRAO and CRAO + BRVO. Fluorescein angiography (FA) showed delayed 'arm to retina' time (>20 seconds) in all 10 eyes and delayed arteriovenous transit time in 9 out of 10 eyes. Optical coherence tomography (OCT) showed hypereflective inner retinal layers (16 eyes) and neurosensory detachment (7 eyes). The most common systemic associations were hypertension and dyslipidemia (n = 7 people; 41.18%) each. Four patients (23.5%) had a plaque in carotid arteries with normal 2D echocardiography. Ten (59%) eyes were treated with intravitreal bevacizumab + laser; four (23.5%) eyes were treated with laser only, and three (17.6%) eyes were treated with laser + anti-VEGF + TSCPC. At last follow up, vision improved in 9 (52.9%) eyes; stable in 3 (17.7%) eyes, and reduced to perception of light in 5 (29.4%) eyes. Conclusion: Combined CRVAO is a rare emergency leading to acute vision loss. Early diagnosis and treatment for ocular complications and systemic evaluation for cardiovascular risk factors are needed.

Objective To describe a series of prompt endoscopic vitrectomy in eyes with post-trauma endophthalmitis and hazy cornea. Methods Retrospective consecutive interventional case series. Cases of endophthalmitis with hazy cornea which underwent prompt endoscopic vitrectomy were analyzed. The study period was from August 2018 to April 2019. The final anatomic and functional outcomes are reported here. Results Four eyes of four patients were included. Mean age at presentation was 24.50±21.29 years (median 24 years). All cases were post-open globe injury. Microbiology showed smear positivity in 3/4 (75%) and culture positivity in 2/4 (50%). The antibiotic susceptibility was 100% for vancomycin and ceftazidime. Mean follow-up was 7.75±1.7 months (median 7.5 months). Favorable anatomic outcome was seen in 100% of cases and favorable functional outcome in 75% cases. Conclusion Endoscopic vitrectomy allows for early intervention in endophthalmitis post open-globe injuries. This enables early resolution of infection and avoids a need for unnecessary corneal interventions.

Purpose: The aim of this study was to compare the management outcome of endophthalmitis with and without the use of topical antibiotics. Methods: A retrospective comparative chart review of 2 cohorts of endophthalmitis (other than those associated with open-globe injury, keratitis, or wound site infection), one managed with topical antibiotics (TA group) and one without (NTA group), was performed. Results: The study included a total of 270 eyes of 270 patients. Of these, 169 eyes were in the TA group and 101 were in the NTA group. Post-cataract surgery was the most common etiology, accounting for 81.06 and 78.2% of cases, respectively ( p = 0.57). A favorable functional outcome at the last visit was seen in 37.5 and 39.6% of eyes ( p = 0.73), and a favorable anatomic outcome was noted in 61.2 and 49.5% of eyes ( p = 0.06), respectively. The median follow-up was 3.5 and 9 months, respectively ( p < 0.0001). Susceptibilities to the common antibiotics used (vancomycin, ceftazidime, and amikacin) were comparable, with the exception of imipenem, for which the susceptibility noted was 95 and 66%, respectively ( p = 0.01). Culture positivity in the TA group was seen in 72 out of 169 eyes (42.6%), while in the NTA group it was seen in 98 out of 101 eyes (97.02%; p < 0.0001). Conclusion: Topical antibiotics do not give any added advantage in the management of endophthalmitis otherwise being treated with intravitreal antibiotics and standard vitrectomy techniques.

To analyze the distribution of diabetic retinopathy (DR) lesions in an Indian population using ultra-wide field (UWF) fundus imaging. Seven hundred fifteen subjects (1406 eyes) with diabetic retinopathy in India were enrolled in this multicenter, prospective, observational study using UWF pseudocolor imaging with Optos Daytona Plus (Optos plc, Dunfermline, Scotland, UK). Images were transmitted to Doheny Image Reading Center, Los Angeles, CA, for grading. The ETDRS grid was overlaid on stereographic projections of UWF images, and images were graded independently by 2 masked graders. Lesion distribution was graded as predominantly central (PCL) or predominantly peripheral (PPL) according to previous criteria, considering both lesion number and area. An image was graded as PPL if > 50% of the lesion area was seen in at least one peripheral field as compared with the corresponding ETDRS field. Diabetic retinopathy severity was also assessed based on the International Classification of Diabetic Retinopathy (ICDR) grading scale. The main outcome measures were lesion distribution (PPL versus PCL): overall and within specific fields in eyes with various grades of DR. Lesion distribution was rated to be PPL in 37% of eyes and PCL in 63% of eyes (P

Ocular tuberculosis can manifest in a wide variety of clinical presentations. The prevalence is higher in endemic areas as a cause of granulomatous uveitis. While posterior segment manifestations are well known, anterior segment granulomas alone are relatively rare. We report two cases of unilateral iris granulomata in two young patients who presented with decreased vision and redness and were found to have well-circumscribed iris granulomas. Both underwent systemic evaluation and had a negative Mantoux test. Biopsy pathology of the lesions revealed granulomatous inflammation but were negative for PCR, staining, and culture for TB. One patient turned out to have multiple pulmonary lesions. The ocular condition initially worsened with steroid therapy alone and improved and resolved completely after starting a 9 months course of anti-tubercular therapy (ATT).

Purpose: To report the clinical presentation, microbiology, and management outcome of endogenous endophthalmitis in Indian patients. Methods: Retrospective chart review of culture-positive (vitreous/urine/blood) endogenous endophthalmitis cases treated in tertiary eye care facility in India was done. Results: The study included 173 eyes of 117 patients. Mean patient age was 25.41 ± 20.46 years (median 24 years). Pre-disposing systemic illness could not be elicited in 79 (67.63%) patients. Commonest predisposing systemic condition in patients where it could be detected (n = 79) was pyrexia of unknown origin (25/79 = 32.0%). Following treatment, 45 out of 173 (26.0%) eyes regained vision of ≥20/400. Commonest isolated organism from vitreous was Streptococcus pneumoniae (36 eyes, 20.8%) and fungi were isolated in 24 (13.8%) eyes, the commonest being Candida spp. (8/24, 33.33%). Favorable functional outcome was seen in 26% eyes and favorable anatomic outcome in 43% eyes. Those with an underlying systemic illness were older (P = 0.02), had greater urine culture positivity (P = 0.003), lesser vitreous culture positivity (0.001), greater gram negative etiology (P = 0.0006), and greater fungal etiology (P = 0.01) as compared to those cases without underlying systemic illness. Conclusion: Endogenous endophthalmitis in India often presents in young immunocompetent individuals without any underlying systemic illness and with negative blood or urine microbiologic work up. Underlying systemic illness leads to greater gram-negative and fungal etiology. Overall visual outcome is poor inspite of prompt management.

International audience; Purpose: To correlate structural changes of combined hamartoma of the retina and retinal pigment epithelium (CHRRPE) with patient age. Design: Retrospective study. Participants: Fifty eyes of 49 patients (age range, 1–74 years) with CHRRPE studied at 9 tertiary vitreoretinal institutions. Methods: We analyzed the clinical findings with respect to lesion topography and pigmentation as well as investigated the OCT findings regarding the thickness, vitreoretinal interface, outer plexiform layer distortion, ellipsoid zone disruption, and retinal pigment epithelium–Bruch's membrane complex involvement of CHRRPE. Main Outcome Measures: Clinical and imaging findings of CHRRPE at different ages. Results: Analysis of 50 CHRRPE patients revealed that younger patients were more likely to demonstrate partial thickness involvement of the retina (P = 0.009) with predominantly inner retinal layer involvement (P = 0.04). The inverse was true for older patients with CHRRPE. In addition, older patients more commonly showed pigmentary changes. Eyes with CHRRPE were more likely to show an increase in central macular thickness independently of tumor location. Conclusions: Based on these findings, we believe that CHRRPE typically begins in the inner retina and continues toward the outer retina over time, with increase in central macular thickness, despite the location of the tumor.

The virome of ocular fluids is naive. The results of this study highlight the virome in the vitreous fluid of the eye of individuals without any ocular infection and compare it with the virome of the vitreous fluid of individuals with retinitis. A total of 1,016,037 viral reads were generated from 25 vitreous fluid samples comprising control and post-fever retinitis (PFR) samples. The top 10 viral families in the vitreous fluids comprised of Myoviridae, Siphoviridae, Phycodnaviridae, Herpesviridae, Poxviridae, Iridoviridae, Podoviridae, Retroviridae, Baculoviridae, and Flaviviridae. Principal coordinate analysis and heat map analysis clearly discriminated the virome of the vitreous fluid of the controls from that of the PFR virome. The abundance of 10 viral genera increased significantly in the vitreous fluid virome of the post-fever retinitis group compared with the control group. Genus Lymphocryptovirus, comprising the human pathogen Epstein-Barr virus (EBV) that is also implicated in ocular infections was significantly abundant in eight out of the nine vitreous fluid viromes of post-fever retinitis group samples compared with the control viromes. Human viruses, such as Hepacivirus, Circovirus, and Kobuvirus, were also significantly increased in abundance in the vitreous fluid viromes of post-fever retinitis group samples compared with the control viromes. The Kyoto Encyclopedia of Genes and Genomes (KEGG) functional analysis and the network analysis depicted an increase in the immune response by the host in the post-fever retinitis group compared with the control group. All together, the results of the study indicate changes in the virome in the vitreous fluid of patients with the post-fever retinitis group compared to the control group.

To describe disease characteristics and outcomes of Vogt-Koyanagi-Harada (VKH) syndrome in paediatric patients.Retrospective chart analysis.Analysis of all patients ≤16 years with VKH syndrome was done. Clinical presentations, complications, recurrences and outcomes in cases of paediatric VKH were reviewed.72 eyes of 36 patients with a mean age at presentation of 13.7 ± 2.34 years were assessed. Mean duration of symptoms and follow up were 9.88 ± 17.3 weeks and 55 months respectively. Clinical signs at presentation included anterior chamber cells2+(34/72eyes, 47.2%), granulomatous keratic precipitates (6 eyes, 8.3%), posterior synechiae (35 eyes,48.6%), disc edema (46 eyes, 63.8%), neurosensory retinal detachments (44 eyes, 61.1%) and 'sunset-glow' fundus (9 eyes, 12.5%). Best corrected visual acuity (BCVA) at the time of presentation was 1.3logMAR or a Snellens equivalent of 20/400 which improved to 0.51logMAR (Snellens equivalent of 20/63) at last follow up. Remission was achieved in 61.1% cases. More than half of our patients developed one or more complications.VKH in paediatric patients poses a challenge due to a delayed presentation and paediatric VKH patients have a worse visual acuity at the time of presentation as compared to adult age groups. Rates of remission may be low along with high risk of complications and hence there is a need for prolonged immunosuppression.

Purpose To evaluate the vascular structure within combined hamartoma of retina and retinal pigment epithelium (CHRRPE) lesions using OCT angiography (OCTA). Design Multicenter, retrospective, observational analysis, Participants Twenty eyes of patients diagnosed with CHRRPE. Methods Retrospective analysis of color fundus photographs, OCT, and OCTA of 20 eyes with CHRRPE. Morphologic characteristics of CHRRPE and the OCT features were correlated with the density of the filigree vascular pattern and with the published histopathologic findings of CHRRPE lesions. Main Outcome Measure Density of flow signals, that is, the filigree vascular pattern seen on OCTA in the deep capillary plexus, graded as high (>20), intermediate (10–20), or low ( Results Of 20 lesions, 11 were peripapillary, 8 were macular, and 1 was equatorial in location. A high density of filigree vascular pattern was observed in most peripapillary CHRRPE lesions, which also showed full-thickness retinal involvement (8/10). A low density of filigree pattern was seen in macular lesions, which showed partial-thickness retinal involvement and preretinal fibrosis (5/6). Conclusions A filigree vascular pattern on OCTA is seen in CHRRPE lesions. High density of this pattern is noted in CHRRPE lesions with a peripapillary location, full-thickness retinal disorganization, and minimal preretinal fibrosis. These findings correlate well with published histopathologic findings of CHRRPE lesions both in terms of topographic and morphologic features. OCT angiography provides a promising method for further study of these lesions.

Purpose To compare the clinical outcomes of Boston Type I keratoprosthesis (Boston Kpro) with its low-cost version, the Aurolab Kpro (auroKPro). Design Retrospective comparative case series. Methods This study included 134 eyes of 130 patients with severe bilateral corneal blindness but with wet ocular surfaces. The patients underwent either Boston Kpro (n = 78) or auroKPro (n = 56) implantation based on the device availability and patient's affordability. The primary outcome measurements were anatomical retention (defined as absence of device extrusion, exchange, or explantation) and functional recovery of 20/200 or better visual acuity at yearly time points until 5-years of follow-up. Results Limbal stem cell deficiency was the most common indication (60.5%) for surgery, followed by multiple failed grafts (35%). Both groups were comparable at baseline with respect to indications for surgery and associated ocular co-morbidities (P > 0.05). The overall anatomical retention rates were similar in the Boston Kpro (55 of 78, 70.5%) and auroKPro (35 of 56, 62.5%) groups (P = 0.11). Kaplan-Meier survival rates at 5 years of follow-up were greater for the Boston Kpro with respect to both anatomical retention (63 ± 6% vs. 43.4 ± 10%, respectively; P = 0.057) and functional recovery (42.4 ± 6% vs. 32.2 ± 7%, respectively; P = 0.345), but these differences were not statistically significant. Complications such as intraoperative device breakage (7%) and postoperative extrusions (12.5%) were significantly more common with the auroKPro (P = 0.023). Conclusions Both the auroKPro and the Boston Kpro are effective treatment options for patients with severe bilateral corneal blindness. The auroKPro can be considered an alternative to the Boston Kpro when affordability or availability of the Boston Kpro is a limiting factor.

To evaluate the anatomical and visual outcomes of inverted flap technique of peeling of internal limiting membrane (ILM) versus standard peeling of ILM for macular holes of basal diameter more than 800 μm.Patients with very large idiopathic macular holes more than 800 μm in basal diameter (ranging from 243 μm to 840 μm in minimum diameter) were retrospectively included in the study. In Group A, 18 eyes of 18 patients underwent ILM peeling using the inverted flap technique. In Group B, 18 eyes of 18 patients underwent conventional ILM peeling. The primary endpoint was the rate of hole closure at 6 months after surgery. The secondary outcome measure was the change in best-corrected visual acuity at 6 months after surgery.There were no significant differences in ocular characteristics of the study groups at baseline except for the age distribution. Mean macular hole diameter was 1,162.8 ± 206.0 μm and 1,229.6 ± 228.1 μm in Group A and Group B, respectively. The hole closure rate was 88.9% (16/18) in Group A and 77.8% (14/18) in Group B (P = 0.66). The mean gain in best-corrected visual acuity was higher in Group A than in Group B (P = 0.12) at 6 months, but this was not statistically significant. There were no severe ocular adverse events in either group.In this multicenter series, inverted ILM flap technique did not lead to significantly higher anatomical closure rates than conventional ILM peeling in large macular holes more than 800 μm in diameter.

To review the clinical profile and report the microbiology and treatment outcomes of endophthalmitis following suture removal.In this multi-center, retrospective interventional case series, 11 eyes of 11 patients who developed endophthalmitis following suture removal from January 2006 to December 2017 were reviewed.Nine of the 11 patients developed a culture-proven, acute onset endophthalmitis [5.3 ± 3.1 days (range 2-10 days)]. Mean age was 15.8 ± 21.2 years (median 7; range, 1-66 years). Presenting visual acuity was extremely low ranging from light perception (PL) to counting fingers close to face (CFCF) at the time of diagnosis of endophthalmitis. Out of the 11 patients, 8 belonged to the pediatric age group; four out of those eight had loose sutures secondary to cataract surgery, two patients had loose sutures secondary to penetrating keratoplasty and 1 case each had loose sutures secondary to corneal tear repair and secondary IOL implantation, respectively. Streptococcus pneumoniae was the most common organism and was identified in seven cases and was susceptible to vancomycin in all these cases. Other bacterial isolates were Haemophilus influenzae and Achromobacter denitrificans. Three out of the 11 eyes had visual outcome of 20/200 or better. Six eyes were phthisical and one eye was eviscerated. Mean follow-up was 26.3 ± 31.2 weeks (range 2-92 weeks). Visual outcomes ranged from 20/40 to no light perception at the last follow-up.Endophthalmitis following suture removal though rare, is observed most commonly in the pediatric population and has an acute and a fulminant course. Streptococcus pneumoniae was the most commonly isolated microorganism. Visual acuity outcomes were poor despite prompt recognition of endophthalmitis and appropriate antibiotic therapy.

Purpose To report the presentation and management outcomes of endophthalmitis with endoscopic vitrectomy. Methods This is a retrospective interventional case series conducted at a tertiary eye care center in south India. Thirty three eyes of 33 patients were included. The medical records of the patients who underwent endoscopic vitrectomy for endophthalmitis from April 2014 to March 2018 were reviewed. Data with regard to age, gender, etiology of endophthalmitis, corneal and retinal examination, type of intervention, final anatomic and visual outcome, and the total follow-up were collected. The main outcome measures were the final visual acuity and evisceration rates. Results The mean age at presentation was 46.84±19.89 years, with a median age of 50 years. Based on etiology, 13 eyes (39.4%) were post-trauma endophthalmitis, eleven eyes (33.33%) were post-cataract surgery, three eyes (9.09%) were endogenous, three eyes (9.09%) were post-perforated corneal ulcer, two eyes (6.06%) were post-retinal surgery, and one eye (3.03%) was post-combined cataract and corneal surgery. Twenty-four eyes (72.72%) had a favorable anatomic outcome at the last visit, and five eyes (15.15%) had a favorable visual outcome. Of those with unfavorable visual outcome, ten eyes had further visual potential. Sixteen eyes (48.48%) showed a positive culture on microbiologic evaluation. The predominant organism isolated was Pseudomonas aeruginosa. Evisceration was required only in one eye (3.03%). Conclusion Endoscopic vitrectomy allows early management of endophthalmitis in spite of hazy media. This ensures a reasonable visual outcome, controls the infection, and reduces the incidence of evisceration in these eyes.

Purpose: To describe clinical presentations and comparative outcomes of primary versus deferred intraocular lens (IOL) explantation in delayed-onset endophthalmitis. Methods: In this retrospective study, a total of 77 eyes of 77 patients that were diagnosed clinically as delayed-onset endophthalmitis and underwent IOL explantation from January 1990 to January 2018 were included undiluted vitreous biopsy and IOL were subjected to microbiologic evaluation. Duration of symptoms, presenting visual acuity, organisms isolated, time to IOL explantation, time to endophthalmitis, resolution after explantation, number of repeat intravitreal injections, and final visual acuity were compared in the primary and the deferred IOL explantation groups. Results: There were primary and deferred IOL explantations. Interval between inciting event and endophthalmitis, between onset of symptoms to presentation, total follow-up, complication rate, and final visual acuity was comparable between the two groups. Median time to IOL explantation in the deferred group was 70 days. Between the primary and deferred IOL explantation groups the number of repeat intravitreal injections was 0.58 ± 0.86 and 2.62 ± 1.78 respectively, (P < 0.0001, 95% confidence interval, CI 2.00–2.22); the number of days to resolution after IOL explantation was 35.16 ± 14.26 and 55.5 ± 8.24 respectively, (P < 0.0001, 95% CI 15.22–25.45). Conclusion: Early IOL explantation in delayed-onset endophthalmitis causes faster clinical resolution and reduces the number of repeat intravitreal injections. Final visual improvement, however, may be unaffected.

Purpose: The sub-retinal injections are not very commonly performed procedures in vitreoretina, but form a crucial step in any cell replacement therapy for retinal diseases. The purpose of this study is to describe the learning curve of a trained vitreo-retinal surgeon in sub-retinal injections in a rat model and its implications in future clinical trials. Methods: This is an in-vivo retrospective animal study using Wistar rats. All ARVO guidelines regarding animal handling were followed. After anesthetization, aspectic preparation and dilating the pupils with 1% tropicamide eye drops, subretinal injection of 10 μl saline was done via a limbal entry. Data recorded included time taken for the procedure, success of injection, associated complications, post-operative infections and complications. The rats were followed up for 1 month post procedure. A trend analysis was done for the above factors to look for improvement in ease of procedure, reduction in procedure time and reduction in complications for the clinician using a novel objective scale. Results: About 20 eyes were studied. Mean weight of the rats was 188 ± 12.82 gram. Mean time taken for the procedure was 14.1 ± 5.07 minutes. There was a significant inverse co-relation between the serial number of the eye and time taken for the procedure (r = −0.89, P < 0.0001). Comparative complications noted between the first ten and the last ten eyes were: conjunctival tear 30% versus 10% (P = 0.27), lens touch 50% versus 10% (P = 0.05), subretinal hemorrhage 40% versus 0% (P = 0.13), vitreous loss 30% versus 0% (P = 0.06). The successful subretinal injection without intraocular complications was achieved in 40% versus 90% (P = 0.02). There was a significant co-relation between the serial number of the eye and ease of the procedure (r = 0.87, P < 0.0001). Post operatively none of the eyes had any infection. Six eyes (12%) developed cataract and 3 eyes (6%) had non-resolving retinal detachment at the last examination visit. Conclusion: Subretinal injections in rats have a definite learning curve even for a trained vitreoretinal surgeon. This should be accounted for and resources allocated accordingly to achieve good technical comfort and negate confounding by the surgeon factor in the results of future clinical trials

Background Cytomegalovirus (CMV) retinitis in patients with Non-Hodgkin’s Lymphoma (NHL) can occur even in the presence of high CD 4 counts and can behave differently when compared to CMV retinitis in human immunodeficiency (HIV) patients. It, therefore, becomes important to understand its varied presentations and the challenges in management of these cases. The aim of this study was to analyse the various patterns of presentations and outcomes of CMV Retinitis in patients with NHL. Study design A retrospective chart review of seven eyes of four patients of NHL presenting with CMV retinitis between June 2017 and May 2020 was done. Methods Clinical patterns of CMV Retinitis, CD4 counts at the time of presentation and the duration of treatment along with recurrences and time for recurrence of retinitis were assessed. Results Granular or indolent retinitis (6 out of 7 eyes) was the commonest form of CMV retinitis in patients of NHL. Three patients had a presenting CD4 count above 150 cells/mm3 and none of them were below 50 cells/mm3. Floaters were the commonest presenting complaint. All patients had vitritis and majority of the patients (3 out of 4) had anterior chamber (AC) inflammation. Two out of the 4 patients had a recurrence (mean time 33.8 days) after stopping the maintenance phase of ganciclovir and one patient had significant myelosuppression related to oral valganciclovir which required discontinuation of the drug. Conclusion CMV retinitis in NHL patients is usually of an indolent or granular type and can occur even in the presence of high CD4 counts as compared to patients with HIV. These patients may require a long term maintenance in view of frequent recurrences after discontinuation of treatment.

Purpose: Vitrectomy with brilliant blue G (BBG) assisted internal limiting membrane (ILM) peeling is the standard operational technique in macular hole surgeries. However, BBG dye, though considered safe and nontoxic, can also occasionally lead to macular toxicity. This study aims to describe the clinical features and characteristics of four eyes who developed macular toxicity after following surgery for macular hole repair.Methods: Retrospective review of four consecutive cases of macular toxicity after conventional BBG assisted ILM peeling. All the cases reviewed, their operative surgical notes were retrieved and analyzed. The ILM was stained twice during surgery with prolonged intraoperative surgical time.Results: All four cases had a prolonged surgical time and the ILM was stained twice during surgery in all cases. The area of macular toxicity was corresponding to the area of ILM peeling which had been exposed to repeated staining by BBG dye. By the end of one month, all four cases had foveal thinning along with choriocapillary atrophy. The mean BCVA was 20/80 before surgery and the final mean visual acuity was

Long non‐coding RNAs (lncRNAs) are emerging as key regulators of endothelial cell function. Here, we investigated the role of a novel vascular endothelial‐associated lncRNA (VEAL2) in regulating endothelial permeability. Precise editing of veal2 loci in zebrafish (veal2 gib005Δ8/+) induced cranial hemorrhage. In vitro and in vivo studies revealed that veal2 competes with diacylglycerol for interaction with protein kinase C beta‐b (Prkcbb) and regulates its kinase activity. Using PRKCB2 as bait, we identified functional ortholog of veal2 in humans from HUVECs and named it as VEAL2. Overexpression and knockdown of VEAL2 affected tubulogenesis and permeability in HUVECs. VEAL2 was differentially expressed in choroid tissue in eye and blood from patients with diabetic retinopathy, a disease where PRKCB2 is known to be hyperactivated. Further, VEAL2 could rescue the effects of PRKCB2‐mediated turnover of endothelial junctional proteins thus reducing hyperpermeability in hyperglycemic HUVEC model of diabetic retinopathy. Based on evidence from zebrafish and hyperglycemic HUVEC models and diabetic retinopathy patients, we report a hitherto unknown VEAL2 lncRNA‐mediated regulation of PRKCB2, for modulating junctional dynamics and maintenance of endothelial permeability., The evolutionarily conserved lncRNA VEAL2 enhances junctional integrity in developing zebrafish vasculature and in hyperglycemic vascular endothelium in humans.

Purpose: Conventional cataract surgeries can be a challenge in eyes with microcorneas due to difficult manipulation in a crowded anterior chamber (AC) and can lead to a high occurrence of corneal edema and an increased rate of complications. Similarly, in cases of dense brunescent cataracts even a lensectomy through posterior approach may prove to be difficult because of inadequate visualization. An endoscopyassisted pars plana lensectomy can help in obviating these difficulties. This study aims to describe the surgical technique of endoscopy-assisted pars plana lensectomy in eyes with brunescent cataract, microcornea, and microphthalmos.Methods: Retrospective review of two cases where endoscopy-assisted pars plana vitrectomy and lensectomy was performed for patients with dense cataract and microcornea and microphthalmos.Result: Complete clearance of the cataract was achieved without having to resort to a sclerocorneal incision. Postoperatively the cornea was clear and there was no postoperative corneal edema.Conclusion: Endoscopy-assisted pars plana lensectomy can help in overcoming the challenges of conventional anterior and posterior approaches of cataract extraction in cases of microcornea with reduced intraoperative and postoperative complications.

A 45-year-old male patient, diagnosed elsewhere as retinal detachment, was seen in the retina services of our institute. There was no history of prior ocular trauma or surgery. His vision was 20/20 in his right eye and 20/125 in the left eye. There were no signs of any ocular inflammation and the

To compare the surgical outcomes of macular hole (MH) surgery performed by trainee surgeons using a three-dimensional heads-up display (3D HUD) versus a standard operating microscope (SOM). A retrospective review of all consecutive medical records patients operated on for MHs by a trainee surgeon between 2017 and 2020 using either 3D HUD or SOM was performed. Minimum hole diameter, maximum hole diameter, total surgical time, and MH closure rates were compared between the two groups. MH retinal detachments, traumatic MHs, and MHs for which inverted internal limiting membrane flaps were used were excluded from the study. Trainee surgeons operated on 51 patients using 3D HUD and 63 patients using SOM. Age at presentation, intraocular pressure (IOP) at diagnosis, maximum hole diameter, minimum hole diameter, surgical time, duration between diagnosis and surgery were comparable between both groups. MH closure rate was significantly (p

Purpose: To describe disease manifestations and outcomes of ocular syphilis in Asian Indian population. Methods: Retrospective analysis of patients diagnosed with ocular syphilis at a tertiary referral center in India. Demographics, history, extraocular and ocular manifestations, ocular and systemic investigations, treatment and visual acuity outcomes were noted. All patients were diagnosed after necessary laboratory investigations including HIV ELISA (Human immunodeficiency virus, enzyme-linked immunosorbent assay), VDRL (venereal disease research laboratory), and TPHA (treponema pallidum hemagglutination). Results: Totally, 20 patients with mean age at presentation 38.25 ± 9.76 were analyzed. 9/20 patients had bilateral involvement. 8/20 had concurrent HIV at presentation with an average CD4 counts of 592.25 ± 411.34 cells/microliter. The mean duration of symptoms at time of presentation was 15.45 ± 35.15 weeks. VDRL test was reactive in 45% (9/20) patients whereas, all patients had a reactive TPHA test. Clinical manifestations included outer retinal placoid chorioretinitis lesions (8/20, 40%), followed by retinitis mimicking acute retinal necrosis as the second most common phenotype (4/20, 20%). Other presenting manifestations noted were panuveitis, miliary retinitis lesions, retinal vasculitis, intermediate uveitis, and anterior uveitis. The clinical phenotypes in immunocompromised included panuveitis, acute retinal necrosis and isolated anterior uveitis. Mean follow up duration was 6.32 ± 6.15 months. An improvement in mean best corrected visual acuity (BCVA) of (0.63 LogMAR, approximately 6 Snellen lines, P < 0.02) was noted at last follow-up. Conclusion: Phenotypic manifestations of ocular syphilis are varied. Non-treponemal tests like VDRL may be unreliable when compared with treponemal tests in diagnosing ocular syphilis. Syphilitic uveitis is considered equivalent to neurosyphilis and is treated similar to neurosyphilis.

Purpose To describe the outcomes of endophthalmitis with opaque cornea managed with primary endoscopic vitrectomy and secondary keratoplasty. Methods Retrospective consecutive interventional case series. All cases of endophthalmitis with opaque cornea which underwent endoscopic vitrectomy followed by secondary keratoplasty were analyzed. The study period was from Jan 2015 to March 2019. The outcome measures were resolution of infection, the magnitude of unnecessary keratoplasties avoided and corneal graft survival. The final anatomic and functional outcomes were reported and compared with relevant literature. Results Seventy-eight eyes of 78 patients underwent endoscopic pars plana vitrectomy for endophthalmitis with the opaque cornea, of these 14 eyes of 14 patients were deemed eligible for further corneal intervention and were included in the study. The mean age at presentation was 42.27 ± 21.6 years (median 36 years). Etiology-wise, eight cases (57.14%) were post-trauma, three cases (21.42%) post-keratoplasty, two cases (14.28%) were endogenous, and one case (7.14%) following corneal dermoid excision and wound melt. Culture positivity was in 5/14 (35.71%). The mean interval between endoscopic vitrectomy and keratoplasty was 5.42 ± 2.69 months (median 3.5 months). The mean follow-up noted was 20.42 ± 11.45 months (median 17.5 months). The infection resolved in 100% of cases. Unnecessary keratoplasties were avoided in 64/78 (82%) cases due to the primary endoscopic intervention. The favorable anatomic outcome was seen in 11/14 (78.57%) of cases and favorable functional outcome in 8/14 (57.14%) cases. Conclusion Endoscopic vitrectomy allows for early intervention in endophthalmitis with the opaque cornea. This facilitates early settlement of infection, globe preservation, greater graft survival, and lesser repeat posterior segment procedures.

AimTo report the foveal cone count in eyes with resolved endophthalmitis vis-à-vis normal fellow eyes using an indigenous adaptive optics scanning laser ophthalmoscopy (AO-SLO).MethodsIn a prospective cross-sectional comparative pilot study, we recruited patients with resolved endophthalmitis in one eye (study eye) and a normal fellow eye (control eye). Collected data included measurement of the best-corrected visual acuity (BCVA), spectral-domain optical coherence tomography (OCT) imaging and AO-SLO imaging and cone counting at the fovea in both eyes.ResultsThe study included 12 eyes of 6 patients. The mean age was 51.66±11.97 years (median 56 years). BCVA in all control eyes was 20/20 (logarithm of the minimum angle of resolution (LogMAR) 0), and in the study, eyes was 0.21±0.13 (median 0.19, Snellen 20/30; p=0.001; 95% CI −0.39 to −0.09). The follow-up was 18.66±12.32 (median 20 months). The cone count at the fovea in the control eye was 4356.33±1993.93 (median 4498), and in the study eye, it was 2357.16±1541.17 (median 2187.5; p=0.03; 95% CI −3556 to −1082).ConclusionsEyes with resolved endophthalmitis with near-normal vision have reduced number of foveal cones even in absence of OCT-detected gross structural changes.Translational RelevanceThe current work describes the application of cellular-level imaging technique called adaptive optics scanning laser ophthalmoscopy (AO-SLO) to the clinical condition of resolved endophthalmitis. The study of retinal cell biology at the cellular level is possible using the emerging technology of AO-SLO. This new investigative modality that has the potential to image the retina at the cellular level until the photoreceptors is more likely to unravel the pathophysiology of a variety of retinal diseases.

Fibrocellular membrane or epiretinal membrane (ERM) forms on the surface of the inner limiting membrane (ILM) in the inner retina and alters the structure and function of the retina. ERM formation is frequently observed in ocular inflammatory conditions, such as proliferative diabetic retinopathy (PDR) and retinal detachment (RD). Although peeling of the ERM is used as a surgical intervention, it can inadvertently distort the retina. Our goal is to design alternative strategies to tackle ERMs. As a first step, we sought to determine the composition of the ERMs by identifying the constituent cell-types and gene expression signature in patient samples. Using ultrastructural microscopy and immunofluorescence analyses, we found activated microglia, astrocytes, and M&uuml, ller glia in the ERMs from PDR and RD patients. Moreover, oxidative stress and inflammation associated gene expression was significantly higher in the RD and PDR membranes as compared to the macular hole samples, which are not associated with inflammation. We specifically detected differential expression of hypoxia inducible factor 1-&alpha, (HIF1-&alpha, ), proinflammatory cytokines, and Notch, Wnt, and ERK signaling pathway-associated genes in the RD and PDR samples. Taken together, our results provide new information to potentially develop methods to tackle ERM formation.

PURPOSE: To report the application of endoscopy in the management of ocular trauma, describe the clinical settings and the treatment outcomes. METHODS: Retrospective, consecutive, non-comparative case series at a tertiary eye care centre. Data recorded included aetiology of trauma, presenting vision, corneal condition at presentation, per-operative clinical findings during endoscopy, prognostication of the cases on table, final visual and anatomic outcome. Odds ratios for a favourable outcome were computed for various surgical indications. RESULTS: The study included 58 eyes of 58 patients. Males constituted 82% of all cases. Mean age at presentation was 35.55 ± 18.9 years, median 31.5 years. Commonest corneal condition causing opaque media was corneal oedema (44.8%) followed by corneal laceration in 25.8%, repaired corneal laceration in 13.7% and scarred cornea in 12%. Commonest indication for surgery was retinal detachment (36.2%) followed by vitreous haemorrhage (29.3%), retained foreign body (13.7%) and combined detachment with haemorrhage in 10.3%. Of the 58 eyes, 17 eyes were deemed inoperable on endoscopic examination and 11 eyes were deemed to have poor prognosis. Of the fair prognosis (n = 30), 60% had final vision of 20/400 (p = 0.0001) compared to 10% before surgery and 13.33% had final vision of 20/40 (p = 0.03) as compared to nil in the pre-operative period. Odds ratio for a favourable visual outcome was best for the indication of vitreous haemorrhage (OR = 9, p = 0.0006). CONCLUSION: Endoscopy in ocular trauma with opaque media provides adequate visualisation and allows for prognostication. In cases deemed to have prognosis, suitable intervention leads to globe and vision salvage.

A 20-year-old man presented to us with injury to the left eye by a glass bulb 3 weeks ago. The acute injury resolved with a peculiar residual localised corneal oedema in the inferior one-third of the cornea . This localised oedema in absence of any evidence of a localised visible injury to the cornea indicated towards a possible retained foreign body. The foreign body visibility was equivocal on gonioscopy. Subsequently via a limbal incision, an endoscope was introduced into the anterior chamber. The endoscopic view revealed the glass foreign body lodged into the inferior angle of the eye which was removed with the help of an intraocular forceps. Over the next week, the corneal oedema resolved completely.

Vivek Pravin Dave,1 Deepika C Parmeshwarappa,1 Avantika Dogra,1 Rajeev Reddy Pappuru,1 Avinash Pathengay,2 Joveeta Joseph,3 Taraprasad Das1 1Smt. Kanuri Santhamma Center for Vitreoretinal Diseases, Kallam Anji Reddy Campus, LV Prasad Eye Institute, Hyderabad, India; 2Retina and Uveitis Service, GMR Varalakshmi Campus, LV Prasad Eye Institute, Visakhapatnam, India; 3Jhaveri Microbiology Center, LV Prasad Eye Institute, Hyderabad, IndiaCorrespondence: Vivek Pravin DaveSmt. Kanuri Santhamma Center for Vitreoretinal Diseases, Kallam Anji Reddy Campus, LV Prasad Eye Institute, Hyderabad, IndiaEmail vivekoperates@yahoo.co.inPurpose: To compare the outcomes of delayed-onset low-gradeendophthalmitis managed with and without intraocular lens (IOL) explantation.Setting: Tertiary eye-care research institute in southern India.Design: Retrospective comparative case series.Methods: The study included all cases of post-cataract surgery delayed-onset endophthalmitis from January 1990 to January 2019.Time to endophthalmitis,duration of symptoms, presenting visual acuity, time to IOL explantation when performed, resolution after explantation, number of intravitreal injections, and final visual acuity were compared in the IOL non-explanted and IOL explanted groups.Results: There were 115 eyes – 61 eyes in the IOL non-explant and 54 eyes in the IOL explant group. Between the two groups there was no statistically significant difference in age (58.37± 14.05 and 56.04± 14.96 years, respectively; p=0.35), vision at presentation (> 20/400 in 29.5%and 29.6% eyes, respectively; p=0.98), and the duration of follow-up (14.38± 16.05, median 8.5 months and 7.06± 3.55, median 6 months respectively; p=0.43).There was a statistically significant difference between the IOL non-explant and IOL-explant groups in the time to resolution of inflammation (92.70± 36.28 and 45.33± 11.2 days, respectively;p< 0.0001) and the number of intravitreal injections (4.57± 0.75, median 5 and 2.79± 2.11, median 2 respectively, p=0.005). Persistent/recurrent inflammation at 6 months was recorded in 18.03% and 5.55% in the IOL non-explant and IOL explant eyes, respectively (p=0.04). Favorable functional outcome was seen in 50.81%vs 68.51% in IOL non-explant and explant eyes, respectively (p=0.05).Conclusion: IOL explantation in delayed-onset endophthalmitis helps in earlier resolution of inflammation, need for lesser number of intravitreal injections and a trend towards better functional outcomes.Keywords: intraocular lens explantation, endophthalmitis, IOL, delayed-onset endophthalmitis, low-grade endophthalmitis

The complement system plays a crucial role in retinal homeostasis. While the proteomic analysis of ocular tissues in diabetic retinopathy (DR) has shown the deposition of complement proteins, their exact role in the pathogenesis of DR is yet unclear. We performed a detailed investigation of the role of the complement system by evaluating the levels of major complement proteins including C3, C1q, C4b, Complement Factor B (CFB), and Complement Factor H (CFH) and their activated fragments from both the classical and alternative pathways in vitreous humor and serum samples from proliferative DR (PDR) patients and controls. Further, the expressions of complements and several other key pro- and anti-angiogenic genes in the serum and vitreous humor were analyzed in the blood samples of PDR and non-PDR (NPDR) patients along with controls without diabetes. We also assessed the pro-inflammatory cytokines and matrix metalloproteinases in the vitreous humor samples. There was a significant increase in C3 and its activated fragment C3bα' (110 kDa) along with a corresponding upregulation of CFH in the vitreous of PDR patients, which confirmed the increased activation of the alternative complement pathway in PDR. Likewise, a significant upregulation of angiogenic genes and downregulation of anti-angiogenic genes was seen in PDR and NPDR cases. Increased MMP9 activity and upregulation of inflammatory markers IL8 and sPECAM with a downregulation of anti-inflammatory marker IL-10 in PDR vitreous indicated the possible involvement of microglia in DR pathogenesis. Further, a significantly high C3 deposition in the capillary wall along with thickening of basement membranes and co-localization of CFH expression with CD11b+ve activated microglial cells in diabetic retina suggested microglia as a source of CFH in diabetic retina. The increased CFH levels could be a feedback mechanism for arresting excessive complement activation in DR eyes. A gradual increase of CFH and CD11b expression in retina with early to late changes in epiretinal membranes of DR patients indicated a major role for the alternative complement pathway in disease progression.