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   2019| June  | Volume 67 | Issue 6  
    Online since May 24, 2019

 
 
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EDITORIAL
Do we need India-specific retinopathy of prematurity screening guidelines?
Santosh G Honavar
June 2019, 67(6):711-716
DOI:10.4103/ijo.IJO_973_19  PMID:31124474
  1,285 526 -
REVIEW ARTICLES
Coats disease: An overview of classification, management and outcomes
Mrittika Sen, Carol L Shields, Santosh G Honavar, Jerry A Shields
June 2019, 67(6):763-771
DOI:10.4103/ijo.IJO_841_19  PMID:31124484
Coats disease is an idiopathic retinal vascular disorder with retinal telangiectasia with intraretinal and/or subretinal exudation without appreciable retinal or vitreal traction. The condition is sporadic with no associated systemic abnormalities. Unilateral involvement in young males is the typical presentation with most cases being diagnosed in the first and second decade of life. Younger the patient, more severe is the presentation and poorer the visual outcome. The management varies with the stage of the disease. Over the years, we have shifted from enucleation to a more conservative approach for the treatment of Coats disease with laser photocoagulation, cryotherapy and surgery for retinal detachment achieving good outcomes. The anti-VEGF agents have come into the scene as important form of adjuvant treatment along with the traditional management options. This article describes the clinical features, underlying pathology, classification and staging, the complications and the management of Coats disease and gives an overview of the changing trends in treatment and outcomes spanning across five decades.
  892 357 -
GUEST EDITORIALS
The Indian Retinopathy of Prematurity (iROP) society: Challenges ahead
Anand Vinekar, Raj Vardhan Azad
June 2019, 67(6):722-722
DOI:10.4103/ijo.IJO_852_19  PMID:31124477
  895 305 -
The changing scenario of retinopathy of prematurity in middle and low income countries: Unique solutions for unique problems
Anand Vinekar, Mangat Dogra, Raj Vardhan Azad, Clare Gilbert, Lingam Gopal, Michael Trese
June 2019, 67(6):717-719
DOI:10.4103/ijo.IJO_496_19  PMID:31124475
  762 328 -
REVIEW ARTICLES
Intra-arterial chemotherapy in retinoblastoma – A paradigm change
Fairooz P Manjandavida, Christina Stathopoulos, Jing Zhang, Santhosh G Honavar, Carol L Shields
June 2019, 67(6):740-754
DOI:10.4103/ijo.IJO_866_19  PMID:31124482
Intra-arterial chemotherapy (IAC), also known as superselective ophthalmic artery chemotherapy or chemosurgery, is currently widely accepted as one of the primary treatment modalities for intraocular retinoblastoma worldwide. Following the introduction of the technique in 1998, IAC has evolved over the past decades to be safer and more effective. Accumulated evidence shows that IAC is more effective in providing eye salvage in group D and E retinoblastoma as compared to conventional systemic intravenous chemotherapy (IVC). In contrast to IVC, IAC has the added benefits of reduced overall treatment duration and minimal systemic toxicity. This review provides a comprehensive update on the history, technique, indications, contraindications, and outcome of IAC. We have also identified the strengths, weaknesses, opportunities and threats (SWOT analysis) of the technique in this review.
  807 277 -
GUEST EDITORIALS
Children - Not just small adults!
Lingam Gopal
June 2019, 67(6):720-721
DOI:10.4103/ijo.IJO_890_19  PMID:31124476
  596 260 -
REVIEW ARTICLES
Pediatric vitreous hemorrhage: A narrative review
Anmol U Naik, Ekta Rishi, Pukhraj Rishi
June 2019, 67(6):732-739
DOI:10.4103/ijo.IJO_688_18  PMID:31124481
Vitreous hemorrhage is one of the most common causes of sudden, painless loss of vision in adults. This is probably one of the reasons why it has been extensively studied and reported in literature. However, the same cannot be said when it comes to vitreous hemorrhage in the pediatric age group. The causes of vitreous hemorrhage in children tend to differ from those of adults. Not much data exist regarding their presentation and management. In addition to trauma, certain spontaneous causes such as pediatric tumors and congenital conditions assume importance while considering the differential diagnosis of vitreous hemorrhage in the pediatric age group. However, it is natural that the treating ophthalmologist is faced with challenges when a child presents with vitreous hemorrhage. In this narrative review, we have attempted to analyze the retrospective observational studies regarding pediatric vitreous hemorrhage reported in English literature till date. The article sheds some light on the prevailing epidemiology, management strategies employed and the visual outcome among different regions of the world.
  631 157 -
ORIGINAL ARTICLES
MII RetCam assisted smartphone based fundus imaging for retinopathy of prematurity
T Lekha, S Ramesh, Ashish Sharma, G Abinaya
June 2019, 67(6):834-839
DOI:10.4103/ijo.IJO_268_19  PMID:31124497
Purpose: The gold standard for evaluating Retinopathy of prematurity (ROP), a potentially blinding disease in preterm babies, is by indirect ophthalmoscopy which is quite subjective. Digital imaging with RetCam, an advanced wide field imaging system is more precise but it is not easily available or affordable. Smartphones are being explored as an alternate cost effective and accessible imaging tool. This is possible because of the good illumination and the built-in high resolution cameras available in modern smartphones. The aim of this study is to illustrate the utility of MII RetCam assisted smartphone based fundus imaging (MSFI) in the documentation and monitoring of ROP. Methods: Single-centre, retrospective observational study of all the preterm babies subjected to MSFI as part of ROP screening from September 2017 to November 2018. iPhone 4S and + 20 Diopter lens attached to the MII RetCam device was used for fundus imaging at baseline and during follow up. The statistical analysis used for the same is the SPSS statistical software. Results: Good quality images of central and peripheral retina could be captured in 33 out of 42 babies (78.57%) with ROP. Serial imaging done in 24 babies with ROP helped in precise monitoring of the disease and planning management. Incidentally detected non-ROP findings were also documented. Unique design of the device enabled imaging by a single examiner. Image database created was useful for academic and counselling purposes. Smaller field images which can cause difficulty in distinguishing the zones is a limitation. Conclusion: MSFI is a potential alternate imaging tool enabling objective documentation and monitoring of ROP in low resource settings.
  606 137 -
Retinal immaturity at first screening and retinopathy of prematurity: Image-based validation of 1202 eyes of premature infants to predict disease progression
Chaitra Jayadev, Anand Vinekar, Roopa Bharamshetter, Shwetha Mangalesh, Harsha L Rao, Mangat Dogra, Noel Bauer, Carroll A B Webers, Bhujang Shetty
June 2019, 67(6):846-853
DOI:10.4103/ijo.IJO_469_19  PMID:31124500
Purpose: To use the extent of retinal immaturity at the first visit to predict progression to any stage and treatment-requiring retinopathy of prematurity (ROP). Methods: Retrospective, multicenter, nonrandomized, observational, clinical, validation study. In all, 601 Asian Indian preterm infants born < 2000 g and/or < 34 weeks of gestation completing ROP screening with RetCam images taken during each visit were included. A total of 1202 eyes of these infants were classified into three groups based on the retinal immaturity at the first screening visit into “mild” (Group 1), vessels reaching the posterior boundary of zone 3; “moderate” (Group 2), vessels entering zone 2 anterior; and “severe” (Group 3), vessels in zone 1 or zone 2 posterior. RetCam images at each subsequent visit were evaluated and the proportion of eyes that progressed to Type 1 or Type 2 ROP was correlated with the degree of retinal immaturity. Results: Of the 958 eyes in Group 1, 200 eyes in Group 2, and 44 eyes in Group 3, any stage ROP developed in 15% of eyes in Group 1, 46.5% of eyes in Group 2, and 100% of eyes in Group 3 (P < 0.001). Sixteen of 128 eyes (12.5%), 12 of 72 (16.6%), and 28 of 44 of eyes (63.6%) in Groups 1, 2, and 3, respectively, required treatment (P < 0.001). Conclusion: Retinal immaturity at first screening visit predicts Type 1 and Type 2 ROP. “Severe” immaturity is more likely to progress to “treatment-requiring” disease. This could be a useful tool for prognostication, counseling, and scheduling follow-up.
  585 109 -
REVIEW ARTICLES
Intraocular medulloepithelioma – A review of clinical features, DICER 1 mutation, and management
Sameeksha H Tadepalli, Carol L Shields, Jerry A Shields, Santosh G Honavar
June 2019, 67(6):755-762
DOI:10.4103/ijo.IJO_845_19  PMID:31124483
Intraocular medulloepithelioma is a nonhereditary neoplasm of childhood arising from primitive medullary epithelium. It most often involves the ciliary body. Most patients present between 2 and 10 years of age with loss of vision, pain, leucocoria, or conjunctival congestion. The mass appears as a grey-white ciliary body lesion with intratumoral cysts. Presence of a neoplastic cyclitic membrane with extension to retrolental region is characteristic. Secondary manifestations like cataract and neovascular glaucoma may be present in up to 50% and 60% patients, respectively. These could be the first signs for which, unfortunately, about 50% patients undergo surgery before recognition of the hidden tumor. Systemic correlation with pleuropulmonary blastoma (DICER1 gene) has been documented in 5% cases. Histopathology shows primitive neuroepithelial cells arranged as cords closely resembling the primitive retina. Histopathologically, the tumor is classified as teratoid (containing heteroplastic elements) and nonteratoid (containing medullary epithelial elements), each of which are further subclassified as benign or malignant. Retinoblastoma-like and sarcoma-like areas may be seen within the tissue. The treatment modality depends on tumor size and extent of invasion. For small localized tumors (≤3-4 clock hours), conservative treatments with cryotherapy, plaque radiotherapy, or partial lamellar sclerouvectomy (PLSU) have been used. Plaque brachytherapy is generally preferred for best tumor control. Advanced and extensive tumors require enucleation. Rare use of intra-arterial and intravitreal chemotherapy has been employed. Systemic prognosis is favorable, but those with extraocular extension and orbital involvement show risk for local recurrence and metastatic disease, which can lead to death.
  475 156 -
ORIGINAL ARTICLES
Smartphone guided wide-field imaging for retinopathy of prematurity in neonatal intensive care unit – a Smart ROP (SROP) initiative
Anubhav Goyal, Mahesh Gopalakrishnan, Giridhar Anantharaman, Dhileesh P Chandrashekharan, Thomas Thachil, Ashish Sharma
June 2019, 67(6):840-845
DOI:10.4103/ijo.IJO_1177_18  PMID:31124499
Purpose: To suggest a low cost, non-contact smartphone-based screening system in retinopathy of prematurity (ROP), and to illustrate its potential clinical application as a potential future tool for teleophthalmology. Methods: Neonatal intensive care unit (NICU)-based bedside ROP screening done between January 2018 and May 2018. Documentation of ROP was done by using a smartphone and +40D, +28D, or +20D indirect non-contact condensing lenses. By using the coaxial light source of the phone, this system works as an indirect ophthalmoscope that creates a digital image of the fundus. With smartphone-based camera we extracted high-quality still images extracted from the video clip. Results: Total of 228 eyes of 114 infants screened for ROP between January 2018 and May 2018. Incidence of total ROP was 23.68%, out of which incidence of type 1 ROP was 8.77%. After initial screening with indirect ophthalmoscope, we uesd smartphone imaging to document ROP in 28 eyes out of 55 eyes having ROP. Image quality was good in 89.28% eyes. Field of view vary from 46°, 53°, and 90° with +20D, +28D, and +40D indirect condensing lenses, respectively, which gives excellent images for bedside ROP documentation. Conclusion: The described technique of smartphone fundus photography is a light weight, cost-effective, user friendly, high-quality wide-field fundus photographs for bedside documentation of ROP in NICUs using readily available instruments that are handy and portable with simple power sources. Smartphones has the potential to be operated with only one hand. It can also be used as a future telescreening device.
  471 131 -
Ultra-widefield fundus fluorescein angiography in pediatric retinal vascular diseases
Shreyas Temkar, Shorya V Azad, Rohan Chawla, Sourav Damodaran, Gaurav Garg, Harika Regani, Shaikh Nawazish, Nimmy Raj, Vatsalya Venkatraman
June 2019, 67(6):788-794
DOI:10.4103/ijo.IJO_1688_18  PMID:31124488
Purpose: To describe the utility of RetCam ultra-wide-field fundus fluorescein angiography in pediatric retinal vascular diseases. Methods: A retrospective chart review was carried out in 43 eyes of 22 pediatric patients who were diagnosed or suspected to have a retinal vascular disease. Fluorescein angiography was carried out using the 130 degree lens of RetCam 3. Fluorescein angiography guided treatment (laser/cryotherapy) was carried out wherever required. Results: Diseases studied included - coats disease, familial exudative vitreoretinopathy, retinopathy of prematurity, congenital retinal folds, double optic nerve head, persistent fetal vasculature and incontinentia pigmenti. RetCam assisted fluorescein angiography was helpful in establishing a diagnosis in 4 patients (18%), in decision making regarding treatment in 18 patients (82%), in deciding need for retreatment in 5 patients (23%), helped in staging of disease in 5 patients (23%) and in detecting clinically subtle findings in 6 patients (27%). Conclusion: RetCam assisted FFA is extremely useful to document peripheral retinal vascular pathologies in pediatric patients and helps to take crucial therapeutic and retreatment decisions.
  456 128 -
GUEST EDITORIALS
Imaging the pediatric retina – Where are we headed?
Sabyasachi Sengupta
June 2019, 67(6):723-724
DOI:10.4103/ijo.IJO_867_19  PMID:31124478
  462 121 -
ORIGINAL ARTICLE
Coats disease in 351 eyes: Analysis of features and outcomes over 45 years (by decade) at a single center
Carol L Shields, Sanika Udyaver, Lauren A Dalvin, Li–Anne S Lim, Hatice T Atalay, Chloe T L Khoo, Mehdi Mazloumi, Jerry A Shields
June 2019, 67(6):772-783
DOI:10.4103/ijo.IJO_449_19  PMID:31124485
Purpose: To assess features and outcomes of Coats disease over 5-decades. Methods: Retrospective review of Coats disease patients at a single center. Features and outcomes were compared based on decade of presentation. Results: There were 351 patients with Coats disease. The presenting median age (6 years), male sex (84%), and unilaterality (100%) did not change per decade. Coats disease classification did not change per decade with Stage 1 (1%), Stage 2 (21%), Stage 3 (68%), Stage 4 (6%), and Stage 5 (1%). Clinical features that changed per decade (1970s vs. 1980s vs. 1990s vs. 2000s vs. 2010s) included 1980s features of more eyes with exudation in all 4 quadrants (22% vs. 58% vs. 44% vs. 33% vs. 27, P = 0.01) and total exudative retinal detachment (33% vs. 53% vs. 39% vs. 27% vs. 21%, P < 0.001). Imaging features that changed per decade included 2010s greater fluorescein angiographic extent of retinal non-perfusion in mean clock hours (4 vs. 4 vs. 3 vs. 5 vs. 6, P = 0.003), and 1980s greater mean height of retinal detachment ultrasonographically (5 vs. 12 vs. 5 vs. 5 vs. 4 mm, P < 0.001). Treatment features that changed per decade included 1980s greater primary enucleation (11% vs. 16% vs. 3% vs. 4% vs. 1%, P = 0.001), and 2010s greater use of laser photocoagulation (55% vs. 33% vs. 38% vs. 40% vs. 72%, P < 0.001), sub-Tenon corticosteroid (0% vs. 4% vs. 5% vs. 8% vs. 29%, P < 0.001), and intravitreal anti-VEGF) (0% vs. 4% vs. 2% vs. 13% vs. 18%, P = 0.003). Outcomes that changed per decade included 2010s findings of more complete resolution of subretinal fluid (64% vs. 59% vs. 38% vs. 58% vs. 72%, P = 0.01) and less need for primary/secondary enucleation (17% vs. 27% vs. 14% vs. 13% vs. 6%, P = 0.04). Conclusion: Eyes with Coats disease in the 1980s demonstrated more advanced findings, often requiring enucleation. Over the decades, greater use of laser photocoagulation and injections has led to improved disease resolution with greater globe salvage.
  406 176 -
ORIGINAL ARTICLES
Endogenous endophthalmitis in children and adolescents: Case series and literature review
Aditya Maitray, Ekta Rishi, Pukhraj Rishi, Lingam Gopal, Pramod Bhende, Rupak Ray, Kuzhanthai Lily Therese
June 2019, 67(6):795-800
DOI:10.4103/ijo.IJO_710_18  PMID:31124489
Purpose: To study the clinical and microbiological profile, treatment modalities, and anatomical and functional outcomes among children and adolescents with endogenous endophthalmitis (EE) at a tertiary eye care centre in India. Methods: Medical records of subjects <18 years, presenting with EE from 1997 to 2007 were reviewed. Cases where the causative organism was identified were included. Treatment regimen included systemic antibiotics, vitrectomy, intravitreal antibiotics, and enucleation. Systemic evaluation to identify the source of infection was done by an internist. Microbiological analysis of blood, urine, and ocular specimens was done. The favorable anatomical outcome was defined as the attached retina, with controlled intraocular pressure and clear media at the last follow up. The favorable functional outcome was defined as vision >3/60 on the final follow up. Univariate regression analysis was done to identify factors predicting functional outcome. Results: Thirty eyes of 30 subjects (23 (77%) males) were studied. The mean age at presentation was 6.8 years (range=1–16 years). Fever was evident in four (13%) and blood culture was negative in all cases. Gram-positive organisms were identified in 11 (37%) eyes, fungi in 3 (10%), and toxocara in 8 (27%) eyes. Twenty-three (77%) eyes underwent vitrectomy. Favorable functional and anatomical outcomes were achieved in 9 (30%) and 12 (40%) eyes, respectively. Eyes undergoing vitrectomy showed significant correlation with good functional outcome (P = 0.05). Conclusion: EE is under-reported and not well studied in children. The absence of systemic features may be evident in a developing country with over the counter availability of antibiotics. Gram-positive infections are common and vitrectomy is a beneficial modality of treatment.
  445 133 -
ONE MINUTE OPHTHALMOLOGY
Retinal elevation in an infant
Antonio N Yaghy, Lauren A Dalvin, Carol L Shields
June 2019, 67(6):725-725
DOI:10.4103/ijo.IJO_429_19  PMID:31124479
  410 160 -
REVIEW ARTICLES
India to gear up to the challenge of “third epidemic” of retinopathy of prematurity in the world
P Sai Kiranmayee, Viswanath Kalluri
June 2019, 67(6):726-731
DOI:10.4103/ijo.IJO_700_18  PMID:31124480
Many of the causes of childhood blindness are avoidable, being either preventable or treatable. Retinopathy of prematurity (ROP) remains one of the most preventable causes of childhood blindness worldwide. Currently, India is facing the third epidemic of ROP. In India, the health system involving the mother and child health services needs to be strengthened with a policy to cover the existing inadequacies in neonatal care and implementation of program covering newborn, especially premature. The access, availability, and affordability of services related to the care of premature babies need strengthening in India. ROP-trained ophthalmologists and neonatal care pediatricians and a professional togetherness is a big issue. Inadequacies in awareness of ROP among the parents, health care workers, counsellors add up to the problem. Community-based health workers such as Accredited Social Health Activist are a good dependable force in India and are needed to be trained in awareness and establishing a proper identification for prompt referral. ROP prevention needs a multidisciplinary team approach. ROP management stands as a good example of all the strategies for prevention, which includes primary prevention (improving obstetric and neonatal care), secondary prevention (screening and treatment programs), and tertiary prevention (treating complications and rehabilitation to reduce disability). Given its demographic and cultural diversity, India faces numerous challenges, with significant rural–urban, poor–rich, gender, socioeconomic, and regional differences. So, we need to gear up to face the present challenge of the third epidemic of ROP and prevent ROP-related childhood blindness as it is the need of the hour.
  450 117 -
ORIGINAL ARTICLES
Intravitreal aflibercept injection in Indian eyes with retinopathy of prematurity
Vasumathy Vedantham
June 2019, 67(6):884-888
DOI:10.4103/ijo.IJO_708_18  PMID:31124509
Purpose: To study the efficacy of intravitreal Aflibercept, an anti Vascular Endothelial Growth factor, (anti-VEGF) in Retinopathy of Prematurity (ROP). Methods: This was a retrospective, interventional consecutive case series of 46 Indian eyes which received intravitreal injection of Aflibercept for High risk Prethreshold ROP, Threshold ROP, and Aggressive-Posterior ROP (AP-ROP). Results: Aflibercept was effective in achieving the primary endpoint, namely regression of ROP following the injection in all 46 eyes (100%) at one week following the injection. 32.6% (15/46) of eyes achieved secondary endpoint namely complete vascularization, with no recurrence of ROP at varying time intervals: as early as 15 weeks to as late as 29 weeks after injection, at intervals ranging from 49 to 64 weeks PCA. Conclusion: Intravitreal Aflibercept was effective in inducing complete regression of all types of ROP in all the eyes in our series. In addition, 32.6% of cases did not need a secondary intervention, with no recurrence of ROP and complete vascularization of the retina. In 81.8% of Zone I ROP eyes, Aflibercept facilitated continuation of retinal vascular development following regression of ROP, resulting in less extensive laser during treatment of ROP recurrence. This is the largest series of Aflibercept in ROP, till date as per MEDLINE search.
  409 131 -
PHOTO ESSAY
Unmodified iPhone XS Max for fundus montage imaging in cases of retinoblastoma
Amar Pujari, Neiwete Lomi, Siddhi Goel, Saumya Yadav, Ritika Mukhija, Prashant Kumar, Atul Kumar
June 2019, 67(6):948-949
DOI:10.4103/ijo.IJO_2144_18  PMID:31124525
  445 93 -
ORIGINAL ARTICLES
Prevalence, risk factors and pattern of severe retinopathy of prematurity in eastern Madhya Pradesh
Anamika Dwivedi, Deepak Dwivedi, Sujata Lakhtakia, Charudutt Chalisgaonkar, Shashi Jain
June 2019, 67(6):819-823
DOI:10.4103/ijo.IJO_1789_18  PMID:31124494
Purpose: To describe the prevalence, characteristics including risk factors, and pattern of severe ROP from eastern Madhya Pradesh region of India. Methods: In this 5-year retrospective study, Baseline characteristics, systemic risk factors, and findings of ROP screening were noted. Factors associated with severe ROP including aggressive posterior ROP (APROP), stage IV and V ROP were analyzed. Statistical analysis was done using SPSS version 20. Results: Of 763 babies screened, 30% were diagnosed to have ROP. Prevalence of severe ROP was 14.2% (109) of which 60 (55.5%) were classic and 30 (27.7%) were APROP. Eighteen (16.6%) were diagnosed as advanced ROP (stage IV and V). Mean gestational age (GA) and birth weight (BW) for severe ROP were 31.05 weeks and 1.34 kg, respectively which were inversely associated with severe ROP. But a significant 10% of severe ROP were seen in late preterm babies, >34 weeks. Low GA and respiratory distress syndrome (RDS) were significant risk factors for APROP. Most important factor for stage IV and V ROP was late presentation for screening. Conclusion: The study found a high prevalence of severe ROP including APROP. Almost 7% severe ROP cases were outside screening guidelines of NNF. Late presentation for screening is the most important factor associated with ROP related blindness.
  421 114 -
Changing patterns of early childhood blinding conditions presenting to a tertiary eye center: The epidemic of retinopathy of prematurity in India
Komal Agarwal, Divya Balakrishnan, Padmaja K Rani, Subhadra Jalali
June 2019, 67(6):816-818
DOI:10.4103/ijo.IJO_709_18  PMID:31124493
Purpose: Retinopathy of prematurity (ROP) is now emerging as one of the major causes of preventable childhood blindness. The proportion of preterm babies has increased dramatically over the past decade. Our study aims to emphasize the need for ROP screening and management services in these preterm infants. Methods: ICD-coded medical records of children less than 10 years of age presenting to a subspecialty eye hospital from 2000 to 2017 were reviewed. ROP, congenital cataract, congenital glaucoma, and vitamin A deficiency were the most common diagnoses. We evaluated the trend of these diseases from 2000 to 2017. Results: Our data suggested a 20-fold increase in the attendance of children with a diagnosis of ROP who now make over 2% of outpatient children. Vitamin A deficiency has declined over time whereas cataract and glaucoma have remained stable. Conclusion: Our data indicate a need to scale up ROP screening integrated with neonatal care, as well as to build capacity for the treatment of acute and late-stage ROP in India.
  397 101 -
A clinicopathological study of persistent fetal vasculature
Surbhi Khurana, Parul Chawla Gupta, Kim Vaiphei, Ramandeep Singh, Jagat Ram
June 2019, 67(6):785-787
DOI:10.4103/ijo.IJO_1375_18  PMID:31124487
Purpose: To study the clinicopathological findings of Persistent Fetal Vasculature (PFV) in patients with congenital cataract and PFV. Methods: Six eyes with anterior or combined PFV with cataract underwent phacoaspiration with primary posterior capsulotomy with anterior vitrectomy with intraocular lens implantation followed by histopathological evaluation of the PFV stalk and membrane. Results: Four and two patients had combined and anterior PFV respectively. There was no postoperative hyphema, vitreous haemorrhage, glaucoma or retinal detachment in six months. Haematoxylin and eosin staining showed inflammatory cells predominantly with extramedullary hematopoeisis and vascularisation. Conclusion: We recommend IOL implantation in PFV, with early and aggressive amblyopia therapy.
  374 113 -
Posterior laser barrage in advancing retinopathy of prematurity: A prospective randomized study
Ruchir Tewari, Parijat Chandra, Ramesh Agarwal, Rajvardhan Azad
June 2019, 67(6):866-870
DOI:10.4103/ijo.IJO_1608_18  PMID:31124504
Purpose: To compare the outcomes of conventional laser photocoagulation versus additional posterior barrage laser in advanced stage 3 retinopathy of prematurity (ROP). Methods: A total of 20 infants with bilateral symmetric zone 2 stage 3 advancing ROP were treated with conventional laser treatment followed by randomization of one eye to receive additional posterior retinal laser treatment. Disc–fovea and inter-arcade distance was measured. The patients were followed up prospectively for 3 months. Structural and functional outcomes and safety profile were analyzed. Results: 18/20 (90%) eyes in the study group and 19/20 (95%) eyes in the control group achieved regression of disease. Faster and complete regression was observed at 4 weeks after posterior laser compared to the control group (P = 0.024). Disc–fovea and inter-arcade distance was comparable in both groups. Conclusion: Additional posterior barrage laser is a safe technique that led to faster and more complete regression in eyes with advancing ROP. Final regression profile was comparable in both treatment modalities.
  394 89 -
Neonatal Intensive Care Unit-based screening program for retinopathy of prematurity and its treatment in an Indian population
Anubhav Goyal, Ananthraman Giridhar, Mahesh Gopalakrishnan, Thomas Thachil
June 2019, 67(6):828-833
DOI:10.4103/ijo.IJO_201_18  PMID:31124496
Purpose: The purpose was to study the incidence, risk factors, and anatomical outcomes after laser treatment in retinopathy of prematurity (ROP). Methods: A retrospective observational study was carried out. Infants admitted to Neonatal Intensive Care Unit of 12 referral hospitals between April 2016 and September 2017 were screened according to the latest Indian guidelines based on the International Classification of Retinopathy of Prematurity. Results: The incidence of ROP in 1648 eyes screened was 25.36% (418 eyes), out of which high-risk prethreshold ROP (type 1) was observed in 9.95% (164 eyes). Decreased hemoglobin (P < 0.001), oxygen requirement (P = 0.008), and number of blood transfusions (P = 0.037) were significant with type 1 than type 2 (low-risk prethreshold) ROP. Stages 1, 2, and 3 were observed in 82 (32.28%), 154 (60.62%), and 18 (7.08%) eyes, respectively. Aggressive posterior ROP (APROP) was observed in 20.73% eyes with type 1 ROP. Ten eyes showing APROP were treated at an early gestational age of 29 weeks. All infants with type 1 ROP were treated with laser photocoagulation only. Conclusion: One-fourth of the infants showed ROP and one-tenth needed laser photocoagulation, the outcome of which was excellent. Risk factors predisposing to ROP were anemia, high oxygen supplementation, increased number of blood transfusions, and septicemia. ROP screening in infants ≥1700 g birth weight associated with various systemic risk factors may be beneficial in the Indian population.
  370 101 -
Safety and efficacy of 532 nm frequency-doubled Nd-YAG green laser photocoagulation for treatment of retinopathy of prematurity
Simar Rajan Singh, Deeksha Katoch, Sabia Handa, Savleen Kaur, Bruttendu Moharana, Mohit Dogra, Mangat R Dogra
June 2019, 67(6):860-865
DOI:10.4103/ijo.IJO_325_19  PMID:31124503
Purpose: To evaluate the safety and efficacy of 532 nm frequency-doubled Nd-YAG green laser for treatment of retinopathy of prematurity (ROP). Methods: This retrospective interventional case series included infants undergoing treatment for ROP with 532 nm green laser between January 2012 and March 2017 at a single tertiary-care referral center. Review of clinical records was done to identify baseline ROP characteristics, procedural difficulties, complications related to the laser procedure and outcome of treatment at ≥ 1 year of follow-up. Results: There are about 347 eyes of 182 infants were included in this present study. ROP presented in zone I in 76 eyes (21.9%) and zone II in 271 eyes (78.1%). Tunica vasculosa lentis (TVL) was present in 43.8% and pre-existing vitreous hemorrhage in 4.6% of the eyes. 532 nm green laser could be performed as a primary procedure in all eyes, including those with TVL. 322 eyes completed a minimum follow up of 1 year with a mean follow up of 22.8 months (range, 12–54 months). At the last follow-up visit, 298 (92.5%) of the 322 eyes had a favorable outcome. On logistic regression analysis, pre-existing fibrovascular proliferation (p = 0.04) and new-onset fibrovascular proliferation after treatment (p = 0.001) were the most significant independent predictors of poor outcome. Complications encountered were new-onset hemorrhage in 36 eyes (11.2%), anterior segment ischemia in two eyes (0.006%) and cataract in one eye (0.003%). Conclusion: 532 nm frequency-doubled Nd-YAG green laser appears to be safe and effective in the treatment of ROP.
  351 111 -
Retrobulbar dexmedetomidine in pediatric vitreoretinal surgery eliminates the need for intraoperative fentanyl and postoperative analgesia: A randomized controlled study
Weidi Ye, Yuhan Hu, Yuntao Wu, Zhirui Zhu, Xiuming Jin, Zhiyong Hu
June 2019, 67(6):922-927
DOI:10.4103/ijo.IJO_1905_18  PMID:31124516
Purpose: This study evaluated the efficacy of retrobulbar ropivacaine plus dexmedetomidine compared with systemic fentanyl in pediatric vitreoretinal (VR) surgery. Methods: This prospective double-blind, randomized controlled study was performed in 60 children undergoing VR surgery, age from 2 to 7 years. After general anesthesia, the following procedure was administrated: (1) retrobulbar block with 0.5% ropivacaine plus dexmedetomidine 1 μg/kg (group RD, n = 20), (2) retrobulbar block with 0.5% ropivacaine (group RB, n = 20), and (3) control group with general anesthesia only (group F, n = 20). Hemodynamics, postoperative pain scores, anesthetics consumption (remifentanil, propofol, fentanyl), and emergence agitation were recorded. Results: Respiratory depression was observed in 7 of the 20 patients in group F after the laryngeal mask airway was removed in the operating room, compared with none in groups RD and RB. All patients in group F required intraoperative rescue fentanyl (average intraoperative fentanyl consumption, 26.6 ± 12.6 μg per patient). Some rescue fentanyl was required in group RB (three patients required one dose of rescue fentanyl). Patients in group RD required none. Groups RD and RB reported lower pain scores than group F at 4 h postoperatively (RD group: P < 0.001; RB group: P =0.002); pain scores in group RD were lower than that in group F at 6 h postoperatively (P < 0.001). Conclusion: Retrobulbar dexmedetomidine as an adjuvant to ropivacaine is a safe and effective alternative to systemic fentanyl. This regimen provides better pain management, hemodynamic stability, and stress response suppression in pediatric VR surgery.
  368 87 -
The safety and effectiveness of 0.16 mg bevacizumab plus or minus additional laser photocoagulation in the treatment of retinopathy of prematurity
Muberra Akdogan, Sadik Gorkem Cevik, Ozlem Sahin
June 2019, 67(6):879-883
DOI:10.4103/ijo.IJO_2115_18  PMID:31124508
Purpose: Retinopathy of prematurity (ROP) is the leading cause of preventable blindness in premature infants. Antivascular endothelial growth factor (anti-VEGF) therapy has been used increasingly in treatment as a pharmacological alternative to laser therapy. In this study, we evaluate the results of low-dose anti-VEGF treatments. Methods: Design: Retrospective--observational study. Infants who had been evaluated for ROP disease between February 2016 and February 2017 were assessed. We retrospectively reviewed the ROP stages, treatment results, and complications. Laser photocoagulation (LPC) and intravitreal bevacizumab (0.16 mg IVB) were used for treatment and fundus fluorescein angiography (FFA) was also performed in some of the cases. Results: IVB was applied to 43 infants. A macular hole was seen in one infant's eye after IVB. LPC was applied to avascular areas in 21 infants. In three patients, persistence of the disease was observed after administration of a low dose of IVB. Additional LFK was performed in these patients. None of the infants who received LPC had any complications. Conclusion: IVB is increasingly becoming the first-line treatment for ROP. For severe ROP, 0.16 mg IVB is effective. Using LPC to treat avascular areas after 70 weeks' gestational age (GA) may decrease the risk of late recurrence and appears to be a safe treatment to use.
  330 122 -
PHOTO ESSAY
Retinopathy in incontinentia pigmenti
Pukhraj Rishi, Niharika Singh, Ekta Rishi
June 2019, 67(6):940-942
DOI:10.4103/ijo.IJO_760_18  PMID:31124521
  320 94 -
ORIGINAL ARTICLES
Surgical outcomes of microincision vitrectomy surgery in eyes with retinal detachment secondary to retinopathy of prematurity in Indian population
Parveen Sen, Pramod Bhende, Tarun Sharma, Lingam Gopal, Aditya Maitray, Prateek Shah, Yogendra Oke
June 2019, 67(6):889-895
DOI:10.4103/ijo.IJO_1030_17  PMID:31124510
Purpose: To analyze and report outcomes of microincision vitrectomy surgery (MIVS) for Stage 4 and 5 retinopathy of prematurity (ROP). Methods: Medical records of 202 eyes of 129 premature children undergoing MIVS for Stage 4/Stage 5 ROP between January 2012 and April 2015 were evaluated. The primary outcome measure was the proportion of eyes with anatomical success (defined as attached retina at the posterior pole at last follow-up). Complications associated with MIVS were noted and analysis of risk factors associated with poor anatomical outcome was also done using logistic regression. Results: Mean age of presentation of babies with Stage 4 ROP (2.9 ± 1.75 months) was lower than those with stage 5 disease (5.62 ± 2.55 months) (P < 0.005). One hundred seventeen eyes (56% or 58%) had Stage 5, 38 (19%) had Stage 4a, and 47 (23%) Stage 4b. Ninety-four eyes (47%) had received prior treatment (laser and/or anti-vascular endothelial growth factors [VEGF]). Lens-sparing vitrectomy (LSV) was performed in 58 (29%) eyes while lensectomy with vitrectomy (LV) was performed in 144 (71%) eyes. At a mean follow-up of 32.5 weeks, 102 (50.5%) eyes achieved anatomical success, including 74% eyes in Stage 4a and 4b and 33% in Stage 5. Complications included intraoperative break formation (19%), postoperative vitreous hemorrhage (28%), raised intraocular pressure (12.7%), and cataract progression (2.4%). Factors significantly associated with favorable anatomical outcome were Stage 4 disease (vs. Stage 5) (odds ratio [OR] 5.8; confidence interval [CI] =2.6–13.8, P < 0.005), prior treatment (laser ± anti-VEGF) (OR 2.5; CI 1.4–4.7, P < 0.005) surgery with 25G MIVS (vs. 23G) (OR: 1.7; CI = 0.98–3.00, P = 0.05) and LSV (vs. LV) (OR 7; CI = 3.4–14.6, P < 0.005). Retinal break was significantly associated with poor anatomical outcome (OR 0.21; CI = 0.09–0.5, P < 0.005). Conclusion: MIVS along with wide angle viewing systems allow surgeons to effectively manage ROP surgeries while at the same time reducing complication rate in these eyes which have complex pathoanatomy and otherwise grim prognosis.
  343 65 -
Refractive, sensory, and biometric outcome among retinopathy of prematurity children with a history of laser therapy: A retrospective review from a tertiary care center in South India
Sasikala E Anilkumar, Vinut Anandi, Parag K Shah, Sandra Ganesh, Kalpana Narendran
June 2019, 67(6):871-876
DOI:10.4103/ijo.IJO_2023_18  PMID:31124505
Purpose: Ocular morbidities like high refractive error, strabismus, and amblyopia are common among laser-treated retinopathy of prematurity children (ROP). Long-term optical status and refractive outcomes including the sensory outcomes were less investigated in these children from this region. The purpose of our study is to evaluate the long-term outcome (refractive, biometric profile, sensory) of treatment for ROP using laser. Methods: This study is a retrospective, cross-sectional, observational, and intervention research among 6–15-year-old children who underwent laser for ROP with a minimum of 6-year follow-up. Results: Eighty lasered eyes of 41 children were assessed. Mean age was 9.71 years (±3.39). Seventy-three eyes (91.2%) achieved visual acuity better than 20/40. The mean visual acuity in LogMAR was 0.18 (20/30). The mean spherical equivalence was −5.29 D ± 4.9. Mean astigmatism measured was −1.53 DC (range: +0.50 DC to −4.5DC). Fifty-three eyes (66.25%) had significant astigmatism. The mean axial length was 23.5 ± 1.35 (21–26) mm. Mean lens thickness was 3.76 ± 0.30 (3.03–4.34) mm. Correlation analysis among the low and high spherical equivalent group signified that axial length (P value = 0.001), visual acuity (P value = 0.0002), and myopic shift (P value = 0.0006) were found to be statistically significant. Stereopsis better than 480 s of arc for near was observed in 41% children. Structural posterior pole sequelae developed in 3 eyes (3.75%). Conclusion: A significant number of children with high myopia, astigmatism, and strabismus had satisfactory visual outcome observed at long-term follow-up after treatment for ROP using laser. Our study revealed that myopia was influenced by an increase in axial length than the lens thickness.
  330 72 -
CASE REPORTS
Post-Ranibizumab injection endophthalmitis in aggressive posterior retinopathy of prematurity
Parijat Chandra, Devesh Kumawat, Ruchir Tewari, Suresh Azimeera
June 2019, 67(6):967-969
DOI:10.4103/ijo.IJO_884_17  PMID:31124535
A preterm infant with zone 1 aggressive posterior retinopathy of prematurity developed infectious endophthalmitis after intravitreal injection of ranibizumab. Urgent empirical intravitreal therapy with vancomycin, ceftazidime, and dexamethasone along with intravenous therapy with amikacin and meropenem helped in early resolution. Vascularization/activity of disease subsided on follow-up, media cleared, and laser photocoagulation was completed. Later the disease reactivated, developed vitreous membranes and central retinal traction, for which 25-gauge lens-sparing vitrectomy was performed. Emergent treatment helped in salvaging the eye from both aggressive ROP disease and devastating endophthalmitis. Rationale approach to such a case is being discussed.
  296 79 -
ORIGINAL ARTICLES
Barriers to timely presentation for appropriate care of retinopathy of prematurity in Odisha, Eastern India
Tapas Ranjan Padhi, Anurag Badhani, Snigdha Mahajan, Laxmi Prabhavathi Savla, Samir Sutar, Subhadra Jalali, Taraprasad Das
June 2019, 67(6):824-827
DOI:10.4103/ijo.IJO_972_18  PMID:31124495
Purpose: To analyze the causes for late presentation in a series of patients with advanced retinopathy of prematurity (ROP) in a tertiary eye care institute in Eastern India. Methods: We analyzed our medical records and ROP database retrospectively from 2007 to 2015 and prospectively thereafter till 2017 to identify the factors for late presentation in babies with advanced ROP (stages 4 and 5). Results: A total of 71 eligible subjects were analyzed. The mean chronological age was 15.1 months (2 months to 14 years). The three important barriers were: (1) the system and neonatal care policy failure (n = 45; 63.3%), (2) parental negligence and ignorance (n = 19; 26.7%), and (3) ophthalmologist's misdiagnosis or unavailability (n = 7; 10%). Majority of the babies (63.3%) were admitted in the neonatal care unit when they were due for ROP screening with an average duration of stay of 35.5 days. Conclusion: The main barriers to early screening for ROP were related to availability of trained human resources, ignorance of “parents and health care personnel,” and distance from the point of care. This calls for training of ophthalmologists, advocacy with neonatologists and parents, and create systems for better coordination and compliance of the care providers.
  297 73 -
Vision-related quality of life in children with treated retinopathy of prematurity
Prem Kesarwani, Subina Narang, Deepak Chawla, Suksham Jain, Meenakshi Chandel, Sunandan Sood
June 2019, 67(6):932-935
DOI:10.4103/ijo.IJO_323_19  PMID:31124518
Purpose: To evaluate vision-related quality of life in children treated for retinopathy of prematurity. Methods: Cross sectional observational study of 54 treated ROP babies 2–7 years of age. The study excluded babies with chronic pediatric conditions and babies of parents suffering from mental illness. Detailed examination including visual acuity was done for all. Two versions of CVFQ questionnaire for children under 3 and above 3 years of age were posed to parents in this study. CVFQ contains six subscales: General health, vision health, competence, personality, family impact, and treatment difficulty. The scores ranged from 0 (worst score) to 1 (best score). Results: The study included 54 children with mean birth weight was 1194 grams, mean gestation age 30 weeks. The age, gender, birth weight, and gestational age didn't affect the overall quality of life (P > 0.05). The severity of ROP (stage 4 and 5) had poorer CVFQ scores (personality and family impact subscales). Competence and personality scores were significantly lower in zone I disease. The quality of life especially general vision, competence, personality, and treatment difficulty subscales had significantly lower values in ROP with higher clock hour involvement (P < 0.05). With myopia after ROP treatment, only personality subscale was significantly affected (P 0.02). Mean CVFQ score including the family impact and treatment difficulty subscale score was also significantly lower in amblyopic and anisometropic children (P value < 0.05). Family impact subscale and overall quality of life was significantly lower in children with strabismus than children without strabismus (P 0.001). Conclusion: ROP has negative effect on the vision-related quality of life of children and their parents. The overall quality of life worsened with the increase in the severity of disease and the occurrence of ocular sequelae of ROP. The vision of the baby may not be the only cause of low scores in the quality of life questionnaire in ROP.
  291 77 -
Prospective study of factors influencing timely versus delayed presentation of preterm babies for retinopathy of prematurity screening at a tertiary eye hospital in India
The Indian Twin Cities ROP Screening (ITCROPS) data base report number 6

Deva Prasad Gopal, Padmaja Kumari Rani, Harsha Laxmana Rao, Subhadra Jalali
June 2019, 67(6):855-859
DOI:10.4103/ijo.IJO_561_18  PMID:31124502
Purpose: To evaluate the factors influencing timely versus delayed presentation of preterm babies for ROP evaluation. Methods: Preterm babies (≤35 weeks gestational age, ≤2000 g birth weight) were prospectively included in the study. Timely presentation was defined as babies who presented for the first ROP screening within 30 days of birth and Delayed as more than 30 days of birth. An event survey to assess factors influencing timely vs delayed presentation was administered to parents/guardian of babies after obtaining informed consent. Results: Data of 278 preterm babies (n = 139 timely vs n = 139 delayed presentation) collected in the event surveys were analyzed. The delayed presenters came at a median duration of 6.3 weeks (1st and 3rd quartiles: 5.3 and 9.1) after birth. The odds of any stage of ROP was 2.6 times and the odds of sight threatening ROP was 6.8 times in those presenting delayed compared to those presenting timely. Major Reasons for delayed presentation were not asked to do so/no referral from pediatrician in 64 (46%) participants and unaware of the importance by 46 (33%) participants. Conclusion: Deviation from screening protocol is an important modifiable risk factor in ROP screening. The study findings suggest the need for creating awareness about timely screening and referral guidelines among the pediatricians involved in “care” of preterm infants at risk of developing ROP.
  284 78 -
COMMENTARY
Commentary: Seeing the big picture: Panoramic smartphone fundus imaging sans accessories
John D Akkara, Anju Kuriakose
June 2019, 67(6):949-950
DOI:10.4103/ijo.IJO_727_19  PMID:31124526
  274 87 -
CASE REPORTS
Lipemia retinalis in a 27 day old neonate: A case report
Noopur Deokinandan Nayak Shinkre, Ugam P S Usgaonkar
June 2019, 67(6):954-957
DOI:10.4103/ijo.IJO_1310_18  PMID:31124530
Familial combined hyperlipidemia, which presents as hypercholesterolemia or hypertriglyceridemia, is the commonest form of genetic hyperlipidemia and is associated with premature coronary artery disease. This is a rare case report of a 27 day-old neonate born out of a third-degree consanguineous marriage, with grade III lipemia retinalis secondary to familial-combined hyperlipidemia.
  277 82 -
Successful treatment of aggressive posterior retinopathy of prematurity with diode laser in ocular albinism: A case report
Anil B Gangwe, Swapnil M Parchand, Raj Vardhan Azad, Deepshikha Agrawal, Priyavrat Bhatia
June 2019, 67(6):962-964
DOI:10.4103/ijo.IJO_768_18  PMID:31124533
Oculocutaneous albinism is characterized by partial or complete absence of melanin in retinal pigment epithelium (RPE) and uveal melanocytes. Absence of typical fundal background from RPE and choroid makes it difficult to diagnose retinal disorders in ocular albinism. Lack of melanin in RPE makes the laser photocoagulation very challenging in these cases. This report presents a unique case of preterm infant of oculocutaneous albinism diagnosed as aggressive posterior retinopathy of prematurity (APROP), which was successfully treated with diode laser photocoagulation. The parameters of the laser used in this case were higher than usual, just enough to achieve blanching of retina. This report highlights the fact that the diagnosis of APROP and its treatment with laser is challenging in the presence of oculocutaneous albinism, but it is possible to achieve complete regression using diode laser at higher parameters.
  275 82 -
In-utero ultrasonography detection of fetal retinoblastoma and neonatal selective ophthalmic artery chemotherapy
Fairooz P Manjandavida, Jiejun Xia, Jing Zhang, Xiao Yun Tang, Hai Rong Yi
June 2019, 67(6):958-960
DOI:10.4103/ijo.IJO_340_19  PMID:31124531
We report a case of non-familial, sporadic fetal retinoblastoma (RB) that was accidently detected at 39 weeks of gestation on pre-natal ultrasonography in left eye (OS). Post-natal examination revealed Group A and, Group D RB in right eye (OD) and OS, respectively. At 35 days, selective ophthalmic artery intra-arterial chemotherapy (IAC) was performed in OS and laser for OD. Pre-natal ultrasound and its application in RB are limited to those cases with a strong genetic predisposition. Our case was accidently detected at late gestation with no familial or genetic predisposition. In addition, this was the youngest reported case that received IAC on literature review.
  283 61 -
Intravenous tocilizumab in idiopathic pediatric uveitis with refractory cystoid macular edema – A case report
Kalpana Babu, Bhagya Sudheer, Anand P Rao
June 2019, 67(6):975-977
DOI:10.4103/ijo.IJO_1938_18  PMID:31124539
A 13-year-old boy with a 4-year history of idiopathic pediatric uveitis and recurrent uveitic macular edema had failed conventional immunomodulatory therapy and presented to us with a vision of 6/24 [right eye (OD)] and 6/9 [left eye (OS)]. Fluorescein angiography showed diffuse vascular leakage along with cystoid macular edema (CME). Intravenous tocilizumab (10 mg/kg body) was given as 14 injections over 12 months. Repeat fluorescein angiography every 3 months showed a dramatic improvement in the vascular leakage and resolution of CME. At 13 months OF follow-up, vision had improved to 6/9p (OD) and 6/6(OS) with no recurrence of inflammation or CME.
  265 70 -
ORIGINAL ARTICLES
Effect of intravitreal and intraperitoneal cyanidin-3-glucoside injection in oxygen-induced retinopathy mouse model
Zeynep E Ercan, Nihan Haberal, Fatma Helvacıoglu, Atilla Dağdeviren, Gürsel Yılmaz
June 2019, 67(6):801-805
DOI:10.4103/ijo.IJO_166_18  PMID:31124490
Purpose: To evaluate the effect of cyanidin-3-glucoside (C3G) in oxygen-induced retinopathy (OIR) mouse model. Methods: In this experimental study, 10 C57BL / 6J type mice exposed to room air comprised two control groups (n = 5 each; a negative control and a group receiving intravitreal sterile dimethyl sulfoxide [IVS DMSO]). Thirty C57BL / 6J type mice exposed to 75% ± 2% oxygen from postnatal day 7 to postnatal day 12 comprised the OIR groups. On postnatal day 12, these mice were randomized into six groups (n = 5 each): two OIR control groups (negative control and IVS DMSO), two intravitreal C3G groups (300 and 600 ng/μL), and two intraperitoneal C3G groups (0.05 and 0.1 mg/kg). We quantified neovascularization by counting endothelial cell proliferation on the vitreal side of the inner limiting membrane of the retina and examined histological and ultrastructural changes via light and electron microscopy and apoptosis by terminal deoxynucleotidyl transferase deoxy-UTP-nick end labeling. Results: The intravitreal C3G groups yielded lower endothelial cell counts compared with the intravitreal DMSO group. The intraperitoneal high-dose group had lower cell counts compared with the OIR control groups. Electron microscopy revealed significantly less mitochondrial dysmorphology in intravitreal groups and the high-dose intraperitoneal mice. We noted no difference in apoptotic cell count between the controls, low-dose intravitreal, and both intraperitoneal groups. However, apoptotic cell count was significantly higher in the high-dose intravitreal group. Conclusion: C3G suppresses endothelial cell proliferation in an OIR mouse model, leads to a reduced hyperoxia-induced mitochondrial dysmorphology, but increases apoptotic cell death in high concentrations.
  270 64 -
CASE REPORTS
To remove the buckle or watch?
Kunal K Shah, Ekta Rishi, Pramod Bhende, Pukhraj Rishi, Tarun Sharma
June 2019, 67(6):973-974
DOI:10.4103/ijo.IJO_712_18  PMID:31124538
Scleral buckling is one of the most effective modality for treatment of rhegmatogenous retinal detachment and in selected cases of retinopathy of prematurity. Although quite safe, it has its own set of associated morbidities. This report presents an interesting case, where the scleral buckle migrated posteriorly reaching up to the optic nerve.
  261 67 -
ORIGINAL ARTICLES
Short-term incidence and management of glaucoma after successful surgery for stage 4 retinopathy of prematurity
Parijat Chandra, Ruchir Tewari, Nitesh Salunkhe, Devesh Kumawat, Abadh K Chaurasia, Viney Gupta
June 2019, 67(6):917-921
DOI:10.4103/ijo.IJO_33_18  PMID:31124515
Purpose: The purpose of this study is to describe the short-term incidence, clinical features, and management of glaucoma in children after successful surgery for stage 4 retinopathy of prematurity (ROP). Methods: The retrospective study included all eyes undergoing successful surgery for stage 4 ROP with good outcomes at a tertiary eye care center between June 2014 and June 2016. Cases developing postoperative glaucoma underwent examination under anesthesia for measurement of intraocular pressures (IOP), corneal diameters, Retcam-assisted fundus imaging, and gonioscopy. Outcomes of glaucoma management were evaluated. Results: Hundred eyes of 70 babies underwent successful surgery for stage 4 ROP (with postoperative attached retina, and minimal sequelae) with minimum follow-up of 15 months. Six eyes (6%) developed postoperative glaucoma. Of these, four eyes had undergone lens-sparing vitrectomy and two were managed with lensectomy and vitrectomy (LV). Median time duration for development of glaucoma after primary vitreous surgery was 17.5 weeks. Two cases could be managed with topical IOP-lowering agents alone, whereas four required filtering surgeries (trabeculotomy with trabeculectomy and 0.04% mitomycin C [MMC] application). Average IOP decreased from 25 ± 2.36 to 12.2 ± 2.05 mmHg at 12 months from glaucoma diagnosis. Conclusion: Glaucoma is a potential adverse event following successful vitreous surgery for stage 4 ROP. A combined trabeculotomy–trabeculectomy along with MMC gives favorable outcome.
  265 60 -
Effect of birth weight on retinopathy of prematurity in discordant twin pairs
İkbal Seza PetriÁli, Caner Kara, Dilek Ulubaş Işık, Nihal Demirel, Ahmet Yağmur Baş
June 2019, 67(6):806-810
DOI:10.4103/ijo.IJO_1197_17  PMID:31124491
Purpose: Since twin pairs with discordance have equal gestational age (GA), discordant twins may constitute an appropriate group to investigate the specific effect that birth weight (BW) has on the development of retinopathy of prematurity (ROP). The present study aims to investigate the effect of BW on any and severe stages of ROP development in twin pairs. Methods: Fifty-two discordant twin pairs (104 preterms) born ≤32 gestational weeks, who were diagnosed with a minimum of 18% discordance between their BWs, were retrospectively analyzed. Twin pairs were separated into two groups based on the BW of each pair. The rate of any stage of ROP, Type 1 ROP, and perinatal risk factors were compared statistically among twin pairs. Results: The rate of any stage of ROP and Type 1 ROP was 24.0% and 4.8% in the whole group, respectively. A statistically significant difference was shown between lower and higher BW groups at any stage of ROP development (34.6% vs. 13.4%, P = 0.02). However, no difference was observed in Type 1 ROP development (7.7% vs. 1.9%, P = 0.17). No significant differences were found between twin pairs regarding neonatal morbidities. The number of small GA (SGA) infants in the smaller twin group was statistically higher than larger group and regression analysis showed that being SGA had significant correlation with any stage of ROP (odds ratio: 4.98, P = 0.02). Conclusion: This study showed that BW serves an effective role at any stage of ROP development in discordant twin pairs; however, no significant difference in terms of Type 1 ROP.
  249 74 -
COMMENTARY
Commentary: Coats disease: Our experience in India
Atul Kumar, Divya Agarwal, Rohan Chawla
June 2019, 67(6):783-784
DOI:10.4103/ijo.IJO_823_19  PMID:31124486
  241 75 -
PHOTO ESSAY
Retinal imaging in incontinentia pigmenti
Subina Narang, Meenakshi Sindhu, Suksham Jain, Jitender Jinagal
June 2019, 67(6):944-945
DOI:10.4103/ijo.IJO_417_19  PMID:31124523
  248 63 -
COMMENTARY
Commentary: Retinopathy of prematurity screening made simple – Smartphone-based fundus imaging
Bhavik Panchal
June 2019, 67(6):839-839
DOI:10.4103/ijo.IJO_842_19  PMID:31124498
  225 84 -
OPHTHALMIC IMAGES
Persistent fetal vasculature feeding a retinoblastoma
MB Thirumalesh, Raksha Rao, Gagan Dudeja
June 2019, 67(6):951-951
DOI:10.4103/ijo.IJO_353_19  PMID:31124527
  223 79 -
ORIGINAL ARTICLES
Surgical outcomes of vitreoretinal surgery for rhegmatogenous retinal detachment in eyes with regressed retinopathy of prematurity
Parveen Sen, Ashutosh Agarwal, Pramod Bhende, Lingam Gopal
June 2019, 67(6):896-902
DOI:10.4103/ijo.IJO_706_18  PMID:31124511
Purpose: To report the anatomical and functional outcomes of vitreoretinal surgery in eyes with “regressed ROP” presenting with rhegmatogenous retinal detachment (RRD). Methods: In this retrospective interventional case series, twenty-two eyes (of 22 patients) with regressed ROP, who underwent surgery for RD. Primary outcome measures were final anatomical and visual outcome for scleral buckling and pars plana vitrectomy (PPV). Visual outcomes were categorized into three groups: improved, remained stable, and deteriorated. Univariate binary logistic regression analysis was used to determine the risk factors for RD. Results: Of 22 eyes in the study, overall anatomic success was achieved in 16 of 22 eyes (72.7%). The macula was attached in 17 of 22 eyes (77.3%) at final visit. In the scleral buckle (SB) group, overall anatomical success was achieved in six of seven eyes (85.7%). Overall, in the PPV group, anatomical success was seen in 10 of 15 eyes (66.7%) at final visit. At final follow-up, significant improvement in best-corrected visual acuity from baseline was seen in 11 cases (50%, P = 0.02), stable in 5 cases (22.7%), and significant visual deterioration was seen in 6 cases (27.3%, P = 0.02). The total mean follow-up duration of the patients was 45.5 months (range: 2.1 months to 11.2 years). Conclusion: Early recognition and surgical intervention in such cases can lead to a high rate of anatomical success and can prevent the development of profound visual impairment in some patients.
  241 61 -
Comparison of retinopathy of prematurity incidence between Turkish citizens and Syrian refugees
Sabit Kimyon, Pelin Çelemler, Alper Mete, Kıvanç Güngör
June 2019, 67(6):811-815
DOI:10.4103/ijo.IJO_1639_18  PMID:31124492
Purpose: More than 3.5 million Syrians came to Turkey seeking refuge and over 470,000 Syrian infants were born since the start of the civil war in 2011. Our aim is to compare the incidence of retinopathy of prematurity (ROP) between Syrian refugees and Turkish citizens. Methods: This multicenter, retrospective study was conducted in Gaziantep University, Faculty of Medicine and Gaziantep Children's Hospital in Turkey. We included the data of patients who were screened for ROP between July 2015 and June 2017. Results: The above-mentioned data of 906 Turkish infants and 199 Syrian infants were included in this study. Mean gestational ages (GAs) were (32.9 ± 2.7) and (32.1 ± 2.8) weeks as well as mean birth weights (BWs) were (1937.5 ± 582.9) and (1696.8 ± 485.5) g, in Turkish and Syrian infants, respectively. GA and BW were significantly lower in Syrian infants while time spent in neonatal intensive care unit was significantly higher. The zone of ROP was lower in the Syrian infants in the first examination and for the most advanced ROP (P = 0.001). Any stage ROP was present in 392 (43.3%) and 81 (40.7%) patients in Turkish and Syrian population, respectively (P = 0.490). The number of patients who required treatment for ROP were 95 (10.5%) and 20 (10.1%) in Turkish and Syrian groups, respectively (P = 0.882). Conclusion: Our findings showed that refugee infants had lower BW and GA than native population but the incidence of ROP did not differ between them. Psychosocial stress is an important risk factor for women at reproductive age as it increases the incidence of prematurity. Additional care and psychological support must be given to refugees during perinatal period to decrease the risk of premature birth.
  240 55 -
COMMENTARY
Commentary: Vitrectomy for stage 4 and 5 retinopathy of prematurity - Selecting the right approach to the vitreous cavity
Mohit Dogra, Simar Rajan Singh, Mangat Ram Dogra
June 2019, 67(6):938-939
DOI:10.4103/ijo.IJO_848_19  PMID:31124520
  241 52 -
PHOTO ESSAY
Multimodal retinal imaging of a 6-year-old male child with incontinentia pigmenti
Alok Sen, Pratik Shenoy, Ashish Mitra, Tanya Jain
June 2019, 67(6):942-943
DOI:10.4103/ijo.IJO_192_19  PMID:31124522
  225 68 -
OPHTHALMIC IMAGES
Lipemia retinalis in an infant
Ramanuj Samanta, Deeksha Katoch
June 2019, 67(6):953-953
DOI:10.4103/ijo.IJO_225_19  PMID:31124529
  217 71 -
PHOTO ESSAY
Multimodal imaging in a patient of Kranenburg syndrome
Srikanta K Padhy, Rebika Dhiman, Prashant Kumar, Toshit Varshney, Atul Kumar
June 2019, 67(6):946-947
DOI:10.4103/ijo.IJO_1816_18  PMID:31124524
  225 63 -
CASE REPORTS
Macular hole following successful stage 4B/stage 5 retinopathy of prematurity surgery
Ekta Rishi, Pukhraj Rishi
June 2019, 67(6):971-973
DOI:10.4103/ijo.IJO_719_18  PMID:31124537
To report three eyes surgically managed for stage 4B/stage 5 retinopathy of prematurity (ROP) with successful retinal reattachment resulting in macular hole formation after 2–3 months. One patient was observed, and two patients underwent membrane dissection and silicone oil injection and maintained attached retina at last follow-up. The case series is novel to present internal limiting membrane peeling around macular hole with hole closure in one patient which is hitherto not reported. Two of the three eyes received intravitreal bevacizumab injection for aggressive posterior ROP before surgical intervention.
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ORIGINAL ARTICLES
Habilitation services for children blind from retinopathy of prematurity: Health care professionals' perspective in Maharashtra
Sucheta Kulkarni, Clare Gilbert, Nilesh Kakade, Kuldeep Dole, Col M Deshpande, Rajvardhan Azad
June 2019, 67(6):928-931
DOI:10.4103/ijo.IJO_573_18  PMID:31124517
Purpose: To explore the knowledge of retinopathy of prematurity (ROP) and habilitation services for children with visual loss from ROP, among health care professionals (HCPs) involved in care of preterm children and to explore their attitudes and practices in relation to referral for habilitation. Methods: A modified knowledge, attitude and practice questionnaire were administered to ophthalmologists and paediatricians associated with ROP care. Data were collected about their knowledge, beliefs and practices of ROP and referral to rehabilitation facilities. Data were analysed to establish level of knowledge, type of attitude and practices and its association with speciality. Results: Response rate was 78% (25/32). Most (14/25, 56%) were ophthalmologists. All (100%) participants knew that ROP can cause blindness. Knowledge about Indian ROP screening criteria was poor among a third (8/25, 32%), more so in paediatricians (5/11, 45.5%). Most (21/25, 84%) did not have knowledge of what a habilitation service entails and where such facilities are located. More than two-thirds (18/25, 72%) believed that special education should be preferred over inclusive education. Overall, 10/25 (40%) of the HCPs had never referred a child for rehabilitation. More than a half (13/25, 52%) were not confident of counselling parents of blind children. All agreed that rehabilitation services are not part of but should be included in medical curriculum. Conclusion: Indian guidelines for ROP screening are not universally known among HCPs. Educating medical undergraduates, providing counselling training to professionals and integration of rehabilitation into the health system will ensure continuity of care for children with visual loss and their families.
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CASE REPORTS
Retinopathy of prematurity in oculocutaneous albinism
Parijat Chandra, Nitesh Salunkhe, Vinod Kumar, Devesh Kumawat, Ruchir Tewari
June 2019, 67(6):960-962
DOI:10.4103/ijo.IJO_931_17  PMID:31124532
We report a case of retinopathy of prematurity (ROP) in an infant with oculocutaneous albinism (OCA), with the challenges faced in diagnosis, and subsequent management. Poor fundus contrast and blanching of retinal vessels on indentation caused significant visualization problems in detection of ridge and extraretinal vessel proliferation. Careful examination revealed zone 2 Stage 3 ROP with preplus disease in both eyes. Laser photocoagulation was attempted, but laser uptake was poor. The disease regressed over 3-week close follow-up. ROP along with OCA is a rare finding. There is a need for high index of suspicion and caution while screening and managing such babies.
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SURGICAL TECHNIQUE
Hybrid clear corneal micro-incision surgical technique for stage 5 retinopathy of prematurity
Parijat Chandra, Devesh Kumawat, Ruchir Tewari
June 2019, 67(6):936-938
DOI:10.4103/ijo.IJO_420_19  PMID:31124519
A safe technique for entry incisions and closure in stage 5 retinopathy of prematurity (ROP) surgery is being described. Three 23G clear corneal incisions are made which allow for safe and snug entry of 25G calibrated infusion and 25G instruments for performing lensectomy, membrane removal and vitrectomy. At the end of surgery, air is injected and corneal entries are hydrated for sutureless closure. The technique was performed in 50 eyes of 36 children with stage 5 ROP. The hybrid technique ensured safe entry and exit with stable anterior chamber during surgery. None of the cases developed retinal breaks during surgical entry nor had any complications such as hypotony, flat anterior chamber, hyphaema or corneal edema in post operative period. Clear corneal entry using 23G incisions for 25G instrument access is a safe and effective technique for performing lensectomy and vitrectomy with sutureless closure in cases with stage 5 ROP.
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COMMENTARY
Commentary: Antivascular endothelial growth factor and retinopathy of prematurity
Ajay Indur Dudani, Anupam Dudani, Krish Dudani
June 2019, 67(6):969-970
DOI:10.4103/ijo.IJO_1220_17  PMID:31124536
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ORIGINAL ARTICLES
Results of surgery for late sequelae of cicatricial retinopathy of prematurity
Hatice Tuba Atalay, Şengül Özdek, Duygu Yalınbaş, Cemal Özsaygılı, Mehmet Cüneyt Özmen
June 2019, 67(6):908-911
DOI:10.4103/ijo.IJO_1083_18  PMID:31124513
Purpose: To report anatomical and functional results of vitreoretinal surgery in our case series of late cicatricial retinopathy of prematurity (ROP) patients with subtotal retinal detachment. Methods: This is a retrospective, consecutive case series. Eleven eyes of 10 patients presented with partial tractional retinal detachment secondary to late cicatricial ROP (cicatricial stage 4B) who underwent vitreoretinal surgery were retrospectively reviewed. Anatomical and functional outcomes were evaluated. Results: The mean gestational age at birth was 28.6 (26–32) weeks. The mean age at surgery was 79 (4–213) months. Patients were followed up for 21.7 (6–40) months. Six eyes (55%) had lens-sparing vitrectomy and five eyes (45%) had lensectomy + vitrectomy. Anatomical success was achieved in 10 eyes (91%). Improvement in visual acuity was noted in nine eyes (82%). Conclusion: Eye grows but fibrotic tissue does not grow with age, and during this period retinal traction may get worse. Relieving these tractions may lead to good anatomical and visual outcomes in selected late cicatricial ROP cases.
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COMMENTARIES
Commentary: Continuation of care - Refraction beyond regression
Manavi D Sindal, M Arthi
June 2019, 67(6):877-878
DOI:10.4103/ijo.IJO_767_19  PMID:31124507
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ORIGINAL ARTICLES
Ocular auto-stimulation and its morbidity in stage 5 retinopathy of prematurity
Devesh Kumawat, Pranita Sahay, Tanveer Alam, Anju Bhari, Parijat Chandra
June 2019, 67(6):912-916
DOI:10.4103/ijo.IJO_2116_18  PMID:31124514
Purpose: To evaluate the characteristics and morbidity due to ocular auto-stimulation (OAS) in stage 5 Retinopathy of Prematurity (ROP). Methods: Stage 5 ROP cases presenting to ROP clinic of a tertiary care centre from January 2017 to December 2017 were recruited. Eye-pressing was elicited on history from parents and categorized as infrequent (performed <50% of waking time) or frequent (≥50% of time). B-scan ultrasonography was performed for configuration of retinal detachment (open or closed funnel). Keratometry was performed in eyes undergoing vitrectomy under general anaesthesia using automated hand-held keratometer. The outcome measures were the presence and characteristics of OAS, enophthalmos, corneal opacity and keratometry values. Results: Out of 93 eyes of 49 babies, 78.5% (n = 73) had OAS. Gestational age, birth weight, sex, retinal funnel configuration, and visual function did not significantly affect OAS. However, post-conceptional age was significantly greater in eyes with OAS (95% CI: 63.1 to 69.9 weeks) than those without OAS (95% CI: 52.4 to 63.4 weeks) (P = 0.018). OAS occurred frequently in 32.8% (n = 24/73) eyes, more commonly in eyes with light followability. Keratometry did not differ significantly with the presence of OAS (P = 0.88). Enophthalmos, corneal opacity, posterior synechiae were noted in 79.5% (58/73), 21.9% (16/73), and 28.8% (21/73) eyes with OAS, respectively. Enophthalmos occurred significantly in eyes with OAS (P = 0.001), while corneal opacity and posterior synechiae did not (P = 0.071 and 0.91, respectively). Conclusion: OAS and its resultant morbidity are common occurrences in stage 5 ROP. The post-conceptional age and residual visual function may govern the characteristics of OAS.
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CASE REPORTS
Late onset Descemet's membrane detachment: 15 years after limbal lensectomy with vitrectomy for ROP
Ekta Rishi, Bhaskar Srinivasan, Niharika Singh, Lingam Gopal
June 2019, 67(6):965-966
DOI:10.4103/ijo.IJO_725_18  PMID:31124534
A case of stage 4B retinopathy of prematurity (ROP) after successful retinal reattachment surgery with maintained vision presented with hazy cornea with spontaneous Descemet's membrane detachment (DMD) 15 years after the surgery, requiring Descemet Stripping Endothelial Keratoplasty (DSEK) to restore vision. There are reports of late spontaneous DMD after phacoemulsification or previous corneal surgeries. This report is unique as there is no published literature of spontaneous DMD after limbal surgery for ROP when searched in PubMed. The immature Descemet's membrane (DM), surgical intervention and changes in immature DM with age would have contributed to spontaneous DMD and warrant a long-term follow-up of premature kids.
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ORIGINAL ARTICLES
Surgical outcomes of immediate sequential bilateral vitreoretinal surgery for advancing retinopathy of prematurity
Parijat Chandra, Devesh Kumawat, Ruchir Tewari, Renu Sinha
June 2019, 67(6):903-907
DOI:10.4103/ijo.IJO_741_18  PMID:31124512
Purpose: Bilateral eye surgery in the same session may be required for advancing stage 4 retinopathy of prematurity (ROP). The purpose of this study was to evaluate the outcomes of immediate sequential bilateral vitreoretinal surgery (ISBVS) in stage 4 ROP. Methods: In a retrospective interventional study at a tertiary care center, 60 eyes of 30 infants who underwent ISBVS for stage 4 ROP between December 2015 and May 2017 were studied. In cases with clear retrolental access, 25G or 27G lens sparing vitrectomy (LSV) was performed and in the rest 25G lensectomy with vitrectomy (LV) was performed through clear corneal entries. The final anatomical outcome measures were the status of tractional retinal detachment (TRD) and macular status. Results: The mean gestational age was 28.4 ± 2.0 weeks and birth weight was 1214.5 ± 329.7gms. The mean postconceptional age at surgery was 40.8 ± 2.2 weeks. Stages 4a and 4b were present in 86.7% and 13.3% eyes respectively. LSV was performed in 95% eyes whereas LV was performed in the rest. None of the eyes developed lens touch, choroidal hemorrhage, postoperative hypotony, corneal decompensation, or endophthalmitis. At last follow-up (mean 45 weeks, range 20–68 weeks), macula was attached in 90% eyes with the TRD resolved completely in 61.7% eyes and significantly decreased in another 25% eyes. Sequalae included macular drag, epiretinal membrane, and progression to fibrotic stage 5 disease. Conclusion: ISBVS is safe and effective for bilateral stage 4 ROP and should be recommended in rapidly progressive cases.
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COMMENTARY
Commentary: Retinal immaturity at first screening and retinopathy of prematurity: Image-based validation of 1202 eyes of premature infants to predict disease progression
Lingam Gopal
June 2019, 67(6):853-854
DOI:10.4103/ijo.IJO_733_19  PMID:31124501
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COMMENTARIES
Commentary: Functional outcome after successful laser for retinopathy of prematurity – Where we stand?
Ekta Rishi, Aashi Bansal
June 2019, 67(6):876-877
DOI:10.4103/ijo.IJO_658_19  PMID:31124506
  174 55 -
OPHTHALMIC IMAGES
Myelinated retinal nerve fibers and persistent hyperplastic primary vitreous
Sonali Gupta, Hannah Shiny, Ravi Kumar Bhukya, Shreyans Jain, Vinod Kumar
June 2019, 67(6):952-952
DOI:10.4103/ijo.IJO_1518_18  PMID:31124528
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