Purpose: To evaluate the results and extrusion rates of the Ahmed glaucoma valve (AGV) implantation through a needle-generated scleral tunnel, without a tube-covering patch, in children. Materials and Methods: A retrospective review of the charts of 106 Mexican children implanted with 128 AGVs operated between 1994 and 2002, with the needle track technique, at our institution, with at least six months follow up was done. Main outcome measures were intraocular pressure (IOP) control, tube extrusions or exposure and other complications. Results: Kaplan-Meier analysis demonstrated a 96.9% survival rate at six months, 82.4% at one year, 78.7% at two years, 70% at three years and 41.6% at four years. Total success at the last follow-up (IOP between 6 and 21 mm Hg without medications) was achieved in 30 eyes (23.5%), 58 eyes (45.3%) had qualified success (only topical hypotensive drugs) and 40 eyes (31.3%) were failures. The mean pre- and post-operative IOP at the last follow up was 28.4 mmHg (SD 9.3) and 14.5 mmHg (SD 6.3), respectively. No tube extrusions or exposures were observed. Tube-related complications included five retractions, a lens touch and a transitory endothelial touch. The risk of failure increased if the eye had any complication or previous glaucoma surgeries. Conclusion: Medium-term IOP control in Mexican children with glaucoma can be achieved with AGV implantation using a needle-generated tunnel, without constructing a scleral flap or using a patch to cover the tube. There were no tube extrusions, nor any tube exposures with this technique.

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Cycloposition has been measured by various methods; however, fundus photography is the most reliable method to evaluate the torsion objectively. We did a prospective study to find out the disc foveal angle (DFA) and its variation in children without squint. We included 210 eyes of 105 children between the ages of 5-15 years. DFA was calculated using standard technique after taking a fundus photograph. The cycloplegic refraction was done and compared. The mean age was 10.6 ± 2.5 years. Mean DFA in right eye (RE) was 6.49 ± 3.25° (0-13°) and in left eye (LE) was 5.80 ± 3.29° (0-12°). The difference between the RE and LE was statistically not significant (P=0.131) (mean 1.15 ±1.39°). Mean DFA in emmetropic children was 6.1° ± 3.4° (n=112 eyes). DFA varies widely in children. The difference observed in DFA measurement for eyes with various refractive errors were compared with DFA measurements for emmetropic eyes.

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Purpose: To compare corneal pachymetry assessment by the Galilei dual Scheimpflug analyzer with that done by ultrasound (US) pachymetry. Materials and Methods: Forty six patients (92 eyes) were subjected to corneal pachymetry assessment by Galilei dual Scheimpflug analyzer and US. All the readings were taken by a single operator. Intraoperator repeatability for the Galilei was assessed by taking 10 readings in one eye each of 10 patients. To study the interoperator reproducibility for the Galilei, two observers took a single reading in both the eyes of 25 patients. Results: The mean central corneal thickness (CCT) measured by US was 541.83 ± 30.56 μm standard deviation (SD) and that measured by Galilei was 541.27 ± 30.07 μm (SD). There was no statistically significant difference between both the methods (P < 0.001). The coefficient of repeatability was 0.43% while the coefficient of reproducibility was 0.377% for the Galilei. Conclusion: Objective, noncontact measurement of the CCT with the Galilei dual Scheimpflug analyzer was convenient, had excellent intraoperator repeatability and interoperator reproducibility, and findings were similar to those obtained with standard US pachymetry.

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Purpose: This study aims to investigate the levels of aqueous vascular endothelial growth factor (VEGF) in diabetic patient groups in comparison to normal subjects, and to correlate elevated VEGF with the severity of diabetic retinopathy (DR). Materials and Methods: Aqueous samples were obtained from 78 eyes of 74 patients undergoing intraocular surgery and they were examined by the enzyme-linked immunosorbent assay. Color photographs, optical coherence tomography scans, and fluorescein angiography were used to evaluate patients preoperatively. Results: A strong statistical correlation was found to exist between the level of aqueous VEGF and the severity of DR ( P < 0.001), whereas, the VEGF levels in a control group and a diabetic group without DR were not significantly different ( P = 0.985). Aqueous VEGF levels were significantly elevated in patients with proliferative DR (PDR) as compared to the control group ( P < 0.001), to diabetic patients without retinopathy (NDR) ( P < 0.001), and to diabetic patients with nonproliferative DR (NPDR) ( P < 0.001). The aqueous VEGF levels were significantly higher in patients with active PDR than in those with quiescent PDR ( P = 0.001). On the other hand, a statistically insignificant ( P = 0.065) correlation was found between elevated aqueous VEGF and the presence of macular edema in the NPDR group. Conclusions: VEGF was elevated in the aqueous humor of patients with DR compared to that in normal eyes. The aqueous VEGF level had a strong correlation with the severity of retinopathy along with a statistically insignificant difference in macular edema.

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A 23-year-old male patient with right nasal Juvenile Nasopharyngeal Angiofibroma (JNA) developed Central Retinal Artery Occlusion (CRAO) during embolization of the tumor using polyvinyl alcohol particles before endoscopic excision. Classic CRAO management was initiated by an ophthalmologist after 12 h. Retrospective evaluation of the angiograms revealed a tiny communication between the external carotid and ophthalmic arteries which had not been noticed before embolization. During endoscopic excision, the tumor was found to originate extraordinarily from midline structures. It was concluded that CRAO might be a rare complication of JNA embolization. Careful preoperative angiographic evaluations to detect communicating arteries and immediate ophthalmologic consultation in case of developing visual symptoms during the procedure are necessary.

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Aims: To present the clinical, indocyanine green angiography (ICGA) features and results of treatment for polypoidal choroidal vasculopathy (PCV) in Indian patients by a retrospective chart review.Materials and Methods: Forty five patients with PCV underwent complete ocular examination, fluorescein angiography (FFA) and ICGA. Treatment was advised for patients with macular involvement and progressive loss of visual acuity. Demographic data, clinical features and results of treatment were analyzed.Results: Mean age at presentation was 61.06 years. Mean follow up was 18 months. The disease was more prevalent in males. Forty three patients had unilateral disease. The most common location of polyps in ICGA was subfoveal (42.5%). Exudative form was seen in 34 of the 47 eyes and the remaining 13 eyes had a hemorrhagic presentation. Thirty four eyes underwent treatment which included thermal laser (n = 11), photodynamic therapy (PDT) (n = 11) and transpupillary thermo therapy (TTT) (n = 12). Statistical analysis was done using the Chi-square test. Subgroup analysis of visual outcome following various modalities of treatment showed that the results of PDT (P < 0.001) and thermal laser (P < 0.001) were statistically significant. Conclusions: PCV is an important differential diagnosis in patients presenting with serosanginous maculopathy and submacular hemorrhage. The disease was more prevalent in males and was unilateral in the Indian population. Timely intervention in cases with symptomatic polyps could achieve stabilization of visual acuity. Thermal laser and PDT were safe and effective.

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Amongst the clinical presentations of retinal artery occlusion, hemi-central retinal artery occlusion (Hemi-CRAO) is rarely described. This case series of four adults aged between 22 and 36 years attempts to describe the clinical profile, etiology and management of Hemi-CRAO. Case 1 had an artificial mitral valve implant. Polycythemia and malignant hypertension were noted in Case 2. The third patient had Leiden mutation while the fourth patient had Eisenmenger's syndrome. Clinical examination and fundus fluorescein angiography revealed a bifurcated central retinal artery at emergence from the optic nerve head, in all cases. Color Doppler examination of the central retinal artery confirmed branching of the artery behind the lamina cribrosa. It is hypothesized that bifurcation of central retinal artery behind the lamina cribrosa may predispose these hemi-trunks to develop an acute occlusion if associated with underlying risk factors. The prognosis depends upon arterial recanalisation and etiology of the thromboembolic event.

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A 59-year-old man with a history of longstanding systemic hypotension developed asymmetric non-arteritic anterior ischemic optic neuropathy (NAION) apparently precipitated by bilateral sequential acute primary angle closure. NAION is very rarely reported in association with raised intraocular pressure. In contrast to optical coherence tomography, the failure of scanning laser polarimetry to detect axonal swelling was another interesting finding. Possible reasoning for these observations is discussed.

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Aim: A clinical comparative trial was conducted to compare the levels of glycosylated hemoglobin (HbA1c) in patients with diabetic cystoid macular edema (CME) with and without serous macula detachment (SMD). Materials and Methods: Thirty patients (group 1) with diabetic CME in both eyes, but without SMD, and 30 patients (group 2) with diabetic CME and SMD in both eyes documented by optical coherence tomography (OCT) and fundus fluorescein angiography (FFA), were included in the study. In addition to the measurement of central macular thickness by OCT and visual acuity (VA) (as logMAR) using the the early treatment diabetic retinopathy study (ETDRS) chart, the concentrations of HbA1c were measured by high performance liquid chromatography (HPLC). Statistical analysis was done by independent samples t test. Results: The mean logMAR VA was 0.8 ± 0.22 (1.0-0.5) in group 1and 0.7 ± 0.16 (1.0-0.6) in group 2. The mean central macular thickness, as determined by OCT, was 468.70 ± 70.44 μm (344-602 μm) in group 1 and 477.80 ± 73.34 μm (354-612 μm) in group 2. The difference between the groups was not statistically significant (P = 0.626). The mean HbA1c levels were 8.16 ± 0.99% in group 1 and 10.05 ± 1.66% in group 2. The difference between the groups was statistically significant (P < 0.001). Conclusions: The presence of SMD and high HbA1c levels in the patients with diabetic CME may be indirectly suggestive of retinal pigment epithelium dysfunction.

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Colletotrichum graminicola is a medically important fungus belonging to the order Melanconiales under the class Coelomycetes. The members of the genus Colletotrichum are primarily plant pathogens which cause anthracnoses (fungal infection in plants). In the past few decades, they are progressively being implicated as etiological agents of subcutaneous hyalohyphomycoses and keratomycoses. Of the five medically important members in the genus Colletotrichum, keratitis due to Colletotrichum graminicola is rare. We diagnosed Colletotrichum graminicola keratitis in a 44-year-old man who presented with a non-healing corneal ulcer since three weeks. Positive smears and cultures from the corneal scrapings established the causative organism as C. graminicola. The patient was treated with a combination of oral ketoconazole and topical fluconazole and natamycin. Infection resolved over 10 weeks and antimicrobials were stopped. We describe the clinical presentation and treatment outcome of Colletotrichum graminicola keratitis.

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Aim: To compare the satisfaction of patients with the services of Vision Center services (primary eye care) in large village (s) and small village (s) in rural settings in Andhra Pradesh state, India. Materials and Methods: We have administered standard questionnaires to randomly selected patients to assess patient satisfaction when assessing Vision Center Services. We used the Chi-square ( P <0.05) to explore differences in satisfaction of patients with Vision Center services located in the large village (s) and small village (s) rural settings. Results: Vision Center patients at the large village (s) expressed higher levels of satisfaction (median 78%) than patients treated at the Vision Center at small village (s) (median 69%). The difference was statistically significant (Chi square P value ranging from <0.001 to 0.03) for all the items except two - 'easy to identify vision center location' and 'spectacles dispensing time' as compared to other (privately run optometry) facilities (Chi square P value=0.498 and 0.993 respectively). The location of the Vision Center, convenience of journey, ophthalmic technician's behavior with patients, are some of the most important factors that determined the patient perception about Vision Center services. Conclusion: The overall satisfaction levels of the Vision Center experience at 78% and 69% were good. However, continual improvement is to be made in service time, staff performance, cost and quality of vision care, especially at more remote primary eye Care Centers.

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The occurrence of acquired conjunctival inclusion cysts following various ophthalmic surgeries such as strabismus surgery, scleral buckling, pars plana vitrectomy, ptosis surgery and phacoemulsification has been reported. We report two cases of conjunctival inclusion cysts following manual Small Incision Cataract Surgery (SICS) in two male patients aged 65 and 67 years. The cysts originated from the scleral tunnel used for manual SICS. Both were treated by excision and confirmed histopathologically. No recurrence was noted at three months follow-up. To our knowledge, conjunctival inclusion cysts following SICS have not been reported previously. Careful reflection of conjunctiva during tunnel construction and posterior chamber intraocular lens implantation may prevent their occurrence.

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A 44-year-old man presented 28 days after cataract surgery (phacoemulsification) in right eye with multiple pinpoint infiltrates in posterior stroma at cataract surgery wound site. Visual acuity was 20/60. Corneal scraping from the floor of the corneal tunnel revealed fungus which was later identified to be Aspergillus flavus. The patient was started on oral voriconazole 200 mg twice daily and topical voriconazole 1% every hour. Two intracameral injections of voriconazole (50 micrograms/ 0.1 ml) were given 72 h apart, five days after starting initial therapy. Infiltrates increased in size and density in spite of 20 days of voriconazole therapy. Full-thickness patch graft was done to arrest progressive necrosis. Four months after surgery, patient had 20/60 best-corrected visual acuity. There was no recurrence in one-year follow-up. Present case illustrates the therapeutic challenge in fungal tunnel infections and possibility of voriconazole-resistant Aspergillus species.

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Purpose: To study the effect of cataract extraction on the retinal nerve fiber layer (RNFL) thickness, and assessment by scanning laser polarimetry (SLP), with variable corneal compensation (GDx VCC), at the glaucoma service of a tertiary care center in North India. Materials and Methods: Thirty-two eyes of 32 subjects were enrolled in the study. The subjects underwent RNFL analysis by SLP (GDx VCC) before undergoing phacoemulsification cataract extraction with intraocular lens (IOL) implantation (Acrysof SA 60 AT) four weeks following cataract surgery. The RNFL thickness parameters evaluated both before and after surgery included temporal, superior, nasal, inferior, temporal (TSNIT) average, superior average, inferior average, and nerve fiber index (NFI). Results: The mean age of subjects was 57.6 ± 11.7 years (18 males, 14 females). Mean TSNIT average thickness (μm) pre- and post-cataract surgery was 49.2 ± 14.1 and 56.5 ± 7.6 ( P = 0.001). There was a statistically significant increase in RNFL thickness parameters (TSNIT average, superior average, and inferior average) and decrease in NFI post-cataract surgery as compared to the baseline values. Mean NFI pre- and post-cataract surgery was 41.3 ± 15.3 and 21.6 ± 11.8 ( P = 0.001). Conclusions: Measurement of RNFL thickness parameters by scanning laser polarimetry is significantly altered following cataract surgery. Post the cataract surgery, a new baseline needs to be established for assessing the longitudinal follow-up of a glaucoma patient. The presence of cataract may lead to an underestimation of the RNFL thickness, and this should be taken into account when analyzing progression in a glaucoma patient.

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Retinoblastoma is a rare malignancy of the retina seen exclusively in children. It is known to cause rapid growth inside the eye and hence treatment should be started as soon as it is diagnosed. We report a case in a five-day-old infant in whom treatment (chemotherapy) was delayed by a month due to high bilirubin levels secondary to physiological jaundice, which gave us the unique opportunity to measure the growth of the tumor over a month. This case emphasizes that immediate treatment is warranted once this rare disease is diagnosed.

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Aim: Bio-adhesives like cyanoacrylate offer an alternative to sutures to attach tissues, including in ophthalmology. This prospective trial evaluated the suitability and bio-tolerance of iso-amyl cyanoacrylate in rectus muscle recession surgery for strabismus. Materials and Methods: We randomized one eye in each of 10 cases of bilateral horizontal rectus recessions to 6/0 polyglactin and the other to iso-amyl-cyanoacrylate. We compared time to reattachment (from disinsertion), complications and inflammatory scores (0 to +3: nil, mild, moderate and severe) on Day One, at two and at four to six weeks post surgery. Results: There were no significant group differences in inflammatory scores (Wilcoxon, all values of P>0.05). All attachments held firm. Gluing took significantly longer by 5.24±1.91 min (95% CI for difference: 3.87-6.61). There were no complications. Conclusion: We feel that although it takes marginally longer, iso-amyl cyanoacrylate offers an effective and safe alternative to sutures for muscle recession in strabismus surgery. Since it is cheaper (vs. polyglactin) and offers multi-use possibility it may also prove to be cost-effective.

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A 3-year-old girl presented with a hemorrhagic conjunctival lesion in the right eye. The medical history revealed premature cessation of breast feeding, intolerance to the ingestion of baby foods, anorexia, and abdominal distention. Prior to her referral, endoscopic small intestinal biopsy had been carried out under general anesthesia with a possible diagnosis of Celiac Disease (CD). Her parents did not want their child to undergo general anesthesia for the second time for the excisional biopsy. We decided to follow the patient until all systemic investigations were concluded. In evaluation, the case was diagnosed with CD and the conjunctival tumor showed complete regression during gluten-free dietary treatment. The clinical fleshy appearance of the lesion with spider-like vascular extensions and subconjunctival hemorrhagic spots, possible association with an acquired immune system dysfunction due to CD, and spontaneous regression by a gluten-free diet led us to make a presumed diagnosis of conjunctival Kaposi sarcoma.

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Glaucoma drainage devices are an option in refractory glaucomas for control of intraocular pressure (IOP). We evaluated the outcome of pars plana Ahmed glaucoma valve along with triamcinolone-assisted vitrectomy in 11 eyes with uncontrolled IOP on maximum tolerable antiglaucoma therapy. The mean preoperative IOP of 33.64 ± 5.99 (range 26 to 44 mmHg) decreased to 17.09 ± 2.26 (range 14 to 20 mmHg) and 17.45 ± 1.81mm of Hg (range 14 to 24 mmHg) at 6 and 12 months following surgery. The mean number of antiglaucoma medications decreased from 3.27 ± 0.05 to 0.64 ± 0.67 and 0.55 ± 0.6 at 6 and 12 months following surgery.

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