India is considered the diabetes capital of the world, and a significant proportion of patients undergoing cataract surgery are diabetic. Considering this, we reviewed the principles and guidelines of managing cataract in patients with diabetes. The preoperative, intraoperative, and postoperative factors are of paramount importance in the management of diabetic cataract patients. Particularly, the early recognition and treatment of diabetic retinopathy or maculopathy before cataract surgery influence the final visual outcome and play a major role in perioperative decision-making. Better understanding of various factors responsible for favorable outcome of cataract surgery in diabetic patients may guide us in better overalll management of these patients and optimizing the results.

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Purpose: To correlate the severity of meibomian gland dysfunction (MGD) with the serum lipoprotein levels. Methods: The study was conducted as a prospective observational study over a period of 18 months. Ninety patients diagnosed with MGD were enrolled after they gave their informed consent according to the inclusion–exclusion criteria. Meibomian gland status was evaluated by meibum quality, expressibility, and numerical scoring. Lipid profile was done from an overnight fasting blood sample and evaluated for total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, and triglycerides (TGs). Results: Patients with higher stages of MGD more often had serum TGs >150 mg/dL, total cholesterol >200 mg/dL, an LDL >130 mg/dL, and serum HDL >40 mg/dL, and there exists an association between increasing stage of MGD, and age, female sex, and increasing values of all the lipid profile components. Conclusion: A very strong association exists between increasing age and increasing severity of stage of MGD. A positive association exists between female sex and increasing severity of stage of MGD. A positive association exists between increasing severity of MGD and increasing levels of all the components of lipid profiles, namely LDL, HDL, total cholesterol, and triglycerides.

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Purpose: To report mortality of patients who were eligible for enrollment in the Collaborative Ocular Melanoma Study (COMS) clinical trials of medium-sized choroidal melanoma or large-sized choroidal melanoma but chose to defer treatment or receive no melanoma treatment. Design: Prospective nonrandomized multicenter cohort study as an adjunct to COMS randomized clinical trials. Methods: Patient follow-up procedures included examinations, correspondence, telephone contacts, and National Death Index searches. Primary outcome was patient death measured by all-cause mortality. Secondary outcomes were melanoma treatment and melanoma metastasis. Results: Of 77 patients eligible for COMS clinical trials who chose to defer or receive no melanoma treatment, 61 were appropriate candidates and 45 (74%) enrolled in the natural history study (NHS). In all, 42 patients (42 eyes) had medium melanoma, and the median follow-up was 5.3 years (range, 4–10.7 years). In all, 22 patients (52%) had subsequent melanoma treatment, and 20 (48%) had no melanoma treatment. For the 42 patients, Kaplan–Meier estimate of 5-year mortality was approximately 30% [95% confidence interval (CI), 18%–47%]. For COMS medium melanoma trial, 5-year mortality was 18% (95% CI, 16%–20%), not statistically significantly different from the NHS patients. After adjusting for differences in age and longest basal diameter, the 5-year risk of death for NHS patients versus COMS trial patients was 1.54 (95% CI, 0.93–2.56). Three patients had large melanoma. Melanoma metastasis was confirmed or suspected in 8 (42%) of 19 deaths. Conclusion: Greater mortality and higher risk of death for NHS patients are probative but not conclusive evidence of a beneficial, life-extending effect of medium melanoma treatment.

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The classic entity of autosomal dominant Blau syndrome (BS) consists of arthritis, dermatitis, and uveitis, occurring as a result of mutations in the NOD2 gene pattern recognition receptor. Sporadic cases are those in which no known gene mutation is identifiable. Uveitis in BS can be refractory to conventional therapy. We report a case of sporadic Blau uveitis managed with adalimumab monotherapy after failing to respond to topical steroids, systemic steroids, methotrexate, and infliximab therapy sequentially. Uveitis resolved completely with adalimumab and the patient has had a disease-free period over a 2-year follow-up with bi-monthly injections for arthritis control.

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Epiretinal membrane over macula secondary to toxoplasmosis compromises vision. We describe the outcome of pars plana vitrectomy and epiretinal membrane removal after adequate treatment of acute infection. The average age of all four male patients was 36 years (range 20–60 years). Following surgery there was an average three or more lines visual acuity improvement, restoration of foveal contour with reduction in central macular thickness. One patient developed choroidal neovascular membrane postsurgery and was effectively treated with intravitreal bevacizumab. Surgery for ERM secondary to healed toxoplasmosis infection has good anatomical outcome and reasonable visual improvement, when the surgery is done in a quiet eye.

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Persistent pupillary membranes (PPMs) are a common congenital anomaly seen in 95% of neonates. Extensive PPMs, occluding the visual axis and resulting in reduced visual acuity, are relatively uncommon. We describe a case of bilateral total PPM in a 36-year-old female who presented with complaints of blurred vision in both the eyes. Dense pupillary membranes obscuring the visual axis need early surgical treatment. It is essential that the lens status remains clear along the visual axis both before and after pupilloplasty.

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Purpose: To compare the efficacy of AT-TORBI plate haptic toric intraocular lens (IOL) (Carl Zeiss Meditec AG, Jena, Germany) and AcrySof loop haptic toric IOL (Alcon Laboratories, Inc., Fort Worth, TX, USA) for correcting preexisting astigmatism of ≥1 diopters (D) in patients undergoing phacoemulsification and to compare the rotational stability of these two toric IOLs. Methods: In this prospective randomized controlled trial. Forty-two eyes of 42 cataract patients with preexisting astigmatism of 1 D or more were randomized to receive plate haptic toric (AT TORBI) or loop haptic toric (AcrySof) IOLs, with 21 in each group. Postoperative evaluation was done at day 1, 1 week, 1 month, and 3 months. Uncorrected distance visual acuity (UDVA), best corrected visual acuity (VA), and IOL position were noted in both the groups. Results: At 3 months postoperatively, the mean log MAR UDVA was 0.23 ± 0.20 and 0.20 ± 0.13 in Groups I and II, respectively (P = 0.7), the mean residual cylindrical refractive error in plate haptic toric group was 0.40 ± 0.31 D and in loop haptic group was 0.45 ± 0.33 D (P = 0.64). The mean IOL rotation at 3 months follow-up in plate haptic group was found to be 3.52 ± 3.84° and in loop haptic group was 2.05 ± 2.56° (P = 0.25). Conclusion: Both types of toric IOLs were equally efficacious for attaining good uncorrected VA and correcting preexisting astigmatism between 1–5 D. Both of them were rotationally stable at 3 months follow-up.

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Purpose: To assess major causes of severe visual impairment (SVI)/blindness (BL) in children studying in schools for the blind in western Uttar Pradesh, India and the extent of inappropriate enrolment of children in blind schools. Methods: Students of five schools for the blind were examined in a tertiary care eye hospital. The anatomical sites and etiology for SVI/BL were recorded using the World Health Organization/Prevention of Blindness standard reporting form. Categorical variable were summarized using frequencies and percentages. Results: A total of 93 students were examined. Male/Female ratio was 3.4:1. The most common anatomical sites of SVI/BL were the whole globe (40.3%) and the cornea (26.4%). Postnatal or childhood causes were noted in 13.8% cases. Forty-one (56.9%) students had hereditary diseases which was most likely caused by chromosomal abnormalities. Three students were having an associated disability, one was deaf and mute, one was physically handicapped, and one was intellectually challenged. Fifty-four (58%) children were blind and 21 (22.6%) children had no visual impairment but were studying in schools for the blind. Conclusion: Schools for the blind should be screened routinely to reduce the incidence of misdiagnosed visual impairment. This will prevent inappropriate enrolment and will definitely help in reducing the social and economic burden of society and of the schools of blind too.

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We report a case of accidental ocular chemical injury by self-medication with a single application of a topical ayurvedic medication containing salicylic acid, phenol, and tincture iodine, which is being used in developing countries for treatment of various dermatological conditions.

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Measles virus is a rare but important cause for acute retinitis as it can eventually lead to the fulminant complication of SSPE. We report a case of a young Indian male with acute viral retinitis who subsequently developed SSPE. It is of paramount importance to consider measles virus and SSPE as a cause in an immunocompetent young adult with necrotizing viral retinitis

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Purpose: To report clinical manifestations of ocular allergy to atropine eye drops used for retardation of progressive myopia in children. Methods: Myopic children, who developed bothersome itching that subsided promptly after cessation of atropine eye drops, were included. History of systemic or ocular allergy, preexisting ocular conditions, and clinical features of allergy were noted. Results: Six children, age 5–15 years, were included. Four developed allergy to 1% atropine sulfate eye drops and two to 0.01% concentration of atropine sulfate. The onset of allergy was within a month to as late as 4 years after using atropine eye drops. The severity of allergy was higher with 1% concentration. The most common symptoms of atropine allergy were itching and burning. The most common signs were lid swelling and hyperemia. The allergic manifestations promptly reversed with the stoppage of eye drops. Reintroduction was possible in three patients, either by reducing the concentration of atropine or using benzalkonium free formulation. Conclusion: Allergy to atropine eye drops in children may develop within a few weeks or after many years of usage. Prompt cessation followed by a reintroduction and continuation of therapy may be possible in few patients.

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Purpose: To compare and report the intra- and postoperative outcomes of phacoemulsification between longitudinal (LPKE) and torsional (TPKE) mode, using active fluidics along with the intrepid balanced tip. Methods: This single center prospective randomized comparative study comprised a total 108 consecutive eyes of 108 patients having senile cataract subdivided into nuclear opalescence (NO) grades II–IV according to the lens opacities classification system III (LOCS III). Cataracts of each grade were randomly assigned to two groups LPKE (n = 54) and TPKE (n = 54) mode, who were operated on by the same surgeon using same machine (Centurion^® Alcon Laboratories, Inc., USA) having features of both active fluidics and intrepid balanced tip. Pre-, intra-, and postoperative evaluations were done independently by a different author, who was masked to the surgical procedures. Patients were evaluated on the postoperative days (PODs) 1, 7, 15, and 28. Intraoperative outcome measures were cumulative dissipated energy (CDE) and ultrasound time (UST). Postoperative outcome measures were endothelial cell loss (ECL), central corneal thickness (CCT), and best-corrected visual acuity (BCVA). Results: Age, gender, and NO-grade distribution among two modes were comparable (P > 0.05). Difference of CDE and UST between modes were found to be significant (P < 0.001) in favor of TPKE with all NO-grades. TPKE mode performs better than LPKE mode with regard to ECL, CCT-change, and BCVA-change, although the differences were found to be insignificant (P > 0.05). Conclusion: When using active fluidics along with the intrepid balanced tip, TPKE mode appeared to be a more efficient mode of PKE with reduced mean UST and CDE across all NO-grades, as compared to LPKE mode. However, ECL, CCT-change, and BCVA-change were seemed to be comparable between the two modes.

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Choroidal nevi are benign fundus lesions that require regular follow with documentation. Conventional color fundus photography (CFP) has traditionally been used to images these lesions. Multicolor imaging (MCI) available on Spectralis spectral domain optical coherence tomography system is increasingly been tested vis-à-vis conventional CFP in various retinal diseases. We present data of the right eye of a 59-year-old gentleman with choroidal nevus who underwent conventional CFP as well as MCI. Nevus appeared orange red on MCI and its size appeared larger than the same measured on conventional CFP. We also report infrared reflectance and near infrared autofluorescence features of choroidal nevus.

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We report a case of a 46-year-old female who developed infectious crystalline keratopathy (ICK) after Descemet's stripping endothelial keratoplasty (DSEK). She underwent DSEK for pseudophakic corneal edema in her left eye. Ten weeks after the procedure, the patient presented with complaints of blurred vision, redness in eye, and ocular pain. Slit lamp examination revealed white nonsuppurative branching deep stromal infiltrate. Microscopic examination of the Gram-stained smear showed gram-positive cocci. Streptococcus viridans was isolated on cultures. Isolated organism was sensitive to linezolid. Based on antibiotic sensitivity report, fortified linezolid (0.2%) eye drop was started on hourly basis. After 10 weeks of topical fortified linezolid (0.2%) therapy, complete resolution of infiltrate with significant corneal scarring and vascularization was seen. Infectious crystalline keratopathy can occur after DSEK.

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Hypertensive retinopathy is seen frequently in patients with systemic hypertension and is usually asymptomatic. An acute rise in blood pressure may lead to exudative changes in the form of macular edema, hemorrhages, and serous macular detachment that can lead to visual decline. The authors report prompt resolution of exudative changes in a case of hypertensive retinopathy following intravitreal bevacizumab.

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Hypereosinophilic syndrome (HES) is a spectrum of myeloproliferative disorder, which is characterized by persistent and marked blood eosinophilia and damage to multiple organs due to eosinophilic infiltration. Idiopathic HES is identified after ruling out all other causes of eosinophilia. Poor prognosis is usually associated with cardiac involvement and malignant transformation of blood cells. We report a rare case of HES in an 8-year-old boy who presented with unilateral proptosis and torticollis. The patient responded well to corticosteroid therapy with reduction of proptosis and torticollis and normalization of serum eosinophil count.

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A 5 year old boy with a history of fall from a height of about 4 feet, presented after one week with swelling, watering and discharge of the right eye. He had severe conjunctival chemosis with superior displacement of the globe. Computed Tomography (CT) showed a linear low attenuation tract in the right orbit extending from the inferolateral wall up to the left uncinate process of the ethmoid bone with increasing Hounsfield unit after 10 days. The parents did not agree for early exploration. After 10 days an exploration was done and a large linear and irregular wooden foreign body (FB) measuring 4.5 x 1.5 cm² was removed from the right orbit and a smaller one from the nasal cavity. Four weeks post surgery, his vision was 6/9 in the right eye with the eyeball in the normal position. This case was challenging because of the late presentation, parents not agreeing for early exploration, difficulty in diagnosing by CT and a large and very deep penetrating FB.

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Mucormycosis caused by Saksenaea erythrospora is an emerging infection seen with soil contamination, burns and/or nosocomial infections. PCR amplification and internal transcribed spacer sequencing is gold standard for its identification. Here, we report a case of necrotizing fungal orbital infection by S. erythrospora in an immunocompetent child.

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Purpose: To investigate subsequent strabismus surgeries in patients with no prior medical record and to evaluate discrepancies between surgical findings and preoperative presumptions made based on patient self-reporting and clinical findings. Methods: The medical records of patients who underwent a subsequent strabismus surgery between January 1992 and October 2017 were retrospectively reviewed. Patients with no available medical records were included in analyses. Discrepancies between preoperative presumptions and surgical findings were investigated. Original ocular alignment and previous surgical details were presumed using alternative methods, including patient self-reporting, review old photographs of patient, and checking conjunctival scarring. Results: Eleven consecutive patients (4 females, 7 males) met the inclusion criteria. The mean age at subsequent surgery was 47.7 years (range, 23–69). Seven patients had exotropia and four patients had esotropia before the subsequent surgery. Seven patients reported originally having exotropia and four patients reported originally having esotropia. However, findings from surgical exploration did not agree with preoperative presumptions from patient self-reporting in 7 of 11 patients (7/11, 63.6%). These discrepancies included errors in the original type of strabismus (7/11, 63.6%), which eye was previously operated on (1/11, 9.1%), and number of prior surgeries (1/11, 9.1%). Conclusion: When planning a subsequent strabismus surgery in patients with no prior medical record, information obtained from the patient should be used with caution. This includes the original type of strabismus and previous surgical details.

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Purpose: The purpose of this prospective experimental study was to evaluate the safety/toxicity of α4β1 integrin blockade in rabbit retina using its monoclonal antibody (Natalizumab). Methods: Twelve New Zealand albino rabbits were divided into three groups (n = 4). Unilateral intravitreal injections of three different concentrations of natalizumab were performed in every rabbit of each group (Group A: 0.625 mg, Group B: 1.25 mg, and Group C: 2.5 mg). Baseline electroretinogram (ERG) and fundus photography were performed prior to injection. At days 1, 7, and 21 postinjection, ERG and fundus photography of each eye were performed. At last follow-up, Group C animals with highest drug concentration were sacrificed and the enucleated eyes were evaluated for retinal toxicity using transmission electron microscopy (TEM). Results: No difference in ERG responses was observed in eyes injected with low and intermediate concentration of natalizumab between day 0 and day 21. Furthermore, rabbits injected intravitreally with highest dose showed reduction in amplitude of “a” wave (P = 0.0017) and a reduction in amplitude of “b” wave of ERG at day 21 (P = 0.0117). TEM revealed changes in the outer plexiform layer and inner nuclear layer, suggestive of toxicity primarily to the photoreceptor synaptic terminals and bipolar cells. Conclusion: Low-dose (0.625 mg) and intermediate-dose (1.25 mg) intravitreal injection of natalizumab appears safe for rabbit retina. However, functional and anatomical changes were observed in rabbit retina following a high-dose (2.5 mg) intravitreal injection of a monoclonal antibody blocking α4β1 integrin.

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Purpose: Hyperhomocysteinemia has been postulated as a potential risk factor for the development and progression of diabetic retinopathy. The aim of this study was to determine the association of hyperhomocysteinemia with proliferative diabetic retinopathy (PDR). Methods: This was a hospital-based, case–control study, conducted at a tertiary care ophthalmic center in South India. Thirty-nine patients with proliferative diabetic retinopathy were enrolled as cases, and 39 age- and gender-matched patients with no diabetic retinopathy (No DR) were enrolled as controls. Fasting serum homocysteine estimation, as well as baseline investigations, were done in all participants. Data regarding demographic profile and risk factors were documented. Data were analyzed using Chi-square test and independent t-test, as appropriate. Results: The prevalence of hyperhomocysteinemia was higher in PDR (59%) compared to “No DR” (48.7%); however, this difference was not statistically significant (P = 0.36). Similarly, the mean serum homocysteine level in cases was higher than in controls, but this was not statistically significant (17.98 + 6.26 μmol/L vs. 17.71 + 8.17 μmol/L; P = 0.87). Longer duration of diabetes, hypertension, anemia, and renal dysfunction were found to be significantly associated with PDR. Conclusion: The prevalence of hyperhomocysteinemia as well as the mean serum levels of homocysteine were found to be higher in the cases with PDR, compared to the controls with No DR, although the difference was not statistically significant. Longer duration of diabetes, hypertension, anemia, and renal dysfunction were significantly associated with PDR.

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Clomiphene citrate is a common drug used for the treatment of chronic anovulation, especially in polycystic ovary syndrome (PCOS) patients. The drug potentially has systemic and ocular side effects. Here, we present ocular side effects in a PCOS patient and emphasize the need to pay attention to visual complaints during treatment course with clomiphene citrate.

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Nephrotic syndrome (NS) is a common disease of childhood but ophthalmic manifestations are seldom reported. We report a rare occurrence of bilateral combined central retinal artery and vein occlusion in a 3-year-old with NS. The child presented with bilateral painless loss of vision, central pallid retinae with cherry red spots, vascular tortuosity, and retinal hemorrhages. There was delayed filling of the arteriolar circulation and a delay in arteriovenous transit time on angiography and increased central retinal thickening on optical coherence tomography. She was treated with oral steroids, subcutaneous low molecular weight heparin, and oral acetylsalicylic acid. The central retinae showed resolution of the hemorrhages, tortuosity, edema, and pallor within 3 weeks. Visual acuity recovered bilaterally to 20/360, 20/190, and 20/40 at 1, 3, and 6 weeks, respectively. We discuss the possible reasons for good recovery in our patient. Though bilateral combined central retinal artery and vein occlusion is rare in pediatric NS, the treating physician should be aware of this entity as it can be successfully managed.

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Purpose: To report long-term safety and efficacy of trabeculectomy with collagen implant in Indian population. Methods: All cases of trabeculectomy with Ologen^® Collagen Matrix implant performed over a 7-year period from May 2008 through April 2015 at a tertiary referral institute were reviewed. A total of 30 eyes of 28 patients were included in the study with two patients undergoing bilateral trabeculectomy. Outcomes measured included intraocular pressure (IOP) control, number of antiglaucoma medications used, bleb morphology, and complications/reoperations. Results: Trabeculectomy resulted in reduction in IOP from 36.46 to 11.65 mm Hg in the immediate postoperative period (day 1), a 68% decrease to 15.18 mm Hg at 84 months (58% decrease). The mean IOP reduction decreased over time from 63% in the first year to 55% after 5 years of follow-up. Fourteen eyes attained a follow-up of 5 years and eight eyes a follow-up of ≥7 years. No sight-threatening complication such as hypotony, bleb leak, and bleb-related endophthalmitis was observed in our series, and only intervention required was 5-fluorouracil needling in one case. Conclusion: Ologen-augmented trabeculectomy is effective in controlling IOP over a long-term follow up from minimal 3 to maximal 7 years. No untoward events jeopardizing bleb safety were noted at any time. This modality is a viable alternative for patients with contraindications to use of antimetabolites.

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We report a procedure using a pressure-controllable flute needle to remove subfoveal retention of perfluorocarbon liquid (PFCL) under silicone oil. With a two-port pars plana approach, we used a 27-gauge dental injection needle to create a retinotomy at the farthest edge of the PFCL bubble from the fovea. A 27-gauge flute needle was then inserted into the edge of the subfoveal PFCL to aspirate it with vacuum pressure. Three patients with subfoveal retained PFCL were treated by this procedure within silicone oil tamponade 1 month after the first operation. They promptly underwent successful removal of the PFCL with postoperative retinal reattachment and good visual outcome. This procedure allows safe and early treatment for subfoveal retained PFCL. Many medical institutions around the world could implement this procedure using common dental injection needles and flute needles.

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A 30-year-old female presented with macular edema and discoid exudation at the posterior pole. Diffuse vascular sheathing was observed at the peripheral retina. Fluorescein angiography revealed multiple microaneurysms at the posterior pole and leakage from the peripheral vessels. Two monthly intravitreal bevacizumab led to minimal improvement, and resolution of macular edema was achieved by an additional intravitreal triamcinolone. The findings at the posterior pole resembled those of Leber's miliary aneurysm. However, this case also demonstrated a peculiar vascular sheathing at the periphery and showed response to triamcinolone, which are evidences for an inflammatory condition.

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Benign eyelid tumors derived from hair follicles are rare and frequently misdiagnosed as basal-cell carcinoma when evaluation is based on clinical evidence alone. The discrepancy between the clinical aspect and the histological diagnosis can be as high as 30–40%, even for experienced clinicians. Unfortunately, this masquerade is not only clinical but also histological. Patients may be subjected to unnecessarily extensive surgery. We present a case report of three patients clinically diagnosed as malignancy but histopathologically proven as benign hair follicle tumors.

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