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Background: A double anterior chamber may be observed after deep anterior lamellar keratoplasty (DALK) and the management may be difficult especially in cases with a total descemet membrane detachment (DMD). Case Observations: We describe a novel "reverse double bubble" surgical technique for safe and effective reattachment of total DMD following DALK. Total DMD with air bubble in the interface was noted on the first postoperative day following DALK for healed keratitis. Intracameral air was injected via a 30-gauge needle inserted through a partial thickness MVR entry made at the posterior limbus, without disturbing the interface air-bubble. During this maneuver, the interface bubble did not change in size and moved towards the centre. The two distinct air bubbles, one in interface and other in anterior chamber indicated that air injection was in the anterior chamber, as per the reverse double bubble technique. The interface air bubble was removed by gently milking with an iris repositor towards the end of surgery. Thus, successful reattachment of DM was achieved despite difficult assessment of the plane of injection with the DM lying fl at on the surface of the iris., Conclusion: The reverse double bubble technique aids in the safe and successful reattachment of total DMD following intraocular surgeries., (© NEPjOPH.)

Purpose: The aim of this study was to evaluate the surgical outcomes of a modified approach in the management of thick submacular hemorrhage in patients with wet age-related macular degeneration., Design: This was a retrospective study., Methods: A retrospective chart review was performed on 10 eyes of 10 patients with submacular hemorrhage secondary to wet age-related macular degeneration treated with 23-gauge pars plana vitrectomy, followed by submacular injection of recombinant tissue plasminogen activator (12.5 μg/0.1 mL), bevacizumab (2.5 mg/0.1 mL), and air (0.3 mL). Gas tamponade was given with 20% SF6 and postoperative propped-up positioning. Patients were evaluated for displacement of hemorrhage, preoperative and postoperative best-corrected visual acuity, occurrence of intraoperative and postoperative complications, and recurrence of hemorrhage. All patients were followed up for 6 months., Results: Displacement of the submacular bleed was achieved in all cases. Improvement of best-corrected visual acuity was seen in 8 of 10 patients. Rebleed was seen in 2 eyes that were retreated with intravitreal injection of recombinant tissue plasminogen activator, bevacizumab, and 20% SF6 gas., Conclusions: This modified technique aids in the effective displacement of thick submacular hemorrhage with simultaneous treatment of the underlying choroidal neovascular membrane, which halts the disease progression resulting in significant improvement of visual acuity.

The purpose of this study was to describe a modified technique of sutureless DSAEK with continuous pressurized internal air tamponade. This was a prospective interventional case series, single-center, institutional study. Twenty-seven patients with corneal decompensation without scarring were included. Aphakic patients and patients with cataractous lens requiring IOL implantation surgery were excluded. Following preparation of the donor tissue, a corneal tunnel was made nasally with two side ports. All incisions were kept long enough to be overlapped by the peripheral part of the donor tissue. Descemet membrane scoring was done using a reverse Sinskey hook, following which it was removed with the same instrument or by forceps. The donor lenticule was then inserted using Busin's glide. Continuous pressurized internal air tamponade was achieved by means of a 30-gauge needle, inserted through the posterior limbus, for 12-14 min. At the end of the surgery, air was partially replaced with BSS, leaving a moderate-sized mobile air bubble in the anterior chamber. At the 6 month's follow-up, CDVA improved from counting fingers at half meter-6/24 preoperatively to 6/9-6/18 postoperatively, and the mean endothelial cell count decreased: to 1,800 from 2,200 cell/mm(2) preoperatively (18.19 % endothelial cell loss). Donor lenticule thickness as documented on AS-OCT was 70-110 µ on Day 1 and 50-80 µ at 6 months postoperative. None of the cases had flat AC or peripheral anterior synechiae formation. None of the patients required a second intervention. There were no cases of primary graft failure, pupillary block glaucomax or donor lenticule dislocation postoperatively. Our modified technique is simple and effective with reduction in postoperative complications associated with DSAEK, thereby maximizing anatomic and functional outcomes associated.

This study evaluates the effect of two macular birefringence protocols (bow-tie retardation and irregular macular scan) using GDx VCC on the retinal nerve fiber layer (RNFL) thickness parameters in normal eyes and eyes with macular lesions. In eyes with macular lesions, the standard protocol led to significant overestimation of RNFL thickness which was normalized using the irregular macular pattern protocol. In eyes with normal macula, absolute RNFL thickness values were higher in irregular macular pattern protocols with the difference being statistically significant for all parameters except for inferior average thickness. This has implications for monitoring glaucoma patients who develop macular lesions during the course of their follow-up.

To analyze the clinical and histopathological characteristics of choroidal melanomas undergoing enucleation at a tertiary care center in India and compare with data from other countries. A retrospective review of in-patient hospital records from 2001-2011. Patients undergoing enucleation with a clinical diagnosis of choroidal melanoma. A total of 80 eyes were enucleated for choroidal melanoma. The mean age of patients was 46 ± 13.1 years. Tumors with spindle cell morphology were the most common subtype. Necrotic tumors had a higher incidence of scleral invasion and orbital involvement compared to other cellular subtypes. The mean age at enucleation in Asian Indians is nearly a decade less than most other races. Predominance of spindle cell subtype is in contrast to findings of previous studies and could be partly related to the genetic and molecular expression of the melanocytes undergoing malignant transformation.

We report an unusual flap-related complication that occurred 4 years after uneventful laser in situ keratomileusis (LASIK) performed in the eye of a 20-year-old woman. She developed dislocation with partial infolding of the LASIK flap with macrostriae and epithelial ingrowth in her left eye after trauma by a wooden chip. The flap was refloated, stretched, smoothened, and hydrated on both under and outer surfaces after epithelial debridement. At 1 week, the uncorrected visual acuity was 20/20 with absence of flap striae. The present case highlights that flap adhesions are not very strong even months and years after LASIK. Flap refloatation and stretching with hydration on both sides of the flap are effective in removing flap striae.

Purpose: To describe the novel technique of tapping macular hole edges for holes with low macular hole index (MHI) and assess its outcomes., Design: A prospective interventional study., Methods: Twenty-eight consecutive eyes with idiopathic large macular holes (MHI < 0.5) were enrolled. A standardized surgical protocol was performed using vitrectomy with brilliant blue G dye-assisted large internal limiting membrane peeling, intraocular gas tamponade with 18% C3F8, and strict postoperative prone positioning for 5 days. Tapping of macular hole edges was performed on all sides using 23-gauge GreenTip soft tip cannula. Hole closure was examined postoperatively using optical coherence tomography., Results: There were 16 females and 12 males aged 63 ± 14.38 years. The mean MHI was 0.32. Hole closure was seen in 25 eyes (89.29%). MHI was less than 0.25 in the 3 eyes with failed macular hole surgery. Epiretinal membrance (ERM) was present in 22 eyes (78.57%). The presence of ERM did not correlate with hole closure (P = 1.00). Continuity of external limiting membrane was a better predictor of functional success than inner segment/outer segment continuity (P < 0.05). Type I hole closure was seen in 20 (80%) of 25 eyes while the remaining 5 eyes (20%) had type II hole closure on optical coherence tomography. Corrected distance visual acuity improved significantly from 0.86 ± 0.2 logMAR preoperatively 0.43 ± 0.22 logMAR postoperatively (P < 0.0001)., Conclusions: Newer technique of tapping macular hole edges provides acceptable anatomical and functional success rates even in large macular holes (MHI< 0.5).

Purpose: To assess the magnitude of caregiver burden and depression in primary caregivers of patients with primary congenital glaucoma., Methods: Fifty-five primary caregivers of children diagnosed with primary congenital glaucoma were evaluated. The magnitude of burden on caregivers was assessed using a Caregiver Burden Questionnaire (CBQ). The overall aggregate burden and burden across 3 domains-socioeconomic, emotional, and psychological-was evaluated. Depressive symptomatology was evaluated using a Patient Health Questionnaire-9 (PHQ-9) standard questionnaire and graded from mild to severe., Results: The mean age of the presenting children was 8.11±46.71 months; all of them were male. The mean age of the study participants was 33.6±8.36 years (53 female, 2 male). Thirty-nine (71%) individuals were identified to have moderate aggregate burden and 3 (5%) had severe aggregate burden. Twelve (22%) subjects were noted to have moderate depression, while 6 of them (11%) had either severe or very severe grades of depression., Conclusions: Caregivers of patients with primary congenital glaucoma have significant emotional and psychological burden. Moderate to severe depression may be present in one-third of individuals giving primary care to children with congenital glaucoma.

A case of autism with CHARGE syndrome with microphthalmos and a superior colobomatous cyst arising from the optic disc is reported. A 7-year-old boy presented with a gradually increasing mass, involving the superior orbit and upper eyelid of right eye of 3 years' duration. Clinical examination revealed bilateral microphthalmos with typical iris coloboma, posterior synechiae, and cataractous lens. Imaging revealed bilateral optic disc colobomas with a superior cyst in the right orbit. Intraoperatively, a single cystic lesion was seen in the superior orbit arising from the optic disc region. Histopathology was suggestive of a colobomatous cyst, positive for glial tissue [glial fibrillary acidic protein (GFAP) positive] and neuroretinal elements (synaptophysin positive) on immunohistochemistry. Genetic analysis revealed a normal karyotype (46, XY).

Purpose: To describe the clinical presentation of primary macular hole retinal detachment (MHRD) secondary to high myopia and to evaluate the surgical outcomes., Methods: Nine eyes of 9 patients with primary myopic MHRD (axial length =26.5 mm) were enrolled. A standardized surgical protocol was performed using vitrectomy with preservative-free triamcinolone acetonide-assisted internal limiting membrane (ILM) peeling and silicone oil tamponade and were followed for at least 6 months from the first surgery., Results: There were 6 women and 3 men with a median age of 52 years. Six (66.6%) patients presented with inferior bullous configuration and 3 had subtotal retinal detachment. The mean preoperative refractive error (spherical equivalent) and mean axial length was 12 ± 3.553 D (range 8.50-19.50) and 28.13 ± 1.65 mm (range 26.50-31.50), respectively. The patients were followed up for a period of at least 6 months. The retina was attached and macular hole closed in all the eyes. There was significant visual acuity improvement from mean preoperative visual acuity of logMAR 1.85 ± 0.11 (range 1.76-1.93) to postoperative visual acuity of logMAR 0.95 ± 0.14 (range 0.84-1.06) (p<0.001)., Conclusions: Retinal detachment in highly myopic eyes can often be secondary to a macular hole with predominance of inferior bullous configuration and primary vitrectomy with ILM peeling with silicone oil tamponade results in good anatomic and functional outcomes.