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Umesh Chandra Behera, Pratima Singh Thakur Retina-Vitreous Service, L V Prasad Eye Institute, Bhubaneswar, 751024, Odisha, IndiaCorrespondence: Umesh Chandra BeheraRetina-Vitreous Service, L V Prasad Eye Institute, Patia, Bhubaneswar, 751024, Odisha, IndiaTel +91-674-3987100Fax +91-674-398 7130Email umeshcbehera@gmail.comPurpose: To study the efficacy and safety of a modified trans-scleral intraocular lens (IOL) fixation technique in aphakic eyes when performed by ophthalmologists in training.Methods: The study was conducted in an institutional setting that included 43 surgeries performed by surgeons training in small incision cataract surgeries. The data were analyzed for stability and position of IOL, refractive changes, best-corrected vision, and associated complications.Results: Mean age of the subjects was 53.8 ± 18.5yrs (range 6– 81yrs). Surgical aphakia (58.14%) was the most common cause. The corrected distance visual acuity improved significantly at six weeks (p = 0.0003). The mean residual spectacle correction was +0.74 ± 1.2D spherical equivalent (cylinder − 1.6± 1.5D at 84 ± 50°) at the 6th-month follow-up (24.35 ± 6.71wks). Lens tilt on ultrasound biomicroscopy (kappa 0.762; p < 0.001) and the IOL centration (kappa 0.411; p = 0.001), assessed by two independent masked observers, were satisfactory at the 6th-month visit. Transient postoperative vitreous hemorrhage was the most common complication (46.5%). Cellular deposits on the IOL surface (18.6%), cystoid macular edema (11.6%), subconjunctival haptic exposure (4.66%), and haptic slippage (2.33%) were the other complications.Conclusion: This method of trans-scleral IOL fixation is an effective rescue procedure for eyes with deficient capsular support when ophthalmologists perform in training.Keywords: aphakia, intraocular lens, posterior capsular rent, trans scleral lens fixation, lens deposits

Purpose: To study intravitreal brolucizumab in the management of persistent macular fluid in chronic central serous chorioretinopathy (CSCR) without choroidal neovascular membrane (CNVM)., Methods: Retrospective case series which included eyes with chronic CSCR with persistent macular fluid for ≥ 3 months without CNVM. Intravitreal brolucizumab was administered in all eyes. Primary outcome measure was the resolution of intraretinal (IRF) and/or subretinal fluid (SRF) on OCT., Results: Five eyes (four patients) with chronic CSCR were included. All eyes showed complete resolution of SRF 1 month following injection. Minimal residual IRF was present in two eyes. Best corrected visual acuity (BCVA) was stable in three eyes, and two eyes showed improvement. Central macular thickness (CMT) and subfoveal choroidal thickness (SFCT) showed reduction., Conclusion: Intravitreal brolucizumab is effective in the rapid reduction of persistent macular fluid in chronic CSCR without CNVM. Long-term follow-up data are required to study recurrence and adverse effect profile.

Purpose: To describe a potential biomarker termed as inner choroidal fibrosis in cases of chronic central serous chorioretinopathy (CSCR) presenting to a tertiary referral center., Design: Observational case series., Methods: Five eyes of 4 patients with CSCR were noted to have a gray-white subretinal lesion in the macula, which was analyzed with multimodal imaging., Results: The lesions were hypofluorescent on autofluorescence, fundus fluorescein angiography, and indocyanine angiography. In all cases, a characteristic heterogeneous, hyperreflective lesion in the inner choroid was seen on optical coherence tomography (OCT), corresponding to the white subretinal lesions. The lesion was distinct from the adjacent choroid, with greater reflectivity and greater thickness than the adjacent compressed choroidal vasculature. The dilated outer pachyvessels were pushed outward or sideways in all cases. On OCT-angiography, the corresponding lesion showed flow void areas. We have termed this zone of inner choroidal hyperreflectivity "inner choroidal fibrosis." Upon analyzing the clinical course, 3 of the patients had a history of choroidal neovascularization. The contralateral eye in 2 of these 3 patients also developed choroidal neovascularization. Three of the eyes had an overlying focal choroidal excavation., Conclusions: We report a potential biomarker of CSCR termed "inner choroidal fibrosis" in 4 cases of chronic CSCR. It can best be identified on enhanced depth or swept source OCT as a region of heterogeneous hyperreflectivity in the inner choroid. This fibrosis could be regarded as a degenerative process secondary to more severe disease in the past., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: We constructed a clinical clue-based algorithm to identify the microbiology-positive post-cataract surgery endophthalmitis., Methods: The Endophthalmitis Infectivity Measurement Algorithm (EIMA) was constructed using presenting Snellen vision (Letter score [LS]) and Inflammation Score (IS, from the cornea, anterior chamber, iris, and vitreous). Retrospective data (70% for training; 30% for testing) was fitted into CHAID (Chi-squared Automatic Interaction Detection). EIMA was validated with prospective data. EIMA-categorized disease severity was weighed against the symptom duration to detect infecting micro-organisms., Results: EIMA was constructed from 1444 retrospective data. The average LS was 6.03 ± 12.11, median IS was 14 (8-24), and culture positivity was 38%. The accuracy and area under the curve of CHAID were 66.36% and 0.642, respectively. EIMA was validated with 175 prospectively collected data. Microbiology positivity (culture + sequencing) was 58.9%. EIMA sensitivity, specificity, and accuracy against microbiology-positive endophthalmitis were 73.7 (95% confidence interval [CI], 64.19-81.96), 81.9 (95% CI, 71.1-90.02), 77.1 (95% CI, 70.20-83.14), respectively. The positive and negative likelihood ratios were 4.08 (95% CI, 2.46-6.67) and 0.32 (95% CI, 0.22-0.45), respectively. There was higher microbial growth in two days or less than in three- to six-day symptom duration (69.9% vs. 28.2%; P = 0.018) endophthalmitis. Gram-negative infection was higher in two days or less (55.6% vs. 20.2%; P = 0.014), and gram-positive infection was higher in three- to six-day endophthalmitis (62.1% vs. 27.7%; P = 0.027)., Conclusions: EIMA identified microbiology-positive endophthalmitis three-quarters of the time., Translational Relevance: EIMA suggested infectivity and the class of microbial infection could help targeted management of endophthalmitis after cataract surgery.

Purpose: To demonstrate the treatment efficacy of intravitreal dexamethasone (DEX) implant in chronic recurrent/persistent central serous chorioretinopathy (CSC)., Design: Prospective, non-randomized, open-label study., Methods: In this study, subjects with chronic CSC without signs of choroidal neovascularization (CNV) received intravitreal DEX implant therapy. The primary outcome measure was the change in visual acuity. Changes in central macular thickness (CMT) and change in subfoveal choroidal thickness (SFCT) on optical coherence tomography (OCT), incidence of recurrent fluid, and safety of DEX implant were secondary outcome measures. Subjects were followed up for a minimum of 3 months after DEX implantation., Results: In total, 20 eyes of 20 subjects (mean age: 47 ± 9 years) with a median disease duration of 23.5 months were enrolled. With a single injection of DEX implant, a reduction in CMT was noted in 90% of eyes. Complete resolution of subretinal and intraretinal fluid was noted in 55% of eyes within 3 months of injection. A significant improvement in vision (mean Log MAR visual acuity 0.66 ± 0.49 vs. 0.54 ± 0.45; P = 0.020), mean CMT (338 ± 110 microns to 238 ± 73 microns; P < 0.001) and SFCT (514 ± 95 microns to 445 ± 111 microns; P < 0.001) was noted over 3 months. Recurrent fluid was noted in 50% of eyes after a mean follow-up duration of 7 ± 4 months. Elevated intraocular pressure, managed by topical therapy, was noted in six eyes., Conclusion: The consistent improvement in visual acuity, fluid resolution, and reduction in choroidal thickness suggests a possible role for DEX implants in managing chronic CSC. A larger randomized trial is warranted., (Copyright © 2024 Copyright: © 2024 Indian Journal of Ophthalmology.)

Aim: Analyze antibiotic susceptibility in the Endophthalmitis Management Study (EMS) and compare it with the current intravitreal antibiotic practice trend of members of the Vitreoretinal Society of India (VRSI) practicing in India., Methods: The microbiology work-up of undiluted vitreous included microscopy, culture-susceptibility, polymerase chain reaction (PCR), and next-generation sequencing (NGS). VRSI members were invited to the survey. The EMS conventional culture-susceptibility (PCR and NGS excluded) results were compared vis-a-vis gram-positive cocci (GPC), gram-negative bacilli (GNB), and less commonly used antibiotics with the current recommended intravitreal antibiotics. p < 0.05 was considered significant., Results: Culture and positivity (culture + PCR/NGS) positivity was 28.8% and 56.1%, respectively. GPC was most susceptible to cefazolin, linezolid, and vancomycin; GNB was most susceptible to amikacin, ceftazidime, colistin, and imipenem. There was no susceptibility difference between cefazolin and vancomycin (p = 0.999) and between ceftazidime and imipenem (p = 1.0). Colistin was superior to ceftazidime (p = 0.047) against GNB. The GNB resistant to amikacin (n = 14) were equally susceptible to ceftazidime and colistin; resistant to ceftazidime (n = 16) were susceptible to colistin; and resistant to colistin (n = 7) were susceptible to ceftazidime. The preference of VRSI members (n = 231) practicing in India was a vancomycin-ceftazidime combination (82%), vancomycin for GPC (94%), ceftazidime for GNB (61%), and voriconazole for fungi (74%)., Conclusion: In EMS, GPC had good susceptibility to vancomycin; GNB had good susceptibility to ceftazidime and colistin. Given the lower resistance of colistin, a vancomycin-colistin combination could be an alternative empiric treatment in post-cataract endophthalmitis in India., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: We aim to report the natural course of non-center involving diabetic macular edema (NCIDME) progression to center involving diabetic macular edema (CIDME) and associated risk factors., Methods: This is a multicenter retrospective comparative study. Data was collected from electronic medical records from 8 centers in India covering. We included patients with type 2 diabetes above 18 years of age with treatment-naïve NCIDME on OCT and best-corrected visual acuity at baseline of 6/12 or better who were under observation for NCIDME and had 2 years follow-up data., Results: Out of 72 patients with NCIDME, 26.38% patients progressed to CI DME by 2 years, and the visit wise proportion was 11.11% at 6 months, 7% at 1st year and 8.3% at 2 years. The change in CST was statistically significant at 2 years in patients who developed CIDME, the mean difference was 137.73 ± 48.56 microns p = 0.045. Duration of diabetes mellitus > 10 years was the only risk factor for conversion to CIDME., Conclusion: A quarter of eyes with NCIDME developed CIDME and 15% progressed from NPDR to PDR by 2 years, highlighting the disease burden in these patients with NCIDME., (Copyright © 2023 Copyright: © 2023 Indian Journal of Ophthalmology.)

Purpose: To analyze the outcome of intervention versus observation for vitreous cavity hemorrhage occurring after a 2-month period of blood-free cavity (late postoperative vitreous cavity hemorrhage-POVCH) in eyes operated by vitrectomy for complications of proliferative diabetic retinopathy (PDR)., Methods: This study was a 10-year retrospective, observational, multi-center study involving eight major vitreoretinal surgical centers across India from January 2010 to December 2019. The primary objective of the study was to assess the visual and clinical outcomes of various management approaches for late POVCH. The key secondary objective was to determine the best management option that prevented recurrence. Patients with follow-up of less than 6 months of POVCH management were excluded., Results: The occurrence of late POVCH was studied in 261 eyes. The median time to occurrence was 7 months (range: 2-87) postvitrectomy/silicone oil removal. The majority (58%) experienced a single, nonrecurring POVCH event. Visual acuity outcome was independent of all management approaches (P = 0.179; mean follow-up 20.7 ± 14.1 months). With watchful observation, spontaneous resolution was noted in 83% (60/72 eyes) of eyes in 81.5 days (interquartile range, 169.75). Silicone oil injection was most effective in preventing recurrence (P < 0.001)., Conclusion: The current treatment practice of late POVCH management in PDR suggests that watchful observation for at least 3 months could be as efficacious as any surgical intervention., (Copyright © 2023 Copyright: © 2023 Indian Journal of Ophthalmology.)

Purpose: To study the acute central serous chorioretinopathy (CSC) management strategies practiced at a tertiary eye care center in eastern India., Methods: In a retrospective chart review study, the clinical outcomes of three different management approaches to treating acute CSC were analyzed. Individuals with follow-ups of fewer than 6 months were excluded. Logistic regression analysis was performed to identify the prognostic markers of CSC resolution., Results: In the 10-year study period (January 2013-July 2022), 206 eyes were included. Placebo treatment was the preferred practice (48.5%; n = 100 eyes). Watchful observation without placebo was the management strategy in 30.6% (n = 63) of the eyes, and 20.9% (n = 43) of eyes received focal lasers. Risk factor modification was attempted in all. There was no significant difference in the resolution rate (P = 0.819), time to resolution (P = 0.331), and disease recurrence (P = 0.067) among the groups. Univariate logistic regression analysis did not favor any of the treatment strategies predicting resolution and recurrence., Conclusion: Alternative treatment modes did not score over the natural history of acute CSC regarding disease resolution, vision gain, and disease recurrence. The study reaffirms observation as the standard of care for acute CSC., Competing Interests: None

Purpose: To report a big data analysis of risk and protective factors in patients with AMD, as well as report on the age-adjusted prevalence in a geriatric Indian cohort in a hospital setting., Methods: This retrospective, observational study of all patients older than 60 years of age. Multiple logistic regression was performed for the binary outcome and the presence of AMD. Variables analyzed include age, gender, socioeconomic status, occupation, urban-rural-metropolitan distribution, self-reported history of diabetes mellitus (DM), hypertension (HTN), or coronary artery disease (CAD), ocular comorbidities, history of cataract surgery, and presenting VA. Odds ratios (OR) and 99% confidence intervals were calculated., Results: Of the 608,171 patients over the age of 60 years who attended our clinics, 1.68% of subjects had a diagnosis of AMD (N = 10,217). Less than half (4,621 of 10,217 with AMD) of them were diagnosed to have dry AMD. Cataract, glaucoma, and diabetic retinopathy were associated with lower risk of AMD. Cataract surgery was associated with the higher risk of AMD (OR = 1.20; 99% CI 1.13-1.29). Smoking was not associated with AMD., Conclusion: Big data analysis from a hospital setting shows that the prevalence of AMD above the age of 60 years is low. More patients with wet AMD present for treatment compared to dry AMD. Smoking was not associated with AMD in the Indian population. Cataract surgery was associated with higher prevalence of AMD., Competing Interests: None

Purpose: An interim analysis of the Endophthalmitis Management Study to examine the outcome of inflammation score (IS)-based treatment and antibiotic susceptibility., Design: A prospective randomized study., Patients and Methods: IS was measured on a 0-4 scale from presenting signs in 4 cardinal ocular tissues. The eyes with IS <10 received vitreous tap and intravitreal antibiotics, whereas eyes with IS ≥10 received vitrectomy and intravitreal antibiotics. These eyes were randomized to 2 intravitreal antibiotic combinations: (1) vancomycin and ceftazidime and (2) vancomycin and imipenem. Microbiology workup of undiluted vitreous included microscopy, culture-susceptibility, Sanger, and targeted next-generation sequencing. The clinical and microbiology outcomes were analyzed for advanced (IS = ≥20) and less advanced (IS = <10) endophthalmitis., Results: Interim analysis was performed after the Endophthalmitis Management Study recruited 56.85% (248/436) of patients and completed 54.6% (238/436) of microbiology workup. A 90-day follow-up was completed in 90.8% (168/185) of eligible people. In eyes with IS ≥20, the time to symptoms was shorter (5.8 ± 6.7 vs 8.5 ± 9.1 d; P = 0.015), and the need for additional treatment was higher (95.8% vs 53.1%; P = 0.0267). Good final vision was associated with good presenting vision (r = 0.30) and IS-based treatment decisions (r = 0.170). Microbiology positivity was 55.9%. Eyes with IS <10 had a higher Gram-positive cocci (33.9% vs 4.8%; P = 0.013) infection. Gram-positive cocci were most susceptible to vancomycin (95.7%), and Gram-negative bacilli to colistin (95.7%)., Conclusions: Considering both IS and presenting vision, rather than only one of them, helps in making appropriate management decisions for acute postoperative endophthalmitis., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2023 Asia-Pacific Academy of Ophthalmology. Published by Wolters Kluwer Health, Inc. on behalf of the Asia-Pacific Academy of Ophthalmology.)

A woman in her 60s presented with vision blur in both eyes, a year post-radiotherapy for oral cancer. The best corrected visual acuity was 20/40 in both eyes. Posterior segment examination was remarkable for a unilateral intervortex venous anastomosis in choroid in her right eye, on the side of her face that had received radiation. Ultra-wide field indocyanine green angiography complimented the clinical findings. We discuss the ramifications of detection of this entity and suggest non-invasive methods of detection., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: We report clinical characteristics, risk factors, treatment outcomes, and prognostic predictors of post-vitrectomy secondary macular holes (MHs)., Methods: This was a retrospective observational case series from November 2014 to December 2020. Eyes that developed secondary MH, two weeks and beyond after primary vitrectomy for non-MH indications, were enrolled. Pre- and intraoperative records were screened to exclude pre-existence of MH. Eyes with multiple vitreoretinal surgeries prior to MH detection and tractional myopic maculopathy were excluded., Results: A total of 29 eyes of 29 patients with a mean age of 52 years developed secondary MH post-vitrectomy. The most common indications for primary vitrectomy were rhegmatogenous retinal detachment (RRD, 48.2%) and tractional retinal detachment (TRD, 24.1%). Time to MH detection after primary vitrectomy was 91.5 ± 117.6 days. The mean minimum hole diameter was 530 ± 298 microns. Epi-retinal membrane and cystoid degeneration was noted in 6 (20.7%) and 12 (41.3%) eyes, respectively (p = 0.088). The mean time from MH detection to MH repair was 34 ± 42 days. The surgical intervention included internal limiting membrane peeling with tamponade in 25 eyes. Overall, 80% showed anatomic hole closure, 90.9% versus 57.1% in the RRD and TRD (p = 0.092), respectively. The mean best-corrected visual acuity (BCVA) at the final visit was 0.71 logarithm of the minimum angle of resolution. Thirteen eyes (52%) had a BCVA of 20/100 or better. Minimal hole diameter (p = 0.029) only predicted final visual acuity. The interval between MH diagnosis and repair did not affect hole closure significantly (p = 0.064)., Conclusion: Secondary MH post-vitrectomy closed successfully with limited visual improvement and trails behind idiopathic MH., Competing Interests: None

Purpose: To correlate optical coherence tomography (OCT)-based morphological patterns of diabetic macular edema (DME), biomarkers and grade of diabetic retinopathy (DR) in patients with various stages of chronic kidney disease (CKD) secondary to diabetes., Design: Multicentric retrospective cross-sectional study was conducted at seven centers across India., Methods: Data from medical records of patients with DME and CKD were entered in a common excel sheet across all seven centers. Staging of CKD was based on estimated glomerular filtration rate (eGFR)., Results: The most common morphological pattern of DME was cystoid pattern (42%) followed by the mixed pattern (31%). The proportion of different morphological patterns did not significantly vary across various CKD stages (p = 0.836). The presence of external limiting membrane-ellipsoid zone (ELM-EZ) defects (p < 0.001) and foveal sub-field thickness (p = 0.024) showed a direct correlation with the stage of CKD which was statistically significant. The presence of hyperreflective dots (HRD) and disorganization of inner retinal layers (DRIL) showed no significant correlation with the stage of CKD. Sight threatening DR was found to increase from 70% in CKD stage 3 to 82% in stages 4 and 5 of CKD, and this was statistically significant (p = 0.03)., Conclusion: Cystoid morphological pattern followed by mixed type was the most common pattern of DME on OCT found in patients suffering from stage 3 to 5 of CKD. However, the morphological patterns of DME did not significantly vary across various CKD stages. ELM-EZ defects may be considered as an important OCT biomarker for advanced stage of CKD., (© 2022. The Author(s), under exclusive licence to Springer Nature B.V.)

Purpose: To describe clinical and imaging characteristics of the outer retinal folds (ORF) in cases of retinitis, retinochoroiditis, and chorioretinitis., Methods: Retrospective review of retinitis cases with presence of ORFs either at presentation or during follow up., Results: ORFs were seen adjacent to retinitis lesions in 16 eyes of 14 cases (retinitis post-febrile illness n = 10, toxoplasma retinochoroiditis n = 2, fungal chorioretinitis n = 2) either at presentation (n = 2) or during follow up (n = 14). Optical coherence tomography (OCT) appearance was outer retinal vertical stout lesions involving ellipsoid, external limiting membrane, and outer nuclear layer. All the cases had a presence of past or concurrent subretinal fluid and/or subretinal hyperreflective material when ORF was seen. ORF resolved with variable outer retinal atrophy over a mean period of 2.86 months., Conclusion: ORF is observed in cases of retinitis with subretinal fluid either at presentation or during resolution. It is not specific to any etiological disease. Differentiation of this sign from vertical outer retinal stripes in viral retinitis on OCT is important to avoid misinterpretation., Competing Interests: None

A systematic review and meta-analysis were conducted to estimate the prevalence of diabetic retinopathy (DR) in India's urban and rural areas. Medline, Scopus, and ScienceDirect databases were searched for population-based studies published in English between January 1990 and April 2021, wherein the prevalence of DR among Indian residents with type 2 diabetes mellitus (DM) was reported. A random-effects model was used to estimate the overall, rural, and urban prevalence. Data from 10 eligible studies were aggregated for meta-analysis. The prevalence of DR was 17.44% (95% confidence interval [CI], 14.33-20.55) in urban and 14.00% (95% CI: 9.13-18.86) in rural population (P = 0.24). The overall DR prevalence was 16.10% (95% CI: 13.16-24.32), and the population prevalence was 1.63% [95% CI: 0.94-2.32]. Prevalence of DR in people with diabetes was lower in the age group of 40-49 years [13.57% (95% CI: 7.16-19.98)] than in the age group of 50-59 years [16.72% (95% CI: 12.80-20.64)] and the age group of 60 years and above [16.55% (95% CI: 12.09-21.00)]. Variability in studies was high: urban (I 2 = 88.90%); rural (I 2 = 92.14%). Pooled estimates indicate a narrow difference in DR prevalence among people with diabetes in rural and urban India. The fast urbanization and increasing diabetes prevalence in rural areas underscore the need for providing equitable eye care at the bottom of the health pyramid., Competing Interests: None

Purpose: To describe clinical and multimodal imaging characteristics of punctate inner retinal toxoplasmosis (PIRT) as an atypical presentation of ocular toxoplasmosis (OT)., Methods: Retrospective review of OT cases with PIRT lesions and review of the literature. We describe five cases (6 eyes)., Results: PIRT lesions were seen adjacent to active/healed toxoplasma retinochoroiditis. The appearance of PIRT was creamy yellowish-white, inner retinal, punctate, and sub-centimetric lesions. The depth of these lesions on optical coherence tomography was till the outer plexiform layer. Co-existing punctate outer retinal toxoplasmosis (PORT) was found in three eyes and recurrent retinochoroiditis in three. The fate of PIRT was resolution with minimal retinal thinning or progression to a full-thickness retinochoroiditis., Conclusion: PIRT was noted in association with typical toxoplasma retinochoroiditis and PORT lesions, and had equal chances of resolution or progression to full-thickness lesions.

Purpose: To evaluate the clinical and microbiological features of a large cohort with culture-confirmed fungal endophthalmitis across India., Design: Cross-sectional, hospital-based, retrospective medical record review., Participants: Seven large tertiary eye care centers from different regions of India., Methods: Patient data were pooled from electronic or physical medical records of each participating center. Fellowship-trained vitreoretinal specialists clinically managed all patients, and in-house microbiology laboratories performed all microbiological workups. The clinical and microbiological procedures were broadly uniform across all participating centers. The essential treatment consisted of vitreous surgery as well as intravitreal and systemic therapies with antifungal agents., Main Outcome Measures: Clinical outcome of the causative event and causative fungus., Results: In the period from 2005 to 2020, 7 centers treated 3830 cases of culture-proven endophthalmitis, and of these, 19.1% (n = 730) were cases of culture-confirmed fungal endophthalmitis. It included 46.9% cases of postoperative (87.4% postcataract surgery), 35.6% of traumatic, and 17.5% of endogenous endophthalmitis. The fungi included 39.0% of Aspergillus (high prevalence in central, east, and south zones), 15.1% of Candida (high prevalence in west zone), and 15.9% of Fusarium (high prevalence in north and west zones). The time to symptom development was between 1 week and 4 weeks in more than one third of the patients, except in patients with traumatic endophthalmitis. Less than half of the patients had hypopyon on presentation. The presenting visual acuity (PVA) in most patients was <20/400. Nearly all patients needed vitrectomy and an average of 2 intravitreal injections of antifungal agents. At least 10% of eyes needed therapeutic keratoplasty, and up to 7% of eyes were eviscerated. After treatment, the final (best corrected) visual acuity (FVA) was >20/400 in 30.5% (n = 222) of eyes and >20/40 in 7.9% (n = 58) of eyes, and 12% (n = 88) of eyes lost light perception. A post hoc analysis showed the male sex to be significantly more associated with traumatic endophthalmitis than with postoperative (P < 0.0001) and endogenous (P = 0.001) endophthalmitis, more isolation of Candida species in patients with endogenous endophthalmitis than in those with postoperative (P = 0.004) and traumatic (P < 0.0001) endophthalmitis, better PVA in eyes with Candida species infection (P < 0.0001), and poorer FVA in eyes with Aspergillus species infection., Conclusions: Fungal endophthalmitis is not uncommon in India. The inclusion of antifungal agents with antibiotics as the first empirical intravitreal therapy before microbiological confirmation should be considered when a fungal infection is suspected., (Copyright © 2021 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Fungal endophthalmitis is a potentially blinding condition. It is more often reported from Asia, including India. The incidence is lower than bacterial endophthalmitis. But it is relatively more challenging to treat than bacterial endophthalmitis. Many eyes may need therapeutic keratoplasty and/or evisceration. The current mainstays of treatment are vitrectomy irrespective of the presenting vision, intravitreal antifungal agents, and systemic therapy; additionally, the patients could require prolonged treatment with repeat vitreous surgeries and intravitreal injections. Difficulty in clinical diagnosis, delay in microbiological culture, and limited options of antifungal drugs make the treatment more difficult and less rewarding. Three common fungi causing endophthalmitis are Aspergillus, Fusarium, and Candida. The former two are molds, often identified in exogenous endophthalmitis, postoperative and traumatic; the latter is yeast and is more often identified in endogenous endophthalmitis. A faster diagnosis with newer molecular microbiological technologies might help institute treatment earlier than it is currently possible. A target trial using big data from different regions of the world might emulate a randomized clinical trial to design a definite treatment strategy. Given fewer antifungal drugs, one must be mindful of antifungal stewardship to prevent resistance to the existing drugs., Competing Interests: None

Purpose: To study the prevalence of systemic conditions in older adults, either self-reported or discovered during routine eye examinations, at multitier eye-care facilities over the past decade, and to explore their association with vision and common ocular disorders, including cataract, glaucoma, and retinopathy., Methods: Retrospective review of a large data set compiled from the electronic medical records of patients older than 60 years who presented to an eye facility of a multitier ophthalmology network located in 200 different geographical locations that included urban and rural eye-care centers spread across four states in India over a 10-year period., Results: 618,096 subjects aged 60 or older were identified as visiting an eye facility over the 10-year study period. The mean age of the study individuals was 67·28 (±6·14) years. A majority of older adults (66·96%) reported being free of systemic illnesses. Patients from lower socioeconomic status had a lower prevalence of chronic systemic disease, but the presenting vision was poorer. Hypertension (21·62%) and diabetes (18·77%) were the most commonly reported chronic conditions in patients who had concomitant systemic illness with visual concerns., Conclusion: The prevalence of chronic systemic illnesses in older adults presenting to multitier eye-care facilities is relatively low, except in those with diabetic retinopathy. These observations suggest a need to include active screening for common chronic diseases in standalone eye-care facilities to achieve a more accurate assessment of chronic disease burden in the older population., Competing Interests: None

Purpose : To analyse clinico-microbiological profile, antimicrobial susceptibilities, and visual prognostic factors in post-traumatic endophthalmitis (PTE). Methods : Retrospective clinico-microbiological data analysis for five years (2014-18). Prognostic factors for visual outcomes were analysed by multivariate logistic regression analysis. Results : Four hundred and eighteen patients with clinically diagnosed PTE were analysed. Culture positivity was found in 46.7% samples (44.5% vitreous, 83.3% non-vitreous). Pathogens isolated were Gram positive cocci (GPC, 49.3%, good susceptibility to vancomycin/cefazolin), Gram negative bacilli (GNB, 28.1%, <90% susceptibility to all antibiotics and 25.8% multidrug resistance), Gram positive bacilli (13.1%) and fungi (9.5%). Poor visual prognosis was associated with culture positivity, fungal or polymicrobial PTE, poor view of fundus and presence of membranes on ultrasound scans. Conclusion : GPC and GNB are the predominant pathogens in PTE, with GNB most commonly multidrug resistant. Culture positivity, polymicrobial and fungal PTE, poor view of fundus and vitreous membranes are markers of poor visual outcome.

Purpose: To describe the course of posterior subhyaloid precipitates (PSPs) accompanying active retinitis. Methods : Retrospective study of three retinitis cases associated with PSPs and literature review. Results : Cases 1 and 2 were Toxoplasma retinochoroiditis. Case 3 had bilateral retinitis post-febrile illness. PSPs were yellowish-white spherical lesions seen in the presence of partial posterior hyaloid detachment (PVD) in the retro-hyaloid space lining the inferior PVD margin. In all 3 cases, PSPs resolved during treatment for primary disease. Resolution of PSPs preceded resolution of retinitis. Literature review revealed similar lesions in CMV retinitis and syphilis in addition to Toxoplasma retinochoroiditis. Conclusion : PSPs were seen in the presence of active retinitis and partial PVD when inflammatory aggregates gravitate inferiorly in the subhyaloid space. They were observed during active retinitis and their resolution preceded the resolution of retinitis, thus providing a potential marker for disease resolution.

Purpose: To study the zonal variations in diabetic retinopathy (DR) and associated factors in people with known type 2 diabetes mellitus (T2DM) attending large eye care facilities in different regions of India., Methods: In this cross-sectional eye-care facility-based study, India was divided into five zones; large eye care facilities with a good referral base and offering an entire range of care for patients with DR were invited. First-time T2DM attendees aged ≥18 years were recruited. All subjects received a comprehensive systemic and ophthalmic examination. DR and systemic diseases were classified as per the international/national standards. Findings were compared between the zones and with the national average., Results: Fourteen eye-care facilities (15% public) from five zones participated. In the cohort of 11,173 people, there were more males (59%); the average age was above 45 years, and in 57%, DM had been diagnosed more than 5 years earlier. Compared with the overall study population, the proportion of people with any DR, sight-threatening DR, and blind were higher in the east zone (42.5%, 95% confidence interval [CI]: 40.2-44.8; 24.3%, 95% CI 22.3-26.3, and 11.5%, respectively); diabetic macular edema was more frequent in the south zone (12.2%, 95% CI 11.2-13.2); people with moderate-to-severe visual impairment were more in the west zone (32.1%) and higher proportion of people in the south-central zone had systemic hypertension (56.8%, 95% CI 54.8-58.9)., Conclusion: The zonal variation in DR and related vision loss could be related to variable health-seeking behavior, availability, and confidence in the available services., Competing Interests: None

Socioeconomic status (SES) may influence the general health and the health-seeking behavior of an individual. Understanding the disease prevalence in different social strata may lead us to the important linkages that SES might have with diabetic retinopathy (DR). The knowledge on the prevalence of DR in the community based on their SES may help design strategies to provide affordable, last-mile care to the population most at risk of this blinding complication of diabetes mellitus. Our systematic search for population-based Indian studies found three studies in the past three decades that evaluated the effect of socioeconomic factors on the prevalence of diabetic retinopathy. The data on the prevalence in various socioeconomic strata was equivocal and the study settings were mostly urban. The parameters used to assess the SES differed among studies. This underscores the need for further research on SES-related diabetic retinopathy complications in India. Future studies should employ more robust socioeconomic scales to define the divide better., Competing Interests: None

Purpose: Diabetic retinopathy (DR) is a potentially sight-threatening complication of diabetes mellitus. The majority of cases are in older adults. This study aims to evaluate modifiable and nonmodifiable protective factors against DR in a geriatric Indian population., Methods: This retrospective observational study uses data from a multitiered ophthalmology network to evaluate several demographic and clinical variables against diabetic retinopathy and visual acuity., Results: Our data show that high myopia, the female sex, and no cataract surgery are associated with lower prevalence of DR (OR = 0.21, 0.65, and 0.76, respectively; P < 0.001). We also found that among those with DR, people categorized as payers, retirees, and those living in urban or metropolitan areas have better visual acuity (OR = 0.65, 0.65, 0.83, and 0.73, respectively; P < 0.001). Among those with DR, females, presence of cataracts, and no cataract surgery had lower associations with sight-threatening DR (STDR) (OR = 0.68, 0.37, and 0.76, respectively; P < 0.001). Prevalence of DR decreased in older age groups while controlling for DM duration., Conclusion: It is probable that high myopia, the female sex, and better glycemic control are protective against DR and STDR in our study cohort of adults over 60 years of age. It is possible that occupations involving manual labor, delayed cataract surgery, and living past the age of 70 are also protective against DR., Competing Interests: None

Purpose: To assess the treatment benefit of eyes with diabetic macular edema (DME) in vitrectomized eyes for tractional complications of proliferative diabetic retinopathy (PDR)., Methods: In a retrospective multicentre observational study in India, the clinical outcomes of eyes with center-involving DME in vitrectomized eyes for tractional complications of PDR in people with type 2 diabetes with at least 12 months follow-up data were assessed. The DME status and visual acuity outcomes were compared between those who received treatment versus those observed., Results: In the 10-year study period, 45 eyes of 44 patients from 5 tertiary centers in India met the inclusion criteria. Center-involving DME was documented after a mean of 7 ± 7 months following pars plan vitrectomy (PPV) for tractional complications of PDR. More than half of the (n = 25) eyes were immediately treated for DME, and treatment was deferred for the rest. At one year, there was a statistically significant reduction in mean central subfield thickness in treated (467.9 ± 124.8 μm to 367.8 ± 143.7 μm; p < 0.001) as well as observed (405.2 ± 132.6 μm to 325.6 ± 149 μm; p < 0.001) eyes, and the change was comparable (p = 0.574). The change in vision was also comparable (0.12 ± 0.31 and 0.22 ± 0.54 Log MAR in the treated and observed group, respectively; p = 0.443)., Conclusion: Treatment for pre-existing or new-onset DME after PPV for tractional complications of PDR may be deferred for up to one year because the DME may resolve spontaneously with time., (© 2021. The Author(s), under exclusive licence to Springer Nature B.V.)

Purpose: To present clinical profile and risk factors of sight-threatening diabetic retinopathy (STDR) among people with age of onset of diabetes (AOD) <25 versus ≥25 years., Methods: A retrospective chart analysis of consecutive patients with diabetic retinopathy (DR) n = 654) treated at 14 eye care centers across India between 2018 and 2019 was performed. Patients were divided into two groups, Group 1: AOD <25 years and Group 2: AOD ≥25 years. DR and diabetic macular edema (DME) were classified using the International Clinical Classification of DR severity scale. STDR included severe nonproliferative DR (NPDR), proliferative DR (PDR), and moderate to severe DME. A multilevel mixed-effects model was used for comparison between two groups: 1) Patients with DR and AOD <25 years and 2) Patients with DR and AOD ≥25 years. Bivariate and multivariate regression analyses were used to evaluate risk factors between the two groups., Results: A total of 654 patients were included, 161 (307 eyes) in AOD <25 and 493 (927 eyes) in AOD >25 group. There was a higher prevalence of PDR with high-risk characteristics in AOD <25 group (24% vs. 12%) at baseline and 12-month follow-up (25% vs. 6%); P < 0.001. Systolic hypertension and poor glycemic control were risk factors in both groups, with no difference in these modifiable risk factors between groups., Conclusion: People with youth-onset DM are likely to present with severer form of STDR despite similar modifiable risk factors. Therefore, strict control of systolic blood pressure, glycemic status, and regular screening for DR are recommended to reduce the risk of STDR irrespective of the age of onset of diabetes., Competing Interests: None

Purpose: To study the initial presenting symptoms of Takayasu arteritis in unsuspecting patients., Methods: The underlying systemic condition was suspected in five subjects at a tertiary eye care center based on their ocular features. Similar reports in the literature were collated and analyzed for the common presenting features of undiagnosed Takayasu arteritis., Results: The most common presenting ophthalmic symptoms were vision loss (86.8%), ocular pain (21.1%), eye redness (18.4%), and photophobia (5.3%). There were no reports of glaucoma at presentation. Pupillary abnormalities (42.1%), microaneurysms in retinal mid-periphery (42.1%) and venous engorgement (28.9%) were the most common presenting signs. Despite systemic symptoms such as headache, dizziness, fatigue, weakness, arm claudication, fever, anorexia, weight loss, and syncope in 76.3% of cases, the patients in this series had never sought medical care before developing ocular symptoms., Conclusion: Takayasu arteritis may remain latent until the ophthalmic complications compel the patient to seek medical attention. Hence, ophthalmologists need to be aware of the seemingly innocuous presentations of the disease.

Purpose: To compare the disease characteristics and treatment outcomes of patients with neovascular glaucoma (NVG) presenting with visual acuity (VA) 6/60 or better in two different health systems., Methods: Retrospective chart review of consecutive patients with NVG who presented between January 2016 to January 2018 in 5 tertiary-centres in India and one eye-specialist centre in London (UK) was performed. The baseline characteristics, treatment provisions, and visual outcomes in the India and UK cohorts were compared., Results: At presentation, 18% (83 of 451) and 22% (59 of 270) of patients with NVG had VA 6/60 or better in India and the UK cohorts, respectively. The aetiologies of NVG were similar with proliferative diabetic retinopathy being the most common cause (60.9%, India; 64.4%, UK; p = 0.38). Previous panretinal photocoagulation was more prevalent in the UK cohort compared to the India cohort (94.9% versus 66.3%, respectively; p < 0.001). The mean number of intravitreal anti-VEGF injections per eye was higher in the Indian cohort (1.65 ± 0.97 versus 1.14 ± 1.02 injections; p < 0.001). The number of eyes with closed angles (36.9% India versus 30.5% UK; p = 0.45) and the number of eyes needing glaucoma interventions (52.1% India; 62.7% UK; p = 0.82) were similar in two cohorts. Among glaucoma surgeries, trabeculectomies were more commonly performed in the Indian cohort (23 vs 4; p < 0.001),while glaucoma drainage device surgeries were more prevalent in the UK cohort (18 vs 4 p < 0.001). After a median follow-up of 21 months (IQR 8.4-34.8 India; 24-36 months UK), favourable visual outcomes (vision stable or improved) were similar in both health systems (52.5% in the Indian cohort vs 43.4% in the UK cohort; p = 0.28). On multivariate regression analysis, the need for trans-scleral cyclophotocoagulation was associated with worse visual outcomes in both cohorts., Conclusions: The causes and clinical profile of neovascular glaucoma with presenting visual acuity 6/60 or better in India and the UK were similar. Only up to 50% of eyes achieved favourable visual outcomes with current management protocols in both health systems.

Purpose: To report the clinical course of ophthalmia nodosa with a retained lenticular seta misdiagnosed and treated as non-infectious posterior uveitis for 7 consecutive years., Methods: Meticulous clinical examination led to discovery of the caterpillar seta embedded in the crystalline lens and the intravitreal setae., Results: Lens-sparing pars plana vitrectomy and removal of free-floating vitreal seta resulted in complete resolution of vitritis and uveitis., Conclusion: Embedded seta within a clear lens may remain sequestered, and may be left untouched under close observation, precluding a clear lens extraction in such patients.

Purpose: The aim of this study was to report visual and anatomical outcomes following treatment for diabetic macular edema (DME) in clinical practice in India., Methods: Retrospective chart review of patients with DME who were initiated on treatment and followed up for at least 1 year at 9 tertiary eye care centers during 2016-2017 was performed. Data on demographics, systemic illnesses, visual acuity and anatomical characteristics of DME, treatment history were collated and analyzed for change in visual acuity level and central macular thickness at 1 year., Results: A total 1853 patients were diagnosed with treatable DME during study period, 1315 patients were treated and 556 patients (1019 eyes) followed up at one year. Although patients achieved significantly better anatomical outcome (central macular thickness of <300μ in 32.3% at baseline compared to 60.7% at 1 year, P < 0.001), visual impairment due to DME did not differ from baseline (mild visual impairment in 53.2% at baseline compared to 56% at 1 year, P = 0.7). Cystoid type of DME was the most common phenotype (432/1019, 42.4%) followed by spongy type (325, 31.9%) and cystoid plus spongy type (138, 13.5%). Bevacizumab monotherapy was the most common (388/1019, 38.1%) treatment followed by combination therapy (359, 35.2%). Mean number of anti-VEGF injections received per eye in a year was 2.1 (SD ± 0.9)., Conclusion: Only about a third of treated DME patients complete one year follow up in India. Most patients receive suboptimal number of treatments. Treated DME cases largely show better anatomical outcome but not a better functional outcome., Competing Interests: None

Purpose: The purpose of this study is to study single surgery reattachment rate, refractive shift, surgical time, cost, and complications of pneumoretinopexy (PR) compared to scleral buckling (SB) in rhegmatogenous retinal detachments (RRDs) with superior breaks., Methods: Data of RRD with superior breaks, from 2013 through 2016, treated either with PR or SB surgery at a tertiary eye-care center were retrospectively reviewed. Treatment outcomes, procedural costs, refractive shift, surgical time, and complications, namely, cataract and glaucoma, were analyzed., Results: Thirty-two cases treated by PR (n = 15) and SB surgery (n = 17) fulfilled the selection criteria. Macula off RRD (91%) was the commonest presentation. Baseline parameters like duration of vision loss, presenting vision, and ocular characteristics were comparable. Single surgery retinal reattachment (66.7% PR vs. 76.5% SB) was analogous (P = 0.698). Retinal reattachment with secondary intervention was achieved in all cases at the last follow-up. Average vision gain in logMAR of 0.8 in PR and 0.6 in SB was not significantly different (P = 0.645) between the two groups, with SB group having a 1.9 Dioptre myopic shift and PR group none. Surgical time was shorter in PR versus SB at 15 versus 85 min and surgical cost (including additional surgery) was 50% less in PR. Complications like cataract progression (P > 0.99) and glaucoma (P = 0.71) were analogous among the groups. Horse-shoe tears were associated with failed primary surgery in 60% of PR and 75% of SB procedures., Conclusion: In RRDs secondary to superior breaks, PR proved to be faster, more economical, and less tissue manipulative than scleral buckle surgery, with equivalent efficacy and safety profile., Competing Interests: None

Introduction: To report the 10-year rate of vitrectomies and the associated factors in people with proliferative diabetic retinopathy (PDR) from a multicentric cohort of people with diabetes mellitus., Methods: Ten centres in India with established vitreoretinal (VR) services for over 10 years were invited to provide long-term data on PDR. People with Type 1 or 2 diabetes with a clinical diagnosis of active PDR in 1 or both eyes were included. Baseline data collected included age, sex, duration of diabetes, source of referral and best-corrected visual acuity, and diabetic retinopathy status in both eyes. Available follow-up data included the numbers of panretinal photocoagulation (PRP) sessions, cataract surgery, treatment of diabetic macular oedema, use of anti-vascular endothelial growth factor (VEGF) therapy, vitrectomy with or without retinal surgeries over 10 years., Results: Over 10 years, 89% needed supplemental PRP after initial complete PRP. One-third required retinal surgery, 16% needed intravitreal injection. Men (74.5%) had significant higher risk for vitreous (VR) surgery. Of the group with low-risk PDR, 56.8% did not require VR surgery, p < 0.001. Of the patients who underwent cataract surgery and had intravitreal anti-VEGF injections, 78.5 and 28.2% needed subsequent vitreous (VR) surgery, p = 0.006 and <0.0001, respectively. Independent predictors of need for vitreoretinal surgery included those who underwent cataract surgery and those with poor baseline visual acuity (logMAR). Eyes at lower risk for VR surgery included the eyes previously treated with PRP and low-risk PDR at baseline., Conclusion: Despite initial "complete" PRP, one-third of our study cohort needed vitrectomies over 10 years, highlighting that these patients require regular follow-up for a long period of time., (© 2020 S. Karger AG, Basel.)

To provide the real-world outcomes of people with proliferative diabetic retinopathy (PDR) in India and highlight opportunities for improvement of their disease status and to evaluate their visual acuity (VA) status. A multicenter retrospective study in which ten centers in India with established vitreoretinal services for over 10 years were invited to provide long-term data on PDR. This study population were of Indian nationality. Patients with a diagnosis of type 1 or 2 diabetes with a clinical diagnosis of active PDR in any or both eyes, who had long term follow-up for up to 10 years were included. Baseline data collected included age, sex, duration of diabetes, source of referral and best-corrected visual acuity, diabetic retinopathy status in both eyes. Available follow-up data on VA were collected at 6 months post baseline, 5 years and 10 years within a ± 3 months window. Evaluating the presenting VA of people with PDR, short-term outcomes at 6 months and the incidence of visual impairment (VI) at 5 and 10 years are the main outcome of the study. Data was available for 516, 424 and 455 patients at baseline, 5 years and 10 years respectively. Gender and duration of diabetes did not have statistically significant effect on VI outcomes. Eyes receiving treatment early in the disease course (i.e. baseline VA ≥ 6/12) had significantly better VA outcomes at 10 years versus eyes treated at a later stage (i.e. baseline VA < 6/12) (p = <0.0001). On comparing eyes with stable treated PDR and persistent PDR at end of 10 year follow up, a significantly higher percentage of eyes in the stable treated group maintained VA of ≥ 6/12 (55.1% vs. 24.2%) (p = < 0.0001), indicating persistent disease activity due to inadequate treatment results in worse VA outcomes. We found no trend in VI or blindness with increasing levels of age at both 5- and 10-year time points (p > 0.05). The age standardized incidence for VI was 11.10% (95% CI 8.1, 14.2) and for blindness was found to be 7.7% (95% CI 5.2, 10.3). Our results suggest that despite robust recent clinical trial results showing that pan retinal photocoagulation is an excellent treatment for PDR, people with diabetes in India need to be made aware of annual screening and treatment of their eyes to avoid vision impairment and blindness.

Purpose: To document the spectrum of eye diseases in people with type 2 diabetes mellitus (T2DM) reporting to large eye care facilities in India., Methods: The selection of eye care facilities was based on the zone of the country and robustness of the programs. Only people with known T2DM certified by internist, or taking antidiabetes medications, or referred for diabetes related eye diseases were recruited. The analysis included the demographic characteristics, systemic associations, ocular comorbidities, and visual status., Results: People (11,182) with T2DM were recruited in 14 eye care facilities (3 in north, 2 in south central, 4 in south, 2 in west, and 3 in east zone); two were government and 12 were non-government facilities. Hypertension was the commonest systemic association (n = 5500; 49.2%). Diabetic retinopathy (n = 3611; 32.3%) and lens opacities (n = 6407; 57.3%) were the common ocular disorders. One-fifth of eyes (n = 2077; 20.4%) were pseudophakic; 547 (5.4%) eyes had glaucoma and 277 (2.5%) eyes had retinal vascular occlusion. At presentation, 4.5% (n = 502) were blind (visual acuity < 3/60 in the better eye) and 9.6% (n = 1077) had moderate to severe visual impairment (visual acuity <6/18-->3/60 in the better eye)., Conclusion: People with T2DM presenting at eye clinics in India have high rates of diabetic retinopathy and vision loss. Cataract is a very common occurrence. Advocacy, infrastructure strengthening, and human resource development are the key to address the growing threats of T2DM and eye care in India., Competing Interests: None

Purpose: To determine the proportion of people with type 2 diabetes mellitus (T2DM) attending large eye care facilities across India who have retinal vascular occlusion (RVO)., Methods: A 6-month descriptive, multicenter, observational hospital-based study of people was being presented to the 14 eye care facilities in India. The retina-specific component of comprehensive eye examination included stereoscopic biomicroscopy, binocular indirect ophthalmoscopy, and fundus fluorescein angiography, and optical coherence tomography was also available when needed. Data recording of the duration of diabetes, hypertension (HTN), stroke, and other variables was obtained from the medical history. The statistical analysis included frequencies, mean, and standard deviations for continuous variables. Odds ratio (OR) and multivariate analysis were undertaken to assess the associations between risk factors and RVO., Results: The study recruited 11,182 consecutive patients (22,364 eyes) with T2DM. About 59.0% (n = 6697) were male. The mean age was 58.2 ± 10.6 years. In this cohort, RVO was detected in 3.4% (n = 380) of patients; 67.6% (n = 257) of them had branch retinal vein occlusion (BRVO) and the remaining 32.4% (n = 123) had central retinal vein occlusion (CRVO). The frequency of unilateral BRVO (n = 220, 85.6%) and unilateral CRVO (n = 106, 86.18%) was much common. Unilateral RVO was more frequent (n = 326, 85.8%) than bilateral diseases (n = 54, 14.2%) (χ 2 = 126.95, P < 0.001). Ischemic CRVO was more common (n = 103, 73.6%) than nonischemic CRVO (n = 37, 26.4%). Macula-involving BRVO was found in 58.5% (n = 172) of cases, suggesting more than 50% of cases in RVO carries a risk of severe vision loss. The duration of diabetes apparently had no influence on the occurrence of RVO. On the multivariate analysis, a history of HTN [OR: 1.7; 95% confidence interval (CI): 1.3-2.1; P = 0.001) and stroke (OR: 5.1; 95% CI: 2.1-12.4; P < 0.001) was associated with RVO., Conclusion: RVO is a frequent finding in people with T2DM. History of stroke carries the highest risk followed by HTN. The management of people with T2DM and RVO must also include comanagement of all associated systemic conditions., Competing Interests: None

Purpose: To estimate the proportion of people with type 2 diabetes mellitus (T2DM) and glaucoma in a facility-based cross-sectional observational study in India., Methods: All people received a comprehensive eye examination. Glaucoma-specific examinations included applanation tonometry, optic disc and cup evaluation, and stereo biomicroscopy in all people; gonioscopy and visual field testing in glaucoma suspects. The International Society of Geographic and Epidemiologic Ophthalmology guidelines were used to diagnose and classify glaucoma., Results: The study recruited 11,182 people (average age: 58.2 ± 10.6; range 39-96 years). Glaucoma was diagnosed in 4.9% (n = 547) people. About 76.8% (n = 420) of those with glaucoma had bilateral disease, and 98.7% (n = 540) were >40 years. Among people with bilateral disease, 94.5% (n = 397) had primary glaucoma - open angle in 59.3% (n = 228) and angle closure in 40.2% (n = 169). Diabetes duration was ≤10 years in 71.5% (n = 300) people. On linear regression, the following were associated with glaucoma: advancing age [compared with < 40 years age group; odds ratio [OR] in 50-60 year age group: 1.36 [95% confidence interval (CI): 1.01-1.8], P < 0.035); >60 years age group (OR: 2.05, 95% CI: 1.57-2.67; P < 0.001), and diabetic neuropathy (OR: 2.62, 95% CI: 1.35-5.10, P < 0.003). Glycemic control did not have significant association (P = 0.425)., Conclusion: Presence of glaucoma in people with T2DM in this cohort was similar to the general population prevalence studies in India. Glaucoma was invariably bilateral. A comprehensive eye examination in people age 40 years and older with diabetes and/or glaucoma is beneficial., Competing Interests: None

Purpose: To assess the proportion of people with type 2 diabetes mellitus (T2DM) with diabetic retinopathy (DR) and sight-threatening DR (STDR) and associated risk factors in select eye-care facilities across India., Methods: In this observational study, data of people with T2DM presenting for the first time at the retina clinic of eye-care facilities across India was recorded. Data collected in 2016 over 6 months included information on systemic, clinical, and ocular parameters. International Clinical Diabetic Retinopathy (ICDR) classification scale was used to grade DR. STDR was defined as presence of severe nonproliferative (NPDR), proliferative diabetic retinopathy (PDR), and/or diabetic macular edema (DME)., Results: The analysis included 11,182 people with T2DM from 14 eye-care facilities (mean age 58.2 ± 10.6 years; mean duration of diabetes 9.1 ± 7.6 years; 59.2% male). The age-standardized proportion of DR was 32.3% (95%Confidence Interval, CI: 31.4-33.2) and STDR was 19.1% (95%CI: 18.4-19.8). DME was diagnosed in 9.1% (95%CI: 8.5-9.6) and 10.7% (95%CI: 10.1-11.3) people had PDR. Statistically significant factors associated with increased risk of DR (by multivariate logistic regression analysis) were: male gender (Odds ratio[OR] 1.57, 95%CI: 1.16-2.15); poor glycemic control-glycated hemoglobin (HbA1c >10%)(OR 2.39, 95% CI: 1.1-5.22); requirement of insulin (OR 2.55, 95%CI: 1.8-3.6);history of hypertension (OR 1.42, 95%CI: 1.06-1.88) and duration of diabetes >15 years (OR 5.25, 95%CI: 3.01-9.15)., Conclusion: Diabetic retinopathy was prevalent in 1/3 rd and sight-threatening DR in 1/5 th of people with T2DM presenting at eye-care facilities in this pan-India facility-based study. The duration of diabetes was the strongest predictor for retinopathy., Competing Interests: None

A rare case of Staphylococcus gallinarum endophthalmitis with intraocular foreign body (IOFB) was managed successfully by vitrectomy, IOFB removal and intravitreal antibiotics with steroids. Intraoperatively, the inferior retina was noted to be pale, possibly secondary to arteriolar occlusion/inflammation. This pale retina detached while peeling the vitreous, but spontaneously reattached postoperatively within a week. The case report describes the natural course of an iatrogenic detachment of pallid retina and the outcome of an uncommon ocular infection., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared.

Competing Interests: Competing interests: None declared.

Purpose: To report a case of low tension neovascular glaucoma in ocular ischemic syndrome., Methods: An elderly man presenting with vision loss after an episode of hemiparesis was investigated to look for the cause of vision loss and treated., Results: Fluorescein angiography demonstrated poor uveal perfusion and treatment with panretinal photocoagulation led to rapid closure of the angle., Conclusion: This case highlights the typical ophthalmic features of ocular ischemic syndrome and emphasizes the necessity of patient education and prognostication.

Purpose: To report a case of macular infarction after doublet chemotherapy with gemcitabine and carboplatin., Methods: A middle-aged lady presenting with bilateral macular infarction post-chemotherapy for metastatic cervical malignancy was investigated for thromboembolic risks and treated., Results: The macular perfusion and edema improved with control of hypertension and treatment with pentoxifylline. Visual improvement was satisfactory, and the possible associated risk such as hypertension was noted., Conclusion: This case underscores the need for active screening of patients on chemotherapy with gemcitabine and carboplatin for retinal vascular occlusive changes when hypertension is associated.

Purpose: To study whether immediate pars plana vitrectomy at the time of sampling vitreous for culture alter the visual and structural outcomes in fungal endophthalmitis., Methods: Surgical results of 66 consecutive patients with culture-positive fungal endophthalmitis attending a tertiary eye care hospital in eastern India were analyzed. Based on the timing of vitrectomy, they were divided into 2 groups: Group 1-immediate vitrectomy (n = 31) and Group 2-diagnostic vitrectomy alone (n = 35) as the first-line intervention. The demographics, clinical features, and visual and structural outcomes were compared between the groups., Results: The proportion of postoperative (54.83 vs. 51.42%), traumatic (29.03 vs. 34.28%), and endogenous (16.12 vs. 14.28%) endophthalmitis and clinical signs such as pain (54.83 vs. 60%), lid edema (48.38 vs. 48.57%), conjunctival congestion (87.09 vs. 94.28%), and corneal involvement (87.09 vs. 80%) in Groups 1 and 2, respectively, were comparable. Logarithm of the minimum angle of resolution vision improvement in Group 1 was significant (P = 0.0278) though there was no statistically significant difference in posttreatment vision between the groups (P = 0.322). Phthisis was seen in 25.8% in Group 1 and 25.7% in Group 2 (P = 0.993). Aspergillus species was the most common fungal pathogen isolated. Early vitrectomy plus intravitreal antifungals in a subset of clinically suspected fungal endophthalmitis resulted in statistically significant visual improvement over diagnostic vitrectomy plus intravitreal antifungals (P = 0.013)., Conclusion: A strong clinical suspicion that translates into early vitrectomy plus intravitreal antifungal antibiotics leads to favorable visual and structural outcomes. A long wait till microbiological confirmation to institute antifungal therapy may result in poorer outcome.

The early clinical manifestations of macular infarction secondary to subconjunctival gentamicin (Gentak; Akorn, Lake Forest, IL) use in an aphakic eye were documented sequentially on swept-source optical coherence tomography (OCT) and fundus fluorescein angiography. The first recorded event after drug toxicity was macular detachment, along with disorganization of outer retinal layers in about 12 hours. The changes in inner retinal layers occurred after 36 hours had elapsed. OCT-documented initial damage to outer retinal layers could be due to the susceptibility of first order retinal neurons, followed by subsequent inner retinal layer involvement and ischemia. This helps in understanding pathogenesis of a catastrophic complication of subconjunctival gentamicin injection commonly used for endophthalmitis prophylaxis. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:456-459.]., (Copyright 2018, SLACK Incorporated.)

Purpose: To report two cases of retinal vascular occlusion and associated subconjunctival hemorrhage in needle optic nerve injury during local bulbar anesthesia., Methods: Surgical records of these two subjects who presented with acute vision loss after cataract extraction were studied, and systemic workup and ocular imaging were carried out to establish the cause., Results: Computerized tomography showed evidence of optic nerve injury., Conclusion: Subconjunctival hemorrhage could be an associated clinical finding in hypodermic needle injury-related retinal vascular occlusion during ocular anesthesia.