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To study the incidence and risk factors of Retinopathy of prematurity in extremely low birth weight babies in a tertiary neonatal care unit in northern India. A prospective cohort study of all neonates born during January 1, 2015 to December 31, 2015, with birth weight less than 1000 grams. Demographic details, risk factors and incidence of ROP were studied. Sixty babies were enrolled for the study with mean birth weight of 892.983±112.933 (560 to 1000) grams and mean gestation age of 29.47±2.258 (25-35) weeks. The incidence of ROP in this cohort was 50% (30 infants), out of which 23% (7 infants) required treatment (laser photocoagulation). The statistical analysis of risk factors on univariate analysis revealed significant association for oxygen exposure, apnoea, surfactant use, anaemia, blood transfusion, intraventricular haemorrhage, sepsis and antibiotic use. On multivariate logistic regression analysis anemia and oxygen exposure > week were found to be independent risk factors for development of ROP. The incidence of ROP was although high in this exclusive cohort of babies born 1 week were found to be independent risk factors for development of ROP in this cohort.

Purpose: To assess the ability of wide field Swept Source OCTA (SS-OCTA) imaging to detect morphological variations in Serpiginous Choroiditis (SC) and Serpiginous Like Choroiditis (SLC) in response to treatment and also analyze these findings quantitatively using Image J software. Methods: Retrospective observational case series of nine eyes with clinical diagnosis of active SC and SLC, who underwent SS-OCTA and fundus autofluorescence (FAF) imaging at baseline and each follow up visit till 6 months. Morphological analysis was done by two independent graders and quantitative analysis to measure the size and intensity of lesion was done using publicly available Image J software at baseline and each follow up visit. Design: Retrospective observational case series. Results: Using SS-OCTA, all the active lesions followed a characteristic healing pattern. Active lesions appear well defined hypo flow void patches and as healing progressed, lesion became more ill-defined and iso-hyper- intense. Significant increase in mean intensity of the lesion could be apparent after 1 and 6 month of treatment. There was reduction in the size of lesions during follow up however this difference was not statistically significant. Conclusion: SS-OCTA could be a useful noninvasive tool to study the treatment response in SC/SLC both morphologically as well as quantitatively. Quantitative parameters need to be designed in further research studies to aid in uniform management and follow up of uveitis cases.

OBJECTIVES To compare the diagnostic accuracy of the ultrasonography-guided optic nerve sheath diameter with transcranial Doppler-guided middle cerebral artery flow indices against the gold standard invasive intraparenchymal intracranial pressure values in children. DESIGN A single-center prospective cohort study. SETTING PICU of a tertiary care teaching hospital in North India. PATIENTS Eligible children (2-12 yr) are admitted to ICU and are undergoing intracranial pressure monitoring using an intraparenchymal catheter. Observations with a parallel measured intracranial pressure greater than or equal to 20 mm Hg were included as case-observations. Children with an invasive intracranial pressure of less than or equal to 15 mm Hg were taken as neurologic-control-observations and healthy children served as healthy-control-observations. INTERVENTIONS The horizontal and vertical diameters of the optic nerves were measured, and averages were calculated and compared. Middle cerebral artery flow indices (pulsatility index and resistive index) were measured bilaterally and averages were calculated and compared in the three groups. Twenty-two measurements of optic nerve sheath diameter were assessed by two different observers in quick succession for interrater reliability. MEASUREMENTS AND MAIN RESULTS A total of 148 observations were performed in 30 children. Four observations were excluded (intracranial pressure between 16 and 19 mm Hg). Of the 144 observations, 106 were case-observations and 38 were neurologic-control-observations. Additional 66 observations were healthy-control-observations. The mean optic nerve sheath diameter was 5.71 ± 0.57 mm in the case-observations group, 4.21 ± 0.66 mm in the neurologic-control-observations group, and 3.71 ± 0.27 mm in the healthy-control-observations group (p < 0.001 for case-observations vs neurologic-control-observations/healthy-control-observations). The mean pulsatility index in case-observations was 0.92 ± 0.41 compared with controls 0.79 ± 0.22 (p = 0.005) and the mean resistive index was 0.56 ± 0.13 in case-observations compared with 0.51 ± 0.09 (p = 0.007) in controls (neurologic-control-observations and healthy-control-observations). For the raised intracranial pressure defined by intracranial pressure greater than or equal to 20 mm Hg, the area under the curve for optic nerve sheath diameter was 0.976, while it was 0.571 for pulsatility index and 0.579 for resistive index. Furthermore, the optic nerve sheath diameter cutoff of 4.0 mm had 98% sensitivity and 75% specificity for raised intracranial pressure, while the pulsatility index value of 0.51 had 89% sensitivity and 10% specificity by middle cerebral artery flow studies. The sensitivity and specificity of 0.40 resistive index value in the raised intracranial pressure were 88% and 11%, respectively. Kendall correlation coefficient between intracranial pressure and optic nerve sheath diameter, pulsatility index, and resistive index was 0.461, 0.148, and 0.148, respectively. The Pearson correlation coefficient between two observers for optic nerve sheath diameter, pulsatility index, and resistive index was 0.98, 0.914, and 0.833, respectively. CONCLUSIONS Unlike transcranial Doppler-guided middle cerebral artery flow indices, ultrasonography-guided optic nerve sheath diameter was observed to have a good diagnostic accuracy in identifying children with an intracranial pressure of greater than or equal to 20 mm Hg.

We aim to look at the complications encountered by a cohort of pediatric uveitis patients from north India. Retrospectively, complications seen in patients younger than 16 years diagnosed with uvei...

Induction of posterior vitreous detachment (PVD) by pharmacologic vitreolysis has been largely attempted through the use of enzymatic reagents. Ocriplasmin has been the only FDA-approved clinical reagent so far. Several adverse effects of ocriplasmin have emerged, however, and the search for alternative PVD-inducing reagents continues. Since i) collagen forms an important structural component of the vitreous, and ii) strong vitreo-retinal adhesions exist between the cortical vitreous and the internal limiting membrane (ILM) of the retina, an effective PVD-inducing reagent would require both, vitreous liquefaction, and concurrent dehiscence of vitreoretinal adhesion, without being toxic to retinal cells. We designed a combination of two reagents to achieve these two objectives; a triple helix-destabilizing collagen binding domain (CBD), and a fusion of RGD (integrin-binding) tripeptide with CBD (RCBD) to facilitate separation of posterior cortical vitreous from retinal surface. Based on in vitro, ex-vivo, and in vivo experiments, we show that a combination of CBD and RCBD displays potential for safe pharmacologic vitreolysis. Our findings assume significance in light of the fact that synthetic RGD-containing peptides have already been used for inhibition of tumor cell invasion. Proteins such as variants of collagen binding domains could have extended therapeutic uses in the future.

Purpose Retinal detachments (RD) secondary to retinal vasculitis are highly complex. We report the clinical profile and outcome of vitrectomy in RDs secondary to retinal vasculitis in terms of intraoperative findings, final anatomical, and functional outcome. Methods In a retrospective review of 68 patients (6 with bilateral RD; 74 eyes) undergoing pars plana vitrectomy (PPV) between 2000 and 2015 for vasculitic RD, tractional RD was present in 50 (67.57%) eyes and combined RD in 24 (32.43%) eyes. Results The mean age was 31.54 ± 9.95 years (62 males, 6 females). Fibrovascular proliferations (FVPs) involved major vascular arcades (22.98%), optic disc (10.81%), both arcades and disc (20.27%), peripheral retina (32.43%), and arcades with peripheral retina (13.51%). A total of 14 (18.92%) eyes had retinal folds, of which 9 had macular drag. Of 24 eyes with combined RD, 3 (12.5%) eyes had macular hole, 15 (62.5%) eyes had the primary retinal break anterior to equator, and 6 (25%) eyes had the primary break posterior to equator. Twenty-one (28.38%) eyes had iatrogenic retinal breaks. Thirty-eight (51.35%) eyes required an internal tamponade [gas in 31 (81.57%) eyes and silicon oil in seven (18.42%) eyes]. A scleral buckle was additionally required in 26 (35.14%) eyes. Postoperative complications included vitreous hemorrhage (27.03%), re-RD (12.16%), and iris neovascularization (9.46%). The median follow-up was 18 months (range 6-122 months). Sixty-eight (91.9%) eyes achieved final anatomical success. Fifty-two (70.27%) eyes had ≥2 lines visual improvement. Conclusion Vasculitic RDs are complicated by tractional/combined RDs, peripherally located FVPs, retinal folds and iatrogenic retinal breaks, and carry a moderate prognosis.

Purpose : To screen for obstructive sleep apnea (OSA) in patients presenting to diabetic retinopathy (DR) clinic and to correlate its presence with the severity of DR. Methods : A prospective, cross-sectional study of diabetes mellitus patients in retina clinic of a tertiary care referral center, North India (January 2019-March 2020). All were subjected to STOP-Bang Questionnaire and Epworth Sleepiness Scale (ESS) score. Patients at high OSA risk (STOP-Bang score ≥5 and ESS score ≥10) were referred to Department of Otorhinolaryngology (sleep clinic) for polysomnography. Based on Apnea Hypopnea Index (AHI), OSA was graded as mild (AHI = 5-14/h), moderate (AHI = 15-30/h), and severe (AHI >30/h). Statistical analysis was done using three models of outcome measures: (1) "No DR" versus "any DR," (2) "Less severe DR" versus "More severe DR," and (3) "No diabetic macular edema (DME)" versus "DME." Results : Of 362 patients screened, 18 (4.97%) had OSA (11 mild, 5 moderate, and 2 severe). Though OSA did not show a significant association with various outcome measures, patients with moderate-severe OSA had higher odds in developing "any DR" (OR = 7.408; 95% CI = 0.533-102.898), "more severe DR" (OR = 1.961; 95% CI = 0.153-25.215), and "DME" (OR = 2.263; 95% CI = 0.357-14.355), on multiple logistic regression. Conclusion : Ours is the first screening study of OSA in DR patients in India, the diabetes capital of the world. We detected OSA in 4.97% of patients in a DR clinic, with an increased risk of "any DR," "more severe DR," and "DME" in the presence of moderate-severe OSA.

Purpose: To use the extent of retinal immaturity at the first visit to predict progression to any stage and treatment-requiring retinopathy of prematurity (ROP). Methods: Retrospective, multicenter, nonrandomized, observational, clinical, validation study. In all, 601 Asian Indian preterm infants born

Purpose: To study the role of ultra-wide field (UWF) fundus autofluorescence (FAF) in the management of CMV (cytomegalovirus) retinitis.Material and methods: In this prospective, observational, non-randomized study, we followed up patients with active CMV retinitis on UWF fundus photograph (FP) and UWF-FAF.Results: A total of 16 patients (24 eyes) were studied. There were 13 males and mean age of patients was 37 (range 9-56) years. On UWF FP, out of 24 eyes, 13 (54.2%) had granular lesions, 3 (12.5%) had necrotizing pattern, 1 (4.1%) had a frosted branch angiitis (FBA), and 7 (29.2%) had a mixed pattern. UWF-FAF showed better delineation of borders of lesions in 7 eyes (29.1%), larger area of involvement in 8 eyes (33.3%), picked up 7 of 9 (77.77%) eyes of recurrence and helped differentiate cotton wool spots from retinitis lesion in one eye.Conclusion: UWF-FAF is useful in the management of CMV retinitis.

PurposeTo study features, management and outcomes of cluster endophthalmitis following intravitreal bevacizumab (BCZ) injection in North India.MethodsIn this retrospective study, 28 patients (23 men) (mean age of 59.07±13 years) who received intravitreal injection of BCZ were included. Demographic details, best corrected visual acuity (BCVA), clinical features, microbiological findings and management of patients who developed endophthalmitis after injection of contaminated BCZ injections were reviewed. The organism isolated was Stenotrophomonas maltophilia.ResultsAll patients suffered from painful diminution of vision within 24–48 hours. Of the 28 eyes, 12 had lid and corneal oedema, raised intraocular pressure (IOP) (difference between mean preinjection and postinjection IOP: 4.42 mm Hg; p=0.005) and toxic anterior segment syndrome-like picture. 16 eyes presented with clear cornea, severe vitritis and poor media clarity. Among these, three eyes showed posterior hypopyon. Seventeen eyes underwent primary pars plana vitrectomy (PPV) and intravitreal vancomycin+ceftazidime based on severity of inflammation. Eleven eyes underwent primary tap and inject. Among these, four eyes required PPV due to persistent inflammation. Eleven eyes showed positive staining for Gram-negative bacilli. Seven eyes were culture positive for S. maltophilia. Mean preinjection BCVA was 0.77±0.48. The first recorded postinjection BCVA was 2.52±0.82. BCVA (at 1 month) improved to 0.88±0.66.ConclusionsS. maltophilia can be found contaminating hospital surfaces and water supply. Early PPV, prompt intravitreal antibiotics and close communication with microbiologists greatly aided in salvaging all eyes from our cohort. Majority of the patients recovered their preinjection BCVA and IOP and achieved quiescence of inflammation.

We hypothesized that fetal oxidative stress and micronutrient deficiencies contribute to higher incidence of retinopathy of prematurity (ROP) in developing countries. In a nested case-control study, preterm infants ( 37 weeks, 1700 g) were included at birth and followed until 40 weeks post-menstrual age (PMA). Maternal, cord, and neonatal serum/plasma samples at 40 weeks PMA were frozen. Samples of "cases" with ROP and gestational age (GA) and birth weight-matched "controls" with no ROP (in 1:4 ratio) were thawed and analyzed.MDA concentration in cord plasma.MDA in maternal and 40-week PMA plasma; copper, zinc, and vitamin A in maternal, cord, and 40-week PMA samples. Thirty-eight cases and 151 controls had a mean (SD) GA of 29.5 (1) and 29.9 (1) weeks respectively. Following were associated with ROP: higher MDA concentration in cord and 40-week PMA samples; lower copper and zinc in maternal serum; lower zinc and vitamin A in cord sample (all p 0.05). MDA [adjusted OR (aOR) = 4.13 (95% CI 1.83-9.27)] and vitamin A [aOR = 0.09 (95% CI 0.02-0.4)] concentration in cord plasma and weight gain (g/kg/week) [aOR = 0.97 (0.95-0.99)] independently predicted ROP.Increased oxidative stress and deficiency of micronutrients from fetal life were associated with ROP.Clinical Trials Registry of India CTRI/REF/2014/12/008174. What is Known: • In developing countries, there is a higher incidence of retinopathy of prematurity (ROP), but micronutrient deficiencies have not been adequately investigated as risk factors. • Few observational studies have shown an association between ROP and postnatal increase in malondialdehyde (MDA) levels and deficiencies of antioxidant vitamins and minerals, but none in cord blood. What is New: • High MDA, low zinc, and low vitamin A levels in cord blood and low copper and zinc levels in maternal blood are associated with the development of ROP. • On multivariable analysis, high cord blood MDA and low cord blood vitamin A are independent predictors of ROP.

Induction of posterior vitreous detachment (PVD) by pharmacologic vitreolysis has been largely attempted through the use of enzymatic reagents. Ocriplasmin has been the only FDA-approved clinical reagent so far. Several adverse effects of ocriplasmin have emerged, however, and the search for alternative PVD-inducing reagents continues. Since i) collagen forms an important structural component of the vitreous, and ii) strong vitreo-retinal adhesions exist between the cortical vitreous and the internal limiting membrane (ILM) of the retina, an effective PVD-inducing reagent would require both, vitreous liquefaction, and concurrent dehiscence of vitreoretinal adhesion, without being toxic to retinal cells. We designed a combination of two reagents to achieve these two objectives; a triple helix-destabilizing collagen binding domain (CBD), and a fusion of RGD (integrin-binding) tripeptide with CBD (RCBD) to facilitate separation of posterior cortical vitreous from retinal surface. Based on in vitro, ex-vivo, and in vivo experiments, we show that a combination of CBD and RCBD displays potential for safe pharmacologic vitreolysis. Our findings assume significance in light of the fact that synthetic RGD-containing peptides have already been used for inhibition of tumor cell invasion. Proteins such as variants of collagen binding domains could have extended therapeutic uses in the future.

A 5-year-old girl presented with decreased vision and outward deviation of her right eye. Fundus examination revealed multiple hard exudates in the macula in the right eye and nasal to the disk in the left eye. The patient was lost to follow-up in the near term but presented 9 months later with reduced vision and an increase in exudates in both eyes. RetCam fluorescein angiography confirmed the diagnosis of bilateral Coats disease.

Purpose To determine ocular biometric and refractive profiles of premature children at risk of retinopathy of prematurity (ROP), comparing those who did and did not require laser treatment. Methods In this prospective study, premature infants underwent biometry and refraction with their first ROP examination. Study parameters were assessed again at 3 months, 6 months, and 1 year. The main outcome measures were spherical equivalent, axial length, and keratometry. Results A total of 122 infants (243 eyes) were included. At baseline, infants without ROP, those with ROP who never needed treatment, and those who later needed treatment had overall comparable axial length (P = 0.53) and myopia (P = 0.05); the highest severity group had higher corneal steepness and more myopia at baseline. At 1 year, children with laser-treated ROP had the shortest axial lengths, with the least decrease in keratometry, and the greatest increase in myopia (−2.0 D; P = 0.001). Anisometropia, if present initially, persisted through the 1-year examination. Mean refractive error was more myopic in zone 1 disease (P = 0.3) and in aggressive posterior ROP (P = 0.15). Conclusions Severe ROP is associated with disruption of emmetropization, and steeper corneas and more myopia at the first ROP examination, before any intervention. In our study cohort, these differences became more marked over the course of 1 year after laser therapy. The myopia in these cases was not axial. Laser therapy did not induce new anisometropia.

Idiopathic retinal vasculitis, aneurysms, and neuroretinitis (IRVAN) syndrome typically affects young, healthy individuals. Despite the dramatic fundus appearance seen in this syndrome, these patients are usually asymptomatic. The syndrome includes peculiar vascular abnormalities in the form of multiple aneurysmal dilatations seen along retinal arterioles and optic nerve-head arterioles, which are best appreciated on fluorescein angiography. Neuroretinitis and retinal vasculitis are seen in all patients, and manifested by staining of the optic nerve head and diffuse leakage from vessels, mainly arterioles, on fluorescein angiography. The devastating vision-threatening outcomes of this syndrome include exudative retinopathy and extensive peripheral retinal nonperfusion areas, which can eventually lead to neovascularization. This review summarizes current knowledge on the variable clinical aspects of this disease, highlighting diagnostic and treatment strategies.

Retinopathy of prematurity (ROP) is a proliferative retinal vascular disease affecting the retina of premature infants. The clinical spectrum of ROP varies from spontaneous regression to bilateral retinal detachment and total blindness. Between these two extremes lies the form of ROP, which is amenable to treatment with laser photocoagulation, anti-vascular endothelial growth factor drugs or surgery. Increasing rates of preterm births coupled with better survival rates but lack of uniform quality of neonatal care and delays in diagnosis have led to increasing ROP blindness. Atypical forms of Aggressive Posterior ROP are seen in heavier birth weight babies in developing countries. Prevention of ROP by following stringent protocols for supplemental oxygen, prevention of sepsis, timely screening and laser treatment by a concerted and collaborative effort of neonatologists and ophthalmologists are required to fight the blindness from ROP.

Importance In a subset of patients with retinal vasculitis, there is occlusion of blood flow through the retinal vessels. These eyes may have higher levels of retinal ischemia and are at high-risk of sight-threatening complications. Background To characterize epidemiology, clinical course, treatment, and outcomes of occlusive retinal vasculitis (ORV). Design Retrospective study Participants 77 uveitis patients with ORV at two large tertiary-care institutions (USA and India). Methods Out of 2438 patients screened, 346 patients were diagnosed with retinal vasculitis of which 77 patients (96 eyes) were diagnosed with ORV. Patients with ORV (capillary, arteriolar and/or venular) were further analyzed. Diagnostic criteria for occlusive vasculitis included: (1) absence of blood flow in vessels (arterioles, venules and/or capillaries), (2) capillary non-perfusion areas and/or arteriolar-venous anastomosis, (3) intraretinal hemorrhages, cotton-wool spots or vitreous hemorrhage. Main Outcome Measures Best-corrected visual acuity (BCVA), treatment and complications. Results The mean age was 32.09±13.51 years. Most common etiologies were tuberculosis and Adamantiades-Behcet's disease in India and systemic lupus erythematosus in USA. BCVA improved from 0.38±0.30 LogMAR (20/48 Snellen's equivalent) (baseline) to 0.25±0.30 (20/35 Snellen's equivalent) at final visit (p

Purpose: Indian children belong to a diverse socioeconomic strata with retinopathy of prematurity (ROP) developing in mature, higher birth weight babies as well. The purpose of our study is to analyze the long-term status of refractive errors and its relationship with ocular biometry in children with ROP who were laser treated at a tertiary center in North India. Methods: Cross sectional study. Children (

The modern-day trocar cannula systems meant for adult eyes pose a challenge in infant's eyes with stage 4 retinopathy of prematurity (ROP) undergoing lens-sparing vitrectomy. This is primarily owing to the length of the trocar, globular lens, smaller axial length, and anteriorly displaced retina. We describe an inexpensive modification of the technique of trocar insertion in such cases wherein the trocar is inserted partially till the cannula impinges the sclera and thereon, the cannula slides over the trocar into the vitreous cavity. This obviates the need for complete insertion of the trocar into the vitreous cavity and hence limits the chances of inadvertent injury to the crystalline lens or the anteriorly lifted retina. We have experience in using this technique in 52 eyes of 44 infants over the past 2 years with no episode of iatrogenic lens touch or retinal break during trocar insertion.

Purpose: To suggest a low cost, non-contact smartphone-based screening system in retinopathy of prematurity (ROP), and to illustrate its potential clinical application as a potential future tool for teleophthalmology. Methods: Neonatal intensive care unit (NICU)-based bedside ROP screening done between January 2018 and May 2018. Documentation of ROP was done by using a smartphone and +40D, +28D, or +20D indirect non-contact condensing lenses. By using the coaxial light source of the phone, this system works as an indirect ophthalmoscope that creates a digital image of the fundus. With smartphone-based camera we extracted high-quality still images extracted from the video clip. Results: Total of 228 eyes of 114 infants screened for ROP between January 2018 and May 2018. Incidence of total ROP was 23.68%, out of which incidence of type 1 ROP was 8.77%. After initial screening with indirect ophthalmoscope, we uesd smartphone imaging to document ROP in 28 eyes out of 55 eyes having ROP. Image quality was good in 89.28% eyes. Field of view vary from 46°, 53°, and 90° with +20D, +28D, and +40D indirect condensing lenses, respectively, which gives excellent images for bedside ROP documentation. Conclusion: The described technique of smartphone fundus photography is a light weight, cost-effective, user friendly, high-quality wide-field fundus photographs for bedside documentation of ROP in NICUs using readily available instruments that are handy and portable with simple power sources. Smartphones has the potential to be operated with only one hand. It can also be used as a future telescreening device.

Purpose: To report the pattern of pediatric uveitis in a tertiary care referral center in North India.Methods: In a retrospective study, records of pediatric uveitis cases presenting at our center between 1996 and 2015 were reviewed for demographic data, anatomic distribution, and diagnosis.Results: Out of 9600 patients with uveitis, 369 children (3.84%; age ≤16 years; males: 54.20%) were included in the study. Anterior uveitis was the commonest presentation (n = 158; 42.81%), followed by posterior uveitis (n = 102; 27.64%). Uveitis was bilateral in 57.18% (n = 211). Infective etiology was seen in 99 children, of which tuberculosis was the commonest cause (n = 55; 14.91%). Among non-infectious etiologies, juvenile idiopathic arthritis (JIA) was the commonest cause (n = 59; 15.99%).Conclusions: While anterior uveitis is the commonest uveitis in children, our cohort reported a high number of posterior uveitis cases compared to previous studies. Tuberculosis and JIA were the commonest causes of pedia...

A 36-year-old immunocompetent man developed endogenous endophthalmitis 1 week after intravenous fluid infusion in a rural setting. Large submacular abscess with posterior hypopyon warranted urgent vitrectomy which revealed Aspergillus terreus on fungal culture. Intravitreal and oral antifungals lead to resolution of inflammation with satisfactory anatomic outcome but poor visual outcome due to submacular scar.