March-April 2025 (Vol 30 No 6)

Subspecialty - StrabismusDOS Times - Volume 30, Number 6, March-April 2025 51 www.dosonline.org3 months and 6/6 at 36 months of age.Visual acuity obtained by TAC procedure is actually the grating acuity, which is expressed in cycles/cm or cycles/degree, whereas, Snellen visual acuity is a 2. Catford Drum Test: It is a detection acuity test useful in infants and children less than 2 years of age. In this test, the child is made to observe an oscillating drum with black dots of varying sizes. Rotation of disc evokes pendular movements. The smallest dot that evokes pendular eye movements denotes the level of visual acuity. Assessment of Visual Acuity from 1 to 3 YearsAbove 1 year of age, of visual acuity, the child is able to visually differentiate the small objects and is able to reach out for toys. Visual acuity tests can use pictures or symbols to assess how well they can see. The pictures or symbols can be placed on a chart to determine if the child can recognize them.So, in addition to the above-mentioned tests, the following detection acuity tests are more useful in this age group:1. Cardiff Acuity Card (CAC) Test: Adoh and Woodhouse introduced Cardiff acuity card (CAC) in 1992 to measure visual acuity development is toddlers (1 to 3 years of age) This test is based on the principle of vanishing optotypes that is targets that disappear at the resolution limit. It means, if the target lies beyond the subject’s (child’s) acuity limit, it is invisible.The set of CAC consists of 33 cards, and each acuity level contains 3 cards. The targets used actually are pictures, which are familiar to the children and also attractive. The pictures are computer generated and positioned randomly either in the top half or bottom half of the card. Six pictures are used (Le train, house, fish, boat, car and duck), which are drawn with a white band surrounded by black bands, half the width of the white band on a neutral gray back ground. With the higher acuity levels, the overall sizes of the pictures remain same, whereas, the width of white and black measure of recognition acuity. After the examination, the acuity score obtained by TAC test is first converted to Snellen equivalent (Table-2) and then to log, relative to 20/20 or 6/6 Snellen acuity.Cycles/cm Test Distance 9.5cmTest Distance19cmTest Distance38cmTest Distance55cmTest Distance84cm38.0 20/57 20/40 20/23 20/16 20/1126.0 20/84 20/59 20/33 20/24 20/1519.0 20/110 20/81 20/45 20/32 20/2113.0 20/170 20/120 20/66 20/47 20/319.80 20/220 20/160 20/89 20/63 20/416.50 20/340 20/240 20/130 20/94 20/634.80 20/460 20/320 20/180 20/130 20/843.20 20/680 20/490 20/270 20/190 20/1302.40 20/910 20/650 20/360 20/260 20/1701.60 20/1400 20/970 20/540 20/380 20/2501.30 20/1700 20/1200 20/670 20/470 20/3100.86 20/2500 20/1800 20/1000 20/710 20/4700.64 20/3300 20/2400 20/1400 20/960 20/6300.43 20/4800 20/3500 20/2000 20/1400 20/9400.32 20/6400 20/4700 20/2700 20/1900 20/13000.25 low vision low vision low vision low vision low visionTable 2: Conversion from cycles/cm to Snellen Equivalents.

Subspecialty - StrabismusDOS Times - Volume 30, Number 6, March-April 2025 52 www.dosonline.orgbands decreases. The acuity values of this test are given in minutes of arc and in Snellen’s equivalent. The range of acuity values varies with test distance (i.e. 6/6 to 6/60 for 1 meter and 6/12 to 6/120 for 50cms).2. Marble Game Test: In it, the child is asked to place marbles in the holes of a card or in a box. The vision of an eye is then noted as being ‘useful’ or ‘less useful’.3. Sheridan’s Ball Test: In this test which was devised by Mary Sheridan in 1960, the Styrofoam balls of different sizes are rolled on the floor at 10 feet in front of the child, and the quality of fixation for each eye is assessed. The smallest size of Styrofoam balls of different sizes are rolled on the floor to which the child gives a good response is a rough way of estimating his/her visual acuity. Alternatively, pairs of miniature toys are used, and the child is asked to name or pick the pair from an assortment.4. Hundreds and Thousand’s of Sweet Test: If the child looks at and picks up small sweets at 33cms distance, he/she might be having at least 6/24 visual acuity.5. Worth’s Ivory Ball Test: Ivory balls ranging in size from 0.5 to 2.5 inches in diameter are rolled on the floor in front of the child at a distance of 18 feet beginning from the largest. One eye is then covered and the child is asked to retrieve each of the balls.[4]The visual acuity of the child is then tested in decimal units (6/6-1.0) with the help of a special formula, mentioned below:Visual Acuity = 0.3 X Object distance (in meters)/Object size (in mm)6. Dot Visual Acuity Test: Child is shown an il-luminated box with black dots of different sizes printed on it. The smallest dot identified denotes the visual acuity of the child.7. Coin Test: In this test, coins of different sizes are shown to the child and is expected to pick up the two faces of coins easily visible.8. Miniature Toy Test: It used 2 sets of miniature objects. One set with examiner standing at 10 feet away and the patient is asked to pick up similar objects from his own set. The object chosen are easily identifiable small toys like automobile, planes, charts, knives, spoons etc.Cover Test: A cover test is often used to check for signs of strabismus (crossed or misaligned eyes). If a child’s eyes deviate when one is covered, it suggests an issue with eye alignment.Behavioural Indicators: Parents can monitor how the child reacts to different visual tasks. For example, if a child frequently squints or holds books too close to their face, it could indicate a refractive error like near-sightedness (myopia).Depth Perception: By 2 years old, children begin to develop depth perception. Activities like stacking blocks or navigating obstacles can give insight into how well they perceive depth and distance.Measurement of Visual Acuity in Preschool ChildrenPreschool-aged children become more aware of their surroundings and more able to engage in structured activities, such as learning to read or playing more complex games. At this stage, they can better participate in visual assessments, and problems with their vision may become more apparent as they begin to interact with reading materials and other children, so in addition to the above mentioned test, the following tests are more useful visual assessment.1. Landolt’s C Test: In this test the broken ring is printed in various directions. The test is performed at a distance of 6 meter and the child is asked to indicate the direction in which the ring is open.2. Broken Wheel Test: A pair of cars in progressively smaller sizes, one of which has a wheel cut across, is shown to the child and the child is asked to identify the one with the broken wheel.3. Illiterate E-cut-out Test: The child is given a cut-out of an E and asked to match this E with isolated E’s of varying sizes.4. Tumbling E-pad Test: The chart consist of E with limbs of E pointing in various directions. The test can be used in two forms either in the form of a chart (like Snellen’s) or printed on an individual card. For children in this age group, mean visual acuity scores given by the tumbling E chart were significantly better than those given by the Landolt C charts.[5]5. Isolated Hand-figure Test: Sjögren has re-placed the E with the isolated figure of a hand, and in some children, it works better than Es.6. Sheridan-Gardiner HOTV Test: The child is handed a card with HOTV and is asked to match the letters on the chart. Snellen’s equivalent of 6/6 to 6/60 can be estimated using this method. The Sheridan Gardiner test is the most accurate of the illiterate vision tests. The choice of letters is large enough to avoid the child guessing and it is easy to use.[6]

Subspecialty - StrabismusDOS Times - Volume 30, Number 6, March-April 2025 53 www.dosonline.org7. Pictorial Vision Charts: When the child is able to verbalize, visual acuity chart showing pictures, rather than symbols, may be used. Pictorial vision charts include Kay picture test, Allen cards test, Lea symbols test and BUST.a. Allen Cards Test: Allen picture card test consists of seven black and white line drawing of birth day cake, telephone, horseman, teddy bear, automobile, house and tree. The child has to recognize and identify them at a closer distance.b. Kay pictures assesses visual acuity in young children who cannot speak using child friendly figures at distance as well as at near. The test includes single-crowded and linear-crowded picture vision testing suitable for children from 18 months to school agec. Lea Symbols Test: LEA symbol can be used to assess visual acuity in children older than 30 months of age by using four pictures-circle, square, house and apple.[7] These optotypes can be presented as single characters, as a wall chart at a distance of 10-20 ft. They can be presented on a video display terminal screen or in the form of a flipbook. These easily identifiable shapes help preschool children to be tested for visual acuity long before they become familiar with the letter and numbers used in other standard vision charts.8. Boek Candy Bead Test: White beads (1mm) are placed on a white felt background under controlled illumination. The child is required to localize randomly placed beads through increased degrees of induced optical blur. Snellen’s visual acuity equivalent of 20/200 is estimated by this method.9. Light Home Picture Cards: Pictures of an apple, a house, and an umbrella presented on chart arranged in Snellen’s equivalents of 20/200-20/10, are used and the child is asked to identify the pictures along the lines.Measurement of Visual Acuity in School Children (Above 5 Years) and AdultsIn this age group Snellen’s visual acuity charts are most commonly employed. Echarts and Landolt’s C charts are used as alter-native to Snellen’s test types in illiterates.1. Snellen’s Test Types: The Snellen Chart uses a geometric scale to measure visual acuity, with normal vision at a distance being set at 20/20. The numerator represents the distance that the patient is standing from the chart (in feet), while the denominator represents the distance from which a person with perfect eyesight is still able to read the smallest line that the patient can clearly visualize. A similar assessment for testing near vision can be done using a pocket card held about 14 inches from the patient’s eyes. There are only nine letters on the chart, known as optotypes: C, D, E, F, L, O, P, T, and Z. Finally, the sizing of letters is geometrically consistent, meaning that optotypes representing 20/40 are twice the size of those representing 20/20.2. LogMAR Visual Acuity Charts: LogMAR stands for Logarithm of the Mini-mum Angle of Resolution. Vision charts with a logarithmic scale are divided into symbol lines of letters or figures, whose size decreases by exactly 0.1 LogMAR per line down the chart. (Normal vision on the logarithmic scale = 0.0). It is used at a distance of 4 meters. A logMAR chart allows measurements to be attained with the same precision at all levels of acuity and provides highly repeatable measurements of visual acuity.[8]Types of LogMAR charts include the original BaileyLovie chart, its reduced versions, and the Early Treatment Diabetic Retinopathy Study (ETDRS) charts.Standardized ETDRS charts are available in three forms:A. CSV-2000 The CSV-2000 is the only computergenerated vision testing instrument available. The standardization methodology incorporated into the CSV-2000 includes a patented technology known as AcQviz that automatically and constantly measures and adjusts screen luminance to a fixed standard light level. The device is offered with a variety of test faces. These test faces are placed on the front of the CSV-1000 to evaluate contrast sensitivity, ETDRS, low contrast acuity, etc.B. CSV-1000 offers a backlit ETDRS test and incorporates highly advanced miniature fluorescent light source technology that is standardized through automated calibration circuitry.C. ESV-3000 is a large-format backlit ETDRS test device that incorporates advanced LED light source technology, also standardized through automated calibration circuitry.Reduced LogMAR (RLM) chart is a visual acuity chart with fewer letters per line than a standard logMAR chart. The RLM chart was developed to improve testretest variability and reduce reading time.Compact reduced LogMAR (CRLM) chart was developed by Laidlaw et al., which is closed spaced than the reduced LogMAR chart.

Subspecialty - StrabismusDOS Times - Volume 30, Number 6, March-April 2025 54 www.dosonline.orgColor Vision: It’s important to screen children for color blindness at this age, especially since it can impact their ability to recognize colors in educational materials or during activities that require color differentiation.Binocular Vision and Eye Coordination: School-aged children should be tested for how well their eyes work together. Issues with eye coordination, such as convergence (the ability to focus on nearby objects), may affect reading and other activities.Tracking and Visual Processing: Children should be able to track words across a page smoothly and maintain focus while reading. Difficulties in visual tracking or visual processing might indicate conditions like dyslexia or attention issues.Digital Eye Strain Screening: With more screen time, adolescents are prone to digital eye strain (or Computer Vision Syndrome). Symptoms like dryness, headaches, blurred vision, or eye discomfort should be monitored.Sports Vision: Adolescents who participate in sports may benefit from specialized eye exams to assess how well they can track fast-moving objects, judge distances, and react quickly in sports settings.ConclusionVisual assessments at each stage of childhood are essential for ensuring healthy eye development and preventing potential issues from affecting a child’s learning, social interactions, and overall well-being. As children grow, their vision needs change, and age-appropriate assessment methods are crucial to identify any concerns. Regular eye exams and timely interventions can make a significant difference in a child’s ability to thrive and reach their full potential. Parents, caregivers, and educators should be proactive in monitoring a child’s visual health to ensure they have the best possible foundation for a bright future.References1. Chalupa L. M., Werner J. S., and Barnstable C. J., The Visual Neuro-sciences, vol. 1 Cambridge, MA, USA: MIT Press, 20042. Odom JV, Bach M, Brigell M, Holder GE, McCulloch DL, Mizota A, et al. ISCEV standard for clinical visual evoked potentials: (2016 update) Doc Ophthalmol. 2016; 133:1–9. doi: 10.1007/s10633-016-9553-y. [DOI]3. PLoS One. 2020 Jun 29;15(6): e0235290. doi: 10.1371/journal.pone.02352904. Keeler, R., Singh, A. D., & Dua, H. S. (2012). Testing vision can be testing: Worth’s ivory-ball test. British Journal of Ophthalmology, 96(5), 633–6335. Treacy MP, et al. The early treatment in diabetic retinopathy study chart compared with the tumbling-E and Landolt-C. Ophthalmology. 2015; 122:1062–1063 e1061. doi: 10.1016/j.ophtha.2014.11.024.6. Kashinatha Shenoy M1*, Gopalakrishna K2, and Preetha3 et al; Research Journal of Pharmaceutical, Biological and Chemical Sciences Visual Development and Visual Acuity Testing in Children ISSN: 0975-85857. Becker RH, Hübsch SH, Graf MH, Kaufmann H. Preliminary report: examination of young children with Lea symbols. Strabismus. 2000;8(3):209–2138. Catherine E Stewart LogMAR-based visual acuity measurements: limits of normality Br Jr Orthopt J 2006; 3: 9-13Neha Kharwas MBBSDepartment of Ophthalmology, Sawai Man Singh Medical College & Hospital, Jaipur (Rajasthan), IndiaCorresponding Author:

Subspecialty - OculoplastyDOS Times - Volume 30, Number 6, March-April 2025 55 www.dosonline.orgLessons Learnt the Hard WayChhavi Gupta MS | Sima Das MDOculoplasty and Ocular Oncology Services, Dr. Shroff’s Charity Eye Hospital, New DelhiIntroductionThe primitive medulloepithelium of the ciliary body gives rise to medulloepithelioma, the second most common intraocular tumour after retinoblastoma. Because it can manifest in various ways, it is uncommon and can often be misdiagnosed. Malignant forms with extraocular extension can be fatal. Thus, early detection and prompt treatment are essential.Case DescriptionA 7-year-old boy hailing from Uttar Pradesh presented to the outpatient department with pain and cosmetic concerns for the right eye. Visual acuity was counting fingers for the right eye and 6/6 for the left eye. On examination, an anterior ciliary staphyloma extending 4-9 clock hours was seen with a clear cornea, ectropion uvea, neovascularisation of the iris, aphakia, and near total cupping. The left eye was stable. He gave a history of a trivial trauma to the right eye, following which he underwent lensectomy elsewhere and subsequently developed secondary glaucoma. He was initially treated medically for glaucoma, but his condition worsened, requiring evisceration and implant surgery. Ultrasonography was not performed due to a visible fundus view.Figure 1: Clinical photograph of a patient presenting to the oculoplasty outpatient department with a painful, blind eye due to ciliary staphyloma, seeking pain relief and improved cosmesis.Figure 2: Contrast-enhanced computed tomography (CECT) orbit (sagittal section) showing a heterogeneously enhancing mass lesion displacing the orbital implant.Figure 3: Histopathological examination reveals multilayered neuroepithelial cells with atypia, arranged in ribbons, cords, bands within a myxoid stroma, and heteroplastic elements such as cartilage.The patient received an ocular prosthesis, but after one year, he returned with an ill-fitting prosthesis and a protruding mass in the socket, accompanied by implant migration. CT imaging revealed a soft tissue mass displacing the implant, prompting an incision biopsy.Histopathology confirmed malignant teratoid medulloepithelioma, exhibiting neuroepithelial cells, atypia, and heteroplastic elements such as cartilage.

Subspecialty - OculoplastyDOS Times - Volume 30, Number 6, March-April 2025 56 www.dosonline.orgFigure 4: (a) Clinical photograph showing a ciliary body mass visible in the temporal quadrant with an overlying vascular retrolental membrane. (b) Ultrasound biomicroscopy demonstrating a ciliary body mass with internal cystic spaces.Medulloepithelioma may also be associated with DICER-1 mutations linked to Pleuropulmonary Blastoma Family Tumor and Dysplasia Syndrome (PPB-FTDS). This syndrome increases the likelihood of developing systemic tumours (nephromas, ovarian tumours and thyroid hyperplasia). Routine screening - chest CT scan and ultrasounds of the thyroid, abdomen, and pelvis, is recommended for patients with DICER-1 mutations.[4]Medulloepithelioma confined to the globe has a 5-year survival rate of 90-95% after enucleation. However, extraocular spread (10-19%) is a major predictor of Following chemotherapy using the VEC protocol (vincristine, etoposide, and carboplatin), the patient was lost to follow-up after six cycles. He later returned with preauricular and cervical lymphadenopathy, and a PET-CT confirmed regional spread. The child underwent further chemotherapy, lid-sparing exenteration, and radiation therapy (EBRT). The retrospective review revealed a missed diagnosis of subluxated lens and secondary glaucoma, common early signs of medulloepithelioma. Additionally, the prior histopathology sample may have missed relevant areas. This case underscores the importance of enucleation in suspicious cases and ensuring complete tissue sampling during evisceration.DiscussionMedulloepithelioma can manifest in children aged 2–10 years, though cases have been reported in adults. It arises from neuroepithelial cells, typically in the non-pigmented ciliary epithelium.[1] Histologically, it is classified into teratoid and non-teratoid types based on Zimmerman’s classification. The teratoid type contains cells from diverse origins, including cartilage, rhabdomyoblasts, and brain tissue.[2]Presenting complaints can range from loss of vision, leukocoria, painful blind eye and strabismus. It can present as a greyish-white ciliary body mass with cysts, loss of zonules or subluxation, lens notch or coloboma, total or sectoral cataract, neovascular glaucoma, localised bulging of iris, correctopia, uveitis, cysts in vitreous, vitreous haemorrhage, retinal detachment and extraocular extension. Neoplastic tissue growing over the lens capsule or anterior hyaloid may form a vascular retrolental membrane. It may be misdiagnosed as retinoblastoma, PHPV, traumatic cataracts, or secondary glaucoma (iris neovascularisation, angle closure, tumour invasion into angle). In this case, the tumour’s slow-growing nature initially caused the child to present with secondary glaucoma and lens-related complications. Ultrasound biomicroscopy (UBM) is crucial for detecting ciliary body tumours that may not be visible on routine examination or B-scan. Histopathology remains the gold standard for diagnosis.[3]mortality and has been rarely reported (<30 case reports). Broughton and Zimmerman et al. reported 4 out of 33 patients (12%) with tumor-related deaths. Treatment for advanced cases may include chemotherapy, radiotherapy, and surgery, but no defined protocol exists.[5]ConclusionEarly diagnosis of medulloepithelioma, a rare paediatric ocular tumour, can be difficult because it can easily mimic more common ocular disorders. A high index of suspicion is essential for timely diagnosis. Imaging modalities can give us timely clues, and in cases in which

Subspecialty - OculoplastyDOS Times - Volume 30, Number 6, March-April 2025 57 www.dosonline.orgaetiology is not clear, enucleation should be preferred over evisceration.References1. Schultz KAP et al - DICER1 and Associated Conditions: Identification of At-risk Individuals and Recommended Surveillance Strategies. Clin Cancer Res. 2018 May 15;24(10):2251-2261. Doi: 10.1158/1078-0432.CCR-17-3089. Epub 2018 Jan 17. 2. Kock L, Priest JR, Foulkes WD, Alexandrescu S. An update on the central nervous system manifestations of DICER1 syndrome. Acta Neuropathol. 2020 Apr;139(4):689-701. Doi: 10.1007/s00401-019-01997-y. Epub 2019 Apr 5. 3. Kaliki S., Shields C.L., Eagle Jr. R.C et al. Ciliary body medulloepithelioma: Analysis of 41 cases. Ophthalmology 2013, 120,pp. 2552 2559.4. Tadepalli SH, Shields CL, Shields JA, Honavar SG. Intraocular medulloepithelioma – A review of clinical features, DICER 1 mutation, and management. Indian J Ophthalmol 2019;67:755-62.5. Ang SM, Dalvin LA, Emrich J, Komarnicky L, Shields JA, Shields CL. Plaque Radiotherapy for Medulloepithelioma in 6 Cases From a Single Center. Asia-Pacific journal of ophthalmology (Philadelphia, Pa). 2019;8(1):30-35.Chhavi Gupta MSOculoplasty and Ocular Oncology ServicesDr. Shroff’s Charity Eye Hospital, New DelhiCorresponding Author:

Subspecialty - OculoplastyDOS Times - Volume 30, Number 6, March-April 2025 58 www.dosonline.orgA Rare Case of Bilateral Congenital Lacrimal FistulaAbhishek Sharma MBBS, MS | Arti Sareen MBBS, MS | Vinay Gupta MBBS, MSIndira Gandhi Medical College Shimla, Himachal PradeshIntroductionBilateral lacrimal fistula is an uncommon condition characterized by abnormal connections between the lacrimal sac and the skin, resulting in persistent tearing and discharge from both eyes. While lacrimal fistulae are more commonly unilateral, bilateral cases are rare and pose unique challenges in diagnosis and management.The etiology of bilateral lacrimal fistulae is not well understood, but it is believed to result from a failure of the nasolacrimal system to develop properly during embryogenesis. This can lead to the formation of fistulous tracts between the lacrimal sacs and the skin, typically near the medial canthi. Patients with bilateral lacrimal fistulae may present with symptoms such as chronic tearing, discharge, and recurrent infections of the lacrimal sacs.Diagnosis of bilateral lacrimal fistulae is based on clinical examination and imaging studies, such as dacryocystography or magnetic resonance imaging, to visualize the abnormal connections between the lacrimal sacs and the skin. Management of bilateral lacrimal fistulae often involves surgical intervention to close the fistulous tracts and restore the normal anatomy of the lacrimal system.We present the case of a 7-year-old boy with bilateral congenital lacrimal fistulae. The child was brought to our clinic by his parents who noticed bilateral openings below and towards the nose from the inner corners of both eyes. There were complaints of tearing from these openings on and off. The diagnosis of bilateral congenital lacrimal fistulae was confirmed using computed tomography scans, which also revealed no other abnormalities in the systemic, nasal, or ocular regions. The patient was kept on observation as there was no complain of any pus discharge or evidence of infection.Case ReportA 7-year-old boy was brought to the ophthalmology outpatient department by his parents due to their concern about watering from the skin overlying the root of his nose on and off. The child did not report any pain, pus discharge, redness, swelling, or history of trauma. His visual acuity was normal, and his eye movements were grossly normal.Upon examination, tiny pits were observed on the medial aspect of both eyes, overlying the lacrimal sac area. These pits were inferomedial to the medial canthus in location and measured approximately 1-2mm in size. No discharge was expressed upon applying pressure to the lacrimal sac area. The upper and lower punctum were visible separately and were found patent on syringing. Fluorescein dye was instilled into the lower fornix, and the dye was seen at the orifice.Computed tomographic imaging was performed, confirming the diagnosis of bilateral congenital lacrimal fistulae. No other systemic, nasal, or ocular anomalies were detected, and there was no family history of lacrimal fistulae. Due to the asymptomatic nature of the lacrimal fistulae, a conservative management approach was chosen, with the decision to closely observe the patient.Figure 1: Photograph showing fluorescein dye extruding out from the abnormal opening infero-medial to the medial canthus of the right eye.

Subspecialty - OculoplastyDOS Times - Volume 30, Number 6, March-April 2025 59 www.dosonline.orgFigure 2: Photograph showing fluorescein dye extruding out from the abnormal opening infero-medial to the medial canthus of the left eye.Figure 3: Photograph showing abnormal opening infero-medial to the right eye in red circle.DiscussionCongenital lacrimal fistulas are a rare condition affecting the lacrimal drainage system. The lacrimal anlage ducts are supernumerary canaliculi that link the common canaliculus or lacrimal sac to the skin due to abnormal budding.[1,2,3] The majority of people with lacrimal fistula are asymptomatic. The most common complaint among symptomatic patients is epiphora, or mucoid discharge from the canaliculus. Additionally, coughing or blowing one’s nose may result in clear discharge.[4] Redness at the medial canthal angle and persistent tears when crying may also occur.Congenital lacrimal fistulae occur in around 1 in 2000 births and can be inherited in an autosomal dominant pattern.[5] Other abnormalities associated with it include preauricular fistulae, hypospadias, and VACTERL syndrome (which includes vertebral, anal, cardiac, tracheo-esophageal, renal, and limb defects). Congenital lacrimal fistulae can be linked to thalassemia and Down syndrome.[5,6,7]The diagnosis is primarily clinical. To confirm the diagnosis, nasolacrimal syringing, fluorescein dye disappearance test, and intubation dacryocystography are performed.[8]As most patients are asymptomatic, no treatment is necessary. Symtomatic fistulae can be treated with techniques such as probing, fistulectomy, and dacryocystorhinostomy.[9]The present case of 7 year old male child had been kept on routine follow up as there was no sign of any infection.Financial Support and SponsorshipNilConflicts of InterestThere are no conflicts of interest.References1. Older J: Congenital Lacrimal Disorders and Management. In: Lacrimal Surgery. edn. Edited by Linberg J. New York: Churchill Livingstone; 1988: 91-108.2. Welham RA, Bergin DJ: Congenital lacrimal fistulas. Arch Ophthalmol 1985, 103(4):545-548.3. Birchansky LD, Nerad JA, Kersten RC, Kulwin DR: Management of congenital lacrimal sac fistula. Arch Ophthalmol 1990, 108(3):388-390.4. Chaung JQ, Sundar G, Ali MJ. Congenital lacrimal fistula: a major review. Orbit.2016;35 (4): 212-20.5. Jones LT, Wobing JL. Surgery of the Eyelids and Lacrimal System. Birmingham: Aesculapius Publishing Co., 1978; 167-173.6. Sullivan TJ, Clarke MP, Brazel S, et al. Congenital lacrimal fistula associated with Down’s syndrome. Am J Ophthalmol 1992; 113: 215-216.7. Harrison AR, Dailey RA, Wobig JL. Bilateral congenital lacrimal anlage ducts in a patient with the VACTERL association. Ophthal Plast Reconstr Surg 2002; 18(2): 149-150.8. Welham RA, Bergin DJ: Congenital lacrimal fistulas. Arch Ophthalmol 1985, 103(4):545-548.9. Ugurbas S, Zilelioglu G. Congenital lacrimal fistula. Eur J Ophthalmol. 2000; 10:22-6.Abhishek Sharma MBBS, MSJunior Resident,Department of Ophthalmology Indira Gandhi Medical College Shimla, Himachal Pradesh, IndiaCorresponding Author:

Subspecialty - RetinaDOS Times - Volume 30, Number 6, March-April 2025 60 www.dosonline.orgRetinopathy of Prematurity - RBSK Guideline and a Medicolegal PerspectiveSonu Beniwal MBBS, DNB | Mansi Jand MBBS, DNB | Bharti Arya MBBS, MSDepartment of Ophthalmology, Medanta The MedicityIntroductionRetinopathy of Prematurity (ROP) is a potentially blinding eye disease that affects the retina of infants born 4 or more weeks preterm and have received intensive neonatal care. It is emerging as a leading cause of avoidable childhood blindness in India and other low and middle income countries (LMIC). The risk of sight threatening ROP is higher in more preterm infants. All eligible preterm infants admitted in special newborn care units (SNCUs) need retina screening because up to 15% of them develop ST ROP (Sight threatening-ROP). Strengthening efforts made by Health Ministries of India over the last two decades to reduce neonatal mortality as part of the millennium development goals (MDG) and the sustainable development goals (SDG) have not only improved survival of the preterm babies, but has also increased the number of babies at risk of blindness from ROP.Risk FactorsA number of risk factors has been identified:• Low birthweight <2000 grams• Poor postnatal growth• Young gestational age (GA) <34 weeks of gestation• High, unregulated oxygen at birth, fluctuations in oxygenation• Respiratory distress syndrome, duration of mechanical ventilation, and steroid use for bronchopulmonary dysplasia• CNS injuries: intraventricular haemorrhage, periventricular leukomalacia • Low plasma IGF-1 levels • Hyperglycaemia • Sepsis, white race, blood transfusion, and multiple births. • ProteinuriaCriteria for ROP ScreeningIn India, screening criteria has been kept broad because of increased risk of sight threatening ROP and variable quality of health facilities. The criteria of gestational age and birth weight are lower in the developed world.All infants admitted to SNCUs/NICUs with the following criteria need examination by retinal evaluation:• All infants born at 34 weeks or less gestational age• All infants weighing 2000g or less at birth• All infants born at more than 34 weeks gestational age with associated risk factors (mentioned above)• Other preterm infants based on the discretion of the paediatrician or neonatologistA Medicolegal Perspective Potential Legal Touchpoints in ROP Care• Paediatrician/Neonatologist related:1. No established screening program in the Special Newborn Intensive Care Units (SNCUs)2. Delayed in referral for ROP screening3. No follow-up when infant is still admitted under the care of the neonatal team4. No clear education or counselling about the impact of failed screening 5. No established protocol and documentation of the oxygen supplementation used by NICU/SNCU teams• Ophthalmologist related:1. Improper, inadequate or inappropriate documentation2. No appointment or counselling about follow-up screening visits once screening is initiated3. Failure to treat on time, or inadequate treatment4. Failure to explain about ocular comorbidities and need for “long term” follow up

Subspecialty - RetinaDOS Times - Volume 30, Number 6, March-April 2025 61 www.dosonline.org• Barriers faced by parents/caregiver related:1. Lack of awareness about possible treatment and complication of ROP in parents2. Cost of travel and treatment3. Others – gender bias and other factors that increase attrition of follow-up especially in rural areas which may not be modifiable in all cases• Based on the legal cases and potential pitfalls in ROP screening, the treating ophthalmologist should always follow the recommended guidelines for screening and treatment of ROP infants.Which infants need to be screened?All infants admitted to SNCUs/NICUs with the following criteria need examination by retinal evaluation:• All infants born at 34 weeks or less gestational age• All infants weighing 2000g or less at birth• All infants born at more than 34 weeks gestational age with associated risk factors (mentioned above)• Other preterm infants based on the discretion of the paediatrician or neonatologistWhen to do the first screening?Before discharge from SNCU/NICU or by 30 days of life, whichever is sooner Screening methodIndirect ophthalmoscopy by a trained ophthalmologist or wide field retinal camera (RetCam) by trained personnelWhere to screen?Preterm infants admitted in the SNCU/NICU in the respective unitDischarged infant in SNCU/NICU for follow up or ophthalmologist clinic Management decisions at each screeningNo further screening required if retinal vessels are mature in both eyes, or ROP has regressed spontaneously, or;Further screening in 3-4 days, or one week, or 2 weeks as the retinal vessels are not mature or ROP is absent, or;Urgent treatment is requiredDocumentation and communicationFindings and the management decision at each screening must be recorded in the medical recordsThe date for the next screening if needed must be documented in the medical records and/or discharge summaryThe date for the next screening must be communicated to parents verbally and in writingFlow Chart 1: Protocol for screening.

Subspecialty - RetinaDOS Times - Volume 30, Number 6, March-April 2025 62 www.dosonline.orgWhich infants needs to be treated?Infants developing signs of ST-ROP (sight threatening) in one or both eyesWhen should treatment be started?Within 48 hours as the disease can progress very fast to retinal detachmentWho should treat?An ophthalmologist trained and competent in treating sight threatening ROPMethod of treatmentLaser treatment by indirect ophthalmoscope to the avascular peripheral retinaIntravitreal anti-VEGF agents: Bevacizumab and ranibizumab are most recent treatment optionsPars plana vitrectomy: In retinal detachmentWhere to treat?In the SNCU/NICU if an inpatientIf discharged from the SNCU/NICU in an eye department if infrastructure and personnel are availableFollow up after treatmentOphthalmologist should follow up at one week. Further decision regarding treatment should be taken.Long term follow upInfants treated for ST-ROP are at high risk of refractive errors and other eye conditions. They should be followed up until at 5 years of ageFlow Chart 2: ROP treatment protocol.References1. Shukla R, Murthy GVS, Gilbert C, Vidyadhar B, Mukpalkar S. Operational guidelines for ROP in India: A summary. Indian J Ophthalmol. 2020 Feb;68(Suppl 1): S108-S114. doi: 10.4103/ijo.IJO_1827_19. PMID: 31937744; PMCID: PMC7001189.2. Quinn GE, Gilbert C, Darlow BA, Zin A. Retinopathy of prematurity: an epidemic in the making. Chin Med J (Engl). 2010 Oct;123(20):2929-37. PMID: 21034609.3. Anand Vinekar, Anil Gangwe, Samarth Agarwal, Sucheta Kulkarni, Rajvardhan Azad, Improving Retinopathy of Prematurity Care: A Medico-Legal Perspective, Asia-Pacific Journal of Ophthalmology, ISSN 2162-0989, https://doi.org/10.1097/APO.0000000000000388.Sonu Beniwal, MBBS3rd year DNB ResidentMedanta The MedicityCorresponding Author:

Subspecialty - RetinaDOS Times - Volume 30, Number 6, March-April 2025 63 www.dosonline.orgAssociations of Post MSICS Intraocular Bleed: A Retrospective Observational StudyMaya Sharma MSDepartment of Ophthalmology, Government District Hospital, Sri Ganganagar, RajasthanAbstract: As diabetes has become endemic in India. Many patients seeking cataract surgery have coexisting diabetes; many of these diabetic patients also have underlying heart disease. Present study is an attempt to find the correlations between post MSICS significant intra ocular bleed and pre existing comorbidity of diabetes and heart disease so that the possible visual outcome can be better explained to such patients and both the surgeon and patient be preprepared for the possible post operative complication and well prepared to deal with them.This study was conducted at Government district hospital in Rajasthan. Here we receive a large number of patients as surgery including investigations and medication is totally free of cost.Material and Method: Patients with post MSICS significant intraocular bleed leading to vision of hand movement close to the face on seventh post operative day were retrospectively observed and correlation between pre existing diabetes and heart disease was assessed.Conclusion: Diabetic patients are more at risk of post op intraocular bleeding especially those who have associated heart diseases. Though the haemorrhage resolves after 1-3 months; but it is so very important to explain preoperatively to the patients about possible post op outcome so that they are better prepared mentally about the possible visual outcome.IntroductionDiabetes is an increasingly common systemic disease in India and worldwide.[1,2,3,4,5,6] Many patients seeking cataract surgery have diabetic eye disease and are at an increased risk of complications and subsequent limitation of vision.[7] Diabetic patients with visually significant cataract pose a unique challenge during cataract surgery; they may be more prone to a more difficult post operative recovery. Some studies have reported that cataract surgery when performed in diabetic patients may lead to relatively rapid progression of Diabetic Retinopathy, precipitate Vitreous Haemorrhage, induce Iris neovascularization and ultimately lead to decrease or loss of vision.[8]It was concluded by a meta-analysis that globally cardiovascular disease is a associated comorbidity in 32.2% of all persons with diabetes (Type 2 Diabetes).[9]Associations of cardiovascular disease events and Diabetic Retinopathy has also been established in many epidemiological studies worldwide.[10,11]Present study was conducted at secondary referral center where whole treatment including surgery and medication is free of cost; we receive a large number of cataract patients. MSICS is performed for the majority of cataractous eyes because it is more cost effective and less time consuming than phacoemulsification. Higher cost effectiveness and lower time consumption of MSICS are proved in many previous studies.[12,13,14,15]It was proposed by a study that ideally, when cataract does not preclude laser treatment, one should achieve and maintain effective control of diabetic retinopathy and maculopathy for at least three months before surgery.[16]At our centre as we deal with a large number of patients and have limited resources; we perform thorough examination of eyes with dilated pupil fundus examination; mostly patients selected for cataract surgery are those with significant cataracts that precludes fundus examination.The purpose of present study is to find the associations of

Subspecialty - RetinaDOS Times - Volume 30, Number 6, March-April 2025 64 www.dosonline.orgpost MSICS intraocular bleed with pre existing comorbidity of diabetes and heart disease (use of Aspirin).Materials and MethodsOver a period of 15 months (August 2023-October 2024); patients who had post MSICS intraocular bleed leading to vision of hand movements close to the face on 7th postoperative day were included in the study. All patients were retrospectively assessed for preexisting diabetes and heart disease and were followed up. As a routine we performed detailed pre operative examination of all cataract patients, which included the following:• Distance vision examination of both eyes• Slit lamp examination of eye with cataract• Fundus examination with dilated pupil• Blood sugar• Urine complete• CBC• Viral markers• ECGHbA1c levels and USG B scan of eyes with mature cataracts are not done as a routine at our centre because these investigations are not available here and are not feasible for all our patients. If at all on fundus examination of either eye of a patient STDR (Sight threatening diabetic retinopathy) was observed; the patient was advised to have strict diabetic control and review with vitreoretina specialist.[17]ObservationsTotal seven patients had such intraocular bleed; intraoperative period was uneventful for all these patients. Retrospective assessment was done for all these patients. Following were the observations on retrograde assessment of these 7 patients who had post MSICS intraocular bleed.Pre op Blood Sugarh/o DM h/o heart disease [on aspirin]Post op Bleed Follow up1. 62y/F Normal Present Present Profuse AC bleed, VHResolved after 4-5 months2. 55y/M Normal Present Absent VH Resolved after 2-3 months3. 58y/M Normal Present Absent VH Resolved after 2-3 months4. 78y/F Normal Present (Poorly controlled)Present VH Resolved after 1-2 month5. 60y/F Normal Absent Present VH Resolved after 1-2 month6. 73y/F Normal Absent Present[PDA] VH Resolved after 2-3 monts7. 77y/F Normal Present Present VH Resolved after 2-3 monthsM-Male, F-Female, AC- anterior chamber, VH- vitreous haemorrhage, DM- diabetes mellitus, PDA- patent ductus arteriosus, post op-post operative.DiscussionApproximately 1000 MSICS surgeries were done over a period of 15 months by a single surgeon who is also the author of this article; 7 out of them had significant intraocular bleed leading to vision of hand movements close to the face on 7th post operative day. 5 out of these 7 patients had history of Diabetes though immediate pre operative blood sugar levels were normal for all of them. 5 out of these 7 patients had history of Heart disease and were on Aspirin though Aspirin was stopped 7 days prior to surgery for all of them as a routine. 3 patients had history of both Diabetes and Heart disease.Prognosis was worse for these 3 patients who had diabetes and also were on Aspirin; their vision improved to only 6/60 to 6/36 whereas for others it improved to 6/12 to 6/9 within 2 to 3 months post op. On follow up 6 months post op one of these 3 patients; the one who had profuse anterior chamber bleed with vitreous haemorrhage (62y/F) her BCVA was 6/18 in the operated eye. For remaining 2 patients (77y/F and 78y/F) BCVA remained 6/60-6/36 6 months post op. It shows that female patients with both diabetes and heart disease (on Aspirin) are at higher risk of post op intraocular bleed and higher age puts them on risk of even worse visual prognosis.

Subspecialty - RetinaDOS Times - Volume 30, Number 6, March-April 2025 65 www.dosonline.orgThough evidence is available for diabetic patients for higher incidence of post op intraocular bleed yet not much information is available about patients on Aspirin. In a study use of Aspirin was not found to be associated with increase in the risk of vitreous hemorrhage in diabetic patients[18] but this was not for post operative patients. This study clearly depicts that both DM and use of aspirin are high risk factors for post MSICS intraocular bleed; coexistence of both of these puts patients on much higher risk of post op intraocular bleed and worse visual prognosis.One other patient needs special mention as she was in her 5th decade of life ; diabetic patient; her blood sugar levels were poorly controlled; she had mature grade 4 cataract in both her eyes; she wanted her eyes to be operated; we did MSICS for her with proper informed consent; pre op blood sugar was 232mg%. To my surprise she had 6/9 vision in her operated eye on 7th post op day with no other complication.Among these 7 patients the patient with PDA had stopped aspirin on her own got her another eye operated and had 6/9 vision on 7th post op day.Probably these two cases indicate that bilateral mature cataracts with associated comoorbidity can be operated upon with proper informed consent and proper precautions.ConclusionDiabetes and use of Aspirin are found to be individual risk factors for post MSICS intraocular bleed even when immediate pre op blood sugar level is normal and Aspirin is stopped 7 days prior to surgery; if exist together they increase the risk even more. Existence of both these risk factors with higher age puts the patient on risk of worse visual prognosis.At centers where resources are limited and large number of cataract surgeries are performed; it is prudent to explain to the patients about risk factors and possible outcomes so that both the patient and surgeon remain better prepared to manage this possible post operative complication of intraocular bleed.References1. International Diabetes Federation. IDF Diabetes Atlas. 9th ed. Brussels, Belgium: International Diabetes Federation; 2019. [PubMed] [Google Scholar].2. International Diabetes Federation. IDF Diabetes Atlas. 8thed. Brussels, Belgium: International Diabetes Federation;2017. [Pub Med][ Google Scholar].3. International Diabetes Federation . IDF Diabetes Atlas. 7thed. Brussels, Belgium: International Diabetes Federation;2015. [Pub Med][ Google Scholar].4. International Diabetes Federation. IDF Diabetes Atlas. 6thed. Brussels, Belgium: International Diabetes Federation;2013. [Pub Med][ Google Scholar].5. Anjana RM, Pradeepa R, Deepa M, ,Datta M, Sudha V, et al. Prevalence of diabetes and prediabetes (impaired fasting glucose and/or impaired glucose tolerance) in urban and rural India: Phase 1 results of the Indian Council of Medical Research-India DIABetes(ICMRINDIAB) Study. Diabetologia2011;54:3022-7.6. Anjana RM, Shanthi Rani CS, Deepa M , Pradeepa R, Sudha V, Divya Nair H, et al. Incidence of diabetes and pre diabetes and predictors of progression among Asian Indians: 10 year follow up of the Chennai Urban Rural Epidemiology Study (CURES). Diabetes Care2015;38:1441-8.7. Raman R, Gella L, Srinivasan S, Sharma T. Diabetic retinopathy: An epidemic at home and around the world. Indian J Ophthalmol2016:64:69-75.8. Diabetic Retinopathy and Cataract Surgery@ Cataractpatients.com9. Einarson TR, Acs A, L udwig C, Panton UH. Prevalence of cardiovascular disease in type2 diabetes: a systemic literature review of scientific evidence from across the world in 2007-2017. Cardiovasc Diabetol. 2018 Jun 8;17(1):83.doi: 10.1186/s12933-018-0728-6. PMID:29884191;PMCID:PMC5994068.10. Chin-Yuan Hsu, Chee-Ming Lee, Kuan-Yu Chou, Chia-Yi Lee, Hung-Chi Chen et al. The association of Diabetic Retinopathy and Cardiovascular Disease: A 13- Year Nationwide Population Based Cohort Study. Int I Environ Res Public Health. 2021 Jul30;18(150:8106. Doi:10.3390/ijerph18158106.11. Kramer CK, Rodrigues TC, CananiLH, GrossJL, Azevodo MJ. Diabetic retinopathy predicts all- cause mortality and cardiovascular events in both type1 and 2 diabetes: Meta –analysis of observational studies. Diabetes Care2011;34:1238-44.12. Ruit S, Tabin G, Chang D , Bajracharya L, Kline DC, Richheimer W, et al. A prospective randomized clinical trial of phacoemulsification vs. manual sutureless small incision extracapsular cataract surgery in Nepal. Am J Ophthalmol. 2007;143;32-8. Doi:10.1016/j.ajo.2006.07.02[Pubmed] [Google Scholar].13. Gogate PM, Kulkarni SR, Krishnaiah S, D eshpande RD, Joshi SA, Palimkar A, et al. Safety and efficacy

Subspecialty - RetinaDOS Times - Volume 30, Number 6, March-April 2025 66 www.dosonline.orgof phacoemulsification compared with manual small incision cataract surgery by a randomized controlled trial; Six – week results. Ophthalmology. 2005;112:869-74.doi:10.1016/j.ophtha.2004.11.055.[pubmed ] [Google Scholar].14. Murlikrishnan R, Venkatesh R, Prajna NV, Frick KD. Economic cost of cataract surgery procedures in an established eye care centre in southern India. Ophtalmic Epidemiol. 2004;11;369-80.doi 10.1080/09286580490888762.[Pubmed] [Google Scholar].15. Gogate P, Deshpande M, Nirmalan PK. Manual small incision cataract surgery is as effective, but less expensive. Ophthalmology. 2007;114:965-8. Doi:10.1016/j.ophtha.2006.08.057[pubmed] [Google Scholar].16. Rice J.Cataract and Diabetic Retinopathy. Community Eye Health. 2011 September;24(75):9.17. Cheung N, Mitchell P, Wong TY. Diabetic retinopathy. Lancet. 2010;376:124-36.doi:10.1016/S0140-6736(09)62124-3.[DOI] [PubMed] [Google Scholar].18. Rajalakshmi R, Pratibha V, Mohan V. Does tight control of systemic factors help in the management of diabetic retinopathy?. Indian J Ophthalmol2016;64:62-8.Maya Sharma MSGovernment District Hospital,Sri Ganga Nagar, RajasthanCorresponding Author:

Subspecialty - RetinaDOS Times - Volume 30, Number 6, March-April 2025 67 www.dosonline.orgDiabetic Retinopathy Studies: OverviewSanjeev Kumar Nainiwal MD, DNB, MNAMS | Jyoti Nagar MBBS | Payal Singh MS | Nitisha Bairwa MBBS | Sunil K Gurjar MBBS |Shailendra Singh MBBS | Versha Jeph MBBS | *Raghunandan Khandelwal MBBS, MS Department of Ophthalmology, *Department of Preventive and Social Medicine, Sawai Man SinghMedical College & Hospital, Jaipur (Rajasthan), IndiaGuidelines for management of any medical problem is based on the results or conclusion of randomised multicentric studies/trials done worldwide. Diabetic retinopathy is the leading cause of blindness in India as well as in the world. Therefore, we are discussing about the various studies related to diabetic retinopathy through this article.Diabetic Retinopathy Study (DRS)[1]Laser photocoagulation was first introduced in 1959 as a treatment for retinal conditions, but it gained wider recognition in clinical practice starting in the 1970s. Although it showed potential, early studies were inconclusive about its actual efficacy in preventing vision loss in patients with diabetic retinopathy. Prior to large-scale randomized trials, there was insufficient evidence to determine whether laser photocoagulation could significantly prevent or reduce the progression of diabetic retinopathy to the point of severe vision loss.Purpose of the Study: The primary purpose of the study was to evaluate the effectiveness of laser photocoagulation in preventing severe vision loss in patients with proliferative diabetic retinopathy (PDR), a more advanced form of diabetic retinopathy where new, fragile blood vessels grow in the retina, often leading to hemorrhage, scarring, and vision loss. The study aimed to answer several key questions:1. Does laser photocoagulation help prevent severe visual loss in patients with PDR who have high-risk characteristics (HRC)?2. Which type of laser—argon or xenon—proves to be more effective for treating PDR?3. What is the natural progression of diabetic retinopathy in untreated patients, especially in the context of PDR and its complications?Study Design: The study utilized a randomized controlled trial (RCT) design to provide robust evidence regarding the effectiveness of laser treatment in diabetic retinopathy. The participants were divided into two groups:1. Laser Treatment Group: One group of patients received laser photocoagulation, with the aim to stabilize or improve their retinal condition and reduce the risk of severe visual impairment.2. Observation Group: The second group received standard follow-up care, where no laser intervention was applied, allowing for observation of the natural course of the disease.The study also compared two different types of laser treatment: argon laser and xenon laser, both of which were used to treat PDR but had different mechanisms of action and potential side effects.Results: 1. The study found that laser photocoagulation significantly reduced the risk of severe vision loss in patients with high-risk PDR. In fact, the results indicated that laser treatment reduced the incidence of severe vision loss by about 50% in these patients, making it a highly effective intervention for preventing further visual deterioration.2. In addition, the study found that the argon laser was more effective compared to the xenon laser. The argon laser is a widely used type of laser in retinal photocoagulation and is known for its precision and ability to target retinal tissue with minimal collateral damage. 3. However, the study was unable to conclusively determine the natural course of diabetic retinopathy without laser intervention. While the observation group showed some progression of the disease, the exact pattern of how PDR evolves in the absence of treatment was not fully explored due to the design of the study, which focused on comparing treatment with non-treatment rather than an exhaustive study of untreated progression alone.

Subspecialty - RetinaDOS Times - Volume 30, Number 6, March-April 2025 68 www.dosonline.orgDisadvantages and Limitations:While the study provided valuable insights into the role of laser photocoagulation in PDR, it also had some limitations:1. Lack of Data on Severe NPDR or Early PDR: The study did not sufficiently define the role of laser treatment in severe non-proliferative diabetic retinopathy (NPDR) or early-stage PDR. Most of the participants were in the advanced stages of PDR, and thus the results could not be generalized to those with less severe forms of diabetic retinopathy. Severe NPDR and early PDR might have different responses to treatment, and the study was limited in addressing this subgroup.2. Natural Course of Disease Not Fully Defined: While the treatment group showed clear benefits, the study did not fully explore the untreated natural course of the disease, particularly the progression of NPDR to PDR or the long-term effects of untreated diabetic retinopathy.3. Limited Insight into Other Treatment Modalities: The study primarily focused on laser photocoagulation and did not evaluate other emerging treatment modalities for diabetic retinopathy, such as antiVEGF therapies (vascular endothelial growth factor inhibitors) or intravitreal steroids, which have become more prevalent in recent years.Conclusion: The study provided compelling evidence that laser photocoagulation, particularly with the argon laser, is effective in reducing the risk of severe vision loss in patients with PDR, especially those with high-risk characteristics. However, it did not provide enough data on the natural progression of untreated diabetic retinopathy or offer insights into treatment for less advanced stages of the disease. Despite these limitations, the study marked a critical turning point in the management of diabetic retinopathy, shaping future research and treatment strategies for this sight-threatening condition.ETDRS- Early Treatment Diabetic Retinopathy Study[2]The ETDRS (Early Treatment Diabetic Retinopathy Study) was a large, multicenter, randomized controlled trial (RCT) that aimed to investigate the role of laser treatment and aspirin in the management of diabetic retinopathy, specifically in individuals with severe non-proliferative diabetic retinopathy (NPDR), proliferative diabetic retinopathy (PDR), and diabetic macular edema (DME).Here is a systematic and detailed explanation of the study:1. Study Design and Structure• Type of Study: Multicenter, Randomized Controlled Trial (RCT)• Duration: The study was conducted over 6 years, starting in 1979 and ending in 1985.• Number of Participants: A total of 3711 patients with diabetic retinopathy were enrolled from multiple centers across the United States.Study Objectives: The primary objectives of the ETDRS were:To evaluate the role of laser photocoagulation in preventing severe vision loss in patients with severe non-proliferative diabetic retinopathy (NPDR) and proliferative diabetic retinopathy (PDR).To assess the role of laser photocoagulation in patients with diabetic macular edema (DME), specifically in preventing moderate vision loss.To determine the effect of aspirin in preventing the progression of diabetic retinopathy and in reducing the risk of vision loss.Study MethodologyParticipants: Patients were diagnosed with diabetic retinopathy (both NPDR and PDR) and/or diabetic macular edema (DME).Randomization: Patients were randomly assigned into two main treatment arms:• Laser Treatment Group: Patients who received laser photocoagulation therapy (mainly focal or panretinal photocoagulation, depending on the condition).• Deferred Laser Group: Patients who were monitored and did not receive laser treatment during the study period unless there was significant worsening of their condition.• Additional Treatment Group: Some patients were also randomized to receive aspirin as an intervention (to evaluate whether aspirin could reduce the progression of diabetic retinopathy or prevent vision loss).Laser Treatment ApproachLaser for Severe NPDR and PDR: For patients with severe NPDR and PDR, panretinal laser photocoagulation (PRP) was the main treatment. This approach aimed to target the peripheral retina to reduce the oxygen demand, thus decreasing the risk of neovascularization (abnormal blood vessel growth).

Subspecialty - RetinaDOS Times - Volume 30, Number 6, March-April 2025 69 www.dosonline.orgLaser for DME: For patients with diabetic macular edema (DME), focal laser photocoagulation was used. This treatment targeted the areas of retinal edema (swelling) in the macular to improve fluid resorption and prevent further damage to the central vision.Outcomes Measured: The study primarily measured vision loss and retinal changes over time, specifically:Vision Loss: The study focused on the severity of vision loss, including both moderate and severe loss of vision.Diabetic Retinopathy Progression: Changes in the severity of diabetic retinopathy and macular edema were assessed using standard retinal photography and clinical examination.Side Effects: The trial also monitored for any complications or adverse effects resulting from laser treatment or aspirin.Key Findings A) Laser Treatment in NPDR and PDR• Role of Laser in Severe NPDR and PDR:• Laser photocoagulation significantly reduced the risk of vision loss in patients with severe NPDR and PDR.• Patients who received panretinal photocoagulation (PRP) experienced a lower rate of severe vision loss compared to those who did not receive laser treatment. This was particularly true for patients with PDR, where laser therapy helped to prevent the progression of neovascularization and retinal detachment.• Result: Laser treatment helped to stabilize the condition and significantly reduced the likelihood of severe visual impairment.B) Laser Treatment in DME• Role of Laser in Diabetic Macular Edema (DME):• Focal laser photocoagulation was shown to be effective in reducing the risk of moderate vision loss in patients with diabetic macular edema.• The study showed that laser treatment reduced moderate vision loss by 50% in patients with DME. This was significant because DME is one of the leading causes of vision impairment in diabetic patients, especially affecting central vision due to macular swelling.• Result: Laser therapy played an important role in improving visual outcomes for patients with DME by reducing retinal edema and preventing further deterioration of central vision.C) Aspirin• Role of Aspirin:• The study also included an evaluation of aspirin as a potential treatment to prevent diabetic retinopathy progression or improve visual outcomes.• However, aspirin did not show a significant benefit in terms of preventing diabetic retinopathy progression or reducing vision loss.• Result: The study concluded that aspirin had no role in preventing the progression of diabetic retinopathy or in reducing the risk of vision loss in these patients. It was therefore not recommended as a treatment for diabetic retinopathy in the study population.Conclusion• Laser therapy (both panretinal photocoagulation for PDR and focal laser for DME) was found to be highly effective in reducing vision loss in diabetic retinopathy, especially in preventing severe vision loss in PDR and moderate vision loss in DME.• Aspirin had no significant role in preventing the progression of diabetic retinopathy or improving visual outcomes, thus not recommended as part of the treatment protocol.DCCT-Diabetes Control and Complication Trial[3]Objective: Investigated the impact of intensive vs. conventional diabetes therapy on diabetic retinopathy (DR) progression in individuals with type 1 diabetes (T1D).Study Design:• Participants: 1441 patients with T1D.• Randomization: Intensive therapy vs. conventional therapy.• Intensive Therapy: Multiple daily insulin injections or insulin pump to achieve near-normal blood glucose control.• Conventional Therapy: Fewer insulin injections, less stringent glucose control.Key Findings:1. Reduced DR Risk:• 76% reduction in risk of DR development with intensive therapy.• 54% slower DR progression.• 47% reduction in development of proliferative DR (PDR) or severe non-proliferative DR.2. Metabolic Memory:• Long-term benefits even after HbA1c levels converged between groups.

Subspecialty - RetinaDOS Times - Volume 30, Number 6, March-April 2025 70 www.dosonline.org• Lower risk of DR progression observed in former intensive therapy group in the EDIC study.3. Hypoglycemia: Intensive HbA1c control led to increased risk of hypoglycemia.Significance:Tight glycemic control significantly prevents or delays long-term complications, especially DR, in T1D patients.Related Studies: ADVANCE and ACCORD trials aimed for an HbA1c target of 7.5% to balance long-term benefits with hypoglycemia risks.UKPDS- United Kingdom Prospective Diabetes Study[4]Purpose: Investigate the effects of intensive blood glucose and blood pressure control on complications in type 2 diabetes.Study Design: Randomized, controlled trial (1977-1997), involving 5,000+ newly diagnosed type 2 diabetes patients at 23 UK sites.Key Findings:1. Microvascular Complications: Intensive glucose control significantly reduced the risk of retinopathy, nephropathy, and neuropathy.2. Cardiovascular Complications: Tight blood pressure control reduced heart attack and stroke risks.3. Long-Term Benefits: Early intensive therapy had lasting effects, even after returning to conventional therapy (legacy effects).4. Risk Reduction:• Glucose Control: 35% risk reduction per 1unit HbA1c decrease.• Blood Pressure Control: 37% risk reduction with BP target of 130/80 mmHg.Implications:• Emphasis on early and intensive management of glucose and blood pressure in type 2 diabetes.• Enhanced understanding of long-term effects and the importance of early intervention.• UKPDS Risk Engine predicts cardiovascular risks for diabetes patients.Study Duration: 20 years (1977-1997), led by Professors Robert Turner and Rury Holman.DRVS- Diabetic Retinopathy Vitrectomy Study[5]Study Questions:1. Is early vitrectomy preferable to delayed vitrectomy in eyes with severe vitreous hemorrhage (VH) from proliferative diabetic retinopathy (PDR)?2. Is early vitrectomy preferable to delayed vitrectomy in eyes with PDR without vitreous hemorrhage?Study Population:• Inclusion Criteria: Patients with advanced active PDR and a best-corrected visual acuity (VA) of 10/200 or better, or patients with recent vitreous hemorrhage due to PDR leading to VA ≤ 5/200 for at least 1 month.• Exclusion Criteria: Patients with previous vitrectomy, photocoagulation within the previous 3 months, intraocular pressure (IOP) > 29 mmHg on medication, severe neovascularization of the iris (NVI), or neovascular glaucoma (NVG).Study Design:• Type of Study: Randomized, prospective multicenter clinical trial.• Randomization: Participants were randomized into two groups:• Early Vitrectomy: Surgery performed within 1 to 6 months.• Delayed Vitrectomy: Surgery performed after at least 12 months.• Primary Outcome Measure: Visual acuity.Study Groups:1. Group N (Natural History Study): 744 eyes with advanced active PDR were observed without intervention for comparison purposes.2. Group NR (Non-Vitreous Hemorrhage): 370 eyes with advanced active PDR but without severe vision loss (VA > 10/200) were treated with either early or delayed vitrectomy.3. Group H (Vitreous Hemorrhage): 616 eyes with PDR and a history of sudden visual loss due to severe vitreous hemorrhage within the past 6 months (VA < 5/200, but not NLP) were treated with either early or delayed vitrectomy.Results:Group NR (4-Year Results):• Early Vitrectomy vs. Delayed Vitrectomy• Patients who underwent early vitrectomy demonstrated better visual outcomes compared to those who had delayed vitrectomy.• Type 1 Diabetes (DM): Patients with type 1 DM had

Subspecialty - RetinaDOS Times - Volume 30, Number 6, March-April 2025 71 www.dosonline.orgsignificantly better visual outcomes when treated with early vitrectomy.• Previous PRP (Panretinal Photocoagulation): A history of PRP improved the chances of achieving good vision after early vitrectomy.Group H (2-Year Results):• Early Vitrectomy vs. Delayed Vitrectomy:Type 1 DM: Early vitrectomy provided better visual outcomes for patients with type 1 DM compared to delayed vitrectomy.Type 2 DM: No significant advantage was seen in early vitrectomy for patients with type 2 DM.Conclusions:• For Eyes with Severe Vision Loss Due to Non-Clearing Vitreous Hemorrhage (≥ 1 Month Duration), early vitrectomy is recommended.• Type 1 DM Patients or Monocular Patients: Early vitrectomy is recommended for better visual outcomes.• For Eyes with Advanced Active PDR:• Type 1 DM or Severe Neovascularization: Early vitrectomy is recommended, especially when extensive neovascularization is present.DRCR.net- Diabetic Retinopathy Clinical Research Network[6]The Diabetic Retinopathy Clinical Research (DRCR) Retina Network, established in 2002, has significantly contributed to advancing the management of diabetic eye diseases. With over 30 multicenter studies and collaboration with more than 160 clinical sites in the U.S. and Canada, these studies have played a critical role in shaping the treatment of diabetic retinopathy (DR) and diabetic macular edema (DME). Recent studies have expanded beyond diabetic retinopathy to include other retinal diseases.Recent Findings and Protocol SummariesProtocol A: Comparison of Laser Techniques for DMEObjective: Compare the efficacy of modified grid laser (ETDRS) versus mild macular grid (MMG) laser for diabetic macular edema (DME).Study Design: Randomized, with visual and fundus photos and OCT taken at various intervals (3, 5, 8, 12 months).Results: At 12 months, the decrease in central macular thickness (CMT) was 88 microns for modified ETDRS and 49 microns for MMG.Protocol B: IVTA vs. Laser for DMEObjective: Compare the efficacy of intravitreal triamcinolone acetonide (IVTA) (1mg and 4mg doses) with laser photocoagulation for DME.Study Design: Randomized into three groups, with outcome measures for visual acuity and OCT.Results:• At 4 months: The 4 mg IVTA group had better visual acuity compared to the 1 mg and laser groups.• At 12 months: No significant difference between groups for visual acuity or OCT results.• Increased intraocular pressure (IOP) and cataract surgery complications were observed in the IVTA groups.Conclusion: Laser remains an effective treatment for DME.Protocol C: Temporal Variation in OCT Measurements for DMEObjective: Study temporal variations in OCT measurements of DME.Results: Less variation observed, but the results were not statistically significant.Protocol D: Evaluation of Vitrectomy for DMEObjective: Evaluate the effectiveness of vitrectomy for DME.Results: Results were less consistent and inconclusive.Protocol E: Peri-bulbar Triamcinolone Acetonide vs. Laser for DMEObjective: Randomized trial of peri-bulbar triamcinolone acetonide with and without focal laser for DME.Results: No significant findings reported.Protocol F: Observation of Diabetic Macular Edema Following Laser for DMEObjective: Study the development of edema after laser therapy for DME.Results: No significant conclusions provided.Protocol G: Monitoring Subclinical Macular EdemaObjective: Study the need for close monitoring of subclinical macular edema.Results: Close monitoring was recommended for patients with subclinical macular edema.Protocol H: Phase 2 Trial of Intravitreal Bevacizumab for DMEStudy design: Randomised trial, patients were randomly assigned to receive either bevacizumab or a control treatment.

Subspecialty - RetinaDOS Times - Volume 30, Number 6, March-April 2025 72 www.dosonline.orgObjective: Investigate the role of intravitreal bevacizumab in reducing DME.Results: 1. Visual Acuity Improvement: Patients receiving bevacizumab showed substantial improvements in visual acuity compared to baseline measurements. This improvement was statistically significant, demonstrating the potential of bevacizumab as an effective treatment for DME.2. Reduction in Retinal Thickness: The use of bevacizumab resulted in a notable reduction in central retinal thickness, which is a key indicator of the severity of DME. The reduction in retinal edema correlated with improvements in vision.3. Safety and Tolerability: Bevacizumab was generally well-tolerated by patients, with side effects being similar to those observed with other anti-VEGF therapies. However, the study also noted the importance of monitoring for potential risks, such as intraocular pressure changes and infection, which are common to any intravitreal injection procedure.Protocol I: Clinical Trial to evaluate the efficacy of anti-VEGF therapy for Diabetic Macular Edema (DME) .Study Overview:• Conducted by the Diabetic Retinopathy Clinical Research Network (DRCR.net).• Investigated the efficacy of anti-VEGF therapy (ranibizumab) for treating center-involving diabetic macular edema (CI-DME).• Compared ranibizumab to laser treatment and triamcinolone (a corticosteroid).Study Design:• Multicenter, randomized controlled trial.• Patients with CI-DME enrolled.• Four treatment arms:1. Ranibizumab with prompt laser.2. Ranibizumab with deferred laser.3. Triamcinolone with prompt laser.4. Laser alone.Key Findings:1. Anti-VEGF Superiority: Ranibizumab significantly improved vision and reduced macular thickening compared to laser therapy alone.2. Sustained Improvement: Long-term follow-up showed that the benefits of ranibizumab were sustained, even with reduced treatment frequency.3. First PRN Regimen: Introduced the “as needed” (prn) regimen for anti-VEGF therapy, reducing treatment burden while maintaining effectiveness.Statistical Results:• At 2 years, ranibizumab groups (with or without laser) showed improved BCVA (8-10 letters) compared to the laser-only group.• Greater reduction in macular thickness in the ranibizumab groups.Conclusion:• Protocol I was a game-changer in the treatment of DME, proving the superiority of anti-VEGF therapy over laser and corticosteroids.• Ranibizumab is now the standard first-line treatment for CI-DME, with a focus on sustained vision improvement and less frequent treatment.Protocol T: Comparison of Anti-VEGF Agents for CIDMEObjective: Compare the efficacy of aflibercept (Eylea), bevacizumab (Avastin), and ranibizumab (Lucentis) for treating visual impairment caused by center-involving diabetic macular edema (CI-DME).Study Design: Randomized, multicenter trial with eyes having visual impairment due to CI-DME.Results:• Baseline VA 20/32 to 20/40: No significant difference between the three anti-VEGF agents in mean change in visual acuity (VA).• Baseline VA 20/50 to 20/320: Aflibercept was superior to bevacizumab and ranibizumab at 1 year, and to bevacizumab at 2 years.• Protocol TX (5-year follow-up):• 68% of patients received at least one anti-VEGF injection between years 2 and 5.• Mean VA improved by 7.4 letters from baseline but was 4.7 letters less than the 2-year follow-up.• Central subfield thickness (CST) remained stable between years 2 and 5.Protocol V: Treatment Strategies for Good Vision in CIDMEObjective: Evaluate three strategies for treating CI-DME in patients with good vision (20/25 or better):• Intravitreal aflibercept every 4 weeks.• Focal/grid laser therapy with deferred aflibercept.

Subspecialty - RetinaDOS Times - Volume 30, Number 6, March-April 2025 73 www.dosonline.org• Observation with deferred aflibercept.Results:• At 2 years, no statistically significant difference in the percentage of patients who lost at least 5 letters of VA across the three groups.• Observation was a reasonable initial strategy, with deferred treatment if VA worsened.• In a post-hoc analysis, 34% of patients in the observation group required rescue treatment with aflibercept.Protocol W: Prevention of Vision-Threatening Complications in NPDRObjective: Assess the role of intravitreal aflibercept in preventing vision-threatening complications of moderate to severe nonproliferative diabetic retinopathy (NPDR).Study Design: Patients were randomized to receive aflibercept or sham injections.Results:• At 2 years:• Cumulative probability of developing proliferative diabetic retinopathy (PDR): 13.5% (aflibercept) vs. 33.2% (sham).• Cumulative probability of developing CI-DME with vision loss: 4.1% (aflibercept) vs. 14.8% (sham).• Aflibercept significantly reduced the incidence of vision-threatening complications but did not result in significant improvements in VA by 2 years.The DRCR Retina Network has significantly advanced the treatment of diabetic eye diseases through rigorous studies. Key findings have led to the adoption of anti-VEGF therapy as a first-line treatment for CI-DME and shown the efficacy of various treatment strategies such as laser therapy, intravitreal injections, and corticosteroids. The network’s ongoing research continues to refine treatment approaches and improve long-term outcomes for diabetic retinopathy and macular edema.References1. Royle P, et al. pan-retinal photocoagulation and other forms of laser treatmrnt and drug therapies for nonproliferative diabetic retinopathy: Systematic review and economic evaluation. NIHR Journals Library; 2015 July.2. The Diabetic Retinopathy Study Research Group. Photocoagulation treatment of proliferative diabetic retinopathy. Clinical application of Diabetic Retinopathy Study (DRS) findings, DRS Report Number 8. Ophthalmology. 1981 Jul;88(7):583–600. [PubMed] 0161-6420.3. “Diabetes congtrol and complications trial(dcct)”: results of feasibility study. The DCCT Research group. Diabetes care.1987 Jan-Feb4. “The uk prospective diabetes study (ukpds): clinical amd therapeutic implications for type 2 diabetes.” Br J Clin Pharmacol.1999 Nov;48(5):643-648.5. “Early vitrectomy for severe vitreous hemorrhage in diabetic retinopathy. two-year results of a randomized trial. diabetic retinopathy vitrectomy study report 2”. The Diabetic Retinopathy Vitrectomy Study Research Group. Arch Ophthalmol.1985 Nov.6. “The diabetic retinopathy clinical research network (drcr.net) and its contribution to the treatment of diabetic retinopathy”. Ophthalmic Res (2019)62(4): 225-230.Payal Singh MSSawai Man Singh Medical College & Hospital, Jaipur (Rajasthan), INDIACorresponding Author:

Subspecialty - Retina & UveaDOS Times - Volume 30, Number 6, March-April 2025 74 www.dosonline.orgUnilateral Granulomatous Uveitis: An Unusual CulpritHitisha Mittal MBBS, MS, DNB | Nishi M. Satish MBBS, MS | Anuj Mehta MBBS, MSDepartment of Ophthalmology, VMMC and Safdarjung Hospital, New DelhiPresentationA 17-year-old girl presented with painless diminution of vision in her left eye for one month. No history of ocular trauma or surgery. No known comorbidities, joint pains, TB or pets at home. On preliminary examination of the affected eye, her visual acuity was counting fingers at 2m and her intraocular pressure was normal. On slit lamp examination, large well defined mutton fat keratic precipitates were noticed on the endothelium. Corneal sensations were normal in both eyes. Posterior synechiae of almost 270 degrees and a posterior subcapsular cataract was noted, obscuring posterior segment view. Ultrasound B scan was done subsequently which was normal. Right eye examination was completely within normal limits. On systemic investigation, Mantoux and IGRA were negative, serum ACE level and chest imaging were normal, HIV, Hepatitis B and C and syphilis tests were all negative. On further probing, the Figure 1: Slit lamp examination shows large mutton fat keratic precipitates over inferior cornea (a) due to exposure to sap from Calotropis plant (b).patient confessed to single usage of milky sap from the Calotropis plant for itching as advised by her grandfather (known as ‘Ak’ in Hindi) in the left eye one month back. She took treatment elsewhere for sudden onset left eye redness after using the sap that resolved in 2-3 days with topical medications. Thus, a Calotropis induced Acute anterior uveitis was suspected and patient started on topical steroids. The symptoms resolved in a month without requirement for oral steroids.DiscussionThe milky white sap of Calotropis is acidic in nature and has been commonly reported to cause corneal edema and epithelial defect on exposure to ocular surface.[1] Very few reports of Iridocyclitis have been reported secondary to Calotropis sap exposure.[2,3] Detailed history including accidental toxin exposure in uveitis patients with no identifiable cause is important as it relinquishes the need for long term oral steroids.

Subspecialty - Retina & UveaDOS Times - Volume 30, Number 6, March-April 2025 75 www.dosonline.orgDeclaration of Patient ConsentThe authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.Financial Support and SponsorshipNil Conflicts of InterestThere are no conflicts of interest. References1. Bahkir FA. Spectrum of Calotropis procera latexinduced ocular toxicity. J Clin Ophthalmol Res 2020;8:125-7.2. Basak SK, Bhaumik A, Mohanta A, Singhal P. Ocular toxicity by latex of Calotropis procera (Sodom apple). Indian J Ophthalmol. 2009 May-Jun;57(3):232-4. Hitisha Mittal MBBS, MS, DNBSenior ResidentDepartment of OphthalmologyVMMC and Safdarjung HospitalNew Delhi – 110029.Corresponding Author:3. Tomar V, Agarwal PK, Agarwal BL. Toxic iridocyclitis caused by Calotropis. Indian J Ophthalmol. 1970;18:15e16.

Subspecialty - Retina & UveaDOS Times - Volume 30, Number 6, March-April 2025 76 www.dosonline.orgPostoperative Endophthalmitis: Basic Concepts of its ManagementSanjeev Kumar Nainiwal MD, DNB, MNAMS | Neha Kharwas MBBS | Nitisha Bairwa MBBS | Manisha Jhajharia MBBS | Versha Jeph MBBS | Priyanka MBBSVitreo Retinal Services, Department of Ophthalmology, Sawai Man Singh Medical College & Hospital, Jaipur (Rajasthan), IndiaEndophthalmitis is defined as an inflammation of the inner coats of the eye associated with exudates in vitreous, which may be infectious or non-infectious in origin. Although the incidence of infections after cataract surgery has widely declined over the decades since the advent of aseptic techniques with the use of prophylactic antibiotics, endophthalmitis still remains one of the most feared complication that the ophthalmic surgeon has faced. Worldwide, the reported incidence of postoperative endophthalmitis is 0.04%-4%. Postoperative endophthalmitis can occur following any penetrating ocular surgery; however, 90% of postoperative endophthalmitis occurs following cataract surgery, because cataract surgery is most frequently performed globally. Post cataract surgery incidence is 0.265% (more with clear corneal incision), post keratoplasty is 0.382%, and post vitrectomy is 0.05%. The incidence of bleb-associated infection is 0.2%-9.6%. This range in the incidence of infection appears to be consistent across numerous patient populations from all over the world. Nagaki et al. reported a statistically increased risk with clear corneal incisions (0.29%) compared to sclerocorneal incisions (0.05%).Source of InfectionThe most common source of infection is probably the patient himself, as it is almost impossible to sterilize the operative field completely. However, there are many other sources which may play a role in the occurrence of endophthalmitis, i.e. the surgeon’s hands, air borne pathogens (either from surgeon’s nose or the air conditioner), solutions injected into the eye, instruments, antiseptics used preoperatively, and drops and ointments used post-operatively. The most frequent pathogens causing acute bacterial endophthalmitis are gram positive cocci i.e. Staphylococcus albus and Staphylococcus aureus, followed by the gram-negative organisms, especially Pseudomonas aeruginosa, streptococcus and fungi. Propionibacterium acnes in the posterior capsule has also been claimed to develop a milder, chronic course that may be unnoticed, and it was reported to be responsible for 41-63% of cases of chronic postoperative endophthalmitis after cataract surgery.[1]Clinical FeaturesThere are two clinical settings in which postoperative endophthalmitis may be seen. These are:(a) 1st postoperative day: This is the less common presentation of the disease. Endophthalmitis that presents at this time is severe in intensity and unusually associated with increased pain, redness, watering, and lid oedema. The clinical sign of most utility in suspecting a diagnosis at this time are an increased number of cells in the anterior chamber and the presence of vitreous exudates. A hypopyon may or may not be present at this time. A decreased fundus glow on the first post operative day can be due to many other reasons and is not very specific for the diagnosis of post-operative endophthalmitis. Similarly decreased visual acuity at this time is not of much relevance in making the diagnosis since it can be due to many other causes. (b) Onset during the postoperative period (usually within 6 weeks of the surgery). This is the more common mode of presentation. Most of these patients give a definite history of occurrence of sudden deterioration of vision between the second post operative day and the sixth week after initial recovery. The decrease in vision is associated with pain (in three-fourth of patients), redness, watering and clinical signs in the form of increase in anterior chamber reaction with or without a hypopyon and vitreous exudates. Deterioration of visual

Subspecialty - Retina & UveaDOS Times - Volume 30, Number 6, March-April 2025 77 www.dosonline.orgacuity in a patient after initial recovery is one of the most consistent symptoms of postoperative endophthalmitis. The presence of a decreased fundus glow on distant direct ophthalmoscopy at this time is a very important sign of endophthalmitis. In the situations described above, the cornea may be hazy, and epithelial oedema may be present. Inspection of the area of incision may sometimes reveal an area of infiltration, usually along the suture track. If present, this is a bad prognostic sign. If the process manifests soon after the surgery with a fulminating course, Pseudomonas infection is a likely cause. However, other gram-negative organisms and Staphylococcus aureus could also induce a similar reaction. The most definitive clinical signs of endophthalmitis are presence of vitreous exudates along with a hypopyon or significant number of cells in the anterior chamber.Figure 1: Slit lamp photograph of Post cataract surgery endophthalmitis.Investigations and ManagementEarly recognition of postoperative endophthalmitis leads to early treatment and better visual outcomes.[2] Every patient suspected of having postoperative endophthalmitis must be examined thoroughly after taking a brief history. Complete slit-lamp examination should be done to note the findings of the incision site, cornea, anterior chamber and anterior vitreous, if visible. Visual acuity should be carefully assessed since it is an important prognostic indicator and is also one of the parameters used for decision making. Ultrasonography should be ordered to assess the posterior segment status. The objective of ultrasonography is to evaluate the eye for the presence and location of posterior vitreous detachment and for the presence of a retinal detachment.Topical concentrated antibiotics (Table-1) should be started immediately along with a cycloplegic-mydriatic (i.e. Homatropine 2% eye drops). Moxifloxacin, and fluoroquinolones in general, penetrate well into the eye. After topical administration at two-hourly intervals, moxifloxacin reaches mean aqueous concentrations of 2.3µg/ml.[4] As a rule, we prefer to start at least two topical antibiotics (for gram positive and gram negative organisms respectively) simultaneously. Anti glaucoma medication is added if required.Role of SteroidsSystemic steroids should be considered in most severe cases once infection has been adequately addressed. According to the Endophthalmitis Vitrectomy Study (EVS), oral prednisolone 1mg/kg body weight is recommended, initiating a day after the intraocular antibiotic (IOAB) therapy, with or without vitrectomy in patients with post cataract or secondary IOL endophthalmitis. Use of systemic corticosteroid is associated with improved visual outcome.Intravitreal corticosteroids play a crucial role in the management of endophthalmitis, as besides the acute infiltration by bacteria, the ocular inflammatory response caused by bacterial infiltration induces significant damage to retinal tissues. Intravitreal corticosteroids work by blocking the inflammation by acting on various steps of the inflammatory pathway. Steroids interfere with inflammatory cell congregation, passage through vessel walls, prostaglandin synthesis, and release of superoxide. Concerns about the use of intravitreal corticosteroids in endophthalmitis stem from the fact that neutrophil sequestration is the primary tissue response to infection, and is necessary for the elimination of infectious material. There are also concerns about secondary host toxicity and the effect of intravitreal steroids on the pharmacokinetics of intravitreal antibiotics. Finally, immunosuppression leaves the body vulnerable to fungal infections, although the length of therapy would not be enough to deeply immunosuppress the patient. Intravitreal Injection of AntibioticsThe mainstay of treatment for post operative endophthalmitis is intravitreal injection of antibiotics. intravitreal administration serves as the only direct access to the vitreous cavity by bypassing the blood retinal barrier and achieving higher concentrations of drugs for prolonged

Subspecialty - Retina & UveaDOS Times - Volume 30, Number 6, March-April 2025 78 www.dosonline.orgperiods of time.[5] Usually a combination of two antibiotics is chosen, which are selected based on their activity against coagulase-negative staphylococci (the most common bacterial cause of endophthalmitis), and gram negative bacilli. The most commonly used and effective combination for this purpose at present is Vancomycin (1mg/0.1ml) and ceftazidime (2.2mg in 0.1ml). While amikacin (400 µg/0.1 ml) could be used in place of ceftazidime, it possesses a higher risk of macular toxicity and should be avoided, if possible. Some people favour intravitreal injection of steroid (Dexamethasone 400µg/0.1ml) to limit post inflammatory consequences. Great care must be exercised in the preparation of antibiotics for intravitreal injection since they are highly toxic.TechniqueIntravitreal injection of antibiotics should be given in the operation theatre under proper aseptic precaution. It is usually performed under topical anaesthesia. However, retrobulbar anaesthesia could be administered if the patient is uncooperative. Facial anesthesia prior to the intravitreal procedure simplifies the procedure for the surgeon and improves the patient’s comfort significantly and is recommended for all, except the most non-cooperative patients. The most common site for administering intravitreal injections is inferotemporally 3mm from the limbus in aphakic and 3.5mm in pseudophakic eyes. Initially around 0.5ml vitreous should be aspirated with a 21 gauge needle for making smears as well as for culture sensitivity, then antibiotics are injected sequentially into the vitreous cavity, with a 26 gauge needle. In case of a dry tap, aqueous paracentesis could be done to obtain material for smear and culture sensitivity and even more importantly, for bringing down the IOP prior to the intravitreal injection. It is not necessary to use different needles for injecting the two antibiotics though.The needle should be pointing towards the centre of the globe. The bevel of needle should be directed up towards the pupil. The antibiotics should be taken in two separate glass syringes. Disposable tuberculin syringes should be avoided. This is so because it is possible to introduce antibiotic slowly drop by drop with a glass tuberculin syringe by rotating the plunger while pushing it forwards. This motion is not possible with disposable syringe. Thus a jet of fluid is more likely to be injected with a disposable syringe. The EVS recommended systemic antibiotics have limited role in patients being treated by intravitreal injections or vitrectomy, however, we do administer Tab Ciprofloxacin 500mg to 750mg BD to patients with enTable 1: Concentrations and dosage of principal antibiotic.Drug Name Topical (%) Intravitreal Systemic Cefazolin Sodium 50mg/ml (5) 2.25mg 25-50mg/kg/day QID IVAmikacin Sulphate 20mg/ml (2) 0.4mg 15mg/kg/day TDS IVVancomycin hydrochloride 50mg/ml (5) 1mg 15-30mg/kg/day OD-BD IVCeftazidime - 2.25mg 1-2gm/day BD-TDS IVGentamycin Sulphate 13. mg/ml (1.35) 0.1-0.2mg 3-5mg/kg/day BD-TDS IVAmphotericin B 1.5mg/ml (0.15) 5µgm 0.4-0.6 mg/kg/day with 5% dextrose over 2-4 hoursDexamethasone - 0.36mg 6mg/kg/dayPrednisolone - - 1mg/kg/day Oral Tobramycin 13.5mg/ml (1.35) - 3-5mg/kg/day BD-TDS IVVoriconazole 10mg/ml 50-100µgm/0.1ml 100mcg/6mg/kg iv bd on day 1 followed by 4mg/kg bddophthalmitis. The rational for this decision is that ciprofloxacin does have significant penetration into vitreous cavity as opposed to the systemically administered drugs tested using the EVS in most of patients.Vitrectomy in EndophthalmitisAs a rule, all patients seen at our centre are given an initial intravitreal antibiotic injection on presentation. Vitrectomy is reserved for patients who do not respond adequately to intravitreal antibiotics within 36-48 hours. While we do prefer to carry out an immediate vitrectomy for patients who present with a visual acuity of light perception only, this is often not possible due to logistic constraints. The timing of vitrectomy surgery is important

Subspecialty - Retina & UveaDOS Times - Volume 30, Number 6, March-April 2025 79 www.dosonline.orgbecause the intravitreal environment associated with the natural history of endophthalmitis alters over time. In the acute stages, there is mainly vitreous infective debris and opacification that responds well to vitrectomy surgery. In the subacute phase, starting from 7 days over several weeks, the endophthalmitis condition is associated with abnormal vitreoretinal adhesions and vitreoretinal traction can develop and worsen during this time.[6]It has been shown in a study carried out at R P centre that the results of immediate intravitreal antibiotic injection followed by vitrectomy within 48 hours are as good as those of immediate vitrectomy in patients with post operative endophthalmitis. If however, the patient has already received an intravitreal antibiotic injection elsewhere, it is advisable to carry out an immediate vitrectomy at presentation. For all cataract surgeons faced with a patient with endophthalmitis, our advice would be:Give an intravitreal anti biotic injection immediately and assess the response after 24 hours. If there is no definitive evidence of improvement, please refer the patient immediately to a vitreoretinal surgeon. We are not in favour of multiple intravitreal antibiotic injections except in patients with an extremely poor prognosis i.e. those with corneal infiltration or those with a cornea too hazy to perform a successful vitrectomy or those with a retinal detachment on ultrasonography.Tips for Vitrectomy int EndophthalmitisToday, there is no doubt that the mainstay of management for post-operative endophthalmitis is intravitreal antibiotics. However, there are certain situations in which vitrectomy may result, not only in salvaging the eye, but also in providing a favourable outcome in patients with this devastating disease process. Some of the practical tips regarding successful use of this very effective tool in the ophthalmologist’s armamentarium are given below:Patient SelectionInaccurate projection of light is not a contraindication for vitrectomy. In fact, it probably has almost no prognostic role at all.Patients with significant corneal infiltration are likely to fare poorly, and may be better managed conservatively.Patients who have not responded to their first intravitreal injection of antibiotics given 48 hours earlier are candidates for an immediate vitrectomy. Multiple intravitreal antibiotic injections should be avoided as the management for endophthalmitis except in cases which are not fit for vitrectomy.Patients with a retinal detachment on USG have a poor prognosis following vitrectomy.Preoperative ultrasonography (USG) is mandatory prior to vitrectomy for endophthalmitis.USG is required to look for presence of a partial/total posterior vitreous detachment and also for presence of a retinal detachment.Patients with dense exudates extending up to the posterior one third of the vitreous cavity on ultrasonography have poorer visual prognosis.Surgery is easier in patients with a partial or total posterior vitreous detachment. The decision regarding when to undertake vitrectomy is however not based on ultrasonography. It is based on clinical factors. Electrophysiological tests like VER and ERG have no role in evaluating patients for vitrectomy for endophthalmitis.Surgical TechniqueSurgery under general anesthesia is preferable for uncooperative patients. As a rule, however, peribulbar anesthesia is adequate for surgery in majority of the patients.The corneal incision must be inspected and strengthened by placing additional sutures before starting vitrectomy.3 port pars plana vitrectomy is carried out in all patients.A 6mm infusion cannula must be used.This 6mm cannula is always possible to visualize within the vitreous cavity by depressing the cannula inwards and forwards towards the pupil (since the patient is aphakic/pseudophakic, there is no risk of lens damage).The infusion bottle must not be kept higher than 24 inches from the patients’ eye.In patients with pseudophakic endophthalmitis, there is almost always a fibrin membrane covering the iris and the pupillary area. This can be removed from the pars plana route by making an iridectomy next to the temporal port with the vitrectomy cutter. An MVR blade of then passed through the iridectomy to engage the fibrin membrane and dislodge it from its adhesions to the iris and the IOL surface. The membrane is then eaten away in the anterior chamber by introducing the vitrectomy probe through the iridectomy. Adequate visualization is possible in all cases by this technique.A high cutting rate and low suction must be kept for the vitrectomy cutter. This will ensure that no undue traction is put on the vitreous gel during the vitrectomy.

Subspecialty - Retina & UveaDOS Times - Volume 30, Number 6, March-April 2025 80 www.dosonline.orgIn over half the cases, vitreous exudates are not found to extend beyond the anterior or mid vitreous during vitrectomy:Only a core vitrectomy is required to ensure a successful outcome in majority of the cases. In the periphery, we should be conservative: the vitreous skirt is only shaved, reducing the risk of a retinal break.Vitreous cavity lavage can be carried out by continuing to use the vitreous cutter (in the cutting mode) placed in the central vitreous cavity for at least 5-10 minutes after the infected gel has been removed. This makes it possible to carry out the lavage without causing any turbulence within the vitreous cavity.Corneal epithelium debridement can be carried out at any time during the vitrectomy if epithelial oedema is preventing adequate visualization, without any risk of causing a corneal ulcer.Should a retinal injury be caused or large areas of necrosis be discovered, we prefer silicone oil injection, but this is rarely necessary.[6]After closure of the sclerotomies, check the corneal wound once more since, the corneal sutures could become loose due to the distortions created. Today, the results of vitrectomy for endophthalmitis have improved considerably. Approximately 80% of patients can expect a visual acuity better bet than 6/60 following vitrectomy for endophthalmitis. The technique thus offers a glimmer of hope to the afflicted patients.Risk Factors for Poor ResultsEarlier studies have re-ported that a positive culture, a more virulent organism, delay in onset of initiation of treatment, presence of concomitant ocular disease such as retinal detachment and rubeosis, and a poor preoperative visual acuity are the predictors for worse visual acuity results.[8] The EVS showed many independent risk factors i.e., older age, history of diabetes, corneal infiltrates and ulcer, abnormal intra ocular pressure, absent red reflex, a ruptured posterior capsule, and visual acuity of light perception are predictors of a poor visual outcome.[8]However, the most important risk factor for decreased final visual acuity was an initial visual acuity of light perception only. Some patients had twice the risk for a worse acuity outcome compared with patients with better than light perception only. It is our experience the most important prognostic factor in patient’s undergoing treatment for endophthalmitis is the presence of significant corneal infiltration. Such patients do extremely poorly even after vitrectomy.It is our clinical experience that the worst prognosis occurs in patients with corneal infiltration, in these patients vision is usually unlikely to be salvaged. Today, however, with appropriate management, it is possible not only to salvage many of the eyes with this devastating condition, and it is possible to help them retain useful vision also.References1. Friling E, Lundström M, Stenevi U, Montan P: Sixyear incidence of endophthalmitis after cataract surgery: Swedish national study. I Cataract Refract Surg. 2013, 39:15-21. 10.1016/j.jers.2012.10.037.2. JI Maguire: Postoperative endophthalmitis: optimal management and the role and timing of vitrectomy surgery, Eye 22, 1290-1300 (2008).3. McCulley JP. Caudle D, Aranowicz JD, Shine WE. Fourth-generation fluoroquinolone penetration into the aqueous humor in humans. Ophthalmology. 2006;113(6):955-959. doi: 10.1016/j.ophtha 2006.01.061.4. Urtti A. Challenges and obstacles of ocular pharmacokinetics and drug delivery. Adv Drug Deliv Rev. 2006; 58:1131–1135.5. Cengiz Aras et al: Silicone oil in the surgical treatment of endophthalmitis associated with retinal detachment: International Ophthalmology; Volume 24, pages 147–150, (2001).6. Negretti GS, Chan W, Pavesio C, et al. Vitrectomy for endophthalmitis: 5- year study of outcomes and complications. BMJ Open Ophthalmology 2020;5: e000423. doi:10.1136/ bmjophth-2019-000423.7. Endophthalmitis Vitrectomy Study Group. Results of the endophthalmitis vitrectomy study: a randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Arch Ophthalmol. 1995;113(12):1479-96.8. Xiaodan Jiang et al: Incidence, Prophylaxis and Prognosis of Acute Postoperative Endophthalmitis After Cataract Surgery: Infection and Drug Resistance 2022:15 4047-4058.Sanjeev Kumar Nainiwal MD, DNB, MNAMS Senior Professor Ophthalmology Sawai Man Singh Medical College & Hospital, Jaipur RajasthanCorresponding Author:

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