Achoo - God bless you!

Background:“Achoo” is the sound that is correlated with sneezing. A sneeze, in rare occasions, it can cause Valsalva retinopathy. Usually, small bleeding gets absorbed with time. But if the haemorrhage stays for a longer period of time, it can lead to de-hemoglobinization of blood which can cause damage to the photoreceptors. If such a damage occurs over the macula, it can cause irreversible visual loss. Hence, prompt and meticulous treatment is indicated in such cases. One such case is described here where a lady suffered from a sudden bout of sneezing and presented to us after a month later. A large sub-internal limiting membrane (ILM) bleed was noted over the macula. Hence a vitrectomy with ILM peeling with drainage of blood was advised. She recovered 20/40 visual acuity one month following surgery.Purpose:This video emphasizes on diagnosis of sub-ILM hemorrhage and the technique in which the sub-ILM bleed can be drained in the modern era of microincision vitreoretinal surgeries.Synposis:A key aspect in such cases is to distinguish sub-ILM from sub-hyaloid bleed. Subtle differentiating points on imaging are described in the video. In cases of sub-ILM hemorrhage, the most important surgical step after performing a core vitrectomy is a good posterior vitreous detachment (PVD) induction. After that, ILM peeling is carried out with the help of finesse loop and ILM peeling forceps. Using proportional vacuum and aspiration alternatively from the cutter, the hemorrhage is displaced and drained. This step can prevent damage to the underlying retinal tissue. After the macula hemorrhage is completely cleared, an air-fluid exchange is done.Highlights:Teaching points include: 1. Diagnostic markers for sub-ILM hemorrhage; 2.The method of PVD induction in cases of Sub ILM hemorrhage; and 3.Technique of drainage of sub-ILM hemorrhage using proportional vacuum and aspiration function of the cutter.Video link: https://youtu.be/hBhfLDy9o-Y     

Reverse Swiss Roll technique for diabetic vitreous membranes

Background:Diabetic membranes are always a challenge for a surgeon because of sticky nature and chances of iatrogenic break while removing.Purpose:To demonstrate a safe reverse swiss roll technique to dissect diabetic vitreous membranes.Synposis:Approaches and techniques for membrane dissection are segmentation, delamination and en-bloc dissection using various types of instruments and illumination. With vitreous cutte, picks and scissors, surgical steps are traditionallu performed by using classic lift and shave technique. After identifying the plane, tissue is lifted and then cut, which puts the retina at risk of break because of traction and active suction. Such a threat can be reduced by placing the cutter above the membrane thereby having the membrane itseld acting as a protective cushion to the retina. Port here, unlike lift and shave technique, doesn’t face the edge of membrane but is exactly 180 degree opposite and membrane curls into port because of suction. Also, hemostasis is maintained by continuous aspiration and cutting as the instrument is moved side to side, retracting from the edge.Highlights:Reverse swiss roll technique is safer compared to lift and shave because of the safety cushion of the membrane between the port and the retina. There is inherently less chances of retinal break because the active suction from the port is directed away from the retina. The technique also minimises traction and localised pull on the atrophic macula.Video link: https://youtu.be/WNnSsP69ZLw     

Innovative method for wound debridement in open globe injury

Background:Open globe injury is a serious sight threatening condition. Full-thickness, non-selfsealing corneal lacerations require repair in the operating room. During repair, debridement of the wound is an important step. Incarceration of the intraocular structures in the wound eg. Iris, lens capsule, vitreous leads to improper healing if not removed properly.Purpose:To demonstrate the technique of wound debridement in open globe injury.Synopsis:Manual removal of incarcerated tissue contents leads to incomplete cleaning & enormous traction on intra ocular contents. In this video, we have tried vitrectomy cutter with higher vacuum for cleaning the edges of the wound especially in the posterior aspect and debri removal, followed by easy suturing. All tissue in the wound edges are removed effectively without any traction on intraocular contents.Highlights:Vitrectomy cutter is a very useful and effective tool to clean wound edges and good apposition & suturing of wound.Video link: https://youtu.be/y_kCxLdwhuQ     

Winning the battle of refractory hypotony

Background:Trabeculectomy, a mainstay in the management of glaucoma is associated with various complications, the most dreaded being hypotony.Purpose :We present a challenging case of late-onset refractory hypotony following trabeculectomy.Synopsis:A 64-year-old male patient diagnosed with primary open angle glaucoma in the right eye underwent combined surgery. Three weeks later, he presented with hypotony which responded well with medical management and then he was lost to follow-up. Two years later, he presented with severe hypotony with shallow choroidal detachment in the right eye, which failed to respond to medical management. Compression sutures were placed over the bleb which also failed to work. Subsequently bleb repair was done with corneal patch graft, which helped resolve the bleb leak, with an improvement in visual acuity and intraocular pressure.Highlights:This video highlights the importance of prompt and timely intervention of an overfiltering bleb in preventing irreversible visual loss.Video link: https://youtu.be/8DrxzqQ4qP4     

Transconjunctival flap sutures: A novel technique to combat hypotony

Background:Hypotony secondary to overfiltration is a recognized complication following trabeculectomy. Persistent hypotony requires intervention .Purpose:We describe a modified version of placing conjunctival compression sutures directly over the scleral flap.Synopsis:A 70-year-old male patient diagnosed with primary open angle glaucoma in both eyes underwent combined surgery in the right eye. On the tenth post-operative day, the patient presented with severe hypotony with 360° choroidal detachment. He was treated with corticosteroids and cycloplegics but developed hypotony maculopathy on the subsequent follow-up. Hence, he was further managed surgically by trans-conjunctival flap sutures to which he responded favorably with resolution of choroidal detachment and improvement in intraocular pressure and visual acuity.Highlights:Transconjunctival suturing of the scleral flap is an effective and minimally invasive treatment to prevent visual loss from hypotony maculopathy for an overfiltering bleb following trabeculectomy.Online Video Link: https://youtu.be/BJtUZcyQZ-w     

Volcano explosion in the eye: Expulsive choroidal haemorrhage

Background :This video shows the dreaded complication of expulsive suprachoroidal haemorrhage in a penetrating keratoplasty . It teaches the various measures that help in preventing and managing the challenge peri-operatively.Purpose:This video is intended to sensitize the corneal surgeons about this rare complication using real-time surgical video and prepare them to face this challenge by demonstrating the preventive and mitigating strategies.Synopsis:A patient who was suitably taken up for an autokeratoplasty had expulsive choroidal haemorrhage in the non-seeing eye. This complication was managed using glycerin-preserved donor corneal button. Further, the video discusses various pre-operative and intra-operative optimizations to avoid such a complication and mitigate the damage caused by it, should it ever happen during a surgery.Highlights:Expulsive choroidal haemorrhage can be a traumatizing event and one must be mentally prepared to manage it. Pre-operative high-risk factors should always be managed and intra-operative maneuvers performed to prevent the complication, as shown in the video.Video link: https://youtu.be/s_ImBugPELw     

Power of compounding intravitreal Bevacizumab - Experience from a tertiary eye care hospital

Background:Bevacizumab vials that are commercially available are fractionated into smaller quantities into the form of pre-filled syringes in a sterile and aseptic laboratory setting.Purpose:To share the long term experience of aliquoting of bevacizumab injections in a tertiary eye care center in India.Synopsis:Compounding of bevacizumab was found to be a cost-effective and sustainable practice that has benefited more patients with an affordable cost, while maintaining high levels of quality.Highlights:Compounding of bevacizumab, when done with aseptic precautions can be a safe and cost-effective practice, the benefits of which can be passed on to needful patients.Video Link: https://youtu.be/C5XOpKHFkew     

Make in India: Normative data for automated perimetry

Background:The normative data set in authomated perimetry is predominantly of non-Indian origin and hence may not be an accurate basis for visual field analysis in Indian population. This video describes an attempt to create a native normative dataset for automated perimetry, which can then be fed in our machines and be used as the normative database.Purpose:To formulate normative data and to increase domain knowledge of normative values for automated perimetry in Indian population of different age groups.Synopsis:Cross-sectional study conducted on patients receiving outpatient care in a span of 3 years, which included 6586 healthy normal patients (13172 eyes) with vision 6/6 unaided or after refractive correction. The patients were tested with 30-2 SITA FAST threshold algorithm on Humphrey Field Analyzer Model no: 745i. Normative data was calculated on basis of age group ranging from 19-75 years categorized to every decade. Normal values were formulated on basis of perimetry performed on normal patients.Highlights:Our work on creating a native normative dataset may add value as well as increase the accuracy of perimetry analysis in Indian eyes.Online Video Link: https://youtu.be/jqgC2Tn7HIg     

Innovative models for vitreoretinal training during COVID-19 times

Background:Vitreoretinal training has been badly affected during the COVID-19 times. Due to lockdown, the number of patients reaching the hospital has dwindled. Hence we propose two simple cost-effective ways to improve resident training.Purpose:To highlight two simple eye models RETILAPP and RETISURGE, and their use in resident training. This video also highlights how to make and customise laser and surgery eye models and its advantages .Synopsis:By using 3D printing, two simple, economical and reusable eye models have been proposed to improve resident training especially during COVID-19 times.Highlights:Use of simple easily available materials and 3D printing to make sustainable eye models for practise as against the simulator based learning.Video link: https://youtu.be/dJau9N-sHUE     

Post-traumatic posterior giant retinal tear and macular hole associated retinal detachment

Background:Blunt trauma to the eye can present with varied manifestations involving both the anterior and posterior segments of the eye. Giant retinal tear (GRT) following trauma occurs most commonly at the equatorial region or anterior to the equator. GRT posterior to the equator is rare.Purpose:To demonstrate the successful management of a post-traumatic posterior GRT and full-thickness macular hole (MH) associated retinal detachment (RD).Synposis:A 21-year-old-male presented with sudden diminution of vision in the right eye (RE) following blunt-trauma with cricket ball. RE vision at presentation was hand movement close to face. Anterior segment of RE revealed pupillary sphincter tear, posterior synechiae and posterior subcapsular cataract (PSC). RE fundus revealed a posterior-GRT, full thickness MH, mild vitreous haemorrhage and rhegmatogenous RD. He was managed with pars plana vitrectomy, encircling scleral band, perfluorocarbon liquid-assisted flattening of GRT, internal limiting membrane peeling, and endotamponade. Post-operatively the retina was attached, MH was closed and the patient achieved an ambulatory vision of 1/60.Highlights:This video demonstrates the successful management of a posterior-GRT and MH associated RD. Removal of adherent hyaloid from the long anterior flap of posterior GRT, peeling of ILM from temporal narrow mobile strip of retina (which has a risk of radial extension of GRT edges) and manoeuvring in suboptimally dilated pupil are illustrated in this video.Video Link: https://youtu.be/p04-_t0Wuuc     

Orbital dermoid cyst

Background:Dermoid cyst, a developmental benign choristoma, is the most common orbital tumor of childhood, arising from ectodermal sequestration along the lines of embryonic fusion of mesodermal processes, lined by keratinized stratified squamous epithelium and expanding slowly due to constant desquamation and dermal glandular elements. Approximately 80% are found in the head and neck region and comprise 3-9% all orbital masses.Purpose:It is mandatory to know about the variable presentations of orbital dermoids and the surgical techniques that can be adopted based on the site, extent, age and aesthetic needs, presence of inflammation and possibility of intraoperative rupture.Synopsis:Orbital dermoids can be classified as juxta-sutural, sutural or soft tissue cysts; superficial or deep; intraosseous or extraosseous, and intraorbital or extraorbital. These smooth, painless, mobile or partially mobile lesions mostly present at the fronto-zygomatic suture with proptosis, displacement, ptosis or diplopia, depending on depth and extent. Therefore, it is important to understand the various presentations and the appropriate surgical techniques.Highlights:We describe the embryological origin, types and clinical features of dermoids in this video and demonstrate the surgical and minimally invasive techniques for their management.Video link: https://youtu.be/-q3xD2igjcQ     

Modified scleral band buckle placement technique

Background:Scleral buckling is considered an art, which has a long learning curve compared to other surgical retina techniques. Unfortunately, this beautiful surgical technique is getting less attention as new retina surgeons don’t get much exposure to this age-old surgical technique, reason being less interest shown by young retina surgeons and tremendous advancement in micro-incision vitrectomy system.This video is a modification of the present technique of placement of band buckle, which uses science rather than art.The most important aspect in band buckle is getting the optimal buckle height which needs a lot of experience before one can achieve it. Most of the surgeons tend to tighten it more than needed that can lead to complications. This new technique is easy to learn and will give controlled reproducible buckle height and can be done safely by the trainees.Purpose:The aim of this video is to simplify the technique of scleral buckling which can produce controlled and reproducible buckle height and will reduce the complications associated with a tight band buckle.Synopsis:A 360-degree peritomy is made. Four recti muscles are identified and separated and traction sutures are passed under their insertions. A partial thickness scleral tunnel is made in all four quadrants. A silicone band (style#41 used in this video) is passed through the scleral tunnel and under the insertion of all four recti.The two ends of the silicone band are trimmed so that they are opposed to each other. Then a 12-mm strip is cut off from one end, and the two remaining ends are tied with a 5-0 nonabsorbable suture. This technique ensures a 2-mm optimal buckle height.Highlights:We present an elegant technique of placing the band buckle in retinal detachment surgery.Video link: https://youtu.be/9_dh6qsd-7A     

Landmark trials in ophthalmology: The age-related eye diseases studies

Background:There are many landmark clinical trials in ophthalmology, the context of which provide a more relevant understanding of their results. The Age-related Eye Diseases (AREDS) studies were conducted in a large population to understand the effect of nutritional supplements on the progress of age-related macular degeneration.Purpose:This instructional video is being presented to familiarize the postgraduate residents as well as interested researchers of the details of the landmark AREDS studies.Synopsis:The video describes the enrollment of participants, their demographics, the protocols of the studies, and the key results.Highlights:The AREDS formulations, the specific effects of key components of the formulations, and results of the trials that guide present day treatment guidelines are discussed.Video link: https://youtu.be/SPsikgx8SCI     

Decoding glaucoma module premium edition

Background:Traditional methods for neuroretinal rim width measurement in spectral domain optical coherence tomography (SD-OCT) employs the Bruch‘s membrane opening (BMO) as the anatomical border of the rim, referenced to a BMO horizontal reference plane, termed as “Bruch’s Membrane Opening-Horizontal Rim Width” (BMO-HRW). BMO-HRW is defined as the distance between BMO and internal limiting membrane (ILM) on the horizontal plane. In contrast, the Spectralis OCT (Heidelberg Engineering, Germany) employs a new parameter called “Bruch’s Membrane Opening–Minimum Rim Width” (BMO-MRW) with Glaucoma Module Premium Edition (GMPE). GMPE provides a novel objective method of optic nerve head (ONH) analysis using BMO, but the neuroretinal rim assessment is performed from the BMO to the nearest point on the ILM, rather than on the horizontal reference plane. It is the BMO-MRW and is defined as the minimum distance between the BMO and ILM in the ONH.Purpose:In this video, anatomy of the ONH and GMPE is decoded from a neophyte user’s point of view, as to why BMO-MRW is more important than the traditional BMO-HRW for glaucoma evaluation.Synopsis:The GMPE concepts are depicted in a novel dynamic (Clinical vs OCT Vs Histology) screenplay, detailing the below focal points with 2D & 3D animations: True Margin of ONH, Bruch’s Membrane (BM), Histology Vs OCT, BMO, Bruch’s Membrane Opening-Minimum Rim Width, Bruch’s Membrane Opening-Minimum Rim Width Versus Bruch’s Membrane Opening-Horizontal Rim Width, Alpha, Beta, Gamma Zone of ONH in OCT, Anatomic Positioning System, Impact of Fovea Bruch’s Membrane Opening Centre Axis.Highlights:This video also highlights, how with the advent of Anatomic Positioning System, scans were able to align relative to the individual’s Fovea-to-BMO-center (FoBMOC) axis at every follow-up, for accurately detecting changes, as small as 1 micron in BMO-MRW, thus creating a new world in diagnosing glaucoma and detecting glaucomatous progression with precision.Video link: https://youtu.be/6RqF5guAziw     

The art of tackling strabismus skillfully by sparing vessels

Background:Detaching a rectus muscle irreparably destroys its ciliary artery circulation which also supplies the anterior segment of the eye.Purpose:To educate strabismus surgeons about a method of detaching a muscle without compromising anterior segment circulation.Synopsis:A limbal based conjunctival incision is made. The muscle is identified, separated from its attachments and secured with 6-0 Vicryl. The anterior ciliary vessel supplying it is isolated by making a small snip incision in the muscle capsule with delicate blunt dissection parallel to the anterior ciliary artery The muscle is detached from its original insertion. The muscle is tied to sclera at the intended point of recession. The intact anterior ciliary artery, thus will continue to function, untouched.Highlights:We recommend pre-placing the sutures in the muscle and also in the sclera at the point of reattachment to avoid possible stretching and breaking of anterior ciliary vessels at the time of muscle detachment and also to dissect the artery free from muscle several millimeters more than the intended recession in order to spare the anterior ciliary circulation in strabismus surgery.Video link: https://youtu.be/Bn050Ihu9rU     

Cataract surgery in colobomatous eyes with advanced cataract

Background:Cataract surgeries are challenging in colobomatous eyes as they are associated with features such as microphthalmia, microcornea, zonular deficit, etc. These factors predispose to capsulorhexis extension, posterior capsular rent, zonular dialysis and result in unfavourable visual outcomes. The most critical step of cataract surgery in such cases is the capsulorhexis as the chances of extension are high in the colobomatous area. In presence of pre-existing zonular dehiscence, nucleus management becomes more challenging in advanced cataracts.Purpose:To illustrate efficient management of advanced cataract in colobomatous eyes.Synopsis:A 39-year old lady presented with complaints of gradually progressive diminution of vision in both eyes. Examination revealed bilateral nuclear sclerosis grade III-IV with irido-lenticular retinochoroidal coloboma (ILRCC). The patient was scheduled for bilateral cataract surgery after a thorough evaluation. Initially, the left eye was planned for phacoemulsification, in the course of which capsulorhexis extension occurred, leading to nucleus tilt and vitreous disturbance during emulsification. Automated anterior vitrectomy was done and the surgical approach was shifted to manual small incision cataract surgery (MSICS) with 3-piece intraocular lens placement in sulcus. The right eye was hence planned for MSICS and a rhexis extension was noted in this eye as well. Comparing the outcome of both the surgeries it was noted that both had capsulorhexis extension, but the management of nucleus and intraocular lens implantation was efficient in case of MSICS than phacoemulsification. Posterior chamber intraocular lens were placed in both eyes and the patient attained good visual outcome.Highlights:MSICS is a better approach to cases of ILRCC with advanced cataract. The capsulo should be tailored according to the site of coloboma such that it should be smaller in the area involving the coloboma and larger away from it.Video link: https://youtu.be/d9FC0eavhRs     

Artificial intelligence in glaucoma

Background:Artificial Intelligence (AI) is an area of computer science that encompasses the creation of intelligent machines that work and react like humans. It deals with the development algorithms that seek to simulate human brain and also mimic cognitive functions typically associated with the human mind such as learning and problem solving.Purpose:Do we need artificial intelligence in Glaucoma? Glaucoma is the second most common cause of blindness in the world. Its prevalence was over 60 million in 2010 and over 80 million by 2020. It is so common, yet so easily overlooked. More importantly, about 50% of patients in developed countries and 90% in developing countries are unaware of having glaucoma. Early detection can delay the progression of glaucoma. Hence the time is ripe to advovate glaucoma screening.Synopsis:The application of AI in ophthalmology mainly concentrates on the diseases with a high incidence, such as diabetic retinopathy, age-related macular degeneration, glaucoma, retinopathy of prematurity, age-related or congenital cataract etc AI involves mainly 1. machine learning that are algorithms with the ability to learn without being explicitly programmed and 2. deep learning in which artificial neural networks adapt and learn from vast amounts of data. But there are limitations to screening - such as disparity between ophthalmologist:patient ratio and also the availability of the specialty services. The large amount of data acquired from patients makes it nearly impossible for ophthalmologists to screen them with equal efficacy and consistency.Highlights:AI in glaucoma aims at including factors such as clinical data, genomic data, life style behaviors, risk factors, and medical history to predict the risk of developing glaucoma, help customise the most appropriate management protocol for a given patient, and estimate prognosis and surgical success.Video Link: https://youtu.be/IwYS7wDMhkY     

Subconjunctival Dirofilariasis presenting as orbital cellulitis

Background:Dirofilariasis is an emerging zoonosis in India. Most of the cases from India have been reported from the states of Kerala, coastal Karnataka and Maharashtra, and a few from the North India, Orissa and Assam. Dogs, cats, foxes and other wild animals are definitive hosts for dirofilaria. Human ocular parasitosis is prevalent in geographical areas where environmental factors and poor sanitary conditions favor parasitism between humans and animals. However, in recent years, migrating population have facilitated the spread of certain parasitic diseases from endemic to non-endemic areas. We report a case of subconjunctival dirofilariasis in a 91-year-old man, who presented with features of orbital cellulitis. An intact live worm, measuring 13.5 cm, was extracted from the subconjunctival space, following which there was prompt resolution of symptoms.Purpose:Given the increase in the frequency of dirofilariasis in humans in recent years, medical practitioners should bear in mind the possibility of ocular dirofilariasis when a patient presents with an ocular or orbital inflammatory lesion.Synopsis:This video illustrates various presentations of ocular dirofilaria and surgical extraction of a live worm from the subconjunctival space.Highlights:Lifecycle and human ocular manifestations of dirofilaria ared elucidated. Rare presentation of subconjunctival dirofilariasis as orbital cellulitis and its resolution following removal of the live worm has been demonstrated.Video link: https://youtu.be/Nj8unz0S85M     

Management of acute corneal hydrops with compression sutures and air tamponade

Background:Acute corneal hydrops is a vision threatening complication of corneal ectasia like keratoconus, keratoconus, keratoglobus, Pellucid marginal degeneration, Terrien’s marginal degeneration and post refractive surgery keratectasia. The associated risk factors for development of corneal hydrops (CH) are early onset of keratoconus, microtrauma associated with contact lens use, eye rubbing, allergic conjunctivitis, atopy, and Down’s syndrome. With the conservative approach of management of CH, it takes longer time (in months) for corneal oedema to get resolved and there is development of vascularization and scarring. This video presents the simple technique of using compression sutures along with pneumodescemetopexy by intracameral air injection for management of CH. It led to rapid resolution of corneal oedema. It is a simple technique, with no need of special gases like C3F8 or SF6 and can be easily performed at a very basic set up.Purpose:To highlight the efficacy of simple technique of applying compression sutures and air tamponade in management of CH and to demonstrate the efficacy of anterior segment OCT in diagnosis and to assess the prognosis of a case of CH.Synopsis:A 9-year-old boy presented with CH, with anterior segment OCT showing torn descemet’s membrane and fluid pockets in corneal stroma. Four full-thickness compression sutures were applied and intracameral sterile air was used for pneumodescetopexy. The serial post operative clinical and OCT picture showed rapid resolution of corneal oedema.Highlights:This video highlights the use of OCT imaging in the diagnosis of CH and full-thickness compression sutures as the safe and effective technique in the management of acute CH.Video link: https://youtu.be/54C3hJB_WTM     

Fine-needle diathermy for corneal vascularisation

Background:Corneal angiogenesis occurs as a sequel to an insult and it brings with it cells that mediate immunity as well as repair and aids in flushing toxins out. These vessels are formed in haste and leak lipid and cells, ultimately resulting in loss of transparency, lipid keratopathy and immunogenicity. So, they may need treatment prior to an optical keratoplasty.Purpose:To demonstrate the procedure of Fine Needle Diathermy (FND) to treat corneal neovascularization, its indications and contraindications.Synopsis:FND uses coagulating current from a monopolar cautery unit to occlude the afferent and efferent blood vessels. FND works best at the stage of mature vessel formation. The needle is placed across a tuft of vessels or parallel to a single large vessel, being mindful of the depth and direction. FND is avoided in necrotic tissue where the blood vessel is needed for healing process. Occlusion of the vessel in these situations may result in tissue melt.Highlights:Corneal neovascularization follows the stages of latent phase, active neovascularization, mature vessel formation and then regression. The treatment modality depends on the stage of angiogenesis. FND works best for neovascularization due to infectious keratitis. Keratoplasty is best performed 3 to 4 months later when regression of corneal vascularization occurs.Video Link: https://youtu.be/2RK6d_a2Gdc