Inverted flap technique with air tamponade and one day face down positioning for posttraumatic macular hole surgery in a young male patient in sub-Saharan Africa

Introduction: Surgery has been the mainstay of macular hole treatment since the first description of its success. Different techniques are, however, described. Our case report looks into the use of the inverted flap technique for managing patients with posttraumatic full thickness macular holes with a single day supervised face down positioning and air tamponade.

Case Report: A 32-year-old young man sustained blunt ocular trauma to his left eye while under training seven months prior to presentation with reduced central vision and metamorphopsia. On examination visual acuities were best corrected 6/6 in the right and 6/60 in the left, anterior segments were normal. Fundoscopy revealed flat retinae, and extensive linear chorioretina scars in the posterior pole suggestive of healed choroidal ruptures and a posttraumatic stage 4 full thickness macular hole (FTMH) in the left. The FTMH measured 877 μm on optical coherence tomography (OCT). The patient had a macular hole surgery using the inverted flap technique with one-day face down positioning and air tamponade. Significant hole closure was seen in the first postoperative week and by six weeks after surgery, the macular hole was fully closed and vision improved to 6/6 best corrected. The inverted flap technique with air tamponade and one day face down positioning can offer another option to retina surgeons treating complex macular holes. Early visual recovery and ability to undertake air travel immediately after surgery is an additional advantage.

Conclusion: Using the inverted flap technique for surgery provides surgeons with another option for repair of complex FTMHs, like those secondary to trauma that have been known to respond poorly to initial standard repair.

National approaches to trichiasis surgical follow-up, outcome assessment and surgeon audit in trachoma-endemic countries in Africa

Background: Poor outcomes of trichiasis surgery, including postoperative trichiasis, are common in many trachoma-endemic countries in Africa. To improve outcomes, WHO recommends regular follow-up and outcome assessment of surgical cases plus audit of trichiasis surgeons.

Aims: To assess national approaches to trichiasis surgical follow-up, outcome assessment and audit, and identify national targets for good surgical outcome (defined as the percentage of patients undergoing surgery for trichiasis remaining free of post-operative trichiasis for a defined interval after surgery).

Methods: A cross-sectional survey was carried out between May and July 2018, involving all 29 known-trachoma-endemic countries in Africa. An emailed questionnaire was used to collect information on national targets for surgical outcomes, policies, monitoring and strategies to address underperformance by surgeons.

Results: All national programmes provided information; 2 of the 29 had not yet implemented trichiasis surgery as part of their trachoma elimination programme. Findings from 27 countries are therefore reported. Only four countries reported having a national policy for trichiasis surgery follow-up and outcome assessment and only two had a national policy for conducting audits of trichiasis surgeons. Only 9 of the 27 countries had a cut-off point at which poorly performing surgeons would be instructed to discontinue surgery until retraining or other interventions had been undertaken.

Discussion: To address the challenge of post-operative trichiasis and other poor outcomes, national trachoma programmes should create and implement policies and systems to follow up patients, assess surgical outcomes and monitor the performance of individual surgeons through post-surgical audits.

Factors Associated With the Uptake of Cataract Surgery and Interventions to Improve Uptake in Low- And Middle-Income Countries: A Systematic Review

Despite significant evidence around barriers hindering timely access to cataract surgery in low- and middle-income countries (LMICs), little is known about the strategies necessary to overcome them and the factors associated with improved access. Despite significant evidence that certain groups, women for example, experience disproportionate difficulties in access, little is known about how to improve the situation for them. Two reviews were conducted recently: Ramke et al., 2018 reported experimental and quasi-experimental evaluations of interventions to improve access of cataract surgical services, and Mercer et al., 2019 investigated interventions to improve gender equity. The aim of this systematic review was to collate, appraise and synthesise evidence from studies on factors associated with uptake of cataract surgery and strategies to improve the uptake in LMICs. We performed a literature search of five electronic databases, google scholar and a detailed reference review. The review identified several strategies that have been suggested to improve uptake of cataract surgery including surgical awareness campaigns; use of successfully operated persons as champions; removal of patient direct and indirect costs; regular community outreach; and ensuring high quality surgeries. Our findings provide the basis for the development of a targeted combination of interventions to improve access and ensure interventions which address barriers are included in planning cataract surgical services. Future research should seek to examine the effectiveness of these strategies and identify other relevant factors associated with intervention effects.

All India Ophthalmological Society – Oculoplastics Association of India Consensus Statement on Preferred Practices in Oculoplasty and Lacrimal Surgery During the COVID-19 Pandemic

Oculoplastic surgeries encompass both emergency surgeries for traumatic conditions and infectious disorders as well as elective aesthetic procedures. The COVID-19 pandemic has brought about a drastic change in this practice. Given the highly infectious nature of the disease as well as the global scarcity of medical resources; it is only prudent to treat only emergent conditions during the pandemic as we incorporate evidence-based screening and protective measures into our practices. This manuscript is a compilation of evidence-based guidelines for surgical procedures that oculoplastic surgeons can employ during the COVID-19 pandemic. These guidelines also serve as the basic framework upon which further recommendations may be based on in the future, as elective surgeries start being performed on a regular basis.

Resurgence of “Bow and Arrow” Related Ocular Trauma: Collateral Damage Arising From COVID-19 Lockdown in India?

Penetrating ocular trauma in children often presents late and may be associated with complications due to delayed presentation as children are not always able to verbalize their injuries. Previous studies have shown that children aged 5 and above were more frequently affected and it was also noted that boys were more frequently affected than girls. Children involved in unsupervised games often get injured and “bow and arrow” injuries were known to be a fairly common cause of penetrating trauma in children, in the past.

Safety Recommendations and Medical Liability in Ocular Surgery During the COVID-19 Pandemic: An Unsolved Dilemma

Ocular surgery is one of the most performed medical procedures in the world. Its limitation or suspension, recursively extended over time, could be associated with a significant increase in the number of blind people worldwide. Indeed, cataract causes more than half of all cases of visual impairment in those countries with limited availability of means for performing eye operations (e.g., Africa or India). In this scenario, the pandemic of coronavirus disease 2019 (COVID-19) quickly resulted in the suspension or sharp reduction of various ophthalmic activities considered non-urgent, including lens replacement surgery or some intraocular injections. Despite the imperative need to continuously practice eye operations to avoid the abovementioned problems, there are currently little-shared and vague recommendations among the various countries on safety in operating rooms (for health care workers and patients) and poor legal protection for surgeons (potentially transmitting the COVID-19 infectious agent). Herein, we individuated and discussed some critical points in safety recommendations and medical liability. A paradigm shift for ocular surgery during the COVID-19 era is now mandatory. While telemedicine has been able to solve some problems in clinical ophthalmology, the lack of adequate health and legal protection for surgeons and patients may result in an excessive reduction in the volume of surgical interventions during a pandemic era and the immediately following period, thus determining inability to ensure health care to all patients.

Severe Acute Multi-Systemic Failure With Bilateral Ocular Toxoplasmosis in Immunocompetent Patients From Urban Settings in Colombia: Case Reports

Propose: To report two cases of severe acute multi-systemic failure with bilateral ocular toxoplasmosis in immunocompetent patients from urban settings in Colombia.

Observations: We report two immunocompetent male patients aged 44- and 67-years-old who, despite not having visited the Amazonian region in Colombia, had severe bilateral posterior uveitis and extensive-bilateral macular lesions and multiple organ failure that required admission to an intensive care unit. Toxoplasma gondii was positive by PCR assay in vitreous humor samples. Patients were treated with intravitreal clindamycin and dexamethasone in addition to systemic treatment with trimethoprim-sulfamethoxazole. In both patients, infection by atypical strains was confirmed; in one case by serotyping and in another one by genotyping (ROP 18 virulent allele). After 2 and 4 months of treatment respectively, the patients showed improvement of the posterior uveitis and its systemic manifestations. However, there was no significant visual acuity improvement due to bilateral extensive macular involvement.

Conclusions and importance: Clinicians should be aware that toxoplasmosis originating from South America could be associated with severe acute multisystemic and intraocular bilateral involvement, even in patients with no history of exposure to jungle environments.

Practice Patterns in the Management of Strabismus in Pakistan

Purpose: To study the current practice patterns of pediatric ophthalmologists in the management of strabismus in Punjab.

Study Design: Questionnaire based Practice pattern survey.

Place and Duration of Study: Teaching hospitals of Punjab from July 2018 to July 2019.

Material and Methods: This study was conducted at ophthalmology departments of various teaching hospitals of Punjab. A questionnaire was designed to find out the current practice pattern for management of strabismus. Ophthalmologists who were members of Ophthalmological Society of Pakistan (OSP), having their expertise in strabismus surgery for more than 5years and practicing pediatric ophthalmology were selected. Discussion was also held regarding questionnaire and practices being performed after filling the proforma. This data was compiled, analyzed and was converted to a summary in points.

Results: We contacted 90 ophthalmologists out of whom 76 responded to our Questionnaire. Complete Orthoptic Assessment was performed by only 46% (35) of the ophthalmologists. Prism cover test was used as a diagnostic tool by 70 (92%) ophthalmologists. Rest of the ophthalmologists used Synoptophore with it. Percentage of ophthalmologists performing cycloplegic refraction was very low. Only 5 (6.57%) surgeons used adjustable sutures. Only 46% of surgeons used to explain the complications of Anesthesia. More than 90% of surgeons explained the surgical procedures being done, its complications, post-operative care and need to use glasses or need for orthoptic exercises. All the surgeons kept follow up of the patients on 1st post-operative day.

Conclusion: The current practices in strabismus need to be standardized and a consensus should be developed at a national level.

Burden and Factors Associated with Refractive Errors Post Cataract Surgery at Kilimanjaro Christian Medical Center: A Hospital Based Retrospective Cross-sectional Study

Aims: To determine the burden and factors associated with refractive errors after cataract surgery in a training institution.

Study Design: A retrospective cross-sectional study.

Place and Duration of the Study: Kilimanjaro Christian Medical Center Eye department. Northern Tanzania, from January 2016 to December 2017.

Methods: A review of files of all adult patients who have had cataract surgery in 2016 and 2017 was conducted. A total of 626 eyes of 554 patients who had post-operative refraction by experienced optometrists were included. Information were extracted from patients’ files then entered into SPSS version 20 for analysis. The main outcomes were post-operative refraction and best corrected visual acuity.

Results: Mean age was 69.3 years (SD=10.7) and ECCE accounted for 76% of surgeries. At least 84.6% had post-operative refractive error and astigmatism was the most common refractive error (56.8%). Spherical error accounted for 27.8%. Spherical error ranged from -12 to 4DS, mean = -0.42 (SD=1.3) DS and median = 0.00DS. The maximum cylindrical error was -7.5 DC, mean = -1.15 (SD=1.36) DC and median = -1.0DC. At least 56% had spherical equivalent within 1D of emmetropia. A BCVA of 6/18 or better was achieved in 92.8%. Age, poor pre-operative VA, poor presenting VA, astigmatism on keratometry, difference between recommended and inserted IOL, ECCE, grade of surgeon and suturing were associated with refractive errors.

Conclusion: Refractive errors following cataract surgery are common. Best corrected visual acuity outcome was in normal recommended range; however, the magnitude of refractive errors was high and the proportion of patients who achieved a final refraction within 1D of emmetropia was below the recommended range. An effort should be made to lower the prevalence and magnitude of refractive errors associated with cataract surgery in training institutions.

Pediatric Cataract Audit at a Tertiary Care Center in Karachi

Purpose: To perform pediatric cataract surgery audit at a tertiary care center in Karachi.

Study Design: Descriptive observational study.

Place and Duration of Study: From January, 2016 to July, 2018 at Ophthalmology Department of Jinnah Postgraduate Medical Center, Karachi.

Material and Methods: All patients with congenital cataract were included in study regardless of presence or absence of systemic association. Patients who were lost to follow up at three months were excluded from the study. Hospital records were reviewed retrospectively and data on patient demographics, preoperative presentations, intraoperative complications and postoperative visual outcomes was documented on predesigned proformas. All patients underwent lens aspiration, posterior capsulotomy and anterior vitrectomy. Surgeries were performed under general anesthesia. Preoperative and postoperative visual acuity was assessed with ability to fix and follow light/objects, Kay picture test and Snellen’s chart according to patient’s age.

Results: Three hundred and twenty six eyes underwent surgery for congenital cataract and sixty for traumatic cataract. Number of male patients was 54.93% and female was 45.07%. The average age of patients with congenital cataract was 5.01 years and that for traumatic cataract was 7.8 years. Amblyopia, nystagmus and strabismus were the commonest ocular comorbidities. Uncorrected visual acuity ranged from 6/18 to light perception preoperatively. Postoperatively 55% children with congenital cataract and 15% children with traumatic cataract had visual acuity better than 6/24.

Conclusion: Early surgery in congenital cataract gives good visual outcomes. In traumatic cataract extraction, the final visual outcome depends on other effects of trauma on ocular structures.