Scleral Buckling: A Review of Clinical Aspects and Current Concepts

Scleral buckling represents a valuable treatment option for rhegmatogenous retinal detachment repair. The surgery is based on two main principles: the closure of retinal breaks and the creation of a long-lasting chorioretinal adhesion. Buckles are placed onto the sclera with the purpose of sealing retinal breaks. Cryopexy is usually performed to ensure a long-lasting chorioretinal adhesion. Clinical outcomes of scleral buckling have been shown to be more favorable in phakic eyes with uncomplicated or medium complexity retinal detachment, yielding better anatomical and functional results compared with vitrectomy. Several complications have been described following scleral buckling surgery, some of which are sight-threatening. Expertise in indirect ophthalmoscopy is required to perform this type of surgery. A great experience is necessary to prevent complications and to deal with them. The use of scleral buckling surgery has declined over the years due to increasing interest in vitrectomy. Lack of confidence in indirect ophthalmoscopy and difficulties in teaching this surgery have contributed to limiting its diffusion among young ophthalmologists. The aim of this review is to provide a comprehensive guide on technical and clinical aspects of scleral buckling, focusing also on complications and their management.

Fundus Examination in Pediatric Patients Using Indirect Ophthalmoscopy

The goal of this chapter is to provide the clinician with an understanding of binocular indirect ophthalmoscopy (BIO) and helpful clinical techniques for success in examining the fundus of the pediatric patient, including scleral depression. The challenging technique to examine the premature infant at risk for retinopathy of prematurity will be explained in detail, including the standard classification of the disease with photos depicting the different location and stages of disease. BIO with the addition of scleral indentation helps the clinician diagnose and locate lesions that may otherwise go undetected, such as retinal holes, tears, or vitreoretinal adhesions. Complete examination of the fundus of a child is no less important than of any other patient who seeks eye care but often requires efficiency and precision (as well as many human arms). Time is a rate limiting aspect when examining children so preparation and experience will lead to success.

Unusual presentation of cornea verticillata with intravitreal methotrexate in a case of primary intraocular lymphoma

A 56-year-old woman presented with floaters and diminution of vision in the right eye for 1 week. On examination, visual acuity was 20/400 in the right eye and 20/60 in the left eye. Indirect ophthalmoscopy revealed vitritis in the right eye and subretinal deposits in both eyes. Vitreous biopsy of the right eye revealed large B-cell-type primary intraocular lymphoma and the patient underwent multiple intravitreal methotrexate injections (400 μg/0.1 mL) in the right eye and systemic chemotherapy for bilateral disease. Following biweekly injections of methotrexate, her visual acuity improved considerably from 20/400 to 20/60 with resolution of vitritis. However, following eighth dose of intravitreal methotrexate, she experienced visual decline to 20/120 along with photophobia, redness and watering. Whorl-shaped opacities, limbitis and corneal haze were noted on slit-lamp examination. Intravitreal methotrexate was stopped, and the patient was started on frequent topical lubricants, loteprednol, topical folinic acid and oral folic acid. Complete resolution of corneal toxicity was observed at 3 weeks and the injections were suspended as there was no recurrence at 6 months follow-up.

Knowledge and skills amongst optometrists in public and private sectors in India

Background: Optometrists with different levels of optometric education in India provide eye care services under various capacities to the public.Aim: The study evaluated the status of optometrists in terms of their knowledge, skills and frequency of skill utilisation in public and private sectors.Setting: A quantitative study design was adopted using a survey questionnaire that was distributed to optometrists providing eye care services in public and private sectors.Methods: A structured and validated questionnaire with closed-ended questions was administered to 650 participants.Results: A total of 400 completed questionnaires were received (response rate = 62%) of which 207 respondents were males (52%) and 193 females (48%). Most (57%) of the respondents were bachelor’s degree holders with 86% of the respondents in the private sector and 14% in the public sector. The knowledge level of ancillary and diagnostic tests (69%) was the least amongst public sector optometrists whilst it was binocular indirect ophthalmoscopy (66%) for private sector optometrists. The skill levels in indirect ophthalmoscopy was least amongst the public sector (56%) and private sector (44%) optometrists. Indirect ophthalmoscopy showed the least frequency of skill utilisation amongst public sector (13%) and private sector (34%) optometrists.Conclusion: The study highlighted the need for mandating best practice standards, and expanding the scope of defined practice, as optometrists are better suited for diagnostic roles and comprehensive eye examinations, and can contribute effectively towards averting preventable blindness.

Inexpensive Binocular Indirect Ophthalmoscopy

We aim to discuss an inexpensive method of conducting binocular indirect ophthalmoscopy without the binocular indirect ophthalmoscope headset. This technique only requires the examiner to hold a light source between their eyes and hold a condensing lens at an arm’s length. This may be particularly valuable in resource-poor settings.

Building Clinical Skills Teaching Materials: A Study of Cognitive Task Analysis Versus Free Recall Instruction to Teach Canine Indirect Ophthalmoscopy

Ophthalmoscopy is a core component of a complete ophthalmic examination. Due to its complex technical aspects and patients becoming uncooperative if the procedure is prolonged, it can be a difficult skill for a novice to learn and develop proficiency in. Skills instruction is typically provided by subject matter experts (SMEs) through free recall without an agreed-upon instructional framework. This can lead to unintentional omission of essential steps and knowledge required to perform skills correctly. Cognitive task analysis (CTA) allows for construction of standardized instructional protocols that encompass the knowledge and skills experts apply when performing tasks. The objectives of this study were to (a) develop a CTA-based teaching protocol for canine indirect ophthalmoscopy and (b) compare the steps verbalized or demonstrated by SMEs during free recall instruction versus those ultimately identified by CTA. Four SMEs participated in free recall instructional sessions and interviews used for the development of a CTA-based teaching protocol for novice learners. The CTA-based protocol identified 66 steps and sub-steps considered essential for successfully performing canine indirect ophthalmoscopy. During instructional sessions, SMEs on average failed to verbalize 57.1% of clinical knowledge steps, did not verbalize or demonstrate 68.3% and 9.5% of action steps and did not verbalize or demonstrate 73.2% and 40.4% of decision steps, respectively. This study demonstrates that SMEs teaching indirect ophthalmoscopy by free recall may unintentionally omit important steps, suggesting that compared with free recall, CTA may generate more comprehensive and thus potentially more effective instructional materials for teaching technical skills in veterinary medicine.

A novel 4.25 kb heterozygous deletion in PAX6 in a Chinese Han family with congenital aniridia combined with cataract and nystagmus

Background The aim of this study is to identify the genetic defect in a Chinese family with congenital aniridia combined with cataract and nystagmus. Methods Complete ophthalmic examinations, including slit-lamp biomicroscopy, dilated indirect ophthalmoscopy, anterior segment photography, and anterior segment optical coherence tomography (OCT) were performed. Blood samples were collected from all family members and genomic DNA was extracted. Genome sequencing was performed in all family members and Sanger sequencing was used to verify variant breakpoints. Results All the thirteen members in this Chinese family, including seven patients and six normal people, were recruited in this study. The ophthalmic examination of affected patients in this family was consistent with congenital aniridia combined with cataract and nystagmus. A novel heterozygous deletion (NC_000011.10:g.31802307_31806556del) containing the 5′ region of PAX6 gene was detected that segregated with the disease. Conclusion We detected a novel deletion in PAX6 responsible for congenital aniridia in the affected individuals of this Chinese family. The novel 4.25 kb deletion in PAX6 gene of our study would further broaden the genetic defects of PAX6 associated with congenital aniridia.

Ultra-widefield retinal imaging for adjunctive resident training in retinal break detection

We evaluated the clinical utility of ultra-widefield imaging as an adjunctive tool for training resident ophthalmologists in the detection of retinal breaks. This was a prospective study conducted at a secondary health care center (Tri-Service General Hospital) in Taiwan. Participants were 44 patients (53 eyes) who were referred to our hospital after being diagnosed with retinal breaks. Patients first underwent an indirect ophthalmoscopy examination of the total fundus without scleral depression by our junior (first and second year) or senior (third and fourth year) resident ophthalmologist and then underwent an ultra-widefield imaging examination with a central image and four gaze-steered (up, down, nasal, and temporal) images to determine the number of retinal breaks in the total fundus and the four quadrants. Of the total 53 eyes, 31 were examined by junior residents and 22 were examined by senior residents. In the group of junior residents, ultra-widefield imaging was significantly better at detecting retinal breaks of the total fundus (49 vs. 33 retinal breaks, p < 0.001) and the temporal quadrant (17 vs. 10 retinal breaks, p = 0.018) than indirect ophthalmoscopy. In the group of senior residents, there was no significant difference in the ability to detect retinal breaks in the total fundus or each of the four quadrants with ultra-widefield imaging or indirect ophthalmoscopy. Our results indicate that, compared to indirect ophthalmoscopy, ultra-widefield imaging with a central image and four gaze-steered images has a better performance and is a useful adjunct tool for the detection of retinal breaks in junior resident training. Additionally, it could be a useful method for teaching indirect ophthalmoscopy examination to junior residents.