Lid Speculum Research Articles

Equipment and Instruments in Pediatric Vitreoretinal Surgery

In this section, special considerations regarding vitreoretinal instrumentation when planning pediatric retinal surgery are evaluated. Instrumentation was designed considering the distinct anatomical and physiological differences in the pediatric population. Instrumentation used in the pediatric population, including eyelid speculum, scleral buckling elements, visualization systems, 25 and 27G short vitrectomy packs, and sutures, is discussed, which may include differences. In addition to instrument design, modifications and techniques used in surgical steps that differ from adults were also evaluated. With awareness of these differences, complications can be prevented and optimum treatment effectiveness may be achieved with the surgeon's operational management.

Clinical presentation and outcomes of Mooren’s ulcer: a 2-year retrospective cohort study

Background: Mooren’s ulcer is a chronic, painful, unrelenting, peripheral ulcerative keratitis with atypical geographic presentation and distribution. This study aimed to retrospectively investigate the clinical presentation and outcomes of patients with Mooren’s ulcer over a 2-year period at the Evangelical Church Winning All (ECWA) Eye Hospital, Kano, Nigeria. Methods: The theatre records of 24 patients with Mooren’s ulcer were retrospectively reviewed, with a focus on those who had up to 2 years of follow-up. The surgical treatment followed a standard procedure of 3 ml of 2% xylocaine and 0.01% adrenaline were administered for peribulbar anaesthesia. The periorbital area was cleaned with 10% povidone iodine, draped, and a lid speculum was inserted to part the lids. The conjunctiva was excised 2 mm from the edge of the ulcer, and the area was lightly cauterized. This was followed by a combination of subconjunctival injection of 2 mg of dexamethasone and 20 mg of gentamycin and a drop of 0.3% of ciprofloxacin and 1% of atropine. Data were analyzed using a social science statistical package (IBM SPSS Inc. Chicago V 19.0) with 95% confidence. Results: The results revealed that Mooren’s ulcer was predominant in an age range of 11 and 30 years. A total number of 24 patients were seen in the two years of review, with an average age of 27.3±13.7 years. There were 19 male and 5 female patients, with a male-to-female ratio of 3.8:1. At presentation, patients had poor preoperative vision, with acuity values of less than 6/60–3/60 range. Postoperatively, 15 eyes had a borderline outcome (cannot see 6/18 but can see 6/60), 12 eyes had good vision (VA 6/18) and 4 eyes ended up with the same presenting vision (VA<6/60) after treatment. One patient had iris prolapse and three patients had evisceration. Conclusions: This study provided the clinical characteristics of patients with Mooren’s corneal ulcer. A comparison of preoperative and postoperative visual acuity showed that early presentation and intervention improved visual outcomes. Although most eyes maintained or improved vision, nearly half demonstrated a borderline result that fell short of the target vision threshold. The retrospective nature of this study limited its ability to review complete patient information. The small sample size also constrained the analysis due to the low incidence of Mooren’s ulcer. Further research is needed to better understand increased susceptibility in younger populations. This will help inform prevention and treatment efforts to address this public health challenge.

Incidence of Blepharoptosis Following Intravitreal Anti–Vascular Endothelial Growth Factor Injections

PurposeWe aimed to determine the incidence of blepharoptosis following intravitreal anti-vascular endothelial growth factor (VEGF) injections and compare the rates of blepharoptosis between patients injected with an eyelid speculum and those injected without a speculum. DesignRetrospective cohort study MethodsInternational Classification of Diseases (ICD-10) was used to identify patients with exudative age-related macular degeneration (AMD) and those who developed ptosis following intravitreal injections. Patients with nonexudative AMD who did not receive intravitreal injections served as control. The outcomes were the incidence of ptosis in the injection group compared to the non-injection group and incidence of ptosis in patients whose injections were performed with an eyelid speculum as compared to those whose injections were performed without specula. ResultsWe recruited 1,100 exudative AMD patients who received at least one intravitreal anti-VEGF injection and 2,258 nonexudative AMD patients who had not received an injection. In the injection group, 18 out of 1100 patients (1.6%) developed ptosis, compared to 52 out of 2258 patients (2.3%) in the non-injection group (p=0.25). Within the injection group, ptosis was mostly bilateral, diagnosed on average 22.4 months following the initial injection, and following more than a one-year injection-free period. 11 out of 537 patients (2.0%) injected without a speculum developed ptosis, compared to 8 out of 444 patients (1.8%) injected with a speculum (p= 0.82). ConclusionsNo statistically significant differences in incidence rates of ptosis were observed. In this analysis, neither intravitreal anti-VEGF injections nor speculum use during injections appears to increase the risk of ptosis.

Chamber shallowing technique for challenging DMEK cases: Tucking cellulose spears under the speculum to augment posterior pressure.

Some anterior chambers do not readily shallow because of insufficient posterior pressure and/or very deep anterior chamber anatomy, which can make unscrolling descemet membrane endothelial keratoplasty (DMEK) tissue more challenging with an unmodified tap technique. We present a hands-free method for augmenting posterior pressure by temporarily tucking cellulose sponges under the blades of the eyelid speculum. The sponges transfer some of the eyelid speculum's weight onto the bulbar surface posterior to the iris, thereby indenting the sclera and causing the iris diaphragm to bulge further forward. This hands-free technique can transform a potentially challenging DMEK case into a more straightforward one by facilitating both a shallow anterior chamber and a bimanual unscrolling technique. However, it only works in bicameral eyes with a vitreous body (e.g., an eye with penetrating keratoplasty, vitreous syneresis, and axial myopia) and will not work in unicameral eyes after vitrectomy (e.g., an eye with an Anterior Chamber Intraocular Lens (ACIOL)).

Tape, fix, and inject: a novel one-person technique of intravitreal injection for the treatment of retinopathy of prematurity under topical anesthesia

Aim The purpose of this study was to describe and evaluate a novel one-person intravitreal injection (IVI) technique for the treatment of retinopathy of prematurity (ROP) under topical anesthesia. Patients and methods This is a retrospective study that was conducted on 44 babies who had IVI for the treatment of severe ROP under topical anesthesia. The swaddled baby’s head and body were fixed to the operating table with strips of adhesive tape, obviating the need for an assistant to hold the baby still. The calibers were used both to fix the globe and to determine the site of the injection by measuring the distance of 1.5 mm from the limbus. Results The mean gestational age of the patients was 29.6±1.5 weeks, with a mean birth weight of 1085.2±239.4 g. The mean procedure duration (between the insertion of the lid speculum at the beginning of the procedure and its removal at the end) for the right eye (64.9±15.6 s) was less than for the left eye (66.4±15.1 s), but the difference was not statistically significant (P=0.29). Inadvertent head movements occurred in 2 (4.5%) cases, with a large postmenstrual age of 37 and 38 weeks at treatment. None of the cases had inadvertent eye movements. Conclusion The technique seems safe and effective, especially in patients with a smaller postmenstrual age at the time of the injection. Additional care should be taken during taping of the head and the body in larger babies. Alternatively, giving sedation or general anesthesia may be a safer option.

Compared Methods for Reducing Stress in ROP Exams; Stake-Holding Examiner Perspective.

To better understand the sensory impact of retinal exam components typically experienced by infants undergoing various retinopathy of prematurity staging examinations, adults concerned for infant welfare and exam quality underwent similar exams to compare their perceived stress. Adults directly involved with ROP exams and infant stress reduction had cardiac monitoring and concomitant ordinal self symptom-score (1-10 Likert) during 15 components of the exam including lid speculum, various scleral depressors, indirect ophthalmoscopy, goniolens and direct ophthalmoscopy and retinal photography (Phoenix ICON) with or without topical anesthesia. Nine adults provided impressions and cardiac rhythm gathered supine over 15 minutes. Pain score for topical anesthetic 2 was less than for tropicamide 4. Lid specula numb scored a median 2 level (from 1 to 10) pain but without anesthetic scored 6. The goniolens numb scored 3. Scleral depression numb scored 3-4 but increased to 7 without topical anesthesia. Direct ophthalmoscope scored 3 through the goniolens and the retinal camera scored 4 pain. Brightness with low 350 Lux indirect scored 6-8 numb and 9 brightness without anesthetic. Full bright indirect, direct ophthalmoscope and the retinal camera all had Lux of 3000-4000 and were scored brightness 9, 7 and 10, respectively. Adults had minimal oculocardiac reflex during on-globe retinal examination methods (range 98% to 102%). Topical anesthesia provided a moderate reduction in pain during on-globe lid-speculum, scleral depressed indirect examination. There was a synergistic augmented sensory response between pain and brightness. Adults did not show the bradycardia typically elicited by retinal examinations in premature infants.

Endophthalmitis prophylaxis in cataract surgery and intravitreal injection in the US

AbstractEndophthalmitis is not a “never event” following cataract surgery or intravitreal injection, therefore the occurrence of endophthalmitis does not necessarily imply a break in technique or that the surgeon somehow “did something wrong”. Endophthalmitis cannot be prevented, but its rate can be reduced using evidence‐based measures. Endophthalmitis prophylaxis techniques include more than the use of antibiotics; specifically, prep/drape, speculum use, wound construction, etc.In the US, intracameral antibiotics are not universally used. The decision to use routine intracameral antibiotics appears to depend on many “non‐medical” factors, including internal health system policies, local standards of care, and other concerns. In the US, there is no packaged antibiotic that is specifically approved for intracameral use so all such agents are used “off‐label”; this factor appears to be suppressing the use of intracameral antibiotics at least in some locations.In the US, intravitreal injections are almost always performed in the clinic rather than in an operating room or similar setting. (In fact, it can be difficult to get reimbursed for anti‐VEGF drugs injected in an operating room.) Many practices use a standard examination room rather than a minor procedure room or a room dedicated to performing injections. Eyelid speculums are very widely used, although there is a growing acceptance of the use of bimanual retraction from a skilled assistant, rather than an eyelid speculum. In many practices, topical antibiotics are not used.It is the author's opinion (although there is little or no evidence from randomized clinical trials to support this opinion) that post‐surgical endophthalmitis differs from post‐injection endophthalmitis in how the microorganisms gain access to the intraocular space. Following cataract surgery, it seems most likely that microorganisms enter the eye through the incision in the postoperative period; this would explain the relatively later onset of infection, as well as the apparent benefits of postoperative topical antibiotics, proper wound construction, and suturing the incision when necessary. Following intravitreal injection, it seems most likely that microorganisms enter the eye at the moment of the injection; this would explain the relatively sooner onset of infection, as well as the apparent lack of benefit of postoperative topical antibiotics.

A STUDY ON RETINOPATHY OF PREMATURITY BY REVIEW OF RISK FACTORS THROUGH SCREENING IN TERTIARY EYE CARE HOSPITAL

Objectives: Retinopathy of prematurity (ROP) is a vasoproliferative disease that affects premature infants.The purpose of the study is to identify various maternal and fetal risk factors for ROP and to categorize the premature babies according to severity of disease and associated risk factors. Methods: This is a cross sectional study conducted on 100 infants from May 2021 to August 2021. Examination was done by a single ophthalmologist specialized to screen the babies. It was done 4 weeks after the birth and Detailed history included the birthweight, gestational age, the postnatal problems, obstetric history were obtained. Pupillary dilatation was done with a mixture of 2.5% phenylephrine and 1% tropicamide.0.5% proparacaine is used for topical anesthesia. An infantile lid speculum was used to separate the lids. Fundus was examined with binocular indirect ophthalmoscope and +20D condensing lens. Results: Prematurity and low birth weight are the most common and important risk factors. Most of the babies had symmetrical disease (88%) and zone 3 is most commonly involved (67%).Apart from prematurity and low birthweight, respiratory distress syndrome with oxygen supplementation was common association (56%).Various maternal risk factors were found to be common associations like pre eclampsia (33%) and gestational diabetes (22%). Conclusion: ROP is associated with several maternal and fetal risk factors. Early detection by screening of the premature babies can prevent blinding complication. Inadvertent and generous oxygen administration must be stopped due to its high association with ROP. All the premature babies must be screened 4 weeks after gestation for the earliest detection of the disease with an ophthalmologist specialized in that field with regular followups and prompt intervention as soon as the disease is identified.

Comparative endoscopic techniques of medial rectus muscle retraction for approaching intraconal tumors: Our experience with five cases

ObjectiveTo examine the role of transnasal endoscopic approaches in the management of intraconal tumors and demonstrate the use of an eyelid speculum in comparison with different techniques of medial rectus muscle (MRM) retraction.MethodsRetrospective data of five patients with intraconal tumors operated on and followed up by the senior authors between December 2019 and April 2022 was collected. Presenting symptoms, technical details, imaging and histology findings, outcomes, and complications were evaluated.ResultsFour primary and one recurrent tumor were identified. The mean patient age was 50 (range, 29–64) years. One tumor was located lateral to the optic nerve, one central and three medial. A complete surgical resection was obtained in four primary cases and a partial resection was achieved in the recurrent case. The MRM was retracted using three different techniques: (1) an infant eyelid speculum creating an operative window between the medial and inferior rectus muscle, (2) external MRM disinsertion transconjunctivally, (3) a four-handed technique performed transseptally by two surgeons. Transient postoperative ophthalmoplegia was recorded in four cases and transient ptosis in one. Three patients completely recovered in 2–3 months while one undergoing MRM disinsertion ended up in restricted strabismus at 15-month follow-up. No other long-term complications have been noted in all five patients with a mean follow-up of 22 (range, 14–32) months. No patients with primary tumors have required additional surgery for tumor recurrence.ConclusionThe indication of endoscopic intraconal surgery may expand to lesions lateral to the optic nerve when the nerve is not in its natural position. The well-known advantages of the endoscopic techniques, namely the lack of external scars, better visualization, less bleeding, and fewer complications, were confirmed. An eye speculum provides a better surgical corridor and eases the pressure exerted on the MRM, which has a promising application prospect.

Can lubrication of the eyelid speculum reduce overall pain perception associated with cataract surgery by phacoemulsification performed under topical anesthesia?

Purpose:This study aimed to evaluate the effect of using the lubricated eyelid speculum on the overall pain perception by the subject patients who underwent cataract surgery by phacoemulsification technique under topical anesthesia.Methods:A prospective interventional randomized comparative study was conducted at the tertiary eye care center, wherein adult patients scheduled for bilateral cataract surgery with phacoemulsification techniques under topical anesthesia were randomized to undergo surgery with two different modes of eyelid speculum insertion, either with or without lubrication of the eyelid speculum. Fifty percent of the patients underwent surgery with eyelid speculum without lubrication, and 50% with lubrication of the eyelid speculum. The primary outcome was to compare the level of overall pain perception among the subject patients of the two groups by using the Visual Analogue Scale (VAS) in the immediate postoperative period.Results:The study included 130 patients who underwent bilateral cataract surgery (n = 260 eyes) under topical anesthesia, wherein n = 130 eyes underwent surgery using lubricated eyelid speculum and n = 130 eyes underwent surgery with dry eyelid speculum. Pain perception score assessed on the VAS (0–10 cm) ranged from 0.5 to 6, with a mean ± standard deviation of 2.06 ± 1.12. A significant correlation was found with two different methods of eyelid speculum insertion with reduced overall pain perception in patients with the use of lubricated eyelid speculum compared to the dry eyelid speculum (P = 0.0001).Conclusion:The overall pain perception associated with cataract surgery performed by phacoemulsification technique under topical anesthesia can be further minimized by lubricating the eyelid speculum prior to insertion for exposing the globe.

Contralateral Forced Eyelid Closure Increases Intraocular Pressure.

The purpose of the study was to describe the influence of contralateral forced eyelid closure on intraocular pressure (IOP). Twenty-one healthy volunteers with no ophthalmic history had their IOP measured in the supine position to simulate the intraoperative environment. Intraocular pressure was measured with a handheld tonometer over three scenarios: (1) both eyes in a relaxed state, (2) eyelid speculum in the right eye with both eyes open and relaxed, (3) eyelid speculum in the right eye with the fellow eye squeezing tightly. Intraocular pressure significantly increased with forced contralateral eyelid squeezing compared with the relaxed state by a mean of 7.71±5.08 mm Hg (95% Confidence Interval of 5.40-7.37), P<0.001. Contralateral eyelid squeezing can significantly increase intraoperative IOP measurements.

Avoiding use of lid speculum and indentation reduced infantile stress during retinopathy of prematurity examinations.

To study the safety and efficacy of indirect ophthalmoscopy with (Sp) or without (speculum free, SpF) the use of lid speculum and scleral indentation for retinopathy of prematurity (ROP) screening. In this crossover randomized controlled trial, preterm infants received either the Sp on their first and the SpF technique on their second examination a week later or vice versa. Video recordings of the infants' reactions were assessed by two observers, using Premature Infant Pain Profile-Revised score and the crying score of the Bernese Pain Scale for Neonates. Fundoscopy adequacy, its duration and adverse events within the first 24 hr postscreening were also recorded. Thirty-seven infants with median (interquartile range) gestational age of 28.7 (28.0, 30.2) weeks and mean (standard deviation, SD) birth weight 1225 (377) grams were enrolled. The mydriasis-induced stress was similar between the Sp and SpF exam (mean difference [MD]: 0.78, 95% confidence interval [CI]: -0.83, 2.38; p = 0.33). The stress induced by fundoscopy (MD: 4.98, 95% CI: 3.58, 6.37; p < 0.001) and examination overall (MD: 2.32, 95% CI: 0.96, 3.67; p = 0.001) were higher in the Sp than in the SpF exam, and so was the crying score during fundoscopy (MD: 1.31, 95% CI: 1.06, 1.56; p < 0.001). Adverse events in the two groups were similar (p = 0.13). Fundoscopy was adequate in identifying the absence of treatment-requiring ROP in all cases, and lasted longer in the Sp than in the SpF exam (p < 0.001). Our study suggests that the use of speculum and indentation should be reserved for the few cases where fundus visualization is insufficient for excluding the presence of severe ROP.

Survey of Intravitreal Injection Techniques and Treatment Protocols Among Members of the Turkish Ophthalmological Association.

Objectives:To describe the intravitreal injection (IVI) techniques, practices, and treatment protocols of ophthalmologists in Turkey from May 20, 2020 to June 4, 2020.Materials and Methods:All members of the Turkish Ophthalmological Association were contacted by e-mail to complete an anonymous, 47-question internet-based survey.Results:Thirteen percent of the participants prescribed prophylactic antibiotics pre-injection, 63.8% (406/636) used antibiotic drops immediately after injection, and 91.8% prescribed topical antibiotics. The majority of IVI procedures were performed in an operating room (65.3%) or clean room (33.6%). Most surgeons used sterile gloves, masks, sterile drape, sterile fenestrated cover, and sterile eyelid speculum. Multispecialists (M) preferred to wear sterile gloves more than retina specialists (RS) (99.0% vs. 95.3%; p=0.004). Also, M prescribed antibiotics more than RS (93.7% vs. 88.8%; p=0.029). RS dilated the pupil more frequently than M (48.3% vs. 39.0%) (p=0.020). RS were more familiar to use different quadrants (right p=0.012; left p=0.001). Most surgeons (82.8%) did not perform injections in both eyes on the same day.Conclusion:Ophthalmologists in Turkey employ a wide range of techniques in care before, during, and after IVI. In addition, IVI techniques and treatment protocols differed between RS and M. Further research is needed to elucidate best practice patterns.

ASSESSMENT OF INTRAOCULAR PRESSURE FOLLOWING THE INTRAVITREAL INJECTION OF ANTI-VEGF

Objective: The objective of the study is to assess the frequency of raised IOP after intravitreal injection of Anti VEGF by using an applanation tonometer.&#x0D; Methods: Each patients who fulfil the presence criteria were nominated by the researcher through ‘the outpatient department (OPD) of ophthalmology, Jinnah Post Graduate Medical Center. Performa was filled. Aim and process of study was explained to all patients. Conversant consent was reserved. Model ocular inspection, including IOP was done.&#x0D; By using either a 30-or 32-gauge needle, 1.25 ml bevacizumab (Avastin) were administered by the researcher under the direct supervision of consultant. Patients were consistently sterilely prepped, that was comprised incerted of topical antibiotic and anesthetic drops, supplement of a lid speculum. Later pointing the injection place on the sclera with a caliper calculating 3.0 to 3.5 mm after limbus, conjunctiva was expatriate somewhat through a sterile cotton-tipped applicator immediately earlier ingoing the eye by a needle. Later injection, place was occluded provisionally it was amended through a sterile cotton-tipped applicator while the needle remained inhibited from the eye. Since the needle was inhibited, a drop of anesthetic was employed on the cornea and IOP was measured. Then next IOP interpretation was measured later 1day of intravitreal Avastin.&#x0D; All pressures were measured using the applantation tonometry. IOPs were measured earlier intravitreal Avastin "baseline IOP" and instantly following injection "T0" and 1day next injection.&#x0D; Results: 235 Patients exactly nominated for the research study. Intravitreal Injection, Bevacizumab was applied in 235 Eyes of overstated 235 patients. Elsewhere of the 235 patients, 133 males and 102 females, Their ages ranged from 30-70 y (mean 52.02 y. The most shared sign intravitreal with bevacizumab, diabetic retinopathy observed in 114 (48.5%) patients, indicated by exudative ARMD in 70 (29.7%) patients, BRVO in 12 (5%) patients, Myopic CNV23(9.7) with CRVO observed in 11 (4.6%) patients, Eale’s sickness in 2(0.85%) patients even as Idiopathic CNV was observed in only 3 (1%) patient. Of the 235 patients, 118 (50.2%) patients with right eye suffered, 117(49.7%) patients with left eye suffered. After 24 h of intravitreal Bevacizumab Raised IOP was observed in only 3 (1.28) patient and 232(98.2) patient IOP was in the normal range. According to our study, the result of stratification with respect to age, side of the eye and gender is not significant as p-value for age (0.838), gender (0.723) and side of the eye (0.556), respectively.&#x0D; Conclusion: In our study, frequency of raised IOP after anti VEGF were found 3(1.28) patient out of 232 (98.2). Anti-VEGF treatment is the foundation for the management of numerous retinal illnesses. Notwithstanding its capable effectiveness in uncertain the sickness and refining, vision for the patients, intravitreal injection of anti-VEGF products may be related with overwhelming problems. To diminish the risk cautious care to the injection method and suitable post-injection observing are essential.

Use of Simultaneous Bilateral Cataract Surgery (SBCS) to Optimize Parameters Affecting the Subjective Perception of the Procedure.

Introduction Simultaneous Bilateral Cataract Surgery (SBCS) is still a relatively controversial procedure. The main objection is the risk of bilateral endophthalmitis or bilateral refractive error. However, SBCS has also some advantages (faster visual rehabilitation, lower risk of nosocomial infection, and lower cost). Performing surgery on both eyes in one session has one additional advantage which has not yet been described in the literature (according to the information available to authors). It allows surgeons to distinguish the effect of minor differences in the surgical protocol on the subjective perception of the procedure more accurately, which is a more suitable method than comparing two independent groups of patients. Purpose To compare the effect of minor changes in the surgical protocol during SBCS on intraindividual subjective perception of surgery (pain, pressure, glare, and perception of the duration of the surgery). Methods During the surgery of the right and left eyes of one patient, we randomly changed one surgical parameter (use of intracameral anesthesia, light intensity of the operating microscope, type of eyelid speculum, creation of the posterior circular capsulorhexis, and communication with the patient during surgery). Patients immediately after both surgeries subjectively evaluated the perception of pain (on the scale 0–10), pressure, and glare (on the scale 0–5) and estimated the duration of the surgery, separately for each eye. Each change was evaluated in a group of 50 patients. Results In the control group with no parameters changed, we noted no difference in subjective perception of the first and second surgery. In subgroups, where we changed the protocol, we detected only minor differences in subjective perception of pain, pressure, glare, and duration of the surgery. Only one statistically significant difference in subjective pain perception was in the subgroup where we used eye intracameral anesthesia (0.34 eyes with intracameral anesthesia, 0.44 eyes with only topical anesthesia). We did not note any statistically significant differences in the perception of the time of surgery. Conclusion SBCS can be used to optimize the parameters of cataract surgery. In our study, we noted a positive effect of intracameral anesthesia on subjective perception of surgery.

The Effect of an Eyelid Speculum on Intraocular Pressure Measurement in Newborns

To evaluate the effect of an eyelid speculum on intraocular pressure (IOP) measurements in newborns. A total of 54 eyes of 27 newborns were involved in the study. The IOP measurements were obtained under topical anesthesia with the Icare PRO (Icare Finland Oy) before and after inserting the infant type of Barraquer wire eyelid speculum. A paired t test was used to compare the measurements. The mean IOP without the eyelid speculum was 9.04 ± 2.13 mm Hg (range: 6.00 to 13.20 mm Hg) in the right eye and 9.26 ± 1.59 mm Hg (range: 7.10 to 13.00 mm Hg) in the left eye. With the eyelid speculum in place, the mean IOP was 11.91 ± 2.23 mm Hg (range: 9.10 to 15.80 mm Hg) in the right eye and 11.70 ± 1.89 mm Hg (range: 8.40 to 14.50 mm Hg) in the left eye (P ≤ .001). The mean differences in IOP between measurements with and without the eyelid speculum were 2.87 ± 2.23 mm Hg (range: 0.20 to 5.20 mm Hg) in the right eye and 2.44 ± 1.48 mm Hg (range: 0.00 to 4.90 mm Hg) in the left eye. The mean difference in IOP between measurements with and without the eyelid speculum for all eyes was 2.65 ± 1.89 mm Hg (range: 0.00 to 5.20 mm Hg). There was no correlation between the difference in IOP after the placement of the eyelid speculum and postconceptual age or weight at the examination (r = 0.11, P = .41, r = 0.32, P = .14, respectively). The Barraquer wire eyelid speculum caused an increase in IOP in newborns under topical anesthesia without a significant difference between postconceptual age and sex in both eyes. The average IOP rise after the eyelid speculum was inserted was 2.65 mm Hg. This effect should be considered when interpreting IOP measurements in newborns. [J Pediatr Ophthalmol Strabismus. 2022;59(1):13-16.].

An effective method to reduce the risk of endophthalmitis after intravitreal injection (IVI): Application of 0.25% povidone-iodine

Background/Aim: The most important complication after intravitreal injection (IVI) is endophthalmitis, which can result in severe vision loss. This study aims to investigate the effect of 0.25% povidone-iodine (PI) application before IVI on the incidence of endophthalmitis in patients who received intravitreal anti-vascular endothelial growth factor (anti-VEGF) injection. Methods: A total of 15345 intravitreal anti-VEGF injections and nine endophthalmitis cases after IVI performed at the outpatient injection room of a single university hospital between January 2017 and January 2020 were included in this retrospective cohort study. Before July 2018, after applying 10% PI around the eyes and 5% PI on the eyes, an eyelid speculum was inserted, and the injection was performed. After this date, in addition to these steps, after placing a speculum and determining the injection site with a caliper, 3-4 drops of 0.25% PI were applied just before injection. Topical antibiotics were not used before or after the injection. Results: Nine cases of endophthalmitis were detected in 3 years. The most common symptoms were vision loss (9/9) and pain in the eye (7/9). All cases had conjunctival hyperemia, cells-hypopyon in the anterior chamber, and cells in the vitreous. The time between injection and re-visiting the clinic due to endophthalmitis symptoms ranged between 2-6 days, and visual acuity varied between hand motion and 0.2. While the number of endophthalmitis cases before July 2018 was 8 (8/8330) in 1.5 years, after the addition of 0.25% PI application to the protocol, only 1 case of endophthalmitis (1/7015) was seen in the last 1.5 years. The rate of endophthalmitis had decreased significantly (P=0.037). Conclusion: Since July 2018, the addition of 0.25% PI to the standard IVI protocol just before injection has significantly reduced endophthalmitis rates. With this method, endophthalmitis rates may be decreased despite the increasing number of IVIs.

Conjunctival flora growth in intravitreal injection settings

Purpose: To study the conjunctival flora in patients undergoing repeated intravitreal injections. Methods: Prospective observational study. Patients undergoing intravitreal injections were randomized into two groups: 1) preparation with povidone-iodine 5% alone, or 2) preparation with povidone-iodine 5% with Maxitrol eye drops. Our standard injection technique included topical anesthesia, a solid bladed lid speculum, and commercially prepared topical povidone-iodine 5% applied for 2 minutes. Cultures were obtained from the conjunctival cul-de-sac on routine office visits prior to any preparation and immediately after injection. Results: A total of 110 Eyes of 86 patients were enrolled in the study. Fifty-five were irrigated with povidone-iodine 5% only, and 55 were irrigated with a combination of povidone-iodine 5% and Maxitrol drops. Compared with the povidone-iodine only group, the Maxitrol and povidone-iodine group did not lead to a statistically significant reduction in patients with positive cultures after injection, (p=0.19). The most common organism cultured was coagulase-negative staphylococcus; however, Enterococcus, Pseudomonas, Staphylococcus aureus, and Bacillus were also cultured. Thirtyseven percent of organisms were resistant to 4th generation quinolones. No cases of endophthalmitis were recognized. Of the positive cultures, 33% were resistant to over 4 antibiotics tested. Conclusion: In this routine clinical setting, conjunctival antisepsis was difficult to achieve despite the use of topical povidone-iodine with or without Maxitrol. No infectious complications were recognized.

Oculocardiac Reflex During ROP Exams.

PurposeReducing physiologic stress including bradycardia during staging eye exams for retinopathy of prematurity (ROP) is desirable. We observed heart rate change during routine retinopathy of prematurity eye examinations and compared the response with our ongoing study of oculocardiac reflex (OCR) elicited by uniform EOM tension during strabismus surgery.Patients and MethodsElectrocardiograph was prospectively monitored during ROP exams featuring indirect ophthalmoscopy with Alfonso lid speculum and see-through scleral depressor without topical anesthesia. Clinical data were retrieved from ROP-Check software. OCR was defined as maximally changed heart rate (HR) as a percent of baseline. Strabismus surgery patients under general anesthesia served as controls.ResultsFrom 10/2017 to 9/2020, 281 infants had ROP exams, and the median OCR was 55.9% of baseline HR (IQR 41.4% to 72.6%), the kurtosis 0.93 and skewness 1.01 representing a drop from HR 169 ± 16 bpm to 102 ± 39 bpm. In comparison, 1493 adult and pediatric strabismus surgery patients had less OCR median bradycardia 87.8% (IQR 72–98%), kurtosis 1.60 and skewness −1.18. ROP %OCR correlated with birth gestational age (%OCR = 2.5 (GA) – 11, r(279)=0.33, p<0.01) and with birthweight (%OCR = 0.02 (BW) + 38, r(279) =0.35, p<0.01). The duration of bradycardia induced by ROP exam averaged 92 ± 34 seconds (range 34–240 seconds).ConclusionBradycardia is common during eye exams in the smallest premature infants with greater degree, more rapid onset and longer duration than OCR during strabismus surgery.

&lt;p&gt;Survey of Intravitreal Injection Techniques Among Retina Specialists in Mexico&lt;/p&gt;

PurposeTo report technique preferences for intravitreal injections among retina specialists in Mexico.MethodsCross-sectional survey. Ophthalmologists with a two-year retina training, active members of the Mexican Retina Association, were contacted through email to answer a survey consisting of 37 items regarding their IVI application technique.ResultsA total of 133 retina specialists participated, with a response rate of 78%. Forty-five percent applied the intravitreal injections in an operating room designated for the procedure. Sixty-three percent reported never injecting both eyes on the same day. Ninety-six percent wore a face mask during the procedure and 91% wore gloves. Eighty-two percent used a lid speculum. Tetracaine drops were the anesthetic method employed by 97% of participants. All participants utilized povidone-iodine for antisepsis. Eighty percent measured the puncture site with a caliper. Superotemporal quadrant was the one chosen to place the injection by 63% of participants. Fifty-nine percent indicated post-injection antibiotic drops for several days. Post-injection counting fingers visual acuity was verified by 53% of the participants. Fifty-six percent of the participants placed an eye-patch after the procedure.ConclusionThere are different practices regarding the application of intravitreal injections among retina specialists in Mexico. Performing this type of survey periodically could show changes in preferences, as new evidence is incorporated into clinical practice.