We are presenting the initial results of inverted internal limiting membrane (ILM) flap technique for large macular hole. Five eyes of five patients with large diameter macular hole (>700 μm) were selected. All patients underwent inverted ILM flap technique for macular hole. Anatomical closure and functional success were achieved in all patients. There was no loss of best-corrected visual acuity in any of the patients. Inverted ILM flap technique in macular hole surgery seems to have a better hole closure rates, especially in large diameter macular holes. Larger case series is required to assess the efficacy and safety of this technique.

A 60-year-old female came to our hospital with defective vision due to persistent diabetic macular edema and was treated with intravitreal ozurdex implant in the right eye. Three days later, the patient presented with diminution of vision, ocular pain, congestion, and hypopyon with no fundus view. B-scan ultrasonography showed vitritis, and diagnosis of endophthalmitis was made. Subsequently, 25-gauge pars plana vitrectomy was performed along with intravitreal vancomycin and amikacin and removal of implant. On culture, there was growth of coagulase-negative staphylococcus which was resistant to ofloxacin antibiotic. A week following treatment, there was significant improvement in the patient's sign and symptoms with improvement in vision. Our case demonstrated that acute endophthalmitis can occur following dexamethasone intravitreal implant.

Purpose:This study aims to evaluate the incidence and risk factors for vitreous rebleed (VRB) following 25-gauge sutureless vitrectomy for vitreous hemorrhage (VH) in diabetic retinopathy.Methods:A retrospective review of 190 diabetic patients having undergone vitrectomy for VH at a tertiary eye care center was analyzed. Demographic data of patients along with risk factors such as blood sugar levels (BSL), blood pressure (BP), anticoagulant use, and pan-retinal photocoagulation status (PRP) were tabulated. Depending on the commencement of VRB, patients were divided into immediate rebleed-within 2 weeks and delayed rebleed-beyond 2–4 weeks.Results:Forty-one patients had VRB, out of which 18 patients had immediate VRB and 23 patients had delayed VRB. The average duration between vitrectomy and VRB was 3.28 months. Twenty-eight patients were male and 13 were females. Average age at presentation was 53.8 years. Thirty-four patients (82.9%) were found to have high BSL and 28 patients (68.3%) had high BP and they developed rebleed (P < 0.01) after an initial hemorrhage-free period (average = 5.15 months). Fifteen patients (36.6%) underwent first time PRP intraoperatively, and they had immediate rebleed (P < 0.01) without any hemorrhage-free period (average = 0.9 months). Eight patients (19.5%) were on perioperative anticoagulants; however, their statistical significance did not persist in the multivariable model. There were neither age nor gender predilection toward rebleed (P > 0.05).Conclusion:The incidence rate of VRB was found to be 21.6%. Age and gender did not contribute to rebleed. Intraoperative PRP was a risk factor for immediate rebleed. Poor glycemic and BP control was a risk factor for delayed rebleed.

Dear Editor, Intumescent cataracts are challenging cases even for experienced phaco surgeons (Bhattacharjee et al, 1999;Ermiss et al, 2003). In these eyes, during capsulorhexis, there are very high chances of anterior capsule tears with peripheral extension due to the high pressure of the hydrated cataractous lens. Following this, the continuation of phacoemulsification is extremely difficult and is associated with complications such as posterior capsule tear, vitreous loss and posterior migration of the lens matter. Different methods have been tried to prevent this uncontrolled extension of capsulorhexis. These include direct aspiration of lens fluid using a 26 G needle mounted onto a syringe. Alternatively, using high-cohesive viscoelastics is also helpful in maintaining the pressure on the anterior chamber and creating a complete capsulorhexis. Use of high-frequency diathermy and preoperative Nd:YAG laser anterior capsulotomy has also been reported as an optional technique (Pham et al, 1998;Coelho et al, 2009). Phaco capsulotomy is a technique where the anterior capsule is punctured using a phacoemulsification probe and then the probe is used to debulk the lens matter by aspirating the intralenticular fluid. Once intralenticular pressure is relieved, the capsule is grasped with a capsulorhexis forceps and the rhexis is completed. The initial surgical steps of cataract removal are the creation of the paracentesis and the main wound, capsular staining using trypan blue and maintenance of the anterior chamber using viscoelastics. Using the main wound, the phacoemulsification probe is introduced into the anterior chamber and the tip of the bevel of the phaco hand piece is directed upwards, centered over the center of the anterior capsule. The settings used during phaco capsulotomy are a power 40 %, a vacuum of 200 mm Hg and an aspiration flow rate of 28 cc/min. The foot pedal is pressed to position three and the anterior capsule is punctured with the phaco tip (Figure). This creates the initial anterior capsule puncture with the release of intra-lenticular fluid which is aspirated. The phaco hand piece is then removed from the eye and the viscoelastics are injected into the anterior chamber to pressurize the anterior surface of the capsule. The anterior capsular tear is visualized and grasped with a capsulorhexis forceps. The continuous curvilinear capsulorhexis is then fashioned with the forceps keeping the force of the pull of the rhexis margin to the centre. Following this, the nucleus is removed by phacoemulsification (Song et al, 1998). In conclusion, phacocapsulotomy is a safe and effective technique which prevents sudden extension of capsulorhexis by depressurizing the intralenticular pressure and debulking the lens. This technique prevents the spontaneous peripheral migration of the capsulorhexis edge, thus reducing the concurrent complications. A large series of cases will be required to prove the efficacy and safety of this novel technique.

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