Treatment before macular grid in patients of diabetic macular edema.

AIM: The aim of this study is to compare the efficacy of intravitreal bevacizumab and posterior subtenons triamcinolone acetate in the management of diffuse diabetic macular edema (DME) and to evaluate their efficacy as an adjunct to modified grid laser in management of DME. DESIGN: This was a prospective, randomized clinical trial of 30 patients. MATERIALS AND METHODS: A total of 30 patients attending the medical ophthalmology clinic at a tertiary care hospital were included in the study. These 30 patients were divided into two groups. Group I (15 eyes) received intravitreal bevacizumab followed by modified grid photocoagulation 2 weeks after injection. Group II (15 eyes) received posterior subtenons triamcinolone followed by modified grid photocoagulation 2 weeks after injection. Each patient in our study was followed up at 1 week, 2 weeks, 1 month, 2 months, 3 months, and 6 months after the initial injection to record the central macular thickness (CMT) and best-corrected visual acuity (BCVA). RESULTS: Both the combination therapies have efficacy to reduce the CMT (P = 0.001). The percentage fall in CMT was greater in bevacizumab + laser group, and there was a significant difference in the CMT values at the end of the study in the bevacizumab group (P = 0.013). The mean BCVA improved in both the groups and this difference was statistically significant compared to the baseline (P = 0.005). However, there was no statistically significant difference in BCVA between the two groups at the end of the study. CONCLUSION: Both intravitreal bevacizumab and posterior subtenons triamcinolone given as an adjuvant therapy along with modified grid laser are equally efficacious in the reduction of the CMT; however, the percentage fall in the CMT was greater in bevacizumab + laser group, and there was a significant difference in the fall in CMT at all the visits as compared to a plateau in the fall of CMT in posterior subtenons triamcinolone group.

Bilateral disc drusen in a diabetic patient simulating diabetic papillopathy as a cause of disc edema.

Bilateral optic disc edema in a diabetic patient may be caused by diabetic papillopathy. We herein report on a patient with bilateral optic disc drusen simulating diabetic papillopathy. A 55-year-old patient with type 2 diabetes presented with decreased vision of 1-month. Diabetic papillopathy was initially considered as there was disc edema in both eyes with focal hemorrhages at the disc margin and mild visual loss. Ultrasound of the optic nerve head revealed optic disc drusen in both eyes and this was also confirmed by the control photograph. Optic nerve head drusen should be considered in the differential diagnosis of a diabetic patient presenting with disc edema.

Posterior Segment Drug Delivery Devices: Current and Novel Therapies in Development.

Ocular drug delivery by conventional routes of administration does not maintain therapeutic drug concentrations in the target tissues for a long duration because of various anatomical and physiological barriers. Treatment of diseases of the posterior segment of the eye requires novel drug delivery systems that can overcome these barriers for efficacious delivery, provide controlled release for the treatment of chronic diseases, and increase patient's and doctor's convenience to reduce the dosing frequency and associated side effects. Thereby, an increasing number of sustained-release drug delivery devices using different mechanisms have been developed. This article discusses various current and future sustained-release drug delivery systems for the posterior segment disorders.

Patterns of uveitis at the Apex Institute for Eye Care in India: Results from a prospectively enrolled patient data base (2011-2013).

The purpose of the study was to identify the clinical and etiological profile of uveitis at the apex institute for eye care in India. This is a prospective, prevalence study. 980 consecutive patients with uveitis referred to uvea clinic, Dr. RP Centre for Ophthalmic Sciences (Ophthalmology division, All India Institute of Medical Sciences). Demographic data of each patient were noted and a thorough ocular examination including slit lamp examination and dilated fundus evaluation was carried out. OCT and fluorescein angiography were undertaken whenever indicated. Uveitis was classified based on the anatomic location of inflammation (IUSG classification). Relevant serological and radiological investigations were obtained based on systemic symptomatology, and if the uveitis was recurrent (even in the absence of systemic symptoms). The presence of a systemic disease was confirmed by obtaining an internist consultation. The main outcome measures include pattern of uveitis according to anatomical classification and the etiology. Out of 980 patients with uveitis, 413 (42.14 %) patients had anterior uveitis, 131 (13.36 %) had intermediate uveitis, 165 (16.83 %) had posterior uveitis, 91 (9.2 %) had panuveitis, 47 (4.7 %) had retinal vasculitis, 22 (2.24 %) had scleritis, 17 (1.7 %) had masquerade syndromes, 8 (0.8 %) had keratouveitis, 22 (2.24 %) had sclerokeratouveitis, 19 (1.9 %) had endophthalmitis and 45 (4.5 %) had other causes of inflammation including trauma and intraocular surgery. Out of all uveitic patients definite etiological correlation could be made out in 225 (23 %) patients; thus 77 % were categorised as idiopathic. Only 9 % of all patients were found to have uveitis with an infectious etiology. Amongst infectious causes of uveitis tuberculosis was the leading cause, accounting for sixty percent of all infectious uveitis (approximately 5 % of overall uveitis). Non-infectious uveitis etiology accounted for more than 90 % of all cases with ankylosing spondylitis being the most common followed by sarcoidosis and juvenile rheumatoid arthritis. Amongst known uveitic syndromes serpiginous like choroidopathy was the most common and was followed by acute posterior placoid pigmented epitheliopathy and Fuch's heterochromic iridocyclitis. Infection, including tuberculosis, is an infrequent cause of uveitis in the study population. Multicentric, collaborative efforts are required to improve levels of clinical evidence and evolve consensus in establishing stringent guidelines for labelling uveitis as being of infectious etiology.

Therapeutic vitrectomy for vitreal recurrence of intraocular lymphoma resistant to intravitreal methotrexate post systemic chemotherapy.

A 49-year-old female with biopsy proven primary vitreoretinal lymphoma and primary central nervous system lymphoma (PCNSL) presented with asymmetric involvement of both eyes. Right eye had primarily retinal and optic nerve involvement with no light perception while the left eye had purely vitreal form of the disease with visual acuity of 6/18. She was treated with recommended DeAngelis protocol for PCNSL and achieved complete remission of CNS disease and in the right eye and responded only partially to the systemic chemotherapy in the left eye. She received multiple intravitreal methotrexate injections (400 µg/0.1 ml) for persisting disease in the left eye. However, she developed resistance to the same after repeated injections for which therapeutic vitrectomy was performed. She achieved final visual acuity of 6/12 in the right eye and 6/18 in the left eye and did not relapse until last follow-up of 2 years.

Detection of retinal lesions in diabetic retinopathy: comparative evaluation of 7-field digital color photography versus red-free photography.

Red-free light allows better detection of vascular lesions as this wavelength is absorbed by hemoglobin; however, the current gold standard for the detection and grading of diabetic retinopathy remains 7-field color fundus photography. The goal of this study was to compare the ability of 7-field fundus photography using red-free light to detect retinopathy lesions with corresponding images captured using standard 7-field color photography. Non-stereoscopic standard 7-field 30° digital color fundus photography and 7-field 30° digital red-free fundus photography were performed in 200 eyes of 103 patients with various grades of diabetic retinopathy ranging from mild to moderate non-proliferative diabetic retinopathy to proliferative diabetic retinopathy. The color images (n = 1,400) were studied with corresponding red-free images (n = 1,400) by one retina consultant (PV) and two senior residents training in retina. The various retinal lesions [microaneurysms, hemorrhages, hard exudates, soft exudates, intra-retinal microvascular anomalies (IRMA), neovascularization of the retina elsewhere (NVE), and neovascularization of the disc (NVD)] detected by all three observers in each of the photographs were noted followed by determination of agreement scores using κ values (range 0-1). Kappa coefficient was categorized as poor (≤0), slight (0.01-0.20), fair (0.2 -0.40), moderate (0.41-0.60), substantial (0.61-0.80), and almost perfect (0.81-1). The number of lesions detected by red-free images alone was higher for all observers and all abnormalities except hard exudates. Detection of IRMA was especially higher for all observers with red-free images. Between image pairs, there was substantial agreement for detection of hard exudates (average κ = 0.62, range 0.60-0.65) and moderate agreement for detection of hemorrhages (average κ = 0.52, range 0.45-0.58), soft exudates (average κ = 0.51, range 0.42-0.61), NVE (average κ = 0.47, range 0.39-0.53), and NVD (average κ = 0.51, range 0.45-0.54). Fair agreement was noted for detection of microaneurysms (average κ = 0.29, range 0.20-0.39) and IRMA (average κ = 0.23, range 0.23-0.24). Inter-observer agreement with color images was substantial for hemorrhages (average κ = 0.72), soft exudates (average κ = 0.65), and NVD (average κ = 0.65); moderate for microaneurysms (average κ = 0.42), NVE (average κ = 0.44), and hard exudates (average κ = 0.59) and fair for IRMA (average κ = 0.21). Inter-observer agreement with red-free images was substantial for hard exudates (average κ = 0.63) and moderate for detection of hemorrhages (average κ = 0.56), SE (average κ = 0.60), IRMA (average κ = 0.50), NVE (average κ = 0.44), and NVD (average κ = 0.45). Digital red-free photography has a higher level of detection ability for all retinal lesions of diabetic retinopathy. More advanced grades of retinopathy are likely to be detected earlier with red-free imaging because of its better ability to detect IRMA, NVE, and NVD. Red-free monochromatic imaging of the retina is a more effective and less costly alternative for detection of vision-threatening diabetic retinopathy.

Evaluation of the effect of scleral buckling on the anterior chamber angle using ASOCT.

PURPOSE: To evaluate the change in anterior chamber angle parameters after scleral buckling surgery using anterior segment optical coherence tomography (ASOCT). METHODS: Fifty-five phakic eyes of 55 subjects undergoing scleral buckling with the placement of an encircling band for primary rhegmatogenous retinal detachment were included in this study. Anterior chamber angle assessment was performed using ASOCT. The trabecular iris angle (TIA), the angle-opening distance, and the trabecular iris space area were the parameters obtained preoperatively and 48 hours, 1 week, and 1 month after the surgery using ASOCT. The intraocular pressure (IOP) was measured using Goldmann applanation tonometry. RESULTS: The mean age of the patients was 43.2±11.3 years; there were 38 male and 17 female patients. There was a significant decrease in all the angle parameters (TIA, angle opening distance, and trabecular iris space area) at 48 hours, 1 week, and 1 month after surgery (P<0.0001). TIA 180 degree decreased from 41.93±14.27 degrees preoperatively to 31.09±10.52 degrees (P<0.0001) and TIA 0 degree from 42.7±14.04 degrees to 32.92±12.17 degrees (P<0.0001) at 48 hours postoperatively. The mean IOP at 48 hours (17.04±3.26 mm Hg) was significantly higher than the preoperative level (12.68±1.96 mm Hg; P<0.001). No significant difference was noted between the mean preoperative IOP and the IOP readings at 1 week (P=0.402) and 1 month (P=0.23) postoperatively. CONCLUSIONS: ASOCT imaging reveals that scleral buckling surgery for retinal detachment induces significant narrowing of the anterior chamber angle.

Prevalence of systemic co-morbidities in patients with various grades of diabetic retinopathy.

BACKGROUND & OBJECTIVES: Though diabetes affects multiple organs, most studies highlight the occurence of only one complication in isolation. We conducted a hospital-based study to estimate the co-existence of significant systemic co-morbid conditions in patients with varying grades of diabetic retinopathy. METHODS: A total of 170 consecutive patients with diabetic retinopathy were prospectively recruited for the study between June 2009 to June 2010 at a tertiary care eye centre in north India. Retinopathy was graded by fundus biomicroscopy and fundus photography and classified into three categories (mild-moderate nonproliferative retinopathy, proliferative retinopathy requiring only laser and proliferative retinopathy requiring surgery). Nephropathy was classified by calculating the six variable estimated glomerular filtration rate (eGFR) for all patients. Nerve conduction studies and clinical assessment were used to determine presence of neuropathy. Co-existence of macrovascular disease and peripheral vascular disease was also ascertained. RESULTS: The percentages of patients with overt nephropathy in the three groups were 19.2, 38.0 and 41.2, respectively. Significant linear trends were observed for serum creatinine (P=0.004), albumin (P=0.017) and eGFR (P=0.030). A higher per cent had abnormal nerve conduction on electrophysiology than that diagnosed clinically (65.4 vs. 44.2, 76.0 vs. 40.0 and 64.8 vs. 48.6, respectively). The odds ratio (95% CI) for co-existence of nephropathy, neuropathy, CVA (cerebrovascular accidents) and PVD (peripheral vascular disease) was 2.9, 0.9, 4.8 and 3.5, respectively. Independent of retinopathy severity, patients with clinically significant macular oedema (CSME) had a higher percentage of nephropathy ( p0 < 0.005). INTERPRETATION & CONCLUSIONS: The co-existence of overt nephropathy, nerve conduction based neuropathy and macrovascular co-morbidity in patients with early grades of diabetic retinopathy was significant. Screening for overt nephropathy by eGFR should be considered in all patients with clinically significant macular oedema.

Endoilluminator-assisted scleral buckling: our results.

AIMS: The aim was to evaluate the long-term surgical outcomes of endoillumination assisted scleral buckling (EASB) in primary rhegmatogenous retinal detachment (RRD). METHODS: Twenty-five eyes of 25 patients with primary RRD and proliferative vitreoretinopathy ≤C2 where any preoperative break could not be localised, were included. All patients underwent 25 gauge endoilluminator assisted rhegma localisation. Successful break determination was followed by cryopexy and standard scleral buckling under surgical microscope. Anatomical and functional outcomes were evaluated at the end of 2 years. RESULTS: At least one intraoperative break could be localized in 23 of 25 (92%) eyes. Median age of these patients was 46 years (range: 17-72). Thirteen eyes (56.52%) were phakic, 8 (34.78%) were pseudophakic and 2 (8.6%) were aphakic. Anatomical success (attachment of retina) was achieved in 22 (95.63%) of 23 eyes with EASB. All eyes remained attached at the end of 2 years. Significant improvement in mean visual acuity (VA) was achieved at the end of follow-up (1.09 ± 0.46 log of the minimum angle of resolution [logMAR]) compared with preoperative VA (1.77 ± 0.28 logMAR) (P < 0.001). CONCLUSION: EASB can be considered an effective alternative to vitreoretinal surgery in simple retinal detachment cases with the added advantage of enhanced microscopic magnification and wide field illumination.

Evaluation of the effect of pan retinal photocoagulation on optic nerve head parameters using HRT3.

PURPOSE: To evaluate the optic disc topography after pan retinal photocoagulation (PRP) in diabetic retinopathy patients using confocal scanning laser ophthalmoscopy (HRT3). METHODS: Thirty eyes of 30 diabetic patients (non-insulin-dependent diabetes mellitus) underwent PRP for proliferative diabetic retinopathy. Subjects with glaucoma or family history of glaucoma, any coexisting neuroophthalmic disease, uveitis, retinal artery or vein occlusion, corneal opacity or lasered previously were excluded from the study. Optic nerve head (ONH) of these patients were evaluated by confocal scanning laser ophthalmoscopy (HRT3) at baseline, 3, and 6 months after completion of PRP. RESULTS: There were 23 males and 7 females with a mean age of 51.8 years (36 to 67 y). The mean intraocular pressure was 13.1±2.57 mm Hg at baseline, 13.4±2.6 mm Hg at 3 months, and 13.3±2.2 mm Hg at 6 months (P=0.6). The global values of ONH parameters showed no significant change from baseline at 3 months. At 6 months, there was a significant increase in vertical cup:disc ratio (P=0.021), cup volume (P=0.036), mean cup depth (P=0.042), and maximum cup depth (P=0.05) as compared with baseline values. CONCLUSIONS: PRP induces significant changes in the ONH in patients with diabetic retinopathy as measured with HRT3. This is an important consideration in the diagnosis and evaluation of progression in glaucoma patients with diabetic retinopathy who have undergone PRP.

Clinicopathologic characteristics of choroidal melanoma in a North Indian population: analysis of 10-year data.

To analyze the clinical and histopathological characteristics of choroidal melanomas undergoing enucleation at a tertiary care center in India and compare with data from other countries. A retrospective review of in-patient hospital records from 2001-2011. Patients undergoing enucleation with a clinical diagnosis of choroidal melanoma. A total of 80 eyes were enucleated for choroidal melanoma. The mean age of patients was 46 ± 13.1 years. Tumors with spindle cell morphology were the most common subtype. Necrotic tumors had a higher incidence of scleral invasion and orbital involvement compared to other cellular subtypes. The mean age at enucleation in Asian Indians is nearly a decade less than most other races. Predominance of spindle cell subtype is in contrast to findings of previous studies and could be partly related to the genetic and molecular expression of the melanocytes undergoing malignant transformation.

Small gauge vitrectomy: Recent update.

Small gauge vitrectomy, also known as minimally invasive vitreous surgery (MIVS), is a classic example of progress in biomedical engineering. Disparity in conjunctival and scleral wound location and reduction in wound diameter are its core principles. Fluidic changes include increased pressure head loss with consequent reduction in infusional flow rate and use of higher aspiration vacuum at the cutter port. Increase An increase in port open/port closed time maintains an adequate rate of vitreous removal. High Intensity Discharge (HID) lamps maintain adequate illumination in spite of a decrease in the number of fiberoptic fibers. The advantages of MIVS are, a shorter surgical time, minimal conjunctival damage, and early postoperative recovery. Most complications are centered on wound stability and risk of postoperative hypotony, endophthalmitis, and port site retinal break formation. MIVS is suited in most cases, however, it can cause dehiscence of recent cataract wounds. Retraction of the infusion cannula in the suprachoroidal space may occur in eyes with scleral thinning. As a lot has been published and discussed about sutureless vitrectomy a review of this subject is necessary. A PubMed search was performed in December 2011 with terms small gauge vitrectomy, 23-gauge vitrectomy, 25-gauge vitrectomy, and 27 gauge vitrectomy, which were revised in August 2012. There were no restrictions on the date of publication but it was restricted to articles in English or other languages, if there abstracts were available in English.

Resolution of serous retinal detachment following partial sclerectomy with mitomycin C in nanophthalmos.

The authors report the results of partial-thickness sclerectomy combined with mitomycin C in a nanophthalmic eye with serous retinal detachment. Partial sclerectomy in two quadrants with adjuvant use of mitomycin C without drainage of subretinal fluid was performed. The patient was monitored with serial fundus photographs and spectral-domain optical coherence tomography (SD-OCT) for up to 16 weeks postoperatively. Best corrected visual acuity improved from counting fingers at 1 meter preoperatively to 6/60 at final follow-up. There was gradual but complete resolution of serous retinal detachment both clinically and on SD-OCT. Partial-thickness sclerectomy with mitomycin C is an effective and safe procedure in the management of nanophthalmic eyes with uveal effusion.

Management of retinal detachment in block related globe perforation with pneumatic retinopexy.

Retinal detachment after ocular perforation related to local anesthesia is a common complication, which is usually associated with a poor prognosis despite complex vitreoretinal surgical procedures. We report a case of 62-year-old male with cataract surgery done 4 weeks back with nasal retinal detachment with a posterior break. Pneumatic retinopexy was performed and laser barrage of the breaks was done the next day when the retina got attached. A vision of 20/30 was achieved at the end of 2 months. To the best of our knowledge, this is a first case report in literature where pneumatic retinopexy was used to manage a retinal detachment caused by block-related perforation.

Isolated homonymous hemianopsia due to presumptive cerebral tubercular abscess as the initial manifestation of human immunodeficiency virus infection.

We report a case of isolated homonymous hemianopsia due to presumptive cerebral tubercular abscess as the initial manifestation of human immunodeficiency virus (HIV) infection. A 30-year-old man presented to our outpatient department with sudden loss of visibility in his left visual field. He had no other systemic symptoms. Perimetry showed left-sided incongruous homonymous hemianopsia denser above the horizontal meridian. Magnetic resonance imaging revealed irregular well-marginated lobulated lesions right temporo-occipital cerebral hemisphere and left high fronto-parietal cerebral hemisphere suggestive of brain tubercular abscess. Serological tests for HIV were reactive, and the patient was started only on anti-tubercular drugs with the presumptive diagnosis of cerebral tubercular abscess. Therapeutic response confirmed the diagnosis. Atypical ophthalmic manifestations may be the initial presenting feature in patients with HIV infection. This highlights the need for increased index of suspicion for HIV infection in young patients with atypical ophthalmic manifestations.

Role of topical nepafenac in prevention and treatment of macular edema after vitreoretinal surgery.

PURPOSE: To evaluate the effects of topical nepafenac in patients undergoing vitreoretinal surgery. METHODS: One hundred and twenty eyes of 120 patients undergoing vitreoretinal surgery were randomized to receive either topical nepafenac 0.1% (60 eyes) or placebo (60 eyes) in this investigator-masked, randomized, comparative case series. Eyes were evaluated for Day 1 postoperative inflammation and 2-, 4-, 6-, and 8-week postoperative retinal thickness and best-corrected visual acuity. RESULTS: Mean Day 1 inflammation grades of 0.95 ± 0.6 and 1.78 ± 0.7 were noted in patients taking nepafenac and placebo, respectively (P = 0.002). The nepafenac and placebo groups had mean central macular subfield thickness of 228.44 ± 29.27 µm and 236.21 ± 29.44 µm at 4 weeks (P = 0.172) and 205.35 ± 25.25 µm and 205.37 ± 24.90 µm at 8 weeks (P = 0.971), respectively. At 1 month, there was no statistically significant difference in the mean visual acuity between the nepafenac group (0.55 ± 0.16 decimal units) and placebo group (0.52 ± 0.17 decimal units). CONCLUSION: Topical nepafenac was safe and reduced postoperative pain and inflammation in patients undergoing vitreoretinal surgery. However, its effect on reducing postoperative macular edema and improving visual acuity as compared with that of the standard postvitrectomy therapeutic regimen was equivocal.

Retinal arterial plaques in acquired immunodeficiency syndrome.

The authors report the unusual observation discrete plaque like excrescencies along the retinal arterial wall in a young patient with acquired immunodeficiency syndrome. Though bilateral, in the right eye there was severe arteriolar narrowing and so these plaques were less identifiable. Fluorescein angiography did not reveal any arteriolar occlusion or areas of capillary occlusion in both eyes. There were no other signs of HIV associated microangiopathy and the patient did not have any concurrent cardiovascular or hematological abnormality. The cause of these plaques remains unexplained and we conjecture that they could represent macro immune-complex deposition along the arteriolar walls.

PAX6 gene analysis in irido-fundal coloboma.

PURPOSE: To screen the paired box gene 6 (PAX6) gene in irido-fundal coloboma. METHODS: The entire coding region of PAX6 including intron-exon boundaries was amplified from cases (n=30) and controls (n=30). All sequences were analyzed against the ensemble sequence (ENSG00000007372) for PAX6. RESULTS: DNA sequence analysis of patients and controls revealed a total of three nucleotide changes (g.31815391Cytosine>Thymine; Glycine72Glycine and g.31812215Thymine>Guanine) of which one was neutral/synonymous change and the remaining two were intronic changes. Of these 3 changes, 2 were novel and one was already reported change. All these changes were non-pathogenic, according to in silico analysis. CONCLUSIONS: In our study no pathogenic PAX6 mutation were identified. This suggests involvement of other coloboma genes. This study expands the SNP spectrum of PAX6, only rare variations which are not causative have been found. Since this is a pilot study in the north Indian population, results should be confirmed in different populations by similar studies. Familial cases are required for determining the underlying genetic loci accounting for this clinical phenotype and may lead to better understanding of disease pathogenesis.

Intravitreal bevacizumab (avastin) for circumscribed choroidal hemangioma.

Circumscribed choroidal hemangiomas are rare ophthalmic entities that cause diminution in vision due to accumulation of subretinal and/or intraretinal fluid in the macular area. Various treatment options ranging from conventional laser to photodynamic therapy have been employed to destroy the tumor and reduce the exudation; however, either the inability to penetrate through the exudative fluid or the collateral retinal damage induced by these treatment modalities make them unsuitable for lesions within the macula. We evaluated the role of intravitreal bevacizumab, a pan-vascular endothelial growth factor (VEGF) inhibitor, in reducing the sub- and intraretinal fluid in three patients with circumscribed choroidal hemangiomas. All the patients had complete resolution of the serous retinal detachment that was maintained till at least 12 months after the first injection. Intravitreal bevacizumab may be used in combination with thermal laser or photodynamic therapy in treating circumscribed choroidal hemangiomas with subretinal fluid.