Efficacy of dexamethasone implant in the management of chronic central serous chorioretinopathy without choroidal neovascularization.

PURPOSE: To demonstrate the treatment efficacy of intravitreal dexamethasone (DEX) implant in chronic recurrent/persistent central serous chorioretinopathy (CSC). DESIGN: Prospective, non-randomized, open-label study. METHODS: In this study, subjects with chronic CSC without signs of choroidal neovascularization (CNV) received intravitreal DEX implant therapy. The primary outcome measure was the change in visual acuity. Changes in central macular thickness (CMT) and change in subfoveal choroidal thickness (SFCT) on optical coherence tomography (OCT), incidence of recurrent fluid, and safety of DEX implant were secondary outcome measures. Subjects were followed up for a minimum of 3 months after DEX implantation. RESULTS: In total, 20 eyes of 20 subjects (mean age: 47 ± 9 years) with a median disease duration of 23.5 months were enrolled. With a single injection of DEX implant, a reduction in CMT was noted in 90% of eyes. Complete resolution of subretinal and intraretinal fluid was noted in 55% of eyes within 3 months of injection. A significant improvement in vision (mean Log MAR visual acuity 0.66 ± 0.49 vs. 0.54 ± 0.45; P = 0.020), mean CMT (338 ± 110 microns to 238 ± 73 microns; P < 0.001) and SFCT (514 ± 95 microns to 445 ± 111 microns; P < 0.001) was noted over 3 months. Recurrent fluid was noted in 50% of eyes after a mean follow-up duration of 7 ± 4 months. Elevated intraocular pressure, managed by topical therapy, was noted in six eyes. CONCLUSION: The consistent improvement in visual acuity, fluid resolution, and reduction in choroidal thickness suggests a possible role for DEX implants in managing chronic CSC. A larger randomized trial is warranted.

Giant Cell Arteritis With Bilateral Central Retinal Artery Occlusion and Tongue Necrosis.

This case report describes a complicated case of giant cell arteritis (GCA) with tongue necrosis and bilateral central retinal artery occlusion (CRAO). An 81-year-old male patient with a history of recent retinal artery occlusion, ischemic stroke, and hypertensive emergency was evaluated. Clinical examination, including a visual acuity assessment, fundus evaluation, and oral examination, was performed. Laboratory investigations, such as erythrocyte sedimentation rate (ESR), were conducted. A temporal artery biopsy was performed to confirm the diagnosis of GCA. The patient presented with sudden vision loss in the left eye following a prior episode of retinal artery occlusion in the right eye. Ophthalmoscopic examination revealed CRAO in the left eye. Additionally, tongue necrosis, a rare manifestation of GCA, was observed. The ESR was significantly elevated. A temporal artery biopsy supported the diagnosis of GCA. The patient was promptly referred for immunologist consultation and initiated on intravenous methylprednisolone therapy. This case highlights the diverse and potentially devastating nature of GCA, involving ocular and systemic manifestations. Bilateral CRAO and tongue necrosis are rare but significant complications of GCA. Prompt diagnosis and early initiation of corticosteroid therapy are crucial to prevent irreversible visual loss and further complications. A multidisciplinary approach involving ophthalmologists and other specialists is essential for the comprehensive management of GCA.

Late postoperative vitreous cavity hemorrhage after vitrectomy for proliferative diabetic retinopathy-observation versus intervention.

PURPOSE: To analyze the outcome of intervention versus observation for vitreous cavity hemorrhage occurring after a 2-month period of blood-free cavity (late postoperative vitreous cavity hemorrhage-POVCH) in eyes operated by vitrectomy for complications of proliferative diabetic retinopathy (PDR). METHODS: This study was a 10-year retrospective, observational, multi-center study involving eight major vitreoretinal surgical centers across India from January 2010 to December 2019. The primary objective of the study was to assess the visual and clinical outcomes of various management approaches for late POVCH. The key secondary objective was to determine the best management option that prevented recurrence. Patients with follow-up of less than 6 months of POVCH management were excluded. RESULTS: The occurrence of late POVCH was studied in 261 eyes. The median time to occurrence was 7 months (range: 2-87) postvitrectomy/silicone oil removal. The majority (58%) experienced a single, nonrecurring POVCH event. Visual acuity outcome was independent of all management approaches (P = 0.179; mean follow-up 20.7 ± 14.1 months). With watchful observation, spontaneous resolution was noted in 83% (60/72 eyes) of eyes in 81.5 days (interquartile range, 169.75). Silicone oil injection was most effective in preventing recurrence (P < 0.001). CONCLUSION: The current treatment practice of late POVCH management in PDR suggests that watchful observation for at least 3 months could be as efficacious as any surgical intervention.

Socioeconomic status and diabetic retinopathy in India.

Socioeconomic status (SES) may influence the general health and the health-seeking behavior of an individual. Understanding the disease prevalence in different social strata may lead us to the important linkages that SES might have with diabetic retinopathy (DR). The knowledge on the prevalence of DR in the community based on their SES may help design strategies to provide affordable, last-mile care to the population most at risk of this blinding complication of diabetes mellitus. Our systematic search for population-based Indian studies found three studies in the past three decades that evaluated the effect of socioeconomic factors on the prevalence of diabetic retinopathy. The data on the prevalence in various socioeconomic strata was equivocal and the study settings were mostly urban. The parameters used to assess the SES differed among studies. This underscores the need for further research on SES-related diabetic retinopathy complications in India. Future studies should employ more robust socioeconomic scales to define the divide better.

Cogan-Reese syndrome with Iris cyst: A novel presentation.

PURPOSE: To report an atypical case of Cogan-Reese syndrome associated with iris cyst in a young adult male. METHODS: Slit-lamp biomicroscopic examination, swept-source anterior segment optical coherence tomography (ASOCT) and ultrasound bio-microscopy (UBM) were done to evaluate and characterize the nature of the iris cyst. Gonioscopy, specular microscopy and confocal microscopy were attempted, but unsuccessful due to the large corneal opacity. RESULTS: On slit-lamp biomicroscopy, a large nasal corneal opacity with overlying band-shaped keratopathy was noted, with history suggestive of a trivial non-penetrating trauma and likely healed corneal ulcer. Through the temporal clear cornea, the iris displayed altered pattern with overlying shiny membrane and multiple, small, discrete, hyperpigmented, irregular nodules suggestive of Cogan-Reese syndrome. On the nasal side, an iris cyst with typical 'stuck-on appearance' onto the endothelium was visible. ASOCT and UBM failed to show any evidence of epithelial downgrowth or Descemet membrane disintegrity, ruling out the possibility of a post-traumatic implantation iris cyst. CONCLUSION: The occurrence of iris cyst in this case of Cogan-Reese syndrome is unique, and could be related to the disease pathogenesis, or a rare co-incidental finding.

ATYPICAL MACULAR HOLES.

PURPOSE: To study the etiology, clinical features, management options, and visual prognosis in various types of atypical macular holes (MHs). METHODS: A review of the literature was performed, which focused on the etiopathogenesis of atypical or secondary MHs, their differentiating clinical features, management strategies, and varied clinical outcomes. Idiopathic or age-related, myopic, and traumatic MHs were excluded. RESULTS: Atypical or secondary MHs arise out of concurrent ocular pathologies (dystrophy, degeneration, or infections) and laser/surgery. The contributing factors may be similar to those responsible for idiopathic or typical MHs, i.e., tangential or anteroposterior vitreofoveal traction or cystoid degeneration. The management is either observation or treatment of the underlying cause. The prognosis depends on the background pathology, duration of disease, and baseline visual acuity governed by the size of MH and morphologic health of underlying RPE and photoreceptors. The closer the morphology of atypical MH is to that of an idiopathic MH, the better the surgical outcome is. CONCLUSION: With the advancements in retinal imaging, atypical MHs are now more frequently recognized. With increasing understanding of the underlying disease processes, and improvement in investigations and surgical treatment, management of atypical MHs may improve in the future.

"Meniscus Sign" to Identify the Lenticule Edge in Small-Incision Lenticule Extraction.

PURPOSE: To describe our technique of lenticule edge identification in small-incision lenticule extraction using the "meniscus sign" to prevent lenticule misdissection. METHODS: Femtosecond laser application for small-incision lenticule extraction was performed. A "double ring" was visible, signifying the edge of the cap cut (outer ring) and lenticule cut (inner ring). The anterior and posterior lamellar planes were delineated in 2 different directions. During creation of the posterior lamellar channel, the lenticule edge was slightly pushed away from the surgeon to create a gap between the inner ring (diameter of the lenticule cut) and the lenticule edge. The lenticule edge assumed a frilled wavy appearance, and the meniscus sign was observed as a gap between the lenticule edge and the inner ring. The meniscus-shaped gap served as a landmark to identify the lenticule edge, and the relationship between the frilled lenticule edge and surgical instruments further acted as a guide to identify the correct plane of dissection. RESULTS: This technique was successfully undertaken in 50 eyes of 25 patients. The meniscus sign was observed in all cases, and no case had cap lenticular adhesions. CONCLUSIONS: The meniscus sign helps to identify the lenticule edge and correct dissection planes and provides a visual landmark during the entire surgical procedure.