BRIDGE ARCH-SHAPED SUBRETINAL FLUID IN NEOVASCULAR AGE-RELATED MACULAR DEGENERATION: Evolution and Outcomes.

PURPOSE: To study factors leading to bridge arch-shaped subretinal fluid (SRF) on optical coherence tomography in wet age-related macular degeneration and evaluate its anatomical and functional outcomes. METHODS: In this single-center, retrospective study, patients with bridge arch-shaped SRF and choroidal neovascular membrane (CNVM) were included. RESULTS: Overall, 623 eyes in 431 patients with chronic CNVM were identified, and 24 eyes (4%) in 21 patients showed bridge arch-shaped SRF. Mean age of patients was 69.19 ± 12.0 years. Type-1 CNVM was noted in 79% cases before development of bridge arch-shaped SRF. Mean early treatment diabetic retinopathy letters visual acuity was 53.93 ± 32.19. Time interval to develop bridge arch-shaped SRF was 21.9 ± 30.63 months. Mean number of intravitreal anti-vascular endothelial growth factor injections given before developing bridge arch-shaped SRF was 6.5 ± 7.09. During the development of bridge arch-shaped SRF, visual acuity reduced by -20.57 ± 31.13 letters (P = 0.033) and fibrotic Type-2 CNVM (n = 18, 75%) was noted. Retinal pigment epithelium tear was noted in 8 eyes (33%). At the final visit, further reduction in visual acuity of -7.136 ± 13.73 early treatment diabetic retinopathy letters (P = 0.011) after developing bridge arch-shaped SRF was seen. Mean number of injections given after developing bridge arch-shaped SRF was 4.76 ± 3.76. CONCLUSION: Bridge arch-shaped SRF is an uncommon finding seen in eyes with Type-2 chronic CNVMs. Presence of retinal pigment epithelium breach and tear and nonaggressive treatment regimen with intravitreal anti-vascular endothelial growth factor injections could be responsible for its pathogenesis. It is a marker of fibrotic enlargement, leading to poor visual outcomes despite showing favorable therapeutic response.

DIRECT LASER PHOTOCOAGULATION TO THE DILATED RIGHT-ANGLED VESSEL IN THE MANAGEMENT OF PROLIFERATIVE TYPE 2 MACULAR TELANGIECTASIA.

PURPOSE: To report a case of proliferative Type 2 macular telangiectasia treated successfully with direct laser photocoagulation to the right-angled vessel. METHODS: Descriptive case report. CASE DESCRIPTION: A 61-year-old man, with no past medical history, was diagnosed and treated previously elsewhere for bilateral proliferative Type 2 macular telangiectasia. He complained of recent onset decrease in vision in his right eye for last 2 months. Right eye visual acuity was counting fingers at 3 m and left eye was 6/18. Fundus examination showed proliferative Type 2 macular telangiectasia in both eyes with active neovascular complex in the right eye. Direct thermal laser photocoagulation to the tips of the right-angled vessels with single-spot PASCAL Synthesis (Topcon Medical Laser System) at 532 nm wavelength was done. After laser, reduction in the hyporeflective space height was noted on optical coherence tomography. No additional intravitreal anti-vascular endothelial growth factor injections were required. At the last 6-months follow-up visit, visual acuity improved to 6/36, N18 in the right eye. CONCLUSION: Direct laser photocoagulation to the right-angled vessel can be considered as possible treatment option for proliferative Type 2 macular telangiectasia, especially in patients nonresponsive to anti-vascular endothelial growth factor therapy. However, long-term follow-ups are required to see whether it is possible to maintain the efficacy.

SPONTANEOUS CLOSURE OF SECONDARY ECCENTRIC MACULAR HOLES FOLLOWING VITREORETINAL SURGERY.

PURPOSE: To report two cases of secondary eccentric macular holes that developed following vitrectomy and present their outcomes. METHODS: Retrospective, observational case report. CASE DESCRIPTION: A 69-year-old woman and a 57-year-old man developed secondary paracentral retinal hole following vitrectomy surgery for stage 4 macular hole and proliferative diabetic retinopathy respectively. In Case 1, the hole was left untreated, whereas in Case 2, laser photocoagulation was done around the paracentral retinal hole. In both cases, spontaneous closure of the paracentral retinal holes was noted 12 weeks and 3 weeks after presentation respectively. CONCLUSION: Secondary eccentric retinal holes are extremely rare following vitrectomy. The pathogenesis of macular holes in our cases is most consistent with contraction of the residual internal limiting membrane or preretinal fibrous tissue. Spontaneous closure of small eccentric retinal holes can occur as well which to the best of our knowledge has not yet been reported in literature.

Recommendations for management of peripheral retinal degenerations.

Some degenerations involving the peripheral retina can result in a rhegmatogenous retinal detachment. Currently, there are no clear guidelines for retinal screening and/or management of these peripheral retinal degenerations in patients with or without recent onset posterior vitreous detachment or in those prior to refractive surgery or intraocular procedures. This article aims to provide a set of recommendations for the screening and management of peripheral retinal degenerations based on a common consensus obtained from an expert panel of retinal specialists.

PHARMACOTHERAPEUTIC CLOSURE OF A PERSISTING TRAUMATIC MACULAR HOLE WITH INTRAOCULAR STEROIDS.

PURPOSE: To report a case of successful closure of traumatic macular hole after treatment with intraocular steroids in a nonvitrectomized eye. METHODS: Retrospective observational case report. CASE DESCRIPTION: A 34-year-old man developed a full-thickness macular hole and submacular bleed after injury with firecracker in the left eye. Visual acuity in the left eye was counting fingers close to face. Intraocular gas, 0.3 cc of 100% SF6, was injected for displacement of submacular bleed. At 2 months after presentation, macular hole persisted with signs of intraocular inflammation. A trial of intraocular triamcinolone injection (2 mg in 0.05 ml) was given, which resulted in complete closure of macular hole and improvement in visual acuity to 6/36 and thereby avoiding the need for ocular surgery. CONCLUSION: Ocular steroids could play an important role in successful closure of persisting macular holes in a setting of blunt trauma, especially in a background of uveitis.

Morphological features of focal choroidal excavation and its association with macular pathology in Asian Indian eyes.

Purpose: To study the characteristics of focal choroidal excavation (FCE) in Indian eyes based on spectral-domain optical coherence tomography (SD-OCT) findings and their association with macular pathologies. Methods: Retrospective study of 26 patients diagnosed with FCE. All patients' clinical and imaging data were reviewed. Results: There were eight females and 18 males aged between 24 and 85 years. FCE was noted in 31 eyes of 26 patients - unilateral in 21 and bilateral in 5. The conforming type was noted in 13 and nonconforming in 19 eyes. The location was extrafoveal in 16 and subfoveal in 15 eyes. The morphology was bowl-shaped in 24, cone-shaped in six eyes, and mixed type in one eye. Associated pathologies were central serous chorioretinopathy in nine eyes, choroidal neovascular membrane in seven eyes, Stargardt's disease in three eyes, Best disease in four eyes, other retinal dystrophies in two eyes, polypoidal choroidal vasculopathy and moderate non-proliferative diabetic retinopathy, each in one eye. The mean FCE width was 1667.2 ± 817.7 µ, mean depth was 95.7 ± 46.4 µ, and the mean choroidal thickness under the FCE was 234.8 ± 85.9 µ. No abnormal choroidal tissue was found under any FCE. Conclusion: FCE is a relatively common entity and frequently associated with macular pathologies. The presence of an FCE did not alter the course or management of these conditions.

Multimodal imaging of an idiopathic florid vascularised epiretinal membrane: Course, treatment, and outcome.

Idiopathic vascular epiretinal membrane is an extremely rare entity and the pathogenesis and clinical course is not clearly understood. A 53-year-old hypertensive female patient presented with complaints of altered vision in the right eye. On examination, her vision was 20/30 and fundoscopy showed a vascularized epiretinal membrane (ERM), which was confirmed on spectral-domain optical coherence tomography. No primary cause was found after investigations. The symptoms and ERM showed slow progression over the next three years with a visual acuity of 20/60. She underwent surgery for removal of the ERM, which was subjected to histopathological evaluation. This is a unique case of a florid proliferative vascularisation of an ERM in the absence of any identifiable cause, which had a good visual outcome following surgery.

Multicolor imaging findings in torpedo maculopathy.

We describe the multicolor imaging findings in two cases of Torpedo maculopathy (TM). Multicolor imaging can be a useful tool in identifying the level of retinal and choroidal layer involvement in TM. This imaging modality further confirms the hypothesis that TM is a localized congenital abnormality of retinal pigment epithelium pigmentation which leads to outer retinal and inner choroidal degeneration.

Clinical applications of the retinal functional imager: A brief review.

The advances in treating blinding conditions often depends on the development of new techniques that allows early detection, treatment, and follow-up of the disease. Functional changes often precede structural changes in many retinal disorders. Therefore, detecting these changes helps in early diagnosis and management, with the intention of preventing permanent morbidity. The Retinal Functional Imager (RFI) is a non-invasive imaging system that allows us to assess the various functional parameters of the retina. The RFI quantitatively measures the retinal blood-flow velocity, oxygen saturation, metabolic demand and generates a non-invasive capillary perfusion map that provides details similar to a fluorescein angiography. All of these parameters correlate with the health of the retina, and are known to get deranged in retinal disease. This article is a brief review of published literature on the clinical utility of the RFI.

Structural-functional correlation using adaptive optics, visual fields, optical coherence tomography and multifocal electroretinogram in a case of torpedo maculopathy.

We present a case of a 37-year-old gentleman with a rare diagnosis of Torpedo maculopathy (TM). We describe the multimodal imaging features of torpedo maculopathy using adaptive optics, visual fields, OCT and multifocal ERG, and understand the clinical and structural-functional correlation in TM. According to us, this is the first case report to describe the adaptive optics imaging findings in Torpedo maculopathy in English Medical literature.

Morphometric analysis of retinal arterioles in control and hypertensive population using adaptive optics imaging.

Purpose: To measure the wall-to-lumen ratio (WLR) and the vascular wall cross-sectional area (WCSA) of retinal arterioles by an Adaptive Optics (AO) retinal camera using semi-automated software and comparing them between control and hypertensive population. Methods: This was a cross-sectional observational study including a hypertensive group and a control group. Subjects were examined and their medical history recorded. Retinal arteriolar morphometry was assessed by rtx1 AO retinal camera using AOdetect Artery semiautomated software. Main Outcome Measures: WLR and WCSA were measured on the basis of retinal arteriolar wall thickness (W1, W2), lumen diameter (LD) and vessel diameter (VD). Influence of age and arterial hypertension on the WLR and WCSA were examined. Results: A total of 150 human subjects were included out of which 110 were controls and 40 were hypertensives under treatment. There was statistically significant difference in the age, systolic and diastolic blood pressures between the control and hypertensive groups (P < 0.01). We found no significant correlation between age and WLR (R2 = 0.049, P > 0.05) or age and WCSA (R2 = 0.045, P > 0.05). We observed a significant difference in WLR and WCSA measurements between control and hypertensive groups (P < 0.01). On measuring intra-observer variability (IOV) we found excellent consistency. Conclusion: AO retinal imaging allows a direct measurement of the retinal vessel wall and LD with excellent IOV. WLR and WCSA reflect the remodelling process and can be used to further aid the early detection and monitoring of systemic hypertension.

PNEUMATIC DISPLACEMENT OF LIMITED TRAUMATIC SUBMACULAR HEMORRHAGE WITHOUT TISSUE PLASMINOGEN ACTIVATOR: A CASE SERIES.

PURPOSE: To evaluate the efficacy of intravitreal gas (perfluoropropane, C3F8)-assisted displacement of submacular hemorrhage (SMH) secondary to recent or old blunt trauma. METHODS: An interventional case series of three patients who presented with SMH after blunt trauma, ranging from 2 days to 2 weeks back. All three patients were treated with an intravitreal injection of 0.3 cc of 100% C3F8 with anterior chamber paracentesis. Strict prone position was advised for 2 weeks with a minimum of 6 to 8 hours per day. Documentation was done with serial recording of corrected distance visual acuity, fundus photographs, and spectral domain optical coherence tomography both before and after intervention. RESULTS: The follow-up period ranged from 2 weeks to 3 months. All patients showed a significant displacement of SMH with recovery of the normal foveal contour; foveal thinning was noted in 2 cases. Best spectacle-corrected visual acuity improved from counting finger at 1 m to 20/30 in Case 1 and counting finger 3 m to 20/40 in Case 2. In Case 3, the visual acuity remained unchanged from the preoperative 20/60 which could be attributed to the presence of a choroidal rupture in the foveal area that became evident after the displacement of SMH. CONCLUSION: Pneumatic displacement is an effective technique in the management of SMH due to recent or old blunt trauma.

Correlation between systemic S100A8 and S100A9 levels and severity of diabetic retinopathy in patients with type 2 diabetes mellitus.

AIMS: S100A8 and S100A9 are myeloid-related damage-associated molecular patterns (DAMPs) primarily involved in the modulation of innate immune response to cellular injury. This study evaluated the correlation between circulating concentrations of S100A8 and S100A9 proteins with the severity of diabetic retinopathy (DR) in patients with type 2 diabetes (T2DM). METHODS: T2DM patients with HbA1c levels >7%, fasting blood glucose >126 mg/dl and history of diabetes were included in this study. DR severity was graded based on ETDRS and Gloucestershire classifications. Plasma samples were evaluated for S100A8 and S100A9 levels using ELISA. RESULTS: In this comparative study, DR patients (n = 89) had increased plasma S100A8 and S100A9 proteins compared to age-matched T2DM controls (n = 28), which was directly related to the severity of DR. Female DR subjects had increased S100A8 expression compared to their male counterparts. Substantial retention of S100A8 and S100A9 production was seen in DR patients above 50 years of age. Duration of T2DM was not found to affect protein levels, however T2DM onset at >50 years old significantly increased S100A8 and S100A9 concentrations. CONCLUSIONS: Our findings suggest that systemic circulation levels of S100A8 and S100A9 are correlated with the progression of DR in T2DM patients, indicating their potential role in DR pathogenesis.

An automated framework to quantify areas of regional ischemia in retinal vascular diseases with OCT angiography.

In this observational and cross-sectional study, capillary nonperfusion (CNP) and vascular changes in branch retinal vein occlusion (BRVO, sample size [n] = 26) and choroidal neovascularization (CNV, n = 29) were evaluated. Subjects underwent imaging using Optical coherence tomography angiography (Angiovue OCTA, RTVue XR, Optovue Inc., Fremont, California). Local fractal analysis was applied to the OCTA images of superficial, deep and choriocapillaris layer. CNP area (BRVO eyes) and vascular parameters were computed using local fractal-based method. Sensitivity and specificity of vascular parameters were assessed with receiver operating characteristics curve. Automated CNP area showed excellent agreement with manually quantified CNP areas in both superficial (intraclass coefficient [ICC] = 0.96) and deep (ICC = 0.96) layers. BRVO eyes showed significantly altered (P < .05) vascular parameters in both superficial and deep layer as compared to normal eyes (n = 30). CNVM eyes had significantly higher capillary free zones (P < .001) as compared to normal eyes. In normal vs BRVO eyes, vessel density and spacing between the large vessels had similar area under the curve (AUC) (P > .05) in both superficial (0.97 and 0.97, respectively) and deep layer (0.99 and 0.98, respectively). Further, capillary free zones showed high AUC (0.92) in differentiating CNV eyes from normal eyes.

Clinical, anatomic, and electrophysiologic evaluation following intravitreal bevacizumab for macular edema in retinal vein occlusion.

PURPOSE: To investigate clinical, anatomic, and electrophysiologic response after single intravitreal injection of bevacizumab for macular edema attributable to retinal vein occlusion. DESIGN: Prospective nonrandomized, interventional case series. METHODS: Twenty-one patients with macular edema attributable to vein occlusion received intravitreal injection of bevacizumab 1.25 mg. Nine patients had central retinal vein occlusion (CRVO), and 12 patients had branch retinal vein occlusion (BRVO). Complete ophthalmic examination including optical coherence tomography (OCT) was done at baseline and follow-up visits. Fifteen patients underwent fluorescein angiography at baseline. Selected patients underwent electroretinography (ERG) and visual evoked potential (VEP) at baseline and follow-up. Follow-up was for 12 weeks. RESULTS: At baseline, mean visual acuity was 20/381 (median, 20/400) and showed improvement to mean 20/135 (median, 20/60) after one month, (P = .001). At 12 weeks, mean visual acuity was 20/178 (median, 20/80) (P = .001). The mean central retinal thickness (CRT) was 647.81 microm (median, 609.00 microm) at baseline and decreased to mean 293.43 microm (median, 222.00 microm) at one month (P = .001). At 12 weeks, mean CRT was 320.90 mum (median, 280.00 microm) (P = .001). ERG and VEP showed no worsening of the waveforms. There was no significant difference in the visual outcome between the BRVO and CRVO groups. CONCLUSION: Intravitreal injection of bevacizumab appears to result in significant short-term improvement of visual acuity and macular edema secondary to vein occlusion. The present report confirms the previous studies. No ocular toxicity or adverse effects were observed. However, prospective, randomized, controlled long-term studies are required with an adequate number of patients.

Unilateral anterior persistent fetal vasculature in a child with blepharophimosis-ptosis-epicanthus inversus syndrome: A surgical challenge.

Blepharophimosis-ptosis-epicanthus inversus syndrome (BPES) is a rare autosomal dominant genetic disease. It is clinically characterized by four major features; blepharophimosis, ptosis, epicanthus inversus, and telecanthus. We report a case of a 1-year-old female with BPES with unilateral anterior persistent fetal vasculature (PFV). On examination, she was found to have all the clinical features of BPES, along with calcified and partially absorbed cataract with elongated ciliary processes in her left eye. B-scan of left eye showed attached retina with no evidence of posterior PFV. Systemic examination was normal. She underwent cataract surgery with primary posterior capsulotomy with intraocular lens implantation under general anesthesia. Literature search did not reveal any previous reports of unilateral anterior PFV and BPES. The clinical features, other associations, and the difficulties in the surgical management of this condition are discussed.