Effect of short-term meditation training in central serous chorioretinopathy

Purpose:

Stress and Type A personality are established risk factors for the development of central serous chorioretinopathy (CSC). Meditation is known to have a positive effect on reducing stress levels. This study aimed to assess the effect of short-term meditation training in patients of CSC.

Methods:

A pilot study was conducted where 40 patients diagnosed with acute and non-resolving CSC were randomly assigned to either of two groups – meditation training and routine care (without meditation). The primary outcome measure was time to resolution of CSC based on optical coherence tomography and fluorescein angiography. Secondary outcome measures were changes in anxiety score (State–Trait Anxiety Inventory [STAI] scores) and blood pressure. The patients were followed up for a minimum period of 4 months.

Results:

Twenty cases were included in each group. The demographic pattern, baseline swept-source optical coherence tomography parameters, and STAI scores were similar in both groups. The time to disease resolution was 9.4 ± 4.22 weeks in the meditation group and 19.5 ± 2.79 weeks in the nonmeditation group (P < 0.001). At 4 months, CSC had failed to resolve in 60% of patients with routine care compared with 8% in cases following short-term meditation training. STAI scores showed a reduction in stress levels in the meditation group. Furthermore, statistically significant improvement in systolic and diastolic blood pressures was also observed following meditation training.

Conclusion:

Short-term meditation training may be a useful approach in the management of patients with CSC as it tends to reduce stress and prehypertension, and promotes earlier resolution of the condition. However, patient’s motivation to complete and pursue the meditation training is a significant barrier.

Selfie fundus imaging for diabetic retinopathy screening

Background

Regular screening for retinopathy and timely intervention reduces blindness from diabetes by 90%. Screening is currently dependent on the interpretation of images captured by trained technicians. Inherent barriers of accessibility and affordability with this approach impede widespread success of retinopathy screening programs. Herein, we report our observations on the potential of a novel approach, Selfie Fundus Imaging (SFI), to enhance diabetic retinopathy screening.

Methods

The study was undertaken over a two-month period during COVID 19 lockdown. 60 diabetic patients participated in the study. Retinal images were captured using three different approaches, handheld smartphone-based photographs captured by patients themselves after a short video-assisted training session (SFI group), and smartphone-based photographs captured by a trained technician and photographs taken on desktop conventional digital fundus camera (Gold standard). Sensitivity and kappa statistics was determined for retinopathy and macular oedema grading.

Findings

Mean age of the study participants was 52.4 years ± 9.8 years and 78% were men. Of 120 images captured using SFI, 90% were centred-gradable, 8% were decentred-gradable and 2% were ungradable. 82% patients captured the image within a minute (majority by 31–45 s). The sensitivity of SFI to detect diabetic retinopathy was 88.39%. Agreement between SFI grading and standard fundus photograph grading was 85.86% with substantial kappa (0.77). For the detection of diabetic macular oedema, the agreement between SFI images and standard images was 93.67, with almost perfect kappa (0.91).

Conclusion

Fundus images were captured by patients using SFI without major difficulty and were comparable to images taken by trained specialist. With greater penetrance, advances, and availability of mobile photographic technology, we believe that SFI would positively impact the success of diabetic retinopathy screening programs by breaking the barriers of availability, accessibility, and affordability. SFI could ensure continuation of screening schedules for diabetic retinopathy, even in the face a highly contagious pandemic.

Detection and monitoring of subclinical ocular siderosis using multifocal electroretinogram

BACKGROUND

Although full-field electroretinogram (ffERG) is the gold standard test to detect physiological dysfunction in siderosis, it measures overall retinal function. This study aims to determine if multifocal electroretinogram (mfERG) can detect subclinical siderosis in eyes with an iron intraocular foreign body (IOFB).

METHODS

Twenty eyes of 20 patients with retained iron IOFB, clear ocular media and good visual acuity (≥20/120) were enroled in this prospective case-control study. The fellow eyes served as control. These were evaluated with ffERG and mfERG at baseline. Serial mfERG was done till six months after pars plana vitrectomy with IOFB removal. Primary outcomes measures were amplitude and peak time of P1 and N1 wave of mfERG.

RESULTS

The median age was 25 years (range 18-55). Most patients (n = 14/20) presented within a month of trauma. Baseline ffERG showed no difference in either 'a' or 'b' wave amplitude or peak time between cases and controls. However, on mfERG, there was a significant decrease in P1 and N1 wave amplitude and delay in P1 wave peak time in <2° retinal ring in cases as compared to controls (p = 0.001, 0.001 and 0.02 respectively) despite variability in results. At 6 months, P1 amplitude showed significant improvement from baseline in cases (p = 0.010). However, P1 peak time did not show significant recovery (p = 0.65).

CONCLUSIONS

mfERG may reveal subclinical electrophysiological retinal dysfunction in eyes with iron IOFB in cases with normal ffERG. P1 peak time may serve as an electrophysiological marker for past retinal damage.

Patterns of uveitis in patients with proven systemic (pulmonary and extrapulmonary) tuberculosis

PURPOSE

To report patterns of uveitis in patients with systemic tuberculosis.

METHODS

Records of patients presenting at uvea clinic of a tertiary eye care centre were evaluated retrospectively, and 47 cases with proven systemic tuberculosis were analyzed for patterns of uveitis. Tuberculosis had been proven with a combination of radio imaging and detection of acid fast bacilli in body fluids. All patients had been reviewed by a specialist as applicable before diagnosing tuberculosis. These patients had undergone a thorough ocular workup. Pattern of uveitis was the primary outcome measure.

RESULTS

Mean age was 35.34 ± 15.56 years. Lung was the commonest systemic focus, seen in nearly 75% of the cases. Anterior uveitis was the most common presentation (48.9%), followed by posterior (25.5%), panuveitis (10.6%) and intermediate uveitis (10.6%). Multifocal serpiginoid choroidopathy (MSC) was seen in only one patient, while granulomatous choroiditis was the commonest type of posterior uveitis.

CONCLUSIONS

Anterior uveitis is the most frequent type of uveitis seen in patients with proven systemic tuberculosis. Rarity of MSC in such patients indicates possibility of etiologies other than tuberculosis in causing MSC.

Prevalence, progression, and outcomes of diabetic retinopathy during pregnancy in Indian scenario

Purpose

The objective of this study is to evaluate pattern of diabetic retinopathy (DR) during pregnancy in females with pregestational diabetes mellitus (DM).

Methods

This is an ambispective observational cohort study conducted at an Indian tertiary care centre. A total of 50 pregnant females with pregestational DM were included while those with gestational DM were excluded from the study. Ocular examination (inclusive of fundus photography) was conducted and systemic parameters (inclusive of Glycated hemoglobin) were assessed during each of the 3 trimesters and 3 months postpartum. The prevalence and progression of DR during pregnancy in the study cohort were the main outcome measures.

Results

Three of the 50 patients had type 1 DM while 47 had type II DM. All the patients with type I DM were insulin dependent while 19 patients with type II DM were insulin dependent. Overall prevalence of DR was 8% (4/50); 2 cases had nonproliferative DR (NPDR), and 2 had proliferative DR (PDR). During the study period, worsening was seen in both the patients with PDR and one required vitrectomy. Mean visual acuity in patients with PDR decreased from 0.77 logMAR units at presentation to 1.23 logMAR at final follow-up. There was no change in the mean visual acuity of patients with NPDR. None of the patients with NPDR converted to PDR. There was no new onset DR in the patients without DR at presentation. Assessment of risk factors for DR revealed significantly higher duration of DM (14 ± 6.32 years vs. 3.43 ± 1.43 years, P = 0.0008). The median age was also higher in the DR patients (31 years vs. 29 years, P = 0.32).

Conclusion

No new onset cases were seen during the course of pregnancy and no conversion from NPDR to PDR was seen; however, a worsening of the two PDR cases was observed. No cases of DR were seen in noninsulin-dependent DM. None of the four participants with DR showed a spontaneous resolution of DR postpartum. Patients with PDR and long-standing DM require careful observation during pregnancy. A registry of diabetic mothers should be set up for development of guidelines for managing such cases.

Endoillumination (chandelier) and wide-angle viewing-assisted fine-needle aspiration biopsy of intraocular mass lesions

Fine-needle aspiration biopsy (FNAB) of intraocular mass lesions is an important intervention in the presence of diagnostic difficulty. FNAB of intraocular mass lesions is also likely to become more commonly recommended for prognostication of tumors such as choroidal melanoma. The most commonly described approach for tumor localization and visualization during FNAB is transillumination and indirect ophthalmoscopic viewing. Herein, we report endoillumination (chandelier) and wide-angle viewing assisted, microscope-based approach for FNAB in two patients using two port minimally invasive vitreoretinal surgical approach. The submission is supported by a video demonstration. The entire procedure was completed under the microscope. Adequate sample was obtained. In the first patient, the inflammatory nature of the lesion was confirmed though magnetic resonance imaging had been reported as melanoma. In the second patient, a clinical diagnosis of amelanotic melanoma was confirmed. Endoillumination-assisted FNAB of intraocular mass lesions is easier to learn and more precise and hence carries lesser risks.

Necrotising scleritis, keratitis and uveitis in primary antiphospholipid syndrome

Ocular manifestations of antiphospholipid syndrome typically include thromboembolic and neuro-ophthalmic complications. In this report we present a case of inflammation of the ocular coats in a patient diagnosed with antiphospholipid syndrome 16 years prior. We discuss management of the case and the possible aetiology of the rare association.

Swept-source optical coherence tomography of an optic disc melanocytoma: The importance of the hyperreflective foci

Optic disc melanocytoma (ODM) has been considered as a benign tumor with few reports of malignant transformation. We present swept-source optical coherence tomography (SSOCT) imaging of a case of ODM. As attaining histopathology is impossible in most cases, we discuss the possibility of using SSOCT as a tool for ruling out choroidal invasion or juxtapapillary melanoma.

Leber's Congenital Amaurosis and Gene Therapy

Retinal blindness is an important cause of pediatric visual loss. Leber's congenital amaurosis (LCA) is one of these causes, often wrongly included in the spectrum of retinitis pigmentosa. The disease has become the center of research after initial reports of success in management with gene therapy. This review discusses in brief the clinical presentation and investigative modalities used in LCA. Further, the road to gene discovery and details of currently applied gene therapy are presented. LCA is one of the first successfully managed human diseases and offers an entirely new dimension in ocular therapeutics.

Clinical manifestations of pachychoroid may be secondary to pachysclera and increased scleral rigidity

Current imaging advancements have led to emergence of pachychoroid as an association of important vision threatening diseases like chronic serous chorioretinopathy and polypoidal choroidal vasculopathy. While the precise relation between thick choroid and such disorder is being investigated, the etiology behind pachychoroid remains elusive. We hypothesize pachychoroid to be a resultant of impeded vascular outflow due to thick sclera and increased scleral rigidity. We discuss our hypothesis in the perspective of other choroidal manifestations of anomalously thick scleral structure.

Hemiretinal Vein Occlusion in Wegener's Granulomatosis

PURPOSE

To report a case of hemiretinal vein occlusion in a patient with Wegener's granulomatosis.

RESULTS

Retinal vein occlusion may occur in patients with Wegener's granulomatosis even in the absence of active inflammation affecting the retinal venules.

CONCLUSIONS

Wegener's granulomatosis should be considered in the diagnostic workup of young patients with major retinal vascular occlusion and concurrent history of pulmonary and/or renal disease.

Retina and the tubercle Bacillus: Four decades of our journey and current understanding

Tuberculosis continues to be a major pandemic with enormous public health implication. Involvement of ocular tissues in the form of tubercles, tuberculomas, panophthalmitis, and iris granulomas are well recognized as definitive manifestations of tuberculosis. For these lesions, confirmatory evidence is available in the form of demonstration of acid-fast Bacillus on Ziehl-Neelsen staining. For other retinochoroidal disorders such as central serous chorioretinopathy, retinal vasculitis, and presumed ocular tuberculosis, hard evidence about the role of Mycobacterium tuberculosis is lacking. In this review, work done at our center over the past four decades in the form of experimental animal studies, nucleic acid amplification assays and clinical studies regarding the above retinochoroidal pathologies and the tubercle Bacillus is presented. It is possible that revisiting experimental animal studies may be a way forward in the current scenario of ambiguity about the cause-effect relationship between M. tuberculosis and few of the retinochoroidal disorders.

Impact of estimated glomerular filtration rate on diabetic macular edema

PURPOSE

Diabetic macular edema (DME) is a major cause of visual impairment in patients with diabetes and is influenced by various systemic factors. This study evaluates the effect of renal status on DME using estimated glomerular filtration rate (eGFR) as a study marker.

METHODS

This was a prospective observational cross-sectional study. One hundred and ninety-five patients of diabetic retinopathy (DR) were included. Group 1 had patients of DR without DME (n = 100), and group 2 had patients of DR with DME (n = 95). All patients were evaluated for DR/DME-related risk factors. eGFR was calculated in all patients. Spectral domain optical coherence tomography (SDOCT) was done to identify the various patterns and severity of DME.

RESULTS

Group 2 patients had significantly higher comorbidities than those in group 1 (p < 0.001). Hba1c, total cholesterol, triglycerides, LDL/HDL ratio, systolic and diastolic blood pressures were significantly higher in group II (p < 0.001 in each). There was no significant difference between the groups in terms of blood urea, serum creatinine or eGFR. eGFR did not show a significant association with a specific SDOCT pattern or severity of DME.

CONCLUSION

Comorbidities are more common and more severe in patients with DME. However, eGFR as a marker was not useful in predicting either the severity or pattern of DME. eGFR, in its present form, may not be useful in the evaluation and management of patients with DME.

Evaluation of fundus autofluorescence patterns in age-related macular degeneration

AIM

To study the various morphological patterns of fundus autofluorescence (FAF) images in patients with age-related macular degeneration (AMD) in Indian population.

METHODS

Totally 179 eyes of 104 patients with clinical diagnosis of AMD were recruited into the study. Autofluorescence images were captured using confocal scanning laser ophthalmoscope and the patterns of FAF were classified.

RESULTS

Of 179 eyes, 27 (15.08%) were early AMD, 58 (32.41%) were intermediate AMD, 94 eyes (52.51%) were late AMD. Of 94 eyes with late AMD, 79 (84.04%) were neovascular AMD and 15 (15.96%) were central geographic atrophy. In eyes with early and intermediate AMD, 9 patterns of FAF were noted. Six patterns (normal, minimal change, focal increased, patchy increased, linear, reticular) were similar to that in the published classification. Two patterns (lacelike and speckled) described in the published classification were not found. Three new patterns (focal hypo-fluorescence, patchy hypo-fluorescence, mixed focal hypo-fluorescence and hyper-fluorescence) were detected. In eyes with neovascular AMD, 6 morphological patterns of FAF were noted. Two patterns (mixed hypo-fluorescence and hyper-fluorescence, central hypo-fluorescence with hyper-fluorescent rim) were similar to that in published classification. Two patterns (normal, near normal or normal background fluorescence in the centre of hypo-fluorescent area) described in the published classification were not found. Four new patterns (minimal change, hypo-fluorescent patch, central hypo-fluorescence with surrounding reticular, bull's eye) were recognized. In eye with central geographic atrophy 5 morphological patterns were noted and these were similar to that in published classification.

CONCLUSION

Phenotypic differences in the pattern of FAF exist in the study population compared to existing classification systems.

Endoillumination (chandelier) assisted scleral buckling for a complex case of retinal detachment

Endoilluminator-assisted scleral buckling combines the advantages of scleral buckling for its external approach and pars plana vitrectomy for its better visual visualization in the management of retinal detachment (RD). It has recently been proven to be safe and efficacious in simple cases. This report discusses successful management of a complex case of RD in a patient with the single functioning eye, where vitrectomy was expected to have a complicated course.

Extensive choroidal infarction in a case of mixed essential cryoglobulinaemia in a postpartum female

A case of mixed essential cryoglobulinaemia resulting in massive choroidal infarction and irreversible vision loss in a postpartum female is discussed. Cryoglobulinaemia can rarely involve ocular vessels and, in this case, was adjunctive to mild hypertension in causing acute choroidopathy. Although the systemic condition of the patient improved after steroids and immunosuppressive agents, the visual loss was permanent.

Scleral abscess following posterior subtenon triamcinolone acetonide injection for diabetic macular edema

A 65-year-old male with uncontrolled diabetes, received posterior subtenon triamcinolone (PST) injection in the right eye for diabetic macular edema. Two days following PST, he developed scleral abscess at the injection site. The Gram stain showed Gram positive cocci in clusters. He responded favorably with systemic control of diabetes, topical concentrated cefazolin, concentrated tobramycin, and intravenous antibiotics. Possibility of infective complications should be considered when using periocular steroids, especially in diabetics. Strict control of diabetes and aggressive systemic antibiotics favor rapid healing in such cases.

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.

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.

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.

Subthreshold micropulse diode laser and double frequency neodymium: YAG laser in treatment of diabetic macular edema: a prospective, randomized study using multifocal electroretinography

OBJECTIVE

The purpose of this study was to compare the efficacy of subthreshold micropulse diode (SDM) laser with double-frequency neodymium YAG (Nd:YAG) laser in treatment of clinically significant diabetic macular edema.

METHODS

Forty-six eyes of 33 patients with clinically significant macular edema (CSME) caused by diabetic retinopathy were randomized to either SDM (810?nm) laser or the conventional double-frequency Nd:YAG (532?nm) laser. Primary outcome measures were: change in the central macular thickness as measured by optical coherence tomography (OCT) and change in macular retinal sensitivity measured using multifocal electroretinography (MfERG). Secondary outcomes were: change in best corrected visual acuity (BCVA) and contrast sensitivity.

RESULTS

The group was divided in half, with 23 eyes assigned to SDM laser and 23 eyes assigned to double-frequency Nd:YAG laser. Mean follow-up period was 6 months. No statistically significant difference was noted in either the primary or the secondary outcome measures between the two groups. Macular thickness decreased from the baseline measures of 298.5?49.3 and 312.9?45.8??m to 274.9?62.9 and 286.7?32.8??m in the SDM laser and Nd:YAG laser groups, respectively. On MfERG, P1 implicit wave time delay at baseline changed from 46.27?4.9 to 45.27?3.4?ms in the SDM group and from 46.55?4.9 to 45.27?4.1?ms in the Nd:YAG group. MfERG recordings of 18 of the 23 eyes treated with double-frequency Nd:YAG laser showed areas of signal void as compared to 4 eyes treated with the SDM laser.

CONCLUSIONS

SDM laser photocoagulation showed an equally good effect on visual acuity, contrast sensitivity, and reduction of diabetic macular edema (DME) as compared to conventional Nd:YAG laser photocoagulation. MfERG recordings, however, suggest that SDM laser results in better preservation of electrophysiological indices.

Primary Vascular Occlusion in IRVAN (Idiopathic Retinal Vasculitis, Aneurysms, Neuroretinitis) Syndrome

IRVAN is a rare retinal vascular disease characterized by the presence of aneurysmal dilations along the retinal arteriolar tree. Visual loss occurs from sequelae to proliferative changes or due to severe macular exudation and rarely from secondary vascular occlusion following laser photocoagulation of the aneurysms. We herein report a patient with a primary vascular occlusion in a patient with IRVAN and suggest that such patients may already have a natural predisposition to develop a vascular occlusion.

Comparison of the efficacy and safety of different methods of posterior subtenon injection

PURPOSE

To compare the safety and efficacy of different methods of posterior subtenon (PST) injection of corticosteroids in the treatment of cystoid macular edema secondary to intermediate uveitis.

DESIGN

Prospective comparative randomized interventional study.

PARTICIPANTS

A total number of 30 eyes with cystoid macular edema secondary to intermediate uveitis were examined.

METHODS

Patients were randomized into 3 treatment groups of 10 eyes each. Each group received PST injection of triamcinolone acetonide 0.5 mL (20 mg) by one of three methods: cannula method (group 1), Smith and Nozik method (group 2), or orbital floor injection method (group 3). Patients underwent Snellen's and ETDRS visual acuity (VA) testing, clinical evaluation, optical coherence tomography (OCT), and fundus fluorescein angiography (FFA) at baseline and follow-up visits.

OUTCOME MEASURES

Changes in Snellen and ETDRS VA, OCT retinal thickness and assessments of safety were recorded in follow-up visits.

RESULTS

Postintervention patients were followed up at the 1st, 2nd, 6th, and 12th weeks. Statistically significant (p = .00) improvement in VA was present in group1 from 0.25 +/- 0.08 (mean +/- standard deviation) to 0.75 +/- 0.24, in group 2 from 0.29 +/- 0.12 to 0.78 +/- 0.23, and in group 3 from 0.24 +/- 0.10 to 0.72 +/- 0.27. Statistically significant decrease in OCT central macular thickness (43.97% in group 1, 32.46% in group 2, and 29.75% in group 3) was noted at 12 weeks. However, the difference between individual groups at each visit did not reach statistical significance. Steroid-induced rise in intraocular pressure was observed in all the three groups with no statistical difference between individual groups.

CONCLUSIONS

The different methods of PST injection are equally efficacious in terms of improving visual acuity. However, the cannula method achieves the greatest quantitative reduction in macular thickness. As the cannula method is as efficacious as Smith and Nozik method it may be a preferable method to deliver posterior subtenon injection of corticosteroids.

Natural history of sub-retinal triamcinolone acetonide deposition after triamcinolone-assisted vitrectomy

PURPOSE

To describe the natural course of subretinal triamcinolone acetonide (TA) deposition after a TA-assisted vitrectomy for retinal detachment.

METHODS

Observational case series.

RESULTS

TA deposition was observed between the neurosensory retina and retinal pigment epithelium in the macular area at the conclusion of vitreoretinal surgery in three patients with retinal detachment. On follow up, TA granules gradually decreased over the next 2 weeks and resolved completely by 3 weeks. Two months after the operation, the retina was observed to be successfully attached and no ophthalmoscopic or functional damage was observed.

CONCLUSION

As no apparent clinically detectable adverse effect was found in the three cases that demonstrated subretinal deposition of TA we opine that active surgical maneuvers to remove the same are not warranted during surgery.

Proliferative vascular retinopathy in polymyositis and dermatomyositis with scleroderma (overlap syndrome)

AIM

To report the occurrence of proliferative vascular retinopathy in two patients with polymyositis/dermatomyositis.

METHOD

Review of case records.

RESULTS

One patient presented, six years after the diagnosis of polymyositis, with obliteration of the superior retinal vessels and associated neovascularization of the disc. The second patient with overlap syndrome was detected to have occlusion of the inferotemporal retinal arteriole and venule with early neovascularization of the retina.

CONCLUSION

Retinal vascular occlusion with development of proliferative changes can occur in polymyositis/dermatomyositis. To the best of the authors' knowledge, this has not been reported earlier in the literature.

Diffuse unilateral subacute neuroretinitis: report of a case from the Indian subcontinent and the importance of immediate photocoagulation

PURPOSE

To report a case of DUSN from the Indian subcontinent and emphasize the importance of immediate photocoagulation.

METHOD

Review of case record.

RESULT

The referring ophthalmologist had photographed the subretinal worm but had not undertaken laser photocoagulation. On presentation to us the patient had features typical of DUSN but no worm could be detected despite repeated examinations. Failure to localize the worm at subsequent examinations resulted in only partial recovery of vision.

CONCLUSION

Whenever the nematode is detected, immediate laser photocoagulation of the worm is necessary as the migratory worm may be difficult to identify later on. This is necessary to prevent the otherwise natural decline in vision.

Prospective optical coherence tomographic evaluation of the efficacy of oral and posterior subtenon corticosteroids in patients with intermediate uveitis

PURPOSE

To prospectively evaluate the efficacy of oral corticosteroids and posterior subtenon injection in the treatment of macular edema in patients with intermediate uveitis using optical coherence tomography (OCT).

METHODS

Twenty-two patients with intermediate uveitis were treated with posterior subtenon injection when the disease was unilateral (group A, n=11) or with oral steroids when the disease was bilateral (group B, n=11). Changes in macular thickness from baseline was determined using OCT in both groups at day 0, day 3, day 14, 6 weeks and 12 weeks.

RESULTS

Statistically significant improvement in Snellen visual acuity in group A was seen at 6 weeks and in group B at 2 weeks. In patients receiving oral corticosteroids, foveal thickness decreased by 63% by day 3. In those treated with posterior subtenon injection, even at day 14 only a 55% reduction of foveal thickness was evident. Spearman's correlation coefficient for visual acuity and foveal thickness was found to be significant.

CONCLUSION

OCT confirms a significantly more rapid decrease in macular edema in patients treated with oral corticosteroids. A short course of oral steroids may be useful in enabling earlier visual recovery in patients treated with posterior subtenon injection for unilateral uveitic macular edema.

Ultrasound biomicroscopy findings of 25 G Transconjuctival Sutureless (TSV) and conventional (20G) pars plana sclerotomy in the same patient

Background

Transconjunctival Sutureless Vitrectomy (TSV) is a recent advancement in vitreo-retinal surgical techniques involving the use of 25 G instruments through self-sealing sclerotomies. It has been hypothesized that there may be less chance of vitreous and retinal herniation in the scleral wound as compared to conventional sclerotomy incision. However there are no reports on differences in 20 gauge and 25 gauge sclerotomies using ultrasound biomicroscopy (UBM). We report herein the differences in sclerotomies undertaken with 20 gauge (G) and 25 gauge instruments in the same patient.

Case presentation

Ultrasound biomicroscopy of the sclerotomy sites was done in the same patient in whom both 20 G and 25 G sclerotomies had to be constructed during pars plana vitrectomy and the differences were studied.

On day 2, we observed a wide gape at the site that had been enlarged using a 20G MVR blade. In contrast, the other two sites made transconjunctivally using the 25G trocar showed only a mild gape. Significant gape continued to persist at the subsequent evaluations on day 7 and day 14 only at the port, which had been enlarged.

Conclusion

Healing of a 25 G sclerotomy is expectedly quite rapid, with inability to detect the site of sclerotomy in a short duration of 2 weeks post-operatively. This is as opposed to conventional sclerotomies, which might take up to 6–8 weeks post-operatively for complete opposition.

Prehypertension may be common in patients with central serous chorioretinopathy

PURPOSE

To test an observational hypothesis that patients with central serous chorioretinopathy (CSCR) may have a tendency towards hypertension compared with normal individuals.

METHODS

In this case-control study we evaluated resting blood pressure in 32 patients with CSCR and compared it with that in 32 healthy controls in a standard laboratory environment. Differences in resting systolic and diastolic blood pressure were measured.

RESULTS

Mean systolic blood pressure was 123.56+/-4.8 in the CSCR group and 113.63+/-12.62 in the control group. Mean diastolic blood pressure was 84.75+/-10.2 in the CSCR group and 76.75+/-0.4 in the control group. The difference in mean blood pressure values between the two groups was statistically significant.

CONCLUSION

Patients with CSCR may be predisposed to prehypertension. Hence they should be advised on lifestyle modification and followed up periodically for early detection of progression to stage 1 or 2 hypertension.

Induction of posterior vitreous separation using LASIK suction ring may have a potential role in the management of diabetic macular edema

A significant percentage of patients with diabetic macular edema respond poorly to conventional laser photocoagulation. One associated factor in such patients with refractory diabetic macular edema is the absence of posterior vitreous detachment (PVD). Several invasive methods, such as surgical induction of PVD result in resolution of macular edema and improvement in visual acuity. Being invasive such modalities may have important surgical risks, such as retinal detachment and endophthalmitis. Recently, laser in situ keratomeilusis (LASIK), a well-accepted refractive procedure, has been reported to produce posterior vitreous detachment in patients with myopia. We herein hypothesize that application of LASIK suction ring, an external procedure, may be useful in the induction of PVD in patients with refractory diabetic macular edema and may have a better safety profile.

Spontaneous Perforation of the Cornea Following Silicone Oil Keratopathy

PURPOSE

To report a sight-threatening complication of silicone oil injection for management of complex retinal detachment.

METHODS

Review of case record.

RESULTS

Spontaneous perforation of cornea may occur following silicone oil injection into an eye for complex retinal detachments. Risk factors are longer duration of oil in the eye, aphakia, silicone oil in the anterior chamber, and extensive and multiple surgeries.

CONCLUSIONS

In high-risk cases, regular assessment of corneal status and removal of silicone oil may help to prevent such a complication.

Comparative evaluation of diode laser versus argon laser photocoagulation in patients with central serous retinopathy: a pilot, randomized controlled trial [ISRCTN84128484]

BACKGROUND

To evaluate the efficacy of diode laser photocoagulation in patients with central serous retinopathy (CSR) and to compare it with the effects of argon green laser.

METHODS

Thirty patients with type 1 unilateral CSR were enrolled and evaluated on parameters like best corrected visual acuity (BCVA), direct and indirect ophthalmoscopy, amsler grid for recording scotoma and metamorphopsia, contrast sensitivity using Cambridge low contrast gratings and fluorescein angiography to determine the site of leakage. Patients were randomly assigned into 2 groups according to the statistical random table using sequence generation. In Group 1 (n = 15), diode laser (810 nm) photocoagulation was performed at the site of leakage while in Group 2 (n = 15), eyes were treated with argon green laser (514 nm) using the same laser parameters. Patients were followed up at 4, 8 and 12 weeks after laser.

RESULTS

The mean BCVA in group 1 improved from a pre-laser decimal value of 0.29 +/- 0.14 to 0.84 +/- 0.23 at 4 weeks and 1.06 +/- 0.09 at 12 weeks following laser. In group 2, the same improved from 0.32 +/- 0.16 to 0.67 +/- 0.18 at 4 weeks and 0.98 +/- 0.14 at 12 weeks following laser. The improvement in BCVA was significantly better in group 1 (p < 0.0001) at 4 weeks. At 4 weeks following laser, all the patients in group1 were free of scotoma while 6 patients in group 2 had residual scotoma (p < 0.05). The mean contrast sensitivity in group 1 improved from pre-laser value of 98.4 +/- 24.77 to 231.33 +/- 48.97 at 4 weeks and 306.00 +/- 46.57 at 12 weeks following laser. In group 2, the same improved from 130.66 +/- 31.95 to 190.66 +/- 23.44 at 4 weeks and 215.33 +/- 23.25 at 12 weeks. On comparative evaluation, a significantly better (p < 0.001) improvement was noted in group 1.

CONCLUSION

Diode laser may be a better alternative to argon green laser whenever laser treatment becomes indicated in patients with central serous retinopathy in terms of faster visual rehabilitation and better contrast sensitivity. In addition, diode laser also has the well-recognized ergonomic and economic advantages.

Insect wing conjunctival granuloma

PURPOSE

To report a case of conjunctival granuloma formation in response to lodgment of an insect wing.

METHOD

Case report and review of the literature. RESULTS Granuloma formation in the conjunctiva can occur following lodgment of an insect wing. This can cause the patient chronic redness, discharge, and discomfort.

CONCLUSIONS

Small foreign bodies with relatively little mass and large surface area can evade the normal protective mechanisms for removal of a foreign body and give rise to a chronic inflammatory response.

Posterior subtenon injection of corticosteroids using polytetrafluoroethylene (PTFE) intravenous cannula

Injection of corticosteroids into the posterior subtenon space is a well established and highly effective modality in the treatment of intermediate uveitis. The conventional technique of posterior subtenon injection involves the use of a sharp tipped 26-gauge, 5/8 inch needle that must be inserted up to its hub to obtain adequate placement of the drug into the posterior subtenon space. With this technique the risk of perforation of the globe, although minimal, remains a potential complication. Herein is described a new technique for injection of corticosteroids into the posterior subtenon space using an intravenous cannula made of polytetrafluoroethylene (PFTE) that allows safer delivery of the drug into the posterior subtenon space.