Brijesh Takkar

Optical Coherence Tomography Angiography of Shallow Irregular Pigment Epithelial Detachments in Pachychoroid Spectrum Disease

family history of glaucoma and the association of axial length with intraocular pressure. Unfortunately, our study has a retrospective design and, as such, lacks specific information on the subjects’ parents. Furthermore, we enrolled only normal children without glaucoma, and so information on family history of glaucoma was not available in most cases. We did not routinely check ocular parameters such as axial length; therefore, comparing axial length with intraocular pressure was not possible. Further prospective study would be required to meet their suggestions. In closing, we agree with the opinion regarding the importance of public education on pediatric glaucoma. We hope that further prospective research on tonometers for children will facilitate detection of undiagnosed childhood glaucoma.

High-resolution Fourier-domain optical coherence tomography findings in subretinal cysticercosis.

We present the optical coherence tomography features of subretinal cysticercosis in a 12-year-old boy with presenting visual acuity of 4/60. The cyst was imaged using high-resolution Fourier-domain optical coherence tomography system (Cirrus; Zeiss Meditec, Inc, Dublin, CA). Clinical examination revealed a subretinal, domeshaped, cystic lesion below the inferotemporal arcade (Figure 1). Within the cyst, a white opacity with contractile motility was seen during examination (the scolex). Fourier-domain optical coherence tomography revealed a hyporeflective cystic subretinal lesion (Figure 2). The cyst wall facing the vitreal side was continuous and well defined (long arrow, Figure 2) while that abutting the pigment epithelial layer was discontinuous and poorly defined as a result of shadowing (arrow head, Figure 2). The scolex produced a comet-shaped echo with anterior broad hyperreflectivity and a gradually tapering hyporeflective tail (marked “S”; Figure 2). The cyst was removed using standard 3-port 23-G pars plana vitrectomy. Vitrectomy was completed after posterior vitreous detachment induction, and retinotomy was made over the area of the Fig. 1. Fundus photographs of the right eye showing sub retinal cysticercosis below the inferotemporal arcade with overlying retinal vasculature. Scolex is seen within the cyst cavity as a white opacity (arrow).

Suprachoroidal injection of biological agents may have a potential role in the prevention of progression and complications in high myopia

The prevalence of myopia and its severe/progressive visually impairing forms is increasing all over the globe. Most of the preliminary clinical research has focused on rehabilitation and treatment of its complications. Pharmacological prevention of myopic progression has shown encouraging results recently and currently the scleral structure is believed to be responsible for disease progression. In this article, we have hypothesized injecting a biological cement in the potential space between the choroid and the sclera to halt the progressive elongation of the eye ball while preventing complications related to myopia.

Blood flow pattern in a choroidal hemangioma imaged on swept-source-optical coherence tomography angiography

This report demonstrates the blood flow pattern in a case of choroidal hemangioma (CH) using swept-source-optical coherence tomography angiography (SS-OCTA). Fluorescein angiography, SS-OCT, and SS-OCTA images of a patient with CH were obtained using a standard protocol. The internal vascular pattern of the tumor was identified on both OCT and OCTA. Dark areas were identified in the CH. These were interspersed between areas of visible blood flow, as imaged on SS-OCTA. Peripheral vascular arcades were also identified within the tumor. SS-OCTA should be evaluated as an imaging tool to study the blood flow within choroidal tumors.

Optical Coherence Tomography and Multifocal Electroretinography in Diabetic Macular Edema: A Neurovascular Relation With Vision.

BACKGROUND AND OBJECTIVES To evaluate retinal neuropathy in patients with diabetic macular edema (DME) with multifocal electroretinograph (mfERG), and to evaluate the simultaneous impact of retinal neuropathy and vasculopathy on visual acuity in subtypes of DME. PATIENTS AND METHODS This prospective, controlled, investigative study conducted at a tertiary eye care center of Northern India included 79 eyes of 50 treatment-naïve patients with DME (Group 1), 94 eyes of 50 diabetic patients without diabetic retinopathy (Group 2), and 100 eyes of 100 normal volunteers as controls. Comprehensive ocular evaluation along with mfERG and optical coherence tomography (OCT) were performed for all patients. N1 and P1 mfERG waveforms in the two central-most rings of macula were evaluated for amplitudes and implicit time. OCT was used to sub-classify types of DME and evaluate macular thickness, ellipsoid zone (EZ), and external limiting membrane (ELM) disruption. Best-corrected visual acuity (BCVA) relative to other variables was the primary outcome measure. The three groups were compared for all the parameters inclusive of OCT and mfERG patterns. Further, OCT subtypes of DME were analyzed for mfERG waveform patterns. RESULTS All mfERG values were significantly lower in Group 1 and Group 2 as compared to Group 3 (P < .05). BCVA strongly correlated with central macular thickness, EZ, and ELM disruption scores in Group 1 (P = .001), but correlated modestly with mfERG waveform amplitudes in Group 1 patients with intact EZ and ELM only. BCVA correlated with mfERG amplitudes in patients with neurosensory detachment, but not in those with cystoid macular edema. CONCLUSIONS Neural changes set in before the clinical changes related to vasculopathy manifest in diabetic patients. Neuroretinopathy in patients with DME affects all retinal layers symmetrically in early stages, but impacts the middle retinal layers severely in advanced disease form. BCVA correlates with electrophysiological changes till the time morphological features are visible when stronger correlation is seen with anatomical disruption. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:626-631.].

A case of iridofundal coloboma with persistent fetal vasculature and lens subluxation

Persistent fetal vasculature and fundal coloboma are important congenital vitreoretinal disorders that can severely affect a childs visual acuity. Each disorder has its own set of potential complications. We discuss the case of a visually challenged child who presented with a combination of both these disorders, along with inferior lens subluxation.

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.

Iatrogenic parafoveal macular hole following Nd-YAG posterior hyaloidotomy for premacular haemorrhage

Premacular sub-internal limiting membrane (sub-ILM) haemorrhage is a known cause of sudden profound loss of vision. Neodymium-doped yttrium aluminium garnet (ND-YAG) posterior hyaloidotomy is an inexpensive, effective and safe treatment modality for rapid drainage of haemorrhage covering the macula. An 18-year-old male patient presented to us with a history of Nd-YAG posterior hyaloidotomy for Valsalva-related premacular bleed. At the posterior pole, a cavity formed by the detached ILM with a central defect in ILM-posterior hyaloid complex was evident. High-definition optical coherence tomography (HD-OCT) showed normal foveal contour with a parafoveal macular hole. Hence, good clinical judgement, appropriate positioning of hyaloidotomy and use of lowest possible energy level is the key to a successful and safe laser drainage of a premacular haemorrhage.

Outcomes of 27 Gauge Microincision Vitrectomy Surgery for Posterior Segment Disease

IN THEIR STUDY ENTITLED ‘‘OUTCOMESOF 27 GAUGEMICROincision Vitrectomy Surgery for Posterior Segment Disease,’’ Khan and associates present their initial experience with the 27 G microincision vitrectomy system (MIVS) in 95 eyes. The study is extremely valuable, as it includes the largest sample of patients operated with 27 G MIVS to date. The current study evaluated intraocular pressure (IOP) and reports an initial fall in IOP over the first week, after which IOP started increasing again by day 30, although minimally. This result was nearly statistically significant (P 1⁄4 .05) in the straight incision group and consistent with both types of incisions. A recently published study of patients operated with 20 G, 23 G, and 25 G vitrectomy systems found mean IOP to decrease from the baseline over a period of 3 months, followed by a steady increase toward baseline value until a follow-up of 2 years. Hence, it appears that IOP increases at a faster rate toward baseline value with a smaller gauge of MIVS. The 0.4 mm sclerotomy of the 27 G system is expected to become watertight quickly vis-à-vis the conventional vitrectomy systems. However, the overall mean IOP in the current study remained low at 3 months. The ambiguity between day 30 and day 90 results can be resolved by evaluating IOP at day 90 in both the incision groups separately, as has been done for other follow-up visits. Movement of viscous fluid through smaller-gauge cannulas is slow, and 25 GMIVS has previously been evaluated for removal of silicone oil in this regard too. It is heartening to note that converting to hybrid vitrectomy was not needed for such cases in this series. However, 3 silicone oil–filled eyes eventually needed sutures for closing a single sclerotomy site at the end of the surgery. The authors interpret this finding in terms of the type of 27 G scleral incision used. As only 1 sclerotomy needed sutures for adequate wound closure in these 3 cases, the need for suture-assisted wound closure is more likely to be linked to the excessive sclerotomy site manipulation involved owing to the complexity of the cases, as evidenced by the need for injecting silicone oil. Nearly half of the silicone oil–filled eyes needed wound suturing. During vitrectomy, it is second nature for the surgeon to hinge the eye with the cutter or the illuminator at the sclerotomy site and rotate it for adequate visualization of peripheral retinal

In response to: “Gautam N, Singh R, Agarwal A, et al. Pattern of Pediatric Uveitis at a Tertiary Referral Institute in North India”

We read with interest the study, “Pattern of Pediatric Uveitis at a Tertiary Referral Institute in North India” by Gautam et al. The study reviews 369 children retrospectively seen over a 20-year period and meticulously identifies various patterns and etiologies of pediatric uveitis. The authors use previously published criteria for diagnosing patients with ocular tuberculosis. We had analyzed and published the patterns of uveitis prospectively at our center in 2015. As in the current study, which evaluated patients below 16 years of age, anterior uveitis was also by far the commonest at our center (at ~50%). However overall (in all age groups), ocular tuberculosis was seen only in 54/980 (~5%) of patients, though it was the commonest infection associated with uveitis (54/89). This is very low in comparison with the findings of the current study, in which nearly 15% were found to have ocular tuberculosis, while 99/369 children were found to have an infective pathology. The authors have also discussed the higher than usually encountered frequency of the disease in their patients in their Table 2, the next most frequent being ~7%, and also from India. Such discrepancy in results is perhaps related to the different criteria used by different institutes to diagnose ocular tuberculosis. Even the paper describing these criteria raised this issue. Perhaps local/international workshops are needed for setting up consensus-based criteria for this disease, as is available for ocular sarcoidosis. In this regard, the criteria used for diagnosing tuberculosis used by the authors were published in 2005, whereas the patients had been enrolled since 1996, nearly a decade before. Therefore it would be very interesting to evaluate the change in trends of disease prevalence in the two periods: 1996–2005 and 2005–2015, and we urge the authors to do the same. As the population in question is pediatric, obtaining ocular samples is not possible every time; but it is necessary to label confirmed ocular tuberculosis as per the criteria. Hence, we also request the authors to ascertain the ratio of presumed versus confirmed tuberculosis. The present study indicates the possibility of a high prevalence of tuberculosis-related uveitis in this age group, and all efforts must be made to rule it out clinically, with investigations. Universally applicable/acceptable criteria are needed for a more uniform understanding.