Charu Gupta

Combined treatment of intravitreal bevacizumab and intravitreal triamcinolone in patients with retinal vein occlusion

Dear Editor, We read with interest the article “Combined treatment of intravitreal bevacizumab and intravitreal triamcinolone in patients with retinal vein occlusion: 6 months of follow-up” by Ehrlich et al. [1]. We congratulate the authors for their interesting study and offer our comments. One major advantage we feel that the authors have not adequately highlighted is the much lower re-injection rate of 2±0.81 in their patients compared to previously published reports with bevacizumab monotherapy alone where monthly injections have been proposed in order to maintain a favorable outcome [2]. We postulate that the reason that repeated administration of intravitreal bevacizumab alone could result in a progressive decrease in biological response could be attributed to tachyphylaxis. Schaal et al. [3] proposed that one solution to avoid this decrease in the biologic effect would be to combine drugs with different modes of action. They demonstrated that combining bevacizumab with triamcinolone acetonide partially alleviated the efficacy decrease observed with bevacizumab alone. We propose that this could be one of the mechanisms by which the re-injection rate would be decreased by using combination therapy, compared to monotherapy with anti-VEGF injections alone. Also, nine out of the 16 patients studied in the article had received previous treatment and there is no data provided on whether these eyes behaved differently anatomically or functionally vis-a-vis the treatment naive eyes. It would be of interest to know if prior monotherapy with anti-VEGF agents had any effect on the subsequent course of the disease and whether this subset of patients differed in their response to treatment, recurrence of edema, and visual recovery compared to treatment of naive eyes.

Non-contact Ultra-widefield Imaging in Lasered Retinopathy of Prematurity

To the Editor: Retinopathy of prematurity (ROP) still remains a challenging condition to detect, image, document and treat. Documentation has become necessary in recent times due to advancement in telemedicine, newer treatment modalities like intravitreal anti-VEGF injections [1] and medicolegal implications. It is important to note that despite advancements in imaging modalities, indirect ophthalmoscopy with scleral depression remains the gold standard for retinal evaluation in ROP management. Currently used Retcam® (Clarity Medical Systems, Inc., Pleasanton, CA) became commercially available in 1997. Retcam utilizes a contact lens with a fiberoptic cable light source connected to a computer monitor for retinal imaging. Its shortcomings include relatively limited field of view (130 degrees) [2] and being a contact system, would be avoided in the immediate post intravitreal injection period to minimize chances of infections. Optos® 200Tx scanning laser ophthalmoscope (Optos PLC, Dunfermline, Scotland) is a recently introduced noncontact ultra wide field (UWF) retinal imaging system. Optos utilizes the optics of an ellipsoid mirror, which has two focal points to create images of the peripheral retina, thereby capturing up to 200 degrees of retina in a single image [3]. Limitations of this modality include high cost of equipment and the need for the operator to be trained in its use. Due to its large size, it is not easy to transport the Optos, unlike the Retcam which is a portable device and can easily be manoeuvred into pediatric nurseries for screening purpose. Patel et al. evaluated its role in ROP babies elegantly using the Bflying baby^ position [4]. We present retinal images from a premature infant born at 27 wk who underwent laser for ROP stage 3 in zone 2. At 38 wk while the right eye shows well regressed disease (Fig. 1), the left eye shows skip areas with preretinal hemorrhage (Fig. 2) for which laser augmentation was done. We believe this to be the first report of UWF non-contact imaging for ROP from the Indian subcontinent with this new imaging modality.

Polypoidal choroidal vasculopathy: Pearls in diagnosis and management

Polypoidal choroidal vasculopathy (PCV) is increasingly recognized as an important cause of exudative maculopathy in Asians as against Wet age-related macular degeneration in Caucasians. A panel of retinal experts methodically evaluated pertinent updated literature on PCV with thorough PubMed/MEDLINE search. Based on this, the panel agreed upon and proposed the current consensus recommendations in the diagnosis (clinical and imaging), management and follow-up schedule of PCV. Diagnosis of PCV should be based on the gold standard indocyanine green angiography which demonstrates early nodular hyperfluorescence signifying the polyp with additional features such as abnormal vascular network (AVN). Optical coherence tomography is an excellent adjuvant for diagnosing PCV, monitoring disease activity, and decision-making regarding the treatment. Current treatment modalities for PCV include photodynamic therapy, anti-vascular endothelial growth factor agents, and thermal laser. Choice of specific treatment modality and prognosis depends on multiple factors such as the location and size of PCV lesion, presence or absence of polyp with residual AVN, amount of submacular hemorrhage, presence or absence of leakage on fundus fluorescein angiography, visual acuity, and so on. Current recommendations would be invaluable for the treating physician in diagnosing PCV and in formulating the best possible individualized treatment strategy for optimal outcomes in PCV management.

Hybrid 20/23-G pars plana vitrectomy in endophthalmitis and trauma: a strategic approach

Purpose: To assess the safety and efficacy of hybrid vitreous surgery combining active 23-G ports with a sutured 20-G 6-mm infusion cannula for performing vitrectomy in endophthalmitis and trauma. Methods: This is a retrospective analysis of 10 eyes with endophthalmitis and 10 eyes with trauma requiring vitreous surgery, having corneal clarity suitable for vitrectomy and best-corrected visual acuity (BCVA) greater than or equal to light perception. All patients underwent hybrid 20/23-G vitrectomy. Intraoperative notes were analyzed for peroperative complications. The BCVA and retinal status at 3 months were analyzed. Results: In the endophthalmitis group, patients ranged from 5 to 85 years of age and showed varied etiologies. Retinal detachment was present in 5 eyes, which received silicone oil tamponade. Mean preoperative logMAR visual acuity (VA) was 2.29 ± 0.45, which improved to 1.10 ± 0.72 at 3 months postoperatively (p<0.001). Trauma cases ranged from 21 to 75 years of age. Retinal detachment was present in 9 out of 10 eyes, all of which received silicone oil tamponade. Preoperative logMAR VA was 2.26 ± 0.71, which improved to 1.33 ± 0.50 postoperatively (p<0.001). At 3 months postsurgery, the retina was attached in all eyes in both groups. Conclusions: The longer sutured 20-G cannula was easier to visualize through fibrin, exudates, and hemorrhage and did not slip out or enter the suprachoroidal space in any of our cases. The 23-G active ports and vitrectomy cutter enhanced safety and efficacy. Hybrid vitrectomy enabled safe surgery in these difficult cases.

Chandelier scleral buckling for retinal detachment in Stevens-Johnson syndrome

A 40-year-old uniocular man presented with a 2-week history of a sudden decrease in vision in the left eye. Visual acuity was light perception with inaccurate projection of rays OD and counting fingers at 1 m, N48 OS. The patient had a history of loss of vision in the right eye 30 years previously because of postvaricella (chicken pox) Stevens-Johnson syndrome. The right showed a total leucomatous corneal opacity (Fig. 1). The left eye showed a vascularized corneal scar involving the nasal two-thirds of cornea, with superficial punctate keratitis. Slit-lamp examination showed keratinization of eyelid margins, congested and inflamed ocular surface, and diminished or near-total absence of tear meniscus in both eyes. He was pseudophakic with a decentred intraocular lens (IOL) in the sulcus. Because of the compromised cornea and nasal corneal opacity, it was extremely difficult to visualize the retinal detachment, which was located in the temporal quadrant on indirect ophthalmoscopy. The presence and extent of the retinal detachment was imaged on ultrasound B scan (Fig. 2). This confirmed a temporal retinal detachment affecting the macula. In view of the significant corneal opacity, intraoperative visualization of the retina posed a major challenge. Various treatment options were discussed. The patient had been comfortable with his level of vision in his only seeing eye before the recent retinal detachment. To circumvent the problem of intraoperative visualization, we planned a modified scleral buckling procedure with a wide-angle noncontact viewing system using 25-gauge chandelier endoillumination. Conjunctival peritomy was performed, and the recti muscles were tagged. A 25-gauge pars plana cannula was placed superiorly at 3.5 mm from the limbus, and the chandelier light (Alcon, Fort Worth, Tex.) (Fig. 3) was inserted and secured. Under its illumination, the retinal detachment could be visualized through the operating microscope on the wide-angle viewing system (Resight;

Ultra-widefield versus conventional angiography in a postvitrectomy, partially gas-filled eye.

We present a case where need for intervention in the fellow eye led us to a chance discovery in a postvitrectomy, gas-filled eye. Although theoretically aware of the ability of wide field imaging through gas, we captured the images presented by sheer serendipity. A 38-year-old-man with OU proliferative diabetic retinopathy (PDR) and vitreous haemorrhage in OD underwent vitrectomy with perfluoropropane gas injection. Imaging was planned after absorption of the gas. However, 3 weeks postoperatively, he reported of seeing a floater in the unoperated eye. To perform immediate angiography-guided laser, we performed fundus fluorescein angiography (FFA) with Topcon TRC-50DX (Topcon, Tokyo, Japan) as well as on Optos (Dunfermline, Scotland). Conventional angiography captured blurred images …