Giridhar Anantharaman

Clinical features, management and visual outcome of polypoidal choroidal vasculopathy in Indian patients.

Aims: To present the clinical, indocyanine green angiography (ICGA) features and results of treatment for polypoidal choroidal vasculopathy (PCV) in Indian patients by a retrospective chart review. Materials and Methods: Forty five patients with PCV underwent complete ocular examination, fluorescein angiography (FFA) and ICGA. Treatment was advised for patients with macular involvement and progressive loss of visual acuity. Demographic data, clinical features and results of treatment were analyzed. Results: Mean age at presentation was 61.06 years. Mean follow up was 18 months. The disease was more prevalent in males. Forty three patients had unilateral disease. The most common location of polyps in ICGA was subfoveal (42.5%). Exudative form was seen in 34 of the 47 eyes and the remaining 13 eyes had a hemorrhagic presentation. Thirty four eyes underwent treatment which included thermal laser (n = 11), photodynamic therapy (PDT) (n = 11) and transpupillary thermo therapy (TTT) (n = 12). Statistical analysis was done using the Chi-square test. Subgroup analysis of visual outcome following various modalities of treatment showed that the results of PDT (P < 0.001) and thermal laser (P < 0.001) were statistically significant. Conclusions: PCV is an important differential diagnosis in patients presenting with serosanginous maculopathy and submacular hemorrhage. The disease was more prevalent in males and was unilateral in the Indian population. Timely intervention in cases with symptomatic polyps could achieve stabilization of visual acuity. Thermal laser and PDT were safe and effective.

Pilomatrix carcinoma of the eyebrow.

Pilomatrix carcinoma is an uncommon malignant neoplasm originating from the hair follicle matrix. It occurs more frequently in head and neck region and rarely on the eyelid and eyebrow. It is often clinically misdiagnosed. The diagnosis is confirmed by excision biopsy and histopathological examination. A 68-year-old woman presented with a mass on her left eyebrow mimicking sebaceous cyst. An excisional biopsy with 4-mm margin was performed under frozen section. Histopathology demonstrated pilomatrix carcinoma with cystic degeneration. Periocular malignancies can have unusual origins with specific clinical features. Preoperative clinical examination is mandatory to rule out unusual features and thereby ensure appropriate management to prevent serious complications.

Ranibizumab-induced retinal reperfusion and regression of neovascularization in diabetic retinopathy: An angiographic illustration

Purpose To report regression of neovascularization and reperfusion of ischemic areas of the retina on Wide-field Digital Fluorescein Angiography following anti-vascular endothelial growth factor injections in a patient with active Proliferative Diabetic Retinopathy. Observations Case report of sixty-one-year-old male patient with proliferative diabetic retinopathy and diabetic macular edema documented on wide field digital fluorescein angiography. The patient was treated with three intravitreal injections of ranibizumab given at monthly intervals. Repeat angiography after third intravitreal injection revealed complete regression of new vessels. Moreover, there was evident improvement in perfusion in the previously noted ischemic areas of the retina. Conclusion and importance Intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections are a valuable treatment option for reversing neovascularization in eyes with proliferative diabetic retinopathy with fewer side effects when compared to standard pan-retinal photocoagulation. Additionally, we also illustrate restoration of retinal perfusion post anti-VEGF therapy indicative of pre-existingsalvageableischemic retina tissue.

Periocular dirofilariasis mimicking lacrimal sac mucocoele.

Abstract Dirofilariasis is a zoonotic infection caused by filarial nematodes belonging to the genus dirofilariae. Dirofilaria is commonly seen in dogs, cats and other carnivorous animals world wide. Mosquitoes of the genus Culex, Anopheles and Aedes are the vectors and the humans are either incidental hosts or dead-end hosts. It affects lungs, liver and other visceral organs. Ocular involvement is rarely been reported. We present a case of 51-year-old female from Kerala, the southern State of India presented with a mass mimicking lacrimal sac mucocoele whose biopsy is proved to be dirofilariasis.

Real-world evidence of safety profile of intravitreal bevacizumab (Avastin) in an Indian scenario

Purpose: The purpose of this study was to evaluate the safety profile of intravitreal bevacizumab (Avastin) as an off-label pharmacotherapeutic agent for various ocular conditions. Methods: Retrospective analysis was carried out on 3806 injections of 1761 patients that were administered with intravitreal bevacizumab injection at a tertiary eye care center in India. The injections were administered on a pro re nata basis for various indications such as age-related macular degeneration (AMD), diabetic macular edema (DME), and retinal vein occlusion (RVO). Results: The mean age of the patients was 61.8 ± 11.59 years. A total of 59.2% of the patients were men and 40.8% women. The most common indications for which the injection was administered were DME (27.5%), AMD (26%), and branch RVO (12.3%). Among the ocular side effects, endophthalmitis was seen in three eyes (0.08%), retinal breaks in none of the eyes whereas 35 eyes had a rise in intraocular pressure (IOP) >21 mmHg (0.9%). Preexisting glaucoma was present in four eyes while remaining 31 eyes did not have any history of glaucoma. IOP rise was significantly more in eyes with preexisting glaucoma as compared to nonglaucomatous eyes (P = 0.04). No systemic adverse events were noted in our study population. Conclusion: Our study provides real-world evidence regarding the safety profile of intravitreal bevacizumab (Avastin). These data suggest that bevacizumab is a safe and economical pharmacotherapeutic agent that can be administered for a variety of ocular disorders. Analyzing the safety of bevacizumab is necessary for a developing country like India as the majority of the population cannot afford the costly ranibizumab as compared to bevacizumab for ocular healthcare.

Spectral domain optical coherence tomography-guided laser treatment of central serous chorioretinopathy in a pregnant woman.

PURPOSE To report a case of central serous chorioretinopathy treated with focal laser photocoagulation guided by spectral domain optical coherence tomography (SD-OCT) without fluorescein angiography. METHODS In this interventional case report, a 27-year-old pregnant lady with central serous chorioretinopathy was evaluated with fundus photography and SD-OCT. She was treated with focal laser photocoagulation to the area of micro rip on the summit of pigment epithelial detachment identified by SD-OCT. RESULTS Successful treatment of serous macular detachment using SD-OCT in a pregnant lady. CONCLUSION We report a case of central serous chorioretinopathy evaluated and treated successfully with SD-OCT without the use of fluorescein angiography.

Real-time in vivo micromorphology and histopathology of choroidal osteoma using enhanced depth imaging.

Choroidal osteoma is a usually unilateral benign tumor of the choroid composed of mature bone. Optical coherence tomography (OCT) has been used to image osteoma for several years. With the advent of enhanced depth imaging (EDI) feature of spectral-domain OCT (SD-OCT), better visualization of the morphology of choroidal lesions has been possible. Herein we present a case of choroidal osteoma in a 45-year-old woman, wherein in vivo morphology of the choroidal osteoma had been visualized using EDI technique of SD-OCT before and after performing photodynamic therapy. EDI OCT has proven to be a valuable noninvasive imaging modality, almost comparable to histopathological examination, for diagnosing choroidal osteomas and for providing an insight into the in vivo micromorphological changes occurring during the course of the disease.

Spectral domain optical coherence tomography findings in tamoxifen retinopathy--a case report.

PURPOSE To report spectral domain optical coherence tomography findings in a case of typical tamoxifen retinopathy. METHODS In this observational case report, a patient with tamoxifen retinopathy was imaged with spectral domain optical coherence tomography and fundus auto fluorescence. RESULTS Spectral domain optical coherence tomography showed numerous hyperreflective spots within the retina, mainly in the inner retinal layers in both the eyes. The external limiting membrane, the Inner Segment-Outer Segment junction, and the photoreceptors were not discernable at the fovea in the right eye. In the left eye, there was foveal atrophy with total loss of photoreceptors. The autofluorescent images showed macular hypofluorescence with foveal hyperfluorescence. CONCLUSION Spectral domain optical coherence tomography demonstrated abnormalities in the outer retinal layers in tamoxifen retinopathy. There were also characteristic alterations in the autofluorescence pattern at the macula in tamoxifen retinopathy.

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.

Management of recalcitrant polypoidal choroidal vasculopathy by feeder vessel laser photocoagulation

Purpose To describe management of residual branch vascular network (BVN) in polypoidal choroidal vasculopathy (PCV) by thermal laser photocoagulation of feeder vessel. Observations Case report of sixty-four year old female with polypoidal choroidal vaculopathy (PCV) with moderate response to seven doses of intravitreal ranibizumab, six doses of intravitreal bevacizumab and one session of photodynamic therapy (PDT). The patient has resolved polyps but persistence of disease activity due to residual BVN and large pigment epithelial detachment (PED). Patient underwent thermal laser photocoagulation of feeder vessel of BVN identified on indocyanine green angiography (ICGA). There was complete resolution of residual BVN and large PED, which was confirmed on ICGA. Conclusions and Importance Recalcitrant cases of PCV without polyps but having BVN with feeder vessel can be managed by ICGA guided thermal laser photocoagulation. The case report illustrates the importance of utilizing multimodal imaging such as video indocyanine green angiography (ICGA) for identification of feeder vessel and its deployment for optimal management of refractory PCV.