Koushik Tripathy

Recent Advances in Management of Diabetic Macular Edema

Diabetic macular edema (DME) is the leading cause of moderate vision loss in diabetics. Modalities to image and monitor DME have evolved much in the last decade. Systemic control is the most important part of management. Available ocular management options include intravitreal antivascular endothelial growth factor (anti-VEGF) agents, laser, steroids (intravitreal or peribulbar), vitrectomy, topical medications and others. Anti-VEGF agents are increasingly being used in clinical practice with good clinical response and are currently the preferred mode of treatment worldwide.

Serial ultra wide field imaging for following up acute retinal necrosis cases

We describe two cases of acute retinal necrosis (ARN) in a post renal transplant diabetic patient and a pregnant female in the first trimester. Serial ultra wide field imaging (UWFI) with comprehensive ocular examination was done to monitor the progression of the disease. All the cases responded favorably with intravenous followed by oral acyclovir, which was captured with UWFI. UWFI provides objective proof of response to therapy in ARN. UWFI may also improve patient education and counseling for this peripheral retinal disorder.

Periarterial Plaques (Kyrieleis’ Arteriolitis) in a Case of Bilateral Acute Retinal Necrosis

Abstract Purpose: To describe unilateral periarterial plaque in a case of bilateral acute retinal necrosis (BARN) due to varicella zoster virus (VZV). Methods: Case report. Results: A 43-year-old diabetic male presented to us with dimness of vision in the left eye for three months. He was already on oral steroids and anti-viral therapy. Best-corrected visual acuity was 6/6 OD and hand movements close to face OS. The right eye showed inferior and temporal retinal thinning and pigmentation and periarterial whitish focal Kyrieleis’ plaques, specifically along arterioles. Left eye had mild vitritis, optic disc pallor, arteriolar attenuation, with retinal whitening and areas of pigmentation involving 360° of peripheral retina along with some involvement of the posterior pole. Serology for human immunodeficiency virus (HIV), herpes simplex virus (HSV), and cytomegalo virus (CMV) was negative. IgM for VZV was positive. Oral Valacyclovir 1 g thrice daily was continued and a slow taper of oral steroids was instituted. Conclusions: ARN should be considered as a differential diagnosis in cases with Kyrieleis’ plaques and a peripheral retinal examination must be done to rule out patches of healed retinitis and vasculitis.

Ultrawide field fluorescein angiogram in a family with gyrate atrophy and foveoschisis.

Gyrate atrophy of choroid and retina is an autosomal recessive condition characterized by peripheral multiple sharp areas of chorioretinal atrophy which become confluent with age. Macula and central vision is typically involved late in the disease. Macular involvements such as cystoid macular edema, epimacular membrane, and choroidal neovascularization have been reported in gyrate atrophy. In this report, we present a family with diminished central vision presenting within 8 years of age. All of three siblings had typical peripheral chorioretinal atrophic lesions of gyrate atrophy and hyperornithinemia. On spectral domain optical coherence tomography, two of elder siblings showed macular edema. Hyporeflective spaces appeared to extend from outer nuclear layer to the inner nuclear layer level separated by multiple linear bridging elements in both eyes. Ultrawide field fluorescein angiogram (UWFI) even in late phase did not show any leak at macula suggesting foveoschisis. Foveoschisis in gyrate atrophy has not been reported before.

Ultra-wide field fluorescein angiography in retinitis pigmentosa with intermediate uveitis

An 18‐year‐old man presented with a history of night blindness and decreased vision in both eyes. There was no family history of retinitis pigmentosa (RP). Best corrected visual acuity was 6/18 in his right eye and 6/24 in the left eye. On slit lamp examination, few pigmented keratic precipitates were seen in both eyes, with occasional anterior chamber cells. There were no cataracts, but retrolental cells were seen in both eyes. Intraocular pressure in both eyes was 16 mmHg. Both eyes showed mild disc pallor, pigment spicules around the equator, and inferior preretinal exudates [Figure 1]. Disc leakage and petaloid leakage in the macula were noted on ultra‐widefield fluorescein angiograms (UWFA, Figure 2). Central macular thickness (CMT) based on optical coherence tomography (Cirrus HD‐OCT, Carl Zeiss Meditec, Dublin, CA) was 500 microns in the right eye and 433 microns in the left eye [Figure 3] with intraretinal cystoid changes. Scotopic electroretinogram was extinguished, and the patient had a small visual field of 10° in both eyes. Chest Ultra‐wide Field Fluorescein Angiography in Retinitis Pigmentosa with Intermediate Uveitis

Unilateral giant peripapillary drusen and retinal drusenoid deposits in a case of X-linked retinoschisis

A 25-year-old man with X-linked retinoschisis presented with multiple giant optic nerve head drusen and multiple retinal drusenoid deposits in one eye. There was an area of coarse pigmentation in the lower half of the retina, with convex upper borders extending on either side of the optic disc, suggestive of a spontaneously resolved retinal detachment. The possible aetiopathogenesis of such occurrence is discussed.

Triads in Ophthalmology: A Comprehensive Review

Abstract Ophthalmology, like any other clinical science, is constantly evolving. As our knowledge in this field expands, we enumerate and describe classical triads of symptoms or signs with relevance to ophthalmology in this article. Characteristic clinical triads for certain systemic conditions with ocular implications are also discussed.

Internal limiting membrane: The innermost retinal barrier

Recently, peeling of internal limiting membrane (ILM) has become one of the most common and effective surgical procedures for macular disorders. The authors discuss the adverse effects of such procedures and explore the possible functions of the membrane. We also suggest a barrier function of this membrane in addition to its possible other physiological roles. Thus, apart from the well-known inner and outer retinal barriers, ILM might be the third and innermost retinal barrier. The possible evidences supporting this hypothesis are presented.

Ophthalmic examination as a means to diagnose Subacute Sclerosing Panencephalitis: an optical coherence tomography and ultrawide field imaging evaluation

BackgroundSubacute sclerosing panencephalitis (SSPE) is a potentially fatal complication of measles. The authors report a case of recurrent myoclonic jerks under investigation, whose ophthalmic examination pointed to the diagnosis.Case presentationA 12-year-old boy with recurrent episodes of myoclonic jerks was found to have optic disc pallor and an irregular macular scar with pigmentation in the left eye. The retinal finding proved to be a strong diagnostic clue for SSPE. There was a history of exanthematous fever in childhood. Antibodies against measles were detected in both the cerebrospinal fluid and serum. Retinitis with intraretinal and subretinal hemorrhage in the right eye was noted 6-weeks after the initial presentation.ConclusionThe authors describe the importance of ophthalmic evaluation in cases of recurrent myoclonic jerks. Optical coherence tomographic features and ultrawide field imaging characteristics of a case of SSPE are described.

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.