Parag K Shah

Intravitreal bevacizumab (Avastin) for post laser anterior segment ischemia in aggressive posterior retinopathy of prematurity

Aggressive posterior retinopathy of prematurity (formerly known as fulminate/type II/rush disease) occurs in zone 1 or posterior zone 2. Treatment involves extensive near confluent laser ablation of a large area of avascular retina. Anterior segment ischemia is a rare complication that can occur due to injury to the long posterior ciliary arteries in the horizontal meridians during aggressive posterior laser treatment. The outcome of this rare complication is very poor. This case describes a favorable outcome of intravitreal injection of bevacizumab (Avastin) in a case of anterior segment ischemia.

Aggressive posterior retinopathy of prematurity in large preterm babies in South India

Objective To describe aggressive posterior retinopathy of prematurity (APROP) in a subset of premature babies, having gestational age (GA) of ≥28 weeks and birth weight (BW) of ≥1000 g. Design Retrospective observational case series. Setting and Patients Case records of 99 babies, who were diagnosed to have APROP between July 2002 and October 2010 were reviewed. Fundus fluorescein angiography (FFA) was carried out in 19 babies. Results The mean GA was 31.7 weeks (range 28–35 weeks) and mean BW was 1572 g (range 1000–2310 g). All these babies received supplemental unblended oxygen 3 days or longer after birth. Of the 52 babies who had an eye exam in the neonatal intensive care unit prior to discharge, 35 babies had loss of vascularised retina from zone II to zone I and four babies from zone III to zone I, when examined as an outpatient. FFA revealed large geographic areas of vaso-obliteration (more than 30 disc areas) posterior to the shunt vessels within vascularised retina. Conclusions Features of severe capillary bed loss in the vascularised retina were seen in our cases. Oxygen could be a precipitating factor in causing this retinopathy of prematurity in large babies.

Severe retinopathy of prematurity in big babies in India: history repeating itself?

ObjectiveTo describe the characteristics of babies with severe retinopathy of prematurity (ROP) attending a tertiary referral eye hospital in South India.MethodsData on consecutive preterm infants with severe ROP presenting between July 2002 and October 2007 were retrieved from medical records. Severe ROP was defined as high risk prethreshold disease or worse.Results144 babies with severe ROP were divided into two groups: group 1 had high risk prethreshold or threshold ROP while group 2 had stages 4 or 5 ROP. The overall mean gestational age was 30.7 weeks (range 25–35 weeks) and the mean birth weight was 1410 g (range 650–2310 g). Most babies had received unmonitored supplemental oxygen (ascertained through discussion with the treating pediatricians).ConclusionMore bigger and mature babies are developing severe ROP in South India than in industrialized countries. The characteristics of babies affected are similar to those seen during the first epidemic of ROP which occurred during the 1950s in Europe and North America. Guidelines on oxygenation and screening policies should be jointly developed by pediatricians and ophthalmologists to end this epidemic of avoidable blindness in India.

Screening for retinopathy of prematurity-a comparison between binocular indirect ophthalmoscopy and RetCam 120

AIM To compare the photographic screening for retinopathy of prematurity (ROP) using RetCam 120 with binocular indirect ophthalmoscope (BIO), which is the current gold standard. SETTING AND DESIGN Prospective, comparative study. MATERIALS AND METHODS A total of 87 RetCam examinations were performed on 27 premature babies. They were stored in a separate file after deleting the identifying information. At the same visit using the BIO with scleral depression, an experienced vitreoretinal surgeon evaluated the fundus in detail. A masked examiner then evaluated the RetCam photographs for presence or absence of ROP, the stage and zone of the disease and the presence or absence of plus disease. These data were then compared with the BIO findings to determine the sensitivity, specificity and the positive and negative predictive values of the method. RESULTS ROP was detected in 63 of 87 examinations by BIO and in 56 of 87 RetCam examinations. Nine RetCam examinations were false-negative and two were false-positive. Sensitivity of RetCam was 85.71% (54/63) and specificity was 91.66% (22/24). The positive and negative predictive values were 96.43% and 70.97% respectively. CONCLUSION Nine cases having ROP were missed by the RetCam. All these cases were either in zone 3 or the outer part of zone 2, which later regressed. These were missed mostly because of the restricted mobility of the camera head caused by its size and the barrier caused by the lid speculum arms. No case of threshold ROP was missed. RetCam may replace BIO for screening of ROP.

Fulminate retinopathy of prematurity - clinical characteristics and laser outcome.

PURPOSE To analyse the clinical characteristics and treatment outcome of zone 1 Fulminate type of Retinopathy of Prematurity (ROP) and compare it to Conventional ROP. METHODS Preterm infants from two neonatal intensive care units (NICU) born between July 2002 and November 2003 were screened for ROP. Cases with Conventional ROP were classified according to the International Classification of Retinopathy of Prematurity (ICROP) while that of Fulminate ROP according to Shapiros classification. Threshold disease was kept the cut off for treatment for Conventional ROP and stage 3A for Fulminate ROP. RESULTS Of the 54 cases that had treatable ROP, 36 (66.67%) had Fulminate type. The mean gestational age and birth weight was higher in Fulminate ROP compared to Conventional disease (31.75 weeks and 1554 gms vs 31 weeks 1387 gms) whereas the mean postnatal age at laser was lower (4.62 weeks vs 6.3 weeks). The average number of laser spots given was 3036.6 for Fulminate disease. CONCLUSION Fulminate ROP had an atypical morphology which was difficult to classify according to ICROP classification and we would like to lay stress upon the importance of screening of premature infants from the age of 4 weeks and to start treatment immediately once Fulminate ROP has been diagnosed.

Retinopathy of prematurity: Past, present and future.

Retinopathy of prematurity (ROP) is a vasoproliferative disorder of the retina occurring principally in new born preterm infants. It is an avoidable cause of childhood blindness. With the increase in the survival of preterm babies, ROP has become the leading cause of preventable childhood blindness throughout the world. A simple screening test done within a few weeks after birth by an ophthalmologist can avoid this preventable blindness. Although screening guidelines and protocols are strictly followed in the developed nations, it lacks in developing economies like India and China, which have the highest number of preterm deliveries in the world. The burden of this blindness in these countries is set to increase tremendously in the future, if corrective steps are not taken immediately. ROP first emerged in 1940s and 1950s, when it was called retrolental fibroplasia. Several epidemics of this disease were and are still occurring in different regions of the world and since then a lot of research has been done on this disease. However, till date very few comprehensive review articles covering all the aspects of ROP are published. This review highlights the past, present and future strategies in managing this disease. It would help the pediatricians to update their current knowledge on ROP.

Severe aseptic orbital cellulitis with subtenon carboplatin for intraocular retinoblastoma

Retinoblastoma is a rare intraocular tumor of childhood. Chemoreduction followed by laser or cryotherapy is the treatment of choice. Subtenon carboplatin injection is also an accepted treatment modality for vitreous seeds, along with systemic chemotherapy. Transient periocular edema, optic neuropathy and fibrosis of orbital tissues are the known side effects of subteneon carboplatin injection. We report a case of severe aseptic orbital cellulitis with necrosis and prolapse of the conjunctiva 48 h after the injection, which resolved well on only conservative management.

Combination therapy of low-fluence photodynamic therapy and intravitreal ranibizumab for choroidal neovascular membrane in choroidal osteoma

Choroidal osteoma is an unusual form of intraocular calcification seen in otherwise healthy eyes. It is a benign idiopathic osseous tumor of the choroid, typically seen in young females. Choroidal neovascular membrane (CNVM) is a complication seen in one-third of these patients and carries a poor visual outcome. We report a case of a 25-year-old hyperthyroid female with choroidal osteoma and subfoveal CNVM in her left eye which was successfully treated using low-fluence photodynamic therapy (PDT) with verteporfin followed by a single injection of intravitreal ranibizumab.

Idiopathic pediatric retinal artery occlusion

We report a case of branch retinal artery occlusion (BRAO) in a healthy young girl. An eight-year-old girl presented with sudden loss of vision in her left eye. She had a pale retina with macular edema consistent with extensive BRAO. A thorough workup was performed to determine any etiologic factor. All test results were within normal limits. Her visual acuity improved from finger counting to 20/40 over two weeks, on immediate treatment with intravenous steroids (methyl prednisolone). This case suggests that BRAO can occur in healthy children without any detectable systemic or ocular disorders and a dramatic improvement may be achieved with prompt treatment with intravenous steroids.

Is myopia a protective factor against central serous chorioretinopathy

AIM To evaluate if any association exists between central serous chorioretinopathy (CSCR) and the refractive status of the eye. METHODS This retrospective, institutional, case control study included 499 patients, wherein 262 patients diagnosed as acute CSCR, were compared with an age and gender matched control group of 237 patients. All patients were evaluated with a detailed systemic and ocular history, objective and subjective refractions for both eyes and complete ocular examination by a retina specialist, at all visits. Optical coherence tomography confirmed the diagnosis of CSCR. RESULTS The mean age was found to be 40±7y in the study group (Group 1) compared to 38±10y in the control group (Group 2). Most common refractive status in the study group, was emmetropia seen in 191 patients (72.9%), followed by hypermetropia seen in 47 patients (17.9%) and astigmatism seen in 21 patients (8.0%). Only 3 subjects (1.1%) had myopia, which was less than or equal to 1.0 D, compared to 70 subjects (29.5%) in the control group, suggesting a statistically significant lower incidence of CSCR among the myopic patients (P< 0.0001). With respect to the systemic factors, 26 (9.9%) patients were using systemic steroids in the study group (Group 1) compared to none in the control group (Group 2) suggesting a statistically significant association of CSCR with systemic steroid use (P<0.05). No other significant systemic risk factors were noted. CONCLUSION Though CSCR is a multifactorial disease, myopia serves as a protective factor for CSCR. Thus, myopic eyes are less likely to develop CSCR. Since both retinal pigment epithelium (RPE) and choriocapillaris are postulated in the pathogenesis of CSCR, chorio-retinal thinning and atrophy seen in myopic eyes are less likely to cause CSCR.