Rohan Chawla

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.

Intraoperative Optical Coherence Tomography Imaging and Assessment of the Macula During Cataract Surgery: A Novel Technique.

The authors describe a technique to qualitatively analyze the posterior segment during cataract surgery using intraoperative optical coherence tomography (iOCT). Macular iOCT can be done before and after intraocular lens implantation after the media is rendered clear following phacoemulsification. A handheld irrigating planoconcave contact lens is placed over the cornea with the operating microscope in retroillumination mode. After focusing the microscope and upon getting a clear view of the posterior segment, iOCT is switched on, centered at the macula, and focused. This technique enables the surgeon to intraoperatively analyze and document the macular morphology and vitreoretinal interface. Potential uses of this technique include intraoperative decision-making regarding concurrent use of anti-vascular endothelial growth factor agents or steroids in cases with dense cataracts where preoperative OCT is difficult. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:846-847.].

Optical Coherence Tomography Follow-up of an Unusual Case of Old Rhegmatogenous Retinal Detachment With a Hemorrhagic Macrocyst at the Macula

A 32-year-old female presented with visual acuity of hand movement close to face, an old inferior rhegmatogenous retinal detachment (RRD), and a large hemorrhagic macular macrocyst (HMM) in the right eye. After 2 weeks of successful vitreoretinal surgery, the HMM started decreasing in height and resolved by 3 months. On optical coherence tomography, a zone of hyperreflectivity in the outer retinal layers was evident on resolution of the cyst. At final follow-up, the visual acuity improved to 1/60 only. Though HMM resolved completely after retinal reattachment, alteration and thickening of microarchitecture of the outer retinal layers ensued.

Nonconforming Deep Focal Choroidal Excavation in a Patient With Choroidal Osteoma: A Diagnostic Dilemma

Evolution of an osteoma may result in neurosensory detachment, deossification, and choroidal neovascularization (CNV). The authors report a rare case of choroidal osteoma with CNV associated with a deep non-conforming focal choroidal excavation. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:944-947.].

Acute vision loss due to central retinal arterial occlusion, partial optic nerve avulsion, and hemorrhage “spurting out” from optic disc after blunt trauma

351 A seven‐year‐old male patient with sudden onset loss of vision in the left eye immediately after blunt trauma to the left eye following a fall from stairs presented to us three days after the trauma. History of epistaxis was present, although there was no history of loss of consciousness, vomiting, or convulsions. On examination, the left eye had a subconjunctival hemorrhage. Orbital emphysema was absent. The anterior segment examination and intraocular pressure of both eyes was normal. The patient had sustained a closed globe injury (CGI) with no full thickness defect in the cornea or sclera. Direct pupillary light reflex in the left eye and consensual reflex in the right eye were absent. Ocular movements were normal; there was no proptosis or enophthalmos on the left side. Vision was 6/6 in the right eye and no perception of light (NPL) in the left eye. Fundus of the right eye was normal. Fundus of the left eye showed whitening of the retina, segmentation of blood columns in the vessels with cherry red spot and blood “spurting out” from the Acute Vision Loss Due to Central Retinal Arterial Occlusion, Partial Optic Nerve Avulsion, and Hemorrhage “Spurting Out” from Optic Disc after Blunt Trauma

Vogt–Koyanagi–Harada disease in a patient of chronic myeloid leukemia

This case report describes the concurrent development of Vogt–Koyanagi–Harada (VKH) disease in a 39 year old male patient of chronic myeloid leukemia (CML). The patient being reported was a known case of CML in remission with history of painless sudden loss of vision in both eyes. Cases of leukemia can present with visual loss due to multiple ocular manifestations of leukemia itself or side effects of modern drugs used for its treatment. Clinical examination and multimodal imaging of our patient were suggestive of concurrent development of VKH. The patient was started on oral steroids, to which he showed a good response. Thus, the cases of CML may rarely develop concurrent ocular disorders not related to leukemia. These associated ocular disorders need to be distinguished from the ocular manifestations of leukemia itself. Our case highlights the concurrent development of VKH as the etiology of visual loss in a case of CML.

Triamcinolone emboli leading to central retinal artery occlusion: a multimodal imaging study

A 19-year-old man presented with unilateral sudden onset vision loss following an intra-articular triamcinolone injection in the right temporomandibular joint. At fundus examination emboli of triamcinolone were visible in multiple retinal arteries. Choroidal ischaemia and occlusion of the central retinal artery and its branches were documented at fluorescein angiography. Optical coherence tomography revealed significant thickening of the inner retinal layers. Optical coherence tomography angiography clearly demonstrated an abrupt cut-off of flow in a vessel below the optic disc. Lack of perfusion of the superficial and deep retinal plexuses beyond the areas of embolisation and at the posterior pole was also appreciated. The visual outcome was poor despite treatment.

Optical Coherence Tomography Angiography Study of Choroidal Neovascularization Associated With Focal Choroidal Excavation.

The authors report the use of optical coherence tomography angiography (OCTA) (DRI OCT Triton; Topcon, Tokyo, Japan) to localize, characterize, and confirm the presence of a choroidal neovascular membrane in a patient of focal choroidal excavation (FCE) with recent-onset metamorphopsia and visual blurring. En face OCTA images just above the level of the retinal pigment epithelium-Bruchs membrane complex typically showed the presence of a glomerulus-like neovascular network with an adjacent dark area suggestive of a Type 2 choroidal neovascularization (CNV). OCTA was found to be a very useful, noninvasive, and quick imaging modality to detect secondary CNV formation in a case of FCE. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:969-971.].

Retinal Arteriovenous Malformation Assessment Using Swept-Source OCT Angiography

Swept-source optical coherence tomography angiography (SS-OCTA) is a promising new imaging modality for assessing retinal and choroidal vasculature. Faster scanning speed, large number of A-scan acquisition, and enhanced depth penetration has enhanced the detailed analysis of retinal layers. The authors discuss SS-OCTA features of a rare case of retinal arteriovenous malformation. Image analysis revealed the anomalous large-caliber vessels occupying up to the entire retinal thickness with associated echolucent changes in the inner retinal layers surrounding the retinal vessels, along with disruption of the outer retinal layers, including the inner/outer segments of photoreceptors beneath the large tortuous vessels outside the foveola in absence of any capillary nonperfusion areas or lack of significant macular edema. At the fovea, the outer retinal layers were intact due to a smaller caliber and less-deep extension of the anomalous vessels. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:216-219.].

Letter to the Editor: Optical Coherence Tomography Angiography of Choroidal Hemangioma

Dear Editor, We read with interest the article on optical coherence tomography angiography (OCTA) of a suspected case of choroidal hemangioma.1 We want to humbly discuss a few facts. The authors mention that “To date, findings from optical coherence tomography angiography (OCTA) have yet to be reported for a choroidal hemangioma.” However, in 2017 we had published our findings in cases of choroidal hemangioma before and after treatment with laser.2 In an asymptomatic patient with an incidentally detected choroidal mass multiple differential diagnoses are possible, including metastasis. It would be interesting to know how the authors excluded other potential mimickers. In our paper, we noted that the choriocapillaris layer had multiple, well-defined hypoflow areas.2 We hypothesize that the changes seen in choriocapillaris layer may not be due to involvement by the hemangioma itself. Vascular alterations in the choriocapillaris layer could just be due to an underlying mass effect of the hemangioma. Also, laser leads to a loss of the choriocapillaris layer. Following this, the visibility of deeper vessels improved, and we could show the vessels within and around the hemangioma by sweptsource OCTA.2 Koushik Tripathy, MD Rohan Chawla, MD ICARE Eye Hospital & Postgraduate Institute Uttar Pradesh, India All India Institute of Medical Sciences New Delhi, India