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   2018| Dec  | Volume 66 | Issue 12  
    Online since November 19, 2018

 
 
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REVIEW ARTICLES
Diabetic macular edema: Evidence-based management
David J Browning, Michael W Stewart, Chong Lee
Dec 2018, 66(12):1736-1750
DOI:10.4103/ijo.IJO_1240_18  PMID:30451174
Diabetic macular edema (DME) is the most common cause of vision loss in patients with diabetic retinopathy with an increasing prevalence tied to the global epidemic in type 2 diabetes mellitus. Its pathophysiology starts with decreased retinal oxygen tension that manifests as retinal capillary hyperpermeability and increased intravascular pressure mediated by vascular endothelial growth factor (VEGF) upregulation and retinal vascular autoregulation, respectively. Spectral domain optical coherence tomography (SD-OCT) is the cornerstone of clinical assessment of DME. The foundation of treatment is metabolic control of hyperglycemia and blood pressure. Specific ophthalmic treatments include intravitreal anti-VEGF drug injections, intravitreal corticosteroid injections, focal laser photocoagulation, and vitrectomy, but a substantial fraction of eyes respond incompletely to all of these modalities resulting in visual loss and disordered retinal structure and vasculature visible on SD-OCT and OCT angiography. Efforts to close the gap between the results of interventions within randomized clinical trials and in real-world contexts, and to reduce the cost of care increasingly occupy innovation in the social organization of ophthalmic care of DME. Pharmacologic research is exploring other biochemical pathways involved in retinal vascular homeostasis that may provide new points of intervention effective in those cases unresponsive to current treatments.
  6,251 1,412 -
FEATURED REVIEW
Central retinal artery occlusion
Sohan Singh Hayreh
Dec 2018, 66(12):1684-1694
DOI:10.4103/ijo.IJO_1446_18  PMID:30451166
The pathogeneses, clinical features, and management of central retinal artery occlusion (CRAO) are discussed. CRAO consists of the following four distinct clinical entities: non-arteritic CRAO (NA-CRAO), transient NA-CRAO, NA-CRAO with cilioretinal artery sparing, and arteritic CRAO. Clinical characteristics, visual outcome, and management very much depend upon the type of CRAO. Contrary to the prevalent belief, spontaneous improvement in both visual acuity and visual fields does occur, mainly during the first 7 days. The incidence of spontaneous visual acuity improvement during the first 7 days differs significantly (P < 0.001) among the four types of CRAO; among them, in eyes with initial visual acuity of counting finger or worse, visual acuity improved, remained stable, or deteriorated in NA-CRAO in 22%, 66%, and 12%, respectively; in NA-CRAO with cilioretinal artery sparing in 67%, 33%, and none, respectively; and in transient NA-CRAO in 82%, 18%, and none, respectively. Arteritic CRAO shows no change. Recent studies have shown that administration of local intra-arterial thrombolytic agent not only has no beneficial effect but also can be harmful. Investigations to find the cause and to prevent or reduce the risk of any further visual problems are discussed. Prevalent multiple misconceptions on CRAO are discussed.
  5,864 1,314 -
REVIEW ARTICLES
Current management of diabetic tractional retinal detachments
Michael W Stewart, David J Browning, Maurice B Landers
Dec 2018, 66(12):1751-1762
DOI:10.4103/ijo.IJO_1217_18  PMID:30451175
Twenty-five percent of diabetes-related vision loss stems from complications of proliferative diabetic retinopathy (PDR). Panretinal photocoagulation has been the preferred treatment of high-risk PDR for decades and more recently intravitreal injections of drugs that inhibit the actions of vascular endothelial growth factor have become popular. But despite these treatments PDR may progress uncontrollably to advanced pathologies such as traction retinal detachments (TRDs), combined traction/rhegmatogenous retinal detachments (TRD/RRDs), vitreous hemorrhages, rubeosis iridis, and traction maculopathies, which produce mild-to-severe loss of vision. TDR have long been the most common indication for PDR-related vitreoretinal surgery. Vitrectomy surgery is indicated for recent (<6 months duration) TRD involving the macula, progressive TRD that threatens the macula, and recent data suggest that chronic macula-involving TRDs (>6 months duration) may also benefit. Combined TRD/RRD represents a particularly challenging surgical condition but advances in surgical instrumentation, dissection techniques, and post-operative tamponade have produced excellent success rates. The recent development of small-gauge vitrectomy systems has persuaded most surgeons to switch platforms since these appear to produce shorter surgical times and quicker post-operative recoveries. Pre-operative injections of bevacizumab are frequently administered for persistent neovascularization to facilitate surgical dissection of pre-retinal fibrosis and reduce the incidence of post-operative hemorrhages. Recent trends toward earlier surgical intervention and expanded indications are likely to continue as surgical instrumentation and techniques are further developed.
  4,087 715 -
REVIEW ARTICLE
Management of chronic central serous chorioretinopathy
Daren Hanumunthadu, Anna C S Tan, Sumit Randhir Singh, Niroj Kumar Sahu, Jay Chhablani
Dec 2018, 66(12):1704-1714
DOI:10.4103/ijo.IJO_1077_18  PMID:30451170
New treatment modalities for the management of central serous chorioretinopathy (CSC) now exist. While acute CSC generally resolves without the requirement for intervention, chronic CSC has been associated with persistent disruption in visual function. Current treatment approaches include photodynamic therapy, oral aldosterone antagonism and subthreshold multifocal laser. There has also been further investigation into a number of new treatments including antivascular endothelial growth factor treatment. Further investigation using developing optical coherence tomography imaging is helping to determine biomarkers of CSC activity, potential indicators of treatment response and indications of chronicity of disease activity. Further comparative study is required to determine the effectiveness of different forms of treatment in a range of patients with varied demographics, aetiology and chronicity of disease.
  3,956 798 -
REVIEW ARTICLES
Management of recurrent rhegmatogenous retinal detachment
Manish Nagpal, Pranita Chaudhary, Shachi Wachasundar, Ahmed Eltayib, Aparajita Raihan
Dec 2018, 66(12):1763-1771
DOI:10.4103/ijo.IJO_1212_18  PMID:30451176
Rhegmatogenous retinal detachment (RRD) repair is one of the most common vitreoretinal surgeries a surgeon performs. In an ideal scenario, RRD can be repaired with a single surgical intervention; however, despite excellent skill, flawless technique, and the introduction of high-end technology, up to 10% of cases require additional interventions to ultimately repair recurrent detachments. It is thus important to study the outcomes of multiple interventions to understand whether performing repeat vitrectomy on patients with a history of failed surgeries is worthwhile. Thus, recurrent retinal detachment (re-RD) remains a significant challenge for vitreoretinal surgeons as well as the patients considering the economic and the emotional burden of undergoing multiple interventions. The advent of microincision vitrectomy system, perfluorocarbon liquids, and effective intraocular tamponades has opened new doors for managing re-RDs. In this article, we have reviewed and summarized the various causes and approaches for management for optimal anatomical and functional outcomes.
  2,936 522 -
ORIGINAL ARTICLES
”Double-layer sign” on spectral domain optical coherence tomography in pachychoroid spectrum disease
Jay Sheth, Giridhar Anantharaman, Shruti Chandra, Sobha Sivaprasad
Dec 2018, 66(12):1796-1801
DOI:10.4103/ijo.IJO_377_18  PMID:30451181
Purpose: The “double-layer sign (DLS)” describes the shallow and irregular elevation of the retinal pigment epithelium from the underlying intact Bruch's membrane visualized on the spectral domain optical coherence tomography. In this study, we evaluated the frequency, characteristics of the space within the double layer and other features in the pachychoroid spectrum to aid the clinical diagnosis of these variants. Methods: This retrospective study evaluated the features of the DLS on multimodal imaging in consecutive patients with a clinical diagnosis of one of the four variants of pachychoroid: pachychoroid pigment epitheliopathy (PPE), pachychoroid neovasculopathy (PCN), chronic central serous chorioretinopathy (CCSCR), and polypoidal choroidal vasculopathy (PCV). The features of the DLS were graded by two masked graders. Results: Overall, 102 eyes of 79 consecutive patients with pachychoroid spectrum were identified for grading. Sixteen eyes with PPE did not show any evidence of DLS. The DLS was identified in 15/16 (93.75%) eyes with PCN, 11/35 (31.43%) with CCSCR, and 32/35 (91.43%) with PCV (P < 0.001). The space within the DLS showed moderate hyperreflectivity in all eyes with PCV and PCN, while the space in the DLS in CCSCR showed uniform hyporeflectivity in 10/11 (%) eyes. Conclusion: The DLS sign was most frequent in polypoidal vasculopathy and PCN. A hyporeflective gap within the DLS favored the diagnosis of CCSCR.
  2,903 513 -
REVIEW ARTICLES
Current management strategy of polypoidal choroidal vasculopathy
Christine P S Ho, Timothy Y Y Lai
Dec 2018, 66(12):1727-1735
DOI:10.4103/ijo.IJO_975_18  PMID:30451173
Polypoidal choroidal vasculopathy (PCV) is a retinal disorder commonly found in Asians presenting as neovascular age-related macular degeneration and is characterized by serous macular detachment, serous or hemorrhagic pigment epithelial detachment, subretinal hemorrhage, and occasionally visible orange-red subretinal nodular lesions. PCV is diagnosed using indocyanine green angiography (ICGA), and the lesions appear as polypoidal aneurysmal vascular lesions with or without abnormal branching vascular network. Although ICGA remains the gold standard for the diagnosis of PCV, various imaging modalities have also facilitated the diagnosis and monitoring of PCV. Recent advances in imaging technology including the use of high resolution spectral domain optical coherence tomography (OCT) and OCT angiography have provided new insights on the pathogenesis of PCV, suggesting a link between PCV and pachychoroid spectrum of macular disorders. With the evolving understanding on the pathogenesis and clinical characteristics of PCV, different therapeutic options have been proposed. These include intravitreal anti-vascular endothelial growth factor (anti-VEGF) monotherapy, combination therapy with anti-VEGF and verteporfin photodynamic therapy, and thermal laser photocoagulation. In recent years, major multi-center randomized clinical trials such as EVEREST, EVEREST II, and PLANET studies have been conducted to compare the efficacy and safety of various treatment options for PCV. This review aims to summarize the results of recent literature, clinical trials and studies to provide an update on the management options of PCV. An overall management strategy for PCV will also be proposed.
  2,252 609 -
LIVING LEGENDS IN OPHTHALMOLOGY
Living legend in ophthalmology - Prof. Sohan Singh Hayreh

Dec 2018, 66(12):1673-1673
DOI:10.4103/0301-4738.245650  PMID:30451163
  2,129 505 -
REVIEW ARTICLES
Choroidal biomarkers
Francesco Pichi, Kanika Aggarwal, Piergiorgio Neri, Paola Salvetti, Andrea Lembo, Paolo Nucci, Chui Ming Gemmy Cheung, Vishali Gupta
Dec 2018, 66(12):1716-1726
DOI:10.4103/ijo.IJO_893_18  PMID:30451172
A structurally and functionally intact choroid tissue is vitally important for the retina function. Although central retinal artery is responsible to supply the inner retina, choroidal vein network is responsible for the remaining one-third of the external part. Abnormal choroidal blood flow leads to photoreceptor dysfunction and photoreceptor death in the retina, and the choroid has vital roles in the pathophysiology of many diseases such as central serous chorioretinopathy, age-related macular degeneration, pathologic myopia, Vogt–Koyanagi–Harada disease. Biomarkers of choroidal diseases can be identified in various imaging modalities that visualize the choroid. Indocyanine green angiography enables the visualization of choroid veins under the retinal pigment epithelium and choroidal blood flow. New insights into a precise structural and functional analysis of the choroid have been possible, thanks to recent progress in retinal imaging based on enhanced depth imaging (EDI) and swept-source optical coherence tomography (SS-OCT) technologies. Long-wavelength SS-OCT enables the choroid and the choroid–sclera interface to be imaged at greater depth and to quantify choroidal thickness profiles throughout a volume scan, thus exposing the morphology of intermediate and large choroidal vessels. Finally, OCT angiography allows a dye-free evaluation of the blood flow in the choriocapillaris and in the choroid. We hereby review different imaging findings of choroidal diseases that can be used as biomarkers of activity and response to the treatment.
  2,066 558 -
GUEST EDITORIALS
A perspective on the evolving field of vitreoretinal diseases
Sabyasachi Sengupta
Dec 2018, 66(12):1668-1670
DOI:10.4103/ijo.IJO_1848_18  PMID:30451161
  1,789 565 -
EXPERT PANELS
Management of central serous chorioretinopathy: Expert panel discussion
Jay Chhablani, Giridhar Anantharaman, Francine Behar-Cohen, Camiel Boon, George Manayath, Rishi Singh
Dec 2018, 66(12):1700-1703
DOI:10.4103/ijo.IJO_1411_18  PMID:30451169
Central serous chorioretinopathy (CSCR), one of the most common diseases in retina clinics, needs a special attention by retina specialists. Considering the challenges in diagnosis, classification, and management of this enigmatic disease and lack of level 1 evidence, there is a need for consensus with regard to establishing management protocols.
  1,813 459 -
Current role of optical coherence tomography angiography: Expert panel discussion
Aniruddha Agarwal, Dilraj S Grewal, Glenn J Jaffe, Michael W Stewart, Sunil Srivastava, Vishali Gupta
Dec 2018, 66(12):1696-1699
DOI:10.4103/ijo.IJO_1048_18  PMID:30451168
Optical coherence tomography (OCT) angiography is a promising technique that provides depth resolved images of blood flow in the retina and choroid with levels of detail far exceeding that obtained with older forms of imaging and offers several advantages over conventional angiography to visualize the chorioretinal vasculature in a rapid and noninvasive manner. However, as with any evolving imaging technique, there are ongoing challenges in terms of need for new equipment, limitations of imaging capability and software processing techniques, as well as in understanding the implications of the imaging and its correlation with pathophysiology of the retina and choroid. This expert panel discussion is structured to provide an insight into the current state of OCT angiography.
  1,677 459 -
GUEST EDITORIALS
Fellowship training in India: How to produce leaders?
Raja Narayanan, Shashank R Gupta, Santosh G Honavar
Dec 2018, 66(12):1671-1672
DOI:10.4103/ijo.IJO_1619_18  PMID:30451162
  1,568 500 -
EDITORIAL
Revolution in evolution
Santosh G Honavar
Dec 2018, 66(12):1667-1667
DOI:10.4103/ijo.IJO_1894_18  PMID:30451160
  1,322 636 -
ORIGINAL ARTICLE
Ocular manifestations of Rickettsia conorii in South India
Manohar B Balasundaram, M Manjunath, Girish Baliga, Forum Kapadi
Dec 2018, 66(12):1840-1844
DOI:10.4103/ijo.IJO_420_18  PMID:30451192
Purpose: Among the major groups of rickettsiosis, the commonly reported diseases in India are: (a) Typhus group induced—scrub typhus, murine flea-borne typhus; (b) Spotted fever group induced—Indian tick typhus; and (c) Q fever. Though many scrub typhus outbreaks have been reported from India, only one outbreak of spotted fever—serologically proven Indian tick typhus (Rickettsia conorii)—has been reported. We report for the first time ocular manifestations of serologically proven R. conorii infection in a cluster of patients. Methods: In this retrospective study, case records patients with serologically proven Indian tick typhus (Rickettsia conorii) were reviewed for clinical manifestations and treatment outcomes. Results: In the months of February to April 2016, a cluster of 12 patients (23 eyes) visited us with defective vision. Examination showed multifocal retinitis; mostly bilateral; patients had a history of fever approximately 4 weeks prior to onset of symptoms. After excluding other causes of multifocal retinitis, a diagnosis of rickettsial retinitis was made after Weil–Felix test (WFT) was significantly positive, and enzyme-linked immunosorbent assay was positive for R. conorii. Course of the disease, visual outcome, and investigations are discussed. Doxycycline along with oral corticosteroids was effective in treating the condition. Conclusion: Systematic fundus examination should be part of the routine evaluation of any patient who presents with fever and/or skin rash living in or returning from a specific endemic area. Clinical clues to diagnosing ocular rickettsiosis could be multifocal retinitis predominantly involving the posterior pole and macular involvement in the form of serous macular detachment or macular hard exudates. A positive WFT still serves as a useful and cheap diagnostic tool for laboratory diagnosis of rickettsial disease. Doxycycline along with oral corticosteroids was effective in treating the condition.
  1,600 268 -
REVIEW ARTICLES
Current concepts of macular buckle in myopic traction maculopathy
Pradeep Susvar, Gitanjli Sood
Dec 2018, 66(12):1772-1784
DOI:10.4103/ijo.IJO_1126_18  PMID:30451177
Since its introduction by Charles L. Schepens, macular buckle (MB) surgery has evolved over the past 60 years. Optical coherence tomography (OCT) has given a paradigm shift to the understanding of myopic macula, thereby helping in objective evaluation of the various manifestation of traction maculopathy. Staphyloma evaluation by ultrasound, wide-field fundus photography, and MRI scans along with OCT has led to the resurgence of MB surgery in the treatment of myopic traction maculopathy (MTM). Various surgical techniques with different buckle materials are being performed with encouraging anatomical and functional success rates. This article reviews the literature to explain the current concept of MB surgery based on its evolution, different kinds of buckle materials, rationale for planning MB surgery, and different surgical techniques for the management of MTM.
  1,470 334 -
SPECIAL EDITORIAL
My ophthalmic research journey and contribution
Sohan Singh Hayreh
Dec 2018, 66(12):1674-1677
DOI:10.4103/ijo.IJO_1520_18  PMID:30451164
  1,227 254 -
COMMENTARY
Commentary: Post fever retinitis and vasculitis: A morphological conundrum
Bhavik Panchal
Dec 2018, 66(12):1844-1844
DOI:10.4103/ijo.IJO_1644_18  PMID:30451193
  1,265 178 -
SURGICAL TECHNIQUE
The claw: A novel intraocular foreign body removal forceps
Maneesh Bapaye, Mahesh P Shanmugam, Natarajan Sundaram
Dec 2018, 66(12):1845-1848
DOI:10.4103/ijo.IJO_759_18  PMID:30451194
Removal of intraocular foreign body (IOFB) from the posterior segment of the eye is challenging. In addition to surgical skill, it requires specific instrumentation to grasp and remove the IOFB. Small metallic IOFB can be removed using intraocular rare earth magnets but metallic IOFB larger than 3 mm and nonmetallic IOFBs like shot gun pellets, stones, or large glass fragments require specialized IOFB grasping forceps for removal. We describe the design and case-based clinical applications of a novel IOFB removal forceps, “the claw” that consists of a titanium handle and a 27-mm, 19-G metallic shaft that houses four retractable prongs made of nitinol wire. When completely extended, the prongs measure 14 mm in length and open up to 8–8.5 mm in the widest extent. The four prongs offer a very secure grip without crushing or splintering the IOFB leading to minimal chances of IOFB slippage and inadvertent retinal trauma.
  1,245 161 -
CASE REPORTS
Leukostasis retinopathy: An uncommon visual threatening complication of chronic myeloid leukemia with severe hyperleukocytosis – A case report and review of the literature
Bo Chen, Xiaoqin Yan, Xian Zhang, Hong Yang
Dec 2018, 66(12):1871-1874
DOI:10.4103/ijo.IJO_627_18  PMID:30451209
To describe a rare case of an unusual visual threatening complication of chronic myeloid leukemia (CML). A 21-year-old male visited the hospital complaining of 1-week painless binocular acute visual loss without any other symptoms. The patient was diagnosed with CML. He then received emergent leukapheresis with imatinib treatment, which achieved obvious hematological remission. However, the visual acuity did not recover along with the CML remission and ocular structure relief. CML-related leukostasis could induce severe leukostasis retinopathy. Hematologists and ophthalmologists should pay more attention to this relatively rare and severe complication of CML.
  1,189 198 -
ORIGINAL ARTICLE
Periocular topotecan for vitreous seeds in retinoblastoma
Purnima R Sthapit, Raksha Rao, Santosh G Honavar
Dec 2018, 66(12):1833-1838
DOI:10.4103/ijo.IJO_737_18  PMID:30451190
Purpose: Refractory or recurrent vitreous seeds account for a large proportion of failure of eye salvage in retinoblastoma. The purpose of this study is to evaluate the efficacy of periocular topotecan (POT) in the management of vitreous seeds in retinoblastoma. Methods: Retrospective, interventional study of patients with retinoblastoma with vitreous seeds who received POT concurrent with intravenous chemotherapy (IVC). Results: Thirty-eight eyes of 35 patients received POT. Five eyes (13%) belonged to International Classification of Retinoblastoma group C, 23 eyes (61%) belonged to group D, and 10 eyes (26%) belonged to group E. Primary treatment included IVC with a combination of carboplatin, etoposide, and vincristine for a mean of 6 cycles (median 6; range 6–9). Concurrent to IVC from the fourth cycle onward, all patients received POT. Focal vitreous seeds were present in 20 eyes (53%) which received a mean of 3 injections (median 3; range 1–7). Diffuse vitreous seeds were present in 18 eyes (47%) which received a mean of 4 injections (median 5; range 1–7). At a mean follow-up of 8.5 months (median 5 months; range 1–15 months), regression of focal and diffuse vitreous seeds was achieved in 16 eyes (80%) and 8 eyes (44%), respectively. In all, 24 eyes (63%) had complete remission of vitreous seeds with POT given concurrently with IVC. Eye salvage was possible in 19 eyes (95%) with focal vitreous seeds and 12 eyes (68%) with diffuse VS. Enucleation was necessary for persistent vitreous seeds and viable tumor in five eyes (13%), viable tumor alone in one eye (0.02%), and recurrent vitreous seeds in one eye (0.02%). None of the patients developed systemic metastasis. Conclusion: POT administered concurrent with IVC is safe and effective in the initial management of vitreous seeds.
  1,110 234 -
ORIGINAL ARTICLES
Correlation of optical coherence tomography angiography and microperimetry (MP3) features in wet age-related macular degeneration
Manish Nagpal, Jayesh Khandelwal, Rakesh Juneja, Navneet Mehrotra
Dec 2018, 66(12):1790-1795
DOI:10.4103/ijo.IJO_866_18  PMID:30451180
Purpose: To evaluate and correlate the functional treatment response using microperimetry (MP3) with the morphological findings on optical coherence tomography angiography (OCTA) in wet AMD pre- and post-treatment with anti-vascular endothelial growth factor (VEGF). This was a single-centre prospective, interventional study. Methods: Patients with wet AMD were treated with 3 injections of intravitreal anti-VEGF at monthly intervals for 3 months and followed at 1, 2, 3, and 6 months postinjection. Using “overlay” features, morphologic characteristics of OCTA at the site of choroidal neovascular membrane (CNVM) lesion were analyzed and correlated functionally with MP3. Data were collected including visual acuity at presentation and follow-up with multimodal imaging features, treatment details, complications (if any), and treatment given for that complication. Descriptive observational analysis and paired t-test was used to compare the appearance of the neovascular network on OCTA imaging with retinal sensitivity on MP3. Results: OCTA in the pretreatment phase revealed CNVM as an abnormal vascular network arising from the choroid and invading the subretinal space. On MP3, decreased retinal sensitivity was observed corresponding to the area of CNVM. Post-treatment, OCTA revealed reduction in abnormal vascular network in 51 (91.07%) eyes that correlated with increased retinal sensitivity at the corresponding area on MP3. Statistical analysis showed baseline mean retinal sensitivity at the site of CNVM as 320.07 dB, which improved to 521.53 and 730.20 dB at 1 and 3 months postinjection follow-up, respectively. Conclusion: Combining the findings of OCTA and MP3 using “overlay” features gives us precise information of structure–function correlation at presentation and also in response to treatment. It also helps to improve patient's compliance, confidence to treatment, and their understanding of the disease process as well.
  1,067 233 -
Comparison of clinical outcomes between “heads-up” 3D viewing system and conventional microscope in macular hole surgeries: A pilot study
Atul Kumar, Nasiq Hasan, Prateek Kakkar, Vineet Mutha, R Karthikeya, Dheepak Sundar, Raghav Ravani
Dec 2018, 66(12):1816-1819
DOI:10.4103/ijo.IJO_59_18  PMID:30451186
Purpose: To compare clinical outcomes of patients undergoing macular hole surgery with heads-up three-dimensional (3D) viewing system and conventional microscope. Methods: In all, 50 eyes of 50 patients with stage 3 or 4 macular hole were randomized and macular hole surgery [inverted internal limiting membrane (ILM) flap technique] was performed in 25 eyes using 3D viewing system and 25 eyes using conventional microscope. All surgeries were performed by a single surgeon. Patients were followed up for a period of 3 months. Logarithm of the minimum angle of resolution (logMAR) visual acuity, macular hole index, intraoperative parameters such as total surgical time, total ILM peel time, number of flap initiations, duration of Brilliant Blue G dye exposure, illumination intensity, postoperative logMAR visual acuity, and macular hole closure rates were recorded and compared between the two groups. Results: The mean age was 67.92 ± 7.95 and 67.96 ± 4.78 years in both groups, respectively (P = 0.98). Gender (P = 0.38) and right versus left eye (P = 0.39) were also comparable. Preoperative and postoperative best-corrected visual acuity (P = 0.86, 0.92), macular hole index (P = 0.96), total surgical time (P = 0.56), total ILM peel time (P = 0.49), number of flap initiations (P = 0.11), and macular hole closure rates (P = 0.61) were not statistically significant when compared between the two groups. Illumination intensity of microscope (100% vs 45%) and endoillumination (40% vs 13%) were significantly less in the 3D viewing system. Conclusion: The clinical outcomes of macular hole surgery using 3D viewing system are not inferior to that of conventional microscopes, and it has the added advantages of better ergonomics, reduced phototoxicity, peripheral visualization, magnification, and less asthenopia, and it serves as a good educational tool.
  1,041 236 -
SPECIAL ARTICLE
Adventure in three worlds
Sohan Singh Hayreh
Dec 2018, 66(12):1678-1683
DOI:10.4103/ijo.IJO_1842_18  PMID:30451165
The author relates an unlikely journey from his rural village in India, through medical school, a prestigious fellowship with Sir Stewart Duke-Elder, and a colorful career in the United Kingdom and the USA, as a clinician and researcher, particularly in the area of vascular disease of the eye and optic nerve
  1,030 224 -
ORIGINAL ARTICLE
Qualitative comparison of choroidal vascularity measurement algorithms
Mohammed A Rasheed, Niroj K Sahoo, Abhilash Goud, Kiran K Vupparaboina, Jay Chhablani
Dec 2018, 66(12):1785-1789
DOI:10.4103/ijo.IJO_663_18  PMID:30451178
Purpose: To compare the accuracy of manual and automated binarization technique for the analysis of choroidal vasculature. Methods: This retrospective study was performed on a total of 98 eyes of 60 healthy subjects. Fovea-centered swept source optical coherence tomography (SS-OCT) scans were obtained and choroidal area was binarized using manual and automated image binarization technique separately. Choroidal vessel visualization in the binarized scans were subjectively graded (grades 0–100) by comparing them with the original OCT scan images by two masked graders. The subjective variability and repeatability was compared between two binarization method groups. Intergrader and intragrader variability was estimated using paired t-test. The degree of agreement between the grades for each observer and between the observers was evaluated using Bland–Altman plot. Results: The mean accuracy grades of the automatically binarized images were significantly (P < 0.001) higher (93.38% ± 1.70%) than that of manually binarized images (78.06% ± 2.92%). There was a statistically significant variability and poor agreement between the mean interobserver grades in the manual binarization arm. Conclusion: Automated image binarization technique is faster and appears to be more accurate in comparison to the manual method.
  856 269 -
OPHTHALMIC IMAGES
Hydroxychloroquine-induced retinal toxicity in systemic lupus erythematosus
Kisha D Piggott, Rajendra Apte
Dec 2018, 66(12):1861-1862
DOI:10.4103/ijo.IJO_899_18  PMID:30451203
  915 207 -
CASE REPORTS
Wyburn–Mason syndrome presenting with bilateral retinal racemose hemangioma with unilateral serous retinal detachment
Bhanu P S Pangtey, Piyush Kohli, Kim Ramasamy
Dec 2018, 66(12):1869-1871
DOI:10.4103/ijo.IJO_455_18  PMID:30451208
Wyburn–Mason syndrome is associated with unilateral retinal racemose hemangioma. Rarely, it presents with bilateral and symmetrical grade of malformation. We describe a 37-year old male, who presented with Wyburn–Mason syndrome presenting with bilateral but asymmetrical retinal hemangioma. The eye with advanced grade of hemangioma was complicated with exudation, intraretinal fluid, neurosensory detachment, and reduced vision. He was treated with one intravitreal injection of bevacizumab, after which both the intraretinal fluid and neurosensory detachment resolved. His vision improved and was maintained till 1 year of follow-up.
  906 164 -
ORIGINAL ARTICLES
Outcome of vitreoretinal surgery for rhegmatogenous retinal detachment in X-linked juvenile retinoschisis
Parveen Sen, Ashutosh Agarwal, Pramod Bhende, Lingam Gopal, Muna Bhende, Pukhraj Rishi, Tarun Sharma, Mukesh Jain
Dec 2018, 66(12):1825-1831
DOI:10.4103/ijo.IJO_607_18  PMID:30451188
Purpose: Rhegmatogenous retinal detachment (RRD) is a vision-threatening complication of X-linked juvenile retinoschisis (XLRS). The aim of this study is to report the anatomical and functional outcomes of vitreoretinal surgery for the treatment of RRD in X-linked juvenile retinoschisis (XLRS). Methods: This is a retrospective, interventional, consecutive case series in which case records of 34 eyes of 28 XLRS patients, who underwent surgery for RRD, were reviewed. Statistical analysis used is as follows: visual outcomes were categorized into three groups: improved, remained stable or deteriorated. Wilcoxon signed-rank test was used to determine the difference in visual acuity at baseline and at final visit. Univariate binary logistic regression analysis was used to determine the risk factors for retinal detachment. Any P value < 0.05 was considered as statistical significant. Results: Mean age of the boys at presentation was 9.2 ± 3.5 years. Indication for surgery was RRD in all eyes. Concurrent vitreous haemorrhage was present in four eyes (11.8%). The primary surgical intervention was scleral buckle in 12 eyes and pars plana vitrectomy in 22 eyes. Persistence of subretinal fluid/redetachment was seen in 15 eyes of which 11 eyes underwent additional surgeries. At final follow up, 27 eyes (79.4%) were noted to have an attached retina. Of the total eyes, in 20, 6 and 8 eyes the visual acuity improved, stabilized and deteriorated, respectively. Conclusion: Favourable outcomes are seen in a majority of eyes after vitreoretinal surgery for RRD in XLRS; however, multiple surgical interventions may be necessary.
  871 188 -
The role of posterior vitreous detachment on the efficacy of anti-vascular endothelial growth factor intravitreal injection for treatment of neovascular age-related macular degeneration
Meira Neudorfer, Audelia Eshel Fuhrer, Dinah Zur, Adiel Barak
Dec 2018, 66(12):1802-1807
DOI:10.4103/ijo.IJO_373_18  PMID:30451182
Purpose: A prospective cohort study investigating the effect of posterior vitreous detachment (PVD) on the efficacy of intravitreal bevacizumab for exudative age-related macular degeneration (AMD), in view of evidence that the vitreoretinal interface impacts the severity of the disease. Methods: Treatment-naïve AMD eyes with (+) complete PVD and without (−) PVD on ultrasonography received three monthly and then pro re nata bevacizumab injections. Best-corrected visual acuity (BCVA) on Snellen charts and optical coherence tomography (OCT) findings were recorded for 12 months. Secondary analysis included PVD definition and group allocation according to OCT baseline scan. Results: Forty-one eyes of 34 patients met the inclusion criteria. At 12 months, median BCVA improved by 0.12 logMAR in the PVD+ group [interquartile range (IQR) −0.52, 0.03, P = 0.140] and remained the same in the PVD− group (IQR −0.12, 0.15, P = 0.643). Median central retinal thickness improved by 43.5 μm and 43 μm in the PVD+ (IQR −143, 3, P = 0.016) and PVD− group (IQR −90, −14, P = 0.008), respectively. All parameters were similar in the two groups at final follow up (P > 0.05). The secondary analysis included 32 eyes of 26 patients and showed no significant differences between the groups at the 12 months endpoint (P > 0.05). Conclusion: Our findings show no significant impact of PVD as assessed by ultrasound or by OCT on visual and anatomical outcomes in exudative AMD treated with bevacizumab.
  845 210 -
OPHTHALMIC IMAGES
Combined central retinal artery and vein occlusion as the presenting manifestation of systemic lupus erythematosus
Pritam Bawankar, Preetam Samant, Sayalee Lahane, Ashish Jain, Pooja Pathak
Dec 2018, 66(12):1864-1864
DOI:10.4103/ijo.IJO_996_18  PMID:30451205
  846 165 -
Persistent fetal vasculature – Clinical spectrum
Aditi Mehta, Simar Rajan Singh, Mohit Dogra, Jagat Ram
Dec 2018, 66(12):1860-1860
DOI:10.4103/ijo.IJO_1042_18  PMID:30451201
  787 202 -
ORIGINAL ARTICLES
Outcomes of rhegmatogenous retinal detachment surgery in eyes with pre-existing glaucoma drainage devices
Unnati Sharma, Smita Panda, Shantha Balekudaru, Vijaya Lingam, Pramod Bhende, Parveen Sen
Dec 2018, 66(12):1820-1824
DOI:10.4103/ijo.IJO_438_18  PMID:30451187
Purpose: To evaluate the outcome of rhegmatogenous retinal detachment (RRD) surgery in eyes with preplaced glaucoma drainage device (GDD) with respect to intraocular pressure (IOP) control as well as success of retinal detachment (RD) surgery. Methods: It is a retrospective case series. The case records of patients who underwent RD surgery after GDD implantation from 2000 to 2014 were screened. The demographic data, ocular examination findings at all visits, details pertaining to retinal detachment and its repair, and the postoperative course was documented. Results: Twelve patients were included in study. The mean age of patients was 24.3 years (median 11 years; range 3-72 years). Male: Female ratio was 3:1. Mean duration between GDD and RD was 24 months (4 days-91 months). Of the ten eyes that underwent surgery, nine eyes underwent pars plana vitrectomy, and in one eye scleral buckling was done. GDD was removed only in one eye. At final follow-up, retina was attached with controlled IOP in 6 (60%) eyes, of which 5 (50%) had improvement in best corrected visual acuity. Conclusion: Pars plana vitrectomy was required in almost all cases for the management of RD in eyes with preplaced GDD. Retinal reattachment with good IOP control could be achieved in 60% of eyes. Removal of the drainage device was not essential for the effective management of the RRD in most cases. With multidisciplinary approach, close follow-up and timely intervention, vision can be preserved along with glaucoma control and successful retinal reattachment.
  807 148 -
CASE REPORT
Progressive, subretinal fibrosis mimicking retinal necrosis with poor visual prognosis in sympathetic ophthalmia: A rare finding
Kalpana Babu, Megha V Jidesh, Bhagya Sudheer, Krishna R Murthy
Dec 2018, 66(12):1877-1879
DOI:10.4103/ijo.IJO_268_18  PMID:30451212
We report a rare finding of progressive subretinal fibrosis mimicking retinal necrosis in 2 cases of sympathetic ophthalmia. Histopathology of the inciting eye and vitreous biopsy of the sympathizing eye ruled out infections and masquerades. Progression of inflammation and rapid deterioration of vision inspite of maximum immunosuppression are key findings in this variant of sympathetic ophthalmia.
  799 142 -
CASE REPORTS
Posterior polar annular and hemispheric choroidal and retinal dystrophy: Optical coherence tomographic angiography description of a rare case
Raja Narayanan
Dec 2018, 66(12):1874-1876
DOI:10.4103/ijo.IJO_367_18  PMID:30451210
Posterior polar annual choroidal dystrophy is a rare disease which affects the retina and choroid in an annular pattern. Our patient was referred to us a case of atypical retinitis pigmentosa. Fundus examination showed a normal optic disc, normal arterioles, and no bone spicules. The right eye showed a hemispheric pattern and the left eye showed an annular pattern of retinal and choroidal dystrophy. We describe the retinal and choroidal angiographic features of this case by optical coherence angiography.
  780 139 -
Choroidal neovascularization associated with combined hamartoma of retina and retinal pigment epithelium: Multimodal imaging
Rajan Gupta, Rajeev R Pappuru, Vivek P Dave, Jay Chhablani
Dec 2018, 66(12):1866-1868
DOI:10.4103/ijo.IJO_992_18  PMID:30451207
Combined hamartoma of retina and retinal pigment epithelium (CHRRPE) has been considered as a congenital benign entity with evidence of choroidal neovascularization membranes (CNVM) being associated with it in literature. This case series gives insight into the pathogenesis and the predisposing factors leading to CNVM formation in peripapillary CHRRPE using swept-source optical coherence tomography. In addition, lack of typical markers of CNVM (subretinal fluid/pigment epithelial detachment) in CHRRPE highlights the utility of optical coherence tomography angiography and the subtle optical coherence tomography findings such as “Bridge Sign” that could be instrumental in early diagnosis of CNVM in CHRRPE.
  733 169 -
ORIGINAL ARTICLE
Influence of orientation of the external linear incision created by the 25-gauge trocar and related factors on sclerotomy closure: A clinical and optical coherence tomographic study
VG Madanagopalan, CK Nagesha, Ashish M Khodifad, Rajiv Raman
Dec 2018, 66(12):1809-1814
DOI:10.4103/ijo.IJO_458_18  PMID:30451184
Purpose: To assess the influence of orientation of the external linear incision created by the trocar and related factors on sclerotomy closure in 25-gauge (25G) transconjunctival vitreous surgery (TVS). Methods: A total of 46 eyes of 46 patients who underwent 25G TVS (23 circumferential incisions and 23 radial incisions) were studied. Clinical and anterior segment optical coherence tomography (AS-OCT)-based comparison of self-sealed and sutured sclerotomies was done. The influence of age, ocular surgeries and injections, axial length, cannula type, sclerotomy quadrant, surgery duration, vitreous base excision, and tamponade on suture rates was analyzed. Results: Of the 46 eyes, 23 eyes required suturing [circumferential: 17 (74%) and radial: 6 (26%); P = 0.003]. A significantly lesser proportion of superonasal quadrant and inferotemporal quadrant sclerotomies needed suturing [9 (24%) and 12 (27%)] when compared with superotemporal quadrant [17 (37%)]. Sclerotomies to the left of the surgeon and the infusion port required significantly lesser suturing [10 (25%) and 13 (28%), respectively] when compared with that of surgeon's right [15 (35%)]. Suturing was significantly lesser when gas or oil tamponade was used [5 (36%) and 2 (20%), respectively] when compared with no tamponade [16 (73%)]. In eyes without tamponade, suturing was lesser with radial sclerotomies (P = 0.003). The odds of having an open sclerotomy tract on AS-OCT were ≥5 when circumferential sclerotomies were used. Conclusion: Self-sealing was more common with radial external incisions. Tamponade was associated with less suturing. Superotemporal sclerotomies and sclerotomies toward the surgeon's dominant hand were often sutured. In this cohort, other factors did not influence sclerotomy closure.
  732 147 -
PHOTO ESSAY
Multicolor imaging features of dissociated optic nerve fiber layer after internal limiting membrane peeling
Kumar Saurabh, Rupak Roy, Samarth Mishra, Barun Garg, Sugandha Goel
Dec 2018, 66(12):1853-1854
DOI:10.4103/ijo.IJO_783_18  PMID:30451197
  734 128 -
SURGICAL TECHNIQUE
Bimanual 25-gauge chandelier technique for direct perfluorocarbon liquid-silicone oil exchange in retinal detachments associated with giant retinal tear
Stuti Astir, Daraius N Shroff, Charu Gupta, Cyrus M Shroff, Indranil Saha, Ranjan Dutta
Dec 2018, 66(12):1849-1851
DOI:10.4103/ijo.IJO_440_18  PMID:30451195
Direct perfluorocarbon liquid (PFCL)-silicone oil exchange presents its own set of challenges in the micro incision vitreous surgery era. We propose a simple bimanual technique to circumvent this problem. Thirteen eyes of patients with retinal detachment associated with giant retinal tears underwent vitrectomy followed by self-retaining endo illuminator (Chandelier) assisted direct PFCL-silicone exchange. No intra or postoperative complications related to the surgical technique were noted. All patients had attached retinas and satisfactory visual recovery at 6 months. Direct bimanual PFCL silicone oil exchange using a Chandelier seems to be a safe and effective technique.
  720 138 -
PHOTO ESSAY
Post-laser regression of diabetic neovascularization: An optical coherence tomography angiography study
Daraius Shroff, Priyanka Gupta, Charu Gupta, Cyrus Shroff
Dec 2018, 66(12):1855-1856
DOI:10.4103/ijo.IJO_813_18  PMID:30451198
  675 146 -
OPHTHALMIC IMAGES
Combined central retinal vein occlusion and branch retinal artery occlusion
Sugandha Goel, Kumar Saurabh, Rupak Roy
Dec 2018, 66(12):1862-1863
DOI:10.4103/ijo.IJO_977_18  PMID:30451204
  638 177 -
PHOTO ESSAY
Multimodal imaging of acute zonal occult outer retinopathy in a Indian male
Mohit Dogra, Nitin Kumar, Basavraj Tigari, Ramandeep Singh
Dec 2018, 66(12):1858-1859
DOI:10.4103/ijo.IJO_570_18  PMID:30451200
  654 152 -
COMMENTARY
Commentary: Nuances in management of rhegmatogenous retinal detachment in X-linked juvenile retinoschisis
Naresh Babu, Piyush Kohli
Dec 2018, 66(12):1831-1832
DOI:10.4103/ijo.IJO_1492_18  PMID:30451189
  674 114 -
PHOTO ESSAY
Panoramic optical coherence tomography angiography features in acute zonal occult outer retinopathy
Navneet Mehrotra, Manish Nagpal, Jayesh Khandelwal, Rakesh Juneja
Dec 2018, 66(12):1856-1858
DOI:10.4103/ijo.IJO_826_18  PMID:30451199
  648 139 -
COMMENTARY
Commentary: Management of central serous chorioretinopathy: Looking beyond the eye
Aniruddha Agarwal, Amod Gupta
Dec 2018, 66(12):1714-1715
DOI:10.4103/ijo.IJO_1412_18  PMID:30451171
  605 152 -
PHOTO ESSAY
Multimodal imaging of multiple macular holes
Aditya Verma, Preet Kanwar Sodhi
Dec 2018, 66(12):1852-1853
DOI:10.4103/ijo.IJO_1092_18  PMID:30451196
  609 122 -
ONE MINUTE OPHTHALMOLOGY
Bilateral mastectomy, choroidal mass: A curve ball
Phillip Gordon, Carol L Shields
Dec 2018, 66(12):1695-1695
DOI:10.4103/ijo.IJO_1750_18  PMID:30451167
  573 131 -
COMMENTARY
Commentary: Periocular topotecan for retinoblastoma
Minal Sharma, Vikas Khetan
Dec 2018, 66(12):1838-1839
DOI:10.4103/ijo.IJO_1626_18  PMID:30451191
  586 108 -
OPHTHALMIC IMAGES
Congenital retinal macrovessel in a patient with rhegmatogenous retinal detachment
Vinod Kumar, Neha Goel
Dec 2018, 66(12):1860-1861
DOI:10.4103/ijo.IJO_838_18  PMID:30451202
  568 112 -
Secondary paracentral retinal hole following internal limiting membrane peeling for a large macular hole
Diva Kant Misra, Ronel Soibam, Awaneesh Upadhyay, Pushkar Dhir, Rammohan Paidi
Dec 2018, 66(12):1865-1865
DOI:10.4103/ijo.IJO_1001_18  PMID:30451206
  538 122 -
COMMENTARY
Commentary: Interfere with the interface?
Ashwin Mohan, Ramesh Venkatesh
Dec 2018, 66(12):1808-1808
DOI:10.4103/ijo.IJO_1191_18  PMID:30451183
  564 87 -
Commentary: Posterior polarannular and hemispheric choroidal and retinal dystrophy: Optical coherence tomographic angiography description of a rare case
Raminder Singh
Dec 2018, 66(12):1876-1876
DOI:10.4103/ijo.IJO_1072_18  PMID:30451211
  504 97 -
Commentary: Qualitative comparison of choroidal vascularity measurement algorithms
Lingam Gopal
Dec 2018, 66(12):1789-1789
DOI:10.4103/ijo.IJO_1674_18  PMID:30451179
  508 90 -
Commentary: Influence of orientation of the external linear incision created by the 25-gauge trocar and related factors on sclerotomy closure: A clinical and optical coherence tomographic study
Atul Kumar, Srikanta Kumar Padhy
Dec 2018, 66(12):1815-1815
DOI:10.4103/ijo.IJO_1640_18  PMID:30451185
  508 88 -