Volcano like pattern in optical coherence tomography in chronic diabetic macular edema

In this article we herein report an interesting vitreo-macular interface abnormality associated with chronic diabetic cystoid macular edema. It is an observational case study of three diabetic patients examined in the diabetic clinic. All the patients had proliferative diabetic retinopathy with chronic macular edema. A serial cross sectional OCT examination and tracking of both the longitudinal progression of macular thickening and vitreo-macular interface revealed cystoid macular edema with a characteristic hyperreflective vitreous shadow emerging from the vitreofoveal interface. All the patients had dehiscence of inner retinal layers. This particular morphological feature at the vitreo-foveolar interface, which we name as "volcano sign", has not been described earlier. The probable mechanism of such a finding probably could be due to slow progressive leakage of chronic cytoid fluid into the vitreous with condensation of the overlying vitreous. Vitreo-macular traction followed by posterior vitreous detachment probably would have contributed to such a morphological event

Treatment of refractory diffuse diabetic macular edema with lntravitreal bevacizumab

To analyze the short term visual acuity and anatomic response after a single dose of off-label intravitreal injection of bevacizumab in diffuse diabetic macular edema [DME] not responding to conventional laser photocoagulation. Prospective analysis of consecutive case series of 45 eyes of 38 patients with refractory diffuse DME who had one intravitreal injection of 1 .25 mg of bevacizumab [Avastin] and followed up for 3 months. All patients passed at least six months since their last laser treatment before inclusion in the study. Patients underwent best corrected visual acuity determination, intraocular pressure measurement, stereoscopic biomicroscopy of the macula and measurement of the retinal thickness by optical coherence tomography [OCT] at base line and follow up visits. At 1 month post-injection, visual acuity improved by 1 line in 7 eyes, unchanged from the pre-injection levels in 24 eyes and deteriorated in 14 eyes. At 3 months post injection, visual acuity improved in 1 8 eyes, it remained unchanged in 13 eyes and deteriorated in 14 eyes. The mean logMAR visual acuities were 0.60 [SD +/- 0.34], 0.64 [SD +/- 0.31] and 0.61 [SD +/- 0.32] at pre-injection, at 1 month post-injection and at 3 months post-injection respectively; but this mean decrease in vision was statistically not significant [P value=0.099]. The foveal thickness on optical coherence tomography had decreased in 27 eyes and it increased in 1 8 eyes at 1 month post-injection. At 3 months following injection, foveal thickness was reduced in 34 eyes, but was increased in 11 eyes. The mean foveal thicknesses were 444.95 micro [SD +/- 1 27.36], 394.95 micro [SD +/- 138.03] and 378.32 micro [SD +/- 112.01] at pre-injection, 1 month post-injection and 3 months post-injection respectively. This decrease in the foveal thickness was statistically significant [P value<0.001]. Intravitreal bevacizumab is effective in patients with diffuse DME which is refractory to treatment with conventional macular laser photocoagulation

Brain metastasis masquerading as progressive glaucoma

Evaluation of the visual fields is an integral part of diagnosing and following-up any patient with suspected glaucoma. If any progressive loss in the visual field is noted the treatment plan may need alteration to suit the clinical circumstances but if the follow-up visual field changes are atypical then other ocular or systemic pathologies need to be excluded before changing the glaucoma management plan. We present an unusual case of brain metastasis from a lung carcinoma that masqueraded as progressive glaucoma in a patient previously diagnosed as primary open angle glaucoma

Pretreatment clinical variables associated with the response to intravitreal bevacizumab [Avastin] injection in patients with persistent diabetic macular edema

The purpose of the study is to determine whether the pre-treatment clinical systemic variables and optical coherence tomography [OCT] findings are associated with the subsequent response to the intravitreal bevacizumab [IVE] in eyes with persistent diabetic macular edema [DME]. Prospective, interventional non-comparative case series study. 38 patients [45 eyes] with refractory diabetic macular edemas; 16 females, 22 males with a mean aged 57.5 year. All patients had persistent DME not responded to other forms of treatments. Complete eye examination; best corrected visual acuity [BCVA] [represented as LOGMAR for adequate statistical analysis], slit-lamp exam, intraocular pressure measurement, stereoscopic biomicroscopy of the macula, and morphologic patterns of diabetic macular edema demonstrated by OCT. All patients had intravitreal injection of 0.05 mL = 1.25 mg bevacizumab [Avastin; Genentech, Inc., San Francisco, CA], and were followed up for 3 months. The pre and post-injection follow-up data were analyzed by Student-t test and Mann-Whitney test for two main outcome measures; visual acuity [LOGMAR] and central foveal thickness [CFT] changes over a period of three months, and the data included demographic factors, type, duration and the control of diabetes mellitus [HbA1C%], grade of diabetic retinopathy, renal function [serum creatinine level], serum cholesterol, blood pressure control and previous treatment by focal laser and/or intravitreal triamcinolone injection. The LOGMAR and central foveal thickness [CRT] improved 30/45 eyes [67%] and 32/45 eyes [72%], respectively during a mean follow-up time of three months. The mean LOGMAR visual acuities were 0.64 [SD +/- 0.34], 0.60 [SD +/- 0.32] at pre-injection, at 1 month post-injection and at 3 months post-injection, respectively; but this mean increase in vision was statistically not significant [P value = 0.099]. The mean foveal thicknesses were 444.95 micro m [SD +/- 127.36], 394.95 micro m [SD +/- 138.03] and 378.32 micro m [SD +/- 112.01] at pre-injection, 1 month post-injection and 3 months post-injection, respectively, this decrease in the foveal thickness was statistically significant [P value <0.001]. The pre and post-injection values of the variables for diabetic duration, diabetic control [HbA1c] and OCT pattern of macular edema showed significant statistical correlations [P <0.05] with LOGMAR only, however the values of the variables for serum creatinine and cholesterol show statistical correlation [P <0.05] with both LOGMAR and CFT. Chronicity and inadequate control of diabetes mellitus, nephropathy, hyperlipidemia and presence of vitreomacular attachment [VMA] are factors associated with poor vision progress after intravitreal bevacizumab injection

Current concepts in intravitreal drug therapy for diabetic retinopathy

Diabetic retinopathy [DR] is a major cause of preventable blindness in the developed countries. Despite the advances in understanding and management of DR, it remains a challenging condition to manage. The standard of care for patients with DR include strict metabolic control of hyperglycemia, blood pressure control, normalization of serum lipids, prompt retinal laser photocoagulation and vitrectomy. For patients who respond poorly and who progressively lose vision in spite of the standard of care, intravitreal administration of steroids or/and anti-vascular endothelial growth factor [anti-VEGF] drugs appear to be a promising second-line of therapy. This review discusses the current concepts and the role of these novel therapeutic approaches in the management of DR

Unilateral papillitis and exudative retinal detachment: an unusual manifestation of ocular syphilis

The common and typical posterior segment manifestations of ocular syphilis are choroiditis, retinitis and retinal vasculitis but since syphilis has a tendency to masquerade any uveitis entity it should be ruled out in all cases of posterior uveitis. We describe an uncommon case of unilateral papillitis and exudative retinal detachment where syphilis was initially a remote possibility. Systemic steroids seemed to make the clinical situation worse. Then a single positive serological test for syphilis [TPABS] suggested ocular syphilis. Complete resolution was obtained with an anti-syphilis antibiotic regimen

Combination therapy of intravitreal injection of bevacizumab [avastin] and photodynamic therapy with verteporfin in the treatment of idiopathic polypoidal choroidal vasculopathy with choroidal neovascular membrane

To report the efficacy of intravitreal bevacizumab followed by PDT with verteporfm in idiopathicIPCV with CNVM and exudation involving posterior pole. Prospective interventional case study. A 48-year-old consented Indian male patient underwent intravitreal bevacizumab followed by PDT with verteporfin after one month in the left eye. Base line complete ophthalmic examination, fundus photography, fluorescein and indocyanine green angiography and optical coherence tomography were done and selected tests were repeated - 1 week, 1 month, 2 months, 3 months and 4 months after treatment. There was reduced exudation from the lesions with flattening of the posterior pole within 4 weeks after intravitreal bevacizumab with vision improving to 6/24 from 6/60 at the end of one month. After one month he underwent PDT according to standard protocol and vision further improved to 6/24 to 6/12 by 2 weeks after therapy and maintained the same till the end of four months of treatment. Treatment of PCV is not well established; in this case combination therapy was effective in the management of IPCV complicated by CNVM. Intravitreal injection of bevacizumab probably led to rapid decrease in exudation of the lesion thus enabling in successful ablation of the CNVM by PDT

Photodynamic therapy and intravitreal triamicinolone acetonide for subretinal neovascular membrane in type 2A parafoveal telangiectasia

To evaluate the efficacy and safety of combined Photodynamic therapy [PDT] with verteporfm and intravitreal triamicinolone acetonide [IVTA] treatment for subretinal neovascular membrane [SRN] secondary to type 2A-parafoveal telangiectasia. Retrospective, non-randomized pilot study of 80 eyes of 40 patients with type 2 PFT examined at our Institute, 6 patients had SRN, out of which 5 patients underwent PDT with verteporfin and IVTA. PDT was applied according to standard protocol. Intravitreal injection of 4 mg of TA. The main outcome measures were visual acuity [VA], the safety issues and the retreatment frequency with the combined treatment Fifteen percent of patients with type 2 A PFT had SRN. Mean follow up period was 11.8 months [range 6 to 14 months]. Mean lesion size was 2580micro, [1000 micro -4800 micro]. Three patients had improvement in VA that is >/= 2 line [Snellen] gain. Two patients maintained stable VA; stable VA was defined as unchanged vision or

Scanning laser ophthalmoscope-optical coherence tomography [SLO-OCT]: review of a newly emerging imaging technique

Scanning laser ophthalmoscope-optical coherence tomography [SLO-OCT] a combined innovative technology provides high-resolution, in depth images of the retina and SLO scans the retina to locate the area of the disease using a single source. The two scanning modes has enabled in better understanding of the extent of disease and aid physician with diagnostic challenges. It is useful in localizing accurately subtle pathology with enhancement of vitreo-retinal interface. The coronal scans are particularly useful to study the retinal pigment epithelial - choriocapillary interface pathology and verify subtle lesions noticed on cross sectional scans. Its ability to scan in undilated pupils is another advantage but requires utmost patient's cooperation. Little ocular movement causes difficulties in obtaining the image, also inability to scan in high myopes. The ability to fuse with other imaging system in future would make SLO-OCT a versatile compact diagnostic tool in the management of posterior segment pathology