A comprehensive review of intravitreal immunosuppressants and biologicals used in ophthalmology.

Systemic immunosuppressants and biologicals have been a valuable tool in the treatment of inflammatory diseases and malignancies. The safety profile of these drugs has been debatable, especially in localized systems, such as the eye. This has led to the search for fairly local approaches, such as intravitreal, subconjunctival, and topical route of administration. Immunosuppressants have been used as a second-line drug in patients intolerable to corticosteroids or those who develop multiple recurrences on weaning corticosteroids. Similarly, biologicals have also been used as the next line of therapy, when adequate control of inflammation could not be attained or immunosuppressants were contraindicated to patients. Intravitreal immunosuppressants, such as methotrexate and sirolimus, have been extensively studied in noninfectious posterior uveitis, whereas limited studies have established the efficacy of intravitreal biologicals, such as infliximab and adalimumab. Most of these drugs have shown good safety profile and tolerability in animal studies alone and have not been studied further in human subjects. However, most of the studies in literature are single-case reports or case series which limits the level of evidence. In this comprehensive review, we discuss the mechanism of action, pharmacodynamics, pharmacokinetics, indications, efficacy, and side effects of different intravitreal immunosuppressants and biologicals that have been studied in literature.

Demography, clinical profile and surgical outcomes of paediatric giant retinal tear related retinal detachments.

OBJECTIVE: To determine the demographic profile, clinical features and surgical outcomes of giant retinal tear (GRT) related retinal detachments (RD) in children. METHODS: In this retrospective study, medical records of children aged 14 years and below, who underwent surgery for RD at our centre in the last 5 years were reviewed. Among these, we selected medical records of children with RDs with GRT, and examined the coloured retinal drawings, ultrawidefield photographs and/or surgical videos. RESULTS: Out of 1536 medical records, 91 eyes of 87 children (5.6% of all RDs) were included. Mean age was 10.21 ± 3.08 years with male:female ratio of 8.6:1. The most common aetiologies for GRTs were high myopia (28 cases-32.18%) and trauma (25 cases-28.73%). Bilateral RD were possibly present in 29/87 (33.3%) cases. Six months follow up data was available for 82/91 eyes. Overall retinal re-attachment was achieved in 52/82 (63.41%) eyes; in 33/82 (40.24%) eyes retinal attachment could be achieved by a single surgery. Absence of proliferative vitreoretinopathy (PVR) (OR: 2.44, p-value:0.03, 95%CI: 1.21-5.08) or PVR-A (OR: 3.62, p-value: 0.03, 95%CI: 1.52-12.26) and presence of preexisting posterior vitreous detachment (OR: 7.14, p-value: 0.02, 95%CI: 1.31-38.73) were associated with successful retinal re-attachment after single surgery. Median time to presentation of cases succeeding after 1 surgery was 10 days. Ambulatory vision (1/60 and better) at final followup could be achieved in 45/82 (54.88%) eyes. CONCLUSION: GRT relatedRDs constitute a significant proportion of paediatric RDs. Anatomical success can currently be achieved in a large number of cases. Early surgery, absence of PVR and presence of PVD are associated with higher surgical success.

Three-years follow-up swept source optical coherence tomography angiography findings in post-fever retinitis.

Post fever retinitis (PFR), characterized by multiple cotton wool spot like lesions in the posterior pole, is commonly reported following viral and bacterial infections. Retinal perfusion defects have been documented with the help of optical coherence tomography angiography (OCTA) in cases of PFR. But long term changes in such cases have not been reported earlier. In the following report, we have described the swept-source OCTA findings of two PFR patients at initial presentation and three years follow-up. Initial OCTA scans may not provide accurate information regarding the perfusion status due to associated retinal edema and inflammation. However, persisting perfusion defects at the superficial and deep retinal capillary plexus were noted on long term follow-up in both the cases.

Intraoperative optical coherence tomography-guided subretinal cocktail injection in a case of ruptured retinal artery macro-aneurysm with multilevel bleed.

Submacular hemorrhage (SMH) following ruptured retinal artery macro aneurysm (RRAM) has better prognosis as compared to other etiologies. Timely intervention from as early as 24 h to less than 7 days is known to provide better visual outcomes in such cases. A variety of surgical techniques have been described in the treatment of RRAM. In this case report, we describe the advantages of intraoperative optical coherence tomography-guided sub-retinal injection of a cocktail mixture consisting of recombinant tissue plasminogen activator, bevacizumab, and air. Faster visual recovery with an immediate displacement of sub-macular bleed can be achieved with this technique in cases of RRAM-associated SMH.

Clinical features, optical coherence tomography findings and treatment outcomes of post-fever retinitis.

OBJECTIVES: To study the clinical features, optical coherence tomography (OCT) findings, treatment options and follow-up outcomes of post-fever retinitis (PFR). SUBJECTS: A total of 19 eyes of 13 patients, diagnosed with PFR (retinitis following febrile episode) over 2 years were retrospectively studied. METHODS: Documented history, baseline clinical features and systemic investigations performed for PFR were reviewed. Fundus findings, foveal architecture on swept-source OCT, the treatment options and the follow-up outcomes including best-corrected visual acuity (BCVA) and central foveal thickness (CFT) were reviewed and analyzed. RESULTS: Common fundus findings included whitish retinitis lesions (100%), macular star (95%, 18eyes), retinal flame-shaped hemorrhages (63%, 12 eyes), inflammatory retinal vessels (30%, 6 eyes), vitreous hemorrhage (one eye) and OCT findings included neuro-sensory detachment (79%, 15 eyes), intraretinal white dots (89.5%,17 eyes). The baseline median log MAR BCVA and CFT were 1.30 (interquartile range (IQR):0.8-1.8) and 423 microns (IQR:182-555). Overall, nine patients (12 eyes) received a combination of oral doxycycline and oral steroids and four patients (7 eyes) received a combination of oral doxycycline, oral steroid and intravitreal anti-vascular endothelial growth factor (IVA). Significant improvement was evident at 8 weeks in median BCVA (0.50, IQR: 0.3-0.8, p < 0.05) and median CFT (223 micron, IQR: 170-256, p < 0.05) though only 26% (5 eyes) attained BCVA > = 6/12. CONCLUSION: Our study puts forth certain characteristic fundus and OCT features of PFR. A combination of oral doxycycline and oral steroids as a treatment option showed improvement in BCVA and CFT. Additional IVA helps in faster visual recovery in patients presenting with severe macular edema at onset.

Polypoidal choroidal vasculopathy: a comprehensive clinical update.

Polypoidal choroidal vasculopathy as a disease is yet to be comprehended completely. The clinical features consisting of huge serosanguineous retinal pigment epithelial and neurosensory layer detachments, although unique may closely mimick neovascular age-related macular degeneration and other counterparts. The investigative modalities starting from indocyanine angiography to optical coherence tomography angiography provide diagnostic challenges. The management strategies based on the available therapies are plenty and not vivid. A detailed review with clarifying images has been compiled with an aim to help the readers in getting a better understanding of the disease.

Do oblate eyeballs exist? A rare case of rhegmatogenous retinal detachment in an elliptical globe.

A patient, being a moderate myope with an axial length of 24.71 mm, presented to us with a fresh rhegmatogenous retinal detachment and marked peripheral chorioretinal degeneration. Difficulty in maneuvering with the standard 23 gauge vitrectomy cutter, inability to identify the break due to poor peripheral contrast, inadequate laser uptake, and an unusual large silicon oil fill (7.3 ml) were a few findings raising suspicion. Postoperative ocular ultrasonography showed an oblate eyeball with a relatively longer oblique axis (26.1 mm) as compared to the axial length confirming our suspicion. Oblateness should be suspected when the chorioretinal degenerations are more marked in the periphery as compared to the posterior pole. Intraoperative difficulties should be kept in mind while operating such cases.

Platelet Transfusion Related Panophthalmitis and Endophthalmitis in Patients with Dengue Hemorrhagic Fever.

Dengue is a vector-borne viral illness of major public health importance. It is endemic in many parts of India and also causes frequent epidemics. Platelet transfusions are given in severe cases of dengue fever to treat and prevent hemorrhagic complications. Here, we report three patients in North India with development of panophthalmitis and endophthalmitis shortly after receiving platelet transfusion.