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Purpose. To identify systemic factors that may influence the response to anti-VEGF therapy in patients with diabetic macular edema (DME). Methods. 35 patients undergoing anti-VEGF injections for centre-involving DME were studied in this prospective observational study. The primary outcome was change in macular thickness one month after treatment, measured using spectral-domain optical coherence tomography (OCT). At baseline, information on various systemic factors was collected including glycosylated hemoglobin (HbA1c), serum VEGF levels, lipid profile and markers of renal function, and blood pressure. Thirty-three of the 35 patients were included in this study. Nonparametric statistical tests were used for the analysis of the data in view of the nonnormal distribution of the outcome variables. Multivariate analysis was performed using logistic regression. Stata 12.1 software was used for the analysis. Main Outcome Measures. Reduction in macular central subfield thickness (on spectral-domain OCT) and change in logMAR visual acuity at one month after injection. Results. Lower HbA1c levels (7% or less) were significantly associated with greater reduction in central macular subfield thickness at one month after injection of bevacizumab or ranibizumab on both univariate analysis (p=0.012) and multivariate analysis (p=0.042). Conclusions. Better glycemic control is associated with a greater reduction in central macular thickness after the first injection of bevacizumab or ranibizumab in diabetic macular edema. Patients with high levels of HbA1c and poor response to anti-VEGF may benefit from strict control of their blood glucose.

Acute retinal necrosis (ARN) following herpes simplex encephalitis (HSE) in an immunocompetent patient is a rare condition. Quantitative real-time polymerase chain reaction (qPCR) has made it possible to identify and quantify viral genome. We report a case of ARN following HSE managed with the help of qPCR. A 45-year-old man developed ARN following HSE and was treated with intravenous acyclovir and intravitreal foscarnet. The retinitis did not respond initially and the qPCR demonstrated a rise in the number of copies of the HSV-1 viral genome. With continued treatment with intravenous acyclovir and intravitreal ganciclovir, the retinitis healed and the qPCR confirmed a reduction in the viral load. qPCR has a high sensitivity and specificity for HSV and is a useful tool for diagnosis and treatment of viral retinitis.

The management of intra ocular tumors has undergone a sea change from the era of enucleation or external beam radiation. With the advent of new chemotherapy protocols, globe and vision salvage have become possible in a majority of cases of retinoblastoma. This article is an overview of the various modalities available for the management of intra ocular tumors and their indications. Chemotherapy has been covered elsewhere in this series of articles on ocular oncology. Photocoagulation and cryopexy are easily administered modalities of treatment for small tumors and totally within the ophthalmologist′s domain. Slightly larger tumors are treatable with brachytherapy. The susceptibility of the tumors to chemotherapy and radiation decide the choice of treatment and the dosage. Management of intra ocular tumors very often needs a multidisciplinary approach including ophthalmologist, oncologist, radiation physicist, and radiotherapist.

Background: Choroidal coloboma, especially with optic disc involvement affects the blood vessel (BV) pattern in the fundus. Aim: The aim of this study was to report the observations on the pattern of retinal BVs in eyes with fundus coloboma. Design: Retrospective observational study. Materials and Methods: Twenty four eyes of 19 patients with fundus coloboma and the disc involvement in the coloboma was classified according to a previous publication. Results: Four varieties of BVs were identified in the area of coloboma - BVs that were continuous with those arising from the optic disc; vessels emanating from the floor of coloboma whose continuity with central retinal artery or its branches could be indirectly established; and those emanating from the floor of coloboma whose continuity with central retinal artery could not be established. In addition, extraocular BVs were visible through the thinned sclera. The retinal BVs often traversed the coloboma to reach the normal retina. The disc itself was found to be small and had no physiological cup (if not colobomatous). Conclusions: One should be aware of the major BVs transgressing the coloboma while performing relaxing cuts in the intercalary membrane, during the surgery for retinal detachments in eyes with coloboma. Physiological cup is usually absent (when the disc is not colobomatous). Hence, any cupping in such eyes should be viewed with suspicion.

Choroidal neovascularization (CNV) is a rare complication associated with coloboma of the choroid. We describe three cases of coloboma choroid where there was loss of vision due to CNV development at the edge of the coloboma. One was managed by photodynamic therapy alone and two were managed by a combination of reduced fluence PDT and intravitreal bevacizumab. Significantly we noted that one treatment session was sufficient to achieve regression of the CNV and improvement in visual acuity.

Aim: To describe the clinical features, treatment and outcome patterns in 307 eyes with Coats′ disease. Materials and Methods: Retrospective chart review of patients diagnosed with Coats′ disease between January 1996 and January 2006 from a single referral center in southern India. Results: Two hundred and eighty patients (307 eyes) with mean age of 15.67 years (range: Four months-80 years) were included. Decreased vision (77%), unilateral affection (90%) and male preponderance (83.4%) were chief presenting features. Anterior segment involvement was seen in 67 (21.8%) eyes. Retinal telangiectasia were seen in 302 (99%) eyes, exudation in 274 (89%) eyes and retinal detachment in 158 (51.5%) eyes. Four-quadrant disease was seen in 207 (67.2 %) eyes. Visual acuity was < 20/200 in 249 (80.9%) eyes. One hundred and nine of 176 treated eyes (61.93%) had favorable anatomical outcome; 207 of 280 eyes (74%) had an optimal structural outcome. Seventeen (5.3%) eyes were enucleated. Complications following treatment included phthisis bulbi (7%), neovascular glaucoma (5%), epiretinal membrane (4.4%) and rubeosis iridis (4.4%). Conclusion: Indian patients with Coats′ disease have a high male predominance, the majority of whom present with severe visual impairment and extensive four-quadrant exudation. Unusual presentations such as pain, vitreous hemorrhage and a high incidence of anterior segment involvement are distinctive to Indian eyes.

Retinopathy of prematurity (ROP) is a significant cause of childhood blindness. The criteria for laser therapy have been revised from threshold ROP to include the earlier stage of high-risk prethreshold ROP. Laser photocoagulation is an established technique for the treatment of ROP. However, the detailed procedure and techniques for laser photocoagulation have not yet been published. Adequate and appropriate laser photocoagulation for ROP is different from the application of lasers in adult retinal vascular diseases, and many ophthalmologists need to be trained in this technique if the outreach of ROP treatment programs is to improve. Laser under topical anesthesia has been practiced in India as a preferred modality especially due to logistics and risks of general anesthesia in these pre-term babies. We discuss the details of the technique as practiced at tertiary care ophthalmic hospitals in India, so that the nuances in treatment parameters and clinical decision-making can be usefully applied to ophthalmic practice. This will ultimately lead to safe and effective treatment delivery in ROP.

Background: While lens-sacrificing vitrectomy is the standard approach to manage Stage 5 retinopathy of prematurity (ROP), scleral buckling has been used to manage some cases of Stage 4. Lens-sparing vitrectomy was popularized by Maguire and Trese in selected cases of Stage 4 disease. Purpose: To assess the functional and visual outcomes after primary lens-sparing pars plana vitrectomy for Stage 4 ROP. Materials and Methods: In a retrospective, interventional, consecutive case series, the records of 39 eyes of 31 patients presenting with Stage 4 retinal detachment secondary to ROP who underwent primary two or three-port lens-sparing vitrectomy from January 2000 to October 2006 were evaluated. The outcomes studied at the final follow-up visit were the retinal status, lens and medial clarity and visual acuity . Favorable anatomical outcome was defined as the retinal reattachment of the posterior pole at two months after the surgery; and favorable functional outcome was defined as a central, steady and maintained fixation, with the child following light. Results: At mean follow-up of 15 months, 74% of the eyes had a favorable anatomical outcome with single procedure. The visual status was favorable in 63% . The lens remained clear in all the eyes at the last follow-up, and the media clarity was maintained in 87%. Intraoperative complications included vitreous hemorrhage, pre-retinal hemorrhage and retinal break formation. Conclusions: Lens-sparing vitrectomy helps to achieve a favorable anatomical and functional outcome in selected cases of Stage 4 ROP.

Purpose: To evaluate the efficacy of transpupillary thermotherapy (TTT) in choroidal neovasularisation (CNVM) secondary to age related macular degeneration ( AMD). Material and methods: Retrospective, non-randomized study of 28 eyes of 28 patients with subfoveal CNVM (classic, occult or mixed) secondary to AMD. Results: Fifteen patients (53.57%) maintained their pre-treatment vision, 2 (7.14%) patients showed improvement of more than 2 lines and 11(39.28%) patients showed deterioration of vision by> 2 lines. Angiographic and clinical regression of CNVM was noted in 19 patients (67.8%) on an average follow up of 15.32 ± 3.31 months. Conclusion: TTT leads to stabilisation of vision in 60% of treated eyes with CNVM due to AMD.

Purpose: To report a series of nine patients of Wegener′s granulomatosis (WG) with diverse ocular and systemic manifestations. Methods: Retrospective analysis of nine consecutive patients seen between 1987 and 2002. Results: The mean age at the time of diagnosis was 43.89 years (range: 33-56 years). Redness, pain and photophobia (8 patients) were the common presenting complaints. Sinusitis (6 patients) and arthralgia (6 patients) were the commonly associated systemic complaints. Necrotising scleritis with peripheral keratopathy (6 patients) was the most common ocular sign. Serum antibodies against the cytoplasmic component of neutrophils and monocytes (cANCA) were positive in 7 of 8 patients. Biopsy diagnosis was done in one patient for whom cANCA was not done. Cyclophosphamide and corticosteroids alleviated the symptoms in 6 patients. Ocular and systemic condition remained stable in 7 patients. One patient expired due to the severity of the disease and another patient was lost to follow-up. Conclusions: Scleritis with peripheral corneal involvement was the most commonly observed ocular manifestation of WG in our series. cANCA was a useful adjunct in the diagnosis of WG. When clinical and serologic findings were inconclusive, biopsy remained indispensable. A combination of cyclophosphamide and corticosteroids is essential and critical not only for the ocular condition but also for the survival of the patient.

Purpose: To report the clinical and microbiological profile of endophthalmitis caused by Acinetobacter calcoaceticus . Methods: A retrospective study of case series of Acinetobacter calcoaceticus endophthalmitis. Outcome measures included ability to sterilise the eye, anatomical result (clear media and attached retina) and visual recovery (visual acuity > 6/60). Results: Of the 20 cases studied, 10 were cases of postoperative endophthalmitis, 3 were posttraumatic, 6 were endogenous and one was bleb-related endophthalmitis. Specific features of interest observed were relative chronicity of presentation and absence of any obvious predisposing factor in endogenous endophthalmitis cases. All cases could be sterilised except one, which needed evisceration. Cases with postoperative endophthalmitis had better anatomical outcome (7/10 with attached retina and clear media) and visual outcome (4/10 regained vision > 6/18). Higher smear positivity was seen in vitreous samples (72.2%) compared to aqueous samples (37.5%). Culture positivity was higher from the vitreous cavity compared to aqueous. The organism was sensitive to ciprofloxacin in a high percentage (88.9%) of cases. Conclusions: Visual recovery in Acinetobacter calcoaceticus endophthalmitis is modest. Ciprofloxacin is the antibiotic of choice

Retinopathy of Prematurity (ROP) is one of the major emerging causes of childhood blindness. A well organised screening strategy and timely intervention can to a large extent prevent blindness due to ROP. This communication proposes a screening strategy and management plan to develop a model for the care of babies with ROP.

Human immunovirus infection in India is rapidly increasing. Ocular lesions due to highly active antiretroviral therapy have been well recognized. Acquired immunodeficiency syndrome can affect all parts of the eye. However, posterior segment lesions are the most common and of these, Human immunodeficiency virus retinopathy and cytomegalovirus retinitis predominate. Often clinical examination can establish the diagnosis of many ocular lesions in acquired immunodeficiency syndrome; therefore, ophthalmologists need to be aware of the more common ones. Various drugs in different routes can used to treat cytomegalovirus retinitis. Highly active antiretroviral therapy has remarkably reduced systemic and ocular morbidity among acquired immunodeficiency syndrome patients. To facilitate care of these patients aseptic precautions for ophthalmic care personnel are now well established and therefore ophthalmologist should not hesitate to provide ophthalmic care to acquired immunodeficiency syndrome patients.

Purpose: To report a case series of penetrating injury complicated by occurrence of intraocular cilia. Methods: Retrospective analysis of charts of 11 eyes of 11 patients with penetrating injury and intraocular cilia, presenting between September 1978 and November 1998. Ten eyes underwent surgery for trauma-related problems such as cataract, vitritis, retinal detachment etc., at which time intraocular cilia were removed. One eye did not have surgery and continues to harbour cilia at the posterior perforation site. Results: Metallic wire was responsible for injury in 6 of 11 eyes with intraocular cilia. Five eyes had significant intraocular inflammation. The cilia were located in the anterior segment in 4 eyes; in the posterior segment in 6 eyes and in both in one eye. At the last follow up, 72.7% had 6/18 or better vision. Poor vision in the rest was due to recurrent retinal detachment (2 eyes) and macular scarring (1 eye). Conclusion: Intraocular cilia are more commonly associated with injury by a metallic wire. The presentation and management of an injured eye does not seem to be influenced by the presence of cilia in the eye.

Purpose: To describe our experience with management of eyes with stage 5 retinopathy of prematurity (ROP) Methods: Closed vitreoretinal surgery was done on 96 eyes of patients with stage 5 ROP. Lens was sacrificed in all but one eye. Surgery involved an attempt to clear all preretinal tissue and open the peripheral trough all round. In most instances bimanual surgery under viscoelastic was performed. Results: At last follow up, anatomical success (defined as attached posterior pole) was achieved in 22.5% cases. Significant postoperative problems included reproliferation and secondary glaucoma. Only two infants obtained mobile vision. Conclusion: Late identification of disease, lack of prior treatment such as laser or cryo, and higher incidence of narrow-narrow funnel configuration were responsible for the poor surgical results noted in this series. The poor surgical and functional results reemphasise the need for prompt screening and management of infants at risk.

Blind eyes can harbor a choroidal melanoma. We report a case of uveal melanoma presenting as staphyloma and complicated cataract in a 45-year-old female. The left eye was blind for six months. She underwent comprehensive ocular examination but fundus examination was precluded due to total cataract. The ultrasound of the eye showed a large mass filling the superior, nasal and inferonasal vitreous cavity with high surface reflectivity and low to moderate internal reflectivity. Magnetic resonance imaging (MRI) confirmed the diagnosis of choroidal melanoma. The patient underwent extended enucleation and histopathology was consistent with uveal melanoma.

We report a case of cystoid macular edema in a patient who underwent bone marrow transplant for aplastic anemia. After having ruled out all the other causes of cystoid macular edema, we concluded that it was secondary to the bone marrow transplant. The patient had mild visual impairment and did not recover the lost vision. In this case report, we describe in detail the clinical presentation, follow-up, and course of medication that this patient had. It is an illustrated case report of cystoid macular edema after bone marrow transplant with mild visual impairment and no recovery.

Purpose: To report the role of Ultrasound Biomicroscopy (UBM) as a tool in the diagnosis and management of cyclodialysis clefts. Methods: Six eyes of 6 patients with hypotony and suspected or diagnosed cyclodialysis clefts underwent UBM evaluation. Post-treatment UBM was performed in four eyes to assess the effect of the treatment. Results: Cyclodialysis clefts were accurately diagnosed and delineated in 6 eyes by UBM. Complete closure was documented after treatment in 3 eyes, and a residual cleft in one eye. These findings were compared to gonioscopic findings. Conclusions: UBM is a safe, accurate and noninvasive diagnostic tool in the diagnosis of cyclodialysis clefts and is of particular use when other conventional methods of diagnosis are inconclusive.

Purpose: To study the occurrence, risk factors and management of subconjunctival cysts formed following the use of intraocular silicone oil as a tamponade. Methods: We analysed 5 cases of single and multioculated subconjunctival oil cysts between 1986 and 1996. Results: Cysts were observed 15 days to 4 months following silicone oil injection. Clinically they showed minimal inflammatory signs but histopathology of removed cysts showed emulsified silicone oil globules with chronic inflammatory cellular infiltration. Conclusion: Though silicone oil is considered to be nontoxic, it can cause chronic inflammation when spilled into the subconjunctival space

Purpose: To evaluate the efficacy of pH-adjusted bupivacaine in conjunction with medial orbital periconal block (periocular anaesthesia). Methods: Sixty consecutive patients undergoing primary vitreoretinal surgery were enrolled prospectively. Results: Adequate anaesthesia and akinesia with no intraoperative supplementation was achieved in 53 eyes (88.3%). Factors influencing intraoperative supplementation were combined vitrectomy with scleral buckling (p=0.005) and duration of surgery of more than 2 hours (p=0.001). No ocular or systemic complication resulted. Conclusion: pH-adjusted periocular anaesthesia is safe and effective in patients undergoing primary vitreoretinal surgery.

Chronic recurrent endophthalmitis can occur following uncomplicated cataract surgery with intraocular lens implantation secondary to organisms sequestered in the capsular bag. There is a need to identify these sequestered organisms to facilitate appropriate management. Frequently, specimens from the anterior chamber and vitreous cavity could be unyielding, especially in the early cases in which the vitreous is still uninvolved. This article highlights the technique of directly sampling the capsular bag material in the effective diagnosis of the organism, which facilitated the total cure by irrigation with appropriate antibiotics into the capsular bag.

Posterior scleritis is relatively uncommon and is often misdiagnosed due to its protean manifestations. We report eight cases of posterior scleritis to analyse the clinical profile, ultrasonographic and computed tomography (CT) scan features of this rare disorder. Fundus findings included serous retinal detachment, choroidal folds, retinal folds, subretinal mass, choroidal detachment, disc edema, and macular edema. There was associated anterior scleritis and anterior uveitis in the majority of the cases. In all cases ultrasound with or without CT scan confirmed the clinical diagnosis. All patients responded to systemic steroids except one who required immunosuppressive therapy. This paper describes the clinical profile of a series of posterior scleritis cases highlighting varied clinical presentation, and the role of ultrasound and CT scan findings in the diagnosis.

An in-vitro study of wave spectral analysis in 8 enucleated eyes was conducted in order to differentiate histological subtypes of malignant melanoma. To obtain the backscattering coefficient for the tissues, we used a broadband focussed transducer with a frequency range of 7-12 MHz and a centre frequency of 10 MHz. Experimental measurement of backscattering coefficient and attenuation coefficient at various frequencies was done by substitution techniques. The backscattering coefficient, scatterer size, and root mean square velocity fluctuation were derived by the numerical method, while the attenuation coefficient at 1 MHz was derived from attenuation coefficient at different frequencies. This study revealed that backscattering coefficient and attenuation coefficient, over a frequency range of 7-12 MHz, show an increase in the spindle cell type compared to the mixed cell type of malignant melanoma. Particularly, the scatterer size was significantly higher in the spindle cell group (p = 0.013) in contrast to the mixed cell type. Spindle cells have uniform and compact histological pattern which contributes to an increase in scatterer size and root mean square velocity fluctuation. The ultrasonically obtained parameters have been shown to have a good correlation with the histology of malignant melanoma.

This report deals with our experience in the management of threshold retinopathy of prematurity (ROP). A total of 45 eyes of 23 infants were subjected to treatment of threshold ROP. 26.1% of these infants had a birth weight of >l,500 gm. The preferred modality of treatment was laser indirect photocoagulation, which was facilitated by scleral depression. Cryopexy was done in cases with nondilating pupils or medial haze and was always under general anaesthesia. Retreatment with either modality was needed in 42.2% eyes; in this the skip areas were covered. Total regression of diseases was achieved in 91.1% eyes with no sequelae. All the 4 eyes that progressed to stage 5 despite treatment had zone 1 disease. Major treatment-induced complications did not occur in this series. This study underscores the importance of routine screening of infants upto 2,000 gm birth weight for ROP and the excellent response that is achieved with laser photocoagulation in inducing regression of threshold ROP. Laser is the preferred method of treatment in view of the absence of treatment-related morbidity to the premature infants.

The management of intraocular tumours has come a long way since the days when enucleation was the only modality of treatment available to the ophthalmologist. Despite the fact that enucleation is still necessary in certain situations, the emphasis is currently on conservative management, thereby saving the eye and some amount of useful vision wherever possible. This review highlights the current trends in the management of adult intraocular tumours with emphasis on newer diagnostic modalities such as computed tomography, magnetic resonance imaging, and fine needle aspiration biopsy. Only those tumours that are most likely to be seen in clinical practice are included.

Advances in the surgical instrumentation and vitreoretinal techniques have allowed intraoperative reapproximation of retina to a more normal position. The use of intravitreally injected liquid materials (viscoelastic liquids, liquid perfluorocarbons and silicone oil), as adjunctive agents to vitreo-retinal surgery play an important role in facilitating retinal reattachment. These materials are used as intraoperative instruments to re-establish intraocular volume, assist in separating membranes adherent to the retina, manipulate retinal detachments and mechanically flatten detached retina. Over the longer term, silicone oil maintains intraocular tamponade. One should be cognizant of the potential uses, benefits and risks of each of these vitreous substitutes.

Infectious endophthalmitis following intraocular surgery is a complication that could cause severe visual loss or loss of the eye. The categorisation of the event that led to intraocular infection will help the clinician to predict the infectious agent and begin appropriate therapy. Most of the cases of postsurgical endophthalmitis are seen following cataract surgery. It is important for all ophthalmologists, irrespective of specialisation and areas of interest,to be familiar with the management of endophthalmitis. This review briefly describes the facets of clinical and laboratory diagnosis, pathology, and management. While the different viewpoints in the management of endophthalmitis are mentioned in appropriate places, more attention is paid to present a rational approach to the management of endophthalmitis.

Viral retinitis is an important infectious disease of the retina which can occur in both healthy and immunocompromized or immunodef icient individuals. The clinical picture and the role of laboratory studies in diagnosis of viral retinitis are still not well-defined. We correlated the clinical picture and virologic study in the serum and vitreous specimens by Enzyme-linked Immunosorbent Assay (ELIS A), rapid immunofluorescence technique and culture in five clinically suspected patients of viral retinitis. None of the patients had any evidence of systemic viral infections. In four patients, the virus was detected by immunofluorescence, ELISA or culture from the vitreous sample. Paired serum samples showed elevation of antiviral IgG titre in two cases and high antiviral IgM titre in all cases. Our study evaluated the role of virological investigations of vitreous aspirate and rising antibody titre in the paired serum samples in the diagnosis of active viral retinitis.

A retrospective analysis of 22 patients who underwent pars plana vitrectomy for endophthalmitis and had culture-proven anaerobic bacteria, was done. Elimination of infection with attached retina and recovery of ambulatory vision ≥2/60 were considered as anatomic success and functional success, respectively. Mean follow-up period was 12.7 months (range, 2 to 48 months). Anatomic success was attained in 14 (63.6%) eyes and functional success in 12 (54.6%) eyes. A poor preoperative visual acuity was found to be associated with poor functional outcome (p < 0.046). In endophthalmitis, a routine anaerobic culture of intraocular specimen is recommended.

Forty non-enucleated eyes with bilateral retinoblastoma which were treated by external beam radiation therapy (EBRT), transconjunctival cryopexy, and photocoagulation were retrospectively analysed for the age of onset and location of new intraocular tumours. Of these 40 eyes, 9 (22.5%) eyes developed 17 new tumour foci over a mean follow-up of 3 years. The risk of new tumour formation was age-related being 47% in children with age at onset of retinoblastoma less than 1 year compared to 4.4% in older children (P < 0.001). Four eyes (44%) had 2 episodes of tumour formation. All tumour foci developed within 11 months of initial treatment at an average episode interval of 4.0 months. In 89% of cases, new lesions ceased to occur by 18 months of age. Our study clearly shows that EBRT did not prevent development of new lesions. The tumour islands which developed in the peripheral retina in 88% of cases were successfully treated with transconjunctival cryopexy. In 8 cases (89%), the eye could be salvaged. All young bilateral retinoblastoma patients should undergo frequent periodic detailed examination of the retinal periphery with 360 degrees scleral depression to pick up new tumour lesion early and to treat them effectively with simple globe saving methods.

A case of progressive outer retinal necrosis (PORN) caused by Cytomegalovirus (CMV), and diagnosed by polymerase chain reaction (PCR) is reported.