RETINA / VITREOUS SESSION-III - All India Ophthalmological Society

RETINA/ VITREOUS SESSION-III 

505 

RETINA / VITREOUS SESSION-III 

Chairman: Dr. R.B. Jain, Co-Chairman: Dr. Shobit Chawla 

Convenor: Dr. Manish Nagpal, Moderator: Dr. Vatsal Shyamlal Parikh 

AUTHORS’S PROFILE: 

DR. NEHA GOEL: M.B.B.S. (2005), Maulana Azad Medical College, New Delhi; M.S. (2009), 

Guru Nanak Eye Centre, Maulana Azad Medical College, New Delhi. Presently, Guru Nanak 

Eye Centre, Maulana Azad Medical College, New Delhi. 

E-mail: nehadoc@hotmail.com 

An Optical Coherence Tomographic (OCT) Study of Post Laser 

Diabetic Cystoid Macular Edema (CME): Intra vitreal Bevacizumab 

(IVB) versus Intra Vitreal Triamcinolone Acetonide (IVTA) 

Dr. Neha Goel, Dr. Basudeb Ghosh, Dr. Usha Kaul Raina, Dr. Meenakshi Thakar, 

Dr. Vinod Kumar, Dr. Vasu Kumar Garg 

(Presenting Author: Dr. Neha Goel) 

Macular Edema is the single largest cause of 

mild to moderate visual loss in persons 

with diabetic retinopathy. In the Early Treatment 

Diabetic Retinopathy Study (ETDRS), focal 

photocoagulation (direct treatment to 

microaneurysms and grid treatment to diffuse 

edema) of eyes with Clinically Significant 

Macular Edema (CSME) reduced the risk of 

moderate visual loss by approximately 50%. 

Despite adequate photocoagulation 15 % patients 

experienced vision loss of 3 lines after 3 years. 

25% of patients with diffuse diabetic macular 

edema lost at least 3 lines with modified grid 

photocoagulation. Also, the OCT pattern 

containing cystoid macular edema (CME) has 

poorer visual acuity and comparatively less 

favourable outcome especially if previous 

attempts at laser have failed. 

Alternative treatments for the management of 

DME include administration of intravitreal 

triamcinolone acetonide (IVTA), which has 

demonstrated promising results in diffuse DME, 

whether refractory or primary. Clinical use of 

Bevacizumab has suggested its efficacy in the 

treatment of macular edema associated with 

diabetes and central retinal vein occlusion and no 

evidence of adverse effects has been noted in 

association with intravitreal injection. 

Unlike CSME for which primarily laser 

photocoagulation has remained the most widely 

accepted and used treatment method, 

management of diabetic CME is still a dilemma. 

Given the difficulties of treating patients with 

diabetic CME unresponsive to laser treatment we 

decided to evaluate and compare the use of IVTA 

and IVB in reducing macular edema and 

improving visual acuity. 

Materials and Methods 

The therapeutic response and ocular tolerance of 

a single IVTA injection of 4mg were compared 

with the outcomes of a single IVB injection of 

1.25mg for the treatment of persistent diabetic 

CME in a 3 month prospective randomized 

interventional case series. Patients were recruited 

and enrolled at the Retina Clinic of Guru Nanak 

Eye Centre. Written informed consent was 

obtained from all the participants before the 

procedure. 

A total of 30 eyes of patients with Type 1 or 2 

Diabetes Mellitus having good metabolic control 

(including HbA1C < 10, blood pressure 275 microns were enrolled in this study. 

Patients with history of myocardial infarction or 

cerebro-vascular accident, history of glaucoma or

506 AIOC 2009 PROCEEDINGS 

Table-1 

Group A Group A P value Group B Group B P value Difference 

baseline 12 weeks baseline 12 weeks between 

groups (P) 

BCVA 0.20 0.32 0.003 0.16 0.22 0.031 0.169 

Mean Macular 

Thickness 347.7 310.9 0.043 340.5 286.8 0.033 0.391 

glaucoma surgery or steroid responsive IOP rise, 

cataract extraction or other intraocular surgery 

within 3 months, laser treatment including YAG 

Capsulotomy within 1 month, history of 

receiving any prior intravitreal or sub tenon 

injection or known allergy to any components of 

the study drugs were excluded from the study. 

Also excluded were patients with any significant 

media opacity precluding clinical and other 

examination, Proliferative Diabetic Retinopathy, 

vitreo-macular traction on OCT and ischemic 

maculopathy on FA. 

All patients underwent detailed history taking 

and base line examination including Best 

Corrected Visual Acuity (Snellen chart), detailed 

anterior segment examination with special 

reference to the lens status, slit lamp 

biomicroscopy using 90D non contact lens, 

Goldmann Applanation Tonometry, fundus 

fluorescein angiography and macular thickness 

mapping using Third generation Optical 

coherence tomography evaluation. All patients 

were kept on a regular follow up for a minimum 

period of 12 wks with respect to above 

mentioned criteria. Potential drug and injectionrelated 

complications were also observed. 

Qualified patients were assigned to receive either 

an IVTA or IVB injection within 1 week of 

baseline. Treatment was performed as an 

outpatient procedure. Topical anesthesia was 

obtained with proparacaine eye drops followed 

by standard per operative cleaning and draping. 

TA was injected into the vitreous inferotemporally 

with a 30 gauge needle at a dose of 4 

mg in 0.1 ml. Indirect ophthalmoscopy was done 

to confirm intravitreal location of the suspension 

and perfusion of the optic nerve head. For IVB 

injection, 100 mg vial of preservative free 

Bevacizumab (Avastin) which contains 4 cc of 25 

mg/ml concentration of the drug was used. 

0.05cc was injected into the eye using a tuberculin 

syringe with 30 gauge needle to deliver a dose of 

1.25 mg followed by indirect ophthalmoscopy. In 

both cases topical antibiotics were administered. 

Results 

A total of 27 patients (30 eyes), 24 male and 6 

female were included in the study. The treatment 

was administered according to random 

assignment in all eyes. 11 right eyes and 4 left 

eyes were allocated to receive IVB (group A) 

while 8 right eyes and 7 left eyes received IVTA 

injections (group B). All patients were followedup 

for 3 months and completed the study. 

The mean age of patients was 58.3 (range 45-72). 

All patients had non insulin-dependent diabetes. 

The mean duration of diabetes was 12.1 years. 15 

patients were hypertensive and controlled on 

drugs. The precise duration of symptoms 

attributable to macular edema was difficult to 

determine, but it was longer than 24 weeks. Mean 

HbA1c was 8.07. 

Maximum improvement in macular thickness 

was seen in both groups at 3 weeks. However 

changes of retinal thickness and BCVA correlated 

weakly. 

None of the patients in group A developed 

cataract progression. In group B, 5 out of 10 

phakic patients had an increase in cataract, 2 out 

of which required surgery at the end of 12 weeks. 

5 out of 15 patients in Group B developed a 

temporary rise in IOP in excess of 22 mm Hg 

which resolved on medical therapy. None of the 

patients in group A developed rise in IOP. 

No severe adverse event was observed 

throughout the study. No systemic or serious 

drug-related adverse events were observed. 

Subconjunctival haemorrhage was the 

commonest side effect noted. Both treatment 

procedures were well tolerated, and no clinical 

evidence of inflammation, uveitis, endophthalmitis 

or ocular toxicity was observed. 

Discussion 

The present study is an extension of currently


507 

published reports in that it allows a direct 

comparison of IVTA with IVB injection for 

persistent diabetic CME regarding safety, as well 

as anatomic and functional outcomes. 

We found comparable efficacy in both groups 

with regards to visual acuity and macular 

thickness reduction. Acceleration of cataract 

might account for the slightly lower, though not 

statistically significant, visual acuity in Group B 

at the end of 12 weeks. Maximum reduction in 

macular thickness occurred at 3 weeks in both 

groups, though a longer follow up is required to 

ascertain the precise duration of action of both. 

Changes of retinal thickness and BCVA 

correlated weakly. One possible explanation is 

the duration of the edema - the longer macular 

edema is present, the more likely it is to cause 

irreversible damage to the photoreceptors and 

this damage reduces the potentially beneficial 

effect that a reduction in foveal thickness is likely 

to have on the visual acuity. 

IVB was not found to be associated with 

progression of cataract or rise in IOP unlike 

IVTA. It may be a suitable alternative in ocular 

hypertensives and steroid responders. 

The current study had some limitations, 

including a relatively small sample size. The 

duration of the follow-up is also relatively short, 

but most injection and corticosteroid-related 

complications other than cataract development 

would be expected within the study interval. 

In conclusion, the findings from our study 

neither advocate nor support the superiority of 

IVB or IVTA for the treatment of persistent 

diabetic CME, but imply that both IVTA and IVB 

injections may be equally efficacious for the 

anatomic and functional aspects of improvement 

tested in this investigation. However 

complications of IVTA namely cataract 

progression and rise in IOP, which did not 

occur with IVB, must be taken into 

consideration. 

A Prospective Study of Outcomes in CMV Retinitis Patients on 

Haart and Additional Anti CMV Regime, Laser Barrage, Parsplana 

Vitrectomy 

Cytomegalovirus (CMV) is a ubiquitous DNA 

virus that infects the majority of the adult 

population. In the immunocompetent host, 

infection is generally asymptomatic. Like many 

other herpes viruses, CMV remains latent in the 

host and may reactivate if host immunity is 

compromised. 

In immunocompromised individuals, primary 

infection or reactivation of latent virus can lead 

to opportunistic infection of multiple organ 

systems. In the eye, CMV most commonly 

presents as a viral necrotizing retinitis with a 

characteristic ophthalmoscopic appearance. 

Untreated CMV retinitis inexorably progresses to 

visual loss and blindness. Multiple antiviral 

agents, delivered locally, systemically, or in 

combination, are currently in use to delay or 

arrest the progress of the disease. In addition, 

highly active antiretroviral therapy (HAART) for 

HIV infection has revolutionized the treatment of 

CMV retinitis by allowing immune reconstitution 

in many individuals. 

Dr. Narendra G. Venkata 

(Presenting Author: Dr. Narendra G. Venkata) 

Mortality/Morbidity: CMV retinitis frequently 

results in considerable loss of visual acuity, and, 

without treatment, almost universally leads to 

blindness. Severe visual loss primarily occurs 

from the direct spread of retinitis into the 

posterior pole, affecting central vision, or from 

retinal detachment (RD) secondary to multiple 

retinal breaks in the peripheral, necrotic retina. 

Early and aggressive treatment with antiviral 

medication for both CMV and HIV, combined 

with improved surgical techniques for RD repair, 

has helped to improve the visual outcomes in 

these patients. 

• Retinal detachment occurs in up to 29%. 

Retinitis permanently destroys the retina; lesions 

change appearance with treatment but do not 

become smaller. Retinitis typically develops if the 

CD4 count is reduced below 50 cells/mL. 

• With the advent of HAART and immune 

reconstitution, some patients suffer from a 

relatively new condition known as immune


recovery uveitis (IRU). IRU occurs when the poor 

immune response of an immunocompromised 

individual is suddenly increased as the restored 

immune system recognizes and reacts to viral 

antigens in the retina. This reaction can lead to 

several complications, including uveitis, leading 

to hypotony, cataract, and glaucoma; epiretinal 

membrane (ERM); and cystoid macular edema 

(CME). 

History: Presenting symptoms vary depending 

on the location of retinal involvement. Posterior 

lesions present with diminished visual acuity. 

More peripheral lesions initially can be 

asymptomatic. Floaters often are noted if 

significant vitritis is present. The eye usually is 

white and quiet. 

• Natural history 

o CMV retinitis is a slowly progressive disease, 

requiring weeks to months to involve the 

entire retina. 

o Initial reports described CMV retinitis as an 

end-stage disease. With the use of antiviral 

medications, the average survival after 

diagnosis ranged from 5.5-8 months. The 

advent of HAART has prolonged survival to 

years in some instances. 

Physical: Patients with suspected CMV retinitis 

should have a complete ocular examination of 

both eyes. A careful examination should include 

the following: 

• A thorough slit lamp examination should show 

a white and quiet conjunctiva. A red hot eye in 

an immunocompromised patient should alert the 

clinician to another possible diagnosis. Fine, 

stellate keratitic precipitates (KP) characteristic of 

CMV may be seen on the corneal endothelium. 

Uveitis may be present in the anterior chamber 

and, if severe, may require treatment. 

• A dilated fundus examination with indirect 

ophthalmoscopy is essential for assessing the 

location and extent of retinal involvement as well 

as for evaluating for retinal breaks or 

detachment. Retinal lesions have several 

characteristics, as follows: 

o Lesions that present posteriorly appear along 

retinal vessels as large areas of thick white 

infiltrate accompanied by retinal hemorrhage 

described as "pizza pie" or "cheese pizza" in 

appearance.The peripheral type of lesion 

demonstrates a more granular appearance 

with satellite lesions and less hemorrhage. 

Behind the advancing border is necrotic 

retina with mottled pigmentation from 

hyperplasia of the RPE. 

o Retinitis follows the nerve fiber layer.Retinitis 

produces wide areas of necrosis, scarring, and 

atrophy. Even severe retinitis is usually 

accompanied by minimal vitritis in the 

immunocompromised patient. If HAART is 

instituted and immune reconstitution occurs, 

then IRU with severe anterior and posterior 

uveitis may occur. Extensive vascular 

sheathing, often described as frosted branch 

angiitis, is a known but uncommon 

appearance. Retinal vascular 

occlusion/nonperfusion can be seen on 

fluorescein angiogram. 

• Peripheral holes and tears frequently occur in 

areas of necrosis. Rate of progression of 

untreated retinitis is 250-350 µm per week. Skip 

lesions can occur. 

• Serial examinations may be necessary at early 

stages to distinguish CMV retinitis from HIV 

retinopathy with multiple cotton-wool spots. 

Optic neuritis can develop without apparent 

retinitis.Most patients with CMV retinitis will 

initially present with unilateral disease. 

Untreated, the immunocompromised patient has 

a 50% risk of developing disease in the 

contralateral eye within 6 months. This is 

reduced to 20% with antiviral treatment and 

further reduced with HAART. 

Causes: Any immunosuppression due to disease 

or medication may allow clinical CMV infection 

to develop. 

• Acquired immune deficiency syndrome 

• Leukemia, lymphoma, and aplastic anemia 

• Use of immunosuppressive chemotherapy 

• Organ transplant recipients 

• The CD4 count is a marker of immune 

dysfunction in patients infected with HIV. 

o CD4 >50 cells/mL - Little risk; screening 

examination every 6 months if CD4 50-100 

cells/mL; screen yearly if CD4 >100 

cells/mL.CD4


509 

regimen was used prior to the routine use of 

HAART. The frequency of examinations 

likely will be modified by assessing viral load, 

result of CMV DNA capture, CD4 count, and 

response to treatment. 

• CMV DNA capture 

o A polymerase chain reaction (PCR) test can be 

qualitative or quantitative. Specimens can be 

obtained from blood buffy coat, semen, or 

urine. Detection of CMV in the blood by DNA 

PCR is most predictive of developing CMV 

disease. Patients with AIDS who test positive 

will have more than a 60% chance of 

developing CMV end-organ disease. 

• HIV test 

• Complete blood count (CBC) with differential 

is important in evaluation for causes of 

immunosuppression and in assessment for side 

effects of ganciclovir use. 

• Blood urea nitrogen (BUN) and creatinine 

baseline assessment and serial measurements are 

used to evaluate for side effects of foscarnet or 

cidofovir use. 

Imaging Studies: 

• Ultrasound is used for evaluation of retinal 

detachment, particularly if vitritis obscures 

adequate fundus visualization. 

• Fluorescein angiogram - Assessment for areas 

of ischemia 

• Chest x-ray - Assessment for concurrent 

Pneumocystis pneumonia 

Other Tests: 

• Fluorescent treponemal antibody absorption 

(FTA-ABS) test or microhemagglutination- 

Treponema pallidum (MHA-TP) - Serologic 

testing for infection with syphilis, a differential 

diagnosis for CMV retinitis 

• Serum toxoplasma titer - Differential diagnosis 

for retinitis with vitritis 

Procedures: 

• Ganciclovir implant 

o This intravitreal implant releases ganciclovir 

at a steady state for up to 8 months.The 

implant provides treatment of CMV retinitis 

in 1 eye only. No systemic effect occurs.The 

initial implant usually is placed in the 

inferotemporal quadrant. Possible 

complications include vitreous hemorrhage, 

retinal detachment, hypotony, and 

endophthalmitis. 

• Fomivirsen implant: Fomivirsen is not used as 

a primary therapy but is approved for cases not 

responding to other therapies. 

• Vitreoretinal surgery 

o Retinal detachment repair is required in 5- 

50% of patients with CMV retinitis. 

o Multiple small holes in several areas of the 

retina are often responsible for the retinal 

detachment. These occur at the junction of 

healthy and necrotic retina. 

o Primary repair with vitrectomy, air-fluid 

exchange, endolaser, and silicone oil 

tamponade has improved surgical outcome. 

• Laser photocoagulation: Small peripheral 

retinal detachments can be repaired with laser 

photocoagulation. 

• Intravitreal injections of ganciclovir, foscarnet, 

or cidofovir 

o These injections offer high levels of 

intraocular drug for short periods of time. 

Staging: CMV retinitis is described by the stage 

and zone of involvement. 

• Stage 

o Active retinitis - 3 general patterns 

1. Hemorrhagic - Large areas of retinal 

hemorrhage on a background of whitened, 

necrotic retina 

2. Bush fire - Yellow-white margin of slowly 

advancing retinitis at the border of atrophic 

retina 

3. Granular - Found in the periphery; focal 

white granular lesions without associated 

hemorrhage 

o Necrotic stage - End result of all patterns of 

active retinitis is the progression to necrosis. 

Retinal tears or holes can develop in these 

areas. 

• Zone of involvement 

o Zone 1 - Within 1500 µm of the optic nerve or 

3000 µm of the fovea 

o Zone 2 - From zone 1 to equator, at vortex 

vein ampullae 

o Zone 3 - From zone 2 to the ora serrata 

• Zone 2 and 3 are the most common sites of 

initial retinal involvement.


Medical Care: An internist or infectious disease 

specialist coordinates medical care. Ophthalmic 

assessment is required on a regular basis, with 

frequency dependent on existence of CMV 

retinitis and on CD4 count. The 

immunosuppressed individual requires 

evaluation for other opportunistic infections and 

surveillance for side effects of prescribed 

medications. 

• Highly active antiretroviral therapy(HAART) 

o This treatment regimen has altered the longterm 

management of CMV retinitis. Because 

the antiviral medications used to treat CMV 

are virustatic, it was necessary for patients to 

continue their use for the rest of their lives. 

The advent of HAART with consequent 

recovery of immune function allows 

individuals to discontinue their CMV therapy 

if the process has resolved adequately with 

initial antiviral treatment. 

Surgical Care: Individuals with CMV retinitis 

commonly require surgical intervention, whether 

for repair of a retinal detachment or for 

intravitreal instillation of ganciclovir by injection 

or implantation. 

• Retinal detachment due to CMV retinitis 

o This condition occurs in 5-29% of eyes in 

various case series. High incidence of 

bilaterality exists.Repair is most successful 

with vitrectomy, endolaser, scleral buckle, 

and silicone oil endotamponade. A total 

reattachment rate of 76% exists; macular 

attachment occurs in 90%. Mean 

postoperative visual acuity is 6/18. 

Prophylactic laser for the other eye with CMV 

did not prevent retinal detachment. 

HAART therapy, has allowed immune recovery 

that, in turn, allows discontinuation of anti-CMV 

medication. This often obviates the need for 

multiple implant procedures or the long-term 

dose related adverse effects of anti-CMV 

medications. Finally, IRU has added a new 

postscript to the treatment of CMV retinitis. 

Complications 

• Untreated retinitis will progress to blindness, 

from retinal necrosis, optic nerve involvement, or 

retinal detachment.CMV retinitis can relapse 

despite ongoing treatment. 

Prognosis 

• Untreated retinitis will progress to blindness, 

from retinal necrosis, optic nerve involvement, or 

retinal detachment. Of treated patients, 80-95% 

will respond, with resolution of intraretinal 

hemorrhages and white infiltrates. If treatment is 

discontinued and the individual is still 

immunocompromised (ie, CD4


511 

PA), vitrectomy and subretinal drainage with 

fluid-gas exchange with or without r-TPA, 

submacular surgery, and anti–vascular 

endothelial growth factor (VEGF) agents, either 

alone or in combination with any of the other 

treatment modalities. However, these treatment 

approaches have been predominantly described 

in isolated, uncontrolled reports, and no 

consensus has been reached on their relative 

efficacy. The purpose of the current study was to 

assess the efficacy of a novel long-term treatment 

regime of intravitreal ranibizumab at three 

monthly intervals as a treatment for 

predominantly hemorrhagic lesions involving 

the fovea in eyes with IPCV. 


All patients with a diagnosis of IPCV were 

identified and they were reviewed and then 

progress recorded for the study. Cases were 

determined by review of the slit-lamp biomicroscopy 

using a 78-diopter lens, colour 

fundus photographs, Optical Coherence 

Tomography (OCT) and fluoroscein angiograms 

showing characteristic lesions of idiopathic 

polypoidal choroidal vasculopathy (IPCV). They 

were subjected to intravitreal Lucentis every 

three months for the period of 2 years as 

maintenance therapy irrespective of whether 

recurrences occurred or not, after various 

primary treatments which included 1 with TTT, 2 

with PDT+IVTA, 1 with PDT+Avastin, 1 with 

PDT+Lucentis, 1 with PDT+Macugen, 1 with 

Avastin monotherapy. We injected intravitreal 

ranibizumab in all the seven eyes of seven 

patients under standard aseptic precautions. The 

injection was given at 3 and 3.5 mm from the 

limbus in aphakic and pseudophakic eyes 

respectively with a 30-G needle on 1 cc syringe 

after the anterior chamber paracentesis. The dose 

given was 0.05 ml in all cases. Although total 

length of follow-up period was variable, 

depending on the individual patient 

circumstances, follow-up visits were on average, 

every month till the completion of 2 years. 

Complications were looked for with care such as 

endophthalmitis, vitreous haemorrhage, RPE 

tears and rip. Subretinal hemorrhage resolution 

was defined as absence of any significant blood 

observed on slit-lamp bio-microscopy using a 78- 

diopter lens and no fluid on OCT and absence of 

leakage on FA. 

Results 

Total no of eyes : 7 (Male : Female = 3: 4) 

Mean age 

: 70 years (58-84 years) 

Mean Follow up : 64 weeks (38- 98 weeks) 

Lesion location : Subfoveal or 

Juxtafoveal (100%) 

Resolution of fluid on 

FFA : All Cases (100%) 

Resolution of fluid 

on OCT : All Cases (100%) 

Mean no. of injections : 5.9 (Max. 9 and Min. 3) 

Status of the other eye : Lost due to IPCV Scar 

5/7 (74%) 

: Normal 2/7 (26%) 

Adverse events : Nil 

VA Change Improved : 3/7 Cases (43%) 

VA Stabilized : 1/7 Case (14%) 

VA Deteriorated : 3/7 Cases (43%) 

Table-1: Changes In Mean VA (LogMAR 

ETDRS) After The Treatment 

Change P Value 

Baseline 0.53 

3 Months 0.57 -0.04 0.705 

6 Months 0.52 0.01 0.595 

9 Months 0.57 -0.04 0.336 

12 Months 0.51 0.02 0.832 

Table-2: Changes In Mean Central Retinal 

Thickness On OCT After The Treatment 

Change P Value 

Baseline 297.25 

3 Months 253.88 43.37 0.233 

6 Months 207.50 89.75 0.107 

9 Months 222.38 66.87 0.263 

12 Months 208.88 88.37 0.092 

Discussion 

Subretinal hemorrhage (SRH) resolved after 

treatment in the first month in all the eyes. No 

significant correlation was observed between 

pretreatment VA, initial SRH size or patient age. 

All the eyes showed complete resolution of fluid 

on OCT and no leakage on FA at end of followup. 

Most importantly 4 eyes maintained vision 

without any further deterioration and showed a 

completetly flat fovea on OCT at end of followup 

period. Important observation is that the


other eye of 5/7 (74%) patients was having a 

disciform scar leading to lost eye due to the same 

disease IPCV. So, most of the affected eyes were 

absolutely precious. Another important 

observation is the scar formation from the 

haemorrhagic polyps after the treatment with 

monotherapy with Ranibizumab is less as 

compared to various other treatment modalities 

and other lost eye. Also, we did not see a single 

case of RPE rip or any other untoward incident. 

Nishijima et. al. demonstrated that the argon 

laser photocoagulation of indocyanine green 

angiographically identified feeder vessels to 

idiopathic polypoidal choroidal vasculopathy 

has also shown promise in treating the 

extrafoveal polyps but can’t be used for the 

subfoveal or juxtafoveal polyps. Saaj Ahmed et. 

al. suggested that photodynamic therapy for 

predominantly hemorrhagic lesions in 

neovascular age- related macular degeneration is 

very effective in IPCV also. His outcomes suggest 

that PDT may help minimize VA loss in eyes 

with AMD associated predominantly 

1. Nishijima et. al.: Laser photocoagulation of 

indocyanine green aniographically identified feeder 

vessels to idiopathic polypoidal choroidal 

vasculopathy. Am J Ophthalmol 2004;137:770–3. 

2. Saad ahmad, Srilaxmi Bearelly, Sandra s. Stinnett, 

Michael J. Cooney, and Sharon Fekrat. 

Photodynamic therapy for predominantly 

hemorrhagic lesions in neovascular age-related 

macular degeneration. Am J Ophthalmol 2008; 

145:1052–7. 

3. Quaranta M, Mauget-Faysse M, Coscas G. 

Sutureless vitrectomy has become popular 

with the introduction of 25G transconjunctival 

vitrectomy in 2002. 1 Recently 23G vitrectomy has 

become more popular because of several 

advantages. 

To describe the initial experience, effectiveness 

and safety profile of 23-gauge vitrectomy. 


Our study is a prospective, consecutive 

References 

hemorrhagic CNV lesions. The juxtafoveal and 

subfoveal polyps have to be treated with either 

PDT (Full fluence or reduced fluence) or the Anti- 

VEGF (Avastin, Lucentis or Macugen) only or in 

various combinations. But with the repeat PDT, it 

can cause the RPE alteration and destruction due 

to the very large area of polyps. 

OCT measurements we employed were those 

taken at the foveal centre. However, this 

approach neglects the volumetric thickness of the 

haemorrhage across the entire lesion. Attention 

to this in future studies may be beneficial. 

The newer therapeutic regime for Idiopathic 

Polypoidal Choroidal Vasculopathy (IPCV) of 

giving 3-monthly maintenance intra vitreal 

Lucentis Monotherapy when compared with 

published natural history data, suggests it may 

provide better outcomes than observation alone 

for eyes with predominantly hemorrhagic 

subfoveal and juxtafoveal lesions in IPCV. 

Further study is warranted to fully detail the 

benefits and risks and to compare combination 

therapy and other available treatment modalities. 

Exudative idiopathic polypoidal choroidal 

vasculopathy and photodynamic therapy with 

verteporfin. Am J Ophthalmol 2002;134:277–280. 

3. Spaide RF, Donsoff I, Lam DL, et al. Treatment of 

polypoidal choroidal vasculopathy with 

photodynamic therapy. Retina 2002;22:529–35. 

5. Hiroyuki Iijima, Tomohiro Iida, Masahito Imai, 

Takashi Gohdo, and Shigeo Tsukahara. Optical 

Coherence Tomography of orange-red subretinal 

lesions in eyes with idiopathic polypoidal choroidal 

vasculopathy. Am J Ophthalmol 2000;129:21–6. 

Outcome of 78 Consecutive Cases of 23-Gauge Vitrectomy 

Dr. Nirmala. R, Dr. N. S. Muralidhar, Dr. Hemanth Murthy 

(Presenting Author: Dr. N. S. Muralidhar) 

interventional case study of 78 eyes of patients 

who underwent 23-gauge vitrectomy operated 

by two surgeons from 06-07-07 to 15-04-08. All 

patients had a minimum follow up of 1 month. 

Patients were seen on 1st PO day, at 1 week, 2 

week, 1 month, 2 month and 3 month post 

operatively. 

At 3 weeks post operative period, the 

keratometric values of central cornea were 

determined using an automated keratometer.


513 

The Accurus Vitrector was used for all surgical 

procedures. 

Seventeen cases were prospectively timed during 

the fourth month of the study to obtain an 

estimate of opening and closing times. 

Surgical opening time was defined as the interval 

between the first instrument contacting the 

conjunctiva through the placement of all 

cannulas and infusion line. The closing time was 

defined as the time required to remove the 

cannulas and infusion line. 

Main outcome measures: Intraoperative and 

post operative complications, patient comfort 

post operatively, preoperative vs. post operative 

corneal astigmatism, and whether surgical goals 

were achieved. 

Results 

Indications for vitrectomy were: Macular hole-18 

eyes; ERM-21 eyes. Vitreous hemorrhage-22 eyes, 

Membrane surgery-14 eyes. Miscellaneous: 3 

eyes (Asteroid hyalosis-1eye, macular 

hole+inferior RD-1 eye, recurrent subtotal 

rhegmatogenous inferior RD-1 eye). Of the 78 

cases, 60 eyes were phakic, 18 eyes were 

pseudophakic. Mean opening time was 180 

seconds (range, 120–300s). The mean closing time 

was 90 seconds (range 60–240s). 

Intraoperative complications: Ports were 

sutured due to leakage in 7 eyes (8.97%). 

Surgical goals: In 66 eyes (84.62%) we were able 

to complete the surgery by 23Gauge approach. 

Silicone oil injection was done in 3 eyes (3.85%) 

after enlarging a single port. 

Single port was enlarged for 20G instruments in 

2 eyes (2.56%). 

Macular hole was closed in 15 eyes (83.33%) - 

clinically, and confirmed on optical coherence 

tomography. 

16 eyes (76.19%) which underwent ERM peeling 

showed normal contour on OCT. 

Of the 36 eyes which had vitreous hemorrhage 

and membrane surgery, vision improved in 33 

eyes (91.67%). 

Postoperative complications: Choroidal 

detachment due to hypotony (IOP< 6 mmHg) 

was seen on 3rd PO day in 3 eyes (3.85%) which 

resolved spontaneously. 

No patient had observable leakage of gas during 

the postoperative period None of the patients 

developed post operative endophthalmitis. 

Significant cataract was seen in 7 eyes (8.97%) on 

follow up. Of these, 1 eye underwent combined 

silicone oil removal with cataract surgery and 

PCIOL implantation 3 months after primary 

vitrectomy. 2 eyes underwent SOR with revision 

vitrectomy and cataract surgery with PC IOL. 

Revision vitrectomy was done in 5 eyes (6.41%). 

Patient comfort: Patients had higher comfort post 

operatively. In the initial period we found 

Subconjunctival hemorrhage to be more common 

postoperatively. The incidence however 

decreased later probably due to the learning 

curve. We found that by day 7 most of the eyes 

appeared normal, with no evidence of post 

operative congestion. 

Post operative astigmatism: The corneal 

astigmatism remained the same in 22 eyes 

(28.20%), there was induced astigmatism of 0.25D 

in 25 eyes (32.05%), 0.5 D in 3 eyes (3.84%) and 

0.75D in 3 eyes (3.84%). The corneal astigmatism 

decreased by 0.25D in 25 eyes (32.05%). The axis 

changed in 12 eyes (15.4%) and remained 

unchanged in 66 eyes (84.6%). 

Discussion 

Our study showed similar results as that 

conducted by Fine et al 2 which was however a 

retrospective noncomparative analysis of 77 

consecutive cases of 23G vitrectomy in a variety 

of vitreoretinal conditions. 

The mean opening time (180s) and closing time 

(90s) was longer in our study, compared to study 

of Fine et al where the opening and closing time 

was 103s and 75s respectively. 

The indications for 23G vitrectomy in our study 

were similar except we did not include any 

patients with retained lens fragments. 

Study done by Barbara et al 3 which was a 

comparative prospective study b/w 23G and 20G 

vitrectomy showed that 23G vitrectomy offers 

higher patient comfort during the early 

postoperative period, similar to what we found 

in our study. 

In our study we found postoperative hypotony 

to be transient, with the incidence being almost 

similar to that of the study by Fine et al. 

We found that the 23g instruments are less 

flexible and behave more like traditional 20-


gauge instruments, allowing more thorough 

peripheral vitrectomy and higher complex 

maneuvers similar to the experience of the 

surgeons in the above mentioned studies. 

In our study there was no significant change in 

corneal astigmatism at 3 weeks when the 

preoperative and post operative K1 K2 readings 

were compared. This parameter has been studied 

for the first time in patients undergoing 23gauge 

vitrectomy. 

23G vitrectomy is safe and effective for a wide 

1. Gildo Y. Fujii, Eugene de Juan Jr, Mark S. 

Humayun, Dante J. Pieramici, Tom S. Chang, 

Eugene Ng, Aaron Barnes, Sue Lynn Wu, Drew N. 

Sommerville A new 25-gauge instrument system for 

transconjunctival sutureless vitrectomy surgery, 

Ophthalmology 2002;109:1807-13. 

2. Howard F. Fine, Reza Iranmanesh,, Diana Iturralde, 

Richard F. Spaide Outcome of 77 consecutive cases 

of, 23-gauge transconjunctival vitrectomy surgery 

References 

variety of vitreoretinal surgical indications. 

Patients were comfortable postoperatively and 

there was no significant induced corneal 

astigmatism. Sutureless posterior segment 

surgery provides for decreased conjunctival 

scarring, better patient comfort, and reduced 

postoperative astigmatic changes. By eliminating 

suturing of sclerotomies surgical opening and 

closing times are reduced. However 

postoperative rates of wound leakage, hypotony, 

and choroidal detachment may be higher. 

for posterior segment disease, Ophthalmology 2007; 

114:1197–1200. 

3. Barbara Wimpissinger, Lukas Kellner, Werner 

Brannath, Katharina Krepler, Ulrike Stolba, 

Christian Mihalics and Susanne Binder 23 gauge 

versus 20 gauge system for pars plana vitrectomy: A 

prospective randomized clinical trial, Br J 

Ophthalmol. doi:10.1136/bjo.2008.140509 


DR. MEENA CHAKRABARTI: M.B.B.S. (’85), Medical College, Trivandrum, University of 

Kerala; M.S. (’89), Govt. Ophthalmic Hospital RIO, Trivandrum; D.O. (’88), RIO and D.N.B. 

(’91), Aravind Eye Hospital, Madurai. Recipient of Several awards instituted by KSOS and 

Editor, Kerala Journal of Ophthalmology. Presently, Senior Consultant and Vitreo Retinal 

Surgeon, Chakrabarti Eye Care Centre, Trivandrum. 

Contact: (0471)2555530, E-mail: tvm_meenarup@sancharnet.in 

Intravitreal Monotherapy with Bevacizumab (IVB) and 

Triamcinolone Acetonide (IVTA) Versus Combination Therapy 

(IVB and IVTA) for Recalcitrant Diabetic Macular Edema 

Dr. Meena Chakrabarti, Dr. Arup Chakrabarti, Dr. Valsa T. Stephen, Dr. Soniarani John 

(Presenting Author: Dr. Meena Chakrabarti) 

Recalcitrant diabetic macular edema is 

characterized by the accumulation of plaques 

of hard exudates in a grossly edematous retina, 

not amenable to the standard modalities of 

therapy and showing a very poor visual 

potential. Majority of these eyes would have had 

several sittings of laser photocoagulation and 

hence it is necessary to employ alternative 

treatment modalities. 

Initial reports on uncontrolled interventional case 

series reported an unprecedented efficacy of 

intravitreal steroids in reducing diabetic macular 

edema often accompanied by significant 

improvement in visual acuity. These 

uncontrolled series were followed by 

randomized placebo-controlled trials 

demonstrating the efficacy of IVTA. The 

beneficial effect of intravitreal injection of 

triamcinolone acetonide in most cases lasts for 6- 

9 months. In the Intravitreal Triamcinolone 

acetonide for clinically significant Diabetic 

Macular Edema that persists after laser treatment 

study (TDMO), the mean number of injections 

was only 2.4 over 2 years with a total potential 

for five injections. It has also been reported that 

repeated intravitreal injection may not be as 

effective as the initial treatment. The high 

incidence of adverse effects include cataract


515 

(54%), glaucoma (20-40%) and need for 

trabeculectomy (6 %) demands caution in its use. 

The introduction of IVTA has been a major 

advance in the treatment of refractory diabetic 

macular edema. 

Patients with diabetic macular edema have been 

found to have increased levels of VEGF in the 

vitreous. Hence intravitreal injection of anti 

VEGF may have a role in reducing diabetic 

macular edema. Their efficiency is similar to 

IVTA, but they do not cause adverse events 

associated with corticosteriods. On the other 

hand, frequent injection (every 4-6 weeks) for an 

extended period may be required, making 

injection related complications such as infectious 

endophthalmitis a major draw back. 

We undertook a pilot study to compare the 

efficacy of intravitreal monotherapy with 

Triamcinolone and Bevacizumab versus 

combination of Bevacizumab and triamcinolone 

in the management of recalcitrant DME not 

amenable to laser treatment. We also assessed the 

OCT patterns in recalcitrant DME which showed 

a favourable response to intravitreal injection of 

Triamcinolone and Bevacizumab. 


The study was designed as a prospective 

randomized interventional study which 

recruited 60 patients who fulfilled all the 

inclusion criteria from March 2006 – March 2008. 

The inclusion criteria for enrolment into the 

study were: 

i) Diabetic age ≥ 10 years, ii) Good Glycaemic 

Control (Hb A1C ≤ 7 gm%), (iii) Stable Renal 

Status, (iv) Controlled serum lipid level, (v) H/o 

prior Focal/ Grid laser PHC (≥ 3 sittings) ≤ 6 

months to the time of enrolment into the study. 

(vi) Presence of DME clinically and 

angiographically, (vii) OCT showing CRT ≥ 300 

µm, (viii) Absence of significant lens opacity, (ix) 

Absence of macular ischemia, (x) Absence of 

VMT or a taut posterior hyaloid phase in OCT. 

Exclusion criteria were poorly controlled 

diabetics with associated nephropathy and 

dyslipidemia, significant cataract precluding 

fundus evaluation or presence of macular 

ischemia. The patients were randomized to 

receive one of the three modes of interventions 

tested in this study. 

Group B: Received 0.05 ml / 1.25 mg Intravitreal 

injection of Bevacizumab (n=20). 

Group T: Received 4 mg / 0.1 ml Triamcinolone 

acetonide injection intravitreally (n=20). 

Group BT: Received both Bevacizumab and 

Triamcinolone acetonide (n=20). 

Thus for the purpose of this study recalcitrant 

diabetic macular edema was defined as the 

presence of gross macular edema in a chronic 

diabetic patient with history of ≥3 sittings of focal 

/ grid laser photocoagulation ≥6 months prior to 

enrollment; OCT showing a central retinal 

thickness ≥300 µm, no angiographic evidence of 

macular ischemia and absence of vitreomacular 

traction or a taut posterior hylaoid. 

All patients underwent a thorough preoperative 

evaluation. The best corrected visual acuity was 

determined after dilated refraction. Slit lamp 

biomicroscopy of the macula, applanation 

tonometry and indirect ophthalmoscopic 

evaluation of the fundus were performed. The 

degree of cataract was assessed prior to 

intervention. All patients underwent a 

fluorescein angiographic evaluation and OCT 

assesment of central retinal thickness and pattern 

of edema as part of the baseline evaluation. An 

informed consent was obtained in all the 

patients. The intervention was performed under 

strict aseptic precautions in the operation theatre 

under topical anesthesia in all the patients. 

Paracentesis was performed to bring the IOP 

under control and the eye was kept patched for 

an hour after the procedure. Postoperatively 3 

hours after the procedure applanation tonometry 

was performed in all patients using the Keeler 

Pulsair non contact tonometer. The patients were 

instructed to use topical antibiotic drops plus, 

topical non steroidal anti inflammatory drops 4 

times daily and topical dorzolamide drops once 

at bed time for a period of 7 days postoperatively. 

Counseling on the appearance of floaters and 

slight visual blurring was discussed with the 

patients. 

The patients were followed up on day 7, 30 days 

and 90 days after the procedure. At each visit an 

assessment of the glycaemic status, control of BP, 

renal status and serum lipid profile was assessed. 

FFA and OCT were performed at 30 days and 90 

days after the procedure. Refraction, tonometry, 

slit lamp evaluation for cataract and


biomicroscopic macular evaluation for degree of 

macular edema was performed at all visits. 

Response to therapy was assessed by 1) 

Improvement in the best corrected visual acuity 

2) Slit lamp biomicroscopy and OCT showing 

reduction in retinal thickness 3) FFA showing 

decrease in fluorescein leakage 4) Progression of 

lenticular changes 5) Presence or absence of post 

treatment IOP spike 6) Recurrence 7) Presence of 

any complications associated with the 

intervention was recorded. All patients in this 

study underwent focal/grid laser 

photocoagulation 4 weeks after the primary 

intervention. 

Results 

The patients were of the age group ranging from 

45-70 years (Mean age 58 years). There were 46 

males and 14 females in our study giving a M: F 

ratio of 3:1. The mean duration of diabetes was 

13.5 years ( Range 7 years -20 years) and the 

mean value of glycosylated haemoglobin at 

baseline was 6.7 ( Range 5.9 - 7.5). Associated comorbid 

conditions were: 

1) Hypertension: 25 (41.67%), 2) Hyperlipidemias 

: 40 (66.67%), 3) Chronic Renal failure : 3 (5%), 4) 

Both HT and HL: 30 (50%), 5) No associated 

disease : 15 (25%). 

50% of the patients had proliferative diabetic 

retinopathy associated with maculopathy and 

50% had background diabetic retinopathy with 

clinically significant macular edema. 

In group T (IVTA Group): An improvement in 

visual acuity was observed in 9/20 eyes (45%) 

who showed a mean reduction of central retinal 

thickness in the OCT scans from a baseline mean 

CRT value of 550 µm ± 26 µm to 285 µm ± 20µm. 

In the remaining 11 patients the mean reduction 

in central retinal thickness was by 20% of baseline 

value (from a mean CRT at baseline of 550 µm ± 

26 µm to 350 µm ± 20µm) at 6 months follow up. 

Although there was no improvement in visual 

acuity, the vision stabilized at the baseline level. 

This reduction in central retinal thickness 

persisted up to 6-9 months after which the 

recurrence of CSME was observed in 15 of the 20 

eyes (75%). These eyes underwent focal/grid 

laser photocoagulation (11/15 eyes : 73.3%) or 

repeat IVTA (4/15 eyes: 27.7%). 

Progression of cataract was noticed in 6 eyes 

(30%) and 2 patients with significant cataract 

underwent phacoemulsification with foldable 

IOL implantation under topical anesthesia. 

Intraocular pressures increased to mid twenties 

in 3 eyes (15%) but could be controlled medically 

with single antiglaucoma medication 

(Dorzolamide). 

There were no cases of endophthalmitis, vitreous 

hemorrhage or retinal detachment in this group. 

Group B (Intravitreal Bevacizumab injection): 

An improvement in visual acuity was observed 

in 11/20 eyes (55%) in this group. All 20 eyes 

showed some reduction in central retinal 

thickness, however a 25% reduction from 

baseline value was obtained in 59% of our 

patients in this group. Maximum beneficial effect 

was observed within 30 days of the injection and 

with additional laser therapy the effect persisted 

up to 9 months. Repeat injection were not 

necessary up to 12 months. However some 

increase in CRT was noticed in 15% of patients 

after 9 months for which additional laser was 

given. Further follow up alone will give an idea 

of the course of disease and the necessity for 

reinjections. Elevation in intraocular pressure 

was noticed in one patient (5%) which was 

amenable to medical therapy. 

Group BT (Combined IVTA and IVB): An 

improvement in visual acuity was observed in 

60% (12/20) eyes. The reduction in the central 

retinal thickness was maximum in this group and 

was observed in 64% of eyes. The reduction in 

retinal thickness peaked at one month post 

injection and persisted up to 9 months. 

Recurrences in 15% of eyes were similar to group 

B showing that an additional injection of TA did 

not have any effect in preventing recurrences. A 

higher incidence of elevated intraocular pressure 

in 22% of cases questioned the efficacy of adding 

TA, when IVB alone would have been effective. 

We divided the patients in to 4 groups based on 

the preinjection OCT findings 

1) Diffuse edema, 2) Cystoid edema, 3) Sub foveal 

serous retinal detachment, 4) Plaques of hard 

exudates under fovea, 5) Combination and tried 

to correlate with the response to therapy as 

measured by CRT and improvement in vision. 

Our results showed that maximum reduction of 

central retinal thickness and maximum visual


517 

OCT GRADING No of Pre injection Post injection Pre injecton Post injection 

Eyes/% CRT (Mean) CRT (Mean) vision (Mean) vision (Mean) 

Diffuse edema 20 (33.33%) 500 µm 309 µm 5/60 6/18 

Cystoid edema 10(16.67%) 422 µm 315 µm 3/60 5/60 

Subfoveal serous RD 14 (20%) 418 µm 256 µm CF 2m 6/36 

Plaques of H/E 6 (10%) 325 µm 250 µm CF1m CF1m 

Combination 10 (16.67%) 550 µm 350 µm CF 2m 4/60 

gain were observed in eyes with greater degree 

of diffuse macular edema and presence of sub 

foveal serous RD. 

Discussion 

Thus the result of this study shows that: 

1. IVTA has an excellent transient effect of 

causing resolution. Recurrences in 75%, 

elevated IOP in 15% of cases after IVTA point 

to the fact that IVTA should be advised with 

caution and the patients monitored regularly 

after intervention. 

2. IVB is as efficacious or more so with respect to 

visual gain (45% Vs 55%) and resolution of 

CSME (45%Vs 59%). The incidence of 

elevated IOP in only 5% and recurrence in 

15% point to the fact that IVB may be a better 

option to IVTA 

3. Combining IVB with IVTA, did not have the 

expected effect of doubling the resolution and 

visual recovery. A higher incidence of 

glaucoma in 22% makes this combination 

unsafe. The incidence of recurrence was same 

as in IVB group. 

4. Greater degree of diffuse edema and presence 

of sub foveal serous RD are indicators of a 

favorable response to IVTA and IVB. 

5. The prediction of poor visual prognosis 

included poor preoperative vision, HbA1C > 

7 during the study period, plaques of hard 

exudates under fovea and presence of large 

cystoid spaces under fovea. 

Our study differed from that of Paccola L et al 

and Shimura.M et al, who demonstrated that one 

single intravitreal injection of triamcilone may 

offer certain advantage over Bevacizumab in the 

short term management of refractory diabetic 

macular edema especially with regard to central 

macular thickness. In our study the response to 

therapy with triamcinolone and Bevacizumab 

were essentially similar with Bevacizumab 

showing superiority with respect to lesser 

incidence of post intervention IOP Spike. 

Similar results were obtained by Soheilian M et 

al in a study which compared the efficacy of 

intravitreal monoptherapy with Bevacizumab 

alone or combined with triamcinolone accetonide 

which showed that intravitreal Bevacizumab 

monotheraoy yielded better visual outcome than 

laser photocoagulation. No further beneficial 

effect of intravitreal triamcinolone could be 

demonstrated. 

Hamid Ahmadieh et al reported that there was 

no significant difference with respect to visual 

recovery and central retinal thickness between 

the IVB and IVB/IVT groups which is again 

similar to our study. 

These results comprehensively prove that there 

is no added benefit of combining IVB and IVTA. 

1. Shimura Masahiko, Nakazawa, Tosu, Yasuda 

Kamako.Comparative therapy evaluation of 

intravitreal bevacizumab and triamcinolone 

acetonide on persistent diffuse diabetic 

macular edema. Am J. Ophthalmol 2008;145: 

854-61. Epub 2008, March 6. 

2. Masoud Soheilian, Alireza Ramezani, Bijan 

Bijanzadeh, Mehdi Yaseri. Intravitreal 

bevacizumab ( Avastin) injection alone or 

References 

combined with triamcinolone versus macular 

photocoagulation as primary treatment of 

diabetic macular edema. Retina 27:1187-95. 

3. Kook, Daniel MD, Wolf, Atmin MD, 

Kreutzer, Thomas MD, Neubaucer, Aljosiha 

MD, Rupert MD. Long term effect of 

intravitreal bevacizumab (avastin) in patients 

with chronic diffuse diabetic macular edema. 

Retina 2008;28:1053-60.


4. L Paccola, R A Costa, M S Fologosa, J C 

Barbosa, I U Scott, R Jorge. Intravitreal 

triamcinolone versus bevacizumab for 

treatment of refractory diabetic macular 

edema (IBEME study). Br J. Ophthalmol 

2008;92:76-80. Epub 2007 Oct 26. 

5. Hartioglou C, Kook D, Neubaucuer A, Wolf 

A. Prighinger S, Strauss R. Intravitreal 

bevacizumab ( Avastin) therapy for persistent 

diffuse diabetic macular edema. Retina 2006. 

6. Hamid Ahmadieh, Alireza Ramezani et al. 

intravitreal bevacizumab with or without 

triamcinolone for refractory DME: a placebo 

controlled trial. Graefes Arch. Clin Exp 

Ophthalmol 2008;246:483-9. 


DR. URVASHI GOJA: M.B.B.S. (2000) and M.S. (2007), Govt. Medical College, University of 

Jammu, J&K. 

Vitreoretinal fellowship (2007-2009), Banker’s Retina Clinic and Laser Center, Ahmedabad. 

E-mail: urvashi.goja@gmail.com 

Visual and Surgical Outcomes After Vitrectomy and Internal 

Limiting Membrane (ILM) Removal in Terson’s Syndrome 

Dr. Urvashi Goja, Dr. Alay S. Banker, Dr. Rohan Chauhan 

(Presenting Author: Dr. Urvashi Goja) 

The French ophthalmologist, Albert Terson, is 

credited with discovering this clinical sign in 

a patient with subarachnoid haemorrhage in 

1900. Terson’s syndrome encompasses any 

intraocular haemorrhage associated with 

intracranial subarachnoidal haemorrhage and 

increased intracranial pressures. Premacular 

haemorrhages have been reported in up to 39% 

of cases; often with a location beneath the ILM. 

The pathogenesis of Terson’s syndrome has been 

controversial. A mechanism similar to Valsalva 

retinopathy, in which an increase in intracranial 

pressure eventually leads to the rupture of retinal 

capillaries, has been supported by most authors. 

Increased intracranial pressure may force blood 

into the subarachnoid space and along the optic 

nerve sheath into the pre-retinal space, or the 

sudden rise in intracranial pressure may lead to 

a decrease in venous return to the cavernous 

sinus or obstruct the retinochoroidal 

anastomoses and central retinal vein, 

culminating in venous stasis and haemorrhage. 

The primary objective of this study was to 

analyse the visual and surgical outcomes after 

vitrectomy and internal limiting membrane 

(ILM) removal in Terson’s syndrome. 


12 eyes of 9 patients were included in the study. 

Informed consent was obtained from each 

patient. Preoperative data collected included age, 

sex, best corrected Snellen visual acuity and 

underlying condition. All cases came with 

history of trauma with subdural, subarachnoid 

or intracranial haemorrhage on CT/ MRI. One 

patient had a history of hypertension with right 

middle cerebral artery aneurysm. In two patients 

sharply demarcated, dome-shaped sub-ILM 

haemorrhage could be clearly identified on 

fundus examination. Rest of the patients had 

vitreous hemorrhage, and sub-ILM location of 

the bleeding that became apparent only during 

vitrectomy. All 9 patients underwent early 

vitrectomy and ILM peeling because of 

insufficient spontaneous visual recovery after a 

mean of 6.38 weeks. Outcome measures included 

improvement in visual acuity and anatomical 

success achieved. 

Surgical technique 

Nine eyes of seven patients underwent a 20- 

gauge three port pars plana vitrectomy. In rest 

three eyes of two patients a transconjunctival, 

sutureless 23–gauge vitrectomy was performed. 

Where necessary the induction of a posterior 

vitreous detachment was done followed by a 

fluid/air exchange. A volume of 0.5 ml TB 0.06% 

solution was injected into the air filled vitreous


519 

Table-1: Patient Demographics, Diagnosis, and Outcome 

NO Case, eye Age Sex Time of Time of Preoperative Final Comments 

PPV (wks) follow up visual acuity visual 

(wks) acuity acuity 

1 1 R 30 M 7 40 6/60 6/9 SAH 

2 1 L 30 M 11 36 6/24 6/12 SAH 

3 2R 41 F 8 3 PL , PR 6/60 Rt. MCA aneu., RDpostop 

4 3R 15 M 3 13 HM 6/9 SDH 

5 4R 35 M 1 12 6/60 6/9 EDH,ICH 

6 5R 35 M 6 20 CF 6/60 ICH 

7 6R 27 M 9 8 CF 6/36 ICH ,SAH 

8 6L 27 M 6 12 CF 6/9 ICH ,SAH 

9 7R 32 M 2 17 PL , PR 6/12 SAH 

10 7L 32 M 1 18 PL , PR 6/36 SAH 

11 8R 35 F 1 20 PL , PR 6/12 ICH 

12 9R 30 M 2 12 CF 6/60 SAH 

SDH = subdural haematoma, EDH = extradural haematoma. PL = projection of light PR = perception of light . PPV = 

pars plana vitrectomy, MCA = middle cerebral artery, ICD = intracranial hemorrhage, SAH= subarachnoid hemorrhage 

cavity over the posterior pole. After 2 minutes, 

still under air, the dye was removed. An air/fluid 

exchange was carried out. The ILM stained a 

faint blue color and was clearly visualised under 

standard illumination. It was directly engaged 

with the intraocular ILM forceps to create a flap 

and then peeled from the nerve fiber layer plane 

usually in a capsulorrhexis fashion. There was a 

distinct contrast between stained ILM and 

unstained retina thus, enabling and facilitating 

the complete removal of this tissue. Where 

possible, the ILM was removed up to both 

superior and inferior temporal arcades allowing 

complete aspiration and evacuation of the 

hemorrhage beneath it. Some cases had 

associated ERM which was also removed. No 

intraoperative complications were observed. 

Results 

Patient demographics, diagnosis, and outcome 

are tabulated in Table 1. Seven patients were 

males and two were females. Mean patient age 

was 32 (range 15- 41). The mean follow up 

period was 17.36 weeks (range 3-40 weeks). 

Preoperative best corrected Snellen visual acuity 

ranged from PL to 6/36. ILM peeling allowed 

complete aspiration of the hemorrhage and 

resulted in excellent visual recovery in all 

patients. There was substantial and rapid visual 

improvement, with eyes achieving excellent final 

visual acuity compared to mean preoperative 

visual acuity ranging from light perception to 

6/36. Postoperative best corrected Snellen visual 

acuity ranged from 6/36 to 6/9. Among the nine 

patients studied, six had improvement of 4 or 

more Snellen lines. None of the cases showed any 

evidence of residual membranes or recurrence. 

No procedure-related complications were 

observed. However, one patient developed 

retinal detachment 4 weeks post-operatively, 

which was successfully reattached with a second 

surgery. The three eyes operated using 23- 

gauge vitrectomy showed significantly faster 

recovery and lesser patient discomfort. 

Discussion 

Terson’s Syndrome presents with collection of 

blood in the sub-ILM space usually over the 

posterior pole. Spontaneous reabsorption of the 

haemorrhage may occur, but this could take 1–2 

months, during which time the persistence of 

blood may irreversibly damage the retina and 

cause permanent visual loss as a result of the 

formation of preretinal tractional membrane and 

proliferative vitreoretinopathy. The toxic effects 

of longstanding haemorrhage are even more 

destructive in macular than in subhyaloidal 

haemorrhage, and haemorrhage beneath the ILM 

tends to remain longer than subhyaloidal 

haemorrhage. Observation for up to 3 months for 

spontaneous clearing of haemorrhage is a 

clinically accepted practice, but others advocate 

early surgery even for these cases, as a prolonged 

persistence of haemorrhage may cause


irreversible retinal damage. Spontaneous 

resorption of the sub-ILM and associated 

vitreous haemorrhages depends on their severity 

and tends to be slow in extensive haemorrhages. 

Prolonged contact of the retina with haemoglobin 

and its catabolites can possibly cause toxic retinal 

damage, which may be irreversible. Other 

potential complications of longstanding 

intraocular blood persistence include cataract, 

epiretinal membranes and other macular 

abnormalities, glaucoma, retinal detachment and 

proliferative vitreoretinopathy. In all our cases 

1. Terson A. De l’he´morrhagie dans le corps vitre au 

cours de l’he´morrhagie cerebrale. Clin Ophthalmol 

1900;6:309–12. 

2. Castren JA. Pathogenesis and treatment of Terson 

syndrome. Acta Ophthalmol 1963;41:430–4. 

3. Ogawa T, Kitaoaka T, Dake Y, et al. Terson 

syndrome: a case report suggesting the mechanism 

References 

we have performed early vitrectomy surgery 

(mean 4.7 weeks) which allowed easy and 

complete removal of ILM allowing early visual 

rehabilitation and avoiding above mentioned 

complications of longstanding haemorrhage. 

Early vitrectomy surgery with complete removal 

of ILM allows early visual rehabilitation without 

any surgical complications. Thus, we 

recommend vitrectomy with ILM peeling should 

be performed not later than four to six weeks 

after the acute injury in Terson’s Syndrome. 

of vitreous hemorrhage. Ophthalmology 

2001;108:1654–6. 

4. Kuhn F, Morris R, Witherspoon CD, et al. Terson 

syndrome. Results of vitrectomy and the 

significance of vitreous hemorrhage in patients with 

subarachnoid hemorrhage. Ophthalmology 

1998;105:472–7. 


DR. SOUMEN MONDAL: M.B.B.S (’97), R.G. Kar Medical College and Hospital, Calcutta 

University; M.S. (2005), RIO, Calcutta University, Kolkata; Vitreo-retina Fellow (2008), Aditya 

Jyot Eye Hospital, Mumbai. Presently, Consultant, Vitreo-retina Services, Priyamvada Birla 

Aravind Eye Hospital, Kolkata. 

E-mail: hisoumenm@yahoo.co.in 

Combine Sutureless Scleral Buckling With 23G Vitrectomy Using 

Fibrin Glue: Is The Sutureless Dream Finally Achieved? 

Dr. Soumen Mondal, Dr. Abhijit Datta, Dr. Dharmesh Kar, Dr. Supriya Dabir, 

Dr. Najeeha Shukri, Dr. S. Natrarajan 

(Presenting Author: Dr. Hemantha Murthy) 

Transconjunctival sutureless vitrectomy 

provides the benefits of sutureless surgery. 

Recently, Mentens et al described the advantages 

of fibrin glue compared to sutures for vitrectomy 

wound closure using a retrospective 

questionnaire review of comparable groups of 

patients. 1 Unfortunately, the benefits enjoyed by 

patients undergoing sutureless vitrectomy 

surgery could not be extended to patients 

requiring scleral buckling, as anchoring the 

buckle elements required sutures. In this pilot 

study, 23 eyes (of 23 patients) with 

rhegmatogenous retinal detachment with 

multiple inferior breaks, we performed 

sutureless scleral buckling and 23G vitrectomy 

without sutures. Moreover, we used fibrin glue 

(ReliSeal) to seal conjunctival peritomy wound 

following 23G vitrectomy. Here we discuss the 

issues related to the combined vitrectomy and 

scleral buckling with use of fibrin glue 

(ReliSeal). 


Twentythree eyes of 23 patients (mean age 53.5 

years) were analyzed in this series. All eyes had 

documented rhegmatogenous retinal detachment 

with multiple inferior breaks and all eyes were 

operated for retinal detachment by single 

surgeon. 

The technique of scleral buckle and 23G


521 

vitrectomy was the same in all cases, Briefly, after 

360 0 peritomy and cleaning the Tenon’s capsule 

from the scleral bed, traction sutures were placed 

along the 4 recti muscles, and the retinal 

pathology was located by assiduous indirect 

ophthalmoscopy. Partial thickness scleral 

dissection was made (2.5 mm x 4mm) in 3 

quadrants (excluding the quadrant having the 

pathology) to accommodate the encircling band 

(#240). Later, a partial thickness scleral tunnel 

approximately 9mm wide was made at the site of 

break(s) to cover the break(s) adequately. The 

tire (#279) was anchored into this recess; on the 

tire the band was passed. This band was passed 

through the 3 scleral tunnels made previously. 

The encirclage band was tightened across a 

Watzke silicone sleeve. 

Then, 23G vitrectomy was done as described by 

Eckardt et al. 2 Following vitrectomy, laser, 

endophotocoagulation (Iridex Corp, CA, USA) 

was done. Following fluid air exchange and 

injection of C3F8 (in a nonexpansile proportion), 

ports were removed. 

The conjunctival peritomy wounds were dried 

and apposed; the cut ends of the apposing edges 

were kept everted to diminish the chance of 

conjunctival inclusion cyst formation. Fibrin 

tissue adhesive (ReliSeal, Reliance Life 

sciences, Mumbai, India) was applied over the 

incision margin to seal the peritomy wound. 

Results 

In the immediate post operative period, 

intraocular pressure was within normal limits, 

the conjunctival wounds were well apposed 

without any sign of dehiscence, retina was well 

attached with good buckle height in all the 23 

cases. 

In the first post operative day, intraocular 

pressure was within normal limits, the 

conjunctival wounds were well apposed, retina 

was attached with good buckle height in all the 

23 cases. There was no incidence of postoperative 

elevation of intraocular pressure, hypotony or 

choroidal edema. 

At 1 month of post operative follow up, all the 

cases maintained good buckle effect with 

successful anatomical attachment of the retina in 

all the 23 cases. There was no extrusion or 

intrusion of the buckles or infection. 

Discussion 

Tissue adhesives, both synthetic and biologic, 

have a long history of use in ophthalmology. 

Recently, fibrin glue (biologic) has gained a major 

role as a suture substitute for attaching biologic 

tissues and as a surface sealant. Literature 

supports expanded use of fibrin glue and a 

number of studies of ophthalmic applications are 

available, including closure of the conjunctiva in 

strabismus surgery, 3 glaucoma surgeries, 4 and 

cataract extraction. 5 

23G vitrectomy has ushered an era of sutureless 

vitrectomy. However, in cases requiring scleral 

buckling in addition, the buckling elements 

required suturing. Also, the conjunctival 

peritomy wound needed to be sutured for 

closure. 

However, with the technique described herein, 

sutureless surgery has become a feasible goal in 

selected group of patients. With the sutureless 

scleral buckling technique combined with the 23 

gauge vitrectomy and use of fibrin glue, no 

sutures were needed for the entire procedure. 

None of the patient showed postoperative 

adverse or allergic reactions, bacterial infections, 

and inflammation was minimal. Healing of the 

conjunctiva took about 5 days. The surgical time 

using fibrin glue is reduced to one-fourth of the 

usual 4-8 min necessary for suturing the 

conjunctiva. The cost for fibrin glue (INR 1200 ≈ 

30 USD per patient) is slightly higher than that of 

Vicryl 8/0 and Ethibond 5/0 (approximately INR 

900 ≈ 22.5 USD per patient). However the 

reduced post operative discomfort from sutures 

and the quicker healing associated with 

documented low rates of infection makes the 

fibrin glue a viable option for the discerning 

surgeon. 

Short term results in our pilot study have shown 

that there were no intraoperative and early post 

operative complications in any of the cases. Also 

a lack of control group of standard operative 

procedure which would have admirably 

highlighted the differences in the two techniques 

can be deemed as a drawback of this study. A 

future prospective study with larger sample size, 

standard control population and longer followup 

would probably address these issues.


1. Mentens R, Stalmans P. Comparison of fibrin glue 

and sutures for conjunctival closure in pars plana 

vitrectomy. Am J Ophthalmol 2007;144:128-31. 

2. Eckardt C. Transconjunctival sutureless 23-gauge 

vitrectomy. Retina 2005;25:208-11. 

3. Spierer A., Barequet I., Rosner M., Solomon AS, 

Martinowitz U. Reattachment of extraocular 

muscles using fibrin glue in a rabbit model. Invest 

Macular edema associated with vascular 

diseases can have different 

etiopathogenesis in various vascular pathologies 

of retina such as Diabetic retinopathy, Vascular 

occlusion and Choroidal neovascularisation. 

Intravitreal Triamcinolone has shown significant 

effect in treatment of macular edema in afore 

mentioned cases. It is the steroid of choice for 

intravitreal use because of its long half life and 

lack of toxicity. However its effect is transient 

and rebound increase in foveal thickness has 

been observed after the effect of drug wears off. 

Bevacizumab is a full length humanized 

monoclonal anti VEGF antibody that inhibits all 

biologically active forms of VEGF and is used in 

neovascular ARMD and is being explored for 

other indications. The drug has demonstrated 

promising results in macular edema associated 

with retinal vascular obstruction and Diabetic 

Retinopathy. 


Clinical, interventional, comparative and 

prospective study conducted at CH NAGRI EYE 

HOSPITAL. 80 patients presenting with cystoid 

macular edema due to diabetic retinopathy or 

retinal venous occlusion were recruited. 

Informed,written consent was obtained from all 

subjects before their participation in the study. 

All patients underwent detailed medical and 

ophthalmologic history. Baseline and follow up 

assessement of the pts included BCVA on 

snellens chart, SLE, fundoscopy with 20D and Slit 

lamp biomicroscopy with 90D,OCT, FFA, Colour 

References 

Ophthalmol Vis. Sci. 1996;38:543–6. 

4. O'Sullivan F, Dalton R. and. Rostron C K. Fibrin 

glue: an alternative method of wound closure in 

glaucoma surgery. J Glaucoma 1996;5:367–70. 

5. J.C. Kim, S.D. Bassage, M.H. Kempski, del Cerro M, 

Park SB, Aquavella JV. Evaluation of tissue 

adhesives in closure of scleral tunnel incisions. J 

Cataract Refract Surg. 1995;21:320–5. 

Comparison of Single Dose Intravitreal Bevacizumab with Single 

Dose Intravitreal Triamcinolone in Cases of Cystoid Macular 

Edema Due To Diabetic Retinopathy and Vascular Occlusion 

Dr. Tejas H. Desai, Dr. Nidhi Mittal 

(Presenting Author: Dr. Nidhi Mittal) 

fundus photography and IOP measurement with 

NCT. Patients with history of previous treatment 

for the condition in the form of Laser 

photocoagulation or intravitreal injection,and 

FFA showing ischaemic macula were excluded. 

Inclusion criteria was cystoid macular edema 

with minimum CFT of 300 microns,assessed by 

OCT. The age of patients ranged from 45 to 75yrs 

(mean 59.36 yrs) with male/female ratio of 15/7. 

Patients were randomly allocated into 2 groups: 

Group I: eyes with cystic edema treated with 

Intravitreal Triamcinolone Acetonide 

(4mg/0.1ml) 

Group II: eyes with cystic edema treated with 

Intravitreal Bevacizumab (1.25mg/0.05ml) 

Patients were followed up on 1week, 1month, 

3month, and 6month post procedure. 

Results 

74/80 patients enrolled for the study completed 

6 mth follow up. Group-I: Out of 35 eyes 

receiving IV TA, 20 eyes had diabetic macular 

edema, 10 eyes had macular edema with CRVO 

and 5 eyes had macular edema with BRVO. 

Group II: Out of 39 eyes receiving IV 

bevacizumab, 16 eyes had diabetic macular 

edema, 13 eyes had CRVO with macular edema 

and BRVO with macular edema was present in 

10 eyes. At the end of 6 months, mean 

improvement in VA was 2.5 lines and mean 

reduction of central foveal thickness was 248.75 

microns in group I. 

Mean improvement in VA was 1 line and mean


523 

reduction in CFT was 131.5 microns in group II. 

IOP rise was observed in 7/35 eyes in group I 

which could be controlled in all patients with 

medication within 2-4 weeks. No significant rise 

was observed in group II patients. Patients from 

both groups experienced minimal 

subconjunctival haemorrhage, foreign body 

sensation, hyperemia, and vitreous floaters for 

few days following intravitreal injection. No 

serious sight threatening adverse effects were 

observed. 

Intravitreal Triamcinolone acetonide is more 

effective as compared to Bevacizumab in Cystoid 

Macular Edema associated with DRP and Retinal 

venous occlusion. 

Discussion 

The conventional agent for intravitreal use in 

Macular edema due to abnormal increased 

vascular permeability in retinal vascular 

pathologies has been Triamcinolone. Anecdotal 

evidence has shown rapid resolution of the 

macular edema but not without side effects such 

as raised intraocular pressure and progression of 

cataract and short coming of recurrence. 14,15,16,17 

Bevacizumab is being tried for similar indications 

in view of its effects on vessel permeability and 

1. Intravitreal bevacizumab (Avastin) treatment of 

diffuse diabetic macular edema in an Indian 

population. Indian J Ophthalmol. 2007;55:451-5. 

2. (ISSN: 0002-93943), Am J Ophthalmol. 2007;144:864- 

71. 

3. Intravitreal bevacizumab (Avastin) treatment of 

macular edema in central retinal vein occlusion: a 

short-term study. Retina 2006;26:279-84. 

4. Intravitreal bevacizumab (avastin) for central and 

hemicentral retinal vein occlusions: Retina 

2007;27:141-9. 

5. Intravitreal bevacizumab (Avastin) in the treatment 

of macular edema secondary to branch retinal vein. 

Retina 2007;27:419-25. 

6. Intravitreal triamcinolone versus bevacizumab for 

treatment of refractory diabetic macular oedema 

(IBEME study). Br J Ophthalmol 2008;92:76-80. 

7. Comparative Therapy Evaluation of Intravitreal 

Bevacizumab and Triamcinolone Acetonide on 

Persistent Diffuse Diabetic Macular Edema. Am J 

Ophthalmol. 2008 Mar 5. 

8. Rosenfeld PJ, Fung AE, Puliafito CA. Optical 

coherence tomography findings after an intravitreal 

injection of bevacizumab (Avastin) for macular 

References 

neo-vascularisation and has shown dramatic 

effects translating into anatomical and functional 

improvement 1,2,3,4,5 but have been studied over 

short term, is not without recurrence over 

periods of weeks to months 18 and needs careful 

approach. There also have been studies 

comparing the two molecules for these 

indications and its observed that Triamcinolone 

is more effective than Bevacizumab in remitting 

macular edema associated with diabetic 

retinopathy. 6,7 Our observation has been that 

Bevacizumab is not as effective as Triamcinolone 

as primary treatment of cystoid macular edema 

in cases of diabetic retinopathy and retinal 

venous occlusion. This might be due to wider 

spectrum of effects of steroids and hints towards 

alternative VEGF independent factors attributing 

to macular edema in Diabetic Retinopathy 1 and 

similarly Retinal vascular occlusions. All the 

same, both agents show significant improvement 

1-5, 8, 10-17 

in macular edema and probably best 

tailored for use according to different stages of 

pathologies, Triamcinolone in early stages with 

macular edema, before neovascularisation sets in; 

and Bevacizumab in cases showing macular 

edema with neovascular component. 

edema from central retinal vein occlusion. 

Ophthalmic Surg Lasers Imaging. 2005;36:336-9. 

9. Schwartz SG, Hickey M, Puliafito CA. Bilateral 

CRAO and CRVO from thrombotic 

thrombocytopenic purpura: OCT findings and 

treatment with triamcinolone acetonide and 

bevacizumab. Ophthlamic Surg Lasers Imaging. 

2006;37:420-2. 

10. Iturralde D, Spaide RF, Meyerle CB, et al. 

Intravitreal bevacizumab (Avastin) treatment of 

macular edema in central retinal vein occlusion: a 

short-term study. Retina 2006;26:279-84. 

11. Pai SA, Shetty R, Vijayan PB, et al. Clinical, 

anatomic, and electrophysiologic evaluation 

following intravitreal bevacizumab for macular 

edema in retinal vein occlusion. Am J Ophthalmol. 

2007;143:601-6. 

12. Spandau UH, Ihloff AK, Jonas JB. Intravirreal 

bevacizumab treatment of macular oedema due to 

central retinal vein occlusion. Acta Ophthalmol 

Scand. 2006;84:555-6. 

13. Stahl A, Agostini H, Hansen LL, Feltgen N. 

Bevacizumab in retinal vein occlusion -- results of a 

prospective case series. Graefes Arch Clin Exp 

Ophthalmol. 2007 Mar 14.


14. Park CH, Jaffe GJ, Fekrat S. Intravitreal 

triamcinolone acetonide in eyes with cystoid 

macular edema associated with central retinal vein 

occlusion. Am J Ophthalmol. 2003;136:419-25. 

15. Williamson TH, O'Donnell A. Intravitreal 

triamcinolone acetonide for cystoid macular edema 

in nonischemic central retinal vein occlusion. Am J 

Ophthalmol. 2005;139:860-6. 

16. Cekic O, Chang S, Tseng JJ, et al. Intravitreal 

triamcinolone treatment for macular edema 

associated with central retinal vein occlusion and 

hemiretinal vein occlusion. Retina. 2005;25:846-50. 

17. Goff MJ, Jumper JM, Yang SS, et al. Intravitreal 

triamcinolone acetonide treatment of macular 

edema associated with central retinal vein 

occlusion. Retina 2006;26:896-901. 

18. Matsumoto Y, Freund KB, Peiretti E, et al. Rebound 

macular edema following bevacizumab (Avastin) 

therapy for retinal venous occlusive disease. Retina 

2007;27:426-31. 

Diagnostic Role of Optical Coherence Tomography in Diabetic 

Maculopathy 

Dr. Anshu Goyal, Dr. Mohan Rajan, Dr. Vasumathy Vedantham, Dr. Bina John 

(Presenting Author: Dr. Anshu Goyal) 

Diabetic Macular Edema (DME) is a major 

cause of visual deterioration in Diabetic 

retinopathy. Diagnosis of diabetic macular 

edema is best made by slit lamp biomicroscopy 

of the posterior pole using a contact lens. It is, 

however, insensitive to small changes in retinal 

thickness, for example, a subtle CSME is difficult 

to appreciate, or small intraretinal cystoid spaces 

or subtle epiretinal changes. Fundus Fluorescein 

Angiography (FFA) is useful in demonstrating 

the leakage of fluid, consequent to the 

breakdown of the blood retinal barrier. Simple 

leakage on angiogram may not always be 

associated with retinal thickening in the macula; 

reports suggest that actual macular thickness is 

better correlated with loss of visual acuity. It is in 

all probability more important in a case of a 

doubtful macular ischemia, when the foveal 

perfusion is in question. 

Optical coherence tomography (OCT) provides 

valuable information about retinal thickness and 

extent of retinal edema in DME. It is also helpful 

in monitoring the response to treatment in DME 

(Laser and/ or Intravitreal Triamcinolone 

Acetonide injection). The role of OCT in assessment 

and management of diabetic retinopathy 

has become significant in understanding the 

vitreoretinal relationship and the internal 

architecture of the retina. In patients with refractory 

DME, Taut posterior hyaloid membrane 

(TPHM) is readily recognized by OCT scan. Focal 

vitreoretinal adhesions, subfoveal subretinal 

fluid, and the axial distribution of fluid in an 

edematous macula that cannot be identified on 

clinical examination can also be evident on OCT. 

In this study, we aim to find out the topographic 

distribution of OCT pattern in DME and to 

evaluate the role of OCT as a primary 

investigational tool in DME. 


A retrospective review of the medical records of 

138 eyes of 71 patients, who presented to the 

retina clinic of Rajan Eye Care Hospital, over a 

period of 17 months (January 2007 to May 2008) 

and were diagnosed to have diabetic 

maculopathy, was performed. 

All patients of age > 21 years, with a confirmed 

diagnosis of DM, and NPDR or PDR with CSME 

diagnosed with slit lamp biomicroscopy with 

90D lens, or clinically and/or angiographically 

confirmed DME in an eye that may have already 

received Argon laser treatments were included 

in the study. Eyes with active proliferative 

retinopathy with vitreous hemorrhage, dense 

media haze interfering with acquisition of good 

OCT image, any other ocular pathology which 

can contribute to reduced visual acuity, macular 

edema due to associated condition other than 

diabetic retinopathy like central retinal vein 

occlusion etc, and those with OCT scans of poor 

quality were excluded. 

The parameters noted down were ocular and 

systemic history, best corrected Snellen’s visual 

acuity BCVA(converted to LogMAR equivalents, 

for statistical analysis), detailed anterior segment 

examination with special reference to the 

assessment of lens opacity, Goldmann 

Applanation Tonometry, slit lamp 

biomicroscopy with 90D lens for macular


525 

assessment, fundus photography, fluorescein 

angiography as needed, and optical coherence 

tomography – macular scans. OCT scans were 

performed through a dilated pupil by an 

experienced ocular photographer, on a Stratus 

OCT (Humphrey Zeiss, Inc., San Leandro, CA). 

OCT scan was used to examine the retinal 

thickness, and topographic pattern of the macula. 

Central macular thickness as measured by the 

automated retinal thickness software algorithm 

built into the OCT scanner was noted. In 

addition, all the scans were graded and classified 

into three groups based on the presence of 

specific morphologic patterns, identified on the 

basis of their unique appearance on OCT 

imaging: 

1. Diffuse, sponge like retinal thickening: 

increased retinal thickness (defined as greater 

than 180 µm) with reduced intraretinal 

reflectivity, especially in the outer retinal 

layers 

2. Cystoid macular edema CME: localization of 

intraretinal cystoid spaces that appeared as 

round or oval areas of low reflectivity with 

highly reflective septa separating the cystoid 

like cavities 

3. Taut posterior hyaloid membrane TPHM: a 

highly reflective signal arising from the inner 

retinal surface and extending towards the 

optic nerve or peripherally. 

Pattern which was most predominant in most of 

the scan area was taken into consideration. 

Presence of subretinal fluid SRF was also noted – 

defined as an accumulation of subretinal fluid 

(which appeared dark) beneath a highly 

reflective elevation, resembling the dome of the 

detached retina. 

The clinical and functional status of the patient 

and the eye was masked while evaluating the 

OCT scans. Data were analyzed to determine the 

relationship between retinal thickness and visual 

acuity in each of the OCT pattern groups. 

Results 

The mean duration of diabetes (measured upto 

the time of OCT evaluation scan) was 12.68 ± 6.63 

years (ranging from 1year to 30 year). The mean 

age of the study group was 59.4 ± 9.3 years 

(ranging from 41 years to 83 years). Class I i.e. 

Diffuse, sponge like retinal thickening was the 

most common pattern seen. This pattern was 

observed in 79 (58.96%) patients. CME pattern 

was seen in 34.58% and TPHM in 7.45% of the 

patients. 

Mean Central Macular Thickness - As compared 

to normal central macular thickness values 

(CMT) (150 to 200µm), mean CMT was increased 

in all the patients and varied depending on the 

OCT pattern of DME. The mean CMT, for the 

entire study group was 318.6 ± 130.28µm, (range 

146 to 847 µm). Class III (TPHM) had the 

maximum mean CMT of 492.9 ± 156.5 µm, (244- 

847 µm), while class I had the least of 256.59 ± 

88.58 µm. 

Mean Visual Acuity - Mean BCVA (in log MAR 

units) for all the patients was 0.429 ± 0.397, 

(approximate Snellen equivalent ~ 6/18) (range 

0 to 1.5 logMAR units). It also varied within the 

subgroups: class I (Sponge like retinal thickening) 

correlated with best mean visual acuity: 0.298 ± 

0.327 logMAR units, (~ 6/12), as compared to the 

worst visual acuity in class III (TPHM): 0.714 

±0.401 logMAR units, (~ 6/36). 

Three variables were associated with bad visual 

acuity: 

1. Increasing macular thickness 

2. Cystoid macular edema 

3. Taut posterior hyaloid membrane 

Visual Acuity Vs Central Macular Thickness - In 

examining the relationship between BCVA and 

CMT, the correlation analysis revealed that; 

BCVA increased by 0.13 logMAR units per 100 

µm increase in central macular thickness, 

(reduction of Snellen visual acuity from 20/20 to 

~ 20/30) in the whole group, as well as in the 

CME group i.e. Class II. 

In class I, BCVA increased by 0.08 logMAR units 

per 100 µm increase in central macular thickness, 

(reduction of Snellen visual acuity from 20/20 to 

~ 20/25). Thus in the setting of sponge like retinal 

thickness in diabetic macular edema, a high 

macular thickness is usually not associated with 

bad visual acuity. 

This relationship could not be analyzed in class 

III because of lack of enough number of patients. 

Cystoid Macular Edema And Subretinal Fluid - 

Out of 45 patients with CME, 9 patients had 

concurrent subfoveal subretinal fluid. Within this 

group, 36 patients had isolated CME, with a


mean central macular thickness of 364 µm as 

compared to 478 µm in those with coexistent SRF. 

Visual acuity (in logMAR units) was 0.61 

logMAR units in isolated CME group; and 0.44 

logMAR units in CME with SRF group. 

Discussion 

A complete and precise characterization of 

macular edema based on the OCT data along 

with the conventional examination methods, can 

be obtained in eyes with diabetic macular edema. 

Each of the topographic pattern subtype on OCT 

may represent a distinct entity that requires 

specific treatment regimen. OCT can thus help us 

to prognosticate and optimize the treatment 

regimen in each case, in the light of recent 

developments in therapeutic modalities. 

Although our study suggests relationship 

between morphologic pattern and visual acuity, 

further investigation and longitudinal studies are 

required to establish the role of OCT as a primary 

diagnostic tool in DME. 

Use of Pascal Parameters in Conventional Lasers 

Dr. Kavitha S. Rao, Dr. Hemantha Murthy, Dr. N.S. Muralidhar 

(Presenting Author: Dr. Hemantha Murthy) 

Pan retinal photocoagulation (PRP) is the 

standard treatment procedure for patients 

with proliferative diabetic retinopathy according 

to diabetic retinopathy study (DRS) and Early 

treatment diabetic retinopathy study (ETDRS) 

and in central retinal vein occlusion with anterior 

segment neovascularisation. Many patients find 

PRP a painful experience, and when this is 

heightened, may lead to significant undertreatment. 

2,3,4 

The PASCAL (Pattern Scan Laser) photo 

coagulator introduced in 2006, uses 532 nm laser 

with altered parameters and has shown 

improved safety, reduction in pain, and reduced 

treatment time compared to a conventional laser. 

Our study was designed to evaluate whether 

shorter duration exposures of the same 

wavelength i.e. 532 nm are more comfortable 

than conventional laser settings, while still 

providing the same effect. 

To study the efficacy of different laser parameters 

in pan retinal photocoagulation, and to prove the 

therapeutic efficacy of the conventional laser 

with PASCAL parameter settings, in terms of 

regression of new vessels at the end of the three 

sittings of PRP, and patient comfort in terms of 

reduced pain and duration of treatment. 

Prospective, non-randomized comparative pilot 

study. 


This study was performed on 20 eyes of 10 

patients, undergoing bilateral PRP for the first 

time and in 2 eyes of 2 patients requiring PRP 

in one eye. 

In 11 patients, the diagnosis was proliferative 

diabetic retinopathy and in 1 patient the 

diagnosis was central retinal vein occlusion with 

neovascular glaucoma. Informed consent was 

taken from each of the patients. All patients 

underwent scatter PRP in 3 sittings at 1 week 

interval. Procedure was done using Mainster 

and quadraspheric lenses, with coupling solution 

and topical anaesthetic. 

One eye of the 10 patients requiring bilateral PRP 

was treated with green laser with 100 msecs 

duration ( conventional laser parameter group, 

CLP), the fellow eye was treated with 50 msecs 

duration ( reduced duration laser, RDL). 

2 patients requiring PRP in one eye underwent 

the first sitting with 100 msecs duration and the 

next 2 sittings with 50 msecs duration. Results 

were compared in terms of efficacy, power 

requirement, duration of procedure, pain and 

adverse events. Patients were followed up at 1 

month and 3 months. 

Efficacy was good laser reaction, signs of 

regression of neovascularisation at 3 months 

follow up. Pain was graded by patients on a scale 

of 0 – 4 (0 = no pain, 1 = occasional pain during 

procedure, 2 = mild pain, not requiring analgesic, 

3 = pain requiring analgesic, 4 = excessive pain 

necessitating stopping the procedure). 

Results 

In CLP group 1(100m sec), average power 

required was 220 mW with Mainster lens, and 

286.3 mW with quadraspheric lens. In RDL


527 

group (50m sec), average power was 241.8 mW 

with Mainster and 320 mW with quadraspheric 

lens. 

In the CLP group the average duration of 

procedure was 12.2 minutes and in the RDL 

group was 9.4 minutes. 

The pain graded was 3.7 in the CLP group and 

2.5 in the RDL group. Patient comfort was better 

in the RDL group. 

In our study, although there was a significant 

difference in the power used in CLP and RDL 

groups, it did not result in any complications. 

This may be due to the reduced laser energy per 

burn reaching the deeper layers of the eye 

secondary to its shorter duration. There was no 

choroidal detachment noticed at any time. 

There were no adverse events seen in our study 

except for the single peripheral pop that occurred 

in one patient in the RDL group. 

Discussion 

The use of lasers to treat retinal diseases dates 

back to the 1960’s. 5 Recent studies 9 have shown 

the need to optimize thermally induced 

therapeutic effect but with minimal retinal 

damage. Laser tissue interaction is influenced by 

wavelength, spot size, power, and exposure time. 

Retinal damage can be reduced by changing 

some of these parameters. 

Fluence is the factor taken into account for the 

PASCAL laser and is calculated by 

Power X time 

Area: Provided the spot size remains unchanged, 

the burn duration of 50 msecs has less fluence 

than a burn duration of 100 msecs when titrating 

to the same burn intensity because of reduced 

diffusion of heat. 1 

By reducing the duration of pulse, a higher 

power is required to achieve similar therapeutic 

effect. 7 In our study also the power required was 

on the average 33mW more when the duration 

was reduced from 100 to 50 msecs. However the 

higher power levels required did not result in 

any complications. This may be due to the 

reduced laser laser energy per burn reaching the 

eye secondary to its shorter duration. 

While the energy per pulse is reduced, the total 

energy delivered to the retina per sitting maybe 

the same because more spots must be delivered 

to compensate for smaller burns. Longer burns 

may cause greater thermal diffusion, resulting in 

damage to the nerve fiber layer and spread to the 

choroid causing pain. In short pulse durations, 

there is minimal diffusion of heat to adjacent 

areas, resulting in localized homogenous burns 

and less damage to nerve fiber layer and spread 

to choroid. This may be the reason for the lesser 

pain and greater comfort in patients. 

In conventional photocoagulation, a 200 µm spot 

will produce a burn with a diameter greater than 

200 µm, due to laser spread, but with 50 msec 

pulse duration, the burn diameter will be less 

than the spot diameter. 5 

A study conducted by Obana A et al has shown 

a narrow safety margin between retinal burn and 

retinal haemorrhage for pulse durations less than 

50 msecs. 7 Point of change from thermo 

mechanical cavitation induced RPE damage to 

pure thermal RPE denaturation of tissue is the 

primary retinal damage mechanism. 8 In our 

study we did not observe any retinal hemorrhage 

in any patient. 

Al Hussainy et al have conducted a study with 

20 msecs duration and have found significantly 

reduced pain during procedure. Shorter 

duration laser burns may be less painful due to 

rapid cool off of the treated tissue compared to 

longer duration burn. 4 This is also the principle 

behind the micropulse laser delivery in which 

pain can be markedly reduced. Hence simple 

reduction of the exposure time and increasing the 

power of conventional lasers can increase patient 

comfort while achieving comparable efficacy. 

PASCAL laser is an attractive option for the painfree, 

fast, easy way of laser delivery for PRP. The 

same efficacy can be achieved in a conventional 

laser by altering the parameters. Shorter pulse 

duration in conventional laser is comparable in 

efficacy to longer pulse duration and is more 

comfortable and painless for the patient. Benefits 

of PASCAL laser can thus be achieved by 

alteration of parameters of conventional laser. 

Ours, being a pilot study, the follow-up was only 

of 3 months duration. A larger study with a 

longer follow up would determine, if reduction 

of duration is also beneficial to the patient in 

terms of lesser field loss and complications.


1. Blumenkranz MS, Yellachich D, Anderssen D. 

Semiautomated patterned scanning laser for retinal 

photocoagulation. Retina 2006;26:370-6. 

2. Royal college of anaesthetists and the Royal college 

of Ophthalmologists. Local anaesthesia for 

Intraocular Surgery. RCA, RCOphth: London, 2001. 

3. Vaideanu D, Taylor P,K McAndrew P, Hildreth A, 

Deady JP, Steel DH et al. Double masked 

randomized controlled trial to assess the 

effectiveness of paracetamol in reducing pain in 

PRP. Br J Ophthalmol 2006;90:713. 

4. S Al-Hussainy, PM Dodson and JM Gibson. Pain 

response and follow-up of patients undergoing PRP 

with reduced exposure times. Eye 2008;22:96-9. 

5. Jain A, Blumenkranz MS, Paulus Y et al. Effect of 

pulse duration on size and character of the lesion in 

References 

retinal photocoagulation. Arch Ophthal. 2008:126:78- 

85. 

6. Sanghvi et al. Initial experience with Pascal 

photogoagulation. A pilot study of 75 procedures. 

Eye 2008;22:96-9. 

7. Obana A, Lorenz B, et al. Therapeutic range of 

chorioretinal photocoagulation with diode and 

argon lasers : an experimental comparison. Laser 

Light Ophthalmol 1992:4:147-56. 

8. Schuele G, Rumohr et al. RPE damage thresholds 

and mechanisms for laser exposure in the 

microsecond to millisecond time regimen. Invest 

Ophthalmol Vis Sci 2005:46:714-19. 

9. Dorin G. Evolution of retinal laser therapy (MIP). 

Can laser heal the retina without harming it? Semin 

Ophthalmol 2004;19:62-8.

RETINA / VITREOUS SESSION-III - All India Ophthalmological Society

Create successful ePaper yourself

Delete template?

Save as template?