The effect of posterior vitreous detachment induced by intravitreal injections on macular edema with retinal vein occlusion

Introduction: To evaluate whether posterior vitreous detachment (PVD) improves treatment outcomes.Methods:The medical records of treatment-naive patients followed up for a minimum of six months due to retinal vein occlusion between January 2007 and January 2016 were reviewed. Patients with initial PVD were excluded. Correlation analysis and binary logistic regression analysis were used to determine the relationship between categorical variables and treatment outcomes. A subgroup analysis (steroids vs anti-VEGFs) was also performed.Results: The study included 95 eyes of 95 patients with macular edema due to retinal vein occlusion. Patients in both groups [central retinal vein occlusion (CRVO) and branch retinal vein occlusion (BRVO)] were similar in terms of demographic data and showed similar improvement during the study. The patients who underwent intravitreal steroid injection (IVD or IVTA) were 12.35 times (95% CI: 4.03-37.85) more likely to develop PVD. The patients in steroid group had a statistically significantly high correlation with visual and anatomic improvements, especially after 5 months of follow-up. The median time of PVD was 5 months (2-11).Conclusion: Commonly used drugs in intravitreal pharmacotherapy induce PVD, which plays an important role for the treatment of underlying macular edema.

A Study on Fundus changes in Pregnancy-induced hypertension: A Four-year Observation

Introduction: Hypertensive disorders complicate 5-10% in all pregnant and together form the deadly triad and hemorrhage and heart disease that contribute greatly to maternal morbidity or mortality. This study aims to identify retinal changes in pregnancy-induced hypertension and analyze the association between retinal changes and hypertension severity. Method: A total of 100 pregnant admitted with pregnancy-induced hypertension(PIH) were included. Patients with pre-existing hypertension, diabetes mellitus, and renal diseases were excluded from the study. The vision, anterior segment, and Fundus were examined. Result: Higher number of PIH were recorded in the 21-30 years age group. Fifty-four pregnant women suffered from mild preeclampsia, 40 pregnant women with severe preeclampsia, and six pregnant women with eclampsia with seizures. 41% of pregnant had normal fundus, and 24% of pregnant had hypertensive retinopathy. Whereas grade 2,3, and 4 retinopathy was observed in 22%, 6%, and 2% of pregnant women. Two percent of pregnants had macular edema, and 3% had central serous retinopathy. No association was observed between the fundus findings with age/gravida. Whereas a significant positive correlation was observed between the fundus findings and hypertension severity (P < 0.001). Conclusion: Overall, 54% of pregnants were recorded with hypertensive retinopathy. A positive correlation was observed between fundus changes with the hypertension severity. This study reports the importance of routine fundus examination in pregnant with hypertension. Retinal change during pregnancy is an important indicator to decide the pregnancy termination or any other opt.

PARS PLANA VITRECTOMY FOR VITREOUS HEMORRHAGE IN CIPTOMANGUNKUSUMO HOSPITAL

Introduction: Vitreous hemorrhage is the presence of blood in the vitreous cavity. This condition could impair the visual function and hindered the clinician’s ability to examine the posterior segment of the eye. Pars plana vitrectomy (PPV) not only act as a surgical treatment of choice but also diagnostic procedure. Immediate PPV has the advantage to optimalize visual acuity Methods: Retrospective descriptive study of vitreous hemorrhage patients underwent pars plana vitrectomy in Ciptomangunkusumo Hospital, Indonesia from January to December 2018 Result: There were 160 cases of vitreous hemorrhage cases undergoes pars plana vitrectomy in 2018. Most frequent etiology was proliferative diabetic retinopathy (49.4%). Rebleeding was found only in 8 cases within the period of three months follow up. Final visual acuity was improved in majority of the cases and found to be related to timing of the surgery. Conclusion: Early vitrectomy along with systemic control of underlying factors lead to improvement of visual acuity in vitreous hemorrhage.

A Prospective Study of Safety Profile and Efficacy of three doses of Intravitreal Bevacizumab in Diabetic Macular Edema

Introduction: Current study aimed to evaluate efficacy of intravitreal Bevacizumab in Diabetic macular edema, and to identify their ocular and systemic complications if any. Method: It is a prospective, interventional study with 68 patients in 82 eyes with Diabetic macular edema. All treated by 3 injection of intravitreal bevacizumab with 1 month interval. Visual acuity, macular edema, and complications evaluated at every month upto 6th months. Ranibizumab was offered if the patient is a non-respondent to Bevacizumab. Results: Majority age group of 61-70 years with a mean age of 59 ± 6.72 years. The mean duration of diabetes was 11.68 ± 7.2 years. The mean baseline BCVA and CRT are 0.64 ± 0.28 Log MAR units and 436.99 ± 135.10 μm. After 3 injections, BCVA values are 0.48±0.27 (p< 0.01)), 0.36±0.24 (p<0.01)), and 0.27±0.24 (p<0.01), 0.23±0.27 Log MAR (p<0.01)) at 1month, 2 months, and 3 months, and 6 months follow-up respectively. CMT levels are 315.79±124.60 μ at 1 month, after 3rd IVA and this significant change (p<0.01) followed with subsequent follow-up with mean CRT of 296.04±122.97 μ (p< 0.01) at 6th month. The BCVA improved ≥ 2 Snellen lines in 69.5% and 78% cases, resolution of CMT in 56% and 69.5% cases at 3 months and 6 months respectively. At the end of the 3rd month, 46 eyes macular edema completely resolved with 3 injections of IVA, 23 eyes persistent macular edema present, 13 eyes refractory to bevacizumab injections. Persistent & Refractory macular edema eyes (36) switched to Ranibizumab injections.In persistent macular edema, significant resolution (p≤0.01) of macular thickness (370.52 ± 71.43 µm vs. 341.08 ± 122.75 µm) without (p=0.09) improvement in visual acuity (0.45 ± 0.20 vs. 0.34 ± 0.23) was observed post Ranibizumab injections. In Refractory macular edema, thickness of cases no significant (497.76 ± 161.07µm vs 407.84 ± 169.64 µm) improvement seen after Ranibizumab injections(p=0.1). Recurrence of macular edema seen in 10.9%. Subconjunctival haemorrhage seen in 10.9%-12.1% cases, raised IOP in 2.4%-3.6% cases at post injection day 1. No other ocular and systemic complications were observed during follow-up. Conclusions: Intravitreal bevacizumab is effective in treatment of diabetic macular edema but therapeutic effect is temporary and repeat treatment is needed. It does not show any potential drug related ocular and systemic side effects, hence it is safe and economical therapeutic agent

DIFFERENCES OF APOLIPOPROTEIN A1 AND APOLIPOPROTEIN B LEVELS IN TYPE 2 DIABETES MELLITUS (T2DM) PATIENTS WITH DIABETIC RETINOPATHY AND WITHOUT DIABETIC RETINOPATHY

Introduction Apolipoprotein A1 are antiatherogenic in blood serum and have an anti-inflammatory while Apolipoprotein B describes a protein structure that is potentially atherogenic.. Meanwhile, the inflammatory process plays a role in the diabetic retinopathy process. The aim of this study was to determine whether there were differences in the levels of apolipoprotein A1 and B in diabetic retinopathy patients and without diabetic retinopathy. Methods: This study used a cross sectional design. The subjects of this study were type 2 diabetes mellitus patients with diabetic retinopathy and without diabetic retinopathy at Dr. Sardjito General Hospital from July to September 2020. Subjects consisted of 32 patients in the group with diabetic retinopathy and 31 patients without diabetic retinopathy. The levels of apolipoprotein A1 and apolipoprotein B were analyzed using independent T test. The factors affecting apolipoprotein A1 and apolipoprotein B were analyzed using multiple regression tests. Result: There were no significant differences (p> 0.05) in age, gender, duration of diabetes, HDL, triglycerides, HbA1c, BMI, physical activity, and smoking history. The mean apolipoprotein A1 level in the diabetic retinopathy group was 1.46 ± 0.177 mg / dL higher than the non-diabetic retinopathy group, namely 1.44 ± 0.27 mg / dL (p = 0.699). The mean level of apolipoprotein B in the diabetic retinopathy group was 1.26 ± 0.289 mg / dl higher than the non-diabetic retinopathy group 1.01 ± 0.26 mg / dL (p = 0.001). The mean LDL levels were 162.5 ± 48.38 mmol / L in the diabetic retinopathy group and 127 ± 38.45 mmol / L in the group without diabetic retinopathy (p = 0.012). Conclusion: Apolipoprotein B levels were found to be higher in the group with diabetic retinopathy than in the group without diabetic retinopathy and there was a significant difference between the two assumed due to an atherogenic process in the diabetic retinopathy group. Further research is needed to assess the causal relationship between elevated levels of Apo B and the incidence of diabetic retinopathy by calculating the ratio of apolipoprotein B to apolipoprotein A1. Keywords: Apolipoprotein A1, Apolipoprotein B, Diabetic Retinopathy

Multifocal Electroretinogram, Central Macula Thickness and Visual Acuity in Diabetic Macular Edema Following Intravitreal Injection of anti-VEGF

Introduction : Diabetic Retinopathy (DR) is one of the major cause of visual acuity deterioration in diabetic patients. The loss of central visual acuity in diabetic patients are mainly due to macula edema, which is found in 29% diabetic patients with the over 20 years duration of disease. The aim of this study is to evaluate and investigate the possible correlation among changes of visual acuity (VA), central macular thickness (CMT) using Spectral Domain Optical Coherence Tomography (SD-OCT). Electrophysiological responses using multifocal electroretinography (MfERG) in diabetic macular edema (DME) following intravitreal injection of bevacizumab. Methods: Single arm clinical trial. Thirty-three eyes of 33 DME patients (16 non-proliferative diabetic retinopathy and 17 non-high-risk proliferative diabetic retinopathy), receives intravitreal bevacizumab 1,25mg. All patients underwent complete ophthalmic examination including ETDRS VA testing, Sixty-one scaled hexagon MfERG and SD-OCT scan at baseline, 1-week and 1-month post-injection. Components of the first order kernel (N1, N2 and P1) in central 2o were measured. Result : MfERG showed reduced P1 amplitude (P<0.05) at 1-week after injection followed by increased P1 amplitude (P>0.05) at 1-month after treatment as compared to the baseline in all subjects. There was 19% improvement CMT and 0.2Logmar VA improvement in 1-month post-injection compared to the baseline (P<005). This study showed no serious ocular adverse effects. There was no significant correlation between changes in visual acuity with changes in CMT or other MfERG parameters. Conclusion: Intravitreal injection bevacizumab resulting in improved VA, reduction in CMT and mild improvement in the MfERG responses. Although VA changes did not correlate with reduced CMT nor with improved responses of MfERG, the combined use of SD-OCT and MfERG may be used to evaluate macular function in DME patient with worsened visual acuity post anti-VEGF injection.

CENTRAL MACULAR THICKNESS AFTER COMBINED THERAPY OF BEVACIZUMAB INTRAVITREAL INJECTION AND TOPICAL DICLOFENAC COMPARED WITH BEVACIZUMAB INTRAVITREAL INJECTION ALONE IN DIABETIC MACULAR EDEMA

Introduction: To evaluate whether the combination of diclofenac eye drops and bevacizumab intravitreal injection would provide additional benefits over bevacizumab alone in the treatment of naïve diabetic macular edema (DME). Methods: A total of 43 patients were enrolled consecutively and randomized into two groups to receive combination treatment with intravitreal bevacizumab and topical diclofenac (group 1) or bevacizumab alone (group 2). Group 1 patients received single bevacizumab intravitreal injection and got self-administered diclofenac eye drop four times daily for one month. Group 2 patients received single bevacizumab intravitreal injection alone. Outcome data were obtained from patient visits at baseline and at 1 month after bevacizumab intravitreal injection. All patients underwent measurement of best corrected visual acuity (BCVA), a complete eye examination, and measurement of central macular thickness (CMT). Result: The mean reduction in CMT in the combination group was 130.42±32.57 µm (p<0.01), while in the bevacizumab alone group the reduction was 141.38±45.27 µm (p<0.01), there is no significant difference between the two groups (p=0.866). The mean improvement of BCVA was 0.32±0.10 log Mar in the combination group and 0.26±0.12 in group 2, there is no significant difference between the two groups (p=0.691). There was no adverse ocular event in the two groups. Conclusion: In patients with naïve DME, adding diclofenac eye drop as adjuvant of bevacizumab intravitreal injection are less likely to have a meaningful effect on reducing the central macular thickness. Keywords: Diabetic macular edema, NSAID, diclofenac, anti-VEGF, bevacizumab, central macular thickness

OCULAR CHANGES IN PATIENTS ON LONG TREATMENT WITH HYDROXYCHLOROQUINE

Introduction: To study the ocular changes in patients on long term treatment with Hydroxychloroquine (HCQ); and detect means for early detection of toxicity.Methods: We conducted a cross-sectional observational study at a tertiary care hospital, in which 100 patients, male and female, aged 35 years or more, taking HCQ for 5 years or more were included. Patients with any known ocular or systemic diseases were not included. Indication, dosage, duration and cumulative dose of HCQ intake were recorded. History of ocular symptoms, visual acuity, colour vision, complete ophthalmic examination, visual field using Amsler grid and 10-2 Humphrey’s automated fields (HVF), Spectral Domain Optical Coherence Tomography (SD-OCT), colour fundus photography, fundus fluorescein angiography (FFA) and fundus autofluorescence (FAF) were recorded. The data was analyzed using descriptive and inferential analysis.Result: 15% of the study population showed signs of HCQ related ocular toxicity. 17%, 21% and 10% patients had abnormal SD-OCT, HVF and FAF findings respectively.Conclusion: HCQ related ocular toxicity has been found in patients in the absence of symptoms. Objective tests like HVF, SD- OCT and FAF were more useful in early detection of toxicity than subjective tests such as Amsler grid, colour vision and FFA.

Relationship of Peripapillary Retinal Perfusion with Peripapillary Retinal Nerve Fiber Layer Thickness in Diabetes Mellitus Patients without Diabetic Retinopathy

Introduction: Impaired blood flow is an early sign of retinal dysfunction in diabetes. Impaired blood flow of the radial peripapillary capillaries can affect the Retinal Nerve Fiber Layer (RNFL) or ganglion cell function. Methods: This was an analytic cross-sectional study in February-April 2019 at Bandung. The subjects of this study were 41 people (79 eyes) divided into two groups, group A (healthy subjects) 19 people (37 eyes) and group B (DM type 2 without diabetic retinopathy) 22 people (42 eyes). Peripapillary retinal perfusion was assesed using OCT Angiography and RNFL thickness was assesed using OCT. Pearson or Spearman correlation statistics test was used to analyze the result. P value ≤0.05 was consiedered significant. Results: There was a decrease in peripapillary retinal perfusion density in the inferior quadrant (P = 0.003) and flux index throughout the peripapillary retinal quadrant (P = 0.0001) but an increase in RNFL thickness in the peripapillary temporal quadrant (P = 0.012) compared to control grup. Positive correlation was found between peripapillary retinal perfusion density and RNFL thickness globally (r = 0.480, P = 0.001), superior quadrant (r = 0.436, P = 0.004), and inferior quadrant (r = 0.608, P = 0.000). A positive correlation was also found between the peripapillary flux and RNFL thickness globally (r = 0.517, P = 0.000), superior quadrant (r = 0.630, P = 0.000), and inferior quadrant (r = 0.519, P = 0.000). Conclusions: There was a relationship between peripapillary retinal perfusion and RNFL thickness in DM patients without diabetic retinopathy. Keywords: Peripapillary perfusion, RNFL thickness, Diabetes.

INTRAOPERATIVE BREAKAGE OF A REUSED 25 GAUGE ILM PEELING FÓRCEPS

A 59 years male presented with painless diminution of vision in right eye for 4 months. His vision was 20/100 in right eye and 20/30 in left eye. Fundus examination revealed epiretinal membrane in right eye with central macular thickness of 747 μm for which he underwent 25 guage pars plana vitrectomy. Intraoperatively after internal limiting membrane peeling, during removal of the pieces of the membrane from the forceps with the endoilluminator pipe, accidentally one blade from the tip of ILM peeling forceps broke. In this report, we describe first case of inadvertent intraoperative fracture of 25- gauge Grieshaber DSP End-Grasping ILM forceps in a case of ERM who underwent vitrectomy and removal of ERM with successful removal of fractured tip of ILM forceps.