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To analyze the efficacy and safety profile of the intravitreal ranibizumab biosimilar molecule, RazumabThis was a retrospective study of treatment-naïve and previously treated PCV eyes undergoing intravitreal therapy with either BRm or IRm from January 2019 to September 2020 as three loading doses followed by a pro-re-nata (PRN) regimen. Changes in the best-corrected visual acuity (BCVA), subretinal fluid (SRF), intraretinal fluid (IRF), SRF height, and subfoveal choroidal thickness (SFCT) and the safety profiles were assessed at weeks 12, 24, and 52, respectively.A total of 22 eyes received IRm and 19 eyes underwent BRm therapy, respectively. Both the groups were comparable in age (P = 0.41) and gender distribution, although the BRm arm had significantly more eyes that were previously treated (P 0.00001) with a greater median number of injections (P 0.0001). At week 52, both groups had similar gains in visual acuity (P = 0.19), SRF resolution (P = 0.8), IRF resolution (P = 0.47), and SRF height (P = 0.71). The IRm eyes exhibited a significant improvement in BCVA (P = 0.001) at all visits with a greater mean number of injections (IRm: 5.41 ± 0.94; BRm: 4 ± 1.45; P = 0.0004), while the BRm eyes showed a similar increase in BCVA but did not reach statistical significance until week 52. The SFCT decreased significantly in the BRm arm at week 52 (P = 0.045). One eye (5.26%) in the BRm arm experienced mild anterior uveitis, which was treated with topical corticosteroids. In either arm, no other ocular or systemic adverse effects were observed.Our real-world data demonstrated the ranibizumab biosimilar Razumab to have comparable visual acuity outcomes to the innovator ranibizumab molecule with an adequate safety profile in the management of PCV. Although these encouraging results support its use as a viable alternative to the innovator molecule, further prospective studies in a diverse patient population are needed to validate our findings.

We describe a unique case of bilateral acquired vitelliform lesions in a 67-year-old-female with pachychoroid associated with subretinal fluid in the right eye (OD) and a nonexudative choroidal neovascular membrane (CNVM) in the left eye (OS). Multimodal imaging performed at baseline and over the ensuing two years showed an increase in the OS vitelliform lesions with a concurrent transformation of quiescent CNVM to an exudative form. Further studies are warranted to gain better insight into the etiopathogenesis of these vitelliform lesions in pachychoroid and their potential role in instigating CNVM activation.

Aim To describe a novel OCT finding called "Plume sign" in macular cysts. Methods Case records of five cases were retrospectively reviewed. Their case history and imaging findings on spectral domain optical coherence tomography (SD-OCT, Spectralis, Heidelberg, Germany) have been described. Results We observed five cases which had a solitary cyst foveal or parafoveal in location, was unique due to the presence of a plume-shaped internal substance, was treated with topical NSAIDs and was associated with good visual outcomes. We observed three cardinal events; firstly, retinal thickening followed by the formation of a foveal or parafoveal solitary cyst. Secondly, a vertical expansion of the solitary cysts in an inverted flask-shaped configuration associated with splitting of the retinal layers suggested by a hyper-reflective line and/or a hyporeflective cleft in the outer nuclear layer. Thirdly and finally, a breach of the outer retina with involvement of the external limiting membrane (ELM) and ellipsoid zone (EZ) with an exit trail of proteinaceous material through the defect in the shape of a plume of smoke hyper-reflective on OCT followed by deturgescence of the cyst. Conclusion In conclusion, we describe the "plume" sign - a novel OCT finding is cysts and provide a possible pathogenic hypothesis.

Purpose To present a case of posterior lenticular surface neovascularization in the absence of any ocular or systemic pathology. Observations A 29-year-old asymptomatic male was detected with the right eye (OD) posterior lenticular surface neovascularization extending for six-clock hours in the temporal portion along with the presence of mild posterior capsular haze. His best-corrected visual acuity was 20/25 in OD and 20/20 in the left eye (OS). No additional abnormality was identified in the remainder of the OD anterior segment and the fundus respectively. OS evaluation was unremarkable. OD imaging including B-scan ultrasonography and ultrasound biomicroscopy (UBM) were essentially normal. The anterior segment optical coherence tomography (AS-OCT) thickened lens capsule with a dense hyperreflective layer adhered to its posterior surface and separating from the capsule in the periphery. Few hyperreflective dots were visible posterior to the ciliary body although no CB thickening was noted. No systemic abnormality was detected. The patient is being managed conservatively and has shown no signs of progression of the neovascularization over six months. Conclusions and importance This is the first reported case of an isolated idiopathic posterior lenticular surface neovascularization occurring in an otherwise healthy patient. Although an unspecified breach in the posterior capsule or undetermined cyclitis can trigger such neovascularization, further histopathological studies of the capsular biopsy and ciliary body can provide better insight into its etiopathogenesis. Additionally, considering the asymptomatic nature of the condition, these patients can be observed and closely monitored.

Unnikrishnan Nair,1,2 Jay U Sheth,1,2 Asmita Indurkar,1 Manoj Soman1,2 1Vitreoretinal Services, Chaithanya Eye Hospital and Research Institute, Trivandrum, Kerala, India; 2Department of Research, Chaithanya Innovation in Technology and Eyecare (Research), Trivandrum, Kerala, IndiaCorrespondence: Jay U Sheth 32, Shiv-Mahal, Mathuradas Road, Kandivali (West), Mumbai, 400067, Maharashtra, IndiaTel +91 9961167200Email drjay009@gmail.comPurpose: To characterize retinal micromorphic changes on en face optical coherence tomography (OCT) and to determine their role in pathogenesis and visual outcomes in macular hole (MH) surgery.Patients and Methods: This is a retrospective, interventional, consecutive case series of 28 eyes undergoing successful MH surgery. Pre- and post-operative en face OCT were manually segmented, and the correlation between parameters such as MH basal diameter and minimal inlet area, area of cyst in inner plexiform layer (IPL) and outer plexiform layer (OPL), percentage of cyst in IPL and OPL, and amount of ellipsoid zone (EZ) defect and external limiting membrane (ELM) defect was performed. Their relationship with visual acuity (VA) outcomes (Group 1: ≥ 20/60; 14 eyes; Group 2: < 20/60; 14 eyes) was also evaluated.Results: A significant positive correlation was noted between the cyst area in OPL and IPL (r=0.768; p< 0.001), which in turn were positively correlated with the basal diameter of the MH in all eyes. The cyst area was significantly more in IPL as compared to OPL in all eyes (p=0.049) and in group 2 (p=0.03) but not in group 1 (p=0.62). As compared to group 2, eyes in group 1 had significantly better pre- and post-operative VA, and significantly smaller basal diameter, minimal inlet area, area of cyst in IPL and OPL, and amount of defect in the ELM (postoperative) and EZ (pre- and post-operative), respectively.Conclusion: An increase in the basal diameter of the MH is associated with a simultaneous congruous enlargement of the area of cyst in IPL and OPL. Based on these imaging findings, we propose that the possible rationale for the origin of these intraretinal cysts could be a breakdown in the physiological retinal pigment epithelium (RPE) pump due to the anatomical separation of the neurosensory retina from the underlying RPE, ie, “RPE contact loss” theory.Keywords: macular hole, spectral-domain optical coherence tomography, en face imaging, intraretinal cysts

Aim To report a case of acute hydrops with a large stromal cleft, in a case of keratoconus, managed with compression sutures and perfluoropropane (C3F8) descemetopexy and subsequent management of corneal vascularization in that eye with combination therapy of laser and anti-vascular endothelial growth factor (anti-VEGF). Background Acute hydrops in keratoconus occurs following a tear or rupture in the Descemet's membrane (DM), resulting in aqueous percolating into the stroma. The presence of large stromal clefts in acute hydrops has been described as a known risk factor for delayed resolution and persistent edema, which in turn can incite inflammation and vascularization and thereby adversely affect the chances of graft survival later. We describe such a case managed effectively with a combination of different treatment modalities. Case description A 12-year-old boy with keratoconus presented with acute hydrops in his left eye. The acute hydrops was managed with compression sutures along with C3F8 descemetopexy. Subsequent development of persistent deep corneal vascularization and recurrence of inflammation after the resolution of hydrops was managed with a combination of argon laser photocoagulation and intrastromal anti-VEGF injections, resulting in complete regression of the deep vascularization and resolution of inflammation. Conclusion In our case, a combination of management modalities to address severe acute hydrops and its subsequent complications resulted in complete regression of the superficial and deep vessels, thus heralding an optimal outcome for a future corneal graft. Clinical significance There are no definite guidelines for the management of acute hydrops in keratoconus. A customized and judicious combination of various treatment modalities described in the literature for acute hydrops and its sequelae can result in an accepted outcome, which can pave the way for an optimum result with elective treatments like keratoplasty later on. How to cite this article Kurian A, Reghunadhan I, Soman M, et al. Regression of Corneal Vascularization Occurring after Corneal Suturing in a Case of Acute Hydrops Managed with a Combination Therapy of Argon Laser Photocoagulation and Intrastromal Ranibizumab Injection: A Case Report. Int J Kerat Ect Cor Dis 2019;8(2):46–49.

Background Macular edema secondary to retinal vein occlusion (RVO) is an important cause of loss of vision. Intravitreal injections (IVI) of anti-vascular endothelial growth factor (VEGF) are the standard of care in this disease, as shown in numerous randomized controlled trials. The purpose of this study was to study the efficacy and safety of ranibizumab, an anti-VEGF agent, in the real-world setting. Methods This was 48 weeks, open-label, prospective, multicentre, observational study. Patients diagnosed with ME secondary to RVO were treated with IVI of Ranibizumab 0.5 mg in real-world conditions. Efficacy was measured by improvement seen in best-corrected visual acuity (BCVA) in terms of Early Treatment of Diabetic Retinopathy Study (ETDRS) Letter Scores and change in central retinal thickness (CRT) measured by optical coherence tomography. Results One hundred eyes of 100 patients (79 with branch retinal vein occlusion and 21 with central retinal vein occlusion) were recruited in the study. The mean (standard deviation, SD) BCVA was 52.8 (21.99) letters at baseline and 62.3 (24.40) letters at week 48. From baseline, there was a significant improvement in BCVA by 7.7 letters (p = 0.001) at 48 weeks. The mean (SD) of CRT was 479.9 (216.25) μm at baseline and it decreased significantly to 284.9 (171.35) μm at week 48 (p Conclusions Ranibizumab is well tolerated and effective in treating macular edema secondary to RVO in real-world clinical settings. However, there is under-treatment compared to controlled clinical trials, and the gain in vision is sub-optimal with under-treatment. Trial registration Clinical Trials Registry - India: CTRI/2015/07/005985.

To evaluate pre-operative qualitative and quantitative parameters of external limiting membranes (ELM) and other associated full thickness macular holes (FTMH) features and their predictive values for post-operative anatomical and functional outcomes. This was a retrospective study of 48 eyes that underwent vitrectomy with internal limiting membrane (ILM) peeling for FTMH and had type 1 closure. All subjects underwent optical coherence tomography (SDOCT, Heidelberg, Spectralis), and the eyes were divided into complete ELM closure (CEC) and incomplete ELM closure (IEC) groups based on the post-operative OCTs within 2 months, and ROC curves were used to estimate which of the pre-operative parameters could best predict eyes falling in the CEC group. The mean pre-op ELM defect was smaller in CEC group (594 μm vs 1126 μm, p

A 36-year-old gentleman with history of central serous chorioretinopathy (CSCR) developed full thickness macular hole in the right eye with recurrence of CSCR 2 weeks after blunt trauma to his right eye. Vitrectomy resulted in complete closure of the macular hole and resolution of the subretinal fluid. Post macular hole surgery he developed two episodes of CSCR recurrence with no reopening of the hole. This report hypothesises the possible mechanisms underlying this unusual association and explains how a surgically manipulated macular tissue could endure significant submacular fluid accumulation.

To describe the demographic, clinical and optical coherence tomography (OCT) characteristics of macular microholes and to determine if the size or character of the microholes has any correlation with vitreomacular interface abnormalities. Case records of 46 eyes of 39 consecutive patients with diagnosed macular microholes were reviewed as a non-interventional retrospective case study. Demographic and clinical features were noted from the detailed case records. Spectral domain OCT images were analysed for microhole and retinal characteristics. SPSS 16.0 was used for statistical analysis. Main outcome measure was the presence of vitreomacular interface abnormalities in large and small macular microholes. Of 39 patients, 21 were male and 18 were female. Most of these patients (56.4 %) presented with visual complaints. Clinically, the commonest feature was a 'red spot' at the fovea on indirect ophthalmoscopy (25 of 44 eyes; 54.3 %). Mean logMAR vision was 0.117 (±SD 0.21). 34 (76.08 %) eyes exhibited a photoreceptor loss, 38 eyes (82.6 %) had lamellar tissue defects involving layers posterior to the outer nuclear layer. The difference between means of the groups with and without vitreomacular interface abnormalities was analysed using the unpaired t test. The presence of vitreomacular interface abnormalities was significantly associated with the size of the microhole, with larger microholes being more likely to have vitreomacular interface abnormalities than smaller ones (p < 0.05). We concluded that there was a positive correlation between the size of the microhole and the presence of vitreomacular interface abnormalities. Visual acuity had no correlation with the size of the microhole; functional vision was generally well preserved in the affected eyes.

Boucher-Neuhäuser syndrome (BNS) is rare autosomal recessive disease, characterised by cerebellar ataxia, hypogonadotropic hypogonadism and chorio-retinal degeneration. The authors report a family (brother, 22 years and sister 24 years) with late-onset BNS (10 years). They had subnormal intelligence; the cerebellar ataxia was progressive over 2emsp14;years with early functional dependence. Puberty was attained in a brother with testosterone injections, while the girl had primary amenorrhoea. There were no associated visual complaints. They both had diffuse periventricular white-matter hyperintensities in cerebral cortex and diffuse cerebellar atrophy in the MRI.

Purpose: To report our experience with the diagnosis and management of Familial Exudative Vitreoretinopathy (FEVR) in a predominantly older Indian population.. Methods: This prospective interventional non-comparative case series included 38 patients of FEVR and their 23 family members. The diagnosis was established by clinical examination, fluorescein angiography and family screening. Prophylactic photocoagulation/cryotherapy or surgical treatment was done depending on the severity of the disease. Results: The mean age of the patients was 23.6 years. The fundus/fluorescein angiographic findings in 116 eyes of our 61 patients (6 eyes phthisical) were as follows: forty eight (41.4%) eyes had only peripheral avascular zone, 8 (6.9%) eyes had peripheral new vessels, and 35 (30.1%) eyes had retinal detachments (RD) - 10 (8.6%) exudative, 5 (4.3%) tractional and 20 (17.2%) rhegmatogenous. Prophylactic photocoagulation or cryotherapy was done in 34 eyes for retinal holes, local exudative detachments and bleeding new vessels. All the eyes retained stable vision over a mean follow-up of 16 months. Only 14 RDs were suitable for surgery: scleral buckling, vitrectomy or both. The reattachment rate was 85.7% (12 of 14) and the best-corrected visual acuity (BCVA) improved to 5/60 or better in 50% of these eyes over a 2-year follow-up. Conclusions: FEVR appears to be more common than reported. Timely diagnosis and intervention is essential in view of the lifelong progression of the disease, late exacerbations, frequent involvement of family members, and poor surgical results. A high index of suspicion, family screening and early prophylaxis are recommended to prevent avoidable blindness from this under- diagnosed disease.

Unnikrishnan Nair,1 Manoj Soman,1 Sunil Ganekal,2 Vaishnavi Batmanabane,1 KGR Nair11Chaithanya Eye Hospital and Research Institute, Trivandrum, Kerala, 2Nayana Super Specialty Eye Hospital and Research Center, Davangere, Karnataka, IndiaPurpose: To evaluate the morphological types of indirect choroidal rupture (ICR) using spectral domain optical coherence tomography (SD-OCT).Methods: This was a prospective interventional study of 18 eyes of 18 patients who presented with a history of blunt ocular trauma resulting in choroidal rupture. All patients underwent detailed ophthalmic evaluation and SD-OCT examination.Results: Mean age of the patients was 32±9.6 years. Morphologically, two types of choroidal rupture were seen on SD-OCT. The first type seen (Type 1 ICR) was a forward protrusion of the retinal pigment epithelium-choriocapillaris (RPE-CC) layer with an acutely angled pyramid or dome shape. This was associated with either a small loss of continuity of the retinal pigment epithelium layer or elevated RPE-CC projection accompanied by a significant quantity of subretinal hemorrhage. The second type observed (Type 2 ICR) was a larger area of disruption of the RPE-CC layer, photoreceptor inner segment/outer segment junction, and external limiting membrane, with a posteriorly directed concave contour depression at that area and downward sliding of tissues into the defect. At presentation, ten eyes were observed to have Type 1 ICR and eight to have Type 2 ICR. Of the 18 eyes, one with Type 1 ICR and two with Type 2 ICR developed choroidal neovascularization (16.6%).Conclusion: Two distinct tomographic patterns of choroidal ruptures were identified on SD-OCT, which may allow ruptures to be classified into two morphological types. There are morphometric and clinical differences between the two types, which may help to prognosticate visual outcome and anticipate complications following choroidal ruptures.Keywords: SD-OCT, ICR, blunt ocular trauma, choroidal neovascularizationA Letter to the Editor has been received and published for this article.

Manoj Soman,1 Sunil Ganekal,2 Unnikrishnan Nair,1 KGR Nair11Chaithanya Eye Hospital and Research Institute, Trivandrum, Kerala, 2Nayana Superspecialty Eye Hospital and Research Center, Davangere, Karnataka, IndiaBackground: The purpose of this research was to study the association between systemic comorbidity in diabetic serous macular detachment (DSMD) and the effect of different forms of combination therapies in its management.Methods: In this prospective analysis, 34 eyes from 34 patients with DSMD were investigated for the presence of systemic comorbidity including anemia, dyslipidemia, nephropathy, and cardiac disease, and treated with combination therapy of either intravitreal bevacizumab + laser (group 1, n = 14) or intravitreal triamcinolone + laser (group 2, n = 20). Sequential macular laser was done 2 weeks after intravitreal pharmacotherapy in both groups. Outcome measures included visual acuity and central foveal thickness at 1 and 3 months.Results: The mean age of the patients was 55.6 ± 7.6 years. The commonest systemic association was nephropathy (82.3%). In group 1, mean visual acuity improved marginally from 6/17 at baseline to 6/16 at 1 month (P = 0.0001) and was maintained at 3 months (P = 0.008); and mean central foveal thickness decreased from 488.7 µm to 318.7 µm at 1 month (P = 0.0001) but increased to 414.4 µm at 3 months (P = 0.049). In group 2, mean visual acuity improved from 6/22 at baseline to 6/19 at 1 month (P = 0.0001) and 6/12 at 3 months (P = 0.0001); and mean central foveal thickness decreased from 428.8 µm to 323.8 µm at 1 month (P = 0.0001) to 269.2 µm at 3 months (P = 0.0001).Conclusion: Nephropathy should be ruled out in patients with DSMD. Although at 1 month both intravitreal triamcinolone and bevacizumab improved vision and decreased central foveal thickness in eyes with DSMD when administered along with focal laser treatment, the former had a more long-lasting effect in maintaining this gain at 3 months.Keywords: diabetic serous macular detachment, nephropathy, combination therapy

Manoj Soman,1 Sunil Ganekal,2 Unnikrishnan Nair,1 KGR Nair11Chaithanya Eye Hospital and Research Institute, Trivandrum, Kerala, India; 2Nayana Superspecialty Eye Hospital and Research Center, Davangere, Karnataka, IndiaBackground: The purpose of this study was to investigate the effect of panretinal photocoagulation (PRP) on macular morphology and thickness in eyes with proliferative diabetic retinopathy (PDR) and without clinically significant macular edema.Methods: This was a prospective study of 76 eyes from 68 patients diagnosed to have PDR without clinically significant macular edema. Baseline and post PRP visual acuity, morphological changes on optical coherence tomography (OCT), and central foveal thickness were evaluated at one week, one month, and 3 months.Results: The mean patient age was 56.47 ± 6.55 years. Sixty-two eyes (81.58%) had stable or improved vision, while 14 eyes (18.42%) had worsened visual acuity at 3 months. Compared with baseline, mean visual acuity dropped as early as one week but was regained by 3 months. Mean preoperative central foveal thickness was 222.05 ± 59.11 μm, which increased significantly to 266.84 ± 84.67 μm at one week (P = 0.001), and remained higher at 264.05 ± 102.56 μm by one month (P = 0.01) and 256 ± 101.38 μm by 3 months (P = 0.04). Thirty-four percent of eyes with a normal macula showed morphological changes following PRP. The most common morphological change on OCT after PRP was spongy edema, seen in 48 eyes (31.6%), followed by cystoid macular edema in 36 eyes (23.7%), vitreomacular traction in 28 eyes (18.4%), epiretinal membrane in 24 eyes (15.8%), and subfoveal serous detachment in 16 eyes (10.5%).Conclusion: PRP may cause a temporary drop in vision in the early post laser phase, and causes macular morphology/thickness changes in eyes with PDR and without clinically significant macular edema. In this study, the change in central foveal thickness did not correlate with a change in visual acuity, and the type of diabetic macular edema on OCT appeared more relevant and correlated better with the visual outcome.Keywords: panretinal photocoagulation, macular morphology, foveal thickness

Unnikrishnan Nair,1 Sunil Ganekal,2 Manoj Soman,1 KGR Nair11Chaithanya Eye Hospital and Research Institute, Trivandrum, Kerala, India; 2Nayana Super Specialty Eye Hospital and Research Center, Davangere, Karnataka, IndiaPurpose: To evaluate the structural changes in the acute phase of central serous chorioretinopathy and after its resolution, using spectral domain optical coherence tomography, to correlate these tomographic changes with visual acuity (VA).Method: This was a prospective study of 100 consecutive patients with acute central serous chorioretinopathy. It was based on presenting the best-corrected VA, divided into three groups (Group 1, n = 36, VA 6/6; Group 2, n = 49, VA 6/9–6/18; Group 3, n = 15, VA > 6/18). All patients underwent fundus evaluation followed by fluorescein angiography and spectral domain optical coherence tomography.Results: The mean age of the patients was 40 ± 7.17 years. The mean log MAR VA was 0.176 ± 0.0185. Single pigment epithelial detachment (PED), and multiple discrete and multiple confluent PEDs were seen in 21%, 17%, and 32% of the eyes, respectively. The location of the PED was subfoveal in 35% of the eyes. The presence of subretinal fibrin and a rough undersurface of the neurosensory retina were noted in 61% and 64% of the eyes, respectively. On en-face scanning, a break in the walls of the PED and overlying fibrin were seen in 32.8% and 45% of the eyes, respectively. The mean subretinal fluid height at the fovea was 279.11 ± 148.78 µ. The mean outer nuclear layer thickness during the active stage was 95.10 µ and during the resolved stage, it was 77.69 µ (P = 0.012). The average photoreceptor lengths were 73.1 µ, 84.6 µ, and 94.9 µ in groups 1, 2, and 3, respectively, in the acute phase; and 69.5 µ, 70.8 µ, and 61.6 µ, respectively, after resolution (P = 0.013, P = 0.010, and P = 0.011).Conclusion: In the acute phase of the disease, poorer VA showed statistically significant association with greater dimensions of subretinal fluid – particularly, greater subretinal fluid height and thinning of the outer nuclear layer at the fovea. The presence of fibrin, subretinal precipitates, subfoveal location, or type of PED did not have any association with poor VA. In resolved central serous chorioretinopathy, poorer VA was associated with a persistently thinner outer nuclear layer, shorter photoreceptor lengths, and inner and outer segment junction atrophy.Keywords: SD-OCT, acute CSC, ONL thickness, photoreceptor thickness, visual acuity correlation