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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

Unnikrishnan Nair, 1, 2 Ashwin Mohan, 1, 2 Manoj Soman 1, 2 1Department of Vitreo-Retina, Chaithanya Eye Hospital and Research Institute, Trivandrum, India; 2CITE, Trivandrum, IndiaCorrespondence: Ashwin Mohan Email research@chaithanya.orgAim: 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.Keywords: plume, CME, fibrin, vertical, expansion

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 neovascularization

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