[Downloaded free from http://www.ijo.in on Wednesday, June 10, 2015, IP: 202.177.173.189]
362
Indian Journal of Ophthalmology
good as SCOLI for intraoperative eye manipulation when surface topical anesthetization was employed.[2] Moreover, as the author mentioned, a 8 mm nuclear necessitated an 8–9 mm incision with sandwich technique; however, it could pass a 7 mm SCOLI through nuclear deformation. The SCOLI technical are applicable to nucleus of different hardness, including brown and black nuclear. For 9 mm diameter nuclear, the limbal incision is enlarged to 8 mm width, with a conjunctival incision of 6 mm. We also use a 7 mm incision joint with chop technique, removing the lens nucleus at twice. In short, we thank Bayramlar et al. for their comments on SCOLI technology; we will try our best to improve the cataract surgical techniques.
Jun Yang, Pinghong Lai1 Department of Ophthalmology, The First People’s Hospital of Yunnan Province, 1Department of Ophthalmology, Jiangxi Provincial People’s Hospital, Nanchang, Jiangxi Province, People's Republic of China Correspondence to: Dr. Pinghong Lai, Aiguo Road 92, Nanchang, Jiangxi Province, People's Republic of China. E-mail: [email protected]
References 1. Bayramlar H, Karadag R, Yildirim A, Cakici O, Sari U. Manual tunnel incision cataract surgery with sandwich technique may be a rationale alternative for mature cataracts. Indian J Ophthalmol 2014;62:896‑7. 2. Yang J, Lai P, Wu D, Long Z. Manual cataract extraction via a subconjunctival limbus oblique incision for mature cataracts. Indian J Ophthalmol 2014;62:274‑8. 3. van Gaalen KW, Jansonius NM, Koopmans SA, Kooijman AC. Comparison of Optical Performance in Eyes Implanted with Aspheric Foldable, Spherical Foldable, and Rigid PMMA IOLs. J Refract Surg 2011;27:98‑105. 4. Shah SK, Praveen MR, Kaul A, Vasavada AR, Shah GD, Nihalani BR. Impact of anterior capsule polishing on anterior capsule opacification after cataract surgery: A randomized clinical trial. Eye (Lond) 2009;23:1702‑6. 5. Aykan U, Bilge AH, Karadayi K, Akin T. The effect of capsulorhexis size on development of posterior capsule opacification: Small (4.5 to 5.0 mm) versus large (6.0 to 7.0 mm). Eur J Ophthalmol 2003;13:541‑5. 6. Bayramlar H, Cekiç O, Totan Y. Manual tunnel incision extracapsular cataract extraction using the sandwich technique. J Cataract Refract Surg 1999;25:312‑5. Access this article online Quick Response Code:
Website: www.ijo.in
Vol. 63 No. 4
Full thickness macular hole following intravitreal ranibizumab injection for diabetic macular edema; a rare complication or coincidence? Dear Sir, Anti‑vascular endothelial growth factors (VEGFs) improved vision and macular edema in patients with diabetic macula edema and reduced the risk of further visual loss. We report a 67‑year‑old woman with type 2 diabetes mellitus who had panretinal photocoagulation for proliferative diabetic retinopathy presented at our department for decreased vision in her right eye (RE). On examination, best corrected visual acuity (BCVA) was 20/400 in the RE. Anterior segment examination was unremarkable and funduscopy of the RE revealed cystoid macular edema (CME). There was no posterior vitreous detachment (PVD) or clinically detectable vitreomacular traction (VMT). Fluorescein angiography of the RE showed late hyperfluorescence in the macular area due to leakage from microaneurysms and areas of increased vascular permeability [Fig. 1]. Optical coherence tomography (OCT) (The Heidelberg Spectralis OCT, Heidelberg Engineering, Inc., Heidelberg, Germany) confirmed the presence of cystoid DME without VMT [Fig. 2]. Central foveal thickness was 830 μm. An informed consent form was taken and intravitreal 0.5 mg ranibizumab injection (Lucentis; Genentech, South San Francisco, CA, USA and Novartis, Basel, Switzerland) was administered without complication. One‑month after the injection of anti‑VEGF, patient complained of newly developed metamorphopsia. BCVA deteriorated to 6/200 and slip‑lamp biomicroscopy revealed a full thickness macular hole (FTMH) with no PVD or VMT. OCT confirmed the presence of a FTHM and no evidence of any areas of partial vitreous separation associated with vitreoretinal adhesions or areas of vitreous traction in any OCT scan [Fig. 3]. Patient underwent pars plana vitrectomy, internal limiting membrane peeling and fluid gas exchange (SF6). One‑month after the surgery there was no FTMH or CME and BCVA improved to 20/200. Anterior‑posterior traction by the vitreous on the macula causes idiopathic FTMH. Pathogenetic mechanism of FTMH associated with macular edema is unclear. A few studies were presented macular hole formation after intravitreal injections for CME.[1‑3] Georgalas et al. postulated that retinal changes due to the massive CME, the absence of PVD in combination with the vitreous traction induced either by the mechanical globe deformation and vitreous synaeresis or by a possible vitreous incarceration at the injection site, could lead to the development of FTMH in central retinal vein occlusion.[1] Lecleire‑Collet et al. have reported a patient with diabetic maculopathy who developed a FTMH after repeated
[Downloaded free from http://www.ijo.in on Wednesday, June 10, 2015, IP: 202.177.173.189]
363
Letters to t he Editor April 2015
intravitreal triamcinolone injections.[2] The authors postulated that repeated intravitreal injections might had an indirect role in the development of FTMH formation by favoring the rupture of distended Müller cells and intraretinal pseudocysts. During breakdown of the blood‑retina barrier, Müller cells become swollen and are eventually lysed. This results in extracellular fluid accumulation in the outer plexiform and inner nuclear layers. Consequently, CME can be caused directly, due to endothelial cell damage, as it occurs in the context of diabetes mellitus may lead to macular hole development.[4] Hussain et al. reported a FTMH after foveal pseudocyst formation in vitrectomized eye and they hypothesised that Muller cell insult was a probable hypothesis of FTMH.[5]
Figure 1: Fluorescein angiography of the eye showing late hyperfluorescence in the macular area
In conclusion, although development of macular hole is a rare adverse effect of the anti‑VEGF injection, this possibility must be kept in mind. Further investigations are required to confirm our results.
Hasan Basri Arifoglu, Arzu Seyhan Karatepe Hashas, Tülay Ersekerci1, Mustafa Atas Kayseri Research and Education Hospital, Kayseri, 1 Finike State Hospital, Antalya, Turkey Correspondence to: Dr. Arzu Seyhan Karatepe Hashas, Kayseri Research and Education Hospital, Kayseri, Turkey. E‑mail: [email protected]
References 1. Georgalas I, Rouvas A, Kotsolis A, Karagiannis D, Ladas I. Full thickness macular hole formation in a patient with cystoid macular edema caused by CRVO treated with intravitreal bevacizicumab. Ophthalmic Surg Lasers Imaging. 2010 Mar 9:1-4. [Epub ahead of print]. Figure 2: Patient optical coherence tomography scan depicting cystoid macular edema without vitreoretinal traction
2. Lecleire‑Collet A, Offret O, Gaucher D, Audren F, Haouchine B, Massin P. Full‑thickness macular hole in a patient with diabetic cystoid macular oedema treated by intravitreal triamcinolone injections. Acta Ophthalmol Scand 2007;85:795‑8. 3. Erdurman FC, Pellumbi A, Durukan AH. Lamellar macular hole formation in a patient with diabetic CME treated by intravitreal bevacizumab injections. Ophthalmic Surg Lasers Imaging 2012;43:e87‑9. 4. Moschos MM, Gatzioufas Z, Rotsos T, Symeonidis C, Song X, Seitz B. Macular hole formation in a patient with Irvine‑Gass syndrome: Coincidence or rare complication? Clin Ophthalmol 2013;7:1437‑9. 5. Hussain N, Hussain A, Natarajan S. Optical coherence tomographic evaluation of foveal pseudocyst in the formation of macular hole. Indian J Ophthalmol 2003;51:353‑5. Access this article online Quick Response Code:
Website: www.ijo.in DOI: 10.4103/0301-4738.158109
Figure 3: Patient optical coherence tomography scan depicting cystoid macular edema and full-thickness macular hole 1-month after intravitreal injection
[Downloaded free from http://www.ijo.in on Wednesday, June 10, 2015, IP: 202.177.173.189]
364
Indian Journal of Ophthalmology
Au t h o r r e s p o n s e : R e p e a t g a s insufflation for successful closure of idiopathic macular hole following failed primary surgery Dear Editor, We appreciate the interest of Goel et al.[1] and their remarks in response to our article “Repeat gas insufflation for successful closure of idiopathic macular hole following failed primary surgery.”[2] We also congratulate them on their success in achieving closure in two cases of primarily failed macular hole closure as shared in their report. They attribute our interpretation of type 2 macular hole closure in a case with residual foveal defect and cuff of subretinal fluid as incorrect. This needs some clarification. Tornambe et al. have classified macular hole surgery outcomes into three possible situations: Elevated/open, flat/open and flat/closed.[3] The first two situations are recognized as type 2 closure while the third situation is considered as type 1 closure; presence/absence of residual foveal defect being the prime determinant. We would like to reemphasize that the focus of our report was on factors related to the closure of idiopathic macular hole following failed primary surgery. Preoperative optical coherence tomography configuration of the macular hole can offer predictive clues to successful re‑surgery.[4] We again thank Goel et al. for bringing up this point thus helping generate clarity on this issue.
Vol. 63 No. 4
Pukhraj Rishi, Sumanth Reddy, Ekta Rishi Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, Chennai, Tamil Nadu, India Correspondence to: Dr. Pukhraj Rishi, Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, 18 College Road, Chennai - 600 006, Tamil Nadu, India. E-mail: [email protected]
References 1. Goel N, Prakash A, Gupta AK. Repeat fluid‑ gas exchange for failed primary macular hole surgery. Indian J Ophthalmol 2014;62:1104‑5. 2. Rishi P, Reddy S, Rishi E. Repeat gas insufflation for successful closure of idiopathic macular hole following failed primary surgery. Indian J Ophthalmol 2014;62:363‑5. 3. Tornambe PE, Poliner LS, Cohen RG. Definition of macular hole surgery end points: Elevated/open, flat/open, flat/closed. Retina 1998;18:286‑7. 4. Hoerauf H. Predictive values in macular hole repair. Br J Ophthalmol 2007;91:1415‑6.
Access this article online Quick Response Code:
Website: www.ijo.in
Copyright of Indian Journal of Ophthalmology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
362
Indian Journal of Ophthalmology
good as SCOLI for intraoperative eye manipulation when surface topical anesthetization was employed.[2] Moreover, as the author mentioned, a 8 mm nuclear necessitated an 8–9 mm incision with sandwich technique; however, it could pass a 7 mm SCOLI through nuclear deformation. The SCOLI technical are applicable to nucleus of different hardness, including brown and black nuclear. For 9 mm diameter nuclear, the limbal incision is enlarged to 8 mm width, with a conjunctival incision of 6 mm. We also use a 7 mm incision joint with chop technique, removing the lens nucleus at twice. In short, we thank Bayramlar et al. for their comments on SCOLI technology; we will try our best to improve the cataract surgical techniques.
Jun Yang, Pinghong Lai1 Department of Ophthalmology, The First People’s Hospital of Yunnan Province, 1Department of Ophthalmology, Jiangxi Provincial People’s Hospital, Nanchang, Jiangxi Province, People's Republic of China Correspondence to: Dr. Pinghong Lai, Aiguo Road 92, Nanchang, Jiangxi Province, People's Republic of China. E-mail: [email protected]
References 1. Bayramlar H, Karadag R, Yildirim A, Cakici O, Sari U. Manual tunnel incision cataract surgery with sandwich technique may be a rationale alternative for mature cataracts. Indian J Ophthalmol 2014;62:896‑7. 2. Yang J, Lai P, Wu D, Long Z. Manual cataract extraction via a subconjunctival limbus oblique incision for mature cataracts. Indian J Ophthalmol 2014;62:274‑8. 3. van Gaalen KW, Jansonius NM, Koopmans SA, Kooijman AC. Comparison of Optical Performance in Eyes Implanted with Aspheric Foldable, Spherical Foldable, and Rigid PMMA IOLs. J Refract Surg 2011;27:98‑105. 4. Shah SK, Praveen MR, Kaul A, Vasavada AR, Shah GD, Nihalani BR. Impact of anterior capsule polishing on anterior capsule opacification after cataract surgery: A randomized clinical trial. Eye (Lond) 2009;23:1702‑6. 5. Aykan U, Bilge AH, Karadayi K, Akin T. The effect of capsulorhexis size on development of posterior capsule opacification: Small (4.5 to 5.0 mm) versus large (6.0 to 7.0 mm). Eur J Ophthalmol 2003;13:541‑5. 6. Bayramlar H, Cekiç O, Totan Y. Manual tunnel incision extracapsular cataract extraction using the sandwich technique. J Cataract Refract Surg 1999;25:312‑5. Access this article online Quick Response Code:
Website: www.ijo.in
Vol. 63 No. 4
Full thickness macular hole following intravitreal ranibizumab injection for diabetic macular edema; a rare complication or coincidence? Dear Sir, Anti‑vascular endothelial growth factors (VEGFs) improved vision and macular edema in patients with diabetic macula edema and reduced the risk of further visual loss. We report a 67‑year‑old woman with type 2 diabetes mellitus who had panretinal photocoagulation for proliferative diabetic retinopathy presented at our department for decreased vision in her right eye (RE). On examination, best corrected visual acuity (BCVA) was 20/400 in the RE. Anterior segment examination was unremarkable and funduscopy of the RE revealed cystoid macular edema (CME). There was no posterior vitreous detachment (PVD) or clinically detectable vitreomacular traction (VMT). Fluorescein angiography of the RE showed late hyperfluorescence in the macular area due to leakage from microaneurysms and areas of increased vascular permeability [Fig. 1]. Optical coherence tomography (OCT) (The Heidelberg Spectralis OCT, Heidelberg Engineering, Inc., Heidelberg, Germany) confirmed the presence of cystoid DME without VMT [Fig. 2]. Central foveal thickness was 830 μm. An informed consent form was taken and intravitreal 0.5 mg ranibizumab injection (Lucentis; Genentech, South San Francisco, CA, USA and Novartis, Basel, Switzerland) was administered without complication. One‑month after the injection of anti‑VEGF, patient complained of newly developed metamorphopsia. BCVA deteriorated to 6/200 and slip‑lamp biomicroscopy revealed a full thickness macular hole (FTMH) with no PVD or VMT. OCT confirmed the presence of a FTHM and no evidence of any areas of partial vitreous separation associated with vitreoretinal adhesions or areas of vitreous traction in any OCT scan [Fig. 3]. Patient underwent pars plana vitrectomy, internal limiting membrane peeling and fluid gas exchange (SF6). One‑month after the surgery there was no FTMH or CME and BCVA improved to 20/200. Anterior‑posterior traction by the vitreous on the macula causes idiopathic FTMH. Pathogenetic mechanism of FTMH associated with macular edema is unclear. A few studies were presented macular hole formation after intravitreal injections for CME.[1‑3] Georgalas et al. postulated that retinal changes due to the massive CME, the absence of PVD in combination with the vitreous traction induced either by the mechanical globe deformation and vitreous synaeresis or by a possible vitreous incarceration at the injection site, could lead to the development of FTMH in central retinal vein occlusion.[1] Lecleire‑Collet et al. have reported a patient with diabetic maculopathy who developed a FTMH after repeated
[Downloaded free from http://www.ijo.in on Wednesday, June 10, 2015, IP: 202.177.173.189]
363
Letters to t he Editor April 2015
intravitreal triamcinolone injections.[2] The authors postulated that repeated intravitreal injections might had an indirect role in the development of FTMH formation by favoring the rupture of distended Müller cells and intraretinal pseudocysts. During breakdown of the blood‑retina barrier, Müller cells become swollen and are eventually lysed. This results in extracellular fluid accumulation in the outer plexiform and inner nuclear layers. Consequently, CME can be caused directly, due to endothelial cell damage, as it occurs in the context of diabetes mellitus may lead to macular hole development.[4] Hussain et al. reported a FTMH after foveal pseudocyst formation in vitrectomized eye and they hypothesised that Muller cell insult was a probable hypothesis of FTMH.[5]
Figure 1: Fluorescein angiography of the eye showing late hyperfluorescence in the macular area
In conclusion, although development of macular hole is a rare adverse effect of the anti‑VEGF injection, this possibility must be kept in mind. Further investigations are required to confirm our results.
Hasan Basri Arifoglu, Arzu Seyhan Karatepe Hashas, Tülay Ersekerci1, Mustafa Atas Kayseri Research and Education Hospital, Kayseri, 1 Finike State Hospital, Antalya, Turkey Correspondence to: Dr. Arzu Seyhan Karatepe Hashas, Kayseri Research and Education Hospital, Kayseri, Turkey. E‑mail: [email protected]
References 1. Georgalas I, Rouvas A, Kotsolis A, Karagiannis D, Ladas I. Full thickness macular hole formation in a patient with cystoid macular edema caused by CRVO treated with intravitreal bevacizicumab. Ophthalmic Surg Lasers Imaging. 2010 Mar 9:1-4. [Epub ahead of print]. Figure 2: Patient optical coherence tomography scan depicting cystoid macular edema without vitreoretinal traction
2. Lecleire‑Collet A, Offret O, Gaucher D, Audren F, Haouchine B, Massin P. Full‑thickness macular hole in a patient with diabetic cystoid macular oedema treated by intravitreal triamcinolone injections. Acta Ophthalmol Scand 2007;85:795‑8. 3. Erdurman FC, Pellumbi A, Durukan AH. Lamellar macular hole formation in a patient with diabetic CME treated by intravitreal bevacizumab injections. Ophthalmic Surg Lasers Imaging 2012;43:e87‑9. 4. Moschos MM, Gatzioufas Z, Rotsos T, Symeonidis C, Song X, Seitz B. Macular hole formation in a patient with Irvine‑Gass syndrome: Coincidence or rare complication? Clin Ophthalmol 2013;7:1437‑9. 5. Hussain N, Hussain A, Natarajan S. Optical coherence tomographic evaluation of foveal pseudocyst in the formation of macular hole. Indian J Ophthalmol 2003;51:353‑5. Access this article online Quick Response Code:
Website: www.ijo.in DOI: 10.4103/0301-4738.158109
Figure 3: Patient optical coherence tomography scan depicting cystoid macular edema and full-thickness macular hole 1-month after intravitreal injection
[Downloaded free from http://www.ijo.in on Wednesday, June 10, 2015, IP: 202.177.173.189]
364
Indian Journal of Ophthalmology
Au t h o r r e s p o n s e : R e p e a t g a s insufflation for successful closure of idiopathic macular hole following failed primary surgery Dear Editor, We appreciate the interest of Goel et al.[1] and their remarks in response to our article “Repeat gas insufflation for successful closure of idiopathic macular hole following failed primary surgery.”[2] We also congratulate them on their success in achieving closure in two cases of primarily failed macular hole closure as shared in their report. They attribute our interpretation of type 2 macular hole closure in a case with residual foveal defect and cuff of subretinal fluid as incorrect. This needs some clarification. Tornambe et al. have classified macular hole surgery outcomes into three possible situations: Elevated/open, flat/open and flat/closed.[3] The first two situations are recognized as type 2 closure while the third situation is considered as type 1 closure; presence/absence of residual foveal defect being the prime determinant. We would like to reemphasize that the focus of our report was on factors related to the closure of idiopathic macular hole following failed primary surgery. Preoperative optical coherence tomography configuration of the macular hole can offer predictive clues to successful re‑surgery.[4] We again thank Goel et al. for bringing up this point thus helping generate clarity on this issue.
Vol. 63 No. 4
Pukhraj Rishi, Sumanth Reddy, Ekta Rishi Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, Chennai, Tamil Nadu, India Correspondence to: Dr. Pukhraj Rishi, Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, 18 College Road, Chennai - 600 006, Tamil Nadu, India. E-mail: [email protected]
References 1. Goel N, Prakash A, Gupta AK. Repeat fluid‑ gas exchange for failed primary macular hole surgery. Indian J Ophthalmol 2014;62:1104‑5. 2. Rishi P, Reddy S, Rishi E. Repeat gas insufflation for successful closure of idiopathic macular hole following failed primary surgery. Indian J Ophthalmol 2014;62:363‑5. 3. Tornambe PE, Poliner LS, Cohen RG. Definition of macular hole surgery end points: Elevated/open, flat/open, flat/closed. Retina 1998;18:286‑7. 4. Hoerauf H. Predictive values in macular hole repair. Br J Ophthalmol 2007;91:1415‑6.
Access this article online Quick Response Code:
Website: www.ijo.in
Copyright of Indian Journal of Ophthalmology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
