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an early sign of chiasmal pathology. With an early diagnosis and subsequent treatment, a complete restoration of visual function was achieved in this case, stressing the importance of early recognition of the disease. We are unaware of previous reports regarding localized bi-superonasal ME secondary to a pituitary adenoma and could find no references to it in the medical literature. Studies including a cohort of patients are warranted for the evaluation of these tomographic findings. In conclusion, it is important to suspect pituitary adenoma in cases of VF deficit and OCT macular alterations.
References 1. Foroozan R. Chiasmal syndromes. Curr Opin Ophthalmol 2003;14:325-31. 2. Monteiro ML, Leal BC, Rosa AA, Bronstein MD. Optical coherence tomography analysis of axonal loss in band atrophy of the optic nerve. Br J Ophthalmol 2004;88:896-9. 3. Lederer DE, Schuman JS, Hertzmark E, Heltzer J, Velazques LJ, Fujimoto JG, et al. Analysis of macular volume in normal and glaucomatous eyes using optical coherence tomography. Am J
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Ophthalmol 2003;135:838-43. 4. Medeiros FA, Zangwill LM, Bowd C, Vessani RM, Susanna R Jr, Weinreb RN. Evaluation of retinal nerve fiber layer, optic nerve head, and macular thickness measurements for glaucoma detection using optical coherence tomography. Am J Ophthalmol 2005;139:44-55. 5. Knox DL, Eagle RC Jr, Green WR. Optic nerve hydropic axonal degeneration and blocked retrograde axoplasmic transport: Histopathologic features in human high-pressure secondary glaucoma. Arch Ophthalmol 2007;125:347-53. 6. Johnson CA. Frequency doubling technology perimetry for neuroophthalmological diseases. Br J Ophthalmol 2004;88:1232-3. 7. Monteiro ML, Medeiros FA, Ostroscki MR. Quantitative analysis of axonal loss in band atrophy of the optic nerve using scanning laser polarimetry. Br J Ophthalmol 2003;87:32-7. Cite this article as: Lavaque AJ, Yilmaz T, Cordero-Coma M. Localized bi-nasal macular edema in optic chiasmal syndrome. Indian J Ophthalmol 2013;61:351-2. Source of Support:Nil. Conflict of Interest: None declared.
Different treatment modalities for choroidal neovascularization in two eyes of one patient with bilateral type 2A parafoveal telangiectasia
and LE stage 5, choroidal neovascularization (CNVM) was made. The patient was treated with photodynamic therapy (PDT) in LE. The visual acuity improved to 20/40 over the next 6 months. At a 4-year follow-up, he developed decreased vision in RE diagnosed as IMT with CNV and was treated with intravitreal ranibizumab. At 6-month follow-up post injection, the vision was 20/40p.
Vivek Dave, Jay Chhablani, Raja Narayanan
Key words: Choroidal neovascular membrane, idiopathic macular telangiectasia, photodynamic therapy, ranibizumab
A 60-year-old diabetic man presented with a history of decrease in vision in both eyes since 2 weeks. At presentation, best corrected visual acuity (BCVA) in the right eye (RE) was 20/30 and that in the left eye (LE) was 20/80. The right fundus revealed a grayish reflex, yellowish crystalline deposits and retinal pigment epithelial hyperplasia at the macula. The left fundus showed subretinal fluid and temporal subretinal hemorrhage near a grayish reflex at the macula. A diagnosis in both eyes of idiopathic macular telangiectasia (IMT) type 2A with RE stage 4 Access this article online Quick Response Code:
Website: www.ijo.in DOI: 10.4103/0301-4738.99851 PMID: ***
Smt. Kanuri Santhamma Retina Vitreous Service, LV Prasad Eye Institute, Kallam Anji Reddy Campus, Banjara Hills, Hyderabad, India Correspondence to: Dr. Raja Narayanan, Smt. Kanuri Santhamma Retina Vitreous Service, LV Prasad Eye Institute, Kallam Anji Reddy Campus, Banjara Hills, Hyderabad – 500 034, India. E-mail:
[email protected] Manuscript received: 23.06.10; Revision accepted: 28.12.10
Idiopathic macular telangiectasia (IMT) was first described by Gass et al.[1] They described three groups of the disease: Group 1 being congenital familial, Group 2 being acquired and Group 3 being obliterative associated with central nervous system vasculopathy. Yannuzzi termed this entity as idiopathic macular telangiectasia with two distinct types (type I or aneurysmal telangiectasia and type II or perifoveal telangiectasia) for better understanding of the disease.[2] The third type, obliterative telangiectasia, was omitted. Most patients retain excellent visual acuity for many years. As less than 5% of all cases of IMT undergo significant visual loss, observation is prudent in most cases. Multiple treatment modalities for treatment of choroidal neovascularization (CNV) secondary to IMT have been reported. We report a case of bilateral IMT with successive development of CNV in both the eyes. The patient was treated with photodynamic therapy (PDT) in one eye and with intravitreal ranibizumab in the other with satisfactory visual outcomes in both the eyes.
Case Report A 60-year-old man presented with a history of decrease in vision in the left eye (LE) for last 15 days. He was a known diabetic on treatment since past 10 years. On examination, his best corrected visual acuity (BCVA) in the right eye (RE) was 20/30 and that in LE was 20/80. Anterior segment examination was unremarkable except nuclear sclerosis grade 1 in both eyes (BE). Fundus examination RE revealed grayish retina temporal to fovea, about 500 µm wide, with multiple
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Indian Journal of Ophthalmology
yellowish crystalline deposits and pigments. The left fundus examination showed the presence of subretinal fluid with subretinal hemorrhage measuring about 400 µm in width. A clinical diagnosis of RE type 2A stage 4 IMT and LE type 2A stage 5 IMT was made. The clinical findings were confirmed on optical coherence tomography (OCT) and fundus fluorescein angiography (FFA) [Fig. 1]. The patient underwent PDT (greatest linear dimension of 1310 µm, a spot size of 2310 µm) as per the standard protocol. At 1 month of follow-up, LE BCVA was maintained at 20/80 with resolution of subretinal fluid and hemorrhage on fundus examination. FFA showed no signs of activity in the LE. The patient was on regular follow-up with stable findings [Fig. 2]. At 4 years of follow-up, he presented with complaints of decrease in vision in RE since the past 4 weeks. The BCVA in the RE was 20/80 and in the LE was 20/40. RE fundus examination revealed the presence of subretinal hemorrhage temporal to the fovea about 300 µm in size and LE scarred membrane. FFA confirmed the activity in RE and scarring in LE [Fig. 3]. The patient received two consecutive monthly
Figure 1: Left eye fundus photograph showing stage 5 idiopathic macular telangiectasia (IMT) confirmed on optical coherence tomogram (OCT) and fundus fluorescein angiography (FFA)
Figure 3: Right eye fundus photograph showing stage 5 idiopathic macular telangiectasia (IMT) confirmed on optical coherence tomogram (OCT) and fundus fluorescein angiography (FFA)
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intravitreal ranibizumab (Lucentis) injections 0.5 mg/0.05 ml in RE. At 1-month follow-up following the second injection, his RE BCVA improved to 20/40 with decrease in retinal thickness on OCT. Improved visual acuity and clinical findings including bilateral macular scar with a vision of 20/40 was maintained till the 6th month follow-up [Fig. 4].
Discussion Treatment of CNV associated with IMT has always been controversial. Multiple treatment modalities including laser photocoagulation, intravitreal triamcinolone, and transpupillary thermotherapy have been reported. Hussain et al., in a prospective interventional case series of 121 eyes with CNV due to IMT, showed effective stabilization of vision over a 1-year follow-up.[3] Recently, antivascular endothelial growth factor (VEGF) drugs have been used in exudative macular disorders with considerable success. Issa et al. in an 18-month follow-up showed decreased fluorescein leakage, decreased central macular thickness and improved visual acuity with intravitreal
Figure 2: Resolution of the choroidal neovascular membrane (CNVM) post photodynamic therapy (PDT) therapy
Figure 4: Resolution of the choroidal neovascular membrane (CNVM) post intravitreal ranibizumab
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bevacizumab (Avastin) although the effect was temporary with a rebound at 3–4 months post injection.[4] Combined PDT with ranibizumab for CNV following IMT has been described in an isolated case report by Rishi et al., wherein at a 16-week follow-up, there was regression of subretinal fluid with a two line vision gain on Snellen charts which was maintained till a 9-month follow-up.[5] In this report, we describe a patient with bilateral CNV secondary to IMT treated in one eye with PDT and in the other eye with intravitreal ranibizumab (Lucentis). Both the treatment modalities were successful in visual improvement. Retinal pigment epithelium damage caused by PDT needs a concerned approach. To the best of our knowledge, this is the first case of treatment of a CNV associated with IMT with ranibizumab alone. Further studies are warranted to establish the role of anti-VEGF with or without PDT for the treatment for CNV secondary to IMT.
References 1. Gass JD, Oyakawa RT. Idiopathic juxtafoveolar retinal telangiectasis.
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Arch Ophthalmol 1982;100:769-80. 2. Yannuzzi LA, Bardal AM, Freund B, Chen KJ, Eandi CM, Blodi B. Idiopathic macular telangiectasia. Arch Ophthalmol 2006;124: 450-60. 3. Hussain N, Das T, Khanna R, Mohan Ram LS, Sumasri K. One year results of verteporfin therapy for subretinal neovascularization associated with type 2A parafoveal telangiectasia. Clin Ophthalmol 2007;1:483-8. 4. Issa P, Finger R, Holz F, Scholl H. Eighteen-month followup of intravitreal bevacizumab in type 2 idiopathic macular telangiectasia. Br J Ophthalmol 2008;92:941-5. 5. Rishi P, Shroff D, Rishi E. Combined photodynamic therapy and intravitreal ranibizumab as primary treatment for subretinal neovascular membrane associated with type 2 idiopathic macular telangiectasia. Graefes Arch Clin Exp Ophthalmol 2008;246:619-21.
Cite this article as: Dave V, Chhablani J, Narayanan R. Different treatment modalities for choroidal neovascularization in two eyes of one patient with bilateral type 2A parafoveal telangiectasia. Indian J Ophthalmol 2013;61:353-4. Source of Support:Nil. Conflict of Interest: None declared.
Conjunctival erosion after glaucoma drainage device surgery: A feasible option
another for providing tectonic durability in the long term. In this report, we present a case of neovascular glaucoma, who developed conjunctival melting over the tube of an Ahmed Glaucoma Valve implant and was successfully managed with Cap Doxycycline.
Suneeta Dubey, Baswati Prasanth, Manisha C Acharya, Ritesh Narula
Key words: Ahmed Glaucoma Valve, conjunctival erosion, Doxycycline
Glaucoma drainage devices (GDDs) have been used in the management of complicated glaucomas. GDDs are associated with various complications such as tube migration, tube or plate exposure or extrusion, ocular motility disturbance and infection. Erosion of conjunctiva and exposure of the GDD remains a risk factor for the development of endophthalmitis. A wide range of materials have been used for this purpose, including sclera, dura, pericardium, fascia lata and cornea. However, there is no evidence to prove that any of these methods is superior to
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Website: www.ijo.in DOI: 10.4103/0301-4738.99852 PMID: ***
Department of Opthalmology, Dr. Shroff Charity Eye Hospital, 5027, Kedarnath Road, Daryaganj, New Delhi, India Correspondence to: Dr. Baswati Prasanth, Dr. Shroff Charity Eye Hospital 5027, Kedarnath Road, Daryaganj, New Delhi – 110 002, India. E-mail:
[email protected] Manuscript received: 29.06.10; Revision accepted: 22.06.11
Glaucoma drainage devices (GDDs) have been used in the management of complicated glaucomas, with a success rates of 22–97% in neovascular glaucoma (NVG).[1,2] Amongst the various complications associated with GDD,[3] erosion of conjunctiva and exposure of the GDD remains a risk factor for endophthalmitis. In a series of 542 eyes, conjunctival erosion overlying the Ahmed Glaucoma valve AGV was present in six of the nine eyes that developed endophthalmitis,[4] thereby emphasizing on providing a durable coverage for exposed GDD. Hence, it is critical to choose an ideal material for the coverage of exposed GDD amongst the wide range of materials available,[5-7] with no evidence to prove the superiority of any for providing tectonic durability in the long term.[8] In this, we present a case of NVG who developed conjunctival melting over the tube of an Ahmed Valve implant and was successfully managed with Cap Doxycycline.
Case Report A 69-year-old male, known case of chronic angle closure glaucoma with advanced glaucomatous neuropathy, was on medical management for his raised intraocular pressures. He was highly noncompliant with his medications and subsequently went on to develop vascular occlusions (superotemporal branched retinal vascular occlusion in the right eye and central retinal vascular occlusion in the left eye) due to sustained high intraocular pressures in both his eyes in a sequential manner followed by NVG in the left eye.
