Diabetic Retinopathy & Medical Retina - aioseducation

Diabetic Ratinopathy 

and Medical Retina 

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DIABETIC RETINOPATHY AND MEDICAL RETINA 

Combined SD OCT, FA and ICGA Features of Idiopathic Central Serous 

Chorioretinopathy (ICSC)................................................................................. 855 

Dr. Navneet Mehrotra, Dr. Manish Nagpal, Dr. Gaurav Paranjpe, Dr. Jainendra 

Shivdas Rahud 

Comprehensive Modern Classification of Diabetic Retinopathy................ 861 

Dr. A.K. Dubey, Dr. Benu Dubey 

23G Vs 20G in the Management of Advanced PDR with and without the Use 

of Intravitreal Avastin....................................................................................... 864 

Dr. Saraswathy Karnati, Dr. Agarwal Amar, Dr. Soosan Jacob 

A Combined 3D Spectral OCT/SLO Topography and Microperimetry – A Step 

Ahead Investigation in DME............................................................................ 865 

Dr. Saurabh Kapoor, Dr. Rupam Desai, Dr. O P Billore, Dr. Jigisha Randeri 

Two Year Follow-up of a Randomized Trial Comparing Intravitreal 

Bevacizumab Alone or Combined with Triamcinolone Vs. Macular 

Photocoagulation in Diabetic Macular Edema.............................................. 868 

Dr. Meena Chakrabarti, Dr. Sonia Rani John, Dr. Arup Chakrabarti 

Prevalence and Risk Factors for Diabetic Retinopathy in Young Diabetic 

Subjects in South India.................................................................................... 873 

Dr. R. Rajalakshmi, Dr. V. Mohan, Dr. M. Rema 

Evaluation of Pattern Erg, Ph Nr, Osc. Potential and 30Hz Flicker in Diabetic 

Retinopathy ...................................................................................................... 878 

Dr. J.L.Goyal, Dr. Babita Karothia, Dr. Ritu Arora, Dr. Basudeb Ghosh 

Investigation into The Levels of VEGF, PEDF and Other Biochemical 

Parameters in Diabetic Retinopathy............................................................... 880 

Dr. Mohammad Arif Mulla, Dr. Gopal Lingam, Dr. Angayarkanni N., Dr. Kaviarasan 

Evaluation of Pattern Electroretinogram in Central Serous Retinopathy....883 

Dr. J. L. Goyal, Dr. Vishram Anil Sangit, Dr. Basudev Ghosh, Dr. Gaurav Goyal 

Outcome of Proliferative Diabetic Retinopathy Surgery with Pre-operative 

Bevacizumab as an Adjuvant.......................................................................... 886 

Dr. Mahesh G., Dr. Giridhar A., Dr. Thomas Tachil, Dr. Rameez Hussain 

Phacoemulsification with Intravitreal Triamcinolone Acetonide Injection in 

Diabetic Macular Edema and Cataract........................................................... 890 

Dr. Shikha Talwar Bassi, Dr. Ekta Rishi, Dr. Vineet Ratra, Dr. Jayant Kadaskar 

847

Diabetic Retinopathy and Medical Retina Free Papers 

DIABETIC RETINOPATHY AND MEDICAL RETINA 

Chairman: Dr. Tewari H.K.; Co-Chairman: Dr. Mary Varghese 

Convenor: Dr. Muralidhar N.S.; Moderator: Dr. Rajamohan M. 

Combined SD OCT, FA and ICGA Features of 

Idiopathic Central Serous Chorioretinopathy 

(ICSC) 

Dr. Navneet Mehrotra, Dr. Manish Nagpal, Dr. Gaurav Paranjpe, 

Dr. Jainendra Shivdas Rahud 

Central serous chorioretinopathy is a sporadic self – limited disease of 

unknown cause that affects predominantly men, usually during the fourth 

and fifth decade of the life. It is characterized by a blister like neurosensory and 

retinal pigment epithelial detachment in the posterior pole of the eye – usually 

involving the macular retina. 1 CSC symptomatically manifests in one eye and 

is bilateral at initial presentation in 5% to 18% of cases. 2-5 Although there is 

documentation of findings suggestive of CSC by fluorescein angiography (FA) 

and by indocyanine green angiography (ICGA) in the fellow asymptomatic 

eyes in several reports, only a few studies have primarily analysed these 

findings. 6-18 Nadelet al 19 after analysis of 69 cases observed pathology (clinical 

and/or fluorescein angiography) in 50% of the fellow asymptomatic eyes. 

Although the recovery of visual acuity is upto the normal level, the quality 

of vision is not the same as before. The patient may noticemetamorphopsia, 

decrease in contrast sensitivity and alteration in the color vision in the affected 

eye for several months (Gas et. al. 1967). 

Eyes with acute central serous chorioretinopathy (CSC) have focal leakage at the 

level of the retinal pigment epithelium (RPE) seen on fluorescein angiography 

(FA). Indocyanine green angiography in eyes with CSC shows multiple areas 

of inner choroidal staining. 17 OCT reveals many anatomical aspects of CSC 

ranging from subsensory fluid, pigment epithelial detachment (PED) and 

retinal atrophy in cases of chronic CSC. With Fourier domain OCT (FD-OCT) 

dense scans could be passed through the site of leakage which depicts the 

various pathologic features like PED and pigment layer irregularities. We did 

simultaneous fluorescein angiography, indocyanine green angiography and 

OCT to get additional information about the morphologic changes at the site 

of leakage and changes in the fellow eyes in these cases. 

MATERIALS AND METHODS 

We prospectively studied 96 eyes of 48 patients with acute CSC with Heidelberg 

retinal angiograph (HRA) (Heidelberg Engineering Inc., Heidelberg, Germany) 

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70th AIOC Proceedings, Cochin 2012 

between September 2010 and July 2011 at Retina Foundation, Ahmedabad. 

This study was approved by the institutional review board, and informed 

consent was obtained from all patients. 

A diagnosis of acute CSC was made based on the presence of a serous 

detachment of the neurosensory retina, focal dye leakage on FA, and the 

duration of recent subjective symptoms within 3 months. Polypoidalchoroidal 

vasculopathy, which is sometimes difficult to differentiate from CSC by FA, 

was excluded by the absence of polypoidalchoroidal vascular lesions on 

indocyanine green angiography. Eyes with other macular abnormalities and 

neovascularlesions were excluded. A fundus examination, measurement of 

the best-corrected visual acuity (BCVA), and SD OCT imaging were performed 

atevery visit. Simultaneous fluorescein and indocyanine green angiography 

were performed using HRA. 

A fundus examination and measurement of the best-corrected visual acuity 

(BCVA) were performed at every visit. Simultaneous fluorescein angiography, 

indocyanine green angiography, autofluorescence and OCT were done in the 

first visit. OCT passing through the areas of leakage was taken as a reference 

and repeated later in each visit. 

Detailed horizontal OCT scans with 49 sections, 30 microns apart were passed 

through the site of leakage. An area of 15 deg x 5 deg on the retina was scanned. 

For simultaneous confocal scanning laser angiography, we inject 1.5 ml of the 

solution prepared from mixing 3 ml of 20% fluorescein to indocyanine green 

powder (25 mg). The mixture was injected as a bolus into the vein. After we 

recorded preinjection images,simultaneous angiograms were obtained during 

the early, mid and late phases. 

RESULTS 

Patient characteristics 

96 eyes of 48 patients of ICSC underwent imaging using spectralis of which 

included 43 males and 5 females. The mean age of the 48 patients was 40.8 years 

(range - 25 - 63). The duration of symptoms ranged from 2 days to 6 months. Three 

eyes had recurrent disease, and 8 patients had CSC in the fellow eye. The mean 

BCVA at baseline was 0.3(on log mar scale). Forty two eyes (75%) showed ink blot 

pattern of leakage, six eyes (10.7%) showed smokestack pattern and eight eyes 

(14.3%) showed no definite leak in angiogram. 34 eyes had one leakage point, 

seven eyes had two leakage points and three eyes had more than two leakage 

points. The indocyanine green angiography showed increased hyperfluorescence 

of the choroidal vein around the leakage site in all eyes. 

Mean number of examinations in the follow up period were 3.6 (range: 2-7). 

Laser photocoagulation was done in 30 patients. 

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Findings at baseline 

At the initial visit a detachment of the neurosensory retina was confirmed by 

OCT examination in all patients. Among total 57 leakage sites in 96 eyes, 22 

points (38.6%) showed retinal PED , and 35 eyes(61.4%) showed an irregular 

RPE layer at the site of leakage. Defect in the RPE layer within the PED was 

observed in 15 leakage sites and those defects exactly corresponded to the 

leakage points. In 14 cases the defect was located at the margin of the PED 

except in one case in which it was noticed at the centre of the PED. In 6 cases 

the PED was irregular. 3 leakage points (5.26%) were underlying a blood vessel. 

Pigmentary changes were noticed in fluorescein angiography in the affected 

eye in 25 cases (52.08%), more widespread and extensive pigmentary changes 

were noticed in 41 eyes (72%) in ICG. In 18 of 57 leakage sites (31.6%), a 

hyperreflective shadow suggesting fibrin in the subretinal space was observed 

around theleakage point. In 17 leakage sites (29.82%), sagging of the posterior 

layer of the neurosensory retina was observed . 

Pigmentary changes during fluorescein angiography in the fellow eye was 

noticed in 23 eyes (48%) and in 30 eyes (62.5%) during indocyanine green 

angiography. PED was noticed in the fellow eye in 12 cases (25%). 

Findings on follow up 

Mean follow up period was days 121 days (range: 28–163 days). At the final 

follow up mean visual acuity was 0.18. At the final examination, complete 

resolution of the SRF was confirmed in all eyes, although PED remained at 

the 5 leakage sites. 1 patient had recurrence in the affected eye after resolution 

of subretinal fluid. Average duration of disappearance of subretinal fluid 

was. Highly reflective substances began to disappear with resolution of 

detachment. Fibrinous exudation also disappeared with attachment of retina. 

The line probably corresponded to the junction of the photoreceptor inner 

and outer segments (IS/OS), which was invisible in the detached retina and 

became apparent after the fluid resolved. The VA did not appear to correlate 

with the presence of irregularities of the IS/OS at the fovea. 

Findings in cases with no definite leak 

6 eyes showed no definite leak on fluorescein angiography. 1 patient had 

PED and 5 patients had pigmentary irregularities on OCT. 4 eyes showed 

pigmentary alterations outside the CSC. 5 eyes showed pigmentary changes 

in ICG extensive than that seen n FA. 

DISCUSSION 

Spectral-domain (SD) OCT system is an advanced ophthalmic imaging that 

reduces the image acquisition time and allows the entire area of interest to be 

imaged on a detailed retinal structural map. 

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The most obvious advantage of truly simultaneous imaging is the negation of 

the possibility that one of the angiogram is of the higher quality as compared 

to the other, which may lead to differences in visualization of the pathological 

states. The other significant advantage of the simultaneous angiography 

technique is the time sequence correlation. Both the dyes are injected and, 

therefore, imaged simultaneously. Therefore, the physiological differences 

in their distribution and circulation through the eye are easily discernible. 

Furthermore, the differences in response to the pathological states of the 

retinal and choroidal circulation are made obvious and are readily comparable. 

Thus, the relative value of each type of dye in normal physiology and different 

disease processes becomes apparent, which is relevant for both clinical and 

research purposes. 

Lastly the time required to perform the entire study is considerably shorter. 

Patient compliance and investigator‘s ease are noteworthy. 

HRA has an added advantage of simultaneously carrying out the OCT with 

FA or ICG. It gives additional information of the pathology. The ability to scan 

images at 40 kHz help reduce eye movement artifacts and increases patient 

comfort, providing cleaner images. TruTrack image alignment technology 

provides eye tracking and guiding of the SD-OCT. This feature aligns 

images in the same examination and finds the same location in subsequent 

examinations to track subtle changes over time. 

Fluorescein angiography has always been a gold standard investigation in 

cases of CSC. It reveals two main types of leaks inkblot pattern and smokestack 

type. No definite leak was seen in 19% 21 of cases in a study than 12% in our 

study. The literature reports 22,23,24,25,26,27,28 the incidence of smokestack leak to be 

7 to 25% and that of inkblot leak 60 to 87%. Spitnaz and Huke 26 observed that 

the leaks are most often found in the superonasal quadrant (33.22%). In our 

study we also found superonasal quadrant to be the commonest site (33.33%). 

The usual number of leakages are one or two in various studies 22,25,26 that too 

in our study. 

Occassionally, in spite of presence of clinically appreciable CSC no leak is 

found in FA. Gass 29 had suggested the following possibilities for such a 

situation – 1) The leaking point has healed; 2) A leak has occurred outside the 

macular area; 3) In presence of the peripheral retinal hole or a choroidaltumor; 

4) Associated with congenital pit of the ONH.; 5) In idiopathic uveal effusion 

syndrome. CSC without leak may be due to healing of the leaking point or 

points and delay in the absorption of the subretinal fluid. 

The development of OCT has provided a better understanding of the 

mechanism in CSC, especially the abnormalities in the RPE layer. We 

visualized clearly a minute defect of the RPE within the PED, which seemed 

858


to correspond precisely to the leakage point on FA. When the retina detached, 

the appearance of the outer retinal layer changed; the external limiting 

membrane persisted, although the IS/OS could not be detected in all eyes, as 

recently reported by Ojimaet al. 30 After resolution of CSC, PED is still evident 

on OCT. In chronic recurrent cases, irregular loss of pigment from the RPE 

was evident angiographically as mottled areas of hyperfluorescence.In some 

cases the descending RPE atrophic tract is nicely visible in FA, which indicades 

previous exudative detachment in the inferior part of the retina. 

Puliafito et. al. 31 used the OCT for the first time in imaging the macular diseases 

including the CSC. Later, Heeet al 32 correlated the OCT findings with slit lamp 

biomicroscopy, fundus photography and fluorescein angiography. They could 

detect detachments with the OCT that remained undetected in FA. Moreover, 

OCT may also help to track the resolution of the subretinal fluid. Morphologic 

changes in eyes with CSC have been reported using optical coherence 

tomography (OCT). OCT shows the various features of CSC, including retinal 

detachment (RD), fibrinous exudation, and cystic changes within the retina. 

Several investigators have applied indocyanine green angiography to 

evaluate the eyes with CSC. They observed that ICG in CSC can reach the 

subretinal space through a RPE defect. Many investigators 33,34,35,36 observed 

correspondence of the ICG leakage with the fluorescein leaking point in 79– 

81% of cases of acute CSC. In the remaining 20% of the cases, it was presumed 

that either the RPE defect was not enough for the passage of the dye, or the rate 

of dye leakage was not enough to produce hyperfluorescence contrasting with 

the background fluorescence. 

We showed that simultaneous imaging using spectralis provides a better 

understanding of the structural changes taking place during the clinical course 

of ICSC. Further studies may providea better understanding of CSC pathology. 

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Jaypee brothers 2005. 

Comprehensive Modern Classification of 

Diabetic Retinopathy 

Dr. A.K. Dubey, Dr. Benu Dubey 

Present management of diabetic retinopathy is largely based on DRS , ETDRS 

and DRVS. The present system most commonly followed for classifying 

diabetic retinopathy is modified ETDRS classification. This is an exhaustive 

classification based on a large multi centric study. However this study was 

conducted when our understanding of relationship between diabetes mellitus 

and diabetic retinopathy was different than present, and also tools like OCT 

and intra vitreal drugs such as anti VEGF and steroids were not available. 

Our understanding towards indications for surgical treatment was also not 

so refined. We present an extended classification which includes the alteration 

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caused in the course of diabetic retinopathy with use of intra vitreal drugs and 

also the helpful information given by OCT. 


A total of 1500 cases of diabetic retinopathy of varying presentations and 

severity treated between 2002 to 2009 were studied. The study included detailed 

analysis of clinical features, outcome of non surgical and surgical treatment 

and also alteration caused in the course of both surgically and non surgically 

treatable cases by intra vitreal anti VEGF and steroid drugs. Manifestations in 

the vitreous with and without active proliferative or non proliferative diabetic 

retinopathy were studied in particular with the help of OCT. 

All cases were subjected to careful history taking including duration of 

diabetes, type of diabetes, other systemic association such as hyper tension 

or renal pathology and also any ocular surgery or concurrent ocular disease. 

Detailed ocular examination included indirect opthalmoscopy, macular 

examination with three mirror contact lens /90D lens, FFA and OCT. 

Treatment methods included laser photocoagulation of varying ranges with 

532 green laser or 810 red diode laser. Diode laser was preferentially used 

for cases with lenticular opacities. Cases requiring vitreous surgery were 

subjected to pars plana vitrectomy with suitable endo laser and tamponade 

as needed. 

RESULTS 

We observed incidence of PDR was significantly high in type 1 DM and was 

observed to increase with duration. PDR with or without CSME was most 

common in the age group of 40 to 60 years. Indications for vitreo retinal 

surgery were more common in type 1 DM. We further observed that about 

28% of the cases required vitreous surgery despite complete regression of the 

neovascular process after PRP. The main indications were recurrent vitreous 

haemorrhage, traction retinal detachment, taut posterior hyaloids, combined 

retinal detachment. Another 12% of cases diagnosed as CSME required 

vitreous surgery for indications of traction over the macula diagnosed as 

traction macular edema with the help of OCT and showing no vascular lesions 

on FFA. 

DISCUSSION 

Review of literature indicates that diabetes mellitus can induce changes 

in vitreous before any vasculpathy. These changes are mainly in the form 

of liquefaction and partial detachment of vitreous. This explains why it 

is possible to have traction macular edema in non proliferative diabetic 

retinopathy without any new vessels. Proliferation of new vessels can result 

862


in vitreous haemorrhage only by pull of vitreous, in other words primary 

changes of partial detachment in vitreous form a causative factor for vitreous 

haemorrhage. However bleeding in the vitreous cavity adds both fibro blasts 

and erythroblasts to the vitreous tissue and this alters the composition of 

vitreous tissue initiating the process of stronger vitreous contraction resulting 

into recurrent haemorrahge, TRD and CRD. However course of the disease 

can be favourably modified with intra vitreal anti VEGF drug injections. Based 

on our observations we attempted to modify and expand the existing ETDRS 

classification with inclusion of vitreopathy as a separate class. 

by “Diabetic Retino- 

The term “Diabetic Retinopathy” may be replaced 

vitreopathy” and may be classified as below. 

Dubey’s classification of diabetic retino-vitreopathy 

1. Non-proliferative diabetic retinopathy (mild/moderate/severe/very 

severe) 

2. Proliferative diabetic retinopathy 

3. Diabetic maculopathy ( focal, diffuse, ischemic, mixed) 

4. Clinical diabetic vitreopathy 

i) Surgical vitreopathy 

ii) Intermediate vitreopathy 

iii) Non-surgical vitreopathy 

Surgical vitreopathy 

i) Posterior pole TRD 

ii) Superior half TRD 

iii) Tractiional macular edema without macular ischemia 

iv) Premacular fibrosis 

v) Recurrent vitreous hemorrhages in laser regressed PDR 

vi) Secondary rhegmatogenous retinal detachment 

vii) Optic disc traction 

viii) Macular heterotropia 

ix) Retinal wrinkling 

x) Dense premacular hemorrhage 

Intermediate vitreopathy 

i) Florid neovascularization with/without any of the above indications 

ii) Anterior segment neovascularization 

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iii) Neovascularization non –responsive to laser with/without any of the 

above indications 

iv) Large non resolving vitreous bleeding in laser-treated or untreated 

PDR. 

Non-surgical vitreopathy 

i) Inferior peripheral TRD 

ii) Recurrent vitreous hemorrhages in active PDR 

iii) Tractional macular edema with ischemia. 

iv) Macular schisis. 

In conclusion a new classification of diabetic retinopathy is presented which 

includes all information from recent understanding of systemic disease, new 

investigative tools, new drugs and new surgical techniques. 

23G Vs 20G in the Management of Advanced PDR 

with and without the Use of Intravitreal Avastin 

Dr. Saraswathy Karnati, Dr. Agarwal Amar, Dr. Soosan Jacob 

The study is aimed to analyze and compare the surgical outcome and 

complications of advanced proliferative diabetic retinopathy including 

tractional retinal detachment with the MIVS and the conventional vitrectomy. 

Subgroup analysis was done to see the influence of intravitreal avastin on the 

overall surgical effect. 

Each group was subdivided into group A in which intravitreal avastin was 

used and group B in which intravitreal avastin was not used. 

Design: 

Retrospective, comparative, interventional case series in a tertiary care 

hospital. 


Patients were grouped into 

Group I: 25 Patients who underwent 23G vitrectomy and 

Group II: 20 Patients who underwent 20G vitrectomy 

Subgroup A: with intravitreal avastin 

Subgroup B: without intravitreal avastin 

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Group I: The total number of patients who underwent 23G vitrectomy was 

twenty five and the mean age of the patients was 63.61 years. The M:F ratio was 

12:9. The mean diabetic age was twenty years. 

Group II: The total number of patients who underwent 20G vitrectomy was 

twenty and the mean age of the patients was 63.61 years. The M:F ratio was 

12:9. The mean diabetic age was twenty years. 

The criteria assessed 

Main criteria: The surgical success and the time taken for visual recovery 

were the main criteria assessed. 

Other criteria assessed: 

• Per-operative: Surgical time taken and the number of sutures required to 

close the ports 

• Post-operative: Patient comfort in terms of signs and symptoms like pain, 

reaction to surgery etc. Hypotony which was defined as IOP


Increasing number of people being affected by the disease worldwide, the need 

for the early detection and management of the disease and its complications 

have made clinicians all over the world search for NEW DIAGNOSTIC 

TECHNIQUES for the early detection of diabetic retinopathy. Ancillary 

investigations like Fundus Fluorescein Angiography (FFA), Ultrasound B-scan 

of the eye, Perimetry and Optical Coherence Tomography (OCT) have gained 

good popularity. FFA being invasive, Ultrasound is not quantitative; Perimetry 

does not give anatomical details while OCT is qualitative, quantitative, noninvasive, 

and accurate with good repeatability. 


The study is a hospital based cross sectional investigational study of 100 eyes 

of Diabetic Macular Edema in various stages. The BCVA was noted in logMAR 

units. Patients were evaluated for the Slit lamp evaluation of the anterior 

segment, Fundus examination with the Indirect Ophthalmoscopy. Macula was 

evaluated using the Slit Lamp Biomicroscopy with the 78D lens and then with 

the 3D SPECTRAL OCT/SLO. Central Retinal Thickness, Topography Map 

and the Microperimetry values were noted using the OCT. Macula was graded 

into different types of edema with the help of Clinical Slit Lamp evaluation 

and the OCT. FFA was done on the Carl Zeiss machine. 

Slit Lamp Examination classified the macula into: 

• Grade I: Focal (Non diffuse) edema 

• Grade II: Diffuse edema 

• Grade III: Cystoid Macular edema 

• Grade IV: With ERM(Epiretinal Membrane) 

• Grade V: With Serous RD (Retinal Detachment)/Tractional RD 

OCT classified macula into : 

• Group I: Spongy Thickening 

• Group II: Cystoid Edema 

• Group III: Serous RD 

• Group IV: Vitreomacular Traction/TRD 

• Group V: Taut Posterior Hyaloid Membrane 

FFA evaluated for No Leak, Focal Leak, Diffuse Leak, Cystoid Leak or 

Ischaemic Macula. 

OCT evaluation was done using the Macular Scan protocol using 6 radial scans 

of the macula. Macular Sensitivity was determined using the Microperimetry 

by an in built eye tracking software of the machine on a 0-20 db scale. 

866


RESULTS AND DISCUSSION 

Table 1 

CRT (µm) 600 

No. of eyes 17 44 16 08 07 08 

Mean (logMAR) Visual Acuity 0.31 0.38 0.72 0.70 0.85 0.98 

Microperimetry (Mean db) 09.85 08.56 05.84 00.37 02.27 02.31 

Table 1 shows that: As the range of the CRT increases from a normal of 600 µm, the mean logMAR value increases significantly (vision decreases) 

from 0.31 to 0.98 and the Retinal Sensitivity by Microperimetry decreases 

significantly from a mean value of 09.85 db to 2.31 db. Mean CRT was 284 µm 

and sensitivity was 7.7db. 

CRT is correlated with logMAR visual acuity (r=0.5, p< 0.001) and sensitivity 

(r=-0.58, p


thickening due to cystic changes of the inner retinal layers/thinning of 

neurosensory retina on OCT co-related most significantly with decreased 

sensitivity. 

REFERENCES 

1. Gupta V, Gupta A, Dogra MR, Singh R. Diabetic Retinopathy Atlas and Text. 2007, 

page 1. 

2. Hindustan Times, New Delhi, Sep 2007: Express news Service may 13 2009. 

3. Sanchez HT et. al. Retinal Thickness study with OCT in patients with diabetes. The 

Association for research in vision and ophthalmology. Jan 2002. 

4. Kim BY et. al. OCT patterns of diabetic macular edema. American Journal of 

Ophthalmology. 2006;Sep:405-12. 

5. Kothari AR, Raman R, Sharma T. Diabetic Macular Edema:Corelation of retinal 

structural alteration with retinal sensitivity loss-a prospective study. AIOC 2010 

proceedings. Retina/Vitreous session. 

6. Okada K et. al. Co relation of the retinal sensitivity measured with fundus related 

microperimetry to visual acuity and retinal thickness in DME. Eye 2006;20:805-9. 

7. Midena E. Microperimetry in diabetic retinopathy. Saudi Journal of Ophthalmology. 

2011;25:131-5. 

8. Hee MR, Puliafito CA, Wong C et al. Quantitative assessment of diabetic macular 

edema by Optical coherence tomography. Arch Ophthalmol 1995;113:1019-29. 

Two Year Follow-up of a Randomized Trial 

Comparing Intravitreal Bevacizumab Alone 

or Combined with Triamcinolone Vs. Macular 

Photocoagulation in Diabetic Macular Edema 

Dr. Meena Chakrabarti, Dr. Sonia Rani John, Dr. Arup Chakrabarti 

Diabetic maculopathy is responsible for majority of visual loss in patients 

with diabetic retinopathy. Strict glycemic and blood pressure control 

remain the most effective interventions to date. Conventional treatment is 

based mainly on laser photocoagulation with the probable mechanism of 

rejuvenation of retinal pigment epithelium cells or improvement of outer 

retinal oxygenation. The Early Treatment Diabetic Retinopathy Study (ETDRS) 

showed that laser photocoagulation reduced the risk of moderate visual loss in 

patients with clinically significant macular edema (CSME) by approximately 

50% (from 24% to 12%) at 3 years although visual acuity (VA) improvement was 

observed in less than 3% of cases (15 letter gain at 3 years). 

868


Alternative or adjunct treatments for DME such as intravitreal triamcinolone 

acetonide (IVT), anti-vascular endothelial growth factor (VEGF) therapy, have 

been the focus of the most recent attentions. 

Anti-VEGF drugs, by affecting endothelial tight junction proteins, decrease 

vascular permeability in ocular vascular diseases such as DME. VEGF-A levels 

are considerably higher in patients with DME showing extensive leakage in 

the macular region than in patients showing minimal leakage. 

The use of anti-VEGF drugs is becoming increasingly more prevalent; 

however, some unresolved issues, such as ideal regimen, duration of treatment, 

potential of combination treatments and safety concern with long term VEGF 

inhibitions, deserve further investigations. The body of data at this point on 

Ranibizumab and Bevacizumab (CATT Trial) suggest that both are equally 

useful in the treatment of DME. In patients with centre involved DME and 

decreased vision we can consider treating with either RBZ or if there are 

financial barriers which Bevacizumab (BCZ). 

Several retrospective uncontrolled case series with limited follow-up and 

variable treatment regimens have reported favourable effects of intravitreal 

bevacizumab (IVB) in the management of nonischemic DME. Prospective, 

consecutive non comparative case series, with variable follow up ranging from 

6 weeks to 12 months have provided more reliable data suggesting a beneficial 

effect of IVB in patients with chronic diffuse DME. Similar studies on 

Bevacizumab are not available. The PACORES (Pan American Collaboration 

study of Bevacizumab) is the only larger multi centered trial proving its 

efficancy. 

This is a prospective, single center randomized 2-year trial, enrolling novice 

patients with CSME into 3 groups to study the efficacy of Bevacizumab singly 

on combined with Triamcinolone Acetonide versus laser monotherapy. 


90 patients with clinically significant DME based on ETDRS criteria were 

included in the study. 

Inclusion criteria: Patients of age >18 years with type I or II diabetes mellitus 

with Hb A1c6/12 and


Baseline Evaluation 

A detailed ophthalmic evaluation including BCVA, slit lamp biomicroscopy, 

applanation tonometry and dilated fundus examination was carried out. All 

patients underwent fundus photography, digital fluorescein angiogram and 

optical coherence tomography (OCT) scan. Retinal thickness was measured in a 

circle (3.5 mm diameter) centred on the fovea. (CRT) was recorded and considered 

for statistical analysis. Eligible eyes were grouped into three: IVB group (Group 

1) eyes receiving IVB injection alone; IVB/IVTA group (Group 2) eyes receiving 

IVB injection plus IVTA, and Laser group (Group 3) undergoing laser alone. 

Surgical Technique 

Under sterile conditions, under topical anesthesia and following application 

of a drape and insertion of a lid speculum, intravitreal injections 0.05ml 

(1.25 mg of Bevacizumab) were undertaken with a 30 guage needle through 

the superotemporal quadrant. Patency of the central retinal artery was 

determined by indirect ophthalmoscopy. The IOP was checked 30 minutes 

after the injection and if the pressure was increased (≥30mm Hg) appropriate 

treatment was commenced. After the injection, topical antibiotic drops and anti 

inflammatory drops were given 4 times daily for 1 week. In the combination 

group all patients received both bevacizumab and triamcinolone injected 

separately under aseptic precautions. 

In the laser treated group, standard focal or modified grid laser was performed. 

Modified ETDRS laser photocoagulation comprised 50-100 µm spot size, laser 

applied only greater than 500 microns from the edge of the FAZ, with focal 

treatment aiming to cause mild blanching of the retinal pigment epithelium 

and not darkening/ whitening of microaneurysms. Areas of diffuse leakage 

or non perfusion were similarly treated in a grid pattern. 

Patients who received injections were examined at 1 and 7 days after injection 

for anterior chamber reaction and intraocular pressure measurement. 

Complete ocular examination and optical coherence tomography were 

performed again at 6, 12, 24 and 36 weeks. Digital fluorescein angiography 

was repeated as needed. 

The protocol for retreatment after the initial loading dose for all 3 groups was based 

on the response to treatment and was repeated if CRT>300 micron. The number 

of repeat injection was 4 in the Bevacizumab gp and 2 in the combined group. 

Outcome Measures 

Primary outcome measure was change in BCVA at week 24, 12 months and 

24 months from baseline and also whether this visual gain was preserved or 

improved at 24 months. Secondary outcomes were CRT changes by optical 

coherence tomography and injection related complications. 

870


RESULTS 

90 eyes of 150 patients were enrolled within a study period of 2 years from 

March 2009-2011. The mean age of the patients was 61.2±6.1 years with 77 

female (55.67%) and 73 male (54.33%) subjects. Out of the 90 patients, 30 each 

were randomized into the Bevacizmuab group, combined IVB/IVTA group 

and in the Laser group. 

The severity of retinopathy did not vary among the 3 groups 55% of the study 

population had focal type of DME, which 45% had diffuse DME. 

Except for the duration of CSME, there were no clinically significant differences 

observed at baseline between treatment groups. The mean ETDRS BCVA was 

6/12 to 6/60 in all the 3 groups with the mean CRT being 440±20 (range: 280 

to 800 in group 1, 468 micron ±19 micron (253 micron – 856 micron) in group 2 

and 464 micron ± 22 micron (281 micron – 846 micron). 

Retreatment was given on a prn basis if there was loss of atleast 2 lines of 

vision between 2 consecutive follow-up or if CRT was ≥ 300 µm. 

Analysis of Results 

All 3 groups are similar with respect to age, sex, diabetic age, HbA1C, pre 

treatment vision, baseline central retinal thickness on OCT. 

Effectiveness of Treatment on Vision There was no statistically significant 

difference between the increase in visual scores in the 3 groups by Anova 

test and hence all three modalities are equally effective wrt visual gain. 

The difference between the 3 groups was also apparent with respect to CRT 

(in OCT). In group I, CRT had significantly decreased from 540µm (range 280 

to 900 µm) at baseline to 376 µm (range: 167 to 698 µm) at 12 months (p


Major Ocular Adverse Effects 

Criteria Laser BVZ BVZ+IVTA 

Endophthalmitis 1% 0% 1% 

Pseudoendophthalmitis 1% 0% 2% 

Ocular Vascular Event 1% 1% 2% 

RD 0% 0% 0% 

Vitrectomy 5% 2% 1% 

Vit HgE 9% 3% 4% 

Cummulative Probability of Cat Sx 

• BVZ + TA : 59% 

• BVZ : 14% 

• LASER : 14% 

The number of repeat injections was 4 in the Bevacizumab group and 2 in the 

combination group. The mean change in visual acuity at 24 months was an 

improvement in all 3 groups (+7.2 letter VS +6.2 letters VS +5.1 letters in the 

Bevacizumab, combination and laser groups respectively. 

IOP Profile 

Elevated IOP Laser BVZ BVZ+IVTA 

Increase>10mm 8% 9% 42% 

IOP > 30 3% 2% 27% 

Initiation of IOP Lowering 5% 5% 28% 

Medications at any Visit 

Eyes with >1 of above 11% 11% 50% 

Glaucoma Surgery 0% 0% 0% 

Cardiovascular and Cerebrovascular Events 

Disease Laser RBZ BVZ+IVTA 

Non-Fatal Mi 3% 1% 3% 

Non-Fatal CVA 6% 2% 2% 

Summary of Results 

At primary end point (month 6) bvz monotherapy resulted in superior bcva 

(+6.50 letters) compared to laser (+0.50) or combination (+3.80 letters). 

During months 6-24 PRN bevacizumab injection /repeat laser in the mpc 

group resulted in maintenance of visual benefits. there was no statistically 

significant difference in the 24 m outcome between both groups. 

Combination therapy was associated with poorer ocular safety profile and less 

favourable outcome at 24 months. 

872


Prevalence and Risk Factors for Diabetic 

Retinopathy in Young Diabetic Subjects in South 

India 

Dr. R. Rajalakshmi, Dr. V. Mohan, Dr. M. Rema 

Diabetes has assumed epidemic proportions in developing countries of the 

world. India today has an estimated 50 million diabetic subjects and a 

significant number of these occur in early adulthood. 1 Earlier it was assumed 

that the majority of subjects with diabetes below 30 years of age had type 1 

diabetes (T1DM), but recently there has been an increase in numbers of early 

onset type 2 diabetes (T2DM). 2,3 

Diabetic retinopathy (DR) is a highly specific microvascular complication of 

diabetes. There is no data from India on the prevalence of diabetic retinopathy 

(DR) in early onset T2DM. In the western world, studies like the Wisconsin 

Epidemiological Study of Diabetic Retinopathy (WESDR) have looked at the 

prevalence and risk factors of DR in T1DM. 4 However, there is paucity of such 

studies in India. 

The purpose of this paper is to look at and compare the prevalence of DR 

and risk factors for DR in T1DM versus early onset T2DM in young diabetic 

subjects. 


This is a prospective clinic based cohort study of the prevalence of DR in young 

diabetic subjects (with T1DM and early onset T2DM). Recruitment was done 

between 2005 and 2006 at Dr. Mohan’s Diabetes Specialities Centre, a large 

referral centre for diabetes at Chennai in South India. All subjects with T1DM 

or early onset T2DM diagnosed below age of 30 years and willing to undergo 

a clinical and biochemical assessment and digital retinal color photography 

were requested to participate in the study. Institutional Ethical committee 

approval and informed consent was also obtained from all the subjects. 

A questionnaire was used to obtain details including the age of the subject, the 

age at diagnosis of diabetes, duration of diabetes, history of hypertension and 

treatment details for diabetes (insulin, or oral hypoglycemic drugs or both). 

Baseline clinical examination included anthropometric measurements and 

recording the blood pressure. Anthropometric measurements like the height, 

the weight were taken and body mass Index (BMI) was calculated. 5 The baseline 

bio-chemical investigations included a fasting and post prandial plasma 

glucose, glycated hemoglobin (HbA1C), Serum lipid profile (Serum cholesterol, 

triglycerides, low density lipoprotein cholesterol and renal function test (blood 

873


urea, serum creatinine, and 24 hours proteinuria/ macroalbuminuria). Serum 

C-peptide (fasting and stimulated) was measured. 

A comprehensive ophthalmic examination was done which included ocular 

history, assessment of the best corrected visual acuity, intra-ocular pressure 

(IOP), anterior segment examination, and fundus examination was done by 

direct and indirect ophthalmoscopy, after dilatation with tropicamide plus 

eye drops. Four-field digital retinal color photography was taken by a trained 

photographer (Carl-Zeiss Digital Fundus Camera). The 4 fields photographed 

were the macula, optic disc and nasal to the optic disc, superior-temporal and 

inferior-temporal quadrants. 6 The grading of the retinopathy was done based 

upon the modified Early Treatment Diabetic Retinopathy Study (ETDRS) 

grading system. 7 The final diagnosis for each patient was determined from 

the level of retinopathy of the worse eye using ETDRS final retinopathy scale 

for individual eyes. 6,7 Diabetic Macular Edema (DME) was defined as retinal 

thickening at or within one disc diameter of the centre of the macula or the 

presence of definite hard exudates. 8 Sight-threatening DR (STDR) was defined 

as proliferative retinopathy (PDR) or DME (clinically significant macular 

edema-CSME) in either or both eyes. 

Statistical Analysis 

All statistical analyses were performed using SAS statistical package (version 

9.0; SAS Institute, Inc., Cary, NC). Regression analysis was done using diabetic 

retinopathy as the dependent variable and other risk variables which had p 

value ≤0.2 in the univariate analysis, as independent variables. For all statistical 

tests, p value


Table 1: Risk factors at baseline for diabetic retinopathy (DR) in type 1 

diabetes and early onset type 2 diabetes, using DR as dependant variable 

RISK FACTORS 

(Increment/ Value) Type 1 diabetes Early onset type 2 diabetes 

OR (95% CI) p value OR (95% CI) p value 

Duration of Diabetes 1.26 (1.15–1.36)


(p=0.02) were the most significant risk factors associated with DR in early onset 

T2DM. The prevalence of DR increased with increasing duration of diabetes in 

both T1DM and early onset T2DM subjects as shown in Figure 1 (p15 

years had DR. Prevalence of sight threatening DR (STDR) also increased with 

increase in duration of diabetes. (T1DM-p


To conclude, Indian youth with T2DM have significantly higher prevalence of 

retinopathy than their peers with T1DM. Emphasis on tight glycemic control 

and repetitive retinal examination of young diabetic individuals for the early 

detection of DR is essential for prevention of morbidity and visual impairment 

due to diabetic retinopathy in the Indian youth. 

Author Disclosure Statement: No competing financial interests. 

REFERENCES 

1. International Diabetes Federation, Diabetes Atlas (2009). Unwin N, Whiting D, Gan 

D, Jacqmain O, Ghyoot G (eds). Fourth Edition, International Diabetes Federation, 

Brussels, Belgium, pp 1–27. 

2. American Diabetes Association. Type 2 diabetes in children and adolescents 

(Consensus Statement). Diabetes Care 2000;23:381–9. 

3. Pinhas-Hamiel O, Zeitler P. The global spread of type 2 diabetes mellitus in 

children and adolescents. J. Pediatr. 2005;146:693–700. 

4. Klein R, Klein BE, Moss SE, Davis MD, DeMets DL. The Wisconsin Epidemiologic 

Study of Diabetic Retinopathy. II. Prevalence and risk of diabetic retinopathy 

when age at diagnosis is less than 30 years. Arch Ophthalmol. 1984;102:520–6. 

5. Deepa M, Pradeepa R, Rema M, Mohan A, Deepa R, Shanthirani S et al. The Chennai 

Urban Rural Epidemiology Study (CURES)—study design and Methodology 

(Urban component) (CURES-1). J Assoc. Physicians. India. 2003;51:863–70. 

6. Rema M, Premkumar S, Anitha B, Deepa R, Pradeepa R, Mohan V. Prevalence of 

diabetic retinopathy in urban India: the Chennai Urban Rural Epidemiology Study 

(CURES) Eye Study-1. Invest. Ophthalmol. Vis. Sci. 2005;46:2328–33. 

7. Early Treatment Diabetic Retinopathy Study Research Group. Grading diabetic 

retinopathy form stereoscopic color fundus photographs: an extension of the 

modified Arlie House classification. Early Treatment Diabetic Retinopathy Study 

Report Number 10. Ophthalmology. 1991;98:786–806. 

8. Early Treatment Diabetic Retinopathy Study Research Group. Photocoagulation 

for diabetic macular edema: Early Treatment Diabetic Retinopathy Study report 

number 1. Arch. Ophthalmol. 1985;103:1796–806. 

9. Mohan V, Jaydip R, Deepa R. Type 2 diabetes in Asian Indian youth. Pediatric 

diabetes, 2007 8 Suppl 9. pp. 28-34. ISSN 1399-543X. 

10. Wong J, Molyneaux L, Constantino M, Twigg S , Yue D. Age of Onset Influences 

Long-Term Retinopathy Risk in Type 2 Diabetes, Independent of Traditional Risk 

Factors. Diabetes Care. 2008;31:1985–90. 

11. Yokoyama H, Okudaira M, Otani T, Takaike H, Miura J, Saeki A, Uchigata Y,Omori 

Y: Existence of early-onset NIDDM Japanese demonstrating severe diabetic 

complications. Diabetes Care 1997;20:844–7. 

12. The DCCT Research Group. The effect of intensive treatment of diabetes on the 

development and progression of long-term complications in insulin-dependent 

diabetes mellitus. N Engl J Med 1993;329:977-86. 

877


Evaluation of Pattern Erg, Ph Nr, Osc. Potential 

and 30Hz Flicker in Diabetic Retinopathy 

Dr. J.L.Goyal, Dr. Babita Karothia, Dr. Ritu Arora, Dr. Basudeb Ghosh 

It has been reported that after 20 years of diabetes, more than 90% of patients 

with type I and about 60% with type II diabetes will have some form of 

retinopathy1. In DR, the primary pathogenesis is generally believed to involve 

the retinal vessels. However, it has become increasingly clear that diabetic 

retinopathy affects not only retinal vasculature, but also neural elements 

of the retina. 2,3,4 Retinal ganglion cells (RGC) are particularly susceptible to 

glutamate excito-toxicity, which plays an important role in ischemic diseases 

like diabetic retinopathy. 5 

Several studies, over the years, have confirmed that Electrophysiology is 

capable of detecting early biochemical and functional abnormalities of the 

retina before changes are evident with either fluorescein angiography or 

by direct ophthalmoscopy. 6,7 Thus, it can occupy a key position in assessing 

treatment directed to preventing or slowing down these subclinical processes. 

Design: Prospective, Cross-sectional study. 


In this study 60 eyes were selected. These included 20 eyes of diabetics without 

NPDR, 20 eyes of diabetics with NPDR and 20 eyes in the control group. Patients 

with history of diabetes of at least 2 years’ duration with best corrected visual 

acuity of at least 6/60 were included. Controls consisted of age- matched non 

diabetic individuals without any anterior or posterior segment abnormalities. 

Electrophysiological tests were performed using Medelec Synergy System 

with Ganzfeld Stimulator, in accordance with the latest ISCEV guidelines. 

Amplitude and latency of different waves were compared amongst the 3 

groups. 

Placement of Electrodes: 

ERG waves were recorded using the following 3 electrodes: 

Ground electrode – surface Ag /Agcl disc electrode over the forehead 

Reference electrode – surface Ag /Agcl disc electrode over lateral canthus 

Active Electrode 

1) Contact lens jet electrode over the cornea for PhNR, Ops and 30 Hz 

Flicker. 

2) Gold foil electrode placed over the inferior limbus for Pattern ERG. 

878


Recording of Waves 

a) Pattern ERG (PERG): It was recorded using a 

reversing checkerboard pattern with the subject 

seated 1 metre away from the monitor in a dark 

room, without mydriasis. 150 stimuli for signal 

averaging at a frequency of 1 pulse per second 

was used. The amplitude and latency of P50 

(positive wave at 50 m.sec) was calculated. 

b) Oscillatory Potentials (OPs): Peak-to 

trough amplitudes of the waves was 

summed to give an overall measure of OP 

amplitude. 

c) Photopic Negative Response (PhNR): 

Its amplitude is defined as the difference 

between the baseline and the trough of 

the negative wave following the b-wave. 

d) 30 Hz Flicker ERG: The amplitude of 

flicker ERG is measured from the trough 

to the peak. 

e) The implicit time of each wave was 

measured from stimulus onset to the 

peak. 

RESULT 

It was found that the amplitude of P50 wave of Pattern ERG showed significant 

decrease with increase in the severity of diabetic retinopathy, with an average 

reading of 3.98 µV ±1.10 in control group, 2.38 µV ±0.81 in diabetics without 

NPDR and 1.81 µV ±0.64 in diabetics with NPDR (P value


thus, early intervention can be undertaken at an appropriate time to prevent 

further progression of the disease, before it reaches an irreversible stage. 

REFERENCES 

1. Klein R, Klein BEK, Moss SE. The Winconsin Epidemiological Study of Diabetic 

Retinopathy, III:Prevalence and risk of diabetic retinopathy when age of diagonosis 

is 30 or more years. Arch Ophthalmol 1984;102:527-32. 

2. Liech E, gardener TW, Barber AJ. Retinal neurodegeneration:early pathology in 

diabetes. ClinExpOphthalmol 2000;28: 3-8 

3. Barber AJ. A new view of diabetic retinopathy: a neurodegenerative disease of the 

eye. Prog Neuropsychopharmol Biol Psychiatry 2003;27:283-90. 

4. Lopes de Faria,Russ H Costa VP. Retinal Fibre layer loss in patients with type 1 

diabetes mellitus without retinopathy. Br J Ophthalmol 2002;86:725-8. 

5. Nakazawa T, Takahashi H, Nishijima K. Pitavastatin prevents NMDA-induced 

retinal ganglion cell death by suppressing leukocyte recruitment. J Neaurochemistry 

2007;100:1018-31. 

6. Coupland SG: A comparison of oscillatory potential and pattern electroretinogram 

measures in diabetic retinopathy. Doc Ophthalmol 1987;66:207–18. 

7. Chen H, Zhang M, Huang S, Wu D. The photopic negative response of flash ERG in 

nonproliferative diabetic retinopathy. Doc Ophthalmol 2008;117:129-35. 

Investigation into The Levels of VEGF, PEDF and 

Other Biochemical Parameters in Diabetic 

Retinopathy 

Dr. Mohammad Arif Mulla, Dr. Gopal Lingam, Dr. Angayarkanni N., 

Dr. Kaviarasan 

To determine the levels of vascular endothelial growth factor (VEGF), 

cytokines, pigment epithelium derived factor (PEDF), along with other 

biochemical parameters in the patients with diabetes, non-proliferative 

diabetic retinopathy (NPDR), proliferative diabetic retinopathy (PDR) and 

compared with age-matched controls 


Study Design: Patients aged between 40-65 years with type II diabetes, NPDR 

and PDR and Macular hole (MH) patients as control were included in this 

study. 

This study was carried out after receiving ethical approval from the 

institutional ethics committee. 

880


Group I: Healthy volunteers (control) 

Group II: Patients with type 2 Diabetes Mellitus 

Group III: Diabetic retinopathy- non proliferative (NPDR) 

Group IV: Proliferative Diabetic Retinopathy (PDR) 

Group V : Macular Hole (MH) (Disease control) 

• Consents were obtained for vitreous and blood specimen separately 

• Clinical proforma was filled and kept in the Department of Biochemistry 

and Cell Biology. 

• Blood/urine samples were collected from all these groups 

• Routine biochemical parameters were done and if they fell into the criteria, 

then the samples were used for the rest of the analysis. 

• Based on the clinical proforma and lab investigations patients were 

grouped. 

Sample collection details 

The fasting blood was collected from the patient by using BD-vacutainer 

system. 

2 ml- Fluoride tube : Plasma for fasting glucose estimation 

Whole blood (EDTA tube) : HBA1C 

4 ml- Plain serum tube : lipid profile, /cytokines/growth factors 

Urine : microalbumin 

Undiluted Vitreous : 250-500 µL 

• The fasting blood samples and urine samples were collected before the 

surgery and then aliquoted and stored in -80°C. 

• The vitreous sample was centrifuged, (using a cooling centrifuge) aliquoted 

and then stored in -80°C. 

RESULTS 

Table 1 shows age, anthropometric measurements and the levels of biochemical 

parameters such as total cholesterol,triglycerides, and µ-albumin. Among all 

the parameters examined, HBA1C, triglycerides, and Urine µ-albumin showed 

a directly proportional relation to diabetic progression. 

Tables 2 shows the vitreous PEDF levels in PDR and MH. The vitreous PEDF 

levels were increased in PDR group when compared to the macular hole. 

Table 3 shows the vitreous VEGF levels in PDR and macular hole. VEGF levels 

were increased in PDR group when compared to macular hole. 

881


Table 1: Anthropometric measurements and biochemical parameters 

in control and diabetic groups 

882 

Group-I Group-II Group-III Group-IV 

(Control) (Diabetes) (NPDR) (PDR) 

(n=6) (n=8) (n=4) (n=10) 

Age (in years) 43.26 ± 6.93 58.36 ± 13.51 48.50 ± 5.51 48.727 ± 6.326 

BMI (m2/kg) 25.59± 3.07 26.27 ± 4.26 24.29 ± 3.41 24.02 ± 3.78 

Fasting Glucose 94.0 ± 7.90 143 ± 28.07* 153.00 ± 84.31 158.364 ± 79.873 

(mg/dL) 

HBA1C (%) 5.37 ± 0.45 6.76 ± 1.69 7.38 ± 1.57* 8.35 ± 2.24* 

Total cholesterol 182.17 ± 21.78 170.29 ±39.87 136.75 ±15.09 199.100 ± 77.331 

(mg/dL) 

Triglycerides 116.0 ± 35.03 108 ± 37.68 110.75 ± 34.73 281.200 ± 253.244 

(mg/dL) 

TC/HDL-C 3.87±0.72 3.63±0.91 3.38 ± 0.97 4.917 ± 1.788 

μ-Albumin 8.95±6.07 49.56±70.77 110.73 ± 105.01 135.67± 97.98 

*P


DISCUSSION 

There are hardly any reports on the elevated levels of PEDF in the serum or 

vitreous of PDR cases. However this study shows unusually higher levels of 

PEDF in the vitreous of PDR cases along with VEGF levels that are usually 

reported as high. In our study vitreous PEDF were increased only in the 

laser treated eyes when compared to the non-laser treated eyes. Among all 

the cytokines examined IL-6 was significantly increased in PDR groups when 

compared to MH and PEDF was negatively correlated with IL-6. 

In conclusion the vitreal concentration of PEDF was significantly higher in PDR 

than in MH. Increased PEDF levels in PDR are probably altered with laser 

treatment. However more cases needs to be looked into to conclude on this. 

Evaluation of Pattern Electroretinogram in 

Central Serous Retinopathy 

Dr. J. L. Goyal, Dr. Vishram Anil Sangit, Dr. Basudev Ghosh, Dr. Gaurav 

Goyal 

Pattern electroretinogram (PERG), an important electrophysiological 

modality is the response of the central retina to an isoluminant 

stimulus, usually a reversing black and white checker board. PERG, a newer 

electrophysiological modality is used to assess the macular photoreceptor 

and ganglion cell function. 

Aim of the study is to pattern electroretinogram in central serous retinopathy, 

primarily affecting the macular function. 


This prospective study was conducted at the Guru Nanak eye centre, New 

Delhi. 20 patients with recent onset (


fundus biomicroscopy, Fluorescein angiography 

and OCT. Pattern ERG was performed in all 20 

patients using the Arden gold foil electrode on 

ISCEV standardized machine. The Arden gold 

foil electrode was used as the active electrode 

with the gold surface touching the corneoscleral 

limbus and non polarisable Ag/AgCl electrodes 

were used as the ground electrode on the forehead 

and reference electrode (outer canthus). 

Stimulus: Full field monocular stimulation was 

given using the Checkerboard pattern on a 17 inch monitor. The central 

fixation spot size was 4 mm. The 

patient was seated at a distance of 

1 meter from the monitor such that 

the screen occupied 12 degree of the 

patient’s visual field, and with a check 

size of 16 the visual angle subtended 

was 1 degree. 150 stimuli for signal 

averaging at a frequency of 1 pps were 

used. PERG consists of a negative 

wave N1, a positive P50 (P1) wave 

driven by the macular photoreceptors 

thus reflecting the macular function 

and a negative N95(N2) wave for the 

assessment of the retinal ganglion cell 

function. P50, at 50 m.sec latency, is 

measured from the trough of N1 to the peak of P50. N2, at 95 m.sec latency, is 

measured from peak of P50 to trough of N95. 

884


RESULTS 

All the patients in the study group had a relatively good best corrected snellen’s 

visual acuity. 11(55%) of the patients had a BCVA of 6/18. 4 patients (20%) had 

a BCVA of 6/12. 3 patients (15%) had a BCVA of 6/9 and only 2 patients (10%) 

had BCVA of 6/24. At 12 weeks after resolution of CSR 19 patients (95%) had a 

BCVA of 6/6. 1 patient (5%) had a BCVA of 6/9. The log MAR visual acuity at 

presentation was 0.42±0.13. At 6 weeks it was 0.13±0.11 and at 12 weeks it was 

0.01±0.04. 

The wave pattern consisted of the following components: 

1) The first small negative N35 wave. 

2) A positive P50 wave at approx 45-60 ms measured from the N35 trough to 

P50 peak. 

3) A larger negative N95 wave at approx 90- 100 ms measured from the P50 

peak to the trough of N95. 

EYE P50 P50 N95 N95 % age % age 

Normal CSR Normal CSR reduction in reduction in 

P50 

N95 

MEAN 3.38 2.47 5.72 4.27 26.69 % 25.63 % 

SD 0.90 0.86 1.85 1.66 – – 

RANGE 2.0-5.1 1.2-4.5 2.9-9.1 1.8-7.7 – – 

The mean P50 value in the normal eye was 3.38 μv (SD 0.9) compared to 2.47 

μv (SD 0.86) in the affected eye reflecting a 26.69% reduction in the mean P50 

value. The mean N95 value in the normal eye was 5.72 μv (SD 1.85) compared to 

4.27 μv (SD 0.1.66) in the affected eye reflecting a 25.63% reduction in the mean 

N95 value. The study showed that both P50 and N95 waves were significantly 

reduced in the affected eye a.c.t normal eye ( P


• To know the functional status in CSR, Pattern ERG is an excellent diagnostic 

modality. 

REFERENCES 

1. Arden, G. B., Vaegen, and Hogg, C.R. .Clinical and experimental evidence that 

the pattern electroretinogram (PERG) is generated in more proximal retinal layers 

than the focal electroretinogram (FERG). Ann. N. Y. Acad. Sci. 1982;388:214-26. 

2. Holder, G. E. Recording the pattern electroretinogram with the Arden gold foil 

electrode. J. Electrophysiol. Technol. 1988;14:183-90. 

3. Chuang, E.L., Sharp, D.M., Fitzke, F.W., Kemp, C.M., Holden, A.L.and Bird, A.C. 

Retinal dysfunction in central serous retinopathy. Eye 1987;1:120-5. 

4. Yozo Miyake, Noriyasu Shiroyama, Ichiro Ota, and Masayuki Horiguchi. 

Local Macular Electroretinographic Responses in Idiopathic Central Serous 

Chorioretinopathy. Am J Ophthalmol 1988;106:546-50. 

Outcome of Proliferative Diabetic Retinopathy 

Surgery with Pre-operative Bevacizumab as an 

Adjuvant 

Dr. Mahesh G., Dr. Giridhar A., Dr. Thomas Tachil, Dr. Rameez Hussain 

The primary goal of any vitrectomy surgery for Proliferative diabetic 

retinopathy is to restore useful vision by restoring the anatomical integrity 

of the retina. This complex surgery also aims at stabilizing the neovascular 

process thereby producing a long term visual and anatomical outcome. To 

accomplish this goal, vitrectomy for Proliferative diabetic retinopathy involves 

removal of the vitreous scaffold, surface fibrovascular membranes, clearing 

of vitreous hemorrhage and taut posterior hyaloid, endophotocoagulation, 

attaching the retina and give tamponade to maintain the attachment. 

Tractional retinal detachment and non resolving vitreous hemorrhage are the 

most common indication for diabetic vitrectomy. 1 The major intraoperative 

complication of diabetic vitrectomy is hemorrhage into the vitreous cavity 

and iatrogenic breaks which can cause serious impact on the anatomical and 

visual outcome. The most common indication of re-operation is recurrent 

hemorrhage in the vitreous cavity. Interventions such as intra venous 

aminocaproic acid, layering of sodium hyaluronate on sites of peeling and 

removal of fibrovascular membranes, intra ocular injections of thrombin, etc. 

were tried to prevent complications from dispersed hemorrhage which didn’t 

yielded the desired results. 

Intra vitreal use of Bevacizumab which is a full length humanized 

monoclonal antibody to the vascular endothelial growth factor has been 

886


shown to enhance clearance of vitreous hemorrhage and induce involution 

of retinal neovascularization. This study aims to retrospectively analyze the 

anatomical and visual outcomes along with the complications encountered 

in vitrectomised eyes for diabetic retinopathy with pre-operative use of 

Intravitreal Bevacizumab as an adjunctive. 


159 eyes of 159 patients who received 1.25mg in 0.05ml of intravitreal 

Bevacizumab, 5 to 8 days prior to pars plana vitrectomy with various intra 

operative procedures like membrane peeling, endolaser, trans scleral 

cryotherapy, fluid air exchange and tamponade with gas or silicone oil which 

were done between January 2009 to September 2010 were retrospectively 

analyzed. 

Age, sex, duration of diabetes with other systemic diseases like hypertension, 

dyslipidemia, and ischemic heart disease were recorded. Previous history of 

treatment to the operated eye like lasers, intravitreal injections was noted. 

Vitrectomised eyes were grouped according to the major indication for 

surgery as group 1 with Non resolving vitreous hemorrhage with or with 

our pre retinal hemorrhage / fibrovascular proliferation and group 2 with 

tractional / combined retinal detachment with or without vitreous or pre 

retinal hemorrhage and fibro vascular proliferation. Eyes were also grouped 

according to the tamponading agents used such as silicon oil, gas and air. 

Further, pre-operative data like Best corrected visual acuity using Snellens 

chart, anterior segment findings like corneal status, cataract. Intra ocular 

pressure etc. before the intra vitreal injection was recorded. All intra vitreal 

injections were given in operation theatre under sterile precautions by a two 

surgeons, 5 to 7 days prior to surgery. A prophylactic antibiotic was given after 

the injection to use till the date of surgery. All surgeries were done by two 

consultant vitreo retinal surgeons. 

Mean age 

56.84 years 

Male to female ratio 3.7 : 2.2 

Mean duration of diabetes 

19.09 years 

Associated systemic diseases Hypertension: 52/159 (65.41%) 

Dyslipidemia: 20/159 (12.58%) 

Ischemic heart disease: 13/159 (8.18%) 

Nephropathy: 7/159 (4.4%) 

Control of diabetes (with HbA1c levels) Good: 6/159 (3.77%) 

Moderate: 132/159 (83.02%) 

Poor: 21/159 (13.21%) 

Major indication for surgery • VH ± pre retinal hge ± FVP : 101/159 

• TRD/CRD ± FVP / VH or Pre retinal 

hge: 58/159 

887


Tamponade Silicon oil : 61/159 (38.36%) 

C 3 

F 8 

and SF 6 

: 49/159 (30/82%) 

FAE : 38/159 (23.9%) 

None : 11/159 (6.91%) 

Pre-operative lens status Phakic : 89/159 (55.97%) 

Pseudophakia : 70/159 (44.03%) 

Pre operative treatment for PDR 

888 

Laser: 

IVTA: 

Abbreviations: VH-Vitreous hemorrhage; TRD-Tractional retinal detachment; CRD- 

Combined retinal detachment; FAE - Fluid-air exchange; FVP- Fibrovascular proliferation; 

IVTA- Intra vitreal triamcinolone acetonide. 

Standard 20G vitrectomy was done for all cases with membrane peeling, 

endolaser photocoagulation, trans scleral cryotherapy and fluid air exchange 

done wherever necessary and tamponading agents like silicon oil, C 3 

F 8 

and SF 6 

were used appropriately. On the first post-operative day, the anterior segment 

and fundus findings including oozing spots, dispersed hemorrhage, retinal 

detachments etc. were analyzed. Recorded findings in the subsequent follow 

up visits including best corrected visual acuity, intra ocular pressure, anterior 

segment changes raised IOP, like progression of cataract, pupillary distortion 

and rubeosis were assessed. Some cases where cataract and filtering surgery 

was performed were also analyzed. Anatomical status of the retina which 

was recorded using fundus biomicroscopy and indirect ophthalmoscopy and 

B scan ultrasonography (where media haze was present) was also analyzed. 

Repeat surgery in case of any complication was retrospectively studied. These 

parameters were assessed separately for all the groups based on indications 

of the surgery and the tamponade used. The mean follow up period was 13.5 

months. 

RESULTS 

Mean age of the patients was 56.84 years. Male to female ratio was 3.7: 2.2. 

The mean duration of the diabetes was 19.09 years. Control of diabetes were 

assessed using HbA1C status of the patient before the surgery which showed 

a 3.77% (6/159) had good control, 83.02% (132/159) had moderate and 13.21% 

(21/159) had poor control of diabetes mellitus. 

Hypertension was to be highly associated with patients with PDR (65.41%), 

12.58% had dyslipidemia and 8.18% were having associated ischemic heart 

disease. Nephropathy was seen in 4.4%. 

101/159 (63.52%) eyes had Non resolving vitreous hemorrhage with or with 

our pre retinal hemorrhage / fibrovascular proliferation as major indication 

for vitrectomy. 58/159 (36.48%) eyes had Tractional / combined retinal 

detachment with or without vitreous or pre retinal hemorrhage and fibro 

vascular proliferation as indication.


Intra operatively, silicon oil was used as tamponading agent in 61/159 (38.36%), 

gases like C 3 

F 8 

and SF 6 

were used in 49/159 (30/82%). No tamponading agents 

were used in 

11/159 (6.91%). Only FAE was done in 38/159 (23.9%) 

VH group TRD group Silicon oil Gas FAE/None 

n=101 n=58 n=61 n=49 n=49 

Mean pre op 1.65±0.44 1.6±0.41 1.72±0.34 1.60±0.48 1.63±0.40 

VA 

Mean Post op 1.01±0.80 1.22±0.61 1.34±0.63 1.18±0.84 0.69±0.60 

VA 

Glaucoma 7/101(7%) 12/58(20.6%) 9/61(14.75%) 4/49(8.6%) 6/49(12.24%) 

Cataract 19/59(32.20%) 21/30(70%) 21/34(61.76%) 10/30(33.33%) 9/25(36%) 

Rubeosis 1/101 1/58 0 1/49 1/49 

Repeat IVA -4/101 IVA-1/58 IVA-I/61 IVA-3/49 IVA-1/49 

surgery/ SOR – 3/101 SOR-6/58 SOR-9/61 

Injections SOI – 3/101 SOI-1/58 RESOI-1/61 SOI-2/49 SOI-1/49 

& procedures VL – 5/101 VL-2/58 VL-0 VL-4/49 VL-3/49 

LASER – LASER- LASER-0 LASER-6/49 1/49 

4/101 3/58 

CRYO- 2/101 CRYO-0 CRYO-2/49 1/49 

CRYO-1/58 TRAB-1/49 TRAB-1/49 

TRAB-2/58 

Other RD – 3/101 2/58 0 RD-3/49 RD-2/49 

complications 

Visual acuity improved in 118 eyes (74.21%), deteriorated in 13 eyes(8.18%), 

stabilized in 21 eyes(13.21%) and 7 eyes(4.4%) lost perception of light. 40 

(44.94%) out of 89 phakic eyes developed significant cataract in which 26 eyes 

underwent cataract surgery. 19 eyes(11.95%) developed Secondary glaucoma. 

11 eyes(57.89%) were treated successfully in which 2 eyes underwent 

Trabeculectomy. 32 eyes(20.12%) had rebleed out of which 7 eyes underwent 

Vitreous lavage. 

DISCUSSION 

Pharmacokinetic studies of intravitreal Bevacizumab in humans show that 

the half life of the drug in the aqueous was 9.8 days. Pre operative intra vitreal 

bevacizumab 5 to 10 days prior to diabetic vitrectomy will harbor maximum 

concentration inside the eye during surgery. Various studies have proved that 

this will enhance clearance of vitreous hemorrhage and induce involution 

of retinal neovascularization thereby preventing complications during 

surgery. Chen et. al. reported that preoperative IVB was helpful in facilitating 

vitrectomy in severe PDR. 

889


Post operative visual outcome after diabetic vitrectomy with the use of 

adjunctive IVB were comparable to similar study conducted by di lauro et. 

al. and Madarres et. al. A compromise in post surgery visual acuity was seen 

in cases where silicon oil was used as the tamponade. A high percentage of 

cataract formation was seen in silicon oil group and also TRD group. Vitreous 

lavage was needed for 7 eyes belonging to gas and FAE groups but eyes with 

silicon oil tamponade showed better anatomic and vascular stability. 

In conslusion Pre operative IVB makes diabetic vitrectomy safer and effective 

for severe PDR thereby enhancing the anatomical and visual outcomes. 

Phacoemulsification with Intravitreal 

Triamcinolone Acetonide Injection in Diabetic 

Macular Edema and Cataract 

Dr. Shikha Talwar Bassi, Dr. Ekta Rishi, Dr. Vineet Ratra, Dr. Jayant Kadaskar 

Diabetic macular edema (DMO) is the main cause of poor visual recovery 

after a cataract surgery in diabetics. 1,2 A study has reported an increased 

aqueous levels of vascular endothelial growth factors and interleukin-6 

postoperatively after a cataract surgery in diabetics which can cause a 

worsening of the DMO. 3 Intravitreal corticosteroids have been documented 

to reduce the diabetic macular oedema. 4,5 The inflammatory response to 

the cataract surgery can be controlled with an intravitreal corticosteroid 

injection during the cataract surgery. On this hypothesis studies have already 

documented a reduction in the amount of increase in center- point thickness 

after a cataract surgery with intravitreal corticosteroid injection. 6 


A retrospective analysis of 18 eyes of 13 diabetic patients with DMO and 

significant cataract, who underwent phacoemulsification with intravitreal 

triamcinolone injection (4 mg) during the surgery was done. Study was 

carried out at tertiary care center in south India. All eyes had a preoperative 

examination including measurement of visual acuity, intraocular pressure, A 

scan biometry, a detailed slit lamp biomicroscopy under maximal mydriasis. 

All patient were evaluated by optical coherence tomography before surgery. 

Central Macular thickness (CMT) was noted preoperatively in all the 

patients. After cataract surgery with phacoemulsification technique 4 mg of 

triamcinolone acetonide was injected through pars plana 3.5 mm to 4.0 mm 

posterior to limbus with 28 guage needle. All eyes were evaluated on first day, 

third day and three weeks later after the surgery. Nine eyes underwent OCT 

at three weeks visit, CMT was noted. The BCVA pre operatively and after 3 

890


weeks were compared with the initial values. The CMT of 9 patients pre and 

post operatively was compared . 

RESULTS 

The comparison of the pre and post cataract surgery CMT using OCT for the 

9 patients revealed a significant reduction in the CMT post cataract surgery. 

The mean initial CMT for 9 eyes was 393.23 microns ± 195.8 (SD) range ( 156- 

693) , and post operative CMT of 9 patients was 172.23 ± 69.28 (SD) range (67- 

314) , (p


Also the mean initial CMT for 9 eyes was 393.23µm ± 195.8 and post operatively 

CMT of same 9 patients was 172.23µm ± 69.28 , (p

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