Purpose: To report a patient with submacular hemorrhage due to retinal angiomatous proliferation ... more Purpose: To report a patient with submacular hemorrhage due to retinal angiomatous proliferation (RAP) in tubercular retinal vasculitis (TRV). Methods: Case report Results: We report a 33-year-old Asian Indian patient of TRV presenting with capillary non-perfusion areas, submacular hemorrhage and venous loops. The patient presented with sudden onset decrease in vision in the right eye. Multimodal imaging revealed presence of retinal vascular anastomosis and stage 2 RAP. Systemic examination was within normal limits. Laboratory evaluation revealed positive Mantoux and interferon gamma release assay. He underwent right eye intravitreal injection of recombinant tissue plasminogen activator (12.5µg/0.1ml) with 100% sulphur hexafluoride (SF6) tamponade. The patient had successful displacement of the submacular hemorrhage with some improvement in visual acuity. Conclusion: This case highlights that rare vascular alterations such as RAP can develop in subjects with ocular tuberculosis.
ABSTRACT Introduction Last few decades in medical retina have encountered significant development... more ABSTRACT Introduction Last few decades in medical retina have encountered significant development in the field of pharmacotherapy. With better understanding of molecular mechanisms and disease pathophysiology, alternate pathways are being targeted in various clinical trials. Areas covered In this review, a comprehensive list of newer therapeutic agents in various retinal conditions like diabetic macular edema (DME), age-related macular degeneration (ARMD), inherited retinal diseases (IRDs) and non-arteritic ischemic optic neuropathy (NAION) have been elucidated. The review highlights alternate pathways involved in pathogenesis of DME and ARMD, and gives a brief summary of several phase I and phase II trials targeting these pathways. The review also briefly highlights the advancements in the field of gene therapy, stem cell transplantation, neuro-protection and retinal implants in IRDs. Lastly, available treatment options for NAION have been discussed. Expert opinion Evidence based medicine has allowed researches and vision scientists to explore newer drugs and target alternate disease pathways. Promising results with initial clinical trials will pave the pathway for larger studies and allow clinicians to overcome treatment burden presently associated with available treatment options.
Haemorrhagic choroidal detachment (HCD) is a dreaded intraoperative complication of ophthalmic su... more Haemorrhagic choroidal detachment (HCD) is a dreaded intraoperative complication of ophthalmic surgery, despite being rare. Multiple systemic and ocular risk factors of HCD have been reported. Acute hypotony during surgery is considered one of the most important precipitating factors. We herein describe a series of events during pars plana vitrectomy surgery for management of rhegmatogeneous retinal detachment which lead to localised HCD. We believe that the pathogenesis of localised HCD is related to compressive decompressive forces during the final tie of the encircling element after fluid air exchange.
Objective: To detect retinal involvement in coronavirus disease 2019 (COVID-19) patients in acute... more Objective: To detect retinal involvement in coronavirus disease 2019 (COVID-19) patients in acute and convalescent phase by their fundus screening.Methods: In a prospective, cross-sectional, observational study (July–November 2020), 235 patients (142 acute and 93 convalescent phase) underwent fundus screening in a tertiary care center in North India. For convalescent phase, “hospitalized” patients (73) were screened at least 2 weeks after hospital discharge, and “home-isolated” patients (20) were screened 17 days after symptom onset/COVID-19 testing.Results: None in acute phase showed any retinal lesion that could be attributed exclusively to COVID-19. Five patients (5.38%) in convalescent phase had cotton wool spots (CWSs) with/without retinal hemorrhage, with no other retinal finding, and no visual symptoms, seen at a median of 30 days from COVID-19 diagnosis.Conclusions: CWSs (and retinal hemorrhages) were an incidental finding in COVID-19, detected only in the convalescent phase...
Purpose: The aim of this work was to study various retinochoroidal parameters in patients with ob... more Purpose: The aim of this work was to study various retinochoroidal parameters in patients with obstructive sleep apnea syndrome (OSAS) and the effect of interventions on these parameters at 6 months follow-up. Methods: A total of 36 patients were recruited prospectively from the otorhinolaryngology clinics of a large tertiary center between September 2018 to March 2020. The subjects were divided into three groups depending upon intervention chosen for OSAS: Group A (surgery, i.e., uvulopalatopharyngoplasty), group B (medical therapy, i.e., continuous positive air pressure) and group C (no intervention). Various retinochoroidal parameters which were studied included retinal thickness (RT), choroidal thickness (CT), choroidal vascularity index (CVI), arteriovenous ratio (AVR), capillary density index (CDI) in superficial and deep retina, at baseline and 6 months of follow-up after the intervention. Results: In group A, CT increased significantly at 6 months (332.76 ± 86.41 um) compared to baseline (306.28 ± 78.19) (P = 0.0004). Similarly, CDI at both superficial and deep capillary plexus increased significantly at 6 months (superficial CDI: 0.65 ± 0.04, deep CDI: 0.38 ± 0.01) compared to baseline (superficial CDI: 0.62 ± 0.03, deep CDI: 0.36 ± 0.02) (P = 0.004 and 0.002 respectively). In group B, CT increased significantly at 6 months (361.38 ± 78.63 um) compared to baseline (324.21 ± 76.97 um) (P = 0.008). Also, CVI showed a significant decrease at 6 months (65.74 ± 1.84%) compared to baseline (67.36 ± 1.57%) (P = 0.019). In group C, all except CDI in deep capillary plexus showed a significant decrease at 6 months (0.35 ± 0.01) compared to baseline (0.36 ± 0.02) (P = 0.003). Conclusion: OSAS alters various retinochoroidal parameters and timely intervention in patients with OSAS can prevent these alterations. Also, these retinochoroidal parameters could serve as one of the markers to monitor the disease progression.
A 47-year-old man presented to our retina clinic with gradual onset diminution of vision in his r... more A 47-year-old man presented to our retina clinic with gradual onset diminution of vision in his right eye for the last 3 months. Anterior segment evaluation was normal in both eyes. Fundus evaluation showed the presence of leopard spot appearance in the right eye with inferior exudative retinal detachment. Multimodal imaging was done to evaluate retinal pigment epithelium function, choroidal thickness, choroidal vascularity and scleral thickness. Multimodal imaging showed increased choroidal thickness, choroidal congestion on indocyanine green angiography and peripheral choroidal detachment with normal sclera thickness in our patient, thus pointing towards a diagnosis of uveal effusion syndrome type 3.
This report highlights the association of tacrolimus use with acute macular neuroretinopathy (AMN... more This report highlights the association of tacrolimus use with acute macular neuroretinopathy (AMN). A 27-year-old woman, a known case of diffuse proliferative membranous glomerulonephritis, developed abnormal body movements, loss of consciousness, and blurring of vision in the left eye, after 3 months of starting tacrolimus. Blood investigations revealed anemia, thrombocytopenia, raised urea and creatinine levels, and raised LDH levels. A diagnosis of tacrolimus induced hemolytic uremic syndrome (HUS) with posterior reversible encephalopathy syndrome (PRES) was made. Ocular examination revealed a reddish-brown petaloid retinal lesion, which was better appreciated on red-free imaging as dark grey area pointing towards the fovea. OCT-A and SD-OCT revealed flow voids in deep retinal plexus, and disruption of ellipsoid and interdigitation zone, respectively, findings consistent with AMN. To the best of our knowledge, it is the first report of association of tacrolimus with AMN.
Purpose: Ocular tuberculosis has protean clinical manifestations. Because of its varied clinical ... more Purpose: Ocular tuberculosis has protean clinical manifestations. Because of its varied clinical presentation, multimodal imaging is essential to characterize the disease activity, presence of inflammation, determining therapeutic response, and detection of complications. Methods: Narrative review Results: In this review, various imaging modalities employed in the management of ocular tuberculosis including fluorescein angiography (FA), indocyanine green angiography (ICGA), optical coherence tomography (OCT), and optical coherence tomography angiography (OCTA) have been reviewed. Not only do these imaging tools complement each other in providing a comprehensive assessment of the pathology, they also help in gaining valuable insights regarding the evolution of the disease. Conclusions: Fundus imaging plays a vital role in the diagnosis and management of patients with posterior uveitis due to tuberculosis. Fundus imaging may have a useful role in defining clinical endpoints for ocular tuberculosis in the future.
Intrachoroidal cavitation (ICC) is a morphological feature outlined by optical coherence tomograp... more Intrachoroidal cavitation (ICC) is a morphological feature outlined by optical coherence tomography and is characterized by presence of a hyporeflective space beneath the unaltered retinal pigment epithelium. It can be peripapillary or macular in location. Macular ICCs are reported in both myopic and non-myopic eyes. We report a case of full thickness macular hole with retinal incarceration into the macular ICC in a patient with pathological myopia. The term “Peripapillary sink hole” has been described in the literature. We propose the use of term “Macular sink hole” for our case owing to similar findings in the macula.
Figure 1: (a) Left eye at presentation showing the inferonasal scleral nodule of 2*2 mm size with... more Figure 1: (a) Left eye at presentation showing the inferonasal scleral nodule of 2*2 mm size with diffuse congestion and dilated tortuous vessels. (b) Left eye 3 months post ATT shows complete resolution of the granuloma leaving a small flat bluish lesion. (c) Fundus image of right eye at presentation shows an inferotemporal well‐defined yellowish elevated choroidal mass with surrounding subretinal fluid. (d) Fundus image of right eye 3 months post‐ATT shows resolution of the granuloma with choroidal thinning and scar formation. There is also the complete resolution of subretinal fluid d c b a segment of one eye and the posterior segment of the other eye. In this case, the diagnosis of extra-pulmonary tuberculosis was confirmed by histopathology and the granulomatous ocular lesions responded well to ATT. This case highlights the variable presentations of ocular TB in two eyes of the same patient.
Diabetic retinopathy is one of the major microvascular complications of diabetes mellitus. The mo... more Diabetic retinopathy is one of the major microvascular complications of diabetes mellitus. The most common causes of vision loss in diabetic retinopathy are diabetic macular edema and proliferative diabetic retinopathy. Recent developments in ocular imaging have played a significant role in early diagnosis and management of these complications. Color fundus photography is an imaging modality, which is helpful for screening patients with diabetic eye disease and monitoring its progression as well as response to treatment. Fundus fluorescein angiography (FFA) is a dye-based invasive test to detect subtle neovascularization, look for areas of capillary non-perfusion, diagnose macular ischemia, and differentiate between focal and diffuse capillary bed leak in cases of macular edema. Recent advances in retinal imaging like the introduction of spectral-domain and swept source-based optical coherence tomography (OCT), fundus autofluorescence (FAF), OCT angiography, and ultrawide field imag...
Intrachoroidal cavitation is a morphological entity usually described in high myopic eyes. It is ... more Intrachoroidal cavitation is a morphological entity usually described in high myopic eyes. It is usually seen in peripapillary location, though macular location has also been reported. It has been associated with optic disc tilting and posterior staphyloma. We report a case of a 27 year old female who presented to us with recent onset scotoma in her visual field. On examination she had a fundal coloboma with intercalary membrane detachment with intrachoroidal cavitation at the edge of the coloboma. We hypothetise that this intrachoroidal cavitation is a secondary phenomenon and is responsible for recent onset scotoma in her visual field.
Introduction: The field of vitreoretinal surgery has shown rapid technological improvements in th... more Introduction: The field of vitreoretinal surgery has shown rapid technological improvements in the past decade. There has been tremendous progress in our capabilities of viewing the retina and the vitreoretinal interface during surgery. Areas Covered: In this review, a comprehensive list of novel techniques and instrumentation in pars plana vitreous surgery have been elucidated. The review includes various enhancements in the visualization systems including operating microscopes and 3D heads-up display systems. Viewing systems such as endoscopic vitrectomy have been described. New vitrectomy machines with advanced duty cycles, vitrectors with modified designs and higher cut rates, and intraocular instruments such as endoilluminators and lasers have been described. The review also covers new dyes, A c c e p t e d M a n u s c r i p t 3 tamponade agents, as well as novel surgical procedures including submacular surgeries, retinal transplants, and gene therapies. Expert Opinion: Novel vitrectomy systems and reduced gauge size of the instruments greatly aid in the management of patients with vitreoretinal diseases. With advances and refinements in this field, there is a great scope of improving the overall structural and functional outcomes of our patients.
Purpose: To report a patient with submacular hemorrhage due to retinal angiomatous proliferation ... more Purpose: To report a patient with submacular hemorrhage due to retinal angiomatous proliferation (RAP) in tubercular retinal vasculitis (TRV). Methods: Case report Results: We report a 33-year-old Asian Indian patient of TRV presenting with capillary non-perfusion areas, submacular hemorrhage and venous loops. The patient presented with sudden onset decrease in vision in the right eye. Multimodal imaging revealed presence of retinal vascular anastomosis and stage 2 RAP. Systemic examination was within normal limits. Laboratory evaluation revealed positive Mantoux and interferon gamma release assay. He underwent right eye intravitreal injection of recombinant tissue plasminogen activator (12.5µg/0.1ml) with 100% sulphur hexafluoride (SF6) tamponade. The patient had successful displacement of the submacular hemorrhage with some improvement in visual acuity. Conclusion: This case highlights that rare vascular alterations such as RAP can develop in subjects with ocular tuberculosis.
ABSTRACT Introduction Last few decades in medical retina have encountered significant development... more ABSTRACT Introduction Last few decades in medical retina have encountered significant development in the field of pharmacotherapy. With better understanding of molecular mechanisms and disease pathophysiology, alternate pathways are being targeted in various clinical trials. Areas covered In this review, a comprehensive list of newer therapeutic agents in various retinal conditions like diabetic macular edema (DME), age-related macular degeneration (ARMD), inherited retinal diseases (IRDs) and non-arteritic ischemic optic neuropathy (NAION) have been elucidated. The review highlights alternate pathways involved in pathogenesis of DME and ARMD, and gives a brief summary of several phase I and phase II trials targeting these pathways. The review also briefly highlights the advancements in the field of gene therapy, stem cell transplantation, neuro-protection and retinal implants in IRDs. Lastly, available treatment options for NAION have been discussed. Expert opinion Evidence based medicine has allowed researches and vision scientists to explore newer drugs and target alternate disease pathways. Promising results with initial clinical trials will pave the pathway for larger studies and allow clinicians to overcome treatment burden presently associated with available treatment options.
Haemorrhagic choroidal detachment (HCD) is a dreaded intraoperative complication of ophthalmic su... more Haemorrhagic choroidal detachment (HCD) is a dreaded intraoperative complication of ophthalmic surgery, despite being rare. Multiple systemic and ocular risk factors of HCD have been reported. Acute hypotony during surgery is considered one of the most important precipitating factors. We herein describe a series of events during pars plana vitrectomy surgery for management of rhegmatogeneous retinal detachment which lead to localised HCD. We believe that the pathogenesis of localised HCD is related to compressive decompressive forces during the final tie of the encircling element after fluid air exchange.
Objective: To detect retinal involvement in coronavirus disease 2019 (COVID-19) patients in acute... more Objective: To detect retinal involvement in coronavirus disease 2019 (COVID-19) patients in acute and convalescent phase by their fundus screening.Methods: In a prospective, cross-sectional, observational study (July–November 2020), 235 patients (142 acute and 93 convalescent phase) underwent fundus screening in a tertiary care center in North India. For convalescent phase, “hospitalized” patients (73) were screened at least 2 weeks after hospital discharge, and “home-isolated” patients (20) were screened 17 days after symptom onset/COVID-19 testing.Results: None in acute phase showed any retinal lesion that could be attributed exclusively to COVID-19. Five patients (5.38%) in convalescent phase had cotton wool spots (CWSs) with/without retinal hemorrhage, with no other retinal finding, and no visual symptoms, seen at a median of 30 days from COVID-19 diagnosis.Conclusions: CWSs (and retinal hemorrhages) were an incidental finding in COVID-19, detected only in the convalescent phase...
Purpose: The aim of this work was to study various retinochoroidal parameters in patients with ob... more Purpose: The aim of this work was to study various retinochoroidal parameters in patients with obstructive sleep apnea syndrome (OSAS) and the effect of interventions on these parameters at 6 months follow-up. Methods: A total of 36 patients were recruited prospectively from the otorhinolaryngology clinics of a large tertiary center between September 2018 to March 2020. The subjects were divided into three groups depending upon intervention chosen for OSAS: Group A (surgery, i.e., uvulopalatopharyngoplasty), group B (medical therapy, i.e., continuous positive air pressure) and group C (no intervention). Various retinochoroidal parameters which were studied included retinal thickness (RT), choroidal thickness (CT), choroidal vascularity index (CVI), arteriovenous ratio (AVR), capillary density index (CDI) in superficial and deep retina, at baseline and 6 months of follow-up after the intervention. Results: In group A, CT increased significantly at 6 months (332.76 ± 86.41 um) compared to baseline (306.28 ± 78.19) (P = 0.0004). Similarly, CDI at both superficial and deep capillary plexus increased significantly at 6 months (superficial CDI: 0.65 ± 0.04, deep CDI: 0.38 ± 0.01) compared to baseline (superficial CDI: 0.62 ± 0.03, deep CDI: 0.36 ± 0.02) (P = 0.004 and 0.002 respectively). In group B, CT increased significantly at 6 months (361.38 ± 78.63 um) compared to baseline (324.21 ± 76.97 um) (P = 0.008). Also, CVI showed a significant decrease at 6 months (65.74 ± 1.84%) compared to baseline (67.36 ± 1.57%) (P = 0.019). In group C, all except CDI in deep capillary plexus showed a significant decrease at 6 months (0.35 ± 0.01) compared to baseline (0.36 ± 0.02) (P = 0.003). Conclusion: OSAS alters various retinochoroidal parameters and timely intervention in patients with OSAS can prevent these alterations. Also, these retinochoroidal parameters could serve as one of the markers to monitor the disease progression.
A 47-year-old man presented to our retina clinic with gradual onset diminution of vision in his r... more A 47-year-old man presented to our retina clinic with gradual onset diminution of vision in his right eye for the last 3 months. Anterior segment evaluation was normal in both eyes. Fundus evaluation showed the presence of leopard spot appearance in the right eye with inferior exudative retinal detachment. Multimodal imaging was done to evaluate retinal pigment epithelium function, choroidal thickness, choroidal vascularity and scleral thickness. Multimodal imaging showed increased choroidal thickness, choroidal congestion on indocyanine green angiography and peripheral choroidal detachment with normal sclera thickness in our patient, thus pointing towards a diagnosis of uveal effusion syndrome type 3.
This report highlights the association of tacrolimus use with acute macular neuroretinopathy (AMN... more This report highlights the association of tacrolimus use with acute macular neuroretinopathy (AMN). A 27-year-old woman, a known case of diffuse proliferative membranous glomerulonephritis, developed abnormal body movements, loss of consciousness, and blurring of vision in the left eye, after 3 months of starting tacrolimus. Blood investigations revealed anemia, thrombocytopenia, raised urea and creatinine levels, and raised LDH levels. A diagnosis of tacrolimus induced hemolytic uremic syndrome (HUS) with posterior reversible encephalopathy syndrome (PRES) was made. Ocular examination revealed a reddish-brown petaloid retinal lesion, which was better appreciated on red-free imaging as dark grey area pointing towards the fovea. OCT-A and SD-OCT revealed flow voids in deep retinal plexus, and disruption of ellipsoid and interdigitation zone, respectively, findings consistent with AMN. To the best of our knowledge, it is the first report of association of tacrolimus with AMN.
Purpose: Ocular tuberculosis has protean clinical manifestations. Because of its varied clinical ... more Purpose: Ocular tuberculosis has protean clinical manifestations. Because of its varied clinical presentation, multimodal imaging is essential to characterize the disease activity, presence of inflammation, determining therapeutic response, and detection of complications. Methods: Narrative review Results: In this review, various imaging modalities employed in the management of ocular tuberculosis including fluorescein angiography (FA), indocyanine green angiography (ICGA), optical coherence tomography (OCT), and optical coherence tomography angiography (OCTA) have been reviewed. Not only do these imaging tools complement each other in providing a comprehensive assessment of the pathology, they also help in gaining valuable insights regarding the evolution of the disease. Conclusions: Fundus imaging plays a vital role in the diagnosis and management of patients with posterior uveitis due to tuberculosis. Fundus imaging may have a useful role in defining clinical endpoints for ocular tuberculosis in the future.
Intrachoroidal cavitation (ICC) is a morphological feature outlined by optical coherence tomograp... more Intrachoroidal cavitation (ICC) is a morphological feature outlined by optical coherence tomography and is characterized by presence of a hyporeflective space beneath the unaltered retinal pigment epithelium. It can be peripapillary or macular in location. Macular ICCs are reported in both myopic and non-myopic eyes. We report a case of full thickness macular hole with retinal incarceration into the macular ICC in a patient with pathological myopia. The term “Peripapillary sink hole” has been described in the literature. We propose the use of term “Macular sink hole” for our case owing to similar findings in the macula.
Figure 1: (a) Left eye at presentation showing the inferonasal scleral nodule of 2*2 mm size with... more Figure 1: (a) Left eye at presentation showing the inferonasal scleral nodule of 2*2 mm size with diffuse congestion and dilated tortuous vessels. (b) Left eye 3 months post ATT shows complete resolution of the granuloma leaving a small flat bluish lesion. (c) Fundus image of right eye at presentation shows an inferotemporal well‐defined yellowish elevated choroidal mass with surrounding subretinal fluid. (d) Fundus image of right eye 3 months post‐ATT shows resolution of the granuloma with choroidal thinning and scar formation. There is also the complete resolution of subretinal fluid d c b a segment of one eye and the posterior segment of the other eye. In this case, the diagnosis of extra-pulmonary tuberculosis was confirmed by histopathology and the granulomatous ocular lesions responded well to ATT. This case highlights the variable presentations of ocular TB in two eyes of the same patient.
Diabetic retinopathy is one of the major microvascular complications of diabetes mellitus. The mo... more Diabetic retinopathy is one of the major microvascular complications of diabetes mellitus. The most common causes of vision loss in diabetic retinopathy are diabetic macular edema and proliferative diabetic retinopathy. Recent developments in ocular imaging have played a significant role in early diagnosis and management of these complications. Color fundus photography is an imaging modality, which is helpful for screening patients with diabetic eye disease and monitoring its progression as well as response to treatment. Fundus fluorescein angiography (FFA) is a dye-based invasive test to detect subtle neovascularization, look for areas of capillary non-perfusion, diagnose macular ischemia, and differentiate between focal and diffuse capillary bed leak in cases of macular edema. Recent advances in retinal imaging like the introduction of spectral-domain and swept source-based optical coherence tomography (OCT), fundus autofluorescence (FAF), OCT angiography, and ultrawide field imag...
Intrachoroidal cavitation is a morphological entity usually described in high myopic eyes. It is ... more Intrachoroidal cavitation is a morphological entity usually described in high myopic eyes. It is usually seen in peripapillary location, though macular location has also been reported. It has been associated with optic disc tilting and posterior staphyloma. We report a case of a 27 year old female who presented to us with recent onset scotoma in her visual field. On examination she had a fundal coloboma with intercalary membrane detachment with intrachoroidal cavitation at the edge of the coloboma. We hypothetise that this intrachoroidal cavitation is a secondary phenomenon and is responsible for recent onset scotoma in her visual field.
Introduction: The field of vitreoretinal surgery has shown rapid technological improvements in th... more Introduction: The field of vitreoretinal surgery has shown rapid technological improvements in the past decade. There has been tremendous progress in our capabilities of viewing the retina and the vitreoretinal interface during surgery. Areas Covered: In this review, a comprehensive list of novel techniques and instrumentation in pars plana vitreous surgery have been elucidated. The review includes various enhancements in the visualization systems including operating microscopes and 3D heads-up display systems. Viewing systems such as endoscopic vitrectomy have been described. New vitrectomy machines with advanced duty cycles, vitrectors with modified designs and higher cut rates, and intraocular instruments such as endoilluminators and lasers have been described. The review also covers new dyes, A c c e p t e d M a n u s c r i p t 3 tamponade agents, as well as novel surgical procedures including submacular surgeries, retinal transplants, and gene therapies. Expert Opinion: Novel vitrectomy systems and reduced gauge size of the instruments greatly aid in the management of patients with vitreoretinal diseases. With advances and refinements in this field, there is a great scope of improving the overall structural and functional outcomes of our patients.
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Papers by Ashish Markan