Tips on Retina Practice- A Practice Series

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Preface

This booklet (Part-I) has been written by
a retina specialist with years of
extensive experience after training from
the premier institute with a view to be
useful to the comprehensive, general
ophthalmologists primarily for
comprehensive ophthalmologists and
will also help those involved in treating
retinal diseases. It is not meant to be the
comprehensive textbook; rather it’s an
easily digestible booklet on tips and facts
about commonly encountered diseases
in day to day ophthalmic practice.

The tips and tricks outlined in this text
are not often discussed or adequately
emphasised in most text books.

It was initially started as a discussion and
then expanded into a full blown practice
series. The suggestions of converting it
into a book would have robbed it of the
appeal and stupendous following that
the discussion generated on different

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online forums. You may already be
aware of this from those discussions but
this book takes away none of the charm
of reading the tips compiled and made
available on your mobile phones or
tablets.
We hope you enjoy reading this.
Suggestions and feedbacks are welcome.

Dr Sanjay Ahuja
Dr Jatinder Bali, ed

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ABOUT THE AUTHOR

Dr. Sanjay Ahuja
did his MBBS
from
UCMS/Safdarjang
Hospital / Delhi
University /1980
Batch (joining).
He completed MD
Ophthalmology
from RPC,AIIMS
in 1990. He completed his Senior
Residency in Retina unit from RPC
(AIIMS) (1990-93) under Prof Khosla,
Prof Tiwari, Prof Atul Kumar & Dr. Lalit
Verma. He worked as Part time Retina
consultant at MM EyeTech (Lajpat
Nagar) with Prof Madan Mohan, Dr. Rishi
Mohan & Dr. Indira Mohan from 1993 to
2007). He ran his private clinics at
Parmanand Colony (Mukherjee Nagar) &
Vijay Nagar (Near Delhi University) from

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1993-2011 which have now been
expanded into a four storey Eye Nursing
Home at Parmanand Colony (Mukherjee
Nagar) with his wife, Dr. Aparna Ahuja,
who is also an Ophthalmologist from
RPC/AIIMS (1990 batch joining)

Dr Ahuja is currently working as..

1. Visiting Prof of Ophthalmology
(Guest Teacher) at Dr. Sur
Homeopathic Medical College
(SHMC) at Moti Bagh, IP
University, Delhi Govt.

2. Head of Ophtha Deptt at Sant
Nirankari Mandal (SNM)
Charitable hospital at Nirankari
Colony, Delhi-9.

3. Honorary senior consultant at
Tirath Ram Shah Hospital (Near
Tis Hazari courts).

He is the co-author of 2 Books on Eye
Disorders for Laymen with Dr. Aparna
Ahuja. He received special cash prizes &
certificates by ICMR, Delhi (2005) &

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Central Health Ministry, Govt. of India
(2008).
He has authored over 50 articles in
Indexed & Non-indexed journals &
Health magazines.

Dr. Jatinder Bali
Delhi.

07 July 2020.

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Edited, Proofed and Published by Dr
Jatinder Bali.

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PRACTICAL
TIPS in
Medical Retina

--Dr Sanjay Ahuja.

Tip-1
Cross sectional image of conventional
OCT scan is the B-Scan structural
image.
Consider it in 2 parts-
1. Inner retina with 3 hyper reflective
layers (viz. From in to out- RNFL,
IPL & OPL) is primarily affected in
retinal vascular disorders e.g DR,
CRVO..
2. Outer retina with 3 hyper reflective
layers (viz. From in to out- ELM,
IS/OS junction or Ellipsoid layer &
RPE) is primarily affected in ARMD,
CSR, etc ...

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Tip-2
In Macular OCT image- To know
whether correct FOVEAL cut has
been obtained, check that OPL (Outer
Plexiform layer) should join RNFL at
one point in the foveal pit.

Tip-3
In this COVID era, one may put the
Cling film over & around the lens
(towards patient’s side) of Fundus
camera, Lasers, OCT or S/L without
any significant compromise in quality.
The film may be cleaned with alcohol
swabs or changed for every patient.

Tip-4
For proper evaluation (qualitative) of
retinal diseases on OCT scan, always
take the black & white (grey scale)
printout & NOT the coloured print.

Tip-5
In OCTA (OCT Angiography) no dye
is injected (hence non-invasive) to
study the retinal & choroidal vessels

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at various levels) The role of dye is
taken up by the moving RBCs in the
capillaries.

Tip-6
To differentiate whether it’s a Red-
free fundus photo (taken with green
filter on fundus camera) or Fundus
Autofluorescence photo (FAF),
Look at the optic disc.
It is dark/black on FAF
but
white on Red-free.
On ICG also, disc is dark but white on
FFA.

Tip-7
Neovascular Membrane in ARMD
can occur at 4 levels (OCT based) viz.
Type-1: Sub-RPE (Occult CNVM on
FFA)
Type-2: Sub-Retinal (Classic CNVM
on FFA)
Type-3: Intra-retinal (RAP or Retinal
Angiomatous Proliferation)
Type-4: is mixed type 1&2

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Main treatment for all is Anti-VEGF
Inj., however response to treatment &
prognosis varies with type.

Tip-8
While giving Intravitreal injection,
always point the needle towards the
CENTRE of the globe & never
anteriorly, as it may damage the lens.
Never try to visualise the needle tip
while inside the globe. Always check
his counting finger vision on the table
itself before patient leaves the OT.

Tip-9
Always treat the Diabetic
maculopathy first before undertaking
Cataract extraction, if possible.
Control DM, HT & Renal condition.
Do his FFA & OCT if possible ie
macula is assessable. If CMT(Central
Macular Thickness) is >300 micron,
always give Intravitreal Anti-VEGF
Inj. Do focal laser if required (for
focal thickening outside FAZ). If its
an old follow-up controlled (DM)

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patient, one may undertake for
surgery within a week, otherwise
better to wait for few weeks & see the
response for yourself. Give the Anti-
VEGF again pre or per operatively
with explained prognosis. Only after 4
weeks of above, undertake the
Cataract surgery.

Tip-10
Never label the child or young adult
complaining of B/L diminution of
vision as a malingerer, even if his
clinical examination is totally normal,
as he may be having Heredomacular
dystrophy like Stargardt’s (Fundus
flavimaculatus) or Cone dystrophy.
These have totally normal fundus in
early phases even though the patient
is definitely symptomatic. Get his
ERG, EOG & FFA.

Tip-11
Standard Fundus camera clicks upto
50 degrees(*) in one shot.
How much is 50*?

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360*/75mm i.e equatorial
circumference of globe =4.8*
(5*approx). Thus 1mm=5*
Optic disc diameter is 1.5mm= 7.5*
Distance between Temporal disc
margin & fovea= 15*
Wide Field camera clicks 50-100*
Ultra wide field camera (e.g. Optos)
clicks 100-200* (i.e approximately
80% of retinal surface)

Tip-12
In newborns, cornea is small & steep,
hence angle of viewing on Indirect
ophthalmoscopy has to be more
vertical rather than oblique unlike for
adults.

Tip-13
ROP simplified.....
WHOM TO SCREEN....
1. Preterm born at< or = 34 weeks
2. Birth weight < or = 2000gm
3. >34 weeks, if risk factors
associated

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WHEN TO SCREEN...
1. At 3 weeks of birth, if GA is <27
weeks
2. At 4 weeks of birth, if GA is > or =
27 weeks
3. At least 1 exam before discharge
from nursery.
HOW OFTEN TO SCREEN....
1. Every 2 weeks if no ROP
2. 2 days-2 weeks depending on zone
& stage.
WHEN TO STOP SCREENING...
1. Till retina fully vascularised.
Temporal retina vascularises last.
2. ROP fully regressed
3. 40 weeks of post-menstrual age
(=GA+Chronological age) if no ROP;
as ROP almost never starts fresh after
40 weeks.
WHOM TO TREAT.....
1. All with PLUS disease (dilatation
& tortuosity of retinal vessels at post
pole)
2. Stage-3 (extra retinal
vascularisation)
3. APROP

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Zone-1 (around disc) is the most
dangerous & Zone-3 (temporal retina)
is the least.

Tip-14
Doing just OCT scan in Diabetic
maculopathy to pick up Central
Macular Thickening & giving Ivit
Anti-VEGF Inj is not enough. FFA or
OCTA must be done to look for
macular ischemia (broken FAZ on
FFA), as it makes prognosis poor & is
unresponsive to any treatment. Anti-
VEGFs treat edema & not ischemia.

Tip-15....
Always click Red-free photo (with
Green filter) on fundus camera to
view retinal vasculature, retinal
hemorrhages, RNFL defects & ERM
as these are then visualised better.
Even pale lesions like drusen &
exudates are also seen better.

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Tip-16.....
OCTA images are ‘en-face’ images
(i.e. facing forwards like standard
fundus images) & NOT cross-
sectional like OCT scans. Images are
taken transversely at different
levels/layers called Segmentation -
done automatically by machine or
manually adjusted by operator on
OCT scan image which is displayed
simultaneously)

Tip-17.....
To differentiate Post cataract
extraction CME & Diabetic Macular
Edema (DME)- Edema in the former
is centered symmetrically around the
fovea & there are no associated hard
exudates or other DR changes. But
both commonly coexist making
differentiation difficult. On FFA, late
disc leakage in CME may give a clue.
On OCT, edema first starts in
superficial retina in CME (entry of
inflammatory cytokines from
vitreous), while in DME, edema starts

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in deeper retina (breakage of inner &
outer blood retinal barriers). CME
generally resolves spontaneously in
80% in 3-12 months.

Tip-18.....
Eales’ disease is a focal disease, only
those areas affected by disease need
to be lasered i.e. scatter laser only of
ischemic/ neovascular areas; while
Diabetic retinopathy is a generalised
retinal disease, hence no role of
focal/local laser (except in
maculopathy) & if laser has to be
done, it has to be full PRP & NOT the
partial scatter of ischemic/
neovascular areas or just posterior
pole scatter.

Tip-19.....
FFA tells about the activity of retinal
disease in form of dye leakage (i.e
breakage of blood-retinal barrier),
while OCTA can’t tell whether
neovascularisation is active or
regressed i.e. disease is now inactive.

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Conversely, in OCTA, image doesn’t
get obscured by dye leakage & hence
clear depiction of CNVM is possible
unlike FFA.

Tip-20....
IRMAs vs Retinal Neovascularisation
(NV)....
IRMAs unlike NV are broader in
calibre, deeper in retina (hence have
fuzzy margins & burgundy (purplish
red) in color (not red of NV), don’t
occur on disc & don’t leak on FFA.
Both indicate ischemia.
IRMAs may form from preexisting
capillaries or as new growths.
Posterior hyaloid or ILM breach on
OCT occurs only in NV.
IRMAs may act as precursors of NV
after they breach ILM & Posterior
hyaloid.

Tip-21.....
On USG-B scan for proper posterior
segment evaluation, ALWAYS do
Transverse & Longitudinal scans

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Transconjunctivally (unless globe
open) under topical anesthesia. In
Transverse scan, mark on the probe is
kept parallel to limbus (perpendicular
in Longitudinal). Each quadrant of
globe has to be scanned
systematically. In each quadrant, go
from limbus to fornix while patient
moves his eyes in other direction.
Area in mark’s direction is always
projected superiorly in monitor.
Axial scan may be done
transpalpebral & in the last.

Tip-22.....
Excessive retinal venous ‘tortuousity’
is the most important characteristic of
venous occlusions (even if
impending). No other common
disease affecting retinal veins causes
it, whether it be severe NPDR (cause
venous dilatation, beading &
looping), Ocular ischemic syndrome
or hypertensive retinopathy. Rare
exceptions are- Congenital venous
tortuousity, Feeder venule of retinal

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capillary angioma & other angiomas,
Sickle cell retinopathy.

Tip-23.....
Ellipsoid layer (IS/OS junction) if
damaged on OCT scan indicates poor
visual prognosis in retinal diseases.
(Most important bio-marker in
diabetic retinopathy). Ellipsoid layer
is hyper reflective layer in outer retina
just inner to RPE & COST layers but
outer to ELM.

Tip-24.....
Never fail to record BP in any patient
with bilateral disc edema & retinal
hemorrhages around the disc
(Malignant HT)

Tip-25.....
In ischemic CRVO, Explain the poor
visual prognosis clearly & risk of
developing NVG (in 30%, in 1-6
months). Do OCT & give anti-
VEGF/Ozurdex for CMT of >300
micron. Followup every month for

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NVI/NVA & fundus & OCT for
CMT(central macular thickness). If
NVI/NVA developing, do PRP if
feasible. Good quality FFA is possible
only after 6 months.

Tip-26.....
Good fundus photo is the one which is
evenly illuminated & focussed from
edge to edge.

Tip-27.....
In Ophthalmic artery obstruction,
vision is even worse than CRAO, and
is almost PL negative. Moreover
cherry red macula is not seen, because
Ophthalmic artery serves both Retinal
circulation (via CRA) & Choroidal
circulation (via Posterior ciliary
arteries which supply choroid, outer
1/3rd retina & even optic disc.) Fovea
has only outer 1/3rd of the retina
retina.

Tip-28.....
VKH may sometimes be confused

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with CSR(CSC). Both cause serous
RD. It is very important to
differentiate them, as VKH needs
systemic steroids which are
contraindicated in CSR.
In VKH unlike CSR, Retrolental/
vitreous inflammatory cells are there.
On FFA in VKH, leaks are multiple &
fill serous RD fully, disc being
hyperemic, also stains in late phases.
Neurosensory retinal detachment area
NEVER fills completely with dye in
CSR.

Tip-29.....
PACHYCHOROID (literally Thick
choroid, Subfoveal choroid of >300
mn), becomes ‘Pachychoroid disease’
(P) if associated. with following 3
features viz.
1. Attenuation of choriocapillaris.
2. Dilated choroidal vessels (outer
Haller’s layer).
3. Progressive RPE atrophy &
Neovascularisation.
P. has many variants (more being

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added with time & includes
CSC/CSR, PCV, etc.) which have
‘common pathogenicity’.
P. is a new concept (2013) which
came after choroidal imaging became
easy with EDI (Enhanced Depth
Imaging) OCT & SS (Swept Source)
OCT. Both use longer wavelength
than conventional OCTs, thus
penetrating deeper with reduced
scattering & signal loss.

Tip-30....
+90D fundus examination steps...
Theoretically field of view is 70
degrees (*),practically it is 35* only.
Use 2-3 mm width of S/L.
Aim light source prependicular or 10*
off-axis.
Place lens half an inch from the
patient’s eye.
Pull back the Joystick while looking
through the slit lamp till beam is
focused on the retina.
Make finer adjustments.
Keep drawing chart ‘upside down’

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while noting findings (inverted
image).

Tip-31.....
In PRP, laser spots should be greyish
white (NOT dense white) ie moderate
intensity, 1.5-2 burns width apart
(spots auto-expand leaving 1-1.5 burn
width only), avoiding major retinal
vessels, old laser spots, chorioretinal
scars, retinal haemorrhages & vortex
veins inside temporal vascular arcade
and nasally within 1 disc diameter of
the disc. Treat inferior areas first (may
get obscured by future bleed). With
200-250 mn spot size (larger spots
cause more pain, as it then needs
greater power), PRP needs 2500-3000
spots for completion.

Tip-32......
No leak on FFA in CSC/CSR
(although SRF still present) may
indicate:
1. Resolving CSC
2. Rule out ‘Optic nerve pit’-

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depression in nerve which has a
totally ‘different colour’ from optic
nerve (neither pink nor white/pale). It
is grey, black or even yellow, because
of glial tissue.

Tip-33.....
On OCT scan print, to know whether
it is of the Right or the Left eye.....
RNFL is much thicker towards the
disc. Hence if RNFL is thicker on our
left side, it is the left eye image.

Tip-34.....
Unexplained (on clinical examination)
deep seated U/L eyeache without
proptosis but with ocular tenderness is
highly suggestive of Posterior
Scleritis (PS). Although rare, it is the
most frequently missed or
misdiagnosed eye disease.
In PS, Inflammation is posterior to
insertion of Recti i.e. Ora serrata. It is
associated with systemic immune
diseases. Choroid, retina & optic
nerve may get associated

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inflammation. USG B Scan is
Typical. ( See Tip- 35).
Tip-35.....
T- Sign on USG-B Scan is typical
(almost pathognomonic) of Posterior
Scleritis. Thick sclera of >2mm
(along with thick choroid &
fluid/edema in Tenon’s capsule)
forms horizontal limb of T. Vertical
limb of T is in optic nerve
(surrounding edema). T is echolucent
(dark/black) on USG.

Tip-36.....
Is it T-1 or T-2 on MRI Scan?
Remember T-2 loves H2O (water),
hence cavities filled with water
(liquid) eg Vitreous & CSF (in
Ventricles) are white on T-2. It is
opposite with T-1.
Fat, Melanin, blood & Aspergillus are
whiter on T-1, hence Dermoid,
Lipoma, Melanoma, Hgic Choroidal
detachment & fresh hge anywhere in
eye (3-14 days old) & Aspergilloma
are whiter on T-1.

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Contrast (Gadolinium) makes
everything more white on T-1, hence
Fat-suppression is must to study
orbital diseases properly.
T-1 delineates Normal anatomy
better, hence grey matter of brain is
grey on T-1 & white matter is white.
Everything is opposite with T-2.

Tip-37......
Brolucizumab (Beovu, Novartis) is
the latest Anti-VEGF approved by
US-FDA (October’19) for wet AMD.
Dosing interval is much longer (12
weeks), although 3 initial monthly
loading doses recommended. Cost is
~1850$ (1.4 lakh INR). Not available
in India. Can cause retinal vasculitis &
obstruction.

Tip-38......
Laser Retinopexy/Barrage laser....
Laser spots are placed 1/2 burn width
apart (become almost confluent with
spread of laser burn). 3 rows are
applied all around the break. If small

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detachment is associated, extend spots
till Ora. Maximum attachment
strength is achieved in 2 weeks.

Tip-39......
Don’t order EOG in very young
children or non-cooperative patients.
EOG records electrical potential
difference between front & back of
eye, hence it requires patient to move
eyes from side to side (electrodes are
near inner & outer canthi) (15 minutes
in dark & light alternately).
EOG is the ‘best’ for Best’s disease
(affected even in early stage also),
while only in advanced stage in
Stargardt.
Normal value (Arden ratio > or =
1.8). Arden ratio term is now replaced
by the new (2017) term- ‘Light
peak:dark trough ratio’.

Tip-40.....
In a case of Rubeosis with only a few
retinal hemorrhages, especially in
mid-periphery, no or minimal venous

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tortuousity & no disc edema (unlike
CRVO) ALWAYS think of Ocular
Ischemic Syndrome. OIS occurs with
>70% obstruction in
Carotid/Ophthalmic artery. Usually
U/L (unlike DR). Do FFA & PRP.
Refer to physician & get Carotid
Doppler (may need Endarterectomy).
CRA perfusion pressure is low.

Tip-41.....
OCT Angiography (OCTA) printout
basically shows 4 kinds of images....
1. Fundus image (Enface structural
image like any fundus photo)
2. Conventional OCT scan image (it is
cross sectional- both horizontal &
vertical)
3. OCT scan image showing
Segmentation levels for OCTA scans,
done either automatically by the
machine or operator adjustable
/scrolled- depending upon the area of
interest.
4. OCTA Segmented scan images
(Enface/frontal view) which grossly

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show 4 levels of vascular planes viz.
i) Superficial capillary plexus
(RNFL/GCL level)
ii) Deep capillary plexus (IPL & INL)
iii) Avascular (outer retina-
ONL/ELM/Photoreceptor/RPE). Any
vascularity at this level is
Neovascularisation/abnormal.
iv) Choriocapillaris

Tip-42.....
If both Diabetic maculopathy
(DDME) & PDR are present together
(commonly happens), always treat
Macular edema first by giving Anti-
VEGF, followed by PRP starting after
a week, as laser aggravates edema.
If patient has both central DDME &
focal edema little away with focal
leak (from microaneurysm or
capillaries). In addition to giving
Anti-VEGF, focal laser should be
done for this focal leak.

Tip-43......
3 most common causes of CNVM are:

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1. AMD
2. Pathological Myopia- CNVM is
small, type-2 (ie subretinal/ beneath
NSR) minimally leaking & is closer
to fovea. Foveal hemorrhage doesn’t
always mean CNVM.
3. Idiopathic- usually of classic
variety (ie subretinal again).
Treatment of choice for all is Anti-
VEGF, however last 2 have much
better prognosis than AMD.

Tip-44......
Intraretinal cystic hyporeflective
spaces on Macular OCT may indicate
CME or ORT (Outer Retinal
Tubulation). VERY important to
differentiate as the latter needs no
treatment, while CME (eg in DR,
AMD..) may need AntiVEGF.
ORT unlike CME has typical thick
hyper-reflective borders around cystic
space & is located only in ONL of
retina & CMT (central macular
thickness) may be normal.
ORT indicates chronic retinal disease

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(photoreceptors get folded outward, ie
towards RPE) eg in n-AMD, HMD,
diabetic maculopathy, etc. ORT
indicates poor visual prognosis.
Both CME & ORT may coexist.

Tip-45......
On FFA, In transmitted
hyperfluorescence (ie window defect)
hyperfluorescence starts in early
phase, increases slowly but fades in
later phases unlike hyperfluorescence
of leakage/ staining or pooling (eg in
active CNVM, Leak of CSC,
NVD/NVE, PED) which increases in
later phases.
For hypofluorescent areas, always
look at the Fundus photo to
differentiate CNP (Capillary non-
perfusion) areas from Blocked
fluorescence. Latter matches with the
extent of blocking material (eg
hemorrhage). Moreover, CNP areas
have normal capillary outlining unlike
blocked fluorescence.

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Tip-46.......
It’s important to differentiate AMD
from PCV (Polypoidal Choroidal
Vasculopathy) as the latter has much
better prognosis (if detected & treated
early) with combined (as per
EVEREST study) Anti-VEGF (treats
fluid) & PDT (treats BVN & Polyps),
while AMD has much poorer
prognosis.
PCV- has Multiple ‘sero-sanguinous
PEDs & hard exudates’ (neovascular
& hemorrhagic disease) in old age
(50-65 years). Commoner in Asians.
Mimics type-1 AMD (sub-RPE/occult
CNVM). Question whether PCV is a
variant of AMD is unsettled? Polyp &
abnormal BVN (Branching choroidal
Vascular Network) are
pathognomonic features arising from
inner choroidal vasculature (cause ?).
Unlike AMD, PCV has/is....
1. No associated druse.
2. More often peripapillary or
multifocal (Macula more commonly
involved in Asians)

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3. Anti-VEGFs alone are not effective
unlike in AMD.
4. Fundus: Reddish-orange round
polypoidal lesions seen (only if large).
5. Retinal hemorrhage is generally
‘large’.
6. FFA- only occasionally detects
polyps. Basically to rule out other
causes of exudation & CNVM.
7. OCT- Polyps seen as elevation
from RPE-Bruch’s. Cystic spaces less
common (hence better prognosis than
AMD). ‘Double layer sign’ is
characteristic at PED margins
(separation of Bruch’s from either
RPE or choroid).
8. ICGA is MUST & confirmatory.
Polyps at termination of BVN seen
better in mid phases with fading
centre or late staining or leaking walls
in late phases.

Tip-47.....
Characteristic FFA picture in
common Optic nerve diseases....

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1. Optic pit- Early hypofluorescence
& late staining of pit, because of
absence of vessels but presence of
glial tissue in pit.
2. Papilledema- Disc capillaries
dilated & leaking. Late staining of
disc.
3. AION- Differential disc capillary
filling in superior & inferior half.
4. Disc drusen- Autofluorescent
before dye injection. Late staining
5. Neuroretinitis- Dilated & leaking
disc capillaries. Macular fan/star is
from leakage of disc capillaries &
NOT from macular capillaries.
6. Leber’s hereditary optic
neuropathy- Dilated disc capillaries
which are NOT leaky.

Tip-48.....
How to identify RNFL defects on
Fundus exam....
1. Normal RNFL is brighter & has
striations (stripy textured pattern).
Brightness & striations reduce with
damage.

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2. Observe parapapillary vessels.
Typically, they appear fuzzy. With
RNFL damage/loss, their borders
become more defined.
About RNFL defects on fundus
exam....
1. Not specific to glaucoma (any optic
neuropathy/ ganglion cell loss) can
cause them.
2. Better seen in Red free photos
(green filter).
3. Occur more often in NTG & early
rather than advanced glaucomas.
4. Could be localised wedge shaped or
diffuse. Former is easier to identify
than diffuse.
5. Associated disc hge common (in
wedge defects).
6. Commoner in superior & inferior
temporal regions.
7. Help in pre-perimetric diagnosis of
glaucoma.

Tip-49......
Typically, early postoperative
endophthalmitis unlike non-infective

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(eg TASS- which starts earlier-within
24 hours with, limbus to limbus
corneal edema, no posterior segment
involvement & responds to steroids)
is characterised by- pain (most
significant but missing in 1/4th), lid
edema, congestion, chemosis & more
AC reaction as compared to that
expected by surgeon (For treatment,
see Tip-50).
Chronic postop endophthalmitis
(presenting after 6 weeks) is mostly
caused by Propionibacterium acnes
followed by Fungal or Staph albus.
Pain & inflammation may respond to
steroids initially but recurs requiring
Intracapsular Vancomycin, Radical
PPV with capsule & IOL removal.

Tip-50......
Management of early (<6 weeks)
Post-cataract endophthalmitis (Es).
Broad outlines....
1. Always consider Es, if early
postoperative patient calls you with
complaints of PDR ie Pain,

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diminution of vision & Redness.
2. Western literature says organisms
in 90% are Gram positive bacteria
(70% Coagulase negative Staph ie
albus). Indian studies blame Gram
negative equally.
3. Look at the Disc & Retinal vessels
& grade Fundal glow with I/O
(Whether both, only disc or none
seen) for follow ups.
4. Take anterior vitreous needle tap
(26 G with TB syringe, 3.5 mm from
limbus) slowly. If dry, take vitreous
biopsy with cutter.
Gram stain & C/S (preferably for all
3- aerobic, anaerobic & fungal). For
PCR, inform lab about suspected
organism(s).
5. Intravitreal (IVit) inj of
Vancomycin (1mg in 0.1ml) &
Ceftazidime (2.25mg in 0.1 ml)
separately, 3.5 mm from limbus. or
Amika (0.4mg in 0.1ml) instead of
Cefta.
6. Moxifloxacin & Concentrated
Tobramycin (1.4%, 5ml of

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0.3%Tobramycin + 2ml of 80mg
Tobramycin Inj) eyedrops every 1
hourly. Homide/Atropine. Anti
glaucoma, if required. Start Topical
steroids after 24-48 hours if condition
stable/ improving (Not if fungal
suspected)
7. IV Ciprofloxacin (200mg BDx 2
days) followed by oral 750mg BD
x10 days. Cipro more broad spectrum
than Moxi. Moxi more effective
against MRSA Staph but less against
Gram-ve.
8. Repeat Intravitreal (IVit) Inj at 48
hours if condition stable but no
significant improvement. If
deteriorated, go for PPV.
9. Improvement means Symptoms
reduced, less AC reaction & glow
improved.
10. As per EVS (Endophthalmitis
Vitrectomy Study), Go for early PPV,
if VA is only PL.
11. EVS applicable to early postop Es
only & NOT to Chronic (>6 weeks)
postop, post traumatic or endogenous

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Es.
12. Treat wound leak, vitreous
incarceration, etc if any.
13. Coagulase-ve Staph has better
prognosis than Coagulase positive
Staph & Gram negatives (eg
Pseudomonas).
14. Prognosis worse with post IVit Inj
Es (organism’s direct entry into
vitreous).

Dr. Sanjay Ahuja

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