Tips on Retina Practice

retina only is being examined.
-Hold the patient‟s hand (proprioception) or
tap on his face to describe the direction,
patient has to look at. Verbal commands
may confuse him.
-If nose is obstructing, while seeing from
side, turn his head towards yourself.
-To look at the periphery, turn your head by
45* on one side.
-For Scleral depression, don‟t ask patient to
look in extreme gazes, only slight eye
turning is enough.

Tip-74.......
Macular Telangiectasia (MacTel) could be
Juxta (central 1.5 mm of Anatomical
Macula), Parafoveal/PFT (1.5-2.5 mm) or
Perifoveal (2.5-5.5 mm) Telangiectasia of
Macular capillaries.
Type -2 MacTel is commoner variety (type-
1 is U/L & congenital, males exclusively,
Coats‟ variant) of an uncommon disease.
Features...
-B/L, after 50, Associated DM/abnormal
GTT or HT common.
-Always think of MacTel, if on fundus
exam, one notices grayish discolouration
(better seen in red- free photo) around fovea
(temporally usually) of BE. Asymptomatic
usually.
-Telangiectatic capillaries seen diving into

deeper retina at right angle, which may
cause Subretinal neovascularisation
(SRNVM) (in 5%) (CNVM of RETINAL
origin & not choroidal)
-FAF detects it earliest with loss of masking
in foveal region (lutein pigment loss).
-FFA- characteristic intraretinal dye leakage
in temporal macula, but NO macular
thickening on OCT (rather foveal
atrophy/thinning).
-Treatment- None effective usually except
Anti-VEGF for Neovascularisation, if
present.

Tip-75.....
Endogenous Endophthalmitis (EE).....
-Always consider if severe anterior uveitis is
not responding to steroids.
-Look for Infected focus (hematogenous
spread) (culture accordingly) &
Immunocompromised host.
-In Indian context, Gram -ve & fungi are
commoner (Gram +ve in west)
-Uncommon (5% of all Endoph).
-Classified into- Focal or Diffuse & Anterior
or Posterior
-Unlike Postop Endophthalmitis, Systemic
antibiotics are must (effective for both
systemic & Ocular manifestations).
Endophthalmitis Vitrectomy Study (EVS)
recommendations don‟t apply here.

-Give antibiotics as per c/s or broad
spectrum- IV Vanco + Amika/Ceftazidime.
Also give them Intravitreally (see Tip-50).
Topical Atropine & steroids also, if fungal
not suspected.
-For suspected/proven fungal, give IV
Voriconazole (400mg BD x 1day as loading
dose, then 200mg BD). Also Intravitreal
Voriconazole (50 microgm in 0.05ml).
Alternatively, use IV & IVit Amphotericin-
B.
-Severe or non-responding cases also need
early PPV.

Tip-76.....
Many retina specialists are now following
the „Treat & Extend‟ regimen instead of
PRN (Pro Re Nata)/ Treat & Observe for
treating wet AMD with Anti-VEGFs. In this,
after a course of 3 injections, IVit is
repeated till the macula is dry; thereafter one
keeps extending the interval between 2
injections (but one keeps giving the
injections), depending upon the response.
While in PRN strategy, after the course,
inject till the macula is dry & thereafter
repeat injection only if required.

Tip-77......
For Prophylactic Cryopexy of large retinal
tear in peripheral retina, place multiple

cryospots around the tear (~2mm whitening
around entire tear) & NOT directly beneath
the break, as it releases more RPE cells
causing macular pucker & PVR.

Tip-78......
Poor prognostic Biomarkers for Diabetic
retinopathy (DR) on SD-OCT scan....
-Disrupted Ellipsoid zone (EZ), earlier
called Inner/Outer segment junction (hyper-
reflective layer between 2 hyper-reflective
layers of RPE & ELM in outer retina, Tip-
23), if damaged, is the most important poor
prognostic biomarker. EZ disruption is also
a poor prognostic marker for AMD, CSC &
RVOs.
-Presence of Hyper-reflective dots (HRDs)
of 20-40 mn size in all retinal layers.
Represent lipid exudation & clustered
microglia (Immune cells/macrophages
within retina). HRDs in fovea especially
indicate poor prognosis.
-Disorganisation of Retinal Inner Layers
(DRIL)- Boundaries between GCL/IPL &
INL/OPL, if lost in >50% of central 1mm
zone of Fovea.
-Outer retinal tubules (ORT)- See Tip-44.
-Presence of ERM, VMA & VMT.

Tip-79.....
OZURDEX Implant.....

-0.7 mg (700mcg) Biodegradable,
Intravitreal Dexamethasone implant.
-US-FDA approved it for...
1. Macular edema (ME) (2009) following
BRVO & CRVO.
2. Non-infectious posterior uveitis (2010)
3. Diabetic ME (2014)
-Therapeutic effect for 3-6 months.
Readminister after 3 months.
-Contraindicated in Infectious uveitis,
glaucoma & any infection in & around the
eye.
-In centre involving DME, generally
reserved for patients unresponsive to Anti-
VEGFs. May be considered first choice in
pseudophakes.
-Now available in 23 G injector
-Dexa is less lipophilic than Triamcinolone
& Flucinolone (Retisert,B&L & Iluvien),
hence accumulates less in Trabecular
meshwork & lens. IOP rise is thus less likely
(>10mmHg in 15%, peaking at 8 weeks).
-Cost is 26-28k
-Given like any other IVit injection (but
needs higher force, thicker gauge) or Trocar-
cannula insertion.
-Procedure- Remove Tab straight up. Enter
at 30* angle on sclera with bevel up & then
perpendicular. Insert till sleeve of needle.
Press Actuator FULLY (audible click heard)
to inject 6mm rod shaped white implant.

Tip-80.....
Common Peripheral retinal degenerations....
Basically in 3 locations...
1. Vitreoretinal- Lattice, WWP & WWOP.
2. Intraretinal- Microcystoid, Retinoschisis
(see Tip-81), Pars plana cysts.
3. Retino-choroidal- Paving stone.
None of these per se need any prophylactic
treatment except occasionally in Lattice (see
Tip-59) & Retinoschisis (see Tip-81).

Tip-81......
RETINOSCHISIS (RS).....
-2 types- Congenital (Rare, X-linked
juvenile) & Acquired (Senile/ degenerative).
-Basically splitting of NSR, typically at OPL
(at RNFL in Reticular) like Microcystoid
degeneration.
-Mostly accidentally found on I/O
-Unlike RD, RS is/has...
Mostly inferotemporal & B/L
Shallow
Immobile
Smooth surface (no corrugations)
Sharply defined margins
Causes absolute scotoma
No RPE mottling
No Shaffer‟s sign (RPE cells in anterior
vitreous)

No retinal break or Demarcation lines
On OCT- break in OPL but no detachment
from RPE.
Laser produces white burn in outer retina.
-Treatment- NIL usually (no laser or
surgery), even if cataract surgery planned.
Extremely rarely causes rhegmatogenous
RD if breaks in both inner & outer laminae.

Tip-82.....
Pseudophakic CME (Post cataract
extraction)......
-Intracellular fluid in Henle‟s OPL
(watershed zone between retinal & choroidal
circulation).
-Important to RULE out missed CNVM of
ARMD & DME (Tip-17).
-Typically between 5-10 weeks postop with
c/o blurring, decreased contrast sensitivity or
colour desaturation.
-More likely with PCR & vitreous loss
-On +90D exam, (Red free/green light
better)- dull FR (if CMT >300 mcn)
-FFA- Asymptomatic, angiographic CME
(in >60%) needs no treatment. FAZ intact.
Petalloid leak in late phase is characteristic.
If associated optic disc leak (Irvine Gass,
inflammatory) present, rules out DME. No
leak in CME with VMT.
-OCT best for monitoring
-Most cases resolve within 3-6 months.

-Treatment...
No standard treatment (No large scale
studies available).
Best treatment is topical corticosteroids with
NSAIDs for 6-12 weeks. Also most
effective in prevention.
Periocular steroids (20 mg post subtenon
Triamcinolone) & IVit AntiVEGF in non-
resolving cases.
-YAG vitreolysis or PPV for VMT.

Tip-83.....
Lexicon used to describe lesions in posterior
segment investigations...
-USG-B Scan- Echogenicity
(Echogenic/Echolucent) & Internal
reflectivity of lesion.
-USG-A Scan-Reflectivity (Hyper/Hypo)
-FFA- Fluorescence (Hyper/Hypo)
-OCT- Reflectivity (Hyper/Hypo)
-ICG- Cyanescence (Hyper/Hypo)
-FAF- Autofuorescence- (Hyper/Hypo/Iso)

Tip-84.....
Before considering AMD in relatively
younger patient (40-50 years of age), rule
out masquerading diseases like Chronic
CSC/CSR & Pattern dystrophies (PD).
PD is/has....
-No associated colloids or CNVM (very
rarely CNVM may develop) unlike AMD.

-Very slowly progressive & have much
better prognosis than AMD.
-Autosomal dominant, B/L, macular
diseases forming various patterns of pigment
deposition because of RPE disorder.
-Includes Adult vitelliform, Butterfly,
Reticular dystrophies, etc.

Tip-85......
Vitreomacular Adhesion (VMA) unlike
Vitreomacular Traction (VMT) (SD-OCT
based International classification of 2013)
is/has...
-NO change in retinal surface contour.
-Asymptomatic (No metamorphopsia or d/v)
-Needs no intervention (VMT needs surgery
if VA is 6/18 or less).
-Has associated partial PVD.
VMA is called Focal if <1.5mm & Diffuse if
>1.5mm.

Tip-86…..
SHUNT (Optociliary) vessels over disc.....
-are collaterals formed between retinal
(CRA) & ciliary circulations (SPCA).
-Found in CRVO (most common cause),
chronic glaucoma, chronic papilledema, &
Optic N. sheath meningioma.
-Unlike NVD, shunt has....
1. Larger caliber (NVD has lacy, irregular
appearance)

2. Never elevated over disc surface.
3. Starts & ends on disc itself.
4. Never leaks on FFA.

Tip-87.......
Subretinal Hyper-reflective Material
(SHRM) deposits (beneath NSR) on SD-
OCT scan -are an important morphological
Biomarkers indicating poor visual prognosis
in n-AMD & CSR/CSC.
-are composed of fibrin, blood, neovascular
complex or shed photoreceptors.
-May lead to subretinal fibrosis (scarring)
especially if ELM is involved.
-In CSC, especially seen in those on long
term steroids use, pregnancy or severe cases.

Tip-88.....
RETINAL HEMORRHAGES can occur at 6
different levels viz.......
1. Subhyaloid- Between posterior hyaloid &
ILM is truly preretinal (Boat-shaped) as in
Valsalva retinopathy.
2. Sub-ILM- Between ILM & RNFL is
actually intra & not preretinal (See Tip-53).
Usually clubbed with Subhyaloid as
Preretinal.
3. Flame shaped hemorrhages- occur within
RNFL eg in HT, RVO, Leukaemia &
Anemia.
4. Dot & blot- Between INL & OPL eg in

DR, MacTel & OIS.
5. Subretinal- Beneath NSR. Has amorphous
(unclear boundaries) shape eg in Type-2
CNVM (Classical) of Idiopathic or Myopic.
6. Sub-RPE- Beneath RPE. Has well defined
boundaries (RPEs‟ tight junctions) eg in
Type-1 CNVM (occult) of AMD & PCV.

Tip-89.....
CRAO is mostly of atherosclerotic origin
(thrombus at lamina cribrosa), while BRVO
is mostly from embolus proximally
anywhere.

Tip-90.....
Toxic Anterior Segment Syndrome (TASS)
unlike Postop Infective Endophthalmitis
is/has...
-acute sterile postop anterior chamber
inflammation.
-Early onset (within 12-24 hours)
-No pain
-Limbus to limbus corneal edema
-Raised IOP
-No vitreous inflammation
-Cause- Endotoxin or chemical mediated
-Fast response to topical steroids (Pred
acetate 1 hourly).

Tip-91.....
Always warn the patient undergoing PRP

laser for Diabetic retinopathy about......
1. No improvement in vision expected.
2. May worsen macular edema with
deterioration of visual acuity. Always give
IVit Anti-VEGF first.
3. Possible loss of peripheral, colour & night
vision.
4. May need supplementation.
5. May not succeed in regressing
neovascularisation & patient may rebleed.

Tip-92.....
As per DRS, PRP for PDR is to be given
only for HRC-PDR cases (NVD or NVE
with vitreous hge; NVD >1/4 disc area).
However practically, most retina specialists
have been doing PRP for Non-HRC PDR
cases also in following situations...
1. Patient not likely to follow up regularly
2. Pregnancy
3. Other eye lost to PDR
4. One eyed
5. Those to undergo cataract extraction soon
6. Associated NVI

Tip-93…..
On FFA, to differentiate Staining from
Leakage (eg of scar, sclera, etc.), always see
coloured fundus photo. In staining, dye (ie
hyperfluorescence) does not extend beyond
margins of scar unlike leakage.

Tip-94…...
Majority of patients with soft exudates, if
DR & RVOs are excluded, will have some
serious systemic disease eg severe HTR,
collagen diseases (SLE), GCA, Embolisms
(carotid/cardiac), OIS, HIV, Leukaemia,
anemia, etc.
Don‟t confuse it with lesions of retinitis
(Toxoplasmosis & CMV) & White dot
syndromes.

Tip-95….
PHOTIC MACULOPATHY.....
-can occur due to Laser (visible or invisible
wavelengths), Solar or Arc welding or even
Microscope light.
-Typically damages outer retina & RPE
(persistent defect)
-Basically photochemical damage (free
radical generation)
-Blue light especially dangerous (absorbed
maximally by macular xanthophyll & RPE‟s
melanin)
-Damage depends on power, duration of
exposure & distance of striking.
-Lasers divided into 4 classes (1-4). Classes
1-3 further subdivided into 2 subtypes each
differently by ANSI (American National Std
Institute) & IEC (International
Electrotechnical Commission).

- Class 1 is in microwatts, Class 2 is upto 1
milliwatt. Class 1&2 are harmless to eyes
unless focussed by optical instruments.
-Class 3R is 1-5 mW (safe to eyes if
carefully handled & 3M is 5-500 mW
(hazardous if exposed directly but not to
diffuse scatter) Class 4 is >500 mW
(hazardous to eyes & skin even if diffuse).
-Photic maculopathy has no cure & recovers
only partially.

Tip-96.......
Drusen of Familial dominant drusen unlike
Flecks of Fundus flavimaculatus (Stargardt‟s
disease) are sharply defined, whiter &
roundish spots.
White dots in Fundus albipunctatus are very
uniformly distributed throughout the retina
& NOT clustered unlike drusen.

Tip-97.......
Most common manifestation of OCULAR
SARCOIDOSIS (OS) is bilateral
granulomatous anterior uveitis (sometimes
non-granulomatous also).
-OS affects retina (vasculitis/candle wax
drippings), choroid & Vitreous.
-Rule out TB, Multifocal choroiditis, VKH
& Intraocular lymphomas.
-Diagnosis of OS although mainly clinical,
International diagnostic criteria (2017) for

OS should be followed....
….Definite OS- Tissue biopsy proven (non-
caseating granuloma from any body tissue)
with Compatible uveitis.
.....Presumed- Biopsy negative, B/L hilar
lymphadenopathy with any 2 out of 7
classical intraocular signs.
.....Probable- Biopsy not done, No hilar
lymphadenopathy but 3 intraocular signs
present & 2 investigations positive (raised
ACE, Lysozyme, ESR, CRP, negative Mx,
etc.)

Tip-98.......
Always consider TB & Sarcoidosis in every
case of granulomatous uveitis, Intermediate
uveitis & Choroidal granulomatous nodules.

Tip-99.......
Branch Retinal Vein Occlusion (BRVO)...
-usually occurs at AV crossings
(superotemporally), elsewhere in
inflammatory causes eg Eales &
Sarcoidosis.
-Newly added risk factors include
Hyperhomocystenemia & Anti-cardiolipin
antibodies (Thrombophilic states).
-Vision affected only if macula involved by
edema, hge, exudate or ischemia.
-Peripheral or nasal BRVO may remain
asymptomatic for months & may present as

vitreous haemorrhage for the first time.
-Do OCT for macular edema & give
repeated AntiVEGF or Ozurdex (second
choice). Later, Sectoral Laser is done if
neovascularisation present or FFA (done
after 3 months) shows >5 DD areas of
ischemia.
-Damaged Ellipsoid zone on SD-OCT (due
to chronic macular edema) is a poor
prognostic Biomarker in BRVO also.

Tip-100.......
Practical considerations while giving
systemic Corticosteroid (CSd) therapy.....
-Diurnal cycle is best mimicked by giving
CSd as single morning dose after breakfast.
-Always add Proton pump inhibitor 1 hour
before breakfast.
-Tapering required only if CSd given for >1
week.
-Alternate day therapy on long term use
minimises Cushingoid side effects, but not
osteoporosis, etc.
-Rule out Koch‟s & DM.
-Dosage has to be increased during acute
stress situations.
-Advise patient to do regular muscle
exercises (avoids muscle wasting), take low
sodium & potassium rich diet, avoid
pregnancy, look for mood changes, always
inform other treating physicians about

treatment & regularly follow up with
internist & always carry the medical card for
an emergency.
-Common side effects include osteoporosis
(give Ca & Vit-D supplements), peptic
ulcer, myopathy, mood changes, cataract
(unlikely with <10mg/day of Prednisone for
<1 year), HT, DM, Menstrual problems,
growth retardation & superinfections.
-Switch to Immunosuppressives, if
prolonged maintenance dose of >10mg/day
of Predni required.
-Deflazecort has fewer side effects on
growth & osteoporosis. 5mg of Prednisone
(prodrug of Prednisolone) or Prednisolone
~6mg of Deflazecort ~ 4mg of
Methylprednisolone (less mineralocorticoid
activity).

Tip-101....
About PARACENTRAL ACUTE MIDDLE
MACULOPATHY (PAMM)...
-Forms an important differential diagnosis
(D/D) of unexplained visual loss in adults.
-Newly diagnosed entity on SD-OCT (2013)
-Patient complains of sudden onset Negative
paracentral scotoma
-Ischemic origin (intra-retinal infarct)
-Fundus- subtle greyish patches in macula
-Hyper-reflective band at INL of retina
(Middle layers & NOT outer retina) on SD-

OCT is pathognomonic.
-Self limiting with partial recovery in weeks.
No known treatment (treat ischemic risk
factors).
-Important d/d with similar lesions is Acute
Macular Neuroretinopathy (AMN) of
younger people involving OUTER retina
(OPL & ONL) with damage to Ellipsoid
zone.

Tip-102....
D/D of Angioid streaks are Choroidal
rupture & Lacquer cracks (Pathological
myopia):
Angioid streaks radiate from disc, are linear
& more often B/L.
Choroidal rupture is U/L & mostly
concentric to optic disc.
Lacquer cracks are also usually B/L,
concentric to disc & are associated with
other signs of pathological myopia
(posterior staphyloma with tilted disc &
scleral crescent).

Tip-103....
Bleb associated Endophthalmitis (BAE)....
-May present months to years after trab.
-Bleb becomes white (purulent), while in
conjunctivitis, it looks RED only.
-If infection from bleb (Blebitis) extends
into posterior segment, it becomes

endophthalmitis causing pain, redness &
visual loss.
-Any endoph in patient with bleb is BAE
unless proven otherwise.
-More often associated with Streptococci,
Hemophilus & Gram negative organisms,
hence more severe.
-EVS does not apply here.
-Needs early aggressive treatment with Pars
plana vitrectomy (PPV) & Intravitreal (IVit)
Vanco & Cefta/Amika.

Tip-104......
Always think of Masquerading Uveitis if
idiopathic posterior uveitis after initially
responding to steroids, fails to respond
thereafter. Also consider it in older patients
(>50 years age) presenting with uveitis for
the first time in their lifetime.
Most common cause is Primary intraocular
lymphoma followed by leukaemia, systemic
malignancies, IOFB, Ocular ischemic
syndrome (OIS) & retinoblastoma, etc.
Vitreous biopsy is the most important
investigation for lymphoma.

Tip-105......
There is no need for any Lab investigation in
a case of first attack of acute anterior non-
granulomatous uveitis.
Cases of post-traumatic, Fuch‟s

heterochromic, Behcet‟s, Sympathetic
ophthalmia & VKH are the clinical
diagnosis & don‟t need any lab
investigations.

Tip-106.......
Old patient (>50 years) complaining of dull
ache around eye & having NVI, always
think of Ocular ischemic syndrome (OIS).
-Occurs due to atherosclerotic blockage of
carotid or ophthalmic artery.
-Narrowed retinal arteries, dilated veins (but
NOT tortuous unlike CRVO) & mid-
peripheral dot & blot hemorrhages are the
hallmarks.
-FFA shows delayed choroidal & retinal
filling.
-Carotid Doppler detects carotid stenosis.
-PRP helps in NVI. Carotid endarterectomy
may be required.

Tip-107.....
In any posterior segment pathology, NEVER
fail to look for Retrolental cells (in anterior
vitreous), which indicate inflammation (after
excluding vitreous hge & RPE cells of
Shaffer‟s sign in RD) & rules out CSC/CSR,
AMD & secondaries.

Tip-108......
Sheathing of disc & peripapillary vessels is
commonly congenital as in Bergmeister‟s
papilla (persistent remnants of fetal
vasculature/ hyaloid artery) & is generally of
no significance. However, sheathing may
also be acquired in various causes of disc
edema.

Tip-109.......
To differentiate Choroidal nevus (flat, gray
subretinal lesion) from choroidal melanoma,
five Classical features favouring the latter
are....
1. Tumor thickness of >2mm or documented
growth
2. Presence of SRF
3. Any visual symptoms
4. Orange pigments over lesion
5. Posterior tumor margin touching the disc
Presence of overlying drusen or RPE
changes indicate chronicity of lesion & is
mostly benign.

Tip-110.....
Following retinal diseases cause CME but
show no leak on FFA...

1. ERM & VMT syndrome
2. X-Linked juvenile retinoschisis
3. Retinitis pigmentosa (RP)
4. Nicotinic acid maculopathy
5. Photic maculopathy
In CMEs with leakage, fluid collection is
predominately in OPL (watershed zone
between retinal & choroidal circulations),
also called Henle‟s layer in fovea & gives
rise to classic Petalloid pattern.
In CMEs without leakage on FFA, fluid
collection is sometimes intracellular &
hence may respond to Carbonic anhydrase
inhibitors especially in Retinitis pigmentosa
(RP).
CME of <300mn is generally not easy to
make out (no loss of foveal reflex), hence
needs imaging for diagnosis.

Tip-111.....
Retinal Cavernous hemangioma mimics
peripheral BRVO. To differentiate- It
appears as dense cluster of saccular
aneurysms alongside the retinal veins which
are neither dilated NOR tortuous unlike
BRVO.
Aneurysmal dilatations are non-leaky on
FFA unlike retinal telangiectasias of Leber‟s
miliary aneurysms & Coats‟.

Tip-112....
Diffuse or localised reddish/ orangish
thickening & discolouration of fundus may
be due to rare vascular hamartoma called
Choroidal hemangioma.
Commoner vascular tumours of retina &
choroid are of 3 types..
1. Choroidal hemangioma- Majority
localised (circumscribed, isolated &
asymptomatic- just needing observation;
rarely cause serous RD or CME), but
sometimes diffuse (part of Sturge Weber
syndrome)
2. Retinal capillary hemangioma (Von
Hippel syndrome)
3. Retinal cavernous hemangioma- Unlike
Capillary hemangioma, it needs no treatment
(non-growing) & causes no subretinal fluid
or exudation & has no feeder vessels
(afferent-efferent).

Tip-113.....
Identifying BRVO may be difficult in a
patient with significant Diabetic retinopathy.
FFA clinches the diagnosis.

Tip-114.....
Blunt trauma with globe compression
ruptures the inelastic portions of the eye
(viz. RPE, Bruch‟s & inner choroid). Elastic

parts (sclera, retina & vitreous) are relatively
spared.
Secondary CNVM (subretinal/type-2)
occurs in 5-10% after choroidal rupture & is
highly responsive to AntiVEGF treatment.

Tip-115......
Ultrasonic Biometry falsely records higher
axial length in Silicone oil (SO) filled eyes,
causing hyperopic refractive error, because
speed of sound is reduced by SO (only
1000m/sec as compared to 1550 in normal
phakic eye).
To compensate, multiply axial length by
conversion factor of 0.71.
Optical Biometry is preferable in SO filled
eyes.

Tip-116....
Compulsory use of mask by patients &
ophthalmologists has made fogging of specs
& all optical Instruments & lenses a major
problem.
Use Anti-fog spray/solution to avoid.
Basically surface tension reducing agents.
Work for 3-6 hours. Spray bottle (1 oz/30ml
for INR 300/ to 1500/) available with
opticians & online (Amazon).

Tip-117......
Impending CRVO is seen as dilated,
tortuous retinal veins with few hemorrhages
& minimal/no loss of vision. Mostly
unilateral & is seen in younger patients with
total recovery in most cases, however a few
may progress to full attack of CRVO.

Tip-118.....
In acute CRAO, on FFA, delay in filling of
retinal arteries is the most specific sign.
Total lack of filling of CRA is seen only in
an occasional case. Choroidal flush (filling)
should be normal in CRAO, if not, think of
Ophthalmic or Carotid artery obstruction.
Normally, choroidal filling on FFA occurs
within 10-15 seconds of dye injection
followed in 2-3 seconds by retinal arterial
filling.

Tip-119.....
Reverse pseudohypopyon is seen with
emulsified silicone oil in anterior chamber
(oil being lighter than aqueous humor, floats
up), while Perfluorocarbon liquid (PFCL)
settles inferiorly in AC (being heavier than
aqueous humour) & is seen as round, clear
oil bubbles.

Tip-120.....
For good Fundus imaging with fundus
camera...
-Use internal fixation target for central
(macular) imaging & external target for
peripheral imaging, if both required.
-Take peripheral image first (if required) &
then central to increase patient‟s
cooperation.
-With large pupils, reduce flash intensity to
avoid over exposed photo.
-With non-mydriatic camera, covering the
other eye dilates the pupil little more. Give
sufficient time for pupil size to recover after
the flash.
-In smaller non-dilating pupils, try off-axis
photography, this moves dark shadow away
from macula & disc.
-Keep objective lens clean (with cleaning
tissue start from centre & move out spirally).

Tip-121.....
The retinal layer(s) primarily affected in
certain diseases is/are (helpful in OCT
interpretation).....
-RNFL & GCL- In Sphingolipidosis (Lipid
storage disorders)
-Inner retina (RNFL to OPL)- DR, Vascular
occlusions
-OPL- CMEs (with or without leakage on
FFA), Lipid deposits in DR, Coats‟, RAM,

Angiomatosis
-ONL & Photoreceptor layer- Cone
dystrophy, Achromatism (achromatopsia) &
Phototoxicity
-RPE- Best, Stargardt, Drusen, CQ &
Phenothiazine toxicity
-Bruch‟s- Angioid streaks, Choroidal
rupture & Lacquer cracks (high myopia)
-RPE-Bruchs-Choriocapillaris complex-
AMD, CSR, VKH, Melanoma, Metastasis

Tip-122.....
Features of Ischemic CRVO unlike non-
ischemic are....
1. Visual acuity of <6/60
2. RAPD
3. Extensive retinal hemorrhages
4. Severe engorgement & torturousity of all
branches of CRV.
5. Multiple soft exudates (6 or more).
6. Abnormal ERG- decreased b-wave
amplitude
7. Extensive CNP areas (>10 disc diameter)
on FFA (done after 3-6 months)
For management, see Tip-25.

Tip-123......
FUNDUS AUTOFLUORESCENCE
(FAF)....
-Detects fluorescence from Lipofuscin (LF)
in RPE non-invasively. Lipofuscin formed

as by-product (of vitamin-A) from
phagocytosed outer photoreceptors‟
segments. LF is the least in fovea, but more
in posterior pole and decreases towards
periphery.
-LF increases with age & in RPE metabolic
dysfunctioning.
-Normal retina is mildly autofluorescent
with dark vessels (blood absorbs AF of LF),
disc (no LF) & macula (luteal pigment also
absorbs autofluorescence/AF)
-Good pics of FAF became possible because
of CSLO (detects such low levels of AF)
-HypoAF occurs in RPE atrophy/loss,
intraretinal fluid/hge, scar or excess lutein.
-HyperAF occurs in Drusen, older hges,
Increased LF in RPEs.
-Optic disc appears dark on FAF photos
unlike in Red-free (white disc)
-FAF can‟t be done if Fluorescein dye is
already injected (same wavelength filters
used in both)
-Most useful to follow up Geographic
atrophy (dry AMD) as increasing hyperAF
in junctional adjoining zones indicates more
progression likely.

Tip-124.....
Extensive Asteroid hyalosis may interfere in
clear fundus viewing, but it doesn‟t obstruct

in good fundal imaging on FFA.

Tip-125.....
Diabetic retinopathy may look very mild on
cursory fundus examination in busy OPD.
However, FFA might reveal serious changes
in fundus. Hence, always order an FFA, if in
doubt.

Tip-126.....
Old CRAO on fundus exam is recognised
by...
-Diffusely narrowed retinal arterioles
persist.
-No retinal edema (opacification/ whitening)
is seen after 4-6 weeks. Diffuse inner retinal
atrophy & thinning ensues. RAPD persists.
-Pale disc (atrophy).
FFA is usually normal in old CRAO, as the
circulation is restored.

Tip-127.....
Intravitreal tap by syringe for specimen
collection in Endophthalmitis is not
advocated by many vitreo-retinal surgeons.
However, it may be tried by comprehensive
ophthalmologist (if he is conversant with
giving Intravitreal injections, which he
should be, as he may require it to give it to
his own postop endoph case, especially if
referred vitreous surgeon is far off).

For tap, always „break‟ the vacuum in
syringe before entering. Abondon, if dry (no
liquefied pocket there). Vitreous biopsy is
then safer by vitrectomy probe after making
3 ports, followed immediately by
Vitrectomy.

Tip-128.....
RETINOBLASTOMA....
-80% have calcification (detected easily on
USG-B scan- high internal reflectivity
spikes & on CT scan) .
-Most important mortality indicator is optic
nerve extension (cut long stump, if
enucleating).
-One-third are B/L & multifocal, which
present earlier (mean age-1 year against
2years of U/L) & are mostly heritable
(germinal mutation of RB1 tumor
suppressor gene). Get genetic testing in
excised tumor or in blood.
-Chemoreduction & Intra-arterial
chemotherapy (by Ophthalmic artery
cannulation) are most promising therapies.

Tip-129......
Laser (NOT the PRP which is done in PDR)
is the Gold standard treatment of ROP.
I-Vit Anti-VEGF (half of the adult dose) is

given if Laser is not available or possible (as
in non-dilating pupil or hazy media).
Disadvantages of I-Vit Anti-VEGF- delays
normal retinal vascularisation, increases
retinal traction, more likely late recurrences
& systemic side effects.
Advantages- myopia less likely, less time
consuming, no intubation required, laser
more damaging in zone-1 (posterior pole),
better results in APROP cases, also useful as
adjunct before vitrectomy for stage-4 & 5,
Laser doesn‟t treat VEGF already present in
vitreous.
As per latest recommendations, use smaller
needle (4mm long, 31-32G) at 1 mm
posterior to limbus for I-Vit injection in
newborn. Remember, newborns have
disproportionately large lens & no Pars
plana.

Tip-130.....
Retinal complications in Covid-19 (SARS
CoV-2) infection....
Occlusion of terminal retinal arterioles of
RNFL & GCL causes ischemia & infarction
seen as superficial (flame shaped)
hemorrhages & cotton wool spots.
HIV, Dengue & Zika viruses cause similar
complications.
Damage is caused directly by virus or

immunogenic or thrombotic coagulopathy.

Tip-131......
Important D/D of ROP in newborn is rare
B/L vitreo-retinopathy- Familial exudative
vitreo-retinopathy (FEVR). FEVR is
inherited, retinal angiogenic disorder with
avascularisation causing ischemia &
neovascularisation of peripheral retina with
subsequent exudation & vitreo-retinal
tractions.
Unlike ROP, FEVR occurs in TERM babies
without h/o oxygen therapy & is progressive
for years.
Coat‟s disease & PFV (earlier called PHPV)
are also similar vitreo-retinopathies of
newborns, but are generally U/L.

Tip-132.....
In acute CRAO (sudden visual loss),
classical retinal whitening, cherry red fovea
& box-carring may take few hours to
develop, till when the fundus may appear
totally normal.
Irreversible retinal injury starts after 90
minutes of total CRAO, however try
measures (decreasing IOP & digital massage
to dislodge embolus) for upto 24 hours.
Visual loss in CRAO most closely correlates
with ensuing degree of retinal

opacification/edema.

Tip-133.....
Subthreshold Laser (STL) is/has....
-Low powered & is invisible (infrared)
during application time.
-Theoretically minimises collateral thermal
damage beyond RPE (ie to NSR), especially
useful in macula unlike conventional lasers.
? Less likely ERM, field defects & CNVM
(side effects of conventional lasers).
-Micropulse laser (eg Iridex) is STL with
pulses in microseconds (milliseconds in
conventional lasers)
-Presently, NOT considered the first-line
treatment.
-Being invisible on application, over &
under treatment likely with difficult
reapplications.
-Transpupillary Thermal Therapy (TTT) was
also a type of STL.

Tip-134.....
Roth spots (white centered superficial
retinal/RNFL hemorrhages)- first described
& considered pathognomonic in SABE may
occur in host of systemic diseases affecting
retinal capillaries (eg DM, HT, Anemias,
Leukemia, HIV, etc.).
Whitish centre is platelet-fibrin thrombus

plugging the ruptured capillary.

Tip-135......
Photodynamic Therapy (PDT)...
-uses Verteporfin (Visudyne)- a
photosensitizer.
-uses low power (full fluence is only 600
mW/sq.cm), long duration (83 seconds),
infrared laser (689nm).
-FDA approved for wet AMD in 1999, but
now only used as second line treatment.
Combined therapy (full fluence PDT with
Ranibizumab) now preferred.
-Now also used in chronic CSR & retinal
capillary hemangioma.
-Main side effect is photosensitivity- patient
has to cover skin fully, face & eyes for 3
days after treatment. Wear gloves, sun-
glasses and wide-brimmed hat.

Tip-136....
OCULOMICS...
is identifying ocular biomarkers of systemic
diseases.
Retina by fundus imaging & OCT is also
being used non-invasively for this purpose.
e.g. In Alzheimer's- RNFL thinning &
increased hard druse in retinal periphery.
In calculating risk of MI & Stroke- more
changes of HT retinopathy, Decreased AV

ratio (either arteriolar constriction or venous
dilatation) pose higher risk.

Tip-137.....
During FFA...
-Take colour & Red-free photos first.
-Predecide- which eye to start with first.
-Inject dye rapidly (after test dose for
anaphylaxis) within 5 seconds.
-Start with photos of Disc & macula in
preferred eye initially. Go clockwise all
around the periphery clicking photos.
- Follow same for other eye.
-If both FFA & ICGA are planned, ICGA is
first performed followed by FFA, while
waiting for late films of ICGA.

Tip-138......
ILM peeling is considered an integral part
of Full thickness macular hole (FTMH)
surgery unlike in ERM surgery, where its
role still remains controversial.
FTMH is now considered as macular
dehiscence, starting as foveal detachment
because of tangential traction & NOT the
dissolution of tissue.
Tip- 139.....
Leber congenital amaurosis (LCA) is the
only congenital eye (retinal) disease where
Gene therapy has been approved by US-
FDA (2018) in one of its variants (in

approx.. 10% cases with RPE65 gene
mutation).
LCA is the most common inherited (auto-
recessive) blindness of children, presenting
with marked visual impairment, nystagmus
& abnormal ERG in newborn.
Fundus picture is variable, being normal
initially or later showing bone-spicule
pigmentation or flecks or whitish plaque
lesions.

Tip-140....
Combined CRAO & CRVO is rare but
possible disease.
Patient presents with sudden, unilateral,
severe painless loss of vision. Patient has
RAPD with features of both CRVO (retinal
hemorrhages with 'tortuous' & dilated retinal
veins) & CRAO (retinal opacification/
edema with cherry red fovea).
CRAO fundus findings resolve faster than
CRVO. Prognosis remains poor.

Tip-141.....
The importance of differentiating Classic
(Type-2/Subretinal) or Occult (Type-1/sub-
RPE) CNVM in ARMD is now reduced, as
both need Anti-VEGF as first line therapy.

Tip-142.....
Pathognomonic feature of Stargardt's
disease (Fundus flavimaculatus) on FFA is
total loss of background choroidal
fluorescence in early phases, so called
'Silent choroid' (blocked by lipofuscin like
material. It doesn't correlate with severity or
duration of disease.

Tip-143.....
In retinal laser, 3 parameters are adjustable
viz. 1. Power in milliwatts (mW), 2.
Duration of exposure in seconds (0.1 second
usually) & 3. Spot size (100-300 mn
usually).
While in YAG laser, only one parameter is
variable- Energy in milliJoules(mJ).
Energy =Power x Time. Energy is what one
delivers & Power is the rate at which it is
delivered.

Tip-144.....
Pregnancy predisposes to progression of
Diabetic retinopathy (DR). Elevated HbA1C
levels at baseline are associated with higher
risk of DR, hence close monitoring is
essential & preferably keep it below <6%,
without causing significant hypoglycemia.
Gestational diabetics don't develop DR.
Pregnancy has no long term effects on DR.

Tip-145.....
Cluster Endophthalmitis (CE) in India is
most commonly caused by Pseudomonas
aeruginosa (usually Multi-drug resistant) &
is because of exogenous contamination
as Pseudomonas is not the normal
conjunctival flora.
New organisms (eg
Stenotrophomonas/aerobic gram negative
bacteria, etc.) responsible for CE are now
being reported worldwide.

Tip-146....
Artificial intelligence (AI) using computer
algorithms in ophthalmology is now most
commonly used for 3 retinal diseases viz.
DR, AMD & ROP. It can greatly help in
real-time tele-ophthalmology screenings.

Tip-147.....
Retinal Function Imager (RFI by Optical
Imaging Ltd., Israel) is a new non-invasive,
stroboscopic, fundus imaging camera, which
detects functional changes in retinal
vasculature before structural changes can be
detected clinically or on conventional
imaging. It provides retinal blood flow
velocity, non-invasive capillary perfusion
maps (nCPM), blood oximetry & metabolic
demand of retina.

It has higher field of view & resolution than
OCTA.

Tip-148.....
In patients of pathological myopia with
severe chorioretinal atrophy, chances of
missing a retinal break are high on I/O &
also during surgery.

Tip-149.....
In RVO related macular edema, both Anti-
VEGF & Dexamethasone implant (Ozurdex)
have similar efficacy, however the former
have lesser adverse effects. Thus, Ozurdex is
usually the second choice in these cases,
being more often indicated in pseudophakes
& anti-VEGF's non-responding cases.

Tip-150......
Pachydrusen- are large (>125mn) drusen
seen as hallmark of Pachychoroid disease
(see Tip-29), but are different from soft
drusen of AMD, being scattered even
around the optic disc & have "well-defined"
& complex margins. They may be isolated
or in clusters. These are sub-RPE deposits
seen as yellowish deposits on fundus photos.

Tip-151.....
Purtscher retinopathy is U/L or B/L retinal
disease with extensive hemorrhages, edema

& soft exudates in posterior pole following
severe crushing injuries of head or body
causing intravascular coagulopathy &
microembolisation.
While Purtscher like retinopathy has similar
fundus picture following many systemic
diseases causing systemic
microembolisations e.g. in amniotic
embolism, pancreatitis, connective tissue
diseases, etc.
Empirically steroids are used.

Tip-152.....
Macular pseudohole is a clinical diagnosis
where...
-Contracting ERM in macula heaps up the
tissue around the macular centre.
-Watze-Allen sign on fundus biomicroscopy
is negative (no break in slit-lamp beam
noticed by patient)
-Metamorphopsia is common but no central
scotoma is noticed by patient.
-OCT scan confirms no loss of central
macular tissue unlike full thickness macular
hole.
Tip-153....
Clinical appearance of Macular CNVM....
-Greyish-green deep (sub-retinal/RPE),
elevated lesion with hyperpigmented
borders.

-lesion has SRF, edema, exudation or
hemorrhages.

Tip-154.....
Retinal Angiomatous Proliferation (RAP) is
a distinct form of AMD with type-3 CNVM.
'Intraretinal' neovascularisation starts from
deep capillary plexus in macula & then
infiltrates deeply towards RPE & choroid
(retino-choroidal anastomosis).
Patient usually presents in its late stage-3
with fluid on OCT seen under RPE, NSR &
Intraretinal, although maximum fluid is
Intraretinal.

Tip-155.....
Both Retinal Angiomatous Proliferation
(RAP) & Parafoveal Telangiectasia
(PFT/MacTel) show telangiectatic macular
vessels, but PFT never causes PED, as it
doesn't affect RPE & only very rarely causes
CNVM.

Tip-156.....
Severe NPDR has any one of the following
(Rule of 4-2-1), but no neovascularisation...
-Intraretinal hges or micros in all 4
quadrants.
-Venous beading in any 2 or more
quadrants.

-IRMAs (see Tip-20) in 1 or more
quadrants.
Any patient with 2 or more of above 3
characteristics is having “Very severe
NPDR”.

Tip-157....
Photocoagulation for Diabetic maculopathy
is now only used for focal macular edema
outside FAZ. Macular grid for Diffuse
diabetic macular edema (DDME) is now
given up in favour of repeated Anti-VEGF
injections.

Tip-158.....
Hypertensive Retinopathy (HTR) of
whichever grade (even of grade-iv in acute
hypertensive crisis with disc & macular
edema) needs no special ophthalmic
treatment but requires urgent medical
control of BP & close monitoring. No anti-
VEGF required for macular edema.
Most patients regain good vision, however
chronic disc or macular edema can cause
vision loss.

Tip-159.....
Paracentral acute middle maculopathy
(PAMM) & Acute macular neuroretinopathy
(AMN) can be differentiated on SD-OCT
scan. In PAMM, hyper-reflective plaque

lesion is seen inner to outer plexiform layer,
while in AMN, lesion is outer to OPL (i.e. in
photoreceptors).
Patients in both the diseases present with
unilateral, sudden onset paracentral scotoma
but commonly have near normal vision &
fundus. Both are actually microvascular
Intraretinal infarcts.

Tip-160....
In OCT macular scan interpretation, 2 basic
points to be noted are-
1. Identify different layers & note which
layer(s) is/are predominantly affected-
vitreoretinal interface or inner or outer
(ELM to RPE) retina?
2. Whether lesion is hypo or hyper-
reflective?

Tip-161.....
Different types of Pigment epithelial
detachments (PEDs) can be differentiated on
OCT scan e.g..
1. Serous PED- is filled with hypo-
reflective, homogeneous fluid.
2. Hemorrhagic- is filled with hypo-
reflective, homogeneous fluid (sometimes
partly heterogeneous) but casts a shadow
obscuring underlying choriocapillaris.
3. Fibrovascular- has heterogeneous &
hyper-reflective contents.

4. Drusenoid- has homogeneous & hyper-
reflective contents.

Tip-162.....
Synchisis scintillans, (cholesterol crystals
because of vitreous degeneration) unlike
Asteroid hyalosis may be seen in both
anterior chamber and vitreous & are free
floating (not attached to vitreous
framework) & settling down with gravity.
Also Asteroid hyalosis are fixed & non-
iridescent unlike Synchisis.

Tip-163....
Exudative retinal detachment (RD) unlike
Rhegmatogenous RD has dome-shaped
elevation with gravity dependent shift of
subretinal fluid. Retina remains more
transparent & has more turbid fluid unlike
Rhegmatogenous RD. Rhegmatogenous RD
always extends towards ora serrata unlike
exudative.
Always try to find the cause in exudative
RD which could be Inflammatory, vascular
or tumour.

Tip-164.....
Diabetic papillopathy is U/L or B/L mild
optic disc edema with mild visual loss & self
recovering in 2-3 months. It is a variant of

non-AION & has no association with
diabetic retinopathy.
It is mainly a diagnosis of exclusion (rule
out AION, NVD, optic neuritis, etc).

Tip-165....
Prophylactic laser for fundal coloboma to
prevent Rhegmatogenous RD is a
controversial subject, although some studies
have shown it to be beneficial. 3 contiguous
rows of laser spots are applied all around at
the coloboma edges except in macular area
(i.e. sparing area between 2 temporal retinal
vascular arcades).

Tip-166......
2 developmental anomalies of peripheral
retina that have strong vitreo-retinal
adhesions are...
1. Vitreo-retinal tufts- small whitish retinal
elevations looking like snowball opacities
on retinal surface.
2. Meridional folds- perpendicular retinal
fold (pleat) between two oral bays.
Both very rarely cause RD & are usually the
incidental findings requiring NO
prophylactic treatment.

Tip-167.....
Most common manifestation of TB in eyes
is granulomatous uveitis (mostly posterior

uveitis in form of choroidal tubercles).These
patients should get systemic steroids along
with ATT to prevent the damage.
Most patients with active ocular TB have no
h/o systemic or pulmonary TB.
Chest CT is better than plain X-ray. In Mx
test, >10 mm induration is considered
positive in endemic areas. Interferon-gamma
release assay tests (e.g. Quantiferon TB gold
test -QFT-G) gives less false positive tests
than Mx in prior BCG vaccination.

Tip-168.....
Choroidal melanocytoma is a benign
greyish-black or dark brown tumour with
feathery margins occuring on or near the
optic disc.
Probably a variant of Choroidal nevus that
has overlied the disc.
Treatment is observation. OCTA is an
important tool to know its depth &
progression (occurs in 15%).

Tip-169.....
ERG detects electrical activity generated by
stimulating retina & recording it at corneal
level (by corneal electrodes).
Patient needs to have well dilated pupils,
steady fixation & could be light (for cone
response) or dark adapted (for Rod
response).

Full-field ERG (ffERG) is a mass response
useful in widespread retinal dysfunction.
Focal ERG (fERG) is for central macula.
While Multifocal ERG (mfERG) is for
central 30° (61 or 103 points) & done under
light adapted conditions only (i.e. for cones
only) & is done for localised macular
abnormalities e.g. HCQ toxicity. Its
waveforms are N1, P1 & N2 (initial
negative, then positive & second negative
deflection) unlike negative 'a' (from both
rods & cones) & positive 'b' wave (from
bipolar cells) of ffERG.

Tip-170....
Eales' disease in general is considered as
diagnosis of exclusion (being idiopathic/
hypersensitivity to tuberculo-protein) &
other causes of Vasculitis must be ruled out
(see Tip-55).
It passes through 3 overlapping stages-
Retinal periphlebitis, ischemia &
neovascularisation.
Wide field FFA has allowed earlier missed
findings of Eales also to be discovered in
time.

Tip-171....
LogMAR/ETDRS chart is more accurate
than Snellen.
Recorded at 4m for distance.

Each row has 5 letters (optotypes) & each
letter has score of 0.02 log units.
Formula of logMAR acuity= x-0.02y, where
x is logMAR value of line completely read
(mentioned on chart) & y is the number of
letters missed in a lower row.
To convert Snellen acuity to logMAR value
say of 6/60- Inverse the Snellen value 60/6
=10 & then take log of 10 i.e. 1.00.

Tip-172....
Xanthophyll is present in IPL & OPL (more)
of macula & has peak absorption of 460nm
i.e. closer to blue light; hence green, yellow
or red wavelengths (higher) are preferred in
retinal lasers to avoid macular damage.
Diode laser had still higher wavelength
(Infrared- 810nm), hence better for macula,
however it penetrates deeper causing
choroidal pain.

Tip-173....
Acute cilioretinal artery occlusion......
-Cilioretinal artery normally fills during
choroidal (pre-arterial) phase of FFA.
-Seen as retinal edema (whitening) in
papillomacular area.
-99% are unilateral & if isolated, visual loss
is usually only mild.

-May be caused by inflammatory retinitis
e.g. Toxoplasmosis in which retrolental
inflammatory cells are always present.
-If associated with AION, always think of
GCA (systemic steroids compulsory).

Tip-174....
Hypertensive choroidopathy (seen in severe
HT) is less common than Hypertensive
Retinopathy & can manifest as...
1. Elschnig spots- RPE damage due to
underlying choriocapillaris infarction. Seen
as well demarcated, round, white or yellow
spots in acute phase of hypertension in
perimacular or peripapillary region. Later
they become pigmented.
2. Siegrist streaks- are hyperpigmented,
linear streaks along the choroidal arteries in
periphvery.
3. Serous RD
All these changes indicate choroidal infarcts
due to choriocapillaris damage.

Tip-175.....
Most uveitis cases have KPs in inferior
cornea, while diffusely scattered KPs are
characteristically seen in Fuch's
heterochromia iridocyclitis (Fuch's uveitic
syndrome/FUS) & Herpetic iridocyclitis.
FUS is U/L, chronic, anterior, often
asymptomatic, uveitis with occasional

vitreous involvement. It NEVER shows
ciliary congestion or posterior synechiae.
Steroids have NO role.
Treatment is symptomatic if cataract or
glaucoma develops.

Tip-176.....
Chronic asymptomatic Rhegmatogenous
retinal detachment is generally inferior with
hyperpigmentation or loss of pigment in
RPE & Demarcation lines (linear pigmented
lines at RD edges), cysts in old RD may also
form.
These RDs may not need any treatment as
they commonly don't progess.

Tip-177.....
Immunosuppressives (IS) in uveitis.....
-NOT the primary therapy (except in
Behcet's)
-Used if steroids- producing serious side
effects, unresponsive disease, can't be
reduced to <10mg/day (prednisolone) for
long term use.
-No standard protocols available.
-Take longer to produce effects (1-6 weeks).
Start along with steroids for initial effect.
-Prior consent, blood counts, LFT, RFT &
systemic workup (rule out TB, HIV, etc.)
essential. Regularly monitor.