Diabetic retinopathy (DR), the most common long-term complication of diabetes mellitus, remains one of the leading causes of blindness worldwide. Tight glycemic and blood pressure control has been shown to significantly decrease the risk of development as well as the progression of retinopathy and represents the cornerstone of medical management of DR. The two most threatening complications of DR are diabetic macular edema (DME) and proliferative diabetic retinopathy (PDR). Focal/grid photocoagulation and panretinal photocoagulation are standard treatments for both DME and PDR, respectively. Focal/grid photocoagulation is a better treatment than intravitreal triamcinolone acetonide in eyes with DME. Currently, most experts consider combination focal/grid laser therapy and pharmacotherapy with intravitreal antivascular endothelial growth factor agents in patients with center-involving DME. Combination therapy reduces the frequency of injections needed to control edema. Vitrectomy with removal of the posterior hyaloid seems to be effective in eyes with persistent diffuse DME, particularly in eyes with associated vitreomacular traction. Emerging therapies include fenofibrate, ruboxistaurin, renin-angiotensin system blockers, peroxisome proliferator-activated receptor gamma agonists, pharmacologic vitreolysis, and islet cell transplantation.

Surgery for late complications of proliferative diabetic retinopathy remains the cornerstone of management even in patients who have received optimal laser photocoagulation and medical therapy. With improvisation in the surgical techniques and development of micro-incision surgical techniques for vitrectomy, the indications for surgical intervention are expanding to include diabetic macular edema with a greater number of patients undergoing early intervention. This review describes the current indications, surgical techniques, adjunctive anti-vascular endothelial growth factor therapy, surgical outcomes, and postoperative complications of pars plana vitrectomy for proliferative diabetic retinopathy and macular edema.

There is currently an epidemic of diabetes in the world, principally type 2 diabetes that is linked to changing lifestyle, obesity, and increasing age of the population. Latest estimates from the International Diabetes Federation (IDF) forecasts a rise from 366 million people worldwide to 552 million by 2030. Type 1 diabetes is more common in the Northern hemisphere with the highest rates in Finland and there is evidence of a rise in some central European countries, particularly in the younger children under 5 years of age. Modifiable risk factors for progression of diabetic retinopathy (DR) are blood glucose, blood pressure, serum lipids, and smoking. Nonmodifiable risk factors are duration, age, genetic predisposition, and ethnicity. Other risk factors are pregnancy, microaneurysm count in an eye, microaneurysm formation rate, and the presence of any DR in the second eye. DR, macular edema (ME), and proliferative DR (PDR) develop with increased duration of diabetes and the rates are dependent on the above risk factors. In one study of type 1 diabetes, the median individual risk for the development of early retinal changes was 9.1 years of diabetes duration. Another study reported the 25 year incidence of proliferative retinopathy among population-based cohort of type 1 patients with diabetes was 42.9%. In recent years, people with diabetes have lower rates of progression than historically to PDR and severe visual loss, which may reflect better control of glucose, blood pressure, and serum lipids, and earlier diagnosis.

Diabetes mellitus (DM) has assumed epidemic proportions and as a consequence, diabetic retinopathy is expected to be a major societal problem across the world. Diabetic retinopathy (DR) affects the vision by way of proliferative disease that results in vitreous hemorrhage and traction retinal detachment or by way of diabetic maculopathy (DME). The present-day management of diabetic retinopathy revolves around screening the diabetics for evidence of retinopathy and treating the retinopathy with laser photocoagulation. DME is treated with laser photocoagulation and/or intra- vitreal injection of anti-vascular endothelial growth factor (VEGF) agents or steroids. Laser remains the mainstay of treatment and is potentially destructive. Systemic management aims at preventing or delaying the onset of retinopathy; reversing the early retinopathy; or delaying the progression of established retinopathy. Evidence from multiple studies has confirmed the protective role of rigid control of blood glucose and blood pressure. The evidence for lipid control versus maculopathy was less definitive. However, the use of fenofibrates (originally used for lowering serum lipids) has shown a benefit on both proliferative disease and maculopathy outside their lipid-lowering effect. Other drugs being tried are the Protein Kinase C (PKC) inhibitors, other peroxisome proliferator-activated receptors (PPAR) agonists, Forsoklin (which binds GLUT 1 receptor), minocycline (for its anti inflammatory effect), and Celecoxib (Cox-2 inhibitor).

There remains a need for strategies that are effective in preventing diabetic retinopathy (DR) or slowing down its progression, which is safe, well-tolerated, and more effective, have a lower risk profile, easy to perform, have more predictable results with less morbidity than the current regimens. Physicians caring for diabetic patients not only need to maximize glycemic control, but also closely monitor and treat other systemic conditions. The consistency of clinical data from the fenofibrate studies showed consistent beneficial effects with fenofibrate in slowing the progression of DR. They demonstrated significant benefit on micro-vascular (i.e., retinopathy and nephropathy) outcome, possibly independent of lipid levels. Can we combine the effectiveness of the current standard procedures with the prevention and slowing down of progression of DR that fenofibrates can offer? Knowledge of the primary mode of action of fenofibrate will be useful for both physicians and patients in determining how best to use this drug as an adjunct in the management of DR and ultimately facilitating the translation of clinical trial data to clinical practice.

Diabetic macular edema (DME) is the main cause of visual impairment in diabetic patients. Macular edema within 1 disk diameter of the fovea is present in 9% of the diabetic population. The management of DME is complex and often multiple treatment approaches are needed. This review demonstrates the benefits of intravitreal triamcinolone, bevacizumab and ranibizumab as adjunctive therapy to macular laser treatment in DME. The published results indicate that intravitreal injections of these agents may have a beneficial effect on macular thickness and visual acuity, independent of the type of macular edema that is present. Therefore, pharmacotherapy could complement focal/grid laser photocoagulation in the management of DME. For this review, we performed a literature search and summarized recent findings regarding combined therapy for DME.

Purpose: To determine the frequency of diabetic retinopathy and its risk factors in diabetic patients attending the eye clinic at the University Hospital of the West Indies (UHWI). Materials and Methods: This was a prospective cohort study of diabetic outpatients attending the Eye Clinic at the UHWI. Data were collected on age, gender, type of diabetes mellitus (DM), type of diabetic retinopathy, other ocular diseases, visual acuity, blood glucose and blood pressure. Statistical Package for Social Sciences (SPSS version 19.0) was used for data analysis. Results: There were 104 patients (208 eyes) recruited for this study. There were 58.6% (61/104) females (mean age 53.6 ± 11.9 years) and 41.4% (43/104) males (mean age 61.7 ± 12.1 years). Type II DM was present in 68.3% (56% were females) of the patients and Type I DM was present in 31.7% (69.7% were females). Most patients (66%) were compliant with their diabetic medications. The mean blood glucose was 11.4 ± 5.3 mmol/L. Elevated blood pressure (>130/80) was present in 82.7% of patients. The mean visual acuity was 20/160 (logMAR 0.95 ± 1.1). The frequency of diabetic retinopathy was 78%; 29.5% had background retinopathy, and 50.5% of eyes had proliferative diabetic retinopathy (PDR) of which 34% had tractional retinal detachments. The odds ratio of developing PDR was 1.88 (95% confidence intervals (CI): 1.02-3.3) for Type I DM compared to 0.74 (95% CI: 0.55-0.99) for Type II DM. PDR was more prevalent in females (χ² , P = 0.009) in both Type I and II DM. Conclusions: Jamaica has a high frequency of PDR which is more common in Type I diabetics and females. This was associated with poor glucose and blood pressure control.

Introduction: To evaluate the vitreoretinal complications in myopes after Visian implantable collamer lenses (ICL) implantation. Materials and Methods: This is a retrospective, observational, non-comparative clinical study that evaluated 617 consecutive myopes who underwent ICL implantation at the Department of Refractive Surgery, Yemen Magrabi Hospital, Sana'a, Yemen between July 2006 and May 2010. Follow up ranged from 6 months to 40 months. Preoperative and postoperative patient evaluation included manifest and cycloplegic refractions, uncorrected (UCVA) and best spectacle-corrected visual acuity (BSCVA), slit-lamp biomicroscopy, intraocular pressure and dilated retinal examination. Investigations included corneal topography, central corneal thickness, anterior chamber depth and white to white diameter. Retinal diseases and complications were recorded and analyzed preoperatively and postoperatively. Results: Preoperatively, 61 (9.9%) eyes had posterior segment pathology requiring prophylactic laser photocoagulation. One eye developed spontaneous rhegmatogenous retinal detachment (RRD), one eye developed traumatic retinal detachment and two eyes required laser treatment postoperatively. The overall retinal detachment rate post-ICL was 0.32%. Conclusions: Posterior segment complications are rare after ICL implantation but dilated vitreoretinal assessment is important before and after the procedure. Patients with suspicious retinal lesions need a comprehensive vitreoretinal evaluation by a retinal specialist. If a patient develops floaters or blurry vision he/she requires further assessment by a vitreoretinal specialist.

Purpose: The purpose of the study is to evaluate the long-term changes in intraocular pressure (IOP) after extracapsular cataract extraction (ECCE) with posterior chamber intraocular lens (PCIOL) implantation versus phacoemulsification with PCIOL implantation in otherwise normal cataract patients in India. Materials and Methods: The study was conducted in the Department of Ophthalmology, King George's Medical College, Lucknow between August 2000 and August 2001. One hundred and seventeen eyes of 115 patients were included in the study. 84 patients were randomly selected for ECCE with PCIOL implantation (ECCE group) and 31 patients were selected for phacoemulsification with PCIOL implantation (Phaco group). IOP was measured pre-operatively and post-operatively, from the 1 ^st month to the 12 ^th month. Statistical significance was indicated by P < 0.05. Results: There was a mean fall in IOP of 2.70 mm Hg (19.74%) in the ECCE group and 2.74 mm Hg (20.57%) in the phaco group. The decrease in the mean post-operative IOP from baseline was statistically significant (P < 0.01) at the end of 2 months in both groups. There was no statistically significant difference in post-operative IOP at any visit between groups (P > 0.05, all post-operative visits). After 4 ^th monthpost-operatively, the IOP was mostly stable, but it was significantly lower than the pre-operative IOP. Conclusion: Significant IOP reduction may be expected after cataract surgery with either ECCE or phacoemulsification with IOL implantation. The lowering of IOP became statistically significant at about 2 months post-operatively, but became almost stable after the 4 ^th month.

Purpose: The purpose of this study is to estimate the prevalence of topical ocular anesthetic abuse among welders in Iran and suggest public health solutions for this issue. Methods: In this cross-sectional study, 390 welders were randomly recruited and queried on the use of anesthetic drops. A questionnaire was administered through structured one-on-one interviews conducted by the first author. Results: A total of 314 welders (80.5%) declared that they had used topical anesthetics at least once during their working lives. Almost 90% of them stated a preference for self-treatment over seeking help from a physician due to cultural and financial reasons. The most commonly used topical anesthetic was tetracaine. Most of the subjects (97.4%) had obtained the drugs from pharmacies without a prescription. Conclusions: The prevalence of topical ocular anesthetic abuse among welders in Iran is alarmingly high and may partially be due to cultural issues. Although most physicians are aware that topical anesthetics should only be used as a diagnostic tool, there is a crucial need to re-emphasize the ocular risks associated with chronic use of these medications. Educational programs for both physicians and the public are necessary to address the problem.

Purpose: To assess the current techniques of ophthalmic anesthesia in Nigeria. Materials and Methods: A cross sectional survey among Nigerian ophthalmology delegates attending the 36 ^th Annual Scientific Congress of the Ophthalmology Society of Nigeria. Self administered and anonymous questionnaires were used and data were collected to include details of the institution, preferred local anesthesia techniques, the grade of doctor who administers the local anesthesia, complications, preferred facial block techniques (if given separately), and type of premedication (if used). Results: Out of the 120 questionnaires distributed, 81 forms were completed (response rate 67.5%). Out of the 74 who indicated their grade, 49 (66.2%) were consultants, 22 (29.7%) were trainees, and 3 (7.1%) were ophthalmic medical officers. For cataract surgery, peribulbar anesthesia was performed by 49.1% of the respondents, followed by retrobulbar anesthesia (39.7%). Others techniques used were topical anesthesia (5.2%), subtenon anesthesia (4.3%), subconjunctival anesthesia (2.6%), and intracameral anesthesia (0.9%). For glaucoma surgery, 47.2% of the respondents use peribulbar anesthesia, 32.1% use retrobulbar anesthesia, 9.4% used general anesthesia, and 6.6% used subconjunctival anesthesia. Among the trainees, 57.8% routinely perform retrobulbar anesthesia while 55.6% routinely perform peribulbar anesthesia. At least one complication from retrobulbar anesthesia within 12 months prior to the audit was reported by 25.9% of the respondents. Similarly, 16.1% of the respondents had experienced complications from peribulbar anesthesia within the same time period. Retrobulbar hemorrhage is the most common complication experienced with both peribulbar and retrobulbar anesthesia. Conclusion: Presently, the most common technique of local anesthesia for an ophthalmic procedure in Nigeria is peribulbar anesthesia, followed by retrobulbar anesthesia. Twelve months prior to the study, 25.9% of the respondents had experienced at least one complication from retrobulbar anesthesia and 16.1% from peribulbar anesthesia. Retrobulbar hemorrhage was the most common complication reported.

Purpose: To compare visual acuity with two visual acuity charts in preschool children. Materials and Methods: Visual acuity measurement with Lea symbols and Bailey-Lovie tumbling E chart was performed on children between 3 and 6 years of age. Visual acuity data from the two charts were analyzed with Bland-Altman plot to determine the limits of agreement. The Wilcoxon signed test was performed in children aged 3-4 years and in children aged 5-6 years separately to evaluate the influence of age. The inter-eye difference between the two charts were further analyzed with the paired t-test. A p value < 0.05 was considered statistically significant. Results: A total of 47 children were enrolled for the study. The average logarithm of the Minimum Angle of Resolution (LogMAR) monocular visual acuity with Lea symbols (0.17 ± 0.13) was better than the Bailey-Lovie tumbling E chart (0.22 ± 0.14). The mean difference between Bailey-Lovie tumbling E chart and Lea symbol chart was 0.05 ± 0.12 in logMAR units. A second analysis eliminating outliers showed the same result but lower differences (n = 43, 0.05 ± 0.05 logMAR units). Visual acuity results between the two charts in children aged 3-4 years showed a significant difference (p = 0.000), but not for children aged 5-6 years (p = 0.059). Inter-eye differences between the two charts was not statistically significant (p = 0.77). Conclusion: Bailey-Lovie tumbling E chart is comparable to the Lea symbols chart in pre-school children. But preference should be given to Lea symbols for children aged 3-4 years as the symbols are more familiar than a directional test for this age group.

Purpose: The purpose of this study was to evaluate the role of probing in congenital nasolacrimal duct obstruction in children age 2 years and older and to establish factors predictive of the outcome. Materials and Methods: A prospective study was conducted on consecutive patients older than 24 months with congenital nasolacrimal duct obstruction. All patients were treated with a simple nasolacrimal duct probing as primary treatment. Outcome measures included an ophthalmologic examination plus a parental history of residual symptoms at one and 6 months after surgery. Results: A total of 82 children with a mean age of 34.5 months (range, 24 months to 60 months) underwent nasolacrimal duct probing. The complete response rate was 54%. Partial response and failure were observed in 25% and 20.8% of the eyes, respectively. Bilateral obstruction was associated with failure of probing (P = 0.007, Odds Ratio: 5.76). However, age older than 36 months was not associated with the failure rate. Conclusion: Primary probing maintains a high success rate without any age related decline in congenital nasolacrimal duct obstruction.

The authors report a rare case of a 48-year-old male with chronic myeloid leukemia (CML) who initially presented with a bilateral proliferative retinopathy. The patient complained of recent visual loss and floaters in both eyes (BE). Ophthalmologic evaluation revealed a best corrected visual acuity (BCVA) of 20/50 in the right eye and 20/200 in the left eye (LE). Fundoscopy showed the presence of bilateral peripheral capillary dropout with multiple retinal sea fan neovascularisations, which were confirmed on fluorescein angiography. Full blood count revealed hyperleukocytosis, thrombocytosis, anemia, and hyperuricemia. Bone marrow aspiration and biopsy showed the reciprocal chromosomal translocation t (9;22), diagnostic of CML. The patient was started on hydroxyurea, allopurinol and imatinib mesylate. He received bilateral panretinal laser photocoagulation and a vitrectomy was performed in the LE. The patient has been in complete hematologic, cytogenetic, and major molecular remission while on imatinib and his BCVA is 20/25 in BE.

Macular detachment causes visual deterioration in 25-75% of patients with congenital optic disc pit. A number of treatment options have been reported to manage the macular detachment in optic pit. An optic disc pit represents a defect in the lamina cribrosa; theoretically, an ideal procedure to treat optic pit associated macular detachment would be one that prevents the flow of fluid across the pit by creating an additional barrier. We present a new surgical technique that employs an autologous internal limiting membrane (ILM) to create this barrier. The technique involves standard vitrectomy along-with ILM peeling. Subsequently, the peeled ILM was inverted and transplanted onto the optic disc pit to close the optic nerve pit. This technique showed satisfactory anatomic result with good functional improvement in visual acuity.

The clinical and imaging findings and therapeutic outcomes of intravitreal bevacizumab injection in a patient with macular telangiectasia type 2 are described. The patient first presented with the non-proliferative stage of the disease for 4 months, then the disease transformed to the proliferative stage. In the proliferative period, the patient was treated with intravitreal bevacizumab injections as-clinically warranted. Over a follow up period lasting 26 months, the patient received 6 intravitreal bevacizumab injections, the visual acuity improved from 20/100 to 20/40, the central retinal thickness decreased from 318 microns to 198 microns. This case implies that the patients with non-proliferative macular telangiectasia type 2 should be followed carefully for proliferative transformation, and intravitreal bevacizumab treatment seems to be effective for proliferative macular telangiectasia type 2.

Central serous chorioretinopathy (CSC) is characterized by serous retinal detachment at the posterior pole. Several factors have been implicated in the pathogenesis, and endogenous or exogenous corticosteroids are thought to play a major role. Here we present a case of a 35-year-old male with complaints of a dark circle in front of his right eye. Fundus examination, optical coherence tomography and fundus fluorescein angiography were performed. The patient was diagnosed with CSC. CSC resolved completely within seven weeks. Four weeks later the CSC recurred and spontaneously resolved over eight weeks. Overall, the patient had three additional recurrences of CSC in the same eye over the next year. A detailed history taking revealed the patient was using 0.1% dexamethasone eye drops nasally for recurrent rhinitis for few days prior to each episode of CSC. This indicates the strong correlation between steroids given by any route and the pathogenesis of CSC.

We report a rare case of trichilemmal cyst involving the bulbar conjunctiva. A 55-year-old female presented with a history of a painless, progressive swelling in the left bulbar conjunctiva adjacent to the nasal limbus of 3 years duration. Wide excision biopsy was performed. Histopathologic examination findings were consistent with those of trichilemmal cyst. Trichilemmal cyst should be considered as differential diagnosis in a case of limbal nodule.

The Charles Bonnet syndrome (CBS) refers to lucid and complex visual hallucinations in cognitively normal patients with acquired vision loss. It can be associated with any type of vision loss including that related to macular degeneration, corneal disease, diabetic retinopathy, and occipital infarct. Neurosarcoidosis, a multi-systemic inflammatory granulomatous disease affecting both the central and peripheral nervous systems, is rarely associated with CBS. We report a patient with biopsy-confirmed neurosarcoidosis who experienced visual hallucinations following the development of a right seventh-nerve palsy, right facial paresthesia, and bilateral progressive visual loss. This case highlights the importance of recognizing that the CBS can occur in visual loss of any etiology.