Lecture: Diabetic Retinopathy: Update on Medical and Surgical Management

Dr. Manish Nagpal: Hello everyone. Good afternoon from India and maybe a good morning or a good evening at different parts of the globe that all of you are logged in from. So what I plan to do is talk about diabetic retinopathy and taking you from all the different aspects of a bit of diagnostics, a bit of all the clinical part of the diagnostics and treatments ranging from laser treatments, Anti-VEGFs, steroids, surgeries and just taken over way of the whole gamut of treatments that are there for diabetic retinopathy in general.

We all know that diabetic retinopathy presents in all sorts of shapes and sizes, the fundus which just vary from starting off a background retinopathy, a few micro aneurysms and a few red dots to some going over to extensive proliferations, tractions, oedema. So over the years, I think our whole understanding of diabetic retinopathy has been evolving as has the emerging technology, as has been the treatment’s options which were there and of course the surgical advances which have been coming on.

I’m not going too much off the theory, but just to briefly know the type 1 diabetic mellitus patients are usually free of retinopathy during the first five years and 95% of them tend to develop 15 years or more, while the type 2 diabetes mellitus may have disease at the time of diagnosis also. 30% of retinopathy within five years and then 80% tend to have 15 years or more in a much more aggressive form.

The Associated risk factors are hypertension, smoking, atherosclerosis, renal function, diabetic nephropathy affects 50% of the individuals in the long run and of course pregnancy has its other risk factors in an associated form.

So the management options, first of all, it’s about timely diagnosis which is most important and the treatment plan which is individual customized for a patient coming to you with a certain type of retinopathy at the time of diagnosis. Earlier we used to have a mainstream of laser treatments and today laser treatment still remains gold standard in some parts, but some of it has changed to intravitreal injections and steroids, anti-VEGs which we use a lot today to treat these patients. And of course surgery is there for certain indications.

So talking of laser, the gold standard is PRP and the panretinal photocoagulation. We need to burn certain parts of the retina so that we have better oxygenation to the more crucial part. So we kill all the peripheral parts so that we can save the central part. And the risk – the criterias for doing PRP is proliferative diabetic retinopathy, high risk pre-proliferative. Any sign of residual hemorrhage, vitreous hemorrhage tells you that there has been some sort of proliferation. Or of course, the Frank Rubeosis is also a guide.

So when you do these tests, when you do diagnostics, you may have clinical examination, you see color photos, document them. If you are in doubt, you can do angiographies. Here you can see a wide field angiogram that shows you very nice proliferations which are leaking and certain capillary non-profusion areas. And then once you diagnose that the patient requires, you do a PRP. So here you are ablating all the peripheral part. In this, we are using a multi-spot laser to do that. A laser can be used in any form; single spot, multi-spot. But here we are ablating them using these five-by-five spots so that we can kill the peripheral retina, reduce the load off oxygen requirement, hypoxia and then keep the central part healthy.

When you do a PRP, what do you look for on a follow-up, the involution of the neovascular tissue, a decrease in the oedema, microaneurysms, hemorrhages, cotton wool spots. A disc pallor would be noted as a part of regression, because you’ve killed some part of the retina and it manifests as a pale disc and of course attenuation of vessels.

So here you can see the – a freshly done laser and a follow-up, the scars become pigmented. And you will see gradually as you treat them that the overall proliferative component gets less and less once the treatment starts. These are again patients who have been treated to central photos and the wide field photos. You can see how the whole PRP manifests. This is an extensive PRP coming toward the central part. And again, this is the other eye of the same patient. You can see the peripheral PRP and some central large scars which are there.

So various types of lasers are done, but the basic idea is to kill the periphery. And then when the patient comes to you sometimes with recurrences of bleeding, you do angiograms and look for any residual areas. Now here in this case, all you see is laser once and no residual areas which are seen.

These are again – now, you can see that the NVD which is seen has regressed after an anti-VEGF regression. So along with laser, we’re also giving anti-VEGFs. If there is no traction existing, you can give associated anti-VEGFs which help with the regression also in this. This is another case which shows you on extensive NVD which has regressed post the use of laser and anti-VEGFs in this situation.

Then you come to the diabetic macular oedema. There have been many ways to classify them, a CSME and all those criterias. But today practically what we follow is something simple, focal and diffused and then you could do a ischemic and then you could go on and do a traction, non-traction. So those are – these are more clinical ones which we would use to, so that we can treat patients based on this. So focal is where there are localized serenades with microaneurysms that you see and then you can go and treat them with laser. Or if you see a slightly diffuse oedema, you could go and do a grid laser to those patients in the circumstances like these.

Well, macular laser again can be done in a grid or a focal one. And at times we use this sub-threshold lasers in the – now these lasers are getting less and less. This laser use of a gross grid laser, but this is what as a sub-threshold patterns we’ve been using or a micro-pulse pattern. People have been using to do great laser so that grid laser is not to burn that tissue, but it’s more to tickle the RP so that it helps clear the fluid much faster.

So these are all examples of different types of grid lasers that one would do. This is using again the multiple – multi-spot laser with a pattern to fit in to the area that you’re trying to laser and then regress the oedema from that area. These are pre and post laser. Now, by the bottom you see post laser treated patients.

Now, what is the concern is ischemia which manifests more often with unexplained loss of vision. Now, you see a clear media and you see there is nothing obstructing the vision, but the patient’s vision is too low. That’s when you need to rule out ischemia. The foveal avascular zone is what needs to be ruled out.

Now, this is a normal in geography that you see here of a normal patient and this is what we see. And while if you do it in a diabetic, you’ll see something like this, a star studded sky with multiple microaneurysms coming up. And in the center you see the clear dark area which is what is the foveal avascular zone and that’s an important area to see that is it enlarged which means there might be ischemia or is it healthy which may be a good prognostic sign for the patient when the treatment goes.

So these are different examples of angiographies in patients of diabetic retinopathy. On the right you see microorganisms coming up very close to the foveal area, although the FAs are itself looks fairly healthy to a large extent. And on the left you see extensive CNP areas which are building up. And it tells you that the prognosis in such a situation is very poor no matter what you do with the patient and your treatment becomes more palliative.

Here again, you see an FA of a patient with unexplained visual loss and you see why, because there is an extensive foveal avascular zone extending to the periphery with no profusion.

And then today you can use OCT angiography to look at the foveal avascular zone. You don’t have to inject a dye just to look at the foveal. And here you can see two eyes of a patient. This is the foveal avascular zone in the left and the right is distorted and enlarged and it tells you that there is a difference. Difference between two eyes is significant always. If you just look at one eye of a patient, you may not be able to comment on whether it’s pathologic or not unless it’s grossly enlarged. But if you compare the two eyes and if one of them is distinctly distorted and different, it tells you that the pathology is worse there, there is more ischemia there. So these are examples of OCT angiography.

This is on the left, an FA which is corresponding to the OCT angiogram showing you a similar loss of capillary profusion on the OCT. And these are more examples of that. So today we use OCT angiography. If you’re only looking at FAZ and you don’t have to inject a die just for that. But if you’re looking at new vessels in the periphery, I think you need an FA for that.

Of course, wide field viewing is the best whenever in doubt when you’re looking at areas you already have a patient who is well treated with laser and has come back to you with a rebleed like this, you need to do an angiography of course. And in a wide field, you want to look at where are the leaks. And here you can see that it tells you what are the potential areas which are still leaking and you will need to top up laser here. I may add an anti-VEGF also while doing treatment.

This is the other eye which looks really clean. Now, no new vessels seen in a well treated laser eye. So these are the technology. The imaging has now improved. The SLO-based ones which give you a very nice image now which tells you the central field and of course as you go to the periphery, you know what’s happening in the periphery. So these are examples of documenting and also assessing how you go ahead with the treatment in these patients.

So you look at this patient and he looks as if more or less he’s regressed with a little bit off oedema. But you do an angiogram and you see that there is still a florid area which needs treatment. So there are lot of skip areas which need treatment in these patients when they come back to you on follow-ups or on regression.

So that’s about the angiography and the OCT angiography and ruling out ischemia and finding out new vessels post treatment, because these are important clinical steps that one takes while following up patients on that.

Then comes the OCT which is now becoming one of the most used modalities when we look at a diabetic macular oedema. And on the OCT, what you’re looking for is different patterns, something like a spongy cystoid oedema, subfoveal serous detachment or a tractional component which is there.

So here you can also divide the classifications as I said before there could be a focal defuse, ischemic and then there could be a traction, non-traction which is how you would look at these. If you look on the right, the non-traction is all about oedema’s spongy cystoid subfoveal serous fluid, while on the left is a clear contraction. So if you distinguish these two, you’d already know how to move ahead with treatments.

Now, this is a spongy oedema, no gross cystoid chain, mile spaces which are seen and there is an enlargement. You could probably also consider doing laser there at times. This is gross cystoid destroyed oedema that you’re seeing. Once again you see cystoid oedema and also subfoveal serous fluid in these patients.

And these are patients typically treated with injections, more commonly anti-VEGFs. You may have to repeat them, because they last a month and then sometimes the oedema may come back. So anti-VEGFs work very well. You can see how the flattening of oedema happens after anti-VEGFs. And if you have very large collections like these, sub-serous fluid with lot of lipids, there usually steroids work better to flatten these. Anti-VEGFs may not work that effectively in such type of oedemas.

here we use Ozurdex in these kind of oedemas with large cystoid space with subfoveal serous collection. And you can see that the oedema becomes less, the exudates become crenated, the OCT becomes flatter. This is the follow-up of a patient. You can see after a month the crenated edges. You do a wide field for picture. You see the Ozurdex sarcophagus kind of a thing. It’s still delivering. It’s still there and you may find it in the inferior fundus at times while doing. And this is a wide field picture of another one of these patients.

So it’s interesting to document how – what size, how it has diffusely liberated some of the steroid and its still doing that. It lasts for about two to two and a half months, maximum three months in most circumstances after which you may have to repeat this.

So most of the times we start off with anti-VEGFs, but when do we use Ozurdex is when it’s non-responding or the patient requires very frequent injections. Patients needing long-term anti-VEGF injections are a large oedema like I showed you with sub-serious fluid, lot of thickness and lot of lipid under the fovea. There I would prefer doing Ozurdex as a first line.

Relative contraindications would be a young patient with clear lens, because Ozurdex can at times bring in earlier onset of cataract. And of course a known steroid responder/glaucoma, you might have a relative contraindication. And very important is aphakia, because aphakia we know that if you inject and it comes into the AC, it causes a lot of inflammation to the cornea and the anterior chamber and one should not use it if the chamber partition is not intact.

This is an example of a patient who’s been undergoing laser treatments and along with that had a lot of oedema. So you can see that on the follow-up, the Ozurdex is lying below. This is upside view – down view. So you can see the floating Ozurdex and then we’re going ahead with further laser in this.

So I think whatever I’ve told you, anti-VEGFs, lasers, Ozurdex, they all can be used separately individually or used them to your advantage. If you have access to them, use them in combinations. Anti-VEGFs help you regress the oedema, also regress proliferations, also allows you to do lesser laser and achieve the regression. And sometimes there is no oedema to begin with and you do a PRP, you can bring oedema. So anti-VEGFs help you reduce the chances of oedema brought in by the laser. So steroids, anti-VEGFs, lasers, all can be used in combination of together.

Then you come to the tractional component. And you could have a picture like this with a very focal vitreomacular traction component which is there or a slightly broader vitreomacular traction which is there. And you can see how thin the fovea becomes in such situations. And when you look at the clinical picture, sometimes you don’t know why the patient has solo vision. And you think there may be ischemia. And actually when you do the OCT, you realize that there is a traction on this.

So vitreomacular traction becomes an important indication for changing the whole management. Whatever I told you, laser, injection, steroid, nothing works. So you may do all those things and say none of the treatments work. But why, because the OCT is showing you a different picture altogether. So it could be a focal vitreomacular traction or a diffused one like a hyaloid – thought hyaloid or a membrane spanning over the retinal macular surface. Sometimes there could be asteroid hyalosis along with VMT and because of asteroid, our visibility becomes less. We’re not able to see, appreciate things as better. But today with the imaging angiography, OCTs are able to bypass and give you enough info to take a decision that this patient has a VMT, has an asteroid which is blocking the view. So you need to go and surgically remove the asteroid and then remove the vitreomacular traction.

So these are some of the macular OCT based indications for surgery and apart from that your surgical indications are which is hemorrhage/subhyaloid, hemorrhage over macula which is non-clearing. In the past, we used to be told that wait for three months. Today I don’t think any of us waits beyond a month or even earlier in case the patients presenting hemorrhage or a subhyaloid hemorrhage is extensive or huge, because you would rather clear it and start your laser treatments, injections rather than wait for nature to take its own toll.

A tractional detachment involving macula or an impending macular detachment a taut hyaloid that we just saw or any membrane/fibrous tissue in the visual axis, anything which is blocking the axis needs to be surgically tackled.

So moving on to the surgical part, I typically use a 25-gauge for most of my surgery and this is the classic 25-gauge tool that we use. And this is our incision making. We – it’s become fairly simple with this [indiscernible] [00:18:21] based MIVS systems. And this is that the end of surgery. Most of the times you are just removing the cannula’s eye press with a metal tip of on inventor just to massage and give back the elasticity to the tissue so that the wound is – heels better.

I also like to put air bubble inside. I do an air fluid exchange before I close so that it helps the wounds feeling much better. And if there is a leak, we would suture those incisions additionally in these circumstances. So this is what surgically we would do.

Let me take you through some surgical examples of simple hemorrhage to some more complex cases. And this is a classic indication where you have which is hemorrhage, which is over the macular area partly with attachments, but not very strong. Relatively a simpler type of a case where you can see the fundus. You have hemorrhage, you have a few additions, but none that are requiring a lot of manipulation or intervention and it’s about clearing up the visual axis and then going and looking at each area individually.

So this is again a similar type of situation. There is a hemorrhage. There are a few scattered subhyaloid hemorrhage plane, there are a few proliferations spanning from this towards the arcade. And here you need to make sure that you’re not pulling on the language and carefully segment each area separately. So my principle is to go and use the cutter for most of the things. It’s a multifunctional tool. Only if I feel in certain situation that a loner cutter may not work, will I shift to bimanually we got. Today with the technology the cutters, it’s become fairly could – it works as a scissor quite effectively in most circumstances.

So this is a subhyaloid hemorrhage that you see here. Again after doing the basic core you go and once you are in the right plane, the cutter is trying to aspirate the subhyaloid hemorrhage. It’s a hyaloid hemorrhage. The good part is that it’s never usually clotted. It’s – once you are in the right plane, you start aspiration and it starts coming off very fast and it tells you that you’re in the right plane. So this is a subhyaloid hemorrhage which is being cleared with the cutter. Again these cutters now are very fine. The port is close to the shaft. So you don’t need a separate exclusion or one could use a soft tip, one could use if somebody prefers. But today it’s much faster, much simpler that the same tool works for everything and you can go very close to the retina to achieve these things quite well.

So you clear up everything, identify the bleeders. Other key is to identify what is bleeding. When you cut the proliferation, sometimes the bleeders would be using, but you have to go and make sure that everything is taken care of. You don’t want to leave an active leader on table. So you need to assess the whole fundus in the retina before you shut down. So here you can see that there are small areas here which I have to collect the blood. So I’m trying to remove that. There is a feeder where we have done a diathermy. And then follow it up with a good PRP all around which is a must for any diabetic case that we go in.

This is another case and as you can see that there is again a subhyaloid component in a disorganized irregular manner instead of a classic central clock. So here you need to find the right plane. And once again to find the right plane, you use the cutter and once you have the plane you expand on that plane so that you get an opening in that tissue. And after that you clear up the blood gradually. As soon as the tissue – the hyaloid is gone from there, you can easily clear up the residual blood. And so we first clear the lower part and then we’re clearing the upper part, gradually pull it off, because sometimes these additions are strong.

So as you’re pulling these – the hyaloid, you need to be very watchful of the underlying retina, the peripheral attachments lest [phonetic] [00:22:46] a break is created or a pull will cause a tear in those circumstances. So here you can see that we have gradually been clearing all around. And then finally the nasal side also was attached the whole hyaloid sheet and eventually everything is free from that. And then you just finish off with a good laser in that.

So there are a lot of people who say, do you do an inside out for an outside in delineation. I don’t have a fixed rule. I use both. In certain cases, I may use both also in the same case. It’s about finding the right plane. As you’re moving your cutter, you would see that you’re finding a plane at some point. And once you find a plane, you start using it. So here it’s in the periphery. You can see that as I move in the periphery, I can see that I find the plane of the hyaloid and I circumferentially, gradually go and then kind of remove that tissue from there.

So I’ve done the nasal part and now I’m coming to the central part, inferior part, superior part and then gradually still here the addition is stronger. So I’m kind of cutting its attachments to the periphery and then disengaging it from the periphery so that every time I pull out it, it should not create a break. And then gradually removing the part which is near the arcade So you can see that I’m carefully with a vacuum of the cutter trying to pull the sheet, but also keeping a watch on the retina as its getting pulled, because as soon as I feel that the resistance is high I’ll stop and segment that rather than pull. But if I feel that, yes, with a little persistence it’s coming off, I would go ahead and finish off the whole – the hyaloid removal from there.

And once that is done, it gives you a very good plain to clear up everything that the whole tissue has – had jumbled up there with blood and fibrous tissue and everything. So you can clear up that whole area and the retina looks much better after having removed the hyaloid from that area. So here you can see that then we’re going ahead with laser to the periphery after that.

This is another similar situation like I showed you, large irregular collection of subhyaloid hemorrhages which are there with some additions of the hyaloid. So you can see that I’m using the same way I – wherever I find plane, I start to insert the cutter there and gradually disengage that tissue and see how is the addition there. So if you keep watching, I’ve removed some of it and I’m removing some of the tissue from here in this area. And I remove a bit, cut it, then again pull at it, then again cut it. And now, if you see right now at this stage as I’m trying to engage, there is a small break which was created just at this juncture. So I left it. Then I stopped pulling and I actually – I started doing it the other way around to remove that tissue.

So one has to be very careful while removing this tear in tissues, because you can – if you’re fast, you’ll break maybe a huge tear and if you’re slow, you may know the starting of it, at the very beginning and it may be a very small break which you’re left with which is very easy to treat instead of a very large ragged break which may be more difficult to treat. At the end and it may bleed also.

So here you see another case, a case where there is a tractional component. And you can see that there is a whole tabletop area which is in a bridging way there is a traction attached. So here my first step is to segregate all of them individually and remove the connection to the periphery. So keep cutting, keep cutting and making sure the retina is divided of this fibrous tissue. And then you take that separately the peripheral part and then separately the central part, because till the time the whole hyaloid sheets are interconnected. It’s very risky for you, because if you work at one place, you may be causing traction to the other side without knowing. So it’s always better to have small areas which you take up in a singular manner and then remove segment and leave small stumps and then look at bleeders. So anywhere it bleeds, wherever you’ve taken of a proliferation, use the diathermy, stop it, raise the pressure.

Now here, there was a big vessel, so I already anticipated the diathermy. And once you have removed everything, I’m trying to assess for residual traction. I put pro flow [phonetic] [00:27:49] carbon, relook at the bleeders which are there and slowly you can see that the retina is flattening. And this is the final picture of a case like that which was totally getting crumpled up with those stiff proliferations at that time.

Now, this is something to show you a small technique of proportional reflux. For a situation like this where there are type planes in which these additions are there, you could use a feature in constellation which is there called proportional reflux in which you can insinuate the cutter into the plane that you want to open up and there you press proportional reflux. So what it does is that it just throws out some of the water from the port which makes – helps you make a plane there. You can see that I insinuate there and then we’ll press the foot pedal. And what you see the debris coming out partly is basically the water coming from the tubing and it creates a space. Some people use viscoelastics to do these planes, but with proportional reflux it’s much easier. You can – you don’t have to put any viscoelastic, you just use the proportional reflux of the saline which is coming in instead and use.

So slowly you can keep on expanding, keep injecting in the plane and as the plane shows up then you go and cut with the cutter. So gradually you can keep expanding and segmenting these areas and removing this fraction also. So proportional reflux is something which can also be tried for some of these situations, it’s a technique.

Now here, I’m using a bit of bimanuality, because the addition retina is detached with traction and stronger additions which are there. And so I prefer a bimanual approach to some extent. But most of the work is still done by the cutter. It’s only – the bimanuality is only for very small bits and pieces where you feel that the addition are strong and for us very small part of the manure you may need the help of a forceps along with the cutter in the other hand. But otherwise most of it still gets done. But it’s always wherever you anticipate, all you need to do is put a chandelier and be ready. It’s very easy nowadays with the 25-gauge chandeliers.

So here I use a forceps to just pick up those the additions which I thought I could not remove with only the cutter without damaging the retina. So the forceps helps you pick up those areas, with the cutter you just insinuate and cut.

So bimanuality, it’s still can be used very effectively. In the past, we were using a lot of scissors and a lot of other instruments to achieve this. Today cutter does most of the work, but you still have access to bimanuality with the chandeliers which are very easily possible to use these days.

Then coming to a small component of surgery where we do for a diabetic macular oedema. When you look at diabetic oedema due to an epiretinal membrane or taut hyaloid or a chronic oedema per se without structural component, that’s an area which also requires surgery at times. And these are situation, these – you can see on the OCT, there is a spanning sheet of hyaloid and the membrane which is there. And this kind of a thing also requires surgery to rectify.

So this is an example of a chronic diabetic oedema that you see here. You can – if you look at the fovea, you can see how thin and cystic those areas are, because of a chronicity of that whole oedema which is there. So here we are – as we can see that we are staining with the brilliant blue, the bluish membrane that you see is an admix of a membrane in the ILM which is coming off from that area. And one has to be careful. If the central area is very thin, I sometimes don’t peel right over the fovea, because at times it’s so thin that you can deroof it. So sometimes you may have to leave that. But if you feel that it’s moving gradually over it, you can go ahead and finish the peel.

So here the membrane does come off with a thin area. But once you have removed this, it gives a breather to the stagnated macula with the chronic oedema. I usually like to top it up with the Ozurdex or a anti-VEGF at end of surgery so that once the mechanical component is gone, you can have one of these agents which are liberating and reducing the oedema component in these cases.

This is another case where you’ll see a whole sheet of a membrane and a hyaloid which is there. It’s – if you can see that the sheet is very loosely adherent to the central part, it’s attached more to the arcades and the whole sheet is very flimsy. So we remove that and you can see that I’m cutting it although it’s a bit stiff. So I’m cutting it, I’ve used the [indiscernible] [00:33:02] so that I don’t want to disturb the fovea, I want the fovea under a good visibility, because if it’s very thin I can inadvertently cause damage to it.

So here what I’m doing is I’m doing the peel, but I will not go right over the fovea, because here the fovea appears very thin to me and I don’t want to risk deroofing it by any means. So gradually I’m removing the ILM. ILM peeling unlike in the macular hole or a PRM is usually more difficult in these, because the macula is very boggy and at times if you pinch a bit deeper, you may constantly keep pulling the retina. And even if you have the right plane, the retina tends to lift up. It’s too spongy, too boggy. So one has to be careful and constantly move tangentially, always move tangentially to achieve that.

So here you can see that I’m kind of peel all around, but I’ll not peel and I just trim off this whole membrane and not peel right over the fovea which is a safer thing to do rather than go right over it and risk the fact that you have created a deroofing in that area.

The other thing with diabetic surgeries is preparatory anti-VEGF. And nowadays, with the availability of anti-VEGFs, a lot of cases which are especially treatment naive. If they come to you with a lot of proliferations and you’re taking for surgeries, I would give them a preparatory anti-VEGF about three to five days or six days before the main surgery. And that reduces the amount of bleeding that takes place during surgery on is very effective and helps. I don’t use it for all the cases, but I use it for a significant number where there is a lot of florid new vessels which have never been treated.

So these are examples of cases. If you see a case like this, florid new vessels with lot of fresh bleeding, you’re better off making sure that the patient undergoes anti-VEGF before the surgery. But mind you, you need to make sure the patient understand that the surgery has to be done. If you inject an anti-VEGF in this case and the patient doesn’t turn off for surgery, he will get a crumpled up retina within a few weeks, because it has this whole anti-VEGFs and this effect of totally crumpling up the retina beyond 10 days or 15 days. So my window is about three to eight days, three to 10 days is max. You need to make sure the patient comes back to you in such a situation. But of course during surgery, it’s amazingly better while operating such a case having had appropriately Avastin or an anti-VEGF before this.

While we talk off preparatory anti-VEGFs, I use a lot of anti-VEGF at the end of surgery. So one of the reasons that I feel we did a study also and published it that it has a role in reduction of postoperative vitreous hemorrhage incidents as well as postoperative cystoid oedema.

Now, one off the reason is that a lot of patients whom you operate for vitreous hemorrhages are just subhyaloid hemorrhages. You cannot assist the macula before the surgery. And all you do is mechanically clear up the hemorrhage, do a laser and come out. But a lot of them have associated macular oedema. A lot of them may have oedema because of the laser that you do. And within a month off surgery even though their media is clear, they may have less vision because of macular oedema. So you may have a patient on the right, you see a very well operated patient with good laser regression has come back to you after one month, vision has improved, but is not improving to a good vision, because patient has a lot of cystoid oedema. While on the left, a similar type of a situation, postoperative one month, patient has a flat history.

So one has to be – if you give an anti-VEGF at the end of surgery, you are reducing the chance off this oedema or if those are preexisting oedema you have reduced that with the help of injection, because your surgery alone, your laser alone is not going to act on the oedema. So that is very important. So this is like we have just cleared the hemorrhage and at the end of surgery after having done in top of laser, whatever is required for this particular case we inject Avastin at the end of surgery or an anti-VEGF at the end of surgery which remains in the eye and acts postoperatively so that we have less incidents of postoperative recurrent bleeding. And we had published data sometime back on this that reduces the incidents of postoperative hemorrhage and reduces postoperative CME as well.

Just to show you one last case of a rebleed, lot of patients rebleed and so this one classic case of rebleed. Some of them which they come within a month and if you take them up, if the ultrasound shows no RD, we do in an air blood exchange also. But some of them, we take up for a resurgery. And here you can see that this is one such case where already has been extensively laser, but the patient has still rebled. They have associated a lot of risk factors, some of them are on chronic kidney treatments, they are on anticoagulants and some of them come back to you with this. So when you take them for resurgery, make sure that you again do a good clean up, make sure you assess the periphery very well, in these cases you could do a top of peripheral laser. Here we’re doing a cryo by peripheral indentation so that – because the laser is done quite well in most of the areas, but still the patient is bleeding. So you want to burn even the residual extreme peripheral areas in such cases.

So for rebleed cases, do consider topping them up with extremely peripheral laser which could be done with your assistant depressing or you could do cryo. I use cryo quite often for such cases, much easier, larger areas get coagulated or at least taut much better and so that area gets hypoxic anoxic quite fast.

So to summarize, I mean we’ve already looked at the surgery, but if we look at the whole medical part, we’ve gone through the gamut of lasers. The laser – gold standard remains laser for small focal cells and that’s for – also for PRP criterias. I don’t think for PRP there is any other option at the moment that one can do except if you just keep injecting anti-VEGFs every month which is again very, very difficult situation. You cannot have so many follow-ups in patients like ours and so PRP remains the gold standard.

Macula laser is going down. There are very few indications, but more and more it has been replaced with anti-VEGFs, because anti-VEGFs do not do any permanent damage, laser does some damage to the tissue. And I think we need to match them together. There are indications for focal treatments, but anti-VEGFs can be used – associated in that. And for most cystoid odemas, diffused oedemas, sub-serous fluid, we are using anti-VEGFs or steroids in these cases. And then as I showed you, if it’s traction versus non-traction, traction becomes surgery while non-fraction you have all these other areas. And the surgical indications apart from the macula part, we’ve already seen.

So this is something the whole gamut of a clinical diabetic retinopathy in the scenario that we all see experience and practically treat as we stand today. The concept keeps changing as I talk, of course new and new things will keep coming. But as of today, this is what I do. We’ll take up a few questions which you’ve been sending. At this stage, I would like to thank Orbis to give this platform. I’ve had some amazing time with Orbis doing some voluntary work. This was at Chittagong in Bangladesh. And I think one of the most valuable experiences I came back learning from spending my time with Orbis to volunteer there, to associate with all the local people, the staff of Orbis which is just amazing, the whole experience leaves you a much better person when you come back. And I think I’m very happy to be associated with Orbis as a whole. So thank you for this platform and thank you for your patience hearing at this stage.

So what I’ll do is now, I can – I have a lot of your questions which are coming in, I’ll just scroll through them and try to answer. There is one which says diabetic retinopathy findings in OCTA? Well, OCT is a vast topic and I think today, I’ll go over more of the practical bit. What I would use it for is unexplained visual loss which I kind of talked about in my – during my talk that is an unexplained visual loss in a patient with clear media I would do a OCTA to look at the FAZ. That’s the most important part in diabetic retinopathy. It is not as effective in finding new vessels elsewhere. The fields are not as good as fluorescein angiography. So for me, the mainstay is finding FAZ is what I would use the OCTA for in diabetic retinopathy.

Featureless diabetic retinopathy, again featureless diabetic retinopathy is where you need adjuncts like angiography. I think fluorescein angiography would pick up wherever you see a patient with a history of diabetic retinopathy and you see a featureless retina or you have to also suspect if one eye has very few changes as compared to the other eye, that eye may be a very high myo, may have a glaucomatous atrophy, maybe [indiscernible] [00:43:23], we don’t know. But sometimes some of these eyes which non-seeing for various reasons have less features of diabetic retinopathy.

And this is the featureless which has got extreme ischemia, the anoxia is so much that you don’t see the classic features. And I think when you suspect something like that, angiography is the most important thing in that.

First time if patient will come with diabetic mellitus, diabetic retinopathy, what all investigation will be required? I think a good clinical examination and today I would say that everybody should do a color fundus photo. If you don’t find anything concrete or if you find the most minimal changes, just a simple color photo is still a very good documentation, because we don’t always remember the fundus. When a patient comes back to you after six months, one year, that’s something which has a very good comparative value and today we should always have a record even from a legal perspective you’re better off. So I think I would just do – if everything else is okay, I would just make the patient understand the need for a good control of diabetes and a good follow-up required and document the baseline and move ahead.

Do we do PRP in severe NPDR? Yes, in a lot of circumstances I would go ahead and treat a non-proliferative diabetic retinopathy or most of the times other eye of a patient who has PDR in one eye. So – or if you have a one eye patient and if you have – so if you have any reason to think that one eye is already bad and has had surgery, the other eye has NPDR, I would go ahead and treat it with PRP. Or if it’s a one eye patient, I would go ahead and treat it. Or if, for any reason I feel the patient is not going to come back for regular follow-ups, I would treat – I would be in a bit off a hurry to do PRP than wait for high risk people if changes do occur.

What is the clinical difference between DR and DME? I’m not sure if – I mean DME is – when we talk off only macula, it’s a clinical term used for us to correlate macular issues while it is a component of diabetic retinopathy in general.

How will you proceeded fresh vitreous hemorrhages there? Good question. So when a patient comes to you with loss of vision and you see a fresh vitreous hemorrhages which is blocking your view, I think most important thing at this stage is to look at the other eye. If it’s a known diabetic patient, you know there is diabetic changes happening there, you know the cause, everything is all known to us by now. So then you need an ultrasound. Especially if you cannot have some view of the funds. If you have a gross view with the hemorrhage and you know retina is on, it’s all right. But if you don’t have a view, make sure you do an ultrasound and if ultrasound shows you an attached retina, it’s well attached, then you can wait for about 20 days. If it doesn’t show you attached or if it shows you proliferations or a large subhyaloid hemorrhage, I would go ahead and treat – operate right away. So within a month, you will be able to take a decision for sure or much earlier rather than late.

Treatment of recalcitrant DME. Well, so it’s – I think we need to know what we call recalcitrant. Is it that we’ve missed a traction and we are treating with anti-VEGF steroid laser? So we need to make sure we’ve done that part correct. The diagnosis is correct. Even if you missed it the first time and he is not responding, make sure you do an OCT rule out, make sure you do an OCTA or an FA to rule out foveal avascular zone that is not expanded, because if that has expanded, there is ischemia. So ischemia has to be ruled out, traction has to be ruled out. Then you can say that whatever else you used has not worked is recalcitrant. And then you have the option of anti-VEGFs not working, you go to steroid, not working, you go to surgery with an ILM peel along with one of the adjuncts. So that’s how I would take it. If after that it’s not working then it’s unlikely to work. But make sure that we’re approaching it right and it’s not a traction and we are treating with this. It may be a taut hyaloid membrane and we keep on injecting drugs, it’s not going to work. So the term recalcitrant DME has to be based on what we see finally and make sure that we have the right diagnosis on that.

intravitreal kenacort, intravitreal triamcinolone, we used to inject a lot in the past, but I think a significant number of those used to come back with very high pressures and that was annoying for the patient as well as us. And what difficult to treat those cases for glaucoma, they would not respond very well to medical line and they often needed more surgical treatments as well. And a lot of them are young patients and it is difficult. So today I hardly find myself using it. I would use an Ozurdex most of the times wherever a steroid is required, because with Ozurdex, the pressure rises is marginal even if it happens in a steroid responder, it max goes to 25, 26 mm and not like a 40, 45 like a kenacort.

So I’m not a huge fan of a kenacort. If it all for any reason I need to give, I may give a sub-tenon which may be easier to remove if it all something goes wrong, but not intravitreal that effective.

Why steroids only work for [indiscernible] [00:49:32], Ozurdex and not anti-VEGF? Well, they all have different mechanisms. I’m not going to do the whole details of that. But essentially steroids have a more trying effect. They work longer. They have a much more trying effect. While anti-VEGFs work against the VEGF, but they don’t have a propensity to drive that effectively. They need – they’re required multiple injections and each of them works a month while this one consistently works for two, two and a half months and I think it’s way more effective for drying thicker fluid and lipids to a large extent.

Apart from angiography, is there any other way of identifying areas of ischemia? Well, I said, if you have access to OCT angiography, yes, that’s probably the other way to know. Otherwise just clinically, if you see and you are not able to explain visual loss, you could consider that it ischemic. But to document, you will need one of these two things to make sure about the exact size, location, you will need that. OCT also might tell you, because OCT measure thinning of the sensory retinal which tells you that there is ischemia. So OCT may also help you with that.

What are lipids and the fovea distinguishing features on OCT? So see, these are clinical findings. I don’t think you need to have know what is the feature, you’re not going to diagnose it on OCT, you will just additionally do OCT to find other things associated. So OCT is not going to diagnose lipid under fovea for you. OCT is only going to show you a thickness, a sub-serous fluid and clinically you see lipid there. So it’s a clinical OCT correlation rather than only looking at OCT per se.

Are there any specific indications for combined anti-VEGFs and Ozurdex injection? Yes. I think this is something that personally I feel that every diabetic who’s had significant oedema, I would like to treat with both if given a choice. Practically it becomes difficult, because costs become high and patients, to explain to them that you’re doing two treatments. But if I have a choice, if there is a significant oedema and the patient also requires a PRP, I would do all three together, do a PRP, give anti-VEGF, give an Ozurdex. So you’re looking at regression, you’re looking at preventing short term macular oedema or regressing oedema and Ozurdex is maintaining that efficacy for a while. So we have access to all these wonderful agents. And personally I would like to use all of them together. But practically we have to choose one. We can’t tell a patient all the time you need two, they can’t afford, they can’t – there are other issues. So then you will choose the relative indications how I discussed in my talk that you start with anti-VEGFs. And – or if there is already a very thick oedema. So even today for some patient who has a extremely thick oedema or something, I may advice a combined if chances practically permit for me to do so.

As far as I understand, you should apply laser photo coagulation when retina is attached. What happens if you coagulate detach retina? Does it attach the tissue? Well, laser will manifest on attached retina. If it is detached, the laser will not work there. It may work only on the edge of attached/detached. But on a frankly detached retina, the laser will not manifest. So that may not help the regression part of it. It – all you can do is try to bridge or sectoralize that tractional area. If it’s a tractional detachment then you’re talking about away from macula. You could just go around and do a laser all around and barricade it along with your PRP. But it may – if it’s not manifesting, the traction may not go from that area.

Should we interfere soon with subhyaloid macular hemorrhage by YAG hyaloidotomy or vitrectomy or should we wait? Yes, good question. So subhyaloid hemorrhage interfering with vision, a fresh one, one could wait 20 days or so. I would call the patient after 20 days and if the – it’s starting to show clearing then I would wait. If in 20 days there is no significant difference, I would go ahead and do a surgery. I’m not a huge fan off YAG hyaloidotomy. In the past I’ve done them, but I always feel that with the YAG you may be able to clear it, but it goes into the vitreous disperses, causes a lot of cloudy vision for a long time and sometimes you still have to do with vitrectomy, because the blood has spilled over in a big way.

And plus with YAG, there is also the small risk that it’s a power, it’s like you blast that, it’s a blind treatment. And sometimes if the power is – it goes a bit behind, you could create a break also. So a lot of people like it, so I’m not – if you have good experience with the YAG, go ahead and do it. But personally, I prefer the controlled approach of a small gauge vitrectomy which is way more effective in my hands than a YAG which is more left to a natural course and it takes a long time for things to resolve.

Do we always have to laser PRP in the same sitting after vitrectomy for hyaloid? Yes, laser should be done always in the same sitting. You cannot leave it for later, because you need the regression to start right away. Plus you may have created some small break here and there or some residual traction and your laser miss save that from getting worse. So even if you’ve cleared everything in a surgery, the mainstay is PRP. So if you fail to do a PRP, it’s bound to bring in a much earlier complication of either postoperative vitreous hemorrhage which has thickered much faster or some other fractional component may come back also. So make sure you do a good PRP at the end of surgery. And during surgery, it’s the easiest to do PRP, because the patient is under well sedated, has got under anesthesia you can do as much as you like without him getting bothered by pain or any other thing.

How much size of ILM peeling? Not a specific size, but it will be two and two and a half. This time it was size off peeling, I would do in this case, it’s just like I would do for macula, whole lot of [indiscernible] [00:56:30].

If a patient has PDR with active proliferation or severe DME that needs immediate anti-VEGF therapy, but at the same time has a carbuncle that has surgically drained and known antibiotics, how long would you wait before giving anti-VEGF injections? So patient with PDR has severe proliferations and severe DME needs, so yes, I would go ahead and do laser. And under the cover of antibiotics, I don’t think I will specifically delay the act of anti-VEGFs just because he’s had this other thing. He should be on antibiotics that is important. If he is not then make sure he is on and then do it after a few days. But if he is on antibiotics, go ahead and do your laser and anti-VEGF. I think – I don’t think it’s a problem.

Under what circumstance would you not consider preparatory anti-VEGFs? Well, most cases I don’t give preparatory anti-VEGFs. As I said, I give it to those where there is a florid neovascular tractional tissue and especially where there is no history of prior treatment. So those are the ones I give. All the rest, we don’t give. In fact, we give anti-VEGF at the end of surgery in those. But if you’re asking for a contraindication, if it’s a grossly tractional detachment where or where you have a doubt if the patient may not turn up for surgery, your time is not defined, how many days you miss, they’ll come after the month, well that’s a contraindication and I will not give in those cases.

What is the best recommendation to reduce postoperative CME, postoperative CME in a diabetic patient per se? So you normally most of the times preoperatively you would start a NACID [phonetic] [00:58:20] of some sort, Nepafenac or something so that you could – that does reduce the risk if you – if the diabetic patient who is more prone to that.

And then as I said, what I do is if I’m doing a vitrectomy for a vascular cost like diabetic, I always like to inject anti-VEGF at the end of surgery. So that definitely reduces the chance of a postoperative CME in these cases.

And if you had a case where you did a lot of manipulation, lot of traction, you may also give us sub-tenon kenacort at the end of surgery along with anti-VEGF inside you give a sub-tenon or you give an Ozurdex inside. So these combinations will help you reduce the CME much better.

In the case where preoperative anti-VEGF already given, do you prefer to give per operative anti-VEGF again? I would love to. I don’t think – but the problem is that there is a surgery involved and there are costs involved with pretreatments, post-treatments. So most of the times it becomes difficult to give two injections to the patient along with surgery. But if you are asking me that what would I prefer, yes, I would prefer giving a preoperative one, then do surgery and at the end of surgery top it up with another one. So which would give the maximum umbrella cover pre, post for that. So in an ideal circumstance, I would love to do this.

Do you think there is a difference in performance between three anti-VEGFs for DME therapy? Which is your preference and why? Well, these are debatable things. It’s difficult. I presume you’re meaning Accentrix versus Avastin. You’re talking of maybe Eylea in this. So you have to choose what works best for you, because practically you’re ending up trying to use what is easily available for you, what is cheaper, what is easier. So all of them are effective. Eylea works a little longer than the other two. But the cost is in India is three times. So we tend to end up using Lucentis or Accentrix in most of the times in these cases or Avastin.

In a patient with DME and PDR anti-VEGF should we inject first or PRP first? I don’t think it matters. Do a PR – practically how we do is when we see a patient and post for both injection PRP, we do the laser sitting and then take the patient OR and we inject, because practically it doesn’t make sense that you inject and then do laser, your visibility may not be great. So – and most of our patients come from outside, so it’s not practically possible that one day you do this, one day you do that. But if you want to, you could do either of them before or after. You could inject two, three days before, then do a PRP if you like. But then there’ll be too many follow-ups and other things. So practically we do both at the same time.

When you use silicone oil in PDR cases, wherever after having done traction removal if I’ve created some breaks or if I feel the traction was too stiff and after – even after having removed the retina is still not well iron, those are the situations that I would have do oil in those cases for that.

When are we treating VMT by vitrectomy? Well, whenever there is a symptom and you can confirm it on the OCT vision is affected by it, patient is disturbed by it, you go ahead and do it. Vision could be six-six parts or six-nine. But if the patient is symptomatic bothered, you can go if it’s confirmed.

Do you inject anti-VEGF postoperatively in fluid or fluid air exchange? Yeah. So no specific reason I – we could inject at any point of time. But what I practically end up doing is that I’ve finished my surgery and I’ve come out and I’m removing the ports and I leave that one port – I mean I removed my [indiscernible] [01:02:32] port and before I remove my cutter port, I inject. So technically because I’ve done an air fluid exchange, it goes into an air-filled eye, auto partial air-filled eye. And so – but I don’t have a specific reason to it, maybe it goes in and sits at the macula better instead of defusing into a larger plane and probably has better efficacy, I don’t know for sure. but I do it in an air-filled eye if you’re asking.

Do you always do ILM peel in diabetics during PRP – DPV? No, I don’t do it in all cases. I would do ILM peel only for chronic diabetic oedemas or where I’ve removed the membrane over the macular area per se is where I would do IML peeling. But all other diabetic cases I would not remove the ILM.

Do you think that Iridex 532 Micropulse laser for macula oedema? I’m not a huge fan of Micropulse, I’m not been convinced about it. I’ve used it in the past when the early generation of Micropulses had come and even today a lot of my colleagues use it. But I’m not yet convinced about Micropulse. And today the need for laser has gone down, because the anti-VEGFs are way more effective for what these lasers do at this stage. So today I don’t – I find myself using it less and less for the purpose that these lasers were used for. So I use it for PRPs and at times for focal circinates, but not largely for grid oedemas, grid-based treatments have reduced over a period of time.

Do you prefer doing delamination under air or fluid? Which one is simpler? Always fluid. Air is always going to be a challenge, because there will be refluxes plus the air is giving pressure over the tissue and you may have less control. So always do that under fluid. Air should come only when most of your job is over and all you’re going to do is laser or diathermies or one of those things. So before that no point having air come in.

Do you inject anti-VEGF twice? Pre-op and post-op, we’ve already talked about. What are your criteria to use gas and the silicone oil after PRP? So silicone oil, I already talked about. Gas, I very rarely use, but it could be just a simple single posterior break at times and not much traction. I may choose to use gas, but more often I just give it an air, because these diabetic cases, anyways we do a very good amount of PRP and more or less the retina is secure and you’re not worried about a detachment per se. So I do use oil in bad TRDs, but I don’t think I use a lot of gas and diabetic cases per se to a large extent. But you could do it for small posterior breaks.

Do you inject anti-VEGF for the end of surgery? That we’ve discussed. Newer cutter designed to help membrane surgery. The new 10000K cutter which has come with the constellation is extremely good. It’s got a bevel shaped and allows you to reach the retinal surface much closer and helps you delaminate the membranes even better than what you can do with your previous generation cutter. So I think if you’re talking of new cutter design, that’s the design that allows you to go very close to the retina without damaging it and getting something – some tissue within its port. So the 10000K cutter is great for that purpose.

And of course, other is a 27-gauge. I prefer using 25, because that works for most of them. But if you compare 27 may be able to insinuate or go closer and a 27 with a 10K cutter may have a very good advantage, because it’s very fine and can reach a plane which none of the other cutters can.

Regarding vitrectomy in PDR is a thorough based dissection required. I would go and do it for every single case. If it’s a pseudophakic eye, I would do much more dissection, but I will not go and depress and do a lot of base dissection even in those cases except if it’s a resurgery. If suppose there is a rebleed, I would go and depress and clean up everything that is there, because we want to reduce the chances of a rebleed again from all these residual area near this clara where they can be proliferations. But for a standard first time surgery that we are doing, I will not go and depress and do an extensive surgery. I’ll do as could a cleanup as possible in the field of view that I have and do a very good laser up to the periphery. But if it’s a phakic eye, I would be careful. I may do a little less than that, because you don’t want to touch the lens.

Would you still use anti-VEGF pre-op when there is VMT, but there is substantial risk of intraoperative bleeding? Yes, I would. As long as I’m sure that the patient is going to come back in four, five days or a week, I don’t think the presence of the VMT will be a contraindication at all. You can still go ahead and do that.

In front of macular oedema with hypertension make it impossible to do anti-VEGF injection, what would you do? Well, I’m not sure if hypertension would be that stronger contraindication. You can still go and do it. But if it all, you’re looking at an option which is going to be less risky, you could, you can go and inject a steroid of some sort if you are avoiding a risk to some extent.

If Ozurdex isn’t available, then how to inject steroid? Yeah, then you give intravitreal triamcinolone, the same way as we have always done in the past or give a sub-tenon kenacort. So if Ozurdex is not available, these are the two options which are there. But you have to constantly monitor the intraocular pressures in these for sure when you do one of these treatments.

Recalcitrant macular oedema in spite of repeated anti-VEGF, what is your experience of anti-VEGF plus steroid injection? Yes, as I said before that’s an excellent idea. I would be happy to inject both together or first maybe give just the steroid, because the anti-VEGFs have been – you’re giving again and again and if it works with only an Ozurdex, great. If not, you can also use both together. I would be happy injecting both in those cases.

For DME treatment naive, would you give three loading doses of anti-VEGF or PRN or begin with Ozurdex? For DME treatment naive, I give only one dose and see. I don’t think I – unlike anti-VEGFs used for a SRNVMs or AMDs where we always ask the patient for three doses, for DME we start with one. Unless you already see a very thick oedema, we prepare them for more than two or three. But most regular oedemas, we will say, okay, let’s – you need injection, you need laser, whatever and then we’ll see after a month. And based on how he behaves, we will give more or if there is a very thick oedema with the sub-serous fluid to begin with, we may say, you’re better off with the steroid or Ozurdex for that matter.

If we use IVDA for complete vitrectomy, do we need anti-VEGF at the end of surgery? Well, IVDA we use a lot for looking at the hyaloid to delineate it to create a PVD, but that – most of it gets washed off. So you can leave some if you like and it may help. So it depends on how much you’re leaving back. If it’s only the stain part which is there, most of it gets washed off and it’s not that effective. So I would still use an anti-VEGF at the end of surgery. But if you are planning to inject more IVDA, then of course you don’t need to – you can inject and then not inject an anti-VEGF for the end of surgery.

In absence of a break or TRD, what are the indications for use of silicone oil? None actually. I would not use silicone oil unless there is a break or a TRD, because I’ve heard people say that we use it to stop bleeding. But I think that’s a contraindication, because if there is a bleeding which is not – you’re not able to stop for whatever reason and now you inject oil, it’s going to create way more problems postoperatively. You’ll have a large collection of blood under silicone oil and that’s a much more difficult situation to treat, that blood doesn’t clear very easily. So silicone oil does not have any property to stop bleeding per se. So don’t use it for anything other than giving tamponade to retina which is not ironed. You’ve just removed fractions and it’s still crumpled at some places and so with the tamponade, you may silicone oil may give a nice ironing effect and keep it on hold for two, three months till you remove it. I use it for that. Or if I have created breaks, I would use it for that.

Is there any difference of visual outcome in ILM peeling of diabetic retinopathy? If you – well, ILM peeling, I would do only if there is a chronic oedema or if there is a thick membrane, I peel and after that I would peel an ILM with a diabetic. But other than that, I don’t think peeling the ILM would have a major role in the outcome. Hyaloid peeling, yes, once you’re going in for a surgery and make sure the hyaloid goes away from the retinal surface, because that will definitely have some bearing on the hyaloid, visual outcome in the future or the proliferations, the scaffold has gone, so the proliferations will be less.

If you do cryo and recurrent hemorrhage, how much area would you do? I sometimes do almost 360 also, light very – I don’t do a very long acting cryo like just as soon as we get the mildest wild [phonetic] [01:13:11] area, you remove it, you can do it all 360 degrees also in that. I don’t think it’s going to be very traumatic.

What are your indications of ILM peel? Do you do ILM peel? Yeah. We’ve discussed that. As a young ophthalmologist, it is impartial to know how to do macular grip since it’s rarely used and we don’t have opportunity to practice. Thank you. So the grid is basically as I said thickly – you titrate the burn, whitish burn outside the arcade and then reduce it to a very mild gray and then use it in a area where you feel there is thickness and that’s what is grid laser, it’s to tickle the RP.

In 25-gauge surgery for PDR with TRD, what percentage you close the eye with air? Gas and oil, how do you decide? Well, 90% are with air, maybe 7% to 8% with oil and gas is extremely rare. But yes, air – I mean if you mean air, that’s in the maximum that we will do for diabetic cases. And the decision is based on as I said the same factors that where I put oil which means there is breaks which I’ve created or there are preexisting breaks. All the traction was stiff and even I – though I’ve removed it, the retina is still a little crumpled up, non-ironed and I’m worried that later on it may get pulled from there. So I would use oil there, all the rest will be air.

Do you cryo through the intact in cryo? Yes, through intact into cryo. No, I don’t open the [indiscernible] [01:14:50] for that. Do you use anti-VEGF injection in non-resolving PDR anti-VEGF PDR plus NVD despite adequate PRP? Yes, of course. We would – anti-VEGFs can be used in any situation as long as there is no gross traction. It will always help regress NVD, NVs in these cases. So you have a good well lasered eye and you do an FA and you still can’t find new essence. The patient has bled. The best thing today that you have is give an anti-VEGF and hope that they may have been a transient bleeder which stops with the anti-VEGF and may not bleed again at all.

How do we differentiate between the exudates of cotton wool for diabetic and hypertensive? Well, they all overlap. So I don’t think you’ll need to also, because we don’t treat cotton wool spots per se. They’re just a clinical feature. So it doesn’t matter how – what way, who is responsible for what. You just have to treat the retinopathy in the classification that you are used to treating PRPs, just your same defined treatment criterias.

In case of enlarged deficit, how do you change your follow-up of these patients? Is it necessary to see them more often? Well, not necessary. Enlarged deficit is more useful for prognosis. So it helps you explain to the patient that we may be doing PRP to reduce complications to neovascular glaucoma to prevent to do all these things, but your vision may not improve. So it’s more to prepare the patient that this is more permanent damage and the treatments are more palliative. So it’s not about seeing them more often or not, but to guide them that this is the situation and sometimes it helps you guide them a better treatment for the other eye which has better function. So you tell them this is permanently lost, because of this same thing will happen here. You better take treatment. So it’s a good documentation for prognosis and to explain to them the fact at that particular time.

Comment, if we can go to suprachoroidal approach to steroid? Yes, people have been doing it. I don’t have a personal experience with it. I do have some colleagues who do that and it is one of the approaches which is an option there for delivering steroid in these cases.

Is Ozurdex still available? Yes, Ozurdex is available in the market. What are the systemic and ocular side effects of anti-VEGF? Well, systemic, what we are worried about practically is that stroke incidence which is theoretical, rare, doesn’t happen that often. But what we do is if there is a history of a stroke in a patient in the past three months before he has come to us, we would defer – in those three months we will not like to give. And even if we – there is an indication we will ask him to talk to his cardiologist and we give them a note that this is what we want to inject and once the person gives clearance then come back and do it.

Well, ocular side effects per se have been – a lot of them have been mentioned off and on, but I think the benefits are way more than anything that we have worried about. Some people have talked about raised IOP, some people have talked about increased ischemia, some people have talked about increased geographic atrophy in SRNVMs when we use them. So a lot of factors are there, but what – but grossly for an oedema which goes down, I think the benefit is way more than all these others. And I don’t see a reason why we should not inject these in patients.

How long we keep macular driving Ozurdex? Usually a max of three months, after that if it has to come back it will start or if the overall condition is good, systemic condition is good, it may remain stable also. But the drug itself will keep it dry for three months max. After that it’s a natural course which may remain dry or will come up.

When do you leave a TRD involving macula alone? That’s a tough question. I mean you go by the symptoms. Sometimes patient is under your follow-up and you are seeing a TRD which was not there and the patient is not worried or has no symptom and all. So there you would not encourage him, but you will make him aware this has happened, show him an OCT that this is what’s happened and you should be seeing less. But – so patient has to be convinced. The other is if there is a gross ischemia. If the – if I already know the patient on the previous follow-up had ischemia is now TRD or now I can, if do a FA or anything which shows a thin retina, even though traction, but thin retina chronic issues with that, then I would leave it alone in those situations.

Does hard exudates respond to systemic lipid lowering drugs as hardly? Well, a lot has been said in the past about giving these drugs. I personally just have them go to the diabetologist and make sure their sugars and lipids are in control. But I don’t describe them myself. And I believe over the period of years there have been debatable things about whether we should give these drugs or not. So I just leave that choice for the diabetologist to investigate. And if there is an clinical presence of high lipids in the body and they’re described fine, but I’ll not prescribe a drug only for that. I would rather treat the eye itself with what I have.

How will you manage a subfoveal exudate? Well, that’s a tough area. You will manage with injections preferred. If there is a lot of lipid, a steroid it is better than anti-VEGF. Surgery has been done in the past. We also tried them, but with unequivocal results. So I can’t say that surgery will work. But in a certain situation if there is a lot of fluid with exudates it may help by flattening that area. But if it’s just a just a small collection of exudate, I’m not sure surgery will be, because these are very thin planes. They don’t have a lot of fluid at times and you don’t have a space to remove them that effectively. And even if you remove them, the tissue there is not that healthy that visually you may gain a lot out of that. So it’s best to be more conservative with the injections in these cases.

What is your view of use of Iluvien in chronic DMO? Do you see massive pressure eyes, have you? Personally I have not had a chance to use Iluvien. But I’ve heard that it is highly effective, but has potentially a high pressurized efficacy also. So – but I don’t have a personal experience with it, so I’m not going to answer you more about.

What dose of anti-VEGF do you give post-vitrectomy? I give the same dose. I have not reduced it. There is a belief that they get absorbed more post that, but I don’t think we reduced it. It’s the same that those that we give before without a vitrectomy.

We have guidelines in UK regarding the use of anti-VEGFs and Ozurdex, especially in phakic eye Ozurdex is not permitted. Do you respect these in your clinical? Yes, to a large extent I will not give in a phakic eye. A phakic eye, Ozurdex would be only in an extreme situation where there is a massive oedema and maybe we’ve given a few anti-VEGFs, especially a juvenile diabetic sometimes when we come to you with extensive oedemas and you’ve already treated with anti-VEGFs and is recurring or is not responding, there I may not consider not using Ozurdex, I would still go ahead and use it and maybe take care of the cataract eventually, because our aim is to flatten the macula anyhow. If it stays oedema does for a long period, it is going to cause permanent damage there and cataract is still a treatable condition. So yes, more often we will not use it. But I will not make it a absolute contraindication and I still use it sometimes. Even in some of the uveitis patients, young patients at times we have used it to phakic eyes with clear lens.

When do you stop treating in chronic DME? As I said, we give anti-VEGFs or first of all we make sure that we have the right cause. There is no traction. You’re – when you say chronic DME, means there is a non-traction, non-taut hyaloid, non – any of those, you’re only looking at oedema per se. And then you’ve given anti-VEGFs, you’ve given Ozurdex and you then tried a surgery. So at that stage you would stop. But before that I would do all these other things.

Do you add adrenaline to your BSS? No, I don’t add adrenaline. What should be the maximum time period to apply laser after anti-VEGF? Well, there is no maximum time period. You can – we do it on the same day.

Indication of vitrectomy human patients under dialysis? Yeah, the indication of vitrectomy remain the same clinically, the dialysis is something which we need to know, because when you post them for surgery you have to choose a day when they’re not on dialysis so that patient – one has to find that convenience of that – the day he comes to you for surgery. But just the fact that the patient is on dialysis will not change the indication for vitrectomy. So that would remain the same. It’s just about tying up with his treatment options that are done.

Post-op anti-VEGF under areas, we inject under it. For vascular fron over the disc, do you prefer laser or endocautery? Yes, during surgery what I do is if there is a vascular fron over the disc, I would go – before cutting or going towards the proliferation or a fron, I would go down with my diathermy close to the disc, but about two to three millimeters over the disc and would apply diathermy. I’ll see a whitest reaction there making sure there is a two, three millimeter stump to the disc. And then I will cut over that white fron. So it’s always best to anticipate this rather than go and cut it very close to the disc, because once a bleeding starts and the stump is extremely close to the disc which is meeting, then you can’t diathermise because you will hit the nerve fibers and you don’t want to do that. And it’s very difficult to stop that bleed. So always when you see a vascular fron on the disc, make sure that you anticipate, you go and cauterize that area above the disc beforehand and then cut over the cauterized area, don’t cut within that met area. So that’s the best way to do that.

There is a risk of PRP worsening, maybe given this approach what would you do? Yes. So that’s what I mentioned that in our sitting we’re nowadays always doing a combination of if a patient is a treatment naive and we’re doing PRP the first time, we always try to inject anti-VEGF along. Even though there is no DME or there is minimal DME, because any laser that you do has a chance of worsening the DME and even though you know its transient, it sometimes the patient also loses faith in you. He says, the day you did laser, after that my vision has dropped and then he becomes unavailable to further treatments which is what I’ve seen in the past. So today I feel with the excess of anti-VEGF that we have, always do PRP with anti-VEGFs unless it’s a very mild PRP that you’re doing or a top up it’s okay. But if you’re doing a proper PRP, always top it up with anti-VEGFs. You’ll get the best of both worlds. You may have to do less laser, because the anti-VEGF will help the regression and it may reduce the preexisting oedema and make sure no oedema comes in, in that immediate post-treatment period. So it’s always good to combine.

I didn’t understand the concept of rebleed. Well, rebleed means that what we grossly consider it that if a patient has cleared up after your surgery and maybe after a month or so has rebled or if you want to say that he’s not improved at all that there’s been an immediate rebled post-surgery and is not clearing. So it depends on how you’re interpreting it. So usually you would wait a month if you know what we have done in the table. We have done everything we’ve done laser and now postoperatively there’s a rebleed, do an ultrasound and wait for a month. Most of them clear up. If they don’t, you have a choice of air blood exchange or going in for the rebled again.

Do you go for any preoperative preparation among patient with dialysis? No, nothing specifically except making sure about anticoagulants, sometimes they – these patients tend to bleed more because they’re on associated drugs and we just make them make sure that we’re not dealing with one of those.

When to initiate anti-VEGF for PRP and when to treat and extend, when to initiate the same criterias of PRP, that’s when we use both. And then for diabetic oedemas, we are not injecting monthly as a rule. We take it as it comes, because these are bilateral eyes and difficult for patients to continuously keep taking injections unless there is a specific indication.

Choice of intravitreal treatment in preexisting glaucoma patients. There is an increased risk of vorticity with combined anti-VEGF [indiscernible] [01:29:40]. So preexisting glaucoma patients, there’s a relative contraindication to steroid. So we would prefer using anti-VEGFs in those cases and avoid a steroid or an Ozurdex to begin with. But as I said, these are not absolute contraindication, because at least where the steroid is Ozurdex, the propensity for pressurized is not that huge. It’s about four or five millimeters, usually 25, 26 and you can control it. If you feel that Ozurdex is extremely useful for your – the oedema, I would see word and give it with an understanding with the patient that we may give anti-glaucoma drugs along.

What situation do you prefer to vitrectomy and the air and resurgence that we’ve done? Do you feel oil has hemostatic effect? No, oil does not prevent bleeding. It is only for a tamponade adding and do not use it if there is a active bleeding going on in the eye which you’re unable to stop.

Is it advisable to cryo port sites? No. In the past, I agree there was a recommendation, but today with vitrectomy surgeries, instrumentation, everything having become much more refined. In the past we used to be worried about tears on the port side, but today I don’t think that’s a thing. But if you’re meaning from the point of view of rebleeds, well I will not do it blindly. But if I’m going in for a rebleed as I showed you in the surgery also, I would do cryo 360 degree. But I’m not specifically looking at port only. It would be more to kill the overall side. And of course look at anything specific if it’s there in a certain area.

Cryo following rebleed is done under directly of microscope or we are? No, I use my regular viewing WO [phonetic] [01:31:40] contact lens and then depress it just, but you can do it under a direct microscope visualization also. So that’s totally your choice of how you view the retina.

What is the maximum number of anti-VEGF injections you can give? I don’t think there is an end point. You can give – a lot of our patients are on 40, 50, also in. So you can. I don’t think there is a number. It’s about requirement and are they efficacious till the time you’re giving them that – the number can be defined.

How can we stop bleeding from the disc from NVD during surgery even after it does not stop? Well, that is the most difficult part. So that’s why at the beginning I was talking that if you see a fron [phonetic] [01:32:26] from the disc, make sure, don’t go and cut it straight away, make sure you anticipate it, first do a diathermy and then cut it. So always do that. If it has still happened, well, you just have to wait and raise the pressure of it for a while, reduce it, then again raise, then again reduce it, maybe put some PFCL, maybe do some laser in the periphery with PFCL in the center, raise the pressure of it. So hoping that a little bit of time will help create a clock there. You could do all these things. But I would certainly not do a diathermy right over the disc surface, because you instantly destroy no fibers there and that’s something that we want to avoid. So unless you have a stump two to three millimeters to do endodiathermy on, I would not suggest to do it under this.

After how many injections will you classify DME non-respondent to anti-VEGF? Again, what we usually do is at least two or so we inject, otherwise we shift to a steroid and that’s how we do it. But there are theoretically many criterias. People give six also and then say that after six if it’s not responding then do it. But I think if – today if I inject two and it has not worked, I would switch to another agent or a steroid or something else.

In a case of TRD once you’ve relieved and settled the retina, is it compulsory to use tamponade? Not always. As I said if it’s a milder – if the retina looks pretty much flat and you’ve done a good PRP, I don’t think you need to put any tamponade except air. I switched to air, but that’s about it. But if I feel that the – it’s not ironed well and there are falls or there is a residual traction with the stump that I cut, but there is still a little bit of redundancy then I would put in those cases.

Would you leave the silicone oil more than three months in front of a bilateral with an important – more than three months in front of a bilateral to actually detachment with an important visual element? Well, you can. If the patient is on follow-up and he’s doing fine with the oil, you can. But typically for a tractional detachment when you put oil unlike a PVR case, you can remove it much faster. You can remove in these diabetics even after one a half, two months, because there is a very good PRP which is already there protecting you from any detachments. And also so that’s totally up to your follow-up and what you feel about the patient.

Apart from diluted kenacort, any other diet that you might prefer? No, we use the triamcinolone, that’s the best – cheapest, most easily available and the best. When and how would cryo help to aid in surgical treatment of advanced diabetic disease and secondly PDR? Well, cryo was used in the indications that I showed you that especially for rebleeds or even for the first time surgeries, if you feel that you are unable to see some part of the periphery with your regular visualization or for maybe there is some sort of capsulorhexis issues and phimosis and you don’t have a peripheral view. The cryo may be more effective than instead of laser to help. So you can definitely use cryo to do a peripheral ablation in any situation like that.

After treating a patient if sugar level is controlled, what will happen to the patient’s retina, especially the area that was affected? Will be affected again? Yes, of course. Diabetes is a lifelong condition and sugar control is not a transient effect. It’s a constant daily process and these effects can keep coming back. So you have to tell the patient that they have to keep it under control as much as possible.

Hope all of you remain safe and sound and hope to see you in-person very soon in the near future. Thank you very much.