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Year : 2021  |  Volume : 59  |  Issue : 4  |  Page : 420-424

Holistic integrative ophthalmology with multiplex imaging

1 Department of Glaucoma and Research, Mahathma Eye Hospital Private Limited, Tennur, Tiruchirappalli, Tamil Nadu, India
2 Department of Optometry and Visual Science, Mahathma Eye Hospital Private Limited, Tennur, Tiruchirappalli, Tamil Nadu, India
3 Department of Cataract and Refractive Surgery, Mahathma Eye Hospital Private Limited, Tennur, Tiruchirappalli, Tamil Nadu, India
4 Department of Vitreo-Retinal Services, Mahathma Eye Hospital Private Limited, Tennur, Tiruchirappalli, Tamil Nadu, India
5 Department of Strabismus and Paediatric Ophthalmology, Mahathma Eye Hospital Private Limited, Tennur, Tiruchirappalli, Tamil Nadu, India

Date of Submission21-Sep-2021
Date of Decision07-Dec-2021
Date of Acceptance07-Dec-2021
Date of Web Publication21-Dec-2021

Correspondence Address:
Dr. Prasanna Venkatesh Ramesh
Mahathma Eye Hospital Private Limited, No. 6, Tennur, Seshapuram, Tiruchirappalli - 620 017, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjosr.tjosr_144_21

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How to cite this article:
Ramesh PV, Aji K, Ray P, Ramesh SV, Balamurugan A, Ramesh MK, Rajasekaran R. Holistic integrative ophthalmology with multiplex imaging. TNOA J Ophthalmic Sci Res 2021;59:420-4

How to cite this URL:
Ramesh PV, Aji K, Ray P, Ramesh SV, Balamurugan A, Ramesh MK, Rajasekaran R. Holistic integrative ophthalmology with multiplex imaging. TNOA J Ophthalmic Sci Res [serial online] 2021 [cited 2022 Nov 30];59:420-4. Available from: https://www.tnoajosr.com/text.asp?2021/59/4/420/333159

  Question 1 Top

Identify this finding. A 35-year-old male patient came for a general ophthalmic examination with no specific complaints. His slit-lamp evaluation [Figure 1]a and [Figure 1]b showed hyperpigmented region on the iris with normal iris architecture. His anterior segment ocular coherence tomography (AS-OCT) [Figure 1]c showed hyperreflective region with back shadowing (red arrow) in the region of hyperpigmentation. Scheimpflug images in default and inverse colour [Figure 1]d and [Figure 1]e showed reduced reflectivity in the 1.85 mm region of hyperpigmentation.

  Question 2 Top

Identify this condition. A 56-year-old female came with complaints of gradual progressive loss of vision in both eyes (OU) for the past 3 years. Fundus evaluation OD [Figure 2]a revealed a macular pathology (red arrow) with the fluid collection and pigmentary changes. Infrared reflectance imaging [Figure 2]b showed a central hyperreflective ring surrounded by hyporeflective mottling. Her OCT macula in default and inverse color [Figure 2]c and [Figure 2]d showed subretinal fluid collection with a thumb-like hyperreflective pigment epithelial detachment.

  Question 3 Top

Identify this condition. A 32-year-old female came with complaints of defective night vision in OU. Her fundus evaluation OD [Figure 3]a showed arteriolar attenuation with pigment clumping in the form of bony spicules in the mid-periphery. Infrared reflectance image [Figure 3]b showed increased visibility of the choroid, sparing the macula, with hyporeflective clumps in the mid-periphery. Autofluorescence fundus image [Figure 3]c showed hypo-autofluorescence areas in the mid-periphery. OCT macula images of OD in default and inverse colour [Figure 3]d and [Figure 3]e showed loss of outer retinal layers sparing the macula.

  Question 4 Top

Identify this finding. A 25-year-old female with uncontrolled glaucoma, despite maximal medical therapy, came for evaluation. Her slit-lamp evaluation [Figure 4]a and [Figure 4]b showed multiple areas of bulging sclera lined by blue tissue underneath. Her AS-OCT [Figure 4]c and [Figure 4]d showed thinning of the sclera in the regions of bulging.

  Question 5 Top

Identify this incidental finding (red arrows). A 22-year-old male came for a routine eye examination with no specific ocular complaints. Fundus evaluation showed a white, glistening excavation in the superotemporal aspect of the optic nerve head (ONH) as shown in [Figure 5]a. The infrared reflectance image showed hyporeflectivity at the superotemporal aspect of the ONH as shown in [Figure 5]b, respectively. OCT of the optic disc reveals disc excavation as shown in [Figure 5]c.

  Question 6 Top

Identify this condition. A 36-year-old female patient came for a routine eye examination. Fundus evaluation [Figure 6]a showed dilated and tortuous retinal vessels over the optic disc and adjacent retina. Autofluorescence image is shown in [Figure 6]b. FFA image [Figure 6]c in the late venous stage showed enlarged and tortuous vessels extending from the optic disc. Magnetic resonance imaging (MRI) brain revealed features suggestive of intracranial arteriovenous malformations (AVM) with cerebral angiography confirming the diagnosis.

  Answers Top

  1. Iris Nevus. Iris nevus is seen as hyperpigmented regions on the iris. They are usually seen in the inferior quadrants. They might grow down into part of the iris stroma. It may be associated with corectopia or iris ectropion. Iris nevus is usually benign, but dilated fundus evaluation needs to be done to rule out uveal melanoma.
  2. Polypoidal choroidal vasculopathy (PCV) (subtype of exudative age-related macular degeneration). PCV is more common in women than men. Indocyanine green angiography will show hyperfluorescence nodules with surrounding hypofluorescence in the early phase. Treatment includes intravitreal anti-vascular endothelial growth factor (VEGF), photodynamic therapy (PDT), and laser photocoagulation. Anti-VEGF with PDT combination shows better outcomes than monotherapy.
  3. Retinitis pigmentosa (RP). RP may occur as a sporadic disorder or inherited in the form of autosomal dominant, autosomal recessive, or X-linked. Genes involved in RP are rhodopsin, USH2A, and RPGR genes. The clinical triad of RP includes arteriolar attenuation, pigmentary changes, and waxy disc pallor. Electroretinogram (ERG) helps in assessing RP. In advanced RP, ERG is extinguished
  4. Ciliary staphyloma associated with uncontrolled secondary angle-closure glaucoma. The common causes of ciliary staphyloma are perforating injury, scleritis, and absolute glaucoma. Patients may require scleral reinforcement surgery in the form of scleral patch graft, lamellar corneal graft, or split-thickness dermal graft.
  5. Optic Disc Coloboma. Colobomas result from incomplete closure of the embryonic fissure. Optic disc colobomas have been associated with microphthalmos, iris coloboma, lens notching, ciliary coloboma, retinal detachment, and macular hole. They usually occur inferiorly. They need to be closely watched for retinal detachment.
  6. Dilated AVM of the retina in Wyburn Mason syndrome (Bonnet-Dechaume-Blanc syndrome). It is a congenital neurocutaneous syndrome. AVMs are seen in the retina, orbit, brain, and skin. MRI and cerebral angiography will be required to analyse any intracranial AVMs. Patients with intracranial AVMs should also be observed for both ocular and systemic complications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published, and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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