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[Downloaded free from http://www.ijo.in on Tuesday, January 12, 2016, IP: 115.111.224.207] 468 Indian Journal of Ophthalmology occurred in three eyes among them. We believe that all three cases represent sterile endophthalmitis that may have resulted from a toxic reaction to the drug or a contaminant in the vials.[2] Actually, the vial of triamcinolone acetonide changed in summer 2010 [Fig. 2]. The presence of an endotoxin might have contributed to the development of sterile endophthalmitis in these patients, but this could not be confirmed. The basis of this assumption derives from several facts: (1) All cases feature acute painless manifestation, whereas infectious endophthalmitis typically presents with pain acutely. (2) The results of vitreous culture were negative, although we performed only in two cases. (3) All patients had a well‑known risk factor for sterile endophthalmitis [Table 1]. In summary, we report three cases of sterile endophthalmitis after changes of triamcinolone acetonide vial in July 2010. Moosang Kim, Seung‑Young Yu1, Hyung‑Woo Kwak1 Departments of Ophthalmology, Kangwon National University Hospital, Chuncheon, 1Kyung Hee University Hospital, Kyung Hee University, Seoul, Korea Correspondence to: Prof. Seung‑Young Yu, #1 Hoegi‑Dong, Dongdaemun‑gu, Seoul 130‑702, Korea. E‑mail: [email protected] References 1. Jager RD, Aiello LP, Patel SC, Cunningham ET Jr. Risks of intravitreous injection: A comprehensive review. Retina 2004;24:676‑98. 2. Roth DB, Chieh J, Spirn MJ, Green SN, Yarian DL, Chaudhry NA. Noninfectious endophthalmitis associated with intravitreal triamcinolone injection. Arch Ophthalmol 2003;121:1279‑82. Access this article online Quick Response Code: Website: www.ijo.in DOI: 10.4103/0301-4738.159906 PMID: *** Hypermetropia, accommodative and decompensated/partially accommodative esotropia and esotropic Duane’s retraction syndrome in infants: Words impact understanding Dear Editor, We read with interest the article by Kekunnaya et al.[1] and would like to make certain observations. The purpose, to study partially accommodative esotropia (ET) in esotropic Duane’s retraction syndrome (DRS), is skewed to say the least. Partially accommodative ET is that part which is left after full correction of the accommodative Vol. 63 No. 5 component, implying that partially accommodative component and eso DRS could be the same. Authors have not clarified as to how they have segregated the two, thereby congealing the entire study and attendant inferences. Terms hypermetropia and accommodative ET are not synonymous, certain criteria have to be met for the latter. By preoperative data, only cases 1, 3 and 6 fall in accommodative category, only case 1 had vertical rectus transposition (VRT), other two did not. Both cases (2 and 4) that ended up with exotropia (XT) lacked a proven accommodative component, so also case 5 with VRT. Accordingly, it is misleading to use the term partially accommodative ET in such cases as the deviation was ostensibly due to eso DRS. We don’t know how many were refractive/nonrefractive accommodative, high/low AC/A ratio, how many went in for deteriorated/decompensated accommodative ET, were decompensated monofixational esotropes, developed intermittent XT with accommodative component or simply passed from eso DRS to exo DRS due to long variable follow‑up.[1,2] Hypermetropia does not increase with the passage of time, it may only decrease due to the process of emmetropization. It is not clear why, at last follow‑up, accommodative component worsened de novo after VRT surgery in cases 3 and 5. Refraction at last follow‑up and change vis‑a‑vis preoperative values is not known to draw any logical conclusions regarding induced (non) refractive accommodative component. Most patients are 1‑year old, one being just 6 months; ocular deviation, motility cannot be assessed reliably, including the effect of glasses on the deviation. Most patients with DRS achieve alignment and fusion with abnormal head posture (AHP) and develop good binocularity. Moderate AHP in a 1‑year old with fusion does not call for surgical intervention, larger AHP in an older child with symptoms like neck pain/cosmetic blemish may earn it. Operating on DRS without clear indications is not in order as a lot of negative planning is involved. Full muscle VRT with Foster augmentation as an alternative to lateral rectus/medial rectus recessions for eso DRS in 1‑year olds may raise ethical issues. VRT may only add to globe retraction[3] (which was core criterion to diagnose DRS in this study), induce a vertical deviation (case 2), and limit adduction. The study does not address these issues, neither documents improvement in abduction if any. There is absolutely no controversy that correction of refractive errors is a prerequisite before other surgical/ nonsurgical measures are contemplated in treatment of strabismus, neither that ortho DRS may adopt AHP if deviation is induced by other concurrent factors. However, reasons for AHP in DRS are legion. XT after years could be due to diverse factors as stated above, words hypermetropia and accommodative ET have been used interchangeably, partially accommodative ET and ET due to DRS have not been pigeonholed, accordingly inferences drawn lack legitimacy. Pramod Kumar Pandey, Vishaal Bhambhwani, Shagun Sood, Kartik Rana, Poonam Gupta, Ranjith P C Department of Ophthalmology, Guru Nanak Eye Centre and Maulana Azad Medical College, New Delhi, India [Downloaded free from http://www.ijo.in on Tuesday, January 12, 2016, IP: 115.111.224.207] May 2015 Letters to the Editor Correspondence to: Dr. Pramod Kumar Pandey, Room 201, Guru Nanak Eye Centre, Ranjit Singh Marg, New Delhi ‑ 110 002, India. E‑mail: [email protected] 469 a b c d References 1. Kekunnaya R, Velez FG, Pineles SL. Outcomes in patients with esotropic Duane retraction syndrome and a partially accommodative component. Indian J Ophthalmol 2013;61:701‑4. 2. Raab EL. Outcome of deteriorated accommodative esotropia. Trans Am Ophthalmol Soc 1989;87:185‑93. 3. Rosenbaum AL. Costenbader lecture. The efficacy of rectus muscle transposition surgery in esotropic Duane syndrome and VI nerve palsy. J AAPOS 2004;8:409‑19. Access this article online Quick Response Code: Website: www.ijo.in DOI: 10.4103/0301-4738.159908 PMID: *** Intravitreal ziv‑aflibercept for recurrent macular edema secondary to central retinal venous occlusion Dear Editor, Recurrent macular edema (ME) secondary to central retinal venous occlusion (CRVO) is a challenging situation. Recently, newer anti‑vascular endothelial growth factor (VEGF) drug, aflibercept (Eyelea®, Bayer Healthcare, Germany), approved by Food and Drug Administration (FDA), has shown good treatment outcomes in randomized clinical trials in patients with ME secondary to CRVO. [1,2] However, this drug is not available in India. Ziv‑aflibercept (Zaltrap; Regeneron, New York, USA), anti‑VEGF drug, is a recombinant fusion protein with a similar mechanism to aflibercept. It was approved by FDA in August 2012, for the treatment of resistant metastatic colorectal carcinoma. Recently, Mansour et al. reported intravitreal ziv‑aflibercept as safe treatment at 4 weeks without any ocular toxicity in patients with diabetic ME and age‑related macular degeneration, and they clarified the concerns about the osmolarity of this preparation.[3,4] Here, we present a single case of off‑label use of intravitreal Zaltrap® in a patient with recurrent ME secondary to CRVO. A 64‑year‑old male presented with a sudden vision loss in both eyes since 1‑month. On examination, his best‑corrected visual acuity was 20/160 in right and left eye respectively. He was diagnosed to have CRVO with ME and was treated with intravitreal bevacizumab in both eyes. His systemic investigations were within normal limits. During the follow‑up of 20 months, he had multiple episodes of recurrent ME and received 12 and 13 anti‑VEGF injections in right and left eye respectively, along with one intravitreal triamcinolone injection and peripheral panretinal Figure 1: Top panel shows severe cystoid macular edema (ME) on spectral domain optical coherence tomography in the right eye (OD) and the left eye (OS) before intravitreal ziv‑aflibercept injection. Bottom panel shows significant decrease in ME at 1‑month follow‑up in both eyes photocoagulation in both eyes. After a treatment‑free interval of 2 months that is, at 22 months of follow‑up, he presented with recurrent edema in both eyes with of 20/200 in both eyes. On examination, there was ME in both eyes, with a central macular thickness (CMT) of 834 μ and 938 μ on optical coherence tomography (OCT) [Fig. 1a and b]. In view of recurrent recalcitrant edema, after obtaining informed consent, he underwent intravitreal Zaltrap ® (1.25 mg in 0.05 ml) in both eyes under aseptic conditions, with an interval of 5 days between two eyes. The patient was subsequently followed at postinjection day 1, day 7 and day 30 (1‑month). He did not have any symptoms of blurred vision or ocular pain related to injection without any signs of inflammation/toxicity. At 1‑month follow‑up, his visual acuity improved to 20/100 and 20/159 in his right and left eye respectively. OCT showed a decrease in edema with CMT of 193 μ and 232 μ [Fig. 1c and d] in right and left eye respectively. As there was no observed clinical toxicity at 1‑month follow‑up and good clinical response, the patient has been advised to undergo another injection of Zaltrap® in both eyes. This is the first report of intravitreal Zaltrap® in eyes with ME secondary to CRVO. Our report presents evidence supporting the clinical safety and efficacy of a single intravitreal Zaltrap® injection and supports its use as the primary or second line of anti‑VEGF therapy in recalcitrant ME due to CRVO. However, further studies are warranted to evaluate the long‑term safety and efficacy of this drug in various situations where anti‑VEGF therapy is indicated. Jay Chhablani Smt. Kanuri Santhamma Retina Vitreous Centre, L. V. Prasad Eye Institute, Hyderabad, Telangana, India Correspondence to: Dr. Jay Chhablani, Smt. Kanuri Santhamma Retina Vitreous Centre, L. V. Prasad Eye Institute, Kallam Anji Reddy Campus, L. V. Prasad Marg, Banjara Hills, Hyderabad ‑ 500 034, Telangana, India. E‑mail: [email protected]