Wednesday 26 December 2012

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Tuesday 28 August 2012

Treatment of diabetic macular edema- the current perspective

             
                     Treatment of diabetic macular edema- the current perspective

                            Dr Dhanashree Ratra, Dr Vineet Ratra

Prevalence of diabetes WHO figures. India leading with maximum number of patients with diabetes in the country


Macular edema is a leading cause of vision loss in about 15% of diabetic patients



Macular edema - leakage seen in fluorescein angiogram despite prior laser treatment.



                   


 Macular edema (ME) is one of the main vision-threatening complications associated with diabetic retinopathy.  Till recently the gold standard for treatment of  diabetic macular edema (DME) was laser photocoagulation .  But we know that laser was not always effective for the treatment of ME especially in the presence of ischemia and the only option available was observation. The past decade has seen introduction of various new drugs and drug delivery systems which have revolutionized the treatment of ME. Recently published clinical trials have shown that intravitreal dexamethasone (Ozurdex®; Allergan, Irvine, Calif., USA) and ranibizumab (Lucentis®; Novartis Pharma) are effective in the treatment of DME.  In this article we review the recent  developments in this field.
Emerging pharmacotherapies for the treatment of DME-
In India, the prevalence of diabetic retinopathy varies from 18-20.8% in known diabetics and 0.27 to 17.6% in general population.1,2,3,4 The incidence of ME varies from 10- 25% in these studies. Reported risk factors for diabetic retinopathy and DME include duration of diabetes, as well as the severity of hyperglycemia, hypertension, and hyperlipidemia. Apart from these microalbiminuria, anemia are also considered responsible.5 Intensive control of the systemic factors and macular photocoagulation have been shown to be effective in treating DME. In the recent times new pharmacotherapies have emerged for the treatment of DME.
Corticosteroids-
Triamcinolone acetonide
In addition to their anti-inflammatory properties, corticosteroids have been reported to reduce the activity of VEGF.  Currently various formulations and delivery systems are being evaluated. The Diabetic Retinopathy Clinical Research Network (DRCR) protocol B compared two doses (1 and 4 mg) of intravitreal triamcinolone acetonide( IVTA) versus photocoagulation for DME.6 For most patients, photocoagulation produced more favorable outcomes than did IVTA at 24 months of follow up. Similar results were reported at 3-year follow-up.7 The most common complications of IVTA are cataract formation  and increased intraocular pressure (IOP). Pseudoendophthalmitis and infectious endophthalmitis occur much less commonly. The rate of infectious endophthalmitis after IVTA is low in reported series. For example, in an analysis of two large randomized controlled trials (RCT) (from the DRCR network and the Standard Care Versus Corticosteroid for Retinal Vein Occlusion (SCORE) trials), the rate of endophthalmitis after IVTA was 0.05%.8 A triamcinolone-eluting intravitreal implant (I-vation, SurModics, Inc., MN, USA) for the treatment of DME was suspended in a phase 2b RCT after the publication of the DRCR network results showing a benefit of laser photocoagulation over IVTA in treatment of DME
Fluocinolone acetonide
To reduce the need for repeated intravitreal injections, several extended-release corticosteroid delivery systems have been studied. A fluocinolone-acetonide- (FA-) eluting intravitreal implant (Retisert, Bausch and Lomb, NY, USA) a nonbiodegradable device that releases 0.59 μg/day of FA into the vitreous cavity has been studied. It must be implanted in an operating room or similar setting. In an RCT, the effects of the device versus photocoagulation for DME were studied. At one year, DME was resolved in 57% of patients with the FA implant versus 20% of patients with photocoagulation. There were no statistically significant differences in final visual acuity between the two groups.9 At 3 years, patients randomized to receive the FA implant had persistent treatment of macular edema, but 95% of phakic eyes developed significant cataract, and about one-third of eyes had IOP above 30 mm Hg.10
A smaller fluocinolone acetonide-eluting device (Iluvien, Alimera Sciences, Alpharetta, GA, USA) may be administered through a 25-gauge device in a clinic setting. The Fluocinolone Acetonide for Macular Edema (FAME) study comprised 2 phase 3 RCTs assessing the efficacy and safety of 0.2 μg/day (low dose) and 0.5 μg/day (high dose) inserts in patients with DME with persistent edema despite at least one macular laser treatment.11 The primary study endpoint was defined as improvement in visual acuity by 15 or more letters at 2 years. At 24 months, the primary endpoint was achieved in 28.7% and 28.6% of low- and high- dose insert groups compared with 16.2% in the sham group. Elevated intraocular pressure requiring incisional surgery occurred in 3.7%, 7.6%, and 0.5% of the low-dose, high-dose, and sham groups, respectively.
Dexamethasone
The dexamethasone drug delivery system (DDS) [Ozurdex, Allergan, Irvine, California] is a biodegradable, sustained-release device approved by the US FDA for the treatment of macular edema associated with retinal vein occlusion and noninfectious posterior segment uveitis. A phase 2 RCT in patients with persistent macular edema secondary to various etiologies, including DME, showed that the dexamethasone DDS produced improvements in visual acuity, macular thickness, and fluorescein leakage that were sustained for up to 6 months.12  In an RCT, the safety and efficacy of the dexamethasone DDS in the treatment of DME was studied.13  Patients with persistent macular edema (at least 90-day duration) were randomized to treatment with 700 μg or 350 μg of dexamethasone DDS or observation. At 3 months, visual acuity improved by 10 letters or more in 30% of eyes in the 700 μg group, 20% of eyes in the 350 μg group, and 12% of eyes in the observation group. A more recent study reported that the dexamethasone DDS improved visual acuity and macular edema in previously vitrectomized eyes with diffuse DME.14
Vascular Endothelial Growth Factor Antagonists-
Four intravitreal anti-VEGF agents are currently available commercially.
Pegaptanib
Pegaptanib (Macugen, Eyetech Pharmaceuticals, Palm Beach Gardens, FL, USA) is a pegylated aptamer that targets the VEGF165 isoform  and was the first anti-VEGF medication reported to have efficacy in the treatment of DME. The Macugen Diabetic Retinopathy Study Group conducted a phase 2 RCT of pegaptanib for fovea-involving DME.15 After 36 weeks of followup, the pegaptanib-treated eyes had better visual acuity, more reduction in central retinal thickness, and less need for laser photocoagulation compared to the sham group. More recently, a phase 2/3 RCT reported that pegaptanib therapy was associated with improved visual outcomes in patients with DME for up to 2 years.16
Bevacizumab
Bevacizumab (Avastin, Genentech, Inc., South San Francisco, CA, US) is a full-length recombinant humanized antibody against all isoforms of VEGF-A. The agent is used commonly as an off-label intravitreal injection. The DRCR network conducted a randomized study of 121 eyes with DME over a 12-week period.17 There were five treatment arms: focal photocoagulation, 2 consecutive 1.25 mg bevacizumab injections, 2 consecutive 2.5 mg bevacizumab injections, 1.25 mg bevacizumab followed by sham injection, and combination of photocoagulation with 2 consecutive 1.25 mg bevacizumab injections. The groups that received two bevacizumab injections without laser had a significant improvement in visual acuity over the laser-only group. There were no detectable differences between the 1.25 mg and 2.5 mg doses. The single injection group had no advantage over the laser-only group. The combination of laser and bevacizumab had comparable results to the laser-only group with a trend toward worse short-term vision than eyes that received two bevacizumab injections.  In the BOLT (Bevacizumab Or Laser Therapy in the Management of DME) study, repeated intravitreal bevacizumab injections were compared with modified ETDRS photocoagulation in patients with persistent DME.18 A total of 80 patients with center-involving DME and at least one prior photocoagulation without evidence of advanced macular ischemia were included. Patients were randomized to 2 arms: intravitreal bevacizumab (injections at baseline, 6- and 12-week follow up with subsequent injections every 6 weeks based on OCT-guided retreatment protocol) or photocoagulation (at baseline with subsequent retreatment every 4 months if clinically indicated by ETDRS guidelines). At 12 months, bevacizumab had a greater treatment effect than did photocoagulation. The bevacizumab arm gained a median of 8 ETDRS letters, whereas the photocoagulation group lost a median of 0.5 ETDRS letters. Approximately 31% of patients in the bevacizumab arm versus 7.9% of patients in the laser arm gained ≥10 ETDRS letters (p=0.01). The decrease in central macular thickness was significantly more in the bevacizumab group compared to the photocoagulation group.
Ranibizumab
Ranibizumab (Lucentis, Genentech, Inc. South San Francisco, CA, USA) is a recombinant humanized monoclonal antibody fragment that binds all isoforms of VEGF-A with high affinity. Various clinical trials have been conducted to assess the efficacy and safety in DME. The Ranibizumab for Edema of the Macula in Diabetes (READ-2) study randomized 126 eyes with DME to 3 groups: ranibizumab only (injection at baseline, months 1, 3, and 5); photocoagulation (at baseline and at 3 months if needed); combined ranibizumab and photocoagulation (photocoagulation and ranibizumab at baseline, and ranibizumab at 3 months if needed).19 Patients randomized to ranibizumab only showed a significantly better visual outcome at 6 months compared with the other 2 groups. For patients with data available at 6 months, improvement of 3 lines or more in vision occurred in 22% of patients in the ranibizumab-only arm, none in the photocoagulation-only arm, and 8% in combined arm. At 24 months, the study reported that intravitreal ranibizumab provided persistent treatment benefits.20 DRCR protocol I evaluated ranibizumab and IVTA in combination with photocoagulation by randomizing patients into four arms: ranibizumab with prompt (within one week) photocoagulation, IVTA with prompt photocoagulation, sham injection with prompt photocoagulation, and ranibizumab with photocoagulation deferred for at least 24 weeks.21 The treatment protocol included a baseline treatment followed by intravitreal study medication or sham injection retreatments every 4 weeks through the 12-week visit. After the 16-week visit, retreatment was at the investigator’s discretion according to web-based predetermined criteria. Ranibizumab with prompt or deferred photocoagulation resulted in more favorable visual acuity and central macular thickness outcomes compared with photocoagulation alone at 1 and 2 years of follow up. In ranibizumab-treated eyes, the results were similar whether photocoagulation was given with the first injection or deferred for at least 24 weeks. IVTA combined with photocoagulation did not result in better visual outcomes compared with photocoagulation alone. However, in pseudophakic eyes, the IVTA with prompt photocoagulation group had similar visual outcomes to the 2 ranibizumab groups, suggesting that cataract formation may have affected the visual acuity outcomes in phakic eyes treated with IVTA. Two-year visual outcomes were similar to 1-year results and reinforced the conclusion that ranibizumab with prompt or deferred photocoagulation should be considered for patients with vision impairment of worse than 20/32 secondary to DME.22 The RESTORE phase 3 study also reported that ranibizumab monotherapy or combined with laser photocoagulation provided superior visual acuity gain over standard photocoagulation in the treatment of DME.23 Two additional phase 3 RCTs (RISE and RIDE) were conducted to evaluate the efficacy, durability, and long-term safety of monthly ranibizumab injections in patients with center-involving DME.  The safety and efficacy of double dose of ranibizumab was  compared in the RESOLVE phase 2 trial. The incidence and severity of systemic and ocular adverse events that are associated with repeated intravitreal injections of two doses of ranibizumab (0.5 mg versus 2.0 mg) in subjects with DME are being investigated in READ-3 study.
Aflibercept
Aflibercept, or VEGF trap-eye, (Eylea, Regeneron, Tarrytown, NY, USA), is a recombinant fusion protein with activity against all VEGF-A isoforms and PlGF that is FDA-approved for the treatment of neovascular AMD and has been shown to have short-term efficacy in the treatment of DME.24  The DA-VINCI study assessed the efficacy and safety of intravitreal aflibercept versus laser photocoagulation in the treatment of DME. Patients were randomized to one of the following treatment arms: 0.5 mg aflibercept every 4 weeks, 2 mg aflibercept every 4 weeks, 2 mg aflibercept every 8 weeks, 2 mg aflibercept as needed, or photocoagulation. At 24 weeks, the mean change in BCVA for aflibercept arms ranged from +8.5 to +11.4 letters compared to the mean change of +2.5 letters in the laser-treated eyes (p<0.01). There was no statistical significant difference between the aflibercept arms. Anatomic effects (mean change in central retinal thickness) ranged from −127 μm to −195 μm in aflibercept arms compared to −68 μm in laser-treated eyes at 24 weeks (p<0.01).  At 52 weeks, the mean change in BCVA for aflibercept arms ranged from +9.7 to +13.1 letters compared to the mean change of −1.3 letters in the laser-treated eyes (p<0.01).25  In this study population, intravitreal aflibercept produced significant improvements in visual acuity and retinal thickness as compared to laser photocoagulation at both 24 and 52 weeks. At this time, aflibercept is not approved by the US FDA for the treatment of DME.
Many more agents are being studied and are in various phases of clinical trials. Exciting times are ahead when we await the results of these trials. However that does not make laser obsolete. It still has its place in the treatment of DME.

  1. Raman R, Rani PK, Rachepalle SR, Gnanamoorthy P, Uthra S, Kumaramanickavel G, Sharma T. Prevalence of Diabetic Retinopathy in India. SNDREAMS Report No. 2 Ophthalmol 2009;116:311-8
  2. Rema M, Premkumar S, Anitha B, Deepa R, Pradeepa R, Mohan V. Prevalence of Diabetic Retinopathy in Urban India: The Chennai Urban Rural Epidemiology Study (CURES) Eye Study, I. Invest Ophthalmol Vis Sci. 2005;46:2328-33
  3. Nirmalan PK, Katz J, Robin AL, et al. Prevalence of vitreoretinal disorders in a rural population of southern India: the Aravind Comprehensive Eye Study. Arch Ophthalmol 2004;122:581–6.
  4. Krishnaiah S, Das TP, Nirmalan PK, Shamanna BR, Nutheti R, Rao GN, Thomas R. Risk factors for diabetic retinopathy: Findings from The Andhra Pradesh Eye Disease Study. Clin Ophthalmol 2007:1(4) 475–82
  5. Raman R, Vaitheeswaran K, Vinita K, Sharma T. Is Prevalence of Retinopathy Related to the Age of Onset of Diabetes? Sankara Nethralaya Diabetic Retinopathy Epidemiology and Molecular Genetic Report No. 5. Ophthalmic Res 2011;45:36–41
  6. Diabetic Retinopathy Clinical Research Network. A randomized trial comparing intravitreal triamcinolone acetonide and focal/grid photocoagulation for diabetic macular edema. Ophthalmology  2008;115:1447–9.
  7. Beck RW, Edwards AR, Aiello LP, et al. Three-year follow-up of a randomized trial comparing focal/grid photocoagulation and intravitreal triamcinolone for diabetic macular edema. Arch Ophthalmol 2009;127:245–51.
  8. Bhavsar AR, Ip MS, Glassman AR. The risk of endophthalmitis following intravitreal triamcinolone injection in the DRCRnet and SCORE clinical trials. Am J Ophthalmol 2007; 144:454–6.
  9. Fluocinolone acetonide ophthalmic- Bausch & Lomb: fluocinolone acetonide envision TD implant. Drugs RD, 2005;6:116–9.
  10. Montero JA and Ruiz-Moreno JM. Intravitreal inserts of steroids to treat diabetic macular edema. Current Diabetes Reviews. 2009; 5: 26–32.
  11. Campochiaro PA, Brown DM, Pearson A, et al. Long-term benefit of sustained-delivery fluocinolone acetonide vitreous inserts for diabetic macular edema. Ophthalmology.2011; 118: 626–35.
  12. Kuppermann BD, Blumenkranz MS, Haller JA,  et al. Randomized controlled study of an intravitreous dexamethasone drug delivery system in patients with persistent macular edema Arch Ophthalmol. 2007;125:309–17.
  13. Haller JA,  Kuppermann BD,  Blumenkranz  MS, et al. Randomized controlled trial of an intravitreous dexamethasone drug delivery system in patients with diabetic macular edema. Arch Ophthalmol. 2010;128:289–96.
  14. Boyer DS, Faber D, Gupta S, et al. Dexamethasone intravitreal implant for treatment of diabetic macular edema in vitrectomized patients. Retina.2011; 31:915–23.
  15. Cunningham Jr ET, Adamis AP,  Altaweel M, et al. A phase II randomized double-masked trial of pegaptanib, an anti-vascular endothelial growth factor aptamer, for diabetic macular edema. Ophthalmology. 2005;112:1747–57.
  16. Sultan MB, Zhou D, Loftus J, Dombi T, Ice KS. A phase 2/3, multicenter, randomized, double-masked, 2-year trial of pegaptanib sodium for the treatment of diabetic macular edema. Ophthalmology 2011;118:1107–18.
  17. Diabetic Retinopathy Clinical Research Network. A phase II randomized clinical trial of intravitreal bevacizumab for diabetic macular edema.  Ophthalmology. 2007; 114:1860–7.
  18. Michaelides M, Kaines A, Hamilton RD, et al. A prospective randomized trial of intravitreal bevacizumab or laser therapy in the management of diabetic macular edema (BOLT study). 12-month data: report 2. Ophthalmology. 2010;117:1078–86.
  19. Nguyen QD,  Shah SM,  Heier JS, et al. Primary end point (six months) results of the ranibizumab for edema of the mAcula in diabetes (READ-2) study. Ophthalmology 2009;116:2175–81.
  20. Nguyen QD,  Shah SM,  Khwaja  AM,  et al. Two-year outcomes of the ranibizumab for edema of the mAcula in diabetes (READ-2) study. Ophthalmology 2010;117:2146-51.
  21. Elman MJ, Aiello LP, et al. Diabetic Retinopathy Clinical Research Network. Randomized trial evaluating ranibizumab plus prompt or deferred laser or triamcinolone plus prompt laser for diabetic macular edema. Ophthalmology 2010;117:1064–77.
  22. Elman MJ, Bressler NM, Qin H, et al. Expanded 2-year follow-up of ranibizumab plus prompt or deferred laser or triamcinolone plus prompt laser for diabetic macular edema.  Ophthalmology. 2011;118:609–14.
  23. Mitchell P, Bandello F, Schmidt-Erfurth U, et al. The RESTORE study: ranibizumab monotherapy or combined with laser versus laser monotherapy for diabetic macular edema. Ophthalmology. 2011;118:615–25.
  24. Do DV, Nguyen QD, Shah SM, et al. An exploratory study of the safety, tolerability and bioactivity of a single intravitreal injection of vascular endothelial growth factor Trap-Eye in patients with diabetic macular oedema.  British Journal of Ophthalmology. 2009;93:144–9.
  25. Do DV, Schmidt-Erfurth U, Gonzalez VH, et al. The da VINCI study: phase 2 primary results of VEGF trap-eye in patients with diabetic macular edema.  Ophthalmology 2011;118:1819–26.
   


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Monday 13 August 2012

Profile of Dr Dhanashree Ratra





Profile of Dr Dhanashree  Ratra


Dr. Dhanashree Ratra, MS, DNB, FRCS (Edin), is a leading ophthalmologist of the country. She was trained at and later worked for 15 years in the world renowned Sankara Nethralaya. She specializes in the treatment of vitreoretinal diseases and is well versed in the management of retinal detachment, diabetic retinopathy, macular degeneration, and retinopathy of prematurity among others.



Education :

·         MBBS from Mahatma Gandhi Institute of Medical Sciences, Sevagram under Nagpur University in Dec. 1990. 
·         Silver medal for scoring highest marks in Anatomy.
·         Silver medal for scoring highest marks in Forensic Medicine.
·         M S Ophthalmology from Mahatma Gandhi Institute of Medical Sciences, Sevagram under Nagpur University in Dec. 1993.
·         Diplomate of National Board in Ophthalmology in June 1994.
·         Fellow of The Royal College of Surgeons, Edinburgh in September 1999.

SPECIAL TRAINING :
Fellowship in Vitreo-Retinal Diseases at Sankara Nethralaya, Medical Research Foundation, Chennai form April 1995 till September 1996.

Best Lady Fellow Award for the year ’96–’97
 

 Current Position




P0SITIONS HELD
Senior Consultant,
Dept of Ophthalmology,
Apollo Hospitals,
154/11, Opp IIM,
Bannerghatta Road, Bangalore 560076





Senior Consultant,
Shri Bhagawan Mahavir Dept of  Vitreoretinal Diseases,
Sankara Nethralaya
18, College Road,
Chennai 600 006
From July 2005 till March 2012

Senior Consultant,
Apollo Hospitals,
578, Elwitigala  Mawatha,
Colombo, Sri Lanka
From July 2005 to October2006


Head and Consultant,
Department of Vitreoretinal Diseases,
Rotary Narayana Sankara Nethralaya,
CN 5, Sector 5,
Salt Lake,
Kolkata
Feb 2003 till June 2005

Associate Consultant,
Dept of Vitreoretinal Diseases,
Sankara Nethralaya,
18, College Road,
Chennai 600006
From  Dec. 1996 to Oct 2002.

Consultant
Dept of Vitreoretinal Diseases,
Shri Ganapathi Nethralaya, Jalna
From December 1996 till February 1998



ACADEMIC POSITIONS HELD

1.    Faculty,  Revision course in Ophthalmology since 2000.
2.    Post graduate teacher and thesis guide for DNB candidates since 1999. 
3.    Faculty for M Phil Optometry by BITS, Pilani from 2006 to 2010.
4.    Mentor and Instructor for vitreoretinal fellowship program since 1998.
5.    Faculty for Ratan Tata Cataract Surgery Fellowship program since 2007.


MANAGEMENT TRAINING AND POSITIONS HELD

     Undergone special training in hospital management in 2002
     Undergone  Leadership  training for 1 year in 2010-2011
     Member of the Strategic Planning Committee for Sankara Nethralaya,       
     2011
     Member, National Advisory Board for Photodynamic Therapy in India,
     since 2005
     Member, National Advisory Board for Ozurdex in India since 2011

AWARDS

     Best Lady Fellow award in 1997

     Best Associate Consultant award in 2003

Best Scientific Paper J M Pahwa  award in the 17th  Annual Conference of the Vitreoretinal Society of India, Kolkata,   4th to 6th December, 2008

     Co-author for the D B Chandra Award for the Best Scientific paper in   
     The 68th Annual All India Ophthalmological Conference, 21st to 24th
     January, 2010, Kolkata

Co-author for the Best poster award in the annual meeting of the         American Academy of Ophthalmology, 23-26th October, 2011 at Orlando, USA.


ACHIEVEMENTS

     Set up and managed Vitreoretinal departments with fully equipped operational facilities to tackle complex vitreoretinal surgeries at Shri Ganapati Netralaya, Jalna in 1996, Rotary Narayana Sankara Nethralaya, Kolkata in 2003 and at Apollo Hospitals, Colombo in 2005.

Helped set up and successfully run Rotary  Narayana  Sankara Nethralaya at Kolkata in 2003.




SCIENTIFIC PAPERS AND POSTERS PRESENTED:


1.    Adult Onset  Vitelliform Macular Dystrophy.  Deshpande D, Shetty NS, Bhende MP, Gopal L. 43rd Annual Conference of the Tamilnadu Ophthalmic Association. Tiruchirapalli, 11th – 13th August, 1995

2.    Supernormal Scotopic Response in Cone-Rod Dystrophy.  Deshpande D, Shetty NS. 43rd Annual Conference of the Tamilnadu Ophthalmic Association, Tiruchirapalli, 11th –13th August, 1995

3.    Treatment for Threshold Retinopathy of Prematurity. Deshpande D, Chaturvedi M, Gopal L, Ramchandran S, Sudha R. 44th Annual Conference of the Tamilnadu Ophthalmic Association, Salem 2nd – 4th August, 1996

4.    Ocular Ischemic Syndrome – A Clinical Challenge. Deshpande D, Shanmugam MP, Bhende P, Shetty NS, Gopal L. 44th Annual Conference of the Tamilnadu Ophthalmic Association, Salem 2nd – 4th August, 1996

5.    Subretinal fibrosis and non rhegmatogenous retinal detachment associated with multifocal central serous chorioretinopathy (CSC)”:
Sharma T, Badrinath SS, Gopal L, Ravishankar K, Shanmugam MP, Bhende P, Bhende M, Shetty NS, Deshpande DA,  Mukesh BN.
(Scientific Poster) Annual Meeting of American Academy of Ophthalmology, Chicago, Illinois, 27- 31 October, 1996.

6.    Electroretinographic studies in cone rod dystrophy. Ratra Dhanashree, Bapaye M, Shetty NS, Kiran Kumari. 18th Asia Pacific Academy of Ophthalmology, Taipei, 10-14th  March 2001.

7.    TPA assisted pneumatic displacement of thick submacular haemorrhage. .Ratra Dhanashree, Anad R, Gopal L, Sharma T, Bhende M, Chopra S, 18th Asia Pacific Academy of Ophthalmology, Taipei, 10-14th  March 2001.

8.    Intraocular Cysticercosis: Clinical Characteristics and Visual Outcome after Surgery. Sharma T,  Sinha S, Shah N, Gopal L, Shanmugam MP, Agrawal RN, Deshpande DA, Sukumar B. American Academy of Ophthalmology, New Orleans, USA,11-14th  November, 2001

9.    Effect of Transpupillary Thermotherapy on Choroidal neovascular membrane due to Age related macular degeneration ,Ratra D.  Continuing Medical Education – Age Related Macular Degeneration and modalities of treatment including Transpupillary Thermotherapy and Photodynamic Therapy , Rotary Narayana Sankara Nethralaya, Kolkata, 18th June, 2003


10. Conversion to Classic choroidal neovascularization after treatment with transpupillary thermotherapy for occult choroidal neovascularization. Ratra Dhanashree, 20th Asia Pacific Academy of Ophthalmology Congress, Kuala Lumpur, Malaysia, 27th-31st March,2005.

11. Autofluorescence findings in Central serous retinopathy, Dhanashree Ratra, Jay Chablani, 17th Annual Conference of the Vitreo-Retinal Society of India, Kolkata, 4th- 6th December, 2008. Adjudged the Best Scientific Paper.

12. Comparative analysis of visual outcomes of combination versus monotherapy for wet AMD, Dhanashree Ratra, Sudhir Sudrik, Tarun Sharma,  17th Annual Conference of the Vitreo-Retinal Society of India, Kolkata, 4th- 6th December, 2008.

13. Combination therapy for wet AMD- standard fluence versus reduced fluence – Indian experience, Dhanashree Ratra, 9th International AMD Congress, Athens, Greece, 9th-10th October, 2009.

14.  Retinopathy of prematurity in term and near term infants, Lala Akhundova, Dhanashree Ratra, World ROP Congress, International conference of Retinopathy of Prematurity, New Delhi, 21st to 23rd November, 2009.

15. Fundus evaluation including direct, indirect ophthalmoscopy and slit lamp biomicroscopy, Dhanashree Ratra, Chief Instructor, Basic Instruction course, 68th Annual All India Ophthalmological Conference, Kolkata, 21st to 24th January, 2010.

16. High speed angiography and ICG angiography, Dhanashree Ratra, Co-instructor, Advanced Instruction Course on Retinal angiography,, 68th Annual All India Ophthalmological Conference, Kolkata, 21st to 24th January, 2010.

17. Retinal arterial occlusions in the young- systemic associations in the Indian population, Dhanashree Ratra, Maneesh Dhupper, 68th Annual All India Ophthalmological Conference, Kolkata, 21st to 24th January, 2010.

18. Indirect Ophthalmoscopy, Dhanashree Ratra, Chief Instructor, Basic Instruction course, 69th Annual All India Ophthalmological Conference, Ahmedabad, 3rd to 6th February, 2011

19.  Management of proliferative vitreoretinopathy and giant retinal tear, Dhanashree Ratra, Co-instructor, Advanced Instruction Course on Vitreoretinal Surgery, 69th Annual All India Ophthalmological Conference, Ahmedabad, 3rd to 6th February, 2011.

20.  Does fluorescein angiography have a role in the management of diabetic retinopathy, Dhanashree Ratra, Co-instructor, Update on recent trends in management of diabetic retinopathy, 70th Annual All India Ophthalmological Conference, Cochin, 2nd to 5th February, 2012.


21.  Management of giant retinal tear, Dhanashree Ratra, Chief instructor, Nuances of Vitreoretinal Surgery- a video based instruction course, 70th Annual All India Ophthalmological Conference, Cochin, 2nd to 5th February, 2012.




PUBLICATIONS:



1.     Treatment for Threshold Retinopathy of Prematurity .Deshpande D, Chaturvedi M, Gopal L, Ramachandran S, Shanmuga Sundaram R  Indian J Ophthalmol 1998; 46:15 – 19.


2.    Subretinal fibrosis and non rhegmatogenous retinal detachment associated with multifocal central serous chorioretinopathy (CSC). Sharma T, Badrinath SS, Gopal L, Ravishankar K, Shanmugam MP, Bhende P, Bhende M, Shetty NS, Deshpande D,  Mukesh BN. Retina 1998;18: 23-29.

3.    Surgical management of retinal detachments related to coloboma of the choroid. Gopal L, Badrinath SS, Sharma T, Parikh S, Mahesh P Shanmugam, Bhende P, Agrawal R, Deshpande DA. Ophthalmology, 1998;105: 804-9.

4.    Ultrasound Biomicroscopy of sclerotomy sites following Pars Plana Vitrectomy for Diabetic Vitreous Hemorrhage. Bhende M, Agraharam SG, Gopal L, Sumasri K, Sukumar B, George J, Sharma T, Shanmugam MP, Bhende P, Shetty NS,  Agrawal RN , Deshpande DA. Ophthalmology 2000;107(9):1729-36.

5.    Endophthalmitis caused by Acinetobacter calcoaceticus: A profile Gopal L, Anand AR, Madhavan HN, Battu RR, Sharma T, Shanmugam MP, Bhende M, Ratra D, Shetty NS, Rao MK. Ind J Ophthalmol 2003;51: 335-240

6.    Intraocular Cysticercosis- Clinical Characteristics and Visual Outcome after Vitreoretinal Surgery. Sharma T, Sinha S,  Shah N, Gopal L, Shanmugam MP,  Bhende P, Bhende M, Shetty NS, Agrawal RN, Deshpande D , Biswas J, Sukumar B. Ophthalmology 2003,110:996-1004


7.    Scleral buckling implant versus explant. Gopal L, D’Souza C, Bhende M, Fogla S, Ratra D, Shetty NS, Sharma T, Shanmugam MP, Bhende P, Battu RR, Badrinath SS. Retina 2003;23: 636-640.

8.    Use of silicone oil in the management of complex retinal detachment- An Indian experience. Silicone Oil Study Group of Sankara Nethralaya. Int Ophthalmol 2004;25(3):129-142.

9.    Off- label use of Bevacizumab in retinopathy of prematurity. Rishi E, Rishi P, Ratra D, Bhende M. (Letter to Editor) Retina 2009;29(2):284-285.

10.  Intravitreal cysticercosis presenting as neovascular glaucoma. Ratra D, Phogat C, Singh M, Choudhari NS. Ind J Ophthalmol 2010;58:70-73.

11.  Postsurgical bacterial endophthalmitis presenting as frosted branch angiitis. A case report. Ratra D, Jafferji S, Biswas J. Retinal Cases and Brief Reports. 2010;4: 20-22.

12.  Diagnostic and therapeutic challenges. Ratra D, Uparkar M, Bernstein PS, Simaraman K, Tabin G, Mandava N, Lipson BK. Retina  2011; 31(1):184-190

13.  Photodynamic monotherapy or combination treatment with intravitreal triamcinolone acetonide, bevacizumab or ranibizumab for choroidal neovascularization associated with pathological myopia. Rishi P, Rishi E, Venkataraman A, Gopal L, Sharma T, Bhende M, Ratra D, Sen PR, Sen P. Ind J Ophthalmol 2011; 59(3):242-246.

14.  Diagnostic and Therapeutic challenges. Unusual retinal vascular lesion. Ratra D, Achar MT, Barbazetto IA, Wong RW. Retina 2011. Nov 10. Epub ahead of print.

15.  Retinal arterial occlusions in the young: Systemic associations in Indian population. Ratra D, Dhupper M. Ind J Ophthalmol 2012;60:95-100.

16. Intravitreous tissue plasminogen activator with pneumatic displacement in submacular hemorrhage. Ratra D, Basia A. Arch Ophthalmol. 2012;130:795-6.

17. Comparison between Humphrey field analyzer and Micro Perimeter 1 in normal and glaucoma subjects. Ratra V, Ratra D, Gupta M, Vaitheeswaran KOman J Ophthalmol.  2012;5:97-102.




PRESENTATIONS AND LECTURES AS INVITED FACULTY

1.    Challenges in Endophthalmitis. Dhanashree Ratra, Annual Conference of the Bombay Ophthalmic Association, Mumbai, 12th August, 2001.

2.    Long term  results of Scleral fixated intraocular lens. Dhanashree Ratra.   6TH International Advanced Vitreoretinal surgery course , Chennai 24th to 26th July, 2003.

3.    Suprachoroidal Haemorrhage, Dhanashree Ratra ,  Indo Israel Ophthalmic Conference, Chennai, India, 12-13th,November, 2005.

4.    Randomized trial of combination therapy for wet AMD- standard fluence versus reduced fluence, Dhanashree Ratra, Meeting of the National Advisory Board for PDT, Mumbai, 20th July, 2008. 

5.    Treat and Extend-  Towards an optimized treatment scheme of Ranibizumab in patients with neovascular AMD, Dhanashree Ratra, 4th Indian AMD Congress, Mumbai, 18th-19th April, 2009.

6.    Surgical management of angiomatosis retinae and Coat’s disease, Dhanashree Ratra, 18th Annual conference of the Vitreo-Retinal society of India, Palampur, 25th to 28th November, 2009.

7.    Lasers in the era of Anti VEGF, Dhanashree Ratra, Annual Conference of the Aurangabad Ophthalmological Society and Maharashtra Ophthalmic Society, Aurangabad, 17th January, 2010.

8.    Posterior segment complications of anterior segment diseases, Dhanashree Ratra, Annual Conference of the Aurangabad Ophthalmological Society and Maharashtra Ophthalmic Society, Aurangabad, 17th January, 2010.

9.    When should  I refer case to VR surgeon, Dhanashree Ratra, CME on Diabetic Retinopathy, Baroda, 10th April, 2010.

10. Juvenile diabetic retinopathy,  Dhanashree Ratra, CME on Diabetic Retinopathy, Baroda, 10th April, 2010.

11. Preferred practice patterns in diabetic retinopathy , Dhanashree Ratra, Diabetic retinopathy – from bench to population, Conference of the Association for Research in Vision and Ophthalmology and Sankara Nethralaya, Chennai, 9th to 11th September, 2010.

12. Differential diagnosis and contemporary management of AMD, Dhanashree Ratra, CME on Retina, Sri Ramchandra University, Chennai, 11th February, 2011.

13. Lucentis in AMD, Dhanashree Ratra  Nellai Sandhippu , The 59th Annual Conference of the Tamil nadu Ophthalmic Association, Thirunelvelli,  5th to 7th August, 2011.

14. Current trends in the management of AMD Dhanashree Ratra Island Ophthafest Port Blair, Andaman and Nicobar, 9th to 11th September, 2011.

15. Do we need Indian guidelines for treatment of RVO with Ozurdex? Dhanashree Ratra Meeting of the National Advisory Board for Ozurdex, New Delhi, 18th September, 2011.

16.  Management of dislocated IOLs Dhanashree Ratra  The annual conference of the Uttarakhand State Ophthalmologic Society, Dehradun , 7-9th October, 2011.

17. Recent advances in the management of AMD Dhanashree Ratra  The annual conference of the Uttarakhand State Ophthalmologic Society, Dehradun , 7-9th October, 2011.

18.  Epidemiology of diabetic macular edema. 2nd  Allergan National  Advisory board meeting,  Mumbai 21st January, 2012.

19.  Retinal imaging. All India Postgraduate refresher course, Chennai, 7th, January, 2012.

20.  Update on retinal surgery. All India Postgraduate refresher course, Pune, 22nd, January, 2012.

21.  Update on lasers for diabetic retinopathy. All India Postgraduate refresher course, Pune, 22nd, January, 2012.

22. Management of dislocated IOLs- The Lasso technique. Bangalore medical college and Research Institute, Bangalore, 15th June, 2012.

23.  AMD- Current concepts, where do we stand? Bangalore medical college and Research Institute, Bangalore, 15th June, 2012.







CHAPTERS IN BOOKS:

1.    Approach to a patient with night blindness, DOS times, Delhi Ophthalmic Society Publications, New Delhi, April 2001. Dr. Dhanashree Ratra

2.    Dr. Dhanashree Ratra, Dr. Rajat Agrawal, Dr. Tarun Sharma, Macular Hole Surgery, Recent advances in ophthalmology, 6,2002, Chapter 8, page 78-94.

3.    Dr. Dhanashree Ratra:  Posteriorly dislocated nucleus and intraocular lens management. Modern Ophthalmology, Edited by Dr. L C Dutta 2002.

4.    Co-authored Sankara Nethralaya Atlas on Retinal Diseases. Jaypee Brothers, 2008

5.    Co-authored Sankara Nethralaya Atlas on Fluorescein angiography, Jaypee Brothers, second edition 2011

6.    Co-authored Sankara Nethralaya Atlas on Ultrasound, Jaypee Brothers , second edition 2011

7.    Padmaja Kumari Rani, Tarun Sharma, Pradeep Susvar, Ashok Rangarajan, Vikas Khetan, Lingam Gopal, Lekha Gopal, Muna Bhende, Dhanashree Ratra.  Case studies, chapter in Age-related macular degeneration, Edited by Sandeep Saxena, Jaypee brothers medical publishers ltd, New Delhi, 2011, 76-97.




MEMBERSHIP IN SOCIETY:

Tamil Nadu Ophthalmological Association

All India Ophthalmological Society

Vitreoretinal Society of India

American Academy of Ophthalmology

Royal College of Surgeons, Edinburgh





CONFERENCES ATTENDED:


1.    Second Scientific Meeting of Sankara Nethralaya Alumni, Chennai, 23rd October 1994.

2.    175th Anniversary of Regional Institute of Ophthalmology, GOH, Chennai, 29th October 1994.

3.    International symposium on “Vitreoretinal Surgery”, Sankara Nethralaya, Chennai, 7th and 9th February 1995.

4.    International Workshop on Phacoemulsification, Chennai, 11th – 13th February, 1996

5.    44th Annual Conference of the Tamilnadu Ophthalmic Association, Salem 2nd – 4th August, 1996


6.    Global Meet on Vitreoretinal Surgery, Sankara Nethralaya, Chennai, 5th to 7th September 1997

7.    International Retinal Meet : Mumbai, 21 – 23rd November, 1997.

8.    CME program on Medical Retina, Sankara Nethralaya, Chennai October 31, 1998.

9.    International Symposium on Ocular tumors, Chennai 7th – 8th February 1998.

10. International Symposium of Intraocular Inflammation, Chennai 4th-5th February, 2001

11. 18th Asia Pacific Academy of Ophthalmology, Taipei, Taiwan (ROC) March 10-14 , 2001.

12. 21st Annual Conference of the Bombay Ophthalmic association, Mumbai, August,12th, 2001


13. 14th World Congress of the International Society for Laser Surgery and Medicine, Chennai ,28th – 30th August 2001.

14. Continuing Medical Education – Age Related Macular Degeneration and modalities of treatment including Transpupillary Thermotherapy and Photodynamic Therapy , Rotary Narayana Sankara Nethralaya, Kolkata, 18th June, 2003

15. 6th International Advanced Vitreoretinal Surgery Course, Chennai, 24th-26th  July, 2003

16. National Advisory Board for PDT Meeting , Dubai , UAE, 25th-, 26th September, 2004

17.  25th Annual Bombay Ophthalmic Association Meeting, Mumbai, 5th-6th December, 2004

18. 20th Asia Pacific Academy of Ophthalmology Congress, Kuala Lumpur, Malaysia, 27th-31st March,2005


19. 7th International AMD Congress, Marbella, Spain, 18th-20th October, 2007.

20. 17th Annual Conference of the Vitreo-Retinal Society of India, Kolkata, 4th- 6th December, 2008.

21. 4th Indian AMD Congress, Mumbai, 18th-19th April, 2009

22. 9th International AMD Congress, Athens, Greece, 9th-10th October, 2009.

23. 18th Annual conference of the Vitreo-Retinal society of India, Palampur, 25th to 28th November, 2009.

24.  68th Annual All India Ophthalmological Conference, Kolkata, 21st to 24th January, 2010.

25. Diabetic retinopathy – from bench to population, Conference of the Association for Research in Vision and Ophthalmology and Sankara Nethralaya, Chennai, 9th to 11th September, 2010.

26.  69th Annual All India Ophthalmological Conference, Ahmedabad, 3rd to 6th February, 2011

27. The annual conference of the Uttarakhand State Ophthalmologic Society, Dehradun , 7-9th October, 2011

28.  70th Annual All India Ophthalmological Conference, Cochin, 2nd to 5th February, 2012

29. 6th Indian AMD Congress, Dubai, 14th July, 2012.


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