Commentary: An insight into the preferred practice of vitreoretinal specialists of India: Medical retina

With the advent of science, our understanding regarding various ocular diseases has improved. This advance has also opened new avenues of management of these diseases with no overall consensus of preferring one modality over the other. In such situations, a standard of care needs to be established but this itself has its own hurdles. Major review articles or meta-analysis usually consist of western data and we know that this may not apply to the real-world settings, especially for a country as diverse as India. In such a situation, it is impertinent for a prestigious society such as vitreoretinal society of India to put forward its preferred practice patterns not only for management but also regarding the investigations required.

It is clear from the responses the preferred practice patterns for central serous chorioretinopathy (CSCR). Observation remains the gold standard for acute CSCR. Acute CSCR is investigated further using fluorescein angiography once it persists for more than 3 months. Although the use of Optical coherence tomography – angiography( OCT-A) may be limited in small practices, it provides a definite advantage in patients who develop secondary Choroidal neovascular membrane (CNVM) as a dye-less procedure. Interpretation of the OCT-A is much more challenging and may require years of practice but is one skill worth acquiring. Photodynamic therapy is an underutilized modality for management of chronic CSCR, mainly due to its financial burden. Although anti-Vascular endothelial growth factor (VEGF) treatment has been used for chronic CSCR, its utility remains speculative and should be reserved for patients with a secondary CNVM.

In case of Polypoidal choroidal vasculopathy (PCV), anti-VEGF monotherapy remains the mainstay of treatment with over-the-counter use of bevacizumab as the preferred anti-VEGF despite the clear benefit provided by aflibercept.[1] Use of PDT is largely used as rescue therapy once monotherapy with anti-VEGF fails and is commonly used for the pachychoroid spectrum of disease.[2] Similar management protocols are used for neovascular Age related macular degeneration (ARMD) with various protocols being tried to minimize the frequency of anti-VEGF. Another common indication for use of anti-VEGF injection is diabetic macular edema and macular edema secondary to vascular occlusion. In patients with refractory macular edema or patients with thromboembolic events following anti-VEGF agents, intravitreal steroids may be used and should be preferred in pseudophakic patients. Financial constraint plays a big role in selection of one agent, and to reduce the financial burden of FDA-approved anti-VEGF, biosimilars like razumab are commonly used but there are still concerns regarding their safety.[3] Similarly, ultrawide field Fluorescein angiography (FA) has its own niche in retinal diseases affecting the periphery such as diabetes mellitus and retinal vascular occlusion.[4] It is one investigation worth investing in for the longer run.

The study published in this issue of the journal adequately provides the different management strategies that are commonly employed in the Indian subcontinent.[5] However, these strategies may differ among the different practices due to their availability. A bigger practice in a metropolitan city can provide a wider range of alternatives for the management of diseases as compared to a small practice in a rural setting. These diversities provide unique challenges to present a unified practice pattern. This study has valiantly tried to overcome these difficulties to provide the preferences of Indian vitreoretinal specialists paving the way for a much more comprehensive practice pattern in the future.