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   Table of Contents - Current issue
Coverpage
January-April 2020
Volume 32 | Issue 1
Page Nos. 1-106

Online since Friday, April 17, 2020

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EDITORIAL  

How and where we begin – Ethical publication p. 1
V Sudha
DOI:10.4103/kjo.kjo_8_20  
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GUEST EDITORIAL Top

Postgraduate residency training in ophthalmology: An overview p. 3
Charles Skariah
DOI:10.4103/kjo.kjo_7_20  
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PERSPECTIVES Top

COVID-19 – Perspectives from an ophthalmologist's point of view Highly accessed article p. 6
V Sudha, K Ajithkumar
DOI:10.4103/kjo.kjo_32_20  
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OPHTHA INSTA Top

Cartwheel-like appearance of a variant of congenital zonular (lamellar) cataract p. 8
Bharat Gurnani, Kirandeep Kaur, Arthi Mohankumar, Veena Kannumsamy, Prasanth Gireesh
DOI:10.4103/kjo.kjo_93_19  
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MAJOR REVIEWS Top

An update on thyroid eye disease: Current knowledge, preferred practice patterns, and future therapies Highly accessed article p. 10
Fairooz P Manjandavida, Shaifali Chahar
DOI:10.4103/kjo.kjo_87_19  
Thyroid-associated ophthalmopathy (thyroid eye disease [TED], thyroid-associated orbitopathy, or Graves' orbitopathy) is the most common, yet a complex and poorly understood autoimmune orbital pathology. It occurs in association with systemic dysthyroid states, most commonly presenting with hyperthyroidism, but also occurs in association with hypothyroidism or euthyroidism. Despite the ongoing research, the pathogenesis and effective treatment strategies remain obscure, hence presenting a challenge for the treating ophthalmologist. The ocular presentation can vary from mild disease to severe irreversible sight-threatening complications. Ocular manifestations can follow the thyroid dysfunction, present parallel to it, or seldom precedes it. The ocular disease has its own natural course divided into an active and inactive phase. Scoring individual patients for the severity of disease has been frequently revised. The clinical examination, activity, and severity aid the ophthalmologist to decide the stage of the disease and come up with the treatment strategy for each patient. Management strategies include a multidisciplinary team effort. Recently, we have witnessed a leap to newer targeted biologic therapy that not only improves the course of the disease but also the quality of life of these patients. In this review, we present an update of the current understanding of etiopathogenesis, clinical features, and management options for this common yet challenging orbital inflammatory disease.
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Cerebral visual impairment in children p. 27
Geetha V.K.P.
DOI:10.4103/kjo.kjo_25_20  
Cerebral visual impairment has gained importance due to increased survival of extremely premature babies. It encompasses visual processing dysfunctions due to disorders of the retrochiasmal pathways and visual association areas. This review describes the physiology of visual processing, clinical approach to children with Cerebral Visual Impairment, and principles of intervention. Functional vision assessment and vision intervention strategies are given emphasis. We have to ensure that these children are able to use vision for learning, for social interaction, and mobility. A literature review was undertaken using Medline and PubMed.
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ORIGINAL ARTICLES Top

Prostaglandin-associated periorbitopathy: A prospective study in Indian eyes Highly accessed article p. 36
M Manju, Marian Pauly
DOI:10.4103/kjo.kjo_90_19  PMID:32317411
Context: Prostaglandin analogs (PGAs) are commonly used antiglaucoma medications in the current era. The purpose of this study is to monitor the periorbital changes in patients started on topical PGA. Aim: The aim of this study is to study the periorbital changes in patients on PGA eye drops. Settings and Design: It is a prospective, uncontrolled, nonrandomized study. Subjects and Methods: During the initial visit, periorbital area was assessed by ptosis, proptosis, and lash length measurement. Color photography of periocular area was taken using a well-illuminated background for documentation and comparison. All the clinical assessments and color photography were repeated after 6 months. Statistical Analysis Used: Data were analyzed using the SPSS software version 16.0 and Microsoft Excel 2007. Results: Six eyes (9.5%) in the initial evaluation and 22 eyes (34.9%) in the follow-up visit showed periocular hyperpigmentation. There was a statistically significant increase in periocular hyperpigmentation with a P < 0.001. Two eyes in the initial evaluation and 23 eyes in the follow-up visit had deepening of the upper eyelid sulcus (DUES). There was a statistically significant increase in DUES with a P < 0.001. Of 63 eyes, 41 eyes (65%) developed prostaglandin-associated periorbitopathy (PAP) at the end of 6 months, and there is a statistically significant increase in the development of PAP after 6 months' P < 0.001. Conclusions: This study demonstrated a statistically significant increase in periorbital changes within 6 months of PGA use. Patients should be informed about the periorbital changes that could happen, and their cosmetic concerns should be addressed properly.
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Clinico-microbiological profile of orbital and periorbital infections p. 41
KN Anupama, S Bindu, PT Jyothi
DOI:10.4103/kjo.kjo_1_20  
Context: Orbital and periorbital infections represent a spectrum of sepsis that carries significant morbidity and mortality. Knowledge of the trend of the type of organisms and their antibiotic susceptibility will help in the institution of appropriate therapy. Aim: The aim of the study was (1) to determine the common pathogens causing orbital and periorbital infections and their in vitro antibiotic sensitivity. (2) To find the correlation between the type of infection, organism isolated, and culture positivity. Materials and Methods: This was a descriptive cross-sectional study for a period of 1 year. Eighty-six patients who presented with orbital and periorbital infections were included in the study. Conjunctival swab or pus aspirate whenever available was taken for gram stain and culture and sensitivity. In vitro antibiotic sensitivity of the organisms isolated was determined. Statistical Analysis: The statistical analysis was done using SPSS version 18 software. Results: The most common infection was orbital cellulitis (34.9%). About 44.12% of swabs were culture positive, and the most common organisms isolated were Staphylococcus aureus and methicillin-resistant S. aureus in our study. The highest in vitro antibiotic susceptibility was to amikacin and gentamicin in this study. Conclusion: This study helped in identifying common causative organisms of orbital and periorbital infections and their antibiotic sensitivity. It indicates the need for modifying our empirical antibiotic therapy, indiscriminate use of which may lead to antibiotic resistance. Periodic surveillance of antibiotic resistance will help to implement interventions to limit the emergence and spread of antibiotic resistance in the community.
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Relationship between myopia and central corneal thickness – A hospital based study from South India p. 45
K Divya, M Raaja Ganesh, D Sundar
DOI:10.4103/kjo.kjo_95_19  
Background and Purpose: The prevalence of myopia has been increasing steadily, and studies on the relationship between myopia and central corneal thickness (CCT) have shown conflicting results. The purpose of this study was to investigate the relationship between myopia and CCT in a hospital based population from South India. Materials and Methods: This prospective, cross-sectional study was carried out from a tertiary care institution in South India between January 2017 and June 2018. One hundred and ninety-four myopic individuals between 11 and 40 years of age with spherical equivalent (SE) ranging from -0.5 to -6 Diopters after cycloplegic refraction were enrolled in the study. CCT was measured in both eyes of each patient using Tomey EM-3000 noncontact specular microscope (Tomey Corporation, Nagoya, Japan). The relation between CCT and myopia was analyzed using Pearson's correlation coefficient. Statistical significance was set at P < 0.05. Results: A total of 388 eyes were analyzed. 50% (n=97) of study participants were females. The mean age of the study participants was 25.47 ± 7.25 years (range: 12–40 years). The mean SE was −-2.79±1.34 D (range: -0.5 to -6.0 D). The mean CCT was 540.53 ± 56.16 μm (range: 441–664 μm). No significant association was observed between CCT and age or gender of the study participants (P = 0.706 and 0.550, respectively). No correlation was observed between mean CCT and SE (Pearson, r = 0.095,P = 0.062). Conclusion: There was no correlation between CCT and degree of myopia. These data contribute to the ongoing discussion on the structural alterations in ocular coats and susceptibility to glaucoma in myopia.
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Microbial profile of lid margin flora in anterior blepharitis as compared with normal: A comparative, descriptive study p. 51
Merie Mathew, Lathika Vasu Kamaladevi, Charles K Skariah
DOI:10.4103/kjo.kjo_9_20  
Context: Blepharitis is a condition that causes inflammation of the eyelids, and identification of the common bacterial pathogens along with its antibiotic susceptibility pattern is essential. Aims: The aim of this study is to identify the lid margin flora in a cohort with anterior blepharitis and to compare the microbiological profile with age-matched controls and determine the antibiotic sensitivity pattern of the flora identified. Settings and Design: A comparative, descriptive study was conducted in the Department of Ophthalmology, Amala Institute of Medical Sciences, Thrissur, Kerala, India, over a period of 18 months. Subjects and Methods: The specimen for the microbial study was collected from the concerned eyelids. Smear was prepared, and primary culturing was done to identify the organism, and antibiotic susceptibility testing was performed. Statistical Analysis Used: Statistical Package for the Social Sciences software (version 23) Amala Institute of Medical Sciences, (Thrissur) was used for the statistical analysis. Results: The predominant age group of cases was 40–60 years, with a female preponderance. The bacteria isolated from cases in the order of decreasing frequency were coagulase-negativeStaphylococcus aureus(CoNS) (40.74%), coagulase-positive S. aureus (35.18%), methicillin-resistant Staphylococcus aureus(MRSA) (9.25%), and diphtheroids (5.55%) and were comparable with controls. MRSA and parasites were exclusively isolated from the cases. CoNS was highly sensitive to tetracycline (87.5%), gentamicin (87.5%), and chloramphenicol (85.4%). S. aureus was sensitive to chloramphenicol (95.1%), clindamycin (87.8%), and tetracycline (85.4%). MRSA was 100% sensitive to vancomycin and linezolid. Conclusions: Microbes identified in cases were comparable with that of controls. CoNS was the most common isolate followed by coagulase-positive S. aureus. They both showed high sensitivity to chloramphenicol and tetracycline but were resistant to penicillin. MRSA was sensitive to vancomycin and linezolid.
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Efficacy of brinzolamide 1% / brimonidine 0.2% fixed combination versus brimonidine 0.2% / timolol 0.5% fixed combination in patients with primary open-angle glaucoma: A comparative study p. 56
Gursatinder Singh, Harvinder Nagpal, Mandeep Kaur
DOI:10.4103/kjo.kjo_83_19  
Purpose: The aim of the study was to compare the intraocular pressure (IOP)-lowering efficacy of brinzolamide 1%/brimonidine tartrate 0.2% fixed combination versus brimonidine tartrate 0.2%/timolol maleate 0.5% fixed combination.Materials and Methods: A prospective, randomized, comparative, interventional study was conducted on forty patients of primary open-angle glaucoma attending the outpatient department of the department of ophthalmology at a tertiary institution in North India. Patients fulfilling the inclusion criteria and having none of the exclusion criteria were enrolled in the study after obtaining written informed consent. Patients were then randomized into two groups (Groups 1 and 2) with twenty patients in each group. Group 1 patients were given a brinzolamide 1%/brimonidine tartrate 0.2% fixed drug combination (BBFC) one drop twice daily and Group 2 patients were given a brimonidine tartrate 0.2%/timolol maleate 0.5 % fixed drug combination (BTFC) one drop twice daily for 6 weeks, and IOP was recorded at baseline and after 6 weeks at 9 am and 11 am.Results: The mean age was 61.05 years in Group 1 and 60.20 years in Group 2; there were 11 males in Group 1 and 14 males in Group 2, and the rest were female. Baseline mean IOP values were similar among treatment groups at all time points. At 6 weeks, the mean IOP of Group 1 was 18.32 mmHg and Group 2 was 18.45 mmHg with a reduction of 7.58 mmHg (29.26%) and 8.15 mmHg (31.83%) in Group 1 and Group 2, respectively. The difference in the IOP lowering at the end of the study between the two groups was not statistically significant (P > 0.05). Conclusion: Our study shows that BBFC seems to be an effective, safe, noninferior, and β-blocker-free fixed combination.
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Early detection of retinal changes in patients using hydroxychloroquine – An optical coherence tomography-based study p. 60
Aiswarya Sasidharan, Anthrayos C.V. Kakkanatt, Mercy Paul, Francy Louis, Arino John
DOI:10.4103/kjo.kjo_91_19  
Background: Hydroxychloroquine (HCQ) is an antimalarial drug, which is now the mainstay treatment for autoimmune diseases. HCQ retinopathy is rare, but it is generally irreversible and can progress even after cessation of drug therapy. The screening tests recommended are dilated fundus examination, color vision, and Humphrey 10-2 visual fields. Now, it is recommended that at least one of the newer modalities such as multifocal electroretiogram and spectral-domain optical coherence tomography (SD-OCT) be used according to availability. The present study is to evaluate the early retinal toxic effects of HCQ using SD-OCT before the symptomatic visual loss or fundus changes have occurred and to assess the correlation between HCQ cumulative dose and effects on the retina. Materials and Methods: A comparative cross-sectional study was performed in 132 patients (66 cases and 66 controls). Macular thickness in nine segments, ganglion cell-inner plexiform layer (GC-IPL) thickness in six segments was assessed using Cirrus HD-OCT and compared with the control group. HCQ cumulative dose was calculated and compared with the retinal thickness. Results: Macular thickness showed statistically significant thinning in six out of nine segments. GC-IPL thickness showed thinning in all six segments. A significant negative correlation was obtained on comparison of HCQ cumulative dose and GC-IPL and macular thickness average. Conclusions: SD-OCT can be used for detecting retinal thinning and GC-IPL thinning in patients on HCQ to detect early structural and functional changes in retina due to HCQ toxicity before any visual symptoms or fundus changes occur.
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SURGICAL CORNER Top

CM T - FLEX IOL an innovative design for subluxated lens secondary to trauma p. 66
M Nivean, Pratheebadevi Nivean, Shruti Nishanth, P A. P. Aysha
DOI:10.4103/kjo.kjo_77_19  
Here, we report a case of a 42-year-old male who came with complaints of blurring of vision in the left eye since 3 months which was progressive in nature. He gave a history of road traffic accident 7 months back following which he developed defective vision. On examination, his unaided visual acuity in the right eye was 6/9 and left eye was 3/60 with pinhole improvement of 6/9 and subluxated cataractous lens in the left eye. He was managed with pars plana lensectomy, vitrectomy, and new foldable Acryflex-T intraocular lens (IOL) (CM T-FLEX) scleral fixated IOL. Two partial-thickness limbal-based scleral flaps of 2.5 mm × 2.5 mm were created 180° apart; sclerotomies were made using 23 gauge needle 1.5 mm away from the limbus. The new Acryflex T–Flex IOL implantation was performed through the 2.8 mm clear corneal incision, and specially designed T-shaped IOL haptics were externalized with the 23 gauge PraNiv T Flex forceps under the scleral flap. Fibrin glue was used to close the scleral flaps and conjunctiva. Postoperative period was uneventful; at the end of 1-month, the patient regained a best-corrected visual acuity of 6/6 with good stable centration of IOL.
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CASE REPORTS Top

Optic nerve hypoplasia with sixth nerve palsy p. 70
C Vidhya, Kanika Gupta
DOI:10.4103/kjo.kjo_50_19  
Optic nerve hypoplasia (ONH) can occur as an isolated anomaly or in association with various ocular abnormalities, cranial abnormalities (agenesis of septum pellucidum, anencephaly, and midline abnormalities of brain), or facial anomalies. Here, we present a case report of ONH with sixth cranial nerve palsy, which has never been reported in literature.
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Repositioning of inadvertent intralenticular ozurdex p. 73
Naresh Babu, Piyush Kohli, Madhu Shekhar, Kim Ramasamy
DOI:10.4103/kjo.kjo_46_19  
With increasing availability and acceptability of intravitreal injections for various pathologies, the number of patients undergoing intravitreal injections has grown exponentially, hence increasing the risk of accidental trauma to the crystalline lens. One of the gravest and rarest complications is the inadvertent intralenticular implantation of ozurdex implant, causing immediate cataract formation. As available resources in the developing countries are limited, aim of the cataract surgery should be to reposition the same implant in the vitreous cavity, through the preexisting posterior capsular dehiscence, and placing an intraocular lens to prevent anterior migration of the implant. Due to the presence of posterior capsular dehiscence, some amount of lens matter may drop into the vitreous and can invoke postoperative uveitis and raised intraocular pressures. We report such a rare case of accidental intralenticular injection of ozurdex implant, our unconventional surgical approach and the long-term follow-up.
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Sonologic similarity in the differential diagnosis of pediatric neovascular glaucoma p. 76
Rajalakshmi Selvaraj, Nirupama Kasturi, Niroj Kumar Sahoo
DOI:10.4103/kjo.kjo_17_20  
B-mode ultrasonography is widely used in ophthalmology to assess the retina and vitreous when there is a media opacity or very small pupil size, which prevents direct examination of fundus. Unlike other specialties which request radiologists to perform ultrasonography as part of their investigation, we ophthalmologists are able to perform B-scan by our side of the department as and when required. Here, we report a pediatric case in which B-scan happened to be done by the radiologists; further details enhanced with Doppler uptake resulted in a diagnostic dilemma to both ophthalmologists and radiologists. A 10-year-old male child presented with severe pain and redness in the left eye with repeated vomiting. Ocular examination revealed neovascular glaucoma in the left eye with an absent perception of light. Ultrasound B-scan performed by a radiologist showed a linear hyperechoic structure extending from the posterior aspect of the lens to the optic disc with Doppler uptake, which they suggested as a possibility of persistent hyperplastic primary vitreous (PHPV). However, evaluation of previous treatment records revealed an earlier diagnosis of circumscribed choroidal hemangioma with bullous retinal detachment. Evaluation of pediatric neovascular glaucoma thought about as PHPV yielded a surprising diagnosis of choroidal hemangioma with retinal detachment. Hence, the latter needs to be kept in mind, although the radiological findings mislead to diagnose PHPV.
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PHOTO ESSAY Top

Allergic conjunctival granuloma with Splendore–Hoeppli phenomenon p. 80
Sushma Ananthakrishna, Marian Pauly
DOI:10.4103/kjo.kjo_88_19  
Allergic conjunctival granuloma (ACG) or Splendore–Hoeppli phenomenon (SHP) (asteroid bodies) is characterized by microorganisms (fungi, bacteria, and parasites) or biologically inert substances surrounded by radiating intensely eosinophilic material thought to be due to the deposition of antigen–antibody complexes and debris from the host inflammatory cells. Noninfective pathologies (hypereosinophilic syndrome and ACGs) demonstrate this phenomenon occasionally. The purpose of this case report is to report a case of ACG with SHP in a 59-year-old female with a presumed noninfectious etiology which completely resolved with surgical excision.
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INNOVATION Top

Custom-made three-dimensional-printed adapter for smartphone slit-lamp photography Highly accessed article p. 83
Ahmed Ateya, John Davis Akkara, Anju Kuriakose
DOI:10.4103/kjo.kjo_12_20  
In this article, we introduce a custom-made smartphone slit-lamp adapter that is designed by one of the authors and made using three-dimensional (3D) printing technology. It is built upon a commercially available part used in selfie sticks and tripods which is used to hold the phone. The rest of the adapter is designed and 3D printed to enable attaching the mobile with that holder to the selected eyepiece. The design depends on each slit-lamp or microscope eyepiece dimensions, and the idea is about making a complementary design that automatically fits the eyepiece which slides in the adapter and then the mobile weight and gravity do the rest to hold the adapter in place. Within few seconds of sliding the phone into the adapter, place the camera against the eyepiece then you are ready to go. It is named blink to allude to its ease of use and quick adjustment like in a blink of an eye.
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CLINICAL CHALLENGE Top

Concerns in the surgical treatment of intermittent exotropia p. 87
Sanitha Sathyan
DOI:10.4103/kjo.kjo_28_20  
Management of intermittent exotropia raises several concerns, regarding the indication for surgery, timing of the surgery, and the type of surgical procedure. This article attempts to highlight the controversial aspects of surgical management of intermittent exotropia and the consensus, in light of current evidence.
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Commentary on Concerns in the Surgical Treatment of Intermittent Exotropia p. 89
R Muralidhar
DOI:10.4103/0976-6677.282655  
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HISTORY CORNER Top

Story of the first human fluorescein angiogram p. 91
C Biju John
DOI:10.4103/kjo.kjo_11_20  
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JOURNAL REVIEW Top

Journal Review p. 94
Deepthi John
DOI:10.4103/kjo.kjo_22_20  
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PG CORNER Top

Scraping in corneal ulcers p. 97
Nadhna Basheer
DOI:10.4103/kjo.kjo_10_20  
Corneal scars resulting from central corneal ulcers are one of the major causes of blindness in developing countries. It is regarded as the second most common cause of preventable monocular blindness in some of the tropical countries. Corneal scraping is the most valuable specimen in cases of corneal ulcer, and its examination is the mainstay in the diagnosis and subsequent management.
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LETTERS TO THE EDITOR Top

Dilemmas in preoperative ocular biometry calculations p. 102
Rose Mary Tomy
DOI:10.4103/kjo.kjo_16_20  
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Reply to queries on ocular biometry p. 103
Prashob Mohan, Arup Chakrabarti
DOI:10.4103/kjo.kjo_19_20  
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Simple and novel technique for pupillary light reflexes p. 105
VP Ravichandran, PR Aswin
DOI:10.4103/kjo.kjo_18_20  
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