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   Table of Contents - Current issue
September-December 2019
Volume 31 | Issue 3
Page Nos. 175-255

Online since Tuesday, December 31, 2019

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Looking back p. 175
VA Bastin
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Small incision lenticule extraction – Current perspective p. 176
Gitansha Shreyas Sachdev, Shreyas Ramamurthy
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Ciclosporin A in ophthalmology: A systematic review p. 182
Kaberi Biswas Feroze
Aim: To systematically analyse data from randomized controlled trials of topical Ciclosporin with the aim of assessing the uses and effectiveness of Ciclosporin in different conditions, optimal dosage and adverse effect profile. Methods: 24 RCTs that had evaluated the uses and efficacy of Ciclosporin in different ocular conditions were selected and were used in this review. Articles published upto December 2018 were identified from the following sources- Medline, Scopus, Web of science and references from relevant articles. Results: The average JADAD score was 3.16. Symptomatic relief and objective improvement of ocular signs were noted in most cases of allergic eye disease, moderate to severe dry eye disease and lid margin inflammatory disease. It was also found to accelerate post surgical corneal nerve healing and recovery of corneal sensation. It was not effective in post keratoplasty graft rejection. Adverse effects reported were minimal and included symptoms like ocular stinging. Conclusions: Even though topical Ciclosporin A is an attractive treatment option in many ocular conditions, more structured RCTs are needed to standardize the dose and provide a detailed adverse effect profile.
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Intraocular lens power calculation in 2019: The cutting edge Highly accessed article p. 191
Prashob Mohan, Arup Chakrabarti
In today's world, with the developments in technology to measure ocular biometric parameters more accurately and the availability of sophisticated methods for intraocular lens (IOL) power calculation, cataract surgery has become no less than a refractive surgery. This along with free and easy access to information regarding the latest technology has heightened patient expectations. The demand for a spectacle-free life after cataract surgery is higher than ever. Newer advances in optical biometry, including swept-source optical coherence tomography technology, supplemented by the availability of highly accurate IOL power calculation formulae including ones that use artificial intelligence have the potential to enable surgeons to achieve near-perfect outcomes in majority of their patients. To hit the bull's eye as far as target refraction is concerned, it is necessary to understand the benefits and limitations of currently available cutting edge technology and formulae and apply them to the cataract surgery practice.
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Ocular biometry p. 202
Sanitha Sathyan
The evolution of cataract surgery to a refractive procedure owes a lot to the advances in the field of ocular biometry. Advanced biometry machines and choice of intraocular power formulae have hugely improved the accuracy of measurements and visual outcomes of the patient. This section explores the recent trends and practice patterns in ocular biometry.
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Comparison of topographic indices and corneal higher order aberrations in eyes with an extreme asymmetry of keratoconus with control eyes p. 206
Zalak A Shah, Shwetambari G Singh, Dipali M Purohit
Purpose: To compare topographic indices and anterior corneal higher order aberrations (HOAs) of forme fruste keratoconus (KC) (fellow eyes) with clinical KC and control eyes. Setting: Tertiary Eye Hospital, India. Materials and Methods: This study retrospectively reviewed 298 patients with KC. Patients were evaluated with placido-based topographer. KC was diagnosed according to Rabinowitz and McDonnell criteria and clinical sign. Twenty-one patients with clinical KC in one eye (Group A), fellow eye (Group B) with normal topography with no clinical sign, and 21 control eyes (Group C) were included in the study. Topographic indices (keratometry, inferior superior ratio, irregularity, shape factor, and eccentricity) and HOAs (trefoil, coma, spherical aberration, total root mean square [RMS], HOAs RMS of third to seventh order for 6 mm diameter) were obtained. Group B was compared with Groups A and C. Results: The prevalence of an extreme asymmetry of KC in our study population is 7.04% with mean age of 21.98 ± 7.39 years. All topographic indices were higher in Group A compared to Group B (P < 0.01) and no significant difference was found between Groups B and C. All HOAs were higher in Group A compared to Group B (P < 0.05). HOAs RMS, oblique trefoil and spherical aberration were significantly higher in Group B compared to Group C (P < 0.02). Of these 21 patients, four had severe to advanced KC in one eye. Conclusions: Corneal HOAs changes are first to appear in fellow eyes of unilateral KC, which may makes them useful tool in monitoring progression and early detection of KC changes in fellow eyes.
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A comparative analysis of ocular biometry in acute and chronic presentations of primary angle-closure glaucoma p. 212
Saritha Valsala Krishnankutty, Gargi Sathish, Padmasree Kamalakshy Madhavan, Vijayamma Narayani
Purpose: Primary angle-closure glaucoma is the predominant form of glaucoma in the Asian population and is a leading cause of blindness. The objective of the study was to compare ocular biometric parameters among acute and chronic presentations of the disease. Materials and Methods: Sixty eyes of sixty patients diagnosed as having either acute (Group A) or chronic presentation (Group B) were studied. Those patients with a history of uniocular pain, headache, defective vision, along with high intraocular pressure (IOP 35 mmHg), shallow AC, and mid-dilated nonreactive pupil were classified as the acute variety. Chronic form was diagnosed in eyes with peripheral anterior synechiae of >180° with a chronically elevated IOP with disc and field changes. Patients with history of intraocular surgeries or trauma, secondary angle closure, active keratitis, or corneal opacities were excluded from the study. Contact ultrasonic biometry was used for measuring axial length, AC depth, and lens thickness. Lens-axial length factor (LAF) and relative lens position (RLP) were calculated. Statistical Analysis: Chi-square test and Independent sample t-test as applicable. Results: Group B patients were significantly older with a male predominance as compared to Group A. Lens thickness and LAF were significantly higher in Group A whereas axial length and AC depth were significantly lower in Group A (P < 0.001). RLP, keratometry, pachymetry, best-corrected visual acuity, and spherical equivalents were comparable in both groups. Conclusion: It is concluded that the mechanism of acute form of primary angle-closure disease can be explained by the ocular biometric parameters alone with possibility of some additional mechanism for the chronic presentation.
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Correlation between pterygium and dry eye p. 217
Aruna Kumari R. Gupta, Yashvi Nathwani
Objective: The aim of this study is to evaluate the correlation between dry eye and pterygium. Materials and Methods: A total of 50 patients, aged between 26 and 70 years, were included in this study. Tear film breakup time (TF-BUT) and Schirmer's test (ST) results were compared in pterygium eye and contralateral normal eye of the same patient. TF-BUT and ST results were compared in pterygium eye and contralateral normal eye for different sizes. The paired t-test was used for the analysis. The Pearson correlation was used to assess the correlations of tear BUT and ST with pterygium size. Results: The mean horizontal size of pterygium ± standard deviation (SD) was 2.35 ± 0.54 mm. The mean ± SD of TF-BUT in pterygium eyes was 7.1 ± 2.34 s compared with 9.18 ± 3.21 s in contralateral normal eyes (P < 0.05). The mean ± SDs of ST results in pterygium eyes and the opposite normal eyes were 8.96 ± 2.66 and 10.94 ± 3.88 mm, respectively (P < 0.05). On analysis, the overall difference in the mean TF-BUT between the pterygium eyes, and the contralateral control eyes was significant (P < 0.01). The difference in the ST between the pterygium eyes and the contralateral eyes was not significant for size < 1 (P = 0.17) and 1-2 (P = 0.4) but was highly significant for size <2 mm (P < 0.001). Most patients with pterygium complained of mild-to-severe ocular discomfort. Ocular Surface Disease Index score was found to be 30.6. Conclusion: Results of the present study strongly suggest that pterygium induce abnormal ocular surface conditions, which lead to dysfunctional TF and development of the dry eye.
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Brittle cornea syndrome p. 221
Rani Menon, Sharika S Menon
Brittle cornea syndrome is a rare generalized connective tissue disorder associated with extreme corneal thinning and other features such as blue sclera, keratoconus, keratoglobus, and high myopia. In this report, the mother and both the children had blue sclera of varying intensity along with corneal thinning in the children which was measurable only in the elder sibling.
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Allergic fungal sinusitis presenting as optic neuritis: A diagnostic dilemma p. 225
R Neena, Mathew Dominic
Aim: To familiarize ophthalmologists with the rare but potentially vision-threatening complication of optic neuritis from allergic fungal sinusitis. This is a case report of a healthy young female who presented with rapidly deteriorating vision and clinical features of acute optic neuritis of the left eye. Computerized tomography of the brain and orbits revealed an invasive bilateral sphenoid sinus mass with encasement of the left optic nerve, bone erosion, and intracranial extension. Ear, nose, and throat examination revealed nasal polyposis with sinusitis. Endoscopic biopsy revealed extensive allergic fungal debris filling sinuses and eroding the medial end of the optic canal on left side suggestive of allergic fungal sinusitis. An emergency functional endoscopic sinus surgery and optic nerve decompression followed by systemic steroid therapy restored her vision. The culture of the nasal biopsy grew Aspergillus fumigatus.
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Bilateral endogenous endophthalmitis – An excellent visual outcome p. 228
Balbir Khan, Rajwinder Kaur
We report a case of a young female patient presenting with bilateral endogenous endophthalmitis (EE) following meningitis due to Neisseria meningitidis with excellent visual outcome. A young 35-year-old female presented with chief complaint of decreased vision in both eyes (right eye more than left eye). On presentation, best-corrected visual acuity (BCVA) was <20/400 in the right eye and <20/120 in the left eye. The patient had a history of fever for which she was admitted in the hospital with the diagnosis of bacterial meningitis and received intravenous fluids with course of intravenous antibiotics. Four days after discharge from the hospital, she noticed diminution of vision; on ocular examination, the anterior segment was normal, and vitritis was present in both the eyes with multiple retinal exudates in between two arcades. Fundus fluorescein angiography and optical coherence tomography (OCT) were done. Diagnosis was made based on clinical profile secondary to bacterial meningitis. She was started on oral antibiotics for 1 week and oral steroids. The patient was kept on follow-up visits at 1 day, 1 week, 2 weeks, and monthly up to 6 months. BCVA, intraocular pressure, complete slit-lamp examination, indirect ophthalmoscopy, fundus photo, and OCT were done on each visit. She responded well to the treatment, with BCVA on the final visit being 20/80 (right eye) and 20/20 (left eye), and macular edema resolved in both eyes on the final visit. To conclude, EE is a rare complication following meningitis due to Neisseria meningitis which if diagnosed promptly and managed effectively can have a favorable prognosis.
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Case report: Biometry in air-filled eye following retinal surgery p. 232
Mukesh Kumar, Abhishek Varshney
A 70-year-old male patient presented with vitreous hemorrhage in his right eye, for which he was advised for pars plana vitrectomy and endolaser. During the surgery, there was inadvertent contact with the crystalline lens with one of the intraocular instruments. This was reported as an intraocular complication. Postoperatively, cataract was developed in his right eye due to lens touch. An early cataract surgery was planned. A scan was done in phakic eye on day three after first surgery, which showed axial length 28.7 mm. On the postoperative day 10, axial length was 22.25 mm using contact method. Surgery was delayed for 4–5 days due to this. No A Scan machine has software for axial length and correct lens power calculation in air-filled eyes following retinal surgeries. A scan machine does not have information or software to calculate intraocular lens power in air-filled eyes after retinal surgery. This information will be helpful in planning early cataract surgeries if required after retinal surgery.
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Bilateral astrocytic hamartoma in retinitis pigmentosa: A rare association p. 235
Gursatinder Singh, Ekta Syal, Divya Tara, Jashandeep Singh
Astrocytic hamartomas are benigh tumors that arise in retina and / or optic nerve anterior to lamina cribrosa (optic nerve head). Hamartomas can be solitary or may be associated with phakomatosis. A 15 year-old patient presented with complaint of night blindness since childhood. Ocular examination showed pigmentary retinopathy at mid peripheral retina with superficial globules at optic nerve head margin in both eyes. Multimodal imaging was done to diagnose it as astrocytic hamartoma. Systemic examination revealed profound sensorineural hearing loss. Family history was positive for retinitis pigmentosa. This case report describes the rare association of astrocytic hamartomas with retinitis pigmentosa..
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Medical hackathon – The beginning of smart innovation p. 239
Ashish Ahuja, John Davis Akkara, Shana Sood, Rohit R Modi, Zain Khatib, Lavina Uttamani
The last decade has seen an innovation boom across the nation and what is special is that these hack inventions are not just creative, they are tailor made to suit our Indian scenario. Doctors are the most trained health care providers of any nation and it is time that we realize that the responsibility of innovation heavily lies on our shoulders too. MedHacks is the start, with a focus on Smart Innovations that are efficient, cost effective, user friendly and 'take to field' portable, this initiative is one of its kind. These frugal innovations pave the path to healthcare access for all. A Medical hackathon is an event in which people from various backgrounds such as clinicians, engineers, designers and software developers come together in an intense three-day workshop to develop solutions that address challenges facing healthcare today. Participants form teams, collaborate within a limited time frame, and focus on a specific health care problem to come up with ideas or solutions. In this manuscript we will be discussing 2 such hackathon events that were conducted in the past during the conferences and the device prototypes developed during these events.
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Smartphone apps for visually impaired persons p. 242
John Davis Akkara, Anju Kuriakose
As ophthalmologists, we often come across visually impaired persons (VIPs) whose poor vision we cannot improve. They would benefit with low-vision aids (LVA), but most are reluctant to use them. The visually impaired find it difficult to use advanced technology, as it is often not designed with them in mind. When the world switched from phones with keyboards to full-screen touchscreens, VIPs found it difficult without the tactile feedback of physical keyboard buttons. However, in recent years, there have been numerous innovative apps to assist people with low vision, to not only navigate their smartphone but also their environment and daily life. Programmers have made the use of the high-resolution cameras, gyroscope sensor, vibration feedback, and audio feedback to convert smartphones into LVA, often for free and with no additional hardware. The authors review some of the smartphone apps available for those with low vision. These apps can bring a certain level of independence and self-confidence in these people who are otherwise often dependent on others.
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Journal review p. 249
Deepa Nanu
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Retinal drawing p. 251
Shahnas Valappil, Anupama Jayan
Retinal drawings are important to document pathology, which help to compare the changes in pathology in follow-up visits, help in better communication when more than one physician is dealing the case, and help in easy follow-up of disease course with a glance. In retinal drawings, the instructor can monitor students – areas of omission and confusion can be detected. They are advantageous over photographs – they are less expensive, provide immediate record, and highlight details that are difficult to photograph and finally help you medicolegally.
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A case of bilateral congenital ectropion p. 255
Amol Ganvir, Nayana Potdar, Chhaya A Shinde
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