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   Table of Contents - Current issue
Coverpage
May-August 2020
Volume 32 | Issue 2
Page Nos. 107-217

Online since Tuesday, August 25, 2020

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EDITORIAL  

Turning the crisis into an opportunity: Today's tragedy can be, tomorrow's possibility Highly accessed article p. 107
V Sudha
DOI:10.4103/kjo.kjo_52_20  
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GUEST EDITORIAL Top

Referral in ocular trauma p. 110
Kalpana Narendran
DOI:10.4103/kjo.kjo_50_20  
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PERSPECTIVES Top

COVID-19 battle: Measures implemented at a tertiary eye care center in South India Highly accessed article p. 114
Iva Rani Kalita, Harsh Vardhan Singh, Rengaraj Venkatesh, K Veena, Natarajan Vengadesan, K Kalaivendan
DOI:10.4103/kjo.kjo_48_20  
The spread of severe acute respiratory syndrome-coronavirus-2 has already taken on pandemic proportions, affecting over 100 countries in a matter of weeks. A global response to prepare health systems worldwide is imperative. Specific containment measures are needed to reduce the risk of spread while simultaneously maintaining the emergency health services. The purpose of this article is to propose the simple and effective measures implemented in our institution to ensure the minimum risk of COVID spread while taking care of the emergency patients. Effectiveness of these measures is still in the early phase of testing, but in view of lack of personal protective equipment for health caregivers, these measures could be implemented with ease and will be helpful in reducing the risk of exposure in both ophthalmic and nonophthalmic institutions.
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OPHTHA INSTA Top

The mystery of the missing pit p. 126
Neethu Pradeep, N Sujatha, V Sudha, PV Geethakumari
DOI:10.4103/kjo.kjo_61_20  
Foveal hypoplasia refers to the underdevelopment of fovea, characterized by the continuity of the inner retinal layers in the presumed foveal area; the foveal avascular zone may be limited or absent, and retinal vessels may be seen coursing through the foveal region. It is usually associated with aniridia, albinism, achromatopsia, or retinopathy of prematurity. Isolated foveal hypoplasia is a rare clinical entity. We hereby report a case of congenital nystagmus with foveal hypoplasia. Fundus finding in isolated foveal hypoplasia though typical is very subtle and often difficult to detect, especially due to accompanying nystagmus. The presence of nystagmus and poor vision in infants or children without any ocular finding should prompt the ophthalmologist to carry out a thorough fundus examination of the foveal area and to perform an optical coherence tomography to confirm the diagnosis.
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MAJOR REVIEWS Top

Surgeries of the lacrimal drainage system – A review p. 128
Shruthi Tara, Sumeet Gupta, Neha Panickar
DOI:10.4103/kjo.kjo_70_20  
Nasolacrimal system serves as a conduit for tear flow from eye to the nasal cavity. Periodic blinking initiates a pump mechanism, helping in the even distribution of tears over the ocular surface, which then flows into the lacrimal sac and finally to the nasal cavity via the nasolacrimal duct (NLD). Obstruction in this system leads to inadequate tear drainage, which clinically presents as epiphora. Lacrimal outflow system disorders are very annoying to the patients, and sometimes vision threatening. Surgery is a definitive solution for most outflow obstructions, and patients should be counseled accordingly. Chronic use of topical medications for NLD problems is neither cost-effective nor efficacious, but only prolongs agony. This article aims to provide a comprehensive insight into the commonly performed lacrimal drainage surgeries. Literature search using PubMed, Cochrane, and Google Scholar with a combination of various words appropriate to this article was done and relevant articles were reviewed.
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Micropulse diode cyclophotocoagulation: A review of the literature p. 136
Reni Philip, Ronnie George
DOI:10.4103/kjo.kjo_80_20  
Transscleral diode cyclophotocoagulation (CPC) has conventionally been reserved for refractory glaucoma, where other surgery is not feasible. The newer micropulse cyclophotocoagulation (mpCPC) has become popular in recent times and is increasingly being used as a primary surgery for glaucoma in eyes with good vision. The available literature on mpCPC and its mechanism, histological changes caused in the eye, the technique of usage, efficacy, safety, potential applications, and comparison with continuous wave CPC and other surgeries have been reviewed. Varying criteria for inclusion and different definitions of success in studies make a direct comparison between studies difficult. The lack of definite evidence to prove superiority of mpCPC and the potential for rare but reported sight threatening complications should be kept in mind, especially before using this in nonrefractory cases of glaucoma when other time tested options are available.
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ORIGINAL ARTICLES Top

Role of mitomycin C in the management of ocular surface squamous neoplasia p. 143
C Menaka, Venkatesh Perumal, R Shankar
DOI:10.4103/kjo.kjo_20_20  
Background: Ocular surface squamous neoplasia (OSSN) in a broader terminology recently introduced in the field of ophthalmology that includes conjunctival malignancies which ranges from mild epithelial dysplasia to invasive squamous cell carcinoma. The routinely used topical chemotherapy for OSSN is mitomycin C (MMC), 5-fluorouracil, interferon-alpha, and cidofovir, and among these, MMC is usually preferred by most of the ophthalmologists because of its cost-effectiveness and lesser side effects. Aim: The aim of study was to evaluate the role of MMC as an adjuvant therapy intraoperatively and postoperatively in the management of OSSN. Methodology: Patients in the age group of 40 years and above with a diagnosis of OSSN were included as our study subjects. The diagnosis of OSSN was made based on the clinical presentation and the cytological picture. A total of 22 patients with OSSN were taken as our study subjects. The tumor was surgically removed in toto along with 3–4 mm of uninvolved conjunctiva. Further, 0.4 mg/ml of MMC was applied over the excised site. Postoperatively, two cycles of 0.04% MMC eye drops were given for 2 weeks with a dosage of 4 times/day. It is given in two cycles, each cycle lasting for a week with an interval of 1 week in between. Results: Postoperatively, only one patient (4.5%) had recurrence which had developed after 6 months. Patients aged more than 60 years and who had the initial size of the lesion as > 8 mm were more prone to recurrence. Other postoperative complications that had occurred were one patient had allergic conjunctivitis and the other patient had punctate erosion. Conclusion: The use of MMC eye drop in the concentration of 0.04% has shown good clinical results without any serious side effects and with a very less recurrence rate during the follow-up period of 1 year when used as alternate 7-day courses.
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A clinical study on the efficacy of posterior subtenon injection of triamcinolone acetonide in patients with post fever retinitis p. 148
Parvathy Prabhakaran Sreelatha, Pavana Krishnaraj Acharya, Kavitha Chikkanayakanahalli Venugopal, Renuka Sivakiran
DOI:10.4103/kjo.kjo_2_20  
Aims: The aim of this study was to assess the visual outcome and fundoscopic changes following posterior subtenon (PST) injection of triamcinolone acetonide (TA) in patients with post fever retinitis. Settings and Design: This was a prospective interventional study. Subjects and Methods: A prospective interventional study was conducted on 12 patients with post fever retinitis responding poorly to systemic steroids or with contraindications to systemic steroids. Patients were treated with PST injection of 0.5 ml TA (20 mg). They were followed up for 6 months during which best-corrected visual acuity (BCVA), fundus changes, and intraocular pressure (IOP) were evaluated. Statistical Analysis Used: Descriptive statistics and paired t-test were used in this study. Results: All patients had BCVA <6/60 at presentation. Three patients (25%) had retinitis patch alone, five patients (41%) had retinitis with macular edema, and four patients (34%) had retinitis and macular edema in the presence of other features such as vasculitis or disc edema at the time of presentation. On a 6-month follow-up after PST with TA, nine patients (75%) improved to a BCVA of 6/12 or more. One patient improved to 6/18 and two patients improved to 6/24. The mean logMAR visual acuity before PST was 1.349 which improved to a mean logMAR of 0.248 following PST injection with TA (P < 0.001). Six patients (50%) had a total resolution at 6 months, four patients (34%) had a total resolution with atrophic scars, and two patients (16%) had an incomplete resolution. None of the patients had a significant increase in IOP. Conclusions: PST with TA can be considered as an alternative treatment for post febrile retinitis, especially when the response to systemic steroids is poor or in the presence of contraindications to systemic steroids.
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Traumatic glaucoma in 100 consecutive cases of ocular blunt trauma in a tertiary care center p. 154
Anitha S Maiya
DOI:10.4103/kjo.kjo_75_19  
Aim: This clinical study was undertaken to evaluate the profile, mechanisms, and course of traumatic glaucoma (TG) in patients who have sustained blunt ocular trauma. Methods: One hundred consecutive patients who sustained ocular blunt trauma (OBT) during the 1-year were enrolled in the study. All the patients underwent a comprehensive ophthalmic evaluation of the anterior and posterior segments along with relevant investigations. Patients who were found to have an intraocular pressure (IOP) ≥21 mm Hg with or without glaucomatous optic neuropathy were considered to have TG and started on appropriate treatment. Results: Eleven of the 100 consecutive patients who sustained OBT developed TG. The age of patients ranged between 8 and 65 years, 8 were male and 3 female; 6 patients were <18 years of age and hyphema (n = 4) was the most common cause of glaucoma followed by traumatic uveitis (n = 2) and lens injuries (n = 1). The average IOP at presentation was 36 ± 9.6 mm Hg and patients required 1.636 ± 0.8 antiglaucoma medications for IOP control. Three patients underwent surgical intervention for managing the complications of the OBT. Only one of the patients required glaucoma surgery. IOP at the final follow-up was 14.6 ± 2.73 mm Hg. Conclusion: TG tends to occur more commonly in children. Certain markers such as hyphema, lens injuries, and uveitis can predict the possibility of glaucoma. TG if detected early and treated energetically can improve visual outcomes in patients with OBT.
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Peripapillary retinal nerve fiber layer thickness changes after panretinal photocoagulation and its relation with visual acuity changes in patients with diabetic retinopathy p. 159
Souda Chereyeri, Lalith Sundaram
DOI:10.4103/kjo.kjo_6_20  
Background: Panretinal photocoagulation (PRP) is currently the main treatment for proliferative diabetic retinopathy. Optical coherence tomography (OCT) is a noninvasive method of analyzingin vivo retinal architecture. Objectives: The objective was to evaluate the effect of PRP on peripapillary retinal nerve fiber layer thickness (RNFLT) in patients with diabetic retinopathy using OCT and to correlate peripapillary RNFLT changes with the changes in visual acuity (VA). Materials and Methods: This is a prospective study including eighty eyes of eighty patients with proliferative diabetic retinopathy (PDR) and severe non-PDR. PRP was done with frequency-doubled Nd: YAG (532 nm) laser. Peripapillary RNFLT was measured by spectral-domain OCT at baseline and 6 months post-PRP and assessed using paired t-test. The baseline VA and changes in VA 6 months post PRP were recorded. The relationship between RNFL loss and changes in VA was assessed using ANOVA and independent t-test. Results: The mean age of the patients was 60 years, with 65% of males and 35% of females. At 6 months post-PRP, there was a significant reduction in average RNFLT with a reduction in all quadrants, except in the temporal quadrant. According to interval changes of VA, the patients were divided into improved (22.5%), unchanged (48.8%), or worsened (28.7%) groups. Improved VA group showed a significant decrease in peripapillary RNFLT. Conclusion: RNFLT reduction following PRP can be due to axonal loss secondary to the direct or indirect effects of PRP. The extremely mild reduction in the temporal quadrant can be due to the sparing of papillomacular bundle during laser treatment.
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Comparison of the scleral tunnel constructed with crescent versus razor blade using the anterior segment optical coherence tomography p. 166
Sowmya Raveendra Murthy, Priyanka Sudhakar
DOI:10.4103/kjo.kjo_5_20  
Aim: The aim of this study is to compare and contrast the efficacy of a razor blade against crescent, in constructing a scleral tunnel in temporal small-incision cataract surgery (SICS) in a community setup. The following parameters were considered for the comparative analysis: a) Structural anatomical dimensions using the anterior segment optical coherence tomography (ASOCT), b)Tunnel integrity based on the need for suturing or subsequent resuturing and c) Section outcome in terms of any associated tunnel complications. Methods: A prospective, comparative study of 100 consecutive cases of temporal SICS was done. The cases were randomly divided to undergo the surgery with tunnel construction either with a crescent knife or a razor blade (50 eyes each), by a singleoperating surgeon (Dr SR). The structural dimensions and integrity of the tunnel were noted using an AS-OCT on the 1st postoperative day. Tunnel-related complications were noted both intra and postoperatively. Results: Of the 100 eyes operated, the mean average depth at section, with crescent was found to be 526 μ, while that with blade was 598 μ. The mean average depth at internal entry was found to be 607 μ with crescent and that with blade was 670 μ. Self-sealing wound was achieved in 49 of the 50 cases with crescent as well as with blade, with only 1 tunnel requiring 1 suture for anterior chamber (AC) formation in case of both crescent and blade. Tunnel complications included Descemet's membrane detachment in 1 eye and premature entry in 1 eye, in razor blade constructed tunnel. The time taken with crescent was on a mean average 32.9 s, while that with blade was 27.3 s. Conclusion: Razor blade constructed scleral tunnels are slightly deeper compared to crescent as noted on AS-OCT. Integrity and complication rates being comparable between the two. The razor blade could be considered as a safe, equally efficacious, if not better, and an economical alternate to crescent knife in a high-volume community setup.
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SURGICAL CORNER Top

Tissue plasminogen activator-assisted surgical removal of massive subretinal hemorrhage p. 171
G Mahesh, Dinesh Rungta
DOI:10.4103/kjo.kjo_64_20  
We describe the surgical technique of managing a case of massive subretinal hemorrhage (SRH) using tissue plasminogen activator [tPA], followed by vitrectomy and SRH drainage.
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CASE REPORTS Top

The resurgence of post-LASIK epithelial ingrowth p. 174
Neena Chris William, Hilda K Nixon, David Pudukadan, Lilan Bhat
DOI:10.4103/kjo.kjo_30_20  
We are reporting a case of a 32-year-old female who presented with a gradual painless progressive decrease in vision in the right eye for 2 months. She underwent laser in situ keratomileusis (LASIK) for myopia in both eyes 8 years back. The right eye showed rolled flap margin with epithelial ingrowth extending from margin to pupillary area. Mechanical debridement was done along with flap wash and mitomycin-C and bandage contact lens placement. Visual acuity showed improvement on follow-up. However, the recurrence was noted at 6-month follow-up. This case highlights the challenges in the management of epithelial ingrowth.
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Commentary: Guidelines for the management of Post LASIK Epithelial Ingrowth or PLEI p. 177
Aneeta Jabbar
DOI:10.4103/kjo.kjo_46_20  
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Atypical cytomegalovirus retinitis in an immunocompetent individual with diffuse large B-cell lymphoma posing a diagnostic enigma p. 179
Amit Kumar Deb, VS Janani, Sushmita Sana Chowdhury, Pratima Chavhan
DOI:10.4103/kjo.kjo_21_20  
Cytomegalovirus (CMV) retinitis is a vision-threatening condition seen with CD4+ count below 50/μL. In the presence of systemic lymphoma, CMV retinitis may pose a diagnostic dilemma due to similar clinical features with intraocular lymphoma. We, hereby, report a rare case of bilateral CMV retinitis in a patient with normal CD4+ counts and a past history of diffuse large B-cell lymphoma (DLBCL). A 51-year-old male presented with sudden-onset painless diminution of vision in the right eye (RE) for a 2-week duration. He had a past history of DLBCL and had been treated with chemotherapy. On examination, his best-corrected visual acuity was perception of light in RE and 20/20 in the left eye (LE). RE fundus examination showed yellowish-white deep retinal lesions with scanty superficial retinal hemorrhages and perivascular exudates. LE fundus examination showed only one focal area of yellowish-white deep retinal lesions along the inferotemporal arcade. A provisional diagnosis of bilateral intraocular lymphoma was made based on the past history of systemic lymphoma. RE vitreous tap was done, and intravitreal injection of methotrexate was given. Vitreous sample revealed CMV DNA on polymerase chain reaction but no evidence of malignant cells on cytology. CD4 count was 393 cells/μl. The patient was subsequently treated with intravenous ganciclovir and oral valganciclovir for bilateral CMV retinitis. This case report highlights the importance of vitreous sample analysis in patients of systemic lymphoma presenting with atypical retinal necrotic lesions to establish an accurate diagnosis and to differentiate between closely mimicking lesions of intraocular lymphoma and viral retinitis.
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Postoperative endophthalmitis due to multidrug-resistant Klebsiella pneumoniae treated successfully with intravitreal colistin and core vitrectomy p. 183
Amit Kumar Deb, Sujatha Sistla, Sushmita Sana Chowdhury, Ajax Jossy, Nirupama Kasturi
DOI:10.4103/kjo.kjo_23_20  
We report a case of Klebsiella-related multidrug-resistant (MDR) postoperative endophthalmitis in a 60-year-old male treated successfully with colistin and core vitrectomy. Vision in the affected left eye (LE) at presentation was hand movements. Vitreous tap with intravitreal antibiotics (vancomycin and ceftazidime) showed no clinical improvement after 48 h. Gram stain of vitreous sample showed Gram-negative bacilli. Bacterial culture showed MDR Klebsiella pneumoniae isolates with sensitivity only to colistin. LE core vitrectomy was performed and intravitreal colistin was administered. At 1 month, vision in LE improved to 20/20 with no subsequent recurrence.
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Femtosecond laser-assisted anterior capsulotomy for capsule phimosis p. 186
Jibi Suresh, SJ Saikumar, J Lakshmi
DOI:10.4103/kjo.kjo_29_20  
The centripetal constriction and fibrosis of the capsulorhexis following cataract surgery are known as anterior capsule phimosis. A 44-year-old myopic female who underwent uneventful phacoemulsification with in-the-bag intraocular lens implantation in the right eye presented 2 months later with cloudy vision due to significant capsular phimosis. Her best-corrected visual acuity was 20/32 in the right eye. She underwent femtosecond laser-assisted capsulotomy using a power of 10 μJ. Femtosecond laser is a more precise and predictable method of treating anterior capsule phimosis as compared to the existing treatment modalities, such as neodymium: YAG capsular opening.
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PHOTO ESSAY Top

This Descemet's membrane has a story! Birth trauma p. 189
Pooja Shukla, Nitu Kumari, Palak Jugal Chirania, Balmukund Agarwal
DOI:10.4103/kjo.kjo_24_20  
We report a case of a 27-year-old male presenting with blurred vision in one eye which was discovered at an army recruitment camp. He was examined and subsequently diagnosed to be having Descemet's membrane tears, due to forceps-induced birth trauma with amblyopia. His vision improved with a rigid gas permeable contact lens to 20/60.
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INNOVATION Top

e-Learning resources for ophthalmologists Highly accessed article p. 191
John Davis Akkara, Anju Kuriakose, Biju Raju
DOI:10.4103/kjo.kjo_92_20  
The Internet has made information available and accessible by all. Specialized knowledge of all sorts is now available literally at one's fingertips. The students of today may actually learn more online than in a conventional classroom. This is true in the medical field and in ophthalmology as well. The vast amount of high-quality multimedia content helps to augment the understanding of the subjects. In this article, we discuss the various types of e-learning resources available to ophthalmologists at present and review a handful of the best online ophthalmology resources.
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CLINICAL CHALLENGE Top

“Quarantine myopia:” Revisiting myopia control strategies during COVID-19 pandemic p. 199
Sanitha Sathyan
DOI:10.4103/kjo.kjo_94_20  
COVID-19 pandemic has accelerated the risk factors associated with childhood myopia such as increased time indoors, increased screen time, less outdoor activity, and less exposure to sunlight. Myopia control strategies are likely to be affected negatively during the times of this pandemic. This report discusses the likely impact of COVID-19 pandemic on the myopia control strategies and raises concerns about the accelerated silent spread of myopia epidemic during a much noisy pandemic.
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Commentary on “quarantine myopia:” Revisiting myopia control strategies during the COVID-19 pandemic p. 201
Jameel Rizwana Hussaindeen
DOI:10.4103/kjo.kjo_104_20  
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HISTORY CORNER Top

Dr. Charles Schepens and the first head-mounted binocular indirect ophthalmoscope p. 203
C Biju John
DOI:10.4103/kjo.kjo_59_20  
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JOURNAL REVIEW Top

Journal Review p. 206
PV Geethakumari
DOI:10.4103/kjo.kjo_83_20  
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PG CORNER Top

Extraocular movements p. 209
I Karthiga
DOI:10.4103/kjo.kjo_58_20  
Extraocular muscles facilitate the eye movements. Examination of extraocular movements helps in the diagnosis of different local and systemic conditions. It also helps in differentiating congenital and acquired lesions.
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LETTERS TO THE EDITOR Top

Unexpected mishap for a beginner surgeon p. 213
R Rammia
DOI:10.4103/kjo.kjo_79_20  
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Expert's comments to “Unexpected mishap for a beginner surgeon” p. 215
Arup Chakrabarti
DOI:10.4103/kjo.kjo_86_20  
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The hidden ocular impact of COVID-19 p. 216
Fayiqa Ahamed Bahkir
DOI:10.4103/kjo.kjo_69_20  
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