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   Table of Contents - Current issue
January-April 2021
Volume 33 | Issue 1
Page Nos. 1-106

Online since Monday, April 19, 2021

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The science of research and the joy of discovery Highly accessed article p. 1
V Sudha
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Spectrum of uveitis in India p. 3
Kalpana Babu, Keerti Mukesh
We look at the spectrum of uveitis in India before the year 2010 and after the year 2010, the changing patterns in uveitis over time, the probable factors for the changing patterns and newer uveitis entities in India.
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Glaucoma in pregnancy: An update and practical guide p. 8
Sirisha Senthil, Dhanya Cheriyath
Lack of clear guidelines and understanding makes management of glaucoma during pregnancy a major challenge. The treatment should be balanced in such a way that it is safe for the mother and the growing fetus while maintaining the intraocular pressure control and stability of glaucoma.
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Asymptomatic iris cyst encroaching anterior chamber angle p. 12
Bharat Gurnani, Kirandeep Kaur, S Balamurugan
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Amblyopia – An update p. 14
Sujatha Nambudiri, PV Geetha Kumari, V Sudha, S Sinumol
Amblyopia is the most common cause for preventable monocular visual loss in children. Visual system at birth is at a stage of dramatic developmental neural plasticity. Abnormal visual impulses from eyes (e.g., visual deprivation and refractive error) can affect normal anatomical and functional organization of the system. Abnormal cortical changes thus produced can be reversed if proper treatment is instituted during this time. This so-called critical period was thought to extend from birth to 7–8 years. However, now, it is understood that cortical plasticity though reduced may extend up to 6th decade of life and this accounts for increased interest in the management of adult amblyopia. Early detection and instituting treatment on detection are important for achieving better outcomes. Classical amblyopia treatment modalities include optical correction of significant refractive errors, occlusion therapy and penalization. Pharmacologic therapy, binocular therapy, and liquid crystal display eyeglasses are the newer treatment options. This review gives a simplified update of amblyopia including simplified pathophysiological concept in different types of amblyopia which will be useful to the clinician. Recent treatment options available for treatment including that in adult amblyopia are also discussed. Literature search using Google scholar, PubMed with a combination of words appropriate to this article was done and relevant articles were reviewed.
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Ocular manifestations of COVID-19 infection: A review of available information p. 22
Kaberi Biswas Feroze
Ocular signs and symptoms have been reported in COVID-19 patients, and there is increasing recognition of conjunctivitis as a prodromal symptom of this disease. There is also a surge of information about corneal, uveal, retinal, and neuroophthalmological involvement in COVID-19 infection. This review attempts to determine from various researches published during the time of the pandemic, the various ocular presentations of COVID-19 infection, its significance, correlation to the severity of systemic disease, and its importance as a mode of transmission of the disease. An extensive search strategy was employed to retrieve articles of ocular manifestations of COVID-19 published from January 2020 to date. Conjunctivitis was found to be the most common ocular manifestation, and viral RNA was noted in conjunctiva and tears, posing a risk for ophthalmologists. Other less commonly seen findings in COVID-19 infections include keratoconjunctivitis, blepharitis, retinal changes, and ophthalmoparesis. However, recent studies show increasing reports of retinal and neuroophthalmological manifestations of the COVID-19 infection.
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Adaptive designs for clinical trials p. 29
Praveen K Nirmalan
The gold standard for interventional studies is the randomized controlled trial (RCT). The RCT follows a linear path with prespecified plans and a little option for flexibility within its implementation. The RCT is also resource and time-intensive and can be a limitation in epidemics or pandemics where more rapid responses can reduce adverse effects. Adaptive designs (ADs) allow for continuous evidence-based modifications to key elements of trial design even as data collection is going on. Reduced use of resources, reduced time to complete the trial, flexibility in the allocation of participants to study arms and improved likelihood for scientifically valid trial results are added advantages with AD. ADs can be applied from early-phase trials to confirmatory trials. In this paper, we introduce key aspects of AD that Ophthalmologists can apply to clinical trials in Ophthalmology. We briefly introduce the rationale for AD, commonly used terminology, and design elements.
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Small incision lenticule extraction versus photorefractive keratectomy: A comparative study p. 33
Reshmi Sreekumari, Hariprasad Vokuda, Krishnaprasad Kudlu
Purpose: The purpose of the study is to compare the objective and subjective quality of vision following small incision lenticule extraction (SMILE) and photorefractive keratectomy (PRK). We compared the postoperative safety, efficacy, predictability, refractive stability, contrast sensitivity, and spherical aberration changes in two groups over a 1-year follow-up period. Materials and Methods: This was a retrospective comparative study of 1-year duration. Fifty eyes of patients who underwent SMILE and 50 eyes of patients who underwent PRK were selected based on the inclusion and exclusion criteria. Methodology: Standard preoperative evaluation for all patients included corneal topography, refraction, anterior segment, retina evaluation, and intraocular pressure. Uncorrected visual acuity, best-corrected visual acuity, spherical aberration, and contrast sensitivity were measured preoperatively followed by 1, 3, 6, 9, and 12 months postoperatively. Results: Ninety-six percent of the eyes of patients who underwent SMILE and 92% of the eyes of patients who underwent PRK achieved postoperative refraction within ±0.5 D of the intended target refraction. No eyes in both the groups had any loss of visual acuity. Both procedures induced statistically significant spherical aberrations. However, the difference between the two groups was not statistically significant (P > 0.05). One hundred percent of eyes in SMILE and PRK group were noted to have a stable postoperative refraction till the last follow-up. Contrast sensitivity was better in eyes of patients who underwent SMILE comparing to PRK. Conclusion: Overall, both SMILE and PRK have shown excellent safety, efficacy, and predictability for correction of myopia and myopic astigmatism. SMILE is better in terms of refractive accuracy and quality of vision.
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Etiological diagnosis of microbial keratitis in a tertiary care hospital in Lucknow p. 39
Nazia Khan, Gopa Banerjee, Prashant Gupta, Poonam Kishore, Arun Sharma
Context: Microbial keratitis is a sight-threatening infection which can lead to devastating outcome if not managed timely and rightly. Aim: The aim is to study the etiology and assess the risk factors of infectious keratitis in patients presenting to the Ophthalmology Department in King George's Medical University, Lucknow (Uttar Pradesh), India. Setting and Design: The study was conducted at the Microbiology and Ophthalmology Department of King George's Medical University, Lucknow. This was a prospective, observational study. Subjects and Methods: A total of 120 corneal scrapings were performed in patients presenting with corneal ulcers between August 2016 and July 2017. Gram staining, KOH mount, and culture on blood agar and Sabouraud's dextrose agar were done for all the scrapings for the identification of bacterial and fungal isolates. Statistical Analysis: None. Results: Microbial etiology was established 34.17% of scrapings. The most common risk factor was trauma (56.7%) of which vegetative trauma was maximum (31/68). Among 41 positive cultures, 34.14% were bacterial while 65.85% were fungal in etiology. The most common bacterial and fungal isolates were coagulase-negative Staphylococcus spp. (50%) and Aspergillus spp. (25.93%), respectively. Conclusion: Trauma was the most common predisposing factor for microbial keratitis in our setting. Fungal infections were more common than bacterial. The “regional” findings play an important role in public health implications to understand the etiology better and to initiate appropriate treatment.
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Bridging the gap – Where do we stand? An inquiry into awareness of diabetic retinopathy among diabetics p. 44
Charmaine Bridgette Solomon, Padma B Prabhu, A Arun Kumar, PT Jyothi
Introduction: Awareness of diabetic patients with regard to diabetic retinopathy, its treatment options was assessed; as well as relation between gender, disease duration, socioeconomic and educational status with awareness of diabetic eye involvement. Methods: This was a hospital-based cross-sectional descriptive study using a semi-structured questionnaire among diabetic patients attending ophthalmology services of a tertiary care teaching hospital in North Kerala. Results: Of 203 patients, 58% were male and 42% were female. Majority belonged to the age group of 61–70 years (35.5%) and duration of diabetes of 1–5 years (28%). Sixty-six percent of patients were aware that diabetes could affect the eye. Awareness of ocular complications was associated with education level of the patients and duration of diabetes. Physicians contributed to awareness in 32% of cases and ophthalmologists in 23%. Most (51%) had an eye checkup only when they had symptoms. Majority (72%) were not aware of treatment options for diabetic retinopathy. Eighty-three percent of patients who knew of ocular involvement underwent screening against 31% of patients who did not. Fifty-one percent of patients who were aware of disease complications were on regular follow-up, as against 33% of patients who were not aware. Lack of knowledge was the most common cause (80%) as a barrier to early ocular screening. Conclusions: Awareness of diabetic ocular complications and knowledge regarding eye involvement, treatment, and follow-up are poor. The gap between merely knowing about eye involvement to fully understanding its implications on visual function still remains to be bridged. Hence, campaigns to increase the knowledge of diabetes and its complications should be carried out through electronic, print, and social media. Increased understanding of their disease results in better health-care attitude among patients.
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Prevalence of corneal astigmatism in patients undergoing cataract surgery in a tertiary care hospital of Malwa region of Northern India p. 51
Priyanka S Gupta, Navdeep K Sidhu, Pankaj V Verma, Ipsa J Singla
Context: Preoperative corneal astigmatism plays a pivotal role in deciding the outcome of cataract surgery. If the values of biometry prevalent in a particular region are known, it will help the cataract surgeons locally even in the remote areas to optimize the postoperative visual outcome. Aims: The aim was to study the prevalence and distribution of different types of corneal astigmatism among the patients in Malwa region of Punjab and its variations according to age. Settings and Design: This was a hospital-based retrospective study conducted on 370 patients of Malwa who underwent cataract surgery between December 1, 2017, and July 31, 2018, in a medical college situated in North India. Subjects and Methods: The records of the patients were reviewed, and biometric data – K1 and K2 – measured by IOLMaster™ 700 (Carl Zeiss Meditec AG, Jena, Germany) were collected. The data were categorized based on demographic variables, type of astigmatism, and extent of astigmatism. Statistical Analysis: The data were subjected to descriptive statistical analysis to yield frequencies, percentages, and means. Results: A total of 370 eyes of 370 patients were studied. The mean age of the studied population was 60.43 ± 9.9 years. Nearly 50.54% were males and the rest were females. The mean of K, K1, and K2 was 44.23 ± 1.65 D, 43.75 ± 1.68 D, and 44.71 ± 1.74 D, respectively. Almost 82.16% of the studied population had mean corneal astigmatism <1.5 D. The corneal astigmatism was against the rule (ATR) in 52.16%, with the rule (WTR) in 27.29%, and oblique in 17.83%. With increasing age, there is a gradual shift of astigmatism from WTR to ATR, in both males and females, which peaks in the sixth decade of life. Conclusions: Majority of patients in Malwa region of Punjab have corneal astigmatism less than 1.5 D. Against-the-rule astigmatism is more common than other types of astigmatism.
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Corneal endothelial cell characteristics and central corneal thickness in patients with type 2 diabetes mellitus p. 56
Rajani Kadri, Namrata Sasalatti, Sudhir Hegde, Ajay A Kudva, Devika Parameshwar, Akansha Shetty
Purpose: To evaluate the morphological features of corneal endothelium and central corneal thickness (CCT) in patients with type 2 diabetes mellitus (DM) and to correlate them with the duration of diabetes and patients glycemic status. Design: This was a prospective, cross-sectional, comparative, hospital-based study. Materials and Methods: The present study was conducted on 192 diabetics and 192 age- and sex-matched healthy controls. Corneal endothelial cell characteristics, CCT were measured using a specular microscope. Statistical comparisons were done between the case and controls using the appropriate parametric or nonparametric test. The associations between the various parameters were studied using the Pearson coefficient of correlation. Results: The mean corneal endothelial cell density (CECD) in the diabetic group (2521.3 ± 300.7 cells/mm2) was significantly lower compared to the nondiabetic group (2629.3 ± 221 cells/mm2) ( P < 0.001). The mean CCT in diabetic group was significantly higher (532.00 ± 24.88 μm) compared to control group (499.47 ± 24.76 μm) ( P < 0.001). The co-efficient of variation though higher and hexagonality though lower in diabetics was not statistically significant. CCT showed a significant positive correlation with duration of DM (r = 0.566, P<0.001). A weak positive correlation was observed between CCT and HBA1C ( r = 0.271, P<0.001) No correlation between CECD and CCT for diabetics with a duration of >10 years when compared with those with a duration of <10 years was observed. Conclusion: Diabetic patients in our study had thicker corneas, decreased CECD, and hexagonality, more irregular cell size than that of age matched controls. However, duration of the disease and the glycemic control did not affect these parameters.
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Awareness and practice toward refractive error correction methods among dental undergraduate students in a tertiary care center in Navi Mumbai p. 61
Reshma Ramakrishnan, Mamta Agrawal, Ishita Mehta, Saurabh Shrivastava, Ayushi Choudhary, Naheed Abidi
Context: Visual impairment is one of the major health-care problems in the world. People pursuing higher education with long hours of studies and excessive near work are more prone to develop refractive error causing visual impairment. Dental students come into this category. In this study, we are trying to evaluate the level of awareness and practices of dental undergraduates toward refractive errors. Aim: The aim of the study was to assess the level of awareness and various practices toward refractive error correction methods among dental undergraduate students of a tertiary care center in Navi Mumbai. Settings and Design: A cross-sectional study was done by recruiting dental undergraduate students as the subjects, after obtaining ethical approval from the institute and informed consent from the students. Subjects and Methods: A random sample of 198 undergraduate dental students were surveyed by a questionnaire. A similar study was conducted in the Goan population, and the questionnaire was taken from that study. Statistical Analysis: Statistical Package for the Social Sciences (SPSS v 21.0, International Business Machines (IBM)) was used for the statistical analysis. Results: Of 198, a total of 165 students, 58 males (35.15%) and 107 females (64.84%), had got their eyes examined. It was found that 135 students (68.2%) knew the difference between ophthalmologist and optometrist. Females have more usage of spectacles. The use of glasses was maximum among the students with family income >180,000/annum. Around 82 (41.4%) students using spectacles noticed that the use of glasses causes limiting effects on their activities. Hundred and four students were aware of the refractive surgeries. There was a statistically significant difference seen about the awareness between students having annual income <30,000 and >180,000/annum (P < 0.05), and 111 students knew about the side effects of refractive surgery. Conclusion: There is a lack of knowledge about refractive errors among dental students. It is important to create awareness among them and thereby in the society.
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Basaloid squamous cell carcinoma of eyelid: A rare presentation in rural India p. 67
Priyanka Dileep Asgaonkar, Gauri Badhe Bankar, Akshita Sharma, Kishor P Badhe
Basaloid squamous cell carcinoma (BSCC) is an aggressive rare sub-variant of squamous cell carcinoma that usually affects the upper aerodigestive tract. Ophthalmic presentation of this variety is rather rare. In our case report, we report a case of primary lower eyelid BSCC, which was treated successfully.
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Orbital rhabdomyosarcoma: An atypical presentation p. 71
Suneetha Nithyanandam, Vandana Bharadwaj, Shubashree Karat, Anupama Janardhanan, Linette Antony Punnoliparambil
Orbital Rhabdomyosarcoma is a lethal malignancy of childhood. It commonly presents in the first decade of life as a rapidly progressive proptosis that can mimic orbital inflammatory disorders. We present a case of a 13-year-old boy who presented with a diffuse right upper lid swelling progressing over 10 days. The detailed evaluation revealed an immobile, firm, and eyelid mass adhering to underlying tissues, not adherent to the skin. The provisional diagnosis of an orbital inflammation was performed. Neuroimaging suggested a preseptal cystic lesion. Intraoperatively, a solid bosselated mass arising from orbicularis oculi, extending into the anterior orbit was excised in toto. Histopathology revealed Stage-1 embryonal rhabdomyosarcoma, confirmed on immunohistochemistry. Postoperatively, the patient underwent systemic chemotherapy. The patient was tumor-free at 2 years follow-up.
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An unusual case of scleral thinning with uveal exposure following pterygium surgery and its management p. 75
Pratima Chavhan, Mary Stephen, K Ramesh Babu, Shankaralingappa Pragathi
To report unusual cases of acute onset, complete, non-infected, localized scleral thinning with uveal exposure post pterygium excision and how to manage a case. A 32-year-old female presented with complaints of mild irritation of both eyes for 3 months. On examination, she was found to be having nasal pterygium encroaching 2 mm over the cornea. She underwent an uneventful right eye pterygium excision with conjunctival autograft and was given topical antibiotics and steroid eyedrops. On follow up after 2 weeks she was found to have full-thickness scleral thinning at the site of pterygium excision with uveal exposure. Scleral patch graft with amniotic membrane transplantation was done. Scleral thinning and uveal exposure following an uncomplicated pterygium surgery without mitomycin is a rare serious complication.
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Conjunctival inclusion cyst presenting as proptosis: A rare scenario p. 78
Indu B Narayanan, JK Ann, Dona Ann Mathew, Ani Sreedhar
Conjunctival inclusion cysts are an uncommon complication following various surgeries. They usually present as cystic masses confined to the anterior segment. We report a case of large inclusion cyst with orbital extension, which presented as proptosis and diplopia.
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A rare case of osseous metaplasia of an eyelid in a child p. 81
Meenakshi Wadhwani, Shubhangi Kursange, Arti Khatri, Sneha Kumari
Osseous metaplasia is the formation of bone within a different tissue. It is a rare phenomenon that occurs primarily in breast tissue and abdominopelvic organs. Intraocular osseous metaplasia is also common. Osseous metaplasia in eyelid is rare entity. We present the case of osseous metaplasia of eyelid in a 6-year-old child. This is the first case of osseous metaplasia occurring in the pediatric population. This case also highlights the importance of coordination between ophthalmologist and pediatrician to obtain relevant history, perform imaging, and hematological test to rule out primary and secondary causes of such swellings to reach accurate diagnosis.
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Foreign body through the looking glass: Scheimpflug Imaging in inverse contrast p. 83
Prasanna Venkatesh Ramesh, Shruthy Vaishali Ramesh
A 55-year-old male presented with foreign-body sensation in the left eye, with a history of hammering a chisel. On slit-lamp evaluation, two iron corneal foreign particles with rust ring were noted. The foreign bodies were removed with 26G hypodermic needle after instilling local anesthetic drops. The purpose of this manuscript was to provide a better understanding of the role of Scheimpflug imaging in objective evaluation of corneal epithelialization in such situations. Scheimpflug imaging along with anterior segment optical coherence tomography can be used to support diagnosis, objectively monitor the healing process (epithelialization) after removal, and reveal unexpected lesions, invisible on slit-lamp biomicroscopy.
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Innovative utilization of patient's triage with integrated information system during COVID crisis p. 87
Prasanna Venkatesh Ramesh, Sathyan Parthasarathi, Shruthy Vaishali Ramesh, Ramesh Rajasekaran, Meena Kumari Ramesh
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The champion runner who became the forerunner in ophthalmic surgery training p. 91
C Biju John
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Journal Review p. 95
Neethu Pradeep
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Basics of eye donation p. 97
Fayiqa Ahamed Bahkir
This writeup deals with the basics of Eye Donation, from who can and cannot donate, how to counsel patients, how to pledge one's eyes, the responsibilities of a donor's family in the donation process. It also touches upon removal of the donor corneal tissue, processing and preservation of donor cornea at the Eye Bank, and the impact of COVID-19 on the eye donation scenario.
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Author's reply to comments on “comparison of the scleral tunnel constructed with crescent versus razor blade using the anterior segment optical coherence tomography” p. 102
Sowmya Raveendra Murthy, Priyanka Sudhakar
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The green glaucoma cricket championship: An innovative glaucoma titled based cricket match initiative for screening and promoting awareness on glaucoma disease process and compliance p. 104
Prasanna Venkatesh Ramesh, Shruthy Vaishali Ramesh, Prajnya Ray, Anugraha Balamurugan, Meena Kumari Ramesh, Ramesh Rajasekaran
World glaucoma week is celebrated annually in the 2nd week of March, to raise awareness on glaucoma. In the light of the existing manpower and resource constraints, we propose this novel concept of glaucoma awareness, through the green glaucoma cricket championship. The overarching goal of this cricket championship was to screen the general public attending the event with noncontact tonometry, confocal fundus scanner and portable virtual reality perimetry; and refer suspicious patients to the base hospital. Every single protocol of this cricket match was specifically designed with a glaucomatous nomenclature, so that the public gathering, can be educated with those terminologies at various phases of the match. Two hundred and twenty people visited during the 3 h awareness cricket match. A total of 154 people above the age of 40 years were screened for glaucoma, of which 15 (9.7%) were found to be glaucoma suspects, and were referred to the base hospital. Ten out of 15 (66.6%) glaucoma suspects presented to the hospital during the glaucoma awareness week 2020, of which 4 (40%) were confirmed to have glaucoma. This manuscript highlights the promotion of awareness and knowledge toward glaucoma, to the general public through cricket, because in India cricket is like religion and Indian's love for the sport is unparalleled.
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