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   Table of Contents - Current issue
September-December 2020
Volume 32 | Issue 3
Page Nos. 219-332

Online since Wednesday, December 23, 2020

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The silent epidemic – Are we neglecting it? p. 219
V Sudha
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Postgraduate surgical training in ophthalmology p. 221
Vivek Oommen Varghese, Thara R Nair, K Mahadevan
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Noncommunicable diseases and noncommunicable eye diseases: What is the way forward? p. 224
Meena Chakrabarti
As humans conquered indectious communicable diseases, nutritional deficiency as well as conditions responsible for maternal and perinatal mortality and lifespan increased, new problems such as diabetes, hypertension, cardiovascular, respiratory, and renal diseases, mental health, and drug abuse became significant health issues. Cloistered under a single umbrella term noncommunicable diseases (NCDs), these conditions as well as noncommunicable eye diseases are characterized by a course that is prolonged with multiple morbidities and an unequal distribution that puts the poor and the vulnerable at a disadvantage. Our country is going through the phase of communicable disease to noncommunicable disease (NCD) transition. And hence it is absolutely vital for us to plan and execute effective strategies to control these conditions.
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Pigment sign in vernal keratoconjunctivitis p. 232
Amanda Mohanan-Earatt, Sanjeev Srinivas
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Emerging retinal diseases and newer terminologies in spectral domain optical coherence tomography p. 234
Divya Alex, Anantharaman Giridhar, Mahesh Gopalakrishnan, Shivam Madan, Swati Indurkhya, Swati Haridas, Sailesh Kumar, Dinesh Rungta
The retina practice has changed in such a way that diagnosis is incomplete without an optical coherence tomography (OCT) image. This article gives a brief update on the emerging spectrum of retinal diseases and newer terminologies in the spectral domain OCT to keep pace with the rapid advancements in the field of imaging.
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Astigmatism correction with toric intraocular lens during cataract surgery p. 244
N Sandhya, Keerthana Zacharia, SJ Saikumar
Currently toric intraocular lens (TIOL) implantation is the most reliable method to correct pre-existing corneal astigmatism of 1D or more at the time of cataract surgery. A good surgical outcome depends on proper patient selection, accurate preoperative measurements, precise intraocular lens (IOL) power calculation and execution of proper surgical plan. Accurate keratometry measurement on a pristine cornea is crucial in TIOL power calculation. The recognition of the importance of posterior corneal astigmatism and its inclusion into various formulas and recent methods to measure it directly have resulted in better postoperative refractive outcomes. Fine-tuning of surgery with digital guidance in TIOL alignment and new lens designs with better rotational stabilities have helped achieve more predictable outcomes. Postoperative IOL rotation is the major cause of patient dissatisfaction after TIOL surgery. However, various correction algorithms and formulas are available which can help optimal corrective re rotation to address this problem satisfactorily.
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Ocular biometry in an adult Ghanaian population p. 252
Samuel Kyei, Frank Assiamah, Michael Agyemang Kwarteng, Victor Kwesi Ansah
Purpose: To measure ocular biometry and its correlates in an adult population. Materials and Methods: The measured biometric data included central corneal thickness (CCT), corneal power (K), anterior chamber depth (ACD), lens thickness (LT), vitreous chamber depth (VCD), axial length (AL), and spherical refractive error (SER) in 162 adult eyes. Results: The mean CCT was 506.7 ± 39.2 μm, mean K was: K1 = 42.50 ± 2.00 D, K2 = 43.50 ± 2.44 D, the mean AL was 24.2 ± 1.3 mm, ACD had a mean of 3.5 ± 0.6 mm, LT (mean of 3.9 ± 0.8 mm), VCD (mean of 16.4 ± 1.39 mm), and SER ranged from -10.00 D – +8.00 D. There were no significant correlations between the CCT and SER (r = 0.06, P = 0.44), LT (r = 0.06, P = 0.59), ACD (r = −0.12, P = 0.12), AL (r = −0.02, P = 0.98), and VCD (r = −0.05, P = 0.68). Pearson's correlation coefficient tests showed that AL was significantly positively correlated with ACD (r = 0.4, P < 0.001) and VCD (r = 0.73, P < 0.001) and negatively correlated with LT (r = −0.22, P < 0.05). A significant negative weak correlation was found between LT and ACD values (r = −0.22, P < 0.05). Conclusion: A thin CCT was observed among an adult Ghanaian population. CCT was found to be independent of AL. Correlation among ocular biometry showed that AL positively correlated with ACD and negatively correlated with LT.
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Trial for a trial: Is there hope? – Optic neuritis treatment trial protocol in patients with traumatic optic neuropathy p. 258
Jainy Joseph Emmatty, Smita Narayan, Rajini K Cherayath
Aims: The aim of this study was to analyze the clinical profile, visual outcome, factors predicting the visual outcome, and response to systemic methylprednisolone as per the Optic Neuritis Treatment Trial (ONTT) protocol in patients with traumatic optic neuropathy (TON). Study Design: This was a prospective observational study. Subjects and Methods: All cases who had decreased visual acuity (VA) following impact head/orbital injury were evaluated with detailed history, and ophthalmic evaluation was done. Those who were diagnosed to have indirect TON were treated with intravenous methylprednisolone 500 mg twice daily for 3 days, followed by oral prednisolone 1 mg/kg for 11 days. Visual outcome was assessed at 1 week, 1 month, 3 months, and 6 months. The results were statistically analyzed. Results: 34.65% had severe loss of vision (<6/60 vision) at presentation. Twenty patients received early treatment (within 3 days) and six patients received treatment after 3 days. Fourteen eyes (53.84%) showed an improvement in VA at 1 month. Among those who had early treatment, 60% improved, but it was not statistically significant. An initial VA of <6/60 and the presence of brain contusions were significantly associated with poor visual outcomes. Conclusions: There is no statistically significant improvement in visual outcome with early initiation of therapy. Severe initial visual loss and presence of brain contusions predict poor visual outcomes. Selected patients will benefit with corticosteroids, and the ONTT protocol with minimal adverse reactions would be a safer choice in them.
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Functional blindness: Blepharospasm with apraxia of eyelid opening p. 263
Titap Yazicioglu
Purpose: The purpose was to evaluate the effectiveness of protractor myectomy surgery in patients with severe blepharospasm whose daily life is severely impaired. Materials and Methods: Records of fifty patients with benign, essential blepharospasm were examined retrospectively and seven were included in the study. All patients underwent a complete ophthalmological and neurological examination. The severity and frequency of spasm was determined by Jankovic Rating Scale, ranging from 0 to 4, and six daily activities were determined by Blepharospasm Disability Index. The primary indication for protractor myectomy was poor response to serial botulinum toxin injections. The main outcome measure was based on whether the spasms were fully healed or the need for additional botox application. Results: Fourteen eyes of seven patients with significant functional disability were included in the study. Excessive blinking and visual disability were the most common symptoms seen in all patients, and all had previously used one or more medications. Myectomy surgery was performed in all patients who were resistant to serial botulinum toxin injections. Of the 14 eyelids, 85.7% showed resolution of spasms and no longer required botulinum toxin treatment following surgery. One patient with keratitis sequelae and dry eye was given botulinum 1 month after the surgery. One patient with residual blepharospasm in the lower eyelid underwent lower eyelid myectomy and blepharoplasty. Transient periorbital edema, hematoma, and echymosis developed following surgery. The patients were followed up for 2 years, and excellent cosmetic result with no contracture was observed in all patients. Conclusion: Protractor myectomy is an effective treatment modality in cases of blepharospasm with severe functional disability.
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A study on changes in choroidal thickness in antenatal women with pregnancy-induced hypertension using spectral-domain-optical coherence tomography p. 268
Sozhamadevi Subramaniyan, Venkatesh Perumal, R Thenmozhi
Aim: To evaluate the choroidal thickness using spectral-domain optical coherence tomography (SD-OCT) in antenatal women with pregnancy induced hypertension. Methods and Material: In this observational study 100 eyes of 50 pregnant women with pregnancy induced hypertension were included and compared with age matched non- pregnant women. Retinal SD OCT scan was done. The choroidal thickness at the fovea, 500 μm nasal and temporal to the fovea were measured manually. Statistical analysis used: Unpaired T test was used. Results: The mean choroidal thickness in pregnant women with PIH was 346.23 μm and in normal non-pregnant women it was 296.16 μm. In Multigravida with PIH (317.91 μm) the choroidal thickness was found to be less when compared with primigravida with PIH(359.53). All these results were statically significant. Conclusions: This study revealed that there was increase in choroidal thickness in pregnant women with PIH when compared to non-pregnant women. However there was a significant decrease in choroidal thickness in multigravida women with history of PIH and also the thickness of choroid decreased with increase in age.Further studies are needed to correlate choroidal blood flow and choroidal thickness in PIH mother.
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Clinical presentation and outcome of patients with optic pathway gliomas: A series of twenty patients p. 271
Sudha Menon, Girish Menon, Reddy Vyjayanth, Neenu George, Vindhya Jagdish
Background: Optic pathway gliomas (OPGs) are rare neoplasms where the management strategy is still evolving. The purpose of this study is to present our experience of twenty cases of OPGs with an intent to add to the general fund of knowledge. Materials and Methods: Retrospective chart review of patients with OPGs surgically managed in a single tertiary centre over a period of 5 years. Variables analysed include Age at diagnosis, sex, clinical manifestations, neurofibromatosis (NF1) status, tumour location, treatment modality, symptomatic progression, and complications. Results: Of the 20 patients with OPG in the study with a mean age of 12.8 years, four patients had NF1 and 16 had sporadic OPG. Dimness of vision (80%) and headache (55%) were the most common presenting symptoms. Majority of the tumours were chiasmatic (40%) in location and vision was affected bilaterally. Subtotal resection could be achieved in 12 (60%) partial decompression in 4 (30%) and gross total resection in 2 (10%). Four patients required additional shunt surgery for hydrocephalus. Postoperative radiotherapy was administered to thirteen patients and only one patient received chemotherapy. At the end of a mean follow up period of 44 months tumour recurrence was noticed in 11/20 (55%) patients. Vision improved in none, remained stable in fifteen and deteriorated in five. Three patients (15%) succumbed to tumour regrowth in the follow up period. Conclusions: OPGs are uncommon tumours with unpredictable outcome. Visual deficits are often irreversible and progressive. Curative resection is difficult and adjuvant therapy has variable response. Overall survival rates are good but progression free and survival rates are suboptimal.
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Efficacy of trash to treasure retcam in diabetic retinopathy screening p. 278
Prithvi Chandrakanth, KS Chandrakanth, AK Sheeja Vishwanathan, R Nirupama, Tresa Mathew
Background: Diabetes mellitus is a global burden and its prevalence has always been on an increase and screening is the only method by which early diagnosis and treatment can be achieved. The current screening tools are expensive, heavy and immovable. Aims and Objectives: To find out the efficacy in terms of sensitivity and specificity of the Trash To Treasure Retcam (T3 Retcam - An innovative, inexpensive, portable and light device) in comparison with direct ophthalmoscope and digital fundus camera (canon CF1). Materials and Methods: This was a hospital-based prospective study with a sample size of 80 patients calculated using Buderer's formula. The patients were ones who have diabetes for more than 5 years and have not more than NS-1 cataract status. They were dilated and examined using direct ophthalmoscope, digital fundus camera, and T3 Retcam. Each examination was carried out by three different consultants who were blinded to each other to reduce bias. Each of them was given a form in which they had to tick the particular finding as to yes or no according to its presence. A comparative analysis was done. Results: Sensitivity of the T3 Retcam was found to be 88.4% and 92% compared to Direct Ophthalmoscope and Canon funds camera, respectively. Specificity was found to be 100%. Conclusion: Trash To Treasure Retcam is a novel, inexpensive device made out of used material in the clinic/outpatient department. This device can help us detect diabetic retinopathy and can also be used as a major tool for screening in camps. It is comparable to the direct ophthalmoscope and digital cameras and yield good data for screening purposes.
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Basics of fluid air exchange in vitreoretinal surgery p. 284
Gaganjeet Singh Gujral
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Ocular juvenile xanthogranuloma p. 287
Shaji Hussain, Anu Mariya Paul
We present a case of a 3-year-old male child with a history of swelling in the left eye of 1-month duration who was seen elsewhere for this complaint and was started on topical steroids. Slit-lamp examination revealed a conjunctival swelling of size 2 mm × 2 mm, well-defined margins, slightly raised from the surface, had a pink hue without any surrounding conjunctival congestion. A clinical diagnosis of foreign body granuloma was made, and the child underwent excision biopsy. Histopathological examination revealed Juvenile Xanthogranuloma (JXG). JXG was first described by Adamson in 1905 in a child who had multiple skin nodules. He defined those lesions by the name congenital xanthoma multiplex. A case of JXG with iris involvement was presented for the first time in 1948 at the Ophthalmic Pathology Club gathering in Washington DC, and it was published 1 year later by Blank et al.
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Iridocorneal endothelial syndrome – A case of contradictions p. 291
Jincy Mariya Paul, Padma B Prabhu, Charmaine B Solomon
Iridocorneal endothelial syndrome comprises a spectrum of disorders, which present with features of corneal edema, iris atrophy, peripheral anterior synechiae, and secondary glaucoma, in varying combinations. Clinical variants include Chandler's syndrome, progressive iris atrophy, and Cogan-Reese/iris nevus syndrome. Although classically described as a unilateral condition in young women, bilaterality, varied age of presentation, and male gender are also possibilities. Here, we report a case of bilateral progressive iris atrophy in an elderly male.
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Scleral patch graft as a rescue for infectious scleritis p. 295
Hilda K Nixon, Lilan Bhat, David Pudukadan, Neena Chris William
We report a case of a 68-year-old male who presented with redness and pain in the right eye with a previous history of pterygium surgery with mitomycin-C in the same eye 2 weeks before onset of symptoms. On examination, visual acuity in the right eye was counting fingers at 2 m improving to 6/24 with pinhole and the left eye was 6/18 improving to 6/12 with pinhole. Right eye showed signs of melting in the nasal sclera with avascularity and perilimbal corneal infiltrate. Scraping was done and culture showed growth of Fusarium species. The patient was started on antifungal drops, and a scleral patch graft was done with multilayered amniotic membrane graft with fibrin glue. On follow-up, the patient showed symptomatic improvement with vascularization of scleral graft and vision improved following cataract surgery.
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Primary conjunctival non-Hodgkin's marginal zone lymphoma p. 299
Nareddy Prasanna
A 41-year-old male patient presented with conjunctival mass in both eyes since 5 years with no history of pain or visual disturbance and nonprogressive. On examination, bilateral, pinkish, freely mobile, nontender conjunctival mass noticed on both sides of cornea, with rest of the findings being normal. No lymphadenopathy. No history of systemic illness. Surgical excision biopsy with histopathological examination of conjunctival mass of both eyes was done. Report showed low-grade Extranodal non-Hodgkin's marginal zone lymphoma. As the isolated ophthalmic features of lymphoma is as such rare, there are high chances of misdiagnosing the condition with the other ocular conditions. Suspicious presentation requires a surgical excision biopsy.
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A challenging case of refractory childhood glaucoma associated with bilateral congenital ectropion uveae p. 302
VK Harshavardhan, Meena Menon
Congenital ectropion uveae (CEU) is a rare disorder, resulting from the proliferation of iris pigment epithelium on the anterior surface of the iris. We report the case of a 3-year-old boy, who was recently diagnosed with glaucoma, on treatment with two topical antiglaucoma medications and referred to us for further evaluation and management. His visual acuity, at presentation, was 6/7.5 (Cardiff) in both his eyes. Slit-lamp examination of both his eyes revealed the presence of ectropion uveae, with intraocular pressure (IOP) of 32 mm Hg. Gonioscopy in both eyes showed anterior insertion of iris. On Fundoscopy, both eyes showed glaucomatous disc changes. He had no systemic associations. Owing to inadequate IOP control, despite optimal medical therapy, he underwent trabeculectomy with intra-operative application of Mitomycin-C. However, the IOP reduction post-trabeculectomy was inadequate, and he subsequently required a bleb needling, which also failed. Hence, he underwent Ahmed glaucoma valve implantation in his right eye, with a favorable final outcome. IOP in the right eye was brought under control following multiple surgical interventions and additional medical treatment. CEU in children can be associated with refractory childhood glaucoma. It is important to evaluate for glaucoma in CEU cases to prevent blindness, especially in young patients and improve their overall prognosis.
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Eye grader-smartphone app for clinical grading scales in ophthalmology p. 305
John Davis Akkara, Anju Kuriakose
Clinical grading scales help us to objectively document clinical findings. Even though there are several good clinical grading scales, it is not feasible to memorize all of them. It would be very convenient to have all this information at your fingertips. Noting the absence of any existing app, the authors programmed a smartphone app with all the necessary grading systems. This app should be useful for all ophthalmic clinicians to quickly lookup these grading systems and helps in objective documentation.
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Unilateral abducent nerve palsy in a diabetic patient with treated cerebellopontine angle tumor p. 311
Sanitha Sathyan
Isolated abducent nerve palsy in a diabetic patient with a history of treatment for cerebellopontine angle tumor poses challenges with regard to clinical diagnosis and management. This case discusses the challenges in clinching the diagnosis clinically, the need for imaging, and the guidelines for management.
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Sir Harold Ridley and the intraocular foreign body that made history p. 315
C Biju John
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Journal Review p. 321
S Reshmi
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Insights into IOLMaster®: A useful tool for cataract surgeons p. 323
Bharat Gurnani, Kirandeep Kaur, Poulomi Das
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Comment on “Role of mitomycin C in the management of ocular surface squamous neoplasia” p. 329
Bharat Gurnani, Kirandeep Kaur
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Comment on ' Comparison of the scleral tunnel constructed with crescent versus razor blade using the anterior segment optical coherence tomography” p. 331
Kirandeep Kaur, Bharat Gurnani
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