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   Table of Contents - Current issue
Coverpage
September-December 2022
Volume 34 | Issue 3
Page Nos. 193-292

Online since Thursday, December 22, 2022

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EDITORIAL  

Awareness about Eye Health in Kerala Highly accessed article p. 193
Smita Narayan
DOI:10.4103/kjo.kjo_110_22  
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GUEST EDITORIALS Top

Prevention of postoperative endophthalmitis – some random thoughts p. 195
Sasikumar Sadasivan Pillai
DOI:10.4103/kjo.kjo_103_22  
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A mother's perspective on balancing family life, science, and ophthalmology p. 197
Rachel S Chong
DOI:10.4103/kjo.kjo_104_22  
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REVIEW ARTICLE Top

Lifestyle modifications – A new dimension in glaucoma management p. 199
Bhawesh C Saha, Rashmi Kumari
DOI:10.4103/kjo.kjo_56_22  
Glaucoma, a neuro-degenerative disease of the eye, is characterized by progressive retinal ganglion cell (RGC) degeneration and a characteristic pattern of visual field loss. Despite a better understanding of the complex pathophysiology of glaucoma in the recent years, reduction of intra-ocular pressure (IOP) remains the primary outcome of different strategies of glaucoma management – medical, laser, or surgical. However, existence of various non-IOP-dependent mechanisms have broadened the targets as well as scope of glaucoma management. Lifestyle modifications have been a supplement in the management of different chronic diseases such as diabetes and hypertension. This option has been explored for glaucoma as well. Existing evidence suggests that some modifications in dietary habits, exercise, yogasanas, sleep postures, and so on have an influence on the underlying pathophysiology of glaucoma development as well as its progression. Increasing interest to investigate the potential of lifestyle modifications in glaucoma as preventive or supportive medicine in glaucoma management forms the basis of several recent research. This review aims to provide a comprehensive overview of the existing evidence relating the effect of different lifestyles, namely, dietary habits, supplements, exercises on IOP), and ocular perfusion pressure (OPP), which ultimately lead to retinal ganglion cell loss and optic neuropathy. Present knowledge indicates the presence of therapeutic potential in various lifestyle modifications over glaucomatous optic neuropathy. Although some findings are conflicting, there is a need for further exploration with well-structured clinical trials.
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OPHTHA INSTA Top

Christmas tree pattern in age related cataracts p. 208
Rajalakshmi Selvaraj
DOI:10.4103/kjo.kjo_161_21  
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ORIGINAL ARTICLES Top

Infectious scleritis: Clinical profile and treatment outcome in a tertiary eye care center in Southern India p. 210
Shivananda Narayana, Bidisha Mahapatra, Kunal Mandlik
DOI:10.4103/kjo.kjo_56_21  
Purpose: The purpose of the study is to study the clinical features, causative organisms, and treatment outcome in cases of infectious scleritis. Design: This is a retrospective study. Materials and Methods: Medical and microbiological records of all patients diagnosed as infectious scleritis between January 2016 and December 2019 were reviewed. Information including age, sex, clinical features, predisposing factor, causative organism, and treatment outcome was extracted from records and analyzed. Results: A total of 12 cases of infectious scleritis were identified. Five (41.6%) cases had a prior history of trauma and 3 (25%) cases had undergone cataract surgery in the past. Redness with pain in the involved eye was the most common presenting complaint (91.6%, n = 11). Most of the cases (n = 11, 91.6%) presented with visible scleral abscess under slit-lamp examination. Fifty percent cases (n = 6) were caused due to fungal infection, most common species being Aspergillus (41.6%, n = 5). Pseudomonas aeruginosa (25%, n = 3) was the second most common causative organism. Microbe-specific medical treatment was given and scleral debridement done for all the eyes. Globe was preserved in 83.3% (n = 10) of the eyes. About 41.6% (n = 5) of eyes had best-corrected visual acuity 6/18 or better at the end of 3 months. Conclusion: Previous history of trauma should raise high suspicion regarding infectious etiology in any case of scleritis. In cases with no antecedent history, subtle clinical differences between autoimmune and infective scleritis, along with response to therapy, should be kept in mind to reach at a diagnosis. In tropical countries like India, fungi, most commonly Aspergillus flavus, are the most common organism responsible for infective scleritis. Along with medical treatment, surgical debridement plays a major role in the management of infective scleritis.
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Evaluation of quality of non-mydriatic fundus images obtained with non-contact TrueColor, confocal scanner during third phase of nationwide lockdown p. 216
Prasanna Venkatesh Ramesh, Shruthy Vaishali Ramesh, Anugraha Balamurugan, Sheik Mohamed Ansar, Aji Kunnath Devadas, Meena Kumari Ramesh, Ramesh Rajasekaran
DOI:10.4103/kjo.kjo_58_21  
Aims: This study aims to evaluate the non-mydriatic fundus image quality obtained with a confocal fundus device. Also, to evaluate the influence of non-mydriatic pupil size on image quality. Settings and Design: A cross-sectional study was conducted in the outpatient department of a high-volume tertiary eye care centre in South India during the third phase of the COVID-19 lockdown. Subjects and Methods: 831 consenting, consecutive patients (1539 eyes) were photographed from May 5 to May 17, 2020, and were graded excellent, fair, adequate, or inadequate; based on white noise, black noise, and image acquisition signals. Pupil diameters were obtained with light-emitting diode flash technology. Statistical Analysis: The collected data were analyzed using SPSS software. Descriptive statistics in the form of frequencies and percentages were calculated. Simple (univariate) linear regression analysis and adjusted regression analysis were used to establish the relationship between pupil size and fundus photo quality. Results: The quality of the fundus photo was excellent in 70.12% (n = 1079), fair in 15.72% (n = 242), adequate in 5.78% (n = 89), and inadequate in 8.38% (n = 129). Of the 1410 obtained images (subtracting the inadequate quality images), 87.66% (n = 1236) were normal and 12.34% (n = 174) were pathological. There was a positive linear relationship between pupil size and quality of retinal photograph; OS (R2 = 0.935) had a slightly better association than OD (R2 = 0.901). Conclusions: The majority of the confocal images were excellent in quality. Our four-point grading system serves as a reliable measure of non-mydriatic photograph quality. Pupil size is a significant predictor of image quality for non-mydriatic photographs in surveillance programs.
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A comparative study of efficacy and safety of alcaftadine 0.25% versus olopatadine hydrochloride 0.2% in allergic conjunctivitis at a tertiary care hospital p. 227
Akila Krishnan, CR Jayanthi, Sriya Sridhar
DOI:10.4103/kjo.kjo_185_21  
Background: Ocular itching is the hallmark symptom of allergic conjunctivitis, accompanied by tearing, conjunctival redness, eyelid swelling, and chemosis. Alcaftadine and olopatadine hydrochloride are classified as dual-acting antiallergic agents, used in the treatment of allergic conjunctivitis. Objective: The aim is to compare the efficacy and safety of alcaftadine 0.25% and olopatadine hydrochloride 0.2% eye drops among patients with allergic conjunctivitis. Settings and Design: Ophthalmology outpatient department at Minto Ophthalmic Hospital, Bangalore Medical College and Research Institute, Bengaluru; prospective, randomized, comparative study. Subjects and Methods: This study was conducted among 120 patients suffering from grade 3 Allergic conjunctivitis and efficacy measured in terms of proportion of patients achieving symptomatic relief of allergic ocular signs and symptoms from grade 3 to grade 0 from baseline to 2 weeks, using Total Ocular Symptoms Score (TOSS) and Conjunctival Hyperemia scale. Safety assessed by monitoring treatment-emergent adverse effects. Continuous data assessed by unpaired, paired t-test and repeated measures-ANOVA and categorical data by Chi-square test. P <0.05 was considered statistically significant, whereas < 0.001 as highly significant. Results: Greater proportion of patients achieved symptomatic relief in the Alcaftadine group (98.3%) compared to the olopatadine hydrochloride group (90%) at end of 2 weeks. A significant and faster reduction in TOSS score was observed from baseline to 2 weeks in alcaftadine treated group compared to the olopatadine hydrochloride group (P < 0.05). Adverse events reported were headache, burning sensation, and mild redness in both groups. Conclusion: Alcaftadine 0.25% demonstrated greater efficacy in reducing ocular signs and symptoms of allergic conjunctivitis from baseline to 2 weeks, compared to olopatadine hydrochloride 0.2% with minimal side-effects.
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To study the effect of intravitreal ozurdex implant in cases of retinal vein occlusion p. 234
Shailender K Chaudhary, Saloni Gupta, Gangadhar Thellam, Rupali Tyagi, Sahil Agrawal
DOI:10.4103/kjo.kjo_230_21  
Introduction: Retinal vein obstruction is one of the leading causes of severe vision impairment and blindness with treatment options mainly including laser, vascular endothelial growth factors, and steroids. This study investigates an intravitreal dexamethasone implant (ozurdex), its efficacy, and complications in patients of retinal venous occlusion. Methods: A prospective, interventional study involving 30 patients with retinal venous occlusion. Patients diagnosed with RVO who had vision loss of at least two lines on Snellen's chart and increased central macular thickness (CMT) on OCT were included in the study. All the parameters such as best-corrected visual acuity (BCVA), CMT, and intraocular pressure (IOP) were noted at baseline for the affected eye. The patients were followed up at 1 month, 2 months, and 3 months following the implant. Result: Baseline parameters were comparable between the groups. Eyes receiving the implant had a statistically significant improvement (P < 0.001) in BCVA on the Snellen chart over the 3 months. There was also a constant decrease in macular edema and the mean difference value of CMT between baseline and 1 month, 2 months, and 3months were also found to be statistically significant. Also, a comparison of IOP between two-time points was done, between baseline and 1 month, 2 months, 3 months, and the mean difference value in IOP was also found to be significant but clinically well within the normal physiological range. Conclusion: The study concluded that an intravitreal dexamethasone implant is an effective treatment for retinal venous occlusion, and it has a statistically significant and clinically meaningful effect on BCVA and CMT. However, it may be associated with a significant rise in IOP but it is well within the physiological range.
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Efficacy, feasibility, and patient acceptance of using low-dose atropine in retarding myopia progression: A general ophthalmologist's perspective p. 240
Lakshmi Cherungottil, Muhemmed Swadique, Aju Ravindran, MA Safarulla, Usha Rani
DOI:10.4103/kjo.kjo_99_21  
Purpose: Assessing efficacy of atropine 0.01% eye drops in retarding myopia progression in children, the feasibility of its use, and patient acceptance outside institutional practice. Design: Prospective observational hospital-based study was conducted in children who were prescribed aropine 0.01% eye drops to retard the progression of myopia. Methods: Fifty-seven children who showed a documented progression of ≥0.5 diopters (D) of myopia were prescribed atropine 0.01% eyedrops. In those patients who followed up, the mean change in spherical equivalent was assessed using a paired t-test and a pairwise correlation test. Data of those who were lost to follow-up were evaluated. Results: Out of the 57 children 10 opted out of the study and of the remaining 47 children 20 (42.55%) were lost to follow-up. The mean age of the remaining 27 children was 9.04 ± 3.05 years and 48.1% (n = 13) were female. The mean age of dropouts was significantly higher than those who were followed up (P = 0.003). The mean duration of follow-up was 10.8 ± 5.1 months (range 3–23 months). The mean spherical equivalent from baseline to last follow-up was 0.329 by the paired sample t-test (P < 0.001). Twelve (44.4%) of the 27 children showed a progression of myopia despite treatment. Conclusion: Mean change in spherical equivalent in our study is comparable to previous studies with hardly any adverse effects suggesting efficacy of atropine 0.01%; practical hurdles in follow-up and adherence need to be improved with better patient education.
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Diabetic nephropathy may predict the retinal changes of patients with diabetes: An Indian population-based study p. 245
Saloni Gupta, Sahil Agrawal, Shailender Kumar Chaudhary, Mitali Jhamb
DOI:10.4103/kjo.kjo_208_21  
Purpose: This study aimed to study and correlate fundus changes in patients with Type 2 diabetes mellitus with different stages of nephropathy. Materials and Methods: It is a prospective, observational study involving 100 patients at a tertiary health-care institute. Type 2 diabetic patients with diabetic nephropathy (DN) were enrolled. Those with uncontrolled hypertension, history of other ocular diseases, or surgeries were excluded. DN was defined as – microalbuminuria, macroproteinuria, and massive proteinuria based on 24-h urine protein analyser values. Participants underwent complete ophthalmic examination with fundus examination, fundus fluorescein angiography, and optical coherence tomography and were graded into various stages of diabetic retinopathy. The influence of nephropathy on retinal changes was assessed using Pearson's correlation analysis. Results: The study population included those with a median age of 56 years (range 38–79 years). In the group with microalbuminuria, 10 (62%) eyes did not have any retinopathy changes. In the macroproteinuria group, 61 (53%) showed mild-to-moderate nonproliferative diabetic retinopathy (PDR). In addition, 30 eyes of patients (48%) with massive proteinuria had PDR which were all statistically significant. Also in 32 eyes (16%) of DN patients, clinically significant macular edema was present, most of which, i.e., 24 (75%), were in the macroproteinuria group. Conclusions: These findings indicated that the severity of proteinuria was significantly associated with fundus changes in Type 2 diabetic patients. Thus, we conclude that DN is a marker of retinopathy and timely ophthalmic evaluation of patients should be done.
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A comparative study on ocular manifestations in patients with polycystic ovary syndrome and healthy volunteers p. 250
Rakendu Puthiyedath, Anthrayose C V. Kakkanatt, Monsy Thomas Mathai, Lola Ramachandran, Amitha Sunny, Sreelakshmi Arun
DOI:10.4103/kjo.kjo_111_21  
Background: Polycystic ovary syndrome is a common endocrinological disorder of females in the reproductive age group.It can produce changes in the ocular tissues and thereby affect vision.In this study,we aim to compare intraocular pressure, central corneal thickness, central macular thickness, retinal nerve fiber layer thickness, Schirmers test and tear break up time between the eyes of women with and without PCOS. Methods and Material: This study included 60 eye of 30 women with PCOS(Group 1) and 60 eyes of 30 healthy women (Group 2). Intraocular pressures (IOP) were assessed using Goldman applanation tonometry, central corneal thickness (CCT) using pachymeter, retinal nerve fiber layer (RNFL) and central macular thickness (CMT) using optical coherence tomography (OCT), Schirmers test using standardized strips and tear break up time (TBUT) were assessed for all women. Results: The Mean Central Corneal Thickness, average RNFL, superior average RNFL and nasal average RNFL thicknesses were higher in patients with PCOS than in healthy women (all p<0.01) respectively. Schirmers test results and Tear Break Up Time values were significantly lower in the PCOS group (both p<0.01). The mean IOP and CMT were similar between the 2 groups. Duration of the disease was weakly positively correlated with CCT and superior RNFL and moderately positively correlated with average RNFL. Conclusions: Women with PCOS had significant increase in central corneal and retinal nerve fiber layer (average, superior, nasal quadrant) thickness and a significant decrease in Schirmer test and TBUT values. It is advisable that all women with PCOS undergo an eye examination for dry eye. Hormonal regulations prior to corneal and refractive surgeries may help improve outcomes.
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CASE REPORTS Top

Fish hook injury to the eye: A unique presentation p. 256
Shubhescha S Parab, Ugam P Sinai Usgaonkar, Vedvati Albal, Vathsalya Vijay
DOI:10.4103/kjo.kjo_220_21  
Fish-hook injuries are relatively uncommon and frequently involve upper extremities. A wide spectrum of ocular and adnexal trauma can occur following fish hook injury. We report an unusual presentation of ocular adnexal injury in a 34-year-old male who presented with a fish hook embedded in the lower eyelid margin with an intact anterior and posterior lamella. The fish hook was retrieved successfully without traumatizing both the lamellae by adopting a “sutureless, gray line split technique.” This case is being reported for its distinctive presentation and to emphasize the need to respect tissue anatomy and minimize surgical trauma while attempting removal of such sharp objects in order to achieve optimal functional and aesthetic outcomes.
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Lacteocrumenasia p. 259
N Sandhya, VG Namitha
DOI:10.4103/kjo.kjo_60_22  
Capsular bag distension syndrome (CBDS) is a rare complication of cataract surgery characterized by collection of turbid fluid between the posterior surface of the intraocular lens (IOL) and the posterior capsule. Here, we report a case of CBDS presenting 7 years after uneventful cataract surgery. Patient presented with blurring of vision in the right eye and his best corrected visual acuity (BCVA) was 6/9 N6. Slit lamp examination showed collection of turbid fluid between IOL and posterior capsule, and the opaque fibrosed capsulorhexis margin was adherent to the optic of IOL which was well placed within the bag. Patient underwent neodymium yttrium aluminium garnet (ND-YAG) laser posterior capsulotomy to release the fluid into the vitreous cavity. 6 weeks after the procedure his BCVA improved to 6/6 N6.
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A missing lens-congenital aphakia? p. 262
Vidharthi Diwakaran, Shwetha Bennavara Venkataswamy, Sanjana Singasandra Marijogaiah
DOI:10.4103/kjo.kjo_1_22  
Congenital aphakia (CA) is a rare disease of the absence of the lens since birth. It may be primary or secondary. Primary aphakia is due to the failure of induction of surface ectoderm to form the lens. It is often associated with ocular maldevelopment. The disappearance of a developed lens by reabsorption or extrusion results in secondary aphakia. A 27-year-old, male patient presented with diminished vision in the left eye since birth, no history of in-utero infection, trauma. On ocular examination, the right eye was normal. The left eye had 30° exotropia; vision was 1/60 with microcornea, corneal opacity, corneal thinning, aphakia, and disc coloboma. B scan revealed posterior staphyloma and aphakia. Congenital Aphakia with associated ocular maldevelopment is a rare case of congenital primary aphakia. It requires a meticulous evaluation and high suspicion to diagnose such a case at birth and follow a multimodal approach to avoid amblyopia and ocular morbidity.
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A case of eyelid avulsion injury caused by bull horn p. 265
Ravina Satish Nachnolkar, Vinisha Dhawade Naik, Ugam P. S. Usgaonkar
DOI:10.4103/kjo.kjo_21_21  
An 18-year-old male presented with a history of injury to the right eye with a bull horn. Examination revealed an avulsed flap of the right upper eyelid from medial canthus up to 1 cm above lateral canthus without any other ocular damage. After a thorough examination, the lid flap was sutured in layers. Postoperative antibiotic prophylaxis was given. The postoperative complication was in the form of mechanical ptosis.
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A case report of eyelid pilomatrixoma: A rare presentation p. 268
Prateek Jain, Sapna Bhandari, Anshuman Pattnaik, Pooja Shivaji Shinde
DOI:10.4103/kjo.kjo_191_20  
Pilomatrixoma is a rare periocular benign tumor involving hair follicle matrix cells. It presents as a hard, painless, and gradually enlarging mass. It is more common in Caucasians, has bimodal age distribution (5–15 years and 50–65 years) and with female preponderance. We present a rare case report of a 35-year-old Indian male presenting with progressively enlarging; noninflammatory mass in the left upper eyelid for which excision biopsy was performed and a diagnosis of pilomatrixoma was arrived at. The main differential diagnosis includes chalazion and it is vital to distinguish them prior to any surgical intervention as both have different lines of management. This article also deals with the clinical as well as histopathological features and syndromic association of pilomatrixoma along with a brief mention of its malignant variation. This case report also includes intraoperative photographs of the lesion which the authors could not find during literature search.
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External ophthalmomyiasis: Slither sign in orb p. 271
Mamta Ramesh Agrawal, Reshma Anand Ramakrishnan, Priyanka Hitesh Gandhi, Ayushi Choudhary
DOI:10.4103/kjo.kjo_201_20  
Ophthalmomyiasis is the myiasis of the eye, a relatively rare condition characterized by infestation of ocular and orbital tissues with fly larvae. Oestrus ovis being the most common causative organism. It typically occurs in shepherds and farmers in rural areas. The clinical symptoms depend on the extent of tissue invasion, which may include conjunctivitis, haemorrhage or ulceration. We report a case of 20 y/M who presented to us with foreign body sensation and watering in right eye since morning, and redness since 1 day. His visual acuity in right eye was 6/9 and in left eye was 6/6. On slit lamp examination, anterior segment of right eye revealed lid oedema, mucopurulent discharge, papillae, conjunctival congestion and moving larvae about 15-20 in number were seen on cornea and conjunctiva. Rest was unremarkable. Causative larvae were removed with forceps under topical anaesthesia followed by instillation of antibiotic eyedrop. The causative larvae were sent for microbiological examination and were identified as the first stage larvae of Oestrus ovis, the sheep nasal bot fly. Very few cases of external ophthalmomyiasis have been reported from urban areas of Maharashtra in India.
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PHOTO ESSAY Top

“Egg in the eye appearance” of traumatic pre-existing posterior capsular defect presenting as near-total cataract p. 274
R Neena, M Vikraman
DOI:10.4103/kjo.kjo_51_22  
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Phthiriasis palpebrarum - An easily missed diagnosis p. 277
K Husna, Nimitha Nageeb
DOI:10.4103/kjo.kjo_89_22  
We report a case of phthiriasis palpebrarum, which was previously misdiagnosed as anterior blepharitis. Several lice and multiple nits were noted on the eyelashes in left eye under slit-lamp examination. The patient was successfully managed by mechanical removal of lice and nits after applying 20% fluorescein dye and subsequent treatment with 0.5% moxifloxacin eye ointment containing soft paraffin as the base.
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STATISTICS CORNER Top

Types of Study Designs p. 279
Sandhya Somasundaran
DOI:10.4103/kjo.kjo_125_22  
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JOURNAL REVIEW Top

Progression patterns of normal-tension glaucoma groups classified by hierarchical cluster analysis p. 283
Jainy J Emmatty
DOI:10.4103/kjo.kjo_38_22  
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PG CORNER Top

Myopia: Strategies to prevent progression p. 285
Geethu Sasidharan, Bindu Thampi
DOI:10.4103/kjo.kjo_53_22  
Myopia is becoming increasingly prevalent, posing a significant economic and social burden across the world. Myopia is one of the most common ocular disorders of the eye causing defective vision in young and adults, which is correctable by optical aids and surgical means. In addition to the disadvantages in terms of vision impairment, myopia increases the risk of myopic macular degeneration, retinal detachment, and cataract producing a significant effect on the quality of life as well. Progressive myopia can lead to potentially blinding complications. This article is aimed at discussing various interventions that can reduce the progression of myopia in childhood and include environmental considerations, pharmacological agents, and newer advances in spectacles and contact lenses.
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LETTERS TO THE EDITOR Top

Comments on: Off-center presentation of ocular myasthenia p. 291
Anooja R Babu
DOI:10.4103/kjo.kjo_126_22  
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Waardenburg syndrome – diagnostic criteria – A puzzle p. 292
Anjali Reghu
DOI:10.4103/kjo.kjo_120_22  
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