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   Table of Contents - Current issue
January-March 2019
Volume 57 | Issue 1
Page Nos. 1-96

Online since Monday, June 10, 2019

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From the editor's desk p. 1
Sharmila Devi Vadivelu
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Clinical outcome of iris-claw intraocular lens implantation Highly accessed article p. 3
D Anandhi, M Rekha Sravya
Aim: The aim of this study is to study the indications, visual outcome, and complications in patients undergoing iris-claw intraocular lens (IOL) implantation. Settings and Design: This is a prospective interventional case series conducted between January 2016 and June 2017 in a tertiary care hospital. Materials and Methods: Seventy-nine eyes of 78 patients with aphakia or subluxation of lens of various etiologies were included in the study. Complete ophthalmological examination was conducted. Retropupillary iris-claw IOL implantation was done in the included patients. Patients were followed-up to 6 months for visual acuity, intraocular pressure measurement, and complications. Statistical Analysis Used: Statistical analysis was performed by the Students t-test. Results: The difference between preoperative and postoperative visual acuity was statistically significant in the group of patients undergoing iris-claw IOL implantation as a primary procedure (P < 0.0001). The difference was insignificant in the aphakic patients undergoing secondary IOL implantation. The interval between the primary surgery and the secondary procedure did not make a statistically significant impact on the visual outcome (P = 0.67). Common complications after iris-claw IOL implantation in this study noted were corneal edema, pupil ovalization, raised intraocular pressure, and iris atrophy. Conclusions: Retropupillary iris-claw IOL implantation is a safe and easy method of managing patients with aphakia and subluxation of the lens.
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Burden of visual disability in children with other disabilities p. 8
Arthur Dinukumar, Ganapathy Kalaiselvi, Mouttapa Fredrick, Kannusamy Veena
Aim: The aim of the study was to assess the visual function of children with other disabilities and to identify the preventable and treatable ocular comorbidities. Materials and Methods: This study was a cross-sectional study included children aged 3–16 years who were on speech therapy sessions. After consent from parents or guardian who accompanied the child, relevant medical history was noted. Distant visual acuities were measured using picture chart, Snellen tumbling E-chart or Cardiff preferential looking cards, and complete ocular examination was performed. Cycloplegic retinoscopy was done in all children. Spectacles and low-vision aids were prescribed appropriately. Results: Out of 83 children with learning disabilities attending speech therapy clinics who were enrolled, fifty four (65%) had ocular disorders. Refractive error was identified in 31 children(37.34%), Strabismus and nystagmus in 12 children (14.45%), cataract in 4 children (4.81%), disc pallor and retinal detachment in 2 children each (2.4%), while microphthalmos, congenital glaucoma and coloboma were noted in one child each (1.2%). Thirty-five children were not cooperative for visual acuity assessment while 13 of them had more than one ocular abnormality. Only two of the 31 students with refractive errors were using spectacles. Conclusion: The poor communication and poor cooperation of these children with disabilities add on to the burden of their disabilities as the ocular abnormalities are not recognized early. Therefore, a multidisciplinary treatment approach needs to be stressed, while the awareness among the parents and caregivers needs to be developed to help these children in their learning process and rehabilitation.
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Ocular axial length changes following trauma: Blunt versus penetrating p. 12
Madhu Shekhar, Hemant Sonawane, Haripriya Aravind
Aims: This study aims to analyze the effect of penetrating and blunt trauma on ocular axial length. Settings and Design: This is a retrospective study. Subjects and Methods: Seventy cases of unilateral ocular trauma visited between January 2012 and January 2015. Blunt and penetrating groups were formed based on the nature of injury. Mode, nature, age at injury, and presenting age were noted. Best-corrected visual acuity, axial length, keratometry, and biometric values of both eyes were documented. Factors statistically associated with changes in axial length in traumatic eyes were measured. Results: Mean axial length in penetrating trauma group was 25.31 mm (standard deviation [SD]: 1.75), and in blunt trauma group was 24.05 mm (SD: 1.13). Using regression analysis, if the axial length in control eye increases by 1 mm, then in the traumatic eye, it increases by 1.34 mm. Similarly, age at injury, penetrating trauma and longer duration between injury and presentation were statistically significant factors associated with increase in axial length in the traumatic eyes. Conclusions: Elongation of the eyeball is significantly greater in penetrating trauma than in blunt trauma. Trauma at a younger age; presentation at a later age and penetrating type of trauma are statistically significant factors associated with an increase in axial length in the traumatic eye.
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Outcomes of phacoemulsification in previously vitrectomized eyes p. 17
Preethika Gandhi, Naveen Radhakrishnan, Madhu Shekhar
Aim: To describe and determine the intraoperative and postoperative complications stemming from technical difficulties and anatomical aspects of patients undergoing phacoemulsification after pars plana vitrectomy (PPV). Materials and Methods: In this prospective study, thirty individual eyes who presented with cataract in a previously vitrectomized eye were analyzed. The indications for PPV, operative details of PPV, and postoperative complications were noted. The best-corrected visual acuity after vitrectomy, type of lens opacity that developed following PPV, visual acuity immediately prior to cataract surgery, duration between PPV and subsequent cataract extraction, estimated intraocular lens (IOL) power, formula used for calculating the IOL power, IOL type, intraoperative complications, best final visual acuity following phacoemulsification, and finally the incidence of neodymium-doped yttrium aluminum garnet capsulotomy were noted. Statistical Analysis: SPSS for Windows, version 11.0.1, and Microsoft Excel 2007 were used. Chi-square test was used to compare complication rates. Results: Overall 86% of the eyes had improved visual acuity post cataract surgery, 11% remained the same, and 3% of it worsened. Intraoperatively, small pupil, deepening of the anterior chamber, bowing of iris–lens diaphragm, difficulty in capsulorrhexis, and presence of posterior-capsular plaque were noted. Posterior-capsule opacification was the most common late postoperative complication. Conclusion: Although challenging, with prior knowledge regarding vitrectomized eyes, such cases can be performed safely and complication rates are acceptably low.
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Functional and structural changes in the macula in diabetic retinopathy – A correlative study p. 21
Ranjan Prasad Senthil, Krishnagopal Srikanth, Kirti Nath Jha, AR Rajalakshmi
Aim: The aim is to study the correlation of macular thickness and sensitivity in type 2 diabetes mellitus patients. Materials and Methods: A cross-sectional comparative study was done on 77 eyes with diabetic retinopathy. Patients were divided into three groups as follows: Group 1 – Diabetic retinopathy without maculopathy, Group 2 – Diabetic maculopathy without clinically significant macular edema (CSME), and Group 3 – CSME. Microperimetry was used to assess macular sensitivity, and optical coherence tomography (OCT) was used to measure retinal thickness. Comparison of retinal sensitivity and thickness was done between groups. Correlation of these parameters to duration of diabetes was also done. Results: The mean macular sensitivity (in dB) in Groups 1, 2, and 3 was 11.57, 11.51, and 8.03, respectively. The mean central macular thickness in Groups 1, 2, and 3 was 199.33, 208.62, and 334.25 μm, respectively. There was statistically significant difference in macular thickness and in macular sensitivity between Groups 1 and 3 (P < 0.001) and between Groups 2 and 3 (P < 0.001). This difference was not statistically significant between Groups 1 and 2 (P > 0.09). Macular sensitivity had a moderate correlation with macular thickness, which was statistically significant (P < 0.001). Conclusions: Macular sensitivity was found to decrease with increasing macular thickness.
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Study of incidence, risk factors, and treatment outcomes in retinopathy of prematurity in a tertiary care center p. 24
Kannegolla Anudeep, Krishnagopal Srikanth, Manavi D Sindal, Kirti Nath Jha
Aim: The primary aim of the study is to determine the association between incidence, risk factors, and treatment outcomes in retinopathy of prematurity (ROP). Subjects and Methods: A longitudinal observational study was carried out on 65 babies who fulfilled the criteria for ROP screening at a tertiary center. Results: Of the 65 babies screened, 24 (36.9%) developed some stage of ROP with 12 developing Type 1 ROP. Mean birth weight, mean gestational age (GA), and duration of oxygen therapy were significantly associated with the development of ROP (P = 0.047, P < 0.001, and P < 0.001, respectively). One-third of the babies had maternal risk factors also. Of the 24 babies with ROP, zone 3 was involved in 13 (54.1%) babies and zone 2 was involved in 11 (45.8%) babies; 7 (29.1%) had stage 1, 9 (37.5%) had stage 2, and 8 (33.3%) had stage 3. Of 24 babies with ROP, 12 (50%) required treatment with laser photocoagulation and all these babies showed regression of ROP following treatment. Conclusion: Birth weight <1.70 kg, GA <32 weeks, and oxygen therapy were associated with development of ROP. ROP regressed with laser photocoagulation.
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Prevalence of convergence insufficiency between 18 and 35 years and its relation to body mass index p. 27
Ramesh Shruthy Vaishali, Kirti Nath Jha, Krishnagopal Srikanth
Background: Convergence insufficiency (CI) is a common condition characterized by patient's inability to maintain binocular alignment on objects as they approach from distance to near. One study has found association between low body mass index (BMI) and CI. The purpose of this study is to find the prevalence of CI and its association with BMI among patients aged 18–35 years. Subjects and Methods: In a prospective study, we recorded convergence among individuals aged 18–35 years. We defined CI as near point of convergence of >10 cm, exophoria greater for near than distance, and positive fusional vergence of <18 ΔD. The prevalence of CI was expressed as percentage of the population. BMI was calculated. We calculated the association between CI and BMI by Chi-square test. P < 0.05 was considered as statistically significant. Results: We studied 142 individuals (male: 61 and female: 81). CI was noted in 27.5% of population; 53.84% of these were symptomatic as per symptom survey questionnaire. The average BMI of the study population was 23.78 ± 4.68. No association was found between BMI and CI (P = 0.773). Conclusions: Among 18–35 years of age, 27.5% of individuals exhibited CI. CI and BMI did not show any association.
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Pearls in the management of Stevens–Johnson syndrome p. 31
Geetha Iyer, Bhaskar Srinivasan, Shweta Agarwal
Stevens–Johnson Syndrome, a life-threatening disorder, can lead to severe ocular morbidity and corneal blindness. The discomfort and visual loss caused leads to a considerable impact on the quality of life. The goals of treatment include measures to reduce inflammation, thereby improving comfort and results for visual rehabilitation. The issues to be addressed include dry eye, lid margin keratinization, adnexal disorders, and fornix obliteration. Measures to address these like punctal cautery and mucous membrane graft have been discussed along with their surgical technique. Visual rehabilitation, following stabilization of the ocular surface, can be achieved with optical iridectomy, cataract surgery or in end-stage disease by performing the modified osteo-odonto keratoprosthesis or Type 2 keratoprosthesis. The procedures to stabilize the ocular surface help in preventing further deterioration of the ocular surface and contribute to improved vision and comfort.
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Interpretation of optical coherence tomography p. 34
Ronnie George, Trupti Sudhir Patel, Murali Ariga, Malarchelvi Pazhani, Pratheeba Devi Nivean
Glaucoma is a progressive disease which can lead to blindness. Early detection is crucial to prevent further damage. Though glaucoma is more a clinical diagnosis but investigative tools like optical coherence tomography can help us diagnose suspicious cupping and early glaucoma. The newer modalities help us to prognostigate the disease by seeing for progression. This article will help the reader interpret OCT with better understanding.
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Duane retraction syndrome: Clinical presentation and management strategy p. 49
Manjula Jayakumar, B Prashanthi
Duane retraction syndrome (DRS) is a special strabismus with variable presentation. It has been best classified by Huber based on electromyography in 1974 into three types. Huber type I is the most common form of DRS with an earlier presentation and also has satisfactory surgical outcomes. Huber type II is the least common presentation. Ahluwalia et al. in 1988 have further divided it into subgroups A, B, and C based on the alignment in primary position, indicating esotropia, exotropia, and orthophoria. Type I has esotropia, type II has exotropia, and type III has esotropia and exotropia equally common. DRS can be associated with other ocular abnormalities and systemic issues when present in syndromes. Hence, these patients need a more detailed evaluation. Management strategy aims at alignment in primary position, correcting anomalous head posture, improving palpebral fissure size, and alleviating upshoots and downshoots. It is challenging to address these patients and they need to be counseled before surgery regarding the outcome that is expected of the surgery.
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Leech as a lifeboat: Reminiscent role in plastic and reconstructive surgery! p. 55
Rohan Dilip Newadkar, Ujwala Rohan Newadkar
Leeching was a popular therapeutic practice since ancient times for various diseases. Previously, it was used as an unscientific home remedy by traditional therapists. Currently, leech came back to contemporary medicine with few applications, which were demonstrated and held by an enormous number of scientific studies and case reports. Leeches are worms of the Phylum Annelida that feed on blood extracted from a host. Medicinal leeches have been evidently revealed to have a role in reconstructive surgery and replantation surgery. Literature exhibited the use of leeches in microsurgeries such as in skin flaps, replantation of amputated tissues of face, scalp, ears, fingers, and penis. Leech therapy increases the blood flow and neovascularization. This article highlights the comprehensive importance of leech therapy in the clinics of plastic and reconstructive surgery.
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Expert corner – Pediatric ophthalmology and strabismus p. 60
Pradeep Sharma, Ramesh Kekunnaya, Sumita Agarkar, Jitendra Jethani, Shalaka Paralkar Sobti, Shruti Nishanth
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Use of air tamponade in macular hole surgery p. 65
Sangeetha Rajagopal, PV Tejaswi Prasad, M Nivean, Pratheeba Devi Nivean
A full-thickness macular hole is a defect in the fovea involving full-thickness extending from internal limiting membrane (ILM) to photoreceptor layer. It needs surgical treatment with the maintenance of prone position postoperatively. Over the years, our understanding regarding the closure of macular hole has improved with optical coherence tomography and various studies have shown varying success results. Conventionally, following vitrectomy and ILM peeing, tamponade of intraocular gas is done to keep the macula dry in the postoperative period. Controversy exists regarding the type of tamponade and the duration of prone position. In this case report, we discuss a case of full-thickness macular hole that was managed surgically with air tamponade.
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White to black: Keratopigmentation p. 68
Nishanth Madhivanan, PA P. Aysha, Shruti Nishanth, Nivean Madhivanan
Here we report a case of 34 year old female who presented to our department with chief complaints of photophobia, glare and whitish colouration of cornea in the left eye since 5 months. She had a history of penetrating ocular injury at the age of 6. She underwent penetrating keratoplasty, followed by cataract extraction and Intraocular lens implantation in 2015. On examination, Visual Acuity of right eye was 6/6 and left eye hand movements with projection of light in all quadrants. Slit lamp examination of left eye showed graft failure with leucomatous corneal opacity. Keratopigmentation was done using tattooing gun and jet black dye. Patient became symptomatically better and cosmetically satisfied. We found there was no fading of colour after three months.
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Early postoperative capsular block syndrome p. 71
Venkatesh Sugantharaj, Machireddy R Shekharreddy, Shruti P Hegde
We report a case of early postoperative capsular block syndrome (CBS) in a patient who presented with moderate blurring of vision and mild periorbital pain in his first postoperative visit (the 5th postoperative day). The unaided visual acuity (VA) was 6/24 and the best-corrected VA was 6/6 with −1.0D Sph/−0.50cylx 140. The anterior chamber was shallow (anterior chamber depth: 2.6 mm), and the intraocular pressure was 24 mmHg. Slit-lamp examination revealed an “in-the-bag” intraocular lens (IOL) with a 360° anterior capsular overlap and a distended capsular bag with an optically clear space between the IOL optic and the posterior capsule. A diagnosis of early postoperative CBS was made, and the retro-optic fluid was drained by making a Nd:YAG opening on the anterior capsule inferior and peripheral to the optic. Posttreatment unaided VA improved to 6/6–2 improving further to 6/5 with −0.50 × 140. This case is presented to highlight that early postoperative CBS can easily be missed if not looked for and can account for a postoperative refractive surprise that is easily correctable.
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Find us in fundus p. 74
M Sivakami, H Shajitha Parveen, M Ananda Babu
Intraocular manifestations of malignancies and lesions elsewhere in the body are widely reported. The ophthalmic features can be due to metastasis in case of malignancy or due to the secondary effects of the lesions causing hematological or neurological complications. On a few occasions, the ocular features predominate and even precede the characteristic features pertaining to the underlying conditions. In such cases, an ophthalmologist can be the first clinician to encounter the patients. The ocular presentations can be bizarre or even misleading, but on careful history elicitation and examination could unveil life-threatening diseases lying hidden elsewhere inside the human body. Here, we present two case reports, where the ocular features helped in the diagnosis of primary pathology elsewhere.
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Combined wavefront guided on the flap photorefractive keratectomy with accelerated collagen cross-linking for postlaser In situ keratomileusis ectasia: A novel technique p. 77
GV Prabhakar, JK Reddy, KS Siddharthan, Anushree Agrawal
Purpose: To report a series of patients who underwent simultaneous wavefront guided photorefractive keratectomy (PRK) followed by corneal collagen cross-linking (CXL) for post lasik ectasia. Methods: Two patients with corneal ectasia who underwent wavefront guided (iDesign Advanced Wave Scan Studio) PRK (STAR S4 IR ) immediately followed by CXL (AVEDRO) were included. Patient's Uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), manifest refraction, keratometry, pachymetry, corneal topography (Oculus Pentacam), were analyzed till 36 months of follow up. Results: 2 eyes had an improvement to UDVA of 20/20 at last follow-up. At 3 years follow up all the 2 eyes are topographically and visually stable maintaining 20/20. Conclusion: Simultaneous wavefront-guided PRK and CXL is effective and safe in achieving both visual quality improvement and topographic stability which is maintained in long term .This technique may offer an alternative and effective method to treat iatrogenic corneal ectasia.
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Optical coherence tomography findings of a combined hamartoma of the retina and retinal pigment epithelium in a 7-year-old boy p. 82
Vaibhav Sethi, Aditya Sethi, Shenouda Girgis, Sahebaan Sethi, Reena Sethi
We report a case of Combined hamartoma of the retina and retinal pigment epithelium (CHRRPE) in a 7 year old child, presenting to us in our single institutional practice. CHR-RPE is a rare and generally benign ocular hamartoma. CHR-RPE is generally sporadic but can occasionally occur as part of neurofibromatosis, nasopharyngeal angiofibroma, Gorlin or Poland syndrome. Vast majority of previously documented cases of CHR-RPE have been published prior to the advent of optical coherence tomography (OCT).Failure to distinguish it from serious malignancies such as choroidal melanoma or retinoblastoma has led to unnecessary enucleation in the past, thus the purpose of this case report is to analyze the optical coherence tomography (OCT) characteristics of CHR-RPE involving the macula.
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Contemporary appraisal on wet-laboratory training for ophthalmology residents p. 84
D Lional Raj, Heber Anandan
Ophthalmic surgery is different from other surgical fields as it requires additional skills of hand-eye coordination. Wet lab training helps the residents to master the initial steps of stereoscopic vision, hand-eye coordination and microsurgical skill in a non stressful laboratory setting. This tool is useful to develop self -awareness among trainess, to identify gaps and to eventually improve their surgical skills with a reduced rate of complications. The need to mandate the wet lab in ophthalmology training as a part of the curriculum in post graduate training in India requires serious consideration to improve the cataract surgical outcome.
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Expert comments on wet-laboratory training for residents p. 87
Haripriya Aravind
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Journal scan p. 88
Aditya Pradhan
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Photo quiz 1 p. 90
Naveen Radhakrishnan, Venkatesh N Prajna
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Photo quiz 2 p. 92
M Sivakami
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Photo quiz answers p. 94
Jiz Mary Santhosh
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