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   Table of Contents - Current issue
Coverpage
October-December 2019
Volume 57 | Issue 4
Page Nos. 271-344

Online since Thursday, December 26, 2019

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EDITORIAL  

From the editor's desk p. 271
Sharmila Devi Vadivelu
DOI:10.4103/tjosr.tjosr_118_19  
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GUEST EDITORIAL Top

Clinical skill versus technology p. 273
Murali Ariga
DOI:10.4103/tjosr.tjosr_117_19  
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ORIGINAL ARTICLES Top

Capsulorhexis flap dimensions between manual continuous curvilinear capsulorhexis and zepto-assisted capsulotomy: A prospective study p. 275
M Nivean, RL Naveena, M Nishanth, Pratheebadevi Nivean, Shruti Nishanth
DOI:10.4103/tjosr.tjosr_93_19  
Purpose: The purpose of this study is to compare rhexis flap dimensions between manual continuous curvilinear capsulorhexis (CCC) and zepto-assisted capsulotomy. Methods: A prospective study including consecutive 10 patients of CCC and consecutive 10 patients of zepto capsulotomy. Two methods were used to compare the CCC and zepto capsulotomy flaps. In the first method, digital caliper was used to compare the vertical and horizontal dimensions of the CCC and zepto flaps under microscope. In the second method, New Eyes software was used to measure the rhexis flap dimensions from the postoperative slit-lamp photo. Dilated slit-lamp photograph is captured and capsulorhexis size, shape, continuity, and intraocular lens (IOL) optic coverage was evaluated. Results: The t-test was used for the statistical analysis. The mean difference between the flap dimensions in the two groups is not statistically significant. The coefficient of variation is more in manual than the Zepto method for all the parameters, i.e., DC_VL (10.0% vs. 0.6%); SW_VL (12.5% vs. 0.8%); DC_HL (14.2% vs. 0.3%); and SW_VL (19.0% vs. 0.3%). Discussion: Zepto-assisted capsulotomy is very precise and has a good predictability and repeatability. Complications can be related to technique. Both methods ensure optimal IOL-optic coverage, but the repeatability of rhexis dimensions is more with zepto than CCC.
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Preoperative subconjunctival injection of mitomycin C versus conjunctival autografting with fibrin glue fixation in the management of primary pterygium p. 279
Asma Ayub Ansari, Veerendra Bhimashankar Atnoor, Kailas Chavan, Ahmed Hussain Syed
DOI:10.4103/tjosr.tjosr_86_19  
Aims: To measure the outcome of preoperative subconjunctival mitomycin C 1 month before bare sclera and conjunctival autografting using fibrin glue in terms of recurrence rate and complications. Settings and Design: This was a prospective, randomized, interventional, hospital-based comparative study. Materials and Methods: Sixty eyes of 58 consecutive patients with primary, progressive pterygium were randomly allocated into two equal Groups (A and B) of 30 each. In Group A, subconjunctival injection of mitomycin C (MMC) (0.1 ml of 0.1 mg/ml) 1 month before bare sclera technique and in Group B pterygium excision with conjunctival autografting using fibrin glue were performed. The study period was from December 2010 to October 2012, and patients were followed up for 18 months. The outcome measures were significant corneoscleral complications and recurrence. Results: The mean age of patients in the study was 38.6 ± 12.6 years with females slightly outnumbering males. Majority (58.6%) of patients were pursuing outdoor occupations. The mean follow-up period of MMC group was 10.2 ± 4.49 months, whereas that of conjunctival autograft with glue group was 10.8 ± 3.66 months. The average surgery time was more for conjunctival autografting with fibrin glue than subconjunctival mitomycin before bare sclera. One (3.33%) patient in the MMC group and 2 (6.67%) patients in the fibrin glue group had recurrence within the study period. Both the surgical techniques were not found to be associated with any serious vision-threatening complications. Conclusions: Subconjunctival MMC 1 month before bare sclera is simple, safe, economical, less time-consuming, technically less demanding, and as effective as conjunctival autografting with fibrin glue fixation.
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Correlation between retinal nerve fiber layer thickness and central corneal thickness in ocular hypertension p. 285
Aditya Mahadevan, Kirti Nath Jha, Srikanth Krishnagopal, G Ezhumalai
DOI:10.4103/tjosr.tjosr_68_18  
Aim: The aim of the study is to determine correlation between the retinal nerve fiber layer thickness (RNFL) and central corneal thickness (CCT) in patients with ocular hypertension (OHT) and age-matched control. Materials and Methods: This was a prospective, observational study, done between January 2016 and June 2017 at a rural tertiary care eye center. Participants diagnosed with OHT, defined as an intraocular pressure (IOP) of 21 mm Hg or higher, with normal optic disc and visual field, in the absence of any other ocular disease, were included in the study. The control group included age- and sex-matched participants with normal IOP, optic discs, and visual fields. Patients with OHT were subdivided into thin (CCT ≤555 μm) and thick (CCT >555 μm) corneas. RNFL was measured with spectral-domain optical coherence tomography and CCT with ultrasound pachymetry. Statistical Analysis: Mean, percentage, and standard deviation were used for descriptive values. Mean, standard deviation, and 95% confidence interval were utilized for the analysis of IOP, CCT, and RNFL. Mean was compared using the independent t-test. P < 0.05 was taken as statistically significant. Results: We examined 65 eyes of 35 OHT patients and 73 eyes of 40 controls. The mean IOP was 23.48 ± 2.47 mmHg, mean CCT was 553.81 ± 38.3 μm, and the mean RNFL was 102.12 ± 12.28 μm in the OHT group. Mean RNFL in OHT was 101.14 ± 10.68 μm in thin corneas, 103.21 ± 13.92 μm in thick corneas, and 104.23 ± 8.37 μm in the controls. There was no significant difference in the average (P = 0.502) or quadrant-wise (superior, nasal, inferior, and temporal) RNFL, comparing the two (thin and thick cornea) OHT groups (P = 0.247, 0.882, 0.897, and 0.551) or the control group. Conclusion: There is no correlation between CCT and RNFL thickness in patients with OHT. Mean retinal nerve fiber thickness in OHT and control revealed no difference.
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Knowledge, attitude, and practice regarding eye donation in patients attending outpatient department of tertiary care hospital of Western India p. 289
Aruna K R Gupta, Jinal Tripathi
DOI:10.4103/tjosr.tjosr_80_19  
Aims and Objectives: The aim of the study is to assess the knowledge, attitude, and practice regarding eye donation in patients attending outpatient department of a tertiary care hospital. Materials and Methods: The data were collected by the questionnaire method from 500 patients waiting in outpatient department of ophthalmology. The questionnaire included questions pertaining to demographic profile, literacy, occupation, awareness about eye donation, willingness to donate, reasons for not pledging, and the sources of information. Results: Percentage of awareness of eye donation was equal in males and females. Significantly less awareness of eye donation was found in illiterate individuals (P < 0.0001) and Muslims (P < 0.0001). 66.6% participants were aware of eye donation and eye camps were the major source of information. 51.50% were willing to pledge their eyes. Lack of awareness was the major reason for not willing to pledge in 32.91% participants. Chi-square analysis between “awareness” and “willingness” groups showed that age group, gender, residency, and occupations were independent factors contributing to willingness to donate, while religion and education showed significant association between awareness and willingness (P < 0.05). Participants who were initially not aware about eye donation (33.6%), after being counseled showed positive responses of willingness to pledge. Conclusion: The data showed that most of the people were aware about eye donation and were willing to donate their eyes; however, the attitude and practice showed mixed responses. Participants had misconceptions about eye donation. Therefore, to reduce the burden of avoidable corneal blindness effective measures should be taken by ophthalmologists, physicians, and especially religious leaders to educate and motivate people for eye donation.
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Evaluation of visual evoked potential as a predictive marker for diabetic neuropathy p. 294
Sankha Subhra Chaudhuri, Asim Kumar Dey, Subhasis Jana, Mousumi Bandyopadhyay, Nabamita Chaudhury, Sukanta Sen
DOI:10.4103/tjosr.tjosr_83_19  
Background: Diabetes mellitus causes neurodegeneration of retina before clinical symptoms and signs of diabetic retinopathy (DR), which may result in permanent visual loss. Hence, through neurodegenerative changes, we can predict and prevent DR well in advance. Aims and Objectives: To assess the neurodegenerative ocular morbidities among patients with diabetes before DR. Materials and Methods: This study included diabetic patients above the age of 40 years who have attended outpatient department of ophthalmology and diabetic clinic under the department of internal medicine in a tertiary care hospital in West Bengal and their age- and sex-matched control group from June 2017 to May 2018. All patients had gone through proper history taking, refraction, intraocular pressure measurement, external ocular examination, slit-lamp biomicroscopy, 90D examination, indirect ophthalmoscopy, and visual evoked potential (VEP). Results: The mean age of cases and controls was 56.87 and 57.29 years, respectively. Male and female percentage of cases and controls were 52.78 and 47.22 and 55.49 and 44.51, respectively. The percentage of Hindu and Muslim patients of cases and controls were 53.89 and 46.11 and 56.1 and 43.9, respectively. The mean P100 latency of the right and left eyes of cases was 108.61 and 107.63, whereas those of controls were 101.03 and 106.35, respectively. The mean P100 amplitude of the right and left eyes of cases was 5.68 and 5.69, whereas those of controls was 6.76 and 6.77, respectively. With respect to duration of diabetes, the mean P100 latency of the right and left eyes for <1 year, 1–2 years, and >2 years was 106.41 and 104.88, 112.19 and 112.15, and 108.38 and 107.31, respectively. With respect to duration of diabetes, the mean P100 amplitude of the right and left eyes for <1 year, 1–2 years, and 2 years was 5.42 and 5.68, 5.76 and 5.52, and 5.83 and 5.79, respectively. Conclusion: Our study shows that VEP changes occur in diabetes patients before the appearance of microaneurysm.
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REVIEW ARTICLE Top

Maintenance and Management of an ophthalmic operation theater in sub-Saharan Nigeria p. 299
Prabu Baskaran, Ashok Rangarajan, Seema Ramakrishnan, Sudeep Singh Gadok
DOI:10.4103/tjosr.tjosr_84_19  
In today's era, the operation theatre (OT) is like the heart of an ophthalmic hospital set up. The maintenance and management of this sensitive area is quite often missed or not taught during the training period. It becomes imperative to have a sound knowledge about OT maintenance and management, particularly if the set up is located in a remote area with limited resources and all the more it makes sense if an ophthalmologist has to manage the entire set up single handedly. The objective of this article is to meet this requirement. Based on accepted clinical guidelines and our own experience, we have to compiled most of the important aspects of OT set up and maintenance.
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CLINICAL PRACTICE GUIDELINES Top

Nummular keratitis – A modern-day conundrum p. 308
Srinivas K Rao, Sanjeev P Srinivas, Anil K Nair
DOI:10.4103/tjosr.tjosr_104_19  
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CASE REPORTS Top

Bilateral juvenile open-angle glaucoma with keratoconus: A rare association and literature review p. 311
Vijayalakshmi A Senthilkumar, Shiva M Krishna, Manoranjan Das, Komal Parin Sangoi
DOI:10.4103/tjosr.tjosr_90_19  
Juvenile open-angle glaucoma (JOAG) is a subset of primary open-angle glaucoma, which affects individuals aged 5 to 35 years. Keratoconus is a bilateral progressive ectatic disorder of the cornea that results in a reduction of vision due to irregular astigmatism. The exact cause and the underlying pathological mechanism are unknown, but both environmental and genetic factors are thought to contribute to the development of the disorder. The association between keratoconus and normal-tension glaucoma has been widely published in literature, whereas the association between keratoconus and JOAG has been reported rarely. This is the third case report pointing toward the possible association of juvenile glaucoma with keratoconus, which emphasizes the importance of thorough glaucoma evaluation among keratoconus patients.
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Varicella zoster virus infection presenting with unilateral panuveitis Highly accessed article p. 316
Suklengmung Buragohain, Dipankar Das, Puneet Misra, Prakhar Chaudhary, Shyam Sundar Das Mohapatra, Isha Agarwalla, Harsha Bhattacharjee
DOI:10.4103/tjosr.tjosr_89_19  
In this case report, we present a unique case of varicella zoster virus (VZV) infection that presented with unilateral panuveitis. The patient came with complaints of burning sensation of his left eye, and on examination, the presence of viral pocks over the face and trunk, anterior chamber cells and flare, and iritis were noted along with vitritis and retinitis and he was diagnosed as left eye VZV-associated panuveitis. VZV infection can present with panuveitis in rare occasions, and this is the first of its kind to be reported in India.
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Endogenous orbital cellulitis with optic neuropathy secondary to an intramuscular abscess in poorly controlled diabetes mellitus p. 319
Muthukrishnan Vallinayagam, Juhi Sahu, Srikanth Krishnagopal, N Vasantha Kumar
DOI:10.4103/tjosr.tjosr_66_19  
Orbital cellulitis is an inflammation of soft tissue posterior to the orbital septum. The predisposing factors are sinusitis, dacryocystitis, hordeolum, dental infections, and penetrating trauma. The hematogenous spread of infection from a distant source is unusual. A 50-year-old diabetic male with poor glycemic control presented with sudden visual loss and swelling of the left eye for 3 days. An intramuscular abscess in the upper arm was the primary source of infection. Clinical examination disclosed orbital cellulitis with optic neuropathy, confirmed on magnetic resonance imaging. Methicillin-resistant Staphylococcus aureus was isolated from the blood culture and pus culture. The patient showed a dramatic resolution with fasciotomy and abscess drainage, adequate glycemic control, parenteral clindamycin, and oral corticosteroids. An expeditious approach is vital to circumvent visual loss due to optic neuropathy. Endogenous orbital cellulitis can occur secondary to an intramuscular abscess. A distant source of infection should be vigilantly excluded in orbital cellulitis.
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Supranuclear vertical gaze palsy with midbrain cavernoma: A rare case of Parinaud's syndrome p. 323
Muthukrishnan Vallinayagam, Kannegolla Anudeep, Kurinchi Sajeeth
DOI:10.4103/tjosr.tjosr_67_19  
Parinaud's syndrome or dorsal midbrain syndrome is a supranuclear vertical gaze palsy, characterized by lid retraction, convergence-retraction nystagmus, light-near dissociation, and spastic-paretic accommodation. It is caused by midbrain or pineal gland tumors, stroke, obstructive hydrocephalus, thalamic hemorrhage, encephalitis, demyelination, brain abscess, and trauma. We report a case of Parinaud's syndrome in a young patient secondary to cavernoma of the midbrain, a rare vascular malformation. The major manifestations included diplopia, skew deviation, restriction of upgaze, light-near dissociation, and convergence-retraction nystagmus. In this case, the visual symptoms were the premonitory presentations instigating medical attention. Parinaud's syndrome was promptly recognized and was referred to a neurosurgeon. An expeditious neuroimaging and prompt neurosurgical intervention contributed to a favorable outcome. Midbrain tumors presenting with vertical gaze palsies have been well documented in the literature. This case highlights the role of an ophthalmologist in the early diagnosis of Parinaud's syndrome which can be instrumental in influencing further management.
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Posterior reversible encephalopathy syndrome at term pregnancy with eclampsia p. 326
Abhinay Ashok, Kirti Nath Jha
DOI:10.4103/tjosr.tjosr_79_19  
The incidence of eclampsia in developed countries is 1 in 3000 and the incidence of posterior reversible encephalopathy syndrome (PRES) is 1 in 400 eclampsia patients. Not many cases of PRES have been reported from Tamil Nadu. This can be an eye opener for ophthalmologists if a patient comes with a sudden loss of vision. PRES is also known as reversible posterior leukoencephalopathy syndrome. It is a cliniconeuroradiological syndrome associated with various clinical conditions presenting with headache, seizures, and cortical visual disturbance. Imaging predominantly shows parieto-occipital white matter changes with vasogenic edema being the most accepted pathophysiology. We report a 25-year-old primigravida who presented in term pregnancy with pregnancy-induced hypertension, seizures, and blindness. Magnetic resonance imaging showed subcortical signal abnormalities in the occipital lobes, which is a sign of PRES. She was managed by controlling her blood pressure levels, and emergency cesarean section was done. Clinical improvement with complete resolution of visual disturbances was observed with supportive treatment.
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PHOTO QUIZ Top

Retina Quiz p. 328
Mayur Rokdey
DOI:10.4103/tjosr.tjosr_109_19  
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PHOTO IMAGES Top

Acute severe corneal hydrops in keratoconus p. 331
Akhil Bevara, Shashidhar Banigallapati
DOI:10.4103/tjosr.tjosr_65_19  
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Scheimpflug imaging in the late postoperative capsular bag distension syndrome Highly accessed article p. 332
Krati Gupta, Harsha Bhattacharjee, Saurabh Deshmukh
DOI:10.4103/tjosr.tjosr_91_19  
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Conjunctival retraction and patch graft exposure after trabeculectomy with mitomycin C p. 334
Vijayalakshmi A Senthilkumar, Mantravadi Shiva Krishna
DOI:10.4103/tjosr.tjosr_82_19  
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Congenital retinal macrovessel: A rare vascular malformation p. 335
Amjad Ali, Mandabi Sengupta, Ganesh Ch Kuri, Dipankar Das, Harsha Bhattacharjee
DOI:10.4103/tjosr.tjosr_78_19  
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Capsular contraction syndrome after cataract surgery in an eye with pseudoexfoliation p. 336
Eswar Sakare, Sudhakar Potti, Akhil Bevara, Navaneetha Devireddy, Thejesvi Gaddale
DOI:10.4103/tjosr.tjosr_68_19  
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Large scleral buttonhole-intraoperative surprise p. 337
Vijayalakshmi A Senthilkumar, Sharmila Rajendrababu
DOI:10.4103/tjosr.tjosr_74_19  
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LETTER TO THE EDITOR Top

Importance of pupil in isolated oculomotor nerve palsy p. 338
Krishnamurthy Ilango
DOI:10.4103/tjosr.tjosr_88_19  
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JOURNAL REVIEW Top

Journal Scan p. 340
R Vasumathi
DOI:10.4103/tjosr.tjosr_113_19  
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PHOTO QUIZ Top

Answers to retina quiz p. 344
Mayur Rokdey
DOI:10.4103/tjosr.tjosr_110_19  
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